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490615097 | PUO | 67095171 | | 7846695 | 11/23/2006 12:00:00 a.m. | ANEMIA | Signed | DIS | Admission Date: 11/23/2006 Report Status: Signed
Discharge Date: 6/20/2006
ATTENDING: CASEBIER , WERNER REGINIA M.D.
SERVICE: LELH .
PRINCIPAL DIAGNOSIS: Anemia and GI bleed.
SECONDARY DIAGNOSES: Diabetes , mitral valve replacement , atrial
fibrillation , and chronic kidney disease.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old woman
with a history of diabetes , chronic kidney disease , congestive
heart failure with ejection fraction of 45% to 50% who presents
from clinic with a chief complaint of fatigue and weakness for
one week. She had had worsening right groin and hip pain , status
post a total hip replacement approximately 13 years ago which had
been worsening for two weeks , and she has also recently completed
a course of Levaquin for urinary tract infection. She presented
to Dr. Bulow office complaining of fatigue and weakness for one
week. She has had some abdominal pain in a band-like
distribution around her right side. She was found to have a
hematocrit of 21 down from 30 eight days ago and was sent to the
emergency department for transfusion and workup of her anemia.
PRE-ADMISSION MEDICATIONS: Caltrate plus D one tab orally twice a day ,
Lantus 7 units subcutaneously every afternoon , NovoLog 4 units/4 units/5 units
subcutaneously three times a day , Imdur 30 mg twice a day , amlodipine 5 mg twice a day ,
furosemide 80 mg daily , valsartan 120 mg daily , warfarin 4 mg
daily , iron sulfate 325 mg orally daily , and multivitamin daily.
PAST MEDICAL HISTORY: Chronic kidney disease , presumed due to
congestive heart failure/diuresis/renal artery disease/early
diabetic nephropathy; type 2 diabetes; previous stroke;
congestive heart failure with ejection fraction of 45% to 50%;
rheumatic valvular disease with mitral valve replacement and
tricuspid valve repair; atrial fibrillation; history of small
bowel obstruction; status post right total hip replacement
approximately 13 years ago.
FAMILY HISTORY: No family history of kidney disease or heart
disease.
SOCIAL HISTORY: She has 10 children , lives alone with home care
in Lanno Ey Me , but has moved in to live with her daughter in
Hunt Obiment Coll She denies tobacco use and drinks alcohol rarely.
ALLERGIES: Codeine and Benadryl.
ADMISSION PHYSICAL EXAMINATION: Vital signs were temperature
96.7 , heart rate 60 , blood pressure 153/74 , respirations 22 , and
SaO2 95% on room air. The patient is a frail elderly woman in no
acute distress. She has poor dentition. JVP is difficult to
assess secondary to tricuspid regurgitation. Lungs were clear to
auscultation bilaterally. Cardiovascular exam showed bradycardia
with heart rate in the 50s that was irregular , S1 plus S2 with
3/6 systolic murmur heard throughout with mechanical sounding S2.
Abdomen was mildly tender to palpation in the mid epigastrium
with no rebound or guarding. Extremities showed venous stasis
changes in her lower extremities bilaterally. Feet were cool
with diminished DP and physical therapy pulses. On neurological exam , she was
alert and oriented x3 and cranial nerves II through XII were
intact.
STUDIES: EKG showed atrial fibrillation with slow ventricular
response with heart rate of 53 , widened QRS , a Q wave in aVL , and
U waves in the lateral leads.
Chest x-ray showed improved pleural effusions and pulmonary edema , stable marked
cardiomegaly.
X-ray of the right hip showed ,
1. Status post right total hip arthroplasty with stable
periprosthetic lucency and cortical remodeling.
2. Severe left hip osteoarthritis.
3. Diffuse atherosclerosis.
EGD on 10/24/06 showed hiatal hernia , fundic polyps with
pathology showing hypoplastic and inflammatory lesions; mild
antral erosions with pathology demonstrating mild regeneration
that was nonspecific and no H. pylori; and duodenitis with
pathology showing normal mucosa but no active bleeding or signs
of recent bleeding.
Capsule endoscopy on 7/5/06 showed a healing gastric ulcer likely in the
antrum , small bowel lymphangiectasia and angioectasia in the distal small
bowel.
Colonoscopy on 9/12/06 demonstrated cecal diverticulum , approximately 3-mm
ascending sessile polyp and several small sessile polyps in the rectosigmoid.
PROCEDURE: Right basilic vein transposition on 9/12/06 by Dr.
Stacie Halechko .
HOSPITAL COURSE BY PROBLEM:
1. GI bleed: In the emergency department , the patient's vital
signs were temperature 95.4 , heart rate 62 , respirations 16 ,
blood pressure 127/66 with SaO2 98% on room air. She was found
to have black guaiac positive stool and GI was consulted. She
was started on intravenous Nexium 20 mg twice a day and was given vitamin K 10
mg subcutaneously and two units of FFP , and she was transfused
three units of packed red blood cells with Lasix 120 mg intravenous for
each bag. Of note , the patient had a colonoscopy in
Pu Fay Mont Ey , Kentucky 46365 on 8/26/05 , which showed bleeding rectal ulcers with
biopsies consistent with ischemic colitis. An EGD on 10/24/06
showed a hiatal hernia; fundic polyps ( path:
hypoplastic/inflammatory ); mild antral erosions ( path: mild
regeneration , nonspecific; no H. pylori ); duodenitis ( path:
normal mucosa ) , but no active bleeding or signs of recent
bleeding. Capsule endoscopy on 7/5/06 showed healing gastric
ulcer likely in the antrum , small bowel lymphangiectasia and
angioectasia in the distal small bowel , which were considered the
likely sources of bleeding. Colonoscopy was performed on
9/12/06 to search for angioectasias for which intervention would
be possible , but demonstrated only a cecal diverticulum and
approximately 3 mm ascending sessile polyp and several small
sessile polyps in the rectosigmoid. The patient was started on
Aranesp but had a 5-point hematocrit drop from 32 to 27 on
9/12/06 for which she required another two units of blood along
with Lasix. The patient's hematocrit remained stable at
approximately 30 to 32 and she will be restarted on
anticoagulation on Thursday , 12/10/06 , one week after her AV
fistula surgery.
2. Renal: The patient has chronic kidney disease and is being
considered for a possible hemodialysis in the future. She was
continued on her Caltrate plus D , multivitamin , and iron
supplementation and she was started on Aranesp 25 mcg weekly and
was given sevelamer 400 mg before every meal for elevated phosphate levels.
Vein mapping study was performed on 7/25/06 , and a right basilic
vein transposition was performed on 9/12/06 by Dr. Halechko . The
patient had postoperative right hand coolness , numbness , and
weakness ( always with dopplerable radial pulse ) from steal
versus neurapraxia , which was improved by the time of discharge.
She will follow up with Dr. Halechko as an outpatient. The
patient's creatinine was 3.3 on admission , improved to 2.0 by
9/12/06 , which was the day of her surgery and increased again to
3.2 on 1/10/06 . She was given intravenous Lasix boluses as she had
evidence of volume overload with over eight-pound weight gain
during her hospitalization , and creatinine improved to 2.7 by the
day of discharge.
3. Cardiovascular:
Pump: The patient's ejection fraction is 45% to 50% and she was
given 120 mg of intravenous Lasix for each unit of packed red blood cells
she received , along with 120 mg orally daily with intravenous boluses of 180
mg as needed for volume overload as judged by an increase in her
weight. Antihypertensive medications were originally held for
her GI bleed and they were restarted on 10/24/06 with systolic
blood pressures remaining in the 120s to 130s.
Rhythm: The patient has atrial fibrillation with slow
ventricular response with heart rates as low as the upper 30s.
Occasionally , her heart rate appeared regular and was thought to
be junctional escape rhythm. She was asymptomatic throughout her
hospitalization. She was discussed with her cardiologist , Dr.
Meduna , who will consider a pacemaker as an outpatient.
4. Endocrine: She is euthyroid with TSH of 2.422. For her
diabetes , she received nightly Lantus with aspart before every meal and
sliding scale when eating and Regular insulin sliding scale every 6 hours
when npo Fingersticks were elevated to 300s early during this
admission but improved to the 100s upon increasing her insulin
dose.
5. Musculoskeletal: The patient is status post right total hip
replacement approximately 13 years ago and complained of right
hip pain upon admission. An x-ray showed stable arthroplasty and
the pain was improved by the morning of 10/24/06 . She will
follow with physiatrist , Dr. Ma Yeagley .
COMPLICATIONS: Right hand weakness , numbness , and coolness
status post AV fistula surgery , possibly secondary to steal or
neurapraxia , significantly improved by the time of discharge.
CONSULTANTS: Dr. Stacie Halechko from vascular surgery , Dr. Jeana Osdoba from gastroenterology.
PHYSICAL EXAMINATION ON DISCHARGE: Stable vital signs. Lungs
with bibasilar crackles. 3/6 systolic murmur heard throughout
plus a mechanical S2. Abdomen benign. Lower extremities with
chronic venous stasis changes. Right upper extremity AV fistula
with +thrill. Decreased right radial pulse with warm
hand distally , and 4/5 strength in hand grip of the right hand.
DISCHARGE MEDICATIONS: Norvasc 5 mg daily , Caltrate plus D one
tablet orally twice a day , Aranesp 25 mcg subcutaneously weekly , Lovenox 50 mg
subcutaneously daily starting on Thursday 12/10/06 ( to be discontinued when patient's
INR is therapeutic on coumadin ) , Nexium 40 mg orally
twice a day , ferrous sulfate 325 mg orally twice a day , Lasix 160 mg orally
daily , insulin aspart 5 units subcutaneously every meal , insulin Lantus 15
units subcutaneously every afternoon , Imdur 30 mg orally twice a day , sevelamer 400 mg
orally before every meal , multivitamin one tablet daily , valsartan 120 mg orally
daily , and Coumadin 4 mg orally every afternoon starting on Thursday
12/10/06 .
DISPOSITION: To home with services.
FOLLOW-UP APPOINTMENTS: The patient will follow up with Dr. Ardella S Norseth in one to two weeks , with Dr. Halechko from vascular surgery
on 5/5/06 at 8:30 a.m. , with Dr. Ma Yeagley from physiatry
on 11/29/06 at 10 a.m. , and Dr. Doris Meduna on 7/9/07 at
11:45 a.m.
CODE STATUS: The patient is full code , and her healthcare proxy
is her daughter , Almeda Leveto .
PRIMARY CARE PHYSICIAN: Ardella Norseth , MD.
eScription document: 1-2024642 CSSten Tel
Dictated By: RODERMAN , LIZETH
Attending: CASEBIER , WERNER REGINIA
Dictation ID 1307929
D: 10/15/06
T: 10/10/06
Document id: 2
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Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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380365284 | PUO | 78244363 | | 6836478 | 11/29/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed
Discharge Date:
ATTENDING: PETTINGER , DOUGLASS MD
DATE OF DISCHARGE: Not known at the time of this interim
dictation.
SERVICE: I Car Health Center .
PRIMARY DIAGNOSIS: Congestive heart failure.
SECONDARY DIAGNOSES: Postpartum cardiomyopathy status post
mitral valve repair , status post tricuspid valve repair , status
post ICD/pacer placement , asthma , and anemia.
HISTORY OF PRESENT ILLNESS: This is a 33-year-old female with a
history of postpartum cardiomyopathy ( EF 15% to 20% ) , status post
pacer/ICD placement , status post mitral valve
replacement/tricuspid valve replacement , who presents with
abdominal pain , decreased appetite , nausea , vomiting , and
occasional chest pain. The patient has had multiple recent
admissions to Pagham University Of . In October 2005 , the
patient presented with chest pain and was found to be in
decompensated heart failure. She ruled out for myocardial
infarction. She was diuresed with torsemide. A MIBI prior to
this admission in October 2005 had showed no evidence of
ischemia. The patient was more recently readmitted in July
2005. During this admission , she underwent mitral valve repair
and tricuspid valve repair given severe mitral regurgitation and
tricuspid regurgitation. She had a catheterization on 6/12/05 ,
which showed normal coronary arteries , no equalization of
diastolic pressures , pulmonary capillary wedge pressure of 19 ,
and 4+ mitral regurgitation. A TTE during this admission showed
an EF of 15% to 20% with wall motion abnormalities. She had mild
right ventricular enlargement and decreased right ventricular
function. Pulmonary artery systolic pressure was 16 plus right
atrial pressures. She was also found to have a 1.5-cm
pericardial effusion. On this admission , the patient's primary
complaints involve decreased appetite , nausea , vomiting , and
abdominal pain. The patient reports frequent vomiting after
meals. The vomitus is nonbloody and nonbilious. The patient
denies diarrhea , in fact , she has been constipated. Her last
bowel movement was on the day of admission , but she did not have
a bowel movement four to five days prior to this time. She
denies fever or chills. She denies dysuria or hematuria. She
denies melena or bright red blood per rectum. She reports
intermittent shortness of breath , which she believes to be her
baseline. She denies weight gain , orthopnea , or PND. The
patient reports occasional tightness in her left chest , which
occurs a few times each week. There are no associated ischemic
symptoms. The pain is nonexertional and it is pleuritic. In the
emergency room , the patient was afebrile with a pulse of 97 and a
blood pressure of 98/58. Her cardiac enzymes were negative x1.
A PE protocol CT was negative for pulmonary embolus. The patient
was noted on this CAT scan to have a pericardial effusion. The
patient was seen by the Cardiology Service who performed a
bedside echocardiogram , which showed effusion , but no evidence of
right atrial or right ventricular collapse.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Postpartum cardiomyopathy , October 2004.
3. Asthma.
4. Status post mitral valve repair , status post tricuspid valve
repair , 9/16/05 .
5. Status post pacer/ICD placement in October 2005.
6. Chronic cough.
7. History of HIT positivity.
8. Status post C-section.
ALLERGIES: The patient has a history of HIT.
MEDICATIONS: Digoxin 0.125 mg orally daily , Colace , Niferex 150 mg
twice a day , Aldactone 25 mg daily , Toprol-XL 25 mg daily , K-Dur 20
mEq twice a day , torsemide 100 mg orally every day before noon , 50 mg orally every afternoon ,
Advair , Nexium 20 mg orally daily , and Coumadin ( unclear if the
patient is taking Coumadin ).
SOCIAL HISTORY: The patient lives with her aunt and her
children. She has a visiting nurse. She denies tobacco or
alcohol use.
FAMILY HISTORY: Remarkable for breast cancer.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.6 , pulse 70 ,
blood pressure 80/60 , respirations 18 , O2 sat 96% on 2 liters.
The patient has no pulses ( 8 mmHg ). The patient is alert and in
no acute distress. She is dysphoric. Her pupils are equal and
reactive to light. Extraocular movements intact. Oropharynx
clear. JVP is 10 cm. There is no Kussmaul's sign. Heart has a
regular rate and rhythm. Normal S1 , S2 with 1/6 holosystolic
murmur at the apex. No S3 or S4 were noted. Lungs are clear to
auscultation bilaterally. Abdomen is soft , nontender ,
nondistended with normoactive bowel sounds. There is no rebound
or guarding. There is no costovertebral angle tenderness.
Extremities: The patient has trace edema bilaterally. She is
warm and well perfused. She has no calf tenderness. She is
alert and oriented x3. Her cranial nerves are intact. She has
5/5 strength throughout. Her affect is dysphoric.
LABORATORY ON ADMISSION: Remarkable for a potassium of 2.8 , BUN
6 , creatinine 0.7 , white count 10.43 , hematocrit 30.1 , platelets
423 , 000 , MCV is 79.4 , INR is 1.4 , PTT 30.9. D-dimer is 3273
despite the negative LENIs and negative PE protocol CT. First
set of cardiac enzymes is negative. EKG shows normal sinus
rhythm at 92 beats per minute with a normal axis. There are
occasional PVCs. There is T-wave inversion/flattening in V2
through V6 as well as leads I , aVL , II , III , and aVF. Urinalysis
shows trace leukocyte esterase , negative nitrites , 4 to 8 white
blood cells , no red blood cells , and 1+ bacteria. Urine hCG is
negative. Chest x-ray shows stable cardiomegaly without
pulmonary edema or infiltrate.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular:
a. Ischemia. The patient reported chest pain on admission. The
chest pain was atypical for ischemia and that it was
nonexertional. It was pleuritic and it had no associated
ischemic symptoms. In addition , the patient had normal
coronaries on a recent catheterization in 3/22 as well as a
nonischemic MIBI in October 2005. The patient's enzymes were
negative on this admission. The patient was continued on her
beta-blocker.
b. Pump. The patient has a postpartum cardiomyopathy with an
ejection fraction of 15% to 20%. She also has a pericardial
effusion on this admission. On admission , there was no evidence
of tamponade by exam or by echocardiogram. The patient had a
repeat TTE on 10/18/05 , which showed pericardial effusion , which
was slightly larger than that seen in July 2005. There was
respirophasic variation , but no collapse. The patient's urine
output decreased on 8/26/05 and she underwent right heart
catheterization , which showed extremely elevated right and left
filling pressures ( pulmonary capillary wedge pressure in the 40s ,
right atrial pressure 27 ). The patient was initially placed on a
Lasix drip. She was also started on intravenous dobutamine to maintain
her blood pressure and for perfusion while being diuresed. After
a few days on this regimen , the patient had a repeat right heart
catheterization , which showed improved , but elevated left and
right filling pressures. A Swan catheter was left in place for
closer monitoring of the patient's hemodynamics and to allow for
tailored therapy. At the time of this dictation , the patient
will be tried on various inotropes including dopamine and
dobutamine with close monitoring of her hemodynamics. The
purpose of this is to assess the effect of these inotropes on her
hemodynamics , so there would be a time when she requires inotrope
therapy at home. The patient was also maintained on digoxin.
Her Aldactone was changed to eplerenone given the possibility
that Aldactone could be contributing to the patient's GI
complaints. At the time of this dictation , there is a plan in
place to try to add hydralazine/Isordil to the patient's regimen
for afterload reduction if her blood pressure can tolerate this.
In the past , the patient had suffered severe hypotension when
such medications have been added.
c. Rhythm. The patient is status post pacer/ICD placement. She
was monitored on telemetry. Her telemetry will be followed
closely for any evidence of ectopy while on dobutamine or
dopamine.
2. Pulmonary: The patient has a history of chronic cough. Past
chest CTs have shown ground-glass opacities most likely due to
edema , which have resolved on more recent imaging. Pulmonary
function test in July 2005 showed an FEV1 of 2.06 , FEV1/FVC of
102 , total lung capacity of 3.09 , and a DLCO corrected of 54%
predicted. The patient was continued on Advair and was given
Atrovent as needed As mentioned previously , a PECT on admission was
negative.
3. Renal/FEN: The patient has hypokalemia in the setting of
diuresis. Her electrolytes were monitored twice a day and repleted as
needed. The patient's creatinine remained stable less than 1
throughout her admission. The patient was maintained on a
low-salt , food-restricted diet.
4. GI: The patient presented with a number of GI complaints
including abdominal pain , nausea , vomiting , and anorexia. It is
not clear what the cause of these symptoms is. The patient had
normal liver function tests. She had a KUB , which showed no
obstruction. Her urine culture showed no evidence of urinary
tract infection. It is possible that abdominal pain was due to
constipation or as a side effect of Aldactone or even to a low
flow state in the setting decompensated heart failure. The
patient was continued on a bowel regimen and a proton pump
inhibitor. At the time of this dictation , the patient's
abdominal complaints have resolved.
5. Heme: The patient has a history of iron-deficiency anemia.
On admission , her hematocrit was 30 with a MCV of 79.4. The
patient takes iron supplementation at home. This was held
temporarily in the setting of constipation. The patient also
takes Coumadin for a low ejection fraction. This is also placed
on hold in the setting of various procedures including her right
heart catheterizations and PA catheter placement. It should be
noted that the patient has a history of HIT positive.
6. ID: On 9/15/05 , the patient had a temperature of 100. This
was status post placement of a PA catheter. There was concern
for a line infection. Blood cultures were drawn and the patient
was started on vancomycin. At the time of this dictation , blood
cultures showed no growths to date , but should continue to be
followed.
7. Psych: The patient has a history of depression. She
appeared dysphoric on admission , but denied any suicidality.
Both Psychiatry and Social Work were contacted who followed the
patient during this admission and who have followed the patient
on previous admission. The Psychiatry Service had recommended
Remeron for sleep , which the patient was given with good effect.
8. Prophylaxis: The patient was given Pneumoboots early on in
her admission and then was out of bed several times each day.
She was also given a proton pump inhibitor.
9. Code: The patient is full code.
The events that occur after the time of this dictation , the
disposition , discharge condition , followup , and discharge
medications will be dictated in an addendum to this discharge
summary.
eScription document: 1-2096456 ISFocus transcriptionists
CC: Douglass Pettinger MD
Kee , Washington
Dictated By: CONEDY , ARMINDA
Attending: PETTINGER , DOUGLASS
Dictation ID 8946563
D: 7/18/05
T: 7/18/05
Document id: 3
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
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381800224 | PUO | 26149384 | | 6808586 | 5/26/2006 12:00:00 a.m. | PNUEMONIA | Signed | DIS | Admission Date: 4/22/2006 Report Status: Signed
Discharge Date: 7/27/2006
ATTENDING: YEAROUS , MARICA MD
SERVICE:
Medicine Service.
ADMISSION INFORMATION AND CHIEF COMPLAINT:
Hypoxemic respiratory failure.
HISTORY OF PRESENT ILLNESS:
The patient is a 57-year-old woman with a past medical history of
OSA , asthma , CAD status post CABG. On 8/19/06 , she underwent a
right total knee replacement at Pagham University Of . On
8/9/06 , she was discharged to rehabilitation. There , she
experienced fever , cough and dyspnea. She was started on
vancomycin , ceftazidime , and Flagyl for presumed pneumonia. In
the PUO ED , the patient was afebrile with a temperature of 97.6 ,
pulse of 88 , blood pressure 117/70 , oxygen saturation 97% on 6
liters nasal cannula. Her exam was notable for crackles in the
left base and 1+ lower extremity edema.
ADMISSION LABS:
Notable for white blood cell count of 20 , hematocrit 3of 5 ,
platelets of 442 , 000 , creatinine of 0.6 , and INR of 1.2. Her
admission EKG revealed sinus tachycardia of 119 beats per minute ,
normal axis , QRS 104 milliseconds , QTC 461 milliseconds , no
evidence of atrial enlargement or ventricular hypertrophy , poor
R-wave progression , 2 mm ST depressions and T-wave inversions in
leads 1 , aVL , V5 , V6 , 1 mm J-point elevation in V3 ( prior EKG
showed T-wave inversions in 1 , and aVL with no ST depressions ).
Her admission chest x-ray revealed bilateral diffuse patchy
opacities.
The patient was presumed to have pneumonia versus CHF. She was
treated with vancomycin , cefotaxime , levofloxacin , and
azithromycin , and was admitted to the Medicine Service for
further evaluation and management.
PAST MEDICAL HISTORY:
1. Left carotid artery stenosis status post CEA.
2. Right carotid artery stenosis , status post angioplasty.
3. OSA.
4. Asthma.
5. CAD status post three-vessel CABG in 2004 and subsequent PCI
to the ramus in 2005.
6. 70-80% RCA stenosis not bypassed during CABG.
7. Hypertension.
8. CHF , ejection fraction 45-50%.
9. AS status post aortic valve replacement.
10. Pericarditis removal.
11. Diabetes.
12. Peripheral vascular disease.
MEDICATIONS AT REHAB:
1. Vancomycin 1 gram intravenous every 12 hours , ( first dose 27 of March ).
2. Ceftazidime 1 g intravenous every 8 hours , ( first dose 7/17/06 )
3. Flagyl 500 mg intravenous every 8 hours , ( first dose 7/17/06 .
4. Advair 100/50 inhaled twice a day
5. Aspirin 325 mg orally daily.
6. Lipitor 80 mg orally at bedtime.
7. Zetia 10 mg orally daily.
8. Lopressor 75 mg orally every 6 hours
9. Lasix 1 tablet orally daily.
10. Colace 100 mg orally twice a day
11. Multivitamin 1 tab orally daily.
12. CaCO3 500 mg orally daily.
13. Cholecalciferol 400 units orally daily.
14. Ferrous sulfate 300 mg orally three times a day
15. Folic acid 1 mg orally daily.
16. Avapro 225 mg orally daily.
17. Lantus 100 units subcutaneously daily.
18. Lispro sliding scale.
19. Coumadin.
20. P.r.n. oxycodone , Tylenol , Benadryl , and Metamucil.
ALLERGIES:
Lisinopril leads to cough and metformin leads to GI distress.
SOCIAL HISTORY:
The patient was formerly employed as a cashier. She has two
children. She is a former cigarette smoker. She does not use
alcohol.
FAMILY HISTORY:
The patient has a positive family history of coronary disease ,
hypertension and diabetes.
HOSPITAL COURSE BY SYSTEM/ PROBLEM:
Persistent pulmonary
1. Hypoxemic respiratory failure. On 1/7/06 , shortly after
her admission to the medical floor , the patient was noted to be
in respiratory distress with tachypnea , accessory muscle use and
oxygen saturation of 68% on 6 liters nasal cannula. She was
placed on a nonrebreather. Her oxygen saturation increased to
93%; however , she continued to be in respiratory distress with
tachypnea and accessory muscle use. She was intubated and
transferred to the Medical Intensive Care Unit for further
evaluation and management. Her respiratory failure was thought
to be secondary to pneumonia with a component of superimposed
volume overload. She was treated with a 10-day course of
vancomycin , levofloxacin and ceftazidime as well as with intravenous
Lasix. She underwent a code green on 7/30/06 during an ETT tube
change , wherein a patent airway was transiently loss. The
patient was slow to wean from the ventilator. Her chest imaging
revealed persistent bilateral opacifications. It was thought
that after an initial infectious insult , the patient developed
ARDS. On 9/14/06 , the patient underwent bronchoscopy and BAL
revealing MRSA and HSV. The patient was treated with a 10-day
course of acyclovir for presumed HSV tracheobronchitis. Given
her inability to be weaned from the vent , the patient underwent a
tracheostomy on 4/17/06 . Post-tracheostomy , the patient
alternated between pressure support ventilation with low driving
pressure and PEEP with a trach collar..
Infectious disease:
1. Fevers. From 1/7/06 to 7/28/06 , the patient was treated
with vancomycin , levofloxacin and ceftazidime for hospital
acquired pneumonia. After discontinuation of her antibiotics ,
the patient continued to spike fevers and evidence of
leukocytosis. In verification into source of her fevers included
serial blood cultures , urine cultures and C-dif. Positive data
included: 7/28/06 , urine culture with yeast , 7/28/06 , blood
culture with coag-negative staph , 9/14/06 BAL washings with HSV ,
9/14/06 , blood culture with coag-negative staph , 7/11/06 , blood
culture with coag-negative staph , 2/29/06 , urine culture with
yeast , 2/29/06 BAL washings with MRSA , 10/28/06 urine with yeast
urine with yeast , 10/28/06 , 6/23/06 , 4/17/06 , and 10/11/06
sputum with MRSA. 7/28/06 , chest CT with bilateral
opacification in the lung parenchyma. 2/29/06 facial CT with
left sphenoid maxillary thickening. 2/29/06 chest CT with
bilateral opacification in the lung parenchyma. Of note , a
2/29/06 abdominal CT showed no evidence of abdominal infection ,
2/29/06 TTE showed no obvious vegetations , and 10/11/06 tap of
the right knee grew no organisms. In light of the data above ,
the patient's indwelling catheters were changed. She underwent
treatment with linezolid x7 days for MRSA line infection. She
also underwent treatment with acyclovir x10 days for HSV
tracheobronchitis. The aforementioned antibiosis was mostly
prophylactic. It was thought that the patient's intermittent
fevers were not infectious , but rather reflected a drug allergy ,
most likely to vancomycin. This hypothesis was supported by a
robust eosinophilia coinciding with vancomycin administration.
Shortly after vancomycin discontinuation , the patient's fevers
resolved. The patient was afebrile for greater than 48 hours off
all antibiotics prior to transfer to rehabilitation.
Cardiovascular:
1. Volume status. The patient's admission weight was 106.2 kg.
It is unclear what her dry weight was. Given that pulmonary
edema was thought to be contributing to the patient's slow
ventilator wean , she was diuresed with a combination of Lasix and
Diuril followed by combinations of torsemide and Diuril. Her
discharge weight was 100.7 kilograms. Her diuretic regimen on
discharge with torsemide 100 mg intravenous three times a day and Diuril 500 mg intravenous
three times a day The patient's diuretic regimen will need be adjusted as
her intake is adjusted. Her creatinine will need to be monitored
very closely. Her weight will need to be checked daily.
2. Pump: The patient underwent echocardiogram on 11/19/06 ,
7/17/06 , and 2/29/06 . On the whole , these studies revealed an
ejection fraction of 45-50% , concentric LVH , global hypokinesis
with regional variation , mild left atrial enlargement , mild
tricuspid regurgitation , a question of mild atrial stenosis , and
pulmonary artery pressures in the 40s. For her heart failure ,
the patient was treated with Lopressor and diuretics as above.
She was not started on an ACE inhibitor given her allergy
( cough ). She was started on low-dose ARB.
3. Ischemia: The patient has a history of coronary artery
disease status post three-vessel CABG and subsequent
single-vessel PPI. She has an RCA stenosis , 70-80% that has not
intervened upon. On admission , in the setting of respiratory
distress , the patient was in sinus tachycardia with rate related
to lateral ST depressions. Her cardiac biomarkers were positive
consistent with NSTEMI. It was thought that the patient
experienced demand ischemia rather than an acute plaque rupture.
On 10/8/06 , her troponin peaked at 8.53 , her CK at 275 , and her
MB of 16.3. The patient was treated with aspirin , Lopressor , and
Zocor. She was not started on an ACE inhibitor as detailed
above. She will likely warrant Cardiology followup with possible
RCA revascularization.
Neuro:
1. Sedation: While intubated , the patient was treated with intravenous
Versed and fentanyl titrated to light sedation. After her
tracheostomy , the patient's Versed and fentanyl drips were
discontinued. She was treated with Seroquel at bedtime to
preclude nighttime agitation. Her QTC should be monitored while
on Seroquel.
GI:
1. FEN: The patient initially received tube feeds via feeding
tube. She underwent a PEG placement on 4/17/06 . She continued
on tube feeds. She also passed speech and Swallow and was thus
started on orally feeds with aspiration precautions. She also
received supplemental multivitamins , calcium carbonate , and
cholecalciferol. The patient will require speech and swallow
evaluation at rehabilitation. Now that she is awake , she may be
able to tolerate orally feeds with aspiration precautions.
2. Bowel regimen. The patient was treated with Colace , senna ,
and Dulcolax.
Heme:
1. Anemia: The patient has known iron deficiency anemia. She
was continued on iron and folate. She may benefit from an
outpatient colonoscopy if she has not had one recently.
2. Bleeding from tracheostomy site: On 4/24/06 , the patient
was noted to have bleeding from her tracheostomy site. She had
no hematocrit drop. She remained hemodynamically stable. She
underwent a bronchoscopy , which showed no active bleeding. Her
mild bleeding was thought to relate to suction trauma. Her
prophylactic heparin was held x1 day. It was thought that the
patient should be discharged on prophylactic heparin because her
DVT risk is so high. Should the patient have intense bleeding
from the tracheostomy site , a hematocrit drop or hemodynamic
changes. Her heparin subcutaneously should be discontinued , her
hematocrit should be monitored closely , and she should be
transfused as needed. She should also at that point probably
undergo reevaluation by Pulmonary or Thoracics.
Endocrine:
1. Diabetes: The patient was treated with Lantus plus regular
insulin every 6 hours plus sliding scale insulin while she was on tube
feeds. Her insulin was changed on the night prior to discharge.
She was started on Lantus 100 subcutaneously twice a day She got her first dose
of 100 units subcutaneously on the evening prior to discharge , her morning
sugars were in the mid 100s. Her blood sugars should be followed
closely on the first one or two days at rehab. The blood sugars
should be monitored every 2-3 hours and her insulin should be
adjusted accordingly. Her insulin dose should be adjusted if her
tube feeds are cycled rather than given continuously or if she is
NPO.
Ortho:
1. Total knee replacement: The patient is status post right
total knee replacement on 8/19/06 . Her right knee has a
well-healed incision and is not erythematous or tender. The
patient was initially on low-dose anticoagulation with Coumadin.
Her Coumadin was discontinued given her acute illness and her
need for procedures. She was treated with heparin subcutaneously
prophylactic doses 5000 units three times a day as described above. She
will need rehabilitation for her knee.
2. Prophylaxis: The patient was treated with subcutaneous
heparin and Nexium.
3. Access: The patient has peripheral IVs.
DISCHARGE STATUS:
On the day of discharge 3/8/06 , the patient was afebrile.
Heart rate was in the 80s , blood pressure was in the
100s-130s/60s-80s. Discharge weight was 100.7 kilograms. The
patient was drowsy , but arouseable. She was breathing on a trach
collar. She had decreased breath sounds at the bases. She had
an S1 and S2 with a 2/6 systolic murmur at the lower sternal
border. Her abdomen was soft and nontender with positive bowel
sounds. Her trach and PEG site were intact without any
surrounding erythema. Her extremities were warm without edema.
She was on trach collar with 50% FiO2 and oxygen saturation of
97%. Her discharge labs included a white blood cell count of 21 ,
stable , hematocrit of 28 , and platelets 436 , 000. Her chem-7
included a sodium of 131 , potassium 3 , chloride 87 , CO2 32 , BUN
67 , creatinine 0.8 , and glucose 154. Her LFTs were normal. Her
INR was 1.1. Her most recent microdata showed sputum with few
polys and a few gram-positive cocci in clusters. Her chest x-ray
showed a trach in place and bilateral hazy infiltrate consistent
with resolving ARDS.
An addendum will be given with discharge medications and doses.
At rehab , the patient's weight should be monitored daily. Her
blood sugars initially be monitored every 2-3 hours. After that ,
her blood sugar monitoring can be spaced out to three times a day or
whenever deemed appropriate by the physician at the
rehabilitation facility. Her hematocrit should be checked
particularly if she has any bleeding from her tracheostomy site;
otherwise , the hematocrit can be checked every day. The white
blood cell count should be monitored if the patient has any
fever. The creatinine should be monitored daily in light of the
patient's changing diuretic regimen. The patient in's and out's
should be monitored closely.
CONTACTS AT THE HOSPITAL:
Totin Hospital And Clinic regarding the patient's inpatient course or
Dr. Marica Yearous . Contacts regarding follow up issues , the
patient's primary care physician , Dr. Erma Dovie Bess at Flofry Bradlrel Memorial Hospital 888-043-9980. The patient's healthcare proxy is her
sister , Miquel Fry who is a registered nurse , her telephone
number 743-396-9384 at home and 528-513-0528 cell phone.
eScription document: 6-0610820 EMSSten Tel
CC: Erma Dovie Bess MD
A
CC: Marica Yearous MD
Dictated By: TROOP , WILFREDO
Attending: YEAROUS , MARICA
Dictation ID 5934052
D: 3/8/06
T: 3/8/06
Document id: 4
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853274428 | PUO | 67747717 | | 716666 | 3/29/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/29/1993 Report Status: Signed
Discharge Date: 12/10/1993
PRINCIPLE DIAGNOSIS: CORONARY ARTERY DISEASE.
OTHER DIAGNOSES: PERIPHERAL VASCULAR DISEASE ,
HYPERTENSION.
ALLERGIES: No known drug allergies.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old male
immigrant from Ma Gosatope
with a long history of angina. He had been followed in the Sungooaks Van Heim , Iowa 05164 for years with strong indication for interventional
evaluation of his coronary artery disease. The patient had refused
and had been being treated medically inspite of the angina pattern.
Recently his angina had worsened and he agreed to undergo more
intensive workup. He was referred for elective cardiac
catheterization. PAST MEDICAL HISTORY: Hospitalization for an
episode of chest pain in Voboville , hypertension and history
of peripheral vascular disease with claudication symptoms.
PHYSICAL EXAMINATION: On physical exam the patient's temperature
was 97.7 , heart rate 60. HEENT: Head and
neck exam unremarkable. Lungs: Clear anteriorly. Heart: Regular
rate and rhythm , no murmurs appreciated. Abdomen: Soft , non-tender.
EXTREMITIES: No edema. Had weakly dopplerable pulses. Of note , his
physical exam was performed on his emergent admission to the
cardiac care unit after becoming unstable at elective cardiac
catheterization.
LABORATORY EXAMINATION: His admission laboratory exam was
remarkable for a normal CBC and serum 20
general exam. His EKG after cardiac catheterization demonstrated
inverted T waves in III , F and some ST depression in V4-V6.
HOSPITAL COURSE: On elective cardiac catheterization the patient
was noted to have a 90% ostial left anterior
descending coronary artery lesion. He had EKG changes ,
symptomatically had chest pain at catheterization. He was referred
for emergent coronary artery bypass grafting. An intra-aortic
balloon pump was placed. He was taken emergently to the Operating
Room where a 4 vessel coronary artery bypass was performed. There
were no intraoperative complications. Postoperatively , the patient
did remarkably well inspite of his dramatic presentation. He had
no vascular complications. His intra-aortic balloon pump was
removed without incident and he had no specific cardiopulmonary
complications. His only issue at discharge was urinary retention.
He failed several voiding trials. Urology Service had consulted and
felt this was likely secondary to benign prostatic hypertrophy.
DISPOSITION: He was discharged home with an indwelling Foley
catheter with follow-up arranged at CHH Urology.
MEDICATIONS: His discharge medications include aspirin 1 a day ,
iron , Colace , Mevacor 20mg every day and Tylenol #3 as needed He will
follow-up with his Cardiologist , urology service and with cardiac
surgery.
Dictated By: MOSHE J. SHUGRUE , M.D. HV78
Attending: DESIRAE R. MARCOTT , M.D. NM7 AV931/1170
Batch: 9267 Index No. D9IIBT325W D: 2/13/94
T: 2/13/94
Document id: 5
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
888816163 | PUO | 23256318 | | 2723475 | 9/25/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Unsigned | DIS | Admission Date: 1/8/2006 Report Status: Unsigned
Discharge Date: 7/16/2006
ATTENDING: KERTESZ , ALETA M.D.
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Mr. Lemick is a 64-year-old gentleman with a previous history of
myocardial infarction x4 who presented to the Emergency
Department on 3/10/06 with shortness of breath and dyspnea on
exertion over the previous two months. The patient has known
coronary artery disease and has undergone multiple PTCAs and
balloon angioplasties in the past of his posterior descending branch
of his right coronary artery in 1996 , and stenting of his
posterior descending coronary artery in 2004 , also stenting of
his distal right coronary artery in 2005. While in the emergency
department , the patient had an episode of substernal chest
pressure radiating to his left jaw and left upper extremity. He
received sublingual nitroglycerin and morphine with relief. EKG
at that time revealed a right bundle-branch block with T-wave
inversions in the leads V2 , V3 , and slightly T-wave elevation in
leads II , III and aVF. On 1/5/06 , he underwent cardiac
catheterization , which revealed the following , posterior
descending coronary artery with an ostial 80% stenosis , right
coronary artery with a distal 60% stenosis , left circumflex
coronary artery with the proximal 60% stenosis , left anterior
descending coronary artery with an ostial 50% stenosis. Right
dominant circulation and right coronary artery had extensive
stenting with 50-60% focal areas of restenosis. Distal right
coronary artery stent before bifurcation has 80% stenosis.
Echocardiogram revealed an ejection fraction of 50% aortic
stenosis with a mean gradient of 41 mmHg and peak gradient of 60
mmHg , calculated valve area is 1 cm2 , mild aortic insufficiency ,
moderate mitral insufficiency , moderate tricuspid insufficiency ,
and mild pulmonic insufficiency. Carotid ultrasound revealed
right internal carotid artery with a 1-25% stenosis , left
internal carotid artery with a 1-25% stenosis. Pulmonary
function tests revealed FVC of 3.11 , 53% , and an FEV1 of 1.66 ,
35% predicted. Chest CT also performed on 5/29/06 revealed
cardiomegaly , massive calcifications involving the aortic valve
and coronary arteries , pleural thickening bilaterally , nodular
density measuring 7 mm in the lateral basal segment of the left
lung most likely represents round atelectasis or focal pleural
thickening , however , subpleural nodule cannot be excluded ,
recommending a repeat chest CT in six months after discharge , and
small ascites punctate calcifications in the pancreas.
PAST MEDICAL AND PAST SURGICAL HISTORY:
Significant for myocardial infarction , class II angina with
slight limitation of ordinary activity , class III heart failure
with marked limitation of physical activity , status post a PTCA
atherectomy and stent placement , hypertension ,
non-insulin-dependent diabetes mellitus , dyslipidemia , gout ,
anemia , positive PPD , status post inhaled treatment , herniated disk ,
history bladder cancer , status post chemotherapy treatment ,
polysubstance abuse including ethanol and tobacco , narcotics , and
intravenous drug abuse. He is also status post a left thoracotomy for
pleural effusion 30 years ago , a hemorrhoidectomy , and bilateral
hand surgeries for contractures.
ALLERGIES:
The patient has no known drug allergies.
MEDICATIONS AT TIME OF ADMISSION:
Atenolol 50 mg once a day , lisinopril 20 mg once a day ,
isosorbide 30 mg daily , aspirin 325 mg daily , Plavix 75 mg daily ,
Lasix 40 mg daily , atorvastatin 80 mg daily , gemfibrozil 600 mg
twice a day , metformin 1 g twice a day , glimepiride 2 mg daily , oxycodone
10 mg every 6 hours as needed for pain , and Nexium 20 mg daily.
PHYSICAL EXAMINATION:
Cardiac exam: Regular rate and rhythm , with a grade 2/6 systolic
ejection murmur at the right upper sternal border. Peripheral
vascular , 2+ pulses bilaterally in the carotid and radial pulses ,
1+ bilaterally in the femoral and dorsalis pedis pulses , and
nonpalpable bilaterally in the posterior tibialis pulses.
Respiratory: Breath sounds clear bilaterally. Extremities:
Mild varicosities. There is 1+ pedal edema in bilateral lower
extremities , otherwise , noncontributory.
ADMISSION LABORATORY VALUES:
Sodium 138 , potassium 3.8 , chloride 97 , CO2 32 , BUN 26 ,
creatinine 1.1 , glucose 66 , and magnesium 2. BNP is 2349. WBC
6.45 , hematocrit 31.6 , hemoglobin 9.9 , and platelets 192 , 000.
physical therapy/INR of 1.3 , PTT of 33.2.
HOSPITAL COURSE:
Mr. Lemick was brought to the operating room on 8/13/06 where
he underwent an elective aortic valve replacement with a 25 mm
Carpentier-Edwards magna valve and a coronary artery bypass graft
x2 with left internal mammary artery to left anterior descending
coronary artery , saphenous vein graft to the posterior descending
coronary artery. Total bypass time was 164 minutes. Total
crossclamp time was 127 minutes. Intraoperatively , the patient
was found to have a calcified trileaflet valve functionally was a
bicuspid due to effusion between the left and right cusp ,
moderate adhesions in the left pleural space , requiring
adhesiolysis to harvest the mammary artery. Transesophageal
echocardiogram post-repair revealed normal function of the aortic
prosthetic valve and mild mitral regurgitation , with intermittent
heart block following bypass predominantly with A pacing. The
patient did well intraoperatively , came off bypass without
incident , was brought to the Intensive Care Unit in normal sinus
rhythm and in stable condition. Please refer to dictation
number 6316454 for the immediate postoperative course. The
patient was transferred to the Step-Down Unit on 7/26/06 . The
patient's mental status waxed and waned with confusion , initially
was with sitters in the Step-Down Unit , and also was in a
rate-controlled atrial fibrillation , with a good blood pressure ,
and tolerated increasing beta-blocker. The patient's mental
status improved , did well off sitters , and continue with
rate-controlled atrial fibrillation. Mr. Lemick was placed on
Coumadin for his atrial fibrillation. Neurologically , he
remained intact , and was placed on levofloxacin and vancomycin
for H. flu and Staph pneumonia , which are both sensitive to
Bactrim , and started on a 5-day course of Bactrim twice a day.
He was cleared for discharge to home on postoperative day #9.
DISCHARGE LABORATORY VALUES:
Sodium 137 , potassium 4.3 , chloride 99 , CO2 28 , BUN 18 ,
creatinine 0.9 , glucose 95 , and magnesium 1.7. WBC 12.07 ,
hematocrit 27.9 , hemoglobin 8.6 , and platelets 396 , 000. physical therapy of
19.3 , physical therapy/INR of 1.6.
DISCHARGE MEDICATIONS:
Captopril 12.5 mg three times a day , Colace 100 mg three times a day while taking
oxycodone , Prozac 40 mg daily , folate 1 mg daily , Lasix 40 mg
daily , Lopressor 25 mg four times a day , Niferex 150 mg twice a day , oxycodone
10 mg every 6 hours as needed pain , multivitamin with minerals one tab
daily , thiamine hydrochloride 100 mg daily , potassium chloride
slow release 10 mEq daily with his Lasix , Bactrim double strength
one tab every 12 hours for five days , Plavix 75 mg daily , Lipitor 80 mg
daily , and Coumadin , the patient received 6 mg of Coumadin this
evening for his atrial fibrillation. He will be followed by
Pagham University Of Anticoagulation Service at
132-202-5576.
FOLLOW UP:
Mr. Lemick will follow up with Dr. Aleta Kertesz in six weeks , his
cardiologist , Dr. Rodger Teems in one week in the Cardiology
Clinic Niy Lastan Stonevir Medical Center . He will also have a
follow-up chest CT to follow up on the 7 mm subpleural nodular
density in the left lung base in approximately six months that
will be set up by his primary care physician and cardiologist.
DISPOSITION:
He is discharged to home in stable condition with visiting nurse.
eScription document: 9-6284140 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: KERTESZ , ALETA
Dictation ID 9473886
D: 1/2/06
T: 3/26/06
Document id: 6
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718175239 | PUO | 85554562 | | 3074401 | 11/4/2005 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 5/7/2005 Report Status: Signed
Discharge Date: 10/8/2005
ATTENDING: HAUB , PERRY M.D.
CHIEF COMPLAINT:
This is a 64-year-old woman with a history of nonischemic
cardiomyopathy who was admitted with increasing volume overload.
HISTORY OF PRESENT ILLNESS:
Ms. Englebert was doing well until approximately two weeks prior to
admission when in the setting of dietary indiscretion she noticed
some shortness of breath and weight gain. She states that she
started to increase her Demadex from 200 mg in the morning and
150 mg in the afternoon to 200 mg twice a day without significant
diuresis. She has continued to participate in cardiac rehab
without significant difficulty. Her weight was stable at 174.
She did , however , noticed worsening of intermittent dyspnea on
exertion and orthopnea , although she denied PND or pedal edema.
She denied abdominal symptoms of bloating , no satiety , nausea or
vomiting. She denied chest pain , discomfort , palpitations ,
lightheadedness or syncope. She does have occasional chest
burning. She also noted burning in her feet bilaterally which
has previously been attributed to neuropathy. On the day of
admission , she presented to the Outpatient Clinic to have an
echocardiogram and repeat exercise stress test with oxygen
uptake. She exercised for 4 minutes and 32 seconds achieving a
peak heart of 90 beats per minute with a blood pressure of 100/64
and stopping secondary to fatigue. Her peak oxygen uptake was
only 9 mL per minute despite on RER of 1.09. This is essentially
unchanged from a prior exercise stress test one year ago.
PAST MEDICAL HISTORY:
Includes nonischemic cardiomyopathy diagnosed in 1996 , with clean
coronary catheterization at that point. She has history of
hypertension , hypertriglyceridemia , and left bundle-branch block
status post ICD and pacemaker placement. Her pacer is
biventricular. She also has a history of urine bleeding. She
had a recent hysteroscopy and laparoscopy which were
unremarkable.
MEDICATIONS ON ADMISSION:
Included lisinopril 10 mg orally daily , Toprol 75 mg orally daily ,
Demadex 200 mg orally twice a day , Aldactone 25 mg daily , KCl 10 mEq
daily , allopurinol 100 mg daily , colchicine 0.6 mg daily and
Evista 60 mg daily.
ALLERGIES:
Penicillin.
PHYSICAL EXAMINATION:
She was afebrile with heart rate of 72 , blood pressure of 104/66.
Her weight was 174. Her JVP was at approximately 16 cm of water
with hepatojugular reflux to the angle of the jaw. Her carotid
upstrokes were brisk without bruits. Her lungs were clear to
auscultation bilaterally. Her cardiac exam was regular in rate
and rhythm with normal S1 and S2 and audible S3. She has 2/6
systolic murmur consistent with mitral regurgitation. Her
abdominal exam was benign except for liver edge that is palpable
approximately two fingerbreadths below the costal margin. Her
extremities were noncyanotic with no clubbing or edema. They
were lukewarm.
SOCIAL HISTORY:
Unremarkable.
FAMILY HISTORY:
Noncontributory.
LABORATORY DATA:
Her most recent labs had showed a sodium of 138 , a potassium 3.9 ,
a BUN of 67 , a creatinine of 1.9 and glucose of 123. Her LFTs
were all normal except for mildly elevated bilirubin of 1.3. Her
last lipids showed a total cholesterol of 128 with 191
triglycerides and HDL of 31 and an LDL of 59. Her last CBC was
unremarkable. Her EKG shows an a-sensed V-paced rhythm at the
rate of 72 beats per minute.
HOSPITAL COURSE BY SYSTEMS:
Cardiovascular: Ms. Englebert is a 64-year-old female with
nonischemic cardiomyopathy and class II-III symptoms who
presented with worsening volume overload in the setting of
dietary indiscretion. Given that she is already maximized on her
outpatient diuretic dose and somewhat worsening of her renal
function , she was admitted for further diuresis with intravenous
torsemide. She was also admitted for the beginning of her
transplant evaluation for potential cardiac transplant. She was
initially started on intravenous torsemide 200 mg twice a day with a goal of 1
to 2 liters of diuresis per day. She was continued on digoxin
and switched over from lisinopril and captopril. Her medications
were adjusted to optimize her diuresis and avoid hypotensive
episodes. She did go for a right heart cath on this
hospitalization that showed increased RA pressure of 14 and a
wedge pressure of 35-44 with V wave. Her cardiac index was
calculated at 1.38. Her SVR was calculated at 1600. Her mixed
venous O2 sat was between 52% and 60% when the readings were
repeated. Given that she appeared quite well and Lasix drip was
started to accelerate her diuresis. She was maintained on
tailored therapy including nitrates for afterload reduction and
the up titration of her captopril. She did have impressive
diuresis on Lasix drip. Her transplant workup at this time
included PFTs that showed an FVC of 2.64 , which his 86% predicted
an FEV1 of 1.82 , which is 75% predicted and FEV1 to FVC ratio of
69%. Her corrected DLCO was 14.6 , which was 56% of predicted.
She did have as well a carotid duplex ultrasound showing no
significant stenosis in either carotid artery. Her ankle
brachial indices were greater than 1 in both lower extremities
and her leg pulse volume recording was all entirely normal. Her
24-hour urine collection showed a value of 920 mg over the total
volume which was in the normal range. She did continued to
respond reasonable well to the diuresis with the exception of a
few episodes of asymptomatic hypotension. Her creatinine did
begin to bump marginally indicating that she had likely been
slightly over diuresed. She subsequently stabilized and was
discharged on a stable dose of diuretics including torsemide 100
mg orally twice a day
Her other discharge medications include captopril 25 mg three times a day ,
Isordil 20 mg three times a day , Claritin , Coumadin 5 mg daily , thiamine and
multivitamin , colchicine , magnesium , Evista , Aldactone 25 mg
daily , digoxin 0.125 mg daily and allopurinol 100 mg daily ,
Toprol-XL 25 mg daily.
She was discharged with plan for regular follow up with her
outpatient cardiologist.
eScription document: 5-4062108 EMSSten Tel
Dictated By: IVASKA , MELDA
Attending: HAUB , PERRY
Dictation ID 9185928
D: 7/7/05
T: 7/7/05
Document id: 7
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
Y |
Y |
Y |
N |
N |
Y |
N |
N |
N |
789882744 | PUO | 49201190 | | 8401704 | 8/29/2005 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/23/2005 Report Status: Unsigned
Discharge Date:
ATTENDING: COLASAMTE , ISABELLE EVON MD
SERVICE:
The patient has been treated on Cardiac Surgery Service.
CHIEF COMPLAINT:
Heart failure.
HISTORY OF PRESENT ILLNESS:
Ms. Rosenblum is a 56-year-old female with past medical history
significant for obesity and idiopathic cardiomyopathy diagnosed
in 1990 with an EF of 15% who was admitted on 7/20/05 for
one-week history of lower extremity edema and worsening heart
failure. She was treated initially on the Medicine Service where
she was aggressively diuresed but was requiring increasing
pressors and progressing in her CHF despite transfer to the CCU
and appropriate management by the medical team. On 1/10/05 , a
transplant heart became available , and she proceeded to undergo a
heart transplant.
PAST MEDICAL HISTORY:
Diabetes , renal failure , gout and obesity.
PAST SURGICAL HISTORY:
Tubal ligation , gastric stapling for obesity , and a Hickman
placement.
MEDICATIONS AT HOME:
Lovenox 40 mg every daily , Lasix 30 intravenous continuously , dobutamine 5 intravenous
cutaneously , milrinone 0.3 mcg/kg/ minute , Colace 100 mg orally
twice a day , sliding scale insulin , metolazone 5 mg orally twice a day ,
probenecid 500 mg orally daily , thiamine 50 mg orally daily ,
vancomycin 1 gram intravenous twice a day MVI therapeutic one tab orally daily ,
carnitine 0.5 grams orally three times a day , and Celexa 30 mg orally daily.
HOSPITAL COURSE:
The patient was initially treated on the Medicine Service but on
1/10/05 was taken to the operating room by the Cardiac Surgery
Service for a heart transplant. For detailed description of the
operative procedure , please see the dictated OP note. The
patient tolerated the procedure and was transferred to the Fre ICU
in a critical condition.
ICU COURSE BY SYSTEMS:
Neurological: Initially , the patient was kept sedated on
propofol as well as intermittent fentanyl and Versed. As she was
weaned towards extubation , her sedating medications were weaned
and she was extubated while on Precedex due to her history of
anxiety. Her Precedex was eventually weaned off and she was
neurologically intact but frequently confused and often
disoriented. Over the next several days , has continued to wean
and she was restarted on her Celexa as well as Ativan for
agitation and anxiety. At the time of transfer , she is
neurologically intact with no focal neurological deficits and she
is no longer confused. She is awake , alert and oriented to
person , place and time and completely appropriate in her speech.
Cardiovascular: Shortly after her operation , she was felt to be
in profound right heart failure. She was started on milrinone
with successive treatment of her right heart failure. Over the
next several days , she was weaned off slowly her pressors and
underwent an echocardiogram which showed moderate-to-severe TR
and a large pericardial effusion with some indentation of the
right atrium with respiration. However , no pericardiocentesis
was performed as the patient was not clinically in tamponade.
She underwent a cardiac catheterization for right heart biopsy ,
the results of which are still pending. At the present time , she
is on diltiazem 15 mg orally every 8 hours for hypertension as well as
milrinone 0.2. Cardiology is following and plans to keep the
milrinone going for the time being.
Pulmonary. The patient was kept intubated for the first several
days while she was unstable and on pressors. However , as she
began to improve , we weaned towards extubation , and she was
successfully extubated. At the current time , she is able to
ambulate on room air and has no pulmonary issues.
GI: The patient was kept npo for the first seven days after
her operation. After her extubation , a Dobbhoff feeding tube was
inserted and she was started on tube feeds until she was able to
clear her speech and swallow. Upon clearing her speech and
swallow evaluation , she was started on minced food with thickened
liquids , which she tolerated with minimal signs or symptoms of
aspiration. She was advanced to a house diet with thickened
liquids and is now taking that well and having normal bowel
movements. She is on Nexium for GI prophylaxis.
GU: Initially , she was given a lot of fluid in order to wean her
pressors; however , she was diuresed aggressively after the first
two postoperative days for currently being on a Lasix drip or
receiving large bolus doses of Lasix. Her creatinine has trended
up minorly postoperatively to a current level of 1.8. She is no
longer receiving any diuretics and is just being managed by
keeping her I's and O's even. She is on no nephrotoxic
medications.
Heme: She is frequently anemic with her hematocrit often
trending downwards to levels as low as 20 or 21. She has been
transfused with multiple units of blood products and will be
transfused today one unit of packed red cells for a hematocrit of
21. She has been started on Niferex for iron therapy , and we are
considering the addition of erythropoietin. Otherwise , she is
stable and has no heme issues.
ID and Immunosuppression:
She has been immunosuppressed on various different medications.
Her current regimen is Cellcept 1500 mg orally twice a day , Neoral 125
mg orally twice a day , prednisone 25 mg orally twice a day For prophylaxis ,
she is also on Valcyte 450 mg orally daily , and Bactrim one double
strength tab every other day as well as nystatin swish and swallow and
powders for her axilla and groin. She has not spiked any temps
and none of her cultures have been positive except for one
urinary culture positive for Gram-negative rods for which she is
on levofloxacin 250 daily for seven days.
Endocrine: Her sugars have been very difficult control. She was
initially on the Portland protocol for several days
postoperatively and on an insulin drip according to her sugar
levels. Diabetes Management Service was consulted and has been
assessing her daily for her insulin needs. She is currently on a
regimen that consist of 30 mg of Lantus every evening as well as
8 units of Novolog with every meal and sliding scale coverage
with Novolog for meals as well. Her sugars are mildly well
controlled but could use tighter glycemic control.
Tubes , Lines , and Drains:
Her wires and chest tubes have been removed. She has no central
access. She just has peripherals.
MEDICATIONS AT THE TIME OF TRANSFER:
Diltiazem 15 mg orally every 8 hours , folic acid 1 mg orally daily , Ativan 1
mg orally every 8 hours and 1 mg orally every 6 hours as needed agitation , magnesium
sliding scale orally twice a day , magnesium sulfate sliding scale intravenous
daily , Niferex 150 mg orally every 12 hours , nystatin 5 ml orally four times a day ,
prednisone 25 mg orally twice a day , MVI therapeutic with minerals ,
thiamine hydrochloride 100 mg orally daily , prednisone 25 mg orally
twice a day , thiamine 100 mg orally daily , milrinone intravenous 0.2
mcg/kg/minute , Neoral 125 mg orally twice a day , Bactrim DS one tablet
orally daily , Cellcept 1500 mg orally twice a day , levoflox 250 mg orally
daily x7 doses , miconazole 2% powder TP every 8 hours , and Celexa 20 mg
orally daily , Nexium 40 mg orally daily , Valcyte 450 mg orally daily ,
Lantus 30 units subcutaneous every bedtime , DuoNeb every 6 hours , Novolog 4
units subcutaneous before every meal , Novolog sliding scale subcutaneous
before every meal , Novolog sliding scale subcutaneously every bedtime , Novolog 8 units
subcutaneous before every meal
DISPOSITION:
She is being transferred to the step-down unit in stable
condition.
eScription document: 8-6359606 EMS
Dictated By: REPLENSKI , DEBERA ZADA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 6445393
D: 3/18/05
T: 3/18/05
Document id: 8
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
Y |
U |
U |
Y |
U |
N |
U |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
Y |
Y |
N |
N |
Y |
N |
N |
- |
N |
Y |
- |
Y |
N |
N |
098812026 | PUO | 57870793 | | 8056405 | 10/6/2003 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 7/14/2003 Report Status:
Discharge Date: 5/6/2003
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Walk
Service: MED
DISCHARGE PATIENT ON: 5/17/03 AT 09:00 a.m.
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DANIEL , CORAZON MERTIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed sob
OSCAL ( CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) )
500 MG orally three times a day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
as needed sob
LISINOPRIL 60 MG orally every day HOLD IF: SBP<100
Alert overridden: Override added on 6/10/03 by
DIMITROV , YOLONDA ZULA , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally three times a day
HOLD IF: sbp<100 , heart rate<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
AMLODIPINE 10 MG orally every day HOLD IF: SBP<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 10
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Meghann Christenson May scheduled ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) restrictive lung disease ( restrictive pulmonary
disease ) chf ( congestive heart failure ) fibromyalgia
( fibromyalgia ) von willebrand's ( hemophilia ) sleep apnea ( sleep
apnea ) iron deficiency anemia ( iron deficiency anemia ) hypoxia
( hypoxia ) GERD , history of TAH/BSO , PICA. ? central hypoventilation syndrome.
OA.
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
45 year-old female with multiple medical problems including pulmonary
hypertension , obstructive sleep apnea , diastolic CHF ( EF 60% ) admitted
initially for elective hemmorhoidectomy but flunked pre-op cardiology
eval and was transfered to medicine in decompensated CHF for diureses.
patient recently hospitalized 7/19/06 for chf exacerbation ( diastolic
dysfunction ) 2nd to dietary and medicine noncompliance ( salty foods ,
stopped her HCTZ ) and continued to smoke. patient diuresed and sent home
on new lasix 60qam 40qpm regimen. patient noticed steady decline in
functional status during the last 3 weeks because of SOB. at baseline
should sat 85% on ra , 95% on 6L02NC at rest and ambulation. ( on home
o2 ) but now , can't ambulate , sating 83-89% on 6l at rest. patient confessed
to not adhering to lasix regimen , still eating pizza and salty foods.
also notes pnd , orthopnea. patient notes intermittent chest pain on and off
lasting 5 minutes not associated with exertion or any other cardiac
sx. 8/15 dobuta mibi-> ischemia in d1 territory. 11/19 :echo->ef 60% ,
Pa pressure 48 + RA. no valve dz. rv enlarged and hypokinetic. A/P:
pump: decompesated CHF ( diastolic dysfxn , ? cor pulmonale component )
2nd to diet/med non-compliance. uptitrate captopril , continue intravenous lasix
60 every day with goal net neg 2 liters , daily weights , strict Iand O. check
cxray. Switched to orally lasix 10/06 , back to lisinopril for d/c Fri.
ischemia: has + mibi in past , but no further workup to d1 lesion. can't
get ecasa 2nd to vWD. continue BB , will hold off on statin since not
hyperlipidemic. rate:tele. rheum:fibromyalgia ( in arms and should )
urology:detrol for urinary incont. psych: depression/?personality
disorder. obgyn: will hold off on premarin given cardiac status.
surgery:post pone hemmerhoidectomy , not needed with stable crit. fen:
twice a day lytes 2gm Na 2000cc water restriction code status full , until can
speak with fiancee. pulm: BIPAP at night. heme: has vonwillebrands
disease and ecasa is a contraindication. if patient needs to go to surgery
will need pre-op and post-op humate-P ( per dr. harajly
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA instructions:
1 ) Please measure patient's weight daly if scale available , can doctor if
her weight goes up by >4 lbs in 48hrs.
2 ) Please assess patient's ability to tolerate BIPAP.
3 ) Home safety evaluation , patient's ability to peform ALDs.
4 ) Please assess med compliance , compliance with no added salt/2L fluid
restriction.
No dictated summary
ENTERED BY: DIMITROV , YOLONDA ZULA , M.D. , PH.D. ( VO0 ) 5/17/03 @ 07:08 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 9
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
- |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
- |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
- |
- |
- |
N |
N |
279704264 | PUO | 05648655 | | 3536057 | 12/10/2005 12:00:00 a.m. | history of ICD placement | | DIS | Admission Date: 12/10/2005 Report Status:
Discharge Date: 11/5/2005
****** FINAL DISCHARGE ORDERS ******
PERKO , TRUMAN 294-06-75-6
Bentry Boulevard , Nida
Service: CAR
DISCHARGE PATIENT ON: 6/20/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRINSTEAD , JACKLYN A. , M.D. , M.S.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
LASIX ( FUROSEMIDE ) 20 MG orally every day Starting Today ( 5/29 )
Instructions: please titrate your dose 20mg/40mg/60mg as
you normally do depending on your degree of swelling
MOTRIN ( IBUPROFEN ) 600 MG orally every 6 hours as needed Pain , Headache
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 6/12/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
on order for MOTRIN orally ( ref # 976338446 )
patient has a POSSIBLE allergy to Aspirin; reaction is Unknown.
Reason for override: patient tolerates motrin
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
2 PUFF inhaled four times a day
MAGNESIUM OXIDE 560 MG orally every day
VERAPAMIL SUSTAINED RELEASE 120 MG orally every day
Starting Today ( 5/29 )
Instructions: please confirm home dose and resume home dose
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
KEFLEX ( CEPHALEXIN ) 250 MG orally four times a day X 10 doses
Instructions: started on 5/29 , continue through 5/3 for
12 total doses Number of Doses Required ( approximate ): 20
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LORATADINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally every day As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
METFORMIN 1 , 250 MG orally twice a day Starting IN a.m. ( 5/29 )
RHINOCORT AQUA ( BUDESONIDE NASAL INHALER )
2 SPRAY inhaled twice a day
SINGULAIR ( MONTELUKAST ) 10 MG orally every day
EFFEXOR XR ( VENLAFAXINE EXTENDED RELEASE ) 75 MG orally every day
Number of Doses Required ( approximate ): 5
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
OXYCODONE 10 MG orally every 4 hours as needed Pain
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Jacklyn Grinstead 10/20/06 1:30pm scheduled ,
Dr. Sachiko Borriello 1/11/06 2:45pm scheduled ,
ALLERGY: broccoli , Aspirin
ADMIT DIAGNOSIS:
ICD placement for HCM
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of ICD placement
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
see below
OPERATIONS AND PROCEDURES:
10/14/05: Metronic dual chamber DDI/ICD paced under general anesthesia
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
REASON FOR ADMIT: ICD placement
HPI: 53yoF with HCM history of medtronic dual chamber DDI/ICD placement under
general anesthesia ( 2/2 obesity ) admitted for ovenight observation. ICD
placed for primary prevention. Had ECHO 6/29 showed septal thickness
16mm , posterior wall thickness 19mm with preserved EF 65%m LV outflow tract
peak gradient 125mmHg. Holter monitoring 11/21 without any arrythmias
but since 8 of July has had increasing difficulties with ambulatio n2/2
palpations up to 20 minutes at a time. One severe presyncopal episode in
August of 2004. Also HF symptoms controlled on lasix , at baseline can work
6 blocks and up one flight of stairs.
*****************
PMH: HCM , htn , hyperchol , asthma , PCOD with infertility , diabetes ,
obesity ( 310 lbs ) , loer back pain , migraines , history of knee replacement ,
tosillectomy , sinus surgery
******************
Admission Meds: albuterol , advair 250/50 twice a day , rhinocort 2 sprays twice a day ,
atrovent 2 puff four times a day , singulair 10mg every bedtime , nexium 40mg daily , lasix
20mg daily ( inc to 40 or 60 during period ) , kcl 20meq
daily , verapamil 120mg daily , patanol 1-2 each eye twice a day as needed , loratidine 10mg
daily , zocor 20mg every bedtime , effexor 75mg daily , metformin 1250mg twice a day ,
mgoxide 500mg daily , ambien as needed , amox prior to procedures
******************
all: aspirin , broccoli , tape
******************
FH: no history of HOCM. no history of sudden cardiac death. mother/grandmother with
diabetes
SH: technical writer lives in Aford Terbberkeprai Bo single parent of twins. no
tob/social etoh/ivdu.
******************
ADMISSION PE: VS 96.4 74 140/90 20 93% RA
GEN: NAD HEENT: anicteric , eomi , perrl , mmm , op clear NECK: carotid 2+
without bruits , no lan , jvp difficult to appreciate 2/2 thick neck LUNGS:
ctab , no c/with r CV: rr , nl s1 s2 , 3/6 SM at RUSB but heard throughout
precordium , inc with valsalva ABD: obese , nl bs , soft , nt/nd , hard to
palpate for masses and hsm EXT: trace edema , warm , dp/patient 2+ b/l. left
radial pulse 2+ SKIN: no rashes NEURO: a&ox3 cn 2-12 intact , moves all
extremities
*************************
LABS/STUDIES
--labs: cbc , bmp , coags wnl
--EKG NSR. TW flat V5/V6 ( old )
--CXR ( portable ): cardiomegaly , no e/o ptx. PA/lat CXR a.m. after no ptx ,
leads in place , no overt failure.
*************************
PROCEDURES:
6/14 history of Medtronic ICD/DDI PPM placement , cannulated via left cephalic
( one axillary attempt )
*************************
A/P
CV:
--pump: HOCM. Euvolemic initially on exam. O/n patient developed increased
swelling of her hands and legs b/l , and also with slightly more SOB and O2
requirement. Unclear whether O2 requirement was 2/2 fluid or 2/2 OSA , a.m.
CXR clear with out e/o overload. patient diuresed with lasix 40mg on day of d/c
about net -500cc. Still with some swelling on d/c but patient reported that her
breathing/activity level was at baseline and she felt comfortable going
home and adjusting her lasix dose as she normally does based on her
swelling. Continued on home cardiac regimen verapamil and zocor.
--rhythm: history of Medtronic dual chamber DDI/ICD placement for primary
prevention for HOCM. Post procedure CXR with out ptx , leads in place. patient will
f/u with Dr. Grinstead . On monitor patient sinus with out events. Routine
peri-procedure antibiotics.
PULM: asthma , cont home regimen. had slight desat o/n requiring 2L O2
which could be 2/2 overload ( see above ) , but also could be 2/2 obstructive
sleep apnea , consider outpt eval for this.
GI: cont ppi
ENDO: ISS. restarted metformin on morning of d/c.
NEURO: cont effexor
FEN: cardiac diet
PPx: teds
CODE: has icd now. full
ADDITIONAL COMMENTS: *Please monitor your weight and swelling and adjust Lasix dose as your
normally do. Please call Dr. Borriello if your swelling does not improve
or you become short of breath or your weight increases >3pounds.
*Take Keflex for 3 day total course. All other medications are the same.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*fluid management
*consider outpt eval for possible obstructive sleep apnea
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE KATE , M.D. ( ZE37 ) 6/20/05 @ 02:11 PM
****** END OF DISCHARGE ORDERS ******
Document id: 10
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
- |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
N |
N |
- |
N |
Y |
Y |
N |
N |
- |
N |
N |
N |
172100234 | PUO | 34013384 | | 881982 | 7/16/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/3/1993 Report Status: Signed
Discharge Date: 3/4/1993
DISCHARGE DIAGNOSIS: ATYPICAL CHEST PAIN.
ASSOCIATED DIAGNOSES: 1. HYPERTENSION.
2. HISTORY OF CORONARY ARTERY DISEASE.
3. SCIATICA.
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old woman
with a history of coronary artery
disease , hypertension and chronic pain , admitted with chest pain.
Her cardiac risk factors are hypertension , increased cholesterol ,
positive family history and history of coronary artery disease. She
has a history of Q wave myocardial infarction with right
ventricular infarct in October 1992. Peak CK's were 2300.
Catheterization showed 100% RCA lesion which was treated with
angioplasty reduced to 20-30% stenosis. The patient had chest pain
the succeeding months and had two catheterizations showing no
change in her coronary arteries. Echocardiogram showed an LVEF of
50%. Subsequent catheterization October 92 , July 92 and September 92
for atypical chest pain , showed clean coronaries. Exercise tread
mill test in September 92 , the patient went three minutes and 31 seconds
with standard Bruce protocol and stopped secondary to atypical
chest pain. Maximum heart rate 162 , blood pressure 176/90 , no ST
or T wave changes. In April 92 she ruled out for myocardial
infarction by enzymes and EKG , after presenting with prolonged
chest pain. VQ scan was low probability. Chest CT ruled out aortic
dissection. The patient was referred to the Pain Service. In
February 1993 the patient had additional sharp chest pain , again
ruled out for myocardial infarction , was seen by the Pain Services
and discharged on trazodone and Relafen plus cardiac medicines.
The patient now presents to the hospital with 24 hours of right
sided chest pain , stating that it was squeezing in her right
breast , felt to be between the shoulder blades. She took two
sublingual Nitroglycerin the day before admission and three on the
morning of admission without relief. She complained of shortness of
breath , dizziness , weakness and nausea , no palpitations were noted.
The pain was not worse with positional changes. The patient is seen
in the Stusri Medical Center emergency room where she received
two sublingual Nitroglycerins which reduced her pain from 7/10 to
1/10 level. She also received 10 mg intravenous Morphine , 725 mg intravenous
Lopressor , two inches Nitro Paste and two liters of oxygen. The
pain was intermittent through the rest of the day. She had no
fever , chills , cough , she did complain of urinary frequency ,
chronic left back pain and right lower extremity pain. ALLERGIES:
Penicillin , erythromycin and tetracycline which causes hives.
PHYSICAL EXAMINATION: Pulse 92 , blood pressure 148/100 ,
temperature 98.1 , she is an obese female in
no acute distress. Cardiac , regular rate and rhythm , SI , SII , no
murmurs , rubs or gallops. The pain is not reproducible by
palpation. Extremities , 1+ edema of the lower extremities with
preserved peripheral pulses.
LABORATORY DATA: Cholesterol 226. EKG showed normal sinus rhythm
of 90 beats per minute , normal intervals , left
ventricular hypertrophy. There were T wave inversions in Leads I ,
V2 , V6 , bisphasic T waves V5 , flat waves V3 , V4 , left atrial
enlargement. Compared with the examination of 2/7/93 T wave
inversions were less deep in V3 through V5.
HOSPITAL COURSE: The patient ruled out for myocardial infarction by
serial EKG and enzymes. Her blood pressure was
initially poorly controlled and she was placed on a regimen of
Aldomet 750 mg orally twice a day; Lopressor 150 mg orally three times a day;
Nifedipine XL 120 mg orally twice a day On 11/28/93 the patient underwent
cardiac catheterization which showed normal coronary arteries ,
mildly elevated pulmonary pressure of 40/24 and mean of 30 ,
capillary wedge pressure of 14 mm mercury. On the afternoon of
5/10 the patient had 600 mg of Levatol and two hours later
complained of light-headedness with a systolic blood pressure in
the 80's. This gradually increased to greater than 110 systolic so
the patient was placed in Trendelenburg position and received 400
cc's of intravenous fluids. She was also noted to have the onset of
wheezing. 02 sat was 95% on five liters of oxygen , chest x-ray
showed cardiac enlargement with regeneration of the pulmonary flow
suggestive of mild congestive heart failure. The patient received
albuterol nebs every 15 minutes x 4 with good response and was felt to
have had a bronchospastic reaction to beta blockers. She did well
for the rest of her hospitalization , had no further chest pain.
DISPOSITION: She was discharged in good condition to home with
instructions to followup with Dr. Weight on Tuesday
May . MEDICATIONS: Enteric coated aspirin 1 orally every day;
Pepcid 20 mg orally twice a day; trazodone 100 mg orally every bedtime; Elavil 25
mg orally every bedtime; Procardia XL 90 mg orally twice a day; Lopressor 100 mg
orally three times a day
Dictated By: LEOLA MUSICH , M.D. GQ35
Attending: YOSHIE S. POSPISHIL , M.D. PD97 AT320/0730
Batch: 5846 Index No. YLBBV91WBO D: 10/10/93
T: 3/10/93
Document id: 11
| Target |
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DM |
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GER |
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HC |
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OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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580084969 | PUO | 29047049 | | 1348217 | 8/20/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: Report Status: Signed
Discharge Date: 6/21/2003
Date of Discharge: 6/21/2003
ATTENDING: RUFUS CARLIE BERNAS MD
ADMITTING DIAGNOSIS: Shortness of breath.
DISCHARGE DIAGNOSES:
1. Pulmonary fibrosis.
2. Pulmonary hypertension.
3. Diverticulitis.
4. Acute renal failure.
5. Gout.
6. Hypertension.
7. High cholesterol.
8. Diabetes Mellitus.
BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
female with a past medical history of significant obesity ,
diabetes , hypertension , hypercholesterolemia , heart failure ,
pulmonary fibrosis , on home O2 who presented with shortness of
breath , and left jaw pain on 8/10/2003 . She had been in her
usual state of health until approximately 6 p.m. on the day of
admission , when at that time , she suddenly became short of
breath. She reports that she then sat down in her wheelchair and
"passed out." However , it is unclear if the patient actually
lost consciousness. The patient also developed jaw pain
radiating to her back while EMTs were present and also complained
of a tug in her chest. The pain was unrelieved by nitroglycerin ,
oxygen; it was constant in nature. At the time of her arrival in
the emergency room , the patient was hemodynamically stable with
an O2 sat of 99% on room air. She was given sublingual nitrate
with no effect. Because of her history of coronary artery
disease , she was tried on heparin and aspirin.
PAST MEDICAL HISTORY:
1. Pulmonary fibrosis , on home O2.
2. Reported history of an anterolateral MI.
3. Diabetes.
4. Hypertension.
5. High cholesterol.
MEDICATIONS: On admission , insulin 70/30 22 units every day before noon 26
units every afternoon , atenolol 25 every day , Zocor 20 every day , Zoloft 50 every day ,
Lasix 60 orally twice a day , Neurontin 100 three times a day , aspirin , and
multivitamin.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: On admission , temperature was 97 , pulse
was 54-60 , blood pressure was 100-120/50-80 , and O2 sat was 98%
to 99% on 6 liters. She was a moderately obese woman in no acute
distress. Her lung are notable for crackles at the bases. Her
cardiac exam was notable for distant heart sounds with a normal
S1 , S2. She had no pedal edema in her extremities.
LABORATORY DATA: On admission were notable for a BUN and
creatinine of 31 and 1.1. Normal LFTs The patient's hematocrit
was 38. Her D-dimer was 736.
Her EKG showed normal sinus at low voltages , poor R-wave
progression.
IMPRESSION: At the time of admission , the patient was a
62-year-old female with morbid obesity and chronic episodes of
shortness of breath , this time accompanied by jaw pain and with a
history of coronary artery disease and multiple risk factors
concerning for acute coronary syndrome. The patient was
initially treated for a possible ischemic event. Diagnosis of PE
results were considered. However , the patient was not
tachycardic. She did not have any chest pain or new O2
requirements and had had several workups for pulmonary embolism
during prior hospitalization with similar systems , so therefore ,
this was thought to be less likely.
HOSPITAL COURSE: By system:
CARDIAC. In terms of ischemia , the patient had 3 tests of
cardiac enzymes , which returned negative. She was maintained on
telemetry , and she had EKG checked , which did not reveal any
changes. This was a patient who had a dobutamine MIBI , which was
negative for any evidence of ischemic changes. During the MIBI ,
there was no evidence of ischemia and/or scar. The patient was
continued on her outpatient medications including aspirin , Zocor ,
and atenolol. However , at a later point in her hospitalization ,
she became hypotensive at which time her atenolol was temporarily
DC'd , but this was restarted prior to discharge. In terms of the
patient's cardiac function , she has a history of CHF and is on
Lasix as an outpatient. An echocardiogram was repeated during
this hospitalization , which was notable for an EF of 60% ,
trace-to-mild MR , moderate TR , and estimated pulmonary systolic
pressure at 70 mmHg. The patient was continued on outpatient
Lasix regimen until at a later point during this hospitalization ,
the patient became hypertensive with acute renal failure at which
time her Lasix was discontinued. Lasix was restarted prior to
discharge. In terms of the patient's rhythm , she had no evidence
of arrhythmias monitored throughout her hospitalization.
GI. On 10/10/2003 , the patient developed acute onset of diarrhea
and lower abdominal pain. Now , this pain was nonradiating ,
alternating sharp and dull but constant , associated with nausea
and vomiting , and frequent stools. At times , the stools were
notable for bright red blood. The patient was therefore started
on levofloxacin and Flagyl as treatment for diverticulitis versus
ischemic colitis. To further evaluate this , a CT scan of the
abdomen was done , which was notable for a thickened colon for 10
cm at the hepatic flexure. Given this information , it was the GI
consult's opinion that this is most likely consistent with
diverticulitis , and the plan was to treat it aggressively with
antibiotics , and once the symptoms resolved , recommended a
colonoscopy several weeks after discharge. The patient was
continued on levofloxacin and Flagyl , but then , several days
later , became hypotensive with systolic blood pressures in the
80s. At this time , the patient's antibiotic coverage was changed
to include Ceptaz and vancomycin , and she also received 1 dose of
gentamicin. By the time of discharge , the patient's abdominal
symptoms have completely resolved. She is no longer having any
abdominal pain , and she needs no longer having any diarrhea and
is tolerating a regular diet without any difficulties. The plan
is for her to have a followup colonoscopy as an outpatient.
PULMONARY: The patient was admitted for shortness of breath. A
differential diagnosis at that time included chronic pulmonary
embolism versus cardiac etiology versus deconditioning in the
setting of a chronic pulmonary fibrosis. To establish that the
patient did not have any PE , she had lower extremity Doppler
exams , which were negative. She also had a physical therapy protocol CT , which
was negative for any evidence of clots. Because the patient does
have cardiopulmonary hypertension , she was started on Coumadin as
prophylaxis for any thrombosis in the setting of her low flow in
her pulmonary vasculature. Throughout this hospitalization , she
was continued on her own home regimen of O2.
RENAL: The patient has baseline chronic renal insufficiency with
a baseline creatinine at 1.4 during this hospitalization at a
time that her diarrhea was very severe , and when her blood
pressures fell in the 80s , the patient developed acute renal
failure with a peak creatinine of 2.4 with decreased urine
output. The thought of the team was that this represented a
renal failure in the setting of her diarrhea , fluid losses , and
hypertension. Her pheno was consistent with this at 0.71. She
was treated with aggressive intravenous fluids. She also had a renal
ultrasound , which was normal. She did have 1 day of hematuria ,
which was thought to be due most likely to Foley trauma , which
resolved at the time of discharge.
ID: The patient's hospital course was notable for a diarrhea as
mentioned in GI. She was initially treated with levofloxacin and
Flagyl and then when she became hypertensive was then change her
Flagyl , Ceptaz , and vancomycin with 1 dose of gentamicin. Her
symptoms dramatically improved on these antibiotics on 9/18 she
was changed from intravenous antibiotics to a orally regimen of Flagyl and
levofloxacin. The plan is for her to continue a total of 14 days
of antibiotics. I anticipate the last day of antibiotic coverage
will be 2/19/2003 .
RHEUMATOLOGY: On 10/27/2003 , the patient was noted to have left
knee pain and was noted to have some focal lateral patellar
tenderness and swelling. A knee aspirate was performed and urate
crystals were identified , and the patient was diagnosed with
gout. Because of her chronic renal insufficiency and diarrhea ,
the decision was made to treat her gout flare with steroids , and
she is currently is on a steroid taper as treatment.
ENDOCRINE: The patient has a history of diabetes. She takes
70/30 insulin at home. She was initially continued on an
outpatient regimen; however , when she started to begin having
massive diarrhea , she was taken off her long-acting insulin ,
because she was not taking anything by orally At this time , she
was not tolerating a regular diet , and her insulin requirements
were increasing. It is recommended that as an outpatient , she
resumes one-half of her regular outpatient insulin dose for 1 or
2 days to ensure that her insulin requirements in her diet are
appropriate , and then , she should resume her regular insulin
dosage.
DISCHARGE MEDICATIONS: Include aspirin 325 mg orally every day ,
atenolol 25 mg orally every day , Lasix 60 mg orally twice a day , Zoloft 50 mg
orally every day , Zocor 20 mg orally every bedtime , Neurontin 300 mg orally twice a day ,
levofloxacin 500 mg orally every day , Coumadin 2.5 mg orally every day ,
prednisone taper - which involves 10 mg of prednisone on 8/14
followed by 5 mg of prednisone on 10/27 , 1/24 , and 3/1 and
then stop , Flagyl 500 mg orally three times a day , insulin 70/30 11 units
every day before noon 13 units every afternoon - once it is established that the patient
has returned to her regular diet , this dosage should be doubled
to her outpatient regular dose , and Flexeril 10 mg orally three times a day
DISPOSITION: The patient has been discharged to a rehab
facility.
FOLLOWUP: The patient is to follow up with her primary care
physician , Dr. Macisaac following discharge.
ADDITIONAL INSTRUCTIONS: Antibiotics should be continued until
2/19/2003 . The patient should have her INR checked in 3 days.
Her goal INR is 2. Once off levofloxacin , her dose of Coumadin
may need to be adjusted.
2. The patient should have an outpatient colonoscopy and treated
for a week to further assess for diverticulitis.
3. Fingerstick blood glucoses should be followed regularly as
the patient's insulin dose is titrated up to her previous
outpatient dose.
eScription document: 3-7746634 KFFocus
Dictated By: HALFACRE , SOLOMON LIESELOTTE
Attending: BERNAS , RUFUS CARLIE
Dictation ID 7393365
D: 1/1/03
T: 1/1/03
Document id: 12
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
- |
N |
Y |
N |
969667536 | PUO | 96328556 | | 1009957 | 11/10/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 11/10/2006 Report Status: Signed
Discharge Date: 2/19/2006
ATTENDING: MANKOSKI , ROSSIE MD
HISTORY OF PRESENT ILLNESS: Mr. Baldon is a 52-year-old gentleman
who was initially admitted to Osri Medical Center due to nausea ,
myalgias and weakness. The patient has a history of type I
diabetes mellitus , end-stage renal disease with
subsequent renal transplant 11 years ago donated by his sister
for which he takes cyclosporine and azathioprine. The patient
had a neuropathic left plantar ulcer seven years ago for which he
underwent transmetatarsal amputation of his left foot at Osri Medical Center .
He has had a chronic recurrent ulcer of the left foot
over the last two years or so. The patient nonetheless was
reasonably doing well and very active. He recently did a 35-mile
bike ride in about four or five days prior to admission. He
developed nausea and vomiting which lasted for one day. He then
developed weakness and hyperglycemia. He tried to increase his
insulin , but found he did not have an adequate response. The
patient became more weak and was brought to the Osri Medical Center Emergency Department where he was found to have moderate
diabetic ketoacidosis and dehydration. The patient's workup also
suggested acute myocardial infarction and was admitted to the
Coronary Care Unit. Echocardiogram was performed which revealed
an ejection fraction of 30% with dyskinesis of the inferior and
apical walls , mild mitral insufficiency , mild tricuspid
insufficiency. Transesophageal echocardiogram revealed mild left
atrial enlargement and intact interatrial septum , mild mitral
regurgitation , left atrium with history of thrombus ,
inferobasilar and inferoseptal akinesis consistent with old
inferoposterior myocardial infarction , mild tricuspid
regurgitation , trileaflet aortic valve , which is quite mobile
with no evidence for significant aortic insufficiency , normal
pulmonic valve and aortic atherosclerosis. No pericardial
effusion and no evidence of endocarditis. The patient developed
a fever the day of admission and blood cultures were drawn which
grew out Streptococcus morbillorum and Bacteroides. His foot
became clearly boggy and grossly infected with necrosis.
Within an hour of that he underwent guillotine amputation of his
left foot. His temperature normalized and his foot cultures grew
out Streptococcus mutans and E. coli as well as Bacteroides
fragilis. He received ampicillin and sulbactam for bacteremia on
11/2/06 . He underwent a coronary cardiac catheterization and
was found to have the following , left main coronary artery with
an ostial 100% stenosis. Formal report is not available at this
time. The patient was then transferred to Pagham University Of for coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for myocardial infarction ,
history of class II heart failure , hypertension , peripheral
vascular disease , diabetic vasculopathy , renal failure and
nephropathy.
PAST SURGICAL HISTORY: Significant for left transmetatarsal
amputation , recent left guillotine amputation of left foot and
renal transplant 11 years ago.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER , Lopressor 25 mg twice a day , lisinopril 40 mg
daily , aspirin 325 mg daily , cyclosporine 50 mg twice a day ,
azathioprine 125 mg daily , NPH insulin 74 units in the morning
and 72 units in the evening.
PHYSICAL EXAMINATION: A 6 feet 2 inches tall , 113.63 kilograms ,
temperature 98.6 , heart rate 79 and regular , blood pressure right
arm 130/65 , left arm 137/68 , oxygen saturation 97% on room air.
Cardiovascular , regular rate and rhythm with a 2/6 holosystolic
murmur. Peripheral vascular 2+ pulses bilaterally. Carotid ,
radial and femoral pulses , nonpalpable left dorsalis pedis and
posterior tibialis pulses and dopplerable right dorsalis pedis
and posterior tibialis pulses. Neurologic , alert and oriented
with no focal deficits.
ADMISSION LABS: Sodium 135 , potassium 3.6 , chloride of 101 , CO2
27 , BUN of 10 , creatinine 0.8 , glucose 113 , magnesium 1.9 , WBC
10.6 , hematocrit 29.9 , hemoglobin 10 , platelets of 501 , and
physical therapy-INR 1.1.
HOSPITAL COURSE: Mr. Baldon was brought to the operating room on
2/1/06 where he underwent an urgent coronary artery bypass
graft x4 with a sequential graft from the saphenous vein graft
from aorta to the ramus and then the second obtuse marginal
coronary artery and left internal mammary artery to left anterior
descending coronary artery and a saphenous vein graft to the
posterior descending coronary artery. Total bypass time was 121
minutes. Total crossclamp time was 104 minutes. The patient did
well intraoperatively , came off bypass without incident and was
brought to the Intensive Care Unit in normal sinus rhythm and in
stable condition. Postoperatively , the patient did well. He was
extubated and transferred to the Step-Down Unit on postoperative
day #1. Infectious Disease Service was called and recommended
treating the patient with levofloxacin and Flagyl for total of 14
days for his left leg BKA site. The patient's chest tubes were
removed and post-pull chest x-ray revealed no pneumothorax.
Dr. Stacie Halechko from the Vascular Surgery Service was consulted and
the patient was scheduled for revision of his left BKA on
11/9/06 . Mr. Baldon was also followed by the Diabetes Mellitus
Service postoperatively for his insulin regimen. He also
experienced some postoperative urinary retention with several
failed voiding trials. The patient will be discharged with a leg
bag and will follow up with a urologist within five to seven days who will be
assigned by his primary care physician. The
patient had already been started on Flomax 0.4 mg daily. The
patient also worked with physical therapy and is able to pivot
with assist and will be discharged to home with physical therapy. Mr. Baldon was
cleared for discharge to home with visiting nurse and physical therapy on postoperative day
#11. Mr. Baldon also had postoperative anemia and was transfused with one unit of
packed red blood cells for a hematocrit of 22 with a repeat at time
of discharge to 23.4. He also required further diuresis and
appears to be hemodiluted. The patient was also instructed on
sternal precautions due to his left BKA and patient and the
family were shown sternal precautions.
DISCHARGE LABS: Sodium 134 , potassium 4.6 , chloride of 100 , CO2
27 , BUN of 15 , creatinine 0.8 , glucose 136 , magnesium 1.6 , WBC
8.30 , hematocrit 23.4 , hemoglobin 7.5 , platelets of 471 , physical therapy 16.7 ,
physical therapy/INR of 1.3 , and a PTT of 37.1.
DISCHARGE MEDICATIONS: Vitamin C 500 mg twice a day , Lipitor 20 mg
daily , azathioprine 125 mg daily , cyclosporine ( Sandimmune ) 50 mg
twice a day , enteric-coated aspirin 325 mg daily , Lasix 40 mg daily
for five doses along with potassium chloride slow release 20 mEq
daily for five doses , Neurontin 300 mg three times a day subcutaneously ,
heparin 5000 units subcutaneously every 8 hours , Dilaudid 4-6 mg every 4 hours
as needed pain , NovoLog 20 units before every meal , Lantus 100 units every 8 p.m. ,
levofloxacin 500 mg daily for two remaining doses , Toprol-XL 100
mg daily , Niferex 150 mg twice a day and Flomax 0.4 mg daily.
Mr. Baldon will follow up with Dr. Rossie Mankoski in six weeks
and his cardiologist Dr. Marcela Jone in one week and an
urologist to be signed by his primary care physician within five
to seven days and also Dr. Stacie Halechko the vascular surgeon in
two to three weeks. He is otherwise clear for discharge to home
with visiting nurse. The patient has also been instructed to
keep his left leg immobilizer brace on until follow up with Dr.
Halechko in two to three weeks.
eScription document: 1-2467341 CSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: MANKOSKI , ROSSIE
Dictation ID 3035580
D: 7/15/06
T: 11/6/06
Document id: 13
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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628567699 | PUO | 85842554 | | 8535988 | 5/26/2007 12:00:00 a.m. | ATRIAL FIBRILLATION , ?ENDOCARDITIS | Signed | DIS | Admission Date: 2/21/2007 Report Status: Signed
Discharge Date: 9/29/2007
ATTENDING: FANIEL , GAYLENE M.D.
SERVICE: Nessopor Gilb Hagund Health Center .
PRINCIPAL DIAGNOSIS: Bacteremia , endocarditis.
OTHER PROBLEMS AND DIAGNOSES:
1. Status post aortic valve repair.
2. Hypertension.
3. Hyperlipidemia.
4. Coronary artery disease status post CABG.
5. CHF.
6. Anemia.
7. Status post hemorrhagic stroke.
8. BPH status post pubic catheter placement.
BRIEF HISTORY OF PRESENT ILLNESS: This is an 82-year-old male
with history of multiple medical problems including recent aortic
valve replacement for aortic stenosis on 4/2 , CAD status
post CABG , CHF , atrial fibrillation with slow ventricular
response , insulin-dependent diabetes who presents from rehab with
positive blood cultures. The patient had been in rehabilitation
following a Totin Hospital And Clinic admission when he spiked a
temperature two days prior to admission and was found to have
blood cultures growing out gram positive cocci. He was also
found to have a positive urinalysis at rehab. The patient was
treated with two doses of ciprofloxacin for positive UA and
admitted to Petersram Medical Center for positive blood cultures and concern
for endocarditis given his recent aortic valve repair.
On review of systems , the patient denies chest pain , shortness of
breath , cough , URI symptoms , rash , nausea , vomiting , diarrhea ,
abdominal pain , dysuria , palpitations , fevers , sweats or chills
and overall reports feeling well.
PAST MEDICAL HISTORY:
1. Status post aortic valve replacement in 4/10 .
2. Hypertension.
3. Hyperlipidemia.
4. CAD status post CABG.
5. CHF.
6. Atrial fibrillation with slow ventricular response.
7. Insulin dependent diabetes mellitus.
8. Anemia.
9. Status post hemorrhagic stroke.
10. BPH status post suprapubic catheter placement during AVR
surgery in 4/10 .
MEDICATIONS:
1. Albuterol nebulizers 2.5 mg every 12 hours
2. Aspirin 325 mg once daily.
3. Sarna.
4. Ciprofloxacin 250 mg twice a day The patient received two doses
prior to admission.
5. Colace 100 mg twice a day
6. Fluticasone one spray in each nostril twice a day
7. Lasix 80 mg every day before noon
8. Flovent two puffs twice a day
9. Subcutaneous heparin 5000 units three times daily.
10. Lispro sliding scale.
11. Lantus 32 units nightly.
12. Simvastatin 30 mg once daily.
13. Albuterol nebulizers as needed for shortness of breath and
wheezing.
14. Tylenol as needed.
15. Senna two tablets orally twice a day
16. Losartan 50 mg once daily.
17. Multivitamin once daily.
18. Iron 150 mg twice a day
19. Potassium chloride 40 mEq twice a day
20. Protonix 40 mg every 12 hours
21. Maalox as needed.
22. Dulcolax as needed.
23. Benadryl as needed.
24. MiraLax as needed.
ALLERGIES:
1. Sulfa ( swelling ).
2. Tetracycline ( swelling ).
SOCIAL HISTORY: The patient has a remote tobacco history. He
has a 40-pack-year history , quit 40 years ago. The patient uses
a walker and wheelchair at baseline.
BRIEF PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Vital
signs: Temperature 98.5 , heart rate 49 , blood pressure 160/56 ,
respiratory rate 18 , oxygen saturation 99% on room air , weight
94.3 kg. General appearance: The patient is in no acute
distress at present. HEENT: Oropharynx is clear. There is no
palatal petechiae. Pupils are equally round and reactive to
light and accommodation. There is no scleral icterus present.
Neck: Supple. There is no lymphadenopathy or masses present.
Cardiovascular: Rate is irregularly irregular. It is
bradycardic. There is a 2/6 systolic ejection murmur at the
right upper sternal border that is heard throughout. Jugular
venous pressure is distended and can be seen at the level of the
ear. Respiratory: There are bilateral basilar crackles.
Abdomen: Obese. There are positive bowel sounds. Abdomen is
soft , nondistended and nontender. No rebound tenderness or
guarding. Skin: There is no stigmata of endocarditis. There
are no splinter hemorrhages. No Osler nodes or red spots. There
is 1+ pitting edema of the bilateral lower extremities. There
are 1+ distal pulses in the upper and lower extremities
bilaterally. Neuro: The patient is alert and oriented x3 and
exam was nonfocal.
LABORATORY DATA: At the time of admission , sodium 144 , potassium
4.5 , chloride 106 , bicarb 30 , BUN 41 , creatinine 1.9 , glucose 83 ,
anion gap is 8. White blood cell count of 8.1 , hematocrit 31.7 ,
platelets 332 , 000. There are 71% neutrophils , 14% lymphocytes
and 12% monocytes. Calcium is 8.7. Urinalysis shows trace
blood , 3+ leukocyte esterase. 40-50 white blood cells , 1-5 red
blood cells , trace bacteria.
STUDIES AT THE TIME OF ADMISSION.
1. Chest x-ray shows status post midline sternotomy and CABG.
There is moderate enlargement of the cardiac silhouette , which is
unchanged from prior x-rays. Right lung is clear. There is a
small left posterior pleural effusion , which has been reduced in
size compared to his previous x-ray dated 8/29/07 .
2. EKG revealed an irregularly irregular rhythm with atrial
fibrillation with a rate of 44. There is left axis deviation , a
right bundle-branch block and Q waves in II , III and aVF , which
is unchanged from an EKG in 5/3 .
HOSPITAL COURSE BY PROBLEM: This is an 82-year-old gentleman
with a history of multiple medical problems most significantly
including recent aortic valve replacement for aortic stenosis , CAD
status post CABG , CHF , atrial fibrillation with a slow
ventricular response who was transferred from rehabilitation with
a fever , positive urinalysis and positive blood cultures with
concerns for endocarditis given his recent AVR. The patient was
initially started on ceftazidime and vancomycin empirically.
Blood cultures were obtained and the patient grew out
two out of two bottles of Gemella morbillorum from his blood.
Urinary cultures were also obtained , which revealed 10 , 000
colonies of Pseudomonas aeruginosa. Cultures were also taken
from the suprapubic catheter wound site and revealed rare MRSA ,
few coag-negative staph and rare enterococci. Once blood
cultures for Gemella morbillorum returned , the patient's
antibiotics were changed to gentamicin and ceftriaxone on
7/17/07 . Ceftazidime was discontinued as was vancomycin. The
patient remained afebrile while inhouse and did not exhibit any
significant leukocytosis or stigmata of endocarditis.
Surveillance cultures obtained after starting antibiotics have
remained negative to date. A TTE was obtained and was negative
for any valvular vegetation. However , given the patient's high
risk for endocarditis , a TEE was obtained , which was also
negative for any ring abscess or valvular vegetation. The
patient , however , will be treated for endocarditis given his high
risk.
1. Cardiovascular:
Ischemia: The patient had no chest pain , chest tenderness or
chest discomfort. He does have a history CAD status post CABG
and was continued on his full strength aspirin. He was also
continued on statin.
Pump: The patient was volume overloaded at the time of admission
and was treated with 60 mg of intravenous Lasix. Following this , he
appeared euvolemic and Lasix was held for several days and then
gradually became volume overload and was again given 60 mg of intravenous
Lasix and then restarted on his home dose of 80 mg orally every day before noon. At the
time of discharge , the patient is slightly volume overloaded , but
diuresing well with 80 mg daily. The patient's Losartan was held
in the setting of his chronic renal insufficiency and initiation
of gentamicin therapy. At the time of discharge , his weight is
96.6 kg. His I/O goal at time of d/c is 500cc negative daily. He should
continue daily weights. Of note , the patient's dry weight is
approximately 93 kg. patient's lasix should be titrated as he reaches his dry weight.
Rhythm: The patient is bradycardic at baseline down into the
mid-to-low 30s , is asymptomatic and has in the past refused
permanent pacemaker placement. All nodal agents should be
avoided for this reason. The patient did have several runs of
nonsustained ventricular tachycardia upto 14 beats. Electrolytes
were checked twice daily to keep magnesium above 2 and potassium
above 4. However , no other medical management was initiated
given his bradycardia.
2. Infectious Disease: As noted above , there was high suspicion
for endocarditis in this with a recent AVR. He was found to have
Gemella morbillorum in his blood and was started as noted above
empirically on vancomycin and ceftazidime and then changed to
gentamicin and ceftriaxone on 7/17/07 once gram-positive cocci
were speciated. The patient was initially treated for
pseudomonal UTI with five days of ceftazidime , but given that
only 10000 CFUs grew out , it was decided that ceftazidime
could be discontinued and that there would be some response to
ceftriaxone plus gentamicin. A PICC line was placed on 7/17/07
for continued intravenous antibiotics and the patient should continue a
full six-week course of ceftriaxone and at least a two-week
course of gentamicin for presumed endocarditis despite
both negative transthoracic echocardiogram and transesophageal echocardiogram
given his high risk for endocarditis.
3. GI: The patient was continued on his home dose of Protonix
and all his stools were guaiaced and were negative in house. The
patient should be continued on as needed Colace.
4. Endocrine: The patient has a history of insulin dependent
diabetes mellitus. His Lantus was titrated up to 36 units
nightly and at that level required no sliding scale insulin.
5. Renal: The patient was found to have a slightly elevated
creatinine above his baseline on admission ( 1.9 with a baseline
of 1.1 to 1.3 ). This elevated creatinine was thought to likely
be due to his CHF and poor forward flow. As the patient was
diuresed , his creatinine decreased to 1.4 at the time of
discharge. Given his creatinine elevation , however , his Losartan
was held and this should be held while the patient is on gentamicin.
6. GU: The patient has a history of BPH and at the time of
admission had a suprapubic catheter that was inserted in 4/10
due to difficulty to pass Foley catheter. The catheter was
clamped and post-void residuals were checked and were only 50 mL
and the patient was urinating without difficulty with tube clamped ,
so Urology was consulted and suprapubic catheter was pulled
without difficulty. Suprapubic wound was dressed with a sterile
dry dressing to be changed daily.
7. Fluids , Electrolytes and Nutrition: The patient has a
current input and output goal of 0.5 L negative daily. He is on a 2L fluid
restriction.
Electrolytes. The patient has been having twice daily
electrolyte checks to keep his magnesium above 2 and his
potassium above 4 given his arrhythmias while he is on 80 mg of
Lasix daily. This should be continued.
Nutrition. The patient was placed on a cardiac , 2-gm sodium
diet and a 2 L fluid restriction.
8. Pulmonary: The patient is to continue on Flovent and
albuterol.
9. Heme: The patient was continued on Niferex twice daily for
iron deficiency anemia. He was also found to have a very mild
eosinophilia , which should be followed.
10. Derm: The patient was found to have a skin tear on his
right hand. This is being treated with neomycin ointment and
sterile dry dressing changes daily.
11. Prophylaxis: The patient was placed on subcutaneous heparin
5000 units three times daily and continued on his PPI.
CODE: The patient is full code.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: Vital Signs:
temperature 98.7 , blood pressure is 118-140/60-70 , heart rate
35-58 , respiratory rate 18-20 , oxygen saturation 94-100% on room
air , 100% on 2 L. Weight 96.6 kg. On general exam , the patient
is in no acute distress. Neuro: The patient is alert and
oriented x3. Pulmonary: There are decreased breath sounds a
quarter of the way up on the left lung field and there are
decreased breath sounds at the bases on the right lung field.
Cardiovascular: There is an irregularly irregular rhythm and
with bradycardia. There is a 2/6 systolic ejection murmur at the
right upper sternal border. JVP is 5-6 cm of water. Abdomen:
There are normoactive bowel sounds present. Abdomen is soft ,
obese , nondistended and nontender. Suprapubic catheter site is
without purulence or erythema. Extremities: There is 1+ pitting
edema to the shins bilaterally with chronic venous stasis changes
bilaterally. Skin: There are no rashes present. There are no
splinter hemorrhages or Osler nodes noted.
LABS AT TIME OF DISCHARGE: Sodium 141 , potassium 4.0 , chloride
108 , bicarbonate 26 , BUN 41 , creatinine 1.5 , glucose 164 , calcium
9.1 , magnesium 2.0 , hematocrit 29.2 , white blood cell count 8.9 ,
platelets 227 , INR 1.1 , PTT 38.1. There are 68% polys , 18%
lymphocytes , 7.1% monocytes and 5.9% eosinophils. Gentamicin
peak is 17.8 with a trough of 0.9.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally once daily.
2. Albuterol nebulizer2.5 mg nebulized every 6 hours as needed for
wheezing.
3. Albuterol nebulizer 2.5 mg nebulized every 12 hours
4. Dulcolax 5 mg orally daily as needed for constipation.
5. Ceftriaxone 2000 mg intravenous daily to be continued until 8/20/07 .
6. Gentamicin 80 mg intravenous daily to be continued at least until
7/25/07 .
7. Colace 100 mg orally twice a day
8. Fluticasone nasal spray one spray in each nostril twice a day
9. Flovent 110 mcg inhaled twice daily.
10. Lasix 80 mg orally every day before noon
11. Heparin 5000 units subcutaneously every 8 hours
12. Lantus 36 units subcutaneously at bedtime.
13. Lispro sliding scale subcutaneously before meals
14. K-Dur 40 mEq orally twice a day
15. Niferex 150 mg orally twice a day
16. Pantoprazole 40 mg orally every 12 hours
17. MiraLax 17 gm orally daily as needed for constipation.
18. Sarna topical to be used daily as needed for itching.
19. Senna two tablets orally twice a day
20. Simvastatin 40 mg orally at bedtime.
21. Multivitamin with minerals one tablet orally daily.
22. Bacitracin ointment to be applied to right hand lesion
twice a day
DISPOSITION: The patient will be discharged to rehabilitation.
At the time of discharge , there are two blood cultures that are
no growth to date but needs to be followed up.
FOLLOWUP PLANS:
1. The patient is to have a basic metabolic panel checked twice
daily while he IS actively diuresing with Lasix and after this
time , should have basic metabolic panel checked at least twice
weekly to follow electrolytes and creatinine while he is on
antibiotics.
2. Please draw a CBC with differential at least once weekly
while he is on gentamicin and ceftriaxone.
3. Please draw a gentamicin trough once weekly and adjust
gentamicin doses as needed.
4. Infectious disease consultant is to determine whether to the
gentamicin should be continued beyond two weeks.
5. Consider surveillance blood cultures one week after
completing antibiotic therapy to document clearance.
6. Please place neomycin ointment to right hand lesion daily and
cover with sterile dry dressings to be changed daily.
7. Continue dry sterile dressing to the suprapubic catheter site
to be changed daily until the wound is healed.
8. Consider repeat urine cultures two weeks after time of
discharge to document clearance of pseudomonal UTI.
9. Would hold off on restarting Losartan until gentamicin is
discontinued.
10. Please follow up all pending blood cultures.
FOLLOWUP APPOINTMENTS:
1. Appointment with Dr. Dulcie Scovel in the Infectious Disease
Clinic at Petersram Medical Center on 9/5/07 at 8 a.m.
The patient was discharged at a weight of 96.7 kilograms. His
dry weight is approximately 93 kilograms. His In's and Out goals
should be -500 cc daily. He is currently on Lasix 80 mg in the
morning.
eScription document: 0-5568862 CSSten Tel
Dictated By: YEAGLEY , MA
Attending: FANIEL , GAYLENE
Dictation ID 9295051
D: 3/10/07
T: 3/10/07
Document id: 14
| Target |
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Dp |
DM |
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HC |
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HTG |
OA |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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756484975 | PUO | 14374811 | | 2938559 | 1/26/2007 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/11/2007 Report Status: Signed
Discharge Date: 1/26/2007
ATTENDING: THEILING , BREE MD
SERVICE:
Cardiology.
PRINCIPAL DIAGNOSIS:
Coronary artery disease.
LIST OF PROBLEMS:
1. Coronary artery disease.
2. Status post MI.
3. Diabetes mellitus.
4. Hospital-acquired pneumonia.
HISTORY OF PRESENT ILLNESS:
Mr. Daughtrey is a 75-year-old female with diabetes , coronary artery
disease , status post CABG in 1995 , recent MIBI , stress test in
July with a small area of reversible ischemia inferiorly who had
peripheral vascular disease , right CVA status post IVC filter for
DVT , triple AAA , status post repair , COPD , who presented to
Norap Valley Hospital with nausea of unclear source and deep lateral
T wave inversions in EKG leads V2-V6. She has noted intermittent
fevers at home to 102 and sent into the Norap Valley Hospital by her
VNA. Please see discharge summary from Norap Valley Hospital for
more details. She was at that time on treatment for a left foot
diabetic ulcer on Augmentin. Over the last week prior to
admission , she had increasing nausea , diarrhea without abdominal
pain. She did have mild fevers and increased cough though she
had no chest pain , orthopnea or urinary complaints. At the
Norap Valley Hospital , they noted that she had deep T-wave inversions
laterally and she was ruled out for DCS by cardiac enzymes. They
transferred her to Pagham University Of for consideration
of cardiac catheterization.
PAST MEDICAL HISTORY:
1. Type II diabetes complicated by peripheral neuropathy.
2. Coronary artery disease status post CABG in 1995.
3. Congestive heart failure.
4. COPD.
5. Peripheral vascular disease.
6. Hypertension.
7. Chronic kidney disease.
8. Abdominal aortic aneurysm , status post repair.
9. Carotid disease status post right CEA.
10. DVT status post IVC filter.
11. Diverticulitis , status post sigmoid colectomy.
12. Gout.
13. Left foot diabetic ulcer , has been treated with multiple
different antibiotic courses including levofloxacin , Flagyl , and
nasalide , as well as Augmentin.
MEDICATIONS PRIOR TO ADMISSION:
1. Augmentin 875 mg orally twice a day
2. OxyContin 8 mg orally three times a day as needed
3. Tylenol as needed.
4. Tessalon perles as needed
5. Ativan 0.5 at bedtime as needed
6. Atrovent nebulizer as needed
7. Lasix 30 mg orally daily.
8. Glipizide 2.5 mg orally daily.
9. Gabapentin 300 mg orally three times a day
10. Multivitamin.
11. Atenolol 25 mg orally daily.
12. Allopurinol 100 mg orally daily.
13. Aspirin 81 mg daily.
14. Lipitor 40 mg daily.
ALLERGY/ADVERSE DRUG REACTIONS:
1. Sulfa , the allergic reaction is unclear , although it has
noted anaphylaxis on previous discharge summaries.
2. Theophylline causes tongue swelling.
3. Quinine reaction unclear.
4. Iodine/intravenous contrast. This is noted in the medical record.
However , the patient does not remember having an adverse reaction
or allergic reaction to intravenous contrast.
5. Iron , this reaction is unknown.
6. Erythromycin , again , the patient does not remember any
reaction , but apparently has hives.
7. Levofloxacin , unclear what the reaction is. She has
tolerated this in April , which she was treated for a foot
ulcer. It is not clear if this is a rash or it was thought to be
possibly related to a fever that the patient had , but it is not
clear what the actual reaction is.
SOCIAL HISTORY:
The patient is an 80-pack-year smoker. He is currently smoking.
PHYSICAL EXAM ON ADMISSION:
Her temperature was 99 , her pulse was 98 , her blood pressure was
105/55. Her respiratory rate was 18 when she was saturating 94%
on room air. In general , she is in no acute distress. Her HEENT
exam was unremarkable. Her cardiac exam was regular rate and
rhythm with a 2/6 systolic murmur at the apex. Her lung exam was
notable for crackles most prominent in the left lower lobe. Her
abdomen was soft , obese , nontender and nondistended with good
bowel sounds. Her extremities were significant for erythema of
the left shin without warmth or tenderness. She also had a small
1.5 cm ulceration on the bottom of her left foot which has been
present for sometime although she says that it looks better than
at first. There was no purulence or purulent drainage from the
wound. Her neurologic exam was unremarkable.
LABORATORY DATA ON ADMISSION:
Her labs were notable for a creatinine of 1.6 , a white count of
4.1 , with 11% eosinophils. Her hematocrit was 31.6 , and her
albumin was 3.
PROCEDURES:
Cardiac catheterization: it was done by Dr. Wero .
FINDINGS:
Showed a right dominant circulation. There were no significant
left main lesions identified. The LAD had a tubular 90% lesion
and the diagonal I had a proximal tubular 60% lesion , there was
also a diffuse 80% lesion of the proximal circumflex. The RCA
had a proximal 75% lesion with a mid diffuse 60% lesion and a PLV
tubular 70% lesion. The coronary artery bypass grafts had a
patent LIMA to LAD graft , the SVG to marginal I had a 100% lesion
during this catheterization due to the moderate amount of
contrast and the patient's chronic kidney disease , they treated
the RCA and placed a 3 x 24 mm Taxus stent
ECHOCARDIOGRAM:
On 7/9/07 , showed an estimated ejection fraction of 50% with
inferoseptal and inferior severe hypokinesis. The RV was normal.
There was mild aortic stenosis. Mild-to-moderate aortic
regurgitation. The valve area was 1.2 cm2. There was mild
mitral regurgitation. There is trace tricuspid regurgitation
with a pulmonary artery systolic pressure of 36 mm plus right
atrial pressure.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular:
a. Ischemia: The patient was admitted because they had deep T
wave inversions in the lateral leads and are still concerning for
anginal equivalence of nausea and vomiting. It was decided on
admission that an echocardiogram would be performed and if there
was evidence of any regional wall motion abnormalities that she
would be taken directly to cath. The echocardiogram as noted
above showed inferior hypokinesis consistent with coronary artery
disease. She was taken to the cath lab on 9/5/07 and they show
two ____ that one of the bypass grafts was completely occluded
and was not visualized. They also saw that there was a proximal
RCA lesion 60% which was found to account for the inferior
hypokinesis given the right arm circulation. This was stented
with a Taxus stent. Because of her kidney insufficiency , it was
decided not to pursue the 80% left circ lesion and this was
deferred until later point as this was not thought to be causing
any problems. Her post cath ECG was unchanged and continued to
have the deep lateral T wave inversions. She did not complain of
any chest pain or nausea and vomiting during her admission. She
was started on aspirin and Plavix initially although as noted
below she did have an apparent allergy to Plavix and thus was
switched to ticlopidine 250 mg twice a day instead of Plavix for
anticoagulation. She was also continued Lipitor 80 mg daily ,
Lopressor 25 mg three times a day After her cath , it was originally planned
that she would go back to cath for intervention on the left
circulation lesion , however , given her other medical problems and
her relative stability hemodynamically and symptomatically , it
was decided that they would wait and decide later if this lesion
needed to be corrected in the future or not.
b. Pump: The patient had no significant issues with her blood
pressure here. She remained in a blood pressure range of 100-120
throughout her stay. She was continued on her beta blocker as
noted above. However , at discharge , this was switched back to
atenolol as her home medications and she refused to change
medications , she said that she would not be able to afford new
prescription. We did increase her dose of atenolol to 25 mg
twice a day from 25 mg daily as her requirement of beta blockade
seemed to be higher than what her home dose was. Given that she
has a concurrent renal disease , it would probably be useful for
her to be on an ace inhibitor ARB as well. This medication
should be added as an outpatient , if her blood pressure tolerates
it. It was on the lower side here , so we did not add it. We did
not diurese her in fact we held her Lasix on admission because
she seemed to be volume depleted given that she was admitted with
a lot of diarrhea , this again will need to be reconsidered if she
had increased edema. This can be restarted.
C: Rhythm: The patient was kept on telemetry , however , there
were no significant episodes of arrhythmias during her admission.
2. GI: The patient was admitted with persistent nausea and
diarrhea from Norap Valley Hospital . The diarrhea resolved one day
after admission. Her fecal leukocytes were positive but her C.
diff was negative. It was unclear what the etiology of this
diarrhea was and we were going to send a repeat stool study ,
however , she did not have any diarrhea afterwards and this may be
antibiotics associated diarrhea but it seemed to resolve
spontaneously.
3. Pulmonary: The patient was admitted with crackles in the
left lower lobe and some wheezing consistent with COPD and
pneumonia. A chest x-ray on admission showed a right lower lobe
infiltrate/atelectasis. We initially continued her on Augmentin ,
which she was taking for her diabetic foot ulcer. However , she
did not appear to clinically respond to this medication. We held
her antibiotics as noted below in the ID section and after that
her white blood cell count increased and she produced some
purulent sputum and Gram-negative rods. The Gram-negative rods
were later speciated as serratia although this information is not
available at the time of her discharge. She was treated for a
hospital-acquired pneumonia with vancomycin and ceftazidime to
complete a 14-day course. Clinically , she appeared to improve on
this regimen , although her white count was still elevated at 15
on discharge , however , given her overall clinical stability , the
lack of fevers and the lack of systemic symptoms. We felt
comfortable with discharging her with close follow up.
4. Infectious disease: The patient was initially admitted on
Augmentin for a diabetic foot ulcer , the notes from Norap Valley Hospital by the Infectious Disease Service recommended a 2-4 week
course of Augmentin for her diabetic foot ulcer. She had
completed three weeks of therapy and thus we discontinued this
medication as it did not seem that there was really any evidence
of active infection in her foot. After holding the antibiotics
for three days , her white count began to rise and she developed a
purulent cough as noted above , this was thought to be a
hospital-acquired pneumonia. She was treated with vancomycin and
ceftazidime and she will complete a 14-day course of these
antibiotics.
5. Endocrine: The patient was home on orally hypoglycemics. She
was switched to coverage with an insulin scale. Her sugars were
relatively well controlled and she did not require much in the
way of supplemental insulin.
6. Renal: The patient has chronic kidney disease. Her baseline
creatinine was 1.5-1.6. She was admitted and had a cath. She
was given Mucomyst and bicarbonated fluids for renal protection
during her dilute. Because of the risk for kidneys , the cath was
done with a little amount of dye as possible. Her creatinine
remained stable throughout her admission and settled out at 1.6
of her creatinine which is the baseline.
ALLERGY:
During the patient's admission , it was noted that she developed a
rash on 4/15/06 . She was seen by the Allergy and Immunology
Service at the request of the cath lab given that there was
concern that she had this rash because of her Plavix. They felt
that this was possible. This was the most likely etiology and in
conjunction with her high eosinophil count it was felt that this
was a drug reaction to the Plavix. She was switched to
ticlopidine 250 mg twice a day and her rash appeared to improve. She
was also given claritin as well as put on a brief prednisone
taper given her diffuse rash and her brisk eosinophilia. She
should follow up with Allergy and Immunology in about one month
to see if the rash has resolved and potentially to try
rechallenge with Plavix at that point.
Cellulitis/diabetic foot ulcer: The patient has had a
longstanding diabetic foot ulcer which has been treated by wound
care VNA and was treated at Norap Valley Hospital . We continued the
Augmentin to a total course of three weeks and then stopped it.
We continued her dressing changes and this will be followed by
the VNA at home. There was no evidence of active infection ,
there was no purulence or erythema around the area of the ulcer
and the erythema around the foot appeared to be stable , this was
most likely chronic venous stasis change and not a true
cellulitis as there was no warmth or tenderness in this region.
CONSULTANTS:
Allergy/Immunology , the attending was Dr. Biggins .
PHYSICAL EXAM AT DISCHARGE:
The patient was afebrile. Her pulse was 86 , her blood pressure
was 120/60 , her respiratory rate was 20. She was 92-96% on room
air. In general , she was in no acute distress. Her JVP was
about 7 cm. She had small amount of crackles at bilateral bases.
Her cardiac exam was regular rate and rhythm with normal S1 and
S2. There was a 2/6 systolic murmur most prominent at the left
lower sternal border. Her abdomen is soft , nontender , and
nondistended with good bowel sounds. She had 1+ edema
bilaterally with small amounts of erythema at the distal end of
the left lower extremity which has been stable. There is no
associated warmth or tenderness. She did have a 1.5 cm small
ulcer on the ventral aspect of her left foot , which did not have
any purulence associated with it. Her neurologic exam was
nonfocal.
LABORATORY DATA ON ADMISSION:
Notable for a creatinine of 1.5 , a white blood cell count of
15.89 , with 82.7% neutrophils , 3.8% eosinophils. Her hematocrit
was 28.6. Her baseline appears to be around 30.
DISCHARGE MEDICATIONS:
1. Ticlopidine 250 mg by mouth twice a day.
2. Atenolol 25 mg by mouth twice a day
3. Lipitor 80 mg daily.
4. Prednisone taper 30 mg on 10/18/07 , 20 mg on 10/3/07 , 10 mg
on 10/18/07 and then stop.
5. Vancomycin 1 g intravenous daily , course to be completed on 1/16/07 .
6. Ceftazidime 1 g daily to be complete on 1/16/07 .
7. Allopurinol 100 mg daily.
8. Neurontin 300 mg three times a day.
9. Tessalon perles as needed.
10. Ativan 0.5 mg at bedtime as needed for sleep.
11. Glipizide 2.5 mg daily.
12. DuoNeb every 4 hours as needed for shortness of breath.
13. Lasix 30 mg by mouth daily.
14. Aspirin 81 mg daily.
DISPOSITION:
Home with services.
PENDING TESTS:
As noted , the patient had a sputum culture that was growing
Gram-negative rods at the time of discharge. The current report
is that it was growing Serratia marcescens which should be staph
sensitive to ceftazidime , which he was prescribed for a total of
14 days.
FOLLOW UP:
She will follow up with Dr. Katheryn Gruntz on 10/12/07 at 9:30
a.m. She has an appointment scheduled.
TO DO LIST:
1. The patient has an 80% left circumflex lesion which was not
stented. This should be , ___28.20__ , whether she needs a second
intervention in the future. She does appear to be asymptomatic ,
but she does continue to have the deep lateral T wave inversion
suggesting the areas of abnormal blood flow in the heart. It was
thought that the right RCA lesion was more likely to be the cause
of her inferior wall hypokinesis , so that was the procedure
performed.
2. The patient was treated for hospital-acquired pneumonia with
vancomycin and ceftazidime. This will continue until 1/16/07 .
She was noted to have a rash here which was thought to be Plavix
related. If the rash resolves on ticlopidine , she may need to
readdress whether or not this was actually due to Plavix. It was
recommended that she follow up with an allergist in about a month
from her hospitalization who can review the records and determine
whether she should start Plavix or maintain on the ticlopidine.
3. Her platelets should be monitored given that she started on
ticlopidine and there is a risk of TTP associated with this
medication.
eScription document: 0-4690211 EMSSten Tel
CC: Katheryn Gruntz M.D.
Menlandlourdes Medical Center
Ry Ale Sa
Dictated By: WOODRUM , ELOY
Attending: THEILING , BREE
Dictation ID 9850445
D: 10/3/07
T: 10/29/07
Document id: 15
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PVD |
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659753603 | PUO | 48763358 | | 201016 | 6/29/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/1/1995 Report Status: Signed
Discharge Date: 10/25/1995
PRINCIPAL DISCHARGE DIAGNOSIS: FEVER , STATUS POST CARDIAC
TRANSPLANT
OTHER DIAGNOSES: 1 ) HEMOLYTIC ANEMIA; 2 ) THROMBO-
CYTOPENIA
HISTORY OF PRESENT ILLNESS: Mr. Breckenridge is a 50 year old
male who is ten years status post
cardiac transplant for an ischemic cardiomyopathy , who presents
with a five week history of a flu like illness and fevers. Cardiac
transplant was in 1985 without complications and in 1989 he had one
episode of herpes zoster , and was treated for cataract. He
remained stable without cardiac symptoms or exertional limitation.
Last had a cardiac catheterization in April of 1994 , showed no
evidence of coronary artery disease , normal LV size and function ,
normal RV and trace MR. Right heart catheterization on 7/10 showed
normal hemodynamics. There was no evidence of rejection on biopsy.
There was no history of signs or symptoms localizing infectious
process until about five weeks prior to this admission when he
developed a flu like symptom , including a dry cough , occasionally
productive of whitish sputum , general malaise , nasal congestion
with occasional blood streaked secretions , arthralgias and fatigue.
He also reports dyspnea on exertion after one flight at moderate
pace with occasional night sweats and loose stools. Multiple family
members were ill with similar symptom complexes. The patient took
one week off from work and felt that he was getting better until
approximately 24 hours prior to admission when he again had
increased weakness , muscle and joint aches , fevers to 101.2 orally ,
shaking chills , continued dry cough and headache. Diarrhea
spontaneously resolved but has had persistent dyspnea on exertion.
The patient denies any PND , orthopnea , chest pain , nausea and
vomiting. Has had anorexia with a 15 pound weight loss in the past
month. He is currently being admitted for evaluation and management
of his flu like illness following his cardiac transplant. He is
immunosuppresed with Cyclosporin , Prednisone and Imuran.
PAST MEDICAL HISTORY: 1 ) Cardiac transplant; 2 ) hyper-
tension; 3 ) status post bilateral
cataract surgeries; 4 ) herpes
zoster flare.
MEDICATIONS ON ADMISSION: 1 ) Vasotec , 10 mg twice a day;
2 ) Mevacor , 20 mg every day; 3 ) Imuran ,
150 mg every day; 4 ) Diltiazem CD , 180 mg every day; 5 ) Prednisone , 10 mg every
day; 6 ) Aspirin , 325 mg every day; 7 ) Cyclosporin , 100 mg twice a day; 8 )
Magnesium; 9 ) Robitussin as needed. The patient has no known drug
allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: He smoked one pack per day. Denies
alcohol use.
PHYSICAL EXAMINATION: The patient is a middle aged male in
no apparent distress. Temperature is
99.3 degrees orally Pulse is 102 and regular. Breaths are 16 , even
and unlabored , 97% oxygen saturation at room air and blood pressure
is 120/76. His skin was within normal limits , mild scleral icterus.
Jugular venous pressure was 6 cm. Carotids were 2+ bilaterally
without bruits. There is no thyromegaly or adenopathy. His lungs
were clear bilaterally. Cardiac exam revealed a normal S1 and S2.
There are no murmurs , gallops or rubs. There is a regular rate and
rhythm. His PMI was non displaced. Abdomen was soft and non tender ,
non distended , normoactive bowel sounds with no hepatosplenomegaly.
Extremities without cyanosis , clubbing or edema or rashes. Distal
pulses were 2+ bilaterally and neurological exam was completely non
focal.
LABORATORY DATA ON ADMISSION: Of significance , BUN was 27 ,
creatinine 1.8 , white blood cells
were 5.3 , with 71% PMNs and 10% bands , 4% lymphocytes , 8% monocytes
and 4% eosinophils. Platelet count was depressed at 90 , 000 ,
hematocrit was low at 30%; LDH was 302 and elevated; bilirubin was
elevated at 2.2 , total over 1.1 direct and Cyclosporin level on
admission was 276. Admission chest x-ray showed enlarged
mediastinal silhouette. There was no infiltrates or effusion. EKG
showed sinus tachycardia , rate of 106; axis was +6 degrees ,
intervals were .14/.08/.30 and RSR prime in V1 anterior T wave
inversion. There were no acute changes. His blood smear showed no
evidence of hemolysis. There are no schistocytes.
HOSPITAL COURSE: This is a 50 year old gentleman who
is ten years status post cardiac
transplant , who presents with waxing and waning flu like illness
with fevers and left shift. Of note is hyperbilirubinemia with an
elevated LDH , in conjunction with anemia , suggestive of hemolysis
and also thrombocytopenia. It was felt that patient most likely
had an infectious process. Infectious Disease was contacted. The
patient had multiple blood cultures , sputum cultures , sputum
analyses and titers drawn with a completely negative workup , except
for E. coli noted on several sputum stains but there is no other
evidence for pneumonia. The patient was empirically treated for
several days on intravenous Cefuroxime with no change in his fever
curve , which had ranged from 100 to 102 degrees for all the days of
admission except the last 24 days of admission when patient was
afebrile. Most likely explanation for the patient's symptoms and
signs is a viral illness of unclear etiology. The fevers , joint
aches , upper respiratory symptoms all resolved by the time of
discharge. With regards to the patient's anemia , there was no
specific diagnosis made , despite extensive workup. The hematology
oncology service was consulted , and stated that the patient's
peripheral smear was normal , as it had been by our reading. They
still wanted to check a PNH screen and G6PD level in three to four
weeks following discharge for possible explanations of his
hemolytic anemia , although may be possibly related to a viral
illness as well. By the time of discharge , the patient's
hematocrit was stable at 30% and there was no further increase in
the patient's LDH or bilirubin; in fact those levels were resolving
by the time of discharge. The thrombocytopenia again may be
related to the viral illness and there is no evidence for hemolytic
uremic syndrome or microangiopathic hemolytic anemia. Also during
this visit , a PPD was checked and it was found that the patient was
anergic , as might be expected with all of his immunosuppressive
drug regimen. At the time of discharge , the patient was feeling
well and no longer complaining of his flu like syndrome.
DISCHARGE MEDICATIONS: 1 ) Aspirin , 81 mg orally every day; 2 ) Cyclo-
sporin , 100 mg orally twice a day; 3 )
Colace , 100 mg orally twice a day; 4 ) Vasotec , 10 mg orally twice a day; 5 )
Mevacor , 20 mg orally every day; 6 ) Magnesium oxide , 420 mg orally every day; 7 )
Prednisone , 10 mg orally every day before noon; 8 ) Diltiazem CD , 180 mg orally every day; 9 )
Imuran , 150 mg orally every day
CONDITION ON DISCHARGE: Good
DISPOSITION: The patient was discharged to home ,
feeling well and was no longer
complaining of symptoms. He will follow up with Dr. Fernande Prewer
in cardiac transplant clinic in several weeks time. The patient
will call for the appointment.
Dictated By: FRANCISCA URBANIAK , M.D. CL8
Attending: SHAVONNE D. MAINER , M.D. WG5 ZN499/0449
Batch: 2594 Index No. HGEINX79OJ D: 4/17/95
T: 4/17/95
Document id: 16
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
068885322 | PUO | 41618858 | | 5143339 | 10/23/2006 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 1/6/2006 Report Status:
Discharge Date: 6/13/2006
****** FINAL DISCHARGE ORDERS ******
TORTORELLA , KASHA 340-64-18-9
Na More Ceanan
Service: ETMCH
DISCHARGE PATIENT ON: 2/5/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NOLAN , BYRON S.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
on order for COUMADIN orally ( ref # 296891962 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: needs
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Instructions: POST-MI
Override Notice: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
on order for COUMADIN orally ( ref # 296891962 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: needs
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
LISINOPRIL 15 MG orally DAILY HOLD IF: SBP<90
Override Notice: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
on order for SPIRONOLACTONE orally ( ref # 049035301 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override: needs
METFORMIN 500 MG orally twice a day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Starting IN a.m. ( 10/5 )
HOLD IF: sbp<100 , heart rate<60 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SPIRONOLACTONE 25 MG orally DAILY
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override: needs
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 2/5/06 by :
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: needs
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/5/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: patient home medicatin
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FOLLOW UP APPOINTMENT( S ):
primary care physician DR STEPANIE TIJUANA LOBAN ( 501 ) 689-2198 8/19/06 @ 3:50 PM ,
CARD DR JONTE ( 376 834-1084 4/7/06 @ 1:00 PM ,
CARD DR GRINSTEAD ( 048 ) 968-4013 CLINIC WILL CONTACT ,
Arrange INR to be drawn on 7/7/06 with f/u INR's to be drawn every
percoumadinclinic days. INR's will be followed by PUO coumadin clinic
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) HTN ( hypertension ) dyslipidemia
( dyslipidemia ) history of STEMI DM ( diabetes mellitus ) LV mural thrombus 1/13
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
IDENTIFICATION: 73F with a history of recent anterior STEMI ( 9/22 ) c/b apical
aneurysm , apical thrombus , and ischemic cardiomyopathy with most recent EF
35% admitted from home with increasing DOE and fatigue.
HISTORY OF PRESENT ILLNESS:
Mrs. Tortorella is a lovely 73yo woman who presented in 9/22 with 3 days of
epigastric and chest pain and was found to have a STEMI. She
subsequently underwent DES to ramus and LAD. Flow through the LAD was
only TIMI 2 by the end of the procedure. Course was complicated by
post-MI pericarditis , apical wall thinning , and mural LV thrombus.
She was discharged initially to short-term rehab , then subsequently went
home with weekly f/u with cardiac rehab. While at short term rehab , she was
treated with doses of lasix as high as 120 mg intravenous. Following discharge from
rehab , she was ultimately taken off of diuresis b/c of "dizzy spells" she
was experiencing while on lasix.
She did well off lasix until 2 weeks ago , when she was noted to have
decreased exercise tolerance and increasing fatigue at cardiac rehab.
She says that she is usually able to ambulate for 15 minutes on the
treadmill; she hasn't been able to do this for the past 2 weeks b/c of
dyspnea and fatigue. This has been accompanied by new-onset PND
( occurring as frequently as 3-5 times/night ) , 5 pound weight gain , and
increasing abdominal girth. She does acknowledge dietary indiscretion
this past week ( had a can of mushroom soup 4 days ago ). No orthopnea.
Mrs. Lobello cardiac rehab. contacted Dr. Jonte ( her primary
cardiologist ) a few days ago to inform her about Mrs. Lobello DOE and
increasing fatigue. Starting 2 days ago , she was placed on lasix 40 mg.
Since then , she has taken a total of 5 doses. She came to urgent care
this PM and was noted to desat. to 85% with ambulation in the setting of
fluid overload. She was subsequently admitted.
PAST MEDICAL HISTORY:
1. STEMI , 9/22 history of PCI to LAD with DESx2 c/b apical aneurysm ,
apical thrombus ( on coumadin ) , and ischemic cardiomyopathy ( with latest EF
35% )
2. Type 2 diabetes mellitus , on insulin
3. HTN
4. Dyslipidemia
ALLERGIES: NKDA
HOME MEDICATIONS:
1. Metformin 500 mg orally twice a day
2. Multivitamin 1 tablet orally every day
3. ASA 81 mg orally every day
4. Lipitor 80 mg orally every day
5. Plavix 75 mg orally every day
6. Tramadol 50 mg orally 6H
7. Insulin lantus 23 U subcutaneously qAM
8. Insulin aspart 8 U subcutaneously qAC
9. Insulin aspart sliding scale
10. Lisinopril 15 mg orally every day
11. Toprol XL 100 mg orally qAM
12. Coumadin 2 mg orally every day
13. Spironolactone 25 mg orally every day
14. Protonix 40 mg orally every day
15. Lasix 40 mg orally every day
SOCIAL HISTORY: Lives with her husband. Distant and minimal 5-6 pack
year smoking history ( quit ~12 years ago ). No EtOH.
PHYSICAL EXAMINATION AT ADMISSION
Tc 98; P 88; BP 136/84; O2 sat 97% , RA
NAD , well-appearing
JVP~8 cm
CTAB
PMI laterally displaced. RRR. S1 and S2 normal intensity. No rubs ,
murmurs , gallops.
+BS. ND/NT.
WWP. No edema.
LABORATORY DATA AT ADMISSION:
1. Na+ 144; K+ 4.1; Cl- 105; CO2 31; BUN 20; creatinine 1.0; glucose
73
2. ALT 40; AST 27; ALK 61; TB 0.4
3. CK 117; CKMB 1.6; troponin <assay
4. Ca2+ 9.7; Mg2+ 1.6
5. WBC 6.62; Hct 35.9; PLT 213
RELEVANT STUDIES:
EKG: NSR. Q waves in II , III , and aVF; along with V1-V4
CXR: Mild pulmonary vascular congestion
7/5/2006 ECHO: Mildly dilated left ventricle ( systolic diameter: 3.57
cm and diastolic diameter: 5.89 cm ). Overall left ventricular function
moderately reduced with EF 35%. Anteroseptal wall is akinetic from
midventricular level to apex , and hypokinetic at the base. Focal basal
inferior aneurysm ( new from 7/5/05 ) and the apex is focally
aneurismal. False tendon , but no obvious thrombus seen. Global right
ventricular systolic function mildly reduced. Trace TR. Trace TR. PASP
17 mmHg+RAP.
11/26 ETT: Duration 3'20'' and stopped d/t fatigue. Attained 4.7 METS.
Maximum heart rate 125 at 85% of predicted. Maximal blood pressure
130/70. ECG ST changes of accentuation of baseline ST , T wave
abnormalities. Apparently , low HR recovery. Imaging with large myocardial
scar in the proximal LAD territory. Small and mild myocardial ischemia
in the OM territory ( small defect involving the basal inferolateral
wall ). Post-stress EF 31%.
OVERALL ASSESSMENT: 73F with a history of recent anterior STEMI ( 9/22 ) c/b
apical aneurysm , apical thrombus , and ischemic cardiomyopathy with most
recent EF 35% admitted from home with increasing DOE and new-onset PND.
Appears to be fluid overloaded , improved with diuresis over 3 day
hospitalization.
HOSPITAL COURSE BY PROBLEM:
1. CARDS PUMP: Volume overloaded with ischemic CMP implicated.
Initially received intravenous diuresis with lasix 80 mg intravenous twice a day and was ~2.5 liters
negative. SBP down to 80 following overdiuresis on 6/14 held diuresis
on 10/7 . Resumed orally regimen with lasix 40 mg orally every day on 10/5 .
Discharged on lasix 20 mg orally every day. Continued spironolactone 25 mg orally
every day. Increased lisinopril to 30 mg orally every day to optimize heart
failure regimen at admission; changed to 15 mg orally every day on 10/7 after
SBP dropped to 10/7 . Also , she had apparently been taking this
inconsistently as well.
2. CARDS ISCHEMIA: No active issues. Recent ETT with small reversible
defect involving the basal inferolateral wall. Continued ASA , plavix ,
lipitor.
3. CARDS RHYTHM: W/ known ischemic cardiac disease and EF~35% ( down
to 31% on post-stress by MIBI ) , inclined for AICD placement ( MADIT ).
Discussed with EP and she will see Dr. Grinstead as an outpatient. Repeat Echo
4/3/06 with estimated EF 40%. Defer decision on EP eval to primary
cardiologist Dr. Jonte
4. PULM: Hypoxia in the setting of volume overload. Weaned O2 with
adequate diuresis.
5. HEME: 9/22 course c/b LV thrombus , has been on
anticoagulation. Repeat echo. without thrombus , however apex quite akinetic
and contrast study with stagnant flow concerning for high risk of thrombus
recurrence. Therefore , warfarin was continued in addition to ASA and
plavix. The decision to continue these three medications is deferred to
patient's primary cardiologist , Dr. Jonte . patient has INR drawn locally but is
managed by the PUO coumadin clinic and will f/u with them.
6. ENDO: Initially on regimen of lantus , lispro , and sliding scale.
Then patient acknowledged that she had never been on insulin the past.
Switched to sliding scale alone , transferred on metformin 500 mg orally twice a day
7. PPX: PPI and on coumadin until discharge.
8. CODE: FULL
*******
LABS AT DISCHARGE:
1. WBC 6.84; Hct 36.8; Platelets 228
2. Na+ 141; K+ 4.6; Cl- 106; CO2 31; BUN 37; creatinine 1.0; glucose 90
3. Ca2+ 9.2; Mg2+ 2.1
4. INR 1.6
5. HDL 48/triglycerides 60
During d/c patient questioned lasix dose was reasurred dose change to 20mg orally
qday. patient produced medication list which was different from discharge meds.
patient refused to stay to have medications rectified on d/c summary and left
without signing d/c summary. patient will be contacted in am to go over
instructions new medications. Attending and primary cardiologist notified.
ADDITIONAL COMMENTS: PLEASE CONTACT URGENT CARE ON 7/3 TO BE SEEN BY 1/12 FOR BLOOD WORK
( CREATININE AND ELECTROLYTE CHECK ). CALL AT ( 212 ) 019-1917.
If increasing SOB or development of CP , please seek medical attention
again.
Please measure and record daily weights. If increases by more than 3
pounds , please call Dr. Jonte .
Continue cardiac rehab. as before.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
( 1 ) Titrate lasix as appropriate
( 2 ) Check creatinine and serum electrolytes
No dictated summary
ENTERED BY: GUPTON , ANGELLA , M.D. ( OX65 ) 2/5/06 @ 06:52 PM
****** END OF DISCHARGE ORDERS ******
Document id: 17
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
Y |
- |
N |
N |
N |
362241745 | PUO | 66750039 | | 209406 | 1/30/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/20/1991 Report Status: Signed
Discharge Date: 2/12/1991
HISTORY OF PRESENT ILLNESS: CHIEF COMPLAINT was a 57 year old man
who was status post percutaneous
transluminal coronary angioplasty times 2 , of a left anterior
descending stenosis for unstable angina , and was admitted for new
onset of angina at rest. The patient's cardiac risk factors
included family history , borderline high cholesterol. The patient
had no prior cardiac history , until 12 of June , when he had substernal
chest pain with exertion. He eventually had cardiac
catheterization which showed an 80% proximal left anterior
descending lesion with thrombosis , good left ventricular function.
The patient had percutaneous transluminal coronary angioplasty to
this lesion. He was without symptoms for about 4 weeks , and then
in 23 of August , the patient noted new onset chest pain and left arm
numbness at rest. An electrocardiogram at that time showed sinus
bradycardia at 50 , T-wave inversions in II with flat T-waves in
III , and was otherwise unremarkable. He had an exercise tolerance
test at the time and went on a 9-minute standard Bruce protocol and
stopped secondary to fatigue. The electrocardiogram showed 3 to 4
millimeter ST depressions in the lateral leads , which was highly
predictive of coronary artery disease. At that time , he was repeat
cardiac catheterization which showed a restenosis of his left
anterior descending lesion. He had a repeat percutaneous
transluminal coronary angioplasty of the lesion without
complications. The patient did well for several weeks and was
pain-free. However , 6 days prior to admission , the patient began
to note occasional episodes of left arm numbness , which was always
relieved with sublingual nitroglycerin. There was no accompanying
dizziness , nausea , vomiting , diaphoresis. The patient at first had
2 or 3 episodes a day , now increased to 7 or 8 times a day at the
time of admission. On the day of adimssion , the patient had almost
constant chest pain and arm pain which lasted almost all day , only
partially relieved by sublingual nitroglycerin. The patient was
very concerned about the pain , and now comes to Pagham University Of for further evaluation. PAST MEDICAL HISTORY included
arthritis , kidney stones , chronic lower back pain. MEDICATIONS ON
ADMISSION were Lopressor 25 milligrams by mouth twice a day ,
aspirin 325 milligrams by mouth per day , Isordil 10 milligrams by
mouth 3 times a day. ALLERGIES included no known drug allergies.
SOCIAL HISTORY revealed the patient was a retired firefighter ,
occasional red wine , no tobacco use. His brother had 3 myocardial
infarctions in the past , no other FAMILY HISTORY.
PHYSICAL EXAMINATION: The patient was afebrile , pulse 54 , blood
pressure 104/70 , respirations 20. There was
no jugular venous distention. Chest was clear. Cardiac
examination showed regular rate and rhythm , normal S1 , S2 , no
peripheral edema. Extremities had good pulses bilaterally in
dorsalis pedis , posterior tibial and femoral.
LABORATORY EXAMINATION: Admitting laboratory values were
remarkable for potassium 4.3 , creatinine
1.0 , hematocrit 40.8. The electrocardiogram showed sinus
bradycardia at 50 , normal intervals , flat T-waves in AVF , V2 and
V3 , QRS axis 0 degrees. Chest x-ray showed no infiltrates or
effusions , no evidence of congestive heart failure.
HOSPITAL COURSE: The patient was admitted on a rule out myocardial
infarction protocol. He had no elevations in his
serum creatinine kinase levels. The patient continued to have
intermittent left arm numbness during his hospital stay. For this
reason , he was taken back for cardiac catheterization , which showed
a 75% proximal left anterior descending lesion believed to be at
the same site as his previous percutaneous transluminal coronary
angioplasty procedures. The patient had successful percutaneous
transluminal coronary angioplasty of the lesion with a 25% residual
stenosis. The patient postoperatively had no further episodes of
chest pain or arm numbness. He had no complications related to the
cardiac catheterization itself. The patient was then discharged.
DISPOSITION: The patient was discharged to home. MEDICATIONS ON
DISCHARGE will be Lopressor 25 milligrams by mouth
twice a day , Ecotrin 1 tablet by mouth per day , diltiazem 60
milligrams by mouth twice a day. The patient was to FOLLOW-UP with
his cardiologist in 1 week.
VH327/5150
KATHERYN SATURNINA GRUNTZ , M.D. WA5 D: 9/5/91
Batch: 5066 Report: H4292Q0 T: 3/9/91
Dictated By: NAOMI K. WOLFENSPERGER , M.D.
Document id: 18
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
Y |
Y |
- |
Y |
N |
Y |
Y |
N |
N |
- |
N |
N |
N |
076954946 | PUO | 61732093 | | 3296510 | 1/21/2006 12:00:00 a.m. | CHF EXACERBATION | Signed | DIS | Admission Date: 3/26/2006 Report Status: Signed
Discharge Date: 7/14/2006
ATTENDING: KATCSMORAK , CARRI MD
DISCHARGE DISPOSITION:
To Rehabilitation Hospital.
DISCHARGE MEDICATIONS:
Enteric-coated aspirin 325 mg orally daily , amiodarone 200 mg orally
daily , Colace 100 mg orally twice a day , insulin NPH 7 units every day before noon and
3 units every afternoon subcutaneously , Atrovent HFA inhaler 2 puffs
inhaled four times a day as needed for wheezing , magnesium gluconate sliding
scale orally daily , oxycodone 5-10 mg orally every 4 hours as needed pain ,
senna tablets one to two tablets orally twice a day as needed constipation ,
spironolactone 25 mg orally daily , Coumadin 1 mg orally every other
day , multivitamin therapeutic one tablet orally daily , Zocor 40 mg
orally daily , torsemide 100 mg orally daily , OxyContin 10 mg orally
twice a day , Cozaar 25 mg orally daily , Remeron 7.5 mg orally every bedtime , and
aspartate insulin sliding scale.
DISCHARGE DIET:
Discharge diet is 2 liters fluid restrict. Liberal house diet.
ADMISSION DIAGNOSIS:
Foot infection.
PRINCIPAL DISCHARGE DIAGNOSIS:
Decompensated congestive heart failure , status post bilateral
knee amputation , status post BKA.
RETURN TO WORK:
Not applicable.
FOLLOW-UP APPOINTMENTS:
Please follow up with primary care physician , Dr. Lizabeth Warpool , at
Loburg Medical Center within one to two weeks.
Please follow up with primary cardiologist , Dr. Earnestine Fiermonte
within one month.
OPERATIONS AND PROCEDURES:
None.
OTHER TREATMENTS AND PROCEDURES:
None.
BRIEF RESUME OF HOSPITAL COURSE:
CHIEF COMPLAINT:
Shortness of breath.
HISTORY OF PRESENT ILLNESS:
A 73-year-old man with a history of coronary artery disease
status post coronary artery bypass graft , ischemic
cardiomyopathy , valvular heart disease , known EF of 15-20% as of
9/19 , was admitted to the Pagham University Of from
Sollic Fredlaer Rehabilitation Hospital Of with signs and symptoms of
decompensated heart failure , and acute on chronic renal failure.
On 8/7/06 , he was admitted with a large left foot toe ulcer
that was nonhealing. Multiple surgeries were performed with
persistent nonhealing wounds: Left great toe amputation on
2/18/06 , which failed to heal despite SFA to perineal artery
bypassing the composite vein. Had a short CICU stay for
hypotension postoperatively , maintained on dobutamine. On
7/25/06 underwent debridement of left medial ulcer. On 10/7/06
transmetatarsal amputation , on 11/22/06 , debridement of
transmetatarsal amputation. On 9/22/06 received a left below
the knee amputation. His renal function had been normal prior to
the final surgery until 5/29/06 to 8/13/06 when his creatinine
rose from 1.3 to 2.2. He was discharged to acute rehabilitation
and was there noted to have this acute renal failure , which was
thought to be due to prerenal azotemia , but his creatinine at
this point had not changed much from 2.2 to 2.5 during his stay.
Diuretics were held at rehabilitation facility until two days
prior to admission. He was noted to have increased shortness of
breath. Patient denies any other symptoms up to that point
except occasional lightheadedness , depressed mood , and lack of
motivation. No orthopnea , uses 1 pillow regularly , denies
paroxysmal nocturnal dyspnea , and denies dyspnea on exertion , but
very limited movement.
PAST MEDICAL HISTORY:
Significant for hypertension , GERD , hypercholesterolemia , CAD
status post MI in 1996 , received a CABG in 5/12 with a LIMA to
LAD , SVG to PDA , SVG to OM1 , and mitral valve annuloplasty.
Diabetes mellitus , insulin-dependent , status post bilateral below
the knee amputation , likely from diabetes related foot ulcers ,
history of atrial fibrillation and atrial flutter , history of
sick sinus syndrome , history of second-degree heart block , AICD
placed 10/27 complicated by hematoma. History of admissions for
hyponatremia. Status post left SFA to perineal artery bypass to
incompetent pain in 10/14 .
MEDICATIONS ON ADMISSION:
Amiodarone 200 mg orally daily. Atrovent one to two puffs inhaled
four times a day as needed for wheezing , Celexa 20 mg orally daily , Coumadin 2.5
mg orally daily , Diovan 80 mg orally daily , enteric-coated aspirin
325 mg orally daily , Lantus 25 units every day subcutaneous , Lasix
160 mg orally twice a day , Lipitor 20 mg orally every bedtime , Lopressor 50 mg
orally twice a day , therapeutic multivitamin one tablet orally daily ,
solsite topical.
IMPRESSION:
On admission , a 73-year-old male with severe cardiomyopathy and
ejection fraction of 15% admitted for decompensated heart failure
in the setting of his diuretics being held due to an acute renal
failure. Review of chart at the time of admission showed renal
failure is actually present since the perioperative period of his
BKA. After being admitted to the cardiology service , he was
diuresed successfully to his dry weight , with a significant
improvement in his oxygen saturation , his creatinine , and venous
congestion.
Other active issues he was treated for include urinary tract
infection , diabetes mellitus , acute on chronic renal failure ,
depression.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Ischemia: Known coronary artery disease
status post CABG x3 , admitted with troponin elevation likely due
to demand in the setting of heart failure for having his
diuretics held. This was noted to trend down post-diuresis. We
continued aspirin. Initially , we held his ACE inhibitor given
history of cough and his ARF , and ultimately restarted the
patient on ARB , after his creatinine had normalized. Statins had
been held until we were certain his liver function tests were
decreasing.
2. Cardiovascular pump: The patient remained in floor volume
overload on presentation , maintained on 2 grams salt daily , 2
liters fluid restriction diet with 1-2 liters per day goal
diuresis attained by using 100 mg intravenous torsemide twice a day with the
addition of 25 mg of hydrochlorothiazide twice a day 30 minutes prior
to each torsemide dose , an average of two liter fluid negative.
Diuresis was affected over the course of a week , and his status
gradually improved. Spironolactone was initially held due to
high K but was re-added on 7/20/06 . His jugular venous
distention dropped from initial presentation above the earlobes
at a 30-degree angle to a JVP of 6-7 cm at 30 degree angle on the
day of discharge. Two days prior to discharge , his creatinine
began to rise , suggesting prerenal azotemia secondary to over
diuresis and when his torsemide was reduced to 100 mg orally daily ,
hydrochlorothiazide was dropped from his regimen , patient's
creatinine began to drop again , and patient was able to maintain
even Ins and Outs of fluid for two days prior to discharge.
3. Cardiovascular rhythm: Patient is ventricularly paced on
symmetry for duration of hospitalization , history of atrial
fibrillation on Coumadin , was maintained on amiodarone during
this hospitalization.
4. Pulmonary: The patient with initial O2 dependence.
Continued inhaled ipratropium his home medication. After
diuresis , the patient was able to achieve oxygen saturation of
100% on room air.
5. Renal: Initial acute on chronic renal failure thought
secondary to volume overload and forward flow in the context of
decompensated congestive heart failure. His renal function
improved , as he was diuresed and his heart likely moved to more
useful part of the starling curve. Renal ultrasound was negative
for hydronephrosis as was test for urine eosinophils.
Hyponatremia was likely due to heart failure improved with
diuresis.
6. Heme: The patient maintained on Coumadin with an INR goal of
2-3. In order to achieve this goal , his Coumadin dose was
adjusted to mg orally every other day. He will be followed by
chemo and Coumadin service after discharge with weekly tests to
make sure that his INR is maintained within this range.
7. Endocrine. Diabetes mellitus , insulin-dependent , covered on
NPH every day before noon and every afternoon with aspartate sliding scale for duration
of hospitalization.
8. Psych: The patient was restarted on Celexa per primary care physician for
likely depressive mood response to recent bilateral knee
amputation. It is what is quite possible that patient's
depression precedes the bilateral knee amputation and informs
much of his overall care. The patient's primary care physician , Dr. Lizabeth D Warpool , aware of the situation and managing as outpatient. The
patient was also seen by the inpatient psychiatry consultation ,
and started on Remeron 7.5 mg orally daily in place of Celexa. He
is discharged on this medication. The patient is status post one
fall from the bed during the hospitalization. Head CT at that
time showed no evidence of bleed or trauma to the head to head.
Examination of back and extremities reveals no focal tenderness
or ecchymoses.
9. Infectious disease. The patient initially treated for
urinary tract infection with uncomplicated course with
ciprofloxacin.
10. Wound: Wound care nurse consulted for BKA wound and small
decubitus on his back , was treated with DuoDERM , BKA site healing
well.
11. Fluids , electrolytes and nutrition: The patient remained on
cardiac , 2000 calorie diabetic diet , however , as it became
apparent that he was severely malnourished , his diet was
liberalized to allow for nutritional supplementation.
12. PPX: The patient maintained on subcutaneous heparin and
Nexium as DVT and GI prophylaxis during this hospitalization.
13. Code status , full code.
TO DO PLAN
1. Discharge the patient to rehab on current regimen. Patient
has been working with physical therapy and OT during this hospitalization and
appears well positioned to take advantage of rehabilitation
facilities services.
2. Maintain new prescription of Remeron , follow up with
psychiatry to assess depressive disorder/adjustment disorder.
3. The patient has been off beta-blocker. primary care physician may choose to
start beta-blocker at a low-dose in the outpatient setting.
4. Fasciculations noted during hospitalization fine
fasciculations at hands in Niland Rawee Hospital . Maybe secondary to
malnutrition and diaries is , but may merit further workup in an
outpatient context.
5. The patient had rising alkaline phosphatase during
hospitalization , CT of chest incidentally showed gallstone
present within the gallbladder , follow up LFTs in the outpatient
context and possible right upper quadrant ultrasound may merit
consideration and further outpatient workup of this patient. The
patient will follow up with Coumadin clinic given goal INR of
2.0-3.0. The patient's creatinine and BUN should be checked
along with electrolytes to make sure patient is doing well on
current maintenance diuretic schedule of 100 mg torsemide orally
daily and spironolactone.
CODE STATUS:
Full code.
DISCHARGE CONDITION:
Stable. Discharged to rehabilitation.
eScription document: 8-9441840 EMSSten Tel
CC: Earnestine M. Fiermonte M.D.
Ing Sa
CC: Lizabeth Warpool M.D.
KERNAN TO DAUTEDI UNIVERSITY OF OF
Ia Blvd.
Dictated By: DIVELBISS , LONNY
Attending: KATCSMORAK , CARRI
Dictation ID 0953106
D: 6/16/06
T: 6/16/06
Document id: 19
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| output/system_intuitive_annotation.xml | intuitive |
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205298095 | PUO | 95928029 | | 638754 | 10/21/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/7/1995 Report Status: Signed
Discharge Date: 10/15/1995
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION.
LIST OF SIGNIFICANT PROBLEMS: DIABETES.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old , white
male with cardiac risk factors of
diabetes , borderline hypertension , male gender , and a positive
family history , who has no prior cardiac history , but now presents
to A Salt Medical Center complaining of substernal chest
pain. Approximately six weeks ago , the patient lifted a 100-pound
bag and the next a.m. , noted substernal chest pressure without
associated symptoms. This pressure lasted approximately three to
five minutes and resolved spontaneously. Since then , the patient
has had two similar episodes of substernal chest pressure that have
occurred while he was exerting himself , once while running during a
basketball game and once again while running on the beach in
Ing Lum Sey Neither episode had associated symptoms ( i.e. , radiation ,
nausea , vomiting , diaphoresis , palpitations ) , and both episodes
lasted less than five minutes and resolved with rest. On the night
prior to admission , the patient was working regripping his golf
clubs and noted a pulling sensation into his chest , which again
resolved with rest. On the morning of admission , the patient awoke
at 4:00 a.m. , noting a 6-7/10 substernal chest pressure associated
with diaphoresis. The pain persisted for five hours , at which time
the patient presented to CHH . At CHH , the patient was found to
have a blood pressure of 152/88 and a heart rate of 76. His
physical examination was benign. However , the patient's
electrocardiogram showed new ST depressions in V2-V5 , T wave
inversions in AVL , and flat T's in 1 and V6. The patient was
treated with two sublingual nitroglycerins and sent to the Pagham University Of . On route to Petersram Medical Center , the patient received
two sublingual nitroglycerin sprays. On arrival , the patient's
pain had dwindled to 1/10 , without associated symptoms. The
patient's blood pressure was 126/80 , with a heart rate of 80. The
patient was treated with an aspirin , a sublingual nitroglycerin ,
nitro paste , Lopressor 5 mg x 1 intravenously , and intravenous
heparin. Upon transfer to the CCU , the patient was pain free. A
repeat electrocardiogram demonstrated resolution of ST depressions
and flat T waves , but persistence of the T wave inversion in AVL.
The patient was admitted for further treatment and to rule out
myocardial infarction. The patient gives no history of edema ,
paroxysmal nocturnal dyspnea , or orthopnea. The patient denies
fevers , upper respiratory infection symptoms , cough , abdominal
pain , nausea , vomiting , diarrhea , dysuria , or weight loss.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for diabetes. The patient has
kidney stones , is status post procedure three to four years ago ,
and a history of sinusitis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: The patient's medications at the time of
admission included only Glyburide 2.5 mg
orally every day
SOCIAL HISTORY: The patient is unmarried. He was the part owner
of a bar. He does not smoke , and he does not
drink.
FAMILY HISTORY: The patient's mother had a myocardial infarction
in her 60's.
PHYSICAL EXAMINATION: The patient is a pleasant , tan male in no
acute distress. Blood pressure , 126/80.
Heart rate , 80. Respiratory rate , 20. Temperature , 98. Oxygen
saturation , 100% on two liters. Head , eyes , ears , nose , and throat
examination was anicteric , with oropharynx benign. Neck was
supple , with no lymphadenopathy. Carotids were 2+ , with no bruits.
Lungs were clear to auscultation bilaterally. Back examination
demonstrated no costovertebral angle tenderness and no spinal
tenderness. Coronary examination revealed a regular rate and
rhythm , distant S1 and S2 , and no murmurs , rubs or gallops.
Abdominal examination was benign. Rectal examination showed guaiac
negative stool. Extremities showed no cyanosis , clubbing , or
edema , with pulses 2+ throughout , and no femoral bruits.
Neurologic examination revealed the patient to be alert and
oriented x 3.
LABORATORY DATA: Laboratory studies on admission revealed the
patient's electrolytes to be within normal
limits , except for a glucose of 293. The first CK returned 970 ,
with an MB fraction of 65.1. Magnesium was 1.6. CBC was within
normal limits , with a hematocrit of 44.1. Coag's were also normal
at 12.7 and 27.4. Chest x-ray showed no enlarged heart and no
infiltrate. Electrocardiogram showed normal sinus rhythm , with a
rate of 60 , and no ST-T changes on the 15 of August , 1995.
However , electrocardiogram at the Kernan To Dautedi University Of Of , pain free , showed normal
sinus rhythm , with a heart rate of 82 , T wave inversions , AVL , and
flat T's in lead 1.
HOSPITAL COURSE: The patient was admitted with a diagnosis of
acute myocardial infarction. Electrocardiogram
changes were consistent with lateral or anterolateral ischemia.
His peak CK's returned at 1 , 330 , with 54.5% MB fractions. The
patient was maintained on heparin and intravenous nitroglycerin for
72 hours after admission and was started on Lopressor and
enteric-coated aspirin at admission. The patient remained chest
pain free for the five days post myocardial infarction and
underwent a submax ETT on the 5 of August , 1995. In addition , an
electrocardiogram was performed , which showed a left ventricle with
73% ejection fraction , upper limits of normal size , and a question
of inferior wall hypokinesis. On the 24 of June , the patient underwent a
submax ETT , which was stopped secondary to chest tightness , with
diagnostic electrocardiogram changes , maximal heart rate of 96 ,
blood pressure of 145/82 , electrocardiogram with 2 mm ST
depressions , persisting into recovery. Because of a positive ETT ,
the patient subsequently underwent cardiac catheterization , which
showed a proximal left circ lesion 70% stenosed , which was
percutaneous transhepatic coronary angioplastied to 20% residual ,
as well as a mid-left circ lesion 70% stenosed , which was
percutaneous transhepatic coronary angioplastied to a 30% residual.
The left anterior descending was found to be diffusely diseased ,
without focal stenoses , and the proximal right coronary artery
showed a 60% shelf-like lesion. The patient did not experience
chest pain or shortness of breath during the procedure. Post
cardiac catheterization/percutaneous transhepatic coronary
angioplasty , the patient was maintained on his glipizide and
atenolol , 50 mg orally every day , and enteric-coated aspirin , as well as
heparin overnight. Two days after the cardiac catheterization , the
patient underwent a second submax ETT. This he performed without
chest discomfort or electrocardiogram changes.
DISPOSITION: The patient was discharged to home on the 16 of September .
CONDITION ON DISCHARGE: The patient's condition at the time of
discharge was stable.
DISCHARGE PLAN: The patient will receive diabetic teaching as
an outpatient with CHH and will follow up with
Dr. Theiling .
DISCHARGE MEDICATIONS: Atenolol 50 mg orally every day , sublingual
nitroglycerins as needed chest pain , and
Glucotrol 5 mg orally every day
Dictated By: MYRTIS VANTULL , M.D.
Attending: BREE M. THEILING , M.D. GP8 AO528/7048
Batch: 9021 Index No. VDTEQY1WXY D: 10/8/95
T: 6/17/95
Document id: 20
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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581312753 | PUO | 77634248 | | 5932655 | 3/20/2006 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 3/27/2006 Report Status:
Discharge Date: 4/5/2006
****** FINAL DISCHARGE ORDERS ******
BONING , FREDDA F 207-67-77-5
Mer
Service: CAR
DISCHARGE PATIENT ON: 8/20/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KATCSMORAK , CARRI GARY , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Override Notice: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
on order for COUMADIN orally ( ref # 178481090 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 100 MG orally DAILY
Alert overridden: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
Number of Doses Required ( approximate ): 20
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FERROUS SULFATE 325 MG orally three times a day Starting Today ( 4/24 )
Food/Drug Interaction Instruction Avoid milk and antacid
GLIPIZIDE 5 MG orally twice a day
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
Alert overridden: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware
ATIVAN ( LORAZEPAM ) 0.5 MG orally every afternoon as needed Insomnia
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
PRAVACHOL ( PRAVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
018429467 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: aware
Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
on order for COUMADIN orally ( ref # 178481090 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: aware
TORSEMIDE 80 MG orally twice a day Starting Today ( 4/24 )
COUMADIN ( WARFARIN SODIUM ) 1 MG orally every afternoon
Starting NOW ( 4/24 )
Instructions: WITHIN HOUR OF PHARMACY APPROVAL
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
on order for ALLOPURINOL orally ( ref # 676820163 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
on order for LEVOXYL orally ( ref # 634337691 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
on order for LEVOFLOXACIN orally ( ref # 675949597 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
Reason for override: aware Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: aware
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Coletta Verry 8/3/06 @ 11AM scheduled ,
Cardiology clinic for blood work ( Nessinee Ker Hospital Medical Center ) 11/1/06 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
congestive heart failure , coronary artery disease , hypertension , diabetes
mellitus , gastroesophageal reflux disease , hypothyroidism , mitral
regurgitation history of repair , lung ca history of lobectomy , endometrial ca history of
TAH/BSO , basal cell carcinoma , chronic renal dysfunction , renal artery
stenosis history of L stent , recurrent flash pulm edema
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous diuretics , electrolyte monitoring , antibiotics
BRIEF RESUME OF HOSPITAL COURSE:
CC: increasing SOB , weight gain
*****
HPI: patient is a 75F with a history of CHF/CAD , a-fib , lung CA history of R wedge
resection. She has been admitted 5-6 times this year for CHF
exacerbation. She was discharged from the hospital on 3/4 after tx
for CHF and PNA and was followed by the CHF RN. Over the past 3 days
since discharge , she has noticed a 3lb weight gain. Additionally , patient
has had increasing SOB , poor sleep. Stable 2 pillow orthopnea but
more comfortable sitting bent over at the waist. Per her primary care physician's
instructions , patient increased Torsemide to 40mg twice a day which did not
increase her UOP.
ROS: +SOB +PND +orthopnea + bilat LE swelling , brief CP , + diarrhea
( 2 per day ) , no palpitations/dizziness.
*****
In ED: T95.6 P74 BP118/65 RR10 SaO2 on 98 on RA patient received 40 Lasix intravenous.
***
Home Medications: 1. ASA 325 , Allopurinol 100 , Nexium 20 , Iron 325 MG
three times a day Glipizide 5 MG twice a day , K-dur 20 twice a day , Levoxyl 100 MCG , Lorazepam 0.5 MG
every day as needed , Toprol Xl 100 MG , MVI , pravastatin 40 mg every bedtime , Torsemide 40 MG
twice a day , Coumadin 1 MG
***
Allergies: NKDA
****
PMH: CRI , hypothyroidism , paroxysmal a-fib , DM , CHF , CAD , lung CA history of
R wedge resection , basal cell CA on lip history of resection , uterine CA s/pTAH.
***
FHx: non contrib
***
Social: Lives with husband across street from KAAH . +tob history ,
-EtOH , -IVDU
***
PE on admit: VS:T: 95.6 P74 BP:118/75 RR10 SaO2 100% on RA , JVP
15cm C/V irreg irreg , no m/g/r. Lungs crackles at R base. Legs
2+ LE edema. +tenderness on L shin/bruise , AAOx3 CXR: no pulm edema ,
improved RLL PNA
****
PE on Discharge - 97.7 P65-84 BP 90-108/50 RR18 93-97% on RA , A&OX3 , more
solid stool , lungs CTA on left , decreased breath sounds on right , JVP
8cm , CV irreg irreg , 1+ lower extremity edema on R , 3+ on LLE
****
Studies: LENI 4/30 - negative for DVT in left lower extremity
C Diff negative
****
Hospital Course: 75F with history of CAD/CHF/lung CA/Afib with 3 days of weight
gain , worsening SOB and orthopnea.
1 )CHF: Patient presented with symptoms of heart failure--PND , elevated
JVP and bilateral LE edema. No clinic evidence of acute coronary
syndrome. She was continued on her CAD regimen of BB , asa , statin. She
was diuresed , initially with lasix 40mg intravenous then 80mg intravenous with excellent
results-->1L negative per day on a twice a day regimen. However , her weight
remained unchanged at 165lb. At time of discharge , she is continuing to
be net negative on orally torsemide. She is discharged with torsemide 80mg
twice a day and will have close VNA and electrolyte follow-up. Dry weight
goal previously had been 155-157lb , but given the resolution in her
symptoms and overall clinical picture , she is discharged above her dry
weight with close follow-up.
2 ) Afib --continue coumadin 1mg , INR on discharge is 2.1
3 ) PNA- Recent RLL PNA for which she completed course of levofloxacin and
cefpodoxime. Diarrhea likely antibiotic associated , was negative for C
diff and responded to lactobacillus supplements.
4 ) Anemia: Chronic iron deficiency. HCT 28.7 but elected not to
transfuse. Continue iron supplement.
5 ) FEN- patient was compliant with a 1.5L fluid restriction and <2g salt
cardiac diabetic diet.
6 ) Diabetes - Was managed on lantus/novolog in house and will resume
orally DM meds on discharge. Continued Levoxyl 100meq. Recent TSH 8/22
wnl. Continue allopurinol for presumed gout.
ADDITIONAL COMMENTS: During this hospitalization you were treated for heart failure. You
should continue to monitor your diet and salt intake. We have increased
your diuretic dose to torsemide 80mg twice a day. Please have your blood
electrolytes checked in 2 days. If you have any chest pain , worsening
shortness of breath , or any other concerning symptom call your doctor or
go to the ER.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. VNA services for cardiopulmonary assessment , weight monitoring , heart
failure monitoring
2. She is discharged on torsemide 80 twice a day and will need her electrolytes
checked in 2 days.
3. Coumadin followed by Dr. Pidro with Flanda Medwan Rorael Memorial Hospital And Health Services
No dictated summary
ENTERED BY: BONEFONT , KEIRA B. , M.D. , PH.D. ( TK84 ) 8/20/06 @ 02:43 PM
****** END OF DISCHARGE ORDERS ******
Document id: 21
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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506204373 | PUO | 74372820 | | 0168083 | 5/4/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed
Discharge Date: 10/2/2005
ATTENDING: PETTINGER , DOUGLASS MD
PRIMARY DIAGNOSES:
1. Atrial fibrillation with RVR.
2. Congestive heart failure.
3. Sick sinus syndrome.
4. Delirium.
OTHER DIAGNOSES:
1. Diabetes , newly diagnosed.
2. Chronic anticoagulation.
3. Hypertension.
4. History of GI bleed.
5. Prior CVA.
HISTORY OF PRESENT ILLNESS:
Mr. Burrs is an 89-year-old male with a history of multiple
medication problems , including hypertension , atrial fibrillation ,
sick sinus syndrome , history of colon cancer and prostate cancer ,
status post embolic stroke in 3/22 , and history of congestive
heart failure with an EF of 40-50% , who presented to the
emergency room complaining of two days of increased lethargy. At
that time , he denied cough , chest pain , shortness of breath , PND
or orthopnea. In the emergency room , the patient was found to
have a heart rate in the 120s with a new left bundle-branch
block. Carotid massage was attempted and the patient blocked to
15:1 due to sick sinus syndrome. An echocardiogram was done in
the emergency room , which revealed an EF of 25%. It was felt
that the patient was in acute congestive heart failure
exacerbation secondary to the atrial fibrillation with RVR. It
was deemed at that time too dangerous to pharmacologically
convert the patient. He was transferred to the Coronary Care
Unit for placement of a transvenous pacer.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Arthritis.
3. Atrial fibrillation , on anticoagulation.
4. History of prostate cancer , status post prostatectomy.
5. History of colon cancer , status post partial colectomy.
6. History of dementia.
7. History of GI bleed.
8. Status post MRSA wound infection.
9. Status post embolic CVA in 6/17/05 .
10. Sick sinus syndrome.
HOME MEDICATIONS:
1. Colace.
2. Coumadin.
3. Folate.
4. Synthroid 25 mcg daily.
5. Toprol 50 mg orally twice a day
6. Protonix.
7. Zyprexa.
8. Aspirin.
ALLERGIES:
No known allergies.
SOCIAL HISTORY:
The patient denies cigarette , drug or alcohol use.
FAMILY HISTORY:
The patient had a father who died at the age of 63 of a heart
attack. There is a family history of colon cancer.
PHYSICAL EXAMINATION ON ADMISSION:
Afebrile , pulse irregular , 125; blood pressure 140/100. Pulse
oximetry was 97% on 2 liters. General: This is an elderly male
in no acute distress. Neck: Supple , no lymphadenopathy , no
thyroid enlargement , JVP at 18 cm with flutter waves. Carotids
are 2+ bilaterally. Pulmonary: Bibasilar rales.
Cardiovascular: Irregular rate and rhythm , tachycardic , S1 , S2
normal. No murmurs , rubs or gallops. Abdomen: Soft , nontender
and nondistended. Bowel sounds are present. Extremities: Warm
bilaterally , 2+ pitting lower extremity edema. No clubbing or
cyanosis.
LABORATORY STUDIES UPON ADMISSION:
Notable for mild elevation of the white blood cell count of 11.0 ,
hematocrit of 40.6 , and platelets of 218 , 000. Electrolytes were
within normal limits. The creatinine was mildly elevated at 1.3.
BNP was markedly elevated at 7931. Coagulation showed an INR of
2.9. LFTs were within normal limits. Cardiac enzymes showed a
CK of 129 , CK-MB of 5.9 , and an elevated troponin at 0.27. EKG:
Atrial flutter with RVR , rate in the 120s , and new left
bundle-branch block. Chest x-ray: Cardiomegaly and
cephalization , no acute infiltrate.
ASSESSMENT AND PLAN UPON ADMISSION:
This is an 89-year-old male with a history of sick sinus
syndrome , atrial fibrillation , on Coumadin , as well as congestive
heart failure , who was admitted for atrial fibrillation/atrial
flutter with RVR , and decompensated congestive heart failure. At
the time of admission , the patient was felt to be at risk
secondary to his sick sinus syndrome and new left bundle-branch
block. He was felt to be at risk for asystole and symptomatic
bradycardia with any blocking agents. Therefore , transvenous
pacer was scheduled to be placed in the Cath Lab.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular:
a. Rhythm: Shortly after admission , the patient had a temporary
ventricular pacer placed on 9/13/05 with a heart rate of less
than 50. After the procedure , the patient was admitted to the
CCU with atrial flutter with RVR and a rate in the 20s. The rate
was intermittently controlled with a combination of intravenous digoxin
and Lopressor. On 6/6/05 , a permanent dual-chamber pacemaker
was implanted with VVI at 50. Throughout the next two days , the
patient's heart rate continued to be difficult to control , but
improved with diltiazem. The patient was initiated on an
amiodarone load on 8/22/05 . The following day , he converted to
normal sinus rhythm spontaneously. At that time , he continued to
be ventricularly paced , and the pacemaker was changed to DDD on
10/21/05 . For the remainder of the hospitalization , the patient
remained in normal sinus rhythm and was dual-paced without any
recurrence of arrhythmias. He will be continued on his
amiodarone load , which was 2.9 g upon discharge and we continued
for a total load of 10 g.
b. Pump: Upon admission , an echocardiogram on 5/23/05 showed
an EF of 20-25% with regional wall motion abnormalities noted in
the intraventricular septum , which was akinetic as well as global
hyperkinesis of the left ventricle. On admission , the patient
had indications of heart failure , including increased JVP and
bilateral lower extremity edema , as well as pulmonary effusions.
The patient was diuresed effectively with low-dose intravenous Lasix. His
admission weight was 91 kg , and upon discharge , it was
approximately 87 kg. The patient was given intermittent Lasix 10
mg intravenous for diuresis to maintain a negative I&O of 500 mL. Upon
discharge , the patient may require continued diuresis with home
regimen of orally Lasix. In addition , the patient was noted to
have marked hypertension throughout his stay. Blood pressure was
occasionally difficulty to control , and at times , required intravenous
nitro drip. Systolic blood pressures were noted to as high as
180 and as low as 100 with intravenous nitro drip. The patient's blood
pressure was managed with calcium channel blocker , beta-blocker ,
as well as ACE inhibitor. Upon transfer to the cardiology floor
on 10/21/05 , the orally diltiazem was increased. Upon discharge ,
the patient will be continued on a home regimen of lisinopril 10
mg orally daily , Toprol-XL 100 mg orally twice a day , and diltiazem
extended release 360 mg orally daily. At the time of discharge ,
the patient's blood pressure was well controlled with systolic
blood pressures ranging from 110 to 120s.
c. Ischemia: Upon admission , the patient had cardiac enzyme
elevation with initially 0.27 , which elevated to a max of 1.27 on
10/23/05 . Initially , the enzyme elevations were thought to be
secondary to demand ischemia in the setting of an elevated heart
rate and volume overload. However , the patient underwent a
cardiac catheterization on 2/25/05 which showed evidence of
coronary artery disease , two-vessel disease , specifically , there
was a LAD proximal 90% lesion as well as diffuse proximal-mid
standing 80% lesion , as well as RTLV-BR mid discrete 80% lesion
beyond the bifurcation of RPDA. On 2/25/05 , the patient had a
successful roto-ablation , angioplasty , and insertion of three
cipher DES to the LAD resulting in TIMI 2 flow. On 1/1/05 , the
patient returned to the cath lab , and at that time , he had a DES
placement at distal RCA. The patient denied a chest pain
throughout his stay. Upon discharge , he was able to ambulate
without significant dyspnea on exertion or chest discomfort.
2. Psychiatry: At the beginning of the hospital stay , the
patient was confused and somewhat agitated. His behavior was
controlled with Haldol as well as as needed Ativan. The patient's
confusion and delirium improved significantly , and the Haldol and
Ativan were tapered off. Prior to discharge , he was reinitiated
on his home regimen of Zyprexa. The patient has a longstanding
history of dementia. Geriatrics consult followed in this case
and advised on titration of a Haldol.
3. Vascular: Following the cardiac catheterization , the patient
was noted to have a right femoral bruit. A vacular ultrasound
was obtained on 7/18/05 and did not show any evidence of an AV
fistula.
4. Heme: The patient is on chronic anticoagulation for atrial
fibrillation. Upon admission , his INR was 2.9 and became
elevated to a supratherapeutic level. Therefore , his Coumadin
was held. The patient will be reinitiated on Coumadin when his
INR is below 2. Goal INR will be between 2 and 3.
5. Endocrine: The patient has a history of hypothyroidism and
was continued on his home dose of Synthroid 25 mcg orally daily.
Thyroid function tests were checked and were within normal
limits. In addition , the patient was noted to have mildly
elevated fasting blood glucoses during his admission. His blood
sugars ranged from 95 to 182. He was maintained on a regular
sliding scale insulin and required only minimal units of
supplemental insulin. A hemoglobin A1c was ordered , and the
results are still pending at this time.
6. GI: The patient was noted to have significant constipation
throughout his stay and was continued on an aggressive bowel
regimen , which included Colace , senna , lactulose , and Dulcolax.
The patient has a history of GI bleed. He was noted to have a
small amount of blood in the stools secondary to constipation ,
but this was resolved with additional bowel movements. His
hematocrit remained stable , with no signs of anemia. The patient
does have a history of colon cancer for which he underwent a
colectomy. He will be followed as an outpatient.
7. FEN: Due to the patient's heart failure , he was placed on a
2-liter fluid restriction as well as 2 g salt restriction. The
patient was continued on a low-cholesterol , low-salt diet. Due
to his mild sedation with Haldol , the patient was evaluated by
speech and swallow and initially placed on mechanical soft diet
with some honey-thick liquids. As his mental status improved
significantly , the patient was returned to a house diet ,
low-cholesterol , low-fat , with the previous salt and fluid
restrictions. The patient was continued on light scale
throughout his stay.
8. ID: The patient was noted to have a urinary tract infection
based on urinalysis upon admission. His culture remained
negative throughout his stay. He was initially given
ceftriaxone. Initially , he was started on Keflex following on
pacemaker placement for antibiotic coverage , which was
discontinued on 1/12/05 . The patient remained afebrile , with no
signs of systemic infection throughout his stay.
9. Prophylaxis: The patient was placed on a PPI. His INR
remained subtherapeutic throughout his stay.
COMPLICATIONS:
None.
CONSULTANTS:
EP fellow , Dr. Cabreja attending Dr. Dominguez .
PHYSICAL EXAMINATION UPON DISCHARGE:
General: This is a pleasant elderly female in no acute distress ,
alert and oriented x3. HEENT: Normocephalic and atraumatic.
Extraocular motions are intact. Pupils are equal , round and
reactive to light. Neck: Supple , no lymphadenopathy.
Cardiovascular: Regular rate and rhythm , no murmurs , rubs or
gallops , normal S1 , S2. JVP at 9 cm. Respiratory: Sparse
bibasilar crackles that cleared with cough. Abdomen: Soft ,
nontender and nondistended , bowel sounds present. Extremities:
Trace edema bilaterally , no clubbing or cyanosis. Pedal pulses
are palpable. Neuro: Cranial nerves II-XII are grossly intact.
There will be an addendum to this discharge summary , which will
include discharge medications and follow-up plans.
eScription document: 5-1521769 EMSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: PETTINGER , DOUGLASS
Dictation ID 8276341
D: 7/18/05
T: 7/18/05
Document id: 22
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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015428741 | PUO | 26040636 | | 315039 | 10/13/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/28/1992 Report Status: Signed
Discharge Date: 11/6/1992
ADMISSION DIAGNOSIS: STATUS POST TRANSIENT ISCHEMIC ATTACK
COMPLICATED BY A LONG HISTORY OF VERTIGO.
HISTORY OF PRESENT ILLNESS: Patient was in her usual state of
health until the day of admission when
she had sudden onset of increased vertigo , dizziness , and near
syncope as well as left leg weakness and dysarthria. She had a
mild frontal headache , no palpitations , no chest pain , and no
shortness of breath. These symptoms lasted two to three hours with
slow gradual improvement. She phoned her CHH doctor who referred
her to Pagham University Of . On admission , she complained
of no residual symptoms. She had no visual changes , no amaurosis ,
no paresthesias or numbness , and was feeling at her baseline. Her
history , of pertinence , in 1988 , she had a syncopal episode. A
Holter at that time revealed some atrial fibrillation and
non-sustained ventricular tachycardia for which she was started on
Atenolol. In 1990 , she had a villous adenoma diagnosed and
underwent an abdominoperineal resection complicated by
post-operative atrial fibrillation. She ruled out for myocardial
infarction at that time. For the past year , she has described
intermittent episodes of dizziness , so called room spinning , and
fatigue lasting for a few minutes occurring only once a month. She
has no other significant past medical history besides hypertension.
ALLERGIES: She has no known drug allergies. She is a non-smoker
and non-drinker. She is a Mexican speaking woman who lives alone
with a number of family members nearby. CURRENT MEDICATIONS: She
was on Atenolol 50 mg every day
PHYSICAL EXAMINATION: She was a pleasant Mexican speaking elderly
woman in no acute distress. Vital signs
showed her to be afebrile , blood pressure 160/80 lying down , 160/80
sitting up , pulse 70 lying down with pulse 76 sitting , and
respiratory rate 16. HEENT: Examination showed normal cranium ,
atraumatic , extraocular movements intact , and pupils equal , round ,
and reactive to light. She had bilateral cataracts detected and
her oropharynx was clear and within normal limits. NECK: She had
no jugular venous distention , neck was supple , she had full range
of motion , and her carotids were 1+ bilaterally with good upstroke.
No bruits were appreciated. LUNGS: Clear bilaterally. No spinal
or costovertebral angle tenderness appreciate. CARDIAC:
Examination showed rate and rhythm were regular , S1 and S2 , an S4
was appreciated , and no S3 with a I/VI systolic ejection murmur.
ABDOMEN: She had a colostomy , her abdomen was soft and non-tender ,
positive bowel sounds , and no masses. EXTREMITIES: No clubbing ,
cyanosis , or edema. No rashes were appreciated. NEUROLOGICAL:
Examination was non-focal. She was alert and oriented times three
and cranial nerves II-XII were within normal limits. Motor
examination showed 5/5 strength with no pronator drift and sensory
examination was grossly within normal limits. Deep tendon reflexes
were 1+ bilaterally and symmetric with downgoing toes and
finger-to-nose was within normal limits.
LABORATORY EXAMINATION: Sodium 140 , potassium 4.1 , chloride 107 ,
bicarbonate 22 , BUN 28 , creatinine 1.2 ,
and glucose 123. Hematocrit was 38.2% , white count 11.2 with a
normal differential , and platelets were 291. physical therapy was 12.9 and PTT
was 24.3. Admission CK was 50. Urinalysis revealed 60-80 white
blood cells , no red blood cells , and 1+ squamous epithelium in the
sediment. Portable chest X-Ray was within normal limits except for
a tortuous aorta and admission EKG showed sinus bradycardia at 58 ,
intervals 0.18/0.09/0.44 , an axis of negative 21 degrees , there was
evidence of left ventricular hypertrophy by voltage criteria , and a
flipped T wave in III which was new compared with an EKG of February
1990. There were no acute ST changes. Head CT on admission
revealed an old lacune in the right internal capsule , some
paraventricular white matter low density changes with evidence of a
lacunar infarct in her right cerebellum which was of indeterminant
age.
HOSPITAL COURSE: The impression on admission was that this was a
75 year old white female with a history of
hypertension and a history of atrial fibrillation , non-sustained ,
who presents with a two to three hour episode of vertigo and left
sided weakness which spontaneously resolved. She was admitted for
further evaluation of this transient ischemic attack thought to be
due either a vertebovascular insufficiency syndrome , anterior
circulation , carotid stenosis , or an embolus from a cardiac source.
Neurology was consulted and , in addition , she was entered on a rule
out protocol for a myocardial infarction. Her abnormal urinalysis
was also of concern despite her lack of symptoms and she was
afebrile. Repeat urinalysis was ordered and urine was sent for
culture and sensitivity. Hospital course over the next few days ,
the patient remained completely asymptomatic except for an
occasional complaint of mild palpitations , occasional vertigo , and
occasional frontal headache. She was started on Coumadin on
hospital day number two for which she entered therapeutic range by
hospital day number four. On hospital day number two , she had a
Holter placed which showed normal sinus rhythm for 24 hours except
for one five-beat run of ventricular tachycardia and two episodes
of atrial fibrillation/flutter , the longest lasting thirteen beats.
On hospital day number two , she had an echocardiogram which showed
concentric left ventricular hypertrophy without evidence of
thrombus or valvular disease. On hospital day number four , she had
a carotid non-invasive study which revealed completely patent
carotid arteries without evidence of stenosis or atherosclerotic
lesions. On hospital day number five , she had a magnetic resonance
imaging of her head with angiogram , the results of which were
pending at the time of discharge. After being hospitalized for
five days , the patient was completely stable in therapeutic range
on Coumadin without focal neurologic findings and without obvious
source of her transient ischemic attack beyond a mild transient
arrhythmia. Therefore , she was discharged with instructions to
follow-up with her regular CHH physician for continued monitoring
of her Coumadin dosing and physical therapy levels as well as long-term
instructions for follow-up care.
DISPOSITION: DISCHARGE MEDICATIONS: Atenolol 50 mg every day and
Coumadin 5 mg every bedtime
BY745/7320
DESIRAE MARCOTT , M.D. RG26 D: 10/10/92
Batch: 5812 Report: U6594M3 T: 3/3/92
Dictated By: DEJA KINTOPP , M.S.
cc: 1. HERMINA T. TUOMALA , M.D.
Document id: 23
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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171486426 | PUO | 43712082 | | 5442797 | 7/6/2006 12:00:00 a.m. | PNEUMONIA | Unsigned | DIS | Admission Date: 6/2/2006 Report Status: Unsigned
Discharge Date: 3/3/2006
ATTENDING: COCOMAZZI , REA M.D.
SERVICE: ENMH .
DISCHARGE DIAGNOSES:
Pneumonia and UTI.
ASSOCIATED DISCHARGE DIAGNOSES:
1. History of right MCA embolic stroke on 5/15 status post
right ICA on 3/1/06 .
2. History of temporal lobe epilepsy.
3. ADD.
4. Stage III non-small-cell lung cancer status post XRT and
chemo.
5. Hypertension.
6. Asthma.
7. Graves' disease.
8. Depression.
9. History of subclavian steal syndrome.
10. History of urinary tract infection.
HISTORY OF PRESENT ILLNESS:
This is a 63-year-old right-handed lady with history of stage III
non-small-cell lung cancer status post XRT and chemotherapy ,
history of right MCA stroke status post right CEA on 3/1/06 for
70% stenosis of the right ICA , question history of right temporal
lobe epilepsy , who was readmitted to the medicine service from
her nursing home for question of altered mental status , fever ,
and cough. The patient was recently admitted from 2/24/06 to
1/5/06 for change in mental status , treated for presumed UTI
but grew with yeast but no bacteria. The patient was consulted
by neurology for increased somnolence. She had a head CT at that
time that shows encephalomalacia in right MCA distribution
consistent with old stroke with no acute intracranial
hemorrhages , midline shifts , or mass effect. No definite
metastatic lesions were observed. Per patient's oncologist , her
response to treatment has been excellent. She has a negative
EEG. MRI/MRA always shows the right MCA infarct. Normal B12 ,
folate , TSH , and RPR. Neurology at that time agreed that no
further evaluation of somnolence is necessary at this time and
leptomeningeal disease is unlikely given her lack of neurological
finding. The patient was then transferred to rehab on 1/5/06 .
Per nursing and discussion with house staff , the patient has had
waxing and waning mental status and at times appearing alert and
appropriate and other times somewhat hallucinating and agitated.
She also had periods of cough and fever and pain on urination.
According to the son , she has had a cough for the last 10 days
prior to admission. She has not been eating adequately with food
sticking out from her mouth and not quite responsive. She had a
chest x-ray done on 7/26/06 that shows a right hilar mass and
right upper lobe infiltrate. She was started on moxifloxacin 400
mg orally daily on 7/26/06 and then she was transferred here at
Lostedin Nassjoh Valley Hospital at the son's request for change in mental
status , cough , and fever and presumed pneumonia.
In the ED , her temperature was 98.8 , pulse 122 , blood pressure
160/68 , breathing at 20. She got vancomycin , levofloxacin , and 4
L of fluids. Chest x-ray was consistent with right upper lobe
pneumonia , question of postobstructive pneumonia. Her UA was
quite dirty with oxalate crystal , yeast , and 100+ white blood
cells. She was started on vancomycin and levofloxacin for
presumed pneumonia and UTI. Her head CT was negative for any
acute change but also shows chronic right MCA infarct. The
patient was transferred to the floor for further management.
PAST MEDICAL HISTORY:
1. Right MCA embolic CVA 5/15 status post right ICA on
3/1/06 .
2. History of temporal lobe epilepsy followed by Adele Ahlm at
TEVH .
3. ADD.
4. Stage III non-small-cell lung cancer status post XRT and
chemo.
5. Hypertension.
6. Asthma.
7. Graves' disease.
8. Depression.
9. History of subclavian steal syndrome.
10. History of urinary tract infection.
PAST SURGICAL HISTORY:
1. She had bilateral salpingo-oophorectomy 30 years ago.
2. History of radioactive iodine for Graves' disease 30 years
ago.
MEDICATIONS ON ADMISSION:
1. Cymbalta 20 mg twice a day
2. Lamictal 20 mg twice a day
3. Zydis 5 mg twice a day as needed
4. Seroquel 100 mg twice a day as needed
5. Niferex 150 mg twice a day orally
6. Lovenox 40 mg subcutaneously daily.
7. Vitamin B12.
8. Toprol XL 100 mg daily.
9. Zocor 20 mg daily.
10. Prilosec 20 mg orally daily.
11. Lactulose 30 mg orally four times a day as needed constipation.
12. Synthroid 125 mcg orally daily.
13. Ritalin 2.5 mg orally twice a day
14. Compazine 10 mg orally twice a day
15. Lidoderm patch 5% topical.
16. Dilaudid 2 mg orally every afternoon
17. NovoLog sliding scale.
18. APAP 500 mg two tabs twice a day
ALLERGIES:
To intravenous contrast , penicillin for which she has a hive reaction ,
valproic acid and sulfa drugs. Demerol causes hypertension.
SOCIAL HISTORY:
She is divorced , with two children. No alcohol use recently.
100-pack-year history of smoking but quit , occasionally still
asks for cigarettes. The patient feels that she feels better on
nicotine patch.
FAMILY HISTORY:
Father died of MI at 73 , mother died in her 80s of emphysema.
PHYSICAL EXAMINATION:
Vital signs: Temperature 98.8 , pulse 122 , blood pressure 116/68 ,
respiratory rate 20 , O2 saturation 90% on 2 L. She was a
chronically ill-appearing , minimally verbal , responding to
commands. HEENT: PERRL , EOMI , dry mucus membrane , poor
dentition , and no orally lesions. Neck: Supple , no LAD , with
healing incisions on the right. Chest: Rhonchorous crackles
right greater than left. Decreased breath sounds in her right
upper lobe with occasional wheezes. Cardiac: Tachy , regular
rate , normal S1 and S2 , no murmur , rub , or gallop. Abdomen:
Soft , nontender , nondistended , mild tenderness on palpation on
the right quadrant. Extremities: No cyanosis , clubbing , or
edema , 2+ DP pulses , contraction from upper extremity from stroke
bilaterally , worse on the left. Left hand in a brace. Skin: No
rashes , petechiae. Neuro: Oriented x2 , waxing and waning
mental status: Left-sided weakness , 0/5 strength upper
extremity , 1/5 strength lower extremity , 2+ reflexes throughout.
LABORATORY DATA:
Her labs are basically unremarkable. Lytes; her white count is
14.2 , hematocrit 37.6. She does have 2% polyps , 6% bands. LFTs
remarkable only for elevated alkaline phosphatase of 126.
Albumin is 3.4. Her cardiac enzymes are less than assay. Chest
x-ray shows overall unchanged ill-defined right hilar mass and
prior new faint parenchymal opacity in the right upper lobe
concerning to early pneumonia that can be postobstructive. EKG
is tachy , normal sinus rhythm , no ST-T wave changes. Head CT , no
acute change , chronic right MCA infarct. Echo , trace MR , EF
55-60% , known LV function with diastolic dysfunction.
ASSESSMENT AND PLAN:
This is a 64-year-old right-handed woman with history of stage
III non-small-cell lung cancer status post XRT and chemotherapy ,
history of right ICA stroke status post right RCA 3/1/06 ,
recent hospitalization for change in mental status and UTI who
was admitted from nursing home for altered mental status , fever ,
and cough and dysuria. Found to have pyuria with calcium oxalate
crystal , new right upper lobe opacity concerning for
postobstructive pneumonia. Her head CT was unchanged. The
patient was admitted for presumed pneumonia and UTI.
ID: The patient has elevated white blood cell count bandemia in
the setting of right upper lobe opacity concerning for
postobstructive pneumonia and also with pyuria with yeast. The
patient received vancomycin and levofloxacin in the ED. She was
briefly put on vancomycin and levofloxacin and added Flagyl for
aspiration pneumonia. She subsequently also switched over to
vancomycin , Ceptaz , and Flagyl to cover for pseudomonas. Her
urine culture grew out yeast and her blood culture was negative
to date. Her antibiotic regimen was changed back to
levofloxacin , Flagyl on orally regimen. On postoperative day #4 ,
she was improving. She did have one brief episode of
hypertension on hospital day #2 that responded to intravenous fluids. She
has required no escalation in antibiotics and tolerated
levofloxacin and Flagyl quite well. She will continue her
levofloxacin and Flagyl for an additional 14 days. She also got
a chest CT that shows right upper lobe pneumonia and also
question of consolidation in right lung with underlying
emphysema. The consolidation is contiguous with the right hilum
and underlying hilar adenopathy or hilar mass cannot be excluded.
She also has small right pleural effusion. The findings were
discussed with Dr. Enamorado who is her oncologist and he felt that
she is likely having post XRT changes and no further workup is
necessary for now. She will continue to finish her course of
antibiotics of orally levofloxacin and Flagyl for 14 days.
Urology: Her UTI shows yeast. Given that the fact that she has
multiple episodes of yeast UTI currently , she was treated with
fluconazole for three days.
Neuro: She has changes in mental status waxing and waning ,
however , the patient's mental status has greatly improved
throughout her hospital stay although with occasional episode of
hallucinations. For example she was thinking that the resident
is her niece. Psych , onch , and geriatrics was asked to see the
patient at the son's request. Both psy onc and geriatrics
believed that her change in mental status is multifactorial , and
is likely a result of delirium rather than dementia. They
recommended avoiding pain meds and oversedating meds and started
her on zyprexa 5mg twice a day , 2.5mg twice a day as needed agitation , and can increase
to 10mg orally every bedtime if necessary for agitation. She was continued on
her Lamictal and Cymbalta and has no further neurological
decompensation. Her Seroquel was decreased to 50 mg twice a day
as needed and Zydis 5 mg orally as needed , however , she was not receiving
these medications as she was not agitated. She had one dose of
seroquel on 3/11 early am and got really over sedated. Seroquel
was d/c and patient should not be receiving seroquel in the
future for risk of oversedation. Her vitals were stable
throughout.
CV: History of controlled prolonged QTC on Haldol. Her Haldol
was DC'd last admission , is now on Zyprexa and Seroquel. Her
EKGs were stable throughout her hospital stays.
Heme/Onch: The patient has history of stage III non-small-cell
lung cancer status post XRT and chemotherapy and is followed by
her outpatient oncologist , Dr. Rossie Mankoski , at the Setlake Caardlin County Medical Center as well as the outpatient psycho/onch social
worker whose name is Dr. Gaylene Faniel . The patient was seen by
psych/onch and geriatric. Dr. Enamorado stated that she does not
have any further chemotherapy treatment planned for the future.
He will evaluate her when he sees her again in clinic. She is
not currently at the best medical condition to receive any
further therapy.
Endocrine: She was given NovoLog sliding scale for diabetes and
levothyroxine for history of Graves' and history of radioiodine
ablation.
FEN: the patient was seen by speech and swallow for question of
dysphagia and difficulty with swallowing and eating. The
patient's video flow examination shows prolonged orally phase , but
she did well on the rest of her video swallow examination so she
was put on a mince ground diet and thin liquids. Alternate
liquids and solids with tongue sweep to remove orally cavity
residue. The patient recommended to sit upright to take small
bites and sips. She should be seen by speech and swallow for
follow up swallow treatments two to three times per week. She
also was given nutrition consult who started the calorie counts.
Nutrition recommended that she may be need long-term nutritional
therapy if she does not meet her nutritional goal. That will be
deferred to her outpatient doctors at a later time. She will
need assists and encouragement with feeding. She was also given
Nexium for prophylaxis and replete her lytes with an American
Diabetic Diet with low salt. She was given Lovenox and PPI for
prophylaxis.
CODE: Full code.
The patient is discharged to rehab in stable condition.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed headache.
2. Albuterol inhaler two puffs inhaler every 6 hours as needed shortness of
breath or wheezing.
3. Aspirin 81 mg orally daily.
4. Dulcolax 5-10 mg orally daily as needed constipation.
5. Vitamin B12 50 mcg orally daily.
6. Colace 100 mg orally twice a day
7. Dilaudid 1-2 mg orally every 12 hours as needed pain.
8. Ibuprofen 600 mg orally every 6 hours as needed pain and temperature.
9. Lactulose 30 mL orally four times a day as needed constipation.
10. Synthroid 125 mcg orally daily.
11. Ritalin 2.5 mg orally twice a day
12. Toprol XL 100 mg orally daily.
13. Flagyl 500 mg orally three times a day x14 days.
14. Niferex 150 mg orally twice a day
15. Senna two tabs orally twice a day
16. Zocor 20 mg orally every bedtime
17. Neurontin 100 mg orally twice a day
18. Compazine 5-10 mg orally every 6 hours as needed nausea.
19. Lovenox 20 mg subcutaneously daily.
20. Lamictal 200 mg orally twice a day
21. Levofloxacin 500 mg orally daily x14 days.
22. Seroquel 50 mg orally twice a day as needed insomnia and anxiety.
23. Nexium 20 mg orally daily.
24. Combivent neb every 6 hours as needed shortness of breath.
25. Zydis 5 mg orally twice a day as needed anxiety.
26. Lidoderm 5% patch topical daily.
27. NovoLog sliding scale before every meal and every bedtime
28. Cymbalta 20 mg orally twice a day
DISPOSITION:
The patient is to be discharged to rehab. She will follow up
with her primary care physician and Dr. Enamorado .
eScription document: 5-7990038 EMSSten Tel
CC: Rea Cocomazzi M.D.
Dictated By: STRAHL , ROSAURA
Attending: COCOMAZZI , REA
Dictation ID 9464454
D: 9/24/06
T: 9/24/06
Document id: 24
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000012052 | PUO | 18541153 | | 8135304 | 4/2/2005 12:00:00 a.m. | UTI | | DIS | Admission Date: 4/10/2005 Report Status:
Discharge Date: 9/6/2005
****** FINAL DISCHARGE ORDERS ******
BACHMAN , LEONIE K. 390-11-18-0
Vallridale Na Ho
Service: MED
DISCHARGE PATIENT ON: 2/25/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ELAVIL ( AMITRIPTYLINE HCL ) 25 MG orally every bedtime
Override Notice: Override added on 10/30/05 by
BUECKERS , CLEMENTINA O. , M.D.
on order for LEVOFLOXACIN intravenous ( ref # 79785165 )
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: aware
ATENOLOL 100 MG orally every day
CIPROFLOXACIN 250 MG orally every 12 hours
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
FLUOXETINE HCL 20 MG orally every day
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 10/30/05 by
BUECKERS , CLEMENTINA O. , M.D.
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
LORAZEPAM 1 MG orally every day as needed Anxiety
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/30/05 by
BUECKERS , CLEMENTINA O. , M.D.
on order for GEMFIBROZIL orally ( ref # 10026063 )
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
AMLODIPINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
VICODIN ( HYDROCODONE 5 MG + APAP ) 1-2 TAB orally every 6 hours
Starting Today ( 9/2 ) as needed Pain
IRBESARTAN 300 MG orally every day
Number of Doses Required ( approximate ): 10
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please follow-up with primary care physician at your previously scheduled appointment. 6/6/05 ,
ALLERGY: ORPHENADRINE CITRATE ,
ANGIOTENSIN CONVERTING ENZYME INHIBITOR
ADMIT DIAGNOSIS:
UTI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
UTI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
?CARDIOMYOPATHY EF=39%( 1989 HTN
SEVERE HYPERCHOL/HYPER TG POORLY CONTROLLED DM history of
CHOLE/APPY/TAH DIFFUSE ABDOMINAL PAIN ELEVATED
LIPASE ALLG: SULFA/AMOXICILLIN
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Labs , Antibiotis , CXR , EKG , Telemetry
BRIEF RESUME OF HOSPITAL COURSE:
CC: n/v/diarrhea
HPI: 66 y'o woman with a hx of HTN , DM , Hypercholesterolemia , known CAD
USOH until 3 wks ago when she developed vague abd discomfort. The
abd discomfort progressed and three days ago she developed acute onset
n/v/diarrhea , dysuria and subjective fevers and chills. She also
reports some back pain. No melena , BRBPR. No gross
hematuria.
PE: T= 99.0 HR= 72 BP=130-170/82-96 in R arm , 102-130/82-100 in L arm.
R=20 02sat= 95 RA. NAD , PERRL , slightly dry MM. JVP 7cm. RRR Nl s1 and
s2. 2/6 SEM audible throughout. No r/g. Lungs CTAB. Abd Soft , ND.
Bsx4. Diffusely tender. NO CVAT. Poor DPP pulses. No
edema.
A/P: 66 y'o owman with HTN , DM , known CAD p/with n/v/f/c
abd pain found to have a UTI and ARF. Also notable on admission were
ST depressions in V3-V5.
1 ) ID-UTI - Rx with ciprofloxacin. Urine cxs notable for greater than
100.00 E. Coli. Blood cx without growth. Improvement in abd pain and CVAT
after one day of treatment with intravenous ciprofloxacin.
2 ) Renal - ARF likely prerenal in the setting of
UTI/infection and pre-renal state. NS followed by maintenance with
complete return to baseline renal function.
3 ) CV - Pump: euvolemic. Holding lasix in the setting of UTI. Hx of
asymmetric BPs secondary to stenosis.
Rhythm: First degree AV block , intermittent Wenkebach but infrequently
dropped beats so no contraindication to nodal blockade.
Telemetry. Ischemia: ST depressions in V3-V% resolved during hospital
course. MI r/o with 3 sets of negative enzymes. One episode of jaw pain ,
relieved with sublingual nitroglycerin. No EKG changes. Will need outpatient stress
test - ETT MIBI or adenosine MIBI.
4 ) Endo- ISS
5 ) FEN - DVT prophylaxis , cardiac diet
FULL CODE
FULL CODE
2 ) Renal
ADDITIONAL COMMENTS: In addition to your home medications please take Ciprofloxacin 250mg
every 12 hours for 10 days and please take ECASA 81mg once a day. Please
follow-up with your primary care physician at your scheduled appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please insure UTI cleared with Ciprofloxacin.
Please Schedule patient for adenosine or ETT MIBI in light of angina and
recent ST depressions.
No dictated summary
ENTERED BY: PARDON , HALEY , M.D. ( NC57 ) 2/25/05 @ 03:21 PM
****** END OF DISCHARGE ORDERS ******
Document id: 25
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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392986061 | PUO | 09031082 | | 4655958 | 10/22/2006 12:00:00 a.m. | ALTERED MENTAL STATUS | Unsigned | DIS | Admission Date: 2/17/2006 Report Status: Unsigned
Discharge Date: 2/28/2006
ATTENDING: SPILLETT , SILVA M.D.
ADDENDUM
HOSPITAL COURSE:
Neuro: Starting on 6/13/06 the patient had an episode of
agitation on hemodialysis where he received Ativan and continued
to be agitated and required multiple code greys to sedate him. A
team meeting was held on 8/13/06 and per psychiatry
recommendations the patient was started on 250 mg twice a day of
Depakote , Haldol was reduced to just Monday-Wednesday-Friday 1 mg
before hemodialysis and 1 mg as needed agitation. The patient did
very well on this regimen and his Depakote level was stable at
39.7 on discharge. The plan is to continue Depakote twice a day 250
mg with Haldol as needed for behavior. In terms of his mental
status on discharge , the patient was A&O x3 and appropriate.
In terms of cardiac , there were no additional events to report.
In terms of pulmonary , the patient was diagnosed with pneumonia
on 10/26/06 and started on ceftriaxone intravenous and Flagyl. This was
changed to cefpodoxime and Flagyl for discharge. In terms of his
pneumonia that was evident right lower lobe pneumonia on chest
x-ray and the patient was also spiking fevers and had audible
rales on exam.
In terms of GI , the patient continued tolerate regular diet and
nutrition continued to follow ensuring adequate orally intake and
adjusting diet per endocrine needs.
In terms of endocrine , the addendum to 6/13/06 , the patient
ultimately discontinued on a regimen of 7 units of Lantus every day before noon
and every afternoon with 5 units aspart before every meal breakfast and lunch and 4
units of aspart before every meal dinner. His sliding scale was very light
and he is only to be covered with one to two units of aspart
during the night as insulin stacks in this patient very easily.
It was recommended if the patient is noted to be in the low 100s
consistently through the course of the day that his next dose of
aspart be either halved or held as the patient easily becomes
hypoglycemic and is unable to recognize the symptoms of
hypoglycemia himself. At the time of discharge , the patient's
fingersticks were well controlled in the 100-200 range.
In terms of ID , the patient began to spike fevers on 9/22/06
with a T. max of 100.6 and blood cultures failed to show anything
as did sputum cultures. On 5/18/06 , the patient spiked to 101.2
and had evidence of pneumonia on his chest x-ray. He was started
on antibiotics of ceftriaxone and Flagyl , which was switched to
cefpodoxime and Flagyl for discharge. The cefpodoxime should be
dosed after dialysis on Monday-Wednesday-Friday.
In terms of disposition , the patient has been discharged to rehab
where he will continue hemodialysis on Monday-Wednesday-Friday
and continues to have the same medication Rx as he did well in
house. Specific care should be given to his insulin regimen as
well as his behavior control and nutrition as noted in the
discharge instructions. Again please c.c. Dr. Ma Yeagley , Dr.
Wei Pilling , Dr. Gabhart on this discharge summary.
ADDENDUM TO MEDICATIONS ON DISCHARGE:
PhosLo 2001 mg orally three times a day , Depakote 250 mg orally twice a day , folate 1
mg orally daily , Haldol 1 mg intravenous on Monday-Wednesday-Friday given
prior to hemodialysis , labetalol 350 mg orally twice a day , lisinopril
80 mg orally daily , Flagyl 500 mg orally three times a day for 14 days , thiamine
100 mg orally daily , Norvasc 10 mg orally daily , gabapentin 300 mg
orally every bedtime , cefpodoxime 200 mg orally three times a week on
Monday-Wednesday-Friday for eight doses given after hemodialysis ,
Nephrocaps one tablet orally daily , sevelamer 2004 mg orally three times a day ,
Advair diskus 250/50 one puff twice a day , Nexium 20 mg orally daily ,
Lantus 7 units subcutaneous twice a day once in the morning and once
evening , aspart 4 units subcutaneous before dinner and 5 units
subcutaneous before breakfast and 5 units subcutaneous before
lunch , aspart sliding scale starting at blood sugar less than 125
give 0 units , blood sugar 125-300 give 0 units , blood sugar
301-350 give 1 unit , blood sugar 351-400 give 2 units , blood
sugar 400-450 give 2 units , albuterol butt paste topical daily ,
and then as needed Tylenol 650 mg as needed pain , headache , or
temperature , albuterol inhaler as needed wheezing , Haldol 1 mg intravenous q.
6h. as needed agitation. If more than three doses given in a day
please check QTC on the EKG. Loperamide 2 mg orally every 8 hours as needed
diarrhea.
eScription document: 6-0295725 EMSSten Tel
CC: Ma Yeagley M.D.
Beach Sa Son
CC: Wei Pilling M.D.
Pagham University Of
Ren Ley An
CC: Dorthy Gabhart M.D.
Ly Mo Dia
Dictated By: EISENHAVER , KAREN
Attending: SPILLETT , SILVA
Dictation ID 3816680
D: 5/23/06
T: 5/23/06
Document id: 26
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376950295 | PUO | 84780901 | | 8136148 | 6/21/2006 12:00:00 a.m. | MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/12/2006 Report Status: Signed
Discharge Date: 1/10/2006
ATTENDING: HARTSELL , DANILLE L. MD
ADDENDUM
The patient is a 76-year-old male with a history of diabetes ,
hypertension , CAD status post MI in 2000 who presented with an ST
elevation MI to the Emergency Room on 8/23/06 . He was brought
to Cath where he was found to have in-stent thrombosis in his LAD. The clot was
aspirated and bare-metal stent was placed in his LAD
and another stent was placed in his diag-2. He suffered multiple V-Tach
cardiac arrests requiring CPR and cardioversion. In the
Cath Lab , he was given bicarb , placed on the epi drip , given
Lasix and was intubated. He was thought to aspirate at the time
of intubation secondary to vomiting. A bedside echo revealed
global hypokinesis with an EF of 35%. He , at that time , was
placed on a balloon pump , dopamine 16 , amio 1 , propofol 1 , and
Integrilin and brought to the CCU. On the floor , his blood
pressures were difficult to control and his PA catheter readings
indicated a wedge pressure of 47. His MAPs were marginal and max dopamine , max
Levophed , epinephrine and dobutamine were required to maintain a minimal blood
pressure.
His family was aware of his prognosis and was there at the time
of his arrest at 3:30 in the morning. CPR was initiated , and
ACLS was performed until the family decided to terminate the ACLS. At that
time , there were no spontaneous breath sounds , no heart sounds , and nonreactive
pupils. The cause of death was thought to be cardiogenic shock
secondary to ST elevation MI. His time of death was 3:47 a.m. on 8/23/06 .
eScription document: 8-2199247 EMSSten Tel
Dictated By: ALEXIS , LEAH
Attending: HARTSELL , DANILLE L.
Dictation ID 8723980
Addendum Created by HARTSELL , DANILLE LACY , M.D.
A: 6/20/06
Dictation ID: 0083618ZAN
Document id: 27
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461171537 | PUO | 89762298 | | 2890032 | 1/1/2004 12:00:00 a.m. | hereditary angioedema | | DIS | Admission Date: 10/22/2004 Report Status:
Discharge Date: 6/21/2004
****** DISCHARGE ORDERS ******
BLANN , GLENNA A. 009-06-32-4
Sundvik Dr. , Leashampinewoodwood Smouth Aank
Service: CAR
DISCHARGE PATIENT ON: 6/21/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VERRY , COLETTA F. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
ATENOLOL 75 MG orally every day
DANAZOL 200 MG orally three times a day
DIGOXIN 0.125 MG orally every other day
Override Notice: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
on order for SYNTHROID orally ( ref # 75444907 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: mda
DIGOXIN 0.187 MG orally every other day
Instructions: alternate digoxin doses
Override Notice: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
on order for SYNTHROID orally ( ref # 75444907 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: mda
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally every day
LASIX ( FUROSEMIDE ) 20 MG orally every day
Alert overridden: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
on order for LASIX orally ( ref # 83364415 )
patient has a POSSIBLE allergy to Sulfa; reaction is RASH.
Reason for override: mda
SYNTHROID ( LEVOTHYROXINE SODIUM ) 50 MCG orally every day
Alert overridden: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: mda
RHINOCORT ( BUDESONIDE NASAL INHALER ) 1 SPRAY nasal twice a day
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ZANTAC ( RANITIDINE HCL ) 150 MG orally every day
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Rolson 611-870-7831 Wednesday , July , 9:15am- Connecticut scheduled ,
ALLERGY: intravenous Contrast , Sulfa , Penicillins , QUINIDINE SULFATE ,
LEVOFLOXACIN , LISINOPRIL , NITROFURANTOIN , STANAZOL ,
PROCAINE HCL , Dairy Products , WHEAT/GLUTEN ,
NITROFURANTOIN MACROCRYSTAL
ADMIT DIAGNOSIS:
hereditary angioedema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hereditary angioedema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HEREDITARY ANGIOEDEMA AFIB - lodose Coum/ASA HYPOTHY
history of SUBDURAL ON COUM history of APPY , TAH tracheostomies x
3 multiple intubations DVT , ivc filter in place GERD polycythemia
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
82 year-old femalew tih long hx of hereditary angioedema- history of multiple
remote prior tracheostomies due to airway edema- now admitted with lip
swelling. In recent years , her primary symptoms have been GI in
nature- with bowel swelling/ N/V/abdominal pain. Has been maintained
on stanazol previously , but on danazol for the last several years.
Patient had a recent admission for LGIB - outpatient elective
colonoscopy ultimately showed a stricture which was dilated. She had
persistent GI symptoms which were thought likely due to an angioedema
attack and her danazol was increased to 200 twice a day In the last week ,
patient was in the midst of tapering this medication down with her
Allergist Dr. Paulauskis , but has now developed upper lip swelling on day
of admission- which appeared to be worsening in the ED.
PMHx: notable for colonic strictures , DVT history of IVC filter , ?DM , HTN ,
afib , CAD history of MI , history of sigmoid colostomy.
Long list of allergies including intravenous contrast , PCN , levaquin.
Meds include danazole 100 every day.
On exam , - afebrile , 99%ra , blood pressure 105/80 , heart rate 80s. sitting up comfortably ,
able to speak with slightly muddled pronouncitation. Left upper lip
swelling to twice size of normal right side. No uvula swelling noted.
No stridor or increased secreations. Lungs clear. Irregular heart rate
with 3/6 HSM at LLSB. Faint crackles at bases. No rashes noted.
Labs remarkable only for Cr 1.2 ( basline ). Normal CBC , Normal coags.
C1Q/c4/c2/c1 esterase inhibitor results all pending.
Impression/Hospital course:
82 year-old F with heriditary angioedema , presenting with lip swelling.
Patient was admitted to CCU for observation in case of airway
instability. She was treated with higher dose danazol ( 200 three times a day ) as well
as FFP ( for which she was premedicated with benadryl ). FFP replaces
C1 esterase inhibitor. She required single dose of intravenous lasix to maintain
I/O status during FFP infusion. She had rapid improvement over 24-48
hours with no signs of airway compromise. She will be followed closely
by her allergist and will leave on a higher dose of danazol. There is
some consideration of re-instituting stanazol in the future.
------
f/u with allergist Dr. Rolson in 5 days
f/u complement panel studies
ADDITIONAL COMMENTS: return to the hospital if you notice any lip swelling or difficulty
breathing
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MALADY , CASSONDRA F. , M.D. , M.S. ( JZ49 ) 6/21/04 @ 02:01 PM
****** END OF DISCHARGE ORDERS ******
Document id: 28
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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242838255 | PUO | 76068155 | | 9428895 | 4/29/2005 12:00:00 a.m. | LEFT LEG WOUND INFECTION | Signed | DIS | Admission Date: 9/4/2005 Report Status: Signed
Discharge Date: 10/21/2005
ATTENDING: FIONA AUTHUR M.D.
ADMITTING DIAGNOSIS:
Bilateral lower extremity wound infection.
DISCHARGE DIAGNOSIS:
Bilateral lower extremity wound infection.
ALLERGIES:
Lisinopril and atenolol.
PAST MEDICAL HISTORY:
Includes chronic venous stasis ulcers in lower extremities ,
diabetes mellitus , hypertension , asthma , sarcoid , restricted
pulmonary disease , and obesity.
HOSPITAL COURSE:
This is a 60-year-old female with a history of chronic venous
stasis ulcers of bilateral lower extremities admitted to the Plastic
Surgery service with infection on 11/9/05 . The patient was
treated with intravenous vancomycin and levofloxacin and the patient has
been afebrile during the stay. She has been getting dressing
changes with acetic acid solution three times a day on her lower
extremity ulcers bilaterally. Over the course of the days the
ulcer looks pretty clean and very nice and she has been doing
very good. Her pain is well controlled and she has been treated
with the bed rest , intravenous antibiotics , and the dressing changes. She
has been told to keep her legs elevated most of the time , so that
the swelling will decrease , and the patient has been afebrile
with the stabe vital signs. She has been taking orally and been
voiding. She has been ambulating independently from bed to bath
and chair and her pain has been well controlled. The lower
extremity wounds are getting well and there is no evidence of any
purulent discharge or evidence of infection. While the patient
was here , her vancomycin and levofloxacin have been discontinued
and the patient is switched to Bactrim double strength as the
wound culture revealed Achromobacter and xylosoxidans , which was
sensitive. The patient will be discharged to home today with the
visiting nurse and services. The patient will return back in
several weeks for the further reconstruction and wound culture
most probably skin grafting.
CONDITION ON DISCHARGE:
Stable.
ACTIVITY:
Legs elevated when not walking.
DIET:
Regular house diet and diabetic diet.
FOLLOW UP APPOINTMENTS:
Dr. Authur , please call to schedule ( 035 )-052-8582 in 7-10 days.
DISCHARGE INSTRUCTIONS:
Dressing changes with 0.25% of acetic acid/1 liter normal saline used
for soaks and dressings.
DISCHARGE MEDICATIONS:
Aspirin 81 mg orally every day , calcium carbonate 500 mg orally twice a day ,
Colace 100 mg orally twice a day , Lasix 40 mg orally every day , NPH insulin
Humulin 40 units every day before noon and 28 units every afternoon subcutaneous ,
labetolol 200 mg orally twice a day , Percocet 5-10 mg orally every 4 hours as needed
for pain and multivitamin therapeutic one tablet orally every day , Zocor
20 mg orally every bedtime , Norvasc 5 mg orally every day , metformin 500 mg orally
three times a day , Cozaar 100 mg orally every day , acetic acid 0.25% topical three times a day
instruction , mixed with 1 liter normal saline for three times a day wet to
dry soak and dressing changes , and Bactrim DS one tablet orally
every 12 hours for two weeks.
eScription document: 5-9424390 EMSSten Tel
Dictated By: KALINGER , NAKESHA
Attending: AUTHUR , FIONA
Dictation ID 5269372
D: 11/12/05
T: 11/12/05
Document id: 29
| Target |
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| output/system_textual_annotation.xml | textual |
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- |
U |
U |
U |
U |
Y |
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Y |
U |
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U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
- |
N |
N |
N |
N |
Y |
N |
Y |
N |
Y |
- |
N |
N |
N |
759646448 | PUO | 39691196 | | 739929 | 7/15/1999 12:00:00 a.m. | FAILED LT. TOTAL HIP REPLACEMENT | Signed | DIS | Admission Date: 7/15/1999 Report Status: Signed
Discharge Date: 9/13/1999
ADMITTING DIAGNOSIS: FAILED LEFT BIPOLAR HEMIARTHROPLASTY
DISCHARGE DIAGNOSIS: CONVERSION TO LEFT TOTAL HIP REPLACEMENT
DATE OF SURGERY: 10/15/99
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old male with
a history of left hip
hemiarthroplasty for avascular necrosis in 10/27 as well as right
hip hemiarthroplasty in 1982. He now has groin pain on the left
side that is worsening. This has been increasing over the past
year. It limits his activity. He is admitted for elective
conversion to a total hip replacement.
PAST MEDICAL HISTORY: Hypertension , asthma , cardiomyopathy , gout ,
tympanoplasty , hernia repair.
ALLERGIES: None.
CURRENT MEDICATIONS: Diltiazem 120 mg twice a day , Theophylline 200
three times a day , Warfarin 6 mg every day , Lasix 80 mg every
day , Indomethacin 25 mg twice a day , cyclobenzoprine 10 three times a day ,
Lisinopril 20 mg every day , K-Dur 20 mEq every day , Isosorbide dinitate 20
mg three times a day , Allopurinol 300 mg every day , Albuterol inhaler two four times a day ,
Salmetrol inhaler two puffs twice a day
HOSPITAL COURSE: The patient was taken to the operating room on
10/15/99 where he underwent an uncomplicated
conversion of his bipolar hemiarthroplasty to a total hip
arthroplasty. Please refer to the dictated operative note for
details of this procedure. The patient tolerated the procedure
well and remained stable postoperatively without complications.
His diet was advanced without difficulty. The patient tolerated
orally pain medication without difficulty. The patient received three
units of autologous blood perioperatively for a low hematocrit. He
was given stress dose steroids. The patient was started on
Coumadin for deep venous thrombosis prophylaxis. The patient
received physical therapy consultation and was made partial weight
bearing with range of motion exercises and continuous passive
motion machine with posterior dislocation precautions. The
patient was discharged to home in stable condition with services on
6/26/99 . He will follow up with Dr. Nwankwo .
MEDICATIONS ON DISCHARGE: Include those on admission plus the
addition of Percocet 1-2 tablets orally every
4h as needed pain and Coumadin adjusted dose to maintain an INR Of
1.5-2.0 for deep venous thrombosis prophylaxis.
Dictated By: SILVIA GREENFELDER , M.D. GB16
Attending: REBEKAH NWANKWO , M.D. HI3 MV054/9024
Batch: 7913 Index No. P4GR5O9ACS D: 6/21/99
T: 6/21/99
Document id: 30
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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125960861 | PUO | 68313462 | | 461521 | 7/9/2000 12:00:00 a.m. | leg edema , anemia , proteinuria , ?NSAID gastritis , colonic polyps | | DIS | Admission Date: 7/9/2000 Report Status:
Discharge Date: 5/2/2000
****** DISCHARGE ORDERS ******
MANNIS , FATIMA 432-90-08-5
Da
Service: MED
DISCHARGE PATIENT ON: 1/25 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BYE , NATHANIAL K. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VENTOLIN ( ALBUTEROL INHALER ) 2 PUFF inhaled four times a day
as needed wheezing , sob
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 100 MG orally twice a day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 20 U subcutaneously every afternoon
Starting Today ( 7/18 ) HOLD IF: 1 )NPO 2 ) till scope is done
REGULAR INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously before every meal & HS Call HO If BS > 400
For BS < 200 give 0 Units reg subcutaneously
For BS from 201 to 250 give 4 Units reg subcutaneously
For BS from 251 to 300 give 6 Units reg subcutaneously
For BS from 301 to 350 give 8 Units reg subcutaneously
For BS from 351 to 400 give 10 Units reg subcutaneously
ZESTRIL ( LISINOPRIL ) 40 MG orally every day
Override Notice: Override added on 9/8 by FRINK , TENA S S. , M.D. on order for GOLYTELY orally ( ref # 05549917 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 11/22 by KRIKORIAN , JOLYNN LORE , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 99266015 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 7/06 by BUSSLER , FRAN SHIRLEEN , M.D.
on order for KCL intravenous ( ref # 57747927 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 7/06 by BUSSLER , FRAN SHIRLEEN , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 99588520 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally twice a day
Starting Today ( 7/18 )
Instructions: take with lasix to increase absorption
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
CARDURA ( DOXAZOSIN ) 4 MG orally twice a day
AVANDIA ( ROSIGLITAZONE ) 8 MG orally every day
KCL SLOW RELEASE 20 MEQ X 2 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 1/25 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Bye 3:45pm 6/15 scheduled ,
ALLERGY: Erythromycins , Penicillins , Cortisone acetate
ADMIT DIAGNOSIS:
leg edema , anemia , proteinuria
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
leg edema , anemia , proteinuria , ?NSAID gastritis , colonic polyps
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
IDDM HTN nephrotic sdm Fe def anemia CHF ( EF 40-45% on
OPERATIONS AND PROCEDURES:
Upper GI: NSAID gastritis , hiatal hernia
Colonoscopy: Polyps that appeared benign , no evidence of bleeding
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Blood transfusions ( three units total )
Diuresis with intravenous lasix
BRIEF RESUME OF HOSPITAL COURSE:
*** 11/22 ***
60 year-old woman c dm , htn , hyperlipidemia , nephrotic syndrome p/with
worsening 3+ le edema up to thighs and lower abdomen. No cp , sob ,
palpitations , dysuria , change in urination. Protein loss in
10 of September around 6g/day. Also Hct decrease in past
months , guaiac + stool in ED. Admitted for diuresis
and possible GI workup.
____________________________________________________________
*** 6/10 ***
colonoscopy today: mult ( about 10 ) polyps in colon , largest one 1cm ,
no active bleeding. No polyp bx taken , given so numerous and patient
on ASA and lovenox. Nodular
gastritis with few erosions , no ulcers. Gastric bx pending.
patient to get repeat colonoscopy in February with bx of
polyps , after d/c asa ,
lovenox.
Sent home on 100 mg twice a day orally Lasix with 10mg twice a day orally Reglan to increase
absorption , on rest of cardiac meds ( Zestril , Cardura ) , on Avandia and
Humalin 20 Units. Avoid NSAIDS and ASA. primary care physician will adjust diuretic
regimen as patient responds.
ADDITIONAL COMMENTS: Please visit Dr. Bye or come back to PUO if leg edema worsens with
diuretic use at home or if notice blood in stools.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr. Bye tomorrow 3:45pm at Tempson Neistone Ino Hospital .
Follow up with GI at PUO in 2 months for colonic polyps.
Avoid NSAIDs , Aspirin
Follow-up H.pylori study.
Adjust diuretic regimen as needed. patient aware of fluid restriction need
of about 1.5L/day and plan.
No dictated summary
ENTERED BY: BUSSLER , FRAN SHIRLEEN , M.D. ( HE58 ) 1/25 @ 02:34 PM
****** END OF DISCHARGE ORDERS ******
Document id: 31
| Target |
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DM |
Gs |
GER |
Gou |
HC |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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U |
Y |
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U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
N |
N |
N |
Y |
N |
N |
Y |
- |
N |
N |
N |
778562534 | PUO | 93827167 | | 1545525 | 3/8/2003 12:00:00 a.m. | anemia | | DIS | Admission Date: 11/11/2003 Report Status:
Discharge Date: 6/20/2003
****** DISCHARGE ORDERS ******
SORICELLI , DOYLE 772-44-89-4
Tempe Mi Veale
Service: MED
DISCHARGE PATIENT ON: 6/24/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 150 MCG orally every day
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 3/2/03 by LALATA , JOHNETTA B JOLYN , M.D. on order for SIMVASTATIN orally ( ref # 40253317 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware.
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 6/24/03 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware.
ATENOLOL 25 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please follow up with Dr. Donehoo in Hematology Clinic next week. Call 922-441-5130 for appt. ,
Please follow-up with your primary care physician. Call for appt. ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
GI bleed , anemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
anemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Thrombocytopenia ( ?ITP ) Osteoarthritis
history of polymyalgia rheumatica history of spinal stenosis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Colonoscopy/EGD on 1/29 -- EGD c no ulcerations , biopsy taken.
Colonoscopy c 1 polyp , removed , also c multiple diverticuli , no
evidence of blood/bleeding.
BRIEF RESUME OF HOSPITAL COURSE:
72yoF c 6cm descending thoracic aneurysm , history of diverticulosis , presented
to primary care physician office c 1 week history of increasing fatigue c exertion , possible DOE.
Also c intermittent upper back pain , only on exertion , but not clearly
reproducible. Hct from primary care physician office 21 , sent to PUO ED for further
workup. H/o some blood in toilet am of admission , o/with denied GI sx.
Trace guaiac positive in ED. Hospital course as follows:
1. HEME -- patient was tx'd 2 U PRBC in ED c Hct response to 25.
Reticulocyte count was 1.1 and iron studies , B12 , folate prior to
transfusion were within nl limits. A chest CT was obtained re: her
thoracic aneurysm , which showed a chronic dissection , aneurysmal
diameter of 6 cm , but no change from previous. Hemolysis labs were
negative. patient was transfused an add'l 2 U PRBC on floor and responded
appropriately. Given her low retic count , there was suspicion she
could have a primary hematologic dz , and she is to follow up with Dr.
Donehoo in clinic at SSR next week.
2. CARD -- patient had some DOE , which was thought to be related to
her anemia. She had negative cardiac enzymes in ED. EKG s changes ,
isolated TwI in III. She was maintained on her usual outpt regimen.
3. GI -- There was a consideration of a possible GI source , given
patient's history. GI was consulted and she received EGD/colonoscopy ,
which revealed extensive diverticulosis , but no evidence of bleeding.
patient is being discharged to home to follow-up with Hematology and with
her primary care physician.
ADDITIONAL COMMENTS: 1. If you have increasing episodes of fatigue with exercise , please
call your primary care physician and arrange for an appt , or come to
the Emergency Department.
2. Please go to your primary care physician's office to have your
blood level ( Hct ) checked on Monday 2/30/03 .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check Hct in your primary care physician's office on Monday.
2. Call the Hematology Clinic at 922-441-5130 to schedule a follow-up
appt with Dr. Donehoo next week.
No dictated summary
ENTERED BY: LALATA , JOHNETTA BEN , M.D. ( UB074 ) 6/24/03 @ 12:30 PM
****** END OF DISCHARGE ORDERS ******
Document id: 32
| Target |
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DM |
Gs |
GER |
Gou |
HC |
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PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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712371137 | PUO | 91183152 | | 2181806 | 1/12/2005 12:00:00 a.m. | Ventral Hernia | | DIS | Admission Date: 6/12/2005 Report Status:
Discharge Date: 4/17/2005
****** FINAL DISCHARGE ORDERS ******
BARTLET , DIANNE L 274-56-92-7
T
Service: GGI
DISCHARGE PATIENT ON: 5/21/05 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COHENS , ANGELINE VICKI , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 150 MCG orally every day
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
LEVOFLOXACIN 500 MG orally every 24 hours
DIET: No Restrictions
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 15 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Cohens 1-2weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Ventral Hernia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Ventral Hernia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Ventral hernia , hypothyroid , history of obesity
OPERATIONS AND PROCEDURES:
6/22/05 COHENS , ANGELINE VICKI , M.D.
VENTRAL HERNIA REPAIR WITH MESH
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
Patient is 58 year-old F who is history of ventral hernia repair. She had an
uncomplicated surgery. She was transferred to the floor and had some
nausea with the morphine PCA overnight. She vomited in the a.m. from the
morphine and it was d/c'd and after orally pain meds she improved greatly.
She had her foley d/c'd and she was pain free all day ( POD1 ). She is on
her synthroid ( 150mcg ) and is ready for d/c home with VNA on levofloxacin
until the drains are removed.
ADDITIONAL COMMENTS: VNA: Please empty the drains and change the dressing every day. Please record
the volume of output.
Keep dressing clean and dry. You may remove the dressing 2 days after
surgery to shower. Leave the steri strips on as they will fall off on
their own. The dressing around the drain will be replaced by VNA.
Stay on the antibiotics until you see Dr. Cohens .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr. Cohens .
Stay on Antibiotics until told not to take them anymore.
No dictated summary
ENTERED BY: SPRATTE , DESIRE M. , M.D. ( EN577 ) 5/21/05 @ 08:54 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 33
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
N |
- |
N |
N |
N |
N |
Y |
N |
N |
- |
N |
- |
N |
759889792 | PUO | 12278269 | | 1944823 | 3/28/2007 12:00:00 a.m. | same | | DIS | Admission Date: 1/10/2007 Report Status:
Discharge Date: 3/20/2007
****** FINAL DISCHARGE ORDERS ******
HAMMETT , FREDERICA 806-57-80-1
Derd I Ecoyork
Service: VAS
DISCHARGE PATIENT ON: 9/15/07 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: YOUNGBERG , JERICA TANYA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 81 MG orally every day
2. ALBUTEROL INHALER 2 PUFF inhaled four times a day
3. CALCITRIOL 0.25 MCG orally every day
4. CLOPIDOGREL 75 MG orally every day
5. DOCUSATE SODIUM 100 MG orally twice a day
6. FOLIC ACID 1 MG orally every day
7. FUROSEMIDE 10 MG orally every day
8. GABAPENTIN 100 MG orally three times a day
9. IPRATROPIUM INHALER 2 PUFF inhaled four times a day
10. LISINOPRIL 2.5 MG orally every day
11. METOPROLOL SUCCINATE EXTENDED RELEASE 50 MG orally every day
12. NIFEREX 150 150 MG orally twice a day
13. OMEPRAZOLE 20 MG orally every day
14. OXYCODONE 10 MG orally every 4 hours
MEDICATIONS ON DISCHARGE:
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours as needed Shortness of Breath , Wheezing
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 10 MG orally DAILY
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
HEPARIN 5 , 000 UNITS subcutaneously every 8 hours
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
If receiving standing regular insulin , please give at same
time and in addition to standing regular insulin
LISINOPRIL 2.5 MG orally DAILY
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally three times a day
HOLD IF: sbp < 95 or heart rate < 65
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OMEPRAZOLE 20 MG orally DAILY
OXYCODONE 5-10 MG orally every 3 hours as needed Pain
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Youngberg , 590-882-9425 1 week ,
Primary care physician please call to make appt ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Non-healing left foot wound
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) pernicious anemia ( pernicious anemia )
copd ( chronic obstructive pulmonary disease ) pneumonia
( pneumonia ) CRI ( chronic renal dysfunction )
OPERATIONS AND PROCEDURES:
7/28/07 YOUNGBERG , JERICA TANYA , M.D.
DEBRIDEMENT LT FOOT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to Lakesmi Sonno Memorial Hospital surgery service on
3/28/2007 for preoperative evaluation/clearance. On 4/14 she was
taken to the operating room where she underwent debridement of her
non-healing left TMA site No concerning intraoperative events occurred;
please see dictated operative note for details. In the PACU she was
noted to be oozing from several points within the wound bed. Two silk
stitches were placed with improved hemostasis. On POD 1 , the oozing
continued and her hct had dropped to 21. She remained hemodynamically
stable but given her cardiovascular history she was transfused a total of
4 units of blood over the next 2 hospital days. Surgicell was also placed
into the wound bed with adequate hemostasis. The remainder of her
hospital course was unremarkable. Patient had adequate pain control and
was tolerating sips on POD0 and was advanced to regular diet by POD1.
She remained neurologically intact postoperatively. Her blood pressure
remained at baseline ( SBP 110-140s ). She was kept on perioperative
Vanc/Levo/Flagyl throughout her hospitalization. On POD 4 , she was
discharged to rehab in stable condition , afebrile , voiding independently ,
with adequate pain control. Her wound had areas of granulation; will
plan to continue wet-to-dry dressings with normal saline for gentle
debridement. Will reevaluate for VAC dressing and possible eventual skin
graft closure on follow up. She was given explicit instructions to
follow-up in clinic with Dr. Youngberg in 1 week.
ADDITIONAL COMMENTS: ADDITIONAL COMMENTS: If you experience fever , increasing pain ,
redness/drainage from your foot , chest pain , shortness of
breath or other concerning symptoms , please seek medical attention
immediately
-Resume medications as prescribed
-Rehab should continue with wet to dry dressings with normal saline to L
TMA wound twice a day.
-ACTIVITY: touch down weight bearing left leg
-ANTICOAGULATION:please continue aspirin and plavix
-Please schedule and attend follow-up appointment with Dr. Youngberg in
1-2 weeks
DISCHARGE CONDITION: Stable
TO DO/PLAN:
please see above instructions/plan
No dictated summary
ENTERED BY: CHOJNACKI , ZACHARY R. , M.D. ( GG08 ) 9/15/07 @ 08:08 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 34
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
- |
Y |
Y |
N |
N |
N |
Y |
- |
N |
N |
- |
N |
N |
N |
378576931 | PUO | 59506466 | | 6678991 | 4/13/2005 12:00:00 a.m. | HEPATIC ABSCESS | Signed | DIS | Admission Date: 5/19/2005 Report Status: Signed
Discharge Date: 4/23/2005
ATTENDING: FREHSE , MARILYN MD
UMZEE MEDICAL CENTER
HISTORY OF PRESENT ILLNESS:
This is a 66-year-old female with a history of coronary artery
disease , chronic atrial fibrillation on Coumadin , pulmonary
hypertension , insulin dependent diabetes mellitus , hypothyroidism
who presented in 5/25 with an apparent perforated appendicitis
for which she was taken to the operating room. Final pathology
during this procedure was serositis. Her postoperative course
was complicated by severe delirium , atrial fibrillation ,
abdominal abscesses requiring IR drainage in 10/10 and 10/7 .
The patient began having recurrent UTI , decreased appetite and
hematochezia at this time. On 8/17/05 , a CT of the abdomen
showed evidence of a colovesical fistula and the patient was
admitted to the Arvai Sonprince Hospital for further management.
On admission , she was found to be in acute renal failure with a
creatinine of 2.3 apparently secondary to dehydration after
recently having been started on Lasix for hypertension by her
primary care physician.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Pulmonary hypertension.
3. Chronic atrial fibrillation , on Coumadin.
4. Hypercholesterolemia.
5. Asthma.
6. Insulin dependent diabetes mellitus.
7. Hypothyroidism.
PAST SURGICAL HISTORY:
Appendectomy in 5/25 .
MEDICATIONS AT HOME:
1. Atrovent twice a day
2. Metaxalone 2.5 mg daily.
3. Lipitor 10 mg daily.
4. Lasix 60 mg daily.
5. Atenolol 50 mg twice a day
6. Diltiazem 120 mg daily.
7. Potassium chloride 10 mg twice a day
8. Colace 100 mg three times a day
9. Folate.
10. Re1glan as needed
11. Lisinopril 20 mg daily.
12. Wellbutrin 100 mg daily.
13. Protonix 40 mg daily.
14. Coumadin.
ALLERGIES:
No known drug allergies.
HOSPITAL COURSE:
The patient was admitted to the Survtheast Centex Health Care . Her creatinine
improved with intravenous hydration on 3/25/05 . She was taken to the
operating room for exploratory laparotomy , cystoscopy with
bilateral urinary stent placement , sigmoid colectomy with primary
anastomosis and diverting ileostomy. During the surgery , she
became hypotensive requiring pressors due to inability to replace
intravenous fluid adequately. She was transferred to the surgical
intensive care unit , intubated on pressors. For the first
several days , she had a inflammatory response-type picture with
significant vasodilation requiring pressors and massive intravenous
resuscitation greater than 30 liters of fluid. Sedation was
slowly weaned as the patient's respiratory status improved. Due
to a question of responsiveness during the first several days , a
head CT was performed which showed no evidence of stroke. She
became slowly more responsive as sedation was weaned with the use
of Precedex and was extubated on 1/22/05 , postoperative day 7
without complications. Her mental status in the intensive care
unit continued to improve. The remainder of the patient's
hospital course will be dictated via systems.
Neurologically , at the time of transfer out of the ICU , the
patient was noted to have subtly improving mental status. Her
family described her at baseline. During her stay on the floor ,
her Zyprexa dose was decreased. She had no further neurologic
issues.
Cardiovascular: In the intensive care unit , the patient required
vasopressin initially and was weaned off during the first three
or four days. Her chronic atrial fibrillation continued. She
was transferred out of the intensive care unit on intravenous Lopressor
which was gradually converted to orally as she tolerated a regular
diet. She was discharged on 100 mg four times a day of Lopressor.
Respiratory: In the intensive care unit , she was noted to have
respiratory failure initially secondary to a SIRS picture and
fluid overload. This significantly improved with diuresis. She
was transferred out on a nasal cannula. On the floor , she had no
respiratory issues. She continued her aggressive chest physical
therapy and was out of bed with physical therapist.
GI: In the Intensive Care Unit , the patient was noted to have a
postoperative ileus. She did not tolerate NG tube feeds. A post
pyloric Dobhoff was eventually placed and tube feeds were
initiated. After transfer out of the intensive care unit , the
patient had difficulty with her Dobhoff catheter and eventually
became clogged and had to be removed. A speech and swallow
evaluation was obtained. A bedside swallow was equivocal and a
fiberoptic swallow was done. She passed this with fine colors
per the speech and swallow team and they recommended that her
diet be advanced as tolerated. She was discharged to
rehabilitation on a regular diet.
GU: In the Intensive Care Unit , she was massively resuscitated
initially and then diuresed for virtually the remainder of her
hospital course. An initial Lasix drip was then changed to intravenous
Lasix boluses. She was discharged on orally Lasix at an equivalent
dose to her standing Lasix during her hospitalization. A
cystogram was obtained prior to her discharge to rehab at the
time of dictation. The result of the cystogram are not
available. If no extravasation is noted , her Foley catheter can
be removed at rehabilitation. If extravasation is noted , she
will need to undergo a repeat cystogram at some point in the
future prior to removal of her Foley catheter.
Heme: The patient was initially on subcutaneously heparin due to concern
for bleeding. She was then started on a heparin drip and was
discovered that she had bilateral lower extremity partial DVTs.
Her heparin drip was titrated to a PTT of 60 to 80 prior to
discharge to rehab. Her heparin was discontinued and she was
started on Lovenox as a bridge to coumadinization. Her Coumadin
began during the few days prior to her discharge when she was
tolerating orally intake.
ID: Due to the colovesical fistula , concern for some liver
opacities on her original abdominal CTs , she was placed on
broad-spectrum antibiotics perioperatively. All antibiotics were
removed on 1/22/05 . She was noted to have a candidal UTI ,
completed a five-day course of fluconazole. A small fever in the
Intensive Care Unit warranted blood cultures being sent and
repeat blood cultures on 10/4/05 eventually noted a
gram-positive cocci. It was felt that this was likely due to a
contaminant as the patient by that time had been afebrile for
several days. However , she was started on vancomycin for
gram-positive cocci , bacteremia. Her central line was removed
and a new central line was placed and she was discharged to rehab
on day 9 of 14 of intravenous vancomycin via her central line. After the
completion of this course of therapy , her central line may be
removed at rehabilitation.
Wound: Due to some drainage from abdominal wound due to her fat
necrosis , the lower portion of the wound was opened. There was
no evidence of active infection noted and a Vac sponge was placed
initially on 10/4/05 to facilitate the healing process. The Vac
was changed every three days during her stay. This most recent
change was on 10/30/05 .
DISCHARGE CONDITION:
Stable.
DISPOSITION:
Rehabilitation.
DISCHARGE MEDICATIONS:
As indicated on the discharge orders sheet.
eScription document: 4-0875054 EMS
Dictated By: MCRORIE , DENISHA
Attending: FREHSE , MARILYN
Dictation ID 1867475
D: 6/5/05
T: 6/5/05
Document id: 35
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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246890980 | PUO | 06157825 | | 1415850 | 5/29/2006 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 5/7/2006 Report Status:
Discharge Date: 4/14/2006
****** FINAL DISCHARGE ORDERS ******
TOMA , AYAKO 346-42-79-7
Chailus Dr. , Tamp , Ohio 00575
Service: CAR
DISCHARGE PATIENT ON: 10/18/06 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NOLAN , BYRON S.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
ALLOPURINOL 150 MG orally DAILY Starting Today ( 10/27 )
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ALLEGRA ( FEXOFENADINE HCL ) 180 MG orally DAILY
as needed Other:allergies Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY inhaled DAILY as needed Other:congestion
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
Alert overridden: Override added on 10/18/06 by :
on order for LASIX orally ( ref # 684454380 )
patient has a POSSIBLE allergy to HYDROCHLOROTHIAZIDE;
reaction is Hyponatremia. Reason for override: md aware
ISOSORBIDE MONONITRATE 10 MG orally every 8 hours as needed Chest Pain
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 40 MG orally DAILY
Alert overridden: Override added on 10/18/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
METOPROLOL TARTRATE 75 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally DAILY
Alert overridden: Override added on 10/8/06 by
LARZELERE , GAYLE C. , M.D.
on order for BACTRIM SS orally ( ref # 382576464 )
patient has a PROBABLE allergy to HYDROCHLOROTHIAZIDE;
reaction is Hyponatremia. Reason for override: on at home
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician , 7/25 , patient has scheduled ,
ALLERGY: Codeine , PERCOCET , HYDROCHLOROTHIAZIDE , EPTIFIBATIDE
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , HTN , GERD , GOUT , A FIB , DM , UTI
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
**Chest Pain**
**84 year-old with CAD history of CABG and PCI with chest pain **HPI: CABG in 1998 ,
then PCI with 2 stents. 2/28 found to have restenosed RCA stent , had
balloon angioplasty. Since then chest pain free. Five days
ago , awoke with chest pain , since then mostly nausea , some pain.
Decreased prilosec dose last week. no diaphoresis.
**Patient Status** afebrile , HR 58 , BP 165/80 100% on RA , diffuse
wheezes , RRR , no murmor , soft NTND belly , weak right dp , no left
dp **Studies**
Labs: nml , negative cardiac enzymes
ECG: V paced
**********
A/P: 84 year-old with CAD history of CABG , PCI , and recent balloon angioplasty for
restenosed stent , now with chest pain , in setting of decreased PPI
dose. Most likely atypical chest pain.
1. CV ( i ) low suspicion for
ACS. Patient was ruled out for MI with serial
enzymes/ecgs. Cont ASA , statin ( low dose ) , plavix ,
nitro. ( p ) HTN here:
- continued ACE , gave captopril for lisinopril to titrate - continue B
blocker ( three times a day for twice a day to titrate )r ( r ) sick sinus syndrome with
pacemaker , v paced 2. GI: appears to be with worsening
GERD - continue PPI , increased dose to
twice a day. Patient would benefit from GI
eval as outpatient. H pylori serologies were ordered. 3. Pulm: diffuse
wheezes , no history of pulm dz , patient says
its old. Wheezes resolved by day of discharge. chest cxray neg -
consider
PFTs in future. 4. GU/ID: uti's , on bactrim
chronically. Patient states he was on levoquin. Dc'd here. 5. Rheum:
allopurinol for gout , renally
dosed 6. Proph: heparin , PPI
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please follow up with your primary care physician. Have your primary care physician refer you for
gastrointestinal follow up.
2. Please etake prilosec twice daily. Avoid late meals , caffeine , spicy
foods , chocolate , and mint
3. Notice the following med changes:
a.levoquin stopped
b. prilosec increased
No dictated summary
ENTERED BY: LARZELERE , GAYLE C. , M.D. ( SJ97 ) 10/18/06 @ 01:15 PM
****** END OF DISCHARGE ORDERS ******
Document id: 36
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
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- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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254826260 | PUO | 67733887 | | 6010668 | 9/6/2005 12:00:00 a.m. | hyponatremia and depression | | DIS | Admission Date: 11/10/2005 Report Status:
Discharge Date: 10/9/2005
****** DISCHARGE ORDERS ******
PREUETT , LATRICIA 002-54-26-6
Oeve Ave , A
Service: MED
DISCHARGE PATIENT ON: 1/5/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOVA , DOUGLASS V. , M.D.
CODE STATUS:
No CPR / No defib / No intubation / No pressors /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
SODIUM CHLORIDE 1 GM orally every day
NORVASC ( AMLODIPINE ) 5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DEMECLOCYCLINE 300 MG orally twice a day
Food/Drug Interaction Instruction
Take 1 hour before or 2 hours after dairy products.
Take 3 hours before or 3 hours after Iron products.
Alert overridden: Override added on 4/9/05 by ALLEBACH , DIEDRE J VALENTINE , M.D.
POTENTIALLY SERIOUS INTERACTION: MAGNESIUM HYDROXIDE &
DEMECLOCYCLINE HCL Reason for override: monitor
GLYBURIDE 5 MG orally every day
DIET: Fluid restriction: 1.5L
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Holter in 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
depression
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hyponatremia and depression
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of SCIATICA history of HIATEL HERNIA history of DUODENAL ULCERS BY
UGI SIADH with neg head MRI , nl TSH , nl cortisol ( 36 ) DM ( diabetes
mellitus ) HTN ( hypertension ) depression
( depression ) gilbert's syndrome diverticulosis ( diverticulosis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
IVF , fluid restriction
BRIEF RESUME OF HOSPITAL COURSE:
HPI:76 year-old M with hx of SIADH ( neg with u in the past ) , DM ,
HTN and depression ( history of ECT ) with recent admission for hyponatremia ( Na
116 ) d/c'd home on 11/28 with Na of 132 , p/with depression , increased SOB ,
weakness , and presumed low Na. Per patient , he has not been feeling well
since d/c. Persist thirst , drinking 1 gallon per day , did take his
meds including demeclocycline. patient also feeling
depressed , lonely. ? SI , no plans. no fevers , ? chills. dull CP x 1
hour , resolved spontly. no cough. patient eval by psych in ED , felt not to
be suicidal , no inpt psych admit or 1:1 sitter
needed. VS: 98.6 , HR 99 , BP 126/64 , 100% RA. NAD , JVP 6cm ,
CTAB , RRR , no murmurs , abd soft , +BS , no pedal edema.
Labs: Na 127 , K 3.5 , Cr 0.8 , Tbili 1.9 , CK 356 , cardiac enzymes flat ,
osm 259 , urine Na <assay , osm 191 , WBC 21.4 63P , 4B , hct 36.4. U/A
neg for UTI.
CXR: no infiltrates.
*************Hospital Course****************
FEN: hyponatremia not significant. continue demeclocycline , 1.5L
fluid restrict , NS as IVF given low urine Na and
osm. Na 130 on day of discharge.
CV: ? hx of CP , no hx of CAD. EKG showed no new changes.
continue norvasc
Psych: patient quite depressed , not on antidepressed
( self d/c'd remeron in the past ) , social work , psych eval said that patient
most likely needs good outpt f/u , needs antidepressant as an outpt ( had
tried many in the past ). patient will be contacted by social workers in
Charv S patient will also see primary care physician re: antidepressant medications.
GI: constipated. Bowel regimen
ENDO: hx of DM , gluc 66 on admision. gluc improved on the following day.
RISS. PPx: PPI ,
lovenox
Dispo: physical therapy eval said that patient is able to walk around without difficulties. no
home physical therapy needed.
DNR/DNI
ADDITIONAL COMMENTS: for VNA: home safety eval , check Na on 2/23/05
for patient: please call Dr. Holter and make an appt to see her. you should
also be contacted by social workers at Meon Wellfor Pipebocock Medical Center . please return to the
hospital if you develop severe fatigue or seizure.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
please follow up on patient's depression treatment , please follow up on patient's
sodium.
No dictated summary
ENTERED BY: ALLEBACH , DIEDRE JENNIFFER , M.D. ( PG59 ) 1/5/05 @ 12:00 PM
****** END OF DISCHARGE ORDERS ******
Document id: 37
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
N |
- |
N |
N |
N |
028944445 | PUO | 26723331 | | 1667532 | 11/5/2005 12:00:00 a.m. | CEREBRAL BLEED | Unsigned | DIS | Admission Date: 11/5/2005 Report Status: Unsigned
Discharge Date: 9/11/2006
ATTENDING: VERNET , ROSANNE SOON
DATE OF DEATH: 1/26/06
PRINCIPAL DIAGNOSIS: Intracranial hemorrhage.
LIST OF PROBLEMS/DIAGNOSES:
1. Hypertension.
2. Diabetes type 2.
3. Atrial fibrillation.
4. COPD.
5. DVTs.
6. Carotid stenosis.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male
with a history of diabetes , hypertension , atrial fibrillation ,
not on Coumadin , and carotid stenosis , transferred from an
outside hospital to Pagham University Of with
intracranial hemorrhage. The patient noticed that about 3:15
p.m. , on 1/14/05 , the patient developed a sudden onset of
weakness on the left side and slurred speech. He was brought to
Norap Valley Hospital , where he was initially communicative and
denying headache , nausea , or vomiting. He was placed in the CT
scanner , and within 15 minutes , became less responsive. The
patient was intubated as a result. His systolic blood pressure
was between the 140s and 160s during this period , controlled with
total of 6 mg intravenous of Ativan and 10 mg intravenous of hydralazine. The
patient was then transferred to the Pagham University Of
Emergency Department. On arrival , the patient was posturing and
his systolic blood pressure was 220. He was treated with intravenous
labetalol , intravenous mannitol , 1 gm Dilantin , and 1 gm vancomycin. The
patient's blood pressure was controlled within 30 minutes.
Neurosurgery placed bilateral extraventricular drains in the
emergency department.
PAST MEDICAL HISTORY: Hypertension , diabetes type 2 , paroxysmal
atrial fibrillation , not on Coumadin , COPD , idiopathic DVTs , BPH ,
and bilateral carotid stenosis.
MEDICATIONS AT HOME: Prozac 40 mg orally daily , lisinopril 10
daily , NPH insulin 42 units every day before noon , 22 units every afternoon , Lopressor
100 twice a day , aspirin 325 mg daily , Advair , and Zocor 20 daily.
ALLERGIES: Sulfa and cephalosporins - rash.
SOCIAL HISTORY: The patient lives with his wife , 80-pack-year
smoking history , quit in 2002. The patient has three daughters.
PHYSICAL EXAMINATION ON ADMISSION TO THE ED: Neurological ,
limited by critical care and EVD placement. Mental status ,
unresponsive to sternal rub. Cranial nerves , pupils are
nonreactive at 3 mm. Motor/sensory , extensor posturing to
nailbed pressure in the upper extremities and triple flexion in
the lower extremities. DTRs , toes are upgoing bilaterally.
RADIOLOGICAL EXAMINATION: Head CT/CTA , 60 mL intracranial
hemorrhage in the right basal ganglia with intraventricular
hemorrhagic extension , and casting of the right lateral ventricle
and extension into the third and fourth ventricles. Compared to
the P Therford Hospital CT scan from 3 hours earlier , there was enlargement
of the intracranial hemorrhage and enlargement of the ventricles.
No AVM or aneurysm. Occluded right internal carotid artery that
reconstitutes at the level of the supraclinoid , which is old.
HOSPITAL COURSE: The patient remained unresponsive and intubated
during the entirety of this hospitalization. He was admitted to
the Neurological ICU following his emergency department care and
extraventricular drain placement by Neurosurgery in the emergency
department. He continued to have extraventricular drainage
throughout this hospital stay. Despite the efforts of draining
the patient's ventricles , there was no improvement in his
clinical exam. During the course of this hospitalization , the
patient did receive antibiotics ( Flagyl , levofloxacin , and
vancomycin ) for pneumonia. He received amiodarone and
beta-blockers for rapid heart rate. The patient unfortunately
did not respond to any of the above treatments , and remains
comatose throughout this hospitalization. After multiple family
discussions , the family decided to proceed with extubation on
9/13/06 . The patient was made comfort measures only on that
afternoon. The patient was treated with a morphine infusion for
comfort. The patient expired at 2:06 a.m. , and the family was
notified.
eScription document: 3-8360825 CSSten Tel
CC: Glynis Margo Verbridge MD
Ressdar Medical Center , Derd News North
Dictated By: TRETT , JERI
Attending: VERNET , ROSANNE SOON
Dictation ID 7713987
D: 10/19/06
T: 8/7/06
Document id: 38
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
N |
N |
N |
818177855 | PUO | 77991840 | | 5847015 | 5/3/2005 12:00:00 a.m. | orthostatic syncope | | DIS | Admission Date: 7/1/2005 Report Status:
Discharge Date: 11/26/2005
****** FINAL DISCHARGE ORDERS ******
SEARCH , ALBINA KATERINE 770-16-15-1
A Moines Cam
Service: MED
DISCHARGE PATIENT ON: 10/3/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
CALTRATE + D ( CALCIUM CARBONATE 1 , 500 MG ( 600 ... )
2 TAB orally twice a day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 10/3/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: md aware
METFORMIN 500 MG orally every day Starting IN a.m. ( 3/28 )
HYDROCHLOROTHIAZIDE 12.5 MG orally every day Starting IN a.m. ( 3/28 )
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
f/u with primary care physician ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
orthostatic syncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
orthostatic syncope
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: I passed out"
HPI: 71 year-old female with pmhx htn , dm , cri brought to puo ED after
syncopal event 2/4/05 . She had seen primary care physician with routine visit; later in
the evening she began to feel "woozy" at a friend's house. She
went to BR and had a loose BM shortly after which she became weak and
diaphoretic and passed out. ED eval revealed BP 150/71 , HR 54 and
otherwise unremarkable physical
exam. PMHX: as
above MEDS: see med list
below. ALL:
NKDA Social: lives alone , independent with adl's , no
etoh or tobacco. PE: 98.9 54 150/71
18 nad ,
alert heent: orally moist , flat
jvp heart: RRRS1__S2__ , no
murmurs Lungs: CTA
bilat abd:
benign LABS: troponin negative X
2 echo: normal LV function
overall EKG:
NSR Assessment: 71 year-old female with syncopal episode in
setting of recent fasting ( for bloodwork ) and loose BM. Likely
vasovagal episode post BM. No evidence of arrythmia or ACS. Concern
about respiratlry function ( and d dimer of 2000 ) was put to rest with
a low prob VQ scan. Planned to restart metformin and HCTZ 12.5 every day one day
post discharge as outpt with primary care physician follow up.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STECK , GAYLORD A. , M.D. ( EB56 ) 10/3/05 @ 12:30 PM
****** END OF DISCHARGE ORDERS ******
Document id: 39
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
N |
- |
N |
N |
Y |
N |
Y |
N |
- |
- |
N |
N |
N |
563635080 | PUO | 32361549 | | 5668913 | 10/29/2006 12:00:00 a.m. | L4-S1 LUMBAR SPINAL STENOSIS | Signed | DIS | Admission Date: 2/24/2006 Report Status: Signed
Discharge Date: 3/6/2006
ATTENDING: LEMMEN , BROOKE M.D.
PRINCIPAL DIAGNOSIS:
Spinal stenosis L4-S1.
PRINCIPAL PROCEDURE:
L4-S1 laminectomy.
DATE OF PROCEDURE:
10/28/06 .
HISTORY OF PRESENT ILLNESS:
The patient is a 76-year-old gentleman with a history of cardiac
transplant 15 years ago followed by the Cardiac Transplant
Service at Pagham University Of . He presented to the
clinic with right buttock and leg pain. It has been
incapacitating to him and present since 5/15 . He had a series
of epidural steroid injections that have not helped.
PAST MEDICAL HISTORY:
Cardiac transplant 15 years ago as stated above with chronic
immunosuppressives , history of gout , hypertension , renal
insufficiency.
ALLERGIES:
Penicillin.
PHYSICAL EXAMINATION:
The patient has a strongly positive straight leg raise on the
right with pain reproduced down the posterolateral thigh , leg and
into the dorsum plantar aspects of the foot. He has 4-/5
strength of the quads , tibials anterior and 3/5 strength in the
EHL and 4+/5 strength in the gastrocsoleus complex. He has a
sensation that is grossly intact to light touch throughout the
right lower extremity. He has diminished reflexes at patellar
tendon , Achilles tendon on the right.
IMAGING:
X-rays showed degenerative disc disease from L4 through S1 with
no significant listhesis. Outside MRI scan was reviewed and had
evidence of spinal stenosis at L4-L5 , a paracentral extruded disc
at L5-S1.
HOSPITAL COURSE:
The patient was cleared for surgical intervention. He was taken
to the operating room on 10/28/06 . The procedure was
uncomplicated. Perioperative antibiotics were administrated. VD
boots were placed for DVT prophylaxis. The patient's
postoperative course was uncomplicated. No nausea or vomiting ,
no chest pain , and no shortness of breath. His diet was
advanced. He was afebrile and was tolerating regular diet. He
was transitioned to orally medications for pain without difficulty.
Physical therapy worked with the patient. He is out of bed
without much difficulty. His dressing was changed on
postoperative day #2 , and his wound continued to be clean and dry
with no evidence of infection throughout his hospital course. He
was cleared by physical therapy to be discharged home.
CONDITION ON DISCHARGE:
Stable.
DISCHARGE STATUS:
Home with Services.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours and as needed
2. Azathioprine 50 mg orally daily.
3. Calcitrol 0.25 mcg orally daily.
4. Codeine 15-30 mg orally every 4 hours as needed
5. Neoral cyclosporin 50 mg orally twice a day
6. Colace 100 mg orally twice a day
7. Lasix 80 mg orally daily.
8. Amaryl 3 mg orally every afternoon
9. Regular insulin sliding scale.
10. Potassium chloride slow release 10 mEq orally daily.
11. Labetalol 600 mg orally twice a day
12. Magnesium oxide 420 mg orally daily.
13. Rapamune 2 mg orally daily.
14. Sulfinpyrazone 200 mg orally twice a day
15. Timolol 0.5% one drop each eye every day before noon
FOLLOW-UP PLAN:
The patient is to keep the wound clean and dry until his follow
up. He is to follow up with Dr. Lemmen on 8/9/06 . He is to
contact the office or the hospital if he has any worrisome
symptoms , worsening pain , fevers , etc.
eScription document: 8-8729663 EMSSten Tel
Dictated By: YAN , DERICK
Attending: LEMMEN , BROOKE
Dictation ID 1687977
D: 2/8/06
T: 2/8/06
Document id: 40
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
Y |
Y |
Y |
N |
Y |
- |
N |
N |
N |
670224474 | PUO | 57155429 | | 1748541 | 3/10/2005 12:00:00 a.m. | OA , L knee | | DIS | Admission Date: 8/21/2005 Report Status:
Discharge Date: 8/13/2005
****** FINAL DISCHARGE ORDERS ******
SMOLINSKY , LARAE 070-17-73-5
S Wi Ester O Coing
Service: ORT
DISCHARGE PATIENT ON: 10/7/05 AT 11:00 a.m.
CONTINGENT UPON physical therapy clearance
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 300 MG orally every day
Alert overridden: Override added on 2/4/05 by
WANTUCK , DELPHA , PA-C
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will monitor
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
HUMULIN N ( INSULIN NPH HUMAN ) 15 UNITS subcutaneously every day before noon and every afternoon
MVI ( MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 2/4/05 by
WANTUCK , DELPHA , PA-C
on order for SIMVASTATIN orally ( ref # 46213778 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: will be monitored
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day as needed Constipation
Instructions: may be given with the patients choice of
beverage
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: dose for 7/2/05 4mg , dose for 4/12 and
thereafter take as directed by anticoagulation
service , duration is 4 weeks
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Reason: Override added on 2/4/05 by WANTUCK , DELPHA , PA-C
on order for SIMVASTATIN orally ( ref # 46213778 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will be monitored
Previous override information:
Override added on 2/4/05 by WANTUCK , DELPHA , PA-C
on order for ALLOPURINOL orally ( ref # 41656086 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will monitor
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
METFORMIN 500 MG orally twice a day
LIPITOR ( ATORVASTATIN ) 20.0 MG orally every day
Alert overridden: Override added on 6/14/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: will be monitored
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally every day
Food/Drug Interaction Instruction Avoid milk and antacid
DIET: House / ADA 2100 cals/dy
ACTIVITY: Full weight-bearing: please increase ROM as much as possible
FOLLOW UP APPOINTMENT( S ):
Dr. Rademan , 2/20/05 1:00XRAY , 2:00APT scheduled ,
Arrange INR to be drawn on 7/14/05 with f/u INR's to be drawn every
Monday/Thursday days. INR's will be followed by PUO Anticoagulation service , 592.004.9708
ALLERGY: LATEX
ADMIT DIAGNOSIS:
OA , L knee
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
OA , L knee
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes mellitus , hypertension , gout , atopic dermatitis
OPERATIONS AND PROCEDURES:
2/4/05 RADEMAN , CAITLIN , M.D.
RT TKR
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
9/1/05-KUB-negative
BRIEF RESUME OF HOSPITAL COURSE:
***Patient underwent elective LTKA for osteoarthritis on 2/4/05 .
Procedure went well and pain was controlled by epidural. Patient
received 1 unit of RBC's on DOS for HCT of 26. POD2 patient had a
distended abdomen and KUB was ordered. Results were negative and there
were no further signs of symptoms of an ileus. POD2
switched to orally pain meds and foley catheter removed. HCT on POD3 was
25.8 and patient was stable. Patient could not clear physical therapy protocol for
discharge on POD4 and subsequently was not dischrarged until POD5 in
stable condition. On POD#5 after two days of intravenous fluid his creatinine
improved to 1/3. His INR on the day of discharge was 1.5.
ADDITIONAL COMMENTS: Coumadin for DVT prophylaxis X3 weeks. Goal INR 1.5-2.5 , draw day after
discharge and every Monday/Thursday. Results & questions to PUO
Anticoagulation service , 083.782.7650. For wound-DSD changes , OTA when
dry. Remove staples on 8/21/05 . Follow up with Dr. Rademan on 2/20/05 .
Weight bear as tolerated with upper extemity support.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Home care for blood draws-results and questions to PUO Anticoagulation
service , 083.782.7650. See instructions for complete detail.
Home care for wound-DSD changes , OTA when dry , remove sutures on
8/21/05 .
physical therapy-weight bear as tolerated with upper extremity support.
Follow up with Dr. Rademan on 2/20/05 .
No dictated summary
ENTERED BY: DEMOREST , MEGHAN O , M.D. ( PI820 ) 10/7/05 @ 02:38 PM
****** END OF DISCHARGE ORDERS ******
Document id: 41
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
N |
Y |
- |
N |
N |
N |
473114375 | PUO | 60927482 | | 2954532 | 10/23/2004 12:00:00 a.m. | Failed Lt THR | | DIS | Admission Date: 10/23/2004 Report Status:
Discharge Date: 5/20/2004
****** DISCHARGE ORDERS ******
LEUENBERGER , BRIAN 014-98-92-6
Hen Blvd
Service: ORT
DISCHARGE PATIENT ON: 3/7/04 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WAGNON , DENNA L. , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
MIACALCIN ( CALCITONIN-SALMON ) 1 SPRAY inhaled every day
Number of Doses Required ( approximate ): 4
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
MVI ( MULTIVITAMINS ) 1 TAB orally every day
PREDNISONE 20 MG orally every day before noon
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting Today ( 9/24 )
Instructions: Or as directed by the anticoagulation service
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/10/04 by
KNUTESON , PRECIOUS D. , M.D.
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: every day inr
PAXIL ( PAROXETINE ) 20 MG orally every day
TRICOR ( FENOFIBRATE ) 320 MG orally every day Starting IN a.m. ( 9/17 )
Override Notice: Override added on 2/10/04 by
KNUTESON , PRECIOUS D. , M.D.
on order for COUMADIN orally ( ref # 00994206 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: every day inr
Previous override information:
Override added on 2/18/04 by KNUTESON , PRECIOUS D. , M.D.
on order for COUMADIN orally ( ref # 37006506 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: every day inr
Previous override information:
Override added on 10/11/04 by KNUTESON , PRECIOUS D. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & FENOFIBRATE ,
MICRONIZED Reason for override: inr
Number of Doses Required ( approximate ): 6
ZELNORM ( TEGASEROD ) 12 MG orally twice a day
Number of Doses Required ( approximate ): 4
LANTUS INSULIN 150 UNITS subcutaneously every bedtime
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
PERCOCET 1-2 TAB orally every 4 hours as needed Pain
ZESTRIL ( LISINOPRIL ) 20 MG orally twice a day
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr Wagnon 9/25/05 Xray at 10:00am Appt at 11:00am 8/7/05 scheduled ,
Arrange INR to be drawn on 11/1/04 with f/u INR's to be drawn every
Mon/Thurs days. INR's will be followed by PUO Anticoagulation Service
ALLERGY: Sulfa
ADMIT DIAGNOSIS:
Failed Lt THR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Failed Lt THR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
SLE , IDDM , HTN , Depression , GERD
OPERATIONS AND PROCEDURES:
10/11/04 WAGNON , DENNA L. , M.D.
REVISION OF L. HIP REPLACEMENT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
N/A
BRIEF RESUME OF HOSPITAL COURSE:
patient underwent a revision Lt THR on 10/11/04 . The patient tolerated the
procedure well and in the PACU was tachycardic with rate of 150 and
SBP< 90. Medicine was consulted recommended transfer to a monitored bed
and to check serial TnI's. patient's troponin levels bumped and medicine
suggested covering patient with beta blockade , obtaining an echo , and
transfusing with 1 unit of PRBCs to maintain a Hct >30. patient was
asx and Medicine continued to follow the patient. POD 1 Zestril was
d/c'd and electrolytes repleted. intravenous hydrocortisone was d/c'd. Troponin
leak was felt to be likely from cardiac strain , demand related. Through
the remainder of her hospitalization her rate was well controled.
Standard care with prophylactic intravenous abx and TEDS/Coumadin/P-boots for DVT
prophylaxis. Wound clean clean and healing. Inta-operative cx
grewalpha heme strep in liquid medium only. The path was reviewed
and this was felt to represent a contaminent. Echo was WNL and
telemetry was d/c'd on POD 2. patient progressed well with physical therapy , and was
deemed safe for discharge home with services and support of parents on
POD 3.
ADDITIONAL COMMENTS: Dry sterile dressing daily. The wound may be left open to air when
dry. You may shower when the wound is dry X 72 hrs , Blood draws for
physical therapy/INR the day after discharge then every Mon/Thurs with results called to
the PUO Anticoagulation Service at 988-605-5355 ext 1. Goal INR is
1.5-2.5;DVT prophylaxis is planned X 6 weeks. Any outpatient
anticoagulation issues or action values should be called to the
Anticoagulation Service.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Blood draws for physical therapy/INR the day after discharge then every Mon/Thurs with
results called to 988-605-5355 ext 9 for outpatient anticoagulation
management
Home services for physical therapy , nursing/wound assessment , and phlebotomy
Follow up with Dr Wagnon as scheduled
No dictated summary
ENTERED BY: SCOVEL , DULCIE , PA-C ( XP60 ) 3/7/04 @ 12:05 PM
****** END OF DISCHARGE ORDERS ******
Document id: 42
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
N |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
- |
- |
N |
N |
N |
009083719 | PUO | 04731180 | | 318684 | 6/5/2001 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 9/10/2001 Report Status:
Discharge Date: 9/21/2001
****** DISCHARGE ORDERS ******
LIEBECK , KELSI 057-82-87-9
Sta La Nahamp
Service: MED
DISCHARGE PATIENT ON: 2/16/01 AT 12:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DICKHAUT , SIOBHAN CARY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
XANAX ( ALPRAZOLAM ) 0.25 MG orally every 6 hours as needed anxiety
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: md aware
CLONIDINE ( CLONIDINE HCL ) 2.5 MG TP Q168H
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 25 MCG orally every day
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: md aware
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally three times a day
Starting Today ( 4/06 )
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: CELECOXIB & WARFARIN
Reason for override: md aware
ZOCOR ( SIMVASTATIN ) 10 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: md aware
CELEBREX ( CELECOXIB ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
POTENTIALLY SERIOUS INTERACTION: CELECOXIB & WARFARIN
Reason for override: md aware
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
MEDROXYPROGESTERONE 5 MG orally every day
ESTRADERM ( ESTRADIOL ) 0.05 MG TP every 72 hours
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Deiss ,
ALLERGY: Tylenol ( acetaminophen ) , Zantac ( ranitidine hcl )
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ATYPICAL cHEST PAIN
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
55 year-old female with hx of HTN , Hyperchol and previous admits for atypical
chest pain all of which have been neg for MI or PE , presented to ED
with hx SOB , diaphoresis and CP that radiated to left neck and arm that
lasted for only several minutes. patient CXR was neg , cardiac enzymes were
neg , Spiral CT neg for PE , and no ischemic changes on EKG , with no
telemetry events noted. patient is discharged in stable condition.
ADDITIONAL COMMENTS: Please call primary care physician or go to ED if shortness of breath or chest pain
develop or worsen.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: COCOMAZZI , REA , M.D. , Q.B.TH ( DE67 ) 2/16/01 @ 12:42 PM
****** END OF DISCHARGE ORDERS ******
Document id: 43
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Q |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
- |
N |
Y |
- |
N |
N |
N |
- |
- |
N |
N |
- |
- |
N |
N |
259895307 | PUO | 80528967 | | 3648858 | 2/28/2004 12:00:00 a.m. | NSTEMI | | DIS | Admission Date: 2/28/2004 Report Status:
Discharge Date: 9/22/2004
****** DISCHARGE ORDERS ******
SWARTZBAUGH , MALCOLM 191-06-56-4
Font Bo Vi
Service: ETMCH
DISCHARGE PATIENT ON: 10/22/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: STEARN , JENNY L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain HOLD IF: sbp less than 100 mmHg
Instructions: Do not administer if receiving intravenous
nitroglycerin.
PREDNISONE 60 MG orally every day before noon
TRAZODONE 50 MG orally HS as needed Insomnia
ZOLOFT ( SERTRALINE ) 50 MG orally every day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime Starting Today ( 3/7 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Instructions: Begin Plavix tomorrow if a loading dose was
administered on the day of the procedure.
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
DILTIAZEM CD 120 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
HYDROCHLOROTHIAZIDE 25 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Pederzani 2-4 weeks ( you will receive a phone call with time from Dr Vorhees office ) ,
Primary care physician 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
NSTEMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTEMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OBESITY RAD MULT TAPERS asthma
( asthma ) OSA ( sleep apnea ) ?diabetes ( ? diabetes mellitus )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac catheterization with stent placement to the LAD.
BRIEF RESUME OF HOSPITAL COURSE:
45yoF with obesity , htn , asthma p/with chest pressure of new onset while
teaching class today. Was assoc with sob and diaphoresis. Was
admitted to ED obs , had negative a set , but tni on b set=2.
ECG reportedly without change but did in fact have twi in precordial
leads. patient developed renewed chest pain on floor assoc with n/v , and
had emergent cath which revealed lad lesion which
was stented with drug-eluting stent.
+++++++++++++++++++++++++++++++++++++++++++++++++
HOSP COURSE BY SYTEMS
1 ) CV: isch-history of stenting to LAD for NSTEMI
-cont asa , statin , plavix
-held hctz but instructed patient to re-start this as outpt.
-initially tx patient with bb , but this seemed to exacerbate her asthma , so
this was switched to diltiazem. Norvasc was stopped
-patient received integrilin x 18h post cath
2 ) Pulm: asthma
-on prednisone 60 for recent exacerbation , will taper after d/c
-cont inhalers
3 ) Psych: cont zoloft , ativan
patient will be discharged to home in stable condition to follow up with her
pcp and her cardiologist.
ADDITIONAL COMMENTS: You have new medicines: diltiazem SR 120 mg a day , plavix 75 mg a day ,
zocor 40 mg a day , aspirin 325 mg a day. Continue your
hydrochlorothiazide. Stop taking norvasc. If needed take
nitroglycerin tablets under your tongue for chest pain ( follow
directions on prescription ). If you have chest pains , shortness of
breath , or any other concerns please call your doctor or come to the
emergency room. Taper your prednisone as instructed on prescription
( and discuss this with your primary care physician )
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with your primary care physician in 1-2 weeks.
Follow up with Dr Pederzani ( cardiology ) in 2-4 weeks.
No dictated summary
ENTERED BY: JACOBSOHN , JAMA J. , M.D. ( TY87 ) 10/22/04 @ 02:33 PM
****** END OF DISCHARGE ORDERS ******
Document id: 44
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
- |
N |
N |
231980943 | PUO | 45274139 | | 628660 | 10/6/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/28/1990 Report Status: Unsigned
Discharge Date: 10/16/1990
HISTORY OF PRESENT ILLNESS: Patient is a 40 year old female with a
history of cholelithiasis who was
recently discharged from Pagham University Of on November ,
l990 after an incisional hernia repair who , soon after , noted onset
of right upper quadrant pain , vomiting , and fever and was
readmitted with an ultrasound at that time showing two 8-9 mm
gallstones in the right upper quadrant. Patient was treated with
intravenous antibiotics but deferred surgery at that time and was
discharged home after defervescing. Approximately six weeks prior
to admission , the patient was seen in the Emergency Ward for
recurrent right upper quadrant pain without nausea , vomiting , or
fever. The patient then was subsequently seen by Dr. Haraguchi in the
Uass Goldman Valley Medical Center and a cholecystectomy was scheduled on a
routine basis. PAST MEDICAL HISTORY: Non-contributory. PAST
SURGICAL HISTORY: Includes a cesarean section in l988 and a
ventral hernia repair in October of l990. CURRENT MEDICATIONS:
Naprosyn as needed for right upper quadrant pain. ALLERGIES:
Include Penicillin which gives her a rash and Compazine which leads
to a dystonic reaction. SOCIAL HISTORY: She does not smoke or
drink.
PHYSICAL EXAMINATION: Patient was afebrile with stable vital
signs. SKIN: Scattered skin tags on her
trunk. NODES: Negative. HEAD/NECK: Benign. BREASTS: Without
masses , tenderness , or axillary adenopathy. LUNGS: Clear to
auscultation. HEART: Regular rate and rhythm with no murmurs ,
gallops , or rubs. PULSES: 2+ bilaterally. ABDOMEN: Obese ,
positive bowel sounds , and non-tender with a small fascial defect
at the umbilicus and a well healed midline scar. NEUROLOGICAL:
Non-focal.
LABORATORY EXAMINATION: Her EKG showed normal sinus rhythm at 7l
beats per minute with an axis of positive
40 degrees , normal intervals , and no ischemic changes. Her chest
X-Ray was clear. Her electrolytes were all within normal limits ,
her BUN was 22 , and her creatinine was l.0. Her glucose was 88.
Her white count was 6.4 , her hematocrit was 33.l , and her platelets
were 259. Her physical therapy was l2.3 and her PTT was 29.9. Her urinalysis
showed 3-4 white blood cells and l+ bacteria.
HOSPITAL COURSE: The patient arrived the same day as her surgery
and was taken directly to the Operating Room.
Patient was placed under general anesthesia and her intubation was
particularly difficult secondary to obesity requiring fiberoptic
intubation and Anesthesia elected , at this time , to place both an
A-line and a central venous access in order to be able to optimally
monitor this difficult obese patient. Patient then underwent a
very uncomplicated cholecystectomy at which time a distended
gallbladder with several stones was found. The patient was taken
to the Recovery Room in stable condition after being extubated. Her
O2 saturation on 40% facemask was 96% in the Recovery Room and both
her nasogastric tube and Foley tube were removed without incident.
Her A-line was also removed before transfer to the floor but her
central line remained in place until the following day. Patient
received two doses of Gentamicin as prophylaxis post-operatively.
The patient had an unremarkable post-operative course with a
post-operative hematocrit of 3l.5 and white count of 8.4. Her diet
was slowly advanced and she remained afebrile with good oxygen
saturations on room air and good urine output.
DISOSITION: She was discharged to home on post-operative day
number five with an appointment to follow-up in the
Uass Goldman Valley Medical Center on Thursday , January , for a wound check.
________________________________ SD321/9795
NADA D. LANGHOUT , JR , M.D. SF2 D: 9/27/90
Batch: 8589 Report: S1567M27 T: 10/2/90
Dictated By: CARMON BOSHERS , M.D.
Document id: 45
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
- |
- |
- |
- |
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- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
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- |
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- |
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- |
076292010 | PUO | 42300636 | | 1403118 | 8/10/2003 12:00:00 a.m. | colonic microperforation , afib | | DIS | Admission Date: 8/17/2003 Report Status:
Discharge Date: 1/17/2003
****** DISCHARGE ORDERS ******
BRETH , BRANDY T 114-82-80-8
Lie Rira
Service: MED
DISCHARGE PATIENT ON: 3/5/03 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: IN , DERICK T , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
FESO4 ( FERROUS SULFATE ) 300 MG orally twice a day
Starting IN a.m. ( 8/3 ) Food/Drug Interaction Instruction
Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
PREDNISONE 5 MG orally every day before noon
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/22/03 by
MOLANDS , MARIETTE ALEISHA , M.D.
on order for NEORAL orally ( ref # 31963625 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & CYCLOSPORINE
Reason for override: will monitor
NEORAL ( CYCLOSPORINE MICRO ( NEORAL ) ) 100 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 9/22/03 by
MOLANDS , MARIETTE ALEISHA , M.D.
on order for LOSARTAN orally ( ref # 91421046 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & LOSARTAN
POTASSIUM Reason for override: will monitor
Previous override information:
Override added on 9/22/03 by MOLANDS , MARIETTE ALEISHA , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & CYCLOSPORINE
Reason for override: will monitor
LOSARTAN 50 MG orally every day
Alert overridden: Override added on 9/22/03 by
MOLANDS , MARIETTE ALEISHA , M.D.
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & LOSARTAN
POTASSIUM Reason for override: will monitor
Number of Doses Required ( approximate ): 3
ATENOLOL 25 MG orally every day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
AMIODARONE 400 MG orally twice a day
Instructions: 400 twice a day x 6 days , then 400 every day x 1 week , then
200 every day Alert overridden: Override added on 3/5/03 by :
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & AMIODARONE
HCL Reason for override: aware
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting Today ( 8/25 ) Instructions: To start on 4/21 .
FLAGYL ( METRONIDAZOLE ) 500 MG orally three times a day X 2 Days
Food/Drug Interaction Instruction Take with food
LEVOFLOXACIN 500 MG orally every day X 2 Days
Starting Today ( 8/25 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 3/5/03 by :
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
LEVOFLOXACIN Reason for override: aware
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Larose ( cardiology ) 6/7/03 scheduled ,
Gastroenterology- Dr. Sampey , call for appointment. ,
ALLERGY: Iv contrast dyes , Codeine , Penicillins , Erythromycins ,
Morphine , Demerol
ADMIT DIAGNOSIS:
Aspiration PNA
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
colonic microperforation , afib
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) hodgkin ( Hodgkins disease ) renal
transplant ( kidney transplant ) htn
( hypertension ) history of appy ( history of appendectomy ) history of A fib ( history of atrial
fibrillation ) hypothyroidism ( hypothyroidism ) polyarteritis
OPERATIONS AND PROCEDURES:
Colonoscopy under general anesthesia.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
74 year-old woman in remission from Hodgkin's Lymphoma
and history of renal transplant( 1/20 ) who p/with hypoxia , low grade fever in
setting of colonoscopy under general anesthesia. patient had PET scan on
4/3 which showed uptake in asc colon and hep
flexure concerning for malignancy. CT colonoscopy
showed 1.6 les in desc colon and colonoscopy under
GA performed due to difficulty of going beyond
hep flexure. patient had hypoxia to 80s when
awakening from anesthesia. Temp to 101.1. CXR showed
?LLL opacity. Thought to be likely Pneumonitis vs. asp PNA. In Pacu
patient also had EKG changes , TWIs and ? BBB assoc
with HR70s-80s. EKGs resolved when rate in 60s.
Physical Exam revealed AOOx3 woman in NAD. PERRL. No carotid bruits.
Cardiac exam remarkable for RRR , 2/6 murmur at RUSB. There are
crackles at LL base to mid lung field. Abd exam there is
rebound and invol guarding. Tenderness in epigastric
and suprapubic area. +BS. No hepatomegaly.
Labs significant for HCt 24 from baseline of 30 , Cr
1.9 from baseline of 1.6. Cardiac enzymes were flat.
HOSPITAL COURSE:****************
1. Pulm-On floor patient's oxygenation improved within one day to 96% on RA
Likely aspiration , but final read on
CXR shows no infiltrate/opacity. Levo/Flagyl given empirically x 5days
though she remained afeb.
2. CV-patient has history of MI , RCA stent , mod AS. Low Hct and EKG changes
concerning for
myocardial injury. Her cardiac enzymes were negative after the initial
hypoxic episode , and EKG changes resolved. Transfused 2u PRBCs. On
4/23 she had Afib with RVR to 130s with chest arm pain which is her
anginal equivalent. ECG with rate related ischemia ST depression
V5-6 , L. +Minimal troponin leak to 0.19 , which subseq downtrended
with nl CK. She was init treated with lopressor 5mg
intravenous but had hypotension to 80's which resolved quickly with IVF. She was
eventually rate controlled with dilt drip. She returned to sinus
rhythm within the day. Cards c/s'd
and recommended amio load. She had PFT's , LFT's and TFT's prior to
d/c. Plan to follow up with Dr. Larose . Consider anticoagulation for
PAF , this is at least 2nd episode. patient to restart ecasa 5d p colonosco
py.
2. GI-patient had abd exam concerning for focal peritoneal
irritation. It is likely that she had a microperforation during
colonoscopy as CT showed fluid in pelvis and she had Hct drop
requiring 2U pRBC. Her exam improved , and she was tolerating orally well
at the time of discharge. She has been afeb and well appearing for
several days prior to d/c. Plan to complete 5d abx. As per Dr. Sampey
her colonoscopy was complex , and she had polypectomy of 2.5 cm polyp.
Path is pending. If + for cancer , the base looked "clean" , so may be
feasible to re-scope her for surveillance at a later time , as per GI.
3. HEME- Hct after colonoscopy went to
24 ( baseline 30 ); post-transfusion HCt of 30.
5. history of Renal transplant. Continuing meds.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HANSBERRY , SHAN ROBERTA , M.D. ( WD511 ) 3/5/03 @ 05:24 PM
****** END OF DISCHARGE ORDERS ******
Document id: 46
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
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- |
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475612587 | PUO | 46047117 | | 7447039 | 1/5/2004 12:00:00 a.m. | depression , anxiety | | DIS | Admission Date: 1/5/2004 Report Status:
Discharge Date: 3/21/2004
****** DISCHARGE ORDERS ******
PICARDO , ASHELY 918-55-83-3
I
Service: MED
DISCHARGE PATIENT ON: 7/20/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MUHLSTEIN , GERARD , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
GLUCOTROL XL ( GLIPIZIDE XL ) 10 MG orally every day before noon
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
90 MG orally every day HOLD IF: SBP < 100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ATENOLOL 50 MG orally every day
LISINOPRIL 20 MG orally every day
Alert overridden: Override added on 4/23/04 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
THIAMINE HCL 100 MG orally every day
FOLATE ( FOLIC ACID ) 1 MG orally every day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
Alert overridden: Override added on 7/20/04 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: WILL MONITOR
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Kleinsasser ( primary care physician ) 10/27/04 scheduled ,
Dr. Augustine Milholland ( Psych , Na Tallton Sti ) 10/8/04 scheduled ,
Dr. Vannorman ( Neurology PUO ) 7/27/04 scheduled ,
ALLERGY: Penicillins , Erythromycins , Aspirin
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
depression , anxiety
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
tobacco abuse htn lbbb since 1989 palpitations
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
53 year-old F with history of nonobstructive CAD , HTN , DM , very depressed and
anxious since death of daughter 10/4 , p/with 1-2 wks of intermittent L
arm pain and L leg pain , also with intermittent sharp CP worse with deep
breath , + tightness , getting worse. CP orginiates in neck and arms
and then goes to chest. + diaphoresis , + palpitations , some SOB with
one flight of stairs , no orthopnea. Pain similar to CP prior to cath
in '00 ( showing non-obstructive CAD ). Also depressed and anxious
since daughter committed suicide , occasionally also has SI , + PLAN.
Thinks pain may be related to anxiety. In ED got sublingual NTG with relief ,
first set of cardiac enz neg.
PMH: CAD , HTN , DM , Deperssion
ALL: PCN , ASA , Erythromycin
MEDS: Atenolol , Glucotrol XL , Lisinopril , Prozac , Nifedipine
SHX: history of suicide of only daughter 10/4 , lives in friend's house , 1/2
ppd x 30 yrs , 1/2 pint vodka per day , history of IVDU 30 yrs ago
FHX: Mom with MI in 50s
LABS: CK 232 , MB 3.0 , TnI < assay HCT 33.8 , MCV 104 RDW 15
EKG: NSR at 79 , old LBBB , QRS 160 , borderline LVH with strain pattern.
unchanged from old
Serum Tox + ALC ( 153 )
PE: T97/2 HR 97 , RR 20 , BP 110/96 , 98% RA.
NAD , ETOH odor. NC/AT EOMI. CTAB. RRR , S1/S2 , CP reproduced with mech
pressure. Abd + BS S/nT/nd Ext WWP , 4/5 L hip flexsion , no C/C/E
IMPRESSION: 53 year-old F with CP likely non cardiac , first set enz neg. ?
costochondritis vs. psych component.
CV: Ruling out for MI given DM , low likelyhood. ASA allergy.
Continued BB/ACE/CCB. On tele during ruleout with no acute events
. Continue BP meds.
PSYCH: Required 1:1 sitter given SI. Was quiet throughout hospital
course , not actively suicidal. Continued prozac. Ativan as needed
withdrwal. Psych felt may benefit from Outpatient psych follow-up.
NEURO: ? L hip weakness , felt to be 2/2 peripheral neuropathy. Getting
head CT to r/o stroke --> HEAD CT was negative. Will need outpatient
neuro f/u with lumbar/thoracic MRI ( see MSK below ).
MSK: L shoulder film showed only degenerative changes , no fracture.
Lumbar and Thoracic MRI for ? spinal stenosis given chronic L shoulder
and LLE pain is pending.
FEN: Lytes were repleted as needed , also geting Thiamine , folate , MVI.
Prophy: Lovenox , Nexium
++++
DISPO: DISCHARGED ON HER REGULAR HOME MEDS. WILL NEED FOLLOW UP ON
THORACIC AND LUMBAR MRI. HAS APPT WITH primary care physician ON 4/9 . OUTPT PSYCH
FOLLOW UP WITH DR. AUGUSTINE MILHOLLAND 10/23 11AM. OUTPT NEURO F/U
WITH DR. VANNORMAN 5/25 2PM.
ADDITIONAL COMMENTS: 1. PLEASE TAKE ALL OF YOUR REGULAR MEDICINES + MULTIVITAMINS , THIAMIN
E , FOLATE. IF THE DOSE ABOVE DOES NOT MATCH YOUR HOME MEDS AND DOSES ,
PLEASE TAKE YOUR HOME MEDS & DOSES.
2. PLEASE FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN , THE PSYCHIATRIST
TOMORROW , AND THE NEUROLOGIST ON 5/25 .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
FOLLOW UP with Psych re. depression , anxiety , SI.
FOLLOW UP WITH Neuro re. L hip weakness , will need to follow-up
THORACIC AND LUMBAR MRI results.
No dictated summary
ENTERED BY: HENDY , CLARETHA , M.D. , PH.D. ( TD18 ) 7/20/04 @ 02:45 PM
****** END OF DISCHARGE ORDERS ******
Document id: 47
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
106565366 | PUO | 86025167 | | 100667 | 6/16/2001 12:00:00 a.m. | Infected R THR | | DIS | Admission Date: 6/16/2001 Report Status:
Discharge Date: 6/19/2001
****** DISCHARGE ORDERS ******
VIANA , BELLE A 436-75-25-7
Au
Service: ORT
DISCHARGE PATIENT ON: 1/29/01 AT 03:00 PM
CONTINGENT UPON Eval by Cardiology
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BELIZ , MEREDITH , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
VENTOLIN ( ALBUTEROL INHALER ) 1-2 PUFF inhaled four times a day
as needed sob/wheeze
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
CEFTRIAXONE 2 , 000 MG intravenous every day
Number of Doses Required ( approximate ): 2
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ENALAPRIL ( ENALAPRIL MALEATE ) 2.5 MG orally every day
PERCOCET 1-2 TAB orally every 4 hours as needed pain
ZOCOR ( SIMVASTATIN ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ISOSORBIDE MONONITRATE 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 15
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: No Restrictions
RETURN TO WORK: after eval by Dr Beliz
FOLLOW UP APPOINTMENT( S ):
Dr Beliz 9/10/01 , PUO pre-admit for OR I&D/removal hardware. 9/10/01 scheduled ,
ALLERGY: Shellfish , Morphine
ADMIT DIAGNOSIS:
Infected R THR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Infected R THR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hodgkins lymphoma ( Hodgkins disease ) Asthma ( asthma ) R total hip
replacement ( total hip replacement ) septic joint ( total hip
replacement ) non Q wave MI; Extensive CAD.
OPERATIONS AND PROCEDURES:
CT-guided aspiration R hip per Radiology 10/26/01 .
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous Abx
BRIEF RESUME OF HOSPITAL COURSE:
Admitted from office 10/26/01 for infected L THR. Aspiration
demonstrated purulent material. Started on Ceftriaxone per ID consult
recs. MIC to both PCN and Ceftriaxone pending. MRI of pelvis completed
6/27/01 as pre-op eval. TU Cardiology was consulted for pre-op
clearance given extensive history of cardiomyopathy and unstentable CAD per
last cardiac cath 3/5 . On further d/with physical therapy , he was adament about being
allowed to be D/C home on Abx for July holiday. Given that his
clinical picture was much improved on antibiotics , both Dr Beliz and ID
MD agreed to this on provision that he return immediately for any
evidence of progressing infection. His R hip pain and exam were much
improved by time of discharge. Will plan for intravenous lon line to be placed
prior to D/C for home dosing of every day Ceftriaxone. ID to be re-consulted
on admission post-op 1/2 for re-eval of abx choice. By that time it
is presumed that the MIC for PCN/CTX will be available for ascertation
of proper long-term Abx care.
ADDITIONAL COMMENTS: Return immediately for increasing temps/shaking chills/pain at R hip.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. D/C home with services for every day CTX dosing.
2. intravenous long line placement.
3. Re-admission for removal of infected hardware and spacer placement
9/10/01 .
4. intravenous Ceftriaxone per VNA 2 Gr intravenous every day for 4/18/01 .
No dictated summary
ENTERED BY: BARRANCA , SONNY M. , M.D. ( MN74 ) 1/29/01 @ 09:20 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 48
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
- |
Y |
N |
- |
N |
Y |
Y |
N |
N |
- |
N |
- |
N |
838440387 | PUO | 59556390 | | 8559314 | 11/24/2007 12:00:00 a.m. | same | | DIS | Admission Date: 8/17/2007 Report Status:
Discharge Date: 8/9/2007
****** FINAL DISCHARGE ORDERS ******
ROTHMAN , BAILEY 329-84-06-2
Newvi Dr
Service: MED
DISCHARGE PATIENT ON: 1/27/07 AT 04:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 325 MG orally every day
2. ATORVASTATIN 80 MG orally every day
3. DOCUSATE SODIUM 100 MG orally twice a day
4. ESOMEPRAZOLE 40 MG orally every day
5. LACTULOSE 30 MILLILITERS orally twice a day
6. LISINOPRIL 10 MG orally twice a day
7. METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally every day
8. CLOPIDOGREL 75 MG orally every day
9. GLIPIZIDE 2.5 MG orally every day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 325 MG orally DAILY
Starting IN a.m. ( 7/1 )
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 7/9/07 by
SOSAYA , AMBERLY , M.D. , PH.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
911430519 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: mda
DULCOLAX RECTAL ( BISACODYL RECTAL ) 10 MG PR DAILY
as needed Constipation
CELEXA ( CITALOPRAM ) 30 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LOVENOX ( ENOXAPARIN ) 40 MG subcutaneously DAILY
Starting Today ( 3/23 )
Instructions: Continue until patient going home , then stop
FERROUS SULFATE 325 MG orally three times a day Starting Today ( 3/23 )
Instructions: PLEASE MAKE SURE patient getting a very adequate
bowel regimen ( given constipation on presentation ) and
constipation while taking iron. Please make sure
getting colace , senna scheduled , and MOM/lactulose to
facilitate a bm every day. Food/Drug Interaction Instruction
Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
GLIPIZIDE 2.5 MG orally DAILY
LISINOPRIL 5 MG orally DAILY
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally every 8 hours
HOLD IF: heart rate<55 , sbp<100 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OMEPRAZOLE 40 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 7/9/07 by
SOSAYA , AMBERLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: mda
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Appointment with your primary care physician , Dr. Scheffer at P Therford Hospital 7/25/07 Wed 2:45pm ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Chest pain , weakness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of CABG x 2 ( coronary artery disease ) RAS c L renal stent
bilateral common iliac artery stents
PAF ( paroxysmal atrial fibrillation ) R CEA DM ( diabetes mellitus )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Trans-thoracic echo
Serial cardiac enzymes and labs
Carotid ultrsound
BRIEF RESUME OF HOSPITAL COURSE:
CC: Severe weakness , chest pain in the ED.
HPI: 82 F with history of HTN , DM , CAD history of CABG x 2 ( stents x 4 ). In RHMC ,
but progressively feeling worse , until acutely weak this a.m.. Could
not get out of bed. Daughter was around and she called EMS
at patient's request. Recv'd asa 325mg x 1 in the ambulance. Denies
CP/SOB/N/V/melanotic stools/BRBPR/cough/fevers/chills/dysuria in the
last few days. Does note decreased apetite , and mostly consuming
liquids in the last two days. Does report taking lactulose x 2 2/2
constipation x 2-3 days Had pacer placement about a month ago.
In ED: SBP 190's , developed CP about 1h after admission. given nitro
and morphine 3mg repeat blood pressure 98/50s , rebounded to 160s/50s prior to
transfer to floor. Chest pain resolved. ? T wave changes in the
inferior leads from previous.
***
PMH: 1. HTN2. DM
3. CAD CABG x 2 ( re-do sternotomy both in the 70's and the 90's ) PCI
x 2 ( 4 stents ) Pacer placement
'2007 4. Left Renal artery stenosis history of
stent 5. Paroxysmal atrial
fibrillation 6. Right carotid
endarterectomy. 7. Bilateral iliac stents
***HOME MEDS:
1. ASA 325 daily 2. plavix 75 daily 3. glipizide 2.5 daily 4. toprol
XL 100 daily , 5. lisinopril 10 every day 6. lipitor 80
daily 7. colace 100mg twice a day 8. omeprazole 40
every day 9. Lactulose every day before noon/every afternoon as needed
constipation 10. senna twice a day as needed
constipation 11. celexa --> patient denies
taking ALLERGIES: PCN
( rash ) FH:
noncontributory SH: lives with son ( Kaemmerling ) ,
4 children A&W in area , retired RN from Put Wathern Hospital
Una Cousins tel No's: 314-416-9306 cell
354-244-8635 Alleen Deck tel: 144-340-9527 and
work 081-927-1533 ext 6613 remote ( 20 yrs ago ) tobacco hx , denies
ETOH and illicit drug use
***
PE on ADMISSION: VS: Afeb HR 59 , BP 165/51 , RR 20 , SaO2 100% 2
L Gen: elderly female lying supine , appearing very
weak and mildly somnolent NAD , oriented to
place/person/time HEENT: NCAT , anicteric sclera , mmm , upper
dentitions CHEST:
CTAB CV: RRR S1S2 , SEM I-II /
VI ABD: many old healed surgical scars , no rashes ,
+BS , soft , NTND , no HSM , no RT/G EXT: wwp , no e/c/c , 2+ DP's. Well
healed surgical scars
SKIN: intact , no rashes NEURO: CN II-XII intact , no focal deficits;
A+O x 3
***
RESULTS: nasal 134 K 4.0 CL 99 CO2 27 BUN 17 CRE 1.1 GLU
110 CA 8.6 PHOS 3.1 MG 2.2 TBILI 0.5 TP 6.2 ALB
3.5 GLOB 2.7 ALT/SGPT 11 , AST/SGOT 18 , ALKP 90 , TBILI
0.5 3:30PM Set: CK 27 , CK-MB 1.5 TROP-I <0.04
WBC 6.18 HCT 27.5 PLT 327 physical therapy 14.8 PTT 33.7
INR-1.2 Urinalysis- entirely
negative
***
Studies/Imaging: Portable CXR:
Neg EKG: Normal sinus , paced @ 61 bpm , TWI in V5 , V6 ,
I , II , AVF ( likely old when c/with prior EKG ) , No acute ST changes
noted
*****
A/P: 83y F with MMP and increasing weakness , new onset of chest pain.
ROMI.
CV- HDS currently.
- Cardiac telemetry and pulse ox continuous
- ASA 325mg every day - Plavix 75mg every day - Atorvastatin 80 mg every day
- Lopressor 12.5mg orally every 8 hours - Lisinopril 5mg orally every day
- ROMI- done- no evidence of MI.
------
Hct 27.5 on presentation. Hx of CAD.
- 1u pRBCs with lasix 20u x 1 intravenous to chase
----
TTE -EF 50% no wall motion abnl. unchanged
----
Neuro- Chest pain has resolved. No current pain issues. No acute
neuro changes. Hx of depression. Morphine 1-2mg intravenous as needed pain , did not
require since day 1.
Consulted psychiatry- recommended celexa 30mg orally every day
Consulted Neurology- Some autonomic instability ( hypotension ) with
standing. Recommended JOBST stockings , and if still problematic
consider low dose mineralocorticoid treatment ( somewhat of a problem
when considering her other comorbidities ).
-----------
***Carotid U/S done - interval worseninig of R mid int lesion to - 55%
*** Will need followup
---------
Resp- Hx of smoking. No current respiratory issues.
Will CTM closely along with fluid status GI-
Constipation cont colace/senna/mom/malox
cont prilosec
Endo- SSI medium scale while in house
TSH 5-8 in house. TFTs done -wnl t3-72 , t4-8. No benefit to thyroid
supplementation , especially given comorbidities ( risk of sinus tach ,
osteoporosis , etc ).
ID- no issues. check UA
Heme- Hct 27.5. 1upRBCs as noted above. Retic's -3.7% appropriate. Some
iron-deficiency anemia. Supplemented with Iron , multivitamin , folate , one
b12 shot.
Psych- will restart celexa. psych consult
obtained.
PPx's : lovenox 40mg subcutaneously while in-house.
Dispo: to rehab
FULL CODE
ADDITIONAL COMMENTS: ** Please use TEDS thigh-high.
** Please call your primary care physician , Dr. Scheffer with questions
** Please obtain Jobst stockings through your primary care physician's office when
available.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please followup with further workup of anemia. Component of iron
deficiency anemia on presentation here. Probably anemia of chronic
disease. ?Role for procrit
2. Carotid ultrasound with 50-55% lesion , asymptomatic. Should follow
No dictated summary
ENTERED BY: SOSAYA , AMBERLY , M.D. , PH.D. ( TX586 ) 1/27/07 @ 03:56 PM
****** END OF DISCHARGE ORDERS ******
Document id: 49
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
032003429 | PUO | 50415670 | | 9990182 | 7/24/2006 12:00:00 a.m. | Coronary artery disease 414.01 | | DIS | Admission Date: 6/5/2006 Report Status:
Discharge Date: 10/23/2006
****** FINAL DISCHARGE ORDERS ******
BEEBEE , MINNIE 809-39-21-7
Pla Las Hisdence
Service: CAR
DISCHARGE PATIENT ON: 10/19/06 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KUSH , QUINN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA 325 MG orally DAILY
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Shortness of Breath
Number of Doses Required ( approximate ): 6
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting IN a.m. ( 8/2 )
CODEINE PHOSPHATE 15 MG orally every 3 hours as needed Pain
HOLD IF: sedated , rr<12
DEXTROMETHORPHAN HBR 10 MG orally every 6 hours as needed Other:cough
HOLD IF: sedated , rr<12
Number of Doses Required ( approximate ): 6
ZETIA ( EZETIMIBE ) 10 MG orally DAILY
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously BEDTIME
HOLD IF: call HO if BG <90
POTASSIUM CHLORIDE IMMED. REL. ( KCL IMMEDIATE... )
*** LOW KCL REPLACEMENT SCALE ORAL orally Scale Frequency
1. Only KCL Immediate Release products may be used for KCL
scales.
2. Do not use sustained-release potassium for KCL scale
doses. 3. Replace KCL based on lab values.
4. As per PUO Potassium Chloride Policy: each 20 mEq dose
is to be given with 4oz of fluid.
5.A serum creatinine must be ordered and checked daily
while patient is ordered for a K-scale.
6.K-scale cannot be used on patients with:
* A serum creatinine greater than or equal to 2.0 mg/dl; or
* A serum creatinine increase of 0.5 mg/dl within 24
hours.
* Hold scale and contact MD if SCr is greater than 2.0.
-----------------------------------------------------------
----------- If K+ Level is less than 3.1 then call H.O.
If K+ Level is 3.1-3.3 , then administer KCL 40 meq orally
followed by 20
meq orally 2 hours later. Recheck K+ Level 2 hours after
dose was given.
If K+ Level is 3.4-3.6 , then administer KCL 40 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 3.7-4.0 , then administer KCL 20 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 4.1-5.0 , then DO NOT administer KCL.
Recheck K+ Level in every day before noon
If K+ Level is greater than 5.0 then call H.O.
-----------------------------------------------------------
-----------
Override Notice: Override added on 10/19/06 by
BALDAUF , WILLOW N. , M.D.
on order for DIOVAN orally ( ref # 269432644 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: aware
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MAGNESIUM GLUCONATE Sliding Scale orally ( orally ) DAILY
-> Mg-scales cannot be used and magnesium doses must be
individualized for patients who have:
- a serum creatinine greater than or equal to 2.0 mg/dL; or
- a serum creatinine greater than or equal to 1.5 mg/dL
and an increase of 0.5mg/dL within 24 hours.
Call HO if Mg level is less than 0.8
If Mg level is less than 1 , then give 3 gm Mg Gluconate
orally and call HO
If Mg level is 1.0-1.5 , then give 2 gm Mg Gluconate orally
If Mg level is 1.6-1.9 , then give 1 gm Mg Gluconate orally
If Mg level is 2.0-2.5 , then Do Not administer Mg
Gluconate Call HO if Mg level is greater than 2.5
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
OXYCODONE 5-10 MG orally every 6 hours as needed Pain
PINDOLOL 5 MG orally twice a day HOLD IF: sbp<90 , HR<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOCOR ( SIMVASTATIN ) 80 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIOVAN ( VALSARTAN ) 160 MG orally DAILY
Starting IN a.m. ( 1/20 )
Alert overridden: Override added on 10/19/06 by
BALDAUF , WILLOW N. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: aware
Number of Doses Required ( approximate ): 5
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 15 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Kush He will arrange. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Elective cardiac catheterization with PCI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Coronary artery disease 414.01
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD
OPERATIONS AND PROCEDURES:
Cardiac catheterization with stent to old CABG vessel
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CXR
BRIEF RESUME OF HOSPITAL COURSE:
CC: Elective Cardiac Cath
HPI: 58 year-old female smoker with hx of CAD , history of CABG x3 , DM II , HTN , and
hyperlipidemia admitted to the CCU after elective cardiac cath history of
abnormal stress test. Cath showed impaired flow in the inferior
and posterolateral zones due to obstructive degenerative disease in
the SVGs to the RCA and LCF-OM. Stent placed in the RCA graft though
there was extensive calcification and difficulty
obtaining full stent expansion , and following the stent deployment
there was poor reflow accompanied by mild chest pain and EKG changes ,
without hemodynamic embarrassment. patient was transferred back
to the CCU stable and without pain. patient was scheduled for call out to
floor , but had an episode of jaw sensation , different from previous
angina. patient was upset by turn of events , but was calmed by staff. Was
then evaluated by Dr. Kush and came out to the floor Na night.
PMH
DMII , HTN , Hyperlipidemia , Cirrhosis history of CABG x 3
1997 history of AAA repair
1996 history of aorto-fem bypass
1996 history of
TAHBSO Meds
Lantus 40u every day Estradiol 0.05
Diltiazem 180 mg every day HCTZ 25 mg
every day Zetia 10mg
every day Diovan 160 mg
every day Plavix 75 mg
every day Zocor 80 mg
every day ASA 325 mg
every day MV
Meds in CCU ASA 325 mg every day
Lantus 20u every day Plavix 75 mg
every day Zetia 10mg
every day Famotidine 20 mg
twice a day Pindolol 5 mg
twice a day Lovenox 40 subcutaneously
every day nicotine
patch MgSO4
SS KCL SS
Novolog SS patient
Status Vitals
Gen - Awake , Alert , NAD HEENT - JVP 6 cm , No
bruits Chest - CTAB with mild rhonchi/wheezes
R>L CV - RRR , Nml S1 , S2 , II/VI SEM at
LLSB Abd - Soft , NT , ND , No
organomegaly Extr - L femoral bruit , R cath site , oozing , no
edema , hematoma , ecchymosis present
Studies CAth -
Right Dominant Circulation
Left Main Coronary Artery
No significant LM lesions identified
Left Anterior Descending Artery
LAD ( Proximal ) , Discrete 90% lesion
LAD ( Ostial ) , Discrete 90% lesion
Left Circumflex Artery
CX ( Proximal ) , Discrete 90% lesion
Right Coronary Artery
RCA ( Proximal ) , Discrete 100% lesion
RT PDA ( Mid ) , Discrete 100% lesion
Coronary Artery Bypass Grafts:
SVG Graft to RT PDA ( Mid ) , Discrete 90% lesion STENT to 20%
LIMA Graft to LAD
SVG Graft to MARG1 ( Ostial ) , Discrete 90% lesion
SVG Graft to MARG1 ( Proximal ) , Discrete 90% lesion
Collateral flow from LAD to RT PDA
A/P
1. Cardiac Ischemia- patient had elective PCI on 9/6/06 with results as
mentioned previously. She did experience jaw sensations and chest pain
post procedure that she describes as different from periprocedure pain ,
and previous episodes of angina. After release from CCU , had no further
events. No current chest or jaw pain. Continuing plavix , zocor , zetia
as outpt and heparin and Integrelin have been discontinued.
Pump- physical therapy has preserved fxn , BP low normal , patient euvolemic.
Rhythm - NSR on telemetry will d/c on Betablocker.
2. Pulm - patient has chronic cough due to Post nasal drip. Taken off of her
antihistamine on admission. It is USOH per patient DID NOT GIVE
ANTIHISTAMINES in this hospital course. CXR was normal with no acute
changes on admission.
3. Renal - NO hx of renal dz , No renal issues during hospital course.
4. Endo - DMII on Lantus , Novolog SS , while in the hospital.
FS Glu monitored. No adjustment needed. Will send out on home doses o
insulin.
5. Heme - patient had cath and subsequent oozing from site in groin. Hct was
stable post cath , Anticoagulation stopped. patient to be discharged on home
meds including plavix and ASA.
ADDITIONAL COMMENTS: Please return if you have any chest pain , jaw pain , shortness of breath ,
groin pain , groin swelling , dizziness , or fever and chills. Please take
medicines as previously prescribed. Please limit activity for the next
few day to non-strenuous work. Please make follow up appts. with primary
care physician and cardiologist within the next 2 weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up on groin site and evaluate for bruits or hematoma.
Please follow Hct to ensure no acute blood loss.
No dictated summary
ENTERED BY: KUSH , QUINN J. , M.D. ( PQ5 ) 10/19/06 @ 05:01 PM
REVIEWED BY: KUSH , QUINN J. , M.D.
****** END OF DISCHARGE ORDERS ******
Document id: 50
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
488940606 | PUO | 19781692 | | 951619 | 8/27/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/8/1991 Report Status: Signed
Discharge Date: 10/17/1991
PRINCIPAL DIAGNOSIS: PERIPHERAL VASCULAR DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male
who presented to the Emergency Room
complaining of blue right toes. The patient has no known vascular
disease. Over the past two years , the patient has developed
progressive claudication. He currently is able to walk about one
block before having to stop. He was otherwise well until about one
and a half weeks prior to admission when , for two days after
cutting his toenails , he noted increasing pain and blue coloring of
his right fifth toe. He thought that he injured the toe when
cutting the nail. He cut the skin on the plantar side of the right
third toe accidently five days prior to admission. He then
presented with blue coloration of the third , fourth and fifth toes
and intense pain over the fifth toe. He has no history of erythema
extending up his foot or leg. He has no history of diabetes. No
fever or chills. No history of atrial arrhythmias. No heart
disease , syncopal episodes. No low back or buttock pain. No
erectile dysfunction. He has no history of an abdominal aortic
aneurysm. He is a smoker with two packs for 20 years. No history
of hypertension or hypercholesterolemia. He had no history of TIA ,
CVA , myocardial infarction or angina. PAST MEDICAL HISTORY:
Varicose veins. MEDICATIONS: None. ALLERGIES: NO KNOWN DRUG
ALLERGIES.
PHYSICAL EXAMINATION: On admission revealed the patient to be
afebrile and stable. Head exam was normal.
Neck exam was supple with full range of motion. Lungs were clear
bilaterally. Heart revealed a regular rate and rhythm , normal S1
and S2 , no CVA tenderness. Abdomen was obese , soft , no palpable
masses , normal bowel sounds. Groin showed no hernias. Pulses were
significant for 1+ dopplerable femorals bilaterally , 2+
dopplerable dorsalis pedis bilaterally , 1+ dopplerable posterior
tibial on the right , 2+ dopplerable posterior tibial on the left
and 2+ dopplerable popliteals. Rectal exam was guaiac positive
with some pain and no visible lesions. ABI was .66 of the dorsalis
pedis on the right , .44 of the dorsalis pedis on the left; .61
posterior tibial on the right and .66 posterior tibial on the left.
HOSPITAL COURSE: The patient was admitted for intravenous
heparinization. He underwent an angiogram which
showed 90% stenosis of the iliac bifurcation on the right , greater
than 50% narrowing of the distal common iliac and diffuse narrowing
throughout the vessel. His SFA and popliteals were patent on the
right. On the left he had occlusion of the left common iliac with
reconstruction of the common femoral. His SFA was occluded
proximally with reconstitution at the adductor canal and one vessel
peroneal run off. His post angio creatinine was 1.1. Cardiology
was consulted and their impression was that he had severe bilateral
peripheral vascular disease with a question of an embolic event to
the right toe. They recommended that if surgery became necessary
that he had perioperative Nitropaste and check postoperative EKG's
and enzymes. He was sent home for follow-up in the clinic.
DISPOSITION: MEDICATIONS: On discharge included Vasotec , 5 mg
orally every day; aspirin , one tablet per day; Nicorette gum
for smoking cessation.
IO582/2817
BUCK MOOSE , M.D. PZ17 D: 11/13/91
Batch: 3692 Report: Q0467J47 T: 2/3/91
Dictated By: DESIRAE MARCOTT , M.D.
Document id: 51
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
010746671 | PUO | 42234794 | | 745127 | 2/20/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/9/1990 Report Status: Unsigned
Discharge Date: 6/26/1990
HISTORY OF PRESENT ILLNESS: This is a 37 year old female who has
had pain in her old appendectomy
incision. The patient has had pain intermittently in the right
lower quadrant in the old appendectomy scar for many years. She
denies nausea or vomiting , or history of intestinal obstruction.
PAST MEDICAL HISTORY: Is significant for hypertension. She had an
appendectomy in 1965. She had a right carpal tunnel release in
1985 , and a right wrist tendon surgery in 1987. She has chronic
obstructive pulmonary disease. MEDICATIONS ON ADMISSION:
Hydrochlorothiazide 25 q-day and Seldane as needed for allergies.
ALLERGIES: PENICILLIN CAUSES A RASH , MORPHINE CAUSES NAUSEA AND
VOMITING. She does not smoke and only occasionally drinks. REVIEW
OF SYSTEMS: Is noncontributory.
PHYSICAL EXAMINATION: Blood pressure is 130/90 , heart rate is 80.
In general , this is an overweight , otherwise
well female. The lungs were clear to auscultation. Heart was a
regular rate and rhythm , with no murmurs , rubs , or gallops. Pulses
were 2+ in the radial and dorsalis pedis. Abdomen: Soft , obese ,
nontender , with some mild incisional tenderness over the area of
the appendectomy scar. Neurological examination was nonfocal.
ASSESSMENT: Was a 37 year old female with pain in the old
appendectomy scar. The plan was for an incisional hernia repair
and exploration.
HOSPITAL COURSE: The patient was taken to the operating room on
8/6/90 . The procedure performed was an
incisional hernia repair by Dr. Throneburg and Dr. Bulls . The patient
tolerated the procedure well and was returned to the floor that
evening. Since that time , the patient has had been somewhat slow
to mobilize. She has complained of some nausea and some pain in
the abdomen. She was given a PCA pump for the pain. The patient
on 10/28/90 developed marked pain and much difficulty ambulating.
Minimal orally intake was thought to be going on at this time. On
10/15/90 , the patient began to be doing much better. She had slow
ambulating despite the PCA pump , but was felt by Dr. Throneburg that the
patient would continue to improve , and we could increase the orally
medications and switch to a plan for discharge tomorrow.
DISPOSITION: She was discharged on the following medications:
Percocet one to two orally q4-6 hours ,
Hydrochlorothiazide 20 mg orally q-day were the extent of her
medications. FOLLOWUP: She is to be followed in the office by Dr.
Throneburg as an outpatient.
________________________________ YK127/4929
FLORETTA THRONEBURG , M.D. , PH.D. OX92 D: 6/16/90
Batch: 2769 Report: J0154F41 T: 2/25/90
Dictated By: ELENA S. BIALY , M.D. FO02
cc: ANDNOCK STOWNCHILD MEDICAL CENTER
Document id: 52
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Q |
U |
U |
U |
Y |
U |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
- |
N |
N |
N |
Y |
- |
N |
N |
- |
N |
- |
N |
598555919 | PUO | 29607759 | | 0366252 | 6/11/2006 12:00:00 a.m. | Chest pain | | DIS | Admission Date: 10/22/2006 Report Status:
Discharge Date: 10/1/2006
****** FINAL DISCHARGE ORDERS ******
PEELMAN , THEODORE 315-81-02-4
Flint En Kanprai
Service: CAR
DISCHARGE PATIENT ON: 2/13/06 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BURVINE , ALVERTA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
NORVASC ( AMLODIPINE ) 5 MG orally DAILY HOLD IF: sbp<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting IN a.m. ( 7/26 )
ECASA 325 MG orally DAILY
ID-RANOLAZINE 1 , 000 MG orally twice a day Starting Today ( 7/26 )
Instructions: AH Study drug- patient has pills at bedside.
Should take
2 pills twice a day ( 1000mg twice a day ) as part of study protocol.
Could be placebo.
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 90 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 5 MG orally DAILY HOLD IF: sbp<90
Alert overridden: Override added on 5/1/06 by
FRIES , SPENCER L. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally every 6 hours
HOLD IF: SBP<90 , HR<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DENAVIR CREAM ( PENCICLOVIR ) CREAM TP every 2 hours W/A X4DAYS
Number of Doses Required ( approximate ): 10
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr Jackson Part , Fencop Sepull Vierf Rd 8/28/06 at 2:45 pm ,
Dr. Burvine Within 6 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of 1vCABG '76 , 3vCABG '94 history of rad
prostatectomy history of prostate CA urethrocolonic fistula history of pilonidal cyst
OPERATIONS AND PROCEDURES:
Cardiac cath , L heart
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
**CC: chest pain
**HPI: 74 year-old man , vasculopath , with history of CABG x 2 ( 1976 & 1994 ) , presents
with history of sudden onset of substernal chest pain which came and went
starting 2 days PTA. Was exerting self when felt onset of dull
pressure like pain a/b slight sob and squeezing sensation -
typical angina. Instead of declining , continued and was constant for
the next 24-30 hours , waxing & waning. Took over 25 sublingual nitro in that
time period. Presented to OMC on day of admission with TNI
elevation , no longer in pain , lateral ST depressions ( subtle ). Had
SOB on night prior to admit; no PND/orthopnea. Pain never a/b
nausea/vom/diaphoresis.
********
**PMHx: CABG x 2: ?DM , hyperlipidemia , radical
prostatectomy **Meds: toprol 200 every day , isosorbide 180 every day , norvasc 5
every day , lipitor 80 every day , asa 325 every day , ibuprofen as needed **ALL:
NKDA **Admit PE: 99.7 100 124/60 20 95% 2L , NAD , mmm , JVP
@ear , bibasilar crackles , RRR , 2/6 SM. NABS , soft , nt , nd. NO PULSE
RLE DP. +2 DP/physical therapy LLE. Neuro: A&Ox3.
********
**Labs: HCT 36 , Cr 0.7 , TNT 0.24 , Ck 214 , MB 21.6 **EKG: ST 100 , St
dep'rn 0.5 mm V4-V6. **CXR: pulm
edema
********
NB: on yyTC trial. if patient having weird ss , eg nausea , stomach
upset , or if he is having severe chest pain , would call the AH team
sooner rather than later. if questions , would call Verna Jonte
( team's cards fellow @ 46735 ) or Dr. Versie Pasaya 27215 )
********
DAILY STATUS: BP 100s , no chest pain , NAD. A&O x 3. JVP at 10 cm.
otherwise unchanged from admission. A/P: 74 year-old M with CABG x 2 p/with chest
pain , NSTEMI likely happened several days prior to admit.
**CV: ( i ) - NSTEMI. L heart cath revealed patent CABG grafts , no
intervenable disease. Decision to medically manage on
GPIIb/IIIa inhib/heparin in house only and ECASA/Plavix/BB/Lipitor/ACE
inhib/nitrates now and at home. Also enrolled in AH study on
ranolazine vs placebo. Troponin trended down. Pain free at time of
discharge. ( r ) on
tele ( p ) chf on exam. post-NSTEMi echo chowed LV EF 40% , mild-mod
dilation. AK ant/inf septum and basal post segment. diuresed , cont lasix
at home , will need lytes checked. **HEME: anemia - iron
studies unrevealing given NL ferritin. Hct stable in house , follow as
outpatient**ENDO: history of ?DM. hgb a1c nl , lipids appropriate. cont
lipitor. Did have elevated figner sticks in house , re-scren for DM as
outpaient. **GU: history of radical prostatectomy which left him with a
recto-ureteral fistula and he often has stool-laden urine. chooses
not to have this repaired at present. **PPX: was on
heparin , ambulate at home **FULL
CODE
ADDITIONAL COMMENTS: Take your new medicines as directed. You will need your electrolytes
checked in the next 1-2 weeks given the new meds , so please see your primary care physician
around 1 week from now for evaluation. If you feel chest pain that is
worsening , shortness of breath , sweating , or other concerning symptoms ,
please call your doctor or call 911.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
primary care physician in 7 days. Check lytes at that time ( starting lasix and ACE inhib ).
Check BP as well.
No dictated summary
ENTERED BY: SHUGRUE , MOSHE , M.D. ( ZB13 ) 2/13/06 @ 03:58 PM
****** END OF DISCHARGE ORDERS ******
Document id: 53
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
N |
Y |
Y |
Y |
N |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
415842495 | PUO | 78560075 | | 3419127 | 4/4/2006 12:00:00 a.m. | bacteremia | | DIS | Admission Date: 9/19/2006 Report Status:
Discharge Date: 10/20/2006
****** FINAL DISCHARGE ORDERS ******
DEARTH , DEIRDRE T. 104-60-01-0
Ta
Service: ONC
DISCHARGE PATIENT ON: 11/8/06 AT 11:00 a.m.
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DOEPKE , MELVIN N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
as needed Pain , Temperature greater than:101 , Other:transfusion
premedication
ALBUTEROL NEBULIZER 2.5 MG inhaled every 4 hours as needed Wheezing
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:congestion
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
2 TAB orally twice a day
PERIDEX MOUTHWASH ( CHLORHEXIDINE MOUTHWASH 0.12% )
15 MILLILITERS MO twice a day
Instructions: pls use this or nystatin s+s
BENADRYL ( DIPHENHYDRAMINE ) 12.5 MG orally x1
as needed Other:pre-transfusion
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
ENOXAPARIN 40 MG subcutaneously DAILY
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals
Starting Today ( 4/9 )
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
INSULIN NPH HUMAN 10 UNITS subcutaneously every day before noon
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG inhaled four times a day
POTASSIUM CHLORIDE IMMED. REL. ( KCL IMMEDIATE... )
***LOW KCL IMMEDIATE RELEASE REPLACEMENT SCALE ORAL orally
Scale Frequency
1. Only KCL Immediate Release products may be used for KCL
scales.
2. Do not use sustained-release potassium for KCL scale
doses. 3. Replace KCL based on lab values.
4. As per PUO Potassium Chloride Policy: each 20 mEq dose
is to be given with 4 oz of fluid.
5. A serum creatinine must be ordered and checked daily
while patient is ordered for a K-scale.
6. K-scale cannot be used on patients with:
* A serum creatinine greater than or equal to 2.0 mg/dl; or
* A serum creatinine increase of 0.5 mg/dl within 24 hours.
* Hold scale and contact MD if SCr greater than 2.0.
-----------------------------------------------------------
----------- If K+ Level is less than 3.1 then call H.O.
If K+ Level is 3.1-3.3 , then administer KCL 40 meq orally
followed by 20
meq orally 2 hours later. Recheck K+ Level 2 hours after
dose was given.
If K+ Level is 3.4-3.6 , then administer KCL 40 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 3.7-4.0 , then administer KCL 20 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 4.1-5.0 , then DO NOT administer KCL.
Recheck K+ Level in every day before noon
If K+ Level is greater than 5.0 then call H.O.
-----------------------------------------------------------
-----------
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
40 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LACTULOSE 30 MILLILITERS orally DAILY as needed Constipation
ATIVAN ( LORAZEPAM ) 0.5-1 MG intravenous every 8 hours as needed Nausea
HOLD IF: sedate or rr<10
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MAGNESIUM GLUCONATE Sliding Scale orally ( orally ) DAILY
-> Mg-scales cannot be used and magnesium doses must be
individualized for patients who have:
- a serum creatinine greater than or equal to 2.0 mg/dL; or
- a serum creatinine greater than or equal to 1.5 mg/dL
and an increase of 0.5mg/dL within 24 hours.
Call HO if Mg level is less than 0.8
If Mg level is less than 1 , then give 3 gm Mg Gluconate
orally and call HO
If Mg level is 1.0-1.5 , then give 2 gm Mg Gluconate orally
If Mg level is 1.6-1.9 , then give 1 gm Mg Gluconate orally
If Mg level is 2.0-2.5 , then Do Not administer Mg
Gluconate Call HO if Mg level is greater than 2.5
MAGNESIUM SULFATE Sliding Scale intravenous ( intravenously ) DAILY
-----------------------------------------------------------
------ Physician Instructions:
Magnesium scales cannot be used on patients with:
-> A serum creatinine greater than or equal to 2.0 mg/dL;
or
-> A serum creatinine increase of 0.5 mg/dL within 24
hours.
-----------------------------------------------------------
-------- Call HO if Mg level is less than 1.2
Hold order if creatinine is greater than 1.9
If serum Mg level is less than 1.4 , then give 5 gm Mg
Sulfate intravenously and call HO
If serum Mg level is less than 1.6 , then give 4 gm Mg
sulfate intravenously
If serum Mg level is less than 1.8 , then give 3 gm Mg
Sulfate intravenously
If serum Mg level is less than 2.0 , then give 2 gm Mg
Sulfate intravenously
Call HO if Mg level is greater than 2.5
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 15 MG orally twice a day
Starting Today ( 4/9 ) HOLD IF: rr<10 or very sleepy
NYSTATIN SUSPENSION 10 MILLILITERS orally four times a day
Instructions: use this or chlorhexidine
ZOFRAN ( POST-OP N/V ) ( ONDANSETRON HCL ( POST-... )
1 MG intravenous every 6 hours X 2 doses as needed Nausea
OXYCODONE 5 MG orally every 6 hours as needed Pain
KCL ( POTASSIUM CHLORIDE )
***MODERATE KCL REPLACEMENT SCALE 10 mEq/HR intravenous Scale
Frequency 1. Replace KCL based on lab values.
2. An infusion pump is required for all intermittent bolus
infusions.
3. KCL 10 mEq/100ml/heart rate is intermittent bolus infusion
standard.
4. A serum creatinine must be ordered and checked daily
while patient is ordered for a K-scale.
5. K-scale cannot be used on patients with:
* A serum creatinine greater than or equal to 2.0 mg/dl; or
* A serum creatinine increase of 0.5 mg/dl within 24 hours.
* Hold scale and contact MD if SCr greater than 2.0.
-----------------------------------------------------------
----------- If K+ Level is less than 3.1 then call H.O.
If K+ Level is 3.1-3.3 , then administer KCL 10 meq x5
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 3.4-3.6 , then administer KCL 10 meq x4
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 3.7-4.0 , then administer KCL 10 meq x3
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 4.1-4.5 , then administer KCL 10 meq x2
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 4.6-5.0 , then DO NOT administer KCL.
Recheck K+ Level in every day before noon
If K+ Level is greater than 5.0 then call H.O.
-----------------------------------------------------------
-----------
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day as needed Constipation
ZOLOFT ( SERTRALINE ) 25 MG orally BEDTIME
Starting Today ( 4/9 )
Override Notice: Override added on 8/3/06 by
THEPBANTHAO , DARCI H. , M.D.
on order for GEODON orally ( ref # 410797777 )
SERIOUS INTERACTION: SERTRALINE HCL & ZIPRASIDONE HCL
Reason for override: md aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
5 MILLILITERS orally DAILY
VANCOMYCIN HCL 1 GM intravenous every 12 hours
Instructions: plan 14 days , started 3/4 , end 11/14
COMPAZINE ( PROCHLORPERAZINE ) 5-10 MG orally every 6 hours as needed Nausea
Alert overridden: Override added on 11/8/06 by :
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROCHLORPERAZINE Reason for override: md aware
DIET: No Restrictions
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
pls f/u with primary oncologist as scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hypotension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bacteremia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
iddm ( diabetes mellitus ) hypercholesterolemia ( elevated cholesterol )
htn ( hypertension ) asthma ( asthma ) arthritis ( arthritis ) obesity
( obesity ) history of ccy ( history of cholecystectomy ) metastatic breast cancer
( breast cancer ) pulmonary embolism ( pulmonary
embolism ) depression ( depression )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
na
BRIEF RESUME OF HOSPITAL COURSE:
CC: Tachycardia
HISTORY OF PRESENT ILLNESS: This 59-year-old woman from Eyclear Romin presents with fever and tachycardia
since 7/12/06 . It is very difficult to elicit a clear story. The
patient has had cough productive of variably colored sputum ( yellow
to green to orange , without hemoptysis ) but it seems she may
have had a similar cough for months. Similarly , she notes dysuria
and increased frequency which it seems has also been present for
weeks to months. She is not short of breath and has no headache ,
chest pain , hemoptysis , abdominal pain , nausea , vomiting , diarrhea ,
numbness , LE swelling , LE pain , rash. She does have some bumps on
her abdominal wall which are painful-it sounds like these are a
direct result of the enoxaprin she had been getting for a PE in
October of this year.
The NVH ER doctor spoke with Kiehne at the nursing home. She said
that the patient had an x-ray two days ago which revealed pneumonia ,
and her referral states that the pneumonia was in the left upper
lobe and left lower lobe; the patient was started on Levaquin 500 mg
orally at that time. In the NVH emergency room , the patient was hydrated
with 3 liters of normal saline and her pulse still remains in the
130s. She was given Levofloxacin 500 mg intravenous. The ER physician was
worried about a pulmonary embolus , did not do a chest CT here
because of her elevated creatinine of 1.9. She was transferred to
the Kernan To Dautedi University Of Of for an MRA to rule out PE. In ER here , IJ central line
placed ( CVP~20 ) and patient given 1L NS. Blood pressure systolic
initially 120s but decreased to 90s ( MAPS>70 ) , and norepinephrine
started. The NE was discontinued promptly given BP improvement
immediately , and continued
SBP>100 PAST MEDICAL HISTORY: Metastatic breast CA-bone
scan which revealed widespread osseous metastasis , and
CNS involvement on head CT , bone marrow bx with invasive disease ,
status post brain radiotherapy 1/2 diabetes , PE 10/06 , tx with
enoxaprin through 4/06 ( discontinued because of doubt over original
dx and significant pain at injection sites ) , hypertension , arthritis ,
depression , bipolar disorder , asthma , high cholesterol , anemia , and
obesity.
ONC HISTORY: patient presented with grade III , ER/PR/HER2-negative in
October 2004. In January 2004 , she underwent right breast lumpectomy
with pathology demonstrating 4.1 cm IDC , no LVI ,
negative sentinel lymph nodes. She underwent partial breast radiation
in January 2004 and deferred on adjuvant therapy. In August 2005 , she
presented with atypical chest wall pain and imaging showed bilateral
pulmonary nodules , thoracic lymphadenopathy , and pleural effusion
consistent with metastatic disease. A bone scan showed wide
spread osseous metastatic disease and head CT demonstrated a CNS
involvement. She was treated with whole brain radiotherapy in October
2006 and with weekly Taxol. She continued through October
2006. Restaging studies showed stable visceral disease but
progression of bony metastatic disease. Therefore on March , 2006 ,
she initiated a second-line Navelbine
therapy. PHYSICAL
EXAMINATION: VITAL SIGNS: Temperature 99.3po , pulse 112 regular ,
BP 120/75 , respirations 18 , sO2=100% on ambient air.
GENERAL APPEARANCE: Laying in bed , coughing paroxysms. No use of
accessory muscles. HEENT: Mucosa dry. No jaundice. +conjunctival
pallor. Pupils reactive bilaterally. NECK: Supple and nontender.
Right IJ in place. HEART: S1 , S2 , tachycardic without murmurs. No
heaves. LUNGS: Crackles in the left lower chest
posteriorly , and diffuse expiratory wheezes. ABDOMEN: Soft and
nontender. Small nodule RUQ subcutaneous , mildly tender to
palpation. BACK: No
CVAT. NEUROLOGIC: A&Ox4 , but somewhat sedate and with
poor attention. Radial and DP pulses are 2+. Sensation and strength
are grossly intact. EXTREMITIES: No calf warmth , erythema , or
tenderness. Mild right heel and Achilles tendon tenderness.
LABORATORY RESULTS AT AH WBC 3.2 , hemoglobin 7.5 MCV=76 , platelets
482 , neutrophils 61% , sodium 141 , potassium 3.2 , chloride 122 , CO2
17 , BUN 20 , creatinine 1.5 , glucose 181. LDH 542 , Ca 6.7 Alb
2.2 Urinalysis: 3+ heme , WBC 25-50 , RBC 15-25 , bacteria 1+ , 2+LE ,
neg nitrites. INR 2.0 PTT 43.3.
LABORATORY RESULTS AT WT WBC 3.5 , hemoglobin 9 , hematocrit 28 ,
platelets 592 , neutrophils 68% , sodium 142 , potassium 3.5 , chloride
111 , CO2 14 , BUN 23 , creatinine 1.9 , glucose 217 , alkaline
phosphatase 261 , AST 26 , ALT 27. Urinalysis: Large heme , WBC 6-10 ,
RBC 0-2 , bacteria trace. Blood cultures: Pending. Urine culture
9/3/06: No growth
Chest x-ray: Revealed questionable left lobe infiltrate with
metastasis. EKG: 120 per minute , sinus
tachycardia. CXR: LLL opacity , LUL opacity. Hilar fullness on
the righT>l , and prominent bronchi ( ?cuffing ) on right. Vertebral
fractures. LLL unchanged from 8/27 , and LUL improved C/with known
metastatic disease.
ASSESSMENT: 59 year-old woman with metastatic breast cancer and a
history of pulmonary embolus presenting with one week of fatigue ,
lethargy , tachycardia and fever. History notable for
productive cough and dysuria , although the chronicity of these issues
is unclear. Now growing 1 bottle from NVH as well as PUO of GPC in
clusters empirically on Vanco , now looks to be coag
neg. Discussed with ID , would like to keep vanco PLAN:
*Tachycardia: Most likely secondary to an infection , either
pulmonary or urinary. With improvement in Cr PE CT was obtained which
was negative. Stable. d/c ASA and statin as no role for long term risk
reduction at this time.
*Cough: Productive cough , yellow to green sputum. Seems to have been
present for months , and it is unclear how much this has changed in
the past week. May be chronic secondary to tumor , or may
represent acute infection. Aspiration plausible given mental status.
The CT did not demonstrate any acute etiology for her symptoms.
*Dysuria: Again , chronicity unclear. UA and urine culture at NVH not
very suggestive of UTI , but UA here with 25 wbc and LE+. Has been on
levofloxacin , so will treat until cultures return with ceftazidime
( d/c 10/20 ). *Bacteremia: coag neg staph x2 , Vanc Sens , plan to
treat via PICC with Vancomycin x14days *Oncology: Discussion with Dr.
Triggs , her primary oncologic fellow , who noted that from my
description the patient does not sound much different from her
baseline state. She is mildly tachycardic at baseline ( although not
to this degree ) , and has chronic productive cough and
dysuria. 5. Renal: ARF , improving with IVF. Likely prerenal
azotemia. 6. Heme: Chronic anemia. Given 1UPRBC in ER.
Unfortuantely , the blood was given before hemolysis or iron studies
sent. Would be indicated , especially in setting of markedly elevated
physical therapy. Should be sent in future. I have called and added
on a peripheral manual blood smear. Last INR similarly elevated ( but
I believe patient was on enoxaprin at that time ). Not on enoxaprin
or warfarin now. May be dues to malnutrition , but
concerning for DIC or liver disease. Administered vitamin
K. 7. Psych: Resumed home zoloft , restart
geodon as needed 8. Goals of care: Discussed with the patient and
Dr. Triggs . The patient expresses that she wants to be intubated or
have defibrillation if needed. Dr. Triggs has discussed this numerous
times with her , and will readdress.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with primary oncologist
call oncologist or return to ed with any change in symptoms
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( HT541 ) 11/8/06 @ 11:03 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 54
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
Y |
U |
U |
Y |
Y |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
N |
N |
N |
N |
N |
Y |
Y |
Y |
N |
N |
Y |
Y |
N |
Y |
550926739 | PUO | 91779890 | | 6838563 | 2/2/2006 12:00:00 a.m. | cellulitis , acute renal failure | | DIS | Admission Date: 4/18/2006 Report Status:
Discharge Date: 5/25/2006
****** FINAL DISCHARGE ORDERS ******
EARLGY , LAI 612-11-25-4
U
Service: MED
DISCHARGE PATIENT ON: 10/1/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
BACLOFEN 50 MG orally three times a day
KLONOPIN ( CLONAZEPAM ) 0.5 MG orally BEDTIME
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LABETALOL HCL 800 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NEURONTIN ( GABAPENTIN ) 600 MG orally three times a day
CALTRATE + D 1 TAB orally DAILY
BECLOMETHASONE DIPROPIONATE 160 MCG inhaled three times a day
Instructions: 2 puff of 80mcg inhaler
LIDODERM 5% PATCH ( LIDOCAINE 5% PATCH ) 2 EA TP DAILY
Instructions: Apply one patch to right upper extremity and
right hand
LOTRIMIN TOPICAL ( CLOTRIMAZOLE 1% TOPICAL )
TOPICAL TP twice a day
Instructions: apply to tinea pedis- between toes
Alert overridden: Override added on 2/6/06 by
OSMERS , TESSA M. , PA
SERIOUS INTERACTION: SIMVASTATIN & CLOTRIMAZOLE
SERIOUS INTERACTION: SIMVASTATIN & CLOTRIMAZOLE
Reason for override: topical
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
DICLOXACILLIN 500 MG orally four times a day X 10 Days
Starting Today ( 1/3 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
LISINOPRIL 40 MG orally DAILY
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Do NOT take tonight 9/17 your INR will be
checked tomorrow
and the coumadin clinic will advise when to restart.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/1/06 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Activity as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lockman primary care physician 12/10/06 at 2:10pm ,
Dr. Chesbro Pain clinic- as needed ,
Arrange INR to be drawn on 10/26/06 with f/u INR's to be drawn every
2 days. INR's will be followed by LMC coumadin clinic 537-738-6908
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cellulitis , acute renal failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension Cl difficile in stool HTN , DVT RLE 1996 history of IVC filter ,
DVT LLE 6/11/02 . increased lipids. CRI. OSA , on c-pap. history of hemorrhagic
CVA , L-thalamic , 1996. history of RLE tendon release surgery. chronic renal
disease with proteinuria ( chronic renal dysfunction ) chronic venous
stasis ( venous insufficiency ) otitis externa ( otitis externa ) gout
( gout ) OSA ( chronic obstructive pulmonary disease ) obesity
( obesity ) CVA ( cerebrovascular accident )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
LENIs- negative for DVT
BRIEF RESUME OF HOSPITAL COURSE:
CC: Fever , leg swelling
HPI: 44M history of CVA ( R-sided weakness ) , DVT history of IVC filter , morbid
obesity , OSA p/with 1 day of right leg swelling , fever to 103 , and
erythema. Had admission for cellulitis 10/5 , however states leg was
never this large. Started very abruptly and progressed rapidly. Left leg
not affected. No trauma or source of infection noted. In addition has
been treated for otitis externa. He is chronically wheezy.
****
ED Course: LENI's no proximal clot. intravenous ancef given. Nebs. NS 500cc
bolus for elevated cre 2.9->3.7.
****
MEDS: albuterol , flovent , coumadin , klonopin , folate , labetalol ,
lisinopril , norvasc , neurontin , lipitor , protonix , CA+D , baclofen.
****
SH: Wheelchair bound , has home aide , no tob or ETOH
****
EXAM: T99.4 , BP 105/51 , P72 , 99RA.
4+ RLE edema. Chronic venous stasis with underlying erythema. Healed
ulcer right foot. Fresh abrasion right foot.
****
Studies/LABS: Cr 3.7( 2.1-2.9 ) , WBC 11 , HCT 32 ( 31-36 ) , LENI's no
proximal clot
****
Hosptial Course: 45M admitted with cellulitis , RLE edema , acute on
chronic renal failure , and otitis externa.
1 ) Cellulitis: Treated with intravenous nafcillin and leg elevation. Changed to orally
diclox for d/c for more 10days.
2 ) Renal failure: Most likely prerenal- responded to IVF. Cr on discharge
was 1.9.
3 ) Otitis externa: Vosol HC 4drops four times a day given
4 ) HTN: patient was hypotensive ( 80s/50 ) 2/2 asymptomatic. IVF bolus given
and norvasc , lisinopril d/c'd. Continued labetalol with holding
parameters. BP slightly improved so lisinopril restarted.
5 ) Pulm: CPAP , albuterol , flovent
6. ) PROPH: INR 3.5- holding coumadin and restart when <3. VNA to draw INR
on 7/28 .
7. ) SKIN: Tinea pedis- lotrim lotion started twice a day
8. ) PAIN: patient was seen by Dr. Bossert ( outpt pain doctor ) re: baclofen pump.
It was decided pump should remain in place despite it not working because
patient would need surgery to remove it and he does not want surgery.
BRIEF RESUME OF HOSPITAL COURSE ADDENDUM 2:
CC: Fever , leg swelling
HPI: 44M history of CVA ( R-sided weakness ) , DVT history of IVC filter , morbid
obesity , OSA p/with 1 day of right leg swelling , fever to 103 , and
erythema. Had admission for cellulitis 10/5 , however states leg was
never this large. Started very abruptly and progressed rapidly. Left leg
not affected. No trauma or source of infection noted. In addition has
been treated for otitis externa. He is chronically wheezy.
****
ED Course: LENI's no proximal clot. intravenous ancef given. Nebs. NS 500cc
bolus for elevated cre 2.9->3.7.
****
MEDS: albuterol , flovent , coumadin , klonopin , folate , labetalol ,
lisinopril , norvasc , neurontin , lipitor , protonix , CA+D , baclofen.
****
SH: Wheelchair bound , has home aide , no tob or ETOH
****
EXAM: T99.4 , BP 105/51 , P72 , 99RA.
4+ RLE edema. Chronic venous stasis with underlying erythema. Healed
ulcer right foot. Fresh abrasion right foot.
****
Studies/LABS: Cr 3.7( 2.1-2.9 ) , WBC 11 , HCT 32 ( 31-36 ) , LENI's no
proximal clot
****
Hosptial Course: 45M admitted with cellulitis , RLE edema , acute on
chronic renal failure , and otitis externa.
1 ) Cellulitis: Treated with intravenous nafcillin and leg elevation. Changed to orally
diclox for d/c for more 10days.
2 ) Renal failure: Most likely prerenal- responded to IVF. Cr on discharge
was 1.9.
3 ) Otitis externa: Vosol HC 4drops four times a day given
4 ) HTN: patient was hypotensive ( 80s/50 ) 2/2 asymptomatic. IVF bolus given
and norvasc , lisinopril d/c'd. Continued labetalol with holding
parameters. BP slightly improved so lisinopril restarted.
5 ) Pulm: CPAP , albuterol , flovent
6. ) PROPH: INR 3.5- holding coumadin and restart when <3. VNA to draw INR
on 8/25 .
7. ) SKIN: Tinea pedis- lotrim lotion started twice a day
8. ) PAIN: patient was seen by Dr. Bossert ( outpt pain doctor ) re: baclofen pump.
It was decided pump should remain in place despite it not working because
patient would need surgery to remove it and he does not want surgery.
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 02:30 PM
ADDITIONAL COMMENTS: 1. ) Please take dicloxacillin 500mg 4x/day for 10days for your leg
infection. Please keep your leg elevated until your infection heals.
2. ) You should no longer take norvasc until you follow up with Dr. Anestos .
She will advise you on whether you need it or not.
3. ) Do not take coumadin tonight. You will have your INR checked tomorrow
and the coumadin clinic will advise you on when to restart it.
4. ) Continue lotrim lotion twice daily between your toes for athlete's
foot until healed.
5. ) Call Dr. Anestos or come back to the hospital if you develop fever ,
pain , or increased swelling or reddness in your leg.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*VNA*
Medication monitoring , BP checks , and INR draw on 7/28 . INR results to be
called into LMC coumadin clinic ( 537-738-6908 ).
*primary care physician*
Norvasc was held 2/2 hypotension. Restart if needed.
TO DO/PLAN ADDENDUM 1:
*VNA*
Medication monitoring , BP checks , and INR draw on 8/25 . INR results to be
called into LMC coumadin clinic ( 537-738-6908 ).
*primary care physician*
Norvasc was held 2/2 hypotension. Restart if needed.
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 01:56 PM
No dictated summary
ENTERED BY: OSMERS , TESSA M. , PA ( YZ90 ) 10/1/06 @ 11:17 a.m.
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 01:56 PM
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 02:30 PM
****** END OF DISCHARGE ORDERS ******
Document id: 55
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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352571489 | PUO | 59749742 | | 770479 | 6/2/1999 12:00:00 a.m. | ISCHEMIC ULCER RT. LEG , LT. FEMORO-POPLITEAL GRAFT STENOSIS | Signed | DIS | Admission Date: 9/30/1999 Report Status: Signed
Discharge Date: 7/7/1999
PRINCIPAL DIAGNOSES: 1. Critical ischemia of the right foot. 2.
Stenosis of the left femoral tibial bypass graft.
HISTORY OF PRESENT ILLNESS: Mrs. Feltus is an 85-year-old woman
who is status post a left femoral peroneal bypass graft in
February of 1998 , who presented with right foot pain and
nonhealing ulcers of the right second and third metatarsal joint.
She underwent angiogram on August , 1999 which revealed right
lower extremity patent superficial femoral artery , a 90 percent
distal popliteal stenosis , and three vessel occlusion distal to the
trifurcation , and a 70 percent stenosis of the distal anterior
tibial supplying the dorsalis pedis. The left femoral peroneal had
a long segmented stricture at the level of the knee. Retrograde
filling of the left dorsalis pedis was identified. The patient
presented for surgical management.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2.
Atrial fibrillation. 3. History of deep venous thrombosis. 4.
Peripheral vascular disease. 5. Status post right hip fracture
surgery. 6. Status post suprapubic total abdominal hysterectomy.
7. Status post left superficial femoral artery to peroneal bypass
graft. 8. History of diabetic nephropathy.
MEDICATIONS: 1. Lasix 20 mg orally every day 2. Humulin 10 in the
morning 6 in the p.m. 3. Digoxin 0.125 mg every day 4. MVI one
tablet orally every day 5. Senokot two tablets orally every day 6. Vitamin C
500 every day 7. Trilisate. 8. Verapamil 60 mg orally three times a day 9.
Coumadin. 10. Lovenox 30 mg twice a day
ALLERGIES: The patient has allergies to penicillin and
Levofloxacin.
PHYSICAL EXAMINATION: The patient was a hard of hearing elderly
woman lying comfortably in bed. Her lungs were clear to
auscultation. Her heart had an irregular rhythm with no murmurs ,
rubs , or gallops. The abdomen was soft , round , non-tender ,
nondistended , bowel sounds were present. Extremities of the
extremities identified superficial ulcers between the right second
and third metatarsals. Vascular examination , on the right side the
right femoral pulse was palpable , popliteal was 2+ dopplerable ,
dorsalis pedis was 1+ dopplerable , and posterior tibial could not
be dopplered. On the left , the femoral pulse was 2+ palpable ,
popliteal was 2+ palpable , the dorsalis pedis had a biphasic
dopplerable signal , and the posterior tibial had a monophasic
dopplerable signal.
HOSPITAL COURSE: On March , 1999 , the patient was brought to
the Operating Room where she underwent a right below the knee
popliteal to anterior tibial bypass with a reversed cephalic vein
graft. She also underwent vein patch angioplasty of the left
femoral tibial artery bypass graft. Her postoperative pulse
examination identified a palpable right dorsalis pedis and a
dopplerable right posterior tibial; left dopplerable dorsalis pedis
and left dopplerable posterior tibial. The patient was ruled out
for myocardial infarction as per the recommendations of the
Cardiology team. Verapamil and digoxin were continued for
appropriate rate control. On postoperative day number one it was
noted that her right arm from which the cephalic vein graft had
been harvested was edematous , and the distal extremity was somewhat
cool. With elevation this resolved. Her digital perfusion was
excellent by clinical examination , and her neurologic function was
intact. The patient was restarted on her Coumadin on postoperative
day number two. Physical Therapy consultation was obtained and
recommended that the patient be discharged to a rehabilitation
hospital to return to her baseline functionable mobility. On
September , 1999 , the patient was discharged to Rehabilitation.
The patient will be discharged to Rehabilitation in stable
condition.
FOLLOW-UP: She will follow-up with Dr. Derham . She will also
follow-up with her cardiologist.
DISCHARGE MEDICATIONS WERE: 1. Trilisate 1 , 000 mg orally three times a day 2.
Digoxin 0.125 mg every day 3. Colace 100 mg orally twice a day 4. Laxative
of choice , one each orally every day as needed constipation. 5. Heparin
5 , 000 mg three times a day 6. NPH insulin 2.5 units in the morning and 10
units in the evening. 7. CZI insulin sliding scale. 8.
Lopressor 12.5 mg orally twice a day 9. MVI with therapeutic minerals ,
one tablet orally every day 10. Verapamil 60 mg orally three times a day
Dictated By: MOZELLA WERME , M.D. OA55
Attending: ROSALINA DERHAM , M.D. SP07 NL887/2405
Batch: 19795 Index No. L8HBOW2BJZ D: 8/12/99
T: 4/1/99
Document id: 56
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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946845360 | PUO | 39737797 | | 390751 | 7/30/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 11/3/1990 Report Status: Unsigned
Discharge Date: 2/16/1990
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old man with
a long history of right sciatica ,
status post L5-L6 diskectomy in 1984 with recurrent pain times four
years. He complained of right buttock , right posterior thigh ,
calf , heel pain , left posterior thigh pain , left calf numbness and
also numbness in his right medial thigh and his left medial leg.
This has been aggrevated with sitting , bending , walking and
relieved by Valium and lying down. PAST MEDICAL HISTORY: Hiatal
hernia. Esophageal spasm producing chest pain , negative ETT.
History of duodenal ulcers and reflux. History of peripheral
vascular disease. CVA in 1985 with some residual right-sided
weakness. PAST SURGICAL HISTORY: Right femoral popliteal bypass
with multiple revisions and angioplasties. Multiple bilateral knee
surgeries secondary to osteoarthritis. Status post intestinal
obstruction. Status post cholecystectomy. MEDICATIONS: On
admission included Carafate , 1 gm orally four times a day; Pepcid , 40 mg orally every
day; Desyrel , 50 mg orally every bedtime; Davocet , orally every six; Valium , 2 mg orally
twice a day; nitropatch , 2.5 mg every 12 as tolerated. ALLERGIES:
PENICILLIN CAUSES A RASH. HABITS: The patient has a 60-pack-year
cigarette history. No ETOH. Retired mechanic.
PHYSICAL EXAMINATION: On admission revealed an obese male
lying comfortably post myelogram who
appeared older than his stated age. He was afebrile. Vital signs
revealed a blood pressure of 120/60. Heart rate of 65.
Respirations 20. HEENT exam was benign. Neck was supple ,
nontender with a moderate muscle spasm. Chest revealed diffuse
crackles , inspiratory and expiratory wheezes , increased lung
volumes. Cardiac exam revealed a regular rate and rhythm. Abdomen
was obese with a well healed midline scar without masses.
Extremities revealed no cyanosis , clubbing or edema. Right medial
scar from right ankle. Left distal leg scar. Neurological exam
revealed the patient to be a poor historian. Alert and oriented
with normal mental status. Cranial nerves II-XII intact. Motor
4/5 right lower extremity. Sensory decreased right medial thigh
and leg , left medial leg. Reflexes 2+ right brachial , 1+ left
brachial. No reflex in the lower extremities bilaterally. Straight
leg raise 30 degrees on the right and 60 degrees on the left.
HOSPITAL COURSE: The patient was admitted for myelogram and
possible surgery pending results. The patient
was admitted to the floor following myelogram. The myelogram
revealed medial deviation of the right L6 nerve root sleeve. Dr.
Chalow , based on the myelogram results , felt that the patient
needed re-exploration of his L5-L6. This operation was done on
4/23/90 . The patient had a partial L5 laminectomy and L5-L6
diskectomy. Postoperatively , the patient had some back pain on
postoperative day number one but was doing well. He had a low
grade temperature on postoperative day number two and was unable to
void and had to be catheterized times two. By postoperative day
number two , the patient was voiding without difficulty. He had
some mild distention which was relieved after a bowel movement. The
patient was tolerating a regular diet and voiding without
difficulty and had no complaints at the time of discharge. The
patient was discharged on 2/22/90 .
DISPOSITION: MEDICATIONS: On discharge included Carafate , Pepcid ,
Desyrel , Darvocet , Valium and nitropatch. He will
return to see Dr. Chalow in approximately one week and will call
him for an appointment.
________________________________ QB705/3994
GAYLENE FANIEL , JR , M.D. IW81 D: 6/17/90
Batch: 0291 Report: Y9773I26 T: 2/28/90
Dictated By: ELENA S. BIALY , M.D. FO02
Document id: 57
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
Y |
N |
N |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
210032808 | PUO | 20003943 | | 1055355 | 10/2/2006 12:00:00 a.m. | Atypical Angina | | DIS | Admission Date: 2/15/2006 Report Status:
Discharge Date: 2/15/2006
****** FINAL DISCHARGE ORDERS ******
AMODT , MALLIE 347-43-78-7
Sa Tulbirmmamehamp
Service: MED
DISCHARGE PATIENT ON: 7/6/06 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REMLEY , EVALYN AMANDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Starting IN a.m. ( 10/29 )
ATENOLOL 12.5 MG orally every day before noon HOLD IF: SBP<100 or HR<50
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
COGENTIN ( BENZTROPINE MESYLATE ) 1 MG orally every day before noon
Override Notice: Override added on 7/6/06 by
ALSPAUGH , KERRY Y. , M.D.
on order for THORAZINE orally ( ref # 294094779 )
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL Reason for override: aware
THORAZINE ( CHLORPROMAZINE HCL ) 400 MG orally every day before noon
Alert overridden: Override added on 7/6/06 by
ALSPAUGH , KERRY Y. , M.D.
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL Reason for override: aware
ECASA 325 MG orally DAILY
GLIPIZIDE XL 10 MG orally DAILY
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
LISINOPRIL 20 MG orally DAILY HOLD IF: SBP<100
METFORMIN 1 , 000 MG orally twice a day HOLD IF: NPO
TRAZODONE 50 MG orally BEDTIME as needed Insomnia
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Tabatha Hollway 2/26/06 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Atypical Angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical Angina
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Diabetes Type II HYPOTHYROID HTN schizophrenia
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
patient got 2 sets of enzymes and they were 12 hours apart and both were
negative.
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old with known CAD , DM , schzioaffective disorder
p/with intermittent chest pain x12 hours. Poor historian. Reports
episode of Left sided chest pressure radiating up to shoulder/arm
while in bed lasting couple of minutes. Diaphoresis. with no
n/v/fever/cough/SOB. Had repeat episode lasting couple of seconds
since this am. No similar episodes of CP in the past. Had recent
cardiac with u and MIBI showing mod defect at the circumflex but decided
no medical trt at this point in time.
PMHx:
HTN
DM
CAD history of MI 1/13 schziophrenic/depression
Hypothyroidism ECHO: EF
65% PET 1/13 with moderate defect of the cx but did
not want any medical trt.
Meds:
Metformin 1000 twice a day Glipizide 10 orally every day , Synthroid 0.1 every day , Lisinipril 20mg
every day , ASA 81 every day , Atenolol 12.5 every day
All: NKDA
SH:No TOB/no ETOH
ETOH FH: CAD of mother and
sister
PExam: T97.7 HR64-85 BP110-165/62-78 RR20 96% on RA
FS 89 and FS 149
CVD: RRR No M/R/G
A/P: 70 year-old female with DM , HTN , CAD history of MI 1/13 , history of Right hip surgery
came in with intermittent chest pain x12 hours likley secondary to
atypical angina.
CVD: ROMI x2 with troponin and ck and CKMB nl. and cont. patient's cardiac
medications for BP control and ECG early R wave but no ST changes. physical therapy
denies any chest pain and SOB. No evidence of active cardiac ishemia.
Known defective circumflex artery but patient refused any medical intervention
at this point in time. Would like to follow up with a primary care physician as an
outpatient.
DM: cont. patient orally hypoglycemics
Normocytic anemia: ?anemia will follow up with primary care physician as an outpatient , the
work up is so far normal.
PPX: Heparin
Full Code
ADDITIONAL COMMENTS: Please Call if patient has any chest discomfort , shortness of breath , or any
increase fatigue or weakness or any other concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please go to your follow up appt.
2. Please come to the ER for evaluation if you have any recurrent chest
pain or any shortness of breath.
No dictated summary
ENTERED BY: LAPATRA , LETA , M.D. ( NT236 ) 7/6/06 @ 04:38 PM
****** END OF DISCHARGE ORDERS ******
Document id: 58
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
N |
N |
921778812 | PUO | 49448215 | | 660802 | 1/20/1998 12:00:00 a.m. | INCARCERATED UMBILICAL HERNIA | Signed | DIS | Admission Date: 6/7/1998 Report Status: Signed
Discharge Date: 5/25/1998
PRINCIPAL DIAGNOSIS: INCARCERATED UMBILICAL HERNIA.
HISTORY: Cristal Lippman is a 78 year old woman with a complex past
medical history including coronary artery disease with a
history of MIs times two in the past , a history of DVT back in
1970 , hypertension , rheumatoid arthritis , gout and history of
atrial fibrillation and atrial flutter as well as onset adult
diabetes mellitus. She presented to the Uass Goldman Valley Medical Center on
the day of admission complaining of an umbilical bulge over the
past several weeks. This umbilical bulge had been increasing
somewhat in size , but had not bothered her and was always
reducible. However , over the preceding weekend it became
incarcerated and then became somewhat painful. It was not
associated with any nausea or vomiting and she reported that she
was having normal bowel movements even in the face of this problem.
She presented initially to the Uass Goldman Valley Medical Center and was
admitted with the diagnosis of incarcerated umbilical hernia.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a history of MI times two in the
past with a recent echocardiogram on 11/8 showing an EF of
55-60%.
2. History of DVT in 1970.
3. Hypertension.
4. Rheumatoid arthritis.
5. Gout.
6. Atrial fibrillation and atrial flutter on Coumadin.
7. Adult onset diabetes mellitus.
PAST SURGICAL HISTORY:
1. Status post appendectomy.
2. Status post mitral valve replacement with St. Jude valve.
3. Left hip fracture repair.
4. Status post mitral valve commissurotomy in 1955.
MEDICATIONS ON ADMISSION: Lasix 80 mg a day , sublingual
nitroglycerin as needed , Propafenone 225 mg
three times a day , Lopressor 150 mg twice a day , Lisinopril 10 mg a day and
Micronase 10 mg twice a day , Isordil 40 mg three times a day , Coumadin 5 mg a day
with 2-1/2 mg every Sunday.
ALLERGIES:: She is allergic to aspirin and penicillin.
PHYSICAL EXAMINATION: She is an extremely pleasant elderly woman
in no acute distress. HEENT - showed
extraocular movements intact. Pupils equally round and reactive to
light. NECK - supple. HEART - regular rhythm. LUNGS - clear.
ABDOMEN - soft , nontender , nondistended with approximately 1.5 cm
in diameter umbilical hernia to the left of her umbilicus. This
hernia was somewhat tender to palpation , but showed no overlying
erythema or evidence of necrosis. She had normal bowel sounds.
EXTREMITIES - no clubbing , cyanosis or edema. NEUROLOGIC - intact.
Preoperative laboratory showed BUN of 35 , creatinine 1.3 ,
hematocrit 42.0 , white count 6.8 , coagulation studies within normal
limits.
HOSPITAL COURSE: Ms. Lippman was admitted to the Arvai Sonprince Hospital on the day of admission with the
diagnosis of incarcerated umbilical hernia. Because of her history
of coumadinization for both her mitral valve as well as her atrial
fibrillation it was felt that it would be necessary to hospitalize
her , hold her Coumadin and heparinize her until it was possible to
do her surgery. However , upon arrival here her admission INR was
noted to be subtherapeutic at 1.3 and she was , therefore ,
immediately started on heparin. The Cardiology Service was
consulted regarding her significant past cardiac history and
recommended an echocardiogram to be performed preoperatively. This
echo was done on 9/6/98 demonstrating an EF of 55% with an
abnormal subdural wall motion , trace areas of aortic insufficiency
and mildly increased right ventricular size and the artificial
mitral valve was noted to be functioning well. The cardiology felt
that in the face of this largely unchanged echocardiogram that
showed stable and should go to the operating room for repair of
umbilical hernia. On 7/1/98 the patient was taken to the
operating room and underwent umbilical hernia repair with primary
reapproximation of the fascia. The procedure was done without any
complications. She was extubated and transferred in stable
condition to the postoperative recovery area and observed on the
floor. She was immediately restarted on her Coumadin as well as
her heparin which she continued for the next three days
postoperatively. The patient did quite well with gradual up in her
INR to a greater than 2 level and she was discharged to home on
4/23/98 on a regular dose.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every four hours as needed
headache , Estrogen cream topical which is
applied to her vagina because of her atrophic vaginitis. Colace
100 mg orally twice a day , Lasix 80 mg orally every day , Micronase 10 mg orally
twice a day , Isordil 40 mg orally three times a day , lisinopril 10 mg orally every day ,
Lopressor 150 mg orally twice a day , Percocet 1-2 tabs every 3-4 hours as needed
pain , Propafenone 225 mg orally three times a day and Coumadin 5 mg orally every day
with 7.5 mg take every Sunday.
DISPOSITION: To home. She will follow-up at the Uass Goldman Valley Medical Center one week after discharge with follow-up with
primary medical doctor in one week after discharge.
Dictated By: EDWARDO MAHAR , M.D. WN52
Attending: DENISHA H. MCRORIE , M.D. FV40 MX775/4997
Batch: 91916 Index No. ECEBVU4WSE D: 1/23/98
T: 6/22/98
Document id: 59
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
905931929 | PUO | 45891990 | | 9580247 | 5/13/2006 12:00:00 a.m. | right leg pain | | DIS | Admission Date: 5/23/2006 Report Status:
Discharge Date: 3/26/2006
****** FINAL DISCHARGE ORDERS ******
HARDMAN , CARLENE 243-20-65-1
Clark Ville
Service: MED
DISCHARGE PATIENT ON: 2/3/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COLLICA , CHANELLE XOCHITL , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
HYDROCHLOROTHIAZIDE 25 MG orally every day Starting Today ( 1/9 )
LISINOPRIL 20 MG orally every day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 2/3/06 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please call Berna Ruka NP at J.ho Jude Medical Center center for appointment within 2 weeks - 538-695-6601 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
right leg pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
right leg pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) dyslipidemia ( dyslipidemia ) history of
CCK history of hysterectomy ( history of hysterectomy ) arthritis ( arthritis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
tylenol , ibuprofen
BRIEF RESUME OF HOSPITAL COURSE:
cc: admit for right leg pain , poor ambulation
hpi: 80F , history of OA , poor baseline ambulation , has had
chronic right sided hip/knee pain with ambulation p/with acute worsening of
R leg pain. Localizes another pain x3days to right medial
supramalleolar area , no trauma , f/c/ns , redness , swelling. +pn
with ambulation to right leg , hip , achy not sharp. Denies bowl/bladder
changes. In ED got ASA.
PMH: see problems SH: lives with older son , seen with other son ,
doesn't do much activity without assistance. STATUS: VS 97.8 , 80 ,
179/83 , 16 , 96%RA , exam wnl except 4x6cm area of dark induration on
medial area above ankle , ttp , no red , slight warm. no edema.
2+b/l ext pulses. Str 5/5 all ext. Stands and walks without intalgia.
neuro sensory intact to LT bil. MEDS: lisinopril 20 , hctz 25 , lipitor
10 , mvi , fosomax.
NKDA LABS: WNL , ddimer <500.
STUDIES: ECG - NSR , ??old septal infract with q's in v1 , v2
infarct. CXR - no effusion , infiltrate , or acute abnl
RIGHT HIP , KNEE , ANKLE , LEG Xrays - no joint space disease or
fractures.
****HOSPITAL COURSE****
Patient was admitted for difficulty for ambulation and work up of her
leg pains. She had two pain syndromes ( 1 ) focal area of induration 2cm
above right medial malleolus with slight warmth but not true redness
or swelling. Likely chronic venous stasis vs. superficial
thrombophlebitis. DDimer was <500 and negative. This improved with
tylenol and though cellulitis was considered she was afebrile , nl WBC
count , and it did not have the clinical signs consistent with
cellulitis. Regardless it should be followed for progression. Also
considered atypical gout and this should be considered in the future if
it persists.
( 2 ) patient complained of right sided aching lower extremity pain that was
present with ambulation. Xrays of the right lower extremity joints
including hip , knee , ankle , and LE bones showed no abnormality. She
was evaluated by physical therapy which recommended use of her cane
and that she did not have acute physical therapy needs. Cleared to go home. Her pains
were treated with tylenol 650mg orally every 6 hours ATC and as needed ibuprofen. The day
after admission her pain had improved and she was ambulating at baseline
with decreased discomfort. She was maintained on her outpatient
cardiovascular medications. Notably she was hypertensive but her
medications were not altered. Her BP should be followed up as an
outpatient and he BP meds titrated as needed.
She was discharged in stable condition to her son. Her NP Berna Ruka
was contacted to continue follow up care. ( 538-695-6601 )
ADDITIONAL COMMENTS: Please take tylenol at least twice daily to help improve you leg pain.
Seek medical attention if your leg becomes more red , swollen , or tender ,
or if you have any fevers , or if you have any new problems with your leg.
Please try to use you cane to assist with your walking. Please call your
nurse practioner within 2 weeks for an appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. tylenol for pain
2. ibuprofen as needed
3. follow up with berna ruka for blood pressure
No dictated summary
ENTERED BY: SCHUNEMAN , ELLENA M. , M.D. ( ZO77 ) 2/3/06 @ 01:40 PM
****** END OF DISCHARGE ORDERS ******
Document id: 60
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
335530998 | PUO | 01416153 | | 9072796 | 3/30/2004 12:00:00 a.m. | Atrial fibrillation , Heart failure | | DIS | Admission Date: 1/10/2004 Report Status:
Discharge Date: 1/18/2004
****** DISCHARGE ORDERS ******
FLOW , SANORA K 099-46-77-9
Ph New
Service: CAR
DISCHARGE PATIENT ON: 4/25/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARNABA , CARA CHANCE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 2/13/04 by
LOLAR , MAIDA R. , M.D.
on order for COUMADIN orally ( ref # 30976892 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor INR
DIGOXIN 0.125 MG orally every day before noon
Alert overridden: Override added on 2/13/04 by
RUBIANO , ELIZ , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN SERIOUS INTERACTION: ERYTHROMYCIN & DIGOXIN
Reason for override: aware
ENALAPRIL MALEATE 10 MG orally twice a day
Override Notice: Override added on 2/13/04 by
RUBIANO , ELIZ , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 56318955 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: following
Previous override information:
Override added on 2/22/04 by RUBIANO , ELIZ , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 09160776 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: aware
ERYTHROMYCIN 333 MG orally three times a day X 8 Days
Starting Today ( 10/8 )
Instructions: To complete course started by primary care physician.
Food/Drug Interaction Instruction
Take non-enteric coated form on empty stomach.
Take with food
Override Notice: Override added on 2/13/04 by
RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 46784321 )
SERIOUS INTERACTION: ERYTHROMYCIN & DIGOXIN
Reason for override: aware Previous override information:
Override added on 2/13/04 by RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 51953380 )
SERIOUS INTERACTION: ERYTHROMYCIN & DIGOXIN
Reason for override: aware Previous override information:
Override added on 2/13/04 by RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 46250363 )
SERIOUS INTERACTION: ERYTHROMYCIN & DIGOXIN
Reason for override: aware -- 1/2 load
Previous override information:
Override added on 2/13/04 by RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 13132258 )
SERIOUS INTERACTION: ERYTHROMYCIN & DIGOXIN
Reason for override: aware Previous override information:
Override added on 2/13/04 by LOLAR , MAIDA R. , M.D.
on order for COUMADIN orally ( ref # 30976892 )
POTENTIALLY SERIOUS INTERACTION: ERYTHROMYCIN & WARFARIN
Reason for override: will monitor INR
LASIX ( FUROSEMIDE ) 80 MG orally every day Starting Today ( 10/8 )
Instructions: Take an additional 40mg in afternoon as
directed by heart failure clinic.
Alert overridden: Override added on 2/22/04 by
RUBIANO , ELIZ , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: takes at home
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
35 UNITS subcutaneously every day before noon and every bedtime
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
Override Notice: Override added on 2/13/04 by
RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 46784321 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: aware
Previous override information:
Override added on 2/13/04 by RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 51953380 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: aware
Previous override information:
Override added on 2/13/04 by RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 46250363 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: aware -- 1/2 load
Previous override information:
Override added on 2/13/04 by RUBIANO , ELIZ , M.D.
on order for DIGOXIN orally ( ref # 13132258 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: aware
Previous override information:
Override added on 2/13/04 by LOLAR , MAIDA R. , M.D.
on order for COUMADIN orally ( ref # 30976892 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: will monitor INR
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 as needed Pain
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every bedtime
Starting Today ( 10/8 )
Instructions: Take 5 mg for the next 2 nights; then your
dose may be changed by Dr. Sewell office.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/13/04 by
LOLAR , MAIDA R. , M.D.
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ERYTHROMYCIN & WARFARIN
Reason for override: will monitor INR
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 12.5 MG orally every day
Starting Tonight ( 3/3 ) Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
NEURONTIN ( GABAPENTIN ) 300 MG orally every bedtime
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before every meal & HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Sewell Office - follow-up for foot 10/19/04 scheduled ,
Dr. Sewell office - to check coumadin dose 3/2/04 ,
Dr. Bernas 1 month ,
Arrange INR to be drawn on 8/3/04 with f/u INR's to be drawn every
3 days. INR's will be followed by Dr. Loan Kuharik
ALLERGY: Penicillins , Cephalosporins , Sulfa ,
TRIMETHOPRIM/SULFAMETHOXAZOLE , TRIMETHOPRIM , Codeine ,
CIPROFLOXACIN HCL
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atrial fibrillation , Heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Congestive heart failure , Diastolic dysfunction , Hypothyroidism
Obesity , Chronic renal dysfunction , Type 2 diabetes , CAD history of CABG x4
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Lasix diuresis , ECHO , Cardiac monitoring , r/o MI protocol , Adenosine
MIBI
BRIEF RESUME OF HOSPITAL COURSE:
80F with history of CAD history of CABG x4 , CHF ( with normal EF ) p/with 2 d of stuttering
chest pressure in setting of Afib with RVR. Recently has been c/o URI
sx , increased wt gain , decreased energy. Day prior to admission , noted
increased chest pressure and mild sob that resolved slowly. On DOA ,
recurrence of pain , came to ED.
ED: Initially in SR --> given NTG x1 with resolution of CP ( BP dropped
in to 90's ). No sig ECG changes compared to prior. Then noted to be
in Afib with RVR. Labs notable for CK 1000 with flat MB and TnI , BNP
180's. Cr 1.5 ( baseline ). On floor --> increased CP with HR 110's ,
slowed with lopressor intravenous 5 mg x1.
Hospital Course:
1 ) Chest Pain/CAD: ECG without sig changes. Started on heparin for ?
unstable angina. Pain treated with ntg , maalox. Adenosine MIBI: no
CP , no ischemia , nl LV function. Heparin stopped. CK elevations thought
secondary to statin , so Zocor d/c'd.
2 ) Afib: Known history in past , with LA 4.8 cm. Started on low dose
beta-blockade and digoxin with good rate control. Started on Lovenox ,
but will d/c only on coumadin.
3 ) CHF: R>L HF. Diuresed with lasix 80 mg intravenous twice a day --> lost 5kgs.
Feeling better history of diuresis. ECHO 7/26 showed preserved RV function ,
nl LV function , nl PA pressure. As BPs slighly low on B-blocker , will
d/c on Lasix 80po every day , with addnl 40 mg orally as needed.
4 ) DM: Continue NPH/RISS. HgA1c 7.3
5 ) Hypothyroid: On synthroid , TSH nl.
D/c home 7/26 , f/u with primary care physician for coumadin , MMC cardiology ( Bernas ).
ADDITIONAL COMMENTS: ( 1 ) Please keep your appointment already scheduled for tomorrow to
check on your left foot infection.
( 2 ) Please also go to Dr. Sewell office on Friday to have a blood test
to check your coumadin dosing.
( 3 ) If you have chest pressure or tightness , increased shortness of
breath , or other concerns , please seek medical attention.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: LOLAR , MAIDA R. , M.D. ( LI309 ) 4/25/04 @ 03:18 PM
****** END OF DISCHARGE ORDERS ******
Document id: 61
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
068924527 | PUO | 38970238 | | 747058 | 6/29/1997 12:00:00 a.m. | BREAST CARCINOMA | Signed | DIS | Admission Date: 10/14/1997 Report Status: Signed
Discharge Date: 9/16/1997
PRINCIPAL DIAGNOSIS: CELLULITIS.
CHIEF COMPLAINT: Ms. Famiglietti is a 47-year-old woman with stage I
breast cancer admitted for spontaneous cellulitis
of the left breast.
HISTORY OF PRESENT ILLNESS: The patient presented last year with
left breast mass approximately 4 cm ,
moderately aggressive histology , but was node negative and ERPR
negative. The cancer was continued T-2 , N-0 , M-0 and was treated
with lumpectomy , XRT , and four cycles of CAF ending 11/27 . She
suffered significant skin breakdown from the radiation therapy but
improved by 11/16 . She represented in 6/20 with two areas of
erythema with underlying lumps in the outer margin of her left
breast. At the time , it had the appearance of inflammatory breast
cancer , but a biopsy turned out to be negative for cancer. She was
treated with three days of nafcillin intravenously in the hospital ,
starting in 7/19 and has been on orally dicloxacillin since then , so
that she could take antibiotics at home. Her skin changes have
waxed and waned since then so that some physicians involved in her
care felt there was improvement in her clinical condition , although
the patient subjectively felt there was none.
More recently , the patient's breast has swollen considerably and
the overlying skin has become erythematous and the erythema has
spread to involve the entire breast and around to the back. She
denies any fevers or chills , but she feels generally ill which had
never been an issue for her. She also reported new left-sided
chest wall discomfort.
PAST MEDICAL HISTORY: ( 1 ) Left breast cancer as above; ( 2 ) Type II
diabetes mellitus for 1-2 years , currently
well controlled with diet and exercise. The patient takes her
blood sugars frequently and states that her sugars are usually
round 100. ( 3 ) Hypothyroidism diagnosed two years ago; ( 4 ) Low back
pain secondary to a motor vehicle accident around a year ago , not
currently an active issue; ( 5 ) Congenital partial left upper limb;
( 6 ) Depression related to her cancer.
MEDICATIONS: Dicloxacillin 500 mg four times a day; Synthroid 150 mcg every day;
Paxil 40 mg orally every day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives by herself with no significant
family to support or close friends since her
breast cancer diagnosis. She is a former private chef but lost her
job secondary to her cancer and spent all of her savings on medical
cost , because she had no insurance. Now the patient is no Medicare
and disability which is presently her only source of income. No
history of alcohol or tobacco use or abuse.
FAMILY HISTORY: One great aunt on her maternal side with breast
cancer.
REVIEW OF SYSTEMS: Significant only for very unusually heavy
menstrual periods since her chemotherapy ,
bleeding often for 10-14 days.
PHYSICAL EXAMINATION: VITAL SIGNS - Temp 97.8 , heart rate 88 and
regular , BP 118/92 , oxygen saturation 97% on
room air. GENERAL - The patient is a pleasant woman lying in no
acute distress. HEENT - Oropharynx unremarkable. NECK - JVP at
sternal angle , no lymphadenopathy , no thyromegaly. CHEST - Lungs
clear to auscultation and percussion except for coarse inspiratory
breath sounds over her left scapula. HEART - Normal heart sounds ,
regular rate and rhythm , with no murmurs or rubs. ABDOMEN - Normal
bowel sounds. The patient had a scar in her left upper quadrant
from an old excisional biopsy. BREASTS - Diffuse erythema and
slight peau d'orange appearance over the entire left breast with
slight erythema over the left nipple , with no nipple discharge. No
masses or axillary lymph nodes appreciated. EXTREMITIES -
Congenital left partial upper extremity with upper extremity
missing below mid upper arm.
HOSPITAL COURSE: The patient was placed on vancomycin and
cefotaxime. There was concern that the skin
changes may have been due to prior radiation , especially given its
distribution in the back. However , the Radiation/Oncology Service
saw and followed Ms. Famiglietti over the course of this admission and
felt very strongly that the changes were not consistent with prior
radiation therapy. Further workup consisted of a bone scan which
was negative , a chest CAT scan which revealed only thick skin on
the left breast , no adenopathy , and minimal lung fibrosis. Of note
is that the patient had no fever or elevated white count over the
course of this admission. The patient had an ultrasound of her
left breast performed prior to her discharge , which revealed a
small fluid collection in the lateral margin of her left breast.
Serosanguineous fluid was aspirated from the collection and gram
stain of the fluid revealed no polys and no organisms. Culture of
the fluid showed no growth on discharge.
Prior to her discharge , a large intravenous line was placed in order to
continue intravenous antibiotics at home.
DISCHARGE MEDICATIONS: ( 1 ) Ancef 1 gm intravenous every 8 hours x14 days;
( 2 ) Synthroid 115 mcg orally every day before noon; ( 3 ) Paxil
40 mg orally every day before noon
DISCHARGE DISPOSITION: To home.
CONDITION ON DISCHARGE: Stable.
Dictated By: COLE AINI , M.D. HD86
Attending: BIBI L. TRIGGS , M.D. YH35 NP210/5460
Batch: 25339 Index No. XHZXEF0LDJ D: 3/4/97
T: 6/10/97
Document id: 62
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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164007289 | PUO | 65202772 | | 1912552 | 9/25/2005 12:00:00 a.m. | diabetic foot | | DIS | Admission Date: 10/19/2005 Report Status:
Discharge Date: 6/12/2005
****** FINAL DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 062-19-87-1
Ster
Service: MED
DISCHARGE PATIENT ON: 6/22/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SHANNON , JULIANA O. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
GLYBURIDE 2.5 MG orally every day HOLD IF: NPO
LISINOPRIL 10 MG orally every day HOLD IF: SBP<95
Override Notice: Override added on 10/10/05 by SCHOEPPNER , AVA S. , M.D. , M.P.H.
on order for KCL IMMEDIATE RELEASE orally ( ref # 82585034 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: as needed
SARNA TOPICAL TP every day
Instructions: for bilateral lower extremity rash
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
HOLD IF: INR>3.o Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 11/6/05 by SCHOEPPNER , AVA S. , M.D. , M.P.H.
on order for CIPROFLOXACIN orally ( ref # 16007380 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & CIPROFLOXACIN
HCL Reason for override: will follow INR
Previous override information:
Override added on 11/6/05 by SCHOEPPNER , AVA S. , M.D. , M.P.H.
on order for SIMVASTATIN orally ( ref # 66599787 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: patient takes at home
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 11/6/05 by
SCHOEPPNER , AVA S. , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: patient takes at home
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
LINEZOLID 600 MG orally twice a day Starting Today ( 8/13 )
Food/Drug Interaction Instruction
This order has received infectious disease approval from
HAGBERG , LILLIA JOCELYN , M.D.
Number of Doses Required ( approximate ): 10
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
ACETYLSALICYLIC ACID 325 MG orally every day
Alert overridden: Override added on 6/22/05 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: ok
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
vasc ular surgery ,
pcp ,
Arrange INR to be drawn on 10/28/05 with f/u INR's to be drawn every
7 days. INR's will be followed by primary care physician
No Known Allergies
ADMIT DIAGNOSIS:
diabetic foot
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
diabetic foot
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) htn ( hypertension ) edema ( peripheral
edema ) obesity ( obesity ) recurrent cellulitis
( cellulitis ) mitral prolapse ( mitral valve prolapse ) uti ( urinary
tract infection ) atopic dermatitis ( dermatitis )
OPERATIONS AND PROCEDURES:
debridement of r foot
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
foot xray
BRIEF RESUME OF HOSPITAL COURSE:
ID: 60 YO female
--- CC: RLE
ulceration/redness/pain ---
DX: Diabetic foot ulcer ---
HPI: 60 YO female with DMII , PVD , chronic AF now with
DDI pacer on coumadin who has had history of recurrent LE ulcerations
and infections. She had the left foot amputated 4/7 and has been
considering amputation of the right. patient was admitted on 10/25 for
cellulitis and R foot ulcer. She was treated with intravenous unasyn for 5
days and switched to Linezolid as out patient med. While in house patient was
seen by ortho and ID.
On 11/27 patient saw dermatologist and ulcer was found to extend to bone
and Left foot appeared cyanotic- worrisome for vascular compromise.
patient was sent to the hosp for further
management. ---
STATUS: VS: T:97.1 HR:75 BP:85/46 RR: 18
SaO2:100%RA GEN: NAD NECK: no JVD CHEST: CTA bilaterally CV:
RRR S1 , S2 3/6 SEM at base , no gallop ABD: soft , NT , ND , bowel sounds
present EXT: Left foot amputated , R with charcot joint/hindfoot
varus , erthema , draining ulcer fifth metatarcel ,
edema. ---
EVENTS: Seen by vascular surg in ED- Left foot not
cyanotic 5/17 admitted to
medicine ---
TESTS/PROCEDURES: 5/17 - RLE plain films - neg for osteomyelitis
--- CONSULTS:
5/17 ID 5/17 Ortho - followed by Dr.
Goodnow ---
PROBLEM LIST ---
1. ) RLE ulcer - diabetic foot ulcer with ? osteo. patient started on vanc
and cipro. Bone scan and plain films from prior hospitalzations were
neg. Will await new plain film result. Ortho and ID were
consulted. ID recommended D/c vanc and levo and starting linezolid. Ortho
debrided wound and could not probe to bone.
---
2. ) LLE cyanosis: Seen by vascular , no emergent intervention
required. patient to be seen by out patient vascular surgeon on 10/28/05 , will
deffer for further testing.
--- 3. ) Elevated CR: Baseline Will
hydrate. ---
4. ) DMII - on glyburide , ADA diet , RISS ---
5. ) AF/SSS - has DDI PPM in and is on coumadin ---
6. ) CKD - likely secondary to DM - at baseline ---
7. ) FULL CODE
ADDITIONAL COMMENTS: pls follow up with your vascular surgeon- Dr Halechko on 10/28/05
Pls follow up with your orthopedic surgeon
pls follow up with your primary care physician
Pls continue daily wet to dry wound changes
pls take antibiotics as prescribed
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Abx- linezolid for 6 wks
INR check on 10/28/05
Follow up appointments with ortho , vascular and primary care physician
No dictated summary
ENTERED BY: FOSTON , ELOUISE C , M.D. ( DY6 ) 6/22/05 @ 02:51 PM
****** END OF DISCHARGE ORDERS ******
Document id: 63
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
Y |
Y |
N |
N |
041716400 | PUO | 53411281 | | 653876 | 9/18/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/19/1993 Report Status: Signed
Discharge Date: 9/10/1993
DIAGNOSIS: OSTEOARTHRITIS LEFT HIP.
STATUS POST OSTEOTOMY FOR OSTEOARTHRITIS
OF THE RIGHT HIP.
HISTORY OF SLEEP APNEA.
OPERATIONS/PROCEDURES: LEFT TOTAL HIP REPLACEMENT BY DR. DEPALO ON
22 of April .
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old male with
left hip pain , now worsening over the
past year , unrelieved with conservative therapy. The patient has a
history of congenital dysplasia of the hip , which was treated with
osteotomy of the right hip in 1988 , with good improvement. PAST
MEDICAL HISTORY was also remarkable for sleep apnea. ALLERGIES
included intravenous pyelogram dye and shrimp. MEDICATIONS ON
ADMISSION were none.
PHYSICAL EXAMINATION: The patient was an obese white male in no
acute distress. He ambulated with a truncal
lurch to the left. Head and neck were within normal limits. Lungs
were clear. Cardiac examination was regular. Abdomen was obese ,
but benign. The left hip was remarkable for being 3/4 inch longer
than the right leg. Flexion was limited to 90 degrees , with 10
degrees lacking full extension. External rotation was 30 degrees ,
internal rotation 0 , abduction 30 degrees with increased pain , and
adduction 20 degrees. The patient's neurovascular examination was
within normal limits.
HOSPITAL COURSE: The patient was admitted on 22 of April , and
underwent left total hip replacement which he
tolerated well. Estimated blood loss was 400 cc. The patient was
in stable condition for the entire hospital stay. His immediate
postoperative hematocrit was 36.3. The patient was febrile for the
first postoperative day , but rapidly defervesced on perioperative
antibiotics with Ancef. On postoperative day #2 , hematocrit had
dropped to 29 and the patient received 2 units of autologous blood ,
which increased his hematocrit to 36. The patient remained stable
over 30 for the rest of his hospital course.
The incision was examined on postoperative day #1 , and was found to
be clean and dry. The patient started physical therapy on
postoperative day #1 , and made rapid progress. The patient was
anticoagulated with Coumadin for a prothrombin time in the range of
14 to 16 , and stabilized at a dose of 8 milligrams per night. At
the last dose , his prothrombin time had gone up over 16 and he was
changed to Coumadin 5 milligrams by mouth at hour of sleep. The
patient was cleared by the Physical Therapy Service and cleared
medically for discharge home on postoperative day #6.
DISPOSITION: The patient will be discharged to home. The patient
is to FOLLOW-UP with Dr. Depalo in 5 weeks.
MEDICATIONS ON DISCHARGE included Coumadin for a full 6-week
course , Percocet as needed. The patient will FOLLOW-UP with the
Coumadin Program through this hospital. The patient had no
problems with his breathing and will require no special therapy at
this time. CONDITION ON DISCHARGE was good.
Dictated By: REFUGIA BAUCHSPIES , M.D. LI40
Attending: SOFIA DEPALO , M.D. IP7 LT132/5850
Batch: 0629 Index No. QDYZHE4U3A D: 4/7/93
T: 3/8/93
Document id: 64
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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371632697 | PUO | 44138434 | | 6358638 | 8/1/2006 12:00:00 a.m. | hematoma vs mass , L iliac muscle | | DIS | Admission Date: 8/11/2006 Report Status:
Discharge Date: 5/28/2006
****** FINAL DISCHARGE ORDERS ******
FRITZE , VILMA C 984-25-26-5
Maryland
Service: MED
DISCHARGE PATIENT ON: 4/24/06 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DELMENDO , CRISTINE V. , M.D.
CODE STATUS:
No intubation
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 9/26/06 by
TEACHMAN , IOLA , M.D.
on order for COUMADIN orally ( ref # 982493499 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: patient's home med
ALBUTEROL INHALER 2 PUFF inhaled four times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
DOXYCYCLINE HYCLATE 100 MG orally twice a day
Instructions: 14 day course complete on 4/12
Food/Drug Interaction Instruction Give with meals
Take 1 hour before or 2 hours after dairy products.
Alert overridden: Override added on 1/8/06 by :
POTENTIALLY SERIOUS INTERACTION: MAGNESIUM HYDROXIDE &
DOXYCYCLINE HCL
POTENTIALLY SERIOUS INTERACTION: MAGNESIUM HYDROXIDE &
DOXYCYCLINE HCL Reason for override: patient already on med
Previous Alert overridden
Override added on 9/26/06 by TEACHMAN , IOLA , M.D.
POTENTIALLY SERIOUS INTERACTION: MAGNESIUM HYDROXIDE &
DOXYCYCLINE HCL
POTENTIALLY SERIOUS INTERACTION: MAGNESIUM HYDROXIDE &
DOXYCYCLINE HCL Reason for override: patient requires
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF NEB twice a day
MONOPRIL ( FOSINOPRIL SODIUM ) 10 MG orally DAILY
Override Notice: Override added on 6/15/06 by
TEACHMAN , IOLA , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
161924900 )
POTENTIALLY SERIOUS INTERACTION: FOSINOPRIL SODIUM &
POTASSIUM CHLORIDE
POTENTIALLY SERIOUS INTERACTION: FOSINOPRIL SODIUM &
POTASSIUM CHLORIDE Reason for override: patient requires
Previous override information:
Override added on 6/15/06 by TEACHMAN , IOLA , M.D.
on order for POTASSIUM CITRATE orally ( ref # 800001769 )
POTENTIALLY SERIOUS INTERACTION: FOSINOPRIL SODIUM &
POTASSIUM CITRATE
POTENTIALLY SERIOUS INTERACTION: FOSINOPRIL SODIUM &
POTASSIUM CITRATE Reason for override: patient requires
Number of Doses Required ( approximate ): 4
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF NEB every 6 hours
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
PREDNISONE Taper orally Give 30 mg every 24 hours X 3 dose( s ) , then
Give 20 mg every 24 hours X 3 dose( s ) , then
Give 10 mg every 24 hours X 3 dose( s ) , then
Give 5 mg every 24 hours X 3 dose( s ) , then
Instructions: start on 2/14
SIMVASTATIN 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/26/06 by
TEACHMAN , IOLA , M.D.
on order for COUMADIN orally ( ref # 982493499 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: patient's home med
SPIRIVA ( TIOTROPIUM ) 18 MCG NEB DAILY
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
primary care physician 1-2 weeks ,
ALLERGY: BACITRACIN , BACITRACIN/NEOMYCIN/POLYMYXIN
ADMIT DIAGNOSIS:
Left leg/groin pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hematoma vs mass , L iliac muscle
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
COPD ( chronic obstructive pulmonary disease ) smoking ( smoking ) pe
( pulmonary embolism ) cad ( coronary artery
disease ) dm ( diabetes mellitus ) htn
( hypertension ) hyperlipidemia ( hyperlipidemia ) osteopenia
( osteopenia ) crf ( chronic renal dysfunction ) adrenal mass ( adrenal
mass ) l inguinal hernia ( inguinal hernia ) history of appy ( history of
appendectomy ) baseline Cr 1.3-1.5 ( 18 )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: left groin/leg pain
*****************
HPI: 67 year-old M history of COPD on 3 L home O2 , recently discharged on 5/17 .
Also has history of PE 2/2 apical thrombwith 10/25 , now therapeutic on
coumadin. Presents now with new onset left leg/groin opain , hurts
only when walking on it with some dysuria. No chest pain , no SOB , no
Fevers/chills , nausea/vomiting/diarrhea. No bac pain. No history of
trauma. Has never had this pain befoer. In the ED , he had labs sent ,
attempted to get an MRI of his spine , however , he was not able to
tolerate this. He was sent back to the ED. He then got 2 mg of orally
Ativan to , with good effect. He had a CT scan and repeat MRI.
He also got Mucomyst for CT scan contrast.
***
PE on admission: Vitals:
98.3 73 16 126/64 96% on 4L NC in ED Chest: Poor air movements
with short breaths - little wheezing but lungs sound tight.
CV: Tachy , s1/s2 no MRG. Ext: Minimal edema . Tenderness over left
medial thigh with significant pain on active and passive movement of
the left hip. No overlying erythema.
**************
Labs on admission: Glucose of 165
139/4.3/99/33/54/1.4 CBC:
20.2>41.3<283 INR of
2.6
**************
STUDIES: MRI , CT scan show density in L pelvis , most consistent with
hematoma
************
HOSPITAL COURSE: 1 ) Neuro: Weakness/pain on left hip flexion , L side
only decr sensation in medial L2 distribution. patient had MRI
and spine CT showing density most c/with hematoma.
2 ) ID - His elevated white count suggested possible
infectious etiology , eg. epidural abscess versus septic joint vs.
subcutaneously abcess , but no significant fluid in the joint.
3 )CV ( I ): Continue aspirin ( P ): Echo 1/14 - Appears euvolemic. Will
continue Monopril and Lasix. CV ( R ): Sinus , no new
issues. 4 ) Pulmonary: On Home O2 , at 96% on 4L. Likely chronic CO2
retainer. Titrating O2 for sats 92-93%. Made his nebs standing while in
house. Complete Prednisone taper and doxycycline from previous admission.
5 ) FEN - Repleted K and Mag as needed. House diet.with low sodium.
6 ) Renal - Creatinine sublingual elevated on admission. Appeared somewhat
prerenal , give IVF as needed 7 ) Endo: ? history of diabetes. Hgb A1C pending ,
fingerstick before every meal , with RISS while in house.
8 ) Heme - History of PE therapeutic on coumadin. Imaging via CT and MRI
suggests likely hematoma , holding coumadin for now , primary care physician can reassess
whether to restart. Suggest repeat CT in 2-3 weeks to confirm resolution
of clot.
Code: DNI ( but not DNR )
ADDITIONAL COMMENTS: You should follow up with your primary care doctor and you should get a
repeat CT of your leg in 2-3 weeks to see if there is any change in size
of the clot.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. follow up CT to monitor resolution of pelvic hematoma
2. coumadin held , consider restarting based on primary care physician recommendations
3. complete course of doxycycline , complete 4/12
4. complete slow prednisone taper as written ( decr dose q3days )
5. Hb A1C 6.4 on 5/14
No dictated summary
ENTERED BY: TEACHMAN , IOLA , M.D. ( QO67 ) 4/24/06 @ 03:13 PM
****** END OF DISCHARGE ORDERS ******
Document id: 65
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
- |
- |
499548584 | PUO | 31146659 | | 0649878 | 10/10/2005 12:00:00 a.m. | chronic diarrhea | | DIS | Admission Date: 8/17/2005 Report Status:
Discharge Date: 6/12/2005
****** DISCHARGE ORDERS ******
JOLIVETTE , MARC 269-50-73-3
Tonnah Co Ton
Service: MED
DISCHARGE PATIENT ON: 7/16/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCMEEN , BUDDY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
ATENOLOL 50 MG orally every day HOLD IF: sbp < 100 , heart rate < 60
ENALAPRIL MALEATE 20 MG orally twice a day HOLD IF: sbp < 100
Override Notice: Override added on 10/4/05 by
HENDY , CLARETHA , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 33121550 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: aware
Previous override information:
Override added on 10/4/05 by HENDY , CLARETHA , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 30841266 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: aware
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
60 MG orally every day HOLD IF: sbp < 100 , heart rate < 60
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 20 MG orally every bedtime
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
METFORMIN 500 MG orally twice a day
IMODIUM ( LOPERAMIDE HCL ) 2-4 MG orally every 6 hours as needed Diarrhea
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: House / Anti Diarrhea , Lactose Restricted
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Petrov ( GI ) 10/9 2pm 10/9 2pm scheduled ,
Colonoscopy 3/17 9:30am 3/17 9:30am scheduled ,
Dr. Heidelberger ( primary care physician ) 4/2 1:30pm 4/2 1:30pm scheduled ,
ALLERGY: CLOPIDOGREL , Penicillins
ADMIT DIAGNOSIS:
chronic diarrhea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chronic diarrhea
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) hyperchol ( elevated cholesterol ) tobacco use
( smoking ) etoh use history of +PPD '93 ( )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
N/A
BRIEF RESUME OF HOSPITAL COURSE:
76M with MMP incl small cell lung CA tx'd with chemo and XRT in remission X 18
mo p/with LLQ + diarrhea orignially on 10/10/05 , CT scan with diverticulitis ,
tx'd with cipro/flagyl. Diarrhea persisted after course completed , primary care physician gave
a second course , but diarrhea persists. Diarrhea is watery , sometiems
black/bloody , occurs throughout the day , not a/with meals. No cramping/abd
pain , notes occasional burning in stomach. No recent travels , no history of food
allergies , no fever/nausea/vomiting/LH. No new meds , no recent weight
loss. Appetite good. In ED , got protonix , guaiac was positive.
ALL: Plavix/PCN gives GI upset
MEDS: ASA , atenolol , lipitor , enalapril , nifedipine xl , zantac ,
metformin.
PE T97.8 HR55 RR20 BP186/92 99% RA. NAD , reading paper. Disconj gaze , L
pupil lat dev. Lungs with sublingual wheeze. CV Dist S1/S2. Abd obese , + BS ,
S/NT/ND. Ext no C/C/E. Neuro Nonfocal.
LABS: Lytes WNL , CBC WNL ( HCT 41.9 ) , Coags WNL.
***********************
IMPRESSION: 76 year-old M with MMP p/with chronic bloody diarrhea x 3 wks , unclear
etiology , ? malabsorption , but clinically very stable , and per GI
curbside , most of the work-up can be done as outpatient.
***********************
GI: Chronic diarrhea , possible due to malabsorption vs. infection.
patient was made NPO on night of admission , and had no bowel movements ,
suggesting malabsorption as a possible etiology. Celiac sprue
studies are pending. Patient was also empirically put on a lactose
free diet. Stool cultures ( including parasites , SSYCE , stool osms/lytes )
were ordered , but could not be sent , as patient had no stool overnight.
Patient started on immodium as diarrhea not thought to be due to an acute
infectious process , with low risk for toxic megacolon. Patient
also scheduled for an outpatient colonoscopy. Protonix for heartburn.
HEME: HCT stable.
ID: Hold off further abx at this point , as there was no response to 2
course of cipro/flagyl.
CV: No acute issues , we continued asa/bb/statin/acei/ccb.
ENDO: RISS. TSH was WNL.
***********************
DISPO: Will follow up with Dr. Petrov on 10/9 at 2pm. Consider outpatient
small intestinal biopsy , ERCP. Follow up on celiac sprue studies.
Patient scheduled for an outpatient colonoscoyp on 3/17 at 9:30am.
ADDITIONAL COMMENTS: 1. You are scheduled for a colonoscopy on 3/17 at 9:30am. No food or
drinks the night before. On 8/25 , only clear liquids. Please drink Oral
Phosphate Soda ( you can pick up over-the-counter at any pharmacy ) the
night before the colonoscopy. Pls call 691-038-4637 for more directions.
2. Please do not take any dairy products.
3. Please resume all of your regular medications. No changes were made.
If the list above does not match your regular meds , please resume your
regular meds.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Outpatient colonoscopy on 3/17 , follow-up results
2. Consider outpatient small intest bx/secretin test/ERCP.
No dictated summary
ENTERED BY: HENDY , CLARETHA , M.D. , PH.D. ( TD18 ) 7/16/05 @ 01:23 PM
****** END OF DISCHARGE ORDERS ******
Document id: 66
| Target |
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GER |
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HTG |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
- |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
743195205 | PUO | 60820941 | | 8690007 | 9/19/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/26/2005 Report Status: Signed
Discharge Date:
ATTENDING: DOCIMO , STEFFANIE T. MD , PHD
SERVICE:
CCU Service.
PRINCIPAL DIAGNOSIS:
Coronary artery disease and aspirin allergy.
LIST OF PROBLEMS:
1. Hypertension.
2. Hypercholesterolemia.
3. Atrial fibrillation.
4. Peptic ulcer disease.
5. Colonic polyps.
6. Prostate adenocarcinoma.
7. Pancreatic cancer , metastatic.
HISTORY OF PRESENT ILLNESS:
Mr. Wrich is a 67-year-old man with cardiac risk factors
including hypertension , hypercholesterolemia. His CAD history
begins one year ago when he began to experience resting jaw pain
responsive to two to three sprays of nitroglycerin. On 5/10/05 ,
he presented to Petersram Medical Center with this pain and he was found to
have T wave inversion , ST depressions in V6 , V1 and aVL. At that
point , his cardiac markers peaked at troponin of 29.6. He was
taken to the catheterization lab where he was found to have a 90%
RCA stenosis. He underwent angioplasty and bare metal stent
placement. After the catheterization , he had six weeks without
pain but over the last two weeks he had begun to experience
increasing jaw pain that was minimally responsive to
nitroglycerin spray. He presented for elective recatheterization
on 1/4 the day of his admission and was found to have 70% LAD
lesion and a 40% proximal RCA lesion. A Cypher stent was placed
in the LAD. He was started on Integrilin for 24 hours and sent
to the CCU for aspirin desensitization. He has taken aspirin for
headaches in his teens and developed rashes. He had taken
aspirin a few times in his 20s and 30s without any recalled side
effects. However , he did take 12 years ago , a dose of
indomethacin and reportedly had to be inducted into a coma in the
hospital for severe adverse reaction to the indomethacin. He
cannot elaborate further on what this reaction was. Therefore ,
given the need to be on aspirin for his new Cypher stent , he was
admitted to the CCU for a course of desensitization.
PREADMISSION MEDICATIONS:
Include Plavix 75 mg orally daily , Lopressor 12.5 mg three times a day ,
captopril 37.5 mg orally three times a day , Imdur 90 mg every day before noon and every afternoon ,
Lasix 40 mg orally daily , Creon six tablets orally daily , Lantus 4
units subcutaneous every bedtime , Humalog subcutaneous with meals , as
needed nitroglycerin sublingual tablets.
ALLERGIES:
Include aspirin , penicillin and NSAIDs which produce rash.
SOCIAL HISTORY:
No tobacco , alcohol or other drug use history. He lives with his
wife and performs clerical work and can perform activities of
daily living without issue.
FAMILY HISTORY:
Mother had esophageal cancer , his father had renal cancer.
PHYSICAL EXAMINATION:
Temperature 96.9 , pulse 87 , blood pressure 130/60 , O2 saturation
97% on room air. His exam was significant for being thin ,
fatigued man with mild icterus , mildly bleeding gums. JVP at 11
cm. III/VI harsh systolic murmur at the base. III/intravenous diastolic
murmur at the base. His lung exam was clear bilaterally. His
abdomen was soft , nontender with two ventral hernias without
issue. He was alert and oriented x3 and had mild 1+ edema
bilaterally.
LABORATORY VALUES:
His white count was 5.4 , hematocrit 30.2 , platelets 251 , 000.
Creatinine was 1.2 after catheterization. His INR was 1.3. CK
was 42 , troponin 0.12.
PROCEDURES:
Catheterization went without event with stenting of his LAD 70%
lesion with Cypher stent.
HOSPITAL COURSE:
1. Cardiac. Mr. Botts cardiac catheterization went
smoothly with identified 70% mid proximal LAD lesion and proximal
40% RCA lesion. A Cypher stent was placed in the LAD , and he was
started on Integrelin and sent to the CCU. His Plavix and Imdur
were continued as per his home dose. His beta-blocker and ACE
inhibitor were held for anticipation of aspirin desensitization.
He did not experience any further chest pain or jaw pain during
his stay and was stable hemodynamically.
2. Allergy. It was agreed that his aspirin should be taken
given that he now has a Cypher stent. Given his vague history of
possible aspirin allergy and question of anaphylactic shock
induced by NSAIDs , it was decided to desensitize him to 81 mg of
aspirin. This was done as per protocol defined by Allergy
Consult Service with doubling increments starting at 5 mg and
going to 81 mg of aspirin over the course of two hours every 30
minutes. Epinephrine and Benadryl were kept at bedside but were
not required because he had no adverse reaction to any of the
doses.
DISPOSITION:
The patient was discharged home in stable condition on all his
home medications as previously prescribed plus aspirin 81 mg each
day. He was instructed that it was important to take his aspirin
every day because if he missed a dose he may have an allergic
reaction that his desensitization was designed to avoid.
DISCHARGE MEDICATIONS:
1. Captopril 37.5 mg orally three times a day to be started one day after
discharge.
2. Lopressor 12.5 mg orally three times a day
3. Plavix 75 mg orally daily.
4. Imdur 90 mg every day before noon and every afternoon
5. Lasix 40 mg orally daily.
6. Creon six tablets orally daily.
7. Lantus 4 units subcutaneous every bedtime
8. Humalog subcutaneous with meals.
9. Nitroglycerin 0.4 mg sublingual as needed.
10. Aspirin 81 mg every day.
FOLLOW UP:
The patient was instructed to call the Totin Hospital And Clinic
Allergy Service for outpatient appointment within two to four
weeks. He was to contact the Onco/Allergy fellow if he
experiences any itching or rash in the next few days.
eScription document: 8-8835652 EMSSten Tel
CC: Alyse Holda
Daonredd Cison Community Memorial Hospital
Medholl Pkwy , Busman Oaks , Rhode Island 95997
Dictated By: HARKLEY , JACQULYN
Attending: DOCIMO , STEFFANIE T.
Dictation ID 0488337
D: 6/6/05
T: 10/23/05
Document id: 67
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
N |
Y |
Y |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
150238522 | PUO | 21988313 | | 7514889 | 9/14/2006 12:00:00 a.m. | solumedrol dose | | DIS | Admission Date: 10/24/2006 Report Status:
Discharge Date: 2/27/2006
****** FINAL DISCHARGE ORDERS ******
SIPHO , GRETTA 603-67-32-0
Lin Chat H
Service: RNM
DISCHARGE PATIENT ON: 1/8/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NORSETH , ARDELLA S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ROCALTROL ( CALCITRIOL ) 0.5 MCG orally EVERY OTHER DAY
FELODIPINE 5 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 8/23/06 by :
POTENTIALLY SERIOUS INTERACTION: TACROLIMUS & FELODIPINE
Reason for override:
NOVOLOG ( INSULIN ASPART )
8 UNITS subcutaneously with breakfast and dinner
INSULIN NPH HUMAN 28 UNITS subcutaneously every day before noon Starting Today ( 9/19 )
INSULIN NPH HUMAN 14 UNITS subcutaneously every afternoon Starting Today ( 9/19 )
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
150 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 750 MG orally three times a day
Starting Today ( 8/24 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
TACROLIMUS 3 MG orally every 12 hours Starting Today ( 9/19 )
Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
Override Notice: Override added on 8/23/06 by
ROBARDS , LYNNETTE I. , PA-C
on order for NORVASC orally ( ref # 109562281 )
POTENTIALLY SERIOUS INTERACTION: TACROLIMUS & AMLODIPINE
BESYLATE Reason for override:
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally EVERY OTHER DAY
VALCYTE ( VALGANCICLOVIR ) 450 MG orally EVERY OTHER DAY
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Norseth - renal transplant clinic Monday 5/8/06 Labs 8:30am then check in at front desk of clinic ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
1. acute renal failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
solumedrol dose
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ESRD history of renal transplant , DM
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ultrasound guided renal transplant biopsy
BRIEF RESUME OF HOSPITAL COURSE:
Transplant Information:
Casue of ESRD: DM2/HTN
Transplant: history of preemptive LURT ( 11/26/06 )
Induction with thymo , warm ischemia about 1 hour
Post op course with DGF ( Cr 2.6 on discharge ) and CHF
---------------------------------------------------
Reason for admission: Elective renal transplant biopsy
---------------------------------------------------
HPI: 66 year old female with ESRD secondary to DM now history of pre-emptive
living unrelated renal transplant 11/26/06 , post op course complicated by
prolonged warm ischemia time leading to delayed graft function. Most
recently patient has accidentally taking FK three times a day instead of twice a day and
had an FK trough level of 20. Even though she is now on
the appropriate medication regimen her creatinine has failed to fall
below 2.0. Patient will therefore be admitted for an elective renal
transplant. She is otherwise well with no concerns or complaints. She
denies taken aspirin since the transplant.
---------------------------------------------------
Review of systems: She denies fever , chills , anorexia , or changes in
weight. She denies headaches , dizziness , lightheadedness , weakness ,
changes in vision , tremor or other focal neurological complaints. She
denies dysphagia , cough , shortness or breath , or chest pain. She
denies nausea , vomiting , diarrhea , constipation , abdominal pain or
other gastrointestinal symptoms. She denies dysuria ,
hematuria , or hematochezia. She denies myalgia or bone or joint pain.
She denies any new skin lesions. Review of systems is otherwise
negative.
---------------------------------------------------
Past Medical History:
1. ESRD - 2/2 DM/HTN
- Urine output: normal
Dialysis access: Has recently had a left forearm fistula created by Dr.
halechko which appears to be maturing well ( after ligation of collaterals )
- Preemptive living unrelated renal transplant 11/26/06 .
2. DM2 started in her 50s. Initially treated with OHA now on insulin.
Some peripheral neuropahty , no autonomic neuropathy by symptoms.
3. Htn also since her 50s
4. G4P4 - no preeclampsia , no renal disease documented while pregnant.
She did have multiple urinary tract infections during her
pregnancies. States she was born with 4 kidneys.
5. Obesity - since childbearing years. She has lost 30 lb of her own
volition since August 05 and continues on a diet and exercise program
---------------------------------------------------
Past Surgical History:
1. AVF creation January 2005 2. Open cholecystectomy 1998 ( done open because
of fatty liver according to patient ) 3. Cataract surgery August , 2006
---------------------------------------------------
Medications: Immunosuppression: FK 4 mg twice a day , MMF 750 mg three times a day
Other meds: Valcyte 450 mg every other day , Bactrim SS 1 tab every other day , Toprol XL 100 mg
every day , Calcitriol 0.5 mcg every other day NPH 26 units every day before noon 12 units every afternoon , Novolog 8 units
before meals
---------------------------------------------------
Allergies: NKDA
---------------------------------------------------
Social History: Denies ETOH , tobacco , or ilicit drug use.
---------------------------------------------------
Family History: NC
---------------------------------------------------
Physical Exam on admit:
General: NAD \HEENT: PERRL , oropharynx clear , neck supple
CVS: RRR , normal S1/S2 , 2/6 SEM
Lungs: CTA bilaterally
Abdomen: obese , soft , nontender , nondistended
Allograft: nontender , JP drain in place , incision well healed
Ext: no edeam
Neuro: awake , alert , and oriented , grossly intact
---------------------------------------------------
Hospital Course: Ms. Sipho is a 66 year old female with ESRD secondary
to DM now history of pre-emptive living unrelated renal transplant 11/26/06 ,
post op course complicated by prolonged warm ischemia time
leading to delayed graft function. Creatinine has failed to fall
below 2.0 and she was admitted for an elective renal transplant
biopsy.
1. Renal - Ultrasound guided renal transplant biopsy 11/24/06 . Received
DDAVP prior to biopsy. Biopsy without complication. Post biopsy Hct
25->21. Vitals stable. Received 1 unit PRBC's. Biopsy results consistent
with acute cellular rejection. Treated with Solumedrol 500 mg intravenous every day X 2
days. Discontinued early 2/2 steroid induced psychosis and hyperglycemia.
2. BP - Elevated blood pressure in setting of high dose intravenous solumedrol.
Increased Toprol to 150 mg every day and added felodipine 5 mg daily.
3. Endo - history of DM. Glucose elevated in setting of high dose steroids. Added
regular insulin sliding scale to her regimen while in house. Discharged
home on out patient regimen and to monitor finger sticks. Should continue
to regulate off of steroids.
4. CVS - Had episode of chest discomfort after first dose of solumedrol.
Also complained of feeling jitter and unable to sleep. EKG with no acute
changes and cardiac enzymes negative. Most likely anxiety related to intravenous
solumedrol. Given ativen as needed while in house receiving steroid pulse. No
further episodes of chest discomfort.
5. Discharged to home in stable condition. Will follow up in renal
transplant clinic.
ADDITIONAL COMMENTS: 1. Take all medications as prescribed
2. Return to the emergency room if you have pain over your transplant
kidney , blood in your urine , feel lightheaded or dizzy.
3. Call with any questions , 511-204-6794
4. Renal transplant clinic with Dr. Norseth on Monday 5/8/06 . Have lab
work drawn at 8:30am and then go check in at the front desk of the renal
transplant clinic.
5. Record your blood sugar readings and bring to clinic tomorrow.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TURREY , CAYLA , PA-C ( ) 10/8/06 @ 12:28 PM
****** END OF DISCHARGE ORDERS ******
Document id: 68
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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- |
717671856 | PUO | 59553955 | | 1415986 | 5/4/2005 12:00:00 a.m. | CHF exacerbation , cellulitis | | DIS | Admission Date: 5/4/2005 Report Status:
Discharge Date: 6/8/2005
****** FINAL DISCHARGE ORDERS ******
CUNDY , SAU S 487-71-68-0
Di Fay Buffnas
Service: MED
DISCHARGE PATIENT ON: 3/23/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DONEHOO , FILOMENA MICKI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
as needed Shortness of Breath , Wheezing
Override Notice: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for NORTRIPTYLINE HCL orally ( ref # 972545479 )
POTENTIALLY SERIOUS INTERACTION: ALBUTEROL SULFATE &
NORTRIPTYLINE HCL Reason for override: home med
TEGRETOL ( CARBAMAZEPINE ) 400 MG orally 10a , 2p , 8p
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Alert overridden: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
SERIOUS INTERACTION: AZITHROMYCIN & CARBAMAZEPINE
Reason for override: home med
CLONAZEPAM 0.25 MG orally 10a , 12p , 2p , 5p , 7pm 10p
Starting Today ( 4/9 )
Alert overridden: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & CLONAZEPAM
Reason for override: home med
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
LISINOPRIL 40 MG orally every day
Override Notice: Override added on 10/19/05 by
HIPKINS , ERMA M. , M.D. , PH.D.
on order for KCL intravenous ( ref # 992307272 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: needs
Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: home med
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally four times a day
HOLD IF: sbp<90 , HR<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NORTRIPTYLINE HCL 150 MG orally HS
Alert overridden: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
POTENTIALLY SERIOUS INTERACTION: ALBUTEROL SULFATE &
NORTRIPTYLINE HCL
POTENTIALLY SERIOUS INTERACTION: ALBUTEROL SULFATE &
NORTRIPTYLINE HCL Reason for override: home med
PHENERGAN ( PROMETHAZINE HCL ) 25 MG orally four times a day
SARNA TOPICAL TP twice a day Instructions: to affected area
COUMADIN ( WARFARIN SODIUM ) 6.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: take 6.5mg on sunday night 1/3 , on monday
4/9 , on
tuesday 4/9 and then await INR results for wednesday dose
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: home med
AZITHROMYCIN 250 MG orally every day Starting Today ( 4/9 )
Instructions: dose ending on 4/26/05
Food/Drug Interaction Instruction Avoid antacids
Take with food
Override Notice: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for TEMAZEPAM orally ( ref # 981948244 )
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & TEMAZEPAM
Reason for override: home med Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
on order for TEGRETOL orally ( ref # 332987421 )
SERIOUS INTERACTION: AZITHROMYCIN & CARBAMAZEPINE
Reason for override: home med Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
on order for COUMADIN orally ( ref # 117673356 )
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & WARFARIN
Reason for override: home med Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
on order for ZOCOR orally ( ref # 964436790 )
SERIOUS INTERACTION: AZITHROMYCIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & SIMVASTATIN
Reason for override: home med Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
on order for CLONAZEPAM orally ( ref # 759554933 )
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & CLONAZEPAM
Reason for override: home med Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
on order for AZITHROMYCIN orally ( ref # 595101284 )
patient has a PROBABLE allergy to Erythromycins; reaction is
GI Intolerance. Reason for override: patient tolerates
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for COUMADIN orally ( ref # 117673356 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: home med Previous override information:
Override added on 10/14/05 by COSE , LATASHIA C. , M.D. , M.B.A.
SERIOUS INTERACTION: AZITHROMYCIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & SIMVASTATIN
Reason for override: home med
VICODIN ( HYDROCODONE 5 MG + APAP ) 1 TAB orally every 8 hours as needed Pain
Instructions: give only if backpain
Alert overridden: Override added on 10/19/05 by
DURRETTE , SEYMOUR , M.D.
on order for VICODIN orally ( ref # 331649511 )
patient has a PROBABLE allergy to Codeine; reactions are
nausea , vomiting. Reason for override:
patient takes with no rxn
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:cough Number of Doses Required ( approximate ): 10
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 10/14/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for LISINOPRIL orally ( ref # 713704980 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: home med
ZYRTEC ( CETIRIZINE ) 10 MG orally twice a day Starting Today ( 4/9 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Number of Doses Required ( approximate ): 2
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
GLYBURIDE 10 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Donehoo 1-2 weeks ,
Endocrine Clinic ( please call 125-634-8399 ) 2-4 weeks ,
Opthamology 2-4 weeks ,
Podiatry 1 week ,
Arrange INR to be drawn on 4/26/05 with f/u INR's to be drawn every
3 days. INR's will be followed by Coumadin Clinic
ALLERGY: intravenous Contrast , Penicillins , Shellfish ,
NARCOTICS , PHENANTHRENES , Bee Stings , LEVOFLOXACIN ,
Cephalosporins , BETADINE/IODINE
ADMIT DIAGNOSIS:
CHF exacerbation , cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation , cellulitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN FIBROMYALGIA SEVERE OA OF R KNEE MIGRAINES
history of LARGE GALL STONE history of DVT IN RLE history of CABG '96 history of st Jude MVR '96
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
See DC Summ
BRIEF RESUME OF HOSPITAL COURSE:
CC: Right toe/leg swelling , cough
*******************
HPI: 60F COPD , pulm HTN and pass admissions for volume overload adn
COPD flares who 5 days ago developed initial sneezing and water eyes
following cough productive of yellow sputum , SOB , sinus pain ,
and purulent nasal drainage. Denies anys ore throat , chest pain ,
abdominal pain , diarrhea , blood in stool , dysuria , rash , joint pain ,
orthopnea. SOB and wheezing requriing increased neb treatments
over last few days ( 1 to 2 up until 4-5/day ) and waking up @ night
with SOB. Yesterday her daughter noticed a region of erythema on
distal aspect of right 2nd toe and abrasion. At baseline , patient has DM
neuropathy affecting distal LE and has decreased sensation. Denied
pain and swelling in lower ext and is new. Denied fevers , chills ,
nausea , vomitting , sweats. In ED , VS were initially normal
inclduing o2 sat but was quite dyspenic and had low sat in 90s which
improved after neb tx. Recevied lasix 40 intravenous and prednisone 60mg , alb
and atrovent nebs , azithromycin 500mg nad clinda 600mg , tylenol
and tessalon.
*******************
PMH: COPD with chest CT on 8/10 showing RLL nodule and air trapping ,
pulm htn , cabg x 2 with recent admission CP in 6/8 with neg PET
stress , DM , post MVR with mech valve ( STJ ) on before meals 1996 , Sjogren's ,
seizure do , depression , history of dvt RLE , rigt TKR
*******************
MEDS: Tegretol 400 three times a day , Klonipin 0.25mg every 2 hours , Atarax 10mg orally four times a day ,
Lisinopril 60mg orally every day , lopressor 75 , g orally four times a day , nortryptilline 150mg orally
every bedtime , glyburide 10mg orally every day , advair 500/50 1puff twice a day , 1-2 alb nebs per
day , lasix 40mg every day , k-dur 20meq every day , zyrtec 10mg orally twice a day , vicodin 1 tab
orally every 6 hours , zantac 150mg orally twice a day , zocor 20mg orally every bedtime , coumadin 6.5mg orally
every bedtime , celexa 10mg orally every day , phenergan 20mg orally
four times a day
*******************
ALL: PCN , iodine
*******************
SH: lives with grandson , 47 pack year hx quit today , no ETOH ,
divorced
*******************
EXAM @ DISCHARGE: T96.8 P73 136/59 R24 96%RA
Gen: Well appearing , breathing comfortably
HEENT: maxillary/frontal sinus tenderness , clear oropharynx , no LAD
Chest: Wheezing intermittent otherwise clear
CV: RRR , mechanical S1 , I/VI ejection murmur LSB , JVP 10
Abd: Obese , NT +BS
Ext: improved edema of lower ext , rigth 2nd toe abrasion of sital
aspect with overlaying scab and surrounding erythema decreased
swelling/stable; no tenderness or warmth , no puss , no exudates
*******************
CXR: no acute pulm/card process , no infiltrate
EKG: NSR 70s , poor RWP , ST seg normal
*******************
HOSPITAL COURSE: 60F history of COPD , RHF , with history consistent
with sinusitis , bronchitis with related COPD exacerbation appearing
to have beginnings of celulitis on RLE.
1. PULM - Patient when first admitted was slightly dyspneic and had
intermittent wheezing. Given steroids ( prednisone orally x 1 ) in ED.
Then also given nebs with rapid improvement within 12 hours. Patient
then continued on nebs round clock with no further evidence of COPD
flare. As a result , patient's slight SOB likely due to slight CHF.
Continued diuresis. Continued Azithro for sinusitis and
bronchitis/cough.
2. CV - Patient more likley to have slight CHF flare with slight LE
edema. Dry weight 104-105kg and patient had 109.9 kg weight on admission.
Patient was diuresed over hospital course with good result. Resuming
home BB + ACE. Patient's Na also slowly trended up and initial
hyponatremia likely due to CHF. Also placed on fluid restriction , daily
weights , strict i/o. ISCH/RHYTHM-no active issues during this hosp.
3. ID - Azithro( sinusitis ) + Clinda ( cellulitis ) x 7 days. Vascular
surgery consult called to eval right 2nd toe and their recommendation is
for coverage for gram + x 7 days and agreed with clinda. Close f/u with
podiatry as outpt. Patient dc'd on clinda due to gi intolerance but will
complete azithro as outpt. Vascular surgery agrees and patient should
follow with podiatry for toe.
4. Endo - patient has DM. RISS , ADA. Endo consult called and recommended while
in house coverage with Novolog SS and glyburide 10mg every day as outpatient , no
insulin as outpt. HbA1c elevated at 7.9. patient needs better control and
will be seen by endo as outpatient. Also will do 24h urine cortisol as
outpatient to eval cushing's as outpt as recommended by endo.
5. Heme - Mech Valve -> goal INR 2.5 to 3.5 , on coumadin every day. INR
therapeutic throughout hospitalization. Will be followed by PUO coumadin
clinic closely.
6. FEN - Mg/K SS; twice a day lytes when diuresed with intravenous lasix.
7. Psych - continued psych meds as inpatient with good result.
8. PPX - on coumadin , gi with h2 blocker
ADDITIONAL COMMENTS: 1 ) Please take all your home medications plus a new medication -
azithromycin ( to be continued until 4/23 ) 2 ) Please follow up with Dr.
Donehoo , coumadin clinic , opthalmology , endocrinology , and podiatry.3 )
Please call your doctor or present to the emergency department if you
experience high fever , trouble breathing , weight gain >5 lb in 3days ,
confusion or any other symptom concerning to you.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
primary care physician: *f/u Na and consider cortisol testing
*appearance of cellulitis R foot
VNA: *please apply xeroform dressing + dry dressing to 2nd toe interspace
of right foot *please check breathing , o2 sat , blood pressure , and
weight and call Dr. Filomena Donehoo if patient desats or gains >5 lb in 3 days.
No dictated summary
ENTERED BY: DURRETTE , SEYMOUR , M.D. ( NK87 ) 4/4/05 @ 01:27 PM
****** END OF DISCHARGE ORDERS ******
Document id: 69
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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717671856 | PUO | 59553955 | | 442649 | 10/12/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/19/1996 Report Status: Signed
Discharge Date: 11/10/1996
PRINCIPAL DIAGNOSIS: Pulmonary edema.
This is a 51 year-old female with fibromyalgia , hypertension and
migraine headaches. She reports two months of dyspnea at night ,
paroxysmal nocturnal dyspnea , and orthopnea. Over the past two
weeks prior to admission , the episodes have been becoming worse.
On the day of admission , she had an episode of severe substernal
chest pressure associated with shortness of breath after carrying
water bottles from her car. She presented to the Emergency Room
for evaluation. In the Emergency Department , V/Q scan was very low
probability. She had lower extremity noninvasive studies which
were also unremarkable.
PAST MEDICAL HISTORY: Fibromyalgia , hypertension , mild asthma ,
osteoarthritis of the knee , migraines , total
abdominal hysterectomy , bilateral salpingo-oophorectomy , chronic
fatigue syndrome , deep venous thrombosis in the right lower
extremity , history of gallstones. Medications on admission
included Nortriptyline , methyldopa , hydrochlorothiazide , Zantac ,
estrogen , Advil , ALternaGEL.
SOCIAL HISTORY: She works as a supervisor to home health aides.
FAMILY HISTORY: Notable for coronary artery disease.
REVIEW OF SYSTEMS: The patient smokes one and one-half packs per
day for 30 years.
PHYSICAL EXAMINATION: Temperature 97.4 , respiratory rate 22 ,
heart rate 100 , blood pressure 150/90.
HEENT: Anicteric. LUNGS: In the Emergency Room were notable for
bibasilar crackles about one-quarter of the way up.
CARDIOVASCULAR: Regular rate and rhythm. II/VI systolic murmur.
No rubs or gallops. ABDOMEN: Benign. RECTAL: Guaiac negative in
the Emergency Department. EXTREMITIES: 1+ pedal edema
bilaterally , right greater than left. NEUROLOGICAL: Nonfocal.
LABORATORY DATA: On admission , hematocrit 41.6 , BUN 13 , creatinine
0.6. Chest x-ray showed mild pulmonary edema.
Electrocardiogram showed normal sinus rhythm at 91 , no ischemic
changes.
HOSPITAL COURSE: The patient was admitted for rule out
myocardial infarction. She had serial CPKs which
were all negative. At that point , her monitor was then
discontinued. The patient's pulmonary edema was treated with two
doses of intravenous Lasix ( 20 milligrams each ). This resulted in
a moderate diuresis and resolution of her shortness of breath
symptoms. She then underwent an exercise test. This was done with
arm ergometry ( 30 watts ). She went ten minutes , stopped secondary
to arm fatigue. Her heart rate went from 100 to 129 , blood
pressure went from 130 systolic to 172. Electrocardiogram showed
no ischemic changes. She had no chest pain or chest pressure with
this and this was deemed a negative test. She then underwent an
echocardiogram which showed vigorous systolic function of 86% , no
valvular lesions , no wall motion abnormalities. There was evidence
of thickening in her ventricular walls.
Given the fact that the patient had an elevated diastolic pressure
and did show some early evidence of thickening in her ventricular
walls , the decision was then made to begin her on a calcium channel
blocker. Verapamil 240 milligrams orally every day was initiated and the
patient tolerated this prior to discharge. This was added in
addition to all her usual medications. She was discharged to home
in good condition.
DISCHARGE MEDICATIONS: Verapamil SR 240 milligrams orally every day;
Zantac 300 milligrams every day; estrogen 1.25
milligrams every day; Advil 800 milligrams orally twice a day as needed;
hydrochlorothiazide 25 milligrams orally every day; methyldopa 250
milligrams every day; Nortriptyline 125 milligrams orally every bedtime
The patient has scheduled an appointment to see a new primary
physician , Dr. Tarsha Prall at Pagham University Of . She
states that appointment is scheduled for April , 1996.
Dictated By: IRVING M. ESCALANTE , M.D. FB73
Attending: LATORIA C. OGDEN , M.D. FA34 NZ467/5275
Batch: 8795 Index No. P5XSZ330KI D: 11/14/96
T: 11/14/96
CC: 1. TARSHA Y. PRALL , M.D. FT68
Document id: 70
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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936688754 | PUO | 83264142 | | 169773 | 10/5/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 2/24/1990 Report Status: Unsigned
Discharge Date: 4/28/1990
HISTORY OF PRESENT ILLNESS: This is a 40 year old , gravida VI para
V , black female with an EDC of 2/9/90
at 29 weeks gestation. She was admitted for blood sugar control
for gestational diabetes. She had a fasting blood sugar of 150 and
had not been by an endocrinologist at CHH . She had gained
approximately 40 pounds to date during this pregnancy. She had a
previous history of greater than eight pound infants delivered
vaginally without difficulty. She had no other complaints during
this pregnancy. She was seen at her first prenatal visit at 24
weeks. She is RH-negative and received RhoGAM 5/30/90 . The
hematocrit on 4/20/90 was 31.8; RPR nonreactive; rubella non-immune;
Pap negative; hepatitis negative; OB GLT 196. She had
amniocentesis for genetic reasons which was 46-XY. PAST HISTORY:
Hyperthyroidism , status post partial thyroidectomy in 1976 , on
Synthroid 0.015 mg daily; endometriosis with right
salpingo-oophorectomy in 1976; tonsillectomy at age nine; menarche
at age 13 with regular cycles lasting approximately three days; no
history of abnormal Pap smears; 1972 , spontaneous abortion and
subsequent D&C; 1974 , normal spontaneous vaginal delivery of a male
infant , 8 pounds 11 ounces; 1978 , normal spontaneous vaginal
delivery of a male infant , nine pounds , with jaundice neonatally;
1979 , normal spontaneous vaginal delivery; 1982 , normal spontaneous
vaginal delivery , 8+ pounds , no complications; 1984 , normal
spontaneous vaginal delivery , six pounds. SOCIAL HISTORY: She has
smoked 3-4 packs of cigarettes per day for the past 25 years.
MEDICATIONS ON ADMISSION: Synthroid and vitamins.
PHYSICAL EXAMINATION: Vital signs stable. She presented as a
pleasant , obese , black female in no acute
distress. The HEENT exam was normal. The neck was supple; no
adenopathy; thyroid full , scar present from partial thyroidectomy.
The lungs were clear. The cardiac exam revealed a normal S1 and
S2; no murmurs or gallops. The breasts were without masses. The
abdomen was obese and gravid. NST was reactive with a baseline of
145. The cervix was long , thick and closed. The extremities were
without edema. The deep tendon reflexes were 1-2+.
LABORATORY EXAMINATION: A finger stick blood sugar was 115 with
her last meal being at noon.
HOSPITAL COURSE: The impression was 29 weeks gestation with
gestational diabetes admitted for glucose
control , status post partial thyroidectomy and anemia. The plan
was to admit her and check every 4 hours blood sugars , begin an ADA diet and
possible insulin. The patient was seen by the endocrinology
service on admission and begun on a diet. Her blood sugars
continued to be high with a fasting in the 120-150 range. She was
begun on insulin and was managed by the endocrinology service and
controlled well on the insulin over the next several days. Her
fasting blood sugar came down to eventually 100-95 on 4/7/90 .
DISPOSITION: The patient was discharged home. MEDICATIONS ON
DISCHARGE: Insulin ten units of regular qAM and 16
units of regular and 16 units NPH qPM. FOLLOW UP will be with Dr.
Bolay of the endocrinology service.
________________________________ DY528/1299
CARMELITA NUNLEY , M.D. HK62 D: 4/22/90
Batch: 2393 Report: K6540X1 T: 6/24/90
Dictated By: CARMELITA NUNLEY , M.D. HK62
Document id: 71
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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268235325 | PUO | 00601670 | | 972549 | 5/3/2002 12:00:00 a.m. | CAD | | DIS | Admission Date: 10/17/2002 Report Status:
Discharge Date: 6/17/2002
****** DISCHARGE ORDERS ******
WRAGG , DONETTE D 774-32-55-5
Roll
Service: CAR
DISCHARGE PATIENT ON: 7/14/02 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed sob
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
Override Notice: Override added on 10/20/02 by
SENGBUSCH , SHALANDA Y. , M.D.
on order for DILTIAZEM orally ( ref # 23434636 )
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & DILTIAZEM HCL
Reason for override: will monitor
Previous override information:
Override added on 10/20/02 by PORTNOY , SHANEL YVONE , M.D.
on order for DILTIAZEM EXTENDED RELEASE orally ( ref #
00093447 )
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & DILTIAZEM HCL
Reason for override: will monitor
Previous override information:
Override added on 10/20/02 by PORTNOY , SHANEL YVONE , M.D.
on order for DILTIAZEM orally ( ref # 98048355 )
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & DILTIAZEM HCL
Reason for override: md aware
HYDRALAZINE HCL 25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
AMARYL ( GLIMEPIRIDE ) 2 MG orally every day
Number of Doses Required ( approximate ): 4
CLOPIDOGREL 75 MG orally every day Starting START THE NEXT DAY
AVAPRO ( IRBESARTAN ) 150 MG orally every day
Number of Doses Required ( approximate ): 4
DILTIAZEM SR 120 MG orally every other day
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
MMC cardiology appointment will be arranged for 3 weeks ,
No Known Allergies
ADMIT DIAGNOSIS:
cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma CVA CAD Hemorrhagic stroke history of CABG ( history of cardiac bypass graft
surgery ) dm ( diabetes mellitus ) anxiety d/o
( anxiety ) osa ( sleep apnea ) hypercholesterolemia ( elevated
cholesterol ) htn ( hypertension )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac Catheterization with L PDA stenting
BRIEF RESUME OF HOSPITAL COURSE:
65 year-old male with HTN , CAD , DM , and
hypercholesterolemia who presents with 3 episodes of exertional CP
over the last 3 days. On 9/21/02 the patient had his forst episode of
SSCP while pushing a grocery cart. It was associated
with SOB above the patient's baseline. There was
no associated n/v or diaphoresis. The pain
resolved over 45 minutes with rest. The patient
again experienced exertional CP while walking on
Monday 9/4/02 . The thrid episode of CP was onthe
morning of 4/2/02 while the patient descended stairs.
The pain was 7/10 and continued until the patient
saw his primary care physician shortly there after and was given two
sublingual NTG. EKG at primary care physician office was unchanged
from baseline. The patient reports that he has not
had CP similar to this since his CABG which was
in 1995. He denies PND , orthopnea , LE edema.
EXAM Notable for JVP of 8 cm , clear chest ,
regular cardaic exam and only trace edema in extremities.
No femoral bruits with 2+ dp and patient pulses.
HOSPITAL COURSE
patient went for left heart cath on 9/30/02 which
revea led a left dominant system with 80%
distal LCx/LPDA occlusion which was stanted; the cath
als o revealed 100% occlusion of SVG-LfPDA and
100 % SVG-marg 2and 70% prox. RCA.
PLAN 1. CV - ischemia - Continue home ischemia
regimen with ASA , avapro and zocor. B blocker
help secondary to asthma attack in past with
lopressor. Heparin held secondary to history of CVA
on anticoagulation.
Rate/rhythm - telemetry. Pump - No signs/sx. failure.
2. Renal - Baseline Cr 1.3; will recieve mucomyst for renal
protection with cath.
3. Endo - Will place the patient on RISS
and continue on amaryl.
4. Pulmonary - Will continue hime regimen of CPAP for OSA.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: PORTNOY , SHANEL YVONE , M.D. ( SE88 ) 7/14/02 @ 03:55 PM
****** END OF DISCHARGE ORDERS ******
Document id: 72
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
102170309 | PUO | 15679004 | | 970948 | 9/3/1998 12:00:00 a.m. | OSTEOARTHRITIS LT. HIP | Signed | DIS | Admission Date: 4/10/1998 Report Status: Signed
Discharge Date: 8/29/1998
DIAGNOSIS: OSTEOARTHRITIS - LEFT HIP , STATUS POST LEFT TOTAL HIP
REPLACEMENT ON 9/3/98 .
HISTORY: Ms. Strassner is a 72-year-old woman with a history of
osteoarthritis , status post right total hip arthroplasty. She
presents now with end stage osteoarthritis of her left hip. Her
original surgery was performed by Dr. Depalo . The patient currently
reports that she is able to ambulate , but with difficulty even
using a cane. She is only able to walk minimally and is not able
to walk one city block. She is unable to go outside of her home or
up and down stairs at this time.
PAST MEDICAL HISTORY: Significant for urinary incontinence which
was treated by her urologist , Dr.
Lorretta Cridge , with Urised for two weeks prior to this
admission. She is also status post right total hip arthroplasty in
August 1997.
ALLERGIES: The patient is allergic to Sulfa.
MEDICATIONS: Ibuprofen on a as needed basis and Urised which she
discontinued just prior to being evaluated
preoperatively.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is married and lives with her husband
at home.
REVIEW OF SYSTEMS: The patient denies chest pain , nausea ,
vomiting , fevers or chills. She has no
shortness of breath. No orthopnea. She has no hematuria or
dysuria. She does report urinary frequency secondary to
incontinence.
PHYSICAL EXAMINATION: On examination , blood pressure is 130/90 ,
temperature is 98.8 with a pulse of 60 and a
respiratory rate 16 , height 5'6" and weight of 180 lb. In general ,
the patient is an elderly woman in no acute distress. Skin shows
no evidence of lesions. There is no evidence of lymphadenopathy.
Head , ears , eyes , nose and throat reveals pupils equal , round and
reactive to light and accommodation with extraocular movements
intact. Her neck is supple with no tenderness. Her breasts have
no masses. Her lungs are clear to auscultation bilaterally.
Heart: Regular rate and rhythm with no evidence of murmur , gallop
or rub detected. Her abdomen is soft , nontender and nondistended
with no masses. Neurologically , the patient is alert and oriented
times three. Cranial nerves II-XII are intact. Examination of the
extremities shows sensation intact to light touch and pinprick in
the L1-S1 distributions. Motor is 5/5 in the iliopsoas ,
quadriceps , AT , EHL , FHL and GS. She has palpable dorsalis pedis
and posterior tibial pulses. Her left hip range of motion has
flexion to 110 degrees. She has external rotation to 20 degrees
and internal rotation to 15 degrees with pain. Deep tendon
reflexes are normal.
HOSPITAL COURSE: The patient was given a prescription for Coumadin
to be taken on the evening prior to her surgery
and was admitted on 5/23/98 at which time she underwent and
uneventful left total hip replacement. She was treated with
perioperative antibiotics and at the time of bladder
catheterization preoperatively , urinalysis and urine culture were
sent. She was treated with perioperative antibiotics and was
continued on Coumadin postoperatively.
On postoperative day #1 , Hemovac drain was discontinued and her
laboratory values revealed a hematocrit of 29.6. She was
transfused with one unit of packed red blood cells. She did
complain of some nausea related to her pain medications which
resolved after treatment with Droperidol initially and then
Compazine later. On postoperative day #2 , her dressing was taken
down and the incision was noted to be clean , dry and intact with no
evidence of erythema or discharge. On postoperative day #3 , she
failed a voiding trial and Dr. Cridge from the Urology Department
was consulted. He recommended continued Foley catheterization or
intermittent catheterization for failure to void or for low output
incontinence , and further recommended suppression antibiotics in
the early post perioperative period. The patient was treated with
Velosef 500 milligrams orally four times a day because of her sulfa drug
allergy. On discharge , she was also given a prescription for seven
days of Velosef.
On postoperative day #4 , the patient was noted to be doing well.
Plans were made for her to be discharged to home with VNA Services
for wound checks , and physical therapy for gait training , partial
weightbearing on the left lower extremity. The patient will also
have physical therapy and INR levels checked two times per week while at home.
DISCHARGE MEDICATIONS: Velosef 500 milligrams orally four times a day ,
Colace 100 milligrams orally twice a day , Coumadin
to keep a physical therapy/INR between 1.5-2.0. We will begin treating her with
2 milligrams orally every bedtime , Percocet 1-2 tablets orally every 4 hours as needed
pain.
DISCHARGE INSTRUCTIONS: The patient was instructed to keep the
incision clean and dry for five additional
days and then was told that she may shower , but take no baths. She
was instructed to take the Coumadin for 3-6 weeks for a physical therapy/INR goal
of 1.5-2.0. She was also instructed to continue the Velosef for
seven days as per Dr. Iseri recommendation. She was instructed
not to drive until this was okay with Dr. Depalo and she was
instructed to remain partial weightbearing on the left lower
extremity. She was further instructed to follow up with Dr. Depalo
in six weeks.
COMPLICATIONS DURING ADMISSION: None.
CONDITION: Stable.
DISPOSITION: Home with VNA Services.
Dictated By: PRECIOUS KNUTESON , M.D. BM182
Attending: SOFIA DEPALO , M.D. YB3 IG327/4592
Batch: 4554 Index No. TNELB33UX D: 7/3/98
T: 2/19/98
Document id: 73
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
Y |
N |
- |
N |
N |
N |
N |
N |
893482958 | PUO | 22863897 | | 5304484 | 10/21/2006 12:00:00 a.m. | 2 episodes lethargy , unsteady gait of unclear etiology | | DIS | Admission Date: 2/2/2006 Report Status:
Discharge Date: 1/9/2006
****** FINAL DISCHARGE ORDERS ******
LINDA , DELICIA K 582-86-98-9
Le , Wisconsin
Service: MED
DISCHARGE PATIENT ON: 7/12/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RUBIANO , ELIZ , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today ( 1/5 )
LIPITOR ( ATORVASTATIN ) 10 MG orally DAILY
GLYBURIDE 2.5 MG orally DAILY X 60 doses
METFORMIN 500 MG orally twice a day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Cecily Wohlford Monday February scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
2 episodes lethargy , unsteady gait
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
2 episodes lethargy , unsteady gait of unclear etiology
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
newly-diagnosed DM history of EtOH abuse ( 7 ) hyperlipidemia
glaucoma L eye ( 3 ) erectile dysfunction dysfunction
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: lethargy , unsteady gait -- readmission after
similar symptoms Wed .
HPI:60M with newly-diagnosed DM , hyperlipidemia , glaucoma , history of EtOH
abuse , and erectile dysfunction presents to ED for 2nd time in 3 days
with unsteadiness and sleepiness. He was admitted 1/29/06 with similar
sleepiness and poor hand coordination and trouble driving , was brought
to ED somnolent and found to have BS 200-300. Workup including head
CTA , MR were negative and patient d/c'ed Thursday night with metformin and
plans for Holter and TTE on Monday. Patient felt great until Friday
morning when noted to have unsteadiness and sleepiness , similar but less
severe than Wed. Returned to ED with BS 277. No fevers , headaches , focal
neuro findings , vertigo , visual changes , CP , SOB , n/v , abd pain ,
dysuria , joint pain. Reported small rash on penis for which was taking
acyclovir this week but stopped Wed for possible neuro side effects.
Admit labs significant for glucose 314 , elevated lipids ( Chol 302 , Trig
323 , LDL 189 ) , otherwise normal , negative cardiac enzymes. Urine toxin
screen was negative. CBC normal except for MCV 78 with normal iron
studies and normal RBC mass. HbA1c was 11.1%. EKG had old j-point
elevation laterally , otherwise NSR without LVH or LAE. Physical and neuro
exam normal. MRI/MRA and CTA were unremarkable in 1st admission 2 days
prior and so were not repeated. Patient was stable overnight and felt
great on Saturday 3/4/06 morning. No abnormal events were recorded on
telemetry overnight and after patient was walked around the floor.
Patient sugars were managed o/n with sliding scale insulin and diabetic
low-fat house diet , and blood sugar in morning responded down to 185.
.
Explanations for episodes considered were TIA of posterior circulation
vs. seizure , less likely atypical migraine or sleep disorder -- see admit
notes for discussion.
.
At time of discharge , patient was stable and feeling very good , eager to
leave for an afternoon function and preferred not to stay for further
workup. He will followup with Dr. Wohlford on Monday. He will be evaluated
this week with TTE with bubble-study to r/o intracardiac source or PFO.
Would also consider EEG if Neurology deems possibility of seizure. In the
meantime , added low-dose glyburide to metformin to manage hyperglycemia
at home , with more strips to monitor blood sugars 3-4x / day. Have also
increased aspirin dose from 81 mg to 325 mg every day Patient was also given
prescription for automatic BP cuff for monitoring at home.
ADDITIONAL COMMENTS: To better manage your blood sugars , added glyburide which you should take
once a day in addition to metformin twice a day. Continue to check your
blood sugars 3-4 times per day. You can also obtain an automatic BP cuff
for monitoring at home. If episode recurs , do not drive , check
sugars and BP , drink fluids , contact MD or return to ED as soon as
possible.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with Dr. Wohlford on February , that week should have TTE with bubble
study to evaluate heart , EEG to r/o seizure , titer hyperglycemia meds
No dictated summary
ENTERED BY: VEAZIE , OK E. , M.D. ( JY28 ) 7/12/06 @ 01:46 PM
****** END OF DISCHARGE ORDERS ******
Document id: 74
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
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- |
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- |
707826215 | PUO | 17768471 | | 9896602 | 6/11/2005 12:00:00 a.m. | k | | DIS | Admission Date: 6/11/2005 Report Status:
Discharge Date: 5/24/2005
****** FINAL DISCHARGE ORDERS ******
YAN , DERICK 728-74-26-8
Cuseine Laremomore Ch
Service: CAR
DISCHARGE PATIENT ON: 2/5/05 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRUNTZ , KATHERYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
PERSANTINE ( DIPYRIDAMOLE ) 25 MG orally every afternoon
LASIX ( FUROSEMIDE ) 10 MG orally every day
ISORDIL ( ISOSORBIDE DINITRATE ) 30 MG orally three times a day
HOLD IF: sbp<90
ATIVAN ( LORAZEPAM ) 3.5 MG orally every bedtime as needed Insomnia
Instructions: home dose
NITROGLYCERIN PASTE 2% 1 INCHES TP twice a day HOLD IF: sbp<90
Instructions: patient will instruct re:application
INDERAL ( PROPRANOLOL HCL ) 10 MG orally four times a day
HOLD IF: sbp<90 , heart rate<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NORVASC ( AMLODIPINE ) 2.5 MG orally every day HOLD IF: sbp<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ZETIA ( EZETIMIBE ) 10 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Katheryn Gruntz ( MMC cardiology ) ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
k
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn elev chol bph , history of turp x4 history of partial gastrectomy IMI '73 CAD
history of CABG x3 ( history of cardiac bypass graft surgery )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
adenosine MIBI
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain , palpitations
HPI: 83 year old male with ho CAD history of CABG in 2000 , prior MIs ,
hypercholesterolemia , pacer for SSS , now p/with one episode of
CP/palpitations @ airport after hassle with security/metal detector
before planned trip to Rawalk Van Side , anxious , diaphoretic ,
SSCP to left shoulder ( 10/8 ) , palpitations , resolved with one
nitroglycerine , pain free in ED. At baseline , experiences CP 2 times
per week , goes to cardiac rehab 3x/week , exertional capacity is
stable.
____________
ALL: unknown antibiotic allergy , avoids ASA 2/2 GI bleed
____________
MEDS:
persantine 25 mg every day
zetia 10mg orally every day
lasix 10-20mg orally every day
isordil 30 mg orally every day
norvasc 2.5 mg orally every day
ativan 3.5 mg orally every day
inderal 10mg orally every day
fibercon
nitropaste 1"
_____
PMH:
( 1 ) CAD history of CABG '74 , '83 , '00 , revised vein graft to PDA , most recent
cath 2001 ( `00% occlusion of LAD/LCx/RCA , patent SVG to PDA , patent SVG
to OM. Most recent ECHO 7/5 ). Stress PET 10/4 , mil dinferior ischemia
( 2 ) history of PCM , dual chamber/ICD in 2001 for SSS
( 3 ) UGIB in 2003
( 4 ) history of partial gastrectomy in remote past for GI bleed
( 5 ) CRI
( 6 ) history of turp
__________
SH: lives with wife , quit smoking in 1972 , no EtOH , immgrated from
Scond , hairdresser.
FH: noncontributory
__________
EXAM:
T 97 HR 65 BP 118/51 O2 95% RA
NAD , pleasant , conversant , a&o x 3
HEENT: EOMI , PERRL , MMM ,
NECK: prominent EJ , no JVD , carotid 2+ bilaterally
CHEST: CTA bilaterally
COR: s1 s2 no m/r/g RRR , occ. irreg beats
ABD: nt , nd , bs+ , surgical scars
EXT: no c/c/e , dp 2+ bilaterally
_________
LABS: CKMB 6.1 , trop <assay , Cr 1.6 ( stable )
CXR: cardiomegaly , PCM in place , history of CABG , no infiltrates or effusions
EKG: NSR with PVCs , first degree AV bloc , normal axis , subtle lateral
t-wave variability compared to 4/3 & 2/1 EKGs
_________
STUDIES:
Dobutamine PET: ( results pending )
_________
HOSPITAL COURSE:
Patient was admitted to rule out myocardial infarction and assess for
degree of ischemia; ruled out for MI with CKMB/troponin negative x 2 and
no significant EKG changes , dobutamine PET stress test showed no
worrisome lesions , patient was discharged to take rescheduled evening
flight to O with follow up with Dr. Kramper upon return.
ADDITIONAL COMMENTS: Your EKG and lab results do not indicate any sign of heart attack , it
appears that you chest pain represented normal anginal pain , and your
stress test/PET study was reassuring for no evidence of significant new
problems with your coronary arteries. As a result , we recommend that you
are medically clear to fly to A tonight.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
--continue outpatient regimen
--clear for flight to Bock Spro O , Colorado 78372 tonight
--follow up with Dr. Gruntz upon return
--if worsening of anginal symptoms , please report to ED in Soglend Sto
No dictated summary
ENTERED BY: DIVELBISS , LONNY O. , M.D. , PH.D. ( RE075 ) 2/5/05 @ 03:33 PM
****** END OF DISCHARGE ORDERS ******
Document id: 75
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
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- |
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- |
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906633106 | PUO | 87581765 | | 0807972 | 9/18/2004 12:00:00 a.m. | RIGHT FOOT ULCER | Signed | DIS | Admission Date: 10/5/2004 Report Status: Signed
Discharge Date: 7/11/2004
ATTENDING: ROSSIE KAYCEE MANKOSKI MD
SERVICE: Vascular Surgery Service.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female with a
complicated past medical history notable for CVA and peripheral
vascular disease with chronic nonhealing foot ulcers. Patient
was seen a week prior to her current admission in Vascular Clinic
for evaluation of nonhealing ulcers of the right foot and was
subsequently scheduled for a right lower extremity angiogram with
subsequent debridement planned shortly thereafter. Two days
prior to admission , however , the staff at her rehabilitation
facility noted increasing erythema in the area of her ulcer
associated with increased complaints of pain from the patient.
Patient was subsequently referred to A Salt Medical Center Emergency Department for further evaluation and
management on 10/5/2004 .
PAST MEDICAL HISTORY: Coronary artery disease status post stent
placement in 1995 , hypertension , hypercholesterolemia , peripheral
vascular disease , seizure disorder , hypothyroidism , systemic
lupus erythematous , anemia of chronic disease , history of stroke
with right-sided hemiparesis since 1996 , and associated high tone
and spasticity of the right lower extremity , history of subdural
hematoma secondary to a fall , migraines , chronic pain syndrome ,
narcotic dependency , interstitial lung disease secondary to
lupus , bipolar disorder , chronic constipation.
PAST SURGICAL HISTORY: Right CEA in 1999 , craniotomy for
subdural hematoma in 1999.
HOME MEDICATIONS: Premarin 0.65 mg every day , iron gluconate 300 mg
orally every day , folate 1 mg orally every day , multivitamin orally every day ,
Plaquenil 200 mg orally every day , Levoxyl
200 mcg orally every day , Toprol-XL 50 mg orally every day , lisinopril 10 mg
orally every day , nicotine patch 14 mcg topical , Celexa 40 mg orally
every day , macrobid 100 mg orally twice a day , sodium chloride tablets ,
hydralazine 10 mg orally three times a day , Ultram 25 mg orally every bedtime ,
Neurontin 100 mg orally every bedtime Dilantin 200 mg orally every day before noon , 100 mg
orally every afternoon , 200 orally every afternoon Lipitor
10 mg orally every day , Advair Diskus 500/50 1 puff twice a day , Colace 100
mg orally twice a day , Zyprexa 5 mg orally every bedtime as needed
ALLERGIES: Sulfa. Question of allergy to Levaquin.
Questionable history of adverse reactions to Prozac , trazodone ,
baclofen , and narcotics.
SOCIAL HISTORY: Patient previously lived with husband. Patient
has been wheelchair-dependent for the past four weeks due to her
chronic ulcers. Smokes 1-2 packs per day until approximately
four weeks prior to admission.
PHYSICAL EXAMINATION IN THE EMERGENCY DEPARTMENT: Afebrile.
Heart rate 66 , blood pressure 110/48 , breathing 18 , satting 98%
on room air. Patient was noted to be in moderate distress
secondary to discomfort of her right lower extremity with
associated spasm and foot pain. Patient's lungs were noted to be
clear to auscultation bilaterally. A well-healed right CEA scar
was noted on the patient's neck. Patient's heart was noted to
have a regular rate and rhythm with no murmurs , rubs or gallops.
Patient's abdomen was noted to be soft , nondistended and
nontender. Extremity exam demonstrated a right leg with severe
knee contracture and spasm. The left side was noted to be
normal. The left foot was noted to have two small clean ulcers ,
one on the medial bunion and one on the tip of the medial great
toe. The right foot was noted to have a large dark necrotic
pressure wound on the lateral aspect and plantar aspect of the
mid foot , an open infected-appearing ulcer was noted on the
medial forefoot with surrounding erythema and a greenish exudate
of film. Pulse exam demonstrated 2+ pulses in bilateral
carotids , radials , and femorals. Right popliteal biphasic
Doppler pulses noted. No pulses were able to be distinguished in
the right foot. The left foot was noted to have biphasic signals
in the DP and physical therapy by Doppler.
LABORATORY STUDIES UPON ADMISSION: Sodium 136 , potassium 4.8 ,
chloride 101 , bicarbonate 23 , BUN 21 , creatinine 1.1 , glucose 74.
ALT was 36 , AST 33 , alk phos 173 , total bili 0.3 , albumin 4.0.
White blood cell count was 9.6 , hematocrit 36.2 , and platelets
232. physical therapy 13.4 , PTT 28.1 , INR 1.0. Chest x-ray demonstrated a
mild interstitial disease with multiple old right rib fractures.
X-ray of the feet demonstrated bilateral osteopenia with no
evidence of osteomyelitis in either foot. EKG was noted to be
normal with a normal sinus rhythm at 63.
HOSPITAL COURSE: Patient was admitted to the Vascular Surgery
Service on 10/5/2004 for further evaluation and management. She
was empirically started on vancomycin and ceftazidime with
wet-to-dry dressings applied to her right foot wound. The
patient was also continued on her prior dose of Macrobid for
previously-diagnosed UTI with her antibiotic regimen to be
discontinued for this purpose on 9/8/2004 . An angiogram
performed on hospital day #2 , revealed a right external iliac
occlusion which was stented near the bifurcation of the internal
and external iliac vessels. A distal stenosis of the external
iliac was opened with balloon angioplasty to good effect. The
patient sustained a mild groin hematoma on the left at the access
site but had no change in her pulse exam there afterwards.
Following her angiogram and percutaneous intervention , the
patient was noted to demonstrate excellent right lower extremity
DP and physical therapy pulses which remained palpable through the duration of
her hospital course. On hospital day #3 , the patient was brought
to the operating room for debridement of her right foot. For a
detailed description of the patient's operative procedure , please
the relevant operative note. Patient tolerated the procedure
well and during the procedure , the patient's ulcer base was found
to be contiguous with the first metatarsal head periosteum , and
therefore , a metatarsal head excision was performed. The
patient's great toe was left in place with moderate debridement
of the deep tissues. The ulcers on the lateral right foot were
not debrided at this time. Following her procedure , the patient
was empirically continued on vancomycin and ceftazidime. Her
operative cultures subsequently grew out coagulase-negative staph
which was sensitive to both Keflex and vancomycin. At this
point , the patient was switched to vancomycin therapy only and
was continued on VAC therapy through postoperative day #3. At
this point , the patient's VAC dressing was changed to demonstrate
a well-vascularized actively bleeding wound with granulation
tissue and no signs of wound necrosis. The patient remained in
stable condition through postoperative day #7 at which point , she
was returned to the operating room for a great toe amputation and
definitive closure of her right foot wound. For a detailed
description of this operative procedure , please see the relevant
operative note. The patient tolerated the procedure well and was
subsequently returned to the Regular Outpatient Floor where she
remained for the duration of her stay. A general overview of the
patient's hospital course by system is as follows:
1. Neurological: The patient demonstrated significant issues
with pain control for the duration of her stay. A fair amount of
her pain was determined to be secondary to her right foot ulcer;
however , the patient was also noted to have significant pain
associated with her contracted right lower extremity. For a
time , the patient was placed in a right lower extremity extension
brace which provided some measure of relief; however , upon
regular examination of her right lower extremity , it was noted
that she was gradually developing pressure ulcers secondary to
the extension brace. A Neurology and Pain Service consultation
was obtained and the patient was subsequently recommended for
Zanaflex therapy which subsequently improved her pain control
dramatically. The patient otherwise remained intact from a
neurological perspective for the duration of her stay ,
demonstrating frequent emotional ability consistent with her
baseline examination.
2. Cardiovascular: The patient remained stable from a
cardiovascular perspective for the duration of her stay with no
evidence of acute hemodynamic instability or compromise. At no
point did she demonstrate evidence of acute myocardial ischemia
or infarction.
3. Pulmonary: The patient remained stable from a pulmonary
perspective for the duration of her stay with no evidence of
acute respiratory decompensation.
4. GI: The patient remained stable from a gastrointestinal
standpoint for the duration of her stay and was noted to be
tolerant of both solid and liquid orally intake. Upon discharge ,
she was noted to be tolerant of both solid and liquid orally intake
and was noted to be independently productive of adequate amounts
of stool and flatus.
5. GU: As described previously , the patient was admitted with a
known diagnosis of a urinary tract infection. She was continued
on Macrobid therapy through 9/8/2004 , at which point this
therapy was discontinued. Subsequent follow-up urinalyses
demonstrated no further evidence of urinary tract infection.
Upon completion of her Macrobid antibiotic course , the patient's
Foley catheter was removed and she was noted to be independently
productive of adequate amounts of urine for the duration of her
stay. She at no point demonstrated any evidence of acute renal
compromise or electrolyte imbalance.
6. Heme: The patient remained stable with a stable hematocrit
for the duration of her stay. She was started on Plavix therapy
following her angiogram , on which she remains at the time of her
discharge. DVT prophylaxis was provided via subcutaneous heparin
for the duration of her stay.
7. ID: As stated above , the patient's operative cultures were
noted to grow coag.-negative staph , sensitive to both vancomycin
and Keflex. For the majority of her stay , the patient remained
on vancomycin therapy but was transitioned to Keflex on
1/11/2004 , on which she remained for the duration of her stay.
At the time of discharge , the patient has been instructed to
complete an additional 10-day course of Keflex therapy. Of note ,
the patient remained afebrile with a stable white count for the
duration of her stay and her wound exam demonstrated no evidence
of further infection at the ulcer site.
8. Endocrine: The patient maintained adequately well-controlled
blood sugars for the duration of her stay with no evidence of
acute endocrinological compromise. The patient was subsequently
cleared for discharge to a rehabilitation facility on
postoperative days 10 and 3 , 7/11/2004 , with instructions for
follow up.
CONDITION ON DISCHARGE: Patient is to be discharged to a
rehabilitation facility with instructions for follow up.
STATUS AT DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Nonhealing right foot ulcer status post
debridement and closure with an angiogram and angioplasty. CVA ,
seizure disorder , depression , hypothyroidism , anemia of chronic
disease , SLE , interstitial lung disease , hypertension , migraines ,
subdural hematoma status post fall , hypercholesterolemia , status
post right CEA , craniotomy and coronary stenting.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed , aspirin
325 mg orally every day , Dulcolax 10 mg PR every day as needed , Colace 100 mg
orally twice a day , Epogen 40 , 000 units subcutaneously every week , iron 325 mg orally
twice a day , folate 1 mg orally every day , heparin 5000 units subcutaneously twice a day ,
Dilaudid 0.5-1 mg intravenous every 4 hours as needed for pain , Dilaudid 4-8 mg orally
every 3 hours as needed for pain , Plaquenil 200 mg orally every day , Levoxyl 200
mcg orally every day , lisinopril 10 mg orally every day , Ativan 1 mg orally
every bedtime as needed , milk of magnesia 30 ml orally every day as needed , Reglan
10 mg intravenous every 6 hours as needed , nicotine 10 mg per day topical patch
every 24 hours , Dilantin 200 mg orally three times a day , senna tablets 1-2 tablets
orally twice a day as needed , multivitamin 1 tab orally every day , Keflex 500 mg
orally four times a day x 40 doses , Toprol-XL 50 mg orally every day , Neurontin 300
mg orally every bedtime , Ultram
25 mg orally every 8 hours as needed , OxyContin 40 mg orally every 12 hours , Zyprexa 5
mg sublingual every bedtime , Plavix
75 mg orally every day , Celexa 40 mg orally every day , Zanflex 4 mg orally
three times a day , Advair Diskus 500/50 1 puff inhaled twice a day , DuoNeb 3/0.5
mg inhaled every 6 hours as needed , Maalox 1-2 tablets orally every 6 hours as needed for
upset stomach.
DISCHARGE INSTRUCTIONS:
1. Patient is to maintain her incision sites clean and dry at
all times.
2. The patient may shower but should pat dry her incisions
afterwards; no bathing or swimming until further notice.
3. No driving while taking prescription narcotic medications.
4. Patient may resume a regular diet.
5. Patient is to limit physical exercise; no heavy exertion.
6. Patient is to follow up with Dr. Pennie Loerwald within 7-10
days; the patient is to call to schedule an appointment.
eScription document: 3-3701532 LMSSten Tel
Dictated By: HALECHKO , STACIE
Attending: LOERWALD , PENNIE MICHEAL
Dictation ID 4949040
D: 11/11/04
T: 11/11/04
ATTENDING: ROSSIE KAYCEE MANKOSKI MD
SERVICE: Vascular Surgery Service.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female with a
complicated past medical history notable for CVA and peripheral
vascular disease with chronic nonhealing foot ulcers. Patient
was seen a week prior to her current admission in Vascular Clinic
for evaluation of nonhealing ulcers of the right foot and was
subsequently scheduled for a right lower extremity angiogram with
subsequent debridement planned shortly thereafter. Two days
prior to admission , however , the staff at her rehabilitation
facility noted increasing erythema in the area of her ulcer
associated with increased complaints of pain from the patient.
Patient was subsequently referred to the Pagham University Of Emergency Department for further evaluation and
management on 10/5/2004 .
PAST MEDICAL HISTORY: Coronary artery disease status post stent
placement in 1995 , hypertension , hypercholesterolemia , peripheral
vascular disease , seizure disorder , hypothyroidism , systemic
lupus erythematous , anemia of chronic disease , history of stroke
with right-sided hemiparesis since 1996 , and associated high tone
and spasticity of the right lower extremity , history of subdural
hematoma secondary to a fall , migraines , chronic pain syndrome ,
narcotic dependency , interstitial lung disease secondary to
lupus , bipolar disorder , chronic constipation.
PAST SURGICAL HISTORY: Right CEA in 1999 , craniotomy for
subdural hematoma in 1999.
HOME MEDICATIONS: Premarin 0.65 mg every day , iron gluconate 300 mg
orally every day , folate 1 mg orally every day , multivitamin orally every day ,
Plaquenil 200 mg orally every day , Levoxyl
200 mcg orally every day , Toprol-XL 50 mg orally every day , lisinopril 10 mg
orally every day , nicotine patch 14 mcg topical , Celexa 40 mg orally
every day , macrobid 100 mg orally twice a day , sodium chloride tablets ,
hydralazine 10 mg orally three times a day , Ultram 25 mg orally every bedtime ,
Neurontin 100 mg orally every bedtime Dilantin 200 mg orally every day before noon , 100 mg
orally every afternoon , 200 orally every afternoon Lipitor
10 mg orally every day , Advair Diskus 500/50 1 puff twice a day , Colace 100
mg orally twice a day , Zyprexa 5 mg orally every bedtime as needed
ALLERGIES: Sulfa. Question of allergy to Levaquin.
Questionable history of adverse reactions to Prozac , trazodone ,
baclofen , and narcotics.
SOCIAL HISTORY: Patient previously lived with husband. Patient
has been wheelchair-dependent for the past four weeks due to her
chronic ulcers. Smokes 1-2 packs per day until approximately
four weeks prior to admission.
PHYSICAL EXAMINATION IN THE EMERGENCY DEPARTMENT: Afebrile.
Heart rate 66 , blood pressure 110/48 , breathing 18 , satting 98%
on room air. Patient was noted to be in moderate distress
secondary to discomfort of her right lower extremity with
associated spasm and foot pain. Patient's lungs were noted to be
clear to auscultation bilaterally. A well-healed right CEA scar
was noted on the patient's neck. Patient's heart was noted to
have a regular rate and rhythm with no murmurs , rubs or gallops.
Patient's abdomen was noted to be soft , nondistended and
nontender. Extremity exam demonstrated a right leg with severe
knee contracture and spasm. The left side was noted to be
normal. The left foot was noted to have two small clean ulcers ,
one on the medial bunion and one on the tip of the medial great
toe. The right foot was noted to have a large dark necrotic
pressure wound on the lateral aspect and plantar aspect of the
mid foot , an open infected-appearing ulcer was noted on the
medial forefoot with surrounding erythema and a greenish exudate
of film. Pulse exam demonstrated 2+ pulses in bilateral
carotids , radials , and femorals. Right popliteal biphasic
Doppler pulses noted. No pulses were able to be distinguished in
the right foot. The left foot was noted to have biphasic signals
in the DP and physical therapy by Doppler.
LABORATORY STUDIES UPON ADMISSION: Sodium 136 , potassium 4.8 ,
chloride 101 , bicarbonate 23 , BUN 21 , creatinine 1.1 , glucose 74.
ALT was 36 , AST 33 , alk phos 173 , total bili 0.3 , albumin 4.0.
White blood cell count was 9.6 , hematocrit 36.2 , and platelets
232. physical therapy 13.4 , PTT 28.1 , INR 1.0. Chest x-ray demonstrated a
mild interstitial disease with multiple old right rib fractures.
X-ray of the feet demonstrated bilateral osteopenia with no
evidence of osteomyelitis in either foot. EKG was noted to be
normal with a normal sinus rhythm at 63.
HOSPITAL COURSE: Patient was admitted to the Vascular Surgery
Service on 10/5/2004 for further evaluation and management. She
was empirically started on vancomycin and ceftazidime with
wet-to-dry dressings applied to her right foot wound. The
patient was also continued on her prior dose of Macrobid for
previously-diagnosed UTI with her antibiotic regimen to be
discontinued for this purpose on 9/8/2004 . An angiogram
performed on hospital day #2 , revealed a right external iliac
occlusion which was stented near the bifurcation of the internal
and external iliac vessels. A distal stenosis of the external
iliac was opened with balloon angioplasty to good effect. The
patient sustained a mild groin hematoma on the left at the access
site but had no change in her pulse exam there afterwards.
Following her angiogram and percutaneous intervention , the
patient was noted to demonstrate excellent right lower extremity
DP and physical therapy pulses which remained palpable through the duration of
her hospital course. On hospital day #3 , the patient was brought
to the operating room for debridement of her right foot. For a
detailed description of the patient's operative procedure , please
the relevant operative note. Patient tolerated the procedure
well and during the procedure , the patient's ulcer base was found
to be contiguous with the first metatarsal head periosteum , and
therefore , a metatarsal head excision was performed. The
patient's great toe was left in place with moderate debridement
of the deep tissues. The ulcers on the lateral right foot were
not debrided at this time. Following her procedure , the patient
was empirically continued on vancomycin and ceftazidime. Her
operative cultures subsequently grew out coagulase-negative staph
which was sensitive to both Keflex and vancomycin. At this
point , the patient was switched to vancomycin therapy only and
was continued on VAC therapy through postoperative day #3. At
this point , the patient's VAC dressing was changed to demonstrate
a well-vascularized actively bleeding wound with granulation
tissue and no signs of wound necrosis. The patient remained in
stable condition through postoperative day #7 at which point , she
was returned to the operating room for a great toe amputation and
definitive closure of her right foot wound. For a detailed
description of this operative procedure , please see the relevant
operative note. The patient tolerated the procedure well and was
subsequently returned to the Regular Outpatient Floor where she
remained for the duration of her stay. A general overview of the
patient's hospital course by system is as follows:
1. Neurological: The patient demonstrated significant issues
with pain control for the duration of her stay. A fair amount of
her pain was determined to be secondary to her right foot ulcer;
however , the patient was also noted to have significant pain
associated with her contracted right lower extremity. For a
time , the patient was placed in a right lower extremity extension
brace which provided some measure of relief; however , upon
regular examination of her right lower extremity , it was noted
that she was gradually developing pressure ulcers secondary to
the extension brace. A Neurology and Pain Service consultation
was obtained and the patient was subsequently recommended for
Zanaflex therapy which subsequently improved her pain control
dramatically. The patient otherwise remained intact from a
neurological perspective for the duration of her stay ,
demonstrating frequent emotional ability consistent with her
baseline examination.
2. Cardiovascular: The patient remained stable from a
cardiovascular perspective for the duration of her stay with no
evidence of acute hemodynamic instability or compromise. At no
point did she demonstrate evidence of acute myocardial ischemia
or infarction.
3. Pulmonary: The patient remained stable from a pulmonary
perspective for the duration of her stay with no evidence of
acute respiratory decompensation.
4. GI: The patient remained stable from a gastrointestinal
standpoint for the duration of her stay and was noted to be
tolerant of both solid and liquid orally intake. Upon discharge ,
she was noted to be tolerant of both solid and liquid orally intake
and was noted to be independently productive of adequate amounts
of stool and flatus.
5. GU: As described previously , the patient was admitted with a
known diagnosis of a urinary tract infection. She was continued
on Macrobid therapy through 9/8/2004 , at which point this
therapy was discontinued. Subsequent follow-up urinalyses
demonstrated no further evidence of urinary tract infection.
Upon completion of her Macrobid antibiotic course , the patient's
Foley catheter was removed and she was noted to be independently
productive of adequate amounts of urine for the duration of her
stay. She at no point demonstrated any evidence of acute renal
compromise or electrolyte imbalance.
6. Heme: The patient remained stable with a stable hematocrit
for the duration of her stay. She was started on Plavix therapy
following her angiogram , on which she remains at the time of her
discharge. DVT prophylaxis was provided via subcutaneous heparin
for the duration of her stay.
7. ID: As stated above , the patient's operative cultures were
noted to grow coag.-negative staph , sensitive to both vancomycin
and Keflex. For the majority of her stay , the patient remained
on vancomycin therapy but was transitioned to Keflex on
1/11/2004 , on which she remained for the duration of her stay.
At the time of discharge , the patient has been instructed to
complete an additional 10-day course of Keflex therapy. Of note ,
the patient remained afebrile with a stable white count for the
duration of her stay and her wound exam demonstrated no evidence
of further infection at the ulcer site.
8. Endocrine: The patient maintained adequately well-controlled
blood sugars for the duration of her stay with no evidence of
acute endocrinological compromise. The patient was subsequently
cleared for discharge to a rehabilitation facility on
postoperative days 10 and 3 , 7/11/2004 , with instructions for
follow up.
CONDITION ON DISCHARGE: Patient is to be discharged to a
rehabilitation facility with instructions for follow up.
STATUS AT DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Nonhealing right foot ulcer status post
debridement and closure with an angiogram and angioplasty. CVA ,
seizure disorder , depression , hypothyroidism , anemia of chronic
disease , SLE , interstitial lung disease , hypertension , migraines ,
subdural hematoma status post fall , hypercholesterolemia , status
post right CEA , craniotomy and coronary stenting.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed , aspirin
325 mg orally every day , Dulcolax 10 mg PR every day as needed , Colace 100 mg
orally twice a day , Epogen 40 , 000 units subcutaneously every week , iron 325 mg orally
twice a day , folate 1 mg orally every day , heparin 5000 units subcutaneously twice a day ,
Dilaudid 0.5-1 mg intravenous every 4 hours as needed for pain , Dilaudid 4-8 mg orally
every 3 hours as needed for pain , Plaquenil 200 mg orally every day , Levoxyl 200
mcg orally every day , lisinopril 10 mg orally every day , Ativan 1 mg orally
every bedtime as needed , milk of magnesia 30 ml orally every day as needed , Reglan
10 mg intravenous every 6 hours as needed , nicotine 10 mg per day topical patch
every 24 hours , Dilantin 200 mg orally three times a day , senna tablets 1-2 tablets
orally twice a day as needed , multivitamin 1 tab orally every day , Keflex 500 mg
orally four times a day x 40 doses , Toprol-XL 50 mg orally every day , Neurontin 300
mg orally every bedtime , Ultram
25 mg orally every 8 hours as needed , OxyContin 40 mg orally every 12 hours , Zyprexa 5
mg sublingual every bedtime , Plavix
75 mg orally every day , Celexa 40 mg orally every day , Zanflex 4 mg orally
three times a day , Advair Diskus 500/50 1 puff inhaled twice a day , DuoNeb 3/0.5
mg inhaled every 6 hours as needed , Maalox 1-2 tablets orally every 6 hours as needed for
upset stomach.
DISCHARGE INSTRUCTIONS:
1. Patient is to maintain her incision sites clean and dry at
all times.
2. The patient may shower but should pat dry her incisions
afterwards; no bathing or swimming until further notice.
3. No driving while taking prescription narcotic medications.
4. Patient may resume a regular diet.
5. Patient is to limit physical exercise; no heavy exertion.
6. Patient is to follow up with Dr. Pennie Loerwald within 7-10
days; the patient is to call to schedule an appointment.
eScription document: 3-3701532 LMSSten Tel
Dictated By: HALECHKO , STACIE
Attending: LOERWALD , PENNIE MICHEAL
Dictation ID 4949040
D: 11/11/04
T: 11/11/04
Document id: 76
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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921778812 | PUO | 49448215 | | 6221735 | 1/20/2006 12:00:00 a.m. | history of UNWITNESSED FALL , R/O SYNCOPE | Unsigned | DIS | Admission Date: 7/1/2006 Report Status: Unsigned
Discharge Date: 2/2/2006
ATTENDING: HANSBERRY , SHAN M.D.
SERVICE:
MH team.
PRINCIPAL DIAGNOSIS FOR ADMISSION:
Status post fall and urinary tract infection.
LIST OF PROBLEMS DURING ADMISSION:
1. Dehydration.
2. Urinary tract infection.
3. Dementia.
4. Diabetes.
5. Demand MI.
HISTORY OF PRESENT ILLNESS:
This is an 83-year-old female with multiple medical problems most
notably for mitral stenosis status post a St. Jude's valve
repair , nonobstructive coronary artery disease , atrial
fibrillation status post pacemaker. The patient currently lives
at home alone and has had numerous recent admissions for
mechanical falls. The patient was admitted this time
11/20/06 after falling at home in the bathroom. The patient was
found by her grandson who called EMS. She was down for
approximately 24 hours. She denied any lightheadedness , chest
pain , shortness of breath. She does recall some frequent
urination for the past couple days and malaise , no fever or
chills. Family states that they are very concerned about the
patient's ability to take care of herself. However , the patient
insists she is independent and does not want to be placed in
rehabilitation or have 24-hour supervision at home.
PAST MEDICAL HISTORY:
Significant for mitral stenosis with St. Jude's mitral valve
repair , nonobstructive coronary artery disease , atrial
fibrillation status post pacemaker.
MEDICATIONS ON ADMISSION:
1. Norvasc 10 mg orally daily.
2. Coumadin 5 mg half a tablet Monday , Wednesday , Friday and
Sunday.
3. Amiodarone 100 mg daily.
4. Lasix 40 mg daily.
5. Glyburide 2.5 mg twice a day
6. Lisinopril 20 mg daily.
7. Isordil 20 mg twice a day
8. Zocor 20 mg nightly.
9. Ultram as needed
ALLERGIES:
The patient is allergic to aspirin and penicillin , both cause a
rash.
REVIEW OF SYSTEMS:
Positive for frequent urination and malaise , no other complaints.
PHYSICAL EXAMINATION ON ADMISSION:
Vital Signs: Temperature 98.7 , blood pressure 160/64 , heart rate
80 , respiratory rate 18 , O2 saturation 98% on room air. The
patient appeared in no apparent distress , awake , alert , and
oriented x3. HEENT: Bitemporal wasting , left eye with purulent
discharge. CVS: Normal S1 , S2 , irregularly irregular , mitral
valve click is audible. JVP is 5 cm. Lungs: Clear to
auscultation bilaterally. Extremities: Trace ankle edema
bilaterally. Neuro: Awake , alert and oriented x3 , no focal
deficits.
PERTINENT LABS ON ADMISSION:
Sodium 146 , creatinine 1.1. INR 2.1. Urinalysis revealed 2+
ketones , 3+ blood , 3+ protein , 15-25 hyaline casts , 25 white
blood cells and 2+ bacteria. Urine cultures and blood cultures
showed no growth. EKG was atrial fibrillation at a rate of with
occasional pacer spikes and old Q-waves in lead III and aVF and
an old right bundle-branch block. Chest x-ray was negative
except for cardiomegaly. CT of the head and neck was negative.
Left hip and pelvic plain films were negative for fractures.
PROCEDURES DURING ADMISSION:
The patient had an echocardiogram , which showed any EF of 60-65%
and moderate-to-severe left atrial enlargement and right atrial
elongation.
ASSESSMENT:
This is an 83-year-old female with a history of multiple falls
who presented after being found down for approximately 24 hours
in her bathroom in the setting of suspected urinary tract
infection and dehydration.
HOSPITAL COURSE BY PROBLEM:
1. Infectious disease: The patient was found to have a urinary
tract infection and was appropriately treated with Levaquin for
three days. After treatment , the patient remained afebrile with
no leukocytosis. Urine and blood cultures were negative , and a
repeat urinalysis was negative.
2. Cardiovascular: The patient had an echocardiogram done which
revealed an EF of 60-65% and moderate-to-severe left atrial
enlargement and right atrial elongation. The patient's mitral
valve was unremarkable. The patient's cardiac enzymes were
cycled , and she was found to have a troponin leak
secondary to demand. Troponin leak did resolve. Serial EKGs
were done , and there were no change when compared with the past
EKG. She was hypertensive on admission and she was continued on
her Lasix and lisinopril , which controlled her blood pressure.
Lasix has been held for the past couple of days due to
dehydration but may be resumed at discharge.
3. Endocrine: The patient was taken off of her orally
hyperglycemic meds while she was an inpatient and placed on
diabetic protocol of NPH 6 units twice a day and 3 units of Aspart
before every meal with the sliding scale. Her blood sugars were well
controlled.
4. Fluids , Electrolytes and Nutrition: The patient was
dehydrated on admission and given gentle intravenous fluids. Lasix was
held and should be restarted at discharge. However , at rehab , if
the patient appears to be dehydrated , her Lasix should be
stopped. The patient's sodium at discharge also went up from
142-146. Free water is encouraged at the bedside. The patient
had a swallow evaluation to assess for any aspiration. Swallow
evaluation recommended mechanical soft diet with thin liquids and
stated that the patient had no signs of aspiration.
5. Hematology: The patient has subtherapeutic INR that is now
being bridged with Lovenox. Her goal INR is 2.5-3.5 given her
St. Jude mitral valve. At discharge , INR is 1.4. The patient
should be continued on Lovenox 60 mg daily , which is renally
dosed as well as Coumadin 5 mg nightly until her INR is
therapeutic and then the Lovenox may be discontinued.
6. Psychiatry: On 8/19/06 , the patient became very agitated
and hostile attempting to exit the bed. The patient was given 1
mg of Haldol and required 4-point restraints. The patient had no
further episodes of this extreme agitation. She does , however ,
have Haldol 0.5 mg twice a day as needed for agitation. She was
placed on Zyprexa 2.5 mg nightly , which currently is controlling
her behavior. The patient was followed by Psych during this
admission. At first , the patient was refusing to go to rehab and
she was clearly not safe to go home. Psych did evaluate the
patient to see whether she was capable of making a decision , and
Psych did not feel that she had good judgment or insight into her
problems. Psychiatry felt the patient needed to go to rehab and
after convincing , the patient is now agreeable to go to
rehabilitation.
7. Disposition: The patient is medically stable and now is
going to the Abois Che Memorial Hospital for rehabilitation. The patient is to
fill out her healthcare proxy performed indicating that her son
and minister will be her healthcare proxy. Physical therapy and
occupational therapy has worked with this patient during the
hospitalization and both recommend rehabilitation prior to
returning home. The patient is a fall risk and needs to be
closely watched while she is being anticoagulated.
PHYSICAL EXAMINATION ON DISCHARGE:
The patient's vital signs are stable. She is awake and alert and
oriented x2-3. She does have some episodes of confusion , and her
speech is somewhat slurred at times. The respiratory exam is
unremarkable.
LABS AT DISCHARGE:
INR was 1.4.
DISCHARGE INSTRUCTIONS:
The patient is to continue Lovenox 60 mg subcutaneously daily and Coumadin
5 mg nightly. Lovenox may be discontinued when INR is 2.5-3.5.
The patient is to follow up with Dr. Aspacio on 10/7 at 2:15 p.m.
The patient's blood sugars should be monitored at rehabilitation
before meals and corrected with a NovoLog sliding scale , and the
patient should be encouraged to drink free water at the bedside
and her electrolytes should be monitored. The patient's Lasix
may be held if she appeared dehydrated.
DISCHARGE MEDICATIONS:
Amiodarone 100 mg orally daily , Norvasc 10 mg orally daily , Lovenox
60 mg subcutaneously daily , Lasix 20 mg orally daily , Micronase 2.5 mg orally
twice a day , Haldol 0.5 mg intravenous twice a day as needed , NovoLog sliding scale
before meals , Isordil 20 mg orally three times a day , lisinopril 20 mg orally
daily , Zyprexa 2.5 mg orally nightly , Zocor 20 mg orally nightly ,
Ultram 25 mg orally every 6 hours as needed , Coumadin 5 mg orally at bedtime
ADVANCE DIRECTIVES:
The patient is a full code. Health care proxy is her son ,
Anciso and her minister.
PRIMARY CARE PHYSICIAN:
Shalonda Aspacio , M.D.
eScription document: 5-2881402 EMSSten Tel
Dictated By: OSMERS , TESSA
Attending: HANSBERRY , SHAN
Dictation ID 5667076
D: 1/18/06
T: 1/18/06
Document id: 77
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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921778812 | PUO | 49448215 | | 151193 | 5/8/2001 12:00:00 a.m. | dehyrdation , bradycardia | | DIS | Admission Date: 6/4/2001 Report Status:
Discharge Date: 8/29/2001
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
Gene Ing
Service: MED
DISCHARGE PATIENT ON: 1/25/01 AT 07:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DICKHAUT , SIOBHAN CARY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
Override Notice: Override added on 6/11/01 by
PRINCE , DARLA V.
on order for COUMADIN orally ( ref # 93989599 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: outpt regimen
LOMOTIL ( DIPHENOXYLATE W/ATROPINE ) 1-2 TAB orally four times a day
as needed as needed diarrhea
MICRONASE ( GLYBURIDE ) 5 MG orally twice a day
Alert overridden: Override added on 6/11/01 by
PRINCE , DARLA V. POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: patient takes this medication as outpt
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: sbp<100
LISINOPRIL 20 MG orally every day HOLD IF: sbp<100
Override Notice: Override added on 1/25/01 by
PRINCE , DARLA V.
on order for KCL SLOW REL. orally ( ref # 40406964 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: k = 3.6
Previous override information:
Override added on 1/25/01 by PRINCE , DARLA V.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
66158137 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: potassium 3.6 in patient with CAD
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
COUMADIN ( WARFARIN SODIUM )
EVEN days: 5.0 MG every day; ODD days: 2.5 MG every day orally
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 6/11/01 by
PRINCE , DARLA V.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: outpt regimen
NORVASC ( AMLODIPINE ) 10 MG orally every day HOLD IF: sbp<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 1/25/01 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: patient has taken med in past without adverse
reactions
DIET: House / Low chol/low sat. fat
FOLLOW UP APPOINTMENT( S ):
Dr. Shalonda Aspacio next week ,
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
congestive heart failure , rule out MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
dehyrdation , bradycardia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CHF HX SYNCOPE ALL - ASA , PCN RA
history of St. Jude MVR for MS ( history of cardiac valve replacement ) Hx AFib/flutte
r ( history of atrial fibrillation ) history of IMI ( history of myocardial infarction ) NIDDM
( diabetes mellitus ) gout
( gout ) Hx DVT '70 ( history of deep venous thrombosis ) history of appy ( history of
appendectomy ) history of umbilical hernia repair ( history of hernia repair ) history of
sigmoidectomy for diverticulitis history of L hip # '95 ( history of hip
fracture ) Chronic diarrhea ( diarrhea )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
78 year-old F with history of CAD , AF , CHF , HTN , history of MVR p/with
progressive SOB , lightheadedness , and 1 episode of angina. Baseline =1
flight of stairs; over past several days patient has become dypneic at
rest. +PND last night. Ass'd dizziness and "weakness" -
felt unable to move around apartment. Awoke SOB this
a.m. - then had episode of L-sided chest pain ,
lasting 2-3 min , ass'd diaphoresis and nausea ,
terminating with NTG sublingual. patient denies F/C , URI sx , pedal
edema. Of note , patient had admission 10d ago for similar
sx , was found to be in CHF , improved with lasix
and ruled out for MI.
PHYSICAL: P 50 , BP 143/60 , R 18 , SatO2 96% 2L , 93% RA. No JVD , pedal
edema , crackles. Neuro exam nl. DATA: CR 1.8 ( baseline 1.5 ). EKG:
brady , 1st degree AVB , iRBBB , old IMI , no change from
prior. CXR: no edema , infiltrates. Cardiomegaly. CKs
74 , 47. TnI
0.02. A/P: DDx = CHF , arrhythmia , neurovasc compromise ,
RAS ( -> HTN -> flash pulm edema and fluctuating CR. ) No objective data
to suggest CHF is active no w.
CV: Ruled out for MI. Holter. Avoid betablockers. No lasix b/c patient
doesn't appear to be in CHF. Stress echo negative for ischemia , wall
motion abnormality
. Neuro: carotid/vertebral
noninvasives negative. patient had neg MRA in 10 of September .
Heme: anticoag with coumadin ( St Jude's valve ) goal INR
2.5-3.5 Renal: follow Cr , lytes. Gave 500 cc NS x2 over 24 heart rate because
Cr up to 1.9 from baseline 1.3-1.5.
a.m.. Dispo: social work consult to evaluate
patient's ability to cope at home , esp in light of 5
admits to hosptial in past 9 months.
ADDITIONAL COMMENTS: 1. Take your medication as directed. Do NOT take Lopressor; it has been
removed from your medical regimen for now.
2. See Dr. Aspacio for follow-up next week.
** VNA: please check vitals , weight , home safety every day. Call Dr. Aspacio if
patient's weight goes up or down by more than 1.5 pounds in 1 day.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KENDRICKS , ADDIE M. , M.D. ( IB70 ) 1/25/01 @ 06:11 PM
****** END OF DISCHARGE ORDERS ******
Document id: 78
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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279824973 | PUO | 72507103 | | 6351030 | 3/2/2007 12:00:00 a.m. | GI Bleeding | | DIS | Admission Date: 1/27/2007 Report Status:
Discharge Date: 1/10/2007
****** FINAL DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 281-36-81-4
Irvte Ster Irvronvillepoa
Service: MED
DISCHARGE PATIENT ON: 1/2/07 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE G. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. DULOXETINE orally every day
2. PANTOPRAZOLE 40 MG orally twice a day
MEDICATIONS ON DISCHARGE:
PROTONIX ( PANTOPRAZOLE ) 40 MG orally twice a day
CYMBALTA 60 MG DAILY
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please call the GI clinic ( 473-999-4367 ) to schedule a followup appointment. ,
Please call your primary care physician to schedule a followup appointment in 1-2 weeks. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
GI Bleeding
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
GI Bleeding
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of gastric bypass surgery ( Roux en Y ) , hypercholesterolemia , Depression
OPERATIONS AND PROCEDURES:
1. EGD ( 11/27/07 ): Dr. Oechsle , GI
2. Colonoscopy ( 4/3/07 ): Dr. Oechsle , GI
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Abd CT
BRIEF RESUME OF HOSPITAL COURSE:
CC: Melena , Lightheaded
HPI: 46F with history of obesity history of laparoscopic Roux-en-Y gastric bypass ( 15
mos prior ) and fibromyalgia p/with melena and LH. patient started on feldene
approx 6 wks prior 2/2 joint pain. Subsequently with epigastric
pain , which resolved after initiation of protonix. 1d PTA patient had
episode of melena followed by LH. On a.m. of adm had 2nd episode of
melena , followed by LH , SOB , palpitations. Found to have SBP in 80's
at work and sent to PUO ED
***************************************************
ED Course: HR 74 , BP 120/60 supine --> HR 99 , BP 129/68 standing ,
guiaic pos , HCT 24 , transfused 2u RBC , Nexium GGT , NPO. CT abd - history of
roux en y , o/with nl
***************************************************
PMH: Morbid obesity history of gastric bypass , osteoarthritis , fibromyalgia ,
Type1 VWD , migraines
***************************************************
ADMISSION MEDS: Feldene ( not taking ) , Protonix , Cymbalta
ALL: NKDA
***************************************************
ADMISSION EXAM: NAD , pale conjunctiva , jvp flat , rrr , abd benign ,
heme pos stool
***************************************************
ADMISSION LABS:
141 109 23
---+-----+---<159 4.6 >-------<203
3.7 27 0.7 24.2
*************************************************
STUDIES:
- Abd CT ( 11/27/07 ): intact anastamosis , history of roux en y , o/with normal
- EGD ( 11/27/07 ): nl GEJ with few shallow erosions. No e/o significant
esophagitis or ulcerations. intact anastamosis. no source of bleeding
- Colonoscopy ( 4/3/07 ): normal
*************************************************
CONSULTING SERVICES: GI , Dr. Oechsle , Dr. Rader
*************************************************
*************************************************
Assessment: 46F history of gastric bypass and recent NSAID use p/with melena ,
LH , rel hypotension , found to have HCT 24 ( baseline 36 )
Hospital Course: The patient was admitted for GI bleeding and anemia.
She was transfused to units of pRBC's in ED for HCT=24-->28-->31-->28.
The patient was initially started on a nexium intravenous drip and then was
restarted on orally PPI once EGD was performed and no source of bleeding
could be identified ( as above ). The patient also underwent colonoscopy
which was normal. The patient remained hemodynamically stable throughout
her hospital course and her symptoms of lightheadedness , palpitations and
shortness of breath fully resolved. No further episodes of melena
occured during her hospitalization. The patient was instructed to avoid
NSAIDs and to continue Protonix 40mg twice a day. The patient was instructed to
have her HCT rechecked at her primary care physician's office the following week and to call
the GI office for followup. Her iron studies ( fe 20 , TIBC 361 , Ferr 9 )
were consistent with iron deficiency and the patient was given an informational
sheet on good nutritional sources of iron for repletion.
CODE STATUS: FULL CONTACT:
ADDITIONAL COMMENTS: You were admitted for GI Bleeding and had an upper endoscopy and
colonoscopy to evaluate the source. Your upper endoscopy demonstrated
mild erosions in the esophagus , but did not identify a definite source of
bleeding. Your colonoscopy was normal.
- As the use of NSAIDs ( including Naproxen , Ibuprofen , feldene ) increases
the risk of GI Bleeding , you should no longer use these medications.
Tylenol is a safe alternative for pain control for you.
- You should have your hematocrit rechecked at your primary care
physician's office on Tuesday , November to ensure that your blood levels are
stable.
- Your iron stores are low because of your recent bleeding. I have given
you a handout listing good nutritional sources of iron.
- Please seek medical attention if the bleeding recurs or you develop
abdominal pain , lightheadedness , heart racing , shortness of breath or
fever.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- Please recheck patient's hematocrit on November to confirm stability.
- Please recheck patient's iron studies to determine whether they recover
appropriately with nutritional iron supplementation.
No dictated summary
ENTERED BY: KILLION , MARIELA K , M.D. ( NN807 ) 1/2/07 @ 05:24 PM
****** END OF DISCHARGE ORDERS ******
Document id: 79
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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619918055 | PUO | 80070487 | | 961124 | 9/2/1997 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 9/10/1997 Report Status: Signed
Discharge Date: 7/22/1997
HISTORY OF PRESENT ILLNESS: This is a 36 year old African-
American female with a history of
diabetes mellitus increased cholesterol who was in her usual state
of good health until two weeks prior to admission when she noted
shortness of breath , chest tightness and numbness in her left arm.
She went to the emergency room and ruled out for an myocardial
infarction in the ED OBS. She had an exercise tolerance test that
was negative with a peak heart rate of 150 and a peak blood
pressure of 142/76. She had no evidence of ischemia and was
discharged to home. The patient was well until the evening of
admission when she had lightheadedness , chest tightness and left
arm numbness once again. She was went to the emergency room and
received one sublingual nitroglycerin and after about an hour her symptoms
dissipated completely. The patient denies any fever , chills ,
nausea , vomiting , abdominal pain or numbness.
PAST MEDICAL HISTORY: Diabetes mellitus times four years.
No history of hypertension. High
cholesterol. History of a c-section. Status post cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: NPH 36 units every day before noon , 30 units every afternoon , regular 12
units every afternoon , Zocor 20 mg orally every day , allegra 60 mg
orally twice a day
SOCIAL HISTORY: The patient is a Pagham University Of
employee. She does not smoke , take drugs. She
uses occasional alcohol.
FAMILY HISTORY: An aunt who had a coronary artery bypass graft
at 65 and a father who had a coronary artery
bypass graft in his 70s.
PHYSICAL EXAMINATION: Temperature 99.2 , blood pressure 155/95 ,
heart rate 106 , O2 sat 97% on room air.
Neck was supple without jugular venous distention. Lungs were
clear to auscultation. Cardiovascular - Regular rate and rhythm
with no murmurs. Abdomen - Soft , nontender , nondistended. She has
no edema.
EKG - Normal sinus rhythm at 92 with a normal axis and intervals
and also without any acute ST or T-wave changes.
Her chest x-ray was negative.
Her blood sugar was 309 , WBC 11.47 , otherwise her labs are within
normal limits.
HOSPITAL COURSE: The patient ruled out by CPKs and no more
symptoms overnight and it was determined that the
patient could be discharged to home. She is to follow-up with Dr.
Marcelina Strauhal , her primary care practitioner as an outpatient.
Dictated By: LATORIA C. OGDEN , M.D. YB07
Attending: LATORIA C. OGDEN , M.D. QC33 AH291/1630
Batch: 6887 Index No. PZVU8Q970H D: 5/29/97
T: 5/29/97
CC: 1. MARCELINA STRAUHAL , M.D.
2. LATORIA C. OGDEN , M.D.
Document id: 80
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
Y |
N |
N |
N |
N |
N |
Y |
N |
N |
Y |
Y |
N |
N |
997044127 | PUO | 54837690 | | 014279 | 3/16/2001 12:00:00 a.m. | sob of unknown etiology | | DIS | Admission Date: 8/30/2001 Report Status:
Discharge Date: 2/29/2001
****** DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
York Cu Naheights
Service: MED
DISCHARGE PATIENT ON: 9/30/01 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SQUIERS , ZULA RAYE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
KLONOPIN ( CLONAZEPAM ) 1 MG orally three times a day
Override Notice: Override added on 11/11/01 by
GEKAS , CLEORA CIERRA , M.D.
on order for AZITHROMYCIN orally ( ref # 64177213 )
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & AZITHROMYCIN
Reason for override: monitor Previous override information:
Override added on 11/11/01 by GEKAS , CLEORA CIERRA , M.D.
on order for AZITHROMYCIN orally ( ref # 43541470 )
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & AZITHROMYCIN
Reason for override: monitor
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
ZESTRIL ( LISINOPRIL ) 10 MG orally every day
NIFEREX-150 150 MG orally twice a day
PERCOCET 1 TAB orally every 6 hours X 7 Days Starting Today ( 9/2 )
as needed pain
AZITHROMYCIN 250 MG orally every day X 4 Days Starting IN a.m. ( 9/2 )
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 11/11/01 by
GEKAS , CLEORA CIERRA , M.D.
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & AZITHROMYCIN
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & AZITHROMYCIN
Reason for override: monitor
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
PREDNISONE Taper orally
Give 60 mg every day X 2 day( s ) ( 9/13/01-09 ) , then ---done
Give 50 mg every day X 2 day( s ) ( 7/27/01-09 ) , then ---done
Give 40 mg every day X 2 day( s ) ( 4/26/01-09 ) , then ---done
Give 30 mg every day X 2 day( s ) ( 3/6/01-09 ) , then ---done
Give 20 mg every day X 2 day( s ) ( 2/7/01-09 ) , then ---done
Give 10 mg every day X 2 day( s ) ( 7/24/01-10 ) , then ---done
Give 5 mg every day X 2 day( s ) ( 5/9/01-10 ) , then ---done
DIET: House / Low chol/low sat. fat
RETURN TO WORK: After Appt with local physician
No Known Allergies
ADMIT DIAGNOSIS:
sob
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
sob of unknown etiology
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1
morbid obesity ( obesity ) obstructive sleep apnea ( sleep apnea )
psoriasis ( psoriasis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
37 year-old multiple admissions for atypical chest pain ,
morbid obesity , restrictive lung dz by PFTs , sleep apnea , borderline
HTN. Had cath last admission and showed clean coronaries. Now comes in
complaining of SOB and "asthma attack" and anxiety. Responded well to
Nebs and Ativan in ED. Will d/c to complete course of Macrolide antibio
tic to cover atypicals for tracheobronchitis at home.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GEKAS , CLEORA CIERRA , M.D. ( OI99 ) 9/30/01 @ 10:58 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 81
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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183239984 | PUO | 43563568 | | 405814 | 7/23/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 7/23/1991 Report Status: Unsigned
Discharge Date: 11/2/1991
DIAGNOSIS: 1 )CORONARY ARTERY DISEASE.
2 )ADULT ONSET DIABETES MELLITUS.
3 )STATUS POST CORONARY ARTERY BYPASS GRAFTING.
4 )HYPERTENSION.
5 )STATUS POST TOTAL ABDOMINAL HYSTERECTOMY AND
BILATERAL SALPINGO OOPHORECTOMY.
OPERATION: Reoperation coronary artery bypass grafting by Dr.
Brooke Lemmen on 11 of October .
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old black
woman who is status post coronary
artery bypass grafting approximately two years ago by Dr. Colasamte
who had developed recurrent substernal chest pain approximately
four months after her bypass surgery. The patient underwent
exercise treadmill testing which showed non-diagnostic ST segment
changes. However , thallium studies revealed decreased perfusion to
the apex , superior portion of the septum as well as the
anterolateral wall. There was reperfusion of the high septal and
anterolateral wall. The patient then proceeded to cardiac
catheterization which revealed 100% stenosis of her previous graft.
Additionally there was 100% mid stenosis of the right coronary
artery , 80% stenosis of the left anterior descending , 90% mid
stenosis of the first diagonal , and 100% stenosis of the circumflex
after the first obtuse marginal. There was anterior hypokinesis as
well as apical and inferior akinesis. There was severely decreased
left ventricular function. The pulmonary pressures were fairly
unremarkable. Thus , the patient presented for reop coronary artery
bypass grafting.
HOSPITAL COURSE: The patient was taken to the Operating Room on
11 of October . Under general endotracheal anesthesia
coronary artery bypass grafting times three was performed. The
right internal mammary artery was grafted to the first diagonal as
well as saphenous vein graft to the left anterior descending , the
old obtuse marginal graft , and the second diagonal. The patient
was found to have dense cardiac adhesions. Her old right coronary
artery graft was occluded and the old obtuse marginal graft was
tightly stenotic at the origin. The left internal mammary artery
was subtotally occluded distally. The patient spontaneously
defibrillated and demonstrated modestly decreased left ventricular
function. The patient was taken to the Cardiac Intensive Care Unit
in stable rhythm with stable vital signs. Postoperatively the
patient's course was thoroughly unremarkable. The patient required
sodium Nitroprusside in the immediate postoperative period. There
was no evidence of postoperative myocardial infarction. The
patient was successfully extubated on the second postoperative day
and her mediastinal and pleural tubes were also pulled without
significant incident. The patient's diuresis was initiated and
tolerated well. The rest of the patient's postoperative course was
unremarkable. She remained in normal sinus rhythm without any
evidence of arrhythmia. She was essentially afebrile and her
wounds were all healing well. However , on chest x-ray it was
demonstrated that the patient had right lower lobe collapse.
Because of her afebrile state and good oxygenation on room air the
patient was not bronch'd in order to re-expand her right lower
lobe. At the time of dictation , one day prior to proposed
discharge the patient's chest x-ray showed some improved aeration
of that lower lobe. Thus , the patient will likely be discharged on
18 of May .
DISPOSITION: DISCHARGE MEDICATIONS: Atenolol 50 mg orally every day , baby
aspirin one orally every day , Diabinese 500 mg orally every day , iron
sulfate 325 mg orally three times a day , Colace , Percocet. The patient will be
discharged to home. FOLLOW-UP: She will follow-up with Dr.
Brooke Lemmen in four to five weeks and with private medical
doctor and cardiologist in one to two weeks. The patient will also
have visiting nurse come in to check on her in the immediate
postoperative period.
DT729/6812
BROOKE D. LEMMEN , M.D. CL7 D: 7/2/91
Batch: 0585 Report: J6220F67 T: 4/19/91
Dictated By: SALVATORE REISLING , M.D. SZ97
Document id: 82
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
486531487 | PUO | 64700595 | | 152723 | 6/23/2001 12:00:00 a.m. | LEFT FOOT INFECTION | Signed | DIS | Admission Date: 10/5/2001 Report Status: Signed
Discharge Date: 10/15/2001
PRINCIPAL DIAGNOSIS: PERIPHERAL VASCULAR DISEASE , STATUS
POST DEBRIDEMENT LEFT FOOT
INFECTION.
HISTORY OF PRESENT ILLNESS: This is a 69 year old gentleman ,
status post previous right first toe
amputation in 16 of July and left first toe amputation on 4/24/01 and
10/13/01 who presented with fever to 101.7 , increased swelling in the
left foot and drainage and pain. He also reported nausea and
vomiting times three days.
PAST MEDICAL HISTORY: Significant for insulin dependent diabetes ,
coronary artery disease , status post CABG in
1975 , status post myocardial infarction , hypertension , high
cholesterol , status post right shoulder joint replacement and
status post bilateral hip replacements.
ALLERGIES: No known drug allergies.
MEDICATIONS: Tylenol 75 mg orally twice a day , Colace 100 mg orally twice a day ,
Lasix 40 mg orally every day , Heparin 5000 units subcutaneously
twice a day , Isordil 20 mg orally three times a day , Percocet , enteric coated aspirin
325 mg orally every day , Zocor 80 mg orally every day.
PHYSICAL EXAMINATION: Temperature was 99.6 , heart rate 100. He
was in no apparent distress. His carotids
were palpable without bruits. He was neurologically intact. He
had decreased sensation in his feet bilaterally. He was clear to
auscultation bilaterally. He had a regular rate and rhythm. His
abdomen was soft , non-tender and non-distended with good bowel
sounds. His pulses - he had bilateral palpable , femoral and
popliteal pulses. He had a palpable DP on the left and a palpable
physical therapy on the left. He had strongly palpable physical therapy on the right. He had
an x-ray of the left foot which showed possible osteo at the tip of
first metatarsal and at the base of the proximal 2nd toe.
LABORATORY EXAMINATION: Significant for sodium of 129 , potassium
3.3 , creatinine of 0.7 , white count of 13 ,
hematocrit of 31 , platelets 390. EKG showed sinus tachycardia.
HOSPITAL COURSE: The patient was admitted to the Vascular Surgical
Service and taken to the Operating Room for an
amputation of the left second and third toes by Dr. Derham . For
more details , please Dr. Gesualdi Operative dictation.
Postoperatively the patient was transferred to the regular floor.
He was started on intravenous antibiotics with dressing changes. He had
significant improvement with the appearance of his foot. He had a
vacuum sponge placed on 11/25/01 as well as debridement and
amputation of the 4th and 5th toes on his left foot. Following
this the patient continued to do well. He was continued on triple
antibiotics. He had minimal drainage from the vacuum sponge and it
was discontinued on 10/4/01 where he had further excision and
drainage and removal of the vacuum sponge. For more details of
this procedure please see Dr. Gesualdi Operative dictation.
Postoperatively from this , his wound edges are clean. The base of
his wound was granulating well. He was on triple antibiotics. He
was afebrile with stable vital signs. He was tolerating a regular
diet. His pain was well controlled on orally pain medications. He
was discharged to rehab on postoperative days 10 , 6 and 2.
DIET: ADA 2100.
ACTIVITY: Full weight bearing with heel touch on his left foot.
FOLLOW-UP: He is to follow-up with Dr. Derham in one to two
weeks.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Colace 100 mg orally twice a day , Lasix 40 mg orally
every day , Heparin 5000 units subcutaneously twice a day , CZI insulin sliding scale ,
Isordil 20 mg orally three times a day , Lopressor 75 mg orally four times a day , Percocet
one to two tablets orally every four hour as needed pain , Zocor 80 mg orally
every bedtime , Atrovent nebulizer 0.5 mg four times a day as needed wheezing , insulin
70/30 , 40 units subcutaneously every day before noon and 40 units subcutaneously every afternoon and
Augmentin 500/125 , one tablet orally three times a day
Dictated By: MOSHE SHUGRUE , M.D. MT443
Attending: ROSALINA DERHAM , M.D. ZM57 CH700/6612
Batch: 5535 Index No. B0HHJN1GWY D: 1/16/01
T: 1/16/01
Document id: 83
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
936708561 | PUO | 47812019 | | 2484250 | 9/27/2005 12:00:00 a.m. | 1 ) Angina , R/o MI. | | DIS | Admission Date: 6/26/2005 Report Status:
Discharge Date: 7/15/2005
****** FINAL DISCHARGE ORDERS ******
DUTSON , AMMIE S. 705-87-97-7
Ri A Kane
Service: CAR
DISCHARGE PATIENT ON: 10/18/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 8/25 )
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 60 MG orally twice a day
HYDRALAZINE HCL 90 MG orally three times a day Starting Today ( 1/3 )
HOLD IF: SBP <95 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LABETALOL HCL 600 MG orally three times a day HOLD IF: sbp<90 , heart rate<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
CLARITIN ( LORATADINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
COZAAR ( LOSARTAN ) 100 MG orally every day HOLD IF: SBP 95
Number of Doses Required ( approximate ): 3
METFORMIN 850 MG orally twice a day
VYTORIN 10/40 ( EZETIMIBE 10 MG - SIMVASTATIN ... )
1 TAB orally every day
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Dulcie Scovel 1 wk. ,
ALLERGY: Latex
ADMIT DIAGNOSIS:
1 )Atypical Chest Pain 2 ) HTN 3 ) NIDDM 4 ) Hypercholesterolemia 5 ) history of
Renal Cell Carcinoma history of resection.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
1 ) Angina , R/o MI.
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HYPERTENSION history of MVA -> RLE FRX ( 1977 ) history of RLE SKIN GRAFT
( 1977 ) MEDICAL NON-COMPLIANCE OBESITY ? HYPERCHOLESTEROLEMIA
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Adenosine MIBI: ( Preliminary report ) Poor quality study due to body
habitus. LVEF 44%. LV dilated. No perfusion defects.
BRIEF RESUME OF HOSPITAL COURSE:
CC:chest pain
HPI: 43 year-old M with hx of HTN , DM p/with atypical CP , concerning for unstable
angina. P/with 1 day history of L sided dull CP radiating to his L arm , started
5/10 . Started at rest , remained for 4 hrs. +Diaphoresis , +nausea ,
mild SOB. Cardiac RF include DM , HTN , Hyperchol , FH , history of smoking. TnI
at ASH neg - 0.04 and 0.05 but continued pain requiring NTG drip. EKG
with TWI concerning for anterolateral ischemia. Initiated
on Heparin , transferred to PUO for management , possible cath.
----------------------------------
PMH: CHF ( dxed 1997 while actively using cocaine ) , HTN ,
Hypercholesterolemia , Renal Cell Carcinoma history of resection.
------------
Status: ( at admission ) T100.5 P 82 R 18 BP 148/70 Pox 99% 2L. Gen:
Pleaseant obese M , NAD. CV: RRR , I/VI SEM LSB , +S3. Resp: CTAB , Ab:
soft , NT , mild distended. Ext: trace edema bilateral. Guaic , no stool
in vault.
---
Procedures/Tests: Labs: Trop SH 0.04 , 0.05 , K2.9 , Hct 35.5 , creat
2.0 EKG: NSR , LVH with repolarization , TWI II , III , F
V4-6. CXR: 9/16: Cardiomegaly , mild pul vasculature engorgement.
No acute pul infiltrate. Adenosine MIBI: 10/18 Poor quality study due to
body
habitus. EF 44%. LV dilated. No perfusion defects.
---
A/P: 43 M admitted with atypical chest pain. Concern for unstable
angina/NSTEMI.
1.
CV ISCHEMIA: significant cardiac hx with borderline TNI at BSH
( 0.04-0.05 ). Admitted to PUO , started on Heparin , ASA , BB
( labetalol ) , statin , ARB ( ANGIOEDEMA with ACE ) , NTG drip , O2. Remained
chest pain free overnight. On 9/10 , NTG drip tapered , hydralazine and
labetalol increased. patient underwent MIBI , notable for LV dilation , EF
44% , no perfusion defects. patient remained overnight to ensure adequate
BP with new medications. Will likely need continued titration of
antihypertensives.
PUMP: CHF: euvolemic; LVEF 44% via MIBI. BP control as above.
RENAL: CRI at baseline Cr of 2.0. Renal dose meds.
2. ENDO: Metformin held , NPH and Novolog SSI initiated for BS control. FS
before meals , excellent BS with range 110-150.
3. ID: low grade temps - UA negative , CXR negative. No signs of systemic
illness.
4. GI: history of hematochezia , no stool on DRE. Guiac stools x 3 as on Heparin.
5. FEN: SLIV. Replete electrolytes aggressively. Cardiac diet.
6. Resp: Stable. Supp O2 as needed
FULL CODE
CODE
ADDITIONAL COMMENTS: Call Dr. Borriello ( 789 ) 237 8732 upon discharge to schedule an appt within
1 wk. Bring this document to the appt. Comply with low chol , low fat , <2g
sodium diet. Weigh yourself daily , if you gain more than 2 lbs in 1 day or
5 lbs in a week contact your doctor as this is a symptom of CHF. Continue
your discharge medications as advised. Do not resume the Norvasc or
Enalapril until instructed to do so by Dr. Borriello . Seek medical attention
for worsening chest pain , shortness of breath marked weight gain.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) F/u with Dr Borriello within 1 wk for BP check. May need medication
titration including reinstitution of Norvasc. Consider further with u anemia
( IDA +/- AOCD ). patient has a history of hematochezia , unclear when prior
colonoscopy.
No dictated summary
ENTERED BY: BIRDETTE , KATHARYN Z. , M.D. , PH.D. ( BG51 ) 10/18/05 @ 11:38 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 84
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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364617096 | PUO | 93272592 | | 2478319 | 4/29/2005 12:00:00 a.m. | acute renal failure | | DIS | Admission Date: 9/4/2005 Report Status:
Discharge Date: 6/10/2005
****** DISCHARGE ORDERS ******
FINEMAN , BLAKE 740-86-75-4
Son Mfre Orlhis
Service: MED
DISCHARGE PATIENT ON: 10/17/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WARRAN , MARCOS , M.D.
CODE STATUS:
Full code No CPR / No defib / No intubation /
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours as needed Pain
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 6/14 )
Alert overridden: Override added on 11/9/05 by
POLO , MALINDA M. , M.D.
on order for ECASA orally ( ref # 76549672 )
patient has a PROBABLE allergy to SALSALATE; reaction is
Unknown.
patient has a PROBABLE allergy to CELECOXIB; reaction is
Unknown. Reason for override: tolerates
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HUMULIN N ( INSULIN NPH HUMAN ) 16 UNITS subcutaneously every bedtime
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain HOLD IF: sbp<90 and call ho
CARDIZEM CD ( DILTIAZEM CD ) 240 MG orally every day
HOLD IF: sbp<100 HR<60 and call ho
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 300 MG orally every day
HOLD IF: sbp<100 and call ho
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ATENOLOL 75 MG orally every day Starting Today ( 6/14 )
Alert overridden: Override added on 11/9/05 by :
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & ATENOLOL
Reason for override: home med
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 11/9/05 by :
on order for LASIX orally ( ref # 68153189 )
patient has a POSSIBLE allergy to CELECOXIB; reaction is
Unknown. Reason for override: home med
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
GLUCOPHAGE ( METFORMIN ) 500 MG orally three times a day
Starting Today ( 6/14 )
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
AVAPRO ( IRBESARTAN ) 300 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Follow up with primary care physician in 1-2 weeks ,
ALLERGY: Penicillins , ACE Inhibitor , Erythromycins , GABAPENTIN ,
TETANUS TOXOID , SALSALATE , CELECOXIB , AMIDE ANESTHETICS
ADMIT DIAGNOSIS:
acute renal failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
acute renal failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) obesity ( obesity ) NIDDM ( diabetes mellitus )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old female with obesity , OSA , HTN , NIDDM , CAD history of Lcx stent 2001 , history of
angioplasty and recent cath on 10/15 ( with
stangle angina and perfusion defect on PET scan in 4/9 in PDA
region ) showing no LM reegion , 40% prox LAD , no lcx , old
100% rca lesion - unable to be wired , sent home
with medical mgt ) who presents with RLQ pain. For
past 3 days had had increased RLG pain , R flank
and back pain , 1st with emesis and diarrhea , no f/v.
no melena , BRBPR , hematemesis. seen at NVH ED where abd CT showed mild
R hydro with 4mm stone at R UVJ. asked to strain urine and d/c with
vicodin. since then has not passed stone but continues
to have R flank pain. No more diarrhea , emesis.
Poor orally intake x 2 days. no orthopnea , PND , has b/l edema. no
dysuria , but has had difficulty maintaining urine stream. seen at MMC
on DOA where creat 2.4 ( bl 1.1 ) and sent to ED. En
route had fleeting L. sided CP , relieved with nitro.
ECG with pseudo-norm of
TWIs. PE: VSS , afebrile , blood pressure 150/40 to 138/60 pulse 76
to 56 , rr 18 , 94% RA , NAD , JVP diff to
assess , obese , RR SEM , + umb. hernia , reducible , + BS ,
+ LEE at bl , no CVAT TnI 1.26 , creat 2.4 , hct
34 , eos 0.4 cxr: ? effusion at l. cpa. b/l
atelect. ECG: nsr @64 , new TWI avl , ? upslop 1mmST in
III Abd Ct: stone in bladder with r. sided
stranding , right hydroureter but no
hydronephrosis
********************************************
71 year-old f with MMP history of cath with RLQ pain , renal failure and brief episode
CP. RENAL: hydrated with IVF @ 150cc/heart rate and
creat improved to 1.7 so hydration stopped given ?
history of some diastolic dysfxn. urine eos sent.
holding nephrotoxic meds ( atenolol , lasix ,
avapro , glucophage )
CV: ( i ) tni slightly elevated but 2nd down to 0.74 , likely demand
ischemia in setting of stress. Cont ASA , plavix , BB , NTG as needed , long
acting nitrate , fasting lipids sent. Holding ARB
until creat normalized. no indication for further
int ervention given likely demand and recent
cath with no intervention possible , would be
poor candidate for 1 vessel cath ( p ) ivf , nl LV fxn
on prior pet ( r )
NSR ENDO: humulin and RISS , holding orally meds
until ready for d/c home
GI: ppi for gerd , ADA low fat , low salt diet
PULM: OSA , on CPAP at home
Ppx: lovenox , nexium
ADDITIONAL COMMENTS: 1. Please call 933-683-0322 Monday am for appointment with your doctor.
2. If you develop chest pain , please take sublingual nitroglycerin as
instructed. If pain does not subside after 3 nitroglycerin , call your
doctor or go to the ER.
3. Please note that your atenolol has been increased to 75 mg. PLease
take one and a half tablets each day. Have your doctor check your blood
pressure and heart rate at next visit.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please use a strainer to check you urine for any stones. If you have
any stones , you can bring them to your primary care physician for analysis.
Continue to drink plenty of fluids.
Please follow up with your primary care physician in 1-2 weeks.
No dictated summary
ENTERED BY: MORDHORST , CAROL T. , M.D. ( VV02 ) 10/17/05 @ 03:13 PM
****** END OF DISCHARGE ORDERS ******
Document id: 85
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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245876836 | PUO | 99067599 | | 484261 | 5/10/2001 12:00:00 a.m. | Fe deficient anemia , CHF | | DIS | Admission Date: 9/7/2001 Report Status:
Discharge Date: 4/15/2001
****** DISCHARGE ORDERS ******
DEBNAR , LANITA 202-70-31-3
Fordlau
Service: MED
DISCHARGE PATIENT ON: 2/2/01 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
ALLOPURINOL 100 MG orally every day
VANCERIL ( BECLOMETHASONE DIPROPIONATE ) 40 MCG inhaled three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FESO4 ( FERROUS SULFATE ) 300 MG orally three times a day
PROZAC ( FLUOXETINE HCL ) 40 MG orally every day
Override Notice: Override added on 10/3/01 by
MATTIONE , DELMAR CHELSIE , M.D.
on order for LASIX intravenous ( ref # 92190548 )
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
FUROSEMIDE , INJ Reason for override: aware
REG INSULIN HUMAN ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously before every meal & HS Call HO If BS > 400
For BS < 200 give 0 Units reg subcutaneously
For BS from 201 to 250 give 4 Units reg subcutaneously
For BS from 251 to 300 give 6 Units reg subcutaneously
For BS from 301 to 350 give 8 Units reg subcutaneously
For BS from 351 to 400 give 10 Units reg subcutaneously
MECLIZINE ( MECLIZINE HCL ) 25 MG orally three times a day
Starting Today ( 5/30 ) as needed dizziness
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
Starting Today ( 5/30 ) HOLD IF: sbp<100 , HR<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 10/3/01 by
TRIGGS , BIBI L. , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: willm otniro
INSULIN 70/30 ( HUMAN ) 90 UNITS every day before noon; 45 UNITS every afternoon subcutaneously every day before noon
90 UNITS every day before noon 45 UNITS every afternoon Starting Today ( 5/30 )
Number of Doses Required ( approximate ): 6
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
TIAZAC ( DILTIAZEM EXTENDED RELEASE ) 360 MG orally every day
HOLD IF: sbp<100 , heart rate<50 Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/3/01 by TRIGGS , BIBI L D. , M.D.
on order for LOPRESSOR orally 50 MG three times a day ( ref # 04587631 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: willm otniro
Previous override information:
Override added on 10/3/01 by TRIGGS , BIBI L. , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE , INJ &
DILTIAZEM HCL Reason for override: will monitor
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
TORSEMIDE 100 MG orally twice a day
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 40 MG orally three times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
CARDIZEM CD ( DILTIAZEM CD ) 360 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/2/01 by :
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE , INJ &
DILTIAZEM HCL
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: aware
DIET: House / ADA 1800 cals/dy
FOLLOW UP APPOINTMENT( S ):
Dr. Seguin 10-14 DAYS ,
Dr. Katcsmorak 2-3 weeks ,
ALLERGY: Penicillins , Morphine , Codeine
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Fe deficient anemia , CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN DEPRESSION OBESITY TAH/BSO
Diastolic CHF ( EF 60 , LVH , 3+MR ) ( congestive heart failure ) atypical
angina ( neg dobutamine 4/4 ) ( angina ) insulin-resistant DM ( diabetes
mellitus ) GERD ( esophageal reflux ) gout
( gout ) CRI ( baseline Cr 1.4 ) ( chronic renal dysfunction )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
diuresis , tranfusion
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB times three weeks , acutely worse over the last two days.
HPI: 70 year-old lady with hisory off COPD on 2L home O2 , CHF ( diastolic ,
2-3+MR , EF 70% ) , CRI ( Cr 2.1-2.9 ) , T2DM , Fe Def Anemia , last two
admissions for decompensated CHF and anemia. patient describes increasing
SOB , decreased exercise tolerance , usually can walk 100+ feet while
leaning on shopping cart , but now SOB with less than 30 feet ,
increasing PND , patient has baseline three pillow orthopnea. She has not
gained weight by her records.
ROS: patient takes daily BS's have been 200-300 , patient takes daily pressures
have been in 140's. No F/Chills/Sweats/gustatory
indulgences/Dysuria/BRBPR/Melena. She has noticed her BM's to be dark
brown and hard since beginning iron supp.s. She has had several
episodes room spinning , beginning three days PTA , no
tinnitus/nausea/ha/ changes in vision or hearing. Sh also notes
numbness in her feet and has some unsteadiness of gait , without change ,
requiring a cane.
PMH: COPD , CHF , CRI , DM , FE def Anemia , per neuropathy.
PE: NAD , JVP>10 , NLS1S2 , 2/6 SM-->Axilla , +S4 , Lungs with crakles one
half way up from bases bilaterally. Abd obese NT , No R/M/G , Ext wa
rm , +2 edema bilaterally , brawny skin changes. Neuro cranial
nerves 2-12 intact , decreased vibration and sensation to light
touch , position sense preserved.
Labs: K 3.6 Cr 2.2 Hct 27 WBC 9 Plat 395 INR 1.2
Normal B12 and folate in 3/5 , with Fe 19 , TIBC 314 , Ferritin 31 and
Retics of 7.3. CXR: failure EKG:LVH , 1st dgree AV block , no STTW
changes.
Hospital Course: In ED patient received one PRBCs with HCT 27-->31 , she was
given 100 intravenous lasix and diuresed 2L. After diuresis of an additional one
liter O/N she reported that she was at her baseline respiratory fxn ,
sating 95% on 2L O2 , she was able to ambulate around the Ala St , Arv without
distress. Her lungs were clearer and her JVD was at 6 cm. Her dry
weight at this time was 256 lbs. Her BS's were elevated at 213 , 109 and
237 on an ADA 1800 diet with 85A and 40P 70/30. It was decided to
increase her 70/30 to 90 and 45. She was begun on meclizine as needed for
BPV. Her dc crit was 30.6. She was seen by Edwardo Mahar from GI who
suggested she be scheduled for an outpt small bowel followthru , becaus
e her prior EGD was negative and she already had the anemia at that
time. If this is negative she should see Dr. Simon at Tona Medical Center for a
capsular camera small bowel study.
ADDITIONAL COMMENTS: please weigh yourself each day and if your weight changes more than two
to three pounds over the course of two days call Dr. Mcgrotty office
and she can adjust your diuretics to remove the excess fluid. Also
please drink diabetic beverages and limit yourself to 8-10 glasses of
fluid per day. You will see the gastroenterologists as an outpatient
for an EGD to evaluate your blood loss.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MATTIONE , DELMAR CHELSIE , M.D. ( ZK97 ) 2/2/01 @ 03:51 PM
****** END OF DISCHARGE ORDERS ******
Document id: 86
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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436074946 | PUO | 08254313 | | 5698548 | 6/14/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/18/2005 Report Status: Signed
Discharge Date:
ATTENDING: GOLEBIOWSKI , LOIDA MD
PREOPERATIVE DIAGNOSES:
Severe mitral regurgitation , chronic atrial fibrillation.
PROCEDURE:
MVP 38-Cosgrove Edwards ring sliding valvuloplasty , left atrial
MAZE procedure , left atrial appendage resection.
BYPASS:
207 minutes.
CROSSCLAMP:
84 minutes.
Two atrial wires , one ventricular wire , one pericardial tube
standard , one retrosternal tube standard , one left pleural tube
standard.
HISTORY OF PRESENT ILLNESS:
A 65-year-old woman with a longstanding history of MVP now with
severe MR. She did develop atrial fibrillation about eight years
ago and has been on Coumadin and rate controlling medications.
More recently , she has noticed a gradual increase in DOE and
decreased exercise tolerance.
PREOPERATIVE CARDIAC STATUS:
Elective: The patient presented with a valve dysfunction. There
was a history of class III heart failure with marked limitation
of physical activity. The patient is in atrial fibrillation.
The patient has a history of atrial fibrillation and flutter
treated with a beta blocker , cardioversion.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST MEDICAL HISTORY:
Thyroid nodules with/nl function , osteopenia , rheumatic fever x2
in childhood.
PAST SURGICAL HISTORY:\.br&T\A in childhood , C sections x 2 , one general anesthesia and one
spinal.
FAMILY HISTORY:
Coronary artery disease. Mother with MI , brother has MR.
SOCIAL HISTORY:
History of alcohol use , one glass of wine , 4 or 5 times weekly ,
last drink 3/2/05 , married with two daughters , the patient is a
speech pathologist.
ALLERGIES:
Rhythmol rash on torso , ACEI cough , amiodarone visual , Zithromax
unknown , Toprol ankle edema , Tambocor double vision.
ADMISSION MEDICATIONS:
??Innopran XL 80 mg daily , Coumadin last dose less than 24 hours
3-4 mg daily , calcium , MVI , Bactrim twice a day since 10/30/05 for
finding off ??"Low density" Staphylococcus aureus in her nares ,
Fosamax once weekly.
PHYSICAL EXAMINATION:
Height and weight: 5 feet 4 inches , 55.9 kg. Vital signs:
Temperature 98 , heart rate 56 , blood pressure 90/60 , 88/60 ,
oxygen saturation 98%. HEENT: PERRLA. Dentition without
evidence of infection. No carotid bruits. Chest: No incisions.
Cardiovascular: Irregular rhythm. 1/6 systolic murmur of
varying intensity. Allen's test left upper extremity normal ,
right upper extremity normal. Respiratory: Breath sounds clear
bilaterally. Abdomen: Lower midline , soft , no masses. Rectal:
Deferred. Extremities: With scarring , varicosities or edema.
Neuro: Alert and oriented. No focal deficits. DTRs 2+.
PREOPERATIVE LABS:
Sodium 138 , potassium 4.4 , chloride 102 , CO2 28 , BUN 25 ,
creatinine 1.2 , glucose 74 , and magnesium 2. White blood cells
589 , hematocrit 38.4 , hemoglobin 12.8 , platelets 154 , 000 , and physical therapy
24.3 , INR 2.2 , and PTT 38.8.
CARDIAC CATHETERIZATION DATA:
6/10/04 performed at Totin Hospital And Clinic . Coronary anatomy ,
right dominant circulation , normal coronary arteries. Echo ,
11/27/05 , 60% ejection fraction , severe aortic insufficiency ,
severe mitral insufficiency , mild tricuspid insufficiency , left
atrium 63 mm , LVEDD 54 mm , bileaflet MVP , 3+ MR , normal VACP.
EKG 6/6/05 , atrial fibrillation at 60. Chest x-ray from
6/6/05 , normal.
ICU PROGRESS EVENT SUMMARY:
10/21/05 , POD1 , required aggressive electrolyte repletion
overnight , frequent PVC , rhythm abnormalities , blood pressure ,
urine output improved with replacing volume. 1/13/05 , POD2 , the
patient continued to have sinus brady requiring pacing , will
require EPS consult today. 7/18/05 , POD3 , the patient continued
to have sinus brady requiring pacing , EPS following. 7/7/05 ,
POD4 , the patient continued to have sinus brady requiring pacing ,
EPS following. 9/8/05 , POD5 atrial flutter with CHB , slow
ventricular escape. Remains pacer dependent , ??with
A-Flutter/CHB underneath Monday. 6/10/05 , POD6 , remains pacer
dependent with atrial flutter , CHB underneath. Plan to
discontinue CT and have PM placed on Monday tentatively. Apical
results 9/8/05 POD7 , right chest tube removed after clamp
trial , no increasing pneumothorax , PPM today.
Date of transfer 9/8/05 , POD7.
Neurologic: Mental status intact , alert and oriented.
Neurological exam: No focal deficit.
Cardiovascular MEDS: Aspirin , heparin drip 700 units per hour.
Respiratory: Extubated on 1/12/05 , room air , out of bed. Chest
x-ray finding: Moderate bilateral pulmonary congestion.
GI: Diet , house. Nexium 20 mg orally daily
Renal fluid: In: 1485 cc , 24 hour urine , out: 1830 mL , balance:
- 345.
Endocrine: Diabetes , NovoLog sliding scale.
Heme: Anticoagulation. Heparin , aspirin , the patient is
anticoagulated with heparin. Reason , MAZE procedure , mitral
valve repair , aspirin , goal INR , PTT , DVT prophylaxis.
ID: Prophylactic antibiotics. Reason for prophylaxis , chest
tubes.
MOST RECENT MEDICATIONS:
Enteric-coated aspirin 325 mg , heparin 700 units an hour , insulin
regular Humulin sliding scale discontinued , magnesium gluconate
sliding scale , orally( 0-rally ) , Kcl immediate release replacement
scale , Nexium 20 mg orally , NovoLog sliding scale before meals Sh
eScription document: 9-6492903 EMSSten Tel
Dictated By: VIARS , THEODORE
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 4272428
D: 9/8/05
T: 5/5/05
Document id: 87
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
N |
- |
N |
Y |
Y |
N |
- |
Y |
- |
N |
N |
662599763 | PUO | 22537055 | | 004658 | 3/15/2001 12:00:00 a.m. | CAD , CHF r/o MI , sm. area of inferolat rev. ischemia by adenosine MIBI , EF: 45% LV dilation | | DIS | Admission Date: 9/28/2001 Report Status:
Discharge Date: 2/7/2001
****** DISCHARGE ORDERS ******
KINSTLER , ALBINA 114-14-65-2
Vale Dalee Ersterson
Service: MED
DISCHARGE PATIENT ON: 10/1/01 AT 01:30 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
ZOCOR ( SIMVASTATIN ) 10 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
VIOXX ( ROFECOXIB ) 25 MG orally every day
Food/Drug Interaction Instruction Take with food
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
ATENOLOL 12.5 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 10/1/01 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: ok
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Annabel Dase 1 week ,
No Known Allergies
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD , CHF r/o MI , sm. area of inferolat rev. ischemia by adenosine MIBI , EF: 45% LV dilation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension hypercholesterolemia obesity lumbosacral disc degeneration
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
r/o MI--ruled out
adenosine MIBI part I stress--small amt. inferior/lateral defect seen.
Part II ( resting ) complete 3/7 Sm. amount of rev. ischemia
inferolateral wall , sum stress score: 4 ( 4-8 is mild abnormal test ). On
echo , there is wall motion abnormality in inferolat. area , LV is
dilated ( 120 ) and EF 43%.
BRIEF RESUME OF HOSPITAL COURSE:
53 year-old african american woman with HTN ,
hypercholesteroleia , morbid obesity presents with 1 month intermittent
chest pressure sometimes associated with sob , diaphoresis.
Pressure sensation became more frequent--once a day for
the past week , and now radiates to left arm. No n/v/f/c/orthopnea/doe.
At baseline , has short walking tolerance. Was late for kernan to dautedi university of of appt.
today-- was sent to ED for r/o. CK 79 , TnI 0.0 and
EKG with t wave inversions v5-6 , inverted P waves v1-2 of unclear
significance. patient ruled out for MI by enzymes , and had adenosine mibi
and echo. MIBI showed sm. amt. of inferolateral reversible ischemia ,
sum stress score 4 ( 4-8 mild abnl ) , and on echo , there is hypokinesis
of inferolateral wall. LV is dilated , EF 45%. Etiology of
cardiomyopathy will need to be followed up with cardiologist , and
because the area of reversible ischemia was so small , she will be
medically managed. patient started on ACEI , ASA , zocor , atenolol ( 12.5 mg
dose chosen b/c patient has had HR 64 and pressures in low 100's ) , zantac ,
NGSL as needed She will continue on HCTZ and vioxx usual meds.
patient was discharged home 2/16 after the test , and will follow up with
Dr. Dase , will need referral to cardiologist. Also suggest sleep study
given body habitus , snoring , and ?adequate oxygenation.
ADDITIONAL COMMENTS: You have had chest pain that was concerning for a heart attack. Your
blood lab tests show that you did not have a heart attack. Your stress
test was abnormal but can be treated by medications.
You should cont. your medications , and also take atenolol , lisinopril ,
zantac , zocor 10 mg once/day at night for your high cholesterol , lis in
addition to a baby aspirin ( 81 mg ) once a day. Call Dr. Dase to set up
a folllow up appointment within 1 wk , you may need to see a
cardiologist , and have a sleep study. Return if chest pain worsens.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: CASTELLAN , ETHAN MOZELL , M.D. ( WZ11 ) 10/1/01 @ 02:20 PM
****** END OF DISCHARGE ORDERS ******
Document id: 88
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
189350399 | PUO | 02584657 | | 738593 | 8/25/1998 12:00:00 a.m. | CEREBRO VASCULAR ACCIDENT | Signed | DIS | Admission Date: 4/10/1998 Report Status: Signed
Discharge Date: 1/19/1998
PRINCIPAL DIAGNOSIS: LEFT SUBCORTICAL STROKE.
PROBLEM LIST: 1 ) DIABETES MELLITUS. 2 ) MULTINODULAR GOITER.
3 ) HYPERTENSION. 4 ) ANEMIA , SICKLE CELL TRAIT.
5 ) STATUS POST TOTAL ABDOMINAL HYSTERECTOMY ,
CERVICAL DYSPLASIA. 6 ) BURSITIS AND MULTIPLE
SITES OF ARTHRITIS. 7 ) HISTORY OF PHYSICAL ABUSE.
8 ) VITILIGO. 9 ) HEMORRHOIDS.
HISTORY OF PRESENT ILLNESS: Approximately two days prior to
presentation , while preparing to
return to bed , the patient noted decrease feeling in her right leg
and right arm clumsiness. She returned to bed and remained there
all day long. She fell onto her bottom secondary to unsteadiness.
She has remained on the couch , except to get water since one day
prior to admission. She was unable to stand up on the day of
admission. This event was felt to be different from her usual
paralysis ( she had had similar symptoms of this before and had
waited for it to resolve ) , except that this event had lasted
greater than 24 hours and she also began to notice dysarthria. She
had not taken insulin for several days , but has had decreased orally
intake secondary to her inability to move. Of note , she had
difficulty swallowing on the morning of admission.
REVIEW OF SYSTEMS: She had no fevers , chills , vomiting or loss
of consciousness. No seizure activity. No
head or neck trauma. No vertigo or tenderness. No recent change
in medications. No chest pain or shortness of breath , no
photophobia or neck stiffness.
PAST MEDICAL HISTORY: History of diabetes mellitus , multinodular
goiter , hypertension , anemia and sickle cell
trait , status post total abdominal hysterectomy , history of
cervical dysplasia , bursitis and multiple musculoskeletal
complaints , just a history of physical abuse and vitiligo ,
hemorrhoids.
MEDICATIONS: Hydrochlorothiazide 12.5 milligrams once a day ,
Norvasc 5 milligrams once a day , Taxol 28 milligrams
once a day , Premarin 0.625 milligrams once a day , Trazodone ,
insulin 12 units of regular and 50 units of NPH in the morning and
14 units of regular and 10 units of NPH in the evening. She had
also been taking Ansaid 100 milligrams orally twice a day as needed joint
pain. She is also reportedly taking a baby aspirin 81 milligrams
once a day.
SOCIAL HISTORY: The patient is on disability. She lives alone as
a widow. No clear history of tobacco or ethanol
use. She has two children. She is independent with ADLs and
mobility.
FAMILY HISTORY: Familial intermittent paralytic syndrome.
PHYSICAL EXAMINATION: Temperature was 97.1 , heart rate 110 ,
respirations 20 , blood pressure 130/70 ,
oxygen saturation 100% on room air. Glucose is 388. Mental status
examination: The patient was alert and oriented times three
following three step command across the midline. No apraxia.
Positive dysarthria. Repetition intact. Memory 3/3 immediately
and 3/3 at 5 minutes. Cranial nerves: Pupils 3-2 bilaterally.
Right central facial paralysis. No pallor or droop. Decreased
sensation to light touch , pinprick and temperature on the right.
Tears well bilaterally. She cannot shrug her right shoulder.
Motor and tone flaccid on the right. Strength: Right hemiplegia
( can only wiggle toes ) , left strength 4-5/5 ( poor effort ). Deep
tendon reflexes are 2+ at the biceps , 1+ at the knees , 0-1 at the
ankle with an upgoing right toe. Sensation: Decreased sensation
to light touch , pinprick and vibration. Temperature on the right
including trunk. Gait not assessed. HEENT: Atraumatic. Neck
supple. Lungs clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm. Abdomen: Soft and nontender. Positive
bowel sounds. Extremities: No edema.
EKG: Sinus tachycardia at 104 per report when compared with EKG
of January , no significant change. Chest x-ray: No
evidence of active cardiopulmonary disease. CT scan of the head on
8/17/98 showed low density area present in the posterior limb of
the left intracapsular capsule consistent with an infarct.
Otherwise , no significant abnormality was seen. Mild age
appropriate involutional changes were present.
LABORATORY: Showed a glucose of 353 , sodium 138 , potassium 4.9 ,
chloride 98 , CO2 28 , BUN 33 , creatinine 1.1 , calcium
10.3 , magnesium 2.0 , troponin 0.09. White count 8.4 , hematocrit
39.8 , platelet count 367 , 000. physical therapy 12.1 , PTT 19.5. INR 1.0.
ASSESSMENT AND PLAN: Ms. Mina is a 57-year-old female with a
past medical history of hypertension ,
diabetes mellitus , multinodular goiter , arthritis and questionable
recurrent bouts of generalized weakness who was admitted for new
onset of right sided weakness ( three days prior to admission ) ,
right leg numbness and weakness , right arm clumsiness followed by
dysarthria.
HOSPITAL COURSE BY SYSTEMS:
1. NEUROLOGY: The patient was felt to have a probable subcortical
stroke of the left hemisphere with preservation of the speech
processing abilities with dense motor and sensory involvement.
This was felt to potentially represent an MCA branch occlusion with
increased edema versus a large lacuna. In addition , given her
history , the team was unable to rule out the possibility of an
embolic event. Therefore , the patient was admitted and ruled out
for a myocardial infarction. Her CKs were 25 , 37 , 37 and 32. She
was placed on a cardiac monitor with no evidence of arrhythmia.
she was placed on subcutaneously heparin and started on full dose aspirin
325 milligrams orally every day
In order to further work up the etiology for stroke , the patient
had an echocardiogram done which revealed evidence of concentric
LVH with preserved systolic function , calculated ejection fraction
of 55%. Other than nonspecific septal abnormality , there was no
evidence of regional wall motion dysfunction. There were early
changes of mitral annular calcification present , some increased
excursion of the mitral leaflet , but this is associated with only
trivial regurgitation. Trileaflet aortic valve without
dysfunction. One plus tricuspid regurgitation. Peak doppler flow
velocity across the tricuspid valve reached 2.5 meters per second
consistent with normal right heart systolic pressures. There was
no evidence of effusion. In addition , the patient underwent
carotid noninvasive studies which revealed no evidence of
hemodynamically significant disease in either carotid artery with
those arteries having minimal plaque and 1-25% stenosis. In
addition , the patient had an MRI/MRA to further evaluate potential
lesions. On MRI there was a focal area of increased T2 signal in
the posterior limb of the left internal capsule , close the genu.
This area demonstrated restricted diffusion on EPI diffusion ,
weighted sequence. A similar smaller area of signal abnormality
was noted in the left globus pallidus adjacent to the left internal
capsule abnormality. These areas represent subacute infarctions.
The ventricles and sulci were minimally prominent , consistent with
the patient's age. There was no other signal abnormality noted.
Major vascular flow voids were normal. There was no mass or mass
effect. Three D , TOF MRN angiogram on the circle of Willis and its
major tributaries did not demonstrate any abnormality. Incidental
note was made of a dominant right vertebral artery. The formal
impression revealed subacute infarcts involving the posterior limb
of the internal capsule on the left as well as the left globus
pallidus. Unremarkable MR angiogram on the circle of Willis.
In addition , given the patient's history of polymyalgias , an ESR
and C-reactive protein were obtained. The ESR was 46. The
C-reactive protein was 1.13. The stroke service was asked to
comment on the possibility of a vasculitic process. In addition ,
the patient's primary rheumatologist was consulted as well. The
patient's primary rheumatologist felt that the patient's stroke was
most likely due to small vessel disease associated with diabetes
and hypertension. He felt there was no evidence for a vasculitis.
He therefore suggested to continue aspirin , but in higher doses to
alleviate her left shoulder pain. The patient did not feel that
she had any vasculitic process. They therefore recommended
continuing aspirin 325 milligrams orally every day , checking a serum
homocystine which remains pending at the time of this dictation ,
reviewing her carotid studies ( mentioned above ) , and continue with
physical therapy occupational therapy and speech therapy.
physical therapy and OT were consulted as well as Speech Therapy.
In addition to continuing the patient on aspirin , continuing subcutaneously
heparin while the patient was immobile , the patient's
antihypertensives were held in order to maintain a systolic blood
pressure between 140-160 and a diastolic blood pressure between
85-90 for the first ten days following her stroke. For the first
few days , the patient was kept in a lying position as much as
possible and her activity level was gradually increased to the
point where she was participating in full physical therapy/OT. At the time of
this dictation , the patient's Norvasc continued to be held with
excellent control of her blood pressure between systolic of
140-160. It should not be reinitiated until roughly ten days after
her stroke.
The patient had relatively poor return of function during her
hospital stay , but was felt to be a good candidate for potential
rehabilitation. Therefore when her medical issues were stable , she
was considered ready for transfer to a rehabilitation facility in
an attempt to further improve her neurologic function. As noted
previously , the patient's antihypertensives should be reinitiated
gradually with a goal systolic blood pressure between 140-160 with
a diastolic blood pressure of 85-90 to be initiated roughly ten
days from the time of her stroke ( presented on 8/17/98 ). As noted
by the work up , the patient had no evidence of an embolic source
for her stroke and her carotid studies were unremarkable.
2. RHEUMATOLOGIC: As noted , the patient has a long history of
diffuse arthritic complaints. She had her sed rate and C-reactive
protein checked. Rheumatology was consulted who felt that her
stroke was not consistent with a vascular process. They did
recommend checking a urinalysis to check for red blood cells and
casts. Her urinalysis showed no protein , no blood , 0-2 red blood
cells , no casts. Only other recommendation was to continue aspirin
and consider higher doses to alleviate left shoulder pain. In
addition , recommended avoiding nonsteroidals while the patient was
on aspirin.
3. ENDOCRINE: The patient has a history of diabetes mellitus and
had not taken her insulin for several days prior to admission. The
patient was placed on her regular insulin schedule as well as a
sliding scale. The patient's blood sugar has ranged from the 150
to the high 200s. As the patient's diet returns to baseline , she
may require adjustments of her NPH and regular insulin doses. In
addition , the patient's Premarin was held during this admission and
further therapy should be decided by the patient's follow up
neurologist.
4. FLUIDS , ELECTROLYTES AND NUTRITION: The patient initially
appeared somewhat dehydrated on admission and was therefore
rehydrated with intravenous fluids. She had good resolution and returned to
baseline of her BUN and creatinine. She was eating well at the
time of discharge. Close observation was paid to her electrolytes
including her potassium. Her electrolytes should be periodically
monitored at least once a week at rehabilitation. She does have a
history of hyperkalemia and should be watched carefully for this.
5. SOCIAL WORK: The patient initially made a comment to the
Medical Team that she had been abused by her husband. The social
worker was consulted and asked to see her regarding this issue of
spouse abuse. It is true that her husband had hit her in the
forehead with a baseball bat in the past. He died several years
ago and no further abuse history could be elicited since his death.
She currently has two supportive children.
The patient was considered stable and ready for discharge to a
rehabilitation facility. When the date of her transfer is made
available , her discharge medications will be dictated along with
follow up.
Dictated By: MA YEAGLEY , M.D. DW15
Attending: CLEVELAND BENNINGFIELD , M.D. UG4 OB199/1000
Batch: 9080 Index No. MVHDR375B D: 10/5/98
T: 1/19/98
Document id: 89
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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696160396 | PUO | 17899982 | | 443053 | 9/19/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 6/22/1991 Report Status: Unsigned
Discharge Date: 11/3/1991
DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient was a 62 year old female
with a history of unstable angina , who
presented for coronary artery bypass grafting. She ruled out for a
myocardial infarction on 11 of August . She had a negative exercise
tolerance test on 29 of March . She then had persistent epigastric
pain with some ST changes on electrocardiogram on 12 of March . She
underwent cardiac catheterization demonstrating multivessel
disease. The patient had an echocardiogram showing mildly
decreased left ventricular function. She then had a positive
exercise tolerance test on 19 of September , and this was positive. She
was referred to the Cardiac Surgery Service for treatment of her
disease.
HOSPITAL COURSE: The patient was taken to the operating room on
30 of June , where she underwent a 2-vessel coronary
artery bypass graft. The patient tolerated the procedure quite
nicely and postoperatively was taken to the Cardiac Intensive Care
Unit for close follow-up. There she progressed quite nicely and
had no major difficulties. She was extubated on postoperative day
#2 without difficulty. She was diuresed appropriately and was
transferred to the postoperative cardiac floor. There , she
progressed in routine fashion. She had a small amount of drainage
from the left lower extremity incision at the vein harvest site ,
but otherwise had no difficulties. At that time of discharge , the
patient had a benign examination with stable , clean , dry and intact
sternum. She had clear lungs and a regular rate on cardiac
examination. Left lower extremity vein harvest site had no
evidence of infection. She did have a temperature to 100.1 on the
night prior to discharge. However , she had a negative white count
and urinalysis was negative. She had a negative chest x-ray ,
except for some mild atelectasis on the day prior to discharge.
She was to follow her temperature at home and report any
temperature greater 100.5.
DISPOSITION: The patient was discharged to home. She was to have
Visiting Nurse Association services. MEDICATIONS ON
DISCHARGE were Lopressor 25 milligrams by mouth twice a day ,
Ecotrin 325 milligrams by mouth each day , Zantac 150 milligrams by
mouth twice a day , Percocet 1 to 2 by mouth every 4 hours as
needed , Serax 15 milligrams by mouth at hour of sleep as needed.
UU184/8148
GENNY S. BARRETTE , M.D. ZD6 D: 2/20/91
Batch: 9493 Report: Y4199D69 T: 10/22/91
Dictated By: STACIE HALECHKO , M.D. ZI49
Document id: 90
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
244081005 | PUO | 47574158 | | 4968067 | 7/28/2004 12:00:00 a.m. | atrial fibrillation and ROMI | | DIS | Admission Date: 10/9/2004 Report Status:
Discharge Date: 8/8/2004
****** DISCHARGE ORDERS ******
NASLUND , MOLLIE J 181-57-19-6
Chinas
Service: CAR
DISCHARGE PATIENT ON: 2/11/04 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BACHMANN , LASHANDA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 3/18 )
ATENOLOL 50 MG orally every day
CHLORDIAZEPOXIDE HCL 10 MG orally three times a day
ENALAPRIL MALEATE 40 MG orally every day
Override Notice: Override added on 11/29/04 by
POLO , MALINDA M. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 37195652 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: will monitor
HYDROCHLOROTHIAZIDE 25 MG orally every day
HOLD IF: sbp<100 and call ho
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3
as needed Chest Pain , Other:throat pain
HOLD IF: sbp<100 and call ho
Instructions: take in sitting position
DILANTIN ( PHENYTOIN ) 200 MG orally twice a day
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after )
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 11/29/04 by
POLO , MALINDA M. , M.D.
on order for SIMVASTATIN orally ( ref # 66920478 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: will monitor
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
Alert overridden: Override added on 2/11/04 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: will monitor
RANITIDINE HCL 150 MG orally twice a day
GLYBURIDE 10 MG orally twice a day
METFORMIN 1 , 000 MG orally twice a day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every day
Instructions: get blood checked ( INR ) in 3 days for Dr.
Gruntz to adjust your dosing ( INR goal 2-3 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/11/04 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENYTOIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: will monitor
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Gruntz 3 days ,
Arrange INR to be drawn on 6/29/04 with f/u INR's to be drawn every
2 days. INR's will be followed by Sco Medical Center primary care physician
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
atrial fibrillation and ROMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atrial fibrillation and ROMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) HTN ( hypertension ) CHF ( congestive
heart failure ) DM ( diabetes
mellitus ) hypercholesterolemia ( elevated cholesterol ) PVD ( peripheral
vascular disease ) past smoking ( past
smoking ) past EtOH ( history of alcohol abuse ) seizures ( seizure )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
adenosine MIBI: Negative for ischemia
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old man with CAD history of 3vCABG/PCI , PAF , HTN ,
NIDDM , CHF ( EF 60% in 1999; diastolic dysfxn ) here with 1-2 wks of DOE
and throat tightness. Originally s/f stress test but found to be in
afib with RVR ( 120s ) before test. Taken to ED where
given intravenous lopressor , ASA , intravenous heparin with
improved symptoms after HR control to 90-100s.
PE: afebrile BP 135/72 HR 111--> 96 RR 20 SaO2 97% 2L; irreg irreg
rhythm no m/g/r , JVP 8 cm , CTAB , soft belly , no LE edema , neg neuro
exam Labs: Neg cardiac enzymes x 1 , Cr 0.9 , Hct
39.5 , WBC 9.37 , INR 1.0; EKG with new TWF I , V6 , TWI
L; CXR
neg. Course: CAD with PAF now with DOE and
throat tightness and re-conversion to afib.
1. CV: -ischemia: Doubted ACS but given signif CAD , needed to ROMI
--> resulted in 3 sets of neg cardiac enzymes. Adenosine MIBI
revealed no ischemia- c/with normal study. Continued on ASA but decreased
to 81mg only , statin , BB: but increased Atenolol to 50 mg from 25mg
every day , ACEI , intravenous heparin.
Held plavix , IIb/IIIa. - Rhythm: atrial fibrillation on admission but
converted to NSR after rate control with beta blockade. Echocardiogram
revealed no dramatic changes from prior studdy in 1999: EF 50-55% with
LA size in the upper limits , no LA thrombus; PASP 35 + RAP and isolated
HK in inferior septum ( similar to mild HK seen in mid-septum in 1999 ).
TSH was within normal limits and D-dimer was negative
suggesting against PE. Rate control was increased with increased
atenolol. patient refused lovenox shots and will be discharged on coumadin
for CVA prophylaxis. INR should be followed on 10/13 am by Lesum On- Community Hospital
at MMC . - Pump: euvolemic but hx of diastolic dyxfxn. Echo was not sign
ificantly altered from 1999 as noted above. No diuresis was necessary.
2. Pulm: suppl O2 and DOE was likely cardiac-related. Workup as above.
3. Renal: stable Cr
4. Neuro: Dilantin for sz d/o. Dilantin level was in therapeutic
range ( 10 ) on admit.
5. GI: Ranitidine for PUD
6. Psych: Chlordiazepoxide per home dosing
7. Dispo: patient will be discharged in stable condition. He should follow
up with Sco Medical Center for INR check on 10/13 days and coumadin
adjustment.
ADDITIONAL COMMENTS: please see Dr. Gruntz in 3 days to check your INR and to adjust your
coumadin dose accordingly.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Have INR checked on 10/13 am for coumadin adjustment by Sco Medical Center
clinic ( INR goal 2-3 ).
No dictated summary
ENTERED BY: SIRIANNI , FLORENCIO YASMIN , M.D. ( WP1 ) 2/11/04 @ 03:07 PM
****** END OF DISCHARGE ORDERS ******
Document id: 91
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
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133355198 | PUO | 89665513 | | 8267773 | 6/20/2006 12:00:00 a.m. | Musculoskeletal pain | | DIS | Admission Date: 1/30/2006 Report Status:
Discharge Date: 1/29/2006
****** FINAL DISCHARGE ORDERS ******
HISRICH , TAMMARA 482-85-96-2
Service: CAR
DISCHARGE PATIENT ON: 8/19/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MAINER , SHAVONNE D. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
AGGRENOX ( ASPIRIN + DIPYRIDAMOLE ) 1 CAPSULE orally twice a day
Override Notice: Override added on 2/12/06 by
VALERI , CLAIRE , M.D. , PH.D.
on order for WARFARIN SODIUM orally ( ref # 584940881 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: ok
Number of Doses Required ( approximate ): 10
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY
Override Notice: Override added on 2/12/06 by
VALERI , CLAIRE , M.D. , PH.D.
on order for WARFARIN SODIUM orally ( ref # 584940881 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: ok
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 2/12/06 by
VALERI , CLAIRE , M.D. , PH.D.
on order for WARFARIN SODIUM orally ( ref # 584940881 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: ok
CHOLESTYRAMINE RESIN DRIED SUGAR FREE 4 GM orally twice a day
DOXAZOSIN 4 MG orally DAILY HOLD IF: sbp <100
HYDROCHLOROTHIAZIDE 12.5MG + LOSARTAN 50 MG
1 TAB orally DAILY HOLD IF: sbp <100
Number of Doses Required ( approximate ): 5
ZESTRIL ( LISINOPRIL ) 30 MG orally DAILY HOLD IF: sbp < 100
LANTUS ( INSULIN GLARGINE ) 10 UNITS subcutaneously DAILY
GLYBURIDE 10 MG orally DAILY
ATENOLOL 50 MG orally DAILY
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
PUO Cardiology Clinic::Dr. Virgen Yueh at 1PM on 5/11/06 scheduled ,
Dr. Gamello within 1 week for follow up ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Musculoskeletal pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
dm ( diabetes mellitus ) htn ( hypertension ) hyperlipidemia
( hyperlipidemia ) gastric ulcer CAD history of RCA stent ( coronary artery
disease ) CRI ( chronic renal dysfunction ) bph ( benign prostatic
hypertrophy ) hearing loss ( hearing impairment )
OPERATIONS AND PROCEDURES:
none.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none.
BRIEF RESUME OF HOSPITAL COURSE:
cc: CP
*****************************
HPI: 75M with hx of DM , HTN , Hchol , recent CVA ( 4/06 ) , Afib ,
CRI , CAD/MI history of RCA stenting ( 2002 ) and poor cardiac f/up ( Dr.
Tolman ) p/with CP. States feeling ok when awoke this a.m.. Then had
fleeting substernal cp ( 30sec ) with out SOB , N/V/Radiation , not like
prior CP. Shortly after had another fleeting episode.
Concerned came to ED where was pain free. Given ASA X 1. Enzymes neg
X1 , EKG with bs line abnormality but unchanged. Per outpt cardiologist ,
preffered admission to KTDUOO team for R/O.
HOSPITAL COURSE: 1. )
CARDS: Admitted for R/O. While presentation not suspicious
for current cardiac event , given history of cardiac dz , mulitple risk
factors and atypical presentations assoc with dm , reasonable to R/O. Note ,
patient did have recent negative stress test at KAAH , though limited study.
In house , continued on ASA , BB , STATIN , ACE. His lipids were mildly
elevated with LDL 80s , though already on Lipitor 80 and cholestyramine.
HGA1c was pending at time of discharge but should be followed as
outpatient to ensure good DM control. Of note , patient had HR to the 40's
inhouse , though asymptomatic. He was maintained on lopressor while
observed and transitioned to his home dose of Atenolol 50qd which has
been a stable , asymptomatic dose. Given extremely low risk presentation
and r/o , patient was discharged following morning for outpatient follow up. If
a repeat imaging is performed , may reccomend for chemical stress study as
prior stress limited. Should note that EKG had evidence of significant
LVH and repol abnormality corroberated with recent echo. Would continue
to assess for possible hypertrophic cardiomyopathy along with familial
risk assessment as outpatient.
Patient also with hx of Parox Afib , now in sinus and recent stroke. His
rate was well cotnrolled in house on BB. On admission , INR was 3.2 and
warfarin dose reduced to 2mg ( from 4mg ). On following day , INR 3.4. patient
instructed to hold dose that evening and will follow in coumadin clinic
on 2/22/06 .
ADDITIONAL COMMENTS: 1. ) Continue medications as directed.
2. ) If fleeting episodes of pain recur , would not worry ( though notify
primary care physician/caridologist if severe , perisistant , or associated with shortness of
breath , prior heart attack symptoms. Can use motrin for occasional pains.
3. ) Follow up with Dr. Virgen Yueh in PUO cardiology clinic as scheduled.
4. ) Follow up with Dr. Gamello with in one week re: follow up on orally
infection.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. ) Titrate meds as outpatient.
2. ) Consider outpatient cardiac imaging ( last done 2005 at KAAH , but
limited study-- consider chemical stress )
3. ) Follow up re: Peri-orally lesions with Dr. Gamello .
4. ) Follow INR at Coumadin Clinic ( Note , Held on D/C and scheduled for
check 2/22/06
No dictated summary
ENTERED BY: VALERI , CLAIRE , M.D. , PH.D. ( VN94 ) 8/19/06 @ 12:12 PM
****** END OF DISCHARGE ORDERS ******
Document id: 92
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
- |
N |
- |
N |
N |
N |
N |
- |
Y |
N |
N |
N |
957523618 | PUO | 16241440 | | 453063 | 10/17/1997 12:00:00 a.m. | AVASCULAR NECROSIS RT. HIP | Signed | DIS | Admission Date: 6/16/1997 Report Status: Signed
Discharge Date: 6/1/1997
FINAL DIAGNOSIS: ( 1 ) OSTEONECROSIS OF RIGHT HIP
( 2 ) PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
PROCEDURE: RIGHT TOTAL HIP REPLACEMENT
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old female
who developed new onset of right sided
hip pain approximately four months ago. She is now severely
limited in her ambulation , as well as activities of daily living ,
secondary to her right hip pain. On radiographs she was
demonstrated to have osteonecrosis of the right hip. There is no
history of steroid or steroid boluses or alcohol use.
PAST MEDICAL HISTORY: Degenerative joint disease bilateral hands.
PAST SURGICAL HISTORY: Status post varicose vein stripping and
bilateral cataract surgery.
MEDICATIONS: Captopril 25 mg twice a day , Hydrochlorothiazide 50 mg
every day , Voltaren 75 mg twice a day , Cimetidine 300 mg orally
twice a day , Permatol 2.5 mg twice a day , and Levoxil 0.125 mg orally every day
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is an obese female with an
antalgic gait on the right. No
lymphadenopathy. HEENT: Benign. She has dentures. Lungs clear
to auscultation bilaterally. Heart: Regular rate and rhythm.
Infrequent ectopic beats. Abdomen: Soft , nontender , nondistended.
Extremities: The right lower extremity sensation and motor are
intact. She has a 30 degree straight leg raise , 90 degrees of
flexion , 10 degrees of internal rotation , 30 degrees of external
rotation , and 2+ dorsalis pedis pulse.
LABORATORY DATA: X-rays demonstrated collapse of the right femoral
head consistent with osteonecrosis on the right.
An old MRI scan also shows these osteonecrotic changes in the right
femoral head.
HOSPITAL COURSE: The patient was taken to the operating room on
10/16/97 . She underwent a right total hip
replacement. The details of this procedure can be seen in the
operative note. Postoperatively the patient was maintained on
Coumadin for deep venous thrombosis prophylaxis. She had a PCA for
pain control and this was quite adequate. She received one unit of
autologous blood for a postoperative hematocrit of 29 on
postoperative day #1. She did not require any further transfusions
and the last hematocrit prior to discharge was 35.4.
Postoperatively the patient developed numerous paroxysmal episodes
of supraventricular tachycardia. A medicine consult was obtained
and it was recommended that she be placed on Verapamil 80 mg three times a day
This appeared to work at first; however , it was unable to control
her tachycardia , particularly with any activity. The patient was
then placed on Lopressor 25 mg twice a day and the Verapamil was
discontinued. The patient did quite well with this and her
paroxysmal supraventricular tachycardia resolved. She was able to
progress with physical therapy without any episodes of increase in
heart rate. The patient was ruled out for a myocardial infarction
and her CK and MB remained negative. Her Hemovac was removed on
postoperative day #1. She had her wound inspected on postoperative
day #2 and thereafter her incision remained clean , dry , and intact
without any evidence of erythema or drainage. As mentioned
previously the patient was maintained on Coumadin for deep venous
thrombosis prophylaxis. She worked with physical therapy on a
daily basis and progressed well once her heart rate was under
control.
DISPOSITION: CONDITION ON DISCHARGE: The patient was tolerating a
regular diet. She was working daily with physical
therapy and progressing well. She had resolution of her paroxysmal
supraventricular tachycardia with heart rate down into the 80s and
90s on Lopressor 25 mg twice a day She had a stable hematocrit and
remained on Coumadin for deep venous thrombosis prophylaxis. Her
incision appeared clean , dry , and intact without any evidence of
infection. She had lower extremity non-invasive tests , as well as
a hip film prior to discharge. She had no evidence of deep venous
thrombosis on her lower extremity non-invasive tests. The patient
will be discharged to rehabilitation. FOLLOWUP: The patient will
follow-up with Dr. Lemmen in six weeks. She is to cal for an
appointment. She will remain on Coumadin for deep venous
thrombosis prophylaxis for a period of six weeks. She should
remain on her Lopressor 25 mg orally twice a day and , if room permits , her
Captopril can be discontinued and Lopressor used as her sole agent
for heart rate and blood pressure control. DISCHARGE MEDICATIONS:
Captopril 25 mg orally twice a day , Colace 100 mg orally twice a day ,
Hydrochlorothiazide 25 mg orally every day , Levoxil 100 mcg orally every day ,
Ativan 0.5 mg orally every 6 hours as needed , Lopressor 25 mg orally twice a day ,
multivitamin 1 orally every day , nitroglycerin sublingual as needed chest
pain , Percocet 1 to 2 orally every 4 hours as needed , Coumadin to be dosed daily
to keep physical therapy and INR in therapeutic range with INR of between 1.5 to
2. She should remain on Coumadin for a period of six weeks.
Cimetidine 300 mg orally twice a day
Dictated By: LOTTIE GUDIEL , M.D. BE6
Attending: BROOKE D. LEMMEN , M.D. OX65 NV975/3783
Batch: 1174 Index No. WUCU3347OE D: 5/5/97
T: 5/5/97
Document id: 93
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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- |
333208802 | PUO | 98278947 | | 6537132 | 4/29/2004 12:00:00 a.m. | ischemic cardiomyopathy | | DIS | Admission Date: 4/29/2004 Report Status:
Discharge Date: 3/1/2004
****** DISCHARGE ORDERS ******
MCCOOEY , CHRISTAL 842-76-53-8
Ty Rockbay T
Service: MED
DISCHARGE PATIENT ON: 6/26/05 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WARRAN , MARCOS , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally twice a day Starting Today ( 5/3 )
GLYBURIDE 10 MG orally twice a day
LEVOTHYROXINE SODIUM 75 MCG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain HOLD IF: sbp less than 100 mmHg
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
LIPITOR ( ATORVASTATIN ) 80 MG orally every bedtime
Starting Today ( 5/3 )
LASIX ( FUROSEMIDE ) 80 MG orally every day
GLUCOPHAGE ( METFORMIN ) 500 MG orally twice a day
BENICAR 20 MG orally every day
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Grap on February , 2005 at Wood Anark Memorial Health Health 575-803-4363 1:00p scheduled ,
Dr Bernas at Hoya Ascience Hospital Medical Center . You will be contacted with an appt in 2-3wks. 860-067-7792 ,
CHF program on Thurs November with Carmon Boshers at Hoya Ascience Hospital Medical Center 860-067-7792 2:30p scheduled ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
ischemic cardiomyopathy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
TYPE intravenous HYPERCHOLESTEROLEMI SMOKER FHX HTN history of CABG CAD
OPERATIONS AND PROCEDURES:
Cardiac catherization with stent for SVG to RPDA and LIMA to LAD
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
48 M admitted via ED with 2 weeks of dyspnoea on
exertion and 2 days of severe peripheral oedema. HCC
: 48 N with CAD history of CABG 1997 , Type II
DM , hypercholesterolaemia , hypertension , EtOH use
who presents with 2 weeks of progressive
SOBOE associated with 2-3 days of severe
peripheral oedema. Describes clear history of orthopnoea
and PND. Denies chest pain ,
palpitations , light-headedness , syncope , fevers , chills ,
weight loss , malaise or other systemic
upset. PMH : CAD , Diabetes , alcohol , CABG
1997 , hyperchol ,
htn. DH : ASA , atenolol 50 , benicar 20 , lipitor
20 , glyburide.
FH : Nil of note SH : Smokes 1ppd , EtoH 6
beers/day O/E : Mildly SOB , T 97.9 , BP 147/105 , HR 108 , RR
24 , Sats 99% on room air. Facial plethora & dusky hue. No jaundice ,
pallor , clubbing , lymphadenopathy. JVP -> earlobes. HS I + II +
S3 with gallop. Occasional bibasal coarse crackles.
Abdomen distended with shifting dullness & mild RUQ tenderness. 3+++
pitting oedema to knees bilaterally. Rash behind
calves. LABS : BNP 1900 , TnI -ve , Hct
52 CXR : New cardiomegaly. No pulmonary
oedema. ECG : Unchanged. TWI V4-V6. Nil
acutely ischaemic.
IMPRESSION : 1. New onset R > L dilated heart failure.
Most likely due to ischemic dz and occlusion of grafts from
previous cabg.
Hospital Course: CV: Upon admission , patient's cardiac enzymes were
cycled x 3 with a troponin bump on second set which resolved by 3rd
set. He r/o'd for hemochromatosis and multiple myeloma. W/u of patient's
new-onset chf included an echo which showed global hypokinesis with EF
20-25%. The patient then recieved cardiac catherization on 6/14 which was
remarkable for 1.elevated L heart filling pressures at 29mmHg and PA
sat fo 49% c/with Lheart failure; 2. LIMA to LAD patent , but 70-80%
stenosis at distal anastomotic site; 3. diminished baseline flow of SVG
to PDA history of stent. patient had transient ST elevation during cath , relieved
with ng. O/N patient had a couple episodes NSVT. Re-cathed on 5/29 as planned
after diuresis for stenting of LIMA to LAD. There was one episode of
NSVT one day following 2nd cath procedure. patient remained in
stable condition with steady improvement every day By d/c , patient's sob , orthopnea
and pnd had resolved. Jvp was wnl , hepatic congestion resolved , abd no
longer distended , LE swelling resolved. His dry d/c wt was 194.0 lb.
patient to f/u with CHF program in 1 wk , cardiologist in 2-3wks and EP service
in 6wks. patient needs f/u echo b/4 his EF appt in October
ENDO: patient's blood sugars were well controlled during
admission. Upon d/c , metformin was added to his home diabetic regimen.
FEN: patient had a nutrition consult to review 2g sodium/2L fluid
restriction diet
PSYCH: Seen by the addiction team. Had no signs/symptoms of etoh
withdrawal during admission. Declined antidepressants , nicotine patch
but agreed to counseling as outpt. patient encouraged to stop drinking and
to quit smoking.
CONDITION: stable
DISPO: home with close CHF program f/u.
ADDITIONAL COMMENTS: call md for chest pain , shortness of breath , temp over 100.4 or
anything concerning
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Echo in 4-6 wks before appt with Dr Grap on 2/16/05 .
No dictated summary
ENTERED BY: THRONEBURG , FLORETTA M. , M.D. , PH.D. ( IG392 ) 5/14/04 @ 11:34 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 94
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
Y |
Y |
Y |
N |
Y |
N |
Y |
N |
N |
Y |
N |
N |
N |
162833261 | PUO | 88950853 | | 7015889 | 2/17/2005 12:00:00 a.m. | GRAND POSITIVE BACTEREMIA | Signed | DIS | Admission Date: 2/23/2005 Report Status: Signed
Discharge Date: 1/22/2005
ATTENDING: POPOVIC , ALEXANDRA MD
DISPOSITION: Short-term rehab.
DISCHARGE DIAGNOSIS: MSSA bacteremia.
HISTORY OF PRESENT ILLNESS: This is an 87-year-old man with a
history of bioprosthetic aortic valve , status post PPM and ICD
placement , who is transferred from Norap Valley Hospital for workup
of bacteremia and concern for sepsis and endocarditis with early
evidence of multiorgan failure. He is 13 years' status post
bioprosthetic aortic valve replacement and also has a history of
afib with diastolic heart failure and a permanent pacemaker , on
Coumadin therapy. Ten days prior to admission to the P Therford Hospital ,
he had extraction of all his remaining teeth. Following that , he
had a gradual onset of malaise , shortness of breath , and general
weakness. He was admitted to Tson Community Hospital following a
fall to the ground where he was found to be febrile with
leukocytosis and there was a question of left lower lobe
infiltrate. Blood cultures at P Therford Hospital quickly returned positive
with Staphylococcus aureus. PE was performed , which was negative
for vegetation , but the patient's oxygen requirement increased
and his blood pressure seemed to be dropping , and thus he was
transferred to Petersram Medical Center for further workup and management.
PAST MEDICAL HISTORY: Afib , hypertension , diastolic dysfunction ,
echo in 1999 with moderate concentric LVH and EF of 65% , right
heart catheterization in 2000 showed elevated right heart filling
pressures and wedge pressure which increased with exercise ,
cardiac output of 4.4 , status post 27-mm bioprosthetic AVR and
ascending two grafts in 1992 , afib with diastolic heart failure ,
left bundle-branch block , permanent pacemaker , hypothyroidism ,
type II diabetes , obesity , distant cholecystectomy , AAA , status
post repair ( ? ) , thrombocytopenia , gout , prostate cancer , status
post hormone therapy , and diabetes mellitus.
MEDICATIONS: Medications on admission were lisinopril 5 every other day ,
allopurinol 100 twice a day , glyburide 6.25 every day , levothyroxine 100 ,
Zoloft 50 , Protonix 40 , Lasix 60 , and Coumadin 2.5.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his daughter who is very
supportive and his wife in Us Mont Na He is retired. No
history of tobacco or alcohol.
PHYSICAL EXAMINATION: On exam , the patient appeared ill. He was
slightly lethargic. Slightly uncomfortable. His oxygen was 96%
on 4 L of oxygen. Heart rate 70s. Blood pressure in the low
80s. Temperature 99.1. HEENT: Notable for slightly elevated
JVP. His lungs showed decreased breath sounds at the left and
right base with rales up to one-third on the right side. His PMI
was nondisplaced. He was in an irregular S1 , normal S2 with no
rubs or gallops. There was a 1/6 systolic murmur at the base.
JVP was approximately 15 cm. Pulses were 2+ and equal
bilaterally. No clubbing , cyanosis , or edema. He was oriented
to person , time , and generally to place , but not to date. His
remainder of neurological exam was grossly intact.
LABS ON ADMISSION: Notable for a potassium of 4.3 , BUN 36 ,
creatinine 2.5 , white count 8.1 , hematocrit 39.4 , CK and
troponins were negative , and INR 2.0. Chest x-ray on admission
showed a question of a left lower lobe infiltrate by report. It
also revealed a left pleural effusion with a question of
infiltrate and a right pleural effusion. EKG showed afib , left
axis deviation , and left bundle-branch block. Echo done at the
bedside shows an EF of approximately 45% to 50% without gross
regional wall motion abnormalities with some paradoxical motion
consistent with left bundle-branch block. There is no obvious
vegetation , but this was a limited study.
HOSPITAL COURSE AND PLAN PER SYSTEM:
Shortly after admission to the Cardiology Team , the patient
continued to have borderline blood pressures. His blood cultures
again grew out MSSA and his oxygen requirement increased and he
was transferred to the CCU for central monitoring and further
supportive care. In the CCU , he was continued on antibiotics.
Initially , the patient was on vancomycin for concern for MRSA.
When his cultures came back , he was switched over initially to
Ancef and gentamicin and then on consultation with ID to
nafcillin. The patient briefly required pressors , but then after
receiving intravenous fluids and continued antibiotics , his blood pressure
normalized to approximately 90 to 100.
Remainder of hospital course by system:
1. ID: The patient had repeated Gram-positive bacteremia with
MSSA up until the January , 2005 , after which time his daily
cultures have shown no growth to date. As above , the patient
will be maintained on nafcillin , gentamicin was discontinued , and
the patient was started in rifampin on 5/24/05 , both antibiotics
which he should continue for at least 4 to 6 weeks. Daily blood
cultures do not need to be resumed unless the patient has a
temperature at which point he should be cultured. He has been
afebrile for the last 3 to 4 days prior to discharge. We did not
do a TEE as the patient is likely not a surgical candidate and he
was felt to be at very high risk of intubation , should he become
septic again or spike temperatures this would be reconsidered.
In the interim , the patient should continue with antibiotics and
follow up with ID Clinic in approximately 3 to 4 weeks.
2. Cardiac:
Ischemia: The patient had a very small troponin leak of 0.15 on
March , 2005 , otherwise his troponins were negative. This was
likely demand ischemia in the setting of sepsis. After the
patient's blood pressure improved , we started him on a low-dose
beta-blocker , which he should continue. We held his ACE as his
blood pressure was generally about 90 to 100. If his blood
pressure improves slightly , we would recommend restarting the ACE
as an outpatient.
Pump: The patient has a history of diastolic heart failure and
an EF of 40%. He was slightly fluid overloaded after transfer
back from the CCU in the setting of getting fluids for sepsis.
He was diuresed intermittently very gently with intravenous Lasix at 20 ,
which seemed to improve the patient's shortness of breath and
wheezing , which correlated with the patient being more wet. He
was restarted on his own Lasix of 60 , for which he should
continue and also recommend having the patient receive daily
weight checks and to adjust Lasix in order to maintain daily
weight.
Rhythm: The patient is afib with left bundle-branch block
occasionally and RVR at Norap Valley Hospital , which seemed to
correlate with fevers. But , he had a normal rate while inhouse
especially while on beta-blocker. He has an AICD , which seemed
to be working fine inhouse as well as a pacemaker.
2. Pulmonary: The patient has maintained on 2 to 3 liters at
which he is saturating at 93% to a 100%. He will likely need
oxygen for a few more days as some of his remaining fluid is
taken off. Please check oxygen saturations daily and titrate off
oxygen as he is able to.
3. Renal: The patient is with chronic renal insufficiency ,
baseline of 1.7. His range in the hospital was 1.7 to 2.5.
Pheno was checked which was approximate 33% and he did not have
any urine Eos or caths to suggest allergic interstitial nephritis
or ATN. Please repeat a creatinine in one week to ensure that it
remains stable. I suspect that as some of his fluid is taken
off , his flow will be better and his creatinine will be slightly
improved.
4. Endo: The patient is with diabetes. He was initially on
Portland protocol while in the Intensive Care Unit. On the
floor , he was maintained on NPH and a Regular Insulin sliding
scale. He should continue on NPH and this should be titrated in
order to maximize blood sugar control , so he should continue on a
Regular Insulin sliding scale. Once the patient is ready for
discharge to home , he should be switched back to his orally
hypoglycemics.
5. Heme: We held the patient's Coumadin or anticoagulation as
it is contraindicated in the setting of endocarditis. Now that
his sepsis seems to resolve , the patient should be restarted on
his Coumadin in approximately 3 to 4 days after discharge with a
goal of an INR of 2 to 3.
6. Psyche: The patient remained generally oriented to person
and situation to hospital while inhouse , but occasionally slide
down especially in the setting of having fevers. He was
continued on his home Zoloft and we added a small dose of
Zyprexa , which seemed to also help. The patient benefits from
regular reorientation which we suggest continuing.
7. Prophylaxis: The patient is to receive heparin three times a day and
PPI for DVT and ulcer prophylaxis respectively.
8. Access: The patient now has a PIC line , which is in place
and can be used for intravenous antibiotics.
DISCHARGE DIET: His discharge diet is a 2-g sodium ADA 1800 to
2000 calories per day , low saturated fat , low cholesterol , and
mechanical soft.
DISCHARGE MEDICATIONS: His discharge medications are as follows;
Tylenol 650 mg orally every 6 hours as needed pain or temperature , aspirin 81
mg daily , Colace 100 twice a day , Lasix 60 orally daily , heparin 5000
units subcutaneous three times a day , NPH 16 units every afternoon , Regular insulin
sliding scale before meals and bedtime , Levoxyl 100 mcg daily , rifampin 300
mg orally twice a day , Zoloft 50 orally daily , Atrovent nebulizer 0.5 mg
nebs every 4 hours as needed wheezing , nafcillin 2 g intravenous every 4 hours , Zyprexa 2.5
mg orally nightly , miconazole 2% powder topical twice a day to rash ,
Advair Diskus 250/50 one puff inhaled twice a day , Duoneb every 6 hours
as needed wheezing , Protonix 40 mg daily , Toprol XL 25 mg orally
daily , and allopurinol 100 mg orally twice a day
TO DO: The patient should follow up with his cardiologist Dr.
Raabe and his primary care physician Dr. Gaylene Faniel once discharged from short-term
rehab. In addition , the patient should be seen by ID Clinic in
approximately 3 weeks to discuss remaining antibiotic therapy.
In addition , the patient should have a set of labs drawn in
approximately 5 to 7 days to recheck his creatinine. Please
check blood cultures if the patient has a temperature. Please
assess the NPH regimen as above. Please restart his Coumadin at
2.5 mg in 3 days with a goal INR of 2.3.
eScription document: 8-6577603 ISFocus transcriptionists
CC: Nerissa H. Robblee MD , PhD
Lakera
CC: Leola Musich M.D.
Cardiology Division , Stusri Medical Center
Gawalk
Dictated By: BERNAS , RUFUS
Attending: POPOVIC , ALEXANDRA
Dictation ID 9459300
D: 2/3/05
T: 2/3/05
Document id: 95
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881607711 | PUO | 89708958 | | 5663643 | 4/30/2005 12:00:00 a.m. | CHANGE IN MENTAL STATUS | Unsigned | DIS | Admission Date: 4/30/2005 Report Status: Unsigned
Discharge Date: 1/4/2005
ATTENDING: CHAIX , TRISH M.D.
ADMISSION DIAGNOSIS:
Change in mental status.
ASSOCIATED DIAGNOSIS:
Urinary tract infection , hypertension , diabetes , and coronary
artery disease.
HISTORY OF PRESENT ILLNESS:
This is an 83-year-old female with history of insulin-dependent
diabetes mellitus , hypertension , pulmonary carcinoid , and
coronary artery disease who presented with weakness and a change
in mental status. Her son found her at home on the floor. The
patient stated that she fell secondary to weakness. Her weakness
and change in mental status had lasted approximately one week.
She also complained of dysuria. No chest pain , no shortness of
breath , no nausea , vomiting , or diarrhea. At baseline , the
patient is alert and oriented x3. She lives alone and functions
independently. In the emergency room , a CAT scan of the head was
negative for acute process. Troponin was 0.2 , and therefore she
was started on intravenous heparin.
PHYSICAL EXAMINATION ON ADMISSION:
Temperature 97.1 , heart rate 78 , blood pressure 190/82 ,
respiratory rate 18 , and oxygen 99% on room air. General: The
patient was in no acute distress , alert , and oriented only x1 to
person. HEENT: NC/AT. Neck: Supple. Cardiovascular: Normal
S1 , S2. Regular rate and rhythm. No murmurs , rubs , or gallops.
Lungs were clear bilaterally. Abdomen was soft , nontender , and
nondistended , positive for bowel sounds. Extremities: No edema
or cyanosis: Neuro exam: Strength was equal bilaterally , but
weak 3/5 throughout. Sensation was intact throughout. Cranial
nerves III through XII were grossly intact.
LABORATORY DATA:
Labs on admission showed a white blood cell count of 12.3 ,
hematocrit was 36.4 , CK of 3499 , and troponin of 0.2. Her EKG
was normal sinus rhythm , new 1 mm ST depression in leads II , III ,
and aVF. Her chest x-ray showed right lower lobe mass , which was
unchanged from her previous x-ray. Her head CT was negative.
Urinalysis on admission showed too numerous to count white blood
cells , plus nitrates , and plus leukocyte esterase.
HOSPITAL COURSE:
This is an 83-year-old with diabetes mellitus , hypertension , and
medically managed twice a day who is admitted with change mental
status and fall secondary to weakness.
1. Infectious disease: The patient was found to have a UTI ,
which is likely the reason for confusion and weakness. She was
started on ciprofloxacin. Urine cultures were sent and grew
Klebsiella and Citrobacter , which were indeed sensitive to
ciprofloxacin and she was continued on the ciprofloxacin.
2. Cardiovascular: Ischemia. She had a troponin leak on
admission of 0.2. A B set of cardiac enzymes was negative for , the
troponin level was less than assay. The leak was most likely secondary to
demand ischemia in the setting of an infection. A C set of her cardiac enzymes
was negative as well. The heparin was therefore discontinued. The
patient does have a history of coronary artery disease , but is
not a candidate for catheterization per her primary care doctor's
notes. In-house , she was continued on aspirin , statin and a
beta-blocker , which was changed during her admission from
Lopressor to labetalol for alpha blocking activity as her blood
pressure remained high and blood pressure optimization was
attempted. Norvasc was also increased to 10 mg daily and
hydralazine was given as needed for blood pressure greater than 140 ,
for which she received a few doses. She was also continued on
lisinopril and Diovan and she was monitored on telemetry. The
only event on telemetry being a short run of SVT.
3. Neurologic: The patient's change in mental status was likely
related to urinary tract infection. The head CT on admission was
negative. Her neuro exam was not suggestive of any focal
deficits. Her Detrol was held during the admission due to its
effect on mental status. Her weakness was likely due to
deconditioning. She was very weak and had trouble sitting at the
edge of the bed or transferring to a chair with physical therapy.
She was seen by physical therapy who recommended rehabilitation
and 24-hour supervision. The family refused transfer to a
Skilled Nursing Facility despite the recommendation and they
understood the concern and risks. They reportedly planned to
supervise the patient on their own , 24 hours everyday.
4. Endocrine: The patient has diabetes mellitus , her blood
sugars were low on admission. Originally , her NPH dose was cut
in half. Her blood sugars were monitored and remained quite low.
Therefore , her evening NPH was halved again to 5 units at
bedtime. Her appetite remained fair during the admission , but not
great.
5. Prophylaxis: She received Lovenox for DVT prophylaxis.
CODE STATUS:
DNR/DNI was instituted after lengthy discussions with the
patient's family.
DISCHARGE INSTRUCTIONS:
1. See the primary care doctor within two weeks.
2. Discuss with your primary care physician when and if you should resume Detrol.
3. Return to the emergency room if you experience fevers ,
worsening confusion , chest pain , shortness of breath , nausea ,
vomiting , diarrhea , or other concerns.
DIET:
No restrictions.
ACTIVITY:
Bed to chair transfers with assistance and supervision and other
instructions per home physical therapy.
PRINCIPAL DISCHARGE DIAGNOSIS:
Urinary tract infection.
OTHER DIAGNOSES:
Hypertension , diabetes , coronary artery disease , hemorrhoids ,
depression , hyperparathyroidism , multinodular goiter.
LABORATORY DATA ON DISCHARGE:
Glucose 160 , BUN 12 , creatinine 0.9 , sodium 141 , potassium 4.1 ,
chloride 112 , CO2 23 , ALT 32 , AST 29 , ALK 68 , bili T 0.5.
Albumin 3.4 , calcium 10.6 , magnesium 2.0 , white blood cell count
6.9 , hematocrit 36.9 , hemoglobin 11.4 , platelets 233 , 000 , PTT
37.4 , and INR 1.1.
MICROBIOLOGY DATA:
Urine showed greater than 100 , 000 , 4+ Klebsiella pneumoniae , as
well as 4+ Citrobacter freundii.
RADIOGRAPHIC DATA:
A portable chest x-ray on 1/13/05 , showed a right middle lobe
mass , unchanged in comparison to the prior exam corresponding to
the patient's known carcinoid tumor , known pulmonary infiltrates
or pleural effusion. Head CT on 1/13/05 showed no acute
intracranial process and widespread degenerative disease of the
cervical spine. No evidence for fracture or dislocation. An EKG
on 2/29/05 had ventricular rate of 5 , a PR interval of 164 , QRS
duration of 78 , showed sinus bradycardia , left ventricular
hypertrophy with repolarization abnormality , ST and T-wave
abnormalities. When compared with EKG of 1/13/05 T-wave
abnormality of inferior lead placement.
MEDICATIONS UPON DISCHARGE:
Enteric-coated aspirin 81 mg daily , ciprofloxacin 500 mg orally
every 12 hours for three more days for a total of seven days , Colace 100
mg orally twice a day , insulin NPH human 10 units subcutaneously every day before noon ,
insulin NPH human 5 units subcutaneously at bedtime , labetalol
200 mg orally twice a day , lisinopril 40 mg orally daily , nitroglycerin
tablets as needed , Tucks topical PR daily , amlodipine 10 mg orally
daily , Fosamax 70 mg orally every week , Diovan 320 mg orally daily ,
Wellbutrin SR 150 mg orally twice a day , and Lipitor 40 mg daily.
eScription document: 5-7165173 EMSSten Tel
Dictated By: RUKA , BERNA
Attending: CHAIX , TRISH
Dictation ID 0107537
D: 2/27/05
T: 2/27/05
Document id: 96
| Target |
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DM |
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Gou |
HC |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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417565467 | PUO | 60288502 | | 795344 | 1/4/1997 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/14/1997 Report Status: Signed
Discharge Date: 3/20/1997
PRINCIPAL DIAGNOSIS: PNEUMONIA.
SIGNIFICANT PROBLEMS:
1. NON-INSULIN-DEPENDENT DIABETES MELLITUS.
2. CORONARY ARTERY DISEASE.
3. STATUS POST CORONARY ARTERY BYPASS GRAFT.
4. CHRONIC ATRIAL FIBRILLATION.
5. HYPERCHOLESTEROLEMIA.
6. CONGESTIVE HEART FAILURE.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old man with
a history of non-insulin-dependent
diabetes mellitus , coronary artery disease , status post three
vessel coronary artery bypass graft in 1993 , chronic atrial
fibrillation , and hypercholesterolemia , who presents with
complaints of recent flu-like symptoms times two days , including
right sided chest pain exacerbated by breathing and coughing , and
nonproductive cough with chills. The patient is followed by Dr.
Banos of the Ainam Iro Hospital , and by Dr. Schwerd of the
Potwood Kinlis Wellscajohns Health Center cardiology team. The patient recalls flu-like symptoms in
early April 1996 , but otherwise , was well until two days ago
when he noted the onset of right sided , sharp chest pain which was
well localized to the right chest , worse with breathing and chest
movement. The patient denied any similarity to previous anginal
pain , which he noted is more substernal in nature and has not
occurred in months. The patient was concerned that the pain was
cardiac and took two sublingual nitroglycerin without relief , and
therefore , presented to the Pagham University Of Emergency
Room. The patient denied any nausea , vomiting , diaphoresis ,
shortness of breath , abdominal pain , melena , constipation ,
diarrhea , and hemoptysis , at the time of admission. He notes
history of chronic venostasis disease in his lower extremities with
bilateral decreased sensation and episodes of neuropathy pain which
has not changed recently.
PAST MEDICAL HISTORY: Significant for: 1. Coronary artery disease
status post three vessel coronary artery
bypass graft in 1993. 2. Non-insulin-dependent diabetes mellitus
times 15 years. 3. Hypercholesterolemia. 4. History of chronic
atrial fibrillation. 5. Peripheral neuropathy in bilateral lower
extremities.
PAST SURGICAL HISTORY: Three vessel coronary artery bypass graft
in 1993 , left carotid endarterectomy in
1987.
SOCIAL HISTORY: No tobacco history , occasional alcohol use.
The patient is a part time practicing lawyer.
FAMILY HISTORY: Father died of coronary artery disease , no history
of diabetes mellitus or high blood pressure.
ADMISSION MEDICATIONS: Glipizide 5 mg orally every day before noon and 10 mg orally
every supper , Mevacor 20 mg orally every day before noon ,
Norvasc 5 mg orally every day before noon , Coumadin 5 mg orally every Sunday , Saturday ,
Tuesday , and Thursday , and 2.5 mg orally every Monday , Wednesday , and
Friday , Nitro-Dur patch 8.4 mg every day before noon off in p.m. , alprazolam up to
2 mg orally every day as needed , Lasix 20 mg orally as needed swelling , usually
one time per week , and Tylenol orally as needed
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: At the time of admission , vital signs
included a temperature to 101.4 , pulse 92 ,
respirations 28 , blood pressure 170/74 , and O2 saturation 89% on
room air with 94%-95% on two liters O2. HEENT examination revealed
moist mucous membranes without lesions. Pupils were equal , round ,
and reactive to light. Extraocular muscles were intact. Neck had
no LAD or JVD. Lungs had crackles present with egophony and E to A
change over the right low lateral lung field , otherwise , clear to
auscultation bilaterally. Heart had an irregular rhythm with a
regular rate. There was a II/VI systolic ejection murmur at the
right upper sternal border and left lower sternal border. There
was normal S1 and S2 , no S3 or S4. Abdomen was soft , nontender ,
and nondistended with positive bowel sounds. Extremities revealed
1+ bilateral pitting edema with bilateral changes of chronic
venostasis , 1+ pedal pulses on the left , but left foot slightly
cool to touch. There was no palpable pulse in the right lower
extremity , but good capillary refill and warm. Neurological
examination revealed cranial nerves II-XII were intact bilaterally.
Motor was intact bilaterally. Sensory was intact to light touch
with decrease in sensory to light touch bilateral lower
extremities. Deep tendon reflexes were 2+ bilaterally.
LABORATORY DATA: White blood cell count was 21.12 , hematocrit
38.8 , and platelets 191. INR was 2.1 , PTT 42.3.
Sodium was 136 , potassium 4.2 , chloride 98 , bicarbonate 25 , BUN 16 ,
creatinine 1.2 , and glucose 279. Admission EKG was significant for
atrial fibrillation at 76 beats per minute with evidence for cold
left bundle branch block. Chest x-ray was significant for right
middle lobe infiltrate consistent with pneumonia.
HOSPITAL COURSE: The patient was admitted to the floor for
administration of intravenous antibiotics. The
patient did well overnight. In the a.m. of 4/5/97 , the patient
had an episode of hypoxia with increased requirement for oxygen and
ultimately required 100% face mask for 93% O2 saturation. The
patient denied any anginal chest pain , nausea , vomiting , or
increased shortness of breath. A stat EKG revealed no changes.
Stat chest x-ray revealed bilateral pulmonary edema. This
responded well to intravenous Lasix. However , the patient continued to
require increased amounts of oxygen over the next two days wherein
he had further episodes of pulmonary edema requiring as needed intravenous
Lasix. During this time , blood cultures from the time of admission
grew out Pneumococcus times two which were sensitive to penicillin.
The patient's broad coverage antibiotics were then changed to intravenous
penicillin. An echocardiogram obtained on 4/5/97 revealed a high
normal left ventricular size with mild concentric hypertrophy ,
hypokinesis with inferior septum , and inferior posterior region ,
ejection fraction 45% , normal RV size and function , left atrial
enlargement , mild to moderate mitral regurgitation , and no aortic
stenosis or insufficiency. The patient was initiated on Captopril
which was then increased titrating with the patient's blood
pressure over his hospital stay. The patient , during his hospital
course , was also noted to have increased blood sugars to the 450
range. Therefore , he was started on a sliding scale insulin
regimen.
The patient improved with regards to his hypoxia and , on the
morning of 6/15/97 , he was breathing room air with an O2
saturation of 93%. His lung examination was significant for only
rare rhonchi on the right side. Chest x-ray of 3/4/97 revealed
improvement of his right lung pneumonia with persistence of
bilateral effusions consistent with his episodes of pulmonary
edema. Fingerstick glucose was 164 reflecting an overall
improvement and decreased need for sliding scale insulin. The
patient was felt to be well and ready for discharge.
DISCHARGE MEDICATIONS: Norvasc 5 mg orally every day before noon , Coumadin 2.5 mg
one orally every Monday , Wednesday , and Friday ,
and two orally every Sunday , Saturday , Tuesday , and Thursday , Nitro-Dur
patch 0.4 mg per day to be removed at night , Captopril 25 mg orally
three times a day , Lasix 40 mg orally every day before noon , penicillin-V 500 mg orally four times a day
times seven more days , Mevacor 20 mg one orally every afternoon , and glipizide
5 mg one orally every day before noon and two orally every afternoon
DISPOSITION: The patient is to be discharged. He will be staying
with family and is to follow up with the Potwood Kinlis Wellscajohns Health Center
cardiology team in 10 days. He is also to follow up with his
En Lesgaleson Graceton-nier County Hospital doctor within three weeks. The patient is not
expected to have any disability and should recover well. He has
been instructed to call should he develop a high fever , further
chest pain , or shortness of breath.
Dictated By: DESIRAE R. KRISHNA MARCOTT , M.D. RT35
Attending: CHRISTINE DARIO , M.D. RZ02 JM517/2189
Batch: 73269 Index No. W2JD8B3JD4 D: 6/15/97
T: 4/9/97
CC: 1. CHRISTINE DARIO , M.D. AW87
2. DR. LATTUS BROOK MEPA COMMUNITY HOSPITAL
Document id: 97
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986414438 | PUO | 61460962 | | 8148399 | 10/20/2005 12:00:00 a.m. | INTRA ABDOMINAL ABSCESS | Signed | DIS | Admission Date: 8/8/2005 Report Status: Signed
Discharge Date: 5/29/2005
ATTENDING: MILAGROS MIRIELLO MD
ATTENDING PHYSICIAN:
Verda Triarsi , M.D.
ADMITTING DIAGNOSIS:
Intraabdominal abscess.
HISTORY OF PRESENT ILLNESS:
The patient is a 77-year-old female with history of hypertension
and perforated sigmoid diverticulitis status post a partial
colectomy at the splenic flexure and Hartmann pouch on 2/28/05 ,
who presented at an outside hospital with chills and fevers of
temperature of 103 degrees Fahrenheit , as well as shortness of
breath and hypotension. The patient was transferred to the
Pagham University Of for further care. She denied
nausea , vomiting , and had only mild abdominal pain and abdominal
distension noted per the patient. However , her fevers and chills
continued.
PAST MEDICAL HISTORY:
Hypertension , chronic back pain , and nephrolithiasis.
PAST SURGICAL HISTORY:
Right total knee replacement , appendectomy , cholecystectomy , and
partial colectomy at the splenic flexure as noted above.
MEDICATIONS:
Lopressor 50 mg orally three times a day , lisinopril 15 mg orally every day , Lasix 40
mg orally every day , aspirin 81 mg orally every day , albuterol nebulizer
as needed , Zyprexa 2.5 mg orally every day , MS Contin 15 mg to 30 mg orally
twice a day , oxycodone as needed , and heparin subcutaneous three times a day
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
The patient presented after a brief stay for one week at A Pa Community Hospital . She is the aunt of a Pagham University Of cardiologist , Dr. Casebolt .
PHYSICAL EXAMINATION:
Temperature is 98.8 , heart rate 94 , blood pressure 80/54 ,
respiratory rate 18 , and oxygen saturation 95% on 2 liters nasal
cannula. In general , the patient was in no acute distress. Her
chest was clear to auscultation bilaterally without any evidence
of wheezes. The heart was regular rate and rhythm with S1 , S2
normal with 3/6 systolic murmur. Abdomen was soft and obese.
Mild tenderness of the inferior aspect of her ostomy stoma. No
rebound tenderness was noted. The stoma color was normal. There
was gas and stool in the stoma bag. Her midline abdominal
incision was open with pink granulation tissue. Extremities were
notable for only trace pitting edema.
LABORATORY DATA:
Chemistry: Sodium 139 , potassium 5.0 , chloride 100 , bicarbonate
34 , BUN 25 , creatinine 0.8 , and glucose 187. Liver enzymes: AST
8 , ALT 13 , alkaline phosphatase 89 , and T-bili 0.2 , and lactic
acid 1.2. CBC: White blood cell count 13.5 , hematocrit 31.3 ,
and platelets 513 , 000. Cardiac enzymes were normal with the CK
of 33 and MB fraction of 1.2. Troponin was less than assay. EKG
showed left anterior fascicular block and sinus rhythm.
IMAGING:
CT of the abdomen showed a 6 cm x 2 cm left-sided intraabdominal
fluid collection and a 4.2 cm fluid collection around the stoma ,
which both were seemed to as consistent with abscess formation.
HOSPITAL COURSE:
The patient was admitted to the Nessinee Ker Hospital Medical Center Surgical Service on
1/12/05 for management of her intraabdominal abscesses as a
complication of recently performed partial colectomy and Hartmann
pouch for perforated diverticulitis. She was started on intravenous
antibiotics with vancomycin , levofloxacin , and Flagyl. By
systems.
Neuro: The patient had intermittent issues with pain control ,
which were managed by putting the patient on orally narcotic agents
as well as fentanyl patch. This seemed to help the patient's
pain. The patient also had an episode of altered mental status ,
which was believed to be due to pulmonary issues of CO2 retention
as noted below. For this reason , the patient had been
transferred to the ICU for 24-hour period observation , and at the
time of discharge , the patient was in adequate mental status
communicating effectively and at her baseline. Otherwise , no
issues at the time of discharge , except for pain control , being
managed by narcotic agents.
Cardiovascular: The patient was stable throughout her
hospitalization. However , it was notable at the time of her
previous admission that the patient would need to undergo an
echocardiogram within one to two weeks. For this reason , the
patient underwent an echocardiogram during her hospitalization
and was found to have normal ejection fraction of 65%. There
were no regional wall motion abnormalities noted. Her aortic
valve showed trace aortic insufficiency and the patient also had
mild degree of aortic stenosis with the valve of 1.4 cm squared.
Her mitral valve was shown to have some degree of mitral
regurgitation and the patient also had some tricuspid
regurgitation as well. Her right ventricle was seemed to be okay
and she did have some evidence of left ventricular hypertrophy.
No evidence of gross cardiac dysfunction.
Pulmonary: The patient on hospital day #6 was found to have
altered mental status in the evening. An ABG was checked , which
showed a pH of 7.42 , pCO2 of 61 , and pO2 of 58 , 92% oxygen
saturation on 3 to 4 liters with the base access of 12. For this
reason , it was determined that the patient would need to be
admitted to the surgical ICU for further monitoring of her
pulmonary status. She was taken to the ICU and admitted there.
During her ICU course , the patient was placed on BiPAP , which
effectively brought her bicarbonate and her pCO2 levels down.
This did effectively decrease her pCO2. Hence by hospital day
#8 , the patient was transferred back to the floor in stable
condition. From her pulmonary standpoint , the patient continued
to have some degree of bibasilar crackles during her
hospitalization. However , given her otherwise stable status , the
patient was encouraged to perform and sent to spirometry and
Lasix was withheld during the later course of her hospital
course. At the time of discharge , the patient was with adequate
oxygen saturation sating 97% on 1 liter at the time of discharge.
GI: The patient had no trouble eating regular diet during her
hospital course. Her ostomy continued to function well with the
stoma pink and healthy. She did have two intraabdominal
abscesses , which were drained on hospital day #2 by
Interventional Radiology. Two IR catheters were placed and these
were left in place until the output was deemed to be minimal , and
a CT scan was performed as well as an abscessogram , both of which
reveled that the fluid collections had resolved. Hence on
hospital day #10 , the patient's interventional radiology drains
were discontinued without complications. At the time of
discharge , the patient was stable with a soft abdomen and no
evidence of infection. The patient did have a midline abdominal
incision open with pink granulation tissue , healing well. The
pain was treated with wet-to-dry normal saline dressing , twice a day
to three times a day
GU: The patient continued to have good urine output during her
hospital course. She did require Foley placement from adequate
monitoring of her urine output at 1.8. Urinalysis , as well as
urine culture was sent , which revealed yeast greater than 100 , 000
yeast , not Candida albicans. She was started on a five-day
course of fluconazole and her Foley catheter was discontinued for
treatment of this infection. At the time of discharge , the
patient was urinating adequate amounts independently without any
issues.
Heme: The patient's hematocrit remained stable during her
hospital course. However , during her stay in the ICU , hematocrit
was found to be 27 and the patient received 1 unit of packed red
blood cells without any complications or events. At the time of
discharge , the patient's hematocrit was found to be 43 without
any event. She continued to receive subcutaneous heparin three times a day
for DVT prophylaxis.
ID: The patient was placed on vancomycin , levofloxacin , and
Flagyl during her hospital course for the intraabdominal
abscesses. Fluconazole was also added for the treatment of a
urinary tract infection with the yeast. The antibiotics were
continued until the drains were removed on hospital day #10. On
hospital day #10 , the patient was transitioned to levofloxacin ,
which is to be continued for a 10-day total course benign
1/27/05 , 10 further days of levofloxacin required for adequate
covered. However , it should be noted that the IR drains were
found to be negative and only revealed purulent fluid. Gram
stain was indicative of sterile purulent fluid. Cultures were
negative.
Tubes , lines , and drains: As noted above , the patient had the
placement of two interventional radiology drains , which were
discontinued prior to discharge. At the time of discharge , the
patient has no Foley and no IR drains in place.
MEDICATIONS AT THE TIME OF DISCHARGE:
Tylenol 650 mg orally every 6 hours as needed pain , albuterol nebulizes 2.5 mg
nebulizer every 4 hours as needed wheezing , aspirin 81 mg orally every day , Pepcid
20 mg orally twice a day , fentanyl patch 25 mcg patch every 72 hours , heparin
5000 units subcutaneous three times a day , lisinopril 50 mg orally every day ,
Lopressor 50 mg orally three times a day , hold for systolic blood pressure
less than 100 and heart rate less than 55 , multivitamins with
minerals one tablet orally every day , Zyprexa 2.5 mg orally every bedtime ,
levofloxacin 500 mg orally every day x13 more doses starting 5/15/05 .
DISPOSITION:
The patient is discharged to F.sley General Hospital for further management. The patient was given adequate
instructions for her further care and the same was passed on to
HHH . The patient is to receive dressing changes ,
physical therapy assistance , and ostomy care. The patient should
follow up with Dr. Miriello in one to two weeks for further
surgical management follow up and should also be seen by Dr.
Verdie Macisaac for her cardiovascular follow up.
eScription document: 1-8710095 EMSSten Tel
Dictated By: FUEST , MARTA
Attending: MIRIELLO , MILAGROS
Dictation ID 4403565
D: 5/15/05
T: 5/15/05
Document id: 98
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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061565028 | PUO | 32789496 | | 1629308 | 10/6/2006 12:00:00 a.m. | gallstone pancreatitis | | DIS | Admission Date: 4/7/2006 Report Status:
Discharge Date: 2/5/2006
****** FINAL DISCHARGE ORDERS ******
KUNDLA , KYRA 940-05-50-7
Do Na Gene
Service: MED
DISCHARGE PATIENT ON: 5/10/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CHAIX , TRISH LOREAN , M.D. , M.P.H.
CODE STATUS:
Full code Other - undefined
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LISINOPRIL 20 MG orally every day Starting Today ( 6/8 )
Alert overridden: Override added on 3/1/06 by NICKLIN , MOIRA J T. , PA
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
NORVASC ( AMLODIPINE ) 5 MG orally every day Starting IN a.m. ( 5/8 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally every 24 hours X 4 doses
Starting Today ( 6/8 )
Alert overridden: Override added on 4/10/06 by
HOLLWAY , TABATHA , PA-C
POTENTIALLY SERIOUS INTERACTION: PROMETHAZINE &
LEVOFLOXACIN Reason for override:
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
325 MG orally every day
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
HYDROCHLOROTHIAZIDE 25 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 200 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
IBUPROFEN 400 MG orally every day Food/Drug Interaction Instruction
Take with food
DIET: consistent carbohydrate di
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Caren Gugliuzza 178-502-7583 1 week ,
Dr Wankum , Surgery , 033-275-2204 1-3 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
epigastric pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
gallstone pancreatitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
AVN reentrant tachycardia history of ablation 2/16 htn
( hypertension ) hyperlipidemia ( hyperlipidemia ) cholelithiasis
( cholelithiasis ) hyperglycemia ( elevated glucose ) gerd
( gastroesophageal reflux disease ) arthritis
( arthritis ) lumbar spine stenosis ( low back pain ) history of PE ( history of
pulmonary embolism ) obesity ( obesity ) depression ( depression ) angina
( angina )
OPERATIONS AND PROCEDURES:
ERCP
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: epigastric pain with N+V
HPI:58F with history of GERD , angina , cholelithiasis p/with acute onset
epigrastric pain which awoke her out of her sleep 3a.m. morning of
admission. patient felt fine day prior to admission , eating well without
difficulty. patient describes pain as dull , constant 6/10 with intermittent
radiation to right shoulder/upper back ( that has since resolved ). No
relief with Nitro x 3 @ home ( expired Rx ). patient describes this pain as worse
and longer lasting than previous anginal experience 1 year ago. No
association with food. No change in weight , no anorexia. Positive
vomiting and nasuea reported 2 hrs after onset of pain. Denies
SOB/cough/f/ch/d/BRBPR.
****
PMH: HTN , angina ( neg stress test 2 yrs ago ) , arthritis , L-spine stenosis
history of PE ( unknown when ) , cholelithiasis , hyperlipidemia , obesity ,
depression
****
Home Meds: lopressor 200mg twice a day , norvasc 5mg every day , hctz 25mg every day , zantac
twice a day , asa 325mg every day , lisinopril 40mg every day , advil ( 2tabs/day ) , motrin as needed
****
All: NKDA
****
PE on Admission: VS: T97.7 HR70 BP172/82 RR22 SaO2 100% RA
Gen:middle-aged F lying on side in bed actively vomiting
HEENT:anicteric sclera , mmm , PERRL , EOMI
Neck: supple , no LAD
Lungs: CTAB
CV: RRR S1+S2 no m/r/g
Abd: obese , NABS , soft , ND , +epigastric tenderness and LUQ discomfort on
deep palpation , no RT/G
GU: no CVA tenderness Rectal: guaiac neg in ED
MS: FROM UEs and LEs Skin: intact , no rashes
Neuro: nonfocal Psych: history of depression
****
Admission Data: Amy 114 , Lip 115 AST 31 ( remaining LFTs wnl )
RUQ U/S: cholelithiasis ( multi small stones ) , gb sludge , no acute
cholecystitis WBC 7.16 coags wnl ALB 4.3 , TP 8.5
EKG: no acute changes , NSR @ 70bpm
CXR: nad
****
Hospital Course: 1. GI: US 1/30 notable for cholelithiasis and sludge ,
CBD not directly visualized due to bowel gas. Intermittent abdominal
pain essentially resolved by 9/26 on bowel rest/IVF/intravenous pepcid.
9/10 diet advanced to clears then solid for lunch , but patient had post
prandial N/V/severe upper abdominal pain. Labs were notable for
Hyperbilirubinemia , lipase of 1100. Clinical picture c/with gallstone
pancreatitis/early cholangitis. GI consulted: plan=ERCP , agreed
with antibx. 2/28 Surgery consulted for ?elective chole , recommended
waiting 1-3wks ( until acute inflammatory state resolves ). patient asymptomatic
prior to ERCP. Stone removed from CBD. Returned to floor , developed
recurrence of upper abd pain , N/V. No fever or peritoneal signs. Likely
post procedural pancreatitis , KUB=neg for perforation. 2/3 patient
asymptomatic , diet advanced.
2. ID: T-max=101.1 on 1/14 . No leukocytosis or shift. Infectious
source could be UTI +/- early cholangitis ( See GI
above ). UA positive for LE and 4+bacteria , U Cx positive for
4+proteus and 4+gm neg rods Levo started 9/26 for UTI , ( will also cover
Gm neg for ?early
cholangitis ) Ampicillin and Flagy started 9/26 for ?early
cholangitis. 3. CV: history of htn , hyperlipidemia , CE set A B neg , tele
d/c'd. Presenting symptoms not attributed to cardiac event.
Continuing baseline lopressor , norvasc , and lisinopril. Holding HCTZ
and ASA for now. 2/28 Norvasc increased to 10mg , with good
response. 4. ENDO: No prior hx of DM , but has history of hyperglycemia
on fasting labs. HgA1C=6.8. On PUO insulin protocol. On 9/10 changed
from q6RISS to pre-meal novolog 7AC and novolog
SS. Nurses providing instructions on FSBS monitoring.
Will likely defer outpt rx to primary care physician. 5. FEN: IVF and NPO except meds for
now. monitor lytes and replete
as needed 6. PPx: nexium + heparin
subcutaneously FULL
CODE
ADDITIONAL COMMENTS: 1. Please follow-up with your primary care provider within 1 week to
discuss new diagnosis of diabetes and to repeat labs ( liver function
tests , amylase & lipase ).
2. Please schedule surgery to remove gallbladder with Dr Wankum within
1-3 weeks. Call 033-275-2204 to schedule.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. F/u with primary care provider to check blood sugar , review journal of
blood sugars , and check liver function tests.
2. F/u with surgery for cholecystectomy.
No dictated summary
ENTERED BY: MORDHORST , CAROL T. ( VV02 ) 5/10/06 @ 03:04 PM
****** END OF DISCHARGE ORDERS ******
Document id: 99
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
- |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
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Y |
N |
N |
N |
- |
Y |
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Y |
Y |
N |
N |
824870494 | PUO | 94307902 | | 3022547 | 10/1/2007 12:00:00 a.m. | Chest pain | | DIS | Admission Date: 7/26/2007 Report Status:
Discharge Date: 8/9/2007
****** FINAL DISCHARGE ORDERS ******
GREENFELDER , NELLIE K 781-11-59-4
Memp
Service: CAR
DISCHARGE PATIENT ON: 1/27/07 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ABSHEAR , CARLTON J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ALBUTEROL INHALER 2 PUFF inhaled four times a day
2. AMLODIPINE 10 MG orally every day
3. ASPIRIN ENTERIC COATED 325 MG orally every day
4. CLOPIDOGREL 75 MG orally every day
5. ENALAPRIL MALEATE 20 MG orally twice a day
6. GABAPENTIN 300 MG orally twice a day
7. IBUPROFEN 600 MG orally every 6 hours
8. OMEGA-3-FATTY ACIDS 2000 MG orally twice a day
9. PAROXETINE CONTROLLED RELEASE 25 MG orally every day
10. PYRIDOXINE HCL 50 MG orally every day
11. CARVEDILOL 6.25 MG orally twice a day
12. ROSUVASTATIN 40 MG orally every bedtime
13. FLUTICASONE PROPIONATE inhaled inhaled twice a day
14. FOLIC ACID 5 MG orally every day
15. HYDROCHLOROTHIAZIDE 25 MG orally every day
16. METFORMIN 500 MG orally every day
17. ESOMEPRAZOLE 20 MG orally every day
18. FENOFIBRATE ( TRICOR ) orally every day
19. HYDROCODONE 5 MG + APAP 500MG 1 TAB orally every day
20. CYANOCOBALAMIN 500 MCG orally every day
21. INDOMETHACIN 25 MG orally three times a day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 325 MG orally DAILY
AMLODIPINE 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Alert overridden: Override added on 2/19/07 by
DUSSAULT , LARAINE , M.D.
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM Reason for override: aware
COREG ( CARVEDILOL ) 6.25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ENALAPRIL MALEATE 20 MG orally twice a day
TRICOR ( FENOFIBRATE ( TRICOR ) ) 145 MG orally DAILY
Override Notice: Override added on 2/19/07 by
DUSSAULT , LARAINE , M.D.
on order for LIPITOR orally ( ref # 515333519 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM Reason for override: aware
Number of Doses Required ( approximate ): 4
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
PAROXETINE CONTROLLED RELEASE 25 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Your cardiologist Dr. Dorough as you had scheduled April , 1:30 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) Spinal Stenosis ( spinal stenosis ) htn
( hypertension ) OSA on CPAP ( sleep apnea ) Hyperhomocysteinemia
( hyperhomocysteinemia ) elevated Lp( A ) Hyperlipidemia
( hyperlipidemia ) LBP and RLE radiculopathy Reiter's like arthritis
( Reiters syndrome ) microcytic anemia ( microcytic
anemia ) glucose intolerance ( glucose intolerance )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac Stress PET
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
===================================================
HPI: 52 year-old M with history of DM , dyslipidemia , CAD history of 2v CABG in '02 for RCA
dissection which was a complication of PCI ( LIMA to LAD , radial to PDA ) ,
and history of multiple catheterizations for CAD and instent restenosis
presenting with atypical chest pain at rest. Since his last intervention
in 10/24 for re-stenting of his LCx , patient had been pain free , able to walk
about 1/2 mile without difficulty. On the morning of admission patient woke
up with sharp chest pain associated with diaphoresis and tingling down
his left arm. However , the pain was different from the pressure he had
felt from his previous admissions that were positive for stenosis. Pain
was described as sharp 9/10 that improved after taking his second dose of
ntg. The diaphoresis and arm symptoms resolved concurrently with the
chest pain. He received a third dose of ntg from the EMS and brought to
ED.
Of note , one week ago patient was struck in the center of his chest by
teenagers "horsing around" next to him. The impact was severe enough to
cause him to fall to the ground. He noticed pain around the region for
the next several days that he described as more pressure like different
from what he felt like this morning. Also noticed that since the
incident he has felt more tired than usual.
In ED patient was hemodyanmically stable HR 54-57 BP 113-142/64-78. patient
was afebrile breathing at 18/min O2 sat 100% 2L. He was given another
dose of ntg by nasal spray , ASA 325 mg , Dilaudid 1mg for back pain ,
Plavix 75mg , and lovenox 100 mg.
===================================================
CARDS HX:
CAD:
- 9/10/2006 cath: p/with CP , negative biomarkers , adenosine MIBI +ve for
reversible perfusion defect , patent grafts , instent restenosis of LCx
stented with TAXUS
- 8/18/06 cath: Neg enz , TWI V4-V6 , patent grafts , no new disease
- 9/12/04 cath: Instent restenosis of LCx from '03 , stent with Cypher
- 10/27/04 cath for CP , no disease , negative enzymes ?ECG changes
- 10/19/03: cutting balloon inflation and 80% pPDA stent ( drug eluting )
- 3/7 02 CABG history of RCA dissection from PCTA ( below ) required IABP
- 2/9/02 instent restenosis of LCx PCTA of OM2 , RCA
- 1/30/02 PCTA of 95% occl of pLAD
- 5/6/01 PCTA of 100% occl of LCx
Heart failure
DM2
Hypercholesterolemia
HTN
===================================================
OTHER PMH:
Costocondritis
H/o slightly elevated anticardiolipin antibody ( 5/6/01 admission )
OSA
Chronic back pain - herniated disc from work Arthritis
===================================================
HOME
MEDS:
Albuterol as needed
Fluticasone 5 mcg every day before noon
Amlodipine 10 mg every day
ASA 325 mg every day
Coreg 6.25 mg twice a day
Plavix 75 mg every day
Vitamin B12 500 mcg every day
Enalapril 20 mg twice a day
Nexium 20 mg every day
Tricor 145 mg every day
Folate 1mg every day
Neurontin 300 mg twice a day
Vicodin 1 tab every 6 hours as needed
Ibuprofen 600 mg every 6 hours as needed
Metformin 00 mg every day
Omega 3 fatty acid 2000 mg twice a day
Paroxetine controlled release 25 mg every day
Vitamin B6 50 mg orally every day
Crestor 40 mg orally every day
Indocin 25 mg three times a day
Hctz 25 mg every day
===================================================
ADMISSION EXAM:
VS: Temp 96.1 HR 59 BP 140/80 RR 20 100% 2L
Gen: Tired appearing , obese African American man lying in bed , pleasant ,
A&Ox3 in NAD
HEENT: nl conjunctiva , anicteric , PERRLA , EOMI , mmm , oropharynx clear
Neck: JVP difficult to assess approx 6 cm , thyroid not palpable
CV: pain with light palpation most signficant on lower left sternal
border , nl S1 S2 , RRR , no murmurs , rubs , S4 heard loudest at lower left
sternal border , chest is tender to light palpation
Lung: CTAB
Abd: +BS , soft , NT , ND
Ext: WWP , no CCE ,
Neuro: nonfocal
===================================================
STUDIES:
CXR: No acute cardiopulmonary process
STRESS PET:
1. The patient's PET-CT test results are normal and suggest no
evidence of flow-limiting CAD.
2. Normal global LV systolic function.
3. The results demonstrate interval improvement from his prior
study of May , 2006.
===================================================
CONSULTS: None
===================================================
HOSPITAL COURSE BY PROBLEM
1 ) CHEST PAIN
On arrival to the floor patient was pain free but began to experience
nausea and vomiting which was relieved by ntg and then with a dose of
compazine. It was unclear if the nausea was related to ischemia or the
dose of dilaudid he received in the ED. However there were no ECG
changes during his nausea. Altogether the nausea lasted for
approximately 10 minutes. He remained pain free during the night with
what he described as some slight pressure over his chest. His chest is
tender at baseline ever since his CABG and it was difficult to assess
whether the pain was MSK or cardiac in nature. He sometimes felt it was
different from when he first presented with an MI , and at other times he
describes the pain as being related to movement and to the kick to the
chest that he received 2 weeks earlier ( see HPI ). Overnight on HD#1
patient did not require any more NTG doses , remained hemodynamically
stable , and three sets of enzymes were negative for MI. patient had several
admissions in the past where he presented with chest pain and underwent
catheterizations , some of which revealed restenosis and some of which
were negative. Given his presentation was very atypical it was decided to
do a stress PET the next day to assess ischemia and then re-evaluate
plan. He was kept on his home regimen of cardiac medications in addition
to lovenox 100 mg subcutaneously for ACS. On HD#2 when moving from his chair to the
bed he began to complain of 2/10 chest pressure that he says felt a
little different than the pain when palpating his chest. Again there
were no ECG changes. He underwent a stress PET which was negative for
ischemia. Given his presentation with a clearly negative study it was
most likely that his symptoms were MSK in origin.
2 ) DM2
Patient's home regimen of orally hypoglycemic agents were held and he was
treated with basal insulin and a sliding scale.
3 ) FEN
NPO for stress PET , K/Mg scales
4 ) PPX
Patient was on lovenox for ACS , PPI
5 ) Full Code
=========================
ADDITIONAL COMMENTS: - Please take your home medications as you were doing. It is VERY
IMPORTANT that you take your aspirin and plavix medications for your
stents.
- Please see your cardiologist Dr. Dorough as you had scheduled on January at 1:30pm.
- Please return if you exprience pain that does not go away after 1 dose
of nitroglycerin , light headedness , fainting , difficulty
breathing , or changes in vision , weakness , or numbness.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: DUSSAULT , LARAINE , M.D. ( YJ28 ) 1/27/07 @ 04:16 PM
****** END OF DISCHARGE ORDERS ******
Document id: 100
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
N |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
Y |
N |
N |
N |
Y |
- |
N |
N |
Y |
N |
N |
N |
023364619 | PUO | 28061312 | |
268606 | 6/22/1991 12:00:00 a.m. | Discharge Summary | Unsig
ned | DIS | Admission Date: 5/30/1991 Report Status: Unsigned
Discharge Date: 2/9/1991
PRINCIPLE DIAGNOSIS: ACUTE BRONCHITIS.
SECONDARY DIAGNOSES: STATUS POST AORTIC VALVE REPLACEMENT.
DEPRESSION.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old white
male who was admitted with complaints
of cough , mild shortness of breath and persistent fevers. In 1981 ,
the patient was admitted to Pagham University Of with
ith
syncope secondary to aortic stenosis. A porcine AVR was performed
at that time. He had an unremarkable course until 1/25/90 , when
echocardiogram performed at CHH showed an AV gradient of
64 mm of
mercury , mild to moderate MR , LVH , and normal function. A blowing
diastolic murmur was noted on physical exam at that time. On
5/16/91 , the patient underwent an ETT that was nondiagnostic due
to
baseline EKG abnormalities. However , he had no substernal chest
pain after 12 minutes and 20 seconds. Around the end of October
1991 , the patient noted increasing fatigue , increased temperature ,
and some upper respiratory symptoms including cough and sore
throat. He claims that his sore throat lasted for nearly a month
then went away for one week only to return again for nearly one
month. He had been treated with amoxicillin without improvement.
One week prior to admission , he had persistent symptoms with a
cough with poor sputum production but the sputum that was produced
was yellow-green in color. He was treated with erythromycin in a
single dose before hospitalization. Also , one week prior to
admission , he noted some left chest pain without radiation that is
typical of his chest pain syndrome which had been previously
diagnosed. On the day of admission , the patient noted increased
persistent elevation in his temperature and a chest x-ray showed
questionable left lingular infiltrate that led to his admission.
PAST MEDICAL HISTORY: Noteable for history of adult onset
diabetes , previously treated with insulin but now diet controlled.
Status post porcine AVR secondary to rheumatic heart disease.
Atypical chest pain syndrome. Depression. MEDICATIONS: On
admission included erythromycin , Motrin and imipramine. ALLERGIES:
NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: Remarkable for
significant past smoking history , past alcohol use , job as a
painter's rigger.
PHYSICAL EXAMINATION: On admission revealed an obese white male
whose appearance was appropriate for his age
in moderate distress. Blood pressure was 160/90. Heart rate 80.
Temperature 101.1. Respiratory rate of 14. Skin revealed
blanching macular rash confined largely to the trunk without
splinter hemorrhages , Janeway's nodes or Osler's nodes. Cardiac
exam revealed normal sinus rhythm , III/VI holosystolic murmur at
the left sternal border , II/VI diastolic murmur at the left sternal
border and a II/VI crescendo/decrescendo murmur at the apex with
extension to the axilla. Lungs revealed scattered rhonchi and few
rales especially in the left lung field. Extremities were without
cyanosis , clubbing or edema.
LABORATORY DATA: On admission included a glucose of 172. White
blood cell count 7.7. Hematocrit 41.2. Platelet
count 403 , 000. Previous work-up at CHH showed an ESR o
f 24.
Urinalysis had 1+ protein , 1+ glucose , 1-3 white cells , 1-3 red
cells , trace bacteria and 2-5 hyaline casts. EKG revealed normal
sinus rhythm at 96 , intervals of 0.20/0.08/0.40 with axis of -30
degrees. There was LVH with strain. Chest x-ray showed a
questionable lingular infiltrate that was read as such by one
radiologist but this was not confirmed by a second radiologist.
There was no sign of congestive heart failure on chest x-ray.
HOSPITAL COURSE: When the patient was admitted , he was initially
treated as if his presenting symptoms were due to
a left lingular pneumonia despite his lack of elevated white count.
However , it was felt that endocarditis a small though real
possibility in this gentleman with AVR. Therefore , he was
originally treated with ampicillin , 2 grams intravenous every six hours;
gentamicin , 100 mg intravenous every eight hours; and erythromycin , 1 gram intravenous every
six hours to cover atypical bacteria including Legionella. Prior
to administering antibiotics , three blood cultures were obtained at
PUO in addition to the two previously obtained at TP . Sputum
sample was also sent for gram stain and C&S. All blood cultures
remained negative throughout the hospitalization. Sputum culture
showed only normal flora. When the second radiologist read the
chest x-ray as being inconsistent with lingular pneumonia , a more
aggressive search for possible endocarditis was undertaken. An
echocardiogram was performed on 8/19 that showed an aortic valve
with 40 mm gradient , 2-3+ AI , 1+ MR , mild LVF and no regional wall
motion abnormalities. There was no evidence of vegetation on the
echo. Side by side comparison of this echocardiogram with the
echocardiogram from 5/25 done at CHH sho
wed no significant
interval change. An Infectious Disease consult was sought and it
was felt by these consultants that endocarditis was an unlikely
diagnosis given the lack of change in echocardiogram and lack of
additional signs of SBE. It was ultimately felt that the patient's
shortness of breath and elevated temperature were due to bronchitis
and he was switched to orally Bactrim to continue a ten day course of
therapy. Although the initial goal of his hospitalization was to
keep him hospitalized until cardiac catheterization and valve
replacement could be performed , the patient's personal situation
made it unfeasible to keep him in the hospital for a longer period
of time than absolutely necessary. Furthermore , there were
questions about whether cardiac catheterization and AVR should be
performed in someone being treated for presumed acute bronchitis
and whether his very poor orally hygiene and dental work can be
corrected prior to surgery. For these reasons , Dr. Bernas
in
Cardiology was consulted as well as Dr. Mccomish in THPC Medicine and
both concurred that the patient could be discharged with close
follow-up by his primary care physician , Dr. Kintopp . His co
ndition
on discharge was stable.
DISPOSITION: MEDICATIONS: On discharge included Bactrim DS , one
twice a day times seven days; imipramine , 50 mg orally every bedtime;
Colace , 100 mg three times a day; Nystatin , 5 cc swish and spit four times a day;
Alupent , two puffs every six hours.
HW854/0652
RUFUS BERNAS , M.D. DA4 D: 03/17/91
Batch: 5465 Report: J8741D75 T: 3/22/91
Dictated By: NAOMI K. WOLFENSPERGER , M.D.
Document id: 101
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
- |
N |
N |
Y |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
285271309 | PUO | 29811367 | |
2116277 | 10/27/2005 12:00:00 a.m. | LEFT FEMUR FRACTURE | Si
gned | DIS | Admission Date: 10/18/2005 Report Status: Signed
Discharge Date: 2/7/2005
ATTENDING: ECKLOFF , VERNA M.D.
HISTORY OF PRESENT ILLNESS: Ms. Medaries is a 79-year-old f
emale
with a history of Ehlers-Danlos , osteoarthritis and left knee
replacement in 1998 , and left hip replacement in 2002 who was leaving her
primary care physician's office and was hit by the elevator door and fell to
the ground. She suffered a left periprosthetic fracture of her left distal
femur. She was initially admitted to TPP Hospital where
she was found to have , by report , a closed distal femur fracture
between her prior ORIF and TKR with no neurovascular deficits.
Operative intervention was referred by TPP Hospital due
to her medical problems and she was treated conservatively with
nonweightbearing and a knee immobilizer. Her course there was
significant for a hematocrit drop requiring 2 units of PRBC's as
well as being ruled out for an myocardial infarction. In addition , she also
had a negative MIBI test. She was transferred to PUO for further management.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis.
2. Osteoarthritis.
3. Hypertension.
4. Ehlers-Danlos.
5. GERD.
6. Ulcerative colitis , status post colectomy with colostomy.
7. Chronic stable angina.
8. Anxiety.
PAST SURGICAL HISTORY:
1. Status post bilateral TKR in 1998.
2. Status post left intramuscular rod for intertrochanteric fracture of the
left femur in 2002.
3. Status post left elbow replacement.
4. Status post lumbar laminectomy x 2.
HOME MEDICATIONS:
1. Atenolol 100 daily.
2. Folic acid daily.
3. Synthroid 0.088 mg daily.
4. Lipitor 10 daily.
5. Zoloft 50 daily.
6. Detrol 2 mg twice a day
7. Enalapril 10 mg twice a day
8. Celebrex 100 mg twice a day
9. Aspirin 81 mg daily.
10. Fosamax 1 Q.K.
ALLERGIES: Kefzol causes rash.
SOCIAL HISTORY: Lives in an apartment in U Mother
recently deceased. No alcohol. No tobacco.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.8 , heart rate
75 , blood pressure 100/50 , respiratory rate 18 , and saturations
94% on room air. No acute distress. Regular rhythm and rate.
No murmurs , rubs , or gallops. Lungs , clear to auscultation
bilaterally. Abdomen was soft , nontender , and nondistended.
Positive for colostomy. Left lower extremity in knee
immobilizer , swollen and tenderness to palpation. Left lower
extremity slightly externally rotated. Bilateral EHL/tibialis
anterior/gastrocnemius intact distally with 5/5 motor. Sensation
to intact to light touch and SPN/DP/sural/tibial nerves/saphenous
distributions. Bilateral 2+ DP/physical therapy pulses bilaterally.
LABS ON ADMISSION: Sodium 137 , potassium 3.6 , chloride 114 ,
bicarbonate 26 , BUN 17 , creatinine 0.9 , glucose 148 , and calcium
9. White count 11.6 , hematocrit 39.6 , and platelets 170. INR
1.1 , physical therapy 14.2 , and PTT 21.7.
HOSPITAL COURSE: Upon admission to PUO ,
Ms. Medaries underwent an echocardiogram to rule out any ca
rdiac
abnormalities. Her ejection fraction was revealed to be 50% with
no wall motion abnormalities and only mild aortic insufficiency.
She was determined to be medically stable to go the operating room by Internal
Meidicine. On January , 2005 , she underwent an open reduction
and internal
fixation of her left femur fracture with a LISS plate placement.
Postoperative film showed good placement of hardware and good
alignment of her fracture. Her postoperative course was
complicated only by mild hypotension ( systolic blood
pressures in the 70s ) and by shortness of breath. She was
successfully treated with fluid boluses and inhaled nebulizers
respectively. Postoperative chest x-ray revealed lower lobe
atelectasis. Once she was more mobile by postoperative day #3 ,
her blood pressure and O2 saturation stabilized. The remainder
of her postoperative course was uncomplicated. She was kept on
perioperative antibiotics and as well as prophylactic Lovenox
while in house. She was kept touchdown weightbearing on her left
lower extremity. Her dressing was removed on postoperative day
#2. She was evaluated by physical therapy who worked with her to
increase her activity. She was deemed safe for discharge to
rehabilitation. Upon discharge , her left lower extremity was
neurovascularly intact. Her incision was clean , dry , and intact
and healing well. She is discharged in stable condition with
instruction to continue Lovenox and left lower extremity
touchdown weightbearing status until followup in clinic in two
weeks.
TO DO PLAN:
1. Touchdown weightbearing , left lower extremity.
2. Follow up with Dr. Compono in two weeks.
3. Continue Lovenox until next appointment with Dr. Compono .
eScription document: 1-4510180 ISSten Tel
Dictated By: WOLFENSPERGER , NAOMI
Attending: Compono , Jim
Dictation ID 7587511
D: 11/7/05
T: 11/7/05
Document id: 102
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
023364619 | PUO | 28061312 | | 071997 | 6/22/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 5/30/1991 Report Status: Unsigned
Discharge Date: 2/9/1991
PRINCIPLE DIAGNOSIS: ACUTE BRONCHITIS.
SECONDARY DIAGNOSES: STATUS POST AORTIC VALVE REPLACEMENT.
DEPRESSION.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old white
male who was admitted with complaints
of cough , mild shortness of breath and persistent fevers. In 1981 ,
the patient was admitted to Pagham University Of with
syncope secondary to aortic stenosis. A porcine AVR was performed
at that time. He had an unremarkable course until 1/25/90 , when
echocardiogram performed at CHH showed an AV gradient of 64 mm of
mercury , mild to moderate MR , LVH , and normal function. A blowing
diastolic murmur was noted on physical exam at that time. On
5/16/91 , the patient underwent an ETT that was nondiagnostic due to
baseline EKG abnormalities. However , he had no substernal chest
pain after 12 minutes and 20 seconds. Around the end of October
1991 , the patient noted increasing fatigue , increased temperature ,
and some upper respiratory symptoms including cough and sore
throat. He claims that his sore throat lasted for nearly a month
then went away for one week only to return again for nearly one
month. He had been treated with amoxicillin without improvement.
One week prior to admission , he had persistent symptoms with a
cough with poor sputum production but the sputum that was produced
was yellow-green in color. He was treated with erythromycin in a
single dose before hospitalization. Also , one week prior to
admission , he noted some left chest pain without radiation that is
typical of his chest pain syndrome which had been previously
diagnosed. On the day of admission , the patient noted increased
persistent elevation in his temperature and a chest x-ray showed
questionable left lingular infiltrate that led to his admission.
PAST MEDICAL HISTORY: Noteable for history of adult onset
diabetes , previously treated with insulin but now diet controlled.
Status post porcine AVR secondary to rheumatic heart disease.
Atypical chest pain syndrome. Depression. MEDICATIONS: On
admission included erythromycin , Motrin and imipramine. ALLERGIES:
NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: Remarkable for
significant past smoking history , past alcohol use , job as a
painter's rigger.
PHYSICAL EXAMINATION: On admission revealed an obese white male
whose appearance was appropriate for his age
in moderate distress. Blood pressure was 160/90. Heart rate 80.
Temperature 101.1. Respiratory rate of 14. Skin revealed
blanching macular rash confined largely to the trunk without
splinter hemorrhages , Janeway's nodes or Osler's nodes. Cardiac
exam revealed normal sinus rhythm , III/VI holosystolic murmur at
the left sternal border , II/VI diastolic murmur at the left sternal
border and a II/VI crescendo/decrescendo murmur at the apex with
extension to the axilla. Lungs revealed scattered rhonchi and few
rales especially in the left lung field. Extremities were without
cyanosis , clubbing or edema.
LABORATORY DATA: On admission included a glucose of 172. White
blood cell count 7.7. Hematocrit 41.2. Platelet
count 403 , 000. Previous work-up at CHH showed an ESR of 24.
Urinalysis had 1+ protein , 1+ glucose , 1-3 white cells , 1-3 red
cells , trace bacteria and 2-5 hyaline casts. EKG revealed normal
sinus rhythm at 96 , intervals of 0.20/0.08/0.40 with axis of -30
degrees. There was LVH with strain. Chest x-ray showed a
questionable lingular infiltrate that was read as such by one
radiologist but this was not confirmed by a second radiologist.
There was no sign of congestive heart failure on chest x-ray.
HOSPITAL COURSE: When the patient was admitted , he was initially
treated as if his presenting symptoms were due to
a left lingular pneumonia despite his lack of elevated white count.
However , it was felt that endocarditis a small though real
possibility in this gentleman with AVR. Therefore , he was
originally treated with ampicillin , 2 grams intravenous every six hours;
gentamicin , 100 mg intravenous every eight hours; and erythromycin , 1 gram intravenous every
six hours to cover atypical bacteria including Legionella. Prior
to administering antibiotics , three blood cultures were obtained at
PUO in addition to the two previously obtained at CHH . Sputum
sample was also sent for gram stain and C&S. All blood cultures
remained negative throughout the hospitalization. Sputum culture
showed only normal flora. When the second radiologist read the
chest x-ray as being inconsistent with lingular pneumonia , a more
aggressive search for possible endocarditis was undertaken. An
echocardiogram was performed on 8/19 that showed an aortic valve
with 40 mm gradient , 2-3+ AI , 1+ MR , mild LVF and no regional wall
motion abnormalities. There was no evidence of vegetation on the
echo. Side by side comparison of this echocardiogram with the
echocardiogram from 5/25 done at CHH showed no significant
interval change. An Infectious Disease consult was sought and it
was felt by these consultants that endocarditis was an unlikely
diagnosis given the lack of change in echocardiogram and lack of
additional signs of SBE. It was ultimately felt that the patient's
shortness of breath and elevated temperature were due to bronchitis
and he was switched to orally Bactrim to continue a ten day course of
therapy. Although the initial goal of his hospitalization was to
keep him hospitalized until cardiac catheterization and valve
replacement could be performed , the patient's personal situation
made it unfeasible to keep him in the hospital for a longer period
of time than absolutely necessary. Furthermore , there were
questions about whether cardiac catheterization and AVR should be
performed in someone being treated for presumed acute bronchitis
and whether his very poor orally hygiene and dental work can be
corrected prior to surgery. For these reasons , Dr. Bernas in
Cardiology was consulted as well as Dr. Mccomish in CHH Medicine and
both concurred that the patient could be discharged with close
follow-up by his primary care physician , Dr. Kintopp . His condition
on discharge was stable.
DISPOSITION: MEDICATIONS: On discharge included Bactrim DS , one
twice a day times seven days; imipramine , 50 mg orally every bedtime;
Colace , 100 mg three times a day; Nystatin , 5 cc swish and spit four times a day;
Alupent , two puffs every six hours.
HW854/0652
RUFUS BERNAS , M.D. DA4 D: 7/27/91
Batch: 5465 Report: J8741D75 T: 3/22/91
Dictated By: NAOMI K. WOLFENSPERGER , M.D.
Document id: 103
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
285271309 | PUO | 29811367 | | 6121133 | 10/27/2005 12:00:00 a.m. | LEFT FEMUR FRACTURE | Signed | DIS | Admission Date: 10/18/2005 Report Status: Signed
Discharge Date: 2/7/2005
ATTENDING: ECKLOFF , VERNA M.D.
HISTORY OF PRESENT ILLNESS: Ms. Medaries is a 79-year-old female
with a history of Ehlers-Danlos , osteoarthritis and left knee
replacement in 1998 , and left hip replacement in 2002 who was leaving her
primary care physician's office and was hit by the elevator door and fell to
the ground. She suffered a left periprosthetic fracture of her left distal
femur. She was initially admitted to Hoplukes I Rehabilitation Hospital where
she was found to have , by report , a closed distal femur fracture
between her prior ORIF and TKR with no neurovascular deficits.
Operative intervention was referred by Hoplukes I Rehabilitation Hospital due
to her medical problems and she was treated conservatively with
nonweightbearing and a knee immobilizer. Her course there was
significant for a hematocrit drop requiring 2 units of PRBC's as
well as being ruled out for an myocardial infarction. In addition , she also
had a negative MIBI test. She was transferred to Pagham University Of for further management.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis.
2. Osteoarthritis.
3. Hypertension.
4. Ehlers-Danlos.
5. GERD.
6. Ulcerative colitis , status post colectomy with colostomy.
7. Chronic stable angina.
8. Anxiety.
PAST SURGICAL HISTORY:
1. Status post bilateral TKR in 1998.
2. Status post left intramuscular rod for intertrochanteric fracture of the
left femur in 2002.
3. Status post left elbow replacement.
4. Status post lumbar laminectomy x 2.
HOME MEDICATIONS:
1. Atenolol 100 daily.
2. Folic acid daily.
3. Synthroid 0.088 mg daily.
4. Lipitor 10 daily.
5. Zoloft 50 daily.
6. Detrol 2 mg twice a day
7. Enalapril 10 mg twice a day
8. Celebrex 100 mg twice a day
9. Aspirin 81 mg daily.
10. Fosamax 1 Q.K.
ALLERGIES: Kefzol causes rash.
SOCIAL HISTORY: Lives in an apartment in Adelp Mother
recently deceased. No alcohol. No tobacco.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.8 , heart rate
75 , blood pressure 100/50 , respiratory rate 18 , and saturations
94% on room air. No acute distress. Regular rhythm and rate.
No murmurs , rubs , or gallops. Lungs , clear to auscultation
bilaterally. Abdomen was soft , nontender , and nondistended.
Positive for colostomy. Left lower extremity in knee
immobilizer , swollen and tenderness to palpation. Left lower
extremity slightly externally rotated. Bilateral EHL/tibialis
anterior/gastrocnemius intact distally with 5/5 motor. Sensation
to intact to light touch and SPN/DP/sural/tibial nerves/saphenous
distributions. Bilateral 2+ DP/physical therapy pulses bilaterally.
LABS ON ADMISSION: Sodium 137 , potassium 3.6 , chloride 114 ,
bicarbonate 26 , BUN 17 , creatinine 0.9 , glucose 148 , and calcium
9. White count 11.6 , hematocrit 39.6 , and platelets 170. INR
1.1 , physical therapy 14.2 , and PTT 21.7.
HOSPITAL COURSE: Upon admission to Pagham University Of ,
Ms. Medaries underwent an echocardiogram to rule out any cardiac
abnormalities. Her ejection fraction was revealed to be 50% with
no wall motion abnormalities and only mild aortic insufficiency.
She was determined to be medically stable to go the operating room by Internal
Meidicine. On January , 2005 , she underwent an open reduction and internal
fixation of her left femur fracture with a LISS plate placement.
Postoperative film showed good placement of hardware and good
alignment of her fracture. Her postoperative course was
complicated only by mild hypotension ( systolic blood
pressures in the 70s ) and by shortness of breath. She was
successfully treated with fluid boluses and inhaled nebulizers
respectively. Postoperative chest x-ray revealed lower lobe
atelectasis. Once she was more mobile by postoperative day #3 ,
her blood pressure and O2 saturation stabilized. The remainder
of her postoperative course was uncomplicated. She was kept on
perioperative antibiotics and as well as prophylactic Lovenox
while in house. She was kept touchdown weightbearing on her left
lower extremity. Her dressing was removed on postoperative day
#2. She was evaluated by physical therapy who worked with her to
increase her activity. She was deemed safe for discharge to
rehabilitation. Upon discharge , her left lower extremity was
neurovascularly intact. Her incision was clean , dry , and intact
and healing well. She is discharged in stable condition with
instruction to continue Lovenox and left lower extremity
touchdown weightbearing status until followup in clinic in two
weeks.
TO DO PLAN:
1. Touchdown weightbearing , left lower extremity.
2. Follow up with Dr. Compono in two weeks.
3. Continue Lovenox until next appointment with Dr. Compono .
eScription document: 1-4510180 ISSten Tel
Dictated By: WOLFENSPERGER , NAOMI
Attending: Compono , Jim
Dictation ID 7587511
D: 11/7/05
T: 11/7/05
Document id: 104
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
742375610 | PUO | 53267321 | | 1941053 | 11/10/2007 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 8/5/2007 Report Status: Unsigned
Discharge Date: 1/18/2007
ATTENDING: PANAGOS , FAITH M.D.
SERVICE:
The patient is admitted to the Renal Service.
PRINCIPAL DIAGNOSIS:
Fungemia.
LIST OF OTHER PROBLEMS AND DIAGNOSES:
1. End-stage renal disease on dialysis.
2. Diabetes mellitus.
3. Hypertension.
4. Hyperlipidemia.
5. MRSA osteomyelitis.
6. AV graft infection.
7. Spinal stenosis.
8. Paroxysmal atrial fibrillation.
9. CVA.
10. Depression.
BRIEF HISTORY OF PRESENT ILLNESS:
This is a 59-year-old woman with morbid obesity , history of
end-stage renal disease on hemodialysis , diabetes , hypertension ,
hyperlipidemia , MRSA osteomyelitis history of spinal fusion and cord compression , AV
graft infection , with multiple MICU transfers for sepsis and recurrent C.
difficile infections , and life-threatening epistaxis , who was doing relatively
well at rehabilitation when she was found to have yeast in her blood that
was identified on a surveillance culture drawn from her hemodialysis
tunneled catheter. The patient is asymptomatic. She has no
fevers or chills. No nausea or vomiting. The patient does
report some lightheadedness which she feels is her baseline. The
patient denies abdominal pain , melena , bright red blood per
rectum. She has baseline stool incontinence and has been having
loose stools. The patient denies any cough , chest pain ,
shortness of breath , palpitations or dyspnea. The patient states
that she is unable to move her bilateral lower extremities since
her spinal surgery. The patient also notes that her right upper extremity
edema has been resolving but began following AV graft removal.
PAST MEDICAL HISTORY:
1. End-stage renal disease on dialysis.
2. Diabetes mellitus with peripheral neuropathy , nephropathy ,
retinopathy.
3. Hypertension.
4. Hyperlipidemia.
5. MRSA osteomyelitis , status post spinal fusion in 8/13 for
cord compression.
6. AV graft infection status post removal in 8/13 .
7. Spinal stenosis.
8. Status post left below-knee amputation secondary to
osteomyelitis.
9. Recurrent C. difficile infections.
10. Paroxysmal atrial fibrillation.
11. CVA in 8/13 .
12. Anemia.
13. Depression.
14. Severe epistaxis in 8/13 .
15. Recent diabetic ketoacidosis in 8/13 .
16. History of hyponatremia.
MEDICATIONS AT REHABILITATION:
1. Nephrocaps one tab once daily.
2. Lopressor 37.5 mg orally four times daily.
3. Lactobacillus two tabs twice daily.
4. Folic acid 1 mg once daily.
5. Nexium 40 mg once daily.
6. Celexa 20 mg once daily.
7. Vitamin C 250 mg once daily.
8. Amiodarone 400 mg once daily.
9. Vancomycin 125 mg orally every 12 hours
10. Neutrophos three times daily.
11. Levaquin 250 mg every other day ( to end 4/18/07 ).
12. Humalog 4 units before every meal
13. NovoLin 12 units every day before noon
14. Heparin 5000 units subcutaneous Monday , Wednesday , Friday.
15. Reglan before every meal and at bedtime.
16. Cymbalta 30 mg every day before noon
17. Fentanyl patch 25 mcg every 72 hours
18. Humalog sliding scale.
19. Zemplar 2 mg intravenous Monday , Wednesday , and Friday.
20. Zinc 220 mg once daily.
21. Percocet as needed.
22. Vancomycin 1 g intravenous Monday , Wednesday , and Friday ( to end
4/18/07 ).
23. Saline nasal spray.
24. Zocor 80 mg at bedtime.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
The patient denies any tobacco , alcohol or illicit drug use. She
lives with her husband. She has several children. The patient
currently is in rehabilitation at Ligreen Weza Medical Center .
BRIEF PHYSICAL EXAMINATION AT TIME OF ADMISSION:
VITAL SIGNS: Temperature 98.1 , pulse 78 , blood pressure 128/45 ,
oxygen saturation 100% on room air.
GENERAL EXAM: The patient is morbidly obesity and ill-appearing.
She has a flat affect with reduced word-finding abilities.
HEENT: Pupils were equal , round and reactive. Extraocular
movements are intact. Mucous membranes are moist. There is no
thrush or epistaxis present.
NECK: Supple , there is no lymphadenopathy or thyromegaly. JVP
is not elevated although was difficult to appreciate secondary to
body habitus.
CARDIOVASCULAR: There is a regular rate and rhythm , normal S1
and S2. There is a holosystolic murmurs , 2/6 at the apex that
radiates to the axilla.
LUNGS: Clear to auscultation on anterior exam. There are no
wheezes , rhonchi or rales.
ABDOMEN: Obese , soft , with diffuse right-sided tenderness to
palpation. There is also right upper quadrant tenderness. There
is a negative Murphy's sign. No rebound tenderness or guarding.
There are distant bowel sounds present.
EXTREMITIES: There is 1+ right upper extremity edema. There is
1+ pitting edema of the right foot. Left leg demonstrate a
below-knee amputation.
NEURO: The patient is alert and oriented x3. Cranial nerves II
through XII are grossly intact. Strength is 4/5 in the bilateral
upper extremities and 3/5 in the bilateral lower extremities.
Reflexes are depressed throughout. There is a right-sided loss
of sensation of the lower extremities from the proximal thigh
down and sensation to light touch is intact on the left lower
extremity.
SKIN: Midthoracic spine is under dressing. The dressing is
clean , dry and intact. There is a sacral decubitus ulcer that is
under dressing. There is right groin maceration.
PERTINENT LAB VALUES:
Sodium 131 , potassium 5.2 , chloride 95 , bicarbonate 31 , BUN 16 ,
creatinine 2.4 , glucose 117. WBCs 14.4 , hematocrit 36.7 , and
platelets 343. There are 61.5% neutrophils. INR 1.0 , PTT 28.9.
ALT 15 , AST 46. Total protein 6.5 , albumin 20. GGT 220.
Alkaline phosphatase 513 , total bilirubin 0.7 , calcium 7.7.
DIAGNOSTIC STUDIES:
A chest x-ray revealed bilateral pulmonary edema and a small
left-sided pleural effusion as well as a layered basal
right-sided pleural effusion.
HOSPITAL COURSE BY PROBLEM:
This is a 59-year-old morbidly obesity woman with a history of
diabetes , end-stage renal disease on hemodialysis with a recent
AV graft infection , sepsis , thoracic cord compression status post
fusion secondary to MRSA osteomyelitis , recurrent C. difficile infections ,
life-threatening epistaxis , who was status post embolization , who
is now admitted to the Renal Service with suspected fungemia
thought to be associated with her tunneled catheter. The
patient , however , is asymptomatic and hemodynamically stable.
1.. Infectious Disease: The patient had a positive blood
culture identified on surveillance blood cultures. The patient
was initially started on micafungin intravenous while speciation and
sensitivities were pending. The patient received five days of
micafungin intravenous 100 mg intravenous daily. Cultures then came back with
Candida glabrata that was sensitive to fluconazole. At that
time , she was converted over to orally fluconazole 400 mg once
daily. Surveillance blood cultures with fungal isolators were
sent on a daily basis while in the hospital , all of which have come back
negative to date. The patient also had her tunneled catheter line pulled on
10/1/07 . She was evaluated by Ophthalmology to rule out
endophthalmitis and was determined not to have evidence of this.
She also received a transthoracic echocardiogram to rule out
vegetation. The patient has a history of MRSA osteomyelitis with
a cord compression status post decompression with hardware and
was continued on levofloxacin and intravenous vancomycin which was
scheduled to continue until 4/18/07 . Blood cultures from
1/25/07 grew out VRE bacteremia , and the patient was at that
time converted from intravenous vancomycin to linezolid 600 mg orally
twice daily on 9/27/07 . She also received one dose of
gentamicin 80 mg intravenous x1. A new tunneled catheter had been placed
on 3/7/07 and given that the blood cultures was VRE grew back
positive on 1/25/07 , it was certain that the new tunneled
catheter was not the source of VRE and the decision was made to treat
through the line. All subsequent blood cultures from 9/27/07
and 2/28/07 are all negative to date. The patient had one
temperature spike to 101 degrees , and she was recultured of these
cultures which were negative. She also had a repeat chest x-ray
which showed only minimal atelectasis and no evidence of
pneumonia. The patient subsequently defervesced. And has been afebrile for
over 72 hours. Also , of note ,
the patient had a history of C. difficile. She was continued on orally
vancomycin for suppression. She did continue to have numerous
loose stools during the hospitalization and C. difficile cultures
were sent twice on 6/8/07 and again on 3/7/07 , both of which
were negative. Also , of note , the patient has sacral decubitus
ulcer that was watched closely for infection.
2. Renal: As noted above , the patient's tunneled catheter was
removed as it was deemed the most likely source of her fungemia.
She was dialyzed once through her temporary femoral line and
tunneled catheter was then placed on 3/7/07 and the patient was
dialyzed approximately every two days with the last dialysis on
10/11/07 . The patient is due for hemodialysis on 7/14/07 .
3. Heme: The patient has a history of anemia that is consistent
with chronic disease. She received 1 unit of packed red cells
during her hospitalization.
4. Gastrointestinal: The patient , on admission , had right upper
quadrant tenderness with an elevated alkaline phosphatase and
GGT. A right upper quadrant ultrasound was obtained and to rule
out biliary obstruction. This study showed a normal liver. A
gallbladder with a few small stones as well as sludge ,
gallbladder wall thickness was normal. There was no sonographic
Murphy's sign , and biliary tree was noted to have a dilated
common bile duct of 7 mm that was unchanged and distal ducts were
not well seen. The intrahepatic ducts were noted to be normal.
The patient's Zocor , however , was held in the setting of elevated
LFTs. Abdominal pain resolved on hospital day 2 and LFTs trended to normal.
Also , of note , the patient had a history of C. difficile
as noted above. She continued to have diarrhea although her C.
difficile cultures were negative. She was treated
symptomatically with Lomotil. A rectal tube was also placed
given her diarrhea and increased pain with soiling of ulcer as well as risk of
infection. Rectal tube should be continued in rehab to prevent
infection of the sacral ulcers.
5. Cardiovascular: The patient has a history of paroxysmal
atrial fibrillation with RVR and was continued on her Lopressor ,
amiodarone. She did not have any episodes of rapid ventricular
rate , nor any episodes of hemodynamic instability or
hypertension.
6. Neuro: The patient has bilateral lower extremity weakness
and loss of sensation of the right lower extremity likely
sequelae of recent cord compression , per Neuro notes in the
medical record from 11/22/06 . The patient also had an episode of
acute delirium. As a result , her Reglan was discontinued as was
her fentanyl patch and her mental status improved although she
still had baseline memory deficits. Psychiatry was consulted and
recommended tapering her Celexa and Cymbalta in the setting of
waxing and waning mental status. The patient has also been
counseled to avoid oxycodone or any other narcotics for pain
control and to try to only use Tylenol.
7. Derm: The patient has a sacral as well as right heel
decubitus ulcer. The wound nurse was consulted , and the patient
received Panafil ointment to the sacral ulcers twice daily.
Sacral wound is to be irrigated with warm saline and then Panafil
is to be applied to open areas twice daily , and then wound is to
be dressed with dry sterile dressing , all twice a day. The
patient has sutures in place from thoracic spinal fusion.
Orthopedics was consulted to remove some of the sutures.
Approximately , 50% of the sutures , however , were not ready to
come out , and the patient should follow up with Dr. Rossie K Mankoski on 1/12/07 for removal of the remaining sutures. This
area should be evaluated at least daily and dressings changed
once daily with dry sterile dressings.
8. Vascular: The patient was noted to have oozing at the site
of her old AV graft and the right antecubital fossa on 7/25 . Vascular
Surgery was consulted and evacuated a hematoma on 7/25 . This wound is to be
dressed with 2 x 2s , soaked to normal saline and is to be changed
three times daily. The patient is to follow up with Dr. Stacie C Halechko from Vascular Surgery in two weeks to evaluate this wound
site.
9. Psychiatry: The patient had a flat affect and was thought to
be appropriately depressed in past hospitalizations. She was
initially continued on Cymbalta and Celexa. Psychiatry was
consulted and felt that the patient was demonstrating some
delirium , but she was currently not depressed and recommended that
her Cymbalta and Celexa be tapered. She is currently in the
process of being tapered , and this taper should continue as noted
in the discharge medication section.
10. Pain: The patient was initially treated with fentanyl and
oxycodone per rehabilitation regimen. Her fentanyl patch was
quickly discontinued in the setting of one episode of acute
delirium. Her oxycodone was continued and she required
approximately 10 mg of oxycodone daily. She , however , has been
counseled to try to wean herself off of oxycodone , and use only
Tylenol for pain given propensity to delirium.
11. HEENT: The patient had a history of severe epistaxis. She ,
however , has not had any epistaxis during this admission. She
was continued on saline nasal sprays.
12. Fluids , Electrolytes , and Nutrition: The patient was seen
by Nutrition consultants. Her zinc and vitamin C were
discontinued to avoid copper deficiency. She was started on
Megace 400 mg twice daily , and she was placed on a liberal diet
to encourage orally intake. The patient required some electrolyte
repletion including repletion of phosphate and potassium. Of
note , phosphate should not be repleted with Neutrophos but with
sodium phosphate for phosphates less than 1.5 possibly
given the potassium load and Neutrophos. At time of discharge however patient
did not have intravenous acess. Patient should recieve one dose of neutraphos 1 packet
x1 upon arrival to rehab. She should then have a basic metabolic panel checked
on 2/12/07 to ensure her potassium is normal.
13. Prophylaxis: The patient was continued on subcutaneous
heparin as well as a PPI.
CODE:
The patient is a full code.
HEALTHCARE PROXY:
Mr. Hobert Brasil , telephone number 793-680-4343.
LAST PERTINENT TESTS AT TIME OF DISCHARGE:
Sodium 136 , potassium 3.7 , chloride 104 , bicarbonate 22 , BUN 9 ,
creatinine 2.2 , glucose 116 , magnesium 1.7 and phosphate 1.0.
ALT 6 , AST 31. Alkaline phosphatase 189 , total bilirubin 0.6.
White blood cell count 11.8 , hematocrit 27.6 , and platelets 295.
physical therapy 1.2 and PTT 24.9.
KEY FEATURES OF PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE:
VITAL SIGNS: Temperature 98.9 , blood pressure 108/60 , heart rate
76 , respiratory rate 20 , oxygen saturation 99-100% on room air.
GENERAL: On general exam , the patient is no acute distress. She
has a flat affect with some word-finding difficulties.
HEENT: Pupils are equal , round and reactive to light and
accommodation. Extraocular movements were intact. Sclerae are
anicteric. Oropharynx is clear. Mucous membranes are somewhat
dry.
PULMONARY: Lungs are clear to auscultation on the anterior exam.
CARDIOVASCULAR: There is a regular rate and rhythm , normal S1
and S2. A II/VI holosystolic murmur at the apex with radiation
to the axilla.
ABDOMEN: There are positive bowel sounds. Abdomen is obese ,
soft , nondistended and nontender. There is no rebound tenderness
or guarding.
EXTREMITIES: There is trace edema of the right lower extremity
at the shin and no edema of the left lower extremity. Both
extremities are warm and well perfused. There is 1+ dorsalis
pedis pulse of the right foot.
NEURO EXAM: The patient is alert and oriented x3. She has her
baseline lower extremity weakness that is unchanged from initial
exam at the time of admission.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed for pain.
2. Amiodarone 400 mg orally every day before noon
3. Celexa 10 mg orally daily x1 dose on 7/14/07 , then
discontinue.
4. Lomotil two tabs orally four times daily as needed for
diarrhea.
5. Nexium 40 mg orally daily.
6. Fluconazole 400 mg orally daily until 1/12/07 .
7. Folic acid 1 mg orally daily.
8. NovoLog sliding scale.
9. NovoLog 4 units subcutaneous before meals
10. Insulin NPH 8 units subcutaneous twice a day
11. Lactinex granules two tabs orally three times daily.
12. Levofloxacin 250 mg orally every 48 hours , to continue until
4/18/07 .
13. Lidoderm patch 5% , place one each daily to buttocks.
14. Linezolid 600 mg orally every 12 hours for 11 days , to end 1/6/07 .
15. Maalox tablets one to two tabs orally every six hour as needed
for an upset stomach.
16. Milk of magnesia 30 mL orally daily as needed for
constipation.
17. Megace 400 mg orally daily.
18. Lopressor 37.5 mg orally four times daily.
19. Miconazole nitrate 2% powder topically twice a day
20. Nephrocaps one tab orally daily.
21. Oxycodone 5-10 mg orally every 4 hours as needed for pain.
22. Panafil ointment topically to open areas in the sacral ulcer
twice daily.
23. Seroquel 25 mg orally daily as needed for agitation.
24. Saline nasal drops two sprays in each nares four times
daily.
25. Trazodone 25 mg orally at bedtime as needed insomnia.
26. Xenaderm topically TP twice a day
27. Vancomycin 125 mg orally every 12 hours , to continue five days until
all other antibiotics are discontinued.
28. Cymbalta 20 mg orally every day before noon for one dose on 1/23/07 , then
Cymbalta 10 mg orally daily for one dose on 7/11/07 , then
discontinue Cymbalta.
29. Zemplar 2 mg intravenous Monday , Wednesday , and Friday.
30. Heparin 5000 units subcutaneous three times a day
31. Neutraphos 1 packet orally x1 upon arrival to rehab
DISPOSITION:
The patient will be discharged to rehabilitation.
PENDING TESTS:
At the time of discharge , the patient has multiple blood cultures
that are pending that should be followed up by physicians at her
rehabilitation.
FOLLOW-UP PLANS:
Please note the patient is due for hemodialysis on 7/14/07 . The
patient should go to her scheduled follow-up appointment with Dr.
Donnette Innarelli of Infectious Disease on 1/30/07 at 10:00 a.m.
She should also go to her follow-up appointment with Dr. Rossie K Mankoski from Orthopedics on 1/12/07 at 9:45 a.m. for evaluation
of her sutures and possible removal at that time. The patient
should also follow up with Dr. Stacie Halechko from Vascular
Surgery in two weeks. She should call the office for an
appointment. The telephone number is 931-223-3069.
The patient is a full code. Her healthcare proxy is Mr. Hobert D Brasil , telephone number 793-680-4343.
PRIMARY CARE PHYSICIAN:
Romona Ranno , M.D.
eScription document: 4-4589403 EMSSten Tel
CC: Donnette Innarelli M.D.
KTDUOO
CC: Rossie Mankoski M.D.
Tbro Hospital
T Van Virg
CC: Stacie Halechko MD
PAGHAM UNIVERSITY OF Na , DIVISION OF VASCULAR SURGERY
Harmna Dr
CC: Romona Ranno M.D.
Va Covea .
Nash Gas Boise
Dictated By: YEAGLEY , MA
Attending: PANAGOS , FAITH
Dictation ID 6706840
D: 10/25/07
T: 10/25/07
Document id: 105
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639512267 | PUO | 07902746 | | 8144438 | 3/13/2005 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 10/26/2005 Report Status: Signed
Discharge Date: 6/17/2005
ATTENDING: VAJDA , FRANCISCO M.D.
SERVICE: MBTH Internal Medicine
ADMISSION DIAGNOSIS: Recurrent syncope.
PRINCIPAL DISCHARGE DIAGNOSIS: Cardiac amyloidosis ,
hypertension , coronary artery disease , left popliteal DVT.
OPERATIONS AND PROCEDURES: None.
OTHER PROCEDURES NOT DONE IN THE OPERATING ROOM: PICC line
placement on 1/22/05 .
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
African-American woman with chronic renal insufficiency , coronary
artery disease , and diabetes and recent admissions for syncope
who was admitted after being found unresponsive and blue with a
systolic blood pressure in the 80s in the bathroom of her nursing
home. Her systolic blood pressure came up to 100 without
intervention , but she was sent to A Salt Medical Center ER for further evaluation. In the ER , her head and
spine CT was negative , her chest x-ray showed right effusion and
her cardiac enzymes were elevated with a troponin of 0.50. She
was given Lovenox , Zofran , and aspirin and admitted for further
management.
PAST MEDICAL HISTORY: Coronary artery disease , diabetes ,
cerebrovascular accidents , cortical blindness , hypertension ,
anemia , monoclonal gammopathy , left upper extremity
thrombophlebitis.
MEDICATIONS AT NURSING HOME: Colace , Nexium , Senna , oxycodone
as needed , aspirin , Plavix , Lopressor , Lipitor , and NPH insulin.
ALLERGIES: Penicillin , sulfa and propoxyphene.
ADMISSION PHYSICAL EXAMINATION: Temperature 98.4 , blood pressure
110/80 , pulse 92 , respirations 95% on room air. The patient was
alert and oriented x1 , she was just alert and oriented to person.
Her neck vein showed a JVP less than 8 cm. Her chest was clear
to auscultation but decreased breath sounds on her right base
were noted. She had regular rate and rhythm. Abdomen was soft
with bowel sounds , nontender. Extremities remarkable for 2+
pitting edema , which were symmetric.
REMARKABLE LABS ON ADMISSION: BUN 67 , creatinine 2.6 , white
blood cell count 6.2 , hematocrit 44 , platelets 136 , BNP 880 ,
troponin 0.5.
PERTINENT RADIOLOGIC STUDIES DURING ADMISSION: CT scan to rule
pulmonary embolus on 3/25/05 was negative. Multiple chest
x-rays showed unchanged right pleural effusion , which was small
and not amenable for thoracentesis. ECG showed normal sinus
rhythm at 90 beats per minutes , low voltage , incomplete right
bundle-branch block , left axis deviation , Q-waves inferior and
anterior , no ST depressions or elevations. This was no
significant change from EKG that was done on 2/3/05 . Lower
extremity ultrasound on 10/21/05 showed left popliteal vein
thrombosis.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: The patient had troponin elevations during
this hospitalization , the highest being 0.8. This was initially
thought to be consistent with a non ST elevation. However ,
patient had no EKG changes. It was also noted that the patient
had similar elevations of her troponin and was recently admitted
to an outside hospital. She was initially continued on cardiac
regimen of aspirin , Plavix , and Lopressor. On 10/21/05 , the
patient had an episode of hypotension with systolic blood
pressure in the 30s of unknown etiology. She was given intravenous
fluids , dexamethasone 4 mg and one dose of gentamicin and
vancomycin for presumed sepsis. A bedside echo that was done
showed severe tricuspid regurgitation , diastolic dysfunction and
ejection fraction of 40% and pulmonary pressures in the 60s.
There were wall motion abnormalities that were noted. The
patient was given additional doses of intravenous fluids and her
blood pressures came back to 120s-130s/60s-70s. At this point ,
the etiology of her low blood pressure was still unknown. On
2/16 , patient was again unresponsive with low blood pressure and
no pulse. Code was called and the patient awoke after few chest
compressions was done and had a blood pressure of 130s/70s. She
was subsequently seen by Dr. Haywood Sasnett , cardiologist at Pagham University Of , who thought her overall picture and
echocardiogram was consistent with cardiac amyloidosis. The
patient was thought to have autonomic insufficiency secondary to
amyloid neuropathy and a fixed cardiac output with restrictive
heart. Serum protein analysis subsequently revealed a
predominance of IgG light chains with elevation of both kappa and
lambda light change , which are suggestive but not confirmatory of
type AL amyloidosis. A fat pad biopsy was also done , results
were pending at discharge. Further blood samples were sent to
Lowai Aham Valley Medical Center for further
analysis. The patient will obtain results via her primary care
physician , Dr. Genny Barrette . Of note , the patient had no
further hypotensive episodes prior to discharge.
2. Hematology: The patient was noted to have a low platelet
count of 136 , 000 at admission. It was thought that this could
be due to possible heparin-induced thrombocytopenia but the hep
antibody was negative. On 4/30/05 , lower extremity ultrasound
done after first episode of being unresponsive was positive for
left popliteal vein thrombosis. The patient was started on
heparin intravenous according to protocol. On 10/12/05 , the
patient had nosebleeds and hematuria and her PTT was noted to be
greater than 150. Heparin was stopped until the PTT was between
60 and 80. The bleeding stopped. She was continued on heparin
and her PTT was maintained between 60 and 80. She was later
switched to Lovenox and Coumadin maintaining her INR between 2
and 3. Lovenox was discontinued and on discharge the patient was
just on Coumadin. Her discharge INR was 2.4.
3. Renal: The patient has chronic renal insufficiency with
baseline creatinine of 2.5. A Foley was placed at admission for
patient comfort. She consistently had low urine output during
her hospitalization , averaging about 300-400 cc of urine a day
even after intravenous fluid administration. She had two days of
hematuria secondary to anticoagulation that resolved after
copious irrigation of the Foley. Her creatinine at discharge was
2.7. There were no acute renal issues.
4. Pulmonary: The patient required oxygen throughout her stay
to keep her saturations above 95%. She had a few episodes of
shortness of breath , which spontaneously resolved. She was given
a few doses of intravenous Lasix and this helped a little with her
shortness of breath , but her chest x-ray remained unchanged from
admission.
5. Endocrine: The patient has a history of diabetes. She had
normal fingersticks during her hospitalization. She was on a
tight glycemic control with a regular insulin sliding scale.
6. Neuro: The patient was on aspirin and Plavix initially given
her history of CVAs and cortical blindness , but on discharge , she
was on Coumadin for anticoagulation. The patient also had a
lidocaine patch that was applied for 12 hours every day and
oxycodone was used as needed pain.
7. Fluids , electrolytes , and nutrition: The patient received intravenous
fluid boluses during hypotensive episodes. Electrolytes were
followed and repeated accordingly. Nutrition was consulted and
she was placed on a soft pureed diet with a 2-L fluid
restriction , no concentrated sweets. She was also given Nepro
supplements given her renal function.
8. Line: The patient initially had an EJ line , then a femoral
line for access as peripheral access was difficult to obtain.
She then had a PICC line placed on 1/22/05 for access.
9. Disposition: There was a family meeting on 1/22/05 during
which the patient's poor prognosis was discussed with Ms. Penny O Rizas , the patient's daughter. The family emphasized that her
code status was DNR/DNI and they were comfortable with the
discharge back to Highot Pkwy. , Ler , Missouri . They also emphasized that the
patient should be rehospitalized for any acute issues.
10. Code status: DNR/DNI.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally daily , and Colace 100
mg orally twice a day , Pepcid 20 mg orally every bedtime , regular insulin sliding
scale , Lopressor 25 mg orally three times a day , oxycodone 5-10 mg orally every 4 hours
as needed pain , senna tablets two tablets orally twice a day , multivitamins
with minerals one tab orally daily , trazodone 50 mg orally every bedtime
as needed insomnia and anxiety , Coumadin 5 mg orally every afternoon , MS Contin
15 mg orally every 12 hours as needed pain , Lipitor 80 mg orally daily , Plavix
75 mg orally daily , midodrine 5 mg orally three times a day , DuoNeb 3/0.5 mg
inhaled every 6 hours as needed wheezing , lidocaine 5% patch applied
topically daily for twelve hours.
DISCHARGE INSTRUCTIONS: The patient was told to call her doctor
for increased shortness of breath , chest pain , fevers or any
other concerns. She was also told to follow up with her primary
care physician as needed.
DISCHARGE CONDITION: Stable. The patient is to be transferred
to Ford Glendcalari No Angelessa where she would be under the care of her
primary care physician , Dr. Genny Barrette .
eScription document: 0-0128264 CSFocus transcriptionists
Dictated By: KILDOW , KEVA
Attending: VAJDA , FRANCISCO
Dictation ID 0608721
D: 10/4/05
T: 10/4/05
Document id: 106
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838440387 | PUO | 59556390 | | 772549 | 2/5/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 8/6/1990 Report Status: Unsigned
Discharge Date: 11/9/1990
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE AND UNSTABLE ANGINA.
HISTORY OF PRESENT ILLNESS: Ms. Rothman is a 66 year old woman status
post a double coronary artery bypass
graft with endarterectomy fourteen years ago. She developed angina
six months ago and has suffered unstable angina over several days.
Her coronary catheterization results on 2/28/90 showed severe
occlusion of her saphenous vein graft and l00% occlusion of her
left anterior descending. An echocardiogram showed excellent left
ventricular function. An intraaortic balloon pump was placed
relieving her intractable angina. PAST MEDICAL HISTORY:
Significant for , in l976 , chest pain and shortness of breath where
she was admitted to A Salt Medical Center for
catheterization , coronary artery bypass graft , and coronary
endarterectomy. She had no chest pain until six months prior to
admission. She was , at that time , on Inderal , , and
Aspirin. Six months prior to admission , she developed recurrent
typical angina and on 19 of March , she developed chest pain at rest when
she went to Put Wathern Hospital and ruled out for a myocardial
infarction. On 20 of January , she had recurrent chest pain with ST
depressions in V3 through V5 and she was transferred here. Past
medical history is significant for as above plus hypertension and
hysterectomy. CURRENT MEDICATIONS: On transfer were Aspirin ,
Diltiazem 60 every 6 hours , Inderal 40 every 6 hours , and Xanax 0.25 as needed
ALLERGIES: She has allergy to Penicillin which causes a rash.
FAMILY HISTORY: She has a positive family history for coronary
artery disease.
PHYSICAL EXAMINATION: She was a healthy appearing woman in no
apparent distress. HEENT: Normal. NECK:
Supple. She had no costovertebral angle tenderness on her back.
LUNGS: Had bibasilar rales. HEART: Showed a point of maximal
intensity at the seventh intercostal space , regular rate and
rhythm , and Sl and S2 normal. She had an S4. Her jugular venous
pressure was flat , her jugular veins were undistended. ABDOMEN:
Positive for bowel sounds and she did not have hepatosplenomegaly
or palpable masses. EXTREMITIES: Without edema. PULSES: Her
carotid pulses were 2+ on both sides without bruit , her femorals
were 2+ with a bruit on the right and no bruit on the left , and her
dorsalis pedis pulses were 2+ bilaterally as well as her posterior
tibialis pulses. NEUROLOGICAL: Her cranial nerves II-XII were
intact. Her motor examination was 5/5 throughout. Her reflexes
were 2+ throughout with downgoing toes.
LABORATORY EXAMINATION: Her EKG showed ST depressions with
biphasic T. Her chest X-Ray from Forestblan Conwake Hospital
was normal without congestive heart failure.
HOSPITAL COURSE: On 4/16 , she had an operation to redo her
coronary artery bypass graft done by Dr. Colasamte .
Post-operatively , she had some difficulty weaning from
cardiopulmonary bypass. She continued to do well without evidence
of ectopy. She was in a normal sinus rhythm and is to be
discharged.
DISPOSITION: DISCHARGE MEDICATIONS: Ecotrin 325 mg orally every day ,
Inderal 20 mg orally four times a day , and Bactrim DS one tablet
orally twice a day times seven days. There were no complications. She
was stable on discharge. Disposition is to home. Follow-up within
a week by her own doctor.
________________________________ IJ933/1538
ISABELLE E. COLASAMTE , M.D. CL7 D: 10/15/90
Batch: 5074 Report: I3567T1 T: 3/5/90
Dictated By: LOWELL BANOS , M.D.
cc: ANDNOCK STOWNCHILD MEDICAL CENTER
Document id: 107
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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472709336 | PUO | 85841461 | | 5856619 | 9/7/2003 12:00:00 a.m. | CAD | | DIS | Admission Date: 3/25/2003 Report Status:
Discharge Date: 10/2/2003
****** DISCHARGE ORDERS ******
MCCOO , JENNINE 122-63-50-9
Ofox Street , Hou Vall , Pennsylvania 81697
Service: RNM
DISCHARGE PATIENT ON: 4/17/03 AT 04:00 PM
CONTINGENT UPON Home services
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FRIBLEY , NOVELLA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ENALAPRIL MALEATE 7.5 MG orally twice a day HOLD IF: b/p<100 systolic
Instructions: Hold on the mornings of dialysis
Alert overridden: Override added on 7/20/03 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: monitoring K Previous Alert overridden
Override added on 7/20/03 by MUSGRAVES , LEONA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: Monitoring K. Previous override reason:
Override added on 6/12/03 by MUSGRAVES , LEONA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: patient needs for his heart. Is on HD ,
will monitor his K. Previous Alert overridden
Override added on 6/12/03 by MUSGRAVES , LEONA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: on dialysis , will monitor K. needs
ACE for heart.
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 2 UNITS subcutaneously every day before noon
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 3 UNITS subcutaneously every afternoon
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Instructions: Hold on the mornings of dialysis
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 200 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: House / ADA 2000 cals/day / Low saturated fat
low cholesterol / Renal diet
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Renal Doctor MWF ,
Dr. Bingman 1-2 weeks ,
Dr. Stautz , cardiology 2 weeks ,
ALLERGY: Lisinopril , Zocor ( hmg coa reductase inhibitors )
ADMIT DIAGNOSIS:
hypercalcemia , hyperkalemia. CHF.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
1. NIDDM 2. AI/AS , bicuspid aortic valve , LVH 3. HTN 4. history of
thyroglossal duct cyst excision 5. history of
noncompliance with meds cad ( coronary artery
disease ) ESRD ON HD ( end stage renal disease ) CHF , unclear etiology
( congestive heart failure ) hyperlipidemia
( hyperlipidemia ) history of syphilis ( history of syphilis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Routine Hemodialysis
Right heart catheterization
BRIEF RESUME OF HOSPITAL COURSE:
56M with SOB admitted on 3/30 . Hx of ESRD on HD ,
CHF with EF of 25% , DM , HTN. patient became acutely sob on 3/18 at rest ,
but then states sob for a few days. No cp , occasional epigastric
burning. +PND , sleeps on 1 pillow , no LE
edema. CV January Cath 90% LAD , 80% Ramus , 80% LCx. EF
25%. No chest pain complaints. +Troponin likely
due due demand ischemia from volume overload. patient
on ASA , Lopressor which was increased over 2
days , Nitrates , and ACE-inhaled patient will maximize
medical management of CV status , and dialysis done 1/1 .
Cardiology Consult 1/1 for Troponin rising to 2.9 ?if CABG candidate ,
cards suggesting med mgt. Increased the lopressor with goal b/p
<130. Troponin max 2.99 on 1/1 . RHcath after
dialysis 6/21 showed increased filling pressures
and adenosine mibi on 10/13 showed minimal ischemia
of inferior-lateral wall and ?defect in
anterior wall. Will switch to Toprol XL 200 every day 6/8 p
HD. 10/2 12 beats , and 6/21 7 beats VT. follow
lytes , will hold off on further intervention for now
per cardiology. ( fellow #08449 ) BNP after
dialysis >assay.
FEN ) Hypercalcemia 15 on admission. patient recieving 50mg of Calcitonin
subcutaneously PTH pending , SPEP pending. May also be related to Phos Lo or
tert. Hyper pth. Hyperkalemia without T wave peaking.
Kayexelate given with Lactulose with good results. Repeat
K improving , dialysis
MWF. PULM ) SOB with hypoxia on admission from CHF.
No clear infiltrates. Doing well on NC O2. On
review of Cxr there is ?consolidation LLL. If
spikes then culture and add pna
coverage. GI ) Constipation likely related to
hypercalcemia. patient on agressive bowel
regimen. RENAL ) ESRD on HD. Dialysis per Renal team. patient
did recieve Vit D recently which may also have con tributed to
hypercalcemia. ENDO ) patient put on decreased NPH regimen. bs of
56 on 3/30 , patient given D50x1 and NPH decreased further.
Will try to maintain tight glycemic control. ADA diet. Last A1C 8.3
in 5/29 . HEME ) Hct high normal , ?intravascularly dry ,
but CHF on exam and CXR. TP increased with
nl albumin. SPEP and UPEP pending , patient did
have increased gamma on spep in 5/29 , but no
monoclonal spike. Also hx of a-phospholipid ab , but no hx
of clotting.
??? )Ant mediastinal mass , stable in appearance on CXR. Will need f/u
as outpatient.
ADDITIONAL COMMENTS: Call your doctor for any chest pains , dizziness , trouble breathing ,
fevers >100.4 , or any other concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up chest CT
Check SPEP , PTH labs
No dictated summary
ENTERED BY: MUSGRAVES , LEONA , M.D. ( KY463 ) 4/17/03 @ 01:22 PM
****** END OF DISCHARGE ORDERS ******
Document id: 108
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
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- |
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- |
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510916525 | PUO | 07122247 | | 760322 | 7/21/2002 12:00:00 a.m. | chf | | DIS | Admission Date: 9/17/2002 Report Status:
Discharge Date: 9/1/2002
****** DISCHARGE ORDERS ******
FULVIO , ANGILA P 456-02-11-5
A Us A , FL
Service: CAR
DISCHARGE PATIENT ON: 3/23/02 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SPRAGLIN , SHONNA ARDIS , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally every day
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 100 MG orally every day HOLD IF: sbp < 90 , HR < 50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COLCHICINE 0.6 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
ZENICAL 120 MG orally every day
TRICOR 54 MG orally every day
ZOCOR ( SIMVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 3/12/02 by :
SERIOUS INTERACTION: GEMFIBROZIL & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: GEMFIBROZIL & SIMVASTATIN
Reason for override: monitoring
LASIX ( FUROSEMIDE ) 80 MG orally every day
ACARBOSE 25 MG orally three times a day
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr Spraglin , 9/9/02 @ 10:40 am ,
Dr Bufford in GI , 10/24/02 @ 1:00pm ,
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
SOB
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
lad stent 2/14 dm ( diabetes mellitus ) obesity
( obesity ) hyperchol ( elevated cholesterol ) gout
( gout ) emphysema ( chronic obstructive pulmonary disease ) renal
insufficiency ( chronic renal dysfunction ) sick sinus syndrome ( sick
sinus syndrome ) pacemaker
Heme + stools with AVM in ascending colon ( cauterized )
OPERATIONS AND PROCEDURES:
EGD
Colonoscopy
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
patient is a 68 year-old male with history of CAD history of PTCA ( LAD and
RCA ) , newly dx DM on actos , CHF ( diastolic dys fxn ) with EF 50% , PVD ,
history of PM placement who presented with increasing sob and doe
over last 6 mo. patient reports this all started after
his d/c from PUO 6 mo ago when he was diagnosed
with DM and started on actos. He reports increasing
DOE and is now unable to walk to the BR
without getting sob. patient denies any chest pain
since his last PTCA in 3/5 . He denies any dietary
or medical noncompliance and denies any weight
gain recently.
He denies orthopnea , PND although he does have OSA nad sleeps with
CPAP , but notes increasing LE edema over the past few weeks as well.
patient also c/o melena and BRBPR starting 1 mo ago. He has
also had a 8 point hct drop since his last admission.
+ increased fatigue , no abd pain , reports
neg sigmoidoscopy 4 mo ago at TH . Lastly patient c/o
B/L LE stiffness/wobbliness , new over past few
mos. PE:
VSS HEENT: PERRLA , EOMI , L strabismus , OP mosit
NECK: JVP not able to be assessed CVS: distant
heart sounds , RRR , nml s1/s2 , no m/r/g CHEST:
bilateral crackles 1/2 way up , no wheezes ABD:
obese , no hepatomegally , ND , + BS , mild RUQ
tenderness EXTREM: 2+ edema to knees b/l , good pulses
B/L RECTAL: FOBT + in ED , no
melena CARDS: ISCHEMIA R/O'd MI , on asa , plavix ,
bb , no ace 2nd to renal fxn PUMP-acute
failure , diurese aggressively with 80 intravenous lasix twice a day ,
follow lytes , I/O , weights PULM- congestion and
edema secondaryto CHF , diuresing GI- FOBT + with
hct drop , GI saw patient , EGD was nml and
colonoscopy revealed a polyp which was removed and an AVM
in the ascending colon which was cauterized. patient is to follow up in GI
clinic for further
evaluation. Most likely source of bleeding was the AVM but
patient reports history of melena and had a clean EGD ,
possible that he also has some AVMs in the small intestine that were
not actively bleeding at this time. HEME: hct 31.4 , tx if < 28 ENDO-
off actos , no SSI at this time , nutrition met with patient regarding d
iet , hga1c is 6.6 , patient did not tolerate actos and metformin
contraindicated secondary to renal
insufficiency , patient started on acarbose 25 three times a day at time of discharge
RENAL- at BL
( 2.2-3.3 ) , will follow with diuresis LE discomfort- likely secondary
edema as it is improving with diuresis
patient was discharged to home in satble conditionto follow up with Dr Bufford
in GI and DR Spraglin in cardiology
ADDITIONAL COMMENTS: Please call your doctor or return to the hospital if you have
increasing sob , weight gain or edema in your legs. Please continue to
take your lasix daily and continue a low salt , low fat and low
concentrated sweets diet. If you have any chest pain take a sublingual NTG x 3
every five minutes and call your doctor or 911 if it does not resolve.
If you continue to have blood in your stools or continue to have black
stools please call the GI doctors at 473-999-4367 and schedule an appt.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BENADOM , EMERITA ETHA , M.D. ( MG66 ) 3/23/02 @ 09:28 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 109
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
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856450649 | PUO | 99098383 | | 772416 | 3/10/2002 12:00:00 a.m. | lower GI bleed | | DIS | Admission Date: 11/13/2002 Report Status:
Discharge Date: 3/26/2002
****** DISCHARGE ORDERS ******
CUBETA , LEOLA T 685-91-92-4
Warsouth Tempe
Service: MED
DISCHARGE PATIENT ON: 2/5/02 AT 01:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LOSAVIO , LEZLIE MELODI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
ALLOPURINOL 300 MG orally every day
FOLATE ( FOLIC ACID ) 1 MG orally every day
ZESTRIL ( LISINOPRIL ) 10 MG orally twice a day
Alert overridden: Override added on 9/15/02 by
MASSI , TERISA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
OXYCODONE 5-10 MG orally every 4 hours as needed joint pain
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
TORSEMIDE 20 MG orally twice a day
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: apply to groins
CELEXA ( CITALOPRAM ) 20 MG orally every day
Override Notice: Override added on 9/14/02 by
RUBIANO , ELIZ JASPER , M.D.
on order for FENTANYL CITRATE intravenous ( ref # 26665156 )
POTENTIALLY SERIOUS INTERACTION: CITALOPRAM HYDROBROMIDE &
FENTANYL CITRATE Reason for override: aware
THIAMINE HCL 100 MG orally every day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
COLCHICINE 1.2 MG orally Q6-8H as needed ankle or joint pain
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Genny Barrette ( primary care physician ) next week ,
Colonoscopy- PUO Monday 5/13 scheduled ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Lower GI bleed
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
lower GI bleed
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid Obesitiy; atrial fibrilation; anxiety; ) depression;
sleep apnea; copd ; chf ( congestive heart failure ) gout; anemia
( anemia ) osteoarthritis ( osteoarthritis ); history of pancreatitis ( pancreatitis )
OPERATIONS AND PROCEDURES:
colonoscopy
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
62yo M with history of morbid obesity , HTN , Afib ( not anticoagulated ) who
presented to Xingcytalcjuanbuffwhi Fairgry Saintsli Healthcare Center on 4/29/02 complaining of signigicant
rectal bright red blood per rectum , weakness , lightheadedness , and
diaphoresis. HPI: patient had been in usual state of health until 7/10 when
he noted 2 episodes of blood in his stool that were associated with
lower abdominal cramping. On 9/10 he began to bleed from his rectum
while at rest and also began to feel weak , light headed and
diaphoretic.
He experienced nausea and LLQ cramping , but denied fever , chills ,
vomiting , chest pain , palpitations , shortness of breath or loss of
consciousness. He also denied dysphagia , odynophagia , or hematemesis.
At XFSHC he was noted to have a BP of 79/48 , P 83 , anda hematocrit of
28.2. He received 2U PRBC and with improvement in BP. A tagged RBC
scan at the time was negative. On 10/21 he again developed BRBPR. Hct
at the time was 20 , and a second RBC scan was negative. He received 6
more units of PRBC and was transferred to the PUO MICU on 10/21 .
Home Meds: allopurinol 300 every day , lisinopril 10 twice a day , vioxx 25 every day ,
ranitidine 150 twice a day , torsemide 20 bi d , citalopram 2o every day , ASA 325 every day ,
celexa 20 every day Hospital course: At PUO initial hct was 28.6.
The patient remained asympotomatic , though he continued to bleed and
required repeated transfusions ( 7U PRBC ). He was also noticed to have
increased physical therapy ( 1.4 ) and decreased PLTs to 108 and received 2units FFP
and 1 unit PLTs. He had no rectal bleeding after 8/10 . Colonoscopy
on 8/10 showed diffuse diverticulosis , but no active bleeding. The
scope was unable to move beyond the hepatic flexure
.
His lisinopril and torsemide were intially held following his
hypotensive episodes , but were restarted on 10/28 with good effect. An
initial UA showed 75-80 WBC , 25-39 RBC and 1+ LE. patient was treated
with 3 days levaquin.
patient c/o of left>right ankle pain- ?gout vs fx
vs DVT. Relieved with tylenol/oxycodone.
Started colchicine
1 ) GI/Heme: Hct 30.7no BRBPR. VSS , checking hct twice a day. No source of
bledding found. Barium enema to
ADDITIONAL COMMENTS: You should take your medications as indicated and avoid vioxx , advil or
aspirin. You should return to PUO for a colonoscopy to evaluate your
right colon. You should follow up with your primary care physician for modification
of any medication regimen and concerns about you gout and atrial
fibrillation. Please return t the ED should you again develop rectal
bleeding , che or should you become lightheaded , short of breath. You
should also work with your VNA for improving mobility and follow the
nutrition recs.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA for decub dressing changes , home physical therapy
No dictated summary
ENTERED BY: LUNDEMO , LADY CELINDA , M.D. ( ZV81 ) 2/5/02 @ 02:41 PM
****** END OF DISCHARGE ORDERS ******
Document id: 110
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
Y |
Y |
Y |
- |
N |
N |
Y |
N |
N |
Y |
N |
N |
- |
777803061 | PUO | 83517641 | | 983052 | 5/21/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/14/1994 Report Status: Signed
Discharge Date: 10/11/1994
DISCHARGE DIAGNOSIS: 1 ) POSSIBLE LEFT HEMISPHERE STROKE WITH
TRANSCORTICAL APHASIA.
2 ) RULE OUT MYOCARDIAL INFARCTION , NEGATIVE.
3 ) HYPERCALCEMIA.
4 ) ELEVATED LIVER FUNCTION TESTS.
5 ) DEPRESSION.
6 ) DIABETES MELLITUS.
HISTORY OF PRESENT ILLNESS: This is a 55 year old right handed
woman with a history of diabetes on
Insulin for three years , hypertension , question of migraine
headaches for more than ten years , and question of benign
positional vertigo admitted with blurred vision , light headedness ,
and slurred and slowed speech since early the morning of
presentation and substernal chest pain times two weeks
intermittently. Patient had a greater than ten year history of
headaches , usually unilateral although alternating between left and
right , frontal and occipital , throbbing , and usually without visual
changes , possible migraine. Most recently , she has had the
headaches present for about three to four days and now has a left
sided frontal and occipital area headache. The morning of
presentation , she awoke and then when she tried to sit up , felt
light headed but without loss of consciousness. Then , when she
tried to talk , she noted slurred and slow speech although she
understood , had positive word-finding , no aphasia , no wheakness , no
numbness , or other sensory changes. Daughter called her Bea Duna Medical Center doctor and she was referred to A Salt Medical Center Emergency Room by ambulance. The patient has also been
complaining of substernal chest pain in the center of her chest ,
dull without radiation , intermittently times two weeks , usually
moderate in intensity , lasting about hours with no precipitating
factors noted , and occurred regardless of activity level , even at
rest associated with mild shortness of breath , no diaphoresis , and
no increased nausea or vomiting. REVIEW OF SYSTEMS: Also positive
for mild temperature rise around 99 degrees Fahrenheit. Of note ,
she does have a borderline personality and significant life
stressors of pressures about her job and death of her granddaughter
last year. In the Emergency Room , a head CT was negative for a
bleed , infarct , or mass lesion. She did have chest pain and had
received two sublingual Nitroglycerins without relief , Maalox with
some relief of that pain , and there were no EKG changes. The CK A
and B were flat. PAST MEDICAL HISTORY: Diabetes mellitus on orally
hypoglycemic times one year and then Insulin times three years
diagnosed as gestational diabetes at first approximately more then
twenty years ago. She also has a history of a hypertension ,
question of benign positional vertigo , cervical radiculopathy ,
bilateral carpal-tunnel syndrome , borderline personality with a
history of major depression , thalassemia trait , gastroesophageal
reflux disease , question of thyroid disease , chronic hepatic
abdominal liver function test rise with a possible biopsy in 6/9
although results are not here , and question of migraines since the
mid 1970s. PAST SURGICAL HISTORY: Cholecystectomy and abdominal
hysterectomy. ALLERGIES: Doxycycline which causes mouth tingling ,
Penicillin which causes hives , Novacaine which causes hives , Diuril
which causes itching and nausea , Aldactone which causes hives , and
Aldomet which causes hives. CURRENT MEDICATIONS: Lasix 40 mg orally
twice a day , NPH Insulin 30 units subcutaneously every day before noon , Acebutolol 400
mg orally twice a day , and Valium as needed SOCIAL HISTORY: No cigarettes
and no ethanol. She is a school teacher. FAMILY HISTORY:
Positive for a cerebrovascular accident in her mother at the age of
21 and no coronary artery disease.
PHYSICAL EXAMINATION: In general , she was an obese black woman
awake but very quiet and reserved but in no
apparent distress. Vital signs showed a temperature of 98 , pulse
78 , blood pressure 140/100 , and respiratory rate 18. Significant
positives included neurological examination of alert and oriented
times three , cranial nerves II-XII generally intact except for
right lower facial weakness with decreased nasolabial fold on the
right , motor was 5/5 in the left side upper extremity and lower
extremity , 5 minus deltoid on the right , and aside from that , 5
throughout , sensory examination was intact to light touch and pin
in upper extremities and lower extremities bilaterally , and toes
were downgoing.
LABORATORY EXAMINATION: Chest X-Ray showed no infiltrates and EKG
showed 79 , sinus rhythm , a first degree AV
block , left anterior hemi-block , a Q in III and F , and poor R wave
progression. Laboratory values showed a white count of 4.7 ,
hematocrit of 38 , platelet count of 181 , calcium was elevated at
11.5 with an albumin of 4.4 , phosphate was 3.1 , and alkaline
phosphatase 294.
HOSPITAL COURSE: Patient was admitted for a rule out myocardial
infarction for the substernal chest pain although
there was a low index of suspicion for heart attack. She ruled out
by CK and had no EKG changes. CHH Cardiology felt that this chest
pain was not related to her heart or ischemic cause and left it up
to the primary provider , Dr. Gruntz , to arrange for an out-patient
exercise stress test if felt necessary. Most likely , the chest
pain represented some type of gastroesophageal reflux disease and
the patient was restarted on Axid. Another issue was question of
new neurologic deficits although the original head CT showed no
evidence of stroke. The stroke may have been too early to detect
leaving diagnosis of either a new cerebrovascular accident , a
manifestation of a seizure , or a conversion reaction secondary to
her borderline personality. Her primary deficit remained the
slowing of speech without actual slurring of speech and without any
deficits in understanding or expression. A lumbar puncture was
done on the second day of hospitalization with a mildly elevated
protein in the sixties and a glucose in the 120 range. Cell count
was low not consistent with infection. A cardiac echo was also
done which showed normal left ventricular function without any
segmantal wall motion abnormalities , there was a question of left
ventricular hypertrophy , and carotid dopplers were done which
showed no significant disease in the internal carotid arteries ,
however , there was a mild left internal carotid artery plaque.
Patient's neurologic status remained stable during her
hospitalization. She was started on Aspirin on admission. After
much discussion with CHH Neurology as well as with Dr. Gruntz , it
was felt that the patient could be followed as an out-patient. It
is recommended that the patient have Neurology follow-up next week ,
had a repeat CT of the head done to see whether ther is a new
infarct , and also an EEG was recommended by the Neurology
Consultation Servicer here for a question of seizures. Patient
will have home Occupational , Physical , and Speech Therapy provided
through Cialis- Beth Colngea Pinball Valley Hospital . Another issue was hypercalcemia. Patient had an
elevated calcium on admission. Patient was guaiac negative without
any mass lesions. Patient's chest X-Ray was also read as clear
without any masses. Patient did have a cursory breast examination
without any evidence of a breast mass and has had mammograms in the
past without any evidence of malignancy. The etiology of the
elevated calcium was unclear although leading diagnoses include
primary hyperparathyroidism , prolonged immobilization , or lying in
bed with some leeching of calcium versus a possible malignancy.
Patient should have her calcium followed as an out-patient. She
did have a PTH level drawn during this admission , the results were
not back at the time of discharge , however , this level should be
checked upon her next visit. Patient is now ready for discharge
home.
DISPOSITION: DISCHARGE MEDICATIONS: Acebutolol 400 mg orally
twice a day , NPH Insulin 30 units subcutaneously every day before noon ,
Lasix 40 mg orally twice a day , Ecotrin one tablet orally every day , and Fioricet
one to two tablets orally every 4 hours as needed for headache. She will
follow-up with Dr. Mildon next Monday.
Dictated By: KAM ISA , M.D. OW71
Attending: KATHERYN GRUNTZ , M.D. BK2 ZK375/2833
Batch: 0358 Index No. BUDBCV3RD2 D: 10/10/94
T: 11/14/94
Document id: 111
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
517077919 | PUO | 45227626 | | 890431 | 1/13/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 8/29/2000 Report Status: Signed
Discharge Date: 11/9/2000
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
SECONDARY DIAGNOSES: 1. ADRIAMYCIN INDUCED CARDIOMYOPATHY.
2. HYPERTENSION.
3. DIABETES.
4. SARCOIDOSIS.
5. LEFT BREAST CANCER.
6. STATUS POST LUMPECTOMY.
7. STATUS POST X-RAY THERAPY.
8. STATUS POST CHEMOTHERAPY WITH ADRIAMYCIN
IN 1984.
9. HYPERCHOLESTEROLEMIA.
10. DEEP VENOUS THROMBOSIS.
11. OBSTRUCTIVE SLEEP APNEA.
12. CORONARY ARTERY DISEASE.
13. STATUS POST MYOCARDIAL INFARCTIONS X 2.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old woman
with a history of breast cancer and
cardiomyopathy , secondary to Adriamycin , as well as other medical
problems , with left hip pain that has been a chronic issue and
which prompted her to present to A Salt Medical Center
Emergency Department on January , 2000. In the Emergency
Department , the patient became progressively lethargic and an
arterial blood gas there revealed hypoventilation , presumed
secondary to obesity and the patient's congestive heart failure.
Blood sugar in the Emergency Department was found to be 46 and the
patient was given D50 , but eventually required a D10 drip to
maintain her sugars. The patient was also placed on BIPAP to
maintain O2 saturations. It seemed that the combination of
congestive heart failure and poor baseline respiration , secondary
to body habitus , led to this acute worsening. The patient was
stabilized in the Emergency Department and sent to the floor on
BIPAP.
PAST MEDICAL HISTORY: The patient's past medical history included
Adriamycin induced cardiomyopathy ,
hypertension , diabetes , sarcoid left breast cancer ,
hypercholesterolemia , deep venous thromboses , OSA , and coronary
artery disease , status post myocardial infarctions x 2.
MEDICATIONS ON ADMISSION: At the time of admission , the patient
was on Elavil 25 mg orally every bedtime ,
Dulcolax 5-10 mg orally every day as needed , digoxin 0.25 mg orally every day ,
Colace 100 mg orally twice a day , Lasix 200 mg orally twice a day , Robitussin DM
10 ml every 4 hours as needed , hydralazine 25 mg orally four times a day , insulin NPH
30 mg subcutaneously twice a day , Zestril 40 mg orally every day , Maalox ,
Milk and Magnesia , nitroglycerin 0.4 mg sublingual as needed , Senna
tablets as needed , Coumadin 5 mg orally every day , Zocor 10 mg orally every bedtime ,
oxycontin 10 mg orally every 12 hours , oxycodone 5-10 mg every 6 hours
as needed pain , and Prevacid 30 mg orally every day.
SOCIAL HISTORY: The patient's social history revealed that she
lives alone with family help for daily chores.
The patient denied a history of tobacco or alcohol use.
PHYSICAL EXAMINATION: Physical examination revealed the patient to
be an obese woman with vital signs revealing
temperature 96 , pulse 93 , blood pressure 115/60 , respiratory rate
24 , and saturations 78% on 1.5 liters of oxygen , with 97% on 4
liters of oxygen. HEENT examination showed no jugular venous
distention. The neck was thick. There was no lymphadenopathy and
no carotid bruits. Extraocular movements were intact. The pupils
were equal , round and reactive to light. Cardiovascular
examination showed a regular rate and rhythm without murmur , rub ,
or gallop. The lungs showed good breath sounds bilaterally , and
few crackles in both bases anteriorly. The abdomen was
non-distended and non-tender , obese , firm , and with hypoactive
bowel sounds. The extremities showed generalized anasarca.
Neurological examination showed the patient to be alert and
responsive at the time of examination. Cranial nerves II-XII were
intact.
LABORATORY DATA: Laboratory data on admission revealed sodium 140 ,
potassium 5.7 , chloride 99 , bicarb 34 , BUN 32 ,
creatinine 1.3 , glucose 40 , white count 8.2 , hematocrit 39.3 ,
platelets 241 , ALT 32 , AST 65 , LDH 717 , CK 436 , with an MB fraction
of 5.4 , troponin I 0.22 , total bilirubin 0.6 , direct bilirubin 0.1 ,
alkaline phosphatase 381 , digoxin 1.8 , calcium 9.4 , and albumin
4.1. Urine tox screen was negative. An INR was 2.5 , PTT 32.0 , and
D-dimer greater than 1000. Arterial blood gas before BIPAP showed
pH 7.41 , pCO2 63 , and pO2 66 on 2 liters of oxygen by nasal
cannula. A portable chest x-ray showed moderate to severe
pulmonary edema , bilateral hilar fullness , right greater than left ,
and cardiomegaly. Abdominal ultrasound was negative for ascites.
A KUB showed free air , non-specific bowel gas pattern , and no
obstruction. A urinalysis showed no protein , 2+ blood , 5-10 red
blood cells , and 1+ squamous epithelial cells. Electrocardiogram
showed normal sinus rhythm in the 80s , low voltage , with no change
from previous studies.
HOSPITAL COURSE: The patient was admitted to the Step Down Unit
for diuresis and continued BIPAP. However , the
patient did not tolerate BIPAP , but diuresed well , in fact , too
well , to intravenous boluses of Lasix , with urine output of 7
liters negative in one day , on May , followed by ventilatory
failure on May , with bicarb greater than assay. The patient
was transferred to the CCU for worsening respiratory acidosis and
not tolerating BIPAP. The patient was intubated at that time. The
patient began spiking temperatures on May , as well , and was
started on a regimen of levofloxacin and clindamycin on September
for the question of aspiration pneumonia. On May , a
Swan-Ganz catheter was floated with pulmonary capillary wedge
pressures of 25 and the patient was started on afterload reduction
with Isordil , hydralazine , and Diamox for metabolic alkalosis ,
which was thought to be contributing to her worsening respiratory
acidosis. On July , ceftazidime was started for Pseudomonas ,
which was found in the patient's sputum. Over the next several
days , the patient had an increased peak requirement to oxygenate
satisfactorily. On November , vancomycin was started for coag
negative Staph , which was cultured from an arterial line , and
levofloxacin was discontinued. On May , the antibiotics were
changed per recommendation of the Infectious Disease consultation
to ceftazidime and Flagyl for Pseudomonas in the sputum culture ,
and the question of C. diff. Vancomycin and clindamycin were
discontinued at that time. On February , amikacin was added for
double coverage for advanced associated pneumonia with Pseudomonas.
Subsequently , the patient slowly improved and it became easier to
oxygenate her , with a decreasing fever curve. A chest CT scan on
January , was consistent with bilateral pneumonia , as well. On
January , the patient was taken off the vent to a trach collar ,
following her tracheostomy and PEG procedure , which she tolerated
well on May .
Other issues in the patient's hospitalization have included
hypernatremia , thought secondary to the patient's receiving large
amounts of Lasix and having no access to free water. This was
treated with free water boluses. The patient also had prerenal
azotemia , which was improving at the time of discharge , as well as
coronary artery disease , which was not an issue , and fluid
overload , secondary to cardiomyopathy , which was much improved.
The patient's course was also complicated by acute renal failure ,
with creatinines rising as high as 2.6 before falling to 1.5 on the
day prior to discharge. The patient's chest CT scan also showed
significant lymphadenopathy , which was noted prior , and was thought
to be secondary to sarcoid , which was recurrent CA , at this point ,
given that there was no biopsy data. Also , a transthoracic
echocardiogram showed a thickened mitral valve , which may be
unchanged from prior studies , and the clinical suspicion for
endocarditis was fairly low. However , if further positive blood
cultures should arise , this might require further work-up. The
patient's course was also complicated by anemia , which has required
several blood transfusions while the has been here. The patient
has had several episodes of bleeding and oozing from various
procedure sites , as well as some guaiac positive stool. The
patient's reticulocyte was found to be 4.9% , while the hematocrit
at that point , on February , was 25.7%. Given her reticulocyte
index of 1.40 , which was inappropriately low , the patient was ,
therefore , started on erythropoietin , as well as iron
supplementation. The patient was also supplemented with tube
feeds , as well as Promod protein supplements , during the course of
her admission. In terms of the patient's endocrine issues , the
patient was treated with insulin , including varying doses of
regular insulin , NPH , and subcutaneously , as well as insulin drips
at times. While in the hospital , Physical Therapy began to see the
patient prior to discharge and the patient was able to transfer
from bed to chair with assistance.
While in the hospital , the patient underwent tracheostomy and PEG
procedure on May , 2000.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on Diamox 250 mg per G-tube twice a day ,
ASA 325 mg orally every day , amikacin 600 mg intravenous every 24 hours , natural
tears two drops each eye three times a day , ceftazidime 1000 mg intravenous every 8 hours ,
erythropoietin 5000 units subcutaneously three times per week ,
ferrous sulfate 300 mg per G-tube three times a day , folate 1 mg per G-tube q.
day , NPH insulin 105 units subcutaneously twice a day , regular insulin
sliding scale before every meal and bedtime , metoprolol 50 mg per G-tube four times a day ,
nitroglycerin 0.4 mg one tablet sublingual every five minutes x 3
as needed chest pain , nystatin suspension 5 ml orally four times a day with the
instructions that a swab may be used if the patient is unable to
swish and swallow , omeprazole 40 mg orally twice a day , potassium chloride
immediate release orally sliding scale , Senna tablets two tabs orally
twice a day , therapeutic multivitamin one tab orally every day , or 5 ml per
G-tube every day , simvastatin 10 mg per G-tube every bedtime , Atrovent
nebulizer 0.5 mg inhaled four times a day , Lovenox 100 mg subcutaneously q.
12 hours with the instructions to check heparin factor 10A levels
after the third dose on May , potassium chronic sliding scale
every day , and Flovent 220 mg inhaled twice a day , with four puffs twice a day
CONDITION ON DISCHARGE: At the time of discharge , the patient was
in stable condition.
DISPOSITION: The patient was to be transferred to the Pulmonary
Rehabilitation program at the Cock Dia Medical Center .
FOLLOW-UP: Follow-up care should include monitoring the patient's
anticoagulation with checking heparin factor 10A levels
for her Lovenox after the third dose on May . The patient
may also be transitioned to Coumadin once a satisfactory
anticoagulation with Lovenox has been achieved. The patient should
also follow-up with her primary care physician , Dr. Dulcie F Scovel at Dick Stookheights Community Hospital as soon as possible while at Wood or
after she is discharged from there.
Dictated By: DOUGLASS PETTINGER , M.D. EK84
Attending: BREE M. THEILING , M.D. PV1 CR448/1427
Batch: 51929 Index No. BESCHH67WM D: 10/8
T: 10/8
Document id: 112
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
Y |
Y |
Y |
Y |
N |
N |
- |
N |
N |
- |
015399716 | PUO | 20146585 | | 1256429 | 2/11/2006 12:00:00 a.m. | hypoglycemia | | DIS | Admission Date: 6/4/2006 Report Status:
Discharge Date: 8/17/2006
****** FINAL DISCHARGE ORDERS ******
SANGH , MARYLN JAUNITA 612-61-00-9
S Port
Service: MED
DISCHARGE PATIENT ON: 4/8/06 AT 08:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY
ATENOLOL 100 MG orally DAILY HOLD IF: sbp < 100
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally DAILY
Alert overridden: Override added on 11/26/06 by
FLEISHER , LUETTA , M.D.
on order for LASIX orally ( ref # 483999344 )
patient has a POSSIBLE allergy to Sulfa; reactions are Rash ,
Swelling. Reason for override: aware
SYNTHROID ( LEVOTHYROXINE SODIUM ) 125 MCG orally DAILY
OXYCODONE 5-10 MG orally every 6 hours as needed Pain
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 11/26/06 by
FLEISHER , LUETTA , M.D.
on order for SIMVASTATIN orally ( ref # 075114515 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
AMLODIPINE 5 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally DAILY
HOLD IF: sbp < 100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
BETAMETHASONE VALERATE 0.1% TOPICAL TP twice a day
Number of Doses Required ( approximate ): 23
HYZAAR ( 25 MG/100 MG ) ( HYDROCHLORTHIAZIDE 25M... )
1 TAB orally DAILY
Alert overridden: Override added on 11/26/06 by
FLEISHER , LUETTA , M.D.
on order for HYZAAR ( 25 MG/100 MG ) orally ( ref #
320700807 )
patient has a PROBABLE allergy to Sulfa; reactions are Rash ,
Swelling. Reason for override: tolerates
Number of Doses Required ( approximate ): 2345
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 4/8/06 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: mda
OMEPRAZOLE 20 MG orally DAILY
GLIPIZIDE 5 MG orally DAILY
Instructions: start when your blood sugars are >100
Alert overridden: Override added on 4/8/06 by :
on order for GLIPIZIDE orally ( ref # 306180354 )
patient has a POSSIBLE allergy to Sulfa; reactions are Rash ,
Swelling. Reason for override:
unclear if has sulfa allergy , will monitor
COLCHICINE 0.6 MG orally EVERY OTHER DAY
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Freed 2/11 @ 9:45am scheduled ,
ALLERGY: Demerol , Sulfa , METFORMIN HCL
ADMIT DIAGNOSIS:
hypoglycemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hypoglycemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension , hyperchol , congestive heart failure , diabetes mellitus ,
gastroesophageal reflux disease , psoriasis , obesity , coronary artery
disease
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous glucose
BRIEF RESUME OF HOSPITAL COURSE:
73yo with hypoglycemia. physical therapy with HTN with LVH and diastolic CHF , DM , CAD ,
hyperchol , recently diagnosed with gout and started on colchicine p/with
hypoglycemia for 1wk. patient saw Dr. Freed re: low FSBS who cut the
dose of glyburide to 5bid , however , over the last week she has ,
nevertheless , been unable to maint a FSBS > 70 with symptoms when <60.
( a1c recently 7.9 ). Her only recent health change is a new diagnosis of
gout ( R ankle ) for which she started colchicine 3d pta. She did have a
recent admission for CHF tx with incr lasix 1wk pta. ROS pos only for
cough of several weeks that seems to coincide with her fluid overload
and infrequent chills over the past two weeks.
*****
Admission Exam: 96 , 74 , 159/76 , 95%ra. NAD , well appearing , CTA B , JVP 10
cm H2O with prom v-wave , RRR With 2/6 SEM at RUSB rad to apex , abd
obese but benign , 2/4 B LE brawny PE with L lateral malleolus tenderness
and slightly reduced ROM.
EKG: NSR 68 , RBBB
Labs: u/a neg , cr 1.4 at baseline
*****
Imp: Hypoglycemia most likely from impair renal clearance of
glyburide. Possibly addition of colchinine/increased furosemide made this
worse.
Hospital Course:
1. Hypoglycemia - Held glyburide and treated with low dose D10 drip.
Finger sticks were checked every every 4 hours and FSBS increased to 150s.
Patient was instructed to eat a normal diet and check her sugars
every 4 hours and when they remain >100 and near 200s , she may start
glipizide. Note: patient has a possible allergy to sulfa which manifest as a
rash after taking an ?allergy medicine. Unlikely to have rash as tolerates
lasix ( sulfa containing ). Will have patient monitor for rash and call if has
any difficulties/prolonged hypoglycemia. VNA services to check in on
patient over the weekend.
2. Gout - patient reports symptoms are much improved. No concern for joint
infection based on exam. Will continue colchicine at renal dose and use
narcotics for as needed relief.
3. HTN - cont home meds of ASA , lasix , statin , hyzaar , atenolol , norvasc
4. CRI - stable , creatinine remained at 1.4 and bBUN improved from 73 to
64 with IVFs.
5. CHF - Cont lasix at 80 as per Dr. Hamblet ( outpt cardiologist ). Instruct
patient to weigh herself daily.
6. GERD - cont PPI , no issues
ADDITIONAL COMMENTS: Check your blood sugar every 4-6 hours until it remains greater than 100.
After it is stable with blood sugars around 200 you may begin glipizide.
If you develop a rash or persistant hypoglycemia , call Dr. Freed or
go to the ED.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. VNA services for home eval and blood glucose monitoring
2. recheck renal function and glucose in 1 week , increase glipizide as
needed
No dictated summary
ENTERED BY: BONEFONT , KEIRA B. , M.D. , PH.D. ( TK84 ) 4/8/06 @ 03:58 PM
****** END OF DISCHARGE ORDERS ******
Document id: 113
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
771151518 | PUO | 29811584 | | 4489791 | 8/20/2004 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 1/15/2004 Report Status: Signed
Discharge Date: 1/26/2004
ATTENDING: SANA ALBOR M.D.
MEDICAL SERVICE:
General Medicine.
DISPOSITION:
Home with services.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg orally every day
2. Enteric-coated aspirin 81 mg orally every day
3. Captopril 12.5 mg orally three times a day
4. Fluoxetine 20 mg orally every day
5. Nitroglycerine 0.4 mg sublingual tablet every 5 minutes x 3
as needed chest pain.
6. Nephrocaps one tablet orally every day
7. Clopidogrel 75 mg orally every day
8. Sevelamer 800 mg orally three times a day with meals.
9. Pepcid 20 mg orally every bedtime
10. Vancomycin at hemodialysis to complete 14-day course as
discussed with dialysis , etc.
DIET:
Low cholesterol low saturated fat ADA 2100 calories per day diet.
ALLERGIES:
No known drug allergies.
ADMISSION DIAGNOSES:
Syncope and chest pain.
DISCHARGE DIAGNOSIS:
Angina.
OTHER DIAGNOSES:
End-stage renal disease , coronary artery disease , status post
CABG , VT , status post ICD placement , peripheral vascular disease ,
history of CVA with residual right-sided weakness , diabetes ,
hypercholesterolemia , low back pain , and peripheral neuropathy.
TREATMENTS AND PROCEDURES:
Pacemaker/ICD interrogated hemodialysis.
BRIEF RESUME OF HOSPITAL COURSE:
The patient is a 68-year-old gentleman with history of severe and
operable coronary artery disease , status post CABG , history of
ventricular tachycardia , status post ICD placement who is on
amiodarone , end stage renal disease on hemodialysis , status post
CVA , who presents with chest pain and a report of a syncopal
episode. He is followed at KAAH and has multiple multiple
admissions for chest pain and rule out MI in the setting of
receiving or having just received hemodialysis. On the day prior
to admission , 9/17/04 , the patient had chest pain and
hemodialysis and was admitted to KAAH where he was ruled out for
MI by enzymes. He was discharged from KAAH on 8/5/04 and later
that day , per the patient , he had a fight with his family members
and stood up and abruptly felt lightheaded and "passed out." He
reports no palpitations or chest pain prior to the event and
believes that he may have been unconscious for 20 minutes.
Talking to the family , the patient was actually attempting to
throw something at this son , fell , and had no loss of
consciousness after falling. The patient reports that he woke on
the floor and developed severe chest pain with radiation to the
left arm and jaw , which is typical with his anginal symptoms
according to his cardiologist. He denies any recent change in
chronic shortness of breath or exercise capacity , orthopnea , or
increased edema. He had a recent MIBI on 4/7 that showed
mild mid anterior and inferior wall ischemia with a
posterior-basal scar. He was deemed an obvious surgical
candidate and has been medically managed.
In the emergency department , he received intravenous fluids , aspirin ,
sublingual nitroglycerin x 3 and morphine with resolution of
chest pain. Upon admission to the medical team , his vital signs
were stable and he denied chest pain. He was admitted to rule
out myocardial infarction.
HOSPITAL COURSE BY ISSUES:
1. Cardiovascular ischemia: This patient with a known history
of CAD who has been medically managed per his primary
cardiologist. He has a history of CABG. His last cath was in
8/22 that showed diffuse disease. At which time , he received
stents to the left main and LAD. On this admission , the patient
ruled out for MI with three sets of negative cardiac enzymes
including troponin. No EKG changes were noted. He was continued
on aspirin products and beta-blocker as well as ACE inhibitor ,
and amiodarone. The patient is not on a statin though he has
been in the past; he reports that he had some sort of a reaction
to the medication. On the day after his admission , he had chest
pain and hemodialysis but was relieved by sublingual
nitroglycerin. Over his hospital course , he continued to have
2-3 episodes of chest pain per day that were relieved by
nitroglycerine and morphine. He had no EKG changes in the
setting of any of these episodes. Isordil was added for improved
pain control briefly. Cardiology was consulted and felt that the
frequency of the pain , the rapid onset and offset , and the
reproducibility of the pain to palpation made angina less likely;
they did not feel that catheterization or further workup was
indicated.
2. Cardiovascular pump function: Initially , the patient was dry
on exam , and demonstrated no signs or symptoms of heart failure.
He was actually orthostatic by symptoms but his blood pressure
remained stable. His story of losing consciousness was difficult
to corroborate; if he did indeed lose consciousness , his history
is consistent with orthostasis. Management was monitored by the
Hemodialysis Service.
3. Cardiovascular rhythm: The patient has an ICD for history of
VT , and he is continued on amiodarone. There was concern that
possible arrhythmia or pacer malfunction could have been the
cause of his symptoms. In addition , when he fell he said he
might have fallen on his pacemaker site. On the morning after
his admission , when he was on hemodialysis , the patient and nurse
both heard a belching sound that seemed to be coming from the
area of the patient's pacemaker. The electrophysiology team was
consulted and pacemaker was interrogated and found to be
functioning well , with no history of arrhythmia or alarm. EKGs
remained unchanged from baseline , except there was a prolongation
of QTC with the initiation of Zyprexa , which was stopped. The
patient's heart rate remained stable in the 50s-60s on his
cardiac regimen.
4. Renal: The patient has end stage renal disease on
hemodialysis and was apparently incompletely dialyzed on the day
prior to admission. Due to chest pain , it was initially
difficult to have the patient complete a course of hemodialysis
but over his hospital stay he was dialyzed effectively. He has
arrangements to follow up with his outpatient hemodialysis after
discharge
5. Psychiatry: After ruling out for myocardial infarction ,
plans were being made to discharge the patient home and the
patient's family was called. They reported concern that did not
want the patient to return home because of abusive and erratic
behavior by the patient. They reported that actually in the
setting of the patient's fall , the police were called and when
they arrived the patient complained of chest pain and was brought
to the hospital by ambulance. There was a history of restraining
or taking out by the wife against the patient , and she reported
feeling unsafe with him from the home. Psychiatry did see the
patient and felt that he was unreliable and was probably not safe
to go home to take care of himself , but that he was also
confident to make decisions and was not acutely psychotic , and
therefore , it should not be committed against his will. The
patient denied any suicidal or homicidal ideation. The patient
was started on SSRI and initially on Zyprexa though this was
stopped because of prolonged QTC. After a few days , the patient'
family changed their mind and decided that they would be okay
with him coming home. The situation was discussed with the
patient's primary doctor , with the family over the phone , as they
would not come in for a family meeting with the patient and he
did go home , but will likely require a psych follow up as an
outpatient.
6. Endocrine: The patient continued on insulin and Regular
Insulin sliding scale for his history of diabetes.
7. Infectious disease: The patient developed a low blood
pressure and was noted to have erythema and pus from the site of
his hemodialysis catheter in the right subclavian position. He
became fully hypertensive and required a brief course of pressors
to maintain blood pressure. The catheter was removed and
cultures were obtained that demonstrated methicillin-resistant
Staph aureus. The patient was treated with vancomycin and
gentamicin dose to his renal function and showed improvement in
his symptoms in clearance of his bacteremia. The gentamicin was
stopped and plans were made for the patient to receive vancomycin
as an outpatient and hemodialysis in follow up. He was dialyzed
from VAF fistula in his arm that had been created a number of
months prior to this admission.
8. Nutrition: The patient was seen by nutrition and was given a
renal carbohydrate controlled low fat low cholesterol diet. He
was continued on Nephrocaps. B12 and folate were normal.
eScription document: 8-8414860 EMSSten Tel
Dictated By: MOOSE , BUCK
Attending: ALBOR , SANA
Dictation ID 7664474
D: 11/3/04
T: 11/3/04
Document id: 114
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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995906475 | PUO | 07554150 | | 625165 | 7/12/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/12/1994 Report Status: Signed
Discharge Date: 1/9/1994
HISTORY OF PRESENT ILLNESS: The chief complaint is abdominal
distention , nausea , and vomiting.
Patient is a 49 year old black female with the onset of mild
epigastric pain , nausea , and vomiting developing several hours
before presentation to the Emergency Room. She has a history of
hypertension , borderline diabetes mellitus , hiatal hernia , and
umbilical hernia. Patient went to sleep on the night of
presentation with mild pain and awoke in the middle of the night
with more severe pain. The pain was intermittent and came in waves
approximately every three to five minutes , somewhat positional , and
worse with lying or standing. She denied shortness of breath and
she said her last bowel movement was earlier on the evening of
presentation which the patient reported as normal in consistency.
She denied bright red blood per rectum and she denied any urinary
tract symptoms. She also denied any gynecological/vaginal
symptoms. PAST MEDICAL HISTORY: Significant for: 1 ) Umbilical
hernia/ventral hernia. 2 ) Hiatal hernia. 3 ) Bilateral tubal
ligation. 4 ) Left lower extremity venous insufficiency. 5 )
Hypertension. 6 ) Borderline diabetes mellitus. CURRENT
MEDICATIONS: None. ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: She was afebrile , heart rate was 76 , blood
pressure of 160/100 , and room air saturation
of 89%. GENERAL: She was an obese black female in moderate
distress. HEENT: Anicteric and 2+ carotid pulses with no bruits.
CHEST: Had distant lung sounds. CARDIAC: Examination was regular
with a I/VI systolic ejection murmur. ABDOMEN: Examination was
large and obese with a ventral supraumbilical hernia with an
indistinct fascial edge , partially reduced but possibly with a
second aspect just above the umbilical hernia , a 5-6 cm mass which
was non-reducible , faint bowel sounds with diffuse tenderness.
RECTAL: She was noted to be guaiac negative on rectal examination
and non-tender. EXTREMITIES: Examination was warm and atraumatic.
Of note , she had 2+ palpable dorsalis pedis pulses and her
posterior tibial pulses were not palpable. Her left calf was
tender which the patient reported to be chronic and her entire calf
was firm with no cords palpable. NEUROLOGICAL: Examination was
non-focal.
LABORATORY EXAMINATION: Her EKG showed a normal sinus rhythm , left
atrial enlargement , question of poor R
wave progression , no ST or T wave changes , and her chest X-Ray was
clear with no active disease. Her KUB showed the nasogastric tube
in place with few air filled loops of small bowel and there was air
and stool in the large bowel. Her laboratories on admission were
notable for an SMA 7 showing a sodium of 141 , potassium of 3.9 ,
chloride 95 , carbon dioxide 32 , BUN 9 , creatinine 0.8 , glucose of
222 , amylase of 33 , her lipase was 10 , white blood cell count was
7.8 , her hematocrit was 53.4 , and platelets were 198.
HOSPITAL COURSE: A nasogastric tube was placed and drained 500 cc
of aspirate after 500 cc of emesis. She was
admitted with a diagnosis of small bowel obstruction with three
supraumbilical reducible hernias and one periumbilical incarcerated
hernia. The plan was to take her to the Operating Room for ventral
hernia repair. On 10/1 , she was taken to the Operating Room and
had a ventral hernia repair. That operation was notable to be a
reducible umbilical hernia which was noted to be incarcerated
without any evidence of strangulation. The hernia was repaired
with Marlex and mesh. Please see the Operative Note for details.
The patient remained intubated after the operation and was taken to
the Recovery Room intubated. After a slow wean from the
ventilator , the patient was extubated later in the day on September and required four liters of oxygen by nasal prongs to maintain
O2 saturations between 90 and 94%. She also underwent a rule out
myocardial infarction protocol post-operatively and did rule out.
Of note , the right calf had a palpable cord , lower extremity
non-invasives were scheduled , and the Cardiology Deep Venous
Thrombosis Service was consulted. They felt that her left lower
extremity deep venous thrombosis was chronic deep venous thrombosis
and venous insufficiency. They recommended Ted stockings and
subcutaneous Heparin. She was additionally seen by the Pulmonary
Service who suggested getting pulmonary function tests once the
patient was clinically stable and agreed to using Ted thigh-high
stockings. The Deep Venous Thrombosis Service recommended
thigh-high stockings with the pressure of 30 to 40 mm of mercury
during the day with Ted stockings regularly at night with the
continuation of subcutaneous Heparin until fully mobile. On
post-operative day three , the patient's nasogastric tube was
discontinued and her diet was advanced. Her Jackson-Pratt drain
was removed. On post-operative day four , the patient had regained
bowel sounds as well as had a bowel movement. Her oxygen
saturation was 94% on four liters and when the oxygen was removed ,
she had a room air saturation between 86 and 88%. She had an
echocardiogram to rule out evidence of pulmonary hypertension in
the setting of sleep apnea felt the most likely diagnosis in this
pickwickian appearing patient. Her echo was without evidence of
pulmonary hypertension. Her pulmonary function tests showed
decreased volume , decreased diffusing capacity , and decreased MIP.
The Respiratory Service recommended home oxygen therapy to maintain
saturations at 90% at rest and with ambulation. A trial of oxygen
at rest and with ambulation was done in the hospital to calculate
the dose of oxygen needed for home therapy. Pulmonary as well
recommended state study as an out-patient and pulmonary follow-up.
On post-operative day five , the patient was noted to have erythema
around her incision , probably a reaction to the tape , however , she ,
as well , had a low grade temperature to 100.1. Given that she had
had a mesh placed , she was started on antibiotic prophylaxis for
possible cellulitis. She was started on Cephradine 500 four times a day for
seven days. As well , further discussion was had with the
Respiratory Consultation Service. They felt that patient's problem
was chronic with hypoxemia leading to an elevated hematocrit and
that she would require home oxygen. The Deep Venous Thrombosis
Cardiology Service recommended repeating her lower extremity
non-invasives prior to discharge , continuing her on her 30 to 40 mm
of mercury stockings during the day , and Teds at night. She had a
follow-up lower extremity non-invasive on the day of discharge
which showed a chronic left lower extremity deep venous thrombosis
with venous insufficiency and no evidence of new deep venous
thrombosis. They recommended follow-up lower extremity
non-invasives after discharge as an out-patient. The patient was
discharged in good condition on June , 1994. She is
discharged on home oxygen at two liters by nasal prongs. With
this , she was able to maintain her O2 saturations greater than 90%.
On the date of discharge , her saturations were in the 94
percentile. She was to be monitored by Nessinee Ker Hospital Medical Center at home.
DISPOSITION: DISCHARGE MEDICATIONS: Tylox one to two tablets
every 3-4h. as needed for pain , Colace , Dulcolax as needed , and
Cephradine 500 four times a day for six days further. She has scheduled
follow-up in the Surgical Clinic January , ten days after
discharge , for follow-up of her chronic venous insufficiency in
KTDUOO and the Pulmonary Clinic with Dr. Knerr on March to
further evaluate her sleep apnea oxygen requirements.
Dictated By: WEINGARTNER , M.D.
Attending: TARSHA Y. PRALL , M.D. PP67 SV911/2943
Batch: 7787 Index No. MRQOS868WV D: 8/26/95
T: 2/2/95
CC: 1. DR. KNERR
2. DR. KLEMANSKI
Document id: 115
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
275624737 | PUO | 95262820 | | 024736 | 7/11/2002 12:00:00 a.m. | INFECTED LEFT GREAT TOE OSTEOMYELITIS | Signed | DIS | Admission Date: 1/16/2002 Report Status: Signed
Discharge Date: 3/26/2002
CHIEF COMPLAINT: Left great toe infection.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old man with
diabetes and hypertension well known
to Dr. Derham after multiple peripheral bypasses and amputations
who presents with a left great toe infection after transfer from an
outside hospital where he was treated for two weeks of a Strep B
sepsis.
PAST MEDICAL HISTORY: Hypertension , coronary artery disease ,
status post coronary artery bypass grafting
in September of 2001 , peripheral vascular disease , chronic renal
insufficiency , insulin dependent diabetes mellitus , anxiety and
depression.
PAST SURGICAL HISTORY: Right metatarsal amputation of the second ,
third and fifth ties , step-wise , with a
split thickness skin graft in September of 2001 to the debridement site ,
left second fifth toe TMA , step-wise , in 2001 with split thickness
skin graft and debridement of sites in September of 2001 , left
femoral popliteal with Dacron in April of 2001 , right femoral to
dorsalis pedis with non-reversed saphenous vein graft in September of
2001 and a coronary artery bypass grafting x 3 in September of 2001.
STUDIES: In the past , the patient had an echocardiogram in September of
2001 that showed a normal left ventricular function and a
questionable small atrial septal defect.
MEDICATIONS ON ADMISSION: Axid 150 mg orally every day , Lipitor 10 mg
orally every day , Lopressor 25 mg orally
twice a day , albuterol and Atrovent , aspirin 325 mg orally every day ,
Percocet , multivitamin , zinc , vitamin C , Colace , ampicillin 1 gram
every 8 hours for seven days , NPH 30 units every day before noon and 20 units every PM.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.2 , heart rate
81 , blood pressure 160/70. LUNGS: Clear.
HEART: Regular rate and rhythm. ABDOMEN: Soft and non-tender.
EXTREMITIES: Pulses palpable in the femoral , carotid and radial
pulses , right dorsalis pedis graft pulse was 2+ palpable with 1+
dorsalis pedis dopplerable pulses on the left. The great toe had a
medial wet ulcer as well as a right plantar ulcer that was dry with
an eschar of about 2 cm. The left leg had 2+ pitting edema with
increased asymmetry to the knee and the left great toe showed some
fibrinous exudate without any pus.
HOSPITAL COURSE: The patient was placed on ampicillin ,
levofloxacin and Flagyl. He was planned to go
the operating room the next day for a left great toe debridement.
Preoperatively , he was seen by Cardiology who recommended that we
double his dose of simvastatin to 20 mg and increase the Lopressor
to 25 mg four times a day and otherwise , he was cleared for surgery. On
July , 2002 , the patient was taken to the operating room for a
left foot debridement and left great toe amputation. This was done
under spinal anesthesia. The patient tolerated the procedure well
and on postoperative day number one , he had a VAC sponge placed to
the wound. He tolerated having the VAC sponge on and was able to
ambulate heel weight bearing only with the VAC sponge.
Cardiology followed the patient and recommended that we change him
to atenolol and add Tricor as an anticholesterol drug.
The Diabetes Management Service was also consulted to help with the
patient's fingersticks and we increased his NPH as well as added
regular insulin in the a.m. and PM.
On March , 2002 , the VAC sponge was taken down and wet to dry
dressing was placed over it. At this time , it was felt that the
wound was not ready for a skin graft yet and the plan was to
discharge him to rehabilitation for wet to dry dressing changes
until the wound was ready for skin grafts.
Thus , the patient is discharged to rehabilitation in stable
condition to continue wet to dry dressing changes as well as to
continue a course of vancomycin , levofloxacin and Flagyl for two
more weeks.
MEDICATIONS ON DISCHARGE: Aspirin 325 mg orally every day , atenolol 50
mg orally every day , Colace 100 mg orally
twice a day , insulin NPH human 45 units every day before noon , 35 units every bedtime , insulin
regular sliding scale 10 units every day before noon and 6 units pre-dinner ,
albuterol and Atrovent , lisinopril 5 mg orally every day , Flagyl 500 mg
orally three times a day x 14 days , Percocet 1-2 tablets orally every 4-6h. as needed
pain , Zantac 150 mg orally twice a day , multivitamin therapeutic one
tablet orally every day , simvastatin 20 mg orally every bedtime , levofloxacin 500
mg orally every day x 14 days , Tricor 200 mg orally every bedtime , vancomycin 1
gram intravenously every 18h. x 14 days.
FOLLOW UP: The patient is to follow up with Dr. Derham and call
his office for an appointment. The patient will also
follow up with his primary care physician in one to two weeks.
Dictated By: EDGARDO CISTRUNK , M.D. IM20
Attending: ROSSIE MANKOSKI , M.D. QH55 QP114/637721
Batch: 0358 Index No. XXHLOF1FA3 D: 8/15/02
T: 8/15/02
CC: OURCON CSTRAND OTTEI MEDICAL CENTER
Document id: 116
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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U |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
249491419 | PUO | 63001608 | | 6396323 | 2/15/2005 12:00:00 a.m. | djd L knee , htn , bee sting allergy , obesity , hepatitis C virus | | DIS | Admission Date: 6/15/2005 Report Status:
Discharge Date: 3/28/2005
****** FINAL DISCHARGE ORDERS ******
AGRESTE , KENNA 874-65-31-1
Roche , AL
Service: ORT
DISCHARGE PATIENT ON: 2/21/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE , M.D.
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
as needed Other:fever greater than 101
Instructions: Do not exceed 4000mg in 24 hours.
ATENOLOL 100 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FAMOTIDINE 20 MG orally twice a day
Override Notice: Override added on 5/25/05 by
ARTERS , JEROLD E.
on order for BUPIVACAINE 0.5% ED 80 ML OTHER ( ref #
19455620 )
POTENTIALLY SERIOUS INTERACTION: FAMOTIDINE & BUPIVACAINE
HCL Reason for override: monitor INR
Previous override information:
Override added on 5/26/05 by SPLETZER , ZENAIDA KAREY , M.D.
on order for BUPIVACAINE 0.5% ED 80 ML OTHER ( ref #
06414152 )
POTENTIALLY SERIOUS INTERACTION: FAMOTIDINE & BUPIVACAINE
HCL Reason for override: monitor INR
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
MVI ( MULTIVITAMINS ) 1 TAB orally every day
OXYCODONE 10-20 MG orally every 3 hours as needed Pain
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day as needed Constipation
Instructions: may be given with the patients choice of
beverage
COUMADIN ( WARFARIN SODIUM ) 7.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Dose for 10/11/05 . Please check INR daily
while in rehab and
then QMonday/Thursday. Goal INR=1.5-2.5 , duration is 3
weeks. INR at discharge was 1.1 after 6mg. Have results
sent to MMC primary care provider.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Reason: Override added on 5/25/05 by ARTERS , JEROLD E.
on order for BUPIVACAINE 0.5% ED 80 ML OTHER ( ref #
19455620 ) SERIOUS INTERACTION: WARFARIN & BUPIVACAINE HCL
SERIOUS INTERACTION: WARFARIN & BUPIVACAINE HCL
Reason for override: monitor INR
Previous override information:
Override added on 5/26/05 by SPLETZER , ZENAIDA KAREY , M.D.
on order for BUPIVACAINE 0.5% ED 80 ML OTHER ( ref #
06414152 ) SERIOUS INTERACTION: WARFARIN & BUPIVACAINE HCL
SERIOUS INTERACTION: WARFARIN & BUPIVACAINE HCL
Reason for override: monitor INR
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 10 MG orally every 12 hours
CHOLECALCIFEROL 400 UNITS orally every day
DIET: No Restrictions
ACTIVITY: Full weight-bearing: please increase ROM , leg strength , and work on ambulation
FOLLOW UP APPOINTMENT( S ):
Please follow-up with Dr. Rademan in 4-5 weeks ,
primary care physician ,
Arrange INR to be drawn on 6/1/05 with f/u INR's to be drawn every
1daywhileinrehab , thenqMOnday/Thursday days. INR's will be followed by Karina Floyd , MD at ( 373 ) 568-4909 MMC primary care provider
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
djd L knee , htn , bee sting allergy , obesity , hepatitis C virus
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
djd L knee , htn , bee sting allergy , obesity , hepatitis C virus
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
same
OPERATIONS AND PROCEDURES:
8/21/05 FANIEL , GAYLENE , M.D.
L. TOTAL KNEE REPALACEMENT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
54 year-old female patient with PMH htn , obesity , bee sting allergy ,
and hepatitis C , underwent left total
knee arthroplasty on 11/10/05 . The patient tolerated the procedure well was
managed per the pathway and had no major events.
Neurologic: Pain was initially managed with an epidural followed by orally
pain mediciation.
Respiratory: The patient's oxygen saturations gradually improved and at
the time of discharge they were weaned to room air.
Cardiovascular: The patient was maintained on his/her home blood
pressure medications and their blood pressure remained well controlled
throughtout their hospitalization.
Hematologic: The patient's hematocrit remained stable throughout the
hospitalization and was 31.4 on POD#2. INR increased
slowly with coumadin and at discharge was xx.
Fluids/Electrolytes/Nutrition: Their potassium and magnesium were
checked frequently during the admission and repleted as needed. They
were tolerating a regular diet at discharge.
Orthopedic: The patient worked with physical therapy and had a achieved
good ROM and was able to ambulate with assist at discharge. Their wound
appeared clean , dry , and intact.
ADDITIONAL COMMENTS: Dry sterile dressing to wound. May leave open to air when dry. May
shower when wound dry x48 hrs. Staple removal/steri-strip application ( on
POD 14 , March , 2005 ). Coumadin x 3 wks. Day after discharge and
biweekly physical therapy/INR blood draws ( every M/R ). Follow up with doctor as scheduled
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Please arrange for blood draws ( physical therapy/INR ) on day after discharge and Q
M/R thereafter. Pleae check daily while in rehab. Have reports phoned in
to A Triaded Health primary care physician , Karina Floyd , MD at ( 272 ) 369-4757. 2 ) Follow up
with doctor as scheduled. Continue
working on knee ROM , strengthening , and ambulation.
3 ) Please check Magnesium level 6/1/05 a.m. and phone results to primary care physician for
further instructions; patient with hx of hypomagnesemia , Mg=1.7 during
hospitalization and history of repletion with 2000mg Magnesium Gluconate orally x 1
on 10/11/05 .
No dictated summary
ENTERED BY: DEMOREST , MEGHAN O , M.D. ( PI820 ) 2/21/05 @ 11:00 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 117
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
Y |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
Y |
N |
855931883 | PUO | 06334183 | | 8949472 | 8/14/2002 12:00:00 a.m. | CELLULITIS | Signed | DIS | Admission Date: 8/14/2002 Report Status: Signed
Discharge Date: 10/6/2002
SERVICE: General Medical Service San Afield Health Care .
PRINCIPAL PROBLEM: Vascular insufficiency.
OTHER DIAGNOSES: Diabetes mellitus , known vascular disease ,
incontinence , recurrent UTIs , hypertension.
HISTORY OF PRESENT ILLNESS: This is an 89-year-old woman with
insulin dependent diabetes , coronary
artery disease , hypertension , peripheral vascular disease , and
ejection fraction of 28% who had a left fem-peroneal bypass in the
past presented with on-going left toe pain admitted for left toe
vascular insufficiency and cellulitis refractory to treatment for
two months. The patient reported having her podiatrist clip her
nails about two months ago which is when her pain in her foot
started. She denies any fever , chills , cough , shortness of breath ,
nausea , or vomiting. At home she was able to ambulate , but had
significant pain localizing to her left foot and toe. She was
recently admitted here on July for the same
complaint treated with intravenous levofloxacin and clindamycin for five
days and then went home on ten days of dicloxacillin , then Keflex.
She comes back on the April with the same pain
and infection in her left foot. On admission she was afebrile with
mild tachycardia and stable blood pressure. Exam was notable for a
soft systolic ejection murmur at the base , non-palpable pulses in
her left lower extremity. Left foot was cool. There was swelling
over the dorsum of her left foot to the ankle. There was a
superficial ulcer along the medial aspect of the nail bed without
purulence. She had normal white blood cell count and negative
blood cultures taken here.
PAST MEDICAL HISTORY: Status post CVA , status post carotid
endarterectomy , status post fem-peroneal
bypass in 1997 , diabetes , hypertension , inflammatory bowel disease ,
congestive heart failure with an EF of 28 to 30% , depression ,
recurrent UTIs , coronary artery disease , status post MI , non-Q wave
MI , cataracts , stress incontinence.
MEDICATIONS ON ADMISSION: Include lactulose , Zocor , Metamucil ,
Paxil , Cozaar , Neurontin , Metformin ,
Lantus.
ALLERGIES: Allergies to sulfa , Mavik , and verapamil.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She lives with her family.
REVIEW OF SYSTEMS: As per the history of the present illness.
ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3 ,
heart rate 100 , blood pressure
184/100 , breathing 20 and satting 97% on room air. GENERAL: No
acute distress , obese. HEENT: Clear. No adenopathy. Oropharynx
clear. NECK: Jugular venous distention less than eight
centimeters. CARDIOVASCULAR: Regular rate and rhythm. No
murmurs , rubs , or gallops. PULMONARY: Clear to auscultation
bilaterally. ABDOMEN: Soft , non-tender , non-distended. No
organomegaly. Obese. EXTREMITIES: Left foot swollen to the ankle
over the dorsum , erythema. Superficial ulceration along the
lateral first toenail bed without purulence. Left foot was cool.
Non-palpable pulses in lower extremity. NEUROLOGIC: She was
intact. Able to ambulate with some difficulty and pain.
HOSPITAL COURSE: The patient was admitted for recurrent vascular
insufficiency with superimposed cellulitis likely
due to her poor lower extremity perfusion from her peripheral
vascular disease. An MRI was obtained which was concerning for
early osteomyelitis and there was concern that her bypass graft in
her left leg was not patent. She had angiography of the left leg
vessels and proceeded to get stenting of the left common iliac and
external iliac vessels without complication on May . Also
during her hospitalization she had elevated LFTs which were
attributed to a three gram dose of Unasyn that she received in the
Emergency Room. The Unasyn was changed to intravenous clindamycin and levo ,
and a right upper quadrant ultrasound showed a calcified
gallbladder wall and no obstruction , and her LFTs then began to
normalize. Her cardiac status remained stable throughout her
admission and she is to be treated with Plavix 75 mg for 30 days
after the stenting of her iliac vessels. A PICC line was placed on
the day of discharge for on-going intravenous antibiotics
PLAN: The plan is as follows: 1. Plavix times 30 days , 75
milligrams a day. 2. intravenous clindamycin and orally levofloxacin
for another ten days , and then switch to orally Flagyl and
levofloxacin for an additional four weeks. 3. She is to follow-up
with her primary care physician , Dr. Desirae Marcott , and Vascular Surgery Clinic as
planned. 4. Please continue checking fingerstick blood sugars
before every meal and bedtime
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Include the following: aspirin , bacitracin ,
Dulcolax , clindamycin 600 mg intravenous every eight
hours for another ten days , Colace enema or laxative choice per day
for constipation , heparin 5000 units subcutaneously twice a day , regular insulin
sliding scale , lactulose 30 milliliters orally twice a day hold for loose
stool , Reglan ten milligrams orally every six for nausea or vomiting ,
oxycodone five to ten milligrams orally every four to six for
breakthrough pain , Fleets Phospho-Soda 45 liters orally twice a day as needed
for constipation , Senna tablets two tabs orally twice a day , Neurontin 100
milligrams orally twice a day , Metformin 500 milligrams orally twice a day ,
OxyContin ten milligrams orally every 12 hours , Cozaar 50 milligrams
orally every day hold for a systolic blood pressure less than 95 ,
levofloxacin 250 milligrams orally every day for the next ten days and
then an additional four weeks after that as described above , Plavix
75 milligrams orally every day times 30 days , and Adalat ( nifedipine
extended release ) 60 milligrams orally every day hold for systolic blood
pressure less than 95 , Lantus 14 units subcutaneously every day before noon
ADDITIONAL PLAN: The patient should have her LFT's rechecked in
the next week to ensure that they are normalizing.
Dictated By: PAOLA ODEA , VO54
Attending: JACKSON PART , M.D. QT06 HB709/506451
Batch: 63927 Index No. T0ND7G2KGG D: 10/10/02
T: 10/10/02
CC: 1. DESIRAE R. MARCOTT , M.D. AB14
Document id: 118
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
127873200 | PUO | 51793321 | | 572141 | 5/17/1999 12:00:00 a.m. | LT. L3-4 HERNIATED DISC | Signed | DIS | Admission Date: 4/9/1999 Report Status: Signed
Discharge Date: 11/24/1999
PROCEDURE: Left L4 hemilaminectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old male with
a three month history of low back pain
with a distant trauma. MRI of the lumbar spine done on May ,
1999 , showed L3-4 moderate diffuse disc bulge which lateralized to
the left , severe central and moderate left and mild CR , foraminal
stenosis , L4-5 mild diffuse disc bulge , mild foraminal stenosis of
L5-S1 , small disc protrusion without stenosis. The patient
complained of a left leg limp with left buttock pain , which he
reports as "unbearable" when standing or walking. The patient
denies having fallen. The patient takes Percocet plus/minus
Tylenol no. 3 one pill every 2-3 h. or two to three pills twice a day The
patient has tried to limit narcotics to six tablets a day.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes mellitus.
3. Hypercholesteremia.
4. Retinitis pigmentosa.
5. Benign prostatic hypertrophy.
6. Nephrolithiasis.
7. Morbid obesity.
8. Microhematuria.
PAST SURGICAL HISTORY:
1. Eye surgery.
2. Knee surgery.
3. Kidney stones.
ADMISSION MEDICATIONS:
1. Cardizem CD 240 mg every day
2. Prinivil 10 mg twice a day
3. Lipitor.
4. Docusate.
5. Codeine.
6. Tylenol no. 3.
7. Percocet.
8. Aspirin 325 mg orally every day
9. Sodium docusate 100 mg orally every afternoon
10. Multivitamin.
11. Dovonex cream 0.005% as needed
12. Lamisil cream 4% as needed
SOCIAL HISTORY: The patient is married. He lives at home with his
wife.
REVIEW OF SYSTEMS: The patient feels well. He is almost
completely blind. Activity is limited
secondary to back pain. He denies paroxysmal nocturnal dyspnea or
POE. MIBI in 4/11 showed no fixed or reversible deficit , ejection
fraction 50%. The patient is constipated. No dizziness or
syncope. There is left leg weakness without falls. The patient
has had non-insulin-dependent diabetes for five to seven years , off
medications since 9/10 , now diet-controlled. He is status post a
30 pound intentional weight loss. He has psoriasis in the elbows ,
knees , and groin.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient was a
well-appearing , obese white male in no
apparent distress. VITAL SIGNS: Blood pressure was 110/85 , pulse
70 , respiratory rate 16. Height was 6 feet 2 inches. Weight was
298 pounds. SKIN: Warm and dry. There was psoriasis in the
bilateral elbows. NODES: No cervical lymphadenopathy was noted.
HEENT: Normocephalic , atraumatic. The right eye is deviated
laterally. Pupils are nonreactive. The left pupil is misshapen.
LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and
rhythm. ABDOMEN: Obese , soft , non-tender. No hepatosplenomegaly.
No palpable masses. NEUROLOGIC: The patient was alert and
oriented x 3. Motor examination was 5/5 to upper extremities , 5/5
to lower extremities , and symmetric bilaterally. His speech was
fluent. His sensory examination was intact to light touch. Deep
tendon reflexes were trace in the upper extremities and absent in
the lower extremities. Dorsal pedis pulses were felt 1-2+
bilaterally. There was no clubbing , cyanosis , or edema.
LABORATORY DATA: Sodium was 138 , potassium 4.3 , chloride 102 ,
bicarb 25 , BUN 28 , and creatinine 1.0. Glucose
was 255. White count was 5 , hematocrit 37 , platelets 151. Calcium
was 8.7. physical therapy was 12 , PTT 23 , INR 1.1. Urinalysis showed 3+
protein , 1+ ketones , 3+ blood , positive nitrites , no WBCs.
IMPRESSION: L3-4 herniated disc.
PLAN: The plan was for the patient to undergo L4 hemilaminectomy.
HOSPITAL COURSE: The patient was admitted on June , 1999 , to the
Neurosurgery service. After consent was signed ,
he was taken to the Operating Room. The patient underwent left L4
hemilaminectomy. The surgeon was Dr. Lehnortt . The anesthesia was
general. Estimated blood loss was 1000 cc. There were no
complications. The patient was stable post-extubation and was
transferred to the Postanesthesia Care Unit. The patient was then ,
after observation , transferred to the regular neurosurgery floor ,
Ri The patient did well postoperatively. However , it was noted
that the patient was not able to void when the Foley was
discontinued. Thus , a Genitourinary was consult was obtained on
June , 1999. It was noted that the patient had his own
urologist , Dr. Cridge . for a previous problem of benign prostatic
hypertrophy. It was recommended by the Genitourinary consult that
he be started on Flomax 0.4 mg orally every day , to try a second voiding
trial. On the repeat voiding trial , the patient was able to void
on his own , voiding 1700 cc on postoperative day three. The
patient was also referred for Physical Therapy and Occupational
Therapy consults to evaluate his physical therapy. It was
recommended that the patient be discharged with home physical
therapy as well as home occupational therapy. Today , on October ,
1999 , the patient is in good spirits. He is feeling well. His
T-max is 99.2 , heart rate 80 , blood pressure 130/80 , respiratory
rate 16. O2 saturation is 94%. Is and Os shows 2100 in and 2800
out. The patient is an obese white male , alert and oriented x 3 ,
with fluent speech. He has no drift. Cranial nerves were grossly
intact. Strength and sensory were intact in all four extremities.
His wound was clean , dry , and intact. The assessment was that the
patient was feeling well.
The patient had a positive urinalysis on admission. He was started
on levofloxacin 500 mg orally every day x 4 days for his presumed urinary
tract infection.
DISPOSITION: The patient is discharged to home with home physical
therapy and occupational therapy in stable condition.
FOLLOW-UP: The patient is to follow up with Dr. Loriann Lehnortt in
approximately one week in his clinic. The patient is
also to follow up with Dr. Cridge in approximately one week if he
continues to have any problems with his voiding. He was given Dr.
Iseri number , 206-6038.
DISCHARGE MEDICATIONS:
1. Colace 100 mg orally twice a day
2. Tiazac 240 mg orally every day
3. Prinivil 10 mg orally twice a day
4. Simvastatin 10 mg orally every bedtime
5. Ecotrin 325 mg orally every day
6. Multivitamin one tablet orally every day
7. Zantac 150 mg orally twice a day
8. Flomax 0.4 mg orally every day
9. Maalox Plus Extra Strength 15 cc orally every 6 hours as needed
10. Serax 15-30 mg orally every bedtime as needed
11. Tylenol 650 mg orally every 4 hours as needed
12. Milk of magnesia 30 cc orally every day as needed
13. Percocet one to two tabs orally every 4 hours as needed pain.
14. Benadryl 25 mg orally every bedtime as needed itching and hives.
15. Xanax 0.25 mg orally three times a day as needed anxiety.
16. Valium 5 mg orally every 6 hours as needed pain and anxiety.
Dictated By: GERMAINE BLACKGOAT , M.D. SE68
Attending: LORIANN LEHNORTT , M.D. FQ72 QZ150/5785
Batch: 00159 Index No. WIDBU87Y0T D: 5/3/99
T: 5/3/99
Document id: 119
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
Y |
N |
Y |
Y |
- |
N |
Y |
N |
N |
N |
000597448 | PUO | 96398256 | | 8452336 | 4/9/2006 12:00:00 a.m. | SEPSIS | Signed | DIS | Admission Date: 6/10/2006 Report Status: Signed
Discharge Date: 3/10/2006
ATTENDING: GILFOY , DEANDRA LAZARO MD
SERVICE: Medicine.
Mr. Elia was admitted with hypoxia and hypotension initially in
the MICU. He is a 66-year-old male with coronary artery disease ,
hypertension , type 2 diabetes , hyperlipidemia , ischemic
cardiomyopathy with an EF of 35% , and history of CVAs. He was
recently admitted in October 2006 for a right middle lobe
pneumonia , spent 2 days in the hospital. He felt fine since then
with some waxing and waning. However , he presented with
increased cough , rigor's , difficulty walking and speaking , and a
fever to 101. He was found at home to be short of breath. He
had blue lips , hands per his family. EMS was called and found
that he had an O2 saturation of 80%; it increased to 97% on 100%
nonrebreather. EKG on admission showed new left bundle-branch
block , but cath lab declined to intervene because he was
tachycardic at that time. It was felt to be secondary to demand.
He was hypotensive in the ED requiring fluids. Subclavian line
was placed.
PAST MEDICAL HISTORY: CAD. He has 3-vessel coronary artery
disease , status post CABG x1 in 1999 , SVG to RCA. He had an
NSTEMI in 1/22 with Cypher stent to 70% proximal LAD and Pixel
stent to 70% ostial D1. He had an NSTEMI in October 2004 with a
new Cypher to D1 instent restenosis and diffuse left circ disease
was seen as well. He has hypertension , also type 2 diabetes , on
orally agents. He has hyperlipidemia. He has mitral valve status
post St. Jude 33-mm valve in 1999. He has ischemic
cardiomyopathy with an EF of 35%. He has had multiple CVAs. He
is on treatment dose of Lovenox after failure of Coumadin and
prophylactic dose of Lovenox. He had a subdural hematoma in the
setting of Coumadin , status post bur-hole drainage in 1999. He
has seizure disorder history. He also has a history of carotid
stenosis , status post a left CEA in 2002. He has GERD and
history of sacral decubitus ulcer.
MEDICATIONS ON ADMISSION: Aspirin 325 daily , Toprol 200 daily ,
lisinopril 20 daily , Lovenox 80 twice a day , fenofibrate 145 daily ,
Lipitor 40 daily , glipizide 10 twice a day , Keppra 500 twice a day ,
Benadryl 25 twice a day as needed for itching , multivitamin , iron
sulfate 325 daily , trazodone 50 daily , Zantac 150 twice daily ,
and miconazole topical daily.
He has an allergy to Dilantin which causes a desquamating rash.
On admission to the MICU , his temperature was 96.7 , heart rate
75 , BP 98/54 , breathing at 14 , satting 97% on 4 L. He was in no
acute distress. Anicteric. OP was clear. Pulmonary exam
revealed crackles , decreased breath sounds at the bases , no
wheezes. He had a regular rate and rhythm with distant heart
sounds , mechanical S1. His JVP was from the jaw. He had
positive bowel sounds , obese , soft , nontender abdomen. His legs
were warm and dry with no rashes. He was awake but not
cooperative. He has a baseline left-sided facial droop , left
forearm flexion , moving all 4 extremities.
His admission chest x-ray showed a diffuse bilateral airspace
disease , right greater than left , no effusion , consistent with
multilobar pneumonia versus pulmonary edema. Echo in September 2005
showed an LVEF of 35% with a kinesis of septum , inferior wall ,
apical lateral segment and mechanical mitral valve. His EKG in
the MICU showed sinus at a rate of 76. When his rate was faster ,
he showed a left bundle-branch block.
COURSE BY PROBLEM:
1. ID: There was a question of multilobar pneumonia based on
his recent admission for pneumonia and the appearance of his
chest x-ray. He was initially on empiric ceftriaxone ,
azithromycin , and vancomycin in the MICU. We discontinued the
vancomycin. Blood cultures were clear. He weaned from oxygen ,
and his chest x-ray cleared within 1 to 2 days. So , it was felt
that he had more of the component of CHF exacerbation. He
completed a short 7-day course of azithromycin.
2. Cardiovascular:
I. Ischemia: He has extensive CAD and showed an elevated CK ,
troponin , and a new left bundle branch in the setting of
hypotension. This was felt to be a demand ischemia. His enzymes were
elevated with his troponin remaining elevated at 5 , but the MB had
decreased from 18 to 2 rapidly. The cardiology consultants felt
that this was demand ischemia as the left bundle-branch block was
rate dependent and recommended continued medical management. He
is already on therapeutic-dose Lovenox for his history of CVA.
II. Pump: He initially had hypertension in the unit. This
resolved and he appeared euvolemic on his home dose of 20 mg of
Lasix daily. A repeat echo revealed no changes.
III. Rhythm: As mentioned above , he exhibited a new left
bundle-branch block in the setting of tachycardia but decreased
rate.
3. Heme: Initially had bleeding from his left subclavian site
in the setting of his anticoagulation; it resolved. Spoke with
the vascular wervice who recommended holding one dose of Lovenox when the
line was removed. This was done , and the line was removed
successfully without any bleeding.
4. Renal: He has chronic renal insufficiency. His creatinine
remained at baseline of 1.2 to 1.5.
5. Neuro: He has a history of multiple CVAs. We kept him on
his treatment-dose Lovenox other than being held for 1 dose to
remove the line. He has seizure disorder. He is on Keppra. He
has a history of sundowning and was placed on Zyprexa briefly but
this was weaned.
6. Endo: At home , Mr. Elia was on orally medications. He was
started on Lantus and lispro and we decided to send him on Lantus
as well as some before meals NovoLog as well.
Mr. Elia was discharged home with services with followup
appointments with Dr. September Petretti on 3/30/2006 at 1330 hours ,
Dr. Andresen on 5/11/2006 at 1550 hours , and with Dr.
Fiermonte on 11/8/2006 at 1400 hours.
DISCHARGE MEDICATIONS: Tylenol 650 mg every 4 hours as needed
for headache , aspirin 325 mg daily , Dulcolax 10 mg daily , Colace
100 mg twice daily , Lovenox 80 mg twice daily , fenofibrate 145 mg
daily , iron sulfate 325 mg daily , Lasix 20 mg daily , NovoLog 12
units subcutaneously with each meal , Lantus 44 mg each night ,
Atrovent nebs 0.5 mg 4 times daily , Keppra 500 mg twice daily ,
lisinopril 20 mg daily , Toprol-XL 200 mg daily , Zantac 150 mg
twice daily , multivitamin , and Lipitor 40 mg daily.
eScription document: 9-8995756 HFFocus
Dictated By: HOLDA , ALYSE
Attending: GILFOY , DEANDRA LAZARO
Dictation ID 8130002
D: 2/5/06
T: 2/5/06
Document id: 120
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
712290326 | PUO | 60172509 | | 8144472 | 9/15/2005 12:00:00 a.m. | SEPTIC SHOCK | Signed | DIS | Admission Date: 11/8/2005 Report Status: Signed
Discharge Date: 9/10/2005
ATTENDING: RAMONEZ , MARA M.D.
HISTORY OF PRESENT ILLNESS:
In brief , this is a 64-year-old male with a history of CAD , CHF
with an EF of 25% on a prior echo with a inferior hypokinesis ,
PE , DVT on Coumadin , morbid obesity , with OSA , chronic renal
insufficiency , who presented with fever , hematuria , dysuria , and
right back pain , admitted for urosepsis requiring vasopressin for
blood pressure support. The patient was admitted to the Medical
ICU. Initially , did not respond to vasopressor regimen and
unclear relative contribution of distributive verus cardiogenic
shock. Electively intubated in an anticipation of procedures
given body habitus. Swan numbers were consistent with
distributive shock in addition to urosepsis with E. coli and
urine culture and sputum culture. The patient also had evidence
of prostatitis and acalculous cholecystitis , status post biliary
drain with E. coli , received desensitization for ceftriaxone for
quinolone-resistant E. coli. The patient improved on antibiotic
regimen , off pressors and continued to have daily fevers , now off
all antibiotics. The patient was trached for obstructive sleep
apnea , now tolerating trache collar and able to take orally
PAST MEDICAL HISTORY:
Morbid obesity , status post ileojejunal bypass in 1972 , gastric
stapling in 1987 , obstructive sleep apnea , on home 3 liters nasal
cannula , home oxygen and BiPAP , asthma , CAD with no intervention ,
a MIBI in 1998 that showed apical anterior MI with mild
stress-induced ischemia and the anterior wall and lateral wall
MI , cardiomyopathy with an EF of 25% , paroxysmal atrial
fibrillation , status post permanent pacemaker for bradycardia ,
atrial flutter with Mobitz type II , PE/DVT status post IVC filter
with an INR goal of 1.5 to 2.0 , chronic renal insufficiency with
a baseline creatinine of 1.9 , BPH , gout , history of GI bleed
secondary erosive gastritis , sigmoidectomy in 3/11 , depression ,
osteoarthritis , nephrolithiasis in 1/20 , and in 5/13 presented
with hematuria.
MEDICATIONS AT HOME:
Included Lasix 50 mg orally daily , atenolol 100 mg every day before noon and 50 mg
orally every afternoon , Coumadin 5 mg orally daily , digoxin 0.250 mg orally
daily , Prevacid 20 mg orally daily , Flomax 0.5 mg orally daily ,
Levoxyl 100 mcg orally daily , colchicine 0.6 mg orally daily ,
allopurinol 100 mg orally daily , B12 1000 units intramuscular every month ,
Roxicodone 10-15 mg orally three times a day as needed pain , Zoloft 100 mg orally
daily , calcitriol 0.25 mcg daily , lorazepam 1 mg orally twice a day , and
Advair 250/50 mg daily.
ALLERGIES:
Incudes erythromycin , which gives him hives , penicillin hives ,
trazodone priapism , and ACE inhibitors , which caused angioedema.
SOCIAL HISTORY:
His daughter is Mamie Zorens , reached at 590-646-4489 , has
VNA services at home , is a nonsmoker , and history of alcohol
abuse.
FAMILY HISTORY:
Significant for mother with diabetes and father with hypertension
and alcoholism.
PHYSICAL EXAMINATION:
A morbidly obese African-American male trached in no acute
distress. Pupils were equally , round , and reactive to light.
His oropharynx is clear with moist mucous membranes. His chest
has vented breath sounds. His heart is S1 and S2 , tachycardic
with no murmurs , rubs , or gallops , sometimes irregularly
irregular. His abdomen is obese with a gallbladder drain , soft ,
nontender , and nondistended. His extremities are warm and well
perfused with 2+ pitting edema to the knees bilaterally. Skin ,
he had healing vesicles on his nose and lips.
HOSPITAL COURSE:
ID: The patient with septic shock secondary to urosepsis and
acalculous cholecystitis secondary to quinolone-resistant E.
coli. He had a desensitization protocol for ceftriaxone to treat
E. coli , completed a 14-day course of ceftriaxone for urosepsis.
He had a biliary drain placed to decompress gallbladder on
11/6/05 . A right upper quadrant ultrasound without dilated
ducts. This will stay in place for six weeks. Also , received a
14-day course of vancomycin for empiric coverage after 8/30/05
coag-negative Staph from the line. This was continued , as the
patient continued to be febrile. Other surveillance cultures
were negative. Vesicular lesions on 11/6/05 on the nose and
lips , received a seven-day course of acyclovir. While patient's
white blood cells count trending down and hemodynamically stable ,
continued to have daily fevers , usually spiking in the afternoon
and then defervescing without medication throughout the day.
LENIs on 5/26/05 showed no new DVTs , although limited due to
patient's body habitus. The patient's galactomannan was
negative. Both arterial line and central line changed 2/4/05 ,
eventually taken out. Fevers felt to be due to antibiotics , now
off all antibiotics with gradual resolution of fevers. ENT
evaluated for sinusitis. No
sinusitis on 10/10/05 . The patient's LFTs were within normal
limits. Chest x-ray is clear. Sputum culture was notable for
yeast. Body habitus prevents chest , abdominal , and pelvic CT
scan.
2. Pulmonary: The patient was trached due to extensive soft
tissue and concern for airway collapse. The patient tolerating
trach with decreased secretions when started on glycopyrrolate ,
and the patient's trache tube was changed on 4/19/05 to a
Bivona #7.
3. Cardiovascular: The patient with known CAD , on beta-blocker ,
consider restarting aspirin , once therapeutic on Coumadin. The
patient has known ACE inhibitor allergy. The patient's fasting
lipid profiles were within normal limits , not on the statin.
Pump: The patient had an echo on 2/4/05 that showed mild to
moderately reduced LV function. Unable to assess the ejection
fraction due to limited study from the size , severe posterior
lateral hypokinesis to akinesis and abnormal septal wall motion ,
moderate tricuspid regurgitation. Volume overloaded , diuresed
with Lasix , now euvolemic , autoregulating. Rate and rhythm: The
patient with paroxysmal atrial fibrillation on anticoagulation ,
status post permanent pacemaker for bradycardia. EP increased
the rate of his pacemaker from 60-80 and the pacemaker rate
should be changed back to 60 with the Medtronic pacemaker.
4. Heme: The patient with a history of DVT , PE , now on Coumadin
with the therapeutic INR goal of 1.5 to 2.0. The history of GI
bleed. He has an IVC filter in place.
5. GI: Status post biliary drain for acalculous cholecystitis
to remain for a total of six weeks by Interventional Radiology
placed on 11/6/05 .
6. Renal: Acute and chronic renal failure resolved after
sepsis. Creatinine at baseline after diuresing post ATN. Renal
ultrasound within normal limits.
7. Endo: Continued on home dose Levoxyl for hypothyroidism.
Became , hyponatremic , hyperkalemic , which resolved on its own.
Cort-stim within normal limits.
8. FEN: The patient is status post trache refusing OG/NG tube.
Speech and Swallow felt that the patient would tolerate orally and
advanced diet as tolerated.
9. PPX: The patient on Coumadin with an elevated INR and proton
pump inhibitor. The patient is a full code.
DISCHARGE MEDICATIONS:
Tylenol 1000 mg orally every 4 hours as needed temperature greater than 101 ,
albuterol inhaler two puffs inhaler four times a day as needed shortness of
breath , diphenhydramine HCL 25-50 mg intravenous every 4 hours as needed other
allergic reaction , folate 1 mg orally daily , glycopyrrolate 1 mg
orally three times a day , Regular Insulin sliding scale , Lacrilube topical
each eye daily , Levoxyl 100 mcg orally daily , Ativan 1-2 mg intravenous
every 4 hours as needed anxiety , Ativan 1 mg orally three times a day , Lopressor 25 mg
orally twice a day; hold if systolic blood pressure less than 90 and
heart rate less than 50 , oxycodone 5-10 mg orally every 4 hours as needed
pain , Pyridium 100 mg orally three times a day as needed bladder spasm ,
multivitamin therapeutic with minerals one tablet orally daily ,
vitamin A 10 , 000 units orally daily x7 doses started on 4/19/05 ,
Coumadin 5 mg orally every afternoon , Zinc sulfate 220 mg orally daily x14
doses started on 4/19/05 , Zoloft 50 mg orally daily , should be
titrated up to 100 mg orally daily , fluticasone 110 mcg inhaler
twice a day , miconazole 2% powder topical twice a day , Combivent 6 puffs
inhaler four times a day , and Nexium 20 mg orally daily.
The patient is now in stable condition , full code.
eScription document: 4-3355807 EMS
Dictated By: HAENER , AMINA
Attending: RAMONEZ , MARA
Dictation ID 0645991
D: 5/10/05
T: 5/10/05
Document id: 121
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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953629529 | PUO | 68303491 | | 7208852 | 7/24/2006 12:00:00 a.m. | Right knee pain/sprain , | | DIS | Admission Date: 6/5/2006 Report Status:
Discharge Date: 3/4/2006
****** FINAL DISCHARGE ORDERS ******
HEISS , EDWINA 028-71-94-6
Las Fre Na
Service: MED
DISCHARGE PATIENT ON: 10/28/06 AT 05:00 PM
CONTINGENT UPON pain control
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TROJAN , LUISE R. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
Starting Today ( 4/06 ) as needed Constipation
HOLD IF: loose stools
LEXAPRO ( ESCITALOPRAM ) 10 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
MOTRIN ( IBUPROFEN ) 600 MG orally every 6 hours X 7 Days
Starting Today ( 4/06 ) Instructions: take with meals
Food/Drug Interaction Instruction Take with food
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day as needed Shortness of Breath , Wheezing
LEVOFLOXACIN 500 MG orally DAILY X 4 Days
Starting IN a.m. ( 8/2 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
METFORMIN 500 MG orally DAILY
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
PERCOCET 1 TAB orally every 6 hours as needed Pain
DIET: House / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
per physical therapy recommendations
FOLLOW UP APPOINTMENT( S ):
Dr Sakumoto x 2-3 weeks or as needed ,
ALLERGY: Penicillins , AMPICILLIN , LISINOPRIL , Cephalosporins
ADMIT DIAGNOSIS:
Right knee/leg pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Right knee pain/sprain ,
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid Obesity , Asthma , Sleep apnea , Depression , Diarrhea , Anemia
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: R thigh/leg pain
---
HPI: 39F with obesity , DM was in RHMC until 5 days prior to arrival. Was
riding in scooter , accidentally hit R thigh against shelf and developed
pain and swelling which progressively got worse over the past few days.
Took 1 vicodin without relief , went to see her primary care physician , Dr. Sakumoto , 11/19
for evaluation. Concerned about DVT so sent patient to ED for eval and
management. Denies sob , no CP , no F/Ch , no history of DVT/PE , no weakness.
Pain is diffuse t/o R leg , worse with movement and palpation.
In ED: vs 98.1 91 149/84 20 96%RA; unable to perform LENI and CT with
contrast 2/2 patient's body habitus so after d/with primary care physician and patient decision made
to tx for cellulitis ( levoflox intravenous 500mg x 1 ) and admit for observation.
---
Home Medications: Naprosyn 500 twice a day as needed , Lexapro 10 every day , albuterol mdi
as needed , combivent four times a day as needed , lasix 40 every day , metformin 500 every day , vicodin as needed ,
miconazole twice a day , IUD
---
ALL: PCN -> GI upset; Ampicillin; Lisinopril -> throat swelling;
Cephalosporins -> GI upset
---
PE on Admission: VS: 97.9 77 140/78 20 97%RA
Gen: morbidly obese AA woman in NAD , comfortable
HEENT: anicteric , OP clear
Neck: JVP unable to assess
CV: distant HS , RRR nrl s1s2 no r/m/g
Lungs: distant BS , ctab , no c/r/with
Abd: obese , soft , NT
Ext: morbidly obese , R leg diffusely tender topalpation , no clear skin
erythema
Neuro: A+Ox3 , grossly intact
---
Data:
WBC 7.7 Hct 34.6 chem wnl D-dimer < 200/neg
---
Hospital Course: 39F with morbid obesity , DM , sent to ED by primary care physician out of
concern for DVT after blunt trauma 5 days ago with increasing
pain/swelling. Swelling is apparently chronic and pain appears to be
msk in nature. D-dimer <200 , so likelihood of DVT is low.
Unable to image to further investigate and physical exam difficult
given body habitus. Decision was made in ED after d/with primary care physician to admit
for observation and tx emperically with abx. No clear e/o
cellulitis on exam , no leulkocytosis. patient not willing to try more
narrow-spectrum abx. Continued on home meds , motrin standing 600
three times a day , oxycodeon +/- APAP as needed for pain , continued on levoflox for chsrt
5 day course , lovenox ppx while in house. patient consult
obtained and patient at baseline mobility status and cleared to go home
with walker ans scooter. If pain continues without improvement ,
recommend outpt ortho referal. Will monitor pain and if feeling
better will d/c home this evening and resume services
primary care physician: Dr Sakumoto contacted and agrees with plan
ADDITIONAL COMMENTS: 1. Please don't drive while on pain medications. While taking pain
medications please monitor bowel movements and take stool softners as
needed.
2. If pain doesn't improve would recommend outpatient orthopedic consult
- discussed with Dr Sakumoto already
3. Return to ED is experience shortness of breath , calf pain , increased
severity of knee/leg pain , chest pain , nausea , vomiting or any other
worrisome symptoms
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TROKEY , CLARITA K. , PA ( ZU74 ) 10/28/06 @ 02:23 PM
****** END OF DISCHARGE ORDERS ******
Document id: 122
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
- |
N |
Y |
N |
N |
Y |
- |
Y |
N |
N |
N |
N |
N |
N |
944703156 | PUO | 27256834 | | 8351142 | 6/21/2006 12:00:00 a.m. | CHF exacerbation due to med nonadherence | | DIS | Admission Date: 1/1/2006 Report Status:
Discharge Date: 5/25/2006
****** FINAL DISCHARGE ORDERS ******
PATETE , TAINA J 456-45-43-5
Delpter Na
Service: MED
DISCHARGE PATIENT ON: 5/18/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
No CPR , No defib , No intubation , No pressors
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMLODIPINE 10 MG orally DAILY Starting IN a.m. ( 7/28 )
HOLD IF: HR<60 , SBP<90 Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ASA 325 MG orally DAILY
PHOSLO ( CALCIUM ACETATE ( 1 GELCAP=667 MG ) )
1 , 334 MG orally three times a day Instructions: with meals
LASIX ( FUROSEMIDE ) 80 MG orally DAILY Starting STAT ( 7/28 )
Instructions: take 80 mg daily for next three days , then
go back to 80 daily alternating with 40 daily.
HYDRALAZINE 25 MG orally three times a day
LABETALOL HCL 200 MG orally twice a day HOLD IF: SBP<90 , HR<60
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOCOR ( SIMVASTATIN ) 10 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
KAYEXALATE ( SODIUM POLYSTYRENE SULFONATE )
30 GM orally EVERY OTHER DAY
VALACYCLOVIR 500 MG orally DAILY X 7 Days
Starting Today ( 7/28 )
Number of Doses Required ( approximate ): 10
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
NO FOLLOW APPOINTMRNT REQUIRED
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation due to med nonadherence
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation due to med nonadherence
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
congestive heart failure , coronary artery disease
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Congestive Heart Failure
*************
ID: 88 year-old with recent STEMI , treated medically , with CHF ( EF40% ) now
with increasing SOB for two days in setting of not taking lasix.
**************
HPI: 88 year-old with history of HTN , CRI history of nephrectomy ( refuses HD ) ,
recent STEMI one month ago , treated medically , as patient refused
cath given CRI and risk of lifelong dialysis. Discharged on lasix
and BP meds , but not taking for past two days. Severe SOB two days
PTA , in setting of non med adherence. daughter in
law ( nurse ) gave lasix and SOB improved. Denies CP ,
N/V , disphoresis , f/c/cough/abd pain/diarrhea/dysuria. Also complains
of four days of pruritic , vesicular rash in dermatomal pattern
on back , chest , R arm , likely zoster.
********************
Patient Status on admission: NAD , afebrile , 95% on 2L , HR 55 , BP115/53 , RR
18 , JVP 9 cm , crackles 1/2 up , RRR but distant heart sounds , no m/g/r ,
abd soft , NT , ND , 1+ pedal edema b/l.
Patient Status on Discharge: NAD , afebrile , 94% on RA , 96% on 2L.
140-150/70-76 HR 40( brief , asymptomatic )-72 RR16-18. no JVD. CTAB.
Abd NT , ND. No pedal edema.
********************
Studies Echo: 3/19 40%. Severe mid-distal anteroseptal
hypokinesis. EKG: Q waves in anterior leads , new TWI/flattening
in V4-V6. old RBBB , 1st degree AV block. CXR: small b/l pleural
effusions , mild interstitial edema , mild
cardiomegaly
**********************
Hospital Course by Problem:
88 year-old with recent STEMI , managed medically , here with CHF
exacerbation in setting non med adherence and zoster. Patient is non
adherent to meds given recent increase in number of total meds since STEMIi.
olypharmacy seems to have overwhelmed the patient , so efforts were made to
reduced his med list to just "essential meds" to improve adherence. Patient
remains on three times a day and twice a day dosed HTNive meds which is not ideal , but we will
defer adjustment of his cardiac regimen to his cardiologist. For now , iron ,
nexium , probenecid , ergocalcitriol , nephrocaps have been taken off the emd
list , but can be added back in if seen fit.
1 ) CV:
ISCHEMIA: Recent STEMI , not stented given potential contrast load
in setting of CRI ( no HD ). On this admission , no chest pain , some TWI in
chest leads , but cardiac enzymes negative. Continue home doses ASA , Zocor.
PUMP: CHF exacerbation: Received 60mg Lasix intravenous x1 ,
diuresed well with resolution of pulm edema , dyspnea. Will discharge on
home regimen Lasix 40mg orally twice a day QDay for next three days , then back to prior
dose of 80 mg orally every day alternating with 40 mg orally every day
Satting 95% on RA at discharge.
Had brief episode of bradycardia to 40 , but no symptoms or EKG changes.
Will keep on high Labetalol dose given severe CAD without stent , only
medical management. Continue amlodipine , Hydralazine for HTN
RHYTHM: no active issues besides asymptomatic bradycardia.
3 ) Zoster ( shingles ): Began Valacyclovir , will dischage with 6 more days
of this med. Calamine for pruritis offered some relief.
4 ) Anemia: secondary to renal failure. cont weekly epo injections and iron
supplements
5 ) DM: diet controlled.
6 ) Med noncompliance: arranged for VNA to help with med scheduling.
7 ) CRI: high BUN/CR , but same as previous admission. Metabolic
acidosis from inability to excrete H+. Refused HD. Continue Phoslo ,
Kaexylate.
8 ) ANEMIA: most likely secondary to renal failure. Will continue weekly
epo shots as needed
9 ) RHEUM: hold probenecid for gout given CRI
ADDITIONAL COMMENTS: Please take all meds daily
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: LARZELERE , GAYLE C. , M.D. ( SJ97 ) 5/18/06 @ 02:47 PM
****** END OF DISCHARGE ORDERS ******
Document id: 123
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
- |
N |
N |
Y |
N |
N |
N |
519654434 | PUO | 49819298 | | 530430 | 9/15/2001 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 9/15/2001 Report Status: Signed
Discharge Date: 2/5/2001
HISTORY OF PRESENT ILLNESS: Mr. Smolinsky is a 59-year-old male
with a history of coronary artery
disease status post small non-ST elevation myocardial infarction in
October of 2000 and also status post cardiac catheterization with 2
vessel disease , small left PICA cerebrovascular accident ,
congestive heart failure with an echocardiogram in October
revealing an ejection fraction of 30%. Also diabetes mellitus type
II complicated by retinopathy , nephropathy and question neuropathy.
History of hypertension , hypercholesterolemia as well who
presented to Dr. Dimpfl clinic on May , 2001 with
progressive increasing dyspnea , increasing abdominal girth and
weight gain over the past few months.
PAST MEDICAL HISTORY: Diabetes mellitus x 20 years , chronic renal
insufficiency with the last creatinine in
January of 3.5 , congestive heart failure with an ejection fraction of
30% in October of 2000 , coronary artery disease status post
myocardial infarction , October 2000 question f silent myocardial
infarction x 2 , history of hyperlipidemia.
MEDICATIONS ON ADMISSION: Aspirin daily , Lasix 80 mg orally every day ,
Zaroxolyn 2.5 mg orally every day , toprol XL
50 mg orally every day , insulin 70/30 65/45 , Actos 45 every p.m , Avapro 300
mg orally every day , Lipitor 10 mg orally every bedtime , sublingual nitroglycerin
as needed.
PHYSICAL EXAM: Temperature 98.1 , blood pressure 116/70 , pulse 88 ,
primary care physician of 18. The patient appeared
to be in no acute distress. Jugular venous pressure approximately
13 cm water. LUNGS: Faint bibasilar rales. CARDIAC:
Tachycardia , regular rhythm without murmurs. ABDOMEN: Positive ,
normal active bowel sounds. Obese , distended and nontender.
EXTREMITIES: 2 plus dorsalis pedis pulse , 2-3 plus edema
bilaterally to the knees.
HOSPITAL COURSE: 1. Cardiovascular: It was felt that given notes
of thyroid dysfunction , his history was
consistent with fluid overload. His jugular venous pressure was
elevated and he had 3plus pitting edema to the knees without
significant rales on chest exam. He was aggressively diuresed with
doses of Lasix 200 mg twice a day intravenous as well as Zaroxolyn. Weight on
admission was 135 kilograms and on discharge he was down to 132
kilograms. A repeat echocardiogram at Pagham University Of
showed an ejection fraction of 30-35 , left ventricular dimensions
of 47 mm , 1 plus mitral regurgitation and global hypokinesis as
well as moderate right ventricular dysfunction. Abdominal
ultrasound showed no ascites despite extremely distended abdomen
and right renal cyst x 2. Follow up abdominal CT also showed there
was no mass or ascites and his distended abdomen was likely due to
adipose tissue. Diuresis was limited by acute and chronic renal
failure and oliguria. Diuresis was held from May , 2001.
Right heart catheterization on February , 2001 showed mildly
elevated pulmonary capillary wedge pressure and moderately elevated
right ventricular pressures. Dopamine was started on June ,
2001 to aid with renal perfusion and diuresis and he was then
weaned off of that on July , 2001. His Lasix was stopped on
July , 2001 and he auto-diuresed until the time of discharge
with stable blood pressure. He remained stable with no dyspnea at
rest and is symptom free at the time of discharge.
2. Renal: His basic chronic renal insufficiency is likely
secondary to poor diabetic control with a creatinine of 2.5 on October , 2001 , 3.3 at the time of admission. Acute renal failure with
increasing creatinine of 6 after aggressive diuresis with a mean of
0.8 percent. Renal function improved with creatinine of 4.1 on
July , 2001 with autodiuresis. The renal service was
consulted to comment on the nature of the patient's renal
insufficiency and acute renal failure as well as to assist in the
use of vasodilators.
3. Endocrine: He has a long standing history of type II diabetes
complicated by retinopathy and neuropathy and nephropathy. He was
maintained on his outpatient endocrine regimen during his stay.
The patient was discharged home with services. He is to follow up
with Dr. Rollinger on November , 2001 at 3:30 p.m. , with Dr. Raabe on
August , 2002 at 3:30 p.m. , Dr. Spillett January , 2001 at 10:00
a.m.
MEDICATIONS ON DISCHARGE: Aspirin 325 mg orally every day , Lasix 80 mg
orally every day , Zocor 20 mg orally every bedtime ,
insulin 70/30 65 units every day before noon , insulin 70/30 45 units every afternoon ,
Toprol XL 50 mg orally every day , Levaquin 250 mg orally every day for a
duration of 7 days , Actos 45 mg orally every afternoon
CONDITION ON DISCHARGE: Stable.
Dictated By: TENESHA PFAFF , M.D. PA78
Attending: FERNANDE R. PREWER , M.D. NP70 RV555/785051
Batch: 12472 Index No. N6QVJDLWN8 D: 11/2/02
T: 11/2/02
Document id: 124
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
N |
Y |
N |
N |
N |
N |
- |
N |
N |
N |
N |
- |
N |
513604071 | PUO | 05855004 | | 3651153 | 8/15/2005 12:00:00 a.m. | RIGHT FOOT GANGRENE | Signed | DIS | Admission Date: 8/5/2005 Report Status: Signed
Discharge Date: 4/7/2005
ATTENDING: LOERWALD , PENNIE MICHEAL MD
DATE OF DISCHARGE:
Unknown.
CHIEF COMPLAINT:
Gangrenous fourth right toe with necrotic right great toe ulcer
and right forefoot cellulitis.
HISTORY OF PRESENT ILLNESS:
Mr. Luc is a 57-year-old male with a history of a poor medical
follow up smoking and untreated diabetes mellitus who first noted
blisters on the tip of his right fourth toe and under medial
right great toe from ill-fitting tissues approximately a year
prior to his admission. Both ulcers have been nonhealing and
cyclically formed dark eschars and superficial scabs which have
been treated with lotion as recommended by his podiatrist. Five
to six months ago , he traveled to St. Lub Blo and spend some time in
hot tubs and Jacuzzi's but his ulcers continued to form eschars
without healing completely and also episodically became
erythematous and painful with involvement of the forefoot. Each
episode usually resolved with foot elevation and rest. On
8/29/05 , after long walks , he noticed that the right fourth toe
turned to a dark purple color , was malodorous. He had pain with
weightbearing and was obliged to heel walk. Over the next
several days , the forefoot became erythematosus and swollen as
well. He denied any fevers , chills , nausea , vomiting , cough ,
headache , although he had an episode of malaise and chills that
lasted three days several weeks prior to his admission. His
appetite had been stable. He had not had any recent weight
change. Functionally , he was doing well. Ambulation was limited
only by foot pain. He denied claudication , chest pressure ,
dyspnea on exertion. He would sleep on one pillow at night with
head flat. He denied lightheadedness or any presyncopal
episodes. On 5/30/05 , he presented to Norap Valley Hospital for
workup of his painful forefoot and toe ulcers. He was afebrile
with vital signs stable. His right fourth toe was described as
blackened with clear demarcation at the metatarsal junction , and
eschar was noted on the right first toe. He is white blood cell
count at that stage was 12.7. Plain films were notable for
suspicious swelling about the fourth toe with evidence of gas
noted within the soft tissues of the medial aspect of the fourth
toe in the proximal interphalangeal joint. He went on to have
ABIs that were 0.32 on the right side and 0.43 on the left side
and PVRs were normal at 5 level only. He also underwent a
cardiac workup that was notable for SPECT/MIBI that showed a
reversible defect involving the basal , mid and apical segments of
the anterior wall consistent with myocardial ischemia. An echo
showed an ejection fraction of 45% and possible septal
hypokinesis. Given the positive stress test and a positive need
for cardiac cath , he was transferred to Pagham University Of for further management. He did not feel that would have
change in appearance since 1/25 although the pain had increasing
intensity. He denied any sensory or motor deficits , but he had
pain whenever he moved his toes or put any weight.
PAST MEDICAL HISTORY:
Rheumatoid arthritis since 1980s that was untreated , type II
diabetes mellitus since 1990s that was untreated , multiple bony
injuries to his right foot , and a football accident as a
teenager.
PAST SURGICAL HISTORY:
Bilateral mastoidectomies in 1970s and 1980s , status post penile
surgery at childhood , status post sebaceous cyst removal in 2004.
MEDICATIONS ON ADMISSION:
None.
ALLERGIES:
NKDA.
SOCIAL HISTORY:
One to three packs per day for 40 years , quit in 1980 , alcoholic
until 1993 but had been sober attending AA since then. Prior
heroin , speed and barbiturate abuse , with history of cocaine ,
tranquilizers , marijuana use; has been clean since 1993. He used
to work for a moving company , no disability and lives alone in
Longwa He is single and has no children.
PHYSICAL EXAMINATION:
On admission , temperature 99.6 , heart rate 72 , blood pressure
150/86 , respiratory rate 16 , oxygen saturation 99% on room air.
General appearance: Elderly looking gentleman in no apparent
distress with bilateral hearing aids. HEENT: No JVP , no carotid
bruits. Cardiac: Regular rate and rhythm. Lungs: Clear to
auscultation bilaterally. Birthmark on right upper back.
Abdomen: Mildly distended , soft , nontender , no pulsatile masses.
Bilateral lower extremity skin hallus with normal color and
temperature down to feet. Right forefoot was erythematous and
edematous and warm with no fluctuance or crepitus. His plantar
surface was tender to palpation immediately beneath the fourth
metatarsal. His right fourth toe was necrotic and malodorous
with no purulent discharge. His anteromedial aspect of his right
great toe had a 0.5 cm round ulcer with dark eschar center and
desiccated edges with mild erythema and induration around it.
Dorsiflexion was 5/5 and plantar flexion 4-/5 and limited by
pain. He had full strength on the left side , normal sensation
throughout both feet. Pulses: Right carotid 2+ femoral
dopplerable , DP dopplerable , physical therapy dopplerable. Left carotid 2+
femoral , 1+ DP , none physical therapy dopplerable. Bedside ABIs: Right side
0.43 , left side 0.51. He was admitted with diagnosis of a
multilevel arterial insufficiency bilaterally and need for fourth
toe amputation impossible for debridement followed by angio for
possible revascularization.
PROCEDURES AND OPERATIONS:
7/23/05: Attending surgeon , Rossie Mankoski , M.D. Open
amputation of right fourth toe.
8/17/05: Attending surgeon , Isabelle Colasamte , M.D. Coronary
artery bypass grafting x4 with saphenous vein graft to acute
marginal distal PDA , left internal mammary artery to the LAD , Y
left radial artery from LIMA to the ramus intermedius to the
posterior left ventricular branch of the circumflex.
7/23/05: Left to right femoral to femoral artery bypass using
an 8 mm Dacron graft.
9/26/05: Attending surgeon , Rossie Mankoski , M.D. Right
femoropopliteal bypass grafting and amputation of the right third
and fifth toe.
HOSPITAL COURSE:
Mr. Luc underwent amputation of his fourth toe on the right
side after his admission. He tolerated his procedure well. A
few days later , he underwent the previously mentioned coronary
artery bypass grafting; please refer to the previously dictated
summary , dictation ID 3749517 for details. After his coronary
bypass grafting , he underwent a femoral-femoral bypass grafting
with debridement of his right toe amputations site. After his
procedure , he had a weak dorsal pedis , a questionable posterior
tibial and normal popliteal signal on Doppler but none of his
pulses were palpable. His femoral-femoral graft was easily
palpable on his abdomen. Due to his poor vascularization of his
right lower extremity , he underwent a femoropopliteal bypass
grafting on the right with a nonreversed saphenous vein grafting
from the ipsilateral leg and amputation of his right and fifth
toe and closure of his lateral foot. He tolerated this procedure
well. The rest of his hospital course was complicated by a
worsening of the left lower extremity perfusion. His left foot
was slightly cooler than his right and his Doppler signals
fainted. An initial mottle appearance of his left lower
extremity improved with time. On 4/8 , his wounds were dry ,
clean and intact. He had a palpable femoral-femoral graft and
dopplerable left physical therapy and DP pulses with monophasic signal. Both
his physical therapy and DP on the right are dopplerable as well with biphasic
signal. The same day , his Foley catheter was removed and he
started mobilizing with heel weightbearing on the right and with
help of physical therapy and the nursing personnel he is
currently actively screened for rehabilitation.
His discharge would be complete. Will await this??_____??.
eScription document: 5-6838290 EMSFocus transcriptionists
Dictated By: ZINIEWICZ , HORACIO
Attending: LOERWALD , PENNIE MICHEAL
Dictation ID 0198894
D: 10/12/05
T: 10/12/05
Document id: 125
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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181574305 | PUO | 44577177 | | 903279 | 6/18/2002 12:00:00 a.m. | NON Q WAVE MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 6/7/2002 Report Status: Signed
Discharge Date: 5/4/2002
DIAGNOSIS: THE PATIENT IS STATUS POST NON ST ELEVATION MI MEDICAL
MANAGEMENT.
PROCEDURES: Echocardiogram.
CHIEF COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: This is a 75 year old woman with
history of hypertension ,
hyperlipidemia and past tobacco use and a history of angina but no
previously known CAD who is now presenting with syncope at
baseline. She had a history of angina with substernal sharp pain
only with exertion and no radiation or associated symptoms and with
a frequency approximately once every several months. She had no
baseline shortness of breath with one flight of stairs and walking
around the house nor orthopnea , no paroxysmal nocturnal dyspnea or
leg edema. She had "a couple of falls/syncope over the last year".
Most recently , about three months ago , without symptoms , the
patient did not seek medical attention. The night prior to
admission , at approximately 11:30 p.m. the patient was hanging
laundry and had a sudden episode of syncope with likely loss of
consciousness of unclear duration but likely for minutes. The
patient denied any prodromal symptoms of chest pain , shortness of
breath , palpitations , light-headnessness , visual changes , balance ,
bowel or bladder incontinence , tonoclonic movements. She
subsequently felt weak and was unable to get up until on the
afternoon admission where she was found by her apartment manager.
REVIEW OF SYSTEMS: Unremarkable. She denied URI symptoms , UTI
symptoms , bright red blood per rectum , melena ,
normal appetite , stable weight , arthralgias , except for mild knee
pain after the fall. She did note right sided arm and leg weakness
for about a year that invoked a question of CVA.
PAST MEDICAL HISTORY: Hypertension , hypothymia , past tobacco use ,
question of an old CVA , COPD not O2
dependent , status post appendectomy.
MEDICATIONS: The patient is on aspirin , lisinopril , atenolol.
ALLERGIES: The patient had no known medical allergies.
SOCIAL HISTORY: The patient lives alone in Okemadorbshore Oer Laughnetill Lane , Sterl Ma , 98713 She has two
daughters who live in Wa I Stam A The
granddaughter lives in Troitry Ri Ville Her son is in North Carolina She
is a smoker with one cigarette every few days for about 45 years.
The patient does not use ethanol.
FAMILY HISTORY: The patient's father died of a myocardial
infarction at 79 and mother died at 27 during
pregnancy.
PHYSICAL EXAMINATION: In the Emergency Department the patient had
a temperature of 97.3 , heart rate of 108 ,
blood pressure of 152/102 satting 96% on room air. Her examination
is notable for poor hygiene , incontinence of urine , stool and a
tachycardia wheeze , poor strength throughout. On the floor her
physical examination showed a heart rate in the 90s , systolic blood
pressure of 110. She is satting 96% on four liters. In general
she was comfortable but in mild respiratory distress with a wheeze.
She was using her respiratory muscles. HEENT , extraocular muscles
are intact , PERRL. Cranial nerves II through XII are intact. Neck
- she had no adenopathy , thyromegaly or GP6. Cardiovascular -
regular rate and rhythm , normal S1 , S2 , no murmurs , rubs or
gallops , distant heart sounds. Respirations - she had some
wheezes , no crackles. She had increased respiratory phase.
Abdomen - she was obese , non-tender and non-distended with left
groin erythematous and scaling with a question of fungal infection.
Extremities - no edema. She had 1+ dorsalis pedis pulses. Neuro
examination - she was alert. She knew she was at the Pagham University Of . She said it was 1982 , September , Thursday. Cranial
nerves II through XII are intact as previously noted. She had 4/5
bilateral lower extremity strength. She had 1+ deep tendon
reflexes with toes down going. She had normal sensation.
LABORATORY DATA: Sodium 134 , potassium 3.9 , chloride 101 , CO2 26 ,
BUN 14 , creatinine 1.1 , glucose 139. She had an
anion gap of 12. White count was 15.7 with 71% polys , 14% bands ,
8% lymphs , 2% monos. Her hematocrit was 47.0 , her platelets were
366 , Troponin was 3.99 , CK 1161 , MB 31.2. Her albumin was 4.1 ,
total bilirubin 0.4 , alkaline phosphatase 66 , ALT 13 , AST 51. Her
lipids - her LDLs 149 , total cholesterol 232 , HDL 49 , coags - her
PTT is 30.1 , INR 1.0. Her head CT showed no evidence of bleed.
She had an old lacunar in the thalamus. She had an old infarct in
her PTM internal capsule. He EKG showed sinus tachycardia at 102
normal axis , normal intervals , diffuse T wave inversions in 1 , 2 , 3
AVF , V2 to V6. Her chest x-ray showed no active process.
HOSPITAL COURSE: The patient was found to have non ST elevation
MRI and there was possible cause of her syncope
and was treated conservatively with medical management.
Cardiovascular - ischemia , ST elevation , myocardial infarction.
The patient was treated with aspirin , heparin , Lopressor ,
captopril , cozaar initially with heart rate and blood pressure
controlled. An echocardiogram showed an ejection fraction of 30%
with apical anterolateral wall motion abnormality and heparin was
discontinued. The patient had no further chest pain.
Pulmonary - the patient has had some wheezing on examination
secondary to COPD and the patient was started on Atrovent nebs and
subsequently had no further wheezing.
I.D. - the patient initially had an increased white count with
bandemia of an unclear cause. Her workup was negative. Her UA
and chest x-ray were negative. She had no fevers. Her white blood
cell count ultimately declined to normal.
Renal - the patient was most likely dehydrated initially and was
given fluids until she had good urine output. Her intravenous fluids
ultimately discontinued. Renal ultrasound was negative for
hydronephrosis or obstruction.
Neuro - Although the patient's CT was negative for acute stroke and
positive for possible infarct the patient declined MRI of the brain
to workup for a possible TIA.
PLAN FOLLOWING DISCHARGE: The patient is somewhat debilitated
following her hospitalization , requires
physical therapy to regain her ability to perform activities of
daily living. Additionally the patient should follow with
Gynecology , is scheduled for a workup for her incontinence which
may also include an issue of uterine prolapse.
Dictated By: GAYLORD STECK , M.D. EB56
Attending: RUFUS C. BERNAS , M.D. BA95 DA906/417048
Batch: 4874 Index No. K4LDYRREY6 D: 6/17/02
T: 10/4/02
Document id: 126
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
Obe |
OSA |
PVD |
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317582123 | PUO | 04593167 | | 6109690 | 11/28/2005 12:00:00 a.m. | VENTRICULAR FIBRILLATION ARREST | Signed | DIS | Admission Date: 2/10/2005 Report Status: Signed
Discharge Date: 1/17/2005
ATTENDING: PANAGOS , FAITH M.D.
CHIEF COMPLAINT:
Status post cardiac arrest.
HISTORY OF PRESENT ILLNESS:
Mr. Cavaiani is a 54-year-old man with a history of diabetes ,
end-stage renal disease , CAD , long QT interval , seizure disorder ,
and mental status changes who presents following cardiac arrest.
The patient presented to his regular hemodialysis appointment at
Delpnecrest Ce Medical Center on 2/20/05 where during his dialysis , he noted that he
began to feel strange. He had a questionable seizure earlier in
the day per history. During the dialysis , he became increasingly
confused and was sent for further evaluation to the Norap Valley Hospital Emergency Room. At the P Therford Hospital ED , an EKG was done ,
which showed tachycardia going in to torsade de pointes followed
by ventricular fibrillation. He underwent a DC cardioversion
shock at 200 joules and was converted to normal sinus rhythm.
The patient was then intubated , as he was being coded.
Furthermore , there is report of the patient developing a
tonic-clonic seizure during the bagging phase of intubation.
Follow this , a repeat EKG was obtained and showed a QT interval
of 540. His baseline is apparently around 510 milliseconds. His
electrolytes at that time were remarkable for potassium of 3.7 ,
bicarbonate of 30 , and magnesium level of 1.6 , and phosphate
level of 0.9. He did have a slightly elevated troponin level.
He was then transferred to the Pagham University Of for
further workup and management. On arrival , the patient was
intubated , sedated , with an amiodarone drip.
PAST MEDICAL HISTORY:
1. Diabetes mellitus , insulin dependent.
2. End-stage renal disease with hemodialysis , on Monday ,
Wednesday , and Friday.
3. CAD , status post a non-ST elevation MI in 6/29 .
4. A long QT syndrome.
5. Seizure disorder.
6. Alcoholic cardiomyopathy complicated by gastritis.
7. Chronic pancreatitis.
8. History of mental status changes with increased ICP.
9. Peripheral neuropathy.
10. Peripheral vascular disease.
11. Penile amputation secondary to infected implant.
12. Depression.
13. Hep B and hep C positive.
ALLERGIES:
Tetracycline.
PHYSICAL EXAMINATION ON ADMISSION:
The patient was noted to be afebrile. His blood pressure was
notable to be 240/79 and heart rate of 72. He was intubated on
arrival on assist-control volume setting with the tidal volume of
500 mL , 12 beats per minute , on 50% oxygen. He was saturating
100% on room air. Pulmonary exam was notable for mechanical
breath sounds without any wheezes , rhonchi or rales.
Cardiovascular exam was notable for regular rate and rhythm , soft
2/6 holosystolic murmur heard loudest at the apex , and 2+ pulses
distally. His abdominal exam was unremarkable. Extremity exam
was notable for status post left leg below-the-knee amputation.
Neurologically , the patient was unresponsive secondary to
sedation , but was able to move all extremities when the sedation
was decreased. He did responded ??_____?? purposefully to pain.
HOSPITAL COURSE BY PROBLEMS:
1. Torsade de pointes status post DC cardioversion: Given his
history of torsade de pointes requiring cardioversion , upon
presentation to A Salt Medical Center , Mr. Grange
electrolytes were vigorously repleted. He underwent an ischemic
workup for the etiology for his initial presentation. He
continued to have a prolonged QT interval and therefore medicated
failed to exacerbate his already long QT interval , at baseline
were discontinued. He was discontinued from his Celexa and
levofloxacin. Throughout the remainder of his hospital course ,
Mr. Cavaiani was closely monitored via telemetry and was noted to
have no further events of ventricular tachycardia.
2. Ischemia: When he presented , the ischemic etiology for his
ventricular tachycardia was considered. He was maintained on
aspirin and also continued on his Plavix. A cardiac
catheterization was done on 7/24/05 , which showed 30% occlusion
of the left anterior descending proximal coronary artery , 65%
occlusion of the ramus , 30% occlusion of the mid circumflex
artery , 50% occlusion of the marginal 1 artery , and 100%
occlusion of the distal RCA. None of these lesions were felt to
have caused his ischemia such that it would have been the
etiological factor for his torsades. He was followed throughout
his hospital course by the Electrophysiology Service.
3. Hypertension: While in the CCU , the patient had an echo ,
which showed severe concentric left ventricular hypertrophy with
an ejection fraction of 55%. He was started on vigorous
after-load reduction , which was titrated to his blood pressure
throughout his hospital course. At the time of discharge , he was
taking Lopressor , lisinopril , Norvasc , Isordil , and hydralazine.
4. End-stage renal disease: The patient was continued on his
repeat dialysis with close follow up from the Renal Service. He
underwent regular dialysis on Monday , Wednesday , and Friday while
at Pagham University Of . His electrolytes were followed
daily and repleted as needed.
5. Seizure disorder: The patient , although on presentation was
believed to have had a tonic-clonic seizure. He was maintained
on his Keppra throughout his course and was seizure-free while
hospitalized.
6. Diabetes mellitus: The patient presented with markedly
labile blood sugars. While admitted to the CCU , he was placed on
the Portland protocol in order to maintain tight glycemic
control. He was followed by the Endocrine Team , who recommended
switch to Lantus for basal control and regular insulin prior to
meals. His glucose levels were followed daily and his insulin
regimen was titrated in order to attain appropriate glycemic
control.
7. Nutrition: The patient was initially started on tube feeds
for nutrition. A NG tube was placed secondary to his altered
mental status. However , during his hospitalization , he had
multiple episodes of agitations , during which he pulled out his
NG tube. He was trialed with a soft diet after consultation with
the Speech and Swallow Service on 2/1 . As he was able to
tolerate these orally feeds , this diet was continued.
COMPLICATIONS:
None.
CONSULTANTS:
1. Electrophysiology Service.
2. Renal Service.
3. Endocrinology Service.
4. Speech and Swallow.
5. Physical therapy.
MEDICATIONS AT THAT TIME OF DISCHARGE:
Tylenol 650 mg orally every 4 hours as needed headache , aspirin 81 mg to be
taken daily , Colace 100 mg by mouth twice daily , folic acid 1 mg
by mouth daily , heparin 5000 units to be injected subcutaneously
three times daily while the patient is immobilized , hydralazine
40 mg by mouth every six hours , to be held for systolic blood
pressure less than 100 , insulin sliding scale , regular insulin 3
units to be taken prior to every meal , Isordil 30 mg by mouth
three times daily , to be held if systolic blood pressure is less
than 90 , Lopressor 25 mg by mouth three times daily , to be held
is systolic blood pressure is less than 100 or if the heart rate
is less than 55 , nystatin mouthwash 500 units by mouth to be used
four times daily , Keppra 500 mg by mouth once daily , Nexium 40 mg
by mouth twice daily , Lantus insulin 10 units subcutaneously once
daily , lisinopril 40 mg by mouth once daily , Norvasc 10 mg by
mouth once daily , to be held for systolic blood pressure less
than 100 , Lipitor 80 mg by mouth once daily , Nephrocaps one
tablet by mouth once daily , and Plavix 75 mg by mouth once daily.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE:
The patient is in no acute distress. He is cachetic appearing
male. Pulmonary exam is notable for breath sounds that are
coarse bilaterally. Upper airways sounds are prominent. Cardiac
sounds are distant. He does have a systolic ejection murmur
loudest at the apex. His abdomen is benign. There was some mild
tenderness noted to be in the epigastrium. However , there is no
rebound or guarding. His extremity exam is notable for status
post left above-the-knee amputation. The patient is to follow up
with his primary care physician and is to follow up with
Endocrinology and to continue his dialysis on Monday , Wednesday ,
and Friday. He is to be discharged to a rehabilitation facility.
eScription document: 0-3434899 EMSSten Tel
Dictated By: OLDOW , TOMAS
Attending: PANAGOS , FAITH
Dictation ID 0004269
D: 1/5/05
T: 1/5/05
Document id: 127
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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340018453 | PUO | 20849307 | | 936776 | 2/16/1997 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 2/16/1997 Report Status: Signed
Discharge Date: 9/14/1997
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION.
OTHER DIAGNOSES:
1. SARCOIDOSIS.
2. HYPERTENSION.
3. NON-INSULIN-DEPENDENT DIABETES MELLITUS.
4. STATUS POST PACEMAKER PLACEMENT.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female
with a history of hypertension ,
hypercholesterolemia , non-insulin-dependent diabetes mellitus , and
with no known hx of CAD admitted with chest pain. She has had
several days of exertional chest pain characterized by substernal
burning pain which , at times , radiates to the left shoulder. It is
sometimes accompanied by shortness of breath without nausea and
occasional diaphoresis. She was seen in the Emergency Department
with chest pain on June , 1997 , with negative troponins and
negative cardiac enzymes. An exercise treadmill test on April , 1997 , for three minutes revealed a maximal heart rate of 127
and maximal blood pressure of 134/80. She experienced chest pain
with 1 millimeter of ST depression in V5 and T-wave inversions in
V4-V6. This study was interpreted as consistent with , but not
diagnostic ischemia. She was started on aspirin and atenolol. On the
morning of admission , she was walking to catch a bus and had an
episode of substernal chest burning lasting less than 10 minutes
with shortness of breath , but no nausea , vomiting , or diaphoresis.
She came by cab to Awake Linebrookser Healthcare Center for her scheduled
exercise ett/mibi test study and was noted to have T wave
inversions in II , III , F , and V3-V6.
On arrival to the Emergency Room , the patient was pain free. She
denied lower extremity edema and had mild orthopnea which was
unchanged. She denied bright red blood per rectum , and stools were
black secondary to iron supplementation. Hematocrit on November ,
1997 , was noted to be 29.3. The patient had been iron supplements
since that time. She had a history of colonic polyps.
PAST MEDICAL HISTORY: 1 ) Significant for a history of
sarcoidosis. Her last pulmonary test was in
April 1995 which showed an FEV 1 of 1.61 , 72% of predicted; FEV
1 ratio to FVC was 80 or 102% of predicted. FVC was 2.01 or 72% of
predicted. In the past , she has been treated with prednisone and
now uses Ventolin inhalers as needed 2 ) History of seizure disorder.
3 ) Status post pacemaker placement in October 1996 for tachycardia
bradycardia syndrome. 4 ) Status post appendectomy. 5 ) Status
post total abdominal hysterectomy for cervical cancer. 6 ) Adult
onset diabetes mellitus , diet-controlled. 7 ) History of left calf
deep vein thrombosis in 1993. 8 ) History of colonic polyps with a
colonic adenoma diagnosed in 1993.
MEDICATIONS AT THE TIME OF ADMISSION: Linsinopril 5 mg every day;
Pravachol 20 mg every bedtime;
aspirin 325 mg every day; atenolol 0.5 mg twice a day; Dilantin 200 mg
twice a day; Ventolin inhaler as needed; ferrous gluconate 325 mg three times a day
ALLERGIES: Penicillin and erythromycin , gives rash.
PHYSICAL EXAMINATION: She was a pleasant female in no acute
distress. Vital signs revealed a
temperature of 97.9; heart rate 78; blood pressure 120/70;
respiratory rate 19. Saturation was 99% on two liters. Head ,
eyes , nose , and throat examination: Pupils were equal , round , and
reactive to light. Extraocular movements intact. Oropharynx was
clear and edentulous. Jugular venous pressure was 8 centimeters.
No lymphadenopathy. Carotids were 2+ bilaterally , no bruits.
Lungs: Diffuse , dry rales. No wheezes. Cardiac: Regular rate
and rhythm. S4 present. 1/6 systolic murmur heard at upper left
sternal border. Abdomen: Cholecystectomy scar. Infraumbilical
midline scar. No masses. No hepatosplenomegaly. Positive bowel
sounds. Rectal: Guaiac negative per the Emergency Room.
Extremities: Femoral pulses were 2+ bilaterally. No bruits. No
lower extremity edema. Dorsalis pedis and posterior tibialis
pulses were 2+ bilaterally. Nonfocal neurological examination. No
motor or sensory deficits.
LABORATORY DATA: Chest x-ray: Bilateral parenchymal opacities ,
most prominent in the right upper lung fields.
Stable and consistent with previous examinations from May ,
1997 , consistent with chronic sarcoidosis. Pacer wires were in
good position. Electrocardiogram on admission , April , 1997 in
the Emergency Room , normal sinus rhythm at 66. T-wave inversion in
I , T-wave inversion in II and AVF , biphasic T-waves in V2 , and
T-wave inversions in V3-V6. Slightly pronounced when compared with
previous electrocardiogram.
Sodium 143; potassium 5.1; chloride 108; bicarbonate 23; BUN 36;
creatinine 1.8; glucose 255. White count 6700; hematocrit 30.9;
platelets 143 , 000; MCV 85.1. Prothrombin time was 11.4. Partial
thromboplastin time was 25.2. INR was 0.9. CK was 79. Troponin
0.0. Dilantin: Less than assay. Hematocrit on November , 1997 ,
was 29.3. Cholesterol total was 258; LDH 43; LDL 166.
HOSPITAL COURSE: Ms. Tollett was admitted for a rule out myocardial
infarction protocol and underwent serial
electrocardiograms and her enzymes were studied. She was started
on Nitrol paste. Aspirin , linsinopril , and atenolol , were
continued. Given her low hematocrit as a possible etiology for
her ischemia , she was transfused with one unit of packed red cells.
Stools were guaiac neg and anemia workup was initiated. She was
continued on her albuterol inhale and nebulizers as needed
On February , 1997 , the patient underwent cardiac catheterization
which showed a 70% residual osteal diagonal stenosis , 0% left
anterior descending stenosis. A stent was placed in the diagonal
artery with 0% residual stenosis. Later than evening , the patient
began to complain of severe left arm pain radiating to her left
chest. Her electrocardiogram changes showed ST elevation in VI and
VII , and T-wave more inverted in VIV. She received morphine and
was already on a nitroglycerin drip , and she was taken back to the
catheterization laboratory. Her spectral study on February ,
1997 , revealed a 90% mid left anterior descending and 95% VI , and
her left anterior descending was stented at this time.
Following her two cardiac catheterizations , she experienced
intermittent atypical chest which was transient in nature without
sustaining any electrocardiogram changes. Her cardiac enzymes were
significant for a CK of 409 with an MB fraction o 21.
On October , 1997 , it was noted that her creatinine had risen to
3.1 , elevated from a level of 1.9 before the catheterization and a
diagnosis of radial contrast induced nephrotoxicity was made. Her
creatinine rose and rose to a peak level of 5.1 on May ,
1997 , and then began to decrease. At the time of discharge , it was
down to 2.2. The patient continued to have excellent urine output
throughout the rise in her creatinine and was normal by the time of
discharge.
Her laboratories at the time of discharge were a sodium of 141;
potassium 4.8; chloride 106; bicarbonate 20; BUN 31; creatinine
2.2; glucose 90. White count 6900; hematocrit 33.9; platelets were
203 , 000. She had an exercise tolerance test and ED study on
June , 1997 , which showed an essentially negative exercise
treadmill test and was a suboptimal study. She exercised for
approximately five minutes on submaximal exercise treadmill test
protocol with no evidence of ischemia , but low exercise tolerance.
Her medications at the time of discharge included: Ticlid 250 mg
orally twice a day; albuterol inhaler 2 puffs four times a day as needed for
shortness of breath; enteric-coated aspirin 325 mg orally every day;
atenolol 37.5 mg orally twice a day; nitroglycerin 1/150 sublingual one
tablet every 5 minutes times three for chest pain; and Dilantin 200 mg
orally twice a day
She is scheduled to followup with Dr. Sana Azua in her office
in one week and will follow up with cardiology as an outpatient.
Dictated By: EVELYNE TEPPER , M.D. RM45
Attending: SANA AZUA , M.D. BZ81 BG161/7283
Batch: 88563 Index No. RUKYHUB64 D: 8/18/97
T: 3/30/97
Document id: 128
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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271464551 | PUO | 45694644 | | 7507698 | 12/10/2005 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 12/10/2005 Report Status:
Discharge Date: 11/5/2005
****** FINAL DISCHARGE ORDERS ******
KAZUNAS , JULIET 018-24-59-6
Chi
Service: CAR
DISCHARGE PATIENT ON: 6/20/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: YAN , DERICK , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
AMOXICILLIN 1 , 000 MG orally twice a day Starting Today ( 5/29 )
Food/Drug Interaction Instruction
May be taken without regard to meals
ATENOLOL 100 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally every day
CLARITHROMYCIN 500 MG orally twice a day Starting Today ( 5/29 )
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 6/12/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
SERIOUS INTERACTION: SIMVASTATIN & CLARITHROMYCIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN &
CLARITHROMYCIN Reason for override: monitorinc
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
LISINOPRIL 10 MG orally every day
Override Notice: Override added on 6/12/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
294238890 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: monitorinc
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
Alert overridden: Override added on 6/12/05 by BLACKGOAT , GERMAINE LAVONNE KATE , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: monitoring
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Alert overridden: Override added on 6/20/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: CLARITHROMYCIN &
ATORVASTATIN CALCIUM Reason for override: monitoring
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day X 14 Days
Starting Today ( 5/29 )
Instructions: can continue at once a day after 2 weeks.
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
call Dr. Loudin for f/u in 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
please see below
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
ATTENDING: Tyacke
primary care physician: Dolores Loudin 545-812-9351
*************************
REASON FOR ADMIT: r/o MI
CC: 73yoF with CAD history of NSTEMI 9/8 p/with chest pressure at MMC office. Was
there for barium swallow 2/2 to ?GERD or guiac positive stools last week.
Before test started had onset of mild substernal chest pressure 2/10
radiating to right shoulder , similar to previous MI but not as severe in
quality. No nausea/diaphoresis. Got nitro , pain got better , then came
back and sent to ED. In ED got nitro and pressure resolved. No bb as HR
in 40s-50s. First set neg , no EKG changes.
*************************
PMH: CAD history of NSTEMI 9/8 , history of cyper stent x 2 to LCx and PDA , htn ,
hyperchol , type 2 DM , GERD with +H.pylori November 2005 , sleep apnea on CPAP ,
arthritis , gallstones
*************************
Cardiac studies:
8/3 ECHO: EF 55% , RWMA with hypokinetic basal inferio segment , abn
diastolic dyxfxn , mild/mod MR/ trace TR , 19+RAP , trace PR 1/3/05 cath: LM and LAD clean. LCx 100% lesion->cypher stent. RCA 40%
lesion , PDA 90%->cypher stent
10/26/05 post PCI adenosine SPECT: small reversible defect in mid/basal
inferolateral wall in LCx territory. transient 1st degree AVB with
adenosine. EF 70% , no RWMA.
*************************
ADMISSION MEDS: asa 325 , plavix 75 , lisinopril 10 daily ( Stopped 2
weeks ago 2/2 cough but cough did not resolve ) , atenolol 100mg daily ,
lipitor 80mg daily ( has not been taking ) , mvi , calcium , amoxicillin
500mg daily , prilosec 20mg daily ( started yest for H.pylori ) , colace as needed
ALLERGIES: nkdan
FH: mother with CAD SH: lives in 1 level house with son. takes flight of
stairs with cane with out problems. lives with son. no tob/etoh/ivdu
*************************
ADMISSION PE: VS 55 122/71 17 99-100%2L
GEN: NAD HEENT: right esotropia , eomi , perrl 3->2 mmm , op clear , dentures
NECK: supple , carotid 2+ without bruits , no lan , jvp 7 LUNGS: ctab , no c/with r
CV: rr , nl s1 s2 , no m/r/g. distant heart sounds. pain not reproducible
ABD: obese , nl bs , soft , nt/nd , no hsm , no masses EXT: 1+ pitting edema
b/l , warm , dp/patient 1+ b/l SKIN: no rashes NEURO: a&ox3 , moves all
extremities , full ROM of right shoulder
*************************
LABS/STUDIES
--labs on admission: Hct 35.9 ( baseline 34-40 )
--cardiac enzymes x 3 neg
--EKG: sinus brady 50 , LAD , LVH , poor RWP , TW flat/inv V4-V6 and 2 , 3 , avf.
no change from 4/20
--CXR ( portable ): cardiomegaly , clear
*************************
PROCEDURES: none
*************************
CONSULTANTS: none
*************************
HOSPITAL COURSE
CV:
--ischemia: Given patient's cardiac history patient admitted for r/o MI. On
admission history of nitro at urgent care and nitro in ED , patient was pain
free. Ruled out for MI with neg cardiac enzymes x 3 and no EKG
changes. Had no more recurrence of chest discomfort at rest or with
ambulation. Continued on asa , plavix , ace , statin. patient instructed to
restart ACE as that is likely not cause of her cough given it has not
resolved. Also advised patient to continue lipitor. Lipid panel ok with LDL 68
HDL 33 total chol 115 trig 69. HR in good control in 40s-60s with BP
110-140/56-90.
--pump: no e/o overload. stable LE edema.
--rhythm: brady but asymptomatic and on stable does of bb , continued. HR
in 40s-60s. tele with rare PVC o/with sinus brady.
PULM: osa , continued on cpap
GI: gerd , on h.pylori treatment. had 2 weeks of clarithyromycin in
early dec with out amoxicillin. restarted full regimen of clarithyromycin ,
amoxicillin , and PPI for 2 week course. cont outpt followup for GERD.
HEME: guiac + stools at pcp office last week. hct stable. will
continue outpt follow.
ENDO: sugar 80-90s , on ISS but no coverage required. patient to restart on
home orally agent
FEN: cardiac diet.
PPx: lovenox , ppi
CODE: FULL
ADDITIONAL COMMENTS: *please call your Dr. or return to the ED if you have any more episodes
of chest discomfort
*please restart your lisinopril. it is unlikely to be the cause of your
cough. please also take your lipitor and resume all other prior
medications , including your orally diabetes medicine
*continue amoxicillin , clarithyromycin , and prilosec for 2 weeks to treat
H. pylori infection
*followup with Dr. Loudin for your GI workup
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*continue outpt GI workup for GERD and guiac + stools
*f/u post H.pylori treatment
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE KATE , M.D. ( ZE37 ) 6/20/05 @ 11:59 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 129
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
Y |
- |
321590523 | PUO | 64755629 | | 4407097 | 10/4/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/14/2006 Report Status: Signed
Discharge Date:
ATTENDING: BERNAS , RUFUS MD
DATE OF ADMISSION: 10/14/2006
DATE OF INTERIM DICTATION: 1/7/2006
PRIMARY DIAGNOSIS: Left hip fracture , right distal tibia
fracture status post fall.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male
with multiple medical problems including coronary artery disease
status post non ST segment elevation MI in August 2005 , status post
PTCA stenting in October of 2006 , history of renal transplantation
status post failure , now with end-stage renal disease on
hemodialysis , diabetes mellitus , and hypertension who presents on
10/14/2006 with a left intertrochanteric hip fracture after fall.
He states he
was in his usual state of
health until the day of presentation when he was walking outside
his house on the deck to take care of his dog and tripped and
fell on to his left side. He denied any preceding symptoms ,
shortness of breath , loss of consciousness , or dizziness.
Imaging upon presentation revealed a comminuted intertrochanteric
fracture of the left femur as well as a refracture and worsening
alignment of a previously nonhealing distal tib-fib fracture of
the right lower extremity.
PAST MEDICAL HISTORY: Coronary artery disease status post non-ST
segment elevation MI in August 2005 , history of stenting
in August 2005 , most recent cath in October 2006. Peripheral
vascular disease , renal transplant for type 1 diabetes ,
living-related renal transplant in 1991 status post rejection and
failure in January 2005 , now end-stage renal disease on
hemodialysis. His dialysis is Tuesday , Thursday , Saturday. He
has had diabetes mellitus type 1 since age 6. He also has a
history of hypertension , hypothyroidism , PEA arrest in October
2006 in the setting of hypercalcemia , peripheral neuropathy , and
right lower extremity open reduction and internal fixation in
October 2006 for nonunion of a tibial fracture.
HOME MEDICATIONS: Aspirin 325 mg daily , PhosLo 1334 three times a day ,
enalapril 20 mg daily , gemfibrozil 600 mg twice a day , Dilaudid as needed
pain , NPH 30 in the morning and 32 in the p.m. , levothyroxine 50
mcg daily , prednisone 10 mg every day before noon , Neurontin 300 mg twice a day ,
Imdur 60 mg daily , Lipitor 80 mg daily , Nephrocaps one daily ,
Plavix 75 mg daily , Caltrate plus vitamin D one tab nightly ,
sevelamer 800 mg twice a day , omeprazole 20 mg daily , NovoLog sliding
scale as per patient , and Toprol 50 mg daily.
ALLERGIES: Penicillin which causes a rash.
SOCIAL HISTORY: The patient lives with his wife. Former smoker.
PHYSICAL EXAMINATION: Upon presentation , the patient's vital
signs 97.7 , 73 , 135/68 , 12 , and 97% on 2 L. Generally , he is in no
apparent distress , alert and oriented x3. Cardiovascular:
Regular rate and rhythm with a 2/6 systolic murmur at the left
upper sternal border. No S3 or S4. Lungs are clear to
auscultation anteriorly. His abdomen is nontender and
nondistended. The patient is obese. The patient's extremities
show 1+ peripheral edema , right greater than left. Right lower
extremity is bandaged. He has 1+ DPs bilaterally.
Neurologically , he is grossly intact.
His EKG upon presentation showed normal sinus rhythm at 73 ,
normal axis , normal intervals , no ST- or T-wave changes but
isolated T-wave inversions in leads III , which are new from
7/14/2006 with peak T waves , QRS of normal duration. His K at
that time was 6.7. Creatinine was 6.1. His white count on
10/14/2006 was 13.1 , 43.9 , and 309 , 000 , to complete a CBC. INR
was 1.
The impression at the time of presentation was a 53-year-old
male with multiple medical problems including coronary artery
disease status post recent revascularization in October of 2006 ,
peripheral vascular disease , renal transplant status post
failure , now on hemodialysis , diabetes , hypertension , and
hypothyroidism who presented with a left hip fracture and worsening of a
previous R distal tib/fib fx.
HOSPITAL COURSE: He was admitted to the orthopedic surgery
service and a preoperative evaluation was begun. On hospital day three ,
he suffered a non-ST segment elevation MI requiring urgent cardiac
catheterization. His EF at that time was noted to be 65%. Left heart
catheterization revealed a single-vessel coronary artery disease involving his
left circumflex with evidence of restenosis , and an angioplasty was
performed. The patient was transferred back to the floor hemodynamically
stable. He continued to undergo dialysis on his Tuesday , Thursday ,
Saturday schedule from the day of his catheterization until 10/16/2006 when he
was taken to the operating room for open reduction and internal fixation of
his left intertrochanteric hip fracture. For a complete summary ,
please refer to the operative note. His right tibial injury was
managed conservatively initially with splinting. On 10/20/2006 ,
the patient returned to the operating room where he underwent a
revision of his fixation of his right lower extremity with
removal of deep hardware and intramedullary rodding of his distal
tibia fracture. A VAC was placed across the lower part of the
incision. On 9/17/2006 , the VAC was changed on the floor and
placed on suction and was noted to be oozing steadily with a
eventual EBL of about 1 L within several hours. His systolic blood
pressures also droped into the 80s to 90s along with symptoms of
diaphoresis. Mr. Gensler was subsequently transferred to the 7D ICU for
management of significant bleeding from his open wound , relative tachycardia ,
hypotension , and diaphoresis , concerning for hemorrhage shock.
The patient at that time was on Plavix , aspirin , and Lovenox , and
it was thought that this combination certainly led to his oozing
during the VAC change. The patient was transfused several units
of blood after hematocrit dropped from 28 to 19 on the day of
transfer. The patient was transferred back to the floor in
stable condition within several days. The patient continued to receive
dialysis Tuesday , Thursday , and Saturday during this time as the
orthopedic surgery service continued wet-to-dry dressings of his
right lower extremity wound , which was open inferiorly. On
1/6/2006 , the A Triaded Health Cardiology Service was again
consulted regarding the safety of discontinuing the patient's
Plavix , aspirin , and/or Lovenox prior to taking the patient back
to the operating room. The service determined that his Plavix
could be stopped safely prior to surgery but should be started
postoperatively. The patient was continued with daily wet-to-dry
dressings until 10/10/2006 when he was taken back to the
operating room for medialization of his right ankle. His Plavix
had been discontinued on 6/18/2006 and was restarted on
postoperative day one. The patient continued to receive dialysis
during this time , which he tolerated well. His subcutaneous
heparin was restarted on 9/25/2006 . However , the patient began
to ooze from his injection sites and his right lower extremity
wound and the subcutaneous heparin was subsequently discontinued.
Thus , the patient is maintained at the current time on aspirin
and Plavix.
Currently , by systems:
Neurologic: The patient is receiving 30 mg of methadone every 8 hours
for pain as well as Dilaudid 0.2 to 0.4 every 3 hours as needed and
oxycodone 20 mg orally every 2 hours as needed pain. He is alert and oriented
x3 and is neurologically intact with the exception of decreased
sensation in his right lower extremity. Cardiovascularly , he has
been hemodynamically stable although his systolics often in the
90s after dialysis. He is being continued on an aspirin 325 mg
as well as Lopressor 12.5 mg four times a day , Imdur 60 mg daily , and
Plavix 75 mg daily. He has prolonged QT ranging from 400 to 500
and his frequent PVCs noted on telemetry. However , he has been
asymptomatic since his episode of hypotension requiring
readmission to the ICU.
Respiratory: The patient has been stable on room air since
transfer from the ICU and denies any pulmonary symptoms. GI , the
patient has had decreased orally intake and nutrition consultation
was ordered. Nutrition has been following the patient
recommending frappes and Boost , which the patient has been taking
minimally. The patient has been having bowel movements and his
abdomen is soft , nontender , and nondistended.
GU: The patient is followed by the renal service for dialysis on
Tuesday , Thursday , and Saturday. Currently on PhosLo 667 mg orally
three times a day , Nephrocaps , Caltrate. His sevelamer is
currently held. The patient makes minimal amounts of urine in
addition to his dialysis sessions.
ID: The patient has been maintained on vancomycin 1 g Tuesday ,
Thursday , Saturday after hemodialysis. He has been afebrile for
the past week. His current white count is 8.6. Hematologically ,
as mentioned previously , the patient presented on aspirin and
Plavix and Lovenox was added. However , due to his episode of
bleeding requiring ICU admission , there was concern regarding
over-anticoagulation. However , the three agents were continued
and the patient stabilized. Per the cardiology service , Plavix
was discontinued approximately one week preoperatively and
restarted one day postoperatively. Subcutaneous heparin was
added back to his regimen on postop day two. However , he began
oozing from his injection sites in his right lower extremity and
thus the subcutaneous heparin was discontinued. The patient's
hematocrit is currently 31.6.
Endocrine wise , the patient has been continued on his home dose
of prednisone which is 10 mg daily , he has also been continued on
NPH and NovoLog which have been titrated per recommendations from
the diabetes service. His wound on the right lower extremity is
granulating appropriately although there are areas of ecchymosis
and skin thickening and darkening around the incision. The
patient is currently receiving twice a day wet-to-dry dressings of the
right lower extremity. His right hip surgery incisions are
clean , dry , and intact with no signs of infection.
eScription document: 9-0063275 HFFocus
Dictated By: POLIVICK , HERTHA
Attending: BERNAS , RUFUS
Dictation ID 8015080
D: 1/23/06
T: 1/23/06
Document id: 130
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
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768403725 | PUO | 51118543 | | 991484 | 11/15/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/23/1993 Report Status: Signed
Discharge Date: 3/16/1993
DISCHARGE DIAGNOSIS: LEFT HEMISPHERE CEREBROVASCULAR ACCIDENT
SECONDARY TO OCCLUSIONS OF THE MIDDLE
CEREBRAL ARTERY
SECONDARY DIAGNOSES: 1. ATRIAL SEPTAL DEFECT
2. PROSTATIC HYPERTROPHY
3. DEGENERATIVE JOINT DISEASE
4. UMBILICAL HERNIA
HISTORY OF PRESENT ILLNESS: Mr. Casas is a 66-year-old right
handed gentleman with no previous
admissions to A Salt Medical Center , who presented on
27 of June , after having fallen out of bed at about 5:45 in the
morning. He was noted to be mute at the time and was unable to
move the right arm and leg. He was brought by ambulance to the
Emergency Room , where much of his motor deficits resolved , as well
as some of his speech deficit. This occurred within an hour.
There was no loss of consciousness associated with the fall , and
the patient was not noted to have any unusual movements or
verbalizations , or tongue biting , or incontinence. He was
"stunned" for a minute ( by the report of his son ) just after
falling. The patient denied headaches , vertigo , double vision ,
hoarseness or numbness , or nausea , vomiting , or palpitations. He
had had no previous neurological symptoms prior to this event.
There was also no chest pain. There was no history of high blood
pressure or heart disease , or recent fever and chills or sweats.
He had been feeling quite well up until this point. PAST MEDICAL
HISTORY: Significant for an umbilical hernia , which had been
present for many years. He also suffered from prostatism. In the
last year , he had regained much of the weight that he had lost
previous on special diet. SOCIAL HISTORY: He did not smoke nor
did he use alcohol or elicit drugs. There was no significant
family history of heart disease or strokes.
PHYSICAL EXAMINATION: The patient is a severely obese gentlemen ,
who had a blood pressure of 115/59 in the
right arm; with a respiratory rate of 12; heart rate of 72. He was
afebrile. HEENT: Remarkable for a slight bruise on the right
temple where the patient hit his head during the fall. The neck
showed no signs of meningismus. The carotids were poorly palpated
secondary to the thickness of his neck. The cardiovascular
examination revealed regular rate and rhythm without any murmurs or
rubs. There were no bruits. The lungs were clear. The abdomen
revealed umbilical hernia , but was otherwise benign. The
extremities had full pulses throughout , and a trace of edema.
There was no calf tenderness noted. On neurological examination ,
the patient was oriented x 3. He was now able to speak , and was
quite alert. He could register 3 words forward and 2 words
backwards. He could count from 20 to 1. His language was abnormal
with waxing and weaning worsening of functions. His meaning was
clear , but he did make errors , calling a pen and pencil. His
speech was mostly fluent but there were quite a few paraphasias.
There was decreased comprehension and decreased repetitions and
there was one prominent error in reading in which he repeatedly
read the "leaf" as "deaf". There was no right/left confusion , and
the patient was able to write. There was no neglect noted.
Long-term memory was essentially intact and there were a few errors
with short term tasks. Cranial nerve examination revealed full
visual fields to confrontation with sharp discs and no evidence of
cholesterol emboli. The discs were sharp. The pupils equal round
and reactive to light and accommodation. Conjugate eye movements
in all directions. There was full sensation on the face to pin
prick. There was a slight decrease nasal labial fold on the right
and some decreased hearing on the right. The palate moved upward
bilaterally and the sternocleidomastoid was strong. The tongue
protruded to the midline. Motor examination revealed normal tone
throughout and to formal testing the patient had 5/5 power in all
extremities except the right iliopsoas which demonstrated 5-/5
power. There was mild right sided drift of the upper extremities.
The patient had sensory decrease to vibration on the right lower
extremity. Pin prick and light touch were within normal limits , as
was joint position sense. The patient was mildly uncoordinated
with slowing of rapid alternating movements in the right upper
extremity. There was normal finger-nose-finger maneuver and
heel-knee-shin maneuvers in both the upper and lower extremities
bilaterally. The gait was not assessed initially ( but during the
rest of the hospital course , was noted to be quite normal ).
LABORATORY DATA: The patient had fully normal electrolytes with a
glucose of 105; sodium 139; potassium 4.4; white
count 7.5; hemoglobin 13.5; hematocrit 39.8; platelets 225; physical therapy and
PTT were 12.6 and 28.4 respectively; calcium was normal. Liver
function tests were normal. EKG showed normal sinus rhythm without
any signs of ischemia. Carotid ultrasounds were done immediately ,
and the patient was noted to have normal carotids without
significant stenosis. A CT scan was obtained without contrast ,
showing evidence of an early left frontal parietal infarction on
the left. There was no evidence of hemorrhage , and there was no
mass effect noted.
HOSPITAL COURSE: The patient was admitted to the Neurology Service
and was started on Heparin , as it was felt that
his event had most likely been an embolic event. During the first
day , his speech waxed and wained , and by 2 of the hospitalization ,
his speech was clearly abnormal with marked deficits in speech
generation with many pauses and profound word finding difficulty.
Repetition and comprehension were somewhat better than the initial
presentation. A repeat CT scan was obtained showing no evidence
for bleeding. This CT scan , now 3 days from the initial event ,
showed an acute infarct in the posterior inferior left frontal lobe
and posterior temporal lobe , and extending into the sylvian
fissure. Again , there was no evidence of hemorrhage or mass
effect , and the patient was continued on Heparin.
Because the patient was unable to fit into the MRI scanner at
Pagham University Of , he had a diagnostic MRI done at the
Bulls Asn Hospital , and this revealed , in addition to the original
lesion noted on CT scan , a second lesion , corresponding with an
occlusion of the posterior division of the middle cerebral artery.
This lesion was in the left parietal region. By the end of the
hospitalization , the patient's aphasia was quite clearly a very
mixed aphasia , with elements of poor comprehension , as well as
difficulties with fluency.
An investigation as to the cause of the patient's stroke was
initiated with an MR angiogram of the cerebral vasculature , which
revealed no significant carotid or posterior circulation defects.
An echocardiogram was done revealing normal ventricular function
with an ejection fraction of 55% without any wall motion
abnormality or thrombi noted. It was felt that the patient's
presentation warranted further review , and a transesophageal
echocardiogram was also done revealing an atrial septal defect , as
evidenced by significant positive bubble study. The patient was
therefore started on Coumadin. While the workup was being done ,
the patient also had an EEG that revealed abnormality consistent
with the 2 infarcts noted on MRI. These were not felt , however , to
be definite seizure phenomena. Coagulation studies were done
showing normal cardiolipin. Protein C was slightly elevated
protein S , a normal ANA , and a sed rate that was slightly elevated
at 26.
The patient was seen by the Speech Pathologist , and therapy was
begun , and this will continue as an outpatient.
The patient continued to have difficulties with voiding , with a
post void residual of 450 after voiding 400. He was seen by the
Urologist and was noted to have a quite large prostate. The PSA
was 14.6. The patient opted not to have surgical intervention
during this hospitalization or in near future. He was started on
Cardura at 1 mg every bedtime , which was slowly increased to 4 mg every bedtime , as
medical intervention for decreasing sphincter tone.
The patient also had some mild pain in the left knee with minimal
effusion , that was noted by x-ray. There was no evidence for
fracture. There was a small increase in his uric acid. He
responded quite nicely to Ibuprofen.
After day 3 , the patient's speech stabilized and gradually
improved , all be it very , very , slowly. He was therapeutic on his
Coumadin at the time of discharge , with his hopes that his INR will
be in the mid 2 range ( 2.3-2.8 ).
MEDICATIONS ON DISCHARGE: 1. Cardura 2 mg orally every bedtime x 2 nights ,
then 4 mg orally every bedtime every night
thereafter. 2. Coumadin 5.0 mg every bedtime to be monitored and adjusted
as needed in the near future. FOLLOW-UP CARE: The patient was
discharged in good condition to his home with the following
follow-up appointments: 1. Primary M.D. , Dr. Desirae Marcott , at the
KTDUOO Clinic on 29 of October , at 10:20 am. 2. Dr. Gailun at the
Urology Clinic on 30 of January , at 3:30 pm. 3. Dr. Stacie Halechko in
the Neurology Clinic on 21 of November , at 2:00 pm. 4. The patient will
continued to receive speech therapy at his home through the
visiting nurses association. CONDITION ON DISCHARGE: He is
discharged in good condition with full 5/5 strength in all 4
extremities , to his home.
Dictated By: EMIKO HAISLEY , M.D. GI0
Attending: MIRNA C. BABULA , M.D. KB83 CG495/0869
Batch: 9671 Index No. VFERI5154B D: 6/23/93
T: 8/17/93
CC: 1. DR. DESIRAE MARCOTT , KTDUOO
Document id: 131
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
076896968 | PUO | 57925512 | | 4942332 | 10/1/2006 12:00:00 a.m. | stable angina , CAD | | DIS | Admission Date: 9/13/2006 Report Status:
Discharge Date: 8/19/2006
****** FINAL DISCHARGE ORDERS ******
PRADIER , EMORY 285-39-91-7
Po
Service: CAR
DISCHARGE PATIENT ON: 10/5/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA 325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
Starting Today ( 9/8 )
Instructions: Substitution of another PPI is acceptable
IRBESARTAN 75 MG orally DAILY
ATENOLOL 25 MG orally DAILY
BACTRIM DS ( TRIMETHOPRIM/SULFAMETHOXAZOLE DOU... )
1 TAB orally twice a day X 14 doses
DIET: House / 2 gm Na / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
Full weight-bearing: as tolerated
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician DR LEMMINGS ( 314 ) 182-7128 5/5/06 @ 10:20 a.m. ,
ALLERGY: ACE Inhibitor , Erythromycins
ADMIT DIAGNOSIS:
coronary artery disease
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
stable angina , CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of anterior MI ( 1992 ) , CAD , HTN , dyslipidemia , obesity , migraines ,
glaucoma , urethrla stricture
OPERATIONS AND PROCEDURES:
4/8 cardiac cath
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Attending: Meckley
------------
CC/HPI: 64 year-old male with history of cad , ant mi '92 presented atypically and med
mngmt , htn , dyslipidemia admitted for ekg changes at routine ETT. Has
been cp free for last 10 yrs. Prior MI had symptoms c/with sweaty , dizzy ,
nausea x 3 days. Since then feels well , walks 45 min qday with wife. no
orthopnea , pnd , le edema , palpitations , syncope , dizziness. had recent
uri. Last ett 2000 reportedly nL ( no records avaialble ). At home today
took asa , bb , In ED got mg intravenous
-----------------
PMH: sinus brady , cad , ant mi , migraine , obesity , glauucoma , urethral
stricture , htn , dyslipidemia
MEDS: atenolol 100 every day , lipitor 40 , asa 325 , isosorbide dinitrate 10
three times a day
ALL: erythromycin - rash , ace - rash
SH: 20 pack year tobacco quit '92 , etoh rare no intravenous drugs , lives with
wife , attorney , son in Ra Na Arv
FH: no cad , stroke , cancer , dm , sudden death
VS on admission: p-41 , blood pressure-104/65 , r-16 , ra
exam on admit: comfortable , jvp 6 , distant bedtime , rrr , clear lungs , no
edema , abd benign obese
Labs on admit: creat 1.2 , wbc - 8 , hct 45 , inr 1 , trop neg x 1 , ck/mb
flat; u/a 17 WBC , 2+ leuks , urine cx pending
---------------
STUDIES:
CXR: clear
EKG: sinus brady , poor rwv prog , biphasic t v1-v5 new , jpt elevation v2
old
ECHO ( 4/8 ): EF 40% , +WMA , nl RV , nl atria , nl LV size , mid-moderate
reduced LV fxn , no AR , trace TR , PAS 16+RAP
CATH ( 4/8 ): dominant L circ system , 99%OM lesion and 99% LAD lesion ,
stented
-----------------
Hospital Course:
1 ) CV: ( I ): cont asa , bb , lipitor , nitrate , consider arb in future , lipid
panel. ruled out by enzymes. cath done 4/8 ( see above ). no plans for
anticoagulation ( P ): cont nitrate , bb , i-o even , echo done 4/8 showing
EF 40%. started capto 6mg three times a day 4/8 , titrate to BP; can't titrate up BB as
HR already low. ( R ): tele , sinus brady monitor with bb. no events while
hospitalized.
2 ) PULM: routine cxr wnL , no acute issues while at PUO
3 ) ID: U/A showed 17 WBC , 2+ leuks , but patient was asymptomatic
4 ) RENAL: trend creatinine , mucomyst/ivf given peri-cath
5 ) GI: cardiac diet , colace , nexium
6 ) FEN: electrolytes repleted as needed
7 ) ppx: hep subcutaneously
8 ) dispo: home post cath , likely 6/1/06; already has appt with primary care physician for
f/u
-------------
FULL CODE
ADDITIONAL COMMENTS: 1 ) follow with dr lemmings as scheduled
2 ) take all of your medications , including plavix everyday , as scheduled;
note that your atenolol has been reduced , you can stop taking the
isosorbide for now , and you are on a short
antibiotic course for possible UTI or low-grade prostate infection.
3 ) refrain from smoking , and maintain regular exercise regimen
4 ) seek medical attention if you have chest pain , chest pressure , extreme
shortness of breath , or other concerning symptoms.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1 ) titrate ARB as tolerated
2 ) consider titrating BB up if patient's HR ever increases
3 ) follow lipid panel as needed
No dictated summary
ENTERED BY: RADEMAN , CAITLIN , M.D. ( OU54 ) 10/5/06 @ 02:43 PM
****** END OF DISCHARGE ORDERS ******
Document id: 132
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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Obe |
OSA |
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356233983 | PUO | 21627069 | | 2650019 | 4/7/2005 12:00:00 a.m. | Upper Respiratory Infection | | DIS | Admission Date: 2/1/2005 Report Status:
Discharge Date: 11/12/2005
****** DISCHARGE ORDERS ******
VOJNA , LARAINE 991-72-53-6
Cunaleigh Sidego
Service: MED
DISCHARGE PATIENT ON: 10/16/05 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
IBUPROFEN 600-800 MG orally three times a day as needed Pain
Food/Drug Interaction Instruction Take with food
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care doctor 14 of July ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Upper Respiratory Infection
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) appendectomy ( appendectomy ) obesity
( obesity ) sleep apnea ( sleep apnea )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Lower extremity ultrasound of the Right leg Negative for deep venous
thrombus
BRIEF RESUME OF HOSPITAL COURSE:
26 M PMHx of HTN , obesity , sleep apnea who was in
RHMC until 2 days prior to admit when developed SOB. patient was otherwise
well until this a.m. when he reports palpitations , cough with sputum ,
SOB. Feeling warm but no cp , vomiting , hemoptysis ,
BRBPR , abdominal pain , diarrhea. No sick contacts. Also reports R leg
pain which he has gotten in past in setting of
pna.
VS T 101.2 P 110 BP 128/72 O2 SAT 95% RA , 98% while ambulating
Exam:
Gen: NAD HEENT: Dry mm
Chest: Dec BS R lower base no wheezing
CV: Tachy regular rhythm
ABD: +BS non tender
Ext: no edema. TTP R calf
All:
Nkda denies smoking
LABS: WBC 14 MCV 70 HCT 47 Nl chem 7 BNP 2
D-dimer 226 Cardiac enzymes Neg
EKG: sinus tachy T wave inv III unchanged from prior
CXR: NL
a/p: 26 obese , HTN , male with SOB
1. URI: likely viral in nature. Nl CXR , nl SATs ,
albuterol as needed wheezing while in hospital but did not affect patient's
sob. Neg D-dimer but due to acute onset SOB and concominant Right lower
extremity pain , LENI's done which were negative for DVT. Patient felt
better with IVF given in ER and did not take any nebulizers while on the
floor.
2.HTN: BP well controlled , patient has never taken HCTZ or any other Rx HTN
medications. will go home on no medications
3. Palpitations: resolved , no cp , no changes in EKG ,
neg enzymes
4.proph: Lovenox
5. Right leg pain: likely musculoskeletal in nature. No DVT found on LENI.
treat with elevation and Ibuprofen as needed follow up with primary care
doctor if right lower extremity pain persists.
6. Low MCV: Consider outpt workup for thalasemia.
ADDITIONAL COMMENTS: follow up with your primary care doctor for further evaluation of your
leg pain. You can elevate your leg and use Ibuprofen as needed for pain
control.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
as above
No dictated summary
ENTERED BY: NOGUEIRA , KATTIE A , M.D. ( PG259 ) 10/16/05 @ 01:44 PM
****** END OF DISCHARGE ORDERS ******
Document id: 133
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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348349961 | PUO | 20253314 | | 136636 | 7/15/1998 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 7/11/1998 Report Status: Signed
Discharge Date: 10/12/1998
PRINCIPAL DIAGNOSIS: PNEUMONIA
OTHER PROBLEMS:
1. Hypertension.
2. Coronary artery disease.
3. Obesity.
4. Insulin-dependent diabetes mellitus.
5. Gout.
6. Depression.
7. Chronic hearing loss.
8. Status post cholecystectomy and appendectomy.
9. Increased triglycerides.
CHIEF COMPLAINT: This is a 65 year old female with pneumonia ,
failed outpatient treatment with zithromycin.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old female
with Insulin-dependent diabetes
mellitus and a complex medical history who seven days prior to
admission started to develop cough , productive of green sputum ,
intermittent mild tactile fevers , rhinorrhea and shortness of
breath accompanied by pleuritic chest pain , right greater than
left. She was seen in A Salt Medical Center emergency
room on June at which time a chest x-ray showed a
question of early pneumonia on the right but officially was read as
only a small left pleural effusion. Her white count at that time
was 5. The patient was treated with orally zithromycin and sent
home. At home she felt slightly better for a day but later on
Tuesday her symptoms continued to worsen with increasing shortness
of breath and productive cough with chills. She had in the past
one sputum culture which was positive for Klebsiella back in
September of 1994 that was Penicillin sensitive. The patient
reported that her chest pain symptoms on admission worsened with
cough and were completely different from her usual angina pain.
She also complained of some headaches and sore throat.
On the day of admission she was seen in clinic where labs were
drawn and a chest x-ray was done and she was admitted directly to
the floor. She denied urinary symptoms , diarrhea , abdominal pain ,
but did complain of a recent gout flare of her right large toe
which was treated with indomethacin. She denied weight loss , night
sweats , the week prior to admission. She had decrease orally intake
prior to admission secondary to being too tired to move around the
house.
PAST MEDICAL HISTORY: Hypertension , coronary artery disease with
a cardiac catheterization in 9/30 showing a
100 percent left anterior descending occlusion and right coronary
artery occlusions , both fed by collaterals , 40 percent obtuse
marginal one lesion. An echocardiogram in February of 1997 showed a
dilated left ventricle and septal akinesis. A study in 3/13
showed fixed inferior lateral defects. History of obesity.
History of Insulin-dependent diabetes mellitus , her 10/27
hemoglobin A1C was 10.6. Gout with recent flare of her right toe.
Chronic hearing loss. Status post cholecystectomy and
appendectomy. Increased triglycerides. On 9/28 a level of 454
triglycerides was noted.
MEDICATIONS ON ADMISSION: Omeprazole 20 mg every day , Isordil 10 mg
three times a day , Atenolol 25 mg every day , Ambien 10
mg every HS , Allegra 60 mg twice a day , Pravastatin 20 mg every day , Remeron 40
mg every HS , Lasix 20 mg every day , Lisinopril 30 mg every day , enteric coated
aspirin 325 mg every day , Insulin-NPH 95 units a.m. with 45 units p.m. ,
Regular Insulin 25 units , 15 units p.m.
ALLERGIES: Augmentin gives itching and Darvon gives GI upset.
SOCIAL HISTORY: The patient lives alone , has visiting nurses. She
is an ex-house keeping worker. She denies
alcohol. She is a former smoker.
FAMILY HISTORY: Father died of unknown type of cancer; father also
had tuberculosis. The brother had tuberculosis at
one point as well.
PHYSICAL EXAM: Temperature 98.4 , pulse 64 , blood pressure 140/90 ,
respiratory rate 22 , satting at 92 percent on room
air. GENERAL: She is an obese , elderly woman breathing deeply but
not using any accessory muscles. HEENT: Extraocular movements
intact. Pupils equal , round and reactive to light and
accommodation. No icterus. Oropharynx was mildly erythematous.
NECK: No jugular venous distention. Submandibular lymph nodes
were enlarged bilaterally. LUNGS: Rales at the right base with
distant sounds. Otherwise clear to auscultation. HEART: Regular
rate and rhythm , faint sound. No murmur , gallop or rub but
difficult to hear. ABDOMEN: Soft , nontender , obese. Appendectomy
and cholecystectomy scars noted. She did have bowel sounds. No
masses noted. EXTREMITIES: Two plus pitting edema to the mid
shins bilaterally. No clubbing , cyanosis. NEUROLOGIC: Reflexes
were symmetrical , nonfocal. Cranial nerves II-XII grossly intact.
LABORATORY DATA ON ADMISSION: Significant for a Chem 7 with a
glucose of 181 , BUN 27 , creatinine
1.5 , white count 6.3 with 74 polys , 19 lymphs. Hematocrit of 36.1 ,
platelets 187. Liver function studies within normal limits.
Normal albumen at 4.4. Chest x-ray showed a right middle lobe
pneumonia.
HOSPITAL COURSE: The patient was admitted for a presumed right
middle lobe pneumonia that had failed outpatient
zithromycin treatment. She was started on cefuroxime and
levofloxacin to cover community acquired pneumonia in the setting
of zithromycin failure. A urinary culture was sent and came back
negative. She was given aggressive nebulizer treatments every four
hours and aggressive chest physical therapy every four hours. Her
cardiac regimen was continued as was her insulin regimen. The
patient was doing well into the second day , and cefuroxime was
stopped and the patient was continued on Levofloxacin alone. With
her anemia , iron studies were sent which showed her to have iron
deficiency with an iron of 28 , TIBC of 288 and a ferratin of 193.
She also complained intermittently of sore throats which were
treated with Cepacol and oxycodone. With significant improvement
in her symptoms by 4/6/98 the patient was discharged to home with
follow up in one week.
DISPOSITION ON DISCHARGE: The patient was discharged to home with
with visiting nurses follow up for
pulmonary checks and home safety evaluation. She was to schedule
an appointment with Dr. Mccullen for the week following discharge.
MEDICATIONS ON DISCHARGE: Tylenol 650 mg orally every 4 hours as needed pain or
fever. Albuterol inhaler two puffs
four times a day with spacer. Enteric coated aspirin 325 mg orally every day ,
Atenolol 25 mg orally every day , Cepacol 1-2 losenges p every 4 hours as needed
throat pain , ferrous sulfate 300 mg three times a day , Lasix 20 mg orally every day ,
NPH Insulin 95 units every day before noon , 45 units every afternoon , Insulin regular 25
units every day before noon and 15 units every afternoon , Isordil 10 mg orally three times a day ,
Lisinopril 30 mg orally every day , omeprazole 20 mg orally every day ,
oxycodone 10-15 mg orally every 4-6 hours as needed headache , Pravastatin 20
mg orally every HS , Ambien 10 mg orally daily , Flovent 220 microgram
inhaler two puffs twice a day with spacer remeron 45 mg orally every HS ,
Allegra 60 mg orally twice a day , Levofloxacin 500 mg orally every day times
fourteen days.
CONDITION ON DISCHARGE: Stable.
Dictated By: SHELLEY STARNAULD , M.D. HP01
Attending: SHALONDA ASPACIO , M.D. DB8 AQ560/6700
Batch: 76014 Index No. S4TUXS1JBQ D: 5/20/98
T: 6/11/98
Document id: 134
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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156883837 | PUO | 43767623 | | 4185602 | 8/6/2006 12:00:00 a.m. | hypertensive urgency | | DIS | Admission Date: 3/6/2006 Report Status:
Discharge Date: 5/7/2006
****** FINAL DISCHARGE ORDERS ******
WAYMAN , CECILIA 155-40-90-2
Otte Thou Sasdita
Service: RNM
DISCHARGE PATIENT ON: 10/8/06 AT 05:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SPILLETT , SILVA A. , M.D.
CODE STATUS:
No CPR , No defib , No intubation , No pressors
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today ( 9/9 )
PHOSLO ( CALCIUM ACETATE ( 1 GELCAP=667 MG ) )
1 , 334 MG orally three times a day
LANTUS ( INSULIN GLARGINE ) 46 UNITS subcutaneously every day before noon
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF NEB four times a day
LABETALOL HCL 800 MG orally twice a day Starting Today ( 3/11 )
HOLD IF: SBP<90 or P<60 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LACTOBACILLUS 2 TAB orally three times a day
LAMICTAL ( LAMOTRIGINE ) 150 MG orally twice a day
Number of Doses Required ( approximate ): 8
ZESTRIL ( LISINOPRIL ) 40 MG orally DAILY
FLAGYL ( METRONIDAZOLE ) 500 MG orally every 8 hours
Food/Drug Interaction Instruction Take with food
NEPHRO-VIT RX 1 TAB orally DAILY
Alert overridden: Override added on 2/8/06 by BLACKGOAT , GERMAINE L K. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
TRILEPTAL ( OXCARBAZEPINE ) 600 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Stautz 7/7/06 at 3pm scheduled ,
Dr. Daurizio 2/22/06 at 2:30pm ,
ALLERGY: Paper tape
ADMIT DIAGNOSIS:
NSTEMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hypertensive urgency
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) htn ( hypertension ) bipolar ( bipolar
disease ) panic ( panic disorder ) renal insufficiency ( renal
insufficiency ) congestive heart failure ( congestive heart failure )
copd ( chronic obstructive pulmonary disease ) cad ( coronary artery
disease ) nephrotic syndrome ( nephrotic syndrome ) smoker ( past
smoking ) hyperparathyroidism ( primary hyperparathyroidism ) gastritis
( gastritis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
HPI: 65M with history of CAD/PDA stent ( '04 ) , HTN , DM ,
ESRD/HD who presented with anginal equivalent. HTN noted to be >200's
systolic. patient ran out of hypertensive meds several days ago. EKG
without significant changes. Admitted for r/o MI , BP
management.
****
PMH: esrd on HD ( MWF ) , DM , HTN , hyperchol , CAD ( 10/7 , PDA stent ) , CHF
( EF 50% , cLVH , inf hk ( 10/5 ) ) , gastritis , obesity , osa , bipolar ,
MSSA , C. diff ( 11/3 ) , nephrotic syndrome , sciatica/spinal
stenosis , primary hyperparathyroidism
****
FH/SH: Prior etoh , marijuana , heroin , cocaine , smoker 1-2 ppd , 40
years quit 5 years ago.
****
ALL: adhesive tape
****
MEDS ( home ): asa 325 , phoslo 1334 three times a day , labetalol 600 twice a day , zestril 40 ,
trazodone , lipitor 80 , lamictal 150 twice a day , nephrolite 1 tab , trileptal
900 twice a day , lantus 46 U every day before noon , combivent
4
****
EXAM:
g: nad
heent: eomi , mmm , jvp not noticeable
cv: rrr , 2-3/6 early mid systolic murmur RUSB
l: ctab
abd: obese , nd/nt
ext: trace edema
n: nonfocal
****
LABS: Admission: BUN 67 , Cr 9.6 , WBC 6.1 , hct 39.5 , plt
235 , Tn 0.1 , cpk 57.1 , mb 7.9 , lft's wnl , lipase 270 , bnp
231
Hospitalization: cardiac enzymes negative x 3
-elevated CK to 876; down to 675 prior to discharge
****
Studies: CXR ( 10/13 ): mild vascular
congestion EKG ( 10/13 ): sr , L axis deviation , lae , poor rwp ,
flattening V5 , less deep twi V6
****
Hospital Course:
+CV: No evidence of acute coronary event ( ekg , enzymes unremarkable ). Due
to med noncompliance ( patient ran out med ) , patient was hypertensive with sbp >
200. patient's home medications listed above were restarted and blood pressure
normalized to sbp 120-140's.
During hospitalization , CK's trended up ( peak 872 , at discharge 675 ) but
troponin stayed less than assay. patient has long history of elevated CK's.
Suspect his elevation may be due to lipitor. patient denied myalgias or chest
pain. Defer to pcp for consideration of switching to other statins that
may not cause elevation of CK. In interim , will patient will not be continued on
lipitor; we have also discharged patient on labetolol 800 mg twice a day as recommended
by his outpatient cardiologist at his most recent visit.
patient also had episode of NSVT ( 12 beats ) during hospitalization. Echo
revealed concentric LVH with EF 45% , slightly decreased from prior; but
essentially unchanged from previous echo. EKG without changes as compared
with ekg 4/3 . Discussed with cardiology service who felt that given EF and
history of LV dysfunction , no indication for pacemaker. Follow up arranged
with patient's cardiologist ( Dr. Stautz ) and pcp ( Dr. Daurizio ).
+ID: ?C. diff. patient reported several days worth of diarrhea daily. Given
history of C. diff , started treating empirically. patient was unable to provide stool
sample as he had no episodes of diarrhea during hospitalization. Given
history of C. diff , will continue flagyl and lactobacillus as outpatient for 11
additional days.
+Renal: ESRD on HD. patient dialyzed on admission with some improvement in BP.
+Endo: DM. Ct home regimen of lantus every day before noon
+Psych: Bipolar , agitation. During hospitalization , patient somewhat agitated
and not cooperative. Agitation responded well to trazodone and patient was
able to sleep overnight. patient resides in group home with access to mental
health resources.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Take your medications every day.
2. Make a follow up appointment with Dr. Marola .
No dictated summary
ENTERED BY: CISTRUNK , EDGARDO JUAN , M.D. , PH.D. ( ZQ96 ) 10/8/06 @ 01:44 PM
****** END OF DISCHARGE ORDERS ******
Document id: 135
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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194054122 | PUO | 94645991 | | 3864406 | 8/28/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/20/2005 Report Status: Signed
Discharge Date: 3/18/2005
ATTENDING: BOARD , KATHIE MIREYA MD
SERVICE: Cardiology Ca War Ri
PRINCIPAL DIAGNOSIS: Acute renal failure.
PROBLEMS AND DIAGNOSIS: Ischemic cardiomyopathy , coronary artery
disease , insulin-dependent diabetes mellitus with neuropathy ,
hypercholesterolemia , hypertension , polyarticular gout , elevated
CK , and osteoarthritis left hip.
HISTORY OF PRESENT ILLNESS: Mr. Quaid is a 65-year-old gentleman
with known cardiomyopathy , coronary artery disease ,
osteoarthritis , insulin-dependent diabetes mellitus , who
presented with a 1 week of progressive fatigue and shortness of
breath. In the prior 2 weeks , he had been started on
hydrochlorothiazide. He had been nauseated and vomiting as a
result of Percocet taken for his left hip pain with resulting
decreased orally intake. He was evaluated in his primary care
clinic and felt to be in decompensated heart failure.
In the Emergency Department , he was dehydrated and found to be in
acute renal failure , hyperkalemic , and uremic. He complained of
joint soreness , particularly in his third proximal
interphalangeal joints bilaterally. His BUN and creatinine were
182 and 4.8 respectively. His potassium 6.4 , his sodium 128 , and
his CPK 1356 , and his uric acid level 11.6. Issues in the
hospital included hyperkalemia , acute renal failure secondary to
dehydration , polyarticular joint soreness and left hip pain. For
his hyperkalemia , the patient was treated with calcium ,
gluconate , insulin , Kayexalate and his potassium level returned
to normal levels by hospital day #2. For his acute renal
failure , the patient was hydrated gently with 60 cc of normal
saline. The renal service was consulted and assisted with
management. The patient was urinating. Renal ultrasound was
normal. Renal function returned to baseline and his creatinine
at discharge was 1.4. His baseline is 1.6. With correction of
his renal function , the patient regained strength. For his joint
symptoms , Rheumatology was consulted who performed arthrocentesis
of the left knee and diagnosed polyarticular gout. No treatment
was initiated in the setting of impaired renal function and a
concern for fluid retention. He has a followup appointment with
Rheumatology in September 2005. For his hip pain , his orthopedist ,
Dr. Lemmen , evaluated him for possible future hip surgery.
Neurology was consulted regarding atrophy of thenar muscles and
elevated CPK. They did not feel a secure diagnosis could be made
and recommended following daily CPK , which trended down over the
course of hospitalization. Followup appointment in Neurology was
scheduled to discuss essential tremor and further investigate the
muscle wasting with nerve conduction studies and EMG if necessary
based on CPK levels. The patient had an echocardiogram on
hospital day #2 , which showed an ejection fraction of 40 to 45% ,
no pericardial effusion , and hypokinesis of the mid and distal
septum , mid and distal inferior wall and decreased global right
ventricular function. The patent foramen ovale was visualized.
At discharge , the patient was afebrile , hemodynamically stable ,
euvolemic , ambulating , and saturating on room air , and on a
stable medical regimen. He was followed by VNA at home starting
February , 2005 , for INR checks.
Followup appointments for Cardiology , Neurology , and Rheumatology
were put in place. The patient was asked to contact his primary
care physician to schedule a followup appointment.
On admission , the patient was afebrile and hemodynamically
stable.
eScription document: 8-1637854 SSSten Tel
Dictated By: THEILING , BREE
Attending: BOARD , KATHIE MIREYA
Dictation ID 5063815
D: 1/12/05
T: 1/12/05
Document id: 136
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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589836784 | PUO | 68474572 | | 862126 | 7/2/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/3/1996 Report Status: Signed
Discharge Date: 10/13/1996
PRINCIPAL DIAGNOSIS: SEVERE CORONARY ARTERY DISEASE , STATUS POST
PERCUTANEOUS TRANSLUMINAL CORONARY
ANGIOPLASTY/STENT PLACEMENT TIMES TWO , LEFT
CIRCUMFLEX CORONARY ARTERY.
HISTORY OF PRESENT ILLNESS: Mr. Breisch is a 50-year-old male
with a history of coronary artery
disease significant for an 80% mid circumflex , 95% mid right , 70%
distal right , 50% distal left anterior descending coronary artery
lesions with posterobasilar hypokinesis in the setting of a
preserved left ventricular ejection fraction , hypertension times
greater than 30 years , and an elevated cholesterol who was in his
normal state of health until the morning of admission. At that
time , he was performing strenuous work in his bakery and began to
suffer from 4/10 chest pain , "heaviness" , and discomfort. The pain
did not radiate. He denies dizziness , shortness of breath ,
palpitations , and diaphoresis. The patient took one sublingual
nitroglycerin and sat down with resolution of pain in approximately
five minutes. The patient then returned to work. Several hours
later , while again performing strenuous work , the patient suffered
a similar episode of chest pain and heaviness which he rates as a
2/10. The patient sat down and , this time , the pain resolved
without sublingual nitroglycerin in approximately three minutes.
The patient was disconcerted by these multiple events and went to
the Tona Medical Center Emergency Room for further work up. While
sitting comfortably in the Emergency Room at Tona Medical Center , the
patient suffered a similar event of chest pain and tightness , which
he reports to be approximately 1.5/10. He took one sublingual
nitroglycerin with resolution of his symptoms in approximately five
minutes. The patient was transferred to A Salt Medical Center at that point. One hour later , in A Salt Medical Center Emergency Room , the patient suffered a similar episode of
chest pain and tightness , this time rated at 1/10 , with resolution
of pain in approximately one minute , not requiring sublingual
nitroglycerin. The patient reported , at that time , that his life
had been very stressful , and that he had been working very hard in
his bakery. Review of symptoms is consistent with above and ,
otherwise , noncontributory.
PAST MEDICAL HISTORY: 1. Coronary artery disease diagnosed in 1994
with catheterization performed in April
1994. There was 80% mid circumflex , 70% distal , 95% mid right , 50%
distal left anterior descending occlusions. Posterobasilar
hypokinesia with preserved left ventricular ejection fraction. 2.
Hypertension times greater than 30 years. 3. Hypercholesterolemia.
4. Hepatitis in 1991 , believed to be of a viral type with complete
resolution of symptoms and no sequela. 5. An exercise tolerance
test in February 1996 that showed 2 mm ST segment depression in the
inferior and lateral leads. The exercise tolerance test proceeded
without chest pain.
PAST SURGICAL HISTORY: Appendectomy in the distant past.
ADMISSION MEDICATIONS: 1. Spironolactone 25 mg orally every day before noon 2.
Simvastatin 20 mg orally every bedtime 3. Atenolol
100 mg orally every day. 4. Diltiazem 60 mg orally three times a day 5. Enteric
coated aspirin 325 mg every day.
ALLERGIES: Shellfish causes a rash.
FAMILY HISTORY: Mother had hypertension , grandmother with coronary
artery disease. There is no history of diabetes
mellitus or cancer.
SOCIAL HISTORY: The patient denies current tobacco use. He
reports a 40 pack year history , quitting five
years ago. The patient denies alcohol use. The patient lives at
home with wife. They have no children. The patient reports that
he is now on a low cholesterol diet , has lost 100 lb over the last
two years , and was successfully walking four to five miles a day
without chest pain or other symptoms until the day prior to
admission.
PHYSICAL EXAMINATION: The patient was afebrile. His blood
pressure was 132/84 , heart rate 62 , and a
room air saturation of 96%. Generally , Mr. Breisch was an
alert , well appearing man in no apparent distress. He was eager to
answer our questions. Head , eyes , ears , nose , and throat
examination was significant only for exanthema under the right eye.
The patient's neck was supple with full range of motion and no
lymphadenopathy. There were bilateral carotid bruits. Carotid
pulses were 2+. The patient had jugular venous distention of 6 cm
with the head of the bed elevated at 15 degrees. Lungs were clear
to auscultation bilaterally. Heart examination was significant for
normal S1 and S2 , and a II/VI systolic ejection murmur that was
heard best at the lower left sternal border , although it was
audible at the right sternal border , left mid axillary line , and
appeared to radiate to the carotids. The abdominal examination was
benign. The patient's extremities were clear of cyanosis ,
clubbing , or edema. The patient had 2+ symmetrical pulses
throughout. The patient was guaiac negative by report was normal
tone. Neurologic examination was nonfocal and significant for the
patient being alert and oriented times three , with a motor
examination showing 5/5 strength throughout. Sensory examination
was intact to light touch. Cranial nerves II-XII were intact. The
patient had deep tendon reflexes that were 2+ throughout.
LABORATORY DATA: The patient was found to have normal
electrolytes. White count was 6.3 and hematocrit
41.2. CPK obtained at Lovelin Medical Center was 148 and serial
CPKs obtained at A Salt Medical Center were 81 , 114 ,
115 , respectively. No MB fraction was done. At Lovelin Medical Center , the patient had an EKG taken that was significant for
normal sinus rhythm at 62 beats per minute with intervals of
169/93/402 with no Q waves , no ST changes. This was consistent
with an EKG from September , 1996. An EKG obtained at A Salt Medical Center showed normal sinus rhythm at 64 beats per minute
with intervals of 172/100/412 with one PVC captured. However ,
there were no Q waves and no ST changes.
HOSPITAL COURSE: The patient was begun on heparin 1 , 000 units per
hour intravenous after an initial 5 , 000 units intravenous bolus.
The patient consistently maintained a PTT in the range of 60-80
seconds. The patient underwent a catheterization the day following
admission which demonstrated 80% occlusion of the ramus branch ,
100% occlusion of the left obtuse marginal branch number one , and a
100% occlusion of the patient's right coronary artery. It was
decided that the patient would be a candidate for both conventional
PTCA to attempt to repair the left circumflex coronary artery.
However , the patient's severe coronary artery disease lead the
interventional radiologists to consider the patient for a laser
wire type of PTCA in the event that PTCA was not successful. As
the laser wire PTCA was not available for several days , it was
decided to have Mr. Breisch remain as an inpatient on heparin to
maintain a PTT of 60-80 while awaiting the laser wire guided PTCA.
Three days following admission , while awaiting PTCA , the patient
had one episode of chest pain that he reports resolved in less than
three minutes with one sublingual nitroglycerin tablet. The
patient denied shortness of breath , palpitations , or diaphoresis.
Since that time , the patient remained totally stable with no
further events of chest pain and no EKG changes noted. The patient
was begun on 250 mg of Ticlid twice a day two days prior to his
catheterization procedure.
On May , 1996 , five days after admission , the patient
successfully underwent PTCA of his left circumflex artery which had
previously had a 100% stenosis. The patient had two stents placed
in the left circumflex artery , leaving a 0% residual lesion. The
patient tolerated the procedure well , returned to the floor. The
catheterization sheaths were removed six hours after the procedure.
Examination the following morning revealed no further bleeding , no
hematoma , and good pulses distally , as well as a warm and dry left
lower extremity. As the patient tolerated the procedure well and
had no further complications , it was decided that the patient could
be discharged the day following his catheterization , maintained on
250 mg of Ticlid twice a day
DISCHARGE MEDICATIONS: Ticlid 250 mg orally twice a day , spironolactone
25 mg orally every day before noon , simvastatin 20 mg orally
every bedtime , atenolol 75 mg orally every day , diltiazem 60 mg orally three times a day , and
enteric coated aspirin 325 mg every day.
DISCHARGE CONDITION: Mr. Breisch will be discharged in stable
condition following his PTCA from the day
before. The patient will be discharged to home.
FOLLOW-UP: The patient will follow up with Dr. Mackenzie Tyacke ,
his outside hospital cardiologist , in one to two weeks.
We suspect that Mr. Breisch will be able to return to his normal
activities of daily living without any further disability.
Dictated By: MOSHE SHUGRUE
Attending: BREE M. THEILING , M.D. QJ3 KM021/9926
Batch: 99344 Index No. T7QMOX25MG D: 2/8/96
T: 8/30/96
CC: 1. BREE M. THEILING , M.D. IY1
2. ELMER L. SIC , M.D. IQ54
Document id: 137
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581312753 | PUO | 77634248 | | 6012792 | 5/8/2002 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 5/8/2002 Report Status:
Discharge Date: 10/13/2002
****** DISCHARGE ORDERS ******
BONING , FREDDA 207-67-77-5
Candfly Drive , Dale , California 84892
Service: MED
DISCHARGE PATIENT ON: 8/12/02 AT 10:00 a.m.
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PIDRO , KUM ANDREW , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
CAPTOPRIL 12.5 MG orally three times a day HOLD IF: sbp<95
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Alert overridden: Override added on 10/14/02 by
AMISTOSO , BRYANNA , MD , MPH
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
CAPTOPRIL Reason for override: aware
LASIX ( FUROSEMIDE ) 40 MG orally three times a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5 MIN X 3
as needed Chest Pain HOLD IF: SBP<[ ].
Instructions: As per chest pain protocol.
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/14/02 by
AMISTOSO , BRYANNA , MD , MPH
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
88453194 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: previously overriden
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ATENOLOL 25 MG orally every day
NITROPATCH ( NITROGLYCERIN PATCH ) 0.2 MG/HR TP every bedtime
GLYBURIDE 5 MG orally twice a day
ISORDIL ( ISOSORBIDE DINITRATE ) 10 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Pidro 3/12/02 scheduled ,
No Known Allergies
ADMIT DIAGNOSIS:
unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF ( congestive heart failure ) cad ( coronary artery disease ) htn
( hypertension ) dm ( diabetes mellitus ) gerd ( gastroesophageal reflux
disease ) hypothyroidism ( hypothyroidism )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cardiac cath and stent of RCA , 10/14/02
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old F with history of CAD , HTN , CHF , and DM with several
recent admissions for flash pulm edema , most recently at PUO 1 week
ago when she had stent placed in L renal artery ( cath showed 30% LAD ,
60% and 70% RCA lesions which were not
intervened upon ). patient well until night of admission , when
she developed SOB while watching TV. Not
anginal equivalent , no CP. Lasted 30 minutes , took NTG
and Lasix 120 , called EMS and was brought to PUO
ER. In ER , was given ASA , Lopressor , and
Heparin. Admission vitals: T 98 BP 119/46 HR 81 O2 sat
97%. Exam notable for: - m/r/g , decreased
BS/dullness at R base , guaiac neg in ER. Labs notable
for Cr 2.0 , Hct 30.5 , neg cardiac enzymes. CXR
with bilat pleural effusions. EKG with downsloping
ST depressions in II , III , F , I , L. Impression:
71F with recurrent CHF and flash pulm edema ,
possibly due to coronary artery lesions or
HTN.
#1 CV- r/o MI. On Heparin , ASA , Plavix , Metoprolol , nitrates , ACE-I ,
statin , lasix. Cardiac catheterization and stent placed in RCA 10/2 ,
patient tolerated procedure well.
#2 Pulm - We continued lasix , as needed nebs for wheezing. patient was stable
throughout hospitalization.
#3 Endo - We checked finger sticks and covered with CZI. Continu
ed synthroid. Once patient re-started orally diet after cardiac cath , we
resumed glyburide.
#4 Renal - increased Cr slightly above baseline. Remained stable
during hospitalization.
#5 F/E/N - NPO in anticipation of cath. Monitored lytes.
ADDITIONAL COMMENTS: 1. Please f/u with Dr. Pidro on 8/30/02 , at 3:15pm
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. F/u with Dr. Pidro to discuss results of cardiac cath , stenting ,
post-cath management , and overall management of CHF and flash pulmonary
edema.
No dictated summary
ENTERED BY: JONTE , VERNA A. , M.D. ( IC69 ) 8/12/02 @ 10:14 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 138
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117585063 | PUO | 19549965 | | 413227 | 11/12/1999 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 10/10/1999 Report Status: Unsigned
Discharge Date: 8/20/1999
ADMISSION DIAGNOSIS: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: This is a 50-year-old man with a
history of an anterior myocardial infarction in 1994.
Catheterization at that time revealed 100 percent proximal left
anterior descending artery disease with collateralization filling
from undiseased left circumflex artery and right coronary artery.
The patient has been symptom free until that time , until the last
two months during which he has developed increasing dyspnea on
exertion. Exercise tolerance test on March , 1999 revealed new
ischemia anteroapically and septally with an ejection fraction of
54 percent. Cardiac catheterization on March , 1999 revealed
total left anterior descending artery occlusion proximally , with
left to left collateralization and right to left collateralization
filling distally. Also , a large left circumflex artery with a 70
percent occlusion , and a right coronary artery which is
nondominant.
PAST MEDICAL HISTORY: 1. Status post myocardial infarction in
1994. 2. History of parathyroid adenoma.
PAST SURGICAL HISTORY: 1. Parathyroidectomy in 1978. 2.
Bilateral arthroscopic knee surgeries. 3. Deviated septum.
SOCIAL HISTORY: Smoking , one-half pack per day for nine years ,
quit 25 years ago. Alcohol , occasional glass of wine.
ALLERGIES: No known drug allergies.
MEDICATIONS: 1. Aspirin 325 mg orally every day 2. Hyzaar 50/12.5
twice a day 3. Pravachol 40 mg orally every day 4. Procardia XL 30 mg orally
every day 5. Tenormin 50 mg orally every day 6. Multivitamins including
Vitamin E and folic acid.
REVIEW OF SYSTEMS: Review of systems is remarkable for fatigue ,
dyspnea on exertion , occasional palpitations , indigestion , reflux
disease , and a local paresthesia in the thumb secondary to a stab
wound.
PHYSICAL EXAMINATION: Pulse 60 and regular , blood pressure 136/86 ,
height 5 feet 11 inches , weight 294 pounds. Skin , warm and dry
without lesions. Nodes , no palpable adenopathy. HEENT ,
normocephalic , atraumatic , pupils are equally round , reactive to
light and accommodation , teeth in good repair. Neck , no jugular
venous distention , no carotid bruits. The lungs are clear to
auscultation. Heart , regular at 60 , no murmurs , rubs , or gallops ,
distant heart sounds. Abdomen , obese , soft , non-tender , positive
bowel sounds. Rectal guaiac negative. Neurological examination ,
alert and oriented x three without focal deficits.
Musculoskeletal , strength 5/5 in all extremities. Extremities ,
pulses 2+ throughout , no clubbing , cyanosis , edema , or
varicosities. Allen's test negative bilaterally. The patient is
right-handed.
LABORATORY DATA: Laboratory tests are within normal limits.
Urinalysis is negative.
HOSPITAL COURSE: The patient was taken to the Operating Room on
April , 1999 and underwent coronary artery bypass graft times two
using left radial artery and left internal mammary artery. The
patient came off bypass without problems , and was taken to the
Intensive Care Unit in stable condition. The patient was extubated
on postoperative day number one. The chest tubes were removed on
postoperative day number two. Epicardial pacing wires were removed
on postoperative day number three. The remainder of the hospital
course was uncomplicated , and the patient is discharged to home in
good condition on postoperative day number five on the following
medications.
DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg orally every day
2. Atenolol 25 mg orally twice a day 3. Diltiazem 30 mg orally three times a day 4.
Percocet one to two tablets orally every 4-6 hours as needed pain. 5.
Pravachol 40 mg orally every bedtime
FOLLOW-UP: Follow-up appointments with Cardiology in one week , and
Dr. Colasamte in four to six weeks.
Dictated By: CHRISTEEN JACOBSON , P.A.
Attending: ISABELLE E. COLASAMTE , M.D. KJ2 NY654/3661
Batch: 01333 Index No. A1HDXT1R93 D: 8/11/99
T: 10/11/99
Document id: 139
| Target |
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GER |
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HC |
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HTG |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
N |
- |
N |
- |
N |
825860830 | PUO | 51901519 | | 5655478 | 10/27/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/29/2004 Report Status: Signed
Discharge Date: 10/22/2004
ATTENDING: STACIE CLEVELAND HALECHKO MD
PRINCIPAL DIAGNOSIS:
Chemotherapy toxicity , atrial fibrillation , dehydration , colitis ,
liver failure.
ASSOCIATED PROBLEMS/DIAGNOSES:
Hypotension , diabetes mellitus , esophagitis , congestive heart
failure.
HISTORY OF PRESENT ILLNESS:
Ms. Lewis is a 68-year-old woman with metastatic breast cancer
that was first diagnosed in 1999 , and she is status post
lumpectomy with lymph node dissection and multiple chemotherapy
regimens. She is currently on Xeloda with excellent response;
per Dr. Toni , her outpatient oncologist , she has virtually no
evidence of metastatic disease on CT. Over the past few months ,
the patient has had chronic problems with nausea and decreased
appetite. This has become especially acute over the past week ,
and as a result , her chemotherapy is now on hold. She has also
had some worsening diarrhea , for which she was prescribed
Imodium , but because of ongoing issues with compliance , it was
felt that she was not taking enough at home. During an
outpatient visit with her cardiologist , her blood pressure was
noted to be 90/50 , so her dose of atenolol and Lasix was
decreased. Of note , the patient is status post a recent
admission to PUO for digoxin toxicity , so this medication is now
also on hold. Of note , the patient is not currently on Coumadin
despite a history of atrial fibrillation due to a history of GI
bleeding , possible interactions with her chemotherapy regimen ,
and ongoing issues with medication compliance. The patient was
admitted for rehydration , management of nausea/vomiting/diarrhea ,
and control of her pain and other symptoms.
REVIEW OF SYSTEMS:
Nausea/vomiting x several months , diarrhea approximately six
times per day , worsening over the past week with green liquid
stool , no blood in stool or vomit , no abdominal pain , no urinary
symptoms.
PAST MEDICAL HISTORY:
Metastatic breast cancer ( diagnosed in 1999 , status post
lumpectomy and lymph node dissection , formerly on numerous
chemotherapy regimens including Adriamycin/cytoxan , Taxol ,
Taxotere/Herceptin , gemcitabine ) , atrial
fibrillation/supraventricular tachycardia , hypertension ,
hypercholesterolemia , cholecystitis , diabetes mellitus ,
esophagitis.
ADMISSION MEDICATIONS:
Lasix 20 mg every day , aspirin 325 mg every day , Xeloda 1500 mg twice a day ( two
weeks/one week off ) , Zofran 8 mg three times a day , as needed nausea , Compazine
10 mg four times a day as needed nausea , Protonix 40 mg twice a day , atenolol 75 mg
every day , Lomotil 1 mg twice a day , trazodone 50 mg every bedtime as needed
insomnia , Percocet 325/5 mg as needed pain , Ativan 1 mg four times a day
as needed anxiety , metformin 850 mg twice a day , Vioxx 12.5 mg every day
ALLERGIES:
Penicillin.
FAMILY HISTORY:
The patient has several uncles and cousins with cancer , but she
is unsure of what type.
SOCIAL HISTORY:
The patient lives with her daughter and grandson. She has no
history of tobacco or alcohol use.
PHYSICAL EXAMINATION:
Vital signs: Temperature 97.9 , pulse 101 , BP 80/66 , respiratory
rate 16 , O2 sat 99% on room air.
General: Alert , italian-speaking , no acute distress.
HEENT: PERRL , EOMI , poor dentition , OP clear.
Neck: No LAD , FROM , supple.
Chest: CTAB.
CV: Irregularly irregular , S1 , S2 , no murmurs/rubs/gallops.
Abdomen: Soft , distended , mild tenderness to palpation in the
lower quadrants bilaterally , slightly tympanitic , normoactive
bowel sounds , no hepatosplenomegaly.
Extremities: Warm/well perfused , trace DP/physical therapy pulses , no
clubbing/cyanosis/edema , ulcer on left large toe , severely
cracked and dry skin on hands and feet.
Neuro: Cranial nerves II through XII grossly intact , 5/5 strength
throughout.
LABORATORY VALUES:
Significant for creatinine 1.3 , glucose 137 , WBC 9.6 with 28
polys and 29 bands , hematocrit 38.1 , total protein 5.2 , albumin
2.0 , ALT 41 , AST 18 , alk phos 61 , total bilirubin 2.5.
An EKG showed atrial fibrillation with rapid ventricular response
at approximately 140 beats/minute. No ST or T wave changes.
HOSPITAL COURSE:
1. GI: Colitis: Given the patient's persistent and chronic
nausea , vomiting , and diarrhea , there was significant concern for
small bowel obstruction on admission. However , a KUB and
abdominal CT were both negative for small bowel obstruction. She
was originally kept npo for bowel rest , and a nasogastric tube
was placed with significant drainage. Stool studies were sent
including C. difficile , ova and parasites , cecal leukocytes , and
Shigella/salmonella/Yersinia/campylobacter studies , all of which
were negative. Because of the concerning nature of the patient's
symptoms , surgery consult was called , however they felt that her
problems were likely nonsurgical in nature. CTs performed two
days and five days after admission showed identical findings of
right-sided colitis. They remained largely unchanged.
Nevertheless , the patient experienced continued nausea and
vomiting and also continued diarrhea throughout this time. Once
her nasogastric tube output decreased significantly ,
approximately one week after admission , the tube was removed and
the patient was started on orally , and her diet was advanced as
tolerated. From that point on , the patient had no nausea or
vomiting , and she is currently tolerating a full diet.
Nevertheless , she continues to have mild diarrhea , now two
episodes per day as compared to6 to 8 episodes per day prior to
admission. In the end , the workup for the underlying cause of
her nausea , vomiting , and diarrhea has been negative. It is
therefore our suspicion that her symptoms are most likely
secondary to toxicity from her chemotherapy medication , Xeloda.
Of note , the patient also has other signs of Xeloda toxicity ,
including possible hepatotoxicity ( see below ) as well as severe
cracking and drying of the skin on her hands and feet.
2. Hepatitis: A CT performed on admission to evaluate for small
bowel obstruction showed a significantly cirrhotic and fatty
liver with no masses. On admission , the patient's total
bilirubin was 2.5; however , her bilirubin levels escalated
precipitously to a maximum of 17.6. At the same time , the
patient developed clinical manifestations of this , including
scleral icterus and jaundice. Also , as her albumin levels
decreased to below 1.5 , she developed significant ascites and
peripheral edema. Gastroenterology consult suggested a right
upper quadrant ultrasound , which was negative for obstruction , a
hepatic MRI , which also showed a cirrhotic and fatty liver , and
also a diagnostic/therapeutic IR guided paracentesis , which
drained 1 liter of sterile fluid. Hepatitis serologies were also
sent , and the patient was hepatitis A and B negative , but C
positive; however , her viral load was less than assay , and her
AFP was within normal limits. A rheumatologic workup for
autoimmune hepatitis was also negative. Because of the acuteness
and the timing of her presentation , it was felt that her liver
failure was likely secondary to a combination of hepatitis and
also toxicity from her Xeloda.
On discharge , the patient's hepatic function had been improving
significantly for three days , with her albumin increasing , her
INR decreasing and her bilirubin levels also decreasing. On
discharge , her total bilirubin was 16.0 down from 17.6 , her
albumin was 1.9 up from 1.5 , and her INR was 1.6 down from 2.6.
It is anticipated that as the patient's nutritional status
continues to improve , her hepatic function will continue to
normalize with resulting normalization of her laboratory values.
3. Cardiovascular: On admission , the patient was in atrial
fibrillation with rapid ventricular response at the rate of
approximately 140 beats per minute. She was also hypotensive ,
with a blood pressure of roughly 90/60. She was placed on
cardiac telemetry , which recorded rapid a. fib. up to the 170s.
As a result , she was given intravenous Lopressor with decreased heart rate
but also significant reduction in her blood pressure requiring
fluid boluses. After 24 hours , after her blood pressure had
stabilized following the administration of intravenous fluids ,
she was started on a diltiazem drip at 5 mg per hour , which
helped to establish stable rate control in the 80s with continued
atrial fibrillation. At the same time , the patient was loaded
with digoxin , but her levels were high; given that the patient
was status post a recent admission for digoxin toxicity , this
medication was subsequently held. In one incident , the patient
developed a temporary junctional rhythm for approximately 5
minutes with a heart rate in the 50s. At that point , input was
elicited from the cardiology consult service , who thought that
her symptoms were likely secondary to the diltiazem drip.
However , given concern for a tachy-brady syndrome , the
possibility of an implantable cardiac pacemaker was discussed.
However , the patient did not have any recurrence of the
junctional rhythm. A TTE was obtained , which showed an ejection
fraction of 60% with trace MR and moderate TR , left and right
atrial enlargement , and normal left and right ventricular
function. Once the patient was again taking orally medications ,
her diltiazem drip was changed to orally diltiazem. For the next
several days , the patient had several episodes each night of 3 to
5 beat runs of NSVT. However , on the three days prior to
discharge , the patient had no events on telemetry , and her heart
rate was stable in the 60s to 80s , with a blood pressure running
from 90-100/50-60. Shortly before discharge , the patient also
developed episodic shortness of breath , which was attributed to
mild pulmonary edema , and she responded well to boluses of intravenous
Lasix. As a result , she was restarted on Aldactone with
effective gentle diuresis. The plan on discharge will be to
follow her volume status carefully and to adjust her diuretic
regimen as needed to maintain her volume status with continued
improvement in her hepatic function.
4. Endocrine: The patient has a history of diabetes mellitus ,
and her metformin was held on admission secondary to an elevated
creatinine. As a result , she was started on a lispro sliding
scale. Given that she was npo for several days , she was not
given any insulin and her blood sugars remained stable in the low
100s. After she again started taking orally , she was restarted on
a sliding scale , and she maintained excellent blood sugar control
between 100 and 150. A hemoglobin A1c obtained during this
admission was also within normal limits. Of note , the patient
has a left toe ulcer , and was seen by orthopedic surgeries and
outpatient totally before admission.
5. Heme: The patient had an INR of 2.6 on admission secondary to
cirrhosis and poor nutrition. As a result , she was given vitamin
K subcutaneously npo as needed. As noted above , despite a history of
atrial fibrillation , the patient is not on Coumadin at home
secondary to poor med compliance. At home , she was only on
aspirin , but this was also discontinue during the admission
secondary to continued guaiac positive stool. Nevertheless , her
hematocrit remained stable throughout her admission and she did
not require any transfusions. As DVT prophylaxis , the patient
was kept on Pneumo boots throughout the admission. At one point ,
she was noted to have left upper extremity swelling greater than
the right upper extremity , but an ultrasound was negative for
DVT. As noted above , on discharge , the patient's INR was
improving secondary to improved nutrition. She will be
discharged without any anticoagulation at present , however this
can be further reevaluated as an outpatient by her cardiologist
and oncologist.
6. FEN: The patient was initially rehydrated with normal saline ,
however this was changed to D5W plus 3 amps of bicarb since she
developed a bicarb gap. Once this gap was closed , she was given
gentle normal saline as maintenance fluids. Once the patient
started taking significant orally , her intravenous fluids were discontinued.
The patient's electrolytes were also repleted as necessary.
Plan on discharge will be to continue following her electrolytes
closely to prevent further exacerbation of her cardiac
arrhythmias.
7. Pain: The patient was given oxycodone orally and morphine intravenous
for pain. The patient was previously on Vioxx at home for
orthopedic pain related to her diabetes , however , given recent
data suggesting possible cardiotoxic effects of Vioxx , this will
be discontinued , and she will be sent home with oxycodone as needed
for pain.
8. Onc: The patient's Xeloda is currently on hold since many of
her symptoms leading up to this admission were likely secondary
to chemo toxicity. As noted above , the patient has other
evidence of chemo toxicity as well , including significantly dried
skin on her hands and feet. The patient's outpatient oncologist ,
Dr. Carmelita Toni , followed her closely during this admission , and
she will follow up with the patient regarding possible changes to
her chemotherapy regimen.
9. Disposition: The patient was seen by the physical therapy
service shortly before discharge , and they noted that she
displayed difficulty even moving from the bed to the chair , which
is significantly below her baseline of being able to ambulate
independently. As a result , after extensive discussions with her
family , it was decided that the patient will be best served by
going to a rehab facility for continued closed supervision of her
medical problems , supervised administration of her medication
regimen , continued strength training and conditioning , and also
continued nutrition. Once the patient is able to be less
dependent on outside assistance , she can be sent home with either
a home health aide or visiting nurse for continued
rehabilitation. Of note , the patient's code status was
established by her outpatient oncologist as DNR/DNI. This was
confirmed with the patient during this hospitalization.
PHYSICAL EXAMINATION ON DISCHARGE:
Vital signs: Temperature 98.3 , pulse 80 , blood pressure 104/64 ,
respiratory rate 20 , O2 sat 99% on room air.
General: Alert , no acute distress , icteric sclerae , and slightly
jaundiced.
Respiratory: CTAB except for few crackles at the bases
bilaterally.
CV: Irregularly irregular S1 , S2 , 1/6 SM at the left upper
sternal border , no rubs/gallops.
Abdomen: Soft , distended ( decreased from prior ) , mildly tender to
palpation diffusely , normoactive bowel sounds.
Extremities: Warm/well perfused , nontender , 1 to 2+ pedal edema ,
1 to 2+ left upper extremity edema , significantly dry/cracked
skin on hands and feet.
LABORATORY VALUES ON DISCHARGE:
Sodium 137 , potassium 4.3 , bicarb 26 , creatinine 1.0 , glucose 61 ,
calcium 7.8 , magnesium 2.2 , WBC 15.1 with 87% polys , HCT 36.8 ,
platelets 101 , 000 , INR 1.6 , ALT 18 , AST 46 , alk phos 103 , T. bili
16.0 , total protein 5.8 , albumin 1.9.
DISCHARGE MEDICATIONS:
Lispro sliding scale ( if blood sugar less than 135 , give 0 units
subcutaneously; if blood sugar is 125 to 150 , then give 2 units
subcutaneously; if blood sugar is 151 to 200 , then give 3 units
subcutaneously; if blood sugar is 201 to 250 , then give 4 units
subcutaneously; if blood sugar is 251 to 300 , then give 6 units
subcutaneously; if blood sugar is 301 to 350 , then give 8 units
subcutaneously; if blood sugar is 351 to 400 , then give 10 units
subcutaneously ) , multivitamin one every day , Protonix 40 mg every day ,
diltiazem 60 mg three times a day , Aldactone 25 mg every day , oxycodone 5 to 10
mg orally every 4 hours as needed pain , trazodone 50 mg orally every bedtime as needed
insomnia , Compazine 5 mg orally every 6 hours as needed nausea , vitamin K 5 mg
orally every day
DISPOSITION:
The patient was discharged to rehab in stable condition.
PHYSICIAN FOLLOW-UP PLANS:
The patient will be discharged to rehabilitation facility , where
she will continue to be given supportive care for ongoing
symptoms of her enteritis and hepatic failure. She will also
receive physical therapy and nutrition to help her return to her
baseline function. Prior to discharge from rehab , her medication
regimen should be simplified as much as possible to prevent
future confusion over her medications , as has happened in the
past.
On discharge from rehab , the patient should be sent home with
either a visiting nurse or home health aide , as insurance
permits. At that point , she will follow up with Dr. Zebley , her
primary care physician; Dr. Toni , her outpatient oncologist; and
Dr. Greigo , her outpatient cardiologist.
eScription document: 8-6122355 EMSSten Tel
Dictated By: OLDOW , TOMAS
Attending: PULLUS , ROLANDE REFUGIA
Dictation ID 0894575
D: 3/1/04
T: 3/1/04
Document id: 140
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
Y |
- |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
057116763 | PUO | 81414902 | | 199811 | 7/29/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/8/1996 Report Status: Signed
Discharge Date: 2/30/1996
PRINCIPAL DIAGNOSIS: LEFT PLEURAL EFFUSION , MOST LIKELY POST-
PERICARDIOTOMY SYNDROME
OTHER DIAGNOSIS: ( 1 ) ADRENAL INSUFFICIENCY , EMPIRICAL DIAGNOSIS
HISTORY OF PRESENT ILLNESS: Ms. Dalegowski is a 52-year-old woman
status post mitral valve repair and
CABG in 6/28 , as well as dilated cardiomyopathy , who presented in
5/24/95 with worsening shortness of breath and left pleural
effusion , and for further evaluation and treatment of these
symptoms.
HISTORY: Patient has a long history of mitral valve prolapse. In
6/28 , she presented to Petersram Medical Center with history of
progressive dyspnea and congestive heart failure noted at an
outside hospital. Ejection fraction at that time on echo was 18% ,
with severe MR and TR. She was admitted and an echo done at the
Kernan To Dautedi University Of Of showed moderate left ventricular dilatation with an EF of
25-30% , with only mild regional variability. There was also right
ventricular dilatation with mild decrease in function. Mitral
valve was thickened with severe MI. CAT at that time showed 71%
left-sided lesion. The patient underwent , in 6/28 , mitral valve
repair and one-vessel CABG lemma to the LAD. She had an uneventful
post-op course. Her post-op echo on 6/12/95 revealed LV
dilatation with clear EF of 23% and good intravenous function. Moderate
residual mitral regurgitation and moderate TR. Post-op weight of
the patient was 177 lb.
Post-operatively , the patient did well initially , when she had PND
and orthopnea that was marked prior to surgery , she is able to walk
now , and when she was only able to walk only 40 ft. before
stopping. She now sleeps flat on her bed with improved exercise
tolerance. She experiences near total resolution of the PND and
orthopnea initially. However , in the period between 6/28 to
7/30 , the above symptoms recurred with progressive shortness of
breath , dyspnea on exertion , cough and positional chest pains. On
3/13/95 , the patient saw her physician and was noted to have a
large left pleural effusion at an outside hospital. A left
thoracentesis was done. Patient noted 1 liter of bloody fluid that
was tapped from her thoracentesis. Post-procedural weight was 169
lb. She was able to breath more easily.
Status post the left thoracentesis , the patient initially felt
well. However , within the next few days , she continued to develop
worsening shortness of breath and dyspnea on exertion , as well as
PND and orthopnea. She , therefore , represents on 1/2/96 for
recurrence of her symptoms and recurrence of left pleural effusion.
PAST MEDICAL HISTORY: ( 1 ) MITRAL VALVE PROLAPSE , MITRAL REPAIR
STATUS POST 1/10 ( 2 ) CABG X1 , EILEMMA TO
THE LAD IN 1/10 ( 3 ) HYPERTENSION; ( 4 ) ASTHMA; ( 5 ) HYPOTHYROIDISM;
( 6 ) HISTORY OF STROKE X3 , LAST STROKE IN 1987; ( 7 ) HISTORY OF TIAs;
( 8 ) HYPOCHOLESTEROLEMIA; ( 9 ) HISTORY OF SEIZURE DISORDER STATUS
POST MVA; ( 10 ) CHRONIC DVTS; ( 11 ) TAH/BSO; ( 12 ) HEPATITIS HISTORY;
( 13 ) CYSTOCELE REPAIR.
ADMISSION MEDICATIONS: Digoxin .25 every day; Vasotec 10 mg every day; Lasix
40 mg every day; Flexeril clear dose twice a day;
Coumadin 7.5 mg alternating with 10 mg every bedtime; Synthroid 15 mcg every day;
Benadryl 50 mg as needed; Prozac 10 mg twice a day; Mevacor 20 mg every day
SOCIAL HISTORY: No tobacco use. Alcohol use none for 10 years.
No drugs. Unemployed since surgery. Married with
two children.
ALLERGIES: Iodine and Atropine which cause shortness of breath.
Codeine which causes a rash. Atrovent unclear side
effects.
PHYSICAL EXAMINATION: GENERAL - patient is afebrile. EXTREMITIES-
left upper extremities and right upper
extremities blood pressures were equal 140/100 , pulse 65 , breathing
at 97% on room air. HEENT - unremarkable. NECK - supple with 2+
carotids and no bruits. JVD less than 8.0 cm at 45 degrees. No
HJR. HEART - showed right ventricular and left ventricular
heaves. No thrills. Regular rate and rhythm. S1 and S2 were
normal. Right-sided systolic murmur increased with inspiration.
Rubs were appreciated when she laid on her left side. LUNGS -
showed decreased breath sounds. Decreased tactile ****** and
dullness to percussion 2/3 up from the base on the left. No rales.
ABDOMEN - soft. Good bowel sounds. No HSM. EXTREMITIES - 3+
edema bilaterally. Otherwise , pulses intact. NEURO - alert and
oriented x3. No focal or neurological deficits in motor or sensory
exam.
LABORATORY DATA: Na 138 , K 4.0 , Cl 97 , Bicarb 24 , BUN 12 ,
creatinine 0.8 , glucose 100. WBC 8.9 , 64% polys ,
22% lymphs , 5 monos , 4 eosin. , 1 baso. Hematocrit 34.3 , platelets
415. LDH 233 , total protein. Digoxin level 1.1. physical therapy and PTT 14.9
and 25.4 with an I&O of 1.5.
U/A was negative.
Chest x-ray showed a large pleural effusion on the left. No
pulmonary edema , and no infiltrations.
EKG - sinus tachy at 108 , with frequent PVCs and bigeminy.
Intervals were normal. Axis of 21 degrees. Left atrial
enlargement. No acute ischemic changes.
HOSPITAL COURSE: Ms. Dalegowski was initially admitted with a
diagnosis of left pleural effusion of unclear
etiology. A left thoracentesis was performed and the fluid was
deemed exudative. It was bloody in appearance and had a white
count greater than 4 , 000 , with a red cell count greater than
500 , 000. Patient met criteria for exudative fluid by
fluid-serum-LDH ratios , fluid-serum-protein ratio and LDH greater
than 200. Subsequent cultures , however , were negative for a
bacterial fungal AFB. Rheumatology etiologies were also R/O with
negative ANA and negative rheumatoid factor. Cytology was sent on
the patient , which also returned negative for malignant cells. A
total of 1.5 liters was drained from the thoracentesis. Subsequent
to the thoracentesis , the patient felt significantly better , with
better exercise tolerance and less orthopnea. She remains with RAO
to sats greater than 95% for the remainder of her hospitalization
and did not require oxygen. A repeat chest x-ray was done prior to
discharge , and compared to post-thoracentesis , showed no
significant accumulation of the left pleural effusion.
Initially it was felt that the patient's symptoms might have some
relationship to some element of congestive heart failure. She was
started on Digoxin and Captopril and maxed at Digoxin .25 every day and
Captopril 50 mg three times a day During this hospitalization , however , the
patient noted in passing , that she had , since her 6/28 surgery ,
developed significant dizziness and orthostatic symptoms upon
sitting up and rising , and had limited exercise tolerance partly
because of shortness of breath , but also partly because of her
dizziness symptoms. She noted occasional vertigo and occasional
diplopia. A work-up subsequently ensued related to the symptoms.
Neurology was consulted and carotid Dopplers , as well as MRA of the
head to R/O vertebral basal insufficiency were performed. Both
carotid Dopplers revealed less than 25 stenosis bilaterally and MRA
of the head revealed no vertebral basal insufficiency. However , it
was noted on repeated measurements of the patient's blood
pressures , that when she sat up and when she stood up , she became
hypotensive. A modified Bruce protocol stress test was performed
to determine the patient's exercise tolerance. Prior to initiation
of the modified Bruce , supine blood pressure was 120/80. Upon
sitting up , the patient's blood pressure was 92 and upon beginning
the modified Bruce within less than one minute , the patient's blood
pressure dipped to 60 systolic , and test was terminated. An
echocardiogram during this admission revealed an ejection fraction
of 30% , moderate LV dilatation , severe global hyperkinesis ,
preserved right ventricular function and size , and only trivial MR
and TR. No significant arrhythmias were noted on the patient's
cardiac monitor throughout her hospitalization , except for one
episode of transient third degree heart block with a ventricular
rhythm. The patient did not demonstrate this rhythm consistently ,
however , during her hypertensive episodes.
On review of the patient's past medical history , however , it was
found that the patient had been on chronic steroids for two years
prior to her 6/28 CABG and prior to the onset of these symptoms of
orthostasis and dizziness. Patient notes that she was more on than
off on orally steroids for treatment of her shortness of breath at an
outside hospital in Wau Pring An At that time , they had deemed that her
shortness of breath symptoms were secondary to pulmonary etiologies
rather than cardiac. We , therefore , suspected adrenal
insufficiency and consulted endocrine. ACTH stem test was
performed and Cortisol , Adolsterone and ACTH levels were drawn at
0:30 and 60 minutes post-administration of ACTH. The patient
developed hives and angioedema with the ACTH which was relieved
with Benadryl intravenous. After the performance of the ACTH stem test
empirically started on Hydrocortisone 80 mg intravenous. The next day the
patient's symptoms resolved and she no longer had any evidence of
orthostatic hypertension or dizziness symptoms related to standing
or walking. Repeated blood pressure measurements for orthostatic
were unyielding. The patient noted her symptoms are completely
resolved and that she felt like a different person. It was ,
therefore , felt that the empiric trial of hydrocortisone was
significant and that the patient most likely had adrenal
insufficiency secondary to chronic steroid for the two years prior
to the 6/28 CABG , and this was consistent with the time closer to
patient's symptoms , which began after the 6/28 CABG when she was
off steroids.
The patient was therefore discharged in stable condition with
diagnosis of a left pleural effusion secondary to most likely a
post-pericardiotomy syndrome , as well as orthostatic hypertension
and dizziness symptoms secondary to adrenal insufficiency. At the
time of discharge , the patient's ACTH stem test was still pending ,
as well as the TSH. It was felt at the time of discharge , the
patient should not be managed on Captopril or Digoxin. It remained
unclear whether or not the patient's current ejection fraction was
adequate for her symptoms.
DISCHARGE MEDICATIONS: Flexeril 10 mg orally twice a day; Benadryl 50 mg
orally twice a day; Prednisone 20 mg orally twice a day;
Prozac 20 mg orally every day; Synthroid 50 mcg orally every day; Mevacor 20 mg orally
every day; Quinaam 325 mg orally every bedtime
DISPOSITION: Patient was discharged home to Ton There
were no complications during this admission. Patient
was discharged in a stable condition , with no estimated disability.
The patient is to follow-up with Dr. Alexandra Popovic in 12/10 .
Dictated By: HERMINA TUOMALA , M.D. QD75
Attending: ALEXANDRA T. POPOVIC , M.D. AG4 BZ475/6971
Batch: 88593 Index No. XXMDW3293X D: 7/22/96
T: 7/22/96
Document id: 141
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
Y |
N |
N |
- |
N |
N |
Y |
N |
Y |
Y |
Y |
N |
- |
094513064 | PUO | 19651095 | | 4756346 | 10/11/2005 12:00:00 a.m. | asthma exacerbation | | DIS | Admission Date: 1/1/2005 Report Status:
Discharge Date: 10/15/2005
****** DISCHARGE ORDERS ******
ROCHE , OLIN 214-43-79-6
Cla Des Ta
Service: MED
DISCHARGE PATIENT ON: 5/24/05 AT 12:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PIDRO , KUM ANDREW , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL NEBULIZER 2.5 MG NEB Q 1hr
as needed Shortness of Breath , Wheezing
Instructions: If patient requests more frequently than
q1hr - call H.O.
ENALAPRIL MALEATE 40 MG orally every day Starting Today ( 7/18 )
HOLD IF: sbp<100 , call HO
HYDROCHLOROTHIAZIDE 25 MG orally every day HOLD IF: sbp<100 , call HO
MAGNESIUM GLUCONATE 500 MG orally twice a day
METHADONE HCL 20 MG orally three times a day
OXYCODONE 10 MG orally every 4 hours as needed Pain
PREDNISONE 60 MG orally every day Starting Today ( 7/18 )
Instructions: 60 mg x5d , 40 mg x5 d , 20 mg x5d then stop
FLONASE ( FLUTICASONE NASAL SPRAY ) 1-2 SPRAY inhaled every day
as needed Other:nasal stuffiness
Number of Doses Required ( approximate ): 4
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
CALCIUM CARB + D ( 600MG ELEM CA + VIT D/200 IU )
2 TAB orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Prall 11/9/05 scheduled ,
Dr Schlesener 2/6/05 scheduled ,
ALLERGY: LOBSTER , FLOWERS , STUFFED ANIMALS , THEOPHYLLINE
ADMIT DIAGNOSIS:
asthma exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
asthma exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) OSA ( sleep apnea ) Morbid obesity
( obesity ) Depression ( depression ) Rx opioid abuse ( substance
abuse ) Asthma ( asthma ) LBP ( low back
pain ) Adhesive capsulitis ( adhesive capsulitis ) Bilat rotator cuff
tear ( rotator cuff tear )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC:wheezing
HPI:2 day history of wheezing chest tightness. Well until 10 days ago
when got cough and runny nose , saw primary care physician started on ampicillin , 4 days
ago developed wheezing ->urgent care got prednisone rapid taper , but
still developed worsening SOB/wheezing despite home nebs. Usual asthma
triggers colds , pets , flowers and dusty carpets.
PMH:asthma with multiple hosp/icu stays never
intubated , HTN , morbid obesity , OSA , OA , chronic LBP and opiate use
Meds:vasotec/hctz/advair/albuterol nebs/methadone 20 three times a day , oxycodone 10
four times a day , nexium , mg , ca
All:theophylline , lobster
PE 97.6 73 139/29 20 97% RA Morbidly obese ,
short sentences , no
accessory muscles
Lungs:prolonged exp , adequate air movement , diffuse
wheezing 1+pedal edema of feet non pitting Peak flow 200 , 250
CXR no infiltrates
HOSPITAL COURSE 51 F with asthma admitted with asthma exacer
bation , likely triggered by URTI.
Pulm:asthma pathway with rapid prednisone taper , alb nebs , continued
advair. Racemic epinephrine for upper airway swelling not tolerated
( in past patient had racing heart , chest tightness ). Baseline PF 420-450.
On day of discharge , lungs clear PF 380. Pulmonary service consulted ,
recommended checking IgE and Aspergillus Ab , pending at time of
discharge.
CV:HTN:continued home hctz. The patients SBP was consistently
140-160 , this may have been due to the steroids , but we
increased her vasotec from 20 to 30 mg orally every day
Neuro:continued home pain regimen of oxycodone and methadone
Code:full
ADDITIONAL COMMENTS: We have increased your nexium for stomach acid suppression to 40 mg
twice a day as we felt acid reflux might be contributing to your
wheezing. We increased your blood pressure medicine ( vasotec ) to 40 mg
once a day. YOU NEED TO GET A BLOOD DRAW TO CHECK YOUR POTASSIUM AND
CREATININE ON TUESDAY BEFORE YOUR APPOINTMENT WITH DR TREBILCOCK
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Get blood draw for creatinine and potassium at KTDUOO on Tuesday before
your appointment with Dr Prall
No dictated summary
ENTERED BY: PAMA , WILLIAMS , M.D. ( CL00 ) 5/24/05 @ 10:11 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 142
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
Y |
N |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
201856607 | PUO | 21325731 | | 600725 | 10/1/2002 12:00:00 a.m. | acute coronary syndrome | | DIS | Admission Date: 3/26/2002 Report Status:
Discharge Date: 6/16/2002
****** DISCHARGE ORDERS ******
JULIAN , CHELSEY J 236-13-49-0
Y
Service: CAR
DISCHARGE PATIENT ON: 3/26/02 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: JOURNEAY , WINFRED TENESHA , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 100 MG orally twice a day HOLD IF: heart rate <55 sbp <100
FOLATE ( FOLIC ACID ) 1 MG orally every day
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally three times a day
HOLD IF: sbp<90
TRAZODONE 25 MG orally HS as needed insomnia
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NORVASC ( AMLODIPINE ) 5 MG orally every day HOLD IF: sbp<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 3/26/02 by
ZERBE , JOANA , M.D. , PH.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to CALCIUM CHANNEL
BLOCKERS Reason for override: Patient tolerates
CLOPIDOGREL 75 MG orally every day
RANITIDINE HCL 150 MG orally twice a day Starting Today ( 3/28 )
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Gort 2 weeks ,
ALLERGY: Glyburide , Capoten ( captopril ) ,
Cardizem ( diltiazem )
ADMIT DIAGNOSIS:
acute coronary syndrome
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
acute coronary syndrome
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CABG X 3 LIMA->LAD , SVG ->OM , RCA history of CHOLECYSTECTOMY '91 L Fem
Aneurysm Repair '91 NIDDM Urinary incontinence HTN
history of TAH/BSO in '73 for fibroids ( history of hysterectomy ) history of multiple
PTCAs/stents
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
1. Cardiac Catherterization 6/2 with stent to distal LAD.
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old F with multiple cardiac catheterizations and interventions in
the past who is admitted for ACS after a clear pattern of crescendo
angina peaking with angina awakening her from sleep this morning at 3
am. She was admitted and started on heparin , but experienced more rest
pain , and was started on intravenous tng and integrillin , per cardiology.
Cath on am of 6/2 with stent to distal LAD.
70F with acute coronary syndrome.
1. CV. CP , 5/10 , on 3/10 while in bed. Treated withSL NTG and
heparin. ECG NSR with TWI in II , III , aVF and STD/TWI in V3-V6.
Vital signs were stable. Per cardiology , patient was started on
ntegrillin and taken to cath in a.m. ( 6/2 ). CAth with mid LAD 80%
lesion ,
PTCA to 0% , 90% CFX lesion , 80% ostial marginal1 lesion , an 80% distal
marginal1 lesion , 100% mid RCA lesion , and 50% proximal RT PDA
lesion. Patient with patent SVG grafts to RT PDA and MARG1 , 80%
lesion of LIMA graft to LAD. Patient with her typical anginal pain
the following evening , relieved by sublingual ntgx3 , lopressor 5 , and ntg drops
ECG with 0.5-1mm STD. Felt to be secondary to post-stent spasm.
Enzymes flat. Integrillin continued for 12 additional hrs. NTG drops
weaned as isordil increased to 40. Patient with continued anginal pain
on exertion the following day with no ECG changes. Patient with
elevated BP throughout admission with systolic blood pressure to 140. Controlled
with atenolol 100 twice a day , isordil 40 three times a day , and norvasc 5 every day.
2. FEN. low chol/low sat fat diet.
3. Endocrine. blood glucose monitored by FS , controlled with insulin
sliding scale.
4. Dispo. d/c to home with plans for follow-up with her cardiologist ,
Dr. Barnaba in 2 weeks.
ADDITIONAL COMMENTS: 1. Please take medications as directed.
2. Please follow-up with Dr. Gort in 2 weeks.
3. Call your primary care doctor or go to the emergency room if you
experience any worsening and/or change of your cardiac symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Continue current medication regimen.
2. Follow-up with Dr. Nanci Gort in 2 weeks to discuss options of
cardiac bypass surgery vs. medical management.
No dictated summary
ENTERED BY: ZERBE , JOANA , M.D. , PH.D. ( PN0 ) 3/26/02 @ 02:58 PM
****** END OF DISCHARGE ORDERS ******
Document id: 143
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
835817476 | PUO | 67163626 | | 9220120 | 8/10/2004 12:00:00 a.m. | Ventricular tachycardia history of ICD placement | | DIS | Admission Date: 9/25/2004 Report Status:
Discharge Date: 8/1/2004
****** DISCHARGE ORDERS ******
SCHRAUGER , PHUNG 948-46-12-0
Vermont
Service: CAR
DISCHARGE PATIENT ON: 10/23/04 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LONGAKER , NATISHA AURELIA , M.D. , PH.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 400 MG orally every day Starting Today ( 1/22 )
Override Notice: Override added on 10/22/04 by LAPATRA , DARWIN M KATIE , M.D. on order for COUMADIN orally ( ref # 99730138 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
81 MG orally every day
Override Notice: Override added on 10/22/04 by LAPATRA , DARWIN M KATIE , M.D. on order for COUMADIN orally ( ref # 99730138 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
DILANTIN ( PHENYTOIN ) 100 MG orally three times a day
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after )
Override Notice: Override added on 10/22/04 by LAPATRA , DARWIN M KATIE , M.D. on order for COUMADIN orally ( ref # 99730138 )
POTENTIALLY SERIOUS INTERACTION: PHENYTOIN & WARFARIN
Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting Today ( 1/22 )
Instructions: Take for 3 days before switching to 2.5 mg
every day orally every bedtime Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/22/04 by LAPATRA , DARWIN M KATIE , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENYTOIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware
KEFLEX ( CEPHALEXIN ) 250 MG orally four times a day X 10 doses
Number of Doses Required ( approximate ): 20
LISINOPRIL 20 MG orally every day
Alert overridden: Override added on 10/23/04 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: mda
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 200 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 40 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Schoeppner at 9:40 am 5/25/04 scheduled ,
Dr. Lefevre , 2-4 weeks , Dr. Pederzani to facilitate pending ,
Arrange INR to be drawn on 7/30/2004 with f/u INR's to be drawn every
2 days. INR's will be followed by Dr. Lefevre
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Ventricular tachycardia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Ventricular tachycardia history of ICD placement
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of Right occipital parietal stroke , CV , Hypertension
Seizure d/o , afib/flutter on home coumadin DM - diet controlled
OPERATIONS AND PROCEDURES:
ICD placement 3/16/2004
Left heart catheterization
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
patient is a 65 year-old with CHF presenting with episode of Vtach
at outside hospital. patient felt somewhat nauseous on coming home from
work on day PTA. Wife noticed pallor when he came home , called
ambulance. Was found to be in monomorphic Vtach to 200 which responded
to lidocaine. Lidocaine drip d/c'd in a.m. of transfer in the abscene of
further VT. patient found to have troponin of 0.8 at
outside hospital. It was initially unclear if the patient had an ischemic
event which caused VT , or if the patient's VT caused a bump in cardiac
enzymes. patient also has anginal equivalent with jaw pain which
worsens when the patient carries heavy things or walks
up flights of stairs. Recent outside echocardiogram showed EF 15-20% ,
with global hypokinesis. PE onadmission with JVP 10 cm , faint crackles ,
II/VI SEM worse with inc. afterload. EKG , unchanged from
11/1 .
HOSPITAL
COURSE 1. Ischemia - The patient was admitted to the cardiac
service. Given the presence of vtach and a slight EKG bump , and
clinical signs of heart failure , the initial presentation was
suspicious for CAD. The
patient was initially diuresed slowly , however , the patient began to develop
worsening HTN and shortness of breath along with a prolonged episode of
vtach and was subsequently
diuresed aggressively by approximately 5 L. The patient was also
loaded with amiodarone. The patient's weight also dropped 5 kg. Left and
right
coronary catheterization were performed and revealed only a discrete rt
PDA lesion 60% and a discrete 60% D1 , otherwise essentially clean. No
interventions were
necessary. The right heart catheterization revealed a PCWP of 6 after
the diuresis. The patient had no further vtach episodes on amiodarone
and was discharged on 400 mg every day of amiodarone.
The patient had an
ICD placed on 3/16/2004 . The initial plan was for the patient to also
have his aflutter ablated to decrease the propensity for vtach ,
however , the presence of a lt atrial clot could not be ruled out during
TEE , so rhythm ablation was deferred. An transthroracic echocardiogram
was
also performed prior to discharge which revealed EF of 30% , with anterior
akinesis and global hypokinesis. A broad differential diagnosis for his
heart failure was entertained , however no conclusive etiology could be
determined. The patient is to follow up with his cardiologist and his P
CP. These appointments were coordinated by the attending physician ,
Dr. Pederzani . He should also follow up with Dr. Schoeppner as described in that
section. For the patient's afib , he should take coumadin , 5 mg , for the
next three nights and should subsequently drop down to 2.5 mg every day ,
unless differently as suggested by his INR which should be drawn on
Monday , May , and Wed September by the VNA. The patient should call an
MD immediately with chest pain , sob , or pallor. The patient's blood
pressure medications were also significantly adjusted to maximum doses
while the patient was under close acute care monitoring to facilitate
optimization of his outpt regimens. Additional changes at the
discretion of the patient's primary care physician , Dr. Lefevre . The patient also presented with an
elevated creatinine which slowly returned to normal levels during the
hospitalization. The elevated creatinine was most likely due to a
combination of hypoperfusion secondary to vtach , and dye load from
catheterization.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
F/u as described above. INR on June . Stop old medications.
Take only medications as prescribed from here.
No dictated summary
ENTERED BY: TIMPSON , JACK T. , M.D. , PH.D. ( JQ078 ) 10/23/04 @ 02:34 PM
****** END OF DISCHARGE ORDERS ******
Document id: 144
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
- |
Y |
Y |
N |
N |
N |
N |
Y |
N |
471313385 | PUO | 50400589 | | 7842531 | 3/28/2006 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 2/5/2006 Report Status:
Discharge Date: 2/27/2006
****** FINAL DISCHARGE ORDERS ******
NIEVA , MISTY L. 591-06-48-3
Well Fran Ville
Service: CAR
DISCHARGE PATIENT ON: 8/19/06 AT 02:00 PM
CONTINGENT UPON Home services
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REISMAN , CATHIE MINDI , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally every day
COLCHICINE 0.6 MG orally every other day
DIGOXIN 0.125 MG orally every day Starting IN a.m. ( 5/8 )
LASIX ( FUROSEMIDE ) 20 MG orally every day
NORTRIPTYLINE HCL 75 MG orally HS
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every bedtime Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: with assistance with walker , fall precautions
FOLLOW UP APPOINTMENT( S ):
Contact Dr. Silvia Greenfelder for follow-up this week ,
Contact Dr. Cratty for follow-up this week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , PVD , CMP ( EF 12% ) , HTN , IDDM ( not currently on insulin ) , PAF ,
hyperlipidemia , history of osteo ( R mid-foot amputation ) , diverticulitis , Gout ,
BPH , CRI , renal cysts , large inguinal hernia
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
diuresis
BRIEF RESUME OF HOSPITAL COURSE:
CC: DOE
HPI: 81 year-old M with history of CAD history of CABG , ICMP ( EF 10% ) , DM , CRI , PVD , Afib
history of pacer ( NOT AICD as originally thought ) , and HTN transferred from TSH
after 1 week of DOE-->SOB at
rest. Baseline orthopnea/PND. At ASH , treated for volume
overload/bronchitis , BNP 363 , enzymes negative , flu negative history of
levoflox x1. Became hypotensive in setting of diuresis , started on
dopa 5 and transferred to PUO for further management. In ED ,
dopa stopped with stable BPs in the low 100s , HR 110s , mentating and
urinating. Started on ASA/low dose BB for HR control , and continued
on ABX.
************************************************
PMH: CAD history of CABG ( 1998 ) , PVD history of several amputation on right foot ,
ichemic CMP ( EF 10% ) , HTN , DM , PAF history of AICD ( 6/27 ) , hyperlipidemia ,
history of osteo 4th toe , diverticulitis , gout , BPH , history of GIB ,
CRI , history of THR c/b NSTEMI ( 1997 ) , renal cysts , inguinal
hernia ALL:
morphine MEDS: lasix 20qd , aldactone 25 every day , coumadin 2-3
every bedtime , HCTZ 25 every day , zocor 20 every bedtime , flomax 0.4 every day , nortryptiline 75 every bedtime ,
colchicine 0.6 every other day , vitamin C ,
tylenol
***************************************************
PE: 99.3/96.2 105-112 104-111/54-68 95%2L GEN: no distress although
breathing minimally labored
HEENT: PERRL , dry MM CV: irreg irreg , nl S1/S2 , no extra heart sounds ,
2/6 SEM at apex CHEST:
CTAB ABD:
benign EXT: trace pitting edema bilat ,
warm GU: large right scrotal
hernia
************************************************8
LABS: BNP 182 , enzymes negative , INR 4.3-->4.0 , Cr 2.0-->1.8 , Hct
42.0 , U/A clean CXR:
pending EKG: afib with bifacicular block , old
anterior/inferior MI
***************************************************
STUDIES: Echo ( 3/17 ): EF 10% , diffuse HK with regional
variation , LAE/RAE , imcomplete MV clouse with mild/mod MR , trace AI ,
moderate TR , RV difufuse HK without
dilation
*************************************************
A/P: 81 year-old M with MMP and extensive cardiac history p/with acute on
chronic DOE/SOB x1 week
1 ) CV ( P ) EF 10% and currently mildly overloaded. In TH , became
hypotensive to aggressive diuresis , diuresed gently here. BP stable off
pressors , watch with diuresis , added BB for rate control ( Toprol 50
every bedtime ).
( I ) no active ischemia. Added ASA/BB. Cont statin , lipids OK.
( R ) history of afib not well rate controlled on admission. Added BB ( new ) and
added dig load. Interrogated pacer on 2/4 -> rate has around 100.
2 ) PULM: SOB/DOE likely related to volume with possible concomitant
PNA/bronchitis. Cont levoflow while in house - felt was likely
bronchitis and levo was causing INR to increase , so d/c'ed at discharge.
3 ) GI: history of GIB , likely why not on ASA in add'n to coumadin. Watch Hct
with low dose ASA. Stable. Nexium
4 ) GU: large inguinal hernia , nothing to do in this admission - eval by
primary cardiologist previously felt not surgical candidate. Cont
flomax.
5 ) ENDO: history of DM , will start RISS. Checking TSH.
6 ) RENAL: baseline CRI ( unknown baseline creatinine ) but trending down in
house. Followed and remained stable at 1.8-2.0
7 ) RHEUM: gout on colchicine
8 ) HEME: on coumadin for afib , holding as
supratherapeutic. INR 5.5 at discharge , will continue and will have
rechecked in two days ( stopped levo which may have resulted in it
continuing to rise ). Hct stable
9 ) ID: on levoflox for presumed bronchitis. Will f/u c/x results from
TH .
10 ) FEN: cardiac diet , scales
11 ) Ppx: INR >2 , nexium
Lytes at discharge Na 139 , K 4.3 Cr 1.8 BUN 66 , INR 5.5 Hct 44 WBC 12 Plat
301
CODE: DNR/DNI
ADDITIONAL COMMENTS: Take all medications as prescribed. Limit fluid intake to 2 liters
daily , check your weights daily and record them for the VNA ( if your
weight increases by >2 lbs/day or < 5 lbs week , contact your doctor ). If
you develop fever , chills , chest pain , or other worrisome symptoms , seek
medical attention. Do not restart Coumadin at this time. Do not restart
HCTZ. You have two new medications - Toprol XL and Digoxin.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Check INR on Wednesday 3/19/06 - forward results to Dr. Phebe Cratty at
Thasstoncheripigapema Memorial Hospital at 749-139-9399 to adjust Coumadin ( should NOT
restart coumadin , INR 5.5 , until INR rechecked and directed to restart by
Dr. Cratty ). Check basic metabolic panel on Wednesday 3/19/06 - forward
results as wellto Dr. Thake ( have held HCTZ and aldactone ). Check daily
weights ( which patient should record ). Check digoxin level.
No dictated summary
ENTERED BY: MARTER , BRYON M. , M.D. , PH.D. ( VD96 ) 8/19/06 @ 02:01 PM
****** END OF DISCHARGE ORDERS ******
Document id: 145
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
690392773 | PUO | 85884018 | | 0186238 | 10/25/2006 12:00:00 a.m. | troponin + ACS , coronary artery disease , htn | | DIS | Admission Date: 10/10/2006 Report Status:
Discharge Date: 4/5/2006
****** FINAL DISCHARGE ORDERS ******
STRITE , FELIPE 801-55-22-6
Fre
Service: CAR
DISCHARGE PATIENT ON: 8/20/06 AT 02:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRUNTZ , KATHERYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ECASA 325 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
INSULIN NPH HUMAN 62 UNITS subcutaneously every day before noon
INSULIN NPH HUMAN 16 UNITS subcutaneously every afternoon
INSULIN REGULAR HUMAN 10 UNITS subcutaneously twice a day
Instructions: Take with breakfast and dinner
LISINOPRIL 40 MG orally DAILY
Override Notice: Override added on 9/12/06 by NOAKES , MARLEEN D. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
072578678 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 9/12/06 by NOAKES , MARLEEN D. , M.D.
on order for KCL intravenous ( ref # 357675217 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 9/12/06 by MUNGIN , AIDE D. , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 392762111 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 9/12/06 by NAPIERALA , JULIE L. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
396244876 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: on hctz
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
SIMVASTATIN 60 MG orally DAILY Starting Today ( 4/24 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
RETURN TO WORK: IN 1-2 WEEKS
FOLLOW UP APPOINTMENT( S ):
Dr. Douse ( MMC Primary Care ) Friday , October , 12:10PM scheduled ,
Exercise stress test about 2wks , MMC cardiology will call to arrange ,
Dr. Letman ( MMC Cardiology ) about 2wks ( after ETT ) , MMC cardiology will call to arrange ,
ALLERGY: TETRACYCLINE ANALOGUES
ADMIT DIAGNOSIS:
Chest pain , hypertensive urgency , possible ACS
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
troponin + ACS , coronary artery disease , htn
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , Htn , history of prostatitis , history of syphilis , asthma , history of PNA , osteoarthritis
OPERATIONS AND PROCEDURES:
Cardiac cath: 80% occlusion L cx , stent placed; 40% lesion proximal LAD ,
80% lesion mid/apical LAD ( not stented ).
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Echocardiogram: EF 60% no regional motion abn , mild LVH , mild LA
enlargement , mild MR+TR , no sig change from 2002.
BRIEF RESUME OF HOSPITAL COURSE:
CC:Left Lower Chest Pain
HPI: 68 year-old man with history of DM HTN hyperlipidemia , asthma presented to
the ED with L-sided chest/flank pain. patient was in his usual
state of health until he awoke from bed to urinate the day of admission.
Upon standing , he felt dull CP. lasted X 7 hours , non-radiating , located
beneath mid-clavicle. No SOB , no N/V , did experience transient positional
lighthededness upon standing. Pain persisted for several hours before he
called his primary care physician ( MMC ) around 6pm. Was instructed to go to the ED at that
time. At home he self-measured SBP to be 236 systolic ( baseline SBP at home
is 160-180 ). patient admitted that he had not taken BP meds for several days.
Chest pain was reproducible on chest palpation. Initial biomarkers: TnI
0.11 , CK 232 , MB 1.9. In ED started on heparin , lopressor ( 5mg intravenous , 25mg
orally ) , ASA 325. No relief from TNG drops , relief from morphine sulfate.
Cardiac risk factors: DM , +dislipidemia , +family hx heart disease. No tob
use.
********************************
PMH: DM , HTN , hyperlipidemia , Asthma , Knee surgery 9/28/03 ,
Penile implant 3/17 .
***************************
ALL: NKDA
***************************
Pre-admission Medication List for STRITE , FELIPE 85884018 ( PUO ) 68 M
1. Acetylsalicylic Acid ( Aspirin ) orally 81 MG every day
2. Hydrochlorothiazide orally 25 MG every day
3. Insulin Nph Human subcutaneously 62 every day before noon , 16U every afternoon ( BEFORE BREAKFAST AND BEFORE
SUPPER )
4. Insulin Regular Human subcutaneously 10U twice a day BEFORE BREAKFAST AND BEFORE SUPPER
5. Lisinopril orally 40 MG every day
6. Verapamil Hcl orally 60 MG every day
***************************
Afebrile , HR 54 BP 124/70 ,
Gen: in no acute distress , A & O X 3 , HEENT PERRL , EOMI , anicteric , OP
clear , JVP approx 7 cm , Carotids full , no bruits noted
Lungs: CTA bilaterally
CV: RRR S1 S2 split , 2/6 SEM RUSB , +s4 , PMI displaced
Abdomen: benign
Ext no edema , palpable DT/physical therapy pulses.
Chest: L midaxilary pain at 8-9 ribs reproduced upon palpation
****************************
EKG: sinus brady at 58bpm , marked first degree AV block , ? ant septal
MI uncertain duration.
****************************
EVENTS: 5/21 - CEs trending down. Cath today. 3VD.
Cypher stentx1 placed in left cx. 80% mid LCx , 40% mid LAD , total occ
RCA ( small vessel ) , post cath EKG fine , loaded with 600mg plavix. ECHO
today EF 60% , no regional wall abnormalities , mild LVH , mild LA
enlargement , mild MR , mild TR , no significant change since 5/26
ECHO. Will stay for 2 more days due to 25 beat run of VT
overnight. 4/30 - Doing well with 3-4 beats of VT x2. Likely D/C to
home tomorrow. Will need post D/C stress test and cardiac rehab.
Likely start niacin or fenofibrate as outpt due to HDL
29.
**************************
HOSPITAL COURSE: patient is 68 year-old male admitted with troponin+ ACS ,
hypertensive urgency , and chest wall pain reprocducible upon palpation.
Stent placed L circumflex.
1. CV: Ischemia: Despite chest pain reproducible on palpation , patient did
have mildly elevated biomarkers. Started on Heparin , intravenous lopressor+25mg orally
lopressor , given ASA 325. Went for cath 5/21 , found to have 3VD: 100%
occlusion R coronary ( small vessel , L dom heart ); 85% occlusion of L. cx--1x
cypher stent placed , restored to 100% with TIMI3 flow. Also 35% lesion
proximal LAD and 80% occ mid-apical LAD ( not stented ). Loaded with 600mg
plavix. Will need to continue on 75mg plavix for >1yr , continue 325mg ASA.
Started on Zocor at 40 , will increase to 60mg every day at discharge. patient had LDL 77
with low HDL , primary care physician will follow lipid panel , decision to treat with niacin vs
fenofibrate will be deferred to primary care physician who will f/u within 1wk of discharge. patient
will also need f/u ETT to eval any residual ischemic disease and need of
intervention in distal LAD lesion ( this test and f/u cardiology appointment
will be arranged by MMC cardiology for about 2wks after discharge ). patient also
d/c on 25mg Toprol XL and 40mg lisinopril , rx for sublingual nitro given.
Pump: Echo revealed EF 60% , no regional wall motion abnormality , mild LVH ,
mild TR+MR ( unchanged from 2002 ). patient has history of severe htn. CCb d/c'd ,
patient started on lopressor 12.5 twice a day ( d/c'd on 25mg toprol ). Cont HCTZ 25 every day ,
lisinopril 40mg daily. SBP elevated to 160 day of discharge , further
changes in regimen deferred for adjustment by primary care physician who should follow closely.
Given low HR , may consider restart of CCb rather than uptitration or toprol.
Rhythm: patient had 25 beat run of asymptomatic VT in setting of ischemia prior to
cath , no events 24hr prior to d/c ( occ PVC couplets ). On beta-blocker ,
primary care physician should follow lytes after d/c.
2. ENDO: patient with poorly-controlled DM. On NPH twice a day plus Aspart before meals+HS during
hospital stay , will discharge on home regimen of insulin , needs f/u with
primary care physician.
3. Pulm: History of asthma , wheezing during hospital stay improved on
advair. Will continue 500/50mg 1puff twice a day for now , primary care physician should address need
for continued treatment.
4.GI. Started on 20mg nexium given treatment with 325mg ASA , primary care physician should
evaluate if continued treatment needed.
FULL CODE
ADDITIONAL COMMENTS: Please continue your new medications: Plavix , Toprol XL , Zocor , asprin
( 325mg daily ) , nitroglycerin as needed for pain , advair , and nexium.
Continue all your other medications except verapamil , which you should
stop for now. Continue your home regimen of insulin. Your primary care
doctor may adjust these medications at your first visit. You will be
contacted by MMC cardiology to set up a stress test and office visit.
It is very important to keep these appointments , and if you do not hear
from their office please call MMC cardiology. If you have any recurrent
chest pain , try nitroglycerin tabs as directed and notify your doctor. If
you cannot reach your doctor , please go to the ED.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
--F/u with primary care physician , who will address BP management ( may need to restart CCB ) ,
lipids ( need for fenofibrate vs nicacin , adjustment of statin ).
Optimization of insulin regimen. Also , need to re-evaluate asthma
regimen.
--F/u ETT and office visit with MMC cardiology who will address need for
further revascularization of LAD lesions.
No dictated summary
ENTERED BY: WAFULA , KARMA A. , M.D. , PH.D. ( BC90 ) 8/20/06 @ 02:43 PM
****** END OF DISCHARGE ORDERS ******
Document id: 146
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
472510821 | PUO | 58706198 | | 117624 | 6/1/2001 12:00:00 a.m. | RESPIRATORY FAILURE | Signed | DIS | Admission Date: 4/27/2001 Report Status: Signed
Discharge Date: 1/10/2001
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old diabetic
woman with end stage renal disease on
hemodialysis on Monday , Wednesday and Friday who has had several
recent hospitalizations for fluid overload thought to be secondary
to her end stage renal disease , last admitted on September , 2001
for the same during which she had a left internal jugular tunneled
catheter placed for hemodialysis. Since her discharge in August ,
she had been complaining of increasing shortness of breath and on
the Friday prior to admission , she was at her usual dialysis
appointment where she got a transfusion of packed red blood cells
and intravenous iron when she began to feel "warm all over". The
following night , her son noted her to be rigorous and she felt the
presence of fever. She was brought to the emergency room having
received three sublingual nitroglycerin en route for shortness of
breath. Her initial vital signs showed a 90% oxygen saturation on
room air and an axillary temperature of 100 degrees. Her blood
pressure and heart rate were stable at 150/75 and 83 respectively.
In the emergency room , she became increasingly dyspneic with an
arterial blood gas of pH 7.26 , pCO2 of 64 , pO2 of 84 and was
subsequently intubated for respiratory distress. She also received
heparin in the setting of a questionable pulmonary embolus. She
had a few runs of ventricular tachycardia and became bradycardic to
the 50s. Lidocaine 100 mg x 1 was given in the emergency room.
PAST MEDICAL HISTORY: Notable for end stage renal disease on
hemodialysis since September , 2001
secondary to her diabetes , right lower extremity calf deep venous
thrombosis in 1995 , long-standing diabetes mellitus , hypertension ,
external hemorrhoids , congestive heart failure secondary to
diastolic dysfunction , diverticulitis , appendectomy in October of
2001 , left cataract surgery.
ALLERGIES: The patient has allergies to penicillin giving her
edema , aspirin giving her edema , Prazosin , Micronase ,
Dyazide , ACE inhibitors and intravenous contrast.
MEDICATIONS ON ADMISSION: NPH insulin 20 units in the morning , 25
units in the evening , Zocor 80 mg at
night and intravenous iron given at hemodialysis.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission to the Pagham University Of medical intensive care
unit , initial physical examination showed a temperature of 105 ,
heart rate 90 , blood pressure 90/50 , respiratory rate 12 on a
mechanical ventilator , oxygen saturation 100%. GENERAL: The
patient was intubated , sedated. HEENT: Normocephalic , atraumatic.
Pupils were equal , round , reactive to light and accommodating.
NECK: Supple , no thyroid nodules noted. CHEST: She had right
greater than left crackles a quarter of the way up the lung fields.
HEART: Regular rate , normal S1 and S2 , no S3 or S4 appreciated.
No rub or gallop. ABDOMEN: Soft , non-tender , non-distended with
hypoactive bowel sounds , but no hepatosplenomegaly. EXTREMITIES:
Trace edema. NEUROLOGICAL: She was sedated and on a ventilator ,
but was responsive to repositioning and touch.
LABORATORY: Her admission laboratory values included a sodium of
140 , potassium 4.7 , chloride 100 , bicarbonate 28 , BUN
31 , creatinine 5.0 , glucose 193. White blood cell count was 13 ,
hematocrit 36 , platelet count 387. Differential showed 77 polys , 4
bands , 15 lymphocytes. INR was 1.0. CK was 56. Troponin I was
0.04. Urinalysis showed 3+ protein , 1+ glucose , 5-7 white blood
cells , 3-5 red blood cells. Admission EKG was normal sinus rhythm ,
flat T-waves in V5 and V6. Chest x-ray was notable for bilateral
infiltrates consistent with pulmonary edema.
HOSPITAL COURSE: The patient is a 68-year-old chinese speaking
woman with end stage renal disease from insulin
dependent diabetes on hemodialysis on Monday , Wednesday and Friday ,
hypertension , coronary artery disease and congestive heart failure
with a history of deep venous thrombosis in 1995 , notably had
several recent admissions for fluid overload and a recent placement
of a tunneled internal jugular catheter for hemodialysis. She was
admitted with fever , chills and shortness of breath on July ,
2001 requiring intubation for three days , pressor support ,
Neo-Synephrine and dopamine for two days , but was then successfully
extubated and weaned off the pressors for management outside the
intensive care unit. Her course in the medical intensive care unit
was complicated by rule in non-Q wave myocardial infarction thought
to be secondary to sepsis and hypotensive state. Her troponins
maxed in the 6-7 range , but this episode resolved without
significant EKG changes. She was titrated up on a beta blocker and
given Plavix in place of aspirin as she has an allergy to aspirin.
She was also continued on her statin. The patient would likely
benefit from further outpatient work-up of her cardiac status once
her rehabilitative course is complete , i.e. imaging and stress.
Her last catheterization was four years ago showing three vessel
stenoses of about 40-50%. She is currently getting hemodialysis
now through her arteriovenous fistula and getting dosed with
vancomycin at hemodialysis for the next four to six weeks. She had
serially positive blood cultures for methicillin-resistant
Staphylococcus aureus. The last was on February , but had
negative transthoracic echocardiogram and transesophageal
echocardiogram ( i.e. no vegetations ). She received gentamicin
briefly in addition to the vancomycin until two consecutive
surveillance cultures were negative and is now off the gentamicin.
She was noted to have a loud neck murmur and had both venous and
arterial ultrasounds which were negative for septic clot or
significant stenosis respectively. Otherwise , her post medical
intensive care unit course was uncomplicated and we restarted her
insulin regimen as her appetite increased. The patient is due for
hemodialysis on tomorrow , Wednesday , March , 2001. She needs
follow up with her primary care physician for further cardiac
evaluation , titration of her diabetes medications and follow up of
her lipids , diabetes and hypertension. Of note , the patient has
refused to give the name of her primary care physician and does not
want to return to her care. She states to the interpreter that she
would like a new primary care physician.
PLAN: 1 ) Dialysis tomorrow on Wednesday , March , 2001. 2 )
Aggressive rehabilitation for her strengthening. 3 )
Titration of diabetes medications and general healthcare
maintenance follow up.
MEDICATIONS ON DISCHARGE: Tylenol 650 mg orally every 4-6h. for
temperature greater than 101 , PhosLo 667
mg orally three times a day , Colace 100 mg orally twice a day , enema or laxative of
choice one per day as needed bowel movement , NPH insulin 15 units
subcutaneously twice a day which is two-thirds of her home dose , needs
titrating up , regular insulin sliding scale , Simvastatin 80 mg
every bedtime , Toprol XL 50 mg every day , Nephro-vite capsule one every day ,
miconazole 2% powder topically twice a day , Plavix 75 mg orally every day ,
Nexium 20 mg orally every day.
Dictated By: PAOLA ODEA , VO54
Attending: COLIN E. NAJI , M.D. LL65 UF789/850205
Batch: 9813 Index No. AUKIIT8LE8 D: 10/30/01
T: 10/30/01
Document id: 147
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
782417239 | PUO | 63069288 | | 7277768 | 2/5/2003 12:00:00 a.m. | supraspinatus tendonitis | | DIS | Admission Date: 6/11/2003 Report Status:
Discharge Date: 4/17/2003
****** DISCHARGE ORDERS ******
FRINGER , BLYTHE J 894-95-81-5
Ebende Ster
Service: MED
DISCHARGE PATIENT ON: 3/25/03 AT 12:00 M
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DICKHAUT , SIOBHAN CARY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 3/25/03 by
KORAN , ALYSIA TWANDA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: will follow
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
LOPRESSOR ( METOPROLOL TARTRATE ) 100 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 3/25/03 by
KORAN , ALYSIA TWANDA , M.D.
on order for ECASA orally ( ref # 53824105 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: will follow
VICODIN ( HYDROCODONE 5 MG + APAP ) 2 TAB orally every day before noon
Alert overridden: Override added on 3/25/03 by
KORAN , ALYSIA TWANDA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
PHENANTHRENES Reason for override:
patient takes this as an outpatient
VICODIN ( HYDROCODONE 5 MG + APAP ) 1 TAB orally every afternoon
Alert overridden: Override added on 3/25/03 by
KORAN , ALYSIA TWANDA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
PHENANTHRENES Reason for override: patient takes
K-DUR ( KCL SLOW RELEASE ) 20 MEQ X 1 orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
COZAAR ( LOSARTAN ) 50 MG orally every day
Number of Doses Required ( approximate ): 2
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
INDOCIN ( INDOMETHACIN ) 25 MG orally twice a day
Instructions: please take twice a day ( as directed by Dr.
Seguin ) until your follow-up appointment on Friday
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 3/25/03 by :
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
INDOMETHACIN Reason for override: monitoring
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Seguin , Friday , 6/3/03 , 11:15 am ,
Arrange INR to be drawn on 1/19/03 with f/u INR's to be drawn every
30 days. INR's will be followed by KTDUOO coumadin clinic
ALLERGY: pentothal , Codeine , Iv contrast dyes , Methyldopa ,
Amitriptyline hcl
ADMIT DIAGNOSIS:
shoulder pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
supraspinatus tendonitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN OBESITY
UTI , ON BACTRIM arthritis ( arthritis ) history of bil TKR ( history of total knee
replacement ) CHF? ( congestive heart failure )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
76 year old woman with CHF , moderate MR , PAF , HTN , and obesity who
presented with left upper arm pain since 3 pm the day of admission.
Denies any SOB , CP , N/V , diaphroresis. Took 5 baby aspirin at
home without relief of pain. Pain came on at rest. No history of
recent trauma. In ED , MSO4 relieved most of pain. Pain was noted to be
positional , increasing when arm is stretched down. Reports
increasing SOB over last several months , increased leg edema with 10
lb weight gain. No orthopnea or PND. PE: HR 58-61 , BP 141/81 98% RA.
PE: tenderness to palpation over L deltoid with pain with resistance to
abduction ( +supraspinatus involvement ). Full ROM in bilateral
shoulders. Chest: CTA bil. Neck: JVP 7 cm. ECG: 1st degree AVB , no
ischemic changes. CXR: no acute cardiopulmonary changes. Initial
enzymes flat. BNP 120
Hospital course.
The shoulder pain was felt to be secondary to supraspinatus
tendonitis/strain. The patient was advised to take a short course of
ibuprofen and was given shoulder exercises to do by physical therapy.
In addition , patient reports increased leg edema , SOB , and weight
gain. She ruled out for MI by enzymes and ECGs. By exam , much of the
changes in her legs appeared chronic. She did not appear to be in
respiratory CHF by exam or BNP. She does admit to dietary
indiscretions over the past few weeks. She was kept on her current
medications doses , including lasix 80 mg twice a day and instructed to keep a
daily weight log. A follow-up appointment was made for her with Dr.
Seguin on 6/3/03 .
ADDITIONAL COMMENTS: 1. Daily weights each am. Please record to show Dr. Seguin .
2. Low salt , fluid-restricted diet
3. Ibuprofen 400 mg three to four times per day until you see Dr.
Seguin for shoulder pain. Please take with food.
4. Shoulder exercises as demonstrated by physical therapy.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
( 1 ) Home physical therapy for cardiopulmonary rehabilitation.
No dictated summary
ENTERED BY: CARRATURA , LOREEN CARLY , M.D. , PH.D. ( CY41 ) 3/25/03 @ 01:30 PM
****** END OF DISCHARGE ORDERS ******
Document id: 148
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
Y |
N |
- |
N |
N |
N |
520818635 | PUO | 29536388 | | 3522838 | 1/27/2004 12:00:00 a.m. | chest pain , coronary artery disease | | DIS | Admission Date: 11/4/2004 Report Status:
Discharge Date: 4/25/2004
****** DISCHARGE ORDERS ******
BICKNESE , LAYNE 892-84-30-7
Dio Sen A
Service: CAR
DISCHARGE PATIENT ON: 9/9/04 AT 07:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRUNTZ , KATHERYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VENTOLIN NEBULIZER ( ALBUTEROL NEBULIZER ) 2.5 MG NEB every 4 hours
as needed Shortness of Breath
ATENOLOL 12.5 MG orally every day Starting IN a.m. ( 8/25 )
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
60 UNITS every day before noon; 70 UNITS every afternoon subcutaneously 60 UNITS every day before noon 70 UNITS every afternoon
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 9/9/04 by
LOBBINS , LUCY , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOVENT ( FLUTICASONE PROPIONATE ) 44 MCG inhaled twice a day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Gruntz within 4-6 weeks , please call 047.691.2876 4-6 weeks ,
Dr. Ma Yeagley , MMC , 617.418.2600 , please see Dr. Schones within the week within 1 week ,
ALLERGY: Aspirin , Sulfa
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain , coronary artery disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ASTHMA/COPD FEV1 .97 , FEV1/FVC .46 INSULIN REQ TYPE II
DM SEASONAL RHINITIS DIVERTICULOSIS NEPHROLITHIASIS history of INTUBATION 6/26
OPERATIONS AND PROCEDURES:
Cardiac catheterization ( 7/25/04 ): LAD prox 40% , no LCX lesions , No RCA
lesions , R PDA mid 30% lesion. Conclusion: non-obstructive CAD ,
normal L heart filling pressures.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Bicknese is a 59 year-old man with poorly controlled diabetes , asthma
who presented with chest pain. Over the past few weeks he has had
intermittent chest pain with activity , lasting 5 minutes , relieved
with rest. He also has shortness of breath when he
climbs stairs , but he said that this is more from
his asthma. He presented to his primary care physician because of
a finger injury , and then told him about the
chest pain. patient was sent to the ED. He has
been chest pain free since the day before admission.
His finger sticks at home have been in the 200-300 range.
HOSPITAL COURSE:
1. CV - ischemia: Mr. Bicknese had a cardiac catheterization on the mor
ning of 10/06 . He has had 3 sets of negative enzymes ( elevated CKMB but
negative troponins ). EKG significant only for j point elevation
diffusely.
-beta blocker was started
-cholesterol was checked ( elevated triglycerides 308 , total cholesterol
146 , HDL 29 ). Baseline LFTs checked.
-statin was started
-aspirin was held because of the patient's stated allergy to aspirin
( causes asthma type symptoms )
-will start patient on low-dose lisinopril
PUMP: no prior echo , consider as outpatient. appears
euvolemic.
rhythm: no active issues.
2. ENDO - on insulin at home but rarely checks his sugars. when he
does it's usually 200-300s. Hemoglobin A1c is 10.7.
Patient was continued on home regimen of NPH insulin but clearly needs
better control of his sugars as outpatient.
3. PULM:
patient says he has had asthma as a child. no record of PFTs but should
obtain as outpatient. Home inhalers continued
4. RENAL: Mr. Bicknese currently has good renal function but needs to
have his Cr checked after starting the lisinopril.
ADDITIONAL COMMENTS: You must have your kidney function checked within 1 week , please make
an appointment with your primary care doctor. Please take your
medications as instructed. Please follow up with Dr. Gruntz , your
cardiologist within 4-6 weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please consider carefully your lifestyle , including your diet and
exercise plans. Although you did not have blockages in your heart
vessels requiring stenting , you have started to have blockages , so the
best thing you can do is to slow this process down. This includes
losing weight through diet and exercise , taking medications including
statin , beta blocker ( atenolol ) and ACE inhibitor ( lisinopril ).
No dictated summary
ENTERED BY: LOBBINS , LUCY , M.D. ( JU4 ) 9/9/04 @ 06:39 PM
****** END OF DISCHARGE ORDERS ******
Document id: 149
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
094282885 | PUO | 73788778 | | 5417638 | 5/26/2005 12:00:00 a.m. | CHRONIC HEART FAILURE | Unsigned | DIS | Admission Date: 5/26/2005 Report Status: Unsigned
Discharge Date: 12/10/2005
ATTENDING: GORGLIONE , JEANNETTE MD
PRIMARY DIAGNOSIS DURING THIS ADMISSION:
Decompensated heart failure.
SECONDARY DIAGNOSES:
1. Non-ST elevation MI.
2. Acute on chronic renal failure.
3. Diabetes mellitus.
HISTORY OF PRESENT ILLNESS:
This is a 61-year-old female with ischemic cardiomyopathy and
chronic renal insufficiency who presented with volume overload.
The patient has a longstanding cardiovascular history: Status
post inferior MI in 1988 , CABG in 1999 with SVG to LAD , OM1 and
PDA , with subsequent PCI of SG to PDA in 1/13 in the setting of
a non-ST elevation MI that evolved into an ST elevation MI. The
patient was readmitted on 10/29/05 with decompensated congestive
heart failure. Since that time , the patient has required
increasing Lasix doses with worsening dyspnea on exertion ,
shortness of breath , a 30-pound increase in weight , worsening
three-pillow orthopnea , and increased lower extremity edema with
weeping sores. The patient presented to Lostedin Nassjoh Valley Hospital
ED on 3/5/05 with blood pressure 196/97 , JVP to 16 cm ,
bilateral crackles , and right greater than left pleural effusion
on chest x-ray. BNP at the time of admission was 22 , 143 ( up from
19 , 189 on 7/13/05 ). The patient was transferred to the CCU for
nitro drip and Lasix drip. She was diuresed with a net output 2
liters on 3/5/05 . The patient was then transferred to the
floor on a Lasix drip at 20 mg/hour plus Diuril 500 mg intravenous as
needed. Her nitroglycerin drip had been stopped on 1/14/05 in
the morning.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Inferior MI in 1988 , CABG in 1999 ,
and ST elevation MI in 1/13 , ( see HPI for details ).
2. Hypertension.
3. Diabetes greater than 20 years.
4. Hyperlipidemia.
5. Chronic renal insufficiency ( baseline creatinine 1.4 to 2.4 ) ,
likely secondary to hypertension and diabetes , but concerned for
renal artery stenosis based on the history.
6. CVA in 1991 - cerebellar.
7. Status post a right CEA in 1981 , and left CEA , that is a
carotid endarterectomy , in 1999.
8. Peripheral vascular disease , status post aortofemoral bypass
in 1999.
MEDICATIONS AT HOME:
Toprol 200 mg daily , Isordil 10 mg three times a day , hydralazine 25 mg
three times a day , Lipitor 80 mg daily , aspirin 325 mg daily , Plavix 75 mg
daily , Lasix 160 mg twice a day , Zantac 150 mg twice a day , PhosLo three times a day ,
and Lantus.
ALLERGIES:
ARBs cause hives.
SOCIAL HISTORY:
A 135-pack-year tobacco history. No alcohol or illicits. The
patient lives alone.
FAMILY HISTORY:
Coronary artery disease ( mother in her 50's ).
IMAGING:
Chest x-ray on 3/5/05 showed a moderate right pleural effusion ,
cephalization and pulmonary edema. EKG showed Q waves in 2 , 3
and aVF with T-wave inversions ( old findings , no acute changes ).
Echo ( 9/19 ): EF 35% ( down from 55% in 5/24 ) , mild concentric
LVH , diffuse global hypokinesis with new akinesis of the
septal-inferior walls.
HOSPITAL COURSE:
1. Cardiovascular:
a. Pump - persistent volume overload , minimal response to
diuresis with 20 mg/hour Lasix drip. Attempted diuresis with
Diuril , Lasix intravenous , and finally nesiritide. Nesiritide
discontinued on 7/11/05 . Torsemide was started on 7/11/05 with
improved diuresis. The patient has consistently refused
dialysis. Blood pressure was controlled during this
hospitalization with hydralazine , Isordil , and Lopressor. All
medications were stopped on 6/12/05 . Ejection fraction 35%.
b. Ischemia - enzymes peaked on 4/13/05 with a CK of 152 , an MB
of 39.6 , and a troponin of 21.44. EKG at this time showed ST
depressions in V4 through V6. The recommendation of the
Cardiology team was that the patient undergo cardiac
catheterization. The patient refused any intervention with
cardiac catheterization due to concerns of further damage to her
kidneys. A decision was made to medically manage the patient.
She was briefly on heparin while this decision was concluded , and
heparin was stopped on 7/6/05 with enzymes trending down , and
no evidence of active ischemia.
c. Rhythm - the patient had bursts of normal sinus ventricular
tachycardia on telemetry. She was maintained on a low-dose
beta-blocker until 7/11/05 . She has been in a normal sinus
rhythm from 4/13/05 through 6/12/05 .
2. Pulmonary: The patient has an oxygen requirement of 2 liters
secondary to a right pleural effusion and congestive heart
failure. The patient's intravenous diuretics were stopped on 6/12/05 in
consideration of changing goals of care. If the patient becomes
short of breath in the absence of diuretics , we would recommend
morphine elixir 10 mg every 2 hours as needed for shortness of breath.
3. Renal: The patient's chronic renal insufficiency was likely
secondary to hypertension and diabetes. MRA on 4/13/05 to
evaluate for renal artery stenosis showed right renal artery
stenosis. The patient's creatinine increased to 4 on 7/11/05 ,
likely secondary to diuresis. Ultrasound was refused. The Renal
consult team was following , but the patient refused any dialysis.
4. Endo: The patient's diabetes was controlled with Lantus
insulin and an aspart insulin sliding scale. There was concern
for hypoglycemia on 6/12/05 in the setting with no orally intake.
All of the patient's diabetic medications have been stopped at
this time.
5. Psychiatry: The Psychiatry consult team was consulted for
major depressive disorder. There was concern for delirium.
Celexa was started for depression. Seroquel was tried as needed for
insomnia and delirium , but it was stopped due to change in mental
status. The patient was able to make her own medical decisions
at the time of refusing cardiac catheterization. She understood
the risk of refusing cardiac catheterization. We will continue
no psychiatric medications at the time of discharge. May
consider Haldol for concern regarding worsening delirium.
6. The patient is currently DNR/DNI , comfort measures only. She
is being transferred to inpatient hospice at Silvtonla Health .
MEDICATIONS AT THE TIME OF DISCHARGE:
Include morphine elixir 10 mg orally every 2 hours as needed for shortness
of breath.
CONDITION AT THE TIME OF DISCHARGE:
Poor.
eScription document: 6-4844758 EMSSten Tel
Dictated By: MANKOSKI , ROSSIE
Attending: GORGLIONE , JEANNETTE
Dictation ID 7863975
D: 6/12/05
T: 6/12/05
Document id: 150
| Target |
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Dp |
DM |
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GER |
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873524333 | PUO | 65864379 | | 835483 | 8/15/2001 12:00:00 a.m. | STENOSIS LEFT BYPASS GRAFT | Signed | DIS | Admission Date: 8/15/2001 Report Status: Signed
Discharge Date: 1/17/2002
HISTORY OF PRESENT ILLNESS: This is a 63 year-old male with a
history of peripheral vascular
disease , hypertension , non-insulin dependent diabetes mellitus ,
coronary artery disease , aortic stenosis , and status post bilateral
lower extremity bypass grafts who presented to the hospital with
increasing left lower extremity pain. He was taken to angiography
at which time tPA infusion was commenced. He is most recently
status post a left femoral to peroneal bypass graft in July of
2001 and has noticed that , in the past two to three weeks , has been
developing increasing rest pain and coolness to the left foot to
the point where he was not able to ambulate. In angiography , he
was found to have an occlusion of the left lower extremity vein
graft in the area of the mid-thigh with no passage of contrast and
minimal reconstitution of collaterals to his foot.
PAST MEDICAL HISTORY: Peripheral vascular disease. Myocardial
infarction. Hypertension. Non-insulin
dependent diabetes mellitus. Aortic stenosis. He is status post a
left femoral to peroneal bypass graft in July of 2001. A revision
with cephalic vein to dorsalis pedis in July of 2001. He is
status post a right femoral to peroneal in September of 2000 and a right
fourth toe amputation in September of 2000.
MEDICATIONS: Glipizide 5 mg twice a day , Hydrochlorothiazide 50 mg
every day , Lisinopril 20 mg every day , Simvastatin 20 mg every day ,
Amlodipine 5 mg every day , Imdur 30 mg every day , and Toprol 100 mg every day and
enteric coated aspirin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient first underwent angiography at which
time they found that the vein graft was occluded.
He underwent tPA treatment and was brought back to angiography.
This time they did not find necessarily any improvement. The
conduit actually opened but it was found that he does have a high
grade anastomotic stricture of the distal anastomosis. He was
taken to the operating room on 10/23/01 for a left lower extremity
thrombectomy via groin and foot cutdown. Status post that
procedure he developed symptoms of acute chest pain and
hypotension. An ECG was performed , as well as troponin drawn ,
revealing that he has an acute myocardial infarction. The
cardiology service was called and the patient was admitted
post-thrombectomy to the cardiac care unit. At that time he was
managed medically for a few days. Based on his severe aortic
stenosis and difficulty in managing his blood pressure , the cardiac
surgery service was consulted. He was scheduled to see cardiac
surgery in office setting but , given his current condition , we were
going to perform his surgery a little bit sooner. He did have a
bout of pneumonia which mildly delayed his surgery.
On 1/18/02 he underwent catheterization which revealed a right
dominant system , a discreet 40% lesion in the proximal left main , a
discreet 30% lesion in the proximal left anterior descending
artery , 100% lesion in the first marginal branch of the left
circumflex artery , as well as 100% lesion in the second marginal
branch of the left circumflex artery. He has a discreet 80% lesion
in the proximal right coronary artery , as well as evidence of
severe aortic stenosis. During catheterization this revealed an RA
pressure of 10 , a pulmonary artery pressure of 49/20 , with wedge of
31. He had a thick cardiac output of 4.77 and cardiac index of
2.1.
Based on the findings of these catheterization results , the patient
was taken to the operating room on 2/13/02 with Dr. Colasamte and Dr.
Narvaez for an aortic valve replacement with a #23
Carpentier-Edwards pericardial valve and mitral valvuloplasty with
an Alfieri suture repair , as well as coronary artery bypass graft
times three with left internal mammary artery to the left anterior
descending artery , left radial to obtuse marginal one , and left
radial to posterior descending artery. Postoperatively he
underwent our routine care and went to the Cardiac Surgical
Intensive Care Unit where he generally did well.
He remained on his aspirin and Lopressor , as well as Coumadin. He
was mildly tachycardic and his Lopressor dose was adjusted.
Because of his diabetes mellitus , he was placed on the Portland
protocol and remained on a full ten-day course of Flagyl and
Cefotaxime for his preoperative pneumonia. On postoperative day #1
he was transferred to the floor where he did well and was able to
ambulate at least to a chair and was deemed that he probably is not
a candidate to go home immediately but a candidate for
rehabilitation. He has been taken off his Portland protocol and
his staples have been discontinued.
On his pre-discharge examination he is stable with clean incisions ,
as well as stable sternum. He is now currently on room air and
will be discharged to rehabilitation.
DISPOSITION: DISCHARGE MEDICATIONS: Coumadin 4 mg orally every bedtime to
maintain INR between 2 and 3 , aspirin , Diltiazem 30
mg three times a day , Simvastatin 20 mg every day , Colace 100 mg three times a day , Nexium 20
mg every day , Niferex-150 twice a day , Glipizide 5 mg twice a day , Lasix 40 mg
twice a day , and Lopressor 50 mg twice a day with CZI sliding scale.
Dictated By: HAYWOOD SASNETT , M.D. HF08
Attending: ISABELLE E. COLASAMTE , M.D. MB7 NQ705/054047
Batch: 3283 Index No. XWBMCCNW68 D: 10/11/02
T: 10/11/02
CC: 1. NATHAN J. ABSON , M.D. YL03
2. A TRIADED HEALTH CARDIOLOGY CLINIC
Document id: 151
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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431408937 | PUO | 16880402 | | 8494629 | 11/20/2005 12:00:00 a.m. | NEW LEFT BUNDLE BRANCH BLOCK | Signed | DIS | Admission Date: 11/20/2005 Report Status: Signed
Discharge Date: 8/12/2005
ATTENDING: TIBOLLA , MADISON M.D.
DATE OF BIRTH: 3/23/1927 .
ADMISSION DIAGNOSIS: Hypovolemia and fatigue.
ASSOCIATED DIAGNOSES: Coronary artery disease , hypertension ,
hyperlipidemia , peptic ulcer disease , severe anxiety ,
cardiomyopathy with ejection fraction between 15% and 20% , and 2+
mitral regurgitation.
CHIEF COMPLAINT: Weakness.
HISTORY OF PRESENT ILLNESS: This is a 78-year-old male with a
history of coronary artery disease status post silent MI and
cardiomyopathy with an ejection fraction between 15% and 20% , who
has a longstanding history of severe anxiety and presented with
fatigue and shortness of breath. On the day of admission , the
patient took an extra dose of Lasix because he thought that he
might be fluid overloade. In the emergency room , it was thought
that he appeared dry and he was admitted for volume
resuscitation.
PAST MEDICAL HISTORY: Coronary artery disease , silent MI in
1998 , hypertension , hyperlipidemia , peptic ulcer disease with GI
bleed , severe anxiety , cardiomyopathy with ejection fraction
previously reported at 20% in October 2005 , 2+ mitral
regurgitation , 1+ tricuspid regurgitation.
MEDICATIONS ON ADMISSION: Lasix 20 mg to 40 mg daily , aspirin
325 daily , Lipitor 5 mg daily , Toprol XL 25 daily , Valium 5 mg
three times a day as needed , Accupril 5 mg daily and Aleve as needed
ALLERGIES: Sulfa causes rash and ciprofloxacin causes
hallucinations.
SOCIAL HISTORY: The patient is an Irish descendent. He lives
alone with many cats. Drinks occasional ethanol , no tobacco or
illicit drugs. He is retired.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM ON ADMISSION: Temperature 95.6 , heart rate 112 ,
blood pressure 153/90 with orthostasis , respiratory rate 18 , 97%
oxygen on room air. General: No acute distress , alert. Pupils
are equal , round and reactive to light and accommodation
bilaterally. Extraocular motor intact. His oropharynx is clear.
Dry mucous membranes. Neck: Supple , JVP flat. Lungs: Clear
to auscultation bilaterally. Heart: Tachycardic with occasional
premature heartbeats. No murmurs , rubs , or gallops. Abdomen:
Nondistended , soft and nontender. Positive bowel sounds.
Extremities: No edema , clubbing , or cyanosis. Neuro: The
patient was oriented. Cranial nerves III through XII intact.
Strength is 5/5 throughout. The sensation was intact throughout.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: Upon admission , the patient appeared dry and
was resuscitated with one liter of intravenous fluids. The patient's
Lasix was held initially on admission. On hospital day #2 , he
was looking well. His weight was 151 pounds which was suspected
to be close to his dry weight which was reportedly 149 pounds.
By 8/18/05 , he was restarted on 20 mg of Lasix daily so that he would stay
euvolemic. He received intermittent intravenous Lasix ( 20mg ) throughout the remainder
of his hospitalization and his orally Lasix dose was settled on 40 mg orally
daily. His captopril was restarted on the 9/19/05 at 6.25 mg three times a day He
tolerated that dose and was switched to Accupril 2.5 mg twice a day He underwent an
echocardiogram on 11/9/05 which demonstrated possible vegetation
on the tricuspid valve verus a flail leaflet. This question of a
vegetation raised concern for possible endocarditis and blood
culture were sent. The patient's temperature had been low on
admission , since there was some concern that he could be
developing sepsis , however nothing grew from the blood cultures
throughout the remainder of his hospitalization. He was seen by
Cardiology , who did not think that this echo result required
further intervention and suspected that it represented a flail
tricuspid valve leaflet. The patient's troponin
One troponin level was elevated at 0.11 initially and then
another troponin was elevated on 10/27/05 in the setting ARF and
acute hepatitis. He recently had a negative stress echo at the
Greene Lidonimill Medical Center , so no additional stress testing
was pursued during this admission. He was switched to Lopressor
25 three times a day and then switched back to Toprol XL. His statin was
discontinued during the admission because of LFT abnormalities
which will be discussed below. He was monitored on telemetry
which demonstrated frequent PVCs and some NSVT. This
should be readdressed in Cardiology Clinic. Cardiology decided to hold off on
placing an AICD and was to see him as an outpt.
2. GI/renal: On the morning of 10/27/05 , the patient developed new confusion
and delirium. He also developed an oxygen
requirement the night before. His labs on morning were notable
for a transaminitis in the thousands , acute renal failure with
hyperkalemia and acidemia with bicarbonate of 13 , and a new leukocytosis ( WBC 9
to 25 ). He was started on broad spectrum antibiotics including coverage for
bartonella as he had many cats. He was empirically started on mucomyst and
acyclovir as per GI in case his LFT abnormalities were due to tylenol
toxicity or HSV. He was initially going to get a liver biopsy but this was
cancelled as his LFTs started to normalize. He had a RUQ with dopplers which
was negative. The etiology of his hepatitis , renal failure and leukocytosis was
never identified throughout the admission. Cardiology did not think that any
of this could be explained by endocarditis and his antibiotics were stopped
once his cultures were negative for multiple days. GI though he could of had
shock liver but he was on telemetry the entire time. His tylenol level was
normal and his hep seriologies were negative. His labs had all normalized by
admission except for his LFTs which were still trending downward.
3. Infectious disease: Due to low temperature and question of
vegetation , there was consideration for endocarditis and sepsis
although that never panned out. He has a history of feeding
stray cats and so bartonella cultures were sent. They take a
long time to come back and should be followed up as outpatient. He had been
placed on antibiotics while awaiting cultures but those were discontinued on
the 8/18/05 as the microbiology data remains negative. He had a CT scan of his
chest and abdomen which did not reveal any infectious source. He had ground
glass opacities on his CT chest which were felt to be due to CHF when reviewed
with the radiologist. He remained afebrile during the admission.
4. Psych: Early on during the patient's admission , he did have
several episodes of tachypnea at rest. They were not positional in nature
and resolved with verbal consolation and redirection and
deep breath. No associated desaturation at that time. The
patient has a history of anxiety and reported that that prompted
him to increase his Lasix dose at home. He refused psychiatric
consultation or social work involvement. His Valium had
initially been initiated but it was held in the setting of
abnormal LFTs. He had no further anxiety attacks after that. It
is likely that he has mild baseline dementia. His delirium
resolved after the acute renal failure and transaminitis resolved.
5. Musculoskeletal: The patient had a little bit of difficulty
ambulating and was seen by Physical Therapy who did think that
further physical therapy would be appropriate. The patient
refused to go to rehabilitation facility , so he was planning to
go home with services including physical therapy at home.
6. Hematology: The patient was set to go home and then it was
noted that his platelets had taken a slow and steady decline
throughout his hospitalization while he was on heparin/Lovenox. There
was concern that this could represent heparin induced
thrombocytopenia and so all heparin products were stopped. He was placed
lepirudin which was chosen instead of Argatroban because
Argatroban was cleared by liver in light of his hepatitis.
His initial PF4 was read as bordeline positive , but the laber later
changed the result to negative. Based on this discrepancy another PF4 was
sent which was borderline positive. As per the hematology consult , they felt
that despite the borderline positive PF4 he did not need prophylactic
anticoagulation and that he should refrain from heparin products in the
future until a repeat PF4 in checked in a few months.
DISCHARGE MEDICATIONS: Aspirin 325 mg daily , Lasix 40 mg daily ,
Toprol XL 25 mg daily , Accupril 5 mg daily , omeprazole 20 mg
daily.
DIET: Low sodium.
ACTIVITY: As tolerated with supervision and advised by the
physical therapist.
FOLLOWUP APPOINTMENTS: Dr. Ramil is the patient's new primary care physician at
the KTDUOO clinic at the Pagham University Of , he has an
appointment for 3/23/05 at 9:45 a.m. and an appointment with Dr.
Catania was made from Cardiology 10/21/05 at 2:45 p.m.
ADDITIONAL INSTRUCTIONS: Do not take Valium or Lipitor until you
are cleared by your doctor to do so due to liver function. Weigh
yourself daily and keep a record and bring that to follow up
appointment. If you develop light headedness , shortness of
breath , chest pain or any other symptoms you are concerned about ,
call your doctor or return to the Pagham University Of emergency room for evaluation.
LABORATORY DATA ON DISCHARGE: Glucose 90 , BUN 18 , creatinine
1.2 , sodium 138 , potassium 4.4 , chloride 103 , CO2 28 , ALT 159 ,
AST 54 , alkaline phosphatase 118 , bilirubin total 1.5 , albumin
3.3 , calcium 9.2 , magnesium 1.9 , white blood cell count 7.79 ,
hemoglobin 14.3 , hematocrit 44 , platelet 199 , INR 1.3 , PTT 42.2 ,
PF4 pending. Arterial blood gasses on the 7/9/05 showed pH of
7.47 , PO2 89 , SO2 98 , PCO2 26 , PCO2 20 , hematocrit 41 , hemoglobin
13.9 , and lipase 78. CK MV on the 11/9/05 of 6.0 , CK was 165.
B12 1704 , folate 14.2 , HDL 24. GB-IgG negative. TSH 2.188.
Troponin on 6/13/05 of 0.45 , troponin 6/13/05 of 0.13 , troponin
on 10/27/05 of 0.33 , troponin on 11/9/05 less than assay ,
troponin on 11/9/05 in the morning 0.11 , troponin on 9/29/05
less than assay. He also had an elevated white blood cell count
during the transaminitis and renal failure up to 28. Final blood
culture , no growth from anaerobic medium. Urine culture , no
growth. HCV viral load of less than 615.
RADIOLOGIC DATA: Ultrasound of the abdomen showed no evidence of
portal vein thrombosis. Portable chest x-ray on 10/27/05 showed
the lung volumes considerably decreased from the previous exam on
9/29/05 . There is hazy opacity in the lower lung sounds
particularly on the right suggesting mild edema. There also
appears to be small right effusion , mild cardiomegaly is again
noted. On 10/27/05 , CAT scan of the abdomen showed no apparent
source of infection , no collection or abscess , limited study
secondary to lack of intravenous contrast , mild ascites , bilateral pleural
effusions right greater than left with subsegmental atelectasis ,
presacral edema and cardiomegaly with left coronary artery
calcification. CAT scan of the chest on 10/27/05 showed
bilateral small pleural effusion , evidence of pulmonary edema and
small volume ascites associated with cardiomegaly , nodular ground
glass opacities at the right base may be due to atelectasis but
somewhat discrete , cannot exclude septic emboli but would be very
localized. A head CT on 9/29/05 showed no acute intracranial
abnormality.
eScription document: 1-4454280 ISSten Tel
Dictated By: RUKA , BERNA
Attending: TIBOLLA , MADISON
Dictation ID 1427058
D: 1/20/05
T: 1/20/05
Document id: 152
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
Y |
N |
- |
- |
N |
N |
N |
N |
N |
N |
633696044 | PUO | 90264324 | | 1235082 | 3/17/2005 12:00:00 a.m. | AORTIC STENSOSIS | Signed | DIS | Admission Date: 2/15/2005 Report Status: Signed
Discharge Date: 4/18/2005
ATTENDING: GOLEBIOWSKI , LOIDA MD
ADMITTING DIAGNOSIS:
Congenital aortic stenosis.
HISTORY OF PRESENT ILLNESS:
A 47-year-old female diagnosed with the aortic stenosis 6 years
ago , followed by serial echos , the last echo done on 10/10/05 ,
showed severe aortic stenosis with an EF of 60% at which time
patient became symptomatic with shortness of breath and referred
for surgical intervention as well as a preop cardiac
catheterization. The patient underwent a cath on admission on
8/19/05 , which showed a right dominant circulation with clean
coronary artery.
PAST MEDICAL HISTORY:
The patient's past medical history is significant for COPD with
bronchodilator therapy , history of lung CA and lymphoma , the
patient with chest radiation in 1978 for lymphoma an as well as
chemotherapy using Adriamycin , Cytoxan and Decadron , history of
fibrocystic breast disease as well as a terrible bowel syndrome
and thoracic outlet syndrome , GERD with hiatal hernia , history of
idiopathic peripheral neuropathy , osteoporosis , endometriosis ,
gastric ulcer. History also of a right rib fracture after a
fall , positive PPD and history of severe bleeding with
menstruation as well as post childbirth.
PAST SURGICAL HISTORY:
Status post laparotomy in 1977 and status post open
cholecystectomy in 1974 , status post sinus repair in 1995 , status
post vaginal hysterectomy , status post BSO D&C , bone marrow
biopsies , status post cystoscopies x5 , status post the right
axilla mass removed and status post Nissen fundoplication.
FAMILY HISTORY:
No family history of coronary artery disease.
SOCIAL HISTORY:
History of tobacco use with a 25-pack-year history. The patient
also off alcohol use , last drink 10/18 .
ALLERGIES TO MEDICATION:
Multiple with iodine allergy , listed here also chalk aluminum
perfume , morphine , Feldene , penicillin , Keflex , sulfa , Novocain ,
Talwin , erythromycin , Flagyl , tetracycline , Tylenol and NSAIDs as
well as aspirin.
MEDICATIONS ON ADMISSION:
Diltiazem 120 orally twice a day , digoxin 0.125 mg orally once a day.
Ipratropium inhaler as needed Demadex 20 mg orally every day , Pepcid 50
mg orally twice a day , Benadryl 50 every hour sleep , Cloraz 7.5 mg as needed ,
Zyrtec 10 mg as needed , and Bentyl 20 mg orally as needed
PHYSICAL EXAMINATION:
Height 5 feet 8 inches , 88 kilograms. Vital signs , heart rate of
100 , blood pressure on the right arm of 140/70 , on the left arm
of 128/70. HEENT , PERRLA. Dentition without evidence of
infection. No carotid bruits , chip of left upper tooth. Chest ,
no incision. Cardiovascular: Regular rate and rhythm , with
III/VI systolic ejection murmur heard throughout her coronary and
radiating to both carotid arteries. Vascular 2+ pulses
throughout. Allen's test bilaterally patent by pulse oximetry.
Respiratory: Breath sounds clear bilaterally. Abdomen: No
incisions , soft , no mass noted. Rectal deferred. Extremities ,
without scarring , varicosity , or edema. Neuro , alert and
oriented with no focal deficits.
LABS:
Laboratory values on preop admitting test center on 5/14/05 ,
chemistries , sodium of 139 , K of 3.9 , chloride of 100 , CO2 of 28 ,
BUN of 11 , creatinine of 0.9 and glucose of 76. Hematology:
White count of 8.4 , hematocrit of 40.9 , hemoglobin of 14.6 ,
platelets of 325 , 000 , physical therapy of 13.4 , INR of 1.0 and PTT of 30.2.
A1c of 5.5. Chest x-ray indicated here as normal. EKG sinus
rhythm at 80 , last echo was done on 10/10/05 which showed an
ejection fraction of 60% , aortic stenosis with a mean gradient of
54 mmHg , peak gradient of 100 mmHg , calculated valve area 0.7 cm2
with mild aortic insufficiency , trivial mitral insufficiency ,
trivial tricuspid insufficiency , and trivial pulmonic
insufficiency.
HOSPITAL COURSE:
The patient was admitted on 8/19/05 , and underwent diagnostic
catheterization before surgery which showed right dominant
circulation and clean coronary artery. The patient on 6/18/05
was taken to the operating room and underwent a minimally
invasive AVR replacement with a 21 Carpentier-Edwards magna
valve. Total cardiopulmonary bypass time was 120 minutes ,
crossclamp time was 51 minutes. The patient was weaned off the
cardiopulmonary bypass without any difficulty , on no pressors and
was taken up to the cardiac surgery intensive care unit and
extubated 4 hours later. The patient's postop course by systems ,
neurologically remained intact but had severe pain issues due to
the chest tube and pain consult was obtained and was put on a PCA
until the chest tube was removed at which point patient was put
back on her preop Ultram and was comfortable without any further
narcotic use.
Cardiovascular: Patient remained in normal sinus rhythm
throughout her postoperative course with rates in the 60s to 70s
with low-dose beta-blocker and thus will be discharged to home on
only on 25 mg three times a day of Lopressor
Respiratory: The patient was extubated 4 hours postoperatively
and weaned off O2 without any difficulty.
GI: The patient had no issues , was put on Pepcid for GI
prophylaxis. The patient with a history of GERD and was put back
on Pepcid
Renal: Due to her allergies to Lasix , the patient was placed on
torsemide and by the postoperative day 4 , patient was making
several liters without any torsemide and so the decision was made
for the patient to be discharged to home without any torsemide ,
even though she was on 20 mg orally every day preoperatively and
recommended patient to follow up with her cardiologist in a week
to see if she needs to be placed back on torsemide and needs
further diuresis.
Endocrine: The patient was on a protein protocol intraoperative
but had no further insulin requirement and was not a diabetic
preoperatively with normal A1c of 5.5 and the patient was
discharged to home without any medication.
Heme: The patient due to her allergies to aspirin and was not
placed on any anticoagulants.
ID: The patient had no infectious issue , was on vancomycin for
surgical prophylaxis. The patient was doing quite well
ambulating and back on Ultram and no further pain issues and a
decision was made for the patient to be discharged to home on
postoperative day 5.
DISCHARGE MEDICATIONS:
The patient will be discharged on these following medications ,
Colace 100 mg orally three times a day , Lopressor 25 mg orally three times a day , Niferex
150 mg orally twice a day , Zocor 50 mg every hours sleep , Ultram 50 mg
every 6 hours as needed pain , and Pepcid 40 mg orally twice a day
FOLLOWUP:
The patient should make these follow up appointments with her
cardiologist Dr. Laramore in 1 week. His phone number is
980-281-7130. If she cannot make an appointment with Dr. Laramore ,
the patient should make the appointment with her primary care physician , Dr. Bobian
in one to two weeks , his phone number is 540-062-7212. The
patient also should follow up with Dr. Golebiowski in 6 weeks for
postsurgical evaluation , his telephone number is 766-081-5735.
eScription document: 2-2783570 EMS
Dictated By: AFZAL , TOMIKA
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 3752530
D: 3/1/05
T: 3/1/05
Document id: 153
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239574113 | PUO | 97119393 | | 1182785 | 3/8/2004 12:00:00 a.m. | SEPTIC KNEE | Signed | DIS | Admission Date: 6/20/2004 Report Status: Signed
Discharge Date: 9/17/2004
ATTENDING: WEI PILLING M.D.
Admitted to the Renal Service.
PRINCIPAL DIAGNOSIS:
Septic arthritis and bacteremia.
HISTORY OF PRESENT ILLNESS:
This is a 54-year-old male with factor IX hemophilia , HCV with
cirrhosis and chronic ascites , HIV , diabetes , end-stage renal
disease on dialysis , and history of multiple infections including
mitral valve endocarditis , and bilateral knee replacement and
left hip replacement who was transferred from rehab with a
painful right knee in a prosthetic joint which was concerning for
a septic joint. He was in his rehab therapy one week prior to
admission when he twisted his knee. He gave him some factor IX
at this time with some relief , but in the intervening time , it
had become more painful , red and swollen , and was unable to walk
without great difficulty where as before he had been tolerating
rehab with a walker without incident. In addition , he had a
temperature to 103.0 degrees , two days prior to admission and was
given vancomycin and gentamicin dialysis the day prior to
admission. The knee , however , continued to worsen , and he has a
significant restriction in range of motion , and he reported to
the emergency department for concern for an infected knee versus
hemarthrosis. He reported some fatigue and decreased orally
intake. He did have chills with his fever. He denied any
shortness of breath , chest pain , abdominal pain , nausea , vomiting
or bleeding. Of note , he has chronic ascites , which for the past
three months has required paracentesis three times weekly with a
total of 3 to 4 liters taken off each time. In the emergency
department , he was loaded with factor IX by the hematology
fellow. The knee was then tapped by Orthopedics , which
demonstrated only some dark blood and minimal fluid. He was
admitted to the Renal Service given that he is a dialysis
patient.
PAST MEDICAL HISTORY:
1. Hemophilia factor IX deficiency.
2. Hepatitis C virus with cirrhosis and chronic ascites.
3. HIV.
4. End-stage renal disease , on dialysis.
5. Diabetes type 2.
6. History of mitral valve endocarditis , MSSA.
7. Status post bilateral total knee replacement and left hip
replacement.
8. History of spontaneous bacterial peritonitis.
9. History of upper GI bleed and lower GI bleed.
ALLERGIES:
Nafcillin , he has a rash.
MEDICATIONS ON ADMISSION:
Included Epogen , heparin , mitogen with dialysis , Neutra-Phos ,
factor IX with dialysis , lactulose , Nephrocaps , Carnitor , insulin
sliding scale , ciprofloxacin 500 every Sunday , Carafate , Protonix
twice a day , Amphojel , Compazine , and oxycodone as needed
SOCIAL HISTORY:
He is married , has five children. He has HIV and HCV from
transfusion. He is not currently working.
FAMILY HISTORY:
Notable for factor IX deficiency hemophilia.
PHYSICAL EXAM ON ADMISSION:
The patient was afebrile , slight tachycardiac at 105 , and
normotensive at 120/72 , sating well on room air. General: He
was cachetic and chronically ill appearing , alert and oriented ,
and comfortable. Neck veins were flat. Cardiovascular exam was
notable for regular rate and rhythm. Normal S1 , S2 and a 3/6
holosystolic murmur at the apex. Chest was notable for mild
bibasilar crackles , otherwise clear. Abdomen was distended ,
notable for flank dullness. He did have normal active bowel
sounds and a peritoneal port on the right. Extremities were
notable for being wasted , warm with absent pulses. Right knee
was erythematous , edematous , and extremely tender to palpation.
LABS ON ADMISSION:
Notable for potassium of 5.2 , BUN of 42 , and creatinine of 4.2.
His liver function panel was within normal limits. His white
blood cell count was 10.4 , hematocrit 36.6 , and platelets
332 , 000. His physical therapy was 15.4 , PTT 62.3 , and INR was 1.2. X-ray of
his right knee demonstrated an effusion and no fracture. A chest
x-ray demonstrated a small left pleural effusion and atelectasis.
His erythrocyte sedimentation rate was 70.
OPERATIONS AND PROCEDURES:
On 8/22/04 , he had an incision and drainage of his right knee by
Dr. Mcalmond of Orthopedics. On 10/20/04 , he had a
hemodialysis-tunneled catheter placed by Interventional
Radiology. On 2/7/04 , he had a PICC line placed at the
bedside , and he underwent hemodialysis.
HOSPITAL COURSE BY PROBLEM:
1. Musculoskeletal and Infectious Disease: He was admitted to
the Renal Service for treatment of septic arthritis of his right
knee , which was a prosthetic joint. Blood cultures were positive
for methicillin-sensitive Staphylococcus aureus , which was the
organism , which had caused his prior endocarditis. He underwent
incision and drainage of his right knee by Orthopedic Service ,
Dr. Mcalmond , on 8/22/04 . In addition , his hemodialysis catheter
was pulled on 10/15/04 because it too had grown blood cultures
positive for MSSA. He had no further positive cultures once his
dialysis catheter was pulled except for 1/4 bottles coag-negative
Staph from 9/23/04 , which was attributed to contamination. He
was treated with vancomycin and gentamicin just after dialysis.
He received a total of seven days of gentamicin and was on day
#14 of a six-week course of vancomycin upon discharge. He had
some low-grade temperature during admission but only one
temperature spiked to 101 degrees. Both Orthopedics and
Infectious Disease Services were consulted and followed him
throughout admission. Orthopedics and Infectious Disease
consultant determined that if any blood cultures became positive
after removal of the hemodialysis catheter , he would need to
return to the OR for joint exploitation. Given his negative
culture this did not occur and he is discharged with prosthetic
joint in place. The joint fluid culture as well synovial tissue
and synovial culture from his I&D were positive for MSSA.
Surveillance cultures were negative for seven days following the
procedure. He was instructed to continue vancomycin for a total
of six-week course and to follow up with Infectious Disease in
two months. He was cleared for physical therapy and returned to
rehab by Orthopedics with instructions to remove his sutures
three weeks after discharge and to follow up with Orthopedic , Dr.
Lemmen , as indicated by his symptom.
2. Hematology: He has factor IX deficiency hemophilia for which
he normally takes every week or twice weekly factor IX before
dialysis. During admission , he was initially loaded with factor
IX in the emergency department for arthrocentesis. Hematology
was consulted and they recommended twice a day factor IX 4000 units
during admission while the situation regarding surgery and line
placement was unclear. He continued receiving twice a day factor IX
until the day of discharge as his last line was placed on that
day. He was to return to factor IX before dialysis only upon
return to rehab and was to follow up with Dr. Otley , his
primary hematologist. In addition , he received erythropoietin
with dialysis.
3. Renal: He has end-stage renal disease and is on hemodialysis
Mondays , Wednesdays , and Fridays. He continued this regimen
while he had his hemodialysis catheter in place , however , when
that was removed , he was dialyzed to a temporary femoral artery
catheter and only as clinically indicated. He was dialyzed most
recently on 10/20/04 after his dialysis catheter was replaced by
Interventional Radiology , and he should return to his Monday ,
Wednesday , Friday schedule. He was continued on his home renal
supplements. He was continued on erythropoietin with dialysis
and midodrine.
4. GI: He has HCV cirrhosis and chronic ascites and history of
spontaneous bacterial peritonitis as well as upper and lower GI
bleed. He had no evidence of bleeding during admission. The
occult blood was negative x3. He additionally had no evidence of
infection or SPP. He was taped by a peritoneal port thrice
weekly with removal of 3 to 4 liters of fluid each time. The
first set was sent for culture , which was negative.
Additionally , he was continued on his twice a day proton pump
inhibitor given his history of upper GI bleed.
5. Endocrine: He has diabetes for which he was covered with
Regular Insulin sliding scale upon admission. Given some
elevated blood sugars up to 300s and the risk of bacteremia , he
was started on NPH and was discharged on 10 every day before noon and 5 every afternoon
with continued Regular Insulin sliding scale for added coverage.
6. Prophylaxis: He was not anticoagulated despite his
immobility. Given his hemophilia , he was placed on TED hose and
pneumoboots and continued on his PPI.
7. FEN: Nutrition was consulted because of his low albumin and
general cachexia. He was placed on a 1.5 liters fluid
restriction and 2 g sodium restriction given his chronic ascites.
He is also on a diabetic diet and renal diet. Nutrition
recommended supplementing with Enlive and Ensure , and the patient
had adequate orally intake during admission. He was not given intravenous
fluids.
DISPOSITION:
He has full code. He was discharged in stable condition to rehab
with instructions to follow up with his new primary care doctor ,
Dr. Denisha Mcrorie , Orthopedics as needed by symptoms with his
regular hematologist , his regular renal physician , and with
Infectious Disease , and to continue antibiotics for a six-week
course.
PHYSICAL EXAMINATION AT DISCHARGE:
It was unchanged from admission with a cardiac exam notable for
regular rate and rhythm and a 3/6 holosystolic murmur at the
apex. Bibasilar rales on pulmonary exam. Distended , nontender
abdomen. His right knee was notable for a clean suture line with
no warmth , erythema or swelling.
DISCHARGE MEDICATIONS:
Tylenol 650 mg orally every 4 hours as needed , Amphojel 30 mL orally three times a day
one-half hour before meals , ciprofloxacin 500 mg orally every week on
Sundays , to be changed to every Monday , Wednesday , Friday when his
six-week course of vancomycin was finished on 3/18/04 , Flexeril
5 mg orally twice a day as needed for muscle spasms , Benadryl 25 mg orally
every bedtime as needed , Colace 100 mg orally twice a day , NPH insulin 10 units
every day before noon , 5 mg every afternoon , Regular Insulin sliding scale. No coverage
blood sugar less than 25 for blood sugar 125 to 150 , 2 units , 151
to 200 , 3 units , 201 to 250 , 4 units , 251-300 , 6 units , 301-350 ,
8 units , 351-400 , 10 units , and notify a physician if blood sugar
is greater than 400 , lactulose 30 mL orally twice a day as needed to
titrate two to three bowel movements per day , milk of magnesia 30
mL orally every day as needed , Neutra-Phos two packets orally every day ,
simethicone 80 mg orally four times a day as needed , Carafate 1 g orally every day ,
vancomycin 1 g intravenous after dialysis and to be redosed for levels
less than 20 , to complete a six-week course , which will be
finished on 3/18/04 , Compazine 10 mg orally every 6 hours as needed ,
Nephrocaps one tab orally every day , miconazole nitrate 2% powder
topical to the groin , Carnitor 0.5 g orally three times a day , midodrine 10 mg
orally one hour before dialysis , esomeprazole 40 mg orally twice a day ,
Maalox tablets chewable one to two tabs orally every 6 hours as needed , and
Epogen 4000 units every Monday , Wednesday , Friday with dialysis.
The patient was discharged in stable condition to La Gno Health for continued rehabilitation. He was
instructed to follow up with the Infectious Disease Service in
two months , and he was call 507-978-7612 for an appointment with
Dr. Denisha Mcrorie at Kernan To Dautedi University Of Of for new
primary care physician on 3/10/04 at 9:20 a.m. , with Dr. Otley
of Hematology in one month , and with Dr. Lemmen of Orthopedics as
needed by return of symptoms.
DISCHARGE INSTRUCTIONS FOR REHABILITATION:
1. Continue vancomycin 1 g intravenous after dialysis until 3/18/04 . He
should be redosed for any vancomycin level less than 20.
2. He should increase his ciprofloxacin to 500 mg orally q.
Monday , Wednesday , Friday after 3/18/04 when his vancomycin is
finished.
3. He should receive dialysis on Monday , Wednesday , and Friday
as he was before admission.
4. He should have paracentesis on Tuesdays , Thursdays , and
Saturdays via port with an estimated removal of 3 to 4 liters as
dictated by the patient's symptoms.
5. He should have suture removal from his right knee three weeks
after his operation on 2/22/04 .
6. He should have a dry sterile dressing change every day to his
right knee.
7. He should receive factor IX Mononine 50 units per kg before
each dialysis with a goal factor IX of greater than 50% activity.
8. He should have follow up with Infectious Disease , his PMD ,
Renal , Hematology , and Orthopedics as needed.
9. He should have Enlive twice a day and Ensure every day as nutritional
supplements.
10. His PICC line on 2/7/04 , it is good position and should be
discontinued after his vancomycin course.
DISPOSITION:
The patient is full code.
eScription document: 1-6241295 EMSSten Tel
CC: Denisha Hannelore Mcrorie , MD
INY TOWNOCHMARBULL DAM HOSPITAL
I
CC: Wei Pilling M.D.
Pagham University Of
Airpen Avenue , Hunt La , Arizona 78470
Dictated By: OSDOBA , JEANA
Attending: PILLING , WEI
Dictation ID 1189195
D: 2/7/04
T: 2/7/04
Document id: 154
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698812086 | PUO | 12566492 | | 908304 | 10/9/2000 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/9/2000 Report Status: Signed
Discharge Date:
CARDIOLOGY KTDUOO SERVICE
ID: The patient is a 53 year old woman with a history of coronary
artery disease , status post myocardial infarction in 1986 ,
congestive heart failure who was admitted for congestive heart
failure exacerbation.
HISTORY OF PRESENT ILLNESS: The patient has a history of diabetes ,
coronary artery disease , hypertension
not well controlled , congestive heart failure who presented with
increasing swelling , shortness of breath , and some chest pain over
the past week to two weeks and weight gain over the past month.
The patient admits to having injuried her knee while climbing a
mountain in Ville Wark Ton almost two months ago and having to be in
a knee immobilizer for that period of time. Was unable to do much
ambulation and was not able to cook with low salt foods as a result
of her immobility. She says the swelling then occurred. She
attempted to increase the level of diuretics that she takes at
home , which has not helped , and now present with some mild chest
pain and congestive heart failure.
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus for 20
years , hypertension not well controlled ,
coronary artery disease , status post inferior myocardial infarction
1986 , peripheral neuropathy , retinopathy , nephropathy , mild
congestive heart failure , possible pneumonia in the past , and
mitral insufficiency.
MEDICATIONS: Elavil 50 milligrams , aspirin 325 milligrams ,
Atenolol 50 milligrams twice a day , Lasix 40 milligrams
orally every day , insulin , lactulose 30 milliliters four times a day , Prilosec 20
milligrams orally four times a day , Zocor 20 milligrams orally every bedtime ,
lisinopril , Tiazac 180 milligrams orally twice a day , Cozaar 50 milligrams
orally twice a day
HOSPITAL COURSE: The patient was admitted , ruled out for an
myocardial infarction , and began diuresis.
Required 80 milligrams intravenous Lasix , then to twice a day , and
increase that to 100 , and then 200 intravenous Lasix twice a day
and added 500 milligrams of Diuril twice a day. The patient began
to respond to the initial diuresis. Was unable to obtain an MRI to
evaluate her renal arteries , secondary to claustrophobia and
orthopnea. On July required addition of clonidine for not
well controlled blood pressure into the 180s and 190s/100 , .
Changed Captopril to ramipril for better lipophilic absorption. On
July Lasix was increased and Clonidine was also increased
from 2.5 to 5 for better diuresis and blood pressure control. The
patient was noted to have a hyperproliferative normal MCV anemia ,
was begun on erythropoietin; however , her level came back to 15
which is normal limits. An echocardiogram in October 2000 showed an
ejection fraction of 60% , normal size and function , 2-3+ mitral
regurgitation. A repeat echocardiogram done on April
showed 4+ mitral regurgitation with decreased function and an
ejection fraction of 45-50%. The patient had a chest x-ray that
showed continued pleural effusions and pulmonary edema , compared to
admission , somewhat improved. Sputum was done and had a gram stain
showing 4+ polys , gram positive cocci in clusters and chains , and a
culture which had 1+ orally flora. On March the patient
continued to diuresis well. On August creatinine to 2.6 up
from 2.2. Continued her Norvasc and Clonidine. On January ,
the patient's creatinine rose to 3.0. Held her diuresis and her
blood pressure medications. The patient was orthostatic. MRI/MRA
showed no evidence of renal artery stenosis and echocardiogram
showed mild mitral regurgitation and an ejection fraction of
45-50%.
DISCHARGE MEDICATIONS: Elavil 50 milligrams orally every bedtime , Ecasa
325 milligrams orally every day , Atenolol 50
milligrams twice a day , erythropoietin 5 , 000 units subcutaneous , regular
insulin sliding scale , lactulose 30 milliliter orally four times a day , Niferex
150 milligrams orally twice a day , nitroglycerin 1 tablet sublingual q5min
x3 as needed chest pain , Prilosec 20 milligrams orally twice a day , thiamine
100 milligrams orally every day , Zocor 20 milligrams orally every bedtime , Tiazac
180 milligrams orally twice a day , Cozaar 50 milligrams orally twice a day ,
Humulogue 10 units every day before noon 20 units every afternoon , Bumex 10 milligrams orally
every day
FOLLOW-UP: With Dr. Marroquin in clinic within one week and Dr.
Blacknall whenever appointment available.
Dictated By: JOANA ZERBE , M.D. LT82
Attending: EARNESTINE FIERMONTE , M.D. GE9 JS182/0313
Batch: 38551 Index No. IDQFWV48HN D: 7/23
T: 6/21
Document id: 155
| Target |
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CHF |
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DM |
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GER |
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HC |
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OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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782162530 | PUO | 01356650 | | 6045650 | 4/29/2004 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 4/29/2004 Report Status: Signed
Discharge Date: 10/7/2005
ATTENDING: HARRIET BUNTZ MD
ATTENDING PHYSICIAN: Harriet Buntz , MD
SERVICE: General Medical Ton Ho Co
PRINCIPAL DIAGNOSIS: Syncope
LIST OF PROBLEMS , DIAGNOSES: Pneumonia , coronary artery disease ,
non-ST elevation MI , diabetes mellitus , prostate cancer.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old man
with multiple medical problems including aortic stenosis with
valve area 0.9cm , coronary artery disease , status post CABG/PCI ,
prostate cancer with question NSCLC vs lung metastasis , asbestos
exposure , asthma who presents with cough and shortness of breath.
Three days prior to admission the patient was seen in the ED and
not admitted. As family felt he was at his baseline in terms of
shortness of breath and he was started on prednisone and
discharged on a Combivent inhaler. The morning of admission the
patient was in the bathroom using the toilet when he fell and had
a loss of consciousness of several minutes , .per patient's
girlfriend. The patient did not remember the event. When seen
in the ED his vitals were: Temperature 99.9 , heart rate 91 ,
respirations 36 , BP 132/61 , oxygen saturation 89% on room air
which improved to 97% on 3 liters. The patient was treated with
levofloxacin and clindamycin and had a chest xray showing a left
lower lobe opacity. At baseline the patient does not use oxygen.
He can walk approximately 50 yards on a flat surface without
being limited by shortness of breath , although he is limited by
some leg pain. He does not have stairs at home. He has never
had syncope before this episode. He also noted cough with specks
of blood in his sputum the day prior to admission as well as a
burning pain in his chest or stomach. He denied any GI symptoms
and any dysuria.
PAST MEDICAL HISTORY: The patient is notable for:
1. Coronary artery disease status post CABG 1998 x4 , status post
PCI 2003 x 2 stents.
2. Diabetes mellitus.
3. Hypertension.
4. Aortic stenosis , aortic valve area 0.9cm. , September 2003.
5. Lung metastasis VA non-small cell lung cancer from metastatic
prostate cancer.
6. Chronic renal insufficiency secondary to hypertension and
diabetes.
7. Peptic ulcer disease.
8. Gastric AVM.
9. Long standing anemia.
10. Asthma.
11. History of GI bleed.
12. History of diverticulosis.
MEDICATIONS AT ADMISSION: Aspirin 81mg every day , folate 1mg every day ,
Imdur 30mg every day , , NPH insulin 21 units every day before noon and 11 units
every afternoon , Lipitor 20mg every bedtime , Losartan 50mg every day , Norvasc 10mg
every day , Pepcid 40mg twice a day , Plavix 75mg every day , Toprol XL 100mg every day ,
Xanax 0.5mg twice a day as needed and Casodex 50mg orally every day
ALLERGIES: Patient has no known drug allergies.
He wishes to be DNR/DNI.
LABORATORY ON ADMISSION: Notable for a troponin of 0.89 ,
creatinine of 2.3 , Hct 30.5 , WBC 22.15. Chest x-ray revealed a
left lower lobe opacity , question post obstructive pneumonia.
EKG revealed irregular inferior lead T wave inversions and a new
Q in lead 3 , also T wave inversion in the lateral leads , lost R
waves in V2 and V3 compared to earlier EKG of February 2004.
PHYSICAL EXAMINATION ON ADMISSION: Was notable for a temperature
of 99.9 , heart rate 91 , BP 132/61 , respirations 36 , satting 96%
on 3 liters. The patient was in no acute distress. His JVP was
flat. His heart exam was notable for a 3/6 diamond shaped
systolic murmur at the base. Lungs had diminished breath sounds
bilaterally and crackles over the left lower lobe. He did have
wheezes. Abdomen was soft , nontender and nondistended. Rectal
exam was guaiac negative.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular. Patient has history of critical aortic
stenosis with valve area of 0.9 cm2. He did present with syncope
ultimately of unknown cause , but possibly related to his AS. At
presentation he also had an non-ST elevation MI with peak
troponin of 0.89. This did trend down in the days following
admission. Four days following admission the patient also had an
episode of acute pulmonary edema which was thought to be ischemic
in nature. This did resolve with Lasix and patient was seen by
Cardiology consult who reviewed the case and confirmed that this
patient is not a surgical candidate for aortic valve repair. It
was also felt that the risks of valvuloplasty would outweigh the
potential benefits and that percutaneous intervention via
catheterization likewise was not indicated at this time given the
patients multiple other comorbidities. The patient will follow
up in Cardiology Clinic with Dr. Christeen Jacobson . She would
like to see him one to two weeks after discharge and her office
will contact patient's family to set up appointment.
2. Infectious Disease. Infiltrates seen on chest x-ray at
admission felt to be pneumonia. The patient was treated with a
10 day course of levofloxacin and Flagyl and was discharged on no
antibiotics.
3. Pulmonary. The patient was treated for COPD exacerbation
during this admission. He was discharged on 30mg of prednisone
with instructions to taper 10mg every 3 days starting the day
following discharge.
4. Endocrine. At the time of admission the patient was on a
regimen of NPH 21 units every day before noon and 11 units every afternoon This was
adjusted over the course of his hospitalization and at the time
of discharge he is discharged on 32 units of NPH every day before noon.and 6
units of NPH every afternoon
5. Renal. Patient had some acute renal failure at admission
likely related to his cardiac status and some intravascular
volume depletion. His creatinine did normalize and he was at
baseline at the time of discharge.
6. Hematology. Patient's hematocrit did fall gradually over the
time of his admission and he was transfused of one unit packed
red blood cells in order to maintain his hematocrit greater than
30.
PLAN: The patient is discharged to rehabilitation in stable
condition on 10/17/05 .
MEDICATIONS AT DISCHARGE: Tylenol 650mg orally every 4.h. as needed , albuterol
nebulizer 2.5mg nebulized 2 every hour as needed , aspirin 81mg orally every day ,
Colace 100mg orally twice a day , Pepcid 40mg orally every day , ferrous sulfate
325mg orally three times a day , folate 1mg orally every day , Robitussin 10ml orally every 4.h.
as needed , NPH insulin 32 units sub-Q every day before noon and NPH insulin 6 units
sub-Q every afternoon , regular insulin sliding scale , milk of magnesia
30ml orally every day as needed constipation , Reglan 10mg orally four times a day , Lopressor
50mg orally four times a day , which can be converted to Toprol XL 200mg every day at
the time of discharge from rehabilitation , Oxycodone 5-10mg orally
every 4.h. , prednisone 30mg orally every day with instructions to taper by
10mg every 3 days starting the day following admission , Senna 2
tabs orally twice a day , Imdur 30mg orally every day , Casodex 50mg orally every day ,
Losartan 75mg orally every day , Plavix 75mg orally every day , Duo Nebs 3/0.5mg
nebulized every 6.h. , darbepoetin alfa 40mcg sub-Q every 2.weeks , Maalox
tablets 1-2 tablets orally every 6.h. as needed upset stomach , Lipitor 20mg orally
every day
eScription document: 3-4520374 RSSten Tel
Dictated By: CHAIX , TRISH
Attending: BUNTZ , HARRIET
Dictation ID 2269664
D: 3/1/05
T: 3/1/05
Document id: 156
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
- |
N |
N |
N |
N |
975146855 | PUO | 93661256 | | 689405 | 9/14/1999 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 9/14/1999 Report Status: Signed
Discharge Date: 5/10/1999
PRINCIPAL DIAGNOSIS: 1. CONGESTIVE HEART FAILURE.
2. ATRIAL FLUTTER.
SIGNIFICANT PROBLEMS: 1. HYPERTENSION.
2. NON-INSULIN DEPENDENT DIABETES
MELLITUS.
3. HYPERCHOLESTEROLEMIA.
4. HYPOTHYROIDISM.
5. ISCHEMIC CARDIOMYOPATHY.
6. STATUS POST CARDIOVERSION TO
SINUS RHYTHM.
HISTORY OF PRESENT ILLNESS: Mr. Kurtis Hotze is a 62-year-old
white man with ischemic
cardiomyopathy , status post coronary artery bypass graft in 1985
with left internal mammary artery to left anterior descending ,
saphenous vein graft to posterior descending artery , saphenous vein
graft to obtuse marginal branch. He had a repeat coronary artery
bypass graft done in 1995 with saphenous vein graft to first
diagonal , saphenous vein graft to obtuse marginal , and saphenous
vein graft to posterior descending artery. The course was
complicated by ventricular tachycardia requiring AICD placement and
treatment with amiodarone. The patient also developed
hyperthyroidism secondary to amiodarone , treated with PTU , then
developed hypothyroidism , treated with Levothyroxine.
Over the past few months the patient has had multiple episodes of
pulmonary congestion. About one week ago prior to this admission the
patient was admitted to Norap Valley Hospital for intravenous diuresis.
Echocardiography demonstrated that a reduced LV ejection fraction in
the mid 20's with moderate mitral regurgitation. Recent EKGs
provided by the Ellesput Host Rehabilitation Hospital and on admission here shows
atrial flutter with variable ventricular rate. On admission the
patient denied peripheral edema , orthopnea , or recent gain in
weight. A recent TSH revealed 10. No recent excess caffeine or
alcohol consumption.
PAST MEDICAL HISTORY: Significant for ( 1 ) coronary artery
disease , status post coronary artery
bypass graft times two; ( 2 ) hypertension; ( 3 ) hypothyroidism;
( 4 ) dyslipidemia; ( 5 ) benign prostatic hypertrophy; ( 6 )
degenerative joint disease; ( 7 ) non-insulin dependent diabetes
mellitus.
ALLERGIES: The patient has a known allergy to morphine and to
tetanus toxoid.
FAMILY HISTORY: Father died of myocardial infarction at age 66.
Mother died of myocardial infarction at age 63.
SOCIAL HISTORY: No tobacco use. No alcohol use. Very active
athletically. He works as a superintendant.
PHYSICAL EXAMINATION: General appearance , very pleasant man
in no apparent distress. Temperature
97.1 , pulse 103 , blood pressure 148/94 , respirations 18 , O2
saturation 97% on two liters. HEENT pupils are equal , round , and
reactive to light. Sclerae anicteric. Oral pharynx clear and
moist. Jugular venous pressure about 8-9 cm. No carotid bruits.
Chest clear to auscultation and percussion. No rales and no
wheezes. Heart paradoxical S2 , II/VI systolic murmur. Abdomen
soft , nontender , with no pulsatile masses. Lower extremities no
edema , no cyanosis , or clubbing. Rectal examination normal , guaiac
negative. Neurological examination grossly intact.
ADMISSION LABORATORY STUDIES: Sodium 141 , potassium 4.4 ,
chloride 101 , bicarb 34 , BUN 19 ,
creatinine 1.3 , glucose 220 , AST 22 , ALK 53 , total bilirubin 0.6 ,
calcium 9.8 , total protein 7.1 , albumin 4.4 , magnesium 1.9 , CK 477 ,
MB 2.7 , physical therapy 12.7 , INR 1.1 , PTT 24.2. Urinalysis 1+ glucose ,
otherwise negative.
EKG revealed atrial flutter with variable block ( 2:1 versus 3:1 ) ,
rate around 120 , left bundle branche block.
Echocardiogram revealed ejection fraction about 25% with 2+ mitral
regurgitation.
HOSPITAL COURSE: The patient's hospital course was notable for the
following: Upon transfer from Norap Valley Hospital
to Pagham University Of the patient had no complaints of
shortness of breath or chest pain. However , the patient was having
atrial flutter with various blocks. The ventricular response at
that time was between 120-130. On the day of admission the patient also had
echocardiogram repeated which revealed ejection fraction 25% with
2+ mitral regurgitation.
Because of his rapid ventricular response , Digoxin was started with
a loading dose of 0.5 mg , then 0.25 mg times two every six hours. The
patient was then on a maintenance dose of Digoxin at 0.125 mg orally
every day , and his Digoxin level has been maintained around 0.9. For
his rate control , the amiodarone was also increased to 400 mg q.
day , and the patient was started on anticoagulation with heparin.
On August the patient underwent cardiac catheterization
which revealed old grafts serving the left anterior descending ,
posterior descending artery , obtuse marginal , patent. The
saphenous vein graft to first diagonal has 70% proximal stenosis.
Left ventricular ejection fraction estimated at 10-15%. Post
catheterization the patient had no complications. The patient also
had a TEE done which showed no thrombosis. Therefore on September the patient underwent cardioversion through his AICD by the
Electrophysiological Service with successful conversion to normal
sinus rhythm. The patient was loaded with Coumadin and meanwhile
on heparin until INR between 2-3.
For further investigation of his cardiomyopathy , iron studies were
sent to rule out hemochromatosis. The results were negative.
Cardiomyopathy consult was also obtained to follow-up the patient.
The patient will be discharged when his INR approaches the
therapeutic level , which is between 2-3.
DISCHARGE MEDICATIONS: Amiodarone 400 mg orally every day , Captopril
25 mg orally three times a day , clonazepam 1 mg orally
every bedtime , Klonopin 0.5 mg orally every day before noon , Digoxin 0.125 mg orally every day ,
Lasix 80 mg orally twice a day , glipizide 5 mg orally every day , levothyroxine
sodium 100 mcg orally every day , magnesium oxide 420 mg orally every day ,
Lopressor 25 mg orally twice a day , nitroglycerin 1/150 ( 0.4 mg ) one tab
sublingual every five minutes times three , Coumadin 5 mg orally every day
until INR between 2-3 then the dose needs to be adjusted
accordingly to maintain INR between 2-3 , Simvastatin 20 mg orally q.
bedtime , isosorbide , mononitrate-SR 30 mg orally every day , and troglipazone
400 mg orally every day.
CONDITION UPON DISCHARGE: Stable.
DISPOSITION/FOLLOW-UP: The patient will be discharged to home
on 10 of August with a follow-up
appointment with Dr. Dominguez , Maude Birdie Cecilia A. of the
Cardiomyopathy Service.
Dictated By: BRIGID ALDACO , M.D.
Attending: BRITTANEY N. HAMBLET , M.D. QF2 QX562/9900
Batch: 09753 Index No. VZFD04123F D: 11/10/99
T: 1/3/99
Document id: 157
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
Y |
Y |
N |
N |
046215586 | PUO | 64304774 | | 5944379 | 5/19/2005 12:00:00 a.m. | Hypertensive urgency | | DIS | Admission Date: 5/11/2005 Report Status:
Discharge Date: 3/28/2005
****** DISCHARGE ORDERS ******
RODRIGUES , MARYROSE 862-48-97-1
Hass Nyonkers Mi
Service: CAR
DISCHARGE PATIENT ON: 5/30/05 AT 12:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: THEILING , BREE MARLYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
LASIX ( FUROSEMIDE ) 160 MG every day before noon; 120 MG every afternoon orally 160 MG every day before noon
120 MG every afternoon
LISINOPRIL 80 MG orally every day
Override Notice: Override added on 5/30/05 by
VARONE , THURMAN B. , M.D.
on order for KCL SLOW RELEASE orally ( ref # 53174398 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 200 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
AMBIEN ( ZOLPIDEM TARTRATE ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DEPAKOTE ER ( DIVALPROEX SODIUM ER ) 1 , 000 MG orally every day
Starting IN a.m. ( 6/29 )
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Primary cardiologist Please make an appt for the next 1-2 weeks. ,
Primary care doctor ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CAD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hypertensive urgency
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity tobacco
OSA ( sleep apnea ) history of asthma/bronchitis ( history of asthmatic bronchitis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac catherization.
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
HPI: 54M with hx chf ef 45% , dm , htn , osa , was admitted to FH with c/o
cp. Found to have BP 190-200 with troponin elevated to 6.o. No ekg
changes. patient sent to PUO for cath. Cath revealed 100% RCA lesion
but well collateralized and no other CAD-->no intervention. R heart
cath with elev filling pressures. patient chest pain free since NVH
admission. PMH: as
above meds: toprol lisinopril , norvasc , asa , statin ,
depakote PE: BP 145/90 , HR 68. JVP 9 , lungs clear , heart
normal. labs: cr 1.5 ( baseline ) , hct 55 , k
3.3 EKG: nsr at 68 with old ST depressions in inf leads
and TWIs in v3-v6. CXR:
nl
**************************************************
A/P: 54M with hx chf admitted with chest pain , elev troponin in setting
of elev BP likely demand 2/2 hypertensive emergency.
1 )CV: Presented with chest pain and troponin elevation. Non-sig CAD
discovered at cath. However , elev filling pressures on right heart cath.
Keys to management are aggressive BP control with meds , low salt diet ,
weight loss. cont asa , statin. Cont lasix 160 in a.m. , 120 in PM for
volume control. Troponin trended down and patient remained asymptomatic in
house. Monitored on tele-->no events.
2 )Renal: Cr 1.5 , remained stable at baseline. Gave mucomyst.
3 )Endo: DM on diet control. Hba1c pending. RISS in house.
4 )pulm: hx osa on cpap. Likely contributing to pulm htn given hct 55.
Cont cpap and encourage weight loss. No SOB.
ADDITIONAL COMMENTS: Please be sure to continue your medications as prescribed.
Continue to monitor your BP. Cutting out salt , losing weight , and taking
your meds will help lower your BP.
If you re-experience chest pain or shortness of breath , call your doctor
or return to the hospital.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: VARONE , THURMAN B. , M.D. ( UU934 ) 5/30/05 @ 10:24 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 158
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
Y |
N |
104444086 | PUO | 05391370 | | 8665762 | 7/29/2006 12:00:00 a.m. | Tracheobronchitis | | DIS | Admission Date: 5/4/2006 Report Status:
Discharge Date: 5/14/2006
****** FINAL DISCHARGE ORDERS ******
VIDLER , ELEONORE A 557-72-14-5
Orlersanlum
Service: CAR
DISCHARGE PATIENT ON: 5/17/06 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HOLDA , ALYSE ANGELES , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
AMIODARONE 300 MG orally DAILY
Override Notice: Override added on 5/27/06 by
POK , LIZETTE W. , M.D.
on order for SIMVASTATIN orally ( ref # 219550065 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
SIMVASTATIN Reason for override: aware
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 6/28/06 by :
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
ATORVASTATIN CALCIUM
SERIOUS INTERACTION: GEMFIBROZIL & ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: GEMFIBROZIL &
ATORVASTATIN CALCIUM Reason for override: aware
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:cough Number of Doses Required ( approximate ): 20
CLOPIDOGREL 75 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY nasal DAILY
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 88 MCG inhaled twice a day
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 5/27/06 by
POK , LIZETTE W. , M.D.
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: home meds
GLYBURIDE 10 MG orally DAILY
GUAIFENESIN DM 5 MILLILITERS orally every 6 hours as needed Other:cough
HYDROXYZINE HCL 25 MG orally twice a day as needed Anxiety
HOLD IF: Oversedation
LANTUS ( INSULIN GLARGINE ) 18 UNITS subcutaneously BEDTIME
HOLD IF: Last fingerstick <75.
ISOSORBIDE MONONITRATE 60 MG orally twice a day
HOLD IF: HR<50 , SBP<95 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 10
LOSARTAN 50 MG orally DAILY
METFORMIN 1 , 000 MG orally twice a day
METOPROLOL TARTRATE 50 MG orally twice a day
HOLD IF: HR < 55 , SBP<100 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: House / 2 gm Na / ADA 2100 cals/day / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Follow-up with Potwood Kinlis Wellscajohns Health Center Cardiology in 1-2 weeks 1-2 weeks ,
Follow up with Donnette Innarelli 2 weeks ,
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
CHF exacerbation , rule out PE
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Tracheobronchitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) MI ( myocardial infarction ) CABG
( cardiac bypass graft surgery ) PTCA
( angioplasty ) DM ( diabetes mellitus ) HTN
( hypertension ) hyperlipidemia ( hyperlipidemia ) prostate ca ( prostate
cancer ) in-stent restenosis
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
PFTs
PE Protocol Chest CT
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
****************************
HPI: 76M hx/o CAD , HTN , DM who p/with 2 wk hx/o incr DOE , incr fatigue ,
incr cough. Initially productive of yellow sputum which resolved c
course of e-mycin. Cough , discomfort and fatigue persisted ,
no fevers , chlls , one episode of sweats. No change in wt , baseline is
174lbs , at MD office 178lbs. No LE swelling. 2-pillow orthopnea at
baseline , no change now. No PND. Called Potwood Kinlis Wellscajohns Health Center , primary care physician no callback so
taken to hospital for rule out of cardiac cause for sxs. Took lasix
orally on the way to ED In PUO ED: Rcv'd additional 40mg intravenous Lasix ,
combivent , albuterol c resultant improvement in sxs. D-dimer up to
1750 , BNP lower than prior at 106 , cardiac biomarkers negative x 1.
Labs otherwise unremarkable. PE CT scan obtained which was
neg.
********************
PMH: CAD: IMI 1970 , 2 subsequent non-Q wave MIs 1970s , CABG '74 , '82.
Cath 9/27 c patent LIMA to LAD , occluded SV graft to OM and
occluded SV graft to RCA. PCI to left main in ramus. Cath 9/18
PTCA and brachytherapy to the left main stent; Ischemic CMP - LVEF
=33% by MIBI 3/06 , DM2 , Hyperlipidemia , Obesity , Pros ca history of
radiation therapy 8/06 , GIB , history of ICD/pacemaker implantation
for NSVT , HTN , Syncope , PVD , Subclavian stenosis history of PCI 4/3 , history of
CEA , Hypothyroidism
**************************************************
MEDICATIONS: Aspirin 81 mg every day , Plavix 75 mg every day , Imdur 60 mg twice a day ,
Lisinopril 20qd , Lipitor 40 mg every day , Gemfibrozil 600 mg twice a day , Lasix 20
mg every Mon + Thurs , Metoprolol 50 mg twice a day , Amiodarone 300 mg every day ,
Glyburide 10mg twice a day , Metformin 1000 twice a day , NPH ? Dose , Nexium 40 mg every day ,
Hydroxyzine 25 mg twice a day , SLNTG as needed
ALLERGIES/SENSITIVITIES: KEFLEX
FAMILY HISTORY: Father had CHF.
******************
DISCHARGE PHYSICAL
GENERAL: NAD. Voice has become horse , but coughing much improved since
admission ( still has a moist sounding cough occasionally )
LUNGS: Bilateral Rales/moist wheezes/tracheobronchial breath sounds. No
crackles. Much improved from admission.
Cardiac: RRR , nl S1 s2 , distant heart sounds , no m/r/g
Abdomen: S/NT/ND +BS
Extremities: WWP , 1+ peripheral pulses , no edema
******************
DATA: Cr 1.2 , K 4.6 , Glc 127 , Lactate 1 , D-dimer 1751 ,
troponin neg ,
CXR: no acute CP process
PE CT: No PE.
PFTS: FVC=1.4 ( 48% ) FEV1=1.02( 45% ); FEV1/FVC=94% predicted TLC= 3.19
( 61% ) - no inhaler trial due to albuterol usage 2 hrs prior
******************
HOSPITAL COURSE:
1. CV Ischemia: Continue home medications. Troponin negative x 1. Index
of suspicion low for cardiac cause of this coughing
Pump: Continue home antihypertensives. Patient has history of CHF with
low EF ( 30% ). BNP @ this time =102 ( lower than last admission when
symptomatic with CHF ). Returned to home diuretic dose. D/C lisinopril
and begin losartan for possible captopril cough.
Rhythm: Maintained on tele. Continue amiodarone. Paced rhythm.
2. Pulm: Believe cough is most likely secondary to tracheobronchitis vs
post infectious tussive syndrome. PFTs continue to demonstrate
restrictive lung disease. Provided tessalon perles , chest patient , duonebs.
Completed 5d course of azithro. Pulm c/s involved c recs to induce sputum
( orally flora ). Patient will be discharged on flovent , flonase , with as needed
albuterol inhaler - will follow up with Donnette Innarelli in 2 weeks.
3. Renal: Elev Cr to 1.2. Restarted lasix during hosp course. Patient
appears euvolemic on this dose.
4. FEN: Maintained K & Mg. Patient received diabetic , sodium restricted ,
fluid restricted , low fat , low cholesterol diet.
FULL
CODE
ADDITIONAL COMMENTS: 1. Please call your cardiologist for a follow-up appointment. Continue
your medications as you were taking them prior to this admission with the
following additions: Tessalon Perrles and Guaifenasin for your cough as
needed.
2. The following medications have been added to your medication list -
Flovent , Flonase , and alubeterol inhaler to use as you need it for SOB.
3. If you develop chest pain or chest pressure , lightheadedness or
dizziness , nausea or vomiting , you should contact your health care
provider.
4. If you develop fever to >101 you should contact your physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- Check Creatinine
- Follow volume status and adjust diuretics
- Assess cough and provide additional cough suppresants pRN
- WBC shoudl decr c treatment.
No dictated summary
ENTERED BY: POK , LIZETTE W. , M.D. ( LV48 ) 6/28/06 @ 04:18 PM
****** END OF DISCHARGE ORDERS ******
Document id: 159
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
536815366 | PUO | 34000260 | | 793872 | 2/24/1993 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/11/1993 Report Status: Unsigned
Discharge Date: 9/13/1993
DISCHARGE DIAGNOSIS: IDIOPATHIC CARDIOMYOPATHY.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old Hispanic
female with a history of idiopathic
dilated cardiomyopathy for the past ten years. Patient has been
managed medically , however , recently , the patient's heart failure
has progressed to the point where conventional therapy is unable to
sustain her. The patient was admitted in September 1993 with dyspnea and
chest pain. At that time , the patient ruled out for myocardial
infarction and was discharged home on exogenous oxygen therapy.
Patient returned shortly thereafter with shortness of breath and
was begun on intravenous Dobutamine. She was subsequently
discharged home after her heart failure resolved. Patient ,
however , returned a third time with similar complaints of shortness
of breath and dyspnea and remained in the hospital awaiting a heart
transplant. PAST MEDICAL HISTORY: The patient has a history of
non-Insulin dependent diabetes mellitus as well as a history of
treated tuberculosis. PAST SURGICAL HISTORY: Patient has a
history of total abdominal hysterectomy and right
salpingo-oophorectomy. Patient has no known tobacco or ethanol
history. Catheterization on May demonstrated a pulmonary
capillary wedge pressure of 38 with a pulmonary artery pressure of
80 systolic/50 diastolic. Cardiac index was 1.4 and an echo
demonstrated severely dilated left ventricle with an ejection
fraction of between 25 and 30%. CURRENT MEDICATIONS: Lasix 120 mg
orally twice a day , Glucotrol 10 mg orally twice a day , Vasotec 10 mg orally
twice a day , Coumadin 2.5 mg orally every day , Digoxin 0.125 mg orally every day , and
two liters nasal cannula O2.
PHYSICAL EXAMINATION: Patient was a sickly appearing female who
was short of breath. HEENT: Unremarkable.
NECK: Remarkable for jugular venous distention to the angle of the
jaw. CARDIAC: III/VI holosystolic murmur appreciated with an S3
gallop. ABDOMEN: Liver was 13 to 14 cm. Otherwise , the abdomen
was soft. EXTREMITIES: 2+ pitting edema to the mid shin.
LABORATORY EXAMINATION: BUN was 24 , creatinine 1.2 , physical therapy was 16.1 ,
PTT was 34 , white count was 8 , hematocrit
49% , and digoxin was 1.4. EKG showed a normal sinus rhythm at 110
with a left bundle-branch block pattern and first degree AV block.
Chest X-Ray revealed cardiomegaly and liver function tests were
grossly normal.
HOSPITAL COURSE: Patient underwent a heart transplant on October
without perioperative difficulty. The patient
was transferred to the Intensive Care Unit immediately
post-operatively and remained there for her first several days
post-operatively. The patient's early post-operative course was
complicated by right sided heart dysfunction and elevated PA
pressures. Echocardiogram demonstrated normal left ventricular
function. The patient ruled out for a myocardial infarction
post-operatively and was managed on Dobutamine and Inocor. As PA
pressures remained elevated , the patient was switched to Milrinone
and her other pressors were weaned off gradually. The patient had
chest tubes left in place for approximately twelve days
post-operatively at which time the chest tubes were discontinued.
Patient's Swan was removed on post-operative day ten and CVP
monitoring was used to estimate right heart function. The
patient's Milrinone was gradually weaned off and the patient's CVP
remained in the 12 to 16 mm range. The patient was subsequently
transferred to the floor where she did well. The patient was
biopsied twice prior to discharge , both times demonstrating no
rejection. Of note , the patient appeared to develop Cyclosporin
toxicity early in her post-operative course with rapidly rising
creatinine levels and elevated liver function tests. The patient
was placed on Trental 800 mg orally three times a day and subsequently given a
seven day course of OKT3 after which time the patient was restarted
on her Cyclosporin with no ill effect. The patient was noted to
have a left sided pleural effusion that was tapped approximately
two and a half weeks into the patient's post-operative period. 400
cc of pleural fluid was removed which grew no bacteria out. The
patient's effusion was followed by chest X-Ray and was noted again
to reaccumulate. Approximately one and a half weeks later , a chest
tube was placed with the recovery of approximately 700 cc of fluid.
This was done with ultrasound guidance. The chest tube remained in
place approximately five days and was subsequently removed. A
residual small left pneumothorax was noted. This pneumothorax was
unchanged over the ensuing three days after chest tube removal and
the patient was discharged home with a stable small left
pneumothorax.
DISPOSITION: DISCHARGE MEDICATIONS: Patient is discharged home on
Dapsone 100 mg orally twice a day , Cyclosporin 225 mg orally
twice a day , Imuran 25 mg orally every day , Magnesium Gluconate 1 gram four times a day ,
Procardia XL 90 mg orally every day , Trental 800 mg orally three times a day ,
Prednisone 30 mg orally every day , Humulin NPH 18 units subcutaneously
every day before noon , Lasix 40 mg every day before noon every day , K-Dur 40 mEq orally every day , and Serax
15 mg orally twice a day as needed for agitation. The patient is to
follow-up with the Transplant Clinic as well as the Endocrine
Clinic and will receive VNA nursing care at home for wound checks.
Dictated By: LATASHIA COSE , M.D. DK26
Attending: ISABELLE E. COLASAMTE , M.D. VA5 OP217/6483
Batch: 4209 Index No. ARUYK8817B D: 11/20/93
T: 3/26/93
Document id: 160
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558149349 | PUO | 81640946 | | 9003914 | 10/28/2005 12:00:00 a.m. | NSTE MI , history of cath | | DIS | Admission Date: 7/27/2005 Report Status:
Discharge Date: 1/20/2005
****** FINAL DISCHARGE ORDERS ******
VESELKA , STARLA 777-37-71-9
Airv
Service: CAR
DISCHARGE PATIENT ON: 7/7/05 AT 05:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SASNETT , HAYWOOD R. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 3/29/05 by
RAMIL , FELIPA C. , M.D.
on order for TYLENOL orally ( ref # 12029994 )
patient has a PROBABLE allergy to PERCOCET; reaction is GI
Intolerance. Reason for override: aware
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Starting Tomorrow ( 1/11 )
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
LANTUS ( INSULIN GLARGINE ) 64 UNITS subcutaneously every day
Starting IN a.m. ( 6/28 )
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
200 MG orally every day Starting Today ( 10/9 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 20 MG orally every day
LASIX ( FUROSEMIDE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Sasnett 1 weeks ,
Dr. Mose ( primary care physician ) 1-2 weeks ,
ALLERGY: Shellfish , PERCOCET
ADMIT DIAGNOSIS:
coronary artery disease
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTE MI , history of cath
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
type 2 dm-insulin requiring ( diabetes mellitus ) htn ( hypertension )
gerd ( esophageal reflux ) , osa ( sleep apnea ) , obesity , asthma , diabetic
retinopathy
OPERATIONS AND PROCEDURES:
cardiac catherization
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
**CC: chest pain
**DIAGNOSIS: 57F , with HTN , DM , elev chol , obesity , presented at
P Therford Hospital with 15 hrs chest pain after eating. Pain felt like heart
burn , R-sided , lasting for hours. At TH , Tn6.9 , MB 43 , downsloping
Ts in aVL , pain responded to NTG. Of note , patient had
increasing DOE and orthopnea over past 3 months. Has hx of TB tx in
1980s and was being evaluated as outpt. Brought to PUO for cath. TnI
6.9 , CKMB 43. At cath , patient found to have 99% stenosis of LCx --> stented
DES.
**DAILY EVENTS: cath **DAILY STATUS: afebrile , 121/58 , 70-90 , 93-99% RA
**PROCEDURES: 2/14 cath with stent of LCx , LVEDP 36 ,
responding to lasix , hypercapnia during procedure which improved with
decreased O2. Echo 10/10 EF 50-55% basal ant hypokinetic , rest
nl , trace MR **PROBLEM
Hospital course:
1. CV: Ischemia: NSTEMI history of cath. On ASA , plavix. Her lopressor was
increased to 75 three times a day to optimize for post MI ( HR range should be 55-65 ).
Will change to toprol XL 200 every day at home. Lipitor 80 for ACS. Pump:
continue to need diuresis for HF up to 40 mg intravenous every day now slightly
overloaded-->euvolemic. Will send home with lasix 20mg every day for gentle
diuresis. Captopril started - change to lisinopril 20mg every day EF: 50-55% with
basal anterior hypokinetic - rest nl. Rhythm: tele to watch for
arrhythmia. no events on tele.
2. DM: on lantus and novolog SS at home. hold metformin post MI for up to
5 days - please consult your physician prior to restarting metformin. Up
lantus to 64 units every bedtime Please follow up with your doctor. HA1c is 8.4
--> elevated.
3. RESP: on flovent and albuterol at home , on Advair twice a day and duonebs
as needed
4. GERD: on PPI
5. Dispo: Please follow up with Dr. Sasnett in 1 week ( call for
appointment ). Please call your doctor or return to hospital if
experiencing shortness of breath , chest pain , palpitations or other
concerns. Please continue to check your weight daily to make sure you're
not gaining weight ( putting on fluids ). Please see your primary care
physician regarding your diabetes control. Your hemoglobin A1c was 8.4.
ADDITIONAL COMMENTS: Please call your doctor or return to the ED if experiencing chest pain ,
shortness of breath , palpitations or any other concerns. Please call and
schedule appointment to see Dr. Sasnett in 1 week.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
F/u with primary care physician
F/u with Dr. Sasnett
No dictated summary
ENTERED BY: STRAHL , ROSAURA A. , M.D. , PH.D. ( WP69 ) 7/7/05 @ 02:16 PM
****** END OF DISCHARGE ORDERS ******
Document id: 161
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
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397819455 | PUO | 11493557 | | 7256875 | 4/22/2004 12:00:00 a.m. | presyncope | | DIS | Admission Date: 1/24/2004 Report Status:
Discharge Date: 1/26/2004
****** DISCHARGE ORDERS ******
WIENKE , JEANETTA W. 357-77-97-5
Na
Service: MED
DISCHARGE PATIENT ON: 8/22/04 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RESTER , TIEN T , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 100 MG orally every 12 hours
NICOTINE TRANSDERMAL SYSTEM 7 MG/DAY TP every 24 hours
Number of Doses Required ( approximate ): 2
ATENOLOL 50 MG orally every day
DIET: cardiac diet
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Shonna Saber 1 week ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
near syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
presyncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
morbid obesity ( obesity ) diverticulitis history of sigmoidectomy ( diverticuli
tis ) cervical stenosis history of laminectomy C2-7 ( ) homeless in past
( ) tobacco dependence ( )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Exercise stress test / echo
BRIEF RESUME OF HOSPITAL COURSE:
44 year-old M with history of presyncopal episodes presents
with another presyncopal event. HPI: Patient was in his USOH until the
DOA when he was coming from the bathroom ( post
micturation ) and started feeling lightheaded , noted that
his peripheral vision was darkening , and noticed
some nausea. He was able to make his way to the bed
to lie down. He believes that he never
lost consciousness but was very close. He notes
this episode is characteristic of his last 2
episodes of presyncope. He notes no chest pain , SOB ,
or diaphoresis during the event. Once he
was conscious he called EMS for transport to the
PUO . Of note , he was here at the PUO about 6 weeks
ago for a rule out MI , which was negative. Review
of symptoms was significant for back pain
associated with spinal stenosis. Otherwise , it was
negative. PMH: spinal stenosis , morbid
obesity , diverticulosis , cervical stenosis ,
history of laminectomy , history of
sigmoidectomy. All:
PCN Meds: Oxycodone , percocet ( for back
pain ) , nicotine patch ,
colace SH: oxycontin dependence; nicotine
dependence; moving from house in 2 days d/t
eviction FH: 1 cousin with MI at 44 , 1 cousin with
HTN
PE: 98.7 , P 56 RR 18 BP 153/72 , 100RA Labs: normal lytes , tsh , INR , CBC
notable for HCT of 39.1 , LFT's nl , ekg NSR , no changes from prior or
evidence ofischemia or infarction
IMP: 44 year-old male with presyncopal event most likely vasovagal given
his description of the event , and the several negative cardiac test
s.
Brief Hospital Course:
CV: ROMI protocol. Patient had negative cardiac enzymes. EKG normal.
Echo showed some LVH with normal bi-ventricular fxn and LA dilata
tion in the preliminary report. An exercise stress test was normal;
no changes after 12 minutes of exercise. Will follow up with primary care physician
regarding the episodes. He was placed on beta-blockers to help with the
near sycopal episodes and to improve BP control as evidenced by his
LVH. Also , will need to discuss utility of holter monitor or other
event monitoring devices with his primary care physician.
Neuro: continued pain meds for
back pain secondary to spinal stenosis
PSYCH: continue nicotine patch.
FEN: morbidly obese; nutrition saw him and discussed cardiac healthy di
ets.
ENDO: adrenal masses seen on recent CT. f/u with primary care physician.
DISPO: f/u with primary care physician
ADDITIONAL COMMENTS: If you should have similar symptoms or nearly lose consciousness ,
contact your primary care physician or return to the PUO for evaluation. SHould you hae a
headache , vision changes , or other worrisome symptoms , please return
for evaluation.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow up with primary care physician regarding 1 ) use of beta blockers to prevent
presyncopal events 2 ) ? holter or event monitor to assess possible
arrhythmic events. 3 ) f/u for spinal stenosis 4 ) reconditioning
physical therapy 5 ) f/u adrenal masses on recent CT
No dictated summary
ENTERED BY: BURVINE , ALVERTA AUDREY BEBE , M.D. ( YO26 ) 8/22/04 @ 02:47 PM
****** END OF DISCHARGE ORDERS ******
Document id: 162
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
Y |
N |
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N |
396327604 | PUO | 71534390 | | 2828476 | 4/27/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 6/18/2006 Report Status: Signed
Discharge Date: 6/22/2006
ATTENDING: CADOFF , LINDY MD
SERVICE: GMS Eans
ATTENDING: Dr. Lindy Cadoff
PRINCIPAL DISCHARGE DIAGNOSIS: AFib with LVR , CHF.
ASSOCIATE DISCHARGE DIAGNOSIS: History of AFib , hypertension ,
diabetes , CHF , pulmonary hypertension , COPD , asthma and chronic
renal insufficiency , baseline creatinine 2.
CHIEF COMPLAINT: Dyspnea and hypoxia.
HISTORY OF PRESENT ILLNESS: This is an 80-year-old female with
history of AFib , atrial flutter , hypertension , diabetes , CHF ,
pulmonary hypertension , COPD and CRI at baseline of 2 who
recently discharged from Stusri Medical Center for CHF. Prior to this
admission , the patient was at baseline Class III heart failure
with dyspnea on exertion at about 20 feet. Following the CHF
admission , the patient is on 2 liter home O2 and stated she had
been stable for about a week , but able to do her chores with 2
liter O2. Had been fully at home VNA and saw her primary care physician on the day
prior to admission without any change in her status. On the
night prior to admission , however , she stated she had heart
raising and could not sleep. Overnight , she had increased
shortness of breath , but without any chest pain or
lightheadedness. Daughter called in the morning and saw the
patient with increasing oxygen requirement to 3 liter and called
VNA who noted her sat in 80s on 4 liter and told the patient to
come into the hospital. The patient stated that she has been
tried to stick to her low-sodium diet and taking the home
medication. Of note , the patient has been taking double dose of
Sunday meds. Denies fever , chills , chest pain and worsen cough.
She has baseline cough with white sputum production. In ED , the
patient was sating at 99% on non-rebreather. Has AFib with rate
in the 70 and temperature is 98. Her BUN was elevated. EKG
unchanged. The patient received Lasix 40 intravenous x1 and admitted.
PAST MEDICAL HISTORY: Atrial flutter , hypertension , diabetes ,
CHF , pulmonary hypertension , COPD/asthma , chronic renal
insufficiency , baseline of 2 , history of C-section in 4/3 , anemia ,
hiatal hernia , PMR and colonic polyp.
MEDICINE ON ADMISSION: Digoxin 0.125 every day before noon , diltiazem ER 300
daily , iron sulfate 325 twice a day , Advair 250/50 twice a day , Lasix 20
twice a day , NPH 26 every day before noon and 16 every afternoon , Combivent two four times a day ,
fluvastatin 20 at bedtime , MVI one daily , Coumadin 2.5 every afternoon ,
1.5 Monday and Thursday , Avapro 300 mg orally daily was held ,
Fosamax 70 mg every week and aspirin 81 daily.
ALLERGIES: Halothane and atenolol.
FAMILY HISTORY: Mother and sister with heart disease.
SOCIAL HISTORY: She lives at home by herself.
PHYSICAL EXAMINATION: Vital sign on admission , temperature 96.5 ,
heart rate 78 , blood pressure 110/70 , respiratory rate 20 and O2
sating 100% on non-rebreather. She is in mild respiratory
distress , wearing a facemask. JVPs at 10. Chest: Bilateral
crackles one-half up to the lungs. Decreased lung sound at
bases. Cardiac: Irregularly irregular S1 and S2 , 2/6 systolic
murmur. GI: Soft , nontender and nondistended. Positive bowel
sounds. Extremities: 1+ edema bilaterally and 2+ pulses.
Neuro: Alert and oriented x3. Nonfocal.
LABORATORY DATA: On admission , significant creatinine of 2.8 ,
potassium 4.5 , hematocrit 34.3 and INR 2.8. Her LFTs panels are
within normal limit. BNP is 559 , CK is 99 , MB 2.5 , troponin less
than assay , dig 2.4 , which is elevated. Her UA is significant 2+
blood , 2+ protein , 2 to 4 white blood cell count , 1+ bacteria , 2+
squames. EKG shows dig effect , AFib , rate of 61 , T-wave
inversion in I , II , aVL , aVF , V6 otherwise uncharged. Chest
x-ray bilateral infiltrate , left greater than right effusion.
TTE on 5/22 , decreased LV size , ejection fraction 80% , no wall
motion abnormality , normal RV , moderate LAE , trace MR , TR ,
hypodynamic heart , PA systolic pressure at 38.
ASSESSMENT AND PLAN: This is an 80 years old female with history
of AFib and CHF , diastolic dysfunction with EF of 80% and COPD
who was recently discharged for CHF with low dose lasix of 20mg now
is found to be in CHF in a setting with suspected AFib with LVR.
The patient also had acute on chronic renal insufficiency likely
secondary to low flow from her volume status. The patient was
admitted for diuresis and for the rate control.
HOSPITAL COURSE BY SYSTEM:
Ischemia: There is no evidence of ischemia. The patient was
ruled out with serial enzymes. She was continued on aspirin , no
betablocker , and short acting diltiazem and statin. Her
beta-blocker was initially not initiated , however , on three days
prior to discharge , she was started on short-dose beta-blockade
due to hypertension. She tolerated that reasonably well ,
however , did have episodes of bradycardia to 40s. Decision was
reached to defer starting betablockade on her until her
appointment with her cardiologist. Her BB was discontinued.
Pump: The patient was volume over loaded on chest x-ray with BNP
greater than 500. The patient has EF of 80% with hypodynamic
heart. The patient was diuresing initially with 80 intravenous Lasix and
subsequently increased to 120 twice a day of intravenous Lasix. She was
diuresed slowly at about 500 mL everyday. Ultimately , her Lasix
was switched over to 160 orally twice a day with very good diuresis , but
her creatinine was elevated , prompting decreasing her Lasix back
down to 120 orally twice a day She will continue on this dose on
discharge and has a followup with her primary care physician for
creatinine trial and make sure that her creatinine is trending
down. We did not want to over diuresis the patient given her
volume dependence and the diastolic dysfunction especially as we
suspect that the heart failure is secondary to her rhythm , but
not really significant volume overload. She had a repeat chest
x-ray three days prior to admission , which shows slightly
improving pulmonary edema and pulmonary effusion. She was to
repeat lytes and her creatinine was followed very closely.
Rhythm: She was in afib with RVR initially. The patient was
started on diltiazem three times a day We hold her dig initially as her
level was elevated to 2.4 eventually. Her dig was restarted at
0.125 mg orally every three days. Her dig level will need to be
followed as an outpatient. Her dig was stable on this particular
dose. We also started her on short acting beta-blocker with
Lopressor at 6.25 three times a day She will be reduced to 6.25 twice a day on
discharge. The patient tolerated the Lopressor though had a few
episodes of bradycardia. BB was d/c on discharge.
Pulmonary: The patient has shortness of breath , despite
secondary to CHF and COPD. The patient was given nebs and her
Advair. She was on 4 liter of oxygen on discharge and she will
be self-weaned at home to 2 liter as possible.
Heme: She has chronic baseline shortness of breath. She was
continued on her Coumadin for anticoagulation. INR was stable
throughout the hospital stay.
Renal: Has acute renal insufficiency on chronic renal
insufficiency. Her Avapro was held initially. Suspect that her
acute renal insufficiency is secondary to poor flow in the
setting of AFib and atrial flutter and failure. Her renal
function actually improved slightly upon diuresis , however , she
bumped her creatinine slightly on discharge secondary to
high-dose Lasix. Her Lasix will be decreased to 120 twice a day orally
on discharge and her creatinine will be checked two days after
discharge.
ID: No evidence of infection. She has some sputum that was sent
with normal flora. Blood culture and urine culture was negative.
Chest PA and lateral was also negative for any evidence of
consolidation or infection.
FEN: She was kept on the low-salt ADA diet , cardiac diet with K
and mag repletion.
Prophylasix: patient was anticoagulated with Coumadin and also on a
PPI.
CODE STATUS: She was full code.
DISPOSITION: She is to follow up with her primary care physician
and also cardiologist. She has appointment Dr. Wurth on
3/24/2006 at 2:40 p.m. and Dr. Theiling , the cardiologist on
2/25/2006 at 8:40 a.m.
DISCHARGE MEDICATION: She is on aspirin 81 mg orally daily , DuoNeb
3/0.5 neb every 6 hours , Fosamax 70 mg orally every week , Tessalon Perles
100 mg orally three times a day as needed , digoxin 0.125 orally every three days ,
diltiazem extended release 120 mg orally daily , iron sulfate 325 mg
orally twice a day , Colace 100 mg orally twice a day , Advair 250/50 one puff
twice a day , Lasix 120 mg orally twice a day , insulin NPH 26 every day before noon and 16
every afternoon , Imdur 30 mg orally daily , lovastatin 20 mg orally at bedtime ,
and omeprazole 20 mg orally daily.
eScription document: 5-1370081 VFFocus
CC: Bree Theiling MD
Dillto Gepalm University Health Center
Flintfrelo Gas News
Dictated By: STRAHL , ROSAURA
Attending: CADOFF , LINDY
Dictation ID 7602619
D: 10/22/06
T: 10/22/06
Document id: 163
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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457177743 | PUO | 82151855 | | 9552685 | 8/13/2006 12:00:00 a.m. | Gastroesophageal Reflux Disease | | DIS | Admission Date: 3/15/2006 Report Status:
Discharge Date: 8/28/2006
****** FINAL DISCHARGE ORDERS ******
BARBIER , ENOLA 100-70-76-1
Land Ge Vent
Service: MED
DISCHARGE PATIENT ON: 1/15/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CASSEM , JERAMY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ATENOLOL 50 MG orally DAILY
ECASA 325 MG orally DAILY
INSULIN NPH HUMAN 100 UNITS subcutaneously before dinner
METFORMIN 1 , 500 MG orally every afternoon
METFORMIN 1 , 000 MG orally every day before noon HOLD IF: hold 6/18 am dose
RANITIDINE HCL 300 MG orally DAILY
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician DR TETRICK 8932 ) 433-9449 7/6/06 @ 12:10 PM ,
ALLERGY: TRIMETHOPRIM/SULFAMETHOXAZOLE
ADMIT DIAGNOSIS:
R/O Myocardial Infarction
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Gastroesophageal Reflux Disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Diabetes Mellitus , obesity , anxiety
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Stress MIBI , Cardiac catheterization
BRIEF RESUME OF HOSPITAL COURSE:
CC: "Anxiety in my chest"
ID/Dx: patient is a 44 year-old woman with history of of type II DM on insulin ,
morbid obesity , and anxiety who presents with chest tingling and SOB.
patient was in her RHMC until yesterday when after a large meal ,
late at night , she awoke with a strange feeling in her chest which
she could not describe - this feeling was associated with some air
hunger and mild nausea. No diaphoresis , radiation. Denies
pain , or previos sx like this. EKG and CXR were normal.
*** Status at discharge
VS: AF BP: 135/80 HR: 80-90 RR 16 O2sat: 100%
RA PULM: CTAB. CXR nl
CV: RRR nl s1/s2. no m/r/g. No EKG changes
RENAL: Cr 1.0
NEURO: A&O x 3. nonfocal exam
** RELEVANT PMHX As in HPI
** ALLERGIES: Bactrim --> rash
** Impression: 44F history of DM2 , obesity , and anxiety d/o presents with
strange chest sensation. EKG , enzymes normal. MIBI showed severe perfusion
deficit , however , cardiac cath showed clean coronaries. Her symptoms could
still be explained by GERD or anxiety , with the perfusion deficit either aa
byproduct of the patient's size or caused by transient vasospasm.
*** Hospital Course and Plan by system
GI/FEN- patient was maintained on 100U NPH , with lispro SS for meals. She had
intermittent reflux pains which were helped with H2 blocker. She should
continue on H2 blocker at home for these symptoms.
CV- cardiac enzymes x 2 were negative with no ischemic EKG changes. Stress
MIBI performed as inpatient with results as above. The study was limited
due the patient's size. D/C with ASA , BBlocker.
Resp- Baseline CXR - clear. No shortness of breath throughout her hospital
stay.
Renal- Cr 1.0 , eGFR 76. Her elevated Cr may reflect increased creatinine
production ( due to obesity ) vs. renal insufficiency.
Endo- Diabetes as above. Also history of of hyperthyroidism , however , TSH and
free T4 were normal.
patient was discharged from the hospital in stable condition. To follow-up with
Dr. Tetrick in next two weeks.
ADDITIONAL COMMENTS: Please follow-up with your primary care physician in the next two weeks.
Return to the emergency department if you feel severe chest discomfort or
new shortness of breath.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WRAIGHT , ALYSSA D. , M.D. ( VW00 ) 1/15/06 @ 08:34 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 164
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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593109802 | PUO | 52570701 | | 9466870 | 5/19/2004 12:00:00 a.m. | CHF | | DIS | Admission Date: 5/6/2004 Report Status:
Discharge Date: 8/18/2004
****** DISCHARGE ORDERS ******
RAVER , KATHERYN 691-15-40-8
Alb , Virginia 75291
Service: MED
DISCHARGE PATIENT ON: 9/28/04 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GOUD , JULISSA LEONIA , M.D.
CODE STATUS:
No defib / No intubation /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
as needed Shortness of Breath
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day Starting Today ( 5/8 )
Instructions: Please take twice a day until you see Dr.
Goud in clinic.
INSULIN NPH HUMAN 110 UNITS subcutaneously every day before noon
INSULIN NPH HUMAN 30 UNITS subcutaneously every afternoon
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 as needed Chest Pain
VERAPAMIL SUSTAINED RELEAS 240 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOVENT ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
DIOVAN ( VALSARTAN ) 160 MG orally every day
Number of Doses Required ( approximate ): 5
VIOXX ( ROFECOXIB ) 12.5 MG orally every day
Food/Drug Interaction Instruction Take with food
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG inhaled every 6 hours
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / NAS / ADA 1800 cals/day / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Julissa Goud 11/18/04 ,
ALLERGY: Ace inhibitors
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD DM HTN OBESITY
CHF ( congestive heart failure ) restrictive lung disease ( restrictive
pulmonary disease ) asthma ( asthma ) retinopathy
( retinopathy ) history of cataract surgery ( history of cataract extraction )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB x 1 week
HPI: 63 yoF with hx of resistant DM ( familial syndrome assoc with
acanthosis nigricans ) , morbid obesity , CAD history of NSTEMI in 11/27 followed
by CAGB x 4 in 1997 , HTN , who presents with 1 wk of SOB.
Multiple admissions over the past year for breathing issues usually
2/2 either asthma or CHF. Now has had increasing dyspnea over one
week. She does not feel her usual wheezing. Denies
dietary indiscretion or med non-compliance. Appears to
hav e fluid overload on CXR and clinical exam. Got
80 intravenous lasix in ED --> put out 1200 cc.
PE notable for RR 22 , O2 sat 98% on 2L ,
bibasilar crackles , decreased bs throughout ,
scattered wheezes , JVP ? 8 , nl heart
exam
LABS/STUDIES notable for cardiac enzymes
negative x3 , BNP marginally elev at 191 , glucose 286 , otherwise cbc and
chem 7 wnl , A1c elev at 10.3 , TSH 3.847 , elev PTT at 64.9 of uncertain
significance
************HOSPITAL COURSE***************
*CV: Ischemia- ruled out for MI , cont ASA , statin , ccb , no b-block as
has
asthma and low-prob for ischemia. Pump- appears to be overloaded.
BNP somewhat elev at 191 , diuresed 2L with significant subjective
improvement. R&R- on tele while being ruled out , no events.
*PULM: Sx could also be 2/2 asthma. Put
on duonebs
four times a day with every 2 hours albuterol o/n. As better with diuresis , will not give
prednisone ( trying to avoid as BS are very difficult
to control on
steroids. )
*ENDO: hx of very
resistant DM. Will put on home insulin regimen and RISS.
Will check TSH in case this is contributing to tiredness and weight --
nl at 3.847. Will check A1c to see how BS control has
been -- elev at 10.3.
*FEN: On cardiac ,
low-salt , ADA 1800 diet. Checking lytes and
repleting as needed
*HEME: had newly elev PTT x 3 readings here ( all in low 60's ) , new
since last admission. Uncertain significance. After discussion with
primary care physician/attending , given patient's overall feelings about aggressiveness of care
will not work up for now.
*PPX: Put on heparin 5000 subcutaneously three times a day for DVT ppx. Put on PPI as has hx of
? GERD.
*CODE: DNR/DNI.
ADDITIONAL COMMENTS: Please call your doctor if you have fever , chills , shortness of breath ,
or chest pain. If you cannot reach your doctor , go to the emergency
room. You will need to call Dr. Oatis office to make an
appointment for Friday 8/27/04 . Until you see Dr. Goud , please take
your lasix pills twice a day ( in the morning and at night ). Dr.
Goud will decide on Friday whether to continue you on twice a day
pills or only once a day.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
patient is f/u with Dr. Julissa Goud on Friday 8/27/04 . He will decide at
that time whether patient is to continue to take lasix twice a day or on her usual
80 every day schedule.
No dictated summary
ENTERED BY: RUMBURD , ALISIA JIM , M.D. ( HZ26 ) 9/28/04 @ 01:53 PM
****** END OF DISCHARGE ORDERS ******
Document id: 165
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
- |
N |
N |
N |
N |
Y |
N |
Y |
- |
618248223 | PUO | 12220761 | | 4498235 | 9/29/2005 12:00:00 a.m. | CELLULITIS | Signed | DIS | Admission Date: 1/22/2005 Report Status: Signed
Discharge Date: 10/26/2005
ATTENDING: VAJDA , FRANCISCO M.D.
DISCHARGE DIAGNOSIS:
Prepatellar bursitis versus prepatellar cellulitis with bursitis.
SECONDARY DIAGNOSES:
Peripheral vascular disease , diabetes , chronic renal
insufficiency , CAD , and history of sepsis from right lower
extremity cellulitis in the past.
CHIEF COMPLAINT:
Right lower extremity edema and pain in right knee.
BRIEF HISTORY OF PRESENT ILLNESS:
This is a 68-year-old male with severe PVD , diabetes mellitus ,
chronic kidney insufficiency , presents with increased right lower
extremity edema and pain progressing over four days. The patient
was recently admitted to an outside hospital for questionable
viral gastroenteritis and discharged four days ago. Since the
last admission , he was noted to have increased right lower
extremity pain and erythema , was sent home on levofloxacin as an
outpatient for presumed cellulitis. Actually , despite being on
levofloxacin , right lower extremity edema and pain increased over
four days and became more painful to walk. The patient had
subjective fevers , but none documented on record. The patient
with no severe pain over the right patellar. It hurts to flex
and/or bend the knee. Baseline right lower extremity is now much
worse than it was prior. The patient was without pain in calf or
thigh. There is no shortness of breath or chest pain. Wife
provides daily diabetic foot care , and he had recurrent
cellulitis of the right lower extremity in the past , but none in
the past year. No history of trauma. In the ED the patient with
small right knee effusion was tapped by ortho and fluid sent to
lab , it was bloody without any other growth at that time. The
patient was also given vancomycin in the ED prior to admission.
PAST MEDICAL HISTORY:
Includes PVD , peripheral vascular disease , diabetic neuropathy ,
diabetes mellitus type II , chronic renal insufficiency , CAD
status post CABG , history of GI bleed in the past , history of
sepsis from right lower extremity cellulitis in the past , status
post right femoral-peroneal bypass.
ALLERGIES:
No known drug allergies.
MEDICATIONS ON ADMISSION:
Carbamazepine 100 mg twice a day , NovoLog 5 mg before every meal , Lipitor 80 mg
once a day , Lopressor 25 mg twice a day , Avandia 8 mg once a day ,
Prilosec 20 mg once a day , and NPH insulin 50 mg subcutaneously twice a day
SOCIAL HISTORY:
He lives with his wife , has adult children.
FAMILY HISTORY:
Sister with diabetes mellitus and CAD.
PHYSICAL EXAMINATION:
On admission , the patient was afebrile 97.5 , pulse of 84 ,
systolic blood pressure was noted to be 137 , respiratory rate 20 ,
and 95% on room air , was found to be hard of hearing , but
otherwise in no apparent distress. Lungs were CTAB with no
wheezes. Cardiac exam was regular rate and rhythm. S1 and S2.
No S3 or S4. JVP was difficult to assess and no audible murmurs ,
had truncal obesity on abdominal exam with ventral hernia.
Nontender and active bowel sounds. Extremities had edema two
times the size of the left lower extremity , 20 x 10 cm patch of
pink erythematous and induration of warmth over the right knee ,
exquisitely tender over the patellar with small area of
induration over the right patella. Nontender long joint lines ,
small effusions , and pain with passive range of motion over the
patellar area. Feet were clean without cracking , maceration , or
ulcers.
PERTINENT LABS ON ADMISSION:
Creatinine of 2.3 , BUN of 74 , glucose of 119 , sodium and
potassium of 136 and 4.3. White cell count was 8.7 with normal
differential , 78% polys , hematocrit 34.1 , and platelets 298 , 000.
INR was 1.0. ESR was 98. Uric acid was noted to be normal.
Synovial fluid did not show crystals and gram-stain was negative.
LENI's , right lower extremity did not show DVT above the right
knee.
HOSPITAL COURSE BY SYSTEM:
1. Musculoskeletal/ID/Rheum: This is right knee prepatellar
bursitis versus cellulitis. The patient with plain film and
x-ray , which did not show any large prepatellar bursal effusion.
No other trauma or fracture to be seen on x-ray. The patient was
doing well in-house , however , the erythema and pain did not
respond to intravenous vancomycin and orally levofloxacin at renal dosing ,
and was thought by rheumatology who graciously consulted on this
patient to have a likely prepatellar bursitis. It is also
possible this patient had a cellulitis overlying the prepatellar
area , but there is no evidence of joint infection. Tap on
11/7/05 of the prepatellar bursal fluid showed no crystals , no
polynuclear cells , and no organisms were seen. Given this ,
again , prepatellar bursitis is the primary diagnosis and the pain
did slowly resolve while inhouse. The patient was able to bend
the knee and do weightbearing , although with pain prior to
discharge without any evidence of systemic infection or sepsis.
Blood cultures on admission were no growth. Prior to discharge ,
Rheumatology suggested starting colchicine 0.6 mg twice a day for two
days followed by 0.6 mg daily for two days , followed by every
other day 0.6 mg for one week. Follow up with A Triaded Health
as an outpatient , to follow up prepatellar bursitis and to check
uric acid , although normal on admission at this time. The
patient was stable without any signs of joint infection or
spreading fascial infection or worsening cellulitis. The
patient will also be started on Keflex despite the fact that he
did not respond to antibiotics , and this is likely a prepatellar
bursitis. In case , it is small component of cellulitis , the
patient will be kept on 10 days of orally Keflex at renal dose 500
mg twice a day as an outpatient and will be followed by A Triaded Health in the future.
2. Diabetes mellitus: The patient was initially not placed on
home NPH 50 mg twice a day and required increased NovoLog sliding
scale to 10 standing before every meal plus sliding scale. However , after
addition of 50 mg twice a day , NPH as per patient's home dose , the
patient's blood sugars ranged from 90s to 180s , which is far
improved from prior sugars in the 300s on admission. The patient
will continue on home dose NPH insulin with a NovoLog sliding
scale. Also will continue orally Avandia.
3. Cardiovascular: There were no active issues on this
admission.
4. Pain: The patient had approximately two to three times 25 mg
of oxycodone as needed for pain. This will be continued for several
days as needed for pain on discharge.
5. Vascular: The patient with full LENI did not show any
thrombus in the right lower extremity on LENI.
6. Renal: The patient with chronic renal insufficiency , which
looks like acute on chronic given for unknown reasons , the
patient was initially placed on Lasix twice a day , but was taken down
to 80 mg once a day for lower extremity edema and swelling , given
creatinine of approximately 1.9 to 2.2. Discharge creatinine was
2.0. This will be followed up by A Triaded Health as an
outpatient. It seems that this is chronic renal insufficiency
from long-standing diabetes without a severe acute component.
The patient was on prophylactic Lovenox and Nexium while
in-house.
DISPOSITION:
Home on orally Keflex and colchicine as noted above.
DIET ON DISCHARGE:
Diabetic diet , 2 , 100 calorie per day , a low saturated fat , and
low-cholesterol diet. Walking , with weightbearing as tolerated.
Elevate legs and knees with prolonged sitting.
DISCHARGE MEDICATIONS:
Include his home medications , fish oil capsule orally twice a day ,
Avandia 8 mg orally daily , carbamazepine 100 mg orally twice a day ,
Novolin sliding scale , Lipitor 80 mg orally daily , metoprolol
tartrate 25 mg orally twice a day , will be on Keflex 500 mg twice a day x10
days , Lasix 80 mg orally daily from now on given renal
insufficiency , Avalide is being held until future notice , Novolin
5 to 10 units before breakfast and dinner , Prilosec OTC 20 mg
twice a day , colchicine as noted above 0.6 mg twice a day for two days , 0.6
mg daily for two days , followed by seven day of every other day ,
colchicine , oxycodone 5 mg every 4 hours as needed for pain , will receive
eight tablets for pain control and four tablets of Ativan 0.5 mg
as needed for anxiety three times a day , again four pills only at the time of
discharge.
DISCHARGE DISPOSITION:
The patient is stable.
eScription document: 9-7996646 EMSFocus transcriptionists
Dictated By: JULIUSSON , LAVELLE
Attending: VAJDA , FRANCISCO
Dictation ID 5776005
D: 4/30/05
T: 4/30/05
Document id: 166
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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201031748 | PUO | 23139147 | | 0627699 | 10/28/2003 12:00:00 a.m. | NECROTIZING FASCIITIS | Signed | DIS | Admission Date: 7/1/2003 Report Status: Signed
Discharge Date: 9/25/2003
PRINCIPAL DISCHARGE DIAGNOSIS: NECROTIZING FASCIITIS.
HISTORY OF PRESENT ILLNESS: This is a 73-year-old female with a
history of insulin-dependent diabetes
mellitus and critical AS , who presented to the Emergency Department
from her primary care A Triaded Health office presenting with a
right thigh mass present x 4 days. The patient was unable to
ambulate secondary to this abscess pain , patient with chills and
fevers to 102. Her glucose had become difficult to control since
the start of the abscess , and she presented to the Emergency
Department tachycardic and hypotensive.
PAST MEDICAL HISTORY: Past medical history includes
insulin-dependent diabetes mellitus , morbid
obesity , critical AS , hypertension , hypercholesterolemia , and
anemia.
MEDICATIONS: Her home medications include Glyburide , Metformin ,
hydrochlorothiazide , Protonix , Lipitor , and Zestril.
ALLERGIES: Allergies include Penicillin.
PHYSICAL EXAM ON ADMISSION: In the Emergency Department here at
the Kernan To Dautedi University Of Of , her temperature was
101.5 , her heart rate was 128 , blood pressure 103/52 , and she was
breathing regularly , saturating 98% on room air. She was generally
a mildly ill appearing obese female. Cardiovascularly , she was
tachycardic and regular. She had a 2/6 systolic murmur louder on
the right. Her lungs were clear to auscultation bilaterally. Her
abdomen was soft and obese , nontender , with audible but low bowel
sounds. Rectal exam was trace guaiac-positive by report. Her
extremities showed a large right thigh abscess with a boil
immediately below the pannus , with positive erythema , tenderness
down to the knee and up to the groin. There was no labial or
perirectal involvement.
LABS ON ADMISSION: BUN of 73 , creatinine of 3.8 , and a glucose of
357. White blood cell count of 18.4. EKG on
admission showed sinus tachycardia , with some T wave inversion , and
chest x-ray showed some mild pulmonary edema. The UA showed some
trace blood and trace leukocyte esterase.
HOSPITAL COURSE: Patient was taken emergently to the operating
room for an incision and drainage of this
abscess , which was believed to be a necrotizing fasciitis.
Postoperatively , the patient remained intubated and was in the
Surgical Intensive Care Unit. She was started on NeoFed for
control of her blood pressure to get it to the 70s , and was
receiving metoprolol and esmolol for a heart rate that had gone up
to the 130s. She was on triple antibiotics for full coverage and
treatment of her infection. On postoperative day 1 , the patient
remained in the Intensive Care Unit. She was awake and appeared
comfortable on fentanyl for analgesia. She was evaluated by
A Triaded Health Cardiology. She continued to need Levophed for
her blood pressure. Her cardiac enzymes and EKGs were being
continuously followed for evaluation of cardiac complications. She
continued to be on a ventilator and her diabetes was controlled
with an insulin drip. On postoperative day 2 , Plastic Surgery was
consulted and continued to follow the patient for future
necessitating closure of this right thigh wound. On postoperative
day 3 , patient remained in the Intensive Care Unit. Blood pressure
was improving , NG tube was removed , and a diet was started. By
postoperative day 4 , the patient was feeling well. She remained in
the Intensive Care Unit. She was tolerating Percocet for pain.
The wound appeared to have healthy tissue. She continued to
necessitate an insulin drip. The cultures on the wound showed
positive Enterococci and Corynebacter. She continued to be on
vancomycin , levofloxacin , and Flagyl for these microbes. On
postoperative day 4 , she was transferred to a regular nursing floor
in stable condition. On the regular nursing floor , the patient
continued to do well , tolerating all her diabetes meds by mouth.
Her vital signs were stable , with blood pressures 140/70s and a
heart rate ranging in the 70-75s. On postoperative day 8 , a VAC
sponge was placed on the wound , rehab screening was initiated , and
on postoperative day 9 the patient was transferred to a
rehabilitation facility. She was in stable condition. She was
working with Physical Therapy. She was tolerating a regular diet
and tolerating all of her medications , with continued stable vital
signs. Her wound showed healthy tissue and was covered with a VAC
sponge , that needs to be changed every three days. She continues
to be on triple antibiotics , and on the day of discharge she is day
9 of a 21-day course. Her vancomycin is dosed daily , depending on
her vancomycin level , that must be drawn also daily. Patient is to
follow up with Dr. Zufelt in one week and is to follow up with
Plastic Surgery in three weeks for evaluation of closure of the
wound. Patient is to follow up with her primary care physician and
her A Triaded Health cardiologist as needed after discharge from
rehab.
Her discharge medications include vitamin C 500 mg orally twice a day ,
glyburide 2.5 mg orally every day , heparin 5000 U subcutaneously three times a day , a sliding
scale of regular insulin , Flagyl 500 mg orally three times a day day 9 of 21 ,
Percocet 1-2 tablets orally every 4-6h. as needed pain , multivitamin
therapeutic with minerals one tablet orally every day , vancomycin 1 g intravenous
every day dosed daily only when the daily vancomycin lab levels are less
than 15 , zinc sulfate 220 mg orally every day , Maalox , levofloxacin 500 mg
orally every day , esomeprazole 20 mg orally every day
DISCHARGE INSTRUCTIONS: DIET: House diet , ADA , 2100 calories a
day. ACTIVITY: As tolerated , no
restrictions , elevate feet for any prolonged sitting periods.
FOLLOWUP: As previously noted , with Dr. Zufelt , Plastic Surgery ,
and A Triaded Health followup.
Dictated By: FLORENCIA KLEMEN , PA
Attending: DESIRAE MARCOTT , M.D. FV86 DM033/286053
Batch: 3095 Index No. QKTS8T10UE D: 5/30/03
T: 5/30/03
Document id: 167
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
074981892 | PUO | 65633683 | | 715127 | 7/2/1997 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Unsigned | DIS | Admission Date: 4/17/1997 Report Status: Unsigned
Discharge Date: 3/15/1997
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE
PROCEDURES PERFORMED: October , 1997 , coronary artery bypass graft
times three with left internal mammary
artery to left anterior descending artery , saphenous vein graft to
posterior descending artery , and saphenous vein graft to diagonal
one.
HISTORY OF THE PRESENT ILLNESS: Mr. Eguia is a 74 year-old
gentleman , status post inferior
myocardial infarction in 1995 , and percutaneous transluminal
coronary angioplasty of the left circumflex in September , 1995. The
patient is also status post stenting of the left anterior
descending artery in September , 1996. After that time , the patient
continued to have chest pain , although with decreased frequency and
intensity. The patient did receive Ticlid for six to eight weeks
following the stenting.
The patient presented with increased frequency and duration of his
chest and epigastric pain. The patient denied shortness of breath ,
orthopnea , paroxysmal nocturnal dyspnea , diaphoresis , nausea or
vomiting.
PAST MEDICAL HISTORY: Significant for coronary artery disease ,
hypertension , hyperlipidemia , paroxysmal
atrial fibrillation in 1982 , osteoarthritis and diet controlled
diabetes mellitus.
ALLERGIES: Amoxicillin , which gives him arthritis.
MEDICATIONS: Enteric coated aspirin 325 milligrams orally every day;
Imdur 120 milligrams orally every day before noon and 60 milligrams
orally every afternoon; Cozaar 100 milligrams orally every day before noon; Atenolol 50
milligrams orally every day; Norvasc 5 milligrams orally twice a day
SOCIAL HISTORY: The patient has no smoking history and rarely
drinks alcohol.
PHYSICAL EXAMINATION: Sclerae are anicteric. Oropharynx without
lesions. Carotids 2+ without bruits. The
neck is supple. The lungs are clear to auscultation.
Cardiovascular examination is a regular rate and rhythm with an S4.
Normal S1/S2. Abdomen is soft , nontender , nondistended , with
normal active bowel sounds. Extremities are without edema.
Dorsalis pedis pulse and posterior tibial pulse and femoral pulses
are 2+ bilaterally without bruits in the femoral arteries.
Neurological examination is without gross focal abnormality.
LABORATORY DATA: White blood cell count 9.8 , hematocrit 40.8.
Glucose 188 , creatinine 1.8. CK 40.
HOSPITAL COURSE: The patient was admitted to the Medical Service
for management and evaluation of his angina. He
underwent cardiac catheterization on June , 1997 , demonstrating
90% proximal left anterior descending artery stenosis , 99% diagonal
one ostial stenosis; circumflex was okay. The right coronary
artery had a mid stenosis of 50%. The patient arrived in the
Catheterization Lab with mild angina on 200 micrograms per minute
of intravenous nitroglycerin. Post catheterization , the patient
developed 5/10 chest pain with an increasing pulmonary capillary
wedge pressure to 40 and D-waves of 52. Increasing the
nitroglycerin led to resolution of these changes. The patient had
intra-aortic balloon pump placed via the right femoral artery with
return of the wedge to approximately a mean of 6 and his pain was
relieved. The patient returned to the Cardiac Intensive Care Unit
where he underwent aggressive heart rate and blood pressure
control. He was evaluated by Cardiac Surgery and taken to the
Operating Room on October , 1997 , for coronary artery bypass
grafting times three as described above. The patient was
transferred to the Cardiac Intensive Care Unit. Electrocardiogram
remained unchanged. He was extubated without difficulty. The
intra-aortic balloon pump was removed. The patient was noted to
have slight confusion on postoperative day number one and two.
Lopressor was restarted and the patient was gently diuresed. His
chest tubes were discontinued. On postoperative day number three ,
the patient was noted to be slightly more confused with left facial
droop and aphasia that resolved with mild left lid lag in the early
afternoon. The patient was evaluated by Neurology. A head CT scan
was performed , demonstrating no hemorrhage or acute stroke. There
was a small left cerebellar hemisphere lesion that was believed to
be consistent with a lesion that was greater than 24 hours old.
The patient , however , became progressively encephalopathic. The
patient underwent an echocardiogram and carotid studies , which
demonstrated no evidence of embolic source. The patient's
expressive aphasia and facial weakness , however , recurred. The
patient again underwent head CT scan , demonstrating acute right
parietal infarction that appeared cortically based. Given the
recent intra-aortic balloon pump placement , the aorta could not be
ruled out as a source for embolus. Therefore , heparin was started ,
as was Coumadin. The goal INR is 2 to 3. Also the patient had a
history of paroxysmal atrial fibrillation , and although had no
evidence of atrial fibrillation , there was concern over potential
cardiac source for embolization. The patient's aphasia and left
facial droop improved steadily. He was evaluated by the Speech and
Swallowing Service. He had no difficulty with swallowing; however ,
it was felt that he would benefit from language therapy in addition
to his physical therapy and occupational therapy. The remainder of
the patient's course was uncomplicated from a cardiac standpoint.
His chest x-ray prior to discharge demonstrated very small left
sided effusion without any significant failure.
DISPOSITION: The patient will be transferred to rehabilitation
for reconditioning and intensive speech , physical
therapy and occupational therapy. He will follow-up with Potwood Kinlis Wellscajohns Health Center
Cardiology in one to two weeks. He will follow-up with Dr. Stukowski
in four to six weeks. He will receive physical therapy ,
occupational therapy and speech therapy. He must also follow-up
with his internist , as he has been requiring a sliding scale
insulin dosing , with previously diet controlled diabetes.
DISCHARGE MEDICATIONS: Tylenol #3 one to two tablets orally every 3-4h.
as needed pain; Colace 100 milligrams orally
three times a day; sliding scale insulin; Lopressor 50 milligrams orally twice a day;
Coumadin , with goal INR of 2-3 , to be dosed every day after checking a
prothrombin time.
Dictated By: SHERISE WANKUM , M.D. YC13
Attending: JANAY D. STUKOWSKI , M.D. GV72 PA711/2263
Batch: 0035 Index No. K8GS6Y9EZM D: 4/27/97
T: 4/27/97
Document id: 168
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
Y |
Y |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
N |
Y |
Y |
Y |
N |
N |
N |
N |
N |
N |
304719250 | PUO | 72839397 | | 8924448 | 7/24/2006 12:00:00 a.m. | VOMITING | Signed | DIS | Admission Date: 6/5/2006 Report Status: Signed
Discharge Date: 12/10/2006
ATTENDING: STEVINSON , DEE M.D.
PRIMARY CARE PHYSICIAN: Dr. Carletta Tetrick of MMC .
PRINCIPAL DIAGNOSIS: Vomiting and hypertension.
OTHER PROBLEMS AND DIAGNOSIS: Include diabetes , end-stage renal
disease , gout , hypercholesterolemia , and primary biliary cirrhosis.
HISTORY OF PRESENT ILLNESS: This is a 51-year-old woman with
end-stage renal disease on three times a week hemodialysis who
vomited during hemodialysis on the day prior to admission. She
completed her hemodialysis , went home , and continued to have
multiple episodes of non-biliary emesis. She was unable to take
orally's including her antihypertensive medications. She did not
report any change in appetite though she was reluctant to eat due
to concerns about vomiting. She did not have any sick contacts.
She did go to a barbeque over the weekend but no one else at the
picnic was known to be sick. She does not feel feverish per se
but does report some sensation of feeling heated while at dialysis ,
no chills. She has had normal bowel movements. She does report
a cough , which is productive of clear sputum. No chest pain , no
shortness of breath. She does have some abdominal pain that
occurs with her vomiting and retching. No visual changes from
baseline. She also reports dysuria and some increased frequency
of urination on the morning of admission. Of note , the patient
has been admitted in July of this year with
a similar presentation of nausea and vomiting with increased blood
pressures , which resolved with treatment for nausea and the
resumption of her blood pressure medications.
MEDICATIONS: Her medications prior to admission included regular insulin
on a sliding scale , aspirin 81 mg per day ,
Plavix 75 mg per day , metoprolol 50 mg three times a day ,
nifedipine 30 mg four times a day , losartan 100 mg once a day ,
allopurinol 100 mg every other day , Nexium 20 mg once a day , ursodiol
300 mg once a day , and Colace twice a day. The patient also
reports taking clonidine 0.1 mg three times a day.
PAST MEDICAL HISTORY: Remarkable for end-stage renal disease on
hemodialysis three times a week , diabetes mellitus type 2 with
retinopathy and neuropathy , hypertension , coronary artery disease
status post stent x4 in September 2005 , shown on repeat cardiac
catheterization in October 2006 to be patent , gout , primary
biliary cirrhosis , hypercholesterolemia , polymyalgia rheumatica. She is also
status post hysterectomy and status post cataract
surgery.
ALLERGIES: Though she does not report having any drug allergies , her
chart notes unspecified reactions to orally
hypoglycemics and calcitriol.
SOCIAL HISTORY: She does not use tobacco and does not drink
alcohol. She lives with relatives.
PHYSICAL EXAMINATION: On admission , the patient's vital signs
were temperature 97.8 , heart rate 79 , blood pressure 148/79. Her oxygen
saturation was 95% on room
air. She was not in any acute distress. Her JVP was flat. Her
mucous membranes were moist. She did not have cervical
lymphadenopathy. Her lungs were clear. Her cardiovascular exam
showed regular rate and rhythm with a loud 3/6 systolic murmur best
heard at the left upper sternal border. Her abdomen was
nontender and nondistended. Bowel sounds were present. No
hepatosplenomegaly was noted on exam. She did not have rebound
or guarding. She did not have lower extremity edema. Distal pulses
were present.
LABORATORY DATA: Pertinent labs on admission include: white
blood cell count of 4 with 81% polys and hematocrit of 35.5. Her
bilirubin was slightly elevated at 1.3. Her amylase was 82. Her
lipase was 15. Her EKG showed sinus rhythm. Studies included a
chest x-ray on 10/28/06 , which showed stable cardiomegaly with
some interval progression in her mild interstitial edema and
stable bilateral effusions. She had a CT of her abdomen and
pelvis on 10/19/06 , which showed small bilateral pleural
effusions and a small pericardial effusion , splenomegaly with a
spleen measuring 16 cm. The liver appeared normal other than for
an area of focal fat or perfusion anomaly adjacent to the
falciform ligament. Gallstones were present. The stomach and
the small bowel were decompressed. There were no findings to
explain nausea or vomiting , and there was no evidence of bowel
obstruction. The patient also had an MR angio of the abdomen on
10/19/06 , which was unremarkable. Splenomegaly , cholelithiasis ,
and a trace pericardial effusion were noted.
HOSPITAL COURSE BY PROBLEM: This is a 51-year-old woman with a
history of end-stage renal disease who presented with nausea and
vomiting and hypertensive urgency likely secondary to her
inability to tolerate her orally blood pressure medications.
1. GI. The patient had nausea and vomiting , which was
controlled with Reglan initially intravenous. She was then transitioned to
orally She had resolution of her nausea , but the nausea returned
when the Reglan was stopped , so she was maintained on a standing
dose of 5 mg Reglan before meals. An abdominal CT was done
and did not find evidence of obstruction or any other findings to
explain nausea or vomiting. An MR angiogram of the abdomen was
also done to evaluate for the possibility of vascular disease ,
but this exam was unremarkable.
2. Cardiovascular. There was concern for demand ischemia given
the patient's history of coronary artery disease and high blood
pressure. She did have a troponin of 0.38 , which came down to
0.25 , and then was undetectable. With treatment for nausea , the
patient was able to take her orally medications and her blood
pressures were controlled. Her metoprolol dose was increased to
75 three times a day
3. Renal. The patient was continued on Monday , Wednesday ,
Friday hemodialysis while she was in the hospital.
4. ID. The patient continued to have a low-grade temperature
while she was in the hospital. Multiple blood cultures were
drawn , which did not show any growth. She did have one UA , which
showed bacteria but which also had epithelial cells. She did
receive a seven-day course of antibiotics. She was
initially started on levofloxacin , vancomycin , and Flagyl given
concern for an abdominal process and then was switched and
covered briefly with ceftazidine before continuing the rest of
her course on levofloxacin. The patient was also tested for
tuberculosis given her persistent fevers and her history of
cough. She had a PPD placed on the day of discharge , which will
need to be read at dialysis on 6/15/06 . The patient's
allopurinol was discontinued due to a concern that it could be
contributing to her fever.
5. Endocrine. The patient was maintained on an aspart sliding
scale and had modest blood glucose levels in the 100s.
6. Rheumatic. The patient had persistent fevers. She also had a
history in her chart of polymyalgia rheumatica though she was
not familiar with this diagnosis. She had an elevated ESR of 102
and an elevated CRP of 184. She also had a history of
hilar adenopathy seen on previous chest CT scans. A repeat chest
CT has been ordered and is pending at the time of discharge. The
Rheumatology Service was consulted and evaluated the patient. An
SPEP and IPEP were ordered to rule out gammopathy , and ANA was
ordered along with complement studies and antimitochondrial
antibodies. The results of these tests are pending and the
patient has been scheduled to follow up in the PUO Rheumatology Clinic
the week after discharge.
7. Consultants. The patient was seen by Dr. Fran Bussler of the MMC
Hematology Service and by the Rheumatology Service.
PHYSICAL EXAMINATION AT DISCHARGE: On the day of discharge , the
patient was afebrile with a temperature of 97.3 , heart rate of
69 , and blood pressure of 155/77. Her oxygen saturation was 95%
on room air. Her physical exam was not significantly changed.
Her abdomen was benign. Her lungs were clear. Her heart had a
regular rate and rhythm with a systolic murmur.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily , clonidine 0.1 mg
three times a day , Plavix 75 mg orally daily , Nexium 20 mg orally daily ,
losartan 100 mg orally daily , Reglan 5 mg orally before every meal and bedtime ,
metoprolol 75 mg orally three times a day , nifedipine 30 mg orally four times a day , and
ursodiol 300 mg orally daily.
eScription document: 7-2459120 CSSten Tel
CC: Carletta Marie Tetrick MD
Sa Tope More
Dictated By: HENDY , CLARETHA
Attending: STEVINSON , DEE
Dictation ID 2749614
D: 10/11/06
T: 9/29/06
Document id: 169
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
540051921 | PUO | 40400548 | | 4134998 | 8/5/2005 12:00:00 a.m. | COLONIC POLYPS | Signed | DIS | Admission Date: 11/24/2005 Report Status: Signed
Discharge Date: 7/3/2005
ATTENDING: SISEMORE , LIZETTE FLORENTINA MD
PRIMARY CARE PHYSICIAN: Meredith Hepler , MD
PRINCIPAL DIAGNOSIS: Adenomatous polyps at the ileocecal valve.
LIST OF PROBLEMS:
1. Adenomatous polyp at the ileocecal valve.
2. Past history of pulmonary embolism.
3. Diabetes mellitus.
4. Vaginal yeast infection.
HISTORY OF PRESENT ILLNESS: Ms. Wilczewski is a 51-year-old lady who
was found to have an adenomatous polyp at the ileocecal valve ,
which was not amenable to colonoscopy resection. The patient was
referred for colonoscopy after gastrointestinal bleeding was
identified. The patient does have a past history of pulmonary
embolism that was diagnosed in year 2000 that was of unknown
origin and has since been on Coumadin and Coumadin was withheld a
week before her operation , on 1/7/05 . The patient was on
metformin for her diabetes mellitus. This medication was also
withheld on the day of her operation.
PAST MEDICAL HISTORY:
1. Pulmonary embolism in 2000.
2. Diabetes mellitus` type 2.
3. Obesity.
4. Hypercholesterolemia.
5. Probable COPD.
6. Hypertension.
7. Moderate obstructive sleep apnea.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Laparoscopic tubal ligation.
SOCIAL HISTORY: The patient has a long history of smoking. She
smoked about 35 pack years. The patient quit five months ago
before her admission.
ALLERGIES: The patient is allergic to intravenous erythromycin , which
causes rash.
MEDICATIONS:
1. Lipitor 10 mg once a day.
2. Metformin 500 mg in the morning , 100 mg in the afternoon.
3. Coumadin 11 mg.
4. Tylenol as needed for joint pain.
REVIEW OF SYSTEMS: Negative for cardiac , pulmonary , GI , and GU
symptoms.
PHYSICAL EXAMINATION: The patient was obese and in no acute
distress. Lung exam revealed no wheezing or rhonchi. Abdomen
was soft , nondistended and nontender.
LABORATORY DATA: CBC , white blood cell count was 6.5 , hematocrit
was 30.7 , platelet count was 310 , 000.
HOSPITAL COURSE:
1. Adenomatous polyp at ileocecal valve. The patient was
scheduled for a laparoscopic ileocecectomy on 1/7/05 . However ,
the frozen section revealed an invasive adenocarcinoma. The
procedure was converted to an open right hemicolectomy along with
umbilical hernia repair. Postoperative course for the patient
has been rather uneventful and the pathology report revealed that
the tumor is a stage T2 , N0 tumor with no lymph node involvement.
2. Past history of pulmonary embolism. The patient's Coumadin
was withheld a week before operation and the patient was placed
on heparin. Her Coumadin was restarted on 10/13/05 and on her
home dose of 11 mg. Her INR steadily increased over the course
of her hospital stay up to 1.7 at her discharge. The patient
will follow up with her Coumadin Clinic and as well as with primary care physician
to monitor her INR after her discharge.
3. Diabetes mellitus. The patient has diabetes mellitus and her
metformin was withheld on the day of her surgery. During her
hospital course , she was placed on Regular Insulin sliding scale.
Her metformin was restarted on 9/4/05 .
4. Vaginal yeast infection. The patient complained of white
creamy discharge from her vagina on 9/13/05 and miconazole
suppository was prescribed for five days. At the time of
discharge , her discharge from her vagina has resolved.
PHYSICAL EXAM AT DISCHARGE: The patient's heart exam revealed
regular rate and rhythm , no murmurs and lungs were clear. Her
abdomen was obese , but soft and nontender with active bowel
sounds. Her wound was clean , dry and intact. Her INR was 1.7 at
discharge.
DISCHARGE MEDICATIONS:
1. DuoNeb 3/0.5 mg every 6 hours
2. Coumadin 12 mg orally nightly.
3. Lipitor 10 mg orally once a day.
4. Metformin orally 500 mg in the morning , 1000 mg in the
afternoon.
5. Colace 100 mg twice a day orally
6. Dilaudid 2-4 mg every 3 hours orally
The patient was discharged in stable condition. She will arrange
to have her INR draw on 5/7/05 with follow-up INRs to be drain
every two days and INR will be followed by her primary care
physician , Dr. Hepler . The patient is full code.
eScription document: 1-4143335 CS
Dictated By: LALATA , JOHNETTA
Attending: SISEMORE , LIZETTE FLORENTINA
Dictation ID 0821115
D: 4/10/05
T: 4/10/05
Document id: 170
| Target |
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DM |
Gs |
GER |
Gou |
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| output/system_textual_annotation.xml | textual |
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864945124 | PUO | 81278338 | | 7940017 | 1/3/2005 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 10/21/2005 Report Status: Signed
Discharge Date: 9/21/2005
ATTENDING: ROSSIE MANKOSKI M.D.
This discharge summary covers admission 7/30/05 until 9/26/05
PRIMARY ADMISSION DIAGNOSIS: Congestive heart failure.
OTHER MEDICAL DIAGNOSIS: Familial cardiomyopathy.
BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old
man with familial cardiomyopathy and a last ejection fraction of
50% well known to the heart failure service secondary to multiple
admissions for decompensated CHF in the setting of poor medical
and dietary compliance presents with gradual fatigue and
increasing abdominal girth , orthopnea , paroxysmal nocturnal
dyspnea , and feeling "fluid overloaded." He denies any chest
pain , fevers , chills , or other symptoms.
PAST MEDICAL HISTORY: Familial cardiomyopathy , history of an
AICD placed in 2001 , last ejection fraction of 50% with a
biventricular pacing , and severe mitral and tricuspid
regurgitation.
CURRENT MEDICATIONS: Digoxin 0.125 , Isordil 30 three times a day ,
spironolactone 25 twice a day , torsemide 200 orally twice a day , K-Dur 20
once a day , and folate 5 once a day.
ALLERGIES: ACE inhibitors cause a cough and rash and lisinopril
causes cough.
SOCIAL HISTORY: The patient smoked 2 packs per day times
approximately 10 years and drinks occasional ethanol. He denies
any history of other drug use. He is married and is with 2
children. He does not work currently secondary to his
cardiomyopathy. He also has a brother who is status post cardiac
transplant.
EXAMINATON DATA: Temperature 96 , Pulse 97 , blood pressure 90/70 ,
and oxygen saturation 97 on room air. Admission weight 83.8
kilograms. JVP was greater than the angle of the jaw. Cardiac
exam was regular rate and rhythm with 2/6 systolic murmur at the
apex. Respiratory exam showed a few bibasilar rales. Abdomen
was distended with mild shifting dullness. There was trace
bilateral extremity edema.
LABORATORY VALUES: Creatinine 1.5 , sodium 129 , potassium 2.7 ,
magnesium 2.2 , ALT 32 , AST 31 , hematocrit 40.6 , white blood cell
count 7.3 , platelets 281 , INR 1.2 , PTT 35.4 , and BNP 594.
INITIAL ASSESSMENT: This is a 36-year-old man with familial
cardiomyopathy admitted for CHF exacerbation.
Problem#1. Cardiovascular: The patient was admitted in
decompensated failure. He reports compliance with his
medications; however , likely some component of this
decompensation is secondary to dietary indiscretion with foods
and fluids. The patient was diuresed during his hospital stay
initially with intravenous torsemide; however , this was
unsuccessful and a Lasix drip with BNP drip was started on
hospital day #3. He reached a total weight loss of approximately
2 to 3 kilograms and was converted to orally medicines including
torsemide. Moreover , he failed to maintain a stable weight on
this regimen and ultrafiltration was attempted. That removed
approximately 900 cc of fluids. This failed secondary to
intravenous access clotting and the patient's frustration with
having to lying still. The patient was subsequently converted to
orally torsemide and metolazone , torsemide 200 twice a day , metolazone 5
twice a day , and spironolactone 25 twice a day as an orally regimen. Per the
patient's request and reaching a somewhat adequate goal with this
hospitalization , the patient requested to be discharged. He
reported that he would follow up with the CHF nursing staff and
with Dr. Lyn and although we repeatedly stressed the importance
of free water restriction and fluid restriction , he continued to
be noncompliant with this while inhouse. At the time the patient
was discharged , it was felt that he was not optimal
hemodynamically , but had excellent followup plans and stated that
he would return if his condition worsened.
DISCHARGE MEDICATIONS: Digoxin 0.125 once a day , Isordil 10
three times a day metolazone 5 twice a day , spironolactone 25 twice a day , torsemide
200 twice a day , and K-Dur 60 twice a day
There are no pending studies at the time of discharge. The
patient will follow up with the CHF nurse in approximately 2 days
and see Dr. Lyn in clinic within 1 week.
eScription document: 0-4901193 ISSten Tel
Dictated By: MARCOTT , DESIRAE
Attending: MANKOSKI , ROSSIE
Dictation ID 8398488
D: 11/6/05
T: 7/20/05
Document id: 171
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
Q |
- |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
N |
N |
N |
- |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
723352006 | PUO | 51637887 | | 967611 | 10/9/1997 12:00:00 a.m. | INFERIOR MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/9/1997 Report Status: Signed
Discharge Date: 4/14/1997
DISCHARGE DIAGNOSIS: Myocardial infarction.
PROBLEM LIST: 1. Status post acute myocardial infarction.
2. Prostate cancer diagnosed September 1997; status post radiation
therapy.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old man
without prior cardiac history. He has
cardiac risk factors including possible hypertension , and possible
history of hypercholesterolemia. The patient has had a history of
atypical chest pain , including a cardiac workup in the past with an
echocardiogram in 1995 showing concentric left ventricular
hypertrophy , asymmetric septal hypertrophy. He had a normal
ejection fraction at this time. In October of 1997 , he had an
exercise tolerance test at which time he went eight minutes , with a
maximal heart rate of 151 , maximal blood pressure 226/90 , and no
electrocardiogram changes. At 2 p.m. on the day of admission he
developed substernal chest pain with a crushing tightness ,
radiating to both shoulders and his jaw. He was not short of
breath. He experiences pain on and off through the afternoon ,
although the pain was never completely gone. At 6 p.m. , he became
acutely worse , and at that time called the EMT and was brought to
A Salt Medical Center Emergency Department. Within the
Emergency Department , the patient was noted to have ST elevations
in the inferior leads. He was enrolled in the NPA/TPA trial.
Infusion was begun at 8:15. The patient was given Lopressor ,
oxygen , morphine , aspirin , and heparin. He did not drop his
pressure with sublingual nitroglycerin.
PAST MEDICAL HISTORY: His past medical history includes prostate
cancer in September 1997 , status post XRT , as well
as a possible transient ischemic attack in 1990.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: Medications included Zantac as needed
FAMILY HISTORY: Family history was negative for coronary artery
disease.
SOCIAL HISTORY: The patient is married with three children. He
denies any tobacco or alcohol use.
PHYSICAL EXAMINATION: Physical examination on admission
demonstrated a well-appearing black male in
no acute distress. Vital signs were a heart rate of 48 , blood
pressure 83/30 in the Emergency Department , he was afebrile , with
oxygen saturation level 99 percent on two liters. HEENT
examination , the oropharynx is benign , he had a left facial droop.
The neck was supple , 2+ carotids without bruit. Jugular venous
distention was normal. The chest was clear to auscultation
bilaterally. The heart had a regular bradycardic rhythm with a 2/6
systolic ejection murmur. The abdomen was soft , non-tender ,
non-distended , positive bowel sounds , no organomegaly. The
extremities were warm and well-perfused , no clubbing , cyanosis or
edema , trace distal pulses. Neurologically , he was alert and
oriented x three , cranial nerves 2 through 12 are grossly intact
except for a left facial droop. Motor and sensory were grossly
intact.
ADMISSION LABORATORY: Admission labs showed a sodium of 144 ,
potassium 4.2 , chloride 108 , bicarbonate of
22 , BUN 16 , creatinine 1.3 , glucose 136. White count was 8 with a
hematocrit of 35 , platelets were 239 , CK was 276 with an MB of 0.8.
Troponin on admission was 0.0. INR was 1.0 , partial thromboplastin
time was 22.6. The patient's first electrocardiogram in the
Emergency Department showed normal sinus rhythm at 70 with
first-degree AV block , axis of 56 degrees. He had ST elevations of
4 millimeters in leads 3 and aVF , 3 millimeters in 2 , ST depression
0.5 to 3 millimeters V2 through V5 , 1 and aVL. Chest x-ray did not
showed acute disease in the Emergency Department.
HOSPITAL COURSE: Within the Emergency Department , the patient
initially had resolution of his electrocardiogram
changes , but had persistent jaw pain , remaining at 5/10. He was
taken to catheterization , which demonstrated a mid right coronary
artery lesion of approximately 95 percent with a clot , but with
TIMI-III flow. No intervention was done at that time. The patient
initially required vigorous intravenous hydration to maintain good
blood pressure , but remained essentially stable and pain-free. He
had a drop in hematocrit from 35 on admission to 28 after his
catheterization secondary to blood loss of the right femoral triple
lumen site placed in the Emergency Ward prior to tPA , blood loss at
catheterization , small hematoma and dilution. He was given two
units of packed red blood cells with an appropriate bump in his
hematocrit. The patient was then transferred to the Floor , where
he maintained his good course. He had no postcatheterization or
post myocardial infarction chest pain. The decision was then made
to take the patient back to the Catheterization Laboratory to have
percutaneous transluminal coronary angioplasty with stenting of
this lesion , and to see if it continued to persist.
Dictated By: ALEJANDRA DEERDOFF , M.D. VU38
Attending: KATHERYN SATURNINA GRUNTZ , M.D. XE9 JB463/3847
Batch: 33280 Index No. O7RDM27AWP D: 4/26/97
T: 10/28/97
Document id: 172
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
- |
N |
N |
N |
483324190 | PUO | 56537889 | | 0649718 | 7/14/2007 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 3/17/2007 Report Status: Signed
Discharge Date: 1/7/2007
ATTENDING: GOLEBIOWSKI , LOIDA MD
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Mr. Maness is a 78-year-old gentleman who presented with
increasing dyspnea on exertion and New York Heart
Association Class III heart failure. The patient also complained of fatigue
over the last four years prior to admission. He currently denied
any angina , diaphoresis , nausea , orthopnea , PND , presyncope or
syncope. The patient had been treated with serial transthoracic
echocardiograms which revealed an ejection fraction worsening
from 60% down to 40% along with aortic stenosis. The patient underwent
cardiac catheterization , which revealed no significant coronary artery disease
and elevated left and right
heart filling pressures. Cardiac catheterization was abandoned
prematurely due to the increasing filling pressures. Echocardiogram was
performed which revealed an ejection fraction of 40% , aortic stenosis with a
mean gradient of 31 mmHg , a peak gradient of 50 mmHg , calculated valve
area of 0.7 cm2 , mild mitral insufficiency , mild tricuspid
insufficiency , mild left atrial enlargement , moderately
hypertrophied left ventricle , global reduction in left
ventricular function more in the apex of the left ventricle
mildly enlarged right ventricle with preserved right ventricular
function , heavily calcified trileaflet aortic valve with
significant restriction and leaflet excursion , reduction left
ventricular function compared to previous transthoracic echo one
year prior to this present study.
PAST MEDICAL HISTORY:
Significant for class III heart failure with marked limitation of
physical activity , diabetes mellitus insulin-dependent ,
dyslipidemia , cardiac arrest , status post cardiac catheterization
on 7/13/05 . The patient's course was complicated by marked
bradycardia requiring insertion of a temporary pacemaker via a
right internal jugular and then complete heart block requiring a
St. Jude dual chamber pacemaker and generator.
PAST SURGICAL HISTORY:
Significant for permanent pacemaker placement , status post
cholecystectomy , history of skin cancer , and status post
tonsillectomy.
ALLERGIES:
Patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
Atenolol 12.5 mg daily , aspirin 325 mg daily , metformin 500 mg
twice a day , and Humalog insulin 12 units four times a day
PHYSICAL EXAMINATION:
Per physical exam , 5 feet 10 inches tall , 138 kilograms ,
temperature 96 , heart rate 80 and regular , blood pressure right
arm 110/65 , left arm 112/60 , oxygen saturation 98% on room air.
Cardiovascular: Regular rate , and rhythm with 2/6 systolic
ejection murmur. Peripheral vascular 2+ pulses bilaterally
throughout. Respiratory: Breath sounds clear bilaterally.
Neurologic: Alert and oriented with no focal deficits ,
otherwise noncontributory.
ADMISSION LABS:
Sodium 140 , potassium 4.0 , chloride of 106 , CO2 27 , BUN of 13 ,
creatinine 0.8 , glucose 156 , and magnesium 1.9. WBC 5.91 ,
hematocrit 46 , hemoglobin 16.4 , platelets of 181 , 000 , physical therapy of 12.9 ,
physical therapy/INR of 1 , and PTT 28.1.
HOSPITAL COURSE:
Mr. Maness was brought to the operating room on 7/9/07
where he underwent a minimally invasive aortic valve replacement
with a 25-mm Carpentier-Edwards pericardial valve. Total bypass
time was 101 minutes , total crossclamp time was 63 minutes. Intraoperatively ,
the patient was found to have a calcified trileaflet
aortic valve. The patient came off bypass without incident , was brought to the
Intensive Care Unit on 3 mcg of epinephrine and insulin and
Precedex. The patient did well and was brought up in stable
condition in normal sinus rhythm. Postoperatively , the patient
was extubated and the Electrophysiology Service was consulted to
evaluate his internal pacemaker which was reprogrammed and
functioning well. The patient continued to require vigorous
diuresis with a Lasix drip. He was extubated on postoperative day #1 without
incident. The patient was transferred to the Step-Down Unit on
postoperative day 5. The patient experienced some postoperative
tachycardia and his beta-blocker was increased with good result.
He was also found to have a positive urinary tract infection and
was started on ciprofloxacin for a total of five days. The
patient at one point required 5 liters of nasal cannula to get
his saturations in the 90s. He did continue to require
intravenous Lasix but had weaned Lasix drip and had intermittent
boluses of 40 mg intravenous to promote diuresis with good result. He was
weaned off his oxygen and the patient began to ambulate and was
cleared for discharge to home with visiting nurse on
postoperative day #9.
DISCHARGE LABS:
Are as follows sodium 139 , potassium 4.0 , chloride of 102 , CO2 of
30 , BUN 15 , creatinine 0.8 , glucose 163 , magnesium 1.8 , WBC 9.52 ,
hematocrit 33.1 , hemoglobin 10.8 , platelets of 286 , 000 , physical therapy 14.6 ,
physical therapy/INR of 1.1.
DISCHARGE MEDICATIONS:
Are as follows: Ciprofloxacin 500 mg every 6 hours for remaining four
doses , baby aspirin 81 mg daily , Lasix 40 mg twice a day , for three
days along with potassium chloride slow release 20 mEq twice a day for
three days , Motrin 400 mg every 8 hours as needed pain , NovoLog 24 units
subcutaneously before every meal , Lantus 60 units subcutaneous every 10 p.m. , Toprol-XL
300 mg daily , patient was also discharged on NovoLog sliding
scale subcutaneous before every meal Mr. Maness will follow up with Dr.
Loida Golebiowski in six weeks and his cardiologist Dr. Jackson E Part in one week.
DISPOSITION:
He is discharged to home in stable condition with visiting nurse.
eScription document: 8-2640197 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 4635588
D: 10/3/07
T: 10/3/07
Document id: 173
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
- |
Y |
N |
- |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
Y |
615038343 | PUO | 94076394 | | 6670088 | 11/22/2003 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 11/22/2003 Report Status: Signed
Discharge Date: 11/19/2003
ATTENDING: DESIRAE ROBERTA MARCOTT MD
DISPOSITION: Rehabilitation.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed
headache , vitamin C 500 mg orally twice a day , enteric-coated aspirin
325 mg orally every day , calcitriol 0.25 mcg orally every day , PhosLo 1334 mg
orally three times a day , Colace 100 mg orally twice a day , doxepin 10 mg orally
three times a day , Epogen 40 , 000 units subcutaneous every week , Lasix 80 mg
orally twice a day , NPH insulin 8 units subqutaneously every day before noon , Regular
insulin sliding scale , lactulose 30 mL orally four times a day , Maalox 50 mL
orally every 6 hours , as needed indigestion , magnesium , Hydrocet 30 mL orally
every day as needed constipation , Lopressor 100 mg orally three times a day , Bactroban
topical twice a day apply to affected areas , Serax 15-30 mg orally
every bedtime as needed insomnia , Percocet 1 tablet orally every 6 hours as needed
headache , sodium bicarbonate 650 mg orally three times a day , MVI therapeutic
with minerals 1 tablet orally every day , Zoloft 50 mg orally every day , Proscar
5 mg orally every day , Zocor 40 mg orally every bedtime , sotalol 40 mg orally
twice a day , Flonase 1-2 sprays inhaled every bedtime , Flomax 0.8 mg orally
every day , Mirapex 0.5 mg orally three times a day , miconazole 2% powder topically
applied twice a day to affected areas , Nexium 20 mg orally every day , DuoNeb
3/0.5 mg nebs every 6 hours as needed wheezing , Atrovent 0.06% 2 sprays
inhaled twice a day
The patient is to measure weight daily.
DIET: Low cholesterol , low saturated fat.
ACTIVITY: Walking as tolerated.
FOLLOWUP: Followup appointment with Dr. Escher , his primary care physician ,
next available.
ALLERGIES: Ciprofloxacin and Codeine.
ADMITTING DIAGNOSES:
1. CHF.
2. Cellulitis.
OTHER DIAGNOSES:
1. Obesity.
2. Type 2 diabetes.
3. Hypertension.
4. High cholesterol.
5. Ventricular tachycardia.
6. Restless legs syndrome.
7. Sleep apnea.
8. Recurrent UTIs.
9. Left ear deafness.
OPERATIONS AND PROCEDURES: None.
OTHER TREATMENTS AND PROCEDURES: None.
HISTORY OF PRESENT ILLNESS: The patient was admitted with a
chief complaint of an increased shortness of breath at rest and
increased sleepiness in the daytime. He is a 61-year-old with
multiple medical problems , sent to Ahohi after
treatment for lower extremity cellulitis on 10/9/2003 at I Warho Hospital . He was doing well and cellulitis was
improving and participating in physical therapy until 2 weeks
when he became progressively increased shortness of breath with
exertion. He has orthopnea at baseline but no PND , no increased
swelling of lower extremities , also had increased daytime
sleepiness ____ conversation while eating earlier in the day than
previously.
REVIEW OF SYSTEMS: He denies fevers , chills , nausea , vomiting ,
cough , or abdominal pain. He reports occasional chest pain at
rest lasting 2-3 minutes without radiation not associated with
shortness of breath or diuresis. His last episode of chest pain
was 3 days ago. He denies palpitations. He has had 3 episodes
of gross hematuria but no abdominal pain , no frequency , or
dysuria. Also complains of shoulder and neck pain , cramping ,
constant at 4/10 , not improved or worsened with movement , not
better or worsened anytime of the day. Rehab reports increased
ammonia on his labs. The patient has been given increased doses
of lactulose and has now continuous diarrhea times several days
but no blood in his stool. The patient urinates every 1-1/2
hours.
PAST MEDICAL HISTORY: Significant for obesity , obstructive sleep
apnea , restless legs syndrome , hypertension , congestive heart
failure , right ventricular hypertrophy , status post MI with an
echo in October 2003 showing EF of 70% , diabetes , peripheral
neuropathy , and new light chain gammopathy , chronic renal
insufficiency , cellulitis , panniculitis , venous insufficiency ,
frequent UTIs , and BPH.
MEDICATIONS: His medications on admission are the same as his
medications on discharge.
PHYSICAL EXAMINATION: On admission , he was afebrile. His vital
signs were stable. He was sleepy , unable to stay awake
throughout the interview. His neck was supple. His JVP was 15
cm. His chest had crackles at the bases. His heart was regular.
His abdomen was obese. His extremities were warm , well perfused
and wrapped. On neurologic exam , he was alert and oriented x3 ,
sleepy , with poor dentition , decreased reflexes throughout ,
decreased sensation below the knee , no asterixis , but an
intention tremor.
HOSPITAL COURSE: Cardiovascularly , he was continued on his home
medications and given intravenous Lasix , ____ 1-2 liters , negative. An
echo showed an EF of 40-45% with global dysfunction but no
regional wall motion abnormality. His BNP was checked on
admission and was found to be 761. He was kept even to negative
daily at the time of discharge. He was euvolemic on Lasix 80 mg
orally twice a day
Pulmonary wise , he has obstructive sleep apnea. The patient
provided his own CPAP and that was checked by respiratory and
found to be adequate.
Renal wise , he had a chronic renal insufficiency with a
creatinine baseline at 4. The goal was to have him negative 1
liter per day. A renal ultrasound was checked that was within
normal limits and showed no hydronephrosis.
ID wise , his UA was positive. A Foley was placed on admission
for volume monitoring. He had too-numerous-to-count whites on
admission and received 5 days of Augmentin for presumed UTI.
Endocrine wise , he has diabetes. He was admitted on glyburide
and this was discontinued secondary to rise in creatinine. He
was placed on subcutaneous NPH insulin and regular sliding scale ,
which may be changed over to orally glucose control agents as an
outpatient.
The patient was discharge to Bussadd Southrys Community Hospital for further care ,
wound dressing care for his lower extremity ulcer , and physical therapy and OT.
On discharge , he was stable.
PLAN: Plan is to follow up with Dr. Huff regarding his
pulmonary status , to rehab for further physical therapy/OT and wound care. The
patient needed his CPAP mask replaced and humidifier added. He
should be on CPAP 16 cm of water while sleeping. He was to
follow up with Dr. Fran Bussler in Nephrology , Dr. Malachi in
Hematogy , and his primary care physician , Dr. Helene Escher .
eScription document: 9-3032126 BFFocus
Dictated By: RUNNING , HYON
Attending: DANIEL , CORAZON MERTIE
Dictation ID 3689591
D: 11/29/03
T: 10/9/03
Document id: 174
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
- |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
897690089 | PUO | 19068324 | | 8497097 | 2/6/2006 12:00:00 a.m. | CHF | | DIS | Admission Date: 2/20/2006 Report Status:
Discharge Date: 10/7/2006
****** FINAL DISCHARGE ORDERS ******
SHALASH , MARLANA S 645-11-64-9
Garlfaydale T Beach
Service: MED
DISCHARGE PATIENT ON: 10/24/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCCOLGAN , LISBETH CARROLL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASPIRIN ENTERIC COATED 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally BEDTIME
CALCIUM + D ( 250 MG ELEM. CA ) ( CALCIUM CARBON... )
1 TAB orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FEXOFENADINE HCL 60 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LASIX ( FUROSEMIDE ) 60 MG orally DAILY
Starting Today ( 6/7 )
METFORMIN 500 MG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SPIRONOLACTONE 12.5 MG orally DAILY
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 7/12/06 by
DUSSAULT , LARAINE , M.D.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: monitor
DIOVAN ( VALSARTAN ) 80 MG orally DAILY HOLD IF: SBP<90
Alert overridden: Override added on 7/12/06 by
DUSSAULT , LARAINE , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: monitor
Number of Doses Required ( approximate ): 4
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
CARDIOLOGY DR PREWER ( 048 ) 968-4013 7/17/06 @ 3:00 PM ,
ALLERGY: Erythromycins , LISINOPRIL
ADMIT DIAGNOSIS:
SOB
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , DM II , Hypercholesterolemia , OA , PMR , Osteoporosis , catarcts.
OPERATIONS AND PROCEDURES:
MIBI
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Echo
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB for 1-2 weeks
Dx: CHF
****
HPI: 79F funciotnal , with HTN , DM II , and hyperlipidemia , who
presents with 1-2 weeks of new DOE- reports getting short of breath
after 1 flight of stairs , or even when going to the bathroom , however
continue to preform all ADLs. She also noted bilateral LEE , PND , and
fatigue. She has HTN that was well-controlled , so as her DM II. Her last
Echo in 2004 showed EF of 60% with LVH.
ROS is otherwise negative for orthopnea , change in appetite , or weight ,
new flu- like symptoms , history of DVT and pain in calfs. Dx'd with
borderline hyperthyroidism few months ago , discontinued
Methimazole 1 month ago.
****
PMH: HTN , DM II , Hyperlipidemia , OA , history of LKR , B/L hip replacement ,
PMR , Osteroperosis , pulmonary nodule ( stable ) , hyperthyroidism ,
catarcts , macular degeneration.
****
home meds: Triametrene/HCTZ , ASA , Iron , Metforrmin , Lipitor ,
Prilosec , Diovan , Calcium+D , Fexofenamine.
****
Allergies: Erythromycin , ACE-I
****
Physical exam on admission:
T-97.0 , HR-60R , BP-138/90 , RR-24R , O2sat-95% RA
NAD , clear o-p , no thyromegaly , JVP-16cm , +HJR.
Laterally displaced PMI , RRR , S1 , S2 , +S3 gallop , on MRG.
Bibasillar rales in both bases ( 1/3 up ). Abd is soft , NTND , no
HSM. Ext- warm , 2+ LEE , peripheral LE neuropathy ( loss of proprioception )
DP 2+/2+.
****
Hospital course:
This is a lovely 79 year-old lady with multiple risk factors for
atheroscosis , including long standing HTN with evidence of LVH on Echo
from 2004 , DM II complicated by neuropathy , hyperlipidemia , and age.
She presented with overt symptoms and clinical signs of congestive heart
failure , including complaints of progressive shortness of breath , PND ,
fatigue , and peripheral edema. Her physical exam was significant for an
elevated JVP , lower extremity edema , pulmonary rales , laterally displaced
PMI , and S3 gallop , all consistent with heart failure. Even though the
patient had cardiolmegaly on CXR from 2004 , her LVEF was about 60% ,
suggesting a recent development of CHF. Her EKG showed NSR with new LBBB ,
and no QW. Due to her multiple atherosclerotic risk factors , new LBBB ,
and evidence of neuropathy , the initial impression was that she had a
recent ischemic event. Three sets of cardiac enzymes were negative
during her first 24 hours stay. She had a stress MIBI showing no
scars or evidence of reversible ischemia with a calculated EF of 23%. An
Echo showed dilated LV , with globaly reduced LE function and near normal
pulmonary pressures , suggestive of dilated cardiomaypathy. Extensive
interviewing of the patinet was negative for other possible etiologies of
HF , TSH and A1C were normal , and and the cause of her dilated CMP
remained undifined. she was diuresed to a dry weight of 57Kg , responded
well to orally Lasix ( 40-60mg ) , treated also with Toprol XL 25mg , and
Spironolactone 12.5mg. Her symptos completely resolved both at rest and
with gentle ambulation. One can argue toward evaluating her coronaray
arteries either by cath or CTA to exclude balanced ischemia. However
considering her age , no changed in EKGs , negative MIBI , and an Echo with
globaly reduced EF , we choose to medicaly treat her. she will be
evaluated in the future for AICD/CRT , then a cath can also be considered.
She will follow up with Dr. Fernande Prewer .
ADDITIONAL COMMENTS: 1. Please go to your primary care within a week to check your potassium
levles.
2. Please avoid salty food ( and don't add to food ).
3. weight yourself twice weekly.
4. Attend your appointment in the cardiology clinic.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check Chem-7
2. Follow weight.
3. In six months eval for CRT/AICD
No dictated summary
ENTERED BY: DUSSAULT , LARAINE , M.D. ( YJ28 ) 10/24/06 @ 11:47 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 175
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
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- |
- |
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- |
- |
024104019 | PUO | 60851490 | | 044332 | 11/10/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 5/24/1990 Report Status: Unsigned
Discharge Date: 10/20/1990
PRINCIPAL PROBLEM: CORONARY ARTERY DISEASE.
PROBLEM LIST: 1. CORONARY ARTERY DISEASE.
2. HYPERTENSION.
3. ARTHRITIS.
CHIEF COMPLAINT: Mr. Laxen is a 63 year old man with a
history of progressive angina and a positive
exercise tolerance test here for cardiac catheterization.
HISTORY OF PRESENT ILLNESS: CARDIAC RISK FACTORS: Hypertension ,
positive family history; there is no
diabetes. There is a questionable high cholesterol. There is a
positive tobaco history. This 63 year old man has had hypertension
for two years treated with Tenormin. Approximately eight months
ago , he noted the onset of right arm pressure on exertion walking
up five flights of stairs to his job as a brick layer , and relieved
by rest. He had no episodes of rest pressure. This was associated
with neck tightness and shortness of breath. There was no nausea ,
vomiting , or diaphoresis. He denied paroxysmal nocturnal dyspnea ,
orthopnea , or pedal edema. He has noted two episodes of discomfort
at night associated with shortness of breath which resolved
spontaneously in five minutes. On 2/25/90 , he underwent an
exercise tolerance test , and he went 3 minutes and 34 seconds with
a heart rate of 97 , blood pressure 160/80. After one minute , he
noted left arm tightness and jaw pressure , and the EKG showed 2 mm
of ST depression in III , III F , V4-V5 , and after three minutes ,
actually noted chest tightness as well. He now presents for
cardiac catheterization. PAST MEDICAL HISTORY: Is significant for
arthritis. Status post appendectomy. Hypertension and angina.
MEDICATIONS ON ADMISSION: Include Tenormin 50 mg orally q-day ,
Isordil 40 mg orally three times a day , however , he did not take the isordil
secondary to the headache , Ecotrin one orally q-day. ALLERGIES:
There are no known drug allergies. SOCIAL HISTORY: He had a
tobacco history of one to two packs per day for ten years. He quit
five years ago. There is no alcohol use , no intravenous drug
abuse. He is a retired brick layer and retired earlier this year.
FAMILY HISTORY: Is positive for an uncle who had a myocardial
infarction , and the father had diabetes.
PHYSICAL EXAMINATION: This is an obese white male in no apparent
distress. The pulse is 50 and regular ,
blood pressure 130/80 , respirations 18 , temperature 97.2. The
HEENT exam was benign. Neck: He had a flat JVP. Carotids were 2+
bilaterally. The lungs were clear to auscultation. Cardiovascular
exam: He had a normally placed PMI , distant heart sounds , positive
S4 , no murmurs noted. The abdomen was obese , nontender. Rectal
exam: Normal tone. The prostate was non-nodular. He had heme
negative stools. Pulses: The peripheral pulses were intact. He
had left medial malleolar brawny skin.
LABORATORY EXAMINATION: He had normal electrolytes , a creatinine
of 1.3 , normal liver function tests. His
hematocrit was slighlty low at 38.8 with a slight high MCV of 95.3 ,
and a high MCH of 32.9. His cholesterol was 267 , triglycerides
296. The physical therapy was 11.6 , and the PTT was 31.4. The urinalysis was
benign. EKG showed normal sinus rhythm at a rate of 43 , and a
negative 30 degree axis , intervals .18/.08/.42 , and he had Q's in
II , III and F , and flat ST segments. He had T-wave inversions in
III. His chest x-ray showed no acute disease. There was no
cardiomegaly.
HOSPITAL COURSE: The patient was admitted , and he underwent
cardiac catheterization on 10/5/90 . He was found
to have normal RA pressures but lightly high RV pressure of 38/10 ,
wedge 12 , cardiac output 9.2 , and a cardiac index of 4.3. His SVR
was 878 , and the PVR was 104. He had an 80% proximal LAD lesion.
His other vessels were good. The next day , on 2/10/90 , he
underwent laser angioplasty of his LAD with good results , however ,
while the sheaths were in after the procedure , he developed left
arm tightness. Re-injection of his coronaries showed clot in the
LAD , and he underwent balloon angioplasty of the lesion with good
result. The patient experienced no more chest and no more arm
discomfort or jaw discomfort during this admission. The only
complication of the procedure was a left groin hematoma which was
stable , and he had a stable hematocrit as well. No bruits were
noted over his femoral arteries. The patient was noted to have an
anemia , a mild macrocytic anemia , on admission. Workup for this
concluded a normal ferritin , normal iron , normal TIBC , with a
saturation index of 22%. He had a normal B12 and a normal folate.
The thyroid functions were within normal limits. His reticulocyte
count was mildly decreased at 0.4.
COMPLICATIONS: There were no significant complications ono this
patient's admission.
DISPOSITION: DISCHARGE MEDICATIONS: Included Tenormin 50 mg orally
q-day , Isordil 20 mg orally three times a day , Ecotrin one orally
q-day. The patient was in good condition upon discharge. He is
discharged to home. FOLLOWUP: He will followup with his own
cardiologist , Dr. Part , in one to two weeks.
________________________________ LJ808/8174
ROSSIE MANKOSKI , M.D. BJ95 D: 4/10/90
Batch: 1914 Report: N1966A5 T: 6/24/90
Dictated By: MARCELINE NEWYEAR , M.D.
cc: JACKSON E. PART , M.D.
Land
Document id: 176
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
- |
- |
N |
N |
N |
532820630 | PUO | 23787995 | | 1808723 | 2/3/2006 12:00:00 a.m. | FAILURE TO THRIVE | Signed | DIS | Admission Date: 5/19/2006 Report Status: Signed
Discharge Date: 1/9/2006
ATTENDING: BUSSLER , FRAN M.D.
PRIMARY CARE PROVIDER:
Dr. Glynis Margo Verbridge
Berg Community Healthcare
Ge
PRINCIPAL DIAGNOSIS: Metastatic gastric cancer.
LIST OF OTHER PROBLEMS AND DIAGNOSES: Coronary artery disease
status post myocardial infarction in 1992 followed by CABG of two
vessels. Upper GI bleed from a gastric ulcer , anemia , GERD ,
hypertension , diabetes type 2 , and history of buttock cellulitis.
BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male , history of CAD status post MI and CABG , upper GI bleed from
gastric ulcer admitted for failure to thrive , nausea and vomiting
and chronic abdominal discomfort. The patient most recently was
admitted on 1/26/2006 for upper GI bleed from a gastric ulcer ,
which was cauterized on EGD during that admission , however ,
without any biopsy. Unfortunately , he was then discharged on
iron supplementation , told to avoid aspirin and alcohol in set up
with a followup EGD in 3 months , however , since then the patient
has had persistent nausea and vomiting combined with burping and
inability to tolerate orally , especially solids. His vomit has
been nonbloody yellow. He also reports a 20 pound weight loss
over the last two months. He describes a chronic epigastric
discomfort over the time , which is more of a "hunger feeling then
an acute pain". Denies any change in bowel movements including
hematochezia although he has chronic black colored stools , which
he attributes to his iron supplementation. He reports weight
loss. He reported a weight loss to his primary care physician who sent him to the
ED for further evaluation of this abdominal pain with a suspicion
of GI bleeding. In the ED , he only had minimally guaiac positive
stool , however right upper quadrant ultrasound revealed multiple
hepatic lesions. The patient was then admitted for inability to
tolerate orally and the concurrent workup of cancer.
ALLERGIES: The patient has no known drug allergies.
BRIEF ADMISSION PHYSICAL EXAM: On admission , the patient had
stable vital signs with a temperature of 98.1 , pulse of 57 , blood
pressure 158/72 , respirating 16 with an oxygenation of 96% on
room air. He was in no apparent distress , alert and oriented x3.
He had a flat JVP. He had a sternal scar. He had regular rate
and rhythm with a normal S1 and S2 , no murmurs , rubs or gallops.
His lungs were clear to auscultation bilaterally. His abdomen
was slightly obese. It was soft with positive bowel sounds. He
had mild discomfort to deep palpation but no tenderness , no
palpable hepatosplenomegaly but questionable dullness to
percussion at the left final intercostal space in the mid
axillary line. His extremities were without edema with good
pulses.
PERTINENT LABS: Chemistry panel was unremarkable. His CBC was
unremarkable as well. He had except for low hematocrit of 31.2.
His LFTs were unremarkable except for mildly elevated , AST at 31.
As mentioned above , he had right upper quadrant ultrasound ,
which showed multiple hepatic lesions.
HOSPITAL COURSE BY SYSTEM: GI/Onc: The patient was admitted
with nausea , vomiting and inability to tolerate orally , along with
a weight loss. He had an emergency room right upper quadrant
ultrasound with hepatic lesions , which was highly suspicious of
malignancy and he was thus admitted for inability to tolerate
orally and a concurrent workup of his hepatic lesions for
malignancy. He had an abdominal CT , which confirmed that there
was a gastric mass and hepatic lesions with surrounding
lymphadenopathy. He subsequently had an EGD , which revealed a
fungating mass which was later confirmed on biopsy to be invasive
adenocarcinoma , poorly differentiated. He was then referred to
oncology who informed the patient of his diagnosis with his
family. The patient decided to undergo chemotherapy with full
FOX. He was then placed with the Port-A-Cath access on
2/2/2006 and he received his full FOX on 1/9/2006 without
incident. Throughout he was controlled on antiemetics. He was
continued on his outpatient dose of Nexium as before NSAIDS and
aspirin were avoided.
Heme: The patient had a stable hematocrit on admission. He
however given his history of GI bleeding , was closely watched and
was transfused for goal hematocrit above 28. He only received
one unit of packed red blood cells on 1/30/2006 as noted. The
patient received an EGD with biopsy of his of his lesion on
1/29/2006 . There was some problem with controlling his bleeding
postbiopsy surgery and interventional radiology were aware of
this. He was closely monitored for any hematocrit drop.
Fortunately , his hematocrit remained stable and he did not
require any acute intervention. He did receive some orally vitamin
K intermittently for his elevated INR of 1.5.
Musculoskeletal: The patient did complain of his spine pain. He
says this pain however has been chronic throughout the years. He
did have a spinal MRI , which did not show any evidence of
metastatic disease or cord compression. It did reveal only mild
degenerative joint disease.
Cardiovascular: The patient was maintained on his home
medications for his hypertension , coronary artery disease and
history of MI. There were no acute issues during this hospital
stay.
Endocrine: For his diabetes , the patient was held off his orally
hypoglycemics and put on an insulin sliding scale as well as a
standing NPH insulin dose. For his hypercholesterolemia , he was
continued on his home dose of Vytorin , which was administered as
separate Zetia and Zocor.
Fluids , electrolytes and nutrition: Given his poor inability to
tolerate orally , he was given intravenous fluids on admission. His diet was
advanced to clears and intermittently he was held npo for
procedures and for his episode of bleeding status post his
biopsy. However , he was then successfully advanced on his diet.
Nutrition was consulted and did leave recs for possible TPN
administration. If the patient should not be able to tolerate
orally in the long run however , he is doing well and TPN will be
held off for now.
Prophylaxis: The patient is prophylaxed on a PPI on his home
dose as well as Lovenox. The patient is full code.
Key features of physical exam at discharge , the patient remains
in stable condition. His physical exam is unchanged.
DISPOSITION AND FOLLOW UP TESTS: The patient will be discharged
home with VNA as well as with an infusion pump to administer
outpatient chemotherapy of 5-FU. The patient should follow up
with his primary care provider Dr. Verbridge and as well as his
oncologist , Dr. Bussler . He will continue on his chemotherapy
protocol per Dr. Bussler . His orally intake should be monitored and he
potentially should have an appointment with outpatient nutrition
to evaluate whether TPN should be started or not. He should
continue on his antiemetics , his pain control and a bowel
regimen.
eScription document: 7-8426749 HFFocus
Dictated By: MARCOTT , DESIRAE
Attending: BUSSLER , FRAN
Dictation ID 1210522
D: 7/12/06
T: 10/17/06
Document id: 177
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
975102819 | PUO | 37701119 | | 4176839 | 5/25/2006 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 4/29/2006 Report Status: Signed
Discharge Date: 5/7/2006
ATTENDING: SPRAGLIN , SHONNA M.D.
CHIEF COMPLAINT: Shortness of breath and jaw discomfort.
HISTORY OF PRESENT ILLNESS: Ms. Bartholomeu is a 71-year-old woman
with a history of coronary artery disease and atrial flutter who
started to develop shortness of breath , which worsened the night
prior to admission. This is consistent with her previous
sensation that she gets when her heart rate increases with atrial
flutter. She also noted some jaw soreness , which she commonly
feels with increased heart rate. At the time , she was seen in the
hospital , she was asymptomatic. She also gets some pain under
her breasts bilaterally when her heart rate increased. She
denies any orthopnea and no leg swelling or PND. Her exercise is
limited by claudication , which worsens in cold weather. Also
when she gets up quickly , she continues to feel lightheaded but
no loss of consciousness. She is steady on her feet.
REVIEW OF SYSTEMS: No fever , some nausea today , no vomiting , and
little bit of diarrhea for one week but nonbloody. She has a
history of colitis. No dysuria. No hematuria. No new joint
pains.
PAST MEDICAL HISTORY: Notable for hypertension , sick sinus
syndrome with bradycardia status post a pacemaker placement in
1986. She has had high cholesterol. She has coronary artery
disease status post an MI in 1992 , a CABG in 1992 , LIMA to LAD ,
SVG to PDA. She has also had PCI x2. She has peripheral
vascular disease. She is status post angioplasty. She has
diabetes , status post cholecystectomy , status post pelvic floor
suspension x2 , status post appendectomy and status post lysis of
adhesions for bowel obstruction and colitis.
MEDICATIONS ON ADMISSION: Digoxin 0.125 mg daily , lisinopril 5
mg daily , Pravachol 20 mg each night , diltiazem XR 360 mg daily ,
Plavix 75 mg daily , Asacol 1200 mg twice daily , cilostazol 50 mg
twice daily , Toprol-XL 300 mg daily , Coumadin 2 mg daily ,
metformin 500 mg twice daily , nitroglycerin , lorazepam 0.25 mg in
the morning and midday and then 0.5 mg at night , she does not
take aspirin.
ALLERGIES: She has allergies to sulfa , which cause a rash ,
penicillin causes angioedema , tetracycline , and H2
blockers.
SOCIAL HISTORY: She lives alone. She has a 40+ pack
year of smoking , quit in 1986. No drinking currently but has in
the past.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission , temperature 96.1 , pulse 82 ,
blood pressure 130/60 , respiratory rate 24 and saturating 92% on
3 liters. General: She is in no acute distress , appears stated
age. HEENT: She is anisocoria , left greater than right ,
reactive to light. Neck is supple. JVP is 6 cm.
Cardiovascular: Regular rate and rhythm , normal S1 , S2 , no
murmurs , rubs or gallops. Respiratory: She has crackles at the
bases. Abdomen: Positive bowel sounds , soft , nontender , and
nondistended. Extremities: Warm and dry , no edema , and 1+
distal pulses. She is alert and oriented x3.
Her EKG shows V pacing with underlined flutter. Labs were
notable for a creatinine of 0.8 , and a hematocrit of 29.2. CK
and troponins were negative. Studies performed during her
admission , chest x-ray showed atelectasis. An echo prior to
admission showed mildly reduced EF , hypokinetic septum , LAE ,
dilated RA , and normal AR , 3+ MR , trace PR. A MIBI performed
during this admission showed moderate aortic ischemia in the
anterior wall and in the diagonal territory. Chest x-ray on
10/2/2006 , later on admission showed improved pulmonary edema ,
slightly increased size of small effusions , and no infiltrate.
She had a TEE , which showed no clot and a mild-to-moderate
decreased EF. She had a TTE with bubble study on 7/5/2006 ,
which showed no shunt , and an EF of 45%. She had PFTs , which
showed a mixed restrictive and obstructive picture that was
mild-to-moderate in severity.
HOSPITAL COURSE:
Cardiovascular:
1. Rhythm: Ms. Bartholomeu has a long history of atrial flutter ,
which has been poorly controlled despite extremely high doses of
beta-blockers , diltiazem , and digoxin. She underwent a TEE and
DC cardioversion and remained out of atrial flutter , and V paced
at 60 beats per minute for remainder of her admission.
2. Ischemia: She has a significant history of coronary artery
disease. After her DC cardioversion , she continued to complain
of shortness of breath and was found to be hypoxic on room air
which we discussed below. She did have the positive MIBI as
discussed above , but given her significant previous
interventions , the thought was to continue to manage her
medically since this would not likely be amenable to intervention.
3. Pump: In 2002 , she had an EF of 45 to 55%. She was not on
any signs of decompensated CHF , although her shortness of breath
did improve marginally with some gentle diuresis. A repeat TTE
on 7/5/2006 showed an EF of 45% , which was relatively unchanged
from 2002.
Respiratory: Status post her cardioversion , she was found to be
saturating in the mid 80s on room air and desaturating further on
ambulation. Pulmonary was consulted and a room air ABG was
obtained that showed pH 7.48 , pCO2 33 , and pO2 52. She had no
evidence of carbon monoxide , no methemoglobinemia. Her PFTs were
as described above. With a gentle diuresis and with more
ambulation , she improved. It is unclear why she had this transient
hypoxemia. Pulmonary recommended a trial of Advair and Spiriva ,
if these made her feel better to continue these , if not then she
could stop them. Also mentioned , she underwent a bubble study
which showed no shunt. In sum , there was a question as to whether this may be
related to atelectasis plus some underlying
COPD plus her underlying small effusion. She was scheduled to
follow up with pulmonary clinic after discharge.
Peripheral vascular disease: She has been improved since three
years ago and she had a peripheral PCI. She was stable on
cilostazol.
Heme: On Coumadin for her atrial flutter.
Endo. We held her orally anticoagulants and her orally agents while
she was inhouse and insulin sliding scale was restarted metformin
on discharge.
Ms. Bartholomeu was discharged to home with a plan to have her INR
checked as usual with Dr. Seidner office and to have follow up
PFTs at her followup appointment with the Rywalt Cine Rehab on 10/9/2006 at 3 p.m. at Boise Also she
is to follow up with Dr. Spraglin who would arrange with her ,
after she home.
DISCHARGE MEDICATIONS: Tylenol 650 mg by mouth every four hours
as needed for headache , digoxin 0.125 mg by mouth daily , Lomotil
2 tabs by mouth four times daily as needed for diarrhea ,
lisinopril 5 mg daily , lorazepam 0.25 mg by mouth in the morning
and midday and then 0.5 mg lorazepam at bedtime , Coumadin 3 mg at
bedtime , Pravachol 20 mg by mouth at bedtime , diltiazem XR 360 mg
daily , Plavix 75 mg daily , Asacol 1200 mg by mouth twice daily ,
cilostazol 50 mg by mouth twice daily , metformin 500 mg by mouth
twice daily , Advair Diskus 250/50 one puff inhaled twice daily ,
Spiriva 18 mcg inhaled daily , Lopressor 100 mg by mouth four
times daily and Lovenox 60 mg subcutaneously twice daily and to continue
until she had her INR checked and it was greater than 2.
eScription document: 5-2248208 PFFocus
Dictated By: HOLDA , ALYSE
Attending: SPRAGLIN , SHONNA
Dictation ID 5404350
D: 5/5/06
T: 5/5/06
Document id: 178
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
076506902 | PUO | 32642067 | | 064021 | 1/20/2002 12:00:00 a.m. | AORTIC STENOSIS , RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/14/2002 Report Status: Signed
Discharge Date: 5/12/2002
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old gentleman
who is admitted for aortic valve
replacement on August , 2002. He has has asymptomatic aortic
stenosis. He also has known coronary artery disease having
undergone angioplasty of his left anterior descending coronary
artery in 1991. Catheterization at that time demonstrated an 80%
left anterior descending lesion and a 60% first diagonal lesion.
He has had a 4-5 year history of shortness of breath diagnosed with
mild aortic stenosis and followed clinically. In the planning
process for knee surgery , serial echocardiograms were performed
showing decreased aortic valve area and decreasing ejection
fraction. Most recent echocardiogram shows moderate to severe
aortic stenosis and has been suggested to have the valve replaced
before undergoing knee surgery. The patient was admitted for
elective aortic valve replacement prior to knee surgery. He has a
history of class II heart failure , slight limitation of physical
activity. He is in normal sinus rhythm.
PAST MEDICAL HISTORY: Hypertension , insulin dependent diabetes
mellitus , hypercholesterolemia , degenerative
joint disease of the bilateral knees , left greater than right ,
status post left total knee replacement in 1994 with persistent
symptoms to undergo surgery for his knee , benign prostatic
hypertrophy , decreasing hearing , left greater than right.
PAST SURGICAL HISTORY: A total knee replacement in 1994 ,
appendectomy in the 1960s.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Diltiazem ER 180 mg once a day , Isordil
30 mg three times a day , enteric coated
aspirin 325 mg once a day , Zocor 10 mg once a day , Cozaar 25 mg
once a day , Humulin N 30 units in the morning and 14 units in the
evening.
PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 80 and regular.
HEENT: Dentition is without evidence of
infection. NECK: No carotid bruits were heard. CHEST: Clear.
HEART: Regular rate and rhythm. He has a systolic ejection murmur
at 3/6 in the aortic area radiating to the carotids. ABDOMEN:
Soft and non-tender. EXTREMITIES: Left total knee replacement
incision , no varicose veins. NEUROLOGICAL: Intact.
LABORATORY: Laboratory studies on admission include a BUN of 13 ,
creatinine 1.3 , white blood cell count 6.0 , hematocrit
40.7. His echocardiogram performed on June , 2001 demonstrated
an TPP Hospital65% , aortic stenosis with a mean gradient
of 42 mm Hg , peak gradient of 63 mm Hg , calculated valve area of
0.9 cm squared with mild mitral insufficiency , trivial
insufficiency and a mildly dilated left atrium. EKG shows normal
sinus rhythm at 88. Chest x-ray is clear.
HOSPITAL COURSE: The patient underwent coronary arteriography on
August , 2002 at Pagham University Of .
This examination showed a right dominant system with a diffuse 40%
lesion of the left main , discrete 50% lesion of his proximal left
anterior descending coronary artery , a 70% lesion of his mid left
anterior descending artery with an 80% distal lesion. He also had
an 80% lesion of his first diagonal and a diffuse 50% proximal
lesion of the same vessel , 70% ostial lesion of his circumflex and
an eccentric 45% lesion of his right coronary artery with a 70%
lesion in his large left ventricular branch. The patient went to
the operating room on August , 2002 where he underwent an aortic
valve replacement with a #23 Carpentier-Edwards pericardial valve
and a coronary artery bypass grafting x 3 with a left internal
mammary artery to the left anterior descending coronary artery ,
saphenous vein graft to the first marginal and saphenous vein graft
to the posterior left ventricular branch. His intraoperative
course was uneventful. He was seen in consultation by the Diabetic
Management Service for blood sugar control and initiation into the
Portland Protocol for intravenous insulin. His postoperative
course was complicated by an episode of rapid atrial fibrillation
which was treated with replacement of his electrolytes and
initiation of Lopressor therapy and also mild anemia that was
monitored and addressed with diuresis for fluid overload. His
postoperative course was uneventful. He continued to require
diuresis for pleural effusion. Chest x-ray on discharge
demonstrated small bilateral pleural effusions. His hematocrit on
discharge is 25.6. At this point in time , there is no need to
transfuse the patient. He is stable. Heart rate is stable. He is
on room air oxygenating at 97%. He is to be discharged to
rehabilitation on the following medications.
MEDICATIONS ON DISCHARGE: Colace 100 mg three times a day ,
albuterol nebulizers 2.5 mg every 4 hours ,
Atrovent 0.5 mg four times a day , Niferex 150 mg twice a day , Lopressor 50 mg
three times a day , Lasix 40 mg once a day , enteric coated aspirin
325 mg once a day , simvastatin 20 mg at bedtime , potassium replacement
20 mEq once a day , CZI scale , NPH insulin 20 units in the morning
and 10 units pre-dinner.
FOLLOW UP: The patient is to be discharged to the care of Dr.
Desirae Marcott , Kernan To Dautedi University Of Of ,
Andyau Ing
Dictated By: CHRISTY CLARDY , P.A.
Attending: ISABELLE E. COLASAMTE , M.D. DV9 FZ011/964517
Batch: 7514 Index No. DHOROAEI00 D: 4/12/02
T: 4/12/02
CC: DESIRAE R. MARCOTT , M.D. AB14
SACHIKO S. BORRIELLO , M.D. YJ0
Document id: 179
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
Y |
N |
N |
N |
Y |
N |
- |
N |
N |
Y |
N |
243310435 | PUO | 41727528 | | 1264412 | 10/25/2007 12:00:00 a.m. | peripheral vascular disease | Signed | DIS | Admission Date: 9/25/2007 Report Status: Signed
Discharge Date: 3/14/2007
ATTENDING: BUSSLER , FRAN M.D.
PRINCIPAL DIAGNOSIS: Ascites.
DISCHARGE DIAGNOSES: Ascites.
OTHER DIAGNOSES:
1. End-stage renal disease.
2. Hypertension.
3. Diabetes.
4. Prostate cancer.
BRIEF HISTORY OF PRESENT ILLNESS: This is a 63-year-old man with
coronary artery today disease status post CABG , diabetes
mellitus , peripheral vascular disease , status post bilateral
below-the-knee amputations , end-stage renal disease - on
hemodialysis , and metastatic prostate cancer presenting with
new-onset ascites. He notes that since his last below-the-knee
amputation in 9/24 , he has noticed increased abdominal girth ,
smaller after hemodialysis. He denies fevers , chills , jaundice ,
abdominal pain , nausea , vomiting , diarrhea , or bright red blood
per rectum. He has had some weight loss. He denies PND ,
orthopnea , or lower extremity swelling. On the day of admission ,
the patient was in the preoperative area for revision of his
below-the-knee amputation of the right leg because it had poor
wound healing. During the preoperative evaluation , however , it
was noticed that he had significant abdominal swelling. He was ,
therefore , admitted to the medicine for further workup and
evaluation.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis Monday , Wednesday ,
Friday at Delpnecrest Ce Medical Center . 2. Hypertension.
3. Diabetes mellitus.
4. Prostate cancer.
5. Coronary artery disease status post two-vessel CABG in 1991
and status post proximal RCA stents in 5/22 , EF of 50% to 55%.
6. Status post bilateral below-the-knee amputations secondary to
diabetic ulcers.
7. Atrial fibrillation.
8. Peripheral vascular disease.
9. History of subthalamic stroke in 8/06 .
10. History of GI bleed - on Coumadin.
ALLERGIES: Penicillin.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg daily.
2. Plavix 75 mg daily.
3. Norvasc 10 mg daily.
4. Lyrica 100 mg twice daily.
5. Insulin NPH 10 units twice daily.
6. Lipitor 10 mg at bedtime.
7. Phospho 1334 mg before every meal
8. Folate 2 mg daily.
FAMILY HISTORY: The patient has multiple family members with
diabetes mellitus.
SOCIAL HISTORY: The patient is unemployed. Former smoker , 45
years ago. Currently , no alcohol and no illicit drugs. The
patient lives with wife in A Wacinville Sterl He has five daughters and
one son , all lives in local area and provide help and support to
the patient. One daughter is a physical therapist.
PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS: Temperature 96.4 , heart rate 90 , blood pressure
110/68 , respiratory rate 18 , oxygen saturation 92% on room air.
GENERAL: The patient is in no acute distress.
HEENT: Pupils equal , round , and reactive to light. Oropharynx:
Clear , mucous membrane is moist. No scleral icterus.
NECK: Supple , JVP with prominent V waves , difficult to assess
height.
LUNGS: Clear to auscultation bilaterally. No crackles , wheezes ,
or rhonchi.
CARDIOVASCULAR: Regular rate and rhythm. Normal S1 , S2 , 2/6
systolic murmur at left sternal border plus RV heave.
ABDOMEN: Tense , distended , nontender , positive fluid wave ,
normoactive bowel sounds.
EXTREMITIES: Status post bilateral below-the-knee amputations.
No significant edema. Right lower extremity addressed with
gauze.
SKIN: No rashes , no ecchymosis or petechiae.
NEUROLOGIC: Alert and oriented x3. Nonfocal neurological exam.
NOTABLE LABORATORY VALUES ON ADMISSION: Sodium 133 , potassium
5.2 , chloride 88 , bicarbonate 28 , BUN 44 , creatinine 6.4 , glucose
178. ALT 24 , AST 16 , alkaline phosphatase 284 , total bilirubin
0.7 , direct bilirubin 0.2. Total protein 8.1 , albumin 4.1.
Calcium 9.1. White blood cell count 7.25 , hematocrit 45.1 , and
platelets 189. Ascites fluid with 2.3 albumin , 4.3 total
protein. Serum ascites: Albumin gradient equals 1.8. White
blood cell count 460 with 20% polys , 1230 red blood cells. Gram
stain negative , culture negative.
NOTABLE STUDIES:
1. Abdominal ultrasound , 8/10/2007: Gallstones with
extrahepatic common bile duct measuring 8 mm. Large amount of
ascites was marked for paracentesis. Patent portal and hepatic
veins with normal direction of flow.
2. Echocardiogram , 9/5/2007: Ejection fraction of 55%. No
regional wall motion abnormality. Interventricular septum
flattened in diastole consistent with right ventricular volume
overload. Severe concentric left ventricular hypertrophy. Right
ventricular hypertrophy. Mild-to-moderate left atrial
enlargement. Moderately dilated right atrium. Mild-to-moderate
mitral regurgitation. Moderate-to-severe tricuspid regurgitation
consistent with pulmonary artery systolic pressure of 28 mm plus
right atrial pressure. Dilated inferior vena cava. No
significant pericardial effusion.
3. Chest x-ray , 1/5/2007: Low lung volume with bibasilar
subsegmental atelectasis and no pneumonia.
4. Finger films , 1/5/2007: Mild first carpometacarpal and
scaphotrapeziotrapezoid osteoarthritis; otherwise unremarkable
evaluation of the second digit.
5. Portable chest x-ray , 7/5/2007: Bibasilar subsegmental
atelectasis , greater on the left , again identified. Unchanged
study from prior.
6. Repeat echocardiogram on 9/12/2007: Ejection fraction of
55% , no regional wall motion abnormalities. Pulmonary artery
systolic pressure 29 mm plus right atrial pressure. No
significant change from prior study of 9/25/2007 .
PROCEDURES: 9/25/2007 , therapeutic paracentesis , 4 liters of
ascitic fluid removed without complication. Chemistries and cell
counts of ascitic fluid as described above in the laboratory
section.
HOSPITAL COURSE: This is a 63-year-old man with history of
end-stage renal disease - on hemodialysis , coronary artery
disease , diabetes , severe peripheral vascular disease status post
bilateral knee amputations , who presented with two months of
worsening ascites of unclear etiology. His hospital course by
problem is as follows:
1. Gastrointestinal: The patient underwent a therapeutic
paracentesis with ascites fluid revealing chemistries with total
protein greater than 2.5 and serum ascites albumin gradient
greater than 1.1 consistent with a transudative ascites , likely
due to volume overload with resultant right heart failure.
Ascites had 460 white blood cells with 20% polys. Therefore , it
was not consistent with spontaneous bacterial peritonitis.
Ascitic fluids were negative for growth of bacteria and cytology
of the ascitic fluids identified no malignant cells. After
consultation with the cardiology service , it was concluded that
the ascites was due to massive volume overload , and therefore the
patient should undergo reduction of volume through
ultrafiltration at dialysis. This process was begun as an
inpatient by the renal service. While the patient was an
inpatient , efforts to remove fluid was complicated by
development of hypotension during dialysis as
well as by atrial fibrillation with rapid ventricular response
with heart rates up to the 140s. Due to the difficulties with
removing fluid at dialysis , the patient was offered the option of
undergoing ultrafiltration by CVVH or an ultrafiltration machine ,
but the patient and the family declined to participate in such
care. It should also be noted that despite our efforts , the
patient was not compliant with fluid restrictions that were put
into place in the patient's diet order , therefore also making it
difficult to treat the patient's volume overload. The patient
was discharged with the plan to continue ultrafiltration at outpatient
dialysis in an attempt to continue to remove fluid and reduce the
patient's volume overload. This plan was communicated by the
attending renal , Dr. Fran Bussler , to the patient's outpatient renal
attending , Dr. Desirae Marcott .
2. Renal: As described above , the patient has end-stage renal
disease - on hemodialysis. As described above , ultrafiltration
was attempted at hemodialysis to remove as much fluid as possible
and to reduce the patient's volume overloaded state.
Ultrafiltration should be continued as an outpatient to continue
to attempt to counteract the patient's volume overload.
3. Cardiovascular: Ischemia , the patient has a history of
coronary artery disease status post CABG and stent , but his usual
aspirin and Plavix were initially held given that surgical
revision of his right below-the-knee amputation had been planned.
However , after discussion with the patient's vascular surgeon ,
Dr. Jerica Youngberg , it was decided that the patient's volume
overload should be corrected prior to his undergoing surgical
revision of his right leg. Therefore , aspirin and Plavix were
restarted on 11/16/2007 . Pump: The patient has evidence of
right heart failure by echocardiogram. On physical exam and as
described above , this is likely a consequence of the patient's
volume overload. Again , as described above , volume was removed
through ultrafiltration at dialysis. Rhythm: The patient has a
history of atrial fibrillation but is not anticoagulated , likely
for fear of noncompliance. The patient was in normal sinus
rhythm for the majority of this admission but on 1/8/2007 , the
patient went into atrial fibrillation with rapid ventricular with
rates to the 120s to 140s. However , the patient refused to
accept monitoring on cardiac telemetry and also refused to
cooperate with the administration of intravenous medications for
heart rate control. Therefore , the patient's dose of orally
Lopressor was slowly titrated upward as tolerated by his blood
pressures , but on discharge his rate remained in the low 100s and
were not optimally controlled. However , the patient refused
further management of his atrial fibrillation , and it was
therefore decided that this should be managed as an outpatient
with continued slow readjustment of his orally beta-blocker
regimen.
4. Endocrine: The patient was continued on his home insulin
regimen and fingersticks were monitored on a before every meal and nightly
basis with adequate control of blood sugars.
5. Vascular: As described above , the patient has a right
below-the-knee amputation , which need surgical revision. As
described above , after discussion with the patient's vascular
surgeon , Dr. Jerica Youngberg , it was decided that the patient's
surgical revision of his right leg would be addressed after his
issues with volume overload are resolved.
6. Infectious disease: It was noted that the patient has as a
likely paronychia of his left index finger. Plain films were
obtained , which did not reveal any evidence of osteomyelitis. A
hand surgery consult was obtained , and it was noted that there
were no vascular issues with his left hand and that no urgent
surgical debridement of the left finger was necessary. The
patient was treated with orally levofloxacin and will continue
taking levofloxacin for a total of 3-week course to end on
6/11/2007 . Oxycodone was administered for pain control of his
left finger as well as for pain control of his right leg.
Prophylaxis , the patient was placed on subcutaneous heparin for
DVT prophylaxis and placed on Nexium for GI prophylaxis.
The patient was full code during this admission.
PHYSICIAN FOLLOWUP PLANS: The patient has a followup appointment
with his vascular surgeon , Dr. Jerica Youngberg , on 10/26/2007 at
2:30 p.m. , phone number 931-223-3069. The patient should call
his doctor his primary care physician , Dr. Tarsha Prall ,
telephone #245-453-9949 , for appointment in two to three weeks.
The patient will continue dialysis at Delpnecrest Ce Medical Center under the
direction of Dr. Desirae Marcott on a Monday , Wednesday , Friday
schedule. This patient should complete a total of 14-day course
of levofloxacin to end on 6/11/2007 for his left fourth finger
paronychia/skin infection. The patient's beta-blocker should be
titrated upwards as tolerated by blood pressure for better
control of his paroxysmal atrial fibrillation. As described
above , ultrafiltration should be used during dialysis to remove
total body volume.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth daily.
2. PhosLo 1334 mg by mouth before every meal
3. Plavix 75 mg by mouth daily.
4. Folate 2 mg by mouth daily.
5. Insulin NPH 14 units subcutaneous twice a day
6. Levofloxacin 250 mg by mouth every 48 hours until 6/11/2007 .
7. Toprol 50 mg by mouth daily.
8. Nephrocaps one tablet orally daily.
9. Oxycodone 5 mg by mouth every 4 hours as needed pain.
10. Lyrica 100 mg by orally twice daily.
11. Zocor 20 mg by mouth nightly
12. Zinc sulfate 220 mg by mouth daily.
eScription document: 4-7272564 HFFocus
Dictated By: MARCOTT , DESIRAE
Attending: BUSSLER , FRAN
Dictation ID 3274203
D: 8/20/07
T: 8/20/07
Document id: 180
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625914758 | PUO | 55905410 | | 481061 | 6/29/2002 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/23/2002 Report Status: Signed
Discharge Date: 5/10/2002
PRINCIPAL DIAGNOSES: 1. CORONARY ARTERY DISEASE.
2. AORTIC STENOSIS.
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female
with a history of coronary artery
disease , congestive heart failure and chronic renal insufficiency
who presented with substernal chest pain on April , 2002 to the
Pera Tonbrid Medical Center . She was admitted by the
emergency department to the Cardiology Service and work-up revealed
aortic stenosis and coronary artery disease.
PAST MEDICAL HISTORY: Significant for hypertension , peripheral
vascular disease , bilateral lower extremity
claudication , insulin dependent diabetes mellitus ,
hypercholesterolemia , renal failure after her catheterization in
2001 with her creatinine running in the high 2.0 to 3.0 range ,
congestive heart failure. The patient has had a previous stent to
the LAD and circumflex in 1999. She has also had a myocardial
infarction in 1998 associated with prolonged chest pain and has a
history of class 3 angina and class 3 heart failure.
ALLERGIES: The patient is allergic to intravenous dye. She
developed renal failure to this. She has no other
known drug allergies.
MEDICATIONS ON ADMISSION: Lopressor 50 mg orally three times a day , amlodipine
10 mg orally every day , Isordil 30 mg orally
three times a day , aspirin 325 mg orally every day , Lasix 160 mg orally twice a day , NPH
insulin 20 units every PM and 40 units every day before noon , Epogen 2 , 000 every day and
Zantac 150 mg orally twice a day
PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed ,
well-nourished female in no acute distress.
HEART: Regular rate and rhythm. LUNGS: Clear to auscultation.
ABDOMEN: Soft , non-tender , non-distended. EXTREMITIES: She had
bilateral varicosities and she is status post amputations of two
toes. Her pulses to her lower extremities were intact , but faint.
LABORATORY: Cardiac catheterization revealed a 90% circumflex
lesion , 100% right coronary artery occlusion and the
circumflex was subsequently stented. An echocardiogram performed
showed a 40% ejection fraction with aortic stenosis , a peak
gradient of 35 and a calculated valve area of 1 cm squared.
HOSPITAL COURSE: The patient was taken to the operating room on
August , 2002 for an aortic valve replacement
with a St. Jude #23 mechanical valve and a coronary artery bypass
grafting x 3 to the LAD , obtuse marginal and LVB1. The patient
tolerated this procedure well and was transferred to the intensive
care unit for close monitoring. However , the patient did develop
an uncontrolled left-sided nose bleed in the operating room and ENT
was called to pack the nose. The postoperative course was
remarkable for sluggish urine output for which Renal consult was
called in to follow. The patient was treated with diuretics and
her urine output subsequently improved. The patient was kept on
pressors and mechanical ventilation for several days and was then
extubated on January , 2002 after her volume overload was
controlled. The patient was transferred to the floor on July ,
2002 off her torsemide drip and tolerating intravenous intermittent
doses of torsemide. Otolaryngology removed the packing from the
patient's nose and she just had minor oozing after this not
requiring any treatment. Both Cardiology and Renal continued to
follow throughout the patient's hospital course and by May ,
2002 , the patient was tolerating a regular diet , urinating well
with orally antidiuretics and without subsequent nose bleeds. It was
decided that the patient was ready to be discharged to
rehabilitation at this point.
MEDICATIONS ON DISCHARGE: Tylenol , aspirin 81 mg orally every day ,
Dulcolax and Colace as needed , Epogen
10 , 000 units subcutaneously every week , Lasix 40 mg orally twice a day , NPH
insulin 25 units every day before noon and 15 units every dinner and regular insulin 4
units every day before noon , Lopressor 25 mg orally three times a day , Ocean Spray four times a day ,
Coumadin orally every day and she should have her Coumadin adjusted
according to her INR , simvastatin and Nexium.
CONDITION ON DISCHARGE: The patient was discharged in good
condition.
FOLLOW UP: The patient will follow up with Dr. Stukowski in six
weeks. Prior to this , she should follow up with her
primary care physician within one week and her cardiologist within
one to three weeks. Pera Tonbrid Medical Center is aware of
the plans and is helping in arranging follow up appointments.
Dictated By: ALEJANDRA DEERDOFF , M.D.
Attending: JANAY D. STUKOWSKI , M.D. HT37 VL887/558385
Batch: 5828 Index No. BAFSDGM6W7 D: 10/25/02
T: 10/25/02
Document id: 181
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195619812 | PUO | 33640513 | | 2966465 | 6/26/2007 12:00:00 a.m. | history of angioplasty and stenting | | DIS | Admission Date: 7/4/2007 Report Status:
Discharge Date: 4/21/2007
****** FINAL DISCHARGE ORDERS ******
SAKAL , KARLY K. 974-03-12-0
Villewari Inday Cho
Service: CAR
DISCHARGE PATIENT ON: 1/16/07 AT 10:00 a.m.
CONTINGENT UPON labs/ekg
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LYN , JR , FLOYD T. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. MYCOPHENOLATE MOFETIL 1000 MG orally twice a day
2. OXYBUTYNIN CHLORIDE XL 10 MG orally every day
3. INSULIN GLARGINE 20 UNITS subcutaneously every day before noon
4. FUROSEMIDE orally every day
5. CLOPIDOGREL 75 MG orally every day
6. PRAVASTATIN 40 MG orally every bedtime
7. PREDNISONE 5 MG orally every day
8. CYCLOSPORINE ( SANDIMMUNE ) 75 MG orally twice a day
9. METOPROLOL SUCCINATE EXTENDED RELEASE 50 MG orally every day
10. FENOFIBRATE ( TRICOR ) 48 MG orally every day
MEDICATIONS ON DISCHARGE:
ENTERIC COATED ASA 325 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 10/8 )
CYCLOSPORINE ( SANDIMMUNE ) 75 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 10/3/07 by MOAG , EVELINA S REVA ONIE , M.D. on order for TRICOR orally ( ref # 364082208 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
FENOFIBRATE , MICRONIZED Reason for override:
patient home meds Previous override information:
Override added on 10/3/07 by MOAG , EVELINA STANLEY REVA , M.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
CYCLOSPORINE Reason for override: patient home meds
TRICOR ( FENOFIBRATE ( TRICOR ) ) 48 MG orally DAILY
Alert overridden: Override added on 10/3/07 by MOAG , EVELINA S REVA ONIE , M.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
FENOFIBRATE , MICRONIZED
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
FENOFIBRATE , MICRONIZED Reason for override:
patient home meds Number of Doses Required ( approximate ): 4
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
INSULIN GLARGINE 20 UNITS subcutaneously DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 1 , 000 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
TNG 0.4 MG ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
DITROPAN XL ( OXYBUTYNIN CHLORIDE XL ) 10 MG orally DAILY
Number of Doses Required ( approximate ): 3
PRAVACHOL ( PRAVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/3/07 by MOAG , EVELINA S REVA ONIE , M.D. on order for TRICOR orally ( ref # 364082208 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
FENOFIBRATE , MICRONIZED Reason for override:
patient home meds Previous override information:
Override added on 10/3/07 by MOAG , EVELINA STANLEY REVA , M.D.
on order for CYCLOSPORINE ( SANDIMMUNE ) orally ( ref #
269133558 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
CYCLOSPORINE Reason for override: patient home meds
Previous override information:
Override added on 10/3/07 by MOAG , EVELINA STANLEY REVA , M.D.
on order for PRAVACHOL orally ( ref # 313060758 )
patient has a PROBABLE allergy to SIMVASTATIN; reaction is
muscle aches. Reason for override: patient home meds
PREDNISOLONE SODIUM PHOSPHATE 5MG/5ML 5 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: light activity , no heavy lifting or driving x 2 days. ok to shower , no swimming or bathing x 5 days
Lift restrictions: Do not lift greater then 10-15 pounds
FOLLOW UP APPOINTMENT( S ):
Heart failure Clinic 2-4 weeks ,
ALLERGY: SIMVASTATIN
ADMIT DIAGNOSIS:
history of cardiac transplant
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of angioplasty and stenting
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of cardiac transplant 1992 ( history of cardiac transplant ) Diabetes mellitus
type II ( diabetes mellitus type 2 ) Trochanteric bursitis ( trochanteric
bursitis ) Dyslipidemia ( dyslipidemia ) DJD spine ( OA of cervical
spine ) Hx vocal cord injury postop Hx gastritis with UGIB ( history of upper
GI bleeding ) Hx postop seizure
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of LAD angioplasty and stenting
BRIEF RESUME OF HOSPITAL COURSE:
71 year old female that is now 15 years following
cardiac transplantation , with a multiplicity of medical issues ,
including allograft coronary artery disease , bilateral carotid
disease ( underwent carotid stenting in January 2006 ) , History of TIA ,
diabetes and significant obesity. Her baseline renal cr was
1.7. The LCX was stented in November
2006. Current meds
includes CellCept 1000 mg orally twice a day , prednisone 5 mg
daily , cyclosporine 75 mg orally twice a day , Toprol-XL 50 mg daily , TriCor ,
once daily , Pravachol 40 mg daily , Plavix 75 mg daily , Lasix , 40 mg
daily , insulin , aspirin , Ditropan 10 mg daily and
vitamins. Elective cardiac catheterization Was performed
today for her annual post cardiac transplant evaluation revealed
double vessel disease proximal LAD 95% lesion , LeftnCX
( Proximal ) , 75% lesion CX ( Mid ) , 95% lesion , MARG1 ( Ostial ) , 95%
lesion . Successful PTCA/Stenting - LAD using XB3.5guide ,
BMW , which was predilated with a 2mm balloon , 2 DES was used ( 3 by
18 ) and( 3 by 18 ) cypher stents which was subsequently postdilated to
3.2 , no residual
stenosis Right groin access was closed with
Starclose. PCI of the LAD today and possible planned PCI of
LCX in 1-3 weeks. Check renal function over the next 2
days Plan:
PCI of the LAD today and possible planned PCI of LCX in 1-3
weeks. Check renal function over the next 2
days
6/9/07
Up , eating and voiding well. Ambulating on POD - "tired" but no change
from baseline.
No Chest pain , shortness of breath , groin or flank pain. No palpitations.
Multiple questions regarding activity , medications reviewed with patient.
PHYSICAL EXAM: 96.4 80-90s 110/60 97%ra voiding to BR
NAD. JVP not elevated.
COR RRR , S1S2 , no murmur appreciated
Lungs - CTA bilat , no RRW
EXT - warm , no edema
Right Groin-soft , no ecchymosis , no hematoma or bruit. Palpable femoral
pulse.
EKG: SR at 95 wtih inc RBBB , flat T 1 , L , no change from prior.
TELE: no tele events
A/P:
**CV:12 years post transplant , resume meds per transplant team.
*CAD: 1 day post Cypher DES to LAD with significant residual disease ,
please see cath report for full details. Will need ASA 325 daily x life ,
Plavix 75 daily for minimum of 12 months and should continue out indef.
Importance of both stressed and patient understands! sublingual TNG as needed chest
pain. a.m. enzymes pending.
*PUMP: no evidence of volume overload , CHF.
*RHYTHM: no palps , no tachy/brady tele events.
*HTN: BP well controlled HR up some on Toprol XL 50 , lasix 40.
*LIPIDS: will cont pravachol 40 , tricor 48.
**PULM: no issues.
**RENAL: baseline 1.5 - 1.7 , a.m. pending. encouraged increased orally intake
over next several days , if urine output falls she will call , she should
have renal fx rechecked on monday with local MD.
**ENDO: check hgb a1c as outpt. cont insulin
**DISPO: stable and ready for DC this am pending labs , attending eval.
FU with Transplant team , they will be in contact regarding date of staged
PCI to LCx. To call with any concerns. All Questions answered.
Addendum: renal fx fine but asxatic MB bump to 25 , rechecking and dc if
stable , keep until tomorrow if up.
ADDITIONAL COMMENTS: -you must take aspirin for life
-you must take plavix for a minimum of 1 year- DO NOT STOP ASPIRIN OR
PLAVIX FOR ANY REASON UNLESS SPEAK WITH YOUR CARDIOLOGIST FIRST!!!
-resume other medications at usual doses
-you will need your kidney function test on monday 3/19 after receiving
contrast- this should be followed by heart transplant clinic
-drink plenty of fluids over the next several days , if your urine output
falls please call.
-you will need to return for another intervention in the next several
weeks- this should be set up through transplant clinic
-call with questions or concerns
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: LEASON , SUN , M.D. ( VT97 ) 1/16/07 @ 09:39 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 182
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019021061 | PUO | 06669575 | | 3216541 | 9/23/2006 12:00:00 a.m. | hyperkalemia 2/2 orally intake and stopping lasix | | DIS | Admission Date: 4/1/2006 Report Status:
Discharge Date: 8/19/2006
****** FINAL DISCHARGE ORDERS ******
WAYMAN , CECILIA 996-56-47-1
Fran Enthisgarl
Service: MED
DISCHARGE PATIENT ON: 10/5/06 AT 12:00 PM
CONTINGENT UPON basic labs
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DELMENDO , CRISTINE V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALLOPURINOL 300 MG orally DAILY Starting Today ( 3/23 )
Alert overridden: Override added on 2/26/06 by
HEIDELBERGER , LATICIA THADDEUS , M.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will follow
AMIODARONE 200 MG orally DAILY
Override Notice: Override added on 2/26/06 by HEIDELBERGER , LATICIA T VELVA , M.D. on order for COUMADIN orally ( ref # 506729106 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: will follow
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY
Override Notice: Override added on 2/26/06 by HEIDELBERGER , LATICIA T VELVA , M.D. on order for COUMADIN orally ( ref # 506729106 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will follow
ATENOLOL 25 MG orally DAILY Starting Today ( 9/8 )
ISOSORBIDE DINITRATE 20 MG orally three times a day
COUMADIN ( WARFARIN SODIUM ) 2.5 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 2/26/06 by HEIDELBERGER , LATICIA T VELVA , M.D.
on order for ALLOPURINOL orally ( ref # 990666503 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will follow
Previous override information:
Override added on 2/26/06 by HEIDELBERGER , LATICIA THADDEUS , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: will follow
CLARITIN ( LORATADINE ) 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
Starting Today ( 9/8 )
ATORVASTATIN 10 MG orally DAILY
Override Notice: Override added on 2/26/06 by HEIDELBERGER , LATICIA T VELVA , M.D. on order for COUMADIN orally ( ref # 506729106 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: will follow
Previous override information:
Override added on 2/26/06 by HEIDELBERGER , LATICIA THADDEUS , M.D.
on order for ATORVASTATIN orally ( ref # 547272330 )
patient has a PROBABLE allergy to SIMVASTATIN; reaction is
MUSCLE ACHE. Reason for override:
Patient on atorvastatin and tolerates. Has allergy to
simvastatin
CELEXA ( CITALOPRAM ) 30 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
LISINOPRIL 20 MG orally DAILY Starting Today ( 9/8 )
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours
PULMICORT RESPULES ( BUDESONIDE NEBULIZER SUSP )
0.25 MG inhaled every 12 hours
DIET: House / 2 gm Na / Low saturated fat
low cholesterol / 2 gram K+ , Renal diet
ACTIVITY: Resume regular exercise
Elevate feet with prolonged periods of sitting
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Azua pcp 2/11 @ 9 ,
Dr Sniezek renal 10/20 @ 2 ,
Dr Nolan card 2/1 @ 11:20 ,
puo anticoag 988-605-5355 clinic will contact ,
Arrange INR to be drawn on 7/28 with f/u INR's to be drawn every
3 days. INR's will be followed by Dr. Azua
ALLERGY: Sulfa , SULFUR , SIMVASTATIN , Codeine
ADMIT DIAGNOSIS:
Hyperkalemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hyperkalemia 2/2 orally intake and stopping lasix
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) DM ( diabetes mellitus ) CAD ( coronary artery
disease ) history of IMI history of RCA angioplasty history of pacer for
bradycardia prostate cancer history of XRT asthma
( asthma ) history of CVA ( history of cerebrovascular accident ) afib on coumadin
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
kayexalate , IVF
BRIEF RESUME OF HOSPITAL COURSE:
CC: Called to come in for hyperkalemia
HPI:81 YO male with CAD and
chronic kidney disease who was seen in Cardiology Clinic 3/11 and was
noted to be feeling well. Labwork at that time revealed andelevated
creatinine at 3.4. It was felt that this may be secondary to over
diuresis give that his LV function had improved recently on ECHO. His
lasix was held and he presented for follow up today. He had no complaints
and on repeat lab work his creatinine had improved to 2.3 ( baseline ) ,
however , his potassium was elevated at 6.3 from 6.0 3/11 . He was called
to come into the ED. In the ED his VS showed T: 96 HR: 60 RR: 16 BP:
101/58 SaO2: 100% RA. He was given kayexalate 60 X 1 and admitted to
medicine for further care. On further history he notes he is eating one
banana daily and at least one glass of orange juice daily. He is also
eating oranges daily. He denies any recent medication changes or NSAID
use. Overall he states he feels well and denies acute
complaintsROS:Negative for visual change , hearing change , fever , chills ,
dizziness , headache , neck pain , neck stiffness , bowel or bladder
incontinance , weakness , sensory change , cough , shortness of breath , chest
pain , palpitations , vomiting , diarrhea , weight change , dysuria ,
hematuria , rash , other joint pains
PMH:1. ) Ischemic cardiomyopathy - EF by ECHO 11/20/2006 60-65% ( improved
from prior )2. ) CAD history of IMI in 1993. MIBI in 2002 showed no reversible
defects3. ) ICD PPM4. ) CVA with transient amnesia in 19915. )
Atrial fibrillation in past now in NSR6. ) Asthma7. ) Prostate
cancer history of radiation8. ) Hypertension9. ) Hyperlipidemia10. )
Gastritis11. ) Allergic rhinitis12. ) Gout13. ) Depression14. )
Chronic kidney diseasea. Seen by Dr. Loewe 10/13/2006b.
Creatinine 2.2-2.8
----
MEDICATIONS:1. ) ASA 81 mg orally daily2. ) Atenolol 25 mg orally daily3. )
Isosorbide dinitrate 20 mg orally TID4. ) Atorvastatin 20 mg daily5. )
Amiodarone 200 mg orally daily6. ) Coumadin 2.5 mg orally daily7. )
Allopurinol 200 mg daily8. ) Flovent 110 mcg BID9. ) Nasonex10. )
Claritin 10 mg daily11. ) Celexa 30 mg orally daily12. )
Lisinopril 20 mg orally daily
ALLERGIES: SULFA ` rashCODEINE ` rash
SHX: Retired VP of an insurance company. Married with six children. No
ETOH or tobacco use
FHX: Non-contributory
-----
VS: T: 96 BP: 101/58 HR: 100 RR: 16 HR: 60
GEN: NAD , laying on stretcher
HEENT: PERRL , EOMI , anicteric sclerae , mmm , no orally lesions or thrush
NECK: Supple , no adenopathy , no JVD , no bruits
CHEST: CTA bilaterally
CV: RRR S1 , S2 no m/r/g
ABD: soft , NT , ND , bowel sounds present
EXT: no clubbing , cyanosis , edema
SKIN: no rash
NEURO: Alert and oriented X 3 , no focal deficit of strength or sensation
------
81 YO male with chronic kidney disease and ischemic cardiomyopathy who
presents after being called with hyperkalemia on labs. He has no acute
complaints and his renal function has returned to baseline after holding
his diuretic for several days. History reveals significant potassium
intake and ACEi use.
RENAL: CKD of unclear etiology now with creatinine at baseline.
Hyperkalemia on labwork. His lasix was held over night and will be
restarted at d/c. ACEI was also held. patient was given dietary education
for low K diet. He will be d/c on his home medications. He received a
total of 90mg of kayexalate and K is 5.8 post 60mg and is 4.3 on 4/8 . patient
will be d/c without ACEI and patient is to continue with lasix.
CV:
ISCHEMIA: Known CAD with no active symptoms
7 Continue ASA
7 Continue atenolol ( consider changing to Toprol XL given renal
dysfunction )
7 Continue statin
7 Nitrates per home regimen
PUMP: Euvolemic on exam with preserved LV function on last ECHO
7 I/O and daily weights
7 Will restart ACEI given improved potassium
7 Restart lower dose lasix of 40mg every day
RHYTHM: History AF on coumadin. AV paced here with ICD. Had ?brady
episodes to 30s and 40s per nursing but on looking at tele with EP , patient is
paced at 60. So no interrogation of his AICD was done ( last was in November
05 )
7 Continue amiodarone
7 Continue coumadin with goal INR 2-3
GOUT: Currently asymptomatic - continue allopurinol per home regimen
HEME: Anemia at baseline. Further workup as outpatient. Hct drop
from 34-> 29. Repeated Hct was stable at 31. Likely Hct drop from 34-->
29 is from dehydration/rehydration. Iron studies c/with iron deficiency.
Started on iron sulfate. Reticulocytes high - 14%. Needs GI with u.
PULM: History of asthma with no acute symptoms. Continue home Flovent.
Started pulmicort per pulm clinic note as occasionally wheezy.
FEN: patient was continued on cardiac , low sodium , 2 liter fluid restricted
diet with Lytes twice a day. He's euvolemic on exam
PPX: Pneumoboots ( on coumadin ) , PPI
CODE: Full
DISPOSITION: to rehab per family's request given frequent falls
ADDITIONAL COMMENTS: please adhere to a low K diet and measure your weight daily. please call
your doctor if you experience palpitations , shortness of breath , chest
pain , abdominal pain , fever , chills , nausea , vomiting or any other
concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Daily labs for K , hct , INR x3 days , then q3d until stable. Discharge
hct 29.5 , please forward lab results to Dr. Azua . Please call PUO if
hct<27 ( page Dr. Jeana Osdoba Y#41130
2. Daily weights , make sure patient is not volume overloaded
3. Monitor vital signs
4. physical therapy/OT
5. Started duoneb , can decrease to as needed in 1-2 days if breathing remains
stable
6. For primary care physician: patient with fe-deficient anemia , diverticulae on anticoag , hct
stable , started iron , elevated retics , may need GI with u
No dictated summary
ENTERED BY: GORRELL , JULIETTE D. , M.D. ( RQ415 ) 10/5/06 @ 12:47 PM
****** END OF DISCHARGE ORDERS ******
Document id: 183
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
N |
N |
Y |
Y |
Y |
N |
N |
N |
N |
N |
N |
152307321 | PUO | 82935889 | | 1775965 | 8/8/2005 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed
Discharge Date: 3/28/2005
ATTENDING: WARRAN , MARCOS MD
PRIMARY CARE PHYSICIAN:
Brendan Danyelle Wurth , M.D.
PRINCIPAL DISCHARGE DIAGNOSIS:
Pneumonia.
SECONDARY DIAGNOSES:
1. COPD.
2. Arrhythmia.
3. AVNRT/SVT.
CHIEF COMPLAINT:
On admission was shortness of breath and fever.
HISTORY OF PRESENT ILLNESS:
This is a 73-year-old male with COPD , hypertension , chronic renal
insufficiency , CHF , with ejection fraction of 60% , pulmonary
hypertension , and arrhythmias who was discharged on 5/10/05 but
returned later in the evening complaining of worsening shortness
of breath and fevers at home. On prior hospitalization , the
patient had presented on 10/10/05 with acute shortness of breath
and hypertension with chest pain and was ruled out for MI and PE.
In addition , he was treated for minor COPD exacerbation with
steroids and nebulizer but not antibiotics and was discharged on
5/10/05 at baseline home O2 of 2 liters and was afebrile. At
presentation on 9/30/05 , the patient noted worsening shortness
of breath with increasing oxygen needs and in the ED was found to
have a temperature of 102.4. On chest x-ray , the patient was
found to have left lower lobe pneumonia that had not been noted
on chest x-ray from 10/10/05 and on the PECT on 4/19/05 . The
patient was admitted on 9/30/05 for pneumonia and increasing
oxygen requirements.
PAST MEDICAL HISTORY:
Past medical history is notable for a. fib with SVT not on
Coumadin , hypertension , COPD with home oxygen at 2 liters ,
hyperlipidemia , gout , coronary vascular disease , chronic renal
insufficiency , and type II diabetes controlled on diet.
MEDICATIONS:
His medications at time of admission included aspirin 81 mg
daily , allopurinol 100 mg daily , Lopressor 50 mg three times a day , the
patient was on the prednisone taper , Hytrin 2 mg daily , Zocor 40
mg every bedtime , Flovent , Prilosec , and Atrovent.
ALLERGIES:
He has allergies to sulfa , lisinopril , and quinine causing
platelet deficiency.
SOCIAL HISTORY:
The patient had quit cigarette and denied any alcohol or illicit
drug use.
FAMILY HISTORY:
Noncontributory.
PHYSICAL EXAMINATION:
Physical exam at the time of admission was notable for a
temperature of 101 , blood pressure 95/53 , oxygen saturation of
86% on 2 liters , pulse of 96 , and respiratory rate of 24. The
patient was noted to have crackles with left side being greater
than right. His cardiovascular exam had normal S1 , S2 regular
rate and rhythm with no rubs , murmurs or gallops. His
extremities were notable for trace edema. Neurologically , he was
intact.
LABORATORY DATA:
His labs at time of admission was notable for a creatinine of
1.7 , and a white cell count of 16 , he had a ABG with pH of 7.42 ,
PaCO2 of 35 , PaO2 of 52 , and 89% oxygen saturation on 2 liters.
His EKG showed T wave inversions in V2-V3 , flat V4 , borderline
first-degree AV block in sinus rhythm. Chest x-ray was notable
for left lower lobe pneumonia.
ASSESSMENT:
On assessment , this is a 73-year-old gentleman recently
discharged for minor COPD flare , presenting with acute hypoxemia
likely secondary to left lower lobe pneumonia with COPD.
HOSPITAL COURSE BY SYSTEM:
1. Pulmonary:
a. Hypoxia: The patient presented with acute and chronic
hypoxia. The patient initially required short term MICU stay for
a BiPAP and was gradually weaned to facemask over 24 hours. On
day two of admission , he was weaned to 8 liters and was
transferred to the floor where his respiratory management was
continued. On 10/4/05 , day 3 of hospitalization , the patient
had been weaned to 5 liters when he began coughing and abruptly
desaturated to 70% oxygen saturation with complaints of shortness
of breath and chest pain and required nonrebreather. The patient
had no EKG changes and a chest x-ray was unchanged from prior on
9/30/05 . The patient was given DuoNeb and chest physical therapy. He was
stabilized and was able to be managed on the floor and
transitioned back to 8 liters. At time of discharge , he has been
weaned to 4 liters with 91-97% oxygen saturation. The patient
does continue to desaturate with activities and requires further
pulmonary rehabilitation including chest physical therapy to remove mucus
plugging noted on CT PE from earlier hospitalization in April .
b. Pneumonia: The patient presented with left lower lobe
pneumonia. He was started on vancomycin , ceftriaxone , and
azithromycin on 9/30/05 . He had a sputum culture positive for
MRSA and was therefore continued on vancomycin. He was briefly
transitioned to vancomycin with ceftazidime and Flagyl from
8/14/05 to 08 , but was switched back to vancomycin with
cefotaxime and azithromycin on 5/26/05 . On day of discharge , he
will be leaving on vancomycin to complete two more days of
treatment for a total 10-day course. In addition , he will be
discharged on Levaquin for an additional seven-day course of
treatment for his pneumonia.
c. COPD: The patient has a history of COPD exacerbation and was
most recently discharged on 5/10/05 for mild COPD exacerbation
treated with DuoNeb and steroid taper. During this hospital
course , the patient continued on DuoNeb treatments as well as a
steroid taper. Given his acute clinical course in this
hospitalization , the patient did not have pulmonary function test
performed but with benefit from PFT studies as an outpatient. At
time of discharge , the patient is on 4 liters of oxygen and is
currently on prednisone 5 mg which will be tapered to his home
regimen of prednisone 5 mg every other day.
d. Hypertension: The patient had been noted to have a pulmonary
artery pressure in 2003 in the 60s but on this admission had an
echo at time of admission that noted that his pulmonary artery
pressure was now at 98 mmHg. The patient was followed by the
Kernan To Dautedi University Of Of Service to assess his pulmonary hypertension.
The patient will be followed as an outpatient by the
Kernan To Dautedi University Of Of Service and will likely need right heart
catheterization to assess his right heart function as well as his
pulmonary hypertension.
2. Cardiovascular:
a. Pump: The patient has congestive heart failure with
diastolic dysfunction with an ejection fraction around 60% as
noted on an echo done on 9/30/05 . The patient initially had his
Lasix held due to his creatinine of 1.7 at time of admission.
However , given his acute respiratory status , as well as his
increasing edema during his hospital course , the patient was
again aggressively diuresed for his CHF exacerbation with Lasix.
At time of discharge , the patient still has trace edema and his
creatinine has remained at his baseline of 1.1-1.2. The patient
will be discharged on his home Lasix regimen of 40 mg orally
although he required intravenous Lasix on multiple occasions during his
hospital course.
b. Hypertension: The patient has a history of hypertension.
Overall , his systolic blood pressure remained in the range from
110-130s. The patient was on Lopressor during his hospital
course and had no acute issues regarding his hypertension.
c. Ischemia: The patient had been ruled out for MI with three
sets of negative cardiac biomarkers. He was continued on
telemetry and remained on a regimen of aspirin , beta blockers , as
well as statin during this hospital course.
d. Rate: The patient has a history of arrhythmias with
paroxysmal atrial fibrillation and SVTs. At last admission on
10/10/05 , the patient presented to the ED in SVT and hypotensive
and reverted back to normal sinus rhythm after one dose of intravenous
Lopressor. The patient was continued on Lopressor 50 mg three times a day
during his hospital course with his DuoNeb treatments. The
patient did occasionally have heart rate into the 140s consistent
with AV nodal reentry tachycardia. These incidences did not last
more than 2 minutes and the patient was in general asymptomatic
from these arrhythmias although did occasionally did complain of
some shortness of breath on occasion during these periods of
arrhythmia. The patient is being continued on Lopressor 50 mg
three times a day
3. Endocrine: The patient has a history of type II diabetes
that was under diet control as an outpatient with steroid
treatment for his COPD exacerbation. The patient did have his
blood glucose measured regularly three times a day and required a
regular insulin sliding scale for his steroid-induced diabetes.
With tapering of the steroids , the patient's blood glucose has
generally ranged between 100-150 and has required less insulin.
While the patient is on steroids , we will continue to monitor his
blood glucose level and cover with insulin as needed. The
patient will follow up with his primary care physician and
discuss further his overall need for orally hypoglycemic agents.
4. Renal: The patient has a history of chronic renal
insufficiency with baseline creatinine around 1.1-1.2. At
initial time of presentation , his creatinine was 1.7 and his
Lasix had been held. However , the patient developed lower
extremity edema with shortness of breath and required Lasix for
his CHF exacerbation. His creatinine was followed closely during
his hospital course and with Lasix diureses his creatinine did
rise slowly to 1.4 , however , the benefits of diureses for CHF
exacerbation outweighed his chronic renal insufficiency state.
We would recommend that the patient follow up with his primary
care physician to monitor his renal state.
5. FEN: During this hospital course , the patient's electrolytes
were monitored and repleted as needed. He had no acute issues
regarding his electrolytes or nutritional status. However , the
patient should continue on low-salt 2 g sodium diet as well as
limit his fluid intake to 1.5 liters per day.
6. ID: The patient , at initial time of admission , had a
temperature of 101.2 with white cell count as high as 16. He was
found on chest x-ray to have a left lower lobe pneumonia and was
started on a antibiotic course as dictated above in pulmonary.
The patient remained afebrile through the extent of this hospital
course while on the antibiotic therapy his sputum cultures were
positive for MRSA. At time of discharge , he will be continued on
his antibiotics on vancomycin for an additional two days for a
total of 10-day course and he will also be started on Levaquin
for a seven-day course. At time of discharge , the patient
remained afebrile with his white cell count of 12.6. The patient
is on prednisone , which can slightly his overall white cell
count. The patient is aware that if he had worsening of his
sputum production as well as fevers , to seek medical attention.
7. Heme: The patient had no active issues.
8. GI: The patient had regular bowel movements during his
hospital course and deferred bowel regimen. He was on proton
pump inhibitor for prophylaxis and would be continued on this as
an outpatient.
PROPHYLAXIS:
The patient received heparin 5000 units subcutaneous three times a day
CODE STATUS:
The patient is full code.
DISPOSITION:
The patient will be discharged to rehab for further management of
his pneumonia as well as for pulmonary rehabilitation with
physical therapy.
DISCHARGE MEDICATIONS:
At time of discharge includes Tylenol 650 mg orally every 4 hours as needed
for headaches , aspirin 81 mg orally daily , allopurinol 100 mg orally
daily , Lasix 40 mg orally every day before noon , heparin 5000 units subcutaneous
three times a day , regular insulin Humulin sliding scale subcutaneous before meals ,
Lopressor 50 mg orally three times a day to be held if pulse is less than 60
systolic blood pressures are less than 110. The patient will be
discharged on a prednisone taper. He is currently at 5 mg every 24 hours
x2 doses and then to be continued on prednisone at 5 mg every 48
hours. Hytrin 2 mg orally daily , vancomycin 1 g intravenous daily for an
additional two days , Zocor 40 mg orally every bedtime , Nexium 20 mg orally
daily , Levaquin 500 mg orally daily , DuoNeb at 3/0.5 mg nebulizer
every 6 hours and levalbuterol 1.25 mg nebulizer every 6 hours , as well as
albuterol nebulizer 2.5 mg nebulizer every 2 hours as needed for shortness
of breath and wheezing , with these cautioning using albuterol in
patient given history of SVT after albuterol treatments.
FOLLOW-UP APPOINTMENT:
The patient has follow up with Dr. Wurth , his primary care
physician , at S Wilthes Hospital on
Monday 10/21/05 at 9.40 a.m. He also has an appointment with Dr.
Piontkowski , his pulmonologist , on Monday , 1/29/05 at 10.40 a.m.
and the patient will need to contact the Kernan To Dautedi University Of Of Service
to follow up his pulmonary hypertension and right heart
dysfunction within the next month , phone number to reach him is
by 274-244-3762.
eScription document: 2-5861807 EMSSten Tel
CC: Brendan Danyelle Wurth MD
Wildbirc St , Peo Rageden Rock , Kansas 59764
CC: Hermina Tuomala MD
Ata Sti Ma
Dictated By: CHRISTAL , OLIN
Attending: WARRAN , MARCOS
Dictation ID 4634782
D: 2/21/05
T: 2/21/05
Document id: 184
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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612716361 | PUO | 94726297 | | 2285874 | 5/14/2007 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | Signed | DIS | Admission Date: 10/18/2007 Report Status: Signed
Discharge Date: 3/18/2007
ATTENDING: CLARDY , CHRISTY MD
PRINCIPAL DIAGNOSIS: COPD exacerbation.
SECONDARY DIAGNOSES: Include pneumonia , acute renal failure and
hyperkalemia.
HISTORY OF PRESENT ILLNESS: Briefly this is a 60-year-old
gentleman with COPD on 3 liters home O2 and a history of multiple
past intubations to his noncompliant with his home oxygen therapy
and chronic renal insufficiency with a baseline creatinine of
approximately 2 , coronary artery disease status post end-stomy ,
diastolic heart failure who presented to the Emergency Department
with shortness of breath , chest tightness and wheezing times
several days. He also complained of a productive cough and was
found to have a room air oxygen saturation of 82% that improved
to the mid 90s on nonrebreather. He was admitted to the ICU
where he was started on BiPAP and given prednisone and nebulizer
treatments. Chest x-ray identified a right middle lobe
infiltrate and the patient was placed on vancomycin , levofloxacin
and ceftazidime. Ceftazidime was later discontinued. He was
quickly weaned to 5 liters nasal cannula. An ABG checked on
admission showed partial CO2 of 60 which is the patient's
baseline. He was also found to be on acute renal failure with a
creatinine of 4.9 that improved with gentle fluids. Potassium
was elevated at 6.4 and the patient did undergo a single run of
hemodialysis.
PAST MEDICAL HISTORY: COPD , coronary artery disease status post
end-stomy , diabetes , chronic renal insufficiency , hyperlipidemia
and gout.
HOME MEDICATIONS: Include aspirin 81 mg orally daily , Norvasc 10
mg orally daily , Toprol 100 mg orally daily , Avapro 150 mg orally
daily , Lasix 80 mg orally daily , Lipitor 40 mg orally nightly , TriCor
48 mg orally daily , NPH 55 units in the morning , 34 units in the
evening , NovoLog 8 units before every meal , allopurinol 300 mg orally daily ,
Singulair 10 mg orally daily , albuterol 2 puffs as needed , Combivent
as needed , Advair 500/50 twice a day , multivitamin once per day , folate 1
mg orally daily and loratadine 10 mg orally daily.
ALLERGIES: There are no known drug allergies.
SOCIAL HISTORY: A 30-pack-year history of smoking , history of
current alcohol use , five drinks per day.
PHYSICAL EXAMINATION: On transfer to the floor temperature is
96 , pulse 82 , blood pressure 150/72 , respiratory rate is 24 ,
oxygen saturation 94% on 5 liters nasal cannula. He is in no
apparent distress. Heart is regular rate and rhythm without
murmurs , rubs or gallops. He has good air movement but
expiratory wheezes and prolonged expiratory phase. There are no
rales. His abdomen is soft , obese , nontender and bowel sounds
are present. There is 1+ pitting edema bilaterally.
LABORATORY DATA: On admission to the floor , BUN 211 , creatinine
3.5 , potassium 4.4. White count 13.4 , hematocrit 25.8 , platelets
492 and INR 1.3. Microbiology , numerous blood , sputum and urine
cultures are negative. Studies and echocardiogram from 7/21
shows an EF of 55-60% with no regional wall abnormalities.
IMPRESSION: This is a 60-year-old gentleman admitted for a COPD
exacerbation in the setting of likely pneumonia with acute on
chronic renal failure and hyperkalemia that has resolved since
his admission.
HOSPITAL COURSE BY PROBLEM:
1. Pulmonary: The patient was kept on prednisone 60 mg orally
daily for the first several days of his floor admission and he
was continued on DuoNeb every 6 hours , albuterol labs were added every 6 hours
staggered with DuoNeb such that he was receiving nebulizer
treatments every three hours. He was continued on chest physical therapy. The
patient was started on CPAP overnight for history of obstructive
sleep apnea. He had not been compliant with CPAP as an
outpatient. Advair was continued. The patient did well with
this regimen and his oxygen requirements were titrated from 5
liters to 2.5 liters at the time of discharge. At this level of
oxygen he was satting in the low to mid 90s with ambulatory sat
of approximately 90%. The importance of continuing use of home
oxygen both during the day and at night was discussed at length
with the patient , though he continued to complain that he had
difficulty going about his daily activities wearing his oxygen. Prednisone
was slowly tapered and at the time of discharge the patient was
taking 40 mg of prednisone per day. He will take 20 mg starting
the first day after his discharge and will complete a slow
approximately 2-week taper. His home dose of Lasix was
continued. The patient was not felt to be clinically volume
overloaded. However , he auto-diuresed 1-2 liters the majority
of the days he was admitted to the floor. Followup was arranged
with the patient's primary care provider and his pulmonologist
Dr. Hernandes . The possibility of inpatient pulmonary rehabilitation
was discussed at length with the patient and his wife who were
extremely resistant to any other inpatient care. He is therefore
discharged with home VNA , though the possibility of inpatient vs outpatient
pulmonary rehabilitation should be considered at his followup.
2. Renal: The patient's creatinine trended down throughout his
time on the floor. This happened in the setting of continued
auto-diuresis , suggesting that his initial renal failure was due
to a low flow state as result of heart failure rather than
hypovolemia. At the time of discharge his creatinine was 1.3.
He was followed by the Renal Team during his admission. His ARB
was initially held but then restarted upon improvement of his
creatinine. Per renal , his elevated BUN in the range of 200 was
felt to be secondary to steroid use. This had normalized by the
time of discharge. The patient was worked up for a possible AV
fistula or graft placement in the left upper extremity in the
near future. He will follow up with vascular surgery as an
outpatient for vein mapping as an outpatient. He should not receive blood
draws in the left upper extremity of avoidable.
3. Infectious disease: The patient was continued on vancomycin
and Levaquin for a seven-day course. He completed this course
during this hospitalization and he discharged off antibiotics.
All cultures were no growth at the time of discharge.
4. Cardiovascular: He was continued on aspirin and
anti-lipidemics. His Lopressor was titrated for hypertension and
he is discharged on 300 mg of Toprol per day the rest of his
antihypertensive medicines have not changed. He was kept on tele
during his admission and did have occasional episodes of NSVT
usually triplets or couplets. These were asymptomatic.
5. Endocrine: Mr. Hargrow insulin requirements increased
dramatically during his ICU admission , likely as a result of
steroid use and stress. His insulin requirements fell to their
preadmission levels during his admission on the floor.
6. Prophylaxis: He was maintained on heparin and proton pump
inhibitor.
CODE STATUS: The patient is full code.
PHYSICAL EXAM ON DISCHARGE: He is in no apparent distress.
Heart , regular rate and rhythm without murmurs , rubs or gallops.
His lungs are clear to auscultation bilaterally without wheezes ,
rales or rhonchi. Abdomen is soft , obese , nontender , bowel
sounds are present. He has trace peripheral edema bilaterally.
DISCHARGE MEDICATIONS: Please see remainder of discharge
paperwork.
DISPOSITION: To home with VNA. He should follow up with both
his primary care doctor and pulmonologist. These appointments
have been arranged for him.
eScription document: 7-0533577 CSSten Tel
CC: Luz Hilger M.D.
I Temedma Doch Health University And Hospital
Holl
CC: Christy Clardy MD
KTDUOO
Tarmney Pkwy. , Ward Ro Co , Colorado 85636
CC: Lawerence Niu M.D.
Bondering Ogenete Memorial Hospital
Liet Well
Dictated By: BENTHAM , VIVIEN
Attending: CLARDY , CHRISTY
Dictation ID 6879635
D: 10/26/07
T: 10/26/07
Document id: 185
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
Y |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
135358408 | PUO | 11671436 | | 522676 | 3/14/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 7/16/2000 Report Status: Signed
Discharge Date: 6/13/2000
PRINCIPAL DIAGNOSIS: CARDIOMYOPATHY.
HISTORY OF PRESENT ILLNESS: Ms. Montecillo is a 49 year old woman with
history of non ischemic dilated
cardiomyopathy thought to be either familial or secondary to
alcohol use who is on the transplant list and presents with
worsening CHF symptoms.
Ms. Tassone cardiac history began in 1995 when she was admitted
with worsening dyspnea. Echocardiogram at that time revealed an
ejection fraction of 15% with global hypokinesis and 3+ mitral
regurgitation. Catheterization revealed a right dominant system
with clean coronary arteries. Exercise test at that time revealed
a peak VO2 of 12.6 liters per kg per minute. IN October of 1997 , a
repeat echocardiogram revealed an ejection fraction of 20% with
moderate mitral regurgitation and significant left atrial
dilatation. At that time , she received tailored therapy with
Digoxin , diuretics and ACE inhibitors. In February of 1997 , she
was again hospitalized , this time with severe pancreatitis
resulting in acute renal failure , hypotension and respiratory
failure requiring intubation in the ICU. In April of 1997 , she
developed progressive dyspnea on exertion , orthopnea and PND. In
October of 1998 , repeat echocardiogram revealed severe left
ventricular dilatation with an EF of 10 to 15% , global hypokinesis
and left atrial dilatation secondary to mitral regurgitation. She
was hospitalized most recently in August 1999 for abdominal
discomfort thought to be secondary to worsening right heart failure
and improved with aggressive diuresis.
She has done well since then until approximately three weeks prior
to admission when she developed worsening dyspnea and intermittent
tachycardia. She reports four pillow orthopnea and three nights of
PND. She becomes short of breath walking up only five stairs , and
reports approximately three weeks of a dry cough , productive
occasionally of clear sputum. She denies fever , chills , nausea ,
vomiting or diarrhea , GI , or GU symptoms.
PAST MEDICAL HISTORY: 1. Dilated cardiomyopathy. 2. Non insulin
dependent diabetes mellitus. 3. History of
severe pancreatitis. 4. Status post appendectomy. 5. Status post
ovarian cyst removal. 6. History of alcoholism. 7. Chronic
renal insufficiency. 8. History of myocarditis.
ALLERGIES: Penicillin leads to hives.
MEDICATIONS: 1. Amiodarone 200 mg orally every day , 2. Lasix 200 mg orally
twice a day and 200 mg intravenous once per week with a visiting
nurse. 3. Diuril 500 mg orally every day. 4. Zaroxolyn 2.5 mg once per
week before the intravenous Lasix dose. 5. Aldactone 50 mg orally twice a day 6.
Coumadin 4 mg alternating with 2 mg orally every day. 7. Digoxin
0.0625 mg orally every day , 8. Ativan 2 mg orally every bedtime , 9. Colace 100
mg orally twice a day 10. KCl 20 mEq three times a day , 11. Multivitamin one every day.
SOCIAL HISTORY: She used to smoke 1/2 pack per day for 35 years
but quit one year ago. She has a significant
alcohol history drinking one quart of rum per day but quit 2 and
1/2 years ago and never used any illicit drugs.
FAMILY HISTORY: Has two sons with cardiomyopathy; both are
teenagers. Her maternal grandmother and her aunt
both died of sudden cardiac death at ages 60 and 40.
PHYSICAL EXAMINATION: Heart rate in the 120s , blood pressure
84/70 , respiratory rate 28. In general ,
this is a slightly tachypneic woman in no apparent distress.
HEENT: PERRLA. EOMI. OROPHARYNX: Clear , moist mucous membranes.
CHEST: Slight bibasilar crackles about 1/3 of the way up. HEART:
Tachycardic with S1 , S2 , S3 and S4 gallops. No murmurs , She has a
palpable right ventricular heave , a laterally displaced PMI and JVP
greater than 18 cm. ABDOMEN: Bowel sounds present , soft ,
non-tender , nondistended , no hepatosplenomegaly. EXTREMITIES: No
clubbing , cyanosis or edema , lukewarm.
LABORATORY: Electrolytes normal with a potassium of 4.9 , magnesium
1.9 , BUN 17 , creatinine 1.1. INR was 1.3. Her WBC
was 9.5 , hematocrit 39.2 and platelet count 225. LFTs were normal.
Chest x-ray revealed cardiomegaly but no congestive heart failure ,
unchanged since 10/26/99 . EKG revealed sinus tachycardia at 110
beats per minute with an incomplete left bundle branch block and
first degree AV block.
HOSPITAL COURSE: Ms. Montecillo was started on a Dobutamine drip at 2
mcg per kg per minute and was diuresed
aggressively with intravenous Lasix as well as orally Zaroxolyn and
Aldactone. Her symptoms improved greatly with diuresis and her
weight dropped from 73.5 kg on admission to a discharge weight of
70 kg. Her Dobutamine was weaned off and she was switched from
Lasix to orally torsemide. She remains on the cardiac transplant
list.
DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg orally every day , 2. Diuril
500 mg orally every day , 3. Digoxin 0.0625 mg
orally every day , 4. Colace 100 mg orally twice a day , 5. Ativan 2 mg orally every
bedtime 6. Aldactone 25 mg orally every day. 7. Coumadin 4 mg orally every bedtime ,
8. torsemide 100 mg orally every day , 9. K-Dur 20 mEq orally three times a day
CONDITION ON DISCHARGE: Stable.
Dictated By: ARLYNE ROIS , M.D. ZE12
Attending: FERNANDE R. PREWER , M.D. LW64 FC791/9418
Batch: 00769 Index No. S4JI2WTBY3 D: 3/23
T: 10/16
Document id: 186
| Target |
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842095400 | PUO | 81454020 | | 4226481 | 7/5/2004 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 5/22/2004 Report Status: Signed
Discharge Date: 1/11/2004
ATTENDING: ISABELLE EVON COLASAMTE MD
PRINCIPAL DIAGNOSIS: Coronary artery disease , left main coronary
artery stenosis.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old woman with a
history of diabetes mellitus , obesity , and hyperlipidemia as well
as peripheral vascular disease who has had progressively
worsening dyspnea on exertion. Her symptoms are markedly worse
since October . She underwent cardiac catheterization in 7/17 ,
which revealed left main coronary disease with two-vessel disease
in the left dominant system. Abdominal aortogram revealed severe
and extensive bilateral aortofemoral disease. She is referred to
Pagham University Of for CABG and surgical
revascularization.
PAST MEDICAL HISTORY: Coronary artery disease status post PTCA
and stent in 7/10 . Hypertension , peripheral vascular disease
with claudication , left worse than right , on exertion ,
insulin-dependent diabetes mellitus , and hypercholesterolemia.
PAST SURGICAL HISTORY: None.
FAMILY HISTORY: Positive for an aunt who died of coronary artery
disease.
SOCIAL HISTORY: Positive for a 30-pack-year smoking history , the
patient quit 15 years ago.
ALLERGIES: Cimetidine causing stomach pain and lisinopril
causing cough.
MEDICATIONS: On admission , atenolol 100 mg orally twice a day ,
isosorbide 40 mg orally three times a day , Lasix 80 mg orally twice a day ,
simvastatin 80 mg orally every day , metformin 500 mg orally three times a day , Avapro
300 mg every day , and insulin.
PHYSICAL EXAMINATION: 5 feet 5 inches tall , 89 kilos. HEENT:
PERRLA. Oropharynx benign. Neck: Without carotid bruits. The
patient has a history of cataract. Her chest is without
incisions. Cardiovascular: Regular rate and rhythm , grade II
systolic murmur. Breath sounds are clear bilaterally. Abdomen:
Soft , no incisions , no masses. Extremities: Without scarring ,
varicosities , or edema. 1+ pedal pulses in the posterior tibial
distribution bilaterally. Dorsalis pedis is nonpalpable on the
left and 1+ on the right. Radial pulses are 2+ bilaterally.
Neuro: Alert and oriented , grossly nonfocal exam.
PREOPERATIVE LABORATORY DATA: Chemistries include sodium of 141 ,
potassium 3.9 , BUN of 18 , creatinine of 1 , and glucose of 109.
Hematology includes white blood cell count of 7 , hematocrit of
42 , and INR of 1. Her glycosylated hemoglobin is 6.3. Cardiac
catheterization data from 1/15/2004 reveals 50% distal left
main , 90% ostial LAD , 70% mid LAD , 70% ostial OM1 , 70% ostial
OM2 , and a left dominant circulation. Echocardiogram from
5/4 estimates ejection fraction at 55%. There is mild aortic
insufficiency and mild mitral insufficiency. EKG: Normal sinus
rhythm at 50. Chest x-ray reveals aortic calcification.
HOSPITAL COURSE: The patient was admitted on 6/17/2004 .
Because of her diffuse arthropathy and Jehovah's Witness status ,
it was planned that she have an off pump revascularization if
possible and on 6/17/2004 she was taken to the Operating Room
and underwent off pump CABG x1 with LIMA to LAD. Intraoperative
findings included calcified LAD. She received no blood products
and was taken to the Intensive Care Unit following surgery in
stable condition. She was extubated on postoperative day #1.
She was started on Plavix and aspirin for her off pump CABG and
she needed ongoing diuresis and blood pressure control. She was
followed by Cardiology during the postoperative period as well as
the Diabetes Management Service for blood sugar control. The
patient was slow to ambulate and needed encouragement. She
required intravenous Lasix to return to her preoperative weight.
She was successfully weaned off oxygen on postoperative day #6 ,
she was noted on that same day to have had 10 beats of VT which
was pointed out to Cardiology and her beta-blocker was increased.
She had no further problems with arrhythmia and the remainder of
her postoperative course was uncomplicated.
DISPOSITION: She is discharged to home in good condition on
postoperative day #8 on the following medications:
Enteric-coated aspirin 325 mg orally every day , Colace 100 mg orally
three times a day as needed constipation , ibuprofen 600 mg every 6 hours as needed pain ,
NPH insulin 28 units every day before noon and 12 units every afternoon , Niferex 150 mg
orally twice a day , Zocor 80 mg orally every bedtime , Plavix 75 mg orally every day ,
Avapro 300 mg orally every day , atenolol 100 mg orally twice a day , and
metformin 500 mg orally three times a day
FOLLOWUP: She is to have follow-up appointments with her primary
care physician an associate of Dr. Heiple in one week , with her
cardiologist Dr. Bernas in one month , and with her cardiac
surgeon , Dr. Colasamte in four to six weeks.
eScription document: 5-8283079 EMSSten Tel
Dictated By: JACOBSON , CHRISTEEN
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 6333562
D: 1/2/04
T: 1/2/04
Document id: 187
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
Y |
Y |
U |
U |
U |
Y |
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U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
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- |
N |
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- |
073405629 | PUO | 74060660 | | 9258938 | 9/12/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 9/12/2005 Report Status: Signed
Discharge Date: 7/30/2005
ATTENDING: KERTESZ , ALETA MD
ADMITTING DIAGNOSES:
Coronary artery disease and CHF.
HISTORY OF PRESENT ILLNESS:
This is a 72-year-old female with history of coronary artery
disease and status post an MI back in 2004 , who at that time
underwent a cardiac catheterization and angioplasty of the LAD
with placement of a stent. She had an adenosine stress test done
in 8/21 , which showed a fixed apical , anterior apical , and
inferior apical defect with an EF of 28%. The patient was
admitted to an outside hospital with complaints of shortness of
breath after eating a large mail at the Chinese restaurant. She
was found to be in flash pulmonary edema and was treated with
Lasix and aspirin in the emergency room. She was transferred to
the Pagham University Of and underwent a cardiac
catheterization , which showed coronary artery disease and
referred for surgical intervention.
PAST MEDICAL HISTORY:
Significant for CAD status post MI as stated above , as well as
CHF. The patient also has history of hypertension , history of
peripheral vascular disease with claudication in both legs , but
status post fem-pop bypass in her right leg. She has history of
also insulin-dependent diabetic with associated diabetic
peripheral neuropathy and diabetic autonomic neuropathy , which
she is on the Neurontin. The patient also has history of
hypercholesterolemia , history of COPD with chronic bronchitis ,
past history of DVT and history of depression. Creatinine
clearance estimated on this admission was 67.4 mL per minute.
PAST SURGICAL HISTORY:
Status post LAD stenting in 6/8 , also status post fem-pop of
his her right leg , as well as right toe amputation. The patient
also is status post TAH and BSO.
FAMILY HISTORY:
No family history of CAD.
SOCIAL HISTORY:
History of tobacco use , 25-pack-year history.
ALLERGIES:
Listed as Cefobid and cephalosporins. The allergic reaction is
not noted.
MEDICATIONS ON ADMISSION:
Lopressor 25 mg orally twice a day , losartan 25 mg orally once a day ,
aspirin 325 mg orally once a day , Plavix 75 mg orally once a day ,
Lasix 40 mg orally once a day , simvastatin 40 mg orally once a day ,
Humulin insulin 70/30 45 units every day before noon and 25 units every afternoon ,
Protonix 40 mg orally once a day , Neurontin 300 mg orally three times a day , and
Wellbutrin 100 mg orally three times a day
PHYSICAL EXAMINATION:
The patient is 5 feet 3 inches and 109 kilos. Vital signs:
Temperature of 98 , heart rate of 66 , and blood pressure on the
right arm of 130/54 , and on the left 128/60. O2 sat of 98.
HEENT: PERRLA. No carotid bruit. Chest: No incision.
Cardiovascular: Regular rate and rhythm , no murmurs noted.
Pulses on the carotid , radial and femoral are 2+ throughout , on
the left dorsalis pedis was 1+ and posterior tibial nonpalpable
on the right , 2+ dorsalis pedis and nonpalpable posterior tibial.
Allen's test on the left upper extremity by pulse oxymetry was
normal , on right upper extremity with poor refill with
compression of the radial artery. Respiratory rales are present
bilaterally. Abdomen: TAHBSO scar noted , soft , no mass noted.
Rectal: Deferred. Extremities: Right scar status post fem-pop
bypass and second toe is status post amputation. Varicose veins
is noted in both legs with 2+ pitting edema. Neuro: Alert and
oriented with no focal deficits.
LABORATORY DATA ON ADMISSION:
On 4/4/05 , sodium 136 , K of 4.1 , chloride of 101 , CO2 of 30 ,
BUN of 28 , creatinine of 1.3 , glucose of 286 , and magnesium of
1.9. Hematology from the same day , white count of 12 , hematocrit
of 38 , hemoglobin of 12.9 , platelets 263 , 000 , physical therapy of 13.4 , INR
1.0 , PTT of 29.5 , and A1c of 7.5. Cardiac catheterization was
done at the outside hospital on 4/4/05 , which showed a 50% left
main , 80% ostial LAD , a 70% distal LAD , 80% ostial circumflex , a
55% proximal RCA and 90% mid RCA , a 50% ostial PDA , codominant
circulation with inferior hypokinesis. The ventriculogram showed
an EF of 45%.
HOSPITAL COURSE:
The patient was transferred from the outside hospital status post
cath for surgical revascularization. The patient had an EKG on
4/4/05 , which showed first-degree AV block with a rate of 61
and ST depressions in leads I , II , and aVL. Chest x-ray showed a
calcific aortic knob , otherwise clear. The patient was evaluated
for conduit for her surgery and underwent venous mapping and
found to have some vein in her left leg , and on 9/29/05 , the
patient was taken to the operating room and underwent a coronary
artery bypass grafting x3 , a LIMA to the LAD , and a sequential
vein graft to the ramus and to the obtuse marginal three. On the
TEE intraoperatively , there was noted to be a PFO , which was
closed at that time. The patient's total cardiopulmonary bypass
time was 106 minutes , and cross clamp time was 106 minutes. The
patient came off the heart-lung machine without any difficulty ,
on no pressors , and was taken to the Cardiac Surgery Intensive
Care Unit and extubated the following day. The patient's
postoperative course by systems.
Neurological: The patient remained intact and was started back
on Neurontin for her diabetic peripheral and autonomic
neuropathy. The patient also was restarted back on her
Wellbutrin for her depression.
Cardiovascular: The patient initially was in a sinus bradycardia
with a backup pacing wire , temporary pacing wire , and started on
low-dose beta-blockers; however , the patient had no further
bradycardia and her Lopressor was titrated up for discharge dose
of Toprol 50 mg orally twice a day and captopril for hypertension and
the patient remained in normal sinus rhythm throughout her
postoperative course.
Respiratory: The patient was extubated on postoperative day #1 ,
and weaned to room air by postoperative day #4 with gentle
diuresis , and due to her preop CHF and EF of 38 , the patient will
be discharged on her preoperative doses of Lasix 40 mg orally once
a day , and should follow up with Dr. Tamez in 1-2 weeks to
further evaluate her Lasix requirement.
GI: The patient was on Nexium for GI prophylaxis , but on
discharge was switched over to her preoperative Protonix.
Renal: The patient had a stable BUN and creatinine throughout
her postoperative course with a discharge creatinine of 0.9 and
BUN of 24. Preoperatively , her creatinine was 1.3 with a
estimated clearance was 67.
Endocrine: The patient is an insulin-dependent diabetic and
required an insulin drip intraoperatively and transitioned to a
sliding scale followed closely by the Diabetes Service and will
be discharged on Lantus 22 units , as well as NovoLog with meals.
Heme: The patient had a stable hematocrit throughout her
postoperative course. She has been anywhere from the 23-25 , was
stable and on Niferex to boost her hematocrit , as well as Nexium
for GI prophylaxis while she is on the aspirin and Plavix status
post cardiac surgery instant.
ID: The patient was on vancomycin for surgical prophylaxis , but
had no other infectious issues postoperatively and will not be
discharged on any antibiotics. By postoperative day #8 , the
patient was in stable condition and will be transferred to the
rehabilitation center on these following medications.
DISCHARGE MEDICATIONS:
Acetaminophen 325-650 mg every 4 hours as needed fever or pain ,
enteric-coated aspirin 325 mg orally once a day , Wellbutrin 100 mg
orally three times a day , captopril 12.5 mg orally twice a day , Colace 100 mg orally
three times a day , Lasix 40 mg orally once a day , Motrin 400-600 mg every 8 hours
as needed pain , Niferex 150 mg orally twice a day , oxycodone 5 mg orally
every 4 hours as needed pain , simvastatin 40 mg orally every hours sleep ,
Toprol 50 mg orally twice a day , Neurontin 300 mg orally three times a day , Plavix 75
mg orally once a day , Lantus 22 units subcutaneously every hours
sleep , NovoLog 10 units subcutaneously with breakfast and then
NovoLog 6 units with lunch and with supper , and Protonix 40 mg
orally once a day.
FOLLOW-UP APPOINTMENTS:
The patient should also follow up make these follow up
appointments with her cardiologist , Dr. Tamez in one to two
weeks. His telephone number is 877-097-1445. The patient should
also follow up with Dr. Kertesz in six weeks for postsurgical
evaluation. His telephone number is 766-081-5735.
eScription document: 7-7882412 EMSSten Tel
Dictated By: AFZAL , TOMIKA
Attending: KERTESZ , ALETA
Dictation ID 8336271
D: 5/22/05
T: 5/22/05
Document id: 188
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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| output/system_textual_annotation.xml | textual |
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117386686 | PUO | 30153030 | | 400441 | 1/30/1997 12:00:00 a.m. | MORBID OBESITY , HYPERTENSION | Signed | DIS | Admission Date: 3/20/1997 Report Status: Signed
Discharge Date: 7/2/1997
HISTORY OF PRESENT ILLNESS: Patient is a 59 year old female with
morbid obesity with weight of
approximately 389 pounds. She had been treated with Redux without
much success. Fatty mass index was greater than 60. She had had
unsuccessful multiple attempts at weight reduction and presented to
Pagham University Of for gastric reduction surgery.
PAST MEDICAL HISTORY: Significant for arthritis in hips and knees
and hypertension.
PAST SURGICAL HISTORY: Patient underwent an umbilical hernia
repair in 1992 , a cholecystectomy in 1989 ,
and a mastoidectomy in 1970.
CURRENT MEDICATIONS: Levoxil 0.125 every day , Procardia XL 90 , nadolol
40 every day , Trazodone 150 mg every bedtime , and Lasix
20 every day
ALLERGIES: Patient had no known drug allergies.
PHYSICAL EXAMINATION: On admission , patient was morbidly obese ,
skin turgor was good , no adenopathy , and
HEENT examination was normal. The breasts had no lesions , the
lungs were clear , heart showed regular rate and rhythm , distal
pulses were intact , and abdomen was soft with no masses , a large
pannus , and no palpable hernias.
HOSPITAL COURSE: The patient was admitted for same day surgery on
4/22/97 and underwent a Roux-en-Y gastric bypass
without any complication. For more information of the
intraoperative course , please refer to the Operative Note. Patient
was discharged stable to the PACU. She did , however , have
decreased saturations. Patient had a history of sleep apnea and
there was some concern over maintaining good SAO2. Therefore , the
patient was transferred to the ICU overnight for closer monitoring.
Patient did well overnight and on postoperative day one , was
transferred out to the floor on cardiac monitor. Patient began
gastric day one diet , tolerated it well , and progressively advanced
her diet during her hospital stay. There were no complications and
the remainder of her postoperative course was uncomplicated and
normal.
DISPOSITION: Patient is discharged to home in stable condition on
2/25/97 .
DISCHARGE MEDICATIONS: Levoxil 0.125 every day , Procardia XL 90 every day ,
nadolol 40 every day , Trazodone 150 mg every bedtime ,
Lasix 20 every day , and Roxicet elixir 15 mg every 3-4h. as needed pain.
Dictated By: CHRISTY CLARDY , M.D. DX11
Attending: ZORA DIERKER , M.D. GA83 RI703/4620
Batch: 34558 Index No. TEVK6P8JM8 D: 2/25/97
T: 10/18/97
Document id: 189
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
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OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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792607802 | PUO | 81699986 | | 856451 | 10/12/1997 12:00:00 a.m. | MITRAL STENOSIS | Signed | DIS | Admission Date: 11/27/1997 Report Status: Signed
Discharge Date: 3/10/1997
ADMISSION DIAGNOSIS: MITRAL STENOSIS.
HISTORY OF PRESENT ILLNESS: Ms. Shaftic is a 74 year old black
female with a history of rheumatic
heart disease and history of atrial fibrillation who was
transferred from an outside hospital for treatment of her
symptomatic mitral valve stenosis. For the past two years , Ms.
Shaftic had experienced a steady very gradual decline in her
exercise tolerance with a decreased ability to make her bed or
vacuum. However , she noticed this only in retrospect. On
6/4/97 , she presented to an outside hospital complaining of the
abrupt onset over one day of weakness , shortness of breath , 1/10
chest pain radiating to bilateral elbows , and dizziness. Symptoms
occurred at rest and were not positional and there were no
relieving or aggravating signs. They lasted approximately nine
hours resolving in the Emergency Department at the outside hospital
before therapy was initiated. Chest x-ray at this time showed mild
congestive heart failure which responded to Lasix 20 mg intravenous
push in the Emergency Department. She was admitted , ruled out for
a myocardial infarction with CK of 31 , 67 , 64 , and 59 , and sent to
catheterization on 3/8/97 which showed a left ostia at 30% , 25 mm
mitral valve gradient , pulmonary artery pressure of 8 , wedge of 18 ,
and cardiac output of 5.3. Echo revealed right and left atrial
enlargement , mild mitral regurgitation , mild tricuspid
regurgitation , ejection fraction was 60% to 65% , and mitral
stenosis with a mitral valve area of 0.9 cm squared down from 1.2
cm squared in 6/10 . Ms. Shaftic remained at this outside hospital
for one week essentially symptom free on bedrest and medical
management while awaiting transfer for definitive treatment at the
Pagham University Of . She was transferred to the Pagham University Of on the evening of 6/25/97 in good condition
and remained symptom free on bedrest. She complained of no
paroxysmal nocturnal dyspnea , orthopnea , hemoptysis , fever , chills ,
nausea , vomiting , diarrhea , or change in bowel or bladder habits.
Her cardiac risk factors included hypercholesterolemia ,
hypertension , she was not diabetic , did not smoke , and had a plus
or minus family history with a sister who died at 68 of a cardiac
arrest.
PAST MEDICAL HISTORY: Significant for rheumatic heart disease
without a history of rheumatic fever that
was diagnosed in 1994 , she had atrial fibrillation , she ruled out
for myocardial infarction in 6/10 and again prior to admission at
the outside hospital , she had a normal exercise tolerance test in
4/16 , submaximal full without anginal symptoms at baseline , she
had a history of peptic ulcer disease , a hiatal hernia , peripheral
vascular disease , and chronic bronchitis.
PAST SURGICAL HISTORY: Significant for a left saphenous ligation.
CURRENT MEDICATIONS: On admission , Lasix 40 mg orally every day , Zocor 10
mg orally every day , isosorbide 10 mg orally three times a day ,
Coumadin 5 mg every day and 2.5 mg Thursday , and Lanoxin 0.125 mg every day
ALLERGIES: She was allergic to penicillin which gave her a rash
and to Darvocet which gave her dysphoria.
FAMILY/SOCIAL HISTORY: Essentially noncontributory.
PHYSICAL EXAMINATION: She was a moderately obese white female
comfortable in bed with a heart rate of 56
and 94 , respiratory rate of 18 , blood pressure of 110-130/70-80 ,
and temperature 98.1. HEENT: Examination was essentially
unremarkable , carotids were 2+ with good upstrokes and no bruits ,
jugular venous pressure was 7 cm , pupils equally round and reactive
to light , extraocular movements intact , cranial nerves intact
bilaterally , supple neck with no lymphadenopathy , and notable for
bilateral arcus senilis. LUNGS: Mild crackles at the right base ,
otherwise clear to auscultation. CARDIAC: Examination was
irregularly irregular , she had an increased S1 , a normal S2 , she
had an opening snap after S2 , she had a soft low diastolic rumble
in the left lateral decubitus at the apex , and she did not have a
sternal heave. ABDOMEN: Soft , nontender , nondistended , had bowel
sounds , did not have hepatojugular reflux , and did not have masses.
EXTREMITIES: Warm , well perfused without clubbing or cyanosis , she
was moving all of her extremities quite well , and she had good
distal pulses. Strength was grossly intact and symmetric at 5/5
throughout and she did have some nonblanching slightly raised
pruritic red plaques on her left ankle consistent with psoriasis
which was diagnosis which she carried. NEUROLOGICAL: She was
alert , oriented , conversant , appropriate , and interactive and had a
grossly nonfocal neurologic examination.
LABORATORY EXAMINATION: On admission , significant for CHEM 7 with
a sodium of 137 , a potassium of 4.0 ,
chloride of 99 , bicarbonate 26 , BUN 21 , creatinine 0.9 , glucose of
86 , white count of 5.5 , hematocrit of 42.3 , and 284 , 000 platelets.
physical therapy was 12.9 , PTT was 82.2 , and magnesium of 2.2. Urinalysis was
essentially clean. ECG showed atrial fibrillation in the sixties
without ST-T wave abnormalities , axis about 30 degrees , normal R
wave progression , and no evidence of chamber enlargement on EKG.
HOSPITAL COURSE: Ms. Shaftic , in-house , was taken to valvuloplasty
on 7/27/97 which was without event. She had
valvuloplasty and mitral diastolic gradient was lowered from
approximately 8 mm of mercury to approximately 10 mm of mercury.
Her postprocedure course was uncomplicated , however , slightly
prolonged while transitioning back onto Coumadin
postcatheterization.
DISPOSITION: She is discharged on 9/3/97 in stable condition.
DISCHARGE MEDICATIONS: She is discharged on Lasix 20 mg orally every day ,
simvastatin 10 mg orally every bedtime , Coumadin 3
mg every day and 5 mg on Wednesday orally , and Losartan 25 mg orally every day
Dictated By: DEJA KINTOPP , M.D.
Attending: ALEXANDRA T. POPOVIC , M.D. VN4 DY977/4834
Batch: 95715 Index No. LGTT0Y177B D: 5/8/97
T: 1/4/97
CC: 1. ROSSIE MANKOSKI , M.D. BU14
Document id: 190
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
N |
N |
N |
N |
- |
- |
N |
N |
N |
N |
N |
N |
593024412 | PUO | 67923881 | | 130058 | 2/3/1997 12:00:00 a.m. | AORTIC VALVE DISEASE , MITRAL VALVE DISEASE , CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 2/3/1997 Report Status: Signed
Discharge Date: 6/17/1997
HISTORY OF PRESENT ILLNESS: Mr. Adelblue is a 61 year old man who
was admitted to the cardiac surgical
service on 1/10/97 for aortic valve replacement , mitral valve
replacement. He had an echocardiogram at an outside hospital that
demonstrated a dilated left ventricle and an ejection fraction of
55% with moderate aortic stenosis with moderate to severe aortic
insufficiency with a peak gradient of 35 millimeters of mercury ,
mild to moderate mitral stenosis and moderate mitral insufficiency
with a mitral valve area of 1.1 cm squared. He has had a history
of rheumatic heart disease. His cardiac catheterization on
9/10/97 demonstrated a 95% proximal right coronary artery lesion
and an ejection fraction of 50%.
PAST MEDICAL HISTORY: Included rheumatic heart disease and
hypertension.
PAST SURGICAL HISTORY: Is none.
SOCIAL HISTORY: Former smoker; twenty pack year history.
MEDICATIONS: On admission are Toprol XL 50 once a day , aspirin
once a day , sublingual nitroglycerin and Zocor 50
once a day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM: Unremarkable except for a 3/6 diastolic murmur at
the apex and a 3 to 4/6 systolic murmur at the
lower left sternal border.
LABORATORY: Were all normal , within normal limits.
HOSPITAL COURSE: He went to the operating room on 3/4/97 where
he had a mitral valve replacement with a #31 St.
Jude mechanical prosthesis and an aortic valve replacement with a
#25 St. Jude mechanical prosthesis and a right internal mammary
artery bypass grafting to the right coronary artery. He had no
complications.
He is being discharged on postop day four without complications.
He will be discharged on Lopressor 50 mg twice a day , Lasix 40 mg
once a day for two days with potassium , K-Dur tabs 10 mEq once a
day for two days with Lasix , Coumadin 5 mg one tab once a day or as
directed. The Coumadin has been restarted for right leg DVT that
was discovered post cardiac catheterization and is to be continued
for a total of three months. Percocet is one tab every 4 hours as needed for
pain and he is being discharged to the care of Dr. Hermina Tuomala .
Dictated By: CHRISTY CLARDY , P.A.
Attending: DESIRAE R. MARCOTT , M.D. ZD7 VQ599/7608
Batch: 86472 Index No. B3RDWU108L D: 6/10/97
T: 7/24/97
Document id: 191
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
600597399 | PUO | 21376341 | | 9987563 | 1/16/2007 12:00:00 a.m. | ROMI | | DIS | Admission Date: 8/7/2007 Report Status:
Discharge Date: 8/28/2007
****** FINAL DISCHARGE ORDERS ******
CARRAUZA , DANIELLE L 474-42-87-2
Vo
Service: MED
DISCHARGE PATIENT ON: 9/20/07 AT 09:00 a.m.
CONTINGENT UPON AMA
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MALADY , CASSONDRA F. , M.D. , M.S.
CODE STATUS:
Full code
DISPOSITION: AMA
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 325 MG orally every day
2. ATENOLOL 25 MG orally every day
3. ATORVASTATIN 80 MG orally every day
4. DOCUSATE SODIUM 100 MG orally twice a day
5. LOSARTAN 50 MG orally every day
6. METFORMIN 850 MG orally twice a day
7. TERAZOSIN HCL 1 MG orally every day
8. AMLODIPINE 10 MG orally every day
9. LOSARTAN 50 MG orally every day
10. PANTOPRAZOLE 40 MG orally every day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Starting IN a.m. ( 10/10 )
AMLODIPINE 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ATENOLOL 25 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LOSARTAN 50 MG orally DAILY HOLD IF: sbp < 100
Override Notice: Override added on 9/20/07 by
CASSMAN , ARLENA DIONE , M.D. , PH.D.
on order for KCL intravenous ( ref # 521280966 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: md aware
Previous override information:
Override added on 7/27/07 by JOFFRION , LEWIS J. , P.A.-C.
on order for KCL IMMEDIATE RELEASE orally ( ref #
416130258 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: will monitor
Number of Doses Required ( approximate ): 3
MG GLUCONATE ( MAGNESIUM GLUCONATE ) 400 MG orally DAILY
Starting IN a.m. ( 10/10 )
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
TERAZOSIN HCL 1 MG orally DAILY
Number of Doses Required ( approximate ): 2
DIET: House / 2 gm Na / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician x 1 week ,
ALLERGY: HYDROCHLOROTHIAZIDE
ADMIT DIAGNOSIS:
CP
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
ROMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
essential HTN , NIDDM , CAD , asystolic arrest , Hypokalemia , Chronic
right-sided chest wall pain : 5/11 ETT 6' SBP c 100%PHR no isch ,
prostate nodules , PUD/GERD , headaches , history of flash pulmonary edema
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
primary care physician: Dr. September Petretti ( KTDUOO )
Cards: none active senior living center: 269 221 6868
---------------------------------------------------
CC: chest pain
***
HPI: 76 year-old italian speaking male with NIDDM , HTN , with recent CCU admission
@ KAAH for NSTEMI/asystole arrest/pulm edema , left AMA before
stress/cath. Then ED visit on 5/13 for weakness , c/o of cp , left AMA ,
then admission on 3/25 where he again left AMA before evaluation.
Presented to PUO ED for similar ongoing complaints including constant CP
"burning/nauseous feeling" x 3 days with some associated palpitations
and sob. He states that the pain started 3 days PTA while walking around
house , approx 6/10 however didn't call EMS until today - mostly b/c he
has began to get dizzier and weaker since seen in KTDUOO . Denies
radiation of pain/chills/fevers/cough/weight changes/urinary/bowel sxs.
Per XSRMC patient seen in KTDUOO on 1/3/07 with c/o continued lack of appetite ,
lack of energy , dizziness x 10 days. Denies orthostatic sxs , but does
feel weak when standing up. No change in exercise tolerance , can walk 5
blocks without difficulty ( unchanged ). In KTDUOO he had c/o occ sharp cp ,
bilateral , not associated with exercise/food. He stated sxs are
different from when he had the NSTEMI. In ED , patient currently pain free -
enzymes flat x 1 , EKG unchanged per ED ( however ? <1 mm ST depression in
lateral leads. Given ASA 325 x 1 , Ativan 0.5 mg x 1 , Mg chloride 500 mg
x 1.
*Cardiac Hx per KAAH note:
CAD: MI March likely sx of stable angina , bradycardic to 30's on
atenolol , MIBI 4/11 mild LV enlargement with fixed inferior defect and
no reversible defects.
Echo: EF 35% , LAE , mod MR , mild AI , trace TR with inferior wall HK. 9/21
left PUO AMA prior to MIBI , did not f/u outpt , hx med noncompliance patient
reported cardiac cath in Ra Nohonapro Ward Diagnostic cath only ( no report
available ) per KTDUOO note 4/14 .
***
ROS: recent urgent care visit for c/o weakness and decreased orally
intake ( per LMR ) , + blurry vision , + dizziness and racing heart rate
intermittently at night ( unclear duration ) , as above otherwise
unremarkable
***
PMH: See problem List
***
HOME MEDS: ASA 325 mg daily , lipitor 80 mg daily , amlodipine 5 mg
daily , protonix 40 mg daily , losartan 50 mg daily , terazosin 1 mg
daily , atenolol 25 mg daily , metformin 850 mg every day before noon ( Patient
states compliance with all meds )
***
ALLERGIES: HCTZ - renal failure , hypokalemia ,
***
FH: Mother died 2/2 heart disease , Father had a sudden cardiac death;
no FH of CA , DM , HTN
***
SH: lives alone in assisted living @ Cou Ly Kan no family member or
friends. former heavy smoker , no EtOH/IVDU. from Scoaba Pu Eco , immigrated
in 70's , previously worked as janitor.
***
PE on ADMISSION: VS: Afeb , Tc 96.6 , HR 77 , BP 147/72 , RR 16 , SaO2 95% 2 L
Gen: NAD , NARD , sitting up on stretcher , speaking swedish in full
sentences
HEENT: NCAT , EOMI , PERRL , anicteric , mmm , OP clear
NECK: supple , no LAD , no JVD
CHEST: ctab no with r/c
CV: RRR distant S1S2
ABD: +BS , soft , NTND
EXT: no e/c/c; 2+ DP's b/l
SKIN: intact , no rashes
NEURO: A+O x 3 , nonfocal exam
***
LABS: Na 139 K 3.3 Mg 1.4 CO2 23 BUN 23 CRE 1.6 ( baseline ) CBC nrl
INR 1.1 CKMB + Ti flat x 3
***
RADIOLOGY: Chest PA & Lateral: No significant interval change without
acute cardiopulmonary disease.
***
HOSPITAL COURSE:76 year-old M with significant cardiac history , recent
NSTEMI/asystole arrest a/with ongoing c/o weakness , dizziness and CP x 3
days , currently CP free however multiple RF's for ACS thus admitted
to Medicine for ROMI and further eval/management.
* CV: significant cardiac hx. appears euvolemic on exam. ( I ) subtle EKG
changes on admit , however ? < 1 mm ST depressions in lateral leads ( more
prominent in V5 isolated lead ). cycle enzymes with repeat EKG on admit
( no acute changes ) and serial EKG's with enzymes. R/O complete on HD #2.
Currently CP free however will continue baseline Statin/ASA/ARB. ETT
MIBI ordered. continue above meds and baseline BB/CCB ( P ) HD stable yet
risk for cardiac event thus will treat with BB and titrate as tolerated.
TTE already done on previous admit. ( R ) tele monitoring
***patient became extremely aggitated and refusing treatment/testing on HD #2
and left AMA after lengthly d/with patient , interpreter , and SW - However ,
unfortunately this is what happens repeatedly on all admissions - he
signs out AMA prior to MIBI being obtained****
* Endo: history of NIDDM on Metformin at baseline. A1C and fasting lipids
ordered. Held metformin and instituted DM protocol while in house.
* Renal/ FEN: Known CRI ( baseline CRE 1.3-1.6 ). gentle hydration in ED
for now , careful given EF 20%. hypoMg and hypoK on admit -received
repletion. monitor lytes/replete as needed 2 g Na/low fat/chol carbo
controlled diet. Nutrition consult ordered given recent decrease in
appetite and FTT picture.
* PPx: statin , ASA , lovenox subcutaneously , PPi * Misc: SW consulted. d/with patient at
length if he would benefit from services at home when d/c' d - he
will think it over and get back to team
* FULL CODE
ADDITIONAL COMMENTS: UNFORTUNATELY PATIENT LEFT AMA DESPITE LENGTHY DISCUSSION ABOUT HIS
HEALTH AND RISK FOR MI/DEATH.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
MIBI as outpatient if patient compliant
No dictated summary
ENTERED BY: JOFFRION , LEWIS J. , P.A.-C. ( ZU74 ) 9/20/07 @ 09:46 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 192
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
N |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
- |
N |
N |
- |
N |
N |
N |
N |
N |
N |
744245208 | PUO | 95260896 | | 4536848 | 10/26/2006 12:00:00 a.m. | PNEUMONIA | Unsigned | DIS | Admission Date: 10/11/2006 Report Status: Unsigned
Discharge Date: 7/25/2006
ATTENDING: BRASKETT , TISA M.D.
SERVICE:
General Medicine Service Chat Ville Monttul
PRINCIPAL DIAGNOSIS:
Methicillin sensitive Staphylococcus aureus bacteremia.
OTHER PROBLEMS AND CONDITIONS TREATED:
LGL No known allergies lymphoma with pancytopenia , type II diabetes ,
hypertension , chronic renal insufficiency , genital herpes , PICC
line infection , nonsustained ventricular tachycardia.
BRIEF HISTORY OF PRESENT ILLNESS:
Ms. Morelen is an 88-year-old Italian-speaking female with a history
of large granulocytic lymphocyte lymphoma complicated by
pancytopenia with chronic transfusion requirement. She also has
a history of type II diabetes , chronic renal insufficiency , and a
recent herpes infection undergoing treatment with famciclovir who
presented with fever , chills , cough , and decreased orally intake
from her nursing home with moderate hypotension to systolic
pressures of 80 at the nursing home as well as oxygen saturation
of 91% and on admission was found to have fever without
neutropenia later diagnosed with an MSSA bacteremia and a
component of acute on chronic renal failure.
ALLERGIES:
Fentanyl which caused GI intolerance , lisinopril which causes
cough , morphine which causes vomiting and Percocet which causes
nausea and vomiting.
ADMISSION PHYSICAL EXAMINATION:
Temperature of 98.4 , a pulse of 100 , a BP of 143/64 with a
respiratory rate of 20 with a O2 saturation of 100% on 3 liters.
This is post 4 liters of intravenous fluids and six packs of platelets in
the emergency department at which point she had presented with a
fever to 101 with a initial systolic pressure of 146 over a
diastolic of 91 that had dropped to 100 systolic. In the ED , she
also received vancomycin , levofloxacin , Flagyl , and ceftazidime
as well her PICC line which is present in the right upper
extremity was pulled. A physical examination on admission was
significant for tachycardia with an otherwise normal cardiac exam
without murmurs. Her respiratory exam showed decreased air
movement bilaterally with expiratory wheezes , however , no
evidence of focal decrease in breath sounds. The abdominal exam
was benign and the extremities showed erythema and induration at
the right former PICC site.
ADMISSION LABORATORY:
Significant for sodium of 131 , potassium of 4.9 , bicarbonate of
20 , BUN and creatinine of 63/2.9 up from her baseline of 2. Her
white blood cell count on admission was 4.5 with a hematocrit of
23.7 and platelets of 20.
Urinalysis showed 3+ protein , 1+ blood , 1+ bacteria and 2-4 white
blood cells. An admission troponin was drawn and that was less
than assay.
Her EKG showed a sinus tachycardia with poor R-wave progression
and T-wave flattening in III and AVF. The chest x-ray was
performed on admission that showed right-sided subsegmental
basilar atelectasis with low lung volumes and a large cardiac
silhouette , but no definitive infiltrate or fusion.
OPERATIONS AND PROCEDURES:
1/26/06: PICC line placement in the left upper extremity.
1/26/06: CAT scan of the chest.
2/3/06: Right upper extremity Doppler ultrasound and chest
x-rays were performed on 6/20/06 , 03 .
HOSPITAL COURSE BY PROBLEM:
ID: Based on blood culture results the patient had an MSSA
bacteremia. She was initially treated with broad-spectrum
antibiotics in the emergency department , however , this regimen
was tapered to initially include vancomycin as a single agent and
then further tapered to naphthalene but this was also tapered
finally to a regimen of Ancef dosed at 0.5 g intravenous every 12 hours Her last
positive blood culture was on 2/10/06 and the Ancef should be
continued for 14 days thereafter setting an end date of
approximately 5/2/06 . She completed her course of famciclovir
during hospitalization and had no further evidence of genital
herpetic infection as well the urine culture and urinalysis data
described above showed yeast only and a Foley that had been
intermittently placed during the ED stay was discontinued , and
the patient remained asymptomatic for any further urinary tract
infection.
Cardiovascular: Although the patient initially had transient
hypertension believed to be secondary to infection and mild
hypovolemia in the setting of diuretics and poor orally intake
prior to coming in. She was electively fluid resuscitated and
actually went into mild hypervolemia as evidenced by chest x-ray
findings consistent with pulmonary edema initially. She was
thereafter diuresed as needed. During her hospitalization as her
hemodynamic status stabilized her home blood pressure regimen was
reinstated. However , the following substitutions were made. The
hydrochlorothiazide was substituted with Lasix as her chronic
renal insufficiency dictated as well as her doxazosin dose was
increased from 2 mg per day to 4 mg per day for better blood
pressure control. Her metoprolol dose , which was initially 100
mg twice a day was changed the 62.5 mg four times daily , which
can be converted as her blood pressure normalizes. Captopril and
ARBs were not used due to her history of allergies but additional
antihypertensive medications may be indicated if her pressure
remains elevated. During the hospitalization , she had evidence
of nonsustained ventricular tachycardia asymptomatic on
telemetry , however , with alteration of the dose of Lopressor
there was no further evidence of this. At the time of discharge ,
she was euvolemic from a pulmonary standpoint with mild lower
extremity edema. He discharge weight is 71.1 kilograms and her
daily weights should be followed and the Lasix titrated to remain
euvolemic. There was no evidence of ischemia during the
hospitalization.
Pulmonary: Although she presented with some shortness of breath
and cough she did not continue to have any shortness of breath or
cough during the hospitalization. Due to complaints of right
posterior rib pain during the hospitalization without evidence of
any skin or soft tissue abnormalities she underwent a CT scan of
the chest on 5/5/06 , which showed a small right middle lobe
area of consolidation favoring atelectasis but not impossible to
represent an early pneumonia. They also had tiny pleural
effusions bilaterally as well as a tiny pericardial effusion , a
small calcified right apical node , and an enlarged left thyroid
lobe with extension below the sternum. There was no evidence of
rib fracture or soft tissue abnormality on this CAT scan in the
area of concern. The pain caused by this symptom , which is still
unclear was treated with Lidoderm patch as well as Tylenol 650 mg
orally every 6 hours standing with only modest relief. Other medications
including other narcotics and NSAIDS were not used given her
history of allergies as well as her thrombocytopenia. However ,
these can be further evaluated in the outpatient setting.
Hematology/oncology: The patient has a history of LGL NK
lymphoma. There is no inpatient treatment for this disease;
however , she received transfusions of packed red blood cells for
her hematocrit less than 22 and platelet scales were set as 10.
She also received GCSF during her hospitalization and should
receive her Neulasta in the outpatient setting. Prior to
discharge a left upper extremity PICC line was placed on 5/5/06
and confirmed on chest x-ray with its tip projecting over the
superior vena cava.
Renal: The patient has a history of chronic renal insufficiency
with a component of acute renal failure at the time of admission
as her baseline creatinine increased from 2 to 2.9 , however , her
creatinine returned to her baseline with intravenous hydration initially
and has remained at 1.9-2 stably prior to discharge.
Endocrine: This patient has a history of type II diabetes
initially managed on Glucotrol in the outpatient setting. She
was placed on NPH twice daily in the hospital and will be
discharged on 10 units twice daily with a insulin aspartate
sliding scale prior to meals. Her blood glucose is not optimally
controlled but more aggressive attempts to control her glucose
resulted in symptomatic hypoglycemia , therefore it was felt best
to air on the side of mildly elevated blood glucoses in the range
of 150 to the low 200s in order to avoid transient hypoglycemia.
The incidental finding of the left thyroid lobe enlargement on
the CT of the chest should be evaluated in the outpatient setting
and this may be done in collaboration with the endocrine service ,
however , the projection to the retrosternal space may preclude
most evaluation.
The patient was followed by physical therapy during the
hospitalization and will continue to have physical therapy in the
outpatient setting. There were no complications during the
hospitalization. Her physical examination at the time of
discharge reveals a temperature of 97.2 , heart rate of 71-93 , a
blood pressure of 130-150/57-80 , respiratory rate 20 , O2
saturation of 96%-99% on room air with a lung exam showing
minimal bibasilar crackles. A cardiac exam with regular rate and
rhythm , S1 , S2 , no murmurs and abdominal exam showing obese
abdomen with ventral hernia but otherwise benign and lower
extremities with 1+ edema and nontender. A PICC line in the left
upper extremity and no erythema in the right upper extremity ,
however , resolving induration and minimal tenderness. Her
fingerstick glucose on the a.m. of discharge was 91. Her
discharge labs show a potassium of 4.2 , sodium of 136 , creatinine
of 2 , magnesium of 1.7 , which is repleted. A white blood cell
count of 1 , hematocrit of 22.5 , platelets of 13 with 1% polys ,
86% lymphs , and 4% monocytes.
DISCHARGE MEDICATIONS:
Tylenol 650 mg by mouth every six hours. This should be
continued standing until her right chest wall pain diminishes ,
Ben-Gay topical apply twice daily to back/right flank as
directed , Ancef 0.5 g intravenous every 12 hours should be continued until
5/2/06 , Colace 100 mg by mouth twice daily , Lasix 40 mg by
mouth daily , insulin NPH 10 units subcutaneous twice a day , milk of
magnesia 30 ml by mouth daily as needed for constipation ,
Lopressor 62.5 mg by mouth four times daily , doxazosin 4 mg by
mouth daily , Lidoderm 5% patch may be applied daily as needed for
pain and it must have a 12 off period during the application ,
insulin aspartate sliding scale pre-meal , Maalox tablets ,
Spectazole one to two tablets by mouth every six hours as needed
for upset stomach and Protonix 40 mg by mouth daily.
She will be discharged to the Con Field E and the
final results of the CT of the chest should be followed up. Dr.
Gaylene Faniel , her primary oncologist , has been notified of her
discharge and will continue to follow her in the outpatient
setting. The patient is full code and her healthcare proxy is
Chantal Morelen , her son , at 031-118-2685.
eScription document: 9-3593046 EMSSten Tel
Dictated By: IBRAHIM , MIYOKO
Attending: BRASKETT , TISA
Dictation ID 7718753
D: 3/25/06
T: 3/25/06
Document id: 193
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
563606814 | PUO | 63066133 | | 2078117 | 10/4/2006 12:00:00 a.m. | METASTATIC ADENOCARCINOMA | Unsigned | DIS | Admission Date: 7/27/2006 Report Status: Unsigned
Discharge Date: 10/11/2006
ATTENDING: CADOFF , LINDY MD
SERVICE: General Medicine Service.
PRINCIPAL DIAGNOSIS: Altered mental status.
LIST OF PROBLEMS/DIAGNOSES: Altered mental status , metastatic
adenocarcinoma , diabetes type 2 , history of sarcoid by report ,
status post cholecystectomy , status post laminectomy of T9
through T12.
BRIEF HISTORY OF PRESENT ILLNESS: Ms. Cichosz is a 51-year-old
woman with a history of metastatic adenocarcinoma of unknown
primary origin who presents as a transfer initially from Norap Valley Hospital with altered mental status. The patient was initially
diagnosed with cancer and presenting with lower back pain in
5/15 when she was found to have lytic spinal and pelvic
lesions on MRI. Immunohistochemistry was most consistent with
pancreatic cancer origin. She was admitted to the Pagham University Of in early October for cord compression and
underwent XRT and laminectomy by orthopedic surgeon by Dr.
Brooke Lemmen . During that admission , she was also noted to have
a large pericardial effusion and underwent pericardial window.
She was then discharged from Pagham University Of on
7/20/06 to rehab. At rehab , the patient was noted to have
difficulties expressing herself and word finding at 01:00 a.m. on
the day of admission. Prior to this episode , she had normal
speech and mental status and it is pertinent to note that on the
day prior to admisison she had been seen in Oncology Clinic with
Dr. Elinore Prazak and hence was started on Zometa. The patient
denies any fevers , chills , neck stiffness or focal neurologic
symptoms. She was initially sent to Norap Valley Hospital where a
noncontrast CT scan was done and found to be negative for an
acute process and was then admitted to General Service. At that
point , it had been over three hours since symptom onset and her
cancer further precluded any possible TPA therapy. An MRI was
then attempted to be obtained , however , the patient required
intravenous conscious sedation to attempt the MRI secondary to
agitation and anxiety. The patient received total of 2 mg of
Versed , 4.5 mg of intravenous Ativan and 2 mg of orally Ativan and several
attempts were made to facilitate the MRI. She was unable to sit
for MRI and was able to sit for a head CT with angiography. As
she became more and more somnolent , it was felt that additional
sedation might necessitate intubation. The Anesthesia Service
called and pointed out that the Norap Valley Hospital MRI machine is
not compatible with intubated patients. The patient was then
transferred to Pagham University Of for possible MRI with
intubation. An LP at this time was also unable to be performed
secondary to her restlessness.
PAST MEDICAL HISTORY: Metastatic adenocarcinoma , diabetes
mellitus type 2 , history of sarcoid ( although never had a
biopsy ) , status post cholecystectomy , status post laminectomy of
T9 , T11 and T12.
MEDICATIONS ON TRANSFER: Lorazepam 0.5 mg every 3 hours as needed
agitation , omeprazole 20 mg orally daily , senna two tabs orally
twice a day as needed constipation , metoprolol SR 50 mg orally daily ,
ondansetron 8 mg orally twice a day , furosemide 20 mg orally daily ,
insulin sliding scale , insulin Humalog 6 units before meals , insulin NPH
10 units twice a day , enoxaparin 40 mg daily subcutaneous , docusate
100 mg orally twice a day as needed constipation , Tylenol 650 mg every 6 hours
as needed pain.
ALLERGIES: Penicillin with an unknown reaction.
ADMISSION PHYSICAL EXAM: Temperature of 98 degrees , heart rate
81 , blood pressure 107/51 , respirations 20 , sating 97% on 2 L.
General exam showed a drowsy-feeling patient who was oriented x1
( not for place or time ). HEENT exam shows pupils equal , round
and reactive with no photophobia. Neck exam showed a supple neck
with no lymphadenopathy. Pulmonary exam showed lungs clear to
auscultation bilaterally. Cardiovascular exam showed a JVP that
was difficult to assess , heart rate showed a regular rate and
rhythm , no murmurs , rubs or gallops , distal pulses were bilateral
and 2+ and symmetric. Abdominal exam showed an obese abdomen , is
nontender and nondistended with positive bowel sounds.
Extremities exam showed extremities warm and well perfused.
Neurologic exam showed the patient was alert and oriented only x1
with 2+ patellar reflexes , 2+ ankle reflexes and 1+ brachial
reflexes. The patient was poorly responsive to questions and
commands , hence a motor and sensory exam was unable to be
obtained , however , the patient was moving all extremities.
PERTINENT LABS ON ADMISSION: Included a negative tox screen ,
otherwise unremarkable. EKG showed sinus tach to 103 beats per
minute , slightly low voltage. Chest x-ray showed cardiac
enlargement without acute or active disease. Head CT showed no
acute intracranial abnormality noted. Urinalysis showed trace
leuk esterase , 5 to 10 white blood cells , 200 rbc's , however ,
urine culture showed no growth.
HOSPITAL COURSE BY PROBLEM:
1. Neurologic: The patient was initially admitted to the
medical ICU for possible MRI with intubation. However , upon
arrival , the patient was alert and oriented enough to refuse the
MRI/MRA ( this was desired to rule out metastatic disease versus
leptomeningeal disease ). Because she did not require she was
then sent to the floor on 2/11/06 . A full toxic metabolic
workup was obtained , which showed the ammonia levels within
normal limits and nonreactive RPR , B12 assay that was actually
slightly elevated and a TSH level of 10.6 ( a full thyroid panel
was also sent , which was pending at the time of discharge and
should be followed ). Given the concern for her slight pyuria on
her UA and her altered mental status she was also given a
three-day course of ciprofloxacin , however , her urinary culture
was negative. She presently , within the first 24 hours of her
stay on the floor , her mental status improved remarkably and was
at her baseline. Hence , an MRI/MRA was not performed , as this
would require the patient to undergo further sedation ( it was
felt that her significant amount of benzodiazepines that were
given previously only served to worsen her mental status ). An LP
was not indicated at this time since she had returned to her
baseline. An echo was ordered but was not performed secondary to
the fact that the patient had had a previous echo within the last
month , but was desired to rule the very small chance that she had
marantic endocarditis with embolic phenomenon. At the time of
discharge , the patient was at her neurologic baseline and was
alert and oriented x4. The likely source of her altered mental
status appears to be toxic metabolic multifactorial etiology ,
including the possibility of Zometa effect , the urinary tract
infection and possible hypothyroidism.
2. Onc: The patient has an appointment with Dr. Elinore Prazak of
A Triaded Health Oncology on 2/10/06 to initiate Gemzar
chemotherapy.
3. Ortho: The patient has a followup appointment with Dr. Lemmen
of Pagham University Of Orthopedics on 8/9/06 for
further followup.
4. Endocrine: The patient will be discharged to rehab on a
regimen of Lantus and sliding scale insulin. She should have her
TFTs followed up as they are pending at this time for possible
initiation of hormone replacement.
5. ID: The patient finished a three-day course of ciprofloxacin
for possible urinary tract infection , however , her urinary
culture was negative.
6. Cardiovascular: The patient was initially transferred on
metoprolol , however , her blood pressures have been well
controlled in-house. If her blood pressures are elevated at
rehab , one could consider restarting her metoprolol.
7. Disposition: The patient was in stable condition and
discharged back to rehab for further care.
PHYSICAL EXAMINATION AT DISCHARGE: Temperature of 98.6 , blood
pressure of 110/60 , heart rate 98 , respirations 18 , sating 99% on
room air. General exam shows a slightly obese female who is
alert and oriented x4 in no acute distress. Cardiovascular exam
shows a regular rate and rhythm with no murmurs , rubs or gallops.
Neck shows a supple neck with no JVD. Pulmonary exam shows
lungs clear to auscultation bilaterally. Abdominal exam shows a
slightly obese abdomen that is nondistended and nontender with
good bowel sounds. Skin exam shows a midline back scar that is
healing well and nontender with no erythema. Extremity exam
shows no calf tenderness with trace edema.
MEDICATIONS AT DISCHARGE: Tessalon Perles 100 mg orally three times a day
as needed cough , Colace 100 mg orally twice a day , guaifenesin 10 mL orally
every 6 hours as needed cough , Lantus 20 units subcutaneously every afternoon , Insulin
Regular sliding scale before every meal and at bedtime , Zydis 5 mg orally
nightly , Zydis 5 mg orally twice a day as needed agitation , oxycodone 5 to
10 mg orally every 6 hours as needed pain , Lovenox 40 mg subcutaneously daily.
DISPOSITION: The patient was discharged to rehab for further
care in stable condition.
PENDING TESTS: The patient's thyroid function test should be
followed up.
FOLLOWUP PLANS: The patient has an appointment with Dr. Elinore H Prazak of A Triaded Health Oncology on 2/10/06 . Phone number is
556-854-9775. The patient also has a followup appointment with
Dr. Brooke Lemmen on 4/10/06 . His phone number is 362-878-5639.
The patient should also followup with primary care physician in
one to two weeks.
eScription document: 4-4703379 CSSten Tel
Dictated By: WOLFLEY , LUCRETIA
Attending: CADOFF , LINDY
Dictation ID 1058305
D: 5/1/06
T: 5/1/06
Document id: 194
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Dp |
DM |
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GER |
Gou |
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357007009 | PUO | 73091725 | | 4298924 | 7/19/2006 12:00:00 a.m. | ABDOMINAL PAIN | Unsigned | DIS | Admission Date: 9/17/2006 Report Status: Unsigned
Discharge Date: 10/8/2006
ATTENDING: SCHNURBUSCH , JEFFERSON M.D.
SERVICE: WIH .
DISCHARGE DIAGNOSIS: Acute cholecystitis.
SECONDARY DIAGNOSES:
1. Cardiomyopathy status post cardiac transplant.
2. Chronic renal insufficiency.
3. Hypothyroidism.
4. Diabetes mellitus.
5. Bile leak.
PROCEDURES:
1. Esophagogastroduodenoscopy ( EGD ).
2. Open cholecystectomy.
3. ERCP with biliary stenting.
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old man
status post cardiac transplant for familial cardiomyopathy who
presented with acute onset of epigastric and left upper quadrant
abdominal pain. The patient developed acute epigastric and left
upper quadrant pain after dinner the night prior to admission.
He had nausea and one episode of nonbilious emesis. He did have
a bowel movement and flatus the day prior to admission. He
denied fevers and chills. In the emergency department , the
patient complained of severe abdominal pain and raving in bed.
He received 4 mg of Dilaudid with significant improvement. He
was seen by the GI consult in the emergency department , and EGD
was done and showed gastroparesis. He was also seen by the
surgical consult who felt that he did not have an acute abdomen.
He then had a gastric emptying study , which showed only mildly
delayed emptying and no reflux. Given that he had persistent
abdominal pain following these studies , he was admitted to the
medical service for observation until he could tolerate clear
liquids and his pain was controlled with orally pain medications.
PAST MEDICAL HISTORY:
1. Familial cardiomyopathy status post transplant and AICD.
2. Chronic renal insufficiency with baseline creatinine of 1.9.
3. Hypothyroidism.
4. Tricuspid regurgitation.
5. History of pancreatitis.
6. Gout.
7. Diabetes mellitus , on insulin.
MEDICATIONS ON ADMISSION:
1. CellCept 1500 mg twice a day.
2. Neoral 150 mg twice a day.
3. Prednisone 7.5 mg daily.
4. Lantus 40 units daily.
5. NovoLog prior to meals 12 units , 12 units , 14 units.
6. NovoLog sliding scale.
7. Cartia XT 300 mg daily.
8. Methotrexate 2.5 mg weekly.
9. Pravastatin 20 mg daily.
10. Synthroid 150 mcg daily.
11. Rocaltrol 0.25 mcg daily.
12. Calcium carbonate.
13. Folate 1 daily.
14. K-Dur 20 mEq daily.
15. Colchicine 0.3 mg as needed for gout.
16. Torsemide 40 mg every morning , 20 mg every evening.
ALLERGIES: Penicillin.
SOCIAL HISTORY: He does not smoke , use alcohol , or intravenous drug use.
He is currently unemployed.
FAMILY HISTORY: He has a brother with cardiomyopathy status post
transplant.
PHYSICAL EXAM ON ADMISSION: Vital signs: Afebrile , heart rate
83 , blood pressure 136/91 , and oxygen saturation 99% on room air.
He is lying in bed , comfortable , in no acute distress. His
oropharynx is clear without thrush , exudates , or erythema. His
JVP is flat. His lungs are clear to auscultation bilaterally.
His heart has a regular rate and rhythm with normal S1 and S2 and
no murmurs , gallops , or rubs. His abdomen is soft , nontender ,
and nondistended. There is no rebound or guarding. There are
positive bowel sounds. Extremities: There are 2+ distal pulses
in lower extremities. He has no clubbing , cyanosis , or edema.
He is alert and oriented x3.
LABS AND STUDIES ON ADMISSION: Chemistries on admission: Sodium
141 , potassium 3.4 , chloride 104 , bicarbonate 25 , BUN 23 ,
creatinine 1.7 , glucose 83. LFTs: AST 19 , ALT 21 , amylase 57 ,
alkaline phosphatase 75 , bilirubin 0.7. CK 232 , lipase 31 , CK-MB
1.8 , troponin less than assay. Calcium 9.3 , magnesium 1.4 ,
albumin 4.6. TSH 0.644. White blood cell count 9.9 , hematocrit
44 , platelets 236 , 000. Coagulation factors were within normal
limits. Hemoglobin A1c was 6.4.
Chest x-ray: Negative.
Ultrasound: Normal.
Abdominal CT:
1. Ventral hernia containing nonobstructive transverse colon.
2. Nonspecific low-attenuation segment VII hepatic lesion
3. Oral contrast remains in the stomach.
KUB postcontrast: Oral contrast from the CT abdomen and pelvis
remains in the stomach suggesting possibility of gastric atony
versus outlet obstruction.
EGD: Hypomotility of the stomach , no ulcerations , biopsies
taken. Normal pylorus and normal duodenum.
KUB post-EGD: No free air or obstruction.
Gastric emptying study: Mildly delayed emptying , no reflux.
EKG: Normal sinus rhythm at 80 , normal axis and intervals , right
bundle-branch block , no ST or T-wave changes.
HOSPITAL COURSE BY PROBLEMS: Following several studies in the
emergency department as well as consultations from the
gastroenterologist and the general surgeons , the patient was
thought to have abdominal pain secondary to gastroparesis given
the findings on the EGD and CT as well as the negative ultrasound
and KUB. The gastroparesis was thought to be secondary to his
diabetes. He was admitted to the medical service and his diet
was slowly increased. On the floor , his pain continued , and
within two to three days , he began spiking fevers to 101 to 102.
He had a repeat abdominal CT , which showed a distended
gallbladder with circumferential wall thickening and extensive
stranding of the pericholecystic fat , which represented acute
acalculous cholecystitis. Surgery was reconsulted , and the
patient was taken to the operating room where he had an
exploratory laparoscopy , which was then converted to an open
cholecystectomy for gangrenous cholecystitis. The patient
received perioperative vancomycin , Levaquin , and Flagyl and
continued to do well post surgery with advancement of his diet
and decrease in his pain medication requirement. Vancomycin was
discontinued on 4/14/2006 after six days of vancomycin. He was
continued on the Levaquin and Flagyl. He had a drain that was
left in following surgery , and this was pulled on 4/14/2006 .
Following the pulling of the drain , he developed leakage of
green-tinged serous fluid from his abdominal wound. An abdominal
CT was done which showed a small fluid collection and no abscess.
An ERCP was done which showed a cystic duct stump bile leak.
They did a biliary sphincterotomy and stenting with no further
leak. The patient was continued on empiric Levaquin and Flagyl
following the procedure. His diet was advanced and he tolerated
this well. He had no further pain. He is being discharged on a
total of seven days of Levaquin and Flagyl following the bile
leak.
Endocrine: The patient was continued on lower-dose insulin while
he was npo and this was titrated up as his diet increased.
Cardiovascular: The patient was followed by the cardiac
transplant team. He was initially switched to intravenous cyclosporine
and his CellCept was held. These were transitioned to orally and
restarted following his improvement. Postoperatively , he got
stress-dose hydrocortisone instead of his prednisone and this was
then tapered to Solu-Medrol and then back to prednisone at his
home dose. He was fluid overloaded following the surgery. He
got 100 of intravenous Lasix times several doses , and then restarted on
his torsemide to maintain euvolemia. His Cartia was initially
discontinued for a question of contribution to gastroparesis , but
this was then restarted. He was discharged on all his home
medications with the torsemide at a dose of 40 mg every day before noon
Rheumatology: Following his surgery , he developed bilateral
elbow pain , which was thought to be likely secondary to gout.
The rheumatology service was consulted. A left elbow tap was
attempted , but this did not return any fluid. He was given
several doses of colchicine as needed with improvement. The steroid
taper was slowed and his gout improved. He was discharged
without any elbow pain.
Phlebitis: He developed left arm phlebitis secondary to an
infiltrating intravenous. This was covered by his antibiotics that were
started for his cholecystitis and his arm improved.
FOLLOWUP INSTRUCTIONS:
1. The patient will follow up with the cardiac transplant
service. This will be arranged by them.
2. The patient will need to follow up with Dr. Weingartner from
general surgery ( 264-400-0027 ) to have his staples removed in two
weeks.
3. The patient will need to follow up with Dr. Robblee from
gastroenterology to schedule an appointment to have his stents
removed in six weeks.
4. The patient will continue to take his cardiac medications as
before. His torsemide is dosed now at 40 mg every day before noon
5. The patient will continue on Levaquin and Flagyl as
prescribed for five days following discharge.
DISCHARGE MEDICATIONS:
1. Rocaltrol 0.25 mcg daily.
2. Caltrate 600 plus D 1500 mg daily.
3. Colchicine 0.3 mg orally daily as needed for gout.
4. Neoral 150 mg twice a day.
5. Cartia XT 300 mg daily.
6. Nexium 40 mg daily.
7. Folate 1 mg daily.
8. NovoLog sliding scale.
9. NovoLog 12 units before meals.
10. Lantus 40 units daily.
11. K-Dur 20 mEq daily.
12. Synthroid 150 mcg daily.
13. Methotrexate 2.5 mg weekly.
14. CellCept 1500 mg twice a day.
15. Pravastatin 20 mg nightly.
16. Prednisone 7.5 mg every morning.
17. Compazine 10 mg orally every six hours as needed for nausea.
18. Torsemide 40 mg orally daily.
19. Levaquin 250 mg orally daily x5 doses.
20. Flagyl 500 mg three times a day x15 doses.
21. Dilaudid 2 to 4 mg orally every six hours x5 days as needed
for pain.
eScription document: 2-4204037 HFFocus
CC: Perry Haub M.D.
Pagham University Of Division
Oklahoma
CC: Robbyn Weingartner M.D.
Ville Ro Svillena
Dictated By: PANCHO , MARJORIE
Attending: SCHNURBUSCH , JEFFERSON
Dictation ID 2014435
D: 2/5/06
T: 2/5/06
Document id: 195
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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380009360 | PUO | 39798978 | | 2476422 | 11/29/2006 12:00:00 a.m. | Non cardiac chest pain | | DIS | Admission Date: 4/21/2006 Report Status:
Discharge Date: 7/26/2006
****** FINAL DISCHARGE ORDERS ******
PRZYBYSZEWSKI , BRANDEN 022-64-53-7
Pemgilb
Service: MED
DISCHARGE PATIENT ON: 6/14/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CLARDY , CHRISTY ALVINA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ACEBUTOLOL HCL 400 MG orally DAILY Starting IN a.m. ( 4/30 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ALLOPURINOL 100 MG orally DAILY
VITAMIN C ( ASCORBIC ACID ) 500 MG orally twice a day
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally twice a day
CIPROFLOXACIN 250 MG orally every 12 hours X 4 doses
Starting Today ( 5/30 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
DIGOXIN 0.125 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LOVENOX ( ENOXAPARIN ) 120 MG subcutaneously BEDTIME
TARCEVA ( ERLOTINIB ) 100 mg orally DAILY
( HT: 61.0in. 154.9cm. WT: 129.5kg. BSA: 2.20 )
Primary DX: chest pain Day 1: 3/4/06
Previous- Weight:136kg BSA:2.24
Admit- Weight:129.5kg BSA:2.20
FOLIC ACID 1 MG orally DAILY
FUROSEMIDE 40 MG orally DAILY Starting IN a.m. ( 10/16 )
DILAUDID ( HYDROMORPHONE HCL ) 0.5 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 6/14/06 by
MENIETTO , WYATT M. , M.D.
on order for DILAUDID orally ( ref # 613190927 )
patient has a PROBABLE allergy to PERCOCET; reaction is
Unknown. Reason for override: aware
Previous Alert overridden
Override added on 6/14/06 by MENIETTO , WYATT M. , M.D.
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL &
HYDROMORPHONE HCL Reason for override: aware
LIDODERM 5% PATCH ( LIDOCAINE 5% PATCH ) 1 EA TP DAILY
Instructions: 12h on/12h off , apply to L breast
PRAVACHOL ( PRAVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
VITAMIN B6 ( PYRIDOXINE HCL ) 50 MG orally DAILY
ULTRAM ( TRAMADOL ) 50 MG orally every 6 hours as needed Pain
Override Notice: Override added on 6/14/06 by
MENIETTO , WYATT M. , M.D.
on order for DILAUDID orally ( ref # 613190927 )
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL &
HYDROMORPHONE HCL Reason for override: aware
Previous override information:
Override added on 1/26/06 by NEDDO , SONA D. , M.D. , PH.D.
on order for ULTRAM orally ( ref # 108807772 )
patient has a PROBABLE allergy to PERCOCET; reaction is
Unknown. Reason for override: MD aware
Previous Alert overridden
Override added on 1/26/06 by NEDDO , SONA D. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: MORPHINE & TRAMADOL HCL
Reason for override: will dc morphine
Number of Doses Required ( approximate ): 15
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Hoerter , call to schedule ,
Dr. Purdue call to schedule 500-353-3388 ,
Dr. Prewer cardiology 5/18/07 11:30 scheduled ,
ALLERGY: PERCOCET , DICLOXACILLIN , LISINOPRIL , WARFARIN SODIUM
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of MVA 8/06 history of B TKA htn
( hypertension ) svt ( supraventricular tachycardia ) thrombophlebitis
( superficial thrombophlebitis ) recurrent bilat LE cellulitis
( cellulitis ) pernicious anemia ( pernicious anemia ) afib ( atrial
fibrillation ) dvt ( deep venous thrombosis ) multiple episodes of
cellulitis ( cellulitis )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
*****
81 year old woman with Afib ( on fondaparinux no coumadin secondary to
prior epistaxis ) , NSC lung ca , presents with 3 days of constant chest
pain. pleuritic , not exertional , related mostly to arm movement. Concern
for bone met vs.subsegmental PE on admission. She had been on
fondapurinox as oupt ( hx of lung ca and afib with intolerance of
coumadin ). Continued work up with question of breast
nodule , patient identifies one particular area which she feels is the primary
site of her pain.
*****
In ED: PE CT neg. No ekg changes. ASA and no change with
NGL.
*****
Patient status: AF , BP 125/51 P60 O2 98% RA
RR18 AAO x 3 , obese , resting and breathing
comfortably irr irr 1-2/6 SEM
crackles at left base +palpable L breast
mass at approx 12 oclock a few inches above nipple , diffusely nodular
breasts
abd soft nt
Ext 1+ edema , no calf tenderness
*****
Significant studies:
CT-PE: IMPRESSION:
1. No evidence of pulmonary embolism or deep venous thrombosis.
2. Post right lower lobe resection changes.
3. Interval resolution of the left upper lobe nodule without new
nodules.
per discussion with radiology possible chronic subsegmental PE
CXR-no acute process
+lupus anticoag
*****
Problem List/Hospital Course:
* Chest pain-No met seen on CXR or CT. No large
PE , but evidence for pulm HTN. Given question of chronic PE and outpt
treatment with fondapurinox will transition to lovenox while inpatient
for maintenance ( intolerance of coumadin with epistaxis ). No evidence of
cardiac process on this admission no hypoxia , unclear etiology
of chest pain may be related to painful breast lump , patient will have
mammogram next week for evaluation , continue pain control with Lidoderm
patch , ultram and low dose dilaudid as needed for severe pain.
* Lung CA- Continuing tarceva as per outpatient oncologist Dr Purdue , no new
findings on imaging but would consider bone scan as an oupatient if
continues to have severe pain.
* A fib- Lowered acebutolol dose from 400mg twice a day to 400mg daily due to
intermittent bradycardia ( asymptomatic ). patient to d/c fondaparinux and
continue on lovenox as outpt.
* CHF-gently diuresing , restarting home dose of
lasix on 6/23 at 40 mg daily with improvement in crackles at left base.
Will need to follow daily weights and titrate lasix as needed.
* ID - Klebsiella UTI , treating with Cipro starting 6/23 with 250mg twice a day
* Pain - tx with lidoderm patch , ultram on day of discharge adding low
dose dilaudid for treatment of breakthrough pain.
* Dispo to rehabilitation for continued reconditioning and improvement in
functional status.
* CODE: FULL
ADDITIONAL COMMENTS: Ms Przybyszewski , it was a pleasure to be involved in your care. Please
follow up with your regular primary care provider , Dr. Hoerter and with
your oncologist Dr. Agnus Purdue . Please also keep your appointment to
have mammogram as scheduled on June at PUO . You should also follow up
with yoru cardiologist Dr. Denisha Mcrorie for continued management of
your heart conditions. Please continue to work with the rehabilitation
specialists to try to regain strength and function.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check Factor Xa level to insure Lovenox dosing is therapeutic.
2. Follow up on mammogram scheduled for June
3. Continue to monitor heart rate intermittently to insure adequate rate
control with decreased dose of Acebutolol.
4. Continue Lasix at 40mg daily ( admit dose had been 40mg alternating
with 60mg ) and monitor daily weights.
5. Complete course of Cipro 250mg twice a day x 3 days ( 4 doses to complete on
discharge ) for Klebsiella UTI
6. Follow up with oncologist , primary care physician and with cardiologist as above.
No dictated summary
ENTERED BY: NEDDO , SONA D. , M.D. , PH.D. ( BT93 ) 6/14/06 @ 04:29 PM
****** END OF DISCHARGE ORDERS ******
Document id: 196
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
781260433 | PUO | 96404124 | | 3062193 | 7/17/2006 12:00:00 a.m. | aspiration pneumonia | | DIS | Admission Date: 11/21/2006 Report Status:
Discharge Date: 1/29/2006
****** FINAL DISCHARGE ORDERS ******
ALOSTA , KIMIKO N. 168-48-08-0
A Con Scond Ph Sas Hien
Service: RNM
DISCHARGE PATIENT ON: 8/19/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CUNDICK , QUEEN H. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Shortness of Breath
PHOSLO ( CALCIUM ACETATE ( 1 GELCAP=667 MG ) )
1 , 334 MG orally three times a day Instructions: WITH MEALS
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 7/1/06 by
THEPBANTHAO , DARCI H. , M.D.
on order for LEVAQUIN orally ( ref # 196586130 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: md aware
Previous override information:
Override added on 6/5/06 by CRAGER , MARYANNE , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & SALMETEROL
XINAFOATE Reason for override: needs
LANTUS ( INSULIN GLARGINE ) 120 UNITS subcutaneously DAILY
Instructions: half dose if npo;
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally EVERY OTHER DAY
Starting Today ( 6/27 )
Instructions: to complete 14 day course
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 7/1/06 by
THEPBANTHAO , DARCI H. , M.D.
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: md aware
FLAGYL ( METRONIDAZOLE ) 500 MG orally every 8 hours
Starting Today ( 6/27 )
Instructions: to complete a 14d course
Food/Drug Interaction Instruction Take with food
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
SEVELAMER 1 , 200 MG orally three times a day Instructions: WITH MEALS
ULTRAM ( TRAMADOL ) 50 MG orally four times a day
Override Notice: Override added on 7/1/06 by
THEPBANTHAO , DARCI H. , M.D.
on order for MORPHINE SULFATE intravenous ( ref # 124015968 )
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & MORPHINE
Reason for override: md aware
Number of Doses Required ( approximate ): 12
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
12.5 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: Mechanical Soft/Nectar Consistency / Renal diet / carbohydrate controlled
ACTIVITY: wheelchair bound
FOLLOW UP APPOINTMENT( S ):
5/06 @ 11:30 with Dr chachere pcp ,
ALLERGY: ETHER , Sulfa , Heparin
ADMIT DIAGNOSIS:
fever , cough
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
aspiration pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
depression ( depression ) sleep apnea ( sleep apnea ) asthma
( asthma ) CHF ( congestive heart failure ) HTN
( hypertension ) hypercholesterolemia ( elevated cholesterol ) IDDM
( diabetes mellitus ) anemia
( anemia ) CRI ( renal insufficiency ) GERD ( gastroesophageal reflux
disease ) constipation ( constipation ) recurrent cellulitis
( cellulitis ) history of MRSA bacteremia ( history of bacteremia ) headache
( headache ) charcot marie tooth disease hearing loss ( sensorineural
hearing loss )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
hemodialysis
BRIEF RESUME OF HOSPITAL COURSE:
CC: Cough and purulent sputum
HPI: 49M with ESRD on HD , paraplegia apparently 2/2 charcot-marie-tooth ,
and morbid obesity admitted from home with 2 days of cough and
purulent sputum. Increasingly unable to perform ADLs while living at
home. primary care physician concerned about aspiration and progression of
charcot-marie-tooth. ED course: T 100.3; P 105; BP 148/72; O2 sat
99% , 3 L. PMH: 1. Morbid obesity , 2. Obesity hypoventilation
and obstructive sleep apnea with 3 L home O2 requirement , 3.
Charcot-marie-tooth c/b paraplegia , 4. HTN , 5. Type 2 DM , 6.
Cardiomyopathy with preserved EF~55% by 11/17 echo , 7. Moderate
pulmonary HTN by 11/17 echo , 8. Chronic venous stasis , 9. Severe
depression , 10. Asthma , 11. Peripheral vascular disease , 12. H/o
recurrent cellulitis and history of MRSA bacteremia , 13. Anemia of
CKD , 14. H/o recurrent UTIs ALLERGIES: SULFA , ETHER ,
HEPARIN HOME
MEDS:
*******
ADMISSION NOTABLES P 103; BP 131/71; O2 sat 98% , 3 L; NAD; CTAB; RRR
without r/m/g; +BS , ND/NT; A&Ox3
*******
CONSULTS 1. NEURO
( QYg81436 )
*******
OVERALL ASSESSMENT: 49M with ESRD on HD , morbid obesity , and paraplegia
2/2 charcot-marie-tooth admitted with 3 days of cough and purulent
sputum along with recent symptoms reflux with likely aspiration PNA
*******
HOSPITAL COURSE BY PROBLEM 1. ID: Likely aspiration PNA. On daily
levofloxacin and flagy , will complete a 14 day course. Aspiration
precautions. Sputum culture
and gram stain negative. Resent on 10/2 in setting of fever of 101. NGTD
Clinically improved. Afebrile , clinically well at baseline.
2. PULM: Multifactorial home hypoxemia from OSA , obesity
hypoventilation syndrome , and restrictive lung disease. Has 3 L home
O2 requirement. CPAP recommended to patient in the past , but he has
refused. Supportive care. Outpatient PFTS when pna resolved. Currently at
home 02 baseline.
3. CARDS PUMP: Euvolemic. Home toprol 12.5 mg orally every day. Refusing in
house. 4. CARDS RHYTHM/ISCHEMIA: No active
issues. 5. GI: Post-prandial RUQ pain. RUQ U/S
demonstrated fatty liver , overall poor study secondary to habitus.
Speech and swallow eval. Video swallow unable to be complete
secondary to obesity to evaluate for aspiration. Fiberoptic study did
not demonstrate any vocal cord paralysis. Bedside
monitoring of diaphramatic function twice a day by respiratory.
6. NEURO: Paraplegia 2/2 charcot-marie-tooth disease. Neuro
consulted. Recommended further imaging to r/o cord involvement ,
patient unable to complete Ct secondary to habitus , refusing
MRI. 7. PSYCH: Ativan as needed Psych consult refused. Awaiting
social work eval. patient states he feels safe at home.8. PPX: PPI. Holding
heparin , in light of
desquamating rash in the past. 9. CODE: FULL
primary care physician Dayne 612-056-8715
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with primary care physician as scheduled
complete antibiotic course
complete regular dialysis as sceduled
reutn to Ed with fevers , chills or other concerning symptoms
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( HT541 ) 8/19/06 @ 12:29 PM
****** END OF DISCHARGE ORDERS ******
Document id: 197
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
N |
Y |
Y |
Y |
- |
N |
758176852 | PUO | 71816968 | | 340316 | 10/13/1998 12:00:00 a.m. | DEGENERATIVE JOINT DISEASE RT. KNEE | Signed | DIS | Admission Date: 10/16/1998 Report Status: Signed
Discharge Date: 3/11/1998
ADMISSION DIAGNOSIS: OSTEOARTHRITIS , RIGHT KNEE.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old gentleman
who has had bilateral knee pain for a
number of years. The pain has been worse on the right than the
left. His symptoms have limited his ambulation and his ability to
climb stairs. He was seen preoperatively for evaluations and had
two units of autologous blood available prior to a planned right
total knee replacement.
PAST MEDICAL HISTORY: Significant for osteoarthritis of his knees ,
hypertension , benign , tachycardia , history
of prostate cancer in 1991 , history of diverticulitis and history
of sleep apnea.
PAST SURGICAL HISTORY: Significant for status post radical
prostatectomy in 1991 , status post left
retinal repair in 1990 and status post cystoscopy in the 1970s for
benign bladder polyps.
ALLERGIES: The patient had no known drug allergies.
MEDICATIONS ON ADMISSION: 1 ) Hyzaar 50/125 mg orally twice a day 2 )
Lopressor 50 mg one orally every day before noon. 3 )
Lopressor 25 mg one orally every bedtime 4 ) Norpace 100 mg orally three times a day 5 )
Lodine every day. 6 ) Clonazepam 0.5 mg orally every bedtime 7 ) Nasocort
sprays , two sprays every day. 8 ) Zyrtec 10 mg orally every day. 9 )
Multivitamins. 10 ) Aspirin one orally every other day 11 ) Vitamin E. 12 )
Vitamin C.
SOCIAL HISTORY: The patient quit smoking twenty years ago. He
drinks a glass of wine every day. The patient is
married and resides in Tinorf O Southaperv , Massachusetts 65928 The plan after
discharge was to discharge to home. His occupation is an attorney
in private practice.
DIET: No added salt and low fat.
REVIEW OF SYSTEMS: Significant for wearing glasses and some visual
deficits in the left eye secondary to the
retinal tear. Neurologically , the patient has a history of
osteoarthritis of his cervical spine and intermittent numbness of
the hands. Pulmonary-wise , the patient has a history of sleep
apnea and uses a C-PAP machine. Cardiovascularly , the patient has
a history of hypertension , tachycardia , but no history of coronary
artery disease , myocardial infarction , chest pain , congestive heart
failure or deep venous thrombosis. Gastrointestinal-wise , the
patient has a history of diverticulitis and was hospitalized in the
70s. He has a history of polyps that were negative on colonoscopy
three years ago. Genitourinary-wise , the patient has a history of
stress incontinence and impotence. Musculoskeletal-wise , he has a
history of osteoarthritis. His primary care physician was Dr.
Alyse Holda .
PHYSICAL EXAMINATION: Vital signs: Blood pressure 150/88 , heart
rate 60 , height 5'8" , weight 240 lbs. HEENT
showed a normal pharynx with no carotid bruits. Extraocular
movements are intact. His lungs were clear to auscultation
bilaterally. His heart was regular rate and rhythm with normal S1
and S2 and no murmur. His abdomen was obese , but soft and
non-tender with no evidence of organomegaly and some well healed
previous surgical incisions. Neurologically , his cranial nerves
were intact. On physical examination , he was seen to have
bilateral genu varus. The right was greater than the left. He had
active range of motion of the right knee from 0 degrees to 90
degrees. He was stable with varus and valgus stress. He had 1+
dorsalis pedis pulse and posterior tibial pulses and no edema. He
was neurovascularly intact except for mild diminution of sensation
on the dorsum of the right foot and medial right ankle. He was
instructed to discontinue taking NSAIDS and aspirin prior to his
surgery and given a single dose of Coumadin 7.5 mg orally on the
night prior to his surgery.
HOSPITAL COURSE: On August , 1998 , the patient was admitted to
the hospital where he underwent right total knee
arthroplasty. Tourniquet time for the initial procedure was 86
minutes. He received perioperative antibiotics. He was started on
Coumadin in the postoperative period as well and put on the total
knee pathway postoperatively. He received epidural anesthesia in
the perioperative period. He was followed by the Pain Service for
control of his pain. The Cardiology Service saw him on
postoperative day number one and noted that he was doing well with
no intraoperative events. The Physical Therapy Department saw the
patient postoperatively and he was placed on the CPM machine. By
postoperative day number three , the patient was more comfortable.
He was getting out of bed for his meals. His hematocrit was stable
after initially receiving some autologous blood transfusions. He
had postoperative x-rays of his knees taken. These were reviewed
by the attending surgeon , Dr. Gaylene Faniel . Plans were made for him
to be discharged to home on postoperative day number four with VNA
services. An attempt was made for the patient to be seen by Dr.
Brannigan for some complaints of foot pain , Dr. Moczygemba for complaints
of shoulder pain and Dr. Wimpey for some complaints of cervical
spine problems. At the time of this dictation , it was not certain
whether these consults would be completed prior to this patient's
ultimate discharge home , but if not , they will be done on an
outpatient basis.
MEDICATIONS ON DISCHARGE: 1 ) Aspirin 325 mg orally every other day 2 )
Clonazepam 0.5 mg orally every bedtime 3 )
Norpace 100 mg orally three times a day 4 ) Colace 100 mg orally twice a day 5 ) Iron
sulfate 300 mg orally three times a day 6 ) Lopressor 50 mg orally every day before noon and 25
mg orally every PM. 7 ) Multivitamins one tablet orally every day. 8 )
Coumadin to keep the physical therapy/INR between 1.5 and 2.0. 9 ) Nasocort 2
puffs inhalation every day. 10 ) Zyrtec 10 mg orally every day. 11 )
Hyzaar one tablet orally twice a day 12 ) Tylenol as needed
DISPOSITION: The patient was discharged to home with VNA services.
He should continue exercises for improved range of
motion.
FOLLOW-UP: The patient will be followed up by Dr. Gaylene Faniel as
an outpatient in ten to fourteen days from discharge.
VNA services will draw physical therapy/INRs two times per week and these results
will be sent to the patient's primary care physician who will
follow them for Dr. Gaylene Faniel . The duration of Coumadinization
should be six weeks.
ACTIVITY: The patient is weight bearing as tolerated on the right
lower extremity.
COMPLICATIONS: There were no complications:
Dictated By:
Attending: GAYLENE FANIEL , M.D. FB.T HQ33 JO674/8915
Batch: 7546 Index No. CJBFCBF85 D: 1/8/98
T: 1/8/98
Document id: 198
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
- |
Y |
N |
N |
N |
Y |
N |
N |
- |
N |
N |
N |
756711765 | PUO | 25805132 | | 5964582 | 7/27/2005 12:00:00 a.m. | PREGNANCY , LABOR | Signed | DIS | Admission Date: 4/16/2005 Report Status: Signed
Discharge Date: 1/14/2005
ATTENDING: CONCILIO , GERALDO MD
ADMITTING DIAGNOSIS:
Diabetes management and teaching.
DISCHARGE DIAGNOSIS:
Diabetes management and teaching.
ID/CHIEF COMPLAINT:
Ms. Wakenight is a 32-year-old G6P2-0-3-2 at 22-6/7 weeks' gestational
age admitted for blood sugar control after first prenatal visit
in Special OB Clinic. Her dating is by her last menstrual
period , which was 9/26/05 , giving her an estimated date of
confinement of 2/27/05 . An ultrasound at 14 weeks done during
an ER admission for vaginal bleeding confirmed her gestational
age. Prenatal screen were not known at the time of admission.
HISTORY OF PRESENT PREGNANCY:
Ms. Wakenight had been scheduled to see a midwife at Co Birm Na but
had been unable to keep appointment. Her pregnancy thus far has
been notable for:
1. Late prenatal care.
2. Hypertension. She has had blood pressures that were
140's/90's several months prior to pregnancy. Her blood pressure
in clinic on the day of admission was 139/79.
3. Diabetes , likely type 2 , class B diabetic. Predates
pregnancy , per the patient her blood sugars prior to pregnancy
ranged from the 120-180 range and that she reports she has never
needed to take insulin. She had a visit at Rich Ba South and was
given a glucometer and known fasting sugars ranged from the
90s-140s and one hour postprandials ranged from 140-230.
4. She is a smoker.
5. History of depression. She currently takes Remeron and is
followed by her outpatient psychiatrist with whom she has had a
longstanding relationship. Given that the Remeron was a class C
medication , she was discontinued on that.
HER PAST OB HISTORY:
She had three prior first trimester TABs and two priors
spontaneous vaginal deliveries. Her largest baby was 7 pounds 12
ounces.
GYN HISTORY:
She has a history of high-grade SIL , status post colpo with
biopsies. Her last Pap was a year ago and within normal limits.
PAST MEDICAL HISTORY:
Also , notable for a history of renal stones and migraine
headaches.
PAST SURGICAL HISTORY:
She had laparoscopic cholecystectomy.
MEDICATIONS:
Her only medication is Remeron.
ALLERGIES:
She has no known drug allergies.
SOCIAL HISTORY:
She smokes approximately seven cigarettes daily.
PHYSICAL EXAMINATION ON ADMISSION:
Her blood pressure is 139/79. She is well appearing. Her heart
was regular rate and rhythm. Her lungs were clear to
auscultation bilaterally. Her abdomen was soft and obese. It is
difficult to assess fundal height. Pelvic exam had normal
mucosa , normal cervix. Bimanual exam revealed approximately 22
weeks size uterus with audible fetal heart tones.
HOSPITAL COURSE BY SYSTEM:
1. Diabetes: Given the late time in the day of her appointment
and the inability to establish proper diabetic teaching as an
outpatient , she was admitted for diabetic teaching and control.
She had never previously used medications and has had reportedly
poor control with diet. Risks of diabetes were discussed. She
was started on a regimen of 14 of N every day before noon and 14 of N at bedtime
with 6 of Humalog premeal as per Dr. Bloomingdale . Her sugars overnight
while in-house were as follows: 100 fasting , 175 approximately
two hours postprandial , 157 and then a fasting of 94 this is
while receiving that stated insulin regimen. She was seen by the
Diabetes Management Service and Dr. Fuente on 5/10/05 who
recommended increasing her prebreakfast and predinner Humalog to
8. She will need an Ophthalmology consult as an outpatient.
Hemoglobin A1c was sent and was 5.3.
2. Hypertension: Given her elevated blood pressure of 139/79 in
clinic and her history that was notable for potentially a
longstanding hypertension , her blood pressure was monitored
closely and baseline preeclampsia labs were sent. Her blood
pressure overnight was within normal limits with values this
morning of 108/60 seated and 90/50 lying. She had a normal BUN ,
creatinine , ALT , AST , and uric acid. A 24-hour urine protein was
completed during this hospitalization and the results are pending
at the time of this dictation.
3. History of depression: Her Remeron was discontinued and I
discussed her symptoms of depression with her in greater detail.
She said that she primarily uses Remeron as a sleep aid and the
major side effect she experiences with withdrawal of Remeron is
nightmares. She does not feel as if she has a problem with
depression and declined a psychiatry consultation while in the
hospital. She has an outpatient psychiatrist whom she has a
longstanding relationship with. I advised to discuss her
pregnancy with her psychiatrist and to be in contact should she
have any concerns. She reported that she always knows if she
needs additional help and will be in contact with her doctor.
4. Fetal well-being: Baseline and prenatal laboratories were
sent on 4/19/05 . Her blood type is B positive. Her antibody
screen was negative. Her RPR was nonreactive. Her hepatitis B
surface antigen is negative , rubella immune , gonorrhea and
chlamydia are negative. She had an ultrasound done on the
5/10/05 which revealed a singleton intrauterine gestation. Her
placenta was posterior and not previa. She had normal Dopplers
and normal fetal survey. The fetal risks of uncontrolled
diabetes were discussed and she expressed that she understood all
of these concerns.
5. Cardiac. A baseline EKG was obtained which revealed normal
sinus rhythm , normal axis , normal rate , however , her QT-interval
was slightly prolonged at 491 msec. The upper limit of normal in
women is 460. I briefly discussed this finding with the Medicine
Consult Service and Cardiology Service who felt that this is
likely attributable to her low potassium of 3.2. Therefore , high
content potassium foods were encouraged and she will have a
repeat EKG at her prenatal visit next week to evaluate for
resolution of this prolonged QT. Of note , she reports that her
mother had a congenital heart condition and experienced her first
heart attack at the age of 27 due to what she thought was an
enlarged heart. Her mother ultimately died at the age of 56 from
a heart attack. She reports aside from her mom who she does feel
had this condition since birth; no one in her family has
experienced sudden cardiac death. She also has never experienced
palpitations or chest pain.
6. History of kidney stones. A urinalysis was sent which
revealed 1-5 red blood cells and the urine culture showed 10 , 000
of mixed flora.
DISCHARGE INSTRUCTIONS:
Given Ms. Silmon strong desire to be discharged after only a day
of admission , she was discharged to home with the following
instructions:
She is to take her fingerstick blood sugars fasting and at one
hour postprandial intervals and record them prior to her
follow-up appointment. She is also instructed to eat foods high
in potassium and to call the office in an urgent manner should
she develop chest pain or palpitations. She has appointments
scheduled for 6/6/04 with Dr. Sovie in special OB Clinic ,
Dr. Bloomingdale in Endocrine Clinic and Nutrition. She was given
prescriptions for NPH to take 14 units subcutaneously a.m. and 14 units
subcutaneously at bedtime and Humalog 8 units prebreakfast , 6 units
prelunch , and 8 units predinner. She is also advised to take
prenatal vitamins one tablet orally daily. She understands all
these follow up plans and has no concerns with her discharge at
this time.
eScription document: 3-6608463 EMS
Dictated By: CISTRUNK , EDGARDO
Attending: CONCILIO , GERALDO
Dictation ID 0308392
D: 5/10/05
T: 5/10/05
Document id: 199
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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353016536 | PUO | 48115317 | | 3580457 | 10/21/2007 12:00:00 a.m. | pulmonary fibrosis | Unsigned | DIS | Admission Date: 7/22/2007 Report Status: Unsigned
Discharge Date: 8/5/2007
ATTENDING: COLLICA , CHANELLE XOCHITL M.D.
PRINCIPAL DIAGNOSIS: Diabetes.
ADDITIONAL DIAGNOSES: Cirrhosis and IPF.
SERVICES: GMS No
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female
with a history of IPF , on home oxygen at 3 l nasal cannula at
baseline , cryptogenic cirrhosis , and insulin-dependent diabetes
mellitus who was recently admitted from 9/10/07 through 4/28/07
for hyperglycemia and volume overload , who presented with
hyperglycemia and weight gain. Of note , during the patient's
previous admission , she was diagnosed with a urinary tract
infection as well as spontaneous bacterial peritonitis based on a
diagnostic paracentesis , which showed greater than 250
neutrophils. During that admission , the patient was treated for
a urinary tract infection and the SBP and was sent home on a
course of orally cefpodoxime. Of note , during that previous
admission , the patient was also hyperglycemic and was discharged
on an insulin regimen of Lantus 90 with good aspartate sliding
scale. At home , the patient's blood pressures were in the 200 to
300s and at times even higher. Over the week prior to admission ,
it was noted that the patient gained somewhere from about 8 to 10
pounds with increasing abdominal girth and lower extremity edema.
As noted above , the patient's fingersticks were noted to be
elevated in the 300s and so her Lantus was titrated from 90 units
daily to 100 units by the visiting nurse. The patient was
previously discharged on Lasix 40 mg twice daily , which was
titrated up to 80 mg twice daily also by the visiting nurse and
her primary care physician. The patient had no additional
shortness of breath , and her oxygen sat was unchanged on her home
dose of O2. She had no chest pain , no cough , and no fevers. No
nausea , vomiting , or diarrhea. The patient had finished a 7-day
course of cefpodoxime on the day of admission. The patient's
mental status was unchanged as felt by the daughter.
PAST MEDICAL HISTORY:
1. Idiopathic pulmonary fibrosis , on 3 L home O2.
2. Insulin-dependent diabetes mellitus.
3. Cryptogenic cirrhosis complicated by ascites and esophageal
varices as well as possible hepatic encephalopathy.
4. Hypertension.
5. Status post cholecystectomy.
MEDICATIONS AT HOME:
1. Fosamax 35 mg orally weekly.
2. Caltrate 600 mg plus D 1 tabler daily.
3. Cefpodoxime 200 mg daily , which was completed the day prior
to admission.
4. Clotrimazole troche orally four times daily.
5. Dexamethasone 1 mg orally three times a day
6. Lasix 80 mg orally twice a day
7. Lantus 100 units subcutaneously every morning.
8. Combivent 2 puffs inhaled 4 times daily.
9. Lisinopril 20 mg daily.
10. Nadolol 10 mg orally daily.
11. Prilosec 20 mg orally daily.
11. Bactrim DS 1 tablet orally daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her daughter , Amadon , who
is her healthcare proxy and can be reached at 991-279-1860. The
patient has never drunk alcohol , smoked , and never used any
illicit drugs. The patient is originally from O and
irish-speaking.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS: The patient was afebrile. Temperature was 96.9 ,
heart rate was 62 , and blood pressure was 90/50. She was
breathing 16 times and was saturating 99% on her home baseline
dose of oxygen at 3 L.
HEENT: Notable for tongue that showed thrush.
NECK: JVP was difficult to asses but thought to be slightly
elevated. There was no lymphadenopathy.
LUNGS: Dry inspiratory crackles at both bases.
CARDIOVASCULAR: The patient has slow heart rate with normal S1
and S2. No murmurs , rubs , or gallops.
ABDOMEN: Slightly distended , soft , and nontender with no
guarding and positive bowel sounds.
EXTREMITIES: Remarkable for 3+ edema , pitted , to the knees.
NEUROLOGIC: No asterixis and no focal deficits.
LABORATORY DATA ON ADMISSION: Electrolytes were remarkable for
BUN and creatinine of 65/1.6 as well as a potassium of 6.0.
Albumin was noted to be 2.6. CBC showed a white count of 8.51 ,
hematocrit of 34.7 , and platelets of 92 with less than 5% bands.
STUDIES: EKG reveals sinus bradycardia at 50 beats per minute
with normal axis and normal intervals and nonspecific ST
abnormalities , unchanged from prior EKGs. A chest x-ray showed
unchanged coarse bilateral opacities with no acute process.
IMPRESSION: The patient is a 76-year-old female with history of
idiopathic pulmonary fibrosis and cryptogenic cirrhosis
complicated by ascites and esophageal varices , who was admitted
with hyperglycemia and volume overload.
HOSPITAL COURSE BY SYSTEM:
1. Endocrine: The patient was admitted with hyperglycemia and
sugar in the 600s. The patient was initially started on insulin
drip at 4 units per hour , and her sugars quickly normalized. The
patient was transitioned over to subcutaneous insulin regimen
that included Lantus and before every meal aspartate as well as sliding
scale. The patient's fingersticks remained labile throughout
this admission and at times were elevated in the 300s and other
times were normal in the range of 70 to 90. The patient's
insulin was titrated , and she was discharged on a regimen that
included Lantus 90 units subcutaneously daily as well as
aspartate 28 units subcutaneously before each meal. It was
noticed that the patient had the most difficulty with
postprandial sugars often after lunch and dinner. Therefore , we
recommended that if she continues to have hyperglycemia , that it
would be best to titrate the before every meal aspartate. It would be best
to avoid titrating the Lantus too much given that her fasting
sugar in the morning was often normal. The patient had no
hypoglycemic episodes during this admission. Of note , the
patient was not previously on before every meal insulin dosing at home;
however , following discharge from rehabilitation , it was thought
that this would not likely be the best regimen for her. This was
discussed with the patient's family and caregivers who were
amenable to this idea , however , will likely need further
teaching.
2. GI: The patient has a history of cryptogenic cirrhosis
complicated by ascites and esophageal varices. The patient was
thought to be grossly volume overloaded due to her cirrhosis and
hypoalbuminemia on admission. The patient was initially diuresed
with intravenous Lasix with good results. The patient did have a bump in
her creatinine due to this aggressive diuresis and her Lasix was
held for several days , but her orally Lasix was restarted prior to
discharge. The patient was discharged on 60 mg of orally Lasix
twice daily. The patient on admission was thought to have
significant amount of ascites based on abdominal exam. The
patient had recently completed a course of treatment for
spontaneous bacterial peritonitis and had no abdominal tenderness
but did have distention. An abdominal ultrasound was obtained as
a diagnostic paracentesis was considered given that the patient
had an episode of confusion; however , abdominal ultrasound
revealed only a small lot of ascites that was not amenable to
paracentesis. The patient has a history of esophageal varices
and was continued on her nadolol for prophylaxis. The patient
was continued on her Bactrim for SBP prophylaxis. The patient
did have an episode of confusion and delirium during this
admission , which was felt to be likely due to hepatic
encephalopathy. The patient's delirium improved with the
initiation of lactulose. The patient was discharged on lactulose
30 mL four times a day , which we titrated so that the patient has at least
3 bowel movements daily. At the time of discharge , the patient
was alert and oriented. Of note , the patient was not started on
Aldactone for management of her volume overload given that she
was admitted with hyperkalemia and has a history of elevated
potassium.
3. Neurologic: The patient had had one episode of delirium
during this admission where she was confused , did not know where
she was , and was not interacting with her family appropriately.
The patient had a workup at that time , which included an
infectious workup , which revealed no evidence of infection. The
patient was started on lactulose , which had to be an administered
initially by retention enema as she was refusing to take orally
The patient's mental status improved within 24 hours of starting
the lactulose , and she was continued on this regimen and will be
discharged on it. Of note , the patient had no asterixis on
discharge.
4. Renal: The patient has a history of chronic kidney disease
with a baseline creatinine of 1.3 to 1.7. The patient was
admitted with a creatinine of 1.6 , which did increase slightly
with increased diuresis. The patient's Lasix was held for a day
or two and then she was restarted on her orally home Lasix regimen ,
which was titrated to 60 mg orally twice a day Of note , the patient's
lisinopril was held on admission due to hyperkalemia. The
lisinopril was not restarted prior to discharge given the
patient's history of hyperkalemia and several episodes during
this admission , which required the administration of Kayexalate.
The patient likely should be on an ACE inhibitor for chronic
kidney disease , but this can be re-added as an outpatient with
very close monitoring of her potassium as this was felt to be
indicated by the patient's primary care physician. Of note , the
patient was normotensive off lisinopril during this admission.
5. Pulmonary: The patient has history of IPF and had no acute
pulmonary issues during this admission. The patient was
saturating well on her home dose of O2 throughout the entire
admission. The patient was continued on her home dose of
dexamethasone for IPF.
6. Infectious Disease: Prior to discharge , the patient was
incidentally noted to have a urine culture that was growing
greater than 100 , 000 colonies. The patient was afebrile and had
no symptoms of dysuria but did have a mildly elevated white count
of 11 , 000. Based on the patient's recent UTI , she was started on
cefpodoxime for a short 5-day course. Results of this urine
culture will need to be followed up and her antibiotics adjusted
as necessary. The patient was continued on her Bactrim for both
SPEP and primary care physician prophylaxis.
CODE STATUS: The patient was full code throughout this entire admission.
PHYSICAL EXAM AT THE TIME OF DISCHARGE: The patient home was
afebrile and normotensive with the heart rate in the 60s to 70s
and was saturating in the high 90s on her baseline 3 L of O2 via
nasal cannula. Her weight at the time of discharge was 198
pounds. Her cardiac exam was normal. Her lungs had fine
crackles at both bases. Her abdomen was obese with no fluid
wave. Her extremities had bilateral pitting edema to the knees
and she had no asterixis.
DISCHARGE MEDICATIONS:
1. Cefpodoxime 200 mg orally daily times 5 days , this medication
should be discontinued after the last dose on 10/1/07 .
2. Fosamax 35 mg orally weekly.
3. Artificial tears 2 drops to both eyes 3 times a day as needed
for dryness or irritation.
4. Caltrate 600 plus D 1 tablet orally daily.
5. Clotrimazole troche topically to the mouth twice daily.
6. Dexamethasone 1 mg orally three times a day
7. Colace 100 mg orally three times a day
8. Lovenox 30 mg subcutaneously daily , this medication can be
discontinued once the patient is ambulating on a regular basis.
9. Lasix 60 mg orally twice a day
10. Aspartate insulin 20 units subcutaneously before every meal
11. Insulin aspartate sliding scale before every meal
12. Lantus 90 units subcutaneously every day before noon
13. Combivent 2 puffs inhaled four times a day
14. Lactulose 30 mL orally four times a day , which can be held if the
patient is having greater than 3 bowel movements daily.
15. Miconazole powder applied topically to affected area twice
daily.
16. Nadolol 10 mg orally every 24 hours
17. Prilosec 20 mg orally daily.
18. Bactrim 1 tablet orally every 24 hours
FOLLOW-UP:
1. The patient was discharged on 60 mg of Lasix twice daily.
The patient's weight at the time of discharge was 198 kg. The
patient should be weighed daily , and her primary care physician
should be contacted for any weight gain greater than 5 pounds.
The patient should have a chem-7 checked within the next 2 to 3
days to follow her creatinine as well as her potassium.
2. The patient had a urine culture sent prior to discharge that
revealed 100 , 000 colonies of bacteria that were not yet
identified at the time of discharge. The patient was then
started empirically on cefpodoxime based on past microbiologic
data. The results of this urine culture should be followed up in
a day or two and her antibiotics can be adjusted as necessary.
FOLLOW-UP APPOINTMENT:
1. The patient has appointment with her gastroenterologist , Dr.
Crowdis , on 3/6/07 at 2:20 p.m. in the afternoon.
2. The patient has follow-up appointment with her primary care
physician , Dr. Sakumoto , on 10/26/07 at 10:15.
DISPOSITION: The patient was discharged to rehabilitation in
stable condition.
eScription document: 8-1885304 SSSten Tel
CC: Rossie Mankoski MD
Colnley Mor Health
Ler
CC: Chanelle Xochitl Collica M.D.
CC: Misti Reinstein , MD
Pagham University Of
Alabama
Dictated By: RANDKLEV , VERNON
Attending: COLLICA , CHANELLE XOCHITL
Dictation ID 5618542
D: 3/16/07
T: 3/16/07
Document id: 200
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
Y |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
Y |
N |
Y |
- |
773981468 | PUO | 11147158 | | 8841577 | 5/24/2006 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 8/3/2006 Report Status: Signed
Discharge Date: 8/13/2006
ATTENDING: TYACKE , MACKENZIE MD
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old woman with a
history of an ischemic cardiomyopathy with an ejection fraction
of 35% and also a history of coronary artery disease status post
MI , insulin-dependent diabetes , peripheral vascular disease and
chronic renal insufficiency who presented with volume overloaded.
The patient was recently discharged after a 9-day admission from
6/10/2006 to 05 for a CHF exacerbation. During the
previous admission , she had been diuresed with a Lasix drip and
then started on amiodarone and Coumadin for a new paroxysmal
atrial fibrillation. After discharge , she presented to MMC
Cardiology Clinic on 1/16/2006 with a jugular venous pressure at
15 cm and severe bilateral lower extremity edema and a BNP of
2500. The assessment in clinic was that she had been under
diuresed in the previous admission and therefore she was directly
admitted to Totin Hospital And Clinic for reinitiation of aggressive
diuresis. Of note , the patient had recently changed from Lasix
to torsemide after the last discharge as her outpatient
medication. She endorsed worsened orthopnea , dyspnea on
exertion , paroxysmal nocturnal dyspnea as well as early satiety.
She denied any chest pain or other anginal equivalents.
PAST MEDICAL HISTORY:
1. Ischemic cardiomyopathy with an ejection fraction of 30%-35%.
2. Paroxysmal atrial fibrillation , newly on Coumadin and
amiodarone.
3. Coronary artery disease status post MI.
4. Peripheral vascular disease status post left tibial bypass
and fem-pop bypass.
5. Hypertension.
6. Hyperlipidemia.
7. Glaucoma.
8. Diabetes with retinopathy.
9. Osteoarthritis.
10. Anemia.
11. Obesity.
12. Chronic renal insufficiency with a baseline creatinine of
2.9 followed by MMC Renal Clinic.
MEDICATIONS AT HOME:
1. Torsemide 100 mg every day before noon and 50 mg every afternoon
2. Ativan 0.5 mg orally three times a day as needed anxiety.
3. Folate 1 mg orally daily.
4. Lipitor 80 mg orally at bedtime.
5. Lantus 18 units subcutaneously nightly
6. Coumadin 1 mg every afternoon
7. Lopressor 25 mg orally twice a day
8. Procrit 40 , 000 units subcutaneously every other week.
9. Nitroglycerin sublingual as needed chest pain.
10. Aspirin 81 mg orally daily.
11. Vitamin B12 subcutaneous injections at clinic.
12. Amiodarone 200 mg orally daily.
13. Iron 325 mg orally three times a day
14. Metolazone as needed
ALLERGIES: Lisinopril and nonsteroidal anti-inflammatory agents.
SOCIAL HISTORY: The patient is married and lives at home with
her husband. She quit tobacco with rare alcohol use and no
drugs.
FAMILY HISTORY: Noncontributory. There is no family history of
cardiac disease.
PHYSICAL EXAMINATION: On admission , temperature was 98.9 , heart
rate 70 , blood pressure 104/50 , respiratory rate of 20 , oxygen
saturation 95% on room air. In general , the patient was
comfortable in no acute distress. HEENT , Pupils were equal ,
round , and reactive. Oropharynx was clear. The JVP was greater
than 15 cm , chest exam showed bilateral crackles at the bases
with bibasilar dullness well as well as right greater than left
base. Cardiovascular was regular rate and rhythm with a S3 and
no murmur. Abdomen soft , nontender , nondistended with a
nonpulsatile liver. Extremities showed 3+ pitting edema
bilaterally to the hips with bilateral changes of arterial and
venous insufficiency. Laboratory studies were significant for an
INR of 1.6 , BUN of 110 , creatinine 3 , white blood cell count of
11.7 and a hematocrit of 27.9.
EKG on admission was a normal sinus rhythm with evidence of a
previous anterior MI with lateral repolarization , ST and T wave
abnormalities , and possible LVH.
Chest x-ray showed bilateral effusions , left greater than right
with increased vascular markings and fluid in the right fissure ,
but no discrete infiltrates.
IMPRESSION: This is a 70-year-old woman with ischemic
cardiomyopathy with an EF of 35% , coronary artery disease status
post MI , insulin-dependent diabetes , peripheral vascular disease ,
chronic renal insufficiency who presented in volume overload
after a recent admission with insufficient diuresis.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular. In terms of pump , the patient was clearly in
gross volume overload from both the right sided and left-sided
failure on presentation. Her blood pressure was stable and she
had no evidence of severely decreased cardiac output or/and organ
perfusion. She was started on the Lasix drip at 10 mg per hour
and Zaroxolyn at 2.5 mg orally daily. Her Lopressor was held for a
decompensated heart failure. She initially diuresed well
overnight; however , on the second day her diuresis tapered off
and her Lasix drip was turned up to 20 mg per hour and the
Zaroxolyn was increased to twice a day She met her I&O goal of
greater than 1 liter negative overnight the following night ,
however , a day later , she again had poor diuresis and the
Zaroxolyn was changed to Diuril. At this time , a repeat chest
x-ray showed a very little change in her bilateral pleural
effusions , so her diuresis up to this point was felt to be
insufficient. After the transition from Zaroxolyn to Diuril ,
which was given 250 mg intravenous twice a day , she was noted to have an
increase in creatinine from 2.9. gradually up to 3.2; however ,
remained stable for the next few days and the patient was able to
maintain good diuresis on this regimen without bump in her
creatinine.
On 4/25/2006 , she was noted to have greatly improved lower
extremity edema and that improved lung exam and she had met her
goal weight of less than 85 kilograms. Lasix drip was
discontinued in the afternoon on 4/25/2006 and she was restarted
on her home orally torsemide regimen of 100 mg orally every day before noon and 50
mg orally every afternoon for anticipated discharge home on 8/13/2006 . The
Diuril was also discontinued. The patient was anticipated to be
stable on twice a day torsemide and orally on metolazone at home. Her
new dry weight on this admission was established at 85 kilograms
and this should be at a goal for diuresis should she require
admission in the future.
She will follow up with her MMC cardiologist for further
monitoring of her volume status after discharge. In terms of
rhythm , the patient had a new presentation of atrial fibrillation
on the prior admission and was started on amiodarone and Coumadin
at that time. She was in normal sinus rhythm on presentation at
this admission and remained in normal sinus rhythm throughout the
admission and was monitored on telemetry with no other events.
She was continued on her home dose of amiodarone and continued on
Coumadin; however despite the dose being decreased from her home
dose of 1 mg every afternoon to a 0.5 mg every afternoon , her INR continued to rise
and was eventually 3.5. Her Coumadin was discontinued. She was
recommended to be discharged off Coumadin and follow up with her
primary care provider during the week following discharge to
recheck her INR and restart her Coumadin when it falls below 2.5.
In terms of ischemia , the patient had no acute evidence of
ischemia on presentation. Denied any chest pain and had no
changes consistent with ischemia on her EKG. She was continued
on aspirin and Lipitor throughout the admission.
2. Renal: The patient has chronic renal insufficiency at
baseline. Her creatinine did increase from a baseline of 2.9 to
3.2. During this admission , however , remained stable after that
point. She continued on renally-dosed medications and actually
required repletion of both potassium and magnesium despite her
renal insufficiency throughout the admission in the setting of
aggressive diuresis. Her electrolytes were stable prior to
discharge home. She was followed by the MMC Renal Clinic with
whom she has had a previous conversations about the possibility
of hemodialysis in the future and she will see them shortly after
this discharge:
3. Pulmonary: The patient had dyspnea on exertion and bilateral
pleural effusions on her chest x-ray on admission. This was all
felt to be consistent with her heart failure. She did have no
signs or symptoms of any infectious etiology either on imaging or
as a part of her clinical picture. Her dyspnea on exertion and
her lung exam both improved with her aggressive diuresis.
4. Endocrine: The patient had erratic fingersticks early in the
admission with a very low fingerstick blood glucoses in the
morning initially , so her p.m. Lantus dose was decreased from 18
units to 16 units and the NovoLog sliding scale was started.
On 11/10/2006 , she was noted to continue to have lower sugars in
the morning , but routinely elevated sugars in the afternoon
greater than 200. She was started on before every meal NovoLog regimen.
However , on this regimen , she was found 1 morning to have a
fingerstick blood glucose of 33 and to be hypothermic with a
temperature of 94 taken rectally. This was thought to be
secondary to hypoglycemia which may have progressed over several
hours prior to assessment and her temperature returned to normal
at 98 after her blood glucose was aggressively repleted. It was
felt that the patient likely had decreased metabolism of her
injected insulin in the setting of worsening renal failure , so ,
her Lantus was decreased in accordance with a curbside
consultation with the diabetes management service. She will be
discharged home on a similar regimen to her home regimen simply
with a decreased Lantus dose down to 12 units nightly. She
should continue to monitor her fingerstick blood glucoses at
home. We were hesitant to change the types or timing of her
insulin during this hospitalization. I left that item to be
further managed by her primary care provider after discharge:
5. Hematologic: The patient has a chronic normocytic anemia
felt likely to be secondary to her chronic renal insufficiency.
Her iron studies were rechecked on this admission and her iron
studies were also normal. She was continued on Aranesp through
this hospitalization and she is on Procrit as an outpatient and
she will continue on that with further discussion with the MMC
Renal Clinic after she is discharged.
6. Fluids , electrolytes , and nutrition: The patient was fluid
restricted to 2 liters of fluid per day orally and potassium and
magnesium were repleted as needed and she was maintained on a
cardiac diet. Prophylaxis was with Coumadin and Nexium.
DISCHARGE PLAN: The patient will be discharged to home with VNA
services for some home physical therapy. She will follow up with
her primary care provider Dr. Kimberly at MMC and also with the
MMC Cardiology Clinic and Renal Clinic. She should have her INR
checked within 4-5 days after discharge and her Coumadin
restarted when her INR is less than 2.5.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Amiodarone 200 mg orally daily.
3. Lipitor 80 mg orally daily.
4. Folate 1 mg orally daily.
5. Lantus insulin 12 units subcutaneous nightly.
6. Ativan 0.5 mg orally three times a day
7. Metolazone 2.5 mg orally daily as needed for fluid retention as
directed by your physician.
8. Multivitamin one tablet orally daily.
9. Torsemide 100 mg orally every day before noon at 50 mg orally every afternoon
10. Vitamin B12.
11. Iron.
12. Procrit 40 , 000 units subcutaneously every other week.
eScription document: 7-7455764 RFFocus
Dictated By: YEAGLEY , MA
Attending: TYACKE , MACKENZIE
Dictation ID 8128407
D: 6/5/06
T: 4/7/06
Document id: 201
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
706455839 | PUO | 02523649 | | 1645821 | 6/13/2005 12:00:00 a.m. | CARDIAC ISCHEMIA | Signed | DIS | Admission Date: 8/25/2005 Report Status: Signed
Discharge Date: 9/21/2005
ATTENDING: ALETA KERTESZ MD
HISTORY OF PRESENT ILLNESS: Mr. Latella is a 54-year-old male with
no significant past medical history , who presented to his
cardiologist with complaints of chest pressure while he was
working out. This was approximately one month prior to
admission. Since this time , he has been having similar episodes
of chest discomfort while working out. Stress test was positive
for anterior lateral ischemic changes , which was followed by
cardiac catheterization showing diffuse LAD disease. The patient
was referred to Dr. Kertesz for coronary revascularization.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus ,
hyperlipidemia , COPD , asthma.
SOCIAL HISTORY: No history of tobacco use.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS: Lisinopril 20 mg orally daily ,
atorvastatin 40 mg orally daily , Xanax dose unknown.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.7 , heart rate
70 , blood pressure in the right arm 160/100 , blood pressure in
the left arm 150/100. HEENT: Dentition without evidence of
infection. No carotid bruit. Chest: No incisions.
Cardiovascular: Regular rate and rhythm without murmur.
Peripheral pulses are all 2+ include the carotid , radial ,
femoral , dorsalis pedis , posterior tibial. Respiratory: Breath
sounds clear bilaterally. Extremities: Without scarring ,
varicosities or edema. Neuro: Alert and oriented with no focal
deficits.
PREOPERATIVE LABS: Sodium 141 , potassium 3.7 , chloride 102 ,
carbon dioxide 32 , BUN 17 , creatinine 1.2 , glucose 95 , magnesium
2.1 , white blood cells 7.37 , hematocrit 46.8 , hemoglobin 16.2 ,
platelets 174 , 000 , physical therapy 13.7 , INR 1 , PTT 28.1.
CARDIAC CATHETERIZATION DATA: On 5/3/05 coronary anatomy 95%
osteal LAD , 90% proximal LAD , 70% LAD left dominant circulation.
ECG on 5/3/05 was normal sinus rhythm at 61. Chest x-ray on
5/3/05 was read as normal.
HOSPITAL COURSE: Date of surgery 7/9/05 .
PREOPERATIVE DIAGNOSIS: Coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease.
PROCEDURE: CABG x2 with a LIMA to the LAD , SVG1 to the D1. Bypass
time was 60 minutes. Crossclamp time was 41 minutes. One
Ventricular wire , two pericardial tubes , and one left pleural
tube were placed.
FINDINGS: Unable to perform off pump CABG due to the difficult
position of the D1 target. After the operation , the patient was
transferred to the cardiac intensive care unit under stable
condition. His course was uncomplicated in the cardiac intensive
care unit. He was transferred to the cardiac step-down unit.
All epicardial pacing wires and chest tubes were removed without
complication. He was weaned from his oxygen requirement and
diuresed to below his preoperative weight.
DISCHARGE MEDICATIONS: He will be discharged home on
postoperative day #4 in stable condition on the following
medications. Aspirin 325 mg orally every day , Niferex 150 mg orally
twice a day , oxycodone 5 mg orally every 6 hours as needed pain , Toprol XL 100 mg
orally every day , Flovent 44 mcg inhaler twice a day , Lipitor 40 mg orally
daily.
PLAN: Mr. Latella is to follow-up with Dr. Kertesz cardiac surgeon
in six weeks and Dr. Mainer , cardiologist in two weeks.
eScription document: 0-1911989 JSSten Tel
Dictated By: TRIARSI , VERDA
Attending: KERTESZ , ALETA
Dictation ID 2417666
D: 5/24/05
T: 5/24/05
Document id: 202
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
N |
N |
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- |
N |
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N |
N |
277590281 | PUO | 18300979 | | 0628820 | 10/6/2004 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 10/6/2004 Report Status: Signed
Discharge Date: 11/22/2005
ATTENDING: BACHMANN , LASHANDA MD
ADMISSION DIAGNOSIS:
Dyspnea on exertion.
DISCHARGE DIAGNOSES:
1. CHF.
2. Stage intravenous esophageal cancer.
PRESENTING SYMPTOMS:
Mr. Gitt is a 68-year-old gentleman with stage intravenous esophageal
cancer who was two weeks status post his third cycle of
chemotherapy for his cancer. He also had ischemic cardiomyopathy
with a known ejection of 20% and coronary artery disease status
post CABG in 1993. He presented with progressive shortness of
breath over the three days prior to admission. He denied any
fever. However , he did note increase in his weight and increased
lower extremity edema over the last week. He has three-pillow
orthopnea at baseline , but has been sleeping both upright for the
three days prior to admission. Two weeks prior to admission , he
was walking in the mall and was able to accomplish all of his
ADLs without difficulty. On admission , he was unable to walk
more than 20 feet without becoming severely dyspneic. He does
describe having diminished appetite , increased fatigue , and three
days of copious watery stool , possibly related to his
chemotherapy.
PAST MEDICAL HISTORY:
Significant for pneumonia two weeks ago treated as an outpatient ,
esophageal cancer stage intravenous status post chemo x3 cycles ,
obstructive sleep apnea , ischemic cardiomyopathy , COPD , atrial
fibrillation status post pacemaker and AICD placement , gout ,
pulmonary vasculitis , and also CAD.
OUTPATIENT MEDICATIONS:
Include amiodarone , digoxin , colchicine , Atrovent , lisinopril ,
spironolactone , torsemide , Ativan , Zocor , and Prilosec.
ALLERGIES:
He has no known drug allergies.
SOCIAL HISTORY:
He lives at home and denies alcohol use.
PHYSICAL EXAMINATION ON ADMISSION:
The patient was afebrile with the temperature of 95.8. His heart
rate was in the 90s. His blood pressure was 90/60 breathing at a
rate of 22. His room air oxygenation was 82% , but increased to
98% on 3 liters nasal cannula. He was slightly uncomfortable
sitting straight up in bed and visibly tachypnic. His lung exam
demonstrated bilateral scattered wheezes throughout the lung
fields and bibasilar crackles. His JVP was approximately 15 cm.
Heart exam reveled regular rate and rhythm with prominent S3.
Abdominal exam was nontender. His extremities had 2+ pitting
edema to the knees.
PERTINENT LABS:
On admission , he had a creatinine of 1.7 , which is at his
baseline and BUN of 46. His BNP was 2960 , CK 48 , CK-MB 1.0 , and
troponin 0.1. Hematocrit 44.5 , white count 7.8 , and D-dimer was
150. His INR was 1.3.
OPERATIONS AND PROCEDURES:
The patient had a palliative esophageal stent placed on 4/5/05 .
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: The patient presented with exam and labs
findings consistent with decompensated heart failure. For this ,
he had a known ejection fraction of 20%. While he was in the
hospital , he had strict I's and O's and was diuresed with Lasix
and torsemide. His diureses was somewhat limited by systolic
blood pressure with a range of 85 to 110 during his
hospitalization. On discharge , his weight was down to 82.1 kg
and was down from 87.5 on admission. The patient did have slight
leak in his troponin of 0.1 on admission , but his EKG was
unchanged and his enzymes x3 were negative except for the
troponin , which did not trend to higher. His cardiac medical
regimen was maximized with an ACE inhibitor or statin and baby
aspirin was started on him. He was discharged home on torsemide
100 mg daily in addition to his spironolactone dose.
2. Pulmonary: The patient received Atrovent nebulizers in-house
to help with his shortness of breath. His primary etiology ,
however , was pulmonary edema secondary to decompensated heart
failure. His diuresis goal of 1.5 liter a day was achieved with
the combination of dopamine , nesiritide , and Lasix drips. He was
most responsive to combination of nesiritide and dopamine. At
the time of discharge , the patient's room air saturations were
94% with ambulatory saturations of 86%. He was therefore
discharged home with oxygen to use overnight and when
symptomatic.
3. Gastrointestinal: The patient was admitted with diarrhea
that was felt to be related to his chemotherapy , which has been
completed two weeks earlier. Stool was sent out for C.
difficile , which was negative. His colchicine was initially held
because of his diarrhea , but the patient then developed a flare
of his gout in his right great toe. Colchicine was resumed to
treat this with good results. The patient received palliative
stent to his esophagus on 4/5/05 that is placed by Dr. Ortmeier
without complications. The patient had plans to follow up with
is outpatient oncologist for ongoing care of his esophageal
cancer after discharge.
4. Renal: The patient's creatinine was 1.7. His baseline
chronic renal insufficiency was with the creatinine of
approximately 1.3 to 1.5. At discharge , his creatinine was 1.6 ,
which has been stable throughout his entire stay. He briefly
required having a Foley catheter placed on 4/4/05 because of
urinary retention , but it was removed the next day without
difficulty and did not have problems with voiding prior to
discharge.
5. Hematology: The patient was placed on DVT prophylaxis with
Lovenox. He did exhibit some right leg edema more pronounced
than his left leg edema , but this is felt to be due to his gout
in his right great toe.
The patient was discharged to home with services and physical therapy was
arranged to go and do a home safety evaluation.
PHYSICAL EXAMINATION ON DISCHARGE:
The patient's vital signs were stable. He was resting
comfortably in bed. Crackles in his lungs were notably
diminished from admission. He no longer was tachypnic. His
heart had a regular rate and rhythm , S1 , S2 , occasional S3. No
murmurs. Abdomen was soft and nontender. His extremities had
trace pitting edema.
DISCHARGE MEDICATIONS:
1. Amiodarone 300 mg daily.
2. Colchicine 0.6 mg every other day.
3. Digoxin 0.125 mg every other day.
4. Ferrous sulfate 325 mg daily.
5. Lisinopril 5 mg daily.
6. Ativan 0.5 mg twice a day
7. Spironolactone 12.5 mg daily.
8. Trazodone 50 mg at night.
9. Multivitamins one tablet daily.
10. Torsemide 100 mg daily.
11. Prilosec 20 mg twice a day
12. Simvastatin 80 mg at night.
DISPOSITION:
The patient was discharged to home with services. He had
instructions to follow up with his primary care doctor , Dr.
Theiling in one weeks' time.
eScription document: 4-6967524 EMS
Dictated By: LAVERGNE , TAMEIKA
Attending: BACHMANN , LASHANDA
Dictation ID 3614178
D: 10/13/05
T: 10/13/05
Document id: 203
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
054315021 | PUO | 50016379 | | 2501708 | 10/21/2006 12:00:00 a.m. | SYNCOPE | Unsigned | DIS | Admission Date: 5/15/2006 Report Status: Unsigned
Discharge Date: 8/20/2006
ATTENDING: COLASAMTE , ISABELLE EVON MD
ADMITTING DIAGNOSIS:
Coronary artery disease.
HISTORY OF PRESENT ILLNESS:
This is a 75-year-old male who had syncopal episodes the day
before admission. He was out brushing snow off of his car when
he lost consciousness. The patient awoke on the ground and
walked inside and called 911. The patient was admitted to the
emergency room , and at that time , he complained of no chest pain ,
no palpitations , but underwent a cardiac workup , which revealed
three-vessel coronary artery disease with LAD , circumflex , and
right distribution , and was consulted for surgical
revascularization.
PAST MEDICAL HISTORY:
Significant for hypertension , diabetes , on orally agents ,
hypercholesterolemia , history of prostate cancer , treated with
XRT , and spinal stenosis.
PAST SURGICAL HISTORY:
Status post TURP.
FAMILY HISTORY:
No family history of coronary artery disease.
SOCIAL HISTORY:
No history of tobacco use.
ALLERGIES:
Penicillin , no reaction is noted on this H&P.
ADMISSION MEDICATIONS:
Atenolol 12.5 mg orally once a day , baby aspirin at 81 mg orally once
a day , heparin intravenous , Lipitor 80 mg orally once a day , glyburide , no
dose indicated , and psyllium no dose indicated.
PHYSICAL EXAMINATION:
Height 5 feet 6 inches , weight 63 kg. Vital signs: Temperature
of 98.2 , heart rate of 61 , blood pressure in the right arm of
152/58 , blood pressure on the left arm of 160/60 , and O2
saturation of 100%. HEENT: PERRLA , dentition without evidence
of infection , no carotid bruits. Chest: No incision.
Cardiovascular: Regular rate and rhythm , no murmurs noted.
Pulses , 2+ pulses throughout except for dorsalis pedis and
posterior tibial bilaterally which was present by Doppler only.
Allen's test of both left and right upper extremity by pulse
oxymetry is listed here as normal. Breath sounds are clear
bilaterally. Abdomen: No incisions , soft , no mass noted.
Rectal was deferred. Extremities: Without scarring , varicosity
or edema. Neuro: Alert and oriented , with no focal deficits.
The patient has a torn right biceps muscle which formed a mass
that was palpable distal to the humerus.
PREOPERATIVE LABORATORY VALUES:
Chemistries on 1/10/06 , sodium 138 , K of 4.4 , chloride of 102 ,
CO2 of 29 , BUN of 34 , creatinine of 1.2 , glucose of 193 , and a
magnesium of 2.1. Hematology from the same day , white count of
10.5 , hematocrit of 39.7 , hemoglobin of 13.9 , and platelets of
147 , 000. physical therapy of 14.9 , INR of 1.2 , and a PTT of 23.5. Cardiac
catheterization on 1/10/06 performed at the Kernan To Dautedi University Of Of showed
coronary anatomy of 75% proximal and 50% mid LAD , a 75% ostial
and 90% proximal circumflex , and 95% proximal OM1 , and 100%
proximal RCA with a right dominant circulation. Echo on 1/1/06
showed an ejection fraction of 55% , the aortic valve was
trileaflet , mildly thickened and sclerotic , with mild-to-moderate
aortic regurgitation , without ventricular dilatation , mitral
valve is normal in structure with mild-to-moderate mitral
regurgitation , tricuspid valve is structurally normal with
minimal tricuspid regurgitation.
HOSPITAL COURSE:
The patient was admitted on 4/5/06 to the Cardiology Service
for cardiac workup including an echo and cardiac catheterization
and referred for surgical vascularization and was taken to the
operating room on 2/10/06 and underwent a coronary artery bypass
grafting x3 with a LIMA to the LAD , a saphenous vein graft to the
obtuse marginal 1 and a saphenous vein graft to the PDA. The
patient came off the heart-lung machine without any difficulty ,
on just TNG and insulin and extubated 7 hours postoperatively.
HOSPITAL COURSE BY SYMPTOMS:
1. Neurologically , remained intact.
2. Cardiovascular: The patient remained in normal sinus rhythm
throughout his postoperative course. The patient with his prior
history presenting with syncopal episode was evaluated by the
Electrophysiology Service , and with his past history of
nonsustained VT , the patient underwent EP studies to evaluate if
needed a permanent pacer or ICD. The patient was taken down to
their suite and found to have normal HV as well as sinus node.
There was no inducible atrial or ventricular arrhythmias , and no
VA conduction on baseline , and felt that he had normal studies
and did not require any pacer or ICD , and will be just discharged
on some beta-blocker.
3. Respiratory: The patient was weaned to room air by
postoperative day #2 , and discharge chest x-ray showed no
evidence of edema or effusion.
4. GI: The patient was placed on some Nexium for surgical
prophylaxis , but with no prior history , was not discharged on any
medication.
5. Renal: The patient was on just very low-dose Lasix in the
immediate postoperative period , but the patient was autodiuresing
on his own quite well , and by postoperative day #2 , Lasix was
discontinued , and throughout his postoperative course , the
patient had a stable BUN and creatinine.
6. Endocrine: The patient was just on orally agents for his
diabetes and required some insulin drip perioperatively , but by
day of discharge , the patient was back on his preoperative
glipizide and will not be discharged on any insulin.
7. Heme: The patient had a stable hematocrit , did not require
any transfusion , and discharged with a hematocrit of 32.
8. ID: The patient was on vancomycin for surgical prophylaxis
but had no further infectious issues and will be discharged on no
further antibiotics. By postoperative day #5 , the patient was
doing quite well , and a decision was made for the patient to be
discharged to home in stable condition.
DISCHARGE MEDICATIONS:
Vitamin C 500 mg orally twice a day , full aspirin 325 mg orally once a
day , Colace 100 mg orally three times a day as needed constipation , glipizide 5
mg every afternoon and 50 mg orally every day before noon , Motrin 400 mg orally every 8 hours as needed
pain , Niferex 150 mg orally twice a day , oxycodone 5 mg to 10 mg orally
every 4 hours as needed pain , Toprol-XL 25 mg orally once a day , and Lipitor
80 mg orally once a day.
FOLLOW-UP APPOINTMENTS:
The patient should make these follow up appointments with his
cardiologist , Dr. Barnaba in two weeks. Her phone number is area
code 860-067-7792 , and with Dr. Colasamte in six weeks for
postsurgical evaluation , his phone number is area code
766-081-5735.
DISPOSITION:
Discharged to home in stable condition on postoperative day #5.
eScription document: 0-4507220 EMSSten Tel
Dictated By: AFZAL , TOMIKA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 7270520
D: 6/13/06
T: 6/13/06
Document id: 204
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
692608510 | PUO | 56604818 | | 212326 | 1/15/2002 12:00:00 a.m. | CHEST PAIN , RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/14/2002 Report Status: Signed
Discharge Date: 7/20/2002
ADMITTING DIAGNOSIS: CORONARY ARTERY DISEASE
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE , IN-STENT
RESTENOSIS
PROBLEM LIST: 1. CORONARY ARTERY DISEASE
2. IN-STENT RESTENOSIS
HISTORY OF PRESENT ILLNESS: Mrs. Rieley is a 53-year-old female
with a cardiac history as follows. In
October of 2001 she presented with substernal chest pain and had a
positive exercise tolerance test. Cardiac catheterization at
I Warho Hospital revealed a 40% LAD , 50% left circumflex ,
80% RCA , and 90% RCA. Stents were placed to both the proximal and
mid RCA lesions. In August of 2001 , the patient represented with
substernal chest pain and had a positive exercise tolerance test.
Cardiac catheterization revealed in-stent restenosis. She was
treated with angioplasty and brachytherapy. In July of 2002 , she
underwent repeat cardiac catheterization for recurrent angina and
was again found to have in-stent restenosis. Again , she underwent
a angioplasty to zero percent. Later in July of 2002 , she
presented with chest pain; however , cardiac catheterization
revealed no significant stenosis. Finally , in September of 2002 , the
patient presented with her usual chest pain and a cardiac troponin
I of 0.15. MIBI showed inferior ischemia and cardiac
catheterization showed an RCA instent restenosis. She underwent
PTCA without stenting.
Today , the patient presents complaining that she has had a sharp
chest pain across the precordium with onset three days prior to
admission and was relieved with sublingual nitroglycerin. Her
symptoms were intermittent until the day of presentation when she
experienced 10/10 chest pain that was only partially relieved with
sublingual nitroglycerin and was associated with shortness of
breath. She presented to Gle Ra Csylv Valley Medical Center Emergency Department
where she was given aspirin 225 mg , nitroglycerin sublingually
x one , and Plavix 75 mg x one. On presentation , her blood pressure
was 98/54 and she was given one bolus of heparin 5 , 000 units.
While in the Emergency Room she had recurrent pain and was started
on intravenous nitroglycerin.
PAST MEDICAL HISTORY: ( 1 ) Coronary artery disease - please see
history of present illness.
( 2 ) Hypercholesterolemia.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS: Plavix 75 mg every day , atenolol 25 mg every day , Zestril
5 mg every day , Imdur 30 mg every day , lipitor 20 mg every day ,
aspirin 325 mg every day , and sublingual nitroglycerin as needed
FAMILY HISTORY: Her father died of a myocardial infarction at
age 55. She has three brothers and one sister who
are in good health.
SOCIAL HISTORY: The patient was never a smoker. She denies any
alcohol use. She is divorced and has two sons.
One son is an anesthesiologist here at I Warho Hospital .
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.4 , heart rate
56 , blood pressure 144/75 , 99% on room air.
GENERAL: She appeared comfortable and in no acute distress.
HEENT: Extraocular muscles were intact. Oropharynx clear with
moist mucous membranes. NECK: Jugular vein pressure of 6 cm.
Supple and no lymphadenopathy. CARDIOVASCULAR: Bradycardic with
regular rhythm. Normal S1 and S2. No murmurs , rubs or gallops.
LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft and
without tenderness or distention. EXTREMITIES: Warm and without
edema. DP pulses 2+ bilaterally. NEUROLOGICAL: Nonfocal.
RECTAL: Guaiac negative.
Chest x-ray revealed no acute cardiopulmonary process.
Echocardiogram in September of 2002 revealed normal left ventricular size
and function with an ejection fraction of 60% , mild hypokinesis at
the distal anterior anteroseptal region , normal RV size and
function with borderline RVH , trace MR , and trace PR.
LABORATORY DATA: On admission , sodium 143 , potassium 4.1 ,
chloride 109 , bicarb 25 , BUN 19 , creatinine 1.0 ,
glucose 106 , calcium 8.9. White blood cell count 5.6 , hematocrit
32.4 ( baseline 32-34 ) , platelets 180. CK 75 , troponin .02 ,
physical therapy 14.3 , INR 1.1 , PTT 28.3 , cholesterol 165 , LDL 94 , HDL 45 ,
triglycerides 129. Electrocardiogram on 5/6/02 revealed sinus
bradycardia at 49 with normal axis , normal intervals and no acute
ST changes. A T-wave inversion seen in lead III on 3/12/02 was no
longer present.
HOSPITAL COURSE: ( 1 ) Cardiovascular: The patient was admitted for
cardiac catheterization on 5/6/02 , which
revealed a 90% in-stent restenosis of the RCA stent. No
intervention was made at that time. Post cardiac catheterization
she was kept on Plavix , aspirin , atenolol , Zestril , lipitor , and
intravenous TNG. Because of recurrent chest pain on 8/11/02 she
was restarted on heparin. There was an attempt to wean both the
intravenous TNG and heparin on 9/4/02 with a planned transition to
orally Isordil. However , the patient again had chest pain at rest ,
leading to restarting of a heparin drip and intravenous TNG. There
were no EKG changes at that time and the pain was relieved by
nitroglycerin. Of note , the patient did have a small hematoma and
bruit at the right femoral artery catheterization site. Ultrasound
of the groin on 9/4/02 was negative for pseudoaneurysm. Because
of recurrent in-stent stenosis , the patient is planning to be
transferred to Wo Thamervo Memorial Hospital in T on 9/1/02 for
Robimycin coated stents.
( 2 ) Hematology: The patient was maintained on intravenous
unfractionated heparin with a goal physical therapy of 60-80. Her PTT on the day
of discharge was in therapeutic range.
( 3 ) Renal: The renal function was stable post catheterization.
CODE: The patient is full code.
DISPOSITION: The patient is planned to undergo transfer to Wo Thamervo Memorial Hospital in H Pa Co for Robimycin
coated stents. The transfer will take place by ambulance on
9/1/02 .
DISCHARGE MEDICATIONS: Unfractionated heparin at 900 units per
hour , intravenous TNG at 40 mcg per minute ,
enteric coated aspirin 325 mg every day , atenolol 25 mg every day , Colace
100 mg twice a day , Zestril 5 mg every day , Zocor 60 mg orally every bedtime , Plavix
75 mg every day , Serax 15-30 mg orally every bedtime as needed insomnia , benadryl
25 mg orally every bedtime as needed insomnia.
DISCHARGE LAB DATA: Sodium 135 , potassium 4.2 , chloride 103 ,
bicarb 25 , BUN 19 , creatinine 0.9 , glucose 99 ,
calcium 9.1 , magnesium 1.9. White blood cell count 5.7 , hematocrit
33 , platelets 179 , physical therapy 14.5 , INR 1.2 , PTT 68.6.
DISPOSITION: The patient is discharged in stable condition to
Wo Thamervo Memorial Hospital in Moineslo Le
Dictated By: TELMA DALONZO , M.D. ZZ71
Attending: LEOLA C. MUSICH , M.D. YK17 XB325/977456
Batch: 0340 Index No. RSQOCZ194Y D: 11/25/02
T: 11/25/02
CC: 1. LEOLA C. MUSICH , LAKESMI SONNO MEMORIAL HOSPITAL OF CARDIOLOGY
TELEPHONE 201-035-5205*ULV 357-144-4121
2. BRITTENY TOMBLESON , M.D.*TELEPHONE 066-890-0596
Document id: 205
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
- |
Y |
- |
N |
N |
Y |
N |
N |
Y |
N |
680159882 | PUO | 61129049 | | 8154759 | 6/21/2006 12:00:00 a.m. | pneumonia | Signed | DIS | Admission Date: 9/3/2006 Report Status: Signed
Discharge Date: 8/30/2006
ATTENDING: COSE , LATASHIA MD , MBA
PRINCIPAL DIAGNOSIS:
The diagnosis responsible for causing the admission is pleural
effusions.
DISCHARGE DIAGNOSIS:
Pleural effusions secondary to congestive heart failure.
CHIEF COMPLAINT:
Shortness of breath.
HISTORY OF PRESENT ILLNESS:
The patient is an 86-year-old male with a history of congestive
heart failure , coronary artery disease , atrial fibrillation ,
chronic renal insufficiency , and non-small cell carcinoma of the
left lung , status post resection in 1997. He presents with
shortness of breath. He lives in a nursing home and was
diagnosed with pneumonia more than three weeks prior to
admission. The pneumonia , per report , was bilateral , left
greater than right. He was started on a 10-day course of
levofloxacin , which he completed. He subsequently developed C.
diff colitis and was treated with Flagyl. Three days prior to
the present admission , he noticing increased shortness of breath ,
worsened with any movement in bed. A chest x-ray at the nursing
home reportedly showed an increased opacity in the right lower
base , concerning for recurrent pneumonia. For this , he was
restarted on levofloxacin. On the day of admission , his oxygen
saturation dropped to 77% on room air , with improvement to the
mid 90's on 3 liters of oxygen. He noted a mild dry cough. Her
denied headache , dizziness , chest pain , hemoptysis , abdominal
discomfort , or dysuria. His son reported that he has mild
orthopnea at baseline , unchanged in recent days. Notably , he was
admitted to the Kernan To Dautedi University Of Of in 5/23 for subacute shortness of
breath , thought to be due to a CHF exacerbation , treated with
Lasix diuresis. An echocardiogram at that time showed an
ejection fraction of 55% , with mild left atrial enlargement , and
mild concentric left ventricular hypertrophy , along with
inferobasal wall hypokinesis.
REVIEW OF SYSTEMS:
As above in the history of present illness , along with
constipation , pain with movement of the right knee and right heel
ulcer , status post skin graft.
PAST MEDICAL HISTORY:
1. Congestive heart failure , ejection fraction 55% , concentric
LV hypertrophy.
2. Coronary artery disease , status post multiple angioplasties
of LAD and left circumflex in mid 1990's.
3. Non-small cell carcinoma of the left lung , status post
resection in 1997.
4. Atrial fibrillation , diagnosed in 2005 , on Coumadin.
5. Diabetes mellitus , diagnosed more than 20 years ago , on
insulin.
6. Chronic renal insufficiency.
7. Peripheral vascular disease , status post angioplasty in 2006.
8. Osteoarthritis , worst in the right knee.
9. Hypothyroidism.
10. BPH , status post TURP , 1988.
11. Status post appendectomy.
12. Right heel ulcer , status post skin graft.
13. Gout.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg daily.
2. Metoprolol 25 mg three times a day
3. Lasix 40 mg daily.
4. Levofloxacin 750 mg daily.
5. Coumadin 3 mg daily.
6. Colchicine 0.6 mg twice a day
7. Prilosec 20 mg daily.
8. Zocor 40 mg daily.
9. Questran 2 mg twice a day.
10. Aspirin 81 mg daily.
11. Iron sulfate 325 mg daily.
12. Neurontin 100 mg every day before noon and 200 mg every afternoon
13. Flomax 0.4 mg daily.
14. Zoloft 50 mg daily.
15. Synthroid 25 mcg daily.
16. Lantus 32 units daily.
17. NovoLog 6 units before every meal
18. Colace.
19. Senna.
20. Tylenol as needed
21. Dilaudid as needed
ALLERGIES:
The patient is allergic to penicillin , which causes a rash.
SOCIAL HISTORY:
He has been living in a nursing home for the last month. His son
is a neurologist. He smoked cigars for many years , currently a
nonsmoker. Her denies any alcohol or illicit drug use.
FAMILY HISTORY:
Notable for a father with diabetes and a brother with heart
disease.
SUMMARY OF THE HOSPITAL COURSE:
1. Shortness of breath: The patient initially presented with
shortness of breath , saturating 77% on room air. He was noted on
chest x-ray to have moderate bilateral effusions. The effusions
were likely secondary to congestive heart failure , although
pneumonia with parapneumonic effusions could not be excluded.
Given that he was afebrile with a decreasing white count and not
increasingly hypoxic , parapneumonic effusions were considered
less likely compared to worsening CHF. Given the concern for
CHF , he was given Lasix 40 mg intravenous approximately one to two doses a
day for large volume diuresis , with a goal of total body balance
of 2 liters negative per day. Over the course of his
hospitalization , his bilateral effusions improved , although there
were small effusions noted on the chest x-ray at the time of
discharge. His oxygen requirement decreased , and on the day of
discharge , he was saturating 97-98% on 1 liter. Of note , the
patient was brought to ultrasound for a planned guided
thoracocentesis , but the effusion sites were small such that in
the context of this clinical improvement , thoracocentesis was
deferred. He was maintained initially as well with vancomycin
and levofloxacin , although the vancomycin was discontinued after
four days , and the levofloxacin was discontinued on discharge ( of
note , he received 10 days total of levofloxacin starting from
3/27/2006 at his nursing home ). Echocardiogram noted an
ejection fraction of 55-60% with left ventricular hypertrophy ,
consistent with diastolic dysfunction. The etiology of his
congestive heart failure and pleural effusions was therefore
thought to be atrial fibrillation with RVR. In terms of follow
up , he needs daily weights; if he gains greater than 2 pounds
over 24 hours , it is recommended that his Lasix dose be doubled
for that day. As a discharge , he is being sent out on Lasix 40
mg orally daily.
2. Cardiovascular:
a. Ischemia: The patient initially had a small troponin leak
0.32 , which was thought secondary to demand ischemia from atrial
fibrillation with RVR. For this , he was briefly started on a
heparin drip. Subsequently , cardiac enzymes trended down. The
patient was maintained on Coumadin and aspirin 81 mg , along with
Zocor and Questran for hyperlipidemia. On hospital day #3 to #4 ,
telemetry noted pauses. EKG showed in addition to pausing , new
T-wave inversions in anterior precordial leads , associated with
ST depression. This is thought to be either due to ischemia or
digitalis toxicity. His digoxin levels measured 1.3 to 1.4 , so
digoxin was held , with improving in pausing , but no change in
T-wave inversions. In discussions with his outpatient
cardiologist , it was thought that his T-wave inversions could
possible be ischemic , although the appropriate course of action
was not to pursue further anticoagulation or evaluation for
catheterization , given the patient's other medical issues. He
was maintained on Coumadin , aspirin , Zocor , Questran , and
Lopressor.
b. Rhythm: The patient continued to be in atrial fibrillation
throughout his hospitalization and was rate controlled with
Lopressor 37.5 mg three times a day ( increased from a home dose of 25 mg
three times a day ). He was also maintained on Coumadin 2 mg daily for
anticoagulation. On admission , there was a report that he had
runs of ventricular tachycardia and he was placed on a lidocaine
drip for several hours in the emergency department. No
documentation regarding telemetry strips or QRS morphologies
could be obtained to verify this rhythm , however. In addition ,
throughout his hospitalization , he had occasional runs
nonsustained VT and SVT. As discussed above , he was thought to
have mild digoxin toxicity given pausing with a digoxin level of
1.3 to 1.4. His digoxin was therefore held and subsequent
improvement in pausing was noted. Of note , on discharge , his
digoxin has been discontinued. His primary care physician and
cardiologist should consider whether or not to restart digoxin as
an outpatient.
c. Pump: The patient was aggressively diuresed with 40 mg intravenous of
Lasix approximately one to two times per day , for a total
diuresis of roughly negative 9 liters over the course of his
hospitalization. Echocardiogram showed an ejection fraction of
55-60% with left ventricular hypertrophy , consistent with
diastolic dysfunction. As discussed above , he will be discharged
on Lasix 40 mg orally daily. Note , as mentioned above , if he gains
greater than 2 pounds over a 24-hour period , his Lasix dose
should be doubled for that day.
3. C. diff: The patient had a positive C. diff as an inpatient.
He had been on Flagyl , which was started at the nursing home for
a prior diagnosis of C. diff. Because of persistent bowel
movements , he was switched to orally vancomycin 250 mg four times a day , and
upon discharge , he was started on a probiotic ( Saccharomyces
boulardii 250 mg four times a day ) to replenish his gut flora. We will
recommend that he continue orally vancomycin and the probiotic for
10 days after his diarrheal symptoms have resolved. If these
symptoms do not improve on the regimen within the few days
following discharge from Petersram Medical Center , we will recommend consider
adding metronidazole intravenous and getting an infectious disease
consult.
4. Diabetes: The patient had several bouts of hypoglycemia
during the course of his hospitalization. These were appeared to
be related to poor orally intake. His Lantus was changed to 15
daily , and he was covered with a NovoLog sliding scale. After
the changes , his fingersticks ranged in mid 100's.
5. Hypothyroidism: The patient's TSH was low with a normal free
T4 suggestive of sick euthyroid. He was continued on Synthroid
25 mcg daily.
6. Musculoskeletal: Given the patient's creatinine clearance of
less than 50 , his colchicine dose for gout was switched from 0.6
mg twice a day to 0.6 mg daily. We continued his Neurontin for
neuropathic pain , and Tylenol for right knee osteoarthritis. He
was seen by Plastic Surgery registered nurse who recommended
Panafil with dressing for his right heel ulcer. He also has a
small ulcer developing on his left big toe , which will need close
observation as follow up.
DISCHARGE MEDICATIONS:
Tylenol 650 mg orally every 8 hours as needed for headache , aspirin 81 mg
daily , Questran 4 mg daily , colchicine 0.6 mg daily , Nexium 20 mg
daily , Lasix 40 mg daily , Neurontin 100 mg every day before noon and 200 mg
every afternoon , Lantus 15 units subcutaneously at bedtime , Synthroid 25 mcg orally
daily , Maalox one to two tablets orally every 6 hours , metoprolol 37.5 mg
orally three times a day , Panafil ointment topical twice twice a day , Saccharomyces
boulardii 250 mg orally four times a day , Zoloft 50 mg every day before noon , Zocor 40 mg at
bedtime , Flomax 0.4 mg daily , vancomycin 250 mg orally every 6 hours ,
Coumadin 2 mg orally every afternoon , and iron sulfate 325 mg daily.
eScription document: 0-9671938 EMSSten Tel
Dictated By: BLACKGOAT , GERMAINE
Attending: COSE , LATASHIA
Dictation ID 7488490
D: 5/26/06
T: 5/26/06
Document id: 206
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
Y |
N |
N |
- |
Y |
N |
- |
Y |
N |
N |
N |
407166584 | PUO | 61820940 | | 8440055 | 9/23/2005 12:00:00 a.m. | FEMORAL FRACTURE | Signed | DIS | Admission Date: 9/23/2005 Report Status: Signed
Discharge Date: 10/18/2005
ATTENDING: BOHANAN , SHEA M.D.
SERVICE: General Medicine Service.
PRIMARY CARE PHYSICIAN: Velda Brucato , M.D. Phone number is
( 385 )-490-7931.
PRINCIPAL DIAGNOSIS FOR ADMISSION: Left femur fracture.
PROBLEMS:
1. Left femur fracture.
2. Atrial fibrillation with rapid ventricular response.
3. Delirium on baseline dementia.
4. Hyponatremia.
5. Mild incisional cellulitis.
6. Insulin dependent diabetes.
7. Hypothyroidism.
8. Mild hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old woman
with past medical history significant for osteopetrosis ,
persistent atrial fibrillation , baseline dementia , and
hypothyroidism who presents at a transfer from IIH
to the Pagham University Of with a nondisplaced hairline
fracture of the left femoral neck noted after the sudden
development of severe pain with ambulation on March , 2005.
Her husband describes her developing leg pain when weightbearing
as she was getting out of car in March , 2005. He denies any
recent fall and trauma. Transfer paper from HTH
suggest , the patient may have fallen prior to admission. Her
baseline , her husband states , Ms. Bica can walk with a walker ,
uses bathroom herself , feed herself , and handle petty cash and
recognizes family members. She needs assistance with bathing and
remainder of her actual daily living. He reports that his wife
has been confused since early after admission to HTH . He states that she does not drink alcohol.
As per her past medical hospital , Mr. Bica states that his wife
has not suffered a heart attack , although she did have
difficulties for heart rhythm and he recalls for having a stress
test but no cardiac catheterization. The patient's cardiologist
did send copies of a recent vicinity inspect in January 2005 and was
negative for ischemia and echocardiography. She was admitted to
the Orthopedic Service on June , 2005 , for hip replacement
and has since then transferred to the Medicine Service on
November , 2005 , for medical management.
PAST MEDICAL HISTORY: Significant for persistent atrial
fibrillation on Coumadin , osteopetrosis , dementia ,
hypothyroidism , depression , bilateral TKR in 1993 , laminectomy ,
and cholecystectomy.
FAMILY HISTORY: Significant for brother with heart problems.
SOCIAL HISTORY: She lives with husband Lawver who is her health
care provider , phone number is ( 916 )-216-8910. No alcohol. No
tobacco.
REVIEW OF SYSTEMS: Unavailable to be obtain secondary to the
patient confusion.
ALLERGIES: No known drug allergies.
MEDICINES ON TRANSFER: Zocor 20 mg every bedtime , Remeron 15 mg every bedtime ,
levofloxacin 500 mg , Coumadin 3 mg/4 mg alternating every other day ,
digoxin 0.125 mcg/0.25 mcg alternating every other day , Cymbalta 60 mg
every day , trazodone 50 mg every bedtime , Synthroid 75 mcg every day , Risperdal
0.25 mg every day , and propranolol 20 mg every day
ADMISSION PHYSICAL EXAMINATION: Temperature 96.9 , pulse 94 ,
blood pressure 142/68 , respiratory rate 16 , and O2 saturation 94%
on room air. In general , the patient was somnolent , arousable ,
but confused but no apparent distress. HEENT: Normocephalic and
atraumatic. Anicteric sclerae. Pupils were equal and round to
light. She had moist mucous membranes and no lymphadenopathy.
Her neck was supple with full range of motion. Chest had faint
bilateral crackles at the bases right greater than left.
Cardiovascular: She had irregularly irregular rhythm. S1 and
S2. No murmurs , gallops , or rubs. JVD was less than 10 cm.
Abdomen: Soft and nontender and mildly distended with positive
bowel sounds. Extremities: There was no edema. DP were
palpable bilaterally. She was warm and well perfused. Neuro:
The patient was alert and oriented to self only. She was
somnolent , follow command , but no focal abnormalities were noted.
PERTINENT LABORATORY TESTS AND STUDIES: TSH within normal
limits. CT head on June , 2005 , showed a possible old small
left posterior frontal contusion. CT pelvis on June , 2005 ,
showed a hairline left femur fracture plus osteopetrosis. EKG
was irregularly irregular but otherwise unremarkable. Urine
cultures taken on March , 2005 , and February , 2005 ,
no growth to date. Stool Clostridium difficile , toxin assay has
been negative to date as well taken on the February , 2005.
Chest x-ray on admission was unremarkable. Chest x-ray following
surgery was significant for bilateral pleural effusions right
greater than left. Chest x-ray on the morning of discharge
significant for bilateral pleural effusion somewhat improved over
prior study.
OPERATIONS AND PROCEDURES: On January , 2005 , Dr. Eckloff did a
Girdlestone on May , 2005. Dr. Aspen , a left hip
hemiarthroplasty. Please see a full dictated operative notes for
details.
HOSPITAL COURSE: She is a 76-year-old female with atrial
fibrillation , dementia , and presenting with a left hip fracture
for orthopedic surgical correction on June , 2005. She had
a surgery but without complication and a postoperative course
complicated by delirium , atrial fibrillation with RVR , and new
hyponatremia.
1. Ortho: She presented with left femur hairline fracture. She
had a Girdlestone procedure performed and a left hemiarthroplasty
performed without complications. She was treated postoperatively
with cefazolin and has been discharged will be discharged on
Keflex. She developed a mild incisional cellulitis with no signs
of abscess and no fever.
2. Cardiovascular:
A. Ischemia: She was screened preop in the determined
intermediate risk. She was given a beta-blocker for surgery and
has no signs of symptoms of ischemia throughout this
hospitalization.
B. Pump: The patient was found to be mildly hypertensive and
was started on lisinopril with good control.
C. Rhythm: The patient with known atrial fibrillation. She
developed a rapid ventricular response on postoperative day #3.
Heart rates in the 140s. Blood pressure was stable. This was
difficulty to control with intravenous and orally beta-blocker , calcium
channel blockers , and digoxin so she was intravenous amiodarone loaded and
is currently undergoing a orally amiodarone load as well. To date
on January , 2005 , she has had seven days of orally 400 mg three times a day
and with current loading plan is seven more days of 400 mg
amiodarone twice a day followed by 400 mg every day indefinitely. She is
currently weight controlled. Heart rates in the mid to low 60s.
She is getting amiodarone and Toprol-XL 300.
3. Neurology: The patient has baseline dementia and per husband
was developing delirium prior to transfer to Pagham University Of . Differential diagnosis of this delirium infection
versus medications versus electrolytes. This is also complicated
by stress of surgery. Psychiatry was consulted , and initially
she was restarted on her Cymbalta. However , this was stopped
development of hyponatremia. Postoperatively , the patient has
slowly improved in terms of mental status and this new baseline
at discharge.
4. Infectious Disease: The patient has been afebrile
throughout. There was a report of a Gram-negative UTI at the
outside hospital for which she received a course of Levaquin.
She received postop prophylaxis of cefazolin until the September , 2005 , when this was stopped. Subsequently , she had increased
her white blood cell count to 23 , but no fever. UA , chest x-ray ,
and stool for C. diff was sent and are all negative to date. Her
white count has subsequently come down to 17 on the day of
discharge , and she has remained afebrile. Keflex was restarted
given the possible incisional site mild cellulitis , and she to be
continued until the staples were out after seven days course with
improvement. The patient developed a nonbloody diarrhea on
May , 2005. C. difficile studies were sent and have come
back negative to date. She was started on prophylactic dose of
Flagyl , which will be discontinued prior to discharge.
5. Pulmonary: The patient developed pleural effusion postop but
never was compromised in terms of oxygenation or ventilation.
She is making modest improvement at discharge and was self
diuresing.
6. Fluids , Electrolytes , and Nutrition: On admission , the
patient had a sodium of 140 which seems to gradually dropped to
her course to a nadir of 119 on the November , 2005. No obvious
med changes except for the SSRI that was subsequently stopped.
She was started on free-water restriction and urine lytes were
drawn. These lytes were consistent with picture of SIADH , so
free-water restriction has worked. On the day of discharge , her
sodium is 131 , and she should be continued on free-water
restriction and recheck in a week. Otherwise , electrolytes were
repleted as needed The patient was given a low fat ADA diet.
7. Endocrine. The patient's sugars are moderately well
controlled on regular insulin sliding scale. NPH insulin was
added and has been titrated up to 12 units every day before noon with regular
insulin sliding scale for coverage on top of that. The patient
with known hypothyroidism was euthyroid on admission. TSH was
within normal limit. Her home dose Synthroid continued and
should be indefinitely.
8. Hematology: Given the patient atrial fibrillation , she had
been on Coumadin at the outside hospital; however , on
presentation , her INR was subtherapeutic at 1.2. She was put on
Lovenox prophylactic dose prior to the surgery , and following
surgery Coumadin was restarted and up titrated to 30 range. On
discharge , she was therapeutic with an INR of 2.0 , Coumadin dose
of 5 mg every bedtime Her hematocrit has fell following the surgery ,
and she has transfused 4 units of packed red blood cells on
May , 2005. Since then , her hematocrit has increased
appropriately and she has been stable throughout her rest of
admission. On discharge , the hematocrit was 39.0.
9. Prophylaxis: Given her high risk for DVTs , the patient was
prophylactic with Lovenox while waiting for her INR to become
therapeutic. She also given pneumo boots and TED stocking.
Finally , she was given Nexium for peptic ulcer disease
prophylaxis. No consultants were called; however , the orthopedic
service initial have this patient contact would be Dr. Gaylene G Faniel .
At discharge , she is afebrile , T max of 97.9 , pulse between 49
and 64 , blood pressure between 98 and 120/44 to 60. She is
breathing 18 times per minute and satting between 94% and 98% on
room air. Fasting sugars have been well controlled. On exam ,
she is in no apparent distress. She is alert and oriented x2 to
place and person but not the time. She is also alert to her
situation. HEENT: Her pupils are equal and reactive to light.
She has anicteric sclerae. Chest exam , she has slightly
decreased breath sounds at the right base but no crackles or
wheezes. Cardiovascular: She has irregularly irregular S1 and
S2. No murmurs , gallops , or rubs. Abdomen: Soft and obese with
mildly distended positive bowel sounds , nontender. Extremities:
Warm and well perfused. She has left hip incision with staples
with no signs of dehiscence but a 5 cm round area of erythema
which is nontender. Neuro exam is nonfocal.
DISCHARGE MEDICINES:
1. Tylenol 650 mg orally every 4 hours as needed for pain and headache , do
not exceed 4 g in 24 hours.
2. Amiodarone 400 mg orally twice a day x7 days , then 400 mg orally every day
indefinitely.
3. Dulcolax 10 mg to 20 mg p.r. every day as needed constipation.
4. Calcium carbonate 500 mg orally every day
5. Ferrous sulfate 325 mg orally three times a day
6. Folate 1 mg orally every day
7. Insulin NPH 12 units subcutaneously every day before noon , hold if blood
glucose less than 100.
8. Regular insulin sliding scale , blood sugar less than 125 give
0 , 125 to 150 give 2 , 151 to 200 give 3 , 201 to 250 give 4 , 251
to 300 give 6 , 301 to 350 give 8 , 351 to 400 give 10.
9. Synthroid 75 mcg orally every day
10. Lisinopril 20 mg orally every day , hold if systolic blood pressure
less than 100.
11. Milk of magnesia 30 mL orally every day as needed constipation.
12. M.V.I. one tablet orally every day
13. Metamucil sugarfree one packet orally every day as needed
constipation.
14. Sarna topical every day
15. Fleet Enema one bottle p.r. every day as needed constipation.
16. Coumadin 5 mg orally every afternoon
17. Keflex 500 mg orally four times a day x7 days.
18. Toprol-XL 300 mg orally every day , hold for heart rate less than
55 , hold for blood pressure less than 100.
19. Risperdal 0.5 mg orally every bedtime
20. Remeron 15 mg orally every bedtime
21. Miconazole powder 2% topical twice a day
22. Cholecalciferol 400 units orally every day
23. Nexium 20 mg orally every day
DISPOSITION: This patient will be discharged to the
Rehabilitation Facility in stable condition.
PHYSICIAN PLANS:
1. Ortho , discontinued staples on postop day #14 , which is
March , 2005. She is to followup with Dr. Aspen on July , 2005 , for x-rays at 8 a.m. and with Dr. Aspen himself at 9
a.m. Phone number is ( 926 )-688-3908.
2. Cardiovascular.
A. Ischemia. Make appointment with cardiologist in one month.
B. Pump. Continue lisinopril and Toprol holding for systolic
blood pressures less than 100.
C: Rhythm. Continue amiodarone 400 twice a day for seven days
starting at 5th and then afterwards 400 every day indefinitely.
Continue Toprol-XL 300 mg every day and consider decreased in Toprol
for bradycardia. The patient is to make an appointment with
cardiologist in one month for assessment.
3. Hematology: INR goal 2 to 3 on Coumadin for atrial
fibrillation for prophylaxis.
4. Infectious Disease: P.O. Keflex until staples out in
resolution of cellulitis.
5. Pulmonary: primary care physician follow for assessment in resolution of
pleural effusion.
6. Fluids , Electrolytes , and Nutrition: Free-water restriction
for one week and followup sodium in one week if sodium scaled to
135. The patient can have regular ADA 2000 per calorie diet with
no salt added.
7. Endocrine: Continue NPH 12 units every day before noon and regular insulin
sliding scale for coverage. Continue Synthroid on a current
dose.
8. Prophylaxis: The patient is therapeutic on Coumadin. No
Lovenox is required; however , she should benefit from pneumatic
boots for TEDs while in bed given a high risk for DVT following
an orthopedic procedure.
eScription document: 3-4748678 SSSten Tel
Dictated By: MCRORIE , DENISHA
Attending: BOHANAN , SHEA
Dictation ID 4438789
D: 9/23/05
T: 9/23/05
Document id: 207
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
- |
Y |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
630372501 | PUO | 76001088 | | 9349530 | 1/20/2006 12:00:00 a.m. | Atypical chest pain | | DIS | Admission Date: 7/1/2006 Report Status:
Discharge Date: 4/17/2006
****** FINAL DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 673-14-60-6
Ty Rythim Highway
Service: MED
DISCHARGE PATIENT ON: 7/1/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Alert overridden: Override added on 7/1/06 by :
on order for ACETYLSALICYLIC ACID orally ( ref # 904484800 )
patient has a POSSIBLE allergy to IBUPROFEN; reaction is GI
upset.
patient has a POSSIBLE allergy to KETOROLAC TROMETHAMINE;
reactions are Rash , GI upset.
patient has a POSSIBLE allergy to NSAIDs; reactions are GI
upset , patient tolerates home asa. Reason for override: aware
XANAX ( ALPRAZOLAM ) 1 MG orally every 4 hours as needed Anxiety
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
DIGOXIN 0.125 MG orally DAILY
Alert overridden: Override added on 7/1/06 by
GRIZZAFFI , SHEA MARIEL , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: home med
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
Alert overridden: Override added on 7/1/06 by
GRIZZAFFI , SHEA MARIEL , M.D.
on order for LASIX orally ( ref # 322216390 )
patient has a POSSIBLE allergy to DYAZIDE; reaction is SOB.
Reason for override: home med
ISOSORBIDE DINITRATE 30 MG orally three times a day Starting Today ( 9/7 )
LEVOTHYROXINE SODIUM 50 MCG orally DAILY
Override Notice: Override added on 7/1/06 by
GRIZZAFFI , SHEA MARIEL , M.D.
on order for DIGOXIN orally ( ref # 150330120 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: home med
LISINOPRIL 2.5 MG orally DAILY
Override Notice: Override added on 7/1/06 by
GRIZZAFFI , SHEA MARIEL , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
338912460 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
12.5 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 1
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 30 MG orally four times a day
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
SENNA TABLETS ( SENNOSIDES ) 1 TAB orally twice a day as needed Constipation
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Partial weight-bearing: Uses cane
FOLLOW UP APPOINTMENT( S ):
Dr. Christy Clardy , call for appt. ,
ALLERGY: DYAZIDE , Penicillins , NSAIDs , Erythromycins ,
AZITHROMYCIN , Tape , IBUPROFEN , KETOROLAC TROMETHAMINE ,
BUPROPION HCL , GABAPENTIN
ADMIT DIAGNOSIS:
Atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
fibromyalgia ( fibromyalgia ) htn ( hypertension ) history of gastric bypass
( history of gastric bypass surgery ) obesity
( obesity ) anemia ( anemia ) spinal stenosi ( spinal
stenosis ) CAD history of MI ( coronary artery disease ) history of coronary stent
( history of coronary stent ) pacemaker
( pacemaker ) Hyperlipidemia ( hyperlipidemia ) anxiety
( anxiety ) TAH ( hysterectomy ) ccy ( cholecystectomy )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
HPI: 58 year-old women with history of CAD , history of MI with LAD stent 2004 , HTN ,
hyperlipdemia , complex PMHX admitted with 1 day history of SSCP. patient has had
multiple admissions and ED visits ( approx > 10 ) for chest
pain over the past several months since April . Her most recent
cardiac work-up includes a MIBI ( 11/5/06 ) which demonstrated a mild
small fixed perfusion defect in inferior-basal region - likely
representing soft tissue attenuation and a CTA which is negative for
aortic dissection in 6/26/06 . patient was in her USOH until several days
PTA when she developed occ palpitations. At 5PM of the
evening of admission she developed lightheadedness and ringing in her
ears and subsequently developed SSCP radiation to her back and
bilateral shoulders and left arm. + SOB. Chest pain intensity 10/10
and similar to pain of prior MI and similar to mult prior visits.
EMS called and patient given sublingual NTG without relief. Pain lasted approc 2
hours and was ultimately relived with morphine in the ED. In
addition , patient report a recent bilateral lower ext cellulites treated
with 7days of levo. patient continues to have some warmth and erythema in
her bilateral lower ext. Last admit here 6/10 with EGD
confirming gastro-jejunal anastamotic ulcer - told to hold ASA and
Plavix , but has been taking. In ED , given morphine 6 mg intravenous , asa , and
ativan and admitted to GMS.
****
ROS: abd pain assoc with old ventral hernia , worsening. 2wks smelly ,
dark stools.
****
PMH:
1. CAD
a. history of acute anterior MI ( 4/20 )
b. history of cardiac catheterization ( 1/28/04 ) with LAD stent ( 3.5 x 23
Cypher ). LAD had 90% proximal stenosis , RCA and LCX were patent
c. history of cardiac cath ( 5/25 ) with no significant stenoses
d. Echo ( 4/30/2005 ) EF 60% , mild MR , dilated LA , no wall motion
abnormalities.
e. history of pacemaker placement on 9/15/05 for hypotensive episode and
bradycardia requiring ICU stay at KAAH
f. Adenosine MIBI ( 8/3 ): negative for ischemia , LVEF: 63%
2. Stated history of atrial fibrillation ( no documentation )
3. UGI Bleed ( 4/1/06 ) - EGD - friable ulcer located at an
anastomosis site from her previous bypass surgery. Transfused 2UPRBCs
4. Stated history of CVA
5. HTN
6. Hyperlipidemia
7. "Adrenal tumor"
8. history of DVT ( 1990 )
9. history of PE
10. Fibromyalgia
11. Anxiety disorder
12. Anemia of unknown etiology
13. DM2 - diet controlled since bariatric surgery
14. Hypothyroidism
15. history of Gastric bypass ( 4/9 )
16. history of Hysterectomy ( 1990 )
17. history of C-section
18. history of CCY
19. history of multiple abdominal hernia repairs
20. history of UTIs
21. Chronic pain treated with narcotics
22. Peripheral neuropathy
23. Herniated Disk
24. Osteoporosis
25. Carpal tunnel syndromes in both hands
26. Cervical spondylosis
****
MEDS: Isosorbide 30 mg orally three times a day , Levothyroxine 50 mg orally every day , Lisinopril 2.5
mg orally every day , Lipitor 20 mg orally every day MS contin 30 four times a day , Senna , Colace , Dig
0.125 every day , Plavix 75 mg orally every day , Lasix 40 mg orally every day , Toprol XL
12.5 mg orally every day , Xanax 1mg five times a day , Percocet 2 every 4 hours , Nexium
****
ALL: PCN- anaphylactic shock , Paxil-feels underwater ,
Toradol-vomiting , Motrin- bleeding , Wellbutrin-rash , Macrolides-rash ,
Dyazide-dyspnea , Gabapentin-alopecia , NSAIDS - GI
upset SH: 40 pack year history of tobacco. Quit approx 9 mos
ago. No EtOH. Lives with daughter. Family History: Mother died of
GIB ( patient with no further details ). Sister and brother with UC. 2
sisters died of an MI , first at 47.
****
PE: Well appearing. No distress 98 77 160/80 16 98% RA , HEENT:
PERRL , EOMI , JVP 6. COR: RRR S1 , S2 nl. 1/6 SM @
LUSB RESP: Coarse BS bilaterally. No wheezes , rhonchi.
ABD: Obese , BS present , Soft , NT , ND guaiac neg ( in ED ) , midline ventral
hernia that is soft , mobile , slightly tender , EXT: WWP.
1+pitting edema LLE>RLE. +Erythema , warmth bilateral LLE.
****
LABS: neg enzymes x2 , UA neg , hct 29.3 with MCV 87.4 , dig 0.6.
ECG: NSR , unchanged from prior CXR: no acute process
****
A: 58 year-old F with CAD history of MI with recurrent episodes of non-ischemic
chest pain. Doubt dissection , doubt ischemia and doubt active LE
cellulitis. P:
1. CV: I: complete r/o with enzymes x2 , no stress eval req. Cont ASA ,
plavix , statin , isosorbide , bb.
2. HEME/ID: doubt cellulitis or DVT , most c/with stasis changes 2/2 chronic
LE edema. Low hct , though with in baseline , guaiac neg in ED.
3. GI: known gastro-jejunal ulcer on EGD 6/10 , guaiac neg now but could
be intermittently bleeding given history of dark stools. May benefit from repeat
EGD. Continuing Plavix and ASA given CVA , CAD and no clear evidence of
bleeding.
3. PSYCH: cont MS contin , Xanax and psych meds - may benefit from outpt
Psych evaluation.
4. FEN: cardiac diet , lyte scales
5. PPX: ppi , lovenox
ADDITIONAL COMMENTS: Keep legs elevated whenever possible
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. GI follow-up to consider repeat EGD to evaluation Ulcer. Holding
Plavix for now.
2. Surgery follow-up to consider surgical management of ventral hernia.
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( RQ87 ) 7/1/06 @ 02:07 PM
****** END OF DISCHARGE ORDERS ******
Document id: 208
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
Y |
N |
N |
- |
N |
- |
Y |
N |
N |
- |
- |
N |
N |
631556849 | PUO | 86885928 | | 2632645 | 4/2/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/28/2006 Report Status: Signed
Discharge Date:
ATTENDING: BOHANAN , SHEA M.D.
PRIMARY CARE PHYSICIAN: Kristian Maglione , NP
SERVICE: DMCO
PRINCIPAL DIAGNOSIS: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Ms. Thivener is a 49-year-old woman
with a history of CHF , COPD on 3 to 4 liters at home , CAD , status
post CABG , PE with a recent admission for cellulitis complicated
by hypoxic respiratory failure requiring intubation as well as
recent admission for shortness of breath and fluid overload
complicated by PE while anticoagulated leading to a pulseless
electrical activity. The patient was also admitted to PUO from
5/15/06 to 07 for respiratory distress again with fluid
overload requiring diuresis. The patient was discharged to the
De Pike Hospital . On the day of admission , the patient
complained of burning chest pain and shortness of breath
different from her previous cardiac chest pain. The patient also
notes that she did not feel well.
REVIEW OF SYSTEMS: Positive for chest pain , shortness of breath ,
no palpitations , no neck , jaw or back pain , no nausea or
vomiting , no dizziness , positive body swelling and positive
20-pound weight gain over one month.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg orally daily.
2. BuSpar 10 mg orally three times a day
3. Lasix 120 mg intravenous twice a day
4. Metazolone 2.5 mg orally twice a day
5. Colace 100 mg orally twice a day
6. Prozac 20 mg orally daily.
7. Methadone 10 mg orally daily.
8. Lopressor 12.5 mg orally three times a day
9. Senna two tablets orally twice a day
10. Verapamil 40 mg orally three times a day
11. Coumadin 33 mg at bedtime.
12. Multivitamin.
13. Folate.
14. Zocor 40 mg orally at bedtime.
15. K-Dur 80 mg orally three times a day
16. OxyContin 10 mg orally at bedtime.
17. Seroquel 300 mg at bedtime.
18. DuoNeb as needed
19. Albuterol as needed
20. Protonix 40 mg orally daily.
21. Insulin Aspart sliding scale.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is homeless , but occasionally lives
with family. No tobacco history. Positive ETOH. Positive
addiction , methadone.
PHYSICAL EXAM ON ADMISSION: Vital signs stable. Cardiac ,
irregularly irregular. No murmurs , gallops or rubs. Pulmonary ,
bibasilar crackles and wheezes. Abdomen , firm , distended ,
nontender , no rebound or guarding. Lower extremities , edematous.
ASSESSMENT AND PLAN: A1 49-year-old woman with a history of CHF ,
COPD , CAD , status post CABG , status post PE with CHF exacerbation
complicated by acute renal failure , hyperkalemia and UTI.
PLAN:
1. Cardiovascular: Ischemia. Because of the patient's new
onset of CHF , she was ruled out for MI shortly after admission.
Serial enzymes and EKGs were negative for ischemia. The
patient's chest pain , however was not consistent with the
patient's usual cardiac pain. During her stay , the patient was
maintained on an aspirin , beta-blocker and a statin , although the
chest pain was gone on arrival to the ED. Throughout the three
months of the patient's stay , she did experience similar burning ,
substernal chest pain. EKGs and enzymes sent during these
episodes were always negative for ischemia. It was felt that
this pain was likely secondary to GERD , as it often responded to
Maalox , benzo , lidocaine and/or food.
2. Pump: The patient's primary symptoms of shortness of breath
likely due to fluid overload. The patient was diuresed with intravenous
Lasix on the medicine floor. However , on 10/22/06 , the patient
experienced somnolence , low respiratory rate and desaturations in
the setting of opioid administration for pain. The patient
responded partially to Narcan and was transferred to the CCU for
three days for increased monitoring and continuation of diuresis
with a goal of negative 2 liters per day. The patient was
transitioned off methadone and on to oxycodone as needed The
patient was maintained on BiPAP and given albuterol and DuoNeb
inhalers. She passed through this acute decompensation with no
further complications and was transferred back to DMCO on
7/7/06 . On the floor , the patient was transitioned to orally
Lasix. She was diuresed with a goal of 1 to 1.5 liters per day.
intravenous Lasix were administered as needed shortness of breath/physical
exam consistent with fluid overload. One week prior to transfer ,
the patient was transitioned back to intravenous Lasix as her daily output
had slowed on orally Lasix , she was unable to make TBB goals. On
transfer , the patient shows signs of fluid overload , lower
extremity edema at bedtime BiPAP requirement , but relatively
while pulmonary compensation. The patient's dry weight is about
200 pounds.
3. Rhythm: The patient has a history of afib. She was rate
controlled with Lopressor and verapamil. She was also
anticoagulated for both her afib and a recent PE with an INR goal
of 2 to 3. Rate control was obtained with the beta-blocker and
calcium channel blocker. During the stay , the patient's heart
rate is often slightly faster than goal ranging in the 90s to
110s. Further rate control is limited by the patient's BP with
systolics often in the 90s to 100s. The patient was begun on
verapamil , which was titrated up with her beta-blocker , which was
titrated down. On transfer , the patient was on verapamil 60 mg
orally three times a day and atenolol 70 mg orally daily.
4. Pulmonary: The patient's pulmonary issues as described
above. The patient also has a history of PE and COPD/asthma.
Post MICU , the patient was maintained on 4 to 5 liters oxygen by
nasal cannula and during the day with BiPAP at nighttime. The
patient's O2 requirement remained stable until transfer , although
requiring albuterol nebs as needed The patient was kept on Coumadin
for PE with an INR goal of 2 to 3.
5. Renal: The patient's baseline creatinine was 0.8. On
admission , the patient had ARF felt to be due to CHF/volume
overload leading to poor cardiac output , decreasing perfusion to
the kidneys. As the patient was diuresed , her renal function
improved. This was stable throughout her stay until 10/24/06
when her creatinine began to rise. It was felt that this was due
to a combination over diuresis leading to a prerenal state. No
medication changes have been made near that time except for Lasix
orally to intravenous. In the setting of creatinine bump , Lasix and
spironolactone were discontinued on 10/12/06 . On 10/25/06 , Lasix
20 intravenous daily was restarted because of an improving creatinine , but
again held when creatinine returned as 1.5. On transfer , the
patient not on Lasix secondary to creatinine bumps/ARF. We did
not hydrate but monitor creatinine and continue diuresis when
able. Likely prerenal secondary to intravascular depletion
caused by liver cirrhosis leading to poor intravascular
albumin/osmotic pressure. In the setting of discontinuing of
Lasix and poor renal function , the patient did become
hyperkalemic x2 during the week of transfer. The patient did not
initially respond to Kayexalate and lactulose , as she did not
have a bowel movement likely due to opioid use. The patient did
respond to insulins and D50. On 5/30/06 , the patient again had
the elevated potassium to 5.5 , Kayexalate and lactulose x2 ,
produced two bowel movements lowering her K appropriately.
6. ID: During the stay , the patient was treated for UTI with a
three-day course of levofloxacin. Upon discharge , the patient
was asymptomatic.
7. GI: The patient was known to have vascular ectasias in her
stomach. The patient is still guaiac positive during her stay
with no active bleeding. Complicating this is the patient's need
for anticoagulation secondary to recent PE and afib. This is
felt to be the cause of her slowly dropping hematocrit for which
she required occasional weekly transfusions of packed red blood
cells. The patient on a PPI twice a day The patient also has
cirrhosis leading to poor synthetic function , poor intravascular
osmotic pool contributing to fluid overload.
8. Heme: As above , the patient required several transfusions of
TIBCs , although no more than once every one to two weeks. Felt
due to slow GI losses.
9. Endocrine: During the patient's stay , she was on a basal
Lantus with Aspart coverage. This was titrated up to achieve
good glycemic control. On discharge , the patient was on Lantus
42 units subcutaneously at bedtime and Aspart 10 units before meals/bedtime with an
Aspart sliding scale. This achieved fingerstick glucoses of 120s
to 160s.
10. Psych: The patient has a history of addiction and came to
PUO on methadone. During the patient's stay , methadone was
tapered and the patient transitioned to oxycodone. The patient
often complained of back pain and burning foot pain felt to be
neuropathy , which was relieved by opioids. The patient often
refusing NSAIDs. On transfer , the patient was on oxycodone 5 to
10 mg orally every 6 hours as needed pain , often taking 10 mg x4 a day. The
patient also complaints of anxiety and insomnia for which 0.5 mg
of Ativan achieved good resolution. At transfer , the patient was
not on standing Ativan just requiring occasional one-time orders
at bedtime. Neurontin was also titrated up during the patient's
stay. Finally , the patient was started on nortriptyline at
bedtime for pain with good effect.
PHYSICAL EXAM ON DISCHARGE: The patient was alert and oriented
x3 sitting up in a cardiac chair , able to walk to the bathroom
unassisted. Off of O2 , although does experience mild shortness
of breath. Pupils equal , round and reactive to light and
accommodation. Extraocular movements intact. Cardiovascular ,
irregularly irregular with no murmurs , gallops or rubs.
Pulmonary , faint bibasilar crackles and no wheezes. Abdomen ,
distended and nontender. Extremities , warm , well perfused with
dressings on the lower calf , which are clean , dry and intact.
Neuro , cranial nerves II through XII grossly intact. Strength
5/5 throughout with no sensory deficits.
MEDICATIONS ON DISCHARGE:
1. DuoNeb every 6 hours as needed shortness of breath/wheezing.
2. Aquaphor topical daily.
3. Atenolol 25 mg orally daily.
4. BuSpar 10 mg orally three times a day
5. Digoxin 0.0625 mg orally daily.
6. Duloxetine 60 mg at bedtime.
7. Nexium 40 mg orally twice a day
8. Neurontin 300 mg twice a day and 600 mg at bedtime.
9. Ibuprofen 100 mg orally every 6 hours as needed pain.
10. Insulin Aspart 10 units subcutaneously , before meals plus sliding scale.
11. Lantus 42 units subcutaneously at bedtime.
12. Lactulose 30 mL orally four times a day
13. Maalox liquid maximum strength 10 to 20 mL orally every 6 hours
as needed upset stomach.
14. Reglan 10 mg orally four times a day as needed nausea.
15. Miconazole nitrate 2% powder topical twice a day
16. Nortriptyline 25 mg orally at bedtime.
17. Oxycodone 5 mg orally every 6 hours as needed pain.
18. Seroquel 3000 mg orally every afternoon
19. Sarna topical daily.
20. Verapamil 60 mg orally three times a day
21. Coumadin 3.5 mg orally every afternoon
TO-DO PLAN: To accepting MD.
ACTIVE ISSUES:
1. Fluid balance. The patient is still volume overload with a
baseline weight at 200 pounds , however , the patient
intravascularly dry likely secondary to cirrhosis. Discharge
diuresis was limited by acute renal failure likely prerenal. The
patient has received packed red blood cells for a low hematocrit
and for colloid fluid resuscitation. The patient responds to
Lasix 40 mg intravenous or 80 mg orally Please continue when renal function
improves.
2. Electrolytes. The patient hyperkalemic twice this week
secondary to poor urine output and acute renal failure , responds
to lactulose and K. The patient's EKG was unchanged.
3. GI bleed. The patient has vascular ectasias in her GI tract ,
however , she is on Coumadin for afib and PE. She is on Nexium 40
mg orally twice a day and her stools are guaiac positive.
4. Heme. The patient has a slowly dropping crit , might be
secondary to the slow GI bleed. Transfused with a goal
hematocrit greater than 25. Her INR goal is 2 to 3.
5. Physical therapy has worked with the patient and she is able
to get out of bed to the bathroom by herself , though slowly.
6. Pulmonary. The patient is on BiPAP at night , able to secure
facemask on by herself. She is on 4 to 5 liters of nasal cannula
during the daytime , though she often takes , but removes the
oxygen.
7. Psych/Pain: The patient is on oxycodone at minimum , has
received 10 mg x3 a day , now at 4 to 5 per day. The patient is
full code.
eScription document: 2-0927787 CSSten Tel
CC: Kristian Maglione NP
Ryscent Medical Center
CC: Talitha Boynes M.D.
Lu Ant Wood
CC: Shea Bohanan M.D.
Rie Di
Dictated By: BOYNES , TALITHA
Attending: LATORIA OGDEN , M.D. JH54
Dictation ID 4047032
D: 10/29/06
T: 10/29/06
Document id: 209
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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509221029 | PUO | 25145895 | | 791130 | 5/22/2001 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/14/2001 Report Status: Signed
Discharge Date:
PRINCIPAL DIAGNOSIS: HEART FAILURE.
SECONDARY DIAGNOSES: 1. AORTIC INSUFFICIENCY.
2. VALVULAR CARDIOMYOPATHY.
3. MITRAL REGURGITATION.
4. TRICUSPID REGURGITATION.
5. HYPERTENSION.
6. HEMOLYTIC ANEMIA.
7. CHRONIC RENAL INSUFFICIENCY.
HISTORY OF PRESENT ILLNESS: This is a 50-year-old man with
valvular cardiomyopathy , status post
three aortic valve replacements , who presents with no acute
complaints but a progressive decline in daily function.
Mr. Yantis history begins in 9/13 when he presented with
shortness of breath , dyspnea on exertion and orthopnea in the
setting of medications ( Lasix and/or Procardia for hypertension )
noncompliance. He was found by echo to have severe aortic
insufficiency with moderate mitral regurgitation , left ventricular
hypokinesis and an ejection fraction of 45%. He subsequently
underwent aortic valve replacement along with a mitral valve
repair. Aortic valve pathology showed myxomatous degeneration.
One month post-surgery , he required repeat aortic valve replacement
with dehiscence and was documented to have an annular abscess with
cultures positive for yeast , for which he was treated with
amphotericin-B , vancomycin and gentamicin. At this time , he also
required coronary artery reimplantation and annular repair. This
hospital course was additionally complicated by development of
third degree heart block necessitating the implantation of a
permanent pacemaker. After discharge , Mr. Nemani did generally
well for the following years until 9/4 , when he again presented
with increasing shortness of breath. Echo then revealed moderate
to severe aortic insufficiency and moderate mitral regurgitation.
Cardiac catheterization showed clear coronary arteries. At this
time , his aortic valve was again replaced with a St. Jude's valve.
Again , following discharge , Mr. Nemani did generally well until
4/19 when again he presented with shortness of breath. At that
time , echo showed at least mild perivalvular aortic regurgitation
with left ventricular dilatation ( The systolic diameter of 6.1 cm ) ,
along with 1+ mitral regurgitation , 2+ tricuspid regurgitation , and
an ejection fraction of 15-20%. Stress testing at this time showed
a physical work capacity of 15.1. It is not documented what was
done at this time , but apparently his Lasix was increased from
40 mg twice a day to 80 mg twice a day with good effect. Regarding this
admission , Mr. Nemani reports that he has been feeling fine and is
here in the hospital because his doctors want to replace his valve ,
or if that doesn't work as it hasn't the last three times , to give
him a new heart all together. He reports no increasing dyspnea ,
fatigue , ankle edema or abdominal girth. He sleeps on three
pillows at night and has not recently been short of breath when
lying flat. He is able to do chores around the house without
getting short of breath , but usually does get short of breath after
one flight of stairs. He doesn't complain of significant
disability or quality of life impairment as a result of his heart
condition. He notes that he has not been able to participate in
the marching band over the last year , but that he can play sitting
down. Mr. Nemani attributes his disease to having been
noncompliant with his Procardia following the cerebrovascular
accident in 1993. He says that , "He brought on his heart problems
himself."
PAST MEDICAL HISTORY: Otherwise , notable for an embolism to his
left foot in 1998 as a result of having
stopped Coumadin therapy , chronic renal insufficiency with
creatinine ranging from 1.4-2.2 in 2/12 , and he is status post
exploratory laparotomy in 1960 from a gunshot wound.
ALLERGIES: He is allergic to Zestril , which gives him perioral
angioedema.
MEDICATIONS: Lasix 80 mg twice a day , atenolol 50 mg every day , Avapro
150 mg every day , Coumadin 5 mg every day , Zantac 150 mg
twice a day , Niferex 150 mg every day
FAMILY HISTORY: His family history is negative for heart disease.
SOCIAL HISTORY: He has a 35 pack-year smoking history , but quit
one year ago. He has occasional alcohol use.
Mr. Nemani is on permanent disability leave from his job at
Angeles Ny Ral , which involved a lot of heavy lifting. He lives at home
with his wife and 19-year-old son , and spends most of his day
there. He is active in Harcmatche Pkwy. , where he likes to play the base
drum.
PHYSICAL EXAMINATION: GENERAL: He is a thin , healthy-appearing
black man in no apparent distress. VITAL
SIGNS: Heart rate 65 , blood pressure 120/70 , oxygen saturation 98%
on room air. NECK: His carotid pulses variance and normal in
volume. Jugular venous pressure 7 cm. LUNGS: Clear. His PMI is
vibratory in quality and prominent , lateral to the anterior
axillary line. He has a normal S1 , an ejection sound , and a loud
prosthetic S2 , a III/VI systolic murmur at the right upper sternal
border , and a III/intravenous holodiastolic murmur at the left lower sternal
border radiating to the right upper sternal border. ABDOMEN:
Non-distended , with no organomegaly. EXTREMITIES: Warm with faint
pulses.
LABORATORY DATA: Remarkable for a creatinine of 2.3 , hematocrit
33.5 , with a MCV of 83.5 , RDW of 28.8 ,
reticulocyte count of 6.6 and LDH of 1077. Mr. Nemani had an echo
here that showed severe aortic insufficiency with a severely
dilated left ventricle ( and diastolic diameter of 7.0 and systolic
diameter of 6.3 ) , as well as mild to moderate mitral and tricuspid
regurgitation and an ejection fraction of 20-25%. Exercise testing
showed an oxygen uptake of 12.7. On cath , his pulmonary artery
pressure , wedge pressure and pulmonary vascular resistance was
47/16 , 13 and 379 , which fell to 26/4 , 5 , and 137 , respectively
with Nipride. His systemic vascular resistance was markedly
elevated at 2400 and a thick cardiac output and cardiac index were
3.62 and 2.31. Amlodipine was then started and Lasix was increased
in an effort to reduce his systemic vascular resistance and
pulmonary wedge pressure. The remainder of the transplant workup
results were unremarkable except for a significantly reduced
diffusing capacity of 59% corrected , a creatinine clearance of 48.4
and a prostate specific antigen of 18.1. Prostate biopsy and bone
scan were both negative. His admission was otherwise notable for
an elevated creatinine to 3.0 in the setting of perioperative
levofloxacin and gentamicin , as well as aggressive vasodilator
therapy. He was allowed to drift back down to his baseline of low
2's before discharge.
Mr. Nemani was discharged home in stable condition on the following
medications:
DISCHARGE MEDICATIONS: Atenolol 25 mg every day , Lasix 120 mg twice a day ,
Coumadin 5 mg every day , amlodipine 2.5 mg every day ,
Avapro 150 mg every day , Niferex 150 mg every day , ranitidine 150 mg twice a day
DISCHARGE FOLLOW-UP: He will follow-up with Dr. Mathew Stautz in
two weeks.
Dictated By: ETTA SIX , M.D.
Attending: LEOLA C. MUSICH , M.D. RF92 EB738/801999
Batch: 01917 Index No. RJUDKV45S8 D: 6/13/01
T: 6/13/01
CC: 1. ROCHELL TYNDALL , M.D.
2. MATHEW STAUTZ , M.D.
Document id: 210
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
- |
N |
N |
- |
N |
N |
Y |
N |
Y |
N |
430667193 | PUO | 00488711 | | 846171 | 1/20/1999 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 10/10/1999 Report Status: Unsigned
Discharge Date: 4/13/1999
PRINCIPAL DIAGNOSES: 1 ) CORONARY ARTERY DISEASE.
2 ) MITRAL REGURGITATION.
PROCEDURE: CORONARY ARTERY BYPASS GRAFT TIMES FOUR AND MITRAL
VALVE REPAIR ON January , 1999 BY DR. ISABELLE COLASAMTE .
HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old woman who
was a patient on the Medicine Service ,
admitted on April , 1999 for cardiac evaluation prior to renal
transplant. She had known end stage renal disease. She was
dialysis dependent since 1995 except for two years between 1997 and
1999 , through which time she had a prior transplant. In addition ,
she has hypertension , diabetes mellitus times 22 years , insulin
dependent , status post cardiac arrest from hypercalcemia in 1999 ,
peripheral vascular disease and claudication and a known
echocardiogram showing an ejection fraction of 30%. She has a
history of atrial flutter controlled on Amiodarone. At the present
time , a cardiac catheterization performed on April , 1999 showed
left main disease tapering at 40% , LAD disease at 40-45% in the mid
vessel , circumflex disease at 60% proximally and 70-80% in the mid
vessels and right coronary artery proximal to middle disease at
40-60%. An Adenosine MIBI on May , 1999 showed evidence of an
old infarct inferolaterally with severe ischemia elsewhere.
Echocardiogram here at this institution showed an ejection fraction
of 40% with global hypokinesis and severe lateral hypokinesis with
2+ mitral regurgitation.
PAST MEDICAL HISTORY: As above , end stage renal disease since
1995 , status post transplant in 1997 with
rejection in 1999 , status post fistula in the right arm , insulin
dependent diabetes mellitus times 21 years with chronic renal
insufficiency and diabetic retinopathy , status post laparoscopic
cholecystectomy , status post dilatation and curettage , coronary
artery disease as above.
MEDICATIONS ON ADMISSION: 1 ) Cozaar 50 mg orally every day. 2 )
Prilosec. 3 ) Amiodarone 200 mg orally q.
day. 4 ) Insulin sliding scale. 5 ) Lopressor 25 mg orally twice a day
PHYSICAL EXAMINATION: On physical examination , she is afebrile
with hemodynamics normal on room air. She
is a well appearing , swollen , obese woman in no acute distress.
She had normal dentition. She had no carotid bruits and no jugular
venous distension. Chest is clear bilaterally without rales.
Heart is regular with a two out of six systolic ejection murmur and
no gallops. Abdomen is obese , benign with a left lower quadrant
incision , status post transplant nephrectomy. Peripheral vascular
examination demonstrates palpable radial and axillary pulses , 1+
palpable femoral pulses and a barely palpable dorsalis pedis and
posterior tibial pulses , both of which were monophasic doppler
signals.
LABORATORY: Preoperative creatinine pre-hemodialysis was 6.7 and
hematocrit was 34.1.
HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery
Service from the Medicine Service on January ,
1999 after she underwent a coronary artery bypass graft times four
and mitral valve repair. The patient tolerated the procedure well
and was transferred to the cardiac surgery intensive care unit for
postoperative care. She underwent dialysis on postoperative day
number one and was extubated after dialysis with a clearing of her
anesthetic medications and paralytic indications. She required
some inotropic support in the immediate postoperative period. She
was gradually weaned from her pressure requirement after
extubation. Coumadin was begun given her history of mitral valve
repair. Nutrition was consulted for lack of appetite. She did
well on her dialysis and was transferred to the floor on
postoperative day number four. Echocardiogram was obtained which
was normal. The patient had an otherwise unremarkable
postoperative course which was somewhat slower than average based
on her severe medical problems and need for dialysis. Her chest
tubes were discontinued on postoperative day number three as well
as her epicardial wires without problems. At the time of discharge
dictation , she is ambulating independently , tolerating a renal diet
on no supplemental oxygen.
FOLLOW-UP: The patient will follow-up with Dr. Colasamte in six
weeks. She will follow-up with her cardiologist in one
to two weeks and she will follow-up with the Renal Team in one to
two weeks.
MEDICATIONS ON DISCHARGE: 1 ) Colace 100 mg orally twice a day 2 )
Lopressor 25 mg orally twice a day 3 )
Coumadin to be dosed based on the recommendations of her Coumadin
Service with a goal INR of 2.0 to 2.5. 4 ) Celebrex 100 mg orally
twice a day which was added by another physician.
Dictated By: FRANCISCA A. URBANIAK , M.D. EZ60
Attending: ISABELLE COLASAMTE , M.D. KU4 CT735/4018
Batch: 15077 Index No. OHEA73DSY1 D: 9/29/99
T: 9/30/99
Document id: 211
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
- |
Y |
Y |
- |
N |
Y |
Y |
Y |
N |
- |
426587352 | PUO | 72105976 | | 8848596 | 9/13/2005 12:00:00 a.m. | DEHYDRATION , NEUTROPENIC , LUNG CANCER | Signed | DIS | Admission Date: 11/26/2005 Report Status: Signed
Discharge Date: 10/26/2005
ATTENDING: COHENS , ANGELINE VICKI MD
PRINCIPAL DIAGNOSIS: Urosepsis.
LIST OF PROBLEMS AND DIAGNOSES: Diabetes , obesity , severe COPD ,
obstructive sleep apnea , hypercholesterolemia , anemia , colonic
polyps , uterine fibroids , gastrointestinal bled , neutropenic
enteritis , nonsmall cell lung cancer , chronic renal
insufficiency , status post appendectomy , gout , and
osteoarthritis.
BRIEF HISTORY OF PRESENT ILLNESS: For further details please see
the chart. The patient is a 64-year-old female with multiple
medical problems including severe COPD , ( on home O2 2 liters
baseline sat below 90s ) , nonsmall cell lung cancer , diagnosed in
1999 status post multiple chemotherapy regimens , most recently
ALIMTA from 9/27/2005 to 09 , diabetes , obesity , and
chronic renal insufficiency , who was admitted to MICU on
11/26/2005 for neutropenia , nausea , vomiting , abdominal pain ,
shortness of breath , requiring intubation , hypertension , prerenal
azotemia with a creatinine of 2.9; all of which are believed to
be secondary to sepsis.
MEDICATIONS ON ADMISSION: Included Avapro , Lipitor , Decadron ,
ranitidine , Humalog , allopurinol , Alimta , Flonase , vitamin D ,
B12 , and Colace.
ALLERGIES: Bactrim , resulting in acute renal failure and
hyperkalemic , and penicillin resulting in anaphylaxis.
SOCIAL HISTORY: Pertinent for the fact that she lives at home.
She has a remote history of smoking , quit 15 years ago , and
denies alcohol.
FAMILY HISTORY: Pertinent for hypertension , stroke , thyroid
cancer , and cervical cancer.
FINDINGS ON ADMISSION PHYSICAL EXAMINATION: Shows a temperature
of 98.9. pulse of 116 , and blood pressure 84/47 , and 96% on
ventilation. General exam: She is an obese female , intubated
and awake , motioning to take her tube out. Skin exam showed
scattered group petechial areas over the torso , abdomen , and
under the right breast. HEENT Exam shows pupils equal , round ,
and reactive and anicteric , with a normal JVP. Pulmonary exam
shows decreased mildly decreased breath sounds at the right base.
No crackles , increase in expiratory phase , few scattered rales.
Cardiac exam shows tachycardia otherwise regular rhythm. A 2/6
systolic murmur across precordium. Abdomen is soft , obese ,
positive bowel sounds , nontender , and nondistended with chronic
skin changes below the pannus. Extremities show trace to 1+
edema to the shins , with 2+ dorsalis pedis pulses bilaterally.
Neurologic , the patient is awake; however , the exam is otherwise
difficult to perform secondary to the patient being intubated.
PERTINENT LABS ON ADMISSION: Show a white count of 0.74 with 46%
polys and 6% bands , resulting in an absolute neutrophil count of
340 , a hematocrit of 26.2 , and platelets of 37. Creatinine of
3.1 , a PTT of 83.5 and INR of 1.4 , and lactic acid of 1.4.
Chest x-ray on admission shows right infrahilar mass , bibasilar
opacities , with chronic alveolar disease versus new fusions , I
cannot rule out infiltrate. Abdominal CT shows small bowel wall
thickening and left-sided atelectasis versus pneumonia.
PROCEDURES: Status post intubation and extubation.
HOSPITAL COURSE BY PROBLEMS:
1. Infectious disease: Ms. Balzano was admitted with fever and
hypertension , and I was concerned for sepsis , I initially thought
nosocomial pneumonia versus GI as the primary source. She
required intubation and pressors , and was started on vancomycin ,
Levaquin , and aztreonam along with Flagyl empirically. Her urine
grew Enterococcus and she was changed to Levaquin only on
6/21/2005 to treat an enterococcal UTI and possible nosocomial
pneumonia. An abdominal CT was obtained , which shows small bowel
wall thickening and injection of the SMA territory concerning for
a neutropenic enteritis. Surgery was consulted and she was
managed conservatively with antibiotics initially and then with
bowel rest. She is no longer neutropenic and was off Neupogen
over a week prior to discharge. She was afebrile over the last
week and will stay and finish the 14-day course of Levaquin for
UTI.
2. GI: Ms. Balzano was treated with bowel rest for her neutropenic
enteritis and once she was no longer neutropenic without
abdominal pain , she was started on clear liquid diet. However ,
she developed intermittent GI bleed , secondary to likely
sloughing of her mucosa status post neutropenic enteritis. GI
was consulted and she was again placed on bowel rest. Though ,
she has a history of colonic polyps , GI also felt that the
culprit of her GI bleed is mucosal sloughing as well. She
continued to have intermittent episodes of bloody diarrhea
whenever she was re challenged with orally intake. Her C-diff is
negative. Colonoscopy was deferred secondary to
thrombocytopenia. She required multiple red blood transfusions
to maintain her hematocrit greater than 26 , though she was never
hemodynamically unstable. Finally , after given sustained bowel
rest , her blood stools resolved , and she was able to tolerate
orally contrast and an abdominal CT on 9/6/2005 showed no small
bowel wall thickening or any other intraabdominal process causing
her symptoms. Her diet was advanced , and she was tolerating
regular diet at the time of discharge without problems.
3. COPD: On home O2 , typically requiring 2 liters with baseline
sat over 90s. Ms. Balzano was intubated on admission for increased
shortness of breath and hypoxia. She was extubated the following
day on 8/22/2005 . She requires BiPAP nightly , now stable on 2
to 4 liters nasal cannula during the day.
4. Heme: On chemotherapy induced anemia with hematocrit drop on
admission to 21 from the baseline of around 26. She responded
well initially to three units of packed red blood cells over
10/18/2005 and 09 . However , in the setting of her GI
bleed from a sloughing mucosa secondary to resolving neutropenic
enteritis and recent chemo , she required multiple further RBC
transfusions to keep her hematocrit greater than 30. She was
also thrombocytopenic , status post chemo and required multiple
platelet transfusions to keep her platelets greater than 30 , 000.
Hematology was consulted secondary to suboptimal busted platelet
levels status post transfusions , which was felt to be secondary
to poor marrow response in the setting of recent chemo ( workup
was negative for other possible causes refractory
thrombocytopenia , nystatin , allopurinol , were held given possible
worsening of her thrombocytopenia ). On discharge her hematocrit
and platelets were stable respectively at 29.8 and 46 , 000 and she
had not required a transfusion in greater than 24 hours prior to
discharge.
5. Acute on chronic renal failure: The patient's baseline
creatine is 1.7; however , on admission it was noted to be 3 ,
likely secondary to hypovolemia from vomiting and diarrhea ( FENa
was 0.22% ). Her creatinine is now back to baseline with
hydration. Her creatinine was 1.1 prior to discharge.
6. Nonsmall cell lung cancer: The patient is on Alimta started
for her neutropenia , which has since resolved. She will follow
with her oncologist Dr. Angeline Cohens for further therapy.
7. Endocrine: Because of her insulin-dependent diabetes , the
patient was placed on portland protocol while on the stress dose.
Steroids were discontinued on 6/21/2005 and she passed a
cortisol stimulation test on 6/21/2005 as well. She was changed
to standing insulin on 6/21/2005 and her Lantus was up titrated
along with sliding scale insulin to maintain blood sugars in the
80s to 120s. She will return home on her home regimen.
8. FEN: TPN was started on 10/4/2005 , given her bowel rest for
possible neutropenic enteritis. She restarted orally intake on
10/16/2005 and tolerated advancement to diabetic diet , and she
was weaned off her TPN prior to discharge.
CONSULTANTS: General Surgery , Hematology , and Gastroenterology.
PHYSICAL EXAMINATION AT DISCHARGE: Vital signs: T max 98 , blood
pressure 120/60 , pulse 88 , and respirations 20 sating at 95% on
3.5 liters of oxygen. General exam shows an obese female resting
and in no acute distress. Nasal cannula in place. HEENT Exam
was normocephalic , atraumatic. Pulmonary exam showed decreased
air entry , decreased breath sounds , but otherwise no obvious
wheezes or rhonchi. Cardiovascular exam shows regular rate and
rhythm , no murmurs , rubs , or gallops , but decreased heart sounds.
Abdominal exam shows an obese abdomen , nontender , nondistended ,
positive bowel sounds. Extremities show 1 to 2+ edema
bilaterally to the knee. Skin exam shows a area where left
internal jugular line was removed and the site is intact and
dressed. Improved erythema in her intertriginous areas.
Neurologic exam shows the patient is alert and oriented x3
without any focal neurologic deficits.
The patient was discharged in stable condition and she will
follow up with Dr. Angeline Cohens in one week.
The patient is full code.
DISCHARGE MEDICATIONS: Tylenol 650 to 1000 mg orally every 6 hours as needed
pain , headache , if fever is greater than 101 , Peridex mouth wash
10 mL twice a day , nystatin mouth wash 10 mL swish and swallow 4
x day as needed , oxycodone 5 mg orally every 6 hours as needed pain ,
simethicone 80 mg orally four times a day as needed gaseousness , trazodone 25 mg
orally at bedtime , miconazole nitrate 2% powder topical twice a day to
areas between skin folds including under the right breast , Nexium
20 mg orally daily , Lantus 30 mg subcutaneous daily , DuoNeb 3/0.5
mg Nebs every 3 hours as needed shortness of breath , aspart 4 units before
each meal subcutaneously , folate 3 mg orally daily , Avapro 150 mg
orally daily , meclizine 25 mg orally three times a day , Combivent 2 puffs
inhaled four times a day , vitamin D 125 0.25 mcg orally daily.
eScription document: 6-5119037 AFFocus
Dictated By: WOLFLEY , LUCRETIA
Attending: COHENS , ANGELINE VICKI
Dictation ID 5620294
D: 7/16/05
T: 2/16/05
Document id: 212
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
N |
Y |
N |
- |
Y |
Y |
Y |
N |
- |
Y |
Y |
N |
N |
961515206 | PUO | 47409541 | | 6202963 | 7/10/2004 12:00:00 a.m. | Atypical chest pain | | DIS | Admission Date: 7/8/2004 Report Status:
Discharge Date: 11/26/2004
****** DISCHARGE ORDERS ******
DEBNAR , LANITA 026-99-98-9
Y Sili Ri
Service: MED
DISCHARGE PATIENT ON: 3/6/04 AT 05:00 a.m.
CONTINGENT UPON Home services
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SHANNON , JULIANA O. , M.D. , PH.D.
CODE STATUS: No CPR / No defib / No intubation / No CPR / No intubation
/
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally every other day
Override Notice: Override added on 3/18/04 by SABER , SHONNA , M.D.
on order for COUMADIN orally ( ref # 11902405 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: will monitor.
Previous override information:
Override added on 3/18/04 by SABER , SHONNA , M.D.
on order for COUMADIN orally ( ref # 05676197 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: will monitor.
LASIX ( FUROSEMIDE ) 120 MG orally twice a day Starting Today ( 7/29 )
HOLD IF: SBP <100
Alert overridden: Override added on 9/16/04 by
RADEMAN , CAITLIN , M.D. on order for LASIX orally ( ref # 54228906 )
patient has a POSSIBLE allergy to SULFISOXAZOLE; reaction is
g6pd.
patient has a POSSIBLE allergy to G6PD Deficiency; reaction is
Unknown.
patient has a POSSIBLE allergy to Sulfa; reaction is G6PD
DEFICIENCY. Reason for override: patient takes at home
LEVOTHYROXINE SODIUM 25 MCG orally every day
Override Notice: Override added on 3/18/04 by SABER , SHONNA , M.D.
on order for COUMADIN orally ( ref # 11902405 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: will monitor.
Previous override information:
Override added on 3/18/04 by SABER , SHONNA , M.D.
on order for COUMADIN orally ( ref # 05676197 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: will monitor.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
TRAZODONE 50 MG orally HS as needed Insomnia
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 2/3 )
Instructions: QMWF Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 3/18/04 by SABER , SHONNA , M.D.
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor.
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 2/3 )
Instructions: QTTSS Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 3/18/04 by SABER , SHONNA , M.D.
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor.
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 3/18/04 by SABER , SHONNA , M.D.
on order for COUMADIN orally ( ref # 11902405 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor.
Previous override information:
Override added on 3/18/04 by SABER , SHONNA , M.D.
on order for COUMADIN orally ( ref # 05676197 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIOVAN ( VALSARTAN ) 120 MG orally every day
Number of Doses Required ( approximate ): 4
INSULIN LISPRO Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
HOLD IF: 1/2 doses while NPO
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LANTUS ( INSULIN GLARGINE ) 42 UNITS subcutaneously every day HOLD IF: Npo
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 150 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PROTONIX ( PANTOPRAZOLE ) 40 MG orally twice a day
PROCRIT ( EPOETIN ALFA ) 4 , 000 UNITS subcutaneously QWEEK
IRON ( FERROUS SULFATE ) 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Keetan 1-2 weeks ,
Dr. Sachiko Borriello 1-2 weeks ,
Arrange INR to be drawn on 1/6/04 with f/u INR's to be drawn every
3 days. INR's will be followed by KTDUOO clinic
ALLERGY: PERCOCET , METOCLOPRAMIDE HCL , SULFISOXAZOLE ,
Cephalosporins , G6PD Deficiency , Aspirin , Codeine ,
NALIDIXIC ACID , LESTRILL , intravenous Contrast , Penicillins ,
METRONIDAZOLE , AMITRIPTYLINE , LISINOPRIL , Sulfa , LIDOCAINE ,
TETRACYCLINES , clindamycin , CARROTS , CELERY
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Asthma HTN RAD G6PD DEF IDDM
history of ischemic colitis Arthritis DJD Allergic rhinitis Glaucoma
Bursitis history of appy , TAH , Zenker's divertic removal
hx dvt 1988 obstructive sleep apnea Diastolic Dysfunction gout ( gout )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
2-stage pharmacologic MIBI; echocardiogram
BRIEF RESUME OF HOSPITAL COURSE:
76 year-old AAF with mutiple med. problems including , DM2 , CAD ,
CHF( dystolic ) , HTN , CRI ( base 1.9 ) , ischemic colitis , DVT ,
hyperchol , gout , and G6PD who presents with 2 weeks of chest pain.
Describes pain( 8/10 ) as mid chest and b/l; feels like pressure.
Associated with numbness radiating down medial side of L arm. patient
reports Nitro helped and she has been taking 2 tabs every other
day. Exertion makes pain worse but it can happen at
rest.associated with naseua , cough ( + white sputum ) , DOE , orthopnea( 3
pillows ) , and PND. No weight gain or change in diet reported. has not
missed med doses. patient was at primary care physician today and given NGT tabs which did not
resolve all pain; sent to ER for eval. In ER , found to be stable; first
set of cardiac enzymes were wnl. EKG shows no changes. Pain improved
with more nitro in ER. Meds: PPI , lantus , lasix , lipitor , valsartan ,
procrit , levothy , toporol , SSI , imdur , NTG. coumadin , FE , allopurinol ,
trazadone. ALL: ASA , codine , metochloprazide , sulfas , clinda ,
penicillin , cephlasporins , metronidazole , lisinopril , amitryptline ,
lidocaine , tetracycline , carrots , celery , lestril , intravenous contrast.
PSH: Cath with no stent , append. Soc: No tobacco/etoh/drugs Fam Hx:
ext DM2 and HTN PE: vitals afebrile and stable , obese eld. female with
incr. JVP ( 9 cm ) , s3 , diffuse end exp wheezes at times , umb. hernia
and 3+ LE edema. Labs: Enzymes and EKG 3 negative
Hosptial course: 76 year-old AAF with mutiple medical problems including
extensive cardiac history who presents with worsening DOE and chest
pressure. Likely diastolic CHF although ischemic cardiac issues need
to be ruled out.
1. CV- pump:clinical picture c/with diastolic CHF. Echo 1/25 sho
wed EF 65% with mild concentric LVH. patient responded well to
Lasix 160mg intravenous twice a day with I/O goal of 1-2L neg /day. strict I/O , 2 g nasal
and 2L fluid restrict. patient's DOE significantly improved after
agressive diuresis. Lasix was changed to 120mg orally twice a day on d
ischarge. Ischemia-MIBI on 2/3 showed EF 70% ,
No wall motion abnormality. Normal RV function. No evidence of cardiac
ischemia. Rhythm: On tele. No significant arrhythmias.
2. Pulm- nebs as needed for wheezing though likely cardiac rather than
bronchospastic.
3. Renal- check lytes twice a day with diuresis.
4. GI- on PPI for GI protection.
5. Heme- Coumadin for A-fib. INR goal 2-3
6. Endo- cont lantus with SSI for DM2
7. Code: CAN defibrillate but no CPR , and DNI.
ADDITIONAL COMMENTS: If your symptoms recur or worsen , please seek medical care.
Avoid salt in your diet.
Please make followup appointments with Dr. Keetan and Dr. Borriello .
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1 ) Please schedule followup appointments with Dr. Keetan and Dr. Borriello
in the next 1-2 weeks. Please have blood test for chem7 and magnesium
and follow up the result with Dr. Cecere discuss with Dr. Keetan
about your Lasix dose which was increased during this hospital
admission..
No dictated summary
ENTERED BY: SABER , SHONNA , M.D. ( RG06 ) 5/21/04 @ 02:39 PM
****** END OF DISCHARGE ORDERS ******
Document id: 213
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
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Y |
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U |
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| output/system_intuitive_annotation.xml | intuitive |
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544406034 | PUO | 51709541 | | 2887002 | 2/3/2006 12:00:00 a.m. | AORTIC STENOSIS , MITRAL REGURGITATION , ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 2/3/2006 Report Status: Signed
Discharge Date: 10/4/2006
ATTENDING: MANKOSKI , ROSSIE MD
DISPOSITION:
To home with VNA service.
PRINCIPAL DISCHARGE DIAGNOSIS:
Status post MVP with 30 Cosgrove ring , AVR with a 25 CE and PFO
closure and MAZE.
OTHER DIAGNOSES:
Hypertension , diabetes mellitus type 1 , gout , paroxysmal atrial
fibrillation , prolapse mitral valve with moderate MR.
HISTORY OF PRESENT ILLNESS:
The patient is an 83-year-old male with past medical history
significant for insulin-dependent diabetes mellitus , paroxysmal
atrial fibrillation , severe aortic stenosis and moderate MR. His
symptoms also consisted of dyspnea on exertion. He states that
he gets short of breath walking on an incline after one to two
blocks. He has no angina , orthopnea , no neurologic symptoms.
Stress echo on 8/10/06 showed no evidence of ischemia but
importantly a fall in BP with exercise and was not able to go
beyond 2.5 minutes due to fatigue. Echo also demonstrated an
aortic stenosis with a neck area of 0.9 cm2 with a peak gradient
35 , mean of 21 , and a junctional moderate MR from myxomatous
prolapse. Cardiac cath at PUO on 3/4/06 showed single-vessel
CAD involving LAD. The patient was initially scheduled to
undergo AVR , plus MVP and MAZE on 1/26/06 . Preop chest x-ray
revealed pulmonary fibrosis and mild pulmonary edema , which was
also confirmed with CT of chest without contrast. PFTs were
suggestive of restrictive lung disease. Pulmonary service was
consulted and it is considered that the patient's fibrosis has
not progressed and that new chest x-ray changes may be likely due
to his interstitial pulmonary edema. It was suggested that the
risk of pulmonary complications after cardiac surgery would be
moderate. Carotid ultrasound showed 65-70% RCA occlusion , which
is asymptomatic. The patient is rescheduled for AVR , plus MVP
and plus MAZE on 5/5/06 .
PREOPERATIVE CARDIAC STATUS:
Elective. The patient presented with valve dysfunction with
history of class II heart failure. Recent signs and symptoms of
congestive heart failure included dyspnea on exertion/pedal
edema. The patient is in atrial fibrillation.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST SURGICAL HISTORY:
Multiple shoulder replacement revision , status post laminectomy ,
status post cholecystectomy , status post appendectomy , status
post inguinal hernia repair.
FAMILY HISTORY:
No family history of CAD.
SOCIAL HISTORY:
The patient lives at Arizona , has remote history
of smoking , quit 30 years ago. He is a social drinker. The
patient is retired manager of Daleton Jose Ni
ALLERGIES:
No known drug allergies.
PREOP MEDICATIONS: Toprol 25 mg daily , lisinopril 20 mg daily ,
digoxin 0.25 mg daily , aspirin 325 mg daily , Lasix 10 mg daily ,
allopurinol 100 mg daily , colchicine 0.6 mg daily , Colace 100 mg
twice a day , Neurontin 400 mg orally three times a day , potassium slow release 20
mEq , metformin 500 mg three times a day NPH 25 mg subcutaneously every day before noon and 12 units
subcutaneously every afternoon
PHYSICAL EXAMINATION:
Height and weight 5 feet 6 inches and 68 kilos. Vital signs:
Temperature 98.7 , heart rate 45 , BP right arm 135/90 and left arm
148/90. Oxygen saturation 92% on room air. HEENT:
PERRLA/Dentition without evidence of infection/no carotid
bruits/patient has dentures. Chest: No incisions.
Cardiovascular: Regular rhythm , harsh 3/6 systolic ejection
murmur. All distal pulses are intact. Allen's test left upper
extremity normal , right upper extremity normal. Respiratory:
Bibasilar crackles. Abdomen: No incisions , soft , no masses
palpable , abdominal aortic pulse with bruit. Extremities , 1+
bilateral lower extremity edema. RFA cannulation site without
bleeding or hematoma. Neuro: Alert and oriented , no focal
deficits.
LABORATORY DATA:
Chemistries: Sodium 131 , potassium 4.3 , chloride 97 , CO2 25 , BUN
16 , creatinine 1.2 , glucose 263 , magnesium 1.3 , BNP 236.
Hematology: WBC 8.61 , hematocrit 39.3 , hemoglobin 13.3 ,
platelets 176 , physical therapy 15.2 , INR 1.2 , PTT 29.3 , arterial blood gas
from 2/4/06 showed a pO2 of 136 , pH 7.46 , pCO2 36 , TCO2 of 26.
Base excess of 2. UA was normal. Carotid imaging , left internal
carotid artery less than 25% occlusion , right internal carotid
artery 65-70% occlusion. Cardiac catheterization data from
3/4/06 performed at PUO showed coronary anatomy , 25% ostial
LAD , 60% proximal D1 , 35% proximal circumflex , 40% osteal OM2 ,
50% distal RCA , 50% proximal RCA , right dominant circulation.
Ventriculogram showed 78% ejection fraction , hemodynamics PA mean
of 33 , PCW 19 , cardiac output 2.88 , and cardiac index 1.61. SVR
2420 and PVR 389. Echo from 8/10/06 shows 65% ejection
fraction , aortic stenosis , mean gradient 21 mmHg , peak gradient
35 mmHg , calculated valve area of 0.9 cm2 , trivial aortic
insufficiency , moderate mitral insufficiency , trivial tricuspid
insufficiency , and moderate pulmonic insufficiency , no regional
wall motion abnormalities , bileaflet and mitral valve prolapse.
EKG from 2/22/06 showed atrial flutter with rate 68. Right
bundle-branch block and LVH. Chest x-ray from 3/4/06 reveals
aortic calcification , pulmonary fibrosis with subpleural
predominance , mild pulmonary edema. The patient was admitted to
CSS and stabilized for surgery. Date of surgery 11/27/06 .
PREOPERATIVE DIAGNOSIS:
Atrial fibrillation , atrial flutter , aortic stenosis , and mild
mitral regurgitation.
PROCEDURE:
An AVR with a 25 CE pericardial valve. MVP with a 30
Cosgrove-Edwards ring , cleft repair , posterior leaflet , ring
annuloplasty , leaflet resection , posterior leaflet , sliding
valvuloplasty , PFO closure by atrial MAZE procedure. Left atrial
appendage resection and right atrial appendage resection.
Bypass time: 219 minutes. Crossclamp time 156 minutes. There
were no complications. The patient was transferred to the unit
in stable fashion with lines and tubes intact. In the ICU ,
starting postop day #1 , the patient was extubated , postop day #2
remains AV paced. Transferred to Step-Down Unit on postoperative
day #2.
SUMMARY BY SYSTEM:
Neurologic: Pain control , Toradol.
Cardiovascular: On Coumadin , captopril issues was being AV paced
through a.m. with transfer and now in first-degree AV block ,
holding Lopressor.
Respiratory: No issues , have been extubated postoperative day
#1.
GI: Passed speech and swallow. Diet was advanced as tolerated ,
Nexium for GI prophylaxis.
Renal: Started Lasix 20 twice a day
Endocrine: Diabetes insulin treatment with subcutaneously insulin.
Hematology: Anticoagulation with Coumadin , recent MAZE
procedure/atrial fibrillation.
ID: No issues.
Transferred to the Stepdown Unit where he
proceeded to progress well. Postop day #2 , chest tubes removed
wires left in. Postop day #3 , slow junctional rhythm with rates
in the 40s being externally V paced , rate of 88 and wires not
working. EP states if further rhythm is not recover by postop
day #4 to #5 to reconsult. Foley reinserted for retention of 400
mL output. Started Flomax. On low-dose Coumadin for MVP/MAZE in
case pacemaker was needed. We will need rehabilitation upon
discharge. Post-day #4 remains to be V paced with junctional
rhythm. The wires are in and do not conduct or capture. EP
feels the patient may require pacemaker , we will observe for now.
Upper extremity noninvasive studies for left greater than right
arm swelling , negative for DVT. Holding Coumadin pending
possible pacemaker placement. Past video swallow today for
regular diet.
Postop echo pending for MVP. Rehabilitation when medically
ready. Postop day #5 , postop showed slow junctional rhythm with
EP following for possible pacemaker , and they set a pacemaker at
heart rate of 40. The patient in junctional rhythm/afib , heart
rate in the 60s , A wire and do not conduct or capture. V wire
set at a backup rate of 40. EP just came by and feels patient is
likely recovered conduction. Possibly an atrial fibrillation
versus accelerated junctional with heart rates in the 80s and
thinks pacemaker will not be indicated. Plan to discontinue
wires in a.m. if the patient's rhythm remain stable.
Postop echo done for MVP. EF 55% , No comment on MR. Foley
discontinued last night after insertion voiding well today on
Flomax. Low-dose Lovenox anticipate eventual discharge to
rehabilitation on Lovenox/Coumadin and bridge after pacemaker.
White count up slightly to 11.1 low-grade temps. UA negative.
Rehabilitation when medically ready given possibility of
pacemaker requirement. Postop day #6 , spoke with EPS as the
patient is in stable sinus rhythm with first-degree AV block ,
okay to remove wires implanted for pacemaker , ambulating well for
room air. We plan to send to rehab when bed available. Postop
day #7 , the patient was evaluated by Cardiac Surgery Service to
be stable to discharge to home with VNA service with the
following discharge instructions.
DIET: Low-cholesterol , low saturated fat. ADA 2100 calories per
day.
FOLLOW-UP APPOINTMENTS:
Dr. Mankoski 117-219-4079 in five to six weeks , Dr. Reedy
428-217-7862 in one week , Dr. Trossbach 407-965-4347 in 1-2
weeks. To do plan make all follow-up appointments , local wound
care , wash wounds daily with soap and water , watch all wounds for
signs of infection ( redness , swelling , fever , pain , or discharge )
and call primary care physician/cardiologist at PUO Cardiac Surgery Service at
117-219-4079 with any questions. INR goal of 2-3 for atrial
fibrillation.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Allopurinol 100 mg daily , enteric-coated aspirin 81 mg daily ,
colchicine 0.6 mg daily , Colace 100 mg twice a day as needed
constipation , Lasix 40 mg daily for five days , Neurontin 400 mg
three times a day , as needed , neuropathic pain , Motrin 600 mg every 8 hours as needed
pain , insulin NPH 12 units subcutaneously nightly , insulin NPH 25 units
every day before noon , K-Dur 20 mEq daily for five days , lisinopril 20 mg daily ,
metformin 500 mg three times a day , Niferex 150 mg twice a day , Flomax 0.4 mg
daily , and Coumadin with variable dosage to be determined based
on INR.
eScription document: 2-3226839 SSSten Tel
Dictated By: CRIDGE , LORRETTA PA
Attending: MANKOSKI , ROSSIE
Dictation ID 0045434
D: 3/9/06
T: 3/9/06
Document id: 214
| Target |
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Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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209096147 | PUO | 08723508 | | 3250992 | 9/19/2005 12:00:00 a.m. | Congestive heart failure due to cardiac ischemia | | DIS | Admission Date: 11/2/2005 Report Status:
Discharge Date: 6/10/2005
****** FINAL DISCHARGE ORDERS ******
DEFONT , BETSY 614-54-76-0
Luman Ave.
Service: CAR
DISCHARGE PATIENT ON: 7/20/05 AT 07:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CAOILI , VALERI M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALLOPURINOL 150 MG orally every day
Override Notice: Override added on 1/20/05 by
CHRISTAL , OLIN E. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 57417309 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
Override Notice: Override added on 1/20/05 by
CHRISTAL , OLIN E. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 57417309 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 80 MG every day before noon; 40 MG every afternoon orally 80 MG every day before noon
40 MG every afternoon Starting IN a.m. ( 7/29 )
INSULIN NPH HUMAN 26 UNITS every day before noon; 8 UNITS every afternoon subcutaneously
26 UNITS every day before noon 8 UNITS every afternoon
HOLD IF: please give 1/2 dose if NPO
Instructions: please give 1/2 dose if NPO
RESTORIL ( TEMAZEPAM ) 30 MG orally HS
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Take 2mg Tues and Thurs , all other days take
4mg every night Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 1/20/05 by
CHRISTAL , OLIN E. , M.D. , PH.D.
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
PROSCAR ( FINASTERIDE ) 5 MG orally every day
Number of Doses Required ( approximate ): 3
IPRATROPIUM NEBULIZER 0.5 MG NEB four times a day
as needed Shortness of Breath
Override Notice: Override added on 4/13/05 by
CHRISTAL , OLIN E. , M.D. , PH.D.
on order for PHENERGAN orally ( ref # 67135298 )
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROMETHAZINE Reason for override: aware
NORVASC ( AMLODIPINE ) 5 MG orally every day Starting IN a.m. ( 6/29 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COZAAR ( LOSARTAN ) 50 MG orally every day Starting IN a.m. ( 6/29 )
Number of Doses Required ( approximate ): 7
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ACTOS ( PIOGLITAZONE ) 30 MG orally every day
Food/Drug Interaction Instruction
May be taken without regard to meals
COLCHICINE 0.6 MG orally every day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXYCODONE 5 MG orally every 6 hours as needed Pain
Instructions: shingles pain
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Gaylene Faniel , primary care physician 2/29/05 at 1:00 PM scheduled ,
Dr. Reyes Mcpeck , Cardiology 2/8/05 at 1:00 PM scheduled ,
Arrange INR to be drawn on 2/5/05 with f/u INR's to be drawn every
3 days. INR's will be followed by primary care physician
ALLERGY: QUININE , CALCIUM CHANNEL BLOCKERS , LISINOPRIL
ADMIT DIAGNOSIS:
Shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive heart failure due to cardiac ischemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NQW-MI 7/21/96 IDDM history of BILAT CEA , REPEAT R CEA CAD
CHRONIC RENAL INSUFFICIENCY L subclav stenosis history of stent history of brachial
artery PTCA AF/aflutter
hyperchol ( elevated cholesterol ) bph ( benign prostatic hypertrophy )
s/ choly ( cholecystectomy )
OPERATIONS AND PROCEDURES:
cardiac catheterization with PCI with drug eluting stents x 2
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Diuresis
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
HPI: 78 year-old vasculopath with last EF 60% in 2000 , known aFIB , presenting
with SOB x3days and incr'd LE edema. patient reports recent good health; no
anginal sxs and exercise tol usu 50-100ft without SOB. 3d PTA he noted
increasing SOB with less exertion. Also SOB at rest. No orthopnea , ?
1episode of PND and 2d of incr'd LE edema. He denies CP , nause ,
fever , abd pain or palpitations. In ED today , afeb , P 116 , afib , SBP
130s , 97% on 2L. Given intravenous lopressor 5mg , orally lasix. BNP 776 and TnI
0.25.
***PMH: CAD ( history of CABG 3v x2; history of PTCA in '96 &'97 ) ,
bil CEAs , DM , elev lipids , CRI , history of CCY , afib , sev post-herpetic
neuralgia
***MEDS: actos , nph , asa , lipitor , cozaar , norvasc ,
coumadin , k dur , lasix , proscar , atenolol , restoril , ?lyrica ,
***PE: afeb , 96 , BP , 97% on 1L
JVP 11cm , rales at bases , ant&post exp wheezes; disp PMI , S3 not
heard but irreg irreg , soft sys murm->no radiation; abd obese , soft ,
+BS , EXT with 2+ edema to
knees.
***STUDIES:
CXR with obscured cp-angles; mild cephalization
ECHO 2000- EF 60% with inf hypokinesis , mild TR , PAP 40mmHg
ETT-MIBI 6/10 isch in Lcx region
Cardiac Cath 6/9 - see below.
***HOSPITAL COURSE****
78 year-old man ext CAD , AFIB now presenting with CHF , mod rapid AFIB and tnI leak.
Likely CHF in setting of rapid AFIB and demand ischemia from progression
of CAD.
1. CV- ischemia- peak TnI 0.29 and trended down , CK+MB flat. Dobutamine
MIBI showed reversible defect in Lcx territory. Cont current med mgmt:
asa , statin , lopressor , cozaar. Cardiac catheterization on 10/28/05 showed
showed aortic stenosis of 33.8mmHg , calculated AVA 0.83cm. Mean PACPW of
23. Left main coronary artery and 3 vessel disease history of bypass grafts seen.
Hazy eccentric proximal LM 70% stenosis , LAD occuluded after 2 large
septal branches , ramus intermedius and Lcx without obstructive stenosis.
RCA totally occluded. Left subclavian stent patent without gradient. LIMA
patent with 20% ostial stenosis. SVG to PDA patent with 80% ostial in stent
restenosis and mid SVG 30% eccentric stenosis. Thus 2/3 grafts patent.
Cypher DES placed in SVG to PDA with TIMI 3 flow. Left main coronary artery
also stented with Cypher DES with TIMI 3 flow. patient should be on Aspirin
indefinitely and plavix 3 months minimum.
PUMP-vol overloaded by exam , confirmed by cath , diuresis w. lasix intravenous twice a day
with good results.
RHYTHM- afib-rate ctrl with lopressor; held coumadin , gave heparin when
INR<2. Restarted coumadin on discharge on prior dose 4mg every bedtime except 2mg on
Tues/Thurs.
2. PULM- CXR showed mild interstial edema from CHF/CAD. Atrovent nebs
given smoking hx but wheezing likely cardiac asthma. Given pleural
effusions and fixed wheeze primary care physician should consider Chest CT to evaluate for
lung nodules/malignancy.
3. ENDO- Reg insulin scale; hold actos; continue NPH 1/2 dose given npo
after MN. Nl TSH.
4. FEN- 2000cc fluid restric; low salt , ada diet.
5. Renal - Cr baseline 1.3 bumped to 1.6 then stable there at d/c.
Retarted orally home regimen. patient instructed to get primary care physician renal function test f/u
u within week of discharge.
5. Heme- normocytic anemia-Iron nl. intravenous Heparin as above for
AF. Coumadin restarted on 1/20/05
6. TED stockings.
7. FULL CODE
ADDITIONAL COMMENTS: Please seek medical attention if you have worsneing chest discomfort ,
shortness of breath , feelings of confusion or are unable to pee , have
gained significant weight ( more than 5 pounds over a week or faster ) or
any other troublesome or worrisome symptoms
**VERY IMPORTANT , PLEASE CALL YOUR DOCTOR TUESDAY OR AS SOON AS POSSIBLE
AND HAVE YOUR COUMADIN and your KIDNEYS and POTASSIUM CHECKED****
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
*See your primary doctor early this coming week 2/16/05 to check
INR/coumadin+renal function ( creatinine , potassium ). On discharge
creatinine was 1.6
*Take your medicines as directed in discharge orders
*Resume potassium supplements as directed by primary physician , held in
setting of acute renal function change
*See your primary care physician per appt section
*See your cardiologist per appt section
No dictated summary
ENTERED BY: SCHUNEMAN , ELLENA M. , M.D. ( ZO77 ) 7/20/05 @ 07:03 PM
****** END OF DISCHARGE ORDERS ******
Document id: 215
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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041529309 | PUO | 81159403 | | 722527 | 3/30/1997 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 1/5/1997 Report Status: Signed
Discharge Date: 7/6/1997
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
OPERATIVE PROCEDURES: Coronary artery bypass graft x3 , 3/4/97 .
HISTORY OF PRESENT ILLNESS: Mrs. Worsley is a 72-year-old female
with no coronary artery disease who
was transferred from an outside hospital with unstable angina , to
the Cardiology Service. Her risk factors include positive family
history , hypertension , and hypercholesterolemia. Her cardiac
history included a myocardial infarction in 1983 , followed by
post-infarct sustained in 1989 , which was treated medically. She
had a preop evaluation prior to bladder surgery , at which time , an
ETT was positive and cardiac cath revealed 70% proximal LAD , 70%
mid LAD , 70% distal LAD , 50% proximal circumflex , total occlusion
of obtuse marginal I , an 80% occlusion obtuse marginal II
occlusion. She was managed medically without any further symptoms
until 11/27 when she developed chest pain on exertion , which was
again treated medically. On 2/9/97 , she was admitted to Akcare Hospital for elective bladder suspension which was attempted
laparoscopically but complicated by bladder rupture and was
converted to an open procedure. Intraoperatively , she was noted to
have ST changes. She was taken to the ICU where she ruled out for
a myocardial infarction. However , subsequently , she developed
chest pain and shortness of breath , with ST depression. She was
therefore transferred to the I Warho Hospital for cardiac
catheterization and possible coronary revascularization.
PAST MEDICAL HISTORY: Hypertension , hypercholesterolemia , coronary
artery disease.
PAST SURGICAL HISTORY: Bladder suspension in 1995 and 1997.
ALLERGIES: No known drug allergies.
MEDICATIONS: Procardia XL 30 mg orally every day; atenolol 30 mg orally
every day; Mevacor 20 mg orally every day; Premarin 0.625 mg orally
every day; Bactrim DS 1 tab orally twice a day; Dilatrate 40 mg three times a day;
Compazine 10 mg as needed every 8 hours; Darvocet 100 mg as needed every 4 hours; heparin
subcutaneously
SOCIAL HISTORY: The patient does not smoke.
FAMILY HISTORY: Significant for coronary artery disease.
PHYSICAL EXAMINATION: VITAL SIGNS - Afebrile , pulse 77 , regular , BP
120/60 , two liters saturating 97%. SKIN - No jaundice , no anemia.
No clubbing , cyanosis , or pedal edema. NECK - Soft right carotid
bruit. LUNGS - Clear to auscultation. HEART - Normal heart
sounds , II/VI systolic murmur at left sternal border. ABDOMEN -
Soft , non-tender , non-distended. Surgical incision healing well.
EXTREMITIES - No varicose veins , bilateral dorsalis pedis , 2+
edema.
LABORATORY DATA: Na 133 , K 3.1 , Cl 100 , CO2 30 , BUN 4 , creatinine
0.6 , glucose 106. White count 10.9 , hematocrit
27.4 , platelets 211. EKG normal sinus rhythm , with Q-waves in aVF.
Chest x-ray shows no active infiltrate.
HOSPITAL COURSE: She was taken to the Cath Lab and underwent a
cardiac catheterization on 1/10/97 . This
revealed an occluded right coronary artery , 70% left circumflex
stenosis , a totally occlused obtuse marginal , 70-80% LAD stenosis ,
serial 70% stenosis in diagonal I , left ventricular ejection
fraction of 50% , and inferior akinesis.
She was taken to the Operating Room on 3/19/97 and underwent
coronary artery bypass graft x3 , LIMA to LAD , saphenous vein graft
to posterior descending artery , saphenous vein graft to obtuse
marginal.
Postoperatively , he remained in the ICU for three days postop
because of rapid atrial fibrillation which required increasing
amounts of beta blocker therapy. She was transferred out of the
unit on postop day #4. She underwent a cystogram on 4/17/97 which
did not show any evidence of a leak. She continued to remain in
atrial fibrillation intermittently , which responded to increasing
dose of Lopressor and lateral conversion of Lopressor to atenolol
100 mg twice a day She continued to develop atrial fibrillation every
morning in spite of increasing doses of atenolol. Therefore ,
procainamide was started on 5/28/97 and she is being discharged on
1/4/97 after having remained in sinus rhythm for 24 hours on
atenolol 100 mg twice a day and Procan SR 500 mg four times a day
DISCHARGE MEDICATIONS: Atenolol 100 mg orally twice a day; Percocet 1-2
tabs orally every 4 hours as needed pain; Coumadin dose
to be based on INR range of 2-2.5; Axid 150 mg orally twice a day;
cephradine 500 mg four times a day x7 days for redness at saphenous vein
graft harvest site above the medial malleolus; Procan SR 750 mg
orally four times a day
DISCHARGE DIET: No diet restrictions.
DISCHARGE ACTIVITY: As tolerated.
DISCHARGE FOLLOW-UP: Arrangements have been made for follow-up
with Dr. Abshear and Cardiology in one week ,
and Dr. Marcott in 4-6 weeks.
DISCHARGE DISPOSITION: To home , with services.
CONDITION ON DISCHARGE: Stable condition.
Dictated By: CORETTA TAHIR , M.D. UN19
Attending: DESIRAE R. MARCOTT , M.D. WC1 UH472/0442
Batch: 79663 Index No. ZHFVC23OB6 D: 1/4/97
T: 1/10/97
Document id: 216
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
294596496 | PUO | 80152317 | | 0251891 | 10/9/2006 12:00:00 a.m. | AORTIC STENOSIS | Unsigned | DIS | Admission Date: 10/5/2006 Report Status: Unsigned
Discharge Date: 8/29/2006
ATTENDING: COLASAMTE , ISABELLE EVON MD
ADMITTING DIAGNOSIS:
Aortic stenosis and coronary artery disease.
HISTORY OF PRESENT ILLNESS:
The patient was diagnosed with coarctation of the
aorta in the early 1960s when he was told that he had a heart
murmur. At that time , he received no treatment and since the 1980's , has been
treated for hypertension , with blood pressures
unresponsive to medication. In 1/16 , the patient underwent
stenting of that coarctation and since then he has been followed
by serial echos. In the recent echo , he was noted to also have
progression of his aortic valve stenosis. The patient now
presents with marked limitation of his activities with some
complaint of the anginal type symptoms that wakes him one to two
times a week. The patient had a cardiac catheterization done on
10/15/06 , which showed a 70% mid circumflex and 70% proximal OM2 ,
and a 40% proximal LAD and patient is now referred for aortic
valve replacement as well as coronary artery bypass grafting.
The patient's past cardiovascular intervention , as stated above ,
stenting of the coarctation on 1/16 and status post two
cardiac catheterizations.
PAST MEDICAL HISTORY:
The patient's past medical history is significant for the
coarctation , aortic stenosis and coronary artery disease. The patient also has
history of hypertension , history of diabetes on both orally and
insulin therapy. The patient also has history of
hypercholesterolemia , glaucoma bilaterally with right cataract
that was repaired.
PAST SURGICAL HISTORY:
Inguinal hernia repair in 1994 , cataract surgery in 2004 ,
circumcision in 1995 and status post stenting of this coarctation
in 2002.
FAMILY HISTORY:
Mother with diabetes and father with Parkinson's disease.
SOCIAL HISTORY:
A cigar smoker , a retired history teacher.
ALLERGIES:
Beta-blocker , "drops" his heart rate too low and penicillin causes
a rash.
MEDICATIONS ON ADMISSION:
Amlodipine 10 mg orally daily , diltiazem 360 mg orally daily ,
lisinopril 40 mg orally daily , isosorbide 30 mg orally once a day ,
aspirin 81 mg orally daily , Vytorin 10/80 mg orally once a day ,
metformin 1 g orally twice a day , Lantus 28 units an hour sleep ,
vitamin C , Xalantan one drop each eye , Trusopt one drop right eye
twice a day for his glaucoma and multiple vitamins.
PHYSICAL EXAMINATION:
5 feet 9 inches , 112 kilograms. Vital signs: Temperature of 97 ,
heart rate of 74 , blood pressure in the right arm of 110/60 and
left arm 130/60 , on room air 96%. HEENT: PERRLA , dentition
without evidence of infection. No carotid bruit. Chest: No
incision. Cardiovascular: Regular rate and rhythm with grade
III murmur. Pulses: 2+ pulses throughout. Allen's test of the
left upper extremity normal by pulse oxymetry. Respiratory:
Breath sounds clear bilaterally. Abdomen: No incision , soft , no
mass noted. Rectal: Deferred. Extremities: Without scarring ,
varicosity , or edema. Neuro: Alert and oriented with no focal
deficits.
LABORATORY DATA:
On admission , chemistries from 4/23/06: sodium of 143 , potassium
of 4 , chloride of 104 , CO2 of 29 , BUN of 9 , creatinine of 0.8 ,
glucose of 82 , and a magnesium of 1.8. Hematology from the same
day: white count of 12.7 , hematocrit of 43.3 , hemoglobin of 14.2 , platelets at
275 , 000 , physical therapy of 13.2 , INR 1 , and a PTT of 29.9.
Cardiac catheterization done on 10/15/06 , coronary artery stenosis with a
70% mid circumflex , 70% proximal OM2 , and a 40% proximal LAD.
EKG on 10/15/06 normal sinus rhythm at 74. Chest x-ray reported
as normal from 8/4/06 .
HOSPITAL COURSE:
The patient was admitted on 2/4/06 and was taken to operating
room and underwent an aortic valve replacement with a 21 St. Jude
Regent valve and an aortic root patch and a CABG x1 with the
saphenous vein graft to the obtuse marginal #1. The patient's
total cardiopulmonary bypass time was 156 minutes , cross clamp
time was 220 minutes. The patient came off the heart lung
machine without any difficulty on no pressors and was taken up to
the Intensive Care Unit and extubated 14 hours postoperatively.
The patient's postoperative course by systems:
Neurologically:remained intact.
Cardiovascular: The patient initially was not on any pressors but for
pressure , required pacing and was started
on some dopamine as well as vasopressin , which was on until
postoperative day #3. By postoperative day #4 , patient was started on low-dose
beta-blockers , however , had some bradycardia and no further
beta-blockers were given throughout his postoperative stay. The
patient remained in normal sinus rhythm in the rates of 70s-80s on no
medication.
Respiratory: The patient was extubated 14 hours postoperatively
and was on Lasix for diuresis. He will be sent home on five more
days of Lasix at 20 mg orally daily. His discharge chest x-ray
shows minimal edema. No pleural effusion and no pneumothorax.
GI: The patient was tolerating orally without any difficulty and
was on Nexium for GI prophylaxis. However , he had no prior history
of GERD or ulcer and will not be on any medications on discharge.
Renal: The patient had a stable BUN and creatinine throughout
his postoperative course and will be discharged with just 5
more days of Lasix 20 every day , with potassium replacement.
Endocrine: The patient was on orally and insulin ,
preoperatively and required an insulin drip intraoperatively and
closely followed by our Diabetes Service. The patient is
requiring a little bit more Lantus then he took preoperatively , as well as
some insulin with meals. The patient should follow his
fingersticks as he was preoperatively and follow up with his primary care physician
for his diabetric management.
Heme: The patient is on Coumadin for his
mechanical aortic valve. However , his INR on day of discharge was still
not therapeutic with an INR of 1.4. The decision was made for the patient to be
able to be discharged to home with a Lovenox bridge. He will be sent
home with 120 mg of Lovenox until his INR is greater than 2. A
phone call was placed through the Gallsbat Terver Hospital . They will follow
closely due to the lovenox bridge then will also follow his coumadin dosing.
The patient is also on baby aspirin for his coronary artery
disease. The patient had a stable hematocrit with a discharge
hematocrit of 26 and INR stated above of 1.4.
The patient is otherwise in stable condition. A decision was made that the
patient to be discharged to home on postoperative day #8.
DISCHARGE MEDICATIONS:
He will be discharged on these following medications:
eScription document: 0-2191526 EMSSten Tel
Dictated By: AFZAL , TOMIKA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 8362918
D: 5/5/06
T: 5/5/06
Document id: 217
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
- |
N |
Y |
N |
N |
N |
424863953 | PUO | 86555086 | | 4945009 | 6/17/2006 12:00:00 a.m. | chest pain | | DIS | Admission Date: 11/19/2006 Report Status:
Discharge Date: 2/21/2006
****** FINAL DISCHARGE ORDERS ******
SHEARER , OSWALDO 187-99-98-5
Norf Pocoll Sta
Service: MED
DISCHARGE PATIENT ON: 7/26/06 AT 10:30 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOVA , DOUGLASS V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today ( 2/24 )
MECLIZINE HCL 25 MG orally three times a day Starting Today ( 1/11 )
as needed Other:vertigo
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Jeansonne 1 week ,
ALLERGY: Morphine
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid obesity Asthma
H/o diverticulitis H/o multiple ventral hernias and multiple abdominal
hernias Chronic diarrhea and abdominal pain
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
--------- HPI: 45M with morbid obesity and previous
smoking history admitted with 2 days of mid-sternal , at rest and
exertional CP that radiates down left arm and is associated with
nausea. Has also had persistent vertigo for past 2 days , associated
with rhinorrhea+sore throatx2 days; and tinnitus. No shortness of breath.
Slight nausea. No fevers or chills. ---------
ED COURSE: CP on arrival to ED , relieved with fentanyl. 2 sets of
negative enzymes. ---------
DAILY EVENTS: 2/14
Admitted ---------
DAILY STATUS , 2/14 T 96.4; P 83; BP 110/72; O2 sat 94% , RA. NAD.
CTAB. RRR without r/m/g. NABS , ND/NT. Well-healed scars. Vertigo and
slight unsteadiness on ambulation.
--------- STUDIES:
2/5 MRI/MRA: No intracranial process
2/5 CXR: No acute process
2/5 EKG: NSR. LVH by aVL~11. Upsloping of ST
segment in V2 , likely early repolarization. ---------
CONSULTS: ---------
IMPRESSION: 45M with CP and vertigo admitted for rule-out observation
protocol. Aspects of CP suggestive of angina , though no EKG changes
nor biomarker
leak. ---------
COURSE: 1. CARDS ISCHEMIA: Low probability for ACS. Serial
cardiac enzymes. On ASA. Lipids show elevated LDL at 160 , low HDL at 25
and triglycerides of 188. Initiated Zocor 20mg daily in hopsital , LFTs
here ALT 64 AST 49 , Alk phos 71. Given cardiac risk factors ( obesity
hx of smoking elevated lipids ) and pain which was suggestive of anginal
pain , plan for adenosine-MIBI as outpatient ( cannot exercise secondary
to very weak abdominal muscles after multiple abdominal surgeries ).
2. CARDS PUMP: LVH in the setting of morbid obesity.
Echo ordered , if not during inpatient stay should f/u as outpatient.
Euvolemic and normotensive as of 2/24 .
3. CARDS RHYTHM: On tele no events during monitoring.
4. NEURO: Acute onset of vertigo likely 2/2 BPPV or labryrinthitis. On
meclizine standing. MRI/MRA without acute process. On HD2 with almost
complete resolution of symptoms on meclizine , will d/c with med for
symptomatic management.
5. GI: Has chronic abdominal pain and diarrhea. Appears to be at his
baseline. Continue eval. as outpatient.
6. PPX: Lovenox 40 mg subcutaneously every day and PPI while in hospital.
7. CODE: FULL
ADDITIONAL COMMENTS: Please call your regular physician Dr. Jeansonne to schedule an
appointment for the week following your discharge. At that appointment ,
you should discuss scheduling an outpatient stress test and an
echocardiogram to further evaluate your heart. In addition , you should
discuss your recent episodes of chest pain and the new medication we have
added , Zocor , for your elevated cholesterol. Please call your doctor or
return to the emergency department if you again develop chest pain ,
shortness of breath , or begin to feel unwell.
again.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. patient should have adenosine MIBI as outpatient given cardiac risk factors
( elevated LDL , decreased HDL , smoking history , obesity ) , unable to do
exercise stress test secondary to weak abdominal wall history of abdominal
surgery.
2. Needs outpt ECHO to evaluate high voltage QRS despite obesity.
3. Started on ASA 81mg and Zocor 20mg during hospitalization DLDL 160 , HDL
25 , TG 188.
4. Vertigo - neg MRI/MRA likely viral labrynthitis vs BPV d/c with
meclizine for symptomatic management , f/u for resolution of symtpoms.
No dictated summary
ENTERED BY: BARNABA , CARA C. , M.D. ( GS07 ) 7/26/06 @ 10:44 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 218
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
- |
- |
N |
N |
N |
N |
N |
237778376 | PUO | 81640922 | | 975158 | 2/12/2000 12:00:00 a.m. | ARRYTHMIA | Signed | DIS | Admission Date: 8/8/2000 Report Status: Signed
Discharge Date: 9/10/2000
IDENTIFICATION: Ms. Bellucci is a 50 year-old woman with a history
of end stage renal disease , status post renal
transplant and a history of coronary artery disease , status post
coronary artery bypass grafting , now with syncope and palpitations.
HISTORY OF THE PRESENT ILLNESS: This is a 50 year-old woman with a
history of end stage renal
disease , status post transplant ( cadaveric ) in February of 1997 ,
history of insulin dependent diabetes mellitus , and coronary artery
disease , status post coronary artery bypass grafting in February
of 1996 , left internal mammary artery to the left anterior
descending and saphenous vein graft to obtuse marginal , who reports
having done fairly well until six months ago when she had an
episode of chest pain which was relieved by Nitroglycerin.
Approximately one month ago , she was standing in her kitchen saying
good-bye to her husband at which point she passed out. Her husband
noted her getting pale and rolling her eyes back , states that this
lasted approximately 13 seconds. She had no symptoms afterwards.
A few months prior to this , the patient reports having had slurred
speech for a few minutes. More recently , she has had several
episodes of skipped heart beats during and after which she feels
short of breath. These episodes last a few minutes and are
sometimes relieved by sitting up. The mostly happen at night. She
had one episode of rapid heart rate last week which was also
associated with shortness of breath.
REVIEW OF SYSTEMS: No fevers , no bowel changes , no urinary
changes , no shortness of breath , no paroxysmal
nocturnal dyspnea , and no orthopnea.
PAST MEDICAL HISTORY: 1. End stage renal disease. 2.
Hypertension. 3. Status post renal
transplant. 4. Insulin dependent diabetes mellitus. 5. Coronary
artery disease , status post coronary artery bypass grafting in
1996. 6. Hypertension. 7. Hypercholesterolemia. 8. Chronic
renal insufficiency with a creatinine of 1.7 last in January of 1999.
9. Cataracts.
ALLERGIES: Erythromycin , which causes hives , Benadryl , which
causes hives , Penicillin , which causes a rash , and
Dramamine which causes hives.
MEDICATIONS: 1. Aspirin 81 mg orally every day. 2. Prilosec 20 mg
orally every day. 3. Simvastatin 40 mg orally every day. 4. Cyclosporine
125 mg orally in the morning and 100 mg orally in the afternoon. 5.
Insulin sliding scale. 6. Lasix 60 mg orally every day. 7. Atenolol
75 mg orally every day. 8. Prednisone 5 mg orally on even days , 10 mg
orally on odd days. 9. Cellcept 1 , 000 mg orally twice a day 10. Prempro
0.625 mg orally every day.
SOCIAL HISTORY: Cigarettes one-half pack per day x31 years.
Alcohol none. The patient is on disability.
FAMILY HISTORY: The patient's mother passed away with diabetes
mellitus.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.8 , pulse 96 ,
blood pressure 120/70 , and
respirations 18. GENERAL: In no apparent distress. HEENT:
Pupils equal , round , and reactive to light. Extraocular movements
were intact. Cranial nerves II-XII normal with bilateral carotid
bruits , right more than left. LUNGS: Clear to auscultation
bilaterally. HEART: Regular rate and rhythm with S1 and S2. No
murmurs appreciated. ABDOMEN: Soft , non-tender , and
non-distended. Bowel sounds positive. EXTREMITIES: Without edema
and warm.
LABORATORY DATA: The patient had a sodium of 137 , potassium 4.4 ,
chloride 104 , bicarbonate 15 , BUN 86 , creatinine
3.1. Creatinine on June , 1999 was 2.7 and creatinine on
May , 1999 was 3.0. ALT was 6 , AST 11 , alkaline phosphatase
44 , bilirubin total 0.4 , direct bilirubin 0.1 , calcium 9.5 ,
cholesterol 360 , and HDL 40. White blood cell count was 7.08 ,
hematocrit 25.9; on June , 1999 , the patient's hematocrit was
31.9 , and platelets 279. Echocardiogram from September of 1999 had
moderate to severe left ventricular hypertrophy , ejection fraction
of 55% , borderline hypokinetic inferior left ventricular wall , mild
mitral regurgitation , and left atrial dilatation. Carotid
noninvasives from October of 1999 showed no significant right or
left internal carotid stenosis.
HOSPITAL COURSE: This is a 50 year old woman with a history of
end stage renal disease , status post renal
transplant in February of 1997 , history of insulin dependent diabetes
mellitus , coronary artery disease , status post coronary artery
bypass grafting in 1996 ( left internal mammary artery to left
anterior descending and saphenous vein graft to obtuse marginal ) ,
now with episodes of rapid heart rate and episodes of skipped beats
in association without shortness of breath. Also , the patient has
had a hematocrit drop from 31 to 26 on admission and a history of
blood in stool over the last month. The patient was guaiaced on
admission and during her stay and remained guaiac negative
throughout the whole time. The patient was placed on cardiac
monitoring and had no events recorded on the monitor. On September , 2000 , the patient's hematocrit dropped to 21. She was
transfused two units of blood and her hematocrit went up to 31. An
exercise tolerance test MIBI was performed which was negative for
ischemia. The patient's ejection fraction from the MIBI was
approximated to be 69%. On August , 2000 , carotid
non-invasives were repeated which revealed moderate internal
carotid plaque on the right. Otherwise , she had mild stenosis of
the other arteries. An echocardiogram was also performed which
revealed concentric left ventricular hypertrophy with an ejection
fraction of 65%. The patient was taken to Electrophysiology Study
on October , 2000 which revealed nonsustained ventricular
tachycardia with possible right ventricular outflow tract origin.
It was hoped that she could be maintained on Lopressor and
Verapamil. Due to the results of this study , the patient was
already on Atenolol for Beta blockade and Verapamil was tried.
However , her blood pressure did not tolerate this medication. The
day after the electrophysiology procedure on March , 2000 , the
patient was orthostatic. She was given a 250 cc fluid bolus and
encouraged to drink more orally fluids and she was discharged in
stable condition the next day. The patient remained symptom free
during the entire hospital course. The patient's triglycerides
were checked during the hospitalization and found to be very high
in the 1 , 500 range. The patient was therefore taken off
Simvastatin and started on Gemfibrozil.
DISCHARGE MEDICATIONS: 1. Aspirin 81 mg orally every day. 2. Vitamin
C 100 mg orally every day x14 days. 3. Epogen
2 , 000 subcutaneously every week. 4. Lasix 60 mg orally every day. 5. Gemfibrozil
300 mg orally twice a day 6. Lisinopril 5 mg orally every day. 7. Prilosec
20 mg orally every day. 8. Prednisone 5 mg orally on even days , 10 mg
orally on odd days. 9. MVI with minerals one tablet orally every day.
10. Thiamine 50 mg orally twice a day 11. Bicitra 15 ml orally twice a day
12. Cyclosporine micromeral 125 mg orally every day before noon and 100 mg orally q.
p.m. 13. Cellcept 1 , 000 mg orally twice a day 14. Prempro 0.625/0.25
mg orally every day. 15. Nephrocaps one tablet orally every day.
Dictated By: SELENA TILLER , M.D. VY32
Attending: JEANNETTE GORGLIONE , M.D. ZS19 JK240/0801
Batch: 36268 Index No. QJEW6195L2 D: 10/2
T: 11/9
Document id: 219
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
N |
Y |
N |
045911026 | PUO | 32796229 | | 8269616 | 3/19/2003 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 3/19/2003 Report Status: Signed
Discharge Date: 1/25/2003
ATTENDING: DENISHA MCRORIE MD , PHD
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Ms. Kington is an 80-year-old woman
with known history of congestive heart failure and flash
pulmonary edema who presents with gradually increasing shortness
of breath for 2 weeks. Patient denies any chest pain , nausea ,
vomiting , palpitations or syncope. She does acknowledge sitting
orthopnea , paroxysmal nocturnal dyspnea for approximately 48
hours before admission , no lower extremity edema. She denies any
changes in diet or changes in medical adherence. She states her
weight has been about constant at 180 pounds on her home scale.
She does note that she has poor exercise tolerance at baseline
but even now unable to perform activities of daily living for 48
hours , so she came to the Kernan To Dautedi University Of Of Emergency Department with her
daughter. She was found to be hypertensive , hypoxic with
clinical and chest radiographic evidence of congestive heart
failure. She was treated with oxygen , intravenous Lasix and nitro-paced
in the ER and admitted for further treatment of her CHF
exacerbation. Her physical exam revealed a heart rate of 52
beats per minute , respiratory rate of 20 , blood pressure of
176/74 , and she was satting 97% on 4 L of oxygen. The patient
was in no acute distress , she is pleasant , a little overweight ,
alert and oriented times person , place and time. Her jugular
venous pressure was approximately 12 cm of water. She did have
pulses parvus et tardus , no Kussmaul sign. She had rales
one-half way up the pulmonary fields bilaterally. Her heart was
regular rate and rhythm , bradycardic. There was a 3/6 systolic
murmur with a slurred S2. Her abdomen was benign. She had no
lower extremity edema. She had cool extremities and neurologic
exam , other than patient being alert and oriented , was nonfocal
with no motor deficits.
LABS ON ADMISSION: Revealed a sodium of 142 , potassium 4.2 ,
chloride 105 , bicarb 26 , BUN 31 , a creatinine 1.9 , a glucose of
152. A white count within normal limits , a hematocrit of 41.8 , a
platelet count of 289 , calcium 8.8. Her coags revealed a PTT of
32.7 , an INR of 3.2 , her creatine kinase was 41 , her MB fraction
was 1.9 , her troponin was negative. Her BNP , brain natriuretic
peptide , was 885. Her chest x-ray was consistent with pulmonary
edema. Her EKG showed sinus bradycardia at
48 beats/minute. No significant ST or T-wave abnormalities. No
significant from change from 1/8 .
PAST MEDICAL HISTORY: Patient has known aortic stenosis with an
AVA of 1.0. She has coronary artery disease status post acute MI
in 2001 , status post two-vessel CABG , she had the left internal
mammary to the LAD and a saphenous vein graft to the OM-2. She
has atrial fibrillation , for that she is on amiodarone and
Coumadin. She has diabetes mellitus. She has
hypercholesterolemia , hypertension , peripheral vascular disease ,
bladder cancer status post resection.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Amiodarone 300 mg each day.
2. Aspirin 81 mg each day.
3. Lasix 120 mg by mouth twice a day.
4. Zestril 40 mg orally each day.
5. Zocor 40 mg orally every night before bedtime.
6. Niferex 150 mg twice a day.
7. Insulin NPH 48 units in the morning and 4 units in the
evening.
8. Levoxyl 25 mcg each day.
9. Coumadin 2.5 mg on Monday , Wednesday and Friday , and 3 mg on
Tuesday , Thursday , Saturday , Sunday.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She denied all vises , such as tobacco , alcohol or
drugs. She lives with her daughter , Arone .
REVIEW OF SYSTEMS: As in HPI , no fever , chills , rash , medications
changes or urinary symptoms.
ASSESSMENT ON ADMISSION: She was an 80-year-old woman with known
coronary artery disease here with a chief complaint of worsening
shortness of breath consistent with congestive heart failure
exacerbation most likely left-sided diastolic dysfunction. There
was no clear etiology , however , dietary or medication issues were
not likely given the patient's excellent awareness and
involvement in her care. The suspicion was that the patient may
have had increasing blood hypertension out of control , increasing
oxygen demand and creating diastolic function and pulmonary
edema. The role of her aortic valve was unclear , however , there
may have been gradual progression and renal artery stenosis
cannot be rule out as an etiology.
HOSPITAL COURSE:
1. Cardiovascular: In terms of her cardiovascular system , she
was diuresed with intravenous Lasix and her electrolytes were followed
closely. She came in with a weight of 84.7 kg and left with a
weight of 83.7 kg. For two days in the middle she was diuresed
with intravenous Lasix
120 mg twice a day and she was converted to orally Lasix and actually
continued her diuresis , in fact after pacemaker placement , which
will be noted below , she may have actually continued to urinate
even more so on the last day of her admission. Her blood
pressure was stable throughout her stay , in the low 100s ,
consistently below 150 systolic and above 100 systolic.
Rhythm: In terms of her rhythm , she was found at several points
throughout her stay in the first several days to have bradycardia
consistent with junctional rhythm and because of her atrial
fibrillation treated with amiodarone; it was thought she would
benefit from a pacemaker also because of her beta-blocker. So , a
pacemaker was placed on 6/21/2003 without complications. The
pacemaker was a dual-chamber PPM. Her INR before it was placed
was 1.7 , and there was some oozing from the site , however , her
hematocrit was stable and her hemodynamics were stable for 24
hours after the procedure. Electrophysiologists analyzed the
device and found that it was working properly. She is scheduled
for follow up with Dr. Brant on 4/13/2003 at 9:40 in the
morning. She has been advised to limit her driving until that
appointment. She has also been advised that she will not be able
to have an MRI in the future. She will be discharged on Keflex
( cephalexin ) 250 mg orally 4 times a day for 3 days on discharge
for her pacemaker and if she has any problems at all with her
pacemaker she should call Dr. Brant at
telephone # ( 096 ) 685-9419 , ayjxy # 15546.
2. Pulmonary: The patient had PFTs done in 9/18 which showed
an FVC of 73% of predicted , FEV1 of 77% of predicted , and FEV1 to
FVC ratio of 108% , and FEF 25/75 of 80% , a TLC of 50% of
predicted , an SVC of 73% of predicted , a residual volume of 40%
of predicted , and an RV/TLC of 72% of predicted. Her DLCO
uncorrected was 44%; her DLCO corrected was 44%. During her
stay , patient had low O2 saturations at rest ranging from the
high 80s to the low 90s , but often below 88% and on exertion
consistently in the mid-80% range , not depending on where the
probe was placed. She was unable to be weaned from the oxygen
and will be sent home on oxygen. She should be followed up with
a CT of the chest. A CT of the chest was done on this admission ,
however , it was consistent with CHF and other things could not be
ruled out. Of note , on the chest CT there were found to be liver
lesions which will be commented on below. The patient should
also be worked up for her pulmonary issues.
3. Radiology: The patient had this chest CT which showed
multifocal bilateral ground-glass opacities in the lungs , diffuse
haziness , some septal thickening with slight basil predominance ,
multiple borderline mediastinal nodes in the anterior
mediastinum , an AP window region with the largest node on image
21 measuring 1.3 x 2 cm , there were extensive vascular
calcifications , cardiomegaly with multi-chamber enlargement and
particularly dense coronary calcifications , trace right and left
pleural effusions. Visualized organs of the upper abdomen
demonstrate multiple ill-defined low attenuation foci in the
liver but no other abnormality. Review of bone window shows
extensive thoracic degenerative change , sternal wires and
epicardial pacer leads. The lung findings were consistent with
cardiomegaly and CHF , but could not rule out other diagnostic
possibilities including atypical pneumonia , hypersensitivity ,
pulmonary hemorrhage or less likely lymphangitic tumor. In order
to workup the liver mass , an ultrasound of the abdomen was
attained. The liver showed a mass 2.9 x 2.8 x 2.2 cm , it was
hyperechoic in the posterior segment of the right lobe of the
liver corresponding to the dominant mass seen in the CT of
7/21/203 and 11 , gallbladder was normal with no stones ,
the biliary tree was normal , as were the right kidney and left
kidney , pancreas , although it was poorly visualized. The spleen
was normal , the aorta was normal , pleural effusion was noted on
the left which was small and prominent hepatic veins were noted.
The radiologist's impression was that the ectogenic mass on the
right lower lobe of the kidney corresponded in the location of
the mass reported on prior CTs , may be a hemangioma or other
ectogenic masses which could not be excluded and he noted that
the patient could not hold her breath sufficiently well to
evaluate the mass with Doppler. If indicated , the PMD should
either get a nuclear scan , CT , the radiologist suggested MRI but
that is now impossible given the pacemaker , for confirmation and
further evaluation. Also , it was noted that she had prominent
hepatic veins possibly due to the right heart failure.
OTHER ISSUES:
4. Endocrine: The patient was continued on her Levoxyl 25 and
her home dose of insulin with good blood sugar controls generally
below fingerstick of 200.
5. Heme: The patient was continued on her Niferex. Her
hematocrit was stable throughout her stay with her admission
hematocrit being 41.8 and discharge hematocrit being 38.8. Her
white count also was not elevated. She is discharged with a
white count of 6.8. Her INR on admission was 3.2 , her Coumadin
was held and 1 mg of vitamin K was given before her procedure.
Her INR on the day of the procedure , 6/21/2003 , was 1.7 and on
discharge it was 1.3. She will be reinstituted on her same
Coumadin level , to follow up with Dr. Mankoski and to have her
Coumadin level checked on 5/25/2003 and be followed as she was.
DISCHARGE MEDICATIONS: As admission medicines except #1 , she will
be taking cephalexin for 3 days and that is the only difference.
Her primary care doctor can consider can titrating her CHF
medicines and/or her hypertension medicines.
eScription document: 0-1128036 LMS
CC: Denisha Mcrorie
MMC
Dictated By: SUGIMOTO , ARDELL
Attending: MCRORIE , DENISHA
Dictation ID 5295868
D: 8/23/03
T: 8/23/03
Document id: 220
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
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- |
- |
- |
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673650047 | PUO | 52446531 | | 975540 | 8/1/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/24/1995 Report Status: Signed
Discharge Date: 9/2/1995
PRINCIPAL DIAGNOSIS: ACUTE CEREBROVASCULAR ACCIDENT.
SECONDARY DIAGNOSIS: 1. ADULT ONSET DIABETES MELLITUS.
2. FOCAL MOTOR SEIZURE DISORDER.
3. CARDIOMYOPATHY.
4. CONGESTIVE HEART FAILURE.
5. ASTHMA.
6. CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
7. GOUT.
8. IDIOPATHIC EOSINOPHILIA.
9. CHRONIC VENOSTASIS , STATUS POST
DEEP VENOUS THROMBOSIS.
10. RECURRENT CELLULITIS.
HISTORY OF PRESENT ILLNESS: This is a 53 year old , white male
with insulin dependent , adult onset
diabetes mellitus , past alcohol abuse , cardiomyopathy , congestive
heart failure , and seizure disorder , who has been relatively
disabled due to shortness of breath , since 1992. The patient was
at home on the day of admission when he noted difficulty lighting a
cigarette with his right hand , as well as keeping it in his mouth.
The patient had difficulty speaking and his arm became
progressively weaker over the next several hours. The patient was
able to eat and drink with some difficulty. He noted word finding
difficulty , dysarthria , and arm weakness. The patient denied
headache , visual problems , loss of sensation , loss of
consciousness , urinary symptoms , diplopia , vertigo , nausea ,
vomiting , or difficulty ambulating. The patient was brought to the
Emergency Room by his son when his symptoms continued to worsen.
PAST MEDICAL HISTORY: Past medical history is significant for
alcoholism , cardiomyopathy , congestive heart
failure , coronary artery disease status post myocardial infarction ,
insulin dependent diabetes mellitus complicated by focal motor
seizures with hyperglycemia , deep venous thrombosis , venostasis
ulcers , cellulitis , diabetic retinopathy , idiopathic eosinophilia ,
asthma , chronic obstructive pulmonary disease , gout ,
hepatosplenomegaly , and ascites.
MEDICATIONS ON ADMISSION: Medications on admission include
hydroxyurea 500 mg orally every day before noon ,
Colchicine 0.6 mg orally twice a day , Lisinopril 10 mg orally every day , insulin
NPH 30 units every day before noon and 20 units every afternoon , Indocin 25 mg orally three times a day
as needed gout , and Lasix 80 mg orally every day.
ALLERGIES: The patient has an allergy to Penicillin.
SOCIAL HISTORY: His social history is notable for occasional
alcohol use. Of note , his last use of alcohol was
one week prior to admission. The patient had previously used
alcohol quite seriously , with one case of beer every day times 33
years , quitting heavy alcohol use after his myocardial infarction.
The patient smokes tobacco one pack per day. He used cocaine for
three years but quit cocaine use three years prior to admission.
REVIEW OF SYSTEMS: Review of systems is notable for very poor
exercise tolerance with a one block maximum
limit. The patient stops due to shortness of breath and
claudication. He also has two pillow orthopnea.
PHYSICAL EXAMINATION: This is a pleasant , obese , middle aged ,
53 year old , white male with a right facial
droop and in no acute distress. Temperature is 97 , pulse 84 , blood
pressure 126/70 , and O2 saturation is 99 percent on room air. His
heent examination was notable for no nystagmus and no diplopia.
His tongue was deviated to the right. His neck was supple with a
full range of motion. He had no bruits or lymphadenopathy. His
cardiac examination revealed tachycardia , regular rate and rhythm ,
S1 and S2 , and a 2/6 systolic ejection murmur heard loudest at the
axilla. His lung examination showed fine crackles at the left base
with diffuse wheezes. His abdomen was obese , soft , distended , and
non-tender. He had normoactive bowel sounds and liver span of 15
cm. His extremity examination was notable for chronic venostasis
changes , right greater than left , with 1+ peripheral pulses. His
neurological examination was notable for his being alert and
oriented times three. His ability to name was intact but he had
word finding difficulty. He had no right and left confusion. He
had downward droop of his right nasolabial fold , as well as a right
orally droop and a central seventh deficit. His tongue showed right
deviation. His sensory ability was intact overall. He had
decreased motor tone in his right upper extremity with 4/5 strength
in his right arm. His right arm lacked coordination and he had
difficulty initiating movement with his right arm but his strength
was still 4/5. His left upper extremity was 5/5 strength with good
coordination. His lower extremities were both 5/5.
LABORATORY DATA: Sodium was 140 , potassium 4.8 , chloride 104 ,
bicarbonate 19 , BUN 44 , creatinine 1.6 , and
glucose was 164. White count was 11 , 000 , hematocrit 43.3 , and
platelet count was 163 , 000. physical therapy was 14.1 , INR 1.4 , PTT 29.1.
Urinalysis showed 20 to 25 hyaline casts with 3-5 red blood cells.
There were no white blood cells.
HOSPITAL COURSE: The patient was admitted to the Medical Service
with a presumptive diagnosis of a left sided
stroke. A head CT was performed on hospital day number one but was
negative with no evidence of cerebral infarct or bleeding.
However , a follow up head CT on hospital day number three
demonstrated acute infarct in the left insular capsule and left
corona radiata. A carotid ultrasound was obtained on hospital day
number five which demonstrated bilateral carotid plaques with less
than 50 percent stenosis of both carotid arteries. Because of the
patient's history of diabetes and his cardiac history , especially
given his prior myocardial infarction , the patient was placed on a
ROMI protocol. The patient ruled out for a myocardial infarction
and he was given a cardiac echocardiogram on hospital day number
two. The echocardiogram demonstrated increased left ventricular
size with preserved systolic function and an ejection fraction of
65 percent. He had dilated left and right atria and he had
thickened mitral valve leaflets with 4+ mitral regurgitation , with
flow reversible into his pulmonary veins. He also had 3 to 4+
tricuspid regurgitation with slow reversal into the vena cava. He
had a trileaflet aortic valve with mild sclerosis but no
insufficiency or stenosis. He also had increased right heart size
with right heart pressures of 55 to 60 mm of mercury. He was noted
to have a trivial pericardial effusion. Of note , there was no
evidence of any thrombus in the heart. However , because of the
nature of his stroke , which was felt to be embolic by neurology , as
well as his enlarged atria. The patient was placed on intravenous Heparin
and he was then started on orally Coumadin for long-term
anticoagulation. The patient did very well after his stroke and
his original slurred speech improved markedly over the course of
his admission. He also regained full strength in his right arm ,
although he continued to have some decreased coordination in that
arm. The patient also demonstrated inability to swallow without
difficulty and an esophagogram with video analysis was performed on
hospital day number six , prior to his discharge. The video study
of his swallowing demonstrated that he had essentially normal
swallowing and he was cleared to go home on a regular diet. Of
note , his blood pressure tended to be low , around 100 to 110
systolic , while in the hospital , so his Lisinopril was discontinued
and he was given instructions that Lisinopril would be restarted by
his CHH attending after his discharge. His hydroxyurea was
increased from 500 mg to 1 gram every day. The patient did quite well
after his stroke and he was discharged home with services on
April , 1995.
MEDICATIONS ON DISCHARGE: His discharge medications were
Colchicine 0.6 mg orally three times a day , Lasix 40
mg orally every day , insulin NPH 30 units subcutaneous every day before noon and 20
units subcutaneous every afternoon , Atrovent inhaler two puffs four times a day as needed
wheezing , multivitamins one capsule orally every day , Coumadin 4 mg orally
every bedtime , and Indocin 25 mg orally three times a day as needed gout pain.
DISPOSITION: DIET: The patient is on an ADA 1800 calorie diet.
ACTIVITY: He has no activity restrictions.
Dictated By: FRAN BUSSLER , M.D. OU51
Attending: BETHANIE A. LAVENTURE , M.D. KU4 YA549/6681
Batch: 14079 Index No. N4LFK01SRH D: 2/13/95
T: 10/10/95
Document id: 221
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
- |
N |
N |
N |
N |
N |
N |
818547575 | PUO | 21605394 | | 256588 | 2/26/2001 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 2/1/2001 Report Status: Signed
Discharge Date: 1/6/2001
ADMISSION DIAGNOSIS: CONGESTIVE HEART FAILURE AND ATRIAL
FIBRILLATION.
DISCHARGE DIAGNOSIS: CONGESTIVE HEART FAILURE , ATRIAL FIBRILLATION
OTHER SIGNIFICANT PROBLEMS: Hypertension , non insulin dependent
diabetes mellitus , hyperlipidemia , and
coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old italian
speaking male with multiple cardiac
risk factors and extensive cardiac history including a
long-standing history of hypertension , non insulin dependent
diabetes mellitus since 1995 with hemoglobin AIC of 10.5 on
11/16/01 , 20 pack year smoking history and family history
significant for MI in his brothers at age 46 and 50 and history of
hyperlipidemia. The patient had his first MI in 1990 complicated
by congestive heart failure. An echocardiogram at an outside
hospital revealed EF of 22% with a dyskinetic apex and a dilated
left atrium. In August of 1995 , he had another MI , was
hospitalized at I Warho Hospital where he required
intubation secondary to pulmonary edema. In April of 1995 , he
was admitted again for congestive heart failure and an
echocardiogram demonstrated an EF of 25 to 30% , anterior and
anterolateral hypokinesis , moderate inferior and mild septal
hypokinesis and mild MR. Cath. in 1995 showed three vessel disease
and the patient underwent four vessel CABG in October of 1996 with
saphenous vein graft to the PDA , OM1 and OM3 and a LIMA to the LAD.
During the surgery , the patient had an ICG placed prophylactically
as part of the CABG patch study. Since the surgery , he has had
additional episodes of congestive heart failure with report of a
hospitalization in September 2000 in Otte The patient
reports he was hospitalized at that time for difficulty breathing
and a third MI. He required intubation during this hospitalization
and the course apparently was complicated by renal failure. Since
September 2000 , the patient has reportedly felt well with no difficulty
breathing or chest pain. More recently , two months prior to
admission , the patient was found to have atrial flutter. He was
started on 80 mg of sotalol and his arrhythmia spontaneously
converted. Today , the patient presented to his
electrophysiologist , Dr. Dominguez for routine interrogation of his
pacemaker and was found to have atrial fibrillation with a rapid
ventricular rate in the 120s. Additionally , the patient reports
worsening lower extremity edema bilaterally for the past six days
and decreased urine output. The patient denies chest pain ,
shortness of breath. He has had no palpitations , diaphoresis ,
nausea , vomiting. He denies dietary indiscretion or any medication
changes. He has had no fever , dysuria or cough. He has stable two
pillow orthopnea and dyspnea on exertion but no paroxysmal atrial
fibrillation. His most recent echocardiogram was in September of
2000 which showed a dilated left ventricle with EF of 15 to 20% and
global hypokinesis. The right ventricle was moderately enlarged
with depressed function. He had a thickened aortic valve and no
aortic stenosis or aortic regurgitation. He had mild MR with an
enlarged left atrium at 5.7 cm.
PAST MEDICAL HISTORY: As stated , hypertension , diabetes ,
hyperlipidemia , coronary disease and
congestive heart failure.
MEDICATIONS ON ADMISSION: Glyburide 10 mg orally twice a day , Isordil 10
mg orally three times a day , Digoxin 0.125 mg every day ,
Captopril 12.5 mg three times a day , Coumadin 3 mg orally every day , Lasix 80 mg
orally twice a day , Simvastatin 20 mg orally every bedtime , folate 1 mg orally q.
day , and Amiodarone 200 mg orally every day.
Of note , upon further questioning , it turns out the patient had
been taking amiodarone and had only been started on sotalol briefly
but became hypotensive with that and so he was switched to
amiodarone.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He has a 20 pack year history of smoking and
currently continues with binge drinking of greater
than four whiskey drinks at a time. He lives in Ran with
his wife and children and he has not had work since his CABG.
FAMILY HISTORY: Significant for coronary artery disease in both
his brothers at age 46 and 50.
PHYSICAL EXAM: Vitals: Temperature 95.5 , blood pressure 120/80 ,
heart rate 80 to 120 , oxygen saturation 95% on room
air. GENERAL: This is a 59-year-old male male , well nourished in
no acute distress. HEENT: Normocephalic. Pupils are equal , round
and reactive to light. Extraocular movements are intact. Oral
mucosa is moist. Enlarged bilateral submandibular glands. NECK:
No lymphadenopathy or tenderness. JVP at about 9 cm. LUNGS:
Clear to auscultation bilaterally without wheezes or rales.
CARDIOVASCULAR: Tachycardic , irregularly irregular with normal S1 ,
S2 and 3/6 holosystolic murmur heard best at the apex. ABDOMEN:
Soft , moderately distended , non-tender. Incisional scars noted
ventrally and centrally. There is no shifting dullness.
EXTREMITIES: 2 to 3+ pitting edema to mid thigh with notable
scrotal edema. 2+ femoral pulses appreciated on the right. Pedal
pulses not appreciated though. Tibial pulses not appreciated.
Lower extremities were warm to touch. NEURO: Grossly nonfocal.
ADMISSION LABORATORY: Sodium 137 , potassium 4.4 , chloride 98 ,
bicarbonate 28 , BUN 34 , creatinine 1.8 and
glucose of 146 , calcium of 10.2. White blood cell count is 6.5 ,
hematocrit 44.6. Platelets 181. INR is 1.7. PTT is 26.3.
Troponin is 0.06. ALT is 16 , AST 34 , alkaline phosphatase 100 , CK
181 , T. bili. 1.7 , total protein 8 , albumin 4.7.
EKG shows an irregular rhythm , atrial fibrillation at a rate of
approximately 100 to 110 , no LDH , no RVH , and no acute ST , T wave.
Chest x-ray showed cardiomegaly , small pleural effusion , and
pulmonary vascular distribution and mild interstitial edema.
HOSPITAL COURSE: The patient was admitted to cardiology service
for rate control and diuresis. He remained in
atrial fibrillation throughout the hospital course with rates
between 60 and 100. His Digoxin was continued and a low dose of
Lopressor 6.25 twice a day was started for rate control. The patient
ruled out for MI with CKs of 18 and 124 and Troponin of 0.06. He
was diuresed with intravenous Lasix that was titrated up to a dose of 200 mg
intravenous twice a day proceeded by 500 mg of Diuril twice a day Over the course of
the hospitalization , the patient's fluid status was negative 7.5
liters with marked improvement in his lower extremities edema. His
weight at discharge was 88 kg which is baseline per the patient.
He was restarted on his amiodarone 200 mg daily and an
echocardiogram was obtained which demonstrated 4+ MR and TR , and an
EF of 15 to 20%. This was similar to an echocardiogram from
September of 2000. The patient will follow-up with Dr. Rossie K Mankoski on July and Dr. Rossie Mankoski on November for
consideration of electrical cardioversion. He will also continue
on orally Lasix , Zaroxolyn and Coumadin as well as his previously
stated outpatient medications.
DISCHARGE MEDICATIONS: Included aspirin 81 mg daily , amiodarone
200 mg every day , Captopril 12.5 mg orally
three times a day , Digoxin 0.125 mg orally every day , folate 1 mg orally every day ,
Lasix 240 mg orally every day before noon and 160 mg orally every afternoon Glyburide 10 mg
orally twice a day , Isordil 10 mg orally three times a day , Zaroxolyn 5 mg orally twice a day
taken 30 minutes prior to Lasix dose. Lopressor 6.25 mg orally
twice a day , Coumadin 5 mg orally every bedtime , simvastatin 20 mg orally every bedtime
Discharge diet is ADA 2000 kilocalories , low fat , low cholesterol ,
low salt ( 2 gram sodium ) and 1500 cc fluid restriction.
Dictated By: MELLIE WIEBERG , M.D. WS76
Attending: JACKSON E. PART , M.D. WJ2 GI526/498453
Batch: 4908 Index No. P7UXZV9PQV D: 3/8/01
T: 3/8/01
Document id: 222
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
- |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
441862105 | PUO | 75435228 | | 0272229 | 7/10/2006 12:00:00 a.m. | cardiomyopathy , coronary artery disease , atrial fibrillation , substance abuse | | DIS | Admission Date: 9/22/2006 Report Status:
Discharge Date: 7/30/2006
****** FINAL DISCHARGE ORDERS ******
BRINGHAM , CARISSA S 377-89-84-9
Tonventsquite
Service: CAR
DISCHARGE PATIENT ON: 9/10/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LIPPHARDT , ERMELINDA S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain , Headache
AMOXICILLIN 500 MG orally four times a day
Food/Drug Interaction Instruction
May be taken without regard to meals
ASPIRIN ENTERIC COATED 325 MG orally DAILY
Override Notice: Override added on 2/8/06 by BONTON , DANIELL L I. , M.D.
on order for WARFARIN SODIUM orally 10 MG every afternoon ( ref #
518691853 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: md aware Previous override information:
Override added on 2/8/06 by BONTON , DANIELL L. , M.D.
on order for WARFARIN SODIUM orally ( ref # 923343277 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: md aware
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 2/8/06 by BONTON , DANIELL L I. , M.D.
on order for WARFARIN SODIUM orally 10 MG every afternoon ( ref #
518691853 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: md aware
Previous override information:
Override added on 2/8/06 by BONTON , DANIELL L. , M.D.
on order for WARFARIN SODIUM orally ( ref # 923343277 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: md aware
Previous override information:
Override added on 11/1/06 by BONTON , DANIELL L. , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
018099252 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: md aware
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 80 MG orally DAILY
LISINOPRIL 40 MG orally DAILY
Override Notice: Override added on 11/1/06 by BONTON , DANIELL L I. , M.D. on order for K-DUR orally ( ref # 997225637 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 11/1/06 by PARDON , HALEY , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
ATIVAN ( LORAZEPAM ) 1 MG orally every 6 hours as needed Anxiety
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 11/1/06 by BONTON , DANIELL L I. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: md aware
THIAMINE HCL 100 MG orally DAILY
WARFARIN SODIUM 10 MG orally every afternoon Starting NOW ( 1/13 )
Instructions: WITHIN HOUR OF PHARMACY APPROVAL
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/8/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: md aware
Previous Alert overridden
Override added on 2/8/06 by BONTON , DANIELL L. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: md aware
DIET: House / 2 gm Na / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Niziol , call 312-062-3692 8/24/06 , 3 pm scheduled ,
ALLERGY: orally CONTRAST
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cardiomyopathy , coronary artery disease , atrial fibrillation , substance abuse
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cardiomyopathy , HTN , substance abuse
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
DC cardioversion
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
HPI: 52M with hx of HTN , obesity who was in his USOH until approx 6-7
months ago when he developed bilateral LEE > on L greater than R. In
last 2 months he reports developing DOE which has
progressed and he now reports experiencing SOB at rest that has
become acutely worse over the last few days. He states that he is
unable to lay flat , he states that he even feels SOB when sitting and
his sxs are best he is standing with his arms raised above his head.
Reports PND as well and a cough productive of white foam x 2-3 days.
He also reports bloating and increased abd
girth. Denies CP , Arm pain , palpiatations , n/v. No melena ,
BRBPR , no calf pain. Has had some loose stool in setting of
amoxicillin which he is on history of root canal 3 days ago and 2.5
wks ago. No fever/chills. IN ED: 97.1 82 183/100 32 85-93%
RA Received ASA 325mg orally every day , Lasix 40 , lopressor 5 intravenous ,
morphine 4 , KCL 40 , heparin 5 , 000uIV and 1 , 000u/heart rate Then started on
nitro drip. EKG with sinus tachycardia to 140.
Repeat EKG with normal axis , NSR , LVH , LAE , TWI in V1 ( new ) STE in
v2( old ) and V3( new ) - strain pattern , every waves in III , II , AVF.
*****
PMH: Appy , diverticulitis , obesoty , HTN , erythema nodosum.
*************************************************
Meds: Lasix 40 every day , Lisinopril 20 every day , aspirin 81mg orally every day , prilosec ,
kdur , amoxicillin All: NKDA
*************************************************
SocHx: Car salesman. Social smoker - 2-3 cigs/wk - none in last 3
yrs. Drinks 1-2 drinks every other night...but notes suggest more
ETOH use. FamHx: No hx of CAD , Mother with lymphoma , Father with
A.flutter.
***********************************************
Labs: Cr 0.8 , WBC 8.95 , Hct 43.6 CK 143 , CKMB 4.5 , Tn
0.3 CXR: Cardiomegaly , pulm edema , ? L-sided
iniltrate.
*****
STUDIES:
Cardiac PET:
Final impression:
The patient's PET-CT test results are abnormal and consistent
with the following:
1. Mild calcified coronary plaque burden.
2. A medium size area of prior MI in the distal LAD territory ,
with evidence of mild residual stress-induced peri-infarct
ischemia.
3. Severe LV systolic dysfunction.
ECHO:
Left Ventricle: The left ventricle is moderately dilated. There is
severe concentric left ventricular hypertrophy. Overall left ventricular
function is normal. The estimated ejection fraction is 55%. There are no
obvious akinetic areas.
Right Ventricle: The right ventricle is not well seen. The right
ventricular size is normal. Global right ventricular systolic function
is normal.
Left Atrium: There is moderate left atrial enlargement.
Right Atrium: The right atrium is mildly dilated.
Aortic Valve: The aortic valve is trileaflet , mildly thickened , and
calcified.
There are mildly elevated transaortic gradients consistent with aortic
sclerosis. There is mild to moderate aortic regurgitation.
Mitral Valve: The mitral valve is mildly diffusely thickened. There is
trace
************************************************
A/P: 52M with hx of HTN , with hx of progressive SOB , LEE , x mos with
acute worsening in last few days with associated troponin
leak.
1 ) ISCHEMIA: Small troponin leak which resolved - demand in setting of
CHF and HTN. ASA 325 , lipitor 80. Elevated LDL 113. homocysteine
WNL , hga1c elevated , CRP normal. Caridac PET notable for mild
calcified coronary plaque burden , med sized area of poor perfusion
suggestive of prior MI in distal LAD territiory. LVEF 35%.
2 ) PUMP: New CHF - ischemic vs hypertrophic vs alcoholic cardiomyopathy ,
exacerbation due to slow volume accumulations ( NSAIDs , Amoxicillin ,
dietary non-compliance ) - ECHO shows EF 55% , severe cLVH , AI. Diuresed
approx 10 liters with intravenous lasix. Weight from 155 kg ( admit ) to 149.5 kg
( discharge ). Lisinopril increased to 40 every day.
3 ) RHYTHM: Atrial fibrillation in setting of volume overload which
resolved with diuresis and beta blockade. patient had a failed DC
cardioversion. Anticoagulated initially with heparin bridging to
Coumadin.
4 ) Heme/Anticoagulation: patient started on coumadin 10 mg daily x 2 days
prior to discharge. INR 1.1 and ___ prior the 2 days prior to discharge.
patient sent home with lovenox bridge. Will be followed at PUO coumadin
clinic.
5 ) EtOHism - MVI/thiamine/folate. No signs of alcohol withdrawal.
6 ) Nutrition - 2L fluid restrict , 2 gram sodium diet , nutrition
consulted/educated in house.
7 ) Dental Pain - as needed oxycodone and amoxicillin continued.
ADDITIONAL COMMENTS: New Dose:
Furosemide ( Lasix ) 80 mg daily
Lisinopril 40 mg daily
*****
New Medications:
Aspirin 325 mg daily
Toprol XL ( metoprolol ) 100 mg daily
Lipitor ( atorvastatin ) 80 mg daily
Coumadin ( warfarin ) 10 mg daily
Magnesium 1000 mg daily
Potassium ( K-dur ) 20 mEq daily
Multivitamins
Thiamine 100 mg daily
Folate 1 mg daily
*****
Please follow up with the coumadin clinic for monitoring of your INR
( coumadin level ). Coumadin clinic is at Min Stock Joi , Maryland
*****
Monitor your weight daily. If it increases by 3 pounds , then double your
lasix and call Dr. Niziol .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. f/u INR with goal 2.0 to 3.0
2. monitor electrolytes as patient being discharged with diuretics and
increased ACEI.
3. Monitor weight and sodium/fluid restriction compliance
4. Continue to stress importance of abstaining from EtOH.
No dictated summary
ENTERED BY: BONTON , DANIELL L. , M.D. ( PC41 ) 9/10/06 @ 09:44 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 223
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313615200 | PUO | 85677707 | | 020201 | 7/2/1993 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 7/2/1993 Report Status: Unsigned
Discharge Date: 2/15/1993
DISCHARGE DIAGNOSES: RECURRENT ENDOCARDITIS AND END-STAGE CARDIAC
VALVULAR DISEASE.
PROCEDURES PERFORMED: Mitral valve replacement on 2 of November and
cardiac transplantation on 18 of September .
HISTORY OF PRESENT ILLNESS: The history of present illness is that
of a 55-year-old female with a history
of rheumatic heart disease and endocarditis , who presented to the
Kernan To Dautedi University Of Of on 3 of August to the Cardiology Service with progressive
weight gain , lower extremity edema and shortness of breath. The
patient had a history of rheumatic fever as a child , and she
presented in 1985 with mitral and aortic valvular endocarditis
following a root canal. She subsequently underwent aortic and
mitral valve replacement secondary to her aortic and mitral
insufficiency. Her perioperative course was complicated by a brain
abscess which was without neurologic residual deficit. In 1989 the
patient again presented with recurrent endocarditis and underwent a
repeat mitral valve and aortic valve replacement. For the past year
prior to presentation , she has had increasing symptoms of right
heart failure including lower extremity edema and ascites which did
not improve with medical treatment. She has also presented with
complaints of shortness of breath. In February of 1993 she underwent
a transesophageal echo which revealed a perivalvular leak for which
she underwent her third mitral valve replacement. Tricuspid
annuloplasty was performed at that time. The patient has never
significantly improved past her most recent surgery and her most
recent transesophageal echo performed in Nclo Rd. three
weeks prior to presentation demonstrated again a perivalvular
mitral leak. The patient has had a significant lower extremity
edema with a weight gain of 30 pounds since her discharge one month
ago. She has no shortness of breath at rest but does have
significant dyspnea on exertion with minimal effort. She denies
fever or chills.
PAST MEDICAL HISTORY: Past medical history is as stated above. She
also has some chronic renal insufficiency
with baseline BUN and creatinine of 40 and 2.0. She is status post
cholecystectomy in 1990.
MEDICATIONS: Her medications on presentation to the Kernan To Dautedi University Of Of were
Lasix 100 mg twice a day , Digoxin 0.25 mg every other day ,
Coumadin 5 mg alternating with 2.5 mg every day , and Captopril 12.5
mg three times a day. She is allergic to penicillin and codeine.
PHYSICAL EXAMINATION: Her admission physical exam was notable for
a tired appearing female with a cardiac exam
notable for mechanical valvular heart sounds and 4+ pitting lower
extremity edema.
LABORATORY DATA: Her admission BUN and creatinine were 61 and 1.9.
HOSPITAL COURSE: She was admitted to the Cardiology Service and
was evaluated by the Cardiac Surgical Service , and
it was felt that mitral valve repair and/or replacement would be
beneficial to the patient. She , therefore , underwent mitral valve
repair on 2 of November but was without significant symptoms for her
right heart failure , and was placed on the cardiac transplant list.
She underwent successful cardiac transplantation on 18 of September . Since
that time , her main issues have centered over management of her
residual ascites with diuresis of her third spaced volume.
Additionally she had had some nose bleeds preoperatively which were
felt to be related to nasal polyps for which she was seen by the
ENT Service. She underwent routine post transplant biopsies and
echocardiograms , all of which showed adequate acceptance of organs
and good LV function. She continued to do quite well with the
exception of some dysphagia early in her postoperative course which
was found to be possibly secondary to some esophageal ulcerations ,
but these have subsequently resolved and she is tolerating a
regular diet. She was noted two days prior to transfer to the
Wilc Ple Hospital to have some diffuse mild
abdominal pain , and KUB and upright revealed large amounts of
stool , and she felt great relief from soap suds enemas. She has
been stable on her medications with adequate cyclosporine levels.
Imuran was recently held secondary to neutropenia.
DISPOSITION: The patient was transferred to the Wilc Ple Hospital on approximately the third
postoperative week from her cardiac transplant.
DISCHARGE MEDICATIONS: Her discharge medications include Mylicon 80
mg orally three times a day , Trental 400 mg orally three times a day ,
Nystatin cream topically once per day , Mycostatin powder topically
once per day , terbutaline 5 mg orally twice a day , Nystatin swish and
swallow 10 cc orally three times a day , magnesium oxide 280 mg orally twice a day ,
human regular insulin 4 units subcutaneously every day before noon and before dinner and
NPH insulin 28 units subcutaneously every day before noon , omeprazole 20 mg orally every day before noon ,
cyclosporine 150 mg orally twice a day plus levels checked daily ,
potassium 40 mEq every day before noon , prednisone 27.5 mg orally every day before noon , Lasix 40
mg orally every day before noon , Percocet as needed for pain and Serax 10 mg as
needed at night for sleep.
FOLLOW UP: She will follow up with the Cardiac Transplantation
Service. She is referred to Wilc Ple Hospital for physical therapy rehabilitation as well as medications
management and assistance. She is discharged to Howood Medical Center on 8 of April .
Dictated By: TRISH CHAIX , M.D. PT27
Attending: JANAY D. STUKOWSKI , M.D. JA65 HT158/4655
Batch: 321 Index No. A1TOQR5DRV D: 5/12/93
T: 5/12/93
Document id: 224
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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581312753 | PUO | 77634248 | | 4592107 | 2/13/2006 12:00:00 a.m. | flash pulmonary edema | | DIS | Admission Date: 5/26/2006 Report Status:
Discharge Date: 5/25/2006
****** FINAL DISCHARGE ORDERS ******
BONING , FREDDA 207-67-77-5
Ville
Service: CAR
DISCHARGE PATIENT ON: 10/1/06 AT 03:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KATCSMORAK , CARRI GARY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally DAILY
Alert overridden: Override added on 10/28/06 by
DIVELBISS , LONNY O. , M.D. , PH.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: Md aware
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY
Override Notice: Override added on 10/28/06 by
DIVELBISS , LONNY O. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 849214828 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: md aware
LASIX ( FUROSEMIDE ) 80 MG orally DAILY
Starting Today ( 1/3 )
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
Alert overridden: Override added on 10/28/06 by
DIVELBISS , LONNY O. , M.D. , PH.D.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: md aware
LISINOPRIL 2.5 MG orally DAILY
PRAVACHOL ( PRAVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/28/06 by
DIVELBISS , LONNY O. , M.D. , PH.D.
on order for NIASPAN orally ( ref # 292287567 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: md aware
Previous override information:
Override added on 10/28/06 by DIVELBISS , LONNY O. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 849214828 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: md aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 1
NIASPAN ( NICOTINIC ACID SUSTAINED RELEASE )
0.5 GM orally DAILY
Alert overridden: Override added on 10/28/06 by
DIVELBISS , LONNY O. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: md aware
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
GLIPIZIDE 5 MG orally twice a day
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
CARD DR VERRY ( 048 ) 968-4013 ( call office to make appt ) scheduled ,
CV Surgery Dr. Isabelle Colasamte at 898-5547 ( call next week for appt. ) ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
pulmonary edema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
flash pulmonary edema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF ( congestive heart failure ) cad ( coronary artery disease ) htn
( hypertension ) dm ( diabetes mellitus ) gerd ( gastroesophageal reflux
disease ) hypothyroidism ( hypothyroidism ) mitral regurgitation
( 2 ) lung ca history of lobectomy ( lung cancer ) endometrial ca history of TAH/BSO
( endometrial cancer ) basal cell ca ( basal cell
carcinoma ) CRI ( chronic renal dysfunction ) renal artery stenosis history of
L stent ( renal artery stenosis ) recurrent flash pulm edema ( pulmonary
edema )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: CHF
HPI: 75F with iCMP , CAD history of MI history of multiple stents to LAD , LCx ,
moderate/severe MR with multiple recent presentations for
decompensated CHF , history of recurrent bronchoalveolar Ca , stage intravenous , 1 wk
history of increased lasix requirements with increased dyspnea , several
episodes of PND. On the a.m. of admission she p/with SOB , dyspnea , all not
relieved by NTG or lasix. She presented to KAAH ED with BP 173/74 , HR
112 , admitted and transferred to PUO . At baseline ambulates 1.5
blocks flat ground , stops 2/2 DOE , never uses stairs. anginal
equivalent of throat/jaw discomfort.
PMH: CAD history of MI , mult stents to LAS , LCx , mod-severe MR , iCMP , high
chol , HTN , DM , PAF , PVD history of RAS stenting , uterine CA history of TAH/BSO
2004 , ACD , CRI baseline Cr 2.0 , stage intravenous NSCLC ( T4NxM1 ) , recurrent.
ALL: NKDA
MEDS: lisinoptil 2.5 , pravachol 40 , asa 81 ,
coumadin 2 , niaspan 500 , lasix 80qam 40qpm , metoprolol 25mg orally twice a day ,
levoxyl 100mcg , allopurinol 100 , nexium 20 , glipizide 5mg every day before noon mg
every afternoon
SH: former smoker , 30py , no EtOH no IVDU
EXAM: 96.6 97 112/48 22 100%
( 3L ) NAD JVP 9 bibasilar rales s1 s2 iii/vi SEM ii/vi
HSM abd benign ext warm no edema dp2+ bilat. a&ox3 STUDIES:
ECHO 9/19 EF 40% mild cLVH mid/dist sept apex AK , mod surrounding
HK , mild LAE , mod/severe central MR , trace TR , PA 41+
RVP. CATH: 2001: LAD 60% OM2 100% RCA 40% collaterals
RLV->OM2 MIBI 3/14 adenosine , limited by soft tissue ,
large sie moderate intensity fixed basal/inf/septal defect
UA: 2+ prot , neg nit/le/wbc EKG 10/22 ( KAAH ) sinus tachy , incomplete
LBBB , leftward axis deviation , 1st deg AVB , 1mmST dep
v5/v6 , TWI L/I/6 CXR 10/22 ( KAAH ) AP , mod pulm edema , postop
changes chem 7 wnl , INR 2.1 , CC wnl , enzymesflat
IMPRESSION:
75F with iCMP , mod-sev MR , recurrent stage intravenous bronchoalveolar lung Ca p/with
decompensated CHF.
HOSPTIAL COURSE BY SYSTEM
( 1 ) CV: Ischemia: a/b/c sets negative so ruled out for an MI. ETT 4.4 mets ,
Baseline ST changes in inferior and lateral leads limits specificity.
ASA , BB , statin , ACE continued. Cath ( 10/10 ) showed:
Left Main Coronary Artery
No significant LM lesions identified
Left Anterior Descending Artery
LAD ( Proximal ) , Generic 50% lesion
Left Circumflex Artery
CX ( Mid ) , Generic 80% lesion
Right Coronary Artery
RCA ( Ostial ) , Generic 40% lesion
RCA ( Mid ) , Generic 50% lesion
Moderate , non-severe CAD. A 50% mid LAD , a small true AV groove LCX with a
70-80% , a 40% ostial RCA with a mid vessel 50% stenosis. PUMP: flash
pulmonary edema of unknown origin no longer volume overloaded
after diuresis in KAAH ED and at PUO . Mild diuresis by ayugmenting pm
dose lsix to 80 while hospitalized , returned to 80qd prior to discharge.
Main change in regimen is that we reduced lasix dose to 80 every day orally Lasix.
MIBI On the day of discharge. patient was assessed by cardiac surgery for MVR
+/- CABG , but prior to surgery dental evaluation suggested possible
extraction; OR date cancelled , patient received dental films 4/8 , cleared for
OR , will go home 4/8 and patient will follow up with Dr.
Colasamte of Cardiac Surgery for scheduling of palliative MVR. patient will also
buy a home BP monitor so as to self check her
BP when short of breath to see if the HTN comes first or after.
RHYTHM: NSR , on tele , replete lytes
( 2 ) PULM: no O2 requirement
( 3 ) RENAL: baseline CRI , followed creatinine twice a day while diuresing
( 4 ) ONC: bronchoalveolar Ca stable per primary oncologist. Discussed with
Dr. Enamorado .
( 5 ) FEN: cardiac ADA 2g salt 2L fluid restrict. Aggressive K
repletion
( 6 ) Ppx: INR therapeutic for majority of hospitaliation , nexium ( off
coumadin for INR<2.0 for
catheterization , holding coumadin after d/c for anticipated cardiac
surgery ).
( 7 ) FULL CODE ( has been DNR/DNI before )
ADDITIONAL COMMENTS: You have been cleared for cardiac surgery , please follow up with Dr.
Isabelle Colasamte in the next week to schedule a date. Please call Dr.
Gihring office or present to the ED with any worsening of symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
--d/c to home on prior regimen exceopt lasix dose changed to 80mg every day ,
holding coumadin in anticipation of cardiac surgery
--f/u with Dr. Colasamte , cardiac surgery , on Monday
--use of lasix/NTG if episodic SOB
--f/u with Coletta Verry
--per dental , should cover with clinda as prophylaxis during cardiac
surgery
No dictated summary
ENTERED BY: DIVELBISS , LONNY O. , M.D. , PH.D. ( RE075 ) 10/1/06 @ 03:41 PM
****** END OF DISCHARGE ORDERS ******
Document id: 225
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OSA |
PVD |
VI |
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976282656 | PUO | 64160306 | | 2492688 | 9/27/2005 12:00:00 a.m. | MULTIPLE MYELOMA , FAILURE TO THRIVE | Signed | DIS | Admission Date: 6/26/2005 Report Status: Signed
Discharge Date: 10/11/2005
ATTENDING: ARGUST , STEPHAN KURT MD
PRINCIPAL DIAGNOSIS:
Fluid overload/CHF.
LIST OF PROBLEMS AND DIAGNOSES:
1. Cardiac
2. Renal/genitourinary
3. Heme
4. Onc
5. Endocrine
6. Pain
7. Psychiatric
BRIEF HISTORY OF PRESENT ILLNESS:
The patient is a 69-year-old male with a history of multiple
myeloma , and worsening BPH ( benign prostatic hypertrophy ) ,
requiring a Foley. The patient was seen in Setlake Caardlin County Medical Center on the day of admission and was noted to have a
hematocrit drop from the 37 range to 28.5 along with hypotension
and an increasing creatinine rising from 1.2-2.3 in one week's
time.
The patient was noted to have recently significantly increasing
lower extremity edema. He reports that over a 3-4 day period , he
went from having almost no edema to having very large legs , which
he describes "tree trunks." The patient reports that these were
painful at first , but are no longer painful. He reports that
they were always symmetric. The patient reports no prior history
of CHF ( congestive heart failure ) , or any severe cardiac
problems , which he is aware , but does report having heart attack
at 27 years old. The patient did not know the details of these
cardiac events at 27 years old , and has received minimal followup
for this issue. He does report that he was intermittently seen
by a cardiologist , and had a normal catheterization four years
ago. He reports he has never had an echocardiogram.
The patient also reports an episode of 30-minute chest tightness
the day prior to admission while he was having a Foley catheter
placed. The patient did not tell anyone about this at that time ,
and this pain desisted on its own. The pain was described as
substernal burning pain , with no left arm pain , no jaw pain , no
shortness of breath or diaphoresis , and no nausea or vomiting.
The patient has had no orthopnea or PND.
The patient has had a recent history increasingly worsening BPH.
The patient has a 15-year history of BPH , and is followed by Dr.
Haley Tonsil at Pagham University Of . The patient was
recently admitted to PUO for anuria , had a cystoscopy , clot
evacuation and was discharged on 7/24/05 with a Foley in place.
The patient followed up with Dr. Tonsil on 10/21/05 , had his
Foley removed , but failed this trial and he represented to an
outside hospital with clots and anuria. The patient's bladder
was irrigated and the Foley was replaced. He reports that he has
been passing clots but that he has been passing urine. The
patient also reports that his urine while having clots at times ,
is mostly clear and yellow , and that he continually makes urine
and has to replace the Foley bag.
PAST MEDICAL HISTORY:
1. Multiple myeloma ( Kappa ).
2. BPH.
3. Insulin-dependent diabetes mellitus type II.
4. Hypertension.
5. Nephrolithiasis.
6. Myocardial infarction at 27 years old.
ALLERGIES:
NKDA.
MEDICATIONS ON ADMISSION:
1. Verapamil 180 mg once daily.
2. Lisinopril 20 mg once daily.
3. Lasix 20 mg once daily.
4. Aldactazide 50/50 mg on Monday , Wednesday , and Friday.
5. Flomax 0.4 mg once daily.
6. Lipitor 10 mg once daily.
7. Proscar 5 mg once daily.
8. Percocet as needed for pain.
9. Lantus 15 units daily.
10. Humalog sliding scale insulin
11. The patient's chemotherapy - Velcade , last 8/4/05 .
12. Other medications recently used in association with
chemotherapy , Zometa , Aranesp.
13. As needed medications:
a. Lorazepam.
b. Ranitidine.
c. Senna.
SOCIAL HISTORY:
The patient used to work in construction and demolition. He had
never smoked , and has never drank alcohol. The patient was with
his wife , they have no children.
FAMILY HISTORY:
1. Cardiovascular - The patient's dad father of MI at 60 years
old.
2. Diabetes mellitus - The patient's sister died of
complications of diabetes.
3. Cancer - The patient does have history of cancer in his
family , but is unclear of the details.
BRIEF PHYSICAL EXAM:
Vital signs: Temperature 96.5 , pulse 70 , blood pressure 100/62 ,
respiratory rate 20 and the patient is satting 95% on room air.
General: The patient is alert , oriented , in no acute distress ,
and is not ill appearing. HEENT: Normocephalic , atraumatic ,
oropharynx is clear. No lesions or ulcers. No lymphadenopathy.
Anicteric sclerae. Cardiovascular , has JVP elevated to the angle
of the jaw. Regular rate and rhythm , with frequent premature
beat. No S3 or S4 appreciated. Pulmonary: A few crackles at
the left base otherwise clear to auscultation. Abdomen: Soft ,
nontender , bowel sounds present and normoactive. No
hepatosplenomegaly , no frank dullness. Extremities: 2-3+
pitting edema to the knees , symmetric bilaterally , shins
lukewarm. Strength 5/5 throughout in upper and lower
extremities. Neurological: The patient is alert and oriented
x3 , has normal affect. Reflexes in the biceps , patellar , and
Achilles tendons are equal bilaterally. Sensation grossly intact
on upper and lower extremities.
PERTINENT LABORATORY RESULTS:
On admission , the patient's white blood cell count was 7.2 , his
hematocrit was 28.5 , down from 37 one week previously. The
patient's platelet count was 238 , 000. The patient's chem-7 was
unremarkable with the exception of a creatinine of 2.3 , up from a
baseline of 1.2-1.4 over one week's time. The patient had a BNP
checked , which turned out to be 312 , elevated. The patient has
also had several recent imaging studies including renal
ultrasound on 2/6/05 , which showed multiple bilateral renal
cysts but no obstruction. An abdominal MRI was obtained on
2/20/05 , which showed small amount of ascites , an enlarged
prostate , multiple renal cysts , no other pathologies was noted.
The patient also had a CT to evaluate his ureters on 10/8/05 ,
which showed no stones in the kidneys or ureters , but an enlarged
prostate.
A cystoscopy report from 9/23/05 from a recent admission to
Pagham University Of showed oozing from tortuous veins in
the prostate.
The patient had an EKG , which showed first-degree block with a
left bundle branch block , and frequent PVCs. This was noted to
be present on an old examination , after consultation with an
outpatient cardiologist at Lovelin Medical Center . The patient
had a troponin I of 0.11 , slightly elevated. The patient's CK
was 136 , MB fraction 4.3 , both within normal limits. On
admission , the patient coagulation parameters showed an INR of
1.2. Other pertinent data includes an orally reported cardiac
catheterization at Tona Medical Center in 2001 , which showed no
obstructive coronary disease , but diffuse coronary artery
disease , with an ejection fraction of 50%. An adenosine MIBI
obtained in 2002 at Lovelin Medical Center showed possible old
inferior infarct , global hypokinesis and an ejection fraction of
35-40%. An echocardiogram obtained during this admission
demonstrated the patient's EF at this point to be 25% , rather
with global hypokinesis.
OPERATIONS OR PROCEDURES:
There were no operations or procedures performed during this
admission.
HOSPITAL COURSE BY PROBLEM:
Cardiovascular - the patient was determined initially to be
likely in congestive heart failure , with elevated neck veins , and
increased leg edema and a low blood pressure. Because the
patient was determined to be in CHF , he was diuresed with intravenous
Lasix , and later with orally Lasix , the patient was diuresed
approximately 2 liters per day over a 4-5 period. The patient's
blood pressure subsequently rose. After consultation with
Cardiology , it was determined that a beta blocker and an ACE
inhibitor should be added to the patient's medication regimen as
his blood pressure would allow , for demonstrated benefit and
congestive heart failure.
Because the patient was initially determined to have some risk of
myocardial infarction , had reported chest pain the day prior to
admission , and had slightly elevated troponins. The patient's
troponin and CK-MB were followed until they began decreasing. It
is likely that these very small elevations were due to small
amount of ischemia from demand , due to the patient's fluid
overload and anemia. The patient was continued on his statin
medication.
The patient on admission had frequent PVCs , and some short runs
of ventricular tachycardia lasting less than 5 beats. After
diuresis , the patient had no further runs of VT , and had only
minimal ectopy. The patient's electrolytes including potassium
and magnesium were checked daily and repleted as necessary.
Aspirin was withheld from the patient for now , despite having a
benefit in cardiac disease of this kind. This is because the
patient's hematocrit was low and he had recently had bleeding
likely from his bladder. Urology Department was consulted
regarding this decision.
Renal/genitourinary: The patient has a long known history of BPH
and is followed closely at Pagham University Of by Dr.
Haley Tonsil . The patient was recently admitted for these
problems due to obstruction , and instrumentation. On admission ,
the patient's urine did not have any red blood cells , and he had
no obvious clots at any point. After consultation with Urology ,
and after the patient had been diuresing well with Lasix , the
patient's Foley catheter was removed and after this point he had
no problem with urinating. The patient was maintained on Proscar
in addition to Flomax.
Heme: The patient's hematocrit drop was likely due to two
factors. First of all , the patient is known to have been losing
blood in the form of clots from his bladder. This is likely due
to bleeding from the surface of his prostate where a recent
cystoscopy had demonstrated tortuous veins. In addition , the
reading of hematocrit of 24.5 on admission was likely secondary
to dilution , the patient was massively fluid overloaded. The
patient's hematocrit rose after diuresis , and was maintained in
the 31-32 range without transfusion during admission. He was ,
however , typed and screened , and the plan was to transfuse him
should his hematocrit decrease below 30 , given his cardiac
history.
Oncologic: The patient is followed closely by Dr. Malachi at
Setlake Caardlin County Medical Center . His most recent treatment was on
8/4/05 and his multiple myeloma seems to be responding well to
therapy. During this admission , multiple myeloma was not an
active issue. See Brook Mepa Community Hospital notes for more information.
Endocrine: The patient has a history of type 2 diabetes , he
takes Lantus and Novolog at home. He was continued on these
medications while as an inpatient.
Pain: The patient was offered oxycodone as needed for pain. He did
not complain of any pain during admission.
Psychiatric: The patient , though pleasant and cooperative on
admission , became increasingly combative. On the night of
1/5/05 , he became very combative , and attempted to hit one of
the cross covering physicians. The patient was initially tried
on several medications to control this agitation including Ativan
and Zyprexa. These apparently were not effective at first. The
patient continued to have difficulty sleeping and was very
agitated. At one point , he would not take his medications.
Psychiatry was involved , and after much discussion with the
patient and involvement of social work , the patient did calm down
and agreed to medical care. At one point when he became
agitated , he was given Haldol intravenously , in addition to
Ativan , after being given these medications , the patient slept
very well through the night. When he awoke the next morning , his
mood was much improved , and he apologized for his behavior ,
reporting he did not know what happened. Because of the change
in mental status , several studies were obtained to investigate
this , a head CT showed no acute disease , only some bony changes
likely chronic due to multiple myeloma. In addition , the
patient's electrolytes were checked which were normal , the
patient's fingerstick blood glucose was checked which was normal.
In addition , an RPR was sent , in addition to folate and B12.
These labs were pending at the time of discharge and will be
followed up by his outpatient physicians.
CODE STATUS:
Full code.
COMPLICATIONS:
There were no complications during this admission.
CONSULTANTS:
1. Cardiology - the patient was seen by cardiology fellow , Dr.
Cornelia Zable , who set him up with follow up in the Totin Hospital And Clinic Cardiology Clinic.
2. Urology: Dr. Haley Tonsil , Pagham University Of .
3. Psychiatry: Dr. Luquin , Setlake Caardlin County Medical Center
Psychiatry.
KEY FEATURES OF PHYSICAL EXAM ON DISCHARGE:
At the time of discharge , the patient was mentating very well ,
thinking clearly , and was pleasant and cooperative. The
remainder of the patient's exam was much improved from his
admission and his lower extremity edema had decreased to 1+ , and
he continued to diurese well with orally Lasix. The patient's JVP
while still slightly elevated at 7 cm , was much decreased from
admission JVP , which had gone to the angle of the jaw. On
discharge , the patient was urinating well and had no urinary
symptoms.
DISCHARGE MEDICATIONS:
1. Colace 100 mg orally orally twice daily.
2. Ferrous sulfate 325 mg orally three times daily.
3. Lasix 80 mg orally once orally daily.
4. Lopressor 25 mg orally twice daily.
5. Proscar 5 mg orally daily.
6. Zyprexa 5 mg orally daily before bed.
7. Flomax 0.4 mg orally daily.
8. Nexium 20 mg orally daily.
9. Lantus 15 units subcutaneously each morning.
10. Humalog , sliding scale per patient's prior scale.
11. Lisinopril 2.5 mg once daily.
12. Lipitor 10 mg orally daily before bed.
DISPOSITION:
The patient was discharged to home with VNA followup.
PHYSICIAN FOLLOW-UP PLANS:
The patient has been setup to follow with the CHF Clinic at
Pagham University Of with Dr. Annabel Verfaille . The patient
has also been setup for a follow-up appointment with Cardiology
at Pagham University Of on 3/26/05 at 9 a.m. , the
patient will be setup for followup at the Nonup Community Hospital , the patient has also been setup with
Urology followup , they have contacted him directly. The
patient's inpatient psychiatry followup was contacted while an
inpatient , he will be contacted with further follow-up plans once
he has left the hospital.
ADVANCE DIRECTIVE:
The patient describes his wish to be full code at the time of
hospitalization.
eScription document: 2-5530900 EMSSten Tel
CC: Dominick Luquin MD
SSR Psychiatry
Lande Southlaretroit , Maine
CC: Haley Tonsil MD
Jose
Dictated By: MAINER , SHAVONNE
Attending: MAX Z. BALLER , M.D. OJ18
Dictation ID 9071924
D: 1/1/05
T: 1/1/05
Document id: 226
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OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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112270161 | PUO | 66883454 | | 318528 | 8/28/1998 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 3/24/1998 Report Status: Signed
Discharge Date: 6/25/1998
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
OTHER SIGNIFICANT PROBLEMS: 1 ) HYPOTHYROIDISM.
2 ) ATRIAL FIBRILLATION.
3 ) HYPERTENSION.
4 ) HYPERCHOLESTEROLEMIA.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old woman
with a history of myocardial
infarction , atrial fibrillation , hypertension and congestive heart
failure who presents with shortness of breath.
The patient is status post inferior posterior myocardial infarction
on March , 1998. Thrombolysis was deferred secondary to severe
hypertension ( systolic blood pressure was greater than 200 ).
Catheterization revealed 80% RCA stenosis with thrombus. She
underwent PTCA and stenting and ReoPro under the Nessinee Ker Hospital Medical Center study.
An echocardiogram revealed an ejection fraction of 45% , inferior
posterior lateral hypokinesis , 2+ tricuspid regurgitation , 2+
mitral regurgitation , moderate aortic insufficiency. She was
treated with Ticlid for 30 days , aspirin , Lopressor , Verapamil and
Captopril. That hospital course was complicated by asymptomatic
paroxysmal atrial fibrillation in the setting of pneumonia and new
diagnosis of hyperthyroidism ( TSH less than assay , T4 16.1 , T3 133 ,
THBR 1.24 ). She was started on Procainamide and subsequently as an
outpatient on PTU without recurrence of atrial fibrillation. She
has been treated with Coumadin. On April , 1998 , she was admitted
for left upper extremity weakness with a question of transient
ischemic attack in the setting of subtherapeutic INR. Head CT scan
was negative and brain MRI/MRA was also negative. On September ,
1998 , she was admitted to Pande Memorial Hospital for flash pulmonary
edema requiring intubation. She was in normal sinus rhythm , but
hypertensive. She ruled out for myocardial infarction and repeat
catheterization showed patent stent , otherwise unchanged. She was
subsequently started on Lasix and was well until the night prior to
admission when she developed gradually worsening shortness of
breath , wheezing and chest pain. Also , she had an increase in
orthopnea from one to two pillows , diaphoresis and worsening of her
baseline right shoulder pain with no edema. She had a cough
productive of scant white sputum for three days prior to admission ,
no fever or chills. In the emergency room , her blood pressure was
found to be 230/100 with an oxygen saturation of 91% on room air
increasing to 95% on two liters. She had crackles one-third of the
way up her lung fields bilaterally. EKG was in normal sinus
rhythm. Chest x-ray showed edema and effusion. She improved
quickly with oxygen , nitrates and Lasix.
PAST MEDICAL HISTORY: Significant for coronary artery disease ,
status post myocardial infarction in
October of 1998 , congestive heart failure with an ejection
fraction of 45% , hypertension , diabetes mellitus , paroxysmal atrial
fibrillation , hyperthyroidism , bilateral retinal detachment , status
post left cataract surgery , status post appendectomy , status post
cholecystectomy.
MEDICATIONS ON ADMISSION: 1 ) Atenolol 100 mg orally every day. 2 )
Lisinopril 20 mg orally every day. 3 )
Aspirin 325 mg orally every day. 4 ) Coumadin 2 mg orally every day. 5 )
Procainamide 500 mg orally four times a day 6 ) Simvastatin 20 mg orally every day.
7 ) PTU 100 mg orally twice a day 8 ) Lasix 10 mg orally every day. 9 )
Prilosec.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: She immigrated from the Di in
1981. She lives with her daughter and has a two
pack per day smoking history times 40 years. She has no alcohol
use.
PHYSICAL EXAMINATION: On physical examination , she was breathing
comfortably , supine at 30 degrees. Vital
signs: Temperature 98.4 degrees , heart rate 61 and regular , blood
pressure 153/75 , respiratory rate 18 , with an oxygen saturation 93%
on three liters. HEENT examination revealed that the sclerae were
anicteric. Pupils were equal , round and reactive to light.
Extraocular movements were intact. Oropharynx was benign. Neck
revealed that the jugular venous pressure was elevated to her ear.
Carotids were 1+ on the right , 2+ on the left. There was a
question of a right carotid bruit. There was no thyromegaly.
Lungs revealed crackles half way up bilaterally , no wheezing.
Cardiac examination was regular rate and rhythm with an S4 ,
intermittent S3 , no murmurs. Abdomen revealed normal active bowel
sounds , soft and non-tender , mildly distended with a pulsatile
liver. Extremities revealed no clubbing , cyanosis or edema. There
were 2+ dorsalis pedis pulses bilaterally. There was no calf
tenderness. Skin was warm and dry. Neurological examination
revealed that cranial nerves III-XII were intact. Motor was five
out of five throughout. Sensory was intact to light touch
throughout. Reflexes were 2+ bilaterally with downgoing toes.
Rectal examination was guaiac negative in the emergency room.
LABORATORY: Admission laboratory studies revealed a sodium of 140 ,
potassium 4.4 , chloride 105 , bicarbonate 26 , BUN 19 ,
creatinine 0.6 , glucose 149. White blood cell count was 12.3 ,
hematocrit 38.8 , platelet count was normal. CK was 44. Troponin
was 0.03. INR was 1.8. EKG showed normal sinus rhythm at 90 with
old inferior Qs , left ventricular hypertrophy with strain in I and
L which were old , T-wave inversion in III and V6 as well as
pseudonormalized T-waves in V1 through V4 which are new compared
with October , 1998. Chest x-ray showed cardiomegaly , pulmonary
vascular redistribution , Kerley B lines , but no infiltrate.
HOSPITAL COURSE: 1 ) Congestive heart failure: The assessment was
that the patient presented in acute congestive
heart failure , most likely due to diastolic dysfunction in the
setting of hypertension. Other contributing factors possibly
playing a role in the patient's heart failure could have included
medication non-compliance and dietary indiscretion. Another
possibility entertained was that the patient could have had
transient atrial fibrillation triggering heart failure , however all
of her EKGs showed her to be normal sinus rhythm , questioning this
possibility. The patient was diuresed with intravenous Lasix and
stabilized on orally Lasix during her hospital course.
She ruled out for myocardial infarction by CKs , Troponin and EKG.
2 ) Hyperthyroidism: The patient's TSA was measured to be at less
than assay on May , 1998 raising the possibility that uncontrolled
hyperthyroidism could also be contributing to her cardiac
dysfunction. An Endocrine consult was obtained with the
recommendation that her PTU be increased to 100 mg three times a day Her T4
and THBR were measured and found to be 8.1 and 0.91 which were
within normal limits after the increased dose of PTU. The patient
is to receive follow-up in the Thyroid Clinic for definitive
therapy , possibly iodine ablation of known thyroid nodules in her
left lobe.
3 ) Elevated white blood cell count on admission , but with a normal
differential: The patient remained afebrile throughout her
hospital course. Urinalysis was negative for infection and repeat
chest x-ray showed no infiltrate.
4 ) Hypertension: The patient's blood pressure remained in the
range of 110-155/50-70s during her hospital course on Atenolol ,
Isordil and Lisinopril.
MEDICATIONS ON DISCHARGE: 1 ) Aspirin 81 mg orally every day. 2 )
Atenolol 100 mg orally every day. 3 ) Lasix
80 mg orally every day. 4 ) Isordil 20 mg orally three times a day 5 ) Lisinopril
40 mg orally every day. 6 ) Procainamide SR 500 mg orally four times a day 7 ) PTU
100 mg orally three times a day 8 ) Coumadin 4 mg orally every day.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISPOSITION: The patient was discharged to home with VNA services
to check weights and assistance with medication.
FOLLOW-UP: The patient is to follow-up with Dr. Aspen on February ,
1998 and Dr. Orehek in the Thyroid Clinic on August ,
1998.
Dictated By: JOSUE M. KINSLER , M.D. LC40
Attending: JOSUE M. KINSLER , M.D. ZZ37 RQ075/5440
Batch: 49883 Index No. EHYCC2UQA D: 8/18/98
T: 10/20/98
Document id: 227
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
312310065 | PUO | 84445745 | | 2301637 | 2/18/2003 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 7/13/2003 Report Status: Signed
Discharge Date: 1/10/2003
PRINCIPAL DISCHARGE DIAGNOSIS: Coronary artery disease , status
post CABG times three and colon
cancer.
HISTORY OF PRESENT ILLNESS: 77-year-old man with a history of
myocardial infarction , status post
catheterization in 1997 showing MVD decided not to have CABG at
that time , but presented for CABG in July 2003. He had been doing
well on medical management , but began having episodes of chest and
shoulder pain over the few days prior to admission , which were
accompanied by EKG changes. He was transferred to the Pagham University Of for catheterization , which again showed MVD , and
an EF of 43%. This patient's history makes him class three angina ,
as well as , class three heart failure with marked limitation of
physical activity during his preoperative evaluation in normal
sinus rhythm.
REVIEW OF SYSTEMS: The patient's gastrointestinal system was
negative at the time of admission.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus.
3. Hyperlipidemia. 4. Depression.
5. Cholelithiasis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 25 mg orally every day , Lisinopril
20 mg orally every day , isosorbide 30 mg orally
every day , aspirin 325 mg orally every day , atorvastatin 20 mg orally every day ,
Paxil 40 mg orally every day.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: Positive tobacco. The patient smokes cigars , and
a history of occasional alcohol use. The patient
is married.
PHYSICAL EXAMINATION: VITAL SIGNS: Height 170 centimeters , weight
91 kilograms , temperature 96.9 , pulse 64 ,
blood pressure 140/70 , measured in the right arm. HEENT:
Normocephalic , atraumatic. There is no scleral icterus. Pupils
are equal , round , and reactive to light. Oropharynx is clear.
Dentition is intact without evidence of infection. NECK: Supple.
There are no carotid bruits. CHEST: Clear to auscultation
bilaterally. CARDIOVASCULAR: Shows a regular rate and rhythm.
with an S4 and intermittent S3. Pulses are as follows: Pulses are
2+ throughout bilaterally in the carotid , radial , femoral , dorsalis
pedis , posterior tibial artery. ABDOMEN: Soft , non-tender ,
non-distended with no palpable masses and active bowel sounds.
RECTAL: Examination was guaiac positive. EXTREMITIES: Warm and
well-perfused with no edema or varicosities. NEUROLOGICAL: Shows
that he is alert and oriented with no observed focal deficits.
LABORATORY DATA: Preoperative laboratory studies on 6/8/03:
Sodium 142 , potassium 3.7 , chloride 106 , carbon
dioxide 29 , BUN 14 , creatinine 0.9 , glucose 152. Magnesium 2.0.
White blood cells 4.6 , hematocrit 33.1 , platelets 181 , physical therapy 13.9 , PTT
34.0 , INR 1.1.
An ECG on 4/7/03 showed normal sinus rhythm at 64 beats per minute
with inverted T's in leads II , III , and AVF. Chest x-ray on
11/8/03 is normal.
HOSPITAL COURSE: The patient underwent the following procedures
while a patient here at A Salt Medical Center 1. EGD 12/10/03 , by Dr. Cujas . 2. Coronary artery
bypass grafting times three with saphenous vein graft to PDA ,
saphenous vein graft to second obtuse marginal artery , and LIMA to
LAD , by Dr. Colasamte . 3. Colonoscopy 11/10/03 . 4. Right colectomy ,
sigmoid colectomy , open cholecystectomy , transverse mucous fistula ,
and sigmoid mucous fistula on 3/20/03 that was by Dr. Calver .
HOSPITAL COURSE BY SYSTEMS: Neurological: The patient has had no
neurological events during his
hospitalization. He continues on Paxil 40 mg orally every day for
depression , and he has no pain.
Cardiovascular: The patient is a 77-year-old gentleman who
presents with recurrent unstable angina. His prior episode had
been in 1977 at which time he was found to have modest triple
vessel coronary disease. He had been medically managed
successfully , but presented with recurrent unstable angina. An
ejection fraction was 42% with inferior hypokinesis to akinesis.
Preoperatively , he was found to have severe triple vessel coronary
artery disease. The patient was taken for coronary artery bypass
grafting times three as described above on 10/6/03 . This was
performed by Dr. Colasamte without complications. The patient
improved well postoperatively. He was at the point of being ready
for discharge to rehabilitation when a bed was available. Because
he had been found to be guaiac positive preoperatively , it was
decided to perform a colonoscopy before his discharge. The rest of
his GI history will be discussed below in the GI section.
The other significant event regarding the patient's cardiac system
occurred on his way to the Operating Room on 3/20/03 , with an acute
abdomen. While transferring the patient to the Operating Room
table , he had a cardiac arrest lasting one and a half minutes. He
was rapidly intubated and stabilized. Following the operation a an
EKG was needed emergently. The patient ruled out for an MI. He
did have postoperative atrial fibrillation. He is currently in
normal sinus rhythm , but slips in and out of atrial fibrillation.
His rate is well controlled on Lopressor 100 mg orally four times a day ,
amiodarone 200 mg orally every day. He has been anticoagulated with
Coumadin , and he is currently therapeutic with his most recent INR
on 10/14/03 of 2.6. His most recent Coumadin doses have been five mg
on 9/26/30 , three mg on 10/10 , zero mg on 9/19/2 ,
and four mg on 10/27 . The patient's primary cardiologist is Dr.
Meduna , and the patient will follow-up with Dr. Meduna .
His most recent INR is 2.4 on 6/17/03 , and his Coumadin will be
dosed at rehabilitation today.
Respiratory: The patient was intubated for his procedures. He was
extubated without difficulty. He currently has no respiratory
issues. His oxygen saturation is 96% on room air. His most recent
chest x-ray was a portable chest x-ray on 5/25/03 , which showed
subsegmental atelectasis and a minimal right pleural effusion , but
no evidence of congestive heart failure or other disease processes.
Gastrointestinal: A preoperative work-up before his coronary
artery bypass graft surgery showed that the patient was guaiac
positive and EGD on 12/10/03 by Dr. Cujas showed no lesions as a
likely cause of his GI bleeding , but did reveal some gastritis. It
was decided that it would be safe to proceed with surgery , and have
the patient follow-up with a colonoscopy after his procedure.
Discharge was planned , and before discharge a colonoscopy was
performed on 11/10/03 by Dr. Karapetyan . A single large pedunculated
smooth polyp at 25 centimeters from the anus was found. After this
procedure the patient did well initially , but then did develop
abdominal distention. At first it was thought that his symptoms
were due to Ogilivie's syndrome or pseudo-obstruction , however ,
because of his distention it was not felt safe to perform a barium
enema. A KUB showed air throughout the colon and small bowel. He
had absolutely no pain or tenderness. The General Surgery Service
was consulted and an NG tube was placed , and he was given enemas
p.r. He did well with no complaints of pain or tenderness ,
however , a KUB on 9/8/03 showed that his cecum was distended 12
centimeters and the white count was over 20. CT scan showed a
cecum to be 14 centimeters and there was a suggestion of narrowing
of the sigmoid colon. It was decided to take him to the Operating
Room. A routine chest x-ray showed free air in the diaphragm which
was concerning and surgery was undertaken. Please see the
operative note of Dr. Calver for details regarding this procedure.
A right colectomy , sigmoid colectomy , cholecystectomy ,
transverse mucous fistula , and sigmoid mucous fistula were
performed. The patient improved well postoperatively. We were
able to advance his diet and discontinue his two JP drains. At
discharge the patient was tolerating a regular diet. His wound is
healing well and his staples have been removed. Intraoperatively
the patient was found to have obstruction of the sigmoid colon and
a pathological specimen revealed adenocarcinoma moderately
differentiated , four centimeters in maximum dimension. The tumor
invaded through the rest of the pericolonic fat. Margins were
clear and ten lymph nodes were negative for disease. The stage of
the tumor is T4BN0MX. The patient will follow-up with Dr. Calver
regarding further management of this cancer.
GU: Two attempts have been made to discontinue the patient's Foley
catheter most recently on 10/14/03 . He had a high postvoid residual ,
the Foley catheter was left in. The patient is on Flomax. He will
be discharged with a Foley in place and discontinuation of the
Foley should be tried again in seven days. His most recent set of
electrolytes on 6/17/03 include a potassium of 4.3 , magnesium 1.8.
He is making good urine output.
Hematology: The patient has had no hematologic issues during his
hospitalization. His anticoagulation for atrial fibrillation is
covered above. His most recent laboratory values on 6/17/03 , are
white blood cells 6.8 , hematocrit 30.4 , platelets 247 , physical therapy 25.7 , PTT
49.8 , INR of 2.4.
Infectious disease: The patient was treated with perioperative
ampicillin , levofloxacin , and Flagyl. He is currently on no
antibiotics and has no infectious disease issues. His white count
is 6.8 and he is afebrile.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: Dr. Calver call for appointment in one to two weeks.
Dr. Meduna call for an appointment in one to two
weeks. Dr. Colasamte call clinic for appointment in four weeks. Dr.
Donehoo call for appointment after discharge from rehabilitation.
MEDICATIONS ON DISCHARGE: Ecasa 81 mg orally every day , glyburide five
mg orally every day before noon , ibuprofen 200 mg orally q.
four to six hours as needed pain , lisinopril 20 mg orally every day ,
Lopressor 100 mg orally four times a day hold for SBP less than 90 , heart rate
less than 50 , Coumadin every day , Paxil 40 mg orally every day , simvastatin
40 mg orally every bedtime , Flomax 0.4 mg orally every day , Humalog insulin
sliding scale blood sugar less than 150 give zero units , 151 to 200
give four units , 201 to 250 give six hours , 251 to 300 give eight
units , 301 to 350 give ten units , Nexium 20 mg orally every day.
Dictated By: LIZABETH WARPOOL , M.D. JK76
Attending: JENNIE CALVER , M.D. ZO325 DL963/335769
Batch: 66166 Index No. G4LHO4266P D: 6/14/03
T: 6/14/03
Document id: 228
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
745816481 | PUO | 53863389 | | 0947434 | 11/25/2004 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | Signed | DIS | Admission Date: 2/4/2004 Report Status: Signed
Discharge Date: 2/17/2004
ATTENDING: JERAMY CASSEM M.D.
DISCHARGE DATE AND TIME:
The patient is being discharged from the Medical Intensive Care
Unit at 1:00 p.m. on the 2/17/2004 .
DISPOSITION:
The patient is to be discharged to Asidea Rehabilitation Hospital today.
ADMISSION DATE:
The patient was admitted to Pagham University Of on
2/4/2004 and was admitted to the Medical Intensive Care unit on
6/29/2004 .
PRINCIPAL DIAGNOSES:
The patient was admitted to Pagham University Of with the
diagnosis of changes in mental status secondary to hypercarbia.
The patient was admitted to Medical Intensive Care Unit with
hypercarbic respiratory failure.
PAST MEDICAL HISTORY:
Significant for COPD , CHF , CAD , non-insulin-dependent diabetes
mellitus , renal insufficiency , chronic venostasis , cellulitis ,
obesity , gout , sleep apnea , asthma , hypertension , urinary
retention , degenerative joint disease of the right knee. The
patient is status post CABG 1999 three vessels. The patient has
an 80-pack-year smoking history. The patient is on two liters of
nasal cannula at home. The patient is full code.
HISTORY OF PRESENT ILLNESS:
The patient is an 80-year-old gentleman with a long history of
COPD who is on 2 liters of nasal cannula at home with
80-pack-year of smoking history.
Briefly , the patient is an 80-year-old gentleman who was admitted
to Pagham University Of on 2/4/2004 with drowsiness and
slurred speech. Initial ABG showed pH of 7.25 , PCO2 of 82 , PO2
of 56 , sating 87%. He quickly awakened after Narcan was
administered. Recently , he had been taking an increased amount
of opiates for pain and he was admitted with a diagnosis of
hypercarbia secondary to increased opiate intake and COPD flare.
The patient had a long history of COPD. He has an 80-pack-year
of smoking history and is normally on 2 liters of nasal cannula
at home. He was initially treated for COPD on the floor and
given gentle hydration as he also suffers chronic renal
insufficiency. He was given Percocet for pain control. The
patient appears to be improving by serial arterial blood gasses.
Had decrease in creatinine and improved mental status. At 11:00
a.m. on the 6/29/2004 the patient was found breathless and
pulseless. At that time , his ABG showed a pH of 7.04 , PCO2 of
95 , PO2 of 47 , he was sating 54%. An ACLS code was 1. The
patient received 1 mg atropine and 0.04 of Narcan. He appeared
to be aspirating when intubated. He was admitted to the Medical
Intensive Care Unit where he was until 2/17/2004 , when he was
discharged.
ALLERGIES: The patient has questionable penicillin allergies
with unknown reaction.
PERTINENT PHYSICAL EXAM:
In general , the patient is an obese Hispanic male who is sedated
and intubated. He responds to commands and is oriented to voice
on admission to the Medical Intensive Care Unit. His skin showed
his lower extremities with changes of chronic venostasis. He had
erythema to the knees , nonpitting edema bilateral to the knees
and induration of skin on legs , medial thigh , and bilateral
popliteal fossae. His feet had onychomycosis bilaterally with no
clearcut abrasions or cuts. The rest of his skin exam was
remarkable for multiple ecchymoses , one weeping plaque on the
abdomen at heparin injection site. His right subclavian line was
nontender and nonerythematous with one leaking port. Head and
neck exam: His pupils were equal , round and reactive to light and
accommodations. His extraocular movements were intact. His
oropharynx was clear. His endotracheal tube and OG tube were in
place. His chest sounds were clear anteriorly. He had decreased
breath sounds laterally. He had isolated wheezing at the left
midclavicular line. His heart sounds , S1 and S2 were heard. His
abdomen was obese. He had a large panus , no appreciable
organomegaly , tenderness and hyperactive bowel sounds.
Extremities: He was moving all four extremities spontaneously.
They were warm and perfused. Neurologically , his cranial nerves
were grossly intact. There were no focal anomalies.
On addition , the patient had a sodium of 140 , a potassium of 5.4 ,
chloride of 104 , carbon dioxide of 24 , BUN of 72 , creatinine of
2.1 , glucose of 153. She had an ionized calcium of 1.04 and
magnesium of 2.1.
HOSPITAL COURSE BY PROBLEM:
1. Pulmonary. The patient was admitted to the MICU with
hypercarbic respiratory arrest and aspiration pneumonia per
symptoms , signs and chest x-ray. Given the history and timing of
the arrest , the patient likely was hypercarbic secondary to COPD
exacerbation , as hypercarbic arrest occurred several days in
house where opiates were not administered. It is highly
improbable that the arrest happened secondary to opiate ingestion
rather patient likely had COPD exacerbation. Also , the patient
has significant cardiac history of CHF and CAD , which may have
contributed. Subsequent chest CT on the floor demonstrated that
in addition the patient had very significant pleural effusions.
The patient was treated for aspiration pneumonia with
levofloxacin and Flagyl and aztreonam. He was also treated with
albuterol Atrovent nebulizers. Aggressive physical therapy was
also provided for the patient. The patient after completing his
antibiotic treatments for aspiration pneumonia was noted to have
MRSA growing in his sputum. He was given a 14-day course of
vancomycin as well to treat MRSA pneumonia. To help the
patient's pulmonary status , significant diuresis was attempted.
The patient was typically diuresed at 1-2 liters per day. The
aggressive diuresis was estimated to have taken in the
neighborhood of 15-20 liters of the patient and this likely
remarkably helped the patient's breathing status and his ability
to get off the ventilator. The patient had a tracheostomy and
peg placed on 8/27/04 and began breathing on trache collar on
the 6/11/04 and has been breathing until the present time
successfully on trache collar.
2. ID. The patient was diagnosed with aspiration pneumonia. He
was also colonized with MRSA and VSE by the end of his course.
During his initial MICU admission he was diagnosed with
vancomycin sensitive enterococcal UTI. He was treated with
antibiotics for all of these. His aspiration pneumonia was
treated with levofloxacin , aztreonam and Flagyl. Subsequent MRSA
pneumonia was treated with vancomycin. The patient has not had ,
at the time of admission , white count or a significant fever and
his cultures two days prior to discharge have been negative.
3. Cardiovascular. The patient has a significant cardiac
history for CHF and CAD. His heart rhythm has been mostly stable
during the course of his hospitalization. Hypertension has been
treated with Lopressor.
4. Renal. The patient has a history of chronic renal
insufficiency. However , renal function had improved during the
patient's hospital course. At the time of discharge , the patient
had a creatinine of 0.9 , a BUN of 38 , a potassium of 3.9 and a
creatinine of 0.9. Presumably , the aggressive diuresis that was
conducted did not affect the patient's renal function adversely.
5. Endocrine. The patient has a history of
non-insulin-dependent diabetes mellitus. He was put on Lantus
and insulin sliding scale , by the end of his day he was on 80
units of Lantus plus requiring additional insulin on the sliding
scale.
CODE STATUS:
The patient is full code. The proxy for the patient is his
daughter , Broyles , who was actively involved in the patient's care.
NUTRITION:
The patient was fed on Jevity tube feeds during most of his
medical ICU course.
DISCHARGE PHYSICAL EXAM:
The patient's physical exam was notable for a tracheostomy in
place with a clean site of insertion. GJ tube placed in the
abdomen with a clean surgical wound. Clear sounding lungs with
breath sounds that can be heard more extensively than before from
the anterior side , resolving chronic venostasis and with those
exceptions the patient's exam remain similar to his admission
exam. In general , the patient is interactive , alert and
oriented.
DISCHARGE MEDICATION:
Include Tylenol 650 mg orally every 6 hours as needed pain , acetylsalicylic
acid 325 mg orally every day , Dulcolax 10 mg orally every day , hold of
diarrhea , Colace 100 mg orally twice a day , fentanyl patch 75 mcg per
hour topical patch , change every 72 hours or hold if there is a
change in mental changes , Lasix 120 mg orally every day , Haldol 4 mg
orally every 4 hours as needed for agitation , insulin sliding scale ,
subcutaneous insulin every four hours , if the blood sugar is less
than 110 , give 0 units , if the blood sugar is between 111 and
130 , give 1 unit , if the blood sugar is between 131 and 150 , give
2 units , if the blood sugar is between 151 and 200 , give 3 units ,
if the blood sugar is between 201 and 250 , give four units , if
the blood sugar is between 251 and 300 , give 6 units , if the
blood sugar is between 301 and 350 , give 8 units , if the blood
sugar is greater than 351 , then contact the officer. Lactulose
orally every 6 hours as needed constipation , Ativan 2 mg orally every 6 hours as needed
anxiety , milk of magnesia 30 mL orally every day as needed constipation ,
Lopressor 25 mg orally three times a day hold if systolic blood pressure is
less than 100 or heart rate is less than 55 , senna tabs two tabs
orally twice a day , multivitamins , Zocor 20 mg orally every bedtime , avoid grape
juice or grape fruit with this medication , Lovenox 40 mg
subcutaneously everyday , K-Dur slow release of potassium 20 mEq
orally every day , Zyprexa 10 mg G tube twice a day , miconazole nitrate 2%
powder topical TP twice a day , Nexium 20 mg orally , Lantus 80 units
subcutaneously every bedtime , please give the patient half a dose if he
is npo , DuoNeb every 6 hours as needed for shortness of breath.
CODE STATUS:
The patient is full code and the health care proxy is Broyles .
eScription document: 8-0365370 EMSSten Tel
Dictated By: ESANNASON , BELINDA
Attending: CASSEM , JERAMY
Dictation ID 7716683
D: 3/20/04
T: 3/20/04
Document id: 229
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
Y |
Y |
N |
N |
N |
Y |
- |
N |
N |
N |
N |
- |
N |
579817978 | PUO | 25198085 | | 310152 | 11/9/2002 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 6/19/2002 Report Status: Signed
Discharge Date: 2/27/2002
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE.
OTHER DIAGNOSES: VULVAR ABSCESS , HYPERTENSION , INSULIN DEPENDENT
DIABETES MELLITUS , HYPERCHOLESTEROLEMIA ,
DEPRESSION , PERIPHERAL NEUROPATHY , AND ASTHMA.
DISCHARGE DISPOSITION: To rehabilitation.
HISTORY AND PHYSICAL EXAM: The patient is a 48-year-old female
with a history of diabetes mellitus ,
hypertension , congestive heart failure , coronary artery disease ,
recently discharged from I Warho Hospital for treatment of
a vulvar abscess , during admission had an episode of CHF. Workup
was significant for a diminished ejection fraction of 30% , global
hypokinesis , and reversible ischemia on MIBI scan , and three-vessel
coronary artery disease on cath. At that time , CABG was
recommended , but the patient deferred. She now returns with
congestive heart failure and again recommended for CABG. She has a
history of class III heart failure. Patient's signs and symptoms
of congestive heart failure include dyspnea on exertion , pulmonary
edema on chest x-ray. Patient is in normal sinus rhythm.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus on insulin
therapy , hypercholesterolemia , depression ,
peripheral neuropathy , and asthma.
PAST SURGICAL HISTORY: She had a total abdominal hysterectomy and
bilateral salpingo-oophorectomy.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: History of tobacco use , 36 pack year smoking
history.
ALLERGIES: Penicillin , Cipro , narcotics , and Flagyl.
MEDICATIONS: Atenolol 25 mg orally every day , lisinopril 20 mg orally q.
day , enteric coated aspirin 325 mg orally every day ,
Nexium , Zocor , NPH 4/11 .
PHYSICAL EXAM: Heart rate 80 , blood pressure in the right arm
100/62. HEENT: No carotid bruits.
CARDIOVASCULAR: Regular rate and rhythm , no murmurs. Allen's test
in the left upper extremity: Abnormal loss of pulse wave form and
low perfusion signal on the monitor; right upper extremity:
Abnormal loss of pulse wave form and low perfusion signal on the
monitor. RESPIRATORY: Breath sounds clear bilaterally. PULSES:
Carotid , radial , femoral , dorsalis pedes , and posterior tibial 2+
bilaterally. ABDOMEN: No incisions , soft , no masses.
EXTREMITIES: Without scarring , varicosities , or edema.
LABS: Sodium 135 , potassium 4.3 , chloride 100 , carbon dioxide 23 ,
BUN 36 , creatinine 1.2 , glucose 266 , magnesium 2.1. White
blood cells 11.78 , hematocrit 37.3 , hemoglobin 12.6 , platelets 329 ,
physical therapy 12.7 , INR 1.0 , PTT 27.5. Urinalysis was consistent with
infection. CARDIAC CATHETERIZATION: Coronary anatomy: 80% LAD
stenosis , 50% obtuse marginal stenosis , 50% right coronary artery
stenosis , right dominant circulation. Echo with 30% ejection
fraction , moderate mitral insufficiency , trivial tricuspid
insufficiency.
Patient was admitted on 7/5/02 and stabilized for surgery. On
6/21/02 the patient was taken to the operating room , where she
underwent a coronary artery bypass graft x 3 , with LIMA to the LAD ,
saphenous vein graft to the right coronary artery , and saphenous
vein graft to the diagonal 1. Patient was transferred to the
Intensive Care Unit in stable condition. Immediate postoperative
complications included hyperglycemia treated with a Portland
protocol , leukocytosis for which pan cultures were done and only a
urinary tract infection was found , levofloxacin treated , and white
blood cells came down. Patient also had a low ejection fraction ,
and captopril and low dose Lopressor were started , and pulmonary
edema , for which aggressive diuresis was started. Patient was
treated prophylactically for a vulvar abscess which was I&D'd on
10/18/02 with clindamycin. GYN was consulted and recommended to D/c
antibiotics. Patient was mobilized , diuresed , had no further
complications , and eventually was discharged to rehab on 11/25/02 .
DISCHARGE INSTRUCTIONS: Diet is no added salt , low saturated fat ,
low cholesterol , 2100 kilo/calorie ADA
diet , limited to 2 L intake a day. Follow-up appointment with Dr.
Barrette in 6 weeks , Dr. Gruntz in 1-2 weeks.
TO DO PLAN: Keep feet elevated while sitting , shower patient
daily , monitor finger stick glucose as indicated , and
make follow-up appointments. Monitoring cardiovascular status and
local wound care should be paid attention to.
DISCHARGE MEDICATIONS: Albuterol nebulizer 2.5 mg nebulized every 4
hours as needed wheezing , enteric coated
aspirin 325 mg orally every day , Lasix 40 mg orally three times a day , Robitussin DM
10 mL orally every 6 hours as needed cough , ibuprofen 600 mg orally every 6
hours as needed pain , NPH insulin 22 U every 8:00 a.m. 10 U every bedtime
subcutaneously , and regular insulin 4 U every 8:00 a.m. 4 U every 5:00
p.m. subcutaneously , CZI insulin sliding scale , regular insulin
sliding scale every breakfast and supper. For blood sugar of <80 give
0 U subcutaneously , blood sugar from 80-125 give 4 U
subcutaneously , blood sugar from 126-200 give 6 U subcutaneously ,
blood sugar from 201-300 give 8 U subcutaneously , and if blood
sugar is from 301-400 give 10 U subcutaneously. If blood sugar is
>400 , call Dr. Barrette . Milk of Magnesia 30 mL orally every day as needed
constipation , Lopressor 25 mg orally three times a day , Niferex 150 mg orally
twice a day , Serax 15 mg orally every bedtime as needed insomnia , simvastatin 20 mg
orally every bedtime , Atrovent nebulizer 0.5 mg nebulized four times a day as needed
wheezing , K-Dur 20 mEq x 1 orally three times a day , levofloxacin 500 mg orally q.
day x 2 days , Nexium 20 mg orally every day , and lisinopril 20 mg orally
every day.
Dictated By: KAM ISA , PA-C
Attending: GENNY S. BARRETTE , M.D. LL6 DR995/499405
Batch: 2059 Index No. SBUCHI69E5 D: 5/3/02
T: 5/3/02
CC: 1. GENNY S. BARRETTE , M.D. , PUO CARDIAC SURGERY.
2. KATHERYN GRUNTZ , M.D. , MENLANDLOURDES MEDICAL CENTER , La I Van
Document id: 230
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
950440305 | PUO | 45326415 | | 7828571 | 6/11/2006 12:00:00 a.m. | Pulmonary hypertension | | DIS | Admission Date: 10/22/2006 Report Status:
Discharge Date: 10/1/2006
****** FINAL DISCHARGE ORDERS ******
HAWVER , OTHA A 423-35-25-2
Oroy Pkwy , Ranisadepa Gas Pem , South Dakota 82331
Service: CAR
DISCHARGE PATIENT ON: 5/1/06 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BURVINE , ALVERTA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally BEDTIME
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
2 TAB orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day before noon
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day before noon
Starting Today ( 9/11 )
Instructions: please give before 1st meal of day
LASIX ( FUROSEMIDE ) 40 MG orally every day before noon
INSULIN 70/30 HUMAN 40 UNITS subcutaneously twice a day
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LABETALOL HCL 400 MG orally every 8 hours Starting Tonight ( 3/4 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LEVOXYL ( LEVOTHYROXINE SODIUM ) 112 MCG orally DAILY
Starting Today ( 7/26 ) Instructions: to start as outpatient
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 6/14/06 by
FRIES , SPENCER L. , M.D.
on order for OXYCODONE orally ( ref # 038053214 )
patient has a PROBABLE allergy to Codeine; reaction is NAUSEA.
Reason for override: patient states takes at home
ALDACTONE ( SPIRONOLACTONE ) 12.5 MG orally every day before noon
Food/Drug Interaction Instruction Give with meals
DIOVAN ( VALSARTAN ) 160 MG orally DAILY
Number of Doses Required ( approximate ): 5
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Rufus Bernas , 787-0966 June , 2006 @ 9AM scheduled ,
Dr. Vaeth ( primary care physician ) as previously scheduled ,
ALLERGY: AMOXICILLIN , Codeine , LISINOPRIL ,
NUTS AND STRAWBERRIES
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pulmonary hypertension
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of R CEA ON 10/2 DM SINCE 1980 S.P L
CAD with cardiac catheterization; 2005 and 2006 with stent placement in the
LCX , LAD , RCA THR history of L TIBIAL FRACTURE HTN history of PTCA 3/3 RCA
OPERATIONS AND PROCEDURES:
L heart cardiac catheterization , which showed no change from prior
studies. R heart cardiac catheterization: pulmonary hypertension
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
HPI: 77 year-old woman with known CAD ( history of 4 stents to LCX/LAD/RCA on two
separate occasions ) presents with the sudden onset of severe sharp chest
pain at 4AM on the day of admission which awoke her from sleep. Severe ,
L sided , worse with inspiration & a/b nausea & diaphoresis; no SOB. Pain
not initially relieved by nitro. Presented to ED where EKG was without
changes and enzymes neg but D Dimer elevated at 801. Cont'd to c/o chest
pain; heparin initiated , along with ASA/Plavix ( home dose ); found to have
HTN at SBP 235 b/l arms; In the emergency department , she was treated with
hydralazine , sublingual nitro , nitro drip and then pain free; given lopressor 25.
Admit for with u of pain.
*****
PMHx: IDDM , diastolic CHF , hypothyroidism , history of RCEA , total hip
replacement
Cards HX: 8/13 cath with stents to LAD/LCX 11/3 cath with stents x 2 to
RCA
Echo data: known EF 55% in '03
*****
ALL: PEANUTS & STRAWBERRIES
*****
PE on ADMIT: NAD , BP 142/56 on nitro , RR 18 , 96% on 2L , 70 , afeb; no
bruit; JVP 8cm; rrr , no m/r/g , bibasilar crackles , reproducible sharp
pain. abd nl. alert , oriented x 3 tho sometimes requires
repeating. Nonfocal.
*****
**Labs: Cr 1.8 ( b/l ) Hct 34.4 ( b/l ) D Dimer 871 CK , MB fraction , TNI
<assay three times.
**CXR: cardiomegaly , no pulm edema
**V/Q scan: intermediate prob
**lenis - neg
**PE protocol chest CT: neg for PE. Ground glass diffusely. +LAD. Pulm
nodule , will need repeat for f/u in 6-12 months.
*****
Discharge Exam: BP systolic 130s , rare chest pain , occ'l crackles at bases
which clear with coughing; alert , oriented x 3 , somewhat anxious. otw at
baseline.
*****
A/P: 77F with ho CAD p/with chest pain of sudden onset: Original ddx includes
acs/usa/PE/hypertensive urgency or emergency/msk/chf. Given the excellenet
response to heparin and a negative cardiac catheterization , and the
continuoation of pain despite control of hypertension , the cardiac team
felt that the most likely diagnosis was a pulmonary embolism. However , had
neg lenis and PE CT , so unlikely PE. She was discharged home with follow up
with Dr. Nolan and with her usual primary care physician. Will need monitoring of lytes and
Cr given possibility of contrast induced nephropathy in setting of
underlying elev Cr.
**CV: ( i ): Chest pain was initially concerning for ischemic pain;
however , cardiac catheterization was unchanged from prior cath. She
will continue asa/plavix/BB/statin; she ruled out for MI with serial
enzymes and ekgs. Given an intermediate to high probability story
and an intermediate V-Q scan , she was continued on heparin and PE protocol
CT of chest was obtained , which was neg for PE but showed a pulmonary
nodule; she will need repeat CT for nodule f/u in 6-12 months. Excellent
oxygentation , stable walking and nearly pain free at time of discharge.
( r ): no active issues , telemetry monitoring was nl.
( p ): HTN , with ss , uptitrated labetalol for BP.
**PULM: PE intermediate pretest prob - elev d dimer but no ekg changes , no
o2 req , no known ca , no obvious dvt risks. lenis negative , PE CT neg , so PE
considered unlikely , will not anticoagulate. Pulm nodule on CT , will need
6-12 month f/u scan. Of importance however , has
pulm hypertension that is new on R heart cath and given no other
explanation for sudden pressure changes ( impressively higher since last
cath ) , may have primary pulm HTN. Given ground glass in lungs and pulm
nodule , should have outpt pulm eval for pulm parenchymal disease in near
future.
**endo: DM on 70/30 at home. Poor control given HbA1c elev and high
finger sticks in house. Chgd to nph and short acting pre-meal insulin for
tight control. patient agreed to incr freq of subcutaneously insulin for tight control ,
still high sugera in house. Wanted to send with NPH and short acting pre-meal
regimen but patient refused to change home regimen despite repeated explanations
of value of tighter control. Agreed that she would return to home regimen of
70/30 and f/u ASAP with Dr. Sana Albor of Endocrinology to optimize
insulin regimen; also should f/u with outpt pcp for titration. H/o
hypothyroidism. TSH elevated; gave script for
112 mcg of levoxyl ( an increase ) and contacted her o/p endocrinologist for
follow up.
**MSK: arthritis: oxycodone and tylenol as needed
**FEN mag/k/calcium
**ppx: heparin while in house.
**Code status: FULL CODE
ADDITIONAL COMMENTS: Work with your VNA for aggressive diabetes management. Please assess
blood sugars and titrate insulin as per your doctor. Please assess blood
pressures as well. Check your electrolytes with VNA in 1 week.
Continue diabetes teaching. thank you
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Check Cr , lytes in 1 week by VNA given contrast load and risk of
nephropathy. Pulmonary consult to eval for primary pulm
disease. Repeat chest CT 6-12 months to f/u nodule. Titrate insulin by
finger sticks at primary care physician. Monitor BP.
No dictated summary
ENTERED BY: WESTBERG , KAMALA M. , M.D. , PH.D. ( QE231 ) 2/13/06 @ 07:23 PM
****** END OF DISCHARGE ORDERS ******
Document id: 231
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
- |
N |
N |
Y |
Y |
N |
N |
Y |
N |
Y |
N |
281801955 | PUO | 38766817 | | 221952 | 9/25/2000 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/23/2000 Report Status: Signed
Discharge Date:
PRINCIPAL DIAGNOSIS: Right lower extremity cellulitis.
Type II diabetes mellitus.
Peripheral vascular disease.
Congestive heart failure.
Hypertension.
Chronic abdominal distention.
Chronic renal insufficiency.
Status post left femoral popliteal bypass
in 1997.
Status post skin graft on right heel for
diabetic ulcers in 1997.
Coronary artery disease.
Status post open reduction internal fixation
left ankle.
Spondylolothesis.
Hypercholesterolemia.
Peripheral neuropathy.
Diabetic gastroparesis.
Diabetic retinopathy.
Carpal tunnel syndrome.
Anemia.
HISTORY OF PRESENT ILLNESS: Ms. Rodger Eagleman is a 66 year-old woman
with a history of type II diabetes
mellitus , congestive heart failure , peripheral vascular disease who
presents to us with right leg swelling , pain and tenderness times
2-3 days. The patient was last discharged from Pagham University Of for congestive heart failure exacerbation and chronic
abdominal distention on November , 2000. She was in her usual state
of poor health until three days prior to admission when she noted
an increase in lower extremity edema bilaterally. Two days prior
to admission she noted fever , increased abdominal distention and
abdominal pain. She noted rash in the right lower extremity the
day prior to presentation which had rapidly progressed over one
day , extending from heel to knee. She had not been walking for
four days due to swelling in bilateral legs. She denies chest pain ,
dyspnea , constipation , diarrhea , orthopnea , PND , nocturia , melena.
She does not keep track of her own weight. Her last bowel movement
was one day prior to admission which was normal brown , slightly
loose.
PAST MEDICAL HISTORY: Significant for 1. coronary artery disease.
She had a stress test in 1994 which showed
anterior ischemia with no fixed defects. She had an echo in July ,
1997 which showed left ventricular hypertrophy with an EF of 55%
with minor inferior hypokinesis. 2. Congestive heart failure.
3. Type II diabetes mellitus. Last hemoglobin A1C was 9.5 in September ,
2000. Complications include peripheral neuropathy , retinopathy ,
nephropathy with a baseline creatinine of 1.3 to 1.9 and diabetic
gastroparesis. 4. Hypercholesterolemia. 5. Chronic low back pain.
6. Chronic constipation. 7. Anemia. 8. Peripheral vascular
disease , status post left femoral popliteal bypass in 1997. 9.
Status post right heel skin graft for ulcer in 1997.
10. Carpal tunnel syndrome , status post release in 1998.
11. History of Azotobacter pneumonia in 1997. 12. Status post
cholecystectomy. 13. History of C. difficile colitis. 14. Status
left ankle fracture open reduction internal fixation in February ,
1998.
MEDICATION: On admission include Insulin NPH pork 45 units every day before noon ,
8 units every afternoon , Lopressor 25 mg twice a day , Vaseretic
10/25 mg every day , Dulcolax 10 mg every day , aspirin 325 mg every day , Senokot 2
mg twice a day , Diazepam 5 mg twice a day , Lipitor 10 mg every day , Colace 100 mg
twice a day , Lasix 60 mg every day , lactulose 30 mg twice a day , Neurontin 300 mg
three times a day , Naprosyn as needed
ALLERGIES: Include Aldomet , nifedipine , darvocet which makes her
drowsy , Percocet which makes her vomit.
SOCIAL HISTORY: She lives with her sister in Akjo , North Dakota 91638 The son is
involved in her care. She does not have a history
of smoking or drinking. Her husband died a year ago of
complications from cardiac bypass.
PHYSICAL EXAMINATION: Vital signs: Temperature 102.1 , blood
pressure 148/68 , pulse 84 , respirations 22 ,
sating 92% on two liters. General examination: This is an obese
woman lying at a 30 degree angle on the bed , pleasant and not in
acute distress. Head and neck examination was benign. Lungs have
rales up one-third of the lungs bilaterally , no wheezes or rhonchi.
Heart regular rate and rhythm , S1 , S2 with S3 and II/VI systolic
murmur , best heard over the base. Jugular venous pulsation at 11
cm. Abdominal examination was soft , nontender , mildly distended ,
no mass and normal bowel sounds. Extremities showed diffuse
erythema from right heel extending to 5 cm below the knee , mild
tenderness , edema greater in the right leg than the left leg. 3+
pitting edema bilaterally. She also has a 5 cm x 5 cm skin graft
over the right heel with some skin breakdown around the graft site ,
slightly weepy , no pus. Neurologic examination: The patient is
alert and oriented times three. Cranial nerves are intact. The
patient does not have any sensation in bilateral legs. Normal
strength.
LABORATORY DATA: Significant for hematocrit of 30.7 , white blood
count 10 , 340 , with a differential of 76 polys , 14
bands , 5 lymphocytes. Chem-7 was significant for creatinine of
1.8. Her liver function tests were within normal range. Her CK
first set was 120 with an MB of 2.6 and troponin of 1.39 , coags
normal D-dimer of greater than 1 , 010. Her urinalysis was negative.
Electrocardiogram showed 1 mm ST depression in the lateral leads ,
unchanged from baseline. Chest x-ray revealed bilateral
interstitial prominence , could be consistent with pulmonary edema ,
no focal opacities.
HOSPITAL COURSE:
PROBLEM #1 , CELLULITIS: On admission , the patient was started on
cefazolin and Flagyl for broad coverage of cellulitis given she has
a history of diabetes mellitus. In addition , levofloxacin was
also started on hospital day #2 to cover gram negative organisms.
Blood cultures on admission are negative. Because of the skin
graft on the patient's right heel , plastic surgery was consulted to
assess the integrity of the skin graft. They concluded that the
skin graft is intact and the source of the cellulitis was not in
the heel. On hospital day #3 , Flagyl was discontinued because the
patient could not tolerate orally sores and the GI upset. Therefore ,
we elected to change the antibiotic regimen to Clindamycin and
levofloxacin. cefazolin and Flagyl were discontinued. On hospital
day #6 the patient developed diarrhea. Given her history of C.
difficile in the past and the lack of improvement in her
cellulitis , Infectious Disease were consulted. We started
cefotaxime and Vancomycin on hospital day #7. The patient
continued to have low grade temperature spikes with daily blood
cultures which have all been negative. Wound culture of the bullae
on the right lower extremity was also taken which has also been
negative. Vancomycin was discontinued due to low suspicions of
resistant organisms. The patient also had LENIs which were
negative for DVT as well as a right foot film which showed no signs
of osteomyelitis. Unfortunately , the cellulitis does not look
significantly improved. We postulate that this is due to a
combination of noncompliance with strict elevation , peripheral
edema from congestive heart failure , peripheral vascular disease
and diabetes. The patient continued to spike low grade
temperatures. We carried out pan culture which have all been
negative so far including urine , blood. At the time of this
dictation the patient has been on cefotaxime for seven days.
Infectious Disease recommends an MRI to rule out osteo and deeper
infection since the cellulitis is very slowly improving.
PROBLEM #2 , CHRONIC RENAL FAILURE AND CHRONIC RENAL INSUFFICIENCY:
On admission we started to diurese the patient as she was volume
overloaded by examination. In addition , we started her on her
outpatient blood pressure medications to control her hypertension.
However , on hospital day #2 , the patient's blood pressure dipped
into the high 90s to 100 with a rise in creatinine. We withheld
all blood pressure medication as well as diuresis. Her creatinine
continued to climb from 2.2 to 3.3. The urinalysis showed numerous
red blood cells and no eosinophils. Of note , her urine culture
grew out lactobacillus which was not treated. Renal was consulted ,
and it was thought that the patient's acute renal failure was due
to prerenal causes from a drop in blood pressure as well as mild
ATN. The patient's creatinine responded to gentle fluid boluses
and resolved on its own by hospital day #7. During the period of
acute renal failure , the patient also had marked hyponatremia which
also resolved as the renal function improved. The patient's
creatinine improved to 1.1 on hospital day #10. At this time , she
underwent a CT with contrast to delineate a possible liver mass.
Her subsequent creatinine climbed to 1.8. We had also started her
on her outpatient dose of enalapril and Lasix. We elected to
discontinue the enalapril and Lasix due to her increased
creatinine. We will observe and add back an ace inhibitor as
tolerated.
PROBLEM #3 , CORONARY ARTERY DISEASE , STATUS POST NON Q-WAVE
MYOCARDIAL INFARCTION: The patient was admitted on a rule out
protocol. On her third set of enzymes she showed a CK of 142 , CK MB
of 2.2 but a troponin of 6.64. The patient was asymptomatic with
no chest pains and no electrocardiogram changes. Cardiology was
consulted and it was felt that the patient had a small non Q-wave
myocardial infarction with a troponin leak. A repeat echo on this
admission showed preserved EF at 55% with no observable wall motion
abnormalities. As the patient has refused catheterization in the
past , it was decided that she be managed medically. She was
started on Metoprolol 12.5 mg twice a day as well as aspirin. The
patient has remained symptom free.
PROBLEM #4 , HYPERTENSION: The patient was initially slightly
hypotensive at a systolic blood pressure of 90s to 100 on hospital
day #1. Her enalapril and outpatient dose of Atenolol were held.
She was started back on Metoprolol after the non Q-wave myocardial
infarction. Currently , her blood pressure is maintained between
130-150 systolic. We attempted to add back enalapril at this time
to preserve her kidney function given her diabetes. However , her
creatinine increased mildly , thus we have elected to hold enalapril
again.
PROBLEM #5 , GASTROINTESTINAL: The patient has a history of chronic
constipation on home regimen of Dulcolax , senna , Colace and
lactulose. A KUB was obtained on admission which showed air in the
colon but no obstruction. It was thought that her chronic
distention is from diabetic gastroparesis and relative immobility.
The patient developed diarrhea during her hospital course for which
her laxatives were held. Her stool has been C. difficile negative.
She has tolerated very little food due to abdominal distention.
She has continued to advance her diet currently to some small
snacks during the day. Her laxatives were re-instituted. Because
the patient continued to spike a low grade temperature and she had
some abnormal liver function tests , we pursued a renal ultrasound
to rule out her renal abscess which was negative , as well as a
right upper quadrant ultrasound. The right upper quadrant
ultrasound showed a possible liver mass for which we ordered a
followup CT of the abdomen. The CT of the abdomen showed normal
variant of the shape of the liver , caused by a bowel loop that was
anterior to the liver. This is unchanged compared to a study that
she had in 1996.
PROBLEM #6 , ANEMIA: On admission the patient was slightly anemic
with a hematocrit of 30. During her past hospitalizations , the
patient always had a hematocrit around 30. On this admission her
stools were trace guaiac positive. She received two units of packed
red blood cell transfusion with an appropriate response to a
hematocrit of 36. GI was consulted. However , since the patient was
stable with no further decrease in the hematocrit , it was decided
that the patient would pursue an outpatient workup of her anemia in
terms of colonoscopy.
PROBLEM #7 , VASCULAR: The patient has a history of peripheral
vascular disease on admission. The Vascular Surgery service was
consulted to help manage refractory cellulitis. ABIs were obtained
of the right leg which showed 0.5 to 0.6 on the right lower
extremity and normal on the left lower extremity which has been
previously bypassed. Pulse volume recording revealed mildly
decreased signal in both the right and left leg. The conclusion
was that the patient had right femoral popliteal disease with
normal resting pressures on the left. However , as the patient is
not very mobile , she does not complain of any claudication
symptoms. It was decided that no surgery is indicated for her at
this time. We used heparin subcutaneous injections as her DVT
prophylaxis during her hospitalization.
PROBLEM #8 , CONGESTIVE HEART FAILURE: The patient has congestive
heart failure from diastolic dysfunction. On examination , she has
1+ edema throughout her body including her upper limbs in the chest
area. However , attempts at diuresis were aborted due to acute
renal failure. She continued to diurese on her own without any
pharmacologic interventions , as her creatinine improved. At this
time her Lasix is held because of a small bump in creatinine from
likely the contrast in CT as well as in the enalapril. Overall , she
is total body volume up , however , much improved from admission.
PROBLEM #9 , TYPE II DIABETES MELLITUS: The patient's blood sugars
were poorly controlled during the hospitalization with finger
sticks in the high 100s to low 200s. This is partially due to the
patient's reluctance to take her full dose of NPH Insulin because
she is inconsistent with eating. She also has a sliding scale to
cover her. We will encourage her to continue with her full dose of
Insulin as she tolerates food better.
PROBLEM #10 , PERIPHERAL NEUROPATHY AND LOW BACK PAIN: The
patient's Neurontin dose was reduced to 100 mg three times a day from her
outpatient dose of 300 mg three times a day due to renal insufficiency. She
also received Diazepam currently at 2.5 mg twice a day , reduced from her
outpatient dose of 5.5 mg twice a day because of renal insufficiency.
She also requires morphine sulfate on a as needed basis. Her pain
control is satisfactory at the time of this dictation.
Dictated By: ROXANNA MOLTER , M.D. VG2
Attending: KATHLYN KAMMERDIENER , M.D. UL28 HB062/3575
Batch: 4229 Index No. FWXJ6BXAC9 D: 3/9
T: 3/9
Document id: 232
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
- |
- |
N |
N |
Y |
N |
- |
N |
402105256 | PUO | 89357151 | | 9349370 | 8/20/2005 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 7/15/2005 Report Status:
Discharge Date: 11/20/2005
****** FINAL DISCHARGE ORDERS ******
FORSLUND , ERICKA E 640-32-71-6
Greenmi Mont
Service: CAR
DISCHARGE PATIENT ON: 5/23/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NIZIOL , CHELSEA JESSI , M.D. , B.CH.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 200 MG orally every day
COLCHICINE 0.6 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 200 MG orally every day
ZAROXOLYN ( METOLAZONE ) 2.5 MG orally 3x/Week M-W-F
Starting Today ( 11/25 )
METOPROLOL TARTRATE 25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXYCODONE 5 MG orally every 8 hours Starting Today ( 11/25 ) as needed Pain
PHENOBARBITAL 180 MG orally three times a day Starting Today ( 11/25 )
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally every bedtime
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 20 MG orally every 12 hours
LANTUS ( INSULIN GLARGINE ) 38 UNITS subcutaneously every bedtime
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
ATORVASTATIN 10 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 15 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Take 15 mg twice per week only.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/23/05 by :
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
Reason for override: patient's home regimen
COUMADIN ( WARFARIN SODIUM ) 12.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Take 12.5 mg five times per week
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/23/05 by :
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
Reason for override: patient's home regimen
MAGNESIUM GLUCONATE 500 MG orally twice a day
KCL SLOW RELEASE 20 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
INSULIN LISPRO subcutaneously Instructions: before meals and every bedtime as directed
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Timpson 4/5 3:00pm scheduled ,
Coumadin clinic ,
Dr. Dario call to schedule 1-2 weeks ,
Arrange INR to be drawn on 9/8/05 with f/u INR's to be drawn every
7 days. INR's will be followed by Coumadin Clinic
ALLERGY: MEPERIDINE HCL , SILDENAFIL CITRATE , GABAPENTIN ,
SPIRONOLACTONE , NITRATE , DIGOXIN , AMLODIPINE
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
VV pacer ( pacemaker ) CAD history of CABG ( coronary artery disease ) CHF
( congestive heart failure ) Afib ( atrial
fibrillation ) CVA ( cerebrovascular accident ) IDDM ( diabetes
mellitus ) Peripheral neuropathy ( peripheral neuropathy ) Obesity
( obesity ) PVD ( peripheral vascular disease ) CRI ( chronic renal
dysfunction )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
HPI: 70 year-old man MMP including ischemic CMP CAD history of
CABG , CRI , A-fib/BiV PM- multiple hospitalizations for CHF
exacerbation- presents with 1-2 weeks worsening dyspnea. Recently
restarted on lisinopril- became hyperkalemic- lasix and zaroxolyn were
decreased. patient denied any CP , fevers , palpitations , lightheadness ,
dizziness. No AICD firing.
PMH: as above- ho CVA with word finding difficulties-
Admit Labs: Cr 1.4 K 4.5 trop neg No EKG changes- V paced , LBBB ,
LAD VSS BP 130/70 HR 80 100%RA , NAD- word finding
difficultues- JVP 15+ , chest CTA , HRT 2/6 harsh SEM at apex rad to
LUSB +s3 , ext 2-3+PE L>R- motor/sensory intact- no
deficits CXR: stable cardiomegaly , new mass in
RUL labs: cr 1.4 ( 2.3 on 9/21 ) , CK 128 CKMB:7.3 trop
flat Course: In ED given 60 intravenous lasix , put out
700cc.
all: multiple SH: smoker in
past
A/P: 70 Yo ischemic CMP with decompensated CHF in the
setting of recent change in diuretic regimen. CV: fluid overloaded- back
to dry weight with intravenous Lasix ( 114 lbs ). ACE inhaled was discontinued. Echo:
EF 55%- with mod MR , mild AS.
I: known ho CAD- ruled out for MI
R: ho A-fib , V paced- on coumadin- held initially for INR>3 , then
re-started home dose since 2.6 on day of discharge. PM
NEURO: ho CVA- on phenobarbitol
RENAL: diabetes , hyperkalemia: Held ACE and watched lytes
on intravenous lasix. Cr and electrolytes stable throughout hospitalization.
DNR-not DNI
ADDITIONAL COMMENTS: You should re-start your coumadin this evening , and follow-up with the
coumadin clinic. Please continue to do daily weights.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Needs outpt CT to evaluate RUL mass. Has outpatient ECHO scheduled.
No dictated summary
ENTERED BY: KANOZA , CHER L. , M.D. , PH.D. ( EY428 ) 5/23/05 @ 12:00 PM
****** END OF DISCHARGE ORDERS ******
Document id: 233
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
Y |
- |
Y |
N |
N |
N |
N |
N |
N |
058204568 | PUO | 03295339 | | 5744657 | 6/12/2006 12:00:00 a.m. | PERIPHERAL ARTERY DISEASE , CONGESTIVE HEART FAILURE , CHRONIC RENAL FAILURE | Signed | DIS | Admission Date: 5/7/2006 Report Status: Signed
Discharge Date: 10/1/2006
ATTENDING: KUSH , QUINN JAKE MD
This is an interim dictation from 7/3/06 through 04 while
the patient was on the General Medicine Service.
HOSPITAL COURSE BY SYSTEM:
Renal: The patient has chronic kidney disease likely due to her
diabetes mellitus. The patient's postoperative course was
significant for contrast induced oliguric acute renal failure. A
renal consult was obtained on 2/6/06 and the patient was seen
by Dr. Ahlborn to evaluate her acute on chronic renal failure.
Dr. Ahlborn that her acute renal failure may be due to chronic
kidney disease from renovascular disease or possibly due to
interstitial nephritis in the setting of a drug allergy. The
patient was also seen by Dr. Pelosi , Johnsie Michelina Adriene T.
from the Nephrology Department while she was an inpatient. After
consideration of possibilities causing her acute renal failure ,
it was thought that her acute renal failure was most likely due
to cholesterol emboli syndrome given her eosinophilia , stepwise
progression of renal impairment and her chronic course. The
patient will need to be followed by a nephrologist as an
outpatient. In addition ,
the patient has known renal artery stenosis that may have
contributed to her acute renal failure and she did have a
possible drug allergy to diuril and perhaps a component of her
renal failure was also due to acute interstitial nephritis. On
1/27/06 , the patient developed gross hematuria. At this time ,
the urinalysis showed red blood cells but no evidence for
ATN. This gross hematuria was in the setting of a
worsened coagulopathy. She had a renal ultrasound at that time
that was negative for renal obstruction. Gradually with
resolution of her coagulopathy , the patient's urine output
increased and her creatinine improved with supportive measures
alone. The patient did have gradual improvement in her urine
output and her creatinine decreased to 2.8 prior to discharge.
The patient is currently off diuretics at this time. Daily
weights should be checked and if her weight increases by more
than 3 pounds Dr. Kush should be notified. The patient was also
started on calcitriol given elevation of parathyroid hormone.
Cardiovascular: Rate and rhythm: The patient has a history of
atrial fibrillation with a slow ventricular response. The
patient was started on metoprolol 12.5 mg orally every 6 hours for rate
control , however , this dose was decreased to 12.5 mg orally twice a
day , given some bradycardia on her telemetry. The patient was
also started on Flecainide 75 mg orally every 12 hours She will continue
on these two medications upon discharge.
Congestive heart failure: The patient had evidence for
congestive heart failure and pulmonary hypertension during this
hospitalization. The patient did become volume overloaded on
physical examination with an oxygen requirement , elevation of her
JVP and shortness of breath. She was diuresed with Lasix during
her postoperative course. The patient was transferred to the
medical Service on 2/10/06 for management of her renal failure
and volume overload. The patient did undergo a trial of renally
dosed dopamine to see if this medication improved her cardiac
output and renal function. The patient showed no improvement on
this medication and it was discontinued after a short trial. The
patient's diuresis was discontinued prior to discharge as the
patient did have acute worsening of her renal function , which may
have been related to over aggressive diuresis. The patient was
instead started on spironolactone for management of her
congestive heart failure. As stated above , she should have daily
weights checked.
Ischemia: The patient has no history of coronary artery disease.
She was maintained on aspirin , statin and a beta-blocker during
the admission.
Hematology: The patient was started on iron supplementation for
her anemia in the setting of chronic kidney disease. The
patient's Coumadin was held briefly in the setting of a
coagulopathy that she developed on 1/27/06 . The patient was
evaluated by the Hematology Service and was seen by Dr. Staffeld and
Dr. Hurni from the Hematology Service for workup of her
coagulopathy. The patient had elevation of her INR to 5.8 and a
slight reduction in her hematocrit to 25 , as well as elevation of
her PTT to 97. Workup included factor 7 level , mixing study ,
anticardiolipin antibody , lupus anticoagulant , Von Willebrand's
panel , hepatitis B and C testing as well as complement levels.
The patient received one unit of packed red blood cells as well
as 2 units of FFP on 1/27/06 as well as vitamin K with much
improvement in her coagulopathy and increase in her hematocrit to
about 29. The patient should not receive any
heparin flushes. The patient showed no evidence for DIC or
hemolysis. Her coagulopathy was most likely thought to be due to
residual Coumadin with factor deficiency in the setting of her
decreased renal clearance. At this time , the results of the
inhibitor screen are pending and should be followed up as an
outpatient. The patient was restarted on Coumadin prior to
discharge. Her INR goal is 2 to 3 and her Coumadin dosing should
be monitored by Dr. Kush . Her current Coumadin dose is 1 mg
orally once every evening and her most recent INR 1.2. The patient
will follow up with Hematology as an outpatient.
Infectious Disease: The patient had a wound culture that grew
pseudomonas for which she was briefly treated with a course of
ceftazidime. The patient completed a course of ceftazidime and
remained afebrile off antibiotics with no signs of active
infection. A wound care consult was obtained for the patient's
decubitus ulcer. She should have DuoDERM dressing applied every
three days to her ulcer.
Pulmonary: The patient continues to have an oxygen requirement
despite diuresis. She did not show clinical signs of pneumonia.
Her oxygen requirement is thought to be due to atelectasis ,
deconditioning , as well as her known congestive heart failure and
likely pulmonary hypertension. She requires supplemental oxygen
at 2 liters nasal cannula to maintain oxygen saturations in the
mid 90s. This should be continued at her rehabilitation.
Endocrine: The patient has a history of diabetes and was
followed by the Diabetes Nursing Service during her stay. She
was on Avandia during the admission in addition to Lantus and
NovoLog before meals. Upon discharge , the patient will be on
Avandia 4 mg orally every noon as well as NovoLog 4 units
subcutaneous before every meals in addition to a NovoLog sliding
scale. The patient was also started on thyroid supplementation
and will be on Synthroid as an outpatient.
Fluids , electrolytes and nutrition: The patient had hyponatremia
thought to be in the setting of volume overload and total body
water excess. This improved somewhat with diuresis. In
addition , the patient developed dysphagia with liquids during her
hospitalization. She was evaluated by the Speech and Swallow
Service and had evidence of aspiration on bedside swallow
examination as well as video swallow examination. The patient
was also evaluated by the ENT Service and was seen by Dr.
Oshima on 11/26/06 . On laryngoscopy , she was found to have a
left vocal cord paralysis. She underwent MRI imaging of her neck
and chest. She did not have any evidence of mediastinal mass and
no abnormalities of the recurrent laryngeal nerve were seen.
Gradually , the patient has had some mild improvement in her
hoarseness and dysphagia. She benefits from turning her head to
the left with each swallow to minimize the risk of aspiration.
The patient was also followed by the Nutrition Service throughout
her hospital stay.
Vascular: The patient is status post left femoral distal bypass
on 8/21/06 . The patient continued to be followed by the
Vascular Surgery Service during her hospitalization. She should
have three three times a day wet-to-dry dressings applied to her left lower
extremity up to her thigh daily. She will follow up in Vascular
Clinic with Dr. Youngberg in two weeks upon discharge.
Allergy: The patient had a DIURIL induced drug rash. She showed
no signs of mucous membrane involvement and no signs of
Stevens-Johnson syndrome.
Prophylaxis: The patient was placed on a PPI as well as her
Coumadin.
Disposition: The patient was followed by the Physical Therapy
Service while an inpatient and will benefit from inpatient
rehabilitation.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 8 hours as needed for
pain , aspirin 81 mg orally once a day , allopurinol 100 mg orally once
a day , amitriptyline 10 mg orally twice a day , Plavix 75 mg orally
once a day , Aranesp 40 mcg subcutaneous every week , Benadryl 25 mg
orally every six hours as needed for itching , Colace 100 mg orally
twice a day , flecainide 75 mg orally every 12 hours , NovoLog sliding scale
before meals and every evening - if fingerstick less than 125
give zero units , if fingerstick 125-150 give 2 units , if
fingerstick 151-200 give 3 units , if fingerstick 201-250 give 4
units , if fingerstick 251-300 then give 6 units , if fingerstick
301-350 then give 8 units , if fingerstick 351-400 then give 10
units and call physician if fingerstick greater than 400 or less
than 70 , NovoLog 40 units subcutaneous before meals - please
hold if npo , levothyroxine 75 mcg orally once daily , milk of
magnesia 30 mL orally daily as needed for constipation , metoprolol
12.5 mg orally every 6 hours -hold if systolic blood pressure less than 90
or heart rate less than 55-to be discontinued after one day. The patient will
then be started on Nadolol 20 mg orally qday , Niferex 150 mg orally
twice a day , Protonix 40 mg orally once a day , Avandia 4 mg orally to be given at
noon daily - please hold if npo , Sarna topical daily , Zocor 20
mg orally at bedtime , Coumadin 1 mg orally once every evening , Tucks
PR daily , spironolactone 25 mg orally once daily , calcitriol 0.25
mcg orally once daily.
FOLLOW UP APPOINTMENTS:
1. Dr. Youngberg , 590-882-9425 , Pagham University Of
Vascular Surgery in two weeks.
2. Dr. Kush , 865-556-8789 in two weeks.
3. Dr. Hurni , 334-911-6817 , Hematology at Totin Hospital And Clinic in
one month.
4. Nephrologist follow up to be arranged
DIET: Mechanical soft honey consistency. Advance as tolerated.
ADA 2000 calories a day , 2 grams potassium a day renal diet.
ACTIVITY: Walking as tolerated.
TO DO:
1. Wound care for decubitus ulcer.
2. Follow appointments with primary care physician , Hematology ,
Nephrology , and Vascular Surgery.
3. Please check fingersticks before meals and every evening.
4. Please follow INR every two days with goal INR of 2-3 on
Coumadin.
5. Please measure daily weights. If weight increases by three
pounds , please notify Dr. Kush .
6. T.i.d. wet-to-dry dressings to be applied to the left lower
extremity up to the thigh.
DISPOSITION: The patient is a full code.
eScription document: 8-4874617 CSSten Tel
Dictated By: JERRETT , RACHEAL
Attending: KUSH , QUINN JAKE
Dictation ID 6255304
D: 2/13/06
T: 2/13/06
Document id: 234
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
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Q |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
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Y |
N |
N |
N |
- |
- |
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Q |
N |
N |
516880662 | PUO | 11923443 | | 551469 | 2/2/2002 12:00:00 a.m. | SCIATICA | Signed | DIS | Admission Date: 10/11/2002 Report Status: Signed
Discharge Date: 3/27/2002
CHIEF COMPLAINT: Sciatica.
HISTORY OF PRESENT ILLNESS: Forty-six-year-old fell out of bed
yesterday reaching for something. She
fell on her coccyx. She had no loss of consciousness , no head
trauma. She was unable to get up secondary to pain and body
habitus. EMS was called and returned patient to bed , however , she
refused to come into the hospital in spite of her pain. The
following morning she was still with consider lower back and
buttock pain radiating to her right leg. She took her normal
oxycodone and Vicodin doses without relief , and EMS brought the
patient to the hospital. The patient states that pain is like
previous episodes of sciatica , radicular pain , but exacerbated by
her fall. In the emergency department , patient was afebrile , vital
signs stable. She received Ativan , Motrin , Dilaudid with little
effect. Plain films were negative for fracture. She was unable to
ambulate , and therefore admitted.
PAST MEDICAL HISTORY: Significant for insulin-dependent diabetes
mellitus , myocardial infarction non-Q-wave
September , 2001 , a MICU admission during that time , in September , 2001 ,
for urosepsis , diabetic ketoacidosis and this non-Q-wave MI. Also ,
sciatica with previous history of a herniated disc L5-S1 , question
obstructive sleep apnea with mild pulmonary hypertension by
previous echo.
PAST SURGICAL HISTORY: Total abdominal hysterectomy and bilateral
salpingo-oophorectomy complicated by wound
infection.
MEDICATIONS: Zocor , Zestril , aspirin , Toprol , morphine , insulin
and Vicodin.
STUDIES: September , 2001 , MIBI showed an old , moderately sized MI
in mid LAD distribution with moderate residual
peri-infarct ischemia. An September , 2001 , echo showed left
ventricular ejection fraction 50% , hypokinesis in the inferior
septum , mildly enlarged RV , pulmonary artery pressures of 39 plus
RA , suggestive of mild pulmonary hypertension and mild MR and TR.
LABORATORY DATA: On admission , labs were significant for a glucose
of 121 , creatinine 1.4 , baseline was one ,
potassium of 5.2 , CK of 355 , a UA with plus two leukocyte esterase ,
85 whites , plus two bacteria.
PHYSICAL EXAM: Patient had temperature of 99 , heart rate 67 ,
respirations of 17 , blood pressure 130/50 , and
saturation 97% on room air. She was in no distress. She was
obese. She had no head trauma. Her neck was supple , normal S1 ,
S2. Her lungs were clear to auscultation bilaterally. Her abdomen
was markedly obese , positive bowel sounds , nontender. She had a
skin abrasion on her left elbow. She had no spinal tenderness , no
pelvic tenderness. She was unable to raise her right leg secondary
to pain. She did have pain with straight leg left on the right.
She had normal sensation in upper and lower extremities.
HOSPITAL COURSE: Patient was admitted and was scheduled to undergo
an MRI for evaluation of acutely herniated disc
at an outside facility at York , secondary to not being able to
fit within the coils at our own facility. However , she was unable
to receive this MRI secondary to inability to have assistance with
transfer of her when she reached the facility. Initially , her pain
was managed with both immediate-release and sustained-release
morphine and Valium for spasm. She also received around-the-clock
high-dose NSAIDs and was evaluated by physical therapy and
nutrition. Her UTI was treated with Bactrim. On hospital day
three , her creatinine jumped to 2.9 from 1.4. She was also
hyperkalemic to 5.9. Her NSAIDs were stopped and Neurontin was
DCed secondary to somnolence. However , she continued to have
worsening renal failure , hypertension and somnolence , and blood gas
showed primary respiratory acidosis , hypercarbia and she was
ultimately transferred to the MICU for intubation for airway
protection secondary to aspiration. By April , her creatinine had
returned to baseline. She was extubated without complications.
Her renal function was presumed to be secondary high-dose NSAIDs ,
and her intubation was deemed to be secondary to a primary
respiratory acidosis from opioid intoxication exacerbated by renal
failure. Issues are as follows by systems:
Pulmonary: Overnight pulse oximetry was performed , which will be
analyzed to assess for obstructive sleep apnea. Patient will most
likely need a form of sleep study at rehabilitation or as an
outpatient to address this obstructive sleep apnea issue. Data
from this admission do not support a diagnosis of obesity
hypoventilation syndrome , because there was no daytime hypercapnia
by both ABGs and Chem-7 panel.
Renal: Acute renal insufficiency resolved with hydration ,
withdrawal of NSAIDs. We will hold her ACE inhibitor secondary to
recent renal failure , and she will need to have this evaluated in
two weeks or so.
Infectious disease: The patient with low-grade fevers on empiric
Levofloxacin and Flagyl day seven of 14 for aspiration pneumonia
suffered during hypocarbic respiratory arrest. The patient was
also placed on two days of vancomycin , after one of the blood
cultures in the ICU grew coagulase negative Staph. All cultures
since then have been negative. Patient also had two episodes of
liquid stool on Flagyl , day six. She was already receiving therapy
for C. difficile. Because she has been in the hospital more than
three days , an O&P is very low yield. Stool cultures and a repeat
chest x-ray will be done if clinical worsens tomorrow.
Neurologic: Patient with known small right lateral recess disc
herniation impinging on right nerve root at L5-S1. She has
previous received steroid injections for this and has refused
surgery secondary to very bad experience with the total abdominal
hysterectomy complicated by wound infection. She has had an acute
exacerbation of this pain with her fall. We were unable to obtain
an MRI at outside facility because of her body habitus and need for
assistance with movement. She would benefit from aggressive physical therapy and
pain control with eventual surgery if these more conservative
measures fail.
Pain: The patient was oversedated on pain medications and was
actually intubated for the need to balance desire to alleviate pain
with need for patient to have adequate respiratory drive.
Endocrine: Continue NPH and CZI and ADA diet. Will begin Meridia.
Patient also seen by nutrition and was given number for weight loss
program.
CV: Non-Q-wave MI in September , 2001. Patient with preserved EF , no
valve disease. Will continue current cardiac regimen. Will need
to restart ACE inhibitor in two to three weeks , now that renal
failure resolved.
Prophylaxis: Subcutaneous Heparin , Protime pump inhibitor , and
Dulcolax and Lactulose as needed for constipation while on narcotics.
Social: I have written a letter regarding the patient's need for
first-floor apartment secondary to inability to use stairs. It is
in her chart.
Additional comments: Please monitor patient carefully for
oversedation on current medications. Patient will need sleep study
to rule out obstructive sleep apnea.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every six hours for pain ,
Albuterol nebulizer 2.5 mg nebulizer q.
four hours as needed wheeze , aspirin enteric-coated 81 mg orally every day ,
Dulcolax 10 mg p.r. every day as needed constipation , Valium five mg orally
three times a day muscle spasm , hold if oversedation or respiratory rate less
than 10 , and call HO , Colace 100 mg orally twice a day , fentanyl patch 50
mcg per hour t.p. every 72 hours , hold respiratory rate less than 10 ,
oversedation , Heparin 10 , 000 units subcutaneously twice a day , NPH
Humulin insulin 35 units every day before noon , 25 units every afternoon , hold if blood
sugar less than 100 , CZI insulin sliding scale subcutaneously ,
blood sugars less than 200 give 0 units , if blood sugar is 201 to
250 , give four units , if blood sugar is 251 to 300 , give six units ,
if blood sugar is 301 to 350 give eight units , if blood sugar is
351 to 400 give 10 units and call house officer , magnesium
gluconate sliding scale orally every day , Lopressor , Metoprolol tartrate
37.5 mg orally four times a day , hold systolic blood pressure less than 90 ,
heart rate less than 55 , Flagyl 500 mg orally three times a day x seven more
days , oxycodone 10 mg orally every six hours as needed pain , hold
oversedation , respiratory rate less than 10 , Senna tablets two
tablets orally twice a day as needed constipation , Zocor 10 mg orally every bedtime ,
Neurontin 100 mg orally twice a day , hold oversedation , levofloxacin 500
mg orally every day x seven days , Micolazole two-percent powder topical
t.p. every day , instructions - place in skin folds , Nexium 20 mg orally
every day , Trazodone 50 mg orally every bedtime as needed sleep.
Dictated By: DELMAR MATTIONE , M.D. ZK97
Attending: RASHEEDA BRAGAS , M.D. BE55 IG239/457310
Batch: 1548 Index No. CWDUVY45W0 D: 10/8/02
T: 1/6/02
Document id: 235
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
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N |
Y |
N |
Y |
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N |
612763388 | PUO | 68428296 | | 6197724 | 5/20/2005 12:00:00 a.m. | UPPER GI BLEED | Signed | DIS | Admission Date: 5/7/2005 Report Status: Signed
Discharge Date: 6/12/2005
ATTENDING: COCOMAZZI , REA M.D.
SERVICE:
General Medicine Vi All T
PRINCIPAL DIAGNOSIS:
Hematemesis.
PROBLEMS/DIAGNOSES CONSIDERED DURING THE HOSPITALIZATION:
Hematemesis , insulin-dependent diabetes mellitus; uncontrolled ,
hypertension , congestive heart failure , acute renal failure due
to NSAID abuse , hypothyroidism , paroxysmal supraventricular
tachycardia with rapid ventricular response , gastroesophageal
disease , hiatal hernia , and Barrett's esophagitis.
HISTORY OF PRESENT ILLNESS:
This is a 75-year-old female with a history of type II diabetes
mellitus , insulin dependent , as well as a history of CHF and
supraventricular tachycardia in addition to a history of
gastroesophageal reflux disease , hiatal hernia and esophageal
stricture status post three dilations in the remote past. She
was recently discharged from the Pagham University Of on
10/8/05 after admission for UTI and acute renal failure in the
setting of NSAID abuse because of low back pain. She was
discharged to the nursing home on that day and experienced mild
nausea and emesis that evening. Her symptoms progressed over the
night and continued throughout the next day , and she presented
with complaints of coffee-ground emesis without melena ,
dizziness , orthostasis , or palpitations. She has no abdominal
pain , diarrhea , or constipation. She did have a history of sick
contact , her previous roommate , during the hospitalization had
gastroenteritis. Therefore , on 9/29/05 , she was transferred
from the nursing home to the Pagham University Of for
evaluation of the hematemesis.
PERTINENT REVIEW OF SYSTEMS:
She denied any symptoms of orthostasis. She denied any visual
complaints , dizziness , or imbalance. She had no incontinence ,
dysuria , frequency , or urgency. She had no chest pain and no
shortness of breath.
MEDICATIONS ON ADMISSION:
NPH subcutaneously 35 units every day before noon , NPH subcutaneously 10 units
every afternoon , NovoLog sliding scale , Reglan 5 mg by mouth twice a day ,
Protonix 40 mg by mouth twice a day for 14 days and then once
daily , Lopressor 12.5 mg by mouth three times a day , Tylenol 1000
mg by mouth three times a day , Atrovent nebulizer 0.5 mg inhaled
as needed , Spiriva 18 mcg inhaled daily , Lipitor 10 mg by mouth
daily , PhosLo 667 mg by mouth before meals , Synthroid 200 mcg by
mouth daily , miconazole nitrate 2% cream twice a day application ,
Actonel 35 mg by mouth once a week , on Sunday , Detrol LA 4 mg by
mouth daily , nifedipine XL , and Neurontin 300 mg by mouth daily.
ALLERGIES:
Include albuterol , which causes supraventricular tachycardia ,
penicillin causes rash , ibuprofen , which causes acute renal
failure , and sulfa drugs , which cause an unknown reaction.
PHYSICAL EXAMINATION:
On admission , the physical exam was notable for temperature 96.2 ,
heart rate 87 , blood pressure 146/90 , respiratory rate 20 , and O2
sat on room air is 93%. Her general physical examination showed
no icterus and no conjunctivae pallor. Pulmonary exam was
benign. Cardiovascular exam showed regular rate and rhythm , S1 ,
S2 , occasional pauses , but good peripheral pulses. Abdominal
exam showed an obese abdomen , normoactive bowel sounds , soft ,
nontender , and nondistended. The exam of the extremities showed
pitting edema to the knee , otherwise was nontender and she has
good muscle strength throughout. The neurological exam was
nonfocal. The vomitus was examined and it was shown to be
gastroccult negative.
LABORATORY DATA:
Pertinent laboratory findings showed sodium of 140 , chloride of
102 , bicarbonate of 19 , creatinine of 2.6 , down from max of over
6 , anion gap 19 , glucose on chemistry 351 , normal liver test ,
hematocrit of 36.8 within her normal range , and normal coags.
OPERATIONS OR PROCEDURES PERFORMED NOT IN OR:
She had an upper GI series on 8/30/05 , a video swallow on
1/19/05 , and upper endoscopy on 11/6/05 .
HOSPITAL COURSE:
In summary , in terms of the hematemesis from the GI standpoint ,
there was no blood shown in the emesis during the
hospitalization. Her symptoms were treated with Reglan ,
initially intravenous than orally The differential diagnosis on admission
was gastroenteritis due to sick contacts , gastritis secondary to
pervious history of NSAID use , ulcer , recurrent esophageal
stricture , other enteritis or DKA given elevated glucose levels
and anion gap on admission. Other things considered were
atypical cardiac ischemia. In order to evaluate the cause of the
hematemesis , she underwent the barium swallow on 8/30/05 .
Unfortunately , this test was canceled prematurely due to evidence
of aspiration on the initial swallow. She was kept npo from
10/21/05 to 07 until video swallow could be performed ,
which showed minimal aspiration with swallowing , but was
improved with chin tuck maneuver. An initial diet of mechanical
soft with liquids was recommended with advancement as necessary.
GI was consulted , Dr. Himelfarb attending , and upper endoscopy
was performed on 11/6/05 , which showed nonerosive esophagitis
and a hiatal hernia , both known by history , otherwise , there was
no ulcerations and no stricture. The emesis subsided during the
hospitalization. She was continued on Nexium while in-house as
well as Reglan as needed and tolerated regular house feeds prior to
discharge with no emesis. As an aside , she developed diarrhea
while in-house. Given history of pervious antibiotic use for
UTI , C. diff cultures were sent , both are pending at this time.
The suspicion is low. She is being treated with Imodium as needed
In terms of her history of acute renal failure , the creatinine
had continued to decrease through her hospitalization , but after
aggressive diuresis , she had slight increase in her creatinine ,
but this responded well to reducing the rate of Lasix and mild
hydration. From a cardiovascular standpoint , her hospital stay
was complicated by two distinct episodes of supraventricular
tachycardia with rapid ventricular response , one on 11/27/05 and
one on 9/9/05 . The event on 11/27/05 occurred at 5:00 p.m.
with heart rates in 200 range. She was treated with Lopressor 5
mg followed by diltiazem 20 mg x2 , which then caused reduction in
the heart rate to the 90s. Diltiazem 60 mg orally four times a day was then
added to her regimen. On 9/9/05 , at 2:00 a.m. , she had heart
rate to the 160s , again was treated with diltiazem 20 mg intravenous x1
and her heart rate decreased to the 90s. At that time , her
diltiazem dose was increased to 90 mg four times a day From an infectious
disease standpoint , there were no obvious infections diagnosed
during this stay , but the results of stool cultures are pending.
Her pulmonary status remained stable with good O2 saturation on
room air throughout the hospitalization. From an endocrine
standpoint , her diabetes was moderately controlled during her
hospitalization. She was switched from her standing NPH to
regular insulin sliding scale while npo because of low blood
sugars. After initiating orally intake , her sugars were initially
uncontrolled and aggressively managed with Regular Insulin
sliding scale in addition to an NPH standing regimen. Upon
discharge , Ms. Massei was afebrile with heart rate of 72 , range
68-93 , normotensive with the blood pressure of 120/50 with good
O2 saturation on room air of 93%. Her cardiac and pulmonary
exams were benign. Abdomen exam was also benign , but symptoms of
loose bowel movements were still notable without abdominal pain.
DISCHARGE MEDICATIONS:
Tylenol 650 mg orally every 6 hours as needed for pain , headache , or
temperature , diltiazem 90 mg orally four times a day , Lasix 40 mg
by mouth daily , NPH 10 units subcutaneously nightly , NPH 40 units
subcutaneously every day before noon , Atrovent inhaler two puffs inhaled four
times a day , Synthroid 200 mcg orally daily , Imodium 2 mg orally
every 6 hours , Spiriva 18 mcg inhaled daily , Reglan 10 mg by mouth four
times a day as needed for nausea , Lipitor 10 mg by mouth daily ,
Protonix 40 mg by mouth daily , KCl slow release 20 mEq by mouth
twice a day , miconazole nitrate 2% powder topical TP twice a day , and
NovoLog sliding scale subcutaneously before meals and at bedtime.
CONSULTANTS:
The following consultants were used in her case: GI , Dr.
Himelfarb , 087-7172 and Speech and Swallow , Lyda Steinert , beeper
number 45768.
PENDING TESTS:
Clostridium difficile stool culture.
FOLLOW UP PLANS:
Ms. Massei will follow up with her primary care physician Dr.
Leola Musich on Wednesday , 3/29/05 at 3:00 p.m.
ADVANCE DIRECTIVE:
She was full code.
eScription document: 0-0973194 EMS
Dictated By: IBRAHIM , MIYOKO
Attending: COCOMAZZI , REA
Dictation ID 8967827
D: 6/22/05
T: 6/22/05
Document id: 236
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
- |
N |
N |
Y |
- |
Y |
Y |
N |
N |
- |
015634120 | PUO | 59679705 | | 280328 | 7/11/2002 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 1/16/2002 Report Status: Signed
Discharge Date: 2/12/2002
CHIEF COMPLAINT: CHEST PAIN , SHORTNESS OF BREATH.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with a
history of insulin-dependent diabetes
mellitus , HTN , IPF and some CAD who presents with the first episode
of chest pain and shortness of breath. The patient first
experienced a sudden onset of substernal chest pressure and severe
shortness of breath five days prior to admission which resolved in
one hour but continued to have some substernal chest pain and
dyspnea on exertion with even mild exertion , i.e , crossing the
room. This occurred over the next several days. The patient
described the substernal chest pressure as being like hit in the
chest and this lasted about fifteen minutes. The patient did have
some nausea and vomiting associated with her symptoms and was most
comfortable sitting up. The patient did continue to have increased
shortness of breath at rest and worsened dyspnea on exertion with
around two episodes per day of severe chest pressure/dyspnea/pain
that required her to remain still over the next five days. She
also noted diaphoresis with all those episodes. She denied any
fever , chills , URI symptoms , cough , change in bowel movements. The
patient did complain of some bilateral foot edema 1-2 weeks prior
to admission. The patient has had stable two-pillow orthopnea and
notes no weight gain or loss , but notes decreased exercise
tolerance over the past month. The patient presented to her
primary care physician today secondary to continued shortness of
breath and was sent to the emergency department where
electrocardiogram revealed some ST depressions anterolaterally with
a troponin leak with a troponin level of 0.19 and was thus admitted
to the cardiology Ville service.
PAST MEDICAL HISTORY: Insulin-dependent diabetes mellitus x 30
years , hypertension , IPF diagnosed in 1986
treated with digoxin and prednisone , osteoarthritis , obesity ,
pneumonia , colonic polyps with guaiac-positive stool , TKR on 9/30 ,
cholecystectomy , Bell's palsy x 20 years , LBP , right cataracts ,
catheterization in 1998 showed a LAD lesion of 40% and a circ
lesion of 30% , RCA lesion of 30%.
MEDICATIONS ON ADMISSION: Captopril 50 mg twice a day; Lasix 40 mg
every day; Lopid 600 mg twice a day; Axid 150 mg
twice a day; insulin 70/30 90 every day before noon and 40 every afternoon; atenolol 50 mg
every day
ALLERGIES: intravenous contrast , patient gets hives. Bactrim , also hives.
FAMILY HISTORY: Father died of myocardial infarction at age 81 ,
brother died of myocardial infarction at age 38 ,
mother died of myocardial infarction at age 73.
SOCIAL HISTORY: A housekeeper , lives with her granddaughter , has
a boyfriend.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4 , heart rate
65 , respiratory rate 20 , blood pressure
142/64 , oxygen saturation 99% on three liters of O2. GENERAL:
Lying in bed , labored breathing. HEENT: NC/AT. EOMI , PERRLA.
NECK: JVP around 8 cm , no carotid bruits. PULMONARY: Dry , fine
crackles one-third of the way up bilaterally. No wheezes , no focal
dullness. CARDIOVASCULAR: Distant heart sounds , regular rate and
rhythm , normal S1S2 , no murmurs , rubs or gallops. ABDOMEN: Obese ,
soft , nontender , positive bowel sounds. EXTREMITIES: Trace pedal
edema. NEURO: Alert and oriented x 3. DTRs 2+. Sensation intact
distally.
LABORATORY DATA: White count 8.44 , hematocrit 34.2 platelets 408 ,
sodium 138 , potassium 5.6 , chloride/bicarb
109/19 , BUN/creatinine 20/1.1 , glucose 249 , ALT 13 , AST 16 , CK 68 ,
alk phos 119 , TP 7.4 , albumin 4.2 , CA 9.2 , TB 0.4 , troponin 0.19 ,
INR 1.1 , D-dimer 573 , PTT 29.3.
Electrocardiogram normal sinus rhythm at 67 , LAD , LDH , RBBB , ST
depressions V3-V6 , 0.5 mm in 2 and 3. Echo 11/10/01: Ejection
fraction 55-60% , no wall motion abnormalities , trace AI , trace MR ,
mild TR. 9/15 adenosine MIBI: No symptoms , 1 mm ST
depressions in 1 , 2 and V4-V6. Chest x-ray: Positive for mild
pulmonary edema , retrocardial infiltrate and left effusion.
HOSPITAL COURSE: This is a 65-year-old female with a history of
coronary artery disease , hypertension , diabetes ,
IPF who presented with five days of chest pain/SOB beginning with
sudden onset five days prior to admission and had EKG changes
consistent with a non-Q-wave myocardial infarction anterolaterally.
Of note her troponin was 0.19. The differential diagnosis included
unstable angina and PE with worsening IPF superimposed on heart
disease. From a cardiovascular standpoint the patient has known
coronary artery disease with EKG changes which is likely status
post non-Q-wave myocardial infarction with a question of continued
unstable angina. The patient was initially put on aspirin ,
Lopressor 37.5 three times a day , heparin , oxygen and hooked up to a cardiac
monitor and EKG every day and was ruled out for enzymes. The patient
underwent cardiac catheterization which revealed LAD ostial 90% ,
proximal 80% , diag ostial 90% , left circ 90% , 80% lesions , marginal
1 , TUB 90% , RCA 50%. The patient underwent PTCA and stent x 2 with
good results. The patient remained chest pain free and had no
chest pain on exertion , i.e. , with ambulation. The echo showed
preserved left ventricular function with a good ejection fraction.
The ejection fraction was found to be 55%. There was no discrete
evidence of wall motion abnormality although the inferior and
posterior segments were not well visualized. There was left
ventricular hypertrophy. There was stromal mild right ventricular
hypertrophy and overall right heart function appeared to be
preserved. There was trivial to 1+ tricuspid regurgitation with
right heart pressures within normal limits. There was thickened
aortic leaflets with trivial central insufficiency and no evidence
of any outflow tract obstruction. There was similar mild mitral
regurgitation with the elliptic ring , the left atrial size was
slightly increased and there was no evidence of any effusion. From
a pulmonary standpoint the patient had LENIs which were negative
for a deep venous thrombosis. PFCs revealed a restrictive
physiology and poor diffusion consistent with IPF. The FEV1 was
69% predicted , TLC was 63% predicted , with a DLCO of 56% predicted.
The patient did have a retrocardiac infiltrate on chest x-ray and
the patient was treated with levofloxacin 500 mg every day for fourteen
days. From a GI perspective the patient had a history of colonic
polyps but tolerated the aspirin and was put on Nexium prophylaxis.
The patient was hypokalemic on 3/19 with a curious whitening on
EKG and peak T waves. The patient was treated with insulin , given
calcium and treated with Kayexalate x 3 and the hypokalemia quickly
resolved. The origin of the hypokalemia was unclear. The patient
did have an elevated potassium with a low bicarb which was
consistent with a type 4 RTA and also had hypoglycemia which was
then treated with prednisone overnight for intravenous contrast dye allergy.
The patient was also on Captopril which was discontinued secondary
to her renal issues.
DISCHARGE MEDICATIONS: ASA 325 mg orally.every day; atenolol 75 mg orally
twice a day; Lasix 40 mg orally.every day; Lopid 600 mg
orally twice a day; nitroglycerin 1/150 one tab every 5 minutes x 3 as needed
chest pain; Zocor 10 mg orally every bedtime; Norvasc 5 mg orally.every day; xalatan
one drop each eye every bedtime; Alphagan one drop each eye twice a day; levofloxacin 500
mg orally.every day; clopidogrel 75 mg orally.every day; insulin 70/30 90 units q.
a.m. , 40 units every afternoon subcutaneously; Axid 150 mg orally twice a day
Dictated By: LASONYA RECIO , M.D. FK774
Attending: JEANNETTE GORGLIONE , M.D. YD63 MQ948/867612
Batch: 35910 Index No. AYALIS9UVB D: 4/16/02
T: 4/16/02
Document id: 237
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
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- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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994913119 | PUO | 38621702 | | 4540853 | 11/7/2007 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/26/2007 Report Status: Signed
Discharge Date:
ATTENDING: SASNETT , HAYWOOD M.D.
ADMITTING INTERN:
Vonnie Chant , M.D.
ADMITTING RESIDENT:
Abe Girardi , M.D.
ESTIMATED DATE OF DISCHARGE:
4/5/07 .
PRINCIPAL DIAGNOSIS:
Congestive heart failure , amyloid , and pneumonia.
SECONDARY DIAGNOSES:
Include hypertension , diabetes , peripheral vascular disease
status post left BKA , status post pacemaker for sick sinus
syndrome , hypercholesterolemia , pseudogout , spinal stenosis.
HISTORY OF PRESENT ILLNESS:
This is an 88-year-old Nashmer , Hawaii 18637 male with a history of CHF with
an estimated EF of 45-50% and diastolic dysfunction as well , also
with a history of hypertension , diabetes , peripheral vascular
disease , history of a CVA , history of hypercholesterolemia , who
was recently admitted to the Kernan To Dautedi University Of Of for a CHF exacerbation.
During the recent admission , his home Lasix was increased from 20
mg orally daily to 80 mg orally twice a day During the past admission , he
had a negative lower extremity ultrasounds for right leg edema
and chronic swelling and during the last admission , he was
diuresed with Lasix and discharged home on 6/28/07 . During the
two days prior to admission , the patient experienced increasing
shortness of breath , orthopnea , and PND. The VNA who visited the
patient noted a fever of 101 Fahrenheit and so the patient went
to the Emergency Department. In the Emergency Department , the
patient was afebrile , had a heart rate of 80 , blood pressure
130/80s , respirations 16 satting 95% on 2-4 liters. Of note , the
patient has no oxygen requirement at home at baseline. The
patient had crackles on exam. The chest x-ray showed improved
effusions from prior but did not rule out pneumonia. His right
leg was still swollen but unchanged from prior. In the Emergency
Room , he was given intravenous Lasix 100 mg and 750 mg of levofloxacin x1.
The patient was admitted to the Cardiology Service for volume
overload and the question of pneumonia.
HOME MEDICATIONS:
Tylenol as needed , aspirin 81 mg every daily , diltiazem extended
release 120 mg daily , Colace 100 mg twice daily , iron sulfate 325
mg three times daily , folic acid 1 mg daily , Lasix 80 mg orally
twice daily , gabapentin 100 mg twice daily , NPH insulin 20 units
subcutaneously daily , regular insulin sliding scale , Xalatan eye
drops one drop each eye every afternoon , metoprolol 12.5 mg twice daily ,
senna tablets twice daily , simvastatin 40 mg once daily.
ALLERGIES:
intravenous contrast and latex.
SOCIAL HISTORY:
The patient is a retired cook. He is originally from Hass , Iowa 65174
He has a history of past tobacco use , quit 30 years ago and in
the past drank alcohol rarely. He is wheelchair-bound at
baseline. He lives alone. VNA visits him. He has three
daughters in Beau Ville
FAMILY HISTORY:
The patient notes there has been no one in his immediate family
who had an MI.
PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS: Temperature of 100.0 Fahrenheit , heart rate 71 ,
blood pressure 116/64 satting 100% on 2 liters. His nasal
cannula oxygen respirations 16.
GENERAL: In no acute distress , lying bed , speaking in full
sentences.
HEENT: OP clear without erythema. The patient has dentures.
Pupils were equal , round and reactive. Extraocular muscle was
intact.
NECK: No lymphadenopathy. No carotid bruits. Neck was supple.
JVP listed in chart as 12 cm
CARDIOVASCULAR: Regular rate and rhythm , II/VI systolic ejection
murmur at the left lower sternal border.
RESPIRATION: The patient had crackles half way up each lung
bilaterally. There was no egophony , there was no dullness to
percussion.
ABDOMEN: Positive bowel sounds , soft and nontender. There was a
mild distention and no masses.
EXTREMITIES: The patient has a left BKA. The right leg showed
2+ pitting edema halfway up his anterior shin. His left leg had
no ulceration or lacerations and no tenderness.
NEURO: Alert and oriented x3. Cranial nerves II through XII
intact. Generally , nonfocal exam.
REVIEW OF SYSTEMS:
The patient has a minimal chest pain in the past couple of days
only with cough , otherwise no chest pain. The patient was chest
pain-free in the Emergency Room and there was no nausea ,
vomiting , diaphoresis , palpitations , no rash , no diarrhea ,
positive constipation , increased leg swelling since the last
admission , no hematuria , no dysuria. The patient had a
productive cough of clear phlegm and no hemoptysis. The patient
had a good medication compliance.
ADMISSION LABS:
Of note on admission , the patient had a creatinine of 1.1 which
was at his baseline. The patient had a hematocrit of 35.2. Of
note , his baseline hematocrit is between 31 and 32. BNP was 570.
Troponin was 0.78 , AST 62 , ALT 26 , alkaline phosphatase 183 ,
albumin 3.6.
Admission EKG was V-paced with left axis deviation , no acute ST-T
wave changes. It was unchanged from prior. The patient was in
atrial fibrillation on the EKG.
Admission chest x-ray from 10/30/07 , decreased size small
bilateral effusions , associated with some segmental bibasilar
atelectasis versus consolidation. No frank evidence of CHF.
CONSULTANTS:
Hematology of MMC , Dr. Robbyn Weingartner .
ASSESSMENT:
This is an 88-year-old MT male with a history of
hypertension , diabetes , CHF who presented with increasing
shortness of breath likely secondary to CHF and also presented
with a fever concerning for pneumonia for which he was treated
with antibiotics. The patient also had a new diagnosis of
amyloid during this admission.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular:
A. Ischemia: The patient has no known diagnosis of CAD;
however , he has many risk factors. The patient had a troponin of
0.7 on admit which subsequently trended down. This troponin leak
was thought to be due to demand. The patient remained chest
pain-free during his entire hospital course , and had no acute
ischemic issues. The patient was continued on his aspirin ,
beta-blocker and statin medications.
B. Pump: The patient has a history of CHF with an EF of 40-45%.
In the past , this congestive heart failure had been presumably
attributed to ischemic for hypertensive etiology. However ,
during this admission , the patient had a cardiac biopsy that was
positive for amyloid suggesting that amyloid is the cause
underlying his CHF. The patient appeared mildly fluid overloaded
on admission. He was successfully diuresed with 100 intravenous Lasix for
several days. The patient has been switched to his home dose of
Lasix of 80 mg orally twice a day and was euvolemic for several days
prior to his discharge. His euvolemic weight on 8/10/07 was
64.5 kilograms. His discharge weight will be reported in an
addendum. During this admission , he was continued on his
beta-blocker. His calcium channel blocker and diltiazem was
discontinued during this admission given his likely restrictive
heart physiology with his new diagnosis of amyloid. The patient
was started on a nitrate during this admission in order to reduce
preload. As mentioned above , the patient had a catheterization
with an endomyocardial biopsy that was positive for amyloid. A
panel of other amyloid-related tests were also sent out. Of
note , serum genetic amyloid testing was pending at the time of
discharge. Of note , the patient had a serum immunofixation test
that was within normal limits. The patient had a urine
immunofixation test with a positive monoclonal spike with Lambda
light chain. The patient also had a serum-free light chain assay
that was equivocal/positive. The patient also had positive
proteinuria on a spot urine. The patient also had a bone marrow
biopsy done by Dr. Robbyn Weingartner of MMC in order to further
define this subtype of amyloid that this patient has and in order
to facilitate a screening of his family members for amyloid. He
also had a bone marrow biopsy given the monoclonal spike on his
urine immunofixation test.
C. Rhythm: The patient has a pacemaker originally put in for
sick sinus syndrome. He is V-paced. The patient was discovered
to be in atrial fibrillation on this admission. On 7/9/07 , the
EP Service changed the pacemaker setting to VVI given that the
patient was in atrial fibrillation and decreased the heart rate
to the 60s-70s. The patient remained on telemetry throughout his
stay which was uneventful. The patient was also started on
Coumadin for anticoagulation given his atrial fibrillation and
the diagnosis of amyloid. The patient remained subtherapeutic
and on 7/11/07 , his INR was still subtherapeutic at 1.5 , and he
will most likely be discharged on Coumadin 3.5 mg every evening
which will be adjusted as necessary at the Rehabilitation
Facility.
2. Infectious Disease: The patient presented with a mild cough.
The patient had a fever on admit but was afebrile after one to
two days on antibiotics. The patient had no leukocytosis.
Again , there was a question of pneumonia on the chest x-ray and
his clinical findings were suspicious for pneumonia. The patient
received a five-day course of levofloxacin at 750 mg daily. The
course of antibiotics ended on 1/27/07 . The patient had blood ,
urine and sputum cultures which were negative.
3. Heme: The patient has baseline anemia between hematocrit of
31 and 32 which remained stable during his hospitalization. The
patient also has a baseline thrombocytopenia with platelets at
approximately 170 which remained stable throughout his
hospitalization and again the patient as stated above was started
on Coumadin during this admission for atrial fibrillation and for
amyloid. The Coumadin was slowly increased up to 3.5 mg given
subtherapeutic INR. The patient had a bone marrow biopsy done on
5/10/07 as mentioned above in order to further define the
amyloid ??_?? and because of the monoclonal spike on the urine
immunofixation. The final results of the bone marrow biopsy are
pending.
4. Endocrine: The patient has a history of diabetes. At first ,
he was on his home dose of NPH insulin which was 20 units
subcutaneous daily as well as an insulin sliding scale. Because
of persistent hypoglycemia , the patient's NPH was reduced to 10
units of NPH insulin subcutaneous daily.
5. FEN: The patient had a low-salt diet and a 2-liter fluid
restriction and was seen by Nutrition inhouse.
6. Renal: The patient had a creatinine of approximately 1.0
which stayed stable throughout his hospitalization.
7. GI: The patient has chronic LFT abnormalities likely
secondary to CHF; however , the etiology is uncertain.
8. Question restless leg syndrome: On 2/19/07 , the patient was
complaining of myoclonic jerks of his right leg which is an old
problem. His general exam was within normal limits. He was
given a trial of magnesium supplementation inhouse for this.
9. Low back , sacral pain: His low back pain appears to be
chronic and it was treated with oxycodone successfully. The
patient also was noted to have a skin tear on his right buttock
which showed no signs of infection and a DuoDERM was placed over
it for wound care. The patient also had a stage I sacral
decubitus ulcer and a DuoDERM was placed on it for wound care and
for protection.
10. Prophylaxis: The patient was on DVT dose Lovenox inhouse
and was also on Coumadin.
11. Physical Therapy: Of note , the patient has a left BKA. The
patient's family brought in his prosthetic leg as well as his
walker. Physical Therapy inhouse worked with the patient , and it
was determined that the patient was unsafe to go home and it was
recommended that he go to a rehabilitation facility to which the
patient finally agreed.
CODE STATUS:
The patient is full code. Healthcare proxy is daughter , Suzie L Nati . Home phone number is 824-014-2675 , work number
329-918-2002.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed
2. Aspirin 81 mg orally daily.
3. Colace 100 mg orally twice a day
4. Ferrous sulfate 325 mg orally three times daily.
5. Folic acid 1 mg by mouth once daily.
6. Lasix 80 mg orally twice daily.
7. Gabapentin 100 mg by mouth twice a day
8. Insulin NPH 10 units subcutaneous daily.
9. Combivent 2 puffs inhaled four times daily as needed shortness
of breath or wheezing while the patient is recovering from his
pneumonia.
10. Isosorbide dinitrate 20 mg orally three times daily.
11. Xalatan eye drops one drop each eye every afternoon
12. Metoprolol tartrate 12.5 mg by mouth twice daily.
13. Oxycodone 2.5 mg by mouth every six hours as needed pain.
14. Senna tablets two tablets by mouth twice daily.
15. Simvastatin 40 mg by mouth at bedtime.
16. Multivitamin one tablet by mouth daily.
17. Coumadin 3.5 mg by mouth every afternoon
MEDICATION CHANGES MADE DURING THIS ADMISSION:
Diltiazem was discontinued. NPH insulin was reduced from 20
units daily to 10 units daily. A multivitamin was added.
Isosorbide dinitrate was added. Coumadin was added.
TO-DO LIST FOR REHAB AND VNA:
1. Monitor blood pressure.
2. Monitor blood sugars.
3. Please check INR on 1/1/07 and every two to three days
thereafter and adjust the Coumadin as necessary for target INR of
2-3.
4. Please do wound care on right buttocks and sacrum ( the
patient has a skin tear on the right buttocks but no signs of
infection , and the patient has a stage I decubitus ulcer on the
sacrum ). Please apply DuoDERM and do wound care.
5. Please have VNA do home safety evaluation when the patient
goes home , and please continue physical therapy.
FOLLOW-UP APPOINTMENTS:
The patient will follow up with his cardiologist , Dr. Katheryn S Gruntz , of MMC . His office is aware that he needs an
appointment in the next one to two weeks and his office will call
the patient with confirmation of this appointment. Dr. Lozano
office number is 739-177-8584.
CONTINUING CARE PLAN FOR M.D.s:
For cardiologist ,
1. Follow up final results of amyloid genetic test.
2. Follow up final results of bone marrow biopsy.
3. Follow up final results of the heart biopsy including special
stains.
For Primary Care Physician ,
1. Manage insulin regimen.
2. Follow low back pain which appears to be chronic.
3. Follow decubitus ulcer stage I.
4. Follow INR and adjust Coumadin as needed.
5. Monitor LFT which appear to be chronically elevated and
workup as necessary.
6. Question of restless leg syndrome. Please reassess and treat
as needed.
7. Monitor hematocrit and platelets.
An addendum to this stat dictation will follow when the patient
discharge is confirmed including a finalized medication list for
discharge and a final discharge weight.
eScription document: 0-9152366 EMSSten Tel
CC: Katheryn Gruntz M.D.
Menlandlourdes Medical Center
West
Dictated By: CHANT , VONNIE
Attending: SASNETT , HAYWOOD
Dictation ID 7627459
D: 7/11/07
T: 7/11/07
Document id: 238
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
Y |
Y |
N |
N |
295659539 | PUO | 66600893 | | 2491787 | 7/12/2005 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | Signed | DIS | Admission Date: 3/9/2005 Report Status: Signed
Discharge Date: 1/21/2005
ATTENDING: HAUB , PERRY M.D.
PRINCIPAL DIAGNOSIS:
This is the diagnosis responsible for causing the admission is
sinus arrest with apnea.
HISTORY OF PRESENT ILLNESS:
The patient is a 71-year-old male with a history of nonischemic
dilated cardiomyopathy ( EF of 55% on this admission , although
prior admission indicating an EF of 35% ) , diabetes , obstructive
sleep apnea , obesity hypoventilation syndrome , atrial flutter
status post ablation. On 5/24/05 , he presented with shortness
of breath as well as a witnessed apneic episode. His recent
history is significant for having stopped his Lasix dose one week
prior to admission due to increased frustration with
incontinence. Since then , he has had increasing shortness of
breath , orthopnea , bilateral lower edema , and dyspnea on exertion
to the point of symptoms upon walking 10 feet. In the Pagham University Of Emergency Department , he was found to be
saturating 91% on room air and 99% on a nonrebreather. An ABG
showed a pH of 7.31 and a PCO2 of 55; he was tried on BiPAP
without improvement in either PCO2 or PO2. While being
interviewed by the medical residents , he was seen to have a
30-second apneic episode with loss of consciousness and cyanosis;
his sensorium quickly returned after this event , although he
retained no memory of this occurrence. He received Lasix 80 mg
x1 , Solu-Medrol , and DuoNebs in the ED. He was admitted to the
CCU initially with CHF/apnea/sinus arrest , and subsequently
transferred to the hospital floor when he was stable.
PAST MEDICAL HISTORY:
1. Congestive heart failure , nonischemic dilated cardiomyopathy ,
2/13 echo with an EF of 35% and global left ventricular
hypokinesis; 7/18 echo with an EF of 55% , without hypokinesis.
2. Atrial flutter , status post ablation ( 2003 ).
3. Atrial fibrillation.
4. Hyperostosis frontalis.
5. Complex renal cyst versus angiomyolipoma , resected via
laparoscopy in 8/2 .
6. Morbid obesity with obesity hypoventilation syndrome.
7. Obstructive sleep apnea.
8. Chronic renal insufficiency ( baseline creatinine 2 ).
MEDICATIONS:
1. Allopurinol.
2. Iron.
3. Lisinopril.
4. Toprol-XL.
5. Coumadin ( discontinued on 11/28/05 ).
6. Albuterol inhaler as needed
7. Aspirin.
8. Flomax.
9. Hytrin.
SOCIAL HISTORY:
The patient lives alone at E He is a retired Kpep Highway , Nashouversa Troit Walk , Connecticut 83407
employee. He is an ex-smoker , quit in the 1960s. He is a heavy
drinker in his 20s , but now he rarely drinks alcohol.
FAMILY HISTORY:
Gastric cancer in his father.
ADMISSION PHYSICAL EXAMINATION:
Temperature of 96 , pulse of 53 , blood pressure of 125/65 , and
saturating 94% on 2 liters by nasal cannula. In general , alert
and oriented , in no acute distress. HEENT: Pupils are equally
round and reactive to light , sclerae are anicteric , moist mucous
membranes. Cardiovascular exam: Regular rate and rhythm , normal
S1 and S2 , although JVP difficult to assess due to body habitus.
Lung exam: Clear to auscultation bilaterally , no wheezes or
crackles. Abdomen: Obese , soft and nontender , normal abdominal
bowel sounds. Extremities: 2+ edema.
LABORATORY STUDIES ON ADMISSION:
Notable for creatinine of 2.3 ( at baseline ) , BNP of 500. His
admission EKG: Sinus rhythm with occasional bradycardia to the
40s , no ST changes.
SUMMARY OF THE HOSPITAL COURSE BY ISSUE:
Assessment and Plan: A 71-year-old female with a history of
obesity hypoventilation syndrome , restrictive lung disease ,
diabetes , nonischemic dilated cardiomyopathy with a preserved EF ,
who was admitted for congestive heart failure , sinus arrest ,
ultimately treated with diuresis and a pacemaker placement.
1. Cardiovascular: Ischemia: No active issues during this
hospitalization. Pump: The patient had a history nonischemic
dilated cardiomyopathy with a preserved EF , ( an echo during this
hospitalization revealed an EF of 55% without hypokinesis ,
although prior echo in 2003 showed an EF of 35% with global left
ventricular hypokinesis ). On admission , the patient had signs
and symptoms of volume overload in a setting of having not taken
his Lasix for about a week. He was admitted initially to the
CCU , and subsequently transferred to the floor , with aggressive
diuresis of approximately 10 kg since admission ( including
diuresis with ultrafiltration in the CCU ). Following transfer to
the floor , he was switched to Lasix diuresis , which was titrated
down gradually to 40 mg daily , ( cautioned with administration
giving a rise in creatinine ). The patient was also maintained on
captopril , which was up titrated to 25 mg three times a day ( held at one
point due to the rise in the creatinine ). The patient was also
titrated up on metoprolol to 25 mg twice a day Rhythm: The patient
was followed by the Electrophysiology Service. In the CCU , he
was noted to have sinus arrest of 8-9 seconds in the setting of
apnea. Following transfer to the floor , he was noted to have
sinus arrest of 4 seconds , again in the setting of apnea. His
last such episode was on 8/16/05 . In addition , the patient has
history of atrial fibrillation/flutter , status post ablation. On
4/30/05 , he underwent pacemaker placement through cephalic
veins , which he tolerated well.
2. Pulmonary: The patient , as noted above , had several episodes
of apnea , some of which were associated with sinus arrest.
Following diuresis , the patient's apnea episodes improved. He
was recommended for formal sleep study as an outpatient.
3. Renal: The patient was admitted with a creatinine roughly
around baseline ( 2 ) , which rose briskly during his
hospitalization to a peak of 3.2 on 4/30/05 . His FENa on
admission was 6-8%; a repeat FENa in the setting of his peak
serum creatinine of 3.2 and following 10 kg of diuresis was
1.86%. His urine eosinophils were negative. His UA showed
evidence of a UTI plus triple phosphate crystals; urine culture
showed greater than 100 , 000 colonies of mixed morphology. It was
thought that the rise in the patient's creatinine was likely due
to a combination of intravascular depletion and possibly UTI.
The patient was started on antibiotics following his pacemaker
placement , which would be expected to cover GU microbial flora
and SNHU microbes.
4. Endocrine: The patient had a history of diabetes and was
maintained on a Regular Insulin sliding scale.
5. ID: The patient was expected to having an UTI as noted
above. Following his pacemaker placement , he was placed on
cefazolin while in-house , followed by Keflex. The patient should
stay on Keflex for four days.
DISCHARGE MEDICATIONS:
1. Albuterol inhaler two puffs inhaled four times a day as needed wheezing.
2. Allopurinol 100 mg orally daily.
3. Captopril 25 mg orally three times a day
4. Colace 100 mg orally twice a day
5. Ferrous sulfate 325 mg orally daily.
6. Lasix 40 mg orally daily.
7. Heparin 5000 units subcutaneous three times a day
8. Regular Insulin sliding scale subcutaneous before every meal
9. Lopressor 25 mg orally twice a day
10. Oxycodone 5 mg to 10 mg orally every 6 hours as needed
11. Keflex 250 mg orally four times a day x12 doses , starting on 3/25/05 .
12. Flomax 0.4 mg orally daily.
13. Nexium 20 mg orally daily.
eScription document: 6-8525026 EMSFocus transcriptionists
Dictated By: BLACKGOAT , GERMAINE
Attending: HAUB , PERRY
Dictation ID 5521689
D: 3/25/05
T: 3/25/05
Document id: 239
| Target |
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Dp |
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| output/system_textual_annotation.xml | textual |
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Y |
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| output/system_intuitive_annotation.xml | intuitive |
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110986064 | PUO | 68044412 | | 9317497 | 10/21/2006 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/21/2006 Report Status: Unsigned
Discharge Date:
ATTENDING: Nakai , Rheba , MD
OUTPATIENT PRIMARY CARE PHYSICIAN:
Rea Cocomazzi , M.D. Phone Number 146-555-5291
DATE OF DISCHARGE:
4/20/07
ADMISSION DIAGNOSIS:
Cellulitis and CHF.
CHIEF COMPLAINT:
Shortness of breath , left leg pain.
HISTORY OF PRESENT ILLNESS:
Mr. Tian is a 74-year-old man with severe venous stasis , CHF
with an EF of 60% , atrial fibrillation on Coumadin , COPD , history
of severe left lower extremity cellulitis in October 2006 status
post surgical debridement , who presents with shortness of breath and
left lower extremity cellulitis. The patient was in his usual
state of health on the day of admission and was getting up to the
bathroom when he felt suddenly short of breath and wheezy. He
called EMS. He notes that his left leg and foot have been
painful and swollen x2 weeks with redness tracking up the leg.
He has had no fever , chills , coughs or chest pain. In the ED , he
received nebulizers , vancomycin and levofloxacin.
PAST MEDICAL HISTORY:
CHF with an EF of 60% , history of right heart failure likely
secondary to pulmonary hypertension and obstructive sleep apnea ,
atrial fibrillation on Coumadin , osteoarthritis , bilateral
chronic venous stasis , benign prostatic hypertrophy , COPD ,
hypercholesterolemia , obesity.
HOME MEDICATIONS:
Coumadin 2 mg orally nightly , Lasix 80 mg orally twice daily , Zocor
10 mg orally nightly , potassium 20 mEq orally daily , Azmacort with
ADAP 100 mcg inhaled 3 puffs twice daily , albuterol 2 puffs
inhaled twice daily , Atrovent 0.5 mg inhaled every 6 hours as needed
shortness of breath , ferrous sulfate one tab orally twice daily
( patient not taking ).
ALLERGIES:
Penicillin causes rash , Bactrim rash , Cipro causing constipation ,
patient has tolerated levofloxacin in the past.
FAMILY HISTORY:
The patient lives at home with a roommate. He is retired , worked
in advertising for 20 years for Blo South He has no
children. He smoked 60 pack years and quit 26 years ago. He
does not drink any alcohol , use any intravenous drugs or illicit
substances.
SOCIAL HISTORY:
The patient has a living sister , Harris Hasselkus who has cancer.
She is his healthcare proxy. Her phone number is 805-421-4260.
ADMISSION PHYSICAL EXAMINATION:
Vital signs: Temperature 96.5 , pulse 85 , blood pressure 98/36 ,
respiratory rate 22 , oxygen saturation 99% on 2 liters.
Generally , the patient is obese with short of breath , alert and
oriented x3. Cardiovascular exam: Remarkable for an irregular ,
irregular rhythm with distant heart sounds , no murmurs , rubs or
gallops. Normal S1 and S2 , his JVP was noted to be at the jaw.
Lungs: Remarkable for diffuse wheezes. Abdomen: Obese ,
nontender , without masses. Extremities: He had bilateral
pitting edema , left lower extremity was noted to be erythematous
to the inguinal crease with weeping. He was neurologically
nonfocal.
ADMISSION LABS:
Remarkable for sodium of 129 , potassium 5.7 , creatinine of 1.5 up
from his baseline 0.9-1.3 , BUN of 30. Magnesium 1.6 , INR 2.8%.
First set of cardiac enzymes were negative with a BNP of 127.
WBC is 28.5 , hematocrit 34.7 , platelets of 189 , baseline
hematocrit is usually in the high 20s. Differential: Notable
for 97 neutrophils and 20 bands.
EKG remarkable for atrial fibrillation with a rate of 82 , Q-waves
in V1 and V2 without ST changes , low voltage. His T-wave was
upright in V2 and V3 which is changed from his prior EKG in
11/26 . Chest x-ray notable for pericardial effusion which
shows increase in size and question of fluid at the bilateral
bases.
ASSESSMENT AND PLAN:
Mr. Tian is a 74-year-old man with severe venous stasis , CHF ,
atrial fibrillation requiring Coumadin , COPD , severe left lower
extremity cellulitis status post surgical debridement who
presents with shortness of breath and recurrent left lower
extremity cellulitis.
HOSPITAL COURSE:
1. Cardiovascular: The patient had some pseudonormalization in
V2 , V3. He was ruled out for MI. He was continued on his
aspirin and Zocor. His CK was noted to be increasing , but he was
clinically unchanged , and there was low suspicion for necrotizing
fasciitis or myositis. He was not felt to be cardiac in origin.
The patient has right heart failure. He was overloaded on exam.
His JVP was difficult to assess given his history of tricuspid
regurgitation. He did have enlarged heart on his chest x-ray and
an echo on 1/3/06 showed a precordial fat-pad without effusion.
His EF was unchanged. His PA pressure was 35+ RA. His IVC was
nonpulsatile suggesting increased RA pressures. He responded to
Lasix 80 mg intravenous. He was not diuresed on this admission. He was
continued on his home dose of Lasix at 80 mg orally twice daily.
2. Atrial fibrillation: The patient has no need for rate
control at this time. Coumadin was held for GI bleeding that the
patient developed on 6/10/06 . He had an episode of hematemesis
in the setting of an INR of 3 which was thought to be a
Mallory-Weiss tear from coughing. His hematocrit stabilized at
27. His fibrinogen D-dimer were normal. He was made npo ,
received four units of FFP and 2 units of packed red cells. An
NG tube was placed which has been since removed. The GI Service
recommended an intravenous proton pump inhibitor. On 11/9/06 , his diet
was advanced. He was tolerating that well and his hematocrits
were stable at this point.
3. Respiratory: The patient had wheeziness on exam when he was
admitted. He received DuoNebs every 6 hours and on exam , his wheeziness
resolved.
4. ID: The patient has recurrent cellulitis secondary to venous
stasis. Cultures from the debridement in 11/26 were negative.
Blood cultures drawn as needed 6/7/06 were positive for
acinetobacter diphtheroids. Wound cultures of the left leg
showed 2+ acinetobacter , beta streptococcus group G
corynebacterium. From the right leg , he grew 2+ MRSA ,
corynebacterium and beta strep. The organisms were sensitive to
levofloxacin , his staph aureus MRSA. Blood culture 6/10/06 is
no growth to date at the time of this dictation. Stool on
6/10/06 was positive for C. diff and urine culture 1/3/06
showed Gram-negative rods. Surgical Service recommended
antibiotic treatment. The patient was started on vancomycin
( started 6/7/06 ) , levofloxacin ( started 6/7/06 ) , aztreonam
was added on 1/3/06 for Acinetobacter in his blood. He
was given gentamicin x1 on 6/10/06 in the setting of
hypotension. He will continue vancomycin and levofloxacin for
four weeks and will stop on 6/13/06 . He will continue Flagyl
for six weeks ( started 8/27/06 to stop on 10/11/07 for his C.
diff ). The wound culture from his bilateral lower extremities is
polymicrobial. If the erythema spread , he becomes febrile , or his
legs become more tender , please have a low threshold for
noncontrast CT and surgical consultation. Lower extremity
Dopplers were negative for DVT but there is incomplete
visualization at all of his left leg veins.
5. Renal: The patient had acute on chronic renal failure ,
( baseline creatinine 0.9-1.1 ) , hyponatremia , hyperkalemia on
admission. There was some question of adrenal insufficiency but
he had a normal random cortisol. His fractional excretion of
urea was 26% and he has since been volume resuscitated. His
creatinine responded accordingly.
6. Prophylaxis: The patient has been on Coumadin that was held
in the setting of GI bleed. We have held his Lovenox as well.
He is on an orally proton pump inhibitor.
CODE STATUS:
The patient is DNR/DNI. Pressors are okay. Healthcare proxy is
Harris Hasselkus who is his sister 805-421-4260.
CONSULTS:
GI: Dr. Bernhart . ID: Dr. Wohlford . Surgery: Dr. Naomi Wolfensperger .
TO DO:
1. Continue intravenous antibiotics.
2. Follow up all cultures.
3. Resume Coumadin.
4. Continue prophylactic Lovenox.
5. Have the patient follow up with his primary care doctor in
one to two weeks after discharge from rehabilitation.
6. Have him follow up with the GI Service in one to two weeks
after rehabilitation.
DIET:
The patient should measure his weight daily. He should be fluid
restricted to 2 liters daily. He should on a low-cholesterol ,
low-fat , 2 grams sodium diet.
ACTIVITY:
He should elevate his feet with prolonged periods of sitting.
DISCHARGE MEDICATIONS:
Pending.
eScription document: 0-1638286 EMSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: Nakai , Rheba , MD
Dictation ID 4671647
D: 7/15/06
T: 7/15/06
Document id: 240
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
Y |
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| output/system_intuitive_annotation.xml | intuitive |
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682349409 | PUO | 25903098 | | 0136646 | 8/23/2003 12:00:00 a.m. | SUBOPTIMAL LT. VENTRICULAR LEAD | Signed | DIS | Admission Date: 10/19/2003 Report Status: Signed
Discharge Date: 1/8/2003
IDENTIFICATION: Mrs. Beyser is a 62-year-old female who came
to the I Warho Hospital for evaluation
of her cardiomyopathy and pacer placement.
HISTORY OF PRESENT ILLNESS: She had developed a left bundle branch
block at age 40. At 51 , the patient
developed a viral cardiomyopathy with resulting cardiomyopathy.
She has been medically managed since then , and in September 2002 ,
required a permanent pacer ICD to prevent VT in the setting of
ejection fraction of 10%. Lead dislodged in April 2002 as the
patient was wallpapering , and it was replaced suboptimally. The
patient now presents with shortness of breath at minimal activity
with fatigue and occasional paroxysmal nocturnal dyspnea. Request
new pacer lead placement via left thoracotomy.
PREOPERATIVE CARDIAC STATUS: A history of class III heart failure ,
marked limitation of physical
activity , recent signs and symptoms of congestive heart failure ,
including paroxysmal nocturnal dyspnea , dyspnea on exertion , pedal
edema. The patient is in paced rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: Status post ICD pacer
placement.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus , insulin
therapy , hypercholesterolemia , recurrent
bronchitis , agoraphobia , panic attacks.
PAST SURGICAL HISTORY: Status post appendectomy , status post
cholecystectomy , and hysterectomy.
FAMILY HISTORY: Coronary artery disease significant. Father had
MI.
SOCIAL HISTORY: History of tobacco use , three pack
cigarette-smoking history , history of alcohol use ,
remote , heavy , and now three beers per month. The last one
6/26/03 .
ALLERGIES: No known drug allergies.
MEDICATIONS: Carvedilol 25 mg orally twice a day , lisinopril 10 mg orally
every day , Digoxin 0.125 mg every day , Coumadin Lasix 240 mg
orally twice a day , atorvastatin 20 mg orally every day , slow release potassium ,
Claritin 10 mg , Actos 45 mg every day , Premarin 0.625 mg every day , Xanax
5 mg five times daily , Lantus 48 U p.m. , Centrum every day , vitamin E
400 U every day
PHYSICAL EXAMINATION: VITAL SIGNS: Height 5 feet 5 inches , weight
95 kg , temperature 98 , heart rate 68 , blood
pressure 104/60. HEENT: Dentition without evidence of infection ,
no carotid bruits. CHEST: no incisions. CARDIOVASCULAR: Regular
rate and rhythm , no murmurs. PULSES: Carotid 2+ , radial 2+ ,
femoral 2+ , dorsalis pedis 2+ , posterior tibialis 2+ bilaterally.
RESPIRATORY: Breath sounds clear bilaterally. ABDOMEN: Soft , no
masses. The incision on the abdomen is on the right upper
quadrant. RECTAL: Deferred. EXTREMITIES: 1+ pitting edema.
NEUROLOGICAL; Alert and oriented , no focal deficits , anxious ,
independent female.
LABORATORY DATA: Sodium 140 , potassium 3.9 , chloride 105 , carbon
dioxide 24 , BUN 17 , serum creatinine 1.0 , glucose
109 , magnesium 2.1. WBC 7.43 , hematocrit 39.3 , hemoglobin 13.6 ,
platelets 219. physical therapy 15.1 , INR 1.2 , PTT 29.8. Urinalysis normal.
Echo was done on 8/13 - 10% ejection fraction , trivial aortic
insufficiency , severe mitral insufficiency. EKG , 8/21/03 , paced
rhythm at 68.
HOSPITAL COURSE: She was taken to the operating room on 10/27/03 .
Preoperative diagnosis was a failed coronary
sinus lead. Postoperative diagnosis was epicardial lead placed.
Procedure was a posterior lateral thoracotomy , automatic implanted
cardioverter defibrillator.
Immediately after surgery she was taken to the cardiac surgical
ICU , where she was extubated and the blood gases were appropriate.
Initially , she had volume infusion to stabilize hemodynamics.
Later , she underwent gentle diuresis. She was slowly weaned from
oxygen and she was transferred to the floor in stable condition on
postoperative day #2.
On the floor , she was started on her cardiac meds. Her epicardial
pacing wires were pulled out. Her chest tubes were pulled out. No
evidence of any pneumothorax. She is ambulating very well and food
intake is okay. The discharge decision was made on 2/12/03 . The
day before discharge , she had a chest x-ray and a question of
pneumonia , so she was started on levofloxacin and attending
surgeon , Dr. Raup agreed with the discharge decision , sending
her home on a seven-day course of levofloxacin. The pre-chest
x-ray looks okay.
CONDITION ON DISCHARGE: Stable.
DISCHARGE PHYSICAL EXAMINATION: She is afebrile , temperature is
97 , heart rate 82 V-paced , blood
pressure 104/60. She is on room air 96% saturation. Her weight is
9 kg above her preop weight.
DISCHARGE LABORATORY DATA: ______ sodium topical application
three times a day for the cold sores , Xanax 0.5 mg
five times a day , orally Premarin 0.625 mg orally every day , Colace 100 mg
orally three times a day as needed for constipation , Lasix 240 mg orally twice a day ,
ibuprofen 600 mg every 4-6h. as needed for pain , lisinopril 10 mg orally
every day , Niferex 150 mg orally twice a day , Percocet 1 tablet every 4 hours as needed
for pain , Coumadin doses variable based on INR level , therapeutic
multivitamins 1 tablet orally every day , simvastatin 40 mg at bedtime ,
Claritin 10 mg orally every day , carvedilol 25 mg orally twice a day ,
levofloxacin 500 mg orally every day x7 days , today is day two , Lantus
20 U at bedtime subcutaneously , K-Dur slow release potassium 40 mEq
twice a day
She needs to make a follow-up appointment with Dr. Raup four
weeks from the date of discharge. She needs to see Dr. Dragun ,
cardiologist , 1-2 weeks from the date of discharge , his heart
failure team physician. The patient is on Coumadin. INR should be
drawn on 4/8/03 and later twice a week , every three days. INR
should be followed by Dr. Nina Surace , ph# ( 449 ) 532-5773. INR
should be checked tomorrow and later twice a week. A therapeutic
INR level is between 2-3. Duration of treatment is until further
follow up.
Dictated By: LEANNA WHISENHUNT , M.D. JK96
Attending: ARLETTA RAUP , M.D. RQ85 FR078/307164
Batch: 9331 Index No. UWEEMN8PBG D: 10/24/03
T: 10/24/03
Document id: 241
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
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U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
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N |
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N |
166569053 | PUO | 90836853 | | 1003759 | 3/1/2004 12:00:00 a.m. | MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 3/1/2004 Report Status: Signed
Discharge Date: 9/8/2005
ATTENDING: ISABELLE EVON COLASAMTE MD
DATE OF ADMISSION: 2/23/2005
DATE OF DISCHARGE: 2/27/2005
SERVICE: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: Mr. Lacuesta is a 58-year-old
gentleman with significant medical history of past acute
myocardial infarction in 1994 who presented with complaints of
substernal chest pressure for 2 days on 6/19/2005 . The patient
stated that the pain was substernal in nature with radiation to
the left side. It was 3-4/10 in intensity. The pain resolved
spontaneously. The patient after sometime has a similar brief
episode of substernal chest pressure that made him come to the
hospital where he was found to have a troponin level of 0.29 with
flat CPK and MB. He was admitted to Ouf County General Hospital during
his previous heart attack where he had a PTCA done of his left
anterior descending coronary artery. He underwent cardiac
catheterization on 6/19/2005 , which revealed a left main coronary
artery with a mid 35% stenosis , left circumflex coronary artery
with a proximal 75% stenosis , first obtuse marginal with an
ostial 90% stenosis and a 45% stenosis , left anterior descending
coronary artery with a mid 95% stenosis , first diagonal coronary
artery with an ostial 85% stenosis , second diagonal coronary
artery with a proximal 95% stenosis , right dominant circulation ,
posterior descending artery 50% stenosis with a mid 90% stenosis.
Echocardiogram on 10/28 revealed an ejection fraction of 50% ,
trivial mitral insufficiency , trivial tricuspid insufficiency ,
and very mild basal septal hypokinesis.
PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: Significant for
myocardial infarction on 1/1/2004 . Also , myocardial infarction
in 1994 , history of class II angina with slight limitation of
ordinary activity , recent signs and symptoms of unstable angina ,
history of class II heart failure with slight limitation of
physical activity. Signs and symptoms of congestive heart
failure and dyspenia on exertion. He is status post a recent
stent placement of his left anterior descending coronary artery
with PTCA and arthrectomy in 1994. History of hypertension ,
dyslipidemia , and chronic obstructive pulmonary disease. He is
status post right knee surgery and a fissurectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER: Lopressor 50 mg 4x a day , intravenous
nitroglycerin , enteric-coated aspirin 325 mg once a day ,
intravenous heparin , theophylline , simvastatin 40 mg once a day ,
and Nexium 40 mg once a day.
PHYSICAL EXAMINATION: Cardiac exam: Regular rate and rhythm
with no murmurs , rubs , or heaves. Peripheral vascular: 2+
pulses bilaterally throughout. Respiratory: Breath sounds are
clear bilaterally , is otherwise , noncontributory.
HOSPITAL COURSE: Mr. Lacuesta was brought to the Operating Room
on 5/26/2005 where he underwent a coronary artery bypass graft
x5 with a sequential saphenous vein graft connecting to the ramus
and then the first obtuse marginal coronary artery and saphenous
vein graft to the posterior descending coronary artery and a left
internal mammary artery to left anterior descending coronary
artery. Total bypass time was 168 minutes. Total crossclamp
time was 139 minutes. The patient did well intraoperatively ,
came off bypass without incident. Intraoperatively , the patient
was found to have small diffuse diseased coronaries and was put
on Plavix for poor targets. He was brought up to Intensive Care
Unit in normal sinus rhythm and stable condition.
Postoperatively , the patient did well. He was extubated and
transferred to the Step-Down Unit on postoperative day #2. The
patient was followed by the Diabetes Service and monitored for
his hypoglycemic medications. He remained in normal sinus rhythm
with controlled rate and was cleared for discharge to home with
visiting nurse on postoperative day #6.
DISCHARGE LABS: For Mr. Lacuesta are as follows: Chemistries are
pending at this time except for potassium of 4.7 , complete blood
counts were also pending at this time.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 325 mg once a day ,
captopril 6.25 mg 3x a day , glipizide 10 mg twice a day ,
Lopressor 100 mg 4x a day , oxycodone 5-10 mg every 4 hours as needed
pain , Plavix 75 mg once a day , Glucophage XR 500 mg twice a day ,
Lantus insulin 10 units subcutaneously in the evening , and Lipitor 20 mg
once in the evening.
Labs from 8/8/2005 are as follows: Glucose of 181 , BUN 15 ,
creatinine 1.2 , sodium 138 , potassium 4.9 , chloride 103 , CO2 of
26 , magnesium 2.0 , WBC is 7.16 , hemoglobin 10.7 , hematocrit 32.5 ,
platelets of 281 , 000 , and physical therapy-INR 1.0.
DISPOSITION: Mr. Lacuesta will be discharged to home in stable
condition with visiting nurse.
FOLLOWUP: He will follow up with Dr. Isabelle Colasamte in 6 weeks
and his cardiologist Dr. Shavonne Mainer in 1 week.
He is discharged in stable condition with visiting nurse.
eScription document: 6-9333549 BFFocus
Dictated By: BARBELLA , PRISCILLA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 5461528
D: 11/27/05
T: 5/18/05
Document id: 242
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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098812026 | PUO | 57870793 | | 6150872 | 10/20/2005 12:00:00 a.m. | Shortness of breath | | DIS | Admission Date: 8/3/2005 Report Status:
Discharge Date: 10/22/2005
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Lum Ster O
Service: MED
DISCHARGE PATIENT ON: 5/2/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MOLANDS , MARIETTE ALEISHA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ATENOLOL 100 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 500 MG orally three times a day
LASIX ( FUROSEMIDE ) 40 MG orally every day
HYDROCHLOROTHIAZIDE 50 MG orally every day
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 3
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 10
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours as needed Shortness of Breath , Wheezing
NYSTATIN ( POWDER ) TOPICAL TP twice a day
Instructions: Please apply to inframammary areas
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Meghann Christenson ( primary care physician ) please call ,
Dr Irving Escalante ( Cards ) 11/24 at 9:20 am scheduled ,
Dr Glynis Verbridge ( Pulm ) 9/17 at 9 am scheduled ,
ALLERGY: Aspirin , IRON DERIVATIVES , NSAIDs , FERROUS SULFATE
ADMIT DIAGNOSIS:
Shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Shortness of breath
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid obesity ( obesity ) Restrictive lung dz ( restrictive pulmonary
disease ) CHF ( congestive heart failure ) OSA ( sleep apnea ) Fibromyalgia
( fibromyalgia ) von Willebrand's dz ( von Willebrands disease ) Fe-def
anemia ( iron deficiency anemia ) Chronic hypovent syndrome GERD
( gastroesophageal reflux disease ) Atypical chest pain ( atypical chest
pain ) history of TAH/BSO ( history of TAH/BSO ) OA ( osteoarthritis ) Pulm HTN ( pulmonary
hypertension ) Eczema ( eczema ) Hemorrhoids
( hemorrhoids ) history of Syphilis ( history of syphilis )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: 47F obese on home O2/bipap + CHF p/with incr DOE
HPI: patient with morbid obesity , pulm HTN , OSA , CHF , history of mult adm for incr
SOB ( most recent 8/13 ) likely from wt gain , sev obesity , diet , poor
compliance with meds + bipap. patient admits only takes meds in a.m. , refuses
others 2/2 'side effects'. Uses bipap sporad , only 2h every bedtime patient unreliable ,
story varies for different MDs. Basically , at baseline uses scooter but
walks short dist with mild SOB , now SOB after slightly shorter dist. No F/C ,
edema/abd girth , N/V/D. patient notes sputum + incr O2 req from 3->5L chronic
x 6 mos. Incr DOE since d/c'd from PUO 1 mo ago , refuses to take extra
Lasix or other diuretics at home , has been using incr bipap since , but
still only 4h every day
Exam: 96.1 72 158/73 24 94 on 5L. NAD , v obese , AOx3. JVP 7. CTAB with poor
air mvmt. RRR. Obese , abd benign. No LE edema. Neuro nonfocal.
Data: Cr 1.0 , Glu 130. QBC 13.5 with 90P , Hct 38.4. Cardiac enz neg , BNP 10.
TTE 11/1 EF 65% with R/LVH , decr RV syst fxn. PFTs 3/14 FEV1 + FVC 22%. CXR
stable CM , NAP.
Impression: 47F with morbid obesity , restrictive lung dz , mild CHF , OSA ,
pulm htn , on home O2 + bipap , now p/with same chronic SOB.
Hospital Course:
1. CV: I-No issues. P-HTN , cont BB , HCTZ , Lasix. patient refuses other meds.
No s/sx CHF + BNP 10 , but patient felt better in past with diuresis , given intravenous
Lasix with -2L until Cr bumped 1.0 -> 1.2. R-NSR.
2. Pulm: Sev restr dz + OSA , 5L home O2 + bipap , chronically worse ,
likely 2/2 progr effects of obesity/decond on top of comorbidities. HCO3
40 on adm. Cont suppl O2 + bipap as needed , will d/c on 5L home O2. Cont
Duonebs as needed
3. Ppx: GERD , patient refuses PPI; no Hep 2/2 von Willebrands -> pneumoboots.
4. Code: Full.
5. Dispo: Complic social/psych issues , patient history of numerous adm to PUO despite
no acute issue. patient with progr worse chronic SOB 2/2 deconditioning on top of
sev restrictive dz from obesity , OSA , pulm htn. patient v difficult , occ aggr ,
splitting , causing probs for RNs on floor. Told she was ready for d/c , patient
combative with team , refused to cooperate with setting-up home services. Will
d/c with VNA , patient says she has set-up nl PCA for tmrw ( refused allowing care
coord to set up for her ).
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow-up with Dr Christenson ( primary care physician ) , Dr Pee ( Cards ) , and Dr Leuga
( Pulm ) in clinic. If you have any worsening shortness of breath , please
call one of your doctors.
No dictated summary
ENTERED BY: REITMEYER , LOVIE H. , M.D. , PH.D. ( SS08 ) 5/2/05 @ 03:32 PM
****** END OF DISCHARGE ORDERS ******
Document id: 243
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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402990568 | PUO | 69687681 | | 263281 | 9/14/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/14/1994 Report Status: Signed
Discharge Date: 8/3/1994
DISCHARGE DIAGNOSIS: UNSTABLE ANGINA/CORONARY ARTERY DISEASE.
SECONDARY DIAGNOSES: 1 ) HYPERTENSION.
2 ) HYPERCHOLESTEROLEMIA.
3 ) TOBACCO USE.
4 ) DIABETES MELLITUS.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old woman
with longstanding hypertension ,
coronary artery disease ( status post two vessel coronary artery
bypass graft in 1992 ) , hypercholesterolemia , positive tobacco use ,
positive family history for coronary artery disease , adult onset
diabetes mellitus , chronic obstructive pulmonary disease , peptic
ulcer disease ( with history of gastrointestinal bleed ) , and stable
angina who presented with rest angina in a crescendo pattern not
relieved by sublingual nitroglycerin. The patient had no chest
pain history until 1992 when she presented with chest pain and had
a markedly positive exercise tolerance test. She had recurrent
typical chest pain and fatigue at 3 minutes and 45 seconds on
standard Bruce protocol with a maximal heart rate of 129 , maximal
blood pressure 120/80 , and 1 mm ST depressions. Patient was
treated medically but returned with chest pain at rest. Cardiac
catheterization revealed single vessel coronary artery disease ( 80%
mid right coronary artery ) for which a PTCA was attempted but was
complicated by dissection so the patient had an emergent saphenous
vein graft to the right coronary artery and LIMA to the left
anterior descending. Patient was on an intraaortic balloon pump
when she developed a cold right lower extremity and had an emergent
right femorofemoral bypass. The patient did well until 2/11 ( with
rare episodes approximately four per year of rest angina which
began approximately six months post-coronary artery bypass graft
and were all relieved by sublingual nitroglycerin ) when she
developed worsening right lower extremity claudication requiring
angioplasty. In 4/17 , recurrent right lower extremity
claudication prompted a femoropopliteal bypass. The patient was
now currently contemplating repeat femoropopliteal bypass. On the
day of admission , the patient had an approximately four hour
episode of chest pain while visiting with her daughter. The
patient did not have sublingual nitroglycerin with her at the time.
Upon returning home , the patient obtained relief with one
sublingual nitroglycerin ( patient had described the pain at 9/10
with left chest to axilla pain and no other radiation ). The
patient was able to sleep. The patient awoke in the morning and
shortly thereafter , had chest pain which was not relieved with one
sublingual nitroglycerin. Therefore , the patient came to the
Emergency Department. The patient had repeat episodes of chest
pain while in the Emergency Department and no EKG changes were
noted. Two sublingual nitroglycerins resolved each episode.
PAST MEDICAL HISTORY: 1 ) Longstanding hypertension. 2 ) Peptic
ulcer disease/upper gastrointestinal bleed
in the 1970s. The patient had an upper GI series/colonoscopy which
were negative per the patient. The patient had an ongoing stable
pattern of gastritis/gastroesophageal reflux disease that was
minimized by avoiding fatty foods. 3 ) Adult onset diabetes
mellitus. 4 ) Chronic obstructive pulmonary disease with no
hospitalizations or intubations and currently not on any therapy.
5 ) Hypercholesterolemia. 6 ) Vascular disease as above. 7 )
Status post herniated disc.
CURRENT MEDICATIONS: Lopressor 50 mg/25 mg/50 mg , Pepcid 20
twice a day , Procardia XL 60 every day , enteric coated
aspirin 500 mg every day , hydrochlorothiazide 25 mg every day , Elavil 50 mg
every bedtime , and K-Dur 20 mEq every day
ALLERGIES: 1 ) Amoxicillin which caused hives and a rash. 2 )
Fish which caused nausea , vomiting , and pruritus.
SOCIAL HISTORY: The patient was a retired operating room
technician. 2 ) Patient had significant tobacco
use of three packs per day times 35 years decreased to one pack per
day in the last two years. 3 ) Alcohol was none since 1992 with
one beer per night prior to that.
FAMILY HISTORY: Mother who died of a cerebrovascular accident ,
otherwise non-contributory.
PHYSICAL EXAMINATION: This revealed an obese middle-aged woman who
was feisty but in no acute distress. Her
temperature was 98.2 , heart rate 84 , blood pressure 122/74 , and
respiratory rate 16. HEENT: Extraocular movements intact , pupils
equally round and reactive to light ( but left slower to react ) and
oropharynx benign. NECK: No lymphadenopathy , thyromegaly without
nodular feeling , 2+ carotids without bruits , and jugular venous
pressure approximately 7 cm. LUNGS: Coarse dry crackles at the
bilateral bases with decreased breath sounds throughout. CARDIAC:
Point of maximal intensity was not appreciated , regular rate and
rhythm , normal S1 , S2 was split , and no S3 , S4 , or murmurs.
ABDOMEN: Soft , non-tender , non-distended , obese with no
hepatosplenomegaly , and no femoral artery bruits with 1+ palpable
pulses bilaterally. EXTREMITIES: Trace pretibial edema
bilaterally with 1+ right dorsalis pedis pulse and trace left
dorsalis pedis pulse. RECTAL: Occult blood negative ( per
Emergency Department physician ). NEUROLOGICAL: Grossly non-focal
except for 4/5 right lower extremity proximal muscle strength , 1+
deep tendon reflexes throughout , and toes downgoing bilaterally.
LABORATORY EXAMINATION: On admission was notable for a hematocrit
of 49 and first CK of 19. Chest x-ray
showed no active disease. EKG showed a normal sinus rhythm of 90 ,
axis 70 degrees , normal intervals , no ST or T wave changes , no left
ventricular hypertrophy , and no change as compared with 4/17 .
HOSPITAL COURSE: The patient was first ruled out for a myocardial
infarction and the patient did , in fact , rule
out. The patient did have some recurrent chest pain episodes
in-house , again with no EKG changes , relieved with sublingual
nitroglycerin. Her anti-ischemic regimen was intensified and the
patient underwent a dobutamine MIBI which revealed inferior
ischemia with a minimal work-load. Cardiac catheterization
revealed that her saphenous vein graft to the right coronary artery
had stenosed which was successfully PTCA to 20% residual stenosis.
Slow competitive flow was seen in the LIMA but the LIMA to the left
anterior descending was patent. The patient did well
post-procedure.
DISPOSITION: Patient is discharged to home with close follow-up by
her primary physician.
DISCHARGE MEDICATIONS: 1 ) Atenolol 100 mg every day 2 ) Lasix 40 mg
every day 3 ) Vasotec 10 mg every day 4 )
Nitroglycerin sublingually as needed 5 ) Axid 150 twice a day 6 ) Serax
15 mg every bedtime 7 ) Elavil 50 mg every bedtime 8 ) Enteric coated aspirin
325 every day 9 ) Glipizide 7.5 mg every day before noon
Dictated By: JULIANN STASKO , M.D. JW59
Attending: EARNESTINE M. FIERMONTE , M.D. TG7 JM144/1905
Batch: 16190 Index No. ETUWIH4ZOT D: 3/7/96
T: 3/26/96
Document id: 244
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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286935862 | PUO | 45189341 | | 613388 | 4/17/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/17/1996 Report Status: Signed
Discharge Date: 8/23/1996
DIAGNOSIS: 1 ) LEFT THIGH CELLULITIS , LEFT THIGH ABSCESS , STATUS
POST I&D.
2 ) ACUTE RENAL FAILURE.
HISTORY OF PRESENT ILLNESS: Mrs. Bown is a pleasant 52 year old
obese black female with history of
diabetes , chronic lower extremity venous stasis , history of
cellulitis who presented with left lower extremity pain , edema , and
erythema. The patient has had a long history of diabetes since
1984 for which she has been treated with diet and glyburide with
poorly controlled blood sugars until Metformin was added in
October of 1996. In the past five years the patient has also
become morbidly obese with a weight of greater than 200 pounds.
Since 1995 she has noted development of significant bilateral lower
extremity swelling. In October of 1996 she was treated for diabetic
stasis ulcers on both of her legs with cellulitis requiring home intravenous
antibiotics. Part of the bilateral lower extremity swelling was
attributed to the presence of a large uterine fibroid which was
thought to be compromising venous return. Her massive edema was
treated unsuccessfully with Lasix.
The patient was doing well until about a week prior to admission
when she developed some diarrhea consisting of two to three bowel
movements a day. Her stool was watery brown without any blood or
mucus. She also reported some nausea and vomiting as well as
chills. She believes that she had fevers , but these temperatures
were not measured. One day after the onset of her diarrhea the
patient noted the development of burning pain on her left anterior
thigh just above her knee. This was associated with increased
erythema and mildly increased swelling in that area. She reports
that her diarrhea , there had been stool running down her left thigh
the previous day. This area of erythema on her left leg
subsequently spread to the lateral surface of the thigh and was
associated with increasing pain. The pain was so severe that it
prevented the patient from her daily activities and from walking.
The patient presented to the Emergency Department on 4/8 for
worsening of her lower extremity pain and decreased orally intake.
On the day of admission the patient states that her diarrhea had
resolved and that she has had no abdominal pain. She has had no
chest pain or shortness of breath or any other localizing signs of
infection except her left leg. On admission she was found to have
a temperature of 100 degrees Fahrenheit and she was placed in the
Short Stay Unit. Subsequently her admission labs were noted to
reveal elevated LFTs and an elevated BUN and creatinine with a
white blood cell count of 35 , 000. Because of these abnormalities
and renal failure , the patient was transferred out of the Short
Stay Unit to the General Medicine team for further care.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes mellitus.
Bilateral lower extremity edema with chronic
venous stasis changes. HIstory of cellulitis. History of
hypertension. Uterine fibroid. Hypercholesterolemia.
Osteoarthritis. Hemoglobin C trace.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Glyburide 5 mg twice a day Lisinopril 20 mg
twice a day Lasix 80 mg every day before noon Metformin
500 mg twice a day Naprosyn 375 mg twice a day as needed
MEDICATIONS ON TRANSFER FROM SHORT STAY UNIT: Ancef 1 gram intravenous every 8.
Colace 100 mg twice a day
Insulin sliding scale. Lisinopril 20 mg twice a day
FAMILY HISTORY: Notable for a sister with diabetes mellitus.
SOCIAL HISTORY: The patient denies alcohol , cigarettes , or drug
use. The patient lives in Milford and cares
for four young grandchildren.
PHYSICAL EXAMINATION: The patient was an obese , pleasant , African
American woman in no apparent distress. Her
temperature was 99.4 , blood pressure 110/74 , pulse rate of 92 ,
respiratory rate 20 , O2 sat 96% on room air. Her HEENT exam was
nonicteric with moist oropharynx and no lesions. The neck was
supple without any lymphadenopathy. She had a right EJ intravenous line.
There were no carotid bruits. Her lungs were clear to auscultation
with no CVA tenderness. Her heart was regular rate and rhythm.
There was a faint S4 and a loud P2 component to the S2 sound. Her
abdominal exam was obese , non-positive for bowel sounds. There was
mild tenderness over the periumbilical region with some fullness/
suggestion of a mass. There was no rebound or guarding , no right
upper quadrant tenderness , no hepatomegaly/splenomegaly ( exam
limited by obesity ). Her extremity exam revealed marked bilateral
swelling in both lower extremities with chronic stasis changes.
There were multiple venous plaques on the pretibial areas of both
legs with one venous plaque being ulcerated on the right pretib
area. Examination of her left thigh revealed a patch of erythema
and warmth that was very tender to the touch. Neurologic exam was
alert and oriented times three , intact cranial nerves III-XII.
There was slight decrease in sensation in the patient's lower
extremity , left greater than right to pin sensation. Her motor
exam was otherwise unremarkable. Her rectal exam was reported to
be guaiac negative per the Emergency Department.
LABORATORIES ON ADMISSION: Sodium 133 , potassium 5.2 , BUN 43 , and
creatinine of 3.7. The patient's last
creatinine value on record was in September of 1996 which was 0.6. Her
LFTs revealed an ALT of 71 , AST of 57 , LDH 717 , alkaline
phosphatase 196 , total bilirubin 1.1 , direct bilirubin 0.6. Her
amylase was 8. Her albumin was 2.1 and her calcium was 8.2. Her
CBC on admission revealed a white cell count of 34 , 000 , hematocrit
of 29 , and platelets of 624 , 000. The differential on the white
blood cell count was 78 polys , 38 bands , 6 lymphs , 3 monocytes , and
no eos. Her MCV on her hematocrit was 77. Her physical therapy and PTT were
both within normal limits. Her urinalysis revealed 3+ protein , 1+
leukocyte esterase , 8-12 white blood cells , 20-25 red blood cells ,
and 2+ squamous epithelial cells.
Chest x-ray on admission revealed low lung volumes with possible
left total effusion that was blurring left lower lobe air space
disease. Abdominal ultrasound performed on admission revealed no
hydronephrosis , a normal liver biliary system. Study was limited
secondary to body habitus. Lower extremity non-invasive studies
revealed no evidence of deep venous thrombosis. However , exam was
limited secondary to habitus.
HOSPITAL COURSE: By issues:
1. Left thigh cellulitis: The patient was started on Ancef
renally dosed for her left thigh cellulitis. Her legs were kept
raised and her white blood cell and fever curves followed. An
Infectious Disease consult as well as a Dermatology consult was
obtained to assist with antibiotics as well as dressing for her
lower extremity changes. Blood cultures and wound cultures sent
did not reveal any organisms. Because of the patient's very high
white blood cell count , the ID consult team was concerned for the
possibility of toxic shock syndrome; therefore , Clindamycin intravenous was
also added to her regimen of antibiotics. Also per ID
recommendation , stool cultures were sent for E. coli 0167: H7 which
was negative. Although there was an initial fall in the patient's
white count during the first several days of antibiotics , this
white count subsequently began rising again. This was associated
with continued poor resolution of the pain in the patient's left
thigh and perhaps worsening erythema. Because the patient's left
leg did not appear to be getting better on antibiotics , a Surgical
consult was obtained to rule out a deeper seated infection in the
patient's thigh. Imaging of the patient's leg with MRI was
attempted but was unsuccessful secondary to the patient's large
size. A CT of both of her legs were obtained instead which
revealed no evidence of an abscess in her left leg , however , it did
incidentally detect a large effusion in the patient's left knee.
One week after admission the patient noted acute worsening of the
pain in her left knee. Because of the known left knee effusion , a
concern for a septic knee joint was raised. A Rheumatology consult
was obtained. The left knee was tapped using ultrasound guidance
removing 20 cc of turbid knee fluid. Studies on the left knee
effusion revealed 13 , 000 white blood cells with negative gram stain
and negative crystal exam times 3. Cultures of the left knee fluid
did not grow any organisms. Despite these findings , we were still
concerned that this was a partially treated septic joint given the
patient had been on antibiotics for one week. For this reason an
Orthopedic consult was obtained and the patient was taken to the OR
for possible debridement. On 6/19 the patient was taken to the
Operating Room where an abscess on the left lateral distal thigh
was found and drained. A total of approximately 20 cc of pus was
removed by Dr. Denk . There was no connection between the pus
collection and the left knee effusion. After the drainage , the
patient's clinical status improved dramatically with a decrease in
her white count and increased mobility of her leg. She was
continued on Ancef intravenous and orally Ofloxacillin which had been added
for gram negative coverage. The Clindamycin was subsequently
discontinued. On the day prior to discharge the patient's white
blood cell count had fallen to 10 , 000. She remained afebrile.
2. Renal: On admission the patient was noted to have a creatinine
of 3.7 with a baseline known to be 0.6 in September of 1996. However , on
searching through the patient's records it appears that the patient
had been noted to have increased proteinuria since September of 1996.
The acute renal failure was initially thought to be secondary to
dehydration; the patient was given intravenous hydration with no improvement
in her creatinine. For that reason , a Renal consult was obtained
on the third day of admission. It was the impression of the Renal
Service that the patient's acute renal failure was likely
multifactorial secondary to a combination of diabetic nephropathy ,
low albumin , volume loss secondary to diarrhea , infection , and
medications which included NSAIDs as well as ACE inhibitor. For
that reason , the patient's nephrotoxic medications , which include
Lisinopril and Metformin , were discontinued. The patient's
electrolytes and volume status was followed closely for the rest of
the course of the hospitalization with continued gradual
improvement. Her creatinine peaked at 4.7. On discharge the
patient's creatinine had resolved back to 2.2.
3. Right upper extremity swelling: On the day after the patient
returned from the Operating Room for the drainage of her left
thigh , she was found to have new onset of swelling in her right arm
and breast. Initially we were concerned for the presence of a
right upper extremity deep venous thrombosis. Upper extremity
non-invasive studies were obtained which were negative for any
clots. An echocardiogram was also obtained showing no evidence of
right heart dysfunction. A nuclear flow study was also attempted
but was unsuccessful because of the failure to obtain venous access
on the patient's right arm. The Erfston Hospital team was also
consulted regarding the use of heparin. However , given that the
patient had poor access and had an anemia , it was decided that the
patient would not be heparinized. Her right upper extremity
swelling was observed closely and with elevation of the right arm
over the next few days gradually resolved without any
complications. On the day prior to discharge a repeat right upper
extremity ultrasound was obtained which revealed no evidence of
blood clots in her right arm.
4. Hematology: On admission the patient was found to have a low
hematocrit with a low MVC. Iron studies were performed which
revealed the likely presence of iron deficiency. For that reason
the patient was placed on iron sulfate 30 mg three times a day The patient
was guaiac negative , thus ruling out evidence of a chronic GI
bleed. The patient's anemia is also likely a reflection of her
renal dysfunction.
5. GI: Although the patient had experienced some diarrhea prior
to admission , her diarrhea resolved in the hospital. All of her
stool studies were negative. Abdominal ultrasound revealed no
abnormalities in the patient's liver or biliary system to account
for the mild transaminitis found on admission. It is likely that
the patient had a bout of viral gastroenteritis a few days prior to
admission which resolved spontaneously.
DISPOSITION: To Hodi Anbarre University Hospital .
DISCHARGE MEDICATIONS: Ancef 1 gram intravenous every 8 hours times 14 days.
Ofloxacin 200 mg orally twice a day times 14 days.
Lotrimin topical applied twice a day to toes and webs of toes. Nystatin
powder topical twice a day applied to groin area. Polysporin ointment
topical applied to right pretibial ulcer with dressing. Iron
sulfate 300 mg orally three times a day Atenolol 50 mg every day. Oxycodone 5-10
mg orally every 4 hours as needed pain. Miracle Cream as needed Colace 100 mg
orally twice a day
ADDITIONAL INSTRUCTIONS: The patient will require , at Teran Skinver Careteher Hospital ,
dressing changes on her left leg as needed
saturation ( probably at least every shift ) with 4 x 8 Kerlix/ABD
pads/Kerlix wrap with fine dry bulky soft dressing.
The patient is discharged with intravenous Ancef for an additional 14 days
as well as orally Ofloxacin for 14 days. The patient will require
follow-up with a doctor while at Teran Skinver Careteher Hospital to determine changes in
the antibiotics regimen. As for the patient's right pretibial
ulcer , that will require daily wet to dry dressing with the
application of Polysporin.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: The patient is to be followed up by her primary CHH
doctor to be arranged.
Dictated By: JOANA I. ZERBE , M.D. NH8
Attending: MELDA X. IVASKA , M.D. XH48 OB833/6665
Batch: 2997 Index No. YDUDS34EQZ D: 2/15/96
T: 2/15/96
CC: 1. MELDA X. IVASKA , M.D.
2. DR. DENK
Document id: 245
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CHF |
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DM |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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969667536 | PUO | 96328556 | | 2998379 | 11/10/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 11/10/2006 Report Status: Signed
Discharge Date: 2/19/2006
ATTENDING: MANKOSKI , ROSSIE MD
ADDENDUM
HISTORY OF PRESENT ILLNESS: Mr. Baldon is a 52-year-old gentleman
who was initially admitted to Osri Medical Center due to nausea ,
myalgias and weakness. The patient has a history of type I
diabetes mellitus , end-stage renal disease with
subsequent renal transplant 11 years ago donated by his sister
for which he takes cyclosporine and azathioprine. The patient
had a neuropathic left plantar ulcer seven years ago for which he
underwent transmetatarsal amputation of his left foot at Osri Medical Center .
He has had a chronic recurrent ulcer of the left foot
over the last two years or so. The patient nonetheless was
reasonably doing well and very active. He recently did a 35-mile
bike ride in about four or five days prior to admission. He
developed nausea and vomiting which lasted for one day. He then
developed weakness and hyperglycemia. He tried to increase his
insulin , but found he did not have an adequate response. The
patient became more weak and was brought to the Osri Medical Center Emergency Department where he was found to have moderate
diabetic ketoacidosis and dehydration. The patient's workup also
suggested acute myocardial infarction and was admitted to the
Coronary Care Unit. Echocardiogram was performed which revealed
an ejection fraction of 30% with dyskinesis of the inferior and
apical walls , mild mitral insufficiency , mild tricuspid
insufficiency. Transesophageal echocardiogram revealed mild left
atrial enlargement and intact interatrial septum , mild mitral
regurgitation , left atrium with history of thrombus ,
inferobasilar and inferoseptal akinesis consistent with old
inferoposterior myocardial infarction , mild tricuspid
regurgitation , trileaflet aortic valve , which is quite mobile
with no evidence for significant aortic insufficiency , normal
pulmonic valve and aortic atherosclerosis. No pericardial
effusion and no evidence of endocarditis. The patient developed
a fever the day of admission and blood cultures were drawn which
grew out Streptococcus morbillorum and Bacteroides. His foot
became clearly boggy and grossly infected with necrosis.
Within an hour of that he underwent guillotine amputation of his
left foot. His temperature normalized and his foot cultures grew
out Streptococcus mutans and E. coli as well as Bacteroides
fragilis. He received ampicillin and sulbactam for bacteremia on
11/2/06 . He underwent a coronary cardiac catheterization and
was found to have the following , left main coronary artery with
an ostial 100% stenosis. Formal report is not available at this
time. The patient was then transferred to Pagham University Of for urgent coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for myocardial infarction ,
history of class II heart failure , hypertension , peripheral
vascular disease , diabetic vasculopathy , renal failure and
nephropathy.
PAST SURGICAL HISTORY: Significant for left transmetatarsal
amputation , recent left guillotine amputation of left foot and
renal transplant 11 years ago.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER , Lopressor 25 mg twice a day , lisinopril 40 mg
daily , aspirin 325 mg daily , cyclosporine 50 mg twice a day ,
azathioprine 125 mg daily , NPH insulin 74 units in the morning
and 72 units in the evening.
PHYSICAL EXAMINATION: A 6 feet 2 inches tall , 113.63 kilograms ,
temperature 98.6 , heart rate 79 and regular , blood pressure right
arm 130/65 , left arm 137/68 , oxygen saturation 97% on room air.
Cardiovascular , regular rate and rhythm with a 2/6 holosystolic
murmur. Peripheral vascular 2+ pulses bilaterally. Carotid ,
radial and femoral pulses , nonpalpable left dorsalis pedis and
posterior tibialis pulses and dopplerable right dorsalis pedis
and posterior tibialis pulses. Neurologic , alert and oriented
with no focal deficits.
ADMISSION LABS: Sodium 135 , potassium 3.6 , chloride of 101 , CO2
27 , BUN of 10 , creatinine 0.8 , glucose 113 , magnesium 1.9 , WBC
10.6 , hematocrit 29.9 , hemoglobin 10 , platelets of 501 , and
physical therapy-INR 1.1.
HOSPITAL COURSE: Mr. Baldon was brought to the operating room on
2/1/06 where he underwent an urgent coronary artery bypass
graft x4 with a sequential graft from the saphenous vein graft
from aorta to the ramus and then the second obtuse marginal
coronary artery and left internal mammary artery to left anterior
descending coronary artery and a saphenous vein graft to the
posterior descending coronary artery. Total bypass time was 121
minutes. Total crossclamp time was 104 minutes. The patient did
well intraoperatively , came off bypass without incident and was
brought to the Intensive Care Unit in normal sinus rhythm and in
stable condition. Postoperatively , the patient did well. He was
extubated and transferred to the Step-Down Unit on postoperative
day #1. Infectious Disease Service was called and recommended
treating the patient with levofloxacin and Flagyl for total of 14
days for his left leg BKA site. The patient's chest tubes were
removed and post-pull chest x-ray revealed no pneumothorax.
Dr. Stacie Halechko from the Vascular Surgery Service was consulted and
the patient was underwent revision and closure of his left BKA on
11/9/06 . Mr. Baldon was also followed by the Diabetes Mellitus
Service postoperatively for his insulin regimen. He also
experienced some postoperative urinary retention with several
failed voiding trials. The patient will be discharged with a leg
bag and will follow up with a urologist within five to seven days who will be
assigned by his primary care physician. The
patient had already been started on Flomax 0.4 mg daily. The
patient also worked with physical therapy and is able to pivot
with assist and will be discharged to home with physical therapy. Mr. Baldon was
cleared for discharge to home with visiting nurse and physical therapy on postoperative day
#11. Mr. Baldon also had postoperative anemia and was transfused with one unit of
packed red blood cells for a hematocrit of 22 with a repeat at time
of discharge to 23.4. He also required further diuresis and
appears to be hemodiluted. The patient was also instructed on
sternal precautions due to his left BKA and patient and the
family were shown sternal precautions.
DISCHARGE LABS: Sodium 134 , potassium 4.6 , chloride of 100 , CO2
27 , BUN of 15 , creatinine 0.8 , glucose 136 , magnesium 1.6 , WBC
8.30 , hematocrit 23.4 , hemoglobin 7.5 , platelets of 471 , physical therapy 16.7 ,
physical therapy/INR of 1.3 , and a PTT of 37.1.
DISCHARGE MEDICATIONS: Vitamin C 500 mg twice a day , Lipitor 20 mg
daily , azathioprine 125 mg daily , cyclosporine ( Sandimmune ) 50 mg
twice a day , enteric-coated aspirin 325 mg daily , Lasix 40 mg daily
for five doses along with potassium chloride slow release 20 mEq
daily for five doses , Neurontin 300 mg three times a day subcutaneously ,
heparin 5000 units subcutaneously every 8 hours , Dilaudid 4-6 mg every 4 hours
as needed pain , NovoLog 20 units before every meal , Lantus 100 units every 8 p.m. ,
levofloxacin 500 mg daily for two remaining doses , Toprol-XL 100
mg daily , Niferex 150 mg twice a day and Flomax 0.4 mg daily.
Mr. Baldon will follow up with Dr. Rossie Mankoski in six weeks
and his cardiologist Dr. Marcela Jone in one week and an
urologist to be signed by his primary care physician within five
to seven days and also Dr. Stacie Halechko the vascular surgeon in
two to three weeks. He is otherwise clear for discharge to home
with visiting nurse. The patient has also been instructed to
keep his left leg immobilizer brace on until follow up with Dr.
Halechko in two to three weeks.
eScription document: 1-2467341 CSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: MANKOSKI , ROSSIE
Dictation ID 3035580
Addendum Created by MANKOSKI , ROSSIE K. , M.D.
A: 2/2/07
Dictation ID: 5272823JDU
Document id: 246
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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500428092 | PUO | 11359155 | | 7974526 | 9/25/2006 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 1/8/2006 Report Status: Signed
Discharge Date: 10/12/2006
ATTENDING: REISMAN , CATHIE MINDI MD
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female
who is transferred from an outside hospital for further
management of her CHF. The patient is a 67-year-old female with
history of coronary artery disease who was first evaluated back
in 2002 when she had a stent placed at CEMH for symptomatic
coronary artery disease. She reports feeling well until 10/14
when she developed substernal chest burning and pressure and was
admitted to Osri Medical Center , where a dobutamine echo was
positive for ischemia , details unclear and she was transferred to
CEMH for further care. At C Enwiram Memorial Hospital ,
angiography was performed on 8/7/06 with placement of a Cypher
stent in her LAD. The evening following discharge , the patient
reported severe substernal chest pressure and activated her local
EMS. On the way to the hospital , she suffered a Vfib arrhythmia
requiring CPR and 9 defibrillations. At Osri Medical Center ,
she was acutely intervened upon with PTCA and found to have a
thrombosed LAD stent. At this point , she was transferred to
Pagham University Of on an intraaortic balloon pump for
support. Repeat angiography was performed revealing suboptimal
deployment of the initial stent , which was subsequently outsized
to a diameter of 3.5 mm and additional stenting was performed
distal to the original stent with good anterograde flow noted
postprocedure. The patient was managed in the CCU , where she
remained intubated on the intraaortic balloon pump. Hospital
course was notable for distributive and cardiogenic shock as well
as aspiration pneumonia and HSV , treated with acyclovir. She
improved after two weeks and was discharged on 5/14/06 with an
EF of 40% at the time of discharge. The patient was readmitted
to Osri Medical Center on 6/16/06 with a CHF exacerbation , was
subsequently diuresed and discharged on 1/27/06 .
Echocardiography at that time demonstrated an EF of 55% with 2 to
3+ MR and RVSP of 45 mmHg. The patient represented to Osri Medical Center on 9/23/06 reporting progressive dyspnea , weight
gain , PND , orthopnea and cough. At that time , she underwent
repeat angiography demonstrating RA 14 , RV 55/13 , PA 61/25/42 ,
PCWP 35 with V 246 , LHC with AO 86/57. Angiography revealed a
right dominant circulation and LMCA , which was patent , LAD 20%
mid , D1 40% , ostial left circumflex 20% mid , RCA 60% prox , LV
gram with an EF of 25% associated with global hypokinesis and
severe MR. The patient was subsequently transferred to Totin Hospital And Clinic for further management of her advanced heart failure.
PAST MEDICAL HISTORY: Significant in addition to above for
hypertension , type 2 diabetes on insulin , obesity , COPD ,
hyperlipidemia , GERD , hypothyroidism , depression , status post
appendectomy and status post cholecystectomy.
MEDICATIONS ON TRANSFER: Include aspirin 325 daily , Lasix 80 mg
intravenous twice a day , Diovan 160 mg daily , Plavix 75 mg daily , levothyroxine
88 mcg daily , Lipitor 20 mg daily , Zetia 10 mg daily , Aldactone
25 mg daily , Protonix 20 mg daily , Advair 500/50 one puff daily
and insulin 70/30 , 30 units subcutaneously twice a day
ALLERGIES: Include erythromycin.
SOCIAL HISTORY: The patient lives with her husband and works in
a clothing company. She smokes 1-2 packs per day x46 years until
nine years ago. No alcohol use. No illicits.
FAMILY HISTORY: The patient reports coronary artery disease in
one sibling. No premature cardiac catheterization. Mother died
of cervical cancer. Father died of alcoholism.
REVIEW OF SYSTEMS: The patient denies fever , chills , nausea ,
vomiting , abdominal pain , hemoptysis , bright red blood per
rectum , hematochezia , or melena , no chest pain or palpitations.
Positive for cough and shortness of breath. No changes in mental
status or loss of consciousness , no dysuria , no exposures. No
recent travel. No presyncope or dizziness.
LABORATORY DATA ON ADMISSION: Notable for creatinine of 1 from
baseline of 0.7 to 0.8. Hematocrit of 34 , baseline 37. ALT 68 ,
AST 33 and alkaline phosphatase 384 down from 616 on last
admission. INR 1. EKG , sinus rhythm at 90 , normal axis
intervals with old anterior septal MI.
PHYSICAL EXAMINATION: Notable for afebrile , heart rate in the
90s , blood pressure 98/60 , respiratory rate 18-20 , satting 98% on
3 liters. The patient was in no acute distress , pleasant ,
resting comfortably. Oropharynx clear. JVP 10 cm with 2+
carotids without bruits. No thyromegaly , no lymphadenopathy.
Decreased breath sounds with bibasilar crackles with prolonged
expiratory phase and intermittent expiratory wheezing. Regular
rate and rhythm , S1 and S2. Notable S3 , no MR appreciated.
Abdomen was obese , distended , soft , nontender , no
hepatosplenomegaly. Positive bowel sounds. Extremities , 1+
lower extremity edema to the shins with 1+ DP and physical therapy pulses
bilaterally. Pretibial erythema , right greater than left. No
other rashes. Right groin minimally tender without bruit. Cath
site clean , dry , intact. Neurologic exam is nonfocal.
ASSESSMENT AND PLAN: In summary , this is a 67-year-old female
with multiple cardiac risk factors including hypertension ,
hyperlipidemia , diabetes , coronary artery disease status post LAD
stent complicated by a subacute thrombosis with marked left
ventricular dysfunction with a reportedly revascularized right
coronary territory and severe MR on repeat echo. Despite
diuresis at the outside hospital , the patient remained volume
overloaded with biventricular failure on exam. The patient was
admitted to medically optimized heart failure regimen to further
clarify component of mitral regurgitation. Repeat TTE and right
and left heart catheterization to further evaluate and optimize
medical management. The patient was maintained on aspirin ,
Plavix , ARB , statin and Zetia. Beta-blocker was continued at low
dose given decompensated state. Adenosine MIBI was completed ,
which was notable for recovery 1 mm ST depressions in leads II ,
III and aVF , which resolved. There is no further evidence of
ischemia. EF was notable to be severely depressed; however ,
moderate MR on outside hospital echo was not reproducible here.
Cardiovascular surgery was initially consulted to further
evaluate for benefit of mitral valve replacement surgery;
however , this will likely not be of benefit given mild MR on
repeat echo. In addition a contrast echo was performed to
further evaluate for evidence of clot given the severe right
ventricle malfunction , and anticoagulation was started; however ,
there was no evidence of clot on echo. In addition , on echo ,
reevaluated for dyssynchrony , which was negative. The patient
was diuresed with intravenous Lasix until near euvolemic and then
transitioned to orally regimen. The patient was maintained on
Aldactone. The EP service evaluated for possible placement of
AICD versus biventricular pacemaker; however , given the patient
is not yet outside of three-month window and was noninducible on
EP study , she will need close monitoring as an outpatient with
repeat echo in 2 months and a further EP study to readdress. The
patient will be anticoagulated in the meantime. Respiratory:
The patient has history of COPD with no evidence of acute
exacerbation. Inhalers were continued. PFTs and VO2 study may
be considered as an outpatient. Renal: Creatinine was mildly
elevated compared with baseline , likely secondary to mild dye
nephropathy and overaggressive diuresis. Creatinine stabilized ,
will need to be followed closely as an outpatient as well as
electrolytes. GI. The patient was maintained on a bowel
regimen. LFTs were elevated on admission consistent with right
heart failure versus statin. LFTs trended down on admission.
Hemoglobin and hematocrit remained stable at baseline. The
patient will remain on heparin to Coumadin bridge with Lovenox
bridge as an outpatient if needed. Endocrine: The patient has a
history of poorly controlled diabetes and was maintained on
insulin as an inpatient with sliding scale coverage. History of
hypothyroidism , on Levoxyl. TSH within normal limits. ID: No
acute issues. The patient was treated for asymptomatic
bacteriuria secondary to possible permanent pacemaker placement.
She developed itchiness , which is likely secondary to the
Bactrim. Provided supportive care , the patient should avoid
Bactrim in the future secondary to intolerance. No serious
reactions were observed. Psychiatric: The patient has a history
of depression. She was continued on home medications. FEN: The
patient was maintained on a cardiac diet with sodium and volume
restriction , K mag scales. Nutrition was consulted.
Dermatologic: The patient has a history of HSV , status post
acyclovir treatment. No evidence of further infection. The
patient had pretibial erythema , which derm was consulted for ,
which they felt was consistent with venous stasis. She improved
with steroid cream and compression. The patient was prophylaxed
with Protonix and heparin. The patient was instructed to follow
up with cardiology , weigh herself daily with careful notice to
weight gain reporting to the physician and to returne to the ED
with worsening shortness of breath or chest pain. The patient
was instructed to follow a fluid restricted , low-fat ,
low-cholesterol diet as well as a restricted sodium diet. She
will follow up with her primary care physician Dr. Mangold at 771-077-6316 on
1/4/06 at 2:45. Dr. Raabe at 575-803-4363 on 3/12/06 at 3:45.
INR will be drawn on 1/1/06 with followup INRs to be drawn
every five days. INRs will be followed by primary care physician.
DISCHARGE MEDICATIONS: Include aspirin 325 mg orally daily ,
albuterol 2 puffs inhaled four times a day as needed wheezing , Colace 100 mg
orally twice a day , fluoxetine 20 mg orally daily , Lasix 80 mg orally daily ,
insulin NPH 35 units subcutaneously twice a day , regular insulin sliding scale ,
the patient will not be discharged on the last sliding scale med ,
levothyroxine 88 mcg orally daily , nortriptyline 50 mg orally at
bedtime , oxycodone 5-10 mg orally every 6 hours as needed pain , spironolactone
25 mg daily , Coumadin 5 mg daily , simvastatin 20 mg daily ,
Toprol-XL 25 mg daily , Ambien 5 mg orally daily as needed insomnia ,
Diovan 40 mg orally twice a day , Plavix 75 mg daily , Advair 500/50 one
puff inhaled twice a day , esomeprazole 20 mg orally daily and Zetia 10
mg orally daily.
eScription document: 8-9847457 HFFocus
Dictated By: YEAGLEY , MA
Attending: REISMAN , CATHIE MINDI
Dictation ID 9748828
D: 1/1/06
T: 1/1/06
Document id: 247
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
- |
N |
N |
Y |
N |
N |
N |
N |
N |
- |
474827665 | PUO | 79422241 | | 8704916 | 10/16/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/4/2005 Report Status: Signed
Discharge Date: 8/17/2005
ATTENDING: QUIRARTE , VICTORIA M.D.
SERVICE: General Medical Service , Hassprai Birm Ven
ADMIT DIAGNOSIS: Congestive heart failure.
DISCHARGE DIAGNOSES: Congestive heart failure , aortic valve and
mitral valve dysfunction.
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is 59-year-old female who is
status post mitral valve repair , aortic valve repair , history of
endocarditis , history of rheumatic heart disease , hypertension ,
diabetes mellitus , and congestive heart failure who presents with
increasing shortness of breath , nausea , vomiting , and abdominal
pain. She has been under significant stress at home since last
summer and notes slowly declining health since that time. She
has had increasing shortness of breath as well as dyspnea on
exertion since September 2004 and has gotten worse in the past one
month , and even significantly worse in the past week. The
patient notes increasing lower extremity edema on the right side
greater than the left. She states that this is her baseline with
the right side being more than the left. She has no increase in
her abdominal girth , the patient has two-to three-pillow
orthopnea ( from one-pillow orthopnea , one month ago ) , she does
have some paroxysmal nocturnal dyspnea , she has no increased
nocturia. The patient notes that the shortness of breath is "not
angina; I do not have that." She does not have any
lightheadedness , diaphoresis , or radiation of pain. The patient
says that she does not check her weigh at home , but "knows" she
is in failure when she is short of breath. She also notes
nausea , vomiting , and some abdominal pain stating that it started
about a week and a half ago. She had gone to see the ED on the
Sunday prior to admission where the patient reportedly had a
benign exam , low-grade temperature , given recent Levaquin for an
upper respiratory tract infection , she was then started on Flagyl
for a possible C. difficile infection. The patient's diarrhea
stopped , but she had still remained some abdominal pain and
increased cough , which was nonproductive. She went to her primary care physician on
the day of admission for increasing shortness of breath and was
sent to the ED for diuresis. In the ED , she was given 60 mg of
intravenous Lasix with good output per report. She did have some decrease
in her shortness of breath shortly thereafter. She also
complained of 10/10 abdominal pain and was given some Dilaudid.
On the floor during the interview , she did have some projectile
vomiting. She was able to pass gas. She reported no fevers ,
chills , or night sweats. She reported no bright red blood per
rectum. She reported no change in her bowel , bladder , or urinary
habits.
PAST MEDICAL HISTORY:
1. Rheumatic heart disease , status post mitral valve repair and
aortic valve repair. In 1981 , she had porcine mitral valve
repair. In 1991 , she had St. Jude valve , mitral valve , and AVR.
2. Endocarditis in 1991 and porcine mitral valve.
3. Diabetes mellitus.
4. Hypertension.
5. Status post ankle fracture and subsequent ORIF in 2001.
6. Status post ventral hernia repair.
7. Status post laparoscopic cholecystectomy.
8. Status post breast biopsy.
9. Congestive heart failure.
10. Atrial fibrillation.
11. TIA.
ALLERGIES: No known drug allergies. Dove soap does give her
hives.
MEDICATIONS:
1. Lasix 40 mg orally every other day alternating with 80 mg orally Lasix
every other day
2. Digoxin 0.125 mg every other day alternating with 0.25 every other day
3. Lisinopril 20 mg orally every day
4. Coumadin 6 mg orally every other day , alternating with 4 mg every other day
5. Omeprazole 20 mg twice a day
6. Metformin 500 mg daily.
7. Insulin 70/30 65 units every day before noon , 35 units every afternoon
8. Calcium 600 mg orally twice a day
9. Magnesium 400 mg orally twice a day
10. Multivitamin.
11. Iron tablets.
12. Actonel every Wednesday.
SOCIAL HISTORY: The patient quit smoking in 2001. Her maximum
was three to four packs per day for 35 years. As far as her
alcohol history , she drinks occasional alcohol. She does not
take any illicit drugs. She used to work as a hairdresser. She
has had increased stress at home secondary to a son who has
schizophrenia and another son who abuses drugs and has violent
tendencies.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs are remarkable
for temperature of 98.7 , pulse 60 , blood pressure 111/61 ,
respiratory rate 30 , O2 saturation 96% on room air. These were
vitals when the patient arrived to the floor. General: She is
alert and oriented x3. She is anxious , but pleasant in nature.
HEENT: Her left eye is artificial. Her right eye is
approximately 3 mm. She has moist mucous membrane. She has a
small erosion on the right upper gum. There is no erythema or
exudate seen within the tonsils. Neck: JVP noted to be
approximately 6 cm. Her neck is supple. There was full range of
motion. There are no carotid bruits and there is no
lymphadenopathy present. Cardiovascular: Heart is of regular
rate and rhythm with occasional premature beats. She has a S1
and S2 that are mechanical in nature. She has a 3/6 holosystolic
murmur heard at the apex. There are no rubs or gallops
appreciated. She additionally has a right RV heave. Her PMI is
diffuse , but nondisplaced. Chest: Faint crackles at the left
base , otherwise clear. No wheezes or rhonchi are heard.
Abdomen: Slightly tympanic. Her right lower quadrant is
slightly tender. She has active bowel sounds. Her liver edge is
not palpable. The spleen tip is nonpalpable. Extremities:
Warm , 1+ dorsalis pedis pulses bilaterally. She does have some
1+ lower extremity edema on the right greater than the left. It
is slightly pitting.
LABORATORY EXAM ON ADMISSION: Sodium 126 , potassium 4.4 ,
chloride 93 , bicarbonate 24 , BUN 28 , creatinine 1.4 with a
baseline of 1.2 and 1.3 , glucose 160. CBC is notable for a white
blood cell count of 9.9 , hematocrit 27.9 , platelet count 274 , 000.
Her liver function tests are notable for ALT 56 , AST 83 ,
alkaline phosphatase is 52 , total bilirubin 0.1 , albumin 4.2 , and
total protein 7.4.
STUDIES: Her EKG showed no change. It was in junctional rhythm
at 65 beats per minute. She had frequent PVCs. There was a
normal access. There were some nonspecific T-wave inversions.
CHEST X-RAY: Showed mild vascular congestion. There was no
evidence of any effusion.
IMPRESSION: This is a 59-year-old female with a rheumatic heart
disease , status post St. Jude's MVR and AVR , congestive heart
failure who presents with mild volume overload and abdominal pain
with nausea and vomiting.
BRIEF HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular:
a. Ischemia: When the patient was admitted , she was ruled out
for an MI. She did have a slight increase of her troponins ,
which were attributed to mild demand ischemia. In addition , she
had some slight anemia , which could also be contributed to the
demand as well in addition to the clear volume overload. She did
fine from the standpoint , had no ST changes on any of her EKGs.
The patient laid her head workup for future AVR and MVR with the
Surgical Service , with Dr. Stukowski . Her workup was extensive and
included a cardiac catheterization , which showed no significant
coronary artery disease. The hemodynamics were notable for the
following: RA of 12 , PA of 92/23/44 , pulmonary capillary wedge
pressure of 22 with V waves to 42. The mitral valve was grossly
normal with appropriate leaflet motion. The AV was also grossly.
The overall conclusion was elevated right-sided heart pressures.
She had no evidence of major atherosclerotic disease of the
coronary arteries.
b. Pump: Please see cath report as above. The patient was
admitted and diuresed with intravenous Lasix , so she came down to a
euvolemic state. Her diuresis was continued with 80 mg intravenous Lasix
on a twice a day basis. She was diuresed until there was a subsequent
bump in her creatinine to 1.8 , 1.9. After that point , diuresis
was slowly modified. She was then placed back on a regimen of
120 mg of orally Lasix every other day That is the dosing of Lasix on which
she is discharged.
c. Rhythm: The patient has a history of paroxysmal atrial
fibrillation that has been rate controlled with a beta-blocker.
On admission , her digoxin was stopped. She was evaluated by the
EP Service. They recommended epicardial lead placement at
surgery due to her tachybrady syndrome. The patient was
discharged on diltiazem 30 mg four times a day She will have her
medications modified status post her valvular repair in the very
near future.
d. Presurgical workup: In addition to echo , right and left
heart cath , the patient had a TEE performed. TEE showed normal
left atrial appendage without evidence of localized thrombus.
St. Jude's valve was well seated in the aortic position. There
was no significant aortic regurg that was noted. A St. Jude's
valve was well seated in the mitral position as well. There was
trace mild regurgitation noted. There was slight asynchronous
motion of the prosthetic valve apparatus that was noted. The
tricuspid valve was normal in appearance. There was mild
regurgitation present. Visualized portion of the thoracic aorta
revealed minimal atheromatous plaque.
2. Pulmonary: The patient remained stable from her pulmonary
standpoint. She continued to sat well on room air. She did not
required any nebulizers during her stay.
3. GI: The patient was initially admitted with some abdominal
pain and also nausea and vomiting. She had a KUB performed for a
question of potential bowel obstruction. A single frontal view
of the abdomen was obtained and is reported in the final
radiology report. There was gas seen within the loops of small
bowel as well as the colon. There is no bowel dilatation seen.
The overall impression was no evidence of any high-grade bowel
obstruction. It is likely that some of her pain was secondary to
hepatic congestion. The nausea and vomiting eventually resolved
and perhaps this is some type of viral illness or
gastroenteritis. She did have some episode of diarrhea prior to
admission along with some abdominal cramping. The patient was
continued on her PPI for GERD prophylaxis. At one point , she
required increasing her dosage of Nexium secondary to GERD-like
symptoms. It seemed that increasing the amount of Nexium she
received , precipitated some diarrhea. She was returned to a
normal dosing of Nexium 40 mg orally every day while in-house. She was
discharged on omeprazole 20 mg orally twice a day , which she will
continue to take as an outpatient. In addition , she was given
prescription for Colace and also Senokot today. She should
continue using.
4. Heme: Her hematocrit remained relatively stable during her
stay with averaging of 26 to 27 as far as her hematocrit. We
were not concerned with keeping her hematocrit 30 or above at all
times given her clean coronary arteries seen from the left and
also right heart catheterization. She did have a slight dip in
her hematocrit at one point requiring two units of packed red
blood cells. Her hematocrit bumped appropriately to 30 or 31.
She required no subsequent transfusions thereafter. With regard
to anticoagulation , she was placed on the heparin drip at 950
units per hour to maintain a PTT between 60 and 80 secondary to
her mechanical valves that are in place. On discharge , the
patient was transitioned to Lovenox 60 mg twice a day with a renal
dosing. She will continue to take this Lovenox as an outpatient
and stop it one to two days prior to her surgery as instructed.
She has home VNA in place.
5. Renal: Her BUN and creatinine was relatively stable on
admission. It did elevate to as high as 3.3 , 3.4 on her
admission secondary to her ongoing diuresis. When diuresis was
held for several days given her markedly increased urine output
and as she became more hydrated and euvolemic , her creatinine
returned to its baseline of 1.2 , 1.3. She has no active issues
now.
6. Endocrine: We appreciated the Diabetes Service for following
her very closely while in-house. Several modifications were made
to her regimen while here to get good control of her blood
glucose. She was maintained on a stable regimen of NPH 60 units
in the morning , NPH 30 units in the evening. She also was placed
on a sliding scale. She also received NovoLog of 15 units in the
morning with breakfast and also 15 at dinner. She was not
receiving any of the NovoLog while at lunch. She will continue
to take this regimen in home. All of her prescriptions were
provided by Bruce Amadon , who is following with the Diabetes
Service. They will become again involved with her care as she
plans for surgery in the very near future.
7. Infectious disease: The patient was stable from an ID
standpoint during her entire admission. On September , 2005 , the
patient was noted to have an increase in her white blood cell
count upwards towards the 20 , 000. This was one day prior to a
planned surgery on April , 2005 with Dr. Stukowski to repair her
aortic valve and also her mitral valve. The surgery was delayed
as a result of this , so an infectious workup could ensue. She
had a urine sent that showed , the suggestion of a urinary tract
infection. Levaquin was given for treatment of her UTI.
Surveillance cultures were drawn daily. Given the fact that she
had a right groin hematoma that performed after the heart
catheterization we questioned whether or not this could be some
type of infectious source. She had the hematoma aspirated , it
was negative for any organisms. She had no other identified
places as far as source of infection. It was believed that she
could potential have endocarditis as she has had in the past.
One of her cultures actually grew out a species of Abiotrophia.
There is only one culture positive , that was taken on February .
She has had no subsequent cultures growing out at the time of
this dictation. We appreciate the Infectious Disease Team
following. Their recommendations were to hold antibiotics unless
subsequent cultures began to grow out. Their recommendations
were to continue to follow all cultures and to perform a TEE. A
repeat TEE was performed and showed no evidence of any lesions or
change in bowel function. There were clearly no vegetation seen
on either any transthoracic echos or TEEs. ID made
recommendations as far as perioperative antibiotics , which would
include two weeks of ceftriaxone 1 g intravenous twice a day under the
assumption that this would be completing a course of her therapy
after SBE. They would also recommend sending all valve tissue
for Gram stain and culture as well as pathology. If the Gram
stain and culture were positive , they would suggest extending the
course of the above-mentioned antibiotic therapy.
8. Neurologic: The patient was given Darvon and also codeine as
needed for her pain. She complained of right groin pain
secondary to the hematoma. Her pain is much improved that she is
able to ambulate easily around the Ma Stin Den on discharge. The
hematoma is resolving and her pain is resolving as well.
9. Fluids , electrolytes , and nutrition: The patient is
tolerating orally well. Her electrolytes were repleted as needed
daily.
10. Psychologic: The patient was seen by social work. It is
clear that she has many anxieties about the surgery and also in
going home and returning to her social environment. She
necessitated volume prior to many procedures given her severe
anxiety.
11. Disposition: The patient is stable from a medical
standpoint with all cultures clear and no evidence of active
infection. Her white blood cell count is now normal. She is now
awaiting surgical repair of her valve and will have a surgery
scheduled with Dr. Haegele office in the next one to two weeks.
DISCHARGE MEDICATIONS:
1. Diltiazem 30 mg orally every 6 hours
2. Colace 100 mg orally twice a day
3. Lasix 120 mg orally every other day.
4. NPH 60 units in the morning.
5. NPH 30 units in the evening.
6. Lisinopril 40 mg orally every day.
7. Senokot three tablets orally twice a day
8. Multivitamin one tablet orally every day
9. Lovenox 60 mg subcutaneously twice a day
10. Caltrate plus vitamin D 600 mg one tablet orally twice a day
11. NovoLog sliding scale before every meal and bedtime
12. NovoLog 15 units subcutaneously with breakfast and dinner
did not give at lunch.
13. Maalox tablets quick dissolve.
14. Codeine 15 mg to 30 mg orally every 4 hours as needed pain.
15. Magnesium oxide 400 mg orally twice a day
16. Omeprazole 20 mg orally twice a day
17. Niferex 150 mg orally twice a day
FOLLOW-UP PLANS:
1. The patient was given instructions to call Dr. Haegele
office to coordinate her appointment for her valve repair in the
next one to two weeks pending her surgeon's return.
2. The patient instructed to call Dr. Victoria Quirarte on January ,
2005 , to discuss surgical plans and also to follow up.
3. The patient should have all her blood cultures followed up
prior to her surgery. If any of her blood cultures become
positive in the interim , we will begin a long course of
antibiotic therapy and delay surgery at the discussion of the
Cardiovascular Service.
DISCHARGE CONDITION: Stable.
eScription document: 5-8492613 IS
Dictated By: QUELLA , STACEY
Attending: QUIRARTE , VICTORIA
Dictation ID 9017225
D: 10/4/05
T: 7/16/05
Document id: 248
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
U |
Y |
U |
U |
U |
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U |
U |
Y |
U |
Y |
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| output/system_intuitive_annotation.xml | intuitive |
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020505906 | PUO | 47746833 | | 366783 | 11/10/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/10/1993 Report Status: Signed
Discharge Date: 6/5/1993
PRINCIPAL DIAGNOSIS: STATUS POST MYOCARDIAL INFARCTION.
OTHER DIAGNOSES: 1. CONGESTIVE HEART FAILURE.
2. DIABETES.
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
4. PERIPHERAL VASCULAR DISEASE.
HISTORY OF PRESENT ILLNESS: Ms. Sobe is a 60 year old woman with
adult onset diabetes , hypertension , and
severe peripheral vascular disease status post cerebrovascular
accident in 1986 , who was recently admitted to I Warho Hospital between 7/8/23 with what was presumed to be an
exacerbation of her chronic obstructive pulmonary disease and new
onset congestive heart failure. PFT's during that admission showed
FVC of 1.92 , 59% , FEV1 of 1.42 estimated at 55% and FEV1/FVC ratio
94%. An echocardiogram performed during that admission showed
normal left and right ventricular function and size. Since her
discharge , Ms. Sobe has become progressively weak and has noted
gradually increasing shortness of breath on exertion. She denies
fevers and chills , reports a dry cough but no nausea or vomiting.
The cough was nonproductive. She has had poor orally intake , however ,
no change in her bowel habits and no symptoms consistent with an
upper respiratory tract infection. She denies any episodes of chest
pain , however , notes that she requires three pillows to sleep on ,
new onset orthopnea and new onset pedal edema. She presented to the
I Warho Hospital to the emergency department after having
increased shortness of breath the night preceding the 6 of July and was
noted on arrival to the emergency room to have a blood pressure of
200/100 with an oxygen saturation on 100% face mask of 85%.
Portable chest x-ray was consistent with congestive heart failure
and she has been on Lasix , Morphine Sulfate , in addition to
nebulizer treatment. She initially responded well to this
treatment , diuresing 1.4 liters in urine output and her O2
saturation rose to 96% on six liters. At that point , she was
transferred to the floor to the general medical service. PAST
MEDICAL HISTORY: Notable for cerebrovascular accident in 1986 ,
diabetes mellitus since 1985 , she has been insulin dependent;
hypertension; congestive heart failure; chronic obstructive
pulmonary disease with a long history of smoking. MEDICATIONS ON
ADMISSION: Xanax .25 mg every bedtime as needed , Lasix 20 mg orally every other day ,
insulin NPH 32 units and 6 units Regular every day before noon , enteric coated
aspirin one tablet every day , Elavil 25 mg every bedtime , Proventil two puffs every
6 as needed ALLERGIES: No known drug allergies. FAMILY HISTORY:
Notable for both parents who died of myocardial infarctions , mother
at age 65 and father at age 75 , both parents also had hypertension
and her mother had diabetes. She has several children , all of whom
are in good health. She lives with daughter. She has a sixty pack
year history of smoking but no longer smokes and denies any alcohol
use.
PHYSICAL EXAMINATION: Obese , white female in mild respiratory
distress. Blood pressure 120/60 , heart rate
120 , respiratory rate 16 , temperature 98 with oxygen saturation 94%
on three liters. HEENT exam was notable for normocephalic ,
atraumatic head. Extraocular movements were intact and pupils were
equal , round , and reactive to light and accommodation. Oropharynx
was clear and sclera were also clear and anicteric. Neck exam was
supple. Jugular venous pressure was 10 cm and the carotids were
without bruits. Neck was without adenopathy. Lungs; rales
one-half way up from the bases bilaterally. Cardiac exam showed
that she was tachycardic but with a regular rhythm and S1 and S2
were heard clearly with an S4 , there were no murmurs or rubs noted.
Abdomen; notable for positive bowel sounds , soft , non-tender ,
non-distended , no hepatosplenomegaly and no other masses felt.
Extremities; 2+ pitting edema bilaterally with 1+ DP and physical therapy pulses
bilaterally without femoral bruits. Rectal exam showed no masses
and was guaiac negative. Neuro exam; alert and oriented x3.
Cranial nerves were bilaterally intact and motor strength was 5 out
of 5 , and sensation was grossly intact as well as her coordination.
Reflexes were symmetric and toes were bilaterally down-going.
LABORATORY EVALUATION: On admission , sodium was 142 , potassium 4.6 ,
chloride 106 , bicarbonate 24 , BUN 13 ,
creatinine 0.7 , glucose 220. LFT's were within normal limits.
Albumin was 3.1 , calcium 9.0 , cholesterol 208 , triglycerides 220.
CBC showed a white count of 16 with hematocrit of 34.3 and
platelets 352 , MCV 91. The differential on her white count
demonstrated 82 polys , 12 lymphocytes , 5 monocytes , 1 eosinophil.
Her first CK was 33 with no MB fraction and an arterial blood gas
/showed pH of 7.41 , 31 , 77 , 23 , and 96%. Chest x-ray was consistent
with congestive heart failure with bilateral pleural effusions and
increased pulmonary vascular redistribution. EKG showed sinus
tachycardia at 120 with normal intervals and axis , with some
flattening in the STT waves in the lateral lead. Urinalysis was
negative.
HOSPITAL COURSE: Patient was initially admitted to the floor where
she received another dose of intravenous Lasix and 30 mg
orally Nifedipine. Twenty minutes later , patient was noted to be
hypotensive with a systolic blood pressure of 70. She was given a
small intravenous bolus of 100 cc normal saline with no response to her
systolic blood pressure. She was noted to be nauseated and vomited
x1 with midscapular back pain but no chest pain. She was markedly
diaphoretic , but did not complain of palpitations. Her blood sugar
was 181 and EKG at that time showed further T-wave flattening in
inferior leads. She was started on Dopamine 20 micrograms per
kilograms with initially no response. At that time , she was
transferred to cardiac unit for further management. In the CCU ,
she was weaned from intravenous Dobutamine and her blood pressures rapidly
came up to systolic blood pressure of 130. Her requirement for
oxygen was weaned from 100% face mask to 3 liters via nasal
cannula , with her O2 saturations remaining 94-95%. She was started
on a beta blocker and her rule out protocol for myocardial
infarction showed flat CK's , CK's numbering 33 , 58 , and 147 , with
no MB fractions and no further EKG changes , and no further episodes
of nausea , vomiting , or diaphoresis. On the third hospital day ,
she was transferred to the cardiology Ette La Hatul service. Soon after
transfer , a routine 12 lead EKG revealed deepening and inversion of
T-waves in the lateral leads , as well as the inferior leads. Her
heart rate at that time was 110 , blood pressure 130/90. She did not
complain of chest pain , shortness of breath , or diaphoresis.
Patient was given one tablet of sublingual Nitroglycerin with no
change in her heart rate and her blood pressure went to 180/60 and
she complained of a headache. She was given 5 mg intravenous push Lopressor
every 5 minutes x3 with response of her heart rate to 90. EKG post
intervention was without change and she was maintained on 3 liters
oxygen via nasal cannula , without change in her O2 saturation. At
that time , the patient was started on Heparin 5 , 000 units intravenous bolus
and maintained at 1200 units per hour , and a rule out protocol was
again started. Her CK's were flat and there were no further EKG
changes. The decision to proceed with cardiac catheterization was
presented to the patient and on the 4th hospital day , the patient
initially refused cardiac catheterization. However , after further
consideration , she agreed to cardiac catheterization on the 7th
hospital day , 6/4/93 . Because of her history of acute renal
failure with creatinine rising from baseline of 1 to 1.7 on
previous admission with the initiation of Captopril , she had
concurrently an abdominal aortogram to rule out renal artery
stenosis. Her right heart catheterization showed a pulmonary
capillary wedge pressure of 15 with a diffusely diseased left
coronary system , right coronary with serial stenoses of 50%
proximal and 30% distal , and anterior apical hypokinesis with
preserved LV systolic function. An echocardiogram revealed
anteroseptal akinesis at the apex without any mention of thrombus ,
moderately dilated left ventricle with ejection fraction estimated
at 30%. It was felt at this time that the patient had suffered
myocardial infarction at the time between her two I Warho Hospital admissions. Her catheterization results suggested that
she would be best managed medically and her hospital course then
was notable for aggressive diuresis with Lasix and one time dose of
Zaroxolyn , and rate control initially with Diltiazem with moderate
success and then by the 7th hospital day the addition of Lopressor.
Patient diuresed well with loss of 2-3 kilograms and with decrease
in her oxygen requirement was able to be weaned to room air with
oxygen saturations 92-93%. By the time of her discharge , her O2
saturation was 95% on room air and she was able to ambulate without
assistance or complaints of chest pain or shortness of breath.
ID: On admission , patient's white blood cell count was noted to be
16 and it was persistently high throughout the first four or
five days of her hospital course. She remained afebrile until the
6th hospital day , when she was noted to have one temperature of
101. Blood culture , urine culture , sputum , and chest x-ray did not
reveal any evidence of infection and patient's white count was
noted to fall to 9.8. No intravenous antibiotics were given.
DIABETES; Patient was maintained on her normal dose of insulin
and except for the day when she went to catheterization ,
and covered with CZI sliding scale. Her blood sugars initially ran
in the 200 to 300 range but by the end of admission she was more
well controlled between 100 and 200 , and did not require addition
of CZI sliding scale. Of note , patient had described previous
incidences of feeling diaphoretic and hungry in which she would eat
presumably secondary to hypoglycemia. After starting her beta
blocker , she continued to have these sensations of hypoglycemia and
if so , it was though to be safe to continue with the beta blocker
treatment.
PERIPHERAL VASCULAR DISEASE; Patient has a history of femoral
stenosis and had been suggested that
she have a femoral angioplasty several years previously. Patient
refused that procedure at the time and has had no further
complications. During this admission a renal arteriogram was
performed , which showed no evidence of renal artery stenosis with a
mild non-flow in the stenosis in the right renal artery. Renal
cortex was smooth by arteriography.
DISPOSITION: There were no complications. Patient was able to
ambulate and was stable on discharge. Her congestive
heart failure was largely resolved , and she was discharged to home
with follow-up to be with Dr. Carmelita Toni in KTDUOO Clinic.
MEDICATIONS: Xanax 0.25 mg orally every bedtime as needed; Digoxin 0.25 mg orally every
day; Lopressor 50 mg orally twice a day; enteric coated
aspirin one tablet orally every day; Lasix 60 mg orally every day; insulin 32 units
NPH in the morning along with six units Regular insulin in the
morning; Elavil 25 mg orally every bedtime She is to continue with her
diabetic diet with 2100 calories and to have low salt , low
cholesterol diet.
Dictated By: CORYELL , CHRYSTAL LALA
Attending: LEOLA C. MUSICH , M.D. AQ28 VY407/4516
Batch: 3295 Index No. VRTUU8653X D: 11/13/93
T: 3/23/93
CC: 1. CARMELITA TONI , M.D. PX57
Document id: 249
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
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OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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995906475 | PUO | 07554150 | | 372680 | 11/15/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/14/1996 Report Status: Signed
Discharge Date: 11/29/1996
PRINCIPAL DIAGNOSIS: RESTRICTIVE PULMONARY DISEASE.
OTHER DIAGNOSES: 1 ) OBSTRUCTIVE SLEEP APNEA.
2 ) CHRONIC HYPOXIA.
3 ) STATUS POST HYPERCARBIC RESPIRATORY ARREST.
4 ) OBESITY.
5 ) MILD HYPERTENSION.
6 ) RECURRENT LOWER EXTREMITY DEEP VENOUS
THROMBOSES.
7 ) OSTEOARTHRITIS SECONDARY TO MECHANICAL
DERANGEMENTS SECONDARY TO OBESITY.
8 ) TYPE II DIABETES MELLITUS.
9 ) DEPRESSION.
HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old morbidly
obese black female with a history of
restrictive lung disease , obstructive sleep apnea , recurrent lower
extremity deep venous thromboses requiring multiple
hospitalizations who was initially evaluated on March , 1996 for
right knee pain. Evaluation revealed a small right knee effusion
consistent with mechanical derangement secondary to obesity. The
tap was negative for crystals and had negative cultures. The
patient was initially supposed to go home , however due to
inadequate support , she was kept overnight on the evening of September , 1996. Overnight she received Vistaril , Percocet as well as
some Demerol and Oxycodone. On the morning of March , 1996 , she
was found to be unresponsive with bloody saliva dripping from her
mouth. A Code Green was called. They were unable to find a blood
pressure. The patient was intubated. Dopamine was started.
Narcan was given. The blood pressure recovered. The patient
awakened and the patient's initial arterial blood gas prior to
intubation was 7.04 pH , pCO2 137 and pO2 of 85 and she was
subsequently admitted to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY: Her past medical history is significant for
a restrictive lung disease. Past pulmonary
function tests revealed an FEV of 1.8 which is in the 56th
percentile and FEV1 of 1.6 which is in the 59th percentile , TLC of
3.3 in the 54th percentile and DLCO at 116th percentile. She has
been on long term home oxygen with oxygen saturation between 85%
and 90% on two liters of nasal cannula. Arterial blood gases on
prior admissions have revealed pO2 in 50 , pCO2 in the high 40s to
low 50s. She has a history of obstructive sleep apnea. She has
been evaluated in the past with even trace apnea screen in August
of 1994 which revealed approximately 19 apnea events in just over
10 hours. The oxygen saturation decreased to 61% at the minimum
and subsequently she had respiratory monitoring in September of 1995 with
C-PAP which revealed a decrease in the apnea episodes to 19 events
in about 480 minutes with oxygen saturation decreasing to a minimum
of 71%. Apparently , by report , attempts had been made to start the
patient on the C-PAP at home , but the patient had been resistant
and she has a long history of medical non-compliance. She has a
history of recurrent deep venous thromboses in which she has had
multiple medical admissions , most recently about six in the past
year , most recently in October of 1996 , for cellulitis of the left
lower extremity , in July of 1996 , bilateral calf tenderness with
negative non-invasive studies and in September of 1996 , most recently
with right lower extremity cellulitis and this was complicated by
apparent chronic obstructive pulmonary disease flare. The patient
has had multiple VQ scans in the past , all of which have been low
probability. The patient has been on chronic Coumadin , however
there is a question of whether or not , she has been taking it
regularly. There has also been a question in the past of possible
diastolic dysfunction. In September of 1994 , she had an
echocardiogram which showed some left ventricular hypertrophy , no
regional wall motion abnormalities and an ejection fraction of
approximately 55% , no right ventricular hypertrophy or tricuspid
regurgitation. Other past medical history includes a history of
depression. The patient has been managed with Zoloft 50 mg orally q.
day. She is status post midline hernia repair. She is status post
bilateral tubal ligation. The patient has chronic hypoxemia ,
obesity , obstructive sleep apnea , chronic lower extremity deep
venous thromboses and obstructive lung disease.
MEDICATIONS ON ADMISSION: 1 ) Diltiazem 120 mg orally every day. 2 )
Glyburide 10 mg orally every day. 3 )
Albuterol 2 puffs four times a day as needed 4 ) K-Dur 20 mEq orally every day. 5 )
Axid 150 mg orally every bedtime 6 ) Zoloft 50 mg orally every day. 7 ) Lasix
20 mg orally every day. 8 ) Coumadin alternating 10 mg with 7.5 mg orally
every day.
SOCIAL HISTORY: Significant for the patient living alone. She
occasional has her son stay with her. She is
divorced and she has refused chronic care in the past.
HABITS: Positive for cigarettes about a 20 pack year history. No
alcohol , no intravenous drugs.
HOSPITAL COURSE: 1 ) Pulmonary: The patient was admitted to the
Medical Intensive Care Unit on March , 1996
status post a respiratory arrest thought to be secondary to
hypercarbia through the combination of the patient's underlying
lung disease as well as excessive sedation. She was intubated on
March , 1996 and quickly extubated on April , 1996 without
complications. Her chest x-ray on admission was significant for a
mild interstitial pulmonary edema and cardiomegaly. After
extubation , the patient was weaned to bi-PAP with which she was
able to maintain saturations between 86-90% while in the Medical
Intensive Care Unit. The patient was transferred to the floor on
February , 1996. Given the patient's history of restrictive lung
disease , it was thought that it was time to have a full work-up to
search for a possible etiologies , questioning possible obesity vs.
parenchymal disease. She had an echocardiogram on August , 1996 ,
which revealed an ejection fraction of 75% , mild left ventricular
hypertrophy , no regional wall motion abnormalities , a top normal
sized right ventricle , trace tricuspid insufficiency and a
suggested pulmonary arterial pressure in the range of 36 mm of
Mercury plus the estimated right atrial pressure. This
echocardiogram was performed with a bubble study and there was no
obvious intra-cardiac shunt either by color doppler or saline
infusion. They were unable to exclude diastolic dysfunction given
the presence of left ventricular hypertrophy. Her chest CT on
August , 1996 was significant for cardiomegaly and pulmonary
edema , patchy opacities in the right apex and lung bases with a
nodular quality of unclear etiology and a lucent lesion in the
right lobe of the liver that was too small to characterize. In
order to further help sort out the etiology of her restrictive lung
disease , the patient underwent a PA gram on September , 1996 to rule
out the possibility of chronic pulmonary emboli. This study
revealed no evidence of pulmonary emboli. She had a normal
pulmonary vascular distribution , elevated right heart pressures
with pulmonary arterial pressure of 44/13 with a mean of 28 mm of
Mercury , right ventricular pressure 52/2 with a mean of 20 mm of
Mercury and a pulmonary capillary wedge pressure of 23. The
Pulmonary Service had been consulted and it was thought that it was
difficult to sort out exactly what was going on. It was unclear
what the nodular lesions described on the CT represented , whether
it was inflammation or some sort of firm nodule. It was decided to
follow-up on the CT in the future and to have the patient had a
repeat sleep study as well as repeat pulmonary function tests. The
overall impression was that her restrictive lung disease was most
likely secondary to obesity. While the patient was on the floor ,
we attempted to restart her on the bi-PAP , however the patient
resisted using both the C-PAP and the bi-PAP practically every
night complaining that she had an upper respiratory infection that
made it difficult for her to wear the machine. On the evening that
she did actually try both the C-PAP and the bi-PAP , she was noted
to have labored breathing with the C-PAP at 5 mm of Mercury and
four liters nasal cannula with a pulse oximetry dropping to 81%.
When she switched to bi-PAP with settings of 12 mm of Mercury
inspiratory and 7 mm of Mercury expiratory , she was able to
maintain oxygen saturations between 88% and as high as 93% oxygen
saturation. Her oxygen saturations throughout hospitalization
ranged between 91-93% on two liters nasal cannula during the day
and as well as 88% overnight. It was decided that the patient
given her history would require bi-PAP on discharge as well as her
home oxygen.
2 ) Infectious Disease: The patient as noted above spiked a
temperature to 101 degrees on March , 1996 while in the Medical
Intensive Care Unit and subsequently never had elevated
temperatures nor an elevated white blood cell count. She was
started on Clindamycin and Ofloxacin intravenously and then
switched to orally on February , 1996 to complete a ten day course.
On March , 1996 , the patient as stated , remained afebrile
throughout her hospitalization and never had an elevated white
blood cell count. She did complain of upper respiratory symptoms
beginning on February , 1996 described as general head fullness ,
sinus tenderness and nasal congestion. She was started on Afrin 2
puffs twice a day for three days with some relief as well as Robitussin
and Sudafed. Her physical examination was notable some maxillary
sinusitis and the patient was actually discharged after a brief
time on Afrin nasal spray.
3 ) Cardiovascular: Echocardiogram was performed during this
admission and is as described above. The patient remained
hemodynamically stable throughout this admission.
4 ) Hematology: The patient had a history of recurrent lower
extremity deep venous thromboses. She was maintained on Heparin
until all of her procedures had been completed and was restarted on
Coumadin on September , 1996. Her physical therapy and PTT were followed until
the point that she had established a therapeutic INR. On August , 1996 , her physical therapy and PTT were notable for a physical therapy of 17.5 with a PTT
of greater than 200 and INR of 2.2. Heparin was discontinued and a
repeat PTT on the evening of July , 1996 revealed a physical therapy of 18.5
and a PTT of 67.6 and an INR of 2.5. She was discharged the next
day on 7.5 mg of Coumadin every bedtime Of note , the patient had been
admitted with about a 2 X 2 cm ulcer of her medial left malleolus
which appeared to heal well with granulation and scarred by the
time she had been discharged.
5 ) Rheumatology: The patient as noted was admitted for evaluation
of right knee pain. The patient did not complain of right pain
subsequent to her discharge from the Medical Intensive Care Unit.
Her cultures and crystals were negative and she is to follow-up as
an outpatient with the Rheumatologist in their clinic.
6 ) Endocrine: The patient maintained stable bowel sounds on
Glyburide 10 mg orally every day.
7 ) Gastrointestinal: The patient remained stable and was able to
tolerate a low cholesterol , low saturated fat diet and was
maintained on Axid 150 mg orally twice a day However , on the date of
discharge , the patient was complaining of a burning sensation in
her throat after drinking orange juice which tended to come and go ,
but did not radiate and she was switched from Axid to Prilosec 20
mg orally every day on March , 1996.
8 ) Gynecology: While on the floor , the patient started
complaining of some vaginal spotting. She has menopausal since her
40s and has had not had any recent gynecological following. It was
decided for the patient to either follow-up with her primary care
physician or with the GYN clinic at A Salt Medical Center for evaluation of this spotting for ruling out endometrial
carcinoma.
9 ) Neurological: The patient did not demonstrate any evidence of
depression and was stable on Zoloft.
10 ) General Care: The patient underwent Physical Therapy and
Occupational Therapy throughout the hospitalization. It was
thought that she would benefit greatly from inpatient pulmonary
rehabilitation or possibly weight loss reduction , however the
patient repeatedly declined pulmonary rehabilitation and weight
loss reduction and felt that she would be able to manage herself at
home.
The patient was discharged on March , 1996 in stable condition
to home with VNA services to follow-up on her blood sugars , her
home oxygen as well as her bi-PAP.
MEDICATIONS ON DISCHARGE: 1 ) Lasix 20 mg orally every day. 2 )
Glyburide 10 mg orally every day. 3 )
Procardia XL 30 mg orally every day. 4 ) Zoloft 50 mg orally every bedtime 5 )
Coumadin 7.5 mg orally every bedtime 6 ) Ofloxacin 200 mg orally twice a day times
one day. 7 ) Clindamycin 200 mg orally every 6 hours times one day. 8 )
Prilosec 20 mg orally every day. 9 ) Potassium chloride slow release 20
mEq orally every day. 10 ) Tylenol 650 mg orally every 4-6h. as needed pain.
11 ) Maalox 50 mg orally every 6 hours as needed indigestion. 12 ) Albuterol
inhaler 2 puffs inhaled four times a day as needed wheezing. 13 ) Afrin 2 puffs
twice a day times three days.
FOLLOW-UP: The patient is to follow-up with Dr. Verlie Jeniffer Swanda on
August , 1996. She also had an appointment on January , 1996 with the GYN Clinic. Pulmonary follow-up is as follows:
On February , 1996 at 9:00 a.m. , she is to have a repeat CT to
follow-up the nodularities found on the most recent CT. On
February , 1996 at 10:30 a.m. , she is to have a pulmonary function
test and to follow-up at 11:30 a.m. with the Pulmonary Clinic. She
is to call Rheumatology at her convenience.
The patient was to proceed with bi-PAP , however due to the
need for medical assistance , she may not receive it for another two
weeks and is to continue with her home oxygen.
Dictated By: GERTHA M. LESCHES , M.D. IJ16
Attending: DEVIN MARISHA CARLA BRADY , M.D. GQ9 LU795/0185
Batch: 09824 Index No. BRNSS68K4Z D: 9/7/96
T: 5/29/96
CC: 1. VERLIE J. EVIE SWANDA , M.D. UV35
2. JULIANA MICHON , M.D. KTDUOO CLINIC IN Westjer Minewsnash
Document id: 250
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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520297510 | PUO | 06673173 | | 821873 | 6/10/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/25/1995 Report Status: Signed
Discharge Date: 7/20/1995
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION
SECONDARY DIAGNOSES: HYPERLIPIDEMIA
HISTORY OF PRESENT ILLNESS: Mr. Helmstetter is a 54 year old professor
at Tempe Lare , status
post coronary artery bypass graft ( 5 vessel bypass ) 8 years ago who
presents with recurrent substernal chest pain times one day. The
patient was transferred from Stusri Medical Center after developing the
acute onset of substernal chest pain while driving his automobile.
The patient was under no extraordinary circumstances ( e.g.
emotional stress , exertional stress ) at the time he developed chest
pain. Since the time of his five vessel CABG in 1987 , the patient
had experienced no intercurrent angina.
The patient's coronary risk factors include a positive family
history and a previous diagnosis of hyperlipidemia. However the
patient does not have hypertension , diabetes and he is not a
tobacco smoker.
As mentioned , the patient's chest pain was substernal and radiated
to the upper epigastrium. He experienced an element of burning
with exertion. Prior to this episode of recurrent chest pain , the
patient had had multiple exercise tolerance tests which were read
as normal. He graded the chest pain at 8/10.
The patient presented to CHH urgent care where his pain was not
relieved with four sublingual nitroglycerin. An EKG demonstrated
lateral ST wave depressions. The patient was transferred to
Stusri Medical Center where intravenous TNG , morphine and Nifedipine were given.
The patient's pain decreased to a level of 4/10. Despite these
maneuvers , the patient's pain continued through the night and in
the morning. In the morning , he received additional morphine and
intravenous Heparin was begun. Subsequently the patient became pain-free.
The patient was transferred to Pagham University Of for
further management.
PAST MEDICAL HISTORY: Hyperlipidemia. Bilateral anterior and
lateral thigh achiness with exertion
times six months ( workup in progress ).
MEDICATIONS: On presentation to Stusri Medical Center ,
Lovastatin 40 mg every every m. , 20 mg every afternoon and
enteric-coated aspirin one tablet every day.
MEDICATIONS ON TRANSFER FROM ALEJO NYHEG MEMORIAL HOSPITAL intravenous nitroglycerin , intravenous heparin , Nifedipine sublingual , morphine as
well as aspirin and Lovastatin.
The patient has no known drug allergies.
FAMILY HISTORY: The patient's father developed angina secondary
to coronary artery disease at age 54 and died
at age 75 from an MI.
SOCIAL HISTORY: The patient is married and lives at home with
his wife. He works as a professor at
Sta and restores buildings in his free time.
HABITS: The patient denies tobacco use. He is an
occasional alcohol drinker.
PHYSICAL EXAMINATION: On physical examination , Mr. Helmstetter is
a pleasant middle-aged man , mildly
anxious but in no acute distress. Vital signs on transfer:
temperature 98.6 , heart rate 78 , blood pressure 110/78 , respiratory
rate 22 with oxygen saturation of 99% on 4 liters of oxygen.
HEENT: unremarkable. Neck: no jugular venous distention ( JVP
less than 6 cm ) , carotids were 2+ bilaterally with no bruits or
delayed upstroke. Lungs: clear with good breath sounds
bilaterally. Coronary: regular rate and rhythm with good heart
sounds and a clear Sl and S2. There were no rubs , murmurs or
gallops appreciated. There was no S3 or S4. The point of maximum
impulse was not displaced. The patient's spine was not tender and
there was no evidence of costovertebral angle tenderness. Abdomen
had good bowel sounds and was soft and nontender to palpation. No
masses were palpated. Groin demonstrated decreased femoral pulses
bilaterally with a faint left femoral bruit. Rectal: normal
rectal tone with an anodular prostate. Stool was soft , brown and
guaiac negative. Extremities demonstrated no clubbing , cyanosis or
edema. The patient's pulses at the dorsalis pedis and posterior
tibialis were 2+ bilaterally. Neurologic examination was nonfocal.
Electrolytes on presentation were within normal limits. His LFTs
were notable for a slight increase in his LDH to 252. The
patient's first CK on presentation was 2300 with a quantitative MB
of 10.2 ng/ml. Cholesterol was 79. Albumin 2.8. Protime 12.4 ,
INR 1.1. PTT 40.7 , consistent with heparin therapy. CBC was
notable for a normal white count , hematocrit and platelet count.
Urine had a specific gravity of 1.021 , pH 5 , negative dipstick
evaluation.
Chest x-ray demonstrated clear lung parenchyma and no bony
abnormalities. EKG on admission to Pagham University Of
showed normal sinus rhythm at a rate of 73 with normal intervals
and an axis of 0. The patient had Q waves in leads 3 and F and
biphasic T waves in leads V4 through V6. There was minimal change
in these abnormalities with resolution of the patient's pain. Of
note , EKGs taken at Stusri Medical Center during the patient's initial
admission were notable for T wave depressions in leads V4 through
V6.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Intensive Care Unit on intravenous heparin and
nitroglycerine as well as continuation of his aspirin and
Lovastatin. The patient's pain was treated with morphine sulfate.
His CKs were followed serially every 8 hours and achieved a peak CK
of 2790 on 6/16/95 at 12 a.m. with an MB fraction of 188.8 ng/ml.
Thereafter the patient's CKs rapidly declined. On 3/30/94 , the
patient's CK was 317 with an MB fraction of 3.5 ng/ml.
After 24 hours pain-free in the Cardiac Intensive Care Unit , the
patient was transferred to the Cardiac Step-Down floor. His intravenous
nitroglycerin and intravenous heparin were discontinued and the patient
remained pain-free. Echocardiogram performed on 6/16/95
demonstrated inferior and posterior hypokinesis with an ejection
fraction of approximately 46%.
On 3/9/95 , the patient underwent exercise tolerance testing with a
submax modified Bruce protocol. The patient exercised 9 minutes
and was able to complete the study without dyspnea on exertion or
chest pain. He achieved a maximum heart rate of 108 and a
maximum blood pressure of 160/80. EKG was notable for unifocal
PVCs and up to 2 mm ST depression in leads V2 through V4 which
persisted up to 15 minutes into recovery. The patient was given
one sublingual nitroglycerin and these EKG changes resolved.
The exercise tolerance test was interpreted as strongly positive
for ischemic coronary artery disease.
On 1/9/95 , the patient underwent a submax MIBI to assess coronary
perfusion of the heart. Similarly , the exercise component of this
examination demonstrated EKG changes consistent with ischemic
coronary flow. Nuclear imaging demonstrated a fixed apical lateral
defect in the patient's heart consistent with a healed or healing
transmural infarct. There was no evidence of ischemic reperfusion
defects.
The results of these tests were discussed with the patient and his
wife in conjunction with the treating medical team of Dr. Tyacke .
The patient was offered the opportunity for coronary
catheterization to evaluate his anatomy , but he declined at the
present time. It was decided that the patient would be maximally
medically managed and discharged to home with close followup under
Dr. Tyacke and Dr. Blanke . The patient's cardiac medications were
appropriately adjusted while an inpatient to achieve maximum
cardiac benefit.
On presentation , the patient also complained of progressive
anterior and lateral thigh pain. This pain was brought on by
exertion and had increasingly limited his ability to walk over the
last six months whereas he had been able to walk four to five miles
a day in recent months. He had been able to walk only
approximately one-quarter mile before developing pain in his
anterior thighs as well whereas he had been able to climb several
flights of stairs a few months ago. He now was able to walk only
half a flight to a flight of stairs at a time before having to
rest. Six months ago , the patient had achieved a 25 pound weight
loss but , by his report , because of his inability to exercise
effectively , he had regained 15 pounds. The patient did not
experience this same anterior thigh pain while riding a bicycle or
swimming. As an inpatient , Mr. Helmstetter underwent a non-invasive
vascular study of the femoral and popliteal arteries. These
demonstrated no significant arterial occlusions as assessed by
pressure manometry. The possibility of myositis or neuromuscular
compromise was entertained and these are to be followed up as an
outpatient.
The patient also complained of symptoms consistent with an upper
respiratory viral infection which he had been experiencing over the
past two weeks. While an inpatient , he had a number of febrile
episodes , achieving a maximum temperature of 101.4. The patient
was treated symptomatically with Tylenol and started on Biaxin 500
mg orally twice a day He received a five day course of orally Biaxin with
resolution of his fever and decrease in his symptomatology.
The patient never complained of shortness of breath , palpitations ,
diaphoresis , nausea , vomiting or recurrent chest pain as an
inpatient. However physical examination demonstrated rales 4 to 5
cm above the bases bilaterally. The extremities remained free of
edema and the patient's jugular venous pressure never exceeded 6
cm. A chest x-ray on 5/7/95 demonstrated evidence of early
congestive heart failure. The patient was treated with daily doses
of intravenous Lasix with resolution of his rales. By the time of
discharge , there was no evidence of continued heart failure and the
patient's Lasix was discontinued.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 mg orally every day
2. Cholestyramine one packet orally every bedtime
3. Lovastatin 20 mg orally every bedtime
4. Lopressor 50 mg orally three times a day
5. Sublingual nitroglycerin 1/150 tablets to be taken as needed
with chest pain
DISPOSITION: The patient is being discharged to home with
followup in CHH under Drs. Mackenzie Mallory Tyacke .
The patient was instructed to call CHH Urgent Care if his chest
pain recurs and does not resolve with sublingual nitroglycerin.
Dictated By: GAYLENE FANIEL , M.D. NX03
Attending: MACKENZIE TYACKE , M.D. WA4 HU716/7643
Batch: 759 Index No. AIRQP95G50 D: 8/13/95
T: 8/13/95
Document id: 251
| Target |
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HTG |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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537124853 | PUO | 72340071 | | 3106821 | 11/3/2006 12:00:00 a.m. | RESPIRATORY FAILURE | Signed | DIS | Admission Date: 2/4/2006 Report Status: Signed
Discharge Date: 8/30/2006
ATTENDING: MANKOSKI , ROSSIE M.D.
CHIEF COMPLAINT/REASON FOR ADMISSION:
Confusion , mental status change , and hypercarbic respiratory
failure.
HISTORY OF PRESENT ILLNESS:
The patient is a 54-year-old woman with history of asthma/COPD ,
morbid obesity , obstructive sleep apnea , but does not tolerate
BiPAP who presented to the emergency room with worsening
somnolence. Apparently over the past week the patient has become
progressively more confused and lethargic. At baseline , she is
alert and oriented and walks intermittently with walker ,
although , at most time she is bedbound because of her obesity and
an injured knee at the end of October . Over the previous week
apparently , the patient had difficulty with her home oxygen
machine and she felt like she "was not getting any air".
Apparently , her son had called the company that supplies the
oxygen. They had come in and said that he should figure out how
to fix it according to him , as she had not been getting oxygen
for the week prior to admission. She had not had any increase in
cough or sputum production. No fever or chills. No chest pain.
No nausea , vomiting , or diarrhea. She also had not any change in
her baseline lower extremity swelling/deformity and no increased
erythema or pain in her lower extremities. She has not had any
recent long trips , although she had been somewhat bed bound after
this knee injury. On the day of admission , the patient had
increasing shortness of breath , fatigue , and somnolence and
apparently hallucinations. The Emergency Medical Service was
called and she was unarousable at home and they found her oxygen
sats to be 40%. By the time she in to the ER she was lethargic
and moaning incoherently. Her vitals at that time were
temperature of 97.6 Fahrenheit , blood pressure of 178/46 mmHg ,
heart rate of 106 and regular , breathing 36 times a minute and
satting 90% on 100% nonrebreather. Her fingerstick at that time
was 220. Her trachea was intubated and she was given Fentanyl ,
Valium , albuterol , and Atrovent nebs and Solu-Medrol in the
emergency room.
PAST MEDICAL HISTORY:
Significant for hypertension , severe left ventricular
hypertrophy , asthma/COPD without known pulmonary function testing
in the past , morbid obesity weighing approximately 460 pounds ,
obstructive sleep apnea - she could not tolerate CPAP in the
past , osteoarthritis , and type 2 diabetes mellitus as well as a
distant history of pulmonary embolus. After having a total
abdominal hysterectomy and bilateral salpingo-oophorectomy in
4/3 , she was anticoagulated for several months , but not since
then.
ALLERGIES:
No known drug allergies.
HOME MEDICATIONS:
Lisinopril 40 mg by mouth each day , furosemide 40 mg by mouth
each day , glyburide 5 mg by mouth each day , albuterol inhalers ,
Motrin 600 mg by mouth each day , and metoprolol 25 mg by mouth 3
times a day , and she is also on 3L nasal cannula home oxygen 24
hours a day.
SOCIAL HISTORY:
She is a former bus driver. She lives at home with her son ,
Rodrigues who is 30 years old , has a visiting nurse. No tobacco or
alcohol or illicit drugs.
FAMILY HISTORY:
Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION:
Her temperature was 97.6 degree Fahrenheit , her heart rate was
106 and regular , her blood pressure was 130/50 , respiratory rate
of 24 , and oxygen saturation 98%. At that point , she was
intubated. She opened her eyes to sternal rub but not to voice.
Her pupils were equal and 2 mm bilaterally. Her neck was supple.
Pulmonary: Sounds were coarse anterior and laterally.
Cardiovascular: She had distant , distant heart sounds ,
tachycardic. Her jugular venous pressure was unable to be
assessed given her neck size and her distal , radial , and dorsalis
pedis pulses were all palpable 1+. Abdomen is obese. Bowel
sounds were present , soft , nontender , and nondistended. She had
a midline scar. Extremities were cool with chronic venostasis
changes perhaps lymphedema changes bilaterally. Left lower
extremity was 23 inches and right lower extremity was 18 inches
at the calf. Neurologic: As stated , she opens her eyes to
sternal rub at that time.
LABS ON ADMISSION:
She had a sodium of 144 , potassium 4.3 , chloride 95 , bicarbonate
of 40 , BUN of 16 , creatinine of 0.7 , and glucose of 236. Calcium
of 8.9 , magnesium of 1.9 , phosphorous of 4.7 , ALT of 23 , AST of
18 , total bilirubin of 2.1 , alkaline phosphatase of 78 , and
albumin of 3.9. Urinalysis was significant for 3+ protein , 2+
blood , positive leukocyte esterase , negative nitrites , and
bacteria as well as trichomonas. Her D-dimer was 1330. Her
white count was 13 , 000 with 90% neutrophils , 2% bands , and 5%
lymphocytes. Her hematocrit was 42.4% and platelet count was
164 , 000. Her MCV was 93 and she had an anti-PF4 antibody , also
known as a HIT antibody , which was negative. Her INR was 1.2 and
her PTT was 26.3. Her urine and serum tox screens did not reveal
any toxins. Her chest radiograph was a poor quality film given
the girth. The film was rotated. The ET tube was 3.5 cm from
the corner , otherwise , extraordinarily limited , but no gross
consolidation or effusions were noted. A pulmonary embolus CT
scan or V/Q scan were considered to rule out a pulmonary embolus;
however , the patient's abdominal girth prevented either of these
studies from being done. Lower extremity noninvasive studies
were performed , which did not show any clot although this was
also limited by her chronic lower extremity changes. Urine
culture and blood cultures were sent on 10/28/06 . The urine
culture grew mixed flora and the blood cultures have been
negative to date.
ASSESSMENT AT THE TIME OF ADMISSION:
This is a 54-year-old woman with chronic obstructive pulmonary
disease on home oxygen as well as obstructive sleep apnea ,
hypertension , and left ventricular hypertrophy and obesity with
mental status changes and respiratory changes consistent with an
exacerbation of recurrent obstructive pulmonary disease and
hypoxemia.
HOSPITAL COURSE BY SYSTEM:
1. Pulmonary: Her trachea was extubated within several hours of
coming to the Medical Intensive Care Unit. At first , she was
doing quite well on BiPAP at 25 and 5; however , she became a bit
more somnolent and the decision was made to intubate her trachea
once again within several hours. An ABG at that time was done ,
which revealed an arterial blood gas at that time with an FiO2 of
60% revealed a pH of 7.19 , a CO2 of 119 , and an oxygen of 106
with saturation of 97%. As we were preparing to intubate the
trachea , the patient became more alert and requested to speak to
her son beforehand and saying she did not want to have the tube
down her throat. Her son came in and she continued making more
sense and asking us not to intubate her trachea. The decision
was made to observe her with the BiPAP , which was done. Within
several hours her carbon dioxide had decreased to 103 and then by
3 hours after that it actually decreased to 80. Her arterial
blood gas at that time showed pH of 7.32 with a PCO2 of 80 , a PO2
of 71 on 2L of actual nasal cannula and then O2 saturation of
95%. She remained on BiPAP intermittently at various setting.
Her final settings were pressure support of 20 and a PEEP of 5.
Her CO2 ranged from the mid 60s to 99 without a very clear
correlation between her mental status and her CO2s. The thought
was that her baseline CO2 was probably somewhere in the 70s given
that her pH was normal with PCO2 around in the low 80s. It was
thought that she is a chronic carbon dioxide retainer. Her
bicarbonates on admission here previously had been in the mid to
high 30s and low 40s just as they were during this admission and
that she just had an acute hypercarbic event. Throughout her
stay she has had episodes where she become slightly less
responsive always will awake with appropriate physical stimuli
and will give appropriate responses. She was treated for her
pulmonary disease initially with corticosteroids , which were
discontinued given that we did not feel that she had large a
inflammatory component to this , Levofloxacin 500 mg a day ,
albuterol and Atrovent nebulizers and she was started on an
inhaled corticosteroid.
2. Vascular: The possibility of a pulmonary embolus was
considered especially given her history of pulmonary embolus in
the past. Unfortunately , diagnostic imaging was inadequate given
her girth and lower extremity issues. There is discussion of
putting her on chronic anticoagulation for the possibility of
pulmonary embolus; however , we felt she had a low to moderate
probability of pulmonary embolus and that the risks of long-term
anticoagulation outweigh the benefits given that she probably did
not have a pulmonary embolus or deep venous thrombosis. This was
discussed with the patient and she agreed with that decision.
This can be readdressed in the future. The decision was also
centered around the fact that her previous pulmonary embolus was
in the setting of pelvic surgery and likely did not reflex any
increased likelihood of thrombosis. However , she should be
continued on subcutaneous enoxaparin or other prophylaxis for
deep venous thrombosis while she is bedbound.
3. Cardiac: The patient has a history of hypertension and left
ventricular hypertrophy. She should be continued on
enteric-coated aspirin 81 mg a day , lisinopril 40 mg a day , and
she will discharged on atenolol 25 mg per day.
4. Endocrine: The patient has type 2 diabetes mellitus. She was
managed in the hospital on a low dose of insulin NPH and Aspart
sliding scale. On discharge , she will be resumed on her home
dose of sulfonylurea. It may be considered that she will be good
candidate for metformin given her weight and likely poor control
of her diabetes.
5. Obstructive sleep apnea with known elevated pulmonary artery
systolic pressure at approximately 90+ right atrium and
echocardiogram during her last admission at Pagham University Of . The patient should be counseled and encouraged to use
her BiPAP or CPAP machine at home all the time at night given her
likely severe obstructive sleep apnea and known vascular effects
of that.
MEDICATION ON DISCHARGE:
1. Lisinopril 40 mg by mouth each day.
2. Atenolol 25 mg by mouth each day.
3. Enteric-coated aspirin 81 mg by mouth each day.
4. Enoxaparin 40 mg subcutaneous each day.
5. Albuterol and Atrovent nebulizers every 4 hours and as needed
wheezing or shortness of breath , this may be changed to inhalers
when the patient can tolerate and she should be educated on that.
6. Flovent.
7. Levofloxacin 500 mg by mouth each day for 5 more days.
8. Flagyl 500 mg by mouth twice a day for 11 more days for
treatment of trichomonas.
9. Glyburide 5 mg by mouth once daily.
10. Regular insulin sliding scale as determined by the doctor at
rehabilitation with meals.
11. BiPAP 20 for pressure support and 5 of PEEP every night all ,
night and during the day as required. It would be recommended
that she was on BiPAP continuously for at least 48 hours after
discharge as tolerated by the patient except to speak with her
family.
eScription document: 1-8900909 EMSSten Tel
Dictated By: SUGIMOTO , ARDELL
Attending: MANKOSKI , ROSSIE
Dictation ID 8430094
D: 11/8/06
T: 11/8/06
Document id: 252
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
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Y |
U |
U |
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Y |
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U |
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| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
833886231 | PUO | 11020818 | | 302346 | 4/1/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 10/29/2000 Report Status: Signed
Discharge Date: 7/9/2000
PRINCIPAL DIAGNOSIS: Congestive heart failure.
SECONDARY DIAGNOSES:
1. Coronary artery disease.
2. Diabetes mellitus.
3. Hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old woman
with coronary artery disease and
cardiomyopathy admitted with clinical shortness of breath. The
patient has a long history of coronary artery disease with most
recent echocardiogram in 8/06 showing dilated left ventricle ,
ejection fraction of 30% to 35% , inferior posterior thinning and
akinesis and severe hypokinesis of the distal septum to apex.
There was remaining wall of hypokinesis. There was also trace
aortic insufficiency and hypertrophied right ventricle. The most
recent catheterization was 11/4/99 showing a left main with 30%
distal stenosis , occluded left anterior descending , right coronary
artery with 40% proximal and mid 70% stenoses. The grafts were
without significant disease. The left heart catheterization showed
left ventricle pressures of 220/80. Left ventriculography revealed
an ejection fraction of 50% to 55% with trace mitral regurgitation.
( Please refer to past medical history for further details of the
patient's cardiac history ). The patient now reports malaise for
one week with increasing dyspnea on exertion. She also reports
fever to 101 two days ago with cough productive of white sputum.
She reports that she went to Urgent Care and received Bactrim. She
also had received Bactrim 48 hours ago. She also complains of
increased orthopnea , baseline two-pillow orthopnea and now
five-pillow orthopnea and nighttime cough. She denies dietary
indiscretion or medical noncompliance and reports that her
peripheral edema is stable. She denies dysuria or frequency and
also believes that her weight has increased although notes on chart
indicate that her baseline is 220 to 228 pounds.
PAST MEDICAL HISTORY: Coronary artery disease , cardiac risk
factors were age and hypertension. Diabetes
mellitus , nonproliferative anemia , one non-Q wave myocardial
infarction in 1981 , coronary artery bypass grafting in 1995 at
Pagham University Of with left internal mammary artery to
left anterior descending graft , saphenous vein graft to posterior
descending artery graft , saphenous vein graft to obtuse marginal
graft. Several admissions for congestive heart failure including
one in 1996 which included an echocardiogram with ejection fraction
of 40%. Decreased from earlier 59% with inferior posterior
hypokinesis. Congestive heart failure admission in 2/11 with an
echocardiogram that showed ejection fraction of 30% to 35% ,
decreased from previous echocardiogram. Non-Q wave myocardial
infarction in 8/06 at Pagham University Of with troponin of
6. Baseline left bundle branch block. Insulin-dependent diabetes
mellitus. Status post right carotid endarterectomy.
Hypercholesterolemia , hypertension , status post appendectomy ,
status post right mastoidectomy ( secondary to recurrent otitis ).
History of recurrent transient ischemic attacks. Amaurosis fugax
in left eye. The patient was treated with Coumadin after 2/14
admission. Head CT showed no sign of infarct. Echocardiogram was
negative for PFO. Ejection fraction at the time was 60%.
Loculated pleural effusion in 4/9 with apparent decortication and
lysis. Nephrolithiasis but none times greater than two years.
Bell's palsy resolved.
ALLERGIES: Penicillin causes hives. Ceclor causes a rash.
MEDICATIONS: Digoxin 0.125 mg orally every day , EC-ASA 81 mg orally every day ,
Plavix 75 mg orally every day , clonidine 0.1 mg orally every day ,
Cozaar 50 mg orally twice a day , Lopressor 12.5 mg orally twice a day , Zestril 20
mg orally twice a day , Zocor 20 mg orally every day , Hytrin 2 mg orally twice a day ,
Lasix 120 mg orally twice a day , NPH 50 every day before noon , 8 every afternoon subcutaneously ,
Slow-K eight once a day.
SOCIAL HISTORY: Retired housewife , married , rare alcohol use , no
tobacco use.
FAMILY HISTORY: Notable for mother with myocardial infarction at
age 40 and a father with myocardial infarction at
age 40.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.1 , pulse 59 ,
blood pressure 180/82 , respirations 22 , and
96% on room air. Weight 226 pounds. General: Large woman lying
in bed in no acute distress. HEENT: Jugulovenous pressure greater
than 12 cm , oropharynx clear , no thyromegaly. Chest: Bibasilar
crackles and diffuse wheezes and rhonchi , no E to A changes.
Cardiovascular: Regular rate and rhythm. There was a II/VI
systolic murmur loudest at bases , question S4 , S1 and S2. Abdomen:
Soft , protuberant , nontender , benign. Extremities: Bilateral
edema to knees , minimally pitting. Neurologic: Cranial nerves and
strength intact.
LABORATORY/X-RAY STUDIES: Notable for BUN of 55 ( baseline high 20s
in 8/06 ) , creatinine of 1.7 , baseline
of 1.0 to 1.2. Hematocrit of 35.5 with MCV of 80.
HOSPITAL COURSE: The patient was admitted with presumptive
diagnosis of recent tracheal bronchitis
complicated by overlying congestive heart failure. She was treated
with doxycycline and never spiked a fever in-house. Her cough was
essentially nonproductive and thus sputum was not sent. She was
diuresed progressively and responded well symptomatically to this
diuresis. Her pulmonary examination improved. The patient's
examination was complicated by some asymptomatic bradycardia into
the 40s , particularly at night while lying down. On admission , her
Digoxin level was low at 0.5. An attempt to increase her beta
blocker appeared to exacerbate this bradycardia and thus she was
discharged on the same dose that she was admitted with , i.e. ,
Lopressor 12.5 mg orally twice a day Notably , even when these medications
were held , her pulse was often in the high 40s or low 50s without
symptoms and remained less than 60 even while walking some of the
time. Her thyroid stimulating hormone was measured and was normal
at 3.13. The patient's elevated BUN and creatinine were thought
secondary to her congestive heart failure and in fact , her
creatinine decreased with diuresis. Recent iron studies in 2/30
were suggestive of anemia of chronic disease and her hematocrit of
35 on review was towards the low end of normal range during the
past year.
DISPOSITION: The patient was discharged to home in stable
condition. Discharge medications were EC-ASA 325 mg
orally every day , clonidine 0.1 mg orally twice a day , Digoxin 0.125 mg orally
every day , doxycycline 100 mg orally twice a day times five days , NPH insulin 8
units every day before noon , start 50 units every day before noon and 8 units every afternoon , Zestril 20
mg orally twice a day , Hytrin 2 mg orally twice a day , Zocor 20 mg orally every afternoon ,
Imdur 30 mg orally every day , Demadex 100 mg orally every day , Cozaar 50 mg orally
twice a day , Plavix 75 mg orally every day , Lopressor 12.5 mg orally twice a day She
will follow up with Dr. Fiermonte in one week in his clinic.
V.N.A. will check the patient's weight , pulse and blood pressure at
home. They will also check the patient's potassium and creatinine
and call in abnormal results to Dr. Fiermonte .
Dictated By: JACKSON PART , M.D. PV74
Attending: SUNSHINE D. RAABE , M.D. JM23 MA857/9316
Batch: 70489 Index No. R5JM2E5UYX D: 10/15
T: 10/15
Document id: 253
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
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U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
N |
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N |
N |
N |
041565203 | PUO | 66040331 | | 001134 | 10/17/2001 12:00:00 a.m. | afib , history of TIA | | DIS | Admission Date: 3/16/2001 Report Status:
Discharge Date: 7/23/2001
****** DISCHARGE ORDERS ******
KRAMPER , MADLYN 577-42-88-7
Waywar Dr , Ster Land Paranass , Louisiana 75575
Service: CAR
DISCHARGE PATIENT ON: 6/5/01 AT 05:00 PM
CONTINGENT UPON Home services
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: JOURNEAY , WINFRED TENESHA , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
DIGOXIN 0.125 MG orally every day
PROZAC ( FLUOXETINE HCL ) 40 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every bedtime
Starting Today ( 2/3 )
Instructions: or as directed by doctor
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/21/01 by
VANNORMAN , ETHYL E. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
LOVENOX ( ENOXAPARIN ) 70 MG subcutaneously every 12 hours
Alert overridden: Override added on 1/4/01 by
VANNORMAN , ETHYL E. , M.D.
SERIOUS INTERACTION: HEPARIN & ENOXAPARIN SODIUM
Reason for override: AWARE
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Earnest Obeso 1-2 weeks ,
Dr. Katheryn Gruntz 4-6 weeks ,
Dr. Flo Titterness 1 month ,
No Known Allergies
ADMIT DIAGNOSIS:
afib c RVR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
afib , history of TIA
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , depression , history of positive PPD , recv'd inhaled , history of substance abuse
( cocaine )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
47 year-old female c history of HTN , depression , substance abuse , presented to ED
on 2/2/01 c complaints of rapid heart beat , palpitations , and chest
heaviness/pain radiating to left arm. Symptoms progressed to left-sided
weakness/ heaviness and sensory loss. In ED , patient found to be in afib c
RVR , rate controlled c Diltiazem intravenous. CT/CTA showed question of a clot
in M2 vessel , therefore Heparinized and transferred to A Eerock Tonbusontlo , Kentucky 97268 for acute
stroke care. TTE showed LVH , mild LAE , no thrombus. EKG's c afib , LVH ,
ST/T wave changes c/with strain pattern. CPK's , troponin flat. MRI
showed very small white matter changes in right hemisphere not felt to
be clinically significant ( no evidence for acute stroke ). Neurologic
defecitcharacterized by left hemiparesis and hemianopsia in ED ,
over time evolved into left eye blurriness/decreased vision , left
facial numbness ( no droop ) , right arm and leg numbness and weakness.
Above exam felt to be inconsistent with single lesion , opinion of psych
and neurology was that the above symptoms represented psychogenic
augmentation of an initial real neuro defecit from TIA/small embolic
stroke which recanalized. Transferred to floor on 9/21/01 in afib c
rate in 90's on Digoxin and Lopressor. Started on Coumadin that night ,
Heparin continued at therapeutic range until initiation of Lovenox on
hosp. day # 6. Spontaneously converted to NSR on Lopressor 100 mg orally
three times a day on 3/18/01 , Lopressor decreased to 50 orally three times a day secondary to sinus
bradycardia , then converted to Atenolol 25 mg orally every day for once
daily dosing. Neurologic deficit spontaneously resolved overnight on
3/18/01 . On exam , only subtle weakness detected on left arm and finger
extention , numbness completely resolved. Patient will be discharged to
home in stable condition with instructions to follow up with primary care physician in 1-2
weeks and with Dr. Journeay in 4-6 weeks. Coumadin titration will be
carried out by MMC Na office. VNA sercices will carry out
Lovenox administration/education. Plan is for 4-6 weeks of therapeutic
anticoagulation on Coumadin , then reassess need if still in NSR.
ADDITIONAL COMMENTS: You should call Dr. Voglund office tomorrow morning for an appt. this
week. You will have VNA come to your home this evening for Lovenox shot
administration/education. You should take Coumadin as well for the next
month as directed by your doctor. You will need to have blood drawn
through the MMC Sie Pkwy office for INR levels starting tomorrow.
Call your doctor or return to the ED if you have chest pain ,
palpitations , lightheadedness , weakness , or other worrisome symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: VANNORMAN , ETHYL E. , M.D. ( IA62 ) 6/5/01 @ 02:00 PM
****** END OF DISCHARGE ORDERS ******
Document id: 254
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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663917208 | PUO | 66936113 | | 847052 | 5/15/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/27/1994 Report Status: Signed
Discharge Date: 8/10/1994
PRINCIPLE DIAGNOSIS: PLEURISY , POSSIBLY SECONDARY TO A POST
VIRAL SYNDROME.
SECONDARY DIAGNOSIS: 1. HISTORY OF PULMONARY EMBOLI IN 1971
AND IN 1988.
2. HISTORY OF STREP PHARYNGITIS IN July
OF 1994 , TREATED WITH PENICILLIN.
HISTORY OF PRESENT ILLNESS: This is a 54 year old female with
a history of pulmonary emboli in the
past , now with complaint of four days of pleuritic chest pain and
left arm heaviness. Coronary risk factors include a positive
family history , no smoking , diabetes mellitus , hypertension or
elevated cholesterol. The patient's history begins in 1971 when ,
after a tubal ligation , she had a pulmonary emboli which was felt
to be secondary to prolonged bedrest. She received Heparin and was
coumadinized for one year. In 1988 she had lower abdominal pain ,
extensive work up of which revealed a pulmonary emboli , and again
she was heparinized and coumadinized for one year. On September , 1994
she developed the acute onset of intermittent chest pressure and
left arm heaviness , associated with night sweats. There was no
shortness of breath , palpitations , light-headedness , nausea or
vomiting. The pain was exacerbated by deep breaths as well as
yawning and movement. It was not relieved by any factors. On the
morning of admission the discomfort progressed from intermittent to
constant and was unrelieved with two Advils , at which time she
subsequently presented to the Pagham University Of
Emergency Ward. In the Emergency Ward her examination was
negative. Chest x-ray was negative. VQ scan was with intermediate
probability. She received Heparin and was subsequently transferred
to the floor. She denied any fevers , chills , cough , shortness of
breath , diarrhea , constipation , abdominal pain or dysuria. It is
noteworthy that the patient had an Emergency Ward visit on April
at which time she complained of sore throat. Rapid Strep test was
positive for Strep pharyngitis. She was treated with a course of
Penicillin. PAST MEDICAL HISTORY: Her past medical history is as
above. She also has a history of dysfunctional uterine bleeding ,
iron deficiency anemia , lumbosacral disc disease , status post
laminectomy times three. MEDICATIONS ON ADMISSION: Medications on
admission are Motrin as needed ALLERGIES: She has no known drug
allergies. FAMILY HISTORY: Her mother died from complications
from hypertension. Her father died from a cerebrovascular
accident. She has one sister who is deceased from burn injuries ,
one brother who passed away from a myocardial infarction at age 57 ,
and two brothers who passed away from natural causes. SOCIAL
HISTORY: She is a clerk. She is divorced with five children. She
never smoked. She drinks alcohol occasionally. She has no HIV
risk factors and no known TB exposures.
PHYSICAL EXAMINATION: On physical examination she is a
well-developed , well-nourished female
appearing her stated age and in no apparent distress. Temperature
is 98 , pulse 94 , blood pressure 140/88 , and respirations 16. Heent
shows extraocular movements were intact. Oropharynx revealed no
erythema , edema or exudate. Mucous membranes were moist. Neck was
supple with no lymphadenopathy. Carotids were 2+ bilaterally.
Lungs revealed right basilar rales. Coronary examination revealed
a regular rate and rhythm with positive S1 and S2 and no S3 or S4.
There were no murmurs , rubs or gallops. Abdomen is soft and
non-tender with positive bowel sounds. There was no
hepatosplenomegaly or masses noted. Rectal was guaiac negative in
the Emergency Ward. Extremities revealed no clubbing , cyanosis or
edema. Neurological examination was non-focal.
LABORATORY DATA: Sodium was 142 , potassium 4.1 , BUN 15 , creatinine
.8 , and glucose 74. Liver function tests were
within normal limits. CK was 697 with an MB of 8.5. White count
was 4.1 , hematocrit 37 and platelet count was 252 , 000. physical therapy was
12.5 , PTT 29.3. Chest x-ray , which was a portable film , was clear.
VQ scan was read as intermediate probability. EKG revealed a sinus
bradycardia at 54 with normal axis and intervals. She had flipped
T waves in leads 3 , F , and V1 through V3 , biphasic T waves in V4 ,
flat T waves in V5 and V6. There was poor R wave progression and Q
waves in 1 and L.
HOSPITAL COURSE: It was felt that during the patient's
presentation the most likely diagnosis was a
pulmonary embolus , given her clinical history and her intermediate
probability of VQ scan. The elevated CK with the very low MB was
felt not to represent a myocardial infarction but to represent a CK
leak from presumed pulmonary infarction. The patient was
heparinized with the goal of maintaining her PTT in the 60 to 80
range. She had a thrombotic work up sent off , namely an
antithrombin 3 , protein C and protein S , all of which , with the
exception of the Russell viper venom , returned within normal
limits. The Russell viper venom is pending at the time of
dictation. The patient underwent lower extremity noninvasives on
hospital day number one which returned as negative. She had a D
dimer sent which was also normal. At this point the DVT Team here
at the Pagham University Of was consulted , given the
conflicted data for pulmonary emboli. The team felt that , given
the patient's clinical history and the implications of chronic
Coumadin therapy , that a pulmonary embolus should be definitely
ruled out by pulmonary arteriogram. On hospital day number two the
patient underwent a PA gram which revealed a mean RA pressure of 7
mm of mercury , a mean RV pressure of 12 mm of mercury , and no
filling defects to suggest a pulmonary embolus. At this point the
patient's Heparin was discontinued. The day prior to obtaining the
pulmonary arteriogram the patient had a good PA and lateral film ,
which revealed no focal infiltrates and no effusions. On hospital
day number three the patient underwent an echocardiogram which
revealed normal left ventricular size and mild left ventricular
hypertrophy with vigorous function and no regional wall motion
abnormalities. She had no pericardial thickening or pericardial
effusion to suggest pericarditis. She had structurally normal
cardiac valves , no significant mitral or tricuspid regurge. She
had a minimal amount of aortic regurgitation and normal right heart
size and function. At this point , given the fact that the patient
was not felt to have a myocardial infarction , given her low MB
total CK ratio , and also that she was not felt to have a pulmonary
embolus , given the negative PA gram , the diagnosis of pleurisy
secondary to possible close viral syndrome was considered. The
patient was started on Naprosyn at 500 mg orally twice a day on hospital
day number three , to which she responded quite well. After
discussion with the patient's primary doctor it was felt that ,
given the fact that serious causes for pleuritic chest pain had
been ruled out , the patient's management could be followed in an
outpatient setting. On hospital day number four it was felt that
she was safe to be discharged to home. Operations and procedures
performed during this hospitalization were pulmonary arteriogram by
Survn's General Hospital on April , 1994. There were no complications.
DISPOSITION: MEDICATIONS ON DISCHARGE: Discharge medications
include Naprosyn 500 mg orally twice a day with meals. The
patient is being discharged to home. FOLLOW UP: She will follow
up with Dr. Gladis Hollendonner on August , 1994 at 1:30 p.m.
Dictated By: FLORETTA THRONEBURG , M.D. JD63
Attending: IRVING ESCALANTE , M.D. YO2 KA792/9584
Batch: 7272 Index No. JESZ732JS D: 9/20/94
T: 5/30/94
Document id: 255
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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171486426 | PUO | 43712082 | | 2232169 | 4/7/2006 12:00:00 a.m. | URINARY TRACT INFECTION | Signed | DIS | Admission Date: 6/17/2006 Report Status: Signed
Discharge Date: 4/17/2006
ATTENDING: DEPSKY , GWYNETH MD
INTERIM SUMMARY
DATE OF DISCHARGE: To be determined.
ADMISSION DIAGNOSIS: Altered mental status.
DISCHARGE DIAGNOSIS: Altered mental status.
SECONDARY DIAGNOSES:
1. Non-small cell lung cancer.
2. Right MCA embolic stroke.
3. Graves' disease.
4. Depression.
5. Attention deficit disorder.
6. Hypertension.
7. Asthma.
8. Temporal lobe epilepsy.
9. History of subclavian steal syndrome.
10. Urinary tract infection.
HISTORY OF PRESENT ILLNESS: This is a 64-year-old lady who has a
past medical history of right upper lobe lung cancer , status post
chemotherapy x2 cycles , as well as x-ray therapy. Her
chemotherapy has included VP-16 and cisplatin. She is status
post a large right middle cerebral artery stroke in 5/15 ,
status post a right carotid endarterectomy on 3/1/06 . She has
been at the Centli Community Hospital Of since her last Totin Hospital And Clinic admission. She was there for stroke rehabilitation and
completed a ten-day course of vancomycin for a MRSA urinary tract
infection. She was found , on the day of admission , by her son to
be difficult to arouse. The patient was brought to the Stusri Medical Center by Emergency Services. The blood pressure was 66/44 , a
pulse of 100 , a respiratory rate that was normal and blood sugar
of 133. She denied complaints of chest pain , shortness of
breath , nausea , vomiting , diaphoresis. She denied any other
pain.
PAST MEDICAL HISTORY:
1. Non-small cell lung cancer , diagnosed 6/8 , stage 3 ,
present in the right upper lung , status post neoadjuvant XRT and
two cycles of chemotherapy.
2. Right MC embolic stroke in 10/5 .
3. Status post right carotid endarterectomy on 3/1/06 .
4. Graves disease.
5. Depression.
6. Diabetes.
7. Hypertension.
8. Asthma.
9. Temporal lobe epilepsy.
10. History of subclavian steal syndrome.
PAST SURGICAL HISTORY:
1. Bilateral salpingo-oophorectomy 30 years ago.
2. History of radioactive iodine for Graves' disease 30 years
ago.
PHYSICAL EXAMINATION ON ADMISSION: Notable for being alert and
oriented x2 , nonconversant , angry and in pain. Neurological exam
was notable for a left upper femoral paralysis with increased
deep tendon reflex on the left , bilateral lower extremities with
2+ Achilles patellar reflexes. Her heart was tachycardic , but no
murmurs , rubs or gallops. Lungs were clear to auscultation
except for bibasilar rales. Her abdomen was full , nontender and
nondistended. Her extremities had no cyanosis or edema and had
2+ DP pulses. In the emergency room , her pulse was 100 and her
blood pressure was 148/60. She was somnolent. She had 1 gm of
vancomycin , magnesium and Levaquin 500 mg.
ALLERGIES: Penicillin , for which she has a hive reaction;
valproic acid , sulfa drugs. Demerol causes hypotension.
MEDICATIONS ON ADMISSION: Mechanical soft diet , aspirin 81 mg ,
baclofen 5 mg three times a day , B12 1000 mg daily , iron sulfate 325 mg
daily , Cymbalta 20 mg orally twice a day , Neurontin 100 mg twice a day ,
Lamictal 200 mg twice a day , Prilosec 20 daily , levothyroxine ,
Glucophage 500 once a day , Reglan 10 once a day , niacin 500 once
a day , Senna 2 tabs twice a day , Zocor 20 mg once a day , Nicoderm
patch , Colace 100 mg orally twice a day , Lopressor 100 mg orally twice a day ,
lidoderm 5% patch to the low back. She also had as needed of
Tylenol , ducolox , Mylanta , lactulose , Seroquel 100 mg , prednisone
50 mg , and Dilaudid 1 mg.
SOCIAL HISTORY: Divorced with two children. No alcohol use
recently.
FAMILY HISTORY: Father died of a MI at 73. Her mother died in
her 80s of emphysema.
LABORATORY DATA: The patient had a creatinine of 1 , her ALT was
25 , AST was 35 , her hematocrit was 33 , her white count was 6.6 ,
and her platelets were 241 , 000. She had normal differential.
Her albumin was 3.5. Her urinalysis was dark , with 3+
leukoesterase , negative nitrates , greater than 200 white blood
cells per high peripheral , 2-4 red blood cells per high
peripheral , 1+ bacteria. Her EKG showed a sinus rhythm of 100.
Her left bundle branch block with a QTc of 500 , but no change
compared to baseline.
Her head CT showed an old right middle cerebral artery implant.
HOSPITAL COURSE: The patient was admitted for initial
presentation with somnolence and altered mental status with one
hypotensive blood pressure by EMS , but subsequently no
hypotension in the absence of fluid resuscitation. Her urine
culture appeared to indicate an infection , and so she was covered
with antibiotics initially. It was also determined that she had
a significant polypharmacy and enumerable sedating medications at
her rehabilitation and there was suspicion that the medications
contributed to her initial presentation of somnolence and altered
mental status.
1. Infectious disease: The patient was initially treated with
vancomycin for a presumed repeated MRSA UTI. However , her urine
culture did not grow any bacteria , it only drew out yeast. Thus ,
she was transitioned over to a ciprofloxacin 700 mg orally twice a day
regime for a total of 12 days for a presumed urinary tract
infection.
2. F/E/N: She was tolerating orally food and medications and a
Nutrition consult was obtained. She had calorie counts which
showed adequate intake. She did not have any other metabolic
abnormality that required correction.
3. Cardiovascular: The patient's primary cardiovascular
abnormality was a prolonged QTc which occurred in the setting of
prior use of Haldol and other antipsychotics for behavioral
modification. Her QTc was monitored with serial EKGs. The
longest it had reached was 530 ms. Haldol was discontinued in
order to preserve the QTc. In addition , she was given some
amounts of Seroquel and her QTc was continued to be monitored.
4. Heme/Oncology: The patient has a history of stage III
non-small cell lung cancer status post XRT and chemotherapy and
is followed by her outpatient oncologist , as well as the
outpatient psychosocial oncology social worker , as well as the
psychosocial oncology physician whose name is Gaylene Faniel .
5. Neurological: The patient is status post both a large right
MCA stroke , as well as a right-sided carotid endarterectomy from
a previous admission. Her neurological deficits are consistent
with her prior neurological deficits. Specifically , they include
a left-sided hemiparesis , as well as agnosia on the left side.
Her mental status included intermittent disorientation. She was
generally at her best , alert and oriented to herself , as well as
her age , as well as her location in the Pagham University Of . However , she would intermittently loose track of where
her location was and believed that she was in Teran Skinver Careteher Hospital , not in
the hospital. She was also intermittently confused. She also is
complicated , given her histories of seizures and stroke. It was
considered initially that her altered mental status was due to
polypharmacy. However , her sedating medications were
discontinued including her Reglan was discontinued as well as her
baclofen , Dilaudid and trazodone. Her Cymbalta was continued per
the recommendations of the Psychiatry consult. The psychiatric
consultants also suggested a one-to-one sitter. At no time was
the patient actively suicidal or homicidal. It was also later
decided that her Dilaudid would be discontinued. In addition ,
her standing Seroquel was made as needed In addition , the
patient's family also suggested that the patient's base mental
status did not improve despite removing all the medications. At
this point , a Neurology consult was obtained. This Neurology
consult is pending at the time of this dictation and will be
reported in a later dictation. Given the patient's history of
complex seizures and olfactory hallucinations , she was continued
on her Lamictal , as well as her Cymbalta , which was for her
history of depression.
6. Pain: The patient's pain in her left hand existed and she
was treated with tramadol and Tylenol for this pain. She could
not specifically describe this pain.
7. Endocrine: The patient was maintained on Novolog sliding
scale for diabetes. She was also continued on a replacement dose
levothyroxine for her history of Graves' and a history of
radioiodine ablation. For behavioral modification , as well as
for intermittent agitation and disorientation , the patient was
maintained on as needed Seroquel 100 mg orally twice a day , as well as
Zydis 5 mg orally twice a day as needed This was titrated from standing to
as needed over the course of her hospitalization in order to try to
decrease any sedating medications that may be altering her
alertness and orientation.
NOTE: This dictation will be addended at a later date with
discharge medications , as well as further hospital course and the
patient's neurological state , as well as any follow up that is to
be planned.
eScription document: 1-7702322 SSSten Tel
Dictated By: SCHUNEMAN , ELLENA
Attending: DEPSKY , GWYNETH
Dictation ID 5237737
D: 11/22/06
T: 11/22/06
Document id: 256
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
Y |
N |
N |
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Y |
Y |
N |
N |
N |
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- |
000012052 | PUO | 18541153 | | 7574104 | 9/21/2003 12:00:00 a.m. | Pancreatitis | | DIS | Admission Date: 9/21/2003 Report Status:
Discharge Date: 8/14/2003
****** DISCHARGE ORDERS ******
BACHMAN , LEONIE 390-11-18-0
Ter
Service: MED
DISCHARGE PATIENT ON: 11/18/03 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
AMITRIPTYLINE HCL 30 MG orally every bedtime
PREMARIN ( CONJUGATED ESTROGENS ) 0.625 MG orally every day
FLEXERIL ( CYCLOBENZAPRINE HCL ) 10 MG orally three times a day as needed Pain
Alert overridden: Override added on 1/24/03 by
PRAINO , ISIDRA , M.D.
on order for FLEXERIL orally 10 MG three times a day ( ref # 98627066 )
DEFINITE ALLERGY ( OR SENSITIVITY ) to MUSCLE RELAXANTS ,
SKELETAL Reason for override: aware meds
Number of Doses Required ( approximate ): 4
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FLUOXETINE ( FLUOXETINE HCL ) 40 MG orally every day
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 11/18/03 by
SENGBUSCH , SHALANDA Y. , M.D.
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 10 UNITS subcutaneously every day before noon
Starting Today ( 3/7 )
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 50 UNITS subcutaneously every bedtime
LORAZEPAM 1 MG orally every day
AMLODIPINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
IRBESARTAN 300 MG orally every day
Number of Doses Required ( approximate ): 5
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 11/18/03 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: aware
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Alert overridden: Override added on 11/18/03 by :
SERIOUS INTERACTION: GEMFIBROZIL & ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: GEMFIBROZIL &
ATORVASTATIN CALCIUM Reason for override: aware
DIET: House / Adv. as tol. / ADA 1800 cals/day / Very low fat ( 20gms/day )
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Youngberg , vascular surgery , Tole Fre No , 12:50 pm , you need to ask Dr. Heinen for a referral for this appointment 8/24/03 scheduled ,
Dr. Desirae Marcott , 11:30 a.m. 6/17/03 scheduled ,
MRI/A of abdomen , PUO Hston Norf Pu , 11:20 a.m. , please arrive 30 min prior to appt and have only clear liquids that morning 8/16/03 scheduled ,
ALLERGY: Amoxicillin , Sulfa , Ciprofloxacin ,
Orphenadrine citrate ,
Angiotensin converting enzyme inhibitor
ADMIT DIAGNOSIS:
Pancreatitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pancreatitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
?CARDIOMYOPATHY EF=39% , HTN , SEVERE HYPERCHOL/HYPER TG POORLY
CONTROLLED DM history of CHOLE/APPY/TAH DIFFUSE ABDOMINAL PAIN
ALLG: SULFA/AMOXICILLIN
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
The patient is a 64-year-old with known CAD , atherosclerotic peripheral
vascular disease , and type 2 diabetes presented with back pain. She
describes a sudden onset of 8/10 stabbing back pain 4 days ago without
a clear precipitant. The pain was non raditating and partially releived
with analgesics. She denied any bowel or bladder incontinence or saddle
anesthes ia. She denied any fevers , chills , nausea , vomiting , or
diarrhea. She does however complain of some urinary frequency ( on
lasix ) in the last few days with out any dysuria or urgency. Of note
over the past month she has had increasing had shortness of breath
however she denies any orthopnea or PND. The patient has long standing
pedal edema and has increasing abdominal distension over the last month
but has not noticed any change in her weight. The patient has CAD and
her angina equivalent is jaw pain. However in the last 6 months she has
had intermittent left sided chest pain that radiates to her left arm.
In the ED the patient was ruled out for an aortic dissection , MI and
had a negative D-Dimer. However lipase levels have been elevated with
norm al LFTs. She was admitted with a diagnosis of pancreatitis.
Hospital course:
1.GI- history of cholecystectomy. Her lipase was mildly elevated on
admission to 200 , fell to 60 with NPO and IVF. However , MRA read with
radiology 4/4 shows diffuse atherosclerotic disease including
stenosis of celiac artery , vascular surgery was consulted for concer
about mesenteric ischemia. They do not think she is having symptoms of
ischemia , would like abdominal MRA to further assess abdominal
vasculature. Triglycerides very high , could be cause of her
pancreatitis , starting gemfibrozil. LDL was 151.
2. Cardivascular- Ischemia-On a beta blocker , statin , ARB , ruled out
for an MI , but has 6 month history of chest pain. Adenosine MIBI
negative. Started gemfibrozil. Pump-We changed atenolol to toprol XL
and amlodipine.
3. Endocrine- Has had poor glucose control. HbA1c 13. We continued
NPH every bedtime and started a.m. NPH as well.
4. Renal-Chronic renal insufficiency , Cr stable.
5. ID - Patient c/o urinary frequency. U/A negative.
6. Psych-On amitryptilline and fluoxetine.
ADDITIONAL COMMENTS: Please take all medications as described. You will need to follow a
low fat and low carbohydrate diet to control your cholesterol and
diabetes. Please take insulin in the morning as well as the night ,
check your fingersticks twice a day and record them. Please see
Dr. Heinen on 5/14 and ask him to help with your insulin regimen.
Please go to your MRI appointment 8/21 and see Dr. Youngberg 6/23 .
Call your doctor or go to the emergency room if you develop severe chest
pain , shortness of breath , or abdominal pain.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: SILMAN , CHIEKO , M.D. ( RA70 ) 11/18/03 @ 02:03 PM
****** END OF DISCHARGE ORDERS ******
Document id: 257
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
- |
N |
256580457 | PUO | 49104881 | | 440843 | 1/12/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/12/1994 Report Status: Signed
Discharge Date: 6/25/1994
PRINCIPAL COMPLAINT: SPINAL STENOSIS.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old female
who complained of lower back pain and
bilateral leg pain. She noted that in , October of 1993 , she had
the onset of some low back pain , and in October of 1993 , it went
down into her lower extremities. The pain is currently in the
lower back and bilateral buttocks , to the bilateral knees , and all
aspects of her legs below the knee. She reports diminished
sensation of the anterior aspect of her leg on the right side , but
this has only occurred once on the left side. She has no motor
complaints and denies any bowel or bladder dysfunction. Her pain
is specifically made worse with walking. She cannot walk even as
far as a block before she has to stop and sit. She also
demonstrates transition pain when she gets up , in and out of a bed
or chair. She has diabetes , and has been on insulin for eight
years. In the past , for her back , her treatment has consisted of
Motrin , and three epidural steroid injections. Two were done in
October . The second obtained approximately 80% relief for three
months. The last one was of no help whatsoever. Her x-rays on
review shows that she has degenerative spondylolisthesis at L4-L5.
Her CT scan and MRI scan both demonstrate the presence of a slip at
L4-L5. There is rather marked L4 neural foraminal narrowing
bilaterally , with only some narrowing of the lateral recesses of
the canal. The distribution of her pain sounds most likely to be
of L4 nerve root.
PAST MEDICAL HISTORY: Significant for insulin dependent diabetes
mellitus with retinopathy , atypical anxiety
disorder , aortic stenosis with history of rheumatic fever , and
glaucoma in the left eye , and congenital nystagmus , and amblyopia.
PAST SURGICAL HISTORY: Left knee arthrotomy; right ankle open
reduction , internal fixation; right carpal
tunnel , and cervical laminectomy.
ALLERGIES: Elavil , Zomax and Naprosyn.
MEDICATIONS: Insulin , NPH , 8 units subcutaneously every day; Prozac 10 mg
orally every day , and Timolol .5% , one GTT O.S. twice a day
PHYSICAL EXAMINATION: The patient is slightly obese , and stands
with a normal alignment. She can reach her
hands down to her ankles. Extension is about 20 degrees , and
causes bilateral posterior SI and leg pain. Reflexes are all 3+ in
the lower extremities. The toes are upgoing and in clonus
bilaterally. This spasticity has been noted in the past by Dr.
Lubow , CHH neurologist , who followed her for quite a long time
for this problem. Romberg exam is negative. Pulses are 1+
dorsalis pedis , and trace in the posterior tibial bilaterally.
Detailed sensory/motor exam of the lower extremities reveals no
deficit , but she does have significant spasticity. Indeed , it is
actually difficult to test her EHL and anterior tibial with her
knees extended , as she has marked plantar flexion and tone in that
region with the knees flexed. The patient is able to demonstrate
good EHL and anterior tib function. Straight leg was negative
bilaterally. Hip range of motion is normal and pain free.
Patrick's test was negative. Femoral stress test was negative. Of
note , the patient had an old medial left knee scar surgery. The
patient was afebrile. Vital signs stable. HEENT was within normal
limits. Lungs were clear to auscultation. Heart was regular rate
and rhythm with a II/VI systolic murmur , and no radiation to the
carotid. Abdomen was soft , non-distended , non-tender. No
splenomegaly was noted.
HOSPITAL COURSE: The patient underwent posterior decompression
with L4-L5 and pedicle screw fixation with iliac
crest bone graft , as well as a discectomy at L4-L5 , and complete
foraminotomies of L4 root bilaterally. The patient received
approximately 6 liters of lactated Ringer's , one liter of Hespan ,
500 cc of albumin , 3 units of packed red blood cells , 2 units of
cell saver. Estimated blood loss was 2000 cc. The patient did
well postoperatively , with her physical therapy , and mobilizing
well. Of note , the patient did spike a fever to 102.2; however ,
her workup was only significant for atelectasis on her chest x-ray ,
and trace leukocytes in her urine , with cultures being negative.
Of note , the temperature was associated with dysuria. Thus , the
patient was started on Bactrim , one orally twice a day times 10 days. The
patient did well in physical therapy , and was discharged on
postoperative day five. The patient is discharged to home with
Selo Ksa Community Hospital Of .
DISPOSITION: Discharged to home with full Selo Ksa Community Hospital Of .
FOLLOW UP: The patient will follow up with Dr. Tappeiner at CHH .
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE: Niferex 100 mg orally twice a day , Bactrim DS ,
one orally twice a day times 10 days , Colace
100 mg orally twice a day , Timoptic .5 , one drop O.S. twice a day , NPH 8 units
subcutaneously , Prozac 10 mg orally every day.
Dictated By: MATHEW STAUTZ , M.D. YK2
Attending: KYLEE D. TAPPEINER , M.D. BN33 JI158/0202
Batch: 897 Index No. VCMC8S9S8A D: 9/26/94
T: 9/26/94
Document id: 258
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
- |
- |
- |
- |
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- |
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- |
| output/system_intuitive_annotation.xml | intuitive |
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376950295 | PUO | 84780901 | | 864694 | 4/18/2002 12:00:00 a.m. | chest pain | | DIS | Admission Date: 9/13/2002 Report Status:
Discharge Date: 4/25/2002
****** DISCHARGE ORDERS ******
AIDT , JR , BRITNI 568-86-35-3
Ton- Hosaltnot De
Service: MED
DISCHARGE PATIENT ON: 2/26/02 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REFFITT , LAVETA GUILLERMINA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day HOLD IF: HR<50 , SBP<100 and call HO
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime Starting Today ( 8/14 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COZAAR ( LOSARTAN ) 50 MG orally every day
Number of Doses Required ( approximate ): 10
LANTUS ( INSULIN GLARGINE ) 40 UNITS subcutaneously every day before noon
DIET: House / ADA 2000 cals/day / Low saturated fat
low cholesterol
RETURN TO WORK: as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Desirae Marcott as needed ,
Dr. Carlton Abshear as needed ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( ) low back pain ( ) retinal vein occlusion
( ) history of hernia repair ( ) benign familial leukopenia
( ) polyclonnal gammapathy syncopal episode '95 ( )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cardiac cath 11/22
BRIEF RESUME OF HOSPITAL COURSE:
patient is a 72 year-old man with known CAD history of MI in 'oo
with stents placed in PDA and RCA , IDDM , and HTN who presented to
cardiologist for routine appt with c/o CP since 7am morning of
admission. Pain described as "light" and worse when pushed
on chest , felt it at rest and on exertion.
History not totally consistent with angina but
given cardiac history and patient is a diabetic , he
was admitted for r/o MI. Cardiac enzymes and he
has been pain free since arrival. EKG with
new TWI/flattening in V5V6 , no other
acute changes. Had ETT 4/24/02 which was c/with but
not diagnostic of ischemia. Underwent cath on 11/22 which
revealed non-obstructive CAD - 35% pLAD , 40% mid LAD , 50% pRCA ,
no intervention done. Patient stable post-cath without chest pain ,
d/c home on 2/16 .
ADDITIONAL COMMENTS: Call your doctor if you develop chest pain or difficulty breathing.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ROBBLEE , NERISSA H. , M.D. , PH.D. ( MF01 ) 2/26/02 @ 10:20 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 259
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Q |
U |
U |
U |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
N |
N |
Y |
Y |
Y |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
420486631 | PUO | 63790614 | | 1065485 | 1/4/2002 12:00:00 a.m. | pancreatitis | | DIS | Admission Date: 9/15/2002 Report Status:
Discharge Date: 10/10/2002
****** DISCHARGE ORDERS ******
MARSINGILL , LASHAUNDA 312-72-78-6
Gilb Do E , Alabama
Service: MED
DISCHARGE PATIENT ON: 11/3/02 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DICKHAUT , SIOBHAN CARY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed wheeze
Instructions: with spacer
ATIVAN ( LORAZEPAM ) 0.5 MG orally twice a day as needed anxiety
HOLD IF: rr<10 , oversedated
METFORMIN 850 MG orally twice a day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
AVANDIA ( ROSIGLITAZONE ) 4 MG orally twice a day
LISINOPRIL 5 MG orally every day
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
ATENOLOL 50 MG orally every day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please call the office of Dr. Julissa Goud next week to make a follow-up appointment ,
ALLERGY: Demerol , Trazodone , Benadryl ( diphenhydramine hcl ) ,
Nsaid's , Codeine , Clarithromycin , Amitrip ( amitriptyline hcl )
ADMIT DIAGNOSIS:
pancreatitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pancreatitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN UTI Hematuria Pancreatic divisum diabetes II slep apnea ccy
pancreatitis 1998 history of appy , history of tubal ligation
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous fluid hydration
intravenous pain control
BRIEF RESUME OF HOSPITAL COURSE:
59 year-old F with complicated GI history including
GERD , gastritis , peptic ulcer , pancreatitis/pancreatic cyst , chronic
GI distress , and PANCREATIC DIVISUM who presented 11/10 with
a 2-month history of increasing epigastric pain and an elevated
lipase. Got CT ab with peripancreatic stranding around panc head
and US which showed history of ccy nl biliary tree. Patient went home 6/1/02
but came back 9/24 with 10/10 same pain following bowel of oatmeal
with milk at home. A/P : Pancreatitis in patient with pancreatic
divisum , recent ab CT and US done. ( 1 ) GI : patient was made NPO and given
aggressive IVF hydration to keep HCT below 40 as well as intravenous narcotic
for pain control. patient's diet was advanced to liquids 1/3 and solids
4/9 which she tolerated , and was discharged in good condition. patient was
asked to follow a bland , ADA , low-fat diet. Note that patient's ab CT 5/26
were reviewed with a radiologist and compared with prior exam 1/23 , and
neither CT demonstrated a pancreatic cyst. ( 2 )endo: held
metformin/glyburide while NPO and placed on CZI. Placed
on home meds on d/c ( 3 ) pain: patient has percocet from prior admission for
pain control ( 4 ) CV: HTN on atenolol , lisinopril , was placed on intravenous
lopressor while npo , and returned to home meds on d/c ( 5 ) anxiety :
ativan as needed ( 6 ) ?asthma : alb as needed with
spacer ( 7 ) Dispo: patient has been considering changing PCPs and understands
that she herself should call her primary care physician for a follow-up appointment next
week.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
per hospital course
No dictated summary
ENTERED BY: OSDOBA , JEANA , M.D. ( WZ98 ) 11/3/02 @ 02:26 PM
****** END OF DISCHARGE ORDERS ******
Document id: 260
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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125960861 | PUO | 68313462 | | 615748 | 9/16/2000 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 1/13/2000 Report Status:
Discharge Date: 5/5/2000
****** DISCHARGE ORDERS ******
MANNIS , FATIMA 432-90-08-5
S
Service: MED
DISCHARGE PATIENT ON: 4/10 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BYE , NATHANIAL K. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VENTOLIN ( ALBUTEROL INHALER ) 2 PUFF inhaled four times a day
as needed sob/wheeze
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally twice a day Starting THIS EVG
HUMULIN N ( INSULIN NPH HUMAN ) 30 U subcutaneously every afternoon
Instructions: please give one half dose if patient is NPO
ZESTRIL ( LISINOPRIL ) 40 MG orally every day
HOLD IF: hold for sbp less than 100
Alert overridden: Override added on 9/10 by
KOZUB , TYLER R. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor K+
Previous Alert overridden
Override added on 9/10 by KOZUB , TYLER R. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: also on lasix
Previous Override Notice
Override added on 9/29 by KOZUB , TYLER R. , M.D.
on order for KCL IMMEDIATE REL. orally SCALE every day ( ref #
22126055 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 9/29 by PALLEY , JESICA CYRUS , M.D.
on order for KCL intravenous ( ref # 96283238 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: ho aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
AFRIN ( OXYMETAZOLINE HCL ) 2 SPRAY nasal twice a day as needed congestion
CARDURA ( DOXAZOSIN ) 4 MG orally every day
PRAVACHOL ( PRAVASTATIN ) 40 MG orally every bedtime
LEVOFLOXACIN 500 MG orally every day
AVANDIA ( ROSIGLITAZONE ) 8 MG orally every day
K-DUR ( KCL SLOW RELEASE ) 20 MEQ X 1 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 4/12 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: also on lasix , will monitor
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
DR. Bye ( primary care physician ) next week ,
ALLERGY: Erythromycins , Penicillins , Cortisone acetate
ADMIT DIAGNOSIS:
pneumonia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
*** 9/29 ***
60F with HTN , IDDM , Hyperchol , new onset CHF ( 10/20 ) who was alos being
tx for CAP with?abx , no p/with incr SOB and leg swelling. Symptoms
began 21/2 wks ago with URI , progressed to nonproductive cough and
wheezing 1 wk ago. Seen by primary care physician 5 days ago found to have pul edema
?infiltrates , started on lasix and ?abx. Tiazac and clonidine d/ced
due to SE ( leg swelling ). patient now with inc SOB , subjective low grade
fever , orthopnea , PND , wheezing. No CP.
PE: T97.9 , P80-90 , BP 172/92 R20 , 93-95%RA JVD 10 cm , +S4 , bibasilar
crackles ( R>L ) , 3+ pitting edema to knees. Guiac -ve. Labs: K 3.5 ,
Hct 27.4 , UA 2+pr 1-4WBC/RBC , CK 420 , MB.9 , tn.03 , EKG: old septal
infarct , low voltage. CXR cardiomegaly , B. pleural effusions
?R.infiltrates
A/P
1. CHF exacerbation ?ischemia/infarct , infx , meds. intravenous lasix , I/O net 1l
b. HTN: uncontrolled missed am meds. Continue current meds
c. hyperchol: continue current meds d. CAD r/o MI has multiple risk
factors. Get cardiac enz , CHO
2.PUL/ID: ? pneumonia. Levofloxacin; sputum cx
3. Renal: Proteinuria. SPEP/UPEP pending , 24hr urine
4. Heme: microcytic anemia: Fe studies , retics , guaic stools
5. Endocrine: HbA1c 8.5. Continue meds , CZI , FSG
6. FEN: borderline low K+ , on lasix. K scale
7. Vascular: LE edema: most likely CHF. also c/o nephrotic syndrome ,
hypothroid. slightly low albumen and liver dyfun unlikely. Check TSH ,
LFTs
8. Prophylaxis with heparin subcutaneously
____________________________________________________________
*** 10/18 ***
1. CHF: still with JVD , crackles. Continue to diurese. lasix 40 mg this
am 2. HTN: BP not controlled. Added procardia 30
three times a day 3. Dispo: home ( on orally lasix ) once
diuresed adequately
____________________________________________________________
*** 9/10 ***
1. CHF: asymptomatic but still with signs of failure. Continue to
diurese 2. BP uncontrolled: Procardia d/ced by primary care physician?.
Incr zestril to 60 3. Dispo: tomorrow if improved
2/20
Much improved , stable
1. CHF: well diuresed. Added lasix 4o orally twice a day and Kdur 20. Echo:
showed slight decr EF , mild LVH , mild systolic/diastolic dysfunc
2. HTN: better control. Zestril decr to 4o as per Attg ( and renal )
3. Renal: U/S showed multiple small renal cysts and R. adrenal mass
that is unchged. Followed by nephrologist
4. Dispo today with follow up with primary care physician
ADDITIONAL COMMENTS: Return to ER if develop Shortness of breath/chest pain/fever/chills
Keep appt with Dr. Bye
Colonoscopy to evaluate fe-deficiency anemia
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KOZUB , TYLER R. , M.D. ( ZV64 ) 4/10 @ 03:42 PM
****** END OF DISCHARGE ORDERS ******
Document id: 261
| Target |
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Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
778562534 | PUO | 93827167 | | 158756 | 8/8/1997 12:00:00 a.m. | DEGENERATIVE JOINT DISEASE LT. KNEE | Signed | DIS | Admission Date: 8/8/1997 Report Status: Signed
Discharge Date: 5/20/1997
BRIEF HISTORY: This 67-year-old white female is admitted for
a left total knee replacement for end-stage
arthritis. The patient has a long history of lateral knee pains ,
more on the left than the right. The patient has been limited in
her activities of daily living , and it is the plan to have a total
knee replacement.
PAST HISTORY: Osteoarthritis , hypertension , hypercholesterolemia ,
hypothyroidism , spinal stenosis , and a history of
PMR in 1980. Surgeries include right knee arthroscopy ,
subumbilical hernia repair , and RIH in 1990. She is status post
hammer toe repair.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Synthroid 0.50 mg every day , atenolol
25 mg every day , hydrochlorothiazide 20 mg
orally every day , PremPro orally every day , calcium 1200 mg every day , vitamin E 400
mg orally every day
PHYSICAL EXAMINATION: On examination , the physical examination
was within normal limits , including the
skin , nodes , breasts , lungs , heart , and abdomen. On neurologic
examination , the cranial nerves were intact II to XII. The left
knee had a healed transverse scar , with an active range of motion
from 0 to 115 degrees.
HOSPITAL COURSE: The patient was admitted for a left total knee
replacement. She tolerated the procedure well.
The details of the procedure are in the Operative Note by Dr. Caitlin L Rademan . The patient was transferred from the Recovery Room to the
floor without any complications. By postoperative day one the
drain was removed. By postoperative day 2 , wound dressings were
changed. The wound was dry , clean , and intact , without any
hematoma. The patient was neurologically intact throughout her
lower extremities. The patient was started on physical therapy
without any event. Her hematocrit was below 30 , down to 28.3 ,
requiring one unit of autologous blood. The patient did very well
in the postoperative period , without any complications. She was
able to tolerate orally and was voiding without difficulty. She was
walking with physical therapy. In view of her improvement , it was
planned to discharge the patient to rehabilitation. She was to be
followed by Dr. Rademan six weeks from discharge.
The patient is discharged on her previous medications as taken at
home and on Coumadin on a every day basis to keep the INR between 2 and
3. She is also given Tylenol #3 for pain control.
Dictated By: LILI MCELRAVY , M.D. UR39
Attending: CAITLIN RADEMAN , M.D. RJ.A. FV66 JR668/0176
Batch: 9631 Index No. VLWYHY5TPX D: 1/23/97
T: 1/23/97
Document id: 262
| Target |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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265823853 | PUO | 00787670 | | 103110 | 10/17/2000 12:00:00 a.m. | VOMITING | Signed | DIS | Admission Date: 8/6/2000 Report Status: Signed
Discharge Date: 7/6/2000
PRINCIPAL DIAGNOSIS: VOMITING.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female
with a past medical history of
diabetes and hypertension who was recently admitted from October ,
2000 through July , 2000 with abdominal pain diagnosed with
diverticulitis , treated with levofloxacin , ampicillin and Flagyl
and discharged home. However , subsequently , she began to have
several episodes of vomiting that was initially clear and then
turned brown with some dark blood in the morning. The patient
denies any bright red blood per rectum or melena. In the emergency
department , the patient had a negative NG lavage and treated with
Compazine. She was also seen by Surgery whose initial assessment
was Flagyl related emesis and changing antibiotics to levofloxacin
and clindamycin. Gastrointestinal was also consulted who felt that
the blood was most likely from a Mallory-Weiss tear.
PAST MEDICAL HISTORY: Diabetes , hypertension , anemia , status post
cholecystectomy , status post appendectomy ,
small bowel obstruction , bilateral cataracts , bilateral tubal
ligation , diverticulitis , chronic renal failure.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.4 , heart rate
88 , blood pressure 156/116 sitting , standing
169/74. ABDOMEN: Bowel sounds positive , soft and non-tender and
non-distended. RECTAL: Guaiac negative.
LABORATORY: White blood cell count was 7.7 , hematocrit 36.2 ,
platelet count 315. INR was 1.2 , PTT 26.6. BUN and
creatinine were 36 and 4.4 respectively. Amylase was 56 , lipase
151 , total bilirubin 0.3 , alkaline phosphatase 103.
HOSPITAL COURSE: Because of persistent nausea and vomiting despite
having stopped the Flagyl and decreased dose of
levofloxacin on April , 2000 , the levofloxacin was discontinued.
The patient had a gastric emptying study which was within normal
limits and did not show any evidence of gastroparesis. On January , 2000 , an upper endoscopy was done that revealed two discrete
esophageal ulcerations in the distal esophagus with surrounding
esophageal erythema , most likely consistent with pill esophagitis.
The patient was started on Prilosec 40 mg twice a day and antibiotics
were stopped at that time as she had completed a ten day course.
In addition , the patient also had problems with hypertension to the
200s. This was treated with labetalol. Renal MRI study was done
that was negative for renal artery stenosis. The patient was
discharged home in stable condition.
MEDICATIONS ON DISCHARGE: Lasix 160 mg orally every day , NPH 40 units
subcutaneously every day before noon , regular insulin 10
units subcutaneously every day before noon , lisinopril 20 mg orally twice a day , Lopressor
50 mg orally twice a day , Norvasc 10 mg orally twice a day , Avandia 2 mg orally
twice a day and Prilosec 20 mg orally twice a day
Dictated By: GERMAINE BLACKGOAT , M.D. UA89
Attending: OLA FRASCHILLA , M.D. KU44 KS934/601598
Batch: 93650 Index No. BGLYZ98YWV D: 3/3/01
T: 3/3/01
Document id: 263
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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378576931 | PUO | 59506466 | | 4426080 | 4/16/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/1/2004 Report Status: Signed
Discharge Date: 10/19/2004
ATTENDING: MARILYN FREHSE MD
HISTORY OF PRESENT ILLNESS:
This is a 66-year-old female who presented with one day of
abdominal pain. She was constipated for seven days and presented
with abdominal pain on 10/17/04 .
PAST MEDICAL HISTORY:
Significant for hypertension , atrial fibrillation on Coumadin ,
diabetes mellitus , high cholesterol , coronary artery disease ,
gallstones and diverticuli.
PAST SURGICAL HISTORY:
Nonsignificant.
ADMISSION MEDICATIONS:
Avandia 4 mg twice a day , lisinopril 20 mg twice a day , Hytrin one every bedtime ,
Lasix 80 mg x1 , spironolactone 25 mg x3 , atenolol 50 mg twice a day ,
Lipitor 10 mg x1 , Flovent , Bextra 10 mg x1 , Nexium 20 mg x1 ,
Humulin 22 units every day before noon , Coumadin 5 mg , and baby aspirin 81 mg.
For this reason , the patient was admitted to the ED and the chest
x-ray at that time showed free air below the diaphragm. The KUB
showed dilated small bowel and the abdominal CT showed multiple
free air. For this reason , the patient was brought to the OR on
10/17/04 , the same day and she underwent exploratory laparotomy
and appendectomy as well. The patient had been diagnosed at that
time of perforated appendicitis. The surgery was uncomplicated
and the patient afterwards was transferred to the SICU. Please
refer to the interim dictation for the patient for the SICU
course. In the SICU , mainly she had three problems and for this
reason , she was kept in the unit. She had rapid atrial
fibrillation , oliguria , and confusion. The patient was
transferred back on the floor on 2/5/04 on no antibiotics and
was stable with NG tube in place and through this NG tube , the
patient was fed. The patient underwent speech and swallow
evaluation at that time and the Speech & Swallow cleared her for
mechanical soft diet and the NG tube was discontinued.
The postoperative course mainly has been characterized by slow
recovery and decrease in mental confusion , for presence of
flatus , bowel movement and advanced diet to mechanical soft diet.
The patient also was restarted on Coumadin on postop day 9 , and
on postop day 13 , she was started also on baby aspirin. The
patient is discharged in stable condition.
On physical examination , she is alert and oriented x3.
Respiratory: She is clear in both lungs. She is saturating on
room air 92% during the day. However during the night and most
likely due to her position in the bed , she requires sometimes
oxygen 2 liters nasal cannula for saturation 97%. Cardiac: The
patient is in atrial fibrillation , stable condition. Heart rate
is controlled at 93. She is on atenolol 50 mg twice a day GI: The
patient is on mechanical soft diet. The abdomen is nonpainful.
Nondistended. Bowels sounds are present. The patient had
already bowel movement and she is passing flatus because she had
in the last two days three bowel movements in one day. C. diff
and leucocytes were sent that are so far negative. GU: The
patient is back on home Lasix 80 mg x1 plus spironolactone 25 mg
twice a day The patient has been voiding fine and with no problem in
urinating and the Foley was discontinued on postoperative day
#12. ID: The patient is on no antibiotics. Heme: The patient is
back on Coumadin and her INR is 3.5. She received yesterday a
dose of Coumadin 2.5 mg. She is back on baby aspirin also at 81
mg. She is also on subcutaneous heparin twice a day as prophylaxis
for DVT and she is also on pneumo boots.
The recent labs on discharge are glucose 100 , BUN of 6 ,
creatinine 0.8 , sodium 144 , potassium 3.3. She received a dose
of 20 mg orally potassium today. Chloride is 104 , CO2 32 , anion
gap 8 , calcium 8 , magnesium 1.8. PTT 34.7 , PTT 6.3 , INR is 3.5.
The patient is discharged with the following medications: Flovent
220 , inhaled x2 , Pepcid orally 20 mg twice a day , subcutaneous heparin 5000
units twice a day , atenolol 50 x2. She is on Seroquel 25 mg x1 orally ,
insulin scale , Lasix 80 mg orally every day , spironolactone 25 mg
twice a day , Simvastatin 10 mg x1 , baby aspirin 80 mg orally as needed She
is on albuterol at 2.5 mg every 12 hours and she is on Zofran for nausea.
She is on no pain medication and she does not have any pain.
The patient is discharged in stable condition and she will need
follow up with Dr. Marilyn Frehse in three weeks and the patient
also will need to restart her Humulin dose for glucose control
and the patient will need to have anticoagulation and therefore
begin Coumadin for INR range between 2 and 3.
eScription document: 3-5842457 EMSSten Tel
Dictated By: ASKIN , MAVIS
Attending: FREHSE , MARILYN
Dictation ID 9521811
D: 10/30/04
T: 10/30/04
Document id: 264
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
N |
N |
N |
N |
N |
- |
N |
N |
N |
N |
N |
- |
637493403 | PUO | 95118952 | | 9218494 | 6/10/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/1/2005 Report Status: Signed
Discharge Date:
ATTENDING: GILFOY , DEANDRA LAZARO MD
ADDENDUM
INTERIM HOSPITAL COURSE: The patient was maintained on Lasix ,
which was decreased to 60 mg orally twice a day given his low blood
pressure. However , he is maintained on this dose without hold
parameters given his third spacing of fluids. His blood pressure
remained in the high 80s to low 100s. His nadolol had been held
and was decreased to 20 orally every day to be given only if his blood
pressure is greater than 95. He was continued on lactulose. His
methadone was increased to 30 three times a day for control of his pain. In
addition , he was placed on MSIR 15-30 orally every 3 hours as needed pain. He
was given Neosporin topical for scrotal swelling and minor
multiple abrasions on his scrotum. He will be discharged to
Skilled Nursing Facility with hospice care.
DISCHARGE MEDICATIONS: Dulcolax 10 mg orally every day as needed , folate 1
orally every day , Lasix 60 orally twice a day , Motrin 600 p.r. every 6 hours as needed
pain , NPH 8 units every day before noon and 15 every afternoon , Regular Insulin sliding
scale , lactulose 60 orally every 4 hours titrated four to six bowel
movements per day , methadone 30 mg orally three times a day , nadolol 20 orally
every day , hold if SBP less than 95 or heart rate less than 55 ,
nicotine 40 mg a day topical every 25h. , multivitamin one tab orally
every day , thiamine 100 orally every day , Neosporin topical twice a day , MSIR
15-30 mg orally every 3 hours as needed pain hold if oversedation , miconazole
powder topical twice a day , Nexium 40 orally every day , magnesium oxide 400
orally every day and Maalox as needed upset stomach. He will continue his
Regular Insulin sliding scale to monitor sugar and wean down on
his NPH as needed. Continue comfort measures , wound care ,
methadone and morphine as well as MSIR as needed for breakthrough
pain. He will be continued on Lasix for comfort for peripheral
edema and nadolol only as tolerated by blood pressure. He will
be continued on lactulose for four to six bowel movements a day
as tolerated to help with his hepatic encephalopathy.
DISPOSITION: The patient will be discharged to rehab in poor
condition with poor prognosis. The patient has comfort measures
only.
eScription document: 1-2606583 CS
Dictated By: STEADINGS , MURIEL
Attending: GILFOY , DEANDRA LAZARO
Dictation ID 1043995
D: 2/7/05
T: 2/7/05
Document id: 265
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
833886231 | PUO | 11020818 | | 6743250 | 2/7/2004 12:00:00 a.m. | dizziness | | DIS | Admission Date: 2/7/2004 Report Status:
Discharge Date: 8/14/2004
****** DISCHARGE ORDERS ******
HIRSCHHORN , PERLA 167-09-84-2
Ing Pe Ille
Service: MED
DISCHARGE PATIENT ON: 9/10/04 AT 06:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOVA , DOUGLASS V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day Starting STAT ( 7/13 )
Alert overridden: Override added on 1/16/04 by
GUPTON , ANGELLA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: MD aware , patient on this regimen at home
AMIODARONE 200 MG orally every day
Alert overridden: Override added on 1/16/04 by
GUPTON , ANGELLA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
SERIOUS INTERACTION: DIGOXIN & AMIODARONE HCL
Reason for override: MD aware patient on this regimen at home
DIGOXIN 0.125 MG orally every day
Override Notice: Override added on 1/16/04 by
GUPTON , ANGELLA , M.D.
on order for AMIODARONE orally ( ref # 02722603 )
SERIOUS INTERACTION: DIGOXIN & AMIODARONE HCL
Reason for override: MD aware patient on this regimen at home
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 120 MG orally twice a day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 47 UNITS subcutaneously every day before noon
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally every day as needed Constipation
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval ( 7/13 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 1/16/04 by
GUPTON , ANGELLA , M.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 14801906 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: MD aware , patient on this regimen at home
Previous override information:
Override added on 1/16/04 by GUPTON , ANGELLA , M.D.
on order for AMIODARONE orally ( ref # 02722603 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: MD aware patient on this regimen at home
Previous override information:
Override added on 6/2/04 by GUPTON , ANGELLA , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: MD aware
SIMVASTATIN 80 MG orally every bedtime Starting STAT ( 10/24 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 6/2/04 by
GUPTON , ANGELLA , M.D.
on order for COUMADIN orally ( ref # 90396622 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: MD aware
NORVASC ( AMLODIPINE ) 10 MG orally every day HOLD IF: SBP < 95
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 60 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KCL IMMEDIATE RELEASE 40 MEQ orally twice a day
HOLD IF: potassium > 4.5
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
COZAAR ( LOSARTAN ) 100 MG orally every bedtime Starting STAT ( 10/24 )
HOLD IF: SBP < 95 Number of Doses Required ( approximate ): 3
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day Starting STAT ( 7/13 )
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LEVOTHYROXINE SODIUM 50 MCG orally every day
Alert overridden: Override added on 9/10/04 by :
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: aware
DIET: House / 2 gm Na / ADA 2100 cals/day / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Fiermonte ( cardiology 218-381-1632 ) at 11:00am 2/12/04 ,
Dr. Blackgoat ( primary care physician 369-250-7383 ) at 10:45am 2/10/04 ,
Dr. Chisler ( endocrinology 125-634-8399 ) at 3:00pm 10/11/04 ,
Arrange INR to be drawn on 3/25/04 with f/u INR's to be drawn every
7 days. INR's will be followed by Dr. Buck Moose
ALLERGY: Cephalosporins , ERYTHROMYCIN , Penicillins
ADMIT DIAGNOSIS:
dizziness , ataxia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
dizziness
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of right CEA LBBB on EKG hypertension
diabetes EF 25-30% CHF ( congestive heart
failure ) Ischemic Cardiomyopathy ( cardiomyopathy ) Atrial Fibrillation
( atrial fibrillation ) , symptomatic bradycardia history of AICD/pacer
placement , ?TIA
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Chest PA and Lateral.
AICD Interrogation ( Dr. Adele Ahlm )
BRIEF RESUME OF HOSPITAL COURSE:
Ms Hirschhorn is a 71F with DM , CAD , history of 3vCABG , history of RCA stent in 10/22 ,
CHF( EF=45% in 10/22 ) , history of bradycardia now with AICD/Pacer , history of R-CEA ,
history of ? TIA , who presents with dizziness , ataxia x 24H.
patient denies CP , SOB , palpitations. patient denies melana; BRBPR. NO new meds ,
no N/V/F/C. This is unlike anything she has had in the past.
In the ED , labs were all within normal limits. While on a monitor she
had an episode of bradycardia to the 40s. Dr. Dominguez of
the EP service interogated the device and indicated that it was
working properly with no arrhythmias. Telemetry in the ED also did
not record the bradycardic episode , suggesting that perhaps it was an
artifact. patient's toxicology screen was negative. Her vitals in the ED with
ere 98.0 , 55 , 176/60 , 18 , 98%RA. No dysmetria; no dysdiadocokinesia;
negativ e Romberg's sign.
Hospital Course:
1. CV: patient ruled out for MI; 24H telemetry showed no arrhythmias.
patient's BB was held while in house because of worry about
bradyarrhythmia , hypotension. Continued antihypertensive and CAD
treatment with with Cozaar , Lasix , Norvasc , Isosorbide , Digoxin ,
Amiodarone. patient is also on Coumadin , Plavix , and ASA , which was
continued in house. patient was discussed with patient's cardiologist , Dr.
Fiermonte who indicated this was not a new complaint in the patient and
also that she has been non-compliant in the past. physical therapy was on Coreg but
this was held prior to admit for low BP's. patient was hypertensive with SB
P 150's while inpt but we will d/c patient off Coreg and defer to Dr.
Fiermonte for reinstitution of beta blockade
2. NEURO: patient's neuro exam was normal with no focal signs , and no signs
of cerebellar dysfunction. Nevertheless given her significant vascular
risk factors there was concern for vertebral-basilar insufficiency.
MRI/MRA was not possible given patient's AICD/pacer. Upon discussion with
team CT/CTA were deferred given patient's renal insufficiency and risk of
contrast nephropathy coupled with our feeling that any findings would
not change patient management. This will be discussed with patient's primary care physician , Dr.
Buck Moose .
3. ENDO: patient was continued on home insulin regimen with coverage with
insulin sliding scale. patient was found have a TSH of 158 FT4 1.8 , FT3 56.
Upon discussion with patient , she revealed that she had previously been
diagnosed and begun on replacement but did not know what it was for and
subsequently stopped it on her own. patient started on synthroid to be f/u
with endocrine. This may be the etiology of her symptoms.
4. Prophylaxis: Nexium; patient was already anticoagulated with ASA , plavix
and Coumadin.
5. Disp: patient to follow-up with Dr. Fiermonte for managment of CHF/BP , and
with Dr. Blackgoat for f/u of potential neurovascular etiology of symptoms.
patient to f/u with endocrinology for managment of hypothyroidism.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. continue levothyroxine for hypothyroidism. f/u endo for management
2. f/u with Dr. Fiermonte for possible reinstitution of beta blockade and
CHF/BP management
3. f/u Dr. Blackgoat for with u potential vertebral-basilar insufficieny with
recognition of risk of intravenous contrast nephropathy vs utility of
information
No dictated summary
ENTERED BY: GUPTON , ANGELLA , M.D. ( OX65 ) 9/10/04 @ 06:12 PM
****** END OF DISCHARGE ORDERS ******
Document id: 266
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
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693663152 | PUO | 30550848 | | 937362 | 3/7/2001 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 2/29/2001 Report Status:
Discharge Date: 7/2/2001
****** DISCHARGE ORDERS ******
LAFOLLETTE , HULDA 988-92-06-0
Ofay Stonminland , Ohio 43470
Service: CAR
DISCHARGE PATIENT ON: 2/21/01 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 9/30/01 by
RUBIANO , ELIZ , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
Reason for override: patient taking as outpt
WELLBUTRIN ( BUPROPION HCL ) 200 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FESO4 ( FERROUS SULFATE ) 300 MG orally twice a day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ZESTRIL ( LISINOPRIL ) 10 MG orally every day
Alert overridden: Override added on 2/21/01 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
ATENOLOL 50 MG orally twice a day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Rufus Bernas 1-2 weeks ,
ALLERGY: Quinine ( quinine sulfate ) , Tegretol ( carbamazepine )
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
vitilago NIDDM ( diabetes mellitus ) depression
( depression ) hypercholesterolemia ( elevated cholesterol ) esophagitis
CAD 4/8 , PTCA htn ( hypertension ) ana ( positive ANA )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
63 year-old male , history of CAD history of MI x2 , history of cath 1/20 which
showed 100% LCfx lesion unable to be stented. At baseline , has
stable angina with exertion. Has been on medical management on
atenolol , ace-i , asa until day of adm when he woke up with L
arm and shoulder pain reminiscent of old MI.
Tried NTG sublingual x3 without full relief , called EMS. In
ED , EKG without significant change , TnI flat.
Started on heparin for unstable angina. Continued to have L shoulder
discomfort intermittently , which seemed best relieved by tylenol and
hot compresses. Serial CK's were flat , and while in hospital , had no
recurrence of chest pain. He is to follow-up with Dr. Bernas , with
possibility of ETT-MIBI as outpatient to better define his coronary
disease.
ADDITIONAL COMMENTS: 1 ) Please remember to take the increased dose of zestril 10 mg by mouth
once a day. Take all of your other medicines as you were before.
2 ) Please make a follow-up appointment with Dr. Bernas for the next
week or two.
3 ) If you experience chest pain with activity , rest , take a
nitroglycerin once every 5 minutes up to three times; if the pain does
not go away , call 911 immediately. If you experience an increase in
chest pain or shortness of breath at rest , return to the hospital
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) ETT-MIBI as outpatient
2 ) Check K , Cr within 1-2 weeks history of change in zestril dose
3 ) Given history of heartburn , not responsive to zantac and guaiac pos stool ,
should have referral to GI and EGD as outpatient
No dictated summary
ENTERED BY: RUBIANO , ELIZ , M.D. ( GI61 ) 2/21/01 @ 02:12 PM
****** END OF DISCHARGE ORDERS ******
Document id: 267
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254101103 | PUO | 99630440 | | 2634994 | 1/13/2004 12:00:00 a.m. | Diverticulosis , colitis | | DIS | Admission Date: 9/17/2004 Report Status:
Discharge Date: 10/7/2004
****** DISCHARGE ORDERS ******
LATE , VICKI HYACINTH 540-19-12-3
Delp Sand New
Service: MED
DISCHARGE PATIENT ON: 5/24/04 AT 07:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ATENOLOL 25 MG orally every day
CAPTOPRIL 25 MG orally three times a day Starting Today ( 8/25 )
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Override Notice: Override added on 9/9/04 by
PETRETTI , SEPTEMBER L. , M.D.
on order for GOLYTELY orally ( ref # 39489742 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 9/9/04 by MAROLA , TIA GWEN , M.D.
on order for KCL intravenous ( ref # 45809647 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
DIGOXIN 0.125 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally every day
Starting Today ( 8/25 )
FESO4 ( FERROUS SULFATE ) 325 MG orally twice a day
Starting Today ( 8/25 ) Food/Drug Interaction Instruction
Avoid milk and antacid
ATROVENT INHALER ( IPRATROPIUM INHALER ) 1-2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
Override Notice: Override added on 9/9/04 by MAROLA , TIA G CAMILLA , M.D. on order for PHENERGAN orally ( ref # 72576595 )
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROMETHAZINE Reason for override: will follow
OXYCODONE 5 MG orally every 4 hours Starting Today ( 8/25 ) as needed Pain
Alert overridden: Override added on 9/9/04 by
REITMEYER , LOVIE H. , M.D. , PH.D.
on order for OXYCODONE orally ( ref # 25444624 )
patient has a PROBABLE allergy to Morphine; reaction is
delirium. Reason for override: patient takes percocet for pain at
home
ZOLOFT ( SERTRALINE ) 150 MG orally every day
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
as needed Other:allergies , nasal congestion
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LEVOFLOXACIN 500 MG orally every day X 5 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
PULMICORT ( BUDESONIDE ORAL INHALER ) 1 PUFF inhaled twice a day
ASACOL ( MESALAMINE TABLET ) 800 MG orally six times a day
Alert overridden: Override added on 9/9/04 by MAROLA , TIA G CAMILLA , M.D. on order for ASACOL orally ( ref # 61732277 )
patient has a PROBABLE allergy to Aspirin; reaction is Unknown.
Reason for override: take at home
SINGULAIR ( MONTELUKAST ) 10 MG orally every day
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
ALDACTONE ( SPIRONOLACTONE ) 25 MG orally every day
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 5/24/04 by :
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & SPIRONOLACTONE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: md aware
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 5/24/04 by :
on order for LASIX orally ( ref # 78685834 )
patient has a POSSIBLE allergy to Sulfa; reaction is RASH.
Reason for override: patient takes at home
PHENERGAN ( PROMETHAZINE HCL ) 25 MG orally twice a day as needed Nausea
Alert overridden: Override added on 5/24/04 by :
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROMETHAZINE Reason for override: patient takes at home
HYOSCYAMINE ( L-HYOSCYAMINE SULFATE ) 0.125 MG orally four times a day
Starting Today ( 8/25 )
Instructions: Please take with meals and before bedtime.
Alert overridden: Override added on 5/24/04 by :
POTENTIALLY SERIOUS INTERACTION: PROMETHAZINE & HYOSCYAMINE
POTENTIALLY SERIOUS INTERACTION: PROMETHAZINE & HYOSCYAMINE
Reason for override: md aware
FIBERCON ( CALCIUM POLYCARBOPHIL ) 625 MG orally twice a day
DIET: House / ADA 2000 cals/day / Low saturated fat
low cholesterol / Please follow diet as prescribed by nut
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Tetrick next week , please call ,
Dr. Danni 6/7/04 scheduled ,
ALLERGY: Penicillins , Sulfa , QUININE SULFATE , Aspirin , Morphine
ADMIT DIAGNOSIS:
Abdominal pain , colitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Diverticulosis , colitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Dilated cardiomyopathy ( cardiomyopathy ) CHF ( congestive heart failure )
Hyperchol ( elevated cholesterol ) Asthma ( asthma ) OSA , on bipap ( sleep
apnea ) Depression ( depression ) DM ( diabetes mellitus type 2 ) Breast
ca , history of B mastectomy ( breast cancer ) Diverticulosis ( diverticulosis )
HTN ( hypertension ) history of DVT ( history of deep venous thrombosis ) history of LGIB ( history of
lower GI bleeding ) Anemia ( anemia )
OPERATIONS AND PROCEDURES:
Colonoscopy
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: 56F with chronic abd pain p/with wkness
HPI: patient has history of diverticulitis , LGIB , history of mult recent hosp adm for CHF
exacerb + divertic flares. patient is history of d/c from NVH 11/3 for colitis , dx
by bx from colonoscopy. patient was adm for crampy abd pain , nausea , loose
stool 8-10x/d , wt loss. patient given rx for Phenergan + Percocet. Saw outpt
GI MD who rx Asacol , started on 6 then incr to 10 without relief. patient also
trying diet modif with some improvement. Sx ( abd pain , nausea , freq BM )
largely unchgd , varies day-to-day , but avg 6 soft BM/d. patient has exper
incr wkness x 10d , called primary care physician this a.m. , told to come to PUO . No
melena/BRBPR , V , F/C , urinary sx.
Exam: 98.4 89 99/61 18 100 RA. NAD. Dry MM. JVP 5 cm. CTAB. RRR. TTP
LUQ/suprapub/epigastric. Neuro nonfocal.
Labs: BUN 47 , Cr 1.2. LFTs WNL.
Hospital Course:
1. GI: Colonoscope showed signif diverticulosis + patchy colonic
erythema. No e/o IBD , likely symptomatic tics + bowel irritation. Cont
Asacol , Phenergan , Oxycodone. Added Hyosciamine on d/c. patient will f/u with
Dr. Danni .
2. CV: I-No active issues. P-Held diuretics + ACE on adm 2/2 dehydr ,
restarted Captopril after IVFs.
3. FEN: Encourage orally fluids. Gentle IVFs with NS.
4. Pulm: OSA , on bipap at home , O2 NC here at nt.
5. Ppx: Lovenox , PPI.
6. Dispo: Will d/c home today or tmrw.
7. Code: Full.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow-up with Dr. Tetrick in one week and with Dr. Danni in two
weeks. If you have severe abdominal pain different from your current
pain , if you have bloody or black stools , or if you develop shortness
of breath , please contact your primary care physician or return to the Emergency
Department.
No dictated summary
ENTERED BY: REITMEYER , LOVIE H. , M.D. , PH.D. ( SS08 ) 5/24/04 @ 06:40 PM
****** END OF DISCHARGE ORDERS ******
Document id: 268
| Target |
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HTG |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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540167155 | PUO | 66456892 | | 7983940 | 7/3/2005 12:00:00 a.m. | APLASTIC ANEMIA | Signed | DIS | Admission Date: 9/21/2005 Report Status: Signed
Discharge Date: 7/13/2005
ATTENDING: JONE , MARCELA MD
HISTORY OF PRESENT ILLNESS:
Patient is a 41-year-old female with a history of aplastic anemia
since age 12 , blood transfusion dependent , usually every two
weeks. Also history of iron overload , diabetes , avascular
necrosis , status post hip replacement , shoulders/multiple Hickman
associated line infections , who presented with somnolence and
total body pain on 10/11 . At that time , she was unable to
provide a history ??_____?? moments of clarity and would say pain
all over. She has had episodes of somnolence from excessive pain
medication use ??______?? presentation when she was found to be
bacteremic on the previous hospital stay on 3/21 . According to
her daughter , she had one day of inability to walk with
complaints of pain in her legs. She had not reported to have any
symptoms such as chills , fevers , nausea , vomiting , but her pain
became increasingly intense and she became unable to get
comfortable sleep. In the Emergency Department , her vitals
showed a temperature of 98.7 , pressure 99/67 , heart rate 106 ,
respiratory rate of 20 , sating 100% on room air. In the ED , she
was given deferoxamine , vancomycin , and ceftazidine. Blood
cultures were sent at that time.
PAST MEDICAL HISTORY:
Notable for aplastic anemia treated with thymoglobulin. She had
a trial of thymoglobulin. However , she had a reaction and did
not tolerate it. Also treated with cyclosporine in the past.
Also history of HCV , avascular necrosis , polyarticular arthritis
with bilateral hip replacement and bilateral shoulder
replacement , diabetes , difficult to control on insulin , iron
overload secondary to transfusions , hypothyroidism , amenorrhea
status post TAH for endometriosis/cervical carcinoma ,
osteomalacia and blind right eye.
MEDICATIONS:
Her medication on admission were Lantus 25 subcutaneously every day before noon , Novolog
12 units subcutaneously before meals , Zoloft 100 mg daily , lisinopril 20 mg daily ,
which was held , Ambien as needed , hydrochlorothiazide 25 mg daily ,
quinine sulfate 260 mg orally at bedtime , thiamine , folate ,
oxycodone 90 mg orally three times a day as needed , methadone 40 mg orally three times a day ,
Baclofen 10 mg orally three times a day , Protonix 40 mg orally daily , Levoxyl 75
mg orally daily , vitamin D , calcium carbonate , Desferal 2 g daily ,
however , written as no longer necessary.
ALLERGIES:
Her allergies include NSAIDs and aspirin secondary to low
platelets and acetaminophen secondary to liver problems.
FAMILY HISTORY:
Remarkable for diabetes mellitus.
SOCIAL HISTORY:
She lives with three children. Has a history of tobacco one pack
per day for 20 years , occasional alcohol and prior history of
cocaine. Her healthcare proxy is Dorothy Rydolph , phone number
937-340-7812 or cell phone 173-123-2196 and her code status is a
full code.
PHYSICAL EXAMINATION:
Her physical exam on admission notable for a temperature of 96.9 ,
heart rate 109 , blood pressure 136/92 , respiratory rate of 16 ,
sating 95% on room air. Physical exam was notable for difficulty
with following commands. Heart was regular rate and rhythm. No
murmurs , rubs , or gallops. Lungs with poor respiratory effort.
No wheezes or crackles appreciated. Abdomen was soft , nontender ,
nondistended , no hepatomegaly. She had no lower extremity edema
and on neuro exam , required frequent refocusing to main
attention; however , was able to count backwards from 10. She did
not initiate any spontaneous speech except when distressed or in
pain.
LABS:
On admission notable for a white count of 0.67 , hematocrit 19.6
and platelets of 11 , 000. Her differential had 53% polys , 30%
bands. BUN of 14 , creatinine of 2.2 , glucose of 288. Her ALT
was 64 , AST 71 , alk phos 107 , total bili 0.7 , and her UA revealed
LE positive , 6-10 white blood cells , 2-5 red blood cells and 4+
bacteria. Urine cultures were sent at that time.
ASSESSMENT:
A 41-year-old female , long standing aplastic anemia transfusion
dependent , history of avascular necrosis , history of multiple
infections , who came in with decreased mental status as well as
leg pain. Subsequently found to have urosepsis as well as a
Klebsiella bacteremia with course complicated by development of a
cholecystitis.
HOSPITAL COURSE BY SYSTEM:
1. ID: Blood cultures grew Klebsiella as well as urine culture
grew Klebsiella , determined to be a urosepsis During her hospital
course. Was hypotensive requiring transport to the MICU as well
as pressors. She was initially treated with ceftazidine that had
been ??_____?? levofloxacin when her cultures came back
sensitive. Also hospital course complicated by development of
cholecystitis. She was started on amp as well as Flagyl to cover
for her cholecystitis in addition to the Levaquin. She was to
complete a 10-day course of amp , levo , Flagyl after her last
positive culture , which would take her up until 9/12 to
discontinue the antibiotics. Prior to discharge additional blood
culture was collected to ensure that she had cleared her
bacteremia prior to replacing the Hickman line. This blood
culture should be followed up before the Hickman line is placed.
2. Neuro. Patient had decreased mental status as well as pain
on admission. Baseline , she does have chronic pain and is high
dose of oxycodone as well as methadone at home. However , on
admission , she had acute full body pain. This pain improved as
her infection was treated and returned to her baseline level.
Her mental status , which according to her daughter , she is
frequently somnolent , was decreased from baseline. However , as
her sepsis resolved , her somnolence improved.
3. Pulmonary. During hospital course had one episode of dry
cough with scant hemoptysis in the setting of low platelets. Her
cough did not persist and her oxygen saturation at the time of
discharge was 95% on room air.
4. Cardiovascularwise from a pump perspective , her EF was 35%
with global hypokinesis , trace AI. Initially she was fluid
overloaded following resuscitation; however , autodiuresed. She
was restarted on hydrochlorothiazide for her hypertension.
Rythmwise , initially she had sinus tachycardia in the setting of
her sepsis. Then on 3/28 , developed atrial flutter with rates
up to 150s. She was given intravenous Lopressor , when she converted back
to sinus rhythm. She was then continued on orally metoprolol for
rate control. She was not anticoagulated due to her low
platelets and bleeding risk.
5. Vascular: It was noted that she did have swollen lower
extremity that was tender , right greater than left , after
transfer out from the MICU. Pulses were intact. She was able to
move her feet. ??_____?? were performed and did not show any
evidence of DVT. Her swelling continued to decrease as she
diuresed.
6. GI: During her MICU stay , she developed right upper quadrant
pain and ultrasound suggestive of cholecystitis. Surgery was
consulted; however , due to her high surgical risk , it was decided
that she would be managed medically. Her bilirubin continued to
trend down. She continued to tolerate orally liquids and food and
did not complain of a new right upper quadrant pain. Given her
chronic esophagitis , as well as epigastric discomfort , she was
kept on a PPI. In addition , she may also continue Carafate as
needed. She also has a history of hepatitis C , which she is to
follow with Liver Clinic following discharge.
7. Heme: She has a history of aplastic anemia of unknown
etiology since age 12. She was maintained with a hematocrit goal
of greater than 23. Her platelets fluctuated as low as 3. She
did receive two units of HLA matched platelets , which increased
her platelets to 19. However , in the past she has been known to
tolerate platelets less than 5 and unless a concern for bleeding ,
I would not further transfuse.
8. Renal: Her creatinine was maintained at her baseline of 1.5.
Electrolytes were fallena and repleted as necessary.
9. Endocrine: Diabetes. Her sugar levels were difficult to
control. She was kept on Lantus as well as Novolog for her
insulin regimen.
PROPHYLAXIS:
Pneumaboots given her low platelets as well as a PPI.
TUBES , LINES AND DRAINS:
She does have a 3 port right IJ catheter in place and which she
will be discharged with until her Hickman can be placed. Follow
up has been scheduled for her to have IR place another Hickman.
Prior to placement , she should have her final blood cultures
evaluated.
MEDICATIONS AT THE TIME OF DISCHARGE:
Include Dulcolax 10-20 mg ??_____?? as needed constipation , Colace
100 mg orally twice a day , hydrochlorothiazide 25 mg orally daily , Levoxyl
75 mcg orally daily , methadone 40 mg orally three times a day , oxycodone 30-60
mg orally every 4 hours as needed for pain , Zoloft 100 mg orally daily ,
levofloxacin 500 mg orally every 48 hours , to receive final dose on
3/22/05 , Protonix 40 mg orally daily , Lantus 25 units subcutaneously every day before noon ,
Novolog 12 units subcutaneously before meals , ampicillin 500 mg orally every 6 hours , to
complete final dose on 3/22/05 , Toprol XL 50 mg orally daily ,
thiamine 100 mg orally daily , folate 1 mg orally daily , Baclofen 10
mg orally three times a day , calcium carbonate 1250 mg orally three times a day , Flagyl 500
mg orally three times a day , to complete last dose on 3/22/05 and vitamin D
50 , 000 units orally every week.
DISPOSITION:
Patient is to follow up with Interventional Radiology , telephone
number 595-260-0817 for placement of Hickman line. In addition ,
she is scheduled to follow up with Liver Clinic , with Dr. Reinstein
on 1/13/05 at 4:00 p.m. and finally to follow up with
Dr. Myrtis Vantull her hematologist regarding future treatment of
her aplastic anemia. If she has any questions in the meantime or
Dr. Robblee is not available , Dr. Mew may be contacted.
eScription document: 8-1165571 EMSSten Tel
CC: Marcela Jone MD
Lem Arb
CC: Stacey Pavlik MD
Van
Dictated By: MARCOTT , DESIRAE
Attending: JONE , MARCELA
Dictation ID 5666335
D: 4/18/05
T: 4/18/05
Document id: 269
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
HC |
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HTG |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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540167155 | PUO | 66456892 | | 359991 | 11/25/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/27/1999 Report Status: Signed
Discharge Date: 3/23/1999
SERVICE: ONCOLOGY INPATIENT Sant
PRINCIPAL DIAGNOSIS: APLASTIC ANEMIA , HERE FOR HICKMAN PLACEMENT.
HISTORY OF PRESENT ILLNESS: Mrs. Eisermann history dates back to
1976 , when she was diagnosed with
aplastic anemia. She did not have a bone marrow donor match at
that time and was thus treated with steroids without significant
effect. She has been transfusion dependent since 1986 and has
required every 2 weekly packed red blood cell transfusions and as needed
platelet transfusions for epistaxis. She has had multiple
complications of her aplastic anemia , including hemochromatosis ,
bronzed diabetes , history of hepatitis B and hepatitis C positivity
secondary to transfusions , avascular necrosis of both hips , status
post bilateral total hip replacements , chronic shoulder bony damage
( both orthopedic prostheses secondary to chronic steroid use ) ,
history of perirectal abscess with Klebsiella while neutropenic ,
history of multiple Port-A-Cath infections. Her past history is
also significant for status post total abdominal hysterectomy for
high grade SIL in 1997.
Today Ms. Rydolph presents for placement of a Hickman catheter
which had fallen out at the beginning of April of this year.
REVIEW OF SYSTEMS: Negative for fever , chills , nausea , vomiting ,
abdominal pain , upper respiratory infection
symptoms , urinary tract infection symptoms , shortness of breath ,
chest pain , palpitations.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Desferal was last given two months
prior to admission; Methadone 10 mg
three times a day; oxycodone 5 mg 3-4 times a day; Percocet 2-3 tabs every 4 hours as needed
pain ( Ms. Rydolph was counseled to intake no more than two
Percocets every 8 hours ); Reglan 10 mg orally four times a day as needed with meals for
nausea; insulin 50 units NPH in the morning , 10 units regular in
the morning , 10 units NPH at 5:00 p.m.
PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: 99.3 , heart rate
75 , blood pressure 120/74 ,
respiratory rate 18 , satting 100% on room air. HEENT: Pupils
equal , round , reactive to light and accommodation. Extraocular
movements intact. Oropharynx is without erythema. Mucous
membranes were moist. NECK: Supple with 2+ carotids bilaterally.
LUNGS: Clear bilaterally. HEART: Regular rate with normal S1 and
S2 , no murmurs. ABDOMEN: Soft with normoactive bowel sounds; no
hepatosplenomegaly. She had no palpable liver nodules. She has
slight nonpitting edema bilaterally in her ankles which was
baseline. NEUROLOGIC: She was alert and oriented x3. Cranial
nerves II-XII were intact.
SOCIAL HISTORY: She has a distant history of alcohol use. She is
a single mother with three children , ages 13 , 9 ,
and 9.
FAMILY HISTORY: Remarkable for diabetes in multiple family
members.
HOSPITAL COURSE: Mrs. Rydolph is a 35-year-old woman with a long
history of transfusion dependent aplastic anemia
with multiple complications secondary to hemochromatosis and
chronic steroid use. She was admitted for replacement of a Hickman
catheter which had fallen out in April of this year. Prior to the
procedure she was transfused with two bags of platelets. She had
one bag of platelets on call to the Interventional Radiology Suite ,
but did not require these platelets. She was also transfused two
units of packed red cells for a hematocrit of 23. On July ,
1999 , she had a right internal jugular venous Hickman catheter
placed without difficulty. There were no complications from the
procedure. There is no pneumothorax by fluoroscopy. The tip was
in the proximal right atrium , okay to use. Both lumens aspirated
freely and were flushed with heparin prior to being sent back up on
the floor. On the evening of July , 1999 , Ms. Rydolph began an
infusion of Desferal while in house , watching carefully for signs
of anaphylaxis , as she has not received an infusion in over two
months. After she completes her Desferal infusion , she will be
sent home with visiting nurse for Hickman catheter care and
followup with Dr. Myrtis Vantull in clinic.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Discharged to home with home services for Hickman
catheter care and monitoring of CBC.
Dictated By: FRAN BUSSLER , M.D. TW36
Attending: DOUGLASS NATASHIA PETTINGER , M.D. ZN2 RE156/1952
Batch: 38348 Index No. HCXVQZ9S55 D: 10/23/99
T: 10/23/99
QF9
Document id: 270
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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805023121 | PUO | 28791746 | | 0628374 | 3/13/2005 12:00:00 a.m. | PPM placement | | DIS | Admission Date: 10/26/2005 Report Status:
Discharge Date: 1/21/2005
****** DISCHARGE ORDERS ******
BRIGHTLY , LACI K 823-68-52-0
Inwellnix Olare
Service: CAR
DISCHARGE PATIENT ON: 3/25/05 AT 01:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: POPOVIC , ALEXANDRA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ZESTRIL ( LISINOPRIL ) 2.5 MG orally every day
ZOLOFT ( SERTRALINE ) 50 MG orally every day
KEFLEX ( CEPHALEXIN ) 250 MG orally four times a day X 12 doses
Starting when intravenous ANTIBIOTICS END
Number of Doses Required ( approximate ): 20
ARICEPT ( DONEPEZIL HCL ) 10 MG orally every afternoon
Number of Doses Required ( approximate ): 1
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
GLUCOPHAGE ( METFORMIN ) 500 MG orally every day
GLYBURIDE 1.25 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Local cardiologist 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHB
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
PPM placement
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM ( diabetes mellitus type 2 ) HTN ( hypertension ) CAD ( coronary artery
disease ) CRI ( chronic renal dysfunction ) mild dementia ( dementia )
OPERATIONS AND PROCEDURES:
PPM placed 3/14/05 without complications
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: PPM placement
HPI: 74M with 3VD history of recent MI in 2/17 ( with subsequent stent of 100% RCA ,
but residual LAD dz ) transferred from TH for PPM placement for
symptomatic bradycardia. PPM placed with no cx.
DAILY STATUS/EXAM: arm in sling , ox3 , sleepy but easily rousible , cn
intact , rrr s1s2 no m/r/g , ctab , no LEE , distal pulses 2+ , PPM site
bandage C/D/I.
TESTS: CXR - clear , no PTX post procedure
*********PROBLEM LIST**************
1. BRADYCARDIA history of PPM placement. PPM appears to be working well. cont
standard care ( post procedure abx , overnight observation , cxr to r/o
PTX ).
2. 3VD: no evidence of active ischemia. cont home meds incl plavix , asa ,
highdose statin , bb , acei.
3. DM: we held orally hypoglycemics in house and used a RISS. patient to resume
meds on dispo.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up as arranged by cardiology
No dictated summary
ENTERED BY: AKIN , GIA RANDOLPH , M.D. ( TZ48 ) 3/25/05 @ 01:23 PM
****** END OF DISCHARGE ORDERS ******
Document id: 271
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
Y |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
797900970 | PUO | 47203512 | | 830627 | 7/10/2001 12:00:00 a.m. | hemoptysis | | DIS | Admission Date: 2/18/2001 Report Status:
Discharge Date: 9/21/2001
****** DISCHARGE ORDERS ******
MALANEY , SHAWNA 853-13-69-7
Louis
Service: MED
DISCHARGE PATIENT ON: 7/26/01 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CAOILI , VALERI M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
XANAX ( ALPRAZOLAM ) 1 MG orally three times a day HOLD IF: sedation
MECLIZINE ( MECLIZINE HCL ) 25 MG orally every 8 hours as needed vertigo
NORTRIPTYLINE HCL 100 MG orally HS
TRAZODONE 50 MG orally HS
VERAPAMIL SUSTAINED RELEAS 120 MG orally every day HOLD IF: sbp<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEURONTIN ( GABAPENTIN )
300 MG qAM; 300 MG qNoon; 600 MG qPM orally 300 MG qAM
300 MG qNoon 600 MG qPM
SEROQUEL ( QUETIAPINE ) 200 MG orally three times a day
Number of Doses Required ( approximate ): 12
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
DIET: No Restrictions
RETURN TO WORK: When you feel ready
FOLLOW UP APPOINTMENT( S ):
Adell Lickfelt at Brook Mepa Community Hospital within 2-4 weeks ,
Pulmonary Clinic , 947-164-2074 within 2-3 weeks ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
Hemoptysis , history of PE , INR 7.5
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hemoptysis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
depression ( depression ); history of drug overdose ( drug overdose ); PE
( pulmonary embolism ); gerd
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
38 F with history of recent PE ( 6/22 ) p/with episode of hemoptysis , CP and SOB
and found to have supratherapeutic INR of 7.2 , post oropharyngeal
abrasions. HCT stable and hemodynamically stable. No evidence of
further bleeding during hospitalization , altho' patient reports recent
hematochezia x 1. Also c/o GERD sx.
CXR nl; EKG unremarkable , NSR 90s , nl axis , no right heart strain , no
sttw changes. DDimer nl. Recently had r/o mi ( 6/22 ) although
CRFs only cigs , prior cocaine. ECHO 6/22 unremarkable with no
wma. patient on Verapamil for HTN.
patient recently had PPD- and without cough/sputum/not systemically ill.
Tx'd with Vit K , PPI trial initiated , domestic violence social work
consulted. Tox screen was negative. patient also noted to have clinical
depression with hx si/sa/drug overdose , and was continued on her usual
psych meds.
D/c'd back to jail on Coumadin with close INR follow up , on PPI ,
and current meds regimen.
Will follow up with her usual primary care physician and Pulmonary Clinic to assess
for underlying pulmonary ds , especially given risks of prior cocaine ,
?other drugs , for lung injury.
ADDITIONAL COMMENTS: Your INR was too high , and needs to be followed closely. Contact your
doctor if you have further bleeding , feel faint or lose consciousness ,
or have worsened shortness of breath or chest pain. You are starting a
new medicine for gastroesophageal reflux ( prilosec ) which should
decrease your discomfort. Follow up with your doctor and with the
Kernan To Dautedi University Of Of Pulmonary Clinic. Your INR should be drawn every 3 days and to
be maintained between 2-3 as before. After it is stable 5 times you can
go back to once a week monitoring.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Restart coumadin at 5 mg orally every day and start monitoring every three days
until the INR is stably between 2-3 for 5 consecutive draws. Adjust
coumadin dose as necessary.
Follow up with primary care physician in 2-3 weeks
Follow up with pulmonary clinic in 2-3 weeks , call the number included
in this discharge summary.
No dictated summary
ENTERED BY: KRENTZ , MILA KATHERINE , M.D. ( AZ76 ) 7/26/01 @ 07:35 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 272
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
009083719 | PUO | 04731180 | | 765142 | 11/19/1997 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 5/25/1997 Report Status: Signed
Discharge Date: 9/7/1997
HISTORY OF PRESENT ILLNESS: This is a 51 year old greek
speaking female from the Paul And Gilb with a history of hypertension who presents with two
episodes of chest and abdominal pain that she describes as
beginning on the left side of her chest as a heaviness and then
moved to her left arm. This pain was also associated with
epigastric pain. The patient said that she got some relief with
Advil and came to the emergency room. In the emergency room she
had no chest pain but had some epigastric discomfort associated
with numbness. In the emergency room the patient received aspirin ,
nitroglycerin and Maalox and was free of symptoms.
PAST MEDICAL HISTORY: Significant for hypertension , anxiety. Of
note , the patient had an echo in April
1994 and her ejection fraction at that time was 65% with no
regional wall motion abnormalities. An exercise tolerance test was
also done at that time showing two minutes and 20 seconds with no
evidence of ischemia.
ALLERGIES: Zantac to which she gets a rash.
MEDICATIONS: Procardia XL 90 mg orally every day , Xanax 0.25 mg four times a day
as needed , Provera.
SOCIAL HISTORY: She lives with her son , does not smoke , does not
drink alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temp 98.6 , heart rate is 71 , blood pressure
148/80 , respiratory rate 18 , oxygen
saturation was 96% on two liters. She was a pleasant female in no
apparent distress. Her neck was supple. There was no carotid
bruits. Lungs are clear to auscultation. Cardiovascular - Regular
rate and rhythm without murmurs. She had left lateral chest pain
that was elicited with palpation. Her abdomen was soft , nontender ,
nondistended. Extremities - No clubbing , cyanosis or edema.
LABORATORY DATA: CK of 41 , troponin of 0.2.
EKG - Normal sinus rhythm with normal axis and intervals and a
T-wave inversion in 3.
HOSPITAL COURSE: The patient ruled out for an myocardial
infarction by serial enzymes and went for four
minutes and 30 seconds on a standard Bruce protocol. Her maximum
heart rate is 147. Her maximum blood pressure was 177/84. She had
no chest pain. No ST or T-wave changes and no evidence of
ischemia.
She is being discharged to home on her same medication. In
addition , she will be started on Prilosec 20 mg orally every day
Dictated By: LATORIA C. OGDEN , M.D. YB07
Attending: LATORIA C. OGDEN , M.D. TJ48 NM212/8433
Batch: 0581 Index No. GXDZEB02HR D: 3/30/97
T: 4/24/97
CC: 1. ELIZEBETH HATCHITT , GAREN'S MEMORIAL HOSPITAL
Document id: 273
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
N |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
325236852 | PUO | 47804624 | | 2511318 | 11/12/2003 12:00:00 a.m. | RECURRENT L4-5 HERNIATED DISC , L5-S1 SPINAL STENOSIS , INSULIN DEPENDENT DIABETES | Signed | DIS | Admission Date: 5/11/2003 Report Status: Signed
Discharge Date: 8/21/2003
PRIMARY DIAGNOSIS: L4-L5 , L5-S1 HERNIATED NUCLEUS PULPOSUS.
PROCEDURE: Revision decompression at S1 with iliac crest graft
fusion. Instrument fusion with a later iliac bone
graft.
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old male with
a history of lumbar spinal stenosis ,
status post L3-L4 , L4-L5 foraminotomy , left-sided L5-S1 foraminal
decompression , and L4-L5 laminectomy with new L4-L5 , L5-S1
herniated nucleus pulposus , and lower back pain with radicular
symptoms. He described his back pain as 80% of his complaint , and
20% is his radicular symptoms. The pain is greater on the right
than on the left. He has had conservative management. He
complains of bowel and bladder changes with decreased rectal tone ,
and control with urine and feces. He denies any lower extremity
weakness or numbness throughout his perineum. He was recently seen
in the Gle Ra Csylv Valley Medical Center Emergency Room on 1/11/02 , for low back
pain and sciatica; however , he left AMA. He presents for elective
decompression and instrument infusion of his lumbar spine.
PAST MEDICAL HISTORY: Obesity , hypertension , diabetes mellitus ,
coronary artery disease , GI bleed. A
history of seizure disorder and peripheral neuropathy.
PAST SURGICAL HISTORY: Bilaterally total knee arthroplasty;
shoulder surgery; aortic valve replacement ,
times two; cardiac catheterization; hydrocele repair.
MEDICATIONS: Please see nurse's note.
ALLERGIES: Coumadin , is not a true allergy , however , he has been
unable to achieve therapeutic INR.
SOCIAL HISTORY: He is a reformed smoker and drinker. He is a
retired salesman.
PHYSICAL EXAMINATION: Pertinent neurologic findings. Bilateral
lower extremity edema. Light touch is
intact throughout with slight decrease in bilateral feet consistent
with neuropathy , left greater than right. Decreased sensation.
Motor strength is 5/5 with the quads , hams , GS , TA , EHL. The left
side fatigues sooner than the right. A negative clonus. DTRs are
equal bilaterally quads , hams and Achilles. Capillary refill is
less than two seconds.
MRI from 6/17/02 , reveals left-sided L5-S1 herniated HNP with
foraminal narrowing.
The EKG shows no ST elevation or depression; however , there is no
prior study for comparison.
Laboratory values: Potassium 4.7. Hematocrit 38.5. INR 1.0.
Urinalysis negative.
HOSPITAL COURSE: The patient underwent lumbar spine decompression
with L4-S1 instrument infusion with augmentation
of the iliac crest bone graft. Postoperative course was
uneventful. The patient remained afebrile , hemodynamically stable.
Autologous blood was necessary. He was required to maintain a
hematocrit above 30. He remained afebrile. Normal perioperative
antibiotics were given , however. His orally intake was delayed
secondary to delay in return of GI function. He did have an
episode of dark emesis early in his postoperative course on
postoperative day #1/2. He was slow to mobilize with physical
therapy. This was in part secondary to his pain level and also
intermittent confusion , for which a medicine consult was obtained.
Kayexalate was given for elevation of his potassium; otherwise , his
confusion resolved with decrease of his narcotic medications.
Physical therapy was able to resume. He was able to advance
appropriately. Hospitalization was prolonged secondary to waiting
for a rehab placement. At the time of discharge , his incision was
clear , dry and intact.
He was discharged to the _____ rehab with the following
instructions. Discharge medications: OxyContin , Percocet , and
Colace , in addition to preoperative medications. Activity:
Weightbearing , as tolerated. When out of bed , must have brace on.
Followup: Follow-up in six weeks. Call for an appointment.
Diet: As tolerated.
Dictated By: STACEY QUELLA , M.D. CI03
Attending: DEBBIE WIMPEY , M.D. CW4 OU583/457018
Batch: 04398 Index No. E0MV3NS8B1 D: 3/2/03
T: 6/24/03
Document id: 274
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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178751561 | PUO | 79638392 | | 0560581 | 3/30/2006 12:00:00 a.m. | history of Lt TSR & Biceps Tenodesis | | DIS | Admission Date: 3/30/2006 Report Status:
Discharge Date: 10/13/2006
****** FINAL DISCHARGE ORDERS ******
OUIMET , DAMION 499-62-42-8
Ard Do
Service: ORT
DISCHARGE PATIENT ON: 7/12/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SEIDNER , ETSUKO JAMA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 1 , 000 MG orally every 6 hours
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
ASPIRIN ENTERIC COATED 325 MG orally DAILY
ATORVASTATIN 10 MG orally DAILY
THORAZINE ( CHLORPROMAZINE HCL ) 10 MG orally every 4 hours
as needed Other:agitation
CLONAZEPAM 1-2 MG orally twice a day as needed Anxiety
PREMARIN ( CONJUGATED ESTROGENS ) 0.625 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally three times a day
NEURONTIN ( GABAPENTIN ) 1 , 200 MG orally three times a day
DILAUDID ( HYDROMORPHONE HCL ) 6-10 MG orally every 2 hours
as needed Pain , Other:breakthrough pain
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS Medium Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 3 units subcutaneously
If BS is 251-300 , then give 5 units subcutaneously
If BS is 301-350 , then give 7 units subcutaneously
If BS is 351-400 , then give 8 units subcutaneously
Call HO if BS is greater than 350
Please give at the same time and in addition to standing
mealtime insulin
LACTULOSE 30 MILLILITERS orally four times a day as needed Constipation
LAMICTAL ( LAMOTRIGINE ) 225 MG orally DAILY
Number of Doses Required ( approximate ): 5
METFORMIN 1 , 000 MG orally twice a day
METHADONE 40 MG orally twice a day
PRILOSEC ( OMEPRAZOLE ) 40 MG orally DAILY
PROGESTERONE 100 MG orally DAILY
Instructions: patient takes "prometrium" at home
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
DIET: House / Low chol/low sat. fat
ACTIVITY: Lt UE Ultrasling
FOLLOW UP APPOINTMENT( S ):
Dr Seidner 7/11/06 at 9:15am 7/11/06 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Lt Shoulder OA
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of Lt TSR & Biceps Tenodesis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Osteoarthritis , Asthma , Type II Diabetes , Chronic Pain Syndrome ,
Depression , Hypercholesterolemia , GERD
OPERATIONS AND PROCEDURES:
4/30/06 SEIDNER , ETSUKO JAMA , M.D.
LEFT TOAL SHOULDER ARTHROPLASTY , BICEPS TENODESIS
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
N/A
BRIEF RESUME OF HOSPITAL COURSE:
patient underwent a Lt TSR , and biceps tenodesis on 4/30/06 for endstage OA.
patient tolerated the proecdure well , and had an uncomplicated postoperative
course with exception of pain management issues. patient was followed by the
POPS with acute pain managed with PCA , intravenous Ketamine , and adjustment of orally
Methadone dose. patient was HD , and neurologically stable with no transfusion
requirements during her hospitalization. Standard care with prophylactic
intravenous abx , and TEDS/P-boots for DVT prophylaxis. patient mobilized OOB with physical therapy ,
and was seen PROM per Dr Seidner TSR protocol. Refer to the page 3 for
details. Wound was clean and helaing at time of discharge. PCA/Ketamine
was D/C'd on POD 2 , and patient was transitioned to orally analgesics. patient
stable for transfer to rehab on Coll Atlterstote Saca
ADDITIONAL COMMENTS: DSD every day The wound may be left OTA when dry. Patient may shower with an
occlusive dressing
Precautions:
7 Sling should be worn continuously for 3-4 weeks
7 While lying supine , a small pillow or towel roll should be placed
behind the elbow to avoid shoulder hyperextension / anterior
capsule stretch / subscapularis stretch. ( When lying supine
patient should be instructed to always be able to visualize
their elbow. This ensures they are not extending their shoulder
past neutral. ) - This should be maintained for 6-8 weeks
post-surgically.
7 Avoid shoulder AROM.
7 No lifting of objects
7 No excessive shoulder motion behind back , especially into
internal rotation ( IR )
7 No excessive stretching or sudden movements ( particularly
external rotation ( ER ) )
7 No supporting of body weight by hand on involved side
7 Keep incision clean and dry ( no soaking for 2 weeks )
7 No driving for 3 weeks
7 Passive forward flexion in supine to tolerance
7 Gentle ER in scapular plane to available PROM ( as documented in
operative note ) - usually around 300
( Attention: DO NOT produce undue stress on the anterior joint
capsule , particularly with shoulder in extension )
7 Passive IR to chest
7 Active distal extremity exercise ( elbow , wrist , hand )
7 Pendulum exercises
Early Phase I: ( out of hospital )
7 Continue above exercises
7 Begin scapula musculature isometrics / sets ( primarily
retraction )
7 Continue active elbow ROM
7 Continue cryotherapy as much as able for pain and inflammation
management
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr Seidner as scheduled on 7/11/06
No dictated summary
ENTERED BY: SCOVEL , DULCIE , PA-C ( XP60 ) 7/12/06 @ 09:36 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 275
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
- |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
753578182 | PUO | 47094392 | | 391452 | 7/10/1998 12:00:00 a.m. | MITRAL STENOSIS | Signed | DIS | Admission Date: 10/12/1998 Report Status: Signed
Discharge Date: 11/15/1998
HISTORY OF PRESENT ILLNESS: Ms. Vercher is a 68 year old female
with known heart murmur since the
1950s. She has a been closely followed since approximately 1990
for multi-valve disease. In early February of 1998 she presented
with chest pressure and was seen at Pagham University Of for
cardiac catheterization which revealed no significant coronary
artery disease but markedly increased filling pressures. Her right
atrial pressure was 14/16/10. Right ventricular pressure was
75/100 , pulmonary artery pressure was 75/35/50 and her pulmonary
capillary wedge pressure was 32/36/30. Echocardiogram on 3/16/98 ,
revealed mild left ventricular hypertrophy and mildly decreased
systolic function with an ejection fraction of 45 percent , normal
right ventricular size and function , moderate mitral stenosis and
three plus mitral regurgitation , moderate aortic insufficiency and
aortic stenosis , three plus tricuspid regurgitation and a dilated
inferior vena cava.
PAST MEDICAL HISTORY: Significant for rheumatic fever ,
hypothyroidism , borderline diabetes
mellitus , atrial fibrillation , breast cancer for which she had
radiation therapy.
PAST SURGICAL HISTORY: Significant for a right lumpectomy in the
1990s. She has had an appendectomy in 1993
and a tonsillectomy and adenoidectomy in the past.
ALLERGIES: Penicillin ( causes rash and itch ).
PHYSICAL EXAM: Unremarkable.
HOSPITAL COURSE: Ms. Vercher was brought to the operating room on
4/6/98 where she underwent an aortic valve
replacement with a #19 St. Jude valve , a mitral valve replacement
with a #27 St. Jude valve and a tricuspid valvuloplasty with a
DeVega annuloplasty. The patient intraoperatively was found to
have a tricuspid valve with a dilated annulus but normal leaflets.
Transient right ventricular dysfunction requiring epinephrine and
nitroglycerin. The patient came off of bypass and was paced. The
patient went back into atrial fibrillation. The patient was
brought up to the intensive care unit in stable condition. Ms.
Vercher was extubated on postoperative day number one. She was noted
to have bradycardia postoperatively which required pacing and she
was found to have no significant underlying rhythm. She was seen
by the electrophysiology service who had suggested we continue
following her and hope to find a recurrence of her AV node
function. She was discharged to the step-down unit on
postoperative day number two. She was found to have an intrinsic
rhythm of atrial fibrillation with a left bundle branch block with
a heart rhythm of 55-65. Ms. Vercher continued in atrial
fibrillation with a rate in the 80s and was able to come off of her
external pacemaker. The patient was started on Dextran to augment
anticoagulation which increased her INR for discharge planning.
She will be discharged to home in stable condition.
MEDICATIONS ON DISCHARGE: Coumadin as directed; Captopril 25 mg
every 8 hours , Digoxin 01.25 mg every day , Colace 100
mg three times a day: Levoxil 50 mcg once a day , Lasix 80 mg once a
day , potassium chloride 40 mg once a day.
LABORATORY DATA AT DISCHARGE: On 3/29/98 , her glucose was 112 ,
BUN 10 , creatinine 0.9 , sodium 133 ,
potassium 4.2 , chloride 99 , C02 of 25 , magnesium of 2.4 , digoxin
level was 0.6. White blood cells 10.6 , hemoglobin 11.4 , hematocrit
35.1 , platelets 319 , physical therapy 18.3 , INR of 2.3.
DISPOSITION ON DISCHARGE: Ms. Vercher will be discharged to home in
stable condition with visiting nurse.
She will follow up with her cardiologist in the next 1-2 weeks and
Dr. Golebiowski in the next six weeks.
Dictated By: PRISCILLA BARBELLA , P.A.
Attending: LOIDA F. GOLEBIOWSKI , M.D. QQ6 AI106/1223
Batch: 45238 Index No. Z5JAWW6GMA D: 3/29/98
T: 3/29/98
Document id: 276
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
Y |
U |
Y |
U |
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Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
N |
N |
N |
N |
Y |
N |
Y |
N |
N |
Y |
- |
498672224 | PUO | 19582987 | | 6350853 | 7/5/2006 12:00:00 a.m. | shoulder pain | | DIS | Admission Date: 8/7/2006 Report Status:
Discharge Date: 6/15/2006
****** FINAL DISCHARGE ORDERS ******
VILLAVERDE , NORINE B 960-90-29-3
Sade
Service: MED
DISCHARGE PATIENT ON: 7/17/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
Starting Today ( 10/18 )
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 4
LEVOXYL ( LEVOTHYROXINE SODIUM ) 125 MCG orally DAILY
LISINOPRIL 5 MG orally DAILY
NAPROXEN 500 MG orally twice a day Food/Drug Interaction Instruction
Take with food
TIMOLOL MALEATE 0.5% 1 DROP each eye twice a day
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Freddrick please call to arrange within 1-2 weeks ,
ALLERGY: TETANUS
ADMIT DIAGNOSIS:
shoulder pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
shoulder pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cellulitis of right leg x 3 mitral valve prolapse hypertension glaucoma
history of parotid tumor removal pvd history of thyroidectomy 2/2 multinodular goiter
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: L shoulder pain
*******
HPI: 64yo F with PMH of HTN and multinodular goiter who p/with couple of
weeks of L shoulder pain worse with movement and improved with rest not
assoc with trauma but suggestive of muscle etiology. In ED had ECG with
TWI and decision made to admit for a r/o. 2 major cardiac risk
factors ( age/HTN ). Walks regularly and denies any exertional
symptoms , N/V or palpitations. Occasional dyspnea on mod exertion
but unchanged recently. Also with some sore throat assoc with mild
rinorrhea -> allergic vs viral URI.
********
PMH: HTN , multinodular goiter , MVP , glaucoma , mild osteoarthritis of
L before meals.
********
All: none
********
DAILY STATUS 96 125/73 85 99%
RA Throat no erythema , exsudates.
JVP flat , RRR no murmurs , CTA b/l , no LE edema. Tenderness on
palpation of infrascapular region and pain on abduction of L arm. No
weakness or change in sensation. Full ROM. No erythema , edema or
tenderness of shoulder joint.
********
DAILY EVENTS: Admitted from the ED -> ASA
325
********
TESTS/PROCEDURES ECG:NSR with normal axis and intervals. Borderline RAE;
LAE; with flat/biphasic T waves in v2-v4.
CXR: unremarkable
********
HOSPITAL COURSE ** SHOULDER PAIN: most likely musculoskeletal in
etiology. NSAIDS and physical therapy. ** ECG changes: low suspicion for ACS.
R/o with enzymes/ECGs. ETT performed on Saturday for 3'30" , non-diagnostic
heart rate. Will leave to primary medical doctor to determine how to
proceed with outpatient evaluation.
** Hypothyroidism: con't thyroxine.
** Sore throat: likely 2/2 post nasal drip. Steroids intranas.
ADDITIONAL COMMENTS: none
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: LANE , DELOIS , M.D. , PH.D. ( JJ70 ) 7/17/06 @ 04:02 PM
****** END OF DISCHARGE ORDERS ******
Document id: 277
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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- |
896455168 | PUO | 50867619 | | 4449832 | 11/23/2004 12:00:00 a.m. | OSTEOMYELITIS | Signed | DIS | Admission Date: 5/22/2004 Report Status: Signed
Discharge Date: 10/10/2004
ATTENDING: JERICA TANYA YOUNGBERG MD
HISTORY OF PRESENT ILLNESS: The patient was admitted on 9/14/04
for a right plantar surface neurotrophic ulcer secondary to
diabetes mellitus. The patient has a long-standing history of
peripheral neuropathy and slight history of peripheral vascular
disease. This has been treated thus far by podiatric
debridements until the day of admission when the patient
presented low-grade fevers and chills. The patient also has a
history of diabetes mellitus , hypertension , distant past of
pancreatitis , gout , neuropathy , high cholesterol , and chronic
renal insufficiency. He has had a left fourth and fifth toe
amputation before. He has also undergone recent eye surgery of
unknown origin and had some unknown pancreatic surgery in 1968
most likely for phlegmon or some sort of pancreatic condition.
The patient was admitted on 9/14/04 with a right plantar surface
neurotrophic ulcer as well as recent history of low-grade fevers
and chills.
The patient notes that the ulcer came about after some unknown
trauma to the foot. He had been followed by podiatrist and had
outpatient MRI revealing osteo at the fifth metatarsal head and
the fourth metatarsal shaft , presented to the Totin Hospital And Clinic
emergency department after having a fever of 101.3 degrees. On
admission , the patient had a low-grade fever of 99.7 degrees ,
pulse in the 90s , respiratory rate 16 , and blood pressure 144/67.
He was saturating 95% on room air.
MEDICATIONS:
At the time of admission were as follows:
1. Lantus 100 mg every afternoon
2. Humalog 20 units every afternoon
3. Humalog sliding scale.
4. Neurontin 300 mg three times a day
5. Lisinopril 40 mg every day
6. Allopurinol 300 mg every day
7. Hydrochlorothiazide 25 mg every day
8. Zocor 20 mg every day
9. TriCor 50 mg twice a day
10. Atenolol 25 mg every day
11. Eyedrops prednisolone and atropine.
12. The patient was on iron supplementation.
PHYSICAL EXAMINATION: Notable findings and/or that the patient
had clear breath sounds and regular rate and rhythm. On cardiac
examination had a slight murmur 2/6 along the left sternal border
and otherwise had a obese abdomen. The extremities and back
revealed no abnormalities except for a right foot ulcer along the
fourth and fifth metatarsal distal heads. The patient also had a
somewhat cyanotic appearing and somewhat edematous and swollen
fifth right toe. The patient had decreased sensation bilaterally
in the feet up to mid shin. The patient also had a known history
of drug allergies.
LABORATORY DATA:
At the time of admission , the patient's significant labs were as
follows , his potassium was 4.3 , BUN was 38 , creatinine was 3.2 ,
and his blood glucose was 187. His white blood cell count was
12.6 and hematocrit was 27.8.
HOSPITAL COURSE:
The patient was admitted to the vascular surgery service under
Dr. Youngberg and was started on vancomycin , levofloxacin , and
Flagyl. He continued to have low-grade fevers over the course of
the next three days. Finally , on hospital day 3 , had a fever of
103.2. It was decided that at the time of admission , the patient
would need to undergo an amputation of the third and fourth toe
as well as metatarsal heads to remove the infected bone and
source of osteomyelitis. On hospital day 3 , the patient was
taken to the operating room. It should be noted at that time
that the patient's creatinine bumped before his operation from a
BUN of 39 and a creatinine of 2.1 to a BUN of 59 on hospital day
3 and a creatinine of 3.9. This occurred coincidentally the day
after the patient had several MRIs of is lower extremities to
better understand the vascular supply to his lower extremities.
Therefore , the patient had contrast dye. Although , this dye was
gadolinium , which is sued commonly for MRA and is not usually
associated with any soft of renal toxicities.
The patient was taken to the operating room on hospital day 3 for
a right fourth and fifth toe amputation and nonhealing ulcer
debridement. Please refer to the operative note by Dr.
Youngberg for further details. The patient tolerated the
procedure without any problems and the patient control was
adequate by postoperative day 1. However on postoperative lab
checkup , it was see that the patient's creatinine bumped to 4.9
with a BUN of 61. This was viewed and was monitored by serial
BUN and creatinine checks. The following , BUN and creatinine
came back at 69 for BUN and 5.2 for creatinine. On postoperative
day #1 , the patient's creatinine continued to rise and was found
to be 6.5 with a BUN of 81. At this point , the renal service was
consulted for further input as far as possible causes of acute
renal failure in the phase of chronic renal insufficiency and
postoperative period. The patient's vancomycin level came to be
in the therapeutic range of 30.8. FENa was checked which
revealed 0.74% FENa. This was rechecked and revealed a FENa of
0.97% both , which indicated prerenal failure. Renal team also
advised checking for other causes of the patient's anemia as well
as other causes of the renal failure. Labs have been sent and
some are currently pending regarding the C3-C4 and anti-GMB
antibodies.
The patient's creatinine continued to rise despite advanced
management including with intravenous resuscitation , fluid volume boluses ,
and occasional boluses of Lasix. Eventually , the patient's BUN
and creatinine rose to 94 and 8.3 by postoperative day 2. By the
following day , however postoperative day 3 , the patient's
creatinine and BUN began resolving that BUN of 95 and a
creatinine 7.8. However , at the same time , the patient began
having hypoglycemic episodes in response to the Lantus dose that
he was getting at home and continue to get here in hospital. It
was summarized by the renal team as well as by the surgical
service and that the patient may have not been taking his
medication at home and now was being his medications , while here
in the hospital. By postoperative day 4 , the patient continued
to have dysregulation of his fingerstick blood glucoses ranging
from a high of 367 to a low of 52 where she began to be
symptomatic , somewhat somnolent , and groggy.
This patient's blood glucose control was evaluated by the
diabetes management service and it was summarized by them that
the patient's renal insufficiency had a significant role in the
patient's hypoglycemic episodes and that he ended up having
insulin toxicity due to poor creatinine clearance and renal
functioning level. It should be noted that in light of this
patient's postoperative complications of acute renal failure in
the phase of chronic renal failure and chronic renal
insufficiency , the patient never required a hemodialysis because
the potassium levels remained stable. The high that the patient
reached was 5.6 of potassium on the same day that he had a
creatine of 8.3 , which was on postoperative day #2 , This was
treated with kayexalate and along the same lines , the patient's
medications were evaluated and it was decided to decrease it to
twice a day dosing and to start holding lisinopril , Neurontin , and
vancomycin for their possible renal toxic effects. A renal
ultrasound was obtained on postoperative day #1 as well as
Doppler flow studies. The renal ultrasound revealed normal
parenchyma with somewhat decreased renal indices indicating some
decreased amount of blood flow to their kidneys. At the same
time , an MRA of the renal arteries was obtained which revealed no
stenosis lesions of the kidneys.
The patient was eventually started on PhosLo and Ferrlecit as
well as Epogen 10 , 000 units every week at the recommendation of the
renal service. This was continued during the duration of the
patient's stay and should continue in the postoperative
hospitalization. In light of this postoperative complications ,
the creatinine became stable by postoperative day 3 and blood
pressure medications were restarted at previous doses and were
titrated to the need that the patient demonstrated by his blood
pressure control. This was eventually attained on atenolol at
150 mg every day However , renal service recommended that the patient
be given Lopressor 100 mg twice a day This seems to have controlled
the patient's blood pressure for the time being. Physical
therapy was also involved in evaluating the patient and assisted
in the management of this patient's care.
It should also be noted that a wax sponge was placed on the
patient's right open wound. This was placed on postoperative day
#3 , 4/18/04 . The patient seems to be tolerating this well. The
diabetes management service , the physical therapy , and the renal
teams continued to follow the patient closely during the duration
of his stay until it was felt that the patient's postoperative
complications and issues including blood glucose control as well
as renal insufficiency were under control. From an operative
standpoint , the patient tolerated the procedure well and it was
decided to continue the patient on levofloxacin for a one week
course and the patient is to be discharged to the rehab facility ,
which is the Thoeaston Healthcare for their ability to
care for wax sponge excellently.
The patient was seen by Dr. Ditommaso in the renal staff and by the
diabetes management service by Dr. Shirlene Lorson , pager #125-41. The
physical examination at the time of discharge was unchanged from
the previous few days where the patient was seen to have adequate
Doppler signal in all his pedal pulses , DPs as well as PTs and a
faintly palpable right DP and as well as faintly palpable left
DP.
DISCHARGE MEDICATIONS:
The patient is to be discharged on the following medications ,
Tylenol 650 to 1000 mg orally every 4 hours as needed for temperature greater
than 101 , allopurinol 100 mg orally every day , enteric-coated aspirin 81
mg orally every day , Lopressor 100 mg orally twice a day , PhosLo 1334 mg orally
before every meal , please give with meals , Colace 100 mg orally twice a day , Epogen
10 , 000 units delivered subcuticularly every week starting on Monday ,
already given one dose intra hospital stay. Please give the next
dose on 7/9/04 or 07 , iron 325 mg orally three times a day , Percocet 1
to 2 tablets orally every 4 hours as needed pain , prednisolone 1% one drop in
the effected eye twice a day , Zocor 20 mg orally every bedtime , Neurontin 300
mg orally twice a day , atropine 1 mg one drop in the affected eye ,
levofloxacin 250 mg orally every morning starting on the 10/6/04
and continuing for one week , Lispro 6 units subcuticularly
before every meal , hold if the patient is not eating much or if the patient
does not have a meal sitting right in front of him at the time of
dosage and also Lispro sliding scale as per the discharge paper
work in which the patient receives two units if the blood glucose
is between 125 to 150 and onwards from there 3 units for 150 to
200 , and so forth. Please also give the patient half his sliding
scale dose at the bedtime if his blood glucose is greater than
200 and recheck his blood glucose 1 to 2 hours later , TriCor 54
mg orally every day , Lantus 25 units subcutaneous every day , and DuoNeb 3/0.5
mg nebulizer every 6 hours as needed wheezing.
The patient is to be followed up at the rehab facility at Sa Pehall . Please also note , the patient should follow up with the
renal service as per the discharge report in two to three weeks
as well as Dr. Youngberg as per the paper work in one to two
weeks. The wax sponge should be change every three days and
please follow up with Dr. Youngberg regarding the longevity of
the wax sponge.
He should follow up with Dr. Youngberg as well as the attending
in the renal service Dr. Ditommaso . The clinic number for the renal
service is 0243325.
eScription document: 5-3237165 EMSSten Tel
Dictated By: FUEST , MARTA
Attending: YOUNGBERG , JERICA TANYA
Dictation ID 1513685
D: 3/9/04
T: 3/9/04
Document id: 278
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
416969526 | PUO | 31495638 | | 618327 | 4/3/2002 12:00:00 a.m. | cad | | DIS | Admission Date: 1/21/2002 Report Status:
Discharge Date: 1/4/2002
****** DISCHARGE ORDERS ******
BRANAUGH , ARLETTE ALAN 023-97-39-6
No
Service: CAR
DISCHARGE PATIENT ON: 10/11/02 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PART , JACKSON , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
EC ASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LOPID ( GEMFIBROZIL ) 600 MG orally twice a day
INSULIN NPH HUMAN 53 UNITS subcutaneously twice a day
INSULIN REGULAR HUMAN 3 UNITS subcutaneously twice a day
ZESTRIL ( LISINOPRIL ) 40 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5 MIN X 3
as needed Chest Pain Instructions: As per chest pain protocol.
NEURONTIN ( GABAPENTIN ) 300 MG orally every bedtime
CELEXA ( CITALOPRAM ) 20 MG orally every day
GLUCOPHAGE ( METFORMIN ) 850 MG orally twice a day
GLUCOPHAGE ( METFORMIN ) 850 MG orally twice a day
Instructions: do not start until 11/18/02
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: IN 3 days DAYS
FOLLOW UP APPOINTMENT( S ):
Dr. Latoria C. Maynard Ogden 1-2 weeks ,
No Known Allergies
ADMIT DIAGNOSIS:
history of diagnostic catheterization
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cad
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of GI BLEED ( history of unspecified GI bleed ) niddm ( diabetes mellitus ) HTN
( hypertension ) high chol ( elevated cholesterol ) cad ( coronary artery
disease ) djd ( osteoarthritis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of cath
BRIEF RESUME OF HOSPITAL COURSE:
68 year-old man with history of DM and CAD ( NO MIs ) ,
multiple caths , presents with syncope x 2 , 3 days ago.
Cardiac history: -cath 4/8 for USA: R dom , nl LV fxn , nl
R pressures , mult stents in prox LCX and
OM1 -cath 10/21 for CP: 40% in-stent restenosis
OM1 , 70% LAD , 70% PDA , 80%
PVL. -cath 10/11 70% RCA stented x2 , OM1
instent restenosis cutting
blade. patient was in his USOH until 3 d PTA when he had
2 episodes of syncope. One occurred while
putting up blinds , the other while sleeping later
that night. Both episodes ended with patient on the
floor , not remembering how he got there. No warning ,
no CP , SOB , palp , nausea , diaphoresis , aura.
No post-ictal state , or loss of bowel or bladder
fxn. He does state that he had an episode of L
jaw pain earlier that day , after walking for
2 miles , relieved by 1 sublingual nitro. No DOE ,
PND , orthopnea. On the first fall he hit his L leg ,
and presented to the ED with leg pain today.
No history of prior MI. Exam: HR 60s , BP
140s/70s. Lungs CTA , JVP 7 cm , RR , +S4 , good pulses , no
LE edema , abd benign. CK496 , MB low , TnI
flat. Plan:
1. CV: Arrhythmia vs ischemia vs orthostasis. Ischemia--r/o for MI ,
continue asa , lopressor 25 three times a day , zestril 40 , isordil 10 three times a day ,
consider additional agent for BP. check lipids , not
on statin. Will monitor. check
orthostatics. Pump--euvolemic , check echo for ? structural
heart disease
Rhythm--on tele. 2. DM: continue
metformin , insulin , czi
ss.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with Dr. Raabe , your cardiac issues are under control. Return to the
ED if you have SSCP with and WITHOUT breathing ( plueritic ). Con't
celexa for discomfort.
--do not start glucophage until tomorrow ( 11/18/02 )
No dictated summary
ENTERED BY: KUHLS , GREGORY T ( ) 10/11/02 @ 11:01 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 279
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
N |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
Y |
N |
Y |
- |
N |
N |
Y |
N |
N |
N |
803287069 | PUO | 64744160 | | 6155792 | 6/1/2004 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 6/9/2004 Report Status:
Discharge Date: 10/18/2004
****** DISCHARGE ORDERS ******
KREITZER , CHELSEA 450-94-58-6
Ville
Service: MED
DISCHARGE PATIENT ON: 11/18/04 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DOCIMO , STEFFANIE T. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 3/21 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HYDROCHLOROTHIAZIDE 25 MG orally every day HOLD IF: SBP<100
LISINOPRIL 40 MG orally every day HOLD IF: SBP<100
Override Notice: Override added on 5/13/04 by
AMADON , MONA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 32012147 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Ayyad at 609-196-6115 on Tue. 8/5/04 ( Tue ) at 10:30am scheduled ,
ALLERGY: Penicillins , Compazine ( phenothiazines )
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
menorrhagia htn
obesity ( obesity ) GERD ( gastroesophageal reflux disease ) Plantar
faciatis ( plantar fasciitis ) diffuse arthralgia ( arthralgias )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT MIBI
BRIEF RESUME OF HOSPITAL COURSE:
CC:Chest pain.
HPI: 47 yoF with HTN , obesity , p/with L chest pain. patient was admitted in 6/22
for chest pain and had neg ETT MIBI. patient in USOH until 1 mo PTA , patient
came to PUO to pick up meds , and dev L chest pain under L breast , asso
with N/diaphoresis/weakness/SOB/LH , which eventually went away with
resting. On DOA , at 8am , patient dev similar sx , L chest pressure under
L breast while driving , asso with N/Diaphoresis/LH/ weakness/SOB/stomach
discomfort. L CP radiated to back , 7/10 , lasting for 3 heart rate until arrived
in ED. There was no palp/cough/change in vision/ pain is not
positional , non-pleuritic. patient took home BP meds and went to her primary care physician
was found to have BP 130/94 , new RBBB , and new TWI in lat leads. rx'd
ASA 325mgx1. primary care physician sent her to ED , P50 , BP109/77 98%RA , rx'd ASA325mgx1 ,
MSO4 4mgIVx1 , heparin 6000U+heparin drops 1200U/heart rate patient became pain
free after MSO4. ROS neg for PND/SOB/DOE/Orthopnea/V/ abd pain , etc.
+constipation 2 BM/month. On admission , AF , VSS. P40s
PE notable for reproducible CP L chest ( ribs ) under breast. JVP flat ,
Brady , S1 , S2 , no m/r/g. Labs notable for Hct 35.3( bsl ). 1st set of
enzymes neg. EKG:SB at 48bpm , new RBBB , and new TWI
V1-V5 , new TW flatterning in V6 , changed from 10/11/02 . CXR:neg.
********Hosp Course***************
1.CV-I-Ruled out MI by enzymes and EKGs. Patient was briefly on
heparin without any compliation. ETT MIBI 8/27/04 showed no
reversible perfusion defect. EF 51% ( WNL ) , walked 9' on
standard bruce protocol. Lipid panel: CHL 178 , TRI 207 HDL 25 CLDL 1
12 VLDL 41. Patient was started on zocor. cont ASA/BB/sublingual NTG as needed CP.
P-No evidence of CHF , cont HCTZ/ACEI for BP control. Hold off
BB/verapamil given brady.BP remained stable in hospital
R-SB-Tele-hold off BB/verapamil given brady. BP remained stable. HR
in low 60s upon discharge. TSH Pending.
2.GI- Pain may be GI related given history of GERD. inc PPI+bowel regimen
3. Pain- Avoid NSAIDS and will use tylenol as needed pain. 4.FEN-heplock ,
Replete lytes. low fat/low chol diet. 5.FC
ADDITIONAL COMMENTS: 1.please measure your blood pressure daily. If your systolic blood
pressure is greater than 160 or diastolic pressure greater than 100 ,
please call your primary care physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: AMADON , MONA , M.D. ( FR65 ) 11/18/04 @ 05:12 PM
****** END OF DISCHARGE ORDERS ******
Document id: 280
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
141445265 | PUO | 18125885 | | 9741086 | 4/19/2003 12:00:00 a.m. | atypical noncardiac chest pain | | DIS | Admission Date: 4/19/2003 Report Status:
Discharge Date: 8/12/2003
****** DISCHARGE ORDERS ******
LAZARINI , ALEJANDRINA 579-93-49-2
Ca
Service: CAR
DISCHARGE PATIENT ON: 8/25/03 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRUNTZ , KATHERYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally twice a day
Starting Today ( 2/12 )
Instructions: increased dose for costochondritis , patient does
not wish to take 650 four times a day dosing
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ENALAPRIL MALEATE 5 MG orally every day
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
INSULIN 70/30 ( HUMAN ) 80 UNITS every day before noon; 60 UNITS every afternoon subcutaneously
80 UNITS every day before noon 60 UNITS every afternoon
Number of Doses Required ( approximate ): 6
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
PSYLLIUM 2 TSP orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 25 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LASIX ( FUROSEMIDE ) 20 MG orally every day
FAMOTIDINE 20 MG orally twice a day
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Lemmings 1-2 weeks ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
chest pain , cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical noncardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) CAD ( coronary artery disease ) history of cabg ( history of
cardiac bypass graft surgery ) IDDM
( ) hypercholesterolemia ( elevated cholesterol ) peripheral neuropathy ( )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
adenosine MIBI
BRIEF RESUME OF HOSPITAL COURSE:
62M with history of CAD and prior MI leading to CABG in 3/16 . Frequent
chest pain since on exertion and in times of stress. Admitted to PUO
8/24 with CP and ruled out for MI. Cath showed non-occlusive disease
( 70% ) an OM which was stented. Well since with frequent CP with very
minimal exertion. Today walking outside after dinner had another
episode of his usual chest pain , +SOB , 5/10 , no radiation/LH/
palpitations , c/o nausea and vomiting; called EMS -> PUO EW , given 2
NTG with resolution of symptoms. Concerning for increasing frequency
of CP.
OUTPT MEDS: plavix 75/lasix 20/enalapril 5/pepcid 20/toprol xl 25/ASA
325/insulin 70/30/ 80units am , 60 units pm/zocor
Hospital course:
1. Card - ruled out for MI , repeated Adenosine MIBI which confirmed no
ischemia. continue outpt regimen of enalapril/lasix/toprol/zocor.
2. GI: patient with rapid new rise in transaminases ddx: most likely due
to relative hypotension early in admission per GI c/s , vs. NASH ( fatt
y infiltrate on RUQ US , no evidence of stones ). also on ddx are ETOH ,
viral hepatitis , hepatic congestion , hemochromatosis - labs not c/with
those.
Finally , patient experienced droplets of bright red blood when straining
for BM. Have advised patient to follow up with Dr. Lemmings regarding this
to determine the need for a GI work up. Have left message with MMC
answering service to advise the nurse practitioner and primary care phy
sician of these issues
FULL CODE
ADDITIONAL COMMENTS: 1. See Dr. Lemmings to follow up on your liver function tests that
were elevated when you were admitted.
2. See Dr. Lemmings to evaluate the bleeding you experience with bowel
movements.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Call to make an appointment with your primary care doctor within a
week of your discharge
No dictated summary
ENTERED BY: CLARDY , CHRISTY ALVINA , M.D. ( BL29 ) 8/25/03 @ 01:36 PM
****** END OF DISCHARGE ORDERS ******
Document id: 281
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
332967911 | PUO | 25905798 | | 5253790 | 7/10/2005 12:00:00 a.m. | bladder stone | | DIS | Admission Date: 2/12/2005 Report Status:
Discharge Date: 8/17/2005
****** DISCHARGE ORDERS ******
PIRRONE , VONDA 576-92-11-6
Kan
Service: MED
DISCHARGE PATIENT ON: 10/4/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCMEEN , BUDDY , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
PROSCAR ( FINASTERIDE ) 5 MG orally every day
Number of Doses Required ( approximate ): 10
NORVASC ( AMLODIPINE ) 5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
GLIPIZIDE 5 MG orally every day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Haley Tonsil ( PUO urology ) 163-566-5922 on Friday , January , 2005 2/7/05 scheduled ,
Dr. Buddy Mcmeen ( PUO primary care - KTDUOO ) 647-166-4998 on Wednedsay , August at 3:15 pm ( please arrive 2:45 pm for registration ) 3/1/05 scheduled ,
Dr. Clorinda Bernhart ( PUO primary care - KTDUOO ) 647-166-4998 Tuesday , August at 1:30 pm 2/30/05 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hematuria
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bladder stone
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
?CAD; reflux; ARF; BPH history of turb; bladder stone history of lithotripsy; DM
OPERATIONS AND PROCEDURES:
1/10/05 TONSIL , HALEY , M.D.
CYSTOSCOPY OF BLADDER , CLOT EVACUATION , BLADDER BIOPSIES EHL BLADDER
STONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
CC: hematuria
HPI: patient is an 87 year-old man with PMHx BPH history of TURP 2000. Four weeks prior
to admission , patient developed URI with subjective fever , headache , and
cough. Three weeks prior to admission , patient noted gross hematuria
shortly after shoveling snow. Hematuria has persisted without relation to
exercise. patient denies antecedent trauma , new medications , urinary
hesitancy or dribbling , urinary incontinence , dysuria , flank pain ,
f/c , night sweats , He has family history of kidney disease or CA. He
reports decreased orally intake and weight loss. ROS is
negative for neuro sx , chest pain , SOB , orthopnea , PND , LE swelling ,
n/v/d. ROS is + for BRBPR. PMHx: reflux history of surgery; BPH history of TURP
( PUO , 2000 )
MEDS: none
ALL: none
SH: former cigarette smoking , no EtOH; patient lives
alone in Ton Ancoll Li he was born + raised in Arb and flew planes
in WWII; after coming to US in 1950's , he worked as radiology tech @
Owagold Ave.
ED COURSE: afebrile , VSS; exam notable for firm ,
distended bladder , large but smooth prostate , and brown guiaic +
stool. Labs notable for bicarb 19 , AG 15 , BUN/Cr 112/5.3 ( baseline
1.2 ) , glucose 438 , u/a with 3+ glucose , 3+ ketones , 3+ protein , 3+
blood , 3+ leuk est , +nitrites , ++RBCs , WBCs. EKG with new , lateral TWI.
I-CT notable for calcified bladder mass + intravessicular hemorrhage.
There was bilateral perinephric stranding , hydroureter , no hydronephrosis ,
homogeneously enlarged prostate , sigmoid diverticulosis , no LAD , and no
lytic lesions. Failed attempts @ placement of 16 fr , 20 fr. Coudet cath
placed with with d of 400+cc hemolyzed blood , flushed with 1.5L D5W. Rx'ed
with 2L NS , 6 units subcutaneously insulin. Also with levo ( in light of
manipulation ). Seen by urology team which recommended cystoscopy.
ADMISSION EXAM: T 97.1 P 90 BP 160/86 RR 26 SAT 98% RA; thin ,
cachectic man; MM dry; JVP flat; crackles R base; heave , S1S2 reg ,
3/6 systolic murmur throughout precordium radiating to carotids , no
rub; abd soft , NT , ND , +BS; ext wwp with thready DP's;
neuro nonfocal
ADMISSION LABS: WBC 12.2 , Hct 41.1 --> 35.1 on repeat , Plt 258 , INR 1.0 ,
Na 138 , K 4.7 , Cl 104 , HCO3 19 , BUN 112 , Cr 5.3 , Glu 429 , AG 15 , Ca 8.0 ,
UA as above
ADMISSION EKG: NSR , 86 bmp , Qtc 440 , no atrial
enlargement , no ventricular hypertrophy , TWI II , III , avF ( new ) , 1 mm
STD II , avF , biphasic T V4 ( new ) , TW flat I , TWI V5-V6 ( new )
ADMISSION CXR: nl cadiac silhouette , clear lungs
HOSPITAL COURSE:
86 year-old man with acute renal failure , gross hematuria , bladder mass.
RENAL:
*ARF* Original ddx included prerenal ( decreased orally intake , glucosuria )
vs. renal ( URI --> glomerulonephritis ) vs. postrenal ( mass , clots -->
B obstruction ... but no hydronephrosis ). Cr came down from 5.3 to near
nl with hydration suggesting prerenal etiology. Urine examined under
microscope was without red blood cell casts. On presentation , patient had no
acute indication for dialysis. He was not uremic , had no rub , had good
urine output , had mild acedemia , and had normal K. As noted , his Cr came
down to near normal with hydration.
*bladder mass* A bladder mass surrounded by blood clots was identified on
the patient's admission CT. Due to conern for bladder cancer , urine
cytology was sent. Results are pending. On 8/19 , the urology team
performed a cystoscopy which revealed a large bladder stone surrounded by
hemorrhage. The clot was evacuated and the stone was broken up by
electrohydraulic lithotripsy. Biopsy samples were
taken from the inflamed bladder wall. Pathology results are pending. A
3-way foley catheter was placed and continuous bladder irrigation was
initiated. The patient received peri-procedure antibiosis with ancef and
gent. The large size of the bladder stone suggests urinary retension ,
perhaps due to persistent BPH ( despite 2000 TURP ). The patient was started
on flomax and proscar , as recommended by the urology team. The patient was
discharged with a foley catheter in place. He will return to PUO urology
clinics on 10/22 for a voiding trial.
CV:
pump
*HTN* In house , patient was treated with norvasc and lopressor. He was
discharged on norvasc and toprol XL. Ace inhibition was not initiated due
to the patient's renal insufficiency.
*murmur* On exam , patient had a systolic ejection murmur heard best at the
R and L upper sternal border and radiating to the carotids. An ECHO
revealed a preserved ejection fraction of 65% , no RWMA , nl
diastolic function , normal RV size and function , nl LA and RA size ,
and mild AS with a valve area of 1.4. The patient is not
symptomatic from his AS , by history. He denies syncope , chest pain ,
orthopnea , PND , or LE edema.
rhythm: NSR
ischemia:
*CAD*
patient reported no chest pain. His admission EKG showed new inferior/lateral
ST-T changes. Cardiac markers revealed CK 330 , CKMB 7.5 , and Tn I<assay.
His EKG changes could represent old infarct ( although ECHO showed no
RWMA ) or could represent demand ischemia in the setting of
hypertension and anemia. patient was treated with a bblocker , as above. patient was
not treated with ASA given his hematuria , but such
therapy may be started on an outpatient basis. patient was not treated with an
acei due to his creatinine , but such therapy , too , may be started on an
outpatient basis. patient may also benefit from outpt. stress testing. Lipids
profile showed cholesterol 156 , triglycerides 119 , HDL 39 , LDL 93.
GI: *reflux* patient was treated with nexium and mylanta as needed.
He was maintained on a cardiac , diabetic diet.
ENDO: *new DM , most likely type II* On admission patient had a small anion
gap , mild elevation of +B-hydroxybutyrate , and +ketones in his urine.
With hydration , his gap closed. The ketoacidosis was likely from
starvation. patient's HGa1c was 10. ( He had not seen a physician in years ). He
will be d/c'ed on glipizide 5. ( Metoformin was not started out of concern
for rising creatinine. He may benefit from the addition of a second orally
agent as an oupatient ). patient will be given a glucometer and asked to check
his blood sugar mornings.
HEME: *anemia* patient had a normocytic anemia , likely related to hematuria ,
gu+ stool. Iron studies revealed a Fe 49 , TIBC 294 , Ferr 73. He
was started on a multivitamin with iron. He would benefit from outpatient
colonoscopy. Prior to discharge , hematocrit was stable in the mid 30s.
ID: patient was afebrile. Admission u/a was suggestive of UTI. Ucx , however ,
was negative. CXR was clear. patient received abx peri-cystoscopy.
PROPH: pneumoboots ( patient was not treated with lovenox given his
hematuria )
CODE: full
ADDITIONAL COMMENTS: patient will require VNA for nursing and home physical therapy.
DISCHARGE CONDITION: Fair
TO DO/PLAN:
1 ) Please take your medications as directed. If you have questions about
your medications , please call Dr. Buddy Mcmeen 082-115-4944. 2 ) Please
follow-up with Dr. Haley Tonsil in the PUO urology clinic on Friday ,
10/2/05 . His office assistant will call you with a time. Dr. Tonsil will
determine when it is safe to remove the foley catheter. 3 ) Please call
Dr. Fadeley or present to the emergency department if you experience
fever , dizziness , chest pain , shortness of breath , bleeding in urine , or
any other symptom concerning to you.
No dictated summary
ENTERED BY: TROOP , WILFREDO V. , M.D. ( HK24 ) 10/4/05 @ 11:56 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 282
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
821573033 | PUO | 20161161 | | 3787262 | 4/30/2006 12:00:00 a.m. | Back pain | | DIS | Admission Date: 12/10/2006 Report Status:
Discharge Date: 9/9/2006
****** FINAL DISCHARGE ORDERS ******
LAFLORE , VITA 656-31-96-3
Orl
Service: MED
DISCHARGE PATIENT ON: 7/17/06 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE G. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
TIAZAC ( DILTIAZEM EXTENDED RELEASE ) 360 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 8/9/06 by
THEPBANTHAO , DARCI H. , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: aware
BENADRYL ( DIPHENHYDRAMINE ) 25 MG orally every 6 hours
as needed Itching
DISOPYRAMIDE-CONTROLLED RELEASE 300 MG orally twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
TENEX ( GUANFACINE ) 2 MG orally DAILY
HYDROXYZINE HCL 25 MG orally four times a day
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
NOVOLOG ( INSULIN ASPART ) 9 UNITS subcutaneously before meals
INSULIN NPH HUMAN 50 UNITS subcutaneously twice a day
LACTULOSE 30 MILLILITERS orally twice a day as needed Constipation
LEVOXYL ( LEVOTHYROXINE SODIUM ) 200 MCG orally DAILY
LISINOPRIL 20 MG orally DAILY
Alert overridden: Override added on 10/17/06 by
THEPBANTHAO , DARCI H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
200 MG orally every day before noon Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 8/9/06 by
THEPBANTHAO , DARCI H. , M.D.
on order for TIAZAC orally ( ref # 948678026 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: aware
Number of Doses Required ( approximate ): 4
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 10 MG orally every 12 hours
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
TOPAMAX ( TOPIRAMATE ) 125 MG orally three times a day
Number of Doses Required ( approximate ): 4
ZOMETA ( ZOLEDRONIC ACID ) 2 MG intravenous Monthly
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Malachi , SSR 4/12 @ 3pm scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Back pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Back pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN history of PAF converted with nad history of TAH/BSO history of colectomy/stoma/rversal
DM
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI
BRIEF RESUME OF HOSPITAL COURSE:
CC: Back pain
HPI: 61 year-old F with IgA lambda multiple myeloma , chronic R lumbar pain
who presents with several days of worsening pain. Distribution same ,
intensity worse; constant. On DOA unable to ambulate/bear weight ,
limiting ability to care for herself. No trauma , no neuro deficits , no
incontinence.
In ED: given MSO4 , valium , benadryl
ROS: reports every day temp to 101 at home , with sweats , no chills. No
localizing sx. No wt loss , no appetite. B/l forearm pruritic rash , worse
than baseline annual sun-exposure rash.
****
PMH: MM with IgA lambda , sz d/o , htn , DM , chronic back pain
****
ALL: NKDA
MEDS: ASA , lisinopril , norpace , dilt , toprol , tenex , aranesp , topamax ,
levoxyl , nexium , NPH 50 twice a day , ISS , zometa qmo
****
PE: 96.4 89 146/73 18 99% RA. A+O x3 , NAD , obese , RRR , CTAB , abd
soft with baseline RLQ ttp , mult scars , NABS , guaiac neg with nl tone ,
no neuro deficits with 4/5 plantar flexor and hip flexor on R , toes
equiv , DTRs 1+ b/l. No bony tenderness , mild ttp over R lat
paraspinal musculature. Neg straight leg raise.
****
LABS: K 3.5 , Cr 0.9 , UA neg , Bld Cx neg
STUDIES:
pelvis and L spine: mild L5-S1 disc space narrowing , no compression
fx , no lytic or blastic lesions
MRI: prelim read , L4-5 disc bulging with local nerve root compression ,
bone marrow heterogeneity as previously on MRI 8/3
****
A: 61 year-old F with MM , chronic R lumbar pain here with worsening pain
limiting ADLs
COURSE:
1. NEURO: Started low dose oxycontin twice a day with oxycodone for breakthrough
pain. No lesions to suggest lesion 2/2 MM. F/u final MRI read , but needs
trial of medical management , outpatient physical therapy , followed by Pain and/or
Neurosurgical evaluation if still symptomatic.
2. HEME/ONC: IgA pending , f/u at SSR as scheduled for Zometa 4/12
3. CV: Continued extensive list of home antihypertensive medications
4. ENDO: Continued home insulin regimen , A1c pending. TSH low at 0.174 ,
may need adjusted Levoxyl dosing.
5. ID: no clear source for fevers aside from MM , no source identified on
MRI , UA/Cx or Bld Cx. Afebrile here , unclear if this could be neoplastic
versus thermometer error versus operator error.
6. DERM: Pruritic papular rash over b/l upper arms , somewhat like her
baseline annual sun-associated allergy. Started atarax , benedryl as needed
ADDITIONAL COMMENTS: Seek medical attention if you notice weakness in your legs , or problems
with bowel or bladder incontinence.
Your pain medications can cause constipation , use the provided
medications as indicated to avoid this side effect.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. F/U with Dr. Malachi as scheduled , IgA is pending.
2. Consider Pain or Neurosurgery evaluation if pain not control with orally
pain medications
3. F/U A1c , pending
4. Consider change in Levoxyl dose given low TSH
No dictated summary
ENTERED BY: HENDY , CLARETHA , M.D. , PH.D. ( TD18 ) 7/17/06 @ 09:40 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 283
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
Y |
N |
Y |
N |
Y |
- |
N |
N |
N |
N |
N |
- |
012699841 | PUO | 68188036 | | 2455294 | 9/7/2007 12:00:00 a.m. | labile hypertension | | DIS | Admission Date: 10/5/2007 Report Status:
Discharge Date: 1/7/2007
****** FINAL DISCHARGE ORDERS ******
BALLES , KATI 048-76-12-9
Lare
Service: MED
DISCHARGE PATIENT ON: 10/28/07 AT 03:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. UNABLE TO OBTAIN MEDICATION HISTORY
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 325 MG orally DAILY
NORVASC ( AMLODIPINE ) 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ATENOLOL 50 MG orally DAILY
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY inhaled DAILY
FUROSEMIDE 40 MG orally DAILY
GLYBURIDE 10 MG orally twice a day
LANSOPRAZOLE 30 MG orally DAILY
LISINOPRIL 40 MG orally DAILY
LORATADINE 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
METFORMIN 850 MG orally three times a day
AVANDIA ( ROSIGLITAZONE ) 8 MG orally DAILY
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Kintopp please call his office ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
dizziness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
labile hypertension
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension , GERD , atypical chest pain
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC/CX: lightheadedness
*****
HPI: 58F with hx of aytpical CP with neg cath in 2004 and neg stress mibi
in 2007 , htn , hyperlipidemia , DM2 p/with 1 weeks of LH and feeling
faint. Checked BP at home , was 215/100->ED last night , repeat BP
SBP down to 160 , LH improved. Went home , saw primary care physician today , where BP was
140/80 , patient c/o cp , ecg showed non-specific st changes , referred to ED
for further with u.
Sx started with transient right ear pain , radiating to head , followed
by LH. Later developed left sided tooth pain , and SSCP. No assoc
sx. No sob , le edema , orthopnea ,
pnd. In ED afeb , HR 50 , BP 180/88->120/60 , CXR with
globular appearance of heart , o/with no change , admitted.
*****
PMH: DM2 ( last a1c 7.8 ) , HTN , hyperlipidemia , gerd , asthma , carpal
tunnel syndrome , chronic LE edema , R>L
*****
MEDS AT HOME: asa , atenolol 50 , norvasc 10 , lasix 80 , lisinopril 40 ,
metformin , avandia , glyburide , albuterol as needed , lansoprazole , flonase ,
loratadine
*****
NKDA
*****
SH no etoh , no tob
*****
EXAM ON ADMIT: afeb , 56 , blood pressure supine 140/70 not orthostatic , 100% RA ,
NAD , fluent , oro-p clear , mmm , jvp 7 , carotids nl , lungs ctab , rrr ,
2/6 murmur at LUSB without radiation , occ S4 , abd benign ,
1+ edema on R to knee , L without edema , good distal pulses , neuro exam
nonfocal
*****
LABS ON ADMIT: hct 33.6 ( at baseline ) , tni<0.04
*****
ECG: NSR LVH , nonspec st-t wave changes , unchanged from
prior.
*****
Imp: 58F with htn , hx atypical cp , admitted with LH x 5 days and brief
cp , without acute ecg change , LH now resolved.
***********************Hosp Course***********************************
1 ) Lightheadedness: unclear etiology but most likely 2/2 elevated BP
>200s as sxs resolved with BP lowering. She was not orthostatic , hct at
baseline , cardiac enzymes negative , and prior MRI/MRA in 2004 without
acute process. Her BP remained well controlled back on her home regimen
( ? compliance but she states she was taking her meds ). Will have outpt
MRI/MRA done , though low suspicion for disease and unclear if would
intervene if disease present. Given HTN spells , concern for a cause of
secondary hypertension. Labs sent for plasma catecholamines , aldoseterone
and plasma rening ( pending as of discharge )
2 )DM: -Aspart SS while in house but continued her home DM meds on day of
discharge.
3 )Disp: d/c to home and she will f/u with Dr Kintopp in clinic.
ADDITIONAL COMMENTS: Please be sure to take all of your blood pressure medications every day
as prescribed. We think your symptoms were caused by very high blood
pressures.
Please be sure to follow up with Dr Kintopp .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please follow up with plasma catecholamines , plasma renin and
aldosterone ( taken when patient supine , in am ).
2. Consider HCTZ if an additional agent is needed for BP control
No dictated summary
ENTERED BY: BONTON , DANIELL L. , M.D. ( PC41 ) 10/28/07 @ 04:28 PM
****** END OF DISCHARGE ORDERS ******
Document id: 284
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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939666784 | PUO | 03873551 | | 0425429 | 9/6/2006 12:00:00 a.m. | DIVERTING ILEOSTOMY | Unsigned | DIS | Admission Date: 9/6/2006 Report Status: Unsigned
Discharge Date: 2/27/2006
ATTENDING: WEINGARTNER , ROBBYN M.D.
PROCEDURES:
1. Revision low anterior resection of end anastomosis.
2. Revision of ileostomy.
3. Left ureteral stent placement on 7/11/06 .
HISTORY OF PRESENT ILLNESS: Mr. Braun is a 53-year-old , HIV
positive male with history of diverticulitis complicated by
colovesical fistula who underwent laparoscopic-assisted LAR with
takedown of fistula on 2/10/06 . He developed an anastomotic
stricture and subsequently underwent dilation several times
without benefit. He presented for revision of his LAR
anastomosis and revision of his ileostomy due to prolapse.
OR COURSE: The patient had a redo LAR with very difficult
dissection and intraoperative placement of left ureteral stent
and redo ileostomy. Please see operative dictation report for
details.
PAST MEDICAL HISTORY:
1. HIV.
2. Diabetes mellitus.
3. Coronary artery disease status post MI , status post stent in
1999 and 2000.
4. GERD.
5. Diverticulitis.
6. Psoriasis.
7. IBS.
8. Hypertension.
9. Hyperlipidemia.
PAST SURGICAL HISTORY:
1. A laparoscopic-assisted LAR and takedown of colovesical
fistula on 2/10/06
2. Exam under anesthesia and ablation of AIN on 8/4/2006 .
3. Excision of hemorrhoid on 7/1/2005 .
MEDICATIONS:
1. Aspirin 325 mg daily.
2. Avandia 2 mg daily.
3. Vitamin D.
4. Vicodin as needed
5. Lipitor 40 mg daily.
6. Lexiva 700 mg daily.
7. Norvir 100 mg daily.
8. Atenolol 12.5 mg daily.
9. Acyclovir 400 mg daily.
10. Truvada 200/300 mg every other day.
11. Glyburide 1.25 mg daily.
HOSPITAL COURSE: The patient was taken to the operating room as
described above. He was stabilized in the PACU and transferred
to the regular floor for a routine postoperative care. He was
given an epidural for pain control as well as intravenous Lopressor for
perioperative beta blockade while the patient was npo He was
given supplemental oxygen and was weaned as tolerated. The
patient was placed on the colectomy pathway postoperatively and
his NG tube was removed in the morning on postoperative day #1.
He was advanced to sips with no nausea or vomiting. He had a
Blake drain in his pelvis and that was left initially postop
until the output decreased. His Foley and left ureteral stent
were in place for two days and then his JP drain was sent for
creatinine analysis to look for a ureteral leak. This was found
to be negative for leak and his JP drain was subsequently
removed. The patient was given subcutaneous heparin for DVT
prophylaxis and he was given Ancef and Flagyl x2 two doses
perioperatively as well as his home HIV meds.
The patient initially had an uneventful postoperative course and
was tolerating a house diet and had adequate ostomy output with
no nausea or vomiting by postop day #3. However , by
postoperative #5 , the patient's abdomen was more distended and he
had increasing nausea with any type of food by mouth. A KUB was
obtained at that time which was consistent with ileus. The
patient was switched back to clear liquids until his ostomy began
to function once again. He was given intravenous fluids for continued
hydration at that time. By postoperative day #7 , the patient's
ileus had resolved and he was passing gas and stool into his bag.
However , the output from his bag was greater than 1200 mL per
day. The Metamucil was added as well as Imodium to decrease the
output of his ostomy. By postop day #7 , in addition to his high
ostomy output , the patient had sinus tachycardia approximately
110 beats per minute. His Lopressor was increased to 20 mg every 4 hours
for increased blood pressure control , and heart rate control. By
postoperative day #8 , his heart rate was 80s to 90s and blood
pressure was 120s/70s. His ostomy continued to put out greater
than 3 to 4 L over the course of next few days. During this
time , the patient was tolerating a regular diet with no nausea or
vomiting , but his stools were increasingly liquid and high
output. His fluid loss was supplemented with LR in a 1:1 fashion
to of avoid dehydration. By postoperative day #11 , the patient's
ostomy continued approximately 4 L and a tincture of opium was
begun as a the third line agent to decrease the ostomy output.
This decreased ostomy output to approximately 1 L and the patient
symptomatically was improving and feeling good. He was
tolerating a regular diet with no nausea and no vomiting. His
pain was well controlled on orally pain meds , and the patient
stated that he would be able to keep himself well hydrated on
discharge.
DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg orally daily.
2. Truvada one tablet orally every other day.
3. Nexium 20 mg daily.
4. Lexiva 700 mg orally daily.
5. Imodium 2 mg orally every 6 hours
6. Oxycodone 5-10 mg orally every 3 hours as needed pain.
7. Metamucil two packets orally twice a day
8. Norvir 100 mg orally daily.
DISCHARGE CONDITION: Good.
DISPOSITION: Discharged home with services.
Discharge.
INSTRUCTIONS: The patient was instructed to keep himself well
hydrated by continuing to drink water and beverages such as
electrolyte- containing sports drinks for continued hydration.
He is instructed to match his ostomy output in a 1:1 fashion with
liquids as described. He is instructed not to drive or operate
heavy machinery while taking narcotics. He is instructed to seek
immediate medical attention for fever greater than 101 degrees
Fahrenheit , increasing abdominal pain , or concerns regarding his
surgical site.
FOLLOWUP: The patient was instructed to follow up with Dr.
Weingartner in Surgery Clinic in approximately one to two weeks.
eScription document: 2-2210065 MFFocus
Dictated By: HALECHKO , STACIE
Attending: WEINGARTNER , ROBBYN
Dictation ID 6913924
D: 1/8/06
T: 10/8/06
Document id: 285
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
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- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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921778812 | PUO | 49448215 | | 6724029 | 1/10/2003 12:00:00 a.m. | Congestive Heart Failure | | DIS | Admission Date: 2/21/2003 Report Status:
Discharge Date: 4/26/2003
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
Villquat St. , Wood Scondfre
Service: MED
DISCHARGE PATIENT ON: 6/10/03 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
Alert overridden: Override added on 11/5/03 by
KNECHT , MARTINE , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: on as outpt
LAC-HYDRIN 12% ( AMMONIUM LACTATE 12% ) TOPICAL TP twice a day
Instructions: apply to LE
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
GLIPIZIDE 5 MG orally twice a day
Alert overridden: Override added on 11/5/03 by
KNECHT , MARTINE , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: on gluburide as outpt
Previous Alert overridden
Override added on 11/5/03 by KNECHT , MARTINE , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: on as outpt
PLAQUENIL ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
LISINOPRIL 20 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
SARNA TOPICAL TP every day
COUMADIN ( WARFARIN SODIUM ) 5 MG mwfsun; 2.5 MG ttsat orally
5 MG mwfsun 2.5 MG ttsat Instructions: every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 11/5/03 by
KNECHT , MARTINE , M.D.
on order for AMIODARONE orally ( ref # 60471369 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: on as outpt
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LASIX ( FUROSEMIDE ) 160 MG orally every day
Alert overridden: Override added on 6/10/03 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: taking without problems
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Call 041-877-2543 for appt with Dr. Aspacio or Dr. Goud ,
Arrange INR to be drawn on 9/29/03 with f/u INR's to be drawn every
7 days. INR's will be followed by KTDUOO coumadin clinic
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
Congestive Heart Failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive Heart Failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CHF history of St. Jude MVR for MS ( history of cardiac valve replacement )
AFib/flutter ( history of atrial fibrillation )
history of IMI ( history of myocardial infarction ) NIDDM ( diabetes mellitus ) gout
Hx DVT '70 ( history of deep venous thrombosis ) history of appy ( history of appendectomy )
history of umbilical hernia repair ( history of hernia repair ) history of
sigmoidectomy for diverticulitis history of L hip # '95 ( history of hip fracture )
PE ( pulmonary embolism )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
80 year-old lady with history of IMI , MVR , Afib and CHF.
She presents with 2 weeks of DOE and increasing abdominal
girth. Increased lasix at home with no effect. Seen in KTDUOO one week
ago for LE swelling - LENIS negative and given orally levo.
Presents in KTDUOO today with persistent LE swelling and tightness in
the chest on waking up in the night last night. Associated with SOB ,
nausea. No diaphoresis or vomiting. Pain relieved in the
ED with with SLNGT ( did not take her own at
home ). CXR - with no infiltrate. RR 14 RA sat 93% and
97% on 2l.
HOSPITAL COURSE
1. CVS - ruled out for mi by enzymes and EKGs. Cont lisinopril ,
isordil and norvasc. BNP level 135. Diuresed well to intravenous lasix ,
converted back to orally for discharge. Rhythm - in Afib , may have
contributed to exacerbation. Well controlled on amio.
2. HEME - cont couamdin , LENIs done and are neg for DVT.
3. ENDO - changed glyburide to glipizide for hepatic clearance.
4. RENAL - creatinine stable - follow with diuresis.
5. PULM - has restrictive pattern on PFTs , may need outpt CT chest.
ADDITIONAL COMMENTS: We will call you with appt time for your next test - called a
dobutamine ECHO.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Go to the appointment for your next cardiac test tentatively
scheduled for 11/9/03 . You will be notified if the date changes.
2 )Take all medications as prescribed
3 )Call for an ambulance if you have sudden chest pain or shortness of
breath.
4 )Follow up with Dr. Aspacio after your test next week.
No dictated summary
ENTERED BY: SPILLETT , SILVA A. , M.D. ( ZN585 ) 6/10/03 @ 05:56 PM
****** END OF DISCHARGE ORDERS ******
Document id: 286
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
479131543 | PUO | 81765574 | | 5729559 | 10/10/2005 12:00:00 a.m. | CHEST PAIN | Signed | DIS | Admission Date: 8/17/2005 Report Status: Signed
Discharge Date: 7/6/2005
ATTENDING: COLASAMTE , ISABELLE EVON MD
ADMITTING DIAGNOSIS: Coronary artery disease.
PRINCIPAL DISCHARGE DIAGNOSIS: Status post CABG.
HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with a
history of hypertension , dyslipidemia , coronary artery disease
status post PTCA to the LAD x3 in 1992 and twice in 1993. He
also has a history of hypothyroidism and hypocalcemia status post
total thyroidectomy for premalignant lesion. The patient
presented to an outside hospital on 10/2/05 with chest pain
radiating down his left arm. His EKG showed STD depressions ,
troponin was 6.2 , creatinine was 1.4. The patient was
transferred to Pagham University Of where a cardiac
catheterization done on 10/4/05 revealed 80% proximal LAD
lesion , 75% proximal circumflex lesion , 100% mid RCA lesion and
an ejection fraction of 40%.
HOSPITAL COURSE: He was admitted , made ready for surgery , taken
to the operating room on 2/7/05 at which time he underwent a
CABG x4 with a LIMA to the LAD and a Y sequential graft that
connects the saphenous vein graft to the aorta to the RCA and
then a sequential left radial artery graft that connects
saphenous vein graft to OM2 and then OM3. Intraoperatively , a
calcified distal ascending and aortic arch found. There was a
soft spot to cannulae. The patient was cooled to 22 degrees and
the distal RCA to the saphenous vein graft anastomosis was sewn
under fibrillatory arrest. Proximal to the aorta was done under
circulatory arrest. Proximal radial anastomosis was placed on
the proximal part of the saphenous vein graft to the RCA.
Immediate postoperative course was uncomplicated. He was
transferred to the Intensive Care Unit on postoperative day #1.
He was neurologically intact , but been pulling at lines and
catheters stating he wanted them out and trying to climb out of
bed , so he was placed on a 1:1 sitter. Nitroglycerin was weaned.
He was started back on Lopressor and captopril for hypertension.
He had an NG tube placed for gastric dilatation. He was
extubated overnight on postoperative day #1.
On postoperative day #2 , he again was hypertensive. Captopril
was added , increased Lopressor and the diltiazem. He self DC'd
his Foley as well as intravenous on postoperative day #2 , stating he was
going to leave the hospital. On postoperative day #3 , Psych was
consulted. They felt that imaging was warranted , however , his
behavior improved overnight. He was transferred to the Step-Down
Unit on postoperative day #3. He was in sinus rhythm. His NG
tube had been removed. His diet was being advanced as tolerated.
He was auto diuresing. He was back on his hypothyroid meds. On
postoperative day #4 , he was doing well. He was mobilizing ,
diuresing. Physical therapy was consulted. They felt the
patient would meet the criteria for rehabilitation. A rehab bed
became available and patient was accepted on 3/1/05 .
At the time discharge , Mr. Chisholm looked well. His vital signs
were stable and he was in sinus rhythm. His discharge laboratory
values included sodium 142 , potassium 3.8 , chloride 106 , CO2 25 ,
BUN 22 , creatinine 1.3 , glucose was 94. White blood cell count
was 7.7 , hematocrit 25.4 , platelets 243. His INR was 1. His
chest x-ray revealed satisfactory postoperative appearance. His
discharge condition was stable.
DISCHARGE DISPOSITION: To rehabilitation.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours as needed for pain.
2. Full aspirin 325 mg orally daily.
3. Calcium gluconate 1000 mg orally twice a day
4. Captopril 25 mg orally three times a day
5. Diltiazem 60 mg orally three times a day
6. Colace 100 mg orally three times a day as needed for constipation.
7. Ibuprofen 600-800 mg orally every 6 hours as needed for pain.
8. Synthroid 125 mcg orally daily.
9. Lopressor 50 mg orally every 6 hours
10. Niferex 150 mg orally twice a day for hematocrit less than 35.
11. Multivitamins with minerals.
12. Caltrate Plus D , two tablets orally every day.
13. Nexium 40 mg orally daily.
14. Zydis 2.5 mg orally twice a day as needed for anxiety.
15. Novalog sliding scale.
DISCHARGE INSTRUCTIONS: Include to make follow appointments with
Dr. Colasamte in four to six weeks , Dr. Dario , his cardiologist , in
one to two weeks , and Dr. Feduccia , his primary care physician , in
two to four weeks.
OTHER INSTRUCTIONS: Local wound care , shower daily , continue to
monitor CV status , continue to ambulate , keep legs elevated while
seated in a chair and bed , continue to monitor blood glucose
levels and follow up with primary care physician.
eScription document: 9-1629146 MCS
CC: Isabelle Colasamte M.D.
Pagham University Of
Nebraska
Dictated By: VERRY , COLETTA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 3833299
D: 3/1/05
T: 3/1/05
Document id: 287
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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921778812 | PUO | 49448215 | | 544926 | 5/21/2001 12:00:00 a.m. | CHF | | DIS | Admission Date: 9/3/2001 Report Status:
Discharge Date: 9/26/2001
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
Genewa
Service: MED
DISCHARGE PATIENT ON: 7/16/01 AT 03:00 PM
CONTINGENT UPON echocardiogram
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GILFOY , DEANDRA LAZARO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
HOLD IF: sbp <90 , heart rate <45 and call h.o.
Override Notice: Override added on 9/12/01 by SPECKEN , GARRETT X M. , M.D. on order for COUMADIN orally ( ref # 34424815 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: will monitor
Previous override information:
Override added on 9/12/01 by SPECKEN , GARRETT X. , M.D.
on order for COUMADIN orally ( ref # 49101822 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: will monitor
LOMOTIL ( DIPHENOXYLATE W/ATROPINE ) 2 TAB orally three times a day
GLYBURIDE 10 MG orally twice a day HOLD IF: NPO
Alert overridden: Override added on 9/12/01 by
SPECKEN , GARRETT X. , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: takes at home
PLAQUENIL ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: sbp <95
LISINOPRIL 20 MG orally every day HOLD IF: sbp <95
Alert overridden: Override added on 9/12/01 by
SPECKEN , GARRETT X. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
COUMADIN ( WARFARIN SODIUM )
2.5 MG orally Q Tu , Th , Fri , Sat , Sun
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/12/01 by
SPECKEN , GARRETT X. , M.D.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: will monitor
COUMADIN ( WARFARIN SODIUM ) 5 MG orally Q Mon , Wed
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/12/01 by
SPECKEN , GARRETT X. , M.D.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: will monitor
NORVASC ( AMLODIPINE ) 10 MG orally every day
HOLD IF: sbp <95 and call h.o.
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
Alert overridden: Override added on 7/16/01 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: will follow
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Shalonda Aspacio please call to schedule in 1-2 weeks ,
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CHF HX SYNCOPE ALL - ASA , PCN RA
history of St. Jude MVR for MS ( history of cardiac valve replacement ) Hx AFib/flutte
r ( history of atrial fibrillation ) history of IMI ( history of myocardial infarction ) NIDDM
( diabetes mellitus ) gout
( gout ) Hx DVT '70 ( history of deep venous thrombosis ) history of appy ( history of
appendectomy ) history of umbilical hernia repair ( history of hernia repair ) history of
sigmoidectomy for diverticulitis history of L hip # '95 ( history of hip
fracture ) Chronic diarrhea ( diarrhea )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
78 year-old with CAD , HTN , DM , A-fib and history of CHF who presents with
2-3 months of progressively worsening shortness of breath. The evening
before admission she had an episode of chest pain which lasted a few
minutes. It was associated with worsening shortness of breath ,
diaphoresis and nausea. She was not able to get to her TNG because
she was feeling weak/dizzy. The morning of admission she was still
feeling weak and short of breath , so her minister called the
paramedics. When they arrived she was started on oxygen which led to
symptomatic improvement. On arrival in the ED her sat was 88% on room
air. She received lasix 20 intravenous with significant symptomatic
improvement. PMH: HTN , CHF , mitral stenosis , St. Jude's valve , DM , RA ,
sigmoid collectomy for diverticulitis ALL: Sotalol , ASA , procainamide ,
PCN , Sulfa , quinaglute MEDS: Amiodarone 200 every day , Lomotil 2 tab three times a day ,
glyburide 10 three times a day , plaquenil 200 twice a day , isordil 20 three times a day , lisinopril 20 every day ,
coumadin 2.5 QTu , Th , Fr , Sa , Su , 5 mg QMo , We , lasix 40 twice a day , lopressor 50
twice a day , Norvasc 10 every day , TNG SHX: Life long non-smoker , non-drinker FHX:
father with DVT , mother with CAD Exam: afebrile , heart rate 42-60 , BP 174/67 ,
O2 95% RA ( after lasix ) , neck exam notable for right carotid bruit ,
8cm JVP , lungs with bibasilar rales , right greater than left , cardiac
exam with metalic S1 , I/VI systolic murmur , +S3 , abdomen with
reducible ventral hernia , extremities with pitting edema left > right
( baseline asymetry ). DATA: Labs notable for creatinine of 1.6
( basline ~1.3 ) , BUN 31 , INR of 2.4. EKG with 1st degree AVB , rate 44 ,
inferior Qwaves , no acute ST Twave abnormalities. CXR with
cardiomegaly , poor inspiratory effort. HOSPITAL COURSE Admitted to
GMS Ster , Florida 94291 with CHF exacerbation. Treated with lasix 20 intravenous twice a day. Lopressor
held secondary to bradycardia. Has ruled out for MI. ECHO with
normal EF around 55-60% and no effusion or new valvular abnormalities.
patient to be d/c'd to home in stable condition to follow up with her primary care physician
Dr. Shalonda Aspacio .
ADDITIONAL COMMENTS: Please call Dr. Aspacio to make a follow up appointment in 1-2 weeks.
Please continue all your medications as before. Continue to have your
blood checked with the coumadin nurse in KTDUOO . Call your doctor if you
have worsening chest pain or shortness of breath.
DISCHARGE CONDITION: stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BERCIER , REGGIE L. , M.D. ( RH69 ) 7/16/01 @ 05:17 PM
****** END OF DISCHARGE ORDERS ******
Document id: 288
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
Y |
Y |
N |
- |
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N |
878696591 | PUO | 75926089 | | 331833 | 6/28/1998 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 10/13/1998 Report Status: Signed
Discharge Date: 4/6/1998
PRINCIPAL DIAGNOSIS: RIGHT GROIN ABSCESS.
PROBLEM LIST: ( 1 ) Status post renal transplantation , living
related donor April 1997 , ( 2 ) hypertension , ( 3 )
insulin-dependent diabetes mellitus , ( 4 ) pulmonary hypertension ,
( 5 ) hyperthyroidism , ( 6 ) hyperparathyroidism , ( 7 )
hypertriglyceridemia.
HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old white
man who presents with complaints of
fever to 103 and chills , a productive cough and groin pain lasting
three days. At age three , the patient was diagnosed with Wilms'
tumor on the left , which was resected and subsequently treated with
wide field radiation. The patient , thereafter developed
radiation-induced tyroid cancer , at which time he underwent
subtotal thyroidectomy. In addition , the patient developed
radiation nephritis in his remaining right kidney and pulmonary
fibrosis. In April of 1997 , the patient underwent living related
donor renal transplantation for chronic renal failure. The patient
was at that point CMV antigen negative , however , the donor kidney
was CMV antigen positive. The patient underwent an uncomplicated
transplantation , however , the postoperative course was complicated
by cytomegalovirus infection , presenting with diarrhea and
requiring hospitalization in February 1997. The patient was treated
with ganciclovir and subsequently maintained on Cytovene. The
patient remained healthy until August 1997 , at which time he was
again admitted for a recrudescence of his cytomegalovirus
infection. In August 1997 , the patient presented with a
three-day history of fever to approximately 105 , anorexia , dry
cough , fatigue , headache , dizziness , sweats , nausea and dyspnea on
exertion. The patient was , at that point , treated with
ganciclovir , however his fevers persisted and he was discharged
after five days of therapy. At that time , the patient's CMV
antigen test was negative , however , his shell vial cultures , both
returned as positive. The patient was maintained on ganciclovir
therapy in the post hospital course until April , 1997 , at
which time his peripherally inserted catheter was removed.
Subsequently , the patient has been healthy for approximately four
weeks , then on June , 1998 , he noted a groin lump on the
right. From June , 1998 , he noted feeling
worse with fevers and chills , and a productive cough beginning on
September , 1998. The patient's groin lump , subsequently , became
painful , and he passed several loose bowel movements.
PAST MEDICAL HISTORY: ( 1 ) Wilms' tumor , ( 2 ) status post left
nephrectomy with wide field radiation
therapy , ( 3 ) NCH renal disease status post living related donor
renal transplant from father in April 1997 , ( 4 ) hypertension , ( 5 )
insulin-dependent diabetes mellitus , ( 6 ) pulmonary hypertension ,
( 7 ) hyperthyroid , ( 8 ) hyperparathyroid , ( 9 ) hypertriglyceridemia ,
( 10 ) gout , ( 11 ) CMV infection in February 1997 and August 1997 ,
( 12 ) history of perirectal abscess , ( 13 ) history of atrial
fibrillation spontaneously converted in October 1998.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
ADMISSION MEDICATIONS: Synthroid 150 mcg every day , NPH insulin 14
units every day before noon , regular insulin as needed ,
nadolol 80 mg every day , Prednisone 10 mg every day , Neoral 100 mg twice a day ,
CellCept 1 g twice a day , Axid 150 mg every day , Lasix 80 mg orally as needed ,
Coumadin 4 mg every day
SOCIAL HISTORY: The patient lives at home with his wife and has
four children. He denies alcohol or tobacco use.
FAMILY HISTORY: No coronary artery disease. No history of cancer.
PHYSICAL EXAMINATION: The patient is a pleasant , but ill-appearing
man in some respiratory distress , lying in
bed. Temperature is 103 , heart rate 70 , blood pressure 160/80 ,
respirations 26 , oxygen saturation 90% on 4 L oxygen. HEENT
examination was notable for cushingoid facies and flushing was
evident. No lymphadenopathy. The neck was supple , mucous
membranes moist and sclera were anicteric. Chest examination
revealed crackles on the right to half way up. Heart examination
revealed a noisy precordium with a prominent T2 and a 2/6 systolic
ejection murmur. Abdominal examination was negative. Extremity
examination revealed some slight swelling of the lower extremities.
Cutaneous examination was notable for evidence of thin subcutaneous
tissues and development of a buffalo hump.
LABORATORY DATA: White count of 11.3 with 46 polys , 36
lymphocytes and 7 bands , hematocrit was 32.4 and
platelets were 143 , 000. Coagulation studies revealed a prothrombin
time of 15.8 and an INR of 1.8. Electrolytes were within normal
limits , blood urea nitrogen was 39 , creatinine was 2.5 , glucose was
85 , calcium 10.2. Liver function tests revealed an alkaline
phosphatase of 342 , total protein was 7.9 with an albumin of 3.9.
Cholesterol was 194 , triglycerides were 249. Cyclosporine level
was 303.
HOSPITAL COURSE:
1. INFECTIOUS DISEASES: Surgery was consulted and the right groin
abscess was drained and a wick was inserted. This wound was
dressed and continued care was preformed by nursing staff. Blood
cultures on admission revealed no growth and on hospital day two
revealed no growth. Wound cultures revealed few coagulase ,
negative staph. Antibiotics were initiated , first vancomycin ,
gentamicin and Flagyl were initiated , however gentamycin was
subsequently discontinued and ceftazidime was initiated. The
patient had one fever spike on hospital day one to 101.9. The
patient subsequently had no fever spikes , however , on hospital day
three Levaquin was initiated and intravenous antibiotics were
continued until hospital day four. At that point , the patient had
been afebrile for 48 hours and the decision was made to switch the
patient to orally antibiotics , including Levaquin and Augmentin. The
patient continued to defervesce , his breathing improved , the pain
in his right groin improved , dressing changes were continued and
the patient remained afebrile for more than 24 hours after
initiating orally antibiotics.
2. CARDIOVASCULAR: The patient has a history of hypertension and
has been maintained on nadolol , recently requiring a doubling in
his dose from 40 mg every day to 80 mg every day He was admitted and placed
on 80 mg every day of nadolol , however , his blood pressures continued to
run up to 170 systolic and up to 110 diastolic. At that time , the
decision was made to initiate a second antihypertensive medication
and nifedipine XL was chosen. He was maintained for two days at 30
mg on this medication and his blood pressures subsequently
stabilized at 130/80. The patient also carries a diagnosis of
pulmonary hypertension , presumed from the February 1997 , results
of his echocardiogram. These results revealed a pressure gradient
in the pulmonary arterial system , and on this admission a
subsequent echocardiogram was obtained to assess left ventricular
function and his pulmonary vascular status. The results of this
study revealed 2+ tricuspid regurgitation and 1+ mitral
regurgitation , unchanged from prior studies and a pulmonary
arterial pressure of approximately 45 mmHg , also not notably
changed.
3. PULMONARY: On admission , the patient reported a productive
cough , in addition to difficulty breathing. This was evaluated
with a chest radiogram , which revealed possibility of a right sided
pulmonary process , corroborated on examination by evidence of
crackles half way up. The decision was made to rule the patient
out for another flare of his CMV infection. Studies for CMV
antigen and CMV from the buffy coat were sent and the final results
revealed a positive CMV antigen , but a negative buffy coat. The
patient's pulmonary status improved on oxygen and on intravenous
antibiotics. A induced sputum sample was obtained and studies were
sent for atypical organisms including CPT , fungi , in addition to
bacteria. All these studies were negative. In addition ,
Legionella antigen was also negative. Prior to discharge , the
patient's pulmonary status had returned to baseline and had
entirely resolved.
4. GASTROINTESTINAL: On admission , the patient reported multiple
loose bowel movements. However , in his hospital course this did
not continue to be an issue. The patient also regained his
appetite during the hospital course.
5. HEMATOLOGIC: The patient was continued on his anticoagulation
for history of atrial fibrillation at 4 mg daily with an INR
remaining in his goal parameters , which were set at 1.6-2.0. The
patient however , has recently spontaneously converted to sinus
rhythm and throughout his hospital course remained in sinus rhythm
with continuous monitoring.
6. RENAL: On admission , the patient's creatinine level was 2.5
and remained stable throughout his hospital course. His
cyclosporine level was 303 on admission , on hospital day four , a
level of 700 was obtained , however , this determined from a history
that this level had been drawn shortly after the patient had taken
the cyclosporine. During his hospital course , vancomycin levels
were followed. These levels reached a maximum of 19.8 on hospital
day four , at which time intravenous antibiotics were discontinued.
7. ENDOCRINE. The patient carries a history of multiple endocrine
issues including hypercalcemia and hyperparathyroidism , diabetes
mellitus , hyperthyroidism on thyroid replacement therapy following
subtotal thyroidectomy , and possibility of mineral corticoid
deficiency. The Endocrine Team was consulted. Thyroid studies and
parathyroid studies were sent and revealed a TSH of 0.02 , a T4 of
6.0 , a THPR of 1.47. On discharge , the patient's parathyroid 1 , 25
vitamin D and 25 vitamin D were still pending. The Endocrine Team
recommended decreasing his Synthroid dose to a level of 125 mcg
daily. In addition , they recommended a bone densitometry study for
evaluation of his bone mass following chronic maintenance on the
steroid therapy and a history of hyperparathyroidism. The team
thought that the patient's previous question of a mineral corticoid
deficiency was likely due to his prior Cozaar therapy. They did
not fell it was necessary at this point to preform a cortizone
stimulation study or to further assess this possibility of a
mineral corticoid deficiency.
DISCHARGE MEDICATIONS: Augmentin 250/125 mg three times a day , Levaquin 250
mg every day , CellCept 500 mg twice a day , Neoral 100
mg twice a day , Prednisone 10 mg every day , Synthroid 125 mcg every day , INP
insulin 14 units subcutaneously every day before noon , regular insulin subcutaneously as needed , Axid
150 mg every day , nadolol 80 mg every day , nifedipine XL 30 mg every day , Coumadin
4 mg every day , iron sulfate 300 mg every day
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home.
FOLLOW-UP: 1. Bone densitometry September , 1998.
2. Dr. Marylyn Derden March , 1998.
3. Dr. Denier in October .
Dictated By: REYES MCPECK , M.D.
Attending: WEI N. PILLING , M.D. NF7 YB160/0189
Batch: 51435 Index No. R6DJVP5LXR D: 1/17/98
T: 9/7/98
Document id: 289
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
Y |
N |
Y |
- |
164007289 | PUO | 65202772 | | 7515480 | 1/25/2005 12:00:00 a.m. | Cellulitis and foor ulcer- Diabetic foot | | DIS | Admission Date: 11/13/2005 Report Status:
Discharge Date: 6/26/2005
****** FINAL DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 062-19-87-1
La Andgadie Range
Service: MED
DISCHARGE PATIENT ON: 8/1/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SHANNON , JULIANA O. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
BENADRYL ( DIPHENHYDRAMINE HCL ) 25 MG orally every 6 hours as needed Itching
FUROSEMIDE 40 MG orally every day HOLD IF: sbp<90
GLYBURIDE 2.5 MG orally every day
LISINOPRIL 10 MG orally every day HOLD IF: sbp<90
Override Notice: Override added on 8/30/05 by
VERBLE , KESHA O. , M.D.
on order for KCL SLOW RELEASE orally ( ref # 07897057 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: patient requires
COUMADIN ( WARFARIN SODIUM ) 2.5 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 9/9/05 by
FOSTON , ELOUISE C , M.D.
on order for BACTRIM DS orally ( ref # 43070234 )
SERIOUS INTERACTION: WARFARIN & SULFAMETHOXAZOLE
Reason for override: ok Previous override information:
Override added on 8/30/05 by FOSTON , ELOUISE C , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: ok
SIMVASTATIN 20 MG orally every bedtime Starting ON 9/15/2005 ( 4/06 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 8/30/05 by
FOSTON , ELOUISE C , M.D.
on order for COUMADIN orally ( ref # 58206563 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: ok Previous override information:
Override added on 10/8/05 by HEIDELBERGER , LATICIA THADDEUS , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will follow
LINEZOLID 600 MG orally twice a day Food/Drug Interaction Instruction
This order has received infectious disease approval from
HAGBERG , LILLIA JOCELYN , M.D.
Alert overridden: Override added on 9/9/05 by
FOSTON , ELOUISE C , M.D.
SERIOUS INTERACTION: TRAMADOL HCL & LINEZOLID
Reason for override:
Number of Doses Required ( approximate ): 6
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
derm clinic ,
vascular surgery ,
orthopedic surgery ,
primary care physician ,
Arrange INR to be drawn on 9/15/05 with f/u INR's to be drawn every
7 days. INR's will be followed by primary care physician
ALLERGY: Penicillins , Cephalosporins , QUINOLONES ,
CIPROFLOXACIN
ADMIT DIAGNOSIS:
Cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Cellulitis and foor ulcer- Diabetic foot
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) htn ( hypertension ) edema ( peripheral
edema ) obesity ( obesity ) recurrent cellulitis
( cellulitis ) mitral prolapse ( mitral valve prolapse ) uti ( urinary
tract infection ) atopic dermatitis ( dermatitis )
OPERATIONS AND PROCEDURES:
debridement of R foot ulcer by othopedics
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
bone scan
cxr
BRIEF RESUME OF HOSPITAL COURSE:
ID: 60 YO female
--- CC: RLE
ulceration/redness/pain ---
DX: Diabetic foot ulcer ---
HPI: 60 YO female with DMII , PVD , chronic AF now with
DDI pacer on coumadin who has had history of recurrent LE ulcerations
and infections. She had the left foot amputated 4/7 and has been
considering amputation of the right. An ulcer developed 1/9 treated
with dressing changes and local care. Now having
swelling/erythema/pain X 2 days. Admitted for intravenous
abx. ---
STATUS: VS: T:98.4 HR:84 BP:112/70 RR: 20
SaO2:100%RA GEN: NAD NECK: no JVD CHEST: CTA bilaterally CV:
RRR S1 , S2 3/6 SEM at base , no gallop ABD: soft , NT , ND , bowel sounds
present EXT: Left foot amputated , R with charcot joint/hindfoot
varus , erthema , draining ulcer fifth metatarcel ,
edema. ---
EVENTS: 7/23 admitted to
medicine ---
TESTS/PROCEDURES: 7/23 - RLE plain films - no evidence of
osteo 7/23 - MR RLE -
pending ---
CONSULTS: 11/19 ID - has multiple allergies and has been on
several agents in the past 11/19 Ortho - followed by Dr.
Goodnow ---
PROBLEM LIST ---
1. ) RLE ulcer - diabetic foot ulcer with ? osteo. Plain films
negative but early signs may be absent. Started on unasyn in ED and
toleratied. Allergic to quinolones and cephlosporins. Bone scan
ordered. Wound swap cx grew 2+ staph aureus. Susceptibilities
showed MRSA.ID consult recommended to cont unasyn and switch to Po
linezolid as outpt since patient refused to take bactrim stating allergy to
med.
Ortho consult- debrided wound to vaible tissue. patient Was seen by Dr Goodnow
her out patient orthopedist- will have out patient reconstructive theapy of her
right foot after vascular eval.
On 7/28 patient developed rash on her legs and attributed it to the unasyn. She
had no breathing difficulty or any other symptoms. She was treated with
benadry and the unasyn was discontinued.
As at discharge patient had shown marked improvement of both cellulitis and
ulcer. patient to follow up with out patient care takers.
---
2. ) DMII - on glyburide , ADA diet , RISS. ---
3. ) AF/SSS - has DDI PPM in and is on coumadin. Last INR check was
subtherapeutic at 1.3. patient to follow up with coumadin clinic.
---
4. ) CKD - likely secondary to DM - at baseline ---
5. ) FULL CODE
ADDITIONAL COMMENTS: Please follow up with your primary care physician in 1-2 wks
Please ensure your right foot is elevated and wound dressing changes are
done daily
pls follow up with all your out patient doctors
Pls call urgent care clinic on thurs at 6/7/05 at 021 490 8405 to have a
doctor check your ulcer
pls follow up with your coumadin clinic to have INR checked
Pls take antibiotics for 7 days
DISCHARGE CONDITION: Stable
TO DO/PLAN:
follow up with otho , vascular surg , derm and primary care physician
Follow up with coumadin clinic
Cont daily wet to dry wound dressings
No dictated summary
ENTERED BY: FOSTON , ELOUISE C , M.D. ( DY6 ) 8/1/05 @ 12:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 290
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
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- |
- |
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388356560 | PUO | 10361274 | | 099948 | 10/23/1998 12:00:00 a.m. | ASTHMA FLARE | Signed | DIS | Admission Date: 7/12/1998 Report Status: Signed
Discharge Date: 7/3/1998
PRINCIPAL DIAGNOSIS: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE.
TRACHEOBRONCHITIS.
ADDITIONAL DIAGNOSIS: HYPERTENSION.
DIABETES MELLITUS.
OSTEOARTHRITIS.
CORONARY ARTERY DISEASE.
STATUS POST TOTAL ABDOMINAL HYSTERECTOMY ,
BILATERAL SALPINGO-OOPHORECTOMY.
TROCHANTERIC BURSITIS.
HISTORY OF OTITIS.
ECHOCARDIOGRAM IN April 1994 SHOWING NORMAL
LEFT VENTRICULAR FUNCTION AND MILD LEFT
VENTRICULAR HYPERTROPHY.
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old woman
with the above medical problems , who
presented with increasing shortness of breath , dry cough , and
wheezing. She was a former smoker , quit 7-8 years ago , but had a
20 pack year smoking history. She was recently diagnosed over the
summer with a chronic cough which was thought secondary to reactive
airway disease and responded to Serevent. Over the 24 hours prior
to this admission , she developed general malaise , fevers , dry
cough , and some nausea and vomiting with blood. There was no
diarrhea. She had some nasal congestion. She was sent in by the
VNA Services as she had a temperature of 101.7 degrees and was
unable to take orally's. In the Emergency Department , she was given
intravenous fluids , Solu-Medrol , and nebulizers.
PAST MEDICAL HISTORY: As above.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lisinopril 10 mg orally every day , Isordil 10
mg orally three times a day , aspirin 81 mg orally every day ,
Tenormin 50 mg orally every day , Micronase 5 mg orally every day , and Serevent
two puffs every day before noon and every afternoon
SOCIAL HISTORY: The patient has VNA services. She smoked 20 pack
years in the past but quit seven years ago. She
does not drink alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Noncontributory.
PHYSICAL EXAMINATION: On admission , temperature was 101.9 , heart
rate 76 , blood pressure 135/89 , respiratory
rate 26 , with room air saturation of 94%. She was ill appearing
and had a white nasal discharge. Oropharynx was clear. Neck was
supple. There was no lymphadenopathy. Chest revealed diffuse
scattered wheezes with decreased breath sounds. Cardiovascular
exam revealed a regular rate and rhythm without murmur. Abdomen
was obese , soft , nontender. Extremities were without edema ,
nontender , and without cords.
LABORATORY DATA: CBC was normal with hematocrit of 43 and white
count of 6.8. SMA-7 was normal , with normal
renal functions. Urinalysis was dark yellow with a concentrated
specific gravity , otherwise negative. EKG showed normal sinus
rhythm at 74 with nonspecific ST-T wave changes. Chest x-ray
showed left lower lobe atelectasis which was unchanged when
compared to April 1997 , no acute disease.
HOSPITAL COURSE: The patient was admitted and treated with
Albuterol and Atrovent nebulizers and Prednisone ,
as well as Biaxin 500 mg orally twice a day She was also given gentle
intravenous fluid hydration and Axid for her nausea and vomiting
which resolved. The patient improved slowly over three days with
respect to her breathing and oxygenation. On the day of admission ,
her room air 02 saturation was 92% , and she was feeling well. She
was discharged in stable condition.
DISCHARGE MEDICATIONS: Same medications as on admission , with the
addition of Axid 150 mg orally twice a day ,
Albuterol inhaler two puffs four times a day as needed shortness of breath ,
Atrovent two puffs inhaled four times a day , Biaxin 500 mg orally twice a day times
ten days , Prednisone taper 40 mg orally every day times three days then 20
mg orally every day times three days.
FOLLOW-UP: She will follow-up with Dr. Pasho in KTDUOO Clinic
on 27 of February .
Dictated By: DEANDRA L. GILFOY , M.D. HC88
Attending: DEANDRA L. GILFOY , M.D. GF30 HC576/3566
Batch: 48233 Index No. S1NYNF14UB D: 6/11/98
T: 3/17/98
Document id: 291
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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738473724 | PUO | 59543157 | | 6032625 | 10/4/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 1/18/2005 Report Status: Signed
Discharge Date: 11/5/2005
ATTENDING: KERTESZ , ALETA MD
DEPARTMENT: Cardiac Surgery Department.
DISCHARGE DISPOSITION: To home with Visiting Nurses.
DISCHARGE DIAGNOSIS: CAD.
OTHER DIAGNOSES: Hypertension , hyper lipidemia , and
non-insulin-dependent diabetes mellitus.
HISTORY AND PHYSICAL EXAMINATION: The patient is a 68-year-old
male who is a non-insulin-dependent diabetic who has had
substernal chest pain with a resultant ST depressions that
crossed the anterior precordium which cleared with Lopressor and
nitroglycerin. The patient was treated with intravenous heparin ,
nitroglycerin and beta-blockers at Xingcytalcjuanbuffwhi Fairgry Saintsli Healthcare Center and
transferred to Pagham University Of on 6/18/05 for
cardiac catheterization and scheduled for cardiac surgery after
three-vessel disease was found on cardiac catheterization.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus , and
hypercholesterolemia.
PAST SURGICAL HISTORY: Spinal fusion 20 years prior and a right
calcaneal spur removal 25 years prior.
FAMILY HISTORY: CAD.
SOCIAL HISTORY: No history of tobacco use.
ALLERGIES: No known drug allergies.
MEDICATIONS: Atenolol 50 mg orally daily , nifedipine 30 mg orally
daily , aspirin 325 mg orally daily , simvastatin 20 mg orally daily ,
glipizide 10 mg orally daily , and gabapentin 300 mg twice a day
PHYSICAL EXAMINATION: Blood pressure in the right arm 137/71 and
in the left arm 148/73. HEENT: No carotid bruits. Chest: No
incisions. Cardiovascular: Regular rate and rhythm , no murmurs.
Pulses +2/4 bilateral carotid , radial , femoral , dorsalis pedis ,
and posterior tibial pulses. Allen's test was failed
bilaterally. Respiratory: Breath sounds clear bilaterally.
Abdomen: No incisions , soft , no masses. Extremities: Without
scarring , varicosities , or edema. Neuro: Alert and oriented , no
focal deficits. The patient did have swelling and venous stasis
changes in the left lower extremity.
LABORATORY DATA: Sodium 135 , potassium 4.3 , chloride 102 , carbon
dioxide 24 , BUN 11 , creatinine 0.7 , glucose 226 , magnesium 1.4 ,
white blood cells 8.7 , hematocrit 39 , hemoglobin 13.7 , platelets
208 , physical therapy 14.3 , INR 1.1 , and PTT 29.4. Urinalysis is normal.
Cardiac catheterization showed 50% left main stenosis , 90%
proximal LAD stenosis , 50% ostial LAD stenosis , 90% mid D1
stenosis , 70% ostial circumflex stenosis , 90% proximal circumflex
stenosis , and 90% proximal RCA stenosis.
HOSPITAL COURSE: The patient was admitted on 6/18/05 and taken
to the operating room on 3/17/05 where the patient underwent a
CABG x 4; an SVG to OM1 and OM2 and RCA and LIMA to LAD with an
LAD endarterectomy. The patient was transferred to the Intensive
Care Unit in stable condition. Immediate postoperative
complications included some ST elevations in the inferior leads ,
which improved as time went on. The patient did have some volume
overload , treated with gentle diuresis. The patient had some
hyperglycemia in the postoperative period , treated with a
Portland protocol. Eventually , the patient was transitioned to
subcutaneous insulin and orally hypoglycemic agents. The patient
was transferred to the Step-Down Unit in normal fashion. Chest
tubes and pacemaker wires were removed without difficulty. Of
note , the patient did have a temperature of 101.5 on 3/29/05 .
Blood cultures were sent , one bottle grew out coagulase negative
Staph. , which was thought to be a contaminant. All other blood
cultures were negative and the patient remained afebrile
throughout the postoperative period following the temperature
spike on 3/29/05 . The patient was diuresed , mobilized , and
eventually was discharged to home with Visiting Nurse on
1/12/05 .
DISCHARGE INSTRUCTIONS:
DIET: No added salt , ADA 2100-calorie diet , low-saturated fat ,
low-cholesterol.
FOLOWUP: Follow up Dr. Kertesz in six weeks and Dr. Blackgoat in one to
two weeks.
TO DO PLAN: Monitor cardiovascular status , local wound care ,
should pay attention to make follow-up appointments.
DISCHARGE MEDICATIONS: Full strength aspirin 325 mg orally daily ,
Colace 100 mg orally three times a day as needed constipation , Lantus 10 units
subcutaneous at bedtime , Novolog 4 units subcutaneous before every meal ,
Novolog sliding scale at before meals and at bedtime , Niferex 150 mg orally
twice a day , oxycodone 5-10 mg orally every 4 hours as needed pain , Neurontin 300
mg orally twice a day , Plavix 75 mg orally daily , Glucophage XR 1 gram
orally every 12 hours , Lipitor 80 mg orally daily , and Toprol XL 200 mg
orally daily.
eScription document: 5-3193515 ISSten Tel
Dictated By: ISA , KAM
Attending: KERTESZ , ALETA
Dictation ID 3617678
D: 1/12/05
T: 1/12/05
Document id: 292
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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392986061 | PUO | 09031082 | | 584645 | 5/8/2001 12:00:00 a.m. | NON-HEALING ULCER LT. FOOT | Signed | DIS | Admission Date: 6/4/2001 Report Status: Signed
Discharge Date: 1/19/2001
DIAGNOSIS: Gangrenous left great toe
HISTORY OF PRESENT ILLNESS: Mr. Merles is a 48 year old male with a
history of brittle diabetes and known history of peripheral
vascular disease , end stage renal disease on hemodialysis and a
long history of smoking , who initially presented with dry gangrene
of the distal aspect of his left great toe.
He underwent a first toe amputation on April , 2001 , and this was
complicated by poor healing requiring debridement twice during this
hospital stay. The wound was then irrigated and closed in the
Operating Room on March , 2001. However at his follow up visit
to the clinic , his wound was erythematous and appeared to be
questionably infected. Thus , the wound was opened and debrided on
the day prior to the current admission. The patient reported a
history of chills but no fever.
Mr. Merles now presents preoperatively for an operative debridement.
PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes.
2. End stage renal disease on hemodialysis on Tuesday , Thursday
and Saturday.
3. Hypertension.
4. Peripheral vascular disease.
5. ETOH abuse.
6. Tobacco abuse.
7. Hepatitis C virus positive.
MEDICATIONS ON ADMISSION: Enteric coated aspirin , 325 mg orally
every day; Atenolol , 50 mg orally every day; calcium acetate , 1334 mg orally
every day; Zestril , 40 mg orally every day; Prilosec , 20 mg orally every day;
insulin , 70-30 , 20 units subcutaneously every day before noon , 8 units
subcutaneously every afternoon; Norvasc , 10 mg orally every day and Percocet as needed
pain.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission , the patient was afebrile with
stable vital signs. In general , he was a thin appearing , middle
aged Hispanic gentleman in no acute distress. His lungs were
clear. His heart was regular rate and rhythm with a III/VI
systolic ejection murmur radiating to his neck. His abdomen was
soft , non-tender , non-distended. His extremities had no edema.
His pulse examination showed palpable bilateral femoral pulses and
dopplerable DP , physical therapy and peroneal pulses bilaterally. On his left
great toe , there was an open wound with no purulent discharge and
minimal erythema in the surrounding skin.
ADMISSION LABORATORY DATA: Sodium 136 , potassium 4.9 , chloride 96 ,
bicarbonate 36 , BUN 17 , creatinine 3.8 and a glucose of 469. CBC -
9.4 , hematocrit 30.3 and platelet count of 460. INR of 1.2.
Of note , his angiogram showed that his left common iliac artery had
diffuse disease. His external iliac artery on the left had a 40%
proximal stenosis. His left SFA had proximal 50 to 60% stenosis
and mid-50% stenosis. His popliteal had 50% disease and his tibial
peroneal trunk on the left had moderate disease.
HOSPITAL COURSE: The patient was admitted to the Vascular Service
and started on Vancomycin , Levofloxacin and Flagyl. His wound was
changed twice a day and he was prepared for an operative debridement of
his left great toe. His pulses continued to be dopplerable. Of
note , the patient had very difficult to control diabetes , being
admitted with sugars in the 400 to 500 range , requiring intravenous insulin
boluses.
On hospital day #3 , he was taken to the Operating Room for a
debridement of his left great toe amputation and an amputation of
his second toe with primary closure. This was done under ankle
block and was uncomplicated.
The patient had a postoperative course significant for his very
difficult to control diabetes with intermittent hypoglycemia to the
40s and hyperglycemia up to the 600s range. He did receive a
consult by the diabetes team who changed his regimen to 70-30
insulin , 22 units every day before noon , 8 units of NPH insulin at 10:00 p.m. and
four units of regular insulin every afternoon , one-half hour before his
supper. He was to be covered with a sliding scale four times a
day.
The patient did receive Vancomycin , Levofloxacin and Flagyl for the
majority of his hospital stay for a total of ten days. He was
afebrile and his white blood count remained in the 8.0 to 9.0
range.
Mr. Merles received his dialysis as per his usual schedule of
Tuesday , Thursday and Saturday.
The patient did have some intermittent diarrhea , for which C. diff
was sent and his cultures at this time are still pending with no
fecal leukocytes seen on his stool sample.
On postoperative day #5 , the patient did have a white blood count
up to the 10 , 000 to 11 , 000 range and on postoperative day 7 , there
was some slight , questionably purulent drainage from his incision
line , thus a couple of sutures were removed and his wound was
opened. There was no fluid collection or pus found in the deep
wound. The wound was dressed with wet to dry dressing changes
twice a day using normal saline and was directed specifically to not be
packed tightly but just to be wicked open.
His antibiotics were changed to Augmentin and Levofloxacin
impirically , as the patient's cultures from the wound drainage from
negative as of the time of discharge. He will also be continued on
Flagyl for impiric coverage of C. diff , in case his C. diff toxin
turns out positive. His antibiotics should continue for another
six days post-discharge and this will complete a 2.5 week course of
antibiotics for him.
The patient had no cardiac issues while in house. He was
hemodynamically stable.
Of note , his sugars did trough on postoperative day #9 to a low of
46 and he was reconsulted by the diabetes team with recommendations
to decrease his insulin; 70-30 in the morning to 18 units , instead
of 22 units. He will continue his NPH and regular insulin coverage
as previously recommended.
On discharge , the patient is afebrile with stable vital signs. His
lungs are clear. Heart is regular rate and rhythm. Abdomen is
soft , non-tender , non-distended. His pulses are still dopplerable
bilaterally. His wound has no erythema and is packed open with
clean granulation tissue and some slight fibrinous exudate in the
wound. He has no distal edema.
DISCHARGE MEDICATIONS:
1. Vitamin C , 250 mg orally every day
2. Enteric coated aspirin , 325 mg orally every day
3. Atenolol , 50 mg orally twice a day
4. Calcium acetate , 1334 mg orally three times a day
5. Folate , 1 mg orally every day
6. Heparin , subcutaneously , 5000 units twice a day; regular insulin
sliding scale.
7. Zestril , 40 mg orally every bedtime
8. Flagyl , orally , 500 mg orally three times a day for six more days.
9. Prilosec , 20 mg orally every day
10. Thiamine , 100 mg orally every day
11. Zinc sulfate , 220 mg orally every day
12. Simvastatin , 10 mg orally every bedtime
13. Norvasc , 10 mg orally every day
14. Nephrocaps , 1 capsule orally every day
15. Insulin , 70-30 , 18 units every day before noon subcutaneously , NPH insulin , 8 units
every 10 p.m. subcutaneously , regular insulin , 4 units subcutaneously every afternoon , half
hour before supper.
16. Augmentin , 500/125 , 1 tab orally every day x 6 days.
17. Levofloxacin , 250 mg orally every other day x three more doses.
18. Percocet , 1 to 2 tabs orally every h as needed pain.
ACTIVITY: The patient is restricted to left heel touch only , to
use a walker for ambulation assistance. He is not to put any
pressure on his amputation site.
PLAN FOR FOLLOWUP: Dr. Rossie Mankoski in one week and with his
dialysis on Tuesday , Thursday and Saturday per his usual schedule.
Follow up with his primary care physician for optimization of his
glycemic control in one week.
DISPOSITION: The patient is discharged in stable condition to
rehabilitation.
Dictated By: LYDA STEINERT , M.D. GQ101
Attending: ROSSIE MANKOSKI , M.D. SH56 IX242/587494
Batch: 6321 Index No. PIICVC406R D: 10/29/01
T: 10/29/01
Document id: 293
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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362195603 | PUO | 96454934 | | 8288557 | 10/4/2003 12:00:00 a.m. | non-ischemic chest pain | | DIS | Admission Date: 9/5/2003 Report Status:
Discharge Date: 5/11/2003
****** DISCHARGE ORDERS ******
REINEMAN , JR , TWYLA 634-12-74-8
A Monte
Service: CAR
DISCHARGE PATIENT ON: 6/26/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCPECK , REYES DALE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting Today ( 8/21 )
FOLIC ACID 1 MG orally every day
ATIVAN ( LORAZEPAM ) 1 MG orally every bedtime
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
DARVOCET N 100 ( PROPOXYPHENE NAP./ACETAMINOPHEN )
1 TAB orally every 4 hours as needed Pain
ZOCOR ( SIMVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NORVASC ( AMLODIPINE ) 2.5 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
ALTACE ( RAMIPRIL ) 2.5 MG orally every day
Override Notice: Override added on 6/26/03 by ITSON , YOLANDE L LINH , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 79879502 )
POTENTIALLY SERIOUS INTERACTION: RAMIPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 6/26/03 by ITSON , YOLANDE LOISE , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
17926577 )
POTENTIALLY SERIOUS INTERACTION: RAMIPRIL & POTASSIUM
CHLORIDE Reason for override: md awaer
Previous override information:
Override added on 2/25/03 by GREIGO , VIOLET S. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL Reason for override: aware and monitoring
CLOPIDOGREL 75 MG orally every day
VIOXX ( ROFECOXIB ) 25 MG orally twice a day
Food/Drug Interaction Instruction Take with food
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Nadia Wankum , 472-174-6998 , in about 1 week 1 week ,
Dr. Shonda Cafagno , 702-551-0404 , in about 4 weeks 4 weeks ,
ALLERGY: Atarax ( hydroxyzine hcl ) , Sulfa
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
non-ischemic chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , CAD , high cholesterol , OSA , OA , depression , anxiety
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
exercise tolerance test
BRIEF RESUME OF HOSPITAL COURSE:
45 year-old M with multiple cardiac risk factors ,
including known CAD history of MI ( 10/12 with PCI to LAD , complicated by
instent thrombosis 1 week post-cath->successfully restented ) ,
HTN , dyslipidemia , obesity , and positive FHx
presents with acute onset of chest pain. The patient
has had several episodes/admissions for recurrent
c/p since then with caths consistently
demonstrating non-significant disease. Last cath in 3/8
showed R dominant system with 30% proximal LAD lesion.
ETT-MIBI in 1/23 ( 9:30 , 5.2 METS , HR 153 , BP 130/80 , was non-ischemic
but terminated 2/2 fatigue ) showed large fixed defect in
anterior , anteroseptal , anterolateral , inferior , LV
apex with EF of 35%. Seen 9/7 at TEVH for
syncope , dx with VT and had AICD
placed.
On this occasion
he noted sudden onset of 8/10 chest pain while
at rest at 6:30 pm on the evening of admission.
The pain was sharp/stabbing and was bilateral
with radiation to the L arm. He also had
diaphoresis , SOB , and nausea but denies vomitting , F/C ,
LH , dizziness. He took 1 TNG sublingual with some relief.
EMS transported to Lakesmi Sonno Memorial Hospital where his vitals were 98.2 , 73 , 92/62 ,
15. Rec'd intravenous TNG , heparin , MSO4 , ASA with pain down to 4/10.
Transfered to PUO . A: 45 year-old M with known CAD history of MI in 10/12 ,
history of recent ICD placement for syncope/VT at TEVH ,
now with his angina at rest. Given non-oclusive
CAD on multiple recent caths ( including 2 mos ago
at PMC per patient ) , likelihood of ischemia now
is low.
P: CV: Ischemia-r/o MI , asa , toprol , heparin , plavix , zocor. Ruled out
by ensymes , ETT was non-ischemic. Pump-euvolemic , no history of CHF
Rhythm-has AICD , on tele , replete lytes
GI: has lost 40 lbs on liquid diet , consider nutrition consult as
outpatient
CODE: FULL CODE
ADDITIONAL COMMENTS: Please be sure to contact Dr. Wankum ( 472-174-6998 ) to set up an
appointment to be seen in about 1 week. Also , be sure to set up an
appointment to see Dr. Cafagno ( 702-551-0404 ) in about 4 weeks.
You should contact your doctor or return to the emergency room if you
experience any of the following symptoms: chest pain , chest pressure ,
shortness of breath , dizziness , lightheadedness , nausea , vomitting , or
any other concerning symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Consider increasing CCB as patient seems to feel it helps his
symptoms.
2. Consider adjusting HTN meds as patient was relatively hypotensive
( SBP 90-110 ) in hospital ( althought asymptomatic ).
3. Consider outpatient cardiac rehabillitation.
4. Consider nutrition consult as outpatient to ensure adequate
nutrition status on "liquid diet"
No dictated summary
ENTERED BY: ITSON , YOLANDE LOISE , M.D. ( RT19 ) 6/26/03 @ 02:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 294
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
- |
N |
N |
Y |
N |
N |
N |
N |
852642797 | PUO | 17440552 | | 6015762 | 3/24/2006 12:00:00 a.m. | Atrial flutter , CAD history of Stent | | DIS | Admission Date: 5/29/2006 Report Status:
Discharge Date: 4/1/2006
****** FINAL DISCHARGE ORDERS ******
TORTORELLA , KASHA 031-41-66-7
Scoboton-aran
Service: MED
DISCHARGE PATIENT ON: 2/6/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DELMENDO , CRISTINE V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
DILTIAZEM EXTENDED RELEASE 240 MG orally every afternoon
Starting Today ( 7/14 ) Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every day before noon Starting Today ( 7/14 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 2/6/06 by :
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: MD Aware
ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/6/06 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MD Aware
PERCOCET 1-2 TAB orally every 4 hours as needed Pain
DIET: House / Adv. as tol. / NAS / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Dorsett ( covering for Dr. Desirae Marcott ) , primary care physician , Souwill Frysto Health Care ( 161-856-3442 ) 10/1/06 , 3:20pm ,
Dr. Violet Greigo , PUO Cardiology ( 575-803-4363 ) 1 Month , Office will call with time. ,
Arrange INR to be drawn on 4/12/06 with f/u INR's to be drawn every
3 days. INR's will be followed by PUO Cardiology Coumadin Clinic
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Atrial flutter
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atrial flutter , CAD history of Stent
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Colon cancer history of Partial Colectomy ( 6/22 ) with Leucovorin and 5FU , OA
history of Bilateral Total Hip Replacement , Hypothyroidism
OPERATIONS AND PROCEDURES:
Dipyridomole Stress PET-CT ( 10/19/06 ). Cardiac Catheterization with Taxus
Stent to Marg 1 ( Ostial ) 95% Lesion ( 3/6/06 ).
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
LENIS ultrasound for DVT evaluation , Trans-thoracic ECHO to look for
structural changes in heart , PE-CT to rule in PE.
BRIEF RESUME OF HOSPITAL COURSE:
CC: New Atrial Flutter
-----
HPI: 58F with history of colon CA history of partial colectomy and 5FU/Leucovorin ,
hypothyroid p/with new a. flutter during pre-op eval for TKR scheduled
for DOA. patient had no symptoms , no palps , no awareness of flutter. No
CP , no SOB , no acute diaphoresis , +stable DOE x years , no N/V/LH. Also
notes L>R leg swelling after plane ride from New Wark Ro 2 days PTA , and
reports that she has long periods of inactivity due to severe knee pain.
+extensive diaphoresis and dyspnea with exertion particularly noticeable
since hip replacement surgery in August 2005. No wt loss , tremor , rash , joint
pain , hair changes , difficulties swallowing , changes in appetite or sleep.
TSH WNL in 9/19 . In ED had mildly elevated d-dimer ( 541 ) , ECG with
persistent A flutter in 130s , given 40 intravenous dilt , 60 orally dilt , and PECT with
mistimed dye so unable to determine if PE. BPs stable throughout.
-----
PMH: OA , hypothyroid , colon CA ( history of curative resection with
5FU/leucovorin chemo ) , history of B THR , history of bladder extension
MEDS: no regular medications , was supposed to be on lasix , lipitor ,
synthroid , but self-d/c'd; takes percocet for knee pain
ALL: NKDA
-----
INITIAL ASSESSMENT: 97.0 102 ( to 130s in ED ) 108/70 20 97%RA
A&Ox3 , NAD , comfortable. No thyromegaly/nodules. Regular ,
tachy , nl S1S2 no murmurs , distant heart sounds. CTAB. Abd benign ,
trace LEE , 2+DP.
Labs notable for D-dimer 540 , Cr. 0.7 , negative enzymes.
EKG: A. flutter with 2:1 block at 150 , no clear ST-T abnormalities , nl
axis. CXR: no acute process. LENI: no clot above the knees bilaterally.
PECT: mistimed dye , nothing remarkable
-----
HOSPITAL COURSE:
CV-I: 2 negative sets of enzymes on admission. Given persistent exertional
dyspnea , the patient had a Myocardial PET on 10/19/06 revealing
mild-to-moderate basal inferior and inferior septal wall defects ( fully
reversible ). Concern for stable angina -- started ASA 81mg orally every day , Zocor
20mg orally every bedtime ( LDL 98 , HDL 59 ). Cardiac cathetherization on 3/6/06
revealed 95% Marg 1 ( ostial ) lesion that was opened with a TAXUS
stent. PATIENT NEEDS ASA INDEFINITELY AND PLAVIX FOR AT LEAST 3
MONTHS.
CV-P: TTE revealed mild posterior wall thickening , slightly
decreased LV function ( EF 45% ) , no significant AI , mild TR , mild RVH , no
obvious LAE , and no classic signs of RV response to increased afterload
( eg. PE ).
CV-R: New A. flutter , possible triggers include PE , ischemia ,
hyperthyroid. Rate controlled on Diltiazem 60mg orally every 6 hours and Lopressor
12.5mg orally every 8 hours Will change to Diltiazem ER 240mg orally every day and Toprol XL 50mg
orally every day. Need to anticoagulate x 1 month prior decision regarding benefit of
cardioversion. Patient will be discharged on Coumadin 5mg orally every bedtime ( to be
followed by Coumadin Clinic ).
PULM: Moderate suspicion PE ( high until LENI negative ). Repeat PECT
on 10/3/06 revealed no evidence of PE. Good room air O2 sats at the
time of discharge.
ENDO: TSH 5.365 ( 0.5-5 ) , T4 5.8 ( 5-11 ) , Free T4 0.9 ( 0.8-1.8 ) --
borderline hypothyroidism. Cortisol 14.5.
HEME: Restarting Coumadin 5mg orally every bedtime at the time of discharge ( held for
cardiac cath ). Patient needs to have INR checked by VNA in 3 days ( INR
Goal 2-3 ).
RENAL: Mucomyst started given double dye load , gentle IVF. Cr 0.8 at the
time of discharge.
GI: H/o colon CA history of chemo , resection. Stable. No acute issues.
MS: Eager for TKR -- on hold in the setting of plavix , anticoagulation
for atrial flutter. Prn oxycodone , tylenol.
CODE: FULL
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow-up with Dr. Dorsett ( covering for Dr. Malecha ) on 10/1/06 .
PUO Cardiology Clinic to call with appointment for 1 month post-discharge
with Dr. Violet Greigo .
VNA to check INRs ( first draw 4/12/06 , then twice per week until
therapeutic ). Please call results to PUO Cardiology Coumadin Clinic
( 988-605-5355 ).
No dictated summary
ENTERED BY: HAMPON , LUCINDA R. , M.D. ( KS765 ) 2/6/06 @ 01:44 PM
****** END OF DISCHARGE ORDERS ******
Document id: 295
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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478442898 | PUO | 00760285 | | 7388008 | 11/10/2006 12:00:00 a.m. | morbid obesity | | DIS | Admission Date: 12/10/2006 Report Status:
Discharge Date: 3/14/2006
****** FINAL DISCHARGE ORDERS ******
TROWERY , DEDE 257-79-60-1
O
Service: GGI
DISCHARGE PATIENT ON: 5/30/06 AT 06:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COHENS , ANGELINE VICKI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
CONCERTA ( METHYLPHENIDATE EXTENDED RELEASE ) 54 MG orally every day before noon
ROXICET ORAL SOLUTION ( OXYCODONE+APAP LIQUID )
5 MILLILITERS orally every 4 hours as needed Pain
PHENERGAN ( PROMETHAZINE HCL ) 25 MG PR four times a day as needed Nausea
CYMBALTA 20 MG orally DAILY
DIET: Stage II
ACTIVITY: Resume regular exercise
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Cohens 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
.
OPERATIONS AND PROCEDURES:
Laparoscopic gastric band placement
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to the Nessinee Ker Hospital Medical Center surgery service on 11/10/2006 after
undergoing laparoscopic gastric banding. No concerning intraoperative
events occurred; please see dictated operative note for details. She was
transferred to the floor from the PACU in stable condition. Patient had
adequate pain control and no issues overnight into Liore Chilikers Zaision Highway She had an UGI
on Swarras which was negative for obstruction or leak. At that time she was
started on a Stage I diet which she tolerated. She was then advanced to
clears and discharged to home a Stage II diet. Her incision was C/D/I ,
with no evidence of hematoma collection or infection. The remainder of
the hospital course was relatively unremarkable , and she was discharged
in stable condition , ambulating and voiding independently , and with
adequate pain control. She was given explicit instructions to
follow-up in clinic with Dr. Cohens in 1-2 weeks.
ADDITIONAL COMMENTS: May shower 2 days after surgery , but do not tub bathe , swim , soak , or
scrub incision for 2 weeks. Bandage strips will fall off over time.
Seek medical attention for fevers ( temp>101.5 ) , worsening pain , drainage
or excessive bleeding from incision , chest pain , shortness of breath , or
any other symptoms of concern. Follow up with your surgeon in 1-2 weeks.
Please do not drive or consume alcohol while taking pain medications.
Crush pills , open capsules , or take elixirs.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: CRITTLE , AMANDA A. , M.D. ( PD78 ) 5/30/06 @ 04:44 PM
****** END OF DISCHARGE ORDERS ******
Document id: 296
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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874062468 | PUO | 55475693 | | 3187544 | 11/20/2005 12:00:00 a.m. | CHEST PAIN | Unsigned | DIS | Admission Date: 11/20/2005 Report Status: Unsigned
Discharge Date: 10/8/2005
ATTENDING: TAPLIN , AVRIL MD
SERVICE:
CFH .
ADMITTING DIAGNOSIS:
Rule out MI.
PRINCIPAL DISCHARGE DIAGNOSES:
Angina , tachycardia , and hypertension.
OTHER DIAGNOSES:
Hypertension , chest pain , GERD , coronary artery disease ,
osteoarthritis , anxiety , diverticulosis , hypercholesterolemia ,
and chronic dizziness.
HISTORY OF PRESENT ILLNESS:
The patient is an 80-year-old woman with history of coronary
artery disease and difficult to control hypertension who
presented with chest pain in the setting of the elevated blood
pressure and tachycardia. Two days prior to admission , the
patient had developed the abrupt onset of palpitation , chest
pain , diaphoresis , anxiety , and shortness of breath. She took
her blood pressure and this was found to be greater than 200 with
the rapid pulse. She called her primary care physician and was instructed to call
911. She was taken to the Pagham University Of ED. Of
note , she had not taken her Toprol-XL for the prior three days.
In the emergency department , the systolic blood pressure was in
the 180s. This was controlled with her home medications and intravenous
Lopressor. The patient was ruled out for an MI in ED/OBS. She
went for a MIBI on the morning of admission , but this was
canceled because the patient was dizzy. Of note , the patient has
had an identical admission several months earlier for a labile
blood pressure. During that admission , the patient's hydralazine
and beta-blocker was titrated up with improved blood pressure
control. She was ruled out for pheochromocytoma and renal
artery stenosis. She did have elevated plasma metanephrines
during that admission. She was discharged at that point on an
improved antihypertensive regimen as described above. She also
reports having had a similar episode two weeks ago.
PAST MEDICAL HISTORY:
Hypertension , angina , osteoarthritis , GERD , diverticulosis ,
hyperlipidemia , coronary artery disease status post CABG x4 and
multiple stents , chronic dizziness , stable cath 8/4 .
HOME MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Lasix 40 mg daily.
3. Hydralazine 10 mg every 8 hours
4. Ibuprofen 400 mg every 8 hours as needed
5. Propoxyphene 1-2 tablets every 8 hours as needed
6. Ativan 0.5 mg daily as needed
7. Lactulose as needed
8. Tylenol as needed
9. Sublingual nitroglycerin as needed
10. Nexium 20 mg daily.
11. Meclizine 125 mg three times a day as needed
12. Avapro 300 mg daily.
13. Celexa 10 mg daily.
14. Lipitor 20 mg daily.
15. Imdur 120 mg daily.
16. Toprol 100 mg daily ( held last several days ).
ALLERGIES:
ACE inhibitor , amlodipine , and niacin.
SOCIAL HISTORY:
No smoking , no ethanol. She lives in Ment Lum by herself , has a
helper ( visiting aid ). No family nearby. Her family lives in
Naand Hwy.
FAMILY HISTORY:
Her brother died at 61 years old of CVA. Her mother died at 75
years old with CVA. Her sister had an MI at age 80.
PHYSICAL EXAMINATION ON ADMISSION:
Vital signs: Heart rate 98 , blood pressure 172/70 with a range
of 103-172/40-70. O2 saturation was 97% on room air. Her exam
was significant for tachycardia with a regular rate , normal S1
and S2 , and soft systolic ejection murmur at the right upper
sternal border. The remainder of the exam was unremarkable.
LABS ON ADMISSION:
CBC was within normal limits. Chem-7 was significant for BUN of
22 and creatinine of 103. Calcium was 10.5 , phosphorus was 2.5 ,
and albumin was 4.3. LFTs were normal. Her D-dimer was 1305.
She had two sets of negative cardiac enzymes. Coags were normal.
EKG: Normal sinus rhythm at the rate of 75 beats per minute ,
left axis deviation , LVH , left atrial enlargement. T-wave
flatting in lead III only.
STUDIES:
1. Chest x-ray ( 9/29/05 ): No acute cardiopulmonary process.
2. PE CT ( 11/9/05 ): No PE.
3. Head CT ( 11/9/05 ): Left-sided meningiomas , unchanged from
2004.
4. MIBI ( 10/27/05 ): Area of reversible ischemia , unchanged from
2002.
CONSULTS:
Cardiology ( MMC ): Jenell Alysia Haarstad .
HOSPITAL COURSE BY PROBLEMS:
1. Paroxysmal hypertension/tachycardia: This was in the setting
of not taking her Toprol. She does have a history of labile
blood pressure and difficult to control hypertension. This
symptom was thought to look very much like pheochromocytoma , but
this was ruled out last admission. Renal artery stenosis was
also ruled out last admission. Given the description and the
fact that she had elevated plasma metanephrines on the previous
admission , one possible diagnosis that was considered with pseudo
pheochromocytoma. Studies for pheochromocytoma , pseudo
pheochromocytoma , carcinoid , and hypothyroidism ( including
24-hour urine metanephrines were sent ) these all returned as
negative. Her TSH was normal. She was initially put on four times a day
Lopressor and hydralazine. The hydralazine was then discontinued
due to hypotension. Her Lopressor was changed to Toprol-XL , this
was also discontinued for hypotension. Her ultimate regimen was
titrated based on her blood pressures and eventually she was put
on Avapro 75 mg daily , atenolol 25 mg daily , and her home dose of
Imdur 120 mg daily. Her target blood pressures were 140s to 150s
and with this regimen , she was well controlled and asymptomatic
upon discharge.
2. Ischemia: She was initially ruled out for MI. Her MIBI
showed reversible ischemia unchanged from 2002 despite two
catheterizations in intervening time. She was seen by MMC
Cardiology , and this defect was felt to be nonintervenable. She
was discharged home in stable condition and chest pain free.
3. Dizziness/nausea: She had episodes of this during her
hospitalization. It was of unclear etiology and she has had a
previous significant prior workup ( see previous discharge
summary ). She received as needed meclizine and Compazine and was
discharged home without any dizziness or nausea.
4. Calcium: She had borderline high calcium and a PTH was sent
and returned mildly elevated. This will need to be followed up
as an outpatient.
DISCHARGE CONDITION:
Stable.
TO DO PLAN:
Further workup for question of elevated PTH in the setting of
high calcium suggestive of hyperparathyroidism.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Atenolol 25 mg orally daily.
3. Colace 100 mg orally twice a day
4. Lasix 40 mg daily.
5. Ibuprofen 400 mg every 8 hours as needed pain.
6. Lactulose 30 mL orally four times a day as needed constipation.
7. Ativan 0.5 mg orally daily as needed anxiety.
8. Meclizine 12.5 mg orally three times a day as needed dizziness.
9. Nitroglycerin 1/150 one tablet sublingual every five minutes
x3 doses as needed chest pain.
10. Compazine 10mg orally every 6 hours as needed nausea.
11. Imdur 120 mg orally daily.
12. Avapro 25 mg orally daily.
13. Celexa 10 mg daily.
14. Nexium 20 mg orally daily.
15. Lipitor 20 mg daily.
eScription document: 6-4629100 EMSSten Tel
Dictated By: PANCHO , MARJORIE
Attending: TAPLIN , AVRIL
Dictation ID 6542496
D: 6/17/05
T: 6/17/05
Document id: 297
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166827879 | PUO | 75649962 | | 763389 | 10/12/2000 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | Signed | DIS | Admission Date: 10/5/2000 Report Status: Signed
Discharge Date: 4/21/2000
SERVICE: The patient received care on the Pi'walt Run Community Hospital .
PRINCIPAL DIAGNOSIS: CHRONIC PULMONARY EMBOLI.
SIGNIFICANT PROBLEM LIST: 1. Sick sinus syndrome with pacemaker.
2. Chronic obstructive pulmonary
disease.
3. Restrictive airway disease.
4. Congestive heart failure.
5. Abdominal aortic aneurysm.
6. History of peripheral vascular
disease.
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female
with a past medical history of chronic
obstructive pulmonary disease and restrictive lung disease ,
peripheral vascular disease status post right carotid
endarterectomy , status post bilateral femoral to popliteal bypass
surgery , sick sinus syndrome status post cardiac pacemaker
placement in 1993 , history of squamous cell carcinoma and abdominal
aortic aneurysm diagnosed two weeks prior to admission , who
presented to the I Warho Hospital Emergency Department on
10/7 with a two day history of shortness of breath and
paroxysmal nocturnal dyspnea and worsening fatigue times two weeks.
The patient was recently admitted and evaluated in Ro Comemp where
she spends a significant part of the winter , and was diagnosed with
a viral syndrome and "asthma" flare. The patient was hospitalized
and underwent a Cardiolite stress test which was negative , as per
her Menlandlourdes Medical Center primary care doctor ,
Dr. Mcfee . The patient also had an echocardiogram done in
Ert S which demonstrated a normal ejection fraction , but evidence
of hypertrophic cardiomyopathy without obstruction. The patient
was evaluated with a CT scan in Cape Laulub Paulrisa which demonstrated an
abdominal aortic aneurysm greater than 5.0 cm. The patient had had
prior surgery on her abdominal aorta , and the patient was to
follow-up with Dr. Loerwald at the I Warho Hospital on
4/20 . The patient had also been found on the CT scan down in
Irv to have a pelvic mass for which she had been evaluated by
ultrasound and Gynecology follow-up has been arranged.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease ,
restrictive airway disease , congestive heart
failure. Recent echocardiogram less than two weeks prior to
admission demonstrated normal ejection fraction and changes
consistent with hypertrophic cardiomyopathy without obstruction.
Dyslipidemia. Squamous cell cancer in the past. Sick sinus
syndrome , status post pacemaker placement in 1993. Peripheral
vascular disease , status post bilateral femoral to popliteal
bypass. Status post right carotid endarterectomy. Abdominal
aortic aneurysm diagnosed two weeks prior to admission.
Depression. Seizure disorder.
ALLERGIES: Penicillin and ampicillin cause nausea.
HOSPITAL COURSE: The patient was admitted to the Short Stay Unit
for a chronic obstructive pulmonary disease flare
versus chronic pulmonary emboli. The patient had lower extremity
noninvasive studies which demonstrated a left popliteal vein
thrombosis. The patient's V/Q scan was initially set-up through
the Short Stay Unit. Her V/Q scan was subsequently performed and
read out as intermediate probability of the lower end of the
spectrum by the nuclear radiologist , with significant changes
consistent with chronic obstructive pulmonary disease. The patient
was started on initially unfractionated heparin and then
transitioned to Lovenox and Coumadin , and started on prednisone for
a presumed chronic obstructive pulmonary disease flare. While the
patient was in the hospital , her respiratory status was stable with
oxygen saturations in the high 90 percent range on a maximum of 2.0
liters nasal cannula. At discharge , the patient was sent home off
oxygen. The patient was evaluated by Dr. Dominguez for pacemaker
function and the battery was in need of replacement. The patient
was taken to the Procedure Room on 4/20 and underwent pacemaker
battery replacement by Dr. Dominguez without complication. While in
the hospital , the patient had a routine CT scan at the request of
Dr. Loerwald , who will follow-up with the patient regarding surgery on
her abdominal aortic aneurysm shortly after discharge. The patient
was discharged in stable condition.
PHYSICAL EXAMINATION: Pertinent findings on physical examination
on the day prior to discharge. Temperature
maximum 98.8 , temperature current 98.4 , pulse 56 , blood pressure
120/80 , respiratory rate of 20 , O2 saturation 95 percent on room
air. General , well-developed , well-nourished , in no apparent
distress. HEENT , pupils are equal , round , and reactive to light ,
extraocular movements are intact , the mucous membranes are moist ,
no pharyngeal injection , no conjunctiva injection , no icterus. The
neck is supple , no thyromegaly , no lymphadenopathy , no masses.
Cardiovascular , regular rate and rhythm , S1 and S2 , clear to
auscultation , no murmurs , no gallops , no rubs , jugular venous
pressure at 8.0 cm , no carotid bruits bilaterally. The lungs are
bilaterally clear to auscultation , no crackles , no rhonchi , no
wheezes. The abdomen is soft , nontender , nondistended , positive
bowel sounds , no hepatosplenomegaly , positive pulsatile abdominal
mass measuring approximately 5.0 cm. Bimanual examination ,
extremities are warm , trace left-sided pedal edema , no clubbing , no
cyanosis other than her left calf cord. Neurologic examination ,
alert and oriented times three. Motor 5/5 proximal and distal
muscle groups tested. Sensory and cranial nerve examinations were
within normal limits.
LABORATORY DATA: Laboratory studies on the day prior to discharge ,
sodium 143 , potassium 4.3 , chloride 105 ,
bicarbonate 30 , BUN 14 , creatinine 0.8 , glucose 141 , calcium 9.0 ,
magnesium 2.0. White blood cell count 6.5 , hematocrit 35.8 ,
platelets 255 , 000 , partial thromboplastin time 22.8. Repeat
echocardiogram during this hospitalization , ejection fraction 60
percent , 2+ tricuspid regurgitation , 2+ mitral regurgitation ,
systolic pulmonary artery pressure greater than 50.0 mm of mercury
above the right atrial pressure , restrictive physiology
demonstrated mild aortic insufficiency and left atrial enlargement.
OPERATIONS AND PROCEDURES: On 4/20 , pacer battery replacement ,
no complications , Dr. Dominguez operator.
DISCHARGE MEDICATIONS: Vitamin C 500 mg orally twice a day , atenolol 50
mg orally every day , Atrovent inhaler two puffs
inhaled four times a day , lisinopril 40 mg orally every day , Dilantin 60 mg every day before noon ,
60 mg every noon , 120 mg every bedtime all orally , Zoloft 25 mg orally every day ,
Zocor 40 mg orally every bedtime , Flovent 220 mcg inhaled twice a day , calcium
carbonate and Vitamin D one tablet orally twice a day , Pepcid 20 mg orally
every bedtime , Lovenox 40 mg subcutaneous every 12 hours , Coumadin 2.5 mg orally
every day , clindamycin 300 mg orally four times a day times three days , Albuterol
inhaler two puffs inhaled four times a day as needed wheezing or shortness of
breath.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home.
ESTIMATED DISABILITY: Minimal.
Dictated By: ALEJANDRA DEERDOFF , M.D. IT78
Attending: DESSIE R. ELENE L ARENDZ , M.D. PO7 HD115/4530
Batch: 42509 Index No. U7HJ7A1H5H D: 4/13
T: 3/16
CC: 1. DESSIE R. ELENE L ARENDZ , M.D. DZ7 MENLANDLOURDES MEDICAL CENTER .
Document id: 298
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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348772145 | PUO | 95269951 | | 9898141 | 11/16/2007 12:00:00 a.m. | INCACERATED HERNIA , SEPSIS , | Unsigned | DIS | Admission Date: 8/28/2007 Report Status: Unsigned
Discharge Date: 2/26/2007
ATTENDING: ALUQDAH , SELMA DELORSE M.D.
DISCHARGE MEDICATIONS: Include Tylenol 325 to 650 mg orally every 4 hours
as needed pain , DuoNeb 3/0.5 mg every 6 hours as needed , amiodarone 400 mg
orally twice a day for six more days and then 400 mg orally daily , hold
for systolic less than 90 , heart rate less than 55 , econazole
nitrate topical daily , heparin 5000 units subcutaneously every 12 hours ,
Regular Insulin sliding scale subcutaneously every 6 hours , Imodium A-D
2 mg orally twice a day , metoclopramide 10 mg orally four times a day , Lopressor 50
mg orally every 6 hours , hold for systolic less than 90 , heart rate less
than 55 , omeprazole 40 mg orally twice a day , oxycodone 1 mg per 1 mL
solution for a total of 5 mg orally every 4 hours as needed pain , Carafate 1
gm orally four times a day , and Ambien 2.5 mg orally nightly.
DIET: The patient is currently on a house diet. TPN was d/c'ed on the day of
discharge.
ACTIVITY: He may walk as tolerated.
ADMISSION DIAGNOSIS: Incarcerated chronic ventral hernia status
post sigmoid colectomy , colostomy , and Hartmann's operation.
The patient is to follow up with Dr. Ercolano in two weeks and
Dr. Aluqdah who is the attending in two weeks. He should also follow up with Dr.
Pavek , cardiology in 2 months , and Dr. Sampey , GI in 2-4 weeks.
HOSPITAL COURSE: This is a 72-year-old male admitted for an
incarcerated chronic ventral hernia , postoperative day 6 , status
post sigmoid colectomy , colostomy , and Hartmann's operation.
Hospital course was complicated by postoperative acute
respiratory failure , respiratory acidosis with metabolic
acidosis , pleural effusion , hypokalemia , myocardial infarction ,
thrombocytopenia , and delirium. He has a known history of penile
cancer status post penectomy complicated by perineal
urethrocutaneous fistula , chronic anemia requiring transfusions ,
non-insulin-dependant diabetes , hypertension ,
hypercholesterolemia , obesity , and recurrent UTIs. The patient
had a suprapubic catheter placed by Urology. His postoperative
course otherwise was alright. He started having atrial
fibrillation on 7/28/07 , initially remained stable with normal
blood pressures. He was transferred to the floor on 7/28/07 ,
wherein he developed rapid ventricular response to 120. On
6/6/07 , he began hypotensive with systolics of 70. Cardiology
was consulted. He was initially treated with Lopressor and
diltiazem drip. He remained hypotensive despite intravenous boluses. He
was switched to amiodarone mode and drip , but again he became
hypotensive. Therefore he was transferred to the unit and given
a digoxin load and was transferred for a possible
electrocardioversion. He remained asymptomatic throughout the
day with low blood pressures. In the ICU , he was again started
and maintained on amiodarone intravenous. He tolerated it without a
problem. He did have an episode of bright red blood from his NG
tube in the ICU and GI was consulted. They felt given that his
hematocrits have stabilized after two units of packed cells , he
did not need to be urgently scoped. He was started on Pepcid intravenous
and a Nexium drip , and had hematocrit measured every 6 hours , which
remains normal. He was transferred back to the floor on these
medications and was started on TPN after a PICC line was placed
and continued to do well. He was scoped by GI on 3/24/07 , which
showed diffuse gastritis thought to be due to the NG tube , and
two ulcers turned out bleeding. Postprocedure , he was started on
Carafate and was transferred to Nexium orally after he was taking a
diet. Again , his PICC line was safe on 4/15/07 and he was
started on TPN on 9/25/07 . The NG tube was removed on 3/24/07
and his diet has been slowly advanced. He is being discharged on
TPN as his total caloric needs are still not being met by orally
nutrition and he is in good condition on discharge.
He was not anti-coagulated for his Atrial Fibrillation due to his risk of GI
bleeding , as decided by GI.
eScription document: 3-6943268 CSSten Tel
Dictated By: WANKUM , NADIA
Attending: ALUQDAH , SELMA DELORSE
Dictation ID 8628981
D: 4/2/07
T: 4/2/07
Document id: 299
| Target |
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Dp |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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336377410 | PUO | 49618388 | | 9183205 | 4/6/2003 12:00:00 a.m. | hypovolemia , chronic renal insufficiency | | DIS | Admission Date: 5/29/2003 Report Status:
Discharge Date: 1/28/2003
****** DISCHARGE ORDERS ******
NORDHOFF , MONIQUE 557-29-59-9
En Field
Service: MED
DISCHARGE PATIENT ON: 7/1/03 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
PHOSLO ( CALCIUM ACETATE ) 1 , 334 MG orally before meals
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
GLIPIZIDE 10 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
Alert overridden: Override added on 10/24/03 by
MERAS , SANDY S. , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NITRATES
Reason for override: tolerates
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Override Notice: Override added on 1/15/03 by
MERAS , SANDY S. , M.D.
on order for ZOCOR orally OTHER every bedtime ( ref # 83003043 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
Previous override information:
Override added on 1/15/03 by MERAS , SANDY S. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Alert overridden: Override added on 7/1/03 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: Patient requires.
PREVACID ( LANSOPRAZOLE ) 15 MG orally every day
POTASSIUM CHLORIDE SUSTAINED RELEASE 40 MEQ orally every day
Ingredients contain 40 MEQ KCL every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Follow-up with Dr. Lemmings , your primary care provider at MMC Wayne Ao Terand 11/14/03 scheduled ,
Please follow-up with your kidney ( renal ) doctor to follow-up your chronic renal insufficiency within the next 2 weeks. ,
Please follow-up with your primary care provider to re-schedule your colonoscopy. ,
ALLERGY: Nitroglycerine ( nitroglycerin intravenous )
ADMIT DIAGNOSIS:
r/o mi
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hypovolemia , chronic renal insufficiency
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of CABG , history of POLYPECTOMY , history of NEPHROLITHIASIS , history of chronic renal
insufficiency ( history of chronic renal dysfunction ) , gout ( gout ) , history of
gastritis/duodenitis ( history of gastritis ) , history of hiatal hernia ( history of hiatal
hernia ) , history of GERD ( history of esophageal reflux ) , history of hypercholesterolemia
( history of elevated cholesterol ) , htn ( hypertension ) , CAD history of cabg
OPERATIONS AND PROCEDURES:
An ETT-MIBI was repeated on 6/13/03 and compared with the one of 4/12
showed interval improvement in cardiac status. Bruce protocol ,
exercised for 5:15 , terminated due to fatigue , Max HR: 112 ( 77% ) , BP
( 148/75 ) , no stress arrythmias , no ischemic EKG changes , no perfusion
defects , LV EF=61%.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
74M history of CABG 92 , DM , HTN , CRI , p/with history of near-syncope , dizziness , CP this
PM while awaiting f/u colonoscopy for recent polypectomy. +diaphoresis ,
no SOB. CP substernal no radiation. +palps. Noted to be hypotensive
sent to ED. patient NPO except meds for colonscopy x24hrs , took all meds
this a.m.. patient reports history of 3 episodes of CP 1d PTA relieved with sublingual NTG
each time. patient with ETT-MIBI 4/12 stopped after 3min for 2:1 AV block and
small area of ischemia but believed to be 2ndary to overBB , no CP.
Known Guaiac+ after polypectomy. Denies N/V , abd pain , F/C/NS. In ED
patient given 2L IVF , ASA 325 with resolution of CP. Initial TnI<assay.
All: intravenous Nitroglyerin -> dizziness
Soc: No Tob , Rare EtOH , no IVDU. Lives with wife in Ville Prings , indep
ADLs. FMH: Father MI at age 65
PE: 97.0 55 144/80 16 98% RA NAD. no JVD , RRR II/VI SEM RUSB , CTAB ,
abd benign. 2+ femoral pulses , no bruits.
Data: Hct:29.5. Cr:4.3 ( baseline 3.5 ) Ca:6.6 IoCa:0.87. CK#1: 127 ,
MB#1: 1.5 , TnI<assay.
EKG: Sinus brady. 1st degree AVB. Slightly prolonged QT. +LVH.
Hospital course:
1 ) CV: ROMI: enzymes x3 neg. No further CP. Cont. ASA/lopressor/statin
( inc to 80mg given LDL=142 ). Cont. Norvasc. Held
Lasix. Repeat ETT-MIBI 6/13/03 , Bruce protocol showed interval
improvement since 4/12 , exercised 5:15 stopped due to fatigue , max HR:
112( 77% ) , max BP:148/75 , terminated due to fatigue , no ischemia noted ,
no arrythmias , no perfusion defects noted , peak stress LVEF=61%. On
tele without events. Prior to d/c restarted Lasix 40mg
twice a day and Potassium.
2 ) Endo: DM , Cont. Glypizide. RISS , FSBS wnl.
3 ) Renal: Cr: 4.3 , likely pre-renal. Cr improved to baseline 3.4 o
n date of d/c after IVF. Nephrocaps started. PTH elevated at 242.
Ca:6.6/IoCa:0.8
7 on admission , repleted. Start PhosLo for low Ca , high PO4. Epo
started 11/19 as outpt , did not do in-house. patient will require close out
patient monitoring of CRI , consider dialysis as outpt. Also consider checking
Vit D level and adding calcitriol. 4 ) FEN: IVF hydration. K:2.9 on
admission , repleted. ADA 2100kcal/low fat/salt.
5 ) Prophyl: Ted stockings. Nexium for GI.
6 ) Heme: Hct 26.6 repleted with 2U pRBCs , with post-transfusion Hct:
32.8. Guaiac negative.
7 ) Code: Full
ADDITIONAL COMMENTS: You were admitted for chest pain that was subsequently found to not be
a heart attack. A repeat excercise stress test was repeated
since 4/12 to evaluate your heart and it showed that your heart is in
better health. You were started on Nephrocaps and PhosLo for your kidne
y condition. Please follow-up with Dr. Lemmings as schedule for 10/20 .
If you feel chest pain , dizziness or shortness of breath , please call
your doctor or come to the ER.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow-up with your primary care provider , Dr. Lemmings at MMC
Haygno Gatbalt Parkseas Road , Co Green Vi , Kansas 04320 You have an appointment scheduled for Friday 10/20 at 9:20am.
You will need outpatient follow-up for your chronic renal
insufficiency.
No dictated summary
ENTERED BY: MERAS , SANDY S. , M.D. ( VX90 ) 7/1/03 @ 03:42 PM
****** END OF DISCHARGE ORDERS ******
Document id: 300
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
U |
Y |
Y |
U |
U |
U |
Y |
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U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
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009846710 | PUO | 50140079 | | 766381 | 5/29/1997 12:00:00 a.m. | PERIPHERAL VASCULAR DISEASE | Signed | DIS | Admission Date: 9/13/1997 Report Status: Signed
Discharge Date: 10/6/1997
PRINCIPAL DIAGNOSIS: LEFT FEMOROPOPLITEAL BYPASS GRAFTING AND
RIGHT FIFTH TOE AMPUTATION SITE SPLIT
THICKNESS SKIN GRAFTING
PROBLEMS: 1 ) PERIPHERAL VASCULAR DISEASE
2 ) HYPERTENSION
3 ) TYPE II DIABETES MELLITUS
4 ) ELEVATED CHOLESTEROL
HISTORY OF THE PRESENT ILLNESS: This is a 49 year-old male who
has developed type II diabetes
mellitus approximately ten years ago but has been without regular
medical follow-up. He has also experienced worsening peripheral
vascular disease. In this context , he was admitted to Pagham University Of approximately one month ago , when on May , he
underwent debridement of diabetic foot ulcers and amputation of the
right fifth toe. On October , he also underwent a right
femoropopliteal bypass graft. He was discharged from Pagham University Of on February , 1997 to home , followed by VNA for
dressing changes. He did well postoperatively; however , he began
experiencing increasing pain in both legs over the two days prior
to admission. He treated this with Tylenol. He states this
glucose levels have been doing well , although he is not able to
cite any numbers.
PAST MEDICAL HISTORY: 1 ) Hypertension. 2 ) Peripheral vascular
disease. 3 ) Type II diabetes mellitus. 4 )
Elevated cholesterol.
MEDICATIONS: Medications on admission included Vasotec 5
milligrams every day; Glyburide 5 milligrams every day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco: two packs per day times 40 years ,
presently an active smoker. Alcohol: denies
alcohol intake in the last six weeks; history of previous heavy
alcohol use. The patient is divorced. He currently lives with his
girlfriend. He is currently disabled and is not working.
REVIEW OF SYSTEMS: GENERAL: 35 pound weight loss over the past
three years. ENT: Recent blurring of vision.
NEUROLOGICAL: Numbness and tingling on the left foot dorsal
surface. CARDIOVASCULAR: Hypertension , but no known history of
cardiac events. PSYCHIATRIC: Admits to some depression.
PHYSICAL EXAMINATION: This is an ill appearing , uncomfortable
gentleman in mild distress on admission.
VITAL SIGNS: Afebrile. Blood pressure 130/82. Pulse 84.
Respiratory rate 16. SKIN: Warm and dry. There are no palpable
nodes. HEENT: Normocephalic and atraumatic. LUNGS: Clear to
auscultation throughout. HEART: Regular rate and rhythm. Normal
S1/S2. ABDOMEN: Soft , nontender , with active bowel sounds.
NEUROLOGICAL: The patient is alert and oriented times three.
EXTREMITIES: There is no edema. There is a right groin incision
with slight separation of the surgical wound at its most distal
aspect , approximately one centimeter magnitude. PULSES: Popliteal
pulse is by Doppler only on both sides. The posterior tibial pulse
is non Dopplerable. The dorsalis pedis pulse is detectable with
Doppler , stronger on the left than on the right. On the left foot ,
there were two necrotic areas on the heel approximately 0.5
centimeter in diameter. The first metatarsal joint has a 1.2
centimeter wound which is dry , tender and not erythematous outside
of its margins , boggy at the distal aspect. There is a small
amount of tan exudate present at the distal wound edge. On the
right foot , there is a distal lateral wound 4.6 centimeters in
width , 3.1 centimeters in length , and 1 centimeter deep. There is
pale green fluffing on the plantar edge of the wound. The right
heel has a 4.2 X 2.5 centimeter open area approximately 2-3
millimeters deep in the wound bed; pink with scattered white
material fluffing. There is no surrounding erythema or bogginess.
LABORATORY DATA: On admission , glucose was 81 , sodium 137 ,
potassium 4.7 , chloride 101 , bicarbonate 26 , BUN
and creatinine of 18 and 0.9 respectively. CK was 145. CBC was as
follows: white blood cell count of 10 , hematocrit 43.1 , platelets
425 , with a normal differential. Urinalysis was notable only for
1+ protein on the dip.
HOSPITAL COURSE: During admission , the patient underwent a left
femoropopliteal bypass graft and split thickness
skin grafting to the right fifth toe amputation site , as well as
debridement of other lower extremity wounds on April . He
tolerated the procedure well and postoperatively progressed without
complications. He was taken off epidural pain medications and
switched to orally medications and resumed a regular diet shortly
after the operation. The debrided wounds on the right foot were
treated with Xeroform dressings covered with Kerlix and an Ace
bandage. These wounds have shown signs of vascularity and healing ,
and the split thickness skin graft has taken in a satisfactory
manner. The patient has begun to increase his activity with the
guidance of the physical therapist , and is now moving on crutches
with touch down weight bearing of the right foot and no weight
bearing on the right side. There were no complications during this
admission. The patient complained of some blurring in the right
eye. This was followed by an Ophthalmology consult , during which
it was determined that there has likely been a gradual decline in
the patient's vision due to a combination of development of
cataracts as well as peripheral vascular disease. It was felt that
the appropriate management would be to have the patient return to
Ophthalmology Clinic on an outpatient basis.
DISCHARGE MEDICATIONS: Vasotec 5 milligrams orally every day; Glyburide
5 milligrams orally every day; Wellbutrin 75
milligrams orally every day; heparin 5 , 000 units subcutaneously twice a day;
CZI sliding scale insulin subcutaneously; Ativan 1 milligram orally
every bedtime as needed insomnia; Betadine topical ointment to surgical wound
site; MSIR 15-30 milligrams orally every 3-4h. as needed pain; Lanolin
ointment to the feet every day
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To rehabilitation facility.
FOLLOW-UP: 1 ) The patient will follow-up with Ashore Cleod Health at
Pagham University Of in approximately one week;
appointment as indicated in the discharge instructions in the
Kernan To Dautedi University Of Of computer. 2 ) Follow-up in Centcent Hospital in three weeks to start regular outpatient
medical management of the patient's medical issues. 3 )
Ophthalmology Clinic follow-up in three weeks to address the
blurring of the vision recently.
ESTIMATED DISABILITY: The patient is disabled and has been
prior to admission.
Dictated By: HERTHA CHWIEROTH , M.D.
Attending: ROSSIE K. MANKOSKI , M.D. KN95 PA891/4836
Batch: 2852 Index No. B1KE9V6N1Y D: 4/1/97
T: 4/1/97
Document id: 301
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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639512267 | PUO | 07902746 | | 1124152 | 8/5/2004 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 8/5/2004 Report Status: Signed
Discharge Date: 5/26/2005
ATTENDING: MARCOS WARRAN MD
PRINCIPAL DIAGNOSES:
1. Hypoglycemia.
2. Altered mental status.
OTHER DIAGNOSES:
1. Volume overload likely secondary to CHF.
2. Possible pneumonia.
PAST MEDICAL HISTORY:
Significant for:
1. Bilateral occipital CVAs.
2. Diabetes , on insulin.
3. Hypertension.
4. Chronic renal insufficiency.
5. Coronary artery disease.
6. Visual impair with tunnel vision.
7. Monoclonal gammopathy.
8. Bilateral occipital CVAs.
9. History of left upper extremity thrombophlebitis.
10. Microcytic anemia.
HISTORY OF PRESENT ILLNESS:
The patient is a 75-year-old woman who was found at home with
altered mental status by home services and home nursing with
confusion. Her fingerstick was 37 , which increased to 42 with
orange juice with improvement of her mental status. Her insulin
regimen has been stable for quite some time. She had taken her
regular dose of Novolin 40 units on the morning of admission.
She was sent to the emergency department. She has noted
increasing bilateral lower extremity edema over one or two
months , increased dyspnea on exertion , nocturia. In the ED , her
ambulatory sat was 91% on room air. Glucose was still low and on
chest x-ray there was evidence of a right pleural effusion and
right lower lobe consolidation versus atelectasis. She was given
Lasix , glucose , Levaquin , and blood cultures were drawn. She was
admitted for treatment of pneumonia.
She has an allergy to propoxyphene.
MEDICATIONS:
1. Lasix 80 mg orally every day in the morning , 40 mg orally every day in the
evening.
2. Atenolol 75 mg orally every day
3. Lipitor 10 mg orally every day
4. Amitriptyline 25 to 50 mg orally every bedtime as needed
5. Multivitamins.
6. Aspirin 325 mg orally every day
7. Folate 100 mg orally every day
8. Lisinopril 20 mg orally every day
9. Iron gluconate 325 mg orally three times a day
10. Novolin 34 to 40 units subcutaneously every day
11. Epogen 5000 units subcutaneously every week.
FAMILY HISTORY:
Father died of an MI in his 70s , mother died of leukemia. No
history of hematologic disorders in her family. No history of
thalassemia that the patient knows of.
SOCIAL HISTORY:
She lives in an assisted living facility and has extensive home
care services and lives alone. She was previously a nurse. She
has children who live nearby.
PHYSICAL EXAM:
Vital signs: Temperature was 95.2 , blood pressure 111/69 , heart
rate 73 , sating 97% on room air. She was alert and oriented x3.
Speech and mentation were normal. No lymphadenopathy. 2/6
systolic murmur at the base radiating to across her precordium.
Distant heart sounds. Right lower lobe with decreased breath
sounds and decreased phrenitis , wheezing throughout her right
lung. Abdomen: Obese , soft , nondistended , nontender , benign.
Extremities: 2 to 3+ pitting edema bilateral and symmetric.
Neurologic: She was moving all extremities well. Left eye with
slight lateral deviation. Extraocular movements intact. Pupils
equally round and reactive to light. Evidence of an old
cataract.
ADMISSION DATA:
BNP of 1111 , creatinine was 2.4 which was below her baseline of
2.6 to 2.8 , white count was 6.6 with no left shift , hematocrit
was 35.7 which is up from her baseline of 27 to 33. MCV was 67.4
which is stable and it has been in this range and she was found
to have in 5/25 a monoclonal gammopathy on SPEP. EKG showed
an inferoseptal Q wave , poor R wave progression , low voltage left
axis deviation. Echo in 5/25 showed an EF of 50 to 55% with
moderate-to-severe MR and TR , septal hypokinesis and a MIBI at
that time showed no reversible ischemia. Chest x-ray as
describes above. UA negative for UTI.
IMPRESSION:
The patient was evaluated to be low likelihood for having
pneumonia. She was thought to more likely have volume overload
secondary to CHF. Because of her visual problems and declining
physical condition and deconditioning , patient's current living
situation and arrangements are possibly insufficient for her
increasing needs and error in self administration of medications
or increasing renal insufficiency or poor orally intake may have
precipitated her hypoglycemic episode and altered mental status.
HOSPITAL COURSE:
ID/Pulmonary: Right lower lobe pneumonia versus CHF , pleural
effusion. This was treated initially with levofloxacin although
it is unlikely consolidated lobar pneumonia because of the
patient's good clinical status , lack of fever and white count and
lack of toxicity. Sputum culture and gram stein were
unremarkable. Pleural effusion on the right decreased only
minimally with diuresis of 1 to 2 liters overnight and for
diagnostic and therapeutic purposes , the patient underwent a
thoracentesis on 3/1/05 and had withdraw 800 cc of clear yellow
fluid whose chemistries and cell count were consistent with a
sterile transudative effusion. Gram stein was negative.
Cultures are pending at this time and a chest x-ray may be
repeated to rule out underlying pneumonia revealed by draining of
the effusion. Urine legionella was negative.
Renal: Chronic renal insufficiency. Creatinine is at a baseline
of 2.6 and it decreased significantly on this admission possibly
because of improved forward flow from discontinuation of her ACE
inhibitor.
Endocrinology: The patient was admitted with hypoglycemic
diabetes possibly secondary to infection or logistical and social
barriers. Her NPH dose was cut to 20 units subcutaneously every day with
lispro sliding scale before every meal and every bedtime which she needed only
minimally about 5 units a day and her sugars were well controlled
on this regimen which supports the hypothesis that her NPH dose
of 34 units a day was too high beyond a certain point.
Cardiac:
A. Pump: The patient with CHF , known valvular dysfunction ,
exhibiting pulmonary edema , lower extremity edema and orthopnea.
She was initially diuresed with intravenous Lasix and it was noted that
her weight was up 10 pounds from her prior admission. She was
transitioned to orally Lasix after diuresing very well on this
regimen. She continued her Lipitor and aspirin , atenolol was
changed metoprolol given her renal insufficiency. Lisinopril was
switched to captopril , then discontinued given her bumping
creatinine while diuresing on the ACE inhibitor. She was
slightly hypotensive with systolic blood pressures in the 90s to
100s at one point and responded to a bolus of fluid , decrease in
the captopril and holding the Lasix , unclear etiology , looks
otherwise low. Lasix was decreased to 80 mg orally twice a day and the
patient should have daily weights and electrolytes checked and
repleted to ensure that her diuresis is only moderate everyday no
more than one liter a day but is consistent such that she is able
to maintain her electrolytes and loose fluid overtime.
Heme: The patient has a monoclonal gammopathy and a microcytosis
which might suggest thalassemia. She is on iron and Epogen with
an improved hematocrit from the prior admission but no change in
her MCV , which suggests that she has more than renal disease
causing her microcytosis. Further workup of her monoclonal
gammopathy will be deferred to her primary care physician.
Diabetic diet: Low sodium , low fat , low cholesterol.
Prophylaxis: Heparin and H2 blocker.
DISPOSITION:
The patient has been screened for admission to Bussadd Southrys Community Hospital where
she will go today. Her goal is intense physical therapy and
learning greater independence in her daily functioning. Her
pelvic films were negative for fracture. She should be ambulated
three times a day
DISCHARGE MEDICATIONS:
1. Lasix 80 mg orally twice a day
2. Metoprolol 12.5 mg orally twice a day
3. Lipitor 10 mg orally every day
4. Amitriptyline 25 to 50 mg orally every bedtime as needed
5. Multivitamins.
6. Aspirin325 mg orally every day
7. Colace 100 mg orally twice a day
8. Lisinopril should be held for the moment.
9. Iron gluconate 325 mg orally four times a day
10. NPH 20 units subcutaneously every bedtime
11. Lispro sliding scale before every meal and every bedtime
12. Epogen 5000 units subcutaneously every week.
Ms Rizas should follow up with Dr. Labauve when she is able to
within the next week or two. Labauve is her primary care
physician , Lashawna Labauve her primary care physician number is 116-406-5401. She
should b switched to Toprol as her blood pressure tolerates and
to lisinopril as her creatinine tolerates after low-level
diuresis of about 50 cc to one liter a day. Studies pending
include cytology and culture of pleural fluid and follow-up chest
x-ray on the day of her discharge. Lasix dose can be increased as
needed for better diuresis.
eScription document: 8-2888039 EMSSten Tel
Dictated By: LALATA , JOHNETTA
Attending: WARRAN , MARCOS
Dictation ID 3657222
D: 4/5/05
T: 4/5/05
Document id: 302
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
N |
N |
N |
N |
N |
- |
N |
Y |
N |
N |
N |
N |
106565366 | PUO | 86025167 | | 707470 | 5/25/2001 12:00:00 a.m. | history of PTCA | | DIS | Admission Date: 5/25/2001 Report Status:
Discharge Date: 11/13/2001
****** DISCHARGE ORDERS ******
VIANA , BELLE A 436-75-25-7
Seypurcge 1
Service: CAR
DISCHARGE PATIENT ON: 6/15/01 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BACHMANN , LASHANDA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed SOB
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 5 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5 MIN X 3
as needed Chest Pain HOLD IF: SBP<[ ].
Instructions: As per chest pain protocol.
TERBUTALINE ( TERBUTALINE SULFATE ) 5 MG orally four times a day
AZMACORT ( TRIAMCINOLONE ACETONIDE ) 2 PUFF inhaled four times a day
KEFLEX ( CEPHALEXIN ) 500 MG orally four times a day
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIET: House / Low chol/low sat. fat
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Katheryn Gruntz , Cardiology 8/1/01 scheduled ,
Dr. Damon Krinsky , MMC ,
ALLERGY: Shellfish , Morphine
ADMIT DIAGNOSIS:
history of PTCA
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of PTCA
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hodgkins lymphoma ( Hodgkins disease ) Asthma ( asthma ) R total hip
replacement ( total hip replacement ) septic joint ( total hip
replacement ) non Q wave MI
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac catheterization , 5/18/01:
1 ) Chronic total occlusion of the proximal L.circumflex artery with
collaterals to distal vessels.
2 ) RCA ostial discrete 45% lesion.
Unsuccessful angioplasty of LCX; no stenting.
3 ) No significant LM or LAD lesions.
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Viana is a 58 year-old man with a hx of Hodgkins lymphoma history of radiation
tx , hypertension , and non-Q wave MI admiited to PUO for cardiac
catheterization and observation history of cath. Catheterization results as
above. Mr. Viana tolerated the procedure well without adverse event or
complication at the groin site. He remained afebrile , with stable
electrolytes , hematocrit and WBC. EKG was without evidence of acute
ischemia and cardiac enzymes remained flat. His SBP ran in the 90's to
low 100's and his Lisinopril was decreased as a result. Imdur was also
added to his cardiac regimen
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: SCHEMMER , ANNIS M , M.D. , M.P.H. ( IG96 ) 6/15/01 @ 03:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 303
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
921778812 | PUO | 49448215 | | 1528943 | 11/21/2006 12:00:00 a.m. | mechanical fall | | DIS | Admission Date: 6/24/2006 Report Status:
Discharge Date: 7/21/2006
****** FINAL DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
A
Service: MED
DISCHARGE PATIENT ON: 1/4/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GILFOY , DEANDRA LAZARO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 100 MG orally DAILY
NORVASC ( AMLODIPINE ) 10 MG orally DAILY HOLD IF: SBP<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TEARS NATURALE ( ARTIFICIAL TEARS ) 2 DROP each eye three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
Alert overridden: Override added on 9/27/06 by
DYSINGER , ROZANNE RANDI , M.D.
on order for LASIX orally ( ref # 440656582 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: AT HOME
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
GLIPIZIDE 2.5 MG orally DAILY
Alert overridden: Override added on 9/27/06 by
DYSINGER , ROZANNE RANDI , M.D.
on order for GLIPIZIDE orally ( ref # 869072686 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: AT HOME Previous Alert overridden
Override added on 9/27/06 by DYSINGER , ROZANNE RANDI , M.D.
on order for MICRONASE orally ( ref # 869072686 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: AT HOME
PLAQUENIL SULFATE ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: SBP<110
LISINOPRIL 20 MG orally DAILY HOLD IF: SBP<100
Alert overridden: Override added on 9/27/06 by
DYSINGER , ROZANNE RANDI , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: WILL FOLLOW
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain HOLD IF: SBP less than 100
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
TRAZODONE 25 MG orally BEDTIME as needed Insomnia
DIET: No Restrictions
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician ,
ALLERGY: QUININE , Aspirin , Sulfa , Penicillins
ADMIT DIAGNOSIS:
mechanical fall
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
mechanical fall
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CHF
history of St. Jude MVR for MS ( history of cardiac valve replacement ) Hx AFib/flutte
r ( history of atrial fibrillation ) history of IMI ( history of myocardial infarction ) NIDDM
( diabetes mellitus ) gout
( gout ) Hx DVT '70 ( history of deep venous thrombosis ) history of appy ( history of
appendectomy ) history of umbilical hernia repair ( history of hernia repair ) history of
sigmoidectomy for diverticulitis history of L hip # '95 ( history of hip
fracture ) PE ( pulmonary embolism ) heart block ( third degree heart
block ) history of DDD pacer ( history of pacemaker )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: history of fall
*****
HPI: 83 year-old F with afib , HTN , DM , CAD , MVR recently
discharged from rehab who sustained mechanical fall at home while
reaching for grapes. No prodrome , LOC , head trauma , CP , palp , SOB.
Admitted for rehab placement.
*****
PMH: HTN , DM , CAD , history of MVR , history of heartblock history of pacemaker , afib on
coumadin , RA , history of DVT/PE
*****
PE: AVSS irreg irreg CTA B L hip ecchymoses neuro CN intact , strength
5/5
*****
Labs/studies: hip film neg fx cardiac enzymes neg x 3 INR 5.2
*****
HOSPTIAL COURSE: 83F hx CAD history of AVR , PPM with mechanical fall. Story
sounds purely mechanical , no reason to suspect syncopal event or
otherwise. patient evaluated by physical therapy , who thought that sending patient back to inpt
rehab would not necessarily improve her outcome that much. patient insisted on
going home , so attempts made to maximize home services. INR 5.2 when patient
admitted , so coumadin held. 3.9 the day of d/c , will be checked by VNA and
results sent to primary care physician.
HEME - Hold coumadin for goal INR 2.5-3 , restart when appropriate
CV - kept on home meds
SERVICES - patient will have home VNA and home physical therapy to try and ensure safety at
home.
CODE - FULL
ADDITIONAL COMMENTS: 1. Please check patient's INR on coumadin on Mon 2/24 and forward results to
Shalonda Aspacio so patient can restart coumadin when appropriate
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Please f/u patient's INR and restart coumadin when appropriate
No dictated summary
ENTERED BY: CRANFORD , JULIAN H. , M.D. ( BV602 ) 1/4/06 @ 12:27 PM
****** END OF DISCHARGE ORDERS ******
Document id: 304
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
Y |
N |
- |
Y |
N |
Y |
N |
N |
N |
- |
693320474 | PUO | 33360126 | | 3558344 | 6/10/2005 12:00:00 a.m. | tremor | | DIS | Admission Date: 6/10/2005 Report Status:
Discharge Date: 11/10/2005
****** INCOMPLETE DISCHARGE ORDERS ******
ABO , RON P 271-00-85-8
Lin Li Beth
Service: MED
DISCHARGE PATIENT ON: 7/5/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
Incomplete Discharge
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
CEFTRIAXONE 2 , 000 MG intravenous every day
DIGOXIN 0.25 MG orally every other day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 20 MG orally every other day
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally twice a day
HOLD IF: SBP < 100
PRIMIDONE 50 MG orally twice a day
VANCOMYCIN HCL 1 GM intravenous Q36H Starting STAT ( 5/3 )
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NORVASC ( AMLODIPINE ) 5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LOVENOX ( ENOXAPARIN ) 30 MG subcutaneously every day
COREG ( CARVEDILOL ) 25 MG orally twice a day HOLD IF: SBP<90 , HR<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every afternoon
ESOMEPRAZOLE 20 MG orally every day
LANTUS ( INSULIN GLARGINE ) 7 UNITS subcutaneously every day
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
INSULIN ASPART 17 UNITS subcutaneously before meals Starting Today ( 11/13 )
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
primary care doctor 1 week after d/c from rehab ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
tremor
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) dm ( diabetes mellitus ) afib ( atrial
fibrillation ) cad ( coronary artery disease ) bph ( benign prostatic
hypertrophy ) gerd ( gastroesophageal reflux disease ) hiatal hernia
( hiatal hernia ) djd ( degenerative joint
disease ) pmr ( polymyalgia rheumatica ) diverticulitis
( diverticulitis ) history of AAA repair 1994 ( 10 )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
88 year old man who comes in from rehab with ?hypothermia and rigors. 6
weeks ago the patient was diagnosed with osteomyelitis of the finger. He
had a PICC line placed and was discharged with intravenous abx. At the tail end of
his antibiotic regimen he spiked a fever and was admitted to PUO . His
course of antibiotics was extended and he was discharged to rehab on
ceftriaxone and vanc. Today at the nursing home he was observed to be
"shaking" and the staff was concerned for rigors. However , the patient
says his hands were just quivering. At the time , his temp at rehab was 92
degrees. He was sent to the ED for evaluation.
In the ED , his temperature was normal. He was not complaining of further
chills or rigors. However , his EKG demonstrated new ST depressions in
V3-V5. The patient denied any CP/N/SOB/diaphoresis. His first set of
enzymes were negative. He was given aspirin.
PMH: HTN , CAD , DM , AFib , PMR , BPH , DJD , hiatal hernia. AAA repair and
sigmoid colectomy
All: NKDA
Medications on Admission: Lasix 20 every other day , Isordil 40 twice a day , Prednisone 2 every day ,
Primidone 50 twice a day , Norvasc 5 every day , Coreg 25 twice a day , Flomax 0.4 every day , Prilosec OTC
20 every day , Lipitor 20 every day , ISS , Lantus 7 every day , Novolog 17 before every meal , Lovenox 30 every day ,
Vancomycin 1 gm every other day , Ceftriaxone 2 gm every day , Digoxin 0.25 every other day , Colace 100 twice a day
Medications in ED: NS 500 cc , Aspirin
PE:97.2 150/70 76 14 97 RA
elderly , NAD , NCAT , JVP flat , CTAB , RRR 3/6 SEM at RUSB , soft , NT/ND ,
guiac neg , no C/C/E , fine tremor in both hands ( not pill rolling ) CN
grossly intact , no rashes
***
EKG: new ST depressions laterally with TWI , remained unchanged through
hospital course
Labs: notable for negative cardiac enzymes x 3
***
Hospital Course:
CV: The patient had 3 sets of negative cardiac enzymes. His EKG remained
unchanged. It is not clear how old these EKG changes may be. We recommend
outpatient stress test and cardiology follow-up. The patient was
bradycardic to the hi 30s overnight without symptoms. His EKG showed A Fib
with no evidence of junctional escape rhythm or Digoxin toxicity. His
Digoxin level was 1.9. His morning Coreg was held and his HR remained in
the 50s during the day with no symptoms voiced by the patient. He will be
discharged to rehab on his admission regimen. The patient's A Fib is old
and he is currently anticoagulated with Lovenox. No changes were made to
this regimen.
Neuro: The patient has a history of tremor and is treated with Primidone.
No changes were made to this regimen.
ID: The patient is being treated for osteomyelitis. His Ceftriaxone and
Vancomycin were continued. His temperature remained normal during the
hospital course and no rigors were observed. The patient did not complain
of any further chills. Blood cultures showed NGTD at the time of
discharge.
ENDO: The patient was continued on his outpatient regimen of Lantus ,
standing insulin qAC and insulin SS
GU: The patient was continued on Flomax for his BPH.
PPX: The patient is on Lovenox and required no further anticoagulation.
Full Code
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up with you primary care physician within 2 weeks
No dictated summary
ENTERED BY: MELLENDORF , DENICE T , M.D. , M.B.A. ( AS68 ) 7/5/05 @ 02:50 PM
****** END OF DISCHARGE ORDERS ******
Document id: 305
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
- |
Y |
- |
N |
- |
N |
Y |
Y |
N |
Y |
N |
- |
N |
- |
172100234 | PUO | 34013384 | | 6895913 | 5/14/2007 12:00:00 a.m. | atypical chest pain , depression/anxiety | | DIS | Admission Date: 10/18/2007 Report Status:
Discharge Date: 1/18/2007
****** FINAL DISCHARGE ORDERS ******
KAZUNAS , JULIET 292-57-27-6
Xandma Sisidelicharl
Service: MED
DISCHARGE PATIENT ON: 10/25/07 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COLLICA , CHANELLE XOCHITL , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Alert overridden: Override added on 3/7/07 by
TEWARI , KIARA W. , M.D. , PH.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 324006668 )
patient has a POSSIBLE allergy to IBUPROFEN; reaction is Hives.
Reason for override: patient tolerates
ALBUTEROL MDI ( ALBUTEROL INHALER ) 2 PUFF inhaled every 4 hours
as needed Shortness of Breath , Wheezing
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours as needed Wheezing
NORVASC ( AMLODIPINE ) 5 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 40 MG orally BEDTIME
DULCOLAX ( BISACODYL ) 5 MG orally DAILY as needed Constipation
CANDESARTAN 32 MG orally DAILY
Override Notice: Override added on 2/28/07 by
KATZER , CALANDRA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
932287035 )
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE Reason for override: aware
Previous override information:
Override added on 2/28/07 by TEWARI , KIARA W. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
909145495 )
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 2/28/07 by AKIN , GIA RANDOLPH , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
574947267 )
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE Reason for override: will follow
Previous override information:
Override added on 2/28/07 by AKIN , GIA RANDOLPH , M.D.
on order for KCL intravenous ( ref # 581272624 )
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE Reason for override: will follow
Previous override information:
Override added on 9/27/07 by TEWARI , KIARA W. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
758746109 )
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE Reason for override: will monitor
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ESOMEPRAZOLE 20 MG orally DAILY
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally every day before noon
Starting ON Monday 5/18/07
Instructions: Please start this medication on Monday
5/18/07 . Alert overridden: Override added on 10/25/07 by :
on order for LASIX orally ( ref # 735169597 )
patient has a POSSIBLE allergy to SULFA ( SULFONAMIDES );
reaction is Unknown. Reason for override: home med
GLIPIZIDE 5 MG orally twice a day
Alert overridden: Override added on 10/25/07 by :
on order for GLIPIZIDE orally ( ref # 393098135 )
patient has a POSSIBLE allergy to SULFA ( SULFONAMIDES );
reaction is Unknown. Reason for override: home med
KLOR-CON ( KCL SLOW RELEASE ) 20 MEQ orally DAILY
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 10/25/07 by :
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: home med
LABETALOL HCL 200 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 80 MG orally DAILY
Override Notice: Override added on 2/28/07 by
KATZER , CALANDRA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
932287035 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 2/28/07 by TEWARI , KIARA W. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
909145495 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 2/28/07 by AKIN , GIA RANDOLPH , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
574947267 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
Previous override information:
Override added on 2/28/07 by AKIN , GIA RANDOLPH , M.D.
on order for KCL intravenous ( ref # 581272624 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
Previous override information:
Override added on 9/27/07 by TEWARI , KIARA W. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
758746109 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
ATIVAN ( LORAZEPAM ) 0.5 MG orally twice a day as needed Anxiety
NIFEREX TABLET 150 MG orally twice a day
Number of Doses Required ( approximate ): 4
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 60 MG orally every 8 hours
Alert overridden: Override added on 3/7/07 by :
on order for OXYCONTIN orally 60 MG every 8 hours ( ref # 207973130 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: patient tolerates
Previous Alert overridden
Override added on 3/7/07 by TEWARI , KIARA W. , M.D. , PH.D.
on order for OXYCONTIN orally ( ref # 741293452 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: patient tolerates
PERCOCET 1-2 TAB orally every 6 hours Starting Today ( 1/9 ) as needed Pain
Alert overridden: Override added on 10/25/07 by :
on order for PERCOCET orally ( ref # 774929683 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: home med
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
DIET: House / 2 gm Na / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please call Psychiatry outpatient clinic on Monday. ,
Please call your primary care physician on Monday to make an appt this week. ,
ALLERGY: Erythromycins , Penicillins , CLINDAMYCIN , IBUPROFEN ,
MORPHINE CONTROLLED RELEASE , SULFA ( SULFONAMIDES )
ADMIT DIAGNOSIS:
chest pain , dyspnea on exertion
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain , depression/anxiety
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of IMI Non-cardiac chest pain Lumbosacral disc
dz Chronic pain syndrome Migraines HTN Anxiety
Depression ALLERG:PCN , Erythro , Tetracy
history of PTCA 1/11 FOR OCC RCA POSITIVE ETT/MIBI 93: ANT/LAT WALL ISCHEMIA
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Chest x-ray ( 3/14/07 ): PA and lateral views of the chest are compared to
prior dated 10/9/06 . Cardiomediastinal contours are stable with mild
cardiomegaly and tortuous and calcified aorta. There are no signs
of overt edema. There is no parenchymal focal consolidation.
There are no pleural effusions or pneumothoraces. Stable mild
cardiomegaly. No signs of failure.
-----
Myocardial Perfusion PET ( 3/19/07 ):
1. Clinical Response: Non-ischemic.
2. ECG Response: No ECG changes during infusion.
3. Myocardial Perfusion: Abnormal.
4. Global LV Function: Normal.
The patient's PET-CT test results are abnormal and consistent
with the following:
1. A small sized region of myocardial scar along with mild
residual periinfarct reversibility in the distribution of the PDA
coronary artery.
2. Normal global LV systolic function.
3. The results are essentially unchanged from her prior study
report of August , 2005.
---------
Renal U/S ( 4/14/07 ): normal
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain , dyspnea on exertion
****
HPI: Ms. Kazunas is a 61 year-old woman with a history of chronic pain
syndrome and CAD ( cath in 9/19 with stent to OM1 ) , who presents with
2 days of worsening subsernal chest pain at rest. Chest pain/pressure
began one week ago but has worsened over past 2 days , and has had
accompanying worsening of chronic symptoms of shortness of breath , DOE ,
and orthopnea. In addition , she has had back pain , pain in her breasts ,
nausea , palpitations , headache , dizziness , PND , and decreased appetite.
Pain is worse with inspiration. She denies fevers , chills , vomiting ,
abdominal pain , dysuria. In ED , BP was initially 199/119 , which
came down to 167/90s with one sublingual ( which did not relieve her
pain ). Pain was relieved by Dilaudid. Admitted to GMS for ROMI and
evaluation of dyspnea.
****
PMH: Chronic pain syndrome , CAD ( history of IMI 1993 , history of OM1 and RCA Cypher
stenting in 9/19 ) , DM , HTN , hypercholesterolemia , Asthma , OSA ,
fibromyalgia , Anxiety , depression , hiatal hernia , migraine headaches , CHF
with diastolic dysfunction , PMR , OA of knees , right L4-S1 radiculopathy
****
MEDS: albuterol nebs/inhaled as needed , ASA 325mg daily , candesartan 32mg daily ,
folate 1mg daily , glipizide 5mg twice a day , Klorcon 20mEq daily , labetalol 200mg
twice a day , Lasix 40mg twice a day , Lipitor 40mg every bedtime , Lisinopril 80mg daily , Niferex
150mg twice a day , Norvasc 5mg twice a day , sublingual Ntg as needed , Oxycontin 60mg every 8 hours , Percocet
5/325mg q4-6h as needed , Plavix 75mg daily , Protonix 20mg daily , Colace
300-400mg three times a day.
****
ALL: Erythromycin , PCN , Clindamycin , NSAIDS , sulfas , morphine controlled
release
****
Soc hx: ex-smoker ( 0.5ppd x 45yrs , quit 5yrs ago ) , no EtOH or drugs
*****
Fam Hx: M died at 62yo of kidney failure and heart disease , father died at
71yo of stroke and DM and heart disease
****
PE: AF , P-58 , BP- 148/90 , 100% on 1L , RR-12; appears
moderately uncomfortable. JVP flat. Lungs clear; Heart RRR , no
murmurs. Abd soft , nontender , nondistended , +BS. 2+ LE edema
( chronic ). Strength 2/5 in left leg due to pain.
****
LABS: cardiac biomarkers negative x3. Creatinine of 1.2 increased to 1.8 ,
then trending down to 1.3 on day of discharge.
LFTs normal; D-dimer 474.
****
EKG: NSR , slightly prolonged QT , Nonspecific ST-Twave changes.
****
STUDIES: see above section
****
IMP: 60 year-old woman with history of CAD and chronic pain syndrome , presenting
with 2 day history of chest pain and worsening dyspnea on exertion.
HOSPITAL COURSE:
1. CV( I ): With history of CAD and symptoms consistent with new
ischemia , patient was admitted for ROMI. Ruled out with 3 sets of negative
cardiac biomarkers. Underwent myocardial perfusion PET-CT which showed
EF 58% with small area of scarring unchanged from previous study in 2004.
Continued home regimen of ASA , Labetalol , Candesartan , Lisinopril ,
Norvasc , and Plavix. Substituted Simvastatin for Lipitor.
2. CV( P ): On admission , patient appeared euvolemic on exam , with significant
hypertension , thought to be secondary to pain. Continued home
hypertensive regimen , as well as Lasix 40mg twice a day. patient's
hypertension did improve with pain control. However , patient's creatinine
increased from 1.2 to 1.8 and patient appeared dry on 3rd day of admission.
Lasix was held and patient was given gentle IVF , which resolved ARF to Cr 1.3.
patient has been instructed to hold her Lasix until Monday 5/18/07 , upon which
she will resume at 40mg daily. She will follow-up with her primary care physician next week to
assess need to adjust Lasix dosing.
3. CV( R ): Monitored on telemetry with no events.
4. GI: No active issues. Continued PPI.
5. PAIN: Continued home pain med regimen of Oxycontin 60mg every 8 hours plus
oxycodone 5-10mg q4-6h as needed for breakthrough. patient continued to have
significant pain which presented in different locations. Most significant
was right breast/right underarm pain. Suspected etiology of this pain is
exacerbation of chronic pain syndrome vs musculoskeletal. Heating pads
offered some relief. patient's pain was improved by discharge with no specific
intervention. patient will follow-up with primary care physician to assess resolution of pain.
6. PSYCH: patient has significant anxiety regarding lack of specific
diagnosis for her increased pain. Also expresses considerable amount
of anxiety/depression over life stressors ( son in Laterprostock Bo Rie , recent death of
sister ). Suspect that anxiety/depression may be significantly contributing
to increased pain. Psychiatry was consulted who felt that patient was
expressing normal bereavement and that anti-depressant medication was
not indicated at this time. They recommended follow-up in the
Psychiatry outpatient clinic , for which the patient has been provided
a phone number to call. patient felt significant improvement of anxiety
after talking to Psychiatry consult. Psych recommended Ativan as needed for
anxiety , and patient was given prescription for Ativan 0.5 mg orally as needed
for anxiety.
7. RENAL: patient had ARF on day 3 with increased Cr 1.8 up from 1.3.
Likely dehydration as patient appeared clinically dry. Gave IVF and
held Lasix. Renal U/S was normal ruling out obstuctive etiology. With
hydration , patient creatinine normalized to 1.3 on day of discharge. patient will hold
Lasix until Monday 5/18/07 , then resume at 40mg daily. patient will follow-up
with primary care physician regarding adjusting Lasix dosing as needed.
FULL CODE
ADDITIONAL COMMENTS: FOR VNA: Monitor patient's vital signs , volume status , and general pain
assessment.
------
FOR PATIENT:
1. Please call your doctor if you experience worsening chest pain ,
shortness of breath , fainting , lightheadedness , or other concerning
symptoms.
2. Please do not take your Lasix until Monday 5/18/07 . On Monday , please
resume Lasix at 40mg once daily.
3. We have started you on Senna 2 tabs twice daily for constipation in
addition to the Colace 100mg twice daily that you have been taking. If
you become constipated , you can take Dulcolax 5mg once daily as needed.
4. We have given you a prescription for Ativan 0.5mg to use as needed
twice daily for anxiety.
5. Please call you primary care physician to make an appt next week to assess your pain and
need for Lasix dosing.
6. Please call the Psychiatry outpatient clinic to make an appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
FOR VNA: Monitor patient's vital signs , volume status , and general pain
assessment.
------
FOR primary care physician:
1. patient's Lasix held until Monday 5/18/07 , then restarted at Lasix 40mg
daily ( down from prior 40mg twice a day dosing ) due to ARF with Cr 1.8. Cr 1.3 and
K 3.8 on day of discharge. Creatinine and Potassium will need to be
rechecked next week and Lasix dosing adjusted according to patient's volume
status.
2. Reassess pain med regimen.
3. patient need outpatient Psychiatry follow-up for depression/anxiety. She
has been provided with phone number for outpatient Psych clinic to
schedule an appt.
No dictated summary
ENTERED BY: TEWARI , KIARA W. , M.D. , PH.D. ( NR37 ) 10/25/07 @ 06:03 PM
****** END OF DISCHARGE ORDERS ******
Document id: 306
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
Y |
N |
- |
Y |
N |
N |
N |
N |
Y |
N |
183239984 | PUO | 43563568 | | 9754530 | 1/20/2006 12:00:00 a.m. | heart failure | | DIS | Admission Date: 2/10/2006 Report Status:
Discharge Date: 8/28/2006
****** FINAL DISCHARGE ORDERS ******
JULIAS , EARLEAN S 139-19-92-6
Gas
Service: CAR
DISCHARGE PATIENT ON: 8/24/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAUB , PERRY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
CIPROFLOXACIN 250 MG orally every 12 hours Starting Today ( 2/16 )
Instructions: Please continue until 7/25
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
DARBEPOETIN ALFA 100 MCG subcutaneously QWEEK
Reason for ordering: Renal Disease
Last known Hgb level at time of order: 9.6 g/dL on
8/3/06 at PUO
Diagnosis: Anemia of other Chronic Illness 285.29
Treatment Cycle: Maintenance
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
GOLYTELY 4 , 000 MILLILITERS orally x1
Ingredients contain 76 MEQ KCL x1 Starting ON 10/13 ( 6/18 )
HYDRALAZINE HCL 20 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LANTUS ( INSULIN GLARGINE ) 36 UNITS subcutaneously BEDTIME
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
10 MEQ orally DAILY Starting Today ( 2/16 )
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
TORSEMIDE 50 MG orally twice a day Starting IN a.m. ( 5/11 )
CELEXA ( CITALOPRAM ) 20 MG orally DAILY
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
Elevate feet with prolonged periods of sitting
FOLLOW UP APPOINTMENT( S ):
Dr. Perry Haub 3/15 @ 8:30am scheduled ,
Dr. Karapetyan for COLONOSCOPY 5/9 at 9:30AM in Endoscopy suite at PUO Moom Road , Jack Co , North Carolina 61282 scheduled ,
ALLERGY: lisinopril , ACE Inhibitor
ADMIT DIAGNOSIS:
heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Type II DM ( diabetes mellitus type 2 ) HTN ( hypertension ) Fe deficieny
anemia ( iron deficiency anemia ) CHF ( ischemic CMP , EF 40-45% )
( congestive heart failure ) CAD ( coronary artery
disease ) history of CABG ( 1989 , re-do 1991 ) , history of LAD stent ( 2003 ) ( history of
cardiac bypass graft surgery ) Depression ( depression ) Home
O2 PVD ( peripheral vascular disease ) R carpal tunnel syndrome ( carpal
tunnel syndrome ) LBP history of injury ( 1986 ) ( low back
pain ) GERD ( gastroesophageal reflux disease ) Hemorrhoids
( hemorrhoids ) ?history of CVA ( ? history of cerebrovascular accident ) chronic
angina ( angina ) CRI ( baseline CR 1.6-2.0 ) ( chronic renal dysfunction )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
**CC: CP
**HPI: 68yoF with end-stage ICMP , EF 40% , HTN , anemia , who is on an
outpt biweekly BNP infusion protocol , now p/with CP. patient gets BNP
infusions biweekly , was seen in clinic on DOA , and found to
be grossly vol overloaded by ~10 lbs , likely 2/2 dietary
indiscreation/med non-compliance. She also was c/o SSCP , but no signs
of ischemia on EKG. She has had on/off CP now for ~5yrs , and is near
unintervenable CAD. She was sent to the ED , admitted for r/o MI and
started on intravenous NTG for HTN and CP.
**PMH: CAD history of 2 CABG's and multiple PCI's , CHF EF 40% , chronic CP , NSVT ,
home O2 , HTN , DM , lipids , PVD , anemia guaiac + stools
**PE on Admission: afeb , 80's , 110/60 , 97% 2L. NAD , JVP 15-20cm , CTA B ,
RRR 2/6 SM at LUSB with S3 , dist abd , NT , +BS , 2-3+ LE edema.
***************HOSPITAL COURSE****************
*CVS: ISCHEMIA: She was r/o for MI/ishemia by enzymes , and remained CP
free thereafter. Attempts to obtain an Adenosine MIBI were made , however
wre cancelled 2/2 pts inability to lie flat for the procedure. She will
follow up with Perry Haub as an outpt and have a PET done. PUMP: Her CP
was likely 2/2 demand from vol overload and increased wall tension.
She was diuresed using diuril and a Lasix drip to her dry weight of 173
lbs. She was then started on Torsemide 50mg orally twice a day which she will be
discharged on. RHYTHM: no events
*GI: She has a hx of Fe defeciency and chronic guaiac pos stools of
unclear etiology. There have been no documented endoscopies. Her HCT
slowly fell while in house to the mid-20's , and she was transfused 1 bag
of PRBC's with good effect. Her discharge HCT was >30. GI was
consulted , and arranged for her to have an outpt C-scope with Dr. Karapetyan
on 5/9 . She will take a GoLytely prep the day before , and take only
half of her Lantus in anticipation. She will continue taking
Darbepoitiein as an outpt as well as Fe.
*ENDO: NPH twice a day and SS
*ID: she developed a mixed-flora UTI while her Foley was in place , and
was started on Cipro which she will continue for 10d total.
*FULL CODE
ADDITIONAL COMMENTS: Please note that instead of Lasix you will now take Torsemide 50mg twice
a day , and your hydralazine will now be 20mg three times a day. All of
your remaining meds will remain the same. Please call and follow up with
Dr. Perry Haub , and have your infusions continued twice a week as you
have been doing. We have also scheduled a colonoscopy for you on 5/9 at
9:30am with Dr. Karapetyan - Please take the GoLytely prep the day before
and stop eating all foods at 4pm the night prior in preparation for this
procedure. Please take only 15units of Lantus the day before and of the
Colonoscopy since you will not be eating. After the colonoscopy , you may
resume your regular insulin regimen.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MANGANELLI , ADELINA , M.D. ( PG98 ) 8/24/06 @ 12:11 PM
****** END OF DISCHARGE ORDERS ******
Document id: 307
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
302833316 | PUO | 14368263 | | 9751747 | 2/24/2006 12:00:00 a.m. | ESRD | | DIS | Admission Date: 4/17/2006 Report Status:
Discharge Date: 2/2/2006
****** FINAL DISCHARGE ORDERS ******
LEUENBERGER , BRIAN 713-62-70-9
Cincoma All
Service: RNM
DISCHARGE PATIENT ON: 1/18/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PELOSI , JOHNSIE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMITRIPTYLINE HCL 25 MG orally BEDTIME
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
325 MG orally DAILY
Override Notice: Override added on 8/19/06 by
MOLE , DARIUS E.
on order for COUMADIN orally ( ref # 350399912 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: atrial fludder
CIPROFLOXACIN 250 MG orally every 12 hours
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 8/19/06 by
MOLE , DARIUS E.
on order for COUMADIN orally ( ref # 350399912 )
POTENTIALLY SERIOUS INTERACTION: CIPROFLOXACIN HCL &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: CIPROFLOXACIN HCL &
WARFARIN Reason for override: atrial fludder
Previous override information:
Override added on 2/12/06 by HENDY , CLARETHA , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: SEVELAMER HCL &
CIPROFLOXACIN HCL Reason for override: will follow
VASOTEC ( ENALAPRIL MALEATE ) 20 MG orally twice a day
HOLD IF: sbp < 100
Alert overridden: Override added on 7/1/06 by
HENDY , CLARETHA , M.D. , PH.D.
on order for VASOTEC orally ( ref # 187417100 )
patient has a PROBABLE allergy to LISINOPRIL; reaction is
COUGH. Reason for override: takes at home
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LASIX ( FUROSEMIDE ) 200 MG orally twice a day
HUMALOG INSULIN ( INSULIN LISPRO )
18 UNITS subcutaneously at dinnertime
HUMULIN N ( INSULIN NPH HUMAN ) 50 UNITS subcutaneously every day before noon
Starting Today ( 10/29 )
HUMULIN N ( INSULIN NPH HUMAN ) 25 UNITS subcutaneously every afternoon
COZAAR ( LOSARTAN ) 50 MG orally DAILY HOLD IF: sbp < 100
Number of Doses Required ( approximate ): 10
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
200 MG orally twice a day HOLD IF: sbp < 100 , heart rate < 60
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 20
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
LYRICA ( PREGABALIN ) 25 MG orally twice a day
SEVELAMER 1 , 200 MG orally three times a day
Instructions: please dose with meals
Override Notice: Override added on 2/12/06 by
HENDY , CLARETHA , M.D. , PH.D.
on order for CIPROFLOXACIN orally ( ref # 575740738 )
POTENTIALLY SERIOUS INTERACTION: SEVELAMER HCL &
CIPROFLOXACIN HCL Reason for override: will follow
TRAMADOL 25 MG orally every 6 hours as needed Pain
Number of Doses Required ( approximate ): 8
DIET: House / NAS / ADA 1800 cals/day / Low saturated fat
low cholesterol / Renal diet
ACTIVITY: as tolerated
FOLLOW UP APPOINTMENT( S ):
Dialysis 9/12/20 at PUO ,
Dr. Bockemehl ( primary care physician ) at Li 10/19 at 4pm scheduled ,
Dr. Norseth ( Renal ) at PUO 8/21 at 12:30pm ,
Dr. Loerwald ( Vascular Surgery ) at PUO 2/28 at 12:45pm ,
ALLERGY: FLUORESCEIN DYE , TETRACYCLINE ANALOGUES , LISINOPRIL ,
intravenous Contrast
ADMIT DIAGNOSIS:
ESRD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
ESRD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN Dx`89 DM insulin dependent Dx `89 obesity
( obesity ) L knee DJD nephrotic syndrome 4/8 ( nephrotic
syndrome ) hypercholesterolemia ( elevated cholesterol ) history of medullary
CVA 7/4 right PICA 7/4 Echo-mod LVH , EF 65% , no WMA Anemia ( anemia )
OPERATIONS AND PROCEDURES:
N/A
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
1. Fistulogram and Angioplasty of Fistula 4/25
2. New tunneled catheter 11/3
3. Initiation of Dialysis
BRIEF RESUME OF HOSPITAL COURSE:
CC: Acute renal failure
*****
HPI 55 year-old female patient with history of CRI , insulin dependent DM with
retinopathy , diabetic nephropathy and diabetic PNP , HTN and history of
medullary CVA was sent to the ER by her primary care physician due to an increased
creatinine at 9 ( baseline Crea: 6 ) , reveald during routine blood
work. Her CK was measured at 269 and her LDH was at 376. The patient
reported , that she was put on Lyrics recently for her PNP and , since
2-3 weeks she has to go to the bathroom every hour for
urination. She has no fevers , chills or night sweats. She also denied
weight gain , pain , nausea or
palpitations
****
PMH
HTN Dx `89 ,
DM insulin dependent with diabetic retinopathy , nephropathy and PNP Dx `89 ,
Obesity ,
L knee DJD ,
Nephrodic syndrome 4/8 ,
Hypercholesterolemia ,
history of medullary CVA 7/4 right Pica ,
Anemia?etiology 22 of June
****
ALL: Fluorescein dye , unknown reaction
Tetracycline analogs , unknown reaction
Lisinopril , cough
intravenous contrast , anaphylaxis
****
MEDS at admission
Amitryptiline HCL 25 mg orally
every day Calcitriol 2 TAB orally
every other day Cozaar 50 mg orally
twice a day Ecasa 325 mg orally
every day Epo 5000U subcutaneously
Qweek Fes04 325 mg orally
every day Humalog insulin prefilled pens 18 U and adjust as
directed subcutaneously with dinner Insulin NPH human 50 U with breakfast , 25 U at hrs
subcutaneously twice a day
Lasix , 200 mg orally twice a day
Metolazone 2.5 mg orally every day
Metoprolol 75 mg orally twice a day
Nifedipine XL 60 mg orally twice a day
Protonix 40 mg DR orally every day
Renagel 800 mg orally three times a day
Vasotec 20 mg orally twice a day
****
SHx: married , 12 year-old son , is at home , no history of alcohol , nicotine or illicit
drug abuse
****
FH: Father died of heart attack; mothers and sisters have insulin
dependent DM
****
PHYSICAL EXAM: Tmax 98.4 T 97s-98s , P 90s-110s , BP 110-120/60-70 , RR
20 , O2 93-100% RA , FFS 212 Obese. NAD. CTAB. RRR S1/S2. S/NT/ND.
Chronic venous statis changes. Neuro nonfocal.
****
EKG: tachycardia , atrial fludder , 2:1 block
2/12/06 urine culture: E.coli>100.000 TCC ,
Echo 10/22/06: EF 55-60% , LVH , calcification of aortic and mitral valve ,
some mitral regurgitation , right heart difficult to see. no signs for
perIcarditis. Final report pending.
Fistulogramm 9/14/06: blockage found , was ballon-dilated with good
results.
****
Impression: 55F with CRI p/with progression of CKD to ESRD. UTI may be
contributing factor. Now initiated HD.
****
Hospital course:
CARDIAC: Mildly tachycardic in-house , going in and out of Atrial Flutter
and Atrial Fibrillation. Beta Blocker titrated to Toprol XL 200 mg twice a day
with satisfactory rate control. Nifedipine and Metolazone were
held in-house , given need for BP room for rate control. Her BP
remained well-controlled despite her being off of these meds. She was
otherwise asymptomatic. Patient was begun on Coumadin on discharge , with
INR to be followed by primary care physician and PUO Coumadin clinic. TSH WNL. Echo also
unremarkable with EF 55-60%.
RENAL: ARF , likely progression of CKD with UTI contributory cause.
Initiated dialysis on 10/13 . Repeat dialysis on 5/24 noted poor flow , was
referred to IR for fistulogram. Fistulogram revealed stenosis of graft ,
which was angioplastied with good flow. Nevertheless , patient had placement
of HD catheter on 11/3 as access to the graft was still difficult. She
has f/u with vascular surgery ( Loerwald ) for possible graft correction
in near future. patient continued on Lasix 200 mg twice a day , Cozaar and Vasotec ,
per renal. Sevelamer was increased to 1200 three times a day due to slight
hyperphosphatemia.
ALLERGY: patient notes potential allergy to intravenous dye. She received prednisone
60 mg 12 hours and 2 hours prior to her fistulogram. She tolerated the
fistulogram well.
ID: E Coli UTI. Treating with Ciprofloxacin for 7 days.
ENDOCRINE: Continued insulin while in-house. Three episodes of early
morning hypoglycemia ( FS 30-50s ) were noted. Her evening NPH were
decreased while she was in-house. These episodes were asymptomatic ,
likely due to poor POs and repeated runs of NPO while she was in-house.
She is to resume her regular insulin regimen on discharge.
HEME: Begun on coumadin at discharge for new AFib. She will have her
labs drawn at her primary care physician's office. The PUO coumadin clinic ( 405 ) 082-3371
will follow her INRs , with target 2-3.
FEN: Renal diet+diabetic+low fat diet.
PPX: PPI , heparin 5000U twice a day , colace
CODE: FULL CODE
DISPO: Home with Home physical therapy services
ADDITIONAL COMMENTS: 1. Please continue dialysis as instructed by your renal doctors.
2. Take coumadin 5 mg every night. See your primary care physician , Dr. Bockemehl on 10/19
at 4pm. Your primary care physician will draw your blood , check an "INR" and send it to the
PUO coumadin service. The coumadin service will then call you and tell
you to adjust your coumadin dose if necessary.
2. Your new medicines are: Toprol XL 200 mg twice a day , Sevelamer 1200
mg three times a day with meals , Ciprofloxacin 250 mg twice a day for 5
days. STOP Nifedipine and Metolazone until you see Dr. Bockemehl .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Renal service at PUO will set up o/p dialysis - in the meantime , she
will get HD at PUO .
2. Coumadin: INR eventually to be drawn regularly at primary care physician's office. Please
call in the results to PUO Coumadin Clinic at 988-605-5355 - they will
instruct the patient to vary her dose if needed to target INR 2-3.
3. GRAFT: Please see Dr. Loerwald ( vascular surgery ) at PUO on 2/28 at
12:45pm for evaluation of possible revision of your graft.
4. VNA: Please draw initial INR on Monday while her eventual draws at primary care physician
office is being set up.
No dictated summary
ENTERED BY: HENDY , CLARETHA , M.D. , PH.D. ( TD18 ) 1/18/06 @ 04:01 PM
****** END OF DISCHARGE ORDERS ******
Document id: 308
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
Y |
Y |
Y |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
Y |
Y |
N |
Y |
Y |
N |
Y |
Y |
- |
N |
Y |
090097769 | PUO | 54245204 | | 9412414 | 10/29/2006 12:00:00 a.m. | morbid obesity | | DIS | Admission Date: 2/24/2006 Report Status:
Discharge Date: 10/29/2006
****** FINAL DISCHARGE ORDERS ******
PORST , ISIDRA L 086-39-39-0
Geneno Blvd. , Olk Ard A , New Mexico 00896
Service: GGI
DISCHARGE PATIENT ON: 5/13/06 AT 09:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VOLTAREN ( DICLOFENAC SODIUM ) 75 MG orally twice a day as needed Pain
Instructions: please crush Food/Drug Interaction Instruction
Take with food
Alert overridden: Override added on 5/13/06 by :
SERIOUS INTERACTION: KETOROLAC TROMETHAMINE , INJ &
DICLOFENAC Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
Instructions: syrup
AROMASIN ( EXEMESTANE ) 25 MG orally BEDTIME
Starting IN a.m. ( 5/11 ) HOLD IF: NPO
Instructions: crush before giving
Number of Doses Required ( approximate ): 2
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
Instructions: please crush
ROXICET ORAL SOLUTION ( OXYCODONE+APAP LIQUID )
5-10 MILLILITERS orally every 4 hours as needed Pain
ZANTAC SYRUP ( RANITIDINE HCL SYRUP ) 150 MG orally twice a day
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Instructions: please crush Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ACTIGALL ( URSODIOL ) 300 MG orally twice a day
DIET: stage II gastric bypass
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please call Dr. Hornbeak immediately to schedule follow-up appointment ,
Please see primary care doctor in 2-3 weeks for medication management ,
ALLERGY: LEVOFLOXACIN
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
PMH HTN Hyperlipidemia Left breast cancer history of lumpectomy , chemo , XRT
Adenomatous polyp history of excision Obstructive sleep apnea , uses CPAP Asthma
GERD Hiatal hernia OA Gallstones Hepatic cyst Venous stasis LLE PSH
Left breast lumpectomy , October 2005
Left breast biopsy , left axillary LN biopsy , October 2005
STSG venous stasis ulcer on LLE , April 2003
Debridement left venous stasis ulcer , April 2003 Hysterectomy
L knee tibial osteotomy Umbilical hernia repair Jaw surgery
OPERATIONS AND PROCEDURES:
laparoscopic roux-en-y gastric bypass
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to the Nessinee Ker Hospital Medical Center surgery service after undergoing
LRYGB. No concerning intraoperative events occurred; please see dictated
operative note for details. Patient was transferred to the floor from
the PACU in stable condition. Patient had adequate pain control and no
issues overnight into POD1. The patient had an UGI on POD1 and 2 that
were
negative for obstruction or leak but did not show contrast past the
pouch. She did vommit POD 1 , but was able to tolerate the contrast on
POD2. Her lack of empting thought secondary to edema at surgical site and
it resolved by POD 3. The patient was then started on stage I gastric
bypass diet and advanced the following day to a Stage II diet that was
tolerated as well. JP draion removed POD 6. The remainder of the
hospital course was relatively unremarkable , and the pateint was
discharged in stable condition , ambulating and voiding independently , and
with adequate pain control. At discharge the incision was C/D/I , with no
evidence of hematoma collection or infection. The patient was given
explicit instructions to follow-up in clinic with Dr. Hornbeak in 1-2 weeks.
ADDITIONAL COMMENTS: You may shower 2 days after surgery , but do not tub bathe , swim , soak , or
scrub incision for 2 weeks. Bandage strips will fall off over time.
Seek medical attention for fevers ( temp>101.5 ) , worsening pain , drainage
or excessive bleeding from incision , chest pain , shortness of breath , or
any other symptoms of concern. Follow up with your surgeon in 1-2 weeks.
Please do not drive or consume alcohol while taking pain medications.
Resume home medications , but please note: zantac syrup is to replace
nexium. Crush all medicines. ***Please note- START
actigall in two weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KONEN , GENOVEVA M. , M.D. ( SH710 ) 5/13/06 @ 09:26 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 309
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
- |
N |
- |
Y |
N |
N |
N |
N |
- |
N |
978279966 | PUO | 99285615 | | 574624 | 10/20/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/21/1996 Report Status: Signed
Discharge Date: 10/1/1996
PRINCIPAL DIAGNOSIS: DYSPNEA ON EXERTION , KNOWN CORONARY ARTERY
DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old gentleman
with chest pain syndrome and known
coronary artery disease admitted with increasing exertional
dyspnea , thought to be his anginal equivalent. He was admitted for
medical management and possible laser angioplasty of an occluded
left circumflex coronary artery. In January 1995 , the patient was
admitted with an acute chest pain syndrome. Cardiac
catheterization , at that time , demonstrated 100% occlusion of the
left circumflex artery which was heavily calcified and not amenable
to balloon angioplasty. The patient underwent an exercise
tolerance test on May , 1995 where he exercised six minutes and
stopped secondary to fatigue. The patient had no chest discomfort
or ECG changes during the exercise test. He was discharged home on
a medical regimen , including enteric coated aspirin ,
hydrochlorothiazide 25 once a day , metoprolol 100 mg twice a day , nitro
patch 0.2 mg per hour , and sublingual nitroglycerin as needed The
patient also continued on Verapamil SR 240 mg twice a day for his high
blood pressure. At home , the patient reports that he has not been
exercising as frequently as he used to and his exercise regimen
usually consisted of 15 minutes on a ski machine three times a
week. He continues to get some exertional dyspnea and also has
episodes of chest pain , usually after a meal , while he is lying in
bed. This probably represents a reflux disease. Due to the
increasing frequency of his dyspneic episodes with exertion , the
patient contacted his primary cardiologist , Earnestine Fiermonte , and it
was felt that he probably needed to be admitted for better medical
management and to have an attempted laser angioplasty of his
occluded left circumflex artery.
ADMISSION MEDICATIONS: Enteric coated aspirin one tablet orally
every day , hydrochlorothiazide 25 mg orally
every day , Verapamil SR 240 twice a day , K-Dur 10 mEq every day , Lopressor 100
mg orally twice a day , and nitro patch 0.2 mg times two patches times two
hours every day.
PHYSICAL EXAMINATION: The patient is an elderly gentleman in no
apparent distress. His heart rate was 52
and regular. Blood pressure was 160/94. HEENT examination was
unremarkable. His lungs were clear. Cardiovascular examination
was significant for an S4 , normal S1 , S2 , no murmurs. His abdomen
was benign. His extremities had no clubbing , cyanosis , or edema.
LABORATORY DATA: His ECG showed sinus bradycardia at 56 with left
anterior vesicular block and right bundle branch
block , borderline left atrial enlargement. Chest x-ray was clear.
SMA-7 was normal other than a slightly high creatinine at 1.7 and a
low potassium of 3.1. He had a normal CBC and normal physical therapy/PTT.
ASSESSMENT: In summary , this is a 76-year-old gentleman with known
coronary artery disease , known occlusion of the left
circumflex with an exercise tolerance test one year ago without
evidence for ischemia. He presents with chest pain , shortness of
breath syndrome , etiology of which is unclear.
HOSPITAL COURSE: He was admitted to the Cardiology Enford Ard Ster team where
he underwent a exercise tolerance test on April ,
1996 , during which he went 4 minutes and 22 seconds. He stopped
secondary to dyspnea on exertion and leg fatigue with no chest
pain. He had nonspecific changes in his ECG , and his MIBI images
revealed inferolateral ischemia. On July , 1996 , he underwent
cardiac catheterization with laser assisted PTCA of his left
circumflex lesion , which he tolerated well. His post
catheterization course was slightly complicated by increased
bleeding from the groin site , as well as the possible development
of a hematoma versus pseudoaneurysm as a bruit was heard in the
right groin. This was evaluated with a vascular ultrasound which
showed no hematoma and no pseudoaneurysm. He was observed
overnight and was discharged on 8/26/96 in stable condition. His
blood pressure medications were manipulated for better control of
his significant hypertension , as well as for increased outpatient
compliance. During his hospitalization , urine cultures were sent
which grew alpha hemolytic Streptococcus. This was treated with
ampicillin initially and he will be sent home on pen-VK. Also of
note , during this admission , hemoglobin A1C was sent which was
slightly elevated at 7. He started on glyburide 5 mg orally every day.
However , the patient felt that he did not need to take this and
refused it. His medical team felt that it was more important for
him to be compliant with his hypertension and cardiac medications ,
at this juncture , and the issue of restarting glyburide will be
brought up in the outpatient setting by Dr. Fiermonte . He is
discharged today , August , 1996 with VNA services to monitor
medicine compliance and measure blood pressures , as well as for a
home safety evaluation.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
atenolol 100 mg orally every day ,
hydrochlorothiazide 25 mg orally every day , lisinopril 40 mg orally every day ,
Adalat CC 30 mg orally every day , nitroglycerin 1/150 one tablet
sublingually every 5 minutes times three as needed chest pain , Prilosec 20
mg orally every day , simvastatin 20 mg orally every bedtime , and pen-VK 250 mg
orally four times a day times five days.
Dictated By: FLO VERSIE TITTERNESS , M.D. JT55
Attending: EARNESTINE M. FIERMONTE , M.D. JJ5 AP176/7685
Batch: 10277 Index No. H1SJTGAUT D: 8/26/96
T: 8/18/96
Document id: 310
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
693115462 | PUO | 19551473 | | 9339465 | 3/27/2005 12:00:00 a.m. | CAD | | DIS | Admission Date: 6/10/2005 Report Status:
Discharge Date: 5/24/2005
****** DISCHARGE ORDERS ******
JERGENSON , OTILIA 740-75-78-0
Ry Ln.
Service: CAR
DISCHARGE PATIENT ON: 6/28/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARNABA , CARA CHANCE , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
LASIX ( FUROSEMIDE ) 60 MG orally twice a day
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 10/17/05 by
MCELRAVY , LILI , M.D.
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
54 UNITS every day before noon; 32 UNITS every afternoon subcutaneously 54 UNITS every day before noon 32 UNITS every afternoon
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LISINOPRIL 20 MG orally every day
Override Notice: Override added on 10/17/05 by
STIDMAN , GENOVEVA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 37884001 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: to replete k
NIFEREX-150 150 MG orally every day
Instructions: please give at a separate time from
levofloxacin
Alert overridden: Override added on 10/17/05 by
STIDMAN , GENOVEVA , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
POLYSACCHARIDE IRON COMPLEX Reason for override:
will separate temporally from levo administration
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual every 5 minutes X 3
as needed Chest Pain HOLD IF: SBP < 100
ZOCOR ( SIMVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/17/05 by
MCELRAVY , LILI , M.D.
on order for GEMFIBROZIL orally ( ref # 53243522 )
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 12.5 MG orally every day
Starting Today ( 1/14 ) Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 90 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ESOMEPRAZOLE 20 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician in 1-2 weeks ,
Dr Gruntz in 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of 4v CABG '94 ( coronary artery disease ) CHF , EF 50% '01
( congestive heart failure ) DM ( diabetes mellitus ) Anemia , 32-36
( anemia ) CVA ( cerebrovascular accident ) history of CCY ( history of
cholecystectomy ) Blindness ( visual impairment )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old WF with history of CAD history of CABG , CHF , CVA , chronic anemia , adm with
CP x 1 day; awoke at rehab with urinary urgency and nurse not
available , had cp that spont resolved; No orthopnea/PND , LE edema ,
LH/dizzy , chills , EKG showed lat ST depr , NZ( - ) x1; Exam: NAD. JVD
<10 cm. RRR 3/6 SEM +S3. CTAB. Abd dist , tympanic. Guaiac neg. no LE
edema bilat.
Hospital Course: 1. CV: I-recent cath 11/8 showed 100% prox LAD , 90%
LCx , 40% marg 1 , 100% prox RCA , 2 occl + 1 patent CABG v ( unchgd from
last cath in '99 ). patient was r/o with nz's ans serail EKG's; needs to Cont
med mgmt with ASA , ACE , Plavix. P-H/o CHF with likely diast dysfxn , echo 4/2
showed EF 55% , no WMA , tr MR , trivial peric eff. patient remained euvolumic
in house on aint lasix; R/R: patient had been on toprol 75 on admit but has
HR here in 40s when awake without any B-Blocker. will dc on 12.5 every day; consid
emergency room o/p EP eval for pacer to get B-blocker on baord.
2. Endo: patient was cont on her home dose of nph + RISS.
3. Renal: Cr Stable.
ADDITIONAL COMMENTS: please take all meds as prescribed; if you HR is low<45 please call
your doctor immediately; monitor weights; f/u with pcp and cardiogist
in 1-2 weeks;
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
patient to cont on anti anginal regimen and maint lasix; moniotr weights;
patient/ot twice a day; consider o/p eval for possible ppm if bradycardis still an
issue; abx for 7 days for UTI;
No dictated summary
ENTERED BY: MCELRAVY , LILI , M.D. ( TA80 ) 6/28/05 @ 02:13 PM
****** END OF DISCHARGE ORDERS ******
Document id: 311
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
842385275 | PUO | 27156611 | | 3489868 | 8/28/2003 12:00:00 a.m. | CHF | | DIS | Admission Date: 10/20/2003 Report Status:
Discharge Date: 3/17/2003
****** DISCHARGE ORDERS ******
BRIDENBAKER , FAYE E 573-05-52-4
St.e
Service: CAR
DISCHARGE PATIENT ON: 10/2/03 AT 06:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KUSH , QUINN JAKE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting IN a.m. ( 9/22 )
FOLATE ( FOLIC ACID ) 1 MG orally every day
LACTOBACILLUS 2 TAB orally three times a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 75 MCG orally every day
LOPERAMIDE HCL 4 MG orally twice a day
DITROPAN ( OXYBUTYNIN CHLORIDE ) 1.25 MG orally twice a day
LEVATOL ( PENBUTOLOL SULFATE ) 20 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 7
MVI THERAPEUTIC W/MINERALS ( THERAP VITS/MINERALS )
1 TAB orally every day
KAOPECTATE SUSPENSION ( BISMUTH SUBSALICYLATE ... )
30 MILLILITERS orally every day
BACTRIM DS ( TRIMETHOPRIM /SULFAMETHOXAZOLE DO... )
1 TAB orally twice a day X 7 Days Starting Today ( 9/22 )
CASODEX ( BICALUTAMIDE ) 50 MG orally every day
Number of Doses Required ( approximate ): 7
AVAPRO ( IRBESARTAN ) 75 MG orally every day
Number of Doses Required ( approximate ): 7
LASIX ( FUROSEMIDE ) 10 MG orally every day
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
AS CURRENTLY SCHEDULED ,
ALLERGY: Unknown , Ace inhibitors
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , history of MI ( coronary artery disease ) pancytopenia ( pancytopenia ) DM
( diabetes mellitus ) HTN
( hypertension ) lgib ( lower GI bleeding ) pvd ( peripheral vascular
disease ) chf ( congestive heart failure ) cva ( cerebrovascular
accident ) prostate ca ( prostate cancer ) pmr ( polymyalgia
rheumatica ) history of colonic resection
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
74 year-old M with hx CAD history of 5v CABG 3/10 , CHF , HTN , DM , PVD , prostate CA history of
prostatectomy presents with 2 d hx SOB , confusion , shoulder pain. patient
was in USOH out with wife to lunch Friday ( 3 d PTA ) before admission ,
ate onion soup and club sandwich , then on Sat felt nauseated , SOB ,
confused. Wife noted that patient could not lie down to sleep Sat night
( usually 3 pillow orthopnea ). Sx cont through Sun , wife brought to ED
on Mon , day of admission. patient recently in PUO ED , rx for UTI 1/7 . In
ED patient afebrile , HR 59 , BP 152/61 , Sa 97% on 4L NC. On exam found to
have JVP elevated 12-14 cm H2O , bibasilar rales , dec breath sounds at
bases , RRR , no murmurs , no gallops , 1+ pitting edema bilat LE. Labs
significant for Na 144 Cl 113 , Hco3 19 , BUN 30 , Cr 1.9 , platelets 97.
UA showed 15-20 WBC , 2-5 RBC. EKG was unchanged , CXR showed worsening
bilat pleural effusions.
Hospital Course:
1. CV- patient was not r/o secondary to low probability of ischemia. CHF
exacerbation likely secondary to Na overload from patient's meal the Friday
before admission. patient was diuresed gently with 20 lasix intravenous x 2 on the
first day of admission and then received 20 orally lasix on the day of
discharge. The patient's pulmonary status and mental status improved with
diuresis and his JVD decreased to approx 8 cm H2O on exam.
2. ID: patient with presumed UTI , rx with bactrim
3. Disposition: patient was eval by physical therapy , who made recs for home physical therapy for the
patient This arrangement was satisfactory for the patient and his wife. He
will follow up with all of his physicians with his regular scheduled
appointments.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ARUIZU , JULIANNE MARIE , M.D. ( QS40 ) 10/2/03 @ 12:51 PM
****** END OF DISCHARGE ORDERS ******
Document id: 312
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
571068456 | PUO | 46331544 | | 2127146 | 1/8/2006 12:00:00 a.m. | morbid obesity , history of lap gastric bypass | | DIS | Admission Date: 3/4/2006 Report Status:
Discharge Date: 7/10/2006
****** FINAL DISCHARGE ORDERS ******
HOTZE , KURTIS 652-85-97-9
Desco Verl Ragefordfont
Service: GGI
DISCHARGE PATIENT ON: 2/18/06 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACTIGALL ( URSODIOL ) 300 MG orally twice a day
Starting IN a.m. on 8/29/06
ROXICET ELIXIR ( OXYCODONE+APAP LIQUID )
5-10 MILLILITERS orally every 4 hours as needed Pain
ZANTAC SYRUP ( RANITIDINE HCL SYRUP ) 150 MG orally twice a day
DIET: Stage 2 gastric bypass
ACTIVITY: as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Hornbeak 2 weeks ,
Primary care physician 1 week ,
ALLERGY: Aspirin
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity , history of lap gastric bypass
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OSA
OPERATIONS AND PROCEDURES:
lap roux-en-y gastric bypass
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
upper gi
BRIEF RESUME OF HOSPITAL COURSE:
42 year-old male with morbid obesity.
PMH: OSA
MEDS: benadryl , fioricet
ALL: ASA - swelling
Patient admitted to surgical service and underwent Lap Roux en Y gastric
bypass without complication. Postoperative course uneventful.
Neuro: Pain initially controlled on PCA but transitioned over to orally pain
elixir when taking orally's.
CV: No issues with BP or HR during hospital stay.
Resp: Ambulating POD1 without difficulty.
GI: UGI on POD1 was negative for leak or obstruction , and patient was
started on Stage 1 gastric bypass diet per protocol. Upon discharge
patient is tolerating stage 2 gastric bypass diet.
GU: Foley removed POD1 without difficulty , upon discharge patient is
voiding without difficulty.
Heme: Received DVT prophylaxis with SQH and SCDs while in house.
At time of discharge patient is afebrile , vitals stable , tolerating stage
2 gastric bypass diet , ambulating.
ADDITIONAL COMMENTS: Do not drive while taking narcotic pain medication. Call or go to local
ER for fever>101 , increased redness/discharge from incision site , or if
you develop sudden onset of abdominal pain , nausea/vomiting. Crush all
medication.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE , M.D. ( UK91 ) 2/18/06 @ 02:02 PM
****** END OF DISCHARGE ORDERS ******
Document id: 313
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| output/system_intuitive_annotation.xml | intuitive |
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007844210 | PUO | 44738326 | | 7545562 | 8/6/2006 12:00:00 a.m. | RIGHT CHRONIC LEG ULCER | Signed | DIS | Admission Date: 3/6/2006 Report Status: Signed
Discharge Date: 1/16/2006
ATTENDING: BILSBOROUGH , MOHAMED BEA MD
CHIEF COMPLAINT: The patient was transferred from Griffcoo Nonster Hospital for care of a right calf ulcer , fever and
elevated white blood cell count.
HISTORY OF PRESENT ILLNESS: Ms. Christenson is a 77-year-old woman
with multiple medical problems including history of
cerebrovascular accident with resultant expressive aphasia ,
seizures after this cerebrovascular accident , chronically
ventilator dependent , end-stage renal disease on hemodialysis as
a complication likely of gentamicin in July 2006 , history of
peripheral arterial disease with multiple toe amputations and
atrial fibrillation who was recently admitted at Tonsta Ean Villebaxt Hospital for an increasing BUN and creatinine ,
who was transferred from Porangecatheox Medical Center Of after she
developed an ulcer on her right lower extremity. At baseline ,
the patient is bed bound , but is alert , able to smile and
communicates by mouthing words occasionally. She developed a
right calf hematoma several weeks prior to this admission that
was incised and drained by the Surgical Service about one to two
weeks prior to admission. Since then she has had daily dressing
changes at her rehabilitation and at first her skin was noted to
be intact. On 10/13/06 , the patient had an increased temperature
to 100.1 degrees Fahrenheit and then four days prior to
admission , she was noted to have a white blood cell count of
22 , 000. She was placed on empiric vancomycin , levofloxacin and
metronidazole on 10/13/06 for possible treatment of
ventilator-assisted pneumonia and she had remained
hemodynamically stable. There was no note of increased
secretions or other problems with ventilation. On the day of
admission , the patient was on hemodialysis and a blister erupted
over her right calf wound , which revealed an underlying deep
ulcer down to the muscle. At that point , the patient's son
requested admission to Pagham University Of for
evaluation of the ulcer by the patient's vascular surgeon , Dr.
Derham .
REVIEW OF SYSTEMS: Was only notable for several days of diarrhea
prior to admission.
PAST MEDICAL HISTORY:
1. Chronically ventilator dependent since April of 2005
secondary to status epilepticus and failure to wean off the
ventilator. The patient was on SIMV with a backup rate of 2 ,
pressure support of 20 and PEEP of 5 and an FIO2 of 0.4 on
admission.
2. End-stage renal disease secondary to gentamicin-induced acute
tubular necrosis on hemodialysis Monday , Wednesday and Friday.
3. Status post aortic valve replacement with a St. Jude's valve
in 1998 for aortic stenosis.
4. Atrial fibrillation.
5. Coronary artery disease.
6. Congestive heart failure with a preserved ejection fraction of
55% and diastolic dysfunction.
7. Type 2 diabetes.
8. Obesity.
9. Peripheral arterial disease.
10. Seizure disorder since 1974.
11. Cerebrovascular accident with expressive aphasia in 1974.
12. Primary biliary cirrhosis. No biopsy for diagnosis , on
ursodiol.
13. History of pressure ulcers on her lower extremities and
presacrally.
14. Hypercholesterolemia.
15. Remote history of pulmonary sarcoidosis , not noted to be
active.
16. Depression with psychosis postpartum.
17. Esophageal ulcers in the past.
18. Low back pain.
19. Status post L1-L2 spinal fusion.
20. Status post right second , third and fourth toe amputation by
Dr. Derham .
20. Status post tracheostomy and gastric tube.
MEDICATIONS AT REHABILITATION. Coumadin 4 mg by mouth daily ,
simvastatin 10 mg by mouth daily , ursodiol 600 mg by mouth daily ,
Nexium 40 mg by mouth twice a day , Prozac 20 mg by mouth daily ,
Keppra 500 mg daily and then 250 mg after hemodialysis
additionally , Synthroid 75 mcg daily , Reglan 10 mg three times a
day , albuterol and Atrovent six puffs four times a day through the vent ,
Artificial Tears three times a day , Colace 100 mg twice a day ,
erythropoietin 10 , 000 units with hemodialysis , insulin NPH 30
units every day before noon , sliding scale insulin , multivitamin and calcium
carbonate with vitamin D three times a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a widow. She has been at Porangecatheox Medical Center Of for a long time. The phone number there is
651-835-9986. She does not use tobacco , alcohol or illicit
drugs. She has two sons , Agueda Ramonita Schraub . Their health care
proxy to our knowledge is Schraub with a phone number of
966-899-4891 , Breutzmann telephone number is 802-848-3597.
FAMILY HISTORY: Notable for multiple family members with stroke ,
diabetes , hypercoagulability and a son with two pulmonary emboli.
PHYSICAL EXAMINATION: On admission , the patient's temperature
was 96 degrees Fahrenheit , heart rate was 60 and irregular , blood
pressure was 115/65 , respiratory rate was 28 on the ventilator
and oxygen saturation was 100%. She was on pressure support at
15 and 5 with an FIO2 of 100% at that time. In general , the
patient was an elderly woman who was able to follow commands by
squeezing a hand but otherwise is unable to communicate , in no
obvious respiratory distress. HEENT: The patient had a
tracheostomy. Her pupils were equal and reactive to light. No
jaundice. Her neck was supple. There were exudates under her
tracheostomy ties. There is erythema around her tracheostomy
site. Pulmonary: The patient had coarse rhonchi diffusely.
Cardiovascularly: The patient had an irregularly irregular
rhythm , but no other abnormalities were noted. The jugular
venous pressure could not be assessed. Her abdomen was obese.
There is a G-tube , which was clean , dry and intact with no
exudate. She had a yellow liquid stool. Extremities: There are
multiple pressure ulcers on her lower extremities , the most
notable was a deep right calf ulcer down to the muscle with some
clotted blood , no pus or surrounding erythema. She also had a
stage II to III sacral decubitus ulcer about 5 cm in diameter.
Neurologically: The patient was awake , was unable to communicate ,
but did express understanding by following commands. Tubes/
access: The patient has as a left arm midline , which was placed
in mid July at Porangecatheox Medical Center Of . She has a right-sided
Hickman line for hemodialysis. Tubes and drains , the patient has
a Foley in place. Her chest radiograph on admission showed
status post thoracotomy with a tracheostomy tube in place ,
enlarged heart , elevated right hemidiaphragm which is old , a
question of a right lower lobe infiltrate and bilateral mild
pulmonary edema.
LABORATORY DATA: Sodium of 137 , potassium of 3.3 , chloride of
96 , bicarbonate of 28 , BUN of 49 , creatinine of 2.5 , glucose of
165 , her calcium was 9.5 , her anion gap was 13. Her ALT was 9 ,
AST was 60 and alkaline phosphatase 127. Total bilirubin was
0.6 , total protein of 7.2 with an albumin of 3.0. She had 15 , 400
white blood cells , hematocrit of 32.8% with an MCV of 100 ,
platelets of 307 , 000 , PTT of 68 , INR of 3 , 84% lymphocytes and 2%
monocytes. Her urinalysis showed 2+ protein , 2+ blood , 3+
leukesterase , nitrite negative , greater than 200 white blood
cells , 10 to 15 red blood cells , 4+ bacteria , 1+ calcium oxalate
crystals , 4+ budding yeast. No eosinophils.
ASSESSMENT ON ADMISSION: The patient is a 77-year-old woman
history of diffuse vascular disease and end-stage renal disease
who presented with fever , elevated white blood cell count and a
new right calf ulcer.
Hospital course and plan as well as discharge medications will be
dictated separately.
eScription document: 2-0994330 CSSten Tel
Dictated By: BIRDETTE , KATHARYN
Attending: BILSBOROUGH , MOHAMED BEA
Dictation ID 9266593
D: 11/12/06
T: 11/12/06
Document id: 314
| Target |
Ast |
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CHF |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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263175973 | PUO | 25953994 | | 3110465 | 2/7/2006 12:00:00 a.m. | WEAKNESS | Signed | DIS | Admission Date: 7/15/2006 Report Status: Signed
Discharge Date: 6/2/2006
ATTENDING: DELMENDO , CRISTINE M.D.
PRINCIPAL DIAGNOSIS:
Failure to thrive.
OTHER DIAGNOSES:
Marfan syndrome , migraine , restrictive lung disease , diabetes
mellitus , history of aortic dissection , and opioid abuse.
HISTORY OF PRESENT ILLNESS:
This is a 59-year-old woman with multiple medical problems
including Marfan syndrome , restrictive lung disease , and diabetes
who presented with failure to thrive at home. She was seen by
her VNA on the day of admission who was worried about her
declining clinical picture including lethargy and poor
responsiveness and the decision was made in conjunction with the
primary care physician to admit. On admission , the patient is complaining of
chronic hip and leg pain that she describes as sciatic leg. She
was recently discharged from Norap Valley Hospital after being
admitted for pain control and opioid addiction. She was seen by
the psychiatry team there who thought that she has also had
significant anxiety components and she was started there on
suboxone as needed for pain given it has less potential for
abuse. She was also followed by the pain clinic and had been
using fentanyl patches.
PAST MEDICAL HISTORY:
Marfan syndrome with aortic insufficiency and mitral valve
regurgitation. She is status post mitral valve replacements with
a St. Jude valve , also migraines , restrictive lung disease , and a
history of a subdural hematoma in 1990 and 2002. She has
radiologic evidence of an old left-sided CVA , diabetes mellitus ,
history of aortic dissection , she is on 4 L of home oxygen ,
glaucoma , GERD , status post pacemaker placement , subdural
evacuation , question hiatal hernia. EV repair.
ADMISSION MEDICATIONS:
Clarinex 5 mg daily , Lasix 40 mg orally twice a day , Duragesic patch 12
mcg per hour , digoxin 0.25 mg daily , Coumadin 2 mg daily , Fosamax
weekly , glyburide 2.5 mg daily , Tylenol With Codeine as needed ,
Lipitor 10 mg daily , Lidoderm , MS Contin 15 mg twice a day , oxybutynin
5 mg daily , Protonix 40 mg daily , Zoloft 25 mg daily.
SOCIAL HISTORY:
Tobacco use in the past about 14 years two packs per day , no
alcohol , no recreational drug use.
FAMILY HISTORY:
No known family history of Marfan. It may be mild disease in a
sibling. She has a sister who is also involved in her care.
Contact information for the sister is the e-mail address
dfxpswdm@ovp.uyf.
ALLERGIES:
Tetracycline analogs unknown reaction , nitrofurantoin unknown
reaction , ampicillin unknown reaction , quinidine unknown
reaction , morphine excessive somnolence , sulfa drug hives ,
erythromycins unknown reaction , ciprofloxacin hives. According
to the patient , she has taken ampicillin without trouble in the
past.
PHYSICAL EXAMINATION ON ADMISSION:
Temperature 98 , pulse 68 , blood pressure 90/60 , respiratory rate
16 , satting 91% on 2 L. She was in no acute distress. She was
talkative. Her mucous membranes are moist. Cranial nerves II
through XII are intact. Pupils were small. Neck: Her JVP was
flat. Cardiovascular: Regular rate and rhythm with occasional
ectopy. Respiratory: Clear to auscultation with bibasilar rales
bilaterally. Abdomen: Soft , nontender , nondistended.
Extremities: No edema. Neurologic: Alert and oriented x3.
Skin was flaky. She had ridging in her nails.
ADMISSION LABORATORIES:
Notable for sodium 142 , potassium 3.7 , chloride 93 , bicarbonate
40 , BUN 23 , creatinine 0.8 , glucose 139 , calcium 8.7 , ALT 85 , AST
88 , T. bili 0.9 , alkaline phosphatase 70 , albumin 4.0 , PTT 36 ,
INR 2.1 , digoxin level was 2.5 , white count 7.8 , hematocrit 34.6.
Chest x-ray moderate-to-severe cardiac enlargement , tortuous
aorta , evidence of prior cardiac surgery , left lower lobe
parenchymal opacification right base , no significant change from
baseline. EKG was within normal limits. There were no signs of
heart failure and the faint right lower lobe opacity was
suggestive of vessel crowd/atelectasis.
HOSPITAL COURSE BY SYSTEM:
Consults: She was followed by her outpatient cardiologist , Dr.
Kush , e-mail address nizwde@ltwfywcn.dgp. His phone number is
363-604-9315. Kernan To Dautedi University Of Of beeper is 05024. For psychiatry , the
contact person is Arlene Mcquiggan . Can be paged through the
Kernan To Dautedi University Of Of paging system.
1. Neurologic: This is a patient with chronic pain syndrome ,
plus or minus history of narcotic addiction and recent detox at
Norap Valley Hospital and likely abused/overuse of narcotics prior to
this admission at home. The plan was to treat her without using
narcotics. She was maintained on Tylenol , ibuprofen , tramadol ,
clonazepam , and Zyprexa. On 10/27/06 , she fell in her room and
hit her head on the side of the bed/commode. She denied any loss
of consciousness. She does not remember the event. She was
alert and oriented x2. She was given a head CT , which showed no
acute intracranial abnormality , no hemorrhage , infarct , mass , or
midline chest. She did have some mild-to-moderate ischemic and
involutional changes and she had evidence of a prior craniotomy
on the left. Slight asymmetry of the sulci versible since 7/25 .
Ventricles unchanged and within normal limits. She was seen by
the neurology service. They suggested continuing to follow her
neurological exam checking a lipid profile and involving physical
therapy in her care. On their neuro exam , they found that she
had a normal affect , slow procity and tone , a tendency to loose
her chain of thought. Cranial nerves II through XII intact. 4/5
weakness in the left quad and right hamstrings muscles otherwise
5/5 throughout. Upgoing toe on the right and muted on the left.
Otherwise reflexes 2 throughout bilateral sensation and they were
unable to walk the patient at that time.
2. Psych: She was seen by the psych service here. Speech ,
appearance , behavior and her initial mental status examination:
Appearance and behavior , he was slightly disheveled wearing
hospital gown , supine in bed , calm , some PMR. Speech was slow at
times and normal volume and tone. Mood was euthymic. Affect
restricted. Thought content , denied auditory hallucinations ,
visual hallucinations , suicidality , homicidality , however , she
did report that she had auditory and visual hallucinations the
night preceding the examination. Her thought process was
circumstantial. Her insight and judgment was impaired. She was
oriented to place , name , and time. Memory was 3/3 at 0 minutes ,
0/3 at 3 minutes , and 2/3 with multiple choice. Her language was
fluent. She knew the order of recent presidents. Their
impression was that she had an abnormal cognitive exam including
short-term memory and concentration deficits. Recent auditory
and visual hallucinations and delusions in the setting of her
elevated digoxin level and recent falls they did recommend
continued hospitalization and then rehabilitation.
AXIS I: Multifactorial acute delirium and depression and opioid
abuse by history.
AXIS II: Deferred.
AXIS III: Past medical history as described above.
AXIS intravenous: Severe.
AXIS V: 30.
They recommended treating the underlying causes of delirium ,
which did improve during the hospital stay using Zyprexa 5 mg
orally at bedtime , as needed Klonopin with a slow taper. She had a CT
of the cervical spine without contrast. This showed cervical
spondylosis with reversal of normal cervical lordosis. No
evidence of fracture and left C4 , C5 foraminal lesion. C1
through C4 vertebral bodies were intact. No disc herniation ,
central foraminal stenosis at C5-C6 and the C7-T1 was
unremarkable.
Cardiovascular: Pump: She has a history of aortic root
dissection. Her echo in the past was consistent with aortic root
dilatation , stable. She is maintained on Coumadin for her
valves. Her goal INR is 2.5 to 3.5. Since she was
subtherapeutic at admission she was maintained on Lovenox until
her INR became therapeutic. Her goal INR is 2.5 to 3.5. Her
Coumadin doses were adjusted daily during her hospital stay and
will continue to need to be adjusted. She will need to continue
to have her INR checked daily and her dose generally has been
between 3.5 and 3.75 mg per day. This will need to continue to be
adjusted and the goal should be the higher end of 2.5 to 3.5.
Rhythm: She had a pacemaker placed in the past secondary to a
second-degree AV block. She was continued on her nadolol. Her
digoxin level was held since it was supratherapeutic at admission
and then restarted at 0.125 mg per day. Her digoxin level should
be followed at the skilled nursing facility. Ischemia: She has
no history of coronary artery disease. She is on Lipitor at
home. She was maintained on Zocor 20 mg here and she was not on
aspirin per Dr. Kush .
Endocrine: She has a history of diabetes mellitus. She was
maintained on her glyburide and she refused to have any insulin
during this admission.
GI: She has a history of GERD. She is on Protonix at home. She
was maintained on Nexium during her hospital stay. She was also
given a bowel regimen given her narcotics use.
Urology: She had a history of recent urinary retention in the
setting of narcotic use as well as taking a medication for
urinary incontinence. A urine culture taken on 10/26/06 grew out
greater than 100 , 000 colonies of E. coli that was pan
susceptible. She does have multiple medication allergies , but
she was started on ampicillin since she has taken this in the
past without difficulty.
Pain: She was seen by the pain service inhouse. They commented
that she had whole body pain , but was having difficulty
self-medicating appropriately. Suggested that she would be in an
environment where her medications could be controlled. They
recommended starting her on Cymbalta , generic name is duloxetine.
They recommended starting at 30 mg at bedtime and titrating up
gradually to 60 mg twice a day as tolerated. They also recommended a
Lidoderm patch to the tender area holding narcotics and they will
be happy to see this patient again once she is discharged.
Code: She is full code.
Prophylaxis: She was on Coumadin , Lovenox when her Coumadin was
subtherapeutic , and she was on a PPI.
PHYSICAL EXAMINATION ON DISCHARGE:
She was afebrile pulse ranging from 66 to 72. Blood pressure
ranging from 96 to 110/60 to 70 , respiratory rate 18 to 20 ,
satting 93%-98% on 4 L. General: Well appearing , in no acute
distress. Pulmonary: She had crackles at the bases bilaterally.
Cardiovascular: Regular rate and rhythm with occasional ectopy.
Loud mechanical click. 2/6 systolic ejection murmur. JVP is
about 8 cm. Abdomen: Soft , nontender , positive bowel sounds.
Extremities: She has trace edema bilaterally.
DISCHARGE LABORATORIES:
Sodium 139 , potassium 4.1 , chloride 91 , CO2 43 , BUN 11 ,
creatinine 0.6 , glucose 181 , calcium 9.1 , magnesium 1.4 , digoxin
level 0.6 , white blood cell count 5.96 , hematocrit 35.1 ,
platelets 252 , 000. INR 3.5 , PTT 51.9.
DISCHARGE MEDICATIONS:
Tylenol 1 g every 4 hours as needed pain and headache , albuterol nebulizer
2.5 mg nebulizer every 4 hours as needed shortness of breath and wheezing ,
amoxicillin 500 mg orally three times a day for a total of 8 additional doses
starting this evening of 8/21/06 , clonazepam 1 mg orally twice a day
as needed for anxiety , digoxin 0.125 mg orally daily should be
adjusted as needed based on levels , Colace 100 mg orally twice a day ,
Lasix 40 mg orally twice a day , glyburide 2.5 mg orally daily , ibuprofen
600 mg orally every 6 hours as needed pain , milk of magnesia 30 ml orally daily
for constipation , nadolol 60 mg orally daily holding for a systolic
blood pressure below 100 or heart rate below 55 , timolol maleate
0.25% one drop each eye daily , potassium slow release 40 mEq
daily , Pepto-Bismol suspension 30 ml orally four times a day upset stomach ,
tramadol 50 mg orally every 6 hours as needed for pain , Zyprexa 2.5 mg orally
twice a day as needed agitation , latanoprost one drop each eye every afternoon ,
brimonidine tartrate one drop each eye every 8 hours , Zydis 5 mg
sublingual at bedtime , Lidoderm 5% patch topical daily , Maalox
tablets one to two tablets orally as needed every 6 hours for upset stomach ,
duloxetine 30 mg orally at bedtime , Lipitor at 10 mg orally daily ,
Protonix 40 mg orally daily.
FOLLOW-UP APPOINTMENT:
She has a follow-up appointment with Dr. Hoerter on 1/26/06 at
3:30 p.m. She will also need follow up with Dr. Kush to be
arrange.
This patient will be going to Viter Setter's Memorial Healthcare Center Kofsund Lane
TO DO:
1. INR: Her INR goal is 2.5 to 3.5 prefer the higher end of
that for her mechanical valves. She will need daily INR checks
given that she is not in a steady state. The likely dose of
Coumadin need to be 3.5 to 3.75 mg per day.
2. For her UTI , she needs an additional eight doses of
amoxicillin to complete her course of treatment.
3. Per the pain team , her duloxetine , which is now at 30 mg at
bedtime can be titrated as high as 60 mg twice a day as needed.
eScription document: 5-5457684 EMSSten Tel
CC: Viter Setter's Memorial Healthcare Center
Wa Fort Salt
Dictated By: TARBERT , BEATA
Attending: DELMENDO , CRISTINE
Dictation ID 9844160
D: 8/21/06
T: 8/21/06
Document id: 315
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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N |
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N |
U |
Y |
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U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
N |
N |
N |
N |
- |
N |
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N |
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- |
N |
362241745 | PUO | 66750039 | | 193617 | 1/25/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/25/1991 Report Status: Signed
Discharge Date: 1/15/1991
PRINCIPAL DIAGNOSIS: RESTENOSIS OF LEFT ANTERIOR DESCENDING
CORONARY ARTERY AND STATUS POST ANGIOPLASTY.
OTHER PROBLEMS: RESTENOSIS OF LAD CORONARY ARTERY FOLLOWING PTCA
IN July .
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
firefighter , who is status post PTCA
in September 1991 who presents with a two day history of fleeting
left arm pain. CARDIAC RISK FACTORS: ( 1 ) Includes a distant
history of smoking , ( 2 ) borderline increased cholesterol , ( 3 )
positive family history. He does not have hypertension. He does
not have diabetes mellitus. The patient was without significant
cardiac history until 11/10/91 when he developed mild substernal
chest pain with exertion relieved by rest. There was shortness of
breath and diaphoresis. On 9/30/91 , he again had substernal chest
pain with exertion and was relieved by rest , but recurred with more
exertion. There was no radiation to the neck or the arms. At
Ternley Alestate Hospital , where he presented with the pain , the
pain was gone with oxygen and one sublingual Nitroglycerin. EKG
was initially normal , but with more changes. There were flipped
T-waves which were relieved by intravenous heparin and sublingual
Nitroglycerin. His CK's at that time were 54 , 59 , 46 , 54 , and 36.
The isoenzymes were negative. On 4/26/91 , he was transferred to
the Pagham University Of . Catheterization revealed 70-80%
stenosis of the proximal LAD which was thrombosed. His LV function
was approximately 76% ejection fraction. On 5/22/91 , he developed
substernal chest pain after the heparin was stopped , which resolved
with restarting the heparin. On 2/2/91 , he had a PTCA which
decreased the lesion from 90% stenosis to 10% without
complications. On 10/23/91 , he was discharged on Lopressor and
Aspirin. Since then , the patient has been pain free and without
shortness of breath. One day prior to admission , while a passenger
in a car back to Cean Sta Sy , he noted 5-10 episodes of fleeting 15
second episodes of achiness in his left arm from the shoulder to
the fingertips. He denies shortness of breath , chest pain , or neck
pain. He denies a history of trauma. He has a history of
arthritis , but not to the left arm. On the day of admission , he
had a few more episodes of "achy" pain in the left arm. He
presented to CHH , and his EKG showed T-wave inversions in II ,
T-wave flattening in III , with normalization in v2 and V3. He had
upright T-waves in V4 , V5 , and V6 compared to downhard T-waves on
10/23/91 . There were no Q-waves. Again , he denied chest pain ,
shortness of breath , neck or jaw pain , diaphoresis , or
palpitations. He presented to the Pagham University Of
Emergency Room. PAST MEDICAL HISTORY: Includes arthritis in the
knees , history of kidney stones , and low back pain. MEDICATIONS ON
ADMISSION: Lopressor 25 mg orally twice a day and Aspirin one tablet orally
every day He has no known drug allergies. FAMILY HISTORY: Was
positive for a mother with diabetes and heart disease. SOCIAL
HISTORY: He is a retired firefighter. REVIEW OF SYSTEMS: Showed
no melena , no bright red blood per rectum , no dysuria , no abdominal
pain , and no evidence of claudication. He has occasional knee
discomfort.
PHYSICAL EXAMINATION: He is afebrile with a blood pressure of
130/90 , heart rate 60 , and a respiratory
rate of 18. He was a well developed , well nourished white male in
no acute distress. His HEENT exam was benign. Neck: Carotids
were 2+ without bruits. Back exam showed that the lungs were clear
to auscultation. There was no CVA tenderness. Heart exam was a
regular rhythm and rate , bradycardiac , S1 and S2 , without murmurs ,
rubs , or gallops. Abdominal exam was benign. Pulses were 2+ ,
carotids were 2+ on the right and the left , 2+ at the femorals
bilaterally , the posterior tibialis was 2+ , and the dorsalis pedis
was trace to 0 in both feet. All of the toes were warm. The feet
were warm and without discoloration. Rectal exam was deferred.
Extremities: Without clubbing , cyanosis , or edema.
LABORATORY EXAMINATION: Were unremarkable. The BUN was 13 ,
creatinine 0.9. He had a CK of 39
initially , and the following results were 33 eight hours after the
initial one , and then 24 eight hours after the second CK. His
liver function tests were unremarkable. The physical therapy and PTT were 11.7
and 30.3 respectively. He had a white count of 8.5 thousand , and
he had a hematocrit of 39.4 with an MCV of 87 and 261 , 000
platelets. His chest x-ray showed normal heart size. There was no
effusions or infiltrates. The EKG showed sinus bradycardia at 55 ,
normal intervals , axis of -60 degrees. There were T-wave
inversions in II and T-wave flattening in III , pseudonormalization
in V2-V3 , with upright T-waves in V4 , V5 , and V6 compared to a
10/23/91 tracing. Because of the atypical nature of the chest pain
and because it did not reproduce the chest pain that he had in
September , the patient was not put on intravenous heparin. He was given an
exercise stress test , full Bruce protocol , the following day which
showed marked lateral 3-4 mm depressions in the lateral leads ,
consistent with ischemia. He had no chest pain or shortness of
breath during the entire exercise stress test which lasted
approximately ten minutes. He stopped secondary to fatigue only.
He was brought to cardiac catheterization on the following day ,
7/7/91 . A stenosis of the LAD lesion was found in the same place
where this stenosis had been two months ago. PTCA of this lesion
was successful although the final report is pending at the time of
this dictation.
DISPOSITION: He is discharged to home on Lopressor 25 mg orally
twice a day and Aspirin 80 mg orally every day He is advised to
followup with his physician , Dr. Bree Theiling at CHH . He is
discharged home in fair to good condition. He should have no
difficulties in activities because of this hospitalization.
TB064/7264
BREE M. THEILING , M.D. IY1 D: 3/10/91
Batch: 4563 Report: N2674F74 T: 3/3/91
Dictated By: CLARETHA C. HENDY , M.D.
cc: 1. BREE THEILING , M.
c/o CHH - Aubelle Riiford
Document id: 316
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357007009 | PUO | 73091725 | | 9215128 | 11/23/2006 12:00:00 a.m. | NEW ONSET DIABETES | Unsigned | DIS | Admission Date: 10/21/2006 Report Status: Unsigned
Discharge Date: 3/26/2006
ATTENDING: HAUB , PERRY M.D.
DIAGNOSIS: New-onset diabetes
HISTORY OF PRESENT ILLNESS: A 45-year-old man with a history of
familial cardiomyopathy and status post cardiac transplant in
2002 , and chronic renal insufficiency presented with greater than
two weeks of polyuria , polydipsia , blurry vision , muscle cramps ,
and myalgias and reported approximately a 15-pound weight loss
over three weeks with decrease in usual lower extremity edema.
Was seen by his primary care physician on the day of admission and found to have a
fingerstick of 1000. The patient also reported sore throat and
cough times several days , but otherwise review of systems is
negative.
PAST MEDICAL HISTORY:
1. Cardiomyopathy , status post transplant and AICD placement.
2. Chronic renal insufficiency.
3. Hypothyroidism.
4. Tricuspid regurgitation.
5. History of pancreatitis.
6. Gout.
MEDICATIONS ON ADMISSION: Calcium carbonate 1250 mg three times a day ,
Cartia XT 300 mg daily , CellCept 1500 mg twice a day , colchicine 0.6
mg daily as needed , Neoral 150 mg twice a day , folate 1 mg daily , K-dur
20 mg daily , magnesium oxide 400 mg twice a day , methotrexate 2.5 mg
daily , Pravastatin 20 mg daily , prednisone 7 mg daily , Rocaltrol
0.25 mg daily , Synthroid 150 mcg daily , Torsemide 40 mg daily ,
Vitamin C , Vitamin E , and cyclosporin 150 mg twice a day
ALLERGIES: Penicillin leads to "shaking."
PHYSICAL EXAMINATION ON ADMISSION: Notable for temperature 98.8.
Blood pressure 140/82 , heart rate 92 , saturation is 97% on room
air. The patient is obese , but well appearing. Weight 117.7
kilograms. Cardiovascular examination: Regular rate and rhythm.
Soft , 2/6 systolic murmur heard best at the left sternal border.
No lower extremity edema.
ADMISSIONS LABORATORIES: Notable for a blood glucose of 1064 ,
creatinine 2.2 from a baseline of 1.8 , sodium 130 , potassium 4.9.
EKG normal sinus rhythm at 87 beats per minute , evidence of left
atrial enlargement , incomplete right bundle-branch block , and
anterior T wave changes that are unchanged from prior EKGs.
HOSPITAL COURSE BY ISSUE:
1. Endocrine: The patient with new-onset diabetes. Endocrine
service was consulted and the patient was controlled with a
combination regimen of Lantus , Novolog before every meal , combined with a
Novolog sliding scale. The patient was discharged with followup
with Ross Allegrini , the diabetic teaching nurse and with Dr. Thode
in the diabetes clinic and with VNA services to assist with home
medications. The patient demonstrated proper understanding of
blood glucose testing and insulin administration prior to
discharge.
2. Cardiovascular: The patient was intravascularly dry. At the
time of admission , he was aggressively hydrated and euvolemic
prior to discharge.
3. Rheumatology: The patient had mild acute gout flare during
admission for which he was started on colchicine.
4. Renal: The patient with chronic renal insufficiency , likely
transplant , immunosuppression medication related. Baseline
creatinine is 1.8. Creatinine at admission of 2.2 likely related
to prerenal acute renal failure. Creatinine at discharge had
normalized to 1.6.
DISCHARGE MEDICATIONS: Vitamin C 500 mg twice a day , Rocaltrol 0.25
mcg daily , calcium carbonate 500 mg three times a day , colchicine 0.3 mg
orally twice a day , cyclosporin 150 mg twice a day , folic acid 1 mg daily ,
Synthroid 150 mcg daily , magnesium oxide 420 mg twice a day ,
prednisone 7.5 mg every day before noon , Vitamin E 400 units daily , Pravachol 20
mg at night , Cartia XT that is diltiazem extended release 300 mg
daily , CellCept 1500 mg twice a day , Lantus insulin ( Glargine ) 40
units subcutaneous every day before noon , Novolog 12 units before breakfast ,
Novolog 12 units before lunch , Novolog 14 units before dinner ,
and Novolog sliding scale before every meal The sliding scale is as
follows: If blood sugar is 150-200 take 4 units , if blood sugar
is 201-250 mg take 6 units , if blood sugar is 251-300 take 8
units , if blood sugar is 301-350 take 10 units , if blood sugar is
350-400 take 12 units , if it is greater than 400 , the patient is
instructed to call his doctor.
eScription document: 0-4267562 HFFocus
Dictated By: VERBLE , KESHA
Attending: HAUB , PERRY
Dictation ID 0406499
D: 8/13/06
T: 8/13/06
Document id: 317
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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062177486 | PUO | 63004275 | | 8340339 | 8/25/2005 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 4/4/2005 Report Status: Signed
Discharge Date: 11/13/2005
ATTENDING: STUKOWSKI , JANAY MD
SERVICE: Cardiac Surgery Service.
DISPOSITION: To home with VNA service.
PRINCIPAL DISCHARGE DIAGNOSIS: Status post CABG x 2 , AVR with a
21 magna prosthetic valve.
OTHER DIAGNOSES: Diabetes mellitus type II ,
hypercholesterolemia , and history of epistaxis with
cauterization.
HISTORY OF PRESENT ILLNESS: Mr. Dossie is a 69-year-old male
with a history of rheumatic fever in the childhood who was found
to have aortic stenosis about 5 years ago. He has been followed
with serial echos. His most recent study shows critical AS. He
admits to a few episodes of throat tightness with activity and a
single episode of lightheadedness with vigorous exercise.
PREOPERATIVE CARDIAC STATUS: Elective , the patient presented
with critical coronary anatomy/bowel dysfunction. The patient
has a history of class 1 angina. There has been no recent
angina. The patient does not have symptomatic heart failure.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: None.
PAST SURGICAL HISTORY: Hemorrhoidectomy about 10 years ago.
FAMILY HISTORY: Coronary artery disease , sister with MI , sister
died in her sleep , family history very high cholesterol.
SOCIAL HISTORY: History of alcohol use , two glasses of wine per
day , last drink 1/25/05 . Married with one child and one
grandchild. The patient is a retired chef.
ALLERGIES: Topical reactions to unknown substance not latex. No
known drug allergies.
PREOPERATIVE MEDICATIONS: Lisinopril 5 mg daily , aspirin 81 mg
daily , atorvastatin 80 mg daily , and metformin 850 mg twice a day
PHYSICAL EXAMINATION: Height and weight 5 feet 7 inches , 72.72
kilograms. Vital signs: Heart rate 72 , BP right arm 136/68 , left
arm 134/62 , and oxygen saturation 95% room air. HEENT:
PERRLA/dentition without evidence of infection/left carotid
bruits/right carotid bruit , sounds like referred murmur from
valve. Chest: No incisions. Cardiovascular: Regular rate and
rhythm , 3/6 harsh high-pitched systolic murmur throughout. All
distal pulses intact. Allen's test , left upper extremity normal
and right upper extremity normal. Respiratory: Breath sounds
clear bilaterally. Abdomen: No incisions. Flat and soft. No
masses. No bruits. Extremities: Without scarring ,
varicosities , or edema. Neuro: Alert and oriented. No focal
deficits. Deep tendon reflexes 2+.
PREOPERATIVE LABORATORY DATA: Sodium 138 , potassium 4.1 ,
chloride 101 , CO2 27 , BUN 18 , creatinine 0.9 , glucose 158 , and
magnesium 1.6. Hematology: WBC 8 , hematocrit 45.1 , hemoglobin
15.5 , and platelets 205. physical therapy 13.9 , INR 1.0 , PTT 27.5 , and A1c
7.5. UA was normal.
CARDIAC CATHETERIZATION DATA: Echo from 5/14/05 shows 60%
ejection fraction , aortic stenosis , mean gradient 51 mmHg , peak
gradient 70 mmHg , calculated valve area 0.8 sq. cm. Mild aortic
insufficiency. EKG from 11/28/05 showed normal sinus rhythm rate
of 72. Chest x-ray from 11/28/05 reveals aortic calcification ,
dilated ascending aorta with wall calcifications.
The patient was admitted to our service and stabilized for
surgery. Date of surgery is 1/25/05 .
PREOPERATIVE DIAGNOSIS: Aortic stenosis and CAD.
PROCEDURE: An ascending aortic resection with AVR , 21
Carpentier-Edwards magna valve and CABG x 2 with a LIMA to LAD
and SVG1 to OM1.
BYPASS TIME: 165 minutes.
CROSSCLAMP TIME: 90 minutes.
CIRCA ARREST: 18 minutes.
COMPLICATIONS: There were no complications.
HOSPITAL COURSE: The patient was transferred to the unit in A
stable fashion with lines and tubes intact. On postoperative day
#1 , chest tubes with bloody output overnight , 400 from all , 250
first hour and then150 , then dropped off to 30-60 an hour. EP
stable off pressers with mean arterial pressures in the 60s.
Hematocrit stable at 29.9. Coag stable with INR1 .4 , 1.3 this
a.m. Changed to Precedex from propofol as wildly sedation weaned
and extubated at 4:30 in the morning of postoperative day #1
without incident. Postoperative day #2 doing well , extubated
without incident , stable BP and chest tube output all day. Out
of bed and ambulating around Jose Nanor Venville in p.m. , started diuresis with
10 mg of intravenous Lasix three times a day. The patient was transferred to the
Step-Down Unit on postoperative day #2 , where proceeded to do
well. He was started on Lopressor. Pressure was stable at
110/60 and rate 85 per minute on Lopressor 12.5 four times a day ,
saturating at 98% on 2-4 liters of oxygen delivered via nasal
cannula. Diet was advanced as tolerated. Started on an insulin
sliding scale and followed by diabetes management for the
duration of his course and given vancomycin for chest tube
prophylaxis. Transferred to the Step-Down Unit on postoperative
day #2. On postoperative day #3 , wires and chest tubes were out.
Postoperative chest x-ray looks good. No pneumonia , in the
process of being transfused 2 units. The patient developed fever.
Transfusion panel recommended by hematology ordered and repeat
hematocrit. He remained asymptomatic otherwise. Repeat
hematocrit was 25 and the patient was not further transfused. On
postoperative day #4 , hematocrit was stable. The patient was
ambulating well. PA and lateral looks good.
Plan is for discharge on postoperative #5 , 11/27/05 . The patient
was evaluated by Cardiac Surgery Service to be stable to
discharge to home with VNA service with the following discharge
instructions.
DIET: ADA 2100 calories per day.
FOLLOWUP APPOINTMENTS: Dr. Stukowski , 919-772-1227 in five to six
weeks , Dr. Meduna 520-515- 3844 in one to two weeks , Dr.
Winkels 322-111-0145 in one to two weeks.
TO DO PLAN: Make all followup appointments , local wound care ,
wash all wounds daily with soap and water , watch all wounds for
signs of infection , redness , swelling , fever , pain , or discharge.
Keep legs elevated while sitting/in bed. Call primary care physician/cardiologist
or Pagham University Of cardiac surgery service at
117-219-4079 with any questions.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 325 mg daily ,
captopril 6.25 mg three times a day , Colace 100 mg three times a day as needed
constipation , Lasix 20 mg daily for five days , ibuprofen 600 mg
every 6 hours as needed pain , Niferex 150 mg twice a day , Toprol XL 50 mg daily ,
K-Dur 10 mEq daily for 5 days , metformin 850 mg twice a day every 8 hours a.m.
and 5 p.m. , Amaryl 2 mg every afternoon with instructions to give at 5
p.m. , Nexium 20 mg daily , and atorvastatin 10 mg daily.
eScription document: 8-4102194 IS
Dictated By: CRIDGE , LORRETTA PA
Attending: STUKOWSKI , JANAY
Dictation ID 8339335
D: 11/27/05
T: 11/27/05
Document id: 318
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007269174 | PUO | 78290430 | | 896170 | 10/29/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/10/1995 Report Status: Signed
Discharge Date: 4/24/1995
PRINCIPAL DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
ID: The patient is a 73 year old female status post CABG x four in
1993 at the Pagham University Of referred from Landhi Terblack Ebro Medical Center for work up of chest pain.
HISTORY OF PRESENT ILLNESS: The patient was first diagnosed with
coronary artery disease/angina in April
1993. The patient was initially tried on medical management ,
however , she failed initial medical therapy and underwent
catheterization on 3/13 which showed 90% left main , 70% left
circumflex and 95% RCA lesions. She then underwent CABG lema to
LAD in SVG to PDA diagonal and DM. Since her CABG she has had
right sided chest pain associated with sternotomy. Also esophageal
spasm pain which is relieved by Mylanta. On August , 1995 , she
developed chest pain while walking to the Cock Dia Medical Center where she
volunteers. She walked there as usual and once in the Sports Health Health , she took two sublingual nitros with relief partially and
went to EW there. She had no nausea , vomiting , diaphoresis , no
palpitation , no shortness of breath but had pain radiating to jaw
and tingling of both arms. After the third sublingual nitro in the
EW , she was pain free and this pain lasted for about 1/2 hour. At
the TA she was admitted for rule out myocardial infarction , had two
flat CK and the night before transfer she had substernal chest pain
radiating to both arms with no EKG changes x two and en route in
the ambulance , she also experienced substernal chest pain with no
EKG changes.
PAST MEDICAL HISTORY: Includes 1 ) coronary artery disease status
post CABG as above , 2 ) esophageal spasm , 3 )
peripheral neuropathy and left foot drop secondary to diabetes
mellitus , 4 ) hypercholesterolemia , 5 ) carpal tunnel release in
her left hand in 1987 , 6 ) cataract operation and glaucoma.
MEDICATIONS ON ADMISSION: ECASA 325 mg a day , Lopressor 50 mg
twice a day , lisinopril 10 mg every day , Zantac
150 mg every HS , pravastatin 20 mg every HS , multivitamins and heparin intravenous.
ALLERGIES: Include epi eye drops which gives her itchy eyes ,
Bacitracin ointment which gives her pruritus.
FAMILY HISTORY: Significant for a father who died of a myocardial
infarction at age 65. He also has borderline
diabetes mellitus and was a smoker. Sister with coronary artery
disease and a smoker; another sister with AVR and a myocardial
infarction and positive family history for hypercholesterolemia and
diabetes mellitus.
SOCIAL HISTORY: The patient is a known smoker , denies ethanol use ,
denies other drug use. She is a retired nurse.
Family lives in Florida , lives alone on Hoton Peake Ha
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature was 100.2 , pulse
72 , blood pressure 126/68 , O2 sats of 95% on
room air. GENERAL: She was a well appearing elderly female.
HEENT: Significant for bilateral cataract operations. Oropharynx
was negative. NECK: Supple with no lymphadenopathy , JVD less than
6 cm , no carotid bruits. LUNGS: Positive for crackles at the left
base. HEART: Regular rate and rhythm , normal S1 , S2. ABDOMEN:
Positive bowel sounds , soft , non-tender , non-distended.
EXTREMITIES: Good pulses bilaterally , no clubbing , cyanosis or
edema. NEUROLOGIC: Alert and oriented x three and non-focal other
than a left foot drop.
LABORATORY: Significant for SMA-7 with BUN of 16 , creatinine of
0.7 and glucose of 187. CKs at the Cock Dia Medical Center were
41 and 55. Chest x-ray at the Cock Dia Medical Center showed clear reports.
EEG showed no change from her previous. EKG had normal sinus
rhythm and no acute ischemic changes.
HOSPITAL COURSE: The patient was admitted for rule out myocardial
infarction and her third CK came back negative.
She experienced some sense of her right arm tingling once her blood
pressure cuff was up also associated with headache related to Nitro
paste. However , she had no EKG changes and this right arm tingling
subsided with blood pressure cuff taken off. She defervesced on
her own with no signs or symptoms of infection with clear UA , clear
chest x-ray and low white count. After the patient ruled out ,
she underwent a Dobutamine MIBI. She reached her maximum heart
rate of 136 and had a blood pressure of 168/80 with no substernal
chest pain which showed EKG changes consistent with but not
diagnostic for ischemia and MIBI images showed question of new
lateral wall MI and moderate severe ischemia of the lateral wall in
the left circumflex territory. The patient was then scheduled for
cardiac catheterization and the patient tolerated the procedure
well. The patient was then discharged on a new medication regimen
with the addition of diltiazem. She did well post procedure with
no recurrent substernal chest pain and tolerated ambulation. She
was then discharged to home on July , 1995.
MEDICATIONS ON DISCHARGE: Included ECASA 325 mg orally every day ,
diltiazem SR 90 mg orally twice a day ,
lisinopril 10 mg orally every day , Lopressor 50 mg orally twice a day ,
multivitamins one capsule orally every day , nitroglycerin 1/150 one
tablet sublingual every 5 minutes x three as needed chest pain ,
pravastatin 200 mg orally every HS , phospholine iodide 0.26% one drop each eye
twice a day , Zantac 150 mg orally twice a day
FOLLOW UP: The patient is to follow up with Dr. Vandeweert and Dr.
Theiling .
Dictated By: KEN WESTFALL , M.D. AK5
Attending: CARA C. BARNABA , M.D. TI20 KL396/3821
Batch: 99169 Index No. IYLSGF44TH D: 1/17/95
T: 1/17/95
CC: 1. KERI L. VANDEWEERT , M.D. WV9
2. BREE M. THEILING , M.D. IY1
Document id: 319
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804989302 | PUO | 41320764 | | 8541558 | 8/29/2005 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 6/26/2005 Report Status: Signed
Discharge Date: 4/14/2005
ATTENDING: ABSHEAR , CARLTON MD
CHIEF COMPLAINT:
An 86-year-old female with diabetes , end-stage renal disease on
hemodialysis , coronary artery disease , hypertension , history of
recent CVA , presents with hypotension and shock , question of
sepsis.
HISTORY OF PRESENT ILLNESS:
The patient , as mentioned above an 86-year-old with history of
end-stage renal disease , insulin dependent diabetes , CAD status
post MI , bilateral above the knee amputations secondary to
peripheral vascular disease , cerebrovascular accident in 10/18 ,
who was initially admitted on 10/26/05 for nausea , vomiting , and
diaphoresis. Previously , the patient was admitted to P Therford Hospital
for vertigo that was consistent with a right pontine lacunar
infarct , but despite being on Plavix and aspirin that was in
10/18 . Her hospital course was complicated by an MI , and the
patient was medically managed. The patient was again admitted to
the P Therford Hospital on 5/18/05 for hypotension and unresponsiveness
after dialysis. She had negative CT at that point. Since that
admission , she had been doing well until 10/26/05 when she had
nausea vomiting and diaphoresis following hemodialysis. She was
admitted to rule out cardiac cause versus infection. Her
hospital course was complicated by continued hypotension and
decreased temperature. In the emergency department , on
presentation , the patient had a temperature of 95.8 , heart rate
of 102. Her blood pressure was 83 to 122 over 40s to 60s. Her
respiratory rate was 16. She was sating 95% on room air. She
got 500 mg of levofloxacin and her Lopressor was held due to
hypotension , and she was admitted with concern for infectious
process. She was initially admitted to the floor where she was
found to be afebrile with the rate of 92 , respirations of 20 , and
blood pressure was 100/57. Her exam revealed bibasilar rales ,
left greater than the right. Her abdominal exam revealed
nontender and nondistended abdomen with positive bowel sounds.
Her extremities revealed warm. She had bilateral below the knee
amputations. Her cardiovascular exam revealed regular rate and
rhythm with the 2/6 systolic murmur.
PAST MEDICAL HISTORY:
Significant for chronic renal insufficiency , end-stage renal
disease on hemodialysis , insulin-dependent diabetes , CVA ,
bilateral below the knee amputations , CAD , status post MI in
10/18 , hypertension , and peripheral vascular disease.
MEDICATIONS:
Folate 1 mg daily , aspirin 81 mg daily , NPH , Isordil , lisinopril ,
Plavix 75 mg , Paxil 10 mg , Pravachol 20 mg , Neurontin , Protonix
40 mg , vitamin B12 100 mcg , and Nephrocaps.
SOCIAL HISTORY:
She lives with her grandchildren. She does not smoke or drink.
FAMILY HISTORY:
Significant for sister with coronary artery disease.
PHYSICAL EXAMINATION:
Neurologic exam: She is alert and oriented x3.
LABORATORY DATA:
Significant for CK of 39 , MB of 2.3 , and troponin of 0.36. Her
white count was 8. Her hematocrit was 36.2 , and her platelets
were 298 , 000. Her INR was 1.3. Her EKG revealed a regular rate
and rhythm. Normal axis. T-wave inversions and flattenings in
the lateral leads on low voltage in the limb leads. Her chest
x-ray showed left lower lobe consolidation and left effusion.
IMPRESSION:
An 86-year-old female with end-stage renal disease on
hemodialysis , presenting with episodes of nausea , vomiting , and
diaphoresis of unclear etiology.
HOSPITAL COURSE BY SYSTEM:
Cardiovascular: Upon admission , the patient had a slight
troponin leak. It was unclear for initial presenting symptoms or
subsequent secondary to ischemia. On her second hospital day ,
she developed hypotension. Initially , her systolic blood
pressure dropped to the 80s and her blood pressure medicines were
held. Subsequently , her blood pressure dropped into the 70s and
she required dopamine and was transferred to the Cardiac Care
Unit. In the Cardiac Care Unit , she was started on the dopamine
drip of 10 mcg/kg/minute. In the Cardiac Care Unit , the initial
differential diagnoses were hypertension was cardiogenic versus
septic physiology. However , her white count revealed significant
elevation of 24.6 with bandemia , 10% bands. She also had an
elevated lactate of 9.3 concerning for GI etiology. Possibly gut
ischemia was the cause of her infection. She was covered broadly
with amp , vanc , levo , and Flagyl. She subsequently required the
addition of Neo-Synephrine as a second pressor agent to maintain
her blood pressure. Dopamine was weaned off. However , on the
second day in the CCU , on 9/26/05 , the patient developed sudden
hypotension. Physicians were called to see the patient and at
that time she was found to have no palpable pulse. Code was
initiated. The patient was found to be in pulseless electrical
activity. Chest compressions were initiated , and she was mask
ventilated , and she received multiple rounds of epinephrine and
atropine. She received 2 amps of bicarbonate and 1 amp of
calcium gluconate given concern for hyperkalemia in the setting
of end-stage renal disease. Anesthesia then arrived and the
patient was intubated. Despite all efforts , the patient's rhythm
deteriorated to asystole , and she was pronounced dead at 5:30
p.m. on 9/26/05 , which was the time of death.
eScription document: 5-9599002 EMSFocus transcriptionists
Dictated By: RAMIL , FELIPA
Attending: ABSHEAR , CARLTON
Dictation ID 8681389
D: 4/3/05
T: 4/3/05
Document id: 320
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
849420538 | PUO | 24466939 | | 823225 | 10/20/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/13/1990 Report Status: Unsigned
Discharge Date: 11/23/1990
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE.
ADDITIONAL DIAGNOSES: 1 ) HYPERTENSION.
2 ) DIABETES MELLITUS.
HISTORY OF PRESENT ILLNESS: Napoleon Gillmer is a 56 year old woman
with coronary artery disease , history
of unstable angina , and status post PTCA in September of l990
presenting with crescendo exertional angina. Cardiac risk factors
include positive for hypertension and diabetes , family history , and
elevated cholesterol. Negative for tobacco and negative for
previous myocardial infarction. The patient initially presented in
September of l988 with chest pain. She had an exercise tolerance
test at that time where she went nine minutes with non-diagnostic
changes. In April of l988 , she had an exercise tolerance test
with thallium. She went 7 minutes and 33 seconds stopping because
of shortness of breath with non-diagnostic changes and demonstrated
reperfusion defects. She was treated at that time with Diltiazem
and Enalapril. Patient did well until February of l990 when she
was admitted to the Pagham University Of with unstable
angina and electrocardiogram changes. An exercise tolerance test
at that time demonstrated six minute and twenty second duration
with blood pressure response of l46/86 and global greater than 2 mm
ST depressions. The patient went to Catheterization where she had
normal filling pressures. She was noted to have a 30% left
anterior descending lesion , a 90% Dl lesion , and a 40% OMBl lesion.
At that time , her ejection fraction was 43% and she was noted to
have inferior hypokinesis. Patient was treated at that time with a
PTCA. Her Dl was reduced from 90% to 20% without complications.
Patient has done well since that time until about five days prior
to admission when she noted increasing exertional angina while
walking up stairs that was relieved easily with one Nitroglycerin.
This continued to progress , always symptoms occurring with exertion
with several episodes of pain on the day of admission not
associated with shortness of breath , diaphoresis , nausea , vomiting ,
or radiation. Patient said that her longest episode of pain was
approximately twenty minutes. This was because she did not have
her Nitroglycerin with her and was unable to take any medication.
Patient denies any history of rest pain. In addition , the patient
had some suggestion of difficulty sleeping at night requiring more
pillows. However , she denies that this is related to her
breathing. Patient has no history of medical non-compliance and
denies any constitutive symptoms such as fevers , chills , sweats ,
rash , abdominal pain , nausea , vomiting , or change in bowel habits.
PAST MEDICAL HISTORY: 1 ) Hypertension. 2 ) Diabetes , adult
onset. 3 ) Elevated cholesterol. 4 ) Carpal-tunnel syndrome. 5 )
Status post total abdominal hysterectomy. 6 ) Colonic polys. 7 )
Gravida XIV , para 9 , AB 5. 8 ) Thyroid tumor resection. CURRENT
MEDICATIONS: 1 ) Lopressor 50 mg orally twice a day 2 ) Isordil l0 mg
orally three times a day 3 ) Ecotrin one tablet orally every day 4 ) Lovastatin 20 mg
orally every day 5 ) Insulin 60 units of NPH and 20 units of CZI every
morning and 20 units of NPH and 6 units of CZI every afternoon. 6 )
Nitroglycerin as needed ALLERGIES: The patient denies any known drug
allergies. SOCIAL HISTORY: The patient lives with her husband who
is very supportive and has a close relationship to all of her nine
children.
PHYSICAL EXAMINATION: On admission , the patient was a pleasant
obese white woman in no apparent distress.
Her temperature was 98.6 , blood pressure l52/84 , pulse 70 , and
respirations l6. SKIN: Without lesions. HEENT: Clear oropharynx
without any lymphadenopathy. Pupils equal and reactive to light.
NECK: Demonstrated a well healed thyroid scar , supple without
masses. CHEST: Clear. There was a question of some crackles at
the bases. CARDIOVASCULAR: There was no evident jugular venous
distention , carotids were l+ bilaterally , and Sl/S2 without
murmurs , rubs , or gallops. ABDOMEN: Obese , soft , and non-tender
with normal bowel sounds. EXTREMITIES: Without edema. PULSES:
Dorsalis pedis 2+ bilaterally and posterior tibial of l+
bilaterally. NEUROLOGICAL: Non-focal.
LABORATORY EXAMINATION: On admission , electrolytes were within
normal limits. Hematocrit was 40 , white
blood cell count was l3.0 , and platelets were 28l , 000. Chest X-Ray
was within normal limits. ECG demonstrated a sinus rhythm at 90
beats per minute with an axis of 0 , intervals of 0.l6/0.06/0.32 ,
and there were some T wave inversions in I and L with l mm ST
depression that was upsloping in V4 through V6 without significant
change from March , l980.
HOSPITAL COURSE: Patient was admitted to a monitored bed and was
ruled out for myocardial infarction with serial
CK enzymes of l76 , l33 , and ll5. There were no evident changes in
her serial EKG. Of note , however , her second EKG had lead
reversal. Patient did well after admission with no evident chest
pain. There was some concern on admission with the story of
difficulty sleeping at night raising the possibility of some
congestive heart failure. However , throughout the admission , the
patient showed no symptoms of this. Indeed , she slept well
throughout the nights without any difficulty breathing and there
was no evidence of congestive heart failure on her chest X-Ray. The
patient went for cardiac catheterization which demonstrated that
she had , in fact , reoccluded her Dl vessel to 95% stenosis and of
note , she also had her OMBl with a 50% lesion. However , it was
noted on catheterization that there was a small dissection proximal
on the Dl vessel providing a relative contraindication to reattempt
at PTCA. Therefore , this procedure was not attempted. It was felt
that the best approach for this patient would be to improve her
medical management at the present time and then at some future date
if necessary , to bring the patient back to catheterization with the
hope that an attempt at PTCA could be made later. The patient's
Lopressor was increased to 75 mg orally three times a day and her Isordil was
increased to 30 mg orally three times a day The patient underwent exercise
tolerance test using the standard Bruce protocol and she went for
six minutes and four seconds stopping because of shortness of
breath denying any chest pain. However , she did have l.5 mm flat
ST depressions in leads II , III , and F and the lateral leads as
well as a l/2 mm ST elevation in aVL.
DISPOSITION: Patient was sent home on her current medical
management with the understanding that she should
report any changes in her symptomatology as well as should maintain
close follow-up with Dr. Theiling . She will carry with her , at
all times , Nitroglycerin. DISCHARGE MEDICATIONS: 1 ) Ecotrin one
tablet orally every day 2 ) Insulin 60 units of NPH and 20 units of
Regular every day before noon and 20 units of NPH and 6 units of Regular every afternoon 3 )
Lovastatin 20 mg orally every afternoon 4 ) Lopressor 75 mg orally three times a day 5 )
Isordil 30 mg orally three times a day CONDITION ON DISCHARGE: Good. Her
disposition is to home with follow-up appointments within a week
with Dr. Theiling .
________________________________ DV312/5856
CARA BARNABA , M.D. HL86 D: 7/6/90
Batch: 7869 Report: H6859Q4 T: 2/6/90
Dictated By: VERNON RANDKLEV , M.D.
Document id: 321
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
N |
Y |
N |
N |
N |
N |
Y |
N |
- |
N |
N |
N |
Y |
490615097 | PUO | 67095171 | | 8610728 | 5/29/2006 12:00:00 a.m. | chf | | DIS | Admission Date: 5/7/2006 Report Status:
Discharge Date: 1/6/2006
****** FINAL DISCHARGE ORDERS ******
HAMMETT , FREDERICA 438-54-75-5
Louis
Service: MED
DISCHARGE PATIENT ON: 3/9/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain , Headache
NORVASC ( AMLODIPINE ) 5 MG orally twice a day HOLD IF: SBP < 100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CALTRATE + D 1 TAB orally twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally DAILY
Food/Drug Interaction Instruction Avoid milk and antacid
NOVOLOG ( INSULIN ASPART ) 5 UNITS subcutaneously before meals HOLD IF: NPO
LANTUS ( INSULIN GLARGINE ) 5 UNITS subcutaneously BEDTIME
ISOSORBIDE MONONITRATE 30 MG orally every day before noon
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 10
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
DIOVAN ( VALSARTAN ) 40 MG orally DAILY HOLD IF: SBP < 100
Number of Doses Required ( approximate ): 10
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Feazel 10/9 @ 230 scheduled ,
Dr Norseth 4/25 4pm scheduled ,
pcp 2 weeks ,
orthopedics , as needed ,
Arrange INR to be drawn on 6/26 with f/u INR's to be drawn every
7 days. INR's will be followed by dr cjkjwnmspeuplfdre / clinic
ALLERGY: Codeine , DIPHENHYDRAMINE
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM ( diabetes mellitus ) mitral valve replacement ( cardiac valve
replacement ) afib ( atrial fibrillation )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: right hip pain
===========
HIP HPI: 85 year-old f with MMP , history of RTHR 12 y/a with 6 mo right hip pain. Full
ROM , occurs at night execpt pain during daytime 1 d PTA. Not worse with
walking. ?weakness subjectively. Currently hip pain free. Seen by outpt
ortho in Coll Velu A X-rays ?DJD. ?infection labs but no tx-- Considered outpt
tap. No fevers , chills , no other joints. No trauma.
===========
HF HPI: patient with history of HF recently at TH . Endorses chronic DOE but not
worse. +5 lb weight gain. Limited activity at baseline. No increased LE
edema. Salt on July . No CP. Dry wt 120-122. Uo in ED1L today 2/2
lasix 40 intravenous x2.
===========
PMH:
Type 2 diabetes for at least 12 years with no reported retinopathy or
neuropathy.
CVA - an embolic event related to valvular heart disease
Osteoporosis.
Hypertension.
CHF - diastolic dysfunction. ( EF 45% )
Paroxysmal atrial fibrillation.
Mild aortic stenosis.
Rheumatic valvular disease with mitral valve replacement in 1988.
Second mitral valve replacement and tricuspid valve repair 2000.
pulmonary hypertension.
Incarcerated hernia and rectal prolapse 5/15 .
Rib fracture secondary to falls.
============
Meds: coumadin 5 , isosorbid 30m divan 40 , lasix 40 twice a day , novalog 5 before meals ,
norvasc 5 twice a day , FE ( intravenous and orally ) , colace , lantus 5 , senna ( coreg was
recently d/c'ed )
===========
Allergies: codeine , benadryl
===========
Exam: afeb , HR 50 , BP140/60 , 94% RA 16
Gen-nad , jvp to 7
CV s1s2 irregular 2/6 sem l/r upper sternal border , 2/6 hsm apex ,
Pulm- crackles at b/l bases
abd distended but benign ,
extremities 1+ edema , chronic venous stasis. Hip has pain only with
internal rotation , not with flexion , straight leg raise , nor with
palpation of hip.
===========
Studies:
CXR: cardiomegaly , history of valve , pulm edema
ECG: afib rate 58 non-specific ST-T changes
Right hip films: DJD , no evidence infx , no fx.
Rt Hip CT- no fx , no fluid , no infection.
Lenis- negative for dvt.
============
Assessment: 85 year-old f with history of HF 2/2 valvular disease on coumadin , DM ,
with 6 months right hip pain of unclear eitiology found to be in HF.
============
Plan:
1. Right Hip pain: No fx on plain film. no clear evidence of infection
though ESR up--realize this is non-specific. CT hip neg. Will tx pain
conservatively with tyleno.l , Patient has been offered , but refused low
dose oxycodone while in house. Took tylenol with good relief. No pain
this morning or over night , nor with ambulation.
2. CV
a ) ischemia: no history of CAD. ECG stable.HR 50s.
b ) pump: HF EF 45% 2/2 valvular disease here in warm/wet HD profile HF.
Diuresed with lasix 40 intravenous twice a day , fluid restriction. volume status closely
followed with daily weights. Continued on home nitrates to decrease
preload. history of MV replacement on coumadin. Patient was slowly diuresed
over her time in the hospital and this morning , she has minimal crackles
at the bases , only slight pedal edema and jvp of 8. Yesterday - 1liter.
She feels much improved. Will send home on her home dose of lasix 40 twice a day
and remind her not to take in salt. Her daughter is aware of her dry
weight of 122-123 on her home scale. She will weigh her in the morning to
recalibrate her own scale.
c ) rhythm: afib continued on coumdin. INR on dod 3/3- asked to take half
dose coumadin tonight and recheck on monday. On tele while in house. Does
continue to be bradycardic in 50s , but aymptomatic.
3 ) DM: continue home lantus and SSI.
4 ) Renal: CKD mildly increased likely 2/2 HF. Continue fe , May need epo in
the future , continue ARB. watched cr with diuresis- did not bump
appreciably. Cr stable 7/25 at 2.4 , increased on 1/10 2.6 , then down again
on 7/26 to 2.4.
5 ) PPX: coumadin , no indication for GI ppx
6 ) GI: constipation , colace , senna
7 ) Patient is stable for discharge with VNA to home.
ADDITIONAL COMMENTS: 1. please take a half dose of coumadin tonight , as your INR was elevated
today to 3.3. You may resume your regular dosing schedule tomorrow. But
you should have your INR rechecked by the VNA on Monday and called into
the coumadin clinic 592.004.9708
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. have your INR drawn on Monday by the VNA and call the coumadin clinic
as directed to adjust your dosing
No dictated summary
ENTERED BY: DUTCH , CAROLYNN F , M.D. , M.P.H. ( FM112 ) 3/9/06 @ 04:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 322
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
N |
Y |
- |
N |
Y |
Y |
N |
N |
Y |
N |
N |
- |
630372501 | PUO | 76001088 | | 6725410 | 2/15/2006 12:00:00 a.m. | Upper GI bleed , erosive gastric ulcer at anastamosis site | | DIS | Admission Date: 10/16/2006 Report Status:
Discharge Date: 5/22/2006
****** FINAL DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 673-14-60-6
Balt A Ceboise
Service: MED
DISCHARGE PATIENT ON: 11/18/06 AT 01:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
XANAX ( ALPRAZOLAM ) 1 MG orally every 4 hours as needed Anxiety
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
DULCOLAX ( BISACODYL ) 5 MG orally DAILY
DULCOLAX RECTAL ( BISACODYL RECTAL ) 10 MG PR DAILY
as needed Constipation
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
DIGOXIN 0.125 MG orally DAILY
Alert overridden: Override added on 11/18/06 by :
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: monitor
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
Starting Today ( 7/18 )
as needed Other:Leg swelling , shortness of breath
Alert overridden: Override added on 11/18/06 by :
on order for LASIX orally ( ref # 315069114 )
patient has a POSSIBLE allergy to DYAZIDE; reaction is SOB.
Reason for override: tolerates
ISOSORBIDE DINITRATE 30 MG orally three times a day
LACTULOSE 30 MILLILITERS orally four times a day as needed Constipation
LEVOTHYROXINE SODIUM 50 MCG orally DAILY
LISINOPRIL 2.5 MG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 30 MG orally four times a day
HOLD IF: somnolent , RR<10
TNG 0.4 MG ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
ZANTAC ( RANITIDINE HCL ) 300 MG orally twice a day
as needed Upset Stomach , Chest Pain
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
FLEET ENEMA ( SODIUM BIPHOSPHATE ENEMA ) 1 BOTTLE PR twice a day
as needed Constipation
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician , call for apt within two week ,
ALLERGY: DYAZIDE , Penicillins , NSAIDs , Erythromycins ,
AZITHROMYCIN , Tape , IBUPROFEN , KETOROLAC TROMETHAMINE ,
BUPROPION HCL , GABAPENTIN
ADMIT DIAGNOSIS:
Upper GI bleed
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Upper GI bleed , erosive gastric ulcer at anastamosis site
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
fibromyalgia ( fibromyalgia ) htn ( hypertension ) history of gastric bypass
( history of gastric bypass surgery ) obesity
( obesity ) anemia ( anemia ) spinal stenosi ( spinal
stenosis ) CAD history of MI ( coronary artery disease ) history of coronary stent
( history of coronary stent ) pacemaker
( pacemaker ) Hyperlipidemia ( hyperlipidemia ) anxiety
( anxiety ) TAH ( hysterectomy ) ccy ( cholecystectomy )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Upper Endoscopy
BRIEF RESUME OF HOSPITAL COURSE:
CC: substernal chest pain
---
DX: UGIB
---
HPI: 58 year old female with multiple hospitalizations for substernal
chest pain presented to the ER with the same. She reported 3-4
days of profound fatigue , dizziness and dark foul smelling stools.
She had one episode of clear emesis the morning of admission. She
complained of pain in the chest , back , abdomen and legs. She
takes Oxycontin for chronic pain. In the ER she was noted to have a
HCT of 20.4 and maroon colored heme positive stools. ROS otherwise
neg.
---
PMH: see list
---
Meds on admission:
Isosorbide 30
Levothyroxine 50
Lisinopril 2.5
Lipitor 20
MS contin 30 four times a day
Senna
Colace
Dig 0.125
Compazine as needed
Plavix 75
Lasix 40 as needed
Toprol XL 25
Xanax 1mg five times a day
Percocet 2 every 4 hours
Zantac 150 twice a day
---
ALL: PCN-anaphylaxis , Macrolide-rash , Paxil , Motrin-bleeding ,
Wellbutrin-rash
---
EXAM on admission: T 98.5 , HR 73 , BP 112/56 , RR 18 , O2 99% on RA
GEN: No acute distress
HEENT: NCAT , anicteric , PERRL , MMM , Pharynx clear
NECK: supple , no LAD or JVD
CHEST: CTA
HEART: RRR , II/VI systolic murmer.
ABD: Soft , diffusely tender without rebound. Heme positive stool.
EXT: No edema or cyanosis
NEURO: Alert and oriented X3 , conversant , moves all extremities , no gross
focal deficits.
---
DATA: Cardiac enzymes neg X1. HCT 20.4 on admit , 24.7 after 2U PRBC.
BUN 55 , Cr 1.1. CXR: no acute cardiopulmonary
process
---
HOSPITAL COURSE BY SYSTEM:
GI: The patient was admitted to the hospital for likely UGI bleed given
significant anemia , guaic positive maroon stools and elevated BUN. She
was transfused with 2 U PRBC initially , placed NPO , IVF and GI consult
was obtained. GI took her to endoscopy and did upper endoscopy on
morning of November . They found a friable ulcer located at an anastomosis
site from her previous bypass surgery. No active bleeding and blood
vessels were identified at the area. This represents the likely source
of her bleed. 2 more units of blood were ordered to keep goal over 30
but she only bumped to 26.6 from 20 after total of four units initially.
It is possible the blood was drawn distal to where IVF was adminitered
and there could have a been a dilutional effect. One more unit was given
for a total of five which put her over 30. Her HCT was monitored and
stayed stable at 30 after that for the remainder of her hospitalization.
She was placed on twice a day PPI. Her asprin and plavix were held on admission
as well as her BP meds.
---
CV: She does have a history of CAD history of MI and coronary stents. She
had a negative MiBi a month prior to admission. A set of enzymes upon
admission were negative , another troponin was negative on the
13 of June . Her HTN meds were held upon admission. Her goal HCT is >30
given CAD. She is on digoxin for question of afib which was on
hold during admission. Cardiac telemetry revealed no events. She had one
episode of "chest pain" on the night of the 13 of June which was actually
located in the epigastric region. An EKG was performed at that time
which was unchanged from the admission EKG. She was HD stable without
event on telemetry. She received NTG tabs X3 without any relief and a
follow up troponin was negative for the third time.
---
PAIN: She was continued on current pain regimen.
---
PPX: Teds , Pneumoboots
---
ENDO: She was continued home Levothyroxine
---
GI: She was constipated during admission and had not had a bowel
movement despite very aggressive regimen. Her abd became slightly
distended. The patient then started to refuse bowel meds as she was
getting prepared for discharge and was afraid to have movement on ride
home. She agreed to maintain agressive regimen at home and was instructed
to follow up with primary care physician or ER if she can not produce results within a day.
---
She was stable for discharge on January and discharged with instructions
to follow up with primary care physician within two weeks or sooner if lightheadedness ,
bloody or black stools , vomiting , chest pain or other concerns.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: RUKA , BERNA , PA-C ( YP61 ) 11/18/06 @ 11:08 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 323
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
- |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
472510821 | PUO | 58706198 | | 4486854 | 7/25/2005 12:00:00 a.m. | atrial fibrillation | | DIS | Admission Date: 7/25/2005 Report Status:
Discharge Date:
****** FINAL DISCHARGE ORDERS ******
HUERTES , ANNAMARIE DAMARIS 210-49-59-4
Rii , Oregon 43122
Service: RNM
DISCHARGE PATIENT ON: 7/13/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SPILLETT , SILVA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
AMITRIPTYLINE HCL 10 MG orally every bedtime as needed Insomnia
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally every day
PHOSLO ( CALCIUM ACETATE ( 1 TABLET=667 MG ) )
667 MG orally before meals
VOLTAREN ( DICLOFENAC SODIUM ) 1 DROP OD four times a day
Number of Doses Required ( approximate ): 5
GLIPIZIDE 10 MG orally twice a day HOLD IF: NPO
IMDUR ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally every day
HOLD IF: sbp<100 , call HO Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEPHRO-VIT RX 1 TAB orally every day
Alert overridden: Override added on 7/13/05 by
CLAYBURN , NIKI , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
CITALOPRAM 20 MG orally every day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 7/13/05 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 7/13/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: aware
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Partial weight-bearing: with cane
FOLLOW UP APPOINTMENT( S ):
Dr. Mordhorst 1 week ,
Dr. Overstrom ,
Arrange INR to be drawn on 1/2/2005 with f/u INR's to be drawn every
3-5 days. INR's will be followed by KTDUOO clinic -034-6287
ALLERGY: intravenous Contrast , METHYLDOPA , Penicillins , PRAZOSIN
ADMIT DIAGNOSIS:
atrial fibrillation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atrial fibrillation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM history of RLE DVT ( calf ) HTN ABDOMINAL PAIN EXT HEMORRHOIDS MS CHEST
PAIN cad ( coronary artery disease ) history of CABG ( history of cardiac bypass graft
surgery ) history of appy ( history of appendectomy ) history of ccy ( history of
cholecystectomy ) ESRD on HD ( end stage renal disease ) Afib with RVR
( atrial fibrillation ) hyperchol ( elevated
cholesterol ) chf ( congestive heart failure ) vitiligo
( vitiligo ) obesity ( obesity ) history of MRSA pneumonia ( history of pneumonia )
OPERATIONS AND PROCEDURES:
MRI Back: Negative
CXR: Cardiomegaly. No acute process.
ECHO: EF=20%
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
n/a
BRIEF RESUME OF HOSPITAL COURSE:
72 year-old female DM , CAD s/pCABG , HTN , ESRD on HD presented after having
fevers , chills and back pain. Found to be in atrial fibrillation with
rapid ventricular response. Initially hypotensive to the 80's. Blood
pressure improved with better rate control.
Hospital Course:
1. CVS: New onset afib. Ruled out for MI by enzymes. ECHO showed
reduction in last known ef to 20%. patient euvolemic on exam and by chest
x-ray. Rate well controlled with lopressor 25mg four times a day.
2. ID: Afebrile in-house. MRI back to r/o epidural abcess was negative.
3. HEME: Plan to initiate anti-coagulation with Coumadin 5mg orally every day INR
to be followed at dialysis.
4. RENAL: Seen by renal service. Plan for dialysis tomorrow at Norap Valley Hospital .
5. DISPO: Discharge to assisted living with VNA.
ADDITIONAL COMMENTS: Take coumadin as prescribed. Have INR drawn at dialysis on Tuesday and
reported to KTDUOO coumadin clinic at 268-445-9819.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check INR at AH Tuesday.
2. Home safety eval to assess for fall risk.
3. Stop taking lopressor and start Toprol XL 100mg in the morning.
No dictated summary
ENTERED BY: RAMIL , FELIPA C. , M.D. ( UH79 ) 7/13/05 @ 04:21 PM
****** END OF DISCHARGE ORDERS ******
Document id: 324
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
N |
N |
Y |
N |
N |
- |
N |
Y |
Y |
Y |
N |
N |
098812026 | PUO | 57870793 | | 9555088 | 11/15/2003 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 4/24/2003 Report Status:
Discharge Date: 1/15/2003
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Turpsiness Highway
Service: MED
DISCHARGE PATIENT ON: 8/30/03 AT 08:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LEGORE , TERRY ROSETTE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
HYDROCORTISONE 2.5% -RECTAL CREAM TP twice a day
Instructions: Apply to hemorrhoids
BEN-GAY TOPICAL TP twice a day
Instructions: Apply liberally to legs
Alert overridden: Override added on 3/12/03 by
GILSTRAP , KIRSTIN GARNETT , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to SALICYLATES
Reason for override: aware
PREMARIN ( CONJUGATED ESTROGENS ) 1.25 MG orally every day
LASIX ( FUROSEMIDE ) 60 MG every day before noon; 40 MG every afternoon orally twice a day 60 MG every day before noon
40 MG every afternoon Starting Today ( 5/8 )
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally three times a day Instructions: With meals
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally every bedtime as needed insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 10
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 10
OSCAL 500 + D ( CALCIUM CARB + D ( 500MG ELEM C... )
1 TAB orally three times a day Number of Doses Required ( approximate ): 10
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
ATENOLOL 100 MG orally every day
ZESTRIL ( LISINOPRIL ) 60 MG orally every day
Alert overridden: Override added on 4/4/03 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
DIET: Fluid restriction: 2 liters
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Quella regarding hemorrhoid surgery as previously scheduled ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
SOB
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) restrictive lung disease ( restrictive pulmonary
disease ) chf ( congestive heart failure ) fibromyalgia
( fibromyalgia ) von willebrand's ( hemophilia ) sleep apnea ( sleep
apnea ) iron deficiency anemia ( iron deficiency anemia ) hypoxia
( hypoxia ) GERD , history of TAH/BSO , PICA. ? central hypoventilation syndrome.
OA.
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
45 year-old F with history of CHF , pulm HTN , fibromyalgia p/with 2 wk history of inc SOB , inc
PND , inc orthopnea , inc abd/LE distention. patient reports mult dietary
indiscretions , eating pizza and subs. Also has self-d/c'd HCTZ , b/c
makes her "pee too much." Also has not been wearing BiPAP at night
and continuing to smoke. Reports occ episodes chest "cramps" similar to
her chronic cramps; no increase in freq or severity , no radiation ,
no diaph , no n/v. Denies change in UO. Does not know change in weight.
To TH ED where vss , given nebsx1 , neurontinx1 , lasix 80 intravenous x1. Then
tfx to PUO for further with u. On floor , temp 96.2 , HR 80 , BP 110/80 , sat
95% on 7L NC , obese healthy-looking F in NAD. JVP at 13 cm , lungs CTAB ,
RRR , lots of BS's , neuro nonfocal , ext with 1+ edema. On atenolol ,
zestril , norvasc , premarin , detrol , lasix 60 every day , nebs as needed at home. Labs
sig for Cr 0.7 , CK 48 , TnI .05 , QBC 9.5 , Hct 41.3. From CV point of
view , thought to be CHF exac. ROMI'd without events on monitor
and diuresed 2L/day. intravenous Lasix 80 twice a day to start transitioned to 60 orally
twice a day BNP>assay. 8/24 dobut MIBI with mod sized ant septal wall defect
c/with diagonal lesion , 3/14 Echo with EF 55-60% , mild LAE/RAE ,
no WMA , mod large RV. No further CV studies. Cont previously meds on
d/c. From FEN point of view , 2 L fluid restriction , 2 g Na
restriction. Nutrition consult , but patient very resistant to diet changes.
From GI point of view , GERD; nexium started. From pulm point of view ,
CXR c/with sublingual fluid overload , no focal findings , no pulm edema. Given NC
O2 and BiPAP at night.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GILSTRAP , KIRSTIN GARNETT , M.D. ( GK51 ) 8/30/03 @ 09:00 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 325
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
098812026 | PUO | 57870793 | | 7548809 | 1/30/2000 12:00:00 a.m. | sleep apnea | | DIS | Admission Date: 1/30/2000 Report Status:
Discharge Date: 11/12/2000
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Nato Street , Angeles A Ta , South Carolina 68288
Service: MED
DISCHARGE PATIENT ON: 3/18 AT 08:00 a.m.
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650-1 , 000 MG orally Q4-6H
as needed headache
TYLENOL LIQUID ( ACETAMINOPHEN ELIXER )
650-1 , 300 MG orally Q4-6H as needed headache
TYLENOL #3 ( ACETAMINOPHEN W/CODEINE 30MG ) 1-2 TAB orally every 4 hours
as needed pain Instructions: max dose tylenol = 4gram/day
LAC-HYDRIN 12% ( AMMONIUM LACTATE 12% ) TOPICAL TP twice a day
Instructions: to lower extremities
CEPACOL 1 LOZENGE orally every 4 hours as needed sore throat
FLAGYL ( METRONIDAZOLE ) 500 MG orally twice a day X 5 Days
Starting Today ( 5/29 ) Food/Drug Interaction Instruction
Take with food
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day as needed CONSTIPATION
DICLOXACILLIN 500 MG orally four times a day X 12 Days
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 20 MG orally every day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Korman one week ,
Dr. Huff next week ,
Dr. Reyburn nest available ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
sleep apnea
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
vonWillebrand factor disease iron deficiency anemia
history of TAH for chronic bleeding obstructive sleep apnea morbid obesity
pickwickian/restrictive lung disease hypertension Bacterial vaginosis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
*** 5/9 ***
43yo morbidly obese F c history of OSA p/with fatigue , SOB , orthopnea , cough ,
and LEE , thought to be CHF. RA sat on adm was 85% , up to 91% on 5 L
NC. Plan is to get echo , empirically diurese. LEE
is probably venous stasis: will get LENIs , then
apply compression stockings if LENIs neg. This is
a very difficult and demanding patient. 3/2
sats on 4L low 90s. patient asking for tx for
cellulitis , none seen clinically only longstanding
venous stasis. Also requesting coryza tx , refusing
inhaled steroids or claritin. Spoke with Dr. Huff ,
outpt pulm , who rec cpap 18-19 cm H2O for 8 with O2.
patient refusing tx. LENIS negative , limited study.
patient refusing subcutaneously hep. 6/14 patient is not tolerating
cpap at night second to feeling of
suffocating. She is also refusing inpatient rehab
despite social work and care coord assistance
with home/bills issues. patient has definite IDA and
would benefit from iron. She doesn't tolerate orally
and will need intravenous patient was consented. Tolerated iron intravenous Gyn appt
rec flagyl for BV. Echo showed slightly inc ef
and lv/a enlarg. EKG with possible lat
strain. 5/29 patient is still not compliant with cpap because her nose burns
with the oxygen despite humidification. Exam of nose is unremarkable.
She is also refusing BP medication because she claims that she does not
have high BP. She has an elevated wt ct and some pain and swelling of R
LE. Will tx with diclox for cellulitis. patient recd flu shot and pneumovax.
She says that she does not have a fever , cough or feels ill at this
time. patient suffered very minor trauma to Right first toe on her car.
Examination is unremarkable. This can be followed up with primary care physician. Dr.
Reyburn ( her hematologist ) said that she is not a candidate for dvt
prophylaxis second to bleeding; she should not receive any
anticoagulants unless strong clinical indication.
ADDITIONAL COMMENTS: Please have appt with Dr. Korman and Dr. Huff in one week. See Dr.
Reyburn at next available appt. Please have VNA for every other day
to do respiratory eval and assistance with medical care. Please have
physical therapy/OT to see patient twice weekly. patient must use CPAP at 18-19 cm H2O for 8hrs
night with O2 at 4-5 L & with ambulation. Sitz bath to vagina twice/d. Call
your doctor if short of breath , chest pain , nausea/vomiting , worsening
leg pain , headaches or other worrisome symptoms. patient is to go to Locono Sterenni Hospital as an outpatient. Home health aid twice per wk.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: SIDDELL , STEPHAN C. , M.D. ( LT82 ) 3/18 @ 09:46 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 326
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
N |
N |
N |
N |
- |
Y |
Y |
N |
N |
Y |
N |
- |
- |
347061506 | PUO | 50190354 | | 2923847 | 5/24/2007 12:00:00 a.m. | musculoskeletal chest pain | | DIS | Admission Date: 10/16/2007 Report Status:
Discharge Date: 4/30/2007
****** FINAL DISCHARGE ORDERS ******
SHAMEL , GEMMA 579-33-75-3
Ne E
Service: MED
DISCHARGE PATIENT ON: 6/6/07 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ASPIRIN ENTERIC COATED 325 MG orally every day
2. FUROSEMIDE 60 MG orally twice a day
3. METOPROLOL SUCCINATE EXTENDED RELEASE 50 MG orally every day
4. SIMVASTATIN 20 MG orally every bedtime
5. WARFARIN SODIUM 6 MG orally every afternoon
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 1 , 000 MG orally every 6 hours
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 7/28/07 by
GETTINGS , OTELIA H. , M.D.
on order for COUMADIN orally ( ref # 296899503 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda Previous override information:
Override added on 10/28/07 by GETTINGS , OTELIA H. , M.D.
on order for COUMADIN orally ( ref # 052554642 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
IBUPROFEN 400 MG orally every 8 hours Food/Drug Interaction Instruction
Take with food
LISINOPRIL 2.5 MG orally DAILY
Alert overridden: Override added on 6/6/07 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: ok
METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally DAILY
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SIMVASTATIN 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 7/28/07 by
GETTINGS , OTELIA H. , M.D.
on order for COUMADIN orally ( ref # 296899503 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: mda Previous override information:
Override added on 10/28/07 by GETTINGS , OTELIA H. , M.D.
on order for COUMADIN orally ( ref # 052554642 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: mda
COUMADIN ( WARFARIN SODIUM ) 3.5 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 7/28/07 by
GETTINGS , OTELIA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Tetrick 3/6/07 , 10:10 am scheduled ,
Arrange INR to be drawn on 7/27/07 with f/u INR's to be drawn every
7 days. INR's will be followed by MMC coumadin clinic
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
musculoskeletal chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity , atrial fibrillation on coumadin , hypertension
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac MIBI: preliminary results suggest this was a poor study , small
reversible inferior septal defect was thought to likely be artifact.
BRIEF RESUME OF HOSPITAL COURSE:
cc: chest pain
---------------------
hpi: 60F with afib on coumadin , hypertension. Woke up at 10 am with L
sided chest and back pain. Radiation to arm with motion. +nausea ,
+crampy abdominal pain. Worse with arm and body movement. Has 1 year
history of progressive sob with exertion and increasing lower extremity
edema.
---------------------
pmh: htn
afib diagnosed 2/8
echo 2/5 concentric LVH. Overall left ventricular function is low
normal to mildly impaired. The estimated ejection fraction is 50%.
mild-mod MR Mild lae , no pfo/asd.
-----------------------
meds: zocor lasix coumadin toprol asa
-----------------------
all: nkda
-----------------------
sh: remote prior history of smoking , social alcohol no drugs
-----------------------
physical on admission: afeb , 48 , 142/74 , 99 on
ra obese jvp 8-10 cm lungs: cta b/l tenderness to palpation of anterior L
chest and posterior L scapular and pain in shoulder with movement
irr irr 2/6 sys murmur , feint apical murmur abd: benign ext: chronic
venous stasis changes , trace - 1+ le edema , +tophi
-----------------------
labs: K 3.3 , cr .9 studies:
portable cxr: clear ekg: brady at 48 with multiple atrial foci ,
varying pr intervals , different p wave morphology , q's in
III and avF ( change from prior ) , no st changes
stress test in 04: no ischemia , 4 minutes on bruce got her to 100% of
predicted heart rate
-----------------------
events: 6/10 with transient LBBB
----------------------------------
hospital course: 60F with htn , afib presents with acute onset L sided
chest/back/shoulder pain , atypical for cardiac cp.
1. ischemia: It was felt that patient's chest pain was likely
musculoskeletal. It was worse with movement of her arms and chest and ws
reproducible with palapation. She was ruled out for MI with serial
enzymes and ekgs. We continued her asa , lowered her dose of bblocker
given bradycardia , and started the patient on an ace inhibitor. She
underwent ETT and went into rate related L bundle branch block. Full
report as follows: 1. Peak METS = 5.7 2. Duke Treadmill Score = +4
( Moderate risk: -10 to +4 ) 3. HR Recovery = 29
ASSESSMENT:1. Diagnosis: No evidence for ischemia at HR achieved.
Reduced sensitivity because ECG uninterpretable due to rate related LBBB.
2. Prognosis: Elevated prognostic risk based on low functional capacity
and a low Duke score of +4 ( Moderate risk: -10 to +4 ). 3. Arrhythmia:
Probable rate related LBBB at peak. 4. Hemodynamics: Normal exercise
hemodynamics.
Cardiology was consulted and they recommended a MIBI and echo to
better evaluate her cardiac function. She then underwent a MIBI which
showed a small inferior septaldefect , which was thought to likely be
artifact. Given the small area , it was felt medical management would be
the best approach. She was discharged on small dose of bblocker , ace
inhibitor asa and statin.
Pump: The patient's lasix had recently been increased to 60 mg twice a day She
was not felt to be volume overloaded and was continued on this dose in
house. Her echo was done on the day of discharge and can be followed up
as an outpatient. Her blood pressures ran on the low side so she will
be discharged on a lower dose of her bblocker.
rhythm: Patient has underlying conduction system disease
with 1 degree av block and developed a left bundle branch block at a HR
of 150 during her ETT. She was continued on coumadin for history of
afib
musculoskeletal pain: pain improved with standing tylenol and motrin
standing , with oxycodone for breakthrough
endocrine: Her fasting glucoses showed borderline glucose intolerance
with values around 110. These should be followed as an outpatient.
fen: low fat , low salt diet
ADDITIONAL COMMENTS: Please follow up with you primary care provider. You did not have any
signs of significant heart disease. Please call your doctor if your
shortness of breath worsens , you develop new chest pressure , or you feel
lightheaded.
We have started a new medicine for your blood pressure and have lowered
the dose of your other blood pressure medicine.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u final MIBI results
f/u final echo results
f/u electrolytes on ace-inhibitor
consider PFTs to better evaluate reason for progressive shortness of
breath on exertion ( does not appear to be cardiac in cause )
titrate bblocker and ace-inhibitor
follow fasting glucose values
No dictated summary
ENTERED BY: MUNDT , SUMMER M. , M.D. ( DY980 ) 6/6/07 @ 04:16 PM
****** END OF DISCHARGE ORDERS ******
Document id: 327
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506204373 | PUO | 74372820 | | 2450981 | 5/4/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed
Discharge Date: 10/2/2005
ATTENDING: PETTINGER , DOUGLASS MD
ADDENDUM:
DISCHARGE MEDICATIONS:
Include:
1. Tylenol 650 mg orally every 4 hours as needed
2. Amiodarone 200 mg orally daily.
3. Enteric-coated aspirin 81 mg orally daily.
4. Dulcolax 10 mg PR every other day.
5. Colace 100 mg orally twice a day
6. Folate 1 mg orally daily.
7. Haldol 0.25 mg orally twice a day as needed This medication should be
used sparingly as the patient gets oversedated easily. Do not
give over Haldol 0.25 mg at one time.
8. Insulin regular sliding scale subcutaneous before meals and at
bedtime.
9. Lactulose 30 mL orally four times a day as needed for constipation.
10. Protonix 40 mg orally daily.
11. Synthroid 25 mcg orally daily.
12. Lisinopril 10 mg orally daily.
13. Metamucil sugar free one packet orally daily.
14. Simvastatin 80 mg orally at bedtime.
15. Toprol XL 100 mg orally twice a day hold if systolic blood pressure
less than 100 , heart rate less than 55.
16. Diltiazem extended release 360 mg orally daily , hold if
systolic blood pressure less than 100 , heart rate less than 55.
17. Plavix 75 mg orally daily , this medication should not be held
for any reason.
18. Maalox chewable 1-2 tablets orally every 6 hours as needed
DISPOSITION:
Upon discharge , the patient will be transported to the Howood Medical Center where he will continue physical therapy , occupational
therapy , as well as continued medication titration. Upon
discharge , the patient is in stable condition tolerating orally
intake well. He was ambulating with minimal assistance.
FOLLOW-UP APPOINTMENT:
The patient has follow-up appointment scheduled with Dr. Holtmann
on 9/10/05 at 8:50 a.m. He has follow up with Dr. Coda , his
Internal Medicine physician , on 7/9/05 at 9:00. In addition ,
he will follow up with Dr. Dominguez on 4/4/05 at 9:30 a.m.
TO DO:
Includes:
1. The patient should have his INR checked everyday. The
Coumadin was initiated at 1 mg orally daily on 7/18/05 . The
dosage may need to be titrated in order to keep an INR between a
goal of 2-3.
2. The patient should be continued on an aggressive bowel
regimen to avoid constipation.
3. The patient should have daily weights checked , he may require
additional diuresis if he shows symptoms of volume overload
including an increase in greater than 2 pounds weight gain in one
day or 5 pounds weight gain in a week or shows symptoms of volume
overload such as respiratory distress or increasing lower
extremity edema.
4. The patient will follow up with Dr. Holtmann for Cardiology
followup on 9/10/05 .
eScription document: 9-7492611 EMSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: PETTINGER , DOUGLASS
Dictation ID 0117592
D: 7/7/05
T: 7/7/05
Document id: 328
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834899235 | PUO | 99686864 | | 132371 | 10/19/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/4/1993 Report Status: Signed
Discharge Date: 2/29/1993
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old male
with a history of hypertension
admitted with acute anterior myocardial infarction and a very poor
historian. His cardiac risk factors include a history of cigarette
smoking , hypertension , family history , questionable history of
hypercholesterolemia and no history of diabetes. The patient is
followed by Dr. Bua for hypertension. Approximately one year
ago , he was sitting on a bike awaiting an exercise test and he felt
lightheaded without any chest pain. He was admitted to OCGH for
question of rule out myocardial infarction. He had an exercise
tolerance test one day later without chest pain or shortness of
breath. He exercises daily as well as jogging. Two weeks prior to
admission , the patient walked one block , he had acute shortness of
breath while awaiting for a train. He had a head cold with
congestion and cough at that time. He had no chest pain but did
have diaphoresis and mild nausea and vomiting as well as
lightheadedness and some palpitations lasting approximately one
hour in duration. On the day of admission after taking a shower in
the morning , he had increasing shortness of breath gradually at
rest with epigastric tightness without radiation but he did have
nausea , vomiting and diaphoresis. He was seen at Pagham University Of because he was "unable to breathe". In the
emergency room he had a blood pressure of 207/150 with saturation
of 93% , rales and positive S4. He was treated with nitroglycerin ,
morphine , Lasix and Nitropaste. He was also given Lopressor , 15
mg. EKG showed Q's in V1-2 , 1-2 mm ST increasing in V1 , lateral T
wave inversions. Blood pressure dropped to 99/67 with treatment
and he was sent for emergent cardiac catheterization.
HOSPITAL COURSE: EKG showed normal sinus rhythm at 91 , -15
degrees axis. There were left atrial
abnormalities. There was ST elevation of 1-2 mm in V1-3 , T wave
inversion in I , L , V4-6; Q's in V1 and V2. This was new compared
with prior EKG. The patient underwent cardiac catheterization
which revealed pulmonary capillary wedge of 30 , RV 46/14 , PA 46/30 ,
ramus occluded 50%. The patient developed left arm pain with
inflation and slow flow after PTCA. The patient had decreased
blood pressure and heart rate and was treated with Narcan and
atropine. The patient was treated with nitroglycerin , heparin and
aspirin. He was also started on Lopressor. He was given intravenous Lasix
for diuresis and magnesium. The patient's third set CPK came back
at 429 with 10 MB's. The patient was stable overnight. His
electrophoresis came back negative. It was felt that an acute
myocardial infarction was less likely and it was felt that
pulmonary edema was secondary to his hypertensive disease being out
of control. His heparin was discontinued and he was switched to
atenolol and lisinopril. The patient underwent exercise tolerance
test where he completed a submaximal predischarge protocol without
pain or dyspnea. His resting EKG showed evidence of anterior
septal myocardial infarction with a peak heart rate of 120 , blood
pressure 180/90. There were some mild fixed defects anteriorly.
He also developed some dysuria after removal of the Foley with
100 , 000 enteric gram negative rods.
DISPOSITION: The patient was discharged to home in stable
condition. MEDICATIONS: On discharge included
aspirin , one orally every day; lisinopril , 20 mg orally every day; atenolol , 100 mg
orally every day; Bactrim DS , one orally twice a day times seven days;
nitroglycerin , as needed; Pyridium , 200 mg orally three times a day times two days.
The patient will follow-up with Dr. Abshear .
Dictated By: GAYLENE G. FANIEL , M.D. RI88
Attending: CARLTON J. ABSHEAR , M.D. GH1 FL328/5202
Batch: 6765 Index No. ZIOSXY3YJI D: 2/18/93
T: 5/5/93
Document id: 329
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231980943 | PUO | 45274139 | | 403714 | 1/28/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/17/1990 Report Status: Unsigned
Discharge Date: 6/27/1990
PRINCIPLE DIAGNOSIS: VENTRAL HERNIA.
SECONDARY DIAGNOSES: POSTOPERATIVE ILEUS.
ASTHMA.
HISTORY OF PRESENT ILLNESS: This 39-year-old Hispanic female
presented for an elective repair of an
incision ventral hernia. She developed the hernia at the upper
margin of a previous cesarean section incision in her third
postpartum month. Her only risk factor is obesity. She denied
wound infection , chronic cough , constipation or previous abdominal
hernias. She is not required to do heavy lifting in her activities
of daily living or her occupation. The hernia now causes pain but
has no associated symptoms of nausea , vomiting or obstendation.
PAST MEDICAL HISTORY: She has suffered from chronic headaches
which have been investigated in the past; a CT scan and EEG are
reportedly normal according to the patient. She has been treated
for these symptomatically with the use of Naprosyn. OBSTETRICAL
HISTORY: She is gravida VIII , para VI , A II with two miscarriages
being spontaneous. She had a cesarean section with her last
delivery. She is also status post tubal ligation. MEDICATIONS: On
admission included Naprosyn , as needed for headaches. ALLERGIES:
PENICILLIN WHICH CAUSES A RASH; COMPAZINE , DYSTONIC REACTION;
ANESTHESIA , IN THE PAST SHE BECAME BRADYCARDIC WITH SYMPTOMS OF
LOCAL PHLEBITIS FOLLOWING ADMINISTRATION OF AN UNKNOWN ANESTHETEIC
AGENT. SOCIAL HISTORY: She has a very remote smoking history and
does not consume alcohol. She is currently involved with a weight
loss program at a nutrition center.
PHYSICAL EXAMINATION: On admission revealed a pleasant , obese
Hispanic female was in no acute distress at
the time of exam. Her blood pressure was 130/88. Her temperature
was 98.6. Her pulse was 78 and regular. Respiratory rate was 20.
She weighed greater than 300 pounds. Her head and neck exam
revealed pupils that were equal and reactive to light and
accommodation. Fundoscopic examination was normal. She had normal
orally pharyngeal mucosa with no exudative lesions present. Her
thyroid was palpable at the isthmus only and was nontender. Her
breast examination revealed no masses or tenderness and no skin or
nipple changes. Chest expansion was decreased secondary to chest
wall obesity. Her air entry was symmetric bilaterally with no
adventitious lung sounds. Her heart sounds were normal with no
evidence of murmurs , rubs or clicks. Her abdomen was benign with
normal bowel sounds and no palpable masses. She had a midline
incisional scar from her previous cesarean section. At the upper
margin , there was a soft reducible hernia that measured 5 x 7 cm.
There was a palpable 1-2 cm defect in the fascia. She had no
evidence of hepatosplenomegaly. Rectal exam was guaiac negative.
Neurological exam was nonfocal with cranial nerves III-XII grossly
normal. Her sensory exam showed light touch and pinprick was
normal. Babinski's were downgoing bilaterally.
LABORATORY DATA: On admission revealed a white blood cell count
of 7.9 with normal differential. Hematocrit was
31.1. SMA 20 showed normal electrolytes. Liver function tests
were all within normal limits with the exception of a mildly
elevated LDH at 199. Urinalysis was negative. Chest x-ray was
within normal limits. EKG showed normal sinus rhythm at 75 beats
per minute with normal intervals and normal axis.
HOSPITAL COURSE: The patient underwent repair of her ventral
hernia with mesh placement on 11/17/90 . The
procedure was well tolerated with no intraoperative complications.
In the postoperative period , she had an exacerbation of ashtma that
responded well to inhaled albuterol nebulizer treatment. In
addition , she had a prolonged postoperative ileus and required intravenous
hydration until postoperative day number six. At that time , she
was able to tolerate both a clear and regular house diet and began
to pass flatus and bowel movements. The patient was discharged
home in stable condition.
DISPOSITION: The patient was discharged home in stable condition.
MEDICATIONS: On discharge included Colace , 100 mg orally
twice a day; Tylenol , 650 mg orally every four hours as needed and hydrogen
peroxide to her incision on a as needed basis. Her staples were left
in place. She will be seen in follow-up in the Uass Goldman Valley Medical Center within one week after discharge. She is to avoid any heavy
lifting for the next six week period.
________________________________ JS694/0734
NADA D. LANGHOUT , JR , M.D. , PH.D. SF2 D: 12/10/90
Batch: 4735 Report: Q9735Q8 T: 10/2/90
Dictated By: MARIBEL BOYANTON , M.D. OA2
Document id: 330
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598555919 | PUO | 29607759 | | 922553 | 1/12/1994 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/12/1994 Report Status: Unsigned
Discharge Date: 9/15/1994
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: Mr. Quon is a 52-year-old man status
post coronary artery bypass graft x1 ,
with saphenous vein graft to the left anterior descending in 1976.
He presents with a 5-6 week history of unstable angina. He had an
echocardiogram which revealed recurrent coronary artery disease.
The patient was referred to Dr. Golebiowski for reoperative coronary
artery bypass graft.
PAST MEDICAL HISTORY: The patient has a history of coronary artery
disease and peripheral vascular disease.
PAST SURGICAL HISTORY: The patient is status post a radical
prostatectomy complicated by osteitis pubis
and a urethral colonic fistula.
CURRENT MEDICATIONS: Aspirin , Lopressor , Procardia XL , intravenous
heparin and intravenous nitroglycerin.
ALLERGIES: No known drug allergies.
LABORATORY DATA: BUN and creatinine 16/1.2 , white count 5500 ,
hematocrit 46.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service on September , 1994 , where he was
stabilized and finally taken to the Operating Room on July ,
1994 , at which time he underwent a reoperative coronary artery
bypass graft x3 , with a left interior mammary artery to the left
anterior descending. The patient tolerated the procedure well and
was hemodynamically stable in the unit. He was weaned overnight
and extubated on postoperative day 1. He was started on aspirin
and Lopressor , weaned off his O2 and started on diuretics. He was
transferred to the unit on postoperative day 1.
Once on the unit the patient was gradually advanced to a regular
diet and weaned off his O2. He was diuresed down to his
preoperative weight. He had a routine postoperative course.
DISPOSITION: Home on August , 1994.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS: Aspirin one tablet orally every day; Lopressor
25 mg orally three times a day; and Percocet as needed
FOLLOWUP: The patient will follow up with Dr. Pittinger and will
contact his office for an appointment after discharge.
Dictated By: MYRTICE J. STILL , M.D. NL4
Attending: LOIDA F. GOLEBIOWSKI , M.D. CG6 SL785/1102
Batch: 0608 Index No. J3KB4UQDT D: 1/13/94
T: 6/15/94
Document id: 331
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279704264 | PUO | 05648655 | | 4563880 | 3/3/2004 12:00:00 a.m. | HOCM , CHF exacerbation | | DIS | Admission Date: 3/3/2004 Report Status:
Discharge Date: 2/3/2004
****** DISCHARGE ORDERS ******
PERKO , TRUMAN 294-06-75-6
Birm
Service: CAR
DISCHARGE PATIENT ON: 4/13/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PART , JACKSON , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VERAPAMIL SUSTAINED RELEAS 240 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
METFORMIN 500 MG orally twice a day
ZYRTEC ( CETIRIZINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Number of Doses Required ( approximate ): 4
SINGULAIR ( MONTELUKAST ) 10 MG orally every day
VENLAFAXINE EXTENDED RELEASE 37.5 MG orally every day
Number of Doses Required ( approximate ): 3
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LASIX ( FUROSEMIDE ) 20 MG orally every day
VENTOLIN ( ALBUTEROL INHALER ) 2 PUFF inhaled four times a day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day Instructions: 10mg every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Sachiko Borriello 1-2 weeks ,
ALLERGY: broccoli , Aspirin
ADMIT DIAGNOSIS:
shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
HOCM , CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HOCM , mild asthma , CHF , type II DM , morbid obesity
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
52F with HOCM , peak gradient 125 mmHg on TTE in 6/29 , CHF , HTN ,
morbid obesity , hypercholesterolemia , new type II DM , recently
started on furosemide for volume overload with subsequent 30-lb+ wt
loss , admitted with increasing shortness of breath , orthopnea , DOE ,
5-lb wt gain x 2 days. 6 wks prior to admission , significant wt gain
noted , and dyazide changed to furosemide , with subsequent 30-lb wt
loss since April . Over last 2 days has felt increasing SOB ,
orthopnea , and 5-lb wt gain from 307->311. Also wheezing ,
non-productive cough , post-nasal drip; no fevers/chills. Of note , has
increased fluid intake by 10 glasses of water per day. No near-syncope
since 2002 , no chest pressure/pain , rare palpitations. Other PMH:
depression , R TKR. Exam: 98.6 148/73 79 25 93% RA. Comfortable , full
sentences. JVP diff to assess; chest clear; II/VI sys M LSB increased
with valsalva , decreased with leg raise. Obese abd , 1+LE edema. CXR mod
cardiomegaly , no edema. EKG: NSR@76 , unchanged TWF/I V5-V6.
*****Assessment and Hospital Course*****
52 year-old woman with increasing shortness of breath , weight gain in setting
of increasing fluid intake:
**CV: Pump: volume overload secondary to CHF , excessive fluid intake
likely secondary to new onset DM. Diuresed with 20mg lasix intravenous in ED ,
40mg intravenous lasix on floor , with resolution of orthopnea and DOE.
Maintained on verapamil for ventricular relaxation. Will see Dr.
Reedy as outpatient for potential ablation of HOCM. Seen by Dr.
Carri Katcsmorak genetic counselor to discuss genotyping of HOCM , for
herself and her children.
-Isch: low suspicion , ruled out by enzymes. Continued verapamil for
HTN.
-Pump: no issues--in NSR during entire hospitalization.
**Pulm: PFTs notable for restrictive pattern--TLC 56% , FVC 59% , FEV1
57% , FEV1/FVC 100% , DLCO corrected 66%. ?May benefit from outpatient
referral for sleep study for OSA/OHS. Continued outpatient regimen of
singulair , zyrtec , atrovent , albuterol , advair.
** Endocrine: new type II DM , with significant polydipsia likely
contributing to volume overload. Increased metformin to 500mg twice a day
** FEN: discussed outpatient weight loss program for morbid obesity
with Dr. Soulasinh attempt to arrange after discharge.
** Psych: cont venlafaxine for depression
** PPX: lovenox , nexium
ADDITIONAL COMMENTS: Please call Dr. Borriello for a follow-up appointment in 1-2 weeks.
Please call Dr. Melda Ivaska office at 428-217-7862 ( Boshers ) to
set up an appointment for possible ablation of your cardiomyopathy. Dr.
Carri Katcsmorak number is ( 327 ) 497-9727 , if you would like to speak
further about genotyping your cardiomyopathy , and obtaining genetic
tests on your children.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KATZER , CALANDRA , M.D. ( TR28 ) 4/13/04 @ 03:34 PM
****** END OF DISCHARGE ORDERS ******
Document id: 332
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721267430 | PUO | 28643509 | | 733642 | 11/10/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/10/1993 Report Status: Signed
Discharge Date: 4/18/1993
DISCHARGE DIAGNOSIS: 1 ) CORONARY ARTERY DISEASE.
2 ) STATUS POST TORSADE ARREST.
3 ) ATRIAL FIBRILLATION.
OPERATIONS AND PROCEDURES: Coronary artery bypass grafting times
three on 5/12/93 .
HISTORY OF PRESENT ILLNESS: Patient is a 72 year old man with a
history of myocardial infarction in
1979 and exertional angina times the last several months which was
well controlled on sublingual TNG until he experienced a twelve
hour episode of chest pain which was followed by exercise stress
test on 2/6/93 . The patient , previous to his recent onset of
chest pain , had been very active with thirty to forty minutes of
exertion daily without chest discomfort. For the past five days
prior to admission , he noted progressive acceleration in his chest
pain symptoms which were occurring with minimal exertion. The
patient's local physician performed an exercise stress test and the
patient developed symptoms at seven minutes of walking with
associated ECG changes. Several hours after the stress test , he
had recurrent chest pain at home and took a total of twelve
sublingual TNG without relief. He presented to the Pagham University Of Emergency Room. CURRENT MEDICATIONS: Medications
at home including Tenormin , Allopurinol , and Coated Aspirin.
ALLERGIES: No known drug allergies. Cardiac risk factors were
negative for hypertension , hypercholesterolemia , tobacco , and
diabetes.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service where he appeared to rule in for
myocardial infarction. He was admitted to Dr. Ameen
service and underwent cardiac catheterization on 2/25/93 . This
revealed a 50% distal left main lesion , 100% mid left anterior
descending lesion , 70% mid left circumflex lesion , 70% D1 lesion ,
and 100% right coronary artery lesion. In the Cardiac
Catheterization Laboratory , the patient had an intraaortic balloon
pump secondary to ongoing chest pain and was referred to Dr. Marcott
for coronary artery bypass grafting. The patient was taken to the
Operating Room for coronary artery bypass grafting on 5/12/93 . At
that time , he underwent an uncomplicated coronary artery bypass
grafting times four with grafts including vein grafts to the left
anterior descending , the D1 , OM1 , and proximal descending artery.
Patient tolerated the procedure well and post-operatively , was
noted to be somewhat hypoxic. His post-operative chest film the
morning of post-operative day number one was notable for
opacification of the left hemithorax. The patient was taken back
to the Operating Room for evacuation of blood from the left chest
and at that time , small bleeding site was found from a sternal wire
on the left side. The patient returned to the Intensive Care Unit
and did well post-operatively being extubated post-operative day
number one. His initial post-operative course was notable for
atrial fibrillation with rates in the 100 range as well as some
intermittent hypotension. The patient was transferred back to the
Tondill Graceston Lor Medical Center on A In Call for further management. On the day of
his transfer , however , while being treated for rapid atrial
fibrillation , he experienced a torsade arrest and a Code Blue was
called. The patient was blindly intubated and from this event , was
felt to have experienced an aspiration pneumonia. Patient was
successfully resuscitated and was extubated several days later at
which point he was transferred back to the Cardiac Surgical
Service. From that time on , he had a stable post-operative course
with intermittent slow atrial fibrillation which was well tolerated
by the patient. He continued to progress well and consideration
was made for need for transfer to a rehabilitation facility but the
patient made good progress with his cardiopulmonary rehabilitation
by the Physical Therapy Service and was safe for discharge to home
on post-operative day number thirteen.
DISPOSITION: DISCHARGE MEDICATIONS: Digoxin 0.125 mg every day ,
Captopril 12.5 mg orally three times a day , Tylenol #3 as needed
for pain , Atrovent two puffs four times a day as needed , and Enteric Coated
Aspirin one per day. He will follow-up with his local Cardiologist
in one to two weeks and with Dr. Marcott in six weeks.
Dictated By: TRISH CHAIX , M.D. PT27
Attending: DESIRAE R. MARCOTT , M.D. SK9 JN475/4975
Batch: 2158 Index No. QEGZ8I0XA4 D: 11/18/94
T: 9/19/94
Document id: 333
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
- |
N |
N |
N |
N |
N |
- |
N |
N |
N |
- |
989655309 | PUO | 79037331 | | 070464 | 3/4/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/24/1991 Report Status: Signed
Discharge Date: 11/10/1991
PRINCIPAL DIAGNOSIS: DEEP VENOUS THROMBOSIS IN THE DISTAL
RIGHT POPLITEAL VEIN.
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old former
triage nurse who has suffered from
degenerative joint disease since 1977 when she was hit by a Woody'sal Blvd. , Nash , Virginia 45704
bus. She was hospitalized at that time and had a left calf deep
venous thrombosis secondary to extended bedrest. Her joint disease
involved primarily the L4 to S1 vertebra ( comprising two joint
spaces , and she reported this to have been exacerbated by an
attempted rape in 1980. At present , the patient suffers
considerable daily pain inhibiting her ability to work. The
patient recently received a facet block in October of 1991 at the
Pagham University Of by the Pain Service which only seemed
to increase her pain. She described steadily worsening pain in
recent months and an increased portion of her time is therefore now
spent at bedrest due to her decreased mobility. The patient
described first experiencing left calf pain one and a half weeks
prior to this admission which manifested itself as a crampy pain of
short duration. She apparently saw her private medical doctor at
this time , Dr. Rossie Mankoski , who sent her out on nonsteroidal
anti-inflammatory drugs. On 4/12 , five days prior to admission ,
the patient awoke at night with severe right leg cramping. She , at
that time , went to the Kendsonre Ale Ater Hospital Emergency
Room where a noninvasive vascular study was positive for non
obstructive peroneal vein thrombosis. She was discharged on
Anaprox. On 4/29 , the patient returned to the KAAH Emergency Room
complaining of increased pain and with great anxiety due to her
perceived risk of pulmonary embolus. The patient has had this
condition in the past and was quite concerned about it. Noninvasive
vascular studies at that time showed the lesion to be obstrutive in
the peroneal vein. However , there was no evidence of deep venous
thrombosis at that time. She was discharged on Coumadin , 5 mg every
day. On 8/18 , the patient experienced further worsening pain and
came to the Pagham University Of for a second opinion. She
was heparinized in the Emergency Room and admitted to the Medical
Service. REVIEW OF SYSTEMS: The patient denied chest pain ,
shortness of breath , dyspnea on exertion , abdominal pain , nausea ,
vomiting , diarrhea or constipation , any recent weight loss or any
additional constitution of symptoms. PAST MEDICAL HISTORY:
Occasional migraine headaches. L4-5 ruptured disc status post bus
accident in 1977. As stated above , she had a left lower extremity
deep venous thrombosis following that hospitalization. Previous
positive PPD , she had one year of treatment. Mugging in 1980 with
exacerbation of her joint disease. Emergency Room admission in 1988
for questionable cholecystitis. Facet block times two in 1986 and
1991. Periods of incremental menorrhagia. She is followed by Dr.
Leuga at the Pagham University Of . Endometrial biopsy
recently performed was negative. Asthma. Gastritis. Appendectomy.
ALLERGIES: FISH. ERYTHROMYCIN. LACTOSE INTOLERANCE. FAMILY
HISTORY: The patient was raised by foster parents. She has some
knowledge of her natural parents. Her mother was retarded and died
of a pulmonary embolism. Her maternal grandmother had an
endochondroma. First cousin with pancreatic cancer. Maternal
grandmother had cancer of the cervix. SOCIAL HISTORY: She is
divorced times 11 years. She lives with her 16-year-old daughter.
She has a positive smoking history. She denied drinking. She
denied intravenous drug use.
PHYSICAL EXAMINATION: On admission revealed a well developed ,
well nourished white woman in no acute
distress. The patient is mildly agitated and overly circumstantial
in her dialogue. Blood pressure 112/78. Pulse 100. Respiratory
rate is 24. Temperature 99.3. Skin was without lesions. HEENT
exam was within normal limits. Neck was supple without adenopathy.
She has a positive right anterior cervical mobile mass which
appeared to be a lipoma. She was without any jugular venous
distention. Chest was clear to auscultation and percussion. Breast
exam was refused. Cardiac exam revealed a regular rate and rhythm
with normal S1 and S2 without S3 , S4 or any rubs , murmur or gallop.
Abdomen revealed positive bowel sounds. Abdomen was soft ,
nondistended without any hepatosplenomegaly. The patient had
normal sphincter tone , no masses , guaiac negative. Extremities
revealed right calf tenderness to palpation , slightly swollen , no
warmth , positive Homan's sign. No cords were felt. The left calf
was unremarkable with some point tenderness and right inner thigh ,
again no cords felt. There was no CVA tenderness. There was
positive point tenderness in the region of L4-5 , L5-S1.
Neurological exam revealed the patient to be alert and oriented
times three. Cranial nerves II-XII were intact. No deficit of
sensory proprioception or position sense.
LABORATORY DATA: On admission included a sodium of 140. Potassium
of 4.3. Chloride 105. Bicarb of 30. BUN 25.
Creatinine 1.2. Glucose 89. CBC was notable for a white blood
cell count of 11.9 with 22 lymphocytes , 7 monocytes , 67
neutrophils , 2 eosinophils. Hematocrit was 41.4. Platelet count
150 , 000. physical therapy was 16.6. PTT 29.8. All other values were within
normal limits. Urinalysis was significant for a pH of 8.0 , 1-3
white cells , 0-2 red cells , 1+ bacteria. Chest x-ray was
remarkable for no infiltrates or effusions , positive hiatal hernia.
EKG revealed sinus rhythm at 90 with intervals of 0.18/0.08/0.36 ,
no ST changes , no change since 11/23 .
HOSPITAL COURSE: The patient is a 49-year-old female with a
history of prior deep venous thrombosis with
recent decreased mobility who presented with a painful right calf
with a documented right peroneal vein obstruction. Although the
clot is only documented to be below the knee , the question of
progression must be addressed. Initially , in light of strong data
supporting these events , anti-coagulation to prevent progression of
these clots , the decision was made to further anti-coagulate the
patient as she had minimal risks for this procedure. On admission ,
there was no evidence of pulmonary embolus by history of physical.
Right calf pain/deep venous thrombosis: On the second hospital
day , the patient had noninvasive Doppler studies of her lower
extremity which were significant for deep venous thrombosis in the
distal right popliteal vein. There were no other abnormalities
seen in either lower extremity. The patient was initially treated
with heparin since her physical therapy was subtherapeutic on admission and
continued on Coumadin. By the second hospital day , the patient was
therapeutically Coumadinized and the dose was adjusted accordingly
with the goal of 17 to 19. As far as her leg pain was concerned ,
the patient was treated with Percocet for this problem. Physical
therapy came and evaluated the patient and helped her with
regaining her mobility. She was fitted with compression stockings.
Arrangements were made for VNA for the patient upon discharge.
2 ) Back pain - This is a longstanding problem for which this
patient has been treated for for many years. She refused any
consultation at this time by the Kernan To Dautedi University Of Of Pain Service. Instead , we
treated her with Percocet for these symptoms. 3 ) Agitation -
Patient is extremely agitated demonstrating almost hypomanic state
with pressured speech and Flight of ideas. She was initially on
Clonipin on admission on which she was maintained. In addition ,
she was given additional benzodiazepines to help with sleep.
DISPOSITION: CONDITION ON DISCHARGE: Stable. Patient was
therapeutically anti-coagulated and she was given a
regimen of Coumadin to take to be followed by Dr. Rossie Mankoski .
Disposition is to home with visiting nurse service. DISCHARGE
MEDICATIONS: Coumadin 2.5 alternating with 5 mg every day , Clonazepam
0.5 mg orally three times a day , Percocet one tablet orally every 4-6h. , Darvocet l00
mg orally every 8 hours as needed , Senokot 300 mg orally three times a day , and Cimetidine
300 mg orally three times a day Patient is to be followed by Dr. Rossie K Mankoski .
JD192/5519
ROSSIE MANKOSKI , M.D. PI36 D: 4/1/91
Batch: 4149 Report: I6270O4 T: 2/6/91
Dictated By: WENDI NEWAND , M.D.
Document id: 334
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
659480679 | PUO | 04818275 | | 8786189 | 11/27/2006 12:00:00 a.m. | DEHYDRATION , CHRONIC ABDOMINAL PAIN | Unsigned | DIS | Admission Date: 10/2/2006 Report Status: Unsigned
Discharge Date: 4/1/2006
ATTENDING: HANSBERRY , SHAN M.D.
SERVICE: GMS PACE team.
PRINCIPAL DIAGNOSIS: CHF exacerbation.
LIST OF DIAGNOSIS DURING ADMISSION:
1. CHF/dilated cardiomyopathy
2. Chronic headache.
3. Chronic abdominal pain.
4. Iron deficiency anemia.
5. Hypertension.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female with a
past medical history significant for CHF exacerbations , dilated
cardiomyopathy with an EF of 25-30% , history of depression ,
bipolar disorder , and history of polysubstance abuse who
presented to Pagham University Of on 10/2/2006 ,
complaining of worsening shortness of breath and abdominal pain.
The patient had noted that she had increasing lower extremity
edema , decreased appetite and nausea; however , she had no weight
loss. Of note , the patient was recently admitted overnight on
3/3/2006 , with similar complaints. In the ED , the patient
complained of abdominal pain , which reportedly is chronic. Pain
is thought to be related to keloids at the sites of her open
cholecystectomy scar and hysterectomy scar. The patient had a
CAT scan of her abdomen done on her last admission on 6/2/06 ,
which showed diffuse micronodular opacities with wide ranging
differential diagnosis including infectious colitis , lymphoma , or
mastocytosis. A colonoscopy is recommended for further
evaluation. The patient was admitted to the hospital for control
of her shortness of breath , which was related to CHF exacerbation.
PAST MEDICAL HISTORY: Significant for dilated cardiomyopathy ,
history of depression , bipolar disorder , polysubstance abuse , and
hepatitis C.
PREADMISSION MEDICATIONS: Aspirin 81 mg daily , Elavil 100 mg
every bedtime , Klonopin 0.5 mg twice a day , iron 325 mg three times a day , Lasix 80 mg
twice a day , lisinopril 20 mg daily , spironolactone 25 mg daily , Zocor
20 mg every bedtime , Toprol-XL 50 mg daily , Imdur 60 mg daily , Cozaar 25
mg daily , Aricept 5 mg daily , Seroquel 300 mg every bedtime , Prilosec 20
mg daily , and potassium chloride 40 mEq daily
ALLERGIES: The patient is allergic to penicillin and
erythromycin.
SOCIAL HISTORY: The patient currently resides at home alone.
REVIEW OF SYSTEMS: Positive for chronic headache and chronic
abdominal pain , as well as worsening shortness of breath as noted
above.
PHYSICAL EXAMINATION: On admission , the patient was afebrile.
Heart rate 92 , blood pressure 154/91 , and respiratory rate 18.
O2 saturation was 100% on 2 liters and 96% on room air. The
patient was comfortable in no apparent distress. She is awake ,
alert , and oriented x3. The patient had an elevated JVD. Her
heart was regular rate and rhythm with a normal S1 and S2. Chest
was positive for bibasilar crackles and wheezing throughout.
Abdomen was obese , soft , and nondistended. Diffuse tenderness ,
especially at cheloid site. Extremities , 2+ pitting edema.
LABORATORY DATA: On admission , creatinine 0.9 , BUN 21 and
hematocrit 36.1. BNP was greater than assay. EKG with normal
sinus rhythm with a rate of 80 , which showed biatrial
enlargement , LVH and a prolonged QT. This was unchanged from
prior EKGs. Chest x-ray showed stable cardiomegaly with no acute
cardiopulmonary process.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular: The patient's shortness of breath was
attributed to her CHF , and the patient was treated with Lasix 80
mg intravenous twice a day with a goal of greater than 1 liter negative per
day. The patient's weight was monitored daily. On admission , it
was 180.4 pounds and on discharge , it was 167 pounds. The
patient's creatinine was also closely monitored and it did bump
to 1.3 on 4/18/2006 , but then on discharge , it went back down to
1.1. The patient was discharged home on her usual home dose of
Lasix , which is 80 mg orally twice a day The patient's ambulating O2
saturation was 99% on room air. The patient did have some
intermittent episodes of nonsustained ventricular tachycardia.
She remained asymptomatic. Her electrolytes were repleted
aggressively and the patient's metoprolol was increased from 12.5
mg to 25 mg three times a day As a result , the patient was sent home on
Toprol 75 mg daily instead of her prior home dose of 50 mg daily.
The patient had cardiac enzymes checked because of her
intermittent episodes of NSVT. The patient's troponin was less
than assay. She was continued on aspirin , spironolactone ,
lisinopril , Imdur , Zocor , and Cozaar. The patient also has
outpatient appointments with cardiology in the CHF clinic.
2. GI: The patient has a history of chronic abdominal pain and
a history of ischemic colitis. Pain during this admission was
similar to previous pain. On exam , the patient was diffusely
tender; however , it seemed to mostly be at the site of her
keloids. The patient was referred to have an outpatient
colonoscopy. The patient's primary care physician was notified
to arrange this procedure.
3. Neurology: The patient has a history of chronic daily
headaches and migraines , and she had a persistent headache during
this admit. She was treated with Tylenol , Reglan and warm
compresses as needed , which did control her pain. The patient also
was continued on Elavil. A followup appointment in the headache
clinic was made with Dr. Kaelin on 1/7/2000 .
4. Psychiatry: The patient has a history of drug seeking
behavior. No narcotics were prescribed for headaches during this
admission. She was continued on Klonopin 0.5 mg every 12 hours and
Aricept 5 mg daily. New psychiatry followup appointment was
arranged prior to discharge.
5. Hematology: The patient had both microcytosis and
hypochromia by RBC indices , which were suggestive of iron
deficiency anemia. She was continued on her iron
supplementation.
6. Dermatology: The patient did complain of some right deltoid
pain. On exam , right deltoid was tender and erythematous;
however , it did improve without any treatment and on day of
discharge , it was only mildly tender with no erythema.
7. Prophylaxis: The patient was continued on Nexium and was
given Lovenox 40 mg daily for DVT prophylaxis.
PHYSICAL EXAMINATION: On discharge , the patient's vital signs
were stable. Her JVP was flat. Lungs were clear , and the
patient only had trace edema in her lower extremities. Weight on
discharge was 167 pounds. Oxygen saturation while ambulating
with 99% on room air.
DISCHARGE INSTRUCTIONS: The patient was given a prescription for
her new increased dose of Toprol 75 mg orally daily. The patient
had physician home care set up for her where she will have CHF
monitoring and daily weights. The patient was instructed on a
1.5 liter fluid restriction at home and low-sodium diet. The
patient is to follow up with her primary care physician , Dr.
Carol Mordhorst on 6/1/2006 , at 11:00 a.m , follow up with
Dr. Milholland , psychiatry on 7/14/2006 , at 1:00 p.m. , Dr. Kum A Pidro from cardiology on 1/26/2006 , at 9:00 a.m. and Annabel E Verfaille in CHF Clinic on 5/25/2006 , at 3:30 p.m. Lastly , the
patient is to follow up in the headache clinic with Dr. Kaelin
on 11/21/2006 . The patient was notified that she should have an
outpatient colonoscopy and that Dr. Mordhorst can arrange this for
her.
ADVANCED DIRECTIVES: The patient is a full code.
PRIMARY CARE PHYSICIAN: Carol Mordhorst , M.D.
eScription document: 7-8012197 VF
Dictated By: OSMERS , TESSA
Attending: HANSBERRY , SHAN
Dictation ID 8941866
D: 2/6/06
T: 2/26/06
Document id: 335
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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641167400 | PUO | 19683722 | | 5041630 | 6/26/2007 12:00:00 a.m. | Cardiomypathy | | DIS | Admission Date: 2/20/2007 Report Status:
Discharge Date: 1/7/2007
****** FINAL DISCHARGE ORDERS ******
HARBEN , CHERELLE 577-01-66-3
Capepalmbi
Service: MED
DISCHARGE PATIENT ON: 10/28/07 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PERSONIUS , SVETLANA BART , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. ALBUTEROL INHALER 2 PUFF inhaled four times a day
2. ACETYLSALICYLIC ACID 81 MG orally every day
3. ATENOLOL 50 MG orally every day
4. FERROUS SULFATE 325 MG orally three times a day
5. FLUOXETINE HCL 20 MG orally every day
6. LISINOPRIL 40 MG orally every day
7. METFORMIN 850 MG orally twice a day
8. OTC OMEPRAZOLE 20 MG orally ONE TAB every day
9. METOCLOPRAMIDE 5 MG/5 ML SYRUP 10 MG orally four times a day ( before meals + HS )
10. TRAZODONE 50 MG orally every bedtime
MEDICATIONS ON DISCHARGE:
LANTUS ( INSULIN GLARGINE ) 35 UNITS subcutaneously every day before noon
ACETYLSALICYLIC ACID 81 MG orally DAILY
ALBUTEROL INHALER 2 PUFF inhaled every 6 hours
as needed Shortness of Breath , Wheezing
ATENOLOL 50 MG orally DAILY Starting IN a.m. ( 6/18 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FLUOXETINE HCL 20 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
Starting AT 2:00 PM ( 9/9 )
LISINOPRIL 40 MG orally DAILY
Override Notice: Override added on 9/25/07 by
BELIZAIRE , ROSAMOND LEONARDA , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
535801005 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: low potassium
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally every 6 hours as needed Nausea
OMEPRAZOLE 20 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day as needed Constipation
TRAZODONE 50 MG orally BEDTIME as needed Insomnia
DIET: House / 2 gm Na / Carbohydrate Controlled
ACTIVITY: resume activities as tolerated.
FOLLOW UP APPOINTMENT( S ):
Annabel Verfaille ( CHF nurse ) 220-030-7587 u69847 5/26/07 @3pm scheduled ,
Dr. Blacknall ( Diabetes ) 821-230-2405 2/5/07 @9am scheduled ,
Dr. Quirarte ( GI ) 473-999-4367 3/17/07 @3:40pm scheduled ,
Dr. Napierala ( Cardiology ) 575-803-4363 9/28/07 @1:30pm scheduled ,
Dr. Marchak ( primary care physician ) TBD ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Cardiomypathy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM-2 NSTEMI HTN Hyperlipidemia GERD Asthma Anemia Depression Fe def anemia
Gastritis
OPERATIONS AND PROCEDURES:
n/a
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
n/a
BRIEF RESUME OF HOSPITAL COURSE:
CC: DOE , leg swelling
---
HPI: 44 year-old F history of HTN , DM , CHOL , previous negative cath presenting with
progressive DOE and orthopnea x 3-4wks. No exertional CP , N/V. At
baseline is able to walk miles. Developed b/l LE edema in past 72hours
( 3days after starting Reglan ).
Currently undergoing an outpt GI eval for abd pain/N/V by Dr. Boden and
was recently started on Reglan. Recent EGD showed erosive esophagitis ,
non-erosive gastritis , and duonenitis ).
--
ROS: No recent F/C , URI s/s , diarrhea. Reports poor compliance with DM
diet.
---
ED COURSE: T97.2 , HR122 , 150/82 , RR18 , 100%RA. Clinical picture c/with CHF ,
treated with Potassium , Lasix , and Aspirin. Admitted to GMS-PACE.
---
PMH: see problem list
---
PRE-ADMISSION MEDS: see PAML integrated list
---
ALL: NKDA
---
SH: unemployed , 1-1.5ppd smoker , none in 3wks. ETOH consumption
3days/wk.
---
FH: DM , HTN , lung CA ( mom ) , gastric CA ( dad )
---
ADMIT EXAM: T97.8 , HR116 , 148/90 , RR14 , 100%RA
Gen: obese , no distress.
HEENT/Neck : no LAD , diff to appreciate JVP , neck supple.
Chest: clear
CV: tachy s1s2 , I/VI systolic murmur most prominent in the axilla.
Abd: obese , +BS , trace RUQ tenderness without guarding.
Ext: 1-2+ pitting edema to thighs.
Neuro: Ox3 , no focal deficits.
---
ADMIT DATA:
*Labs: Na138 , K3.4 , Cl103 , CO@=26 , Bun15 , Cr0.9 , Gluc265 , Ca8.8 , TP6.2 ,
Alb3.2 , Tbil0.9 , Alt61 , Ast48 , AP130 , BNP870 , Fe13 , WBC5.9 , Hct32.1
( MCV60 ) , Plt548 PT15.1 , PTT28.2 , INR1.2.
*UA: 2+prot , 10WBC , 1RBC , 1+sq epi , neg nit , neg LE
*CXR: Stable mod cardiomegaly without evidence of PNA or pulm edema. No
signif change since 2/16/2007 .
*ABD US: Diffuse gallbladder wall thickening , probable sm gallbladder
polyp again seen , trace right pleural effusion and pericardial effusion.
---
ASSESSMENT/PLAN: 44yo fem who was undergoing an outpt GI workup for abd
pain N/V and was recently started on Reglan. She p/with and 3-4wks of DOE ,
orthopnea , PND , and LE swelling , BNP=870. Was admitted for treatment of
CHF.
---
HOSPITAL COURSE:
1. CV:
*Pump: Cont'd ACE ( Lisinopril 40daily ) , utilized Lasix ( max Lasix dose
40IV twice a day ) to initiate diuresis. Orthopnea resolved after 3days of
diuresis. ECHO obtained on HD#4=nl LV size with mild conc hypertrophy , and
severely reduced function ( EF15-20% ) and global hypokinesis. Mod RVE
and hypertrophy , and globally reduced function. Mild LAE , mod RAE.
Trace to mild MR , mod to severe TR , trace PR , and sm pericardial
effusion. The CHF service consult ( Dr. Napierala ) obtained hx of 20oz
port wine consumption 3+days/wk. CHF team is attributing non-ischemic
cardiomyopathy to idiopathic vs ETOH. Rec'd goal SBP<120 ,
agreed with diuresis , ACE , +/-adding ARB , and changing b-blocker back to
Atenolol.
CHF team advised there is was clear indication for anti-coagulation. F/u
appts made Julie Lucien Daniele M. Napierala . patient will have VNA-CHF
home services.
Admit wt=197.6lbs , d/c wt=185.5lbs.
*Isch: Hx of NSTEMI , pos MIBI , neg cardiac cath 11/3 . Has a baseline
abnormal EKG that is concerning for inf/lat ischemia. Had a troponin
leak this admit in setting of CHF. Repeat CAD workup not pursued. Cont'd
Aspirin , and B-blocker ( was initially on Metoprolol 25tid , then
transitioned back to Atenolol 50daily per CHF service recs ).
Tchol=119 , HDL=26 , LDL=77. patient is DM , but no statin was started b/c of
elevated LFTs.
*Rhythm: Episode of NSVT 10/23 ( R-on-T VT in setting of QT prolongation
QTc=526 ). No additional ventricular arrhythmias were recorded on
via continuous telemetry monitoring. CHF service advised deferring AICD
placement unless patient fails 6mos of optimal medical CHF managment. Repeat
EKG's 10/13 QTc=495 , 5/9 QTc=478. Decision was made to cont Fluoxetine ,
given the minute risk that this med would contribute to QT prolongation.
2. GI:
*Team suspects hepatocongestion/GI venous congestion and/or gut ischemia
from poor arterial perfusion as cause of recent GI c/o's and LFTs. Low
grade abd pain and N/V resolved as team treated CHF , transaminases
remained ess unchanged.
as needed Reglan was continued. If GI symptoms return , patient may need additional
outpt workup ( HIDA scan , gastric emptying study ). patient has an existing GI
appt to see Dr. Boden in 11/13 .
*Cont'd PPI for gastritis , duodenitis seen on EGD 10/25 . It is unclear if
this can completely explain patient's Fe def anemia. She will need an outpt
colonoscopy to further eval.
*Celiac sprue studies were sent=pending at time of discharge.
3. ENDO: hx of DM-2 , HgA1c=8.8. patient advised team that she prefer to
discontinue Glucophage in favor of starting insulin. During this admit DM
was managed with twice a day NPH , pre-meal novolog , and before meals/HS novolog scales. On
10/13 patient's total insulin requirement was 44units. FSBS 6/12 8am ) ,
271( 12pm ). patient to transition to Lantus 35units every day before noon to begin 7/25 . VNA
arranged for insulin teaching and to assist primary care physician with dose titration. Syringe
education was provided.
4. HEME:
*RBC: microcytic hypochromic fe deficient anemia. RI=2.19. patient did not
save stool to perform stool guaiac testing. Cont'd Ferrous Sulfate this
admit , added Colace and Senna for constipation prophy. Will likely need
outpt colonoscopy , team deferring this to primary care physician and Dr. Boden ( outpt GI ).
Hg-electrophoresis was sent=pending at time of discharge.
*Coags: mildly elevated PTT/INR this admit. Suspect nutritional
depletion of vit K +/- ?liver dysfunction from CHF/liver congestion
leading to mild auto-anticoagulation. INR improved as patient able to
tolerate POs. She was not treated with Vit K.
5. MISC:
*Nutrition consulted for heart failure and DM diet teaching.
BCMC social worker was consulted to assist patient with maintaining abstinence
upon discharge. patient given instructions to f/u with her outpt Trent E Roma at Na South Litsanaflint Corp Hi
*Full code during this admission.
ADDITIONAL COMMENTS: ATTENTION PATIENT:
1. Take meds as listed , if you stop taking your meds for any reason , then
you need to notify your outpatient doctors.
2. Weigh yourself daily , write down the result , and bring the record to
your followup appointments.
3. Take your blood sugar before meals and at bedtime , write down the
results , and bring the record to your followup appts. Review your results
with your visiting nurse , who will help assist you and your primary care physician to make
insulin dose adjustments.
4. You need to continue to abstain from alcohol consumption , otherwise
your heart muscle is likely to continue to weaken. F/u Trent Roma to
assist you.
5. Follow the diet as instructed by the kernan to dautedi university of of staff nutritionist.
6. If your breathing worsens , have periods of lightheadedness or
palpitations , if you gain >2lbs in 24-48hours , if you become more swollen ,
then notify your doctors or return to the ER for re-eval.
7. If your blood sugar result is <70 , drink orange juice and a small meal ,
then call your doctor b/c your diabetes medication may need to be
adjusted. If your blood sugar results are above 250 , notify your doctor
b/c your diabetes medication may need to be adjusted.
8. If you have black or bloody stools notify your primary care physician and/or Dr. Boden .
9. The schedules in KTDUOO are not available and won't be until next week. I
Verna Eckloff ( 173-309-9107 ) will call you with the appointment details.
Call Verna Eckloff or your primary care physician's office if you are not contacted by 6/26 .
***
ATTENTION VNA:
1. patient is newly dx'd with cardiomyopathy , she will need CV-pulm-volume
assessment and CHF education.
2. patient just started on insulin , please assess her ability to
appropriately draw up and inject insulin. Also please review her FSBS
results and notify patient's primary care physician and/or endocrinologist if you think her
insulin needs adjustment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
ATTN primary care physician:
1. please monitor BP , volume status , renal function , proteinuria , DM
mangement , anemia/iron deficiency , thrombocytosis , LFTs , and coordinate
care with outpt providers.
2. please arrange referral to Dr. Quirarte for an outpt colonoscopy to
investigate source of Fe def anemia.
3. if/when LFTs correct , decide if patient would benefit from statin.
4. follow LFTs , decide if needs viral hepatitis panel or other studies.
5. f/u on celiac sprue labs.
6. f/u on Hg-electrophoresis results.
7. assess for med compliance.
8. titrate Lantus
No dictated summary
ENTERED BY: HOLLWAY , TABATHA , PA-C ( CW08 ) 10/28/07 @ 06:02 PM
****** END OF DISCHARGE ORDERS ******
Document id: 336
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887833478 | PUO | 26367322 | | 1047066 | 8/19/2004 12:00:00 a.m. | REACTIVE AIRWAY | Signed | DIS | Admission Date: 7/7/2004 Report Status: Signed
Discharge Date: 9/8/2004
ATTENDING: DOUGLASS BOVA M.D.
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS ON ADMISSION: This is a 73-year-old
female with known coronary artery disease , status post CABG , now
with CHF of 30% and a long history of second hand smoke
inhalation , who presented with shortness of breath. One week
prior to admission , she had had upper respiratory infection
symptoms and with some sick contacts. One day prior to
admission , the patient began with increased shortness of breath
over a 3 to 4-hour period while lying down. She came to the
emergency room where she was found to be wheezing. She did not
have any chest pressure or pain , but she did have some shortness
of breath and a cough productive of white sputum. She had no
wheezing , nausea , vomiting , diarrhea , and no change in her eating
habits. No missed medications. She denied any PND , DOE or
orthopnea , and she had not noticed increased leg edema. In the
emergency department , she was given Atrovent , prednisone , Lasix ,
albuterol nebulizers and Solu-Medrol as it was unknown at the
time whether or not this was a CHF exacerbation or a COPD
exacerbation.
PHYSICAL EXAMINATION: She was afebrile at 97.5 with a pulse of
71 , blood pressure of 111/63 , and respiratory rate of 18 ,
saturating 98% on 2 liters. Physical examination was more
significant for a DVD at 10 cm. Heart exam was significant for
gallops being absent. No S3 or S4. Respiratory exam was
significant for some wheezes , but no rales however.
ADMISSION LABORATORY: A Chem 7 was significant for hyponitremia
at 132 and a hyperkalemia at 5.4. Her digoxin level was
therapeutic at 1.8. Total bilirubin was 1.8. A BNP was mildly
elevated at 189. First set of enzymes were cardiac enzymes to
rule out MI were negative.
ADMISSION MEDICATIONS: The patient's admission medications were
digoxin 0.25 mg daily , Cozaar 50 mg twice a day , Lipitor 80 mg daily ,
Coreg 12.5 mg twice a day , spironolactone 12.5 mg daily , aspirin 81 mg
daily , nitroglycerin as needed , and Lasix.
ALLERGIES: Included Captopril , which gave her a cough.
SOCIAL HISTORY: She lived with family. Denied any drinking and
smoking , but however did have significant second hand smoke
inhalation history by her husband having been a heavy smoker
during their many years of marriage.
PAST MEDICAL HISTORY: Significant for coronary artery disease in
which she had an acute myocardial infarction in 1995 for which a
stent was placed in the LAD. She then had an instant V stenosis
and had then a two-vessel CABG , which was the SVG to the LAD , and
the SVG to the RCA. In 1997 , she had a SVG , LAD stent to
stenosis to then to VStent. In 1988 she had a third SVG LAD
stent placed and an ICD was placed for a low VF and presumably
arrhythmias. The cardiac risk factors include hypertension ,
hyperlipidemia , and smoke inhalation history.
She was admitted for shortness of breath , presumes likely
secondary to a CHF or reactive airway disease precipitated by an
upper respiratory tract infection.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Ischemia. The patient was cycled through
three sets of enzymes , which were all negative. The patient did
not have chest pressure or pain at any moment of her
hospitalization and did not need any nitroglycerin. There were
no EKG changes. She was continued on her statin , beta blocker ,
and ACE inhibitor , and aspirin. Cardiovascular pump. The
patient oscillated between the mildly fluid overloaded to
euvolemic. She was maintained on Lasix , and did well that way.
The patient received an echo on May , 2004 , which showed
normal left ventricular cavity size and wall thickness with
overall systolic function being moderately in pair with ejection
fraction of 35%. There was severe hypokinesis and akinesis
involving the mid distal septum apex and distal inferior and
lateral walls , and there was also abnormal septal motion
consistent with intraventricular conduction delay. An ICP was
seen to be in place and the aortic valve was mildly calcified.
The left atrium was mildly enlarged. There was also moderate
tricuspid regurgitation with velocity of 2.9 m/second detecting
pulmonary artery systolic pressures of 33mmHg. It was determined
that since 7/26 there had been no significant interval change.
Rhythm: The patient was in normal sinus rhythm with an ICD
placed. There were no issues.
2. Pulmonary: Initially when the patient was admitted with her
significant coronary history , she was being treated like a CHF
exacerbation. However , despite her being relatively refractory
treatment it was decided to increase the treatments for a
possible COPD exacerbation. In this way , she was receiving
Duonebs and albuterol nebulizers 2-2 hours alternating and it was
decided to change her from orally prednisone to 60 mg orally every day before noon
In addition , Tessalon Perles and guaifenesin was added. Finally ,
azithromycin was added so as to possibly treat any atypical
pneumonia as the patient had only some interstitial pattern on
her chest x-ray , and did not have any focal area of
consolidation.
3. Endocrine: When the patient was admitted , she was maintained
on her home dose regimen for diabetes mellitus. However , when
being admitted she was given orally prednisone for COPD
exacerbation , and therefore , had uncontrolled blood sugars.
Because a finger stick blood glucose and insulin sliding scale
did not fully control her blood glucose. She at one point began
to have an non-gap metabolic acidosis. Anticipating possible
decay , she was started on regular lab draws and insulin drips.
Her gap promptly closed and the patient was , otherwise ,
asymptomatic. She did not have any potassium , fluid or other
complications. Throughout she was also receiving NPH insulin in
the a.m. and p.m.
The patient was discharged to follow with her primary care
physician , and the patient received at home VNA services.
DISCHARGE MEDICATIONS: Her discharge medications included
1. NPH insulin10 units in the a.m. and 4 units in the p.m.
2. Flovent , Tessalon Perles and guaifenesin.
3. Zocor 40 mg daily.
4. Coreg 12.5 mg twice a day
5. Digoxin 0.125 daily.
6. Cozaar 50 mg twice a day
7. Azithromycin 25 mg daily.
8. Lasix 20 mg orally daily.
9. Combivent inhaler.
eScription document: 0-6747046 ISSten Tel
Dictated By: MOOSE , BUCK
Attending: BOVA , DOUGLASS
Dictation ID 3425125
D: 11/11/04
T: 1/27/04
Document id: 337
| Target |
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| output/system_intuitive_annotation.xml | intuitive |
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924868217 | PUO | 34874777 | | 9987296 | 3/25/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/25/2003 Report Status: Signed
Discharge Date:
ATTENDING: GWYNETH ALMEDA DEPSKY MD
Ms. Debrita is a 90+-year-old woman with a history of coronary
artery disease including a non ST elevation MI in 4/13
medically managed , congestive heart failure with an ejection
fraction of 25% and severe aortic stenosis with a valve area of
1.0 who was transferred from the Norap Valley Hospital with shortness
of breath several days after discharge from that hospital where
she was treated for , a multilevel pneumonia and CHF exacerbation.
She had been hospitalized at P Therford Hospital where she was treated for
pneumonia and after treatment had returned to her rehabilitation
facility/skilled nursing facility where she was not eating and
was found to be very tachypneic and diaphoretic and tachycardiac
for the three days prior to admission here. The night prior to
admission , she had been readmitted to Norap Valley Hospital where she
was found to have a worsening CHF exacerbation with symptomatic
bradycardia with heart rate in the 20s. The patient received
diuresis , had a chest MRA to rule out pulmonary embolism , which
was negative and was transferred to Pagham University Of
for telemetry. The bradycardia was thought to have been from a
recent increase in the patient's Toprol XL dose. On admission ,
the patient was afebrile. Temperature 96.5 , pulse in the 70s and
80s , pressure 140/80 , breathing a 100% on four liters. Exam
significant for an awake , alert , pleasant older women , very hard
of hearing , decreased breath sounds with rhonchi right greater
than left and decreased breath sounds in the right middle lobe ,
poor inspiratory effort. Exam also significant for a hard
systolic ejection murmur , crescendo decrescendo heard best at the
right upper sternal border radiating to the carotids , also
audible at the apex. Her JVP was at 12 cm. She had no lower
extremity edema. Her labs were significant for a creatinine of
2.7 , a slightly elevated dedimer at P Therford Hospital , a chest x-ray that
showed a right middle lobe pneumonia that was resolving ,
cardiomegaly.
HOSPITAL COURSE:
1. Cardiovascular: There was no evidence of acute ischemia. She
had a small elevation of her troponins in the morning after
admission thought secondary perhaps to CHF exacerbation or
chronic renal insufficiency. She was restarted on a very low
dose of Lopressor keeping atropine at her bedside in case of
symptomatic bradycardia. She did have a heart rate occasionally
in the 40s during this hospitalization , but was asymptomatic
throughout. In terms of her rhythm , in addition to the
asymptomatic bradycardia , she did have several runs of
non-sustained ventricular tachycardia. These diminished with
repletion of magnesium and again were asymptomatic. The
electrophysiology was consulted and they did not feel that any
intervention was indicated given the asymptomatic nature of her
arrhythmias. In terms of her congestive heart failure
exacerbation was thought to be the primary reason for her
tachypnea and dyspnea. She was diuresed gently given her aortic
stenosis and tolerated well a net fluid loss of 500 to a 1000 cc
per day with great increase in her comfort breathing. Notably
she never had an increased oxygen requirement even when
tachypneic. We will do a dry weight before her discharge and
send her out on a dose of Lasix 80 mg orally twice a day with a dry
weight to be followed at the skilled nursing facility. She will
also have a follow up appointment with Dr. Cole Aini at
Norap Valley Hospital .
2. Infectious disease: On chest x-ray , the patient has a
persistent right middle lobe process an on the second day of her
hospitalization had increasing tachypnea , was found to be fluid
overloaded and was gently diuresed as mentioned earlier. Because
a recurrence of her pneumonia cannot be ruled out , we will
complete a 14-day course of levofloxacin and Flagyl , which was
added for the concern of aspiration to add anaerobic coverage.
3. Renal: The patient has chronic renal insufficiency. The
patient's creatinine has improved during her hospitalization and
is currently 2.0. We have replaced her magnesium and put her on
a small dose of daily K-Dur 10 mEq per day to compensate for her
Lasix diuresis.
4. Neuro: The patient was seen by the speech and swallow
service. Their recommendations were mechanical , soft , solid diet
with thin liquids , out of bed at all meals.
The patient will be discharged on Flagyl to finish a 14-day
course , levofloxacin to finish a 14-day course. The patient's
levofloxacin should be taken until 1/29/03 and the patient's
Flagyl should be taken until 8/30/03 . The patient will also be
discharged on the salicylic acid 81 mg , Phoslo 667 mg three times a day ,
Lasix 80 mg orally twice a day , heparin was given for prophylaxis as an
inpatient , but she should be treated according to NH policies ,
lisinopril 20 mg orally every day , Lopressor 12.5 mg orally twice a day ,
multivitamin , simvastatin 20 mg every bedtime , K-Dur 10 mEq x1 orally
every day , and Nexium 40 mg orally every day
She will be discharged to the NH in good condition.
Thank you for the opportunity to care for this lovely patient.
eScription document: 5-6603422 EMSSten Tel
Dictated By: BUCCHERI , FELICE
Attending: DEPSKY , GWYNETH ALMEDA
Dictation ID 4200224
D: 9/9/03
T: 9/9/03
Document id: 338
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961677284 | PUO | 29991274 | | 330887 | 4/13/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/8/1996 Report Status: Signed
Discharge Date: 2/9/1996
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
PRINCIPAL PROCEDURE: Coronary artery bypass graft.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old , morbidly
obese gentleman with multiple cardiac
risk factors transferred from Ogea Medical Center after
presenting there with a ventricular fibrillation arrest in the
setting of chest pain , having ruled in for a myocardial infarction
with several subsequent VT/VF arrests. He has a history of insulin
dependent diabetes mellitus , hypertension , hypercholesterolemia ,
and former tobacco use. He had multiple exercise tolerance tests
in 1993 which were highly predictive of ischemia with significant
EKG changes and symptoms in the recovery phase. He was put on
maximal medications , and his most recent exercise tolerance test in
4/06 was not as positive as previously , but still suggestive of
ischemia. The patient relates increasing exertional chest pain for
several months , and increasing antianginal medications required.
He had witnessed syncope at work , 911 was called , and he was found
to be in VF and defibrillated into asystole , which then converted
to atrial fibrillation. He did not require intubation. He was
taken to Ogea Medical Center , admitted , and ruled in for a
myocardial infarction. Despite some short term memory loss related
to the incident , he does recall having chest pain just prior to
syncope. On the night before transfer , he was resting comfortably ,
sitting at the side of the bed for the first time when he went into
VF on the monitor and loss consciousness. He was immediately
cardioverted to sinus rhythm and begun on lidocaine. He had
another episode of VT two hours later which deteriorated into VF ,
again requiring cardioversion sinus bradycardia. Lidocaine was
increased to 3 mg per hour and arrangements were made to transfer
to the Pagham University Of . On arrival , he denied chest
pain.
PAST MEDICAL HISTORY: Notable for insulin-dependent diabetes
mellitus , hypertension ,
hypercholesterolemia , orthopedic problems including severe shoulder
dislocations as a child with chronic shoulder osteoarthritis and a
recent meniscal tear of the knee.
ADMISSION MEDICATIONS: Subcu insulin 70/30 50 every day before noon , NPH 50 mg
every afternoon , Corgard , Procardia XL , Mevacor ,
enteric coated aspirin , and TNG as needed
HOSPITAL COURSE: The patient was admitted to the cardiology
service initially. He was seen in
catheterization and found to have a complex LAD stenosis that was
60% in the mid and 70% in the distal LAD , 40% proximal left
circumflex , 70% complex stenosis in the OM2 , and an occluded RCA.
His LV gram showed an ejection fraction of 40%-50% with
anteroapical akinesis. He had no further chest pain or ectopy on
the TNG , lidocaine , and beta blockers , and he was successfully
diuresed. Given these findings , he was taken to the Operating Room
on 1/26/96 , at which time he had a coronary artery bypass graft
with a LIMA to the LAD , and a saphenous vein graft to the OM1 and
to the PDA. He came off bypass and required atrial pacing and
renal dopamine. However , postoperatively , on transfer to the
Intensive Care Unit , he did not require any further pacing.
Dopamine was weaned successfully to renal dose and then to off.
The patient extubated without difficulty by postoperative day one
and he was started on Lopressor and enteric coated aspirin. He had
a high insulin requirement which , over the course of his stay , ran
up to over 100 units total per day. He was transferred to the
floor by postoperative day one. Because of his obesity , he
required a big boy bed and he was seen by physical therapy to
improve his mobilization. He was successfully weaned off oxygen
and was ambulating by the time of discharge without any trouble.
Because of his history of VF/VT , he was planned for EP studies and
these were negative. The patient's stay , however , was prolonged by
evidence of cellulitis , particularly of his right saphenous vein
graft site. There was no breakdown or discharge , however , there
was erythema and warmth , which was treated with intravenous antibiotics
( ultimately Ancef intravenous ) and elevation. The patient's white count
remained stable. He was never febrile. The redness was ultimately
decreased by the time of discharge , and he was sent home on orally
Keflex.
DISPOSITION: To home with services.
DISCHARGE MEDICATIONS: Albuterol inhaler two puffs four times a
day , enteric coated aspirin 325 mg orally
every day , NPH 65 units every day before noon and 45 units every afternoon subcutaneously , Mevacor 20 mg
twice a day , Lopressor 25 mg three times a day , Niferex 150 twice a day ,
Percocet one to two tablets orally every 3-4h. as needed , Colace 100 mg orally
three times a day while on Percocet , and Keflex 500 mg orally four times a day
FOLLOW-UP: The patient will have follow up with Dr. Tien T Rester , primary medical doctor , for wound monitoring
and management of his sugars. He will have follow up with Dr.
Carlton Abshear of cardiology and with Dr. Desirae Marcott of cardiac
surgery.
Dictated By: MILAGROS MIRIELLO , M.D. OI85
Attending: DESIRAE R. MARCOTT , M.D. OZ4 GI726/6251
Batch: 62105 Index No. R2HUUS9G2Y D: 9/25/96
T: 4/10/96
Document id: 339
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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723352006 | PUO | 51637887 | | 570436 | 10/9/1997 12:00:00 a.m. | INFERIOR MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/9/1997 Report Status: Signed
Discharge Date: 4/14/1997
DISCHARGE DIAGNOSIS: MYOCARDIAL INFARCTION.
PROBLEM LIST: 1 ) STATUS POST ACUTE MYOCARDIAL INFARCTION.
2 ) PROSTATE CANCER DIAGNOSED 8/21 STATUS POST
RADIATION THERAPY.
HISTORY OF PRESENT ILLNESS: Patient is a 69 year old man without
prior cardiac history. He had cardiac
risk factors including possible hypertension and possible history
of hypercholesterolemia. The patient had had a history of atypical
chest pain including cardiac work-up in the past with an echo in
1995 showing concentric left ventricular hypertrophy with
asymmetric septal hypertrophy. He had a normal ejection fraction
at this time. In 8/7 , he had an exercise tolerance test at which
time he went eight minutes with a maximal heart rate of 151 ,
maximum blood pressure of 226/90 , and no EKG changes. At 2 p.m. on
the day of admission , he developed substernal chest pain with
crushing tightness radiating to both shoulders and his jaw. He was
not short of breath. He experienced this pain on and off through
the afternoon although the pain was never completely gone. At 6
p.m. , he became acutely worse and at that time , called the EMT and
was brought to the Pagham University Of Emergency
Department. Within the Emergency Department , the patient was noted
to have ST elevations in the inferior leads. He was enrolled in
the FORESTBLAN CONWAKE HOSPITAL trial. Infusion was begun at 8:15. The patient was
given Lopressor , oxygen , morphine , aspirin , and Heparin. He did
not drop his pressure with the sublingual nitroglycerin.
PAST MEDICAL HISTORY: Included prostate cancer in 8/21 status
post x-ray therapy as well as a possible
transient ischemic attack in 1990.
ALLERGIES: The patient had no known drug allergies.
CURRENT MEDICATIONS: Zantac as needed
FAMILY HISTORY: Negative for coronary artery disease.
SOCIAL HISTORY: The patient was married with three children and he
denied any tobacco or alcohol use.
PHYSICAL EXAMINATION: On admission demonstrated a well appearing
black male in no acute distress. His vital
signs were a heart rate of 48 , blood pressure 83/30 in the
Emergency Department , and he was afebrile with oxygen saturation of
99% on two liters. HEENT: Examination showed oropharynx benign
and he had a left facial droop. NECK: Supple , 2+ carotids without
bruit , and jugular venous pressure was normal. CHEST: Clear to
auscultation bilaterally. HEART: Had a regular bradycardic rhythm
with a II/VI systolic ejection murmur. ABDOMEN: Soft , nontender ,
and nondistended with positive normal bowel sounds and no
organomegaly. EXTREMITIES: Warm , well perfused , and no clubbing ,
cyanosis , or edema with trace distal pulses. NEUROLOGICAL: He was
alert and oriented times three , cranial nerves II-XII were grossly
intact except for a left facial droop , and motor and sensory were
grossly intact.
LABORATORY EXAMINATION: On admission showed a sodium of 144 ,
potassium 4.2 , chloride 108 , bicarbonate
22 , BUN 16 , creatinine 1.3 , glucose 136 , white count was 8 with a
hematocrit of 35 , platelets were 239 , CK was 276 with an MB of 0.8 ,
troponin on admission was 0.0 , INR was 1.0 , and PTT was 22.6.
Patient's first EKG in the Emergency Department showed normal sinus
rhythm at 70 with first degree AV block , axis of 56 degrees , he had
ST elevations of 4 mm in leads III and aVF and 3 mm in II , and ST
depression of 0.5 to 3 mm in V2 through V5 , I , and aVL. Chest
x-ray did not show acute disease in the Emergency Department.
HOSPITAL COURSE: Within the Emergency Department , the patient
initially had resolution of his EKG changes but
had persistent jaw pain remaining at 10/25 . He was taken to
catheterization which demonstrated a mid right coronary artery
lesion of approximately 95% with a clot but with TIMI 3 flow. No
intervention was done at that time. Patient initially required
vigorous intravenous hydration to maintain good blood pressure but
remained essentially stable and pain free. He had a drop in his
hematocrit from 35 on admission to 28 after his catheterization
secondary to blood loss at the right femoral triple-lumen site
placed in the Emergency Ward prior to TPA , blood loss at
catheterization , small hematoma , and dilution. He was given two
units of packed red blood cells with an appropriate bump in his
hematocrit. The patient was then transferred to the floor where he
maintained his good course. He had no postcatheterization or
postmyocardial infarction chest pain. The decision was then made
to take the patient back to the catheterization laboratory to have
PTCA with stenting of his lesion and to see if it continued to
persist. The patient was taken on the day prior to discharge back
to the catheterization laboratory where he was successfully
angioplastied and stented. Immediately on returning to the floor ,
the patient did have a rigor postcatheterization but he remained
afebrile and did well over the remainder of his hospital course.
It was felt that the rigor was probably related to allergic
reaction to the dye as he was treated with Benadryl and steroids
without complication.
DISPOSITION: The patient will have visiting nurse services. He
will have blood drawn to check platelets in two days
as he had a fall in his platelet level to 60 after the
administration of the reapro. He will also need follow-up CBC in
two and four weeks because he is on ticlid.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Lopressor 25 mg orally three times a day , sublingual
nitroglycerin as needed chest pain , Axid 150 mg orally twice a day , and
ticlid 250 mg orally twice a day to complete a two week course.
FOLLOW-UP: The patient will follow-up with Dr. Katheryn Gruntz ,
cardiologist with CHH . He will have echocardiogram
done on his first hospital visit. The patient will also follow-up
with Dr. Jackson Part in the clinical trial center as follow-up for
his participation in the PILI HOSPITAL study.
Dictated By: ALEJANDRA DEERDOFF , M.D. VU38
Attending: KATHERYN SATURNINA GRUNTZ , M.D. UP4 QG076/0377
Batch: 70656 Index No. KHOSH90FCY D: 4/26/97
T: 3/30/97
Document id: 340
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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015634120 | PUO | 59679705 | | 4877083 | 2/7/2005 12:00:00 a.m. | UNSTABLE ANGINA | Unsigned | DIS | Admission Date: 2/7/2005 Report Status: Unsigned
Discharge Date: 8/8/2005
ATTENDING: WANKUM , SHERISE MD
DEATH SUMMARY: The patient was a 69-year-old female with a
history of coronary disease status post prior myocardial
infarction and surgery in 2002 who presented to Pagham University Of Emergency Department on 5/10/05 with three days
of chest pain and shortness of breath. Of note she had been
noncompliant with prior regimens and treatments and despite
diuretics started three days by her primary care physician she
reported new shortness of breath and chest pain at rest. An EKG
in the emergency department revealed widespread ST depressions.
She was treated for pulmonary edema with intravenous nitroglycerin , Lasix ,
aspirin , heparin , beta-blockers , and then she was taken urgently
to the cath lab where coronary angiography revealed a left main
coronary artery thrombosis with proximal and distal stenoses of
about 70% , 50% of her LAD , and 60% of her first diagonal. The
patient was transferred to the coronary care unit after placement
of an intraaortic balloon pump for further management and
evaluation.
PAST MEDICAL HISTORY:
CHF , hypertension , hyperlipidemia , CAD , prior myocardial
infarction , restrictive lung disease , diabetes mellitus , chronic
renal insufficiency , morbid obesity , and iron deficiency anemia.
HOME MEDICATIONS:
Aspirin , hydralazine , nitroglycerin , quinine , Norvasc , Lasix ,
Toprol , lisinopril , albuterol , and famotidine.
ALLERGIES:
She was allergic to erythromycin , Bactrim , and intravenous contrast.
FAMILY HISTORY:
Noncontributory.
REVIEW OF SYSTEMS:
Noted no fever , chills , sweats , coughs , abdominal pain , nausea ,
or vomiting.
PHYSICAL EXAMINATION:
She was morbidly obese with moderate respiratory distress lying
at about 30-degree angle. Her O2 saturation was 97% on 3L nasal
cannula. Temperature was 99 degrees , pulse was 80 and regular ,
BP was 140/50 , and respirations about 20. Mucous membranes were
moist and intact. Pupils were equal , round , and reactive to
light. Her sclerae were anicteric. Her conjunctivae were pale.
She had a 15-cm of JVD with 2+ carotids without bruits. Coarse
breath sounds bilaterally with crackles two-thirds of the way up
the bases. Cardiac exam was regular rate and rhythm with 2/6
holosystolic murmur. Her abdomen was obese , soft , nontender , and
nondistended. She had no clubbing , cyanosis , or palpable edema.
She has 1+ distal pulses noted.
Her EKG was normal sinus rhythm with ST depressions in the
inferolateral leads and a right bundle-branch block was present.
Her chest x-ray revealed bilateral pulmonary infiltrates
consistent with edema. So the patient was admitted to the
coronary care unit and a consult with Cardiovascular Surgery and
serial crits were performed. The patient's condition continued
to deteriorate. She developed respiratory distress. Anesthesia
was called and her airway was secured via an emergent intubation.
The patient subsequently developed signs of abdominal pain and
presumed sepsis and ischemic bowel. She was brought to the
operating room for an exploratory laparotomy. Status post an
exploratory laparotomy the patient had a complex course in the
surgical ICU where she underwent multi-organ system dysfunction.
Her prognosis was very dire. This was explained to the family
and on 7/12/05 at 2:20 a.m. the family decided to withdraw care ,
which will be consistent with both the patient and family's
wishes and desires , and the patient was pronounced dead at 2:24
a.m. on 7/12/05 .
DATE OF DEATH:
7/12/05
TIME OF DEATH:
02:24 a.m.
eScription document: 8-3547411 EMSSten Tel
Dictated By: EBBESEN , LORENZA
Attending: WANKUM , SHERISE
Dictation ID 7762607
D: 11/4/06
T: 11/4/06
Document id: 341
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
Y |
Y |
Y |
N |
- |
Y |
N |
N |
N |
380009360 | PUO | 39798978 | | 1452435 | 10/23/2006 12:00:00 a.m. | epistaxis | | DIS | Admission Date: 9/3/2006 Report Status:
Discharge Date: 5/6/2006
****** FINAL DISCHARGE ORDERS ******
PRZYBYSZEWSKI , BRANDEN 022-64-53-7
Ownnoville Re Stin
Service: MED
DISCHARGE PATIENT ON: 6/16/06 AT 05:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SVENNINGSEN , CHRISTIAN VIVAN , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
ACEBUTOLOL HCL 400 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
FONDAPARINUX 2.5 MG subcutaneously DAILY
LISINOPRIL 20 MG orally DAILY
Alert overridden: Override added on 7/30/06 by
GETTINGS , OTELIA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MDA
PRAVACHOL ( PRAVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Milly Hoerter , MD scheduled ,
Dr Klingbeil , Adan 5/10 1pm scheduled ,
ENT clinic scheduled ,
ALLERGY: PERCOCET , DICLOXACILLIN
ADMIT DIAGNOSIS:
epistaxis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
epistaxis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of MVA 8/6 history of B TKA htn
( hypertension ) svt ( supraventricular tachycardia ) thrombophlebitis
( superficial thrombophlebitis ) recurrent bilat LE cellulitis
( cellulitis ) pernicious anemia ( pernicious anemia ) afib ( atrial
fibrillation ) dvt ( deep venous thrombosis ) multiple episodes of
cellulitis ( cellulitis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
anterior nare cauterization for nosebleed
BRIEF RESUME OF HOSPITAL COURSE:
primary care physician: Milly Hoerter , Oncologist: Adan Klingbeil
CC: epistaxis HPI: 80 year-old F with PMH of DVT on coumadin , Afib ,
non-small cell ca history of resection on tarceva , morbid obesity that
presents with persistent epistaxis. She was actually seen by ENT in the
ED on 5/13 , was found to have an anterior R nare bleed that was
cauterized and she was sent home. Later that night she woke up with a
nosebleed and she came to the ED when the bleeding persisted. VS 60
92/52 96% RA with some lightheadedness. She continued to bleed
in the ED. Her hct was 24 down from 27 on 5/13 and her INR 3 ( 2.7 on
5/13 ). She was transfused 2U PRBCs and 3U FFP. ENT was consulted and
the anterior R nare was cauterized successfully.
***
PMH: DVT on coumadin , Afib , non-small cell ca history of resection on
tarceva , morbid obesity
***
Meds on admit: coumadin , asa , lisinopril , tarceva , b12 , folate ,
lasix , pravachol , allopurinol Allergies:percocet ,
dicloxacillin
***
Exam on admition: AF 66 122/64 20 99% RA obese , NAD not bleeding , RRR ,
2/6 SEM LUSB , crackles at bases , abd benign , trace LE
edema
***
LABS: hct 24.4 wbc 4.7 , plt 211 , INR 3 , CR 1.3
***
ECG:NSR 60s , 1st degree AV block , nl axis , no acute ST
changes
***
exam on d/c: unchanged
labs on d/c:cr1.2 , hct 26.5 , INR 1.2
**********
Daily events: primary care physician and oncologist to decide appropriate anticoagulation
regimen for patient
***
A/P: 80 year-old F history of DVT on coumadin , non-small cell ca history of resection on
tarceva , morbid obesity presents with persistent nosebleeds.
1. Epistaxis - history of cauterization by ENT with no recurrence. Off
coumadin history of 3U FFP with INR 1.8. Will hold off on coumadin for now
and allow for nose bleed to fully heal. primary care physician contacted and after
communication with the patient's oncologist the plan is to stop tarceva for
now until she sees her oncologist. She will also be off coumadin and
start on Arixtra 2.5mg subcutaneously daily.
2. history of DVT- appears to have been on coumadin as far back as 1993 with a
documented history of L superficial femoral vein DVT. She has multiple risk
factors for DVT inclding morbid obesity , malignancy and prior history of DVT
she will require continuation of anticoagulation. patient's oncologist Dr.
Purdue aware and recommends stopping coumadin and starting arixtra.
3. Heme - transfused 2U PRBCS on admission and no further evidence of
bleeding. Hct stable at 26%. She was transfused an additional 1UPRBC
before d/c.
FEN - cardiac diet
6. Full code
ADDITIONAL COMMENTS: Please stop taking coumadin( warfarin ). Also stop taking TARCEVA until you
follow up with your oncologist. Please use Ocean nasal spray starting 2/8
to keep nose from getting dry.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Stop coumadin and tarceva until f/u with oncologist.
Start anticoagulation with Arixtra.
No dictated summary
ENTERED BY: GETTINGS , OTELIA H. , M.D. ( QG33 ) 4/22/06 @ 12:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 342
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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682730232 | PUO | 29871457 | | 5609992 | 3/18/2003 12:00:00 a.m. | ? SEPTIC JOINT | Signed | DIS | Admission Date: 3/18/2003 Report Status: Signed
Discharge Date: 11/17/2004
ATTENDING: FRANCISCO VAJDA M.D.
DATE OF BIRTH: 10/17/1936 .
PRINCIPAL DIAGNOSIS: Septic arthritis.
OTHER DIAGNOSES:
1. Rheumatoid arthritis.
2. Hypertension.
3. Diabetes mellitus.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old male
with a history of rheumatoid arthritis , hypertension , diabetes
mellitus , interstitial lung disease , sinus bradycardia with pacer
who presents with 2 days of fever and diffuse joint swelling of
his MCP's , DIP's , knees , elbows , ankles , and especially his left
elbow. He reports that his fever was as high as 101 , and he has
been experiencing malaise over the past 2 days. He denies any
chest pain or shortness of breath. He denies diarrhea or
dysuria. He has no history of recent trauma.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis , treated with Enbrel and etodolac.
2. Diabetes mellitus.
3. Interstitial lung disease.
4. Iron deficiency anemia.
5. Sinus bradycardia status post DDD pacer placement.
MEDICATIONS: Glyburide 5 mg every day , Glucophage 1000 mg twice a day ,
etodolac 400 mg twice a day , Enbrel , Serevent , risedronate 35 mg every day ,
Niferex 150 mg three times a day , folic acid 1 mg every day , Prevacid 30 mg every day ,
and Flomax 0.4 mg every day
HOSPITAL COURSE BY ORGAN SYSTEM:
1. Infectious Disease: In the emergency department , the
patient's left elbow was tapped by the orthopedic service. The
fluid was sent for Gram stain and culture , and showed 92 , 000
white blood cells with 95% polys , and no crystals. Gram stain
and culture remained negative throughout the patient's hospital
stay. The infectious disease service was consulted as well as
the patient's outpatient rheumatologist. Given the patient's
clinical history and the high white cell count found in the joint
fluid , it was decided that he would be started on cefotaxime and
vancomycin. On 4/22/2003 , despite cultures still being
negative , it was decided to manage the patient conservatively ,
and he was taken to the operating room , where the joint was
irrigated , and the fluid was sent as well as a biopsy of the
joint tissue. Pathology severe mixed acute and chronic synovitis
with foreign body giant cell reaction. The cultures sent from
the operating room remained negative until the time of discharge.
A nasal swab looking for MRSA was sent and came back negative.
Based on these findings , it was decided that vancomycin will not
be necessary as an outpatient , and the patient was discharged on
intravenous ceftriaxone every 24 hours for 4 weeks. By the time of discharge , he
had been afebrile for greater than 48 hours.
2. Rheumatology: Enbrel , which is a potent immunosuppressant ,
was held during this admission because of a suspicion for
infection. The patient was continued on NSAIDs for pain. The
rheumatology service followed the patient during his admission
throughout.
3. Cardiovascular: The electrophysiology service saw the
patient in the emergency department and interrogated his
pacemaker. They concluded that it was sensing correctly.
Following his joint washout , the patient did have an episode of
confusion , and his heart rate was found to be in the low 100s.
The EKG was difficult to interpret because of the patient's
pacer , and enzymes were sent , which later came back negative.
During his admission , a grade 2/6 systolic murmur was heard at
the right sternal border , thought to be a flow murmur , but it
should be worked up as an outpatient if it persists. The patient
was treated with metoprolol during his admission for his
hypertension , and this was transitioned to atenolol , and he was
discharged on atenolol 50 mg every day
4. GI: The patient was treated with Nexium during his
admission , and was maintained on a cardiac diet.
5. Heme: The patient has been worked up as an outpatient for
significant anemia. The conclusion after bone marrow biopsy is
that he has profound iron deficiency anemia. He is currently on
3 times a day Niferex , and this was continued during his
admission. He was transfused with 2 units of packed red blood
cells for a hematocrit under 30. His post-transfusion hematocrit
was only 32.
6. Pulmonary. The patient has a history of interstitial lung
disease and COPD. This was not active during this admission , and
he was continued on his Serevent and albuterol as needed
DISCHARGE INSTRUCTIONS: The patient was instructed to call if he
had any fever , pain not controlled with medication , nausea or
vomiting not controlled with medication , worsening elbow
stiffness or pain , or any concerns about his health. He was
instructed to go to the Lame Medical Center office in Inevis St , Ohunt
at Ford Go Ra every day for intravenous ceftriaxone infusion.
He was instructed to call Dr. Pederzani in the orthopedics department
for an early followup appointment. He was also instructed to
schedule an early followup appointment with Dr. Kistner in
rheumatology.
DISCHARGE MEDICATIONS:
1. Serevent Diskus 1 puff inhaled twice a day
2. Flomax 0.4 mg orally every bedtime
3. Glucophage 1000 mg orally twice a day
4. Etodolac 300 mg orally twice a day
5. Multivitamin.
6. Oxycodone 5-10 mg orally every 4 hours as needed pain.
7. Glyburide 5 mg orally every day
8. Folic acid 1 mg orally every day
9. Vasotec 10 mg orally twice a day
10. Ceftriaxone 1g intravenous every 24 hours
11. Atenolol 50 mg orally every day
FOLLOWUP: He was scheduled to follow up with the orthopedist ,
Dr. Pederzani in 7 days , and was scheduled to follow up with Dr. Kistner
in rheumatology soon after discharge.
The patient was discharged after he had been afebrile for greater
than 48 hours.
eScription document: 7-7499829 AFFocus
Dictated By: STEADINGS , MURIEL
Attending: VAJDA , FRANCISCO
Dictation ID 6902751
D: 5/24/04
T: 5/24/04
Document id: 343
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
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476925131 | PUO | 90822564 | | 6941601 | 3/12/2006 12:00:00 a.m. | CHF , Atrial Fibrillation | | DIS | Admission Date: 3/12/2006 Report Status:
Discharge Date: 5/18/2006
****** FINAL DISCHARGE ORDERS ******
ZIEN , KYLIE 385-77-16-0
No Ha E
Service: CAR
DISCHARGE PATIENT ON: 10/4/06 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: POPOVIC , ALEXANDRA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 7/12/06 by
BONEFONT , KEIRA B. , M.D. , PH.D.
on order for COUMADIN orally 8 MG every afternoon ( ref # 334740090 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/12/06 by HIGHTREE , SHONDRA D. , M.D. , M.P.H
on order for COUMADIN orally 8 MG every afternoon ( ref # 489672087 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: Previous override information:
Override added on 10/15/06 by HIGHTREE , SHONDRA D. , M.D. , M.P.H
on order for COUMADIN orally ( ref # 856830667 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MDA , patient on as outpt.
AMIODARONE 200 MG orally DAILY
Alert overridden: Override added on 8/3/06 by HIGHTREE , SHONDRA D V. , M.D. , M.P.H
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: MDA
NORVASC ( AMLODIPINE ) 10 MG orally every day before noon HOLD IF: sbp<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CALCITRIOL 0.25 MCG orally EVERY OTHER DAY
EZETIMIBE 10 MG orally DAILY
Alert overridden: Override added on 10/15/06 by HIGHTREE , SHONDRA D V. , M.D. , M.P.H
on order for EZETIMIBE orally ( ref # 157889774 )
patient has a PROBABLE allergy to EZETIMIBE 10 MG -
SIMVASTATIN 80 MG; reaction is sick/fatigue.
Reason for override: MDA
PROSCAR ( FINASTERIDE ( BPH ) ) 5 MG orally DAILY
Number of Doses Required ( approximate ): 10
LASIX ( FUROSEMIDE ) 80 MG orally twice a day Starting Today ( 7/13 )
GLUCOMETER 1 EA subcutaneously x1
GLYBURIDE 15 MG orally DAILY
AVAPRO ( IRBESARTAN ) 300 MG orally every day before noon HOLD IF: sbp<100
Override Notice: Override added on 7/12/06 by
TIMPSON , JACK T. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
633129150 )
POTENTIALLY SERIOUS INTERACTION: IRBESARTAN & POTASSIUM
CHLORIDE Reason for override: mda
Number of Doses Required ( approximate ): 10
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
200 MG orally DAILY HOLD IF: SBP < 100 , HR < 50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain HOLD IF: SBP < 100
PRAVASTATIN 80 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 7/12/06 by
BONEFONT , KEIRA B. , M.D. , PH.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
755380056 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: aware
Previous override information:
Override added on 7/12/06 by BONEFONT , KEIRA B. , M.D. , PH.D.
on order for COUMADIN orally 8 MG every afternoon ( ref # 334740090 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: aware
Previous override information:
Override added on 7/12/06 by HIGHTREE , SHONDRA D. , M.D. , M.P.H
on order for COUMADIN orally 8 MG every afternoon ( ref # 489672087 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: Previous override information:
Override added on 10/15/06 by HIGHTREE , SHONDRA D. , M.D. , M.P.H
on order for COUMADIN orally ( ref # 856830667 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: MDA , patient on as outpt.
Previous override information:
Override added on 10/15/06 by HIGHTREE , SHONDRA D. , M.D. , M.P.H
on order for PRAVASTATIN orally ( ref # 361847855 )
patient has a PROBABLE allergy to EZETIMIBE 10 MG -
SIMVASTATIN 80 MG; reaction is sick/fatigue.
Reason for override: MDA
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 7/12/06 by
BONEFONT , KEIRA B. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Please follow coumadin clinic instructions
for changing coumadin dose. Thank you.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 8/3/06 by HIGHTREE , SHONDRA D V. , M.D. , M.P.H
on order for AMIODARONE orally ( ref # 479648390 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: MDA Previous override information:
Override added on 7/12/06 by BONEFONT , KEIRA B. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous Alert overridden
Override added on 10/15/06 by HIGHTREE , SHONDRA D. , M.D. , M.P.H
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MDA , patient on as outpt.
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
PUO ANTICOAG ( 405 ) 082-3371 CLINIC WILL CONTACT ,
Dr. Vincenza G Ola Oroz 575-803-4363 5/5/06 10:20am ,
NORSETH , ARDELLA S. , M.D. MH 10/1/2006 16:00 ,
Primary care: Mirna Babula ,
Arrange INR to be drawn on 7/11/06 with f/u INR's to be drawn every
7 days. INR's will be followed by Coumadin clinic
ALLERGY: PSEUDOEPHEDRINE , ACE Inhibitor , LISINOPRIL ,
EZETIMIBE 10 MG - SIMVASTATIN 80 MG , FOSINOPRIL SODIUM
ADMIT DIAGNOSIS:
AF with RVR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF , Atrial Fibrillation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NIDDM HTN hyperlipidemia atrial fibrillation tobacco use obesity
carpal tunnel syndrome
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CXR 3/27 opacity in LLL ( edema vs atelectasis vs infiltrate )
CXR 8/7 likely atelectasis in left base
ECHO 10/24 EF 30% , inferior/post akinesis , LAE ( 5cm ) , mild TR/MR MIBI:
2/25 EF 35% , old IMI , no ischemia.
CXR 8/3 improved edema/effusions.
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
************
DIAGNOSIS: 62 M with CAD ( old IMI ) , NIDDM , Tob , PAF , CRF now p/with ~1
week progressive DOE , but no CP. patient had 24 heart rate severe exacerbation of
SOB , called EMS. patient also c/o 48 hours shaking chills , anorexia ,
increased abd distention. At baseline with 2 pillow orthopnea , LE
edema. In ED was in Afib with RVR ( 100-150 per EMS ) , was given ASA ,
NTG , Dilt intravenous. Cardiac enz neg. No known COPD although 25 pkyr
smoking.
************
Admission exam: 98 , 128/60 , 84-104 , 3L CPAP
97% GEN: mild distress , OBESE , pleasant , full
sentences HEENT: PERL , EOMI , no
bruits LUNGS: Crackles ~1/3 up
bilat. CV: irregular rate , rhythm , no
m/r/g EXT:2+ LE edema bilat
************
HOSPITAL COURSE BY SYSTEM:
--CV:
1. ) [I] -- Unlikely ACS ( no suspicious ECG changes , no rise in enz ).
Cont'd ASA , CCB , BB , ARB , restarted statin ( Pravastatin ) , and ezetimibe
for LDL at 140.
2. ) [P] -- EF 35% on 4/6 MIBI , now 30% on echo. CHF and volume
overloaded. Responded well to diuresis with intravenous Lasix. Was transitioned to
orally Lasix. Fluid restricted to < 2L. Repeat CXR was significantly
improved , and edema lessened as well.
3. ) [R] -- AF with RVR , rate controlled on BB but was still sometimes in
low 100s. Given this the decision to start amiodarone was made and patient
tolerated this well. Still in Afib on discharge , but rate in 80s. patient
will f/u with Dr. Oroz ( outpt cardiologist ) in 4-6 weeks. If still in
Afib will consider electrically cardioverting.
--PULM: OSA on CPAP at home. Cont'd CPAP in house. patient transitioned from
NC to RA on HD 3.
--HEME/ID: Blood/Urine cx neg. Stopped Abx after one dose of Levoflox in
ED. UA 2+ protein. Did not seem clinically infected given CXR
resolution of questionable opacity post-diuresis. On Coumadin at home ,
INR initially 3.3 , so Coumadin was held. Restarted when <3.0. Cont home
Coumadin for goal INR 2.0-3.0.
--FEN/GI: ADA diet. Elevated LFTs ( Bili 1.3 ) ( likely from heart failure
backup ) now resolved.
--RENAL: Cr 1.6 baseline. patient's Cr was as high as 1.9.
--ENDO: A1C was 5.7. Patient's outpt glyburide was discontinued while in
hospital given renal dysfxn. Insulin basal and SS was started and
titrated. patient will return to Glyburide and daily fingersticks at home.
Will recommend switching to glipizide , but will defer to primary care physician.
--NEURO/PAIN: Tylenol as needed No issues.
--PROPHY: PPI , coumadin
--GU: BPH --
finasteride
--CODE:FULL
--primary care physician: Dr. Mirna Babula , Dr. Oroz
--FAMILY: Son ( radiologist ) 648-853-1112 , wife 647-711-0921
ADDITIONAL COMMENTS: Hello Mr. Zien , it was a pleasure taking care of you while you were in
the hospital. As you know , you were diagnosed with heart failure and
atrial fibrillation. We helped you by getting rid of some excess fluid
from your lungs , and slowed your heart rate down. We also started you on
an antiarrhythmic ( amiodarone ) to try to convert you into sinus rhythm.
After discharge please continue taking your amiodarone. Also please
following these instructions: 1. ) Weigh yourself daily ( your current
weight is 200 pounds ). If you gain significant weight , especially within
one or two days ( e.g. >3-5 pounds ) this may be fluid building up in your
lungs. Please call your doctor. 2. ) Please taking measures to stop
smoking. 3. ) Please check your blood sugar everyday in the morning before
breakfast and record these values for your doctor. 4. ) Please see an
opthalmologist within 1-2 months for a check-up. 5. ) Please take Lasix 80
mg twice a day. 6. ) Please continue taking ezetimibe and pravastatin for
your cholesterol control. 7. ) Please see your primary care doctor , your
renal doctor , and your heart doctor soon. 8. ) Please take 6 mg Coumadin a
night and get your INR checked at the Kernan To Dautedi University Of Of Coumadin clinic on 7/11/06 .
They will then instruct you to change your dose accordingly. Your goal
INR is 2-3.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. ) Cardiology -- consider electric cardioversion in 4-6 weeks if still
not in sinus rhythm on amiodarone. Please check LFTs , PFTs , TFTs ( last
value 10/15/06 nl )
2. ) Primary care -- titrate hypoglycemics -- consider switching from
glyburide to glipizide given renal dyxfxn?
3. ) Coumadin -- goal INR 2-3 to be managed at PUO coumadin clinic.
No dictated summary
ENTERED BY: HIGHTREE , SHONDRA D. , M.D. , M.P.H ( YG28 ) 10/4/06 @ 04:55 PM
****** END OF DISCHARGE ORDERS ******
Document id: 344
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
691249262 | PUO | 95133876 | | 0211321 | 11/8/2007 12:00:00 a.m. | Noncardiac chest pain | | DIS | Admission Date: 1/25/2007 Report Status:
Discharge Date: 2/22/2007
****** FINAL DISCHARGE ORDERS ******
KNUDSON , ATHENA T 047-86-35-6
Sterna Pkwy
Service: MED
DISCHARGE PATIENT ON: 8/22/07 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Starting Today ( 7/6 )
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Alert overridden: Override added on 9/10/07 by GOLDFEDER , MAXINE H R. , M.D.
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM Reason for override: mda
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ZETIA ( EZETIMIBE ) 10 MG orally DAILY
TRICOR ( FENOFIBRATE ( TRICOR ) ) 145 MG orally DAILY
Override Notice: Override added on 9/10/07 by GOLDFEDER , MAXINE H R. , M.D. on order for LIPITOR orally ( ref # 244117134 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM Reason for override: mda
Number of Doses Required ( approximate ): 10
ALLEGRA ( FEXOFENADINE HCL ) 180 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LANTUS ( INSULIN GLARGINE ) 5 UNITS subcutaneously every afternoon
HUMALOG INSULIN ( INSULIN LISPRO )
Sliding Scale ( subcutaneous ) subcutaneously before meals Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
If ordered before every meal administer at same time as , and in addition
to ,
standing insulin aspart order. If ordered HS administer
alone
ISORDIL ( ISOSORBIDE DINITRATE ) 60 MG orally three times a day
Starting Today ( 7/6 ) HOLD IF: sbp<100
LISINOPRIL 40 MG orally DAILY HOLD IF: sbp<110
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally before meals
Instructions: give 30 minutes before meals
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally every day before noon HOLD IF: sbp<110 or heart rate<55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 20
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every afternoon HOLD IF: sbp <110 or heart rate <55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 20
NITROQUICK 0.4MG ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
PRILOSEC ( OMEPRAZOLE ) 40 MG orally DAILY
COMPAZINE ( PROCHLORPERAZINE ) 5-10 MG orally every 6 hours as needed Nausea
ZOLOFT ( SERTRALINE ) 150 MG orally DAILY
TRAZODONE 100 MG orally BEDTIME
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Hora 3/3/07 scheduled ,
Dr. Reinstein 10/11/07 scheduled ,
ALLERGY: SHELLFISH
ADMIT DIAGNOSIS:
Unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Noncardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) cabg ( cardiac bypass graft surgery )
diabetes ( diabetes mellitus type 2 ) htn
( hypertension ) hyperlipidemia ( hyperlipidemia )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest Pain
**
HPI: 42F with DM2 , CAD history of CABG ( LIMA->LAD , SVG-> OM1 and OM2 ) and 5
subsequent stents ( LM , LAD , RCA , LCx ) presents with left sided chest
pain while watching TV , radiating to left arm/jaw , associated with
diaphoresis , palpatations , SOB , not relieved with SLNTG , went to
ED at TH , got nitro , morphine , sent to PUO ED where her cardiologist
is Dr. Hora . "A" set negative , EKG with ?new TWI in V3-V4 ( old
TWI V1-V2 ). ROS otherwise negative.
**
PMH: IDDM2 , CAD history of 3V CABG ( 2003 ) with multiple stents , gastroparesis ,
scleroderma ( 1994 ) , HTN , dylipidemia
** Home Meds: Toprol 100qam and 50qpm , plavix 75 , zetia 10 , lisinopril
40 , allegra 180 , zoloft 150 , tricor 145 , isordil 60 three times a day , lipitor 80 ,
compazine 10 three times a day as needed , reglan 10 three times a day , lantus 5 every afternoon , humalog ss before meals/bedtime ,
ASA 81 , protonix 40
**
Admit Exam: T97.6 , P72 , BP 100/60 , 98% 2L PE: NAD , NCAT , Heart RRR ,
3/6 SEM at USB , no r/g , Chest CTAB , abd obese , s/nt/nd , +bs , ext wwp ,
no c/c/e , neuro nonfocal
**
Admit Data:
Notable Labs: Glu 171 , Hct 29.6 , A set negative , ALT/AST 58/50
EKG: NSR , TWI V1-V4 ( V3-V4 new ) , poor RWP
UA: negative
**
COURSE: 42 year old female with extensive cardiac history presents with
chest pain.
1 ) CV: [I]: The patient has a long history of similar presentations , some
with positive findings , others without. She was ruled out with cardiac
biomarkers x3. EKG had old TWI in V1-V2 , and new TWI in V3-V5.
During course of admission she had persistent chest pain radiating to
her left arm. She was anticoagulated with lovenox , and kept chest pain
free on nitro drops and morphine. An exercise MIBI was negative for
any ischemia. Her chest pain on this admission is likely non cardiac
and she will follow up with GI , Dr. Reinstein in one month. Will
discharge home with no changes to her medications. Continue ASA , statin ,
BB , ACE-I , plavix , isordil , and lipid lowering meds. [P]: Has HTN , though
blood pressure's usually low on this admission in the low 110's for systolics.
Continued her home blood pressure meds. Echo was done and showed normal LVEF~55% , and
no RWMA. [R]: NSR , on telemetry.
2 ) ENDO: Cont lantus and humalog for DM2.
3 ) FEN: ADA , low chol/fat , lytes SS
4 ) PPx: lovenox , ppi
Full Code
ADDITIONAL COMMENTS: Please resume taking your normal home medications. If you have any
prolonged worsening of your symptoms , seek medical care.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-should follow up with her gastroenterologist for evaluation of non
cardiac chest pain
-follow up with her cardiologist for management of CAD , HTN
No dictated summary
ENTERED BY: GOLDFEDER , MAXINE H. , M.D. ( VK81 ) 8/22/07 @ 05:10 PM
****** END OF DISCHARGE ORDERS ******
Document id: 345
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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300231637 | PUO | 40669153 | | 637605 | 6/25/1998 12:00:00 a.m. | MORBID OBESITY | Signed | DIS | Admission Date: 6/25/1998 Report Status: Signed
Discharge Date: 3/1/1998
PRINCIPAL DIAGNOSIS: MORBID OBESITY.
OTHER DISCHARGE DIAGNOSES: HYPERTENSION , NONINSULIN DEPENDENT
DIABETES MELLITUS , CONGESTIVE HEART FAILURE , OBSTRUCTIVE SLEEP
APNEA , AND PERIPHERAL VASCULAR DISEASE.
OPERATIONS AND PROCEDURES: ON 4/11/98 , UNDERWENT ROUX-EN-Y
GASTRIC BYPASS BY DR. ZORA DIERKER
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old male with
a history of morbid obesity of approximately 450 pounds , type II
diabetes mellitus and vascular complications , status post two left
foot surgeries , congestive heart failure , hypertension , obstructive
sleep apnea on positive airway pressure who has not had any
appreciable weight loss despite multiple diet attempts.
PAST MEDICAL HISTORY: As above.
MEDICATIONS ON ADMISSION: Rezulin 600 milligrams orally every afternoon ,
Metformin 850 milligrams orally twice a day , insulin 14 units of NPH , 6
units of Regular every day before noon , 20 units of NPH with 6 units of Regular every
p.m. , Lasix 40 milligrams every day , atenolol 50 milligrams orally every day ,
and aspirin 325 milligrams orally every day.
He has no known drug allergies.
He quit smoking cigarettes in 1989 after a twelve pack per year
history.
PHYSICAL EXAMINATION: Blood pressure 122/72 , heart rate 72. He is
an obese 55-year-old male in no acute distress. Abdomen is obese
and soft.
LABORATORY: Admission laboratory data included sodium 142 ,
potassium 5.1 , chloride 104 , bicarb 28 , creatinine 1.3 , glucose
195 , hematocrit 31.6 , white count 7.0 , platelets 173 , physical therapy 12.2 , PTT
26.5. EKG revealed first degree AV block. Chest x-ray revealed no
acute pulmonary disease.
He underwent Roux-en-y gastric bypass by Dr. Dierker on 4/11/98
with no intraoperative complications. He had a G tube placed
intraoperatively and was admitted to the surgical intensive care
unit postoperatively where he continued a steady and stable
postoperative course. He was maintained on nocturnal CPAP at 15
centimeters of water with aggressive pulmonary toiletry and was
ambulated early in his postoperative course. On postoperative day
#1 , he was transferred to the floor and began a standard post
gastrectomy diet , continued to improve and was monitored through
progression of his gastrectomy diet.
He was discharged home on postoperative day #4 after having a bowel
movement. His T tube was clamped on postoperative day #2 after 48
hours of gravity drainage. He was discharged in stable condition.
His diet will continue to be the Randall postgastroplasty diet
which at this point includes 120 cc of Carnation Instant Breakfast
eight times per day and small meals.
Activities are as tolerated.
He will follow-up with Dr. Dierker in one week and should call to
schedule his appointment. He will also have follow-up with his
primary care physician and should call to schedule this
appointment. He will have his staples removed on follow-up and
should call the office with any questions , fever , redness or
drainage from his incision.
Discharge medications include aspirin 325 milligrams orally every day ,
atenolol 50 milligrams orally every day , Tums 1250 milligrams orally three times a day ,
Lasix 40 milligrams orally every day , NPH insulin 14 units every day before noon and 20
units every afternoon , CVI insulin 6 units every day before noon and 6 units every afternoon ,
Lisinopril 20 milligrams orally day , multivitamin elixir 5 milligrams
orally every day , Axid 150 milligrams orally twice a day , Roxicet elixir 10 mls every
four to six hours as needed pain , Metformin 850 milligrams orally three times a day ,
Rezulin 600 milligrams orally every day. He was instructed to crush all
pills and mix well with water or Jello.
Dictated By: TABITHA NEGLIO , M.D. MZ31
Attending: ZORA DIERKER , M.D. LG65 VM062/4329
Batch: 88610 Index No. O7KIXD3QSA D: 1/24/98
T: 1/24/98
Document id: 346
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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729903734 | PUO | 03707858 | | 792844 | 1/5/1995 12:00:00 a.m. | PYELONEPHRITIS | Signed | DIS | Admission Date: 11/4/1995 Report Status: Signed
Discharge Date: 8/6/1995
FINAL DIAGNOSIS: ( 1 ) URINARY TRACT INFECTION
( 2 ) CORONARY ARTERY DISEASE
( 3 ) MYOCARDIAL INFARCTION STATUS POST
PTCA
( 4 ) LEFT VENTRICULAR ANEURSYMECTOMY
( 5 ) AICD PLACEMENT FOR VENTRICULAR
TACHYCARDIA
( 6 ) NEPHROLITHIASIS
( 7 ) HYPERTENSION
( 8 ) HYPERCHOLESTEROLEMIA
( 9 ) ADULT ONSET DIABETES MELLITUS
( 10 ) STATUS POST TOTAL ABDOMINAL HYSTERECTOMY
AND BILATERAL SALPINGO-OOPHORECTOMY
( 11 ) STATUS POST APPENDECTOMY
( 12 ) STATUS POST CHOLECYSTECTOMY
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old woman
with ischemic cardiomyopathy who now
presents with fever , malaise , and rigors. In April of 1991 the
patient suffered an anterolateral myocardial infarction and was
treated with TPA. She had recurrent chest pain five days later and
was retreated with TPA without improvement and then underwent PTCA
of her left anterior descending artery. The left ventriculogram at
that time revealed an ejection fraction of 20%. This myocardial
infarction was complicated by pericardial tamponade and hypotension
treated with pericardiocentesis. She also subsequent to this had
suffered recurrent episodes of congestive heart failure and
ventricular tachycardia. An echocardiogram at this time revealed a
significantly decreased ejection fraction with a new left
ventricular aneurysm and moderate mitral regurgitation. She was
evaluated for cardiac transplant but opted for Amiodarone and
aneurysmectomy/AICD implantation. In February of 1991 a cardiac
catheterization revealed an ejection fraction of 18%. The patient
was seen in cardiomyopathy clinic on 1/18/95 and complained of
chills and weakness and subsequent urinalysis was consistent with
urinary tract infection. She was started on Bactrim orally Since
then she has had increased nausea and vomiting with three episodes
of falling and imbalance. She denies dizziness , lightheadedness ,
palpitations , or chest pain. She denies fever or chills although
she had rigors in the emergency room.
PAST MEDICAL HISTORY: Ischemic cardiomyopathy. Hypertension.
Increased cholesterol. Diabetes mellitus.
Coronary artery disease status post anterior myocardial infarction
complicated by ventricular tachycardia and congestive heart
failure. Left ventricular aneurysmectomy. AICD placement. Status
post total abdominal hysterectomy and bilateral
salpingo-oophorectomy. Status post cholecystectomy and
appendectomy.
MEDICATIONS: Coumadin , Cardene , Digoxin , Synthroid , Zocor ,
Captopril , Lasix , K-Dur , vitamin C , insulin , and
magnesium.
FAMILY HISTORY: Notable for brother who suffered a myocardial
infarction at the age of 50. She does not smoke
and does not drink alcohol.
PHYSICAL EXAMINATION: She is a well appearing woman in no apparent
distress. Temperature 101.2 , pulse 77 ,
blood pressure 102/52 , oxygen saturation 91% on room air. The
examination was notable for lungs that had faint bibasilar rales.
The heart examination showed a regular rate and rhythm with S1 and
S2 and 2 out of 6 systolic murmur at the left upper sternal border
radiating to the left lower sternal border. Abdomen: Soft and
nontender. No hepatosplenomegaly. Back: No costovertebral angle
tenderness. Rectal: Guaiac negative. Extremities: No clubbing ,
cyanosis , or edema.
LABORATORY DATA: Admission laboratory data was unremarkable.
Chest x-ray showed no congestive heart failure
and no infiltrates. The ECG was unchanged compared with previous
ECGs. The urinalysis was notable for too numerous to count WBCs.
The urine culture showed Escherichia coli.
HOSPITAL COURSE: The patient was admitted and started on intravenous
antibiotics , specifically Ampicillin and
Gentamycin. She was gently hydrated. Over the next several days
she continued to improve although she still felt moderately weak.
Her urine cultures grew an organism which was sensitive to
Ampicillin and she was discharged on orally Ampicillin to follow-up
with her primary cardiologist , Dr. Dominica Heinen , to document
resolution of her symptoms and to return to normal state of health.
Dictated By: CARLY M. CALABRETTA , M.D. BZ47
Attending: CARLTON J. ABSHEAR , M.D. FG9 TY134/8443
Batch: 27570 Index No. IIJL260H87 D: 4/3/97
T: 8/28/97
Document id: 347
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
N |
- |
N |
356637867 | PUO | 54795665 | | 7788205 | 8/3/2005 12:00:00 a.m. | RULE OUT MYCOCARDIAL INFARCTION | Signed | DIS | Admission Date: 6/12/2005 Report Status: Signed
Discharge Date: 9/27/2005
ATTENDING: TONI , CARMELITA M.D.
ADDENDUM:
SERVICE:
Cardiac Surgery Service.
This is a dictation addendum to the previously dictated note with
confirmation #791591.
PRIMARY DIAGNOSIS:
Coronary artery disease.
SECONDARY DIAGNOSES.
1. Hypertension.
2. Type II diabetes mellitus ( uncontrolled ).
3. Dyslipidemia.
4. Postoperative deep sternal wound infection requiring surgical
debridement and pectoralis/omental flap closure on 1/25/05 .
5. Postoperative urinary tract infection requiring antibiotic
treatment.
PROCEDURE:
1. On 3/1/05 , urgent coronary artery bypass graft times three with a Y
graft ( SVG1-OM; SVG2 to LAD , with proximal part of SVG2 taken from SVG1;
SVG3-PDA ).
2 On 1/25/05 , urgent sternal wound debridement for deep sternal
infection with pectoralis/omental flap closure with assistance of Pagham University Of department of Plastic Surgery.
HOSPITAL COURSE:
Following transfer from the Intensive Care Unit to the Cardiac
Surgery Step-Down Unit on 5/10/05 , postoperative day #18 , the
patient remained afebrile with antibiotics continuing to infuse
in the form of imipenem and vancomycin with Infectious Disease
Service following the patient for previous resistant urinary
tract infections and sternal wound growing 1+ E. coli. Plastic
Surgery Service continued to follow the patient with JP drains
continuing to drain scant amounts of serosanguineous fluid.
Diabetes Management Service also continued to follow the patient
for assistance and controlling the patient's postoperative
hyperglycemia. On 6/12/05 , the patient continues remained
afebrile in sinus rhythm with stable blood pressure , oxygenating
well on room air. Mr. Beckfield continued to diurese well and he
continued to increase his activity level. A PICC line was placed
on 6/12/05 in the form of a 4-French single lumen PICC catheter ,
41 cm long , 41 cm in with post-placement chest x-ray
demonstrating the tip of the PICC line to be in the SVC , okay for
use. On 1/18/05 , the patient continued to remain afebrile with
normal white blood cell count , saturating well on room air with
stable blood pressure and heart rate in sinus rhythm , rate
controlled. The patient continued to increase his activity
level , ambulating with nursing assistance around the nursery. He
continued on imipenem and vancomycin per Infectious Disease for a
total course of six weeks. Plastic Surgery Service deemed the
patient safe for discharge to rehabilitation facility with
anticipation of close follow up with Dr. Authur in clinic in one
week. The patient demonstrated no further episodes of confusion ,
agitation or compulsivity and was cleared by Psychiatry for
discharge and the patient was deemed competent to make all
medical decisions. Mr. Beckfield was discharged on 11/16/05 ,
postoperative day #22 from CABG and postoperative day #9 from
sternal wound debridement with flap closure. Mr. Beckfield was
discharged to a rehabilitation facility for continued
cardiopulmonary rehabilitation. He will continue physical
therapy and continue to receive his antibiotics for a total of
six weeks by his PICC line.
PHYSICAL EXAMINATION:
On day of discharge , 11/16/05 , the patient is afebrile with
temperature 98.0 degrees Fahrenheit , heart rate 78 , sinus rhythm ,
blood pressure 110/68 , oxygen saturation 96% on room air , and
today's weight listed as 98.2 kilograms , note preoperative weight
listed as 98.0 kilograms , flap JP drain remains in place ,
draining 90 cc of fluid , yesterday 11/16/05 and 45 cc by the time
of discharge on 11/16/05 . HEENT: No carotid bruits or JVD
appreciated. PERRL. Pulmonary: Breath sounds are diminished at
bilateral bases with rare coarse breath sounds and rhonchi , and
no wheeze appreciated. Coronary: Regular rate and rhythm ,
normal S1 , S2 , no murmurs , rubs , or gallops appreciated.
Abdomen: Slightly distended , mildly tympanic , nontender ,
positive bowel sounds. Extremities: Trace edema to mid calves
bilaterally with 2+ pulses at upper extremities bilaterally , 1+
pulses at bilateral lower extremities. Skin: Midline sternotomy
incision well approximated and healing well , sutures in place ,
mildly erythematous and indurated and tender at lower portion of
the incision. No sternal click elicited on examination and JP
drain in place , draining well scant amounts of serosanguineous
fluid. No erythema surrounding JP drain site minimally invasive
SVG harvest incision site well approximated and healing well with
no erythema or drainage present.
LABORATORY DATA:
On day of discharge , 11/16/05 , sodium 138 , potassium 4.3 , BUN 17 ,
creatinine 1.1 , calcium 8.4 , magnesium 1.7 ( replaced ). White
blood cell count 8.7 , hematocrit 26 , platelet count 477 , 000 , and
INR 1.2. Microbiology 1/25/05 , wound culture with final read of
no growth from #1 culture , culture #2 growing 1+ E. coli. On
3/8/05 E. coli urinary tract infection growing greater than
100 , 000 colonies. On 8/23/05 , urinary culture growing
klebsiella greater than 100 , 000 colonies. Blood cultures
3/29/05 and 03 with no growth on final read.
DIAGNOSTIC IMAGING:
Chest x-ray PA and lateral view obtained on day of discharge
11/16/05 demonstrates mild bilateral pulmonary edema , bibasilar
atelectasis , small bilateral pleural effusions , no areas of
consolidation or pneumothorax present , PICC line present in the
right upper extremity with tip vein SVC.
DISPOSITION:
Mr. Beckfield is discharged today , 11/16/05 to a rehabilitation
facility for continued cardiopulmonary rehabilitation. The
patient has been instructed to call to schedule follow up
appointments as listed on his discharge summary. The patient
will follow up with his cardiac surgery , Dr. Carmelita M. Toni , in
six to eight weeks. Additionally , the patient will see his
plastic surgeon , Dr. Fiona Authur , in one week in Plastic
Surgery Clinic. The patient will also follow up with his primary
care physician and cardiologist in one to two weeks after leaving
his rehabilitation facility. The patient has been instructed to
continue to shower and wash on incisions with soap and water
daily and to monitor incisions for signs of worsening infection
such as fever , change in drainage , odor or color , increase in
drainage , worsening redness , or worsening pain. Antibiotics to
continue for a total of six weeks with last dose of imipenem to
be given on 2/28/05 and last dose of vancomycin to be given on
2/3/05 . Please check BUN and creatinine as well as vancomycin
trough level every week on Mondays and call primary care physician
if creatinine greater than 1.5 or vancomycin trough levels
greater than 20. Chest JP drain to remain in until follow-up
appointment with Dr. Authur in Plastic Surgery Clinic in one
week. Please call to schedule. Please record JP drain output
and send record with the patient to appointment. The patient
will follow up with his primary care physician for continued
evaluation and management of his hypertension , uncontrolled type
II diabetes mellitus , and dyslipidemia. Primary care physician
to also refer patient to a cardiologist for continued evaluation
and management of his hypertension and coronary artery disease.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Include the following: Tylenol 650 mg orally every 6 hours as needed pain or
temperature greater than 101 degrees Fahrenheit , enteric-coated
aspirin 325 mg orally daily , Colace 100 mg orally three times a day as needed
constipation , Robitussin 15 mL orally every 6 hours as needed cough ,
imipenem-cilastatin 500 mg intravenous every 6 hours via PICC line with last dose
to be given on 2/28/05 , vancomycin 1 g intravenous twice a day , last dose on
2/3/05 to be given via PICC line , Niferex 150 mg orally twice a day ,
Serax 15 mg orally every bedtime as needed insomnia , amlodipine 5 mg orally
twice a day , Toprol XL 100 mg orally daily , atorvastatin 80 mg orally
daily , Lantus 22 units subcutaneously at bedtime , Novolog units subcutaneously with
lunch and supper , hold if npo given in addition to sliding
scale Novolog , Novalog 12 units subcutaneously with breakfast , hold if
npo give in addition to sliding scale Novolog , 0.9% sodium
chloride intravenous flush syringe 1 mL intravenous every 8 hours for Medlock flush , 0.9%
sodium chloride intravenous flush syringe 1 mL intravenous every 1h. as needed post
medication infusion , multivitamin with minerals one tablet orally
daily , Novolog sliding scale before meals give with meals if blood sugar
less than 125 , give zero units subcutaneously , if blood sugar is 125-150 ,
give two units subcutaneously , if blood sugar is 151-200 , give three units
subcutaneously , if blood sugar is 201-250 , give four units subcutaneously , if blood
sugar 251-300 give six units subcutaneously , if blood sugar is 301-350 ,
give eight units subcutaneously , and if blood sugar is 351-400 , give 10
units subcutaneously and call physician , Novalog sliding scale subcutaneously at
bedtime , if blood sugar is less than 200 , give zero units subcutaneously ,
if blood sugar is 201-250 give two units subcutaneously , if blood sugar is
251-300 , give three units subcutaneously , if blood sugar is 301-350 , give
four units subc , if blood sugar is 351-400 , give five units subcutaneously
and call physician.
Mr. Beckfield has done quite well following his
coronary artery bypass graft procedure and deep sternal wound
debridement and flap closure. It is anticipated that with close
follow up with his primary care physician and cardiologist as
well as continued physical therapy and close monitoring at
rehabilitation , the patient will soon return to his lively
independent preoperative level of functioning.
Please do not hesitate to call for further questions or concerns.
eScription document: 0-6532938 EMS
CC: Genny Barrette M.D.
I Temedma Doch Health University And Hospital
Bock Sto Mongbeau
CC: Fiona Authur M.D.
Pagham University Of
Os
Dictated By: SURGEON , PRICILLA
Attending: TONI , CARMELITA
Dictation ID 7388270
D: 11/16/05
T: 11/16/05
Document id: 348
| Target |
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CHF |
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| output/system_intuitive_annotation.xml | intuitive |
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208309292 | PUO | 57452004 | | 418082 | 10/7/1998 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 10/21/1998 Report Status: Unsigned
Discharge Date: 10/29/1998
ADMISSION DIAGNOSIS: CORONARY ARTERY BYPASS GRAFT.
IDENTIFICATION: Mr. Smolen is a 55 year old male , who had
increased symptoms of dyspnea on exertion and
fatigue and had a positive exercise tolerance test on 6/1/98 .
BRIEF HISTORY: He was admitted to I Warho Hospital for
cardiac catheterization , which demonstrated a right
dominate system with diffuse 30% to 40% lesions of his left main ,
90% lesion of his left anterior descending coronary artery , 100%
lesion of his circumflex and OM 1 and a 100% lesion past his obtuse
marginal #2 , 60% proximal right coronary artery lesion and a 70%
posterior descending coronary artery lesion. On 6/1/98 he had an
echocardiogram which demonstrated good LV function. He is admitted
for CABG.
PAST MEDICAL HISTORY: His Past Medical History includes
non-Hodgkin's lymphoma , status bone marrow
transplant and chemotherapy in 1992 and 1993; history of
hypercholesterolemia , hypertension , insulin dependent diabetes ,
gastroesophageal reflux disorder and chronic renal insufficiency.
ALLERGIES: He has an allergy to Benadryl , it gives him the
jitters.
MEDICATIONS ON ADMISSION: His medications on admission are
Toprol XL 200 mg every day Procardia XL 90
mg every day , Lipitor 20 mg every day , aspirin 325 mg every day , Zantac 150 mg
twice a day , NPH humulin insulin 32 units each morning and 18 units each
evening subcutaneously , Valium 5 mg every day , Minipress 1 mg twice a day
PHYSICAL EXAMINATION: His physical examination was within normal
limits , no varicosities.
LABORATORY DATA: His laboratories on admission included BUN
of 40 , creatinine of 1.7. His white count was
6.5 and hematocrit was 35.0. EKG showed sinus rhythm with first
degree AV block. Chest x-ray , no active disease.
PROCEDURE: He was taken to the Operating Room on 4/10/98 where he
underwent harvesting of the left radial artery for
graft and he underwent a coronary artery bypass grafting x three
with a left internal mammary artery to the left anterior descending
coronary artery , saphenous vein graft from the posterior descending
coronary artery to the aorta and a radial artery from the saphenous
vein graft to the obtuse marginal coronary artery.
HOSPITAL COURSE: His postoperative course was complicated by
fever to 101 on two occasions , his white count at
that time was 5 and 6 respectively. His cultures were negative ,
sputum , blood , line tip and chest x-ray were negative. He had , on
postoperative day 5 , an episode of rapid atrial flutter and was
chemically converted to sinus rhythm with Corvert and has remained
in sinus rhythm on Lopressor and diltiazem for 24 hours. He will
be discharged today , postoperative day 6 , to the care of Dr. Carlton J Abshear on the following medications. Of note , his saphenous vein
harvest site showed some slight erythema to be treated with
antibiotics by mouth.
DISCHARGE MEDICATIONS: He is discharged on the following
medications: Axid 150 mg twice a day , Lipitor 20
mg once a day , NPH Humulin insulin 32 Units every morning , 18 Units
every evening; Diltiazem 60 mg three times a day , Lopressor 150 mg twice a day ,
enteric coated aspirin 125 mg once a day , Valium 5 mg once a day ,
Keflex 500 mg four times a day for 7 days , Percocet 1 to 2 tablets
every four hours as needed for pain.
Dictated By: CHRISTY CLARDY , P.A.
Attending: ISABELLE E. COLASAMTE , M.D. MT4 HX605/5118
Batch: 97914 Index No. PTTBDC26O2 D: 4/18/98
T: 3/10/98
Document id: 349
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
Q |
U |
U |
U |
Y |
U |
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U |
Y |
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U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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Y |
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- |
N |
874486955 | PUO | 72680439 | | 910714 | 9/14/1999 12:00:00 a.m. | STROKE | Signed | DIS | Admission Date: 5/6/1999 Report Status: Signed
Discharge Date: 5/28/1999
CHIEF COMPLAINT: This patient presented with an acute stroke and
was brought in by her daughter.
HISTORY OF PRESENT ILLNESS: Sixty-six year old obese African
American woman of previous CVA of
unclear etiology and unclear clinical sequelae. She was driving as
a passenger in a car around 11:00 o'clock in the morning and
experienced a sudden speech arrest which was witnessed by her
daughter-in-law. She has also difficulty moving her right arm and
she had some tearing of her left eye as well as a skewed look on
her face. By 11:40 a.m. , the ambulance had arrived and she was
admitted to the I Warho Hospital emergency department
where the protocol for acute stroke was instituted. The patient
had a CTA done which showed questionable luminal narrowing of the
distal left middle cerebral artery. CT scan was normal and the
patient was given intravenous TPA at 1323 p.m. She was given a 9
mg bolus dose over two minutes and 81 mg given over the following
hour. She was transferred to the neuro. intensive care unit of
I Warho Hospital .
PAST MEDICAL HISTORY; Diet controlled diabetes , obesity ,
hypertension as per the Kernan To Dautedi University Of Of internal
medicine associate records. She also has history of ulcerative
colitis and is on treatment. She is status post MI in 1988 and
there is question of an old stroke in the past. There is also
question of asthma.
MEDICATIONS: Currently is aspirin 325 mg and Asacol although she
wasn't sure of the dose.
SOCIAL HISTORY: Nonsmoker , married with several children. At
baseline , she is wheelchair dependent due to
chronic hip and back pain although she ambulates at home.
REVIEW OF SYSTEMS: Revealed chronic mild shortness of breath.
FAMILY HISTORY: There was no significant other family history.
PHYSICAL EXAMINATION; Blood pressure is 138/76 , heart rate was 80
and paced. She was an obese lady lying on
her back. HEAD AND NECK: Revealed no evidence of trauma. There
were no bruits in the neck. CHEST: Clear. There were bilateral
wheezes. ABDOMEN: Soft , non-tender. EXTREMITIES: Normal , obese
with no edema. NEURO: The patient is awake and alert , looking
around. She was mute however. She was able to follow one step
commands. She had a question of a right field compromise
difficulty crossing the midline. She had a right upper motor
neuron seventh weakness with decreased power on the right side of
the face. She had flaccid right arm. Her right leg had some power
with flexion at the knee but was generally weak. She had optimum
coordination and absent pinprick and proprioception on the right.
All of this was documented at 12:30 a.m. By 14;30 a.m. , after the
patient was given intravenous TPA , the patient's language had
returned completely to normal. She had normal speech including
comprehension and naming. Her ability to distinguish left from
right was intact. Her repetition was intact. SHe had full range of
movement of the eyes with full fields of confrontation. She had a
mild right arm drift on the right side but her strength was 4+/5
distally and proximally. There was normal power in the right lower
lobe and the plantars were normal. There was no increase in
reflexes. The patient was transferred to the intensive care unit
for the neurological service of I Warho Hospital .
HOSPITAL COURSE: Blood pressure monitoring was instituted per
protocol , nasal oxygen was given and no antiplatelet
therapy was given for 24 hours. Head of bed was raised to 30
degrees. Head CT was repeated the following morning , the results
of which show that there is slight left basal ganglion internal
capsule , acute and subacute infarct in the left middle cerebral
artery distribution which was evolving from the previous study.
THere was no evidence of intracranial hemorrhage. The patient had
further investigations to look for a cause of this presumed embolic
stroke. She had an echocardiogram done which showed the aortic
root at 3.5 cm , the atrium at 3.2 which is slightly dilated. There
was normal ventricular size and overall preserved systolic
function , trace aortic insufficiency , 1+ tricuspid regurgitation ,
trace mitral regurgitation. Holter monitor was done which showed
persistent atrial flutter. The patient was coumadinized and some
discussion pertaining to cardioversion was entertained by the
electrophysiology service. However , this was not done as an
inpatient. The patient continued to do remarkably well after her
intravenous thrombolysis over the next couple of days. She had
persistent drift on the right arm; however , her speech remained
completely normal. SHe was reviewed by the chronic pain service on
several occasions for chronic back and leg pain. She reached
normal levels of Coumadin within several days and was discharged
without rehabilitation. She will be followed by the cardiac
service and a plan for complete cardioversion was instituted within
one month. The patient went home on Coumadin. She was finally
discharged on 5/11/99 .
Dictated By: LUIS CHAIN , M.D. BR29
Attending: DERICK D. YAN , M.D. OY27 OE201/0492
Batch: 19401 Index No. U0MC0858YP D: 10/29/99
T: 10/29/99
Document id: 350
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
U |
U |
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Y |
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U |
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U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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725330728 | PUO | 59936370 | | 808262 | 10/22/1997 12:00:00 a.m. | ACUTE MYOCARDIAL INFARCTION | Unsigned | DIS | Admission Date: 8/13/1997 Report Status: Unsigned
Discharge Date: 7/6/1997
ADMISSION DIAGNOSIS: CORONARY ARTERY DISEASE.
PROCEDURES: CORONARY ARTERY BYPASS GRAFT X TWO , 26 of July .
HISTORY OF PRESENT ILLNESS: The patient was admitted to the
Cardiology Service on 24 of October for
work-up of unstable angina. She is a 72-year-old woman with
multiple cardiac risk factors , admitted with unstable angina.
Cardiac risk factors include postmenopausal , age , hypertension ,
hyperlipidemia , and diabetes. She presented to the hospital with a
one week history of intermittent chest pain at rest. On 10 of April ,
she presented to Pagham University Of with postprandial
chest pain , no EKG changes , and she was admitted to the CCU to rule
out myocardial infarction. ETT on 4 of November was positive. The
patient was sent home with plan for outpatient MIBI scan and was
instructed to call the primary M.D. if she had recurrent chest
pain. She developed recurrent chest pain within 48 hours of
discharge but did not call her doctor. The pain resolved
spontaneously but recurred with rest or exertion. She was
readmitted to the Pagham University Of on 24 of October with
worsening chest pain. Her saturation was found to be 88% and she
had evidence of congestive heart failure. An EKG revealed ST
elevation in V1 , V2 , and inferior leads. The chest x-ray showed
moderate congestive heart failure. She was treated with intravenous TNG ,
Heparin , aspirin , Lopressor and the chest pain improved. EKG
changes normalized but persistence of concave ST segment elevation
in inferior leads. The patient was admitted for further
management.
PAST MEDICAL HISTORY: Coronary artery disease; positive Persantine
thallium scan in 1994; insulin dependent
diabetes mellitus; hypertension; hyperlipidemia; previous tobacco
smoker; glaucoma; cataract; nephrolithiasis; chronic renal
insufficiency with creatinine in the 2.0 range.
ALLERGIES: Lisinopril with cough.
MEDICATIONS ON ADMISSION: Mevacor 40 milligrams once a day ,
Isordil 20 milligrams three times a day , Axid ,
Atenolol 50 milligrams once a day , NPH insulin 44 units in a.m.
with 22 units in p.m. , Cozaar 25 milligrams once a day , Dyazide 25
milligrams once a day , and eye drops.
PHYSICAL EXAMINATION: Afebrile , pulse 70-regular , blood pressure
130/80 , respiratory rate 20 , 100% on face
mask. No jaundice , no anemia , no cyanosis , no clubbing , no pedal
edema. The lungs were clear to auscultation. The heart was
regular with positive S4 , no murmurs. The abdomen was obese , soft ,
benign. No evidence of varicose veins , all peripheral pulses were
palpable. The neurological examination was intact.
LABORATORY DATA: The EKG revealed normal sinus rhythm with ST
elevation in the inferior leads. The sodium was
144 , potassium 5.3 , chloride 109 , CO2 17 , BUN 51 , creatinine 2.4 ,
glucose 251 , WBC 13.7 , hematocrit 36.1 , and placement 253.
HOSPITAL COURSE: The patient was admitted to the ICU and was taken
to the Cardiac Catheterization Laboratory on
28 of November and underwent cardiac catheterization. The pulmonary
capillary wedge pressure was 16. The patient had 99% obtuse
marginal one stenosis , 90% ramus stenosis , 80% mid-LAD artery
stenosis involving the diagonal 1 , which in addition had a 90%
lesion , an 80% distal LAD lesion at the apex. The patient was
taken to the Operating Room on 26 of July and underwent coronary
artery bypass graft x two with LIMA to LAD , saphenous vein graft to
obtuse marginal branch 1. Postoperatively , she was taken to the
ICU where she was extubated in postoperative day 1. However , her
respiratory status progressively worsening with increasing oxygen
requirement and she was reintubated on 11 of July . Throughout this ,
she was aggressively diuresed and she was slowly weaned off the
ventilator. She had a bout of atrial fibrillation on postoperative
day 5 , which responded to Lopressor. Her hypertension was treated
initially with intravenous Hydralazine. In view of the extreme slow wean
off the ventilator , a Pulmonary consultation was obtained and on
their advise , diuresis was continued and she was weaned down to
pressor support and was fully extubated on postoperative day 7.
She was transferred to the floor on postoperative day 8 where she
continued to do well except for intermittent bouts of atrial
fibrillation. She has , however , remained in sinus rhythm for the
past 96 hours and she is being discharged in a stable condition on
postoperative day 13 , on 22 of November .
DISPOSITION: Home with services.
DISCHARGE DIET: Low cholesterol , low saturated fat diet , diabetic
diet.
ACTIVITY: As tolerated.
FOLLOW-UP CARE: Appointment with Cardiology in two weeks , Dr.
Pittinger in 4-6 weeks.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE: HCTZ 25 milligrams once a day , NPH
insulin 44 units every day before noon with 22 units
every afternoon with a CZI sliding scale , Lopressor 50 milligrams orally
three times a day , Percocet 1-2 tablets orally every 3-4 , Azmacort four puffs
nebulizer four times a day , Coumadin ( dose to be based on INR with INR range
being 2-2.5 ) , Axid 150 milligrams twice a day , Betagan eye drops 0.25%
one drop to both eyes twice a day , Digoxin .125 milligrams orally every other day
Dictated By: CORETTA TAHIR , M.D. UN19
Attending: DILLON C. PITTINGER , M.D. MS1 AJ542/5165
Batch: 69476 Index No. TYLDW067RW D: 1/4/97
T: 5/27/97
Document id: 351
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
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U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
Y |
N |
N |
N |
N |
N |
Y |
N |
Y |
N |
N |
N |
- |
106565366 | PUO | 86025167 | | 9840114 | 5/28/2007 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 1/8/2007 Report Status:
Discharge Date: 9/29/2007
****** FINAL DISCHARGE ORDERS ******
VIANA , BELLE A 436-75-25-7
Ry
Service: MED
DISCHARGE PATIENT ON: 8/1/07 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 81 MG orally every day
2. BUPROPION HCL 100 MG orally three times a day
3. FUROSEMIDE 80 MG orally every day before noon
4. NICOTINIC ACID 500 MG orally before meals
5. THERAPEUTIC MULTIVITAMINS 1 TAB orally every day
6. WARFARIN SODIUM 4 orally every afternoon
7. METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally every day
8. KCL SLOW RELEASE TAB 20 MEQ orally every day
9. TIOTROPIUM 18 MCG inhaled every day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain
Instructions: Not to exceed 4 , 000 mg/day
ASA 81 MG orally DAILY
WELLBUTRIN ( BUPROPION HCL ) 100 MG orally three times a day
LASIX ( FUROSEMIDE ) 160 MG every day before noon; 80 MG every afternoon orally 160 MG every day before noon
80 MG every afternoon
POTASSIUM CHLORIDE SLOW REL. TAB ( KCL SLOW RE... )
20 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 1/15/07 by
MATTON , TAMIE MINTA , M.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor.
LISINOPRIL 5 MG orally DAILY HOLD IF: sbp<100
Override Notice: Override added on 1/15/07 by
MATTON , TAMIE MINTA , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
795522321 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor.
Previous override information:
Override added on 1/15/07 by MATTON , TAMIE MINTA , M.D.
on order for POTASSIUM CHLORIDE SLOW REL. TAB orally ( ref
# 698502645 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor.
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY HOLD IF: sbp<100 , heart rate<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
NIACIN ( NICOTINIC ACID ) 500 MG orally three times a day
Food/Drug Interaction Instruction Give with meals
OXYCODONE 5 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 3/10/07 by
ELFENBEIN , SEPTEMBER KANDACE , M.D.
on order for OXYCODONE orally ( ref # 091863853 )
patient has a PROBABLE allergy to Morphine; reaction is hives.
Reason for override: patient has tolerated in the past
SPIRIVA ( TIOTROPIUM ) 18 MCG inhaled DAILY
Instructions: Patient may refuse
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Katheryn Gruntz or his partner/physician assistant Please make appointment to be seen this week ,
ALLERGY: Morphine
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hodgkins lymphoma ( Hodgkins disease ) Asthma ( asthma ) R total hip
replacement ( total hip replacement ) septic joint ( total hip
replacement ) non Q wave MI
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Diuresis with lasix
Chest Xray
BRIEF RESUME OF HOSPITAL COURSE:
CC: LE swelling and SOB
***********************
HPI: 64 year-old with PMH of CAD history of MI , CHF , CABG , MVR presents with 3
days of worsening LE edema and 1 day of shortness of breath. Was very
busy and stopped taking his lasix , also dietary
indiscretion. Negative ROS otherwise.
*********************
PMH: CAD history of MI in 2002 history of CABG/MVrepair 2006
CHF: EF 25-30% ( last echo 9/21 )
LPCA and RAICA stroke 7/2 residual discoordation and reading
difficulties
Hodkin's lymphoma 1978 history of chemo and mantle rxn
Non-hodkins lymphoma 1991: chemo
HTN
S/p fall with C7T1 fx 11/19 ( in context of CVA )
history of humerus fx 1/21
?cardiac asthma
**************
PSH: 4 vessel CABG c MV repair and re-op for bleeding S/p THR in 1994
with removal and replacement 2002 for septic joint ( had MI during this
time )
***********
Meds: Lasix 80 Po twice a day , asa 81 mg every day , Toprol XL 25 mg every day , Coumadin 5mg
M , Th , 4mg other days , Kdur 20mEq every day , Wellbutrin 100 three times a day , Niacin 500
three times a day , Spiriva 18 mg every day as needed , VitE , VitC
***********
All: NKDA
***********
SH: Per ED was living in car and that's why didn't take Lasix. Per patient
works as teacher for photography students , lives alone in apt.
Divorced , raised 5 adopted children. Hx of 3ppdx17 yrs , quit 25 years
ago , no EtOH , no illicits. FH: M and S c BCA , S , CHF , B prostate
CA
****************
PEX on admission 96.3 100 100/60 22 98%
RA Significant
for +JVP
CV: RRR c multiple PVCs , 3/6 SEM Lungs: crackles at bases ,
R>L Ext: 3+edema R>L , stasis changes , multiple small
excoriations
*************
Labs: chemistry wnl , 1 set cardiac enzymes negative , BNP 217 , INR
3.9 CXR: chronic small bilateral effusions , R>L , no
evidence of edema , PNA , largely unchanged from 1 yr prior.
ECG: NSR , evidence of LVH , old t-wave inversions
*************
Hospital Course:
1. Neuro: no issues , Wellbutrin continued.
2. CV: Likely CHF exacerbation caused by dietary indiscretion and
stopping lasix. Stable sats and minimal CXR evidence for significant
pulmonary edema. Mildly overloaded - diuresis with lasix
intravenous , goal of 1-1.5 L/day. Weight up about 10 lbs. No need for new echo
given recent one and clear other reason for exacerbation. Formal rule
out: 2 sets negative. Continue all cardiac meds , optimize regimen ( why
not on ACE/ARB? )
3. Pulm: Sats good , CXR without evidence of sig new pulmonary edema.
Never required oxygen and walking saturation 97-98%. Diuresis.
4. FEN/GI: 2L fluid restriction , low salt diet. Check electrolytes twice a day
and replete K as needed.
5. GU/Renal: renal function at baseline
6. Heme: Antiocoagulation for valve. Supratherapeutic on admission ,
coumadin held.
7. ID: no signs of infection , PNA , broncitis etc.
8. Code: Full
9. Dispo: patient was very eager to leave on HD2 , while moderate diuresis
achieved , still over weight. Nevertheless , saturation stable , clinically
safe to go home. Will continue diuresis at home with twice normal am dose
of lasix , and follow-up with primary care physician's office this week.
ADDITIONAL COMMENTS: VNA: Please check weights , BPs and respiratory status. The patient's
baseline systolic blood pressure is 80-100
Instruction for patient:
Weigh your self daily , maintain a low salt diet and limit your fluids
Take 160 mg of lasix in the morning and continue 80 in the evening
Do NOT take Coumadin for the next two days ( your INR is high ) and then
restart taking only 4 per day.
Your doctor will need to check your potassium , Creatinine and INR this
week.
Please call your doctors office if you experience worsening shortness of
breath , increased leg swelling , lightheadedness , dizziness , chest pain or
any other complaints.
You will need to call for an appointment to be seen by Dr Lozano
nurse/physician's assistant THIS week. Please bring a copy of these
discharge instructions to your appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Check INR , check potassium and creatinine on the week following
discharge.
No dictated summary
ENTERED BY: ELFENBEIN , SEPTEMBER KANDACE , M.D. ( IF94 ) 8/1/07 @ 03:31 PM
****** END OF DISCHARGE ORDERS ******
Document id: 352
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
129188447 | PUO | 59954123 | | 0887588 | 6/16/2004 12:00:00 a.m. | Esophagitis | | DIS | Admission Date: 7/10/2004 Report Status:
Discharge Date: 9/15/2004
****** DISCHARGE ORDERS ******
HANIBLE , ALDO 034-71-89-9
Phinga
Service: MED
DISCHARGE PATIENT ON: 7/10/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SVENNINGSEN , CHRISTIAN VIVAN , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
CLONAZEPAM 0.5 MG orally every day
Override Notice: Override added on 5/15/04 by
RYDALCH , SARAH K. , M.D.
on order for DIFLUCAN orally ( ref # 41174855 )
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & FLUCONAZOLE
Reason for override: Aware.
DIFLUCAN ( FLUCONAZOLE ) 100 MG orally every day X 12 doses
Starting Today ( 8/11 ) INDICATIONS:
Other: suspected esophageal candidiasis in poorly
cnotroled diabetic
Alert overridden: Override added on 5/15/04 by
RYDALCH , SARAH K. , M.D.
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & FLUCONAZOLE
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & FLUCONAZOLE
Reason for override: Aware.
LISINOPRIL 5 MG orally every day
Override Notice: Override added on 4/18/04 by
RYDALCH , SARAH K. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 34046372 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: Aware.
Previous override information:
Override added on 4/18/04 by RYDALCH , SARAH K. , M.D.
on order for KCL intravenous ( ref # 02616356 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: Aware.
MOM ( MAGNESIUM HYDROXIDE ) 30 MILLILITERS orally every day
Starting Today ( 8/11 ) as needed Constipation , Upset Stomach
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
LIPITOR ( ATORVASTATIN ) 20 MG orally every bedtime
ATENOLOL 25 MG orally every day
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
REMERON ( MIRTAZAPINE ) 15 MG orally every bedtime
CELEXA ( CITALOPRAM ) 20 MG orally every day
METFORMIN 500 MG orally twice a day
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please call you MD on Monday to schedule an appointment in the next 2 weeks Monday ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
esophagitis , chest pain , coronary heart disease , hypertension , NIDDM ,
depression
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Esophagitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NIDDM anxiety history of appy HTN cad history of 6/22 cath with Lcirc stent dyslipidemia
depression ( depression )
OPERATIONS AND PROCEDURES:
MIBI 2/8/04 with small perfusion defect and no reversibility
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
59 year-old female with NID DM , GERD , HTN , Depression , known CAD history of
circumflex stent 2002 , admitted with atypical chest pain. Cath in
2003 showed 2-V disease , admission for chest pain in 2003
resulted in a mibi being done , revealing no ischemia ,
no arrhythmias , negative enzymes. Presented with 36-48 hours of chest
pain , deep boring/squeezing in lower left chest , xyphoid region ,
suprasternal notch. Pain is reproducible on palpation , does not
radiate , is accompanied by diaphoresis , no dyspnea , nausea/vomiting.
Unrelieved by nitroglycerin. Minimal relief with morphine 4
mg in ED. No relief with maalox , orally lidocaine susp. First set cardiac
enzymes negative. PE: Nl cardiac exam. Chest
wall compression over left lower ribs reproduces pain-no
superficial erythema , swelling. Lungs CTAB.
Abd benign. Ext without C/C/E; pulses
symmetric. EKG: NSR 79 bpm , normal axis and intervals. 1 mm
ST segment depression V3-V5 , inverted Ts in V3-V5. C/W EKG findings
in September 2004. CXR: negative for effusions , infiltrates ,
edema , normal bony structures
A/P: 59 year-old woman with known coronary diseae presenting with atypical
chest pain.
CV: r/o MI with negative cardiac enzymes. mibi on 7/28 showed small
perfusion defect without reversibility.
Pulm: No active issue
Endo: NIDDM. SSI
Renal: No active issues.
Neuro: No active issues.
Psych: MDD-continue remeron , celexa , clonazepam.
GI: Esophagitis responded quickly to KBL and diflucan. Tolerating orally
on a.m. of discharge. Will complete two week course of Fluconazole.
Consider outpatient EGD if sx do not improve with tx.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GUSTOVICH , MARLO , M.D. , PH.D. ( NN129 ) 7/10/04 @ 12:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 353
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
- |
- |
N |
N |
Y |
N |
Y |
N |
402105256 | PUO | 89357151 | | 0928211 | 10/7/2005 12:00:00 a.m. | chf | | DIS | Admission Date: 5/22/2005 Report Status:
Discharge Date: 3/18/2005
****** DISCHARGE ORDERS ******
NEMANI , BARBERA 640-32-71-6
Port Lake Bock
Service: MED
DISCHARGE PATIENT ON: 10/22/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REFFITT , LAVETA GUILLERMINA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
Override Notice: Override added on 10/16/05 by
PALMERTREE , CRISTA S. , M.D.
on order for COUMADIN orally ( ref # 83685904 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: ho aware. will monitor
Previous override information:
Override added on 9/6/05 by GILSTRAP , KIRSTIN GARNETT , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware
ALLOPURINOL 200 MG orally every day
Override Notice: Override added on 10/16/05 by
PALMERTREE , CRISTA S. , M.D.
on order for COUMADIN orally ( ref # 83685904 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: ho aware. will monitor
Previous override information:
Override added on 9/6/05 by GILSTRAP , KIRSTIN GARNETT , M.D.
on order for COUMADIN orally ( ref # 83888929 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FESO4 ( FERROUS SULFATE ) 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 200 MG orally twice a day Starting IN a.m. ( 9/20 )
REGULAR INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ZAROXOLYN ( METOLAZONE ) 2.5 MG orally every day
Starting IN a.m. ( 9/20 )
Instructions: please give 30 minutes before lasix
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXYCODONE 5 MG orally twice a day as needed Pain
PHENOBARBITAL 64.8 MG orally three times a day
Override Notice: Override added on 10/16/05 by
PALMERTREE , CRISTA S. , M.D.
on order for COUMADIN orally ( ref # 83685904 )
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
Reason for override: ho aware. will monitor
Previous override information:
Override added on 9/6/05 by GILSTRAP , KIRSTIN GARNETT , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & PHENOBARBITAL
Reason for override: aware
SENNA TABLETS 2 TAB orally twice a day
COUMADIN ( WARFARIN SODIUM ) 10 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 11/21 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/16/05 by
PALMERTREE , CRISTA S. , M.D.
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
Reason for override: ho aware. will monitor
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 10 MG orally every 12 hours
DIOVAN ( VALSARTAN ) 80 MG orally every day
Number of Doses Required ( approximate ): 10
LANTUS ( INSULIN GLARGINE ) 38 UNITS subcutaneously every day before noon
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 10/22/05 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: ho aware
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: Fluid restriction: 2 liters
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Coumadin check , osri medical center , 9/29 ,
Dr. Dario , 4/19 . Please call his office to find out what time ,
Arrange INR to be drawn on 4/6/05 with f/u INR's to be drawn every
4 days. INR's will be followed by KTDUOO coumadin clinic
ALLERGY: MEPERIDINE HCL , SILDENAFIL CITRATE , GABAPENTIN ,
SPIRONOLACTONE , NITRATE , DIGOXIN , AMLODIPINE , LISINOPRIL
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
VV pacer ( pacemaker ) CAD history of CABG ( coronary artery disease ) CHF
( congestive heart failure ) Afib ( atrial
fibrillation ) CVA ( cerebrovascular accident ) IDDM ( diabetes
mellitus ) Peripheral neuropathy ( peripheral neuropathy ) Obesity
( obesity ) PVD ( peripheral vascular disease ) CRI ( chronic renal
dysfunction )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old M with history of CHF presents with 3 wks of slowly
inc weight , abd girth , SOB and DOE starting after colonoscopy. Since
then , wt inc approx 20 lbs ( "dry" wt around 242 , this a.m. at home
261 ). patient swears he has been sticking to his diet and taking
all his meds. Of note , 2 episodes of PND and occ dull CP 4-6 min in
length usu with exercise , last today on way into ED. Spoke to primary care physician Sat
and she inc his zarox from 2.5 to 5 every day before 200 orally every day before noon lasix
without effect. Denies f/c , occ diarrhea still since colo , stable 8
pillow orthopnea. Labs on adm: Stable CRI , Hct stable , no inc WBC ,
1st set enz neg. BNP 143. PE on adm: JVP 15 cm , 3+ LLE and 2+ RLE
edema ( usu asymm ) , abd distention without tenderness , clear
lungs. CXR: NAD , EKG paced and
unchanged. Rx 100 intravenous lasix in ED without much
effect.
************************Hospital Course*******************************
CHF exacerbation.
1. CV: i: ROMI x 3 negative enzymes , cont home asa , bb , statin.
p: placed on lasix intravenous 200 twice a day with good diurhesis on admission. 260 lbs
on admit. 253 on d/c with much improved symptoms and patient eager to go.
Increased home regimen of lasix to 200 orally twice a day with 2.5 mg zaroxylin
before morning dose. patient to be f/u by CHF nursing service to adjust lasix
if necessary. Cont diovan. Christine Dario at Lingsol Medical Center
R: tele while active diuresis
Endo: RISS and lantus. TSH wnl.
Rheum: cont allopurinol
Heme: INR 1.8 , restarted coumadin ( coumadin:takes 10MF and 12.5 rest of
week at home ). No bleeding issues. To be f/u at osri medical center on 9/29 to have INR drawn.
Renal: Creatinine bumped to 2.4 in context of diurhesis. Improved to
2.2 on d/c. patient will have BMP drawn on 9/29 with inr to ensure stability.
Neuro: Cont phenobarb history of cva with sz. Level
21.9
Pain: Cont oxycontin and oxycodone for chronic
pain.
FULL CODE
ADDITIONAL COMMENTS: Please weight yourself daily and report weights to norma osborne.
The only change we have made to your medications is the following:
- Please take lasix 200mg twice a day at 8am and 4pm
- 30 minutes before your morning dose , please take 2.5 mg of zaroxylin.
- if your weight is increased by 2 Lbs or more from previous day , call
annabel verfaille ( CHF nurse )
DISCHARGE CONDITION: Stable
TO DO/PLAN:
4/19 Dr. Dario . 9/29 INR and BMP check
No dictated summary
ENTERED BY: PALMERTREE , CRISTA S. , M.D. ( TH744 ) 10/22/05 @ 12:24 PM
****** END OF DISCHARGE ORDERS ******
Document id: 354
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
510330616 | PUO | 27396055 | | 7635974 | 11/9/2007 12:00:00 a.m. | Non-cardiac chest pain | | DIS | Admission Date: 5/27/2007 Report Status:
Discharge Date: 5/27/2007
****** FINAL DISCHARGE ORDERS ******
FALETTI , JULIANNA W 977-67-32-9
Ver
Service: MED
DISCHARGE PATIENT ON: 5/3/07 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAGBERG , LILLIA JOCELYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ACETAMINOPHEN 650 MG orally every 4 hours
2. ACETYLSALICYLIC ACID 81 MG orally every day
3. ATENOLOL 25 MG orally twice a day
4. CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 1500 MG orally twice a day
5. DOCUSATE SODIUM 100 MG orally three times a day
6. FERROUS SULFATE 325 MG orally three times a day
7. FLUTICASONE NASAL SPRAY 1-2 SPRAY nasal every day
8. FOLIC ACID 1 MG orally every day
9. KCL SLOW RELEASE TAB 20 MEQ orally every day
10. MULTIVITAMINS 1 TAB orally every day
11. NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN
12. OMEPRAZOLE 20 MG orally twice a day
13. OXYCODONE 10-15 MG orally every 3 hours
14. PSYLLIUM ( METAMUCIL ) SUGAR FREE 1 PACKET orally every day
15. SENNOSIDES 2 TAB orally twice a day
16. TRAMADOL 50-100 MG orally every 6 hours
17. TRIAMTERENE 75 MG/HYDROCHLOROTHIAZIDE 50 MG 1 TAB orally every day
18. VALSARTAN 40 MG orally every day
19. DOCUSATE SODIUM 100 MG orally three times a day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain
ECASA 81 MG orally DAILY Starting Today ( 7/18 )
Override Notice: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
on order for COUMADIN orally ( ref # 836575113 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
ATENOLOL 25 MG orally twice a day
CALCIUM CARBONATE/ VIT D 1 , 500 MG/200 IU( 600 MG ELEM CA )
1 TAB orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally three times a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FLUTICASONE NASAL SPRAY 2 SPRAY inhaled DAILY
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
K-DUR ( KCL SLOW RELEASE TAB ) 20 MEQ orally DAILY
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
on order for VALSARTAN orally ( ref # 891217326 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: mda
Previous override information:
Override added on 5/3/07 by COONE , TERESITA R. , M.D.
on order for TRIAMTERENE 37.5 MG/HYDROCHLOROTHIAZIDE 25 MG
CAP orally ( ref # 154666474 )
SERIOUS INTERACTION: POTASSIUM CHLORIDE & TRIAMTERENE
Reason for override: mda
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
OMEPRAZOLE 20 MG orally twice a day
OXYCODONE 10-15 MG orally every 4 hours Starting Today ( 7/18 )
as needed Pain HOLD IF: sedation , RR<10
Override Notice: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
on order for ULTRAM orally ( ref # 071576789 )
POTENTIALLY SERIOUS INTERACTION: OXYCODONE HCL & TRAMADOL
HCL Reason for override: home medication
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1-2 PACKET orally DAILY as needed Constipation
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: mda
ULTRAM ( TRAMADOL ) 50 MG orally every 6 hours Starting Today ( 7/18 )
as needed Pain
Alert overridden: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & TRAMADOL HCL
POTENTIALLY SERIOUS INTERACTION: OXYCODONE HCL & TRAMADOL
HCL Reason for override: home medication
Number of Doses Required ( approximate ): 3
TRIAMTERENE 37.5 MG/HYDROCHLOROTHIAZIDE 25 MG CAP
1 CAPSULE orally DAILY
Alert overridden: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
on order for TRIAMTERENE 37.5 MG/HYDROCHLOROTHIAZIDE 25 MG
CAP orally ( ref # 154666474 )
patient has a PROBABLE allergy to Sulfa; reaction is ALOPECIA.
Reason for override: tolerates at home
Previous Alert overridden
Override added on 5/3/07 by COONE , TERESITA R. , M.D.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & TRIAMTERENE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & TRIAMTERENE
Reason for override: mda
VALSARTAN 40 MG orally DAILY
Alert overridden: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: mda
Number of Doses Required ( approximate ): 5
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 5/3/07 by
COONE , TERESITA R. , M.D.
on order for ULTRAM orally ( ref # 071576789 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & TRAMADOL HCL
Reason for override: home medication
Previous override information:
Override added on 5/3/07 by COONE , TERESITA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: mda
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Wagnon 5/9 at 11:30 scheduled ,
Dr. Milks ( please call to set up an appointment ) ,
ALLERGY: Penicillins , Sulfa
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn obesity history of sarcoid arthritis ( polyarticular arthritis )
diverticulosis ventral hernia depression
Recurrent chest pain with clean coronary arteries
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
-------------
HPI: 66yoF with obesity , sarcoid , chronic non-cardiac CP , clean cath in
2005 , PE's , recent THR , now p/with SSCP x1 heart rate at rest with SOB. Dev'd SSCP
while seated on DOA , no radiation , but +diaphoresis and n/v. Took ASA
and came to ED where pain and SOB spontaneously resolved without
intervention. EKG with no new changes. First Tn neg. Admitted for roMI.
---------------
PMH: sarcoidosis , chronic recurrent SSCP - clean cath in 2005 , PE's
on coumadin , recent THR , HTN , morbid obesity , depression , OA , gout ,
osteoporosis
---------------
DAILY STATUS: afeb , 140/90 , 60 , 99%RA. NAD , pain free. RRR no mrg ,
CTA B. mild chest wall tenderness. SNTND +BS. no LEE.
---------------
STUDIES: CXR - hilar LAD + cardiomegaly. EKG on 11/27/07 - NSR , TWI in
III , F , II ( all old )
---------------
***************HOSPITAL COURSE******************
*CVS: p/with SSCP that spontaneously resolved. No EKG changes , cardiac
biomarkers neg x 2 12 hours apart. Has a hx of recurrent atypical CP
with frequent rule outs and clean cath in 2005. Very low
likelihood for cardiac pain given prior hx , no ekg changes and neg
enzymes. May consider Ad-MIBI as an outpatient , although may be
difficult to interpret given large body habitus. We continued the
patient's home anti-HTN's , BB , ASA.
*PULM: hx of sarcoid , though not on meds currently. hx of PE , though
therapeutic on Coumadin currently. Continue inhalers
*ORTHO: recent L THR. Continue Coumadin for DVT ppx. Has follow-up with
Dr. Wagnon on 5/9
*ENDO: questionable history of DM ,
*PPX: Coumadin
*CODE: FULL
ADDITIONAL COMMENTS: You were admitted to the hospital with chest pain. We were concerned
that you chest pain might be from your heart. Fortunately all of the
heart muscle protien test were negative suggesting that the pain was from
some other source. You should continue all of your home medications.
Please call and make an appointment with your primary care physician , Dr. Milks , to review
you medications and discuss recent hospital admissions. If you develop
recurrent chest pain , shortness of breath , lightheadedness or other
concerning sx please contact a physician immediately.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*Consider outpatient adenosine MIBI
*Monitor blood sugar
*Continue monitoring sarcoid
*Patient will follow-up with ortho regarding recent hip surgery
No dictated summary
ENTERED BY: COONE , TERESITA R. , M.D. ( JZ110 ) 5/3/07 @ 06:34 PM
****** END OF DISCHARGE ORDERS ******
Document id: 355
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
Y |
Y |
Y |
N |
Y |
N |
N |
N |
N |
517077919 | PUO | 45227626 | | 8315894 | 10/16/2004 12:00:00 a.m. | Congestive Heart Failure | | DIS | Admission Date: 5/11/2004 Report Status:
Discharge Date: 6/19/2004
****** DISCHARGE ORDERS ******
KISHIMOTO , BRIANA 104-13-35-2
Jose Ver
Service: MED
DISCHARGE PATIENT ON: 9/14/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
Override Notice: Override added on 9/23/04 by GERZ , JEANNA L E. , M.D. , M.P.H.
on order for WARFARIN SODIUM orally ( ref # 70672901 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: patient on as outpt.
ALLOPURINOL 100 MG orally every day
Alert overridden: Override added on 9/23/04 by GERZ , JEANNA L E. , M.D. , M.P.H. SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will monitor
DIGOXIN 0.125 MG orally every day
Override Notice: Override added on 9/23/04 by GERZ , JEANNA L E. , M.D. , M.P.H. on order for LEVOXYL orally ( ref # 96827820 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: patient has been on this as an outpt
LEVOXYL ( LEVOTHYROXINE SODIUM ) 75 MCG orally every day
Override Notice: Override added on 9/23/04 by GERZ , JEANNA L E. , M.D. , M.P.H.
on order for WARFARIN SODIUM orally ( ref # 70672901 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: patient on as outpt.
Previous override information:
Override added on 9/23/04 by GERZ , JEANNA L. , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: patient has been on this as an outpt
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 8
NEURONTIN ( GABAPENTIN ) 200 MG orally every day
COZAAR ( LOSARTAN ) 100 MG orally every day HOLD IF: sbp<100
Number of Doses Required ( approximate ): 9
CELEXA ( CITALOPRAM ) 20 MG orally every day
LANTUS ( INSULIN GLARGINE ) 50 UNITS subcutaneously every bedtime
WARFARIN SODIUM 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( 11/24 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/14/04 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: patient on as outpt. will monitor
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
TORSEMIDE 100 MG orally every day before noon
TORSEMIDE 50 MG orally every afternoon
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Borriello , primary care physician 2 weeks ,
Glinda Bancourt , CHF clinic , Sco Medical Center , 10:30am 1/28/04 scheduled ,
Rossie Mankoski , pacer/icd clinic 9:30am ( 974 ) 555 8356 6/6/04 scheduled ,
INR check at regular location 1/28/04 ,
ALLERGY: SHRIMP
ADMIT DIAGNOSIS:
Congestive Heart Failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive Heart Failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Adriamycin induced CMP , HTN , IDDM , Sarcoid , Left Breast CA- history of lumpect
and XRT/Adria-'84 , hypercholesterolemia , ? GI origin of epigastric
pain , dvt ( deep venous thrombosis ) , osteoarthritis ( unspecified or
generalized OA ) , hypothyroid ( hypothyroidism ) cad ( )
OPERATIONS AND PROCEDURES:
VVI/R ICD placement 5/6/4 by Dr. Dominguez
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
This is a 60 year old female with a history of breast cancer and
chemotherapy induced CMP( EF 20% , followed by CMP clinic; on 2 L O2 at
night ) , COPD , history of DVT now anticoagulated , HTN , afib , DM , admitted
with presumed CHF flare. Ms. Kishimoto was recently admitted for
CHF flare and received intravenous diuresis. She reponded well and
was discharged at a dry weight of approximately 185 pounds. Ms.
Kishimoto presented on this admission with 2 days of increasing SOB ,
abdominal discomfort , nausea and vomitting. She denied increasing
edema , change in number of pillows. She did endorse PND present but
states that it is unchanged. In ED , the patient was afebile , inital
ly with oxygen saturation in the high 90's on 2 L. BP 154/84. BNP was
greater than 3000. CXR showed pulmonary edema. Abdominal CT was
obtained due to concern for the patients abdominal pain and showed
an engorged , fatty liver , ascites , pleural effusions ( not seen
on CXR ). A surgical consult was obtained and the surgeons felt the
patients abdominal pain was not surgical in nature but rather secondary
to CHF.
Hospital Course:
1 ) Cardiovascular: a ) Pump- CHF exacerbation. We diuresed the patient
initially with intravenous lasix until her respiratory status
imroved and the patient was able to maintain good oxygen saturation on
room air. At the time of discharge her oxygen saturation on room air
was in the high 90's and was between 94-96 % with ambulation. We
continued the patient's home doses of beta blocker , angiotension
receptor blocker and statin. The patient was again encouraged to
adhere to a low-salt diet and weight herself daily. The patient will be
discharged on Torsemide 100 mg orally every am and 50 mg orally every pm , a regimine t
has worked will for the patient in the past. She will f/uw iht the
Dick Stookheights Community Hospital CHF Clinic ( Glinda Bancourt ) on 5/6 at 10:30 am. The
patient will be followed by Lau VNA who will assist in her CHF
monitoring and assess her for home physical therapy. b ) Rhythm- The
pa tient is know to have frequent PVCs and non-sustained ventricular
tachycardia which was agian noted on this admission on telemetry.
She was asymptomatic with the NSVT and remains hemodynamically stable.
We obtained an electrophysiology consult to evaluate the need for an
AICD or biventricular pacing. The patietns electrolytes and magnesium
were monitored and rempleted and she was maintained on a beta blocker.
On 2/14 the EP service placed a VVI/R ICD device without complications.
It was interogated ont he day of d/c and the patietn was provided with
written instructions from the EP service for d/c. She will follow-up
with the Dr. Dominguez on 10/30 as described. c ) Ischemia:
Patient with a history of CAD.
ED initially concerned for a myocardial infarction. She was ruled o
ut for an MI with negative cardiac enzymes x 3. Serial EKG's
were unchanged. We continued the patient on ASA , beta blocker , s
tatin and ARB. 2 )Heme: Ms. Kishimoto has a history of DVT , therapeutic
on coumadin at the time of admission. We did decreased her
dose while being treated with levofloxacin. In addition her coumadin
was held for her EP procedure. At the time of d/c she will be
resuming her regular dose of coumadin and should follow-up at her
usualy MMC lab to have her INR checked on Thursday 5/6 . 3 )ID: +UA on
admission treated for three days with levofloxacin. ( Last day was
11/19/4 ). Her cx grew citrobacter which was sensitive to levo. Repeat
UA was negative. 4 ) GI: Abdominal discomfort presumably due
to hepatic congestion. Abdominal CT showed no acute surgical process.
Abdominal pain was resolved with diuresis. She does have a
chronic elevated alk phos which may be related to her
sarcoid. 6 )Endocrine: Continued
levoxyl for the patient's hypothyroid. patient with IDDM. We decreased
her lantus dose from 50 u subcutaneously to 30 u subcutaneously on admission as orally
intake was initially low. patient can resume regular
insulin dose after discharge when she resumes her
outpatient eating habits. 7 ) General: physical therapy consulted to assist in
prevention deconditioning while in the hospital. VNA will evaluate need
for home physical therapy services.
ADDITIONAL COMMENTS: 1. Weight yourself daily , call your doctor when your weight increases
2. Follow-up with your Primary Care Physician in 2 weeks
3. Follow-up at the CHF clinic on Thursday 5/6 with Glinda Bancourt at
10:30am.
4. New Medication: ( Replaces lasix ) Torsemide 100 mg every morning and
100 mg orally everynight.
5. Follow-up with Dr. Delgardo ( 713 )399-6523 3/11 at 9:30 am for your ICD.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Keep appointments as outlined above.
2. Have your INR checked on Friday 5/6 .
3. Weight yourself daily. Call your primary care physician if your weight increases.
4. Follow written EP discharge instructions.
5. Nakjuscot St. , Nahjose News O , Florida 54885 VNA will resume services adn follow patient for CHF as well as
assess need for home physical therapy.
No dictated summary
ENTERED BY: GERZ , JEANNA L. , M.D. , M.P.H. ( ZC607 ) 9/14/04 @ 04:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 356
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
811368569 | PUO | 78610408 | | 6322478 | 8/25/2006 12:00:00 a.m. | epistaxis , chest pain | | DIS | Admission Date: 1/10/2006 Report Status:
Discharge Date: 4/29/2006
****** FINAL DISCHARGE ORDERS ******
CASTELLAW , DANNY 206-32-82-0
Louisiana
Service: MED
DISCHARGE PATIENT ON: 8/20/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
CALTRATE + D 1 TAB orally DAILY
CITALOPRAM 20 MG orally DAILY
DOXEPIN HCL 20 MG orally BEDTIME Starting STAT ( 9/21 )
FEXOFENADINE HCL 60 MG orally twice a day as needed Wheezing
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PROCTOSOL HC 2.5% ( HYDROCORTISONE 2.5% -RECTAL )
CREAM PR twice a day as needed Pain , Constipation
LISINOPRIL 2.5 MG orally DAILY
Alert overridden: Override added on 10/8/06 by
MUNDWILLER , MORA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: TRIAMTERENE & LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: mda
SKELAXIN ( METAXALONE ) 400-800 MG orally three times a day
as needed Pain , Other:muscle spasms
Number of Doses Required ( approximate ): 12
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/8/06 by ANDRAE , KEIKO
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
608470593 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: md aware
Previous override information:
Override added on 1/8/06 by ANDRAE , KEIKO
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: md aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 1/8/06 by ANDRAE , KEIKO
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: md aware
MAXZIDE-25 ( TRIAMTERENE 37.5MG/HYDROCHLOROTHI... )
1 TAB orally DAILY
Override Notice: Override added on 10/8/06 by
MUNDWILLER , MORA H. , M.D.
on order for LISINOPRIL orally ( ref # 584696322 )
POTENTIALLY SERIOUS INTERACTION: TRIAMTERENE & LISINOPRIL
Reason for override: mda Previous override information:
Override added on 1/8/06 by BORRIELLO , SACHIKO S. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
333564028 )
SERIOUS INTERACTION: TRIAMTERENE & POTASSIUM CHLORIDE
Reason for override: MD aware Previous override information:
Override added on 1/8/06 by ANDRAE , KEIKO
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
398793190 )
SERIOUS INTERACTION: TRIAMTERENE & POTASSIUM CHLORIDE
Reason for override: md aware Previous override information:
Override added on 1/8/06 by :
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & TRIAMTERENE
Reason for override: MD request Previous Alert overridden
Override added on 1/8/06 by ANDRAE , KEIKO
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & TRIAMTERENE
Reason for override: md aware
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: on MONDAY/WEDNESDAY/FRIDAY
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 1/8/06 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: MD aware Previous Override Notice
Override added on 1/8/06 by ANDRAE , KEIKO
on order for SIMVASTATIN orally ( ref # 113030097 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: md aware
COUMADIN ( WARFARIN SODIUM ) 2.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: every day Tues , Thursday , Sat , Sun
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 1/8/06 by ANDRAE , KEIKO
on order for SIMVASTATIN orally ( ref # 113030097 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: md aware
DIET: House / NAS / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please call Dr. Mangel office at ( 827 )406-4614 for the next available follow-up appointment ,
Arrange INR to be drawn on 2/7/06 with f/u INR's to be drawn every
14 days. INR's will be followed by Dr. Dunagan
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
rule out MI/epistaxis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
epistaxis , chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN hyperchol
history of TAH/BSO hx of PE 6/23 ( history of pulmonary embolism ) panic d/o ( panic
attacks ) depression ( depression )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHO
BRIEF RESUME OF HOSPITAL COURSE:
cc: nose bleeds , c/p
HPI: 58 year-old female with hx of 1 DVT/PE ( 1998 ) and HTN presenting
today with nosebleeds and c/p for past one day. patient statred having
nosebleeds yesterday morning. She noticed large clots coming
out of her nostrils. She had three more episodes since that time ,
two from her nose and one from her mouth/coughing up blood. patient also
felt some right sided c/p that radiated to her back and R-shoulder.
She denies palpitation sor sweating. patient felt c/p was 2/2 anxiety , a
feeling that she was going to die , and her nosebleeds. patient had a cold
one week prior and took Nyquil , , but denies antihistamine
use or dry nose. Denies recent trauma or syncope. SHe did , however ,
feel dizzy with the nosebleeding. patient has hx of nosebleeds in the
past history of cauterization.
ER: BP 201/109 with HR-86 , was given NTG and morphine , ASA; EKG
showed inverted T's in lateral leads
*************************************************
ROS: no sob , blurry vision , blackouts , hematuria/dysuria ,
hematochezia; pos bleeding gums and easy bruising since coumadin
tx
*************************************************
Allergies: nkda
*************************************************
Medications: Doxepin HCl 20mg every bedtime , Maxzide 37.5/25 every day , Coumadin 5 mg
orally mwf , 2.5 orally every day tues , thurs , sat , sun; Simvastatin 40 every bedtime , Calcium
carbonate 650 every day , skelaxin 400-800 three times a day , MVT every day , prilosec 20 every day ,
proctosol-hc cream as needed , allegra 60 as needed , citalopram 20
every day
**************************************************
PMH/PSH: end stage rigid pes planovalgus deformity , PE ( 1998 ) ,
hypercholesterolemia , htn , fibromyalgia , menorrhagia hx history of
hysterectomy and ex lap , mva ( 1999 ) with chest injury , gerd , obestiy ,
hx of 2 miscarriages
**************************************************
Soc hx: no smoking , etoh , or drugs; is a schoolteacher , lives with
husband and son
*************************************************
Fam hx: CHF , hypercoagulability ( daughter died of PE , and other
daughter had PE )
**************************************************
PE: VS:98.5/801/ 160/80 /18 / 98%( 2L )
Gen:nad
HEENT: perrla; petechiae on tip of tongue; nostrils with dry scabbing
but no active bleeding; throat noneryth; no throat
petechiae
Pulm: cta b/l; no c/r/r
CV: rrr; ns1/s2; no m/g/r; DP's 2+ b/l
ABD: soft , ntnd; pos bs
EXT: no c/c; mild non-pitting edema L>R lower
pretibial regions with scaling and tenderness; palpable cord in R ankle
Neuro: a and o; cn 2-12 intact; dtr's 2+ in ue/le
b/l; babinksy's downgoing b/l
Skin: scaling in pretibial areas; no obvious bruising
*************************************************
Labs: Tn less than 0.10 , d dimer 218; INR-2.6 , HCT 38.3
( MCV-88.9 )
*************************************************
Studies: EKG-T wave inversions in lateral leads
*************************************************
A/P: 58 year-old female with hx of DVT and menorrhagia history of hysterectomy
admitted for epistaxis and c/p.
1-Epistaxis: may be secondary to anti-coagulation vs underlying blood
dyscrasia vs allergic rhinitis vs recurrence of previous epistaxis
( possible AVM ) vs longstanding HTN vs tumor. patient had another episode
of nosebleed/clot while an inpatient , but no uncontrollable bleeding.
There was no need to tamponade patient's nares , however , in light of her hx
of menorrhagia , previous DVT/PE , and family hx of DVT's , it will be
important to assess for different causes of hyper/hypocoagulability in
this patient as an outpt ( platelet d/o , von willebrand's disorder , hemophilia ,
osler-weber-rendu d/o ). It will be also important to assess for possible
nasal AVM or ?tumor( low likelihood ). Coumadin was continued as patient has
high risk of forming DVT's. Her BP was also controlled with
HCTZ/triamterene and captopril to help control bleeding. patient's BP dropped
significantly in response to Lopressor and HR's were down in the 40's ,
thus her Lopressor was held. Patient needed captopril for high BP , thus
will D/C on lisinopril 2.5. She needs to be followed up for compliance and
understanding of importance of BP control , as patient was not compliant on
medications on presentation , had very high BP on presentation.
2-chest pain: ACS vs PE vs GERD vs panic attacks. As patient has several
cardiac risk factors , her CE's were cycled and she was ruled out for MI.
An Echo was obtained to assess for systolic dysfunction , but EF was 65% ,
no effusions were found , and there was only mild MR. patient does not have an
official DM dx , however , given her obesity , she is at high risk for
glucose intolerance , thus a HbA1C will need to be obtained as an
outpatient. patient also has a hx of hypercholesterolemia , and a fasting lipid
profile was obtained. It will be important that she take her statins
regularly. The patient had palpable cords and calf tenderness ( L>R ) , so LENI's
were obtained prior to d/c and these were negative for DVT , although it
was a poor study due to her size. patient also has a hx of GERD , thus the c/p
may have been 2/2 esophageal spasm or GERD as it radiated to the back and
right shoulder. patient denies having had spicy foods or nausea/vomiting before
the episodes , however. patient had chest tenderness along the sternum and L
ribcage , which may have contributed to her feeling of c/p. Finally , patient
seems to have a hx of anxiety , per herself and her daughters and as she
felt she was going to die and felt stressed during the nosebleeding , this
could have caused her c/p. Patient had a adenosine MIBI prior to discharge
and this was negative for any ischemic changes , and she was discharged to
home to follow-up with her primary care physician for further medical management of cardiac
risk factors.
3-Fibromyalgia: patient was asymptomatic , but we continued her home regimen
and pain control.
4-FEN: IVF were avoided given high BP on admission and K and Mag were
repleted as needed. She should continue a low choles/fat , and no salt
added diet.
FULL CODE
ADDITIONAL COMMENTS: Your blood pressure was very high on admission but was easily controlled
with blood pressure medication. This was probably due to not using your
blood pressure medications regularly. It is crucial that you take your
blood pressure medications regularly as prescribed as uncontrolled high
blood pressure can lead to heart disease , kidney disease , and eye
disease. You must also watch your diet and eat low cholesterol , low
fat foods and no added sodium , as this can worsen your blood pressure
or even lead to heart failure. You must also continue your coumadin
regularly as prescribed as you have a high risk of forming blood clots.
Please come to the ED if you have continued uncontrolled nose bleeds ,
severe uncontrollable headaches , fainting spells , chest pain , or
shortness of breath.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow-up HGBA1C , BP control , lipid panel , and chest pain with primary care physician as
an outpatient.
2. We recommend that the patient have a pharmacologic stress test as an
outpatient to evaluate for possible areas of potential cardiac ischemia.
No dictated summary
ENTERED BY: BORRIELLO , SACHIKO S. , M.D. ( EP65 ) 8/20/06 @ 04:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 357
| Target |
Ast |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
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- |
N |
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N |
860080645 | PUO | 00103112 | | 988742 | 3/23/2000 12:00:00 a.m. | ACUTE PULMONARY EDEMA | Signed | DIS | Admission Date: 2/12/2000 Report Status: Signed
Discharge Date: 6/3/2000
PRINCIPAL DIAGNOSIS: FLASH PULMONARY EDEMA.
SECONDARY DIAGNOSIS: 1. TYPE II DIABETES X15 YEARS.
2. HYPERTENSION.
3. HYPERCHOLESTEROLEMIA.
4. LEFT CAROTID ENDARTERECTOMY.
5. HYPOTHYROIDISM.
6. CORONARY ARTERY DISEASE.
7. SILENT INFERIOR MYOCARDIAL INFARCTION IN
1990.
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old female
with multiple medical problems ,
including coronary artery disease , status post stent to the left
circumflex in 1999 , silent MI in 1990 , hypertension , type II
diabetes , and hypercholesterolemia , who presented to an outside
hospital with acute onset of shortness of breath that occurred
while the patient was watching T.V. This dyspnea was associated
with chest heaviness , but the patient denies nausea , diaphoresis ,
or radiation. The patient reports similar symptoms when she
presented in 4/5 to an outside hospitalization and was ultimately
stented for a left circumflex lesion. On the day of admit , the
patient was seen at the Clare'sry Hwall Medical Center , where she was
apparently in respiratory distress , and treated with oxygen ,
nitroglycerin , aspirin , Lasix , CPAP , and morphine. Chest x-ray , by
report , showed CHF. The patient improved with diuresis and was
admitted on a R/O protocol for flash pulmonary edema. Her
troponin-I and initial two CKs were flat. She was then transferred
here for cardiac cath , as cardiac ischemia was the suspected
culprit for her presentation. The patient states she sleeps with
one pillow. She has no PND or palpitations. She further denies
fevers , chills , constipation , nausea , vomiting , cough , bright red
blood per rectum , melena , or dysuria. The patient denies diet or
medicine indiscretion. The patient has had no further chest pain
or shortness of breath since the day she was admitted to the
outside hospital.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient has a mother , who died of a myocardial
infarction in her 90s.
MEDICATIONS: Premarin 0.625 mg orally every day; Provera 2.5 mg orally
every day; ECASA 325 mg orally every day; atenolol 50 mg orally
every day; lisinopril 10 mg orally every day; glyburide 10 mg orally every day;
metformin 1000 mg orally twice a day; Prozac 20 mg orally every day; Levoxyl
0.1 mg orally every day; Zocor 10 mg orally every day; Lasix 20 mg x1 orally every day
( The patient does not take Lasix on a regular basis at home. );
Nitropaste 1' every 6 hours; fluocinonide 0.5% cream applied twice a day
SOCIAL HISTORY: The patient denies tobacco use for the past 13
years. She has a 60 pack year history of tobacco
use. ( Three packs per day x20 years ). The patient reports rare
alcohol use and denies any drug use.
PHYSICAL EXAMINATION: VITAL SIGNS: Temp 98.6 , heart rate 74 , BP
122/79 , respiratory rate 20 , satting 94% on
room air. GENERAL: The patient is alert and oriented x3 , pleasant
female sitting in the bed in no apparent distress. HEENT: PERRL.
The patient has dentures. No lesions in her pharynx. NECK: JVD
approximately 7 cm. HEART: II/VI systolic ejection murmur heard
best at the base. No S3 , S4. LUNGS: Bibasilar crackles.
ABDOMEN: Obese , positive bowel sounds , soft , non-tender ,
non-distended. EXTREMITIES: No clubbing , cyanosis , or edema. Her
feet skin is intact. She has bilateral bruits in her groins. She
has a 1+ dorsalis pedis pulse on the right. No dorsalis pedis
pulse was appreciated on the left. NEURO: Non-focal.
LABORATORY DATA: Na 136 , K 4.3 , Cl 100 , bicarb 25 , BUN 36 ,
creatinine 1.5 , glucose 162. ALT 6 , AST 10 , CK
45 , alk phos 40 , T. bili 0.3 , D. bili 0.1 , albumin 3.6 , mag 1.7 ,
troponin-I 0.05. White count 8.4 , hematocrit 31.3 , platelets 298 ,
MCV 88 , RDW 13. physical therapy 11.6 , INR 0.9 , PTT 25.1. Urinalysis showed 1+
protein , 3+ blood , 2+ leukocyte esterase , negative nitrites , 35-40
white cells , 80-85 red cells , 1+ bacteria , 1+ epi , no casts. EKG ,
on admission , showed a normal sinus rhythm at 70 , LVH with probable
strain laterally. No significant changes from an EKG done on
1/25/99 . Of note , an EKG done at the outside hospital on 2/10
showed inverted Ts in I , L , and V2-V6.
HOSPITAL COURSE: The patient was admitted to this hospital with a
recent episode of flash pulmonary edema. When
this had happened previously , cardiac catheterization had revealed
an occluded left circumflex lesion that was stented. There were ,
therefore , concerns that the patient may have re-occlusion either
of the stent or of one of her other vessels. Her metformin was
held. She was given pre-cath hydration fluids , and then she
underwent cardiac catheterization. The results of this study were
as follows: The patient had a 40% ostial LAD lesion and an 80% mid
D1 lesion , both of which showed no change from her prior
catheterization. The patient left circumflex stent was widely
patent. The patient's RCA was noted to be occluded and was filling
with collaterals from left to right. At the time of the
catheterization , the patient's renal arteries are also evaluated.
There was a question of an ostial left renal artery stenosis.
However , no other renal disease was noted.
Because the patient's catheterization was unchanged from a prior
study , it was unclear as to the significance of her D1 lesion. For
this reason , the patient underwent an ETT MIBI , the results of
which are as follows: The patient underwent a modified Bruce ,
heart rate of 66% of maximum predicted heart rate. She exercised
for 4 minutes 30 seconds and stopped secondary to dyspnea. She had
no new EKG changes and no chest pain. The MIBI portion of the test
showed a nontransmural anterior and inferior MI , with peri-infarct
ischemia involving 3-5 segments. At the time of this dictation , it
is felt that the patient's CAD is an unlikely explanation for her
presentation. Dr. Journeay will review the MIBI results and decide
whether a repeat catheterization with PCI is warranted. The most
likely explanation is that the patient has diastolic dysfunction
given her age and history of diabetes. Dr. Raabe is interested in
enrolling her in a study that evaluates angiotensin receptor
blockers in treatment of this disorder.
The patient had an echo during this hospitalization. The left
ventricle is mildly dilated with an EF of 50%. The patient has
apical , septal , and lateral hypokinesis. Her right ventricle size
and function is normal. The patient also has a dilated left atrium
with mild mitral regurgitation.
DISCHARGE FOLLOW-UP: She is to follow-up with her primary care
physician in two weeks and her primary
cardiologist in four weeks.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Please note that an addendum to this discharge summary will be
added with the patient's discharge medications.
Dictated By: ANGELIQUE ROMACK , M.D. TL25
Attending: DENISHA H. MCRORIE , M.D. BM3 FO865/9172
Batch: 76345 Index No. NXYV0L7IHF D: 4/11
T: 2/7
CC: 1. DENISHA H. MCRORIE , M.D.
Document id: 358
| Target |
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DM |
Gs |
GER |
Gou |
HC |
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876052391 | PUO | 13862165 | | 166428 | 11/1/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/29/1999 Report Status: Signed
Discharge Date: 4/18/1999
FINAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: This is a 70 year old female with a
history of coronary artery disease ,
hypertension , type II diabetes mellitus , and peripheral vascular
disease who is status post a PTCA/stent of obtuse marginal 1 in
July of 1990 which restenosed and required rotablation and
restenting in January of 1998 who presents now with unstable angina.
The patient had increasing chest pain over the past month
progressing to pain at rest. The patient presented with substernal
chest pain to the emergency room department with a blood pressure
of 230/90. The patient's blood pressure was controlled with intravenous
Lopressor and the patient was admitted for rule out myocardial
infarction. The patient underwent cardiac catheterization on
5/18/99 which revealed the following: A stent restenosis of left
circumflex artery , a 60 percent left anterior descending artery
stenosis , a 70 percent diagonal ostial stenosis , a 40 percent
ostial right coronary artery stenosis , and 95 percent ostial
posterior descending artery stenosis. No myocardial infarction was
noted and ejection fraction was approximately 50 percent
calculated. The patient was subsequently scheduled for coronary
artery bypass graft.
PAST MEDICAL HISTORY: Coronary artery disease. Hypertension.
Congestive heart failure. Type II diabetes
mellitus requiring insulin. Peripheral vascular disease.
Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Left lower extremity revascularization.
PHYSICAL EXAMINATION: chinese-speaking female. HEENT:
Unremarkable. Carotid pulses 1 plus
bilaterally with no bruits. Lungs clear to auscultation
bilaterally. Heart: Regular rate and rhythm. No murmurs.
Abdomen: Soft , nontender , nondistended. Firm to palpation in both
lower quadrants in area of lower midline scar. Extremities:
Tenderness to palpation in bilateral lower extremities which was
diffuse and nonspecific. Peripheral pulses revealed 1 plus
dorsalis pedis pulse and 1 plus posterior tibial pulse on right
lower extremity and 2 plus dorsalis pedis pulse and 2 plus
posterior tibial pulse on left lower extremity with 1 plus edema
bilaterally. Neurologic: The patient was conscious and alert and
oriented times three with no deficits.
LABORATORY DATA: Sodium 140 , potassium 4.7 , BUN 18 , creatinine
1.0 , glucose 205. WBC 12 , hematocrit 37 , INR
0.1. ECG revealed normal sinus rhythm with nonspecific ST-T wave
changes.
MEDICATIONS: Aspirin 325 mg every day , Atenolol 125 mg orally twice a day ,
Captopril 100 mg orally three times a day , Colace , Axid 150 mg
orally twice a day , Amlodipine 10 mg orally every day , Imdur 120 mg orally twice a day ,
and insulin NPH 22 units every day before noon and regular 10 units every day before noon
ALLERGIES: Penicillin- rash.
HOSPITAL COURSE: On 8/17/99 the patient was brought to the
operating room and underwent a coronary artery
bypass graft times three with a left internal mammary artery to the
left anterior descending artery and saphenous vein graft to obtuse
marginal and saphenous vein graft to posterior descending artery.
After surgery the patient was transferred to the Intensive Care
Unit in stable condition. On postoperative day #1 the patient was
extubated without incident.
On postoperative day #2 the patient experienced a period of atrial
fibrillation with a rapid ventricular response and rates in the
150s. The patient was treated with intravenous Lopressor and Diltiazem drip
at 10 mg/heart rate The patient subsequently converted spontaneously to
normal sinus rhythm. Postoperatively the patient continued to
experience hypertension with systolic blood pressures ranging from
160s to 190s. The patient was started back on Lopressor and
Captopril and gradually increased to preoperative doses. The
patient was also started back on Amlodipine for further blood
pressure control. The patient continued to experience brief
episodes of atrial fibrillation with spontaneous conversion to
normal sinus rhythm. The patient was followed by her cardiologist
postoperatively , Dr. Agliam . The patient was started on
anticoagulation with Coumadin. The patient's atrial fibrillation
continued to decrease in frequency and duration and , at the time of
discharge , the patient had been in normal sinus rhythm for greater
than 24 hours. The patient was seen by physical therapy service
and it was felt that the patient would benefit from rehabilitation.
The patient is scheduled to be discharged on postoperative day #8
to rehabilitation facility in stable condition with all wounds
clean and dry.
On day of discharge her sodium is 137 , potassium 3.9 , BUN 16 ,
creatinine 0.9 , glucose 163. WBC 16.7 , hematocrit 31 , platelet
count 340 , INR 2.3.
DISPOSITION: DISCHARGE MEDICATIONS: Atenolol 125 mg orally twice a day ,
Captopril 100 mg orally three times a day , Colace 100 mg orally
three times a day , Lasix 40 mg orally every day , insulin 22 units NPH subcutaneously every day before noon
and 10 units regular subcutaneously every day before noon , CZI regular insulin sliding
scale , Percocet 1 to 2 tablets orally q3 - 4h as needed pain , Zantac 150
mg orally twice a day , Coumadin dosed to INR of 2 to 2.5 , and Amlodipine 5
mg orally every day FOLLOWUP: The patient is to follow-up in six weeks
with cardiac surgeon , Dr. Huitron , with primary care physician , Dr.
Squiers , in one to two weeks , and with cardiologist , Dr. Agliam ,
in one to two weeks. The patient was discharged to the Old Artontho Yale-fran Medical Center .
Dictated By: DESIRAE MARCOTT , P.A.
Attending: GAYLENE G. FANIEL , M.D. GD65 QH655/5952
Batch: 6098 Index No. ZYPH2815XQ D: 10/8/99
T: 10/8/99
QF9
Document id: 359
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
VI |
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767073610 | PUO | 93027999 | | 7769134 | 10/16/2004 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/16/2004 Report Status: Signed
Discharge Date: 4/3/2004
ATTENDING: CHANELLE XOCHITL COLLICA M.D.
PRINCIPAL DIAGNOSES: Dizziness , blurred vision.
LIST OF OTHER DIAGNOSES: Congestive heart failure , coronary
artery disease , diabetes mellitus , hypertension , and glaucoma.
HISTORY OF PRESENT ILLNESS: This patient is a 56-year-old man
with known coronary disease , congestive heart failure , and
diabetes mellitus , presenting with an episode of weakness and
blurry vision. The patient had a recent admission at Pagham University Of 7/20/04 through 10/17/04 with malignant
hypertension and CHF. At that time , he had 3+ lower extremity
edema , a BNP of 1374 , and an ejection fraction of 20%. On echo ,
he was diuresed and lost 10 kg of fluid and was discharged to
follow up with the CHF Service. Since that time , he has been
maintained on 60 mg orally of Lasix , recently increased to 60 mg
twice a day , also with some recent increases in his Toprol XL and
amlodipine. The patient presented to the emergency department on
the day of admission with an episode of weakness and blurred
vision. He states that he was at work helping set up for a party
and he became somewhat week. His vision blurred and this
resolved when he sat down to rest. He reports having had one
similar episode approximately one month ago , for which he did not
seek medical care. He had no chest pain , no palpitations , no
shortness of breath , no fever or chills at home and in the days
prior to the episode had had good appetite and no complaints of
dysuria.
In the emergency department , his vitals were temperature 97.1 ,
pulse 70 , and blood pressure 147/68. The patient was
comfortable. An EKG revealed a question of ST changes and it was
noted that his creatinine was increased to 2.1 from his baseline
of 1.4 and then his blood glucose was 307. He was admitted in
order to rule out myocardial infarction.
PAST MEDICAL HISTORY: Diabetes , coronary artery disease ,
congestive heart failure , hypertension , cognitive deficits , and
glaucoma.
MEDICATIONS AT THE TIME OF ADMISSION: Amlodipine 7.5 mg ,
Timoptic 0.5 one drop each eye every day , aspirin 81 mg every day , Imdur 120 mg
every day , Zestril 50 mg every day , Toprol XL 150 mg every day , Lasix 60 mg
twice a day , glipizide XL 10 mg every day , and atorvastatin 40 mg every day
SOCIAL HISTORY: Notable for the fact that the patient lives with
his mother and works at Pagham University Of Cafeteria.
PHYSICAL EXAMINATION ON ADMISSION: Notable for vitals as above.
The patient's jugular venous pulsations were visible at less than
10 cm. His heart was regular with S1 , S2 , S4 , and no murmurs.
His lungs had bibasilar crackles , right greater than left. His
abdomen was soft , nontender. No hepatosplenomegaly. His
extremities were notable for no edema. Scattered excoriations
with quite long nails.
LABS AT ADMISSION: Notable for a potassium of 5.3 , blood glucose
of 307 , creatinine of 2.1 , white blood count of 7 , and hematocrit
of 42. BNP was 118. EKG showed normal sinus rhythm at 62 , left
atrial enlargement , left ventricular hypertrophy , and T-wave
inversions with ST changes in I , II , and V1 through V5. Chest
x-ray showed stable cardiomegaly.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: The patient ruled out for MI. He had no
complaints of chest pain at any time during his admission.
Initially , his Lasix and lisinopril were held in the context of
concern over possible hypotension as an etiology of his episode
of weakness. However , these were restarted on the second
hospital day at slightly diminished doses compared to his
baseline.
2. Renal: The patient's creatinine improved and at the time of
discharge , it was back to his baseline of 1.5.
3. Endocrine: The patient's diabetes mellitus is very poorly
controlled. At present , his hemoglobin A1c measured at admission
was 11.4 indicating an average blood glucose level of greater
than 300. While in-house , he continued to receive his baseline
dose of glipizide XL , however , he was also covered with regular
insulin on a sliding scale. The patient has no prior history of
insulin use at home. After consideration of the risks and
benefits of other orally agents including the high nature of his
hemoglobin A1c , it was decided that insulin therapy would be
necessary for adequate control of his diabetes. Various concern
over the patient's ability to successfully manage insulin therapy
at home and so , a simply regimen was selected. To begin with , he
was discharged on standing dose of 6 units of NPH in the morning
and 6 units at bedtime to be given via a prefilled disposable
insulin pen that will involve no need to draw up the medication
himself , but simply to select the correct dose and give the
injection.
4. Neuro: The patient's episode of blurred vision did not
recur. It is possible that his hyperglycemia accounted for this.
He did have an ophthalmologic exam one week prior to admission
that revealed no problems. He had no other neurologic or visual
symptoms during his stay in the hospital.
5. Fluid , electrolytes , and nutrition: The patient was somewhat
hyperkalemic at admission with a potassium of 5.3. This resolved
with a single dose of Kayexalate and his potassium returned to
normal levels. The patient was discharged in stable condition on
6/19/04 . To receive close followup , he will have visiting
nurses' visits including two visits the day after discharge in
order to assist with insulin management and he has an appointment
with his primary care physician , Dr. Contessa Zebley , the day after
discharge on 5/6/04 .
MEDICATIONS AT DISCHARGE: Aspirin 81 mg orally every day , Lasix 40 mg
orally twice a day , lisinopril 40 mg orally every day , Timoptic 0.5% one drop
each eye twice a day , Norvasc 5 mg orally every day , Imdur 120 mg orally every day ,
glipizide XL 10 mg orally every day , atorvastatin 40 mg orally every day ,
Toprol XL 150 mg orally every day , NPH insulin 6 units subcutaneously
every day before noon before breakfast and every bedtime
eScription document: 7-4202417 ISSten Tel
CC: Contessa Zebley M.D.
Dictated By: CHAIX , TRISH
Attending: COLLICA , CHANELLE XOCHITL
Dictation ID 0901523
D: 1/5/04
T: 10/11/04
Document id: 360
| Target |
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GER |
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PVD |
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997044127 | PUO | 54837690 | | 8129759 | 5/20/2007 12:00:00 a.m. | epigastric pain | | DIS | Admission Date: 4/8/2007 Report Status:
Discharge Date: 1/26/2007
****** FINAL DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
Ert Sco Ra
Service: MED
DISCHARGE PATIENT ON: 11/17/07 AT 02:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCAUSLAND , LACY LEOTA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
MAALOX/BEN/LIDO 1:1:1 15 MILLILITERS SWISH & SWALLOW three times a day
ACETYLSALICYLIC ACID 81 MG orally DAILY
ATENOLOL 25 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
Starting Today ( 4/25 )
LIDODERM 5% PATCH ( LIDOCAINE 5% PATCH ) 1 EA TP DAILY
DITROPAN XL ( OXYBUTYNIN CHLORIDE XL ) 5 MG orally DAILY
Number of Doses Required ( approximate ): 10
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Lorretta Cridge ( GI ) 5/28/07 at 11 am ,
Dr. Karina Winterfeldt ( Rheumatology ) 4/3/07 at 12:40 pm ,
Dr. Ginny Daurizio ( primary care physician ) 9/9/07 at 2:50 pm ,
Spine MRI 8/14/07 at 8 am ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
epigastric pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
epigastric pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1
morbid obesity ( obesity ) obstructive sleep apnea ( sleep apnea )
psoriasis ( psoriasis ) history of gastric bypass 6/22 ( history of gastric bypass
surgery ) normal cardiac cath 1/29 ( ) borderline ETT
11/21 history of chole ( history of cholecystectomy ) history of exudative pleural effusion
( history of pleural effusion ) history of splenic
infarct empty sella syndrome ( empty sella syndrome ) chronic LBP with
several herniated discs ( ) chronic HAs ( )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
EGD by Dr. Victoria Quirarte 2/18/07
BRIEF RESUME OF HOSPITAL COURSE:
CC: Abd Pain
HPI: 42F with history of morbid obesity history of gastric bypass 2001 , recent
pouch reduction 6/10 , anxiety , atypical CP with negative MIBI 1/13 ,
narcotic seeking behaviour who presents with epigastric pain x 1 wk. She
was in her USOH until 7/8 when she began to have diffuse leg weakness ,
diffuse pain , chills/night sweats but no fevers. 1 week prior to
admission she seveloped L-sided epigastric pain , worsened after eating ,
and later developed liquidy stools , initially black , then cleared to
yellow. Of note , she had a similar episode of abdominal pain in 6/19 with
neg abd ct and egd.
In PUO ED , the patient was afebrile with stable vital signs , normal
amylase/lipase , lfts , neg hcg , esr 74 , ekg with long QTc ( old ) LVH ,
abdominal ct was negative. She was admitted for ROMI , abdominal pain
control and evaluation of diarrhea.
*********
PMH: history of appy , history of ccy , htn , osa , anxiety , depression , atypical cp with
neg cath 2001 , neg mibi 1/13 ,
history of Roux-en-Y gastric bypass as above , fe def anemia ,
low back pain , hx/o narc seeking
MEDS: Prilosec 40 , atenolol 100 , klonpin 1 three times a day , ditropan xl 5 every day , senna ,
simethicone , percocet 2tab qAM--??? KTDUOO notes say off narcotics log for
positive cocaine on tox screen
abuse
ALL: Motrin
Shx: cocaine use hx , denies etoh and tob
*********
ADMIT PHYSICAL
97 86 133/76 14 100%RA
General: Mild distress , tearful , obese
Neck supple , no masses
Lungs: CTAb
Heart: RRR , nl S1 s2 , no m/r/g
Abdomen: Obese , soft , mild epigastric ttp s rebound/guard
Extremeities: WWP , neg c/c/e
**********
DATA: Labs - Chem7 , Biomarkers , LFTs , Amy/Lip all normal , WBC 9.8 ,
Hct 42 , Plt 279 , ESR 74. U/A - tr prot , 1+ket else neg.
EKG - NSR 81 , prlong QTc 509 , min LVH , pseudonrl T-wave in
III.
CXR: No acute cardiopulmonary process or interval change since prior
exam
ABD CT: 1. Status post cholecystectomy with persistent dilatation the of
the common bile duct , similar in appearance to the prior exam.
An ultrasound examination may be considered for further
evaluation as clinically indicated.
2. Prior Roux-en-Y gastric bypass.
3. Colonic diverticulosis without acute inflammatory changes.
EGD 4/28/07: 1. Normal gastric pouch with intact anastomosis that is 2cm
in diameter.
2. Normal roux limb down to 80cm.
3. there were no findings to explain the patient's abdominal pain.
***********
ASSESSMENT: 42F c multiple encounters with medical system for evaluation
of abdominal pain/ atypical cp admitted for workup of these issues.
1.GI: The differential diagnosis of the patient's abdominal
pain included PUD and enteritis/colitis. She was placed on twice a day
PPI and Maalox/Benadryl/Lidocaine for possible GERD pain. Narcotics
and anxiolytics were held for previous history of narcotic seeking behavior ,
and the patient was agreeable. Her loose stools resolved , with no sample
available for stool culture , fecal leukocytes , fecal fat , C diff or
Guaiac. EGD showed normal gastric pouch and no evidence for ulcers or
other pathology that would explain her pain. She was discharged on her
home PPI.
2.CV: i- The patient has had extensive workup for atypical chest pain in
the past. She was ruled out for MI with neg cardiac biomarkers x 3 , and
was continued on her home beta blocker.
p- The patient had low blood pressures with SBP in the 80's on 7/18 ,
increased to 90's to 100's with fluids. Low blood pressure was possibly
due to fluid depletion from diarrhea and high atenolol dose. Atenolol
100 mg was converted to Lopressor 12.5 mg every 6 hours with SBP in the 120's. She
will be discharged on atenolol 25 mg , to be titrated up by her primary care physician as
needed.
r- The patient had prolonged qtc of 509 ms ( slightly up from up from
480's in the past ) , with no obvious medications that would contribute.
No QT prolonging medications were given.
3. HEME: The patient has long standing anemia with baseline Hct in
mid-30's. Admission Hct was 42 , decreased to 34.9 with intravenous hydration and
remained stable ~35 thereafter. There was no evidence of GI bleed on EGD.
4.RHEUM: The patient has low back pain , with diffuse body pain and ESR
74. PMR is on the differential , and she will follow-up with Rheumatology
as an outpatient.
FULL CODE
ADDITIONAL COMMENTS: -continue home medication regimen except lower dose of atenolol from 100
mg daily to 25 mg daily
-call your doctor with any fevers , chills , bloody or black stool , or
other worsening symptoms
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-titrate up BP medications as necessary
-Rheum follow up for LBP , muscle aches as ESR 74
-GI follow up for abdominal pain and history of bariatric surgery
No dictated summary
ENTERED BY: RODERMAN , LIZETH K. , M.D. , PH.D. ( TF958 ) 11/17/07 @ 04:55 PM
****** END OF DISCHARGE ORDERS ******
Document id: 361
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
- |
N |
N |
N |
N |
N |
Y |
N |
N |
Y |
Y |
N |
N |
997044127 | PUO | 54837690 | | 768311 | 1/2/2001 12:00:00 a.m. | Non-cardiac chest pain | | DIS | Admission Date: 5/20/2001 Report Status:
Discharge Date: 9/22/2001
****** DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
A Sing Scond
Service: CAR
DISCHARGE PATIENT ON: 2/7/01 AT 12:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DOCIMO , STEFFANIE TENNILLE , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
KLONOPIN ( CLONAZEPAM ) 1 MG orally three times a day
Starting Today ( 11/10 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
ZESTRIL ( LISINOPRIL ) 10 MG orally every day
Override Notice: Override added on 2/24/01 by GILDNER , IDA W NORENE , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 02564269 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware , will check K daily
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
NIFEREX TABLET 50 MG orally twice a day
Number of Doses Required ( approximate ): 30
ESOMEPRAZOLE 20 MG orally every day
PERCOCET 1-2 TAB orally Q4-6H as needed pain
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Selia 1 week ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1
morbid obesity ( obesity ) obstructive sleep apnea ( sleep apnea )
psoriasis ( psoriasis )
OPERATIONS AND PROCEDURES:
Cardiac catherization
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
37 year-old woman with CRFs of HTN , prior smoking , positive family hx.
( father with CABG in 50s ) and morbid obesity , history of atypical CP , who
presents with CP. PMH also notable for history of gastric bypass with
80lb weight loss and anxiety with panic/depression. She reports a
history of recurrent CP ~ 1/month x 1 year partially responsive to sublingual
NTG. Pain is now coming more frequently ~2 times/month. MIBI 6/22 with
fixed inf defect , EF 37%. Admitted to PUO 5/10/01 with CP and facial
numbness , red/o for MI , cath deferred at that time. Repeat evaluation
of EF by ECHO showed EF 55-60%. Discharged 5/2 , pain free until
morning of admission when she had onset of left sided CP which she
describes as tightness with radiation to arm while brushing her teeth.
Accompanied by racing heart , dyspnea. Somewhat better with sublingual NTG x
3. Completely allevaited by nitrospray. In ED pain free , no EKG
changes , CK 121 , TnI 0.0. Patient admitted ruled out for MI. Given past
history of recurrent admissions team , patient , and her primary care physician felt that
cardaic catherization was inevitable. She had a cardaic cath via
right radial artery which showed clean coronary arteries. c/b
thumb numbness / tingling but good motion. Patient was discharged to
f/u with her primary care physician to determine the cause of her CP. Of note , patient has
also c/o intermittent diarrhea for several weeks. in house had 2
episodes of watery brown diarrhea trace guaiac positive. fecal leuks ,
cdiff , ova and parasites pending. will f/u with urgent care kernan to dautedi university of of appt
this wk for lab results and f/u of right thumb.
ADDITIONAL COMMENTS: Please call Dr. Selia if you have fevers , chills , cough , shortness of
breath , chest pain , nausea and vomitting. Please follow-up with Dr.
Selia in 1 week.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BINGMAN , MASON D. , M.D. ( BB06 ) 2/7/01 @ 01:51 PM
****** END OF DISCHARGE ORDERS ******
Document id: 362
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
N |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
- |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
N |
Y |
N |
N |
574344071 | PUO | 47507419 | | 0432850 | 4/24/2007 12:00:00 a.m. | chf | | DIS | Admission Date: 2/22/2007 Report Status:
Discharge Date: 9/25/2007
****** FINAL DISCHARGE ORDERS ******
DOIRON , ALONA 177-88-12-3
Anhan St , Che Oak Tonlepo , Vermont 36186
Service: CAR
DISCHARGE PATIENT ON: 8/3/07 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PETTINGER , DOUGLASS N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Override Notice: Override added on 10/12/07 by KOZIKOWSKI , LAURA J B. , M.D. on order for COUMADIN orally ( ref # 618647269 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 2/4/07 by KOZIKOWSKI , LAURA J. , M.D.
on order for COUMADIN orally ( ref # 325576030 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ATENOLOL 37.5 MG orally DAILY
CAPTOPRIL 12.5 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Override Notice: Override added on 4/28/07 by BEOUGHER , GEORGINE J TRACIE ALLA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
502045309 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
CELEXA ( CITALOPRAM ) 40 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
DIGOXIN 0.125 MG orally DAILY
EPLERENONE 25 MG orally DAILY
Override Notice: Override added on 4/28/07 by BEOUGHER , GEORGINE J TRACIE ALLA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
502045309 )
SERIOUS INTERACTION: EPLERENONE & POTASSIUM CHLORIDE
Reason for override: aware
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 60 MG orally twice a day
Starting AT 5:00 PM ( 1/6 )
Alert overridden: Override added on 10/12/07 by KOZIKOWSKI , LAURA J B. , M.D. on order for LASIX orally ( ref # 436977934 )
patient has a POSSIBLE allergy to TAMSULOSIN; reaction is
Genital ache. Reason for override: aware
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
LORAZEPAM 0.5 MG orally DAILY as needed Anxiety
LOVASTATIN 40 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 10/12/07 by KOZIKOWSKI , LAURA J B. , M.D. on order for COUMADIN orally ( ref # 618647269 )
POTENTIALLY SERIOUS INTERACTION: LOVASTATIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 2/4/07 by KOZIKOWSKI , LAURA J. , M.D.
on order for COUMADIN orally ( ref # 325576030 )
POTENTIALLY SERIOUS INTERACTION: LOVASTATIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 8/22/07 by KOZIKOWSKI , LAURA J. , M.D.
on order for LOVASTATIN orally ( ref # 798491567 )
patient has a PROBABLE allergy to SIMVASTATIN; reaction is leg
pain. Reason for override: home med
Previous Alert overridden
Override added on 8/22/07 by KOZIKOWSKI , LAURA J. , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
LOVASTATIN Reason for override: aware
Number of Doses Required ( approximate ): 7
OMEPRAZOLE 20 MG orally DAILY
TEMAZEPAM 15-30 MG orally BEDTIME as needed Insomnia
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 8/22/07 by KOZIKOWSKI , LAURA J B. , M.D. on order for LOVASTATIN orally ( ref # 798491567 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
LOVASTATIN Reason for override: aware
COSOPT ( TIMOLOL/DORZOLAMIDE ) 1 DROP each eye twice a day
Alert overridden: Override added on 8/22/07 by KOZIKOWSKI , LAURA J B. , M.D. on order for COSOPT each eye ( ref # 435600053 )
patient has a POSSIBLE allergy to TAMSULOSIN; reaction is
Genital ache. Reason for override: aware , home med
COUMADIN ( WARFARIN SODIUM ) 1 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Please take 1mg every day except for monday
when you take
2mg , unless your coumadin clinic at the IPH tells you
otherwise. Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/12/07 by KOZIKOWSKI , LAURA J B. , M.D. POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LOVASTATIN & WARFARIN
Reason for override: aware
TRAVATAN 1 DROP each eye BEDTIME Instructions: each eye. thanks.
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Hamblet 6/12 @ 10 ,
Dr. Stautz , please call 575-803-4363 for earlier appointment if able. 2/23 @ 3:40 ,
Arrange INR to be drawn on 5/28/07 with f/u INR's to be drawn every
7 days. INR's will be followed by IPH coumadin clinic
ALLERGY: PREDNISONE , Penicillins , TAMSULOSIN , SIMVASTATIN ,
SPIRONOLACTONE , Fam Hx malignant hyperthermia
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
kidney stone cardiomyopathy-ef25%
degenerative arthritis blurred vision sleep apnea arrhythmias
prior MI spinal stenosis ( spinal stenosis ) barrett's esophagus
( barrett's esophagus ) peripheral neuropathy ( peripheral
neuropathy ) glaucoma ( glaucoma )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
RHC/LHC
BRIEF RESUME OF HOSPITAL COURSE:
primary care physician: Donehoo , Filomena
CARDS: Brittaney Nicki Hamblet CC:SOB
HPI:78M with CAD S/ P stents ( Cypher to LM and LAD in 10/25 ) , ischemic
CM with EF 15-20% , history of AV node ablation 4/3 with BiV pacer , DM , HTN ,
MGUS , hx of syncope due to orthostasis/dehydration presenting w.
SOB. Usually does 30 mins on bike , now having dyspnea with 20 mins ,
stopping after 1 flight of stairs , used to do 2 flights. Sx
progressively worsening over past 1-2 mos. Weight 195 lbs , got
extra lasix , now 190 lb ( he says baseline ) , but has not noticed
difference in sx. +CP 1 week ago while on treadmill , stopped with
resting. +dizzy and lightheadedness ( chronic ) , no orthopena , PND , no
edema. No change in diet. Taking meds.
***
PMHx:ischemic CM , EF 15%-20% ( dry wt per D/C summary 185.2 lb ) , hx
Afib and VT , history of ICD 7/1 , BiV 9/18 , AV node ablation 11/26 , CAD
history of IMI 1982 stents to LM and LAD 10/25 as not candidate for CABG ,
high cholesterol , sleep apnea , DJD , Barrett's esophagus , Glaucoma ,
Graves disease , Diverticulitis , Hypothyroidism , secondary to
amiodarone toxicity , Peripheral neuropathy , restless legs , Spinal
stenosis.
ALL:Prednisone->soreness , PCN->flushing ,
Tamsulosin->genital ache , zocor->leg pain , spironolactone->gynecomastia.
Exam: 95.7 85 98/70 absent overshoot on valsalva
GEN: well-appearing CV: distant HS , non-palpable PMI , diminished carotid
pulses no bruits , JVP 8 cm LUNGS: CTAB Abd: benign , non-pulsatile
liver Ext: cool , 2+physical therapy B/L , no edema Neuro: no facial droop ,
non-focal
***
EKG: CXR:neg
Stress Echo 8/17/06: 66% MPHR , RPP 12000 BPM , stopped for fatigue ,
dyspnea. LV enlarged. EF 15-20%. +RWMA , mid and distal ant wall , mid
and distal ant septum , inf septum , entire apex , and
post wall AK. All other walls HK. At stress: LV not dilated. akinetic
segments remained so. EF up to 25%.
ETT 8/17/06: STANDARD BRUCE , stopped for DYSPNEA & FATIGUE , 3'16" ,
57.74% MPHR , RPP 8200 , no ectopy. Cath 9/22 Right Dominant , LM ostial
70% lesion , prox LAD 70% lesion ( both got Cyphers ) , no RAS. RCA
not evaluated. Cath 7/9 RCA evaluated ( Mid ) , 80%
lesion RCA ( Proximal ) , 60% lesion. Elevated RH
pressures.
PFTs 3/30/92: FEV1 101%
ADENOSINE MIBI 8/18/07: 1. Abnormal and consistent with a large region of
myocardial scar in the distribution of the
right coronary artery and a posterolateral/OM coronary artery
without residual adenosine induced perfusion defect. Test
sensitivity for detecting ischemia is reduced in this patient due
to lack of a separate normally perfused myocardium to compare to.
2. Severe global LV systolic dysfunction. 3. Results
essentially unchanged from January , 2005.
CATH 8/11/07: LHC: R dom , No LM or LAD lesions. Cx with discrete
calcified 80% lesion , RCA with porx diffuse calcified 80%lesion , RT LV-BR
prox tubular 70% lesion , no change since 2005.
RHC: RA 7/8 , 6 RV 27/5 , 6 PA 26/13 , 19 PCWP 16 , CO/CI 3.6/1.8
TTE: 10/6/07: EF 15-20% with global HK and ant/apical/inf/post/mid
sept AK. Severe decr RV fxn , severe LAE , Mild AR , Tr TR/PR , Mod MR ,
no change from prior.
***
Hospital Course:78M with significant CAD , iCM EF 15-20% , presenting with
SOB. Suspected CHF exacerbation.
1. CV:
Ischemia- Checked troponin ( neg ) for hx of CP 1 week ago. Cont
ASA/Plavix , BB. Some concern for ischemia causing his
worsening symptoms so Adenosine MIBI on 6/26 without focal defects , but
no good area to compare it to. LHC without new disease , no
interventions. TSH nl.
Pump: Possibly slightly volume up. RHC with wedge of 16. Changed Lasix
to 60 twice a day Cont Dig/nitrate/BB , ACEi. Checked echo , no change.
Rhythym: Tele. Lyte replete as needed
2. PULM: no COPD by PFTs 1992. No asthma or PNA.
3. Renal: CRI ( 1.4-1.8 ). 1.6 on admit , follow. Stable , got mucomyst pre
cath , no bump in Cr. 1.4 on discharge.
4. GI: Barrett's , on a PPI.
5. NEURO: neuropathy , neurontin , celexa.
6. Optho: glaucoma , on eye drops.
7 FEN: CV , NAS , 2L fluid restrict diet.
8. HEME: Held coumadin for cath , then restarted it with 2mg on 1/16 , 1mg
on 10/2 , INR of 1.7 on d/c.
ADDITIONAL COMMENTS: Please stop taking your Imdur. Please measure daily weights and call
your MD if your weight increases by more than 5lbs in one week or by more
than 2-3 lbs in one day.
Please continue your coumadin and take it as previously. Check your INR
on monday.
Please take Lasix 60 twice a day.
Otherwise resume all of your home medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up volume status. INR was 1.7 on d/c. Will check INR on
5/28/07 .
No dictated summary
ENTERED BY: KOZIKOWSKI , LAURA J. , M.D. ( GM328 ) 8/3/07 @ 11:28 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 363
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
Y |
- |
N |
N |
N |
182796277 | PUO | 05941893 | | 8674702 | 6/10/2007 12:00:00 a.m. | Pulmonary Hypertension , fluid overload , generalized pain | | DIS | Admission Date: 8/28/2007 Report Status:
Discharge Date: 2/18/2007
****** FINAL DISCHARGE ORDERS ******
CURTSINGER , BEE 070-83-52-9
Ins Ro Li
Service: MED
DISCHARGE PATIENT ON: 7/28/07 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PERSONIUS , SVETLANA BART , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. ATORVASTATIN 10 MG orally every day
2. THERAPEUTIC MULTIVITAMINS 1 TAB orally every day
3. ALBUTEROL INHALER 2 PUFF inhaled four times a day
4. AQUAPHOR 1 APPLICATION TOP AS NEEDED
5. ACETYLSALICYLIC ACID orally every day
6. BETAMETHASONE VALERATE 0.1% OINTMENT 1 APPLICATION TOP twice a day
7. CALCIUM CARBONATE 1250 MG ( 500MG ELEM CA )/ VIT D 200 IU ) 1 TAB orally twice a day
8. CLOBETASOL PROPIONATE 0.05% 1 APPLICATION TOP twice a day
9. DOCUSATE SODIUM orally twice a day
10. DIGOXIN 0.25 MG orally every day
11. FERROUS SULFATE 325 MG orally every day
12. FLUTICASONE NASAL SPRAY 2 SPRAY NAS twice a day
13. INSULIN REGULAR HUMAN 8 UNITS/10 UNITS subcutaneously twice a day
14. LACTULOSE 30 ML orally three times a day
15. FUROSEMIDE 40 MG orally every day before noon
16. METOPROLOL TARTRATE 75 MG orally twice a day
17. CLOTRIMAZOLE 1% CREAM TOPICAL TOP twice a day
18. POLYETHYLENE GLYCOL 17 GM orally every day
19. NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual X1
20. INSULIN NPH HUMAN 65 UNITS/68 UNITS subcutaneously a.m./PM
21. PETROLATUM/LANOLIN 1 APPLICATION TOP every 6 hours
22. PANTOPRAZOLE 40 MG orally every day
23. SARNA 1 APPLICATION TOP every day
24. SIMETHICONE 80 MG orally four times a day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain , Headache
ACETYLSALICYLIC ACID 325 MG orally DAILY
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Shortness of Breath
LIPITOR ( ATORVASTATIN ) 10 MG orally DAILY
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
LOTRIMIN 1% CREAM ( CLOTRIMAZOLE 1% CREAM ) TOPICAL TP twice a day
Instructions: to vagina
Alert overridden: Override added on 7/28/07 by :
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & CLOTRIMAZOLE
SERIOUS INTERACTION: SIMVASTATIN & CLOTRIMAZOLE
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & CLOTRIMAZOLE
Reason for override: tolerates
DIGOXIN 0.125 MG orally DAILY Starting Today ( 2/16 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY inhaled DAILY
LASIX ( FUROSEMIDE ) 40 MG orally twice a day Starting Today ( 2/16 )
INSULIN NPH HUMAN 65 UNITS subcutaneously every day before noon
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally twice a day
HOLD IF: SBP <100 or HR <55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
MIRALAX ( POLYETHYLENE GLYCOL ) 17 GM orally DAILY
as needed Constipation Number of Doses Required ( approximate ): 1
MULTIVITAMIN WITH MINERALS THERAPEUTIC ( THERA... )
1 TAB orally DAILY
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
with supervision and assistance
FOLLOW UP APPOINTMENT( S ):
Dr. Abe Girardi 10/13 @945am scheduled ,
ALLERGY: Penicillins , WARFARIN SODIUM , PROPOXYPHENE HCL ,
LISINOPRIL
ADMIT DIAGNOSIS:
Weakness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pulmonary Hypertension , fluid overload , generalized pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chronic Afib G-E Reflux HTN
IDDM , diastolic CHF ( EF 65% ) ( congestive heart failure ) history of
colectomy for diverticulitis ( history of colectomy ) history of ventral hernia
repair ( history of hernia repair ) history of carpal tunnel release ( history of carpal
tunnel repair ) , tricuspid regurgitation , history of CVA , osteoarthritis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHO
BRIEF RESUME OF HOSPITAL COURSE:
CC: pain , weakness
---
HPI: This is an 81 year old female with a history of CVA , CAD , diastolic
heart failure , PAF , congenital non-fused C1 ring who presents with L
sided total body pain , weakness and worsening DOE. Her pain started while
undergoing physical therapy of her L shoulder. She reports balance
problems and difficulty ambulating at home. She has had chronic R
shoulder pain for 5 years , and had neck pain for 2 months. She had a
negative CTA in 6/12 . She had a neck CT 6/12 which showed DJD. After
second physical therapy visit on Thursday 4/19 she awoke the next morning with severe
pain in L neck and head , her neck pain is worse with extension , and
improved with flexion. She reports pain throughout the L side of
her body but specifically at the location of L LE varicose veins. She
also feels alternating heat and cold on L side of body. She reports
difficulty walking well now because of pain , weakness , fatigue and
dyspnea. She has been taking tylenol for pain and this helps. She also
reports abd pain and nausea , and vomited yellow vomit am of admit. ROS
positive as well for worsening DOE , stable two pillow orthopnea ,
worsening chest pain with exertion , dizziness , lightheadedness , loss of
balance , eye pressure , night time coughing , subjective chills , LE
swelling , increased abd girth , headache and constipation. She felt
progressively worse over the weekend and presented today to KTDUOO clinic
from where she was transferred to PUO ER. No fevers , no bowel/bladder
dysfunction.
---
PMH:
1. ) Diabetes Mellitus
2. ) HTN
3. ) CAD
4. ) PAF , not on coumadin
5. ) GIB
6. ) S/p PPM for tachy/brady syndrome
7. ) history of CVA
8. ) Diastolic heart dysfunction
9. ) Hypercholesterolemia
10. )history of SBO history of LOA
11. )Osteoarthritis
12. )Diverticulitis history of colectomy
13. )Cataract surgery
14. )Hernia repair
15. )Hysterectomy
---
MEDICATIONS:
Albuterol inhaler as needed
Aquaphor as needed
Aspirin 325mg daily
Betamethasone Valerate 0.1% ointment as needed
Calcium Carbonate 1 tab orally twice a day
Clobetasol Propionate 0.05% top twice a day
Colace 100mg orally twice a day
Digoxin 0.25mg orally daily
Ferrous sulfate 325mg orally daily
Flonase 2 spray NAS twice a day
Insulin regular 8units every day before noon
Insulin regular 10units every afternoon
Lasix 40mg orally every day before noon
Lipitor 10mg orally daily
Lopressor 75mg orally twice a day
Lotrim cream as needed
Miralax as needed
MVI daily
NTG sublingual as needed
NPH 65units every day before noon , 68units every afternoon
Nystatin powder twice a day
Protonix 40mg daily
---
PE: VS: T96.7 , P 66 , BP 98/70 , RR 18 , O2 98% Sat on RA
GEN: Comfortable , NAD.
HEENT: PERRLA B , EOMI
NECK: +JVD
CHEST: CTA bilaterally
CV: irregular , loud SEM
ABD: +distended , nontender , soft
EXT: 2+ pitting edema bilat
SKIN: no rashes or lesions
NEURO: CN II-XII intact. No focal deficits. Strength 5/5 throughout.
---
CXR: stable cardiomegaly. No overt edema.
---
HEAD CTA:
1. No acute intracranial abnormality
2. Normal CT angiogram of the head and neck , without significant
stenosis , occlusion , or aneurysm.
3. Unchanged small basilar artery caliber.
4. Hypoplastic right V4 segment.
---
Assessment and Plan: This is an 81 year old female with multiple
medical problems who presents with multiple vague complaints. She likely
has more than one medical issue going on simultaneously.
--
CV:
ISCHEMIA: patient has known CAD. Worsening angina with exertion. No s/s
of ACS currently. EKG shows no ST segment elevations. Checked set of
cardiac enzymes which were negative. She was continued on asa , statin , BB
-
PUMP: The patient has history of diastolic heart failure. ECHO over one year
ago showed EF 55-60%. It also showed severe tricuspid regurgitation. Her
symptoms of DOE , fatigue , LE swelling , abd girth could also be explained
by Cor Pulmonale or worsening heart failure. A CXR was performed
which showed stable cardiomegaly and no signs of overt edema but
clinically with her elevated JVP , increased abd girth and LE edema
were suggestive of fluid overload. BNP was low at 122 but likely she was
somewhat overloaded. An ECHO was performed which showed elevated
pulm artery pressure of 45 , moderate tricuspid regurgitation , mild to
moderately enlarged R ventricle and moderately enlarged Right atrium. EF
of 60%. These findings are suggestive of potential cor pulmonale. Plan is
to diurese patient as outpt and repeat ECHO by primary care physician as outpt , then
consideration of cardiology referral. Lisinopril is added as allergy
( hyperkalemia ) , perhaps can be given as small dose with close monitoring.
Defer to primary care physician. The patient was placed on strict I/Os , daily weights. Avoided
fluid restriction given low BP for now.
-
RHYTHM: The patient has fatigue , dizziness , nausea raising the concern for
dig toxicity. She also has known afib. A digoxin level was checked and
came back at 1.4 which might be slightly high for her renal function ,
age and muscle mass. Her digoxin dose was therefore decreased to 0.125mg
daily. She was monitored on telemetry which showed frequent ventricular
pacing and occasional PVCs.
---
ORTHO: The patient had CT of cervical spine in October '07 for neck pain
radiating to the L , as is her current presentation. The CT showed DJD
but no fracture or other concerning finding. No recent trauma. Her pain
is likely from worsening DJD. Plan conservative intervention with
hotpacks , Tylenol. No further imaging indicated. Home physical therapy planned.
---
NEURO: The patient has hx of CVA but current CTA shows no evidence of
acute CVA. Her Neuro exam is fairly unremarkable despite multiple
vague complaints of weakness , numbness , pain. She was continued on
asa. Neuro exam monitored without focal deficits. Treated headache with
Tylenol. If the patient's overall pain persists , she might benefit from pain
consult as outpt
---
PULM: patient has no known pulm disease but has been prescribed albuterol
inhaler. If she in fact has pulm HTN , she may have causative pulm
etiology. CXR showed no acute pulm issues. If ECHO suggestive , PFTs as
outpt per primary care physician.
---
GI: Bowel regimen for constipation. PPI for GERD.
---
ENDO: patient has IDDM. It is not exactly clear what she takes for insulin at
home because she reports that she only takes NPH once a day despite the
prescription in XSRMC . She is unclear on her doses or timing of insulin.
She was hypoglycemic upon admission. Check Hgb A1C--> 7.4. She was
started on Sliding scale Novolog and a.m. NPH for the time being. Monitored
FS which were reasonable. primary care physician to cont management.
---
FEN: Monitored fluid status. Monitored lytes. Avoided K scale while
on digoxin. Low fat , Low chol , NAS , carb controlled diet
---
PPX: Lovenox
CODE: Full
ADDITIONAL COMMENTS: 1. VNA to help with medication reconcilliation. VNA-please go through all
medication bottles in the house and sort out the current ones , help
patient make pill box with most current medications.
2. Digoxin dose has been lowered this admission from 0.25mg to 0.125mg
daily. Lasix has been increased temporarily to twice a day for diuresis until
follow up with primary care physician.
3. VNA to check sodium , potassium and digoxin level June .
4. VNA to check BP while on twice a day lasix. Hold dose if SBP <95 and call primary care physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Monitor fluid status/electrolytes. Repeat ECHO after diuresis. Consider
Cardiology consult for ?Cor Pulmonale.
Monitor renal function and digoxin level.
No dictated summary
ENTERED BY: RUKA , BERNA , PA-C ( YP61 ) 7/28/07 @ 03:33 PM
****** END OF DISCHARGE ORDERS ******
Document id: 364
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
158845951 | PUO | 19054879 | | 9288240 | 10/21/2004 12:00:00 a.m. | r/o MI , SOB multifactorial deconditioning , pulmon disease | | DIS | Admission Date: 10/21/2004 Report Status:
Discharge Date: 5/12/2004
****** DISCHARGE ORDERS ******
MEGAHAN , ANALISA NIKKI 810-08-61-6
Remuld Drive , Nix , Florida 23905
Service: MED
DISCHARGE PATIENT ON: 8/29/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
AMITRIPTYLINE HCL 25 MG orally every bedtime
FUROSEMIDE 40 MG orally every day
Alert overridden: Override added on 8/4/04 by
BUETI , MCKINLEY , M.D.
on order for FUROSEMIDE orally ( ref # 79543734 )
patient has a POSSIBLE allergy to Sulfa; reaction is renal
failure. Reason for override: patient tol at home
GLYBURIDE 10 MG orally twice a day
Alert overridden: Override added on 8/4/04 by
BUETI , MCKINLEY , M.D.
on order for GLYBURIDE orally ( ref # 53635725 )
patient has a POSSIBLE allergy to Sulfa; reaction is renal
failure. Reason for override: patient takes at home
NOVOLIN INNOLET 70/30 ( INSULIN 70/30 ( HUMAN ) )
100 UNITS subcutaneously twice a day
Number of Doses Required ( approximate ): 8
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Override Notice: Override added on 8/4/04 by
BUETI , MCKINLEY , M.D.
on order for CLOTRIMAZOLE 1% CREAM TP ( ref # 90082983 )
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & CLOTRIMAZOLE
Reason for override: will monitor
Previous override information:
Override added on 8/4/04 by BUETI , MCKINLEY , M.D.
on order for LIPITOR orally ( ref # 71619726 )
patient has a PROBABLE allergy to SIMVASTATIN; reaction is
myalgia. Reason for override: patient tol lipitor at home
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Labrecque MMC call to schedule 1wk ,
ALLERGY: Penicillins , Sulfa , ACE Inhibitor , METFORMIN HCL ,
SIMVASTATIN , DRUG ALLERGY , ALLERGY
ADMIT DIAGNOSIS:
SOB/Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
r/o MI , SOB multifactorial deconditioning , pulmon disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , uncontrolled DM , Sleep Apnea , Asthma
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
58 year-old woman multiple cardiac risk factors
( uncontrolled DM2 10.3 HgbAIC , HTN , lipids ) , Asthma , Sleep Apnea ,
with 1 week worsening DOE. patient c/o DOE only when
walking up an incline. patient had one episode of
diaphoresis with this SOB but denies any cp , shoulder
pain , backpain , jaw/neck pain. patient denies any n/v/d.
patient went to primary care physician and due to multiple risk factors was
told to come to ED for r/o MI. patient denies SOB at rest or even when
walking on "flat surface" patient says been over all fatigue last week also
known to be recovering from recent renal stone. patient
admit for r/o MI In ED patient BP elevated
150-160's/80-90 given intravenous lopressor and nitro paste patient BP
stable A/P DOE unlikely due to cardiac problem ,
symptoms more c/with deconditioning in obese , DM women
with underlying pulmon disease.
CV- cardiac enz neg x3- ASA , no BB secondary Asthma
Will need cardiac mibi with adenosine as out patient
hx diasystolic dysfunc with nl EF. patient on telemetry with no
abnormalities. Serial EKGs unchanged with baseline abnl poor
RWprogression BP initially mildly elevated stable this am can rea
ddress meds as an outpt
Endo- DM cont home meds SSI
Pulmon- hx sleep apnea/Asthma on cpap /6lNC
( while in hosp ) at night. no baseline O2 needed
Full code
ADDITIONAL COMMENTS: Please call your doctor if having chest pain , worsening shortness of
breath with exertion or at rest , new onset back/shoulder pain ,
worsening fatigue or any other concerns. Please call your primary care physician to
schedule out patient Cardiac MIBI with adenosine
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BUETI , MCKINLEY , M.D. ( US83 ) 8/29/04 @ 12:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 365
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
- |
074240126 | PUO | 47433866 | | 3691205 | 5/24/2002 12:00:00 a.m. | shortnes of breath not cardiac | | DIS | Admission Date: 5/24/2002 Report Status:
Discharge Date: 2/9/2002
****** DISCHARGE ORDERS ******
FIEGEL , MACY 213-70-67-4
Isher Tere Ave
Service: MED
DISCHARGE PATIENT ON: 1/11/02 AT 10:00 a.m.
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SVENNINGSEN , CHRISTIAN VIVAN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting IN a.m. ( 7/9 )
HUMULIN N ( INSULIN NPH HUMAN )
34 UNITS qAM; 36 UNITS qPM subcutaneously 34 UNITS qAM 36 UNITS qPM
LABETALOL HCL 200 MG orally twice a day Starting Today ( 8/10 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COZAAR ( LOSARTAN ) 25 MG orally every day Starting IN a.m. ( 7/9 )
Number of Doses Required ( approximate ): 5
TRICOR ( FENOFIBRATE ) 108 MG orally every day
Starting IN a.m. ( 1/24 )
Number of Doses Required ( approximate ): 5
LIPITOR ( ATORVASTATIN ) 80 MG orally every bedtime
HUMALOG ( INSULIN LISPRO ) 10 UNITS subcutaneously twice a day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Naumoff in KTDUOO at 2:10 PM 1/1/03 scheduled ,
Dr. Whiley Urgent care 6/17/02 ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
shortnes of breath not cardiac
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of IMI COPD HYPERCHOLESTEROL NIDDM
emphysema ( chronic obstructive pulmonary disease ) dyspnea ( shortness
of breath )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
The patient is a 66 year-old woman with a hx of CAD , emphysema , HTN , and DMII
who presents with a 2 month hx of progressive dyspnea on exertion who
was found to desat on ambulation today to the mid 80s. The patient had
a prior CABG in 1994 and underwent cath with additionally stenting in
2001. She had a recent MIBI ( 5/26 ) with nl EF and mild reversible
defects in peri-infarct territory. She had been doing well until
recently when she noted the onset of progressive dyspnea on exertion
over the last 2 months. She denies chest pain , cough , orthopnea. She
does report PND and new LE edema.
VS: 96.6 61 140/70 24 94 RA
PEx: Lungs: bilateral basilar crackles. CV: rrr , nl s1 and s2 , +s3 ,
II/VI SEM. Extr: bilateral edema over shins , non-pitting.
Hospital Course:
1. Dyspnea: The differential diagnosis for this patient's dyspnea
includes cardiac and pulmonary causes. Based on physical exam it was
not felt that she was in heart failure. However , with hx of CAD , this
was investigated with Echo which showd nl EF and heart function. The
Echo also showed nl RV fxn and no evidence of pulmonary hypertension.
Chronic PE and lung parechymal diseases were investigated with chest CT
which was negative for PE. It also showed moderate to severe
centrilobular emphysema with no evidence of pulmonary fibrosis. She
had PFTs the day of admission which showed decreased lung volumes all
consistent with a restrictive lung pattern. Given the diagnostic
dilemma , the Pulmonary service was consulted , which did not feel that
doe was due solely to pulm etiologies. Thus , desat is unexplained. patient
will be sent home on o2 to be used during exertion only.
2. CV: The patient has a hx of hypertension and is being followed by
her Cardiologist Dr. Romack . Per Dr. Coniglio recommendation , her norvasc
was discontinued as was her atenolol. Desats could be
due to transient diastolic dysfunction with exertion. She has been
started on labetalol 400 twice a day at the time of discharge. Titrate up as BP
tolerates
3. PULM: will be d/c'd on albuterol inhaled
4. F/U: She is discharged to home with follow-up with urgent care next wk
for re-exam of BP , volume status and sats with ambulation. Titrate
labetalol as tolerated. If LE edema persists and patient continues to desat
with exertion , can try lasix. If DOE still persists , consider R/L heart
cath or cardiopulmonary exercise testing
ADDITIONAL COMMENTS: if you have any worsening shortness of breath , call MD immediately.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow-up with Dr. Naumoff on January as scheduled.
2. Call Dr. Romack to schedule follow-up.
3. Call doctors if symptoms worsen.
4. The following are med changes:
- stop norvasc
- stop atenolol
- start labetalol 200 mg twice a day
No dictated summary
ENTERED BY: BURVINE , ALVERTA AUDREY BEBE , M.D. ( YO26 ) 1/11/02 @ 08:43 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 366
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
- |
N |
Y |
Y |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
245876836 | PUO | 99067599 | | 9372044 | 5/13/2006 12:00:00 a.m. | GERD | | DIS | Admission Date: 5/23/2006 Report Status:
Discharge Date: 3/26/2006
****** FINAL DISCHARGE ORDERS ******
DEBNAR , LANITA 202-70-31-3
South Dakota
Service: CAR
DISCHARGE PATIENT ON: 2/3/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MAINER , SHAVONNE D. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally every other day
PROZAC ( FLUOXETINE HCL ) 40 MG orally every day
LISINOPRIL 2.5 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG NEB four times a day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Override Notice: Override added on 6/16/06 by SZWEDA , ALFREDA A C. , M.D. on order for NEPHROCAPS orally ( ref # 015768756 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 6/16/06 by
SZWEDA , ALFREDA A. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
LANTUS ( INSULIN GLARGINE ) 18 UNITS subcutaneously every day
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ACIPHEX ( RABEPRAZOLE ) 20 MG orally every day
Starting Today ( 1/9 )
DIET: House / Adv. as tol. / 2 gram K+ , Renal diet
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Katcsmorak 8/28 at 2 pm ,
ALLERGY: Penicillins , Morphine , Codeine
ADMIT DIAGNOSIS:
angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
GERD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , DEPRESSION , OBESITY , TAH/BSO , CAD history of stent to LAD , Dia. CHF ( EF 60 ,
LVH , 3+MR ) , angina , insulin-resistant DM , GERD ( esophageal reflux ) , gout
( gout ) , ESRD , COPD , OSA ( sleep apnea ) , anemia , multiple failed AV fistula
placements
OPERATIONS AND PROCEDURES:
3/19/06 Coronary Catheterization - no instent restenosis , no critical
coronary artery disease.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest Pain
History of Present Illness
Ms. Debnar is a 75F who began HD one month ago , and presented 10 days
PTA with an NSTEMI ( Troponin 2.9 ) ( 70% LAD lesion which is history of DES ). She
presents again with epigastric and sub-sternal burning sensation which
is similar , but more intense , to her anginal pain 10 days ago. Episodes
started 2 days prior to admission , occurring when lying down to go to
bed and last 1 hour ( spontaneously resolved , about a 2-3/10 ). Second
identical episode 1 day PTA. Neither associated with radiating pain ,
exertion , or DOE. Then had an episode while walking to PCPs office ,
associated with dyspnea and relieved with rest. Sent to ED , where
another episode occurred and was relieved with nitro. Received BB and
ASA in ED. patient denies missing any plavix since DES placement , although
she does state plavix has caused her to have diarrhea. She denies any
radiating chest pain , F/C , weight change. + cough since starting
lisinopril , orthopnea ( unchanged from baseline ).
PMH
COPD , HTN , MR ( 2+ ) , DEPRESSION , IDDM , GERD , history of RT PLEURAL
EFFUSION ( ?IDIOPATHIC ) , GOUT , SLEEP APNEA , Congestive heart
failure , Stent placed to LAD in 11/3 for NSTEMI , ESRD
Admission Medications
ACIPHEX ( RABEPRAZOLE ) 20 MG ( 20MG TABLET DR take 1 ) orally
every day ALBUTEROL ( INHALER ) 2 PUFFS inhaled twice a day x 30
day( s ) ALLOPURINOL 100 MG ( take ) orally
every other day AMBIEN ( ZOLPIDEM TARTRATE ) ( 10MG TABLET take 1
Tablet( s ) ) orally every bedtime as needed insomnia ASA 325 MG orally every day x 100
day( s ) ATROVENT 2 PUFFS inhaled
four times a day CALCITRIOL 1.5 MCG orally Q Mon ,
fri ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED ) 325 MG
( 325MG TABLET take 1 ) orally every day insulin BD syringe 1 /3CC subcutaneously once a
day ISORDIL ( ISOSORBIDE DINITRATE ) ( 40MG TABLET take 1
Tablet( s ) ) orally three times a day LANTUS ( INSULIN GLARGINE ) 10UNITS subcutaneously
Qhs LIPITOR ( ATORVASTATIN ) 80 MG ( 80MG TABLET take 1 ) orally
every bedtime LISINOPRIL 2.5 MG ( 2.5MG TABLET take 1 ) orally
every day LOPRESSOR 75 MG orally
three times a day NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB ( 0.4MG TAB SUBL
take ) sublingual q5min as needed chest pain PLAVIX ( CLOPIDOGREL ) 75 MG ( 75MG
TABLET take 1 ) orally every day
PROCRIT ( EPOETIN ALFA ) 40 , 000 UNITS subcutaneously QWEEK PROZAC 20 MG orally
every day REGULAR INSULIN ( HUMAN )
SS VALIUM 5 MG ( take ) orally twice a day
as needed ZAROXOLYN 2.5 MG orally every day as needed For fluid overload per RNP or MD
ALLERGIES
Penicillins TONGUE SWELLING
Morphine change in mental status
Codeine Mental Status Change
-----
Social History
Quit tob in 1990 , smoked 50 pack years , no EtOH. Lives
alone in War
Vital Signs
Blood Pressure: 144/74 Left Arm Pulse: 89
Regular Weight: 210 Pounds SO2 97% RA
Exam: JVP 7cm , chest clear , CV regular with a 2/6 SEM radiating to
clavicles , abd benign , extr without edema
EKG: poor R wave progression v2->v4 , unchanged from
baseline.
Echo 5/24/2006: The left ventricle is normal in size.
There is borderline concentric left ventricular hypertrophy. Overall
left ventricular function is mildly reduced. The estimated ejection
fraction is 45-50%. There is septal an inferior hypokinesis.
HOSPITAL COURSE
The patient was admitted to cardiac telemetry for atypical chest pain in
the setting of an NSTEMI and stent placement one week prior to this
admission. The patient reports having taken her plavix regularly , and having
not missed a single dose. She had no EKG changes , but did have burning
substernal chest pain at rest while lying down. Her cardiac enzymes
were flat ( troponin 0.21-0.23 in the setting of renal failure/HD ). This
pain was relieved by nitro sublingual. She was taken to cardiac catheterization
for further evaluation of her recent stent. No critical obstructions were
seen and the stent was widely patent. Her pain was relieved with PPI , and
she is discharged with a diagnosis of GERD. This pain is not felt to be
cardiac in origin.
Full code.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
See Dr. Katcsmorak as scheduled.
Take your medications as prescribed. Take Plavix regularly and DO NOT
MISS A DOSE.
If you have the burning chest pain again , you may take mylanta or
pepto-bismol ( or equivalent product ). Take your aciphex daily.
No dictated summary
ENTERED BY: MCCORD , ADAH K. , M.D. , PH.D. ( CT581 ) 2/3/06 @ 11:56 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 367
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381967820 | PUO | 02433774 | | 733936 | 3/5/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 11/23/1990 Report Status: Unsigned
Discharge Date: 1/3/1990
HISTORY OF PRESENT ILLNESS: This is a 39 year old Moottee Fallssquite Go
female with a history of discoid lupus
and pericarditis , who presents with severe substernal chest pain
after having prednisone and Plaquenil discontinued. She first
developed discoid lupus in 1983. She subsequently over the years
developed arthralgias of various joints , was treated with aspirin ,
Motrin and steroids. In 1985 , she developed pleuritic substernal
chest pain. She was diagnosed at Bussadd Southrys Community Hospital with pericarditis
and underwent pericardiocentesis. In 1988 , she was seen at the
Arthritis Clinic by Dr. Loden , who noted a discoid lupus on
examination , a mild anemia , sedimentation rate 85 , CH-50 178 , VNA
positive at 1:160 , positive anti-double-stranded DNA and 3+
positive Smith/anti-Smith antibody. She was treated with Plaquenil
200 twice a day , plus aspirin and Naprosyn. In 5 of October , she was diagnosed
with a lupus flare and was put on prednisone 30 every am. She did well
and in 24 of October the steroids were tapered off and discontinued.
However , she presented with substernal chest pain at that time and
had her prednisone restarted. She was put on another prednisone
taper. In 23 of March , she had a negative brain magnetic resonance
imaging. In 21 of April , she had an echocardiogram which showed
pericardial thickening without evidence of constriction consistent
with prior pericarditis. Over the following several months , she
had occasional flares because of medical noncompliance. She was
put on Plaquenil 200 twice a day , which was increased to three times a day , and Motrin
800 twice a day In 2 of January , she again came to the emergency room with
substernal chest pain and a mild pulsus paradoxus , no jugular
venous distention. An electrocardiogram was without change. Chest
x-ray showed slight increase in the heart size. She was placed on
prednisone 30 every day , Tylenol with codeine and did well. On
16 of October , she was seen in the clinic and had substernal chest pain
consistent with pericardial pain , dyspnea on exertion , increased
arthralgias secondary to discontinuing her steroids. At that time ,
she had her Plaquenil and prednisone restarted. Over the last 3
weeks prior to admission she noticed that the prednisone and
Plaquenil increased stomachaches and she stopped the medication.
Over the last 7 days prior to admission , she has had increasing
dyspnea on exertion and substernal chest pain , which is sharp ,
increases with cough or deep breaths. She denied any orthopnea or
paroxysmal nocturnal dyspnea , palpitations or syncope. She has no
nausea , vomiting , fevers , chills or melena. She does have
increasing joint pain. PAST MEDICAL HISTORY revealed seizure
disorder with Dilantin , hypothyroidism treated with L-thyroxine ,
iron deficiency anemia without prior work-up , thoracic spine
compression fractures , gastritis questionably secondary to
Naprosyn. She has no known ALLERGIES. MEDICATIONS ON ADMISSION
were Plaquenil 200 twice a day , Motrin 80 three times a day , prednisone 10 every am , Dilantin
400 every am , L-thyroxine 0.2 every day , folate 1 mg orally every day , iron sulfate
225 three times a day , Diprosone Ointment twice a day She does not smoke or drink.
FAMILY HISTORY is negative for collagen vascular diseases. She is
the mother of 5 children.
PHYSICAL EXAMINATION: She was an obese Hispanic female in mild
distress. Temperature was 99 , pulse 60 ,
blood pressure 130/70 , respirations 18 , pulsus paradoxus of 10.
Skin showed numerous discoid lesions of the scalp , face and right
forearm and lower extremities with patchy alopecia. Head , eyes ,
ears , nose and throat examination was unremarkable. Neck was
supple , no adenopathy noted. Chest was clear. Cardiac examination
showed regular rate and rhythm , normal S1 , S2 , with a I/VI systolic
ejection murmur at the left lower sternal border , otherwise no rubs
or gallops. Back showed no costovertebral angle or spinal
tenderness. Abdominal examination was benign , liver is 10 cm , and
the spleen tip is not palpable. Rectal examination was guaiac
negative , soft brown stools. She does have external hemorrhoids.
Extremities were negative without cords or Homan's sign. Neurologic
examination was grossly intact , with normal cranial nerve function ,
motor , sensory , coordination and deep tendon reflexes , except for
question of slight slowing of the relaxation phase of the reflexes
in the upper and lower extremities. Musculoskeletal examination
showed diffuse bilateral asymmetric synovial thickening with
slightly decreased range of motion most notably in the right elbow ,
right metacarpophalangeal joint , left carpal , bilateral knees and
ankles.
LABORATORY EXAMINATION: Electrolytes were all within normal
limits. Her CK was 76. Dilantin level
5.6. White count was 4.7 , hematocrit 30 , platelets 352 , 000 , mean
corpuscular volume 83 , ESR 88 , oxygen saturation 99% on room air.
Urinalysis showed specific gravity 1.026 , 2+ protein , 10 to 15
white cells , 8 to 10 red blood cells and a few granular casts.
Chest x-ray showed increased heart size , otherwise negative , no
change from 2 of January . She does have multiple thoracic compression
fractures and osteopenia. The electrocardiogram showed sinus
rhythm with frequent premature ventricular contractions at a rate
of approximately 70 , positive 45 degree axis , normal intervals ,
T-wave inversion in III and V2 through V3 without changes in the PR
or ST segments compared with 2 of January , and no decrease in the
voltages.
HOSPITAL COURSE: Problem #1 was substernal chest pain. This
seemed to be a pericardial pain secondary to
discontinuation of her prednisone and Plaquenil as it happened
numerous times in the past. She was ruled out for a myocardial
infarction. She had an echocardiogram which showed a small amount
of pericardial fluid without evidence of right ventricular
indentation or compromise. She was placed back on her Plaquenil
200 twice a day , and prednisone 30 every day and did well in that regard.
Problem #2 was decreased hematocrit. This was felt to be probably
secondary to hydration as the hematocrit on hospital day #2 went
from 31 to 27 with several liters of intravenous fluid. Stool
guaiacs were negative throughout the hospitalization. The
hematocrit remained stable between 27 and 30 without transfusions
or further intervention. She did have a Coombs test sent which was
mildly positive , although her hematocrit was stable. She was
discharged on folate and iron. Problem #3 is hematuria and pyuria
at the time of admission. Urine culture and urine gram stain were
both negative for infection and this was followed up with a 24-hour
urine collection for protein to assess for potential lupus
involvement of the kidney , and this will need to be followed up on.
DISPOSITION: The patient was discharged for FOLLOW-UP in
Rheumatology Clinic with Dr. Loden . MEDICATIONS
ON DISCHARGE included Plaquenil 200 twice a day , prednisone 20 every day ,
Dilantin 400 every day , L-thyroxine 0.2 every am , Motrin 800 three times a day , Carafate ,
iron and folate.
________________________________ QB917/3517
ELA LODEN , M.D. GG0 D: 5/2/90
Batch: 3737 Report: B5122Q43 T: 10/10/90
Dictated By: DESIRAE MARCOTT , M.D.
Document id: 368
| Target |
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CHF |
Dp |
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GER |
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HC |
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HTG |
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PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
222755927 | PUO | 29577753 | | 9452887 | 2/11/2006 12:00:00 a.m. | FEVER | Signed | DIS | Admission Date: 6/4/2006 Report Status: Signed
Discharge Date: 1/3/2006
ATTENDING: PILLING , WEI M.D.
OUTPATIENT PHYSICIAN:
Dr. Rufus Bernas . Fax number 384-363-4910.
DISCHARGE DIAGNOSES:
1. VRE line sepsis.
2. Left heel osteomyelitis.
3. Type I diabetes.
4. End-stage renal disease on hemodialysis.
CHIEF COMPLAINT:
Fever.
HISTORY OF PRESENT ILLNESS:
This is a 36-year-old woman with a history of type I diabetes ,
chronic renal insufficiency on hemodialysis as well as chronic
skin ulcers who was at hemodialysis on the day of admission when
she developed fevers to 101 , chills , and rigors. The patient
also developed diffuse abdominal pain on the afternoon of
admission and was referred for evaluation. The patient on
questioning reports that she was in her usual state of health
until 2 days prior to admission when she began to have abdominal
cramping with one episode of diarrhea as well as chills. While
she was at hemodialysis on the day of admission , the patient
became febrile with concern for infection and was referred for
evaluation at the Emergency Department.
EMERGENCY DEPARTMENT COURSE:
The patient was treated with vancomycin , ceftriaxone , gentamicin
and clindamycin in the emergency department. She was also
treated with regular insulin as well as morphine intravenous.
REVIEW OF SYSTEMS:
Notable for headaches , bilateral lower extremity edema , as well
as shortness of breath , which she reports is better since having
dialysis on the day of admission. The patient does have
three-pillow orthopnea at baseline which is unchanged. She
denies nausea , vomiting , melena , bright red blood per rectum ,
dysuria or chest pain.
PAST MEDICAL HISTORY: Type I diabetes , chronic renal
insufficiency , chronic dermal ulcers , history of MRSA , peripheral
neuropathy , legally blind , gastropathy , cardiac murmur , seizure
disorder , hepatomegaly , status post excision of infected bone
from her left heel one month prior to admission.
ALLERGIES: Aspirin causes tongue swelling. Codeine ,
erythromycin , beef and pork insulin.
MEDICATIONS ON ADMISSION: Neurontin , Keppra , lisinopril ,
oxycodone , Lasix , vancomycin , Toprol , and insulin , notably Lantus
and NPH.
SOCIAL HISTORY: The patient has four children ages 5 through 20.
She reports no tobacco , alcohol or intravenous drug use. The patient's
mother is at home watching her children.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
103.3 , heart rate 92 , blood pressure 200/95 , respiratory rate of
20 , and 96% on room air. General: The patient is a black woman
with multiple skin ulcers notably over her trunk. Pupils were
equal , round and reactive to light and accommodation.
Extraocular muscles were intact. She does have horizontal
nystagmus , sclerae are anicteric , JVP was flat. Chest: Faint
right basilar crackles. Cardiovascular: S1 , S2 normal , II/VI
systolic murmur at the left upper sternal border. Carotids 2+
without bruit. Abdomen: Decreased bowel sounds , obese , slightly
distended , mildly tender with deep palpation , no rebound or
guarding. Extremities 1-2+ edema , left heel open ulcer with foul
odor and surrounding erythema. Neurological examination grossly
nonfocal.
LABORATORY DATA ON ADMISSION: Sodium 133 , potassium 4.5 , BUN 45 ,
creatinine 8.2. Serum glucose 507 , white blood cell count 14.4
with 4 bands. Hematocrit 30.3 , platelets 525. Normal liver
function test , lipase 29 normal. Urine hCG negative. INR 1.6.
Urinalysis was slightly positive.
STUDIES: Chest x-ray revealed an enlarged cardiac silhouette
concerning for pericardial effusion and bibasilar subsegmental
atelectasis. Left foot x-ray showed evidence of osteomyelitis of
the left calcaneus. Abdominal CT showed diffuse retroperitoneal
lymphadenopathy , pulmonary nodules in the left lower lobe as well
as a low attenuation foci associated with a small bowel of
unclear significance. EKG showed normal sinus rhythm at 85 beats
per minute , normal axis with isolated T-wave inversion in V1.
OPERATIONS AND PROCEDURES:
1. Status post wound debridement left heel 4/10/06 by Dr.
Stacie Halechko , vascular surgery.
2. Status post hemodialysis tunneled catheter placement left
chest 1/27/06 by interventional radiology.
HOSPITAL COURSE BY SYSTEM:
1. Infectious disease: Line sepsis. The patient was treated
with broad-spectrum antibiotics and initially treated with
vancomycin , ceftazidime , and clindamycin as well as gentamicin.
She underwent a transthoracic echocardiogram that was negative
for valvular vegetation and she showed no stigmata of
endocarditis. She had blood cultures from 8/17/2006 that were
positive for vancomycin resistant enterococcus and her antibiotic
regimen was changed to linezolid and clindamycin to cover for
anaerobes in her left heel. The patient's tunneled hemodialysis
catheter was removed on hospital day #2 in the setting of line
sepsis. The patient remained afebrile and will complete a 21-day
course of linezolid for VRE line sepsis. Repeat blood cultures show no growth
to date. The patient
was also admitted with chronic left heel osteomyelitis. The patient had
plain films that showed evidence of osteomyelitis. The Vascular
Surgery Service was consulted and the patient underwent
debridement of her left heel on 4/10/06 by Dr. Halechko and Dr.
Mancera . The patient will most likely need a left below-the-knee amputation
in the future most. The patient's wound culture grew out
Morganella morganii. However , in discussion with the Medical
team , the patient was not treated with antibiotic coverage for
this positive wound culture. A vacuum dressing was temporarily
placed to her wound and currently the wound is being treated with
three times a day wet-to-dry dressings. The patient did have a chest x-ray
that could have been compatible with an early left lower lobe
pneumonia , and had some low grade fevers during this admission. The patient
will also be discharged on a 10 day course of renally dosed Levaquin to cover
for possible community acquired pneumonia. The patient also had abdominal
pain and fevers on admission and had an abdominal CT scan without evidence of
abdominal abscess or other intraabdominal acute process.
2. Renal: The patient has end-stage renal disease , on
hemodialysis. She had her hemodialysis catheter removal. She
had negative blood cultures from 5/16/06 and the Interventional
Radiology Service placed another left chest tunneled hemodialysis
catheter on 1/27/06 . The patient was started on Nephrocaps ,
PhosLo as well as Plavix during this admission.
3. Cardiovascular: The patient had an admission chest x-ray
with an enlarged cardiac silhouette. She underwent a
transthoracic echocardiogram that revealed an EF of 55% and
trivial pericardial effusion. She showed no signs of cardiac
tamponade. The patient was continued on low-dose beta-blockade
and her lisinopril was restarted during the admission. She did
have periods of hypertension during the admission , thought to be
in the setting of volume overload. This did improve with
up-titration of her beta-blocker and hemodialysis. She will be
discharged on lisinopril as well as Toprol-XL. She was monitored
on telemetry throughout the admission.
4. Fluids , electrolytes , and nutrition: The patient tolerated a
renal fluid restricted diet. She did have hyperkalemia of 6.3
during the admission , which was treated appropriately. The
patient's hyperkalemia did improve with hemodialysis. The
patient did have difficult peripheral intravenous access during the
admission. However , she did refuse a central line.
5. Neurology: The patient has a seizure disorder and was
continued on Keppra.
6. Endocrine: The patient upon admission had elevation of her
blood sugars to more than 500. The patient was placed on an
insulin drip , which was titrated off on hospital day #2.
Subsequently , on hospital day #2 , the patient did have periods of
hypoglycemia for which she received amps of D50. The patient's
insulin regimen was adjusted during the admission. Initially ,
she was started on NPH 25 once in the evening and NPH 12 units
once every morning. In addition , regular insulin 6 units before
each meal was added. However , the patient again had periods of
hypoglycemia overnight on 1/27/06 and her insulin regimen was
changed to NPH 12 units subcutaneously twice a day with a NovoLog sliding
scale. However , she continued to have periods of hypoglycemia. SHe will be
discharged on NPH 8 units subcutaneously every day before noon and before every meal and every bedtime coverage with a humalog
sliding scale. She will
be discharged on this regimen and should followup at Ainam Iro Hospital .
7. Prophylaxis: Pneumoboots.
8. Hematology: The patient's hematocrit was at baseline and
stable. The patient did have retroperitoneal lymphadenopathy
seen on abdominal CT scan. This will need to be worked up as an
outpatient. This may represent inflammatory changes in the
setting of line sepsis and osteomyelitis however , malignancy will
need to be excluded.
9. Pulmonary: The patient had pulmonary nodules seen on
abdominal CT scan and will need an outpatient follow-up chest CT
to further evaluate these lesions.
10. GI: The patient had a low-attenuation area seen within the
small bowel on CT scan. In discussion with Radiology , we felt
that further imaging as an outpatient could be considered in the
form of either CT enterography or small-bowel follow-through.
They did not feel that this area represented an area of acute
pathology.
11. Wound care: The patient requires three times a day wet-to-dry dressing
changes for her left heel. She will need to follow up with
Vascular Surgery in one week at either F/a Centrham Health Memorial Hospital , depending on the patient's preference. She
should also have dry sterile dressings placed once daily to her
multiple open dermal ulcers that are chronic.
DISPOSITION: Full code. The patient will have homeVNA services.
FOLLOW-UP APPOINTMENTS: The patient will need to follow up with
either Vascular Surgery at Ouf County General Hospital or with Vascular
Surgery , Dr. Halechko at 590-882-9425 at Pagham University Of in one week. The patient will need to follow up with
Dr. Rufus Bernas , 381-216-5702 at Ouf County General Hospital
Nephrology Department after she is discharged from
rehabilitation. The patient should also follow up with Dr.
??__?? at Crossbarn Memorial Hospital in two to four weeks. Upon discharge
from rehab , the patient will undergo hemodialysis at Rbrownrentu Chemend Medical Center , 525-172-8853 in Manor on
Mondays , Wednesdays , and Fridays.
DISCHARGE MEDICATIONS:
Tylenol 650 mg orally every four hours as needed for headache ,
Keppra 500 mg orally twice a day , PhosLo 667 mg orally three times a
day , Toprol-XL 100 mg orally once a day , Nephrocaps one tablet orally
once a day , Linezolid 600 mg orally every 12 hours for 18 more days ,
insulin NPH 8 units subcutaneously once every morning please take
one-half dose if not eating , oxycodone 5
mg orally every four hours as needed for pain and hold if sedation ,
lisinopril 5 mg orally once a day , Plavix 75 mg orally once a day ,
Humalog sliding scale as follows: If glucose 0-70 , call
physician and drink orange juice; if fingerstick less than 200
then give zero units of Humalog; if fingerstick 201-250 then give
2 units of Humalog subcutaneously; if fingerstick 251-300 then
give 4 units of Humalog subcutaneously; if fingerstick 301-350
then give 6 units of Humalog subcutaneously; if fingerstick
351-400 then give 8 units of Humalog subcutaneously; if
fingerstick greater than 400 , take 10 units Humalog and call physician
if
fingerstick is greater than
400.
Levaquin 250 mg orally qday X 10 days
eScription document: 8-2698432 EMSSten Tel
CC: Rufus Bernas
Nephrology Department
Tonsta Ean Villebaxt Hospital
Dictated By: JERRETT , RACHEAL
Attending: PILLING , WEI
Dictation ID 8885192
D: 2/18/06
T: 2/18/06
Document id: 369
| Target |
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DM |
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| output/system_textual_annotation.xml | textual |
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570822487 | PUO | 60118630 | | 551315 | 1/6/1998 12:00:00 a.m. | MORBID OBESITY , SLEEP APNEA , DIABETES | Signed | DIS | Admission Date: 4/17/1998 Report Status: Signed
Discharge Date: 6/1/1998
CHIEF COMPLAINT: Morbid obesity.
HISTORY OF PRESENT ILLNESS: This is a 37-year-old woman with a
past medical history of depression ,
who is morbidly obese with a height of 5'3 and weight of 533 lb.
PAST MEDICAL HISTORY: Non-insulin dependent diabetes mellitus ,
depression , sleep apnea using C-PAP ,
arthritis bilaterally , status post appendectomy , status post
cholecystectomy.
MEDICATIONS: Lisinopril; Ativan; Provera; cisapride; Elavil;
Prozac; trazodone; quinine; Percocet; Prevacid;
Beconase AQ.
HOSPITAL COURSE: The patient was taken to the Operating Room on
9/27/98 and underwent an uncomplicated vertical
banding gastroplasty. The patient tolerated the procedure well and
because of her large habitus and possible respiratory compromise
from her history of sleep apnea , she was taken to the ICU. She was
extubated readily and remained on her C-PAP face mask.
Over the next several days , the patient tolerated her increasing
diet quite well without bloating , nausea or vomiting. She did
actually ambulate with assistance and was cleared by physical therapy to go. Her
incision was clean , dry , and intact by the time of discharge.
DISCHARGE MEDICATIONS: Colace elixir 100 mg orally twice a day; MVI 5 ml
orally every day; Roxicet elixir 10 ml orally
every 3-4h. as needed pain. Other preop medications should be resumed as
she begins to take solid foods.
DISCHARGE FOLLOW-UP: The patient will follow-up with Dr. Dierker .
DISCHARGE DISPOSITION: The patient was discharged to home with
services.
CONDITION ON DISCHARGE: Stable condition.
Dictated By: DEXTER K. YAMKOSUMPA , M.D. UH25
Attending: ZORA DIERKER , M.D. SE02 UR686/2117
Batch: 72578 Index No. PGJIP71HRH D: 10/20/98
T: 2/13/98
Document id: 370
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N |
- |
739728642 | PUO | 41684491 | | 574978 | 5/12/2001 12:00:00 a.m. | gastritis | | DIS | Admission Date: 4/22/2001 Report Status:
Discharge Date: 4/30/2001
****** DISCHARGE ORDERS ******
KILBRIDE , BRUCE B 587-77-42-5
Virguliet Nah
Service: MED
DISCHARGE PATIENT ON: 3/1/01 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: AZUA , SANA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ELAVIL ( AMITRIPTYLINE HCL ) 25 MG orally every bedtime
TRILISATE ( CHOLINE MAGNESIUM TRISALICYLATE )
750 MG orally three times a day as needed pain
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 300 MG orally three times a day
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 60 MG orally every day
Alert overridden: Override added on 10/1/01 by
MCLAIRD , LUDIVINA S. , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: aware
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 45 U subcutaneously every day before noon
INSULIN REGULAR HUMAN 10 U subcutaneously twice a day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
LISINOPRIL 2.5 MG orally every day
Override Notice: Override added on 10/1/01 by
MCLAIRD , LUDIVINA S. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
83923731 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB orally Q5 MIN X 3
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
PREDNISONE 5 MG every day before noon; 2.5 MG every afternoon orally 5 MG every day before noon 2.5 MG every afternoon
SIMETHICONE 80 MG orally four times a day as needed gas
NEURONTIN ( GABAPENTIN ) 600 MG orally four times a day
ASPIRIN ENTERIC COATED ( CHILDREN'S ) 81 MG orally every day
ARAVA ( LEFLUNOMIDE ) 10 MG orally every day
LIPITOR ( ATORVASTATIN ) 20 MG orally every afternoon
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
ATENOLOL 75 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Abshear , cardiology 1/8/01 scheduled ,
Dr. Azua , internal medicine 2-3 weeks ,
ALLERGY: Sulfa
ADMIT DIAGNOSIS:
epigastric pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
gastritis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypothyroid htn
diabetes mellitus post herpetic neuralgia bilateral total knee
replacement history of appenedectomy history of cholecystectomy
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
69 year-old female with NIDDM , HTN , obese , former smoker admit two weeks ago
after discharge for positive stress test. In October , during
dobutamine part of MIBI patient had severe SOB with desat to 60s , ruled in
for NQWMI , refused cardiac cath or further evaluation. patient now
readmitted with several days of nausea-like epigastric sensation
following meals , esp fatty/caffeine meals , decreased orally intake , then
on day PTA with profound nausea , diaphoresis and SOB while ambulating.
EXTREMELY difficult by history to differentiate cardiac vs GI etiology.
On examination only tachycardic , no signs failure. Plan was to treat
as cardiac disease , and evaluate for GI cause. patient's lopressor was dose
adjusted for tachycarida , continued on ASA , ACE , nitrates. patient not
anticoagulated. Cardiology consult felt new symptoms were GI and did
not recommend in-house cardiac catherization. patient was started on
increased dose of prilosec for presumed gastritis with no evidence of
GIB by hct and heme negative stools. Presumed cause was home asa and
prednisone use. patient will consider outpatient cardiac catherization and
intervention. She is scheduled to see Dr. Ceretti in 2 weeks and Dr.
Azua promptly after that.
ADDITIONAL COMMENTS: Please call your physician with any chest pain that is new , different
in quality , or if accompanied by shortness of breath , nausea , vomiting.
Please record the timing and nature of your symptoms if you continue to
have them. Also please record what makes them come and what makes them
go away.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MCLAIRD , LUDIVINA S. , M.D. ( BV53 ) 3/1/01 @ 12:25 PM
****** END OF DISCHARGE ORDERS ******
Document id: 371
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
871573559 | PUO | 90977187 | | 4380934 | 3/16/2006 12:00:00 a.m. | atypical CP , | | DIS | Admission Date: 6/4/2006 Report Status:
Discharge Date: 4/7/2006
****** FINAL DISCHARGE ORDERS ******
VEVE , ISIAH 556-26-19-5
De St.
Service: MED
DISCHARGE PATIENT ON: 6/3/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TIBOLLA , MADISON , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
325 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ENALAPRIL MALEATE 10 MG orally DAILY
Override Notice: Override added on 3/26/06 by
GORGLIONE , JEANNETTE , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
130450541 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: mda
FENTANYL ( PATCH ) 25 MCG/HR TP every 72 hours
OXYCODONE 5 MG orally every 8 hours as needed Pain
TERAZOSIN HCL 4 MG orally DAILY
Number of Doses Required ( approximate ): 10
MIRTAZAPINE 15 MG orally BEDTIME
Number of Doses Required ( approximate ): 3
METFORMIN 1 , 000 MG orally twice a day
ATENOLOL 25 MG orally DAILY
PREVACID ( LANSOPRAZOLE ) 30 MG orally DAILY
DIET: House / NAS / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Yueh 6/25 @ 1pm ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CP
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical CP ,
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
brugada , history of ICD , depression , diabetes mellitus type 2 , OSA ,
pseudodementia , htn , hypercholesterolemia , gastritis
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: CP
HPI: 43M multiple cardiac risk factors , including tobacco use , HTN ,
hypercholesterolemia , p/with constant CP complaints. 2 days ago , while
ambulating up stairs patient developed sob with cp described as left sided
pressure radiating to left arm. Associated with sob/palp. patient sat
down and pain releaved with rest x 1-2 hours , no sublingual NTG given.
Subsequently , pain returned when patient exercising with his kids , again
lasting apporx 1-2 hrs. patient reports while walking up stairs , again
experienced CP , which prompted him to presented to PUO ED. Per patient , had
left heart cath in 4 of November during ICD placement for ?Brugada , which
revealed nonobstructive CAD ( not in PUO records ). Last ETT with MIBI in
9/8 ambulated for 7:14 , HR 90 PHR , no EKG changes , no perfussion
deficits. TEE 2004 - EF 55% and unremarkable. patient also reports 1-2 days
of orthopnea/PND/nocturia , ROS negative for f/c/cough/URI sx/postural
CP.
****
PMH: Brugada , history of ICD placement , DMII , OSA , peudodementia , HTN ,
hypercholesterolemia , CAD , gastritis/ H. pylori , + tobacco use 15pack
yrs , chronic LBP
****
Home Meds: oxycodone 5mg every day , asa 81 every day , atenolol 25mg every day , terazosin 4
every day , lipitor 10 wd , metformin 1000 twice a day , enalapril 5 wd , prevacid ,
fentanyl patch 25 every day , mirtazapine 15 every day
****
All: NKDA
****
PE on Admission:
VS: Afebrile , HR 80-106 , BP 123/80 , SaO2 98% RA
Gen: NAD , mild discomfort in bed , obese
HEENT: no JVD , no LAD , PERRL , EOMI
Lungs: ctab
CV: RR , S1S2 no m/c/g/r , no reproducible pain with palpation
Abd: obese , NABS , soft , NTND , no HSM/RT/G
Ext: WWP , no edema
Neuro: A+O x 3 , no focal deficits
****
Data:
EKG: NSR @ 90bpm , ST elevation V1 V2 ( OLD ) , T wave inversion in III ,
no acute ST/T wave changes
Cardiac Enzymes x 3 sets negative
ECHO 2/28 Normal LV fx with EF 55% , no regional wall abnormalities , nrl
RV fx/size , mild LAE , RAE , aortic valve mildly thickened , no aortic
regurgitation , trace mitral regurgitation , structurally normal tricuspid
valve with no sig tricuspid regurgitation , trace tricuspid regurgitation ,
nrl pulmonic valve , nrl aortic aortic root size , main pulmonary artery
nrl in size , IVC nrl size with nrl RA pressure , no pericardial effusion
****
Hospital Course:
*CV: history concerning for cardiac event thus patient started on tele
monitoring and cardiac enzymes/serial EKG cycles - negative x 3. tele
monitoring continued until ECHO done on 2/23 in a.m. ( result as above )
Baseline CV meds continued. ( patient has recent with u with MIBI done that was
unremarkable. ) EP consulted to assess pacer - stable with no
interventions needed.
*Pulm: O2 as needed via NC , BS ctab. No further pulm intervention needed yet
patient given as needed ativan for increased anxiety likely related to SOB
complaints.
*Endo: known DMII on orally hypoglycemics , metformin held on admit and patient
put on DM protocol with NPH twice a day , Aspart before every meal , and aspart SS. Carbohydrate
controlled cardiac diet ordered. A1C 6.5. Monitored FSBS. patient will be
d/c home on baseline metformin regimen.
*PPx: lovenox + nexium
FULL CODE
ADDITIONAL COMMENTS: 1. Follow-up with Dr. Boward in 6/10 for routine pacer follow-up
appoinment
2. Monitor finger stick sugars and record for primary care physician to adjust metformin
dose.
3. Return to ER if you experience worsening CP/SOB/Nausea/Vomiting
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TROKEY , CLARITA K. , PA ( ZU74 ) 6/3/06 @ 09:36 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 372
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
Y |
N |
N |
N |
Y |
N |
Y |
N |
N |
Y |
Y |
N |
N |
712290326 | PUO | 60172509 | | 067195 | 10/24/1998 12:00:00 a.m. | PULMONARY EMBOLIS | Signed | DIS | Admission Date: 8/14/1998 Report Status: Signed
Discharge Date: 10/2/1998
DISCHARGE DIAGNOSIS: PULMONARY EMBOLISM.
PROBLEMS: 1 ) MORBID OBESITY.
2 ) OBSTRUCTIVE SLEEP APNEA.
3 ) ASTHMA.
4 ) HYPERTENSION.
5 ) CARDIOMEGALY.
6 ) GOUT.
7 ) CHRONIC RENAL INSUFFICIENCY.
8 ) DEPRESSION.
9 ) ALCOHOL ABUSE.
10 ) SINUSITIS.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old man who
was morbidly obese and presented with
dyspnea , pedal edema , and chest discomfort. At baseline , the
patient was unable to walk from room to room at home without
becoming dyspneic. He used a BiPAP with pressure support of 15 and
PEEP of 10 on room air at night. Over the past two weeks , however ,
the patient had noted gradually worsening dyspnea with minimal
exertion now such as just turning over or sometimes even at rest.
Concomitantly , patient had noted , initially , left calf and ankle
swelling approximately one week ago that improved after several
days then right calf and ankle swelling and tenderness which still
persisted. He also noted upper respiratory symptoms with
intermittent dry cough , sinus pain , and congestion over the past
week. He denied fever or chills. He had experienced intermittent
chest spasm which he distinguished from cardiac pain. This pain
felt like spasms generally experienced in his arms. The patient
had experienced no constipation but had intermittent diarrhea which
was then thought to be secondary to colchicine therapy. The
patient presented to the Emergency Department for further work-up.
PAST MEDICAL HISTORY: Morbid obesity , obstructive sleep apnea ,
hypertension , cardiomegaly , gout , asthma ,
chronic renal insufficiency with baseline creatinine approximately
1.6 , depression , thrombophlebitis , and alcohol abuse.
PAST SURGICAL HISTORY: Ileojejunal bypass in 1972 , gastric
stapling in 1987 , and colon polypectomy.
ALLERGIES: Penicillin gave hives and erythromycin gave hives.
CURRENT MEDICATIONS: Verapamil SR 240 mg orally every day , furosemide 20
mg orally every day , Albuterol two puffs inhaled
three times a day , beclomethasone two puffs inhaled three times a day , phentermine 30 mg
orally every day , buspirone 20 mg orally twice a day , Fluoxetine 20 mg orally every day ,
lorazepam 1 mg orally every day before noon , 1 mg orally every afternoon , and 2 mg orally every bedtime ,
piroxicam 20 mg orally every day , colchicine 0.6 mg orally twice a day , and
trazodone 50 to 100 mg orally every bedtime as needed insomnia.
SOCIAL HISTORY: Lived with daughter and son-in-law , former cab
driver and courier , denied smoking , and drank one
to two pints of alcohol per day.
FAMILY HISTORY: Mother with diabetes , adult onset , father with
hypertension , and alcoholism in father and mother.
PHYSICAL EXAMINATION: Morbidly obese adult male in no apparent
distress with vital signs of temperature
99.4 , pulse 82 , blood pressure 110/80 , respiration rate 28 , and O2
saturation 98% on four liters. HEENT: Pupils equal , round , and
reactive to light , extraocular muscles intact , right sinus
tenderness greater than left , and oropharynx clear. NECK: Supple ,
full range of motion , no lymphadenopathy , and unable to appreciate
jugular venous pressure. CHEST: Minimal expiratory wheezes
diffusely. CARDIOVASCULAR: Normal rate , regular rhythm , distant
heart sounds , grade I/VI systolic ejection murmur along the left
sternal border. ABDOMEN: Morbidly obese , bowel sounds present ,
soft , nontender , nondistended , and no palpable organomegaly or
masses appreciated. EXTREMITIES: 1+ pitting edema of the right
ankle , trace edema on the left , right calf tenderness , no warmth ,
positive Homan's , and pulses 2+ bilaterally. NEUROLOGICAL: Alert
and oriented.
LABORATORY EXAMINATION: On admission , sodium was 147 , potassium
4.2 , chloride 106 , bicarbonate 26 , BUN 24 ,
creatinine 1.8 , glucose 91 , AST 14 , alkaline phosphatase 52 ,
albumin 4.1 , calcium 8.5 , CK 311 , MB 1.5 , troponin I 0.3 , white
blood cell count 8.6 with polys 695 , lymphocytes 21 , monocytes 8 ,
and eosinophils 1 , hematocrit 40.9 , platelets 200 , physical therapy 13.4 , and PTT
25.0. EKG showed a normal sinus rhythm at 74 with intervals
0.22/0.14/0.45 , axis minus 38 degrees , left atrial enlargement ,
intraventricular conduction defect , T wave inversion in II , III ,
and V6 , and no change since 3/11 . Chest x-ray showed low lung
volumes and VQ scan showed high probability for pulmonary embolism
in let lower lobe , left upper lobe , and right upper lobe.
HOSPITAL COURSE: Patient is a 57 year old morbidly obese man with
extensive past medical history now admitted with
progressive dyspnea over the past two weeks and studies showing
pulmonary embolism. The patient was started on intravenous
Heparin. The dose of Heparin was increased until his PTT was in
the range of 60 to 80 seconds. Oral anticoagulation with warfarin
was initiated at 15 mg each night. After three nights of therapy ,
the patient's INR was 1.4 so his dose was increased to 20 mg per
night. After two nights of this therapy , his INR started to rise
to 2.3 and his dose was decreased to 15 mg. His INR the next
morning was 2.6. Intravenous Heparin therapy was discontinued.
The patient also had right ankle pain and erythema that was
consistent with a flare of gout. His dose of colchicine was
increased from 0.6 mg twice a day to three times a day Allopurinol was also
started for uric acid levels of 7.9. The patient had symptoms of
sinusitis likely from his use of BiPAP at home. He was started on
trimethoprim/sulfamoxole double-strength twice a day. Physical
therapy was initiated. The patient was able to transfer himself
from bed to chair and was able to ambulate approximately sixty feet
with minimal dyspnea. An extra-wide heavy duty rolling walker was
obtained to help the patient maintain his balance.
DISPOSITION: The patient is discharged to home with VNA services.
A nurse will draw his blood tests for INR testing. A
home safety evaluation will also be performed.
DISCHARGE MEDICATIONS: Warfarin 15 mg orally every bedtime , Albuterol two
puffs inhaled three times a day with spacer ,
beclomethasone two puffs inhaled three times a day with spacer , rinse with
water after using , allopurinol 100 mg orally every day , colchicine 0.6 mg
orally three times a day , Fluoxetine 20 mg orally every day , folate 1 mg orally every day ,
furosemide 20 mg orally every day , Verapamil SR 240 mg orally every day ,
trimethoprim/sulfamoxole DS one tablet orally twice a day times fourteen
days , docusate 100 mg orally three times a day , and buspirone 20 mg orally twice a day
CONDITION ON DISCHARGE: Stable with INR 2.6.
FOLLOW-UP: He will follow-up in one week with his primary care
physician , Dr. Erma Bess .
Dictated By: CLARITA K. TROKEY , M.D. QD97
Attending: CARMON E. BOSHERS , M.D. HC6 CS779/5815
Batch: 27193 Index No. IXLXQC727H D: 7/8/98
T: 8/10/98
Document id: 373
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
N |
Y |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
Y |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
957472045 | PUO | 07629117 | | 3450458 | 9/1/2005 12:00:00 a.m. | Congestive heart failure with dilated cardiomyopathy | | DIS | Admission Date: 7/15/2005 Report Status:
Discharge Date: 8/21/2005
****** FINAL DISCHARGE ORDERS ******
LOQUE , DANE 141-02-71-4
Van
Service: MED
DISCHARGE PATIENT ON: 6/8/05 AT 12:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
Override Notice: Override added on 10/4/05 by
BORRIELLO , SACHIKO S. , M.D.
on order for COUMADIN orally ( ref # 42557905 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MD aware Previous override information:
Override added on 10/4/05 by BORRIELLO , SACHIKO S. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: Patient has been stable on this
regimen at home.
PHOSLO ( CALCIUM ACETATE ) 667 MG orally three times a day
FOLATE ( FOLIC ACID ) 1 MG orally every day
DIOVAN ( VALSARTAN ) 160 MG orally every day his cardiologist.
Number of Doses Required ( approximate ): 4
CARVEDILOL 6.25 MG orally twice a day HOLD IF: HR < 60 , or SBP < 100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
his cardiologist Number of Doses Required ( approximate ): 8
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 10/4/05 by
BORRIELLO , SACHIKO S. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: MD Aware
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Alert overridden: Override added on 6/8/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: home med
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Escarcega at MH 10/22/05 at 1:30 PM scheduled ,
Dr. Frossard at MH 9/6/05 at 1:40 PM scheduled ,
Chantell Badalamenti at PRMC , call to schedule this within 2 weeks TBA ,
ALLERGY: Penicillins , lisinopril , Hctz , Advair
ADMIT DIAGNOSIS:
Dyspnea and hypoxia on exertion
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive heart failure with dilated cardiomyopathy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Asthma , OSA , CRF , Recent multifocal PNA , history of DVT , hypercholesterolemia ,
obesity
OPERATIONS AND PROCEDURES:
Chest CT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Pulmonary consult
BRIEF RESUME OF HOSPITAL COURSE:
ID: 42 year-old man dilated non-ischemic CM ( EF 23% ,
cath 2/1 = no CAD ) , OSA , CRF almost ESRD ( 2/2 HTN vs. obesity
related GS ) , DVT ( 9/8 , on coumadin ) , asthma , HTN , OSA , mild
hyperhomocysteinemia. ---
CC: 5 weeks worsening DOE 3 miles flat ground --> 50 ft. flat
ground ---
DX: CHF exacerbation AND ? multifocal PNA vs. other primary lung
etiology , CRF almost ESRD ---
HPI: 42 year-old man with above hx , admitted 9/8 dx'd multifocal PNA tx'd
14d levoflox , D/C'd feeling well , then progressive inc DOE now
hypoxia on exertion. No cough/F/C. Last admit 9/8 CT:
multifocal PNA , CTA no PE , LENIS L peroneal DVT. Started Heparin , VQ
negative , converted to coumadin INR 2-3 for DVT. ECHO: EF 25% , mod
RV dsyfn , severe TR ( then F/U cardiac MRI 7/9 EF 23% ,
global hypokinesis , no WMA , nl RV , no valve dz ). Renal consult for
stable CRF Cr 5.5-6.0 , F/U in outpatient clinic , have discussed
vascular access but none placed yet. 9/8 Ddimer 1400 , BNP 2009 ,
Trop 0.84-->0.54 not considered ischemic , no tx. C/O 10lb weight
gain over last month , ROS O/W negative ( no F/C/CP , etc ). Now DDimer
1207 , BNP 2917 , Trop not
sent. ---
STATUS: T 97.2 HR 98-104 BP 160/114 RR 18 95%
RA desat 85% RA walking 50 ft.
comfortable breathing at rest , nice guy , JVP to earlobe , bibasilar
rales , no wheezes , obese , S3 , 1+ pitting edema to B shins , diffuse
PIPA ---
EVENTS In ED: Duonebs , ASA 325 , Lasix 80mg
orally CXR: increased bilat LL opacities to periphery
with some cephalization of vessels , some opacification
ECG: 98 bpm , LAE , strain ---
TESTS/PROCEDURES Chest CT 9/10 ( compare to 9/8 ): Per pulm c/with
scarring/persistent changes after recent multifocal PNA 9/8 , no e/o
of new primary lung path , ground glass c/with pulmonary
edema ---
HOSPITAL COURSE: SOB secondary to CHF exacerbation and fluid overload. No
evidence of infectious pulmonary process contributing to present
symptoms. CXR and CT changes are c/with scarring/changes from recent
multifocal PNA 9/8 , with additional ground glass c/with pulmonary edema.
No clinical or radiologic e/o primary lung etiology for DOE. Pulmonary
team assessed patient and reviewed non contrast chest CT from this
admssion - they confirmed that current sx are likely 2/2 pulomonary
edema. Patient was diuresed with Lasix just over 3L net negative with
improvement in his oxygen saturations ( rest and ambulation ). At time of
d/c JVP 10cm. patient will diurese further at home on Lasix 80 twice a day ( he had
not been taking his lasix for 2d prior to d/c. HTN was
another issue on admission but is most likely due to patient taking wrong
dose of Coreg ( taking every other day instead of twice a day ). On a twice a day Coreg regiments , BP
much better controlled. Etiology of his CMP still remains unclear despite
extensive outpt W/U. Additionally , discrepancy between Echo and
Cardiac MRI is puzzling. No concern for ischemia on this admission ,
clean cath in 2002. Started on ASA and continued on Lipitor. Renal function
remained stable but impaired. He is being evaluated for dialysis as an
outpatient but no vasc access placed yet. Phoslo , nephrocaps continued
here. Finally , patient continued on coumadin for history of recent DVT ( 9/8 ) and INR
remained in therapeutic range. Low suspicion for PE on this admission. He
was discharged in stable condition with outpatient follow up instructions..
ADDITIONAL COMMENTS: 1. Be sure to take your Coreg as instructed.
2. Call your doctor if your shortness of breath gets worse or if you have
chest pain , fevers or dizziness.
3. Take your coumadin as regulated by the anticoagulation
clinic.
4. Check your weight daily and take your lasix as prescribed.
5. Call you primary care doctor and cardiologist Monday morning 9/7 .
Please see one of them this upcoming week.
DISCHARGE CONDITION: Fair
TO DO/PLAN:
Follow up with your primary care doctor , your cardiologist and the renal
clinic.
No dictated summary
ENTERED BY: COSE , LATASHIA C. , M.D. , M.B.A. ( JU10 ) 6/8/05 @ 10:25 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 374
| Target |
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HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
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Y |
U |
Y |
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U |
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Q |
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U |
Y |
Y |
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| output/system_intuitive_annotation.xml | intuitive |
Y |
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N |
907369197 | PUO | 88784623 | | 6586180 | 10/14/2003 12:00:00 a.m. | asthma/copd exacerbation | | DIS | Admission Date: 3/6/2003 Report Status:
Discharge Date: 5/6/2003
****** DISCHARGE ORDERS ******
BUNTING , WAYNE 365-45-28-4
Stary Parkway
Service: ONC
DISCHARGE PATIENT ON: 5/17/03 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KENNET , KIRK WM , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
as needed shortness of breath or wheeze
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
EPOGEN ( EPOETIN ALFA ) 40 , 000 UNITS subcutaneously QWEEK
LASIX ( FUROSEMIDE ) 120 MG orally every day Starting IN a.m. ( 11/24 )
GLYBURIDE 5 MG orally twice a day
ROBITUSSIN ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours as needed cough
MAALOX PLUS EX. STR. 15 milliliters orally every 6 hours
as needed Indigestion
PREDNISONE Taper orally every day
Give 60 mg every day X 2 day( s ) ( 8/15/03-03 ) , then
Give 50 mg every day X 1 day( s ) ( 11/9/03-03 ) , then
Give 40 mg every day X 1 day( s ) ( 9/20/03-03 ) , then
Give 30 mg every day X 1 day( s ) ( 10/30/03-03 ) , then
Give 20 mg every day X 1 day( s ) ( 11/7/03-03 ) , then
Give 10 mg every day X 1 day( s ) ( 3/27/03-03 ) , then
Starting Today ( 5/3 )
SENNA TABLETS 2 TAB orally twice a day
VERAPAMIL SUSTAINED RELEAS 240 MG orally twice a day
HOLD IF: sbp < 90 or heart rate < 55 and call ho
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG NEB four times a day
SEREVENT ( SALMETEROL ) 2 PUFF inhaled twice a day
Alert overridden: Override added on 3/20/03 by
HENRIKSEN , LANE , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & SALMETEROL
XINAFOATE Reason for override: will follow
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day as needed cough
Number of Doses Required ( approximate ): 5
METFORMIN 500 MG orally twice a day
LEVOFLOXACIN 500 MG orally every day X 7 Days
Starting Today ( 1/9 )
Instructions: finish 7 day course for total of 12 days on
antibiotics Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 3/20/03 by
HENRIKSEN , LANE , M.D.
on order for SEREVENT inhaled ( ref # 75914578 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & SALMETEROL
XINAFOATE Reason for override: will follow
WELLBUTRIN SR ( BUPROPION HCL SUSTAINED RELEASE )
150 MG orally twice a day Number of Doses Required ( approximate ): 8
PULMICORT ( BUDESONIDE ORAL INHALER ) 1 PUFF inhaled twice a day
SPACER 1 EA inhaled to bedside Instructions: FOR PATIENT'S
AVAPRO ( IRBESARTAN ) 150 MG orally twice a day
HOLD IF: sbp < 90 and call ho
Number of Doses Required ( approximate ): 10
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
HOME GLUCOSE MONITOR 1 EA x1 Starting Today ( 5/3 )
Instructions: patient also provided with script for lancets & test
strips for 1 month supply & to call MD if BS > 400
and to check finger stick blood sugar at least twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lashawna Labauve , your primary care doctor , 188 013 2259 , please call doctor for appointment within 2 weeks of discharge ,
MMC asthma clinic at Waywo Avenue , please call primary care doctor for appointment within 2 weeks of discharge ,
Dr. Kennet , your oncologist Monday April scheduled ,
ALLERGY: Penicillins , Erythromycins , Shellfish , Nsaid's ,
Codeine
ADMIT DIAGNOSIS:
asthma
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
asthma/copd exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , r/o MI HTN DM Asthma Obesity Sleep apnea CHF ( congestive heart
failure ) pre-syncope ( near syncope ) NHL history of chop 11/19 history of PNA 5/29 ppd
positive
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
51 F with NHL , asthma/copd , history of LLL PNA 5/29 , CHF ,
CAD , DM2 , obesity/osa , p/with sob & chest tightness , likely 2/2 viral
exacerbation of asthma with mild CHF exacerbation , being discharged
comfortable on room air ( RA 95% ) , able to ambulate , with peak flows 300 ,
history of approx 5L diuresis , to continue home asthma meds , finish
antibiotics course & short prednisone taper , and follow-up with primary care physician as
outpatient for asthma clinic referall. HPI: history of CHOP for NHL 3/12/03 .
recent admit to PUO 5/29 for
fever/neutropenia while on chemotx-> LLL PNA , cx's grew nl orally flora ,
rx'd with biaxin x 14 days; mild asthma exacerbation , short pred taper;
also volume overloaded-> intravenous lasix diuresis. history of d/c
( + ) intermitant SOB 2/2 asthma induced by cold
air. 4-6 days PTA , dtr ( + ) viral illness. patient
developed increased sputum production , incr wob/doe , rx'd
with home neb 4-6x every day with symptoms worse at night.
peak flows ( PFs ) nl'y 350-400 range , per patient on doa ,
PF 250-270. Also , 11/27 5 lb wt gain in past wk with
incr LE edema , incr home lasix from 80->120 mg orally
every day ED VS T97 , HR 92 , BP 118/78 , 99% RA , RR 20 ,
given atrovent/alb nebs , 20 intravenous lasix; BNP 96;WBC 6.7 ,
UA wnl , CXR: no pulm edema , infiltrates ,
effusions; LUNG exam: ant-diffuse bilat wheezes &
course upper airway sounds , post- LLL rales , decr.
air movement throughout.
PROBLEM LIST:
( 1 ) PULM/ID: ( a ) 5/8 no o2 requirement 96% 2L
( b ) nebs , nebs as needed , home inhalers ( c ) 5/8
intravenous solumedrol 80 three times a day-> taper to orally prednisone after 1 day. patient's peak
flows on day of discharge 300 which is 75% of her max home peak
flow ( 400 ). patient will be discharged on short prednisone taper , to
finish 12 day Levoquin taper , and to resume her home asthma meds. She
has been instructed to see her primary care physician for referal to MMC asthma clinic
within 2 weeks of discharge. Of note , on admission , WBC 5/8 6.7 , 2/23
history of intravenous steroids , wbc 13.7 down from peak 14s , afebrile with sputum
culture that grew out only orally flora , to finish 12 day levoquin
course.
( 2 ) CV: March vol overload , last EF 11/25 60-65% ( a ) 5/8 lasix 40iv
twice a day , goal 1-1.5L neg ( b ) cardiac diet , 2L fluid rest. , daily wts. patient
diuresed a net of about 5-6 Ls during this admission and will be
sent home back on her outpt dose of 120 mg orally lasix with sign.
reduction of her mild peripheral edema on admission. patient instructed
to follow-up with her CHF nurse for further outpt titration of her
lasix dose. ( c ) sbp 5/8 130- 140s , cont avapro , verapamil with no
further issues , being discharged with sbps 130s.
( 3 ) GI-bowel regimen , nexium while on steroids. Can decide as outpt
if need to continue nexium past 1 month prescription & when patient done
steroids.
( 4 ) Renal: 5/8 cr 1.1 2/23 history of diuresis , cr 0.7 , stable. Follow-up
electrolytes as outpatient while on lasix. In house , electrolyes
were repleted without issues.
( 5 ) ENDO: ada diet , cont home meds , czi while on steroids. patient had
2 high blood sugars ( >400 ) on admission following start of intravenous
solumedrol , with rest averaging in low 200s. patient will be sent home on her
orally glycemic regimen & a rapid , short prednisone taper. Follow-up her
blood sugars for return to baseline after taper. Follow-up pending h
emoglobin a1c at time of discharge. patient states she has done home glucose
monitoring before. She is being discharged with prescriptions for home
glucose monitorin and instructions to test blood sugar at least twice a day
and call MD if BS > 400
( 6 ) Psych: cont wellbutrin
( 7 ) Heme/Onc: ( a ) HCT 5/8 34 , 2/23 33.5 stable , no futher issues ( b ) no
pain ( c ) full code ( d ) off chemotx. patient had chest CT and a nuclear
scan that showed no residual lymph nodes history of her chemotherapy. patient
will followup with her oncologist as outpatient.
ADDITIONAL COMMENTS: Please call your doctor or return to ED if any of you symptoms , such as
chest tightness , wheezinge , or shortness of breath , reoccur , worsen , or
change in any way concerning to you. ( 2 ) Take your entire course of
Levaquin antibiotics & your prednisone taper as instructed. ( 3 ) Watch
your weight on lasix 120 mg orally every day & call your CHF nurse if you are
gaining to much weight or feeling dizzy or lightheaded. ( 4 ) Call your
doctor if the office does not call you with your appointment time/day.
( 5 ) Check fingerstick blood sugar 2 times/day , call MD if BS > 400.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
( 1 ) Follow-up ( f/u ) peak flows on current asthma flare and titrate
asthma meds as needed. patient requests referral to MMC asthma clinic as
outpatient. ( 2 ) F/u weight , volume status , & electrolytes on lasix 120
mg orally every day and titrate lasix dose as needed. ( 3 ) F/u blood sugars after
prednisone taper ends & f/u hemoglobin a1c pending at time of
discharge. ( 4 ) f/u if patient still requires nexium history of prednisone taper
( only given 1 month supply ).
No dictated summary
ENTERED BY: HENRIKSEN , LANE , M.D. ( NI90 ) 5/17/03 @ 01:48 PM
****** END OF DISCHARGE ORDERS ******
Document id: 375
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
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- |
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615038343 | PUO | 94076394 | | 6362454 | 11/20/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/23/2004 Report Status: Signed
Discharge Date:
ATTENDING: WERNER REGINIA CASEBIER M.D.
GMS Sa Vinew San , Virginia 24303 SERVICE
DATE OF DISCHARGE:
To be determined.
CHIEF COMPLAINT:
Increased dyspnea on exertion.
HISTORY OF PRESENT ILLNESS:
This 62-year-old male with morbid obesity , hypertension , chronic
renal insufficiency , prior MI presents with increased lower
extremity edema and dyspnea on exertion over the last several
months. Some of this has been attributed to volume overload and
the patient has had an increased creatinine from approximately in
early February of this year to 5.5 in September . The patient had
previously refused dialysis , but agreed a few weeks ago to begin
the process of dialysis and was scheduled for a fistula
evaluation next week. However , in the past few days , his dyspnea
on exertion has accelerated. Whereas , he used to be able to walk
40 to 50 feet without shortness of breath , he is now only able to
walk 10 feet. Therefore , he is presenting to the emergency
department. In the emergency department , he got his home CPAP ,
was noted on chest x-ray ( of poor quality ) to have a question of
a left lower lobe consolidation and therefore received one dose
of ceftriaxone and azithromycin. His BNP was elevated to 1663
( from 655 one year ago ) and his creatinine rose to 5.9 from 5.5
in September and 4.1 in February . Therefore the patient was felt to
have also an element of volume overload and he was admitted to
the renal service for consideration of dialysis and volume
removal.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes type II.
3. Morbid obesity.
4. Sleep apnea.
5. Chronic hydronephrosis.
6. FSGS ( focal segmental glomerular sclerosis ).
7. Status post chemotherapy for multiple myeloma.
8. BPH.
9. Prior MI ( was not able to cath due to body habitus ).
10. Hypercholesterolemia.
11. Chronic renal insufficiency ( baseline creatinine 4.1 ).
ALLERGIES:
The patient states that aspirin has given him a bleed before from
his urine that resolved when the aspirin was stopped.
MEDICATIONS:
1. Multivitamin.
2. Toprol XL 100 mg every day
3. Lasix 160 mg orally every day
4. Epogen 40 , 000 units every week.
5. Mirapex 1 mg every day before noon , 0.5 mg every afternoon
6. Calcitriol 0.75 mg every day
7. Trazodone 60 mg orally as needed insomnia.
8. Wellbutrin 150 mg orally every day before noon
9. Protonix 40 mg orally every day before noon
10. Bactroban topical twice a day
11. Sotalol 40 mg orally twice a day
12. Lipitor 40 mg orally every day
13. Sudafed 60 mg orally every bedtime as needed nasal congestion.
14. Flomax 0.8 mg orally every day
15. Iron sulfate 325 mg orally three times a day
16. Afrin two puffs as needed
17. Vitamin C.
18. Glipizide 5 mg orally every day
19. Flonase.
20. Vicodin 5/500 mg every 4 hours as needed
21. Nasonex.
PHYSICAL EXAM:
Pulse 92 , blood pressure 160/70 , respirations 18 , 95% on room
air. The patient is wearing his CPAP. He is falling asleep
during the interview. He is in no apparent distress. Heart is
regular rate and rhythm. Heart sounds are distant , but S1 , S2
are heard. There is no murmurs , gallops , or rubs. JVP cannot be
determined. The patient has crackles at the right base. Abdomen
is markedly obese with significant lateral edema particularly on
the left side where his pannus tends to fall. There is
significant scrotal edema. The scrotum appears to be about 7
inches in diameter. The patient has bilateral 3+ pitting leg
edema. He has 2+ DP pulses bilaterally. He has closed ulcers on
his abdomen which he states that have been there for several
years and that he tends to pick at them daily to make them bleed.
LABORATORY EXAM:
Sodium 145 , potassium 3.4 , chloride 107 , bicarb 21 , BUN 68 ,
creatinine 5.9 , glucose 53 , lipase 11 , total bili 1.0 , alk phos
153 , BNP 1663 , calcium 7.8 , phosphate 7.3 , magnesium 1.8 ,
troponin less than assay , white blood cell count 6.2 , hematocrit
33.3 , platelets 144 , 000 , INR 1.3 , BNP was 1663.
Chest x-ray showed left lower lobe opacification , but the patient
was not able to stand for a lateral chest x-ray.
EKG showed first-degree AV block with poor R wave progression and
a question of Q waves in 3 and AVF.
HOSPITAL COURSE:
1. Renal: The patient was felt to be in volume overload. His
chronic renal insufficiency was progressing likely for several
reasons including his chronic hydronephrosis. his focal segmental
glomerular sclerosis , diabetes , and hypertension. He was
initially given large amounts of Lasix but he failed to diurese
significantly and his creatinine rose to approximately 7.0.
Therefore , a tunneled catheter was placed by vascular surgery and
the patient began urinalysis with the purpose of taking out of
volume. Approximately 20 liters of volume were taken off over
several days of dialysis. The patient will continue hemodialysis
three times a week as an outpatient. In addition , he had venous
ultrasound mapping for likely placement of a permanent AV
fistula.
2. Pulmonary: The patient continued to wear his CPAP for his
severe obstructive sleep apnea. His breathing improved somewhat
during his hospitalization but it was not possible to tell how
well he would do if he would attempt to walk again as he was
sedentary and in bed for his entire hospitalization except for
occasionally sitting up on the side of the bed and moving to a
bed chair once or twice.
3. Infectious Disease: There was not clear evidence of pneumonia
critically or on review of the chest x-ray and therefore the
patient was not specifically treated for pneumonia. However ,
upon placement of a Foley catheter , there was a significant
amount of white blood cells in the urine and while the urine
culture appeared not to be negative , the patient was treated with
a 10-day course of levofloxacin ( renally adjusted ) for urinary
tract infection. Foley catheter was initially placed by urology.
Due to difficulties in the anatomy , it may get hard to place.
Once Foley catheter was removed , the patient was able to urinate
on his own.
4. Cardiovascular:
A. Rhythm: The patient was maintained on sotalol and a
beta-blocker for his prior history of ventricular tachycardia.
He did not have any episodes while inhouse on this
hospitalization. The patient's electrophysiologist Dr. Denisha H Mcrorie suggested that given that the patient is on hemodialysis ,
the sotalol should be reduced to 40 mg three times a week to be
given approximately two hours after dialysis. The plan was to
monitor the QT interval and discontinue sotalol as a QT interval
or if the QTC were greater than 500 msecs. A QTC was monitored
during this hospitalization and never exceeded 500 msecs.
Therefore , the sotalol should be continued at this dose on
dialysis days.
B. Ischemia: He is much ruled out for MI. He was maintained on
aspirin , statin , and a beta-blocker.
C. Pump: The patient was volume overloaded on admission and
improved after significant volume reduction by hemodialysis. A
review of the patient's prior cardiac echoes showed that in
9/30 he had an ejection fraction of approximately 70%. In
2/19 , his ejection fraction fell to about 45 to 50%. On
repeat echocardiogram during this admission , a repeat
echocardiogram showed an ejection fraction of about 30 to 35%
with a mildly dilated left ventricle , moderately reduced left
ventricular function. Akinesis in the entire apex of the basal
septum segment and the basal posterior segment of the heart and
hypokinesis in the anterior wall , the anterior lateral wall , the
inferior wall , and the mid anterior septum segment. There is
mild mitral regurgitation. No tricuspid regurgitation and trace
aortic regurgitation without any significant evidence of aortic
stenosis.
DISCHARGE MEDICATIONS:
1. PhosLo 1334 mg orally three times a day , instructions to give with meals.
2. Heparin 5000 units subcutaneous three times a day
3. Bactroban topical twice a day , please apply to legs.
4. Senna two tablets orally twice a day
5. Lipitor 40 mg orally every day
6. Sotalol 40 mg orally three times a week , instructions to please
give two hours after dialysis. Also , please monitor QT interval
every three to four days and discontinue sotalol if QTC is
greater than 500 msec.
7. Toprol XL 50 mg orally every afternoon
8. Wellbutrin SR 150 mg orally every day before noon
9. Nephrocaps one tab orally every day
10. Flomax 0.8 mg orally every day
11. Mirapex 1 mg every day before noon orally , 1 mg every afternoon orally
12. Glipizide 5 mg orally every day
13. Lactulose 30 ml orally four times a day as needed constipation.
14. Afrin Spray two sprays twice a day as needed as needed for nasal
congestion.
15. Sudafed 30 mg orally every 6 hours as needed as needed for nasal
congestion.
16. Saline Spray two sprays inhaled every 12 hours as needed for dry nose
or nasal congestion.
17. Trazodone 50 mg orally every bedtime as needed insomnia.
18. Flonase one to two sprays inhaled twice a day as needed for nasal
congestion.
19. Protonix 40 mg orally every day
20. Epogen 40 , 000 units subcutaneous every week.
21. Multivitamin therapeutic one tablet orally every day
TO DO:
The patient will receive hemodialysis three times a week on
Tuesdays , Thursdays , and Saturdays.
The patient will follow up with Dr. Fran Bussler as an outpatient
within three or four weeks.
The QTC intervals should be monitored every week while at rehab
or at a regular doctor's appointment as an outpatient to ensure
that it is less than 500. If it is greater than 500 , then the
frequency of sotalol administration should be decreased in order
to maintain a QTC of less than 500 msecs.
eScription document: 9-9512654 EMSSten Tel
CC: Denisha H. Mcrorie MD
Cardiac Arrhythmia Service , Pagham University Of
Me A
CC: Fran Bussler M.D.
Dictated By: TUOMALA , HERMINA
Attending: CASEBIER , WERNER REGINIA
Dictation ID 4639948
D: 7/23/04
T: 7/23/04
Document id: 376
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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010700797 | PUO | 27527229 | | 1398265 | 8/21/2006 12:00:00 a.m. | RESPIRATORY FAILURE | Signed | DIS | Admission Date: 10/9/2006 Report Status: Signed
Discharge Date: 9/13/2006
ATTENDING: MARCOTT , DESIRAE M.D.
SERVICE: General Medical Service.
PRINCIPAL DIAGNOSIS: Aspiration pneumonia.
PROBLEMS: Diabetes , atrial fibrillation , CHF , acute renal
failure , thrombocytopenia , elevated LFTs , agitation , aspiration
and rheumatoid arthritis.
HISTORY OF PRESENT ILLNESS: Ms. Eisenzimmer is a 71-year-old woman
with severe obesity who was admitted with hypercarbic respiratory
failure from a rehabilitation facility for rapid shallow
breathing. On arrival in the emergency department , she was hypoxic and
hypoglycemic , responding to fluids , intubation , and transfer to the MICU. She
was subsequently transferred
out of the medical ICU to the general medical floor. Of note , she had a recent
admission to Pande Memorial Hospital for sepsis secondary to
cellulitis and pneumonia , enjoying that admission she developed
ATN secondary to antibiotic use. ROS on arrival to the medicine floor is not
possible , as the patient is disoriented
( at baseline ). She does report low back pain ( chronic ) , is moaning at baseline
( secondary to stroke/aphasia ) , but appears in NAD.
PAST MEDICAL HISTORY:
1. COPD , for which she uses BiPAP at home and no oxygen.
2. CHF , secondary to diastolic dysfunction. Ejection fraction
is 55% with no wall motion abnormalities. She does have a
history of elevated pulmonary artery pressures of 57 above rate
reduction.
3. Obstructive sleep apnea with Pickwickian syndrome.
4. Hypertension.
5. Sick sinus syndrome , status post pacemaker implantation in
2000.
6. Atrial fibrillation on Coumadin.
7. Angina , status post septal MI.
8. Hyperlipidemia.
9. Diabetes type 2 , recently increased to insulin while on
stress dose steroids at her last hospitalization.
10. Osteoporosis.
11. Rheumatoid arthritis.
12. GERD.
13. Cellulitis , with a recent pneumonia.
14. Thrombocytopenia.
15. Iron deficiency.
16. CVA in 1998 with expressive aphasia.
MEDICATIONS ON ADMISSION: Fluconazole , prednisone 20 mg orally
daily , Coumadin 5 mg orally daily , aspirin , atorvastatin , Imdur ,
Lasix , Norvasc , lisinopril , atenolol , Advair , DuoNebs ,
multivitamin , folate , calcium , Lispro sliding scale , NPH insulin ,
senna , Colace and oxycodone.
ALLERGIES: None.
SOCIAL HISTORY: The patient lives with her husband who is her
Healthcare Proxy.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission , temperature 99.1 , heart rate
69 , blood pressure 149/77 with an oxygen saturation of 99% on
100% nonrebreather. Morbidly obese. HEENT examination is significant for fixed
left pupil secondary to surgery , with a pinpoint right pupil.
JVP cannot be assessed secondary to obesity. Pulmonary exam is
significant for diffuse rhonchi with wheezing. Cardiovascular
examination significant for a 2/6 systolic murmur at the left
lower sternal border. Extremities reveal 2+ pitting edema with
2+ pulses.
LABORATORY STUDIES: On admission were significant for sodium of
149 , BUN of 49 , creatinine of 2.3 , glucose of 21 , white count of 13 , hematocrit
of 34 , platelets of 63 , 000 , an alkaline phosphatase of 284 , ALT
of 82 , total bilirubin of 4.0 , direct bilirubin of 2.0 , albumin
of 2.5 and an INR of 2.1. CXR reveals a RLL pneumonia.
HOSPITAL COURSE:
1. Aspiration pneumonia. The patient was admitted with a right
lower lobe pneumonia. She grew MRSA in her sputum and was
treated with vancomycin , levofloxacin and Flagyl. She did well
and was extubated on her first hospital day after arriving in the
MICU. However , she continued to aspirate and failed a bedside
swallow study in the MICU. She was stabilized and transported to
the medicine floor on overnight BiPAP. She again failed bedside
swallow evaluation with thin liquids , and was therefore started
on a very conservative pudding thick puree diet. She did
subsequently aspirate on secretions ( she was not eating at that
time ) and became acutely hypoxic with an ABG that showed a pH of
7.45 , pCO2 of 48 and a PO2 of 36. Her family was brought in and
it was explained that the patient was recurrently aspirating and
was critically ill. A family meeting was held , where it was
decided that the patient would be DNR/DNI , and every attempt
would be made to bring the patient home with hospice. She
actually stabilized from her acute event and was able to wean
from BiPAP to 3 L oxygen nasal cannula. Nevertheless , the
patient's family understood that her respiratory status remained
tenuous and that she would likely re-aspirate. She was
discharged home with hospice services per family request.
2. CHF. The patient diuresed greater than 26 liters during this
admission. Much of this diuresis was without pharmacological
intervention , although she did receive minimal Lasix support. At
the time of discharge , she was tending towards euvolemic or dry and was
not on any Lasix. She was felt to be in the polyuric phase of
ATN , which was resolving.
3. Diabetes. The patient was discharged on insulin NPH and a
sliding scale regular insulin. Her doses have been decreased
because she was found to be hypoglycemic on admission.
4. Atrial fibrillation on Coumadin. Given the patient's history
of bleeding ( she had a GI bleeding while in the MICU in the
setting of an INR of 2.0 ) , Coumadin was held. On review with the
medical team , it was felt that the risk of stroke was far
outweighed by the risk of a significant bleed. Therefore , the
patient is not discharged on Coumadin.
5. Acute renal failure. The patient was treated with
antibiotics prior to this admission , and developed ATN secondary
to that medication. Of note , her urine was positive for
eosinophils on admission. At the time of discharge , the
patient's creatinine was 2.1 , which in part was due to ATN and
also due to significant diuresis. Her baseline creatinine is 1.7
and she is currently trending downwards.
6. Thrombocytopenia. The patient is noted to have a chronic
thrombocytopenia. This was exacerbated with heparin products ,
which were discontinued. She did require platelet transfusions
for a platelet count of 34 in the setting of acute bright red
blood per rectum. However , her platelet count was stable at
greater than 125 on discharge.
7. LFT abnormalities. A right upper quadrant ultrasound was
within normal limits , although was of poor quality given the
patient's obese body habitus. She does have a possible
cholestatic picture , but the patient had no other symptoms.
Given her DNR/DNI status with hospice services pending , no
further workup was performed.
8. Agitation. The patient is , at baseline , mourning and
disoriented , but responsive. She did require Haldol and Ativan
as needed , but also did well with 1 to 1 interaction. Morphine was
adequate for pain control.
9. Speech and swallow evaluation. The patient failed several
speech and swallow evaluations. She is put on a pudding thick
puree diet , but this is palliative , as she will very likely
aspirate even on this diet.
10. Rheumatoid arthritis. The patient was continued on
prednisone 20 mg every day before noon
DISCHARGE EXAMINATION: Temperature 96 , respiratory rate 22 ,
pulse 68 , blood pressure 130/60 , oxygen saturation 99% on 3
liters. Exam is notable for morbid obesity , coarse breath
sounds , right greater than left , large ecchymosis of varying
stages particularly at subcutaneous injection sites , and baseline
disorientation , which is not different from the patient's usual
mental status.
LABORATORY STUDIES ON DISCHARGE: White count 11 , hematocrit 33 ,
platelets 214 , 000 , glucose 134 , sodium 148 , chloride 111 , BUN 40
and creatinine 2.1.
DISCHARGE MEDICATIONS: Albuterol nebulizer 2.5 mg every 2 hours as needed ,
Pepcid 20 mg orally at bedtime , insulin NPH 4 units subcutaneously twice a day ,
insulin regular sliding scale , Ativan 2 to 4 mg orally every 6 hours
as needed anxiety , metoprolol 50 mg orally twice a day , prednisone 20 mg
orally every day before noon , morphine immediate release 15 to 30 mg orally every 3 hours
as needed pain , Norvasc 5 mg orally daily , levofloxacin 500 mg orally
every other day for a total of two weeks , miconazole 2% topical
powder twice a day , DuoNeb every 6 hours and Dulcolax rectal suppository 10
mg PR daily.
DISPOSITION: The patient is discharged to home in very poor
condition. She is discharged with hospice services for end of
life care.
eScription document: 3-6452874 CSSten Tel
Dictated By: MCCORD , ADAH
Attending: MARCOTT , DESIRAE
Dictation ID 8689963
D: 2/10/06
T: 2/10/06
Document id: 377
| Target |
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GER |
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| output/system_textual_annotation.xml | textual |
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465695847 | PUO | 64487163 | | 905441 | 4/16/1999 12:00:00 a.m. | PYELONEPHRITIS | Signed | DIS | Admission Date: 4/16/1999 Report Status: Signed
Discharge Date: 1/10/1999
PRINCIPAL DIAGNOSIS: HYPEROSMOLAR STATE.
SECONDARY DIAGNOSES: Rule in myocardial infarction , diabetes ,
hypertension , congestive heart failure , and
urinary tract infection.
HISTORY OF PRESENT ILLNESS: Emilio Helde is a 65 year-old
woman with a history of hypertension ,
insulin dependent diabetes mellitus , with a history of urinary
tract infections who noted cloudy urine five days previous to
admission with increased frequency but no dysuria. In clinic three
days prior to admission , the patient had greater than 10 to the 5th
colonies of E. coli in her urine culture. Since that time , she
developed left back pain , temperature to 100.0 , chills , nausea , and
vomiting x24 hours.
The patient presented to her primary medical doctor on the day of
admission with a temperature of 98.2 , a blood pressure of 128/54 ,
pulse to 112 , and finger stick equal to 521 with a white blood cell
count equal to 30 , and an anion gap equal to 15. Her sodium
was 128 , CO2 was equal to 20. The patient received one gram of intravenous
ceftriaxone and 5 units of regular insulin x2.
She denied diarrhea , chest pain , shortness of breath , cough ,
syncope , or palpitations. She also denied previous history of an
MI. The patient had had urinary tract infections previously
including an episode of pyelonephritis at age 7 , she denies a
history of kidney stones , she does take high doses of vitamin C.
Risk for coronary artery disease included age , family history ,
postmenopausal state , hypertension , diabetes mellitus , and question
hypercholesterolemia. The patient had a positive stress test in
1997 , and was managed medically. She denied recent shortness of
breath or palpitations. Her last episode of chest pain was
reputedly one year previously , associated with stress of work and
for which she took nitroglycerin. She denied exertion related
chest pain but did admit to calf and "hip" pain with walking. She
denied buttock pain while walking. She denied previous history of
diabetic ketoacidosis.
PAST MEDICAL HISTORY: 1. Diabetes mellitus x20 years , always
insulin dependent , no renal , neurologic , or
ophthalmologic complications. 2. Hypertension x20 years , no
history of MI , CVA , atrial fibrillation ( 4/18 stress test: standard
Bruce with heart rate to 110 , 70% predicted heart rate , blood
pressure 150/70 , positive chest pain improved with sublingual
nitroglycerin , 1 mm ST depression in leads V3-V5 , the patient
remained in sinus rhythm ). 3. Pancreatitis. 4. Asthma x3 years.
5. Hypercholesterolemia ( the patient reports that this issue was
resolved with ? diet ). 6. Cholecystectomy. 7. Appendectomy.
MEDICATIONS: Metoprolol 50 mg orally twice a day; isosorbide dinitrate 20
mg orally twice a day; zestril 5 mg orally every day; Premarin
0.625 mg orally every day; NPH 30 units every day before noon; regular insulin 10 units
every day before noon; vitamin B12; vitamin C 1 gram orally twice a day;
hydrochlorothiazide 10 mg orally every other day.
ALLERGIES: Codeine ( causing syncope ).
SOCIAL HISTORY: The patient works as a nurse at the Kernan To Dautedi University Of Of as
per them with psychiatric patient's. She is
divorced and lives alone. Denies smoking , rarely drinks alcohol.
She has three cats and one dog. Denies recent travel.
FAMILY HISTORY: Father with MI at age 55; he also had diabetes
mellitus. Mother with pulmonary embolism at age
82.
PHYSICAL EXAMINATION: T max 99.3 , pulse 104 , blood pressure
131/60 , respirations 20 , at 96% on room air.
Moderately obese woman lying in bed with chills. HEENT: 8 cm of
JVP. Eyes PERRL and anicteric , neck supple , no adenopathy or sinus
tenderness. CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular tachycardia. 2/6 systolic murmur at the
left sternal border. No gallops or rubs. S1 , S2. ABDOMEN:
Positive bowel sounds , soft , non-tender , no hepatomegaly or masses.
BACK: No costovertebral tenderness bilaterally. EXTREMITIES: No
pedal edema. Dorsalis pedis equals 2+ bilaterally. NEURO:
Oriented. Cranial nerves 2-12 intact. Strength 5/5 in all groups.
LABORATORY DATA: Urinalysis - A specific gravity of 1.025/1+
protein/3+ glucose/trace ketones/trace
blood/negative leukocyte esterase/negative nitrates/3-6 white blood
cells/3-6 red blood cells/1+ bacteria/negative casts/1+ epis.
Sodium 135 , potassium 4 , chloride 97 , CO2 21 , BUN 29 , creatinine
1.6 , glucose 459. Acetest positive. White blood cell count 26.48 ,
hematocrit 41.3 , MCV 89.9 , platelets 278. White blood cell
differential with 81 polys , 13 bands , 4 lymphs , 2 monos. EKG
showed normal sinus rhythm at 113 , axis equal to negative to 37 ,
intervals equal to 152/90/450 , as well as old Qs in V1 and V2 , left
anterior hemiblock , left ventricular hypertrophy. Chest x-ray
showed no infiltrate , no effusions , cardiomegaly , or pulmonary
edema.
HOSPITAL COURSE: The patient's glucose came down quickly with intravenous
insulin and aggressive hydration. She
unfortunately ruled in for myocardial infarction with peak CK on
4/13/99 of 285 , and peak troponin of 6.15 for which she was
treated with beta blockers , aspirin , and heparin , as well as
Zestril and Zocor. She had some recurrent episodes of chest pain
during her admission following her non-Q wave myocardial
infarction.
She also had an echocardiogram on 4/13/99 which showed an ejection
fraction of 45% , and hypokinesis in the middle and distal
intraventricular septum. She had 1+ tricuspid regurgitation and
preserved right heart function.
On 1/12/99 , she underwent cardiac catheterization which showed a
40% osteo left main lesion and a 40% tapered distal lesion. Her
left anterior descending artery was diffusely diseased up to 50% in
its mid portion. The first diagonal had a discrete 70% stenosis ,
and the second diagonal had a discrete 90% stenosis. The right
coronary artery had a 40% discrete proximal stenosis , the posterior
descending artery had a osteo 90% stenosis. The right circumflex
had an 80% proximal stenosis.
The patient had an exercise stress test on 10/4/99 which was a
modified Bruce. The patient completed a 9 minute test with a
maximum heart rate of 100 , which was 65% of predicted. Her maximum
blood pressure was 156/60. She was asymptomatic with no ST changes
and remained in sinus rhythm. The test was therefore interpreted
as negative for ischemia.
It was thought that the patient would probably benefit from CABG
procedure but it was deferred secondary to patient preference , as
well as her infection. With regard to her infectious disease
issues , the patient was treated with levofloxacin. Her white blood
cell count was persistently elevated. She had one urine culture
which appeared contaminated and her blood cultures were negative
for this admission. She had a pelvic and abdominal CT on 2/1/99
which demonstrated bilateral pleural effusions , no evidence of
abscess , and punctate renal stones without evidence of obstructive
uropathy. Her fever resolved.
First it was thought that the patient did have a urinary tract
infection. She maintained relatively benign urinalysis , which was
collected only hours after she received ceftriaxone , it was
difficult to believe that she had ever had pyelonephritis. Because
of her persistently elevated white blood cell count was also
unclear although it did finally decline. In short , the series of
events that led up to her admission appeared likely to be urinary
tract infection leads to tachycardia and demand related myocardial
infarction , and then combination of infection and myocardial
infarction leads to nonhepatic hyperosmolar state. Nonetheless , a
different sequence of pathologies is also possible.
DISPOSITION: The patient was discharged to home in stable
condition.
MEDICATIONS: Aspirin 325 mg orally every day; hydrochlorothiazide 25 mg
orally every day; NPH 30 units subcutaneously every day before noon;
regular insulin 10 units subcutaneously every day before noon; magnesium gluconate
1 gram orally every day; Isordil 30 mg orally three times a day; metoprolol 100 mg
orally four times a day; simvastatin 10 mg orally every day; losartan 100 mg orally
every day; Allegra 60 mg orally every day; levofloxacin 500 mg orally every day;
sublingual nitroglycerin 1 tablet every 5 minutes x3 as needed chest
pain.
Dictated By: JACKSON PART , M.D. PV74
Attending: ROXANNA E. MOLTER , M.D. HV9 SW963/2820
Batch: 03847 Index No. ZTHF3178X8 D: 3/19/99
T: 10/9/99
Document id: 378
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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U |
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U |
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Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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023088484 | PUO | 63607825 | | 077345 | 3/16/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/18/1992 Report Status: Signed
Discharge Date: 10/10/1992
HISTORY OF PRESENT ILLNESS: The patient is a 37 year old woman
with dilated cardiomyopathy admitted
with positional chest pain associated with viral prodrome. PAST
MEDICAL HISTORY revealed the patient was diagnosed with dilated
cardiomyopathy in 10-89. She was worked up at the Lapaulsloan- Of Medical with a conclusion of idiopathic dilated cardiomyopathy ,
work-up unavailable. The patient was discharged on Lasix , digoxin
and an ACE inhibitor. In 15 of April , the patient was admitted to Pagham University Of after complaining of positional chest pain ,
shortness of breath and fatigue. She was diagnosed with dilated
cardiomyopathy and received an echocardiogram , which revealed large
ventricles , 2+ mitral regurgitation , 3+ tricuspid regurgitation. In
23 of June , the patient underwent a bicycle exercise tolerance test and
endured 10 minutes and 16 seconds , limited by fatigue. Peak heart
rate was 104 , peak blood pressure was 156/80 , she had a few atrial
premature beats and no ischemic ST-T changes. Her oxygen uptake
was 16.2 milliliters per kilogram per minute. In 24 of November , the patient
underwent right ventriculogram which showed ejection fraction 24%
and global hypokinesis. On the day of admission , on 11 of January , the
patient complained of 4 days of diarrhea , nausea , vomiting and
malaise , followed by sharp severe chest pain in the mid chest below
the left breast radiating to the back , which was relieved by lying
on the left and aggravated by leaning forward or lying on the
right , also worsened by deep breathing and cough , and also with
ventral palpation. The patient claimed that the pain had never
gone away in the past 12 hours , but again was aggravated by certain
positions. PAST MEDICAL HISTORY was significant for
cardiomyopathy , hypertension , gastritis , ex-intravenous drug abuser
for 10 years , anemia , and recent crack cocaine use. MEDICATIONS ON
ADMISSION included Lasix , Enalapril and digoxin. ALLERGIES were no
known drug allergies.
PHYSICAL EXAMINATION: The patient was an obese black woman in no
apparent distress. Blood pressure was
162/100 , heart rate 90 , respiratory rate 24 , oxygen saturation 99% ,
no pulsus. Eyes were pupils were equal , round , reactive to light ,
extraocular movements intact , muddy sclera. Neck was supple ,
jugular venous pressure was 8 to 10 centimeters , carotids were 2+
bilaterally. Lungs were clear to auscultation and percussion
except for a few bibasilar crackles. Heart showed normal S1 and
S2 , no rubs , distant heart sounds , no murmurs were noted. Abdomen
was obese , soft , normal bowel sounds , she was comfortable with deep
palpation diffusely. Extremities showed no edema. Rectal
examination was guaiac negative. Neurologic examination was
nonfocal.
LABORATORY EXAMINATION: Sodium was 137 , potassium 2.7 , chloride
92 , bicarbonate 37 , blood urea nitrogen 7 ,
creatinine .9 , glucose 159 , AST 58 , creatinine phosphokinase 641 ,
with 23% myocardial bands. White count was 4.6 , hematocrit 31.5 ,
platelets 166 , 000 , ESR 60 , prothrombin time 11.3 , partial
thromboplastin time 18. Chest x-ray showed a big heart with mild
congestive heart failure. The electrocardiogram showed T-wave
inversions in I , II , F , L , V2 through V6 , consistent with a 1990
electrocardiogram done when she was complaining of positional chest
pain similar to the chest pain she is having now.
HOSPITAL COURSE: The patient was admitted with the thought that
her history was consistent with pericarditis , but
was also worriesome for ischemia given her elevated creatinine
phosphokinase with myocardial band fraction of 23 , and her history
of cocaine abuse. Her hospital course was consistent with
continuation of her pain through the first day of hospitalization
despite and aggressive anti-ischemic regimen. It was found that
hermyocardial band electrophoresis showed no myocardial band
fraction detected , and it was decided that we would shift our
therapy to a more anti-inflammatory regimen to control her
pericarditis. At that time , Indocin was started and the chest pain
resolved. With the resolution of her chest pain , the T-wave
inversions corrected. The patient was transerred to the floor on
Indocin 50 milligrams 3 times a day , aspirin , Bactrim , Enalapril
and Carafate and remained without chest pain for the next 2 days.
She was also seen by the ACE team in consultation about her drug
and alcohol problem , and it was decided that she would be
discharged on 21 of January , after arrangement for follow-up with the ACE
team.
DISPOSITION: The patient was discharged to home. MEDICATIONS ON
DISCHARGE included aspirin , Indocin 50 milligrams by
mouth 3 times a day , Enalapril 10 milligrams by mouth each day ,
Carafate 1 gram by mouth 4 times a day. The patient is to
FOLLOW-UP with Dr. Rufus C. Bernas .
Dictated By: LATKO
Attending: RUFUS C. BERNAS , M.D. GG69 SA400/9755
Batch: 2413 Index No. JJL430696 D: 2/30/92
T: 9/2/92
Document id: 379
| Target |
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GER |
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477519396 | PUO | 25278841 | | 312463 | 8/16/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/7/1992 Report Status: Signed
Discharge Date: 2/4/1992
PRINCIPAL DISCHARGE: CORONARY ARTERY DISEASE , STATUS POST
MYOCARDIAL INFARCTION.
OTHER DIAGNOSES: 1. STATUS POST ATHERECTOMY COMPLICATED BY
REOCCLUSION AND MYOCARDIAL INFARCTION.
2. INSULIN DEPENDENT DIABETES MELLITUS.
3. ELEVATED CHOLESTEROL.
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old female
with multiple cardiac risk factors who
presents with exertional chest discomfort and early positive ETT.
The patient has a history of cardiac risk factors of obesity ,
diabetes mellitus , and cholesterol. The patient describes a
6-month history of exertional angina described as chest heaviness
with mild shortness of breath whenever she walked more than one
block or climbed stairs. The patient is followed by Dr. Rossie K Mankoski , LMD at Barbto Be Medical Center . She had an ETT on
5/23/92 , modified Bruce protocol , in which she went 2 minutes and 2
seconds , stopped secondary to typical anterior chest discomfort.
The heart rate was 135 , 83% predicted. EKG changes were
significant for 20 mm horizontal ST depressions in 1 , V4-5 , 1 mm ST
depressions in II , III and F. The patient was referred for cardiac
catheterization. The patient denies orthopnea , PND , and has mild
occasoinal hypertension. PAST MEDICAL HISTORY: Noninsulin
dependent diabetes mellitus , orally agent times six months. Asthma ,
no recent symptoms. MEDICATIONS ON ADMISSION: Glucotrol 7.5 mg
orally q-day , Mevacor 10 mg orally every day , Isoril 10 mg orally three times a day ,
Propranolol 20 mg orally three times a day , Nitroglycerin sublingual as needed
ALLERGIES: ? ALLERGY TO UNRECALLED ANTIBIOTIC. FAMILY HISTORY:
Brother required CABG in his 50's , mother died of heart disease ,
age unknown.
PHYSICAL EXAMINATION: Blood pressure 140/70 , pulse 70. Neck:
negative JVD , 2+ carotids , without bruits.
Chest: Clear to auscultation. Cardiac: Regular rate and rhythm ,
S1 and S2 , a I/intravenous systolic ejection murmur heard best at the right
sternal border. Abdomen: Plus bowel sounds , nontender.
Extremities: +2 femorals , no bruits , positive left DP , trace physical therapy ,
right positive 2 DP and plus 2 physical therapy.
LABORATORY EXAMINATION: BUN/creatinine 12/1.2 , glucose 318 ,
hematocrit 42.3 , white blood cell count
8.38 , cholesterol 222 , triglycerides 173.
HOSPITAL COURSE: The patient underwent catheterization on 1/15/92 .
She had a proximal 95% LAD lesion and diagonal 1
40% stenosis. She had an anomalous posterior circumflex with
luminal irregularities. Her mean RA was 5 , and her mean capillary
wedge pressure was 11. Her cardiac output was 6.2 , wifh an FCR of
1226. The patient underwent athrectomy of her proximal LAD lesion
through a 10 French arterial sheath. The stenosis was reduced
from an 80% to 20% residual. The Heparin was shut off , and
sheaths were pulled later that afternoon. Her post atherectomy
course was complicated on the evening of 11/12/92 by the onset of
severe chest discomfort. The patient had significant flipped
T-waves in III and F and 2 mm ST depressions as well in III and F.
The patient was subsequently brought to the cath lab on 11/12/92
where the LAD was found to be 100% occluded and was dilated to a
30% residual with balloon PTCA. Thrombus was found at the prior
athrectomy site. The patient was transferred to the Cardiac Care
Unit after the PTCA which she proceeded to rule in for a myocardial
infarction with peak CPK's of 1390 with MB's of 55. The patient's
post PTCA course was complicated by several episodes of transient
chest discomfort which was relieved both by Mylanta and sublingual
TNG. These episodes were not compared with EKG nor felt to be
secondary to recurrent dyspepsia. The patient on 2/9/92 , seven
days post MI , had a modified Bruce ETT where she went 9 minutes
without any ischemic changes. The patient's blood sugars remained
elevated throughout her hospital course. She was maintained on
Glucotrol with NPH subcutaneously every day before noon was added with the hope that the
patient would eventually after the stress of her MI , her blood
sugars would return to prior levels. The patient was thus treated
with Mevacor for hypercholesterolemia. The patient was discharged
in good condition on 10/10/92 with followup with Dr. Sakumoto in Colnley Mor Health .
DISPOSITION: MEDICATIONS ON DISCHARGE: Mevacor 10 mg orally q-day ,
Aspirin one orally q-day , Glucotrol 20 mg orally twice a day ,
Isordil 40 mg orally three times a day , Lopressor 200 mg orally twice a day , NPH 26
units subcutaneously each morning.
JW261/5398
RUFUS C. BERNAS , M.D. WW78 D: 7/3/92
Batch: 9108 Report: C6804F0 T: 4/17/92
Dictated By: AIDE D. MUNGIN , M.D.
Document id: 380
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
- |
Y |
Y |
Y |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
- |
Y |
Y |
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- |
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N |
681242988 | PUO | 61350847 | | 2098754 | 8/22/2005 12:00:00 a.m. | abdominal aortic aneurysm , 6cm suprarenal abdominal aortic aneurysm | Signed | DIS | Admission Date: 5/24/2005 Report Status: Signed
Discharge Date: 1/4/2005
ATTENDING: ROSSIE MANKOSKI MD
SERVICE: This patient received care at the Vascular Surgery
Service.
ADMISSION DIAGNOSIS: Abdominal aortic aneurysm.
DISCHARGE DIAGNOSIS: Status post open abdominal aortic aneurysm
( AAA ) repair.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old male
with a history of morbid obesity , sleep apnea , CAD status post
CABG x 4 in 2001 , who presented with vague abdominal pain and was
found by CT scan to have a 6-cm infrarenal AAA. The patient was
initially prepared for a repair in outside hospital that upon
review of the aneurysm extended up to include of the origin of at
least to the left renal artery and this was felt to be a
suprarenal abdominal aortic aneurysm requiring a retroperitoneal
approach. He presents now for surgery.
ALLERGIES: Penicillin leading to a rash.
PAST MEDICAL HISTORY: CAD status post CABG x 4 in 2001 ,
hypertension , hypercholesterolemia , gout , GERD , morbid obesity ,
status post silent MI in 1980 and 1985 , Meniere's syndrome in
left ear , sleep apnea leading to BiPAP use.
PAST SURGICAL HISTORY: Status post CABG x 4 in 2001 , status post
laparoscopic cholecystectomy , 2004 , and status post left knee
arthroscopy.
PREVIOUS STUDIES: PFTs showing an FVC of 3.44 ( 80% predicted ) ,
FEV1 of 2.40 ( 83% predicted ) , and an FEV1/FVC of 70 ( 104%
predicted ). The patient had an negative stress test on 7/23/01
and 6/20/01 and a MIBI , 6/20/01 showing concentric LVH with an
EF of approximately 48% , wall motion abnormalities of the septum
consistent with cardiac surgery , no perfusion abnormalities and
minimal reversible ischemia at the base of the lateral wall with
the volume affected being small.
HOSPITAL COURSE: The patient is a 71-year-old male with a
history of morbid obesity , sleep apnea , CAD status post CABG x 4 ,
presenting with abdominal pain and found by CT scan to have 6-cm
infrarenal abdominal aortic aneurysm. He was taken to the
operating room on 6/28/05 where he underwent an uncomplicated
open repair of his abdominal aortic aneurysm through a
retroperitoneal flank approach. The patient tolerated the
procedure well. He left the operating room with an epidural ,
Foley , and nasogastric tube to low wall suction. He was admitted
overnight to the intensive care unit for a close monitoring of
blood pressure. His blood pressure overnight remained good and
the patient had a negative set of enzymes on postop #0 with a CK
of 146 , MB of 1.7 , and troponin less than assay. The patient was
taken up to the surgical intensive care unit intubated. He
received 7800 units of crystalloid , 6 units of cell saver , and 2
units of packed red blood cells intraoperatively , put out 1200 cc
of urine , 175 cc out of the nasogastric tube , with an EBL of 2400
cc. He was weaned from the ventilator without difficulty on
postop day #1 and was extubated by the evening on postop day #1.
The patient was transferred to the floor. He was out of bed and
to chair on postop day #2 with nursing assistance. Diet was
advanced as tolerated to a low fat , low cholesterol diet. The
patient initially started on his home Celebrex and other
medications. The epidural was capped on postop day #2 , 10/3/05 .
It was removed on 10/5/05 and this is fully discontinued as
well on postop day #3 , 10/5/05 . The patient's nasogastric tube
had been removed on the morning of postop day #1 as well.
The patient continued to do well on the floor. He was placed on
aspirin and subcutaneous heparin for anticoagulation. He was
Hep-Lock'd on postop day #3 as he was taking good orally orally
He was out of bed to chair multiple times during the day.
Physical Therapy saw the patient on postop days # 4 to #5 and
worked with some on his mobility. He , at home , gets out of bed
to a wheelchair and he was back to his preoperative functional
status with a small amount of fatigue on postop day #7 and #8.
The patient continues to work with Physical Therapy and to get
out of bed with nursing staff on a regular basis multiple times
per day.
Incision site remained clean , dry , and intact. On postop days #1
to #2 secondary to his large amount of edema , the patient has
large amount of drainage from his incision site on the flank.
However , this slowed down and the incision site remained clean ,
dry , and intact with the erythema. The patient continues to do
well. By postop days #7 to #8 , the patient was deemed stable for
discharge to rehabilitation. He will follow up with Dr. Derham
in clinic for staple removal in seven days.
DISCHARGE DISPOSITION: Home with Services.
eScription document: 0-6268476 ISSten Tel
Dictated By: CISTRUNK , EDGARDO
Attending: MANKOSKI , ROSSIE
Dictation ID 5732628
D: 4/23/05
T: 4/23/05
Document id: 381
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
275489010 | PUO | 14088690 | | 8520774 | 3/30/2006 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 3/30/2006 Report Status:
Discharge Date: 6/10/2006
****** FINAL DISCHARGE ORDERS ******
SCHRAUB , AGUEDA R. 797-41-87-2
Gard Norollche Ville
Service: CAR
DISCHARGE PATIENT ON: 6/2/06 AT 01:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KUSH , QUINN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
as needed Shortness of Breath , Wheezing
ALLOPURINOL 100 MG orally DAILY
NORVASC ( AMLODIPINE ) 5 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
VITAMIN C ( ASCORBIC ACID ) 500 MG orally twice a day
LIPITOR ( ATORVASTATIN ) 80 MG orally BEDTIME
Starting Today ( 5/19 )
CALTRATE + D 1 TAB orally twice a day
COLCHICINE 0.6 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ENOXAPARIN 100 MG subcutaneously DAILY
ERGOCALCIFEROL 50 , 000 UNITS orally QWEEK
Instructions: Tuesday; Continue until 5/14
FERROUS SULFATE 325 MG orally DAILY
Food/Drug Interaction Instruction Avoid milk and antacid
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY nasal DAILY
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
LASIX ( FUROSEMIDE ) 120 MG intravenous twice a day X 4 doses
Starting Today ( 5/19 )
Instructions: Give lasix 120mg twice a day x2 days total , then
reduce to 120mg every day before noon + 80mg every afternoon.
LASIX ( FUROSEMIDE ) 120 MG every day before noon; 80 MG every afternoon orally 120 MG every day before noon
80 MG every afternoon Starting IN a.m. ON 7/25/06 ( 10
Instructions: Please do strict daily weights and call Dr.
Kush with updates a few times a week
HUMALOG INSULIN ( INSULIN LISPRO )
Sliding Scale ( subcutaneous ) subcutaneously before meals Medium Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 3 units subcutaneously
If BS is 251-300 , then give 5 units subcutaneously
If BS is 301-350 , then give 7 units subcutaneously
If BS is 351-400 , then give 8 units subcutaneously
Call HO if BS is greater than 350
Please give at the same time and in addition to standing
mealtime insulin
HUMALOG MIX 75/25 ( INSULIN LISPRO MIX 75/25 )
34 UNITS subcutaneously every day before noon
HUMALOG MIX 75/25 ( INSULIN LISPRO MIX 75/25 )
14 UNITS subcutaneously Q6PM
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally DAILY
Instructions: patient taking 10 day total course ( started
at rehab facility on 10 of October )
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 6/2/06 by :
POTENTIALLY SERIOUS INTERACTION: RISPERIDONE & LEVOFLOXACIN
Reason for override: md aware , patient already taking it at
rehab
LEVOTHYROXINE SODIUM 175 MCG orally DAILY
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
NADOLOL 80 MG orally every 24 hours HOLD IF: SBP < 100 , HR < 55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
RISPERDAL ( RISPERIDONE ) 0.25 MG orally twice a day
TRAZODONE 25 MG orally every 6 hours as needed Anxiety
MAXZIDE-25 ( TRIAMTERENE 37.5MG/HYDROCHLOROTHI... )
1 TAB orally DAILY
DIET: GROUND / 2 gm Na / ADA 2000 cals/day / Low saturated fat
low cholesterol
ACTIVITY:
activity as tolerated , uses wheelchair
FOLLOW UP APPOINTMENT( S ):
Please call Dr. Quinn Kush for appointment 1-2 weeks ,
ALLERGY: CAPTOPRIL
ADMIT DIAGNOSIS:
shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of PNEUMONIA ( '93 , '95 ) ASTHMA NIDDM CAD-MIx2 , 3v CABG'92 HYPOTHYROIDISM
HYPERTENSION Hypercholesterolemia Urinary Incontinence LVH , LAE Tardive
Dyskinesia Periumbilical Hernia R rotator cuff
injury history of quadriceps tear repair history of ankle fx Elevated ESR Anemia
drop foot copd ( chronic obstructive pulmonary disease ) cri ( chronic
renal dysfunction ) RUE DVT ( in setting of PICC line )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
diureses
BRIEF RESUME OF HOSPITAL COURSE:
cc: shortness of breath
HPI: 78F with ischemic cardiomyopathy , CAD history of CABG , possible COPD ( poor
PFTs in 2004 ) , recent admit in 5/1 for incarcerated hernia history of repair
complicated by left frontal CVA with 100% carotid stenosis , NSTEMI ,
PICC-associated RUE DVT , enterococcus bacteremia , and gout flare. Had
episodes of chest pain and shortness of breath from time to time. This
a.m. , she complained of shortness of breath which has developed over the
last few days. She denies chest pain , nausea , vomiting , diaphoresis.
Staff at Pe Valley Health rehab facility noted tachypnea , dyspnea so EMS was
called. O2 sat was 88%RA , BP 166/80 , HR 78 , RR 38. In the PUO ED , she
was 85% on 3L nc and was put on NRB. She was eventually put on CPAP and
given lasix 120mg intravenous x1 , and nitro drip. O2 sat improved and was put back
on nasal canula and NTG drip was discontinued.
PMH: CAD history of MI , CABGx3 1992 ( LIMA to LAD , SVG to OM , SVG to R PDA ) , PCI
stent of SVG to OM in 2004 , NSTEMI 5/1 , IDDM , Left frontal CVA 5/1 with
100% left internal carotid stenosis , ischemic CMP EF 30% , HTN ,
hypothyroidism , history of repair of incarcerated umbilical hernia 5/1 , history of
cholecystectomy , gout , CRI ( baseline 1.4-1.7 ) , COPD , RUE DVT 5/1 ( PICC
associated , discharged with 2 week total course of lovenox but is still
taking it ) , tardive dyskinesia , history of back surgery
ALL: ACEI -> cough , avoid all narcotics and sedatives
SocHx: living at Pe Valley Health rehab facility , diet: ground , diabetic , no
added salt at Pi'ni Manger Ene Frandecrest Can Medical , 1 person transfer , self-feed
Home meds: Lasix 80mg orally twice a day see D/C med list below ( was not taking
Maxzide-25 at rehab ). also taking 10-day course of levaquin started on
4/30/06 at rehab for unclear reasons.
Hospital course:
1 ) SOB: Patient stayed in the emergency room with resolution of symptoms.
Admitted , but never went upstairs as she was discharged from the
observation unit on 6/2/06 in the a.m.. She diuresed well to 120mg intravenous
lasix x1. Evaluated by Dr. Kush , her outpatient cardiologist.
Likely gradual CHF exacerbation due to increased salt in diet and change
in medications. She was not taking maxzide-25 and remained on lasix 80mg
orally twice a day lasix. She will now need to increase her lasix to 120mg orally bix x2
days , then take 120mg orally every day before noon + 80mg orally every afternoon from now on. Strict daily
weights and low salt <2gm diet.
2 ) RUE DVT: She was still receiving lovenox injections 100 daily , but
apparently was supposed to complete a 2 week total course in February
according to the medical records available. Dr. Kush believed it was okay
for her to stop as she has been on lovenox for approximately 4-5 weeks.
3 ) CODE: FULL. HCP: daughter Gwen Landrey 605-668-7224 , cell:
948-756-5071
4 ) DISPO: D/C to Pe Valley Health rehab facility. May need long-term nursing
home care in the near future. Dr. Quinn Kush is following her closely.
ADDITIONAL COMMENTS: 1 ) Please do strict daily weights. Call Dr. Quinn Kush ( cardiologist )
for any reason including increases in weight. Also call him for updates a
few times a week.
2 ) Low salt diet. Maximum 2 grams of sodium per day.
3 ) We restarted your Maxzide-25 daily.
4 ) Please take your lasix 120mg orally twice a day for 2 days total. You can
then take lasix 120mg orally every morning and 80mg orally every night.
5 ) We stopped your lovenox injections because you have finished your 2
week course.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Please do strict daily weights. Call Dr. Quinn Kush ( cardiologist )
for any reason including increases in weight. Also call him for updates a
few times a week.
2 ) Low salt diet. Maximum 2 grams of sodium per day.
3 ) We restarted your Maxzide-25 daily.
4 ) Please take your lasix 120mg orally twice a day for 2 days total. You can
then take lasix 120mg orally every morning and 80mg orally every night.
5 ) We stopped your lovenox injections because you have finished your 2
week course.
6 ) Check electrolytes ( potassium and magnesium ). Keep potassium above 4.0
and magnesium at 2.0.
No dictated summary
ENTERED BY: NOAKES , MARLEEN D , M.D. ( NK97 ) 6/2/06 @ 01:54 PM
****** END OF DISCHARGE ORDERS ******
Document id: 382
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
495346639 | PUO | 14797163 | | 7367590 | 9/24/2004 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 2/26/2004 Report Status:
Discharge Date: 8/17/2004
****** DISCHARGE ORDERS ******
PEELMAN , THEODORE 057-44-41-1
Warrock Y Terbiro
Service: CAR
DISCHARGE PATIENT ON: 9/30/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
FESO4 ( FERROUS SULFATE ) 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 40 MG orally every day
GLIPIZIDE 2.5 MG orally every day
LISINOPRIL 20 MG orally every day
Override Notice: Override added on 6/7/04 by
GORGLIONE , JEANNETTE , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 19224239 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: mda
CEPHALEXIN 500 MG orally three times a day X 5 Days Starting Today ( 5/10 )
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 25 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Rhyner - MMC A A Gecin Cardiology November ,
No Known Allergies
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
renal cell cancer ( renal cancer ) history of nephrectomy ( history of nephrectomy )
htn ( hypertension ) hyperchol ( elevated cholesterol ) t2dm
s.p IMI ( myocardial infarction ) CHF ( congestive heart failure )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old m with history of DM II , CAD , HTN , history of nephrectomy
for RCC 11/19 , recent IMI ( TnI to 230 ) , now p/with DOEx2 days , orthopnea ,
PND , nocturia. Reports med compliance. Echo on d/c from IMI with EF
40 , LV dilation , no valvlar insufficiency.
Denies CP/palp/anginal equiv. patient originally presented
to UTOSH , treated with lasix , send to
PUO .
VSS BP 140's , HR 70's , O2 sat >96RA on admission
PE with bilat effusions , +S4 gallop
CXR: bilat effusions , vasc congestion
EKG: TWF V5-6 , II , III , F
Labs: cardiac enzymes negative , BNP 650
HOSPITAL COURSE:
CV: patient admitted for CHF exacerbation. Ruled out for MI with
negative serial cardiac enzymes. physical therapy diuresed with intravenous lasix to dry
weight. patient's ACEi advanced to Lisinoprl 20 , Toprol XL continued.
Additionally , patient continued on remaining cardiac regimen of ASA , zocor ,
Plavix. Recommend outpt echocardiogram for further evaluation. patient to
f/u with Dr Vandercook in Kernan To Dautedi University Of Of Cardiology.
Renal: CRI history of nephrectomy for RCC. Creatine stable at baseline
1.8-2.1.
Endo: T2DM , cont on glipizide
ID: patient continued on Kelfex for mole bx on back
Recommend outpt ongoing evaulation of cardiac function. Additionally ,
please re-check creatinine and electrolytes as oupt given CRI and A
CEi use.
FULL CODE
ADDITIONAL COMMENTS: please return to ED if you have any medical problems
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GORGLIONE , JEANNETTE , M.D. ( JJ52 ) 9/30/04 @ 02:45 PM
****** END OF DISCHARGE ORDERS ******
Document id: 383
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
- |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
- |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
- |
431967637 | PUO | 35421668 | | 5592840 | 3/22/2007 12:00:00 a.m. | atypical chest pain , hypertension | | DIS | Admission Date: 10/12/2007 Report Status:
Discharge Date: 3/1/2007
****** FINAL DISCHARGE ORDERS ******
MALANEY , SHAWNA 763-11-53-1
Kan
Service: MED
DISCHARGE PATIENT ON: 6/28/07 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PERSONIUS , SVETLANA BART , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. FLUTICASONE PROPIONATE/SALMETEROL 250/50 1 PUFF inhaled twice a day
2. ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
3. ARTIFICIAL TEARS 2 DROP OD three times a day
4. LORATADINE 10 MG orally every day
5. HYDROCHLOROTHIAZIDE 25 MG orally every day
6. ALBUTEROL INHALER 2 PUFF inhaled four times a day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Shortness of Breath
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
as needed Shortness of Breath , Wheezing
ATENOLOL 50 MG orally DAILY
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
MICONAZOLE NITRATE 2% POWDER TOPICAL TP DAILY
Instructions: to affected areas ( abdominal folds )
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Yenney Cardiology clinic Memp Valle Walk 575-803-4363 2/5 @ 2pm ,
Dr. Mantik 10/10 at 1:50pm ,
Anastacia Debrock nutrition 10/10 at 1:15pm ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain , cough
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain , hypertension
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Asthma , Morbid Obesity , Pneumonia , intertrigo , UTI , otitis media
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac PET
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain , cough
****
HPI: 45 year-old male with morbid obesity and asthma presents with chest pain
and cough. patient c/o SSCP x18h , described as tightness , radiating to his
back that began at night while he was sleeping. Pain is worse with
cough. Denies exertional CP but very limited activity 2/2 obesityNo
associated SOB , but mild nausea and +diaphoresis. Denies leg swelling. He
c/o worsening nonproductive cough x1 day. He often has nighttime symptoms
of cough , relieved by nebulizer treatments. No fevers , chills , no other
URI sx.
****
ED COURSE: 96.0 p106 209/94 rr20 95%RA , CTA Chest peformed and was
neg for dissection , rx'd nitro drops , labetalol , ASA , nexium , albuterol
neb. patient had emesis x1 , rx'd
zofran.
****
PMH: Asthma - Peak flow 400 at baseline. No intubations ,
but many admissions. Obesity -
morbid Nephrolithiasis
Atypical chest pain - negative ETT 2002 Umbilical hernia repair 2001
-- incarcerated HTN -- recent dx , started on
HCTZ
****
EXAM: afeb p98 155/64 rr18
93%RA NAD
mmm , OP clear +diffuse expiratory wheezes and rhonchi , +cough on
forced exhalation rrr , nl S1S2 , no
m/g/r abd obese , BS+ ,
NT/ND wwp , TR edema
bilat
****
LABS: enzymes neg x3 STUDIES:
EKG: poor study with wavering baseline , sinus tach at 100 , no sig
STTw changes , +low voltage criteria CTA Chest: negative for
dissection. Limited study due to body habitus. Incidental finding of
3 subcentimeter nodules in periphery of R lung. Focal
thickening of lateral limb of L adrenal gland
****
HOSPITAL COURSE: 45 year-old M with morbid obesity presents with chest pain and
hypertensive urgency.
* CV: Ischemia- patient ruled out for MI with negative serial enzymes and
EKGs. Cardiac PET showed 2 small areas of of reversible ischemia in the
mid PDA and distal LAD territory. Cards f/u was arranged as an oupatient.
He was given ASA , and beta blocker. Total cholesterol was 111 ,
triglycerides 44 , HDL 49 , LDL 53. Despites evidence of CAD on PET , a
statin was not started since patient has a difficult time with medication
adherence and understanding. Will defer statin initiation to cardiology
as an outpatient if necessary.
For HTN control , patient was given HCTZ and lopressor which sufficiently
controlled his BP. patient was sent home on HCTZ 25mg daily and atenolol 50mg
daily. Consider outpatient with u of thickened adrenal gland if BP is
difficult to control.
* PULM - patient thought to have very mild asthma exacerbation and likely has
a restrictive ventilatory defect from obesity. Advair was increased to
500/50 twice a day. patient was given nebs ATC and prednisone 60mg every day x 3 doses and
then stopped when respiratory status significantly improved.
* GI: patient had trace guaiac + stool. HCT remained stable. Outpt colonoscopy
is recommended. patient also c/o loose stool , c diff was negative. patient likely
has a viral gastroenteritis causing diarrhea and some nausea.
* ENDO: A1C was 7.4 and BS was in mid 100s multiple times during admit.
patient educated on low sugar , low carbohydrate diet. He was seen by nutrition
and will follow up with his outpatient nutritionist.
* PPX: lovenox twice a day ( for weight )
ADDITIONAL COMMENTS: 1. ) Take hydrochlorothiazide 25mg daily and atenolol 50mg daily for your
blood pressure. You should also take aspirin 81mg daily.
2. ) Your blood sugar has been slightly elevtaed. You need to eat a low
sugar , low carbohydrate diet. Please discuss with your nutritionist.
3. ) Follow up with cardiology ( heart clinic ) on 2/5 at Fay Da Walk
on the Tonathense
4. ) Call Dr. Mantik or come back to the emergency room if you
have chest pain , difficulty breathing , fever , or lightheadedness.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. ) Monitor blood sugars and A1C- patient is borderline diabetic and will try
diet modification.
2. ) Recommend outpatient colonoscopy.
3. ) Consider statin therapy.
No dictated summary
ENTERED BY: OSMERS , TESSA M ( YZ90 ) 6/28/07 @ 01:27 PM
****** END OF DISCHARGE ORDERS ******
Document id: 384
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
Y |
- |
N |
Y |
N |
N |
N |
N |
195619812 | PUO | 33640513 | | 0915934 | 1/9/2006 12:00:00 a.m. | L Carotid Artery Stent | | DIS | Admission Date: 2/29/2006 Report Status:
Discharge Date: 6/4/2006
****** FINAL DISCHARGE ORDERS ******
SAKAL , KARLY K. 974-03-12-0
Eroche
Service: CAR
DISCHARGE PATIENT ON: 5/18/06 AT 12:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PETTINGER , DOUGLASS N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Instructions: Starting Today
NEORAL CYCLOSPORINE ( CYCLOSPORINE MICRO ( NEORAL ) )
75 MG orally twice a day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 2/12/06 by
IMHOFF , JACOB , M.D.
on order for PRAVACHOL orally ( ref # 380954536 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
PRAVASTATIN SODIUM Reason for override: md aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
ENTERIC COATED ASA 325 MG orally DAILY
PEPCID ( FAMOTIDINE ) 20 MG orally twice a day
Instructions: resume zantac 150mg twice a day at discharge
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FUROSEMIDE 40 MG orally DAILY
GLYBURIDE 10 MG orally every day before noon
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously every day before noon
Starting IN a.m. on 5/13
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY HOLD IF: SBP < 100 , HR < 55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 1 , 000 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
NABUMETONE 500 MG orally twice a day
Food/Drug Interaction Instruction Take with food
PRAVACHOL ( PRAVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/12/06 by
IMHOFF , JACOB , M.D.
on order for PRAVACHOL orally ( ref # 380954536 )
patient has a PROBABLE allergy to SIMVASTATIN; reaction is
muscle aches. Reason for override: patient requires
Previous Alert overridden
Override added on 2/12/06 by IMHOFF , JACOB , M.D.
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
PRAVASTATIN SODIUM Reason for override: md aware
PREDNISONE 6 MG orally every day before noon
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Rheumatology: Dr. Esannason , 1753436826 2 months time ,
Please call your primary care physician Dr. Rodman for an appointment within 1-2 weeks of discharge ( 165-864-7018 ) , and she may refer you for further diabetes care ,
ALLERGY: SIMVASTATIN
ADMIT DIAGNOSIS:
L Carotid Artery Stent
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
L Carotid Artery Stent
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of cardiac transplant 1992 ( history of cardiac transplant ) Diabetes mellitus
type II ( diabetes mellitus type 2 ) Trochanteric bursitis ( trochanteric
bursitis ) Dyslipidemia ( dyslipidemia ) DJD spine ( OA of cervical
spine ) Hx vocal cord injury postop Hx gastritis with UGIB ( history of upper
GI bleeding ) Hx postop seizure
OPERATIONS AND PROCEDURES:
Left Carotid Artery Stent Placement.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
HPI: Ms. Sakal is a 70 year-old woman with history of Cardiac Transplant 1992 , history of
PCI/Stent 6/19 with 80% lesion LCx history of R Carotid stent placement 6/19 ,
history of DM , HTN , Hyperlipidemia , Smoking , now history of L Carotid Stent Placement
10/24/06 . During annual follow up in 9/30 of her heart transplant , a
complex eccentric 80% lesion was noted in the proximal LCx. She was
admitted in January electively with plans for cardiac cath/PCI/stent.
However in the interim period , she had a symptomatic LUE numbness thought
to be a TIA , concerning for R carotid stenosis. An MRI revealed bilateral
tight carotid stenosis. The LCx and Symptomatic R Carotid artery
underwent cath/stent placement in 6/19 . However , intervention on her
left internal carotid artery ( though 90% occluded by cath ) was deferred
due to already receiving 2 angiographikc procedures during the 6/19
admission. At this time she was tapered off cell-cept and started on
rapamycin - in hopes of slowing progression in her coronary disease. She
then returned to medical attention on 19 of April for catheterization/stent
placement on Left Carotid Artery. During these procedure , a hematoma
developed at the L femoral access site which was managed with compression
during the case. FSBS was 384 prior to the procedure and elevated to 547
during the procedure ( she received D5W+HCO3 during the procedure. ) She
was given 10 u regular insulin x 2 and her FSBS declined to 400s. Her
post-procedure course has been complicated by hyperglycemia and hematoma
formation with a Hct drop of 30 ` 22.
PMH:
1. TIA Patient taken to cath lab after RUE numbness c/with TIA 6/19 .
Bilateral carotid stenoses were seen by angiography. Stenting of R
internal carotid artery performed
2. CAD: Coronary angiography/PCI of LCx lesion. Cypher stent.
Discharged on ASA/Plavix.
3. Heart Transplant Recipient: 1992 2/2 end stage ischemic
cardiomyopathy. Was switched from cellcept and cyclosporine to
rapamycin/cyclosporine during 6/19 admission because of concern of
progression of coronary disease within the allograft. Last Echo 1/17
LV sized decrease , normal overall function. EF 65%. No RWMA. RV Nl
Size/thickness/function. Severe LAE/Mild RAE c/with transplant. No change
from 10/4 study.
4. Hypercholesterolemia
5. DJD Spine
6. Type II DM since 1992
7. Gastritis
8. H/o GIB
Meds on Admission: Rapamune 1 mg twice a day , Prednisone 6 mg Qday , Metoprolol
50 mg orally QDAy , Zantac 150 mg orally twice a day , Nabumetone 750 QDay , Glyburide 5 mg
twice a day , Ditropan 10 mg orally Qday , Plavix 75 mg orally Qday , Zetia 10 mg orally Qday ,
Lasix 40 mg orally Qday , Tums orally three times a day , ECASA 325 , Magnesium 400 mg orally Qday ,
Multivit , Cyclosporine 50 mg orally twice a day , Tricor 48 mg orally QDay
Soc Hx: ExSmoker and drinks wine occassionally. She lives alone.
All: Prior Intolerance of Statins ( full body aches ) and Zetia ( muscular
aches ).
Exam on 5/25/06
Vitals - Afebrile 96/52 95
No JVD , neck supple , CTAB , Distant heart sounds RRR. No M/R/G
appreciated , Soft NT/ND. R Groin- ecchymosis , no marked swelling/hematoma
at site.
Extremities: Tr edema , +1 pulses DP/AT bilaterally.
Assessment: Ms. Sakal is a 70 year-old woman with history of Cardiac Transplant
1992 , history of PCI/Stent 6/19 with 80% lesion LCx history of R Carotid stent
placement 6/19 , history of DM , HTN , Hyperlipidemia , Smoking , now history of L Carotid
Stent Placement 10/24/06 with postprocedure course complicated by hematoma
formation causing acute on chronic anemia , and hyperglycemia.
Labs/Studies:
Chol: Chol 354 , TG 1383 , HDL 29 ( Up from 4/11 Chol 267 , TG 677 , HDL 29 )
HbA1c 11.1 ( up from 10/18 6.9 )
1. Heme: Patient had r femoral hematoma due to bleeding around sheath and
causing fluctuation in Hct. HCT currently stable without transfusions.
Site non-pulsatile and no bruits. Transfusing 1 U pRBC 6/20 for goal
Hct>28.
2. CV( Ischemia ): Patient history of ischemic CM history of heart transplant with
evidence of CAD on allograft. Patient medically managed with pravachol ,
aspirin and plavix. Now history of bilateral carotid stents and stent to LCx.
Attempt to change immunosuppressive regiments to rapamycin in order to
lower progression of CAD however on this regiment , her cholesterol panel
has markedly worsened. Have stopped rapamycin ( 6/20 ) and restarting
cellcept and cyclosporine at prior doses. Will need review in clinic in
30 days with bilateral carotid ultrasounds.
CV( Pump ): Clinically appears euvolemic. On Toprol , restarting lasix at
home dose ( 5/13 ).
CV( Rhythm ): On telemetry , no events seen.
3. Endo: During hospitalization and prior/during procedures has had poor
glucose controls with FSBS in 300s-400s. Patient reports poor glycemic
control at home with FSBS in 300s. a.m. FSBS was 384 and received D5NS
prior to procedure , exacerbating hyperglycemia. Endocrinconsulted and
recommended Qday lantus injection with with Novolog sliding scale + before meals
while in house. HbA1c @ 11 ( markedly worse than 6 in January ) - patient can
not identify other factors which have changed since January other than
immunosuppressants to rapamycin. FSBS were difficult to control in house
despite using 20 QDay of lantus , Ms. Weissgerber FSBS continued to run in
the 200s-300s during the day. She was taught to inject herself with
insulin subcutaneously during her stay. She is discharged on Glyburide 10 QDay and
Lantus 20 QDay. She was taught to keep a diary and will follow up with her
primary care physician.
4. Neuro: TIA/CVA in 6/19 . residual Left numbness/weakness in hand. On
plavix and asa , now history of R and L Carotid Stents.
5. Immunosuppression: As above , have changed immunosuppression from
Rapamycin + Cyclosporine back to Cyclosporine 75 twice a day +Cellcept 1000 twice a day as
patient performed priorto 6/19 .
6. MSK/Rheum: The patient previously complained of myalgias with statins and
was resistant to starting statins because they seemed to worsen her
aches/pains. Rheumatology service was consulted. They believed her pain
is not consistent with statin associated myalgia. Zetia was stopped and
she was started on Pravachol 20 mg every bedtime.
Her back pain is relieved by leaning forward and she walks at Rham
with a shopping cart for exercise which is consistent with spinal stenosis.
They recommended physical therapy and MRI imaging of her back. The MRI
preliminary read shows multilevel degenerative disc disease and moderate
spinal stenosis at one level. Physical therapy saw her and thought she
would benefit from home physical therapy in the future--she was given a prescription for
outpatient physical therapy.
Since she is on long term prednisone she should have a DEXA scan and may
benefit from bisphosphonate therapy.
Discharge Medication: Cellcept 1000 mg twice a day , Lantus 20 subcutaneously every day before noon , Nabumetone 500
mg orally twice a day , Pravachol 20 mg orally every bedtime , Glyburide 10 mg orally every day before noon , Cyclosporine 75
mg orally twice a day , Toprol 50 mg orally QDay , Prednisone 6 mg orally every day before noon , Plavix 75 orally QDay ,
Zantac 150 mg twice a day , Furosemide 40 mg orally QDay , Fe 325 orally three times a day , ECASA 325 orally
QDay
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
[X] Follow up lumbar MRI results for question of spinal stenosis.
[] Follow up A1c with Lantus and have glucose monitoring diary.
[] Carotid Dopplers in 1 months time
No dictated summary
ENTERED BY: BORRIELLO , SACHIKO S. , M.D. ( EP65 ) 5/18/06 @ 09:32 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 385
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
Y |
Y |
Y |
N |
N |
N |
N |
- |
- |
423657954 | PUO | 64891866 | | 8895355 | 7/16/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 5/10/2006 Report Status: Signed
Discharge Date: 9/22/2006
ATTENDING: STUKOWSKI , JANAY MD
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Mr. Petrus is a 75-year-old gentleman with history of
insulin-dependent diabetes and hyperlipidemia who had a history
of myocardial infarction and stent placement of his right
coronary artery in 4/3 . The patient had two recent episodes
of dyspnea on exertion with mild activity which resolved
spontaneously. Cardiac catheterization was performed , which
revealed a left circumflex coronary artery with a proximal 35%
stenosis , first obtuse marginal coronary artery with a proximal
80% stenosis , right coronary artery with a proximal 60% stenosis
and a mid 80% stenosis and a distal 80% stenosis , posterior left
ventricular branch , ostial 80% stenosis and a left anterior
descending coronary artery with a proximal 45% stenosis , and
right dominant circulation. Echocardiogram revealed ejection
fraction of 60% , trivial mitral insufficiency , trivial tricuspid
insufficiency , trivial pulmonic insufficiency , and no regional
wall motion abnormalities.
PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY:
Significant for myocardial infarction in 1980s , PTCA atherectomy
in 1997 , and a recent stent placement of his right coronary
artery in 4/10/06 . History of hypertension , cerebrovascular
accident with no residual presented with left-sided weakness ,
chronic renal insufficiency , diabetes mellitus , chronic
obstructive pulmonary disease , and psoriasis.
ALLERGIES:
The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
nadolol 80 mg daily , and lisinopril 40 mg twice a day , isosorbide 30
mg daily , enteric-coated aspirin 325 mg daily , Plavix 75 mg
daily , hydrochlorothiazide 25 mg daily , atorvastatin 80 mg daily ,
metformin 500 mg twice a day , Lantus 42 units in the evening and
NovoLog 6 units with lunch and 12 units at dinner , triamcinolone
topical ointment , and allopurinol 300 mg daily
PHYSICAL EXAMINATION:
Cardiac exam: Regular rate and rhythm with no murmurs , rubs , or
heaves. Peripheral vascular 2+ pulses bilaterally in the
carotid , radial , femoral pulses , and 1+ bilaterally in the
dorsalis pedis and posterior tibialis pulses. Respirator:
Breath sounds clear bilaterally , is otherwise , noncontributory.
ADMISSION LABS:
Sodium 138 , potassium 3.7 , chloride of 104 , CO2 26 , BUN of 28 ,
creatinine 1.2 , glucose 89 , and magnesium 2.2. WBC 8.73 ,
hematocrit 39.2 , hemoglobin 13.2 , and platelets of 248 , 000. physical therapy
13.3 , physical therapy/INR 1.0 , and PTT of 28.1. Carotid noninvasives revealed
left internal carotid artery with less than 50% occlusion and
right internal carotid artery with a 60% occlusion.
HOSPITAL COURSE:
Mr. Petrus was brought to the operating room on 2/13/06 where he
underwent an urgent coronary artery bypass graft x4 with left
internal mammary artery to the first diagonal coronary artery and
a saphenous vein graft to the second obtuse marginal coronary
artery with a sequential graft and then saphenous vein graft
connecting from the right coronary artery to the first left
ventricular branch. Total bypass time was 127 minutes and total
circulatory arrest time was 11 minutes. Intraoperatively , the
patient's aorta was not clamped due to calcifications ,
appropriate locations for cannulation and proximals were
identified with epicardial echocardiogram. The patient was
cooled to 20 degrees. Distal anastomoses were done under
ventricular fibrillatory arrest with brief circulatory arrest.
Proximals were done under circulatory arrest. The patient did
well intraoperatively , came off bypass without incident. He was
brought to the Intensive Care Unit in normal sinus rhythm and
stable condition. Postoperatively , the patient was initially
ventricularly paced , and started on dopamine which was discontinued
on 8/9/06 . The
patient also had rate controlled atrial fibrillation that was
treated with Lopressor and
started on Coumadin for anticoagulation , he did convert to normal
sinus rhythm. He was extubated on 2/10/06 and he did have some
postoperative low urine output , which improved with his dopamine
and intravenous Lasix. Diabetes Service also followed the
patient throughout his postoperative course for his glucose
control. He was transferred to the
Step-Down Unit on postoperative day #5. Mr. Petrus also received
2 units of packed red blood cells postoperatively for
postoperative anemia. Mr. Petrus was screened by physical
therapy for rehab and was cleared for discharge to rehabilitation
on 8/22/06 . That morning , the patient complained of intense pain
in his feet , which was found to be from a gouty flare ,
rheumatology was consulted and they recommended a short course of
prednisone along with colchicine for approximately three weeks
and then to be restarted on allopurinol 100 mg after his
colchicine course is completed. The patient's pain and swelling did improve
overnight. He was reevaluated the following morning and
cleared for discharge to rehabilitation on November
on postoperative day #9.
DISCHARGE LABS:
Sodium 141 , potassium 4.3 , chloride of 105 , CO2 29 , BUN 35 ,
creatinine 1.4 , glucose 95 , and magnesium 1.9 , WBC 14.6 ,
hematocrit 33.5 , hemoglobin 11.4 , and platelets of 484 , 000. physical therapy
17.3 , physical therapy/INR 1.4 , and PTT of 36.4.
DISCHARGE MEDICATIONS:
Are as follows; allopurinol 100 mg once a day after his
colchicine course is completed , Lipitor 80 mg daily , Plavix 75 mg
daily , colchicine 0.6 mg three times a day for three days and then 0.6 mg
twice a day for three days , and then down to 0.6 mg daily for three
weeks , Lasix 20 mg daily , NovoLog sliding scale before every meal and at
bedtime , NovoLog 12 units with breakfast and lunch and 10 units
with supper , Lantus 44 units at bedtime , potassium chloride slow
release 10 mEq daily , Toprol-XL 200 mg daily , oxycodone 5 mg q.
4h. as needed pain , and prednisone taper , the patient received 24 mg
daily , then 20 , then 16 , 12 , 8 mg , 4 mg and down to 0 mg.
Coumadin , the patient received 7 mg of Coumadin this evening for
his atrial fibrillation. He will be followed by Pagham University Of Anticoagulation Service at 988-605-5355 for
target INR of 2.0-2.5.
FOLLOW UP APPOINTMENTS:
Mr. Petrus will follow up with Dr. Janay Stukowski in six weeks and
his cardiologist , Dr. Earnestine Fiermonte in one week.
DISPOSITION:
He is discharged to rehab in stable condition.
eScription document: 2-5726838 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: STUKOWSKI , JANAY
Dictation ID 5706947
D: 9/24/06
T: 9/24/06
Document id: 386
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
Y |
- |
- |
N |
Y |
N |
N |
Y |
N |
680159882 | PUO | 61129049 | | 6093539 | 2/8/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 3/18/2006 Report Status: Signed
Discharge Date: 11/4/2006
ATTENDING: AUTHUR , FIONA M.D.
ANTICIPATED DATE OF DISCHARGE: 11/16/06
HISTORY OF PRESENT ILLNESS:
The patient is an 86-year-old male with multiple medical problems
including CHF , coronary artery disease , type II diabetes who
presented to the Pagham University Of Emergency
Department on 5/28/06 , with subacute onset of shortness of
breath. He had been bedridden for several months with right heel
ulcerations , and was scheduled to undergo operative repair of
this ulceration , however , he began to feel short of breath one
day prior to admission. His O2 saturation was 70% on room air.
upon presentation. He also described dull nonradiating chest pain
with shortness of breath , which had resolved at the time the
patient arrived in the Emergency Department. He also had
increased right knee pain for one week , presumably due to a combination of gout
and OA. He was taking colchicine at that time as
well. By the time the patient had been seen in the Emergency
Department , his shortness of breath had improved significantly.
PAST MEDICAL HISTORY:
Congestive heart failure , coronary artery disease status
post angio x2 , peripheral vascular disease status post
angioplasty in 2006 and angioplasty of right peroneal artery as
well as tibioperoneal trunk. The above-knee popliteal was also
angioplastied on the right , gout in the right knee , atrial
fibrillation , and chronic renal insufficiency.
PAST SURGICAL HISTORY:
Transurethral resection of the prostate , appendectomy.
FAMILY HISTORY:
Father , diabetes and brother , heart disease.
MEDICATIONS:
Ciprofloxacin , Zoloft 50 mg every day before noon , Lipitor 20 mg every afternoon ,
Coumadin 3 mg daily , aspirin 81 mg daily , Dilaudid 2 mg orally
every day before noon , Digoxin 0.125 mg every day before noon , Lasix 40 mg every day before noon , Colace 100
mg twice a day , Senna 1 tab at bedtime , Neurontin 100 mg every day before noon and
200 mg at bedtime , Lantus 42 units every day before noon , Lopressor 75 mg
twice a day , and colchicine 0.6 daily.
ALLERGIES:
Penicillin.
PHYSICAL EXAMINATION:
Temperature 98 , heart rate 93 and regular. Blood pressure
112/68 , saturating 97% on 4 liters. Generally: He is alert and
oriented , lying in bed , and no distress. His chest has bibasilar
crackles , extending midway up his lung fields. No wheezes.
Cardiovascular: Irregular rhythm , no murmurs , rubs , or gallops.
Abdomen: Nontender , no masses. Extremities: He has 2+ radial
pulses and his lower extremity pulses are not palpable. He has a
right foot dressing and is in a boot. Neurologically: His
cranial nerves are intact bilaterally. His upper extremity
strength is 5/5.
PERTINENT LABS UPON PRESENTATION:
K 3.7 , BUN 30 , creatinine 1.4 , and sugar 117. CBC 11.3 , 30.6 ,
and 421. INR 2.2. Cardiac enzymes: CK 21 , CK-MB 1.4 , troponin
less than assay. Digoxin level 1.1. UA normal.
IMAGING:
Chest x-ray increased vascular congestion. EKG , left ventricular
hypertrophy , AFib , digitalis changes.
ASSESSMENT:
An 80-year-old male with history of coronary artery disease ,
AFib , peripheral vascular disease , gout in the setting of CHF
exacerbation.
HOSPITAL COURSE:
The patient was subsequently admitted to the Medicine Service
where he was cared for until 1/15/06 . During this time , the
patient's lasix was increased to 80 mg intravenous every day before noon an attempt to
diurese the patient with a goal I/O of negative 1 liter a
day. He was continued on his digoxin and metoprolol. He was
ruled out for cardiac event with three negative sets of cardiac
enzymes. He was started on a bowel regimen of Colace , Senna and
MiraLax as needed due to constipation. Regarding his right knee
pain , the Rheumatology Service was consulted on 7/10/06 and
recommended two views of his right knee , which were significant
for a small effusion and severe osteoarthritis. Recommended
Tylenol , opioids for pain and continued colchicine.
Intraarticular steroids were discussed , however , deferred until
after surgical intervention. A Foley catheter was placed to
monitor his I's and O's closely. He was also started on
tamsulosin for his BPH. Regarding his hematologic status , his
Coumadin was initially continued , however , due to a planned
Plastic Surgery intervention , starting on 7/10/06 . The patient
did receive several doses of orally vitamin K preoperatively , which
brought his INR down to 1.3 prior to surgery. Thus on 1/15/06 ,
Mr. Parlin was taken to the operating room for debridement of his
right Achilles ulceration and split thickness skin graft.
Postoperatively , he was transferred to the Plastic Surgery
Service. On postop day #1 , the Rheumatology Service was again
consulted for persistent right knee pain. They elected at that
time to inject steroids intraarticularly. There was not enough
fluid for aspiration , however.
POSTOPERATIVE HOSPITAL COURSE BY SYSTEMS:
Neurologically: The patient tolerated as needed Dilaudid. He was
continued on his doses of Neurontin and Zoloft.
Cardiovascularly: He has continued on digoxin and metoprolol for
rate control of his atrial fibrillation. He was also continued
on 80 mg daily of Lasix , which was decreased to 40 mg after
recommendations from the Medicine Service. The patient did have
an episode of bradycardia into the 30s on 5/12/06 , which was
believed to be secondary to excessive beta blockade. Thus his
Lopressor dose was decreased to 25 mg three times a day
Respiratory: The patient has been saturating well on room air
without pulmonary complaints.
GI: The patient has been tolerating his diet and having bowel
movements.
GU: The patient's Foley catheter was removed on 5/12/06 . The
patient voided without complication. He has continued his
tamsulosin.
Hematologically: He was placed back on his home dose of Coumadin
and his aspirin was restarted. His hematocrit was stable
postoperatively at 27.8 and has continued to be stable and is
currently 29.4. He has also been maintained on subcutaneous
heparin three times a day for DVT prophylaxis.
ID: The patient was started on clindamycin postoperatively for
graft prophylaxis. He has been afebrile and his white count has
been normal and is currently 7.8.
Endocrine: He has been maintained on Lantus and NovoLog before
meals and a NovoLog sliding scale , which have been titrated
according to his blood sugars. His insulin regimen is currently ,
Lantus 32 units daily , and NovoLog sliding scale , and NovoLog 4
units before meals.
Rheumatologically: The patient has been followed by the
Rheumatology Service for right knee gout. The intraarticular
steroid injection improved his pain minimally and thus the
Rheumatology Service is currently planning on injection of
Synvisc intraarticularly. The Rheumatology Service also
recommended a right knee MRI , which was obtained ( showed severe OA , gouty
changes ). Regarding his wound , his dressings were taken
down on 11/16/06 and his skin graft appeared to be taking well.
His donor site is clean , dry , and intact as well and he is
receiving heat lamp treatments daily. Regarding his mobility ,
the patient has been limited significantly due to his severe
right knee pain. The physical therapist will work with the
patient on 11/16/06 , which is the first day that his skin graft
dressings have been taken down.
PERTINENT PHYSICAL EXAM UPON DISCHARGE:
The patient is alert and oriented x3 in no apparent distress
while he is resting. When he attempts to move his right lower
extremity , he does complain of significant right knee pain.
Cardiovascular is irregularly irregular. His lungs are clear
superiorly and slightly decreased in the bases. His abdomen is
soft , nontender , and nondistended. Extremities: His right leg
donor site is clean , dry , and intact with Xeroform in place. His
right lower extremity skin graft was taking well with Xeroform in
place. His right knee is swollen and tender to palpation. The
patient has pain with passive and active range of motion.
DISCHARGE MEDICATIONS:
Acetaminophen 325 mg orally every 6 hours as needed pain , clindamycin
600 mg intravenous , colchicine 0.6 mg orally twice a day , digoxin 0.125 mg orally
daily , Colace 100 mg orally twice a day , iron sulfate 325 mg orally daily ,
Lasix 40 mg every day before noon , heparin 5000 units subcutaneous three times a day ,
metoprolol 25 mg orally three times a day , senna two tabs orally twice a day ,
Coumadin 3 mg orally every afternoon , Zoloft 50 mg orally every day before noon , Zocor 40 mg
orally at bedtime , Neurontin 100 mg orally every day before noon , 200 mg orally
every afternoon , tamsulosin 0.4 mg orally daily , Nexium 20 mg orally daily ,
Lantus 32 units subcutaneous daily , NovoLog 4 units subcutaneous
before meals , and NovoLog sliding scale as well. P.r.n. meds include ,
Tylenol 325 mg orally every 6 hours as needed pain , Dilaudid 1-2 mg orally q.
4h. as needed pain , milk of magnesia 30 mL orally daily , and Maalox
1-2 tablets orally every 6 hours as needed upset stomach.
DISCHARGE INSTRUCTIONS:
The patient should follow up with Dr. Authur in one to two weeks.
He should also follow up with his primary care physician in one
to two weeks. The patient should have his INRs checked two to
three times per week with goal INR of 2-3 for treatment of AFib.
He should also have heat lamp treatment to his split thickness
skin graft donor site 20 minutes three times a day until the Xeroform falls
off. The split thickness skin graft site should be changed daily
with Xeroform and Kerlix dressing. The patient is currently
scheduled for an MRI while inpatient , however , if he does not
receive his MR while in house , he needs to have an outpatient MRI
scheduled. Please refer to the discharge summary for final
details including a final list of medications and the plans
regarding MRI.
eScription document: 8-4757518 EMSSten Tel
Dictated By: POLIVICK , HERTHA
Attending: AUTHUR , FIONA
Dictation ID 8152056
D: 11/16/06
T: 11/16/06
Document id: 387
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
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U |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
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N |
N |
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N |
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Y |
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N |
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109080323 | PUO | 62974095 | | 375970 | 2/10/2000 12:00:00 a.m. | RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/18/2000 Report Status: Signed
Discharge Date: 10/20/2000
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
OTHER PROBLEMS: Diabetes , asthma , smoking , GI bleeding of unknown
etiology , hypertension , hypercholesterolemia.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man with
coronary artery disease with risk
factors of diabetes , hypertension , cigarette smoking , and a report
of hypercholesterolemia. The patient has reported a history of
angina over the past several years which was well controlled by
nitroglycerin. In October of 1997 , he was able to exercise 3
minutes of the Bruce protocol with maximum heart rate of 79 and a
blood pressure of over 80 with no evidence of ischemia on EKG. An
echo at that time was also normal. About a month prior to
admission , the patient began experiencing progressive chest pain
which seemed related to exertion. He described the chest pain as
burning and radiating to his neck. The patient has a history of
gastroesophageal reflux , and was referred for EGD , but this test
was postponed until a further workup of the patient's chest pain.
At baseline he reports exercise-related chest pain everyday as well as
occasional chest pain at rest relieved by about 3-5 nitroglycerin. These
episodes are associated with diaphoresis , shortness of breath , but no nausea or
vomiting.
PAST MEDICAL HISTORY: Significant for coronary artery disease ,
gastritis , GERD , GI bleed in February of
1999 , nephrolithiasis , diabetes , history of atrial fibrillation ,
asthma , hypertension , hypercholesterolemia.
ADMISSION MEDICATIONS: Cardizem , Klonopin , aspirin , Prilosec ,
Paxil , nitroglycerin , as needed , Azmacort ,
albuterol , Mevacor , iron , NPH.
ALLERGIES: None known.
PHYSICAL EXAMINATION: Afebrile , pulse 71 , blood pressure 107/53 ,
satting 97%on room air. Pertinent positive
include occasional bilateral wheezes on lung exam. CARDIOVASCULAR:
Regular rate , normal S1 and S2 , no murmurs , rubs , or gallops.
NECK: No evidence of JVD and no carotid bruits. ABDOMEN: Benign.
EXTREMITIES: No cyanosis , clubbing or edema , and dorsalis pedis
and posterior tibialis pulses were 2+ bilaterally. RECTAL:
Significant for guaiac-positive dark brown stool.
ADMISSION LABORATORY: Significant for hematocrit of 29.4 , with an
MCV of 78 , cardiac enzymes were negative on
admission.
EKG on admission showed normal sinus rhythm with a rate of 70. No
significant ST or T wave abnormalities.
PROCEDURES: Cardiac catheterization status post right coronary
artery stent was performed during the patient's
hospital stay. No complications resulted from this procedure.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular. On February , the patient had an exercise
treadmill test Bruce protocol. He exercised for 2 minutes and 30
seconds achieving a maximum heart rate of 104 with maximum blood
pressure of 130/90 , however , the test was terminated at low
exercise level for shortness of breath an leg fatigue. No EKG
changes were noted during this test. Since this test was nondiagnostic , the
patient was scheduled for a dobutamine MIBI. This test showed a significant
area of ischemia in the inferior and apical regions of the heart. An
echocardiogram performed also showed an area of hypokinesis in the inferior
region of the heart. Cardiac catheterization performed on February showed
100% occlusion of the LAD and 75% occlusion of the right coronary
artery with stent placement. Prior to stent placement , Mr. Eisenzimmer
had two episodes of chest pain in the hospital which resolved with
nitroglycerin. He had no chest pain following stent placement. He also had
transient episodes of atrial fibrillation/flutter.
2. Gastrointestinal. Mr. Eisenzimmer was noted to guaiac positive on
admission. He also reported some symptoms consistent with
gastroesophageal reflux. While in inpatient , his Prilosec was
increased at 20 mg orally twice a day He was followed by GI while in
inpatient and it was recommended that he have a repeat EGD and
colonoscopy as an outpatient.
DISCHARGE MEDICATIONS: Albuterol inhaler 2 puffs inhaled four times a day
as needed wheezing , enteric coated aspirin
325 mg orally every day , Klonopin 0.5 mg orally twice a day , insulin NPH 25 units
subcutaneously twice a day , Mevacor 20 mg orally every day , Lopressor 25 mg orally twice a day ,
nitroglycerin as needed chest pain , Prilosec 20 mg orally twice a day ,
Azmacort 4 puffs inhaled twice a day , Paxil 20 mg orally every day , clopidogrel
75 mg orally every day
DISCHARGE CONDITION: Stable.
DISPOSITION: The patient was discharged to home.
Dictated By: BARB SHINABERY , M.D. JM03
Attending: NATHANIAL BYE , M.D. GL11 SQ570/6814
Batch: 03745 Index No. IVFW867L1U D: 1/1
T: 1/1
Document id: 388
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
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N |
N |
- |
156883837 | PUO | 43767623 | | 3847618 | 5/24/2002 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 5/24/2002 Report Status: Signed
Discharge Date: 7/3/2002
PRINCIPAL DIAGNOSIS: NEPHROTIC SYNDROME , PEDAL EDEMA.
PROBLEM LIST: 1. DIABETES MELLITUS.
2. HYPERTENSION.
3. BIPOLAR DISORDER.
4. PANIC DISORDER.
5. RENAL INSUFFICIENCY.
6. CONGESTIVE HEART FAILURE , DIASTOLIC DYSFUNCTION.
7. CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old man with
a medical history as listed above who
presented with 3 weeks of worsening bilateral leg edema. The edema
started approximately 6 months ago and has worsened over the past 3
weeks. He has gained approximately 20 pounds since the summer. In
August he was seen by his primary care physician and found to be
fluid overloaded and started on Lasix. Unfortunately he has not
responded to even 180 mg orally Lasix every day. Concomitant with the
edema he has increased dyspnea on exertion for about 1 1/2 weeks.
His ability to exercise is limited by his dyspnea and he can only
climb one set of stairs compared to 2 sets about 6 months ago. He
does not have symptoms of orthopnea or paroxysmal nocturnal
dyspnea. In April of 2002 his pulmonary function studies revealed
obstructive dysfunction and he was started on Combivent inhalers
with good response. He has had 2 episodes of chest pain in September of
2002 for which he was admitted for rule out myocardial infarction ,
at that time MIBI was negative. He denies any palpitations on this
admission. His last echocardiogram on September , 2002 showed an
ejection fraction of approximately 65-70% with mild concentric left
ventricular hypertrophy and trace mitral regurgitation. The
patient is homeless , unemployed and left the Ee
several days prior to admission. He has lived with his friends
since then.
PHYSICAL EXAM ON ADMISSION: Blood pressure 180 systolic , jugular
venous pressure at approximately 8 cm.
He has a normal pulmonary exam as well as a normal cardiac exam.
He has evidence of bilateral pitting edema to his hip.
LABORATORY DATA ON ADMISSION: Notable for a urine showing 13 grams
of protein per day.
HOSPITAL COURSE: This is a 62-year-old gentleman with diastolic
dysfunction , congestive heart failure ,
nephrotic syndrome who has failed orally diuretics. In the hospital
he had evidence of nephrotic-range proteinuria. He had a negative BNP
suggesting the nephrotic syndrome to be the major cause of his shortness
of breath more than congestive heart failure. Venous insufficiency and
standing on his feet most days were also likely contributors to his pedal
edema. Of
note , this nephrotic syndrome is likely due to long standing diabetes induced
nephropathy.
1. Cardiology: The plan is to continue enteric coated aspirin 325
mg orally every day and continue with his Ace inhibitor. The patient was
diuresed aggressively in the hospital and by the time of discharge
he had been switched from Diltiazem and metoprolol over to labetalol 1200
mg twice a day He will need Torsemide for diuresis , currently 100 mg every day The plan
will be for him to get daily weights and he will be followed by a
congestive heart failure nurse. His weight upon discharge is 129
kilograms.
2. Respiratory: The patient has no dyspnea or respiratory
distress on discharge. The plan is to continue with his outpatient
inhalers.
3. Diabetes: The patient has good control on Lantus insulin and
will continue that.
4. Peripheral: The patient was fitted for Jobst stockings which
he should wear to his knee and should be used daily. His edema was greatly
improved with stockings and adequate diuresis.
5. Hematology: The patient has relatively new onset normocytic or
macrocytic anemia which will require an outpatient work up.
MEDICATIONS ON DISCHARGE: Enteric coated aspirin 81 mg orally every day ,
Atrovent inhaler 1-2 puffs inhaled
four times a day , labetalol 1200 mg orally twice a day , Lisinopril 30 mg orally
twice a day , torsemide 100 mg orally every day , Flovent 110 mcg inhaled
twice a day , Lamictal 125 mg orally twice a day , Lantus 46 units subcutaneously
every bedtime , Procardia XL 60 mg orally every day , potassium chloride slow
release 10 mEq orally every day.
CONDITION ON DISCHARGE: Stable.
DISPOSITION ON DISCHARGE: To the Try Ln.
He will need close follow-up of his pulse , blood pressure , weight ,
electrolytes , blood sugars , and medical compliance.
Dictated By: ELLIS RETZLER , M.D. EU77
Attending: CHRISTIAN SVENNINGSEN , M.D. ML747 KG523/584220
Batch: 0577 Index No. F3SK6913VA D: 11/12/02
T: 11/12/02
CC: Y Romsquite Ceanshingtuc Ster Ins Gu
Document id: 389
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
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- |
N |
Y |
N |
N |
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- |
Y |
N |
N |
N |
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N |
Y |
076954946 | PUO | 61732093 | | 294496 | 9/9/1999 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 9/9/1999 Report Status: Signed
Discharge Date: 3/28/1999
DISCHARGE DIAGNOSES: 1 ) ATRIAL FLUTTER. 2 ) LEFT PLEURAL EFFUSION.
HISTORY OF PRESENT ILLNESS: Mr. Joy Hollis Carransa is a 56-year-old man
with a history significant for a coronary artery bypass grafting
approximately one month ago with mitral valve annuloplasty ,
diabetes mellitus and hypertension who presented with a cough. The
patient had recently been evaluated on 9/21/99 for cough and was
treated for a pneumonia with levofloxacin.
The patient stated that his cough and malaise began approximately
one week after discharge postoperatively. He stated that his cough
was constant , worsened at night , with some small clear sputum.
Denied any hemoptysis or fevers. He also denied sick contacts. No
nausea and vomiting or diarrhea. The patient had also noted
increased leg swelling over the past several weeks. In addition
the patient was complaining of some orthopnea as well as PND.
PAST MEDICAL HISTORY: 1 ) Coronary artery disease , status post
coronary artery bypass grafting 4/5 ( left
internal mammary artery to left anterior descending , SVG to PDA , OM
[with mitral valve annuloplasty]. 2 ) Diabetes mellitus. 3 )
Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Enteric coated aspirin , Zantac ,
Coumadin , Colace , Niferex , Vasotec and
NPH insulin.
SOCIAL HISTORY: The patient is married , no alcohol , no smoking.
PHYSICAL EXAMINATION: On admission. Temperature 97.9 , pulse 111 ,
blood pressure 133/86 , room air sat 96
percent. General - No acute distress. HEENT: Pupils equal , round
and reactive to light. Extraocular movements intact. Jugular
venous distention 15 centimeters , no lymphadenopathy. Lungs
decreased breath sounds at base with bilaterally crackles on the
left a third of the way up. Cardiovascular - tachycardic , normal
S1S2. Abdomen soft , nontender , nondistended. Extremities 3+ lower
extremity edema to the mid thigh. Venous stasis changes on the
shins. Neuro nonfocal.
LABORATORY DATA: Sodium 137 , potassium 4.5 , creatinine 1.2 ,
glucose 103 , WBC 5.5 , hematocrit 32.4 , platelets
37.6 , CK 113 , Troponin 1.03.
Chest x-ray - left-sided pleural effusion.
HOSPITAL COURSE: Mr. Joy Hollis Carransa was admitted for increasing
cough , left lower extremity edema for presumed
congestive heart failure exacerbation. Hospital course by systems:
1 ) Cardiovascular. The patient was noted to be in new onset
congestive heart failure. He was aggressively diuresed. It was
noted on admission that patient was in atrial flutter with pacing
at a rate of approximately 110-120. An electrophysiology consult
was obtained and pacer was interrogated and mode changed to DDI
from DDD. The patient was loaded on digoxin and subsequently
spontaneously reverted to normal sinus rhythm.
2 ) Pulmonary. The patient was noted to have a persistent pleural
effusion that was new since the patient's coronary artery bypass
graft one month previous. Although it was suspected that this was
likely secondary to congestive heart failure or perhaps
postoperative pleural effusion , etiology was unclear. A pulmonary
consult was obtained. The patient did undergo a
diagnostic/therapeutic thoracentesis of 500 cc of fluid. Analysis
of the fluid showed a pH of 7.48 , total protein of 4.8 ( serum total
protein 7.6 ) , LDH of 158 ( serum LDH 228 ) ,
glucose 135 , amylase 33 with 600 white blood cells , 6 polys , 0
bands , 56 lymphs , 13 monos , 18 macrophages and 7 , 000 red blood
cells. No PMNs were noted. Cytology was still pending at the time
of discharge. Though the pleural effusion did meet criteria for an
exudate , this was difficult to interpret in light of the patient's
recent aggressive diuresis. As fluid did not appear to be
inspected. A PPD with control was planted which was negative ,
however controls were also anergic. Sputum cultures were negative.
It was felt that the patient would likely benefit from repeat
thoracentesis to remove enough fluid so that subsequently chest CT
could be performed. This was to be pursued as an outpatient.
DISPOSITION: The patient was discharged on 7/27/99 with a home
VNA and physical therapy services for vital signs
monitoring and post coronary artery bypass graft rehab services.
FOLLOWUP: The patient was to follow up with Dr. Hernandes on 3/5/99
in the chest diseases clinic , as well as with Dr.
Fiermonte , his outpatient cardiologist. He was also to be seen in
Coumadin clinic.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg every day; digoxin
0.125 mg every day; Lasix 80 mg every day; NPH
insulin 20 units every day before noon , 10 units every afternoon; Lisinopril 5 mg every day;
Lopressor 12.5 mg twice a day; Zantac 150 mg twice a day; Coumadin 7.5 mg q.
bedtime; Zocor 40 mg every bedtime; Niferex 150 mg twice a day
Dictated By: MA YEAGLEY , M.D. IM64
Attending: BRITTANEY HAMBLET , M.D. XF96 WJ203/4702
Batch: 90830 Index No. EMMC7W4U9Z D: 9/30/99
T: 7/27/99
Document id: 390
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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446750099 | PUO | 47621530 | | 942732 | 4/10/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/10/1995 Report Status: Signed
Discharge Date: 10/3/1995
DISCHARGE DIAGNOSES: ( 1 ) GASTRIC REFLUX DISEASE
( 2 ) HYPERTENSION , 15 YEARS
( 3 ) ADULT ONSET DIABETES MELLITUS ,
NON-INSULIN DEPENDENT , 1 - 2 YEARS
( 4 ) HYPERCHOLESTEROLEMIA , TREATED FOR
4 YEARS
( 5 ) HISTORY OF MYOCARDITIS
( 6 ) STATUS POST TOTAL ABDOMINAL
HYSTERECTOMY/BILATERAL
SALPINGO-OOPHORECTOMY IN 1975
WITHOUT ESTROGEN REPLACEMENT
( 7 ) HISTORY OF DEPRESSION
( 8 ) MULTIPLE FOOD AND ENVIRONMENTAL
ALLERGIES
HISTORY OF PRESENT ILLNESS: This is a 57 year old woman with
cardiac risk factors with complaint of
substernal chest pain relieved by two sublingual nitroglycerins.
Cardiac risk factors are hypertension , diabetes mellitus , tobacco
use in the past , hypercholesterolemia , and early menopause with no
estrogen replacement. She was admitted on 11/10/95 with complaint
of chest pain at rest without associated symptoms. There was no
complaint of decreased exercise tolerance , exertional symptoms. No
PND , edema , nausea , vomiting , or diaphoresis at this time. The
complaint at that time was 3 out of 10 chest pressure which
spontaneously resolved. It recurred intermittently without
associated symptoms , no EKG changes. She was ruled out for
myocardial infarction by enzymes and EKG. CKs were 156 , 135 , and
108. She was treated with aspirin , beta blockers , and
nitroglycerin. The concern was for a question of unequal blood
pressures in the patient and complaint of back pain. A GEE was
done to rule out aortic dissection. On GEE there were no valvular
abnormalities or evidence for dissection and no regional wall
motion abnormalities. ETT was done on 8/26/95 . The patient
exercised for 4 minutes 13 seconds on a standard Bruce protocol.
She was stopped secondary to leg fatigue and dyspnea with a heart
rate of 84 - 113 with a target of 138. Blood pressure was 136/80
and elevated to 164/90. There were no EKG changes and no evidence
for ischemia on this study despite limited effort.
On the evening of admission on 7/25/95 she again had the acute
onset of sharp , burning , mid-epigastric versus sternal pain without
radiation and with associated shortness of breath , diaphoresis ,
nausea , and an acid taste. She took two sublingual nitroglycerins
with relief of symptoms. The pain lasted a total of 15 minutes.
She has been pain-free since arrival to the hospital.
MEDICATIONS: Glucotrol 20 mg every day , Cardizem CD , Benadryl 50 mg
three times a day , Provastatin 20 mg every day , Hydrochlorothiazide
12.5 mg every day , Trazadone 50 mg every bedtime , aspirin 1 every day , Lopressor 75
mg every day , nitroglycerin sublingual as needed , Ambien 5 mg every bedtime
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a receptionist. She has three children.
She has never married. She lives alone.
PHYSICAL EXAMINATION: She was afebrile with blood pressure of
132/96 , pulse 95. She was on one liter of
oxygen , saturation of 97%. Respiratory rate was 20. HEENT:
Normal. No JVD. Lungs were clear. Heart: PMI was nondisplaced.
Normal S1 and S2. No S3 or S4. No murmurs , gallops , or rubs.
Abdomen: Soft but obese. Nontender , nondistended. No
hepatojugular reflux. No abdominal bruits. No pulsatile masses.
Extremities: Without edema , cords , or femoral bruits.
LABORATORY EXAMINATION: Notable for potassium of 3.7 , magnesium
1.9. Hematocrit 36 , WBC 11.5. CK first
set was 118. Triponin was 0.0. EKG was notable for normal sinus
rhythm with occasional PVCs. Intervals and axis were within normal
limits. There was a slight upper concavity and ST-T segment in V2
and V3 when compared to old although this could be consistent with
J point elevation and a question of a 0.5 mm segment elevation in
V2. The EKG was without change from previous admission.
IMPRESSION: This is a 57 year old woman with multiple cardiac risk
factors presenting with complaint of substernal ,
midepigastric pain , burning. Although she had multiple cardiac
risk factors , her pain is of an atypical quality and sounds more
consistent with a gastrointestinal source. The GEE was a
suboptimal study and it was deemed more appropriate on admission to
both rule the patient out but consider a pharmacologic stress test
before cathing this patient.
HOSPITAL COURSE: Since the patient's symptoms did sound more
gastrointestinal , she was started on Axid for
possibility of gastroesophageal reflux disease , as well as provided
with Maalox and told to keep the head of the bed elevated. She was
continued on Glucotrol for diabetes mellitus and was instructed on
risk factor modifications , including diabetes mellitus control ,
controlling cholesterol and hypertension. She is currently a
non-smoker.
On the day following admission the patient was ruled out for
myocardial infarction by enzyme sets respectively. A set was 118;
B set was 105; C set was 105; D set was 100. EKGs were without
change. As well , the patient had remained symptom-free during the
hospital course and was scheduled for a Dobutamine MIBI for
6/23/95 . The patient on Dobutamine MIBI study showed heart rate
going up from 70 to 101 , blood pressure 170/80 went up to 230/90.
There were no EKG changes and no chest pressure. MIBI images were
notable for a fixed mild reduced uptake in the inferior wall
consistent with but not diagnostic for myocardial injury. There
were no reversible perfusion abnormalities detected. As such the
patient was discharged home with a change in her medication
regimen.
DISPOSITION: DISCHARGE MEDICATIONS: Atenolol 100 mg orally every day ,
Ecasa 325 mg every day , Glucotrol 20 mg twice a day ,
Hydrochlorothiazide 12.5 mg orally every day , Trazadone 50 mg orally every bedtime ,
Axid 150 mg orally every day , Provastatin 20 mg orally every day FOLLOW-UP: The
patient is to follow-up with Dr. Oaxaca as an outpatient for
further workup and management of gastroesophageal reflux disease ,
as well as following her for her cardiac disease via the risk
factor modification.
Dictated By: VERLIE SWANDA , M.D. UV35
Attending: DEBERA D. OAXACA , M.D. IY34 BG544/2237
Batch: 19305 Index No. QXTVPN36B3 D: 9/30/96
T: 8/28/96
Document id: 391
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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086155789 | PUO | 59824177 | | 367026 | 10/15/2001 12:00:00 a.m. | NSTE MI , refused cath treated medically with lovenox/integrilin | | DIS | Admission Date: 10/15/2001 Report Status:
Discharge Date: 6/3/2001
****** DISCHARGE ORDERS ******
WOLLNER , TEMPLE 052-44-42-1
Ga Pa Gustin
Service: CAR
DISCHARGE PATIENT ON: 6/2/01 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LONGAKER , NATISHA AURELIA , M.D. , PH.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
MICRONASE ( GLYBURIDE ) 5 MG orally every day
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LEVOFLOXACIN 250 MG orally every day X 4 Days
Starting Today ( 7/9 ) Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
ZESTRIL ( LISINOPRIL ) 20 MG orally every day
Alert overridden: Override added on 6/9/01 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: ok
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
Alert overridden: Override added on 6/9/01 by :
POTENTIALLY SERIOUS INTERACTION: HYDROCHLOROTHIAZIDE &
OMEPRAZOLE
POTENTIALLY SERIOUS INTERACTION: HYDROCHLOROTHIAZIDE &
OMEPRAZOLE Reason for override: ok
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Ludivina Mclaird 1-2 wks ,
Dr. Hermina Tuomala , cardiology , Mon , 10/20/02 1:00 pm , Sy Road 11/2/02 ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTE MI , refused cath treated medically with lovenox/integrilin
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
LGIB TOBACCO PAF-no anticoag for distant history of lgi bleed htn dm hyperchol
periph neuropathy h pylori
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
medical treatment of NSTE MI: lovenox/integrilin ( patient refused cath )
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old woman with no known CAD , cardiac RF: HTN ,
DM , hyperchol. , current tob , history of PAF on no anticoag 2/2 distant history of
LGIB , a/with palpitations followed by 10 hrs of chest
tightness. patient at baseline able to do 1-2 flights of
stairs before SOB. No sx of CHF. patient in her USOH ,
eating potato chips at home , when she had
palpitations for a couple of minutes , +LH , felt weak , SOB ,
then had tightness in chest which she has never
had before with her palpitations. Palp. resolved ,
but CP lingered through night 5/10. SSCP
"squeezing" , also in back , and L arm. ?relief with burping.
patient last had tachyarrhythmia 2 yrs ago and has
had none since. IN ED , patient pain releived with
SLNG , and 2" NTP. EKG with TWflattening v5-6 but no
ST elevations , and CK160 , TnI 0.3. patient started
on heparin , integrelin for NSTE MI , and cont. on
ASA , BB , ACEI , statin. Exam notable for VSS , no
JVD , distant heart sounds I-II/VI SEM at USB , nl
S2 , clear lungs , neuro intact. Of note , in past ,
patient has refused multiple medical procedures
( mammos , colonoscopy , EP study ) , and at this point ,
does not want to have a cardiac cath. Admit to
Nessinee Ker Hospital Medical Center for further management/potential cath if
she changes
mind. 1. Cardiac--acute NSTE MI vs. demand-induced
NSTE MI from tachyarrythmia. Cont. ASA ,
BB , ACEinh , statin , heparin , integrilin. Was
discussed many times with patient by different staff benefits
and info about cath , but patient deciced on medical rx.
patient switched from heparin to lovenox/integrilin for proven benefits if
noninvasive managmemetn. for total of 72 heart rate course integ/hep
( finished Wed , monitor until Thurs ). Titrating BP meds for better
control ( 130-160 )--because HR has been in 50's , added HCTZ for BP
control . PUMP: repeat echo ( last one '88 )
for change in fxn: prelim: mild hypokinesis in
lat. wall , awaiting final
report. RATE/RHYTHM: cardiac telemetry , HR's tend to
be low 50's in a.m. asymptomatic , cont. regimen. First time she has had
palpitations in 2 yrs , will need f/u of this issue--no arrythmias in ho
use.
2. Endo: DM II--CZI ss , cont. micronase.
3. GI: nexium , colace.
4. ID: patient with UTI--rx. levoflox x 7 days.
4. DVT proph: on lovenox.
5. code status: FULL
6. Dispo: physical therapy eval , discharge Thursday when 72 heart rate course
lovenox/integrilin complete for rx. NSTE MI. patient in stable condition a
nd will d/c on new meds: HCTZ , nexium ( LGIB history ) , SLNG as needed ,
levoflox x 4 more days. patient f/u with Dr. Lorena Shove in 1-2 wks ,
and with a new cardiologist in 2-4 wks.
ADDITIONAL COMMENTS: You have had a heart attack and because you did not want to have a
cardiac catheterization to fix any blockages that may be in your heart
arteries supplying your heart , we have treated you with medicines. Your
blood pressure was high in the hospital , so we've started you on a
medicine HCTZ , and also an antibiotic , levofloxacin , for a urinary
tract infection which you should take for 4 more days. See Dr.
Mclaird in 1-2 wks , and a cardiologist in 2-4 wks. Call if you have
more chest pain , shortness of breath , palpitations.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: OGDEN , LATORIA CRISSY , M.D. ( WZ11 ) 6/2/01 @ 11:46 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 392
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
- |
Y |
Y |
Y |
N |
N |
N |
N |
N |
N |
600101831 | PUO | 62698226 | | 2097298 | 8/27/2006 12:00:00 a.m. | mechanical fall | | DIS | Admission Date: 8/27/2006 Report Status:
Discharge Date: 2/8/2006
****** FINAL DISCHARGE ORDERS ******
ADSIDE , EMELINA 217-11-32-8
E Burg Ro
Service: MED
DISCHARGE PATIENT ON: 1/3/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DYDELL , ALISON ISABELLE , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
ALLOPURINOL 200 MG orally DAILY
XANAX ( ALPRAZOLAM ) 0.25 MG orally twice a day as needed Anxiety
AMIODARONE 200 MG orally DAILY
Override Notice: Override added on 11/22/06 by KOZIKOWSKI , LAURA J B. , M.D. on order for DIGOXIN orally ( ref # 826580640 )
SERIOUS INTERACTION: AMIODARONE HCL & DIGOXIN
Reason for override: aware
DIGOXIN 0.125 MG orally DAILY
Override Notice: Override added on 3/9/06 by KOZIKOWSKI , LAURA J B. , M.D.
on order for DOXYCYCLINE HYCLATE orally ( ref # 135693754 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & DOXYCYCLINE HCL
Reason for override: aware Previous override information:
Override added on 11/22/06 by KOZIKOWSKI , LAURA J. , M.D.
SERIOUS INTERACTION: AMIODARONE HCL & DIGOXIN
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
DOXYCYCLINE HYCLATE 100 MG orally BEDTIME
Food/Drug Interaction Instruction Give with meals
Take 1 hour before or 2 hours after dairy products.
Alert overridden: Override added on 3/9/06 by KOZIKOWSKI , LAURA J B. , M.D.
POTENTIALLY SERIOUS INTERACTION: ALUMINUM HYDROXIDE &
DOXYCYCLINE HCL
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & DOXYCYCLINE HCL
Reason for override: aware
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
Alert overridden: Override added on 3/9/06 by KOZIKOWSKI , LAURA J B. , M.D. on order for LASIX orally ( ref # 542566456 )
patient has a POSSIBLE allergy to
TRIMETHOPRIM/SULFAMETHOXAZOLE; reaction is renal failure.
Reason for override: home med
INSULIN 70/30 HUMAN 20 UNITS subcutaneously twice a day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 75 MCG orally DAILY
Override Notice: Override added on 11/22/06 by KOZIKOWSKI , LAURA J B. , M.D. on order for DIGOXIN orally ( ref # 826580640 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRAVACHOL ( PRAVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COMPAZINE ( PROCHLORPERAZINE ) 10 MG orally every 6 hours as needed Nausea
Alert overridden: Override added on 1/3/06 by :
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL &
PROCHLORPERAZINE Reason for override: MD aware
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
HOLD IF: loose stools
ULTRAM ( TRAMADOL ) 50-100 MG orally every 4 hours as needed Pain
Number of Doses Required ( approximate ): 8
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
walking as tolerated , dangle feet for 1-2 minutes before getting up , sit immediately if dizzy or unbalanced
FOLLOW UP APPOINTMENT( S ):
ID DR SCOVEL ( 182 ) 829-6984 11/21/07 @ 8:00 a.m. ,
Dr LYN 11/17/07 at 3:30 pm ,
Dr Grinstead 5/21/07 at 2:30pm ,
Dr Kleiboeker 8/1/07 at 2pm ,
ALLERGY: TRIMETHOPRIM/SULFAMETHOXAZOLE
ADMIT DIAGNOSIS:
fall
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
mechanical fall
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM ( diabetes mellitus ) hypothyroid ( hypothyroidism ) ischemic CMP LVEF
25% CRI cr
1.4 history of BIV-ICD for CHF in 03/gen change for ERI 8/10/06 paroxysmal
atrial fibrillation CAD history of MI , CABG metastatic colon carcinoma HTN
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Trall
****
HPI: 76 F with ischemic CMP ( EF 25% ) , metastatic rectal CA , FTT , DM2 who
presents history of likely mechanical fall. Got up to go to door at nursing
home , fell when feet slipped out from under her , no prodrome , no LOC , no
loss of bladder/bowel , fully aware of entire event. No palpitations of
note , no chest discomfort. Lacerations to R side of forehead , sutured in
ED. patient requests on admission that she be allowed to return home , i.e. does
not want rehab or nursing home placement at new facility.
*****
PMH: Ischemic CMP history of ICD with EF 25% , metastatic colorectal ca , ICD
pocket infection ( on doxycycline indefinitely ) , FTT , Hypothyroid , DM ,
Gout , hyperlipidemia , psoriasis.
****
HOME MEDS: Allopurinol , xanax as needed , amiodarone , colace , pravachol ,
doxycycline 100 twice a day , nexium , lasix 40 orally daily , synthroid , toprol ,
compazine , 70/30 NPH 20 u twice a day , Dig 0.125.
****
ALL: Bactrim
****
Admit exam: VS 96.2 , 62 , 98/59 , 16 , 96%ra , pulsus=4.
NAD , lacs on forehead sutured
JVP 9cm
Cor with RRR , S1/S2 , no m/r/g
CTAB
Tr b/l pedal edema , otherwise 2+ periph pulses , extrem warm
Pain over lumbar paraspinous region bilaterally , no bony point tenderness ,
abmulates with assistance but uncomfortable
*****
RELEVANT ADMISSION LABS:
Na 140 , K 3.9 , Cl 109 , CO2 22 , BUN 30 , Cr 1.8 ( baseline 1.6 ) , Gluc 71 , INR
1.1 , WBC 7.33 , Hct 32.6 ( baseline ) , Plat 169 , TnI negative , CK 71 , MG 1.9
--
RELEVANT TESTS:
CT head neg for intracranial hemorrhage.
CT c-spine neg for fracture.
PA xray of spine with L2 compression fx , likely not new but unable to date.
EKG paced , regular , LBBB ( old )
CXR with ? increased cardiomegaly.
*****
Impression: 76F with ischemic CMP , metastatic colorectal ca , FTT , DM who
p/with likely mechanical fall.
--
HOSPITAL COURSE BY PROBLEM:
1. CV-Ischemia: Slight Trop bump to 0.13 on second set of cardiac
biomarkers , likely demand and not ACS as no notable cardiac symptoms
and subsequent rapid resolution on serial biomarker tests. Did not
anticoagulate. Cont'd home statin , BB.
2. CV-Pump: Somewhat volume overload on admission , given intravenous lasix 40 mg x2 ,
then transitioned to home regimen ( 40 mg orally every day ) with subsequent orthostatic
hypotension and dizziness with sitting and standing. Given 250 cc NS bolus
with resolution of symptoms and orthostatic vital signs. Held single dose
of a.m. lasix in setting of overdiuresis , then restarted at home dose. patient
will go home on prior lasix dose ( 40 mg daily ) , as well as home BB , dig ,
amiodarone. Echo done 8/10 to r/o worsening CHF vs pericardial effusion
( 2/2 metastatic CA ) given ? increased cardiomegaly on CXR revealed
unchanged cardiac function ( EF 20% , no changes in chamber or valve
pathology ) and no effusion.
3. CV-R: Hx of pAF , con't home amio and digoxin. EP consult interrogated
pacer for evidence of arrythmia as cause of fall--no events recorded.
Monitored telemetry during hosp stay without notable events.
4. ONC: Cont'd previously established palliative goals after discussion with
outPt Oncologist.
5. ENDO: DM2 , decrease home NPH as had borderline low FSBG in ED and again
on admission and poor orally intake in setting of pain , distress. patient will go
home on prior regimen ( Insulin 70/30 @ 20 U Sc twice a day ).
6. MSK: L2 compression fracture , not sure of timing based on imaging. No
acute , new fractures of note on imaging , as above. Had intermittent left >
R lateral flank and lumbar pain , likely from fall. Titrated up Ultram and
standing tylenol , with good effect. patient ambulating to bathroom without
assistance by time of discharge. Will go home with short course of as needed ultram
50-100 mg orally q4.
7. ID: Hx of pacer pocket infection , treated with doxy 100 twice a day as outPt ,
which was decreased while in hospital to 100 mg qday 2/2 possible side
effects. patient has appmt in early October 2007 to f/u in ID clinic with Dr.
Scovel who has seen her previously.
8. Psych: Cont'd home Xanax as needed with good effect.
9. physical therapy: followed while in house , recommended acute rehab , but given patient's
insistence that she go home with support from her daughter , physical therapy agreed to
plan of physical therapy/VNA for ongoing rehabilitation needs.
FEN--ADA , low Na , low fat/chol diet , lytes stable throughout hospital stay
with return of Cr to baseline with gentle hydration as above.
Ppx--home PPI , heparin , fall precaustions
Code--DNR/DNI
*****
DISCHARGE EXAM:
VS--96.8 , 62 and regular , 128/54 ( lying ) , 120/56 ( standing ) , 97% RA
Otherwise unchanged from admission aside from decreased lumbar and flank
pain.
*****
LABS TO F/U:
1. Cr check at home in 1 week--VNA to call results to Dr. Lyn
*****
F/U APPMTs: see appropriate section of d/c summary
ADDITIONAL COMMENTS: 1. VNA--Please assist patient with home physical therapy to regain balance and walking
function.
2. VNA--Please check orthostatic vital signs and record weights at each
visit , and call results to Dr. Floyd Lyn ( PUO Cardiology ) at
238-479-7749.
3. VNA--Please check creatinine in 1 week and call results to Dr. Lyn
( above ).
4. VNA--If patient's home weight has increased by more than 4 pounds
between visits , please give lasix 40 mg orally TWICE daily for 3 days , then
have patient reweigh and call new weight to Dr. Cannard office ( above ).
5. Please take all of your old medications as prescribed. As discussed ,
contact Dr. Susy Ariel C. Cannard office if you find you need refills
before early October . We have prescribed a new medication--ULTRAM--for
pain control. We expect that your pain will improve over the next few
weeks , and you should stop taking the Ultram as soon as you are able.
Tylenol ( over the counter ) will also help treat your pain. Take the Ultram
only as prescribed , and contact your regular physician ( Dr. Kleiboeker ) if you
feel your pain is poorly controlled. While you are taking Ultram , we also
recommend taking Senna 1 tab twice daily , for prevention of constipation.
6. Return to hospital for worsening dizziness , falls at home , shortness
of breath , chest pain or discomfort , fevers , chills , nausea , vomiting , or
other worrisome symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Determine course of doxycycline in concert with ID clinic ( Dr. Scovel ).
2. Monitor home weights , symptoms of dizziness and evaluate need for
potential adjustment of diuretic regimen in concert with Cards clinic
( Dr. Lyn ).
No dictated summary
ENTERED BY: BERNO , LUCI D. , M.D. ( SZ20 ) 1/3/06 @ 11:16 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 393
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
331007362 | PUO | 76076552 | | 1446142 | 7/7/2006 12:00:00 a.m. | HEART FAILURE | Unsigned | DIS | Admission Date: 1/18/2006 Report Status: Unsigned
Discharge Date: 2/28/2006
ATTENDING: COLASAMTE , ISABELLE EVON MD
DEATH SUMMARY
DATE OF DEATH:
5/23/06 .
HISTORY OF PRESENT ILLNESS:
Mr. Araldi was a 59-year-old who was admitted to Pagham University Of on 7/25/06 from an outside hospital with a
deteriorating ischemic cardiomyopathy. He had a myocardial infarction in 1996
and subsequently had coronary artery bypass grafting also in 1996 with
subsequent occlusion of two grafts. He had four previous stents in native
vessels , had a biventricular ICD placed in 2000 , and he also had a history of
hypertension and hyperlipidemia.
He was admitted with increasing signs and symptoms of heart failure and had
gone from class I failure to class intravenous over the 18 months prior to admission. He
was noted to have a BNP of 1600 and was being treated for pneumonia on
admission. He was initially evaluated for heart transplantation , but due to
clinical deterioration was considered for ventricular assist device. He
required inotropic support prior to surgery. There is no other surgical
history of note.
PAST MEDICAL HISTORY:
As mentioned , also a history of mild polycythemia
and thrombocytopenia.
FAMILY / SOCIAL HISTORY:
Both parents had coronary artery bypass grafts. He had an
80-pack-year cigarette smoking history.
DRUG HISTORY:
At the time of assessment , he was receiving amiodarone 200 mg
three times a day , digoxin 0.125 mg once daily , aspirin 81 mg
once daily , heparin continuous infusion , Lasix continuous
infusion , dobutamine continuous infusion , milrinone continuous
infusion , spironolactone 25 mg once daily.
PHYSICAL EXAMINATION:
Examination revealed a midline sternotomy , respiratory crackles
bilaterally and a pansystolic murmur.
HOSPITAL COURSE:
On 6/16/06 , he underwent cardiac catheterization which showed
complete occlusion of OM2 , proximal RCA , proximal LAD , 90%
occlusion of the D1 , 100% occlusion of the ramus , 100% occlusion
of OM1. His LIMA to LAD graft was patent. He had a complete
occlusion of vein graft to RCA , 50% occlusion of vein graft to
D2. He was also noted to have pulmonary hypertension with mean
PA pressure of 48 mmHg and pulmonary capillary wedge pressure of
33. His cardiac output was 3.5 liters on dobutamine and
milrinone infusions. Echocardiogram showed an ejection fraction
of 15% , trivial AI , mild MR , moderate TR. EKG revealed atrial
flutter at a rate of 104. Chest x-ray was consistent with
congestive heart failure.
On 11/22/06 , he underwent reoperative insertion of a HeartMate left ventricular
assist device and tricuspid valvuloplasty. He was unable to tolerate
chest closure at the end of procedure as his central venous
pressure was high.
Postoperatively he was coagulopathic and inotrope and nitric oxide dependant.
On postoperative day #2 , some progress was made weaning inotropes and on
postoperative day #3 , he had a chest closure with a pericardial patch. He also
underwent exploratory laparotomy and sustained a VT arrest requiring
discontinuation of cardioversion. He continued to require nitric
oxide in view of high pulmonary vascular resistance. On 6/13/06 , he had a
further episodes of ventricular fibrillation and had multiple electrical
cardioversions and required amiodarone and epinephrine. Eventually , he
converted to AV paced rhythm. At this time , he required continued to require
significant inotropic support. He subsequently continued to have multiple
episodes of ventricular fibrillation which were converted with his AICD. At
this stage due to his ongoing hemodynamic instability , he was paralysed with
Nimbex , and his nitric oxide was increased for ongoing pulmonary hypertension.
He continued to be hemodynamically ustable. On postoperative day #5 ,
he developed cool and dusky extremities and was started on
bivalirudin although at this stage his HIT screen was negative. He also became
febrile with temperatures to 103. On postoperative days #6 , 7 and 8 , his PA
pressures slowly began to improve and some slow progress was made weaning his
epinephrine. At this stage , his bilirubin began to increase and he developed
some melanotic stool. He also developed renal failure and by
this stage , his creatinine increased to 2.9. By postoperative
day #9 , his Nimbex and fentanyl infusions were stopped. His PA
mean pressure had reduced to less than 30. He became febrile
fevers and developed some purulent discharge from the VAD driveline.
On postoperative day #12 , he underwent fluoroscopic placement of
a post-pyloric feeding tube and continued to spike temperatures.
His bilirubin continued to rise , and his ammonia level had also
risen. On postoperative day #14 , he continued to be unstable
with deteriorating liver function , ongoing renal failure ,
metabolic acidosis , ongoing fevers , hemodynamically instability
and episodes of ventricular tachycardia. He also had by this
stage developed irreversible loss of fingers and toes. Due to
his unrelenting and deteriorating multisystem organ failure , a
family meeting was held at which the poor prognosis was
discussed. The family elected to withdraw all support and on
5/23/06 , the AICD was switched off as was the ventilator and the
ventricular assist device and comfort measures were instituted.
Mr. Araldi died at 7:30 p.m. on 5/23/06 from multiple organ
failure secondary to complications of ischemic cardiomyopathy and
placement of ventricular assist device.
eScription document: 8-4628610 EMSSten Tel
Dictated By: MUSICH , LEOLA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 2446399
D: 6/10/06
T: 6/10/06
Document id: 394
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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- |
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- |
764105079 | PUO | 69570980 | | 5741106 | 2/15/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/15/2005 Report Status: Signed
Discharge Date:
ATTENDING: PANAGOS , FAITH M.D.
ADMISSION DIAGNOSES: Shortness of breath and failure to thrive.
PRINCIPAL DISCHARGE DIAGNOSES: Clostridium difficile colitis and
ischemic cardiomyopathy.
OTHER DIAGNOSES ON DISCHARGE: Congestive heart failure; coronary
artery disease; hypertension; atrial fibrillation; diabetes type
2; end-stage renal disease , on hemodialysis; history of urinary
tract infections; and benign prostatic hypertrophy.
OPERATIONS AND PROCEDURES: No operations or procedures were
done.
TREATMENTS: No treatments were done.
REVIEW OF SYSTEMS: In addition to what is noted below , he does
note increased fatigue. No fevers , chills , or night sweats. No
palpitations. No diaphoresis. No abdominal pain. Occasional
diarrhea with loss of bowel control. No nausea or vomiting. No
dysuria. No hematuria. No bright red blood per rectum.
CHIEF COMPLAINT: Shortness of breath and failure to thrive.
BRIEF HOSPITAL COURSE: This is a 73-year-old gentleman with
end-stage renal disease , on hemodialysis , with ischemic
cardiomyopathy with an EF of 15% who was treated for C. difficile
colitis and worsening CHF. The patient has a long history of
ESRD secondary to hypertension and diabetes. He began
hemodialysis in January 2005. He also has a long history of
peripheral vascular disease status post right carotid
endarterectomy and bilateral external iliac angioplasty as well
as atrial fibrillation and a history of CVA diagnosed by MRI with
the timing unknown , thought to be secondary to thrombi from his
atrial fibrillation. This gentleman presented with worsening
shortness of breath and dyspnea on exertion as well as worsening
dysphagia and anorexia on January , 2005. Apparently , he was in
good health or at least his usual state of health until April ,
2005 , when he was admitted to Hoplukes I Rehabilitation Hospital for GU
symptoms which are unclear and a loss of appetite. He stayed
there for 30 days and then transferred to a rehabilitation
center. After being discharged there for 1 week , he developed
worsening shortness of breath and was unable to answer the door
when his neighbor knocked. The neighbor brought him into the ED
on January , 2005 , for acute shortness of breath , which the
patient described , has worsened over the past 3 to 4 days. He
has gone from being able to walk across his apartment to now only
being able to take 3 to 4 steps before becoming progressively
short of breath , and he now sleeps on three pillows. In fact , he
currently cannot even get through his HPI without 3- to 5-word
dyspnea. He denies any PND. Concerning for his dysphagia , he
feels like he first lost weight when he was trying to control his
volume status prior to hemodialysis initiation in early January
2005. His goal was to be 114 pounds and he limited his intake in
order to maintain that weight instead of limiting his volume.
About 2 months ago , he began losing his appetite. He states that
this was because of the "his renal diet." It was unclear if the
diet caused this loss of appetite or his loss of appetite was
prior to the diet. Over the past 3 weeks , he has noted
progressive difficulty in swallowing solid foods. He is able to
swallow liquids. Since discharge from rehabilitation a week
prior to admission , he is only able to take liquids. He quotes
he cannot even take noodles and soup. He has no nausea or
vomiting unless attempting to swallow solids and no abdominal
pain. His throat is sore and dry. He constantly wants water and
ice. Also concerning is the report , it is unclear , about a 20-
to 40-pound weight loss over the past 2 to 3 months. In the ED ,
he was afebrile; heart rate 105; blood pressure 136/70;
respirations 18; and 97% on room air. He was given Lopressor for
rate control for his atrial fibrillation. His EKG showed new T
wave inversions in the inferolateral leads and Q waves , which
were new for his baseline in the inferior leads. There was also
an S1 , Q3 , T3 , which was new but absent once his rate was
controlled.
The patient was admitted to the floor and briefly transferred to
the unit for refractory hypertension , though he was found to have
right subclavian stenosis and blood pressure was checked in the
left arm. His blood pressure was fine at 100 to 110 systolic.
He was then transferred back to the floor. An abdominal CT was
done on September , 2005 , which showed marked edematous colonic
wall beginning on the ascending colon all the way through to the
rectum. The differential diagnosis at this time was
pseudomembranous colitis versus ischemic bowel. His lactate
level was normal. He had a benign examination , and because of
the distribution and the past antibiotic use , it was felt that he
most likely had C. difficile , which was found to be culture
positive on August , 2005. He had an echocardiogram , which
revealed an EF of 10% to 15% with global hypokinesis and akinesis
as compared to an echocardiogram done at the outside hospital in
January 2005 with an EF of 30% to 35%. He had severe TR. On July , 2005 , while on hemodialysis , he had an episode of substernal
chest pain. Enzymes were sent and troponin peaked at 18. An EKG
showed ST depressions in V2 through V6 , which resolved with rate
control. He received aspirin and heparin and continued his
Lopressor and statin. The decision was made not to catheterize ,
as he was a poor candidate likely to have three-vessel disease
and not a surgical candidate. The patient made the decision with
the cardiologist , family , and the team. The patient was
scheduled for an EGD and colonscopy to evaluate his dysphagia and
colitis , but this was deferred secondary to the incident of the
non-ST-elevation MI on January , 2005. Subsequently , the patient
was managed medically for his worsening CHF and shortness of
breath with fluid removal at hemodialysis on Tuesdays , Thursdays ,
and Saturdays. The patient began Flagyl orally 500 mg three times a day on
January , 2005 , which should be continued through August ,
2005 , for a full 14-day course.
IMPRESSION: This is a 73-year-old man with acute worsening
shortness of breath in the setting of a 20-plus-pound weight
loss , increasing dysphagia , and progressive fatigue for the past
2 months. He was found to have Clostridium difficile colitis and
ischemic cardiomyopathy with an ejection fraction of 15%. His
course was complicated by non-ST-elevation myocardial infarction
on January , 2005 , with a troponin peak of 18 , which was likely
demand ischemia from tachycardia in the congestive heart failure
setting. His EGD and colonscopy was postponed secondary to the
non-ST-elevation myocardial infarction. The patient was managed
medically with fluid removal with hemodialysis for congestive
heart failure. He continues Flagyl orally for Clostridium
difficile treatment. He was transferred on July , 2005 , to a
rehabilitation facility.
PROBLEMS BY SYSTEMS:
1. Gastrointestinal: We are treating his C. difficile colitis
with orally Flagyl 500 mg three times a day from January , 2005 , through
July , 2005. His stool did grow out Staphylococcus aureus ,
but this was likely from colonization from his mouth flora , and
therefore , we are not treating. Per ID consult , we are holding
all other antibiotics and treating only when cultures are
positive. He had a planned EGD and colonscopy , which was
postponed due to the NSTEMI on January , 2005. He should have a
scope done , both upper and lower , 2 to 3 months down the road
once the patient is stable. His LFTs were noted to bump on
July , 2005 , but now are trending down; that is likely
secondary to either shock liver or just his NSTEMI. Continue to
monitor them at rehabilitation. The patient is unable to swallow
solids and is currently on a full liquid diet. After EGD ,
consider barium swallow if nondiagnostic. The patient refuses NG
tube , so encourage orally intake. He will take Nepro if asked. He
should have at least 100 cc of Nepro a day.
2. Cardiovascular: CHF with an EF of 10% to 15% with global
hypokinesis compared to January 2005 EF of 30% to 35%. He has
severe MR and TR. He is on Lopressor 12.5 three times a day and captopril
12.5 three times a day with blood pressure tolerating well. He was started
on digoxin 0.25 three days a week on Sunday , Wednesday , and
Friday , and his current digoxin level is 0.9 on July , 2005.
He was wet on examination routinely and so it was taken off
between 1 to 3 liters at hemodialysis regularly. He had an
NSTEMI on January , 2005 , with troponin peak of 18 , likely demand
ischemia from CHF. Continue aspirin , beta-blocker , and statin.
We discontinued the heparin after 24 hours. A decision was made
not to catheterize , as he is a poor candidate likely to have
three-vessel disease. EKG currently shows Q waves inferiorly
with ST depressions in V3 through V4 and T wave inversions in V3
through V6. The depressions improved with rate control. He does
have a low blood pressure in the right upper extremity , which is
false due to a right subclavian stenosis; always check blood
pressures in the left arm. He has atrial fibrillation and he
used to be on diltiazem for rate control. He was on Lopressor
with good effect. He was restarted on his Coumadin dose at 4 mg
every bedtime on July , 2005 , for anticoagulation. He is on
telemetry. He should be monitored of his INR for a goal INR of 2
to 3 for his atrial fibrillation and change of Coumadin as
accordingly.
3. Endocrine: Now on half-strength NovoLog sliding scale. He
has had trouble with hyperglycemia for the past several days.
His fingersticks can go up to 250. We think this is okay not to
cover , as when we choose to cover him , he dips down into the 40s.
4. Pulmonary: On admission , he had acute shortness of breath
and tachycardia. An EKG showed S1 , Q3 , T3. PE CT was negative.
There was no parenchymal disease. Some hilar lymph nodes were
noted. His repeated chest x-rays were every other day , which
only showed changes in the CHF status. There was routinely no
consolidation or interstitial disease seen. His last chest x-ray
showed bilateral pulmonary edema and that was on July , 2005.
5. Infectious Disease: We are only doing Flagyl orally for C.
difficile treatment. He should continue 500 mg three times a day orally
through August , 2005 , holding all other antibiotics. We
questioned if he is septic when his temperatures drop to 95 to
96 , but all blood , sputum , and urine cultures have been no growth
to date. You could consider a third generation cephalosporin if
a pneumonia develops.
6. Renal: Hemodialysis on Saturday , Tuesday , and Thursday.
7. Hematology: He has anemia. Panel workup with mixed picture
of iron and chronic anemia. We are repleting his iron with
vitamin C. He received 1 unit on October , 2005 , at
hemodialysis. His current hematocrit is 31. Guaiac stools have
been negative.
8. He has a malignancy workup , which has been negative so far.
He has a normal TSH , PSA , and free PSA. No mass is seen on
abdominal CT or chest CT.
9. Prophylaxis: He is on heparin subcutaneously and Nexium.
10. Disposition: He is going to rehabilitation today on February , 2005.
11. Code status: DNR/DNI.
12. Health care proxy: His brother , Phung Schrauger ,
388-878-3905.
PLAN TO DO:
1. Hemodialysis on Tuesdays , Thursdays , and Saturdays.
2. Continue Flagyl 500 mg orally three times a day from January , 2005 , to
August , 2005.
3. Follow INR for goal of 2 to 3 for atrial fibrillation , on
Coumadin 4 mg orally every bedtime currently.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed
headache; aspirin 325 mg orally every day; captopril 12.5 mg orally
three times a day; Peridex Mouthwash 0.12% twice a day; digoxin 0.125 mg orally
every Sunday , Wednesday , and Friday; Lopressor 12.5 mg orally
three times a day; Flagyl 500 mg orally three times a day; nystatin swish and swallow;
Coumadin 4 mg orally every afternoon; Zocor 20 mg orally every bedtime; and Nexium 20
mg orally every day NovoLog sliding scale: If blood sugars are less
than 125 , give 0. Actually , give 0 until blood sugars are 251 to
300 , then give 2 units; 301 to 350 , give 4; and 351 to 400 , give
6. Also , ??___??.
DISCHARGE CONDITION: The patient was discharged , condition
stable.
eScription document: 2-5802408 SSSten Tel
Dictated By: MAGLIONE , KRISTIAN
Attending: PANAGOS , FAITH
Dictation ID 3465444
D: 6/18/05
T: 6/18/05
Document id: 395
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
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U |
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U |
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- |
U |
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U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
N |
N |
N |
N |
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- |
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N |
789882744 | PUO | 49201190 | | 6140946 | 8/29/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 1/23/2005 Report Status: Signed
Discharge Date: 9/27/2005
ATTENDING: COLASAMTE , ISABELLE EVON MD
SERVICE:
Cardiac Surgery Service.
For the beginning of this dictation , I am going to defer to a
pervious discharge summary dictation dictated by Dr. Debera Z Replenski . Confirmation number is 251249. It was dictated on
3/18/05 , therefore this dictation will continue over the
hospital course starting on 10/28/05 , at which time , the patient
was transferred to the Step-Down Unit. We began weaning the
milrinone drip as well as titrating up on her diltiazem and
Neoral. The patient was seen by Speech and Swallow and her diet
was liberalized to thin liquids. She was restarted on her
diuresis. The patient began having positive blood cultures on
11/29/05 . One out of two bottles from 8/23/05 grew out
Gram-positive cocci , but the patient remained afebrile and her
white blood cell count was trending down. Further blood cultures
were sent off. Central line was discontinued on 9/3/05 and tip
was sent for culture. Further blood cultures were negative but
the line tip grew out coag-negative Staph. Echocardiogram
results revealed an ejection fraction of 55% , mild mitral
regurgitation , mild-to-moderate tricuspid regurgitation and
moderate pericardial effusion , without evidence of hemodynamic
compromise. The patient underwent a cardiac biopsy on 3/8/05 ,
which showed focal healing ischemic injury. Despite all negative
cultures , the patient continued on vancomycin , Bactrim ,
levofloxacin and Valcyte. Speech and Swallow then started
regular solids and thin liquid. Her medications continued to be
monitored by the Congestive Heart Failure Service. She did
become slightly hypertensive and they increased her diltiazem.
She continued on her antibiotics. There is a PICC line attempted
to be placed on 5/26/05 , however , they were unable to withdraw.
Therefore , they would return in the morning to attempt it again.
Upper extremity and LENIs were done , which was negative for clot ,
except for in the left cephalic. Congestive heart failure people
then suggested that maybe it would be best that the patient just
stayed in the hospital without getting a PICC line to complete
her course of antibiotics. She also was going to need a repeat
right heart catheterization and biopsy. Her antibiotic course
was finished on 6/12/05 . Only other issue was that the patient
was seen by Ophthalmology and it was recommended that she will
need reading glasses when she is at home. Diabetes management
continued to follow the patient and congestive heart failure did
as well. She underwent a right heart catheterization as well as
biopsy on 11/16/05 , which demonstrated normal left and right
filling pressures. They were 6 and 14. The patient was found
suitable for discharge to home on 11/16/05 . At the time of
discharge , Ms. Rosenblum looked great. Her temperature was 96 ,
heart rate was 96 sinus , blood pressure was 110/80. She was
satting 99% on room air. Her weight was even from preop.
DISCHARGE MEDICATIONS:
Included diltiazem 180 mg orally daily , Lasix 80 mg orally every day before noon and
40 mg orally every afternoon , Ativan 0.5 mg orally twice a day , oxycodone 5 mg to
10 mg orally every 6 hours as needed for pain , prednisone 20 mg orally daily ,
multivitamins with minerals one tablet orally daily , potassium slow
release 30 mEq orally daily , Neoral 100 mg orally twice a day , Bactrim one
tablet orally every other day , CellCept 1500 mg orally twice a day , Celexa
30 mg orally daily , Valcyte 450 mg orally daily , Novolog 4 units
subcutaneously with lunch , magnesium oxide 420 mg orally twice a day , and Pepcid.
DISCHARGE INSTRUCTIONS:
Included to make follow-up appointments with congestive heart
failure team for Tuesday , 6/11/05 , as well as to follow up with
Ophthalmology Clinic for eyeglasses.
DISCHARGE CONDITION:
Stable.
DISCHARGE DISPOSITION:
Home with services.
eScription document: 7-7005358 EMS
Dictated By: VERRY , COLETTA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 4282079
D: 11/16/05
T: 11/16/05
Document id: 396
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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047657566 | PUO | 70437680 | | 9272210 | 6/2/2005 12:00:00 a.m. | FAILURE TO THRIVE , RENAL FAILURE | Signed | DIS | Admission Date: 5/30/2005 Report Status: Signed
Discharge Date: 4/9/2005
ATTENDING: STRATTER , BUNNY M.D.
ADMISSION DIAGNOSIS:
Acute renal failure.
PRINCIPAL DISCHARGE DIAGNOSIS:
Acute renal failure.
OTHER DIAGNOSES:
Right middle lobe pneumonia , COPD , hematuria , acute renal
failure , hypertension , end-stage renal disease , on hemodialysis ,
and coronary artery disease.
BRIEF HISTORY OF PRESENT ILLNESS:
This is a 57-yeare-old man with history of end-stage renal
disease , status post kidney transplant in 5/13 , aortic valve
replacement , coronary artery bypass graft , LIMA to LAD , in
7/7/005 , who is presenting here to the Kernan To Dautedi University Of Of with worsening
lower extremity edema , shortness of breath , and decreased urine
output , and an increased creatinine from 3.3 the baseline to 5.3.
On admission , the patient did not report that the lower
extremity edema felt worse than he normally feels at his
baseline , however , he had developed some left upper extremity
edema as well as his lower extremity edema. He also described a
new shortness of breath on admission , a cough with whitish
sputum , no blood in his cough. He denied dyspnea on exertion ,
but did report being short of breath while lying flat , or
orthopnea. He did not describe any PND. He also reported a
fever on admission with some chills and sweats for two days
before being presented to the emergency department. He also
described a decrease in his urine output one day prior to
admission and dysuria x2 days. The patient denied any nausea ,
vomiting , diarrhea , chest pain or pressure. No palpitations , and
no dyspnea on exertion.
PAST MEDICAL HISTORY:
Significant for end-stage renal disease , aortic valve replacement
in 6/24 , left buttock ulcer , also followed by Plastic Surgery ,
hypertension , diabetes mellitus type II , congestive heart
failure , and hypercholesterolemia.
MEDICATIONS ON ADMISSION:
Included CellCept 1000 mg twice a day , prednisone 20 mg daily ,
valacyclovir 400 mg daily , calcitriol 0.25 mcg daily , metoprolol
25 mg twice a day , Bactrim single strength daily , NPH 16 units every day before noon ,
18 units every afternoon , NovoLog 6 units before every meal with sliding scale ,
Nexium 20 mg daily , Colace 100 mg daily , aspirin 325 mg daily ,
multivitamin , and tramadol 50 mg four times a day
ALLERGIES:
He reports no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION:
His temperature was 97.7 , his heart rate was 93-97 , his
respiratory rate was in the 30s , his blood pressure was 167/90 ,
and his O2 saturation was 97-99% on 2 liters. In general , he was
in fairly significant distress. He had difficulty catching his
breath. His head and neck exam is significant for equal , round
and reactive pupils. No cervical lymphedema , and no icterus.
His JVP was up to about 12 cm. He did not have any carotid
bruits. His cardiovascular exam was significant for rate and
rhythm that were regular at 2/6 systolic ejection murmur and
heard best in the right upper sternal border. He did not have S3
or S4. His chest incision was clean , dry and intact. His
pulmonary exam was significant for crackles bilaterally about a
halfway up his back. His abdomen was soft , nontender , and
nondistended , with positive bowel sounds. Incision of the
abdomen was similarly clean , dry and intact. His extremities
were significant for 3-4+ lower extremity edema , significant
pitting to the thighs , and some dependent decubitus edema as
well. He had 2+ pitting edema in his left upper extremity. He
had a fistula on his right arm. He has a decubitus sacral ulcer
with a VAC dressing in place on admission. Neurologic exam was
significant for alert and oriented x3. His cranial nerves were
all intact. He had no focal deficits.
HOSPITAL COURSE:
1. Cardiovascular: Ischemia: Status post CABG and AVR. On
admission , we held the patient's anticoagulation for a possible
biopsy of his kidney. We continued his Lopressor at twice a day
dosing. The patient ruled out for a myocardial infarction. He
had four-beat runs of NSVT on the day of admission , which he did
not repeat after repletion of his electrolytes. He had chest
pain again on hospital day #3 overnight. He did not have any EKG
changes with his chest. He was given Lopressor x1 , he ruled out
once again. The pain that he had developed was thought to be
likely incisional and not cardiac. Pulmonary exam: The patient
developed acute worsening of pulmonary status while in the
observation area at the emergency department on admission on
hospital day #1. He had an increasing O2 requirement , worsening
pulmonary exam , and a chest x-ray that showed pulmonary edema.
He was not diuresing effectively with more than 360 mg with intravenous
Lasix , which was administered to him in the emergency department ,
so Renal was called urgently to see him in observation and he was
sent for urgent dialysis. At dialysis , they removed greater than
4 liters of fluid and the patient was patient was symptomatically
improved. He did continue to have lower extremity edema
post-dialysis and an oxygen requirement of 2 liters nasal cannula
to maintain his oxygen saturation. He was given intravenous Lasix 80 mg
x1 on hospital day #4 with excellent urine output. His lower
extremity edema improved significantly after hospital day #4.
2. Renal: On admission , the patient's creatinine was 5.3. It
peaked at 6.6 and trended down to 5.1 with clear signs of
improvement. On admission , there was no improvement in his urine
output with large doses of intravenous Lasix , however , and Renal was
consulted to clarify whether this was an acute rejection versus
ATN from toxic doses of cyclosporin. In the emergency
department , he was given one dose of Solu-Medrol 500 mg , however ,
he was found to have elevated cyclosporin levels at 679 , so this
was thought to be the likely cause of his acute renal failure and
his cyclosporin was temporarily held. Since that time , on his
hospital day #1 , his cyclosporin levels trended down to the point
at which there were just slightly over 100 on hospital day #3 and
cyclosporin was reinitiated at lower doses. He was dialyzed on
admission with removal of 4 liters of fluid , CVM , BK , and LDH
were sent from dialysis. His creatinine improved , so further
dialysis and biopsy were deemed unnecessary.
3. ID status: The patient presented with UTI on admission.
This was treated with levofloxacin 500 mg x1 and then 250 mg
every 48 hours for a course of seven days. Blood cultures grew 4/4
Gram-negative rods , and the patient was diagnosed with urosepsis.
After dialysis , the patient was treated with ceftriaxone 1 g
daily and continued on levofloxacin 250 mg every 4-8h. Transplant
and Infectious Disease was consulted who recommended ceftriaxone
be discontinued and the levofloxacin to be continued for two
weeks after discharge with repeat cultures. HSV swap from sacral
wound was sent. These repeat cultures and HSV swab were all
negative , and levofloxacin was continued for two weeks
postdischarge.
4. FEN: We held the patient's fluids. We checked his I's and
O's on a daily basis with daily weights. His hyperkalemia on
admission was 6.1 , resolved with Kayexalate , insulin and D50
meds. He was given additional Kayexalate when he came up to the
floor and his K resolved , backed down to his normal range. The
patient was kept on a renal and cardiac diet. His albumin and
total protein were low , so a nutritional consult was called ,
which optimized his nutritional status.
5. Endocrine: The patient had a tight glycemic control on NPH
16 units every day before noon and 19 units every afternoon , NovoLog 6 units before every meal with
sliding scale , and the patient's sacral decubitus ulcer had a VAC
dressing in place on admission. Plastics was called to address
his VAC. They took down the VAC due to some leakage on admission
and he was treated with 1/4 Dakin's solution and wet-to-dry
dressing three times a day On discharge , he continued on the wet-to-dry
dressings. He will be followed as an outpatient VNA , and will
have the VAC replaced by the VNA as an outpatient. His
hematocrit was stable throughout his hospital stay.
6. Prophylaxis: The patient was kept on Nexium throughout his
hospital stay and we held his anticoagulation for possible
biopsy. He will resume his outpatient anticoagulation and INR
checks with his INR Follow-Up Clinic. He was able to leave the
floor for cigarettes , and he signed an agreement suggesting that
he was going to tolerate the risk of leaving the floor for short
period of time even while on telemetry.
On discharge , his medications included calcitriol 0.25 mcg orally
daily , Colace 10 mg orally twice a day , insulin 16 units every day before noon , 18
units every afternoon , ketoconazole 200 mg daily , Lopressor 25 mg three times a day ,
prednisone 20 mg before every meal , cyclosporin 125 mg twice a day , tramadol 50
mg orally every 6 hours as needed for pain , Bactrim single strength one tablet
orally daily , CellCept 1000 mg twice a day , valacyclovir 500 mg daily ,
levofloxacin 250 orally every other day x2 weeks , NovoLog 6 units
before every meal , Neoral 125 mg twice a day , and aspirin 325 mg daily.
The patient was discharged to home in stale condition.
eScription document: 5-7828795 EMSSten Tel
Dictated By: GOBRECHT , ALVERTA
Attending: STRATTER , BUNNY
Dictation ID 0313513
D: 7/9/05
T: 7/9/05
Document id: 397
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
- |
Y |
N |
Y |
N |
- |
N |
N |
Y |
N |
N |
- |
N |
N |
N |
977547395 | PUO | 22397496 | | 5870767 | 4/13/2005 12:00:00 a.m. | ASTHMA FLARE | Unsigned | DIS | Admission Date: 4/13/2005 Report Status: Unsigned
Discharge Date: 1/13/2006
ATTENDING: DEPSKY , GWYNETH ALMEDA MD
PRIMARY CARE PHYSICIAN: Desirae Marcott , M.D.
PRINCIPAL DIAGNOSIS: Chronic obstructive pulmonary disease
exacerbation.
SECONDARY DIAGNOSES:
1. Acute-on-chronic renal insufficiency.
2. Congestive heart failure.
3. Diabetes.
4. Hypertension.
5. History of upper gastrointestinal bleed.
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman with
history of COPD , CHF , and stage intravenous chronic renal insufficiency ,
who presented to the emergency room on 8/26/2005 with wheezing
and shortness of breath following a three-day prodrome of cough ,
congestion , and chills. In the emergency room , the patient was
noted to have a BNP of 519 and was initially treated with Lasix
in the emergency room , and was admitted at that point for
diagnosis of COPD exacerbation in the setting of an upper
respiratory infection in addition to mild congestive heart
failure. The patient was given orally glucocorticoids and frequent
bronchodilator therapy was initiated. However , the patient's
mental status began to rapidly decline. As he became more
somnolent , he was noted to have an ABG with a pH of 7.16. The
patient was then transferred to the ICU for hypercarbic
respiratory failure after failing an initial trial of BiPAP.
PAST MEDICAL HISTORY: COPD , requiring at least two prior
intubations; congestive heart failure , previously thought to be
diastolic with an EF of 50%; diabetes , hypertension , history of
upper GI bleed in 5/20 secondary to an antral ulcer , pneumonia
in 7/20 left lower lobe nodule , which is stable on followup
CTs; chronic renal insufficiency , thought secondary to diabetes
and hypertension.
SOCIAL HISTORY: The patient is a former smoker with rare alcohol
use. He lives alone and he is a retired chef.
FAMILY HISTORY: Mother died of diabetes. Father had congestive
heart failure. Brother has a history of pituitary cancer and
another brother with lymphoma.
HOME MEDICATIONS:
1. Amiloride 5 mg orally twice a day
2. Clonodine 7.5 mg topically weekly.
3. Hydrochlorothiazide 25 mg orally daily.
4. Lisinopril 20 mg orally twice a day
5. Lasix 160 mg orally twice a day
6. Labetalol 600 mg orally twice a day
7. NPH 25 units in the morning and 15 units in the evening.
8. Protonix 40 mg orally daily.
9. Calcitriol 0.25 mcg daily.
10. Advair.
11. Albuterol/Combivent.
ALLERGIES: IBUPROFEN WITH WORSENING RENAL FAILURE.
PHYSICAL EXAMINATION UPON ADMISSION: Temperature 100.6 , heart
rate 88 , respiratory rate 28 , blood pressure 158/90 , and
saturating 99% on 2 L nasal cannula. General: This is a
pleasant , mildly overweight African-American male visibly
wheezing and speaking in short phrases. HEENT: Pupils are
equal , round , and reactive to light. Oropharynx is clear. Neck:
Supple. No lymphadenopathy. Cardiovascular: Tachycardic. No
murmurs , rubs , or gallops. JVP was increased. Respiratory:
Crackles , bibasilar. Notable for diffuse wheezes. Minimal air
movement. Peak flow was measured at 200. Abdomen: Soft ,
nontender , and nondistended. Bowel sounds are present.
Extremities: Mild clubbing and trace edema bilaterally.
LABORATORY STUDIES UPON ADMISSION: Notable for electrolyte panel
within normal limits. BUN of 52 , creatinine of 3.3 , and glucose
of 154. BNP was 317. Hemogram showed a white blood cell count
of 7.7 , hematocrit 40.6 , and platelets 219. MCV was low at 80.
Chest x-ray showed interstitial edema , no infiltrates. EKG
showed no acute changes from prior.
ASSESSMENT AND PLAN: This is a 65-year-old male with history of
COPD who is admitted for a COPD exacerbation in the setting of a
likely viral URI as well as some mild congestive heart failure
exacerbation.
HOSPITAL COURSE BY SYSTEM: Pulmonary: As noted above , the
patient was noted to be having hypercarbic respiratory failure
with an ABG of 7.16/98/89 on 3 L nasal cannula. He was therefore
transferred to the MICU and at that time required intubation.
The patient's respiratory status improved and he was extubated on
11/5/2005 . The patient was initially treated with Solu-Medrol ,
which was changed to prednisone on 4/20/2005 . The patient was
noted to have thick tenacious secretions and there was concern
for possible pneumonia as an underlying flare for the patient's
COPD. Therefore , the patient was initiated on levofloxacin for a
14-day course. The patient had , upon presentation , been noted to
be mildly volume overloaded but this improved with diuresis prior
to his MICU stay. In the setting of the patient's intubation ,
his pH corrected slowly , but he was still noted to have markedly
elevated partial CO2 pressures. The patient was treated with
chest physical therapy as well as Duonebs. Following extubation , the patient
was transferred to the floor and did well. Medications were
adjusted and he was continued on a prednisone taper , Spiriva ,
Advair 250/50 Diskus , supplemental oxygen , Duonebs , and albuterol
nebulizers as needed. The patient continued to improve , and on
9/3/2005 , he was able to ambulate on room air without dyspnea
or hypoxia. At this point , we suggest outpatient pulmonary
function tests to further evaluate the extent of the patient's
obstructive disease.
Cardiovascular: Ischemia: The patient underwent a negative rule
out MI upon admission. This was obtained due to the newly
decreased EF of 35 to 40% that was noted on echocardiogram upon
admission. The patient has not had any ischemic symptoms;
however , this marked decrease is concerning especially including
the inferior and posterior wall hypokinesis , which is new from
his prior echocardiogram. The patient was continued on aspirin ,
beta-blocker , and statin. An ACE inhibitor was reinitiated when
the patient's creatinine stabilized. The patient will likely
need further cardiac risk stratification as an outpatient to
include an outpatient stress test.
Pump: As mentioned , upon admission , the patient was noted to
have mild volume overload. He has a history of diastolic
dysfunction with a prior echocardiogram showing an EF of 50%. As
noted , the most recent echocardiogram obtained during this
hospitalization shows an EF of 35% with diffuse global
hypokinesis and inferior posterior wall akinesis. There was mild
decreased function of the RV as well , and mild left atrial
enlargement and mild right atrial enlargement. The patient is
noted to have relatively stable pulmonary hypertension with a PA
pressure of 50 plus right atrial pressure.
The patient had been diuresed aggressively in the emergency room
and therefore did not require additional diuresis upon transfer
to the MICU. The patient was initiated on hydralazine and
Isordil for afterload reduction. When the patient's creatinine
stabilized , these were changed back to an ACE inhibitor. The
patient was continued on a beta-blocker as well. The patient was
restarted on half of his home dose of Lasix at Lasix 160 mg orally
daily as of 1/6/2006 when he was noted to be mildly
hypervolemic.
In addition , the patient was noted to have significant
hypertension. He has had a workup previously for secondary
causes of hypertension , which included a negative MRA in 2004.
The patient was continued on a clonodine patch as well as
beta-blocker , ACE inhibitor , and Imdur. The patient's home
medication of hydrochlorothiazide was discontinued , as was the
amiloride , which may need to be reinitiated as an outpatient.
Rhythm: The patient was noted to have four beats of nonsustained
ventricular tachycardia on 11/7/2005 , which resolved with
aggressive electrolyte replacement. While in the MICU , the
patient had a single run of 30 beats of nonsustained ventricular
tachycardia , which improved with electrolyte replacement.
Endocrine: The patient has a history of diabetes and therefore
was continued on a regimen of NPH initially at 20 units twice a day
The patient was noted to have an episode of hypoglycemia with
blood sugars around 40 and therefore the NPH was decreased and
the patient will be discharged on a regimen of 15 units in the
morning and 10 units at bedtime.
The patient was also noted to have hyperparathyroidism likely
from renal disease , therefore secondary versus tertiary
hyperparathyroidism. The patient was therefore continued on
calcitriol.
Renal: The patient has stage intravenous chronic renal insufficiency.
Upon admission , the patient was noted to be oliguric. This is
likely due to a prerenal state given diuresis on admission and
further exacerbated by the patient's underlying renal disease.
Bladder scan was obtained which only showed 3 mL of urine in the
bladder. The patient's urine output increased with afterload
reduction. The patient was noted to have acute-on-chronic
respiratory acidosis with chronic bicarbonate compensation.
There was no anion gap. The lactate was measured and was only
0.6 in the MICU. Throughout the remainder of the
hospitalization , the patient's creatinine continued to improve
and was measured at 3.4 on 1/6/2006 . A renal consult was
obtained during the hospitalization. They did not feel that
there was any indication for acute renal replacement. The
patient should continue to have renally dosed meds and continue
on a renal diet , including Phoslo. The patient will have close
renal followup within the next few weeks.
Hematologic: The patient was noted to have iron deficiency
anemia and was started on ferrous sulfate supplementation. At
this time , an EPO level is still pending.
Infectious Disease: The patient was initiated on levofloxacin
for a 14-day course , which was started on 4/13/2005 , and will be
completed as of 9/11/2006 . Blood cultures and sputum cultures
were obtained and are negative to date. Influenza/adenovirus/RSV
swabs were obtained and were negative.
Prophylaxis: The patient received heparin subcutaneous 5000
units three times a day for DVT prophylaxis , and was continued on Pepcid for
GI prophylaxis.
DISPOSITION: The patient was evaluated by physical therapy and
felt to be at his baseline. He is able to ambulate and maintain
his pulse oxymetry greater than 93%. The patient will be
discharged to home with visiting nurse service.
TO DO:
1. VNA is to check the patient's blood pressure , oxygen
saturation , as well as check weekly electrolytes and creatinine
levels and call results to Dr. Hoban office at 658-680-1482.
The patient is to follow up with Dr. Romig within the next week ,
and at that time , should have his blood pressure meds titrated up
as needed. The patient may require increased dose of Lasix and
the amiloride and hydrochlorothiazide may be resumed as needed.
2. The patient should have a cardiology outpatient followup
regarding his decreased EF and new wall motion abnormalities.
The patient may require stress imaging for further cardiac risk
stratification.
3. The patient should have renal follow up regarding his chronic
renal insufficiency and future need for hemodialysis.
ADDITIONAL COMMENTS: Continue to take all of your medications ,
including the Spiriva and Advair , which replace the Flovent as
well as the prednisone. Follow up with Dr. Romig within one
week. Participate with your visiting nurse services. Seek
medical attention for increased shortness of breath , chest pain ,
fever , chills , or any other concerns. Weigh yourself daily and
contact your doctor if you gain more than 2 pounds in a day or 5
pounds within a week.
DISCHARGE DIET: Mechanical soft , thin , no added salt , ADA 2100
calories per day , renal diet.
ACTIVITY: Walking as tolerated.
FOLLOW-UP APPOINTMENTS:
1. Dr. Romig , internal medicine , within one week.
2. Dr. Dayan , nephrology , on 2/14/2006 at 1:30 p.m.
3. Podiatry on 1/13/2006 at 3:30 p.m.
4. Cardiology within three to four weeks.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Calcitriol 0.5 mcg orally daily.
3. Phoslo 667 mg orally three times a day
4. Clonodine 0.2 mg per day topical patch every week.
5. Ferrous sulfate 325 mg orally three times a day
6. Lasix 160 mg orally daily.
7. Insulin NPH 15 units subcutaneous every day before noon
8. Insulin NPH 10 units subcutaneous every afternoon
9. Labetalol 600 mg orally twice a day
10. Lisinopril 20 mg orally daily.
11. Imdur ER 30 mg orally daily.
12. Levofloxacin 500 mg orally every 48 hours x2 week course , which will
be completed as of 8/8/2005 , next dose is to be administered on
1/13/2006 , then 9/17/2006 and then 8/13/2006 .
13. Advair Diskus 250/50 one puff inhaled twice a day
14. Spiriva 18 mcg inhaled daily.
15. Protonix 40 mg orally daily.
16. Prednisone taper starting as of 1/2/06 40 mg orally daily x1
day , then 20 mg orally daily x2 days , then 10 mg orally daily x2
days , then 5 mg orally daily x2 days , and then stop.
17. Albuterol inhaler two puffs inhaled four times a day as needed for
shortness of breath.
18. Albuterol nebulizer 2.5 mg nebulized every 4 hours as needed for
shortness of breath.
eScription document: 5-3975098 EMSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: DEPSKY , GWYNETH ALMEDA
Dictation ID 9435221
D: 5/17/06
T: 5/17/06
Document id: 398
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074981892 | PUO | 65633683 | | 136901 | 3/4/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/4/1996 Report Status: Signed
Discharge Date: 3/13/1996
PRINCIPAL DIAGNOSIS: UNSTABLE ANGINA.
SIGNIFICANT PROBLEMS:
1. HYPERTENSION.
2. CORONARY ARTERY DISEASE.
3. NON-INSULIN-DEPENDENT DIABETES MELLITUS , DIET CONTROLLED.
4. NASAL POLYPS.
HISTORY OF PRESENT ILLNESS: Mr. Eguia is a 74-year-old man
with a history of coronary artery
disease status post a myocardial infarction in September 1995. At that
time , he had a peak CK of 6 , 700 and an MB fraction of 199. His
infarction was treated with TPA at Bridgesnecrest Memorial Hospital . In January
1995 , he was admitted to Pagham University Of with
substernal chest pain. A catheterization , at that time , showed
100% left circumflex. He had an angioplasty to 20% residual , which
was complicated by a small dissection. He had an LV gram with
inferior hypokinesis , and he also had an 80% OM1 lesion that was
angioplastied to 30% residual. His ejection fraction was 53%. He
has been subsequently followed as an outpatient without recurrence
of his anginal symptoms. Approximately six weeks prior to
admission , his Vasotec was changed to Cozaar and his Niacin was
changed to Pravachol. At that time , he began having some
intermittent substernal chest pain , both at rest and with exertion.
Two weeks prior to admission , he was admitted to an outside
hospital with a complaint of chest pain. He is without current
myocardial infarction. He had an exercise tolerance test and was
then discharged. The results of the exercise tolerance test were
not available at the time of admission here. There was a question
of an irregular heartbeat during his exercise and he stopped the
procedure secondary to fatigue. The patient stopped his own
Pravachol and he changed from Cozaar to Vasotec 10 mg every day , at
that time. As mentioned above , the patient has had increased
frequency of substernal chest pain , both at rest and with exertion
over the last six weeks. At 2 a.m. on the day of admission , the
patient experienced a substernal chest pain as a dull ache without
radiation. He had no other associated symptoms. He does not
associate the pain with any particular level of exertion , that it
can happen sitting still or with activity without any particular
pattern. With today's episode , he had climbed two flights of
stairs and then developed this chest pain which lasted for 10-15
minutes. It was not relieved with rest or after one to two tabs of
sublingual nitroglycerin. By the time he arrived at the Emergency
Department , his chest pain was gone. In the Emergency Department ,
his systolic blood pressure was noted to be 230 and he was treated
with nifedipine times one and intravenous nitroglycerin which brought his
blood pressure down to 140/90 and he was admitted for evaluation.
PAST MEDICAL HISTORY: Coronary artery disease , as above.
Hypertension , non-insulin-dependent diabetes
mellitus times five years , diet controlled , and nasal polyps.
ADMISSION MEDICATIONS: Aspirin , Vasotec 5 mg orally every day , atenolol
5 mg orally every day.
ALLERGIES: Penicillin and Toprol.
FAMILY HISTORY: His father died of coronary artery disease at age
48. His mother died of congestive heart failure
at age 80.
SOCIAL HISTORY: He has been retired since his 60s. He is a former
warehouse owner and shipping business owner. He
occasionally will bicycle eight miles at a time or be able to walk
six miles at a time two to three times a work. He has not done
this since this summer.
PHYSICAL EXAMINATION: He was in no acute distress , no chest pain.
His temperature was 97.1 , blood pressure
140/70 , pulse 68 , saturation 96% on room air , and respiratory rate
14. HEENT examination revealed extraocular muscles were intact.
Pupils were equal , round , and reactive to light and accommodation.
Oropharynx was clear. Neck revealed no JVD , no bruits. Lungs were
clear to auscultation bilaterally. Cardiac examination was
bradycardic , normal S1 and S2 , no murmurs , rubs , or gallops.
Abdomen was soft , nontender , and nondistended with positive bowel
sounds , no organomegaly. Rectal examination was guaiac negative
per Emergency Department. Extremities had no cyanosis , clubbing ,
or edema. There were 2+ pulses , DP and physical therapy. Neurological
examination revealed he was alert and oriented times three , grossly
nonfocal.
LABORATORY DATA: EKG revealed sinus bradycardia at a rate of 43
intervals 0.133 , 0.121 , 0.483 , axis 48 ,
interventricular conduction delay , and small ST depression in V4
and V5 of 0.5 mm. Chest x-ray revealed no edema , no infiltrate ,
question of opacity in the right upper lobe versus first rib.
Sodium was 141 , potassium 5.1 , chloride 106 , bicarbonate 25 , BUN
12 , creatinine 0.9 , alkaline phosphatase 81 , LDH 298 , troponin I 0 ,
and CK 96.
ASSESSMENT: The patient is a 74-year-old male with a history of
coronary artery disease , status post myocardial
infarction and status post angioplasty of his left circumflex and
OM1 branches , admitted with unstable angina over the past six weeks
after a severe episode of chest pain the day prior to admission ,
causing orthopnea and paroxysmal nocturnal dyspnea. He was
admitted for evaluation and for control of severe hypertension.
HOSPITAL COURSE: CARDIOVASCULAR: The patient's blood pressure was
controlled nicely initially on intravenous nitroglycerin. His Vasotec was
increased to 10 mg twice a day and then discontinued. He was weaned
down off of the intravenous nitroglycerin and started on Imdur 60 mg orally
twice a day and was also started on losartan , which was tapered up to 75
mg orally every day with improved control of his blood pressure. The
patient apparently had a poor reaction to Norvasc in the past , so
this medication was not tried.
On 1 of September September 1996 , he underwent cardiac catheterization which
showed a right atrial pressure of 6 , right ventricular pressure
36/8 , pulmonary artery pressure 40/16 , mean of 23 , pulmonary
capillary wedge pressure mean of 11 , left ventricular pressure
195/36 , cardiac output 5.3 , and cardiac index 2.5. He had a 70%
LAD lesion and a 50% first diagonal branch lesion. Circumflex was
okay and he had 40% and 25% serial RCA lesions. A 3.0 micron stent
was placed in the proximal LAD down to a residual of 25%. He was
started on Ticlid and continued on heparin for 48 hours.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day , atenolol 50 mg
orally every day , nitroglycerin sublingual every 5
minutes as needed , Imdur 60 mg orally every day , losartan 75 mg orally every day ,
and Ticlid 250 mg orally twice a day to be taken for one month.
FOLLOW-UP: The patient will follow up with Dr. Holda next week.
Dictated By: ARMINDA J. CONEDY , M.D. PM62
Attending: ALYSE A. HOLDA , M.D. AY9 BC745/7561
Batch: 86993 Index No. R4HC589GPI D: 4/17/96
T: 8/25/96
CC: 1. ALYSE A. HOLDA , M.D. QH4
Document id: 399
| Target |
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HTG |
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OSA |
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| output/system_textual_annotation.xml | textual |
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U |
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U |
U |
U |
Y |
U |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
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923502857 | PUO | 39602883 | | 6482230 | 10/21/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/21/2004 Report Status: Signed
Discharge Date:
ATTENDING: RASHEEDA BRAGAS MD
PRINCIPAL DIAGNOSES: Urinary tract infection and lower extremity
edema.
LIST OF PROBLEMS AND DIAGNOSES: Atrial fibrillation , venous
stasis.
HISTORY OF PRESENT ILLNESS: This is an 87-year-old woman with a
history of atrial fibrillation , congestive heart failure and
lower extremity edema who was admitted to Pagham University Of with increased calf swelling , weight gain , leg pain and
malaise. Over the past few months prior to admission , the
patient had noted a gradual weight gain to about a total of 20
pounds in two months. She had noted an increase in her chronic
lower extremity edema with increasing pain over the last moth
such that she has been taking Percocet for the pain. For the two
to three days prior to admission , the patient complained of
feeling "weak" and unable to get up out of bed due to fatigue and
general malaise. She denies any increasing shortness of breath.
She has had no chest pain , no paroxysmal nocturnal dyspnea. She
always sleeps with the head of her bed elevated , but generally
has not noted any problem with lying flat. The patient has had
some complaint issues with her torsemide in the past due to lack
of ability to pay for medications; however , she states she has
been taking her medications as directed in the weeks prior to
admission. She has had no cough , no fevers and chills. No
dysuria , no diarrhea , no nausea or vomiting.
REVIEW OF SYSTEMS: Positive only for nasal congestion and
chronic constipation.
The patient presented to the emergency department with her chief
complaint of weakness and increasing edema. In the emergency
department , she had lower extremity non-invasive ultrasound
studies , which were negative for DVT and a urinalysis revealed
UTI. She was treated in the ED with 500-mg levofloxacin and
40-mg intravenous Lasix , which resulted in a 1700 cc urine output. Of
note , the patient does have a Lasix allergy , which gives her rash
and GI upset. She does tolerate torsemide. Lasix was given in
the ED before it was known the patient have Lasix allergy.
PAST MEDICAL HISTORY:
1. Atrial fibrillation onset 1986 , on Coumadin.
2. Pacemaker single chamber.
3. Postherpetic neurologia.
4. GERD.
5. Hypercholesterolemia.
6. Obesity.
7. Gout.
8. Venous stasis lower extremities.
9. Echocardiogram 10/8/04: EF 55% low normal left ventricular
function.
ALLERGIES:
1. Quinidine causing rash.
2. Lasix causing rash and GI upset.
3. Penicillin reaction unknown.
4. Erythromycin reaction unknown.
MEDICATIONS: Medications at admission include:
1. Lopressor 25 twice a day
2. Coumadin 5 mg every bedtime
3. Torsemide 20 mg orally every day
4. Percocet as needed
5. Senna two tablets twice a day
6. Colace two tablets twice a day
SOCIAL HISTORY: Social history notable for the fact that the
patient lives alone; however , she does get help with meals and
housework , her family is involved.
PHYSICAL EXAMINATION: At admission was notable for vital as
follows , 98.2 , heart rate 81 , blood pressure 114/60 , respirations
20 , oxygen saturation 98% on room air. The patient was a
tired-appearing woman sitting in bed in no acute distress. HEET
exam notable for a nonreactive right pupil. Jugular venous
pulsation was visible at approximately 8 cm. Heart exam revealed
regular rate and rhythm with normal S1 and S2 with a 2 out of 6
systolic murmur heard at the left upper sternal border with no
radiation. Neck exam revealed jugular venous pulsations at
approximately 8 cm. Heart exam reveals regular rate and rhythm
with normal S1 , S2 and 2 out of 6 systolic murmur at the left
upper sternal border with no radiation. Lungs were clear to
auscultation bilaterally. Extremities revealed extensive
bilateral edema with chronic venous stasis pigmentary changes and
brawny erythremia of the lower shins. DP and physical therapy pulses were not
palpable , but feet were 1.
LABORATORY DATA: Labs at admission were notable for creatinine
of 1.3 , which was consistent with her baseline , creatinine and
the white blood count of 11.5. Hematocrit of 38.3 also
consistent with her baseline. INR was 2.8 and PTT was 48.1.
Cardiac enzymes were negative. BNP was 232. Urinalysis revealed
20 to 25 white blood cells per high-powered field on analysis of
sediment. Chest x-ray revealed persistent mild cardiomegaly ,
some chronic intrastitial markings and a single lead pacemaker.
EKG was completely V-paced rate of 80.
HOSPITAL COURSE BY SYSTEM: In summary , this is an 87-year-old
woman admitted with leg pain and swelling and weight gain likely
secondary to chronic venous stasis and with general malaise due
to urinary tract infection.
1. Infectious disease , urinary tract infection. The patient was
treated with a 3-day course of levofloxacin and a urine culture
was sent , which had no growth at the time of discharge , but was
not yet finalized. Final results pending and discharged.
2. Cardiovascular , the patient has symptoms of total body volume
overloaded in her lower extremities; however , she had symptoms of
left-sided heart failure and it is likely the swelling in her
legs is more secondary to chronic venous stasis than to
right-sided heart failure per se. She was treated with diuresis
with an increased dose of torsemide 40 gm intravenous twice a day was placed on
the low-salt diet and did have a total diuresis of approximately
two liters over the course of her hospital stay with decrease in
swelling of the lower extremity. She was also given TED hose to
compress and mobilize fluid and was maintained with her legs
elevated for anytime that she was resting in bed or in the chair.
The patient was also maintained on her usual cardiovascular
medications including Lopressor and coumadin.
3. Heme. The patient was on Coumadin with the therapeutic INR.
Her lower extremity noninvasive studies were negative for DVT.
4. Cord status. The patient's cord status is do not
resuscitate , do not intubate.
5. The patient's final disposition was still pending at the time
of dication. She will be discharged to either to home with
services or to rehab pending final evaluation by physical therapy
regarding her safety with ambulation and mobility at home. An
addendum to discharge summary with final disposition and follow
up will be dictated.
MEDICATIONS AT DISCHARGE: Medications at discharge are as
follows:
1. Colace 100 mg orally twice a day
2. Lopressor 25 mg orally twice a day
3. Senna two tablets orally twice a day
4. Coumadin 5 mg orally every bedtime
5. Levofloxacin 250 gm orally every day for a total of three doses.
6. Torsemide 20 mg orally every day
7. Lac-Hydrin 12% topical twice a day
8. Oxycodone 5 to 10 mg orally every 4 hours as needed pain.
eScription document: 3-8848586 CSSten Tel
CC: Avril Taplin M.D.
KTDUOO
Mifort Parkway , So Dabie Son , Illinois 35410
Dictated By: CHAIX , TRISH
Attending: BRAGAS , RASHEEDA
Dictation ID 4161413
D: 8/29/04
T: 4/17/04
Document id: 400
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174347248 | PUO | 89533999 | | 9381918 | 7/30/2005 12:00:00 a.m. | Morbid Obesity | Unsigned | DIS | Admission Date: 7/30/2005 Report Status: Unsigned
Discharge Date: 3/8/2005
ATTENDING: HORNBEAK , LAUREL MD
HISTORY OF PRESENT ILLNESS: Mr. Caruth is a 65-year-old male
with a history of morbid obesity , bilateral leg swelling ,
palpitations , remote seizure disorder last one in 1981 ,
obstructive sleep apnea , has started CPAP in 4/10/2005 , and
migraines.
PAST SURGICAL HISTORY: He has a past surgical history of left
meningioma that was diagnosed in 1987 , infection of the plate
that was in his skull that was debrided in 2000 , Achilles repair
in 1975 , and right knee surgery in 1965.
SOCIAL HISTORY: He does not smoke. He rarely drinks alcohol ,
and denied initial drug surgery.
PHYSICAL EXAMINATION ON ADMISSION: His initial height was 5 feet
9-1/2 inches. His weight was 318 pounds on admission.
PAST MEDICAL HISTORY: He came to Pagham University Of
for an attempted lap banding on 7/30/2005 . Unfortunately during
the surgery , there was damage to the thoracic aorta and the
attempted lap banding turned into an exploratory laparotomy ,
median sternotomy , left thoracotomy , and aortic injury repair.
He suffered cardiac arrest on the operating room table. Left
hemothorax and cardiac tamponade secondary to the descending
thoracic aortic laceration which was repaired intraoperatively ,
and his abdomen was left open temporarily with a ??____?? bag and
partial VAC sponge , and he was admitted to the unit on pressors.
HOSPITAL COURSE: Notable for a couple of major events over the
past couple of months , and we will go to those major events. On
7/25/2005 , Mr. Garness was weaned off pressors. On the
10/15/2005 , the mediastinal chest tube was discontinued. On
1/2/2005 , his creatinine started to increase. On 4/15/2005
and 10/12/2005 , the patient was bronched for respiratory distress
with resolution of the respiratory distress. On 10/18/2005 , he
was taken down to the operating room to increase the size of the
endotracheal tube. His abdominal wound dehisced en route , a J
tube was placed , a left triple lumen catheter was placed , and his
exploratory laparotomy wound was able to be closed with wax
sponge to be on top of the wound closure. On 4/30/2005 , he had
a tap of his left chest. There was fluid collection there from
the left thoracotomy. On 8/8/2005 , the left chest tube was
placed and on 1/11/2005 , a left chest tube was discontinued. On
2/7/2005 , he was trached and two chest tubes were placed and a
left VATS was completed again , because of a persisted fluid
collection. On 4/24/2005 , a right PICC was placed and the
triple lumen and his A line were discontinued. On 6/10/2005 , a
TEE was done that showed normal valves with no vegetations and no
major regional wall motion abnormalities. On 9/30/2005 , his
trach was changed to a #7. On 2/10/3005 , his trach was changed
to a #8 Portex. On 11/28/2005 , he had a renal ultrasound for
again a slowly rising creatinine that did not show any evidence
of hydronephrosis. On 3/23/2005 , CVVH was started after Quinton
was placed in the right IJ , on 5/4/2005 , his #8 Portex trach
was replaced with a #8 Shiley. On 10/18/2205 , a clot developed
in the CVVH catheter. On 1/25/2005 , a wound which was being
seen periodically by I&D has had periodic wound I&Ds and VAC
changes. On 6/23/2005 , the right IJ Quinton was discontinued
and a right IJ tunneled hemodialysis catheter was placed. On
2/7/2005 , he had a metabolic heart and began to trach collar
for increasing amounts of time. On 9/20/2005 and 12 ,
there was report that his J tube had been slightly displaced and
then had been pushed in by the ICU team. The patient developed
left lower quadrant pain. He was sent down for the CT of the
abdomen and pelvis , and now the J tube was not fully visualized I
think because it is radiolucent to extravasation of contrast was
not seen and surgery team felt that it was okay to continue tube
feeds safely which we have with no problems. On 6/16/2005 , he
desaturated when he went down for an ultrasound for the left
upper extremity in order to rule out clot because again the left
upper extremity had been swelling , so no studies was completed.
He developed rigor short after with the temperature to 104 , some
mild hypotension and tachycardia. TEE at the bedside show no
dissection or intimal flap blood cultures were drawn. His PICC
was discontinued and the tip was sent for culture , and he
received doses of levofloxacin and vancomycin. He was able to
eventually J-collar through this. On 3/26/2005 , a 3 out of 4
gram negative rods which ended up being enterobacter were
cultured out. We believe that he suffered a transient bacteremia
from the PICC. Levofloxacin was started and ID was consulted
because the enterobacter was resistant about everything except
amikacin and imipenem. On 10/3/2005 , allergy was also consulted
and restarted an imipenem desensitization process which he has
completed , and he is now on imipenem 250 mg every 12 hours for a
total course of 15 days that was started on 10/3/2005 , and a
PICC was replaced. Today , he was planning to go to hemodialysis
in order to exchange the dialysis catheter over wire not that it
is not functioning but because of this transient bacteremia we
would like to give them a new hemodialysis catheter. He has been
able to get hemodialysis with , though some 10 , 000 to 20 , 000 units
of heparin has to be given beforehand in order for the catheters
to flush well , and he will also be going for left upper extremity
either ultrasound or venogram to again rule out a clot in the
left upper extremity due to the increased swelling. His last
temperature here is 98.3 today. His blood pressure runs
systolics 90 to 110 with a heart rate in the 90s to 110s. He is
on no drips or intravenous fluids , just his full strength Nepro of 55
which is his goal and he is essentially anuric , but when we do
straight caths which we tend to do once every 1-2 days , he puts
out usually 100-200 cc of urine and he has been J-collaring
successfully now for over three or four days saturations in the
95% to 100% and an FiO2 of 40%. OT and physical therapy have also been seeing
him.
REVIEW OF SYSTEMS:
Neurologically , his mental status has much improved. He had
initially some ICU delirium after the initial surgery that has
really greatly improved. He right now is on no major mood
stabilizers or antipsychotics. We do give him oxycodone for
pain , which he really has had to use.
Pulmonarywise , we have kept him on J-collar when he does need to
go for a procedure we do send down the vent in case just because
he is still fairly large person and may need the ventilatory
support for positioning. He is right now on Combivent and DuoNeb
nebulizers as needed
Cardiovascularwise , his blood pressure has been stable and so has
his tachycardia. The beta-blocker that he was initially on
Lopressor 12.5 mg three times a day was stopped secondary to the imipenem
desensitization the feeling being that if he did has an
anaphylactic reaction , the epinephrine needed unopposed action
and we did not want any beta-blocker on board. We have held and
would continue it starting at a low dose after he completes his
course of imipenem.
Gastrointestinalwise , he is on tube feeds which he tolerates very
well and there are no issues any more with the J-tube position.
We are requesting a bedside speech and swallow official consult ,
though he has been tolerating ice chips and ice cream with
absolutely no problems on orally He is also on Pepcid intravenous for GI
prophylaxis.
Genitourinarywise , he gets hemodialysis every other day. They
have been taking 4-5 liters per day and again with straight
catheterizing once every 1-2 days and usually get about a 100 cc
to 200 cc of urine. Renal has been following him , and they are
unhappy with his course of dialysis. Again , the hemodialysis
catheter is to be wire exchanged today , which is 11/5/2005 , but
again they have been able to use it just fine so far.
Hematologywise , he is on heparin subcutaneous 10 , 000 units three times a day
Endocrinewise , we have been checking his fingersticks and he is
right now on Lantus 15 units subcutaneous twice a day with a sliding
scale for coverage. He has just been following the fingersticks
that way and imipenem , he is to continue for 14-day course total
of imipenem 250 mg every 12 hours The first dose was given in
the a.m. on 10/3/2005 , and there are no new culture results
after the gram-negative enterobacter was found. All other
surveillance and urine culture have been negative.
eScription document: 4-4577896 MFFocus
Dictated By: ZUFALL , ELMA
Attending: HORNBEAK , LAUREL
Dictation ID 3446338
D: 1/14/05
T: 1/14/05
Document id: 401
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
N |
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- |
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N |
186458854 | PUO | 85262179 | | 1194970 | 11/8/2003 12:00:00 a.m. | Morbid obesity history of Roux-en-Y bypass | | DIS | Admission Date: 7/15/2003 Report Status:
Discharge Date: 6/4/2003
****** DISCHARGE ORDERS ******
TORRELL , JAMAL 990-85-25-7
Ronu Blvd
Service: GGI
DISCHARGE PATIENT ON: 4/4/03 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ROXICET ELIXIR ( OXYCODONE+APAP LIQUID ) 5 ML orally Q3-4H
as needed PAIN
DIET: Stage II Gastric Bypass / stage 2 diet--32oz sugar fee carnation
ACTIVITY: Walking as tolerated
Avoid heavy lifting 4-6wks
FOLLOW UP APPOINTMENT( S ):
Dr. Laurel Hornbeak , 244-399-4003 1-2 wks ,
No Known Allergies
ADMIT DIAGNOSIS:
Morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Morbid obesity history of Roux-en-Y bypass
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid obesity history of Roux-en-Y bypass Hypothyroidism
Obstructive sleep apnea , dependent on CPAP mask
OPERATIONS AND PROCEDURES:
10/28/03 HORNBEAK , LAUREL I. , M.D.
ROUX-EN-Y GASTRIC BYPASS , CHOLECYSTECTOMY
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
50 year-old male with morbid obesity , hx hypothyroidism and sleep apnea ( on
CPAP at night ) , admitted on 10/28 and underwent Roux-en-Y gastric bypass
without complications. He was transferred in stable condition to the
PACU and then to the transitional care unit overnight given his history
of sleep apnea. His postoperative course was relatively unremarkable
except for some oxygen requirement that improved with ambulation. His
NGT was removed on postoperative day 1 and his diet was advanced as per
protocol. On postoperative day 5 , he continued to require
assistance for ambulation , and per physical therapy he will be transferred to VLH for
continued rehab. Will be d/c'ed with adequate pain control , tolerating
gastric bypass stage II diet , with f/u Dr. Hornbeak in 2wks.
ADDITIONAL COMMENTS: Please ambulate as much as possible. Take pain medications as needed.
Do not drive while taking pain medications. Call if fever , chills ,
nausea , vomiting , abdominal pain , abdominal distention , redness or
drainage from wound. Follow up with Dr. Hornbeak in 1-2 wks.
diet: 32oz sugar free carnation per day: breakfast and lunch-8oz
carnation , 8oz crystal light and 4oz sugar free jello. dinner-8oz
carnation , 8oz crystal light , 4oz clear broth and 4oz diet sorbet.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please encourage ambulation. Monitor clinical status. Rehabilitate.
No dictated summary
ENTERED BY: MARTHA , SHONDA G. , M.D. ( DI488 ) 4/4/03 @ 08:22 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 402
| Target |
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CHF |
Dp |
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GER |
Gou |
HC |
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OA |
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| output/system_textual_annotation.xml | textual |
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N |
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Y |
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U |
Y |
Y |
Y |
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Y |
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| output/system_intuitive_annotation.xml | intuitive |
N |
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896890694 | PUO | 49034699 | | 042167 | 7/13/1998 12:00:00 a.m. | ACUTE MYEOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/13/1998 Report Status: Signed
Discharge Date: 11/25/1998
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE , STATUS POST
ANGIOPLASTY WITH STENT TO THE RCA.
MEDICAL PROBLEMS: 1. CORONARY ARTERY DISEASE.
2. STATUS POST MYOCARDIAL INFARCTION X FOUR.
3. STATUS POST MULTIPLE PTCA PROCEDURES.
4. STATUS POST CORONARY ARTERY BYPASS GRAFT
IN 1992.
5. HYPERTENSION.
6. DYSLIPIDEMIA.
7. ADULT ONSET DIABETES MELLITUS.
8. HISTORY OF TRANSIENT ISCHEMIC ATTACK.
9. GOUT.
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old gentleman
with cardiac risk factors including
diabetes; adult onset , hypertension , positive family history ,
dyslipidemia , and also with a distant tobacco use history and with
severe obesity. The patient has a long history of coronary artery
disease starting in 1989. The patient presented with angina and
ruled out for a myocardial infarction at that time. In 1991 he had
unstable angina. A catheterization revealed 100% LAD lesion
proximally , 60% D-1 , 70% distal left circumflex , and normal right
coronary artery. PTCA to the LAD was performed with 30% residual
lesion. In 1992 the patient had two myocardial infarctions. In
February of 1992 a re-catheterization showed an additional lesion of
an OM-2 with 60% complex lesion with a mid LAD total occlusion with
right-to-left collaterals and diffuse PDA disease. In February of
1992 a repeat catheterization was performed for continued unstable
angina and the patient had an 80% left circumflex lesion , a 70%
OM-2 , 100% proximal LAD , 70% distal left circumflex , 70% OM-2.
Over this time period between 1991 and 1992 , the patient had a
total of four myocardial infarctions including a large anterior
wall myocardial infarction. The patient underwent coronary artery
bypass grafting in February of 1992 which was complicated by
ventricular fibrillation arrest in the postoperative Intensive Care
Unit. The patient received a LIMA to the LAD , SVG to the OM-1 and
an SVG to the OM-2. The patient had a repeat catheterization in
February of 1994 for unstable angina which showed diffuse native
disease: 100% LAD with right-to-left collaterals , 70% distal left
circumflex , 100% proximal OM-1 , 100% OM-2 , 50% mid right coronary
artery. The grafts were patent. Since that time the patient has
had minimal chest pain. The patient was seen in the clinic most
recently in January of 1997 for exertional chest pain. The patient
did well with an increase in his Atenolol dose.
On the day of admission today , for this admission , the patient
experienced chest burning at rest while watching TV with no
emotional or exertional stress. The pain lasted 40 minutes ,
radiating to the jaw with an intensity of 8 out of 10. The patient
took a shower without relief , took five sublingual Nitroglycerin
tablets without relief. The patient presented to the Emergency Ward
where his pain was relieved in the Waiting Room. The patient had
no nausea or vomiting , diaphoresis or shortness of breath. The
patient has had no increasing dyspnea on exertion , orthopnea or PND
recently; however the patient is not physically active. Of note ,
an echocardiogram in 1993 showed an ejection fraction of 40% with
apical akinesis and septal hypokinesis.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: The patient is an obese , pleasant male in
no distress. Vital signs: Temperature
97.6 , pulse 88 , blood pressure 127/64 , respirations 18 , oxygen
saturation was 95% on room air. JVP was eight centimeters. There
was a normal S1 and S2. There was a positive S4 , no S3. There was
a 1/6 holosystolic murmur with no radiation. Left basilar crackles
were noted. There was a large abdomen with good peripheral pulses.
LABORATORY DATA: Sodium 138 , potassium 4.4 , BUN 18 , creatinine
0.8 , CK 370 , MB 9.1 , troponin 0.21. White blood
cell count 13 , 000 , hematocrit 45.7 , platelet count 253 , 000 , INR
2.4 , PTT 37.6. The patient's chest x-ray was of poor quality , with
no congestive heart failure and mild cardiomegaly , and bibasilar
atelectasis. The patient's EKG had a normal sinus rhythm with a
rate of 75 , Q waves in III and aVF , V1 and V2. ST elevations in
III and aVF of one millimeter , ST depressions and T wave inversions
in I and L , but no changes when compared to the patient's baseline
EKG.
HOSPITAL COURSE:
CARDIOVASCULAR: The patient ruled in for a non-Q wave myocardial
infarction , and given his extensive history of
previous coronary artery disease and coronary artery bypass
grafting , it was felt most likely that the patient is now
developing an occlusion of his grafted vessels versus occlusion of
his right coronary system. The patient's peak CK was 370 with
positive MB. The patient was continued on aspirin , Lopressor ,
Captopril , Simvastatin , and intravenous heparin , and Nitropaste sliding
scale. The next morning the patient was taken to the
Catheterization Lab where the previous native disease was noted ,
but additional disease of the RCA with serial mid 90% lesions ,
which were stented , a PDA of serial 70 and 90% lesions were
dilated. The patient was placed on Ticlid. The patient
experienced no chest pain after the procedure and EKGs had shown no
changes after the procedure. A submax Bruce protocol exercise
treadmill test was negative prior to discharge.
ENDOCRINE: The patient has a diagnosis of diabetes and his
Metformin was held before the catheterization
procedure , and the patient was continued on insulin sliding scale
and his Glyburide without complications.
DISCHARGE MEDICATIONS: 1 ) Enteric coated aspirin 325 mg orally every
day. 2 ) Colchicine 0.6 mg orally every day. 3 )
Glyburide 10 mg orally twice a day 4 ) Nitroglycerin sublingual tablets
every 5 minutes x three; one tablet as needed chest pain. 5 ) Simvastatin
20 mg orally every bedtime 6 ) Ticlid 250 mg orally twice a day x 14 days. 7 )
Atenolol 100 mg orally every day. 8 ) Lisinopril 500 mg orally every day. 9 )
Coumadin 12.5 mg orally every day.
The patient is to return to work in three weeks.
OPERATIONS AND PROCEDURES: CORONARY ANGIOPLASTY WITH STENT
PLACEMENT.
CONDITION ON DISCHARGE: The patient's condition on discharge was
stable.
DISCHARGE DIET: The patient's discharge diet was a low-cholesterol
low-fat diet , ADA 1800 calorie diet.
COMPLICATIONS: None.
FOLLOW-UP PLANS: The patient will follow-up with his primary
cardiologist , Dr. Theiling , and internist , Dr.
Irving Escalante .
Dictated By: HERMINA TUOMALA , M.D. VN9
Attending: KATHERYN SATURNINA GRUNTZ , M.D. XK1 HX092/2710
Batch: 80828 Index No. FPMXRW1ZKL D: 11/25/98
T: 11/25/98
Document id: 403
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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349952150 | PUO | 01189750 | | 374908 | 10/24/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/3/1990 Report Status: Unsigned
Discharge Date: 11/17/1990
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
STATUS POST CORONARY ARTERY BYPASS GRAFTING.
HISTORY OF PRESENT ILLNESS: This is the second Pagham University Of admission for this 55 year
old white gentleman who in 11/23 was first admitted for cardiac
catheterization for unstable angina. His cardiac risk factors
include adult-onset diabetes mellitus , hypercholesterolemia ,
hypertension , family history of coronary artery disease , and prior
myocardial infarction. In 1982 , he developed exertional angina
treated with Isordil and in 1989 had a stress Thallium test which
showed mild inferior wall ischemia. In 11/23 he was admitted to
Pagham University Of for unstable angina and ruled out for
MI. His unstable angina continued and he was admittedo on 2/25/90
for cardiac catheterization to further study his coronary artery
disease. This catheterization showed a 95% left anterior
descending stenosis proximally and 80% distally , 95% proximal
occlusion of the right coronary artery , and an 80% occlusion of the
posterior descending artery. His cardiac index was 3.7 and it was
decided to schedule the patient for coronary artery bypass grafting
surgery which he underwent on 3/8/90 . He had a left internal
mammary artery to left anterior descending artery saphenous vein
grafts to the posterior descending and diagonal branches. His
course in the ICU was uncomplicated and he was transferred to the
floor on postoperative day #2 , where his course was complicated by
a few episodes of symptomatic atrial fibrillation with maintenance
of good blood pressure but some symptoms of lightheadedness and
diaphoresis.
DISPOSITION: This was brought under good control with Procainamide
and he was discharged on 3/8/90 on Procainamide one
gram orally.four times a day and Glipizide 2.5 mg orally.twice a day , and aspirin once
per day. Followup with Dr. Bree Marlyn C. Theiling of CHH .
________________________________ TQ850/5579
LOIDA GOLEBIOWSKI , M.D. MC6 D: 2/20/90
Batch: 0921 Report: E0675R92 T: 10/9/90
Dictated By: MARYLYN DERDEN , M.D.
cc: Andnock Stownchild Medical Center
Document id: 404
| Target |
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GER |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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013385838 | PUO | 98854523 | | 5090690 | 4/10/2006 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 7/14/2006 Report Status: Unsigned
Discharge Date:
ATTENDING: COLASAMTE , ISABELLE EVON MD
PRINCIPAL DIAGNOSES: Coronary artery disease , left ventricular
aneurysm.
PROBLEM LIST:
1. Congestive heart failure.
2. Atrial fibrillation.
3. Coronary artery disease.
HISTORY OF PRESENT ILLNESS: Briefly , this is a 64-year-old
gentleman with a history of an anterior myocardial infarction in
1976 with resultant left ventricular aneurysm and congestive
heart failure with an ejection fraction of approximately 20%. He
has had increasing chest pain with exertion over the last
several years , which led to an evaluation for ischemia.
Catheterization at the Niland Rawee Hospital in S Arlson Lu showed a 70% left
main lesion and a previously known 100% LAD , OM and RCA disease.
The patient had previously undergone a SPECT thallium scan
2/3/06 in Alabama , which showed a large anterior anteroseptal
infarct involving the septum , anterior wall and apical walls that
were entirely scarred and the lateral wall viability
was unclear on that scan. A chest CT performed in October of 2006 showed a
large left ventricular dilation with remodeling and calcified and
thinned left ventricular apex. His past history is also notable
for a history of nonsustained ventricular tachycardia dating back
to 1983. He had his first AICD placed in 1990 at Daonredd Cison Community Memorial Hospital
and this was replaced at the KAAH in 1993 with a rate-sensing lead via
the left subclavian vein , and in 1997 , a CPI mini AICD was
placed. On presentation on this admission , he did not have a
history of angina , but did have a history of class III heart
failure with marked limitation of physical activity. He was in
atrial fibrillation , which is his baseline rhythm.
PAST MEDICAL HISTORY: As mentioned above , includes also diabetes
with orally treatment only , hypothyroidism , dyslipidemia and gout.
PAST SURGICAL HISTORY: His past surgical history is notable for
a cholecystectomy in 80s and ICD placed via an open chest in
1990 , replacement in 1992 and in 1997 , appendectomy , right
inguinal hernia repair in 1986.
FAMILY HISTORY: His family history is unremarkable , no history
of coronary artery disease.
SOCIAL HISTORY: The patient has an eight-pack year cigarette
smoking history. He has an alcohol intake of two drinks per
month and the patient was formerly a dentist.
ALLERGIES: His allergies include erythromycin giving a rash ,
amiodarone with a suspected pulmonary toxicity and elevated LFTs.
MEDICATIONS ON ADMISSION:
1. Toprol 25 mg orally daily.
2. Valsartan 80 mg orally daily.
3. Digoxin 0.125 mg daily.
4. Isosorbide 30 mg twice a day
5. Aspirin 81 mg daily.
6. Coumadin 1.5 mg daily.
7. Furosemide 80 mg orally twice a day
8. Simvastatin 40 mg daily.
9. Coreg 25 mg twice a day
10. Synthroid 50 mcg daily.
11. Allopurinol 100 mg daily.
12. Potassium 20 mEq daily.
13. Klonopin 0.5 mg twice a day
14. Glucophage 500 mg twice a day
PHYSICAL EXAMINATION ON ADMISSION: Notable for this gentleman
who was 5 feet 10 inches and 95 kg in no acute distress. His
vital signs were temperature of 97.8 , heart rate of 70 , blood
pressure of 122/70 and oxygen saturation 98% on room air. He had
no detectable carotid bruits. Examination of the chest was
notable for a midline sternotomy scar that was well healed and an
irregular rhythm. No murmurs were appreciated. His breath
sounds were clear and equal bilaterally. His abdomen was notable
for scars from a previous right cholecystectomy and a left lower
quadrant incision for placement of ICD. There were no masses and
the abdomen was soft and nontender. His extremities were without
scaring or edema and he did not have varicosities present.
LABORATORY DATA ON ADMISSION: An echocardiogram performed at the
Pagham University Of on 9/24/06 showed an ejection
fraction of 25% with mild mitral insufficiency , mild tricuspid
insufficiency and an AICD wire in the right heart.
OPERATION PROCEDURES: On 6/16/06 , the patient underwent a
mitral valve repair with an Alfieri suture , a CABG x3 with a
Y-graft saphenous vein; SVG2 connects SVG1 to LVB1 , SVG1 connects
to aorta to OM1 , SVG3 to ramus , a left ventricular aneurysm
repair and epicardial lead placement. The bypass time was 257
minutes. The cross-clamp time was 98 minutes.
ICU COURSE:
1. Neurologic: The patient was brought to the Intensive Care
Unit from the operating room on a propofol drip. He was
adequately sedated. Sedation was weaned and he was extubated
without incident. The patient's pain was well controlled with
as needed Toradol. This was transitioned over to Motrin and he was
taking orally.s and as needed Morphine. He also was continued on his
own dose of Clonazepam 2.5 mg twice a day He was neurologically
intact throughout the course of his ICU stay and he was
transferred to floor with no focal deficits , moving all
extremities and pain that is well controlled.
2. Cardiovascular: The patient was brought to the ICU on
Neosynephrine , epinephrine and milrinone drips. The milrinone was
initially given a weaning trial , but his mixed venous oxygen
saturations dropped to the high 40s and low 50s and the milrinone
was restarted. The Neosynephrine was the first drip to be
discontinued and the patient remained on milrinone and
epinephrine. Both of these were slowly weaned , the epinephrine
coming off first and the milrinone coming off two days prior to
transfer out of the ICU. He was in rapid atrial fibrillation and
was initially loaded with digoxin , which did improve the rate
transiently. He continued to have marginal mixed venous oxygen
saturation and poor cardiac performance as assessed by cardiac
output and cardiac index. Postoperatively , he had an intraaortic
balloon pump. The intraaortic balloon pump remained in until
postoperative day# 9 when it was discontinued. Slowly the drips
were weaned. He was started on an afterload reducing agent ,
first a drip of sodium nitroprusside , after he had had a trial of
esmolol. The esmolol did improve his rates slightly but did not
significantly improve his cardiac output or his mixed venous
oxygen saturation. He did seem to have improvement with the
afterload reducing agent of sodium nitroprusside. His rapid
atrial fibrillation remained refractory to medical treatment. He
was given trial of ibutilide , which did not significantly change
his rate or convert him into sinus rhythm. He was loaded with
amiodarone in spite of his prior history of pulmonary and hepatic
toxicity with plan to use a short course of amiodarone to improve
the rate. His rate did improve. He remained in atrial
fibrillation and did not convert to sinus. On postoperative day
8 , he was taken to the operating room and cardioverted
successfully to sinus rhythm. Transesophageal echocardiogram
showed an ejection fraction of 30% and no clots in the atrial
ventricles. He remained in a sinus rhythm for approximately
three days until postoperative day 11 when he switched back into
atrial fibrillation that was refractory to ibutilide. Attempted
cardioversion was done the following day , which failed , and he
remained in atrial fibrillation on transfer to the floor. His
rate was better controlled in the 80s to 90s and he was on a
regimen of digoxin , afterload-reducing agent Captopril 25 mg every 6
h. and low-dose Lopressor 6.25 mg four times a day His pulmonary artery
catheter was discontinued prior to transfer to the floor , and on
transfer to the floor , his mixed venous oxygen saturation was
improved in the high 50s to low 60s.
3. Pulmonary: Initially , the patient required BIPAP while in
the Intensive Care Unit. He needed an aggressive diuresis to
improve his pulmonary status but transfer to the floor , he was
down to 3 L nasal cannula and he was able to ambulate and get out
of bed.
4. GI: The patient was initially started on clear liquids and
was taking very minimal orally's because he had a significant BIPAP
requirement. As the BIPAP was weaned , his diet was advanced and
he was tolerating a regular diet on transfer to floor. He did
have several episodes of diarrhea. Fecal leukocytes and
Clostridium difficile were sent and were negative and the
diarrhea was resolving on transfer to the floor.
5. GU: The patient was aggressively diuresed with a Lasix drip
and with Diuril boluses. His creatinine tolerated the
aggressively diuresis. His sodium remained low in the 130s and
he was transitioned off the Lasix drip to orally Lasix and
continued to be negative on transfer to the floor.
6. Endocrine: The patient has a history of diabetes and
hypothyroidism. He was maintained on dose of Synthroid initially
intravenous. Then , that was transitioned to orally when he was tolerating
orally's. He was on subcutaneous insulin and his sugars were well
controlled. Initially , he was on Portland protocol and was then
transitioned to subcutaneous insulin.
7. Heme: The patient was anticoagulated with heparin initially
for the intraaortic balloon pump and atrial fibrillation. He did
have a marked drop in his platelets and was positive for
heparin-induced thrombocytopenia. He was started on argatroban
and bridged to Coumadin. On transfer to the floor , he remains on
argatroban with a goal PTT of 50 to 70 and he is getting Coumadin
with goal INR 2 to 3.
8. Infectious Disease: The patient had an elevated while blood
cell count throughout the course of his ICU hospital stay. He
had the intraaortic balloon pump in place for nine days. He was
seen by ID and his only positive blood culture was a
coag-negative staph that was believe to be a contaminant. He was
on vancomycin for many days that was not discontinued. He does
have a history of right knee gout , which did flare while he was
in the Intensive Care Unit and part of his elevated blood cell
count was attributed to that. He was started on colchicine and
Allopurinol.
DISCHARGE MEDICATIONS: On transfer to the floor , the patient was
on following medications:
1. Captopril 25 mg orally every 6 hours
2. Lopressor 12.5 mg orally four times a day
3. Digoxin 0.125 mg daily.
4. Lasix 40 mg orally three times a day
5. Allopurinol 100 mg orally daily.
6. Aspirin 81 mg orally daily.
7. Clonazepam 0.5 mg orally twice a day
8. Colchicine 0.6 mg orally daily.
9. Colace 100 mg orally twice a day
10. Regular insulin sliding scale.
11. Synthroid 50 mcg orally daily.
12. Magnesium and potassium scales.
13. Ambien 5 mg orally at bedtime.
14. Nexium 40 mg orally daily.
15. Lantus 12 units subcutaneously at bedtime.
16. Darbepoetin alfa 40 mcg subcutaneous.
17. NovoLog sliding scale and NovoLog four units subcutaneously
with lunch and six units with dinner.
DISPOSITION: He was transferred to the floor in stable
condition.
FOLLOW-UP: He will need continued evaluation with physical and
occupational therapy.
eScription document: 5-0472656 CSSten Tel
Dictated By: ROIS , ARLYNE
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 1186931
D: 5/1/06
T: 5/1/06
Document id: 405
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
- |
767330041 | PUO | 73486376 | | 6350680 | 2/26/2005 12:00:00 a.m. | CHF | | DIS | Admission Date: 6/27/2005 Report Status:
Discharge Date: 6/12/2005
****** FINAL DISCHARGE ORDERS ******
ROERIG , NICHOLE 525-49-56-8
Kalla Rd. , Go , Alaska 70729
Service: MED
DISCHARGE PATIENT ON: 3/22/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DEPSKY , GWYNETH ALMEDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
CLONIDINE HCL 0.3 MG orally twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FAMOTIDINE 20 MG orally twice a day
INSULIN NPH HUMAN 24 UNITS subcutaneously every day before noon
INSULIN NPH HUMAN 8 UNITS subcutaneously every bedtime
LABETALOL HCL 600 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 8/18/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
on order for LABETALOL HCL orally ( ref # 96859473 )
patient has a PROBABLE allergy to ATENOLOL; reactions are
fatigue , BRADYCARDIA. Reason for override:
patient takes this at home
PREDNISONE 5 MG orally every day before noon
SENNAGEN ( SENNOSIDES ) 2 TAB orally twice a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
AMLODIPINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 8/18/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
POTENTIALLY SERIOUS INTERACTION: TACROLIMUS & AMLODIPINE
BESYLATE Reason for override: patient takes this at home
TACROLIMUS 2 MG orally every 12 hours Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
Override Notice: Override added on 8/18/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
on order for AMLODIPINE orally ( ref # 65826885 )
POTENTIALLY SERIOUS INTERACTION: TACROLIMUS & AMLODIPINE
BESYLATE Reason for override: patient takes this at home
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 250 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every day
LASIX ( FUROSEMIDE ) 60 MG orally twice a day X 7 Days
Starting Today ( 9/12 )
Instructions: take in the morning and at 4pm
LASIX ( FUROSEMIDE ) 60 MG orally every day Starting on 5/23
IMDUR ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 5 MG orally every day
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Fleitas 5/25 9:30AM scheduled ,
Dr. Barbagallo 4/5 11:15AM scheduled ,
Dr. Pencil 8/6 11:20AM scheduled ,
Dr. Hazinski 8/23 9:00AM scheduled ,
ALLERGY: ATENOLOL
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , history of CABG '02 ( coronary artery disease ) ESRD , history of renal txplt 5/9
( end stage renal disease ) DM ( diabetes mellitus ) HTN ( hypertension )
Hyperchol ( elevated cholesterol ) Hyperpara ( hyperparathyroidism ) Anemia
( anemia ) Cataracts , history of surg ( cataract )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
CC: exertional SOB
IDENTIFIER/DX: 77yoM with hx htn , DM , CAD history of CABG 2003 , ESRD history of
transplant 5/9 , p/with 2 weeks of increasing exertional SOB , pedel
edema , and left sided reproducible chest pain occ radiating across
right side of chest to back , pleuritic. BNP 1196 , trop 0.1. Ddimer
neg. Admitted for likely CHF. PMH: as above , hyperparathyroidism ,
anemia , cataracts
--------- DAILY STATUS: 97.8 55 176/64 18 98%RA. Gen: lying
flat on stretcher , breathing comfortably , NAD murmur heard over at L
clavicle ( AV fistula ) Lungs: CTAB. CV: RR , S1 , S2 , ?S4 3/6
holosystolic blowing murmur at apex radiating to axilla , 2/6
holosystolic murmur at LLSB , JVP 11cm Ext: with palpable AV fistula of
left forearm. 2+ tender non-pitting pedal edema b/l , cool feet ,
palpable DP/physical therapy pulses b/l ------
DAILY EVENTS: ---------
STUDIES/PROCEDURES: 4/9 ECHO EF 60-65% , mod MR , mod
TR 8/13 stress test with no EKG/ECHO changes c/with
ischemia but non-diagnostic ( peak HR 64 BP 140/66 ) 4/11
cardiomegaly , ?vascular congestion with cephalization , formal read no
CHF 10/26 EKG sinus brady at 50 , LAD , LAE , LVH , nl int ,
non-spec Twchanges , unchaged from 9/8 ---------
CONSULTS: ---------
CC: exertional SOB
HPI: 77yoM with hx CAD history of CABG 2003 , p/with 2 weeks of increasing exertional
dyspnea. At baseline can walk 4-5 blocks , over last couple weeks can
only walk about 1 block before becoming SOB. Was also getting SOB with
minimal activity at home including showering. Sleeps on one pillow , no
orthopnea , no PND. Has had some pedal edema over the few weeks.
Increased urination and increased thirst , no reported change in diet.
Recently stopped HCTZ but no other change in meds. Also with some dull
chest pain over left side that radiates in a band like fashion across his
stenum to back , 3-4/10 in intensity , not brought on by activity , lasts
for seconds at a time when present , pleuritic. Reproducible with
palpation. patient had fallen on his right side several weeks earlier. Some
dull abdominal discomfort in lower quadrants usually improved with bowel
movements , last BM yesterday. No n/v. No calf tenderness , no recent
surgery , no recent travel. March wt 158lbs by records , patient has not
noticed any weight gain.
patient reports not having this pain previously , however by records patient was
evaluated in 3/2/05 for similar atypical chest pains that was
ultimately a neg workup , with ECHO 4/9 with diastolic dysfn EF 60-65% , no
WMA , mod MR , mod TR , stress test 8/13 with no changes c/with ischemia on EKG
or ECHO ( but non-diagnositic due to peak HR 64 BP 140/66 ). He was seen
by Dr Holtzberg at that time who felt that ACS/ischemia was unlikely , and
that symptoms may have been 2/2 CHF and MR ( and his ECHO also showed new
AI at that time ) , and patient was apparently started on ACE at that time for
afterload reduction. He is not on an ACE right now and it is unclear
why. Further with u of ischemia was suggested if the patient had persistent
symptoms but the symptoms seemed to have resolved by these notes.
In ED 97.8 55 176/64 18 98%RA. BNP 1196 , trop-I 0.10. d-dimer 272. Got
ASA . EKG sinus brady no ST/TW changes. D-dimer 272. CXR no obvious
acute cardiopulmonary changes.
------------------
PMH: htn , IDDM , HaA1C ( 7.3 in 9/24 ) CAD history of CABG 2003 , ESRD history of
transplant 11/1 , hyperparathyroidism , anemia , cataracts
------------------
ADMISSION MEDs:
Tacrolimus 2mg twice a day , cellcept 250 twice a day , pred 5mg daily , labetolol 600mg
twice a day , lasix 60mg daily , clonidine 0.3mg twice a day , amlodipine 10mg daily , flomax
0.4mg daily , famotidine 20mg twice a day , asa 81mg daily , NPH 24U every day before noon , 16U every afternoon +
humalog SS , colace , senna , MVI. hctz stopped 10/25 .
ALLERGIES: NKDA per patient ( Per records atenolol->bradycardia , fatigue )
------------------
FH: DM
SH: lives with wife in Ri Po Sey on 1st floor of 3 story complex , dtr lives
upstairs. 2-3 pack year smoking hx , quit 30 years ago. no alcohol or
IVDU.
----------------
ADMISSION PE:
VS T 97.8 HR 55 BP 176/64 RR 18 SpO2 98%RA Wt 164
Gen: lying flat on stretcher , breathing comfortably , NAD
HEENT: NC/AT , PERRL , anicteric , EOMI , MMM without exudates.
Neck: supple , NT , full ROM , 2+ carotid pulses without bruits , no LAD , murmur
heard over at L clavicle
Lungs: CTAB , no c/with r
CV: RR , S1 , S2 , ?S4 3/6 holosystolic blowing murmur at apex radiating to
axilla , 2/6 holosystolic murmur at LLSB , JVP 11cm
Abd: soft , NT/ND , nl BS , no HSM , no masses
Ext: with palpable AV fistula of left forearm. 2+ tender non-pitting
pedal edema b/l , cool feet , palpable DP/physical therapy pulses b/l
Skin: no rashes
Neuro: A and O x 3 , CN II through XII intact. Moving all extremities.
----------------
ADMISSION LABS AND STUDIES: notable for Cr 1.9 ( baseline ) , coags nl , LFTs
nl , TnI .10 ( CK 251 , MB 5.3 ) , BNP 1196 d-dimer 272 ( wnl ) , Hct 36.9
( baseline ). UA unremarkable.
4/9 ECHO EF 60-65% , mod MR , mod TR
8/13 stress test with no EKG/ECHO changes c/with ischemia but non-diagnostic
( peak HR 64 BP 140/66 )
4/11 cardiomegaly , ?vascular congestion with cephalization , formal
read no CHF
10/26 EKG sinus brady at 50 , LAD , LAE , LVH , nl int , non-spec Twchanges
( TWI 2 , 3 , aVl , V5 , V6 , unchaged from 9/8 )
----------------
IMPRESSION: 77yoM with hx htn , DM , CAD history of CABG 2003 , ESRD history of transplant
5/9 , p/with 2 weeks of increasing exertional SOB , pedal edema , and left
sided reproducible chest pain occ radiating across right side of chest to
back , pleuritic , exam notable for elevated JVP but no crackles , CXR not
obvious for congestion , labs notable for BNP 1196 , trop 0.1 , Ddimer neg.
Suspect CHF as cause of increasing SOB. Suspicion for ACS low given
previous neg with u with similar atypical chest pain presentation , at that
time also thought to be 2/2 CHF.
HOSPITAL COURSE:
--CV: I: history of CAD history of CABG , but suspicion for ischemia low. Ruled out by
enzymes and EKG x 3. Suspect elevated troponin 2/2 demand ischemia from
CHF. On ASA , BB. Not on statin , but lipid panel in 10/25 with LDL 87 and
total chol 166. Started on low dose ACE lisinopril 5mg. MIBI no
reversible changes. P: CHF , goal dry weight 158 lbs , admission weight 164
lbs. On Lasix 60mg daily at home. Diuresed , responded well to intravenous Lasix
60mg , with improvement in SOB and clinical exam , dc weight 160.5lbs. Will
send out on 60mg twice a day x 1 week and then back to 60mg daily. Concern that
worsening MR may be constributing to CHF and possibly flash in setting of
htn , but ECHO showed mid/mod MR not changed from 4/9 . Also with trace
AI , mild/mod TR , diastolic dysfunction with restrictive defect , EF 65% , no
WMA , PAP 58+RAP ( which has preogressive increased from previous ECHO
reports , was 41 in 4/9 ) , likely cor pulmonale from left sided heart
failure. MIBI did not show any reversible ishcemia. Was on labetalol
and norvasc for htn and BPs suboptimal in 160s -180s , previously on
captopril 37.5 three times a day but stopped secondary to hyperkalemia. started on low
dose lisinopril 5mg daily for afterload reduction especially in setting
of MR , will need to f/u K closely. patient tolerated 2 doses captopril ( 25
and 37.5 ) without hyperkalemia in hospital but on higher doses of lasix.
Imdur 30mg daily also added. patient also on clonidine. R: on tele , sinus
brady , asymptomatic , no other events.
--RESP: satting fine on room air with resolution of SOB after diuresis.
--GI: constipation , cont colace and senna. On pepcid given on
prednisone.
--RENAL: ESRD history of transplant 11/1 . cont tacrolimus , cellcept ,
prednisone. Tacrolimus levels nl. Followed by renal transplant team
who agreed with management of BPs above.
--HEME: anemia , Hct stable.
--ENDO: diabetes. Continued initially on home nph regimen with novolog
sliding scale. patient became hypoglycemic overnight both nights to the 40s
and to less than 20s ( the latter in the setting of not eating dinner ) ,
both around 3-4am. patient says that in the morning he is sometimes low and
sometimes high in 100s. Suspect this may be happening chronically with
possible rebound hyperglycemia in a.m. Will be sent home on decreased NPH
regimen at night 8U , resume a.m. dose 24U.
--FEN: 2L fluid restriction , low sodium/chol/fat/diabetic diet
--PPx: heparin , pepcid
FULL CODE
ADDITIONAL COMMENTS: We have changed the following medications: 1 NPH 24U in the morning and
8U in the evening , as your overnight sugars have been low 2. Take Lasix
60mg twice a day for one week and then go back to one time a day on 5/23
3. lisinopril and imdur have been added to help control your blood
pressure.
Please drink only 2L fluids daily and keep daily weights. Your weight
goal is 158 lbs , if your weight is over this or increases by more than
2-3 lbs , call Dr. Hazinski .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA: 1. monitor BP 2. monitor weights and CHF symptoms-dry weight 158lbs
3. fingersticks
MD: 1. monitor BP and K--started on lisinopril and imdur 2. goal dry
weight 158lbs 3. titrate insulin regimen--night nph decreased 2/2
persistent hypoglycemia o/n
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE KATE , M.D. ( ZE37 ) 3/22/05 @ 04:32 PM
****** END OF DISCHARGE ORDERS ******
Document id: 406
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
Y |
N |
N |
957249905 | PUO | 23035250 | | 6028155 | 10/4/2006 12:00:00 a.m. | ACS | Unsigned | DIS | Admission Date: 10/14/2006 Report Status: Unsigned
Discharge Date: 2/4/2006
ATTENDING: COLASAMTE , ISABELLE EVON MD
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Mr. Diesel is a 47-year-old gentleman with history of
hypertension , type II diabetes mellitus and dyslipidemia who
presented to the Emergency Department on 4/18/02 with
substernal chest pressure , and ST depressions in V4 and V6 after
undergoing a stress test. He was in his usual state of health
until 1 month prior to admission when he started noticing a
burning in his chest while walking to work. This progressed to a
point where the pain was present with minimal exertion such as
moving a chair. The burning was relieved by rest. He saw his
primary care physician two days prior to admission who started
him on Atenolol and Nitroglycerin spray. The patient underwent
cardiac catheterization on 3/28/06 , which revealed right
coronary artery with a mid 90% stenosis and an ostial 60%
stenosis , a ramus coronary artery with a proximal 90% stenosis ,
left anterior descending coronary artery with a proximal 70%
stenosis , left circumflex coronary artery with a mid 50%
stenosis , first diagonal coronary artery with a proximal 50%
stenosis and a right dominant circulation. Echocardiogram
performed on 3/25/06 revealed an ejection fraction of 60% , mild
mitral insufficiency , and mild tricuspid insufficiency.
PAST MEDICAL AND SURGICAL HISTORY:
Significant for hypertension , history of transient ischemic
attack with visual field cuts in the left eye that lasted
approximately 30 minutes , now completely resolved ,
non-insulin-dependent diabetes mellitus , dyslipidemia , asthma in
childhood , history of thyroid nodule , obstructive sleep apnea ,
status post bilateral inguinal hernia repairs and appendectomy.
ALLERGIES:
The patient is allergic to Compazine where he has a dystonic
reaction.
MEDICATIONS AT TIME OF ADMISSION:
Lopressor 25 mg four times a day , lisinopril 5 mg daily , aspirin 325 mg
daily , atorvastatin 80 mg daily , and intravenous heparin 1100
units per hour.
PHYSICAL EXAMINATION:
Height and weight , 61 inches and 92.70 kilograms. Temperature
97.2 , heart rate of 69 and regular , blood pressure in the right
arm 152/82 and blood pressure in the left arm is 156/85. O2
saturation is 97% on room air. Per Cardiac exam: Regular rate
and rhythm with no murmurs , rubs or heaves. Peripheral vascular:
2+ pulses bilaterally throughout. Respiratory: Breath sounds
clear bilaterally , is otherwise noncontributory.
ADMISSION LABS:
Sodium 136 , potassium 4.3 , chloride of 101 , CO2 29 , BUN of 17 ,
creatinine 1.2 , glucose 148 , magnesium 1.9. WBC 11.18 ,
hematocrit 43.8 , hemoglobin 14.7 , and platelets of 262 , 000. physical therapy
14.1 , physical therapy/INR 1.1 , and PTT of 119.2.
HOSPITAL COURSE:
Mr. Diesel was brought to the operating room on 7/12/06 where
he underwent an elective coronary artery bypass graft x5 with a
sequential graft right radial artery from the aorta to the right
coronary artery and then the first obtuse marginal coronary
artery and left internal mammary artery from the first diagonal
coronary artery and then the left anterior descending coronary
artery and a right radial graft to this left circumflex coronary
artery. Total bypass time was 200 minutes and total crossclamp
time was 145 minutes. The patient did well intraoperatively ,
came off bypass without incident. He was brought to the
Intensive Care Unit in normal sinus rhythm and stable condition.
Postoperatively , the patient did well. He was extubated and
transferred to the Step-Down Unit on postoperative day #2. He
initially had an inferolateral ST changes and a CK bump , which
did trend down at time of transfer to the Step-Down Unit. On
postoperative echocardiogram revealed an ejection fraction of 55%
with no regional wall motion abnormalities. He was also started
on Motrin every 6 hours for postoperative pericarditis and the patient ,
otherwise , had an unremarkable postoperative course and was
cleared for discharge to home on postoperative day #5.
DISCHARGE LABS:
Are as follows , sodium 138 , potassium 4.1 , chloride of 104 , CO2
30 , BUN of 18 , creatinine 0.9 , glucose 129 , and magnesium 1.9.
WBC 7.11 , hematocrit 30.4 , hemoglobin 10.2 , platelets of 225 , 000.
physical therapy 15.3 , physical therapy/INR of 1.2 , and PTT of 36.
DISCHARGE MEDICATIONS:
Are as follows , Lipitor 80 mg daily , captopril 12.5 mg three times a day ,
diltiazem 30 mg three times a day , enteric-coated aspirin 325 mg daily ,
Lasix 40 mg daily for three days , glipizide 5 mg twice a day at 8:00
a.m. and 5 p.m. , Dilaudid 2 mg every 4 hours as needed pain , Motrin 600 mg
every 6 hours for remaining five days , potassium chloride slow release
10 mEq daily for three days and Toprol-XL 100 mg every day. The
patient was also enrolled in a study with ID ranolazine 1000 mg
twice a day , which he will remain or continue taking for 4 month
postoperatively and follow up with the study group.
FOLLOW-UP APPOINTMENTS:
Mr. Diesel will follow up with Dr. Isabelle Colasamte in six weeks
and his cardiologist Dr. Cathie Reisman .
eScription document: 3-7741713 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 3795558
D: 10/28/06
T: 10/28/06
Document id: 407
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
543657704 | PUO | 52211961 | | 1667138 | 6/13/2005 12:00:00 a.m. | PERFORATED VISCOUS | Signed | DIS | Admission Date: 6/13/2005 Report Status: Signed
Discharge Date: 4/6/2006
Date of Admission: 6/13/2005
ATTENDING: WINZER , ELFRIEDA MD
ADDENDUM: This is a continuation addendum to a previously
dictated discharge summary actually dictated on 10/27/06 . This
dictation will review her hospital course from 10/27/06 through
10/6/06 .
ADMIT DIAGNOSIS:
Abdominal wound dehiscence.
PRIMARY DISCHARGE DIAGNOSIS:
Respiratory failure status post tracheostomy , wound dehiscence
with VAC sponge placement.
SECONDARY DISCHARGE DIAGNOSES:
Morbid obesity , obstructive sleep apnea , COPD - on home oxygen
and BiPAP , settings 15/10 , hypercholesterolemia , paroxysmal
atrial fibrillation , coronary artery disease - with echo dated
3/23/05 with EF of 65% and mild AS.
HISTORY OF PRESENT ILLNESS:
This is a 77-year-old female who was transferred originally from
an outside hospital for continued care after a fascial dehiscence
status post subtotal colectomy. She was originally admitted to
the outside hospital on 10/10/05 with abdominal pain. The CT
scan showed free air. She also had acute renal failure with a
creatinine of 1.8. She was taken to the operating room where she
underwent exploratory laparotomy and where she was found to have
a mid descending colonic perforation secondary to diverticulitis.
She underwent a partial left colectomy and end colostomy with
Hartmann's pouch. She was placed on clindamycin and levofloxacin
postoperatively. She was extubated on postoperative day #3. She
had persistent elevated white blood cell count for which they
changed antibiotics to Flagyl and fluconazole. A CT scan
revealed questionable dehiscence of her abdominal wound and a
binder was placed. She was subsequently found to be C. diff
positive. She was reintubated for respiratory distress on
postoperative day #7 along with decreased blood pressures and
increased white blood cell count. She was started on
hydrocortisone and pressors were also started. She was extubated
on postoperative day #13 and was started on orally meds
subsequently. She was started on her home BiPAP settings. She
is also started on diltiazem drip for her paroxysmal atrial
fibrillation. She was transferred over to the Pagham University Of for surgical intervention of her abdominal wound
dehiscence.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. COPD , on home O2 and BiPAP sittings 15/10.
3. Hypercholesterolemia.
4. Obstructive sleep apnea.
5. Paroxysmal atrial fibrillation.
6. Coronary artery disease - echo dated 3/23/05 with an EF of
65% and mild AS.
PAST SURGICAL HISTORY:
1. Total abdominal hysterectomy with BSO.
2. Exploratory laparotomy with left colectomy and end-colostomy
and Hartmann's pouch.
Please see the previously dictated discharge summary for the
remainder of her course up to date of 10/27/06 .
OPERATIONS AND PROCEDURES:
1. On 4/16/06 , tracheostomy.
2. On 2/18/06 , percutaneous endoscopic gastrostomy tube
insertion.
BRIEF HOSPITAL COURSE FROM 10/27/06 THROUGH 9/10/06:
Neuro: The patient was maintained on oxycodone per NG tube
initially and then per G-tube for analgesia. She also received
Seroquel for agitation and hallucinations. Upon discharge to
rehabilitation , the patient was alert and oriented , moves all
extremities and following commands. She had good pain control on
oxycodone elixir and Seroquel.
Cardiovascular: The patient remained hemodynamically stable
after her initial septic event. She remained in a normal sinus
rhythm for the remainder of her ICU course. She was maintained
on Lopressor 100 per per G-tube four times a day Her pressures tolerated
this dose.
Pulmonary: The patient continued on BiPAP failing each trial off
the BiPAP. She would become tachypneic and desaturate with
elevation of her pCO2 once off BiPAP. After several days off
BiPAP trials , the decision was made and discussed with the family
and the patient regarding her need for tracheostomy. It was
explained to her that tidal volumes were low and would drop off
BiPAP and that she would benefit from a tracheostomy placement.
The patient was consented and informed and taken to the operating
room on 4/16/06 where she underwent a tracheostomy. She
tolerated the procedure well. She was quickly weaned to pressure
support ventilation. She was maintained on minimal vent settings
for a couple of days postoperatively. She was eventually trach
collared , as she has been over the last three to four days. The
patient does tire out after two to three hours of trach collar ,
after which we placed her back to pressure support ventilation.
The patient has also had some mild bilateral pleural effusion on
chest x-ray that has not progressed and has been stable
throughout her course. The patient has a history of obstructive
sleep apnea and COPD at baseline. The patient received inhaler
and nebulizers standing and as needed She will need to continue her
trach collar trials most likely having more trach collar trials
at smaller intervals. The patient's current vent settings upon
discharge to rehabilitation are pressure support 5 and 10 , tidal
volumes 350-400 , breathing at a rate of 23 , and saturating 99% on
an FIO2 of 40%.
GI: Patient's abdomen remained stable with a VAC sponge. She
had her VAC sponge changed as needed twice a week with good
granulation tissue forming. There were no signs of infection.
Due to the patient's respiratory failure and need for
tracheostomy , patient also underwent a PEG placement on 2/18/06 .
She tolerated this procedure well. Medications were started on
the day of surgery and her tube feeds were resumed on
postoperative day #1 from her PEG. The patient is currently
receiving Two Cal formula tube feeds at a rate of 45 , which is
her goal rate. She should continue on that. The patient may be
changed to Jevity if she needs more fluid volume. The patient's
abdomen is soft , VAC sponge in place to suction and draining ,
ostomy is functioning well and viable with good output. The
patient should continue on a H2 blocker for a PPI while on the
vent.
GU: The patient is still somewhat fluid overloaded most likely
due to third spacing due to poor nutrition and
hyperprolactinemia. The patient was aggressively diuresed
throughout her stay with the Lasix drip , and albumin and albumin
and Lasix combination. Over the last few days prior to discharge
to rehab , the patient has responded to boluses of Lasix , actually
diuresing quite well and being negative 500 to a liter negative
daily. The patient's weight is actually down from admission.
The patient's urine output is approximately 80 to 100 mL an hour
after a 40 mg bolus of Lasix. The Lasix medication has been held
at this time due to increasing her sodium to 148 on the morning
of discharge. The patient will not be discharged on Lasix.
However , the patient may need a dose of Lasix at 20-40 mg if her
urine output drops off. Upon discharge , the patient has about 1+
edema bilaterally. The patient's electrolytes upon discharge are
sodium 148 , potassium 3.7 , chloride 96 , CO2 , and bicarbonate 40 ,
BUN 33 , creatinine 0.9 , glucose 128 , calcium 9.6 , and magnesium
1.7.
Heme: The patient remained stable from a Hematology standpoint.
Her hematocrit upon discharge was 32. The patient has normal
Coags , INR 1 and PTT 27.3. The patient was maintained on
subcutaneous three times a day for DVT prophylaxis in addition , to
Pneumoboots. The patient was also started on darbepoetin after
getting iron studies before poor nutrition. There is no signs of
active bleeding.
ID. After patient's sepsis , she remained relatively afebrile
throughout the rest of her stay. She was VRE positive , grew
Enterococcus from her ostomy. She had no new positive cultures
for the rest of her course. She was maintained off antibiotics
for the rest of her course.
Endocrine: The patient was maintained on tight glycemic control.
She is written for insulin sliding scale approximately every 6 hours in
addition , to a standing regular insulin 4 units every 6 hours plus
Lantus 15 units every bedtime The patient's sugars have still been
moderately elevated from about 130 to the 200's at times. Her
insulin sliding scale should be tightened.
Tube lines and drains: The patient has a trach , PEG , Foley , and
abdominal VAC sponge , and peripheral IVs.
CONSULTATIONS:
Diabetes Medicine , Nutrition.
COMPLICATIONS:
None.
DISCHARGE INSTRUCTIONS:
1. Diet: The patient should continue on Two Cal tube feeds at a
rate of 45 , which is her goal rate. The patient may switch to
Jevity 1.2 at goal rate of 45 if she needs more fluid volume or
if she is dehydrated.
2. Activity: The patient should be out of bed to chair as often
as possible. She should be trach collared as often as possible
as tolerated.
DISCHARGE MEDICATIONS:
1. Pepcid 20 mg per G-tube twice a day
2. Heparin 5000 units subcutaneous every 8 hours
3. Regular Insulin sliding scale subcutaneously every 6 hours If blood sugar is
less than 110 then give zero units , if blood sugar is 111-150
then give 4 units if his blood sugar is 151-200 , then give 6
units , if blood sugar is 201-250 , then give 7 units , if blood
sugar is 251-300 , then give 10 units , if blood sugar is 301-350 ,
then give 12 units , if blood sugar is 351-400 , then give 14 units
and call the doctor. If blood sugar is greater than 400 , then
call the doctor.
4. Regular insulin 4 units subcutaneous every 6 hours given in addition
to Lantus and sliding scale.
5. Lantus 15 units subcutaneously daily , please give 5 units , if npo
after midnight , please give this Lantus regardless of npo
6. Synthroid 100 mcg per G-tube once a day.
7. Lopressor 100 mcg mg orally four times a day hold for systolic blood
pressure less than 100 or heart rate less than 50.
8. Mycostatin orally suspension 5 mL orally four times a day
9. Flovent HFA 110 mcg inhaler twice a day
10. Xalatan one drop each eye every afternoon
11. Miconazole nitrate 2% powder topical twice a day
12. Seroquel 25 mg per G tube every day before noon
13. Seroquel 50 mg per G tube at bedtime.
14. DuoNeb 3/0.5 mg nebs every 6 hours
15. Aranesp 100 mcg subcutaneous every week.
16. XENADERM topical twice a day
17. Tylenol elixir 650 mg orally every 6 hours as needed
18. Benadryl 25 mg per G tube at bedtime as needed for insomnia.
19. Oxycodone 5-10 mg per her G-tube every 4 hours as needed pain.
20. Seroquel 25 mg per G tube every 6 hours as needed for agitation.
FOLLOW-UP APPOINTMENTS:
The patient will follow with Dr. Elfrieda Winzer within two to
four weeks for follow up of VAC sponge.
TO DO:
The patient will need VAC sponge changes every three to four
days. The patient uses a medium sized VAC sponge. Monitoring
for granulation and wound healing.
eScription document: 4-2749424 EMSSten Tel
CC: Elfrieda Winzer MD
Grandtonkan Na La
CC: Jackqueline Player M.D.
Dictated By: PLAYER , JACKQUELINE
Attending: WINZER , ELFRIEDA
Dictation ID 1155703
D: 10/6/06
T: 10/6/06
Document id: 408
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
- |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
236079949 | PUO | 88880714 | | 5372398 | 3/20/2007 12:00:00 a.m. | Cardiac Transplant vasculopathy | | DIS | Admission Date: 10/28/2007 Report Status:
Discharge Date: 2/13/2007
****** FINAL DISCHARGE ORDERS ******
SCHRAUB , AGUEDA 866-87-68-7
Ogo Vale Scorp
Service: CAR
DISCHARGE PATIENT ON: 3/10/07 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SERVICE , QUINN STEPANIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ENALAPRIL MALEATE 10 MG orally every day
2. FUROSEMIDE 40 MG orally every day
3. PREDNISONE 5 MG orally every day before noon
4. DILTIAZEM EXTENDED RELEASE ( 24 HR CAP ) 360 MG orally every day
5. CLOPIDOGREL 75 MG orally every day
6. KDUR 20 MEQ orally every day
7. RANITIDINE HCL 150 MG orally every day
8. ATORVASTATIN orally every day
9. CYCLOSPORINE MICRO ( NEORAL ) 25 MG orally twice a day
10. SIROLIMUS 1 MG orally every day
MEDICATIONS ON DISCHARGE:
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 7/25/07 by GIRARDI , ABE E T. , M.D.
on order for CYCLOSPORINE ( SANDIMMUNE ) orally ( ref #
137029204 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
CYCLOSPORINE Reason for override: followed
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
CYCLOSPORINE ( SANDIMMUNE ) 25 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Alert overridden: Override added on 7/25/07 by
GIRARDI , ABE E. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
CYCLOSPORINE Reason for override: followed
DILTIAZEM EXTENDED RELEASE ( 24 HR CAP ) 360 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 7/25/07 by GIRARDI , ABE E T. , M.D. on order for SIROLIMUS orally ( ref # 160035291 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & SIROLIMUS
Reason for override: tolerates. will monitor
ENALAPRIL MALEATE 10 MG orally DAILY
Override Notice: Override added on 3/10/07 by
KEARS , JAYE A. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
343182804 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: MD aware
Previous override information:
Override added on 3/10/07 by KEARS , JAYE A. , M.D.
on order for POTASSIUM CHLORIDE SLOW REL. TAB orally ( ref
# 291094784 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: MD aware
LASIX ( FUROSEMIDE ) 80 MG orally DAILY
Starting Today ( 5/2 ) HOLD IF: SBP<95
Instructions: For the next 5 days , then discuss dose with
the transplant nurses
POTASSIUM CHLORIDE SLOW REL. TAB ( KCL SLOW RE... )
20 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 3/10/07 by
KEARS , JAYE A. , M.D.
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: MD aware
PREDNISONE 5 MG orally every day before noon
ZANTAC ( RANITIDINE HCL ) 150 MG orally DAILY
Starting Today ( 5/2 )
SIROLIMUS 1 MG orally DAILY
Alert overridden: Override added on 7/25/07 by
GIRARDI , ABE E. , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & SIROLIMUS
Reason for override: tolerates. will monitor
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Cardiac Transplant Team- they will call you to schedule appointment ,
Dr. Evanosky 10/1/07 @ 10:50AM ,
ALLERGY: METOPROLOL TARTRATE
ADMIT DIAGNOSIS:
Nausea/Vomiting/Diarrhea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Cardiac Transplant vasculopathy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , High cholesterol , history of MI x 4 history of CABG 26 of August pulmonary nodule
( pulmonary nodule )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Dobutamine Stress Echo 6/18/07
Right heart catheterization and biopsy 4/8/07
BRIEF RESUME OF HOSPITAL COURSE:
CC: N/V/D
-----
HPI:
62M history of ischemic cardiomyopathy history of cardiac transplant in October 2000
c/b allograft CAD , DM , HTN. He has been doing well in his USOH until he
developed nausea and vomiting 2 days prior to admission. No unusual
foods , no sick contacts. He had some "discomfort" in his stomach on
Monday that seemed to get better briefly before he developed diarrhea and
vomiting. The following day he felt weak , didn't get out of bed and had
watery non-bloody diarrhea with ~ 10 BMs throughout the day , and NBNB
emesis. On a.m. of admission he still felt poorly and came to the ED. Poor
orally intake. He has had no orthopnea , PND , lower extremity edema and denies
palpitations , lightheadedness , or syncope. His review of systems is
negative in detail with no recent history of fever , chills , nausea , or
neurologic symptoms.
In the ED he received a bolus on NS 500cc and has felt better without any
N/V/D and feels like "he could lift a cow". He had cardiac enzymes sent
which revealed a TnI of 0.06 and 2nd set 0.09. He is admitted to trend
his cardiac enzymes and for Dobutamine stress test in the morning.
-----
PMH: HTN , hyperlipidemia , pretransplant CAD , allograft coronary
disease
------
MEDS: Plavix 75mg daily
Diltiazem ER 360mg daily
Enalapril 10mg daily
Lipitor 80mg daily
Lasix 40mg daily
K-Dur 20meq daily
Prednisone 5mg daily
Sirolimus 1mg daily
Cyclosporine 25mg twice a day
Zantac 150mg daily
------
ALL: Metoprolol--> hypotension/arrest
-----
STATUS: VS 100.2 110 130/90 20 97%
RA nad , perrl , mmm , jvp flat , rrr no m/r/g , ctab , abd
soft nt , no c/c/e. a+ox3 , non-focal neuro.
---------
TESTS: UA: 1.024 , 1+ ket -LE/-NIT
CXR: bandlike opacity with pleural thickening on R base. else -ve.
Echo 5/7 55% EF no wma
Prior Stress Echo: -ve
Dobutamine stress echo 3/5 unchanged from prior , no WMA
-----------
HOSPITAL COURSE BY PROBLEM:
#N/V/DIARRHEA: likely viral gastroenteritis given quick resolution , no
further n/v/d , made no stool to send for stool studies.
#CV-i: severe allograft vasculopathy , suspect demand ischemia given
tachycardia and HTN on admission vs rejection. Continued plavix , ccb ,
acei , statin. not on ASA. Trended enzymes; CK and MB remained flat , TnI
peaked at 0.13. He had a repeat dobutamine stress echo without evidence
of ischemia , no WMA.
#CV-p: volume down 2/2 vomiting and diarrhea. Held lasix o/n. Gentle
hydration with IVF overnight. cont home antihypertensives. RHC revealed
elevated left heart filling pressures ( PCWP 24 ) therefore will double his
lasix dose on discharge to 80mg daily and he will discuss with transplant
nurses next week resuming the prior dose.
#CV-r/r: sinus tachy likely 2/2 hypovolemia , gentle IVFs , on ccb
#CARDIAC TRANSPLANT: continuted home immunosuppressive meds ( prednisone ,
sirolimus , cyclosporin ). Sirolimus level elevated at 38 ( ? true trough ).
He had a RHC and biopsy on 4/5 , final path pending at discharge
# ENDO: was on glipizide recently d/c 2/2 low blood sugars. HgA1c
elevated at 9.2 , but blood glucose < 130 throughtout admission.
#PPx: lovenox , h2 blocker
#FULL CODE
ADDITIONAL COMMENTS: You were admitted to the hospital because of your nausea , vomiting and
diarrhea and were found to have abnormalities some of the enzymes
released from your heart; you had a repeat Stress Echo which showed no
change from the one done in October . You will get the results of your
biopsy next week.
Please call your doctor or return to the Emergency Department if you have
any discomfort in the chest , more nausea , vomiting or diarrhea ,
lightheadedness/dizziness , fatigue , difficulty breathing , fevers/chills
or any other symptoms concerning to you. You should continue taking all
of your medications as before except for Lasix , take a double dose until
you speak with the transplant nurses next week.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please monitor Cyclosporine and Sirolimus levels
No dictated summary
ENTERED BY: KEARS , JAYE A. , M.D. ( XM55 ) 3/10/07 @ 02:59 PM
****** END OF DISCHARGE ORDERS ******
Document id: 409
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
Y |
Y |
U |
Y |
N |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
Y |
Y |
N |
Y |
- |
N |
Y |
N |
Y |
N |
N |
N |
N |
031757986 | PUO | 16238834 | | 9911955 | 4/10/2004 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION | Signed | DIS | Admission Date: 2/10/2004 Report Status: Signed
Discharge Date: 6/23/2004
ATTENDING: MARCELINA STRAUHAL MD
The patient is a 60-year-old woman with a history of chronic
obstructive pulmonary disease with the last FEV1 of 0.42 ,
congestive heart failure with ejection fraction of approximately
40% , who was transferred from Toalemraanne Hermwill General Hospital for continued
treatment for worsening shortness of breath. The patient reports
that one week prior to her admission to the Toalemraanne Hermwill General Hospital ,
two days before transfer to the Pagham University Of , the
patient felt more dyspneic on exertion. She noted that she is
having a hard time even getting to the bathroom. Ordinarily , at
home , her baseline using 1.5 liters of oxygen at rest , but able
to get around the house and upstairs. She went to Toalemraanne Hermwill General Hospital on Sunday. She reports that she had a dry cough without
any sputum production. No fever or chills. No sick contacts.
No hemoptysis. No runny nose or sore throat. This is different
from her usual COPD excerebration , in which it is no longer
proceeded by symptoms of an upper respiratory tract infection.
In addition , the history reveals that the patient usually uses
two pillows to sleep , but recently had been using two pillows
folded and felt short of breath if she lay down more than that.
She would wakeup in the middle of the night when she was short of
breath , but there was no change in that symptom over the previous
months.
REVIEW OF SYSTEMS: The patient has gained 15 pounds in one year
prior to admission. She believes that it was due to previous
steroid use. She also notes that she had some diarrhea that was
"like pudding" 1-3 times per day. Not watery , not bloody , and
not black. No recent antibiotic use.
ALLERGIES: The patient has an allergy to aminophyllin. She has
hypotension and arrhythmias from that. She has a reaction to
beta-blockers in which she has worsening breathing.
PAST MEDICAL HISTORY:
1. COPD in August , 2004. The patient had a FEV1 of 0.42 and
FVC of 1.95.
2. Congestive heart failure , April 2003. An echocardiogram
showed a left ventricular ejection fraction of 40% , inferior
hypokinesis. The ventricle is normal. There is mild aortic
insufficiency , mild mitral regurgitation , normal atria , and
normal tricuspid valve.
3. Cerebrovascular accident.
4. Type II diabetes when she takes steroids.
5. Hypertension.
6. Osteoarthritis.
7. Gastroesophageal reflux disease.
8. Depression and anxiety.
MEDICATIONS: On admission ,
1. Advair 250/50 mg.
2. Albuterol.
3. Atacand 4 mg each day.
4. Celexa 60 mg each day.
5. Clonazepam 0.5 mg two times a day.
6. Coumadin 2.5 mg on Monday and Sunday , and 5 mg on other days.
7. Enteric-coated aspirin 81 mg a day.
8. Folate 1 mg a day.
9. Fosamax 70 mg per week.
10. Lasix 40-60 mg each morning , which the patient had not been
taking because it made her pee too much.
11. Atrovent inhaler.
12. Ritalin 5 mg every morning and at lunch , although she does
not feel that it was benefiting her.
13. Prilosec 20 mg a day.
14. Probenecid 250 mg two times a day.
15. Tylenol No.3 every 6 hours as needed.
16. Vioxx 25 mg each day.
17. Home oxygen 1.5 liters at rest.
PHYSICAL EXAMINATION: Vital signs: Temperature was 96.4 degrees
Fahrenheit , heart rate was 120 and regular , blood pressure was
142/60 , respiratory rate was 24 , and sating 95% on 2 liters of
nasal cannula. General: The patient was talking 2-3 words at a
time. She cannot speak in full sentences. She is using
accessory muscles for breathing. Her jugular venous pressure was
elevated , but with significant respiratory phasic variation. The
patient's hand veins also revealed an increased venous pressure.
The patient had no pallor and no jaundice. Her extraocular
motions were intact. Her pupils were equal and reactive to
light. The patient's oropharynx revealed thrush on the tongue.
Chest exam: There were decreased breath sounds. They were soft
and expiratory wheezes at the bases. No crackles and no rhonchi.
Cardiovascularly , the rhythm was regular , tachycardiac , with a
1-2/6 systolic murmur at the apex. The abdomen was soft , ,
nontender , and nondistended. There were bowel sounds.
Extremities: There was no edema , nontender. Symmetric
extremities. No clubbing.
SOCIAL HISTORY: The patient lives with her husband of 43 years.
They have no children. The patient has not used tobacco since
1984. She has occasional alcohol use. She notes that she drinks
one drink every month approximately.
At the outside hospital the patient's labs were as follows. Her
white count was 12 with 75% neutrophils , 3 eosinophils , and 6-12
bands forms. Hematocrit was 45. Her platelet count was 290 , 000.
Her PTT was 42. Her INR was 2.2. Her Chem-7 and her sodium was
139. Her potassium was 4.5. Her chloride 101 and bicarbonate
was 31 and BUN was 20. Her creatine was 1.1. Her glucose was
118. Her total protein was 7.7 with an albumin of 4.2 , AST of
29 , ALT of 43 , and alkaline phosphatase of 104. Total bilirubin
is 0.3. Her pH was 7.38 with the carbon dioxide of 54 and an
oxygen of 37 on 20% FiO2 , which is ambient air. This was noted
to be an arterial blood gas. Her EKG showed sinus tachycardia at
120 beats per minutes. QRS width was approximately 120
milliseconds in a left bundle branch pattern with normal axis.
No left ventricular hypertrophy by voltage. She had 1-2 mm
ST-depression in 2 , 3 and AVF with T-wave inversions in those
leads , also T-wave inversions with 1 mm ST depression in V5 and
V6. The only change from the January , 2004 , EKG is that of
T-wave inversion in V5 , otherwise stable.
IMPRESSION: At the time of admission , the patient was thought to
be a 60-year-old woman with severe COPD and CHF , who presented
with worsening shortness of breath consistent with a COPD
excerebration. However , this was unlike many of her previous
exacerbations in that she did not experience any upper
respiratory tract infection , and in addition , her jugular venous
pressure was elevated , so it was considered that she might be
having a congestive heart failure exacerbation , as well.
1. Pulmonary: The patient was treated for COPD exacerbation ,
with prednisone 60 mg by mouth each morning , Atrovent and
albuterol nebulizers every 4 hours and albuterol and Atrovent nebulizers
as needed. She was also continued on levofloxacin. Initially ,
the patient received 500 mg of levofloxacin a day. As her renal
function worsened that was changed to 150 mg a day and when her
renal function improved again her levofloxacin was once again
increased to 500 mg a day. This should be continued for a 10-day
course. There is little concern for pulmonary embolism , given
the patient's elevated INR. However , she did have a decreased O2
saturation and her CO2 was not very elevated at the outside
hospital. A D-dimer was sent which was less than 200 , which is
negative , suggestive very highly for a pulmonary embolism. The
patient's pulmonary status improved throughout her stay , and by
May , 2004 , she was sating in the 90% range on 2 liters nasal
cannula , almost at baseline. It was thought by the physical
therapy that the patient would benefit from further pulmonary
rehabilitation. As this dictation is being done , the plan is for
her either to go to pulmonary rehabilitation or to stay at the
hospital until she is fully ready and safe to go home , and is not
at an increased fall risk given her severe osteoporosis.
2. Cardiovascular:
A. Pump: Initially , the patient was thought to possibly be
volume overloaded given the fact that she was not taking her
Lasix and that her JVP appeared elevated. In addition , there was
some question whether she might has been having increasing
paroxysmal nocturnal dyspnea or at least orthopnea. She was
initially diuresed aggressively with 60 mg of intravenous Lasix , two
times. However , lab results suggested that congestive heart
failure was not a large part of her presentation. First , the
brain natriuretic peptide that was sent , showed a value of
proximally 134 , which is approximately a baseline of 141 ,
suggesting that she was not having an acute exacerbation of her
heart failure. In addition , the patient's creatinine increased
from her outside hospital value of 1.0. When it was first
checked at 1:00 in the morning on January , 2004 , at Pagham University Of , it was 1.7. She received her two doses of
Lasix , one on the night of November , 2004 , and then again in the
morning of January , 2004. Her creatinine in the afternoon of March , 2004 , increased to 2.2. Urine electrolytes were sent and the
acute renal failure workup will be discussed below under the
renal section. In terms of her heart failure , the patient was
given intravenous fluids and did not have any further symptoms of heart
failure. Her normal dose of 40 mg of Lasix orally every morning
was restarted on September , 2004 , and she will be continued on that
dose.
B. Rhythm: The patient was monitored on telemetry and after her
sinus tachycardia her heart rate came down as her hyperoxemia
improved and she had no further issues.
C. Ischemia: The patient was continued on aspirin HMG-COA
reductase inhibitor. She was continued on her folic acid , as
well. She was not put on a beta-blocker given her bronchospastic
response to that , but she was continued on her angiotensin
receptor blocker after her acute renal failure resolved.
3. Renal: The patient was admitted with a creatinine of 1.0
from the outside hospital and 1.71 when she first presented. Her
baseline is in the low 1's; 1.0-1.5 as her baseline. The peak
creatinine during her stay was January , 2004 , at 5:00 p.m. and it
was 2.2. Her BUN at that time was 55. Urine electrolytes were
sent , which showed a urine sodium of 39 , and creatinine of 137 ,
and that was only 12 hours after the patient got her last dose of
Lasix. It was felt that the patient had prerenal azotemia and
was given intravenous fluids. Her creatinine improved , and on May ,
2004 , the patient's creatinine was 1.3 , approximately her
baseline. Her BUN at that time was 30 , increased from 23 on April , 2004. The patient will be monitored as an outpatient to make
sure that her Lasix dose is not too high.
4. Musculoskeletal: The patient's creatine kinase was elevated
on admission to 574. It was rechecked on April , 2004 , and it
was 1967. It was felt that this was due to two factors.
Increased release from the muscle , as the patient's MB-fraction
was only 33.5 , which was less than 5% and the troponin was
negative. So this was felt to be due to her increased work of
breathing and release from the muscle and exacerbated by her
acute renal failure and retention of the creatine kinase. Her
creatine kinase decreased by July , 2004 , to 1195. Therefore ,
it was not felt that the patient had rhabdomyolysis causing renal
failure , but rather renal failure causing retention of creatine
kinase disease from increased work of breathing.
5. Hematology: The patient was continued on her Coumadin. The
patient's INR throughout her stay remained therapeutic between
2.4 and 2.6. On May , 2004 , it was 2.5. She was continued on
her home dose. The patient's white blood cell count was elevated
at admission at the outside hospital with a left shift. She was
started on levofloxacin and steroids. Therefore , it is difficult
to interpret her white count deferential. Her white count
remained elevated between 15 and 20 throughout her stay. Her
neutrophil count remained between 70 and 78% of that. A
urinalysis was sent , which did not suggest that the patient had a
urinary tract infection.
6. The patient's TSH was 0.46 with a normal T4 of 7.8. She will
be followed up as an outpatient , as this may represent
subclinical hyperthyroidism. In addition to her thyroid , the
patient's osteoporosis was continued to be treated with calcium
carbonate , vitamin D , and Fosamax during her stay.
7. Rheumatology: The patient was continued on her probenecid
250 mg two times a day. She has no symptoms of gout.
8. Psychiatry: The patient was continued on her clonazepam and
Celexa. She was not continued on Ritalin and will not be
discharged on her Ritalin given her tachycardia. In addition ,
the patient did not feel that the Ritalin was helping her.
9. Pain. The patient's Vioxx was discontinued because of her
renal issues. This will also not be one of her discharge
medications and it should be reassessed by her primary care
doctor. The benefits may outweigh the risks , but this should be
up to Dr. Blomstrom , who has a long-term relationship with the
patient.
10. Infectious disease: The patient had blood cultures sent ,
which were negative. At admission , in addition , her urinalysis
showed many red blood cells. It did have some white blood cells
and leucocyte esterase. This is most likely just because the
patient had bleeding , secondary to her Foley catheter.
DISCHARGE MEDICATIONS: Please use the patient's discharge sheet
for discharge medications.
eScription document: 6-9660402 EMSSten Tel
Dictated By: SUGIMOTO , ARDELL
Attending: STRAUHAL , MARCELINA
Dictation ID 7078869
D: 1/9/04
T: 1/9/04
Document id: 410
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976882156 | PUO | 28389678 | | 8948772 | 6/17/2006 12:00:00 a.m. | polymyositis | | DIS | Admission Date: 11/19/2006 Report Status:
Discharge Date: 5/14/2006
****** FINAL DISCHARGE ORDERS ******
EDSALL , RAQUEL 067-72-87-9
Ville
Service: CAR
DISCHARGE PATIENT ON: 5/17/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CASEBOLT , MOHAMMAD K. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
TIAZAC ( DILTIAZEM EXTENDED RELEASE )
120 MG orally every bedtime BEDTIME HOLD IF: SBP<90 , HR<50
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 5/27/06 by
LENEAVE , JETTA S , M.D.
POTENTIALLY SERIOUS INTERACTION: LABETALOL HCL & DILTIAZEM
HCL Reason for override: will monitor
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 90 MG orally BEDTIME
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LABETALOL HCL 200 MG orally twice a day HOLD IF: SBP<90 , HR<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 5/27/06 by
LENEAVE , JETTA S , M.D.
on order for TIAZAC orally ( ref # 193038607 )
POTENTIALLY SERIOUS INTERACTION: LABETALOL HCL & DILTIAZEM
HCL Reason for override: will monitor
Previous override information:
Override added on 5/27/06 by LENEAVE , JETTA S , M.D.
on order for DILTIAZEM orally ( ref # 403329723 )
POTENTIALLY SERIOUS INTERACTION: LABETALOL HCL & DILTIAZEM
HCL Reason for override: WILL MONITOR
ATIVAN ( LORAZEPAM ) 0.5-1 MG orally every 6 hours as needed Anxiety
MEDROL ( METHYLPREDNISOLONE orally ) 24 MG orally three times a day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain
THIAMINE HCL 100 MG orally DAILY
BACTRIM DS ( TRIMETHOPRIM/SULFAMETHOXAZOLE DOU... )
1 TAB orally twice a day Starting Today ( 10/11 )
Instructions: QMonday , Wednesday , Friday
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Lucy Lobbins in rheumatology 6/16/06 at 11AM scheduled ,
Dr Eusebia Fredley in cardiology 11/7/06 at 4:30 scheduled ,
Dr Genny Barrette , your new primary care physician 1/18/06 at 2:50 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
polymyositis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension , rheumatic valvular disease , polysubstance abuse -
cocaine/alcohol
OPERATIONS AND PROCEDURES:
Cardiac catheterization
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: weakness , chest pain
***
HPI: Mr Edsall is a 65 year old with a past medical history of
hypertension , cocaine/EtOH abuse , rheumatic heart disease with AI/MR , who
presents with chest pain from rehab 12 hours after discharge from 9 day
admission. His chest pain is identical to prior episodes occurring during
his previous admission. He originally presented with 2-3 weeks of
generalized weakness with intermittent chest pain and was diagnosed with
severe polymyositis ( CK up to 33 , 000 ) during last admission. He was given
IVF+bicarb for renal protection from myoglobinuria and became volume
overloaded , with successful diuresis to euvolemia by the time of
discharge. He had intermittent CP occurring at night , described as
nonradiating over left chest associated with SOB. He had persistently
elevated troponin with no ischemic changes on EKG , and his CP was felt to
be due to myocarditis. He was treated with ASA , labetalol , isordil ,
CCB , and ativan with improvement. He was started on intravenous solumedrol
with immediate significant improvement in CK ( down to 10 , 000 ) and
troponin ( 0.64 ). During his 12 hour stay at rehab , he developed CP
with SOB occurring at night. He was then readmitted to PUO for cardiac
catheterization and further care.
****
PMH: cocaine , EtOH abuse ( history of ativan taper last admission ) , HTN ,
colonic tubular adenoma , MS , AI
****
Pre-admission Medication List for EDSALL , RAQUEL 28389678 ( PUO ) 66 1.
ACETYLSALICYLIC ACID orally 325 MG every day
2. ALENDRONATE ( FOSAMAX ) orally 70 MG QWEEK
Give on an empty stomach ( give 1hr before or 2hr after food ) Take with
8 oz of plain water
3. CALCIUM CARBONATE 1500 MG ( 600 MG ELEM CA )/ VIT D 200 IU ( CALTRATE + D ) orally
1 TAB every day
4. DILTIAZEM EXTENDED RELEASE ( TIAZAC ) orally 120 MG every day
Avoid grapefruit unless MD instructs otherwise.
5. DOCUSATE SODIUM ( COLACE ) orally 100 MG twice a day
6. ESOMEPRAZOLE ( NEXIUM ) orally 20 MG every day
7. FOLIC ACID ( FOLATE ) orally 1 MG every day
8. FUROSEMIDE ( LASIX ) orally 120 MG every day
9. ISOSORBIDE MONONITRATE ( SR ) ( IMDUR ER ) orally 30 MG every day
Give on an empty stomach ( give 1hr before or 2hr after food )
10. LABETALOL HCL orally 200 MG twice a day
Hold if HR<60 , SBP<100
Take consistently with meals or on empty stomach.
11. LORAZEPAM ( ATIVAN ) orally 0.5-1 MG every 6 hours as needed: Anxiety
12. PREDNISONE orally 60 MG every day before noon
13. THERAPEUTIC MULTIVITAMINS ( MULTIVITAMIN THERAPEUTIC ) orally 1 TAB every day
14. THIAMINE HCL orally 100 MG every day
15. TRIMETHOPRIM/SULFAMETHOXAZOLE DOUBLE STRENGTH ( BACTRIM DS ) orally 1 TAB every day
***
PATIENT STATUS: Afeb , 72 , 118/52 , 18 , 100%RA NAD , glass eye on left , JVP 9 ,
CTAB , RRR III/VI SEM rad to carotids , intravenous/VI SM at apex , II/VI DM at apex ,
inaudible S2 , right groin site C/D/I no hematoma or pulsatile mass , 2+
distal pulses , multiple scars on body from prior trauma.
Studies: 7/13/06: ECHO - EF 70-75% , mitral rheumatic stenosis
with MR , AS , AI , mild TR , PR.
6/15/06: Biopsy - vasculitis , necrosis
6/15/06: CT head , chest , abd/pel: pleural effusions , no abd process
9/17/06: CXR - pulm edema.
11/7/06: Cardiac cath- nonobstructive CAD , no intervention
6/16 KUB - no free air , nl bowel gas pattern , b/l pleural effusions ,
retrocardiac air bronchograms- likely just atelectasis but can't r/o pna.
10/27 PE CT: Small bilateral pleural effusions , no PE.
****
HOSPITAL COURSE BY PROBLEM:
1. Chest pain and shortness of breath. He was re-admitted for nocturnal
chest pain while at rehab , and concern for myocardial ischemia. He
underwent cardiac catheterization that showed normal coronary anatomy ,
suggesting that the elevated CK-MB and troponin were likely from
myocarditis , as previously suspected. Notably , his chest pain was often
associated with shortness of breath. It was noted on his prior admission
that he had pleural effusions from the high volume diuresis intended to
protect his kidneys from myoglobin toxicity , however he had been diuresing
well to lasix. It was thought that his CP and SOB might be due to PND given
his valvular disease. Consequently , his vasoldilatory medications were
switched to evening dosing , his lasix dose increased , and the head of bed
kept elevated at greater than thirty degrees. On the day after admission , he
had one episode of chest pain with shortness of breath , where he indicated
pain in his RUQ. A KUB was negative , as was a PE protocol CT , and he
responded very well to lasix. He had one further episode of SOB at night ,
again responsive to lasix and position. He had a repeat echo that showed
no progression of his valvular disease from prior admission and equivalent
EF of 70-75%. He was maintained on aspirin , labetalol , diltiazem , imdur , and
ativan as needed
2. Arrhythmias. He was on rate control with calcium channel blockers.
He had several noctural few beat runs of NSVT , but no other significant
events.
3. Rhabdo: He has severe polymyositis causing muscle weakness and elevated
CK , with possible contribution from cocaine. So far , the remaining work up
has been negative. Preliminary biopx sy shows muscle necrosis and
chronic inflammation along with features reminiscent of dermatomyositis. He
was changed back to intravenous solumedrol on admission , and switched to orally solumedrol
on discharge. His CK dropped from 15 , 000 on this admission to 10 , 000 , and
then hovered around that dose. Rheumatology Consult Fellow Lucy Lobbins felt
this was a normal pattern under treatment , and that the true extent of
recovery/impairment will only be known in several weeks to months.
diagnosis.
4. Renal. His Cr was maintained at 1.3-1.5 over the course of his admission ,
likely related to both renal damage from myoglobinuria and possibly from
over-diureses and pre-renal phsyiology , especially in the context of BUN of
42. His lasix dose , initially increased on admission due to excellent
symptomatic response with diuresis , was in the process of slow tapering at
the time of discharge in attempt to identify the appropriate outpatient
dosing , with goal of maximizing symptomatic resopnse and minimizing prerenal
physiology.
5. FULL CODE
ADDITIONAL COMMENTS: Mr Wasmus You were admitted for chest pain , and it was determined by
looking at the anatomy of the vessels supplying your heart that you have
not had a heart attack caused by diminished blood flow to the heart. You
do , however , have an inflammatory condition in which your immune system
attacks and breaks down your muscle. As you know , the recovery process
will be long , and you will need to take medication for it for at least
four to eight weeks. Your rheumatologist , Dr Krinsky , will coordinate your
medication and care. You have an appointment with her in two weeks.
Also , you have disease afflicting the valves of your heart , and you will
need to see a cardiologist. You have an appointment with Dr Fredley for this
issue. In addition , you have an appointment with your new primary care
physician , Dr Killion . Please attend all of these appointments , and be
sure to take all your medications as prescribed. Lastly , it cannot be
emphasized enough that your health depends on the care you take of
yourself , making sure to stop smoking , stop drinking alcohol , and stop
taking any illicit drugs.
Please seek medical attention for difficulty breathing , worsening
weakness , black or bloody stools , or any other concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Myositis. Please follow CK , may need additional agent in the long term.
Per Rheumatology , response may take weeks.
2. Chest pain. His pain is NOT of ischemic origin. He does have rheumatic
heart disease , and appears to have PND with pain and shortness of breath
that is responsive to lasix , position , and oxygen.
3. Lasix dosing. He will need to be tapered on lasix , with attempt to
identify the proper dose for symptomatic relief while not making him
pre-renal.
No dictated summary
ENTERED BY: GOLDFEDER , MAXINE H. , M.D. ( VK81 ) 5/17/06 @ 01:07 PM
****** END OF DISCHARGE ORDERS ******
Document id: 411
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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682582454 | PUO | 74601423 | | 809369 | 3/8/2001 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 1/9/2001 Report Status: Signed
Discharge Date: 5/2/2001
CHIEF COMPLAINT: DYSPNEA ON EXERTION AND LOWER EXTREMITY SWELLING.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male with
history of diabetes and ischemic
cardiomyopathy who presents on 11/26/01 with increased shortness of
breath and fatigue. His cardiac history began in 1980 , when he
suffered from an myocardial infarction and had a second myocardial
infarction in 1986. He had a 3 vessel coronary artery bypass graft
in 1987 with a LIMA-left anterior descending , saphenous vein graft
to OM and saphenous vein graft to the PDA. The patient developed
decreasing functional status postoperatively and recent
echocardiogram showed an ejection fraction of 15%.
In October 2000 , Mr. Rinaldo was admitted to the Pagham University Of with chief complaint of dyspnea on exertion and
fatigue. Cardiac catheterization at that time showed native 3
vessel disease with occlusion of his venous graft to his obtuse
marginal and posterior descending arteries. On that admission , Mr.
Rinaldo was aggressively diuresed and post discharge , he was able to
complete his normal activities of daily living with no shortness of
breath or chest pain. Over the several months prior to admission ,
however , Mr. Rinaldo noted progressive worsening of shortness of
breath , dyspnea on exertion and fatigue , such that , on the day of
admission , he reported that he could not walk from his driveway to
his house without symptoms. He reported no baseline orthopnea , but
states he does have paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY: Significant for coronary artery disease ,
history of gallstones , hypothyroidism ,
nephrolithiasis , cirrhosis and diabetes mellitus.
PAST SURGICAL HISTORY: Significant only for the coronary artery
bypass graft in 1987.
FAMILY HISTORY: His father died of an myocardial infarction in his
50s. His mother also died of an myocardial
infarction in her 70s.
MEDICATIONS ON ADMISSION: 1. Captopril 37.5 three times a day 2. Isordil
30 three times a day 3. Digoxin .125 every day. 4.
Synthroid .25 every day. 5. Lipitor 20 every day. 6. Torsemide 80
twice a day 7. Coumadin 4 mg Monday/Wednesday/Friday , 5 mg other days.
8. NPH 40 units twice a day
PHYSICAL EXAMINATION: On admission , temperature 97 , pulse 69 ,
blood pressure 100/70 , respiratory rate 16 ,
satting 92% on room air. Neck examination revealed jugular venous
pressure , elevated behind the ear and approximately 27 mm with
positive hepatojugular reflux. The lungs were clear to
auscultation bilaterally. Cardiovascular examination revealed
regular rate and rhythm with frequent ectopy , positive S3 and PMI
in the midaxillary line. Abdomen was benign. Extremities showed
no lower extremity edema with 1+ distal pulses and warm to the
touch.
LABORATORY DATA: Significant for a sodium of 146 , BUN 16 ,
creatinine 1.3 , hematocrit 36 , INR 1.4.
EKG showed normal sinus rhythm at 67 with left axis deviation ,
right bundle branch block and Q-waves in leads 2 , 3 and AVF.
Chest x-ray revealed no pulmonary edema.
HOSPITAL COURSE: The patient was admitted to the cardiology Au Ri
service for diuresis and possible inotrope
support. He was diuresed over the course of 10 days using
Torsemide 80 mg intravenous three times a day and his Captopril was gradually increased
as tolerated to a maximum dose of 75 mg three times a day The patient
diuresed without difficulty and by the time of discharge , he had
weighed a dry weight of approximately 96 kilograms.
The patient was also evaluated for possible heart transplant.
Work-up was extensive and included an echocardiogram on 11/20/01 ,
which showed an ejection fraction of 15-20% with global hypokinesis
and akinesis of the inferior septal walls with moderate mitral
regurgitation and moderate tricuspid regurgitation. Abdominal
ultrasound on 11/20/01 , revealed probable cardiac cirrhosis. A
liver spleen scan on 10/1/01 , was consistent with mild cardiac
cirrhosis , as was an MRI of the liver on 4/24/01 . As a result ,
the patient was not considered a candidate for transplant.
Pulmonary function tests on 4/10/01 , revealed a DLCO = 14 , which
was 49% of expected. On 3/20/01 , the patient underwent a
dobutamine MIBI stress test that was consistent with a moderately
enlarged area of prior myocardial infarction of the left circumflex
territory and posterior descending artery territories. The
examination was also suggestive with an area of modest dobutamine
induced ischemia in the territory of the left anterior descending
with preserved viability.
Endocrine wise , the patient's diabetes was managed in-house on a
regular insulin sliding scale. Because his hemoglobin A1C level
was below 6 on discharge , he was placed back on his regiment of NPH
40 units twice a day In terms of his thyroid , we made no adjustments to
his Levoxyl regiment. He has been coumadinized for a low ejection
fraction and was discharged on his regular regiment of 4 mg
Monday/Wednesday/Friday and 5 mg on all other days.
The patient also has a history of depression and he was maintained
on Prozac 20 mg every day.
Hematologically , the patient was noted to have a hematocrit of 36
during his hospitalization. His MCV = 75.1 in a 61-year-old male
with necrocytic anemia. We obtained a colonoscopy which revealed
polyps , all of which were snagged with no complications. The
pathologies are currently pending.
The patient was discharged on 7/15/01 , having diuresed to a dry
weight of 96 kilograms and plan to follow-up with Dr. Board on
7/30/01 .
Dictated By: EARNEST OBESO , M.D. LU48
Attending: SUNSHINE D. RAABE , M.D. GP76 LT031/599217
Batch: 55817 Index No. AZBBJN56Q1 D: 7/30/01
T: 3/30/01
Document id: 412
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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N |
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| output/system_intuitive_annotation.xml | intuitive |
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504884125 | PUO | 81374974 | | 258232 | 10/2/1997 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 4/20/1997 Report Status: Signed
Discharge Date: 8/9/1997
PRINCIPAL DIAGNOSIS: SYNCOPE.
SIGNIFICANT PROBLEMS: 1. IDIOPATHIC CARDIOMYOPATHY.
2. ATYPICAL CHEST PAIN.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old woman who
has lived in Lan Perv Enama since 1993.
She has a history of chest pain and has a baseline EKG with an
intraventricular conduction delay , QRS interval of 0.10. Her
cardiac history includes: In February 1988 , she underwent an
exercise tolerance test for chest pain. The patient went 7 minutes
35 seconds and had a maximum heart rate of 100 , maximum blood
pressure not recorded. She developed a left bundle branch block
with exercise. A thallium scan showed no evidence of ischemia. In
September 1992 , she had an exercise tolerance test for chest pain and
shortness of breath. She went 9 minutes 0 seconds and had a
maximum heart rate of 167 with maximum blood pressure 138/60. She
developed angina during the test. The SPECT scan showed a moderate
fixed defect in the apicolateral wall. In 2/6 , she had an EKG
done which showed normal sinus rhythm with a QRS interval of 0.10
and moderate LVH. In 1995 , the patient states that she had a
cardiac catheterization in Smouth Son Mchocin which showed no coronary
disease , although she was told that she had a cardiomyopathy. The
patient reports feeling well until the day of admission without any
chest pain , shortness of breath , paroxysmal nocturnal dyspnea , or
orthopnea in the recent past. On the afternoon of admission , at
about 2 o'clock in the afternoon , she was watching television. She
arose from the couch and went to the kitchen to get a cup of
coffee. She recalls filling her cup with water , then recalls
nothing else until she awoke with her grandchildren lying on half
of her on the floor and crying. The patient was oriented upon
awakening and recognized her grandchildren immediately. She did
not have any incontinence or tongue biting. She denied muscle
aches , somnolence , confusion , or weakness. She went to the couch
to sit down and had nausea and vomiting about five minutes after
her syncopal episode. She also noted a bump on the right side of
her head and subsequently developed a headache. She did not have
any neurologic symptoms , denied any chest pain or shortness of
breath. She was diaphoretic at the time that she was sitting on
the cough , nauseous and vomiting afterwards. She had no
palpitations and she had no presyncopal sensation or dizziness at
any time. She does report having a history of palpitations in the
past , but none on the day of admission. She had no fevers , chills ,
or other sick contacts. She had no prior history of syncope or
loss of consciousness. She had no history of seizures or transient
neurologic symptoms. In addition , she does report that she has a
history of chest pain. The last time was more than a year prior to
admission. She has no paroxysmal nocturnal dyspnea , no pedal
edema , no orthopnea , and no change in exercise tolerance recently.
She climbs stairs without any problems.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Chest pain , last
episode approximately one year prior to
admission. 3. Palpitations. 4. Question of cardiomyopathy ,
diagnosed by cardiac catheterization in Ri Po in 1995.
ADMISSION MEDICATIONS: 1. Vasotec 10 mg orally every day. 2. Digoxin
0.25 mg orally every day. 3. Lasix 20 mg every day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Negative for coronary artery disease , stroke ,
diabetes mellitus , hypertension , and sudden death.
SOCIAL HISTORY: The patient does not smoke , does not drink
alcohol , and does not use intravenous drugs. She lives
with her daughter in Me at this time of year. She works in an
outreach program as a nurse. She came from Oaks Field Sasver where she
has been since 1993. Prior to that time , she was living in Lan Tulo Den
and receiving medical care at the Pagham University Of .
PHYSICAL EXAMINATION: Vital signs included a blood pressure of
130/70 , pulse 62 ( the patient had a blood
pressure of 200/100 when initially seen in the Emergency
Department ). She was an elderly woman in no apparent distress.
Her HEENT examination was remarkable for having poor dentition.
Her JVP was at 8 cm. Her chest was clear. Her cardiovascular
examination revealed an S1 , S2 and intermittent S3 , no murmurs ,
with regular rate. Her abdomen was soft and nontender. Her
extremities were warm without any cyanosis , clubbing , or edema.
Neurological examination was unremarkable. Her mental status was
entirely intact. Cranial nerve examination was grossly intact.
Her reflexes were 2+ throughout and her toes did not respond to the
Babinski stimulation.
LABORATORY DATA: She had a CK of 119 , magnesium 2.2. Her digoxin
level was 0.7. Troponin I was 0. Electrolytes
were entirely within normal limits , as were BUN and creatinine.
White blood cell count was 10.3 , hematocrit 36.5 , and platelet
count 298. Urinalysis revealed 0-1 white cells , 0-1 red cells , 1+
bacteria , and 1+ epithelial cells. Chest x-ray revealed no
evidence of congestive heart failure or infiltrate. EKG , at the
time of admission , showed normal sinus rhythm at a rate of 93 with
intervals of 0.183 , 0.15 , and 0.417. She had a left bundle branch
block which was new since her 1993 EKG.
HOSPITAL COURSE: The patient was admitted for work up of her
syncopal episode. By hospital day one , the
patient underwent a rule out for myocardial infarction. Her
enzymes were flat and her EKG showed no changes consistent with
acute myocardial infarction. In addition , she underwent an
echocardiogram which revealed an ejection fraction of 30%-35%. She
also had anterolateral wall motion abnormalities. On the following
day , the patient underwent a right sided heart catheterization ,
which revealed that her coronary arteries were completely clean.
She underwent an EP study which was entirely normal. On the
following hospital day , she underwent an exercise tolerance test ,
and no arrhythmias were triggered by her exercise. Carotid
noninvasive studies revealed minimal disease bilaterally , and the
neurology service was consulted. The patient also underwent a tilt
table study , which was entirely normal , with no suggestion of a
vasovagal response. At the time of discharge , the patient had had
no further symptoms and no further episodes of syncope while in
hospital. Her Holter monitor results are pending. The feeling is
that her syncopal event was most likely cardiac related , probably
related to a tachycardic arrhythmia. However , her neurologic work
up is still underway. She is to have an MRI/MRA as an outpatient
and to follow up in KTDUOO clinic , as well as with Dr. Krance for
further discussion as to whether AICD placement might be in order.
DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg orally
every day. 2. Digoxin 0.25 mg orally every day. 3.
Vasotec 15 mg orally every day. 4. Lasix 20 mg orally every day. 5. Atenolol
12.5 mg orally every day.
DISPOSITION: The patient was discharged to home to follow up in
KTDUOO clinic with me ( Katia Poppell ) on 4/29/97 . She
will have an MRA/MRI of her brain scheduled as an outpatient. In
addition , she will be set up with an ECG loop recorder for further
monitoring of events at home.
Dictated By: KATIA POPPELL , M.D. MA60
Attending: DIONNE G. MONSOUR , M.D. MF57 CH107/2535
Batch: 16037 Index No. V5DA2F23ES D: 8/23/97
T: 8/20/97
Document id: 413
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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042580388 | PUO | 02169523 | | 2377689 | 8/4/2003 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 3/24/2003 Report Status: Signed
Discharge Date: 5/30/2003
ADMIT DIAGNOSES: 1. HEART FAILURE.
2. DIABETES MELLITUS.
3. HISTORY OF CEREBROVASCULAR ACCIDENT.
4. ASTHMA.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old woman
with history of dilated cardiomyopathy
and estimated ejection fraction of 35 to 40% who presented with
lower extremity edema , weakness , fatigue , and syncopal episodes x
2. At baseline the patient states that she is able to walk and
perform her activities of daily living without symptoms of heart
failure. Per patient , about five days prior to admission , she
began to notice increasing lower extremity edema , rapidly spreading
from her calves up to her thighs. She also noted symptoms of
weakness and fatigue. On 9/29/03 the patient reported two syncopal
episodes- the first of which was preceded by dizziness after which
she lost consciousness after lying down. She awoke and walked to
her apartment where she apparently lost consciousness a second time
although she does not remember having any prodromal symptoms prior
to the second episode. The patient was found by her neighbor and
taken to the Tonsta Ean Villebaxt Hospital . At Poguary Medical Center ,
the patient was treated for heart failure with diuresis with intravenous
Lasix. An echocardiogram at the Poguary Medical Center showed an ejection
fraction of 10 to 15% , 4+ mitral regurgitation , 3+ tricuspid
regurgitation. The patient ruled out for myocardial infarction and
ECG showed no ischemic changes. The patient did have one run of
11-beat non-sustained ventricular tachycardia. Liver function
tests were noted to be elevated. Her hepatitis panel was
reportedly negative. The patient was transferred from Poguary Medical Center
to I Warho Hospital as her primary care physician and
cardiologist are at I Warho Hospital .
PAST MEDICAL HISTORY: Hypotension. History of cerebrovascular
accident. Type II diabetes mellitus.
Asthma. Dilated cardiomyopathy.
MEDICATIONS: On transfer , Albuterol inhaler , Flovent inhalers ,
Lopressor 50 mg orally twice a day , folate 1 mg orally every day ,
Reglan 10 mg orally three times a day with meals , Colace , iron , Captopril 50 mg
orally three times a day , Coumadin 5 mg orally every day , NPH 35 units every day before noon and
every afternoon , Humalog sliding scale , Digoxin 0.25 mg orally every day , and
Albuterol nebulizers as needed
LABORATORY DATA: Creatinine 1.3. WBC normal. TSH was normal at
2.1 , ESR 8. ECG showed sinus rhythm , left atrial
enlargement , left ventricular hypertrophy , no ischemic changes.
HOSPITAL COURSE: Cardiovascular: The patient has a dilated
cardiomyopathy and was admitted with volume
overload. The patient was diuresed with intravenous Lasix throughout her
hospital course with successful diuresis of 1 to 2 liters of fluid
per day. An echocardiogram showed an ejection fraction of 20 to
25% , severe global hypokinesis , moderate mitral regurgitation , and
moderate tricuspid regurgitation. Right and left heart
catheterization was performed. The right heart catheterization
showed the following: Right atrial pressure was 8 , right
ventricular pressure 35/5 , PA pressure 37/17 , and wedge pressure of
15. The left heart catheterization showed two vessel coronary
artery disease , no obstructive lesions. The patient showed marked
clinical improvement with diuresis with intravenous Lasix. Prior to
discharge the Lasix was changed from intravenous to orally and the patient was
stable on orally regimen of Lasix prior to discharge. The left heart
catheterization , as noted above showed moderate coronary artery
disease. The patient was continued on statin for this reason. The
patient had had two syncopal episodes prior to admission along with
a run of non-sustained ventricular tachycardia at the outside
hospital. This raised the concern along with her low ejection
fraction that she could be having arrhythmias causing syncope. On
telemetry during this admission , the patient was noted to have
additional runs of non-sustained ventricular tachycardia along with
an episode of complete heart block. The electrophysiology service
was consulted and placed an ICD and pacer on 11/25/03 . This
procedure was well tolerated.
Renal: The patient was noted to have low albumin on admission and
protein in her urine , concerning for nephrotic syndrome. Renal
consult was obtained. The 24-hour urine was collected. Renal
ultrasound was negative for hydrosis or renal vein thrombosis. An
SPEP and UPEP were sent which are pending at the time of this
dictation. The renal consult felt that the diabetes mellitus was
the likely explanation for the protein wasting in the urine. The
patient was continued on an Ace inhibitor.
Infectious disease: The patient was noted to have a localized area
of infection at the area of old intravenous site on admission. She was
started on orally dicloxacillin to treat this infection. Surgery was
consulted and ruled out septic thrombophlebitis.
Hematology: The patient was taken off Coumadin on admission but
was continued on heparin for anticoagulation. The Coumadin was
restarted after the pacer and ICD were placed.
Endocrine: The patient was treated on a regimen of Lentes and
insulin sliding scale. Her blood sugars were stable on this
regimen.
DISPOSITION: DISCHARGE MEDICATIONS: The patient will planned to
be discharged on the following medications:
Dicloxacillin 500 mg orally four times a day , Zocor 20 mg orally every bedtime , Lentes 40
units subcutaneously every bedtime , Lopressor 25 mg orally twice a day , Lasix 80 mg orally
twice a day , Lisinopril 40 mg orally every day , and Keflex 25 mg orally four times a day
FOLLOW-UP: She will follow-up with her primary care physician , Dr.
Viray . She will follow-up with her cardiologist , Dr. Mcpeck , on
3/3/03 . She will have a repeat echocardiogram in July to
reassess her ejection fraction and valvular disease.
Dictated By: CARRI G. KATCSMORAK , M.D. KR07
Attending: SUNSHINE D. RAABE , M.D. LU76 VB722/666610
Batch: 5342 Index No. DGOD9V4LAC D: 11/24/03
T: 11/24/03
Document id: 414
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
- |
Y |
Y |
N |
N |
- |
- |
N |
N |
N |
N |
N |
N |
698812086 | PUO | 12566492 | | 784710 | 10/9/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 10/9/2000 Report Status: Signed
Discharge Date: 7/2/2000
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
HISTORY OF PRESENT ILLNESS: Ms. Parda is a 53 year old woman with
history of diabetes mellitus type I ,
hypertension , coronary artery disease , diastolic and systolic
dysfunction , last hospitalized at the I Warho Hospital in
2/30 with congestive heart failure and did well with intravenous Lasix.
After discharge , the patient was able to follow her own weight.
Over the last three days , the patient claims that she has gained
5 lb of weight up 145 lb. , and attempted to increase Lasix dose to
40 mg orally four times a day without any success. She has also had about four
days of shortness of breath. She has only been able to walk about
2-3 blocks a day , but this has decreased to 1/2 a block. She has
also claimed she has had increasing orthopnea to three pillows and
some paroxysmal nocturnal dyspnea. She has also had some dietary
indiscretion , but has not had any medical noncompliance. This was
due to about two months ago , the patient in climbing a mountain ,
injured her knee and put into a knee immobilizer and she was unable
to walk very much so unable to mobilize fluid. She also claims
that she may have had difficulty keeping sodium intake below 2 gm ,
although husband claims that there was no an increase in sodium
intake. She does say a 4:30 p.m. , on the day of admission , the
patient had some neck and left shoulder pain , which was about 5/10 ,
no nausea or vomiting , no diaphoresis. This was relieved with one
sublingual nitroglycerin. She also says that she has had a cough
the Sunday before admission , nonproductive , no chills , no fevers ,
and no dysuria.
PAST MEDICAL HISTORY: Notable for insulin-dependent diabetes
mellitus complicated by nephropathy and
renal insufficiency , with proteinuria most likely secondary to
minimal change in neuropathy and retinopathy. She has had
long-standing hypertension , very difficult to control , with
extensive workup. Coronary artery disease and MI in 1986 , treated
with streptokinase , PTCA complicated by right groin hematoma and
retroperitoneal dissection. She has osteoporosis , cholecystectomy ,
question of multiple sclerosis , status post several MIs
inconclusive.
ALLERGIES: No known drug allergies.
MEDICATIONS: Elavil; aspirin; atenolol 50 mg orally twice a day; Vasotec
40 mg orally twice a day; Lasix 40 mg orally three times a day to four times a day;
Norvasc 5 mg orally every day , just started two days prior to admission;
Cozaar 50 mg orally twice a day; Lipitor 10 mg orally every day; diltiazem 180 mg
orally twice a day; Prilosec 20 mg orally twice a day; insulin sliding scale with
Humalog and Ultralente 20 mg orally every day before noon , 10 mg orally every afternoon
SOCIAL HISTORY: The patient is a cigarettes smoker , one pack a
week x20 years , quit 12 years ago. No alcohol
use. Husband is an anesthesiologist at I Warho Hospital ,
and she has two daughters.
FAMILY HISTORY: Father with hypertension and CVA , died from a MI
at 59. Mother with breast cancer.
PHYSICAL EXAMINATION: VITAL SIGNS: Temp 98 , heart rate 66 , BP
165/81 , respiratory rate 26 , satting 93-94%
on room air. GENERAL: No acute distress. HEENT: PERRLA. NECK:
JVP to the angle of the jaw. LUNGS: Bibasilar crackles. HEART:
Regular rate and rhythm , S1 , S2 , positive S3 , II-III/VI
holosystolic murmur heard best at the left lower sternal border
radiating to the apex. ABDOMEN: Soft , non-tender , non-distended ,
with positive bowel sounds. EXTREMITIES: Minimal edema , 2+
pitting edema , sacral pitting edema , no calf tenderness.
LABORATORY DATA: Na 140 , K 3.6 , Cl 102 , bicarb 27 , BUN 37 ,
creatinine 2.3 , baseline 1.8-2.1 , glucose 116.
CK 73 , Ca 9.3 , troponin 0.13. White blood cell count 8.98 ,
hematocrit 32.2 , platelets 333. Urine - 3+ protein , trace glucose.
Previous echocardiogram shows normal size and function. EF 60% ,
basal inferior hypokinesis , normal size and function , 2-3+ MR , with
mild eczematous dysfunction of valve , and mild left atrial
enlargement. ETT was done in 5/11 . The patient went for four
minutes , heart rate 76 , BP 125/70. Her EKG showed evidence of
ischemia. Imaging report not on the computer.
HOSPITAL COURSE: The patient was diuresed aggressively. On
3/6 , added clonidine and changed captopril
to ramipril for better long-acting blood pressure control for blood
pressures in the 190-200 range.
On 1/14 , increased Lasix and clonidine for improved diuresis
and blood pressure control , hyperproliferative normocytic anemia ,
begin erythropoietin , however erythropoietin level of 15 signifies
some erythropoietin production. Chest x-ray showed continued
pleural effusions and pulmonary edema. Sputum gram stain with 4+
polys , gram positive in clusters and chains , and a culture with 1+
orally flora.
On 2/8 , continued to diuresis patient well.
On 5/2 , creatinine 2.6 , discontinued Norvasc and clonidine.
On 7/23 , creatinine 3.0 , held the diuresis , discontinued ACE
inhibitor and ARD. MRI of the kidneys showed no evidence of renal
artery stenosis. An echo done the same day showed mild MR with an
EF of 45-50%. Dr. Loewe recommended holding all blood pressure
meds. Team also held all diuretics.
On 6/21 , creatinine to 4.0 , urine output only 450 cc in 24
hours despite a bolus of 500 cc.
On 10/10 , changed atenolol to metoprolol for a better renal
clearance. Discontinued Tiazac. Renal failure at the time was
thought to be secondary most likely to prerenal from hypotension
and hypovolemia. This patient was orthostatic , which lead to renal
acute tubular necrosis. The patient had casts in urine. Continued
to have nausea and was put on Compazine , Zofran , and Prilosec.
High protein and creatinine ratio. The patient had a continued
cough , low grade fever , and a white count. Chest x-ray showed no
evidence of infiltrates. Started levofloxacin for presumed URI.
She had a temperature spike to 101.5. She underwent fractional
excretion of sodium 0.61 , protein 4681 , creatinine 75.7 , osmolality
339. UA was bland. No eosinophils were seen. Albumin 3.8.
On 3/11 , BUN and creatinine was 109 and 6.8 , Na 124 , K 5.8. No
EKG changes were seen. The patient was administered Kayexalate
with subsequent drop in potassium. Magnesium and phosphate all
began to rise. The patient became oliguric and anuric , and
continued nausea and vomiting. The patient had more crackles , JVP ,
good sats. A 250 cc bolus of D5 1/2 normal saline was then
administered. Creatinine peaked to 7.2.
On 9/8 , the creatinine was back down to 6.4 without need for
dialysis intervention. Electrolytes were stable. The patient's
symptoms and exam improved. She continued better urine output.
The patient was transfused for a hematocrit of 28 with good
response.
On 5/25 , the creatinine was down to 4.4 , BUN 85. The patient
did feel much better , was diuresed six liters , and had clear lungs.
Increased the Lopressor to 37.5.
On 10/24 , the patient continued to diuresis after ATN recovery.
Lopressor was titrated up and ramipril was started after a
discussion with Dr. Holtmann and Dr. Loewe .
On 2/23 , the patient was doing much better. Creatinine
improved. He continued to titrate up on Lopressor for a SBP of
130s. White blood cell count was mildly elevated to the 12 range.
UA and diff. were unremarkable. The patient is being discharged on
the following medications:
DISCHARGE MEDICATIONS: Elavil 50 mg orally every bedtime; aspirin 325 mg
orally every day; erythropoietin 5000 U subcutaneously
biweekly; lactulose 30 ml orally four times a day; nitroglycerin 1/150 0.4 mg 1
tab sublingual every 5 minutes x3 as needed chest pain; Prilosec 20 mg orally
twice a day; thiamine 100 mg orally every day; MVI 1 tab orally every day; Zocor 20 mg
orally every bedtime; ramipril 10 mg orally every day; Humalog insulin as the
patient takes at home; Lente as the patient takes at home;
Lopressor 150 mg orally every 8 hours; Lasix 20 mg orally twice a day
DISCHARGE FOLLOW-UP: The patient is to follow-up with Dr. Holtmann
and Dr. Loewe this week before she leaves
for her trip. The patient is to also follow-up with
Dr. Cordelia Blacknall at the next available appointment. She is going
on a very long extensive trip , and will need to follow her weight
and in's/out's as best she can. 60-61 kg is her dry weight. She
will adjust her medications accordingly to Dr. Loewe and
Dr. Scipioni recommendations.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: JOANA ZERBE , M.D. LT82
Attending: EARNESTINE M. FIERMONTE , M.D. JL5 OH881/8901
Batch: 5136 Index No. VGDTRGELN4 D: 7/30
T: 7/30
CC: 1. EARNESTINE M. FIERMONTE , M.D.
2. VITO E. HOLTMANN , M.D.
3. MAXIMA MAXIMA LOEWE , M.D.
4. CORDELIA D. BLACKNALL , M.D.
Document id: 415
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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345254752 | PUO | 28611678 | | 3819524 | 2/23/2003 12:00:00 a.m. | BACK PAIN | Signed | DIS | Admission Date: 2/12/2003 Report Status: Signed
Discharge Date: 4/22/2003
HISTORY OF PRESENT ILLNESS: This is a 67-year-old man with a
history of coronary artery disease
status post coronary artery bypass grafting , mitral valve
replacement with previous history of endocarditis in April 2002
who presents with severe back pain. The patient was well until
Friday before admission when he drove 2 1/2 hours to Hertall Louisgreen
and he had some back stiffness. The following day the patient
noted back pain , took some Tylenol but remained "stiff all day".
On the following day , Sunday , he appeared better , able to tolerate
walking well. On Monday he again had severe pain , came to the
emergency department here at Pagham University Of where he
had a CT of the spine and chest without evidence of abnormalities.
He was discharged to home with Percocet. On the morning of
admission the patient was again with pain. He was urged by his
cardiologist to come to the emergency department to rule out
epidural abscess , work up for cause of back pain. He was negative
for any fever or chills. No bowel or bladder incontinence. No
radiation of pain down the legs.
REVIEW OF SYSTEMS: Negative except for HPI.
PHYSICAL EXAM: VITAL SIGNS: Temperature 99.0 , heart rate 78 , blood
pressure 160/80 , respiratory rate 20 , satting 95% on
room air. GENERAL: The patient was sitting in the stretcher ,
comfortable but with pain upon movement. HEENT: Pupils are equal
and reactive to light. Mucous membranes moist. Oropharynx is
clear. CARDIOVASCULAR: Regular rate and rhythm with a mechanical
S1 and S2. PULMONARY: Clear to auscultation bilaterally with
trace bibasilar crackles. ABDOMEN: Obese , nontender ,
nondistended. Positive bowel sounds. EXTREMITIES: Warm and well
perfused. 1+ pitting edema bilaterally. NEUROLOGICAL: Intact.
Lower extremities limited by pain.
PAST MEDICAL HISTORY: Notable for coronary artery disease status
post coronary artery bypass grafting , status
post myocardial infarction , mitral valve replacement with a St.
Jude valve , congestive heart failure , history of endocarditis ,
history of hypercholesterolemia , status post cholecystectomy.
MEDICATIONS ON ADMISSION: Amiodarone 200 mg every day , digoxin 0.125
mg every day , Imdur 30 mg every day , Captopril
50 mg orally twice a day , Toprol 50 mg every day , Lipitor 80 mg every day ,
Coumadin 3 mg orally every day , Levoxine 75 mg every day , Lasix as needed
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife.
FAMILY HISTORY: Non-contributory.
LABORATORY DATA ON ADMISSION: Notable for a white blood cell count
of 11.17 , hematocrit of 44.6 ,
platelet count of 129 , with 27 lymphocytes , 55 neutrophils , D-dimer
278.
HOSPITAL COURSE: 67-year-old male with a history of mitral valve
replacement complaining of severe back pain with
Streptococcus endocarditis in 2002 admitted of thoracic back pain
for four days. The pain progressed to the point where the patient
had difficulty ambulating secondary to the pain. CT scan of the
thoracic and lumbar spine on May , 2003 were negative for
abscess. The patient had no fevers. His admission exam was benign
with no aortic insufficiency and normal neurological exam. There
was variable pain to palpation over the ribs with no pain to
palpation over the spine. The patient was managed conservatively
with Oxycodone , Motrin and Baclofen. He was initially admitted to
GMS , and troponin was initially positive at 0.12 and then became
negative.
1. Infectious disease: Blood cultures drawn on March , 2003
grew 2/2 bottles of gram positive cocci in clusters and pairs. Due
to concern for prosthetic valve endocarditis or potential epidural
abscess , the patient was transferred to cardiology. Infectious
disease consult was obtained. Vancomycin and gentamicin were
started on March , 2003. On October , 2003 a transesophageal
echocardiogram was negative for vegetation. A MRI of the spine was
negative for osteomyelitis , epidural abscess however the MRI did
show severe degenerative joint disease possibly causing the
patient's back pain. The patient has had numerous positive blood
cultures for Streptococcus sanguous ( Viridans group ) , blood
cultures were last positive on March , 2003 with a negative work
up including a negative transthoracic echocardiogram and negative
transesophageal echocardiogram , negative chest CT x 2 , negative
abdominal CT ( which did show a small liver cyst ) , negative tagged
white blood cell count scan and a negative back MRI. Dental
consult saw no abscesses thus no evidence of a large septic source
from the mouth although this particular bacteria raises suspicion
for an orally source. Repeat films and dental evaluation on November , 2003 required the patient to get teeth cleaning as an
outpatient. There is a question of some seeding from bleeding gums
that occur about once weekly while the patient is brushing from
poor dentition and gum care. The dentist recommended deep cleaning
as an outpatient with prophylactic antibiotics. the patient was
initially started on gentamicin , vancomycin , on October , 2003
switched to gentamicin and penicillin. He will complete a 2 week
course of gentamicin and penicillin G on November , 2003. At that time
on August , 2003 the patient should start a 4-week course of
ceftriaxone 1 gram every day. PICC line was placed on August , 2003
to provide long term access for antibiotics.
2. Cardiovascular: The patient was continued on Toprol , Imdur ,
switched from Captopril to Lisinopril. Rhythm: The patient was on
amniocentesis , digoxin , Coumadin for St. Jude valve and paroxysmal
atrial fibrillation. CT and MRI is negative. Pain significantly
improved on January , 2003. The patient was on Neurontin and
OxyContin and oxycodone and Motrin , may benefit from restarting on
Baclofen if pain not well controlled on this regimen or persists
outside the treatment of endocarditis.
3. Endocrine: Continue on Synthroid.
DISPOSITION ON DISCHARGE: Insurance does not cover home
antibiotics so the patient will be
discharged to a skilled nursing facility for intravenous
antibiotics likely to the Griffcoo Nonster Hospital on August ,
2003.
TO DO PLAN:
1. Follow the patient's INR closely while on Motrin and
antibiotics , in the past when on antibiotics his INR has been
difficult to control , goal range for the patient should be
around 2.8 to 3.5 and his Coumadin was increased from 3-4 mg
on August , 2003 given that his INR was trending downward to
2.0 on January , 2003.
2. Complete a 14-day course of penicillin G , gentamicin on November ,
2003 then complete additional four seeks of ceftriaxone
starting on August , 2003 to be completed on July , 2003.
3. The pain is likely secondary at least partially to
degenerative joint disease with some contribution possibly
from an infectious source but unlikely. Should titrate the
pain medications down as tolerated.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE: Amiodarone 200 mg orally every day , digoxin
0.125 mg orally every day , Colace 100 mg orally
twice a day , Motrin 400-600 mg orally three times a day as needed for back or
musculoskeletal pain take with food , Synthroid 75 mcg orally every day ,
oxycodone 5-10 mg orally every 4-6h as needed pain hold if somnolent or
respiratory rate less than 12 , Senna tablets two tablets orally
twice a day , Coumadin 4 mg orally every day , Toprol XL 50 mg orally every day , Imdur
30 mg orally every day , Lipitor 80 mg orally every day , Prilosec 40 mg orally every
day , Lisinopril 10 mg orally every day , Neurontin 300 mg orally three times a day ,
gentamicin sulfate 110 mg intravenous every 12 hours x six days , penicillin G 3
million units intravenous every 4 hours x six days , Ceftriaxone not to be started
until August , 2003 for 28 day course ending July , 2003 1000 mg
intravenously every day , OxyContin 30 mg orally every 12 hours x seven days.
FOLLOW UP: The patient should follow up with Dr. Shonna Saber ,
cardiologist at Pagham University Of who knows
the patient well and who also will follow his INR levels once
discharged from the rehabilitation center.
Dictated By: DAMON BARBARA KRINSKY , M.D. QY56
Attending: REYES D. MCPECK , M.D. KL10 WH105/659436
Batch: 8932 Index No. F3IM0A0JE3 D: 6/12/03
T: 6/12/03
Document id: 416
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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074027992 | PUO | 24754264 | | 9599846 | 12/10/2005 12:00:00 a.m. | CHF , URI | | DIS | Admission Date: 12/10/2005 Report Status:
Discharge Date: 4/20/2005
****** FINAL DISCHARGE ORDERS ******
CANTORAN , VIVIANA G. 981-97-11-2
More Rill
Service: MED
DISCHARGE PATIENT ON: 4/4/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BRAGAS , RASHEEDA K. , M.D. , M.PH.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally every day
LASIX ( FUROSEMIDE ) 100 MG orally every day
INSULIN NPH HUMAN 17 UNITS every day before noon; 7 UNITS every afternoon subcutaneously
17 UNITS every day before noon 7 UNITS every afternoon
AFRIN NASAL SPRAY ( OXYMETAZOLINE HCL )
2 SPRAY nasal twice a day X 3 DAYS.
SALINE NASAL DROP ( SODIUM CHLORIDE 0.65% ) 2 SPRAY nasal four times a day
as needed Other:congestion
MVI THERAPEUTIC W/MINERALS ( THERAP VITS/MINERALS )
1 TAB orally every day
Alert overridden: Override added on 6/12/05 by
GUSMAR , GAYE , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: ok
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 1
SUDAFED 12HR ( PSEUDOEPHEDRINE CONTROLLED RELEASE )
120 MG orally every 12 hours X 5 Days Starting Today ( 8/27 )
TRAVATAN 1 DROP OS every bedtime
GLUCOPHAGE ( METFORMIN ) 500 MG orally twice a day
KCL SLOW RELEASE 20 MEQ orally every day Instructions: Take M , W , F
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 4/4/05 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: ok
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 4/4/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: ok
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
PRINIVIL ( LISINOPRIL ) 10 MG orally every day
Alert overridden: Override added on 4/4/05 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: ok
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Reisman PUO cardiology 9/26 @ 3:OO ,
Annabel Verfaille , Heart Failure Clinic 6/10 3:30 ,
Please call Dr. Jacqulyn Harkley at 139-267-7340 to schedule a follow-up appointment in the next 1-2 weeks. The office will re-open on 2/5/06 . ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF , URI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , LAD stent , IDDM , CHF , ischemic CMP with EF 25-30%
OPERATIONS AND PROCEDURES:
none.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none.
BRIEF RESUME OF HOSPITAL COURSE:
ID/HPI:
82F with with known history of ischemic CMP( EF 25-30% ) CAD history of
stent & diastolic dysfunction who presents with worsening SOB X 6-8
weeks. She reports increased DOE , PND , orthopnea , denies LE swelling.
She had increased SOB on the evening prior to admission. Sh also had
intermittent chest discomfort she believes was 2/2 to her
cough. She admits to nasal congestion for the past month as well as a
nonproductive cough. No , palpitations , syncope , or
known change in weight. No fevers , chills or rash. No recent cahnge in
medications , dietary indiscretion , episodes of
HTN , or dehydration.
In the ED her vital signs were Afeb , pulse 106 , blood pressure 100/60 , SaO2 97% 2L.
Her exam was significant for: a well-appearing woman , crackles as
the lung bases b/l , RRR , nl S1 , S2 , JVP 15cm , Abdomen was benign and the
lower extremities had trace edema. She received lasix 120iv ,
followed by 100iv with 400cc + of urine output. Her labs were
significant for Cr 1.1 , BNP 473 , and one set of negative cardiac ezymes.
EKG: sinus tachycardia with old LBBB/LAFB. prolonged QTc
CXR: b/l effusions , calcified aortic knowb , prominent vasculature ,
chronic interstitial markings.
IMPRESSION: CHF exacerbation with volume overload and no clear initial
precipitant.
HOSPITAL COURSE
1 ) CV: ISCHEMIA - Patient was ruled out for a myocardial infarction.
She had three sets of negative cardiac enzymes. Her EKG showed normal
sinus rhythm , left axis deviation and LBBB , findings that were unchanged
from previous EKG's. There were no findings characteristic of new
cardiac ischemia. The patient was continued on ASA 325mg , Lisinopril 10mg
every day and Simvastatin 20mg orally
PUMP - Patient has history of CHF , with an EF 25-30%. Her history and
exam were consistent with mild CHF. Her BNP was 473. The patient's wt from
previous d/c summary was 66kg. The goal total body balance was neg 1 liters
each day. The patient was given Lasix 200po every day with intravenous lasix as needed. Her
weight on discharge was 63 kg and she improved clinically. Patient was
started on a beta-blocker given her CAD and CHF. The patient was seen by
Annabel Verfaille in the heart failure clinic and will follow up with her as well
as with Dr. Reisman in Cardiology.
RHYTHM - NSR , with LBBB. No acute changes.
2 ) ENDO: The patient was maintained on her home regiment of NPH 17/7 ,
Metformin 500mg twice a day was held given CrCl 33. A Novolog SS was also used.
FSBS were checked. The patient will be restarted on her Metformin and home
insulin regimen for discharge , but the in-patient team reccomends that her
orally hypoglycemics be re-examined given her reduced CrCl.
3 ) ID: WBC mildy elevated at 10.7 on admission. UA was dirty and a
urine culture was sent and pending at the time of discharge. No
dysuria. CXR with no infiltrate. Patient discharged with decongestants and
nasal steroid spray for URI symptoms.
4 ) PULM: SOB most likely secondary to CHF. No acute issues besides URI
sxs.
6 ) FEN: Low salt , cardiac , diabetic diet. Patient fluid restricted to
2L/day. Her electrolytes were monitored daily , given her diureses , and
replaced as
needed. Cr stable at 1.1.
7 ) PROPHYLAXIS: Lovenox 40mg/Esomeprazole 40mg orally every day
8 ) FULL CODE
ADDITIONAL COMMENTS: Please increase your lasix to 100 mg each day.
Start Toprol XL 50 mg for your blood pressure and heart failure.
Take Sudafed for 5 days and use Afrin spray for three days for nasal
congestion. Use saline spray as needed for nasal congestion.
Followup with Dr. Reisman in cardiology and with Annabel Verfaille in the heart
failure clinic as scheduled. Also , please call Dr. Bohanan to schedule a
follow-up appointment in the next 1-2 weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow-up with cardiology and with the heart failure clinic as
scheduled.
No dictated summary
ENTERED BY: LAVERGNE , TAMEIKA A. , M.D. ( ZX00 ) 4/4/05 @ 06:26 PM
****** END OF DISCHARGE ORDERS ******
Document id: 417
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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539837313 | PUO | 67887902 | | 1029054 | 7/30/2003 12:00:00 a.m. | congestive heart failure , atrial fibrillation with rapid ventricular response | | DIS | Admission Date: 11/29/2003 Report Status:
Discharge Date: 11/3/2003
****** DISCHARGE ORDERS ******
GOSNELL , ARDELIA 197-47-01-6
Knighsion Rd
Service: MED
DISCHARGE PATIENT ON: 6/12/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REFFITT , LAVETA GUILLERMINA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASPIRIN ENTERIC COATED 325 MG orally every day
Override Notice: Override added on 1/8/03 by CARRATURA , LOREEN C JEREMY , M.D. , PH.D.
on order for COUMADIN orally 12 MG every bedtime ( ref # 69883665 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/20/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
on order for COUMADIN orally 10 MG every bedtime ( ref # 67258852 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/10/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
on order for COUMADIN orally 8 MG every bedtime ( ref # 56248211 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/10/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
on order for COUMADIN orally ( ref # 79744535 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
DIGOXIN 0.25 MG orally every day Starting IN a.m. ( 2/22 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
FERROUS SULFATE 300 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 100 MG orally twice a day Starting IN a.m. ( 9/15 )
LISINOPRIL 10 MG orally every day
Alert overridden: Override added on 6/12/03 by CARRATURA , LOREEN C JEREMY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
Previous override reason:
Override added on 6/12/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
METOPROLOL TARTRATE 25 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
EUCERIN ( PETROLATUM HYDROPHILIC ) TOPICAL TP twice a day
Starting Today ( 9/7 )
Instructions: to lower extremities , may use moisturizing
lotion of choice
COUMADIN ( WARFARIN SODIUM ) 12 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 1/8/03 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous Alert overridden
Override added on 10/20/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override reason:
Override added on 10/10/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous Alert overridden
Override added on 10/10/03 by CARRATURA , LOREEN CARLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Starting IN a.m. ( 2/22 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
CELEXA ( CITALOPRAM ) 20 MG orally every day
DIET: House / 2 gm Na / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Shelton Gamello , Ta Barlwa Hospital Medical Center , Purlgeorge Blvd , 082-075-0128 , 10/27/03 , 11:30 am ,
Laboratory draw for Coumadin Check , Outpatient Laboratory , South Sto A ,
Ms. Harlan Stops , Psychiatry , O Salto Montna , 053-237-3814 , Thursday , 7/30/03 , 1:45 pm ,
Dr. Herrea , Office with call or mail appointment time , 789-494-9941 ,
Arrange INR to be drawn on 11/24/03 with f/u INR's to be drawn every
7daysorasdirected days. INR's will be followed by Cardiology Anticoagulation Service , 988-605-5355
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
dyspnea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure , atrial fibrillation with rapid ventricular response
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
congestive heart failure , hypertension , atrial fibrillation , history of
appendectomy , chronic venous stasis , pulmonary HTN , hypertension , history of
pulmonary embolism , psych-anxiety/depression , obesity , chronic
pulmonary emboli , cellulitis , conjunctivitis , anemia
( anemia ) pulmonary hypertension ( pulmonary hypertension )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
51 year old man with history of CHF history of multiple admissions , obesity ,
pulmonary HTN , atrial fibrillation now admitted for dyspnea after
admitted dietary indiscretion. Reports cough x 1 day , no fevers ,
increased lower extremity edema. PE: T 99.5 HR 100's RR 22 BP 150/79
88% RA GEN: NAD. CHEST: decreased air exchange with end-expiratory
wheezes. COR: irreg irreg nl S1S2 , no murmurs. LE: chronic skin
changes , 2+ edema bil to shins. LABS: Cr 0.9 , Troponin < assay , WBC 8.
ECG: Afib without new ST-T wave changes. CXR: no edema
Hospital Course.
( 1 ) CV: The patient was admitted with dyspnea and chest pain. On exam ,
he was in volume overload with episodic atrial fibrillation with rapid
ventricular response. At time of admission , he admitted to recent
dietary indiscretions. Of note , his digoxin level at time of admission
was also less than assay , suggesting medication noncompliance. He was
ruled out for MI by serial ECG and enzymes. His dyspnea/chest pain was
associated with atrial fibrillation with rapid ventricular response and
improved with rate control and diuresis. He was digoxin loaded and
aggressively diuresed to a weight of 140.7 kg. On day of discharge ,
his breathing was back to baseline and he appeared euvolemic by exam.
He will be discharged on coumadin for his atrial fibrillation/history
of PE. As his INR was 1.9 at time of discharge , he will not be
discharge on a lovenox bridge but will need to follow-up in 2 days for
an INR check. He will follow-up with Dr. Herrea , Dr. Gamello ( his new
primary care physician ) , and the cardiology anticoagulation service.
( 2 ) PSYCH: The GRH team was consulted for his nicotene addiction and
made referrals for him to the smoking cessation program at the Kernan To Dautedi University Of Of .
Pyschiatry was consulted , and they recommended resuming celexa. In
addition , he was sent up to see a psychiatric social worker for
counseling.
ADDITIONAL COMMENTS: Please call your primary care doctor if you should develop worsening
shortness of breath or weight gain.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow-up with Dr. Gamello next week.
2. Record daily am weights and bring record to doctor's visits. If
weight changes by more than 2 lbs , please call Dr. Herrea office to
adjust your lasix dose.
3. Must go to Louisiana to get lab draw on Thurday , March .
You will be followed by the cardiology anticoagulation clinic to adjust
your coumadin dose.
4. Follow-up next week with the psychiatry social worker.
No dictated summary
ENTERED BY: CARRATURA , LOREEN CARLY , M.D. , PH.D. ( CY41 ) 6/12/03 @ 01:20 PM
****** END OF DISCHARGE ORDERS ******
Document id: 418
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
977295686 | PUO | 66017686 | | 3889598 | 9/10/2006 12:00:00 a.m. | AORTIC STENOSIS | Unsigned | DIS | Admission Date: 5/5/2006 Report Status: Unsigned
Discharge Date: 1/29/2007
ATTENDING: COLASAMTE , ISABELLE EVON MD
PRINCIPAL ADMISSION DIAGNOSIS: Severe aortic stenosis and
congestive heart failure.
HISTORY OF PRESENT ILLNESS: Briefly , Ms. Mcguffee is an
81-year-old female with a known history of severe aortic stenosis
and multiple medical comorbidities who had been transferred from
an outside hospital to the Coronary Care Unit for
congestive heart failure likely related to overwhelming aortic
disease. She had previously declined aortic valve replacement in
the year prior to her admission. She had an echo performed at
outside hospital just prior to admission to Pagham University Of showed an EF of 55-60% with severe aortic stenosis , an
aortic valve area of 0.6 cm square as well as 1+ mitral regurg
and 1-2+ tricuspid regurg. She was admitted to the medical
service at PUO where she was aggressively diuresed. She was also
prepared for urgent aortic valve replacement and possible
coronary artery bypass grafting. At the time of her admission ,
her past medical history included hypertension , peripheral
vascular disease , history of stroke with left upper extremity
sensory loss , diabetes type 2 , hypothyroidism ,
hypercholesterolemia , renal failure with bilateral renal artery
stenosis , parkinsonianism , iron-deficiency anemia , vitamin B12
deficiency , obstructive sleep apnea , seizure disorder and colon
cancer status post resection in 1987. She is unable to elaborate
on the details of that resection. She also had renal artery
stenting in 2005.
ALLERGIES: Stated allergies at the time of admission included
Lipitor for which she had myalgias and an erythromycin with a
reaction of which was unknown.
MEDICATIONS: Her admission medications include labetolol 150
orally daily , amlodipine 5 mg orally daily , Isordil 30 mg orally
three times a day , aspirin 325 mg orally daily , Plavix 75 mg daily , Coumadin 5
orally daily , Lasix 60 mg twice a day , Colace 100 mg twice a day ,
iron sulfate 325 once a day , folic acid 1 mg orally once day ,
hydralazine 25 mg daily and Synthroid 88 mcg daily as well as
Dilantin 300 mg orally twice a day.
PHYSICAL EXAMINATION: At the time of admission , her physical
exam showed a woman 5 feet 1 inches tall , weighing 94 kilos in
obvious mild respiratory distress. Her temperature was 97 and heart
rate was 83 and sinus. Her blood pressure in the right arm was
120/63 , in the left arm was 109/53. She was on 5L of nasal
cannula while satting 99%. The remainder of her physical exam was
notable only for a loud holosystolic murmur at the right upper
sternal border and radiation to her both carotid arteries. Her
Allen's test showed severely dampened waveform in both left and
right radial arteries. Her chest sounded congested with rales
present bilaterally and her extremities showed 1-2+ bilateral
lower extremity edema. Her carotid , radial and femoral arteries
were all 2+ , but her dorsalis pedis and posterior tibial were
present only by Doppler bilaterally.
LABORATORY DATA: Notable lab data at the time of admission
included a BUN and creatinine of 79 and 3.1 respectively and a
beta natriuretic peptide of 39 , 085. Cardiac catheterization performed on
9/10/06 showed 60% lesion of the ostial LAD as well as an 80% proximal LAD
lesion. She also had 90% ostial D1 and a 40% ostial OM1 lesion and right
dominant circulation. Her echo on 5/26/06 showed an ejection fraction of
60% , severe aortic stenosis with a mean gradient of 60 mmHg and a
peak gradient of 99 mmHg. Again her calculated valve area is 0.6
cm square. Her chest x-ray on 5/26/06 was consistent with
congestive heart failure and appeared very fluid overloaded. She
was taken on 9/10/06 to the operating room where aortic valve
replacement with aortic root patch was performed , 21 Biocor
porcine graft was inserted. She also had a two-vessel coronary
artery bypass grafting using vein to her left anterior descending
and vein grafting to her D1 vessel. She tolerated the procedure
relatively well , but her ensuing ICU course was protracted and
very complicated and will be summarized systematically.
Neurologically , the patient suffered no acute complications
postoperatively; however , her state of consciousness waxed and
waned with her overall condition.
From a cardiovascular standpoint , the patient suffered a perioperative MI in
the late hours of 9/10/06 and on to the early hours of 5/17/06 . She also
went into atrial fibrillation on postoperative day two and
suffered rhythm abnormalities for the remainder of her
postoperative course. Multiple conversion attempts were made
both pharmaceutically as well as with electrocardioversion , but
she occasionally did covert to normal sinus rhythm. Ultimately ,
she reverted back into atrial fibrillation. The third
postoperative day , she became hypotensive and asystolic. Chest
compressions were initiated for less than one minute at which
time atrial pacing was initiated and her rhythm was regained with
adequate blood pressure , though she was returned on to several
days of active drips to support her blood pressure. From this
point , Ms. Mcguffee developed dependence on pressors and inotropic
agents to support her blood pressure and cardiovascular system.
After several months with no real recovery of her cardiovascular
status , the family decided to withdraw care and put her on
comfort measures only. She ultimately suffered a cardiac arrest
on 1/16/07 .
From a pulmonary perspective , while she was extubated on the morning of
postoperative day #2 , she was ultimately reintubated and several pulmonary
complications required multiple bronchoscopies , multiple thoracentesis on both
chest for recurrent effusions and several chest tubes had to be placed for
aforementioned effusions. She was ultimately trached by the third
week and although she did occasionally come off the ventilator at
times , she never displayed adequate pulmonary function to be free
from vent dependence for any length of time.
From a GI perspective , with her trach , she underwent a percutaneous
endoscopic gastrostomy tube for enteral feeds and at times needed to be
placed on total parenteral nutrition as she only occassionally tolerated
tube feeds. She did develop a Clostridium difficile infection
and had to be placed on long-term TPN until resolution of that
infection.
Her renal status at baseline was poor , though she was not on dialysis.
Postoperatively , she never recovered any meaningful renal function of her own.
She was placed on continuous venovenous hemodialysis by the third
week ultimately became anuric , requiring triweekly hemodialysis on Monday ,
Wednesday and Friday , a schedule she was managed on until the time of her
death.
From an ID standpoint , she developed many bacteremias and GI
infections as previously discussed. The Infectious Disease Team
was involved in her care and there recommendations were followed
throughout her hospitalization. For the greater duration of her
ICU course , she was maintained on vancomycin , levofloxacin and
Flagyl on and off for multiple infections.
From an endocrine standpoint , she was maintained on her Synthroid dosing and
was on a CZI drip for blood sugar control throughout her ICU course.
Hematologically , the patient was transfused many many blood
products over the course of her ICU stay. She also developed
heparin-induced thrombocytopenia and subsequent clots to her left
lower extremity requiring vascular surgery intervention. She had
embolectomy and thrombectomy of her left common femoral artery as
well as a left common femoral endarterectomy with patch
angioplasty on 3/13/06 . She was maintained on bivalirudin and
Coumadin throughout her ICU course.
Given her preoperative status and multiple medical comorbidities as well as her
overall poor prognosis through many postsurgical complications , a family
meeting on 10/12/07 resulted in decision to withdraw support and provide
comfort measures only. At that time , tube feeds were stopped , hemodialysis was
stopped
and the patient was made comfortable with morphine until her
ultimate cardiac arrest at 0235 am on 1/16/07 .
eScription document: 0-2080012 CSSten Tel
Dictated By: GREENFELDER , SILVIA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 6155910
D: 1/1/07
T: 8/19/07
Document id: 419
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
240705684 | PUO | 18044090 | | 1934196 | 8/28/2005 12:00:00 a.m. | ACUTE RENAL FAILURE | Signed | DIS | Admission Date: 11/20/2005 Report Status: Signed
Discharge Date: 3/18/2005
ATTENDING: HEIDELBERG , AMIE SALLY MD
DISCHARGE DIAGNOSIS: Acute renal failure.
PRINCIPAL DISCHARGE DIAGNOSIS: Acute on chronic renal failure.
BRIEF HISTORY OF PRESENT ILLNESS: Mr. Helt is a 63-year-old
male , stage III CHF and extensive past medical history notable
for hypertension , insulin-dependent diabetes and an MI , status
post CABG in 1989 and an unsuccessful catheterization in October
2005 , who presented following three days of oliguria. The
patient stated that for the last seven weeks , he has been
travelling on vocation , while he was awake , he noted decreased
dosages of many of his medicines specifically , he reduced his own
Lasix dose from 480 mg daily to 180 mg twice a day He also reduced
his Lotrel by half from 10 mg/40 mg to 5 mg/20 mg. He is also
taking Humalog 10 units , Lantus 45 units and Humulin 5 units. He
stated that his glucose levels were well controlled with blood
sugars less than 140. The patient reports that while he was
away , he felt as good as he has ever felt , was able to walk
greater than longer distances and over all felt much stronger.
However , he states that on Thursday night , he noticed that
instead of urinating as normal of 4-5 times per night , he was
found to only urinate 2-3 times. He did not urinate at all on
subsequent days and then put out merely a point of urine on the
day prior to admission. He reported that his urinary stream was
not the usual strength. He did not report dysuria or sensation
of being incomplete voiding. In addition , he noted that his
weight usually fluctuated approximately 4-6 pounds per day , but
that he had gained approximately 12 pounds since his oliguria
presented. He notes that his legs are swollen more than usual
and he denies chest pain , palpitations , or shortness or breath.
MEDICAL HISTORY: The patient's medical history is notable for
CAD , status post CABG , hypertension , hypercholesterolemia , CHF ,
obstructive sleep apnea , insulin-dependent diabetes and a hiatal
hernia.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Upon admission , his vital signs were
stable with a temperature of 95.8 , heart rate of 60 , blood
pressure 90/50 and saturating 99% on room air. The patient was
an obese male. He was normocephalic and atraumatic with equal ,
round and reactive pupils. His hearing and vision were grossly
intact. His neck exam was significant for JVD of 8 cm. He had
no carotid bruits. His pulmonary exam was clear to auscultation
bilaterally. He had a normal PMI. No right ventricular heave.
His rate and rhythm were normal. He had a normal S1 and S2.
Midsystolic and holosystolic murmur best heard at the apex 3 out
of 6. His abdomen was notable for multiple abdominal scars and a
large abdominal hernia. He had positive bowel sounds. His
abdomen was soft and nontender. His extremities were significant
for 1-2+ pitting edema to ankles. There was no erythema , warmth ,
or calf tenderness. His neurologic exam was nonfocal.
His significant labs on admission was hyponatremia , sodium of 130
and potassium of 2.9. A creatinine of 3.0 , BUN of 99 and a
glucose of 80. His white cells were 9.7. His hematocrit was
36.0. His platelet count was 212 , 000. His UA was negative. His
renal ultrasound showed no hydronephrosis. No obstruction and a
left renal cyst. His chest x-ray showed mild cardiomegaly. No
effusions or no evidence of pneumonia.
HOSPITAL COURSE BY SYSTEM:
Renal. The patient's presentation consistent with acute on
chronic renal failure , which was attributed to low-effective
arterial blood volume and extensive cardiac history notable for
diastolic heart failure in addition to hypertension ,
atherosclerosis , most likely contributed to his chronic kidney
disease with a baseline creatinine in October 2005 of 1.6. He
was initially aggressively treated with diuresis with intravenous
furosemide on admission. His ACE inhibitor was held due to
increased renal perfusion. His urine output increased over his
initial two days of admission and his weight decreased from 261
pounds upon admission to 254 pounds , three days later. His
baseline weight prior to this episode of oliguria was 249 pounds.
His diurese were held per recommendations of the renal consult
team in order to allow for further decrease in his creatinine
before he was given them again. He continued diurese and began
his ACE inhibitor therapy prior to discharge.
Cardiovascular: During his hospital stay , Mr. Helt
experienced multiple episodes of his typical anginal symptoms as
well as a more pronounced episode of 10 out of 10 chest pain on
hospital day #3. During each event , the patient was noted to
have no significant EKG changes and his cardiac enzymes were
always negative. He underwent an echocardiographic exam during
this admission , which was essentially unchanged from his previous
echo on October of 2005. His ejection fraction had increased in
fact to 75%. There was minimal left ventricular hypertrophy. He
was continued on his regimen of isosorbide mononitrate 240 mg
orally every day before noon , which actually was changed from 240 mg every day before noon to 120
mg twice a day for more continuous coverage. He also received his
home regimen of aspirin , statins , Plavix and was started on
heparin for prophylaxis. In addition , his magnesium and
potassium were repleted as necessary. The patient continued his
home regimen of Lantus , Humalog and Regular Insulin by
fingersticks and then self-administering what he needed to
coverage levels. He continued his Synthroid for hypothyroidism
and his TSH was within normal limits during this admission. The
patient's discharge medications included aspirin 325 mg orally
daily , allopurinol 100 mg orally daily , Regular Insulin sliding
scale , which he self-administers , levothyroxine , sodium 50 mcg
orally daily , Toprol-XL 100 mg twice a day , Humalog sliding scale , which
he administers to himself daily , Plavix 75 mg , orally daily , Lantus
45 units subcutaneously every afternoon , Lasix 160 mg orally daily , nitroglycerine
sublinguals as needed for chest pain and Lotrel 5/20 mg orally daily ,
Imdur 240 mg orally daily and Lipitor 40 mg orally daily. The
patient was discharged to home with followup appointment with Dr.
Gruntz in 1-2 weeks.
CONDITION ON DISCHARGE: Stable.
eScription document: 4-2323093 VFFocus
Dictated By: GOBRECHT , ALVERTA
Attending: HEIDELBERG , AMIE SALLY
Dictation ID 3683417
D: 7/20/05
T: 7/16/05
Document id: 420
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
Y |
Y |
N |
Y |
N |
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Y |
N |
N |
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Y |
N |
N |
516880662 | PUO | 11923443 | | 747279 | 6/13/2001 12:00:00 a.m. | UROSEPSIS , MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 6/13/2001 Report Status: Signed
Discharge Date: 10/28/2001
PRINCIPAL DIAGNOSIS: 1. BKA.
2. E. COLI UROSEPSIS.
3. NON-Q-WAVE MI.
SIGNIFICANT PROBLEMS: 1. MORBID OBESITY.
2. PULMONARY EDEMA.
3. PULMONARY HYPERTENSION.
4. RULE OUT PE.
5. OBSTRUCTIVE SLEEP APNEA.
6. ACUTE RENAL FAILURE.
This is the third I Warho Hospital hospitalization for
this 46-year-old morbidly obese female with a history of
insulin-dependent diabetes mellitus complicated by BKA on two prior
occasions , admitted to the MICU with BKA , urosepsis , and a
non-Q-wave MI. On presentation to the Emergency Department , the
patient was confused and therefore proved to be a difficult
historian , but she complained of four days of epigastric pain with
radiation under her right breast. She also complained of abdominal
pain for 4-5 days associated with nausea , but denied vomiting ,
diarrhea , constipation , hematochezia , or melena. In addition , she
complained of some dysuria for the same time period , as well as
subjective fevers , but denied cough , shortness of breath , or any
prior history of heart disease or chest pain.
On presentation to the Emergency Department , her vital signs were
notable for a blood pressure of 189/92 , pulse rate of 120 ,
respiratory rate of 20 , and an O2 sat of 90%. She was found to
have a finger stick blood glucose of 354 , a positive urinalysis ,
and an EKG that was concerning for ischemia. She was started on intravenous
insulin , given sublingual nitroglycerin x three , 4 mg of morphine ,
5 mg of Lopressor , and started on a heparin drip and intravenous
antibiotics , and admitted to the MICU for further management.
PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus ,
with a history of BKA in October 1992 in the
setting of E. coli sepsis of unclear source , history of BKA in
October 2001 in the setting of MS Contin withdrawal. 2.
Hypertension. 3. Iron deficiency anemia. 4. Fibroids. 5.
Status post C-section complicated by wound infection and
dehiscence. 6. Sciatica and low back pain secondary to disc
herniation.
MEDICATIONS: The patient was unable to provide the dose of her
medications , but her medication list on admission
included insulin , amitriptyline , Flexeril , Valium , Prozac , and
albuterol and Atrovent inhalers.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Patient was unable to provide significant details
of her family history.
SOCIAL HISTORY: Notable for positive tobacco use , approximately
one cigarette per day. She was unable to say for
how many years. Positive ethanol use , approximately one drink per
week. She denied intravenous drug use or other illicit drug use. She is
married and has three children.
REVIEW OF SYSTEMS: As noted in the HPI.
PHYSICAL EXAMINATION: Vital signs on admission to the MICU:
Temperature 103.7 , pulse 110 , blood pressure
125/55 , respiratory rate 34 , O2 sat 95% on 2 L. In general , she
was an obese African American female who was confused , but alert
and oriented x two. HEENT: Pupils were equal , round , and reactive
to light. Extraocular movements were intact. Oropharynx was dry
and was notable for a fruity odor. LUNGS: Clear to auscultation
bilaterally. NECK: Supple. CARDIOVASCULAR: Regular rate and
rhythm , no murmurs , rubs , or gallops , with normal S1 and S2.
ABDOMEN: Obese , positive bowel sounds , soft , nondistended ,
positive tenderness in the left lower quadrant , with no guarding or
rebound. EXTREMITIES: 2+ distal pulses , 1+ edema. RECTAL EXAM:
Guaiac negative , with normal tone per ED physician.
LABS: Sodium 139 , potassium 3.9 , chloride 105 , bicarb 19 , BUN 37 ,
creatinine 2.1 ( increased from her baseline of 1.4 ) , glucose
379 , calcium 8.1 , magnesium 2.1 , phosphorus 3 , ALT 33 , AST 56 , alk
phos 119 , T bili 1.0 , amylase 13 , lipase 3 , white blood cell count
14.7 , with 85% polys , 9 bands , and 4 lymphocytes , hematocrit 34.1 ,
platelets 122 , physical therapy 14.2 , PTT 29.1 , INR 1.3 , ABG T at 7.4 , PCO2 32 ,
PO2 82 , O2 saturation 96% , CK 12-35 , MB 1.5 , troponin 1.52 , beta
hydroxybutyrate .7. Positive ACE test. Urine and serum toxicology
screens negative. Urinalysis was notable for a pH of 5.5 , specific
gravity of 1.02 , 3+ protein , 3+ glucose , 1+ ketones , 3+ bloods ,
positive leuk esterase and nitrites , 45-50 white blood cells , 3-4
red blood cells , 3+ bacteria , and 1+ squamous epithelium. Urine
beta-hCG was negative. The chest x-ray showed cephalization and
interstitial edema. Her initial EKG showed .5-1 mm ST depressions
in leads 1 and aVL , 1 mm ST elevations in leads V1 and V2 ,
flattened T waves in leads 1 , aVL , V2 , and V3.
SUMMARY: This is a 42-year-old morbidly obese female with a
history of insulin-dependent diabetes mellitus
complicated by BKA on two prior occasions , who was admitted to the
MICU with a BKA in the setting of urosepsis and a non-Q-wave MI.
HOSPITAL COURSE: Her hospital course by systems is as follows:
1. ENDOCRINE: As noted above , the patient
presented with BKA in the setting of urosepsis and a non-Q-wave MI.
She was placed on an insulin drip and hydrated with intravenous
fluids , with improvement. She was eventually transitioned to NPH
with insulin sliding scale coverage. Despite escalating her dose
of NPH up to 65 U subcutaneously twice a day on the day of discharge , she
continued to have elevated blood sugars >200 and required coverage
with insulin sliding scale. This issue will need to be addressed
as an outpatient.
2. PULMONARY: Posthydration , the patient was noted to have
increasing respiratory rates and O2 requirements and rales on exam.
As her creatinine had improved concurrent with hydration , she was
gently diuresed. An echocardiogram was obtained to assess her left
ventricular function in the context of her non-Q-wave MI , which was
notable for normal left ventricular function , with an EF of 50% ,
hypokinesis of the inferior septum , a right ventricle that was
mildly enlarged , with mildly decreased systolic function , normal
aortic valve , mild TR , and mild MR , and a pulmonary artery pressure
of 39 mm of mercury plus right atrial pressure consistent with
pulmonary hypertension and no pericardial effusion. With her body
habitus putting her at risk for DVT and PE , an echocardiogram which
showed evidence of pulmonary hypertension raised the concern for PE
being responsible for her symptoms of tachypnea and tachycardia. A
spiral CT was obtained that was nondiagnostic secondary to her body
habitus. A VQ scan was obtained , which was read as low probability
for PE. In addition , she also had negative LENIs. These studies
taken together alleviated the concern of PE or DVT in her. It was
felt that the patient likely had obstructive sleep apnea secondary
to her body habitus. She was maintained on CPAP during her
hospitalization stay; however , the patient informed the treating
team that she would not be using a CPAP machine once she returned
home secondary to the inconvenience and discomfort.
3. ID: On admission to MICU , given her positive urinalysis , she
was placed on cefotaxime for gram negative coverage. Both her
blood cultures and urine cultures grew out E. coli which were
sensitive to cefotaxime and gentamycin. As she initially continued
to be febrile and continued to have positive blood cultures , one
dose of gentamycin was given for synergy. Subsequently , she
improved. She remains on intravenous cefotaxime for the 7-day period that
she was in the MICU. On transfer to the floor , she was switched to
orally levofloxacin and will take 7 days of orally levofloxacin to
complete a total 14-day course of antibiotics for urosepsis.
4. CARDIOVASCULAR: Patient ruled in for a non-Q-wave MI by EKG
and enzymes. Her peak CK was 1200 , with a troponin of 1.52. She
was initially placed on aspirin , heparin , and a beta blocker. Once
her creatinine normalized , an ACE inhibitor was also added.
Heparin was discontinued once the concern for PE was alleviated.
Her beta blocker and ACE inhibitor were titrated up for a goal
systolic blood pressure of <140 and a pulse of <70. She was
transferred to the floor on hospital day 7 , where she remained
stable. Another guanosine MIBI was obtained , as the patient
reported that she would be unable to exercise , given her chronic
low back pain and sciatica. A planar study was done secondary to
her body habitus , which revealed a moderate sized area of prior
myocardial infarction throughout the mid LAD coronary territory ,
with moderate residual peri-infarct ischemia. The Cardiology
Service did not feel that the degree of this lesion warranted
catheterization , given the sizable risk of catheterization in her.
5. RENAL: On presentation , the patient had a creatinine of 2.1 ,
up from her baseline of 1.4. She was felt to have acute renal
failure , secondary dehydration , in the setting of diabetic
ketoacidosis. She was rehydrated and concurrent with this her
creatinine returned to her baseline and remained stable thereafter.
6. GI: On admission to the MICU , the patient was placed on GI
prophylaxis with Carafate. Once she was tolerating orally's , she was
placed on an ADA diet and her Carafate was discontinued prior to
discharge. Once transferred to the floor , the patient complained
of diarrhea; however , the nurses did not witness and were unable to
obtain a stool sample to check for C. diff toxin. Patient was
treated symptomatically with Imodium as needed diarrhea. Prior to
discharge , the patient was counseled by the Nutrition Service
regarding an appropriate diabetic and coronary artery disease diet.
7. PAIN: On admission , the patient was on several pain medicines ,
including amitriptyline , Flexeril , and Valium for reported history
of sciatica and low back pain. On this hospitalization , these
medications were discontinued and she was placed on Neurontin for
likely diabetic neuropathy.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
NPH Humulin insulin 65 U subcutaneously twice a day ,
human insulin sliding scale: for blood sugars 151-200 give 4 U ,
for blood sugars 201-250 give 6 U , for blood sugars 251-300 give 8
U , for blood sugars 301-350 give 10 U , Imodium 2 mg orally every 6 hours
as needed diarrhea , Niferex 150 mg orally twice a day , nitroglycerin 1/150
one tab sublingual every 5 min. x 3 as needed chest pain , multivitamin
one tab orally every day , simvastatin 10 mg orally every bedtime , Neurontin 600 mg
orally three times a day , levofloxacin 500 mg orally every day x 5 days , Toprol XL 400
mg orally every day , lisinopril 40 mg orally every day
CONDITION UPON DISCHARGE: Stable.
DISPOSITION: Prior to discharge , the patient was evaluated by the
physical therapist , who noted her to walk around the
hospital Poncepor Ro without significant problems. They felt that she
would be safe to discharge to home and did not need home physical therapy , but
agreed that she would benefit from cardiac rehab , for which she was
referred. Patient was discharged to home on hospital day 9 , with
VNA , who will monitor her blood pressure , pulse , and blood sugar ,
and contact her primary care physician with any concerns or questions. She will
follow up with her primary care physician , Dr. Christy Clardy , at TEVH in one week's
time , and she will follow up with Dr. Christeen Jacobson of cardiology
at I Warho Hospital in April .
Dictated By: ROSSIE VANDUYNE , M.D. I
Attending: SACHIKO BORRIELLO , M.D. WJ71 HN198/594484
Batch: 74915 Index No. RHEDVM2RHH D: 4/18/01
T: 4/18/01
Document id: 421
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
- |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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- |
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N |
N |
068885322 | PUO | 41618858 | | 8692888 | 2/10/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/10/2005 Report Status: Signed
Discharge Date:
ATTENDING: FIERMONTE , EARNESTINE M. M.D.
PRINCIPAL DIAGNOSIS ON ADMISSION: Acute coronary syndrome.
DIAGNOSIS AT DISCHARGE: Includes the following; ST elevation
acute myocardial infarction.
OTHER DIAGNOSIS AT DISCHARGE: Post-MI pericarditis , mural
thrombus , type II diabetes mellitus , colonoscopy with colon
polypectomy in 1991 , hypercholesterolemia , status post umbilical
hernia repair , and questionable hypertension.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: Ms. Tortorella is
72-year-old female with a history of hypercholesterolemia , type
II diabetes mellitus , past smoking , and questionable
hypertension , but no known cardiac disease , who presented to this
hospital with vague epigastric pain/chest pain exacerbated by
deep inspiration and on lying flat. The pain persisted for more
than 48 hours , 10/10 in intensity and prevented her from sleep
finally leading to her presentation to the emergency department
on July , 2005 , where EKG showed Q waves in the anterior
leads with ST elevation in inferior leads II , III , and aVF. She
had elevated enzymes. Her troponin peaked to 20. A bedside
transthoracic echo showed anterior wall motion abnormality. She
was started on aspirin , heparin , Plavix , Integrilin , and
Lopressor , and the patient was taken to the catheterization lab
where she was found to have a 100% proximal LAD lesion and a hazy
90% lesion to the ramus. Two Cypher stents were deployed to the
LAD. The procedure is complicated by no-reflow phenomenon. One
Cypher stent was placed in the ramus branch. Right heart
catheterization revealed RA of 12 , RV 36/7 , PA 38/18 , and no
step-up in oxygenation in the right heart. The patient was
transferred to the CCU where her chest pain persisted. The pain
was positional , increased by deep inspiration and it was felt to
be likely post-MI pericarditis. Her EKG changes persisted , but
her enzymes clearly were trending downwards. The diagnosis of
post-MI pericarditis is consistent with echo findings showing
adhesions between the myocardium and pericardium. An
echocardiogram obtained after the percutaneous coronary
intervention showed an LVEF of 35%. The left ventricular size
was normal. The right ventricle was normal in size and the
thickness of the right ventricle was also normal. There was mild
tricuspid regurgitation. There was mild pericardial thickening
with the areas of adhesions at the pericardium near the apex and
there was a trivial pericardial effusion. Also , a mural sessile
thrombus was observed near the apex of the heart. Her EKG
changes continued to show ST elevation in lead II , III , aVF , V2
through V6 , Q waves in D2 , D3 , and aVF , and she also intermittent
right bundle-branch block morphology. She was treated for
ischemia with ACE inhibitors and beta-blockers titrated to
achieve a pulse in the 70s to 80s. We did not increase it
further because of her low ejection fraction she was unlikely to
tolerate such high doses. She was started on aspirin and Plavix ,
which she continued for her myocardial function. She was placed
on eplerenone and Lasix to achieve a dry weight estimated to be
78 kilograms. This should be her goal weight. She has also been
receiving captopril , ACE inhibitors , for left ventricular
remodeling. Rhythm wise , there has been no arrhythmia noted on
telemetry on which she has been throughout her hospital stay.
For her pericarditis , she initially received 650 mg of aspirin 4
times a day. She was continued on this , but later the dose was
reduced as other anticoagulants were started. She was given
tramadol for her pain with improvement of her pericarditis pain.
Given her mural thrombus , she was anticoagulated initially with
heparin achieving the therapeutic PTT of 80 seconds
approximately. She was later bridged to Coumadin with a target
INR of 2. A higher INR should be avoided thus to avoid
hemopericardium. Endocrine wise , she was treated for her
diabetes with an insulin regimen that consists of Lantus and
Regular Insulin. A cardiac MRI was obtained on February , 2005 ,
with following findings. She had moderate to global left
ventricular dysfunction with basal to distal and anteroseptal
akinesis , apical akinesis , and distal inferior dyskinesis. Her
estimated EF was 38%. There is full-thickness delayed
enhancement of the myocardium indicating a 7th segment , out of
the total of 17 segments , myocardial infarction. There was a
large area of no-reflow within the myocardial infarction , which
is consistent with microvascular thrombosis. The distal or the
free wall is also hypokinetic raising the possibility of right
ventricular involvement from the myocardia l infarction. A
concentric moderate-sized pericardial effusion with exudative
features was also seen. The thickest area of the pericardial
effusion appears to be on the dependent aspect measuring 12 mm in
thickness. There is no right ventricular or right atrial
collapse or compression. Renal wise , she had no issues. Her
creatinine was always below 1 , mostly 0.7 or 0.8.
DISPOSITION: Her plan for disposition is to go to rehab. She
has been evaluated by physical therapy.
An addendum will be dictated with the current status of the
patient and her discharge medications at the time that she is
actually discharged from the hospital.
eScription document: 5-8741073 ISSten Tel
Dictated By: BEOUGHER , GEORGINE JENIFER TRACIE
Attending: FIERMONTE , EARNESTINE M.
Dictation ID 3306272
D: 7/9/05
T: 7/9/05
Document id: 422
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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357007009 | PUO | 73091725 | | 496825 | 6/15/1998 12:00:00 a.m. | CONGESTIVE HEART FAILIURE | Signed | DIS | Admission Date: 2/10/1998 Report Status: Signed
Discharge Date: 10/21/1998
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
SECONDARY DIAGNOSIS: 1. CARDIOMYOPATHY.
2. SUSTAINED VENTRICULAR TACHYCARDIA WITH
DIZZINESS.
3. ATYPICAL CHEST PAIN.
HISTORY OF PRESENT ILLNESS: This is a 38 year old man with
congestive heart failure and abdominal
pain for 48 hours. Patient has a history of dilated
cardiomyopathy , idiopathic familial/ETOH. Last ejection fraction
was 30. He presented to Dr. Danker office today with complaints
of nausea and vomiting for 24-48 hours and mild abdominal pain , mid
epigastric. About two weeks ago , the patient developed upper
respiratory symptoms , cough , low grade temperature , malaise. The
patient also had mild chest pain for a couple of days. On
Saturday , the patient was not feeling great , picked up Chinese food
in Sifayda Orlfull , took a few bites , jumbo shrimp , chicken around 5:00
P.M. He did not feel like eating any more. On Sunday , the patient
developed nausea and vomiting , no blood or mucus in the vomit. He
has had dry heaves for 24 hours , no diarrhea. Bowel movement five
times per day , no fevers. Patient also is noted to become
increasingly short of breath , unable to sleep flat , now with
orthopnea. He used to be able to walk without dyspnea on exertion ,
now , after several blocks , he gets short of breath. Positive PND ,
no edema , no chest pain. Last echo was in 11/27 , left ventricular
ejection fraction 6.6% , ejection fraction 33% , 1+ tricuspid
regurgitation , 2+ mitral regurgitation. Via Dr. Nolan , abdominal
pain is a sign of the patient's congestive heart failure. He was
recently admitted with similar symptoms , diuresed , in October of
1998.
REVIEW OF SYSTEMS: No fever , no diarrhea , no chest pain , no
palpitations , no urinary symptoms. Baseline
weight was 170 pounds.
PAST MEDICAL HISTORY: 1. Cardiomyopathy diagnosed in 1992.
Clean coronaries on catheterization. Left
ventriculogram showed 35% with 3+ mitral regurgitation thought
secondary to idiopathic familial and ETOH , followed by Dr. Nolan .
2. Nonsustained ventricular tachycardia. AICD placed in 11/1 .
3. Left renal infarct in 1992 thought secondary to embolic.
Started on Coumadin. 4. History of hyperthyroidism while on
amiodarone. TSH in 3/17 was 4.24. 5. Pancreatitis , status post
increased lipase in 5/11 .
ALLERGIES: Penicillin.
MEDICATIONS: Lasix 160 mg once daily , captopril 50 mg three times
a day , digoxin 0.125 mg once daily , Coumadin 4 mg
once daily , hydrochlorothiazide 25 mg as needed , K-Dur 20 mg once
daily , Axid 150 mg every bedtime
FAMILY HISTORY: Brother died of congestive heart failure in his
50s. Father died of myocardial infarction at age
56. Uncle died at 90. Mother has diabetes mellitus and
hypertension.
SOCIAL HISTORY: He lives alone , has three children. He is a
former intravenous drug abuser , smokes marijuana daily , no
ethanol use , on Disability.
PHYSICAL EXAMINATION: Generally , this is a young African-American
male , mildly ill appearing. Vital signs
with temperature 96.8 , pulse 101 , blood pressure 130/90.
Respiratory rate 20 , saturation 95% on room air. Weight 175
pounds. HEENT showed no jaundice. Neck with JVP 13 cm , positive
hepatojugular reflux , no bruits. Carotids 2+. Chest was clear to
auscultation , status post AICD scar. Cardiovascular: LV apex 7th
intercostal space , tachy , positive ectopy , positive S4 , S1 , S2 , 3/6
holosystolic murmur best heard at the apex. Abdomen with mild
right upper quadrant tenderness/epigastric. Pulsatile liver ,
positive bowel sounds. Rectal refused. Extremities showed no
edema , well perfused. Pulses 1+ dorsalis pedis , 2+ tibialis
anterior. Neurologic exam was alert and oriented x three , grossly
intact.
LABORATORY EVALUATION: White blood cell count 7.3 , hematocrit
42.4 , platelets 240. PTT 30.6 , INR 3.1.
Urinalysis was pending. EKG showed sinus tachycardia at 123 ,
positive PVCs , left axis deviation , nonspecific T wave inversion
AVL , V5 , V6. Chest x-ray showed a very dilated heart , prominent
hila , increased PVR , no effusions. AICD lead seen in right
ventricle.
ASSESSMENT/PLAN: 1. Congestive heart failure. The patient has
clear evidence of left and right systolic
dysfunction. Patient with known cardiomyopathy , may have had
worsening of function with recent viral upper respiratory
infection. No clear dietary indiscretions. Begin Lasix drip ,
strict Is and Os , daily weights , low salt diet , cardiac monitor ,
check echo. 2. Abdominal pain. May have food poisoning on
Sunday. Also may have gastritis or pancreatitis. Right upper
quadrant pain may be secondary to congestive heart failure.
3. History of hypothyroidism. Check TSH.
HOSPITAL COURSE: Cardiomyopathy service , Dr. Roxanna Molter ,
attending , began following patient on the first
hospital day. It was felt that the Lasix drip was ineffective and
recommended starting 200 mg intravenous Lasix three times a day with the goal of
keeping the patient 1.5 to 2.5 liters negative per day. The
patient had difficulty with repletion of potassium during the
entire hospital stay. Patient does not tolerate well either the
immediate release orally form of potassium or the intravenous form. The intravenous
form hurts the intravenous site and the orally form makes him nauseous , but he
still prefers the orally form. Over the course of the admission , 10
mg orally twice daily of slow released potassium was started and ,
eventually , was 30 mg twice daily at the end of his stay.
Captopril was added to the regimen at 12.5 mg three times a day on
the second hospital day and was eventually raised to 50 mg three
times a day as his blood pressure tolerated , which took four days.
Creatinine remained stable throughout admission and did not affect
our ability to diurese with Lasix. After six days , the patient was
adequately diuresed. JVP was now not visible. Lungs were clear.
There was no edema. The patient is tolerating captopril well.
Coumadin , which had been 4 mg per day on admission , was cut to 2 mg
per day because of the high INR on admission. Two days prior to
discharge , INR fell to 1.9. Patient was restarted on 4 mg per day.
At discharge , INR was 1.7. Patient does not wish to stay to have
INR corrected. VNA has been arranged to administer Lovenox and to
check physical therapy , PTT over the next few days until this normalizes to a
therapeutic level.
DISCHARGE MEDICATIONS: Captopril 50 mg orally three times a day , digoxin 0.125
mg orally every day , Lasix 160 mg orally every day before noon ,
Prilosec 20 mg orally twice a day , Coumadin 4 mg orally every day , Compazine 10
mg orally every 6 hours as needed nausea.
Patient is being discharged home with VNA services. He will follow
up with Dr. Rufus Bernas on 11 of May at 9:20 A.M.
Dictated By: DENISHA MCRORIE , M.D. BM51
Attending: ROXANNA MOLTER , M.D. WV9 CY373/0273
Batch: 2042 Index No. X6FASQZZM D: 7/14/98
T: 2/10/98
CC: 1. RUFUS C. BERNAS , M.D. WW78
Document id: 423
| Target |
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864945124 | PUO | 81278338 | | 2085140 | 11/20/2004 12:00:00 a.m. | CONGESTIVE HEART FAILURE , CARDIOMYOPATHY | Signed | DIS | Admission Date: 5/23/2004 Report Status: Signed
Discharge Date: 10/16/2004
ATTENDING: PERRY HAUB M.D.
HISTORY OF PRESENT ILLNESS:
This is a 36-year-old man with a history of a familial
cardiomyopathy , ejection fraction estimated at around 15% with
marked left and right chamber enlargement , severe mitral
regurgitation , tricuspid regurgitation , and PA pressures of 51
plus right atrium , as per an echo in 2003. He was also status
post ICD placement in 2001. At baseline , he has a one staircase
exercise tolerance before becoming short of breath. He also
admits that he has been having increasing orthopnea and
paroxysmal nocturnal dyspnea. He denies , chest pain ,
palpitations , or peripheral edema. He also has a history of
dietary fluid intake and medications noncompliance leading to
heart failure exacerbations. Currently , he states that he has
been eating "salty foods , " and has been drinking a lot of extra
fluids because he has been feeling dry and is not always taking
his medications. Consequently , he has noticed a worsening in his
exercise tolerance , worsening orthopnea , and most notably an
increase in abdominal girth. Because of these symptoms
consistent with decompensated heart failure , his physicians
suggested that he be admitted to the hospital for management of
his decompensated heart failure. Of note , he has been previously
on a transplant list , but has been delisted given his
noncompliance and continuation of tobacco use.
PAST MEDICAL HISTORY:
In addition to the cardiomyopathy is chronic renal insufficiency
with the creatinine ranging from 1.2 to 3.5 at times.
MEDICATIONS ON ADMISSION:
Aldactone 25 mg once a day , K-Dur 40 mEq once a day , lisinopril
2.5 mg once a day , Isordil 20 mg three times a day , digoxin 0.125
once a day , torsemide 200 mg twice , and metolazone as needed for
volume overload.
SOCIAL HISTORY:
As mentioned , he is smoking one-half per day of cigarettes ,
occasional alcohol use , no intravenous drug use.
FAMILY HISTORY:
His mother , his brother , and his cousin and nephew all have the
familial cardiomyopathy.
PHYSICAL EXAMINATION:
On the day of admission , he presented with the JVP in the 18 to
20 range on the physical examination with positive HJR. His
cardiac exam had a positive S3 of laterally displaced PMI with
the right ventricular heave. He also had a 2/6 systolic murmur.
His abdomen was distended , nontender , but likely with ascites and
palpable liver edge. His extremities were warm without edema.
HOSPITAL COURSE:
From the cardiac standpoint , we initially attempted to diurese
him intravenous torsemide 200 mg twice a day However , he did not respond well
enough to this regimen , and therefore we started drip with
Zaroxolyn as needed We also stopped his Isordil and ACE inhibitor
early on because of blood pressures in the 80s. On admission ,
his creatinine was 2.0 and on the next day of admission , it was
2.2 with low blood pressures , at which point , we decided to start
a low-dose dopamine drips at 2 mcg per hour. However , his urine
output was only about 500 cc negative , so we further increased
the Lasix drip from 10 mg an hour to 20 mg an hour after 200 mg
intravenous Lasix bolus. On this combination of the Lasix drip at 20 an
hour and dopamine at 2 mcg per hour , he began to have very good
and effective urine output at approximately 2-3 liters per day ,
negative , also reflected in his total weight , and came in with
admission weight of around 90 kg. On each day , he diuresed about
an half to kilo off until the day of discharge , at which point ,
he was less than 86 kg. We monitored strict I's and O's , checked
daily weight. During the course of his diuresis , his sodium
levels were decreasing mostly secondary to the patient drinking a
lot of free water. The combination of free water intake in the
setting of natriuresis resulted in further worsening of his
hyponatremia from an admission sodium of 128 to 124 , eventually
to 122. We strictly reinforce the need to limit his fluid intake
to less than 2 liters per day , and at that point , his sodium
levels than rebounded to 124 and also 128 on the day of
discharge. We monitored the twice a day lytes. Eventually , his blood
pressures remained stable. His JVP decreased from 18 to 20 on
admission to about 10 to 12 and continued to have good urine
output , thus we weaned off the dopamine , but continued the Lasix
drip for one more day. We then discontinued the Lasix drip and
transitioned him back over to torsemide 200 twice a day orally , which
was his home regimen and watch him for another 24 hours. He
continued to diurese at this dose , but then on the day of
discharge , his I's and O's were finally about 500 cc negative ,
which is a change from about 1 to 2 liters negative per day. His
JVP was about 9 to 10 and his creatinine was stable at 1.7. We
re-added his Isordil at 10 mg three times a day for the last 24 hours and
his blood pressures were stable in the 90s. Given his potassium ,
which was always borderline low in the 33 or 35 range , we decided
to increase his Aldactone dose to 25 mg twice a day , but given his
underlying renal insufficiency , we have decreased his standing
K-Dur from 40 mEq a day to 20 mEq a day. An echo was done , which
showed an ejection fraction of 20% and 4+ MR. They did not
comment on the synchrony on the preliminary report. However , he
is a candidate for Bi-V pacing given his mildly widened QRS
complex stage III heart failure and having been on a very good
heart failure regimen up until this point.
DISCHARGE MEDICATIONS:
At discharge , his medical regimen consisted of digoxin 0.125 mg
once a day , torsemide 200 mg twice a day , Aldactone 25 mg twice a day ,
Isordil 10 mg three times a day , and K-Dur 20 mEq. We also added folate 5
mg to his regimen because he had an elevated homocystine level.
He also takes Ambien at night as needed for insomnia.
DISPOSITION:
He is being discharged to home with plan to follow up with Dr.
Lyn in her Thyroid Clinic on 3/1/05 . He has been again urged
to stop smoking and to be complaint with his regimen because he
is a good heart transplant candidate and for the current time , he
is not listed given the aforementioned reasons. Overall , Mr.
Kinkle states that his symptoms have drastically improved. He
no longer has orthopnea. He is able to exert himself much more
without symptoms of shortness of breath or lightheadedness , and
he is eager to go home
eScription document: 1-4309936 EMSSten Tel
Dictated By: WINZER , ELFRIEDA
Attending: HAUB , PERRY
Dictation ID 2684934
D: 6/19/04
T: 6/19/04
Document id: 424
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
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Y |
N |
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N |
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Y |
N |
N |
Y |
N |
N |
N |
387532293 | PUO | 85861482 | | 6973837 | 10/19/2006 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 8/20/2006 Report Status: Signed
Discharge Date: 8/6/2006
ATTENDING: PART , JACKSON MD
SERVICE: Cardiology Ottejer Pidsence Liet Pervcho
PRINCIPAL DIAGNOSIS: Myocardial infarction.
ADDITIONAL DIAGNOSES: Hypertension and diabetes.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male
with history of coronary artery disease , hypertension ,
hyperlipidemia who presented with chest pain. The patient was
running up and down the steps on the day of admission when he
developed an 8/10 substernal chest pain radiating to his left
arm. The patient denies any associated shortness of breath , but
he did note diaphoresis. The pain persisted for about 20
minutes. The patient called the EMS but by time he was calling
EMS the pain was dissipating. The patient reports no chest pain
since his last non-ST elevation MI in 2001. Of note , the patient
is a very poor historian and has no recollection of past medical
history or medications. In the emergency room , the patient was
presented with the blood pressure of 172/79 , heart rate of 88 ,
and was given intravenous metoprolol and aspirin. The patient's blood
pressure was difficult to control and he received additional intravenous
Lopressor , hydralazine , and nitro paste.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CAD status post MI in 2001.
3. History of stroke.
4. Diabetes , last hemoglobin A1c of 6.9 in September 2005.
5. Hyperlipidemia.
6. Prostate cancer status post XRT in 1999.
7. History of CKD with baseline creatinine of about 1.3.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metformin 1000 mg orally twice a day
2. Zocor 80 mg orally daily at bedtime.
3. Monopril 40 mg orally daily.
4. Glyburide 10 mg orally once daily.
5. Omeprazole 20 mg orally once daily.
6. Felodipine 10 mg orally once daily.
7. Aspirin 81 mg orally once daily.
8. Hydrochlorothiazide 25 mg orally once daily.
9. NPH 10 units subcutaneously each evening.
SOCIAL HISTORY: The patient is a retired truck driver who lives
with his second wife in His The patient
has a history of alcohol and tobacco use but quit about five
years ago. The patient denies any drug use.
FAMILY HISTORY: The patient has a sister with heart disease in
her 40s.
PHYSICAL EXAMINATION ON ADMISSION: Vital Signs: Temperature
97.4 , heart rate 69 , blood pressure 160/70 , respiratory rate 14 ,
sating 90% on 2 liters nasal cannula. In general , the patient
was awake , alert , and in no acute distress , but answered the
questions slowly and had an unusual affect. HEENT: Pupils were
equal , round , and reactive to light. Mucous membranes were moist
and oropharynx was clear. Neck: JVP less than 10 cm , supple , no
lymphadenopathy. Pulmonary exam: Lungs were clear to
auscultation bilaterally. Cardiovascular exam revealed normal
S1 , S2 with no murmurs , rubs , or gallops. Abdomen was obese ,
soft , nontender , nondistended with positive bowel sounds.
Extremities were warm and well perfused without edema. The
patient had 1+ distal pulses bilaterally. Neurologic exam
revealed cranial nerves II-XII were intact. Exam was otherwise
nonfocal.
LABORATORY DATA ON ADMISSION: The basic metabolic panel ( BMP )
was notable for BUN and creatinine of 28 and 1.6 , magnesium of
1.5. CBC revealed a white count of 7.6 with a hematocrit of 43.6
and platelet count 194. Cardiac enzymes were as follows , the
patient initially had a CPK of 84 with an MB fraction of 1.4 , and
troponin level was less than assay. The patient's desat had a
total CK of 88 and a CK-MB of 2.1 and troponin was 0.58. Chest
x-ray had no infiltrates , no effusions. EKG revealed normal
sinus rhythm with PACs , normal axis intervals , with some T-wave
flattening in V5 , V6 , 1 and aVL.
IMPRESSION: The patient is a 75-year-old male with known CAD
status post MI in 2001 status post an RCA stent at that time. It
was thought unlikely that the patient had flow-limiting coronary
artery disease leading to a non-ST elevation MI.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular:
Ischemia: The patient's chest pain was concerning for
flow-limiting coronary artery disease. The patient was continued
on aspirin and loaded with Plavix upon admission. The patient
was anticoagulated with 1 mg/kg doses of Lovenox every 12 hours The
patient was started on a beta-blocker and given 80 mg of Lipitor.
The patient underwent a diagnostic cardiac catheterization on
the day of admission , which showed a right dominant system with
no significant left main lesions. The patient did have a
proximal 90% LAD lesion as well as a proximal left circumflex
lesion estimated to be about 80%. The patient also had mid
circumflex lesion that was also estimated at 80%. The right
coronary artery had a proximal 50% diffuse lesion and a distal
40% tubular lesion. Right PDA had a tubular 90% lesion in the
mid portion as well as a 90% discrete lesion in the proximal PA.
As the patient was found to have three-vessel disease and a
history of diabetes , surgical revascularization was considered.
The patient was evaluated by the cardiothoracic surgical service
who discussed the case at length with the attending cardiologist
on service. In the end , it was decided by both the attending
cardiologist and the attending cardiothoracic surgeon in contact
with the patient and his wife that the best option at this time
was for percutaneous intervention as it was thought that the
patient would have significant difficulty postoperatively because
of his significant dementia. We felt that the patient would have
a difficult time with the necessary rehabilitation following CABG
and that percutaneous intervention would indeed be the best
option. Therefore , the patient underwent a repeat cardiac
catheterization. The patient had a Cypher stent placed to the
mid LAD lesion. The OM2 lesion was also stented with a Cypher
stent across the non-diseased ostium of OM1 and then the proximal
left circumflex lesion was also stented with a Cypher stent. The
final angiograms during this catheterization showed no residual
stenosis or dissection. The plan was for the patient to return
on an outpatient basis for potential percutaneous intervention to
the PDA/PLV and a stenting of the left renal artery which was
found to be stenotic and likely contributing to the patient's
refractory hypertension and chronic kidney disease. The patient
did well following his percutaneous interventions and he was
discharged on a regimen including aspirin , Plavix , Toprol , and
Zocor. The patient will follow up with Dr. Self in the
next few weeks for possible repeat percutaneous intervention.
Pump: The patient has no history of CHF. An echocardiogram
during this admission revealed moderate concentric LVH with basal
anterior septum basal inferior segment hypokinesis. Ejection
fraction was estimated at 60%. The patient remained euvolemic
for the remainder of the admission. The patient was continued on
his dose of ACE inhibitor. The patient has a long history of
refractory hypertension. The patient's hypertension was likely
exacerbated by a left renal artery stenosis found on his cardiac
catheterization. The patient was continued on his home blood
pressure regimen and additional agents were used as needed to
control his blood pressure. The patient was discharged on a
blood pressure regimen that include felodipine 10 mg orally once
daily , Toprol-XL 150 orally once daily , isosorbide dinitrate 20 mg
orally every 8 hours , and Monopril 40 mg orally once daily. Of note , the
patient was on hydrochlorothiazide as an outpatient but this was
held as he recently received multiple doses of intravenous contrast. The
patient's hydrochlorothiazide can be restarted by his primary
care physician after ensuring that his creatinine is okay.
Rhythm: The patient was monitored on telemetry during this
admission and had no issues.
2. Renal: The patient has a history of chronic kidney disease
with a baseline creatinine 1.3 to 1.6. The patient received
Mucomyst and sodium bicarbonate. Continue intravenous fluids in the peri
catheterization period. The patient's creatinine remained within
his baseline range throughout this admission. The creatinine at
the time of discharge was 1.5.
3. Endocrine: The patient has a history of diabetes , which was
controlled with both insulin and orally agents. Oral agents were
held during this hospitalization and the patient was managed with
both long and short acting insulin. The patient's blood sugars
were well controlled and he was discharged on his home regimen
including metformin , glyburide , and nightly NPH.
4. Neurology: The patient has a history of dementia , which was
thought to be multiinfarct in nature. The patient did have
several episodes of agitation and sundowning during this
admission. The patient required medications to control these ,
rather he was oriented and spoke with his wife on several
occasions. The patient had a workup for reversible causes of
dementia including a TSH , B12 , and an RPR. The TSH and B12 were
within normal limits. The RPR was pending at the time of this
dictation.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally once daily.
2. NPH 10 units subcutaneously daily at bedtime.
3. Isosorbide dinitrate 20 mg orally every 8 hours
4. Nitroglycerin 1/150 one tab sublingual every 5 minutes x3 as needed
chest pain.
5. Felodipine 10 mg orally once daily.
6. Plavix 75 mg orally once daily.
7. Toprol-XL 150 mg orally once daily.
8. Metformin 1000 mg orally twice a day
9. Zocor 80 mg orally daily at bedtime.
10. Omeprazole 20 mg orally once daily.
11. Glyburide 10 mg orally once daily.
12. Monopril 40 mg orally once daily.
FOLLOW UP APPOINTMENTS: The patient was to follow up with Dr.
Self on 7/15/2006 at 11:00 a.m. at the Whihop Hospital . The patient is to follow up with his primary
care physician , Dr. Gusmar , on 2/27/2006 at 8:30 a.m. at the Crossbarn Memorial Hospital as scheduled.
DISCHARGE INSTRUCTIONS: The patient was discharged home with
services. The VNA was instructed to draw a BUN and creatinine on
1/27/06 and page Dr. Rodger Teems , pager number 95571 , with
the results. The VNA was also asked to reconcile the patient's
medication list with his discharge medication list and to clarify
any discrepancies with the patient's primary care physician , Dr.
Gusmar . Also , of note , the patient was instructed to discuss with
Dr. Gusmar the fact that his hydrochlorothiazide was held prior to
his discharge. Hydrochlorothiazide can be restarted provided the
patient's creatinine remains within his baseline range following
discharge.
DISPOSITION: The patient was discharged home with services in
stable condition.
CODE STATUS: The patient remained full code throughout this
entire admission.
eScription document: 3-7369193 HFFocus
CC: Pearline T. Self M.D.
Min Scot Lene
CC: Gaye Gusmar M.D.
Peacema Champ
Pa Atl En
Dictated By: RANDKLEV , VERNON
Attending: PART , JACKSON
Dictation ID 5438612
D: 10/7/06
T: 10/7/06
Document id: 425
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209096147 | PUO | 08723508 | | 619775 | 11/22/1999 12:00:00 a.m. | RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 11/22/1999 Report Status: Signed
Discharge Date: 4/2/1999
IDENTIFICATION: A 73-year-old man with a past medical history
significant for extensive coronary artery disease , diabetes ,
hypertension , hypercholesterolemia , and smoking , who presents with
chest pain , and is admitted for rule out myocardial infarction.
HISTORY OF PRESENT ILLNESS: Mr. Defont has a long history of
coronary artery disease with a coronary artery bypass graft in
1989 , left internal mammary artery to the left anterior descending
artery , saphenous vein graft to the diagonal one , saphenous vein
graft to the posterior descending artery , and saphenous vein graft
to the obtuse marginal artery three. In 1992 he had unstable
angina , and catheterization showed that the distal grafts were
totally occluded. He had a redo coronary artery bypass graft with
saphenous vein graft to the posterior descending artery and the
left circumflex , his postoperative course being complicated by
atrial fibrillation. In 1996 , he had a non-Q wave myocardial
infarction with a percutaneous transluminal coronary angioplasty of
the saphenous vein graft to the diagonal one , and saphenous vein
graft to the posterior descending artery. In 1997 , he had a repeat
percutaneous transluminal coronary angioplasty with an saphenous
vein graft to the diagonal one , and an saphenous vein graft to the
posterior descending artery. Most recently he was admitted in
October of 1999 with an exercise tolerance test mibi , for which
exercise for four minutes and seven seconds he had inferolateral
ischemia. Echocardiogram showed an left ventricular ejection
fraction of 50 percent , anterior inferior posterior hypokinesis , 1
to 2+ mitral regurgitation , pulmonary artery systolic pressure of
42.0 millimeters of mercury plus right atrial pressure of 6.
Catheterization showed 100 percent occlusion of his saphenous vein
graft to the diagonal one , which was stented. His right coronary
artery and diagonal one were totally occluded. His left anterior
descending artery was 95 percent. His left circumflex was clear.
At that time he was randomized to the Toscine Medical Center trial. At baseline ,
Mr. Defont denies exertional chest pain or any angina. He does get
short of breath with one flight of stairs , or going uphill for one
block. He gets claudication after walking three house lots.
He was in his usual state of health until one day prior to
admission when he noted the onset of 4/10 aching chest , shoulder ,
and left arm pain while watching television , and it was associated
with shortness of breath. He sat still , waited for it to
dissipate. At 7:00 p.m. , he took one sublingual nitroglycerin with
a decrease of pain. At 11:00 p.m. , he took one sublingual
nitroglycerin and went to sleep before noting no change in the
pain. He was driving to his appointment with Dr. Mcpeck , his
primary cardiologist on the morning of admission , with the return
of the chest pain for one to two minutes and it was gone
spontaneously. At Dr. Sabaj office , he was noted to have new
lateral T wave inversions and was sent down to the Emergency Room
for admission.
Mr. Defont denies any associated nausea , vomiting , diaphoresis ,
exertional or pleuritic chest pain currently , fever , chills , or
cough. He does report stable lower extremity edema , but denies
orthopnea , paroxysmal nocturnal dyspnea , or palpitations. He has
poor exercise tolerance.
His cardiac risk factors include the following: Age , diabetes ,
hypertension , cholesterol , smoking , and family history.
PAST MEDICAL HISTORY: His past medical history is as follows: 1.
Hypertension. 2. Diabetes with fingersticks of 120 to 160 at
home. 3. Hypercholesterolemia , his last panel in August of 1999
with cholesterol of 164 , HDL of 31 , LDL of 93. 4. Atrial
fibrillation. 5. Chronic renal insufficiency. 6. Benign
prostatic hypertrophy. 7. Peripheral vascular disease , status
post carotid endarterectomies bilaterally. 8. Status post
cholecystectomy and inguinal hernia repair.
ALLERGIES: His allergies include Quinaglute , lisinopril , and
verapamil. He thinks they cause gastrointestinal upset.
MEDICATIONS: His medications include the following: 1. Coumadin
5 milligrams every day 2. Atenolol 25 milligrams every day 3. Mitozalone
5 milligrams every day 4. Lasix 160 milligrams every day 5. Atorvastatin
20 milligrams every bedtime 6. K-Dur 60 mEq every day 7. Rezulin 400 every day
8. NPH 34 every day before noon , 10 every afternoon , regular insulin 4 every afternoon 9.
Finasteride 5 every day 10. Colchicine 0.6 milligrams as needed 11.
Aspirin 81 milligrams every day 12. Restoril 30 milligrams as needed
SOCIAL HISTORY: He occasionally drinks alcohol. He has a 120 pack
year smoking history , quit in 1989. He is a retired machinist and
lives with his wife of 53 years.
FAMILY HISTORY: His father died of a myocardial infarction at 77.
His sister had a coronary artery bypass graft at 70. He has many
brother , one of whom is 71 who had a myocardial infarction at 44 ,
and one who had a coronary artery bypass graft at 70.
PHYSICAL EXAMINATION: On physical examination in general , he is a
pleasant elderly man in no apparent distress. His vital signs , his
heart rate was 96 , blood pressure 174/64 , saturating 95 percent on
room air. He had carotid bruits bilaterally. His lungs were
clear. His jugular venous pressure was less than 5.0 centimeters.
His PMI was nonpalpable. He had a regular rate with a 1/6 systolic
ejection murmur at the left upper sternal border without radiation.
Extremities , he had a left femoral thrill and bilateral femoral
bruits. He had 1+ dorsalis pedis pulses bilaterally. His
extremities were warm without edema. His neurologic examination
was non-focal.
LABORATORY DATA: His labs on admission were significant for a BUN
and creatinine of 49 and 1.3 , hematocrit of 40.5. His urinalysis
was normal. Electrocardiogram shows sinus bradycardia at 53 , left
axis deviation , right bundle branch block , no hypertrophy , no Q ,
new T wave inversion in V4 through V6. Chest x-ray was clear. His
Troponin was 0.45 , CK was 197 , his myoglobin was 159 , his INR was
1.5.
HOSPITAL COURSE: In summary , this is a 73-year-old man with
extensive coronary artery disease , who presents with one day of his
typical anginal pain , multiple bruits , new lateral T wave
inversions , admitted for a rule out myocardial infarction. His
hospital course by issue:
1. Cardiovascular: Mr. Defont was catheterized on the evening of
admission , and he was found to have the following. He was found to
have a saphenous vein graft to the diagonal one was 100 percent
occluded. Saphenous vein graft to the posterior descending artery
was open. His left main was 30 percent occluded. His left
anterior descending artery was 99 percent occluded. His diagonal
one was 100 percent occluded. His left circumflex was 80 percent
occluded. His left subclavian which was supplying his left
internal mammary artery was 100 percent occluded. He was taken
back to the Catheterization Laboratory the next day with Dr.
Reedy who performed a left subclavian artery stent and also a
left brachial artery angioplasty. Mr. Defont tolerated this
procedure well. He had no return of his chest pain after the
procedure , and his pulses remained normal , he had no groin
hematoma. He was placed on Plavix. He also continued his aspirin ,
and his Coumadin was restarted after the heparin and intravenous
TNG which were originally put on board to prevent arterial spasm
after the procedure , were discontinued. His next cardiovascular
issue was his blood pressure. He was originally on atenolol 25
milligrams every day , we added back Cozaar 25 milligrams every day which he
had been on before admission and had been stopped a month prior
because he had low blood pressure with a systolic in the 80s.
However , his first day here , his systolic pressure was 120 to 130 ,
and restarted it. He had no problems with that. His blood
pressure a few days after admission was in the 150 to 160 systolic
over 70 , and amlodipine was added to his regimen. He was continued
on his outpatient doses of Lasix 160 milligrams every day before noon and
mitozalone 5 every day He ruled out for a myocardial infarction.
2. Renal: After the first catheterization , Mr. Charpia creatinine
went from 1.3 to 1.8. However , it went back to 1.3 the next day.
After the second catheterization it went up to a peak of 4.3.
However , his urine output remained at 100 to 150 cc an hour with
Lasix 100 milligrams intravenous as needed , in addition to his morning
dose of 160 milligrams every day before noon , and he was given normal saline
intravenous fluids to equalize his ins and outs. He did not have
any signs of cholesterol emboli , no levator reticularis , no
eosinophilia , no blue toes.
3. Fluids , Electrolytes , Nutrition: He had a low potassium on the
morning of admission with a potassium of 2.7 because he had missed
his outpatient K-Dur of 60 mEq every day He had no symptoms , he had no
electrocardiogram changes. He was repleted throughout admission
and was kept on his outpatient dose of K-Dur and had no problems
further with potassium. In addition , he was discharged on a
standing dose of magnesium because his magnesium was routinely low
throughout admission , on the order of 1.5 to 1.8.
4. Hematology: On the day after his catheterization , his
hematocrit dropped from 33.0 to 28.0. He was transfused two units
with an appropriate bump back to 33.0. He tolerated this without
any problems.
5. Diabetes: He was maintained on his outpatient regimen of NPH
30/10 and 4 regular every afternoon , and Rezulin. His blood sugars were
maintained throughout admission.
6. Genitourinary: He was maintained on his finasteride for benign
prostatic hypertrophy. In addition , he had a biopsy prior to
admission which had shown chronic prostatitis. His outpatient
urologist had recommended ciprofloxacin 500 milligrams twice a day for
thirty days. Since the hospital does not carry ciprofloxacin , we
put him on Levofloxacin 500 milligrams every day He had no return of
those symptoms.
7. Musculoskeletal: On hospital day number four , he developed
excruciating point tenderness in the medial aspect of his right
knee. The knee did not appear swollen or red , and he had no source
of trauma. However , it was thought it might be a recrudescence of
his gout. The next day it was more warm and slightly swollen.
Colchicine helped somewhat , and he was then put on a prednisone
taper starting at 40 milligrams and tolerated this well.
DISPOSITION: He was discharged to home in stable condition on
October , 1999. He has follow-up appointments with his primary
doctor , Dr. Stayner , on August , 2000 , his primary cardiologist ,
Dr. Mcpeck , on January , 1999 , and Dr. Reedy who performed
the procedure on the subclavian artery on January , 2000.
MEDICATIONS ON DISCHARGE: His medications on discharge are the
following: 1. Cozaar 25 milligrams every day 2. Restoril 30
milligrams every day every bedtime as needed 3. Nitroglycerin 0.4 milligrams
as needed chest pain , sublingual , may repeat times three every 5 minutes.
4. Regular insulin 4 units every afternoon , NPH 34 units every day before noon 10 units
every afternoon 5. Rezulin 400 milligrams every day 6. Aspirin 81 milligrams
every day 7. Coumadin 5 milligrams every day 8. Clopidogrel 75 milligrams
every day 9. Magnesium oxide 280 milligrams every day 10. Colchicine 0.6
milligrams as needed 11. K-Dur 60 mEq every day 12. Lasix 160
milligrams every day 13. Mitozalone 5 milligrams every day 14. Atenolol
25 milligrams every day 15. Atorvastatin 20 milligrams every bedtime 16.
Finasteride 5 milligrams every day 17. Ciprofloxacin 500 milligrams
twice a day
Dictated By: COLETTA VERRY , M.D. JA00
Attending: BRITTANEY N. HAMBLET , M.D. ZH5 SB958/6394
Batch: 12308 Index No. L1YC4L53F4 D: 2/19/99
T: 4/2/99
Document id: 426
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
314158242 | PUO | 45896863 | | 351461 | 8/27/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/8/1991 Report Status: Unsigned
Discharge Date: 8/26/1991
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HYPERTENSION.
HYPERCHOLESTEROLEMIA.
PROCEDURES: CORONARY ARTERY BYPASS GRAFTING TIMES THREE
WITH RIGHT CORONARY ARTERY AND LEFT ANTERIOR
DESCENDING ARTERY ENDARTERECTOMY.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
gentleman with known coronary artery
disease admitted for pre-coronary artery bypass grafting
evaluation. The patient's cardiac history dates back to the fall
of 1989 when the patient began to experience exertional angina.
The patient has been followed for his angina since that time.
Currently , the patient experiences angina at the end of most work
days. In light of his young age , he was referred for cardiac
catheterization and probable coronary artery bypass grafting.
HOSPITAL COURSE: The patient underwent cardiac catheterization
on 6/25/91 . This showed severe triple vessel
disease with an essentially normal left ventricle. Thus , the
patient was taken to the Operating Room on 6/13/91 . Under general
endotracheal anesthesia , the patient underwent coronary artery
bypass grafting times three with bilateral internal mammary
arteries. The left internal mammary was taken to the left anterior
descending and the right internal mammary artery was taken to the
right coronary artery. The saphenous vein graft was taken to the
first obtuse marginal branch. The patient was found to have
extremely pronounced atherosclerosis of his coronary arteries.
There were no apparent complications and the patient was taken to
the Intensive Care Unit in stable condition. Postoperatively , the
patient had an entirely smooth postoperative course. He was
maintained on low molecular weight Dextran for 48 hours for his
endarterectomy. The patient was started on enteric coated aspirin
on the first day of his operation. The patient was extubated and
all his chest tubes and mediastinal tubes were removed. The
patient diuresed very well and was started on beta blockers. The
patient remained in normal sinus rhythm and sinus tachycardia for
the entire postoperative course.
DISPOSITION: The patient was discharged home in stable condition.
MEDICATIONS: On discharge included Tenormin , 75 mg
orally every day; enteric coated aspirin , one orally every day; Carafate , 1 gram orally
four times a day; iron sulfate , 325 mg orally every day; Percocet and Colace.
PF607/4233
LOIDA F. GOLEBIOWSKI , M.D. MC6 D: 4/1/91
Batch: 5501 Report: H9312Q8 T: 2/6/91
Dictated By: SALVATORE REISLING , M.D. SZ97
Document id: 427
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
214853927 | PUO | 56987195 | | 1123738 | 3/30/2006 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 3/30/2006 Report Status:
Discharge Date: 10/13/2006
****** FINAL DISCHARGE ORDERS ******
BANDEMER , MILLICENT 778-55-94-7
Jers Tole
Service: CAR
DISCHARGE PATIENT ON: 7/12/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAUB , PERRY , M.D.
CODE STATUS:
No CPR , No defib , No intubation , No pressors
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA 325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 4/30/06 by
ODER , STEWART K. , M.D. , PH.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
282334571 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Today March
LOVENOX ( ENOXAPARIN ) 80 MG subcutaneously twice a day
Starting Today March
Instructions: continue until your INR is > 2.0 ( will be
instructed to stop by the coumadin clinic )
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FOLIC ACID 1 MG orally DAILY
HYDRALAZINE HCL 50 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG inhaled four times a day as needed Wheezing
ISOSORBIDE MONONITRATE ( SR ) 90 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LEVOFLOXACIN 500 MG orally DAILY X 14 Days
Starting Today March Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
LISINOPRIL 20 MG orally DAILY
Override Notice: Override added on 10/15/06 by
ODER , STEWART K. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
556055370 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 10/15/06 by ODER , STEWART K. , M.D. , PH.D.
on order for KCL SLOW RELEASE orally ( ref # 098265321 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: awaer
Previous override information:
Override added on 3/12/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
Previous Override Notice
Override added on 10/19/06 by MARTER , BRYON M. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
821750797 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 10/19/06 by MARTER , BRYON M. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 143881763 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 6/2/06 by ODER , STEWART K. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
446944960 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: mda
Previous override information:
Override added on 6/2/06 by ODER , STEWART K. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
842738538 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 4/30/06 by ODER , STEWART K. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
944706119 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Starting IN PM March
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 4/30/06 by
ODER , STEWART K. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
THIAMINE HCL 100 MG orally DAILY
TORSEMIDE 40 MG orally DAILY Starting IN a.m. March
TRAZODONE 50 MG orally BEDTIME as needed Insomnia
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 7/12/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: md aware
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Stautz , cardiology 10/21/06 2:20 PM scheduled ,
Dr. Enamorado , Wil Medical Center call him for an appointment this week ,
Arrange INR to be drawn on 1/25/06 with f/u INR's to be drawn every
4 days. INR's will be followed by PUO Coumadin Clinic to be drawn by VNA initially
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
bph hypertension
copd ( fev1 1.4L ) right bundle branch block alcohol abuse ( alcohol
abuse ) ischemic cardiomyopathy ( 5 ) cardiomyopathy
( cardiomyopathy ) coronary artery disease ( coronary artery disease )
diabetes mellitus ( diabetes mellitus type 2 ) chf ( congestive heart
failure )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
diuresis
BRIEF RESUME OF HOSPITAL COURSE:
cc: SOB
***
HPI: 73 year-old man with NSCLCa , ischemic CMP with progressive SOB for
48-72 hours. Well over weekend. Admits to missing torsemide
yesterday. Baseline ADLS and climb one flight stairs. Two pillow
orthopnea. No CP. Unable to sleep o/n secondary SOB. ? 1 month R
LEE.
***
PMH: ICMP ( EF 25-30% ) , diastolic dysfunction , cyper to RCA 9/21 ,
cypher to LAD 4/3 , NSLCa ( Stage IIIA small cell CA ) , BPH , HTN , COPD
fev1 1.4 L , DM II
***
Meds - lisinopril 40 , lipitor 80 , plavix 75 , ASA 325 , folic acid 1 ,
hydral 50 three times a day , Toprol XL 50 , MVI , thiamine 100 , torsemide 40 , imdur
90 , trazadone 25 , ambien 5 , nexium , mvi , glyburide
5
***
allgy - NKDA
***
Status PERRL , EOMI , anicteric , OP
clear Supple , no thyromegaly , no LAD 2+ carotids , JVP
10-12 cm R: crackles
base Left: very decreased BS
throughout RRR nl S1 , S2 , +
S3 abd
benign trace
LEE
***
EKG NSR - 92 , RBBB , TWI V5-V6 Echo 10/24 - LV 20-30% , regional WMA ,
diastolic dysfunction
Cath 4/3 - R dom , no sig LM , LAD prox 55% , IVUS with severe plaque
with lumen diameter 2 X 1.4 , successful stenting LAD to
0% no sig LCX dz ,
RCA CXR - pulm edema ,
CT PE - Large L upper lobe mass , subsegmental PE Trop 0.17 -> 0.30 ->
0.43 ( med management only , stop trending )
***
Impression: 73 year-old man with ICM with heart exacerbation + PE ( ?
leading in part to heart failure exacerbation )
1 ) CV - P - ICMP with volume overload - diuresis ( twice home dose
torsemide ) with successful diuresis to weight of 69.5 to 67.1 kg ( at
lower weight became hypotensive ) - cont send on previous home diuretic
regimen and same HTN meds with decrease of lisinopril to 20 mg daily
- re: PE -> no RV strain on echo , on exam and EKG , started on treatment
dose lovenox , to transition to coumadin at home with goal INR 2-3
( indefinitely )
- I - CAD with trop leak - combo CHF exacerbation + PE? - cont ASA ,
plavix , ( on Rx dose lovenox for PE ) , BB , nitrate. Recheck in am - mild
bump again .17 to 0.30 to 0.43 - given overall picture with advanced lung
CA , would not recath -> continued optimal medical management
- R - tele -> no issues
2 ) Onc - currently undergoing XRT ( continued in house ) , primary
oncologist Dr. Enamorado , aware , to see again as outpatient
3 ) HEME - subsegmental PE - lovenox twice a day , with bridge to coumadin
DNR- DNI
ADDITIONAL COMMENTS: Take all medications as prescribed. You have several changes to your
medications. You are now only taking 20 mg of Lisinopril. Also , you are
now taking Coumadin 3mg daily ( the cardiology coumadin clinic will tell
you how to adjust your dose ) and lovenox 80 mg twice daily ( you will stop
these injections when you are told to by the coumadin clinic ).
If you develop chest pain , shortness of breath , or other worrisome
symptoms , please seek medical attention.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- Cont lovenox
- Have INR checked on Thursday by VNA nurse , results to Totin Hospital And Clinic Cardiology Coumadin clinic , to adjust coumadin dose.
No dictated summary
ENTERED BY: MARTER , BRYON M. , M.D. , PH.D. ( VD96 ) 7/12/06 @ 01:05 PM
****** END OF DISCHARGE ORDERS ******
Document id: 428
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
218049983 | PUO | 44640543 | | 0249337 | 9/26/2005 12:00:00 a.m. | Diastolic dysfunction | | DIS | Admission Date: 2/24/2005 Report Status:
Discharge Date: 12/10/2005
****** DISCHARGE ORDERS ******
NATI , SUZIE 277-07-54-4
S Ward
Service: MED
DISCHARGE PATIENT ON: 9/3/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FARRY , CHERRIE L. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally every day
LISINOPRIL 40 MG orally every day
Override Notice: Override added on 9/3/05 by
VARONE , THURMAN B. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 36473941 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 11/29/05 by TROOP , WILFREDO V. , M.D.
on order for KCL intravenous ( ref # 25758734 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: Previous override information:
Override added on 8/23/05 by PANCHAL , PENNI M. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 64994396 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
ZOCOR ( SIMVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LANTUS ( INSULIN GLARGINE ) 40 UNITS subcutaneously every day
NOVOLOG ( INSULIN ASPART ) 6-12 UNITS subcutaneously before meals
Starting Today June as needed Other:meals HOLD IF: NPO
Instructions: please , give with meals
MAXZIDE ( TRIAMTERENE 75MG/HYDROCHLOROTHIAZID... )
1 TAB orally every day
Alert overridden: Override added on 9/3/05 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & TRIAMTERENE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & TRIAMTERENE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & TRIAMTERENE
Reason for override: will follow
METFORMIN 1 , 000 MG orally twice a day
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Gerrard - within one week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Diastolic dysfunction
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Hypertension , DM , high cholesterol , obesity
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Diuresis with intravenous lasix
BRIEF RESUME OF HOSPITAL COURSE:
CC: orthopnea , PND , LE edema
HPI: 42 year-old woman with CHF x 1 yr ( EF not known ) , DM , HTN ,
hypercholesterolemia who presents with increasing weight gain ( 25 lb )
DOE , orthopnea , PND , LE edema x last several weeks. patient denies f/c ,
abdominal pain , n/v/d , dysuria , CP. She reports medical
compliance and follows a low-salt diet. patient has had no recent
changes in her medical regimen. patient does reports chronic ,
intermittent palpitations ( first noticed several years ago , but now
more frequent + lengthy ).
In the ED , patient was afebrile , P 88 , BP 157/79 , sat 89% Ra --> 95% 3L. Her
exam was notable for JVD , bibasilar crackles + LE edema. Her labs were
notable for BNP 533 , cardiac markers negative x 1 , WBC 14.6 , UA + . Her
EKG showed LAE , LVH , STD + TWI in lateral leads ( no comparison ). Her CXR
showed evidence of pulmonary edema with small effusions. She was treated
with ASA , NTGN , lasix , and levaquin.
PMHx: CHF ( no ECHO on file ) , DM with retinopathy , nephropathy , HTN ,
hypercholesterolemia , obesity
MEDS:
ASA , atenolol , lisinopril , norvasc , lasix , simvastatin , lantus ,
metformin , maxzide
ALL: NKDA
SOC: 1 ppd x 10 yrs; former 10 beers per week 0 quit 3 yrs ago; no drugs;
lives with 3 children
FAMHx: FHx DM; no family hx MI , heart failure , sudden cardiac death
ADMISSION EXAM:
T 97.6 P 88 BP 157/79 NAD; able to speak in sentences; no
thyromegaly; no carotid bruit; decreased BS with crackles 1/2 way up;
JVP to earlobe sitting upright; RV heave; RRR S1S2
S3S4; abd soft NT; no HSM; ext 3+ pitting edema; warm
without clubbing; alert + oriented - grossly non-focal
ADMISSION LABS: K 4.2 , Cr 0.9 , WBC 14.6 , Hct 37.7 , Plt 277 , CK 199 , CKMB
5.3 , Tn I < assay , BNP 533 UA 3+ protein , WBC , RBC 2-5 , trace LE
ADMISSION EKG: NSR @ 79 bmp; nl axis; LAE; LVH; TWI I , AVL , V5-V6;
STdep I , AVL , V5-V^ ~0.5 mm; no old for comparison
ADMISSION CXR: cardiomegaly , pulmonary edema , small B effusions
HOSPITAL COURSE:
42 year-old woman with DM , htn , hypercholesterolemia , forger cigs p/with
evidence of acute on chronic heart failure.
CV: pump: *CHF/HTN* Possible etiologies include a )
ischemia - ROMI complete , 10/27 ECHO shows preserved EF 60% , PHTN , ETT
MIBI planned as an outpatient b ) HTN c ) thyroid - TSH 0.6. d )
infiltrative - iron studies with no evidence of hemochromatosis. f ) EtOH
g ) other misc. Trigger might be ischemia , arrythmia , UTI. She was
treated with decreased dose of bblocker , acei , hctz , lasix 40 intravenous twice a day with
goal -1/5 to 2L. Diuresed nicely. Changed to 40 orally every day Check daily
weights , I/O , twice a day lytes. Pulmonary HTN discovered on ECHO may relate
to pulmonary edema. Will need to be reevaluated once patient has been
diuresed. Would also favor evaluation for OSA.
ischemia: *no hx CAD , + RF , no CP , +EKG changes* ROMIcomplete , tele ,
lytes. 10/27 ECHO without wma. EKG changes likely due to LVG. Rx with ASA ,
bblocker , acei , statin. Plan for ETT MIBI as an outpatient.
rhythm: *NSR but subjective palpitations* Tele , lytes. No e/o
arrhythmia.
PULM: *DOE* Likely related to CHF. Wean off O2 as
tolerated ( with diuresis ) - came off of O2 and on room air.
GI: Cardiac/ADA diet , bowel reg.
RENAL: *Cr wnl* Bid lytes with aggressive diuresis.
ENDO: *DM* Lantus + lispro with meals.
ID: *UTI by UA* CHeck Cx. continue levo x 3 days ( started 8/3 )
PROPH: lovenox
CODE: full
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow up with Dr. Bebee within one week.
2. Daily weights in the morning , record your weight , if weight up by more
than 3 lbs , call your doctor.
3. You will need a stress test , repeat Echo , and evaluation for causes of
high blood pressure as an outpatient.
No dictated summary
ENTERED BY: PANCHAL , PENNI M. , M.D. ( LN11 ) 9/3/05 @ 05:47 PM
****** END OF DISCHARGE ORDERS ******
Document id: 429
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
- |
619195676 | PUO | 54206513 | | 2252305 | 4/2/2005 12:00:00 a.m. | AORTIC STENOSIS , CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 4/7/2005 Report Status: Signed
Discharge Date: 9/7/2005
ATTENDING: GOLEBIOWSKI , LOIDA MD
SERVICE:
Cardiac Surgery Service.
DISPOSITION:
To home with VNA service.
PRINCIPAL DISCHARGE DIAGNOSES:
Status post coronary artery disease , status post CABG x2 , aortic
stenosis , status post aortic valve replacement PFO , status post
PFO closure.
OTHER DIAGNOSES:
Hypertension , diabetes mellitus , hyperlipidemia , COPD , cataracts
and osteoarthritis.
HISTORY OF PRESENT ILLNESS:
Mr. Zahm is a 72-year-old obese gentleman who reports to primary care physician
complaining of increased episodes of shortness of breath and achy
chest. The patient with prior negative cardiac catheterization
two to three years ago. The patient was sent for repeat cardiac
catheterization , which revealed three-vessel CAD and aortic
stenosis. The patient presents for CABG and AVR.
PREOPERATIVE CARDIAC STATUS:
Elective. The patient presented with bowel dysfunction. The
patient has a history of class II angina. There has been no
recent angina. The patient does not have symptomatic heart
failure. The patient is in sinus rhythm with first-degree AV
block.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST SURGICAL HISTORY:
Gastric stapling in 1983 and 1984 at C Enwiram Memorial Hospital
with more than 100 pounds of weight loss , regained 50 pounds ,
bilateral open knee surgeries in 1960s , partial colectomy in
1960s , status post appendectomy , status post tonsillectomy ,
status post scalenotomy in 1960 , bilateral sinus surgery in 1997.
FAMILY HISTORY:
Mother deceased in her 80s of unknown etiology , estranged from
brother and father.
PAST MEDICAL HISTORY:
Unknown.
SOCIAL HISTORY:
Widowed , five children , six grandchildren. The patient lives
with son , Daffern . The patient currently has part-time business
coaching baseball , hitting and pitching. The patient is a
retired teacher.
ALLERGIES:
Morphine , which results in nausea.
PREOPERATIVE MEDICATIONS:
Verapamil daily , losartan daily , nitroglycerin sublingual 0.4 mg
as needed angina , aspirin 325 mg daily , albuterol two puffs as needed ,
Advair one puff one to two times a day , atorvastatin daily ,
glipizide daily in a.m. metformin daily in a.m. , Relafen , the
patient unable to recall doses of meds.
PHYSICAL EXAMINATION:
Height and weight 5 feet 11 inches , 128.44 kg. Vital signs:
Temperature 97 , heart rate 67 , BP right arm 120/60 , left arm
112/60 , and oxygen saturation 97% on room air. HEENT:
PERRLA/dentition without evidence of infection/no carotid bruits.
All teeth removed , had maxillary and mid mandibular bone
debridement on 2/28/05 , gums pink , healed and without signs of
infection. Chest: No incisions. Cardiovascular: Regular rate
and rhythm , murmur loudest at right sternal border. All distal
pulses intact. Allen's test left upper extremity abnormal ,
decreased ulnar artery flow , right upper extremity abnormal ,
radial artery flow greater than ulnar. Respiratory: Breath
sounds clear bilaterally. Abdomen: No incisions , soft , no
masses. Extremities: Trace edema , small varicosity right leg.
Neuro: Alert and oriented , no focal deficits.
PREOPERATIVE LABORATORY DATA:
Chemistries: Sodium 141 , potassium 4.1 , chloride 107 , CO2 28 ,
BUN 18 , creatinine 1 , glucose 72 , and magnesium 1.9. Hematology:
WBC 4.93 , hematocrit 36 , hemoglobin 11.6 , platelets 193 , 000 , physical therapy
14.5 , INR 1.1 , PTT 29.9. A1c 6.1. UA was consistent with
infection. Cardiac catheterization data from 4/9/05 performed
at outside hospital showed coronary anatomy 90% distal RCA
stenosis , 30% ostial left main , 70% proximal D2 , 80% proximal
OM1 , 50% mid LAD , right dominant circulation. Echo from 7/27/04
showed 65% ejection fraction , aortic stenosis , mean gradient 39
mmHg , peak gradient 65 mmHg , calculated valve area 0.8 cm2 , mild
aortic insufficiency , trivial mitral insufficiency , and trivial
tricuspid insufficiency. EKG from 10/21/05 showed first-degree
AV block , rate of 67 , left anterior hemiblock , right
bundle-branch block and bifascicular block. Chest x-ray 10/21/05
was normal. The patient was admitted to CSS and stable after
surgery.
DATE OF SURGERY:
10/27/05 .
PREOPERATIVE DIAGNOSIS:
CAD and AF.
PROCEDURE:
AVR with a 27 Carpentier-Edwards pericardial valve and a CABG x2
with LIMA graft to LAD , SVG1 to PDA and PFO closure.
BYPASS TIME:
130 minutes.
CROSSCLAMP TIME:
82 minutes.
COMPLICATIONS:
There were no complications.
HOSPITAL COURSE:
The patient was transferred to the unit in stable fashion with
lines and tubes intact. On postoperative day #1 , 9/9/05 , the
patient was pressor-dependent , slow to extubate. On
postoperative day #2 , 1/22/05 , atrial fibrillation , Lopressor
increased to 25 mg four times a day , became subsequently hypotensive. On
10/4/05 , postoperative day #3 was given 1 unit of packed red
blood cells for hematocrit of 24 , transferred to the Step-Down
Unit on postoperative day #3.
SUMMARY BY SYSTEMS:
1. Neurologic: Alert and oriented x3 , appropriate , follows
commands , given Toradol and oxycodone , Tylenol for pain.
2. Cardiovascular: Started on Lopressor. Preoperative EF of
65% , mean arterial pressure 65 , normal sinus rhythm , rate of 66 ,
bradycardic overnight , but stable morning transfer , Lopressor 25
mg four times a day , atrial and ventricular wires in place. The plan is to
discontinue in the next few days.
3. Respiratory: Stable on 2 liters of oxygen delivered via
nasal cannula. Chest tubes discontinued postoperative day #2.
Chest x-ray was pending.
4. GI: Tolerating orally without difficulty , given Nexium and
Simvastatin.
5. Renal: Continue diuresis with Lasix 10 mg orally three times a day ,
started on insulin sliding scale for blood glucose , received 1
unit packed red blood cells for hematocrit of 24 with
post-hematocrit of 28.3 , started on aspirin , given prophylactic
antibiotics with chest tubes , transferred to the Step-Down Unit
on postoperative day #4 , 9/10/05 doing well. Plan to get PA and
lateral chest x-ray may need rehab , will screen when rate
controlled atrial fibrillation for one hour , now in normal sinus
rhythm. On 8/24/05 , wires discontinued flipping back and forth
for normal sinus rhythm in atrial fibrillation , diuresing well.
We will try and get in normal sinus rhythm for 24 hours before
sending home. On 2/21/05 in normal sinus rhythm all day.
Planned to send home in the morning 2/30/05 to go to home , went
into atrial fibrillation , running between 90-120 starting
Coumadin. On 4/10/05 kept one more day for his atrial
fibrillation , seems to be better rate controlled in 90s , started
on Coumadin , has been having low-grade temps but appears to be
atelectasis on chest x-ray. Postoperative day #9 , 8/9/05 , the
patient was evaluated by Cardiac Surgery Service to be stable to
discharge to home with VNA service with the following discharge
instructions.
DIET:
ADA 2000 calories per day , low-saturated fat , low-cholesterol.
FOLLOW-UP APPOINTMENTS:
Dr. Golebiowski at 117-219-4079 in six weeks , Dr. Ivel , his
cardiologist at 611-252-5021 in two weeks , Dr. Rester , his primary care physician ,
at 549-252-5350 in one to two weeks.
TO DO PLAN:
Make all follow-up appointments. Local wound care. Watch all
wounds daily for signs of infection , redness , swelling , fever ,
pain or discharge. Keep legs elevated while sitting/in bed.
Call primary care physician/cardiologist or Pagham University Of Cardiac
Surgery Service at 117-219-4079 with any questions. INR to be
followed by Pagham University Of Anticoagulation Service
at 132-202-5576. Please call with INR results and for Coumadin
dosing. INR goal of 2 to 3.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Enteric-coated aspirin 81 mg daily , Colace 100 mg twice a day as needed
constipation , glipizide 5 mg twice a day , Niferex 150 mg twice a day ,
oxycodone 5 mg per OS every 6 hours as needed breakthrough pain , Toprol-XL
100 mg daily , Glucophage XR 500 mg everyday after supper , Lipitor
20 mg daily , Coumadin with variable doses to be determined based
on INR.
eScription document: 7-8020183 EMS
Dictated By: CRIDGE , LORRETTA PA
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 0694353
D: 8/9/05
T: 8/9/05
Document id: 430
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
- |
- |
- |
- |
- |
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- |
- |
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- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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- |
924310382 | PUO | 19529329 | | 587509 | 10/2/1998 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 10/12/1998 Report Status: Signed
Discharge Date: 9/21/1998
SERVICE: Nokin Hospital .
PRINCIPAL DIAGNOSES: 1. Myocardial infarction. 2. Non-insulin
dependent diabetes mellitus. 3. Chronic renal insufficiency. 4.
History of renal carcinoma.
PRINCIPAL PROCEDURES: 1. Cardiac catheterization on August , 1998.
2. A stress mibi with viability study on May , 1998. 3.
Percutaneous transluminal coronary angioplasty on July , 1998.
BRIEF HISTORY: The patient is a 52-year-old man with a history of
a 35 to 40 pack year smoking , and non-insulin dependent diabetes
mellitus for 14 years. The patient has been waking with occasional
shortness of breath over the preceding three weeks , and having
chest pressure lasting 30 seconds to a minute that resolves
spontaneously. The night prior to admission , the patient woke from
sleep with severe dyspnea , chest pressure , and diaphoresis. He
denied any nausea , pain , or radiation of his symptoms. The
paramedics were called and the patient was noted to have an oxygen
saturation of 70 to 80 percent on room air. He was intubated in
the field and taken to Norap Valley Hospital . The initial
electrocardiogram revealed ST elevations in V1 to V3 , with T wave
inversions in V3 through V6. He was treated with tPA at Norap Valley Hospital . He was treated with intravenous Lasix for presumed
congestive heart failure and hypertension , and was admitted to the
Cardiac Care Unit. He was placed on nitroglycerin drip which was
titrated to his blood pressure. He was successfully extubated the
following morning. He was started on metoprolol , digoxin ,
lisinopril , and a heparin drip. He underwent an echocardiogram
which showed an ejection fraction of 25 percent with global
hypokinesis. He remained pain-free throughout his hospitalization ,
and had no further episodes of dyspnea. He was transferred to the
I Warho Hospital on February , 1998 for further management of
his myocardial infarction.
PAST MEDICAL HISTORY: 1. History of renal carcinoma status post
nephrectomy in 1994. 2. Non-insulin dependent diabetes mellitus.
3. Mild hypercholesterolemia which is not currently being treated.
4. Renal insufficiency and diabetic nephropathy with a baseline
creatinine of 2.0.
MEDICATIONS: Glyburide. At Norap Valley Hospital : 1. Heparin. 2.
Aspirin. 3. Insulin sliding scale. 4. Lisinopril. 5.
Furosemide. 6. Zocor. 7. Lopressor. 8. Digoxin. 9. Pepcid.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He has a 35 to 40 pack year history of tobacco.
He rarely drinks alcohol , and denies any drug use.
PHYSICAL EXAMINATION: The patient is a pleasant , overweight man in
no acute distress. Vital signs: The patient had a temperature of
98.4 , heart rate 77 , blood pressure 143/78 , respirations 18 , and
oxygen saturation of 91 percent on three liters by nasal cannula.
HEENT examination showed pupils that were equal , round , and
reactive to light and accommodation. Conjunctiva were anicteric.
Extraocular movements are intact , and his oropharynx was clear.
Neck examination was supple with his jugular venous pressure at
approximately 8.0 centimeters. There was no lymphadenopathy.
Chest examination was clear to auscultation bilaterally , with no
rales. Heart examination was regular rate and rhythm with a
non-displaced PMI and a positive S3. There was no murmur.
Abdominal examination showed an obese , soft abdomen with positive
bowel sounds. There was no hepatosplenomegaly or tenderness. No
masses were palpated. The extremities were warm with no edema. He
had 1+ femoral pulses bilaterally. His left lower extremity had a
1+ dorsalis pedis and posterior tibial pulses. His right lower
extremity had a 1+ dorsalis pedis pulse with a nonpalpable
posterior tibial pulse. Neurological examination , he was alert and
oriented x three. Cranial nerves 2 through 12 are intact and
symmetric. He had 5/5 strength throughout. Deep tendon reflexes
were 2+ throughout with downgoing toes bilaterally.
LABORATORY DATA: Laboratory studies from P Therford Hospital showed a sodium
of 139 , potassium of 4.5 , chloride 109 , CO2 of 21 , BUN of 22 , and
creatinine of 2.2. Glucose was 236. Liver function tests were
within normal limits with an alkaline phosphatase of 95 , total
bilirubin of 0.4 , and AST of 39. CPKs were 151 , 163 , and 163 with
no MB fractions done. His TnI was less than 0.2 to 0.3. He had a
white count of 14.2 with a hematocrit of 42.9 and platelets of 222.
His triglycerides were elevated at 303 , and his cholesterol was
elevated at 265 with an HDL fraction of 32 and an LDL fraction of
172. His prothrombin time was 11.3 , partial thromboplastin time
28.4 , and INR 0.85. Urinalysis was negative. An electrocardiogram
was performed at the time of admission which showed resolution of
the ST elevations. He had T wave inversions in V2 through V4 , and
flat T waves in V5 through V6.
HOSPITAL COURSE BY PROBLEM: 1. Myocardial Infarction: He was
continued on a heparin drip , Lopressor , and lisinopril. His
digoxin was discontinued at the time of admission. Nitroglycerin
was given only as needed He remained symptom-free throughout his
hospitalization. His elevated cholesterol was treated. He
underwent cardiac catheterization on July , 1998 which showed 50
percent left main obstruction and 90 percent complex mid left
anterior descending. His right coronary artery was occluded. The
patient did well both during and after the catheterization. The
patient underwent a stress mibi test with a viability study on January , 1998 which showed ischemia during his exercise tolerance test.
The mibi showed severe ischemia in 11/25 segments , as well as an
infarct on the apical septum , apex , and base of the inferior wall.
Options were considered including coronary artery bypass grafting
and angioplasty. After a long discussion with the Cardiology
Service , Cardiac Surgery , the Renal Service and the patient , the
decision was made to proceed with angioplasty. On July , 1998 ,
the patient underwent a percutaneous transluminal coronary
angioplasty of his right coronary artery with zero percent residual
blockage. He also had two stents into his left anterior descending
with zero percent residual blockage. The patient tolerated the
procedure well.
2. Renal: The patient has a history of renal cell carcinoma for
which he underwent a nephrectomy in 1994. He also has chronic
renal insufficiency and diabetic nephropathy. As surgery was being
considered for his cardiac disease , a Renal consultation was
obtained to evaluate his renal status. He underwent a renal
ultrasound showing an exophytic mass in his solitary kidney. This
was very concerning for recurrence of carcinoma. He then underwent
an MRI study which showed a nonenhancing mass in the kidney which
was most consistent with a hyperdense , proteinaceous cyst. This
was reassuring , though cancer could not be ruled out 100 percent.
The patient's renal function remained stable throughout his
hospitalization.
3. Non-insulin Dependent Diabetes Mellitus: The patient was
placed on an insulin sliding scale during his hospitalization. He
was instructed to continue with his Glyburide , and to follow-up as
usual with his outpatient provider.
The patient was discharged to home on October , 1998 , one day
following his second catheterization procedure. The patient did
very well following the procedure , and had remained pain and
dyspnea-free.
DISCHARGE MEDICATIONS INCLUDE: 1. Enteric coated aspirin 325 mg
orally every day 2. Lisinopril 2.5 mg orally every day 3. Lopressor 12.5 mg
orally three times per day. 4. Nitroglycerin 1/150 sublingual
tablets , one sublingually every five minutes x three as needed for
chest pain. 5. Axid 150 mg orally twice a day 6. Lipitor 10 mg orally
every bedtime 7. Glyburide 10 mg orally twice a day 8. Ticlid 250 mg orally
twice a day
FOLLOW-UP: The patient was instructed to follow-up with his
primary care physician , and to call the office to schedule an
appointment. The necessary follow-up with Cardiology and with the
nephrologist will be scheduled as an outpatient.
Dictated By: GERALDO CONCILIO , M.D. SD91
Attending: BREE M. THEILING , M.D. YM0 OP237/6104
Batch: 58093 Index No. F7YRP62E66 D: 2/30/98
T: 8/22/98
Document id: 431
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
- |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
597948455 | PUO | 95443893 | | 0599624 | 4/9/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/9/2003 Report Status: Signed
Discharge Date:
ATTENDING: ROSSIE MANKOSKI M.D.
DIAGNOSIS: Left calcaneus osteomyelitis.
HISTORY OF PRESENT ILLNESS: Mr. Rackley is a 61-year-old
gentleman with type II diabetes , coronary artery disease ,
peripheral neuropathy and hypertension who presents for
evaluation of a longstanding left heel ulcer and presumed
calcaneus osteomyelitis. He also has had multiple surgeries in
the past as well as hyperbaric oxygen and has been refractory to
these treatments. He has had a recent flare in 3/16 and has
been treated at Akcare Hospital . At that time the wound grew
out methicillin resistant staph aureus and e. coli. These
organisms have been treated with Vancomycin and Zosyn. However ,
an MRI at that time was thought to be consistent with
osteomyelitis. The patient presented for treatment of this
issue.
Additionally , the patient has had some left shoulder pain and was
admitted at Akcare Hospital on 1/26/2003 . There was concern for
sepsis at the sternoclavicular joint or perhaps at the
glenohumeral joint. The patient had an MRI at the outside
hospital which is not available to us but was concerning for some
abnormal process at the sternoclavicular joint. The patient
states he still has some shoulder pain that localizes to the
sternoclavicular joint. This seems to be improving over time.
PAST SURGICAL HISTORY: Left heel ulcer and calcaneal
osteomyelitis , BPH status post TURP in 1984 , insulin diabetes
mellitus , hypertension , coronary artery disease status post an MI
in 1991 , cataracts.
ALLERGIES: To codeine.
MEDICATIONS: The patient takes insulin NPH 40 every day before noon and 30
every afternoon , Humalog 20 in the morning 60 at night , Norvasc 5 once a
day , Allopril ( sp? ) 40 once a day , Prilosec 20 once a day , K-Dur
10 once a day , Lasix 40 once a day , enteric coated aspirin 80
once a day , Protonix 40 once a day , Reglan 5 twice a day , Xanax
0.25 every bedtime
PHYSICAL EXAMINATION ON ADMISSION: Vital signs on admission are
stable with a temperature of 98.4. A pleasant gentleman. Clear
lungs. Heart regular rhythm. Abdomen soft and nontender. Left
heel has a 1.5 cm ulcer on the posterior aspect that appears to
tract deep to bone. He has generalized decreased neuropathy in
the foot and minimal EHL or FHL. He has 5/5 _____ with limited
range of motion at the ankle.
LABORATORY VALUES ON ADMISSION: White count of 6 , hematocrit of
30 , sed rate of 111.
HOSPITAL COURSE: The patient was admitted to the hospital for
evaluation and treatment of his calcaneous osteomyelitis. An MRI
was obtained which was read with a bone radiologist and
consistent with osteomyelitis. The patient was taken for
debridement to the operating room , after preoperative clearance
by the medicine team , for debridement of calcaneal osteomyelitis
on 7/6/2003 ( see _____ of the procedure ). Postoperatively the
patient was continued on Vancomycin , levofloxacin and Flagyl per
the infectious disease recommendations. The cultures from the
primary debridement ( in which the wound was able to be closed )
was methicillin resistant staph aureus.
The patient did well inhouse. His wound to the foot was changed
while inhouse and looked intact , clean and dry without drainage.
The drain was removed on postoperative day #4.
Regarding the patient's left sternoclavicular joint , CT scan was
obtained which was concerning for infection at the
sternoclavicular joint. An MRI was obtained to better image the
area and to determine whether or not there is some involvement of
the clavicle. On the CT scan there was no obvious collection
amenable to surgical decompression. At the time of this
dictation the MRI was pending.
The patient had also had a preoperative consult with the Plastic
Surgery team but this was not necessary at the patient's wound
was able to be closed in the OR. Additionally , vascular studies
were obtained which were read as excellent PVRs preoperatively.
FOLLOW UP: The patient will follow up with the Infectious
Disease team as well as primary care physician as well as
Orthopedic Surgery team and Dr. Brannigan one week after discharge.
DISCHARGE MEDICATIONS: Per the ID record , Vancomycin 1 gram
every 24 hours as well as gatifloxacin 200 mg once a day. The patient
will continue his home medicines.
LABS: Labs will be checked once per week by the primary care
physician.
WEIGHTBEARING: The patient will be tested on weightbearing of
the left lower extremity.
eScription document: 0-9161171 DBSSten Tel
Dictated By: BARRETTE , GENNY
Attending: MANKOSKI , ROSSIE
Dictation ID 8155873
D: 1/12/03
T: 1/12/03
Document id: 432
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
Y |
Y |
- |
- |
N |
N |
N |
N |
N |
N |
581312753 | PUO | 77634248 | | 3144050 | 4/18/2006 12:00:00 a.m. | CHF exacerbation , PNA , viral gastroenteritis | | DIS | Admission Date: 9/10/2006 Report Status:
Discharge Date: 12/10/2006
****** FINAL DISCHARGE ORDERS ******
BONING , FREDDA F 207-67-77-5
Courcole Ln.
Service: MED
DISCHARGE PATIENT ON: 8/12/06 AT 10:00 a.m.
CONTINGENT UPON 2PM K+
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOHANAN , SHEA K. , M.D.
CODE STATUS:
No CPR / No defib / No intubation /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Override Notice: Override added on 3/17/06 by
PARDON , HALEY , M.D.
on order for COUMADIN orally ( ref # 997171145 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 100 MG orally DAILY
Alert overridden: Override added on 3/17/06 by
PARDON , HALEY , M.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:Cough
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
GLIPIZIDE 5 MG orally twice a day
GUIATUSS ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours
as needed Other:Cough
KCL SLOW RELEASE 20 MEQ orally twice a day Starting Today July
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
Override Notice: Override added on 3/17/06 by
PARDON , HALEY , M.D.
on order for COUMADIN orally ( ref # 997171145 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: aware
LOPERAMIDE HCL 2 MG orally every 6 hours as needed Diarrhea
ATIVAN ( LORAZEPAM ) 0.5 MG orally DAILY as needed Anxiety
METOLAZONE 2.5 MG orally DAILY Starting Today July
as needed Other:Weight gain
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRAVACHOL ( PRAVASTATIN ) 40 MG orally BEDTIME
Instructions: patient reports problems with simvastatin in the
past. please do not substitute. thank you.
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 6/1/06 by
TROOP , WILFREDO V. , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
PRAVASTATIN SODIUM Reason for override:
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 6/1/06 by
TROOP , WILFREDO V. , M.D.
on order for PRAVACHOL orally ( ref # 292069736 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
PRAVASTATIN SODIUM Reason for override:
Previous override information:
Override added on 3/17/06 by PARDON , HALEY , M.D.
on order for SIMVASTATIN orally ( ref # 260427212 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
TORSEMIDE 20 MG orally twice a day
COUMADIN ( WARFARIN SODIUM ) 1 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/25/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: md aware
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please go to your scheduled appt with Dr. Pidro 9/21/06 scheduled ,
Arrange INR to be drawn on 6/9/06 with f/u INR's to be drawn every
3 days. INR's will be followed by Kum Pidro via VNA report to P Therford Hospital Medicine
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation , PNA , viral gastroenteritis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF ( congestive heart failure ) cad ( coronary artery disease ) htn
( hypertension ) dm ( diabetes mellitus ) gerd ( gastroesophageal reflux
disease ) hypothyroidism ( hypothyroidism ) mitral regurgitation
( 2 ) lung ca history of lobectomy ( lung cancer ) endometrial ca history of TAH/BSO
( endometrial cancer ) basal cell ca ( basal cell
carcinoma ) CRI ( chronic renal dysfunction ) renal artery stenosis history of
L stent ( renal artery stenosis ) recurrent flash pulm edema ( pulmonary
edema )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CXR , diuresis with intravenous medications , EKG , R/O MI , Abdo CT
BRIEF RESUME OF HOSPITAL COURSE:
patient: Ms. Boning , 75M
****
CC: increasing SOB , weight gain
****
HPI: patient is a 75F with a history of CHF/CAD , A-fib , lung CA history of R wedge
resection. She has been admitted 5-6 times this year for CHF
exacerbation. She was in her USOH when over the last 6 days she has
noticed a 6lb weight gain. Additionally , patient experienced increasing SOB ,
and required more pillows to sleep. She uses 2 pillows at baseline. Her
SOB/orthopnea worsened to the point when on the night before admission ,
she was unable to fall asleep even when almost sitting up. Per her primary care physician's
instructions , patient took Metolazone 2.5mg and Torsamide 40mg x1 which did
not increase her UOP. patient also noticed a fever to 101 the night before
admission.
****
ROS: +SOB +PND +orthopnea +fever +chills( chronic ) +decreased UOP x
1-2 days. + L leg swelling for weeks , no CP , no N/V/D , no pyuria , no
dizziness , no palpitations.
Vitals in ED: T98.6 P72 BP121/65 RR18 SaO2 on 2L:98%
patient recieved O2 and 40 Lasix intravenous in the ED.
****
Rx on admit:
1. ASA ( Acetylsalicylic Acid ) orally every day 325MG
2. Allopurinol orally 100 MG every day
3. Docusate Sodium ( Colace ) orally 100 MG twice a day
4. Esomeprazole ( Nexium ) orally 20 MG every day
5. Ferrous Sulfate orally 325 MG three times a day
6. Glipizide orally 5 MG twice a day
7. Kcl Slow Release ( Potassium Chloride Slow Rel. ) 20 MEQ every day
8. Levoxyl ( Levothyroxine Sodium ) orally 100 MCG every day
9. Lorazepam ( Ativan ) orally 0.5 MG every day as needed Insomnia , Anxiety
10. Metolazone orally 2.5 MG every day before noon
11. Metoprolol Succinate Extended Release ( Toprol Xl ) orally 100 MG every day
12. Multivitamins ( Ocuvite ) orally 1 TAB twice a day
13. Pravastatin orally 40 MG every bedtime
14. Torsemide orally 20 MG twice a day
15. Warfarin Sodium ( Coumadin ) orally 2 MG every day
****
Allergies: NKDA
****
PMH: CRI , hypothyroidism , paroxysmal a-fib , DM , CHF , CAD , lung CA history of
R wedge resection , basal cell CA on lip history of resection , uterine CA history of
TAH.
****
FHx: non contrib
****
Social: Lives with husband across street from KAAH . +tob history ,
-EtOH , -IVDU
****
PE on admit: VS:T: 97.6 P77 BP:NR RR20 SaO2100% on
2L C/V irreg irreg , no m/g/r. Lungs crackles at L base , faint crackles at
R base. Legs trace edema but equal. No redness , +tenderness on L shin
+faint ecchymosis.
CXR: Small L effusion , +mild pulm edema.
EKG: A-fib , unchanged
****
A/P: 75F with history of CAD/CHF/lung CA/Afib with 6 days of weight gain ,
worsening SOB and PND , with borderline elevated WBC and dysuria.
1 )C/V
+I- patient was R/OMI'ed with all three sets negative for ischemia. This was
to examine for causes of CHF exacerbation. patient was continued on her home
rx of betablocker , asa , statin
+P- patient normotensive. Likely fluid
overloaded given CXR , physical exam , and HPI. patient was diuresed with intravenous
Lasix in the ED. On the floor she received 2.5mg of Metolazone followed
by 60mg of Torsemide. She was then diuresed with 5mg of Metolazone
followed by 120mg of Torsemide. She was roughly negative 1.3L. patient was
doing clinically well when on 4/23 patient's Cr increased to 3.2 from her
baseline of about 2.5. At that time Torsemide and Metolazone were held.
patient's daily weights continued to decrease even off of diuretics. On 3/4 ,
however patient's weight increased to 72.9 kg from 70.6kg. At this time patient was
restarted on her home rx of torsemide 20mg orally twice a day A repeat weight was
checked in the pm returning as 71.7kg. patient was discharged on 3/4 at a
weight of 158 lbs.
of discharge patient was at or better than her baseline function in terms of
her orthopnea/SOB.
+R- During her stay the patient remained in afib with good rate control
on her bblocker.
2 ) Heme: patient was found to be supertheraputic during her stay. Her coumadin
was held throughout her admission as her INR remained 3.9 to 4.0 in the
setting of hemoptysis. On
discharge patient was started on 1/2 her home coumadin with VNA/primary care physician f/u in 2
days. patient d/ced on Coumadin 1mg every afternoon
3 ) ID- patient had a negative UA and urine CTX. However during her admission patient
developed diarrhea. Because of concern for c.diff colitis. patient recieved an
abdominal CT. CT showed no colitis but did show a LLL consolidation likely
PNA. patient was initially treated with azithromycin but as her cough and o2
requirement did not improve , as well as because patient began to spike fevers ,
patient was begun on ceftaz and levo for gram pos coverage ( levo ) double gram
neg coverage , and atypical coverage ( levo ) for presumed hospital aquired
PNA in the setting of patient's multiple hosp for CHF exacerbation this year.
physical therapy improved clinically and was d/ced on levofloxacin 500mg every 48 hours x 7 days
and ceftaz changed to cefpodoxime 200mg orally every day x 7 days.
patient's diarrhea was concerning for c.diff given fever and high whitecount.
however patient had only been on azithromycin x 1 day. Cdiff , fecal leuks , and
all stool studies were negative during admission. Presumed viral
gastroenteritis. patient started on loperamide before discharge to be continued
as needed diarrhea.
4 ) Endocrine - patient's orally DM rx were held during her admission - she was
covered with Lantus and Insulin Asp SS. HgA1c was sent and was in nl
range. Home orally rx were restarted on
discharge. patient was kept on her home dose of levoxyl; TSH was rechecked
and within nl range. patient's home rx Allopurinol was also continued.
****
PE on D/C
C/V irreg irreg no m/g/r. Lungs CTA with faint bibasalar crackles. Trace
pedal edema
****
Code: DNR/DNI
ADDITIONAL COMMENTS: Please resume your normal home medications.
The following antibiotics were added:
Levofloxacin 500mg by mouth every 48 hours for 7 days
Cefpodoxime 200mg by moouth once daily for 7 days
**
The following medications were added:
Tessalon Perels 100mg by mouth three times daily as needed for cough
Guiatuss 10ml by mouth every 4 hours as needed for cough
Loperamide 2mg by mouth every 6 hours as needed for diarrhea
**
The following medications were changed:
Coumadin: Were taking 2mg by mouth in the pm , now take 1mg by mouth in the
pm.
****
Please have your VNA draw your INR to be reported to P Therford Hospital Medicine in
2 days.
****
Call your primary care physician/go to the ED if you experience any of the following:
increase in shortness of breath , chest pain , nausea , vomiting , decrease
in urine output , requiring more than 2 pillows to sleep at night , any
other symptom that concerns you.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
To primary care physician:
patient was restarted on her home RX. Please f/u with patient's recurrent need for
admission for CHF exacerbation.
patient was supertheraputic on her coumadin. It was held during this admission
but restarted on discharge. Please check her coags.
No dictated summary
ENTERED BY: BOYNES , TALITHA , M.D. ( SL05 ) 10/25/06 @ 01:12 PM
****** END OF DISCHARGE ORDERS ******
Document id: 433
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| output/system_textual_annotation.xml | textual |
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956575530 | PUO | 82335153 | | 4920958 | 11/21/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 6/24/2006 Report Status: Signed
Discharge Date: 11/28/2006
Date of Admission: 6/24/2006
ATTENDING: STUKOWSKI , JANAY MD
SERVICE: Cardiac Surgery Service.
This is a discharge summary addendum to the previously dictated
note by Verda Triarsi , dictated on 10/25/06 .
HOSPITAL COURSE: Mr. Shabel had been prepared for discharge
on postoperative day five , 9/6/06 , however , was noted to
complain of left lower extremity tenderness and erythema. White
blood cell count at that time was noted to be 8.9 with the
patient afebrile. He otherwise remained hemodynamically stable
in normal sinus with stable blood pressure and creatinine of 1.1.
On postoperative day 6 , 2/15/06 , white blood count was
increased at 11.7 with the left lower extremity increasingly
erythematous and tender. SVG tract was noted to contain only
minimal fluid. Negative Homans' sign was observed with the
patient demonstrating no calf tenderness on palpation. The
patient continued to remain afebrile. A course of Keflex was
commenced on postoperative day seven , with the patient's white
count increasing to 12.1 with the patient now demonstrating
continued increase in erythema and warmth along the left lower
extremity at SVG harvest site incision , particularly distal to
the knee. Additionally , of note , Mr. Shabel 's Toprol was
increased to 150 mg orally daily with an extra 2 mg of magnesium
administered on postoperative day seven for sinus rhythm in the
high 90s with blood pressure mildly hypertensive , additionally
with frequent PVCs noted on telemetry. Mr. Shabel continued to
ambulate well on room air and remained afebrile. Leukocytosis
was additionally worked up with urinalysis and chest X-Ray ,
which subsequently demonstrated no infection or infiltrate. Mr.
Shabel is discharged to rehabilitation today , postoperative day
eight , having recovered well following his elective coronary
artery bypass graft procedure , hemodynamically stable with left
lower extremity erythema and tenderness significantly improved
24 hours following initiation of Keflex course. White blood cell
count on the day of discharge has improved to 11.2 with the patient
remaining afebrile.
PHYSICAL EXAMINATION: On day of discharge , the patient is a
pleasant male , appearing younger than stated age , alert and
oriented x3 in no acute distress. Vital signs are as follows:
temperature 99.5 degrees Fahrenheit , heart rate 80 , sinus rhythm ,
blood pressure 118/60 , and oxygen saturation 100% on room air.
Today's weight listed as 0.7 kilograms above his preoperative
weight ( preoperative weight listed as 87.3 kilograms ). HEENT: no
carotid bruits or JVD is appreciated. Pulmonary: lungs are clear
to auscultation bilaterally with slightly diminished breath
sounds at left base. Coronary: regular rate and rhythm , normal
S1 and S2 , no murmurs , rubs , or gallops are appreciated. Abdomen:
slightly distended , mildly obese , soft , nontender , and
nondistended , positive bowel sounds. Extremities: trace
bilateral lower extremity edema. Skin: midline sternotomy
incision , well approximated and healing well , with no erythema or
drainage present. No sternal click is elicited on examination.
Left lower extremity thigh is ecchymotic and tender , no drainage
present from proximal SVG harvest site incision. Left lower
extremity distal to SVG incision and knee erythematous although
improved from prior examinations with decreased erythema ,
warmth , and tenderness along prior SVG tract. No calf tenderness
is present. 2+ pulses at all extremities bilaterally. Neuro:
intact , nonfocal examination.
LAB VALUES ON DAY OF DISCHARGE: ( 3/25/06 ) Sodium 135 , Potassium
4.1 , BUN 33 , Creatinine 1.5 , Glucose 79 , Calcium 9.0 , Magnesium
1.6 ( replaced ) , White Blood Cell Count 11.2 , Hematocrit 28.0 ,
Platelet Count: 380 , 000. Microbiology: negative for VRE and MRSA
and routine screening sent on 9/27/06 . Sputum culture was negative
for growth ( sent 2/15/06 ). Repeat sputum and urine cultures
negative for growth ( sent 3/28/06 ).
DIAGNOSTIC IMAGING: Chest x-ray PA and lateral view obtained day
prior to discharge , 3/28/06 , demonstrates bilateral small pleural
effusions , no pulmonary edema present , and calcified granuloma
present left upper lobe unchanged from prior postoperative and
preoperative films , no pneumothorax or infiltrate present.
Stable cardiomediastinal silhouette and no infiltrate present.
DISPOSITION: Mr. Shabel is discharged to rehabilitation today
having recovered well following his elective CABG procedure. Mr.
Shabel is discharged to rehabilitation today , postoperative day
eight , hemodynamically stable , to continue a course of Keflex for
left lower extremity erythema and additionally to continue one
week of diuresis in the form of low dose Lasix for mild persistent
postoperative pulmonary effusions. Mr. Shabel has been
instructed to shower and monitor incisions for signs of increasing
infection such as fever , drainage , worsening pain or increase in
redness. He is to follow up with his primary care physician for
continued evaluation and management of hypertension , dyslipidemia ,
obesity , obstructive sleep apnea , and uncontrolled Type II diabetes
mellitus. Additionally , the patient will follow up with his
cardiologist for continued evaluation and management of blood
pressure , heart rate , heart rhythm , lipid levels , and for possible
future adjustment in medication. Mr. Shabel will follow up with
his cardiac surgeon , Dr. Janay Stukowski , in six to eight weeks.
Additionally , he will follow up with his cardiologist , Dr.
Marilyn Frehse , in two to four weeks and with his primary care
physician , Dr. Temple Kleiboeker , in one to two weeks.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Include the following. Tylenol 325 mg
orally every 6 hours as needed pain for temperature greater than 101 degrees
Fahrenheit , amlodipine 5 mg orally daily , atorvastatin 10 mg orally
daily , captopril 6.25 mg orally three times a day , Keflex 500 mg orally four times a day
times total of seven days , last dose on 6/21/06 , Colace 100 mg
orally twice a day as needed constipation , enteric-coated aspirin 325 mg
orally daily , Lasix 40 mg orally daily x7 days , hydrochlorothiazide
12.5 mg orally daily , NovoLog 3 units subcutaneously before meals , Lantus 24 units
subcutaneously every 10 p.m. , hold if npo , potassium slow release 20 mEq
orally daily x7 days , Toprol-XL 150 mg orally daily , Niferex 150 mg
orally twice a day , oxycodone 5 to 10 mg orally every 4 hours as needed pain , Ambien
5 mg orally nightly as needed insomnia , NovoLog 6 units subcutaneously with
breakfast , hold if npo , NovoLog 4 units subcutaneously with lunch , hold
if npo , NovoLog 4 units subcutaneously with dinner , hold if npo ,
NovoLog sliding scale subcutaneously before meals , blood sugar less than 125 , give 0
units subcutaneously , blood sugar 125 to 150 , give 2 units subcutaneously , blood
sugar 151 to 200 , give 3 units subcutaneously , blood sugar 201 to 250 ,
give 4 units subcutaneously , blood sugar 251 to 300 , give 6 units subcutaneously ,
blood sugar 301 to 350 , give 8 units subcutaneously , if blood sugar 351 to
400 , give 10 units subcutaneously , call physician if blood sugar greater
than 400 , NovoLog sliding scale subcutaneously every bedtime Please recheck
fingerstick in 1 hour if administering NovoLog at bedtime , if
blood sugar less than 200 , give 0 units subcutaneously , if blood sugar 201
to 250 , give 2 units subcutaneously , blood sugar 251 to 300 , give 3 units
subcutaneously , blood sugar 301 to 350 , give 4 units subcutaneously , blood sugar
351 to 400 , give 5 units subcutaneously , blood sugar greater than 400 ,
call physician.
Mr. Shabel has recovered very well following his elective coronary
artery bypass graft procedure and is anticipated to continue to make
excellent recovery with continued close followup with his primary
care physician and cardiologist. Thank you for referring this
patient to our service. Please do not hesitate to call with further
questions or concerns.
eScription document: 3-5207373 CSSten Tel
CC: Janay Stukowski MD
DIVISION OF CARDIAC SURGERY
E Asan Gardna
CC: Temple Kleiboeker MD
Pagham University Of
E Pines Har
CC: Marilyn Vena Frehse MD
Die Fordgreen Ville
Dictated By: SURGEON , PRICILLA
Attending: STUKOWSKI , JANAY
Dictation ID 9948430
D: 3/25/06
T: 2/4/06
Document id: 434
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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721323695 | PUO | 37130759 | | 3348017 | 10/8/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/22/2005 Report Status: Signed
Discharge Date:
ATTENDING: BALLER , MAX ZOFIA MD
DISCHARGE DATE:
Presumed to be 10/9/05 .
PRIMARY ONCOLOGIST:
Desirae Marcott , M.D.
PRINCIPAL DIAGNOSIS:
Pain secondary to a lytic lesion in the right hip.
SECONDARY DIAGNOSES:
Recurrent lymphoma , pulmonary dysfunction secondary to
chemotherapy and obesity.
HISTORY OF PRESENT ILLNESS:
In brief , this is a 57-year-old female with follicular lymphoma
diagnosed approximately eight years ago who has been treated in
the past with CVP and CHOP/Rituxan. She underwent high-dose
chemotherapy and autologous stem cell rescue in 6/22 . Her
transplant was complicated by worsening of her baseline impaired
lung function , and she has been oxygen dependent since the time
of transplant. In 4/9 , she began to have back pain and
eventually was shown to have recurrent or increasing disease in
the retroperitoneum by abdominal CT ( paraaortic at the level of
L2 ). The decision was made to pursue radiation therapy to this
area , which she completed on 10/4/05 . The patient presented
with complaints of pain in the mid lower back radiating in a
band-like distribution around the waist to the abdomen as well as
into the right hip and buttock area. The pain also radiated into
the right thigh with movement for weightbearing. The patient
reports the pain was occasionally associated with numbness in the
right lateral thigh. She denied any radiation of the pain to
below the knee. She denied any numbness in the lower legs , back
or saddle area. She denied any change in bowel or bladder
function.
The patient had fluoroscopic LP on 6/18/05 with a glucose of 69 ,
a total protein of 49.3 , and cytology which was negative. Plain
films of her hip showed enthesopathy of the superior pelvis
bilaterally , lower lumbar spine degeneration , and sclerotic focus
in the proximal region of the right femur. MRI of the lumbar
spine on 8/5/05 showed an irregular soft tissue mass within the
retroperitoneum centered anterior to the spine at the level of
L2 , position posterior to the IVC and right lateral aorta
measuring 4.5 x 2.7 x 3.4 cm; there is a lesion involving the
anterior superior aspect to the L2 vertebral body continuous with
the anterior paraspinal mass with wedging and probable pathologic
compression fracture. No epidural mass.
PAST MEDICAL HISTORY:
1. Recurrent lymphoma.
2. Pulmonary function thought to be due in part to BCNU
chemotherapy , currently on 5 liters home O2.
3. Status post cholecystectomy.
4. Obesity.
MEDICATIONS AT THE TIME OF ADMISSION:
1. Prednisone 10 mg orally daily.
2. Imuran 100 mg orally every day before noon , 50 mg orally every afternoon
3. Coumadin 6 mg orally every bedtime
4. Lasix 60 mg orally daily.
5. Potassium three times a day
6. Folic acid.
7. Multivitamin.
8. Colace 100 mg orally twice a day
9. MiraLax.
10. Paxil 10 mg orally daily.
11. MS-Contin 60 mg orally three times a day
12. Flexeril one tab orally three times a day
ALLERGIES:
Sulfa , latex.
FAMILY HISTORY:
Father died at the age of 50 from a brain tumor. Mother was
diagnosed with uterine cancer , coronary artery disease , and
diabetes.
SOCIAL HISTORY:
The patient lives with her husband in Ni She denies tobacco and alcohol. She has four grown
children.
PHYSICAL EXAMINATION AT THE TIME OF ADMISSION:
Vitals: Temperature 97.6 , heart rate 91 , blood pressure 140/90 ,
respiratory rate 22 , oxygen saturation 97% on 5 liters. In
general , the patient was found to be alert and oriented x3 with
difficulty standing secondary to pain and habitus. HEENT:
Pupils were equally round and reactive to light. Normal sclerae ,
normal conjunctivae. Extraocular movements were intact. Moist
mucous membranes and clear oropharynx. Neck: No
lymphadenopathy , no thyromegaly. Pulmonary: Clear to
auscultation bilaterally with some wheeze at the right base.
Cardiovascular: Regular rate and rhythm , normal S1 and S2 , no
murmurs , rubs , or gallops. Abdomen: Morbid obesity , nontender ,
normoactive bowel sounds , no hepatosplenomegaly. Back: Mild
paraspinal tenderness bilaterally. Extremities: Bilateral lower
extremity edema. Neuro: 2/5 hip flexion and knee extension and
flexion on the right; 5/5 hip flexion and knee extension and
flexion on the right; 5/5 hip flexion and knee extension and
flexion on the left; distal neuropathy.
LABORATORY STUDIES:
At the time of admission , white cell count 9.8 , hematocrit 35.5 ,
platelets 249. INR 2.1 , PTT 45.8. BMP showed a sodium of 139 ,
potassium 4.2 , chloride 99 , bicarbonate 36 , BUN 19 , creatinine
0.6 , glucose 126. LFTs were within normal limits. UA showed 2+
bacteria but no white cells.
In general , this is a 57-year-old female with follicular lymphoma
who presented for workup of lower back pain recurring status post
XRT to the lumbar spine region.
HOSPITAL COURSE:
1. Oncology: CT of the thoracic , lumbar , and sacral spine on
8/18/05 showed no evidence of cord compression but did show a
compression fracture at L2. IR was consulted on 4/18/05
regarding the possibility of kyphoplasty to this area; however ,
they deferred further treatment , as the pain was thought to be
secondary to hip pathology rather than lumbar spine pathology.
CT of the right hip on 4/18/05 showed a lytic lesion in the
posterior acetabulum with an associated fracture. The patient
was evaluated by Orthopedic Oncology as well as Radiation
Oncology. Dr. Aspen with Orthopedic Oncology deferred any
surgical intervention until the completion of radiation therapy.
The patient started radiation therapy to the right hip on
3/29/05 . The contact in Radiation Oncology is Karlene R Kodish , M.D. , pager number 75551. The plan is for the
patient to complete a course of 18 treatments of radiation to the
right hip. The patient will then have a repeat CT of the right
hip in one month's time and follow up with Dr. Aspen . She has an
appointment to meet with Dr. Aspen on 9/8/05 at 2:45 p.m. Per
recommendations of Orthopedic Oncology and Physical Therapy , the
patient is to be touched down weightbearing on the right leg
( toes only ) and full weightbearing on the left leg. It is
expected that she should be able to undergo physical therapy with
the use of a walker. She should be kept on posterior hip
precaution with limitation of hip flexion and internal rotation
of the right hip.
2. Pain: The patient was seen by the Pain Service during this
hospitalization. Her current pain regimen includes methadone 5
mg orally three times a day , Neurontin 300 mg orally every bedtime , and 100 mg orally
every 8. a.m. and every noon , MSIR 30 mg orally every bedtime as well as 15-30 mg
every 2 hours as needed. The patient was also started on Decadron 10 mg
orally every day before noon given her initial concern for spinal cord
compression. She has been tapering off of the Decadron and will
be discharged on 4 mg orally every day before noon with taper as listed in the
discharge instructions. Once the patient has completed Decadron
2 mg orally every day before noon x3 doses , she should then be started on
prednisone 10 mg orally daily per her home dosing for pulmonary
disease. The patient did receive pamidronate 90 mg intravenous x1 during
this hospitalization.
3. ID: UA on admission was more or less benign , and urine
culture remained negative. The patient was afebrile throughout
her hospitalization. She was given a five-day course of
acyclovir 200 mg orally five times per day for concern of recurrent
genital herpes. Given continued complaints of vaginal itching ,
the patient was given fluconazole 150 mg x1 on 10/17/05 to treat
a presumed yeast infection.
4. GI: The patient has a history of constipation secondary to
use of pain medication. She has been having good bowel movement
on MiraLax , Senna , Colace. She has also writing for Dulcolax
as needed for constipation.
5. Heme: The patient is on Coumadin given a recent history of
DVT. She had an INR of 3.7 two days prior to admission , so her
dosing was reduced during this hospitalization. Her INR has been
stable and is at 2.3 at the time of discharge on dosing of 4.5 mg
orally every bedtime
6. Pulmonary: As mentioned above , the patient has a pulmonary
dysfunction with a home O2 requirement of 5 liters. She has been
stable on this home O2 requirement throughout this
hospitalization. She does require CPAP at night for obstructive
sleep apnea.
7. Cardiovascular: No known history of cardiovascular disease.
Echo on 1/28/04 showed an EF of 55%.
8. Endo: The patient is on a sliding scale of regular insulin
while on Decadron. It is intended that this should be stopped
when the Decadron taper has finished.
9. Fluids , Electrolytes , Nutrition: The patient had some
hypocalcemia during this hospitalization. She was started on
Tums 500 mg orally three times a day , with good response. She was also given
pamidronate x1 as listed above.
CODE:
Full code.
DISPOSITION:
The patient is being discharged to the Waurancevi Ster Waolk Jer Ny Mont for further
rehabilitation. She has a lytic lesion in the right hip with
evidence of fracture. Per recommendations of Orthopedic Oncology
as well as physical therapy , please limit right leg to touchdown
weightbearing only. The patient should be full weightbearing on
the left leg with physical therapy involving use of a walker.
The patient was stable at the time of discharge. She should
continue with her radiation therapy to completion and then follow
up with Dr. Gaylene Faniel , in Orthopedic Oncology on 9/8/05 .
MEDICATIONS AT THE TIME OF DISCHARGE: Include ,
Imuran 100 mg orally every day before noon , 50 mg orally every afternoon; Dulcolax 5 mg orally
daily as needed for constipation; calcium carbonate 500 mg orally
three times a day; Flexeril 10 mg orally three times a day; dexamethasone 4 mg orally daily
x2 doses then 2 mg orally daily x3 doses then start prednisone 10
mg orally daily. Colace 100 mg orally twice a day , Lasix 60 mg orally
daily , Regular Insulin sliding scale , methadone 5 mg orally three times a day ,
Sennosides two tables orally twice a day , Coumadin 4.5 mg orally every afternoon ,
MSIR 30 mg orally every bedtime , MSIR 50-30 mg orally every 2 hours as needed for
pain , Paxil 10 mg orally daily , Mepron 750 mg orally twice a day ,
Neurontin 300 mg orally every bedtime , Neurontin 100 mg orally every 8 a.m. and
every noon , MiraLax 17 g orally daily.
eScription document: 7-8827600 EMSSten Tel
CC: Desirae Marcott MD
Do Terb Ce , North Dakota 77293
CC: Max Zofia Baller MD
Ro Eans
Dictated By: MANKOSKI , ROSSIE
Attending: BALLER , MAX ZOFIA
Dictation ID 6174988
D: 10/9/05
T: 10/9/05
Document id: 435
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
- |
Y |
N |
N |
N |
935717561 | PUO | 73655237 | | 0697837 | 10/14/2007 12:00:00 a.m. | med related dehydration | | DIS | Admission Date: 1/7/2007 Report Status:
Discharge Date: 1/16/2007
****** FINAL DISCHARGE ORDERS ******
LEICHNER , EFREN S 812-26-05-1
Rono Sae Memp
Service: MED
DISCHARGE PATIENT ON: 11/8/07 AT 12:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 11/8/07 by :
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: ok
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
DARBEPOETIN ALFA ( NON-ONCOLOGY ) 40 MCG subcutaneously QWEEK
Instructions: on wednesday
TRICOR ( FENOFIBRATE ( TRICOR ) ) 145 MG orally DAILY
Alert overridden: Override added on 10/3/07 by
HOSTIN , KALLIE L. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN &
FENOFIBRATE , MICRONIZED Reason for override: ok
Number of Doses Required ( approximate ): 4
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
INSULIN ASPART 3 UNITS subcutaneously before meals
LANTUS ( INSULIN GLARGINE ) 48 UNITS subcutaneously DAILY
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled twice a day Food/Drug Interaction Instruction
Contraindicated in Patients with Peanut , Soya or Soyabean
Allergy
LABETALOL HCL 100 MG orally twice a day HOLD IF: HR<55 , SBP<100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
Alert overridden: Override added on 10/3/07 by
HOSTIN , KALLIE L. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: ok
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
120 MG orally DAILY Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Debold primary care physician - please call for appointment for this week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hypotension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
med related dehydration
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM; HTN; obesity; >75 PY smoking history; cri ( chronic renal
dysfunction ); left arm numb; h/0 cva ( cerebrovascular disease ); l thr
( total hip replacement )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: hypotension at home
*****************
HPI: 67M with recent PUO admit for fluid overload in the setting of chronic
kidney disease and dietary salt load. He was sent home on higher doses
of his BP meds as well as the addition of HCTZ to his home lasix dose.
He was also sent home on a 10 day course of cipro for a foley-associated
UTI. He did well until the day of admission when he felt tired , checked
his BP himself at home and found it was 86/41 , so he called his doctor
who directed him the the ER. He denies SOB , COP , orthopnea , PND , N/V ,
abdominal pain , or cough. He has had loose stools x 3 days which he
believes is because the VNA increased his stool softeners. In the ED his
BP was 91/60 with a pulse of 60 and he got 1L fluid.
******************
ADMIT EXAM: t96 , p66 , bp118/60 flat - 100/50standingg , weight 231 ( down
10 lbs from discharge one week ago ) , 99%Ra , obese , NAD , JVP 5 ,
holosystolic murmur at apex , lungs clear , abdomen benign , no LE edema ,
alert and fully oriented and conversant.
*******************
DISCHARGE EXAM: t98 , hr62-77 , bp120-130/60-70 , 100%ra , exam otherwise as
above
*******************
DATA: cr 4.9 on admit , 4.2 on discharge ( from 3.8 baseline ) , bun 125
( from 90s ) , bnp 46. lft's nl , CBC nl , coags nl. ECGL RBBB and LAD
( old ). CXR clear. U/A negative for infection. FeNa 2%.
********************
CONSULTANTS: none
********************
IMPRESSION: 68M with fluid-reponsive hypotension in setting of recent
aggressive diuresis and blood pressure medicine augmentation.
1 ) CV( p ): Mr. Leichner was felt to be hypotensive from being dry in the
setting of overdiuresis and increased stool output. His BP was fluid
responsive to 1L in the ED , after which he was able to maintain orally
hydration. His diuretics were held during his hospital stay and his
lasix will need to be resumed once he begins to put on water weight ( he
may not need the HCTZ , as the synergy of the two diuretics appears to
have been too much for him ). His ARB was held in the setting of his
acute on chronic renal failure and will also need to be resumed once his
creatinine improves to his baseline. His labetalol dose was also reduced
to allow him to mount a heart rate response to hypotension. His
nifedipine dose stayed the same. He was tolerating a regimen of
labetalol 100mg orally twice a day and nifedipine 120mg orally once a day on
discharge , with systolic blood pressures in the 120-130s.
2 ) RENAL: as noted above , the patient appeared to be in acute on
chronic renal failure from overdiuresis. He continued to make good
urine output ( 1-2L per day ) and his creatinine trended downward. His
ARB was held but will need to be restarted as an outpatient.
3 ) DM: he was maintained on his home regimen of lantus 48 , aspartate before every meal
and slide scale. He was on a renal , cardiac , diabetic diet.
FULL CODE
ADDITIONAL COMMENTS: 1 ) Mr. Leichner : your lasix , hydrocholorthiazide , and irbesartan were
stopped. Your doctor will tell you when to restart the irbesartan
( avapro ). Please weigh yourself daily and restart your lasix 80mg once a
day if you gain more than 2 pounds.
2 ) Mr. Leichner : your labetalol is now 100mg twice a day ( was 200mg twice a
day ).
3 ) VNA: please check Mr. Leichner blood pressure , heart rate , and weight
twice a week and call or fax results to primary care physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Please note the following medicines were stopped in the setting of
medicine related hypotension: lasix and hydrochlorothiazide. Please
resume as needed.
2 ) Please note the following medicine was held in the setting of acute
renal failure from dehydration: irbesartan. Please resume when
creatinine has returned to patient's baseline.
No dictated summary
ENTERED BY: HOSTIN , KALLIE L. , M.D. ( CJ00 ) 11/8/07 @ 12:21 PM
****** END OF DISCHARGE ORDERS ******
Document id: 436
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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510916525 | PUO | 07122247 | | 4775206 | 10/10/2006 12:00:00 a.m. | CHF , volume overload | | DIS | Admission Date: 2/27/2006 Report Status:
Discharge Date: 8/6/2006
****** FINAL DISCHARGE ORDERS ******
FULVIO , ANGILA P 456-02-11-5
Bricent Ln. , Robuff Poncera En , Wyoming 71229
Service: RNM
DISCHARGE PATIENT ON: 10/7/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NORSETH , ARDELLA S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
Override Notice: Override added on 8/19/06 by
HEAPHY , ALLA L. , M.D. , D.PHIL.
on order for COUMADIN orally ( ref # 773444442 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 300 MG orally every day
Override Notice: Override added on 8/19/06 by
HEAPHY , ALLA L. , M.D. , D.PHIL.
on order for COUMADIN orally ( ref # 773444442 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
ATENOLOL 100 MG orally every day HOLD IF: SBP<90 , HR<50
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally twice a day
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 8/19/06 by
HEAPHY , ALLA L. , M.D. , D.PHIL.
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: SULFAMETHOXAZOLE & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
TACROLIMUS 1 MG orally every day before noon Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
TACROLIMUS 2 MG orally every afternoon Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally Mon , Wed , Fri
Override Notice: Override added on 8/19/06 by
HEAPHY , ALLA L. , M.D. , D.PHIL.
on order for COUMADIN orally ( ref # 773444442 )
SERIOUS INTERACTION: SULFAMETHOXAZOLE & WARFARIN
Reason for override: aware
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 500 MG orally three times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
AMARYL ( GLIMEPIRIDE ) 4 MG orally every day before noon
Number of Doses Required ( approximate ): 90
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
LANTUS ( INSULIN GLARGINE ) 28 UNITS subcutaneously every afternoon
LASIX ( FUROSEMIDE ) 120 MG orally twice a day
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
Alert overridden: Override added on 10/7/06 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: aware
NIFEREX-150 150 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally every day
as needed Other:volume overload as needed
DIET: Fluid restriction
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Spraglin ( cardiology ) 3/8/06 11AM ,
Dr. Newbury ( primary care physician ) 11/12/06 11:20AM ,
Verfaille , Annabel ( nurse with CHF patients ) 154-044-9411 l19838 Within 2 weeks at your convenience ,
Arrange INR to be drawn on 11/12/06 with f/u INR's to be drawn every
14 days. INR's will be followed by Dr. Newbury
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF , volume overload
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pain hypotension
CAD ( coronary artery disease ) CHF ( congestive heart failure ) diabetes
( diabetes mellitus type 2 ) renal transplant ( kidney
transplant ) AAA repair ( abdominal aortic aneurysm ) open chole
( cholelithiasis ) hypertension ( hypertension )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: wt gain , SOB: CHF flare
------------------------------------------------
HPI: 72yo M unrelated living kidney transplant recipient 6/27 with history of
diastolic dysfunction and multiple previous admissions for CHF flares
with volume overload manifested as SOB and increased weight and increased
LE edema. As an outpatient there has been some concern that patient does
not take his diuretics as prescribed for fear of kidney dysfunction.
Patient now states that he has noted progressive SOB since 10/5 with
marked increased in SOB , DOE and orthopnea over 304 days PTA. patient is
currently unable to walk more than approximately 20 feet without becoming
significantly dyspnic , having to sit and take deep breaths for 5-10
minutes to "catch his breath." patient sleeps on 1 pillow which has not
changed. Denies PND. patient also notes increased abd girth and bl LE
swelling. Gained 18-20lb over last 6months PTA. patient took 80mg orally three times a day up
from 80mg orally twice a day lasix over 3d PTA with respective increase in urine
output. ROS: + chronic intermittent chest pain for many years , described
as a"pressure , " that is focal and migratory throughout abd and around
anterior chest - no increase or change in this recently or with exertion.
+ "productive" cough x2-3 days PTA , no blood - but patient unable to say what
color it was productive of as he does "not look at it." patient also complains
of slight asymmetric swelling of LE L > R. + mild diffuse abd pain "
when I push on it , " which patient states he has only noticed over few days
PTA. No Fevers , chills , NS , change in BMs ( 2 nl , brown BMs/day , no blood ) ,
no diarrhea , no constipation , H/A , L/H , change in eye or ear function
recently.
-------------------------------------------------
PMH:CAD , ppm for SSS , DMII , OSA , CPAP , HTN , gout , AAA repair , history of
choly
ALLERGIES:NKDA
-------------------------------------------------
PE VS: T97.0 P:70 BP:140/78 RR:15 O2 Sat: 98%RA Gen Mild respiratory
distress after walking to BR. Conversant. HEENT Sclerae anicteric.
PERRL. EOMI. Oropharynx clear. Gums , lips , normal. No supraclavicular or
cervical LAD. Thyroid nontender and without nodules. JVP=15cmCV Distant heart
sounds. Regular rate and rhythm. No murmurs rubs or gallops
appreciated. Pulm: Mild end expiratory wheezing throughout with slight
decreased BS at R base. Symmetric & clear percussion throughout. Abd +BS.
Nontender. Obese. Nondistended. No clear ascites on percussion. Ext/Skin
WWP. 2+ Bl LE pitting edema to mid shin , L slightly > R. Pulses sym and
full at radial and dorsalis pedis pulses BL. No rashes. No Calf or leg
tenderness BL. Neuro A+Ox3. Follows complex commands. CN 2-12 symmetric
& intact. Strength 5/5 bilaterally in UE and LE. Conversant &
appropriate. No pronator drift. Normal finger-to-nose.
--------------------------------------------------
HOSPITAL COURSE:
ASSESSMENT: 72yo M kidney transplant recipient on immunomodulatory
medications per protocol with history of diastolic CHF presents with progressive
SOB , DOE and wt gain consistent with volume overload and another CHF
flare.
CV: -Ischemia: No acute issues. Continue home ASA , palvix , statin , BB
-Pump: history of diastolic dysfunction. volume overloaded at admission.
Increased home lasix dose of 80mg orally twice a day to 80mg intravenous three times a day while in
patient. he was negative about 2L each day and his weight
decreased from 225 to 216 at discharge. He was close to his
euvolemic state with his JVP decreasing from 15cm at admission
to 6cm at discharge. Patient discharged on 120mg orally twice a day + 80mg orally every day to
be used as needed for volume overload. Patient was also set up to have
assistance from Verfaille , Annabel from the CHF service to assist with following
his daily weights and lasix use. He will f/u with her as well as his
cardiologist within2 weeks of discharge. Continue BB.
-R&R: On telemetry without event throughout hospital course. Continue
home coumadin , currently therapeutic with goal INR 2-3.
--ID: No current infection.
--RENAL: Cre currently at baseline of about 1.7 history of kidney transplant
approx 2y PTA. Continue immunosuppressants at home dosing. Continue
bactrim prophylaxis
--PULM: Given mild wheezing on exam , patient given Duonebs while in
patient with mild improvement in SOB.
--HEME: Baseline HCT 38-41 Continue home iron replacement
--FEN: Electrolytes were replaced as needed ( Mg and K ). Patient tolerated
an ADA , Low Na , 1.5L fluid , low fat , low cholesterol diet.
--ENDO: nl TSH 8/2 and now=2.136. Contiued home amaryl , lantus.
Patient should have diabetes followed closely as an outpaient.
--NEURO: Ambien given as needed
--PPX: Continued home bactrim and allopurinol. Patient therapeutic on
coumadin. PPI , Colace and senna given while in patient. Encouarged
ambulation.
--CODE: Full
ADDITIONAL COMMENTS: Take all medications as directed and follow your daily weights
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow your daily weights and dose of lasix taken. Follow up closely with
your cardiologist and nephrologist as well as with your primary care physician. Call your
doctor if you have any questions or concerns or if you develop any
concerning symptoms including any chest pain , difficulty breathing or
fever. Call your doctor for weight gain of more than 2lb.
No dictated summary
ENTERED BY: HEAPHY , ALLA L. , M.D. , D.PHIL. ( YT43 ) 10/7/06 @ 02:05 PM
****** END OF DISCHARGE ORDERS ******
Document id: 437
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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744135337 | PUO | 95637816 | | 411642 | 3/25/2002 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 6/27/2002 Report Status: Signed
Discharge Date: 1/1/2002
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
SIGNIFICANT PROBLEMS: 1. CONGESTIVE HEART FAILURE.
2. ATRIAL FIBRILLATION.
3. URINARY TRACT INFECTION.
4. DIABETES MELLITUS.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old woman who
was followed in cardiology by
Dr. Service who has presumed diastolic dysfunction , who was in her
usual state of health until 1/23 , when she was admitted to the Tonsta Ean Villebaxt Hospital with a flare of Crohn's ileitis.
At the time of her discharge , she was not restarted on her Lasix
and subsequently developed fluid retention with gradual worsening ,
shortness of breath and lower extremity edema. The patient noted a
20 lb weight gain during this period , as well as increasing
orthopnea and increasing dyspnea on exertion when getting dressed
or doing any different movements. She was seen in cardiology
clinic on 8/3/02 and found to be in much worse congestive heart
failure with new atrial fibrillation. She was transferred then to
the emergency department here at the I Warho Hospital .
Her most recent echocardiogram on 4/29/01 revealed mild to
moderate left ventricular hypertrophy without any regional wall
motion abnormalities. Her systolic ejection fraction was estimated
to be 60% suggesting a diagnosis of diastolic dysfunction and heart
failure. She was admitted with volume overload for diuresis.
REVIEW OF SYSTEMS: The review of symptoms was notable for chest
tightness with occasional palpitations. She
experienced no dizziness , no syncope and no recent diarrhea , no
abdominal pain , no nausea or vomiting. She did report chronic
arthritis.
PAST MEDICAL HISTORY: ( 1 ) Significant for congestive heart failure
due to diastolic dysfunction , ( 2 ) Crohn's
colitis diagnosed in 1963 , ( 3 ) Right breast carcinoma stage II
previously treated , not currently active , ( 4 ) Diabetes mellitus ,
( 5 ) Obstructive sleep apnea , ( 6 ) Gastroesophageal reflux disease ,
( 7 ) Hypercholesterolemia , ( 8 ) Osteoarthritis.
SOCIAL HISTORY: The patient is a prior tobacco smoker , having
smoked two packs per day for 38 years , but has
quit. She does not drink alcohol and does not use any recreational
drugs. The patient lives in A Kaneard Au with a friend and is a retired
x-ray technician.
FAMILY HISTORY: Noncontributory.
ALLERGIES: The patient's medical allergies include penicillin ,
which causes a rash , Demerol and Dilaudid causing
nausea , and Macrodantin.
PHYSICAL EXAMINATION: VITAL SIGNS: Included a temperature of 97 ,
heart rate 76 , blood pressure 90/60 ,
respiratory rate 28 , and a saturation of 97% on room air. The
patient was noted to be in atrial fibrillation. GENERAL: Physical
examination showed that the patient was alert and oriented x3 , in
no acute distress , having shortness of breath while sitting up in
bed. HEENT: Normocephalic , atraumatic , pupils equal , round , and
reactive , extraocular movements were intact. NECK: Showed jugular
venous distention to at least 20 cm. CHEST: Showed crackles
posteriorly approximately half of the way up. CARDIOVASCULAR:
Showed an irregular rhythm and a systolic ejection murmur
consistent with the prior diagnosis of aortic stenosis. ABDOMEN:
Showed profound obesity. EXTREMITIES: Showed significant pitting
edema bilaterally over the calves.
LABORATORY DATA: Showed a white blood cell count of 7 , hematocrit
31 , platelets of 148. Sodium was 142 , potassium
3.9 , BUN 56 , creatinine 1.3 , with a glucose of 75. Liver function
tests were normal. CK was 44 and troponin was 0.02. A chest x-ray
showed mild pulmonary vascular congestion without any evidence of
infiltrates. EKG showed atrial fibrillation at a rate of 72 ,
otherwise no abnormalities beside some nonspecific ST-T wave
changes. Urinalysis showed evidence of an urinary tract infection
with 20-30 white blood cells and was leukocyte esterase positive.
Urine culture was sent at that time.
HOSPITAL COURSE: 1. Congestive heart failure - The patient was
started on intravenous Lasix along with Zaroxolyn and
responded with a brisk diuresis over the course of the admission.
The patient's weight declined by approximately 5.2 kg. It was
estimated that the total volume of fluid removed was approximately
15 liters. The patient was reported great improvement in her
symptoms , was able to ambulate without requiring supplemental
oxygen. The patient was switched to orally Lasix and continued her
diuresis. The day prior to discharge , the patient was switched to
orally torsemide , and she will be discharged on that medication.
2. Atrial fibrillation - The patient was noted to have new onset
of atrial fibrillation while being seen in cardiology clinic on
8/3/02 . Since it was not known how long the atrial fibrillation
had been going on , a decision was made to anticoagulate the
patient. She was initially started on intravenous unfractionated
heparin while starting anticoagulation with Coumadin. The patient
reached a therapeutic INR of 2.5 within approximately 4-5 days and
the intravenous heparin was discontinued. At the time of discharge , the
patient INR was 3.2. She will have INR follow up through her
primary cardiologist , Dr. Service . Currently , the decision to
cardiovert the patient is left in the hands of her outpatient
cardiologist.
3. Urinary tract infection - The patient's initial urinalysis
indicated a bacterial urinary tract infection. Subsequent urine
culture grew out E. coli , which was subsequently determined to be
resistant to levofloxacin. Initially , the patient had been started
on intravenous levofloxacin , which was subsequently changed to orally
cefixime. The patient completed a five-day course of orally cefixime
while here in the hospital and was discharged on that medicine to
complete a 10-day course. Of note , the initial symptoms the
patient had including hematuria , resolved by the time of discharge.
4. Diabetes mellitus - The patient has a long history of diabetes
requiring insulin treatment. She is followed by endocrinologist at
the Ainam Iro Hospital . During this hospitalization , her
blood sugars were maintained with insulin subcutaneous injections.
The patient is to continue the management of her diabetes per her
endocrinologist.
DISCHARGE MEDICATIONS: ( 1 ) Vitamin C 500 mg orally every day , ( 2 ) ferrous
sulfate 300 mg orally every day , ( 3 ) insulin Lente
subcutaneous 30 U every bedtime , ( 4 ) insulin Regular subcutaneous 30 U
every bedtime , ( 5 ) Synthroid 200 mcg orally every day , ( 6 ) Zaroxolyn 5 mg orally
every day before noon , ( 7 ) tamoxifen 20 mg orally every bedtime , ( 8 ) Vitamin E 400 U orally
every day , ( 9 ) Coumadin 5 mg orally every bedtime , ( 10 ) multivitamins 1 tablet
orally every day , ( 11 ) Zocor 40 mg orally every bedtime , ( 12 ) insulin 70/30 35 U
subcutaneously every day before noon , ( 13 ) Neurontin 300 mg orally every day before noon , 100 mg orally at
2:00 p.m. , 300 mg orally every bedtime , ( 14 ) Serevent inhaled 1 puff twice a day ,
( 15 ) torsemide 100 orally every day before noon , ( 16 ) Trusopt 1 drop twice a day ,
( 17 ) Flonase nasal 1-2 sprays twice a day , ( 18 ) Xalatan 1 drop ocular.
every bedtime , ( 19 ) Pulmicort inhaled 1 puff twice a day , ( 20 ) Celebrex 100 mg
orally twice a day , ( 21 ) Avandia 4 mg orally every day , ( 22 ) Hyzaar 12.5 mg/50 mg
1 tablet orally every day , ( 23 ) Nexium 20 mg orally every day , ( 24 ) potassium
chloride 20 mEq orally twice a day , ( 25 ) Suprax 400 mg orally every day x4 days ,
( 26 ) albuterol inhaled 2 puffs four times a day as needed wheezing ,
( 27 ) miconazole 2% powder applied topically on skin twice a day for
itching.
CONDITION ON DISCHARGE: The patient is stable upon discharge.
DISCHARGE DISPOSITION: The patient is discharged to home with the
following services: ( 1 ) Visiting nurse on
Wednesday , 5/6/02 , who will send blood for INR and a basic
metabolic seven panel to be sent to Dr. Service , her primary
cardiologist. ( 2 ) The patient has an appointment scheduled with
Dr. Service on 3/29/02 at 4:00 p.m. , which is already scheduled.
Dictated By: ELLIS RETZLER , M.D. EU77
Attending: FLOYD T. LYN , M.D. CM6 BM004/854711
Batch: 68380 Index No. JTTTBQ7Y66 D: 11/8/02
T: 11/8/02
Document id: 438
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
Y |
Y |
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U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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- |
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517077919 | PUO | 45227626 | | 6922441 | 2/23/2006 12:00:00 a.m. | HEAD TRAUMA , history of FALL | Unsigned | DIS | Admission Date: 10/26/2006 Report Status: Unsigned
Discharge Date: 8/1/2006
ATTENDING: HEIDELBERG , AMIE SALLY MD
PRINCIPAL DIAGNOSIS: Intracranial hemorrhage.
LIST OF PROBLEMS AND DIAGNOSES: Diabetes mellitus , gout , history
of DVTs , status post right lumpectomy , history of NSVT status
post AICD placement , hypertension , coronary artery disease status
post myocardial infarction x2 , COPD on home oxygen ,
hypothyroidism , depression , gastroesophageal reflux disease ,
dilated cardiomyopathy.
BRIEF HISTORY OF PRESENT ILLNESS: She is a 63-year-old female
with multiple medical problems admitted 10/30/06 after
ventricular VFib arrest with AICD discharge and associated fall
on Coumadin. Current mental status limits history but per prior
notes , the patient fell on 11/19/06 with loss of consciousness
for two or three minutes after feeling dizzy. She presented to
the Emergency Department on 10/30/06 with complaints of 8/10
headaches; the RN at the assisted living facility
suggested that she be evaluated immediately postfall. The
patient complains of confusion postfall , lasting until
presentation. She denied nausea or vomiting. Headache had been
constant since fall. Also , complains of right knee pain that was
worse with ambulation. Head CT noted intracranial hemorrhage ,
subdural hemorrhage and small subarachnoid hemorrhage. Her INR
at that time was 3.3. She was admitted to the MICU on the
Neurosurgical Service from 10/30/06 to 10/17/06 without operative
intervention. She received factor VII , multiple units of FFP ,
and subcutaneous vitamin K for elevated INR. She was empirically
started on seizure prophylaxis with Dilantin and Keppra , followed
closely by Neurology and a continuous EEG monitoring. ICU course
was notable for slowly rising LFTs ascribed to Dilantin ,
worsening acute on chronic renal failure , congestive heart
failure with volume overload and persistent encephalopathy.
PAST MEDICAL HISTORY: Again is significant for diabetes
mellitus , gout , history of DVTs , lumpectomy followed by
mastectomy for breast cancer in 2004 , chronic renal failure;
baseline creatinine of approximately 2 , history of NSVTs with
AICD placement , hypertension , coronary artery disease , two MIs in
the past , COPD , home oxygen , hypothyroidism , depression , GERD ,
dilated cardiomyopathy due to Adriamycin with an ejection
fraction of 25%.
SOCIAL HISTORY: She lives in an assisted living facility. No
history of tobacco , ethanol , or intravenous drug use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: The patient is allergic to shrimp.
MEDICATIONS: She came in with the following medications:
Ciprofloxacin 200 mg orally twice a day , Toprol-XL 100 mg orally daily ,
amiodarone 400 mg orally twice a day , digoxin 0.15 mg orally every other
day , torsemide 175 mg intravenous twice a day , metolazone 2.5 mg orally every
Wednesday and Saturday , Zocor 200 mg orally every nightly , Dilantin
100 mg orally twice a day , Neurontin 300 mg orally three times a day , Nexium 40 mg
orally daily , Colace 100 mg orally twice a day , multivitamins orally
everyday , calcitriol every Monday , Wednesday , and Friday , senna two
tabs orally twice a day , simethicone 80 mg orally four times a day , ferrous sulfate
325 mg orally three times a day , levocarnitine 1 gm orally daily , ciprofloxacin
250 mg orally twice a day , heparin 5000 units subcutaneously twice a day for
prophylaxis , levothyroxine 75 mcg orally daily , Celexa 20 mg orally
daily , Combivent two puffs four times a day , Advair 250/50 inhaled inhaled
twice a day , Lantus 29 units subcutaneously every afternoon , lactulose four times a day and
NovoLog sliding scale. She was also on as needed oxycodone , Maalox ,
Zofran , Reglan , Dulcolax , and Tylenol.
PHYSICAL EXAMINATION ON TRANSFER TO FLOOR: Vital signs ,
temperature 96 , pulse 68 , blood pressure 140/70 , respiratory rate
18 , oxygen saturation 100% on room air. She was somnolent ,
seated in a chair , responding to voice , answers single questions
appropriately , but was intermittently requiring painful stimuli
for arousal. Head and neck exam , sclerae were anicteric. JVP
was difficult to assess secondary to jaw movement and tooth
grinding. Cardiovascular exam , regular rate and rhythm , 2/6
systolic murmur at the left upper sternal border and apex , clear
to auscultation bilaterally in both lung fields. Abdomen was
distended and tympanic. Nonpitting edema of the extremities.
Dorsalis pedis pulses were not palpable. Neurologically , she
occasionally answers questions , was alert and oriented x3 when
awake , followed command intermittently , tracking when awake.
Neurological assessment was difficult due to lack of the patient
cooperation. On her skin , there were no gross lesions.
LABORATORY VALUES ON TRANSFER: Sodium 147 , potassium 3.7 ,
chloride 104 , bicarb 29 , BUN 64 , creatinine of 2.6 , glucose of
50 , calcium 9.4 , magnesium 2.5 , ALT 90 , AST 111 , total bilirubin
was 4 , direct bilirubin was 2.3 , total protein 7.1 , alkaline
phosphatase 175 , albumin 3.9. CBC , white blood count 11 ,
hematocrit 37.8 , platelets 227. Urinalysis , 2+ leukocyte
esterase , 9 white blood cells , 20 red blood cells. BNP was 1764 ,
ammonia 48. Dilantin level 10.8.
EKG on transfer , normal sinus rhythm , 73 beats per minute ,
first-degree AVB , right axis deviation , IVCD. Echo on 1/18/06 ,
dilated left ventricle with an EF of 25% unchanged from July
2005 , global hypokinesis with akinesis of inferior septum while
on apex. Mildly reduced left ventricular function with
mild-to-moderate mitral regurgitation , mild-to-moderate tricuspid
regurg , dilated and nonpulsatile IVC. Chest x-ray on 10/30/06 PA
and lateral showed stable cardiac enlargement with prominent
septa interstitium , no evidence of pulmonary vascular edema. AP
chest x-ray on 1/18/06 appear unchanged from prior imaging with
stable mild-to-moderate cardiomegaly and bilateral airspace
disease worse on the right. Appearances were consistent with
asymmetric pulmonary edema. The right cardiac pacemaker device
overlies the chest wall on the right with a single terminating in
the right ventricle. No pneumothorax was visualized. Right
upper quadrant sono 10/30/06 , hepatic cirrhosis , limited
evaluation of gallbladder due to contraction , but no classic
Murphy sign. 7/12/06 , right upper quadrant ultrasound showed
thickened gallbladder wall and gallbladder sludge , small amount
of ascites , trace to small right pleural effusion. CT scan of
the head on 10/30/06 showed 1.7 x 2 cm intraparenchymal
hemorrhage within the right temporal lobe suspicious for
hemorrhagic metastasis. Given additional smaller areas of high
attenuation within the left parietal lobe. A component of which
appears were arachnoid and right convexity also suspicious for
metastatic disease. Hemorrhage likely subarachnoid within the
quadrigeminal plate cistern on the right extending along the
tentorium. 10/30/06 , repeat head CT no significant interval
change in size of intraparenchymal hemorrhage within the right
temporal lobe suspicious for hemorrhagic metastasis. 7/6/06
head CT with gadolinium unchanged parenchymal and subarachnoid
hemorrhage. 1/18/06 CT of head , slight interval decrease in
size of left parietal subarachnoid hemorrhage , which was small ,
unchanged intraparenchymal hemorrhage within the right
temporoparietal region. Stable hemorrhoids within the
quadrigeminal cistern. CT of C-spine on 10/30/06 , no dramatic
bony fracture of the cervical spine , partially imaged right
temporal lobe intraparenchymal hemorrhage. Plain of right knee ,
10/30/06 , findings consistent with osteoarthritis most marked
within the medial compartment , moderate joint effusion , no
radiographic evidence of acute displaced fracture.
IMPRESSION: A 63-year-old woman with traumatic contusion ,
subdural hemorrhage and subarachnoid hemorrhage now
encephalopathic with hepatotoxicity and acute on chronic renal
insufficiency with volume overload in the setting of longstanding
cardiomyopathy.
HOSPITAL COURSE BY SYSTEM:
Neuro: Intracranial hemorrhage status post fall. The patient
followed by Neurology and Neurosurgery. Started on antiepileptic
prophylaxis in the setting of ICH , no tapering on Dilantin.
Also , on Keppra 500 mg orally twice a day which was adjusted for renal
failure. The patient has been on continuos EEG monitoring with
right PLEDs though no frank seizure activity. All AEDs was
stopped and with continuing EEG monitoring , encephalopathy of
unclear etiology , hepatic source versus bleed related hemorrhage
versus medication. The patient was able to ambulate at baseline ,
frequently falls asleep but was always easy to arouse and
talkative to the daughter. On the date of discharge , she was
conversant , alert and oriented x3 and significantly improved in
mental status relative to time of presentation. To follow up
with Dr. Latoria Ogden of Neurosurgery in one month.
Cardiovascular: History of coronary artery disease , no
significant evidence of acute event by cardiac enzymes to explain
VFib. 1/18/06 echo with EF of 25% unchanged from July 2005.
She remained on standing torsemide twice a day , status post VFib
arrest. She was followed by EP on overall amiodarone taper and
telemetry.
Pulmonary: Stable on nasal cannula , though with frequent benefit
from diuresis as needed.
Hematologically , the patient received 3 doses of vitamin K from
admission through 1/18/06 . Received multiple FFP transfusions
to maintain INR less than 1.4. Coumadin was held in the setting
of her recent bleed. Question of anticoagulation to be
readdressed with Dr. Ogden in one month. She received subcutaneous
heparin for DVT prophylaxis , which was okayed by Neurosurgery.
ID: The patient received a course of ciprofloxacin for UTI.
Renal: Acute-on-chronic renal insufficiency consistent with
relative prerenal state in the setting of volume overload. The
patient was diuresed with torsemide and metolazone.
GI: The patient was maintained on a diabetic diet though with
only scant orally intake at first. The patient progressed to
tolerate orally intake and when her mental status had improved she
was requesting meals on her own. LFTs were intermittently
elevated with a peak bili of 4 , peak AST of 111 , ALT of 90.
Right upper quadrant ultrasound remained unremarkable , though
beyond gallbladder sludge. The elevated LFTs were attributed to
be most likely due to Dilantin. The patient was maintained on
standing lactulose to relieve encephalopathy.
Endocrine: Insulin-dependent diabetes mellitus. The patient was
maintained on Lantus as she was outpatient and as well as regular
doses of Regular Insulin on a sliding scale. She had episodic
hypoglycemia at the initial stages of hospital course and
progressed to a more chronic mild hyperglycemia in the 200 to 300
range with further adjustment of her insulin dosage.
Orthopedic: Her right knee pain status post fall. Despite of
the right knee pain , after the fall , there was no evidence of
acute injury and she received supportive care. She continued to
receive heparin prophylaxis and was maintained on pneumoboots for
DVT prophylaxis.
The patient was full code status throughout entire hospital
course.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 as needed headache;
temperature greater than 100.5 , amiodarone 400 mg orally daily x5
doses starting 1/7/06 , amiodarone 200 mg orally daily starting
2/18/06 , Dulcolax rectal 10 mg per rectum daily as needed
constipation , calcitriol 0.25 mcg orally each Monday , Wednesday ,
and Friday , Celexa 20 mg orally daily , digoxin 0.15 mg orally every
other day , Colace 100 mg orally twice a day , Nexium 400 mg orally daily ,
ferrous sulfate 325 mg orally three times a day , Advair Diskus 250/50 one puff
nebulized twice a day , Neurontin 300 mg orally three times a day , heparin 5000
units subcutaneously twice a day , Lantus 20 units subcutaneously every afternoon , Regular Insulin
sliding scale subcutaneously , Combivent two puffs nebulized four times a day ,
potassium chloride immediate release 20 mEq orally x1 starting
10/8/06 , lactulose 20 mL orally four times a day , levocarnitine 1 gm orally
daily , levothyroxine sodium 75 mcg orally daily , Maalox tablets
quick dissolving one to two tabs orally every 6 as needed upset stomach ,
milk of magnesia 30 mL orally daily as needed constipation , Reglan 10
mg intravenous every 6 as needed nausea , metolazone 2.5 mg orally every Wednesday and
Saturday , Toprol-XL 100 mg orally daily with hold parameters
systemic blood pressure less than 100 , heart rat less than 60 ,
nystatin orally suspension 5 mL orally four times a day , Zofran 1 mg intravenous every 6 x2
doses as needed nausea , oxycodone 5 mg orally every 6 as needed pain ,
sennosides two tabs orally twice a day , simethicone 80 mg orally four times a day ,
Zocor 20 mg orally bedtime , vitamin mineral capsule one tab orally
daily , torsemide 75 mg intravenous twice a day
DISPOSITION: She will be discharged to Spo Medical Center with the following followup appointment. She will see Dr.
Ogden of Neurology within two to four weeks after discharge from
rehab. Please call 222-523-7329 for appointment. Please follow
her volume status closely and taper torsemide when the patient
becomes euvolemic.
eScription document: 3-1718738 CSSten Tel
Dictated By: MCFATE , SETH
Attending: HEIDELBERG , AMIE SALLY
Dictation ID 0115508
D: 10/8/06
T: 10/8/06
Document id: 439
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
Y |
N |
N |
N |
331588317 | PUO | 71222909 | | 3444310 | 5/20/2007 12:00:00 a.m. | HEPATIC ENCEPHALOPATHY | Signed | DIS | Admission Date: 4/8/2007 Report Status: Signed
Discharge Date: 7/22/2007
ATTENDING: REINSTEIN , MISTI M.D.
SERVICE:
GI
BRIEF ADMISSION HISTORY OF PRESENT ILLNESS:
Mr. Lack is a 50-year-old male with a history of Hep-C and NASH
cirrhosis who was transferred from the outside hospital with
presumed hepatic encephalopathy after being found unresponsive in
his apartment. Of note , the patient has been in the ED two days
prior to admission on 3/17/2007 for abdominal pain and
distention , at which time labs were within normal limits ,
including no white count , LFTs , but he did have ammonia of 81.
Plan was for paracentesis , but the patient refused and he left
AMA before follow up with his GI doctor could be arranged. His
family was unable to contact him on the evening on 6/11/2007 . A
friend was sent and checked him out in the following morning on
1/13/2006 and the patient was found alone in his apartment and
unresponsive. He was taken to the Tonsta Ean Villebaxt Hospital by EMS on 10/28/2007 , and the patient was tachycardic and
febrile to 100.2 , and only able to open eyes to commands ,
otherwise noncommunicative per report. A diagnostic and
therapeutic paracentesis of 4 liters was performed , which was
negative for spontaneous bacterial peritonitis. His systolic
blood pressure dropped to the 80's post-paracentesis and he had
elevated cardiac enzymes with troponin of 0.49. The patient's
course at the outside hospital was also complicated by UTI ,
status post two days or ciprofloxacin and an acute renal failure
in the setting of diuresis ( creatinine rising from 0.8 and 1.5 ).
Given the patient's extensive history of cardiac/GI treatment at
the Kernan To Dautedi University Of Of , he was transferred to the Kernan To Dautedi University Of Of on 4/8/2007 .
PAST MEDICAL HISTORY:
1. Nonalcoholic steatohepatitis: Undergoing liver transplant
workup. HAV , HCV reactive. HBV negative. Smooth muscle
antibody positive. Large volume ascites with multiple
paracenteses from 3/29 through 8/13 . Liver biopsied on
8/12 with portal mononuclear inflammation ,
micro/macrovesicular steatosis , focal sinusoidal fibrosis.
2. CAD , status post stent: Cardiac cath done 3/16/2006
revealed proximal LAD with ostial 90% disease , 50% ??____?? LIMA
touchdown , 90% ostial left circumflex , totally occluded RCA ,
patent LIMA to LAD and patent SVG to PDA and radial to diagonal ,
but radial graft to OM was totally occluded. He had a bare-metal
stent placed to left circumflex lesion.
3. Status post CABG in 4/17 with LIMA to LAD , SVG to PDA ,
renal graft to OM and diagonal. Asymptomatic since CABG , but in
workup for liver transplant , the patient was found to have
elevated troponin and taken to cath as above.
4. Hypertension.
5. Diabetes , mild.
6. Asthma.
7. Morbid obesity.
8. Thrombocytopenia.
9. Acute renal failure in the setting of large volume taps.
HOME MEDICATIONS:
Albuterol two puff four times a day , Nexium 40 mg orally daily , Advair 500/50
inhaler one puff twice a day , aspirin 81 mg orally daily , Plavix 75 mg
orally daily , Lasix 20 mg orally daily ( decreased from 40 , prior from
80 in the last month ) , metformin 850 mg orally three times a day , Avandia 8 mg
orally daily , and lactulose 30 mL orally daily.
MEDICATIONS ON TRANSFER FROM TEVH :
Albuterol 90 mcg two puff every 6 hours , fluticasone/salmeterol one puff
twice a day , aspirin 81 mg orally daily , Plavix 75 mg orally daily ,
rifaximin 400 mg orally three times a day , nadolol 400 mg orally daily ,
lactulose 30 mL orally daily , atorvastatin 40 mg orally daily , and
pantoprazole 40 mg orally daily.
ALLERGIES:
1. intravenous contrast: Urticaria.
2. Metoprolol: Bronchospasm.
PHYSICAL EXAMINATION AND STUDIES ON ADMISSION:
Temperature 96.5 , heart rate 54-63 , blood pressure 106/54 ,
respiratory rate 20 , and SAO2 of 96%. General: An
obese-appearing male in no apparent distress. HEENT:
Normocephalic and atraumatic , PERRL , no scleral icterus , JVP
equals 8 cm. No cervical LAD. Lungs are clear to auscultation
bilaterally. No crackles , wheezes or rhonchi. Cardiovascular:
Distant heart sounds , regular rate and rhythm , normal S1 and S2 ,
no murmurs , rubs or gallops. Abdomen: Very protuberant and
distended , bruising throughout , fluid wave present , nontender ,
normal bowel sounds in all four quadrants , no HSM or masses
palpated. Extremities: No cyanosis or clubbing , 2+ pitting
edema to the knees , anasarca , 2+ radial pulses bilaterally.
Derm: Prominent abdominal wall varices , which are common , no
caput , prominent bruising , no palmar erythema or spider angiomas.
Neuro: Alert and oriented to person , place and time. Cranial
nerves II through XII are intact. Motor strength and sensation
are grossly intact. Positive asterixis.
NOTABLE STUDIES AND PROCEDURES:
Diagnostic/therapeutic paracenteses x4 using abdominal ultrasound
to mark site ( volumes removed: 6 liters , 6 liters , 1.2 liters ,
and 6 liters.
HOSPITAL COURSE BY PROBLEM:
1. Hepatic encephalopathy: On transfer , Mr. Lack is alert and
oriented , but still very confused with limited verbal
communication. Baseline ammonia on 1/26/2007 was 66. He was
continued on lactulose and rifaximin , which were titrated to a
goal to 3-4 bowel movements per day. During his hospitalization ,
the patient was noncompliant with lactulose regimen due to
confusion and had two episodes of decreased responsiveness. During these
episodes , there were no EKG or ABG changes suspicious for ischemia or
hypercapnia or hypoxia. Given his agitation , the patient was placed on
restraints after which
his mental status improved , inflicting a possible voluntary and
metabolic component is decompensation. He was able to contract
with healthcare team as his mental status improved and continued
to be compliant with his regimen. At discharge , he continues to
be alert and oriented , appropriately interactive , and an
ammonia of 16. Plans were to follow up with Dr. Reinstein for
continued evaluation of his possible liver transplant and
management of his hepatic encephalopathy. He should continue on
his lactulose regimen and rifaximin.
2. Ascites: Mr. Lack 's intake weight was 225 pounds. He
underwent diagnostic therapeutic paracenteses x4. The first two
and fourth procedures removed 6 liters while the third procedure
removed 1.2 liters. Before and after each tap , the patient was
infused with intravenous albumin at 8 g/liter of ascites fluid removed.
Analysis of ascites fluid showed a SAAG of 1.4 , 2.7 , 3 , and 2.8
respectively , which is consistent with portal hypertension. The
ascites fluid was also negative for spontaneous bacterial
peritonitis. Following each procedure , Mr. Lack remained
hemodynamically stable with blood pressures of 80-90/40-50. His
blood pressure and weights remained stable following
paracentesis , reflecting limited reaccumulation fluid.
Discharge weight is 299.9 pounds. He should continue on
diuretics to maintain his ascites at a reasonable level including
Lasix 80 mg orally daily and Aldactone 200 mg orally twice a day
3. Renal insufficiency: Lasix and Aldactone were initially
started on Mr. Lack 's stay at the TEVH , but they were
discontinued after increasing in serum creatinine from baseline
of 0.8 to 1.4 at the time of transfer. The patient's renal
insufficiency was likely secondary to hypotension with consequent
renal hypoperfusion. Renal ultrasound at the outside hospital
was negative. Following transfer , Mr. Lack was given empiric
hydration challenge with intravenous normal saline and albumin. He proved
responsive to this treatment with creatinine dropping from 1.4
to 1.1. He was restarted on Lasix 20 mg orally and Aldactone 50 mg
orally , and gradually titrated up to a discharge dose of Lasix 80
mg orally daily and Aldactone 200 mg orally daily. His serum
creatinine has remained stable at 0.7 to 0.9. He will follow up
with Dr. Reinstein .
4. Hypotension: Mr. Lack had been hypotensive at the outside
hospital following paracentesis with normal saline placement.
His regimen of lisinopril and nifedipine were consequently held
and discontinued. Given his systolic blood pressures of 80's to
90's , nadolol was also discontinued at the time of transfer.
Throughout his current hospitalization , Mr. Lack 's blood
pressures have remained stable in the 80-90/40-50.
5. Troponin leak: Mr. Lack 's troponin leak at the outside
hospital is likely due to hypovolemic hypoperfusion. He was
continued on aspirin , Plavix , and Zocor at the outside hospital
as he has status post stents and CABG. At the time of transfer ,
his troponin had decreased from 0.49 to 0.15. He has maintained
on aspirin , Plavix , and Zocor , remained stable and asymptomatic
throughout the stay. A repeat troponin performed on 1/26/2007
was less than 0.1 ( less than assay ).
6. UTI: Mr. Lack had positive urinalysis at the outside
hospital. He was treated with 3-day course of Cipro. A
urinalysis performed during this admission was negative.
7. Guaiac-positive stool: Likely secondary to straining ,
esophageal , and anorectal varices. The patient's hematocrit had
been stable at 35 to 43. At discharge , recommended workup in EGD
as an outpatient with Dr. Reinstein .
8. Contact dermatitis: On hospital day #9 , the patient
developed a contact dermatitis on inner aspect of his thighs ,
thought to be secondary to his urinary and fecal incontinence.
He was treated with topical hydrocortisone and miconazole. He
also developed an infected skin tag on his back , which was
treated with topical bacitracin. These should be continued to be
treated at rehab and followed up by his primary care physician.
9. Diabetes mellitus: Throughout his hospitalization , Mr.
Heinzen blood glucose levels were well controlled with
fingerstick showing blood sugars to 100 to 190. The patient's
metformin and Avandia were held and he was started on insulin
sliding scale , but required minimal coverage. At discharge from
rehab , he should be restarted on his orally regimen of Avandia and
metformin. He will follow up with his primary care physician , Dr. Gerrard .
10. Heme: On admission , INR was 1.7 , likely due to decreased
synthetic function of his liver. He was given a 3-day course of
vitamin K with a good response. At the time of discharge , the patient's
INR was 1.6.
11. Code status: Full code.
12. Disposition: To rehab.
DISCHARGE MEDICATIONS:
Aspirin 81 mg orally daily , albuterol inhaler two puffs twice a day
as needed wheezing , bacitracin topical twice a day applied to affected
area , Plavix 75 mg orally daily , Colace 100 mg twice a day , Nexium 40 mg
orally daily , Advair Diskus 250/50 two puffs inhaler twice a day , Lasix
80 mg orally daily , heparin 5000 units subcutaneously every 8 hours , hydrocortisone
1% cream topical twice a day , applied to affected areas , insulin
aspart sliding scale , lactulose 45 mL orally three times a day , miconazole
nitrate 2% powder topical , applied to affected areas twice a day ,
rifaximin 400 mg orally three times a day , simvastatin 40 mg orally at bedtime ,
Aldactone 200 mg orally daily , and multivitamin one tablet orally
daily.
FOLLOW-UP PLAN:
1. Please take all the medications as directed. Continue to
work with physical therapy. Follow up with your appointments
with Dr. Reinstein and Dr. Gerrard . Please notify your doctors
if you become increasingly confused , experiencing chest pain ,
lose consciousness , rapid weight gain or any other concerning
symptoms.
2. Dr. Reinstein , GI: At follow-up appointment , please assess the
patient for worsening ascites , medication compliance , and renal
insufficiency. Please titrate diuretics and lactulose. Consider
outpatient EGD to assess your esophageal varices.
3. Dr. Gerrard : At follow-up appointment , please assess
patient's contact dermatitis on his lower extremities , and
infected skin tag on his back. Please assess the patient's blood
glucose levels. Continue to monitor the patient's renal function
and blood pressure.
4. Rehab: Physical therapy to work with the patient. Ensure
medication compliance. Monitor for acute changes in mental
status and blood pressure.
Prior to discharge , transition the patient back to orally diabetic
regimen of Avandia 8 mg orally daily and metformin 850 mg three times a day
CC:
Dr. Reinstein
Dr. Gerrard
eScription document: 2-6353374 EMSSten Tel
Dictated By: SURACE , NINA
Attending: REINSTEIN , MISTI
Dictation ID 9770678
D: 6/25/07
T: 6/25/07
Document id: 440
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931325247 | PUO | 82325227 | | 415496 | 2/22/1997 12:00:00 a.m. | R/O PULMONARY EMBOLUS | Signed | DIS | Admission Date: 2/22/1997 Report Status: Signed
Discharge Date: 4/23/1997
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
OTHER SIGNIFICANT PROBLEMS:
1. NON-HODGKIN'S LYMPHOMA.
2. HODGKIN'S DISEASE , STATUS POST MECHLORETHAMINE , VINCRISTINE ,
PROCARBAZINE , AND PREDNISONE CHEMOTHERAPY TEN YEARS AGO.
3. HYPERTENSION.
4. STATUS POST TOTAL ABDOMINAL HYSTERECTOMY.
CHIEF COMPLAINT: Three days of shortness of breath.
HISTORY OF PRESENT ILLNESS: Ms. Pittsinger is an African American
female who is 72 years of age with a
history of Hodgkin's disease status post MOPP chemotherapy , and
more recently diagnosed with non-Hodgkin's lymphoma for which she
is being treated with CHOP chemotherapy. She was tolerating the
chemotherapy without complications until developing symptoms of
fatigue as well as shortness of breath over a three to four day
period prior to admission. In July 1997 , Ms. Pittsinger presented to
the Oncology Clinic with a biliary obstruction that was shown to be
a peripancreatic mass and a left subclavicular lymph node. Biopsy
of the subclavicular lymph node revealed non-Hodgkin's lymphoma ,
for which she was treated with CHOP chemotherapy. Given her
previous exposure to Adriamycin for treatment of Hodgkin's disease
ten years previously , the patient's cardiac function was followed
and serial echocardiograms over the past six months. The previous
three cycles of CHOP chemotherapy were complicated with a
peripancreatic abscess which was treated with intravenous then orally
antibiotics with good resolution. She , subsequently , three more
cycles of CHOP chemotherapy and was in near complete remission by
gallium scan; however , a persistent abdominal mass was still
detected on Computerized Tomography scan. Her therapy was stopped
after five cycle of CHOP due to the maximum Adriamycin dose of 460
mg/m2. The patient was being restaged and was found to develop
acute shortness of breath over the weekend , denying any chest pain ,
nausea or vomiting , or light-headedness. The patient denies any
changes in her activities except for becoming more tired with
exertion and wakening up suddenly the night prior to admission
feeling short of breath.
PAST MEDICAL HISTORY: Includes Non-Hodgkin's lymphoma , Hodgkin's
disease , hypertension , and a total abdominal
hysterectomy with bilateral salpingo-oophorectomy.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Reveals a well-developed , well-nourished
elderly woman who is able to speak complete
sentences , but with some difficulty. Her vital signs were a heart
rate of 140; respiration rate of 32 to 36. Oxygen saturation of
92% on room air and is afebrile. The neck examination revealed a
jugular venous pressure of 8 centimeters. No thyromegaly or
lymphadenopathy was appreciated. Chest examination revealed
bilateral lower lobe rales , no rhonchi or wheezes were appreciated.
Coronary examination revealed tachycardic rate and rhythm with a
positive S3. The abdomen was benign. There is no edema at the
lower extremities.
LABORATORY: Electrocardiogram revealed a sinus tachycardia at 130 ,
normal axes and intervals. No ST or T wave changes.
Her profile-7 is remarkable for a potassium of 3.3 , otherwise
unremarkable. The patient has an elevated LDH. Cholesterol level
was 243 and elevated triglyceride level of 197. Complete blood
count was significant for an elevated white count of 11 , 600;
hematocrit of 39.9 with an MCV of 91.2; and platelet count of
131 , 000. There was a normal differential of the complete blood
count. Her coags are also within normal parameters. The
urinalysis was benign.
HOSPITAL COURSE: Problem number one is the patient's shortness of
breath. Given the acute onset of shortness of
breath and dyspnea upon exertion , causes contributing to the change
in pulmonary status included pulmonary embolism , congestive heart
failure , and pneumonia. Of note , the patient's chest x-ray
revealed bilateral pleural effusions. However , the patient was
afebrile. Therefore , our suspicion for pneumonia was low. The
patient received an echocardiogram to evaluate cardiac function.
The echocardiogram on June , 1997 , revealed a mildly enlarged
ventricle with moderately decreased systolic function. Estimated
ejection fraction was 30%. Global hypokinesis was identified along
with a marked significant involvement of the apex as well as the
anterior septal and inferior regions of the heart. Normal right
ventricular systolic function was observed. Also noted is that
there was a small pericardial effusion with an elevated PA pressure
of 36. There was also the existence of mild to moderate mitral
regurgitation and mild tricuspid regurgitation. All of this had
little change from the echocardiogram taken on May , 1997 ,
which revealed an ejection fraction of 30% to 35% along with
hypokinesis and a small pericardial effusion. This was markedly
different from the patient's echocardiogram in January 1997 with
revealed an ejection fraction of 67% with normal left ventricular
function and no wall motion abnormalities. The patient was started
on a Lasix regimen in order to start diuresis with good response to
intravenous Lasix. The patient also was less dependent on oxygen
supplements , however , the patient still reported episodes of
dyspnea upon minor activity. A cardiology consultation was
obtained to evaluate the deterioration in the patient's cardiac
function. This deterioration was associated with the toxicity of
Adriamycin. A repeat echocardiogram was obtained to evaluate the
pericardial effusion as well as an abnormality identified on the
May , 1997 , echocardiogram consistent with a possible rupture
of one of the chordae tendineae. There was little difference
between the echocardiogram from May , 1997 , June , 1997 ,
and February , 1997. The patient was maintained on a regimen of
Lasix as well as Ace inhibitors. Initially , the addition of
ionatrope was considered. However , given the patient's history of
potassium and magnesium wasting , it was decided to add digoxin to
the patient's medical regimen.
The patient was also evaluated for the possibility of developing a
pulmonary embolus. Lower extremity noninvasive examinations
revealed patent vasculature , but no indication of a lower extremity
deep venous thrombosis. The patient also received a VQ scan which
revealed a low probability of the presence of a pulmonary embolus.
After the obtaining of a VQ scan which was negative , the heparin
that was initially stated upon admission of the patient , was
stopped.
The patient was discharged on a regimen of enalapril as well as
Lasix in order to manage the congestive heart failure. The
etiology of the congestive heart failure was thought to the
Adriamycin-induced cardiomyopathy.
Fluids , electrolytes , and nutrition: The patient has a history of
a potassium and magnesium wasting. Serial profile-7s were obtained
and potassium and magnesium were regularly supplemented. The
patient was discharged with a daily regimen of potassium.
DISPOSITION: The patient showed marked clinical improvement with
diuresis as well as actively reduction with an Ace inhibitor. The
patient was warned that she needed to watch her salt intake. Of
note , the patient was noted not to be compliant with a low-salt
diet. Three days before admission , the patient admitted to having
a Chinese food dinner which may have contributed to the patient's
element of congestive heart failure.
The patient was discharged with the following medications: Colace
100 mg twice a day; Vasotec 10 mg every day; Lasix 20 mg every day; KCl 10 mEq
every day; and magnesium gluconate 500 mg every day
The patient was discharged in stable condition , with followup with
Dr. Harajly of Wil Medical Center Oncology.
Dictated By: TELMA DALONZO , M.D. MP64
Attending: ROLANDE R. PULLUS , M.D. EP70 WT544/9235
Batch: 88563 Index No. ZJXSHX91JU D: 8/18/97
T: 3/30/97
Document id: 441
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488583106 | PUO | 72758167 | | 5137881 | 4/24/2005 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/24/2005 Report Status: Unsigned
Discharge Date:
ATTENDING: COLASAMTE , ISABELLE EVON MD
INTERIM DICTATION
DATE OF SURGERY: 7/3/2005
PREOPERATIVE DIAGNOSES: Infective endocarditis , coronary artery
disease.
POSTOPERATIVE DIAGNOSES: Infective endocarditis , coronary artery
disease.
PROCEDURE: Mitral valve replacement , #28Other annuloplasty
ring , ring annuloplasty , leaflet resection , post leaflet
chordoplasty with Gore-Tex suture , Vegetectomy , SBE , CABG x1.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male
with signs of past medical history of diet-controlled diabetes
mellitus , type 2; HTN , status post MI with RCA stent in 1999 who
presents to ICU from emergency department after being found down
at home with change in mental status. The patient was in USOH
until approximately six to seven days PTA when he noticed sudden
onset of sharp left shoulder pain without substernal chest pain
or pressure. The patient notes that the pain in his body all
over and his shoulder continued to be excruciating and without
relent. He also noted onset of upper and lower extremity
weakness and that his legs felt heavy. After he did not show up
to work for several days , the patient was found down in his house
incontinent of urine. He was found to have profound metabolic
acidosis , hypertensive , hypovolemic , febrile , covered all over
the skin with hemorrhagic rash and required fluid resuscitation
and Levophed infusion. Lumbar puncture showed over 100 white
blood cells. Urine was dirty and the patient found to have rash
on back and extremities , which were biopsied by dermatologist on
6/28/2005 . The patient has since had four of four blood
cultures positive for gram-positive cocci in clusters(
preliminary Staphylococcus aureus , MSSA. ) Two of four bottles of
gram-negative rods enteric and pink , status post stenting and had
more than 1100 Staphylococcus aureus from 4/24/2005 urine
culture. TTE on 6/28/2005 showing vegetation on mitral valve.
PREOPERATIVE CARDIAC STATUS: Urgent: The patient presented with
infection of myocardial infarction in October 1999 requiring
hospitalization associated with prolonged chest pain. The
patient does not have symptoms of heart failure. Recent signs
and symptoms of congestive heart failure include pedal edema.
The patient is in normal sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: Stent in October 1999.
PAST MEDICAL HISTORY: Stroke , extremity weakness , history of
permanent muscle weakness of all four extremities , loss of
consciousness. The patient was found at home unconscious within
two weeks of surgery , diabetes mellitus , insulin therapy ,
infective endocarditis:active , receiving vancomycin ,
levofloxacin , Flagyl , ceftazidime , gentamicin , Nafcillin ,
hypercholesterolemia , heparin-induced thrombocytopenia , HAT
during hospitalization in 1999 , creatinine clearance 158.18.
PAST SURGICAL HISTORY: None.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: No history of tobacco use.
ALLERGIES: Heparin , HIT .
ADMISSION MEDICATIONS: Heparin low molecular weight last dose
less than 24 hours , enoxaparin , Lovenox 40 mg subcutaneously daily ,
norepinephrine 3 mcg per kg per minute continuous , simvastatin 40
mg orally daily , Nexium 40 mg orally daily , ceftazidime 2000 mg intravenous
every 8 hours , gentamicin 560 mg intravenous every 24 hours , penicillin G , potassium 3
million units intravenous.
PHYSICAL EXAMINATION: Height and Weight: 5 feet 9 inches , 92.7
kg. Vital Signs: Temperature 99 , heart rate 120 , blood pressure
right arm 107/65 , extubated on 6/10/2005 6 p.m. , FiO2 4 L nasal
cannula , ambulating , oxygen saturation 99%. HEENT: PERRLA.
Dentition without evidence of infection. No carotid bruits.
Chest: No incisions. Cardiovascular: No murmurs. Respiratory:
Rales present bilaterally. Abdomen: No incisions , soft. No
masses. Rectal: Deferred. Extremities: Leg edematous 1+ 2+ ,
diminished muscle strength 4/5. Neuro: Alert and oriented. No
focal deficits.
PREOP LABS: On 2/7/2005 , sodium 143 , potassium 4.1 , chloride
114 , CO2 21 , BUN 11 , creatinine 0.7 , glucose 110 , magnesium 2.1.
Hematology on 6/10/2005 , white blood cells 423 , hematocrit 32.2 ,
hemoglobin 10.9 , platelets 73 , physical therapy 14.9 , INR 1.2 , PTT 28.4. ABGs;
PO2 72 , pH 7.52 , PCO2 28 , total CO2 23 , base excess 0.
Urinalysis consisted with infection.
CARDIAC CATHETERIZATION DATA: On 6/10/2005 performed at PUO .
Coronary anatomy 50% LAD , 45% mid Ramus , dominant circulation ,
LVEDP 15 mmHg. Echo on 6/28/2005 , 55% ejection fraction , mild
mitral insufficiency , trivial pulmonic insufficiency , the mitral
valve is myxomatous. There is a 2-cm focal leaflet mass on the
mitral leaflet that could represent a vegetation. EKG on
6/28/2005 , normal sinus rhythm at 117. Chest x-ray on
6/10/2005 consistent with congestive heart failure and left base
opacity , probably atelectasis has worsened. There is minimal new
right basilar atelectasis. Upper lung zones remain clear. The
heart is enlarged with vascular engorgement , but no frank
pulmonary edema. Central line remains in the CVC. There is no
pneumothorax seen.
PROCEDURE: MVP #28 Other annuloplasty ring , ring annuloplasty ,
leaflet resection , post leaflet chordoplasty with Gore-Tex
suture , Vegetectomy , SBE , CABG x1.
BYPASS: 350 minutes.
CROSS CLAMP: 288 minutes.
Open chest one ventricular wire , one pericardial tube , one
retrosternal tube , two pleural tubes. Open chest/semarch with
bridge fashioned from 60 mL syringe and single lap pad left in
place.
ICU PROGRESS EVENT SUMMARY: POD 1 on 11/10/2005 ; admitted to ICU
postop with open chest after 6 hour pump run. Overnight
vasodilated , requiring pressors , inotrops and methylene blue. POD
2 , Weaned of onoptrops successfully; Cultured from OR- Staff ,
antibiotics changed. Previous allergy ceftriaxone , gentamicin ,
levofloxacin discontinued , one unit of packed red blood cells
given , SVO2 improved; hematocrit stable. Chest open on fentanyl
and Versed/semarch. On 7/6/2005 POD 3 difficult to wean
inotrops Culture from OR staff. Antibiotics changed. Previous
allergy ceftriaxone , gentamicin , levofloxacin discontinued.
Chest washout yesterday , hematocrit stable. Chest remains; open
on fentanyl and Versed ;for 2ND washout+/- closure later this
week. POD 4 stable , remains on epi and vaso , diuresing. Plan to
close chest tomorrow.POD 5Pressors continued , continued
diuresis. Abx adjustments made per ID recommendations ,
discontinue vancomycin and gentamicin. POD 6 , chest closed
yesterday , ongoing pressor requirement. POD 7 , ventilation weaned
to pressure support ventilation , sedation weaned , epinephrine
weaned to off/ , vasopressin weaned. Coffee-ground output via
nasogastric tube today. POD 8 , developed fluctuant collection ,
left supraclavicular fossa . CT confirmed probable collection in
clavicular scapular region , no bony involvement. Aspiration
revealed gram-positive cocci. Orthopedics aware , will review
today , remains vasodilated on vasopressin. Diuresed well. POD
9 , had I&D of collection yesterday , hypertensive 0f pressors ,
requiring increasing Lopressor doses , now on minimal ventilator
support. POD 10 , extubated , hypertensive , requiring Lopressor ,
TNG , Hydralazine. Temperature 102 , failed speech evaluation. POD
11 , remains on nicardipine drip for hypertension , febrile 102.
POD 12 , off nicardipine drip. Abscess in right thigh discharged
spontaneously. PICC line now in. Small amount of fresh blood
per rectum. No drop in hematocrit. Afebrile , taking orally diet ,
diuresing. MRSA. POD 14 , MRSA in sputum , started on vancomycin.
Arterial line discontinued. POD 15 , started on tube feeds ,
hypertensive , Lopressor dose reduced to 50. POD 16 ,
sputum-growing MRSA. Right-sided effusion seen on chest x-ray
with elevation of right diaphragm. Pulled out dop-hof overnight.
POD 17 , VRE isolated from right side abscess. Now oriented x3.
ICU TRANSFER NOTE: Date of transfer , 2/7/2005 .
SUMMARY BY SYSTEM:
1. Neurologic: Mental status intact , alert , and oriented.
Neurological exam , no focal deficits. Now oriented to place ,
month and year. Marked improvement.
2. Cardiovascular: Cardiac medications: Aspirin , Lopressor , .
Heart rate , normal sinus rhythm at 95 , blood pressure 120/60 .
ECG , preop ejection fraction 65% EF. Echo on 6/28/2005 .
Cardiac meds , Lopressor 37.5 orally every 6 hours Exam , RRR. S1 , S2 , WNL.
3. Respiratory: Ventilated more than 24 hours postoperatively.
Extubated on 3/23/2005 , FiO2 3 L nasal cannula , out of bed.
Chest x-ray findings: Extubated on 3/23/2005 , POD 9.
4. GI: Diet. Mechanical soft , liquid consistency , nectar , tube
feeds , Jevity 1.2 tube feeds , rate 100 mL /heart rate , 0 scoops/day
calories.
5. Renal: Fluid in 1700 mL 24 hours , urine output 3200 mL ,
balance -1500.
Weight: Previous day weight 84.5 kg.
6. Endocrine: Diabetes. Meds , insulin 10 units subcutaneously
at 10 p.m. , Lantus 22 units subcutaneously every afternoon
7. Heme: Anticoagulation. Aspirin.
8. ID: Septicemia. Organism , Staphylococcus aureus.
Antibiotics , vancomycin started on 7/3/2005 , penicillin G ,
potassium 3 million units intravenous. Skin lesion infection. Organism ,
VRE. Antibiotics , ceftriaxone 2000 mg intravenous daily , penicillin G ,
potassium 4 million units started on 6/18/2005 . Current
antibiotics , vancomycin day 18 for Staph aureus septicemia ,
penicillin G 3 million units intravenous , ceftriaxone 2000 mg intravenous daily ,
penicillin G , potassium 4 million units day 13 for Staph aureus
septicemia , VRE skin lesion infection. T-max 99.2 Fahrenheit.
ID consult declined , needs inLineziline for right side abscess.
9. Neurologic plan: Continue to monitor neurologic progress.
10. Cardiovascular plan: Watch blood pressure , titrate
Lopressor as tolerated while diuresing.
11. Respiratory plan:OOB with physical therapy , wean oxygen.
12. Gastrointestinal plan: Did well with orally diet yesterday.
Continue to encourage orally diet and monitor calorie intake.
13. Renal plan: Continue gentle diuresis.
14. Endocrine: Controlled.
15. Hematologic plan: Monitor hematocrit. Ensue his wearing
pneumatic boots. Minor procedures: Bronchoscopy , therapeutic
respiration.
MOST RECENT MEDICATIONS: Lopressor 37.5 mg orally every 6 hours , Lasix 20
mg orally three times a day , acetylsalicylic acid 325 mg orally , Naturale Tears
one drop O.U. , Colace 100 mg orally three times a day , insulin regular Humulin
4 units subcutaneously , lactinex granules 2 tabs orally , magnesium sulfate ,
sliding scale intravenously , penicillin G , potassium 4 million
units intravenous , vancomycin 1000 mg intravenous , Nexium 20 mg orally daily , Lantus
22 units subcutaneously every afternoon , NovoLog sliding scale subcutaneously
eScription document: 7-0315173 HFFocus
Dictated By: VIARS , THEODORE
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 0830013
D: 5/28/05
T: 3/22/05
Document id: 442
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
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| output/system_intuitive_annotation.xml | intuitive |
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748055224 | PUO | 49816011 | | 5287968 | 10/6/2003 12:00:00 a.m. | ANGINA | Signed | DIS | Admission Date: 10/6/2003 Report Status: Signed
Discharge Date: 4/23/2003
ATTENDING: EARNESTINE FIERMONTE M.D.
The patient was admitted Pagham University Of Cardiology
Service and Coronary Care Service.
PRINCIPAL DIAGNOSES:
1. Myocardial infarction.
2. Ventricular fibrillation arrest.
OTHER DIAGNOSES:
1. Atrial fibrillation with rapid ventricular response.
2. Diabetes type 2.
3. Peripheral vascular disease.
4. Chronic renal insufficiency.
5. Depression.
6. Hypercholesterolemia.
7. COPD ( chronic obstructive pulmonary disease ).
8. History of GI bleed.
9. Obstructive sleep apnea.
10. Status post cholecystectomy.
11. Status post coronary artery bypass graft with aortic valve
replacement.
12. History of transfusion reaction.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male
with coronary artery disease , status post coronary artery bypass
graft in 1982 , also status post Bjork-Shiley aortic valve
replacement for bicuspid aortic valve , status post redo CABG in
1995 with SVG to OM2 and SVG to LAD , who presented to Stowna Medical Center after developing chest pain unrefractory to
nitroglycerin. En route to the ER , he suffered a ventricular
fibrillation arrest , was defibrillated x1 with 120 Joules to a
rhythm of pulseless electrical activity. He then received fluids
and lidocaine bolus and he recovered his pulse and blood pressure
and was intubated in the field.
Of note , the patient had an AVR Bjork-Shiley and saphenous vein
graft to LAD and left circumflex sequential grafting , original
surgery in 1982. In 1985 , he underwent reoperation with
saphenous vein graft to LAD and saphenous vein graft to OM2. He
has had multiple admissions to Kendsonre Ale Ater Hospital in the past
year. In September 2003 , he was admitted with chest pain. He ruled in
for a non-ST elevation myocardial infarction and was taken to the
catheterization lab. At the cath lab in September 2003 , at Kendsonre Ale Ater Hospital he had a left main with a tight ostial lesion.
He had saphenous vein graft to LAD , it was patent , saphenous vein
graft to OM2 was patent with a tight 95% stenosis proximally in
OM2 at the touchdown site inhibiting retrograde profusion. It
was determined at this point that PCI would be inappropriate. At
that time and echo showed an EF of 25% with moderate mitral
regurgitation and right ventricular systolic pressures of 47. He
was medically managed on nitrates , an ACE inhibitor ,
beta-blocker , digoxin , and Lasix. Per his wife , he had been
doing well since April of 2003 , only sublingual nitrogens on
occasion , but today , on the day of admission he ate lunch with
his son and then developed his typical substernal chest pain , but
this time did not have relief with sublingual nitrogen x 3. He
called EMS who arrived at the scene and he had the following code
status mentioned above with a VF arrest and then a PEA arrest.
On arrival to Stowna Medical Center he had a heart rate of 132 , blood
pressure 89/61 , and respiratory rate 28. He was given normal
saline 2 liters , dopamine drip , Lopressor 5 mg intravenous push , and he
was paralyzed , at which point it was determined that the patient
would likely need urgent cardiac catheterization for suspected
myocardial infarction. He was transferred the Pagham University Of Cardiac Cath lab emergently.
PAST MEDICAL HISTORY:
Coronary artery disease , status post CABG as noted above; history
of multiple non-Q-wave MIs in 1985 and subsequently history of
diabetes type 2 , peripheral vascular disease , depression , chronic
renal insufficiency , hypercholesterolemia , COPD , history of GI
bleed , peptic ulcer disease , obstructive sleep apnea , atrial
fibrillation with rapid ventricular response , status post
cholecystectomy , status post aortobifem bypass graft in 1987 ,
history of transfusion reaction resulting in hemolysis.
ALLERGIES: He has no known medical allergies.
MEDICATIONS ON ADMISSION: Included insulin , Isordil , digoxin ,
aspirin , folate , Lasix , Lipitor , lisinopril , metoprolol ,
Protonix , and Coumadin.
SOCIAL HISTORY: He is a current smoker. He is a retired truck
driver and he is married.
FAMILY HISTORY: Significant for coronary artery disease and
diabetes.
PHYSICAL EXAMINATION: On presentation to Pagham University Of , he had a pulse of 70 , blood pressure 87/54. He was
intubated and had a saturation of 97% on 40% FiO2. He was
intubated and sedated. His JVP was 12 cm of water. He had a
regular rate and rhythm with normal S1 and S2. No murmurs , rubs ,
or gallops. He had a mechanical S2. His abdomen was soft ,
nontender , and nondistended. Bilateral lower extremities were
cool and clammy with 1+ DP and physical therapy pulses bilaterally. He had
ecchymosis as a result of his Coumadin use.
Initial labs were significant for a glucose of 220 , a CK of 565
with an MB of 74 and troponin of 14.0. Hematocrit was 48. His
INR was 1.7. Chest x-ray showed a right upper lobe infiltrate.
EKG with sinus rhythm and a left bundle-branch block with right
axis deviation. Also with inferior T-wave inversions and 1-mm ST
elevation in V3 and 1-mm ST depressions in I and O.
Echocardiogram previously on 3/3 revealed an EF of 39% with
inferior HK and AK , lateral HK , inferoapical DK. He had mild MR
and aortic radiant of 27/16. The right ventricular systolic
function is normal.
In summary , the patient is a 60-year-old male with chronic
coronary artery disease , now status post a VF arrest in the
setting of non-Q-wave myocardial infarction with isolated ST
elevation in V3. He was admitted for critical care to the
Cardiac Intensive Care Unit at Pagham University Of .
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular: Ischemia: The patient was transferred
emergently to the cardiac catheterization lab where
catheterization revealed severe native 3VD and vein graft
disease. His left main is moderately sized with a distal 60%
lesion. The mid LAD was proximally occluded after the first
septa. His left circumference is proximally occluded. The
distal LAD after vein graft is without significant disease and
the distal OM branch after the vein graft is diffusely diseased
with focal 99% lesion after the distal anastomosis. Saphenous
vein graft to LAD is patent , saphenous vein graft to OM has 99%
lesion in distal anastomosis with _____ flow and a tilting disk
aortic valve that appears to be functioning normally. In
summary , the patient had what was considered to be a
nonintervenable coronary artery disease and thus he was admitted
for medical management. He received optimal medical management
for his acute myocardial infarction including aspirin and Plavix ,
statin , beta-blocker , ACE inhibitor as tolerated. His ischemic
EKG changes have resolved at the time of transfer out of the
Coronary Care Unit and he has been chest pain-free for the
remainder of that day. His CK peaked at 1090 on 6/17/03 . Pump:
The patient was anticoagulated with heparin for a goal PTT of
6084 for his Bjork-Shiley valve. His Coumadin was held in the
setting. He had a TTE on 6/17/03 , which showed a left
ventricular ejection fraction of 25% with inferoposterior HK ,
left atrial enlargement , mild to moderate MR , and well-seated
AVR. The patient was rapidly weaned off dopamine and
Neo-Synephrine during his ICU stay and he was transferred out to
the floor , once he was considered to be euvolemic. Rhythm: As
noted above , the patient admitted with status post VF arrest. He
was successfully defibrillated out of that with shock x 1.
However , his course was complicated by an episode of atrial
fibrillation with rapid ventricular rate up to the 160s
associated with hypotension for which he was electively
cardioverted with shock x 1 to normal sinus rhythm after which he
was loaded with a 10-g amio load , and he has remained in normal
sinus rhythm since that episode. However , after the patient had
been transferred to the floor and was stable , he received a
single lead AICD given his history of dilated cardiomyopathy ,
coronary artery disease , and status post VF arrest.
Pulmonary: The patient was initially intubated in the CCU for
airway protection. He was rapidly weaned on the sedation. He
was successfully extubated on 1/28/03 . However , his chest x-ray
was complicated by left lower lobe infiltrate , which was
concerning for pneumonia. He ultimately has sputum culture that
grew out pseudomonas and he has been treated with a 14-day course
for pseudomonal pneumonia. Please see ID section below for more
details.
Infectious Disease: The patient with hypotension and question of
sepsis , septic physiology on 1/28/03 . He was started on empiric
levofloxacin and Flagyl for question aspiration pneumonia by
chest x-ray. He was also given one dose of gentamicin and then
covered his broad into ceftaz , vanc , levo , and Flagyl while
awaiting results. He ultimately had no growth from any blood
cultures , although did have on sputum culture positive for
pseudomonas which was sensitive to ceftazidime , but resistant to
levofloxacin. He was ultimately switched over to single agent
ceftazidime for a total of 14-day course for pseudomonal
pneumonia/bronchitis.
Renal: The patient has chronic renal insufficiency with a
baseline creatinine of 1.6 and 2.0. In the Intensive Care Unit ,
he had a rise of his creatinine up to a peak of 2.8. At the time
of discharge , he still has slightly elevated creatinine at 2.2 ,
although it seems to be normalizing. It is likely that this is
contributed by his Dilaudid received at the time of
catheterization.
Heme: The patient anticoagulated at home with Coumadin and then
during his hospitalization with unfractionated heparin for his
Bjork-Shiley valve with a goal PTT of 60 to 80. At the time of
discharge , he is being recoumadinized with a goal INR of 2.5 to
3.5. Previously , his home dose of Coumadin had been 2 mg orally
every day He will need to have his heparin dripped to 10 units
therapeutically with PTT 60 to 80 until his INR is therapeutic on
Coumadin. Hematology continued the patient also with a
macrocytic anemia , currently on folate therapy. At the time of
discharge , his labs were pending for a B12 level , methylmalonic
acid , and homocysteine did need to be followed up while the
patient is at rehab.
Endocrine: The patient with diabetes. He was continued on NPH
with a Regular Insulin sliding scale with good control of his
sugars. At the time of discharge , he should remain on his NPH
with sliding scale coverage.
FEN: The patient was placed on ADA diet and his electrolytes were
repleted as needed
Prophylaxis: The patient on therapeutic anticoagulation. He was
also placed on a proton pump inhibitor for symptomatic GERD.
Tubes , lines , and drains: The patient had an NG tube for a short
time during his Intensive Care Unit stay while was intubated for
enteral feeding. This was subsequently removed and the patient
has been able to take adequate orally intake. However , he has a
dual lumen peripherally inserted central catheter placed in his
right antecubital fossa on 3/9/03 for intravenous access for intravenous
heparin as well as to continue his 14-day course of ceftazidime.
Pertinent labs at the time of discharge include a BUN of 53 ,
creatinine of 2.2 , white blood cell count of 11.4 with 73% polys ,
20% lymphocytes , 6% monos , 2% eosinophils , and 1% basophils.
Hematocrit of 33.3 , which is stable , platelets of 175. His MCV
was 96.8 and his RDW was 18.0. His last PTT was 66.1 and INR was
1.3.
MEDICATIONS AT THE TIME OF DISCHARGE:
1. The patient is continued on his amiodarone load 400 mg orally
three times a day x 3 days , last day of this dosing scheduled 4/3/03 ; and
the patient is to be switched to 400 mg orally twice a day x 7 days ,
last day of this dose to be 4/30/03 ; and the patient to be
switched to amiodarone 400 mg orally every day , starting on 2/26/03 and
is to remain on this dose indefinitely.
2. Enteric-coated aspirin 325 mg orally every day
3. Ceftazidime 2 g intravenous every 12 hours x 14 days , last dose on 10/6/03 .
4. Colace 100 mg orally twice a day
5. Folate 1 mg orally every day
6. Lasix 80 mg orally every day This is the patient's new baseline
diuretic regimen.
7. Heparin GTT infusion , current rate 900 units per hour ,
continuous. This should be adjusted to achieve a goal PTT of 60
to 80.
8. NPH insulin 15 units subcutaneously every day before noon , 10 units subcutaneously every afternoon The
patient also has Regular Insulin sliding scale subcutaneously before every meal and
bedtime scale. If blood sugar less than 200 , give 0 units. If
blood sugar of 201-250 , give 4 units subcutaneously If 251-300 , give 6
units. If 301-350 , give 8 units subcutaneously If 351-400 give 10 units
subcutaneously and call health officer.
9. Lopressor 12.5 mg orally every 6 hours hold for systolic blood pressure
less than 85 , pulse less than 50. This may be converted over to
once a day form of metoprolol at the discretion of the accepting
physician. However , would not convert to atenolol given the
renal insufficiency.
10. Nitroglycerin 0.4 mg one tablet sublingual every 5 minutes x 3
for chest pain.
11. Senna tablets 2 tablets orally twice a day
12. Multivitamin therapeutic with minerals one tablet orally every day
13. Coumadin 5 mg orally every afternoon x 3 days. The patient should have
INR checked daily during this Coumadin load at which point once
his INR is therapeutic he should be switched to what is suspected
to be his home Coumadin dose of 2 mg orally every day
14. Keflex 500 mg orally twice a day x 3 days , last dose to be on
4/3/03 .
15. Zocor 40 mg orally every bedtime
16. Plavix 75 mg orally every day
17. Nexium 20 mg orally every day
18. Tylenol 650 mg orally every 4-6h. as needed pain.
19. Dulcolax 5 mg to 10 mg orally every day as needed constipation.
20. Morphine sulfate 1 mg to 2 mg intravenous every 4 hours as needed pain.
21. Percocet one to two tablets orally every 4-6h. as needed pain.
22. Trazodone 50 mg orally every bedtime as needed insomnia.
23. Atrovent nebulizer 0.5 mg nebulized four times a day as needed wheezing.
FUTURE CARE: It is recommended that the patient be restarted on
low-dose ACE inhibitor once his creatinine has stabilized. In
addition , he may benefit from further afterload reduction with
nitrates including Isordil , which he was on prior to this
admission. In addition , the patient has the following followup
appointment already arranged.
1. With Dr. Natisha Longaker at Kendsonre Ale Ater Hospital . This is his
primary care physician and this is also the physician who follows
his INR. He has an appointment on 1/20/03 at 11:30 a.m. In
addition , the patient should have every other day INRs drawn x 3 and then
every week INRs x 4 with the results reported to Dr. Longaker for
adjustment of his Coumadin dose.
2 , He also has followup appointment with Dr. Caroline Alise Oeler , the
cardiologist at Kendsonre Ale Ater Hospital . Followup is arranged for
8/23/03 at 4 p.m.
3. The patient also has appointment with the Electrophysiology
Service at Pagham University Of , Dr. Laquanda Nellum , phone
number 538-926-2570. The patient is to have followup with Dr.
Nellum at Electrophysiology Clinic at Pagham University Of on 4/30/03 , the time is scheduled , but unavailable to
me at this time. Please check with Dr. Nellum 's office
regarding time of his appointment.
4. In addition , accepting physician should follow up on B12
level , urinalysis with urine sediment and urine eosinophils as
well as methylmalonic acid and homocystine levels sent on day of
discharge for workup of the patient's macrocytic anemia.
eScription document: 4-3375357 ISSten Tel
CC: Earnestine Fiermonte M.D.
PUO Cardiovascular Division
Busvillegilb Bloolkyonkersfull Sason
CC: Caroline Alise Oeler MD
Naed Na Viewred Rd. , Fayville Ron Chandhunt , North Carolina 09955
CC: Buck Moose
Kendsonre Ale Ater Hospital Department of Medicine
Dictated By: ITSON , YOLANDE LOISE
Attending: FIERMONTE , EARNESTINE
Dictation ID 6496954
D: 8/16/03
T: 8/16/03
Document id: 443
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
- |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
410698291 | PUO | 43967763 | | 9169542 | 3/3/2007 12:00:00 a.m. | Non-cardiac chest pain | | DIS | Admission Date: 5/27/2007 Report Status:
Discharge Date: 9/21/2007
****** FINAL DISCHARGE ORDERS ******
ZANDERIGO , ELLEN 491-00-73-7
Saown A
Service: MED
DISCHARGE PATIENT ON: 10/8/07 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAGBERG , LILLIA JOCELYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ASPIRIN ENTERIC COATED 325 MG orally every day
2. ATENOLOL 50 MG orally every day
3. CITALOPRAM 10 MG orally every day
4. DONEPEZIL HCL 10 MG orally every day
5. INSULIN GLARGINE 54 subcutaneously every bedtime
6. LISINOPRIL 20 MG orally every day
7. OMEPRAZOLE 20 MG orally every day
8. PIOGLITAZONE 15 MG orally every day
9. QUETIAPINE 50 MG orally three times a day
10. SIMVASTATIN 20 MG orally every bedtime
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 325 MG orally DAILY
ATENOLOL 50 MG orally DAILY
CELEXA ( CITALOPRAM ) 10 MG orally DAILY
ARICEPT ( DONEPEZIL HCL ) 10 MG orally DAILY
Number of Doses Required ( approximate ): 5
LANTUS ( INSULIN GLARGINE ) 54 UNITS subcutaneously every afternoon
LISINOPRIL 20 MG orally DAILY
Alert overridden: Override added on 7/28/07 by
KEARS , JAYE A. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MD aware
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
ACTOS ( PIOGLITAZONE ) 15 MG orally DAILY
Food/Drug Interaction Instruction
May be taken without regard to meals
SEROQUEL ( QUETIAPINE ) 50 MG orally three times a day
Number of Doses Required ( approximate ): 5
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Lewallen - please call to schedule ,
Dr. Dominguez 2/18/07 @ 10:00AM ,
Dr. Galvis 10/18/07 @ 1:30PM ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
IDDM HTN CAD "Arrythmias" on holter sss ( sick sinus syndrome ) chf
( congestive heart failure ) cabg ( cardiac bypass graft surgery ) stent
( coronary stent ) hyperlipid ( hyperlipidemia ) CRI ( chronic renal
dysfunction ) cataract ( cataract extraction ) dvt ( deep venous thrombosis )
pe ( pulmonary embolism ) mediast ( anterior mediastinoscopy ) MRSA
psychiatric d/o history of head trauma MVR ( cardiac valve replacement ) Left
humerus fx ( humerus fracture )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
*****
HPI: 78 year old swedish-speaking only woman with HTN , IDDM , CAD history of 2V
CABG , DVT/PE , hyperlipidemia , SSS history of PM , c/o L sided chest pain
accompanied by "shakiness and nerves" that started 3 days ago while she
was at rest , radiating to back , + diaphoresis , productive yellow cough.
patient states that she has had this pain for years and it comes and goes
periodically. Constant , no relieving factors. She denies orthopnea , PND ,
LE edema , N/V/D. Pain resolved when she arrived in the ED and they gave
her sublingual NTG. Also c/o frontal HA that resolved and L shoulder pain
( chronic ). No vision changes , LH/dizziness. In ED: exam unremarkable. She
received ASA , Tylenol , NTG sublingual x 1 , Ibuprofen 400mg x 1. EKG showed Q
waves in inferior leads , CXR with RLL atelectasis. WBC 7.6 , Hct 38.7.
Cardiac enzymes flat. Given her history of DVT a PE protocol CT was ordered ,
however the contrast infiltrated into her arm; per PUO protocol the RUE
needs elevation , ice and can't get contrast for 12h. She was completely
CP free and wanted to go home.
*****
PAST MEDICAL HISTORY: Hypertension , hypercholesterolemia , poorly
controlled diabetes mellitus type 2 , coronary artery disease history of 2V CABG
2000 ( LIMA-->LAD , SVG-->OM1 ) , LAD stent 1997 , congestive heart failure
EF 35-40% , renal insufficiency , anxiety , depression , 9/22 mechanical
fall with fracture of her left humerus and right pelvis , Dementia.
PAST SURGICAL HISTORY: Status post coronary artery bypass grafting and
mitral valve replacement in 2000 , LAD stent in 1997 , and sick sinus
syndrome , status post pacemaker placement.
*****
ALL: NKDA MEDS: ASA 325mg daily; Lisinopril 20mg daily; Atenolol 50mg
daily; Zocor 20mg every bedtime; Lantus 54 units every afternoon; Actos 15mg daily; Aricept 10
mg daily; Seroquel 50mg three times a day; Celexa 10mg daily; Prilosec 20mg daily;
*****
PE: 97.8 61 143/61 18 98% RA. Pleasant , NAD , PERRL , EOMI , sclera
anicteric , MMM , OP clear; RRR , nl S1 , fixed split S2 , no M/R/G. JVP
flat; CTA b/l; WWP , +1 DP pulses , no C/C/E , no calf
tenderness
*****
LABS: cre 1.1 , wbc 7 , hct 38.7 , enzymes neg , lfts wnl
*****
STUDIES:
CXR 1/3/07 : Interval improvement in pulmonary edema since prior
chest radiograph. Bibasilar atelectasis persists.
PE CT 1/3/07 : 1. Slightly suboptimal study without evidence of pulmonary
embolus to the segmental vessels bilaterally. 2. No evidence of deep
venous thrombosis
ECG: NSR , ~75BPM , nl axis Q waves in III , aVF. TWI in V2-V3
*****
A/P: 78F with MMP including CAD , HTN , hyperlipidemia , IDDM , dementia
admitted with chest pain x 3 days now completely resolved CV:
I: known CAD , most recent nuclear stress test with fixed defect. Low
clinical suspicion of ACS , admitted to ROMI with 2 sets of cardiac
enzymes , serial EKGs , however patient refused a lab draw for the second
set. Continued ASA , BB , ACE , CCB , statin. Check fasting lipid panel in a.m.
P: reduced EF , does not appear volume overloaded and CXR improved
compared to prior.
R: history of PPM , monitored on telemetry without events
PULMONARY: stable O2 sats and HD stable , low suspicion for PE. H/o DVT
and presumed PE , but not on anticoagulation
RENAL: history of renal insufficiency , Cr nl
FEN/GI: cardiac diet , K/Mg scales , bowel regimen , PPI
ENDO: IDDM , poorly controlled and with poor compliance at home ( takes her
insulin infrequently ). Continued Lantus , held orally antihyperglycemic
agent , checked HgA1C , pending
NEURO/PSYCH: dementia , continued outpt meds
PPX: Lovenox , PPI
CONTACT: son Ellen Zanderigo 301-232-0395
ADDITIONAL COMMENTS: You were admitted to the hosptial for chest pain. Our tests show that it
is not your heart causing this pain.
Call your doctor or return to the hospital if you have worsening chest
pain/pressure or discomfort , difficulty breathing , nausea or vomiting ,
lightheadedness or dizziness , fevers/chills or any other symptoms
concerning to you.
You MUST take your Insulin every day or your diabetes will get worse. We
have made no changes in your medications.
Please call Dr. Va 's office to schedule an appointment in 7-10
days.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Intensive diabetic teaching to improve compliance and acheive better
glucose control
Consider repeat nuclear stress testing
No dictated summary
ENTERED BY: KEARS , JAYE A. , M.D. ( XM55 ) 10/8/07 @ 10:02 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 444
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
839464477 | PUO | 53023916 | | 9936791 | 6/20/2006 12:00:00 a.m. | URI , CP ( NOS , but likely M/S or pleuritic from cough ) | | DIS | Admission Date: 6/20/2006 Report Status:
Discharge Date: 5/21/2006
****** FINAL DISCHARGE ORDERS ******
PARDA , CRAIG NORMAN 402-17-94-4
Memp O Ve
Service: MED
DISCHARGE PATIENT ON: 9/15/06 AT 06:15 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PERSONIUS , SVETLANA BART , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled every 4 hours Starting Today May
as needed Shortness of Breath , Wheezing
FOSAMAX ( ALENDRONATE ) 70 MG orally QWEEK
Instructions: Give tablet on an empty stomach with a full
glass of water , then wait 30 minutes before the patient eats
or lies down ( to promote absorption and avoid distress ).
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
Number of Doses Required ( approximate ): 1
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Starting Today May
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:cough
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
TIAZAC ( DILTIAZEM EXTENDED RELEASE ( 24 HR CAP ) )
240 MG orally DAILY Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 2/7/06 by
BORGESE , LAKISHA , M.D.
on order for LOPRESSOR orally ( ref # 063313751 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LASIX ( FUROSEMIDE ) 120 MG orally twice a day
INSULIN NPH HUMAN 82 UNITS every day before noon; 18 UNITS every afternoon subcutaneously
82 UNITS every day before noon 18 UNITS every afternoon
INSULIN REGULAR HUMAN 6 UNITS subcutaneously every afternoon
ISORDIL ( ISOSORBIDE DINITRATE ) 30 MG orally three times a day
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
10 MEQ orally twice a day As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
COZAAR ( LOSARTAN ) 100 MG orally DAILY
Alert overridden: Override added on 9/15/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LOSARTAN POTASSIUM Reason for override:
METOPROLOL SUCCINATE EXTENDED RELEASE 200 MG orally DAILY
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 9/15/06 by :
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: takes both at home
SENNA TABLETS ( SENNOSIDES ) 1 TAB orally twice a day
DIET: House / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: resume activities as tolerated
FOLLOW UP APPOINTMENT( S ):
Rossie Mankoski ( cardiology ) 1 of July at 9:20am scheduled ,
ALLERGY: LISINOPRIL
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
URI , CP ( NOS , but likely M/S or pleuritic from cough )
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn iddm dm-2 chf cad hyperlipidemia renal insuff iron def anemia
obesity asthma sleep apnea uterine fibroids psoriasis pulmonary nodule
allergic rhinitis diastolic dysfunction LAE EF=65-70% LVH
OPERATIONS AND PROCEDURES:
n/a
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
patient did not tolerate Cardiac PET scan secondary to anxiety , she refused
study with IVCS.
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
---
HPI:This is a 63 year-old female with history of CAD history of MI and PCI
( stent to D1; see cardiac anatomy below ) , HTN , DM , hypercholesterolemia ,
obesity. She was last in her usual state of health approximately 1
month ago when she developed a "head cold" that has been marked by
frequent coughing and SOB/DOE. Her appetite has been quite poor , and she
reports occasional dizziness. She has been taking her diuretics
faithfully and has been making her usual UOP. She has not been using her
CPAP recently due to her head cold.
She awoke this morning feeling as if she were being choked. She reports
coughing quite violently and bringing up grayish/yellowish sputum
( no blood ). After her coughing spell , she became quite nauseated but
cannot remember if she threw up. She also developed some diffuse
chest tightness that lasted for approximately 10 minutes ,
associated with subjective fevers and diaphoresis. She returned to
sleep , but this time sitting up in her sofa. She reports that she has
been coughing throughout the day with 1 additional fleeting
episode of chest tightness this evening. She was CP-free upon
evaluation in the ED.
Of note , her presenting symptom during her NSTEMI back in '02 was low
back pain.
---
Review of Systems: As above. She further denies weight gain/loss , LE
edema , orthopnea , diarrhea , constipation , abdominal pain.
---
ED Course: Triage vitals: 98.1 , 61 , 138/64 , 16 , 96%
RA. ASA 325 x 1.
---
Home Medications: ( per ZH ambulatory record , not confirmed by patient )
Advair Diskus 250/50 1 PUFF inhaled twice a day
Albuterol Inhaler 2 PUFF inhaled four times a day as needed
Calcium Carbonate 1250MG TABLET three times a day
Cardizem Cd 240 MG orally every day
Claritin 10 MG orally every day as needed ( patient states she does not take this med )
Colace ( DOCUSATE Sodium ) 100 MG orally twice a day
COZAAR 100 MG ( 100MG TABLET take 1 ) orally every day
Ecasa 325MG orally every day
Fosamax ( ALENDRONATE ) 70MG TABLET orally QWEEK
Humulin Nph 100 U/ML VIAL take 82/18 ML subcutaneously every day before noon/every afternoon Take 82units subcutaneously every day before noon ,
and 18 units in pm
Insulin Regular Human 100 U/ML VIAL ( patient states she takes 6 units ML subcutaneously
before dinner )
Isordil 30 MG orally three times a day
Kcl Slow Release 20 MEQ orally every day ( patient states she takes 10bid )
LASIX 120 MG orally twice a day
Lipitor 40 MG orally every day
SENEKOT 1-2 TABS orally every day as needed ( patient states she takes 1bid )
Toprol Xl 200 MG orally every day
ZAROXOLYN 2.5 MG orally every day as needed ( patient states she does not take )
***
Allergies: Lisinopril ( cough )
***
PE on ADMIT: T 96.5 , HR 67 , BP 103/45 , RR 20 , 95%
RA Middle-aged obese female , laying in bed , NAD alert , oriented ,
loquacious and very pleasant anicteric; OP notable for dry MM JVP 6-7 cm
H2O , no thyroid abnormalities , no carotid bruits , supple Clear to
ausculation bilaterally regular , nl S1/S2 , no murmurs , rubs , or gallops
soft , obese , non-tender , non-distended , bowel sounds present , no
hepato-splenomegaly , no bruits , no masses , heme + per ED exam ( no gross
blood ) warm , no cyanosis , clubbing , or edema neuro exam grossly
nonfocal skin exam notable for multiple hypopigmented areas
with heaped up hyperkeratotic borders diffusely across trunk and
extremities
---
Notable Admit Data:
*Labs: Na132 , K4.1 BUN113 , Cr2.9 ( baseline 1.0 ) , GLU 195 , WBC 15.01
Cardiac enzymes neg
*CXR: Stable moderate cardiomegaly with left midlung scarring , unchanged
since prior studies going back to 10/28/2005 .
*EKG: NSR @ 61 , nl axis , intv. Old every V1 , diffuse TWF V2-6 ( new c/t TWI
V4-6 seen in 9/21 study ). Old STD I , II , old TWI I , L. TWF III , F.
---
INITIAL IMPRESSION: 63 year old female with history of CAD history of MI history of
PCI ( stent D1 ) in '02 , HTN , DM , obesity who presents with atypical CP
this morning following a fitful coughing episode that awoke her
from sleep.
---
HOSPITAL COURSE:
1. CV: Started on intravenous Heparin and Lipitor dose increased to 80mg. Cont'd
b-blocker and full dose aspirin. patient was free of CP upon admission and
throughout admission. EKG remained at baseline abnormal but showed no
overt ischemic changes. Her first set of enzymes revealed a slightly
elevated CK 371 with MB fraction of 3.7 , but all three troponins were
negative. Although her story was not convincing for ACS , her TIMI score=4
( known CAD , more than 2 episodes in last 24 h , previous ASA use , 3
cardiac RF's of HTN , DM , CHOL ).
MIBI nondiagnostic b/c of obesity. patient did not tolerate cardiac PET on
8/17 , b/c of anxiety/claustraphobia , then refused to have study with IVCS.
Given the fact that patient ruled out for MI , and that pain did not recur ,
team suspects CP may be related to cough ( M/S and/or pleuritic in
etiology ) and no further inpt CAD workup was pursued. patient to f/u with her
cardiologist 11/3 .
2. RENAL: new ARF likely secondary to taking home lasix in setting of
poor orally's , Cr improved to 1.4 after holding Cozaar and diuretics and
giving IVF. patient instructed to restart Lasix and Cozaar on 7/18 . patient will
be followed by NESSINEE KER HOSPITAL MEDICAL CENTER . Wt upon admit=not recorded , wt upon d/c=258lbs.
3. PULM: Stable O2 sat and exercise tolerance on day of d/c. Sputum cx
grew mixed flora. Cont'd Advair , Albuterol , restarted nocturnal CPAP.
Tessalon ordered as needed.
ADDITIONAL COMMENTS: ATTN PATIENT:
1. if you develop recurrence of chest pain , worsening cough , difficulty
breathing , fever >101 , or any other symptoms that are worrisome to you
call your primary care physician or return to the ER for re-eval.
2. Keep records of your weight and blood sugars and bring the record to
your follow up appointments.
3. Bring your medications to your f/u cardiology appt for review by your
doctor.
ATTN VNA:
1. please reconcile home meds as patient was unable to clarify her pre-admit
meds during this admit and patient is essentially being discharged home on the
medications that were in the PUO computer system. if there are any
discrepancies with available home meds in comparison to d/c med list then
notify patient's primary care physician.
2. daily CV and Pulm assessment ( including daily weights )
DISCHARGE CONDITION: Stable
TO DO/PLAN:
ATTN CARDIOLOGY: During f/u eval can you please review daily wts
and check a creatinine. Decide if diuretics and/or Cozaar needs
adjustment.
No dictated summary
ENTERED BY: HOLLWAY , TABATHA , PA-C ( CW08 ) 9/15/06 @ 06:20 PM
****** END OF DISCHARGE ORDERS ******
Document id: 445
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
385713924 | PUO | 14791481 | | 277071 | 10/3/1999 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 2/26/1999 Report Status: Signed
Discharge Date: 11/17/1999
SERVICE: The patient was cared for on Cardiology Team Co Valle Ro
PRINCIPAL DIAGNOSIS: Syncope.
ADDITIONAL DIAGNOSES INCLUDE: 1. Coronary artery disease. 2.
Bradycardia. 3. Diabetes mellitus. 4. Hypertension. 5.
Chronic renal insufficiency.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old male with
history of acute inferior myocardial infarction in February of
1998 , with total occlusion of the mid circumflex , with fresh
thrombus which was percutaneous transluminal coronary angioplastied
and stented. At catheterization in February , he was noted to have
50 percent right coronary artery , as well. His hospital course at
that time was complicated by atrial fibrillation with Mobitz type I
block. The patient was loaded on procainamide. He also had
several episodes of congestive heart failure. Echocardiogram in
February showed right ventricular dysfunction. At discharge , a
submaximum exercise tolerance test , the patient went three minutes
and twenty-one seconds without evidence of ischemia. On the day of
admission , the patient was in cardiac rehabilitation class when he
became light-headed while seated and lost consciousness for
approximately five seconds. He regained full consciousness. He
denied chest pain , shortness of breath , chest tightness , fever ,
chills , nausea or vomiting. He had no urine or stool incontinence ,
and no focal abnormal motor movements were noted by observers. A
code blue was called , and he went to the Emergency Department.
Electrocardiogram showed old inferior Qs , PRWP , and slightly
elevated T wave in V2 with left anterior fascicular block with
heart rate of 49. Initial CK was 39 with a Troponin I of 0.02. He
was admitted to Ver Pring La for further workup and treatment.
PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Diabetes
mellitus on insulin. 3. Hypertension. 4. Status post bilateral
knee replacements. 5. Asbestos exposure. 6. Chronic renal
insufficiency.
ALLERGIES: Allergies to penicillin.
MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg every day 2. Captopril
75 mg three times a day 3. NPH insulin 18 every day before noon and 8 every afternoon 4.
Procainamide 500 mg three times a day 5. Simvastatin 20 mg once a day.
SOCIAL HISTORY: A 40 pack year history , quit four years ago.
Denies alcohol.
PHYSICAL EXAMINATION ON ADMISSION: A well-appearing gentleman , in
no apparent distress. Vital signs , afebrile , heart rate 50 , blood
pressure 111/87 , respirations 16 , 98 percent on two liters. HEENT ,
atraumatic , normocephalic , oropharynx clear. Neck , carotids 2+ , no
bruits , no cervical adenopathy with the exception of a 2.0
centimeter node in the occipital region. Chest , clear to
auscultation bilaterally. Cardiovascular , bradycardic , regular
rate and rhythm , normal S1 and S2. Abdomen , positive bowel sounds ,
soft , non-tender , nondistended , no hepatosplenomegaly.
Extremities , no edema , no other lymphadenopathy. Neurological
examination , alert and oriented x three , non-focal.
LABORATORY DATA: Admission laboratory is significant for a
creatinine of 1.6 and a potassium of 5.1. Blood count were white
blood cell count 5.5 , hematocrit 44.6 , platelets 233. CK 39 ,
cardiac Troponin I 0.02.
HOSPITAL COURSE: The patient is a 74-year-old male with history of
acute inferior myocardial infarction in February , complicated by
postmyocardial infarction atrial fibrillation and Mobitz type I
block , now admitted following syncopal episode. The
Electrophysiology Service was consulted and prior to
electrophysiology study the patient underwent evaluation for
possible ischemic causes of an arrhythmia. He was initially ruled
out for myocardial infarction by serial enzymes and
electrocardiograms. On standard Bruce protocol exercise tolerance
test mibi , April , 1999 , the patient went four minutes and
thirty seconds , maximum heart rate 121 , maximum blood pressure
210/85. He had typical chest pain for angina and chest tightness
at peak exercise which was relieved with rest. There were no
electrocardiogram changes. He remained in sinus rhythm. Mibi
images showed a mixed MI in basilar half of the inferior wall in
4/20 segments , mild peri-infarct ischemia in 3/20 segments in the
right coronary artery territory. He had normal left ventricular
function , normal left ventricular volume , and global systolic left
ventricular function with left ventricular ejection fraction of 55
percent , wall motion abnormalities and severe inferior wall
hypokinesis and mild septal hypokinesis. Based on the results of
the exercise tolerance test mibi , the patient underwent cardiac
catheterization on April , 1999 which revealed a normal left
main , left anterior descending artery with minor irregularities ,
left circumflex with 90 percent in-stent restenosis in proximal
segment with a dominant left circumflex , and right coronary artery
with a mid 50 percent lesion. The patient underwent successful
percutaneous transluminal coronary angioplasty of the in-stent
restenosis. He was subsequently continued on aspirin. The
Electrophysiology Service recommended that the patient's
procainamide be stopped. Of note , the patient's QT interval was
not prolonged while on procainamide. After the procainamide was
held , the patient underwent electrophysiology study on October ,
1999 revealing normal sinus node recovery time , impaired AV nodal
conduction , no inducible sustained ventricular tachycardia , and no
inducible supraventricular tachycardia or atrial fibrillation. The
patient was discharged to home with plans to follow-up with his
primary cardiologist , perhaps with a Holter or event monitor.
DISCHARGE MEDICATIONS INCLUDE: 1. Aspirin 325 mg every day 2.
Captopril 75 mg three times a day 3. NPH Humulin insulin 18 units every day before noon and
8 units every afternoon 4. Nitroglycerin sublingual tablets. 5. Vitamin
E. 6. Simvastatin 20 mg every bedtime
FOLLOW-UP: The patient will be followed up by his primary care
doctor , in particular the posterior cervical single lymph node
should be followed up by his primary care physician.
Dictated By: MELDA IVASKA , M.D. UY984
Attending: RUFUS C. BERNAS , M.D. KA5 CY278/9428
Batch: 15477 Index No. A6WUSX9UMG D: 2/10/99
T: 11/28/99
Document id: 446
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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326043009 | PUO | 82489284 | | 3666804 | 3/8/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/28/2005 Report Status: Signed
Discharge Date:
ATTENDING: COLASAMTE , ISABELLE EVON MD
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old male
with a history of dilated cardiomyopathy , first diagnosed in
1992. At that time of diagnosis , the patient was found to have
an ejection fraction of 20% , and patient was evaluated for heart
transplantation. The patient was managed medically initially and
did well until 1997 when he began to shows signs of severe
congestive heart failure. On 3/10/04 , patient underwent a
tricuspid valve repair and placement of a HeartMate LVAD and has
since been on the transplant list awaiting heart for transplant.
He now presents for heart transplant. Patient denies any recent
fever or chills , denies chest pain or shortness of breath. He is
without current complaints.
PREOPERATIVE CARDIAC STATUS: Elective. The patient presented
with CHF. The patient denies symptomatic heart failure and is in
normal sinus rhythm. The patient has a history of nonsustained
ventricular tachycardia , AICD placement for VTACH , and LVAD
placement for dilated cardiomyopathy.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: 3/10/04 , tricuspid valve
repair ( annuloplasty - no ring ) , HeartMate LVAD in 1997 , off pump
automatic implanted cardioverter defibrillator , and AICD
placement.
PAST MEDICAL HISTORY: TIA , extremity weakness of the right side ,
which was transient and has since resolved , CVA in 1994 without
residual weakness , chronic renal insufficiency , gunshot wound to
his chest and head at the age of 14 , hepatitis B , and gout.
PAST SURGICAL HISTORY: Status post tricuspid valve repair 6/29 ,
status post HeartMate XVE LVAD placement 2004 , status post off
pump AICD placement in 1997 , status post appendectomy , status
post ganglion cyst excision from right breast.
FAMILY HISTORY: History of familial colon cancer and polyposis.
SOCIAL HISTORY: History of tobacco use , 24-pack-year cigarette
smoking history , quite in 1984. The patient lives at home with
wife and children ( three daughters ). The patient is disabled
since 1997 , used a sales representative for Co Chat Son
ALLERGIES: Allopurinol , hydralazine , heparin HRT positive.
ADMISSION MEDICATIONS: Toprol XL 150 orally twice a day , amlodipine 10
mg orally daily , lisinopril 10 mg orally twice a day , amiodarone 200 mg
orally daily , aspirin 81 mg orally daily , Coumadin 2 mg orally daily ,
Niferex 150 mg orally twice a day , vitamin B1 50 mg orally daily , folate 1
mg orally daily , Zoloft 75 mg orally daily , Nexium 40 mg orally daily ,
and colchicine 0.6 mg orally daily.
PHYSICAL EXAMINATION: Height and weight 5 foot 11 inches , 73.1
kg , temperature 97.8 , heart rate 62 , blood pressure 134/82 in the
right arm , 132/76 in the left arm , satting 97% on room air.
HEENT: Pupils equal and reactive , no carotid bruits. Chest:
Well-healed midline sternotomy. Cardiovascular: Regular rate
and rhythm , no murmurs. Respiratory: Clear to auscultation
bilaterally. Abdomen: Well-healed midline incision , abdomen
firm with device in abdomen: Extremities: Without scarring ,
varicosities , or edema. Pulse exam is 2+ palpable pulses
throughout. Neuro: Alert and oriented. No focal deficits.
PREOP LABS: Notable for a creatinine of 1.5 , hematocrit of 37.9 ,
platelets of 200 , 000. Cardiac catheterization on 3/1/04 normal
coronary arteries. EKG 5/30/05 , first-degree AV block at 59 ,
poor R-wave progression , inverted T in V2 to V3 and V6. Chest
x-ray 5/30/05 normal.
HOSPITAL COURSE: The patient was admitted on 5/30/05 and taken
to the operating room where he underwent a heart transplant and
excision of HeartMate LVAD without complication. For further
details , please see the dictated operative note. The patient was
on bypass for 200 minutes with cross clamp time of 77 minutes.
He left the operating room with one atrial wire , one ventricular
wire , three pair of cardio tubes ( Blake drains ) , and two right
pleural tubes ( Blake drains ). AICD was excised from left
clavicular space and a Blake drain was left in the pacer pocket.
The patient was admitted to the Bussadd Southrys Community Hospital ICU on discharge from
the operating room. The patient was extubated on the evening of
postop day 0 without complications. He was brought up on
epinephrine , milrinone , dopamine , vasopressin , insulin , and
propofol drips.
ICU COURSE BY SYSTEM:
1. Neuro: The patient was extubated early on postop day 1 and
propofol was turned off on arrival to the ICU. The patient was
given Dilaudid intravenous initially for pain , converted to orally Dilaudid.
He was also started on Zoloft on postop day 2 at 75 mg orally
daily for his anxiety. He is relatively anxious but his pain has
been well controlled with Dilaudid. He will leave the ICU on
Dilaudid orally as needed pain.
2. Cardiovascular: The patient was brought up from the
operating room on epinephrine , milrinone , dopamine , and
vasopressin drips. All drips were continued from postop day 1 to
postop day 2. The patient's cardiac output and index were stable
and his next venous saturations were stable in the 70s on this
combination. Epinephrine was weaned slowly from postop days 2-3.
It was off by postop day 4. Dopamine and vasopressin were also
weaned from postop day 4-5. Hemodynamics remained stable.
Milrinone was decreased to 0.4 from 0.5 on postop day 6. The
patient will leave the ICU on postop day 6 and milrinone per Dr.
Colasamte will be weaned at 0.1 per day. The patient has been
hemodynamically stable from a cardiovascular standpoint since
arrival from the operating room. He was started on aspirin 81
daily. Swan was removed prior to discharge from the intensive
care unit on postop day 5 , 11/4/05 .
3. Pulmonary: The patient was extubated early on postop day 1
without complications. The patient remained very wet secondary
to the amount of fluid and products he received in the operating
room. The patient was started on a Lasix drip on postop day 1 ,
which was continued for a goal urine output of 200 to 300 cc an
hours. Patient with negative 3-4 liters in 24 hours over the
postop days 2-5. Lasix was discontinued on postop day 5 prior to
transfer from the ICU as patient had been diuresing a large
amount and creatinine had risen slightly up to 2.1 from 1.5
preoperatively. Urine output will continue to be monitored with
a goal of negative overall fluid balance , as patient remains wet
on chest x-ray.
4. GI: The patient's diet was advanced as tolerated. He is
currently eating a regular low-fat , low-cholesterol diet and is
on Nexium. He also remains on vitamins , folate , Colace , and
lactulose. He has still not had a bowel movement prior to
discharge from the intensive care unit.
5. Renal: The patient was aggressively diuresed beginning on
postop day 1 with a Lasix drip. The Lasix drip was adjusted for
a goal urine output of 200 to 300 cc an hour for several days.
Drip was turned off on postop day 4 for a short period and again
on postop day 5 as urine output remained stable at greater than
200 an hour. Lasix drip is off on postop day 5 prior to transfer
from the intensive care unit. The patient will continue to need
diuresis since he is still wet on chest x-ray. The patient's
creatine has bumped , however , from 1.5 to 2.1 at this point.
6. Endocrine: The patient was weaned from his insulin drip on
postop day 5. He was continued on the Portland protocol during
his time in the ICU as sugars were greater than 150. The patient
was started on postop day 2 on prednisone 35 orally twice a day , Neoral
75 mg orally twice a day , which was since increased to 100. At the time
of discharge , patient remained on prednisone 35 mg orally twice a day ,
Neoral 100 mg orally twice a day , and CellCept 1000 mg orally twice a day per
the transplant team. Cyclosporin levels were followed and doses
were adjusted as needed.
7. Heme: The patient was started on aspirin beginning on postop
day 1. Aspirin is 81 mg orally daily.
8. ID: The patient received vancomycin for his chest tube
prophylaxis. Chest tubes removed on 7/18/05 , postop day 4.
Vanco was discontinued after this. Bactrim was also started on
postop day 1 for primary care physician prophylaxis and Valcyte was started several
days later as the donor heart was CMV positive.
Additional discharge medications and instructions will be
dictated by the PA on the floor when the patient is discharge
home.
eScription document: 5-4237241 VFFocus transcriptionists
Dictated By: CISTRUNK , EDGARDO
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 9808345
D: 5/24/05
T: 5/24/05
Document id: 447
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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- |
N |
Y |
N |
N |
N |
- |
Y |
N |
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N |
464268520 | PUO | 99817034 | | 3288210 | 8/26/2005 12:00:00 a.m. | ACUTE MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 5/1/2005 Report Status: Signed
Discharge Date: 1/6/2005
ATTENDING: EARNESTINE M. FIERMONTE M.D.
SERVICE: Cardiology.
ADMISSION INFORMATION/CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old woman
with a history of coronary artery disease , status post remote IMI
( catheterization in 1989 with RCA occlusion ) , diabetes ,
hypercholesteremia , hypertension , admitted on 5/1/2005 for
chest pain. The patient experienced substernal chest pain
radiating to her left arm and shoulder while moving sofa. She
had associated diaphoresis and nausea but no shortness of breath.
She took 1 sublingual nitroglycerin and 2 aspirin. She was
subsequently transferred to the emergency department. There , her
vital signs were stable. She was found to have new right
bundle-branch block and ST elevations in leads I , aVL , and V2
through V6 as well as ST depressions in leads II , III , and aVF.
She was treated with 5 sublingual nitroglycerin tablets , aspirin ,
heparin , Lopressor , and morphine. She was subsequently taken to
the cardiac catheterization lab , then transferred to the CCU for
further management.
PAST MEDICAL HISTORY: CVA ( remote ) , CAD ( status post remote IMI;
catheterization in 1989 with RCA occlusion ) , diabetes mellitus ,
hypercholesteremia , hypertension , diverticulosis , spinal
stenosis , disk disease , osteoarthritis , status post total knee
replacement , positive PPD in the past.
HOME MEDICATIONS: Medications unknown to patient ( patient
receives care at Tempson Neistone Ino Hospital ).
ALLERGIES: Tetanus toxoid.
ADMISSION EXAM: Pulse 70 , blood pressure 155/77. General
Appearance: Well-nourished woman. Neck: JVP 12 cm. Lungs:
Right-sided wheezes. Cardiovascular: S1 , S2 regular in the 70s ,
2/6 systolic ejection murmur. Abdomen: Soft , nontender ,
nondistended. Extremities: Right groin hematoma with
superficial ecchymosis. Extremities warm with 2+ pulses.
ADMISSION LABS: White blood cell count 13 , hematocrit 44.8 ,
platelets 247 , 000. Coags within normal limits. Sodium 133 ,
potassium 4.0 , chloride 97 , CO2 23 , BUN 24 , creatinine 0.9 ,
glucose 221.
Baseline EKG , 2001 , normal sinus rhythm , 82 beats per minute ,
first-degree A-V block , Q waves in leads II , III , and aVF.
Admission EKG , 5/1/2005 , precatheterization: Normal sinus
rhythm , 98 beats per minutes , first-degree A-V block , right
bundle-branch block , Q waves in leads II , III , and aVF , ST
elevations in leads 1 , aVL , V2 through V6.
Admission chest x-ray , mild cardiomegaly , pulmonary vascular
engorgement and cephalization.
HOSPITAL COURSE:
1. CARDIOVASCULAR: Anterolateral ST-elevation MI - On
5/1/2005 , the patient underwent cardiac catheterization which
revealed 100% stenosis of the LAD , 60% stenosis of the left
circumflex , 80% stenosis of the first marginal , and 100% stenosis
of the RCA , with collateral flow from the LAD to the RCA. Her
LAD was stented. She was treated with Integrilin , aspirin ,
Plavix , Lopressor , captopril , and Lipitor. Her peak cardiac
markers were on 8/29/2005 and were as follows: CK 3344 , MB
386.4 , troponin I 191.4. Her EKG changes were slow to resolve.
Her admission EKG revealed normal sinus rhythm , first-degree A-V
block , and new right bundle-branch block. On 8/29/2005 , the
patient developed transient complete heart block. Gel pads were
placed , but the patient regained her native rhythm. A temporary
wire was placed. On 4/21/2005 , the temporary wire failed to
capture and was adjusted. On 1/23/2005 , the patient was taken
back to the cardiac catheterization lab with the idea of
precluding any further ischemic triggers to complete heart block.
A stent was placed in the first marginal. On 10/4/2005 , early
in the morning , the patient aroused from bed ( despite bed-rest
precautions ). Her temporary wire was apparently dislodged. This
wire was then pulled. The patient developed chest pain without
EKG changes. She subsequently developed hypotension. There was
clinical evidence of tamponade including distant heart sounds and
cool extremities. The patient was taken emergently to the
cardiac catheterization lab. A stat echo performed in the
cardiac catheterization lab revealed a large pericardial effusion
with diastolic collapse of the right atrium and right ventricle.
A pericardiocentesis was performed for 600 mL of bloody fluid.
It was thought that the temporary wire had perforated the right
ventricle and that the whole failed on its own. In the cardiac
catheterization lab , the patient developed asystole. A temporary
wire was replaced. On 8/3/2005 and 10/22/2005 , echocardiogram
showed no evidence of pericardial effusion reaccumulation. The
patient's ejection fraction was preserved at 45 to 50%. There
was evidence of hypokinesis of the apical , inferoseptal , and
basal and mid inferior walls. On 10/22/2005 , the patient's
second temporary wire was pulled. The patient remained in her
native rhythm. She had rare runs of asymptomatic NSVT ranging
from 5 to 11 beats. She was without chest pain or shortness of
breath for the duration of her hospital stay. It was thought
that the patient did not require a permanent pacemaker or AICD
placement at the present time. The patient was discharged on
aspirin , Plavix , Toprol , lisinopril , and Lipitor. She had not
been on a statin previously. Her LFTs will require monitoring.
Notably , her fasting lipids included total cholesterol of 136 , an
HDL of 38 , an LDL of 98 , and triglycerides of 149.
2. PULMONARY: The patient required oxygen by nasal cannula
during her hospitalization. Status post pericardiocentesis , she
was weaned off oxygen. On the day of discharge , she was able to
ambulate on room air without desaturating.
3. ENDOCRINE: Diabetes mellitus. The patient was on orally
antihyperglycemics at home. In-house , she was treated standing
Lantus as well as Novolog standing and sliding scale before every meal She
was discharged on metformin. She has a normal creatinine
clearance.
4. HEME: Hematocrit. The patient's hematocrit dropped down
from the low 40s on admission to the low 30s on discharge. This
drop was attributed largely to blood loss ( right groin hematoma
status post 5/1/2005 cardiac catheterization - subsequently
stabilized; and pericardiocentesis on 10/4/2005 ). There was a
desire to keep the patient's hematocrit above 30 given her acute
coronary syndrome; however , the patient refused for transfusion.
In the days prior to discharge , the patient's hematocrit
stabilized. If her hematocrit remains low , she might benefit
from outpatient anemia workup , including iron studies , B12 ,
folate , reticulocyte count , and smear.
5. INFECTIOUS DISEASE: Urinary tract infection. The patient
developed a urinary tract infection. Urine culture on 8/29/2005
showed greater than 100 , 000 proteus. She was treated initially
with levofloxacin , then Bactrim. A urine culture from 8/3/2005
showed no growth.
6. POSTPROCEDURE PROPHYLAXIS: The patient was treated
transiently with Ancef status post temporary wire placement.
Blood cultures on admission were negative. Blood cultures were
not rechecked given that the patient remained afebrile without
signs of bacteremia.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally daily , Colace 100 mg
orally twice a day , nitroglycerin 1/150 ( 0.4 mg ) 1 tab sublingual every
5 minutes x3 doses , Lipitor 80 mg orally daily , Plavix 75 mg orally
daily , lisinopril 2.5 mg orally daily , Toprol XL 150 mg orally daily ,
metformin 500 mg orally twice a day
DISCHARGE INSTRUCTIONS: The patient was instructed to take her
medications as directed , particularly the Plavix. The patient
was instructed to follow up with Dr. Fiermonte in clinic on
6/24/2005 and with Dr. Genevie Prosperi at the Tempson Neistone Ino Hospital . She was instructed to call her doctor and present
to the emergency room if she experienced any chest pain ,
shortness of breath , palpitations , fainting , or any other
symptoms concerning to her.
DISPOSITION: The patient was discharged to home with home
services.
eScription document: 7-9921852 HF
Dictated By: TROOP , WILFREDO
Attending: FIERMONTE , EARNESTINE M.
Dictation ID 2145641
D: 1/30/05
T: 1/30/05
Document id: 448
| Target |
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| output/system_intuitive_annotation.xml | intuitive |
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789882744 | PUO | 49201190 | | 3468702 | 10/19/2004 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 10/19/2004 Report Status: Signed
Discharge Date: 10/21/2004
ATTENDING: ROSSIE MANKOSKI M.D.
ATTENDING:
1. Rossie Mankoski , M.D.
2. Perry Haub , M.D.
PRINCIPAL DIAGNOSIS: Congestive heart failure.
OTHER DIAGNOSES: Include diabetes , tubal ligation , obesity ,
status post stomach stapling.
HISTORY OF PRESENT ILLNESS: In short , Ms. Giovanna Rosenblum is a
55-year-old woman with a long history of nonischemic dialytic
cardiomyopathy with an EF of 30% , resting tachycardia , diabetes
type 2 , tubal ligation , obesity status post stomach stapling at
PUO with acute decompensation for three weeks , abdominal bloating
and fatigue , status post systemic stapling but that was years
prior and now , has had a decompensation of heart failure for
three weeks , abdominal bloating and fatigue. Of note , she is on
clinical trial with implanted PA catheter placed in 2001. She
was seen in the heart failure clinic with systolic blood
pressures of 90 , baselines 110s-120s and baseline heart rate of
100s. She was admitted for diuresis and possible transplant work
up. The patient was unaware of the transplant plans at that
time.
PHYSICAL EXAMINATION: The patient on exam was afebrile , heart
rate in the 90s , blood pressure 110/80 , 100% on room air , JVP of
13 , clear chest , regular rate and rhythm , S1 , S2 , S3 , S4 , obese
abdomen , liver edge 4 cm below right costal margin , warm and well
perfused with 1+ edema , 2+ DP pulses.
HOSPITAL COURSE:
1. Cardiovascular:
A. Pumpwise , she is unclear trigger for compensation but low ACS
probably at that time. Had diuresed greater than 11 liters on
Lasix drip , Zaroxolyn and dobutamine at 2. Towards the end of
the hospitalization , even if slightly negative , she was changed
to torsemide orally Echo read no effusion and an EF of 15%
thrombus versus veg on device. Patient has implanted device
which measures orally pressures , again from the clinical trial. We
continued her ACE inhibitor , no beta-blocker given though poor
tolerance. She has continued on that. She had a right heart
cath on 2/12/04 showing very high SVR. Discharge was status
post steroid therapy , off nipride and dobutamine , transplant work
up was nearly complete. She was weaned off nipride with
captopril. Her goal event is slightly negative and patient
seemed to be doing very well.
B. Ischemia wise , she had no evidence for ACF and was not ruled
out for MI.
C. Rhythm-wise , normal sinus rhythm. On tele , she had some PVCs
and nonsustained VT. Caution for ectopy , given dobutamine drip
but no ectopy was seen.
2. ID-wise. PICC was placed on 3/6/04 and Cortef was dc'd.
3. Endocrine-wise. Patient's diabetes , she was on glipizide and
Regular insulin sliding scale. We started Lantus and this was
dc'd as an outpatient. The patient will follow up with her
primary care doctor to better control her diabetes.
4. FEN: The patient is on cardiac and diabetic diet with fluid
restriction and salt restriction and on a multivitamin.
5. Heme-wise: She was on heparin for thrombus with a PTT goal
of 60-80. She was started on a Coumadin bridge on 3/6/04 and
sent home with Lovenox shots. Her INR was thought to be followed
up by her primary care doctor and Fernande Prewer . She lives in
Win , so they will both follow up.
6. Musculoskeletal: She is on probenecid for gout status post
Decadron and taper for a gout flare that worsened.
7. Psych-wise: She has depression and anxiety. She is on
Advair and Celexa.
8. Renal-wise: Her creatinine improved from 2 to 1.4 status
post dc of Cozaar and colchicine till 1.1 , I believe , on the day
of discharge.
FOLLOW-UP PLAN: The patient was following up again with Dr.
Eiden and also with Fernande Prewer within two weeks of her
discharge , also following up with her Coumadin Clinic to allow a
close follow of her INR given anticoagulation for the device she
has in place.
DISCHARGE MEDICATIONS: The patient's discharge medicines
included , Ativan 0.5 mg orally every bedtime as needed insomnia , 0.5 mg orally
three times a day of Ativan as well , standing Celexa 20 mg orally every day , Colace
100 mg orally twice a day as needed constipation , Coumadin 5 mg orally
every afternoon , Digoxin 0.125 mg orally every day , glipizide 5 mg orally every day ,
hydralazine 100 mg orally four times a day , Isordil 40 mg orally three times a day ,
lactulose 15-30 mL orally four times a day as needed constipation , Lovenox 80 mg
subcutaneously twice a day , multivitamin 1 tab orally every day , oxycodone 5-10 mg
orally every 4 hours as needed pain , potassium chloride 20 mEq orally every day ,
probenecid 500 mg orally every day , torsemide 100 mg orally twice a day and
Tylenol 650 mg orally every 4 hours as needed headache.
eScription document: 9-8889557 EMSSten Tel
Dictated By: GUSMAR , GAYE
Attending: MANKOSKI , ROSSIE
Dictation ID 6666041
D: 7/8/05
T: 5/11/05
Document id: 449
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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- |
866042595 | PUO | 98727354 | | 499858 | 11/12/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/29/1992 Report Status: Signed
Discharge Date: 3/30/1992
PRINCIPAL DIAGNOSES: SYNCOPE.
SLEEP APNEA.
DEPRESSION.
OPERATIONS/PROCEDURES: ECHOCARDIOGRAPHY.
HOLTER MONITORING.
EXERCISE TOLERANCE TESTING.
SLEEP STUDY.
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old white
male with a history of
insulin-dependent diabetes , hypertension , and coronary artery
disease. The patient presents with multiple syncopal episodes in
the week prior to admission. Cardiac risk factors include
diabetes , hypertension and a positive family history. He does not
smoke and has normal cholesterol. He has chronic stable angina for
which he needs one to three nitroglycerin per day over several
months. He has been gaining weight and has increasing peripheral
edema. He also notes decreased exercise tolerance and increasing
fatigue and dyspnea on exertion. He complains of PND but denies
orthopnea. In 2/10 he had a standard Bruce exercise test in which
he went 8 minutes and 15 seconds , stopping for typical chest pain
with a heart rate of 150 and blood pressure of 186/90. He had no
EKG changes and no arrhythmias. Thallium scanning showed anterior
and apical perfusion defects with delayed reperfusion.
Echocardiography at that time showed mild concentric hypertrophy
and akinesis of the anterior , lateral and apical walls. He had
only mildly decreased left ventricular function and no valvular
disease. The patient has been admitted to the Rotusin Healthcare And Center where he has undergone coronary angiography ,
which showed that his coronary arteries had no significant
obstruction. Over the week prior to admission he had four episodes
of syncope which occurred at various times , not related to meals.
He was usually standing or walking just prior to the episode.
There is a 15 to 30 second prodrome of nausea , diaphroresis , and
the sensation of spinning. He does not have chest pain or
shortness of breath. He has had a total of four episodes with loss
of consciousness and falling. He does have urinary incontinence
but has not been witnessed to have involuntary movements. There is
no post ictal state. There has been no recent change in his
medical regimen. The patient also describes the symptoms of
snoring at night with fatigue and has been noticed to make gasping
sounds during sleep. He complains of waking up frequently at night ,
feeling as though he cannot catch his breath and admits to a weight
gain of 100 pounds over the last several years. He has a history
of depression and suicidal ideation and currently is depressed and
has had thoughts of wishing he were dead. PAST MEDICAL HISTORY:
Peptic ulcer disease , hypertension , depression , diabetes mellitus
for ten years and a distant history of seizures after head trauma.
SOCIAL HISTORY: He is currently a student and former alcoholic.
He is currently separated from his wife and has three sons and a
daughter. FAMILY HISTORY: Remarkable for diabetes in both mother
and father and hypertension in both parents. He claims both
parents had cardiomyopathy. ALLERGIES: The patient claims to have
fever and edema with a rash to Procardia. MEDICATIONS ON ADMIT:
Lasix 20 mg orally.every day as needed , Diltiazem 90 mg orally.three times a day , Quinine 300
mg orally.every bedtime , Isordil 30 mg orally.three times a day , aspirin one per day ,
Atenolol 50 mg orally.every day , Lysinopril 20 mg orally.every day , sublingual
nitroglycerin as needed , NPH insulin 40 units in the morning , 20 at
night , regular insulin 20 units in the a.m. , Sucralfate one gram
orally.four times a day.
PHYSICAL EXAMINATION: Afebrile with a normal pulse and blood
pressure of 130/90. He was not orthostatic ,
head and neck benign. No carotid bruits. Lungs clear. Heart: He
has a normal S1 and S2 with an S4. There is no murmur. Abdomen
obese without masses. Rectal: Guaiac negative. Normal prostate.
He has edema to his knees bilaterally. Neurologic: He has
pressured speech and a tearful affect. He is alert and oriented.
CNs intact. Motor strength is full. He has no sensory deficits
and normal position sense. He has diminished reflexes throughout
but downgoing toes bilaterally.
LABORATORY EXAMINATION: He had a glucose of 323 , but otherwise
normal admission laboratories except for
an LDH of 529 and an alkaline phosphatase of 151. Admission CK was
138 , amylase of 56 , lipase of 52. Hemoglobin A1C 8.3 , cholesterol
170 , UA shows 2+ glucose. Chest x-ray shows a normal size heart
with clear lungs. EKG shows sinus at 70 with normal axis and
intervals. There are flat T waves in I , L , and III , but no change
from a previous EKG.
HOSPITAL COURSE: The patient underwent Holter monitoring in which
he had no arrhythmias. He occasionally had sinus
tachycardia. An exercise test showed that he went six minutes and
17 seconds of a standard Bruce protocol. His maximum heart rate
was 140 and blood pressure was 210/60. There were no EKG changes
with the exception of unifocal PVCs , so that there was no evidence
for ischemia. He had an echocardiogram which showed normal valves
and normal left ventricular function. Notably the right side of
his heart was also normal. The patient also underwent sleep study
during the day after sleep deprivation the previous night. The
study lasted only 1-1/2 hours and the patient was not noted during
that time to have sleep apnea. However , an overnight study was
recommended.
DISPOSITION: Discharge medications are the same as his admission
medications with the addition of Prozac 20 mg
orally.every day He follows up with Dr. Latoria Ogden in KTDUOO clinic.
RG805/7393
NADIA WANKUM , M.D. LD2 D: 11/24/92
Batch: 4488 Report: G3523Z08 T: 8/15/92
Dictated By: KALEIGH IMRIE , M.D.
Document id: 450
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Gs |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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902260517 | PUO | 05373993 | | 297829 | 5/21/1998 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/11/1998 Report Status: Signed
Discharge Date: 6/20/1998
PRINCIPAL DIAGNOSIS: 1. SEVERE PANCREATIC EXOCRINE AND
ENDOCRINE INSUFFICIENCY.
PROBLEM LIST:
1. SEVERE ACUTE PANCREATITIS
2. NEW ONSET INSULIN DEPENDENT DIABETES MELLITUS.
3. HYPERGLYCEMIC , HYPEROSMOLAR , NONKETOTIC ACIDOSIS ( NOW
RESOLVED ).
4. ACUTE RENAL FAILURE. ( NOW RESOLVED ).
5. RHABDOMYOLYSIS. ( NOW RESOLVED ).
6. SEVERE ALCOHOLISM.
7. CONGENITAL HEART BLOCK , STATUS POST PACEMAKER PLACEMENT IN
1980.
8. CORONARY ARTERY DISEASE , STATUS POST SILENT IMI IN 1988.
9. HISTORY OF DILATED CARDIOMYOPATHY , CONGESTIVE HEART FAILURE
LAST ECHO PERFORMED ON 20 of June WITH AN ESTIMATED EJECTION
FRACTION OF 50%.
10. HYPERTENSION.
11. HYPERCHOLESTEROLEMIA.
12. STATUS POST LEFT NEPHRECTOMY SECONDARY TO NEPHROLITHIASIS.
13. HISTORY OF GERD.
14. HISTORY OF SPINAL STENOSIS , LOWER EXTREMITY PAIN AND SCIATICA.
15. PERIPHERAL VASCULAR DISEASE WITH CLAUDICATION.
16. STATUS POST APPENDECTOMY.
17. HISTORY OF RECURRENT URINARY TRACT INFECTIONS.
18. HISTORY OF MEDICAL NONADHERENCE.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old African-
American gentleman with a complicated
medical history including severe alcoholism and coronary artery
disease , congestive heart failure who has at baseline had shortness
of breath , dyspnea on exertion and at times paroxysmal nocturnal
dyspnea also orthopnea. He has a history of medical nonadherence ,
noncompliance. The patient presented four days prior to admission
on 10 of February to his primary care physician Dr. Homby with a cough
chills , but no fever , myalgias , pleuritic chest pain and weight
loss of 9 lb , from 167 to 158 in three months with increased
paroxysmal nocturnal dyspnea. The patient had not been taking his
congestive heart failure/cardiac medications for at least one week.
A chest x-ray at that time was negative for pneumonia but was
suggestive congestive heart failure. He was also diagnosed with a
probably URI. His congestive heart failure medications were
refilled. A PPD was placed at that time. The patient was not
getting antibiotics.
The patient developed progressive malaise , anorexia , was unable to
get out of bed , poor orally He denied any increased alcohol abuse at
that time. There was no abdominal pain per the patient's
girlfriend but there were complaints that the patient's mental
status was worsening. He was more lethargic and was found mumbling
by his girlfriend with increased shortness of breath and EMTs were
called who found the patient to be somewhat somnolent but arousable
with a blood glucose of 483 , blood pressure 110 /palp. He was
transferred to the Pagham University Of emergency room.
The emergency room he was alert and oriented times two with
temperature of 89 rectally , blood pressure 120/68 , respiratory rate
28 , O2 of 100% on 100% face mask. An arterial blood gases pH was
7.13 , pO2 326 , pCO2 28. Acetest was positive. Betahydroxy
butyrate of 1.66. serum glucose was negative at 1800 with an anion
gap of 27 , serum sodium 129 , serum potassium 7.6 , BUN 178 and a
creatinine 7.5. The patient was treated with one liter of normal
saline intravenous over five hours , 20 units of intravenous insulin two amps of
bicarb , 30 grams of Kayexalate , one amp of calcium gluconate ,
Solu-Cortef 100 mg , ceftriaxone two grams intravenous. The patient's mental
status markedly improved after the hydration. The patient was then
transferred to the Medical Intensive Care Unit for treatment
evaluation.
PAST MEDICAL HISTORY: Please see problem list above. Also of
note , the patient has a history of severe
alcoholism , denies any preadmission alcohol binges at that time;
but , later admitted to drinking of one to two gallons of gin and
vodka at a time with his friends and also drinking many beers. At
baseline , the patient has some shortness of breath , dyspnea on
exertion , orthopnea and at times paroxysmal nocturnal dyspnea. His
last echo previously the one done on this admission was in 11/27
which showed an ejection fraction of approximately 30% with
anteroseptal HK , posterior lateral HK , inferior AK , 1+ MR and AR
and an ETT MIBI in 5 of August showed IMI , ischemia. However , an echo
repeated during this admission showed an approximate ejection
fraction of 50% with inferior and septal HK only and mild aortic
insufficiency and mitral regurgitation .
ALLERGIES: No known drug allergies.
MEDICATIONS: Admission- enteric coated aspirin 325 mg orally every day ,
Lasix 40 mg orally every day , sublingual nitroglycerin as needed , Imdur
60 mg orally every day , lisinopril 20 mg , Naprosyn 500 mg orally twice a day
as needed , digoxin 0.25 mg orally every day
SOCIAL HISTORY: The patient as noted above has a history of
severe alcoholism and has been drinking at least to
a month prior to his presentation. He has a history of one pack of
tobacco smoking per day times 30 years. The patient lives with his
girlfriend and "step-daughter" in Vercour Campdi Road
FAMILY HISTORY: Positive for coronary artery disease and also
positive for diabetes mellitus in his sister and
mother and his mother also "cancer".
PHYSICAL EXAMINATION: Vital signs - Temperature 94.0 , pulse 78 ,
and regular , blood pressure 100/66 , O2 is
100% saturation on 100% facemask. Respiratory rate 28. In
general , the patient was responsive to voice and oriented to
Pagham University Of , and said 1997. Head , eyes , ears ,
nose and throat exam showed that he was anicteric. Extraocular
movements are intact. Pupils are equal , round , reactive to light , 2
mm. Oropharynx was dry. There was no jugular venous distention
and low lymphadenopathy. The neck was supple. Lungs - Had few
bibasilar crackles , greater on the right. Cardiovascular - Regular
rate and rhythm with positive ectopy , no murmur , regurg or gallop.
His abdomen was soft , diffusely tender , mildly distended with
positive bowel sounds with no liver edge palpated. He was heme
negative in the emergency room with no rebound. Extremities -
Trace edema bilaterally and were somewhat cool. His skin had no
petechiae , no rash and no splinters. Neurological - He was able to
move all extremities. His reflexes were 2 in the upper and lower
extremities except for the left ankle which was 1 and his right
ankle was 0. His left toe was downgoing. His right toe was
equivocal.
LABORATORY DATA: Significant for a WBC of 11 , hematocrit was
normal at 43 , platelets 160. Significant for
bandemia of 14 , 81 polys , INR 1.3 , SMA-7 was significant for a
serum sodium of 129 , potassium 7.6 , chloride of 91 , bicarb of 11 ,
BUN of 178 creatinine of 7.5 , glucose of 1800. His CK was 126 ,
troponion-I was 0. Lipase was 22 , 610 , amylase was 2840. Liver
function tests were within normal limits , ALT of 11 , AST of 10 , LDH
174 , alk phos of 11 , T-bili of 0.4 , albumin of 3.5 , calcium 9.3.
Phos was elevated at 12.8 , magnesium was elevated at 5.2. UA was
19.5.
ACETEST was positive. A betahydroxybutyrate was 1.66. Digoxin
level was 0.8 , tox screen was negative. UA - had 0-1 wbcs , SG of
1.023.
EKG showed ventricular pacing at a rate of 77.
Chest x-ray showed no pulmonary edema or infiltrates or effusions.
HOSPITAL COURSE: The patient was admitted to the Medical Intensive
Care Unit for further treatment evaluation of his
severe metabolic abnormalities. He also by labs he had a
significant severe pancreatitis and was felt to be either a DKA or
HHNKA. An endocrine consult was obtained and they felt that the
patient was likely not in DKA as the patient's level of
betahydroxybutyrate of 1.66 was not enought to explain the
patient's gap or all his metabolic disturbances. The endocrine
service that more likely the patient had hyperglycemic ,
hyperosmolar , nonketotic acidosis and also severe pancreatitis.
Initial screens for the cause of pancreatitis were negative
including stones. The patient has significant alcohol history and
has been drinking alcohol which is the most likely cause of his
severe pancreatic insufficiency. The patient was aggressively
hydrated with intravenous fluids and his metabolic abnormalities began to
correct. He was also noted by labs to be in acute renal failure
and a renal consult was obtained. The patient's nonoliguric renal
failure was in the setting of severe dehydration secondary to
hyperosmolar state and ACE inhibitors were felt most likely due to
ATN. A renal ultrasound performed on 1 of July showed no evidence of
gallstones or biliary duct dilatation.
An abdominal CT performed on 7 of July showed grade I pancreatitis with
no evidence of a pseudocyst. The patient's clinical course was
complicated by rhabdomyolysis which was felt to be due to a
hypophosphatemic state , but this was not completely clear as the
patient's CKs began to rise while the patient's phosphate was still
secondary to the acute renal failure. The patient's CKs peaked
around 10 , 000 and then began to fall steadily and the patient's
renal function with continued hydration improved steadily as his
creatinine and BUN returned to normal. However , in the night of
20 of June the patient's abdominal pain worsened and there was a
question of peritoneal signs which prompted an emergent exploratory
laparotomy to rule out abdominal ischemia. However , the findings
were not consistent with ischemic bowel , but only severe
pancreatitis was noted. On 25 of July and 20 of June the patient did very well
postoperatively back in the Medical Intensive Care Unit. He was
started on TPN and with a slow wean of his of dextrose , his blood
sugars normalized. On 20 of June the patient's renal function had also
normalized. The patient by 5 of September had marked decreased abdominal
pain , normalized electrolytes and his renal function was at his
baseline with a creatinine of 1.0.
The patient was transferred out of the Medical Intensive Care Unit
to our service on 8 of May on TPN and the following medications:
1. Digoxin 0.375 mg every day
2. Carafate one gram twice a day
3. Albuterol two puffs three times a day
4. Aspirin 325 mg every day
He is also on TPN , but was being advanced to a clear liquid diet
and seemed to be tolerating it well. He also continued to require
a large amount of insulin through his TPN and also through his
sliding scale. The patient did well and was able to tolerate a
clear liquid diet and was advanced in the next two days to a soft ,
solid diet with very low fat.
I will dictate the rest of the patient's events , assessment and
plan by problem list as follows:
1. GI:
I. SEVERE PANCREATITIS: The patient was able to be advanced
to a soft solid diet for the past few days. She has abdominal pain
which had almost resolved and then resumed and the patient
developed a watery diarrhea. It was felt that this could be due to
pancreatic insufficiency versus C. diff colitis and therefore C.
diff samples were sent and the patient was presumptively started on
Flagyl and Pancrease 12 , 000 units three times a day 1/2 hour before meals.
The patient's abdominal pain and diarrhea persisted. This prompted
us to make the patient npo once more and another abdominal CT
was obtained. An abdominal CT performed on 30 of March showed
progression of pancreatitis with increase inflammatory changes.
There was no necrosis or pseudocyst formation noted. Also noted
was some significant small bowel dilatation without any evidence of
obstruction. Therefore , the patient was continued to be kept
npo and TPN was restarted on 25 of April . The patient has tolerated
this well and at this time has no longer had any abdominal pain
either subjectively or on exam. It does occasionally have mild low
back pain which is thought to actually be due to his pancreatitis
as opposed to any musculoskeletal cause.
II. DIARRHEA: The patient also had diarrhea as noted above.
He has been worked up extensively. His diarrhea has now resolved.
He was C. diff negative , but was treated presumptively with Flagyl
for seven days. All stool studies including Shigella , Salmonella ,
Campylobacter , ova and parasites , Microsporidia have been negative.
His stool has been sent for quantitative fecal fast which is still
pending on discharge. He has been repeatedly guaiac negative. As
noted above his diarrhea has resolved.
III. RESOLVED HEME POSITIVITY: The patient earlier in the
course of his Intensive Care Unit stay had some stools that were
heme positive. They were thought to be due to gastritis. He has
now been on initially , after that has been on Prilosec and now
changed over to ranitidine in his TPN and has had multiple guaiac
negative stools in the past ten days.
intravenous. SMALL PERIANAL ULCER: The patient was noted to have a
small perianal ulcer. It is felt to be secondary to pressure from
lying in bed and also secondary to his multiple episodes of
diarrhea which had been going on for days. It is felt that this
should resolve. If it does not , it is suggested that the ulcer be
swabbed and sent for HSV.
2. ENDOCRINE:
I. INSULIN DEPENDENT DIABETES MELLITUS: Due to the patient's
pancreatic insufficiency , the patient will be a life long diabetic.
The patient has been followed by the endocrine service and is now
receiving 45 units of insulin per liter through his TPN. He is
also on a sliding scale regular regimen with finger stick every 6 hours It
is felt that this should be a relatively stable regimen for him at
this time. As the patient is weaned off his TPN and starts to take
orally again , he should be switched over to NPH twice a day with regular
insulin checks on a sliding scale before his meals. The patient
also has a follow-up appointment with the diabetes clinic in three
weeks as noted below.
3. CARDIOVASCULAR: The patient does have a history of congestive
heart failure and has had mild bi-basilar crackles throughout his
stay here. This has not limited him in any way. He has had a good
oxygen saturations. The patient continues to take 40 mg of Lasix
orally every day On the day of discharge , he received an extra 20 mg intravenous
as he has been I&Os positive for the last few days and we noted a
slightly more crackles on his exam. Of note , the patient has a
long history of having paroxysmal nocturnal dyspnea but had been
doing relatively well here. His current medical regimen includes
Isordil 10 mg orally three times a day , Captopril 6.25 mg orally three times a day Both of
these can be titrated upwards as his blood pressure allows. He has
had some labile blood pressures ranging anywhere from the systolics
of 80s to 130s while in the hospital and he has never been
symptomatic and even when he has been , he has had blood pressures
in the 80s and has tolerated this well. He is also maintained on
digoxin 0.375 mg every day He is also taking aspirin for his cardiac
regimen.
4. PULMONARY: The patient had good O2 saturations and usually
ranging from 95 to 97% on room air and has had no pulmonary
problems. He has had bibasilar crackles on exam which is felt to
be due to some mild congestive heart failure for which he is taking
Lasix. He may need some extra doses of Lasix per your directions
the next few days.
5. HEME: The patient's hematocrit has been low in the high 20s on
two occasions. In both cases always drifting down slowly thought
to be due to delutional effects plus repeat a phlebotomy. He has
been transfused a total of three units while he has been in the
hospital here. Otherwise is hematocrit has been stable for
multiple days so has his platelets. Also of note the patient has
been heme negative from below for more than ten days.
6. RENAL: The patient says his baseline creatinine in which his
acute renal failure has resolved.
7. RHABDOMYOLYSIS: This has also resolved with the patient's CKs
having normalized over a week ago.
8. INFECTIOUS DISEASE: The patient has remained afebrile , normal
white count for many days. While here he was also presumptively
treated for C. diff which was actually found to be negative on his
stool examinations with no fecal leukocytes. The patient's
temperature curve should be followed given that the patient
continues to have pancreatitis and is at risk for developing a
phlegmon.
ASSESSMENT AND PLAN:
1. SEVERE PANCREATITIS: The patient continues to be on TPN. A
PICC line has been placed and a triple lumen catheter will be
removed prior to transfer of the patient. It is our feeling that
the patient should remain on TPN for the next two days and then as
per your directions , the patient could be slowly advanced on a orally
diet as tolerated. We feel that the patient deserves another trial
to see if he can tolerate orally before any long term decisions is
made regarding his nutrition and perhaps placement of a J-tube for
long term feeding. The patient's amylase and lipase on the day of
discharge are 47 for amylase and 166 for lipase. These values
continue to remain low even when the patient was having abdominal
pain. This is felt to be due to a relatively burnt out pancreas.
A GI consult was also obtained which agrees with this assessment.
It is felt that when the patient does start taking orally again he
should have pancreas at least 8 to 12 , 000 units three times a day half hour
before meals due to his pancreatic exocrine insufficiency. Also
the patient should be followed clinically very closely including
his white count , fever curve and his abdominal exam for any signs
and symptoms of development of an infection or phlegmon or
pseudocyst because of his pancreatitis. The patient's TPN should
be continued as noted below.
2. ENDOCRINE INSUFFICIENCY: The patient , as noted above , will
require insulin , both through is TPN and his fingersticks should be
checked every six hours. As noted when the patient is switched
over to a orally regimen , we suggest per endocrine recommendations
that NPH be given twice a day and the patient should be covered with an
insulin sliding scale at bedtime.
The patient is being transferred to Surgnor Medical Center on
2 of April in good condition. The patient today denies any abdominal
pain , nausea or vomiting , but occasionally continues to have mild
back pain. His diarrhea has resolved. He is afebrile with a blood
pressure of 120/70 , pulse is 69 , respiratory rate 16 , sat 97 on
room air , with a weight of 69.0 kg. He is comfortable and has had
bibasilar crackles of 1/4 the way up. His abdomen is soft ,
nontender , nondistended with positive bowel sounds. His
extremities are without edema.
On the day of discharge his white count is 8.8 , hematocrit is 36 ,
ADDplatelets of 348. His SMA-7 was within normal limits with a
creatinine of 0.6. His amylase is 47 and his lipase is 160.
DISPOSITION: The patient is being discharged in good condition
to Surgnor Medical Center . His primary care
physician Dr. Homby is aware of the patient's discharge and will
continue to follow with his care. The patient also has an
appointment with Dr. Mclead in the Diabetes Clinic at Liettonoake Gomond Y on 7 of January at 11 a.m.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally every day
2. Albuterol inhalers two puffs four times a day
3. Digoxin 0.375 mg every day
4. Lasix 40 mg orally every day
5. Captopril 6.25 mg orally three times a day
6. Isordil 10 mg orally three times a day
7. Magnesium and potassium sliding scale through IVs while being
here.
DIET: The patient should remain npo for the next two days. His
TPN orders upon discharge should be as follows: He will
have a total of 2 liters per day at a rate of 83.3 ml per hour
constantly. He has a modified central solution of 5% aminoacid ,
18% Dextrose , 400 lipids K-calories per day. His aminoacid should
be through a Novamine solution. His acetate is 0% His sodium
should be 30 mEq per liter , magnesium should be 10 mEq per liter ,
potassium 50 mEq per liter , phosphate 10 millimoles per liter.
Trace elements 1 millimoles per day , vitamin K 10 mg every Mondays ,
MVI 10 ml per day , calcium 94 mg per liter. His insulin in the TPN
should be 45 units per liter of TPN. There should also be
ranitidine 150 mg per liter of TPN. Also in addition to this he
should have 10 mg of Thiamine every Tuesday , Thursday , Saturday and
Sunday , 800 mcg of folate every Monday , Wednesday and Friday and
also 100 mcg of B-12 every Thursday through his TPN.
CONDITION ON DISCHARGE: Good.
OPERATIONS DURING ADMISSION: Exploratory laparotomy performed on
20 of June without complications.
Dictated By: KELVIN MIRISOLA , M.D. RG28
Attending: DESIRAE R. MARCOTT , M.D. BP21 LV542/6302
Batch: 8819 Index No. CFYEJ19IB1 D: 10/30/98
T: 10/30/98
CC: 1. SURGNOR MEDICAL CENTER
Document id: 451
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
Y |
N |
N |
N |
Y |
- |
N |
- |
N |
N |
N |
501106203 | PUO | 40514567 | | 322781 | 1/1/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/21/1992 Report Status: Signed
Discharge Date: 5/13/1992
HISTORY OF PRESENT ILLNESS: This is a 72 year old black female
with a history of hypertension ,
angina , adult onset diabetes , admitted after a syncopal event. She
has a known history of syncope which dates as far back as the late
1960s. In 1970 she had an episode of loss of consciousness with 30
seconds of generalized tonic convulsions witnessed by her daughter.
An EEG at that time showed diffuse theta waves but was nonfocal.
The patient was treated with Dilantin for less than a year. In
1972 she had another episode of syncope associated with
hyperventilation. In 1983 she had yet another episode of syncope
and a 24 hour Holter started after the event showed a heart rate
that went as low as 38 but was not associated with any symptoms. In
1987 she had a vasovagal event which was later aggravated when her
neighbor gave her a nitroglycerin tablet. Throughout this time she
has had multiple other episodes of syncope. Her last episode was
in 1989 , when she was admitted to the Cardiology Team for workup.
Her EKG was unremarkable , 24 hour Holter was normal , an
echocardiogram was normal , and she underwent an exercise stress
test which did not show ischemic changes. In October of 1992 , she
had carotid ultrasounds for symptoms of right hand and leg
numbness. They did not show significant stenosis. In October of
1992 , she was admitted and ruled out for a myocardial infarction
and was started on Isordil and Lopressor empirically but these were
later discontinued. In February of 1992 she had a clinic visit with
Dr. Caroyln Reidherd who is her KTDUOO doctor. The patient indicates
that she has stable exertional angina without limitation of daily
activity , chest pain is relieved with nitroglycerin and her most
recent episode was last week. She has also been on a stable dose
of Micronase for the last couple of years. On the morning of
admission , the patient awoke and felt fine , and was getting ready
to have coffee with her friends upstairs. She was reaching for
something across the table and suddenly felt a sharp pain in her
back and fell unconscious into the chair. Estimated loss of
consciousness was 6-7 minutes. She awoke confused , did not know
her name and had a little bit of difficulty seeing. It was unclear
by her history whether her vision was blurry or whether she felt
that there was a shade across her eyes. She denies any double
vision. Prior to this event she did not experience any prodrome or
aura. She also denied chest pain , shortness of breath or
palpitations. There was no loss of bladder or bowel function
during the event. The patient was given orange juice after the
episode and gradually she regained awareness of her surroundings.
Her vital signs were stable. She was brought to Gle Ra Csylv Valley Medical Center
for evaluation. There was a question of upper extremity twitching
by report from observers. PAST MEDICAL HISTORY: Hypertension
dating at least 10 years back and is presently not requiring any
treatment. She has a history , as mentioned , of recurrent syncopal
events. She was diagnosed a couple of years ago with adult onset
diabetes and has been on a stable dose of Micronase. The patient
also has a history of multiple colonic polyps and in 1983 underwent
a left hemicolectomy for multiple polyps. In 1988 she underwent an
ileal resection for large inflammatory polyps leading to a small
bowel obstruction. She has had a cholecystectomy and an
appendectomy in the distant past. The patient also a history of
glaucoma. In 1973 and 1976 she had a right lower extremity DVT ,
etiology was unclear. The patient does not smoke , drink or use any
drugs. MEDICATIONS ON ADMISSION include aspirin one tablet every day ,
Questran one pack every day , Micronase 5 mg orally every day , Betaxolol eye drops
twice a day to each eye , Pilocarpine eye drops three times a day to each eye ,
eye drops twice a day to each eye. The patient receives monthly Vitamin
B12 injections. She also takes nitroglycerin with chest pain.
FAMILY HISTORY is significant for a brother who suffered a stroke
at the age of 74. There is also a family history of heart attacks.
No family history of gastrointestinal cancer. SOCIAL HISTORY: The
patient is separated and lives by herself in Har Cinberke Walk She has
eight children with many grandchildren. REVIEW OF SYSTEMS is
notable for episodes of sweats and nervousness over the last week
which she describes as being similar to the hot flashes of
menopause which she had at age 49. These episodes are occurring a
few times a day but do not in any way coincide with her syncopal
events. She is also complaining of right hand and foot numbness
which have increased in frequency. The numbness occasionally wakes
her up at night. She denies any motor weakness whatsoever.
PHYSICAL EXAMINATION: She is an elderly , mildly obese female , in
no apparent distress. She was afebrile , with
a blood pressure of 126/70 , a heart rate of 60 , and a respiratory
rate of 18. HEENT exam was notable for pinpoint constriction of
her pupils secondary to her glaucoma eyedrops. Her pupils were
reactive. Her throat was benign. She had dentures. Her neck was
supple , without lymphadenopathy or thyromegaly. Chest exam
revealed bibasilar , coarse crackles. On cardiac exam she had no
jugular venous distention , and carotids were normal without bruits.
She had a regular rate and rhythm with S1 , S2 , and an occasional
S4. There were no murmurs. Abdominal exam was benign. The patient
was guaiac negative. Extremities were without edema and there was
no calf tenderness. The neurologic exam was entirely nonfocal.
LABORATORY DATA: Includes a sodium of 143 , potassium of 4.3 ,
chloride of 109 , bicarbonate of 20 , BUN of 21;
creatinine was 1.0. The glucose was 160. Her calcium and
phosphate were normal. Her hematocrit was 43.4 , her white count
6.45 with a normal differential. Her coagulation factors were
normal. Her liver function tests were normal. A chest X ray
showed a calcific aorta but was otherwise clear. C spine X ray and
head CT on admission were also negative. The EKG showed no changes
from her baseline.
HOSPITAL COURSE: The patient was placed on a cardiac monitor , and
her Micronase was held. In fact , her fingerstick
glucose went as low as 80 that evening. On day two of admission ,
the patient had syncopal event while in house. She was apparently
walking about after having washed her face and was reaching to pull
the curtain when she began feeling lightheaded. She told the nurse
immediately , who tried to get her on the bed , and the patient
collapsed on the bed , was limp and lost consciousness for about 3-5
minutes. She had a systolic blood pressure of 200/105 and a heart
rate of 90. There were no changes on the cardiac monitor , and the
patient was noted to maintain a strong pulse at all times. She was
given Nitro Paste and 1 amp of D50. Fingerstick glucose was then
noted to be 232. The patient was witnessed to have mild twitching
of her jaw and eyelids and after five minutes , she opened her eyes
but was not able to respond. When asked to give her name , she was
not able to answer. The confusion subsided over the next couple of
minutes , and the patient was able to respond and was alert and
oriented. However , she had no recollection of the event. Further
workup included a head MRI , MR angiogram of her vertebrobasilar
circulation , a sleep deprived EEG , a cardiac echo , and a 24 hour
Holter. All of the above were negative. We also applied carotid
sinus stimulation and she showed no change in heart rate to either
side. The etiology of her syncopal event is not completely clear.
It appears that the patient does have a history of a witnessed
seizure but also has had syncopal events consistent with either
bradycardia or a vasovagal event.
DISPOSITION: The patient is discharged to home with plans for a
repeat 24 hour Holter as an outpatient. FOLLOW UP:
She will follow up with Dr. Caroyln Reidherd in the KTDUOO Clinic.
CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS include
aspirin one tablet orally every day , Questran one package orally every day , Pilocarpine
eye drops three times a day per eye , Betaxolol eye drops twice a day per eye ,
eye drops twice a day per eye , sublingual nitroglycerin as needed chest pain ,
Naprosyn 375 mg three times a day as needed
DISCHARGE DIAGNOSIS: SYNCOPE.
OTHER DIAGNOSES: BORDERLINE TYPE II DIABETES , STABLE EXERTIONAL
ANGINA , AND GLAUCOMA.
QK828/9594
CHRISTY CLARDY , M.D. SP0 D: 9/25/92
Batch: 2154 Report: R1592M3 T: 6/6/92
Dictated By: BROADEN , CARIDAD VENITA REYNA
cc: 1. LEOLA MUSICH , M.D./DEPT. OF MED
2. CAROYLN REIDHERD , M.D./DEPT. OF MED
Document id: 452
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
074027992 | PUO | 24754264 | | 1034270 | 5/21/2005 12:00:00 a.m. | Diastolic heart failure exacerbation with volume overload but no clear precipetent. | | DIS | Admission Date: 1/6/2005 Report Status:
Discharge Date: 5/29/2005
****** DISCHARGE ORDERS ******
CANTORAN , VIVIANA G. 981-97-11-2
Weimid Drive
Service: MED
DISCHARGE PATIENT ON: 5/15/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RESNIK , AGUSTINA BRIGID , M.D.
CODE STATUS:
No CPR , No defib , No intubation , No pressors
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
FUROSEMIDE 80 MG orally every day Starting STAT May
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
17 UNITS every day before noon; 7 UNITS every afternoon subcutaneously 17 UNITS every day before noon 7 UNITS every afternoon
LISINOPRIL 10 MG orally every day
Override Notice: Override added on 1/27/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
08233801 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 10/9/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
METFORMIN 500 MG orally twice a day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 5/15/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: Aware
ASPIRIN ( ACETYLSALICYLIC ACID ) 81 MG orally every day
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Jacqulyn Harkley 8/30/05 at 9am January , 2005 at 9 a.m. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF Exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Diastolic heart failure exacerbation with volume overload but no clear precipetent.
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Hypetension , CAD , Diabetes
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
82F with known history of diastolic dysfunction ( EF 55% )
p/with worsening SOB X 4 weeks. She reports icnreased DOE , PND ,
orthopnea , LE swelling. No CP , palpitations , syncope , or known
change in weight. No f/c , cough , rash. No clear precipitant
identified - no change in meds , dietary indiscretion , infectious
history , ischemia sx , episodes of HTN , dehydration , etc. 3d PTA ,
patient decreased Lasix dose as it was difficult to get to
the BR given her SOB. Her sx worsened and she presented to the
ED. ED Vital Signs: 98 105 130/80 16 97%
RA well appearing ,
NAD Lungs: crackles as bases
b/l CV: RRR , nl S1 , S2 , JVP 7cm ( after 700cc
diuresis ) ) Abd:
benign Ext: 1+ pitting edema
symmetric LABS: Cr 0.9 , BNP 591 , WBC 9.6 with nl diff , HCT 42 ,
cardiac enzymes - X 1 , coags nl , U/A negative. EKG: sinus tach with old
LBBB/LAFB. Prolonged QTc CXR: b/l effusions , calcified aortic knowb ,
prominent vasculature , ? RML infiltrate. In the ED , patient was given
ASA , Lasix 40 intravenous ( diuresed 700c ) , and Levaquin 500 for ? of
PNA. IMPRESSION: Diastolic heart failure exacerbation
with voume overload but no clear initial precipitant.
HOSPITAL COURSE
1 ) CV:
ISCHEMIA - The patient was ruled out of MI by serial cardiac enzymes which
returned negative. EKG showed normal sinus rhythm , left axis deviation and
LBBB , findings that were unchanged from previous EKG's , and no findings
characteristic of new cardiac ischemia. The patient was placed on ASA
325mg , Lisinopril 10mg every day and Simvastatin 40mg orally while admitted.
PUMP - The patient was diuresed with Lasix with good result and subsequent
improvement in her SOB. Patient's net diurese was 1650cc and she was no
longer SOB at time of discharge. Her weight on admission was 68.21 Kg and on
discharge was 66.6 Kg. Her BP on discharge was 94/60. The patient was seen
by physical therapy on 5/3/05 , who noted she was able to maintain O2 sats
of 90-93% on room air after traveling 100-150 feet. physical therapy felt that the patient
was safe to be discharged home. To re-evaluate her systolic function , Echo
was obtained ( results pending at this time ). XXX.
RHYTHM - The patient was maintained on telemetry throughout her course
without any evidence of arrythmias.
2 ) ENDO: The patient was maintained on her home regiment of NPH 17/7 ,
Metformin 500mg twice a day She required minimal coverage by sliding scale.
3 ) ID: No evidence of pneumonia by symptoms or CXR. No evidence of
extrapulmonary infection. No antibiotics were given.
4 ) PULMONARY: The patient required minimal pulmonary support with NC O2. y.
5 ) GU: The patient's urine after Foley placement was blood tinged and she
complained of discomfort at the entrance. The foley was D/C'ed and she was
asked to carefully monitor her urine output by not flushing it before
nursing recorded the volume. Her urine was free of obvious blood by 5/3/05 .
6 ) FEN: The patient was maintained on a low salt , cardiac diet , fluid
restricted. Her electrolytes were monitored daily , given her diureses , and
replaced as needed.
6 ) PROPHYLAXIS: Lovenox 40mg and Esomeprazole 40mg orally every day were used used
through her admission.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up with your primary care physician Dr. Jacqulyn Harkley this Friday , February .
If shortness of breath develops , call and see your primary care
doctor. Also be aware of and contact your doctor regarding swelling of
your legs , chest pain or increases in your weight , findings that may
indicate that your heart failure is getting worse. Take all
medications as prescribed.
No dictated summary
ENTERED BY: COSE , LATASHIA C. , M.D. , M.B.A. ( JU10 ) 5/15/05 @ 03:19 PM
****** END OF DISCHARGE ORDERS ******
Document id: 453
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
- |
N |
N |
- |
N |
N |
N |
N |
N |
N |
104444086 | PUO | 05391370 | | 1779005 | 9/18/2003 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 5/2/2003 Report Status: Signed
Discharge Date: 1/18/2003
CHIEF COMPLAINT: This is a 72-year-old man with a history of
significant coronary artery disease , status post
CABG x 2 , stents and brachytherapy who was admitted for an NSVT
leading to fatigue and shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient's symptoms first developed
last September , 2002 when he noticed
fatigue and shortness of breath. He had recently developed
bacteremia after a colonoscopy and never felt that he had quite
recovered. He was being treated with atenolol 25 mg orally twice a day at
the time for his coronary artery disease. His wife and son , who
are a nurse and a PA , respectively , felt his pulse and it was
frequently in the 30s , but was also occasionally normal. He
decreased his atenolol to 25 mg once a day but his symptoms
persisted. He was seen as an outpatient and found to have frequent
PVCs on EKG.
Over the past few months the patient has also noticed increased
angina , both with and without activity. He has had increased
difficulty walking up the stairs causing chest pain and shortness
of breath that are relieved by sublingual nitroglycerin. Then two
days prior to admission the patient also noticed pain at rest but
was again relieved by sublingual nitroglycerin. On the morning of
admission he felt chest heaviness that woke him up from sleep. He
did not take any nitroglycerin but his wife told him that he was
"gasping for breath". Over the past month he had been seeing his
cardiologist , Dr. Schwerd . Because of his shortness of breath he
was started on Lasix for 3-4 days but this also did not relieve his
symptoms. He had Holter monitoring with exercise , going up and
down the stairs , at clinic and this also showed frequent PVCs. He
had an electrocardiogram that showed an ejection fraction of 30%.
PAST MEDICAL HISTORY:
1. He had a coronary artery bypass graft in 1974 and 1982. He had
PCI of his left main coronary artery 6/18 and PTCA and
brachytherapy secondary to in-stent restenosis in April , 2002.
Intervention 6/18 his left main was radiated. His bypass
vessels are LIMA/LAD , SVG/marginal 1 , LIMA/LAD , SVG/RPDA.
2. He had a significant GI bleed secondary to aspirin and
Plavix in 2002. His hematocrit went to 17. The patient has
remained on aspirin and Plavix secondary to his coronary
artery disease.
3. History of prostate cancer treated with radiation , complicated
by radiation prostatitis.
4. Diabetes.
5. Status post right carotid endarterectomy. No history of TIAs
or strokes.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 81 mg; Plavix 75 mg; atenolol 25
mg once a day; Isordil 60 mg twice a
day; lisinopril 20 mg once a day; Norvasc 5 mg once a day; Lipitor
10 mg once a day; gemfibrozil 600 mg twice a day; hydroxyzine 25 mg
twice a day; Glyburide 10 mg twice a day; metformin 1 , 000 mg twice
a day; Nexium 40 mg once a day; iron sulfate 300 mg once a day;
calcium 1250 twice a day; multivitamin once a day; vitamin E; folic
acid; Colace.
FAMILY HISTORY: He has several siblings with coronary artery
disease in their 60s.
SOCIAL HISTORY: He is a former engineer for Oregon , but
stopped working when he was in his 40s because of
his coronary artery disease. He denies any tobacco , alcohol , or
drug use. He lives with his wife.
REVIEW OF SYSTEMS: Two-pillow orthopnea that is stable , no
palpitations.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 95.1 , heart rate
58 , blood pressure 112/50 , breathing 22 ,
satting 98% on room air. HEENT: Extraocular movements intact.
Pupils equal , round and reactive to light and accommodation. JVP
was 10.0 cm with a right carotid endarterectomy scar.
CARDIOVASCULAR: Normal S1S2. LUNGS: Clear to auscultation
bilaterally. ABDOMEN: Soft , nontender , nondistended , positive
bowel sounds. EXTREMITIES: No lower extremity edema. NEURO:
Cranial nerves II-XII intact.
LABORATORY DATA: On admission. Sodium 140 , potassium 5.0 ,
chloride 104 , bicarb 23 , BUN 35 , creatinine 1.5
his baseline is 1.4 , glucose 148 , white count 9.0 , hematocrit 37 ,
platelets 297. Liver function tests were within normal limits. CK
125 , MB 1.6 , troponin 0.02.
Electrocardiogram showed right bundle branch block and 2-3 beats of
normal sinus rhythm interspersed with NSVT.
HOSPITAL COURSE: 1 ) Cardiovascular: Ischemia: It was unclear
whether the patient's worsening chest pain was
from progression of his coronary artery disease or whether this was
demand ischemia from his frequent NSVT. He was ruled out for a
myocardial infarction by enzymes but given the persistence of his
arrhythmia , he was taken for catheterization. His catheterization
showed an LAD 100% lesion , diag 1 80% lesion , left circumflex 100%
lesion , the ramus was widely patent , RCA showed a 100% lesion ,
right PDA 100% lesion. Overall , his LIMA graft to the LAD was
widely patent , his SVG graft to marginal 1 and SVG graft to RCA
were both occluded but had collaterals. What was new from his
previous catheterization was disease in his PDA. It was determined
to further treat the patient's coronary artery disease with medical
management. After his heart rate was controlled with amiodarone
and with a pacemaker , he did however continue to have some fatigue
and shortness of breath. As a result he had an adenosine MIBI to
evaluate for functional ischemia given the findings on his
catheterization. The MIBI showed a moderate sized perfusion defect
throughout the inferior and basal inferoseptal and inferolateral
walls showing a moderate amount of reversibility. His ejection
fraction was estimated at 50% with akinesis of the inferior and
inferoseptal walls with reduced thickening. He did not have any
EKG changes during the procedure. His beta blockade was increased
to Lopressor 50 twice a day and he continued on his nitrates. He was
actually able to tolerate ambulation without feeling any pain or
shortness of breath. It is possible that the symptoms that he had
later on in the hospitalization were secondary to volume overload
which responded well to diuresis. He will follow up with Dr.
Schwerd . It is unlikely that any intervention will be able to be
done but he will explore this as an outpatient.
2 ) Pump: The patient did experience some shortness of breath
several days into his admission. He had been approximately four
liters positive over several days. He was given 20 mg of intravenous Lasix
and responded well. He was sent home with 20 mg of Lasix every Monday
and Thursday.
3 ) Rhythm: The patient's electrocardiogram and telemetry strips
were concerning because while he was technically in normal sinus
rhythm , he was usually only in normal sinus rhythm for 3-4 beats at
a time at most , and in between that , had several runs of NSVT. The
NSVT never progressed to sustained V-TAC and the patient was always
hemodynamically stable. However , there was concern that this could
ultimately progress to ventricular tachycardia or fibrillation. He
was loaded on amiodarone 400 mg orally three times a day which he tolerated
well. He also required an additional 150 mg intravenous x 1 load to
stabilize his rhythm. He had an ICD and DDI pacemaker placed on
7/26 without complication. After the pacemaker was placed he was
still experiencing some fatigue and it was thought that he may have
been overpaced. As a result his settings were adjusted to increase
his AV delayed 240 and he was changed to DDD mode. He also had a
number of beats shortened that would be required to detect the VT ,
to 24. By the time of discharge his amiodarone was decreased to
400 mg every day This may ultimately be decreased even further to 200
but will be decided by Dr. Dobrich .
4 ) Endocrinology: The patient has a history of diabetes. We held
his metformin on admission because of his catheterization but
restarted it upon discharge. Any elevated blood sugars were
covered with an insulin sliding scale.
5 ) Pulmonary: As mentioned above the patient did have some
shortness of breath which was likely due to volume overload. He
responded well to 20 mg intravenous Lasix. He always maintained his oxygen
saturations. He will have pulmonary function tests as an
outpatient to establish a baseline given his new treatment with
amiodarone.
6 ) Heme: The patient does have a history of a GI bleed on aspirin
and Plavix. We monitored his hematocrit closely. He came in at
37. It did decrease to 31. During his hospitalization he had an
episode of bright red blood per rectum. Given his history of
radiation proctitis and proctatitis it is not surprising that he
had this. He always remained hemodynamically stable and did not
require any transfusions. At baseline his hematocrit is probably
closer to 33 and it is likely that the 37 was an elevation from
decreased orally intake. Follow up stools were guaiac-negative.
FOLLOWUP: He will follow up as an outpatient with Dr. Schwerd and
Dobrich on 4/4/03 . He will also have pulmonary
function tests on 5/8 .
DISCHARGE MEDICATIONS: Amiodarone 400 mg orally.every day; aspirin 81 mg
orally.every day; calcium carbonate 1250 orally
twice a day; Colace 100 mg orally twice a day; iron sulfate 300 every day; folate
400 mcg every day; gemfibrozil 600 twice a day; Glyburide 10 mg twice a day;
hydroxyzine 25 twice a day; lisinopril 20 every day; Lopressor 50 twice a day;
M.V.I. every day; vitamin E 1 , 000 units every day; Norvasc 5 mg every day; Imdur
60 twice a day; Plavix 75 every day; Nexium 40 every day; Lipitor 10 every day;
metformin 1 , 000 twice a day; Lasix 20 mg every Monday and Thursday.
Dictated By: ARIE L. TELES , M.D. ZX97
Attending: ALYSE A. HOLDA , M.D. BP6 LH824/057329
Batch: 75335 Index No. ZLHU507M5X D: 1/1/03
T: 1/1/03
Document id: 454
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
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N |
N |
- |
N |
094282885 | PUO | 73788778 | | 8533383 | 10/24/2005 12:00:00 a.m. | NON ST ELEVATION MYOCARDIAL INFARTION | Signed | DIS | Admission Date: 7/6/2005 Report Status: Signed
Discharge Date: 5/24/2005
ATTENDING: SURACE , NINA M.D.
PRIMARY CARE PHYSICIAN: Domenic Lorraine , MD
This is an interim discharge summary dictation and there will be
an addendum , which will include the discharge medications and
follow-up appointments.
ADMITTING DIAGNOSIS: Non-ST elevation MI.
PRINCIPAL DISCHARGE DIAGNOSES:
1. Non-ST elevation MI , status post PCI with drug eluding stent
x3 to the SVG to RT PDA.
2. Acute renal failure , on chronic renal failure.
3. Anemia.
4. Insulin dependent diabetes.
5. Hyponatremia.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female with a
history of significant coronary artery disease status post
inferior MI in 1988 , and status post CABG , who presents with a
non-ST elevation MI. The patient has significant cardiac risk
factors including hypertension , hyperlipidemia , smoking , age
greater than 50 , and diabetes. The patient has a significant
history of multiple vasculopathies with interventions on
bilateral carotids , CABG , aortofemoral bypass , history of CVA ,
and likely renal artery stenosis. The patient presents with a
two-week history crescendo angina present at both resting and
exertion and which occurred two times per week and resolved each
time spontaneously without the requirement of nitroglycerine.
The patient awoke on the morning of admission with a sharp left
precordial pain , which progressed to substernal chest pressure
radiating to the neck down her right arm and left arm and a
feeling of left arm numbness. The patient did experience
significant nausea and vomiting and took multiple nitroglycerins
without relief. She presented to Totin Hospital And Clinic Emergency
Room , was noted to have ST depressions in the inferolateral leads
as well as T-wave inversions in her lateral leads. Troponin at
that time was 14. The patient was admitted for non-ST elevation
MI management and probable cardiac catheterization.
PAST MEDICAL HISTORY:
1. Notable for coronary artery disease status post IMI in 1988 ,
treated with TPA , CABG in 1999.
2. Hypertension.
3. Insulin dependent diabetes times greater than 20 years.
4. Carotid stenosis status post bilateral carotid
endarterectomies.
5. Hyperlipidemia.
6. Status post aortobifemoral bypass in 1999.
7. Status post cerebellar CVA in 2004.
8. Chronic renal insufficiency with a baseline creatinine to
2.5.
9. Diastolic dysfunction , heart failure.
10. Depression.
CURRENT MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Lasix 40 mg orally daily.
3. Plavix 75 mg orally daily.
4. Lisinopril 20 mg orally daily.
5. Toprol-XL 25 mg orally daily.
6. Hydralazine 25 mg orally three times a day
7. Glyburide 10 mg orally twice a day
8. Lantus 18 units every bedtime
9. Isordil 10 mg orally twice a day
10. Nitroglycerin sublingual as needed for chest pain.
ALLERGIES:
1. Angiotensin receptor blockers , which cause hives.
2. Adhesive tape , which cause pleuritis.
SOCIAL HISTORY: The patient is a retired beautician. She has a
45-year history of prior smoking and currently continues to smoke
occasionally. At a high , she smoked three packs per day. Denies
alcohol use. No recreational drug use. The patient currently
lives alone.
FAMILY HISTORY: Significant for mother , who died at age 61 of
pyelonephritis and myocardial infarction. Father died at age 52
of brain tumor. She has two siblings with no heart disease.
REVIEW OF SYSTEMS: Otherwise negative other than mentioned in
HPI.
PHYSICAL EXAMINATION: Upon admission , temp 97 , pulse 78 ,
respiratory rate 16 , blood pressure 144/52 , and pulse oxymetry
99% on room air. General , this is a pleasant elderly female in
no acute distress , slightly slurred speech. HEENT , normocephalic
and atraumatic. Extraocular motions are intact. Neck is supple.
No lymphadenopathy , no thyroid enlargement , bilateral carotid
bruits palpable. Cardiovascular , distant heart sounds , regular
rate and rhythm , a 2/6 systolic ejection murmur heard at the left
sternal base. No rubs or gallops. Crackles heavily at the chest
wall , no wheezes. Abdomen is soft , nontender , and nondistended.
Bowel sounds are present. Extremities , no clubbing or cyanosis.
Pedal pulses , 1+ , left greater than right. Neuro , cranial nerves
II through XII intact. Strength 5/5 diffusely , light touch
intact throughout , no dysmetria , mild difficulty with alternating
movements , and negative pronator drift.
LABORATORY DATA: Labs upon admission included ??__?? creatinine
of 3.1 , otherwise the electrolytes within normal limits , sodium
129 , and glucose 132. LFTs were within normal limits. Hemogram
showed a mildly depressed hematocrit of 32 , troponin elevated at
14.4 , CK 364 , and CKMB 28.3. EKG upon admission showed normal
sinus rhythm at 83 , normal axis , ST depressions noted in leads II
V5 , and V6. No ST elevations. Q waves in III and F. T wave
inversions noted in I through III , F , V6 , poor R-wave
progression.
ASSESSMENT AND PLAN: This is a 61-year-old female with a history
of multiple vasculopathies , who presented with a non-ST elevation
MI. The patient was noted to have markedly elevated troponin and
progressive T-wave inversions laterally.
1. Cardiovascular ischemia , following admission , the patient was
initiated on aspirin , Plavix , nitroglycerin drip , oxygen as needed ,
and the beta-blocker was titrated up as tolerated. ACE inhibitor
as well as hydralazine were held. Over the first night of
admission , the patient noted increasing chest discomfort. The
nitroglycerin was titrated up. EKG showed continued T wave
inversions laterally as well as marked increase in troponin up to
an elevation of 105. Cardiac fellow was contacted and the
patient was titrated up further on her nitroglycerin to a max of
200. The patient did not have chest pain on the night of
admission , however was noted to have EKG changes and elevated
troponin as mentioned. On the morning following admission , on
11/8/05 , the patient was noted to have new onset of chest
discomfort and at that time was noted to have ST elevations in
her inferior leads III and F as well as V6 and L. At that time ,
due to the continued chest discomfort and new ST elevation , the
patient was taken to the cath lab , at which time , she underwent a
cardiac catheterization and was noted to have a three-vessel
disease status post CABG. She was noted to have 90% of occlusion
of the SVG graft to RTPDA status post PDA. These lesions were
intervened upon with drug eluding stents x 3. Following the
catheterization , the patient was continued on her medical
management. She remained chest pain free and the nitroglycerin
drip was discontinued. Following the cath , the patient's
troponins trended down and she had mild ST elevations that
persisted inferiorly but were diminished prior to discharge.
Preventive measures including nutrition and smoking sensation
were obtained. The patient appears reluctant to quit smoking.
Cardiovascular pump , the patient has a history of hypertension ,
which was well controlled throughout her hospitalization.
Isordil and hydralazine were initially held on admission while on
the nitroglycerin drip. The ACE inhibitor was held secondary to
acute renal insufficiency. Therefore , the beta-blocker was
titrated up. Upon discharge , the patient may reinitiate on
low-dose hydralazine and Isordil as well as reinitiation of the
ACE as tolerated with renal function. In addition , the patient
has a history of diastolic dysfunction , which is likely due to
her history of hypertension. An echocardiogram from October 2005
during a prior admission for heat failure showed an EF of 60% , as
well as inferior apical hypokinesis , mild elevated LVEDP. The
patient appeared mildly hypervolemic during her hospitalization
but did not show any signs of acute congestive heart failure.
Initially diuresis was held secondary to acute renal
insufficiency. However , she received Lasix 40 mg intravenous x1 on
2/16/05 due to abdominal discomfort and distention due to mild
volume overload. Cardiovascular rhythm , the patient was
continued on telemetry throughout her hospitalization. She has
no history of arrhythmias and no events were noted on her
telemetry. She obtained EKGs , which showed no significant change
or nodal blockage.
2. Endocrine , the patient has a history of insulin-dependent
diabetes , which was moderately well controlled throughout her
hospitalization. She has a history of hemoglobin A1c of 7.3 as
of February 2005. Upon admission , glyburide was held and the
patient was continued on Lantus as well as a sliding scale of
Regular Insulin. She obtained fingers sticks before meals and bedtime
Glipizide was initiated on 2/16/05 and will be titrated up as
tolerated as an outpatient.
3. Respiratory , this system was stable throughout admission.
The patient had crackles on exam , but no significant pulmonary
edema on chest x-ray. Abdominal CT on 7/16/05 was notable for
moderate right and trace left pleural effusions. The patient
maintained excellent pulse oximetry on room air without any
respiratory compromise.
4. Renal , upon admission , the patient was noted to have acute
renal insufficiency with a creatinine of 3.2. The patient has a
history of chronic renal insufficiency secondary to hypertensive
nephropathy , diabetic nephropathy , and likely renal artery
stenosis. Prior renal ultrasound showed an atrophic left kidney
with mild decrease in perfusion. Following admission , the
patient was initiated on D5W with 3 ampules of bicarb as well as
Mucomyst in preparation for likely cardiac catheterization. She
was continued on intravenous fluids following the catheterization.
Despite these preventive measures , the patient had a marked
increase in her creatinine following cardiac cath with a high
creatinine of 5 on 7/20/05 . Renal consult was obtained and
advised continued treatment. A urine sediment was obtained which
was consistent with ATN. An abdominal CT showed evidence again
of an atrophic left kidney. Creatinine was noted to begin to
decrease on 7/16/05 and was 4.2 the day before discharge. The
patient will follow up with Dr. Norseth in Nephrology within three
months' time.
5. GI , the patient was noted to have right upper quadrant
abdominal pain on 7/20/05 . She had had mild elevations in her
LFTs , most notably an alk phos of 293. However , these values
stabilized throughout the remainder of the hospitalization. An
abdominal CT was obtained without contrast that showed no sign of
obstruction , hepatobiliary disease , but was notable for a ventral
hernia that was not strangulated or incarcerated. The patient
continued to pass and had regular bowel movements. She was
continued on bowel regimen. The pain was thought to be likely
secondary to ventral hernia with increased volume status.
Therefore , she was given a mild diuresis to decrease volume
overload.
6. ID was stable.
7. Heme , the patient was noted to have a hematocrit drop prior
to cath. She dropped from 32 to 26. She was transfused two
units of packed red blood cells prior to catheterization in order
to keep the hematocrit greater than 30. There was no acute
source of blood loss noted. Guaiac stools were negative. There
is likely a component of anemia of chronic disease secondary to
chronic renal insufficiency. The patient's hematocrit continued
to trend down and on 7/16/05 , an abdominal CT was obtained to
rule out retroperitoneal bleed , which was negative. The patient
was transfused one unit of packed red blood cells on 7/16/05 .
She will likely require a further anemia workup as an outpatient.
8. FEN , the patient was not given any electrolyte scales
secondary to her acute renal insufficiency. She was noted to
have hyponatremia with a lowest of 123 and was therefore placed
on free water 1.5-liter restriction with adequate resolution.
The patient was also placed on a less than 2-gm salt restriction
to decrease volume overload. She was noted to have an increased
phosphorous level and was started on PhosLo. She had elevated
potassiums , but this did not exceed 5. The patient was continued
on a cardiac/renal 1800 ADA diet. Prophylaxis included SCD and
Pneumoboots in the setting of anemia. She was continued on a
proton pump inhibitor.
CODE: The patient is DNR/DNI.
DISPOSITION: Upon discharge , the patient was in stable condition
and will be discharged home without service. She was able to
ambulate without chest pain or shortness of breath tolerating
orally intake well. She will have follow-up as noted in the
addendum. The patient was instructed not to smoke and to take
daily weights and if she gained more than 2 pounds per day or 5
pounds in a week , she was instructed to call her doctor. She
should seek medical attention for worsening shortness of breath ,
chest pain , weight gain , dizziness , worsening abdominal pain , or
any other concerns.
PLAN:
1. Follow up with Dr. Lorraine , monitor for continued decrease in
creatinine. Consider reinitiating the ACE inhibitor with
resolution of acute renal insufficiency. Titrate the
beta-blocker and restart nitrates as tolerated. Titrate up
glipizide as needed. Consider further anemia workup. Encourage
smoking sensation. Continue to monitor abdominal pain/LFTs and
consider further evaluation of ventral hernia. Check LFTs with
recent addition of Lipitor.
2. Follow up with Dr. Gerchak post MI management.
3. Follow up with Dr. Norseth for management of chronic renal
insufficiency.
eScription document: 7-6707653 CSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: SURACE , NINA
Dictation ID 6885709
D: 2/16/05
T: 2/16/05
Document id: 455
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
Y |
N |
Y |
N |
281801955 | PUO | 38766817 | | 367524 | 10/28/2000 12:00:00 a.m. | CARDIAC ISCHEMIA | Signed | DIS | Admission Date: 11/2/2000 Report Status: Signed
Discharge Date: 3/4/2000
SERVICE: GENERAL MEDICINE Lis
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
SECONDARY DIAGNOSES: 1. CORONARY ARTERY DISEASE.
2. TYPE II DIABETES.
3. HYPERCHOLESTEROLEMIA.
4. CHRONIC LOW BACK PAIN.
5. L4-L5 SPONDYLOLISTHESIS.
6. ABDOMINAL PAIN.
7. CONSTIPATION.
8. ANEMIA.
9. PERIPHERAL NEUROPATHY.
10. GASTROPARESIS.
HISTORY OF PRESENT ILLNESS: Mrs. Jinkens is a 66-year-old
woman who presented with one week of
increasing shortness of breath with exertion , increasing peripheral
edema , and increasing abdominal distention. She denies any chest
pain , palpitations , chest pressure , nausea , vomiting , or
diaphoresis. She thought that her abdominal distention was
secondary to chronic constipation and her last bowel movement was
four days prior to admission. She felt that her abdominal
distention was contributing to her shortness of breath because she
was unable to take deep breaths. In addition , she has a long
history of chronic anemia with no clear diagnosis. She denied any
melena or bright red blood per rectum. She also has a long history
of low back pain , so she does not lie flat to sleep. In addition ,
she complains of some early satiety. She denies fevers , chills ,
chest pain , palpitations , lightheadedness , nausea , vomiting , weight
loss , or known weight gain.
PAST MEDICAL HISTORY: Poorly controlled diabetes with intolerance
to Humulin insulin ( she believes this made
her retinopathy worse ) , peripheral neuropathy , gastroparesis ,
coronary artery disease , peripheral vascular disease , status post a
left femoral popliteal bypass surgery , chronic constipation , carpal
tunnel syndrome , history of Acinetobacter pneumonia in 1997 ,
chronic anemia , Charcot foot , status post open reduction internal
fixation of a left ankle fracture , status post cholecystectomy ,
history of C. difficile colitis , echocardiogram in 1997 revealing
left ventricular hypertrophy and ejection fraction of 55% ,
Persantine thallium in October of 1994 revealing moderate anterior
ischemia in the left anterior descending territory.
MEDICATIONS ON ADMISSION: NPH pork insulin , 42 units every day before noon;
Lopressor 25 mg twice a day; Vaseretic
10/25 mg every day; aspirin 325 mg every day; Senokot; Niferex 150
twice a day; diazepam 1 mg orally twice a day; Avandia 4 mg orally every day.
ALLERGIES: Aldomet , Procardia , Darvocet causes drowsiness ,
Percocet causes vomiting.
SOCIAL HISTORY: She lives alone. Her son is involved in her
care. Occasionally she lives with him. She does
not smoke or drink. Her husband died of complications of a
coronary artery bypass graft about one year prior to admission.
PHYSICAL EXAMINATION ON ADMISSION: Uncomfortable secondary to
distended abdomen. Temperature
97.3 , heart rate 73 , blood pressure 172/68 , respiratory rate 18 ,
96% on room air. Her HEENT exam revealed a clear oropharynx ,
nonicteric sclerae. Extraocular movements were full. Her neck was
supple with 2+ carotid upstrokes and a faint left carotid bruit.
Jugular venous pressure was difficult to assess secondary to body
habitus. She has bibasilar crackles in her lung fields. Her heart
was regular rate with a normal S1 and somewhat loud S2. She has no
murmurs , rubs , or gallops. Her abdomen was soft , slightly
distended , and obese. She had no shifting dullness and no
hepatosplenomegaly. Her extremities were remarkable for 2+ pitting
edema , right greater than left. She had weak pulses bilaterally ,
weaker on the left than the right.
LABORATORY DATA ON ADMISSION: Sodium 135 , potassium 4.2 ,
chloride 95 , bicarb 30 , BUN 34 ,
creatinine 1.3 , glucose 212 , ALT 15 , AST 14 , alkaline
phosphatase 76 , total bilirubin 0.4 , CK 53 , troponin I - 0.00 ,
albumin 4. White blood cell count 4.9 , hematocrit 28.3 , MCV 86 ,
RDW 13.3 , platelets 303. Urinalysis revealed 3+ leuk esterase with
trace blood , too numerous to count white blood cells , and 10-15 red
blood cells. EKG revealed normal sinus rhythm at 70 beats per
minute with normal intervals and axis. She had an isolated Q wave
in lead III. She also had T wave inversions in V5 and V6 which
were unchanged from prior comparison EKG in 1998.
HOSPITAL COURSE: Mrs. Jinkens was initially admitted to the
short stay unit for blood transfusion , workup of
her chronic anemia , and diuresis for new onset congestive heart
failure. On hospital day #2 , she developed what appeared to be a
32 beat run of ventricular tachycardia. She was thus transferred
to the general medicine service for further management and workup.
Her hospital course by systems is as follows:
1. NEUROLOGIC. Mrs. Jinkens continued to complain of low back
pain which has been a chronic problem and for
which she is followed by Dr. Wimpey in spine clinic here at Pagham University Of . She reports that he has already made
arrangements for her to undergo an open MRI at the Greene Lidonimill Medical Center , as we do not have these facilities here , and
will follow up with him in clinic after she has this test. In the
past she has had cortisone injections without benefits , and it was
felt that since she has no acute exacerbation of this chronic
problem and already had followup in place , further consultation was
not necessary during this hospitalization. She was reinitiated on
Neurontin 300 mg every bedtime , then increased to twice a day , and to be
increased to three times a day as an outpatient. She reports that with this
regimen she finally was able to sleep at night and reports a
significant improvement in her neuropathic pain secondary to
diabetic neuropathy as well as sciatica.
2. CARDIOVASCULAR. Mrs. Jinkens was aggressively diuresed for
fluid overload in the setting of new
congestive heart failure. She responded well to intravenous Lasix. She had
a cardiology consultation , and they determined that the ventricular
tachycardia noted on the monitor was actually an artifact and not
real. A long discussion between the patient , her son , and her
primary care doctor was undertaken. Mrs. Jinkens expressed her
fervent desire not to undergo cardiac catheterization or coronary
artery bypass grafting because of her husband's traumatic
experience with these procedures. Given her reluctance to undergo
intervention , further diagnostic studies were deferred , such as
stress testing. Her medical management was further optimized. She
was continued on enteric coated aspirin. Her beta blocker dose was
increased to 25 mg orally twice a day of atenolol with heart rate control.
Her ACE inhibitor dose was also increased. Simvastatin 40 mg orally
every bedtime was added for LDL cholesterol of 184. In addition , Isordil
was added to her cardiac regimen to decrease preload. She will be
discharged on 160 mg orally every day of Lasix. She was told that her
dose may change , depending on her daily weights at home , and this
should be coordinated with the visiting nurse as well as her
primary care doctor.
3. GASTROINTESTINAL. Mrs. Jinkens continued to complain of
nonspecific abdominal pain as well as
constipation while in the hospital. She also had a significant
bout of nausea and vomiting. She was given an aggressive bowel
regimen including enemas , with good response. On 3/23 , because
of persistent abdominal pain and a somewhat more firm abdomen , a
KUB and upright was performed which was within normal limits. The
next day her pain , nausea , and vomiting had significantly resolved
with the addition of Reglan to her medical regimen for presumed
diabetic gastroparesis.
4. ENDOCRINE. A hemoglobin A1c was checked during this admission
and was 9.5. Because of persistently high morning
sugars , 8 units of NPH at night was begun in addition to her 45
units every day before noon Her blood sugars remained under 200 with this
regimen.
5. HEMATOLOGIC. Mrs. Jinkens initially presented with a drop in
her hematocrit to 28. She was transfused two
units of packed red blood cells with an appropriate increase in her
hematocrit. Iron studies as well as B12 and folate levels were
checked and were within normal limits. LDH , bilirubin , and
haptoglobin were also within normal limits. Her hematocrit
remained stable throughout the further course of her
hospitalization.
6. INFECTIOUS DISEASE. Mrs. Jinkens received a total of three
days of levofloxacin for a urinary tract
infection.
7. Finally , she was seen both by physical therapy and occupational
therapy and home referrals were put in place.
MEDICATIONS ON DISCHARGE: Enteric coated aspirin 325 mg orally
every day; atenolol 25 mg orally twice a day;
Colace 100 mg orally twice a day; Lasix 160 mg orally every day; Lactulose
30 cc orally twice a day , and can increase to four times a day as needed; lisinopril
40 mg orally every day; Reglan 10 mg orally four times a day; Niferex 150 , 150 mg
orally twice a day; Senna tablets , two tabs orally twice a day; simvastatin
40 mg orally every bedtime; Neurontin 300 mg orally twice a day x2 days , and then
increase to 300 mg orally three times a day; NPH insulin ( pork ) 45 units subcutaneously
every day before noon , 8 units subcutaneously every afternoon; diazepam 1 mg orally twice a day as needed
anxiety; nitroglycerin 1/150 , one tab sublingual every 5min. x3 as needed
chest pain; Oxycodone 5 mg orally every 6 hours as needed back pain , not to
exceed four tablets per day; Motrin 600 mg orally every 6 hours as needed back
pain , not to exceed four tablets per day.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient will be discharged to home with home
services. She will have visiting nurse to check her
blood pressure , heart rate , and breathing status. In addition , she
was instructed to weigh herself each day at home and to record
those weights. She is to call her primary care doctor if her
weight increases by more than 2 pounds , and was told that she would
likely be instructed to increase her dose to twice a day She will have
a Chem-7 drawn by the visiting nurse this Monday. Finally , she
will have both home physical therapy and occupational therapy
services. She should follow up with her primary care doctor ,
Dr. Osten , in one to three weeks. She was also instructed to
keep her MRI appointment at the Greene Lidonimill Medical Center , and
then to see Dr. Wimpey in spine clinic after this test was
performed.
Dictated By: FRAN BUSSLER , M.D. TW36
Attending: COLIN E. NAJI , M.D. IC05 LG299/2346
Batch: 2092 Index No. ISVC9Y3X98 D: 4/30
T: 4/30
Document id: 456
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
N |
U |
U |
U |
Q |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
298170577 | PUO | 57065555 | | 023685 | 8/27/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/11/1996 Report Status: Signed
Discharge Date: 1/8/1996
DISCHARGE DIAGNOSIS: INFERIOR/POSTERIOR MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: This is a 67 year old woman with a
history of atrial tachyarrhythmias but
no history of coronary artery disease. She came in with an
inferior/posterior myocardial infarction and was transferred to the
Coronary Care Unit after initiation of TPA. Her cardiac risk
factors included tobacco , a question of hypercholesterolemia ,
negative for diabetes , hypertension , and family history. The
patient was a generally healthy female who smoked and had a history
of palpitations and atrial tachyarrhythmia as well as a junctional
rhythm and AIVR but no prior symptoms of coronary artery disease.
She had been followed by Dr. Fiermonte for complaints of dizziness
with palpitations and a work-up including a 24-hour Holter in 8/5
with frequent atrial premature beats , short bursts of
supraventricular tachycardia with occasional periods of junctional
tachyarrhythmia , and AIVR which correlated with the symptoms. An
echo in 8/5 showed a normal LVF with minimal mitral regurgitation
and systolic bowing. On exercise tolerance test at the time , she
went seven minutes stopping with symptoms of fatigue. Her maximal
heart rate was 76% and she had 1 mm ST elevations consistent with
but not diagnostic of ischemia. She was then managed on Procan
alone with good result for her arrhythmia. She was previously on
digoxin but no longer on it. She was active at baseline able to
walk two miles a day without chest pain , dyspnea on exertion ,
orthopnea , paroxysmal nocturnal dyspnea , ankle edema , claudication
symptoms , or other symptoms of cerebrovascular disease. The
morning of February , 1995 , she was in her usual state of health.
She awoke at 11 p.m. on 11/27/95 with 5/10 substernal chest pain ,
no shortness of breath , palpitations , diaphoresis , or light
headedness , and no prior similar events. She became nauseated and
diaphoretic without radiation to the arms or back and no pleuritic
or positional changes. They called the EMT and her blood pressure
was 116/62 , heart rate of 50 with her chest pain , she had NGT spray
times two en route , and in the Emergency Ward , she complained of
substernal chest pain with her vital signs unchanged. There was no
evidence of congestive heart failure. Her EKG showed 0.5 to 1 mm
ST elevations in II , III , aVF , and V6. There was no recent surgery
and no history of bleeds or cerebrovascular accident. TPA was
initiated within less than thirty minutes following arrival. She
was put on intravenous nitroglycerin , Heparin , morphine , and
aspirin. She had a resolution of her pain within 45 minutes
following the TPA with return to baseline of her ST segments. She
was transferred to the Coronary Care Unit for further care.
PAST MEDICAL/SURGICAL HISTORY: Atrial tachyarrhythmias ,
hypothyroidism , and status post
spinal fusion in 11/19 .
ALLERGIES: She had no known drug allergies.
CURRENT MEDICATIONS: On admission included Synthroid 0.125 mg and
Procan SR 500 mg every day
SOCIAL HISTORY: She had a twenty pack year history of smoking ,
currently smoking half a pack a day , and no
alcohol. She lived with her husband and her brother.
FAMILY HISTORY: Her father died at 94 from cancer.
PHYSICAL EXAMINATION: Temperature was 97.5 , blood pressure 91/48 ,
heart rate of 48 , O2 saturation 99% on three
liters , and weight 115 pounds. She was alert , oriented , and
responsive. NECK: Supple , 2+ carotids without bruits , and jugular
venous pressure was 5 cm. LUNGS: Clear. CARDIAC: She had a
non-displaced point of maximal intensity , regular rate and rhythm ,
and normal S1 and S2 without murmurs , rubs , or gallops. ABDOMEN:
Soft , non-tender , and non-distended. RECTAL: Guaiac negative in
the Emergency Ward. EXTREMITIES: Negative for cyanosis and edema
and 2+ femoral pulses without bruits. NEUROLOGICAL:
Non-contributory.
LABORATORY EXAMINATION: Her sodium was 141 , potassium of 4.5 ,
creatinine of 0.7 , her LDH was 290 , her
first CPK was 53 , cholesterol was 222 , PA was less than assay , her
NAPA was 1.0 , chest x-ray showed no evidence of congestive heart
failure or cardiomegaly , and her EKG in the Coronary Care Unit was
normal sinus with 0.15/0.08/0.2 , 0.5 mm ST elevations in F , and no
Q or flipped T waves.
HOSPITAL COURSE: Patient was admitted to the Coronary Care Unit ,
put on aspirin every day , and kept on Heparin. We
held off on a beta blockade given her heart rate which was often
less than 50 with a systolic blood pressure of 80 to 90. Her
intravenous nitroglycerin was weaned off and she was given some
fluid boluses secondary to the low blood pressure. We started her
on simvastatin for her cholesterol and discussed smoking cessation.
She ruled in for a myocardial infarction. Her peak CK was 789 with
an MB fraction of 79.2 and her troponin was 20. Over the course of
several days , her CPK drifted down to 695 to 604 with MB fraction
of 46.9%. Heparin was discontinued on 8/5/96 and the patient , on
2/23/96 , had been encouraged to get up and walk around. She did
so without any evidence of chest pain , she had no recurrence of
chest pain after this point , and on 8/5/96 , the Heparin was
discontinued and she continued to be pain free with ambulation. On
the morning of 2/27/96 , she had an exercise tolerance test , a
modified Bruce , which was positive. She went seven minutes and
twenty seconds stopping due to chest pain. There was no change in
her blood pressure , her maximal heart rate was 89 , and the EKG
showed 2 mm ST downsloping depressions in V4 and V5 that developed
with exercise and persisted into recovery which was highly
predictive of coronary artery disease. She came back up to the
floor and we discussed doing a catheterization with her. At the
time , we kept her NPO. An hour later , she developed 8/10 chest
pain that was relieved with one sublingual and she was pain free
before the EKG could be done , however , thirty minutes after that ,
she again developed 8/10 chest pain. An EKG showed 2-3 mm ST
elevations in V4 through V6 with pseudonormalization of T waves in
II , III , aVF , and V3 through V6. Her pain decreased to 6/10 , she
had been restarted on Heparin , and put on intravenous nitroglycerin
with her blood pressure tolerating it. She was given six
sublinguals and 8 mg of morphine without relief of pain , heart rate
was 60 , and blood pressure was 100/60. She was taken to the
Catheterization Laboratory. The catheterization showed right
atrial pressure of 1 , right ventricle 24/4 , pulmonary capillary
wedge of 8 , arterial 110/70 , she had a 50% stenosis in her left
anterior descending , and a subtotal occlusion of her left
circumflex which was opened with PTCA to 20%. She was kept on
Heparin for another 24 hours following the PTCA and then the
Heparin was discontinued. She remained pain free after her cardiac
catheterization/PTCA and was discharged home on 8/9/96 with
follow-up with Dr. Fiermonte . Her TSH level was checked given her
history of hypothyroidism and her TSH was 1.0.
DISPOSITION: Patient's hospital course was without complication.
DISCHARGE MEDICATIONS: Aspirin , ECASA , 325 mg every day , Synthroid 125
micrograms every day , nitroglycerin 1/150
sublingually one tablet every 5 minutes times three , and simvastatin 20
mg every bedtime
FOLLOW-UP: Patient is to follow-up with Dr. Fiermonte in two to
three weeks.
Dictated By: GWYNETH A. DEPSKY , M.D. AS80
Attending: CARLTON J. ABSHEAR , M.D. MW2 DV641/4004
Batch: 13980 Index No. HYOHER5C4X D: 3/18/96
T: 9/23/96
cc: Earnestine Fiermonte , M.D. Cardiovascular Division , PUO
Document id: 457
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
536815366 | PUO | 34000260 | | 242887 | 11/3/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/8/1993 Report Status: Signed
Discharge Date: 8/1/1993
CARDIAC SURGERY CONSULT: HERMINA T. TUOMALA , M.D.
ADMISSION DIAGNOSES: 1. CARDIOMYOPATHY OF UNKNOWN ETIOLOGY.
2. RETROSTERNAL CHEST PAIN FOR RULE OUT
MYOCARDIAL INFARCTION.
3. NONINSULIN-DEPENDENT DIABETES MELLITUS.
4. HISTORY OF PULMONARY TUBERCULOSIS.
CHIEF COMPLAINT: Mrs. Emiko Dimalanta is a 54-year-old woman from Memp with a background history of idiopathic
cardiomyopathy and noninsulin-dependent diabetes , and pulmonary
tuberculosis who presented with an 20 minute episode of chest pain
and dyspnea for a rule out myocardial infarction.
PAST MEDICAL HISTORY: Past medical history is remarkable for 1 ) A
cardiomyopathy of 10 years' duration of
unknown etiology. The patient denies alcohol abuse. There is no
history of rheumatic fevers in childhood. There is no valvular
defects , and has no known risk factors for coronary artery disease ,
aside from her noninsulin-dependent diabetes. The etiology at this
point is thought to be viral. The patient experiences intermittent
episodes of mild chest pain and chest pressure with exertion
approximately one episode every 2-3 months and is not currently on
sublingual nitrates. She has no known coronary artery disease and
has not had a myocardial infarction. 2 ) Noninsulin-dependent
diabetes times three years , well controlled on Glucotrol 10 mg orally
twice a day and diabetic diet. She has no known diabetic retinopathy ,
nephropathy or peripheral neuropathy. 3 ) The patient has a history
of tuberculosis approximately 20 years ago , diagnosed from a lymph
node biopsy of the left neck. She was treated for one year with a
combination of medications. She currently experiences no night
sweats , loss or weight , loss of appetite or hemoptysis. She does ,
however , admit to a dry cough especially at night which has been
increasing over the last six months. Her BCG status is unknown.
Past surgical history is remarkable for: 1 ) Status post cesarean
section times one. 2 ) Status post total abdominal hysterectomy ,
right salpingo-oophorectomy for metromenorrhagia approximately
1991. The patient currently denies any post or perimenopausal
symptoms. 3 ) Status post lymph node biopsy of the left neck
approximately 20 years ago for tuberculosis. The patient has no
known drug allergies. Family history is remarkable for diabetes
mellitus ( father ). The patient is a nonsmoker , denies alcohol abuse
or intravenous drug abuse. Medications on admission include
Digoxin 0.1 mg orally every day before noon , Lasix 80 mg orally twice a day , Glucotrol 10
mg orally twice a day , K-Dur 10 mg orally twice a day to three times a day and Capoten 37.5
mg orally four times a day
HISTORY OF PRESENT ILLNESS: The patient has noted increasing
dyspnea and worsening exercise
tolerance over the past six months. She was admitted to Norap Valley Hospital under the care of Dr. Shepps in April of 1992 for
congestive heart failure which resolved with diuresis. Since then
her baseline exercise tolerance is that she is unable to do a full
load of laundry without getting tired , unable to climb a full
flight of steps without getting tired , but does not experience
chest pain. However , today while walking in her sister-in-law's
house she experienced severe retrosternal chest pain radiating to
her left shoulder and back , which is as great as 10 out of 10 for
severity and lasted for approximately one minute. It was associated
with dyspnea , sweating and nausea but no vomiting. She also
experienced some palpitations. Therefore , she had persistent chest
pressure and dyspnea on arrival at the Totin Hospital And Clinic
Emergency Room approximately 20 minutes later , at which time the
pressure and dyspnea were relieved with two sublingual nitrates.
Review of systems is remarkable also for chronic cough increasing
over the last five months , especially since her Capoten dose was
increased. She denies fever , chills , previous episodes of
pneumonia. Of note she was ruled out for active pulmonary
tuberculosis during her admission in P Therford Hospital in September 1992.
PHYSICAL EXAMINATION: On examination on admission , she is a
pleasant , elderly woman. Her vital signs
reveal a temperature of 97.4 orally , heart rate of 80 regular ,
respiratory rate of 20 and blood pressure of 108/80 supine with no
orthostatic hypertension. O2 saturation was 99% on 4 liters. Head
and neck examination were unremarkable with no evidence of
adenopathy and a normal thyroid gland. Respiratory system showed
scattered bibasilar crackles but no focal pathology. Cardiovascular
system showed a heart rate of 80 which was regular at full volume
with occasional ectopic beats. There was no evidence of paradoxical
alternates. Jugular venous pressure was elevated to 10 cm above
the angle of Louis' and had a prominent CV wave. All pulses were
present and equal. The cardiac apex was in the sixth left
intercostal space. Midaxillary line was volume overloaded in
character. No thrills or rubs were appreciated , however , there was
dullness to percussion beyond the apex and an S3 gallop was heard
throughout the precordium. The patient had a soft S1 , a III/VI
pansystolic murmur heard best at the apex and radiating through to
the left axilla. There was also I/VI MVM which could be brought on
with exercise and lying in the left lateral position. A PI murmur
was also heart similar in character to the MI murmur but heard best
on the left sternal border and radiating up the neck. There was
also an ejection systolic murmur at the left sternal border II/VI
in intensity and radiating poorly increased with expiration.
Abdominal examination was soft , nontender , nondistended. There was
a 12 cm hepar which was soft and nonpulsatile. No spring was
palpable. No masses were appreciated. Bowel sounds were present ,
and there was no costovertebral angle tenderness. A well healed
subumbilical midline scar was evident. Rectal examination showed
no masses , guaiac negative brown stool. Bimanual examination was
deferred at this time. Central nervous system examination was
grossly intact. Extremities showed pulses to be present
bilaterally and equal. There was no evidence of deep venous
thrombosis and no pedal edema or sacral edema were appreciated.
LABORATORY DATA: Laboratory examinations on admission showed a
sodium of 136 , potassium 3.4 , blood urea nitrogen
16 , creatinine 0.8 , and a glucose of 136. White count was 8.2 with
a normal differential. Hematocrit was 41.2 and platelets 247. physical therapy
and PTT were 13.4 and 29.4 respectively. Digoxin level was 2.1.
Chest X ray showed significant cardiomegaly with dilatation of both
left and right ventricles but minimal congestive heart failure. The
electrocardiogram showed normal sinus rhythm at 86 beats per minute
with a complete left bundle branch block and no evidence of acute
ischemia. There was no change as compared with electrocardiograms
from 2/10 . The initial CPK was 44.
HOSPITAL COURSE: In summary then the patient is a 54-year-old woman
with cardiomyopathy , noninsulin-dependent
diabetes , who presented now with an episode of chest pain and
dyspnea for rule out myocardial infarction and further evaluation.
Actively she is in hospital where it as follows: 1 ) Cardiomegaly of
unclear etiology: last echo done was in 25 of November by Dr. Kush which
showed an ejection fraction of 25-30% with global left and right
ventricular dilatation. 2 ) Chest pressure and substernal chest pain
and dyspnea: The patient was placed on the telemetry floor , was
monitored for 24 hours and a rule out protocol was performed. The
CK were 44 , 37 , and 34 respectively and there was no evidence of
electrocardiogram changes on serial electrocardiogram. She did have
one run of 4-beat ventricular tachycardia the first 24 hours of
admission. Potassium was replaced in view of the potassium level of
3.4. Initial Digoxin level was 2.1 and Digoxin was held for a
period of 72 hours. She was continued on her Lasix , Captopril and
a sliding scale Nitropaste and was started on one aspirin a day.
3 ) Noninsulin-dependent diabetes was well controlled on diet and
Glucotrol and her sugars remained between 100 and 200 throughout
this admission. 4 ) Status post tuberculosis: In view of her
previous tuberculosis status , a PPD was not performed and the
patient was not ruled out for tuberculosis.
On review of Mrs. Dimalanta 's history and following a rule out for a
recent myocardial infarct , it became apparent that her exercise
tolerance had diminished dramatically over the past three months
and that she was already on optimal medications. It was thought
that she would benefit from a cardiac transplant evaluation at this
point and Dr. Otani was kind enough to consult. A transthoracic
echocardiogram performed on 2 of May showed once again a dilated
cardiomyopathy with an ejection fraction of 15%. There was 2+ of
mitral regurgitation with a pulmonary arterial pressure of
approximately 60. There was also 3+ or PR and evidence of
significant left atrial hypertrophy. No ventricular clicks or
thrombosis were seen. However , in view of the dilated
cardiomyopathy , the patient was started on Coumadin therapy. An ETT
O2 uptake test was performed on 2 of May and the patient performed
for 3.38 minutes on a cycle ergometer. She experienced on chest
pain and there were no obvious electrocardiogram changes. The test
was stopped because of shortness of breath. Her O2 uptake was
calculated at 11.4 per kick per minute. In addition her Capoten
therapy was changed from 37.5 four times a day to 50 mg three times a day At this point
it became apparent that Mrs. Dimalanta had a significant degree of
cardiac dysfunction. A right-sided catheterization performed on
5 of August showed a right atrial pressure of 26 and a pulmonary wedge
pressure of 36. It was decided that she would be an excellent
candidate for cardiac transplantation , and a full cardiac
transplant workup was initiated. The following tests were sent off ,
the results of many of which are still pending: 1 ) One chest X ray
detailed above; 2 ) electrocardiogram as detailed; 3 ) urinalysis and
sediment which are unremarkable; 4 ) SMA-7 with CPK , complete with
differential , physical therapy , PTT , erythrocyte sedimentation rate , reticulocyte
count and bleeding time; 5 ) HLA typing and antibody screen which
are pending; 6 ) blood typing; 7 ) dental consult; 8 ) physiotherapy
consult; 9 ) Social Service consult; 10 ) nutrition consult; 11 )
Gynecology appointment made as an outpatient and a booking for
bilateral mammography was made; 12 ) pulmonary function tests were
performed; 13 ) noninvasive carotid Doppler studies and peripheral
arterial noninvasive studies were performed the results of which
are pending; 14 ) echocardiogram as detailed above; 15 ) exercise
test with O2 as detailed above; 16 ) 24-hour urine for creatinine
and protein; 17 ) HIV antibody test; 18 ) fasting glucose serum
protein , electrophoresis , cholesterol , triglycerides ,
immunoglobulins , hepatitis B and C serology , as well as blood
cultures , sputum cultures and urine cultures were sent; 19 )
psychiatric consults , has not been obtained at this point and will
be done as an outpatient; 20 ) virology titers for cytomegalovirus ,
Ebstein-Barr virus , toxoid , measles and varicella zoster were sent;
21 ) TFT and hemoglobin A1C were sent; and 22 ) right heart
catheterization as detailed above; 23 ) abdominal ultrasound to rule
out gallstones , aortic aneurysm and renal abnormalities were done
and were within normal limits.
DISPOSITION: At this point the patient will be discharged home in a
stable but guarded condition. She will be followed by
the Cardiology and Cardiac Surgery Departments at the Totin Hospital And Clinic . Her primary attending Dr. Shepps from P Therford Hospital
( telephone number 634 251-4380 ) will be updated as to her program.
Outstanding consults were be sorted on an outpatient basis and she
will be listed for a cardiac transplant. Her discharge medications
include Lasix 80 mg orally twice a day , Glucotrol 10 mg orally twice a day ,
Captopril 50 mg orally three times a day , K-Dur 20 mEq orally twice a day , Coumadin 2.5
mg orally three times a day She will also be sent home on home O2 as required.
Digoxin will be started at 0.1 mg orally every day physical therapy and PTT levels will
be checked every weekly and the patient's doses changed accordingly.
Dictated By: DANICA H. ESSER , M.D. HD6
Attending: LACY L. MCAUSLAND , M.D. RR0 AP605/6091
Batch: 4500 Index No. L9AGI48O8Z D: 3/5/93
T: 7/26/93
CC: 1. DR. SHEPPS , NORAP VALLEY HOSPITAL
2. HA I. OTANI , M.D. ZF72
Document id: 458
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
041565203 | PUO | 66040331 | | 177970 | 6/29/1999 12:00:00 a.m. | SUBMUCOUS UTERINE MYOMAS | Signed | DIS | Admission Date: 1/11/1999 Report Status: Signed
Discharge Date: 11/5/1999
PRINCIPAL DIAGNOSIS: FIBROID UTERUS.
OTHER DIAGNOSIS: MENORRHAGIA.
PRINCIPAL PROCEDURE: TOTAL ABDOMINAL HYSTERECTOMY , BILATERAL
SALPINGO-OOPHORECTOMY.
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old gravida
V , para V with a history of
hypermenorrhea and anemia who was seen at Pagham University Of May for these problems. In October of 1999 , she
had endometrial biopsy done that showed secondary endometrium. She
was prescribed Provera and orally contraceptive pills without relief.
She had a dilation and curettage performed at the Pagham University Of on April which showed normal pathology. She
continued bleeding and was prescribed Lupron. Office hysteroscopy
showed submucosal myomas with ultrasound showing a 2.5 x 1.8 cm
intracavitary mass. She was told she could have a hysteroscopy ,
but she is in desire to have an abdominal hysterectomy.
PAST MEDICAL HISTORY: Hypertension , not well controlled. History
of heart murmur with normal echocardiogram
in 1996.
PAST SURGICAL HISTORY: Right herniorrhaphy in 1994.
OB: She had normal spontaneous vaginal deliveries.
SOCIAL HISTORY: Smoking two to three cigarettes per day. Denies
alcohol. She is a recovered cocaine abuser ,
stating she has not used in six months. She had positive PPD in
the past and she was treated with inhaled for a year.
ADMISSION MEDICATIONS: Lupron.
HOSPITAL COURSE: The patient was admitted on 1/30/99 and had a
total abdominal hysterectomy and bilateral
salpingo-oophorectomy with a blood loss of 300 cc. She was then
admitted to the postoperative recovery unit and then to the floor
in stable condition. On postoperative day one , she complained of a
lot of pain and was given much pain medication in response to this.
On her examination , she only had superficial tenderness to
palpation and to light to touch to skin. The patient absolutely
refused to get out of bed for the first two and a half
postoperative days. She was warned of the risk of deep venous
thrombosis and pneumonia but still refused to get out of the bed.
Her postoperative hematocrit was 28.0 , down from 30 on her
preoperative hematocrit. She complained of being unable to eat and
still refused to get out of bed on postoperative day three , so
physical therapy was consulted to help with mobilization. She did
have temperature of 101 on 7/13/99 and blood cultures , urine
culture , and CBC was sent. Her white count was 7.9. Urine cultures
were 10 , 000. The next urinalysis was negative and blood cultures
showed no growth. She continued to have temperatures without good
ambulation. A chest x-ray was performed which was clear. The
patient's affect suggested some secondary game for delaying
discharge from hospital. She was receiving empiric clindamycin and
gentamicin for approximately two days before discharge.
She had been afebrile for greater than 24 hours at the time of
discharge. A pelvic ultrasound performed on the day of discharge
was normal. She was eating well , eating French toast and eggs on
the day of discharge without problems.
Dictated By: GENNY BARRETTE , M.D. KY99
Attending: LATONYA DORSETT , M.D. BD26 FB069/0345
Batch: 36135 Index No. H1SMXYME6 D: 4/13/99
T: 3/28/99
Document id: 459
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
N |
N |
- |
N |
N |
N |
N |
N |
N |
N |
N |
N |
171486426 | PUO | 43712082 | | 1582042 | 4/7/2006 12:00:00 a.m. | URINARY TRACT INFECTION | Signed | DIS | Admission Date: 6/17/2006 Report Status: Signed
Discharge Date: 4/17/2006
ATTENDING: DEPSKY , GWYNETH MD
ADDENDUM:
Addendum to discharge summary , record number #3466344 which was
dictated by Hatstat , Magda Teisha .
ADDENDUM TO DISCHARGE SUMMARY:
NEURO: Neurology consult was obtained for increased somnolence
over the past three weeks , which was noted per the patient's son
which he thinks is a change from baseline. Neurology consult
recommended that we get an MRI/MRA of the brain with gadolinium
contrast to look for leptomeningeal disease and other sources for
increased somnolence which are treatable. They also recommended
an EEG be done. The EEG was done and showed no seizure activity.
The MRI/MRA was done and showed only a right MCA infarct , which
was known and old with no interval change. Gadolinium contrast
was not given because the patient became too agitated and was
moving too much during the study for an effective study to be
obtained. They also recommended that we check certain labs
including folate , B12 , TSH and RPR all of which were essentially
normal. TSH was elevated but patient has a history of
hypothyroidism and is on Synthroid. Neurology was consulted on
the day of discharge and they agreed that no further evaluation
of the somnolence is necessary at this time. If the somnolence
continues into the near future further evaluation may be
necessary. Leptomeningeal disease is unlikely given the lack of
new neurological findings , and since the patient is scheduled for
a PET scan of the chest to evaluate for spread of her known lung
cancer , if there is no interval change in her oncological process
the likeliness of leptomeningeal disease is quite low.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 81 mg orally daily ,
vitamin B12 1000 mcg orally daily , Colace 100 mg orally twice a day ,
Synthroid 100 mcg orally daily , Niferex-150 150 mg orally twice a day ,
Senna two tablets orally twice a day , Zocor 20 mg orally nightly ,
Neurontin 100 mg orally twice a day , Lovenox 40 mg subcutaneously daily , Lamictal
200 mg orally twice a day , Seroquel 100 mg orally twice a day , Nexium 20 mg
orally daily , Lidoderm 5% patch topically daily , NovoLog sliding
scale , Cymbalta 20 mg orally twice a day , Toprol-XL 100 mg orally daily.
DISCHARGE EXAM: On the day of discharge , the patient was
afebrile with a temperature of 96.7. She remained slightly
hypertensive with a blood pressure range of 103 to 152 systolic
and 54 to 90 diastolic. Her heart rate , respirations and oxygen
saturations were all normal. She was urinating on her own
without a Foley catheter. Her blood sugars were stable. A
one-to-one sitter which had been placed prior during her hospital
course was discontinued. Her ciprofloxacin course for her
urinary tract infection was discontinued because she had been
treated fully and her Lopressor was changed to Toprol-XL the
extended release formulation for improved compliance and
convenience. At discharge , Ms. Telander 's mental status
remained at baseline and she showed no signs of agitation at the
time of my exam.
FOLLOW-UP APPOINTMENTS: She has an appointment with her primary
care physician Dr. Defore , phone number is 172-935-6688 on
10/26/06 at 10:40 a.m. She also has an appointment with
Neurology Dr. Pasqualetti , phone number is 799-148-2679 and that is
on 11/18/06 at 12:30 p.m. She has a PET study of her chest ,
which has been scheduled on 8/21/06 at 08:30 a.m.
PATIENT'S ONCOLOGIST: Rossie Mankoski , MD at Wil Medical Center Cancer
Institute , phone number 187-408-0063. His e-mail address is
Ifcodty Fiveg@ OFLY. Sindkdr.mza.
eScription document: 7-8045884 CSSten Tel
CC: Clint Defore M.D.
Wautolea Ee
CC: Rossie Mankoski MD
Ont , Pines Virg Go
Dictated By: SCHUYLER , EVIA
Attending: DEPSKY , GWYNETH
Dictation ID 0261639
D: 3/10/06
T: 3/10/06
Document id: 460
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
Y |
U |
U |
Y |
U |
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U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
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Y |
N |
Y |
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N |
N |
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N |
101792361 | PUO | 27336536 | | 474030 | 3/30/2001 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/19/2001 Report Status: Signed
Discharge Date:
SERVICE: PI'NI MANGER ENE FRANDECREST CAN MEDICAL
PRINCIPAL DIAGNOSIS: ASPIRATION PNEUMONITIS.
IDENTIFICATION: The patient is a 43 year old man with
antiphospholipid antibody syndrome , recently
discharged from Pagham University Of ICU on November , 2001 ,
who returns for hypercarbic respiratory failure , presumed due to
aspiration.
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old man
with a complicated past medical
history , but a recent long hospitalization during the month of September
2001. He was initially admitted to the ENT service at that time
with lingual tonsillitis that was complicated by difficulty
handling secretions. During this admission he had an episode of
desaturation which prompted transfer to the MICU on May , 2001.
He was also febrile at that time with a productive cough. He was
treated with clinda and levo and intubated on October . He had an
acute course of prolonged intubation with extubation finally on January . Post extubation he was heavily sedated , with waxing and waning
alertness , but gradually became more able to follow commands.
The patient was discharged to Vancor on 10/10 with still some
depressed level of mental status. On the day of admission he
developed increased respiratory difficulty and increased
secretions. This was new since his discharge. He became acutely
tachypneic to the 40s and his oxygen saturation dropped into the
80s on 100% nonrebreather. His mother reported that his lungs
"sounded junky." He spiked a fever. Hypotension to a systolic
blood pressure of 70 was also noted. For this reason he was
transferred to Pagham University Of for further management.
PAST MEDICAL HISTORY: ( 1 ) Antiphospholipid antibody syndrome.
( 2 ) Status post CVA with residual
right-sided weakness. ( 3 ) Epilepsy. ( 4 ) Noninsulin dependent
diabetes mellitus. ( 5 ) History of mitral valve repair in 1996.
( 6 ) Irritable bowel syndrome. ( 7 ) Gout. ( 8 ) History of left
atrial clot , status post thrombectomy.
SOCIAL HISTORY: The patient lived previously in a group home and
is a nonsmoker. He has a close relationship with
his mother.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 103.2 , heart rate
100 , blood pressure 101/40.
Vent Settings: SIMV with a rate of 20 on 100% FIO2. Arterial
blood gases - pH 7.4 , pCO2 44 , PO2 120. Generally , this was an
intubated , sedated man who appeared comfortable. HEENT: Exam
unremarkable. NECK: Without jugular venous distention or
lymphadenopathy. HEART: Regular rate and rhythm , no murmurs ,
rubs , or gallops. LUNGS: Bronchial breath sounds bilaterally ,
right greater than left , decreased air entry on the left. ABDOMEN:
Soft , nontender , nondistended , normoactive bowel sounds , no rebound
or guarding. EXTREMITIES: Warm with 2+ distal pulses.
LAB STUDIES ON ADMISSION: Sodium 156 , potassium 5 , chloride 117 ,
bicarb 28 , BUN 49 , creatinine 2.4 ,
glucose 171. Hematocrit 34.5 , white count 16.05 , platelets 226.
INR - 1.5.
HOSPITAL COURSE BY SYSTEMS:
1. Pulmonary. The patient arrived at the Pagham University Of intubated. He had a history of pulmonary hemorrhage
on his previous admission. However he was more easily extubated on
10/27/01 and after that time continued to exhibit and inability to
handle his secretions. He did , however , maintain good saturations
on progressively diminishing amounts of oxygen via nasal cannula.
By the time of discharge , he was able to maintain an adequate
oxygen saturation on room air. He underwent placement of a PEG
tube on 2/3/01 in order to feed him without aspiration after a
speech and swallow study showed that he had problems with
aspiration.
2. Cardiovascular. The patient was managed with metoprolol and
Captopril , which was titrated up during this admission. His
blood pressure was well controlled at the time of discharge. His
hypotension that characterized his presentation did not recur at
all during his hospitalization.
3. Infectious Disease. The patient was to complete a 21 day
course of vancomycin from his prior admission but had ongoing
fever and positive blood cultures for Staph epi. He completed an
additional seven days of vancomycin and was treated with Flagyl for
seven days for his aspiration pneumonia. He was briefly also
treated with ampicillin early in his hospitalization. By the time
he completed his 28 day course of vanco , the patient had
defervesced and had no signs of infection.
4. Heme. The patient came to Pagham University Of
anticoagulated with Coumadin. He however was transitioned to
heparin so that he might be more able to get procedures if needed.
He continued on heparin with an easily managed PTT. After his PEG
tube placement , he was transitioned to Lovenox and Coumadin. He
will be discharged on Lovenox and Coumadin. He will need to be
transitioned to Coumadin alone once his INR is therapeutic.
5. Neuro. The patient continued on his seizures medicines -
Valproic Acid and Neurontin - during his admission. He had no
evidence of seizure activity. His mental status improved
progressively after intubation , however it was clear that he had
deficits in swallowing , significant enough to require the PEG tube.
On discharge he was awake and alert and interactive.
6. Disposition. The patient was felt to benefit from acute rehab
and was transferred to rehab at the conclusion of his
hospitalization to enjoy aggressive physical therapy and OT.
DISCHARGE MEDICATIONS: Albuterol 2.5 mg nebulized every 4 hours , Captopril
18.75 mg orally three times a day , Colchicine 0.6 mg
orally every day , NPH insulin 32 units every day before noon , 32 units every afternoon , sliding
scale insulin for blood sugar less than 200 give 0 units regular
insulin , for blood sugar 201-250 give 4 units regular insulin
subcutaneously , for blood sugar 251-300 give 6 units subcutaneously , for blood sugar
301-350 give 8 units regular subcutaneously , for blood sugar 351-400 give 10
units regular subcutaneously , for blood sugar greater than 400 please call
MD , Lopressor 100 mg orally three times a day , Nystatin suspension 10 ml swish
and spit four times a day , Ocean Spray two sprays nasally four times a day , Carafate 1
gram orally four times a day , Valproic Acid 750 mg orally three times a day , Coumadin 5 mg
orally every day , multivitamin 5 ml orally every day , Zocor 20 mg orally every bedtime ,
Atrovent nebulizer 0.5 mg nebulized four times a day , Neurontin 400 mg p.NG
tube twice a day , Risperdal 1 mg p.NG tube every afternoon , Myconazole 2% powder
topical twice a day , please apply to affected areas , carnitine 300 mg
orally every 4 hours , Nizoral shampoo 5 mg topically every day , Lovenox 80 mg
subcutaneously every 12.h.
INSTRUCTIONS: Please discontinue once INR therapeutic , tube feeds
full strength Jevity plus 30 cc/heart rate advancing rate to
90 cc/heart rate every 8 hours if tolerated.
Dictated By: ALYSE HOLDA , M.D. QM06
Attending: COLIN E. NAJI , M.D. IG70 OA794/695481
Batch: 7620 Index No. GJDHZO49LV D: 4/16/01
T: 4/16/01
CC: 1. RON -TWIN- HOSPITAL
Document id: 461
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
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N |
461171537 | PUO | 89762298 | | 3699014 | 8/24/2007 12:00:00 a.m. | Abdominal pain , hereditary angioedema | | DIS | Admission Date: 9/3/2007 Report Status:
Discharge Date: 2/6/2007
****** FINAL DISCHARGE ORDERS ******
BLANN , GLENNA A 009-06-32-4
Li Roho Dae
Service: MED
DISCHARGE PATIENT ON: 2/25/07 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: OGDEN , LATORIA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally every day
2. DIGOXIN 0.125 MG orally 4X/WEEK TUES/THU/SAT/SUN
3. DIGOXIN 0.187 MG orally 3X/WEEK M-W-F
4. DOCUSATE SODIUM 100 MG orally every day
5. FEXOFENADINE HCL 60 MG orally twice a day
6. LEVOTHYROXINE SODIUM 50 MCG orally every day
7. SENNOSIDES 2 TAB orally twice a day
8. STANAZOLOL 2 MG orally every other day
9. STANAZOLOL 1 MG orally every other day
10. ATENOLOL 100 MG orally every day
11. FUROSEMIDE 20 MG orally 1-3 TABS every day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ATENOLOL 100 MG orally every day before noon
DIGOXIN 0.187 MG orally 3x/Week M-W-F Starting ON FRIDAY
Alert overridden: Override added on 2/25/07 by :
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: home dose
Previous Override Notice
Override added on 8/29/07 by WALTERS , ELIZABET C. , M.D.
on order for SYNTHROID orally ( ref # 112790609 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: md aware
DIGOXIN 0.125 MG orally 4x/weekTuThSaSun
Alert overridden: Override added on 2/25/07 by
SOESBE , KARINE A. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: home med
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
Starting Today November as needed Other:allergy
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LASIX ( FUROSEMIDE ) 20 MG orally every day before noon Starting IN a.m. August
Alert overridden: Override added on 8/29/07 by
WALTERS , ELIZABET C. , M.D.
on order for LASIX orally ( ref # 289337933 )
patient has a POSSIBLE allergy to Sulfa; reaction is RASH.
Reason for override: home regimen
SYNTHROID ( LEVOTHYROXINE SODIUM ) 50 MCG orally DAILY
Override Notice: Override added on 2/25/07 by
SOESBE , KARINE A. , M.D. , PH.D.
on order for DIGOXIN orally ( ref # 124333813 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: home med
Previous override information:
Override added on 2/25/07 by SOESBE , KARINE A. , M.D. , PH.D.
on order for DIGOXIN orally OTHER 3x/Week M-W-F ( ref #
561837992 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: home dose
Previous override information:
Override added on 8/29/07 by WALTERS , ELIZABET C. , M.D.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: md aware
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
STANOZOLOL 2 MG orally every 6 hours Starting IN a.m. October
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Aspacio Friday , August rd , 11am ,
Dr. Rolson Please call for an appointment at your convenience within the next 2-3 weeks , or earlier if needed ,
ALLERGY: intravenous Contrast , Sulfa , Penicillins , QUINIDINE SULFATE ,
LEVOFLOXACIN , LISINOPRIL , NITROFURANTOIN , PROCAINE HCL ,
Dairy Products , WHEAT/GLUTEN , NITROFURANTOIN MACROCRYSTAL , FFP ,
WARFARIN SODIUM
ADMIT DIAGNOSIS:
Abdominal pain , hereditary angioedema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Abdominal pain , hereditary angioedema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HEREDITARY ANGIOEDEMA history of SUBDURAL ON COUM history of APPY ,
TAH tracheostomies x 3 multiple intubations DVT , ivc filter in place
GERD polycythemia
AFib- no coumadin 2/2 SDH ( 44 ) hypothyroidism ( hypothyroidism ) GIB
( lower GI bleeding ) DM- diet controlled ( borderline diabetes
mellitus ) CAD ( coronary artery disease )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Transfusion: FFP x 4 units
Dose adjustment of Stanozolol
BRIEF RESUME OF HOSPITAL COURSE:
primary care physician: Shalonda Aspacio , Inpatient attg: Latoria Ogden ,
Allergy/Immunology Attg: Biggins
Primary Immunologist: Rosalia Rolson
ENT: Schwalbe
.
RFA: Hereditary angioedema abdominal flare
.
CC: Abdominal pain
.
HPI: 83 F with hereditary angio-edema ( C1-esterase inhibitor
deficiency ) and multiple prior attacks characterized by abdominal pain
and distension and airway compromise history of tracheostomy. She was in her
USOH until this morning when she developed worsening abdominal pain ,
periumbilical , constant. The pain was associated with abdominal
distension and typical of prior attacks. No new foods - typically these
episodes are without an identifiable precipitant. No associated
nausea/vomiting or diarrhea. + flatus , had bowel movement this a.m..
Typical BM's are either watery or "pencil thin" due to colonic stricture
( history of multiple dilatations. ) No respiratory distress , rash or hives.
She called her Allergist/Immunologist who advised her to take 2mg
Stanozolol ( instead of 1mg ) and come to the ED. In the past , abdominal
attacks have responded to FFP. Yet , given a history of hives to FFP , she
requires premedication with Benadryl.
.
In the ED , vitals were T99.9 , BP138/80 , HR 69 , RR16 , 99%RA
ED staff discussed case with Dr. Moag ( Immunology Fellow ) and treatment
initiated:Benadryl 50 mg intravenous x 1 , albuerol neb x 1 , duoneb x 1. Stanozolol
2mg orally x 1 .
.
ROS: no recent fevers/chills. No cough/sob. Intermittently suctions
tracheostomy. No recent problems. No chest pain/palpitations.
.
PMH:
1. Hereditary angioedema.
2. Status post multiple tracheostomies for airway protection.
3. DVT , status post IVC filter.
4. Recurrent atrial fibrillation: rate control. No coumadin
5. H/o subdural hematoma after a fall in 1992 , on coumadin
6. Moderate MR.
7. Gastroesophageal reflux disease.
8. Diabetes: diet controlled. Last A1C in 2006.
9. Hypertension.
10. Hypothyroidism.
11. CAD , status post MI.
12. Ejection fraction 40% in 2003.
13. Status post colectomy.
14. Status post hysterectomy.
15. Status post carpal tunnel release.
16. Status post left cataract repair.
17. Status post sigmoid colostomy and reanastomosis ten years ago
complicated by stricture
18. S/p multiple dilations of colonic stricture.
19 . Sensorineural hearing loss , bilateral.
19. Diverticulosis
MEDS:1. Allegra 60 twice a day. 2. Atenolol 100 mg every day before noon. 3. Lasix 20 mg orally daily
4. Digoxin 0.125 every other day MWF. 0.180 on other days.
5. Rhinocort 2 spray twice a day
6. Stanozolol alternating 1mg every day/2mg every day
7. Synthroid 50 mcg daily
8.colace 100 mg twice a day
9. Senna 1 tab twice a day
10. Zantac 150 mg twice a day
11.ECASA 81 mg daily
.
ALL:
1. FFP gives her hives , which is prevented when premedicated with
Benadryl.
2. intravenous contrast gives her rash ,
3. penicillin a rash ,
4. sulfonamides a rash
5. Levaquin a rash
6. stanozolol and nitrofurantoin gives elevated LFTs.
7. Diet: allergic to wheat and eggs/dairy.
8. No flu vaccine 2/2 egg allergy.
9. Tolerates Keflex.
.
SH: Lives with elderly husband who has Alzheimers. She is his primary
care caretaker.
.
ADMIT EXAM:
VS: T: 99.0 P:86 BP: 138/80 RR:20 O2 Sat: 99% RA
Gen: Well appearing , trach collar , fully alert and oriented x 3.
Moderate distress due to abdominal pain. No respiratory distress
HEENT: EOM full , no facial swelling. No Icterus. No orally lesions/airway
swelling. Neck supple. No lymphadenopathy or thyromegaly.
CV: JVP less than 6 cm water , irregularly irregular , 2/6 HSM at apex.
Laterally displaced PMI.
CHEST: bibasilar crackles 1/3 up. No wheezes or rhochi
.ABD: BS normoactive. Prominent distension , tympanic. Tender
mid-abdomen. No rebound/guarding. EXT: No edema. SKIN: No rashes , wheals ,
hives.
RELEVANT LABS:C1 inhaled 9( low ) ,
On admit: Cr 1.2 ( bl 1.0 ) BUN21 , HCT 59.2 ( has been as high as HCT 60 on
9/7 )
u/a: bland
Studies: ECG: Afib 90 , LAD , LVH
CXR: no acute cardiopulmonary process
KUB: mildly dilated loops of bowel. no obstruction
---
Consults: Followed in-house by attg Biggins ( Allergy/Immuno )
Impression: Abdominal pain due to hereditary angioedema.
1. ALLERGY: Patient was admitted with abdominal pain that was similar in
nature to prior episodes of hereditary angioedema flare. She was treated
with ffp x 2units on admission with benadryl premedication. She did
develop a few facial hives without any respiratory distress by the end of
the second unit of FFP. This resolved after FFP infusion stopped and she
was given additional benadryl. She tolerated benadryl well , yet had a
sensation of restlessness afterwards. On 4/4 she got another 2 units FFP
with premedication of benadyrl 25 intravenous prior to each bag as well as ativan
0.5 mg orally prior to transfusions. This was a good combination as she did
not get hives , nor the anxiety that accompanies benadryl. By 8/21 , her
abdominal distension had improved markedly and her pain had largely
subsided. Given the fact that prior episodes have taken a few days for
complete resolution of distension , she was discharged with instructions to
contact her immunologist should symptoms worsen or persist.
She will be discharged on a stanozolol taper as outlined by
allergy/immuno. Please see patient instructions full regimen.
.
During the hospital stay , she had no upper air way symptoms and was given
tracheostomy care.
.
ELEVATED HCT: On admission , HCT was 59 ( baselin is low 40's ). Part of the
elevation was attributed to intravascular volume depletion. Lasix was
held for 3 days and HCT was 42% on discharge. No prior documented history
of polycythemia. Please consider further evaluation as outpatient for
this erythrocytosis.
.
AFib: continued on digoxin and atenolol with good rate control ( HR 70-80s
throughout hospital stay. )
CODE: Discussed with patient. FULL CODE. Daughter hcp.
ADDITIONAL COMMENTS: You were hospitalized for abdominal pain due to your condition of
hereditary angioedema. You received a total of 4 units of FFP with
benadryl and pepcid premedication.
.
MEDICATION CHANGES:
Please continue all medications that you were on prior to this admission
with the following changes:
1. Please follow the stanozolol taper as outlined by Dr. Biggins and
colleagues during your stay:
2 mg every 8 hours for 5/23/07 , then
2 mg every 12 hours for 10/28/07 , then
2 mg every day for 1 week , then
2 mg every other day.
Then you should adjust further as an outpatient in consultation with Dr.
Rolson .
.
Followup: schedule , with Dr. Aspacio .
Please contact Dr. Rolson to discuss how you are doing.
.
CONTACT YOUR DOCTOR OR RETURN TO EMERGENCY DEPT. IF:
Your abdominal pain worsens , you become more bloated or distended , you
develop nausea , vomiting , facial swelling , difficulty breathing , or any
other concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Consider with u for primary for secondary polycythemia
2. Stanozolol taper
No dictated summary
ENTERED BY: WALTERS , ELIZABET C. , M.D. ( FX647 ) 2/25/07 @ 01:20 PM
****** END OF DISCHARGE ORDERS ******
Document id: 462
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
- |
392986061 | PUO | 09031082 | | 6924947 | 9/9/2005 12:00:00 a.m. | type I DM , r/o MI | | DIS | Admission Date: 4/18/2005 Report Status:
Discharge Date: 8/17/2005
****** DISCHARGE ORDERS ******
MERLES , ALESSANDRA 601-95-74-1
Ronreru Blvd. , O Dar , Kansas 49703
Service: MED
DISCHARGE PATIENT ON: 10/4/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KEMICK , WILFRED K. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL ( INHALER ) ( ALBUTEROL INHALER ) 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
PHOSLO ( CALCIUM ACETATE ) 1 , 334 MG orally three times a day
Instructions: please give with meals
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LABETALOL HCL 100 MG orally twice a day Starting Today February
HOLD IF: sbp < 100 or heart rate < 55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
TRAZODONE 100 MG orally HS HOLD IF: sedated
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Override Notice: Override added on 10/2/05 by SZWEDA , ALFREDA A C. , M.D. on order for ZOCOR orally ( ref # 10528750 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
Previous override information:
Override added on 10/2/05 by SZWEDA , ALFREDA A. , M.D.
on order for LIPITOR orally ( ref # 92702251 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
LANTUS ( INSULIN GLARGINE ) 5 UNITS subcutaneously every bedtime
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 10/4/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
OMEPRAZOLE 40 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Andree Ingram , KTDUOO Clinic 8/20/05 scheduled ,
Dr. Brigid Aldaco 5/10/05 scheduled ,
ALLERGY: Aspirin
ADMIT DIAGNOSIS:
hyperglycemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
type I DM , r/o MI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN asthma CRF IDDM ( Brittle Diabetic ) HCV gastric ulcers
OPERATIONS AND PROCEDURES:
6/18/05 --hemodialysis
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
52M with ESRD on M/W/F HD , type I DM , came to KTDUOO clinic on day of
admission for prescription refill--while in clinic , his legs felt weak ,
and he felt diaphoretic , with some chest tightness and shortness of
breath. Gets similar symptoms when his blood sugars are elevated--FS in
400s , symptoms resolved with 5U regular insulin. Recently hospitalized at
Bussadd Southrys Community Hospital for hypoglycemia--lantus reduced from 8U every bedtime to 5U every bedtime.
History of highly brittle DM--on prior regimen , sugars ranged from 30s to
400s. At baseline , chronic LE edema , chronic productive cough , 2 pillow
orthopnea. Denies CP/SOB with exertion , no F/C , N/V , urinary/bowel
symptoms ( anuric ). Dry weight approximately 53-54 kg. In ED , received 5U
intravenous insulin , with resolution of symptoms. K 6.6 , EKG with peaked T-waves ,
?subtle ST depressions in V5-V6. Exam notable for occasional wheezes , few
bibasilar crackles , RRR , II/VI systolic murmur , JVP 8cm , 2+ peripheral
edema.
***HOSPITAL COURSE****
( 1 ) CV: ruled out for MI by EKG/enzymes--will continue home regimen of
labetalol , norvasc , lipitor upon discharge. Received single dose ASA
325mg in ED; 'allergic' to ASA-->epistaxis--no evidence of bleeding
during brief hospital course. Mild volume overload with mild dyspnea
resolved after hemodialysis.
( 2 ) Endo: brittle type I DM , with sugars recently in 30-400 range. FS in
100s-low 200s on home dose lantus 5U every bedtime , with regular insulin sliding
scale. Insulin regimen not increased , as recently admitted to TH with
significant hypoglycemia.
( 3 ) Renal: history of HD on 6/18/05 , with correction of hyperkalemia , volume
overload--will continue HD M/W/F.
( 4 ) Pulm: COPD , chronic cough--continued albuterol inhaler as needed
( 5 ) Heme: no evidence of hemorrhage on ASA , HCT 40 at time of discharge
ADDITIONAL COMMENTS: Please return for your appointments with Dr. Brigid B Aldaco on 4/17/2005 at
3:30pm , and with Dr. Andree Ingram on 10/10/05 at 1:30pm. Please continue
to keep close track of your fingersticks , and review this record at your
appointment with Dr. Ingram .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KATZER , CALANDRA , M.D. ( TR28 ) 10/4/05 @ 11:37 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 463
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558149349 | PUO | 81640946 | | 2506135 | 8/12/2005 12:00:00 a.m. | OSTEOARTHRITIS BILATERAL KNEES | Signed | DIS | Admission Date: 10/22/2005 Report Status: Signed
Discharge Date: 1/1/2005
ATTENDING: GENNY SALVADOR BARRETTE MD
ADDENDUM
This is an addendum to yesterday's dictation. The patient on
11/23/2005 had a hematocrit drawn that was 25. The patient was
asymptomatic , but given her risk factors for coronary artery
disease including diabetes and hypertension , we felt that
transfusing her 2 units prior to discharge will be appropriate.
She has received 2 units of blood on the evening of 11/23/2005
and was discharged on 1/1/2005 , felt that no repeat hematocrit
was necessary as she remained asymptomatic and stable. She will
be discharged on 1/1/2005 .
eScription document: 9-3602668 CSSten Tel
Dictated By: HOLDA , ALYSE
Attending: ODEA , JANEAN JOHNIE
Dictation ID 2587582
D: 8/24/05
T: 8/24/05
Document id: 464
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461171537 | PUO | 89762298 | | 4884682 | 9/20/2004 12:00:00 a.m. | Hereditary Angioedema flare | | DIS | Admission Date: 7/28/2004 Report Status:
Discharge Date: 3/18/2004
****** DISCHARGE ORDERS ******
BLANN , GLENNA A. 009-06-32-4
Ro Ta
Service: MED
DISCHARGE PATIENT ON: 10/15/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TIBOLLA , MADISON TIERRA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ATENOLOL 75 MG orally every day
DANAZOL 200 MG orally every day Starting IN a.m. April
Instructions: 8/19 start regular regimen ( alternating 200
and 400 )
DIGOXIN 0.125 MG orally qtues , thurs , sat , sun
Alert overridden: Override added on 5/22/04 by
ZUFELT , CHANELLE , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: on as an outpatient
DIGOXIN 0.1875 MG orally qmon , wed , friday
Alert overridden: Override added on 5/22/04 by
ZUFELT , CHANELLE , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: on as outpatient
LASIX ( FUROSEMIDE ) 20 MG orally three times a day Starting Today April
Instructions: take per as you were at home
Alert overridden: Override added on 5/22/04 by
ZUFELT , CHANELLE , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: patient on as an outpatient
SYNTHROID ( LEVOTHYROXINE SODIUM ) 50 MCG orally every day
Override Notice: Override added on 5/22/04 by
ZUFELT , CHANELLE , M.D.
on order for DIGOXIN orally ( ref # 68555129 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: on as outpatient
Previous override information:
Override added on 5/22/04 by ZUFELT , CHANELLE , M.D.
on order for DIGOXIN orally ( ref # 51930160 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: on as an outpatient
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ZANTAC ( RANITIDINE HCL ) 150 MG orally every day
ASA ENTERIC COATED ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 10/15/04 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
Reason for override: will monitor
SENNA TABLETS 1 TAB orally twice a day HOLD IF: diarrhea
DIET: Advance as tolerated / Lactose Restricted / wheat restricted
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
GI after 9/2 call to schedule procedure ,
Dr. Aspacio call for appt as soon as possible ,
Allergy/Immunology doctor 2-3 weeks ,
ALLERGY: Iv contrast dyes , Sulfa , Penicillins ,
Quinidine ( quinidine sulfate ) , Levofloxacin , Lisinopril ,
Quinidine ( quinidine sulfate ) ,
Macrodantin ( nitrofurantoin ) , Stanazol ,
Novocain 1% ( procaine hcl 1% ) , Dairy products , Wheat/gluten
ADMIT DIAGNOSIS:
hereditary angioedema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hereditary Angioedema flare
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HEREDITARY ANGIOEDEMA AFIB - lodose Coum/ASA HYPOTHY
history of SUBDURAL ON COUM history of APPY , TAH tracheostomies x
3 multiple intubations DVT , ivc filter in place GERD polycythemia
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT abdomen: no acute obstruction , stricture of descending colon ( old )
BRIEF RESUME OF HOSPITAL COURSE:
patient is an 82 year old woman with long standing hereditary
angioedema who was admitted with symptoms consistent with an angioedema
flare. patient reports one day of crampy abdominal pain with associated
bilious vomiting. These symptoms are consistent with her previous
angiodedema flares.
Normally , patient manages her symptoms by increasing her danazol dose
at home , but this time the increase was not enough to stabilize
her symptoms. Thus , she came to the ED to get FFP , which helps with
flares by repleting the missing complement factors.
patient's first attack was when she was 10. patient has had multiple flares this
past year including 6 admissions. She has had 3 tracheostomies in
the past for flares threatening her respiratory system. Her GI
complications include multiple scarring/strictures - is scheduled for a
dilitation with GI next month. She has also had surgery in the past
( 1994 )
She thinks her trigger this admission is multiple stressors involving
the health of many of her family members.
GI doctor: Loehrs Rheum/All: Jamika Arau
PMHx: HTN , Diverticulitis , Atrial Fib ( no coumadin , rate controlled )
Hypothyroid , DVT , HAE
Meds: atenolol , danazol , synthroid , allegra , ecasa , zantac , digoxin
ALL: sulfa , pcn , levo , ? intravenous contrast
FHx: 2 grandkids with hereditary angioedema
VS: 97.9 152/84 114 14 97%RA irreg irreg , +s4 , cta b , +bs , distended ,
mild diffuse tenderness , no pedal edema
Labs: wbc 10.3 ( with bandemia 10% ) , hct 49.6 plt 304 cr 1.3 , lipase 65
CT: no obstruction , old stricture descending colon
Hospital Course and Plan
82 year old woman with hereditary angioedema admitted with abdominal
flare of her HAE , most likely triggered by stress.
1. HAE: patient much improved after receiving FFP , benadryl and demerol.
Temporarily increased her danazol , on day of discharge had started on h
emergency room home regimen. Her c1 inhaled , c4 , c2 were still pending at discharge.
2. ID: patient was afebrile with no localizing symptoms , but with bandemia with
her normal wbc ( 10% ). Will need monitoring as an outpatient. UA at
discharge was negative.
3.CV: patient with HTN. on Atenolol. patient with Afib. not on coumadin
currently. Unclear why her coumadin was stopped. Should discuss with
her primary care physician as outpatient.
4. Renal: Cr on admission 1.3. Normalized to 1.1. Likely
pre-renal secondary to dehydration during flare. Monitor as outpatient.
5. GI: patient with scheduled dilitation of her known sricture next month.
New meds: none
ADDITIONAL COMMENTS: 1. call your doctor or return to the ED if you have recurrent symptoms
consistent with your angioedema flare , especially abdominal
discomfort/nausea/vomiting , any shortness of breath or difficulty
breathing
2. call your doctor or return to the ED if you have any heart
palpitations/chest pain
3. Resume your home dose of medications , including vitamin c and e
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. f/up normal wbc and bandemia ( 8% ). no signs of infection at
discharge
2. patient with Atrial fibrillation , not on anti-coagulation. ? is she a
candidate ( known subdural in past , ? relative contraindication )
3. f/up complement levels. P at discharge.
No dictated summary
ENTERED BY: FERRIERA , EVAN KRISTIE , M.D. , PH.D. ( HC74 ) 10/15/04 @ 01:20 PM
****** END OF DISCHARGE ORDERS ******
Document id: 465
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DM |
Gs |
GER |
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780050153 | PUO | 58050208 | | 917295 | 2/5/1998 12:00:00 a.m. | FAILED RT. TOTAL HIP REPLACEMENT | Signed | DIS | Admission Date: 6/4/1998 Report Status: Signed
Discharge Date: 2/30/1998
PRINCIPAL DIAGNOSIS: FAILED HEMIARTHROPLASTY , RIGHT HIP.
PRINCIPAL PROCEDURE: CONVERSION OF HEMIARTHROPLASTY TO TOTAL
HIP REPLACEMENT OF RIGHT HIP.
HISTORY OF PRESENT ILLNESS: This 63-year-old female is status
post right bipolar hemiarthroplasty
in 1992. The patient has a history of arteriovenous malformation.
The patient did well until 4 of July when she heard a large noise with
the feeling of increased pain in the right hip. The patient
underwent a closed reduction in the emergency room and was
subsequently discharged with a hip abduction arthrosis. The
patient presents , however , here for conversion of her right bipolar
to a right total hip replacement.
PAST SURGICAL HISTORY: Status post cholecystectomy. Status
post bipolar hemiarthroplasty in 1992.
Status post breast reduction. Status post left hip revision in
1993 of the femoral component of the left hip. Status post left
femoral nerve exploration in 1993. Status post right total knee
replacement in 1997.
ALLERGIES: With penicillin she gets hives.
MEDICATIONS: None.
HABITS: No tobacco , no alcohol.
HOSPITAL COURSE: The patient tolerated the procedure well and
was transferred to the Orthopaedic Floor
postoperatively for pain control and for physical therapy. The
patient rapidly progressed over the next several days and did quite
well. She was ambulating with assistance , partial weightbearing
with physical therapy without difficulty. Her wound is clean , dry ,
and intact with minimal drainage from the old drain site. She was
afebrile throughout her hospital course and required one unit of
blood during her hospital course to maintain her blood count
greater than 30. She otherwise did remarkably well and was quite
comfortable prior to discharge.
Her discharge medications were Percocet 1-2 tabs orally every 4-6 as needed
She was also discharged on Coumadin 3.5 mg orally every day and should
maintain Coumadin therapy for six weeks time. The patient should
have a prothrombin time checked biweekly to maintain an INR between
14 and 17. She otherwise did quite well and we are quite pleased
with her progress. We will see her back in the office in six weeks
time for x-rays and follow-up.
Dictated By: COLE AINI , M.D. BN51
Attending: BROOKE D. LEMMEN , M.D. AH50 WA066/4261
Batch: 8258 Index No. RUUFWS1461 D: 5/29/98
T: 5/29/98
Document id: 466
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330014689 | PUO | 93864965 | | 6363209 | 9/17/2006 12:00:00 a.m. | chest pain | | DIS | Admission Date: 4/6/2006 Report Status:
Discharge Date: 7/13/2006
****** FINAL DISCHARGE ORDERS ******
SHEARER , OSWALDO 852-92-79-3
Villerange Ux Leah
Service: CAR
DISCHARGE PATIENT ON: 8/26/06 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LYN , JR , FLOYD T. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally twice a day
ECASA 325 MG orally every day
ISOSORBIDE DINITRATE 30 MG orally three times a day HOLD IF: sbp<100
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
HOLD IF: heart rate<60 , SBP<100 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
KEFLEX ( CEPHALEXIN ) 500 MG orally four times a day
Instructions: for chronic osteomyelitis right foot
ALTACE ( RAMIPRIL ) 1.25 MG orally every day
Alert overridden: Override added on 7/25/06 by HEEP , GENOVEVA M K. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL Reason for override: patient takes
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please see your primary care physician in So De Villeszaker within 2 weeks. ,
ALLERGY: statins
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CAD dyslipidemia
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT
BRIEF RESUME OF HOSPITAL COURSE:
66 year-old man with CAD history of MI's ( 76 , 98 ) , and 2v CABG
6/29 and stenting to grafts 11/19 and multiple admits at multiple
hospitals in multiple states for CP evals presents with 10/10 CP.
Just discharged same day for identical presentation at KAAH where
enzymes and ekg showed no ischemia despite ongoing CP , and adenosine
mibi was poor study but could not rule out small area of ischemia in
lat wall. He was not re-cath'd. Today at bus stop , developed
recurrence of CP and has not been responsive to NTG , and his enzyme on
presentation was negative and ekg with only nonspecific Tw flat in
II , III and V2-V3 previously noted.
In ED: 86 118/60 99%. Got sublingual Nitro x 2->BP 87/59 P86 118/60. Got sublingual
ntg x2-> BP 87/59. cp 10/10->4/10. patient sitting up laughing. c/o 6-7/10
cp radiating to neck and jaw. sublingual ntg given with out
relief. PMH: CAD MI '76 , '98 ( KAAH ) , PCI 9/24 Bussadd Southrys Community Hospital
Worceangeles Las Ranor , history of 2V CABG 6/29 Akcare Hospital , sternal surgery for Staph
infection 4/9 , PCI to grafts 4/20 Stowna Medical Center , + ETT with ?PCI
H 9/19 , PM placement 10/5 Park adenosine-MIBI KAAH
6/14/06 ->LVEF 68% , mild-mod lateral wall ischemia vs artifact 6/27 ,
obsesity , GERD , chronic osteomyelitis rt foot on keflex , DM2 ( '92 ).
CHF , pAF ( no t on coumadin ) , hyperlipidemia , HTN , CVA with left
sided wkns meds:ASA 325 , amiodarone 200 twice a day , lopressor 50 twice a day ,
imdur 60 twice a day , plavix 75 , protonix , keflex 500 q4 , lasix 60 twice a day , kcl
40 every day , metformin 500 twice a day , micronase 10 twice a day , tylenol c codeine , ativan
5 mg as needed
all: ?statins SH: divorced x2 , son died from HL age 10; son living
in Saint , quit tob 20 y ago , no etoh. antique dealer. FH:
CAD; PE T 97 102/62 68 18
98% Gen: obese in good spirit.
NAD HEENT: JVP
flat Cor: RRR , 3/6 SM
USB Pulm:
CTA Abd:
benign Ext: no edema , 1 cm red spot rt ankle nontender;
WWP neuro: slight dec strenth left
side labs: Cr 1.8 ( bs 1.5 ) , CK 69 , 1.5 TnI<ass , HCT 39 ,
WBC 9 , PLT 354 INR 1.0 PTT 29 EKG: NSR 68 Twave flat II , III , V2-V3.
no new changes.
Impression: 66 year-old M with history of CAD history of MI , CABG + PCI with recent admits for
same and ?+ MIBI 6/26 admitted with chest pain. high prob low-int
risk. CP in patient with known CAD and
ongoing RF's. While story and his behavior and presentation and lack
of response to antianginal therapy , argue against ischemic , we will
need to monitor carefully
1. CV ( I )tele. r/o with enzymes , ekg heparininze until ruled out , given
ongoing pain no further sL nitro given no relief and BP
drops continue asa , plavix , orally
nitrate -ETT 6/10 2 min stopped 2/2 chest pain. no
ischemic EKG changes. ( P ) EF 68 %. euvolemic. cont
nitrate. ( R ) tele. cont bblocker. NSR. monitor for pAF. cont
amiodarone. 2. Endo: check A1c. hold orally agents. SS.
3. Renal: elevated BUN/Cr. gentle hydration. IVF 100 cc/h.
trend. 4. ID- chronic osteomyletis. cont keflex. normal
WBC , afebrile. no sign of acute infection. 5. FEN: NPO. cont PPI for
GERD. 5. ppx: PPI , subcutaneously hep.
6. dispo: FC.
ADDITIONAL COMMENTS: please f/u with your primary care physician in Ford You will need to discuss the issue
starting coumadin therapy given your history of atrial fibrillation.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HIPKINS , ERMA M. , M.D. , PH.D. ( SE52 ) 8/26/06 @ 11:08 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 467
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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110215494 | PUO | 90965472 | | 833726 | 2/6/2001 12:00:00 a.m. | coronary artery disease | | DIS | Admission Date: 11/9/2001 Report Status:
Discharge Date: 6/9/2001
****** DISCHARGE ORDERS ******
ZORENS , MAMIE 652-29-95-9
I
Service: CAR
DISCHARGE PATIENT ON: 6/15/01 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
EC ASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every afternoon Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ATENOLOL 75 MG orally every day before noon Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
CIPRO ( CIPROFLOXACIN ) 250 MG orally twice a day
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Number of Doses Required ( approximate ): 3
INSULIN NPH HUMAN 30 UNITS subcutaneously every day before noon
INSULIN NPH HUMAN 20 UNITS subcutaneously before dinner
INSULIN REGULAR ( HUMAN ) 18 UNITS subcutaneously every day before noon
INSULIN REGULAR ( HUMAN ) 14 UNITS subcutaneously before dinner
LEVOXYL ( LEVOTHYROXINE SODIUM ) 75 MCG orally every day
LISINOPRIL 20 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5 MIN X 3
as needed Chest Pain HOLD IF: SBP<[ ].
PRAVACHOL ( PRAVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
AMLODIPINE 5 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 60 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
WELLBUTRIN SR ( BUPROPION HCL SR ) 150 MG orally twice a day
Number of Doses Required ( approximate ): 2
CLOPIDOGREL 75 MG orally every day
DIET: House / Low chol/low sat. fat
Activity -
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Spraglin 1-2 weeks ,
Dr. Wohlford call ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
coronary artery disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN DEPRESSION CABG( SVG->LAD ) 1973 history of menorrhagia MI
1986 cabg 3v with rad art-rca 6/10 type I DM
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
57 year-old lady with DM , HT , hyperlipidemia and known
CAD history of CABG 25 year ago and multiple PCIs presented with recent
worsening of exercise capacity. Cath today showed severe native
TVD , patent LIMA to LAD , occluded SVG-OM and
radial graft to PDA 80% stenosis. PCI of radial
graft lesion with Nir 2.5x15mm and S660 2.5x12mm
stents resulting in 0% residual. Plan for 16
hours Integrilin and 30 days Plavix.
Angioseal applied to RFA. Uncomplicated postop course and home on
7/12/01 .
ADDITIONAL COMMENTS: call for any further chest pain , groin pain , swelling or bleeding
DISCHARGE CONDITION: Stable
TO DO/PLAN:
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE ( SH71 ) 6/15/01 @ 10:18 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 468
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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376950295 | PUO | 84780901 | | 489565 | 4/4/2000 12:00:00 a.m. | myocardial infarction | | DIS | Admission Date: 10/13/2000 Report Status:
Discharge Date: 1/7/2000
****** DISCHARGE ORDERS ******
AIDT , JR , BRITNI 568-86-35-3
Montana
Service: CAR
DISCHARGE PATIENT ON: 5/2 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ABSHEAR , CARLTON JAUNITA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
EC ASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 4/10 by
IGARTUA , DENAE KAM , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: noted , will monitor
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5 MIN X 3
as needed Chest Pain
SIMVASTATIN 20 MG orally every bedtime
CLOPIDOGREL 75 MG orally every day X 30 Days Starting Today April
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Peggy Romig 10/13 scheduled ,
No Known Allergies
ADMIT DIAGNOSIS:
MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
myocardial infarction
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( ) low back pain ( ) retinal vein occlusion
( ) history of hernia repair ( ) benign familial leukopenia
( ) polyclonnal gammapathy syncopal episode '95 ( )
OPERATIONS AND PROCEDURES:
cardiac catheterization with stents x3 to LAD
repeat cardiac catheterization with stent to RCA
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
*** 11/28 ***
70 year-old with SSCP , anterolateral ST elevation , taken emergently to cath-
LAD lesions ( 80% prox , 80% and 70% mid , 100% distal ) stented , also
has 75% ostial RCA , 50% mid RCA and 50% PDA
lesions. Ruled in for MI by enzymes.
5/23 patient doing well on asa , lopressor , plavix , simvistatin. Plan is
to go to cath to stent RCA lesions. Will start ace inhaled , titrate
as tolerated. patient has elevated random glucose-
will check hga1c
5/23 patient had cath with stenting of RCA to 0% and plasty of PDA. Had
asymptomatic episode of junctional escape rhythm
4/14 doing well , will transfer to floor , change beta blocker to
atenolol , ace to lisinopril
ADDITIONAL COMMENTS: patient instructed not to take Viagra
patient informed of follow-up appt 6/20
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Patient to continue plavix for 30 days and other medicines
indefinitely.
Follow-up with Cardiologist as scheduled.
If recurrent chest pain , return to Emergency Room.
No dictated summary
ENTERED BY: BARTCH , GEORGEANNA T. , M.D. ( NF88 ) 5/2 @ 01:26 PM
****** END OF DISCHARGE ORDERS ******
Document id: 469
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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166180688 | PUO | 85730590 | | 7554444 | 1/24/2006 12:00:00 a.m. | stroke | | DIS | Admission Date: 11/15/2006 Report Status:
Discharge Date: 10/11/2006
****** INCOMPLETE DISCHARGE ORDERS ******
BECKENDORF , ALLA 848-61-91-4
No I
Service: NEU
DISCHARGE PATIENT ON: 1/1/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEADING , JESSICA TAMA , M.D.
CODE STATUS:
Full code
Incomplete Discharge
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEURONTIN ( GABAPENTIN ) 100 MG orally BEDTIME
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
LOVENOX ( ENOXAPARIN ) 40 MG subcutaneously DAILY
Starting Today February
HOLD IF: patient ambulates extensively each day
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
VITAMIN B COMPLEX 1 TAB orally DAILY
Alert overridden: Override added on 1/1/06 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: for high homocysteine
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LISINOPRIL 10 MG orally DAILY
DIET: House / ADA 1800 cals/dy
ACTIVITY: as per physical therapy
FOLLOW UP APPOINTMENT( S ):
neurology Naomi Wolfensperger 422 825-8427 2-3 months ,
primary care physician 2-3 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Left Sided Weakness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
stroke
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
stroke
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI/MRA of brain , echocardiogram , holter monitor
BRIEF RESUME OF HOSPITAL COURSE:
CC: L arm/leg weakness for 4 days
HPI: 79 year-old RHF with diet controlled DM ( HgbA1c 6.2 in 1/13 ) , HTN , CAD
( NSTEMI MI 3/5 ) , hyperlipidemia who presents who at baseline is fully
independent ( lives by herself , shops , pays bills ) and noted L arm/leg
weakness Thursday morning when she awoke at 7AM. Sister noted slurred
speech when they spoke that day around noon - patient denied.
Went to primary care physician 7/2 where head CT was performed ( result unkown ). Daughter
describes some waxing and waning of symptoms ( improvement Thursday later
in the day so that she could run to the bus , then worsening Friday ).
Since then mild improvement.
Came to ED at daughter's insistence , BP 166/72 HR 56. Thought to have
peripheral neuropathy and admitted to medicine for placement. MRI showed
DWI restricted diffusion in R pons.
No nausea , vomiting , diplopia , hiccups , dizziness/vertigo , tingling. Had
noted mild HA the night before ( non-localized ).
ROS: Denies f/c/n/v , rash , diarrhea , BRBPR , melena , abd pain , CP ,
palpitations , cough , SOB , DOE , and change in bowel or bladder habits.
Also denies change in vision or hearing , tinnitus , vertigo , numbness ,
incontinence. Had been on ciprofloxacin 4/6/16 for UTI.
PMHx:
HTN , DM with neuropathy , CAD with NSTEMI 3/5 , hyperlipidemia ,
pyelonephritis history of ureteral stricture
Echo 11/7 with normal LV size and function
Meds:
ASA 81 takes every day 1 out of 4 weeks
Lisinopril 10
Said to be taking simvastatin and atenolol but poor compliance
All: NKDA
SHx:
Lives alone , no toxic habits , has daughter , master's degree in
mathematics
FHx:
Mother died at 77 of MI , father at 63 of colon CA , aunt died at 23 of
cardiac condtion , other distant family with MI
VS: afebrile 130/80 70s
PE: GEN NAD
HEENT NCAT , MMM , OP clear
Neck supple , no LAN , no bruits
Chest CTAB
CVS RRR , II/VI midsystolic murmur at L USB not radiating to neck
ABD soft , NT , ND , +BS
EXT no c/c/e , distal pulses strong , no rash
Neuro
MS: AA&Ox3 , appropriately interactive , normal affect
Attention: intact
Speech: fluent without paraphrasic errors; repetition , naming
Memory: x/3 at 5 minutes
Calculations: intact serial 7s
L/R confusion: No L/R confusion
Praxis: Able to mimic saluting the flag , rolling dice , brushing teeth
with either hand.
CN: I--not tested; II , III- mild anisocoria L pupil 3.5->3 , R 4->3.5 ,
VFFC; III , intravenous , VI--EOMI without nystagmus , no ptosis; V--sensation intact to
LT/PP , masseters strong bilaterally; VII-slightly increased palpebral
fissure on L but WNL; VIII--decreased bilaterally; IX , X--voice normal ,
palate elevates symmetrically; XI--SCM/trapezii 5/5; XII-tongue deviates
slightly to L but full strength , no atrophy or fasciculation
Motor: normal bulk and tone; no tremor , rigidity , or bradykinesia.
Decreased rapid finger movements on L No pronator drift. Strength:
| ShAb | ShAd | ElFl | ElEx | WrFl | WrEx | FgSp | HpFl | KnEx | KnFl | Dors | Plan |
L | 4+ | 5 | 4+ | 4+ | 5 | 5 | 4+ | 4+ | 5 | 5 | 5 | 5 |
R | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
Coord: L arm and leg ataxia
Reflex:
| bi | tri | bra | pat | ank | toe |
L | 2 | 2 | 2 | 2 | 2 | mute |
R | 2 | 2 | 2 | 2 | 2 | mute |
Sens: LT , PP , temperature , vibration , and joint position intact. No
evidence of extinction.
Gait: antalgic gait favoring the L , wide-based , unsteady with eyes open
and feet together but worse with eyes closed
MRI of the brain showed an acute right pontine infarct with mild
irregularity of the basilar artery.
Impression was L ataxic hemiparesis , which is clasically a lacunar stroke
syndrome caused by small vessel disease , however can be caused by an
embolism. Her hospital course has been stable.
Reversible stroke risk factor labs included:
HDL 32 , LDL 114 , TG 140 , homocysteine 15.9 , ESR 14 , HGBA1C 6.2
Based on these data , she should be on a statin. She should have tight
sugar monitoring , possibly with an orally agent. High homocysteine can be
treated with B complex vitamins with little side effect.
She should be on daily aspirin for secondary stroke
prevention. Echocardiogram showed no thrombus , normal LV size and
function , normal LA size. At the time of dictation , holter result was not
available , but this will be addressed in outpatient follow up.
She is being discharged to acute rehabilitation. She will benefit from
aggressive physical therapy/OT treatment.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
as above
No dictated summary
ENTERED BY: BELIZAIRE , ROSAMOND LEONARDA , M.D. , PH.D. ( JJ21 ) 1/1/06 @ 03:12 PM
****** END OF DISCHARGE ORDERS ******
Document id: 470
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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637493403 | PUO | 95118952 | | 1927018 | 6/10/2005 12:00:00 a.m. | HEPATIC ENCEPHALOPATHY | Signed | DIS | Admission Date: 1/1/2005 Report Status: Signed
Discharge Date: 6/24/2005
ATTENDING: DEPSKY , GWYNETH ALMEDA MD
INTERIM DICTATION:
The patient progressively worsened over the following days after
the previous interim dictation. He was unable to take any orally
medications , was continued on Roxanol sublingual for pain
control. His respiratory status continued to worsen. His family
was notified. His brother came to see him and then his 3 sons
were at his bedside. He slowly had slowly worsening agonal
breathing and at 10:01 a.m. , I was called to see patient for no
respirations. He had no respirations or breath sounds or heart
sounds after auscultation for 1 minute. His pupils were
nonreactive and fixed bilaterally. His family declined autopsy
and his brother , Baumgard , was notified by the attending.
TIME OF DEATH: 10:01 a.m. on 5/30/05 .
eScription document: 4-7764488 UF
Dictated By: STEADINGS , MURIEL
Attending: DEPSKY , GWYNETH ALMEDA
Dictation ID 0897482
D: 5/30/05
T: 5/30/05
Document id: 471
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
Y |
N |
- |
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- |
Y |
N |
N |
Y |
N |
N |
N |
681931867 | PUO | 05384389 | | 0688580 | 5/29/2006 12:00:00 a.m. | history of R mini-thoracotomy , RUL wedge resection | | DIS | Admission Date: 5/7/2006 Report Status:
Discharge Date: 10/8/2006
****** FINAL DISCHARGE ORDERS ******
MARCHIONESE , VIVIAN 118-94-42-9
Alabama
Service: THO
DISCHARGE PATIENT ON: 9/23/06 AT 09:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: JANEIRO , LORETTE V. , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally BEDTIME
HOLD IF: sedation Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
ATORVASTATIN 40 MG orally DAILY
CELEBREX ( CELECOXIB ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
KLONOPIN ( CLONAZEPAM ) 0.5 MG orally twice a day
HOLD IF: excessive sedation
COLACE ( DOCUSATE SODIUM ) 100 MG orally three times a day
Starting Pod 1 January HOLD IF: diarrhea
FAMOTIDINE 20 MG orally twice a day Starting ON DAY OF SURGERY
Override Notice: Override added on 10/18/06 by SONSTROEM , BRITTENY A R. , M.D.
on order for BUPIVACAINE 0.25% ED 100 ML OTHER ( ref #
659460213 )
POTENTIALLY SERIOUS INTERACTION: FAMOTIDINE , INJ &
BUPIVACAINE HCL Reason for override: aware
Previous override information:
Override added on 10/18/06 by SONSTROEM , BRITTENY A. , M.D.
on order for BUPIVACAINE 0.25% ED 100 ML OTHER ( ref #
351710458 )
POTENTIALLY SERIOUS INTERACTION: FAMOTIDINE , INJ &
BUPIVACAINE HCL Reason for override: aware
DILAUDID ( HYDROMORPHONE HCL ) 2 MG orally every 6 hours as needed Pain
HOLD IF: sedated
LISINOPRIL 30 MG orally twice a day HOLD IF: SBP<100
Reason: Override added on 10/18/06 by SONSTROEM , BRITTENY A. , M.D.
on order for BUPIVACAINE 0.25% ED 100 ML OTHER ( ref #
659460213 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & BUPIVACAINE
HCL Reason for override: aware
Previous override information:
Override added on 10/18/06 by SONSTROEM , BRITTENY A. , M.D.
on order for BUPIVACAINE 0.25% ED 100 ML OTHER ( ref #
351710458 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & BUPIVACAINE
HCL Reason for override: aware
Previous override information:
Override added on 10/8/06 by WIGGIN , MARJORY , M.B.B.S.
on order for KCL IMMEDIATE RELEASE orally SCALE OTHER ( ref
# 867908799 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 10/8/06 by BREINES , AZALEE TYNISHA , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 840972721 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
RITALIN TABLET ( METHYLPHENIDATE HCL TABLET )
20 MG orally Q3.5H as needed Anxiety
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally three times a day
HOLD IF: SBP< 100 , HR< 55
KADIAN ( MORPHINE SUSTAINED RELEASE ( KADIAN ) )
20 MG orally twice a day HOLD IF: excessive sedation
OXYCODONE 5-10 MG orally every 4 hours Starting Today March
as needed Pain
DIET: No Restrictions
ACTIVITY: Elevate feet with prolonged periods of sitting
Walking as tolerated
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Janeiro 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
RUL nodule
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of R mini-thoracotomy , RUL wedge resection
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , HTN , cardiomyopathy , RCA stenosis , history of obestity , nephrolithiasis ,
chronic back pain , history of lingula sparing LUL lobectomy for squamous cell
carcinoma in 8/6 , history of gastric bypass
OPERATIONS AND PROCEDURES:
10/8/06 JANEIRO , LORETTE V. , M.D.
BRONCH RT THORACOSCOPY RT THORACOTOMY RT WEDGE RESECTION MASS
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Marchionese is a 68-year-old man status post left lingula sparing
upper lobectomy on November , 2001 , for a T1N0M0 squamous cell carcinoma
of the lung. He was recently found to have a new right upper lobe nodule
by chest CT scan.
HOSPITAL COURSE: The patient underwent a right mini-thoracotomy , RUL
wedge resection , and mediastinal lymph node dissection , 5/29/2006 . The
patient tolerated the procedure well and was extubated and transferred to
the PACU and TICU without incident. For further details , please see the
dedicated OR note.
The patient's post-operative course was uneventful. His diet was
advanced to a full house diet , his oxygen was weaned to room air , and his
home medications were restarted. POD #1 , following resolution of the air
leak and minimal output , the patient's chest tube was removed. A post
pull CXR showed a small apical space. POD #2 , the chest x-ray showed the
apical space to be stable. His epidural was capped and removed , foley
catheter removed and he voided without difficulty.
The patient was discharged in stable condition on POD #3. He was
tolerating a house diet , ambulating without need of assistance or
supplemental oxygen , and had good pain control on orally pain medication.
He will have VNA services for vital signs , oxygen saturation and wound
care. He will follow with Dr. Janeiro in clinic in 1-2 weeks.
HOME MEDS: Ambien 10 mg ( HS ) , 5 mg as needed; Klonopin 0.5 mg twice a day; Celebrex 200
mg twice a day; lisinopril 30 mg twice a day; Kadian 20 mg twice a day; Lipitor 40 mg d; Ritalin
20 mg d; Oxycodone as needed; Dilaudid as needed
ADDITIONAL COMMENTS: Please follow the instructions in the thoracic discharge packet. Please
resume home medications. Call for questions and medication refills to
465-102-6791. VNA needed for vital signs , oxygens saturation , and wound
care.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: RODARMEL , DONYA MITZIE , M.D. ( AM78 ) 9/23/06 @ 08:26 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 472
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
Y |
N |
N |
Y |
Y |
Y |
N |
Y |
N |
N |
- |
N |
767129253 | PUO | 56620872 | | 8307709 | 2/8/2006 12:00:00 a.m. | Symptomatic Paroxysmal atrial fibrillation , now in sinus rhythm | | DIS | Admission Date: 3/18/2006 Report Status:
Discharge Date: 4/8/2006
****** FINAL DISCHARGE ORDERS ******
SHAFTIC , LUDIE 975-47-61-6
O Rollirv
Service: CAR
DISCHARGE PATIENT ON: 1/16/06 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Alert overridden: Override added on 1/5/06 by
MONTILLA , JADE J.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: mda
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
ALLOPURINOL 200 MG orally DAILY
Alert overridden: Override added on 1/5/06 by
MONTILLA , JADE J.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: mda
COLCHICINE 1.2 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
NEURONTIN ( GABAPENTIN ) 600 MG orally three times a day
Starting Today June
GLYBURIDE 2.5 MG orally DAILY
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
4 PUFF inhaled four times a day
ISOSORBIDE MONONITRATE ( SR ) 60 MG orally DAILY
HOLD IF: SBP < 90 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 1/16/06 by :
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override: mda
SIMVASTATIN 10 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 1/5/06 by
MONTILLA , JADE J.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: MDA
TRAZODONE 100 MG orally BEDTIME
VERAPAMIL SUSTAINED RELEASE 120 MG orally DAILY
HOLD IF: SBP < 90 Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/5/06 by
DAURIZIO , GINNY , M.D. , PH.D.
on order for LOPRESSOR orally 12.5 MG four times a day ( ref # 085493847 )
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override: mda
Previous override information:
Override added on 1/5/06 by DAURIZIO , GINNY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL , SUSTAINED-REL
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL , SUSTAINED-REL Reason for override: mda
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 1/5/06 by
MONTILLA , JADE J.
on order for ACETYLSALICYLIC ACID orally ( ref # 608633774 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: mda Previous override information:
Override added on 1/5/06 by MONTILLA , JADE J.
on order for ALLOPURINOL orally ( ref # 815483726 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: mda Previous override information:
Override added on 1/5/06 by MONTILLA , JADE J.
on order for SIMVASTATIN orally ( ref # 333432799 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: MDA
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Cassem 10/21/06 scheduled ,
Arrange INR to be drawn on 8/10/06 with f/u INR's to be drawn every
30 days. INR's will be followed by Dr. Cassem
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Unstable Angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Symptomatic Paroxysmal atrial fibrillation , now in sinus rhythm
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
COPD history of B TKR PVD history of HTN history of GOUT history of endarterectomy pseudogout
HA's seizures asthma
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
PET nuclear stress test. Exam showed no areas of perfusion abnormalities
BRIEF RESUME OF HOSPITAL COURSE:
CC: CP , SOB , Palpitation , genaral malaise
*****
HPI: 79 year-old Black F with history of CAD history of CABG and angioplasty , DM ,
hyperlipidemia , presents to the ED with non-radiating , sub-sternal
CP , sharp in quality , 8 of 10 , that woke her up from sleep at
4am. Pain persisted after two sublingual Nitro. She called 911.
EMS administered ASA and Lopressor 2.5 intravenous and pain subsided. patient was
found to be in A. Fib with RVR and then brought to the ED.
PMH: DM , CAD , A Fib , Gout , Asthma/COPD , Lung CA history of partial
lobectomy PSH: Bilateral knee replacement , thoracotomy , CABG.
*****
SH: Remote smoking history , no etoh.
*****
Allergies: NKDA
*****
LABS: Trop I - x3 , GLU 111 , INR on D/C 2.1. EKG on D/C: Sinus rhythm
with 1st degree heart block.
*****
Assessment: 79 year-old Black F with symptomatic paroxysmal atrial
fibrillation. patient in sinus rhythm and asymptomatic at time of discharge.
*****
patient has follow up appt on 10/21/06 at 11am with Dr. Cassem ( primary care physician ).
ADDITIONAL COMMENTS: Please check INR in 2-3 days after discharge. Please take all bottles of
medication from home and what you are given in the hospital to your
doctor's appt on 7/18 at 11am
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. I have asked patient to bring all medications at home as well as
medications prescribed on discharge.
2. BB and CCB's were the medications that allowed her to come out of A
fib
3. Patient has been instructed to check INR 2-3 days after D/C. Her dose
was changed due to her INR being subtherapeutic on admission. Please
monitor INR closely. Thank you.
No dictated summary
ENTERED BY: DAURIZIO , GINNY , M.D. , PH.D. ( ZV00 ) 1/16/06 @ 03:59 PM
****** END OF DISCHARGE ORDERS ******
Document id: 473
| Target |
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Gs |
GER |
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OSA |
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| output/system_textual_annotation.xml | textual |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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767129253 | PUO | 56620872 | | 461704 | 5/25/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/18/1992 Report Status: Signed
Discharge Date: 4/22/1992
ADMISSION DIAGNOSIS: 1. Right knee osteoarthritis.
PROCEDURE: Total knee replacement.
PRESENT ILLNESS: The patient is a 64 year old female who
has worsening pain in her right knee
over many years. X-rays reveal osteoarthritis of the right knee.
She is now admitted for right total knee replacement.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Seizure disorder.
3. Gout. 4. CVA in 1987. Surgery:
Ovarian cyst , benign breast mass removed times two. Medications:
Dyazide; Ecotrin; Allopurinol 300 mg orally.every day; Propranolol;
Colchicine 0.6 mg orally.twice a day; Sulindac 150 mg orally.twice a day;
Dilantin 100 mg two tabs three times a day; Ventolin inhaler two puffs
four times a day.as needed
SOCIAL HISTORY: The patient smokes approximately two
packs per week and denies alcohol.
PHYSICAL EXAMINATION: HEENT: Unremarkable. LUNGS: Clear.
CARDIOVASCULAR: Regular rate and rhythm ,
without murmur , rubs or gallops. ABDOMEN: Benign. EXTREMITIES:
Mild valgus deformity of the right knee with 2+ crepitus , medial
and lateral joint line tenderness.
HOSPITAL COURSE: The patient was admitted to the
Orthopedic Service and underwent right
total knee replacement with Kinemax system. She was transferred
to the floor in stable condition. Postoperatively she had a drop
in blood pressure to a systolic of 70 with the epidural in place.
With fluid bolus , her pressure then stabilized.
On the first postoperative night the patient spiked to 103.9 with
a temperature of 99 the following morning. The epidural was
discontinued and a urine culture was sent. The urine revealed 1+
bacteria with 2+ squamous cells and 10 to 15 white blood cells.
Therefore , the Foley was discontinued and the patient given one
dose of gentamicin. A repeat white count revealed white blood
cell count of 12.9. Blood cultures , urine and epidural cultures
remained negative. She was started on CPM and this was continued
psotoperatively with the physical therapist.
On postoperative day three she again spiked to 102.4 and was
complaining of frequent urination and incontinence. Therefore ,
she was started on an empiric course of Bactrim times 48 hours.
Again , blood cultures were performed and these remained negative
at the time of discharge. The patient continued to do fairly
well with physical therapy though her progress was slow. On
postoperative day five her temperature had remained less than
100 degrees for 24 hours and her cultures remained negative. Her
wound remained clean and nonerythematous without discharge. She
had no complaints of shortness of breath or sputum production.
She remained hemodynamically stable.
It was therefore felt she was stable for discharge to the Rehab
Center on 20 of October . She will require aggressive physical therapy
to increase her range of motion and her ambulation.
CONDITION ON DISCHARGE: Stable. Diet: Regular. Medications:
Same as admission with Percocet one to two orally.every 4 to 6 hours
as needed pain. She will also receive one additional day of
treatment with Bactrim.
Followup: The patient will followup with Dr. Genny Barrette .
Dictated By: TASHA FAIT , M.D. DQ57 IY139/1184
JANEAN JOHNIE ODEA , M.D. OR8 D: 10/7/92
T: 10/7/92
Batch: T639 Report: VM948Z33 T:
Document id: 474
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
- |
N |
N |
N |
Y |
N |
603229379 | PUO | 20240916 | | 4321447 | 3/20/2006 12:00:00 a.m. | CHF | | DIS | Admission Date: 3/27/2006 Report Status:
Discharge Date: 10/10/2006
****** FINAL DISCHARGE ORDERS ******
MUCERINO , JACINTO S 933-94-69-2
Louis
Service: RNM
DISCHARGE PATIENT ON: 11/5/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GABHART , DORTHY ELLA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASPIRIN ENTERIC COATED 81 MG orally DAILY
Instructions: At 12 noon.
LIPITOR ( ATORVASTATIN ) 10 MG orally DAILY
Instructions: take at noon
COLESTIPOL HYDROCHLORIDE 10 GM orally DAILY
Instructions: At 6PM. Food/Drug Interaction Instruction
Take before meals. Monitor fat soluble vitamins.
Number of Doses Required ( approximate ): 5
INSULIN GLARGINE 14 UNITS subcutaneously DAILY
HUMALOG INSULIN ( INSULIN LISPRO )
Sliding Scale ( subcutaneous ) subcutaneously before meals
Instructions: patient takes his own scale Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
Please give at the same time and in addition to standing
mealtime insulin
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally DAILY
HOLD IF: sbp<100 , please hold prior to dialysis
Instructions: 12 noon , unless patient is at dialysis.
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KLOR-CON ( KCL SLOW RELEASE ) 20 MEQ orally DAILY
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally BEDTIME
HOLD IF: sbp<100 or heart rate<60 and notify HO if holding
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
FLOMAX ( TAMSULOSIN ) 0.4 MG orally DAILY
Instructions: At 12 noon.
TORSEMIDE 150 MG orally DAILY
HOLD IF: sbp<100 and notify HO if holding
DIET: House / 2 gm Na / 2 gram K+
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
PUO dialysis unit Monday 5/21 10:30am scheduled ,
ALLERGY: Penicillins , LISINOPRIL
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ESRD , PVD , CAD history of 3MIs 3vCABG , ischemic cardiomyopathy 25%
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
4/5 placement of tunneled catheter in RIJ
10/11 Hemodialysis
BRIEF RESUME OF HOSPITAL COURSE:
CC: admitted for HD initiation.
******
HPI: This is a 54 year-old male with ischemic cardiomyopathy with EF 25% ,
severe pulmonary HTN , and chronic kidney disease bl Cr 2.5 who was
admitted 3 weeks ago to PUO for CHF and diuresis. He was begun on
metolazone on as needed basis for weight , but presented to ED with Cr 5.1
and looking dehydrated. He was volume resuscitated with creatinine
decreasing to 3.9. Metolazone was held on d/c with Cr dec to 3.4 , but patient
appeared at renal clinic on 11/18 with extreme SOB and inability to sleep
at night. patient has DOE. +orthopnea , sleeps in chair. Denies any CP or
dizziness. BUN/Cr 102/3.3. Due to the patient's difficult to control volume
status , patient underwent 14-french double IJ TC placement today in IR.
Presently , he is complaining of soreness at the R tunnel catheter site.
Denies CP but has some SOB. Planned for HD tomorrow a.m..
******
PMH: Coronary artery disease status post 3v CABG 1996; PVD history of R AKA.
history of bilateral femoral-popliteal and bypass graft; DM type 1 x 44 yrs , c/b
diabetic nephropathy , diabetic retinopathy , and diabetic neuropathy;
ischemic cardiomyopathy with ejection fraction of 25% to 30% , severe
pulmonary hypertension , BPH , lactose intolerance , COPD , Right
hydronephrosis secondary to a right ureteral stricture. Bilateral renal
artery stenosis
******
ALLERGIES: penicillin causes rash
******
Medications at home:
Aspirin 81 every day , torsemide 150 every day , lipitor 10 , imdur ER 60 , zemplar 1mg
daily , klorcon slow release 20 mEq daily , Flomax 0.4 every day , colestipol 1g
every day , toprol-XL 50 every bedtime , lantus 14 unit subcutaneously , humalog scale , metolazone 5mg as
needed.
******
ADMISSION EXAM:
VS T 95.5 , HR 64 , BP 100/56 , RR 18 , O2sat 99% RA
Gen: in no acute distress sitting at 45 degrees
HEENT: PERRL 3mm pupils. Arcus senilus. EOMI. O/p clear. No LAD.
Tenderness at R tunnel cath site o/with dressing c/d/i.
Chest: bilateral base crackles. Decreased BS to = way up.
CV: RRR S1 and widely split S2. 3/6 harsh SEM loudest in pulmonic area.
+RV heave. JVP > 15cm ( to jaw standing up ).
Abd: soft nontender +BS
Ext: R above the knee amputation. 2+ pitting edema in left leg. No
ulcers in left foot. 0-1+ DP pulses.
Neuro: AO x 3. CN2-12 intact. Motor strength grossly intact. Sensation
intact except decreased in left foot.
******
LABORATORY DATA:
3/20 Na 137 , K 3.3 , Cl 97 , CO2 29 , BUN 102 , Cr 3.3 , Glc 293
9/27 AST 20 , ALT 17 , ALKP 118 , TB 1.0
9/27 WBC 7.4 , HCT 34.3 , PLT 211
1/10 physical therapy 14.4 , PTT 33.7 , INR 1.1
9/3/06 : UA neg.
******
MAJOR STUDIES:
ECG 3/30/06 : NSR 68 , LAD , biatrial enlargement , QRS 196 , BBB. V4-V6 Q
waves and Tw inv V5-V6. vs. prior study on 5/1 unchanged.
PA/lateral CXR 3/1/06 : Interval worsening pulmonary edema. Persistent
small bilateral pleural effusions.
TTE 3/3 Overall LVEF 20%. Global hypokinesis with regional variation.
Global RVSF reduced. Severe LAE. RAE. Trace AR. Mod MR. Mild -mod TR.
Mild PR.
********
HOSPITAL COURSE BY PROBLEM: In summary , this is a 54yo man with CKD and
poorly controlled volume status 2/2 diuresis limited by azotemia admitted
for tunnel catheter placement and initiation of HD.
*Renal: On admission , the patient was volume overloaded by exam. He
underwent TC without complications on 4/5 . The patient underwent first
hemodialysis on 10/11 with improvement of volume status ( decreased
crackles , decreased JVP , less edema. On discharge , we have held zemplar
and metolazone , and told patient to continue his home medications otherwise
( see todo/plan ). The patient is to return Monday for his second dialysis run.
*Code status: Presently , full code. He does not have formal HCP but we
have discussed the importance of arranging for one.
*********
Discharge meds: take all medications as at home with the following
changes:
1. Hold zemplar
2. Hold metolazone
3. Take Torsemide and Klor-Con as per your normal routine. Do not
take Torsemide on Monday.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
take all medications as at home with the following changes:
1. Hold zemplar
2. Hold metolazone
3. Take Torsemide and Klor-Con as per your normal routine. Do not take
Torsemide on Monday.
4. Your dialysis appointment is on Monday 5/21 at 10:30am at the Kernan To Dautedi University Of Of
dialysis unit.
No dictated summary
ENTERED BY: LEWY , JOLYNN P. , M.D. ( LN55 ) 11/5/06 @ 01:26 PM
****** END OF DISCHARGE ORDERS ******
Document id: 475
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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603229379 | PUO | 20240916 | | 790705 | 6/29/1997 12:00:00 a.m. | CELLULITIS RIGHT FOOT | Signed | DIS | Admission Date: 10/14/1997 Report Status: Signed
Discharge Date: 11/17/1997
PRINCIPAL DIAGNOSIS: PERIPHERAL VASCULAR DISEASE.
PROCEDURES: 1. Third and fifth toe amputation with wound
debridement.
2. Lower extremity angiogram.
3. Right transmetatarsal amputation.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
gentleman with a history of severe
peripheral vascular disease who is status post aorto-bifemoral and
bilateral femoral-popliteal bypass grafting , who originally
presented in August of this year with an ischemic right foot and
gangrenous right great toe and fourth toe. Arteriogram revealed a
popliteal stenosis below his bypass with very poor runoff. The
popliteal artery was angioplastied with good results and
restoration of palpable anterior tibial pulses at the mid calf.
The patient only had moderate perfusion of the right foot , however ,
and presented in August of this year for wound debridement and
fourth toe amputation. The patient re-presents with a poorly
healing fourth toe amputation site and wound cellulitis.
PAST MEDICAL HISTORY: He has poorly controlled insulin dependent
diabetes. He is status post myocardial
infarction in 1993 , 1996 and 1997. He has severe peripheral
vascular disease. He is status post bilateral femoral-popliteal
and bypass graft. He is status post aorto-bifemoral. He has a
history of coronary artery disease. He is status post coronary
artery bypass graft x three vessel. He has a history of congestive
heart failure , history of osteoarthritis.
MEDICATIONS: Digoxin 0.125 mg orally every day , Lasix 120 mg orally
twice a day , Zestril 50 mg orally every day , aspirin 325 mg orally
every day , insulin NPH 10 units every day before noon , every afternoon and insulin Regular
sliding scale.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Patient is afebrile. Temperature was 98.2 ,
blood pressure 100/80 , pulse 85 ,
respirations 16. He had saturation of 98% on room air. In
general , he is a white male in no acute distress. HEENT was
normocephalic , atraumatic. Pupils were equally reactive to light
and accommodation. Extraocular muscles were intact. Sclerae were
anicteric. There was no lymphadenopathy. Lungs were clear to
auscultation. Cardiac exam was regular rate and rhythm. Abdomen
was soft , nontender , nondistended , with normal active bowel sounds.
Neurologic exam was nonfocal. Extremities were without clubbing ,
cyanosis or edema. On vascular exam , patient had 3+ bilateral
femoral pulses , 2+ bilateral popliteal pulses. He had biphasic
dopplerable bilateral posterior tibial pulses and a monophasic
dopplerable right dorsalis pedis pulse and no dopplerable left
dorsalis pedis pulse. His right great toe had a black eschar on
the tip. His fourth toe amputation site was with purulent
drainage. His third toe was erythematous and tender to palpation.
HOSPITAL COURSE: The patient was admitted to the vascular service
for wound debridement and intravenous antibiotics. He was
initially evaluated by the cardiology service and endocrine
service. Patient was cleared by cardiology for the procedure and
was considered well managed medically in regard to his coronary
artery disease. In regard to patient's diabetes , he was initially
extremely brittle and requiring extensive fine tuning by the
endocrine service who , at the time of discharge , had his blood
sugars repeatedly under 200 , with easily achieved insulin regimen.
The patient was taken to the operating room initially on the 13 of June of
April where he underwent a right third and fifth toe amputation
with wound debridement. At the time of operation , purulent
drainage with necrotic regions of the bases of the third and fifth
toes were found. The wound was left open with packing , with
further plans for more formal TMA after adequate drainage of the
foot. The patient , from the beginning of the hospital course , was
started on intravenous vancomycin , levofloxacin and Flagyl which he
continued throughout his hospital course. The patient tolerated
this initial wound debridement and toe amputation without incident.
Please see dictated operative report for further details. The
patient underwent an arteriogram on the 30 of August of April which
revealed one vessel runoff via peroneal artery to an irregular
appearing posterior tibial artery. The tibial peroneal trunk and
the proximal peroneal artery were found to have high grade
stenoses. There were numerous collateral vessels to a dorsalis
pedis artery at the level of the ankle. Based on this arteriogram
result and his wound , patient was preop'd for a transmetatarsal
amputation on the 2 of June of April . It was recommended by the
vascular staff that transmetatarsal amputation was the only option
for proximal limb salvage. He was not found to have any
appropriate anatomy for further reconstruction from an arterial
standpoint. The patient was taken to the operating room on the
2 of June of April where he underwent a formal right transmetatarsal
amputation. The patient's wound was debrided back to the viable
tissue and was closed in a primary fashion. Please see dictated
operative report for further details. Patient tolerated the
procedure well without complications and was transported back to
the PACU and the floor in stable condition. Postoperatively , the
patient has required wound packing to a small portion of the wound
which was left open for drainage. Initially , the wound was
erythematous with minimal to moderate drainage. At the time of
discharge , the wound has become far less erythematous , far less
painful and without any drainage. It is thought at this time that
patient now had three weeks of intravenous antibiotics and is stable enough
to go home on a orally regimen. Patient will be discharged on orally
levofloxacin and clindamycin with twice a day wound packing by VNA
service. Patient is discharged to home in stable condition with
followup to be early this week with Dr. Derham . Patient is also
recommended to call his cardiologist for appointment in 1-2 weeks
and his primary care physician in 1-2 weeks as well.
DISCHARGE MEDICATIONS: Tylenol , digoxin 0.125 mg orally every day ,
Colace 100 mg orally twice a day , Lasix 120 mg
orally twice a day , NPH insulin 14 units every day before noon and 14 units every afternoon , CZI
Regular insulin sliding scale before each meal , Zestril 50 mg orally
every day , Niferex 150 mg orally twice a day , Percocet 1-2 tabs orally every 3-4h.
as needed pain , levofloxacin 250 mg orally every day , clindamycin 300 mg
orally four times a day , aspirin 325 mg orally every day
Dictated By: LORETTA GEMMELL , M.D. SW20
Attending: ROSSIE MANKOSKI , M.D. JF70 DW807/9848
Batch: 98607 Index No. N9WTO76JGL D: 5/28/97
T: 1/4/97
Document id: 476
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
- |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
540167155 | PUO | 66456892 | | 5654565 | 1/16/2005 12:00:00 a.m. | LINE INFECTION | Signed | DIS | Admission Date: 11/1/2005 Report Status: Signed
Discharge Date: 3/21/2005
ATTENDING: DONEHOO , FILOMENA MD
CHIEF COMPLAINT: Fevers , pain over her Hickman catheter.
HISTORY OF PRESENT ILLNESS: This is a 41-year-old female with a
history of an aplastic anemia since age of 12 , diabetes mellitus ,
avascular necrosis of bilateral hips and shoulders status post
replacements and multiple previous sinus infections , who presents
with one day of fever and pain around her Hickman site. The
patient was in her usual state of health the week of admission ,
but on the Friday prior to admission , she felt sick and was in
bed all day. She noticed worsening back and knee pain. That had
been present since July when she was in a motor vehicle
accident. She also felt warm to the temperature and noticed
herself to be febrile to 101 degrees. The morning of admission ,
she had worsening pain and induration around her Hickman site and
called her physician who told her to come to the Emergency
Department. On review of systems , she denied cough , sputum
production , nasal congestion , headache , chest pain , shortness of
breath , abdominal pain , nausea , vomiting , diarrhea , rashes ,
dysuria , increased urinary frequency or urgency.
PAST MEDICAL HISTORY: Her past medical history is notable for
insulin-dependent diabetes mellitus , hepatitis C positivity ,
aplastic anemia , transfusion dependent , acute 2 weeks , chronic
kidney disease , avascular necrosis of the hips bilaterally ,
status post bilateral total hip replacements , hepatitis B
secondary hemachromatosis and hypothyroidism and she has an
allergy to acetaminophen.
MEDICATIONS: Her medications include , Nexium 40 mg orally every day ,
Lantus 25 units every bedtime , thiamine 100 mg orally every day , Humalog
sliding scale , folic acid 1 mg every day , Ambien 10 mg orally every bedtime ,
levothyroxine 75 mg orally every day , lisinopril 20 mg orally every day ,
methadone 40 mg orally three times a day , oxycodone 98 mg orally three times a day as needed
pain , quinine 260 mg every bedtime , hydrochlorothiazide 25 mg orally
every bedtime , Zoloft 100 mg orally every day , and Compazine as needed nausea.
SOCIAL HISTORY: She lives at home with her daughter. She does
not drink alcohol. She does not smoke tobacco.
FAMILY HISTORY: Her family history is noncontributory. In the
emergency department , blood cultures were drawn from her Hickman
line and peripherally plain films were obtained of the left knee
and the lumbar spine and she received a single dose of
vancomycin , levofloxacin and Flagyl intravenously.
ADMISSION EXAMINATION: Her temperature was 97.8. Her heart rate
was 80. Her blood pressure was 102/68. Her respiratory rate was
16. She was satting 100% on room air. Generally , she was awake
and alert. HEENT: Mucous membranes were moist. Oropharynx was
clear , pupils equal , round and reactive to light. Her pupils
were pinpoint. Cardiovascular: JVP was at 7 cm of water ,
carotid upstrokes were brisk. Her cardiovascular exam was
regular rate and rhythm , S1 , S2 , no rubs , murmurs or gallops.
Pulmonary: Lungs were clear to auscultation bilaterally.
Abdomen: Her abdomen was soft , nontender , and nondistended. No
hepatosplenomegaly , negative Murphy's sign and she had normal
active bowel sounds. Extremities were warm and well perfused.
She had 1+ edema bilaterally in the lower extremities. She had
left medial knee tenderness but no effusion , full range of
motion. Her neurologic exam was nonfocal.
LABORATORY DATA: Her laboratory evaluation was notable for a
glucose of 49. Her complete blood count was notable for a white
blood count of 1.7 with an absolute neutrophil count of 735. Her
hematocrit was 26. Her platelet count was 7. Plain films
obtained of the left knee showed a stable pattern sclerosis in
the distal femur with an effusion. Plain films of the L-spine
showed no fracture or other pathology.
HOSPITAL COURSE BY SYSTEM: Her blood cultures.
1. ID , her blood cultures grew out coag-negative staphylococcus.
Her Hickman line was pulled and thought to be the source of
infection. She was started on vancomycin intravenously to
complete a 2-week course of vancomycin.
2. Musculoskeletal , the patient had has chronic hip and knee
pain secondary to avascular necrosis and also from her MVA that
she experienced , which likely exacerbated the pain. The
patient's pain seemed to be out of control throughout the
admission. Anesthesia was consulted and the patient was treated
with a fentanyl PCA. She was also continued on her home dose of
methadone 40 three times a day with oxycodone for breakthrough. Toward the
end of the admission , the patient was thought to be somnolent ,
perhaps over sedated from narcotics. Her medication regimen was
titrated back down to her home regimen versus the methadone 40 mg
orally three times a day and her oxycodone was titrated down to 60 mg every 8 hours p.
r.n. , breakthrough pain.
3. Heme , the patient has a history of aplastic anemia. She was
transfused blood for hematocrit less than 25. Furthermore upper
extremity noninvasive vascular studies were obtained to rule out
subclavian clot associated with her prior Hickman and that study
was negative. The decision was made to transfuse platelets only
if the patient was actively bleeding , which she was not.
4. Endocrine: Throughout the patient's admission , her blood
sugars were somewhat difficult to control having episodes of both
hyper and hypoglycemia. The patient was discharged on the
following regimen NPH 34 units in the morning with Humalog
sliding scale with the plan for her to follow up with her primary
physician in office to further adjust her insulin scale. She was
continued on her Synthroid at 75 mg every day for hypothyroidism , this
was not initially during this admission.
5. Cardiovascular system: The patient has a history of
hypertension. She was continued on her lisinopril 20 mg every day ,
and hydrochlorothiazide 25 mg every day
6. Prophylaxis: The patient had pneumoboots for DVT
prophylaxis.
7. FEN: The patient was had her nutrition supplemented with
multivitamin , thiamine and folate.
8. GI: The patient was on GI prophylaxis with Nexium and was
given Colace as a stool softener versus her narcotics.
9. The patient was full code during this admission.
DISPOSITION: The patient was discharged with the diagnosis of
neutropenia and Hickman line infection. She was completed a
course of intravenous vancomycin for coag-negative staphylococcus
bacteremia , which ended on 6/5/05 . Prior to her discharge , she
had a tunneled catheter placed by general surgery , procedure ,
which she tolerated well. Please see separate operative report.
The patient was instructed to follow up with Dr. Donehoo in his
office. The patient was continued on methadone 40 mg orally three times a day
for pain with oxycodone 60 mg every 6 hours , as needed for breakthrough
pain.
DISCHARGE MEDICATIONS: Colace 100 mg orally twice a day , Nexium 40 mg
orally every day , thiamine 100 mg orally every day , folic acid 1 mg orally every day ,
Levoxyl 75 mg orally every day , lisinopril 20 mg orally every day , methadone 40
mg orally three times a day , quinine 260 mg every bedtime , Zoloft 100 mg orally every day ,
hydrochlorothiazide 25 mg orally every day , baclofen 10 mg three times a day ,
NovoLog sliding scale , NPH 35 units every day before noon , vancomycin 1 gram
every day to be continued until 11/19/06 .
DIET ON DISCHARGE: American diabetic association diet.
ACTIVITY ON DISCHARGE: As tolerated.
CONDITION ON DISCHARGE: Stable , improved from admission.
eScription document: 5-5235653 HFFocus
Dictated By: RAMIL , FELIPA
Attending: DONEHOO , FILOMENA
Dictation ID 8538088
D: 8/20/07
T: 8/20/07
Document id: 477
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540167155 | PUO | 66456892 | | 509986 | 6/3/1998 12:00:00 a.m. | GRAM NEGATIVE ROD SEPSIS | Signed | DIS | Admission Date: 5/19/1998 Report Status: Signed
Discharge Date: 1/25/1998
PRINCIPAL DIAGNOSIS: GRAM NEGATIVE ROD BACTEREMIA.
PROBLEMS: 1. APLASTIC ANEMIA. 2. HEMOCHROMATOSIS.
CHIEF COMPLAINT/IDENTIFICATION: The patient is a 34 year-old woman
with a 22 year history of aplastic
anemia , transfusion dependent for 13 years , complicated by
hemochromatosis , now with gram negative rod bacteremia.
HISTORY OF THE PRESENT ILLNESS: The patient is a 34 year-old woman
diagnosed with aplastic anemia 22
years ago. The patient never had a potential donor for transplant
and was immediately treated with immunosuppressive therapy for
aplastic anemia using steroids without efficacy. The patient
suffered complications from steroid use , including avascular
necrosis , resulting in bilateral hip replacements as well as
chronic bony damage to her shoulders for which she uses pain
medications. For the past 13 year , the patient has remained
transfusion dependent and requires a few units on packed red blood
cells on an every two week basis and platelet transfusions whenever
she develops epistaxis. In September of 1998 , the patient developed
diabetes mellitus. The patient had already been known to have an
elevated ferratin due to blood transfusions from years previously.
However , when she had been started on Desferal in the past , she
developed a port-a-cath infection and ultimately leakage of
Desferal to the surrounding skin , which resulted in extrusion of
her port-a-cath through her skin. She was therefore off Desferal
for a number of years. The patient presented in mid September of 1998
with a blood glucose in the 500 to 600 range , associated with
polyuria , polydipsia , and a 19 pound weight loss. An abdominal CT
scan was performed at that time , which was consistent with iron
overload. The patient's ferratin was noted to be the 7 , 000 range.
The patient was begun on Insulin therapy and Desferal 24 hours a
day. A port-a-cath was placed in the patient's left upper chest.
The patient's Desferal was given at 2 grams per 24 hours. She had
a gradual decrease in her Insulin requirements by 50%. In April of
1998 , the patient went on vacation to Tamp Park for two weeks.
Toward the end of her stay , she developed an infected port-a-cath
and was readmitted to the Pagham University Of in early
April with a port-a-cath infection. At that time , four out of four
blood cultures grew out Staphylococcus aureus. Because of concern
of the long term sequelae of Staphylococcus aureus infection , the
patient was treated with Nafcillin for six weeks. The patient did
well on Nafcillin with resolution of her fevers. The patient was
readmitted to the Pagham University Of on October , 1998 to
July , 1998 for a two day history of fevers to 101 associated
with the development of a painful perirectal abscess. The abscess
was assessed and required surgical drainage after a platelet
transfusion to increase the patient's platelets to 42 , 000. The
patient underwent an incision through the Survtheast Centex Health Care . By
July , 1998 , the cultures from her abscess grew gram negative
enteric rods , sensitive to Cipro. All of the patient's blood
cultures were negative. Speciation of the gram negative rods
revealed Klebsiella pneumonia. The patient was discharged home on
Ciprofloxacin , which she took for an additional ten days after
discharge. Since September , 1998 , the patient had been off all
antibiotics and the plan was for Athmann to have another set of blood
cultures drawn to document resolution of all infection prior to the
consideration of putting in a new central access , such as a
Hickman. The patient was seen at the Skill Snerkernfairmri Rehab
on the day prior to admission and reported that she had been
entirely afebrile without chills. The patient also noted that her
blood sugar was well controlled on a stable regimen of Insulin in
the 24 hours after she was seen in the clinic. Two out of four
blood cultures that were drawn in the clinic revealed gram negative
rods. The patient was therefore asked to return to the Pagham University Of for treatment of gram negative rod bacteremia.
PAST MEDICAL HISTORY: 1. Aplastic anemia. 2. Hemochromatosis.
3. Diabetes mellitus. 4. Avascular
necrosis , status post bilateral hip replacement in October of 1997
and July of 1997. 5. Status post total abdominal hysterectomy
for high grade SIL in 1997. 6. History of hepatitis B and
hepatitis C due to transfusions. 7. Multiple port-a-cath
infections in the past.
MEDICATIONS: 1. Insulin 65 units every day before noon of NPH and 15 units q.
a.m. of Regular , 10 units of Regular subcutaneously
pre-dinner , and 20 units of NPH at bedtime. 2. Desferal 2 gram
intravenously every 24 hours 3. Percocet two to three tablets every
two to three hours as needed pain.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a previous history of alcohol use
up to five year prior to presentation. The
patient is a single mother of three children , ages 12 , 8 , and 8.
FAMILY HISTORY: Diabetes mellitus in many extended family members.
PHYSICAL EXAMINATION: The patient is a young African-American
female in no acute distress. HEENT: Pupils
equal , round and reactive to light and accommodation. Extraocular
movements were intact. Clear oropharynx. NECK: No
lymphadenopathy. CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. Left previous
port-a-cath size is well healed. There is no induration or
tenderness at her right PICC line site. ABDOMEN: Benign. BACK:
No spinal tenderness and no costovertebral angle tenderness.
RECTAL: Recent perirectal abscess shows evidence of good
granulation tissue with a slight induration around the site and no
tenderness or warmth on palpation. EXTREMITIES: No lower
extremity edema. VITAL SIGNS: The patient was afebrile. The
patient's temperature was 99.8. Blood pressure was 116/80. Heart
rate was 76. Respiratory rate was 20. Oxygen saturation was 100%
on room air.
LABORATORY ON ADMISSION: Drawn at Skill Snerkernfairmri Rehab on
2/8/98 , the patient's white blood cell count was 2.1 , hematocrit
18 , platelets 2 , 000 , with a differential showing neutrophils 23 ,
bands 2 , atypicals 1 , The patient had an ANC 483 , sodium 138 ,
potassium 4.6 , chloride 106 , bicarbonate 24 , BUN 11 , creatinine
0.8 , glucose 266 , magnesium 2.2 , LDH 1 , 029 , AST 145 , alkaline
phosphatase 227 , total bilirubin 1.4 , and direct bilirubin 1.0.
The patient was admitted to the Oncology Service. The patient had
received 1 gram of Ceftazidine at the Skill Snerkernfairmri Rehab
for gram negative rod bacteremia with no clear source. The patient
was switched to Levofloxacin while awaiting speciation of the
bacteria.
HOSPITAL COURSE BY SYSTEM: 1. INFECTIOUS DISEASE: The patient's
chest x-ray on admission revealed no
evidence of infiltrate. Blood cultures done on 2/8/98 revealed
four out of four bottles growing Bacillus. On 5/11/98 , blood
cultures from the PICC line grew Bacillus as well as from the
peripheral blood growing Bacillus. Urine cultures were negative.
An abdominal CT was performed to determine the source of gram
negative bacteremia , and was unrevealing for the course of
infection. There was a comment made of small liver lesions with a
question of estuta flow phenomenon. An Infectious Disease
consultation was obtained as the patient was completely
asymptomatic and afebrile in the hospital on Levofloxacin.
Recommendations were made by Infection Disease to discontinue
Levofloxacin , which was done on 2/15/98 . Blood cultures were
obtained on 1/3/98 , which revealed no evidence of Bacillus from
the peripheral blood or the PICC line. The patient's right PICC
line was discontinued and a PICC line was inserted in the left
side.
2. HEMATOLOGY: The patient's hematocrit was 18 on admission. The
patient was transfused and her hematocrit improved
to 24 on 5/11/98 . The patient had platelets of 4 on 5/11/98 . The
patient received one bag of platelets with improvement to 43. The
patient was continued on Desferal while in the hospital at 2 gram
every 24 hours
3. ENDOCRINE: The patient was continued on her home Insulin
regimen with the maintenance of adequate blood
sugars. There were no complications during her admission.
DISCHARGE MEDICATIONS: 1. Insulin 65 units of NPH every day before noon , 15
units of Regular every day before noon , 10 units of
Regular pre-dinner , and 20 units of NPH at bedtime. 2. Desferol 2
grams intravenously every 24 hours 3. Percocet two to three tablets
every two to three hours as needed pain.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE FOLLOW-UP: The patient is to follow-up with Dr. Rossie K Mankoski . The patient will also follow-up
with Dr. Langseth for placement of a Hickman if evidence of negative
blood cultures one week after discharge.
Dictated By:
Attending: ROSSIE K. MANKOSKI , M.D. UA95 WY364/6833
Batch: 47578 Index No. YMSKGC5U0O D: 3/3/98
T: 10/4/98
Document id: 478
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540167155 | PUO | 66456892 | | 620700 | 5/11/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 7/24/1990 Report Status: Unsigned
Discharge Date: 9/24/1990
DISCHARGE DIAGNOSES: 1 ) APLASTIC ANEMIA.
2 ) ANTITHROMBOCYTE GLOBULIN THERAPY FOR 10
DAYS.
3 ) OTITIS MEDIA.
4 ) SERUM SICKNESS.
5 ) HIV NEGATIVE.
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old woman
who has a 15 year history of aplastic
anemia without known cause and history of multiple transfusions
admitted for ATG trial. The patient was diagnosed with aplastic
anemia in 1976 at Bussadd Southrys Community Hospital when admitted for epistaxis ,
unknown workup , unknown cause. Denies drug or chemical exposure or
infection. Hct 30 , platelets 100 , 000 , white cell count ran at
around 4000. She was diagnosed at the time with mild aplastic
anemia. No treatment was given. The patient in past has declined
further treatment and often was found to be non-compliant in the
past. Evidently the patient has an HLA identical brother which was
found out during earlier diagnosis. She has a history of brief
trial of androgen treatment. On 14 of September her white count was 2.5 ,
Hct 19.6 , platelets 5000 , MCV 96 , polys 10 , lymphs 87 which is
similar to baseline but platelets are usually more around 10 , 000.
She is maintained on every three week transfusions without platelets.
She is now admitted for ATGAM therapy. The patient has been noted
to be more compliant with transfusions recently than in the past
and has been requiring them more but this may be secondary to her
increased compliance and increased activity. The patient was in
her usual state of health with a cough secondary to smoking and
white sputum. No headache , nausea , vomiting , diarrhea , fever ,
chills , night sweats , dysuria , urine or bowel movement changes. No
history of cauterization for epistaxis. Positive easy
bruisability , gum bleed without trauma , and last episode of
epistaxis on 17 of September which is four days prior to admission which
lasted 45 to 50 minutes. Her last menstrual period was the third
week of 10 of October . She had no menometrorrhagia and she has nausea with
her menses. CURRENT MEDICATIONS: Last month she stopped birth
control pill secondary to non-compliance and uses condoms
otherwise. PAST MEDICAL HISTORY: Notable for Gravida VI Para III
AB III , twins times one. Last pregnancy in 8 of September , discontinued
secondary to birth abnormality. She has a 15 year history of
aplastic anemia and has been previously tested HIV and HPV
negative. SOCIAL HISTORY: Notable for cocaine use , smoking ,
approximately three times a week; alcohol one pint of hard liquor a
week; smoking one half to one pack per day. She lives with her
father , uncle , and three children and occasionally works at
Wau Worthbile
PHYSICAL EXAMINATION: Notable for an obese pleasant woman in no
apparent distress. Temperature 99.3 , pulse
88 , blood pressure 130/80 , respirations 20. HEENT was notable for
being anicteric , fundi were flat , no adenopathy , JVD , bruits or
increased thyroid. Heart with II/VI systolic ejection murmur at
left sternal border. Lungs were clear. No CVA tenderness. Abdomen
with bowel sounds present , liver 10 cm , no guarding or rebound , no
spleen , mass or kidneys palpable. Extremities non-tender , 1+ edema
at ankle , right ankle more than the left ankle. Neuro exam within
normal limits.
LABORATORY DATA: On admission notable for white count 2.4 , Hct
21.7 , MCV 91.8 , platelet count 15 , 000;
differential was polys 7 , bands 1 , lymphs 92. SMA 7 on admission
was sodium 139 , potassium 3.8 , bicarb 22 , glucose 82 , BUN 10 ,
creatinine 0.9 with anion gap 10. LFTs revealed OT 66 , physical therapy 102 , LDH
221 , alk phos 111 , bili 0.3/0.2 , calcium 8.5. Cholesterol 143 ,
triglyceride 113. HIV was negative. HPV was negative. HCV was
negative. Beta HCG was negative.
HOSPITAL COURSE: The patient received a 10 day course of ATGAM
complicated by , during the first day , temperature
to 105 with response to holding ATGAM and starting hydrocortisone
and restarting ATGAM. She was afebrile without symptoms until day
nine of ATGAM when a rash became apparent starting on her right
forearm with a rectangular red erythematous maculopapular patch
which later extended over her entire body and it was pruritic. No
involvement of her orpharynx and no respiratory compromise were
ever noted. This may have been partly secondary either to her
ATGAM being turned up on the night of 6 of March by the patient by
accident or also may have been due to Ceftaz and Vanco which was
started on 6 of March for a febrile episode on the eighth day of
ATGAM. She was also noted during the episode of fever to have an
erythematous eardrum , a couple of posterior cervical nodes one
measuring about 1 cm x 2 cm which was tender to palpation , also
some erythema of the right side of her oropharynx. Strep was
negative. The patient was treated with Ceftaz and Vanc for
possible otitis. This was later changed to Augmentin when rash was
thought to be possibly secondary to Ceftaz and then this again was
changed later to orally Cipro when she was no longer neutropenic and
her symptoms appeared to be resolving. During the episode of the
rash her urine also changed to a dark coke-colored urine which
contained red blood cells , no casts were noted , however , it was
felt to be consistent with serum sickness and so the patient was
changed from the 40 mg prednisone started for the ATGAM so that she
would be afebrile and to minimize reaction of the ATGAM to intravenous Solu
Medrol. She responded well to this with urine changing rapidly to
yellow color still with some RBCs on discharge , however , she will
be discharged on 16 mg prednisone orally twice a day and followed up in
Hematology to make sure the rash continues to fade and that her
urine continues to improve. During hospitalization the patient
required periodic transfusions for platelets and packed red blood
cells. She tolerated the packed red blood cell transfusion well ,
however , in general she noted her usual reaction to platelets with
rigors and chills and was given hydrocortisone 100 mg intravenous at the
same time. Also while using Solu Medrol one night prior to
admission she was given one bag of platelets for which she
developed a little bit of an increased rash which faded rapidly on
stopping the platelets and a platelet blood transfusion reaction
workup was done. The labs on discharge are sodium 135 , potassium
4.8 , BUN 20 , creatinine 1 , LDH 327 , alk phos 263 , magnesium 2.1 ,
calcium 9.4 , white blood cell count 2.4 with 36 polys , 1 band , 55
lymphs , and 8 monos , Hct 27.6 , and platelet count 7000 prior to one
bag of platelets , MCV 88.
DISPOSITION: DISCHARGE MEDICATIONS: Nystatin 5 cc orally four times a day as needed , 60
mg prednisone orally twice a day , 1 gm Carafate orally four times a day , calcium
carbonate 2500 mg orally three times a day , Ciprofloxacin 750 mg orally twice a day for 10 days ,
chlorhexadine glucose 15 cc orally twice a day , Benadryl 25 mg orally four times a day as needed ,
Monistat cream for question of monoliasis , and Tylenol as needed Please
note that prednisone dosage is to be adjusted in Transfusion
Services on 1 of November as per need. The patient is stable on
discharge. The patient is to return to Transfusion Service on
1 of November and to be followed by Dr. Jacqulyn Harkley as an outpatient.
________________________________ HK084/4920
EVELYNE C. TEPPER , M.D. DF3 D: 7/25/90
Batch: 1095 Report: V9334M95 T: 10/15/90
Dictated By: GERMAINE BLACKGOAT , M.D.
cc: 1. WEAGRAFF , JR , KATHLINE G.
Document id: 479
| Target |
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DM |
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GER |
Gou |
HC |
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HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
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U |
U |
U |
U |
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U |
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| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
296953897 | PUO | 75847620 | | 921777 | 11/23/2002 12:00:00 a.m. | B ankle RA flare | | DIS | Admission Date: 1/14/2002 Report Status:
Discharge Date: 11/13/2002
****** DISCHARGE ORDERS ******
SHAMEL , GEMMA 772-66-76-0
Ville Ford Calo
Service: MED
DISCHARGE PATIENT ON: 9/26/02 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DONEHOO , FILOMENA MICKI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ELAVIL ( AMITRIPTYLINE HCL ) 25 MG orally every bedtime
CACO3 ( CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) )
625 MG orally three times a day
LEVOTHYROXINE SODIUM 50 MCG orally every day
LISINOPRIL 15 MG orally every day HOLD IF: SBP<100
NIFEREX-150 150 MG orally twice a day
PREDNISONE 15 MG orally every day before noon Starting Today January
Instructions: Take prednisone 15mgx3d then 12.5mgx3d , then
10mgx3d , then 7.5mgx3d , then 5mgx3d.
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
HOLD IF: SBP<100; HR<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
METFORMIN 500 MG orally every day
GLYNASE ( GLYBURIDE MICRO ) 4.5 MG orally twice a day
Number of Doses Required ( approximate ): 4
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LEVOFLOXACIN 500 MG orally every day X 2 Days
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 9/26/02 by :
POTENTIALLY SERIOUS INTERACTION: POLYSACCHARIDE IRON
COMPLEX & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: already on doing well
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Squiers at 10:15 on Thursday March . ,
No Known Allergies
ADMIT DIAGNOSIS:
r/o mi with RA flare in B ankles
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
B ankle RA flare
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
RHEUM. ARTHRITIS AODM history of GIB ANEMIA ?SYNCOPE
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old F history of RA , DM , chronic anemia with SSCP and B
ankle swelling. patient reports 4-5 hours of CP that is dull and radiating
to L shoulder. She said if feels like a pressure pain not associated
with diaphoresis , N/V , SOB , lightheadedness or
other symptoms. No pleuritic pain. She has had
similar episodes in the
past on 9/17 and 5/5/01 patient had adenosine
MIBI which was neg. for ischemia and
demonstrated EF>70%. EKG was also nl at that time. Today patient
has similar pain that has resolved prior
to presentation to PUO . She had stable vitals
at presentation and physical exam remarkable
for mitral regurg
murmur. CV:cycling enzymes- have been flat x
3 , hemodynamically stable , no CP since admission ,
on lovenox during R/O will D/C , pain reproduced
if apply sternal pressure-likely
costochondritis However patient does describe second type of pain which is
more pressure like and might related to cardiac ischemia , patient does
not have this pain now but should be destinguished from condritis
pain. placed on O2-will
D/C , will place on prednisone to tx ankle pain and it will also help
with sternal pain , will continue home
meds including lisinopril-will increase dose to 15
as BP in 160-170s , statin , toprol
xl . RA:will put patient on prednisone 15mg to tx
ankle flare , will taper
quickly talked with Dr. Hamid her rheumatologist
to discuss her condition-he agrees with
plan Endo-continue synthroid as history of
hypothyroidism , TSH- was normal , T3 was normal , will use
SSI , continue home glyburide and metformin
doses. GI-tolerating orally , continue
nexium.
ADDITIONAL COMMENTS: patient should take Prednisone according to the following schedule:
3 tablets of 5mg on 6/26/27
one 10mg tablet and one 2.5mg tablet on 11/10/29 , 7
one 10mg tablet on 1/9/1 , 8
one 5mg tablet and one 2.5mg on 1/4/4 , 8
one 5mg tablet on 2/5/7 , 8 then off
prednisone , patient needs home Physical Therapy
for home safety evaluation and Nursing for medical compliance.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: PIROS , KASSIE J , M.D. ( UA991 ) 9/26/02 @ 03:10 PM
****** END OF DISCHARGE ORDERS ******
Document id: 480
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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N |
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U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
265806893 | PUO | 09555241 | | 046462 | 10/11/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/2/1991 Report Status: Signed
Discharge Date: 10/11/1991
PRINCIPAL DIAGNOSIS: LYMPHOMA.
HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old with
an FUO recently admitted for further
work-up of fever. Approximately 12 weeks ago , the patient noted
the onset of fevers , intermittent to 102 or 103 , nonproductive
cough , arthralgias , myalgias , sweats and chills. There was some
diffuse abdominal pain. The patient has had recurrent fevers and
was admitted to Pagham University Of on 12/10/91 for a
work-up. This together with CHH work-up has been fairly
extensive. He was discharged from the hospital two weeks ago and
five days ago after afebrile days , he began having fevers again. He
was admitted at this time for further work-up. He has had three
episodes of nausea and vomiting during the febrile episodes in the
last week. He has been passing gas and has been constipated. He
also noted a productive cough. HIV risk factors were negative.
Work-up has included chest CT which revealed enlarged diaphragmatic
lymph nodes , coronary artery calcium deposits and two small liver
cysts. Pelvic CT revealed retroperitoneal lymphadenopathy with a
second cecum. Chest x-ray was normal. Testicular ultrasound
revealed no masses. Abdominal ultrasound was normal with ectatic
aorta. Upper GI series revealed nodularity to the mucosa within
the gastric antrum , question focal gastritis. Endoscopy with
biopsy revealed gastritis , no evidence of malignancy. Serology
revealed hepatitis A IgM antibody negative , hepatitis A IgG
antibody positive , hepatitis surface antigen negative , rubella
immune , RPR negative , Toxo negative , CMV negative , HSV positive
( old infection ). Lyme titer was 11.7 ( normal is 0-9 ). PPD was
negative. SPEP normal. AFP , beta hCG , CEA negative. Malaria
screens were negative. B-12 and folate were normal. HIV was
negative. Multiple blood and urine cultures all negative.
ALLERGIES: PENICILLIN. MEDICATIONS: On admission included
Tylenol and Percocet.
PHYSICAL EXAMINATION: On admission revealed a temperature of
103.4. HEENT exam was within normal limits.
Lungs were clear. Neck was supple with no jugular venous
distention , there was some shotty lymphadenopathy. Cardiac exam
revealed a regular rate and rhythm without murmurs , rubs or
gallops. Abdomen revealed positive bowel sounds , some mild
tenderness , question enlarged liver edge. There was positive
inguinal lymphadenopathy. Extremities revealed no clubbing ,
cyanosis or edema , positive lichen planus. Neurological exam was
nonfocal. Rectal exam was deferred.
HOSPITAL COURSE: The patient was seen by both Infectious
Disease Service and Hematology Oncology Service.
The patient had an ANA which was negative. Rheumatoid factor was
negative. Lyme titer was 4.5. Hepatitis C was negative. CT scan
of the abdomen and pelvis done on 10/11 showed essentially no change
with multiple retroperitoneal lymph nodes , possible increased size
of the left external inguinal lymph node. The ultrasound of the
abdomen was negative for gallstones or biliary duct dilatation but
showed an abdominal aortic aneurysm of 2.5 cm. The patient had a
bone marrow biopsy which showed large atypical cells infiltrating
with fibrosis , a picture consistent with Hodgkin's disease
involving the bone marrow. The patient had defervesced and was
scheduled for discharge on the day which the bone marrow biopsy
results were received. He was informed of the diagnosis and is to
follow-up with Dr. Grap on an outpatient basis.
EJ666/1399
MELDA XIAO IVASKA , M.D. JR0 D: 8/5/91
Batch: 9589 Report: Y5578W57 T: 4/1/91
Dictated By: KRISTIAN N. MAGLIONE , M.D.
Document id: 481
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
028944445 | PUO | 26723331 | | 119164 | 10/19/2002 12:00:00 a.m. | HEMOPTYSIS | Signed | DIS | Admission Date: 2/23/2002 Report Status: Signed
Discharge Date: 3/19/2002
HISTORY OF PRESENT ILLNESS: Briefly , Mr. Lovitt is a 60-year-old man
admitted to the MICU on 3/1 in the
setting of massive hemoptysis. He has an 80 pack year history of
smoking. He was noted to have upper respiratory symptoms three
days prior to admission. One day prior to admission , he had some
pink sputum and shortness of breath. He was admitted to P Therford Hospital
with possible COPD flare. At that time , he had massive hemoptysis ,
was intubated and transferred to PUO for further management.
Initially , he was seen by anesthesia and intubated with a double
lumen ETT for airway protection. He was taken to the O.R. the
following day and found to have an endobronchial lesion at the left
bifurcation of the upper and lower lobes. Samples were taken which
subsequently revealed clot. An endobronchial blocker was placed.
He had no further episodes of hemoptysis. On 3/15 , he had a
bronchoscopic Wang needle biopsy which was nondiagnostic but showed
cells suspicious for non small cell lung cell cancer versus
squamous metaplasia. He was easily extubated in the evening of
3/15 without event.
PAST MEDICAL HISTORY: Hypertension , diabetes , alcohol , PAF , BPH ,
glaucoma , osteoarthritis , DVTs , CVA of total
right internal carotid and 80% of the left internal carotid artery ,
pilonidal cyst.
ALLERGIES: To Keflex.
MEDICATIONS AT HOME: Zestril 30 , NPH , aspirin.
MEDS ON TRANSFER: Also include Diltiazem , levo. and prednisone ,
Nexium , Nitropaste , trazodone , Ativan , Heparin ,
Zestril.
SOCIAL HISTORY: 80 pack years of tobacco. Alcohol in the past.
FAMILY HISTORY: Notable for coronary artery disease.
HOSPITAL COURSE BY SYSTEM: 1. Pulmonary: The patient had no
repeat episodes of hemoptysis on this
admission. He received a total body bone scan with no skeletal
metastasis found. CT of the chest on 2/10 revealed consolidation
improved since admission , no hilar or mediastinal lymphadenopathy
and low attenuation areas of enlargement within both adrenal
glands , unchanged from the admission CT. An abdominal CT showed
calcified gallstone , a left apical adrenal nodule needing further
imaging and a tiny , hypoattenuating liver lesion in the right liver
lobe. A CT scan of the head was negative for metastasis disease.
Because of the finding in the adrenal glands , an MRI of the abdomen
without contrast was also completed on the day prior to discharge.
Results of the study are pending. The case was discussed with Dr.
Sodachanh and Dr. Alicia and Dr. Gumina at length. It was decided
that if there was no evidence of metastatic disease , the patient
would possibly be offered left upper lobectomy for both diagnostic
and therapeutic purposes. If there were evidence of metastatic
disease on biopsy of a visible adrenal nodule , then potential
medical therapy would include chemotherapy and radiation. The
patient did well on the floor with O2 sats remaining in the upper
90s on room air. At one point , two days prior to discharge , he did
develop some mild inspiratory stridor. There was a question of
aspiration pneumonia; however , chest PA and lateral was negative.
2. Cardiovascular: The patient developed atrial fibrillation in
the setting of hemoptysis. He was loaded with intravenous amiodarone and
subsequently returned to normal sinus rhythm. He was on
maintenance dose of 200 mg orally every day and remained in normal sinus
rhythm. He also had hypertension and was started on Captopril and
Lopressor for better blood pressure control. Amiodarone will
likely be stopped at the time of discharge.
3. Renal: Creatinine has been stable throughout hospital course.
4. ID: The patient has been on levo. and Flagyl for presumed
aspiration pneumonia. He completed a two week course of these
medications. PPD was negative. BAL was negative for infectious
organisms.
5. GI: Was on Nexium for GI prophylaxis. Because the patient was
intubated for several days , he had significant swallowing
difficulties with possible aspiration. A video fluoroscopy study
revealed penetration and aspiration of all consistencies secondary
to decreased epiglottic deflection and moderate residue in the
piriform sinuses. Thus the patient received an NG tube and
received all feeds and pills through it. He is to remain NPO until
a repeat video fluoroscopy is performed.
6. Heme: The patient received one unit of packed red blood cells
during his stay and his hematocrit remained stable thereafter.
7. Endocrine: The patient required high doses of insulin , notably
80 in the a.m. and 85 in the p.m. with some breakthrough doses of
insulin as well.
8. Vascular: On the day of discharge , the patient was noted to
have bilateral ankle swelling. However in the setting of normal
creatinine , normal albumin of 3.9 and an echocardiogram with a
normal EF , this was not thought to be cardiovascular or renal in
origin. Furthermore , the patient had no tenderness to palpation
and no pain. LENIs were considered.
Thus the patient was discharged on 8/20/02 in the morning with
follow-up with Dr. Sodachanh and Dr. Alicia .
DISCHARGE MEDICATIONS: Artificial tears two drops each eye three times a day ,
Atenolol 25 mg orally every day , folate 1 mg orally
every day , NPH 85 units in the morning and 80 units in the evening ,
Zestril 30 mg orally every day , Nystatin swish and swallow , Thiamine 100
mg orally every day , trazodone 50 mg orally every bedtime , Ambien 5 mg orally q.
bedtime , Nexium 20 mg orally every day , and multivitamin 12/5 ml orally every day
These will be given through the NG tube until he is stable with
regards to swallowing.
Dictated By: ANNABEL DASE , M.D. HC09
Attending: MARJORY GUMINA , M.D. CN32 LS852/148343
Batch: 35720 Index No. V0OCVRYE31 D: 5/25/02
T: 5/25/02
CC: 1. SCHWEINBERG , LESSIE BREANA CATARINA , M.D.
2. EARNEST ALICIA , M.D.
Document id: 482
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
301178257 | PUO | 00364506 | | 1512667 | 5/5/2005 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 5/5/2005 Report Status:
Discharge Date: 5/4/2005
****** FINAL DISCHARGE ORDERS ******
JULIAS , EARLEAN 467-25-96-0
Tempedo
Service: CAR
DISCHARGE PATIENT ON: 11/18/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARNABA , CARA CHANCE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
DIAZEPAM 10 MG orally every day before noon Starting Today May
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally twice a day
Starting Today May Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PAXIL ( PAROXETINE ) 20 MG orally every day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LISINOPRIL 10 MG orally every day
Alert overridden: Override added on 11/18/05 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
ACETYLSALICYLIC ACID 81 MG orally every other day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Macisaac 1-2 weeks ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Htn , hyperlipidemia , CAD , anxiety disorder , obesity
OPERATIONS AND PROCEDURES:
Cardiac catheterization 8/1 40% LAD lesion , no intervention
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
46 year-old f with history of HTN , high lipids with history of abnormal ETT 2/5 by report
who p/with several months of SSCP , tightness. Occas SOB. Seen by primary care physician on DOA
and sent to ED. 4d worsning sx. Improved pain with sublingual NTG.
In ED , afeb , 168/74 , HR 94 , EKG unchaged , neg first set enzymes.
Started on heparin.
===
Exam:
98.0 , 58-60 , 132/60 , 18 , 98% 2L general: nad , euvolemic , clear chest ,
rrr no mgr , no edema
===
Labs: TNI neg x 2
===
CATH 8/1 40% LAD , no intervention
===
EKG: Intial ECG unchanged from baseline with old TWI in v5-6 , 1 ,
avl 11/12/5 am ECG: TWI in 1 , 2 , l , f , v4-v5
===
Assessment: 46 year-old f with HTN , high lipds with chest pain , non-specific
TW changes and negative enzymes x 2.
===
COURSE: 1. Ischemia: asa , statin high dose , BB , ACE-I . On heparin until
cathed on 10/5 -> no significant CAD. Discharged on lisinopril and
lopressor , zocor , ASA; d/c'd HCTZ for now. Chest pain not thought to be
ischemic in origin.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Liver function tests and fasting lipid profile pending at time of
discharge.
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( RQ87 ) 11/18/05 @ 11:41 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 483
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
243794038 | PUO | 20081301 | | 6640184 | 7/11/2005 12:00:00 a.m. | " | | DIS | Admission Date: 8/8/2005 Report Status:
Discharge Date: 1/11/2005
****** FINAL DISCHARGE ORDERS ******
TOPPI , ELEANOR L. 276-66-58-2
Pos
Service: GGI
DISCHARGE PATIENT ON: 11/7/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MONDELL , MELINA RACHAEL , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LANTUS ( INSULIN GLARGINE ) 10 UNITS subcutaneously every day
HOLD IF: FS <150
RANITIDINE HCL SYRUP 150 MG orally twice a day
ROXICET ELIXIR ( OXYCODONE+APAP LIQUID )
5-10 MILLILITERS orally every 4 hours as needed Pain
COLACE ( DOCUSATE SODIUM ) 100 MG orally three times a day HOLD IF: diarrhea
Instructions: as elixir
PHENERGAN ( PROMETHAZINE HCL ) 25 MG PR every 6 hours as needed Nausea
AUGMENTIN SUSP. 250MG/62.5 MG ( 5ML ) ( AMOXICIL... )
10 MILLILITERS orally three times a day Instructions: for five days
Food/Drug Interaction Instruction
May be taken without regard to meals
DIET: stage 2 post band diet
ACTIVITY: Resume regular exercise
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Mondell 1-2 weeks ,
Diabetes Management Service 3 weeks ,
ALLERGY: Sulfa , Erythromycins
ADMIT DIAGNOSIS:
history of lap gastic band
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
"
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
.
OPERATIONS AND PROCEDURES:
7/12/05 MONDELL , MELINA RACHAEL , M.D.
LAPARO PLACEMENT ADJUSTABLE GASTRIC BAND
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
upper GI series - negative
BRIEF RESUME OF HOSPITAL COURSE:
this very pleasant 54yo with a history of NIDDM failure of other
conventional methods of weight loss , underwent a laparoscopic adjustable
gastric band placement without complication. The patient was transferred to
the PACU in stable condition. Her pain was well controlled with PCA
analgesia on POD0 and transitioned to orally elixir analgesia following a
negative upper GI studfy exhibiting no leaks. Her diet was advanced from
NPO to stage 2 post gastric banding diet , which she tolerated with no
nausea/vomiting. On POD 1 the surgical site was examined and there were
no signs of hematoma. The patient remained hemodynamically stable and was
making good urine. At the time of discharge the patient's pain was well
controlled and she was tolerating a stage 2 diet and was afebrile with
all incisions were clean dry and intact. patient is being sent home on roxicet
and ranitidine elixir as wel as a course of qugmentin suspension as well
as previous home medications.
She will follow up her diabetes in DM clinic as previously arranged and
will take only her lantus in the interim.
ADDITIONAL COMMENTS: Please call your physician or go to the ER if you develop abdominal pain ,
vomiting or overt distension increased pain , increased swelling ,
bruising , fever>101.2/chills , change in wound appearance ( increased
redness or discharge ) or chest pain & shortness of breath. Please avoid
strenuous activity. You may take dressings off and shower 48 hours after
surgery. Do not go swimming , bathing or hot tubbing. Do not drive or
drink alcohol while taking prescription narcotic ( pain ) medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WIGGIN , MARJORY , M.B.B.S. ( AZ753 ) 11/7/05 @ 01:35 PM
****** END OF DISCHARGE ORDERS ******
Document id: 484
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
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- |
- |
- |
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- |
- |
- |
340291628 | PUO | 55100191 | | 110308 | 11/28/2001 12:00:00 a.m. | GANGRENOUS RIGHT FIRST TOE | Signed | DIS | Admission Date: 10/20/2001 Report Status: Signed
Discharge Date: 5/28/2001
PRINCIPAL DIAGNOSIS: STATUS POST RIGHT TIBIAL ARTERIAL BYPASS.
HISTORY OF PRESENT ILLNESS: This is a 57 year old female who is
status post a right femoral posterior
tibial artery bypass in 1997 who presented with progressive right
first toe wound for two months. She denied any fevers or chills or
any erythema around the toe site. She also denied any rest pain.
PAST MEDICAL HISTORY: Significant for peripheral vascular disease ,
non insulin dependent diabetes mellitus ,
hypertension , high cholesterol.
PAST SURGICAL HISTORY: As above. Also is status post right
carotid endarterectomy in '96 , C-section
and appendectomy and bilateral cataracts.
MEDICATIONS ON ADMISSION: Aspirin 325 mg orally every day , Pravachol 60 mg
orally every day , metoprolol 60 mg orally twice a day ,
Glyburide 10 mg orally twice a day , Glucophage 1000 mg orally twice a day ,
Vasotec 20 mg orally every day , vitamin B multivitamin one tablet orally every day ,
and Plavix 75 mg orally every day
ALLERGIES: No known drug allergies.
SURGICAL EXAMINATION ON ADMISSION: She was afebrile with stable
vital signs. She was a
pleasant , mildly obese woman in no apparent distress. She had no
carotid bruits and no jugular venous distention. NECK: Supple.
CHEST: Clear to auscultation bilaterally. HEART: Regular rate
and rhythm. ABDOMEN: Soft , obese , non-tender , nondistended.
RIGHT LOWER EXTREMITY: Had a non healing wound of the right great
toe with minimal surrounding erythema. Pulse examination was
significant for palpable femoral pulses bilaterally and Dopplerable
DP and physical therapy on the left with a faintly dopplerable posterior tibial
pulse on the right and no dopplerable dorsalis pedis.
LABORATORY EXAM: Was significant for AVI of 0.60 and 0.59 at the
physical therapy , and PTT respectively on the way with mildly
decreased PVRs. Her EKG was normal sinus rhythm. Laboratory exams
were within normal limits.
HOSPITAL COURSE: The patient was admitted to the vascular surgical
service and placed on triple antibiotics and
dressing changes. She had no resolution of her symptoms of her non
healing ulcer and as a result , she was taken to the operating room
on 11/11/2001 by Dr. Abson where she had a right femoral tibial
bypass graft and first toe amputation of the right foot.
Postoperatively , the patient was transferred to the regular
hospital floor. She initially had a PCA for pain. She began
ambulating on postoperative day two. She has converted to regular
diet and her pain was well controlled on pain medications. She was
seen in consultation by the cardiology service and made some
adjustments to her beta blockers. She was seen by physical therapy
and her functional status has improved to the point where the day
before discharge , she was able to ambulate three flights of stairs
without difficulty. She had no signs of infection on her leg
wounds and she did have some mild erythema around her right great
toe which was improved after the patient was restarted on Ancef on
postoperative day three. This erythema continued to improve and
was much improved by the time of discharge.
DISPOSITION: The patient was discharged to home with services and
home physical therapy and home visiting nurses.
DISCHARGE INSTRUCTIONS: Her diet is ADA 2100; her activity is as
tolerated. She is to follow-up with Dr.
Abson on Friday , 3/15 . She should call to schedule her
medications.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Atenolol 50 mg orally every day , Atenolol 50 mg
orally baid , Vasotec 20 mg orally every day , Glyburide 10 mg orally twice a day ,
Percocet one to two tablets orally every 4 hours as needed pain , vitamin B 100
mg orally twice a day , multivitamin one tablet orally every day , Pravachol 60 mg
orally every bedtime , Glucophage 1000 mg orally three times a day and Keflex 500 mg orally
four times a day x 7 days.
Dictated By: MOSHE SHUGRUE , M.D. MT443
Attending: NATHAN J. ABSON , M.D. VY52 KP895/0342
Batch: 58520 Index No. L0CORY2Q46 D: 2/28/01
T: 2/28/01
Document id: 485
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
178751561 | PUO | 79638392 | | 037785 | 10/2/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/27/1992 Report Status: Signed
Discharge Date: 9/27/1992
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: The patient is a 41
year old female who is status post
L5-S1 fusion in 22 of August , who complains of right greater than left
bilateral leg pain with moderate LS spine spasms in the same
distribution as before the first surgery ( S1 area ). She has had
epidural steroid injections during the past year and had no relief
of these symptoms. She is presently unable to work for the past 6
weeks. She has been on bedrest for most of the day. She has
minimal relief with non steroidals. She is here for a second
diskectomy after demonstration on CT of marked recurrence on the
right to just above the mid line. She donated 1 unit of autologous
blood. PAST MEDICAL HISTORY: Noteable for the patient having had
difficulty maintaining intravenous's in the past. She also had urinary
retention after her last surgery. She is otherwise healthy. PAST
SURGICAL HISTORY: Status post L5-S1 diskectomy in 3 of June status
post tubal ligation; status post cholecystectomy; C. section x 2
and tonsillectomy and appendectomy. MEDICATIONS ON ADMISSION:
Percocet 4-8 per day. ALLERGIES: NKDA.
PHYSICAL EXAMINATION: The lungs were clear to auscultation
bilaterally. The heart exam was within
normal limits. The belly exam was benign. The orthopedic exam was
noteable for an old well healed surgical scar in the mid line of
the low back. She had a very limited range of motion of the back
secondary to pain. She was tender over L4-S1 centrally. She had
bilateral sciatic notch tenderness , right greater than left. She
had positive straight leg raising sign at 60 degrees on the right
and 80 degrees on the left. She had positive bowstring sign on the
right. She had decreased light touch sensation on the right
lateral thigh , lower leg and foot and otherwise was normal.
Reflexes demonstrated right 2+ at the knee and 2+ at the ankle
compared to 3+ at the knee on the left and 2+ of the ankle. The
toes were bilaterally downgoing. There was no clonus bilaterally.
HOSPITAL COURSE: The patient was operated on on the day of
admission undergoing a re-do of L5-S1 disk and
L5-S1 posterior lateral fusion with right iliac crest bone graft
taken through the same incision. The patient tolerated this
procedure well. Postoperatively , her hospital course went as
follows by systems: 1 ) NEUROLOGIC-The patient continued to have
some degree of pain that was noted on weight bearing of the lateral
aspect of the right thigh but not progressing much further beyond
that towards the foot as it had preoperatively. The intensity of
this pain was also somewhat less than it was preoperatively. There
were no significant symptoms on the left. She also had the expected
surgical pain. 2 ) RESPIRATORY-There were no significant issues.
The patient did have the history of mild childhood asthma and
perioperatively she did demonstrate some end expiratory wheezes
that were treated with Ventolin and Albertol inhaler treatents.
These were resolved by the time of discharge. Her O2 saturations
were well maintained throughout her hospital stay. 3 )
CARDIAC-There were no significant issues. 4 ) GI/NUTRITIONAL-The
patient had no significant problems. She had a bowel movement
prior to discharge. Her diet was advanced without difficulty.
5 ) RENAL/ELECTROLYTE-The patient was able to void when her Foley
was discontinued on postoperative day 4. Electrolytes were followed
and treated on as needed basis. 6 ) HEMOLOGIC-The patient required
transfusion of her 1 unit of autologous blood. Subsequently , with
the patient on Iron Gluconate and Colace , her hematocrit came from
25 after her unit of blood up to 29.1 on her last check prior to
discharge. She will be on iron for 1 month postoperatively. The
patient was maintained on compression boots postoperatively until
she was up and walking more independently. 7 ) INFECTIOUS
DISEASE-There were no significant itssues. 8 ) ORTHOPEDIC-Her
wound showed excellent signs of healing postoperatively. There was
no evidence of infection at any time and her flaps looked viable at
all times. Her postoperative neurologic status was as described
above. The patient was given an Orthomol brace which she is to
wear at all times whenever out of bed.
DISCHARGE DIAGNOSES: 1. RECURRENT RIGHT L5-S1 DISK.
2. HISTORY OF PHLEBITIS AND DIFFICULTY WITH
intravenous'S.
PROCEDURES: Re-do right L5-S1 diskectomy and L5-S1 posterolateral
fusion with right iliac crest bone graft on October ,
by Dr. Brooke Lemmen .
DISPOSITION: MEDICATIONS ON DISCHARGE: Percocet 1-2 orally every
4 hours as needed , Iron Gluconate 325 mg orally three times a day x 1
month , PeriColace 100 mg orally four times a day x 1 month to be held for loose
stool , Voltaren 50 mg orally three times a day as needed TREATMENTS/FREQUENCY: Brace
to be work whenever out of bed. CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home. FOLLOW UP CARE: With Dr. Lemmen .
WK373/5871
BROOKE D. LEMMEN , M.D. SG66 D: 7/18/92
Batch: 1031 Report: W4942X54 T: 9/13/92
Dictated By: DEJA KINTOPP , M.D.
Document id: 486
| Target |
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DM |
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GER |
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| output/system_textual_annotation.xml | textual |
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753578182 | PUO | 47094392 | | 891082 | 8/10/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/19/1996 Report Status: Signed
Discharge Date: 10/2/1996
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old gravida
5 , para 5 , with history of
postmenopausal bleeding and thickened endometrial stripe by
ultrasound. She had a history of breast cancer status post
lumpectomy , radiotherapy , and Tamoxifen therapy with the Tamoxifen
therapy ongoing over the past four years. She was evaluated and
Pipelle biopsy was unsuccessful and fractional dilation and
curettage revealed scant inactive endometrial tissue. This was in
January of 1994. She had a follow-up endometrial biopsy which showed
quantity not sufficient and there was no further follow-up. All of
this was done outside of our offices. She saw Dr. Fulco for
evaluation initially of an irregular cervix on her initial intake
into the Carna Home Hospital system and this history
was reviewed. She had always had normal Pap smears. Colposcopic
biopsy and endocervical curettage were all negative. She had not
at that point had postmenopausal bleeding for a couple of years.
Her uterus was felt to be overly enlarged and ultrasound showed a
1.9 cm irregular stripe. Pipelle was not possible , due perhaps to
stenosis of the internal os. Therefore she was brought for
fractional dilation and curettage and diagnostic hysteroscopy as an
inpatient because of her history of Coumadin therapy for chronic
atrial fibrillation.
PAST MEDICAL HISTORY: Remarkable for rheumatic heart disease with
mitral stenosis and mitral regurgitation , as
well as aortic insufficiency and mild tricuspid insufficiency. She
has had a history of chronic congestive heart failure. Chronic
atrial fibrillation is noted. Breast cancer is noted. There is a
question of a pulmonary edema in 1993.
MEDICATIONS: Tamoxin , Coumadin , Furosemide , Inderal , Lanoxin , Kay
Ciel.
ALLERGIES: Penicillin , erythromycin , and Isordil.
SOCIAL HISTORY: She does not smoke and does not drink.
PAST OB/GYN HISTORY: Spontaneous vaginal deliveries times five.
PAST SURGICAL HISTORY: Beyond the breast surgery , this included
appendectomy in 1994 , as well as fractional
dilation and curettage in 1994.
PHYSICAL EXAMINATION: Basically unremarkable.
HOSPITAL COURSE: The patient was preadmitted for switch-over to
heparin therapy. The heparin was then stopped
four hours prior to her surgical procedure which occurred on
4/11/96 . The findings at hysteroscopy and dilation and curettage
included normal appearing endocervical canal , 7.5 cm cavity , and an
approximately 3 x 1 cm endometrial polyp. She had lush
endometrium. The ostia were not easily visualized. The procedure
was very smooth and done under MAC anesthesia with paracervical
block and she had a minimal blood loss. Postoperatively she did
quite well without fever or other problems. She was put back on
her Coumadin such that , on the day of discharge , her INR was
approaching 2.0. She was discharged with plans for follow-up as an
outpatient regarding her Coumadin therapy.
Dictated By: ROBBYN FULCO , M.D. WE43
Attending: ROBBYN FULCO , M.D. KR08 NO064/7939
Batch: 06121 Index No. XJVSJYM2P D: 6/11/96
T: 7/3/96
Document id: 487
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
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Y |
U |
U |
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Y |
Y |
U |
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Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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Y |
Y |
Y |
N |
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N |
955173142 | PUO | 22999191 | | 7792674 | 5/26/2005 12:00:00 a.m. | Obesity related hypoxia , OSA | | DIS | Admission Date: 10/22/2005 Report Status:
Discharge Date: 9/27/2005
****** DISCHARGE ORDERS ******
HELDE , EMILIO 966-05-69-9
Longarl H Mo
Service: MED
DISCHARGE PATIENT ON: 11/16/05 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETAZOLAMIDE 125 MG orally twice a day
Alert overridden: Override added on 10/20/05 by
RUNNING , HYON , M.D.
on order for ACETAZOLAMIDE orally ( ref # 26337865 )
patient has a POSSIBLE allergy to Sulfa; reaction is headache.
Reason for override: patient has already had
ACETYLSALICYLIC ACID 325 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HEPARIN 5 , 000 UNITS subcutaneously three times a day
NOVOLIN INNOLET N ( INSULIN NPH HUMAN ) 62 UNITS subcutaneously every day before noon
NOVOLIN INNOLET N ( INSULIN NPH HUMAN ) 52 UNITS subcutaneously every afternoon
REG INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
Starting Today April
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 2 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LISINOPRIL 5 MG orally every day Starting IN a.m. June
Alert overridden: Override added on 5/10/05 by
SCOLNIK , WILBUR J. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally every day as needed Constipation
VERAPAMIL SUSTAINED RELEAS 180 MG orally every day HOLD IF: SBP<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 5/10/05 by
SCOLNIK , WILBUR J. , M.D. , PH.D.
on order for TOPROL XL orally ( ref # 81725624 )
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override:
aware Previous override information:
Override added on 10/20/05 by SCOLNIK , WILBUR J. , M.D. , PH.D.
on order for LOPRESSOR orally ( ref # 93080728 )
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override:
aware
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
Starting IN a.m. May HOLD IF: SBP <100 , HR <60
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 5/10/05 by
SCOLNIK , WILBUR J. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override:
aware Number of Doses Required ( approximate ): 1
NASACORT ( TRIAMCINOLONE ACETONIDE NASAL ) 2 PUFF nasal every day
Number of Doses Required ( approximate ): 3
ATORVASTATIN 80 MG orally every day
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
LEXAPRO 10 MG orally every day
DIET: House / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Centli Community Hospital Of 11/16/05 ,
ALLERGY: Sulfa
ADMIT DIAGNOSIS:
hypoxia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Obesity related hypoxia , OSA
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
R CVA ( cerebrovascular accident ) NIDDM ( diabetes mellitus ) Carpal
tunnel syndrome , history of surgical repair ( carpal tunnel repair ) HTN
( hypertension ) high cholesterol ( elevated cholesterol ) Reflex
sympathetic Dystrophy ( reflex sympathetic dystrophy ) CHF ( congestive
heart failure ) a-flutter ( atrial flutter ) UTI ( urinary tract infection )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
59 year-old F with DM , HTN , OSA , history of CVA admitted for
hypoxia to 70s. She experienced similar SOB on prior
episodes. She has had no CP. Her SOB is primarily related to her body
habitus.
IN PUO ED , hypoxic to 80s on RA , up to 90s on 3L NC. Had clear CXR ,
Patient's prior PE protocol was negitive though she did have a positive
D-Dimer. In ED EKG was with inf lat ST segment depressoions that were
unchanged from prior. She also has LA enlargement. While in ED patient's
troponin returned 1.64 ( prior less than assay a couple of days PTA ).
PE: 98.4 80 163/81 98% on 3L L homonomous hemianopsia , Chest clear.
JVP 12-15. 3/6 SM at LUSB. 2+ non-pitting LLE edema , 1+ RLE
edema CK130 MB9.0 Tn1.64
************************************************
Impression: 59 year-old F with DM , OSA , HTN , history of CVA with hypoxia likely
2/2 OSA here with likely demand related ischemia 2/2 hypoxia.* Pulm HTN
is also a possibility as a cause for her desaturation and SOB , but past
echo was unable to get PA pressure due to body habitus. Mainstay of
treatment now seems to be good respiratory rehab , use of CPAP in PM and
ultimately weight reduction.
CV: I- ruled out ACS with serial enzymes. Gave ASA , Lipitor 80 , heparin ,
ACE-I , low dose beta-blocker ( low dose as has COPD/reactive airway ).
PULM: Hypoxia at baseline. Recent PE-CT neg. Last admission her D-Dimer
was elevated but it was also elevated 5 years ago. Overall PE was not
leading diagnosis. On albuterol and nasacort. ABG with acidosis and
co2 retention in addition to sig Aa gradient , bipap and O2. No
facial BIPAP in house.
ENDO: DM. On NPH and humolog. Covering with RISS. TSH nml
PSYCH: On lexapro
PPX: Heparin
FULL CODE
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-pulm rehab at Teran Skinver Careteher Hospital , weight reduction
No dictated summary
ENTERED BY: MOOSE , BUCK , M.D. ( EL71 ) 11/16/05 @ 05:24 PM
****** END OF DISCHARGE ORDERS ******
Document id: 488
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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Y |
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U |
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| output/system_intuitive_annotation.xml | intuitive |
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024218770 | PUO | 34968939 | | 8798682 | 3/10/2006 12:00:00 a.m. | Atypical chest pain | | DIS | Admission Date: 9/22/2006 Report Status:
Discharge Date: 7/21/2006
****** FINAL DISCHARGE ORDERS ******
DAUTRICH , RON P 525-06-48-7
Scondla
Service: CAR
DISCHARGE PATIENT ON: 1/4/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain
ECASA 81 MG orally DAILY Starting Today April
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
AVAPRO ( IRBESARTAN ) 150 MG orally DAILY
Number of Doses Required ( approximate ): 1234
LABETALOL HCL 100 MG orally twice a day HOLD IF: HR<55 , SBP<100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOLOFT ( SERTRALINE ) 100 MG orally DAILY
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Verbridge ( Primary Care Physician ) 1 week ,
ALLERGY: TRIMETHOPRIM/SULFAMETHOXAZOLE , Sulfa
ADMIT DIAGNOSIS:
Rule out MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
proteinuria dx'd in '81 HTN
rectal condylomata history of ( + ) PPD mild R hydroureter on CT
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT 3/1/6 - negative for ischaemia
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
HPI:48F no prior cardiac hx however + hx/o HTN , DM , Hyperchol , +Fhx ,
+35 pk yr tobacco who p/with worsening DOE over the past several months
which has acutely worsened in the past 2 wks while
climbing stairs. Has a long hx/o chest pressure however appears to
be worsening , +Nausea , no vomiting or diaphoresis , relieved by
5-10min rest. CP is reproducible on palpation under breast and is
very localized to a 2cm area under L-breast. Pain has been worsening
in frequency and duration. Was evaluated at MMC urgent care and sent
to PUO ED. Vitals in the ED revealed HTN to 180s SBP on admit ,
otherwise normal. Had some 0.5-1mm ST elevations in inf leads which
are old from prior ECGs. CXR was negative and her first set of
cardiac enzymes was neg. ASA , O2 , BB , 1 inch of nitropaste for elev
BPOf note , patient c/o pain on the R mid-lower back which has been present
x 1 wk , reproducible on light palpation. Reports that it is hard to
dress because of this pain. Had a bone scan on 12/10/06
which was neg for fx and/or costochondritis. ROS: Neg cough , fever.
***********
Cardiac data: ETT-MIBI 6/29 6min on bruce stopped for fatigue ,
MPHR 65% , PRP 21280 , No EKG change , LVEF 61% , Imaging was completely
normal ECHO 2003: LVEF 55% , no RWMAs , mild TR , PASP 21 , pk
vel 2.3m/s ETT 2000: 8min on bruce stopped for fatigue , MPHR
83% , PRP 21608 , No EKG change PMH/PSH: Hyperlipid , HTN , Radiculopathy ,
Colon polyp , Cocaine use x 13 yrs relapse 1 yr ago now
clean , Proteinuria , DMII MEDICATIONS:Avapro 300 every day , Labetolol 100mg
twice a day , Prilosec 20 every day , Zoloft 100 every day , Lipitor 20 every day ,
ASA ALLERGIES:Sulfa - hives , ACEi -
cough
**********
ADMIT PHYSICAL EXAM: 96.4 190/100 L 150/90 R 62 18 O2sat 100%
RAGen: mod distressHEENT: No LAN , no thyromegNeck: JVP flat , no
carotid bruitsCV: RRR , nl S1 S2 , no m/r/gPulm: CTAbAbd: S/ NT/ND +
BS , no guard/reboundExt: No edemaBack: Pain on light palp
over R lumbar spine + CVA tenderness , no rashNeuro: A&0x3
*********
ADMIT LABS: Cr 1.1 , WBC 10.7 EKG: NSR , 1mm ST elev in II , III , avF
stable from prior
ECGs. CXR: Clear , no incr heart size or pleural
abnls
*********
HOSPITAL COURSE: 1. CV: I - no evidence for ischemia as yet , trend
enzymes and maintain ASA , BB , Statin. If rules out , will obtain
stress test in a.m. to risk stratify. P - BP very high on admit , now
more reasonably controlled c nitropaste , restart home meds Avapro
and Labetolol and add additional lopressor as needed for elev BP. R -
NSR , no issues 2. PULM: O2 sat stable , no
issues. 3. RENAL/ID: Cr stable at 1.1 , will check U/A for ?
pyeloneph given CVA tenderness. Cx pending U/A result.
4. GI/FEN: orally diet. 5. HEME: HCT
stable. 6. NEURO: Tylenol for pain , has hx/o drug
abuse PPx: Lovenox subcutaneously ,
nexium CODE: FULL
HOSPITAL COURSE & OUTCOME :
The patient ruled out for MI by biomarkers and ECG. She underwent an
exercise stress test on 3/1/06 - 7 mets achieved with no chest pain or
ECG changes. It was felt that her atypical chest , back , and arm pain
could be neuropathic in nature and she was commenced on low dose
neurontin at 100mg three times a day She will followup with her primary care physician Dr. Verbridge in 1
week.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MAGBITANG , BENITA , M.D. ( LV88 ) 1/4/06 @ 11:49 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 489
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DM |
Gs |
GER |
Gou |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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778338859 | PUO | 64821804 | | 880870 | 9/1/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/9/1991 Report Status: Signed
Discharge Date: 2/24/1991
DISCHARGE DIAGNOSIS: CHOLECYSTITIS.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old female
who presented with the sudden onset of
right upper quadrant and epigastric abdominal pain. The pain had
awoken her from sleep and radiated to her right back. She had an
ultrasound two years prior to admission which showed sludge in her
gallbladder with no other abnormalities noted. She had one
episode of bilious vomiting with nausea prior to presentation.
Patient had been given some Demerol with some relief but she had
persistent pain. The last bowel movement was the day prior to
admission and she had an ultrasound on the night of admission which
showed multiple small stones and a gallbladder with sludge and
thickening of the gallbladder wall. HIDA scan showed no filling of
the gallbladder consistent with cholecystitis. PAST MEDICAL
HISTORY: Significant for hypertension and morbid obesity. CURRENT
MEDICATIONS: Vistaril , Premarin , and Clinoril.
PHYSICAL EXAMINATION: On admission , the patient was an
uncomfortable obese white female in moderate
distress. Vital signs were stable and her temperature was 98.6.
SKIN: Normal. HEENT: Normocephalic and atraumatic. CHEST:
Clear bilaterally. CARDIAC: Regular rate and rhythm with normal
Sl and S2 with a grade II/VI systolic ejection murmur. ABDOMEN:
Soft , non-tender , and non-distended except for in the right upper
quadrant where she had right upper quadrant pain and a positive
Murphy's but no peritoneal signs.
LABORATORY EXAMINATION: Significant for a white count of 7.2 ,
hematocrit of 40.5 , and a normal set of
liver function tests with an amylase of 63.
HOSPITAL COURSE: The patient was admitted to the Arvai Sonprince Hospital , given triple intravenous antibiotics ,
kept NPO , and placed on intravenous hydration. On 17 of January , she
was taken to the Operating Room where she underwent an
esophagogastroduodenoscopy , a cholecystectomy with an
intraoperative cholangiogram , and common bile duct exploration with
T-Tube placement by Dr. Bralley , Dr. Mory , and Dr. Skaff .
Intraoperatively , she was found to have a large inflamed
gallbladder with multiple small cholesterol stones in her
gallbladder and two stones in her common duct. Intraoperatively ,
she was noted to have a short run of an abnormal rhythm with a rate
in the seventies which quickly resolved. Post-operatively , she
continued to remain stable and was transferred to the Recovery Room
and eventually back to the floor. She was ruled out for myocardial
infarction. On 10/5/9l , she was doing well , had been started on
sips of clear fluids , and was up out of bed voiding on her own. By
10/23/9l , she was tolerating a regular diet. Her wound showed some
erythema but continued to heal well. On 1/30/9l , she had a normal
T-Tube cholangiogram and was clamped.
DISPOSITION: She remained afebrile with no abdominal tenderness
and is discharged to home on 10/27/9l to be followed
up by Dr. Bralley in Clinic.
FL182/9814
KAREY A. BRALLEY , M.D. JE3 D: 9/19/91
Batch: 1275 Report: K8405B95 T: 1/3/91
Dictated By: LAUREL I. HORNBEAK , M.D. QZ77
Document id: 490
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
803287069 | PUO | 64744160 | | 4078647 | 2/9/2002 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 2/9/2002 Report Status:
Discharge Date: 10/28/2002
****** DISCHARGE ORDERS ******
KREITZER , CHELSEA 450-94-58-6
Xand Charl
Service: MED
DISCHARGE PATIENT ON: 7/29/02 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
HOLD IF: sbp<100 , call MD
LISINOPRIL 40 MG orally every day HOLD IF: sbp<100
Override Notice: Override added on 10/11/02 by ROMACK , ANGELIQUE B LAURENA , M.D.
on order for KCL intravenous 10 MEQ OTHER ( ref # 07029807 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 10/11/02 by ROMACK , ANGELIQUE BONG , M.D.
on order for KCL SLOW RELEASE orally ( ref # 90067022 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 10/11/02 by ROMACK , ANGELIQUE BONG , M.D.
on order for KCL intravenous ( ref # 27614981 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 10/11/02 by ROMACK , ANGELIQUE BONG , M.D.
on order for KCL SLOW RELEASE orally ( ref # 22362320 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 10/11/02 by FARELLA , ELIDA MABEL , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 13378683 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
MAALOX PLUS EXTRA STRENGTH 15 milliliters orally every 6 hours
as needed Indigestion
VERAPAMIL SUSTAINED RELEAS 240 MG orally twice a day
Starting Today June HOLD IF: sbp<100
Instructions: this it patient's usual dose
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/11/02 by
COWART , MARIA A. , M.D.
on order for LOPRESSOR orally ( ref # 75906021 )
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override:
noted
PREVACID ( LANSOPRAZOLE ) 30 MG orally every day
KCL SLOW RELEASE 20 MEQ X 1 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 7/29/02 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: have been following in house
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lalata , PMD 1-2 weeks ,
ALLERGY: Penicillins , Compazine ( phenothiazines )
ADMIT DIAGNOSIS:
r/o mi
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
menorrhagia htn
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Dobutamine-MIBI
BRIEF RESUME OF HOSPITAL COURSE:
48 year-old F with PMHx HTN who presents with a one day hx
of chest pain. patient describes onset of CP at 11am on day of admission
while walking up 3 flights of stairs. She became SOB , severe headache
and developed tightness in her chest up her neck
and down L arm , also burning under L breast rad
to back. She rested at the top of the stairs and
pain resided but did not go away. Pain returned
3x during day sometimes at rest , also +
nausea not always asso with pain and vomitting x 1.
Cold sweat early in day , not associated with CP. On
arriv al to ED patient described pain 10/10 , nitro x 3
1/10 , given MSO4 , went away sometime after that. patient
also reports resent change in her medications. She
was on max dose Verapamil , Lisinopril , Atenolol
added on
1/9/02 . VS P 54 r18 BP 140s/80s O2sat
99% PE: patient in NAD , skin warm and dry , no JVD , CV
rrr no m/r/g , lungs cta bilat , no
edema.
Hospital course by problem:
1 ) CP: patient with story unlikely to be cardiac origin but has RF for
ischemia in HTN. No sig fhx. Rule out by enzymes. CT chest in ED neg
for PE or dissection. Was kept on BBlock after admission , bu
t c/o feeling heavy and noted significant Bradycardia overnight to
48-52. BBlock was then DC'd and BP was controlled with hctz. On HD#2
patient with episode CP and weakness. No EKG changes on R or L EKG. Pain did
not resolve after 3 nitro. patient received MSO4 1mg and Maalox with
complete resolution of pain and weakness; no further sx for the rest
of the day. Given likely poor exercise tolerance ETT was changed to
Dobutamine-MIBI 10/20 . MIBI was read as negative. DC'd to home with
ECASa , lisinopril , verapamil , hctz.
2 ) HTN: patient on Verapimil and Lisinopril at home. Had tried Maxzide in
past but did not tolerate. Given "weakness" sx , B blocker dc'd.
Started HCTZ for long term management of HTN. Verapamil 480 mg also
split into twice a day dosing. KDur rx'd for hypokalemia.
DC'd to home with f/u by PMD in 1-2 weeks , blood pressure check and k check.
ADDITIONAL COMMENTS: Your dobutamine stress test was negative for coronary disease. Take
your blood pressure medications as prescribed. Please take the
verapamil 240 mg twice a day. Continue to take the hctz in the
morning. HCT will lower potassium low , so we have started a low dose of
potassium in pill form every day. Please make an appointment to see
Dr. Lalata within 1-2 weeks for a check of your blood pressure and your
potassium. You may try maalox for your chest pain , but if it worsens or
you have significant shortness of breath , come to hospital or call MD
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) BP follow-up
2 ) Check potassium , on hctz
No dictated summary
ENTERED BY: RUBIANO , ELIZ , M.D. ( GI61 ) 7/29/02 @ 03:13 PM
****** END OF DISCHARGE ORDERS ******
Document id: 491
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
838440387 | PUO | 59556390 | | 0442280 | 10/24/2007 12:00:00 a.m. | history of pacemaker placement | | DIS | Admission Date: 9/25/2007 Report Status:
Discharge Date: 5/2/2007
****** FINAL DISCHARGE ORDERS ******
ROTHMAN , BAILEY 329-84-06-2
Illinois
Service: MED
DISCHARGE PATIENT ON: 3/28/07 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
CLINDAMYCIN HCL 300 MG orally four times a day X 12 doses
Starting after intravenous ANTIBIOTICS END
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
GLIPIZIDE 2.5 MG orally DAILY
LISINOPRIL 5 MG orally twice a day HOLD IF: SBP < 120
Alert overridden: Override added on 8/3/07 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
Previous Override Notice
Override added on 8/3/07 by MARTER , BRYON M. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 787848224 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally three times a day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Reedy ( cardiac cath ) 231.742-8873 11/14/07 @ 11:20am ,
Dr. Lavera Scheffer ( pcp ) 9/17/07 @ 11:45am ,
Dr. Buck Moose ( cardiology ) 4/14/07 @ 4:30pm ,
Dr. Schoeppner ( EP-pacemaker ) 231.742-8873 11/10/07 @ 8:30am ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
lightheadedness , hypertension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of pacemaker placement
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of CABG x 2 ( coronary artery disease ) , RAS c L renal stent ,
bilateral common iliac artery stents , PAF ( paroxysmal atrial
fibrillation ) , DM ( diabetes mellitus )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
pacemaker placement
BRIEF RESUME OF HOSPITAL COURSE:
CC: lightheadedness , hypertension
HPI: 83yo W c 4 recent admits for LH and elevated BP , with history of paroxysmal
rapid afib and tachy-brady syndrome , admitted for LH , SBP in 190s. No CP ,
no palps , no n/v. In ED SBP to 170s to 130s without intervention. On
prior admits has had intermittent HTN , a fib c RVR c bradycardia/pauses c
lopressor. On last admit , patient was seen by EP and BB and amiodarone
were stopped 2/2 bradycardia/pauses with plan for f/u with outpatient
cardiology. patient represents with similar sxs ( has not seen cardiologist
yet ).
PMH: CAD history of CABG , RAS history of stenting x2 , atherosclerosis of abd aorta and
celiac artery , b/l common iliac stents , afib , DM
Home Meds: ASA 325qd , Lipitor 80qd , plavix 75qd , colace 100bid , nexium
40qd , glipizide 2.5qd , lisinopril 5 twice a day , reglan 10tid , mom every bedtime
All: PCN-->hives
SocHx: retired; lives with son; no etoh/tob/illicits
STATUS: afebrile , HR NSR 70s , 130s/70s
PROC/STUDIES:
6/10 EKG: NSR , lat TW flattening unchanged
6/10 CXR: no acute process
6/10 KUB: nonspecific gas pattern
5/22 pacemaker placement
CONSULTS: EP
Hospital course:
1 ) CV: HTN: Unclear precipitant for intermittent HTN - ?2/2 renal
known renal artery stenosis , HR lability , autonomic syndrome.
Given history of tachy-brady and difficult to control afib with bradycardia and
documented pauses , EP was consulted and a dual chamber GUIDANT pacemaker
inserted without difficulty on 2/22 - programmed to DDI 60 mode. BB was
initiated and plan to continue Toprol XL upon discharge. Plan to continue
clindamycin four times a day to complete 3 day course and to f/u with EP in 2wks. Upon
discharge , patient's heart rate 60 , blood pressure 130s/70s.
Anticoagulation-discussion on previous admit initiated with cardiology
who recommended dc'ing Aspirin and adding Coumadin with Plavix for
anticoagulation , but deferred decision to patient's outpatient cardiologist
Dr. Krinsky . Plan for this admission is the same- continue patient's home ASA and
Plavix now , with plan to f/u with Dr. Krinsky for discussion of risks/benefits
of initiating coumadin.
2 ) Heme+ stool: Trace in ED , HCT stable. Got intravenous nexium , IVF , large bore
IVs initially but no melena. Hct remained stable throughout hospital
course. Would recommend outpatient colonoscopy for further evaluation.
3 ) DM: while in-house , patient was started on NPH and RISS; plan to resume
home meds upon discharge.
4 ) Renal artery stenosis - history of stenting x 2. Cr at baseline.
5 ) Constipation: patient came in with constipation with no bm x1wk pta.
Dulcolax and stool softeners given with good response. Plan to cont stool
softeners upon discharge.
6 ) Code: DNI , not DNR
ADDITIONAL COMMENTS: For VNA: pls check patient's vital signs , cardiopulmonary assessment , assist
with medications
For patient:
1. Please continue to take the antibiotic Clindamycin until you run out
of pills.
2. Please call your doctor or go to the nearest ER if you have
fever>100.4 , chills , nausea , vomiting , chest pain , shortness of breath or
anything else concerning to you.
3. Continue stool softeners for constipation. Resume all home meds.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: EARLES , SHONNA A , MD ( JG84 ) 3/28/07 @ 03:16 PM
****** END OF DISCHARGE ORDERS ******
Document id: 492
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
Y |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
Y |
Y |
Y |
N |
N |
Y |
N |
N |
N |
N |
Y |
Y |
382063361 | PUO | 51031594 | | 4596906 | 11/16/2006 12:00:00 a.m. | UROSEPSIS , ATRIAL FIBRILLATION | Unsigned | DIS | Admission Date: 3/15/2006 Report Status: Unsigned
Discharge Date: 7/27/2006
ATTENDING: HOLLON , MARLEEN ALBINA M.D.
SERVICE: GMS Lumli Wayne A intern.
CHIEF COMPLAINT: Seizure and urosepsis.
HISTORY OF PRESENT ILLNESS: This 75-year-old female with history
of left MCA stroke with residual right-sided weakness , vascular
dementia , insulin-dependent diabetes , CAD with recent admission
for proteus UTI , admitted with mental status changes , possible
tonic-clonic seizure , new atrial fibrillation with RVR , and
hypotension in setting of presumed urosepsis. The patient
presented from her nursing home on responses status post witness
seizure activity and new onset atrial fibrillation with RVR. The
patient recently admitted on 10/22 with proteus UTI requiring
intubation , discharged to rehabilitation and extensive courses of
cefpodoxime. As per the EMS , the patient had tonic-clonic
seizure activity with tachycardiac to 180s and desaturated to
70%. Notable studies at that time , chest x-ray without obvious
infiltrate , head CT without acute changes or left MCA territory
infarct was noted. Urinalysis is notable for grossly infected
urine. The patient was admitted to the MICU where the patient
was aggressively resuscitated with normalization of blood
pressure. The patient's urine culture grew enterococcus and she
was treated with ceftazidime and vancomycin given her history of
MRSA and proteus UTI. The patient was weight controlled with intravenous
Lopressor and transferred to GMS service.
PAST MEDICAL HISTORY: As follows , left MCA stroke , which
resulted in visible right-sided weakness and dysarthria ,
insulin-dependent diabetes , neuropathy , nephropathy , CAD. The
MIBI was on done in 3/3 , which showed a reversible anteroapical
defect , hypertension , peripheral vascular disease , status post
right fifth toe amputation , status post left fem bypass , also
vascular dementia , chronic kidney disease with creatinines of
1.8-2 , GERD , cataracts , depression , venous insufficiency with
right heel ulcer , left heel ulcer with underlying osteomyelitis ,
angina , status post right mastectomy for distant breast cancer ,
status post cholecystectomy , TAH , open distal right tibial
fracture in 11/24 .
PHYSICAL EXAMINATION: Afebrile , pulse 83 , blood pressure is
ranging from 110-150/70-80 , O2 sat 100% on room air. She has
regular rate and rhythm in sinus. Extremity exam is notable for
2+ edema bilaterally right greater than left , upper arm erythema
near her PICC site , which is not new. Heel dressings clean , dry ,
and intact. Neuro exam was notable for baseline right
hemiparesis and aphasia. Pupils of left are greater than right.
Left is surgical pupils and both reactive. At baseline , she has
repetitive speech and also had a history of screaming when wake
at night that can be sued by direction with people.
HOSPITAL COURSE BY PROBLEMS:
1. ID: Admitted with urosepsis , afebrile , leukocytosis
resolving , and urine culture from admit not growing
enterococcus-VRE on intravenous Linezolid for better absorption.
Instruction: Finished 14-day course of Linezolid today day six.
Renal ultrasound was negative for hydro , patient incontinent ,
passing urine , has been afebrile with normal white blood cell
count and blood pressure.
2. CV: Ischemia: History of CAD , enzymes negative x3 here.
Had ST depressions on EKG initially. EKG is normal since
continue aspirin , statin beta-blocker , pump. No known history of
CHF , EF 55% , total body fluid overloaded. We have restarted
Lasix 20 daily , blood pressures had been elevated. The patient
is treated right now with Lopressor , Catapres patch versus
currently 12.5 mg three times a day Instruction: Please titrate as
necessary to home dose of Toprol XL 50 daily. Instruction:
Continue clonidine patch , add Imdur as necessary. Rate: Atrial
fibrillation with RVR visit admit likely secondary to sepsis has
been in normal sinus. No Coumadin now. Rate controlled with intravenous
Lopressor and on aspirin 81. If the patient is in paroxysmal
atrial fibrillation can consider increasing to aspirin 325 mg
later in a week.
3. Neuro: Possible seizures secondary to urosepsis. EEG
negative for epileptic form activity , but the patient is
currently on Dilantin for goal equal to 10 , last level was 8.7
corrected for albumin is 13.5 , currently on Dilantin 100 mg
three times a day Instructions: We checked Dilantin level in one week -
history of CVA , left MCA stroke , has right-sided weakness not
new. Question of new stroke clinically on 11/24 was seen by
Neurology , but they think most likely just Haldol effect and type
of old left MCA stroke. The patient with improved exam in 7/28 ,
so no MRI indicated in the future. The patient does require MRI ,
must get consent from family , discussed with her orthopedist and
radiology. The pain is in her right foot and contact Dr. Hermina T Tuomala from ortho at Pande Memorial Hospital , 164-684-3971.
Mental status remains poor and per the patient's husband the
patient is intermittently conversant at home and occasionally
screams at rehab. Give Haldol if the patient inconsolable. Home
regimen was Remeron , Prozac , and Seroquel. We have held the
Remeron to do its interaction with clonidine and it is decreased
after she had the clonidine for hypertension and also had held
Prozac which has caused serotonin syndrome with the Linezolid on
board. Instructions: Consider restarting these antidepressants
once off Linezolid. Instructions: The patient takes meds. If
husband around so may want at time orally meds around this.
4. Heme: The patient has been PF4 positive , but platelets are
normal.
5. Pulm: Sating well on room air. Normal chest x-ray.
6. Endo: History of insulin-dependent diabetes , on insulin and
glipizide on rehab and now on insulin sliding scale. Has
recently started orally feeding. Currently on insulin sliding
scales for transfer. Instructions: Conversion to glipizide 40
nightly as at home with increasing orally intake.
7. FEN: The patient passed speech and swallow. Currently on
prune , honey , and liquids therefore now.
8. Prophylaxis: On Nexium , off Lovenox for transfer. The
patient is full code.
HOME MEDICATIONS: Aspirin 81 mg daily , Toprol XL 50 mg daily ,
multivitamins , Artificial Tears , mirtazapine 10 mg nightly ,
glipizide 40 mg nightly , Xalatan one drop in each eye nightly ,
Seroquel 50 mg every afternoon , 20 mg every day before noon , Prilosec 20 ,
hydrochlorothiazide 25 mg , Lasix 20 , Catapres patch every
Thursday , Combivent three times a day , Imdur 90 daily , Lipitor 40 mg
nightly , Prozac 20 mg nightly , Dulcolax nightly , Tylenol twice a day ,
Colace 100 mg twice a day , Sena , Mycolog cream to groin twice a day as needed ,
Mylanta one to two nightly as needed , lorazepam 0.5 every 4 hours as needed
ALLERGIES: Ace inhibitors , she gets hyperkalemia.
DISCHARGE MEDICATIONS: As follows , Tylenol 650 mg orally every 6 hours
as needed for pain , aspirin 81 mg orally daily , Dilantin 15 mL orally
every 4 hours upset stomach , Artificial Tears one drop in each eye at
night , aspart sliding scale subcutaneous before and after meals ,
Lipitor 40 mg orally daily , Dulcolax 5 mg orally bedtime as needed
constipation , Catapres patch 0.1 mg per day topically changed
every week , Colace 100 mg orally twice a day , Nexium 20 mg twice a day , Lasix
20 mg daily , Combivent two puffs inhaled four times a day , lactulose 30 mL
orally four times a day as needed constipation , Xalatan one drop in each eye
bedtime , Nasalide 600 mg intravenous every 12 hours , Ativan 0.5 mg orally four times a day
as needed anxiety , Maalox one to two tablets orally every 6 hours as needed
upset stomach , milk of magnesia 30 mL orally daily as needed
constipation , Lopressor 12.5 mg orally three times a day hold if heart rate
less than 60 , blood pressure less than 100 , Mycolog topical
applied to groin twice a day , Dilantin 300 mg orally daily , Seroquel 50
mg orally every afternoon , Sena liquid one teaspoon orally bedtime ,
multivitamin 5 mL orally daily.
Holding the following medications from home are Imdur , Remeron ,
and Prozac.
In addition , the following medications should be titrated
following transfer as the patient tolerates. Titrate from
Lopressor 12.5 mg three times a day to Toprol XL 50 mg daily as the patient
tolerates. Change over the patient from insulin sliding scale to
glipizide 40 mg nightly. Restart hydrochlorothiazide 25 mg daily
and if needed we start Imdur. The patient has been held on the
Prozac again for possible serotonin syndrome and interaction
since the patient is on Linezolid 600 mg intravenous every 12 hours Also add
mirtazapine as necessary , but beware of interaction with
clonidine.
The patient is full code.
eScription document: 5-7462854 CSSten Tel
Dictated By: HOLLWAY , TABATHA
Attending: HOLLON , MARLEEN ALBINA
Dictation ID 6915987
D: 3/8/06
T: 8/27/06
Document id: 493
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
122599067 | PUO | 24742319 | | 9137906 | 6/7/2005 12:00:00 a.m. | OSTEOARTHRITIS RT. KNEE | Signed | DIS | Admission Date: 11/19/2005 Report Status: Signed
Discharge Date: 7/7/2005
ATTENDING: LEMMEN , BROOKE M.D.
PRINCIPAL DIAGNOSIS: Osteoarthritis of the right knee.
PRINCIPAL PROCEDURE: Right total knee replacement and left knee
manipulation.
HISTORY OF PRESENT ILLNESS: This is a 49-year-old man with a
history of right knee pain status post multiple knee surgeries
including left total knee replacement in April 2005 secondary to
osteoarthritis. He now presents with both stiffness of his knee
and also pain and osteoarthritis of the right knee.
PAST MEDICAL HISTORY: Pressure ulcer on the left buttock after
left total knee replacement on 8/21 and obesity.
PAST SURGICAL HISTORY: Left total knee replacement on 9/29/05 ,
multiple bilateral knee arthroscopies.
MEDICATIONS: Oxycodone as needed
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient underwent a right total knee
replacement and the left knee manipulation on 10/17/05 , and
tolerated the procedure well. The patient's pain was well
controlled in the postoperative period with a PCA. The patient
was placed on Coumadin and began physical therapy with a CPM. The patient was
made weightbearing as tolerated bilaterally. On postoperative
day 1 , the patient's pain was well controlled and the patient had
a peripheral nerve catheter femoral site in place as well for
pain control. The patient tolerated sitting to the edge of the
bed with physical therapy. The patient was neurovascularly
intact and the dressing was clean and dry. On postoperative day
2 , the patient's wound was clean , dry , and intact. The patient
again was seen by physical therapy and the patient's femoral
nerve catheter was removed. The patient's hematocrit was stable
at 30.2 and INR was 1.2. On postoperative day 3 , the patient
remained afebrile , stable vital signs. Hemovac continued to have
an elevated output at 175/25 hours , otherwise his condition
remained unchanged. On postoperative day 4 , the patient's
hemovac was discontinued. The patient was tolerating the CPM on
the right 70 degrees and on the left 85 degrees and the patient's
wound remained clean , dry , and intact with no erythema. On
postoperative day 5 , the patient was feeling well and continued
to have slow progression with physical therapy. On postoperative
day 6 , the patient remained afebrile. Vitals were stable. The
wound was clean , dry , and intact. Hematocrit was stable at 27 ,
INR 1.4. The patient continued to progress with physical therapy
and rehab screening was initiated. On postoperative day 7 ,
2/6/05 , the patient was discharged to rehab facility.
DISCHARGE MEDICATIONS: Colace 100 mg orally twice a day , multivitamin 1
tablet orally daily , oxycodone 10 to 15 mg orally every 4 hours as needed pain ,
Metamucil one tablet orally daily as needed constipation , Coumadin 8
mg orally x 1 , and Xenaderm Topical twice a day to ulcer.
CONDITION: Stable.
DISPOSITION: Follow up with Dr. Lemmen at 9/19/05 , where x-rays
will be taken at 1:00 p.m.
DISCHARGE INSTRUCTIONS: Keep the wound clean , dry , and intact.
If he were to experience fevers , wound drainage , chest pain ,
shortness of breath , please call the emergency room. The goal
INR is 1.5-2.5 with Coumadin for 3 weeks , should notify the
anticoagulation services when the patient is discharged home.
Anticoagulation number is 132-202-5576.
CONDITION AT DISCHARGE: Stable. The wound is clean , dry , and
intact. The left knee range of motion was right 0 to 75 degrees
and left 0 to 85 degrees in CPM. Range of motion on exam , right
knee extension was short of full extension by 40 degrees , knee
flexion was 58 degrees , left knee extension was short of
extension 30 degrees , and left knee flexion was 74 degrees. It
is advised that the patient continue using the CPM for at least
an hour and a half each day on each knees.
eScription document: 7-8269375 ISSten Tel
Dictated By: MUSICH , LEOLA
Attending: LEMMEN , BROOKE
Dictation ID 4450426
D: 2/20/05
T: 2/6/05
Document id: 494
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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045840358 | PUO | 81304558 | | 9769212 | 10/20/2006 12:00:00 a.m. | fibromyalgia | | DIS | Admission Date: 10/20/2006 Report Status:
Discharge Date: 5/18/2006
****** FINAL DISCHARGE ORDERS ******
MALANEY , SHAWNA E 247-07-03-7
Befen Brookcand Hwy , Ne Ph Sa , Maine 96319
Service: MED
DISCHARGE PATIENT ON: 10/4/06 AT 02:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DEPSKY , GWYNETH ALMEDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
1 TAB orally DAILY
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 4 hours as needed Wheezing
AMITRIPTYLINE HCL 25 MG orally BEDTIME as needed Insomnia
ATENOLOL 100 MG orally DAILY HOLD IF: SBP<100 , HR<50
BUSPAR ( BUSPIRONE HCL ) 15 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ESOMEPRAZOLE 40 MG orally twice a day
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LASIX ( FUROSEMIDE ) 80 MG orally DAILY
Starting ON 8/4/06 ( 10
Instructions: if patient starts to have shortness of breath or
increased
edema can increase to goal of previous home dose of 160 every day
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
HOLD IF: oversedation
VICODIN ( HYDROCODONE 5 MG + APAP 500MG ) 1-2 TAB orally every 6 hours
as needed Pain
NOVOLOG ( INSULIN ASPART ) 10 UNITS subcutaneously before meals
Instructions: 1/2 dose if NPO
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
Please give at the same time and in addition to standing
mealtime insulin
LANTUS ( INSULIN GLARGINE ) 60 UNITS subcutaneously BEDTIME
Instructions: 1/2 dose if NPO
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
2 PUFF inhaled four times a day
LORAZEPAM 0.5 MG orally every 6 hours as needed Anxiety
PREDNISONE 10 MG orally every day before noon
SEROQUEL ( QUETIAPINE ) 100 MG orally DAILY
Starting Today September Instructions: for depression
Number of Doses Required ( approximate ): 10
ZOLOFT ( SERTRALINE ) 125 MG orally DAILY
SIMVASTATIN 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TRAZODONE 150 MG orally BEDTIME as needed Insomnia
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Keetan at KTDUOO 1/5/06 1pm scheduled ,
Dr. Kistner at MMC in Capelit Ry Rillbalt 7/11/06 at 1:50PM scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Fibromyalgia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
fibromyalgia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pneumonia arthritis DM Type II asthma obesity depression
ra ( rheumatoid arthritis ) fibromyalgia ( fibromyalgia ) pud ( peptic
ulcer disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Generalized pain
**
HPI: 64F with 20 year history of chronic pain ( RA , OA , fibromyalgia , gout )
who now p/with 11 days of greatly increased generalized pain. Unable to
get out of bed c/b urinating and stooling on bed ( not
incontinent ). Denies F/C/NS , abdominal pain , diarrhea , dysuria.
Otherwise grossly positive ROS ( NOTE: ( + ) palpable CP. SOB unchanged
from baseline. ).
---
PMHx: CAD , CHF ( diastolic ) , Cor pulmonale , DM , HTN ,
Hyperlipidemia , Obesity , H/o duodenal ulcer , Depression/Adjustment
Disorder.
--
Home Meds: Dilaudid 2mg every 4 hours , Elavil 25mg every day , Topamax
100mg twice a day , Lantus 60u every bedtime , Novolog 10u before meals + SS , Advair/Atrovent/Duoneb
, Lasix 160 every day , Lisinopril 20 every day , Atenolol 100 every day , Lipitor 10 every bedtime ,
Protonix 40 twice a day , Zoloft 125 every day , Seroquel 100 every day , Trazodone 150
every bedtime , Buspar 15 every day , Lorazepam 0.5mg every 4 hours as needed
---
VS: Afeb 74 125/52 18 98% ( RA ) Morbidly obese , A&Ox3 , NAD. JVP
difficult to assess. Mild bibasilar crackles. RRR , No murmur.
Abd benign. No edema. No skin breakdown. Neuro non-focal. Pain on
palpation diffusely.
---
CXR: No acute cardiopulmonary process
---
Hospital course:
Generalized pain: She has a history of both rheumatoid arthritis
and fibromyalgia and some symptoms that have been concerning for
Polymyalgia rheumatica. For her acute pain exacerbation , a pain consult
was obtained and recommended using vicodin rather than dilaudid and
neurontin rather that topamax. These changes were made with good effect. A
rheumatology consult was also obtained and
suggested starting prednisone 10mg every day for possible PMR with close
follow up with her rheumatologist Dr. Kistner . They also suggested starting
calcium + vitaminD. Her pain improved on the
prednisone and she was seen by physical therapy who suggested
rehab placement for deconditioning and inability to care for herself.
**Renal: During the hospitalization , she developed new acute renal
failure due to decreased orally intake of fluids and continuation of her home
dose of lasix of 160qd which she then stated she had not been taking.
This was due to a pre-renal state and resolved completely with intravenous fluids.
**Depression: She was continued on her home regimen of elavil , seroquel ,
zoloft , and buspar.
**Diabetes Mellitus: She was continued on her home insulin regimen with
excellent control.
ADDITIONAL COMMENTS: PLease return if you develop fevers , chills , worsening shortness of
breath.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with dr. Keetan in June and Dr. Kistner
No dictated summary
ENTERED BY: KYNASTON , PENNIE C. , M.D. ( VD15 ) 10/4/06 @ 12:33 PM
****** END OF DISCHARGE ORDERS ******
Document id: 495
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
- |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
384779809 | PUO | 62687667 | | 0206295 | 9/7/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: Report Status: Signed
Discharge Date: 9/22/2003
Date of Discharge: 9/22/2003
ATTENDING: ROSSIE MANKOSKI MD
SERVICE: Chief Surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old male
who presented to his primary care doctor in early September with
dysphagia and acolasia and epigastric pain. He had an upper
endoscopy which showed an ulcer in the distal esophagus and
proximal stomach. He had a repeat EGD and biopsies of the ulcer
which showed adenocarcinoma of the proximal stomach and distal
esophagus. Metastatic workup showed only thickening at the GE
junction and one enlarged lymph node in the periportal region 3.4
x 1.6 cm. The patient was referred to Dr. Bingley for resection
and was planned for an esophagectomy.
PAST MEDICAL HISTORY: Past medical history includes
hypertension , ischemic cardiomyopathy , noninsulin dependent
diabetes , kidney stones , status post laser lithotripsy , history
of hyponatremia , myocardial infarction six years ago ,
hypercholesterolemia , and an infrarenal abdominal aortic
aneurysm.
HOME MEDICATIONS: Prevacid 30 mg twice a day , Zocor 10 mg every day ,
Toprol-XL 50 mg every day , Glyburide 2.5 mg every day , Zestril 5 mg
every day , aspirin 325 mg every day and Coumadin alternating 5 and 2.5 mg
orally every day
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient came into the hospital , after
admission was taken to the operating room on 9/5/03 . In the
operating room he underwent exploratory laparotomy biopsy of a
portacaval lymph node. Uterolithotomy on the right side , liver
biopsy , cystoscopy , placement of double J ureteral stent on the
right side and open nephrolithotomy. The large right ureteral
stone was found upon exploration and urology was called for an
intraoperative consult. Please see both Dr. Bingley and Dr.
Bolvin dictated reports for more information. There was a
very high amount of blood loss approximately 17 liters
intraoperatively from venous plexus bleeding of the pelvis and
kidney and the patient was closed after stomach mobilization
without resection of his tumor and admitted to the Doser Lane , Ton surgical
intensive care unit. The patient was left intubated due to his
large fluid and blood product replacement and surrounding facial
edema. He was kept intubated , paralyzed and sedated , started on
Lopressor , put on a rule out MI protocol , kept NPO with an
NG-tube. His electrolytes , CBC and coagulation labs were
corrected. The patient had multiple abdominal drains and was
kept on triple antibiotics. Over the next several days , the
patient was kept intubated and sedated. His chest x-rays
revealed some early ARDS and he continued to need blood product
including red cell and platelet and FFP transfusions. He
underwent bronchoscopy in the intensive care unit and was slowly
weaned on his valve dilatory settings. Over postop day 4 , 5 and
6 the patient began to spike some fevers up to 102. He had been
weaned to pressure support ventilation and was beginning to auto
diurese. He then started on tube feeds of small amounts which
were increased as tolerated.
Over the next couple of days as the patient's sedation was weaned
and he woke up more , it was noticed that he had decreased
movement of his left lower extremity and upon examination and
given his recurrent fevers , there was a question of an epidural
hematoma. He was scheduled for an MRI to assess this. He was
tolerating tube feeds well and these were increased and his labs
were stabilizing. Neurosurgery was consulted and it was
ascertained that the patient did have an epidural hematoma ,
therefore his epidural was removed and this was deemed likely to
be secondary to trauma from the epidural. It was decided that
the patient would benefit from evacuation of epidural hematoma
and the patient was made NPO and taken back to the operating room
on 8/18/03 . He underwent a T5-T8 laminectomy with evacuation of
the epidural hematoma. Please see the dictated operative report
for more information , but a handful of clot was removed from the
area. The patient was transferred back to Nos Kee Sadefay , intubated and
stable having tolerated the procedure well.
Thereafter , the patient was more awake and alert and more quickly
weaned off his ventilatory support. His fingersticks were more
difficult to control and he was therefore started on the
Heartland protocol and was seen by the Diabetes Management
Service. The patient was extubated on 9/11/03 and was doing well
on a face mask on that day. His tube feeds were restarted and
speech and swallow was consulted to evaluate the patient. He
began to be seen by physical therapy for his lower extremity
weakness. The Cardiology Service was consulted on 8/18 and asked
to optimize medical management of the patient's ischemic
cardiomyopathy. They recommended discontinuing and titrating the
patient's Lopressor. He had been somewhat tachycardic previously
and this resolved shortly. Speech and swallow saw the patient
and initially cleared him for soft foods and thickened foods and
this was likely just due to endotracheal tube trauma. After
another day or two they cleared him for all regular foods
including thin liquids without any restrictions.
For the patient's epidural hematoma , he had been started on
Vancomycin and it was decided that he would get a total of a
three week course of Vancomycin. Urology continued to followed
the patient and wanted at least one Blake drain kept in place and
the Foley catheter kept in place. The patient did have a CT scan
on 10/19/03 which demonstrated no urine leak on the CT urogram.
The patient continued to be seen by physical therapy every day
and was doing very well. It was very difficulty initially to
normalize him but by the time of discharge he was up walking with
the walker with physical therapy and doing quite well.
Infectious disease was consulted to confirm the three week course
of Vancomycin was appropriate for the patient's epidural
hematoma , and they agreed and thought no other interventions or
treatment as needed at the time. The patient was transferred out
of the intensive care unit on 10/19/03 .
Neuro: At this time he was getting increasingly more oriented.
He had had some ICU psychosis and confusion and he was taking no
pain medication. He was stable from his neurosurgery procedure
and neurosurgery was following him.
Pulmonary: His lungs were clear. He was now stable on room air.
From a cardiovascular standpoint , he was stable and continued on
his low dose Lopressor.
Gastroenterology: He was tolerating a house diet , eating small
amounts.
GU: As stated , the urologist wanted to keep the Foley catheter
and keep one of the Blake drains upon discharge.
From a hematology standpoint , the patient had a stable
hematocrit. From an infectious disease standpoint , the patient
was continued on intravenous Vancomycin for three weeks. He had a PICC
line placed on 9/22/03 which was put in good position.
From an endocrine standpoint , he was placed on glyburide ,
continued to be followed by diabetes and also on a humalog scale.
From an activity standpoint , he was seen by physical therapy
every day.
Over the ensuing few days he was begun on calorie counts to see
how much of the diet he was tolerating and he continued to work
with physical therapy. His glyburide and insulin doses were
tweaked a little bit by the diabetes management service and he
was improving every day as was his mental status. He had been
discharged from the unit with a one-to-one sitter but this was
very soon thereafter stopped on 10/21/03 . He was stable medically
about 3/11 or 2/4/03 for discharge and was ______ for a
rehabilitation facility appropriately. He was accepted to a
rehab facility near his home on 5/16/03 , Daonredd Cison Community Memorial Hospital and was ready
to go.
From a neurologic standpoint , he is awake and oriented x3 most of
his time. His back limbs are stable. The staples have been
removed by neurosurgery and he will follow up with Dr. Lehnortt
from Neurosurgery in a couple of weeks. From a cardiovascular
standpoint , he has been restarted on all of his home medications
and his blood pressure and heart rate had been stable on those.
From a pulmonary standpoint , he currently has no issues and is
breathing well on room air. From a GI standpoint , he is
tolerating an ADA diet with diabetic booster , Ensure and has been
eating fairly well the last couple of days. From a GU
standpoint , he is urinating sufficiently and he will keep his
Foley catheter and Blake drain. From an endocrine standpoint , he
is on glyburide twice a day and twice a day fingersticks with
humalog sliding scale. From an infectious disease standpoint , he
has a well functioning PICC and has been fine and will begin on
Vancomycin for a total of three weeks. Today , 5/16/03 is day 8 of
21 of the Vancomycin.
PHYSICAL EXAMINATION ON DISCHARGE: On physical exam , the patient
is awake and oriented in no acute distress. His lungs are clear
to auscultation bilaterally. His heart is regular , rate and
rhythm , no murmurs , rubs or gallops. Abdomen is soft , nontender ,
nondistended with a well healing midline incision scar with some
Steri-Strips still in place. He has one Blake drain in place on
the right side which is functioning well. His extremities have
no edema and his Foley catheter is in place and working well.
OPERATIONS: Operations are as indicated above on 9/5/03 and
8/18/03 . Please see above. Complications are bleeding
intraoperatively 9/5/03 , abortion of the indicated procedure on
9/5/03 and an epidural hematoma requiring reoperation on
8/18/03 .
LABORATORIES: Laboratory results as of 7/22 Sodium 141 ,
potassium 4.2 , chloride 107 , bicarb 25 , BUN 23 , creatinine 1.0 ,
glucose 128 , calcium 8.5 , magnesium 1.8 , white blood count 11.0 ,
hematocrit 36.4 , platelets 322.
CONDITION: Stable.
DISPOSITION: To rehab.
MEDICATIONS ON DISCHARGE: Tylenol orally as needed , Benadryl orally
as needed , glyburide 5 mg orally twice a day , Heparin 5000 units sub q.
twice a day - this may be discontinued when the patient is ambulating
independently , Humalog insulin sliding scale as written in the
discharge instructions twice a day , Zestril 5 mg orally twice a day ,
multivitamin with minerals 1 tab orally twice a day , Vancomycin 1 gram
intravenous via PICC line every 12 hours for 13 more days , Zocor 20 mg orally every bedtime ,
Toprol-XL 15 mg orally every day , Prevacid 30 mg orally every day , and an
aspirin 325 mg orally every day.
TO DO: Continue Foley catheter and JP drain , work on physical
therapy and work on nutrition. Follow up is with Dr. Lehnortt in
approximately two weeks , Dr. Gailun from Urology in
approximately two weeks and Dr. Rossie Mankoski from General
Surgery in approximately two weeks.
eScription document: 8-4635678 DBSSten Tel
CC: Alexandra Popovic M.D.
Scot Ville Atl
CC: Tabatha Hollway MD
Verabamont
Dictated By: MCBURNETT , RON CARRY
Attending: MANKOSKI , ROSSIE
Dictation ID 5992885
D: 1/2/03
T: 1/2/03
Document id: 496
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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873524333 | PUO | 65864379 | | 085018 | 11/8/2001 12:00:00 a.m. | NQWMI | | DIS | Admission Date: 9/28/2001 Report Status:
Discharge Date: 5/9/2001
****** DISCHARGE ORDERS ******
REINITZ , CATHERYN 575-28-66-3
Vaglade Highway , Lare Cean Full , South Carolina 30010
Service: CAR
DISCHARGE PATIENT ON: 1/12/01 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
GLIPIZIDE 10 MG orally every day before noon
HCTZ ( HYDROCHLOROTHIAZIDE ) 50 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 20 MG orally every day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Racer 1 weeks ,
Dr. Uncapher 3 weeks ,
Dr. Abson TBA ,
No Known Allergies
ADMIT DIAGNOSIS:
MI , peripheral vascular disease , diabetes , HTN , history of CVA
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NQWMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
peripheral vascular disease ( peripheral vascular disease ) critical
aortic stenosis ( aortic stenosis ) CAD ( coronary artery disease )
chronic leg ulcers ( lower extremity ulcer ) diabetes ( diabetes mellitus )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Caridac cathetherization , ETT MIBI
BRIEF RESUME OF HOSPITAL COURSE:
63 year old male history of DM , HTN , AS ( 0.9cm2 ) MI x 2 , PVD history of B fem/pop
with bi revisions p/with 2 days of SSCP at rest. Had 2 MI's this pas
t year. First in 3/23 peri-op during a fem-pop bypass NSTEMI
medically manage. The second was in 4/17 during skin graft
surgery. This time he went to cath 70%ramus , 70% RCA lesions X 2.
all three lesions were PTCA/stented. EF at this time 30-35%. Since
his second MI has had 2-3 episodes of CP per week at rest. On
this admission his pain 5/10 lasting for 5-10 min. at a time. Had 7-10
episodes over the two days PTA. Night PTA thought episodes would
resolve. Awoke morning of admission with SSCP , dizziness , palpitaions ,
diaphoresis Sxs similar to previous MI's. Called EMS and was taken to
ED. Peak troponin 1.47. EKG- TW flattening II , II , F and I , AVL.
CV- Anticoagulated with heparin , plavix , integrillin. Echo: mild
concentric hypertrophy , EF 55% , severe aortic stenosis with valve area
of 0.9cm2 , peak and mean gradient 56/36. Adenosine MIBI positive for is
chemia. Taken to cath:LCx 50% , ramus 35% marginal 100% , RCA 50% , 30% ,
90% mid stented to 0%. Aortic gradient 24.7 , AV valve area 0.87. Did
well post cath and will be d/c'd to outpatient follow up.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Patient needs continuing visiting nuse care for cardiac monitoring ,
blood pressure , hear rate. Needs physcial therapy three times a week.
Dressing changes everyday for the first few days post discharge then
evaluate with patient's primary care takers Drs. Racer and Dr.
Abson . Dressing changes will consist of cleaning with saline ,
xerofrom over wond , wrapped in dry dressing.
No dictated summary
ENTERED BY: TEEMS , RODGER , M.D. ( UJ39 ) 1/12/01 @ 02:27 PM
****** END OF DISCHARGE ORDERS ******
Document id: 497
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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693320474 | PUO | 33360126 | | 1288314 | 10/27/2005 12:00:00 a.m. | osteomyelitis right finger , HTN , DM | | DIS | Admission Date: 10/18/2005 Report Status:
Discharge Date: 1/11/2005
****** FINAL DISCHARGE ORDERS ******
ABO , RON P 271-00-85-8
Den Na Du
Service: MED
DISCHARGE PATIENT ON: 11/7/05 AT 02:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
as needed Temperature greater than:101
CEFTRIAXONE 2 , 000 MG intravenous every day X 21 Days
Starting Today March
DIGOXIN 0.25 MG orally every other day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 20 MG orally every other day
Alert overridden: Override added on 7/13/05 by
OSMERS , TESSA M.
POTENTIALLY SERIOUS INTERACTION: GENTAMICIN SULFATE &
FUROSEMIDE Reason for override: aware
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally twice a day
HOLD IF: SBP<100
PREDNISONE 2 MG orally every day before noon
Alert overridden: Override added on 9/23/05 by
MCELRAVY , LILI , M.D.
POTENTIALLY SERIOUS INTERACTION: PRIMIDONE & PREDNISONE
Reason for override: aware
PRIMIDONE 50 MG orally twice a day
Override Notice: Override added on 9/23/05 by
MCELRAVY , LILI , M.D.
on order for PREDNISONE orally ( ref # 116814575 )
POTENTIALLY SERIOUS INTERACTION: PRIMIDONE & PREDNISONE
Reason for override: aware
VANCOMYCIN HCL 1 GM intravenous every 24 hours X 21 Days
Starting Today March
Instructions: please give as soon as patient gets to floor
NORVASC ( AMLODIPINE ) 5 MG orally every day HOLD IF: SBP<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LOVENOX ( ENOXAPARIN ) 30 MG subcutaneously every day
COREG ( CARVEDILOL ) 25 MG orally twice a day
HOLD IF: SBP <90 or HR<50 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 6
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LANTUS ( INSULIN GLARGINE ) 70 UNITS subcutaneously every bedtime
NOVOLOG ( INSULIN ASPART ) 17 UNITS subcutaneously before meals
Instructions: before every meal
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: activity as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Pereira 629-907-2791 , please call for appt. in 2 weeks ,
Dr. Hippenstiel and Farella 144-907-5858 in 1 week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
fever
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
osteomyelitis right finger , HTN , DM
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) dm ( diabetes mellitus ) afib ( atrial
fibrillation ) cad ( coronary artery disease ) bph ( benign prostatic
hypertrophy ) gerd ( gastroesophageal reflux disease ) hiatal hernia
( hiatal hernia ) djd ( degenerative joint
disease ) pmr ( polymyalgia rheumatica ) diverticulitis
( diverticulitis ) history of AAA repair 1994 ( 10 )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI right hand- negative for osteo
BRIEF RESUME OF HOSPITAL COURSE:
CC: fever , decreased orally , lethergy
HPI: 88 M , nursing home resident , with PMH of PMR on steroids , DM ,
HTN , CAD , afib ( not on coumadin 2/2 falls ) p/with T102.4 , poor orally intake
and lethargy at NH. patient was in NH for intravenous Abx ( ceftriaxone x 5 days ,
then oxacillin 4/10/5 ) through PICC for osteomyelotis of R ring
finger after debridement at RGH .
In ED VVS. patient received 1L NS , UCx , Bld Cx ( peripheral and Picc ) and
had LP. ROS otherwise neg.
*****
PE on admission: VS T98.6 HR78 BP136/86 RR20 97%RA
Gen: elderly , thin , frail , confused
HEENT: MM dry , neck supple
Chest: CTA no wheezes or rhonchi
CV: 3/6 HSM at apex , JVP flat
Abd: NABS , NT , ND
Ext: no e/c/c
*****
Data: UA: protein +1 , neg LE , neg Nit
UCx: neg
Bld Cx: neg
EKG: afib , 80 , LAD
CXR: COPD , small L pleural effusion , hilar prominence ? pul HTN
LABS- nasal 131 WBC: 10.8 ( 5.9 on 10/28 ) Bands: 15 Alb: 2.7 CSF Glucose:
80 CSF Prot: 71.7
****
Hospital course: 88 year-old M with uncontrolled DM , Hx of CHF ( EF 30% ) ,
malnutrition , hyponatremia admitted with fever and bandemia. patient
recently treated for osteomyelitis of right 4th finger. Source of
infection most likely osteo of right finger since patient did not finish 4
wks of intravenous antibx previously. Meningitis , endocarditis , UTI , and
PNA ruled out.
1. ) ID: fever , bandemia - recent Hx of osteomyelitis of R ringfinger , history of
debridement and intravenous ABx- x-ray of right finger here is neg for OM. MRI did
not show any evidence of osteomyelitis , however no other source of
infection was found. patient had PICC on admit from recent OM treatment. PICC
infection was r/o by negative PICC cultures; endocarditis r/o by ECHO.
Urine neg. CXR was clear. C-diff is negative.
patient received CTX , Gent , Vanco initially and then gent d/c'd on 11/25 .
patient to be treated with 4 week course of vanc/ceftriaxone for
osteomyelitis. PICC was placed on 10/23 .
2. ) Neuro: patient was delirious on admit. A+O at baseline.
Likely toxic metabolic. MS improved during hospital course and he is
now at baseline.
3. ) Endocrine: uncontrolled DM. On lantus and novolg SS. Lantus inc from
64 to 70. Cont novolog 17u before every meal. FS 120s-190s
4. ) Cardiovascular: EF 30% , got IVF initially , but on 1/5 new crackles
so IVF stopped. Lasix 20mg every other day started on 11/25 . Not on anticoagulation
for afib 2/2 hx of falls.
5. ) Malnutrition: patient seen by nutrition , recs: MVI , suppl. twice a day , no ADA
restriction at this time.
FULL CODE
ADDITIONAL COMMENTS: Continue intravenous ceftriaxone and vancomycin for 4 weeks total ( started on
4/1/05 ) for osteomyelitis of right 4th finger.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Continue intravenous ceftriaxone and intravenous vancomycin for 4 weeks total ( starting
from 4/1/05 ). PICC to be d/c'd once antibiotics completed.
2. Physical and occupational therapy at rehab upon discharge.
3. Come back to the emergency room if you experience fevers or any
change in mental status.
No dictated summary
ENTERED BY: NICKLIN , MOIRA ( CQ698 ) 11/7/05 @ 12:02 PM
****** END OF DISCHARGE ORDERS ******
Document id: 498
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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946845360 | PUO | 39737797 | | 630521 | 1/26/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/9/1990 Report Status: Unsigned
Discharge Date: 9/2/1990
DISCHARGE DIAGNOSIS: PERIPHERAL VASCULAR DISEASE.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old man with a
history of smoking and a history of a
left sided hemisphere stroke who was normotensive , nondiabetic and
does not have known coronary disease who underwent a right-sided
femoral to popliteal bypass graft in February of 1986 for severe
claudication. This resulted in relief. He was readmitted in October
of 1988 for increase in pain in the calves which began at
ambulation of 30 feet. Angiographic evaluation at that time showed
a thrombosed graft and he was taken to the Operating Room for a
saphenous vein in situ right femoral to right popliteal bypass
graft. This was complicated by wound cellulitis which was
medicated in the appropriate manner and he was therefore
discharged. The patient was readmitted in February of 1988 with
graft stenosis and underwent angioplasty. After this procedure , he
had palpable pulses. He was readmitted in September of 1989 for
angioplasty. He presented at this time with progressive pain and
three months of frank rest pain in the right calf and claudication
of the left calf at 400 yards. He denied dependent rubor pallor or
coldness in the foot but he does have pain paresthesias. He has a
history of chest pain and was evaluated by an exercise tolerance
test in the past and was found not to have coronary artery disease
but was felt to have esophageal dismotility which was demonstrated
on the study. PAST MEDICAL HISTORY: 1. Esophageal reflux. 2.
Left hemisphere stroke which resulted in residual right
hemiparesis. 3. Anxiety disorder. 4. Chronic low back pain. 5.
Peptic ulcer disease. 6. Herniated nucleus pulposus. PAST
SURGICAL HISTORY: 1. Femoral popliteal bypass graft in 1986. 2.
Femoral popliteal saphenous vein in situ graft in 1988. 3.
Cholecystectomy in 1986. 4. Lysis of adhesions for small bowel
obstruction in 1970 , repeated in 1970 again. 5. Resection of a
herniated nucleus pulposus in 1985. 6. Knee operation in 1974. 7.
Cystoscopy in 1986. MEDICATIONS: On admission included Pepcid ,
40 mg at bedtime; trazodone , 15 mg at bedtime; Carafate , one four times a day;
nitroglycerin as needed and Flexeril , 10 mg every eight hours as needed back
pain. ALLERGIES: QUESTION OF PENICILLIN AND QUESTION OF DYE.
HABITS: The patient has smoked one pack per day for 45 years.
Alcohol was none. REVIEW OF SYSTEMS: Noteable for five episodes
of pneumonia. Flaccid urinary bladder and chronic chest discomfort
from esophageal dismotility.
PHYSICAL EXAMINATION: On admission revealed a robust white male
in no acute distress. He had no skin
lesions. No lymphadenopathy. Head and neck exams were noteable
only for partial denture plates. The breasts had no masses or
discharge. Lungs were clear to auscultation. Heart had a regular
rate and rhythm without murmurs , rubs or gallops. The pulses were
palpable at the carotid and radials and dopplerable at the
popliteals , dorsalis pedis and posterior tibials bilaterally.
Abdomen was soft and nontender , nondistended. Bowel sounds were
present. There was no hepatosplenomegaly or masses. There was a
right paramedian scar. Genital examination revealed a normal
uncircumcised phallus with a redundant prepuce. Cord , scrotum ,
testes and external rings were unremarkable. Stool was guaiac
negative. Musculoskeletal examination was otherwise noteable for
scars in the knees and lower back. Neurological examination
revealed a numb right lower extremity with a negative pinprick
examination.
HOSPITAL COURSE: The patient was taken to the Angiography Suite
on 2/7/90 where multiple segmental narrowings of
the right graft and complete occlusion of the left distal SFA with
distal reconstitution were discovered. He was taken to the
Operating Room by Dr. Abson on 7/16/90 where a right reverse
saphenous bypass graft from the in situ vein graft to below the
knee popliteal artery was performed by Dr. Abson assisted by
Dr. Muncil and Dr. Michelet . Postoperatively , the patient had
excellent palpable pulses in the foot and he enjoyed an
unremarkable hospital course and was sent home on
INCOMPLETE DICTATION
________________________________ RC829/2702
NATHAN J. ABSON , M.D. YL03 D: 7/23/90
Batch: 2852 Report: E5463G85 T: 9/13/90
Document id: 499
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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172100234 | PUO | 34013384 | | 8921616 | 5/10/2006 12:00:00 a.m. | non-cardiac chest pain | | DIS | Admission Date: 11/3/2006 Report Status:
Discharge Date: 11/4/2006
****** FINAL DISCHARGE ORDERS ******
KAZUNAS , JULIET 292-57-27-6
Reve Nor , Colorado 65159
Service: MED
DISCHARGE PATIENT ON: 3/26/06 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOSSERT , CHAROLETTE S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today January
Alert overridden: Override added on 10/10/06 by
WERGIN , TOMAS HAILEY , M.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 187347336 )
patient has a POSSIBLE allergy to IBUPROFEN; reaction is Hives.
Reason for override: aware
NORVASC ( AMLODIPINE ) 5 MG orally twice a day Starting Today January
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Starting Today January
CANDESARTAN 32 MG orally DAILY
Override Notice: Override added on 10/10/06 by WERGIN , TOMAS H CIERRA , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
965700150 )
POTENTIALLY SERIOUS INTERACTION: CANDESARTAN CILEXETIL &
POTASSIUM CHLORIDE Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
Alert overridden: Override added on 10/10/06 by
WERGIN , TOMAS HAILEY , M.D.
on order for LASIX orally ( ref # 831520066 )
patient has a POSSIBLE allergy to SULFA ( SULFONAMIDES );
reaction is Unknown. Reason for override: aware
LABETALOL HCL 200 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 20 MG orally twice a day
Alert overridden: Override added on 3/26/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MD aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NIFEREX-150 150 MG orally twice a day
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
HOLD IF: rr<10 , overly sedated
Alert overridden: Override added on 11/16/06 by :
on order for OXYCODONE orally 5-10 MG every 4 hours ( ref # 893323722 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: patient on as outpt
Previous Alert overridden
Override added on 10/10/06 by VEAZIE , OK E. , M.D.
on order for OXYCODONE orally 5 MG every 4 hours ( ref # 128162014 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: ok
Previous override reason:
Override added on 10/10/06 by WERGIN , TOMAS HAILEY , M.D.
on order for OXYCODONE orally ( ref # 932113175 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: aware
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 50 MG orally three times a day
Starting Today January
Alert overridden: Override added on 10/10/06 by
WERGIN , TOMAS HAILEY , M.D.
on order for OXYCONTIN orally ( ref # 926796906 )
patient has a PROBABLE allergy to MORPHINE CONTROLLED RELEASE;
reaction is nausea. Reason for override: aware
DIET: Fluid restriction
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Cathie Reisman 3/1/06 2:40 pm ,
ALLERGY: Erythromycins , Penicillins , CLINDAMYCIN , IBUPROFEN ,
MORPHINE CONTROLLED RELEASE , SULFA ( SULFONAMIDES )
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , HTN , hypercholesterolemia , asthma , OSA , obesity
history of IMI Non-cardiac chest pain Lumbosacral disc
dz Chronic pain syndrome Migraines HTN Anxiety
Depression ALLERG:PCN , Erythro , Tetracy
history of PTCA 1/11 FOR OCC RCA POSITIVE ETT/MIBI 93: ANT/LAT WALL ISCHEMIA
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
********************
HPI: 59 year-old woman with CAD ( PCI 9/19 OM1 , RCA ) , obesity , OSA , asthma
p/with R sided chest pain x 3 days ( constant ) , not associated with
exertion radiating to R shoulder , not relieved with
nitroglycerin. Also has had increasing SOB/nausea/vomiting as well
over this period. Took oxycodone/percocet with some relief of her chest
pain. Also c/o HA. No fever/chills. Also over past month , has had
flashes of light and then vision goes dark in R eye , not associated
with HA.
********************
Physical Exam: ED BP 198/109-->120/78; HR 60s-90s; O2sat 98% RA ,
Lungs-clear , JVP 6cm , CV-RRR S1S2 II/VI systolic murmur RUSB ,
Abd-+BS , mild diffuse tenderness; non-pitting edema b/l; good
pulses********************
Studies: Cr 1.2 ( baseline
1.0-1.8 ) Cardiac enzymes-A set neg , B set troponin
0.13 U/A-29 WBC , 3+
squam EKG: NSR with PACs AT 84 bpm , nml axis , LVH , no q's ,
no ST elev/depr , TWI I ( old ) , II , AVF ( new ) , V6 ( new ) ,
pseudonormalization AVL CT dissection
protocol-negative MRA neck 7/3/06 : No evidence of vascular
stenosis , occlusion , or aneurysmal change. Mild tortuosity of
the internal carotid arteries.
Echo 1/18/06 : Severe LVH , EF 50-55% , diastolic dysfunction , basal
inferior akinetic , basal superior dyskinetic , mid-posterior
hypokinetic unchanged from prev. No PFO
June clean coronaries ( stents patent )
********************
Impression and Plan: 59 year-old with hx of CAD , diastolic dysfunction , OSA ,
p/with hypertensive emergency ( BP 190s in ED ) with troponin
leak likely as a result of increased BPs and demand.
Hospital Course by System:
*CV: In ED , BP was 198/109 with HR 98. patient received given ASA 325 ,
Lopressor 5mg , Morphine 2mg , Nitro sublingual , Hydral 10mg , Dilaudid. BP
decreased to 120/78. EKG showed new T wave inversions in AVF and V6 with
pseudonormalization of T wave in AVL. CT chest negative for dissection.
Serial troponins were <0.10 , 0.13 , <0.10 , bump likely result of demand
ischemia. As patient's CP was reproducible on palpation , not likely to be of
cardiac source , somewhat improved with narcotics. patient maintained on home
regimen , with BP control from 120-160/60-90 in house. Echo showed severe
LVH , EF 50-55% , diastolic dysfunction , basal inferior akinetic , basal
superior dyskinetic , mid-posterior hypokinetic , unchanged from prev. patient
will follow up with outpatient cardiologist Dr. Reisman .
*Neuro: patient described HA and episodes of vision loss in R eye lasting 5-10
minutes , concerning for amaurosis fugax vs atypical migraine vs temporal
arteritis ( had been biopsied for temporal arteritis in 10/5 because of
HA and elevated ESR - neg ). Neuro and Ophtho consulted. patient described
vision loss as bilateral to consults - less concerning for embolic event.
MRA demonstrated no carotid stenosis or occlusion. ESR was only mildly
elevated at 32. patient is already on aspirin , Plavix , statin and BP meds for
stroke prevention as per Neuro recs , though they recommended follow up
with outpatient Rheum to with u temporal arteritis if sx continue. Ophtho
exam demonstrated typical dermoid in L eye ( unrelated to sx ) , retinal exam
showed evidence of PVD but no emboli , consult thought presentation not
consistent with giant cell arteritis , most likely atypical migraine.
*Pulm: patient maintained on home regimen of Advair for asthma and CPAP at
night for OSA , no exacerbations in the hospital.
*Renal: Cr increased from 1.2 on admission ( baseline 1.0-1.8 , most likely
2/2 to chronic HTN ) to 1.7 on HD #2. Urine lytes demonstrated Na 100 Cl
78 Cr 152.3 ( FeNa 0.56% ) , UA showed 2+ LE. 10-15 WBC , 2+ bast6 , 1+ sq ,
but not treated because patient asymptomatic.
ADDITIONAL COMMENTS: -continue home medication regimen , but increase labetalol to 200
mg twice a day , norvasc to 5 mg twice a day , oxycontin dose to 50 mg
three times a day ( 40 mg home dose + 10 mg prescribed in hospital )
-make appointment to follow up with primary care physician Dr. Latonya C Dorsett
-follow up with cardiologist Dr. Reisman on 5/10 at 2:40 pm ( his office
will call you if an appointment can be made earlier )
-fluid restricted ( 2 L ) and salt restricted ( 2 mg ) diet
-return to hospital if symptoms worsen
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
-continue home regimen , but increased labetalol to 200 mg twice a day , norvasc to
5 mg twice a day , oxycontin dose from 40 mg to 50 mg three times a day
-f/u with cardiologist Dr. Reisman
-f/u with primary care physician Dr. Latonya Dorsett
-consider modification of HTN regimen if pressures not well controlled
No dictated summary
ENTERED BY: RODERMAN , LIZETH K. , M.D. , PH.D. ( TF958 ) 3/26/06 @ 07:11 PM
****** END OF DISCHARGE ORDERS ******
Document id: 500
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
869841894 | PUO | 04096805 | | 1161107 | 10/10/2005 12:00:00 a.m. | UTI | | DIS | Admission Date: 2/3/2005 Report Status:
Discharge Date: 6/17/2005
****** DISCHARGE ORDERS ******
HAMMETT , FREDERICA 929-50-68-6
S Ville Fortu
Service: MED
DISCHARGE PATIENT ON: 10/4/05 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAGBERG , LILLIA JOCELYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
EC ASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
BACITRACIN TOPICAL TP twice a day
Instructions: Apply to affected areas on face
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HYDRALAZINE HCL 25 MG orally four times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
HYDROCHLOROTHIAZIDE 25 MG orally every day
MG GLUCONATE ( MAGNESIUM GLUCONATE )
Sliding Scale orally ( orally ) every day
-> Mg-scales cannot be used and magnesium doses must be
individualized for patients who have:
- a serum creatinine greater than or equal to 2.0 mg/dL; or
- a serum creatinine greater than or equal to 1.5 mg/dL
and an increase of 0.5mg/dL within 24 hours.
Call HO if Mg level is less than 0.8
If Mg level is less than 1 , then give 3 gm Mg Gluconate
orally and call HO
If Mg level is 1.0-1.5 , then give 2 gm Mg Gluconate orally
If Mg level is 1.6-1.9 , then give 1 gm Mg Gluconate orally
If Mg level is 2.0-2.5 , then Do Not administer Mg
Gluconate Call HO if Mg level is greater than 2.5
MG OXIDE ( MAGNESIUM OXIDE ( HEAVY ) ) 420 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally four times a day
HOLD IF: HR <55 , SBP <100 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
BACTROBAN ( MUPIROCIN ) TOPICAL TP twice a day
Instructions: Apply to ulceration on left forehead
NORVASC ( AMLODIPINE ) 10 MG orally every day Starting Today May
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ALTACE ( RAMIPRIL ) 20 MG orally every day
Override Notice: Override added on 10/12/05 by RAMIL , FELIPA C D. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 59716444 )
POTENTIALLY SERIOUS INTERACTION: RAMIPRIL & POTASSIUM
CHLORIDE Reason for override: aware
LOVENOX ( ENOXAPARIN ) 30 MG subcutaneously every day
ARICEPT ( DONEPEZIL HCL ) 5 MG orally every day
Number of Doses Required ( approximate ): 10
LEVOFLOXACIN 250 MG orally every 24 hours X 1 doses
Starting Today May
Instructions: give one more dose - September
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
SEROQUEL ( QUETIAPINE ) 25 MG orally twice a day
Number of Doses Required ( approximate ): 10
LANTUS ( INSULIN GLARGINE ) 14 UNITS subcutaneously every day
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dermatology ,
Dr. Pattie Flinspach 695-795-6111 ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
dizziness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
UTI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) hx mi ( history of myocardial infarction ) hx
chf ( history of congestive heart failure ) hx cva ( history of cerebrovascular
accident ) reflux ( gastroesophageal reflux disease ) history of L nephrectomy
( history of nephrectomy ) ? meningioma on scan ( ?
meningioma ) gallstones ( gallstones ) history of multiple falls ( history of
falls ) NIDDM ( diabetes mellitus ) dementia ( ? alzheimer's since 11/1 )
( dementia )
OPERATIONS AND PROCEDURES:
na
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
skin bx 10/24/05
BRIEF RESUME OF HOSPITAL COURSE:
CC: 82 year-old female with altered mental status and
dizziness. 82 year-old female with AD , NIDDM , CAD presents with
dizziness and altered mental status X 1 week found to have marked
pyuria c/with UTI. In ED: Afebrile 72 124/58 18 100%ra , got IVF and
levoflox 500mg X 1. PMH: Dementia , CAD , DM , Cerebellar CVA , history of
Nephrectomy , R frontal lobe meningioma PE:
mental: Alert , pleasant , disoriented and forgetful. HEENT: R
periorbital erythema and edema. R nares ulceration and
oozing CVS: JVP flat ,
rrr PULM:
CTA/bl ABD: Soft ,
non-tender Studies:
CXR: Clear CT Brain: Old cerebellar infarct. No ocute
process. Problems:
**Altered mental status/dizziness - likely 2/2 to UTI and volume
depletion. Treat UTI with levoflox. Replete volume with normal
saline. Levo renally dosed.
**Renal insufficiency - chronic 2/2 nephrectomy. Renally dose all
meds. **R periorbital erythema/edema and R nares
ulceration - ? BCC. Equivocal bx last year. Seen by derm - path with unclear
carcinoma. Will need Moh's microsurgery and then plastics reconstruction.
Outpatient derm appointment scheduled.
Superimposed cellulitis. Adequate coverage with levoflox for 7 day
course. If febrile
will add vancomycin.
**Diabetes - Lantus + novolog SS while in house. **FEN - hyponatremia
2/2 to hypovolemia. NS resuccitation.
Full Code
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) patient to follow up with dermatology as an outpatient at the Skill Snerkernfairmri Rehab for Moh's microsurgery.
No dictated summary
ENTERED BY: RAMIL , FELIPA C. , M.D. ( UH79 ) 10/4/05 @ 10:41 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 501
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
- |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
- |
- |
N |
Y |
N |
N |
Y |
N |
253098943 | PUO | 49192751 | | 2498462 | 9/15/2004 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 8/13/2004 Report Status:
Discharge Date: 4/8/2004
****** DISCHARGE ORDERS ******
LOQUE , DANE Z. 425-50-69-2
Peo Baywayne
Service: MED
DISCHARGE PATIENT ON: 5/11/04 AT 08:00 PM
CONTINGENT UPON Rib film completion
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LORRAINE , DOMENIC , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
FAMOTIDINE 20 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally every day
Starting at 2:00 pm September
MOTRIN ( IBUPROFEN ) 300 MG orally every 6 hours
Instructions: syrup form 100mg/5ml
Food/Drug Interaction Instruction Take with food
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Lorraine , one week , patient to call for appointment ,
ALLERGY: PROPOXYPHENE NAPSYL
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
PVD history of surgery history of MI 1984 CHF ( congestive heart
failure ) atypical chest pain ( atypical chest pain ) history of brainstem
CVA congenital R hemiparesis supraglottic laryngeal SCC history of
XRT chronic RLE circumf > LLE ( ) esophageal stricture history of lye
ingestion OA ( osteoarthritis ) history of bilateral rotator cuff
repair recurrent UTI ( urinary tract infection ) anemia of chronic
disease ( anemia ) persistent thrombocytosis diet-controlled DM current
smoker
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: L-sided CP
HPI: 76yoF PMH MI ( 1984 ) , PVD , CVA , DVT , supraglottic laryngeal SCC
history of XRT ( 2002 ) , who presents from home c/o "stabbing pins" CP
that awoke her from sleep at 6 am. The pain
initially started next to the L breast in the
midaxillary line , then radiated to breast , sternum , neck ,
and back around to L midaxillary line. After 30 min
of pain , patient called covering primary care physician & was told to come
to ED. The "stabbing" has faded to a "soreness"
that is replicated with palpation. The pain is
worse with mov't & inspiration; not assoc with
n/v , diaphoresis , SOB. Basline cough has not
worsened; green looser stools x 3 wks; denies dysuria.
Has perhaps felt more tired with walking in recent
weeks. Of note , 1984 MI p/with "squeezing" sensation distinct from this
pain; adm 5/20/01 with similar complaints & labs; ETT &
echo non-ischemic. In ED , T 97.9; HR 71; BP 126/60;
RR 20; 99% on RA. Reg S1 S2 distant , chest
diffusely tender to palp , fine rales 1/2 up bilat , abd
soft , RLE circumf > LLE ( baseline ) , history of amp of L
3rd finger , R 1st toe. A set enzymes neg; WBC 6 ,
HCT 38.9 , DDimer 951. EKG: NSR @ 65 , nl axis , TWI
I , L , V1-4. NEXT EKG: NSR @ 61 with 1 deg AVB.
( Both these patterns seen on old EKGs ). CXR clear.
Given ASA , NTG ( partial relief , but dropped BP ) ,
heparin bolus & cont
infusion.
************* PLAN *************************
IMP--L CP seems MSK , ? rib fractures , rib films preliminary read without
fracture but does have some loss of height of vertebral bodies
suggestive of compression fractures. She was treated with motrin for
muscular pain. CV--ISCH--history of MI; cont
ASA , statin , r/o'd
MI. Not previously on BB , ACEI. PUMP--? some CHF. I/O; Lasix 80 every day.
RHYTHM--transient 1 deg AVB;
tele. PAIN--cont Motrin for chronic throat pain , OA ,
L chest
pain. GI--cont famotidine ,
Colace. PULM--low suspicion for PE; has a history of an elevated d
dimer in past. no furtehr workup at this time; no anticoagulation for
now. patient rule dout for MI whil in house. Her pain was thought to be
musculoskeletal in origin and was treated with NSAIDS. She will need to
follow up with Dr. Lorraine as an outpt. Her rib film final read was
pedning at the time of discharge and will need to be followed up on.
ADDITIONAL COMMENTS: 1. Please follow up with Dr. Lorraine within 1 week of dsicharge
2. Please continue to take all of your medications as directed
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Follow up with Dr. Lorraine
2. Follow up on final read of rib films
No dictated summary
ENTERED BY: BENADOM , EMERITA ETHA , M.D. ( MG66 ) 5/11/04 @ 07:09 PM
****** END OF DISCHARGE ORDERS ******
Document id: 502
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
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777803061 | PUO | 83517641 | | 3036112 | 6/14/2005 12:00:00 a.m. | ROMI , pre-syncope/syncope | | DIS | Admission Date: 3/18/2005 Report Status:
Discharge Date: 9/10/2005
****** FINAL DISCHARGE ORDERS ******
BELONGER , EUNA N 512-67-96-5
Anaver Ce Car
Service: CAR
DISCHARGE PATIENT ON: 10/21/05 AT 03:00 PM
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PEDERZANI , SHIZUKO E. , M.D.
CODE STATUS:
Full code
DISPOSITION: AMA
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
CIPROFLOXACIN 500 MG orally every 12 hours X 14 doses
Starting IN a.m. ON 1/11/2005 ( 09
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
SYNTHROID ( LEVOTHYROXINE SODIUM ) 200 MCG orally every day
LISINOPRIL 10 MG orally every day
Override Notice: Override added on 10/21/05 by
DURRETTE , SEYMOUR , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 83852709 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 1/12/05 by ARMLIN , VINA F KRISTY , M.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
30483447 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 1/12/05 by DURRETTE , SEYMOUR , M.D.
on order for KCL intravenous ( ref # 70298620 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: 60
Previous override information:
Override added on 1/12/05 by DURRETTE , SEYMOUR , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ROXICODONE ( OXYCODONE ) 5 MG orally every 6 hours as needed Pain
PAROXETINE 20 MG orally every day
NOVOLIN INNOLET 70/30 ( INSULIN 70/30 HUMAN )
50 UNITS subcutaneously every day before noon HOLD IF: FS <100
Number of Doses Required ( approximate ): 20
NOVOLIN INNOLET 70/30 ( INSULIN 70/30 HUMAN )
25 UNITS subcutaneously every bedtime HOLD IF: HOLD IF FS<100
Number of Doses Required ( approximate ): 20
DIET: House / ADA 1800 cals/dy
ACTIVITY: Needs walker/24 asssitance
FOLLOW UP APPOINTMENT( S ):
Dr. Gruntz ( MMC primary care physician/Cardiologist ) 11/19/05 scheduled ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Syncope vs. mechanical fall
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
ROMI , pre-syncope/syncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) diabetes ( diabetes mellitus ) history of cva ( history of
cerebrovascular accident ) hypothyroidism
( hypothyroidism ) gerd , hyperparathyroidism
( primary hyperparathyroidism ) cad ( coronary artery
disease ) anemia - ? alpha thal trait Chronic LFT elevation history of
complete with u ( fatty liver )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI/MRA Brain - no acute process. Significant atherosclerotic disease.
Carotids patent.
BRIEF RESUME OF HOSPITAL COURSE:
CC: history of fall brought in by daughter
****HPI: 66 year-old woman with DM , HTN , history of CVA with dementia ,
neuropathy , CAD and recent falls admitted for fall , Possible syncope.
patient was seen in ED on 9/10 for falls and left AMA though admission was
recommended. History obtained from family and patient--but physical therapy IS POOR
HISTORIAN. She notes falling 4 times in last week. Fell today: denies
head trauma , denies LH and reports that she didn't know she was
falling. Her daughter notes increased Rt weakness , worse from after
CVA; Doctor notes poor appetite , nausea. No recent vomiting. Doctor
says patient has had "total body pain" and worsening Rt sided weakness x2.
No F/C/sweats/diarrea. She has had FS ranging from 42-90s at home. patient
denies vertigo , but she uses a walker at baseline. On the
way to ED , she c/o chest discomfort to EMS: was given intravenous lasix ,
morphine , lopressor. Per daughter patient has not had CP , has not used NTG
since 6/27 . In PUO ED , VSS , gluc 82 , K 3.1 , ECG with flat T waves in 2-5
and v3-v6. UA with >60 WBC suggesting UTI. Patient given levaquin.
***PMH: CAD , history of CVA , DM with neuropathy; history of
dialysis in 2004; falls , HTN , hypothyroidism , GERD
***MEDs: novolin insulin twice a day , lisinopril ,
hydralazine , nexium , asa
***STUDIES: CXR - with no acute infiltrate
9/10 hip/pelvic films neg for fx DAILY STATUS: 7/26 patient hemodyn
stable , at times confused; slowed slurred speech her
baseline
HOSPITAL COURSE
***A/P: 66 year-old woman with DM , atherosclerosis , HTN , dementia admitted with for
falls. Workup includes for MI vs. syncope vs. dehydration vs.
hypoglycemia vs. UTI vs. mechanical fall vs. new stroke.
1. CV- known CAD; no recent stress imaging or echo. Will ROMI and
consider risk stratification while in house. Cont ASA , BB , ?
statin. Performed serial EKG x 2 and cardiac enzymes x 2. Patient
refused third set and 3rd ekg after explaining risks/benefits.
PUMP-mildly hypovol by exam. hydrate gently with IVF.
Echo while in house if not had one recently.
Rhythm-on tele. Patient also hypokelamic , hypophosphatemic. Hypomag.
Refused repletion after explained risks/benefits. Discussed with HCP
( son ) as well and patient refused.
2. GU-Levaquin for UTI. Started on Cipro twice a day for treatment for 10
day course. Patient agreed to take this. Understood risks and benefits.
Follow ur cx as outpatient. Continue to treat as outpatient.
Explicitly encouraged patient to take and also reiterated to daughter
who is taking patient home.
3. PULM-stable
4. Neuro- at baseline , but weakness may be due to
UTI , but will need family's continued assessment. Doubt seizure.
MRI/MRA ruled out acute process. No new stroke. Patient;s family and
HCP states patient is at mental baseline for years. Falls originally
thought to be secndary to neuropathy vs new CVA vs hypokalemia. Patient
refused potassium repletion. Continue to follow with primary care physician.
5. ENDO- monitor FS closely , check thyroid panel. Instructed patient to
also half insulin dose as hypoglycemia is likely possibility that
contributes to weakness. INstructed patient to discuss new insulin
regimen with Dr. Gruntz regarding this. Patient stated she understood
and wil do so. Discharged on instructions to take half of insulin dose
in morning and in PM.
6. physical therapy Consult - physical therapy cleared patient to continue home physical therapy , already set up.
7. DISPO - patient signed out AMA. We advised patient to get blood drawn
and electrolytes repleted. However , patient refused. Understood risks.
Also refused to stay in hospital for further workup of any kind and
understood risks. Wrote prescriptions and instructed patient to go see
primary care physician Dr. Pap as outpatient in 1-2 weeks. Gave ateint prescriptions
ADDITIONAL COMMENTS: physical therapy at home and VNA at home to be reinstated
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Please go see Dr. Gruntz MMC at 11/19/05 or in 1-2 weeks and go to
nearest ER if experiencing chest pain or other symptoms
2. Please take Ciprofloxacin as prescribed
3. Please half the insulin dose in a.m. and at bedtime. Do fingersticks
regularly before giving insulin. Do not give insulin if fingerstick less
than 100.
4. Physical therapy at home
5. Resume VNA at home
No dictated summary
ENTERED BY: DURRETTE , SEYMOUR , M.D. ( NK87 ) 10/21/05 @ 03:10 PM
****** END OF DISCHARGE ORDERS ******
Document id: 503
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
- |
N |
- |
Y |
N |
N |
N |
N |
Y |
N |
275624737 | PUO | 95262820 | | 218241 | 9/4/2001 12:00:00 a.m. | OPEN WOUND LT. FOOT | Signed | DIS | Admission Date: 10/13/2001 Report Status: Signed
Discharge Date: 5/16/2001
ADMISSION DIAGNOSIS: NON-HEALING ULCERS , LEFT PLANTAR SURFACE AND
TOES.
DISCHARGE DIAGNOSIS: STATUS POST LEFT LOWER EXTREMITY TOES TWO
THROUGH FOUR AMPUTATIONS FOR NON-HEALING
WOUNDS.
PRINCIPAL PROCEDURES: 6/20/01 - Left foot debridement , amputation
fourth and fifth toes , VAC sponge.
7/30/01 - Left foot VAC sponge change and debridement with washout.
10/20/01 - Amputation of second and third toes and debridement left
foot. Other treatments and procedures - VAC changes , wet-to-dry
dressing changes.
HISTORY OF PRESENT ILLNESS: Latricia Preuett is a 55-year-old with
history of IDDM and peripheral
vascular disease , who presented with 2-3 day history of pain and
swelling left foot , status post debridement of previous DM foot
ulcer in 8/13 with resection of second and third metatarsal heads
in 1/29 , status post revascularization left fem-pop peroneal in
8/13 . One day prior to admission , his visiting nurse noted redness
and tenderness of his left foot. The patient was referred to
clinic and diagnosed with infected open wound , foul-smelling
purulent drainage. The patient to OR on 6/20/01 for left fourth
and fifth transmetatarsal amp and VAC , on 5/2/01 for further
debridement and VAC , 10/20/01 left second and third toe
transmetatarsal amp and VAC application. During this admission , ID
consult was obtained after wound culture grew out numerous
organisms. Recommended vancomycin , levofloxacin , Flagyl , and
linezolid for broad coverage for a polymicrobial DM foot infection.
Nutrition and DM consults were also obtained to optimize insulin
regimen. The patient became afebrile. White blood cells and
fasting sugars rapidly improved with management of antibiotics and
sugar control. At the time of discharge , the wound had healthy
pink granulation tissue , healing well. The patient's sugars were
under good control. The patient was discharged to a rehab hospital
for continuing vancomycin , levofloxacin and Flagyl. Will plan on
patient's return for follow-up appointment in one week's time for
evaluation and possible admission for anticipated plastic closure
with split thickness skin graft.
PAST MEDICAL HISTORY: IDDM , HTN , CAD , PVD , DM retinopathy , DM
neuropathy.
PAST SURGICAL HISTORY: Left ORIF , excision right metatarsal 8 of June ,
excision right metatarsal ulcer 16 of July ,
right fifth toe amp and debridement 3/23 , CABG x3 6/22 , right fem
DP bypass 6/22 , debridement left foot ulcer , left fem-pop peroneal
bypass 8/13 , excision left second and third metatarsal heads 1/29 .
ADDITIONAL COMMENTS: ( 1 ) Wet-to-dry normal saline dressing changes
to left foot wound three times a day Foot care apply
Eucerin cream to bilateral feet except for wound. ( 2 ) NPH and
Regular insulin with sliding scale management. Please note patient
needs to have a snack at bedtime.
PLANNING/INSTRUCTIONS: ( 1 ) The patient is to continue to be heel
weight bearing only in his left lower
extremity. To have three times a day wet-to-dry normal saline dressing
changes. To elevate his left lower extremity when in bed or
sitting in chair. ( 2 ) Vancomycin , levofloxacin and Flagyl
antibiotics. The patient is to complete a two week course on
9/21/01 . ( 3 ) The patient is to return for a follow-up appointment
in one week. He is to call to arrange the follow-up appointments.
At that time , Dr. Derham will reassess the patient's wound ,
possibly admit the patient to hospital for a split thickness skin
graft plastic closure at that time.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed headache ,
albuterol inhaler 2 puffs inhaled four times a day , ECASA
325 mg orally every day , Dulcolax 10 mg PR every day as needed no BM , Colace
100 mg orally twice a day , heparin 5000 U subcutaneously twice a day , Atrovent inhaler
2 puffs inhaled four times a day , lisinopril 5 mg orally every day , Maalox Plus extra
strength 15 ml orally every 6 hours as needed indigestion , Lopressor 25 mg orally
three times a day , Flagyl 500 mg orally three times a day , Percocet 1-2 tabs orally every 4 hours
as needed pain , Zantac 150 mg orally twice a day , Serna lotion topically to
bilateral lower extremities as needed , vancomycin 1 gm intravenous every day ,
simvastatin 10 mg orally every bedtime , levofloxacin 250 mg orally every day The
patient is to have NPH 40 U every day before noon , 45 U every afternoon , CZI sliding scale
as written in the discharge orders. ( Please see discharge orders. )
DISCHARGE ACTIVITY: Heel weight-bearing only left lower extremity ,
elevated left lower extremity when
sitting/lying down , return to work not applicable.
DISCHARGE FOLLOW-UP: Follow-up appointments with Dr. Derham in one
week. Call for an appointment to reassess
wound.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged to Numiles Memorial Hospital .
Dictated By: MA YEAGLEY , M.D. GK80
Attending: ROSSIE MANKOSKI , M.D. XR04 AG713/951766
Batch: 2562 Index No. TXYFR0096Y D: 5/21/01
T: 5/21/01
CC: 1. NUMILES MEMORIAL HOSPITAL ( 072 ) 800-0779.
Document id: 504
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
187962058 | PUO | 67768475 | | 310050 | 11/18/1997 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 1/12/1997 Report Status: Signed
Discharge Date: 4/3/1997
DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: The patient is a 35 year old female
with hypertension and diabetes. On
the day of admission , she became very upset with her daughter and
then developed chest pressure , shortness of breath , left arm
numbness and dizziness. She called the emergency medical
technicians , and her symptoms resolved after 2 sublingual
nitroglycerin , and she was admitted to the Short Stay Unit. PAST
MEDICAL HISTORY includes adult-onset diabetes mellitus ,
hypertension. The patient has no known drug ALLERGIES.
MEDICATIONS ON ADMISSION were atenolol , 50 milligrams each day ,
hydrochlorothiazide , 25 milligrams each day , Lisinopril , 10
milligrams each day , metformin , 500 milligrams twice a day. SOCIAL
HISTORY revealed the patient does not smoke nor drink. FAMILY
HISTORY is notable for hypertension.
PHYSICAL EXAMINATION: Temperature was 98 , respiratory rate 16 ,
heart rate 94 , blood pressure 150/80 , oxygen
saturation 94% on room air. She was comfortable. Head , eyes ,
ears , nose and throat examination showed no jugular venous
distension. Lungs were clear to auscultation. Cardiovascular
examination showed regular rate and rhythm , normal S1 and S2.
Abdomen was benign. Extremities had no clubbing , cyanosis nor
edema.
HOSPITAL COURSE: The patient was admitted to the Short Stay Unit
to rule out myocardial infarction. She had no
events on the cardiac monitor and serial CPK's were negative. On
hospital day #2 , she underwent an exercise test with a standard
Bruce protocol , going 9 minutes with a maximum heart rate of 180 ,
maximum blood pressure 200/100. She had no symptoms , no
electrocardiogram changes and no evidence of ischemia.
DISPOSITION: The patient was discharged home. MEDICATIONS ON
DISCHARGE are her usual medications. She is to
FOLLOW-UP in KTDUOO clinic.
Dictated By: IRVING M. ESCALANTE , M.D. FB73
Attending: IRVING M. ESCALANTE , M.D. ZC13 BW818/5817
Batch: 9477 Index No. UMVP3174BG D: 10/26/97
T: 10/26/97
CC: 1. KAM R. ISA , M.D. UB10
Document id: 505
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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362195603 | PUO | 96454934 | | 022214 | 7/1/2002 12:00:00 a.m. | Non cardiac chest pain | | DIS | Admission Date: 1/18/2002 Report Status:
Discharge Date: 10/15/2002
****** DISCHARGE ORDERS ******
REINEMAN , JR , TWYLA 634-12-74-8
Lem Imi Ville
Service: CAR
DISCHARGE PATIENT ON: 5/27/02 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed constipation
ENALAPRIL MALEATE 5 MG orally every day before noon HOLD IF: SBP<100
Alert overridden: Override added on 5/27/02 by
SLUNAKER , VANESSA QUIANA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
ENALAPRIL MALEATE Reason for override: aware
Previous override reason:
Override added on 8/3/02 by MANNIX , FLETA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 29330778 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: will follow
ENALAPRIL MALEATE 10 MG orally every afternoon HOLD IF: SBP<100
Alert overridden: Override added on 5/27/02 by
SLUNAKER , VANESSA QUIANA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
ENALAPRIL MALEATE Reason for override: aware
ATIVAN ( LORAZEPAM ) 1 MG orally three times a day Starting Today October
as needed anxiety HOLD IF: RR<12 or patient is lethargic
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
ZOLOFT ( SERTRALINE ) 100 MG orally every day
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
VIOXX ( ROFECOXIB ) 25 MG orally every day
Food/Drug Interaction Instruction Take with food
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day as needed dyspepsia
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Gaylene Faniel , MD 2-4 wks ,
ALLERGY: Atarax ( hydroxyzine hcl ) , Sulfa
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( ) CAD ( prior MI x2 , 10/12 ( ) high cholesterol ( ) OSA ( ) OA
( ) depression ( ) anxiety ( )
OPERATIONS AND PROCEDURES:
Cardiac catheterization ( 3/3/02 )
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
44 year-old man with history of CAD history of MI x2 10/12 with PCI ,
in stent thrombosis , and re-stenting subsequently admitted multiple
times for CP , cath performed 9/17 and 2/1 showed mild CAD , presented
to TH with increasing CP at rest
associated with fatigue and SOB. Managed on Hep , TNG
drops , plavix , ACE , B blocker , demerol; ROMI'd. But
pain recurred , transferred to PUO for
cath. Fam Hx: F-MI , 53. Soc Hx: past smoker ( 40
py ) PE: 80 102/72 18
93%RA CV: RR , nl S1 S2 , no murm , no carotid
bruits , JVP=10. Ext: trace edema. Rectal: trace heme
pos. Labs: EKG: NSR75; LAE , TWI 1 , L; Q 1 , L ,
V1-3. CK 63; TnI .03 CXR:pending. Cr
.9. CV: Pain may not be cardiac , but poss cath to
r/o. ASA , Plavix , Hep intravenous , B Blocker , ACE ,
Zocor. Mild fluid overload , will plan Lasix to keep
I/0's 500-1000cc neg. Pain could represent
pericarditis , but dx of exclusion. Cardiomegaly on CXR
present since prev echo showing no
effusion. patient has had mult episodes of 2-8/10 CP during
hosp without EKG changes , responsive to NTG ,
managed with as needed Demerol and standing Ativan to
pain-free. Hep drops maintained until
cath. Cath 3/3/02 : NON-OBSTRUCTIVE CAD. LMCA: OK;
LAD: prox tubular 30%; LCx: OK; RCA:
OK. Pulm: Level of suspicion for PE is
low. Will send D-dimer; patient is already starting
Hep , will pursue CT angio if necessary. D-dimer neg ,
PE RULED
OUT. Proph: TEDS , ambulation after
r/o. Psych: Ativan as needed anxiety. Zoloft. Ativan
changed to 1 mg three times a day standing to decrease anxiety
related factors. Given lack of present sig CAD , ruled
out for PE , and low suspicion for
pericarditis , psychiatric etiology for CP becomes more
likely , would recommend psych f/u and tx for anxiety
and depression.
ID: WBC count increasing 4/5 but no other sign/sx infection. Will
monitor. CXR no infiltrates. WBC decreased 7/23 to 13.1 , still no
indication of infection.
ADDITIONAL COMMENTS: Please schedule an appointment with your primary doctor within 2-4
weeks. If chest pain changes in character ( becomes different in
location , sensation ) or is associated with new symptoms ( such as nausea
and vomiting , or severe shortness of breath ) , notify your doctor or
call 911. Please give a copy of these instructions to your primary
doctor at your next visit.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
As above
No dictated summary
ENTERED BY: SLUNAKER , VANESSA QUIANA , M.D. ( NY61 ) 5/27/02 @ 04:17 PM
****** END OF DISCHARGE ORDERS ******
Document id: 506
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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975386508 | PUO | 68593869 | | 896546 | 11/23/2000 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 9/23/2000 Report Status: Signed
Discharge Date: 6/3/2000
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION AND VENTRICULAR
TACHYCARDIA.
SECONDARY DIAGNOSIS: 1. CORONARY ARTERY DISEASE.
2. DIABETES MELLITUS.
3. HYPERCHOLESTEROLEMIA.
HISTORY OF PRESENT ILLNESS: Mr. Pesh is a 75 year old male
with a history of myocardial
infarction x2 , status post CABG x3 in 1993 , who was admitted with a
recent event of stable ventricular tachycardia. The patient's
coronary risk factors include age , male gender , positive family
history , history of myocardial infarction , diabetes mellitus , and
hypercholesterolemia. The patient has no history of hypertension
or tobacco use. The patient's history actually began in 1988 when
he had chest pain and ruled in for an anteroseptal myocardial
infarction. In 9/16 , he presented to the emergency room with wide
complex tachycardia requiring electrical cardioversion at the
I Warho Hospital . During the admission in 1998 , the
patient had a catheterization which revealed proximal LAD
occlusion , an occluded proximal descending artery off his right
coronary artery , normal hemodynamics , anteroseptal hypokinesis ,
inferior hypokinesis , apical thrombus , and aneurysm with an EF of
50%. An EP study revealed 27 and 22 beat runs of nonsustained
V-tach with left bundle branch block inducible after three
ventricular extra stimuli during ventricular drive pacing at 400
msec. The ventricular tachycardia was initially suppressed with
quinidine , but the patient subsequently developed nausea and
vomiting , and the quinidine was switched to aconine. The
patient did well on this regimen until 3/13 , when he developed
dyspnea on exertion , no chest pain , PND , and orthopnea. In 1/16 ,
the patient had an exercise tolerance test , which she failed
secondary to fatigue. During this ETT , his blood pressure actually
fell from 125 to 85 systolic and his EKG revealed 1 mm ST
depression in the limb leads. Therefore , on 8/5/93 , he was
admitted to the I Warho Hospital and underwent cardiac
catheterization , which revealed 100% LAD and RCA occlusion , 60%
proximal ramus stenosis , and left ventriculogram revealed anterior
hypokinesis , inferior hypokinesis , and apical dyskinesis with an
ejection fraction of 48%. The decision was then made during his
1/16 admission to proceed with surgical revascularization. During
his admission , he underwent a three vessel coronary artery bypass
graft with LIMA to the LAD , saphenous vein graft to the right
coronary artery and proximal descending artery , with endarterectomy
to the proximal descending artery. The patient also underwent an
EP study , and it was found that his sustained ventricular was no
longer inducible either at baseline or during isoproterenol
infusion. Since 1993 , the patient has been doing well up until the
day of admission on 3/1 .
On the day of admission , the patient developed light-headedness and
palpitations while using the toilet. The patient denied any chest
pain , dyspnea , nausea or vomiting at the time. EMS was notified ,
and the patient was found to be in V-tach. The patient was taken
to an outside hospital and cardioverted at 100 joules after failing
attempted pharmacologic conversion with Lidocaine , adenosine , and
amiodarone. The patient remained in normal sinus rhythm and was
transferred to the I Warho Hospital for further evaluation
and possible placement of AICD.
On his admission , the patient was without complaints except for
some mild lower abdominal pain , which the patient attributed to his
known constipation.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: CABG in 1993 , details noted above.
SOCIAL HISTORY: The patient denies use of tobacco , alcohol , or
drugs. The patient is currently retired and
living at home with his wife.
MEDICATIONS: Lipitor 40 mg orally every bedtime; metoprolol 25 mg orally
twice a day; Cytotec 200 mcg orally four times a day; glipizide 20 mg
orally twice a day; Glucophage 1000 mg orally every day
PHYSICAL EXAMINATION: VITAL SIGNS: Temp 97.5 , heart rate 63 , BP
140/80 , respiratory rate 16-18 , oxygen
saturation 98% on two liters. GENERAL: This is a very pleasant
male , who is sitting up in bed in no apparent distress. HEART:
Regular rate and rhythm , S1 , S2 were noted , and a I/VI systolic
ejection murmur was noted at the right upper sternal border.
LUNGS: Clear to auscultation bilaterally with good air movement.
ABDOMEN: Soft , non-tender , non-distended , positive bowel sounds.
EXTREMITIES: No clubbing , cyanosis , or edema , 2+ pulses noted in
the upper and lower extremities bilaterally. NEURO: No focal
deficits.
LABORATORY DATA: Glucose 130 , Na 139 , K 4.7 , Cl 107 , bicarb 26 ,
BUN 15 , creatinine 1.1. CK 364 , with a MB
fraction of 43.9. T. protein 6.7 , albumin 4.0 , Ca 9.4 , mag 1.8.
Cholesterol 187 , triglycerides 468 , HDL 28 , LDL 96. Dig level 1.1 ,
troponin-I 6.95. White count 10.09 , hemoglobin 13.6 , hematocrit
38.2 , platelets 232. Differential revealed 19.7 lymphocytes , 5.2
monocytes , 74 neutrophils. physical therapy 11.9 , PTT 25.7 , INR 1.0. UA - Color
was yellow , specific gravity 1.011 , pH 6.0 , negative for protein ,
ketones , bilis , blood , leukocyte esterase , or nitrites , 1+ glucose.
Also negative for WBCs , RBCs , bacteria , casts , squamous
epithelials , and crystals.
HOSPITAL COURSE: The patient remained in normal sinus rhythm since
his transfer from the outside hospital. The
patient had a catheterization , which revealed notable persistent
native vessel disease with patent bypass graft x3. The patient was
started on captopril , which was eventually increased to a dose of
25 mg three times a day , which he tolerated well. The patient had an AICD
placed by the EP service with pacer leads confirmed in good
position. The patient did experience one approximately 10 beat run
of V-tach , which did not trigger the AICD to fire. The patient did
experience some mild lower abdominal and low back pain during his
admission , which was relieved with Ultram , and on the day of
discharge had resolved. The patient had been able to take better
orally and ambulate.
DISCHARGE MEDICATIONS: Vitamin C 500 mg orally twice a day; Ecotrin
325 mg orally every day; captopril 25 mg orally
three times a day; Digoxin 0.25 mg orally every day; glipizide 20 mg orally twice a day;
metoprolol 25 mg orally twice a day; Cytotec 200 mcg orally four times a day;
nitroglycerin sublingual 1/150 1 tab every 5 minutes x3 as needed chest pain;
Vitamin E 400 U orally every day; Keflex 250 mg orally four times a day x3 days;
Ultram 50 mg orally every 6 hours as needed back pain; Lipitor 40 mg orally
every bedtime; Glucophage 1000 mg orally every day
DISCHARGE DIET: Low cholesterol , low saturated fat.
DISCHARGE ACTIVITY: As tolerated. Return to work not applicable.
DISCHARGE FOLLOW-UP: The patient has a follow-up appointment
scheduled with Dr. Rossie Mankoski ,
cardiologist at EP Service , on 7/27 . The patient was also
instructed to make an appointment with his primary care physician
within 1-2 weeks.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: LEOLA MUSICH , M.D. OR931
Attending: CARLTON J. ABSHEAR , M.D. WN7 VA145/3944
Batch: 00150 Index No. REBF6V1JPK D: 11/15
T: 11/2
CC: 1. CARLTON J. ABSHEAR , M.D. RM7
Document id: 507
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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832926516 | PUO | 84467067 | | 0626287 | 1/15/2006 12:00:00 a.m. | Chest discomfort | | DIS | Admission Date: 4/25/2006 Report Status:
Discharge Date: 8/13/2006
****** FINAL DISCHARGE ORDERS ******
SCHLATTER , KALA M 768-44-60-9
Wau Ing Luvanrange
Service: RNM
DISCHARGE PATIENT ON: 9/4/06 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CUNDICK , QUEEN H. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 6/5/06 by
KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 756640775 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 100 MG orally DAILY
Override Notice: Override added on 6/5/06 by
KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 756640775 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
NORVASC ( AMLODIPINE ) 10 MG orally DAILY HOLD IF: SBP < 120
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PHOSLO ( CALCIUM ACETATE ( 1 GELCAP=667 MG ) )
1 , 334 MG orally three times a day
Instructions: to be taken with meals only--no need to give
if NPO
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
GLIPIZIDE 10 MG orally DAILY Starting Today August
LISINOPRIL 2.5 MG orally DAILY
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
150 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
Override Notice: Override added on 6/5/06 by
KATZER , CALANDRA , M.D. on order for ZOCOR orally ( ref # 893445555 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 6/5/06 by
KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 756640775 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 6/5/06 by KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 10 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Instructions: Please start this in the am of 4/28/06
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 6/5/06 by
KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
DIET: House / Renal diet / Fluid Restriction less than 1.5L per day
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Dilella in Sonnew E ,
Please schedule for a cardiac stress test ,
Arrange INR to be drawn on 4/28/06 with f/u INR's to be drawn every
2 days. INR's will be followed by Dr. Dilella
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Chest discomfort
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chest discomfort
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus type 2 )
polycystic kidney disease ( polycystic kidneys )
hypertension ( hypertension ) cri ( chronic renal dysfunction )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ROMI
BRIEF RESUME OF HOSPITAL COURSE:
PI: 36M with ESRD on HD , well-controlled type II DM x
10 years , HTN , and recently dx R. IJ catheter-associated DVT
presented to ED after episodes of chest 'pounding' during and after
HD today. Towards end of HD run , developed a
'pounding' sensation in his L. upper chest/axilla , which lasted for
~20 seconds , then resolved spontaneously. No associated dyspnea ,
diaphoresis , nausea , vomiting , palpitations. Developed another
episode of 'pressure' in his L. lateral chest after HD complete ,
lasted for 4-5 hours , constant , no exacerbating or alleviating
factors , nonpositional , exertional , or pleuritic; again , no
associated symptoms. Exercise tolerance has been stable
recently; works , climbs few flights of stairs without significant
dyspnea , and without any chest pain. Dx with R. IJ catheter-associated
DVT 5/6 after presenting to ED with R. neck pain; sent home
on renally dosed lovenox and coumadin--pain has improved on
lovenox/coumadin. Has lost weight after starting HD. No F/C , no
rashes ( although diffuse pruritus after initiation of coumadin and
lovenox ) , no night sweats , fatigue , palpitations , dyspnea ,
orthopnea , PND , LE edema , abdominal pain , nausea , vomiting , diarrhea ,
constipation , blood in stools , dysuria , hematuria. In ED , EKG notable
for regularized T waves in I , L , V4-V6 , and II; no
definite EKG evidence of LVH or low voltage. Received 325mg ASA , had
PE-CT , which was notable for no PE , no pleural effusions , known
moderate pericardial effusion; admitted for r/o MI.
PMH: -ESRD on HD M/W/F at P Therford Hospital --thought to be
secondary to polycystic kidney disease , started HD 6/10 due to volume
overload , R. SCL tunneled catheter placed 1/8/06 , history of second L. arm
A-V fistula placement
2/11/06 -type II DM x 10 years , last A1c
6.1 -HTN
-secondary hyperparathyroidism , PTH 914 6/10 -anemia , likely secondary
to ESRD , no Fe deficiency on recent Fe
studies -gout
Meds: -coumadin 5mg
every day -lovenox 60
twice a day -toprol 300mg
every day -imdur 30mg
every day -norvasc 10mg
every day -lisinopril 20mg
every day -hydralazine 20mg orally
twice a day -zocor 40mg
every bedtime -glucotrol 10mg
every day -allopurinol 100mg
every day -phoslo 1334 mg
three times a day -calcitriol 0.25mcg
every day -procrit 10000U
qweek -nephrocaps 1 tab
every day Allergies:
NKDA 98.7 77 99-102/55-58 18 97%
RA CV: JVP 8cm , RRR , +S4 , no rubs , no murmurs; pulsus:
8mmHg , no tenderness to palpation of chest wall ADMISSION
LABS: 4/25/2006 nasal 138 , K 3.3 , CL 96 , CO2 29 , BUN
36 , CRE 9.5 , EGFR 7 , GLU 84 ANION 13 TROP-I <ASSAY X2
2/24/2006 HGBA1C 6.1 HCT 35.6 MCV 80 PLT
465 RDW
16.3 %POLY-A 66.9 , %LYMPH-A 25.4 , %MONO-A 5.2 , %EOS-A
2.1 , %BASO-A 0.4 physical therapy 15.6 , physical therapy-INR 1.2 , PTT 83.4 PE-CT: no PE , known
R. IJ catheter-associated DVT , moderate pericardial
effusion 2/9 TTE: LVEF 40% , mod concentric LVH ,
global/diffuse reduction in wall motion , small-moderate
circumferential pericardial effusion; 2.2cm in maximal diameter ,
possible increased intrapericardial pressures without evidence of
frank tamponade
6/9/06 TTE A/P: 36M man with ESRD from PKD , known small
pericardial effusion ( pulses 8mmHg ) , now admitted for
CP. DDx: underdialysis - has been having 4.5h runs ,
compliant with HD - will check URR with HD on
Monday ?Pleural effusion chk SLE TB , ( i.e malignancy - Hx not
suggestive ) , HIV - r/o with HIV test ECHO was done today showing small
pleural effusion.
3. Hypotension-has no pulsus , so unlikely to be
tamponade/ no pulses. Change BP medication regimen.
Toprol XL 300mg every day-->metoprolol 75 mg orally q6 hour Lisinopril 20mg every day-->
Captopril 25mg every 8 hours cont. Novasc 10mg every day , Hold Imdur and
hydralazine Would d/c amlodipine , nitrates and hydralazine for
n now. patient would also have only Lisinipril upon
discharge. 4. Fluid Level- Weight
pat. 5. HEME: D/C lovenox. Start intravenous Hepariin and increase
coumadin to 10mg. 6. FEN: D/C calcitrol per renal
team 7. PPx cont. on
coumadin. Full
Code
***Of Note , the following medication changes were made:
1. Lisinopril 20 is now Lisinopril 2.5
2. Hydralazine and Imdur are d/c 2/2 hypotension
3. Coumadin has been increased to 10mg every day
4. Toprol decreased from 300 to 150 mg every day
ADDITIONAL COMMENTS: Please let Dr. Destree know that we reccomend an excersize stress test as
an out patient.
Plan on having your INR checked on Monday- we have increased your
coumadin to 10mg a day.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please call ( 467 ) 142-1008 to schedule an outpatient cardiac stress
test.
2. Please follow up the results of your outpatient labs such as SLE work
up and also HIV test with your primary care doctor.
3. Follow up your INR tomorrow with the coumadin clinic.
4. Would Recommend the outpatient MD to stop the Calcium Blocker
( Norvasc ) and give beta blocker instead for BP control management.
At the same time , patient would need to put back on his BP as needed.
No dictated summary
ENTERED BY: LAPATRA , LETA , M.D. ( NT236 ) 9/4/06 @ 12:58 PM
****** END OF DISCHARGE ORDERS ******
Document id: 508
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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007127787 | PUO | 39865970 | | 4980731 | 7/8/2006 12:00:00 a.m. | shortness of breath | | DIS | Admission Date: 7/1/2006 Report Status:
Discharge Date: 2/20/2006
****** FINAL DISCHARGE ORDERS ******
GLEMBOCKI , SANDY 490-16-32-7
Kan Own
Service: MED
DISCHARGE PATIENT ON: 10/10/06 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DELMENDO , CRISTINE V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 3/28/06 by YEAGLEY , MA GLADIS NUBIA , M.D.
on order for COUMADIN orally ( ref # 352626747 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ATENOLOL 75 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
Alert overridden: Override added on 3/25/06 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: will monitor
LOVENOX ( ENOXAPARIN ) 90 MG subcutaneously twice a day X 5 Days
Starting on 10/25
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
LANTUS ( INSULIN GLARGINE ) 60 UNITS subcutaneously DAILY
Starting Today January
LISINOPRIL 5 MG orally DAILY
Alert overridden: Override added on 3/28/06 by YEAGLEY , MA GLADIS NUBIA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: watch
GLUCOPHAGE XR ( METFORMIN EXTENDED RELEASE ) 500 MG orally every day before noon
Number of Doses Required ( approximate ): 1
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 3/28/06 by YEAGLEY , MA GLADIS NUBIA , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Raspotnik Please call for appointment next week ,
Dr. Fiermonte next available ,
Arrange INR to be drawn on 6/27/06 with f/u INR's to be drawn every
3 days. INR's will be followed by Dr. Raspotnik
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
shortness of breath
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM type II S/p cholecystectomy Right DVT hypercholesterolemia
history of chole ( history of cholecystectomy ) uterine prolapse , history of TAH ( uterine
prolapse ) htn ( hypertension ) history of small bowel
resection cad , history of IMI and PTCA with stents x2 ( coronary artery disease )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MIBI
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain , diaphoresis
HPI: 66F CAd , history of MI x3 , history of stents , PVD , DM , woke
at 1am with SSCP , nausea , diaphoresis. Called EMS , pain lasted
<30min , got asa , ntg. IN ED was pain free. Recent social stressors as
daughter with high risk pregnancy. Ruled out x 3 enzymes.
PMH: CAD , MI , RCA stent x 2 1999 , OM stent at DIH , DM , PVD , lipids ,
CCY , SB resection , R DVT , antiphospholipid , prothrombin gene
mutation , TAH
STATUS: A+O , jvp 6 cm , RRR , clear lungs , no
edema
HOSPITAL COURSE:
The patient was admitted to GMS Mont for further work up of her shortness of
breath and chest pain for rule out of myocardial infarction. The patient
remained pain free throughout her hospital course and denied any
shortness of breath , increased lower extremity swelling , nausea ,
diaphoresis or other complaints. She had three sets of cardiac enzymes
return negative while in house. Her EKG showed evidence of old TWI with
some minimal flattening of T waves in II and V3. She had CXR showing no
acute cardiopulmonary process. She had adeno MIBI done on 12/10 showing no
evidence of EKG changes or symptoms with HR 51->71 and BP 124->70.
Final reading showed moderate ischemia in inferiolateral wall in L
circumflex territory with EF 59%. Her cardiologist Dr. Fiermonte was
called and recommended cath. She had a cardiac catheterization on 10/25 which
showed only distal disease and was not intervened upon. She will continue
with her medical management.
She was noted to have INR of 1.4 and was taking coumadin ?non-compliant at
home. With her history of hypercoaguable disorders , she was started on
lovenox and coumadin 6mg and to continue lovenox for at least 5 days until
INR is therapeutic. She will have VNA come to check her INR in two days and
again next week and then send information to her primary care physician Dr. Raspotnik for further
follow up andrecommendations.
ADDITIONAL COMMENTS: Ux A Verden VNA - please draw INR on 6/27/06 and 9/23/2006 . Call INR results
into primary care physician Dr. Raspotnik 422-797-9947. Goal INR 2-3. Lovenox may be
discontinued when INR is 2-3. If lovenox refills are needed , Contact Dr.
Raspotnik . Patient should have INR checked every 3 days until she is on a
stable dose of coumadin.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. VNA will draw your blood on Tuesday 9/29
2. Continue taking all of your medications , including coumadin.
3. Take Lovenox injections until told to stop by your doctor.
No dictated summary
ENTERED BY: RUNNING , HYON , M.D. ( QB45 ) 10/10/06 @ 10:40 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 509
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
013762530 | PUO | 16165917 | | 723980 | 7/22/2001 12:00:00 a.m. | Myocardial Infarction | | DIS | Admission Date: 5/2/2001 Report Status:
Discharge Date: 11/16/2001
****** DISCHARGE ORDERS ******
BELONGER , EUNA N 965-06-25-4
Pu Hass Golytuc
Service: CAR
DISCHARGE PATIENT ON: 8/6/01 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PHOSLO ( CALCIUM ACETATE ) 2 , 001 MG orally three times a day
Instructions: 3 TABLETS WITH MEALS this is 3 667mgs tablets
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 1 , 250 MG orally three times a day
DEPAKOTE ( DIVALPROEX SODIUM ) 62.5 MG orally three times a day
Instructions: Please give one half of a 125 mg tablet orally
three times a day Thanks.
LISINOPRIL 2.5 MG orally every day
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB orally Q5 MIN X 3
DARVOCET N 100 ( PROPOXYPHENE NAP./ACETAMINOPHEN )
1 TAB orally every 4 hours as needed for pain
Alert overridden: Override added on 10/10/01 by
UTZIG , MAHALIA G.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
DIPHENYLHEPTANE Reason for override:
patient takes daily at home without adverse effects
Previous Alert overridden
Override added on 10/10/01 by UTZIG , MAHALIA G.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
DIPHENYLHEPTANE Reason for override:
takes daily at home without adverse effects
Previous Alert overridden
Override added on 8/8/01 by UTZIG , MAHALIA G.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
DIPHENYLHEPTANE Reason for override:
patient takes daily at home without adverse effects
TRAZODONE 150 MG orally HS
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CLOPIDOGREL 75 MG orally every day
Override Notice: Override added on 10/10/01 by
UTZIG , MAHALIA G.
on order for INDOCIN orally ( ref # 82799704 )
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
INDOMETHACIN Reason for override: patient has pericarditis
CELECOXIB 100 MG orally twice a day Food/Drug Interaction Instruction
Take with food
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
Alert overridden: Override added on 8/6/01 by :
POTENTIALLY SERIOUS INTERACTION: RANITIDINE HCL , ORAL &
OMEPRAZOLE Reason for override: ok
DIET: House / 2 gm Na / Low saturated fat; low cholesterol / Renal diet
Activity - As tolerated
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Formichelli , call for an appointment within two weeks ,
Dr. Skarupa , Cardiology , within four weeks. ,
ALLERGY: Vancomycin hcl , Nephrocaps , Codeine , Percocet ,
Nephrocaps
ADMIT DIAGNOSIS:
Myocardial Infarction
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Myocardial Infarction
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
28y old women with ESRD from congenital renal hypoplasia on HD. Cardiac
hx for pericarditis no anginal or known CAD. Presented ER TH 4/12 .
Treated with NTG lopressor MSO4 Dilaudid after R/I with Troponin peak
42.1 Cpk 983.6/21 Aggrastat started Cath TH showed RCA 90% , 70% , 40%
lesion PDA 95% , LAD 30% , 65% , Cx40% LVHK , EF 70% Transferred to PUO cath
Lad stented RCA , PDA to 0%. 8/21 had dialysis today , tolerating BB ,
started Statin ACE asa Plavix ECHO shows mild inf HK tr MR TR no
effusion EF 55-60% On 7/23 , patient developed mild hemoptysis and epigastric
pain. Switched indocin to celecoxib. Added esomeprazole.
PMHX: ESRD on hemodialysis due to congenital renal hypoplasia.
Migraines. seizure disorder. history of renal transplant ( was viable from
1991-1993 ).
ROS: no bright red blood per rectum , melena , loss of consciousness ,
diziness , heat or cold intolerance , fevers , chills , dysuria , weight
loss , cough , hemoptysis , diplopia , weakness , or numbness.
PEX: blood pressure 120/62 82 95% ra GEN: wn/wd adult female nad. CV: has
systolic ejection murmur , II/VI. CHEST: lungs clear. ABD: benign
LABS: ETT MIBI: small fixed inferior septal defect with no inducible
ischemia at low workload ( 4 minutes or ETT ). CXR: suggestion of early
CHF , no other abnormality. KUB: unremarkable. TROPONIN PEAK: 42
EKG: RIGHT BUNDLE BRANCH BLOCK ( new ). CATH detailed above.
*****HOSPITAL COURSE*****
see above for complete details. Patient was admitted with acute
non-qwave mi , and taken to cardiac cath lab ( details above ). Her tight
RCA and PDA lesions were intervened upon. Patient continued to have
occasional chest pain , as well as abdominal pain ( and continued to
request DILAUDID - CLEARLY NARCOTIC SEEKING ). she had an ETT-MIBI that
was negative. Further enzymatic studies revealed no evidence of
transaminitis , pancreatitis , or obstructive biliary disease. Underwent
dialysis twice , and this relieved many of her somatic complaints.
Patient is discharged home in good condition , history of NQWMI with
percutaneous intervention.
ADDITIONAL COMMENTS: PAGE 1 VNA INSTRUCTIONS: Please see Ms. Belonger for home safety eval ,
medication review , and medical follow-up.
Please followup with your primary doctor and cardiologist within 2 and
four weeks , respectively. You have had a heart attack , and must be
sure to see your doctors regularly.
Please seek medical attention immediately if you should have chest
pain , shortness of breath , or dizziness/loss of consciousness.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
ENTERED BY: DAW , JANAE K. , M.D. ( NN13 ) 8/6/01 @ 03:53 PM
****** END OF DISCHARGE ORDERS ******
Document id: 510
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
572066042 | PUO | 38406610 | | 037574 | 2/23/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/8/1994 Report Status: Signed
Discharge Date: 5/20/1994
PRINCIPAL DISCHARGE DIAGNOSIS: 1. RIGHT KNEE OSTEOARTHRITIS.
SECONDARY DIAGNOSIS: 1. STATUS POST CORONARY ARTERY BYPASS GRAFT.
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old gentleman
who has been bothered by right knee
pain for several years. Physical examination and x-rays were
consistent with osteoarthritis. He failed conservative measures.
After explanation of risks and benefits , he desired to proceed with
right total knee replacement.
PAST MEDICAL HISTORY: Remarkable for status post myocardial
infarction.
PAST SURGICAL HISTORY: Remarkable for coronary artery bypass graft
times four , appendectomy , tonsillectomy and
adenoidectomy , and cystoscopy.
MEDICATIONS: Aspirin , one every day; Allopurinol 300 every day; Lasix 40
every day; Metoprolol 25 twice a day; Sulindac 150 twice a day;
Atrovent and Vanceril four puffs four times a day
ALLERGIES: He has no known drug allergies.
REVIEW OF SYSTEMS: Negative.
PHYSICAL EXAMINATION: He is a healthy-appearing , but obese
gentleman in no distress. Head and neck
exam is unremarkable. Lungs are clear. The heart is regular with
no murmurs. Abdomen surgery , non-tender , with normoactive bowel
sounds. Extremity exam reveals range of motion of the right knee
from 0 to 100 degrees. He has crepitus in the patellofemoral
joint , mild varus deformity. Neurovascular exam is normal.
HOSPITAL COURSE: He was admitted and went to the Operating Room on
10 of May . He had a right total knee replacement
by Dr. Litrenta . He tolerated the procedure well. In the Recovery
Room , his neurovascular exam was normal. On postoperative day
number one , he was comfortable , with a low grade fever. His
dressing was dry. He remained on the epidural. On postoperative
day number two , his temperature was 101.4. His hematocrit was
31.9. Epidural was stopped , and he continued with physical
therapy. On postoperative day number three , he was afebrile. His
dressing was changed. His wound was clean and dry. His hematocrit
was 32. He will continue to be anticoagulated with Coumadin. In
physical therapy , he was getting 0 to 60 degrees range of motion ,
with the epidural now off. If cleared , he will be transferred on
28 of August .
DISCHARGE MEDICATIONS: Same as on admission. In addition , he will
have Percocet , one to two every three to
four hours as needed , and Coumadin , which will be adjusted based on
his physical therapy , PTT.
FOLLOW UP: He should follow up with Dr. Odea as instructed , and
follow the physical therapy instructions sent by the
therapist here at Totin Hospital And Clinic .
Dictated By:
Attending: JANEAN J. ODEA , M.D. NV0 UD203/5251
Batch: 514 Index No. BSZD8S4TKI D: 11/21/94
T: 11/21/94
Document id: 511
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
- |
Y |
N |
- |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
244284915 | PUO | 04533679 | | 6794970 | 10/22/2007 12:00:00 a.m. | Upper respiratory infection , chest pain | | DIS | Admission Date: 11/10/2007 Report Status:
Discharge Date: 10/22/2007
****** FINAL DISCHARGE ORDERS ******
SHAFTIC , LUDIE M 570-40-80-2
Eum Nas
Service: CAR
DISCHARGE PATIENT ON: 4/18/07 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARNABA , CARA CHANCE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally DAILY
ALBUTEROL INHALER HFA 2 PUFF inhaled four times a day
as needed Wheezing , Other:cough
Alert overridden: Override added on 7/11/07 by :
on order for ALBUTEROL INHALER HFA inhaled 2 PUFF four times a day ( ref
# 450928252 )
patient has a POSSIBLE allergy to EPINEPHRINE HCL; reaction is
SOB. Reason for override: has tolerated previously
Previous Alert overridden
Override added on 7/11/07 by WALTERS , ELIZABET C , MD
on order for ALBUTEROL INHALER HFA inhaled ( ref #
321434584 )
patient has a POSSIBLE allergy to EPINEPHRINE HCL; reaction is
SOB. Reason for override: takes at home
Number of Doses Required ( approximate ): 4
ATENOLOL 100 MG orally DAILY
WELLBUTRIN SR ( BUPROPION HCL SUSTAINED RELEAS... )
150 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY Starting IN a.m. August
GLIPIZIDE XL 10 MG orally twice a day
ROBITUSSIN ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours
as needed Other:cough Instructions: sugar free formulation
KCL SLOW RELEASE 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 7/11/07 by LALATA , JOHNETTA B J. , M.D. on order for DIOVAN orally 80 MG every day ( ref # 622612347 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: md aware
Previous override information:
Override added on 7/11/07 by WALTERS , ELIZABET C , MD
on order for DIOVAN orally ( ref # 815229194 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: md aware - home regimen
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIOVAN ( VALSARTAN ) 80 MG orally DAILY
Alert overridden: Override added on 7/11/07 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: md aware
Previous Alert overridden
Override added on 7/11/07 by WALTERS , ELIZABET C , MD
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: md aware - home regimen
Number of Doses Required ( approximate ): 4
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please see your Primary Card Doctor in the next 1-2 weeks ,
ALLERGY: PROCAINE HCL , EPINEPHRINE HCL , Shellfish , intravenous Contrast ,
DIAZEPAM , ACE Inhibitor
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Upper respiratory infection , chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes hypertension asthma CHF irritable bowel anxiety
lumbar disc disease angina/ ?cad diverticulosis
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHO 5/18/07 : Nl EF 60%. no wma.no evidence chamber enlargement.
CARDIAC PET ( rest/stress with persantine ):Image quality was excellent. The
images demonstrated normal LV size. They also demonstrated normal RV size
with normal RV tracer uptake at rest. There were no regional perfusion
defects seen on the stress or rest images. On Gated PET:
Rest LV ejection fraction of 53% and ESVI 29 ml/m^2. The post-stress LV
ejection fraction was 60% with ESVI 23 ml/m^2. The LV volumes appeared
normal. There were no regional wall motion abnormalities. Demonstrated
normal regional wall thickening. The RV function appeared normal.
BRIEF RESUME OF HOSPITAL COURSE:
RFA: ROMI
.
CC: chest tightness , cough , vomiting
.
HPI: 62F hx dCHF , CABG '04 p/with cough x 2 months , hx asthma ,
laryngitis , and 1 wk hx inc SOB , weakness , and 2d hx vomiting ,
diarrhea. After vomiting , had chest tightness/burning. Occasinal L
lateral chest twinges and anterior chest twinges 2/2 sternal wires and
recent breast reduction. Prior anginal equivalent was bilateral arm
pain/tightness. Also having inc orthopnea , no PND or LEE. Sent in from
primary care physician for TWI in V1-V2 , which have appeared in 75% ECG's in last 2 yrs
since CABG. hypertensive in ED , where she was CP free , given ASA.
.
PMH:
-CAD history of CABG 10/4 ( Stukowski ): 70% pLAD , 90% RCA ,
90% pOM1 , 90% co-dom pLCx. LIMA to LAD , SVG1 to PDA , SVG2 to OM1 ,
SVG2 to D1.
- HTN , lipids. nonsmoker.
- ddCHF on diuretics , dry weight 195lb. followed by MMC CHF NP.
- DM
- asthma
-anemia
- post-partum
DVT/PE - lactose intol , obesity , diverticulosis , IBS ,
lumbar disc disease
- recent breast reduction .
.
Home meds: glucotrol XL 10 twice a day , Lasix 40 every day , ASA 81 , wellbutrin sa
150 twice a day , diovan 80 every day , kdur 20 twice a day , albuterol inhaled as needed ( rarely ) ,
atenolol 75 every day , zocor 40.
.
Allergies: iodine , lactose , valium , lisinopril , novocaine/marcaine/bup
ivacaine ,
.
Admit exam: hypertensive HR
75 A+O
x3 Cor reg 2/6 systolic murmur at
base Chest bilat CTA. ttp over sternum and L
chest. abd benign , ext warm without edema.
. Status: admit to floor , no further chest
pain. .
Studies - ECG: NSR 75 LAD/LAFB. poor RWP. currently TWI in
v1 , v2. ( since CABG , TWI in V1 and V2 come and go ) - CXR: neg.
.
Impression: 62F CAD/CABG , dCHF admitted after presented with chest
pressure and worsening of chronic cough with low grade fever. Likely
combo of URI-triggered asthma cough , gastroenteritis , and ?CHF. unlikely
UA.
Plan:
- Chest pain ( I ): CAD history of CABG , DM. High risk with inc SOB. Not
convincing for unstable angina but having progressive SOB. ECG
changes nonspecific , not concerning as noted on multiple prior EKG's.
Cont ASA , BB , ARB , statin. Noted to be hypertensive during hospital stay
with SBP's in 130-160. HR 60-80s. Will discharge on increased dose of
atenolol ( 100 mg daily instead of 75 mg daily. )
( P ): Repeat echo for progressive SOB. ddCHF. Preserved EF. No wall motion
abnormalities or changes suggestive of worsening systolic/diastolic
function or ischemia. Discharge on home lasix with standing potassium
supplementation.
( R ): Sinus rhythm. No events on telemetry. T waves in V1-V2 originally
noted varied from flat to slightly negative. No other dynamic changes.
.
COUGH: Patient gives a history of chronic cough that has recently
involved sputum production and low grade fever. Her symptoms are
consistent with a viral bronchitis with some reactive airway disease.
She got relief from duoneb and was discharged with a new albuterol
inhaler. She will also be treated with an empiric course of protonix to
treat reflux which may exacerbate reactive airway disease or in itself
cause night time cough. There was no evidence of pneumonia on CXR.
-Sputum gram stain and culture pending at discharge.
ADDITIONAL COMMENTS: You were admitted with concerning changes on your EKG and chest pressure.
Numerous studies were performed and show that your heart gets adequate
blood flow during rest and exercise. You did not have any evidence of
heart attack either. Your cough and chest discomfort are most likely due
to an upper respiratory tract infection. This may also make your asthma
worse. We would recommend using your asthma inhaler during the day for
cough and wheeze. Also we would recommend trying a low dose of stomach
acid reducer ( protonix ) as acid reflux can also make cough worse.
.
KEY MEDICATION CHANGES:
Continue all medicines that you were taking before with the following
changes:
1. Atenolol. Take 100 mg daily ( increase from 75 mg daily. ) You were
noted to have high blood pressure even on your current dose.
2. Prilosec. Take as directed for 2 weeks. This may help your chronic
cough.
3. Albuterol inhaler ( Ventolin. ) Please take as directed.
4. Robitussion , sugar free. Take as directed for cough.
.
Please return to your doctor to check in on how you are doing in the next
2 weeks. Return to the ER if you are having difficulty breathing ,
recurrent chest pain , or other concerning symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Followup sputum gram stain/culture.
2. Blood pressure check on increased dose atenolol.
3. Cough: improved on albuterol inhaler and proton-pump inhibitor?
No dictated summary
ENTERED BY: WALTERS , ELIZABET C , MD ( FX647 ) 4/18/07 @ 03:28 PM
****** END OF DISCHARGE ORDERS ******
Document id: 512
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
859513400 | PUO | 12051989 | | 489152 | 10/15/1997 12:00:00 a.m. | R/O TUBERCULOSIS | Signed | DIS | Admission Date: 10/15/1997 Report Status: Signed
Discharge Date: 5/25/1997
PRINCIPAL DIAGNOSIS: HEMOPTYSIS.
SECONDARY DIAGNOSIS: SCHIZOAFFECTIVE DISORDER.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old male who
presents to the Pagham University Of Emergency Department with low back pain and a five day
history of hemoptysis. The patient has an extensive psychiatric
history and an apparent history of tuberculosis treated in 1987 for
one year ( confirmation of this fact is not found at the present
time ). The patient presents with a five day history of hemoptysis.
The patient notes that he has had blood tinged sputum and
occasional bright red blood for the past five days totalling about
1/8th of a cup a day. He denies any fevers , chills or other sputum
production , but he notes a positive cough. He is homeless and was
exposed to cold and rain during the past week. He has had no
tuberculosis follow-up since 1988. The patient also has
long-standing lower back pain. He had a previous accident where he
was pinned between two cars at age 17. He has had pain in his
lower lumbar spine and occasional sharp pain that radiates down
both legs. He notes no weakness in his lower extremities , no
incontinence. This pain has increased substantially over the past
two months. The patient has noted an extensive psychiatric
history , evidently followed by Dr. Brannigan at the Mi Cotco Wayne Stead Health Services at the Rons County Memorial Hospital ( number 731-9804. ) The
patient was apparently diagnosed with paranoid schizoid
disorder vs. bipolar vs. schizophrenia.
PAST MEDICAL HISTORY: 1 ) Tuberculosis , status post treatment
possibly for one year in 1987 , though no
confirmation of this has been found. 2 ) Psychiatric disorder. 3 )
Status post cholecystectomy.
MEDICATIONS ON ADMISSION: 1 ) Prolixin 5 mg orally twice a day 2 )
Depakote 500 mg orally every day before noon , 1 , 000 mg
orally every bedtime 3 ) Cogentin 1 mg orally twice a day
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.7 degrees ,
heart rate 100 , blood pressure 130/80. Head
and neck examination revealed that the pupils were equal , round and
reactive to light. Extraocular movements were intact. There was
no scleral icterus. Oropharynx was clear. Neck was supple without
any adenopathy , no jugular venous pressure was noted.
Cardiovascular examination was regular rate and rhythm with a two
out of six holosystolic murmur heard best at the apex , no S3 or S4.
Lungs were clear to auscultation bilaterally. Abdomen was obese ,
soft , non-tender , positive bowel sounds. Extremities revealed no
clubbing , cyanosis or edema noted. There were good peripheral
pulses. On rectal examination , the patient had good tone and was
guaiac negative. Neurologically , the patient was intact. On
admission , the patient received a chest x-ray which showed a
possible ground glass infiltrate in the right medial segment of the
upper lung field approximately 1 cm in size , otherwise clear lung
fields.
LABORATORY: The patient's laboratory examinations on admission
were all within normal limits.
HOSPITAL COURSE: The patient was admitted for rule out
tuberculosis and was subsequently kept in the
respiratory isolation room and serial induced sputums were sent for
culture and stain and noted to be negative for acid fast
bacilli or other signs of tuberculosis. The patient was also noted to have no
further signs of hemoptysis while he was in the
hospital and therefore his history of hemoptysis has not been
verified. The patient was very cooperative while in the hospital
and showed no signs of being febrile or other signs of active
infection. No other signs of pulmonary
infection were identified that could account for hemoptysis.
It also did not appear that the patient had any form of possible lung
malignancy because he did not report weight loss or other suggestive features
To further work-up this up however , the patient
received a spiral CT scan of his chest which showed no focal
abnormalities and was notable for clear lung fields and no signs of
tuberculosis. As this was the case , the patient was subsequently
discharged home having been ruled out for tuberculosis. Notable
also , his PPD was negative at 48 hours with a positive mumps and
Candida anergy panel also suggestive of not having tuberculosis.
The patient was evaluated by Psychiatry while inhouse who was in
touch with his primary psychiatrist. The patient was continued on
his medications and noted to be quite stable while he was in the
hospital. He was deemed not medically able to make his own
decisions on admission and was therefore not allowed to leave
when the patient tried to leave on the night of admission. He was
very cooperative however over the course of his admission and was
followed by Psychiatry who have arranged follow-up with him upon
discharge. The patient was seen by Social Work who is actively
working with him to establish a shelter or other place to stay upon
discharge. The patient is amendable to this and anxious to receive
assistance. The patient was subsequently discharged on July , 1997 in good condition with the name and addresses of possible
places to stay and close follow-up with a social worker and his
psychiatrist.
MEDICATIONS ON DISCHARGE: 1 ) Cogentin 0.1 mg orally twice a day 2 )
Depakote 100 mg orally every day before noon , 200 mg orally
every bedtime 3 ) Prolixin. 4 ) Tylenol as needed back pain.
Dictated By: SANA L. ALBOR , M.D. XX93
Attending: MELISA FRANCES VARGO , M.B. SK77 FR961/5290
Batch: 04897 Index No. MEAPNU5C8M D: 11/5/97
T: 8/8/97
Document id: 513
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
N |
N |
- |
N |
Y |
Y |
N |
Y |
- |
Y |
N |
N |
268235325 | PUO | 00601670 | | 575276 | 11/18/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/7/1995 Report Status: Signed
Discharge Date: 1/9/1995
ADMITTING DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
white male with a long standing
history of angina which first started in 1/11 with chest pain who
underwent PTCA of his coronaries which was repeated times one in
1991. In September of this year he had recurrent chest pain , taken to
the emergency room where he underwent TPA and ruled in for an MI ,
now here for elective CABG.
PAST MEDICAL HISTORY: Significant for coronary disease ,
asthma , increased cholesterol and
hypertension , peptic ulcer disease , and sleep apnea.
PAST SURGICAL HISTORY: Status post right hip replacement ,
fracture of his right wrist , T&A , appendectomy.
Cath revealed 70% LAD , 90% distal circ , 50% OCA , 50% proximal D1 ,
30% proximal D2. EF was 71%.
Pre-op meds were nitroglycerin , Ecotrin , Hytrin , Diltiazem 120 four times a day ,
Ventolin , Atrovent , Azmacort.
Preoperative labs were all unremarkable.
HOSPITAL COURSE: The patient was admitted to the hospital and
underwent a coronary artery bypass graft times
four vessels on 20 of July by Dr. Marcott . The patient tolerated the
procedure well and had an uneventful postoperative course. He was
tolerating a regular diet by the time of discharge and was
ambulating without difficulty. He was sent home in stable
condition on Colace 100 mg orally three times a day Tylox 1-2 tabs orally every 4 hours
as needed , Diltizem 90 mg orally three times a day and Ecotrin 325 orally every day.
Dictated By: WAYLON M. GELLINGER , M.D. TT14
Attending: DESIRAE R. MARCOTT , M.D. QK3 RU590/1347
Batch: 4657 Index No. EXNRWK55D3 D: 5/10/95
T: 5/10/95
Document id: 514
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
- |
Y |
N |
N |
N |
Y |
Y |
- |
Y |
N |
N |
N |
N |
416969526 | PUO | 31495638 | | 938694 | 4/12/2002 12:00:00 a.m. | falls | | DIS | Admission Date: 6/10/2002 Report Status:
Discharge Date: 10/16/2002
****** DISCHARGE ORDERS ******
BRANAUGH , ARLETTE ALAN 023-97-39-6
Sa So Doatl
Service: CAR
DISCHARGE PATIENT ON: 6/17/02 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RAABE , SUNSHINE DANA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
53 UNITS subcutaneously every day before noon , every afternoon
ISORDIL ( ISOSORBIDE DINITRATE ) 10 MG orally three times a day
HOLD IF: sbp<90
ZESTRIL ( LISINOPRIL ) 40 MG orally every day HOLD IF: sbp<85
Override Notice: Override added on 8/15/02 by
SENGBUSCH , SHALANDA Y. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 75129274 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: ok
GLUCOPHAGE ( METFORMIN ) 850 MG orally twice a day
CELEXA ( CITALOPRAM ) 30 MG orally every day
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LOPID ( GEMFIBROZIL ) 600 MG orally twice a day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3
as needed chest pain
PERCOCET 1 TAB orally every 6 hours as needed as needed pain
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Raabe as scheduled ,
Dr. Smithmyer as scheduled ,
No Known Allergies
ADMIT DIAGNOSIS:
syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
falls
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of GI BLEED ( history of unspecified GI bleed ) niddm ( diabetes mellitus ) HTN
( hypertension ) high chol ( elevated cholesterol ) cad ( coronary artery
disease ) djd ( osteoarthritis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
68 year-old man with history of DM and CAD ( NO MIs ) ,
multiple caths , presents with syncope x 2 , 3 days ago.
Cardiac history: -cath 4/8 for USA: R dom , nl LV fxn , nl
R pressures , mult stents in prox LCX and
OM1 -cath 10/21 for CP: 40% in-stent restenosis
OM1 , 70% LAD , 70% PDA , 80%
PVL. -cath 10/11 70% RCA stented x2 , OM1
instent restenosis cutting
blade. patient was in his USOH until 3 d PTA when he had
2 episodes of questionable syncope. One occurred while
putting up blinds , the other while sleeping later
that night. Both episodes ended with patient on the
floor , not remembering how he got there. No warning ,
no CP , SOB , palp , nausea , diaphoresis , aura.
No post-ictal state , or loss of bowel or bladder
fxn. He does state that he had an episode of L
jaw pain earlier that day , after walking for
2 miles , relieved by 1 sublingual nitro. Otherwise good exercise tolerance
without angina. No DOE , PND , orthopnea. On the first fall he hit his
L leg , and presented to the ED with leg pain today.
No history of prior MI. Exam: HR 60s , BP
140s/70s. Lungs CTA , JVP 7 cm , RR , +S4 , good pulses , no
LE edema , abd benign. CK496 , MB low , TnI
flat. Plan:
1. CV: Arrhythmia vs ischemia vs orthostasis. Ischemia--ruled out for
MI , continue asa , lopressor 25 three times a day , zestril 40 , isordil 10 three times a day ,
No events on monitor. Given atypical story , absence of past infarct or
known structural heart disease , excellent exercise tolerance and stable
exam it was felt that patient could be safely discharged as followed up as
outpt. Plan for echo and Holter as outpt.
2. DM: continue metformin , insulin , czi ss.
ADDITIONAL COMMENTS: Your X-rays show no evidence of fracture or dislocation in your L leg.
Your bloodwork , ECG , and physical exam show no evidence of heart
injury , and you have had no arrhythmias detected by monitor. You
should resume your normal activities and follow up with your doctors as
scheduled.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: OSTRANDER , DARLEEN L. , M.D. , PH.D. ( TI55 ) 6/17/02 @ 02:56 PM
****** END OF DISCHARGE ORDERS ******
Document id: 515
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
386459848 | PUO | 31341276 | | 7890531 | 2/4/2004 12:00:00 a.m. | angina , CAD | | DIS | Admission Date: 7/15/2004 Report Status:
Discharge Date: 7/21/2004
****** DISCHARGE ORDERS ******
ASCHENBRENNER , HOPE R. 576-69-03-4
Lake Us Ni
Service: CAR
DISCHARGE PATIENT ON: 5/11/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DOCIMO , STEFFANIE TENNILLE , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Instructions: can reduce to 81 depending on cath results
ATENOLOL 50 MG orally every day Starting Today July
HOLD IF: sbp < 90 , heart rate < 50
PEPCID ( FAMOTIDINE ) 20 MG orally every day
GLYBURIDE 7.5 MG orally every day Starting IN a.m. July
HOLD IF: start 8/3/04
Instructions: hold today , start 8/3/04
HYDROCHLOROTHIAZIDE 25 MG orally every day Starting Today July
Instructions: resume outpt regimen
LISINOPRIL 40 MG orally every day HOLD IF: sbp < 90
Override Notice: Override added on 6/20/04 by
CLARDY , CHRISTY ALVINA , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
14332869 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain HOLD IF: sbp less than 100 mmHg
Instructions: Do not administer if receiving intravenous
nitroglycerin.
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
HOLD IF: sbp < 90 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
FOSAMAX ( ALENDRONATE ) 10 MG orally every day HOLD IF:
Instructions: Give tablet on an empty stomach with a full
glass of water , then wait 30 minutes before the patient eats
or lies down ( to promote absorption and avoid distress ).
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
Number of Doses Required ( approximate ): 14
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
CALTRATE + D ( CALCIUM CARB + D ( 600MG ELEM CA... )
1 TAB orally every day
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Earnest Obeso 2:30pm 3/4/04 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
angina
GERD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
angina , CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma htn GERD history of cholecystectomy history of CVA rt sided weakness
OPERATIONS AND PROCEDURES:
Left heart cath - 3V CAD
Lcx - taxus stent to mid LCx occlusion 80% -> 0%
OM1 - taxus stent to 0% occlusion
RCA - proximal 40% ostial 50% lesions , no intervention
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: chest pain
HPI: This is a 75 year-old woman with history of DMII , CAD. Over past 2-3 months
the patient has had burning epigastric pain. Previous anginal chest
pain per patient was chest tightness , but given her history of CAD her
epigastric pain has been investigated for an ischemic cause. The
patient underwent PET CT 2 months prior that revealed an LvEF of 70% ,
no wall motion abnormalities , and inferiolateral and basal
anterolateral wall ischemia ( reversible at rest ) , in the distribution
of the LCx. She presented to her primary care physician 12/10 to review these findings and
complained of current epigastric burning. She was sent as a direct
admit for evaluation of ischemia and possible catheterization.
PMH: GERD , HTN , DMII , CAD LAD/Lcx/OM , CVA
with resolving Rt. hemiparesis , history of CCY ,
osteoporosis , hyperplastic rectal polyp , ASCUS
98 allergies: NKDA
SH: does not smoke or drink Exam: Tm AF P 46 , BP 138/70 sat
99%RA PE: notable for physiologic split S2 ,
prominent S2 , no murmurs/rubs/gallops , o/with normal
exam. EKG: old 1mm st depressions v4-6 ,
I. Labs: troponin < assay.
Impression: This is a 75 year-old woman with multivessel CAD with epigastric
burning , possibly GERD but given risk for ischemia and positive PET
CT deserves diagnostic catherization and intervention to relieve any
pain caused by ischemia.
Hospital Course.
1. card - ischemia: The patient ruled out for acute myocardial
infarction by EKG and cardiac biomarkers. She was continued on her
outpatient regimen of ASA/BB/statin/ACEI/plavix. Left heart
catheterization performed 10/25 shows LCx disease with an 80% mid LCx
lesion opened to 0% with TAXUS stenting. Additionally , a TAXUS stent
was applied to an 80% ostial occlusion of the OM1 with no residual
occlusion. RCA disease was present with proximal 40% and ostial
50% occlusions that required no intervention.
During the procedure the patient experienced bradycardia to 38 and
SBP 86. intravenous fluids were given with recovery of systolic pressure to 90 -
150s , and HR 40s. The patient was asymptomatic during this event , and
has not had any complications. The patient experienced bleeding after
the procedure and integrilin was stopped after two hours of treatment.
The patient has had no further episodes of bleeding or associated chest
pain and is discharged in excellent condition on her outpatient
regimen.
rhythm - the patient was asymptomatic at a rate of 40s - 50s during
her hospital course. Titration of her beta-blockade as an outpt. may
be considered if the patient becomes symptomatic.
2. GI - continue H2 blocker , switch to nexium if continued pain.
3. Endo - Hypoglycemics were held until after the procedure and should
be resumed on discharge.
ADDITIONAL COMMENTS: 1. resume your previous medications
2. you have had two new stents placed to keep the vessels around you
heart open.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. f/u rate control as outpt , adjust BB if patient symptomatic from
bradycardia
No dictated summary
ENTERED BY: CLARDY , CHRISTY ALVINA , M.D. ( BL29 ) 5/11/04 @ 11:47 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 516
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
281801955 | PUO | 38766817 | | 9162026 | 10/10/2005 12:00:00 a.m. | constipation , volume overload , pernicious anemia | | DIS | Admission Date: 10/17/2005 Report Status:
Discharge Date: 11/10/2005
****** DISCHARGE ORDERS ******
DRUGAN , DELMAR JOANNA 615-06-75-5
Rham Tolesant In
Service: MED
DISCHARGE PATIENT ON: 4/9/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HARKLEY , JACQULYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
DULCOLAX ( BISACODYL ) 10 MG orally every day Starting Today July
as needed Constipation
CAPTOPRIL 25 MG orally three times a day Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Override Notice: Override added on 10/26/05 by
LOBBINS , LUCY , M.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
06879617 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 1/12/05 by DEVAUGHAN , MAMMIE M. , M.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
32079701 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 1/12/05 by LOBBINS , LUCY , M.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
77164897 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
VALIUM ( DIAZEPAM ) 5 MG orally every day as needed Anxiety
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
Override Notice: Override added on 1/12/05 by
LOBBINS , LUCY , M.D.
on order for MINERAL OIL ENEMA PR ( ref # 54724135 )
SERIOUS INTERACTION: DOCUSATE SODIUM & MINERAL OIL ,
SYSTEMIC/THERA USE Reason for override: aware
LACTULOSE 30 MILLILITERS orally every 6 hours Starting Today July
as needed Constipation
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally every day as needed Constipation
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally four times a day
METOPROLOL TARTRATE 25 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NIFEREX-150 150 MG orally twice a day
SIMETHICONE 80 MG orally four times a day
SUCRALFATE 1 GM orally four times a day Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
Alert overridden: Override added on 10/1/05 by
LOBBINS , LUCY , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: patient takes at home
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/1/05 by
LOBBINS , LUCY , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
66093682 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: patient takes at home
TOPAMAX ( TOPIRAMATE ) 50 MG orally every day
Number of Doses Required ( approximate ): 5
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
MIRALAX ( POLYETHYLENE GLYCOL ) 17 GM orally every day
Number of Doses Required ( approximate ): 3
CALTRATE + D ( CALCIUM CARB + D ( 600MG ELEM CA... )
1 TAB orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
NPH ( PORK ) 50 UNITS subcutaneously every day before noon
NPH ( PORK ) 30 UNITS subcutaneously every afternoon
REGULAR INSULIN ( PORK ) 7 UNITS subcutaneously qbreakfast
REGULAR INSULIN ( PORK ) 11 UNITS subcutaneously qlunch
REGULAR INSULIN ( PORK ) 7 UNITS subcutaneously qdinner
LASIX ( FUROSEMIDE ) 80 MG orally every day Starting Today July
Alert overridden: Override added on 4/9/05 by :
on order for LASIX orally ( ref # 28424078 )
patient has a POSSIBLE allergy to
TRIMETHOPRIM/SULFAMETHOXAZOLE; reaction is to Bactrim.
Reason for override: patient takes at hom
LINEZOLID 600 MG orally every 12 hours Instructions: to finish 11/4/05
Food/Drug Interaction Instruction
No tyramine-containing foods
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally every day As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 4/9/05 by :
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: MD aware
VITAMIN B12 ( CYANOCOBALAMIN ) 30 MCG intramuscular every day X 7 doses
VITAMIN B12 ( CYANOCOBALAMIN ) 100 MCG intramuscular Q4WEEKS
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Dench , patient to arrange ,
ALLERGY: PERCOCET , TRIMETHOPRIM/SULFAMETHOXAZOLE ,
INSULINS , HUMAN
ADMIT DIAGNOSIS:
anemia , abdominal discomfort
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
constipation , volume overload , pernicious anemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
IDDM HTN DIABETIC FOOT ABDOMINAL DISTENSION cad
pvd history of ORIF OF ANKLE ( ) L4/L5 spondylolisthesis
( spondylolisthesis ) hypercholesterolemia ( elevated cholesterol ) CHF
( congestive heart failure ) peripheral neuropathy ( peripheral
neuropathy ) chronic renal insufficiency ( chronic renal dysfunction )
diabetic gastroparesis diabetic retinopathy
( retinopathy ) carpal tunnel syndrome ( carpal tunnel syndrome ) history of L
fem-pop bypass 1997 history of skin graft on R heel for ulcers
1997 liver mass cellulitis ( cellulitis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
70yo F with advanced DM , MRSA osteo , HTN , PAD ,
CAD now presents with worsening SOB , ab discomfort. Patient recently
admitted for NSTEMI ( MIBI with mod LCX disease and severe HK ) ,
patient declined cath. Patient currently being tx for osteo with orally
linezolid/levo to complete 3wk course ( declined PICC and arterial
bipass ). patient in USOH until 24hrs prior to admission when
she noted SOB , orthopnea , and increased edema. +URI sx and fever
100.2. No BRBPR , hematuria , or melena.
In ED: afeb , 114/49 , 90 , 90 RA , 100 2L; given duoneb and lasix
40 LABS: HCT 24 , Plts 194 , WBC 9.1 , Tn 0.15 , BNP 476 ,
and Na 125 CXR: stable cardiomegaly , some increased pulm
edema , no clear infiltrate but tech poor study
****HOSPITAL COURSE/PLAN*****
70yo now with new anemia and CHF. 1 ) CV-I: continue ROMI , positive
troponin likely anemia related demand; BB , statin ,
ASA 2 ) CV-P: appears vol overloaded , maybe be 2/2 to
med/diet non-compliance. Goal diuresis 1-2L/d met. Follow closely
during
transfusions. Echo 8/28 showed EF 55% , no
RWMA. We discharged this patient on 80 mg orally lasix with standing
potassium , she will be followed closely by VNA. 3 ) CV-R: no issues , on
tele for
RO 4 ) Heme: unclear etiology of anemia , most likely
2/2 to linezolid , other possibilities ACD , CKD , slow GI loss ( guiaic
neg ). Checking iron , retic , smear , hemolysis labs. Transfuse to goal
HCT 30. She received 2 units PRBC on night of admission and then hct
was stable. She had iron and vitamin B12 deficiency and was started on
supplements. 5 ) Renal: creatinine at BL at
1.6. 6 ) ID: R calcaneal osteo with MRSA ( bx
confirmed ) , planned treatment until 8/22 based on last discharge summary.
Change to vanco for concern of
marrow suppresion of linezolid. ID curbside is to use linezolid ,
and treat anemia with PRBC. needs 6 week course from 2/12/05 . Check BCx ,
foot films show no osteomyelitis , sputum cx shows klebsiella , likely
colonizer. Patient repeatedly refused PICC. She also believes
abdominal discomfort largely due to linezolid. Plastics evaluated the
heel and felt was healing nicely. To finish up 6 week course from
2/12/05 , we discharged the patient on linezolid until October , as
patient refused PICC for vanco. 7 ) GI: gastroparesis , giving reglan and
sucralfate. Aggressive bowel regimen. Patient finally responded to
miralax and lactulose , producing large BMs ( KUB showed much stool ) and
relief of abdominal distention and discomfort. 8 ) Pulm: SOB likely 2/2
to
pulm edema and anemia. 9 ) FEN: hyponatremia , patient has history of hyponatremia.
Free water/fluid restrict.
Monitor. Did not rise out of the 126-7 range. Unclear etiology , ?
SIADH. primary care physician aware and informed team that hyponatremia ongoing x 2 years.
10 ) Proph: lovenox ,
PPI FULL
CODE
ADDITIONAL COMMENTS: Please take all of your medications as instructed. You may need to take
more medications to ensure adequate bowel movements ( e.g. MOM , miralax ,
dulcolax , lactulose , colace ). If you experience sharp abdominal pain ,
fever , chest pain , please seek medical attention.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA: please check weight , BP , heart rate. Please give vitamin b12 intramuscular every day
x 7 days. Please check potassium and creatinine q3d and send data to Dr.
Dench . Please ensure patient taking linezolid and bowel regimen as
appropriate. PLease do every day dry sterile dressings to lower extremities.
No dictated summary
ENTERED BY: LOBBINS , LUCY , M.D. ( JU4 ) 4/9/05 @ 04:11 PM
****** END OF DISCHARGE ORDERS ******
Document id: 517
| Target |
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GER |
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HC |
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HTG |
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Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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Y |
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Y |
U |
U |
U |
Y |
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U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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761622641 | PUO | 80826409 | | 9989173 | 7/25/2005 12:00:00 a.m. | SYNCOPE , LEFT SHOULDRE FRACTURE | Signed | DIS | Admission Date: 7/25/2005 Report Status: Signed
Discharge Date: 1/2/2005
ATTENDING: BRAGAS , RASHEEDA MD
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female
with history of insulin-dependent diabetes mellitus ,
hypertension , hyperlipidemia with a known EF of 25 to 30% and
history of Graves disease who presents to us after a fall at home
with a chief complaint of left shoulder pain. The patient states
on the morning of admission , she had a slight headache and
dizziness , but felt better after eating breakfast , was
approaching her daughter , answered the doorbell when she fell.
She denies associated shortness of breath , chest pain ,
lightheadedness , nausea , vomiting , warmth. The patient states
she was wearing shoes , did not believe she tripped. No history
of seizure activity , postictal state , or loss of bowel or bladder
incontinence. After the fall , she complained of left shoulder
pain with movement. The patient denies loss of consciousness ,
head trauma. Started a new medication , gabapentin , this week.
In the ED , she was found to have a fracture of her left surgical
humeral neck and was given Tylenol and Toradol for pain. CAT
scan revealed no acute events.
PAST MEDICAL HISTORY: Significant for insulin-dependent diabetes
mellitus with the last A1c of 11.9 , known retinopathy and
neuropathy , hypertension , history of hypertensive encephalopathy ,
history of Graves disease , CHF , with a known EF of 25 to 30% ,
concentric LVH , and pulmonary pressures of 52 plus right atrial
pressure , dermatomyositis , arthritis , cataracts , B12 diffeciency ,
stress urinary incontinence , status post total abdominal
hysterectomy , bilateral salpingo-oophorectomy , previous syncopal
episode in 2001 where she underwent a Bruce protocol , stress
maybe with poor exercise tolerance with 50% of heart rate and
stopped secondary to fatigue.
ALLERGIES: The patient is allergic to penicillin , aspirin ,
codeine , and simvastatin.
MEDICATIONS ON ADMISSION: Include metformin 400 mg every day , insulin
80 units subcutaneously every bedtime , atenolol 100 mg ,
hydrochlorothiazide 25 mg , Vasotec 40 mg , pravastatin 20 mg ,
Neurontin 300 mg three times a day , amitriptyline 10 mg every bedtime , and folate.
SOCIAL HISTORY: The patient lives alone in the first floor of
her apartment with no stairs. She is a 30-pack-year smoker , quit
approximately 30 years ago. No alcohol use.
FAMILY HISTORY: No pertinent family history.
REVIEW OF SYSTEMS: Negative. no fever , chills , nausea ,
vomiting , or changes in appetite. No bright red blood per rectum
or black tarry stools. No cough. No dysuria or urinary
frequency. No constipation or diarrhea.
ADMISSION PHYSICAL EXAMINATION: The patient was afebrile. Heart
rate in the 50s. BP 130/70 , respiratory rate 16 , satting 99% on
room air. The patient was in no acute distress , pleasant ,
complaining of left arm pain with movement. Mucous membranes are
moist. No lymphadenopathy. No thyromegaly. Oropharynx is
clear. Chest is clear to auscultation bilaterally aside from
some bilateral wheezes in the bases. The patient was
bradycardic. S1 and S2. Distant heart sounds. No murmurs ,
gallops , or rubs appreciated. Abdomen is obese. Soft ,
nontender , and nondistended. Positive bowel sounds. Extremities
exam significant for left shoulder extreme tenderness to
palpation and movement with noticeable edema. Pulses are intact
bilaterally. Skin is clean , dry , and intact. No rashes. The
patient is alert and oriented x3. Cranial nerves II through XII
are grossly intact , moving all extremities. No pronator drift.
Reflexes are symmetric.
LABORATORY DATA: Significant for potassium of 5.8 , creatinine of
1.0 , 0.8 baseline. WBC 10 , hematocrit 34.5. Cardiac enzymes
negative x1. TSH of 27 , T3 109 , T4 4.9. Chest x-ray is clear ,
notable for cardiomegaly.
IMPRESSION: The patient is a 58-year-old female with history of
insulin-dependent diabetes mellitus , hypertension ,
hyperlipidemia , with an EF of 25 to 30% , graves disease , presents
status post fall , denies loss of consciousness. Syncope workup
in ??___?? rule out myocardial infarction , arrhythmia ,
cerebrovascular accident , transient ischemic attacks. In
addition , the patient with left surgical humeral neck fracture
and positive UA. Etiology of syncope unclear. The patient was
bradycardic on admission , may have been over beta-blocker , also
with positive urinary tract infection. In addition , the patient
experienced multiple episodes of a.m. hyperglycemia , which may
have been contributing.
PLAN BY SYSTEMS:
1. Cardiovascular:
A. Ischemia: The patient completed a complete rule out MI
workup with negative enzymes and no EKG changes. The patient was
maintained on beta-blocker , ACE inhibitor , and statin. No
aspirin given secondary to allergy. The patient had a repeat
echo on May , 2005 , which showed an EF of 45% and mild
global hypokinesis and left atrial enlargement.
B. Rhythm: Significant for bradycardia. Lopressor was started
inhouse in order to better titrate pulse rate. The patient was
changed to Coreg 6.25 mg twice a day and titrated to 12 mg twice a day ,
well tolerated. No further episodes of bradycardia.
2. Renal: Baseline creatinine 0.8. Creatinine on admission
1.0 , remained stable , no issues.
3. Infectious Disease: Positive UA on admission. Completed
3-day course of ciprofloxacin. No chronic complaints.
4. Fluids , Electrolytes , and Nutrition: The patient was
maintained on ADA low-salt cardiac diet , repeat it with potassium
and magnesium scales. Hematocrit remained low at 34.5 , but
remained stable. The patient was maintained on folate and B12.
The patient should continue workup of anemia as an outpatient.
5. Endocrine: Initially continued Lantus 80 units
subcutaneously every bedtime with insulin sliding scale. However ,
secondary to a.m. hyperglycemia , changed Lantus to every day before noon and
added before every meal short-acting insulin for better control. The
patient was not restarted on metformin as an inpatient. In
addition , PFTs revealed a mild hypothyroidism with low free T4.
The patient was started on Synthroid , and she should continue to
follow thyroid function tests as an outpatient. Orthopedic was
consulted regarding humerus fracture. The patient was splinted
by Ortho , and she should follow up in clinic as indicated. Pain
control was initially given allergy to Codeine. Trial of around
the clock Tylenol alternating with Lidoderm patch were effective.
The patient also received physical therapy as an inpatient and
will benefit from continued physical therapy at rehabilitation. Followup is
scheduled with Ortho in the discharge summary.
6. The patient was continued on amitriptyline every bedtime for
prophylaxis. The patient was given Nexium and Lovenox.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Tylenol 500 mg orally every 4 hours , amitriptyline
10 mg orally every bedtime as needed insomnia , Dulcolax 10 mg orally every day
as needed constipation , B12 50 mcg orally every day , Colace 100 mg orally
twice a day , Vasotec 40 mg orally every day , folate 1 mg orally every day , HCTZ 25
mg orally every day , insulin regular sliding scale before every meal , lactulose 30
mg orally four times a day as needed constipation , Synthroid 50 mcg orally every day ,
magnesium gluconate sliding scale , milk of magnesia 30 mg orally
as needed constipation , senna 2 tablets orally twice a day , pravastatin 20
mg orally every bedtime , Neurontin 300 mg orally three times a day , Imdur 60 mg orally
every day , Lovenox 40 mg subcutaneously every day , Ultram 50 mg orally every 6 hours
as needed pain , Coreg 12.5 mg orally twice a day , Nexium 20 mg orally every day ,
insulin glargine 80 units subcutaneously every day before noon , Lidoderm 5%
patch topical every day , NovoLog 4 units subcutaneously before meals
FOLLOWUP APPOINTMENTS: The patient has a followup appointment
with Ortho Trauma Clinic on February , 2005 , at 8:30. After
discharge from VLH , the patient should schedule a primary care physician followup
appointment.
Any questions may be answered by Dr. Rasheeda Bragas .
eScription document: 0-5791442 SSSten Tel
CC: Primary Care Physician
Dictated By: YEAGLEY , MA
Attending: BRAGAS , RASHEEDA
Dictation ID 7819699
D: 9/10/05
T: 9/10/05
Document id: 518
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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921778812 | PUO | 49448215 | | 2270244 | 3/24/2006 12:00:00 a.m. | history of mechanical fall , | | DIS | Admission Date: 5/29/2006 Report Status:
Discharge Date: 4/18/2006
****** FINAL DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
ME
Service: MED
DISCHARGE PATIENT ON: 4/15/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain , Headache
AMIODARONE 100 MG orally DAILY
Override Notice: Override added on 4/15/06 by
TROKEY , CLARITA K. , PA
on order for COUMADIN orally ( ref # 175661737 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitoring
Previous override information:
Override added on 1/26/06 by TROKEY , CLARITA K. , PA
on order for COUMADIN orally ( ref # 847921686 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitor Previous override information:
Override added on 8/5/06 by NETTI , DARNELL TATIANA , M.D.
on order for COUMADIN orally ( ref # 606478304 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/28/06 by NETTI , DARNELL TATIANA , M.D.
on order for COUMADIN orally ( ref # 286805594 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/28/06 by NETTI , DARNELL TATIANA , M.D.
on order for COUMADIN orally ( ref # 512568561 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/20/06 by RUKA , BERNA , PA-C
on order for COUMADIN orally ( ref # 924255735 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitor INR
NATURAL TEARS ( ARTIFICIAL TEARS ) 2 DROP each eye twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PLAQUENIL SULFATE ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: SBP <110
LISINOPRIL 20 MG orally DAILY HOLD IF: SBP <110
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
COUMADIN ( WARFARIN SODIUM ) 2.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: patient takes coumadin 2.5 mg/ 5mg once daily ,
alternating days ( 5mg 3d/wk; 2.5mg 4d/wk )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/15/06 by
TROKEY , CLARITA K. , PA
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitoring
NORVASC ( AMLODIPINE ) 10 MG orally DAILY HOLD IF: SBP <110
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
DULCOLAX RECTAL ( BISACODYL RECTAL ) 10 MG PR DAILY
as needed Constipation
CLOTRIMAZOLE 1% TOPICAL TOPICAL TP twice a day
Instructions: apply to feet bilat
GLYBURIDE 5 MG orally twice a day
Alert overridden: Override added on 4/15/06 by :
on order for GLYBURIDE orally ( ref # 236279065 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: patient takes regularly at baseline
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
Starting Today February
Instructions: Of note: patient was on 40 daily at baseline yet
was held during admission for renal insuff , since renal fx
corrected patient restarted on lasix 20 every day on d/c
Alert overridden: Override added on 4/15/06 by :
on order for LASIX orally ( ref # 699506554 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: monitored
DIET: House / NAS / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
per physical therapy recs
FOLLOW UP APPOINTMENT( S ):
Dr. Milito ( NOH MD ) 575-803-4363 10/27 @ 8:30am ,
Dr. Denisha Mcrorie in KTDUOO ( Dr Aspacio is away ) 647-166-4998 10/27 @ 9:15 ,
psych will call the patient within 24-48hrs 053-237-3814 ,
Dr. Kleiboeker - in the arthritis center Sto 068-847-6488 4/2 @ 3:30 ,
Arrange INR to be drawn on 11/14/06 with f/u INR's to be drawn every
3 days. INR's will be followed by Dr. Aspacio ( primary care physician )
ALLERGY: QUININE , Aspirin , Sulfa , Penicillins
ADMIT DIAGNOSIS:
history of mech fall
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of mechanical fall ,
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , CHF , history of St. Jude MVR for MS , Hx AFib/flutter , history of IMI , NIDDM , gout
Hx DVT '70 , history of appy , history of umbilical hernia repair , history of sigmoidectomy for
diverticulitis history of L hip # '95 , PE , heart block ( third degree heart
block ) , history of DDD pacer
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: fall
---
HPI: 83 year old F with hx CAD history of MI , CHF , Afib/aflutter , heart block
history of pacer , history of St. Judes MVR , NIDDM , hx PE , hx L hip fx history of screws since
removed who presents with fall. She was reportedly trying to open her
closet door when she was suprised to realize the door was already ajar
and this resulted in her falling into the closet. She could not get up.
She reported that she hit her "whole body" when she fell. She lay there
through the entire night. The following day she was able to crawl out of
the closet. Her son was concerned when she didn't answer the phone and
called the police who found her lying on the floor. She complained on
admission of L shoulder pain , bilat Knee pain , and L pubic/pelvis pain.
ROS otherwise negative for syncope , LOC , CP , SOB , F/C , cough , diarrhea ,
vomiting.
In ED: patient was found to have troponin leak of 0.23. Her films were
negative except pelvis XRY which showed question of pubic ramus
fracture.
---
Data:
EKG: Prolonged QT interval , otherwise unchanged.
CXR: neg for acute cardiopulm dz
Head CT: neg
Cspine CT: neg
L shoulder film: neg
Bilat knee film: neg
Pelvis XRY: ?pubic ramus fracture
Labs: *Na 146 , *CK 3320 , *CKMB 12.9 , *Trop 0.23-->0.10. *AST 107
Cr: 1.2->1.6
---
Medications on Admission: Amiodarone 100 every day , Colace 100 twice a day , lasix 40mg
every day , Glyburide 5mg twice a day , Plaquenil 200mg twice a day , Isordil 20mg three times a day , Lisinopril
20mg every day , Coumadin 5mg 3dys/week , 2.5mg 4dys/week , Norvasc 10mg every day ,
Neurontin 300mg three times a day
---
ALL: Quinine-hypotension & syncope , PCN-rash , Sulfa , Asa-rash
---
PMH: See list
---
Exam on Admit:
T 98.5 , HR 60-64 , RR 16-18 , BP 149-155/58-81 , O2 99% on 2L
GEN: NAD , of stated age
HEENT: L eye not opening all the way. L eye slightly tender to palpation ,
EOMI , PERRLA B , Dry MM
NECK: no LAD , No JVD
LUNGS: CTA B
HEART: RRR nrml S1 , mechanical S2
ABD: soft , NT , ND
EXT: L shoulder pain to palpation and with extension Hyperkeratosis of LE
to below knees bilaterally. L pelvis tender to palpation. L leg SAR
limited by pain in L pubic area. Strength 5/5 otherwise. No cyanosis.
---
Hospital Course:
1. ) ORTHO: The patient was admitted history of fall with concern for pelvic
fracture from XRY. Shoulder , hip , pelvic films negative for fx or
dislocation except abnl finding R pelvic ramus. Unable to perform MRI
2/2 valve and pacer. CT pelvis negative for pelvic fx. Pain controlled
with APAP as needed physical therapy consult obtained 6/25 and to follow daily at rehab.
---
2. ) GYN: CT pelvis did show R adnexal cyst on prelim read which will need
further characterization by US and outpt follow up.
---
3. ) CV: She has extensive cardiac history as above. Her fall is not
likely related to cardiac issue as it appears mechanical , no syncope ,
chest pain , etc. ISCHEMIA: NSTEMI with small TnI leak , likely demand
related in setting of hypovolemia , fall. Enzymes trended down. PUMP: Dry
on admission. Rehydrated with IVF , orally's encouraged. Euvolemic by 10/22 .
JVP up to 12cm , but difficult to gauge volume status 2/2 TR. To
recommence lasix at half dose 2/10 . primary care physician to monitor and titrate back to
40 mg daily baseline dose if tolerated. IVF d/c'd. RHYTHM: She has
prolonged QT on admission , on telemetry. Unclear etiology ?starvation.
Monitored on tele until ROMI. Avoided drugs that confound. Resolved to
QTc in low 500s. DDD pacer functioning with V-pacing at 60bpm
---
4. )ENDO: Holding Glypizide while in house. Novolog sliding scale.
Starting low dose NPH 6 units twice a day on 10/22 . Monitored FS daily and
adjusted scale as needed
---
5. ) HEME: She is on Coumadin for St. Judes Valve , afib/flutter and hx
PEs. She did not take coumadin the last two nights before admission
because of lying on the floor history of fall. Her INR was subtherapeutic on
admission. Bridged with lovenox and INR therapeutic 10/22 and restarted on
home regimen of 5/2.5mg variable dose.
***Needs to be dosed daily because of variable dose
---
6. ) FEN: of note patient on 80mg lasix daily at home yet dry on admission with
worsening renal fx , thus lasix held. Restarted on lasix 20 every day on day
of d/c - to be monitored by primary care physician
---
7. ) PPX Lovenox/coumadin
---
FULL CODE
ADDITIONAL COMMENTS: 1. VNA to draw INR Q3 days and call primary care physician with result for coumadin dosing
management/adjustments.
2. primary care physician to follow-up with HgA1C and manage DM medications. Recommend patient
be started on STATIN and LFTs followed.
3. Physical Therapy to follow daily at rehab for strength/conditioning/
ambulatory/ safety needs.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TROKEY , CLARITA K. , PA ( ZU74 ) 4/15/06 @ 11:11 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 519
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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719243531 | PUO | 24802754 | | 560392 | 10/15/2002 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/26/2002 Report Status: Signed
Discharge Date:
PRIMARY DIAGNOSIS ON ADMISSION: SYNCOPE.
SECONDARY DIAGNOSIS: CORONARY ARTERY DISEASE , STATUS POST
STENTING , AND BRADYCARDIA.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with
coronary risk factors of diabetes
mellitus , insulin dependent diabetes , hypertension , age , and
elevated cholesterol , who was admitted to the Cardiology Service
after a syncope in vascular clinic. Patient was in her usual state
of health while in vascular clinic , awaiting to discuss the results
of arterial studies with her vascular surgeon , when she noted to
slump over in the chair in the waiting room for about 1-2 minutes.
She was unresponsive at the time. A code blue was called. By the
time the code team arrived to the scene , the patient was awake and
alert , with a regular pulse. Her blood pressure was noted to be in
the 140s. The patient did not recall an aura or a prodrome. She
denied any incontinence and aura or postictal confusion. She was
taken to the Emergency Department for evaluation , where she was
afebrile , with a heart rate of 96.1 , heart rate of 100 , a pressure
of 178/82 , with oxygen saturation of 100% on room air. She was
then transferred to the floor for further evaluation and
management.
Her past medical history is as follows: 1. Coronary artery
disease , status post multiple catheterizations in the past. Her
most recent catheterization was in October of 2000 , which showed a
proximal RCA stenosis of 100% and a distal LAD lesion of 40-50%.
She was also noted to have luminal irregularities at the OM-1 at a
site of previous stenting. 2. Peripheral vascular disease ,
history of chronic ulcers , status post a left femoral to anterior
tibial bypass graft; also , status post a patch angioplasty in the
left groin. 3. Diabetes mellitus. Hemoglobin A1C of 9% in October
of 2002. 4. Hypertension. 5. Blindness , legally blind in both
eyes.
Medications on admission included enteric coated aspirin 81 mg orally
every day , captopril 50 mg orally three times a day , hydrochlorothiazide 25 mg q.
day , Isordil 40 mg orally three times a day , Lopressor 50 mg orally three times a day , NPH 15
U every day before noon regular 5 U every day before noon , Hytrin 5 mg orally every day , Procardia XL
60 mg orally every day , Lipitor 20 mg orally every day , Niferex 150 mg orally
twice a day , and Naprosyn 325 mg orally every day. The patient has no known
drug allergies.
SOCIAL HISTORY: She lives in Nordecho Monte near her daughter. She
spends most of her time at home. She does not
smoke and does not drink alcohol.
PHYSICAL EXAM ON ADMISSION: She was afebrile. Heart rate was 50
and regular. Blood pressure was
140/80. Respiratory rate was 20 , saturation of 98% on room air.
She was a pleasant African American woman lying in bed. She has
her right eye closed. She had a surgical right pupil , with a left
cataract. Her oropharynx was benign , her mucous membranes were
moist. She had no jugular venous distention. There was a question
of soft bilateral carotid bruits. The lungs revealed decreased
breath sound at the left apex , but otherwise was clear to
auscultation. Cardiovascular exam revealed a regular rate and
rhythm , there were no murmurs appreciated in the Emergency
Department. The abdomen was soft , without hepatosplenomegaly. In
the extremities , there are incisional scars at the medial calves on
both legs , with 1+ DP pulses bilaterally , her legs were warm , and
there was no edema. On neuro exam , she was alert and oriented x 3 ,
cranial nerves III-XII were grossly normal , and her motor exam was
without focal deficits.
LABORATORIES OF NOTE: Her potassium was 3.8 , her BUN was 39 , and
her creatinine was 1.9 , her baseline
creatinine being anywhere between 1.7 and 2.0. Glucose was 122.
Her troponin on admission was 0.32 , and of note , back in October
she had also been admitted and was noted to have a troponin in the
.3 range. Her CK on this admission was 308 , with an MB fraction of
3.9. Calcium was 9.2 , magnesium was 2.7 , white blood cell count
6.1 , hematocrit 36 , platelets 238. Her UA was negative. Her EKG
showed normal sinus rhythm at 85 , with left axis deviation ,
evidence of LVH , left atrial enlargement , and some T wave
flattening in V4 through 6 and T wave inversion in 1 and L. Her
chest x-ray was without infiltrate or pulmonary arterial
congestion.
In summary , this is a 65-year-old woman with vasculopathy and
extensive coronary artery disease , who presented with sudden
syncope x 1-2 minutes. Given the history , the story was very
concerning for a malignant arrhythmia. She was admitted for
further workup of ischemic or malignant arrhythmia causes of her
syncope.
Her hospital course is summarized by systems: 1. CARDIOVASCULAR:
The patient was placed on the monitor and no definitye symptomatic arrhythmias
were observed. However , because of her demonstrated asymetrically
hypertrophied left ventricle and ergions of inferoposterior scar ,
electrophysiology study was recommended ( see below and addendum ).
The patient was initially admitted with a troponin of
0.32 , which on repeat examination was 0.87. It was
thought to be consistent with a very small non-Q-wave MI. She was
started on heparin for 48 hours. On 10/30/2002 , the patient had an
adenosine MIBI , which showed a moderate size lesion of
inferolateral and a small apical region of reversible ischemic.
She had a cardiac catheterization on 1/9/2002 , which revealed an
80% proximal circumflex lesion which was stented to 0%. She had an
echocardiogram performed on 3/10/2002 , which showed a left atrium of 2.9 cm.
She had asymmetric left ventricular hypertrophy , with preserved overall
systolic function and an ejection fraction estimated to be 60%. This was
thought to be a potential source of focus for ventricular arrhythmias , and
further supported the decision to go to electrophysiology study.
2. PULMONARY: One of the considerations entertained to explain
the patient's syncope was a potential pulmonary embolus. Though
she had not been hypoxic on presentation , the sudden nature of the
event , as well as her tachycardia , was felt to warrant further
workup for a PE. She had a D-dimer sent , which came back at >1000.
She later had a VQ scan which was read as low probability. Lower
extremity noninvasive ultrasounds of both legs revealed no
thrombus.
3. ENDOCRINE: The patient has insulin dependent diabetes
mellitus. We continued her morning NPH dose and covered her with
regular insulin sliding scale for the remainder of her
hospitalization. Her sugars were relatively well controlled
throughout.
4. SOCIAL/PSYCH: The patient has a known difficult home
situation , with previous known problems with her son and other
family members. Social Services was involved. They interviewed
the patient and involved a consult to Chedent Medical Center . At the
time of this dictation , that evaluation is still pending.
The final disposition of the patient is still pending at this time.
I will complete this dictation at the time of discharge , including
the patient's disposition and disposition medications.
Dictated By: ELIZ RUBIANO , M.D. GI61
Attending: BRITTANEY HAMBLET , M.D. RM52 ER952/661083
Batch: 24972 Index No. ADJDP795YR D: 7/22/02
T: 7/22/02
Document id: 520
| Target |
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GER |
Gou |
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Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
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Y |
N |
N |
893863242 | PUO | 71047122 | | 8847960 | 9/17/2005 12:00:00 a.m. | infected lt. total hip replacement | Signed | DIS | Admission Date: 9/17/2005 Report Status: Signed
Discharge Date: 10/3/2005
ATTENDING: FANIEL , GAYLENE M.D.
SERVICE: Orthopedic Service.
PRINCIPAL DIAGNOSIS: Infected left total hip replacement.
PRINCIPAL PROCEDURE: Removal of infected cemented left total hip
replacement with debridement of the hip and placement of
antibiotic-impregnated cement spacers on 2/16/05 .
HISTORY OF PRESENT ILLNESS: Ms. Breath is a 46-year-old female
with multiple medical problems who initially sustained a left hip
intertrochanteric fracture in October of 2004 and underwent an
ORIF with a DHS on 10/15/04 . The screw ultimately cut off and
she underwent removal of hardware on 9/28/04 with insertion of a
hemiarthroplasty with antibiotic beads. Her culture grew
coag-negative staph at that time and she was treated with six
weeks of intravenous antibiotics. After multiple hip aspirations to
confirm that the joint was no longer infected , she underwent a
left total hip replacement on 8/15/04 by Dr. Lemmen . She ended
up being hospitalized in Navzemoyd Boulevard , Ga Cosey , Arizona 41045 from 3/5/05 to 8/16/05
with an E. coli bacteremia of unclear etiology , although it was
felt likely secondary to pyelonephritis. During that
hospitalization , she developed neck pain and was found to have
MRSA osteomyelitis at C6-C7. She underwent a C6-C7 I&D infusion
on 5/24/05 . She ultimately completed 16 weeks of intravenous vancomycin
for her MRSA spinal infection and at the completion of the
vancomycin therapy in February of 2005 , was started on minocycline
with a plan for a six-month treatment. She ultimately presented
to Dr. Lemmen 's office on 7/13/05 with increasing left
groin/hip/lateral thigh pain over several months duration. Two
left hip aspirates in August , both grew MRSA , and as such , she
was scheduled for an explant of her left total hip replacement
with insertion of an antibiotic spacer on 2/16/05 .
PAST MEDICAL HISTORY:
1. Diabetes mellitus type II.
2. Myasthenia gravis.
3. Hypertension.
4. Steroid-dependent asthma with multiple intubations as a young
adult.
5. Depression.
6. GERD.
7. GI bleeds for which she was hospitalized in the 1980's.
8. DVT and PE in 2003.
9. Obstructive sleep apnea , on home CPAP.
10. Osteoporosis.
11. Peripheral neuropathy.
12. Diverticulitis.
13. Migraines.
14. Obesity.
15. History of pneumonia x3.
16. History of septic right shoulder.
17. Cervical discitis and vertebral osteomyelitis.
PAST SURGICAL HISTORY:
1. Left hip DHS , 10/15/04 .
2. Removal of hardware , left hip with insertion of
hemiarthroplasty with antibiotic spacer on 9/28/04 .
3. Revision left total hip replacement on 11/8/04 .
4. I&D with cervical fusion , 5/24/05 .
5. Arthroscopic right shoulder I&D , August of 2003.
6. Partial colectomy/oophorectomy in February of 2003.
7. Cholecystectomy in early 2005.
MEDICATIONS ON ADMISSION:
1. OxyContin 80 orally twice a day
2. Percocet two tabs orally every 6 hours as needed
3. Neurontin 300 mg orally three times a day
4. Fioricet one to two tabs orally every 6 hours as needed
5. Fentanyl patch 200 mcg every 72 hours
6. Multivitamin.
7. Ativan 1 mg orally three times a day as needed
8. Minocycline 100 mg orally twice a day
9. Protonix 40 mg orally daily.
10. Singular 10 mg orally daily.
11. Reglan 10 mg orally before every meal
12. Os-Cal one tab orally daily.
13. Folate 1 mg orally daily.
14. Lexapro 20 mg orally daily.
15. Mestinon 60 mg orally three times a day
16. Mirtazapine 15 mg orally at bedtime.
17. Zofran 4 mg orally as needed
18. Prednisone 40 mg orally daily.
19. Advair 500/50.
20. Albuterol/ipratropium as needed
ALLERGIES:
1. Imitrex causes vomiting.
2. Vicodin causes vomiting.
3. intravenous contrast dye causes throat burning.
SOCIAL HISTORY: The patient is single and lives alone in Pring Con She quit smoking tobacco 25 years ago and does not drink
alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Remarkable for an obese
female , ambulates with a walker and an antalgic gait on the left.
She had mild tenderness with palpation in her mid cervical
spine. She had some mild distal left upper extremity and
proximal left lower extremity weakness. Gentle range of motion
of her left hip caused pain.
HOSPITAL COURSE: The patient was admitted on 1/9/05 for
initiation of intravenous antibiotic therapy at the request of the
Infectious Disease Service under the direction of Dr. Tiana E Lapin . Prior to the initiation of antibiotic therapy , she had
blood cultures drawn , which ultimately showed no growth. Given
her neck pain and slight weakness , she also had an MRI of her
cervical spine performed , which showed no evidence of
osteomyelitis. Preoperatively , she was seen by both the
Infectious Disease Consult Service as well as the Medical Consult
Service. She was placed on a low-dose beta-blocker at the
recommendation of the Medical Consult Service. On the morning of
hospital day 2 , the beta-blocker was then discontinued under the
recommendation of the Medical Consult Service , as it was felt to
likely add little benefit. She did receive one dose of Coumadin
the night before surgery in preparation for DVT prophylaxis. She
was ultimately taken to the operating room on hospital day 2
where she underwent removal of her left total hip replacement
with irrigation , debridement and placement of an antibiotic
spacer. Estimated blood loss was 2.5 L. She received six units
of packed red blood cells , 9 L of crystalloid and 1 L of albumin.
Intraoperatively , gross pus was found. Intraoperative cultures
were sent , which ultimately grew MRSA. The patient received
perioperative stress dose hydrocortisone. Postoperatively , she
was taken to the surgical intensive care unit and intubated. Her
postoperative hematocrit was 29.2. The morning of postoperative
day 1 , the patient remained intubated but was able to open her
eyes and follow commands. She was neurovascularly intact in the
left lower extremity. She was treated with Lovenox only
initially given that she did not initially have an NG tube so
that orally medications including Coumadin could be administered.
She was continued on the vancomycin. The patient remained
intubated throughout the remainder of postoperative day 1 and
into the morning of postoperative day 2. Her hematocrit had
drifted down to 22.4 on postoperative day #1 for which she was
transfused two units with her hematocrit up to 26.2. She
continued to remain hemodynamically stable and neurovascularly
intact. An NG tube had been placed on postoperative day 1 , so
that orally medications including her Mestinon could be given for
her myasthenia gravis. She was ultimately extubated mid morning
on postoperative day 2. Her dressing was changed at that time
and the incision was clean and intact without any erythema. The
patient remained in the surgical ICU until postoperative day 3 ,
mainly with continued pain issues. She had been on a fentanyl
drip and was transitioned over to Dilaudid PCA. She was started
on clear diet on postoperative day 3 and transitioned over to
regular insulin sliding scale from the insulin drip that she had
been on to the early a.m. hours of postoperative day 3. Her
hematocrit remained stable in the high 20s. Her right IJ central
line was changed out over a wire under sterile technique in the
ICU on postoperative day 3 prior to transfer to the floor. She
was transferred to the floor in stable condition lat in the day
on postoperative day 3. She was taking orally's at that time and
her home medications were restarted including her home
prednisone. Postoperative day 4 , pain continued to be her main
issue and she was seen by the Chronic Pain Service for
recommendations on transitioning her off of the high-dose
Dilaudid PCA. PCA was discontinued and she was started on as needed
oxycodone in addition to her home a fentanyl patch and OxyContin.
Physical Therapy worked with the patient throughout her hospital
stay and were able to first sit her up on the edge of the bed on
postoperative day 4. She continued to remain afebrile ,
hemodynamically stable and neurovascularly intact throughout the
remainder of her hospitalization. Her hematocrit was stable in
the high 20s. She had a PICC line placed on postoperative day 5
for administration of her long-term intravenous vancomycin. The Pain
Service continued to see the patient and titrate her pain
medications with gradually improving effect. The Foley was
discontinued the morning of postoperative day 6 , as the patient
began to be able to move around a little more easily. By
postoperative day 7 , she was more comfortable , was tolerating a
regular diet and voiding every shift without a Foley. She was
afebrile , hemodynamically stable and neurovascularly intact. She
was continued on both Coumadin and Lovenox given that her INR was
still not therapeutic. She should continue on the Coumadin with
a Lovenox bridge until the INR is therapeutic. The patient was
cleared for transfer to rehab on postoperative day 7 by the
Orthopedic Infectious Disease and Physical Therapy services. She
was accepted for transfer to the Circ Stonmont Valley Hospital Medical Center in Akson , North Dakota 07986 ,
Au La Chat
DISCHARGE DISPOSITION: To rehabilitation.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed pain.
2. Erythropoietin 40 , 000 units subcutaneously every week.
3. Fentanyl patch 200 mcg every 72 hours
4. Folate 1 mg orally daily.
5. Regular insulin sliding scale subcutaneously before every meal and at bedtime.
6. Ativan 1 mg orally every 6 hours as needed anxiety.
7. Reglan 10 mg orally before every meal
8. Prednisone 40 mg orally every day before noon
9. Mestinon 60 mg orally three times a day
10. Vancomycin 1.5 gm intravenous every 12 hours for a total of five more weeks
to make six weeks total.
11. Multivitamin one tab orally daily.
12. Neurontin 300 mg orally three times a day
13. OxyContin 100 mg orally three times a day
14. Dilaudid 10 to 12 mg orally every 2 hours as needed pain.
15. Clonidine 0.1 mg orally twice a day
16. Mirtazapine 50 mg orally at bedtime.
17. Singular 10 mg orally daily.
18. Combivent two puffs inhaled four times a day
19. Advair Diskus 500/50 one puff inhaled twice a day
20. Caltrate 600 plus D one tab orally daily.
21. Nexium 40 mg orally daily.
22. DuoNeb 3/0.5 mg nebulized every 6 hours as needed
23. Lexapro 20 mg orally daily.
24. Colace 100 mg orally twice a day
25. Coumadin daily based on goal INR of 1.5 to 2.5. DVT
prophylaxis as planned for a total of four weeks. Her dose the
evening before discharge was 8 mg and at the time of this
dictation. The day of discharge INR is pending.
26. Lovenox 40 mg subcutaneously daily , to be discontinued when her INR
is greater than 1.5 for 48 hours.
DISCHARGE ACTIVITIES: Touchdown weightbearing with anterior
dislocation precautions and troche off precautions.
DISCHARGE FOLLOW-UP APPOINTMENTS:
1. With Dr. Aspen on 10/14/06 with an x-ray at noon and an
appointment at 1:00 p.m.
2. Dr. Lemmen on 10/14/06 at 1:30.
3. The patient should follow up with her Infectious Disease
physician in Brookord Blvd , Ville Coll , Indiana 04958 with whom Dr. Tiana Lapin from the
Kernan To Dautedi University Of Of Infectious Disease Service has been interacting.
4. The patient should follow up with her local spine surgeon.
DISCHARGE INSTRUCTIONS: Dry sterile dressings should be applied
to the wound daily. It may be left open to air when dry. The
staples may be removed as of 10/19/05 if the wound has been
completely dry. Otherwise , that removal should be delayed until
6/12/05 . At that time , the wound should be steri-stripped.
When the patient is discharged home , blood draws for physical therapy and INR
should be arranged every Monday and Thursday with results called to
the PUO Anticoagulation Service at 988-605-5355 extension 1. The
goal INR is 1.5 to 2.5 with DVT prophylaxis for four weeks. The
Anticoagulation Service at the Kernan To Dautedi University Of Of should be notified with
the patient is discharged home. As mentioned , the Lovenox should
be discontinued when the INR has been greater than 1.5 for two
consecutive days. Furthermore , a weekly CBC , BUN and creatinine
as well as vancomycin trough should be monitored while the
patient is on intravenous vancomycin.
eScription document: 7-2559018 CSSten Tel
Dictated By: STENCEL , CAROL
Attending: FANIEL , GAYLENE
Dictation ID 7127104
D: 5/29/05
T: 5/29/05
Document id: 521
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
N |
- |
921778812 | PUO | 49448215 | | 8968535 | 10/30/2002 12:00:00 a.m. | CHF | | DIS | Admission Date: 10/30/2002 Report Status:
Discharge Date: 2/23/2002
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
T
Service: MED
DISCHARGE PATIENT ON: 1/1/02 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CODA , TRANG HIEN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
Override Notice: Override added on 4/4/02 by
SOVIE , GUADALUPE PATRICA , M.D.
on order for COUMADIN orally 5 MG every bedtime ( ref # 26232245 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: md aware Previous override information:
Override added on 4/4/02 by PFAFF , TENESHA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: md aware
BENADRYL ( DIPHENHYDRAMINE HCL ) CREAM TP three times a day as needed pruritis
Instructions: to b/l extremities
Number of Doses Required ( approximate ): 4
PLAQUENIL ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: sbp < 100
LISINOPRIL 5 MG orally every day HOLD IF: sbp < 90 and call h.o.
Override Notice: Override added on 4/4/02 by
SOVIE , GUADALUPE PATRICA , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
29106216 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/4/02 by
SOVIE , GUADALUPE PATRICA , M.D.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: md aware Previous Override Notice
Override added on 4/4/02 by PFAFF , TENESHA , M.D.
on order for AMIODARONE orally ( ref # 89020741 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: md aware
LASIX ( FUROSEMIDE ) 160 MG orally every day before noon
Alert overridden: Override added on 4/4/02 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: md aware
LASIX ( FUROSEMIDE ) 80 MG orally every afternoon
Alert overridden: Override added on 4/4/02 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: md aware
DIET: Patient should measure weight daily
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Shalonda Aspacio 1 week ,
Arrange INR to be drawn on 2/2/02 with f/u INR's to be drawn every
7 days. INR's will be followed by Dr. Shalonda Aspacio
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CHF
history of St. Jude MVR for MS ( history of cardiac valve replacement ) Hx AFib/flutte
r ( history of atrial fibrillation ) history of IMI ( history of myocardial infarction ) NIDDM
( diabetes mellitus ) gout
( gout ) Hx DVT '70 ( history of deep venous thrombosis ) history of appy ( history of
appendectomy ) history of umbilical hernia repair ( history of hernia repair ) history of
sigmoidectomy for diverticulitis history of L hip # '95 ( history of hip
fracture ) PE ( pulmonary embolism )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
EKG , chest x-ray
BRIEF RESUME OF HOSPITAL COURSE:
80 year-old female cc:b/l leg swelling , pain and itching. PMH signficant
for DM , HTN , history of MI with CHF history of MS repaired with St jude's who presents
with 3 weeks of b/l leg swelling redness and itching. She got Erythro
and then avalox from PMD for presumed cellulitis without improvement. patient
states that she has had multple episodes of CP , SOB relieved by NTG
over last couple of weeks , and increasing orthopnea and DOE. On PE
afeb , VSS wnl , 10 cm JVD , rrr , cta b/l , LE - b/l 1-2+
edema with signs of chronic skin changes. Labs sign
for BUN 35 ( 24 on 7/18 ) and creatinine 2.4 ( 1.8
on 7/18 ). EKG 1 deg HB , RBB , Q in III and avf -
no significant change from 10/16/02 .
1 ) CV - sx most likely due to CHF; diuresed with intravenous lasix with prompt
improvement in symptoms and LE edema. Cardiac enzymes negative.
2 ) renal - Cr improved during admission to baseline , likely secondary
to prerenal azotemia.
3 ) ID - d/c antibiotics , no clinical evidence of infection/cellulitis
4 ) pain - tylenol , benadryl cream , elevate legs
5 ) rash on legs and trunk ?drug rxn to erythromycin. Will f/u with primary care physician.
Given topical antihistamines for sx relief.
patient discharged with lasix for diuresis and f/u VNA for wt check , BP check ,
INR , BUN and creatinine check
ADDITIONAL COMMENTS: For VNA: please do daily weight checks ( dry weight 150 ) and blood
pressure checks. Phelbotomy check INR 2 days after discharge from
hospital and thereafter according to instructions from primary care
physician. PLease check BUN and creatinine daily and report results to
primary care physician
For patient: please call primary care physician to schedule
appointment in 1 week
DISCHARGE CONDITION: Stable
TO DO/PLAN:
for VNA: please do daily weight and blood pressure checks
phlebotomy: please check bun , creatinine daily and send results to PMD.
Please check INR 2 days after hospital discharge and then according to
PMD instrutctions. thank you
No dictated summary
ENTERED BY: FERRIERA , EVAN KRISTIE , M.D. , PH.D. ( HC74 ) 1/1/02 @ 10:47 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 522
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
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196429612 | PUO | 75809913 | | 538755 | 5/12/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/20/1991 Report Status: Unsigned
Discharge Date: 7/9/1991
HISTORY OF PRESENT ILLNESS: Patient is a 35 year old black female ,
gravida I , para l , last menstrual
period 9/7/9l with a chief complaint of menorrhagia and a large
fibroid uterus. Patient had a history of chronic pelvic pain for
the past three years with lower back pain. She has had a history
of known fibroids and at the time of this surgery , was requesting
definitive surgery. She has a history of a heart murmur , was seen
by Cardiology in 9/6 , and cleared with a normal echocardiogram
and no need for SBE prophylaxis. Her EKG was within normal limits
except for sinus tachycardia. The patient is status post a
cesarean section. Other medical problems include that she has
recently diagnosed diabetes and takes Glyburide 5 mg orally every day
ALLERGIES: She has no allergies.
PHYSICAL EXAMINATION: Her heart rate was 96 , her respiratory rate
was l2 , blood pressure ll0/70 , and
temperature was 98.9. She was an obese black female in no acute
distress. HEENT: Negative. BREASTS: Clear without masses.
LUNGS: Clear. HEART: Regular rate and rhythm with a I/VI
systolic ejection murmur. ABDOMEN: Soft and non-tender with a
previous midline vertical incision secondary to her previous
cesarean section. PELVIC: She had a fourteen to sixteen week size
fibroid uterus and her adnexa were unable to be evaluated.
LABORATORY EXAMINATION: Patient had a pre-operative hematocrit of
35.3. Her height was five foot two and
she was l80 pounds.
HOSPITAL COURSE: Patient was taken to the Operating Room on
2/6/9l with a pre-operative diagnosis of
fibroid uterus , pelvic pain , and menorrhagia. Post-operative
diagnosis was same. In addition , there were extensive pelvic
adhesions. Procedure was exploratory laparotomy , lysis of
adhesions , total abdominal hysterectomy , and left
salpingo-oophorectomy. Surgeon was Dr. Kam Isa and assistant
was Dr. Sana Azua . Anesthesia was general per endotracheal
tube. Estimated blood loss was 500 cc. There were no
complications. Operative findings included the uterus to be
enlarged at approximately twelve to fourteen weeks in size and
slightly boggy. Both ovaries and tubes were densely adherent to
her pelvic sidewalls and the cul-de-sac. She had adhesions of the
cul-de-sac and rectosigmoid to the posterior portion of the uterus.
She also had omental adhesions to the anterior abdominal wall in
the upper abdomen. Patient's Pathology Report revealed , of the
uterus , leiomyomata with multiple serosal adhesions with
proliferative endometrium and adenomyosis. The left tube revealed
endometriosis and left ovary hemorrhagic corpus luteum. Her cervix
was noted to have mucinous mucus cyst. Patient had a stable
post-operative course. On post-operative day one , her Foley was
discontinued. She was started on sips of clears and had a low
grade temperature to l00.6. Her hematocrit was 30.4 with a white
count of ll.l and a platelet count of 336. Her urinalysis was
clear. On post-operative day three , she was advanced to a regular
diet. She had a low grade temperature to l00 and was continued on
nebulizers. It was felt her low grade temperature was secondary to
atelectasis. Her urine culture was negative. She had one episode
of vomiting on post-operative day four which was felt to be
secondary to a mild ileus. She had a KUB obtained which was
contained with a post-operative ileus with no dilated loops and few
air fluid levels. On post-operative day five , she was feeling
better. On post-operative day six , she was placed on clears and
was then advanced to a regular diet on post-operative day six. She
is discharged home on post-operative day seven in stable condition
tolerating a regular diet after having had a bowel movement.
DISPOSITION: She will follow-up with Dr. Kam Isa at CHH .
VO467/1009
KAM R. ISA , III , M.D CY53 D: 1/27/91
Batch: 0015 Report: W7170U9 T: 9/27/91
Dictated By: TRISH L. CHAIX , M.D. OT39
Document id: 523
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
N |
Y |
- |
Y |
N |
N |
N |
N |
N |
N |
510916525 | PUO | 07122247 | | 3066584 | 7/20/2005 12:00:00 a.m. | Volume overload | | DIS | Admission Date: 2/7/2005 Report Status:
Discharge Date: 5/3/2005
****** FINAL DISCHARGE ORDERS ******
FULVIO , ANGILA P 456-02-11-5
Lan Bofayra Car
Service: RNM
DISCHARGE PATIENT ON: 8/13/05 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VANMARTER , ALFREDO B D. LILA
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALLOPURINOL 300 MG orally every day
ASPIRIN ENTERIC COATED 325 MG orally every day
ATENOLOL 100 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day HOLD IF: SBP<100
TACROLIMUS 1 MG every day before noon; 2 MG every afternoon orally 1 MG every day before noon 2 MG every afternoon
Starting Today August Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally 3x/Week M-W-F
Instructions: Please give on M , W , F
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 500 MG orally three times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
AMARYL ( GLIMEPIRIDE ) 4 MG orally every day before noon HOLD IF: While NPO
Number of Doses Required ( approximate ): 2
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
LANTUS ( INSULIN GLARGINE ) 18 UNITS subcutaneously every afternoon
HOLD IF: While NPO
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Norseth 9/24 at 9AM scheduled ,
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
Volume overload
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Volume overload
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pain hypotension
CAD ( coronary artery disease ) CHF ( congestive heart failure ) diabetes
( diabetes mellitus type 2 ) renal transplant ( kidney
transplant ) AAA repair ( abdominal aortic aneurysm ) open chole
( cholelithiasis ) hypertension ( hypertension )
OPERATIONS AND PROCEDURES:
Replacement of Pacer generator.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
Dx: Volume overload ( Increasing edema and SOB )
*****
HPI:74M ESRD , LURT ( 10/20 ). Now with 3wks increasing edema , with
20lb weight gain. SOB. Has not been compliant with Lasix , and consumed 2
cans of salted cashews.
*****
Physical examination: VSS stable , O2 sat-97% RA , RR-20. Bibasilar rales ,
improved. RRR , S1 , S2 , S3. Increased ab girth. LE edema 2+ B/L.
*****
Labs/Studies: Stable Cr-1.7 , otherwise wnl. EKG- V-Pacer , Prolonged
QT , no St-T changes. CXR-Mild Pul edema , BNP-350.
*****
Hospital course:
74M ESRD history of LURP ( 10/20 ) who presented with volume overload due to
medication and diet non-compliance. He had mild decompensated CHF with
pulmonary edema , however no hemodynamic or respiratory compromise. He did
not have ACS. He was treated with Lasix , daiuresed total of 5L , with
imoprovement of his LE edema and respiratory condition. His renal
function remained stable , with Cr-1.7. FK-506 levels were monitored and
seemed to be on the high side , therefore dose was decreased from 3mg to
2mg/d. At the same admittion , had an uneventful generator replacement in
his pacer. ( Please refer to separate note ).
ADDITIONAL COMMENTS: Take it easy.
Please stick to the low salt diet.
Continue daily Lasix 80mg twice a day!!!
Please write down your daily weights until your appointment with Dr.
Norseth .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Consider ACE-I to better control his BP.
No dictated summary
ENTERED BY: BOSSERT , CHAROLETTE S. , M.D. ( PF61 ) 8/13/05 @ 10:05 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 524
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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997044127 | PUO | 54837690 | | 3849859 | 1/16/2006 12:00:00 a.m. | Abdominal cramps | | DIS | Admission Date: 6/22/2006 Report Status:
Discharge Date: 1/26/2006
****** FINAL DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
Ey
Service: GIX
DISCHARGE PATIENT ON: 8/3/06 AT 01:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SAMPEY , VAUGHN J. M. D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ATENOLOL 50 MG orally DAILY HOLD IF: sbp < 100
KLONOPIN ( CLONAZEPAM ) 1 MG orally three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
LIDOCAINE 5% PATCH TOPICAL TP DAILY
Instructions: Apply to affected area on stomach
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
DITROPAN XL ( OXYBUTYNIN CHLORIDE XL ) 5 MG orally DAILY
Number of Doses Required ( approximate ): 5
PERCOCET 1 TAB orally every 4 hours as needed Pain
COMPAZINE ( PROCHLORPERAZINE ) 5-10 MG orally every 6 hours as needed Nausea
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
SIMETHICONE 80 MG orally four times a day
DIET: Clear liquids / Adv. as tol.
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Sampey in 1 week; Need to call for appointment. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Post-endoscopic pouch reduction pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Abdominal cramps
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1
morbid obesity ( obesity ) obstructive sleep apnea ( sleep apnea )
psoriasis ( psoriasis ) history of gastric bypass 6/22 ( history of gastric bypass
surgery ) normal cardiac cath 1/29 ( ) borderline ETT
11/21 history of chole ( history of cholecystectomy ) history of exudative pleural effusion
( history of pleural effusion ) history of splenic
infarct empty sella syndrome ( empty sella syndrome ) chronic LBP with
several herniated discs ( ) chronic HAs ( )
OPERATIONS AND PROCEDURES:
history of Endoscopic pouch reduction.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none.
BRIEF RESUME OF HOSPITAL COURSE:
CC: Ab pain
**************************
HPI:42F with htn , anxiety , obesity history of gastric ypass 2001 , now with ab
pain. Has had increased pouch sive , inc appetite. Had outpt
endoscopic procedure today with out complication , but post proceudre had
pain ( typically outpt proc ). KUB neg for free air. VS
stable . patient admitted for obs and pain mgmt ,
***************************
STUDIES: KUB/CXR: no free air ( 5/6 , 10/10 )
***************************
Hospital course:
GI: history of procedure.
Watch for complication: 1. ) Perf ( clear kub ) , 2. ) Infection ( afebrile ) ,
3. ) Bleed ( Hct stable ) 4. ) Hernia. patient initially managed with pain meds
with low threshold to escalate therapy as needed ( i.e. abx , etc. ) Blood
cx , urine cx sent for low grade fever 100 , but negative. Serial Kub/CXR
did not show free air , though patient had continued pain ( more crampy in
nature , increasing with food intake ). An AbCT with small contrast
performed to r/o hernia. She passed gas and stool and toelrated clears
( though with some passing discomfort ). She was started on simethicone.
Pain , initially controlled with intravenous opiateswas transitioned to orally ( kept
short acting for presumed short duration. Given positive karnetts
signs , she was also started on local lidocaine patch. She had some
vomiting on day 2 ( non-bloody ) , though following this , did not require
antiemetics. She should follow with Dr. Sampey for post procedure check
and return to baseline.
ADDITIONAL COMMENTS: 1. ) Take small meals. Will slowly be able to advance as directed.
2. ) Continue to take simethicone 4 times daily with meals
3. ) Apply lidocaine patch to affected area on stomach.
4. ) Continue percocet as needed for additional pain. Try to minimize use
as this will slow down bowel function and can increase constipation.
5. ) Take colace , senna as directed for constipation
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. ) Need to follow for resolution for pain.
2. ) Ensure getting sufficent nutrition with reduced pouch size.
3. ) Continue to follow history of endoscopic procedure.
No dictated summary
ENTERED BY: VALERI , CLAIRE , M.D. , PH.D. ( VN94 ) 8/3/06 @ 12:59 PM
****** END OF DISCHARGE ORDERS ******
Document id: 525
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
Y |
N |
N |
- |
N |
N |
- |
N |
N |
Y |
Y |
N |
N |
997044127 | PUO | 54837690 | | 091661 | 11/27/2001 12:00:00 a.m. | atypical CP | | DIS | Admission Date: 5/11/2001 Report Status:
Discharge Date: 4/13/2001
****** DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
Poncene
Service: CAR
DISCHARGE PATIENT ON: 7/29/01 AT 09:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DOCIMO , STEFFANIE TENNILLE , M.D. , PH.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
KLONOPIN ( CLONAZEPAM ) 1 MG orally every day as needed anxiety
BENADRYL ( DIPHENHYDRAMINE HCL ) 25 MG orally HS as needed insomnia
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
ZESTRIL ( LISINOPRIL ) 10 MG orally every day HOLD IF: sbp<100
Override Notice: Override added on 7/29/01 by
CARPENTIER , HYMAN M. , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 50738733 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: following levels
MAALOX PLUS EXTRA STRENGTH 15 milliliters orally every 6 hours
as needed Indigestion
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
NIFEREX TABLET 50 MG orally twice a day
Number of Doses Required ( approximate ): 10
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
your primary care physician 1-2weeks ,
Dr. Brisson 2-3weeks ,
No Known Allergies
ADMIT DIAGNOSIS:
atypical cp
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical CP
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1
morbid obesity ( obesity ) obstructive sleep apnea ( sleep apnea )
psoriasis ( psoriasis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
echocardiogram--prelim report: preserved EF , no RWMAN
BRIEF RESUME OF HOSPITAL COURSE:
37 year-old woman with morbid obesity , history of gastric
bypass , HTN , long history of atypical angina. MIBI 6/22 with fixed inf
defect. COmes in today with episode of CP rad to left shoulder , assoc
with numbness.tingling of left face/left leg ,
weakness right arm.
1. CV - ruled out for MI , echo as above , consider radial cath to
settle issue
of poss cardiac origin for the CP--maybe as outpt 2. neuro - nml exam ,
doubt neuro etiology 3. GI - on
PPI 4. Psych - patient has signif history of anxiety
and depression , poss cause of these sx - will
cont klonipin ,
prozac and follow up with her Dr. Hare at Ey General Hospital 5. Heme
- HCT drop today March - will recheck in pm; no obvious bleeding--d/ch
ome if Hct stable
ADDITIONAL COMMENTS: call your doctor if you have chest pain or SOB
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WIEBERG , MELLIE M. , M.D. ( WS76 ) 7/29/01 @ 05:32 PM
****** END OF DISCHARGE ORDERS ******
Document id: 526
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
- |
827586944 | PUO | 55510007 | | 138638 | 11/11/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/20/1992 Report Status: Signed
Discharge Date: 7/10/1992
HISTORY OF PRESENT ILLNESS: The patient was a 46 year old woman
with a history of asthma , who was
admitted with an asthma exacerbation. She had asthma since
childhood , never intubated , never previously treated with steroids.
She felt upper respiratory symptoms 5 days before admission. She
had dyspnea 2 days before admission. In the emergency room , the
patient had a peak flow of 300 , oxygen saturation 92% on room air.
She was treated with steroids , Solu-Medrol and then prednisone 60
milligrams orally , beta agonist , nebulizer and ampicillin. She had
continuation of orally theophylline as she had been using as an
outpatient. Her lung examination showed wheezes bilaterally in the
emergency room. PAST MEDICAL HISTORY was significant for asthma ,
degenerative joint disease , lower back pain , status post burn
injury. MEDICATIONS ON ADMISSION were Theo-Dur 200 milligrams by
mouth 3 times a day , prednisone 60 milligrams by mouth each day ,
Albuterol nebulizer , ampicillin 500 milligrams by mouth 3 times a
day and Bronkosol. ALLERGIES included sulfa drugs.
PHYSICAL EXAMINATION: The patient was an obese woman in no acute
distress. Temperature was 97.8 , heart rate
84 to 90 , blood pressure 110 to 132/70 to 84. Of note on the
physical examination her lungs had bilateral wheezes.
LABORATORY EXAMINATION: On admission , hematocrit was 41.6 , white
count 9.66 , platelets 199 , 000. SMA-7 was
within normal limits , theophylline level was subtherapeutic. Sputum
gram stain showed many gram positive cocci in clusters and pairs
with a few polys , and grew Hemophilus and a peri-influenza that was
sensitive to ciprofloxacin and Keflex , but resistant to ampicillin.
Chest x-ray was negative.
HOSPITAL COURSE: The patient slowly improved with decreased
wheezing in her breath sounds , increased peak
flow from 300 , went down to 270 , back up to 300 with less dyspnea
at the time of discharge and she was given an echocardiogram to
look for a cardiac etiology of bilateral pedal edema that she was
having. The patient was discharged on 6 of July .
DISPOSITION: The patient was discharged to home. MEDICATIONS ON
DISCHARGE were all her usual medications , plus Keflex
500 milligrams by mouth 4 times a day , prednisone 50 milligrams by
mouth each day. The patient was to FOLLOW-UP with Dr. Yi A Ogrodowicz at Ley Ma No , S Ty Valle , who can follow her pulmonary
status.
ME263/2681
DAMON B. KRINSKY , M.D. YX1 D: 4/25/92
Batch: 5679 Report: T4165A31 T: 4/3/92
Dictated By: DESIRAE R. MARCOTT , M.D.
cc: 1. YI OGRODOWICZ , M.D.
Document id: 527
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
N |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
- |
158845951 | PUO | 19054879 | | 9540064 | 3/4/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/10/2004 Report Status: Signed
Discharge Date:
ATTENDING: MACKENZIE TYACKE MD
The patient is a 58-year-old woman with no known CAD but multiple
cardiac risk factors including hypertension ,
hypercholesterolemia , and diabetes , who presents to the Kernan To Dautedi University Of Of
on the evening of 9/19/04 from her primary care physician office for possible
unstable angina. She was in her usual state of health until
approximately 10 days ago when she noted URI symptoms including
fevers , cough , rhinorrhea , and fatigue. Her coughing was
associated with left scapular pain; however , at this time she had
no chest pain. The patient actually denies any chest pain ,
although her primary care physician had a report of chest pain from her office.
Patient at baseline has excellent exercise tolerance. She works
as a security at the Sto and walks several blocks a
day without any chest pain or shortness of breath. She also
denies any PND , orthopnea , or leg swelling. There is some
question of recent weight gain of approximately 9 lbs according
to the MMC chart but otherwise patient has no other symptoms.
The patient's URI started approximately one week prior to
admission and her symptoms have resolved approximately two to
three days prior to admission. Upon presentation , she has
minimal cough but no fevers or chills. No nausea , vomiting ,
diarrhea , or constipation. No urinary or bowel changes.
PAST MEDICAL HISTORY:
The patient's past medical history is significant diabetes ,
poorly controlled hemoglobin A1c of 12.2 in 5/19
hypertension; hypercholesterolemia; hypothyroidism; asthma;
angioedema; diabetic retinopathy; diabetic neuropathy. No known
CAD. By report , negative ETT at KAAH greater than 10 years ago.
MEDICATIONS:
Her medications on admission are glyburide 10 mg twice a day ,
amlodipine 10 mg orally every day , Lipitor 10 mg orally every day , Lasix 40 mg
orally every day , KCl 20 mEq every day , and insulin 70/30 95 units twice a day
ALLERGIES:
The patient has several documented allergies including angioedema
to ACE inhibitors , angioedema to penicillin , metformin gives her
hives , simvastatin gives her myalgias , and sulfa drugs give her
renal failure.
SOCIAL HISTORY:
The patient has no documented history of tobacco use. She has
occasional alcohol and lives with a friend who is undergoing
surgery for her eyes at present.
FAMILY HISTORY:
She has a mother who had CHF in her 70s and a brother who
sustained CVA in his 70s.
ADMISSION EXAMINATION:
The patient's admission examination , she was afebrile at 97.9
with a pulse in the 80s , blood pressure 150s/90s , and O2
saturation 96% on 1.5 L. Her examination was significant for
general obesity. Her JVP was flat. Her heart was regular rate
and rhythm. She did have a 2/6 systolic ejection murmur with no
radiation. Her extremities , trace edema bilaterally.
Her admission labs were within normal limits. Her hematocrit was
36. Her creatinine was 1.2. She had a BMP that was 7 and her
enzymes have been negative during her admission. Her EKG showed
normal sinus rhythm with left atrial enlargement , T wave
inversions in I , aVL , V4 through V6 with no ST changes. However ,
none of these are new. Her chest x-ray was negative. There was
some question of lingular atelectasis. She had an echocardiogram
in 2002 that showed LVH with normal systolic function and normal
valves.
The patient is a 58-year-old woman with URI symptoms for
approximately 10 days whose symptoms are resolving. Her main
complaint now is fatigue. She denies any kind of chest pain or
shortness of breath and she is low probability for any cardiac
cause of her presentation. She has been on the rule out protocal and has
had serial enzymes and EKGs which have been negative. As an
outpatient , she will receive an echocardiogram to evaluate her
murmur and she will also perform an ETT as an outpatient as well
for risk stratification.
Her medications on discharge are unchanged.
eScription document: 2-1494363 EMSSten Tel
Dictated By: HOLLWAY , TABATHA
Attending: TYACKE , MACKENZIE
Dictation ID 3491864
D: 1/6/04
T: 1/6/04
Document id: 528
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
N |
- |
N |
Y |
Y |
Y |
N |
N |
Y |
Y |
Y |
N |
- |
756484975 | PUO | 14374811 | | 6161561 | 3/27/2006 12:00:00 a.m. | angina | | DIS | Admission Date: 3/7/2006 Report Status:
Discharge Date: 10/14/2006
****** FINAL DISCHARGE ORDERS ******
DAUGHTREY , CRISTA 716-33-91-2
Go An Fay
Service: CAR
DISCHARGE PATIENT ON: 2/15/06 AT 08:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TYACKE , MACKENZIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG inhaled every 6 hours
ALLOPURINOL 100 MG orally DAILY
AMOXICILLIN 250 MG orally three times a day X 9 doses
Food/Drug Interaction Instruction
May be taken without regard to meals
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY Starting Today July
ATENOLOL 25 MG orally DAILY
PULMICORT TURBUHALER ( BUDESONIDE ORAL INHALER )
1 PUFF inhaled twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
Starting Today July
Alert overridden: Override added on 9/6/06 by GOBRECHT , ALVERTA O L. , M.D. on order for LASIX orally ( ref # 813735976 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: home medication
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally four times a day
RANITIDINE HCL 150 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day as needed Constipation
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/6/06 by
TROOP , WILFREDO V. , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
553927728 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override:
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 9/6/06 by
TROOP , WILFREDO V. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override:
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please call your primary care physician for f/u appt ,
ALLERGY: intravenous Contrast , IRON ANALOGUES , Erythromycins ,
LEVOFLOXACIN , Sulfa
ADMIT DIAGNOSIS:
angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
angina
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ASTHMA/COPD aodm history of MI x 2 history of V FIB ARREST history of CABG 1/25 sleep apnea
obesity hypercholesterolemia history of chole history of dvt ->
greenfield aaa repair ( abdominal aortic aneurysm ) diverticular
abscess ( abscess ) gerd ( gastroesophageal reflux
disease ) gout ( gout ) dm neuropathy
( neuropathy ) carpal tunnel ( carpal tunnel syndrome ) chf ( congestive
heart failure ) iron def anemia ( baseline
30 ) cri ( 1.4 to 2 ) history of sigmoid colectomy 2/1 OSA ( sleep apnea ) history of R
CEA
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
74F hx/o CAD history of CABG 1996 , DMII , CHF , hyperlipid , AAA repair , GERD , hx/o
DVT history of Greenfield filter , anemia , who p/with CP c typical and atypical
features after recent TKR. patient was recently seen by Dr. Gruntz and sent
for dobutamine MIBI to risk stratify in prep for R TKR. Had MIBI on 10/8
which showed 86% MPRH , no clinical ischemia , no diagnostic EKG chagnes ,
MIBI c small reversible defect of mod intensity in mid and basal inferior
wall. This was not deemed significant and patient underwent TKR on
4/5 without cardiac complications. She was sent to rehab where she was
stable until 4/28 when she was discharged home. Yesterday she had 3 bouts
of chest pain at rest , lasting 5-10secs at a time , dull SSCP , rad to jaw ,
non-exertional , not assc c SOB , N , V , D. She does however report
intermittent nausea and vomiting since her surgery. SHe was admitted for
a rule out and possible repeat catherization. She ruled out on HD#1
and it was not felt that repeat stress imaging would add new information
given her recent evaluation. She refuses further coronary intervention
and wishes for medical treatment. Discussed c attg who felt that med
mgmt was appropriate. She was additionally treated for nausea with
reglan. A UTI was dx'd on U/A and she was treated c empiric amox ( she is
sulfa and quinolone allergic ) for 3 days. She will be discharged home on
her home medicines including the amoxicillin and reglan as discussed
above.
ADDITIONAL COMMENTS: Please have VNA remove staples on 4/14
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- F/u nausea
- F/u Cr , INR , HCT
- F/u chest pain sxs
- VNA to remove staples from knee replacement on 4/14
No dictated summary
ENTERED BY: CRANFORD , JULIAN H. , M.D. ( BV602 ) 2/15/06 @ 08:58 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 529
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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756484975 | PUO | 14374811 | | 548505 | 2/16/1999 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 4/3/1999 Report Status: Signed
Discharge Date: 4/11/1999
PRINCIPAL DIAGNOSIS:
1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE.
2. BRONCHITIS.
HISTORY OF PRESENT ILLNESS: Ms. Daughtrey is a 67 year old female
with a history of coronary artery
disease , status post CABG , DVT , status post IVC filter placement ,
status post ventricular fibrillation arrest and MI , COPD ,
pneumonia , diverticulitis , and abscess admitted with shortness of
breath , fevers and chills. She was in her usual state of health up
until three days prior to presentation , when she "felt funny." The
patient was a nonspecific historian and could not give any clear
description of her symptoms.
She , apparently woke up on the morning of admission with fevers ,
chills , shortness of breath , and mild nausea. She was febrile to
102.7. She called CHH , and was then taken to the Emergency
Department. In the Emergency Room , she had an O2 sat of 95% on
room air , with a slight desaturation requiring four liters of
oxygen. She had a temperature of 101 , BP 130/70 , and a heart rate
of 120. Of note , she had been recently admitted 7/22/98 to
8/13/99 with a COPD exacerbation. She also has a history of having
been admitted on 11/20 for a COPD flare and bronchitis. She had
recently received a flu shot. No recent travelling or sick
contacts. She currently denies any headaches , sinus pain , nasal
congestion , chest pain , abdominal pain , and shortness of breath.
She complains of mild shortness of breath with nausea and feeling
sick. She also complains of chronic leg pain.
PAST MEDICAL HISTORY: ( 1 ) Coronary artery disease; ( 2 ) COPD;
( 3 ) diabetes mellitus; ( 4 ) infrarenal AAA
documented at 4.5 cm in 6/27 ( 5 ) gout; ( 6 ) history of DVT;
( 7 ) arthritis.
MEDICATIONS: Aspirin 81 mg orally every day; simvastatin 20 mg orally
every bedtime; glipizide 5 mg orally every day; Lasix 40 mg orally
every day; K-Dur 20 mEq orally every day; albuterol and Atrovent; Pulmicort 4
puffs twice a day; MVI 1 tab orally every day; allopurinol 100 mg orally every day;
Neurontin three times a day
ALLERGIES: Theophylline , which gives her anaphylaxis , and to both
sulfa and dye , which are of unclear significance.
SOCIAL HISTORY: She lives alone. She quit smoking one week prior
to admission. She smoked one pack per day for 50
years. She rarely uses alcohol. She has three grown children.
FAMILY HISTORY: Mother with a history of MI at age 75. Father
with a history of lung cancer.
PHYSICAL EXAMINATION: GENERAL: Elderly female in no apparent
distress. VITAL SIGNS: Temp 99 , pulse 100 ,
BP 130/60 , respiratory rate 20 , satting 96% on two liters. HEENT:
PERRL , EOMI , oropharynx benign , no erythema or exudate. No sinus
tenderness. NECK: Supple , no JVD , no bruits , no lymphadenopathy.
CHEST: Revealed rales at the right base , otherwise no wheezes at
the left. HEART: Regular rhythm and rate , normal S1 , S2 , II/VI
systolic murmur at the left upper sternal border. ABDOMEN: Obese ,
positive bowel sounds , soft , diffusely tender , no
hepatosplenomegaly , no masses. EXTREMITIES: Bilateral non-pitting
edema , left greater than right , with mild lower extremity erythema ,
also left greater than right. NEURO: Alert and oriented x3 ,
cranial nerves II-XII grossly intact. MUSCULOSKELETAL: Her left
index and middle finger PIP joints were warm and tender.
LABORATORY DATA: White count 13.4 , hematocrit 33 , platelets 211.
Na 136 , K 4.3 , BUN 28 , creatinine 1.1. CK 47 ,
troponin 0.14. EKG showed normal sinus tach at 125 beats/minute.
She had a new incomplete right bundle branch block , left atrial
enlargement , no acute ST or T-wave changes. Chest x-ray revealed
question of a right lower lobe infiltrate. This was also
consistent with a mild pulmonary edema.
HOSPITAL COURSE: Ms. Daughtrey , in the Emergency Department , was
treated with intravenous cefuroxime. She was subsequently
brought to the floor , and the Medical Team's assessment decided to
treat her empirically for a right lower lobe pneumonia with
levofloxacin. It was not all that clear that Ms. Daughtrey had a
pneumonia , but she was treated for this anyway. She also had a
urine Legionella antigen , which was checked , as well as sputum
cultures which were unremarkable.
From a cardiovascular perspective , Ms. Daughtrey ruled out for a
myocardial infarction , but received some Lasix for mild CHF.
During her hospital course , it was noted that her hematocrit
dropped from 33.3 to 28.4. This was mildly concerning given her
history of an infrarenal AAA. It was decided that she should have
an abdominal CT. This was done , and the abdominal aortic aneurysm
has not changed in size or did not reveal any evidence of leaking.
Ms. Daughtrey quickly improved after being treated with nebulizers.
She was then switched from nebulizers to inhalers and it was
decided that she was well enough to go home. Of note , her right
finger joints were mildly swollen and possibly consistent with a
gouty flare. She was treated initially with Indocin , but then
there was the concern that she could potentially have a GI bleed.
Thus , she was quickly taken off of the Indocin.
Ms. Daughtrey was discharged in stable condition to follow-up with her
primary care physician. Her discharge medications were as follows:
DISCHARGE MEDICATIONS: ( 1 ) Aspirin 81 mg orally every day; ( 2 ) albuterol
inhalers; ( 3 ) allopurinol 100 mg orally every day;
( 4 ) Colace 100 mg orally twice a day; ( 5 ) Lasix 40 mg orally every day; ( 6 )
glipizide 5 mg orally every day; ( 7 ) nitroglycerin sublingual as needed chest pain;
( 8 ) Afrin 2 sprays intranasally twice a day; ( 9 ) MVI 1 tab orally every day;
( 10 ) simvastatin 20 mg orally every bedtime; ( 11 ) Atrovent inhaler four times a day;
( 12 ) Neurontin 200 mg orally three times a day; ( 13 ) levofloxacin 500 mg orally
every day x10 days; ( 14 ) Pulmicort 4 puffs inhaled four times a day;
( 15 ) Combivent 2 puffs inhaled four times a day
DISCHARGE FOLLOW-UP: The patient was to follow-up with Dr. Schlesener .
It was decided that she would require VNA
nursing to provide chest physical therapy 3-4x over the course of the following
week. She is to have a follow-up chest x-ray in several weeks to
reassess the right lower lobe.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: JOYA LETRAN , M.D. EV67
Attending: MARJORY GUMINA , M.D. OM98 GW653/5198
Batch: 64529 Index No. OKTWA81RFU D: 10/29/99
T: 10/29/99
CC: 1. MARJORY GUMINA , M.D. PO16
2. KATHERYN GRUNTZ , MD primary care physician
Document id: 530
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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181060739 | PUO | 96258529 | | 7656776 | 9/19/2005 12:00:00 a.m. | SMALL BOWEL OBSTRUCTION | Signed | DIS | Admission Date: 9/19/2005 Report Status: Signed
Discharge Date: 11/22/2006
ATTENDING: NAJI , COLIN MD
PRIMARY CARE PHYSICIAN: Marcelina Strauhal , MD
CARDIOLOGIST: Leola Musich , MD
GASTROENTEROLOGIST: Gaylene Faniel , MD
PRINCIPAL DIAGNOSES:
1. Small-bowel obstruction.
2. Congestive heart failure.
3. Dilated idiopathic cardiomyopathy.
LIST OF PROBLEMS/DIAGNOSES:
1. Dilated cardiomyopathy.
2. Diabetes type 2.
3. Ulcerative colitis , status post total colectomy with
colostomy.
4. Rheumatoid arthritis.
5. Chronic renal insufficiency.
6. Pyoderma gangrenosum.
7. Sundowning.
HISTORY OF PRESENT ILLNESS: Mrs. Atha is a 74-year-old woman ,
recently admitted to the Norap Valley Hospital on 1/14/05 for CHF
exacerbation and UTI ( Gram-negative rods , Klebsiella ) who
presents to the Kernan To Dautedi University Of Of with one day of abdominal pain , nausea ,
vomiting , and decreased ostomy output. The patient has a history
of multiple abdominal surgeries including a total colectomy for
ulcerative colitis with colostomy , ventral hernia repairs in
1998 , 2003 , and 2004 , revision of her colostomy in 1996 , 1997 ,
and 2003. As a result , she has had a chronic left lower quadrant
hernia. The patient denies any recent fevers , chills , melena , or
hematochezia from the ostomy. She has stable dyspnea on exertion
after 12 feet , she uses a walker at home. She denies PND. She
has two-pillow orthopnea. She has had stable lower extremity
edema in the past day and no dysuria. She also has a history of
a dilated idiopathic cardiomyopathy with an EF of 15 to 20% , MI
20 years ago , diabetes mellitus type 2 , coronary artery disease ,
and chronic renal insufficiency with a baseline creatinine of
approximately 1.8 to 2. In the emergency room , she was given 2
mg of Dilaudid intravenous for pain plus another 1 mg intravenous as well as Zofran
1 mg intravenous. An NG tube was placed , and hooked to suction , which
drained 1 liter of green fluid that was guaiac negative. CT of
the abdomen and pelvis showed high-grade small-bowel obstruction
with a transition point at the left lower quadrant hernia ,
dilated small-bowel loops , and fat stranding. A second
radiologist per the surgical note said that the transition point
may have actually been distal to the hernia and may have been
located within the pelvis. After surgical evaluation , the
patient was admitted to the floor for conservative medical
management of her small-bowel obstruction.
PAST MEDICAL HISTORY:
1. Admission on 1/14/05 to the Norap Valley Hospital for CHF
exacerbation and UTI , discharged on 7/6/05 .
2. Admission to Norap Valley Hospital in September of 2005 for CHF
exacerbation and acute renal failure.
3. Admissions in February and September of 2005 to the Pagham University Of , one admission status post hyperkalemic
arrest.
4. Nonischemic dilated cardiomyopathy with an EF of 15% on an
echo dated September of 2005 at the Pagham University Of , dry
weight of approximately 130 pounds.
5. Coronary artery disease.
6. MI 20 years ago.
7. Diabetes mellitus type 2.
8. Ulcerative colitis , status post total colectomy 50 years ago
with multiple revisions.
9. Ventral hernia repair , twice with mesh.
10. DJD.
11. RA.
12. CRI.
13. Pyoderma gangrenosum.
ALLERGIES: Sulfa and penicillin.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg orally every 24 hours
2. Torsemide 100 mg orally every 12 hours
3. K-Dur 20 mEq. orally every 24 hours
4. Levofloxacin 250 mg orally every 24 hours x3 days ( 7/6/05 to
7/11/05 ).
5. NPH 15 units every day before noon , 7 units every afternoon
6. Magnesium gluconate 500 mg orally every 24 hours
7. Digoxin 0.0625 mg orally every 24 hours
8. PhosLo 667 mg orally every 8 hours
9. Nexium 40 mg orally every 24 hours
10. Hydralazine 20 mg orally every 8 hours
11. Isordil 20 mg orally every 8 hours
12. Carvedilol 6.25 mg orally every 12 hours
13. Ambien 10 mg orally every bedtime
14. Gabapentin 100 mg every 12 hours
15. Prednisone 10 mg orally every 24 hours
PHYSICAL EXAMINATION ON ADMISSION: Vital signs , temperature
96.4 , pulse 84 , blood pressure 132/70 , respiratory rate 14 , and
sat 97% on room air. The patient was pale , ill appearing with an
NG tube in place. Her cardiac exam revealed an S3 gallop. PMI
was displaced and sustained. Heart rate was regular in rate and
rhythm. Lungs were clear to auscultation. Abdomen was distended
and tender , no rebound or guarding. The left lower quadrant
hernia was approximately 15 cm in size and reducible. The ostomy
was without any output. Neurological exam revealed no focal
deficits or facial droops.
OPERATIONS/PROCEDURES: None.
HOSPITAL COURSE BY PROBLEMS:
1. GI: The patient presented with a small-bowel obstruction.
The point of transition was thought to be in the pelvis by the
second Radiology opinion , she was kept npo , NG tube to
suction. SBO resolved on 4/4/05 . Her abdominal exam improved.
Her pain improved. At the time of discharge , her ostomy was
putting out green stool. Lactate levels were followed , with a
peak of 1.4 and then back down to 0.8. The patient was kept on
an intravenous proton pump inhibitor , then switched to orally At the time
of discharge , her diet was being advanced as tolerated. She was
tolerating a mechanical soft diet.
2. Cardiovascular: The patient has CHF with an EF of 15 to 20%.
She was gently hydrated during the small-bowel obstruction. Her
digoxin was continued. Her beta-blocker was switched to
Lopressor. Her diuretics were held. Her hydralazine and Isordil
were held as well as her aspirin in the event that she should go
to the operating room. These were added back. At the time of
discharge , she was on Coreg , hydralazine , Isordil , digoxin , and
aspirin at her home doses. Diuretic can be added back for
diuresis , once the patient is taking improved orally's. The
patient had several runs of V-TAC and frequent PVCs on the
monitor. Her electrolytes were corrected for a potassium of 4
and magnesium of 2. She was asymptomatic with these rhythms.
Her heart rate was in the 90s. Her blood pressure was in the
110s/50s-70s at the time of discharge.
3. Endocrine: The patient was continued on 15 units of NPH
every day before noon , 7 units of NPH every afternoon , as well as a Regular Insulin
sliding scale for very strict glucose control. This regimen
resulted in occasional episodes of hypoglycemia to 33 and 44
respectively. The patient was symptomatic with a blood sugar of
33. She received an amp of D50 and her blood sugar improved. Her
regimen was adjusted at the time of discharge , she was on NPH 8
units subcutaneously every day before noon and a Regular Insulin sliding scale. Her NPH
should be titrated as her orally intake improves. The patient is
on chronic prednisone for rheumatoid arthritis. She was switched
to hydrocortisone 10 mg intravenous every 8 hours She did not require a stressed
dose. She was switched back to her orally dose of prednisone.
4. Renal: The patient's phenol on presentation was 0.25. Her
creatinine was 2.8 , which was elevated from her baseline after
discharge at P Therford Hospital of 2.4. Her creatinine rose to 3.3 and
then began to trend down. Her creatinine was 2.4 and then 2.3 on
the day of discharge. Her acute on chronic renal failure was
thought to represent dehydration as well as poor forward flow due
to third spacing and decreased intravascular volumes. Her blood
pressures tended to be on the low side when she was first
admitted. These improved with rehydration to the point where her
home blood pressure medications could be restarted.
5. ID: The patient was started on levofloxacin 500 mg intravenous
every 4-8h. and Flagyl 500 mg intravenous every 8 hours for an elevated white count on
admission of 14.65 with 87.3% neutrophils. Her blood cultures
from 6/12/05 were positive , two out of four bottles in 24 hours
for Gram-positive cocci identified as MRSA. She was started on
vancomycin 1 gm intravenous every 48 hours This will need to be continued for a
total of two weeks , start day 6/20/05 , stop day 8/7/06 .
Levofloxacin and Flagyl were started on 7/11/05 , stop date
4/16/06 . The patient remained afebrile and her bands trended
down from a peak of 39 to 3 the day prior to discharge.
6. Rheumatologic: The patient was continued on steroids for
rheumatoid arthritis and chronic steroid dependence.
7. Neuro: The patient had episodes of disorientation , likely
due to sundowning two days prior to placement. She required 0.5
mg of intravenous Haldol for extreme agitation. She also required
trazodone 100 mg orally every bedtime for sleep.
8. Physical therapy: The patient was out of bed to chair. She
typically walks with a walker. She will require rehabilitation
for improved coordination and strength.
9. Prophylaxis: The patient was on proton pump inhibitor and
Lovenox during the course of her stay.
DISCHARGE MEDICATIONS: Pending.
The remainder of the dictation will be completed at the time of
discharge.
eScription document: 9-8196966 CSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: NAJI , COLIN
Dictation ID 3494287
D: 1/2/06
T: 8/6/06
Document id: 531
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
N |
N |
- |
N |
N |
N |
N |
- |
N |
N |
N |
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N |
842385275 | PUO | 27156611 | | 4239591 | 1/25/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/3/2003 Report Status: Signed
Discharge Date:
CHIEF COMPLAINT: At the time of admission , altered mental status.
HISTORY OF PRESENT ILLNESS: Patient is a 73-year-old man with a
history of prior delirious episodes as
well as a history of chronic diarrhea who , on the night before
admission , was noted to no longer recognize people at home and to
be confused about his location. On the morning of admission , the
patient had had intractable explosive diarrhea. He does have a
history of chronic diarrhea but the diarrhea on the date of
admission was significantly more severe than usual.
REVIEW OF SYSTEMS: The patient denied any chest pain , nausea ,
vomiting , urinary tract infection , or decrease
in his orally intake.
PAST MEDICAL HISTORY: Significant for congestive heart failure
with an ejection fraction of 50% , coronary
artery disease status post five vessel coronary artery bypass graft
in October 2002 , myelodysplastic syndrome , peripheral vascular
disease , gastrointestinal bleed status post right colectomy ,
prostate cancer status post transurethral resection of the
prostate , and macular degeneration.
CURRENT MEDICATIONS: At the time of admission included opium
tincture , aspirin , Lomotil , Lasix , Ditropan ,
Lopid , Zocor , Atapryl , and iron.
PHYSICAL EXAMINATION: At the time of admission , patient was
afebrile , his heart rate was 60 , his blood
pressure was 145/68 , and he was saturating 95% on room air. His
physical examination was notable for a jugular venous pressure at 5
cm , moist mucous membranes , and soft , nontender , nondistended
abdominal examination. On rectal examination , the patient was
noted to have guaiac positive brown stool.
LABORATORY EXAMINATION: Head CT at the time of admission was
negative for any acute change , chest x-ray
was negative for any evidence of pneumonia , and the patient's EKG
was reviewed and shown to be without change from prior studies.
HOSPITAL COURSE: 1. Neurological - The patient's mental status
improved quickly on admission. As noted above ,
his head CT was negative. It was thought that his mental status
changes were likely secondary to dehydration and were resolved at
the time of discharge.
2. Pulmonary - During resuscitation of the patient's dehydration ,
he developed an O2 requirement although chest x-ray did not show
any evidence for fluid overload or infiltrates. Occasional wheezes
were appreciated on examination and the patient's symptoms improved
significantly with occasional nebulizer treatments of Albuterol and
Atrovent. At the time of discharge , the patient was oxygenating
well.
3. Cardiovascular - There were no acute cardiac issues during this
hospitalization. Patient's losartan was held at admission given
his acute renal failure but other outpatient medications were
continued.
4. Hematology - The patient had a history of MDS and was a patient
of Dr. Harajly . At the time of admission , the patient's hematocrit
dropped 10 points but was thought to be likely due to hydration.
Since that time , the patient's hematocrit has remained stable at
35.
5. Infectious disease - At the time of admission , the patient's
blood cultures , urine cultures , and stool cultures were all
negative. Chest x-ray on January , 2003 was clear. It was felt
that the most likely etiology of his acute worsening of his
diarrhea was viral gastroenteritis. He also did receive a 7-day
course of levofloxacin and Flagyl for empiric abdominal coverage.
The patient remained afebrile since the time of his antibiotics.
6. Gastrointestinal - The patient is status post right
hemicolectomy. He has a long history of diarrhea and presented to
this admission with explosive diarrhea and guaiac positive brown
stool. At the time of admission , Kaopectate and Lomotil were
started. On July , 2003 , he was noted to have increased
distention but a KUB was negative at that time for partial
obstruction or impaction. There were concerns that the patient's
abdominal symptoms might be secondary to ischemia so an MRI was
obtained which showed proximal disease in the SMA , IMA , and celiac
but overall with good distal flow. An abdominal CT was obtained
which showed a thick small bowel and dilated gallbladder with
stranding but no evidence for ischemia. Gastrointestinal
consultation was obtained and on November , 2003 , and
esophagogastroduodenoscopy was performed which revealed grade intravenous
gastritis. As a result , the patient was started on Nexium 40
twice a day
7. Renal - The patient has a history of chronic renal
insufficiency. The entire hospitalization , his BUN was in the
fifties with a creatinine of 2.2. His FENA was less than 0.1% and
the patient was thought to be extremely intervascularly dry. With
gentle hydration , the patient's creatinine eventually improved to
1.9 at the time of this dictation.
OPERATIONS AND PROCEDURES: Included esophagogastroduodenoscopy
revealing gastritis as discussed above.
DISPOSITION: Diet includes that the patient is discharged on a
full orally diet. He was also instructed to supplement
his diet with high nutrition Boost shakes. Nutrition followed the
patient closely during the admission and thought that he would need
close follow-up as an outpatient for his nutrition status.
DISCHARGE MEDICATIONS: Will be dictated in an Addendum to this
Discharge Summary.
FOLLOW-UP: The patient will follow-up with Dr. Kush following
discharge.
Dictated By: SOLOMON LIESELOTTE HALFACRE , M.D. BT540
Attending: QUINN J. KUSH , M.D. QQ9 QK746/663660
Batch: 7535 Index No. RQMP6S9FG2 D: 2/15/03
T: 2/15/03
Document id: 532
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
858943274 | PUO | 63932013 | | 0369799 | 10/25/2005 12:00:00 a.m. | ? cardiac chest pain , new lbbb , history of clean cath | | DIS | Admission Date: 2/10/2005 Report Status:
Discharge Date: 11/10/2005
****** DISCHARGE ORDERS ******
TINDOL , SHARI 131-05-70-4
Van Ey Liy
Service: CAR
DISCHARGE PATIENT ON: 1/1/05 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day Starting Today September
LEVOXYL ( LEVOTHYROXINE SODIUM ) 175 MCG orally every day
LISINOPRIL 20 MG orally every day HOLD IF: sbp < 100
Override Notice: Override added on 5/7/05 by AABY , WALDO O CLEMENTE , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 39716657 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 5/7/05 by LAPATRA , DARWIN MADELEINE , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 05906892 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: awaere
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Starting Today September
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Primary care physician 1 week ,
Dr. Stan Meckley 4-6 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
? cardiac chest pain , new lbbb , history of clean cath
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Hypothyroidism , hypertension , high cholesterol , glaucoma , GERD
OPERATIONS AND PROCEDURES:
Cardiac catheterization , 1/13/05
2D Echocardiography , 1/3/05
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest Pain
HPI: 69 with , hx lipids , htn , obestiy admitted with 2 months progressive
doe , exertional sscp , worse x 2 days.
No resting cp. Presented to tsch , new lbbb compared to 2 months ago.
Heparinized , transferred here for cath. Afeb , vss here. Currently cp
free. heparinized , plavix load given. Taken to cath on
1/13/05 . RESULTS HERE: CLEAN CORONARIES.
PE on admit: VS: afebrile , P 107 , BP 156/91 , O2 99% RA.
Appeared euvolemic to mildly overloaded on exam ( although difficult to
discern 2/2 obesity ).
Lungs CTAB , CV: RRR , No M , G , R
Labs on admit: K 3.4 , Ca 8.4 , WBC 11.71 , Hgb
12.8 , Hct 38.2 , BUN 12 , Cr 0.8 , INR 1.0 , CK 61->226->305 ,
CK-MB 1.0 ->6.2->5.7 , TN-I below assay x 3 , BNP 161.
CXR:Mildly tortuous aorta , otherwise nml
EKG:LBBB , rate at 100. New as compared to July 2005.
***************Hospital Course**************
CV: ISCHEMIA: ASA , beta blocker , statin. Cont ACEI. Lipid panel with HDL
34 , LDL 113 , serial enzymes as noted , on tele. CXR and EKG done. Cath on
4/11 was clean. Echo post cath with normal biventricular systolic and
dialostic function.
PUMP: Holding hctz. Appears euvolemic. Cont ACEI and BB.
RHYTHM: new lbbb , likely represents recent but probably not current
ischemic event. Kept on tele.
ENDO: H/o hyopthyroidism , TSH 0.435 , cont levoxyl.
ID: UA pre cath.
FULL
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: POLO , MALINDA M. , M.D. , M.S.C. ( UY57 ) 1/1/05 @ 02:39 PM
****** END OF DISCHARGE ORDERS ******
Document id: 533
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
244981093 | PUO | 58322584 | | 4672585 | 8/27/2004 12:00:00 a.m. | HO evaluation | | DIS | Admission Date: 8/27/2004 Report Status:
Discharge Date: 9/4/2004
****** DISCHARGE ORDERS ******
HELDE , EMILIO 208-18-08-6
Stin
Service: MED
DISCHARGE PATIENT ON: 8/12/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
PHOSLO ( CALCIUM ACETATE ) 667 MG orally three times a day
PREMARIN ( CONJUGATED ESTROGENS ) CREAM TP every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HUMULIN N ( INSULIN NPH HUMAN )
55 UNITS every day before noon; 25 UNITS every afternoon subcutaneously 55 UNITS every day before noon 25 UNITS every afternoon
METHAZOLAMIDE 50 MG orally three times a day
Number of Doses Required ( approximate ): 7
METHOCARBAMOL 500 MG orally every day
TIMOLOL MALEATE 0.5% 1 DROP OS twice a day
VANCOMYCIN HCL 1 GM intravenous every 24 hours
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) May
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 2/12/04 by
VARONE , THURMAN B. , M.D.
on order for BACTRIM DS orally ( ref # 97030599 )
SERIOUS INTERACTION: WARFARIN & SULFAMETHOXAZOLE
Reason for override: aware Previous override information:
Override added on 2/12/04 by VARONE , THURMAN B. , M.D.
on order for ZOCOR orally ( ref # 19667136 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/12/04 by
VARONE , THURMAN B. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 25 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 60 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
ALPHAGAN ( BRIMONIDINE TARTRATE ) 1 DROP OS twice a day
Number of Doses Required ( approximate ): 5
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: Please apply to buttocks and breast folds.
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
LISINOPRIL 10 MG orally every day
BUMETANIDE 2 MG orally every day Starting Today February
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Verbridge ,
Arrange INR to be drawn on 8/29/04 with f/u INR's to be drawn every
28 days. INR's will be followed by Dr. Glynis Verbridge
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
UTI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
HO evaluation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , hx DKA obesity arthritis HTN
urate nephrolithiasis dvt ( deep venous thrombosis ) obesity related
hypoventilation DJD ( OA of knees ) hypercholesterolemia ( elevated
cholesterol ) depression ( depression ) IDDM ( diabetes mellitus )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: dysuria x 1 week
HPI: 62 year-old woman with a hx of CHF ( EF45% ) , DM , HTN , CRI presents with 1
week of dysuria. Two weeks prior had been dx with UTI and treated
with ciprofloxacin but continue to have dysuria ,
which grew in intensity until it elicited terror.
Also some constipation + abd pain. Repeat urine cx
grew as MRSA. Given bactrim in ED; found with
elevated BUN/Cr and slight hyperkalemia. Given kayexalate
x 1.
PMH: CHF , DM , HTN , CRI , UTI , protein C def history of DVT ( on coumadin ) ,
morbid obesity Meds: see med
section Allergies:
NKDA Exam: T98 H76
BP156/82 General: obese woman ,
NAD Cor: S1 , S2 ,
S4 Abd:
large Labs: BUN/Cr - 85/2.2 WBC 19 K5.7 Hct
31.8 ( baseline )
U/A +
****************************************
62 year-old woman with MRSA UTI.
1 ) UTI: initially rx with bactrim but we d/cd this 2/2 elev Cr ,
electrolye abnormalities and switched to vancomycin on which her
symptoms improved. Thus , we had a PICC line inserted so she cou
ld complete a 14 day course of antibiotics for this complicated
MRSA+ UTI. Blood cxs were drawn to r/o bacteremia given her low grade
temps and were neg to date. We also gave her 3 days of pyridium for sx
relief. The patient will hang her own vancomycin at home.
2 ) Renal insufficiency: baseline 50/2.5; checked urine lytes which
suggested patient was dry and we initiated gentle hydration given
her underlying CHF. This and teh blood we gave her have helped her Cr
return to baseline. Renal US normal. She did have hematuria which may h
ave been 2/2 the foley , though she also had some mild urinary retention
and we are suggesting an outpt cystoscopy.
3 )CV: We were holding her ACE + diuretic until her last day of
admission due to her volume status and Cr elev. we monitored her BP
off of these meds which was stable; We continued her coumadin and her
INR was stable. We restarted her ACE and diuretic( but d/cd her on 2mg
every day of bumex instead of 2 twice a day which she came in on ).
4 ) DM: we continued her home insulin and her FS were well controlled
on this regimen
5 ) Dispo: with PICC line and abx for 10 more days. patient should follow up
with Dr. Verbridge her primary care physician.
ADDITIONAL COMMENTS: Please take your medications as prescribed and listed on the discharge
papers , including your vancomycin.
Please be sure to contact Dr. Verbridge to set up an appointment.
If you being to re-experience severe burning again with urination or if
you begin to get high fevers , please call your doctor or return to the
hospital.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: VARONE , THURMAN B. , M.D. ( UU934 ) 8/12/04 @ 09:37 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 534
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
- |
N |
N |
- |
Y |
N |
N |
- |
N |
N |
N |
007844210 | PUO | 44738326 | | 0581606 | 8/6/2006 12:00:00 a.m. | RIGHT CHRONIC LEG ULCER | Signed | DIS | Admission Date: 3/6/2006 Report Status: Signed
Discharge Date: 1/16/2006
Date of Admission: 3/6/2006
ATTENDING: BILSBOROUGH , MOHAMED BEA MD
ADDENDUM:
ADMISSION TO THE ICU: 2/8/06 .
This will be the hospital course and plan as well as the
discharge medications.
HOSPITAL COURSE:
1. Lower extremity wounds: The patient had several left lower
extremity wounds which by report had been chronic as well as a
deeper acute onset right lower extremity wound which was
ulcerated to the level of muscle. It was thought that this wound
had occurred as a result of a hematoma after incision and
drainage by Surgical Service one to two weeks prior to admission.
There was no obvious evidence of infection , however , it is
certainly possible that there is a soft tissue surrounding that
ulcer. There was some thought of whether that could be
osteomyelitis underlying the ulcer. The patient had tibial and
fibula films which at first there was some consideration of
whether there was abnormality to the bone. On further
consideration , it was felt this is most likely not the case ,
however , to evaluate more specifically a bone scan was performed.
There was no uptake in the area of that ulcer , however , there
was some mild uptake at the left Achilles tendon calcaneal
insertion and marked uptake in the T9 thoracic 9th vertebrae. A
CAT scan of the spine was performed which revealed no evidence of
infection or neoplasm but there was evidence of osteopenia and
possibly a microfracture but no evidence of real compression
fracture. The patient was seen and examined by the Vascular
Surgery Consult Service and Dr. Derham , her primary vascular
surgeon. Their recommendation in terms of wound dressing was
three times a day , wet-to-dry dressing changes with 4 x 8 gauze
sponges. It was recommended that the patient follow up with Dr.
Derham in mid 9/6 . Please call Dr. Derham 's office for an
appointment. The recommendation for three times a day wet-to-dry
dressings without additional ointments or treatments. The
patient should be followed by wound care service. In addition ,
the patient has small necrotic regions on her heels. These
should be treated with Panafil. In terms of her sacral decubitus
ulcer , the patient was seen by the Plastic Surgery Service , they
debrided the wound twice , there was minimal amount of superficial
necrotic tissue which was excised. Their recommendations for
further care were to apply one-quarter strength Dakin's solution
soaked wet-to-dry dressings to be changed twice a day for 48
hours that will be for 36 hours from discharge and then this
treatment should be changed to standard wet-to-dry dressings
twice daily to that sacral decubitus ulcer. They recommend that
she be placed on an air mattress. She should have turns at least
every 2 hours They also recommend that her weight be kept off
the sacrum and that her nutrition be optimized. She was placed
on a multivitamin , continued on calcium , started on zinc , vitamin
C supplements as well. The patient should follow up with Dr.
Naomi Wolfensperger as an outpatient. This should be scheduled by
calling 485-632-1119.
2. Infectious disease: The patient was initially admitted with
a low-grade temperature. It was unclear whether she had a
primary infection and what the source of that infection was.
Cultures were taken from blood , urine , and sputum. All blood
cultures were negative. Urine culture grew extended spectrum
beta-lactamase resistant Klebsiella pneumonia which was
intermediate to ciprofloxacin and sensitive to levofloxacin.
Because the patient has so little urine output it was unclear
whether at first this was a colonizer or an actual infection.
Infectious disease consultation was requested. Their
recommendations were to start ciprofloxacin and then this was
changed to levofloxacin when the final susceptibilities came back
and they continued that for a two-week course. She is currently
on levofloxacin 500 mg intravenous every 48 hours This course will finish on
9/4/06 . Sputum cultures grew multidrug resistant Pseudomonas
aeruginosa as well as a few Acinetobacter which were also
resistant to many antibiotics. After close consultation with
Infectious Disease Consultation Service it was decided that these
were most likely colonizers. There was no evidence of an acute
pneumonia or tracheobronchitis and the patient was not treated
for her colonization with Acinetobacter and Pseudomonas. In the
past she has had multiple other multiple drug resistant organisms
that grew from her sputum cultures at other institutions and it
was felt that unless she demonstrated evidence of clinical
pulmonary infection these should not be treated. Overall , her
hemodynamic status was stable and she was afebrile throughout her
course. Several days into her admission , however , she did have
one episode of low blood pressure initially treated with
intravenous fluids and then norepinephrine infusion for short
period of time. However , on repeat cuff pressure manually it was
revealed that her blood pressure actually was normal and that
there was dysfunction possibly because of her obesity of the
automatic cuff , therefore it was thought that this low blood
pressure was spurious and probably an artifact of the cuff that
was being used. So in conclusion the only medication on
discharge will be levofloxacin 500 mg every 48 hours through 9/4/06 .
3. Cardiovascular: The patient has a history of coronary artery
disease and atrial fibrillation. She was on Toprol 12.5 mg by
mouth two times a day throughout her stay. Her heart rate ranged
from 120s-130s when she was first admitted to 50s-60s on
discharge. This should be readdressed regularly in terms of her
need for rate control. At this point , she will be discharged on
that low dose of beta-blocker. Otherwise , she was admitted on
Coumadin with a INR of 2-3 for her St. Jude's aortic valve. Her
INR was therapeutic on admission. This was actually discontinued
after a couple of days in anticipation of a possible procedure.
It was restarted three days prior to discharge. She was on
heparin as a bridge for anticoagulation in the meantime. She
should be continued on the heparin with a goal PTT of 50-70 until
her INR is therapeutic at 2-3 and this should be rechecked to
make sure that her INR remains therapeutic. Her care was
discussed with her primary cardiologist , Dr. Brittaney Hamblet .
4. Endocrine: The patient has a history of type 2 diabetes.
Her diabetes was controlled with insulin NPH 35 units
subcutaneous every morning with a regular insulin sliding scale
every 6 hours as well. This should be continued and fingersticks
should be done every 6 hours The patient also has a history of
hypothyroidism. Her thyroid stimulating hormone level was
checked and was found to be elevated at 14.5. Her thyroid
replacement dose was increased from 75 mcg per day to 88 mcg a
day. Her thyroid stimulating hormone level should be checked
again in four to six weeks and dose adjustment accordingly.
5. Pulmonary: The patient was continued on her mechanical
ventilation. There were attempts at lower pressure support and
even spontaneously breathing trials. She was not able to
tolerate these for a long period of time , however , it does seem
that she has improved to some degree in terms of her ventilatory
mechanics. She is currently on pressure support ventilation at
15 of pressure support and 5 of positive end expiratory pressure
with an FIO2 of 0.4. We believe that she could probably be
weaned slowly to significantly decreased pressure support and I
believe most likely she will be able at some point to be taken
off the ventilator , although this is certainly not certain. She
will be continued on her nebulizer treatments.
6. Nutrition: The patient was continued on tube feeds. She is
on full strength Nepro at 50 cc per hour. In addition , she is
getting vitamin C supplementation , ascorbic acid 500 mg by mouth
two times a day , Nephrocaps , zinc sulfate 220 mg by mouth daily
and these should be continued as indicated for her renal failure
and wound healing.
7. Psychiatric: The patient was continued on her home dose of
fluoxetine 20 mg by G tube daily and on Zyprexa 10 mg by G tube
at bedtime.
8. Prophylaxis: Throughout her stay , the patient was continued
on her home esomeprazole 40 mg by G tube twice a day and for deep
venous thrombosis prophylaxis , her INR on Coumadin remained above
1.4 and her PTT was kept therapeutic on intravenous heparin.
Intravenous heparin should be continued with PTT checks on
admission and then every 6 hours unit they were fairly stable
between 50 and 70 and that should be monitored at least daily
until her INR is stably therapeutic. It will be very important
to monitor her INR carefully while she is on levofloxacin as
well.
9. Access: The patient has a left-sided midline which was
placed in mid 8/6 . This should be removed within the next
one week and another line placed as preferred by the
rehabilitation physician. In addition , the patient's dialysis
catheter while functional does seem to have eroded through the
skin below her clavicle. The hemodialysis service should be
aware and consider replacement as indicated. At this point there
is no indication of infection of either of those lines , however ,
she is at high risk of infection of both.
10. Renal: The patient was continued on her hemodialysis as per
the Renal Service. Please feel free to contact Dr. Mohamed B Bilsborough , the patient's ICU physician here at Pagham University Of with any questions you may have. As noted in the
dictation , the patient should follow up within the next three to
four weeks with Dr. Derham of Vascular Surgery and also with the
Plastic Surgery Service.
MEDICATIONS ON DISCHARGE:
1. Vitamin C 500 mg by G tube two times a day.
2. Peridex mouthwash 15 mL twice a day.
3. Fluoxetine 20 mg by G tube daily.
4. Heparin intravenous 1050 units per hour , this will be
adjusted based on her PTT from this morning which is not yet
available.
5. Insulin NPH 35 units subcutaneous every morning.
6. Insulin regular sliding scale subcutaneous every 6 hours based on
fingersticks.
7. Atrovent inhaler 8 puffs by ventilator every 6 hours
8. Levoxyl 88 mcg by G tube daily.
9. Metoprolol 12.5 mg by G tube twice a day.
10. Dakin's solution one-quarter strength topical for 48 hours
two times per day and then resume wet-to-dry dressings as
dictated.
11. Ursodiol 600 mg by G tube daily.
12. Coumadin 4 mg by G tube every afternoon , follow INR closely while on
levofloxacin.
13. Zinc sulfate 220 mg by mouth daily.
14. Simvastatin 10 mg by G tube at bedtime.
15. Olanzapine 10 mg by G tube at bedtime.
16. Levofloxacin 500 mg intravenous every 48 hours through the date specified
above.
17. Nephrocaps one tab by G tube daily.
18. Miconazole powder to affected areas twice a day.
19. Keppra 500 mg by G tube daily and 250 mg supplemental dose
by G tube after hemodialysis.
20. Esomeprazole 40 mg by G tube twice a day.
21. Panafil spray topical three times a day to heels with
dressing changes.
22. Papain and urea topical three times a day , to only be used
for those heels if Panafil spray not available.
eScription document: 8-9011365 EMSSten Tel
CC: Mohamed Bea Bilsborough MD
Du Ge Sti STREET , O FRY HOSPITAL
Wood Pring Sun
Dictated By: BIRDETTE , KATHARYN
Attending: BILSBOROUGH , MOHAMED BEA
Dictation ID 6514492
D: 11/12/06
T: 11/12/06
Document id: 535
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
Y |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
450717289 | PUO | 01549936 | | 7735193 | 6/12/2005 12:00:00 a.m. | Hypotension , hypoglycemia | | DIS | Admission Date: 4/20/2005 Report Status:
Discharge Date: 11/1/2005
****** FINAL DISCHARGE ORDERS ******
LAURO , ROSELEE L 908-49-96-7
Bile Arb Ton , Florida
Service: MED
DISCHARGE PATIENT ON: 2/24/05 AT 01:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ZOLOFT ( SERTRALINE ) 100 MG orally every day
NEURONTIN ( GABAPENTIN ) 600 MG orally three times a day as needed Pain
AMBIEN ( ZOLPIDEM TARTRATE ) 5 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEOSYNEPHRINE 0.25% ( PHENYLEPHRINE HCL 0.25% )
2 SPRAY inhaled every day
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally every day X 1 doses
Starting on 1/14/05 Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
TRICOR ( FENOFIBRATE ) 145 MG orally every day
Number of Doses Required ( approximate ): 3
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
LANTUS ( INSULIN GLARGINE ) 30 UNITS subcutaneously every bedtime
Starting Today September
Instructions: Please give half-dose if patient is NPO
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
METFORMIN 1 , 000 MG orally twice a day
NIFEREX TABLET 50 MG orally twice a day
Alert overridden: Override added on 2/24/05 by :
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
POLYSACCHARIDE IRON COMPLEX Reason for override: Aware
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please follow up with primary care physician ,
ALLERGY: ANTIHISTAMINES , TRICYCLIC COMPOUNDS
ADMIT DIAGNOSIS:
hypotension , hypoglycemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hypotension , hypoglycemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NIDDM HTN history of CHOLE history of APPY history of
RSO hyperlipidemia ( hyperlipidemia ) morbid obesity
( obesity ) Osteoarthritis R knee ( OA of knees ) Migraines ( migraine
headache ) GERD ( gastroesophageal reflux disease ) Ruptured L Achilles
tendon hx of MRSA cellulitis ( history of cellulitis ) history of TAH ( history of hysterectomy )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Antibiotics , IVF
BRIEF RESUME OF HOSPITAL COURSE:
CC: Lightheadedness and unsteady gait.
HPI: 52 year-old morbidly obese woman with hx of T2DM , migraines , HTN p/with
several hours of lightheadedness , unsteady gait , thick feeling of
her tongue , and difficulty gripping items b/l in the morning of the
day she presented. States symptoms NOT the same as her hypoglycemic
sx. No focal numbness , weakness , or paralysis. In ED
found to be hypoglycemic to 50s , then hypotensive to 70s/40s. Given
3L NS-->BP responded then dropped again; back up to systolics 110s
with additional fluids. By time of admission hypotension ,
hypoglycemia , and episode of lightheadedness and unsteadiness had
resolved. PE: T 97.7 HR 74 BP 114/61 RR 10 Sat 98%
RA Gen: Obese , NAD , AAO x
3 HEENT: PERRL , anicteric , pale conjunctivae ,
EOMI Neck: No
JVD Chest: CTA
b/l CV: RRR; difficult to assess due to body
habitus Abd: Obese , soft ,
NT Ext: No edema , R lateral toes amputated; L toes
with blisters Neuro: AAOx3 , dec sensation LE b/l , 5/5 strength
all extremities , no cerebellar signs , no wide stance gait , limps on
left foot Labs: Hgb 9 , Hct 28.8 , Cr 1.4 , WBC 12.4 , bicarb 21;
After 7-8L NS bicarb down to 13 , Cr to 1.1. UA: first 1+LE , 10-12 WBC;
cath specimen 1-2 WBC , neg LE; a.m. cortisol 26; Iron 45 , Ferritin 9
IMP: 52 year-old obese woman with T2DM , HTN , migraines
admitted for lightheadedness , unsteady gait , and unexplained
hypotension in ED.
1 )CV--nl EKG , no sx ofischemia. patient hypotensive in ED , then
normotensive for >24 hours prior to discharge--possible autonomic
neuropathy vs. hypovolemia vs. anemia vs. sepsis. Holding
antihypertensives; IVF given; on levaquin for ?UTI
2 )Neuro--lightheadedness/unsteady gait , no focal
neurological sx. Likely hypotension and/or hypoglycemia; following
neuro exam
3 )Endo--DM with hypoglycemia; held oralhypoglycemics except glyburide while
in hospital and placed on SSI
4 )Heme--normocytic anemia , patient is also iron deficient; patient transfused 2u
PRBCs 11/3 with rise of Hgb to 9.2 on 10/9 retic index is 3.6% , which is
too low for her degree of anemia; will need outpt follow-up
5 )ID--on levofloxacin for 3 days for ?UTI; following blood/urine cx
6 )Proph--PPI , lovenox
ADDITIONAL COMMENTS: Please follow up anemia with primary care physician
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: FOLLANSBEE , DENNIS A. , M.D. , PH.D. ( GJ981 ) 2/24/05 @ 12:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 536
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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322886432 | PUO | 28967004 | | 3162069 | 7/18/2006 12:00:00 a.m. | HEMATURIA | Signed | DIS | Admission Date: 1/26/2006 Report Status: Signed
Discharge Date: 5/19/2006
ATTENDING: REMLEY , EVALYN M.D.
ADMISSION CONDITION: Stable.
ADMISSION DIAGNOSIS: Foley trauma.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with
hypotension , diabetes , and obesity. He was in his usual state of
health until November , 2006 , when he had a sudden loss of function
of his lower upper extremity and lower right extremity. He was
admitted to Pagham University Of Neurology Service , where
an MRI revealed a right internal capsule lacunar stroke. He was
out of the TPA window. As a result , he was treated with aspirin
and statin. An echo showed a normal EF and no evidence of
thrombosis. There was no evidence of a-fib. His hospital
course , however , was complicated with Foley trauma and hematuria
for which he required continuous bladder irrigation. The patient
also developed a UTI by UA , but not a positive culture data. The
patient was seen briefly by Urology , who recommended continued
bladder irrigation and followup. He was then treated with
ceftazidime x3 and the patient was discharged to rehab on November
with a chronic bladder irrigation and urology followup for a UT
urogram.
The patient did fairly well in rehab until the day prior to
admission , which was on November , 2006 , after one day of being
discharged from rehab when , during a physical therapy session ,
the patient accidentally manipulated the Foley catheter causing
increased pain and worsening hematuria. So , then the patient
came to the ED the next day after the patient was already
discharged. The patient came to the ED on November , 2006. The
patient was hemodynamically stable but complained of severe
pelvic pain and received 10 mg of intravenous morphine , Dilaudid ,
Percocet , Valium and Ativan. The patient then became
increasingly sedated and developed an O2 requirement , and was
eventually on lung non-rebreather. By the time he was admitted
to the medicine floor , the patient was very sedated and difficult
to arouse. ABGs showed a 7.25/71/90 and he received 0.04 mg of
Narcan. He immediately awoke; however , then continued to become
sedated within 30 minutes. As a result , the patient was sent to
ICU on May , 2006. The patient had systolic blood pressure in
the 60s and was given Narcan and intravenous fluids. However , the
systolic pressure only responded to 90s. The patient also
complained of diffuse abdominal pain. However , KUB showed a
nonspecific bowel gas pattern. The patient was required to
continue Narcan boluses and his ABG started to show improvement.
It was 7.33/56/113 on 100% non-rebreather. During the overnight
ICU stay , the patient did very well. Eventually , the patient was
hemodynamically stable with systolic pressure maintaining very
well over 100 with a JVP over 10. The patient was more awake the
next day after admission to ICU overnight.
HOSPITAL COURSE BY SYSTEM
Cardiovascular: As a result , the patient was hypotensive on the
floor at the beginning due to being over-narcotized in the ED.
Systolic pressure dropped to the lowest in the 60s. However ,
after the ICU stay , as well as boluses with Narcan intravenous fluids , the
patient's blood pressure returned to be stable , with systolic
blood pressure above 100. The patient's echo was also normal the
week before and there were no signs of systolic dysfunction. The
patient was continued on aspirin and statin and , after the ICU
stay , the patient was transferred back to the floor and the
patient's cardiovascular was stable and the patient's
antihypertensive regimen was resumed. The patient's heart rate
was usually maintained between 50 to 67. At times , the patient's
Lopressor has to be held due to the low heart rate. As a result ,
Lopressor was titrated down from 25 mg to 12.5 mg twice a day This
happened during the hospital stay. The patient also resumed back
on his captopril 6.25 mg three times a day The patient was admitted to the
floor on telemetry and throughout the 3-4 days prior to
discharge , the patient was stable on the floor and remained
cardiovascularly and hemodynamically stable. The patient was
continued on statin and aspirin.
Pulmonary: The patient has weaned off the non-rebreather after
the stay from ICU and has been satting well between 96-97% on 3-4
liters. The patient's lungs have remained cleared and the
patient's Lasix has resumed at 20 mg daily due to the patient
having a negative Lasix of 40 mg daily. The patient was resumed
back to his original regimen upon discharge. The patient has had
minimal crackles during his stay here in the hospital.
Infectious disease: The patient was given vancomycin and
ceftazidime in the setting of hypotension and concern for
possible sepsis at the beginning. However , due to no growth to
date with the blood cultures , the infectious etiology of
hypotension is unlikely. As a result , antibiotics were not
continued when the patient was transferred back to the floor.
Urology: The patient continued to have hematuria upon admission
to the MICU , likely secondary to Foley trauma. The patient
continued to have chronic continued bladder irrigation for the
following two days after discharge from the MICU. Under the
evaluation by the urologist , the patient does not need chronic
bladder irrigation anymore. The urologist suggested that the
bladder has actually stopped bleeding with clear urine drained.
Of note , the patient was very agitated at one point on the second
day upon discharge from the MICU and pulled the Foley out , which
created a trauma to the bladder neck. However , the bleeding
stopped very quickly and the urologist placed a second Foley into
the bladder without any complications. Urology recommended that
the patient be followed by Dr. Lorean Kadow as an outpatient. In
their opinion , the patient does not have any urological symptoms ,
and the patient should have the Foley for the following 4-5
weeks. Per Urology , the patient may not be able to control his
bladder due to the stroke that the patient had the week before ,
so the patient will need chronic Foley for the next 4-5 weeks
until followup with the urologist in the office. The patient's
hematocrit has been stable at 29 throughout the hospital stay.
Endocrinology: The patient has a history of diabetes and
continued to have NPH and subcutaneous heparin.
Renal: The patient had prerenal azotemia at one point prior to
transfer to the floor due to hypotension. However , the patient's
creatinine recovered dramatically from 1.5 to 0.7 upon discharge.
The patient also had an obstruction in which the patient was
unable to void , which created a postrenal azotemia at one time ,
but both prerenal and postrenal azotemia have resolved upon
discharge.
Neuro: Mental status intact. The patient has been doing very
throughout the two days prior to discharge. The patient was
alert and oriented x3. However , the patient occasionally
complained about the leg pain from the side in which the patient
has lost motor function. The patient remained to have left
hemiparesis and required 100 mg Neurontin three times a day for pain control
regimen. Otherwise , the patient was evaluated by both , will be
followed by Neurology on April , 2006.
Diet: The patient had normal cardiac diet and the patient will
continue on the diet when the patient is discharged to rehab.
Prophylaxis: The patient should resume his Lovenox 40 mg daily
and the patient should have aspirin and Nexium for prophylaxis.
Psychiatry: The patient was given Ambien 10 mg orally at bedtime
for sleep and he responded very well with the regimen. The
patient was also given Seroquel for anti-anxiety medication.
MEDICATIONS:
1. Aspirin 325 mg orally daily.
2. Captopril 6.25 mg orally daily.
3. Colace 100 mg orally twice a day
4. Lovenox 40 mg subcutaneous daily.
5. Pepcid 20 mg orally twice a day
6. Lasix 40 mg orally daily.
7. Lantus 35 units subcutaneous each morning covered with a RISS
sliding scale.
8. Lopressor 25 mg orally three times a day
9. Zocor 40 mg orally each night time.
10. Ambien 10 mg orally each night time.
11. Neurontin 100 mg three times a day
ALLERGIES: No known allergies.
SOCIAL HISTORY: The patient used to live in Fage Blvd. , Ral Pa Worth with his
daughter , but now with his stroke , the patient will stay in
rehab.
FAMILY HISTORY: Diabetes and history of stroke.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Tylenol 1 gm orally four times a day
2. Aspirin 325 mg orally daily.
3. Duoneb 3/0.5 mg inhalant form every 4 hours as needed wheezing.
4. Bacitracin and neomycin for the topical three times a day
5. Bacitracin on the urinary meatus due to the continued use of a
Foley , topical twice a day
6. Captopril 6.25 mg orally three times a day ( hold is systolic pressure is
less than 95 ).
7. Nexium 20 mg orally daily.
8. Lasix 20 mg orally daily. We did not resume the patient's home
regimen of Lasix and patient's discharge medication will continue
to be Lasix 20 mg orally daily.
9. Insulin aspartate 8 mg subcutaneous before meals and hold if the patient
is NPO.
10. Novolog sliding scale.
11. Lopressor 12.5 mg orally twice a day
12. Nicotine patch 21 mg daily.
13. Seroquel 25 mg orally every 6 hours
14. Zocor 40 mg orally bedtime.
15. Ambien 10 mg orally bedtime.
eScription document: 6-7998137 PSSten Tel
Dictated By: LAPATRA , LETA
Attending: REMLEY , EVALYN
Dictation ID 6315758
D: 10/10/06
T: 10/10/06
Document id: 537
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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800843851 | PUO | 29407184 | | 5730805 | 1/16/2007 12:00:00 a.m. | hypertension | | DIS | Admission Date: 10/25/2007 Report Status:
Discharge Date: 10/7/2007
****** FINAL DISCHARGE ORDERS ******
Stinegan Rd 174-51-86-5
Port Elipeo Berkeari
Service: MED
DISCHARGE PATIENT ON: 11/19/07 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 325 MG orally every day
2. ALLOPURINOL 100 MG orally every other day
3. AMIODARONE 200 MG orally twice a day
4. ATORVASTATIN 80 MG orally every day
5. CLOPIDOGREL 75 MG orally every day
6. DOCUSATE SODIUM 100 MG orally twice a day
7. DOXAZOSIN 2 MG orally every day
8. ESOMEPRAZOLE 40 MG orally twice a day
9. FERROUS SULFATE 325 MG orally every day
10. FUROSEMIDE 20 MG orally twice a day
11. GEMFIBROZIL 300 MG orally twice a day
12. HYDRALAZINE HCL 50 MG orally twice a day
13. ISOSORBIDE MONONITRATE ( SR ) 120 MG orally twice a day
14. LORAZEPAM 0.5 MG orally twice a day
15. METHADONE 20 MG orally twice a day
16. METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally every day
17. WARFARIN SODIUM 1.5 MG orally every bedtime
MEDICATIONS ON DISCHARGE:
ALLOPURINOL 100 MG orally EVERY OTHER DAY
Override Notice: Override added on 5/10/07 by CREAR , CAMILLE J A. , M.D. on order for COUMADIN orally ( ref # 093527741 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
AMIODARONE 200 MG orally twice a day Starting Today April
Override Notice: Override added on 5/10/07 by CREAR , CAMILLE J A. , M.D. on order for COUMADIN orally ( ref # 093527741 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 5/10/07 by WOLFLEY , LUCRETIA S. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
AMIODARONE HCL Reason for override: will monitor
ECASA 325 MG orally DAILY
Override Notice: Override added on 5/10/07 by CREAR , CAMILLE J A. , M.D. on order for COUMADIN orally ( ref # 093527741 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 5/10/07 by WOLFLEY , LUCRETIA S. , M.D.
on order for ECASA orally 325 MG every day ( ref # 528609960 )
patient has a POSSIBLE allergy to NSAIDs; reaction is Unknown.
Reason for override: patient tolerates
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 5/10/07 by CREAR , CAMILLE J A. , M.D. on order for COUMADIN orally ( ref # 093527741 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: aware
Previous override information:
Override added on 5/10/07 by WOLFLEY , LUCRETIA S. , M.D.
on order for GEMFIBROZIL orally ( ref # 265093153 )
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
GEMFIBROZIL Reason for override: will monitor
Previous override information:
Override added on 5/10/07 by WOLFLEY , LUCRETIA S. , M.D.
on order for AMIODARONE orally ( ref # 254334903 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
AMIODARONE HCL Reason for override: will monitor
CLOPIDOGREL 75 MG orally DAILY Starting IN a.m. November
Alert overridden: Override added on 5/10/07 by
WOLFLEY , LUCRETIA S. , M.D.
on order for CLOPIDOGREL orally 75 MG every day ( ref # 344788858 )
patient has a POSSIBLE allergy to TICLOPIDINE HCL; reaction is
Unknown. Reason for override: patient tolerates
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
DOXAZOSIN 2 MG orally every afternoon Starting Today April
HOLD IF: sbp<100
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
FERROUS SULFATE 325 MG orally DAILY
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 20 MG orally twice a day HOLD IF: sbp<95
GEMFIBROZIL 300 MG orally twice a day
Override Notice: Override added on 5/10/07 by CREAR , CAMILLE J A. , M.D. on order for COUMADIN orally ( ref # 093527741 )
POTENTIALLY SERIOUS INTERACTION: GEMFIBROZIL & WARFARIN
Reason for override: aware Previous override information:
Override added on 5/10/07 by WOLFLEY , LUCRETIA S. , M.D.
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
GEMFIBROZIL Reason for override: will monitor
HYDRALAZINE HCL 25 MG orally twice a day HOLD IF: sbp<100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 120 MG orally twice a day
HOLD IF: sbp<100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
ATIVAN ( LORAZEPAM ) 1 MG orally twice a day Starting Today April
as needed Anxiety HOLD IF: sedated or rr<12
METHADONE 20 MG orally twice a day HOLD IF: sedated or RR<12
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally twice a day
Starting Today April HOLD IF: HR<50 , SBP<100
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/10/07 by CREAR , CAMILLE J A. , M.D. POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: GEMFIBROZIL & WARFARIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Birgit Konstantinidi ( Inqueens Lane , Monte Holl Sa , Alabama 59501 MMC ) within one wk; Dr. Jaqua office will call you with appointment dat/time; if you do not hear from his office in one day , then call 486-705-2610 to make an appointment ,
Arrange INR to be drawn on 6/28/07 with f/u INR's to be drawn every
3 days. INR's will be followed by VNA/ MMC coumadin clinic
ALLERGY: NSAIDs , TICLOPIDINE HCL , HYDROMORPHONE HCL
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hypertension
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , history of CABG history of PTCA GOUT PROTEINURIA CRI hypertriglyceridemia htn
asymmetric BP afib history of PM GERD ( gastroesophageal reflux
disease ) NIDDM ( diabetes mellitus ) pancytopenia
( pancytopenia ) neuropathy ( neuropathy ) hepatitis B ( hepatitis
B ) BPH ( benign prostatic hypertrophy )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
titrated blood pressure meds
BRIEF RESUME OF HOSPITAL COURSE:
CC: CP , hypertension
***
HPI: patient is a 60yo man with CAD history of CABG ( 1988 LIMA to LAD and RIMA to
RCA ) and stent to OM 9/21 . Cath 11/29 with native LAD dz , patent LIMA ,
occluded RIMA and RCA with L to R collaterals. patient also has a history of
HTN , afib , mobitz II heart block history of PM 11/29 , CRI. He has frequent CP
( "punching/choking sensation" ) and multiple hospital admissions ( most
recent 8/29/21 on cards service ). patient recently told by
cards to stop hydral ( took 1/2 dose ). On 10/10 am noted SBP 190.
Developed punching/choking CP with mild dizziness and SOB. Sx lasted few
hours. EMS called. patient given ASA and nitro spray. In ED HR 90s ,
SBP 170s. Markers negative. EKG unchanged. Rx'ed with morphine , nitro ,
lopressor. CP stuttered , then resolved. patient admitted to GMS for
further mgt.
***
PMH: see PMHx
***
HOME MEDS: methadone 20 twice a day , ativan 0.5 twice a day , asa 325 every day , plavix 75
every day , lipitor 80 every bedtime , gemfibrozil 300 twice a day , amio 200 twice a day , to XL 25 every day ,
imdur 120 twice a day , hydral taking 25 twice a day , lasix 20 twice a day , coumadin ,
colace , iron , nexium 40 twice a day , doxazosin 2 every day , allopurinol 100 every other day ,
***
ALL: NSAIDS , ticlopidin
***
Admit PE: 97.5 69 140s/70s L 116/66 R sat 98% 2L NAD ,
AXOX3 CV: JVP 7 , RRR 2/6 SEN @
LSB Pulm:
CTAB Abd:
benign Ext: no edema ,
2+DP neuro:nonfocal
***
ADMIT LABS: Wbc 3 hct 31 plt 119 ( pancyto old ) , co2 19 , lytes ok , INR
1.9 , biomarkers neg x 2
***
STUDIES: EKG:a-paced , no acute ischemic changes 10/10 CXR: stable , mild
cardiomegaly , no acute process
8/19 Echo: 60% , no significant change from prior study
10/21/15 PFTs: wnl.
***
CONSULTS: none
***
EVENTS: none
***
HOSPITAL COURSE BY SYSTEM
1 ) CV: Patiet with CAD history of CABG , stents , recurrent CP. On admission ,
patient's CP was in setting of HTN to 190s. It occured likely
secondary to strain from hypertesnion. EKG remained unchanged.
Patient had neg biomarkers x 3. He was continued on ASA , plavix ,
nitrates , lopressor ( increased ) , statin , gemfibrozil , hydralazine.
Presumably not on acei 2/2 severe CRI. Of note , has history of assymetric BP b/with
2 arms. ON discharge patient's BP was 120-164/77-87. Patient was
euvolemic with stable weight ( 74.8kg ) from discharge so he was continued
on home
lasix. Patient had rate controlled afib with PM in place , and continued
lopressor , amio.
2 ) NEURO: For neuropathy , continued home methadone.
3 ) PSYCH: For anxiety , continued ativan as needed at 1mg dose. Consider
psychiatric evaluation for anxiety.
4 ) PULM: Satting well on RA. PFTs ok on amio.
5 ) RENAL: *CRI* Cr stable. Renally dose new meds + replete lytes
6 ) GI: *hep B* LFTs wnl.
7 ) HEME: *pancytopenia* Stable. patient seen by heme , but is refusing bone
marrow bx. Continue iron replacement. Continued coumadin at 2mg every bedtime
INR on discharge was 1.8 ( Goal 2-3 ).
8 ) ENDO: *NIDDM* Diet controlled. SSI
9 )RHEUM: *gout* No flare. Continue renally dosed allopurinol.
10 ) GU: *BPH* Continue doxazosin.
FEN: cardiac , diabetic diet
PROPH: PPI/ coumadin ( if ROMI neg )
***
CODE: FULL
***
CONTACTS: Wife Booser 723-882-3793 ( HCP ) , Daughter Musgrave
164-231-1570
ADDITIONAL COMMENTS: *If you develop shortness of breath , fatigue , palpitation , chest pain ,
you should seek medical help.
*If you SBP is greater than 180 , recheck your pressure in 30 minutes. If
it is still elevated. Call your doctor.
*We changed your toprol 25 to lopressor 25mg twice a day
*We changed your hydralazine 50mg to 25mg twice a day twice a day
*It is important that you follow up with Dr. Konstantinidi regarding your blood
pressure medications as they may need to be changed further once you
leave the hospital
*Your ativan dose was changed to 1mg as needed for anxiety twice a day.
Please talk with Dr. Konstantinidi about being evaluated by a
psychologist/psychiatrist for anxiety
*You will need to have your coumadin level checked on 3/17 and adjusted
according to the MMC coumadin clinic
FOR VNA:
-draw INR on 3/17 . Goal INR 2-3
-monitor BP
-monitor for sob , dizziness
-monitor daily weights ( dc weight 74.9kg )
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-f/u INR and re-start/adjust coumadin as needed
-check Cr ( was slightly above baseline CRI Cr level in house )
-adjust blood pressure meds as needed
No dictated summary
ENTERED BY: CREAR , CAMILLE J. , M.D. ( BO07 ) 11/19/07 @ 12:30 PM
****** END OF DISCHARGE ORDERS ******
Document id: 538
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
Y |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
Y |
- |
Y |
Y |
Y |
N |
N |
N |
N |
- |
800843851 | PUO | 29407184 | | 0034692 | 4/2/2005 12:00:00 a.m. | chronic coronary artery disease | | DIS | Admission Date: 4/7/2005 Report Status:
Discharge Date: 11/7/2005
****** DISCHARGE ORDERS ******
All Ley N 174-51-86-5
Frannaont Des
Service: CAR
DISCHARGE PATIENT ON: 1/22/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARNABA , CARA CHANCE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LASIX ( FUROSEMIDE ) 20 MG orally every day
GEMFIBROZIL 600 MG orally twice a day
HYDRALAZINE HCL 25 MG orally twice a day HOLD IF: sbp<100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ISORDIL ( ISOSORBIDE DINITRATE ) 60 MG orally three times a day
HOLD IF: sbp<100
METHADONE HCL 10 MG orally twice a day HOLD IF: oversedation , rr<10
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
HOLD IF: sbp<100 and heart rate<45 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
TEGRETOL XR ( CARBAMAZEPINE EXTENDED RELEASE )
100 MG orally twice a day Number of Doses Required ( approximate ): 10
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
ALLOPURINOL 100 MG orally every other day
ACETYLSALICYLIC ACID 81 MG orally every day
Alert overridden: Override added on 1/22/05 by :
on order for ACETYLSALICYLIC ACID orally ( ref # 37874656 )
patient has a POSSIBLE allergy to NSAIDs; reaction is Unknown.
Reason for override: takes at home
DIET: House / NAS / ADA 2100 cals/day / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
MMC Cardiology to be scheduled ,
ALLERGY: NSAIDs , TICLOPIDINE HCL
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chronic coronary artery disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , history of CABG history of PTCA GOUT PROTEINURIA CRI hypertriglyceridemia htn
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT MIBI
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain , r/o MI
HPI: patient is a 59 year-old m with CAD history of 2v cabg 1998 and multiple PCI , HTN ,
hyperchol , T2DM admitted with 3 wks of CP/diaphoresis/n/v/ SOB for
which he has been taking many SLNT. patient reportschest pain
chronically with exertion after walking about 3 blocks since cath
2001. ROS also + for 30 lb weight loss , chills , decreased appetite.
PMH: peripheral neuropathy , CAD , HTN , hyperchol diet controlled DM ,
CCY , EtOH abuse. VS 96.1 43 173/79 100%
RA ADMISSION EXAM: T 97.2 P 54 BP 158/71 O2 97%
2L NAD , resting horizontal nystagmus , neuro exam o/with
nonfocal , neck supple , jvp 7 , lungs with L base crackles , ?S4S1S2 50s ,
abdomen with mild LLQ tenderness , ext wwp with trace edema over
shins ADMISSION LABS: WBC 5.18 , HCt 40.1 , Plt 141 K 5.6 ,
Cr 2.4 , BNP 103 , cardiac markers flat x 1 ADMISSION EKG: sinus brady ,
1st avb , nl axis , QTC 426 , TW flat III + AVF , 1/2 mm STD I ,
avL ADMISSION CXR: borderline cardiomeg , no acute cp
process HOSPITAL
COURSE: 59 year-old man with extensive hx CAD p/with 3 wks crescendo
angina. EKG with non-specific changes. Cardiac markers neg.
CV: i - *known CAD , crescendo angina , EKG with non-specific changes ,
card markers neg x 3 ). ROMI neg , ECHO final report pending at this time
but prelim read with EF 65% , no RWMA , tr MR , LAE , mild LVH.
ETT MIBI with area of mild reversible defect unchanged from prior MIBI
in 2003; rec continued medical management ( prior cath with PDA filled by
right collateral with atretic RIMA to RCA ). Given risk of renal damange
with cath and unclear benefit of distal territory revasc deferred cath
for now and opting for medical management. Rx with asa , heparin x 36hrs ,
isordil. Continued on beta blocker and hydralazine for BP control;
would resumre ACE as outpatient if renal function remains stable.
Consider peripheral vasodilator if htn -
hydral added p - *HTN* See above. *euvolemic* briefly had sinus
bradycardia to 40s overnight , daytime HR in 70s Tele. Replete lytes as
needed given high
cr. *chol* Rx with gemfibrozil. NEURO: *peripheral neuropathy* Rx with
methadone , tegratol *etOH* Rx with as needed ativan in case of
with d PULM: *subjective dyspnea* Ddx ischemia , lower prob
PE. No evidence of PNA , edema , atelectasis. Eval ischemia as above.
No PECT given lower prob + high cr.
GI: *GERD* nexium *bowel reg* RENAL: *CRI* with in baseline , at discharge Cr
2.5. *hyperk*No sx or EKG
changes. Likely 2/2 CRI. Give kayex. Lasix intravenous x1. Recheck.
WNl ENDO: *DM* continue diabetic diet , was on sliding scale while in
house ONC: *weight loss , chills* Check megoo sweven hospital records
re: age-appropriate cancer screening. F.u PSA wnl. PROPH:
heparin/nexium CODE:full
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: FIGURA , CAREY T. , M.D. ( VT32 ) 1/22/05 @ 05:29 PM
****** END OF DISCHARGE ORDERS ******
Document id: 539
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
Y |
N |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
- |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
825117226 | PUO | 83039078 | | 759489 | 4/19/1997 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/28/1997 Report Status: Signed
Discharge Date: 10/1/1997
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old male
with a history of asthma , chronic
obstructive pulmonary disease and a significant psychiatric history
including mania , depression and psychosis.
His cardiac risk factors include hypercholesterolemia , tobacco use ,
family history. He does not have diabetes mellitus , although he
has had chemical diabetes mellitus in the past while on steroids.
He has been hypertensive.
He is transferred from Darnla Nashris Doweeksbar County Memorial Hospital with questionable
chest pain during the chronic obstructive pulmonary disease
bronchitis flare. In 10 of January he had an asthma flare. He had a
respiratory arrest with intubation. Catheterization at that time
showed a 40% LAD lesion. His wedge pressure was 20 mmHg. He had
normal LV function on LV gram at that time. In 11 of March he had a
nonQ-wave myocardial infarction with CKs approximately 300. In
2 of July he had another nonQ-wave myocardial infarction. CK is
approximately 700. In 7 of March he had an exercise tolerance test in
which he went nine minutes. He had 1 mm ST depression in 2 , 3 and
F. He reached maximum heart rate of 137 , blood pressure 186/80.
Since that time he has had multiple , multiple admissions for asthma
chronic obstructive pulmonary disease flares and rule out for
myocardial infarction; each time ruling out. In 28 of May he was in the
emergency room with vasovagal episode , treated with atropine. In
12 of November he had an exercise tolerance test with thallium of which he
underwent four minutes. He had a blood pressure of 164/80. He did
not have any chest pain , ectopy or evidence of ischemia on EKG ,
although there was questionable old infarct or ischemia at the apex
on the thallium images. In 9 of February he had a chronic obstructive
pulmonary disease flare. He went to Akcare Hospital . He had a
chest pain. He refused cardiac catheterization at that time and
was felt to be not competent to do such. Then his mental status
improved and he was deemed competent. He continued to refuse
cardiac catheterization. In 10 of September he was transferred from
Tibay Thesardslost A The Medical Center to Ngreen Medical Center County after difficulty
breathing and coughing up green-brown sputum for a couple of days.
He had chest pressure radiating to his left arm and his jaw and
this lasted for hours. He ruled out at Ngreen Medical Center County for
myocardial infarction. He had 0.5 mm ST depressions in V4 through
V6. He was treated there for unstable angina with nitropaste ,
aspirin , heparin and transferred to Pagham University Of on
aminophylline and heparin intravenous drips.
PHYSICAL EXAMINATION: Admission - Vital signs - 98.1 temperature ,
84 heart rate , 146/82 blood pressure , room
air sat was 98%. He was slightly labored breathing on admission ,
but was not in respiratory distress. His jugular venous pulsations
were visible approximately 3 cm above the angle. He had decreased
breath sounds bilaterally and moderate , diffuse wheezing
throughout. Heart - Sounds were very distant across the precordium
although audible at the epigastrium , S1 and S2 were normal. There
was no murmurs , gallops or rubs. He did not have any rashes. His
mental status was intact although he had increased rate of speech
and rapid thoughts.
LABORATORY DATA: Admission - 141 sodium , 4.1 potassium , 100
chloride , 27 bicarb , 118 glucose , 26/1.2 ,
BUN/creatinine. WBC 10.39 , hematocrit 44.1 , platelet count 190.
CK was 100. troponin 0.7 , calcium was 9.5 , magnesium 2.2 , valproic
acid 42 level.
EKG on admission revealed normal sinus rhythm at 68 beats per
minute. He had a normal axis. His R-wave progression was normal.
Intervals are 0.128 , 0.96 , 0.394. He had inverted Ts in 1 and L
and nonspecific T-wave changes throughout with some 0.5 mm ST
depressions at baseline in his inferior leads.
Chest x-ray was normal.
He was admitted and declined catheterization initially , asking about an
exercise test first. He had his sputum gram stain
which showed gram positive cocci and gram positive rods. He was started on intravenous
cefuroxime. His heparin and aminophylline were discontinued on
admission. He was treated mainly for chronic obstructive pulmonary
disease flare. He had a history of steroid induced psychosis. He
was treated with inhaled steroids and Albuterol and Azmacort via
nebulization. He improved his peak flows on admission which were
approximately 250; discharge peak flows were between 500 and 700.
He underwent an exercise echocardiogram on 11 of August which showed one
mm ST depression on top of the half mm baseline ST depressions of
the inferior leads , potentially consistent with ischemia although
when the echo images were reviewed they were not thought to be
consistent with ischemia. There was no change in wall motion
during exercise as compared to rest.
This patient is scheduled to follow-up with me , Dr. Lottie Gudiel in
the Sa Pehall on April , 1997 at 1:50 p.m.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day , Cogentin 1 mg
orally every afternoon , Cardizem 90 mg orally three times a day ,
Depakote 500 mg every day before noon , 750 mg every afternoon Ativan 1 mg orally twice a day ,
Trilafon 8 mg orally every bedtime , Azmacort four puffs inhaled four times a day ,
olanzapine 10 mg orally every bedtime , Albuterol MDI two puffs four times a day and
as needed Azmacort two puffs four times a day
Dictated By: BROOKE LEMMEN , M.D. HN76
Attending: GERMAINE L. BLACKGOAT , M.D. MM9 XE564/2763
Batch: 2702 Index No. VLRB813M53 D: 1/3/97
T: 1/3/97
CC: 1. LETEREASTSTERNSROCK MEDICAL CENTER FAX 042-216-7060
ATTENTION: LATORIA OGDEN
Document id: 540
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
- |
N |
- |
N |
N |
N |
- |
N |
N |
Y |
N |
N |
N |
868961981 | PUO | 41778500 | | 6417988 | 10/21/2004 12:00:00 a.m. | morbid obesity | | DIS | Admission Date: 10/21/2004 Report Status:
Discharge Date: 4/3/2004
****** DISCHARGE ORDERS ******
TROWERY , DEDE 541-89-89-4
Ba Di Rock
Service: GGI
DISCHARGE PATIENT ON: 1/5/04 AT 07:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MONDELL , MELINA RACHAEL , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
OXYCODONE SOLUTION 5-10 MG orally every 4 hours as needed Pain
CELEXA ( CITALOPRAM ) 20 MG orally every day Instructions: crush
PHENERGAN ( PROMETHAZINE HCL ) 12.5 MG PR every 6 hours as needed Nausea
PEPCID ( FAMOTIDINE ) 40 MG orally every day
DIET: carnation
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Mondell 338-172-3762 1 week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
morbid obesity history of lap band
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
mild htn
OPERATIONS AND PROCEDURES:
5/6/04 MONDELL , MELINA RACHAEL , M.D.
LAPAROSCOPIC ADJUSTABLE BAND PLACEMENT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ugi - no leak/obstruction
BRIEF RESUME OF HOSPITAL COURSE:
42 year-old female with morbid obesity now history of uncomplicated lap band .
please refer to op-note for details. Post op patient npo with ivf.
UGI obtained with no leak or obstruction. Diet was then transitioned to
clear liquids and well tolerated. Upon dishcarge patient is on all orally pain
medications , with pain well controlled . patient is voiding , ambulating and
tolerating her diet. Of note , patient had new onset right calf pain
prior to discarge. Patient reports the pain started while walking
earlier in the day. Pain only with walking , while calf contracted. No
pain at rest. On exam , patient has no lower leg swelling , no erethema ,
no palpable cords , and a negative Homan's Test. Point of pain in right
calf muscle could be reproduced with point pressure and while patient
stood on right toe. Patient will be discharged with strict
instructions to go directly to ED if she experiences new onset leg
swelling , warmth , erethema , or worsening leg pain at rest. Patient
will also go to ED if new SOB or tachycardia/palpitations.
ADDITIONAL COMMENTS: -Go to ER if your right lower leg becomes swollen , red , or hot...or if
pain becomes markedly worse at rest. ALSO go to ER if you develop new
shortness of breath or feel that your heart is racing.
do not drive while on narcotics , Monitor wound for redness or puss like
dishcarge. Fever >101 , nausea or vomiting please call Dr. mondell or
return to Er.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: CROCKET , CHARLESETTA DOT , M.D. , PH.D. ( HE65 ) 1/5/04 @ 09:01 PM
****** END OF DISCHARGE ORDERS ******
Document id: 541
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
- |
Y |
N |
Y |
Y |
Y |
N |
- |
N |
N |
N |
N |
405012066 | PUO | 35123591 | | 7161873 | 6/7/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/19/2005 Report Status: Signed
Discharge Date:
ATTENDING: BINGMAN , MASON M.D.
SERVICE: Surgical ICU.
PRINCIPAL DIAGNOSIS: Perforated colon status post colectomy.
ACTIVE PROBLEMS LIST:
1. Status post colectomy , perforation of colon.
2. Coronary artery disease.
3. Congestive heart failure secondary to Adriamycin.
4. Atrial fibrillation
5. Respiratory failure status post tracheostomy.
6. Chronic obstructive pulmonary disease ( steroid dependent ).
7. Pseudomonas pneumonia.
8. Chronic pain.
9. Chronic renal insufficiency.
10. Steroid dependent.
11. Perforated colonic diverticula.
12. Sepsis.
13. Anxiety with adjustment disorder.
PAST MEDICAL HISTORY:
1. Coronary artery disease as above.
2. Congestive heart failure , ejection fraction 30% , secondary to
ischemic cardiomyopathy and Adriamycin toxicity.
3. Atrial fibrillation ( paroxysmal ).
4. Nonsustained ventricular tachycardia.
5. Hypertension.
6. Steroid-dependent chronic obstructive pulmonary disease.
7. Staphylococcus bacteremia.
8. Acute on chronic renal failure.
9. Leg blisters.
10. Transient ischemic attacks.
11. Gout.
12. Cholecystectomy.
13. Appendectomy.
14. Testicular cancer status post chemotherapy.
ALLERGIES: No known drug allergies , history of Achilles tendon
rupture with levofloxacin.
MEDICATIONS:
1. Amiodarone , 200 mg daily , T-tube.
2. Peridex , 15 mL orally twice a day
3. Digoxin , 0.0625 mg , T-tube every other day
4. Pepcid 20 mg T-tube twice a day
4. Folate , 1 mg , T-tube daily.
5. Heparin , 5000 units subcutaneously three times a day
6. NPH , 9 units subcutaneously every day before noon
7. Insulin regular , sliding scale every 4 hours
8. Prednisone , 5 mg , T-tube every day before noon
9. Multivitamin daily.
10. Sarna topically daily.
11. Nystatin suspension 5 mL orally four times a day
12. Thiamine , 100 mg , T-tube daily.
13. Flovent , 88 mcg MDI twice a day
14. Collagenase topically daily.
15. Combivent , 2 puffs MDI four times a day
16. Albuterol , 2 to 4 puffs four times a day as needed
17. Darbepoetin alpha 100 mcg subcutaneously every week.
18. Xenaderm topically twice a day
19. Ativan NG tube 0.521 mg every 6 hours as needed anxiety.
20. Trazodone 50 mg orally every bedtime as needed insomnia.
21. Oxycodone 1 mg/mL , 10 mg solution via T-tube every 4 hours as needed
pain.
HOSPITAL COURSE: This is a 50-year-old man who was admitted to
Osri Medical Center on March , 2005 , with respiratory failure
and fever diagnosed with pneumonia and COPD flare. He was
started empirically on antibiotics. Sputum culture was positive
for Pseudomonas and treated with ceftazidime and levofloxacin.
Also , noted at Osri Medical Center to have 4/4 blood cultures
positive for coagulation-negative Staphylococcus. He was placed
on vancomycin. During the course of this hospital stay , he had
other medical issues including: Non-ST elevation myocardial
infarction. Also noted to have upper gastrointestinal bleed due
to supratherapeutic INR. Also had acute on chronic renal failure
with a creatinine of 7.7 , thought to be due to intravenous contrast. He
was transferred to Totin Hospital And Clinic ICU after going into
respiratory distress at Merla Medical Center , for which he was intubated.
He was continued on antibiotics at Re Health . In
the lakesmi sonno memorial hospital surgical ICU at the Kernan To Dautedi University Of Of , he was also noted to have
an improvement in his acute renal failure with his creatinine
improving to 2.0 range. With intravenous fluids , his non-ST elevation MI
appeared to be resolving; however , was noted to have ongoing
fevers despite antibiotics. Noted on abdominal CT to have free
air. He was taken to the operating room on June , 2005 ,
and had sigmoid colectomy with colostomy and he remained
intubated postoperatively , and was transferred to Sst.co Virg Co Surgical
ICU. Postoperatively , he was continued on broad-spectrum
antibiotics including vancomycin , ceftazidime , and was continued
on fluconazole for fungemia. Intraoperatively , he was noted to
have perforation in his sigmoid colon. He in the ICU , required
Levophed and vasopressin. The patient was noted to have ongoing
respiratory failure. He required reintubation on October ,
2005 , after a brief period of extubation. He returned to the
operating room on October , 2005 , where he had an ileostomy ,
T-tube placement , and a tracheostomy. In addition , his abdomen
was explored and adhesions were lysed. Postoperatively , he was
noted to have further improvement of his renal failure. He was
noted to have improvement in acidosis; however , had ongoing slow
wean off the ventilator. He was noted to have on followup CT to
have intraabdominal fluid collections along with his daily
fevers. On January , 2005 , he had a CT-guided drainage and
placement of a drain for one of these fluid collections. He had
some ongoing improvement and was continued on vancomycin , Flagyl ,
fluconazole , and ceftazidime post procedurally. Repeat cultures
of sputum yielded ongoing Pseudomonas in the sputum sensitive to
ceftazidime. Also noted to have Aspergillus in his sputum.
Thought to have possible colonization of his airways. On
followup CT , he was noted to have ongoing fluid collection as
well as daily fevers. He was discontinued on his central lines
and had a change-out of his arterial line. He also obtained a
tagged white blood cell scan , which revealed an area of
enhancement in his right lower quadrant consistent with possible
abscess; however , this patient had decreasing frequency of fevers
with discontinuation of lines and continuation of antibiotics. Moreover , the
area of enhancement on the tagged cell scan did not correlate with a
significant fluid collection on abdominal CT. After consultation with the
Infectious
Disease Service , Interventional Radiology Service , and the Surgical Service , it
was decided that there would be no intervention done on this
collection at this time. Otherwise , the patient now is starting
orally and is having ongoing low-grade temperatures , but clinically
improving. From the respiratory standpoint , was liberated from mechanical
prior to discharge from the ICU.
LABORATORY DATA: White cell count 16 , 000 , hematocrit 27 ,
platelets 443. Chem 7: Sodium 134 , potassium 4.3 , chloride 95 ,
bicarbonate 28 , BUN 36 , creatinine 1.7 , calcium 9.1. physical therapy 14.9 ,
INR 1.2 , PTT 34.1.
ASSESSMENT AND PLAN: This is a 50-year-old man with history of
coronary artery disease , congestive heart failure , chronic
obstructive pulmonary disease , chronic renal insufficiency , who
is status post colectomy with ileostomy secondary to perforated
sigmoid colon , status post tracheostomy for respiratory failure ,
prolonged ICU course secondary to pneumonia , sepsis , acute on
chronic renal failure , and paroxysmal atrial fibrillation.
Neurological: The patient is now off sedative drips. He is
alert and oriented and has chronic pain secondary to degenerative
lower back disease; however , his pain has been well controlled
with his current regimen. Psychiatric consult was obtained and
he is noted to have an adjustment disorder with anxiety.
Plan is to continue oxycodone as needed and continue Ativan as
needed.
Cardiovascular: Status post non-ST elevation myocardial
infarction , congestive heart failure with an ejection fraction of
30% , has had no further signs of pulmonary edema by x-ray or by
clinical symptoms. He is off pressors. He has been
hemodynamically stable and in normal sinus rhythm.
Plan is to continue amiodarone via T tube and continue digoxin.
We will diurese with Lasix as needed to keep I's and O's even.
Respiratory: Continues to be slow steroid wean. Liberated from mechanical
ventilation prior to transfer out of the ICU. S/p tracheostomy , history
chronic
obstructive pulmonary disease , completing course of Pseudomonas pneumonia
treatments on ceftazidime.
Gastrointestinal: Continues to be on tube feeds , goal rate. We
will start advancing orally diet as tolerated with a plan to wean
tube feeds as the patient is able to tolerate further orally's. We
will plan to start orally medications as tolerated.
FEN/GU: Chronic renal insufficiency with baseline creatinine 1.5
to 1.7. Acute renal failure , resolved. He has been having good
urine output with no major electrolyte abnormalities. We will
continue to diurese with Lasix as needed to keep I's and O's
even.
Endocrine: This patient remains on insulin sliding scale. We
will titrate to keep euglycemic.
Heme: The patient has been anemic with hematocrits in the mid
20s and has been stable , likely due to nutrition and anemia of
chronic disease. We will continue to watch hematocrit on the
floor and continue DVT prophylaxis.
ID: Currently on day #19 of ceftazidime of 21. The patient has
been doing well off vancomycin , fluconazole , and Flagyl. He has
been having low-grade temperatures , but improved from the last
several weeks. We will continue to monitor JP output as well as
to follow clinically. He is noted to have an ongoing fluid
collection in his abdomen and may warrant a followup CT at some
point in the future. Transferred to floor with cardiac
monitoring.
DISPOSITION: This patient's condition is stable.
eScription document: 5-3468483 ISSten Tel
Dictated By: KATCSMORAK , CARRI
Attending: BINGMAN , MASON
Dictation ID 0074696
D: 7/20/05
T: 7/20/05
Document id: 542
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
N |
Y |
N |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
Y |
N |
N |
618613143 | PUO | 28927194 | | 1921156 | 10/28/2005 12:00:00 a.m. | Epididymitis , UTI | | DIS | Admission Date: 1/17/2005 Report Status:
Discharge Date: 7/15/2005
****** FINAL DISCHARGE ORDERS ******
SHEARER , OSWALDO 044-02-91-1
Kirkcand Scotow Lone Drive
Service: MED
DISCHARGE PATIENT ON: 1/5/05 AT 11:30 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALLOPURINOL 300 MG orally every day
Alert overridden: Override added on 1/5/05 by
ESANNASON , BELINDA , M.D. , PH.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: home med
ATENOLOL 50 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 1/5/05 by
ESANNASON , BELINDA , M.D. , PH.D.
on order for LASIX orally ( ref # 81763538 )
patient has a POSSIBLE allergy to Sulfa; reaction is Rash.
Reason for override: home med
LISINOPRIL 20 MG orally every day
Override Notice: Override added on 1/5/05 by
ESANNASON , BELINDA , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
50764218 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
HYTRIN ( TERAZOSIN HCL ) 5 MG orally every bedtime
Number of Doses Required ( approximate ): 4
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 1/5/05 by
PARDON , HALEY , M.D.
on order for LEVOFLOXACIN intravenous ( ref # 09666866 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
Reason for override: md aware Previous override information:
Override added on 1/5/05 by
ESANNASON , BELINDA , M.D. , PH.D.
on order for ALLOPURINOL orally ( ref # 76926811 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: home med
ISOSORBIDE MONONITRATE 20 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 3
FLOVENT ( FLUTICASONE PROPIONATE ) 44 MCG inhaled twice a day
NASONEX ( MOMETASONE FUROATE ) OINTMENT TP every day
Number of Doses Required ( approximate ): 4
WELLBUTRIN SR ( BUPROPION HCL SUSTAINED RELEASE )
150 MG orally every day Number of Doses Required ( approximate ): 4
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
LEVOFLOXACIN 500 MG orally every day X 14 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 10/18/05 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
Reason for override: md aware
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please follow-up with your primary care physician in 2 weeks ,
Arrange INR to be drawn on 11/18 with f/u INR's to be drawn every
3 days. INR's will be followed by MMC - Deloy
ALLERGY: Sulfa
ADMIT DIAGNOSIS:
Scrotal Cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Epididymitis , UTI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
sleep apnea ( sleep apnea ) hypertension ( hypertension ) gout
( gout ) diverticulitis ( diverticulitis ) urethral strictures
( 2 ) GERD ( gastroesophageal reflux disease ) Depression
( depression ) DVT ( deep venous thrombosis )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT scan , Scrotal US , cardiac ECHO , bladder scan , labs , antibiotics.
BRIEF RESUME OF HOSPITAL COURSE:
CC: Scrotal edema
HPI:55 y'o man with a hx of HTN , obesity , DVT , BPH , recurrent UTIs ,
urethral strictures likely 2ndary to hx of gonorrhea and a recent hx
of urethral dilatation 8/10 and subseqeunt self-cath/dilatation
as recently as 10/6 who p/with 5 days of urinary frequency , urgency , and
incontinence and 2 days of scrotal edema and erythema. Saw primary care physician 8/22
for UTI symptoms and mild scrotal tenderness. Was started on
nitrofurantoin at the time. Some resolution in UTI symptoms but
persistentfevers f/b development of scrotal swelling and sqeezing
scrotal pain.
No n/v/d/recent travel/recent STDs. Not sexually active. No hx of
prostatitis. Seen in ED , given Levo and Cefotax and had neg CT abd
pelvis.
PE: T= 101.0 HR=95 R=20 BP=102/64 95%
RA Obese , NAD , MMM , JVP 7cm.RRR Nl s1 and S2 , 2/6
Holosystolic murmur greatest at apex , CTAB , abd soft , ND/NT. No
inguinal LAD. Scrotum erythematous , warm , swollen , mild tenderness to
palpation. Could not palpate epidydymis. penile retraction , 2+
DPP , venous statis changes. No edema.
CTabd/Pelvis - Notable for horshoe kidney , steatic hepatosis , and
scrotal thickening.
Scrotal US - No evidence of torsion. Pos for epididymitis
A/P: 55 y'o man with hx of BPH. urethral strictures ,
recuurent UTIS , here with UTI and likely scrotal cellulitis v.
hydrocele v. epidydimitis.
1 ) GU - UTI with urine culture performed as outpatient that was positive
for E.coli per MMC record: Treating with Levofloxacin. Epididymitis-
covering with Levofloxacin. Continuing terazosin for BPH. Post-void
bladder scan ontained with no evidence of residuals. Encouraging daily
staright cath 3-4cm into urethral meatus to prevent re-stenosis.
Teching performed for patient and partners on procedure.
2 ) CV - New aortic murmur. ECHO performed with results pending at time
of discharge. Continue ACE ,
beta-blocker , isosorbide , lasix as per home reg
3 ) Pulm - CPAP for sleep apnea
4 ) FEN: on coumadin + TEDS for DVT prophylaxis , PPI ,
cardiac diet. FULL CODE
ADDITIONAL COMMENTS: 1 ) Please take Levofloxacin - 1 pill a day for 14 days.
2 ) If scrotal swelling , redness , or pain get worse or if you develop
persistent fevers please phone your primary care physician or return to the Emergency room.
3 ) Please follow-up with your doctor regarding the results of the cardiac
ECHO. 4 ) Please straight catheterize yourself once a day to keep the
urethral meatus open.5 ) Please be sure to have INR checked in 2-3 days.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Please follow-up on ECHO results.
2 ) Please check INR 2-3 days after discharge because Levofloxacin can
increase INR.
No dictated summary
ENTERED BY: PARDON , HALEY , M.D. ( NC57 ) 10/18/05 @ 10:07 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 543
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
Y |
N |
N |
N |
Y |
N |
N |
624301994 | PUO | 98865948 | | 556175 | 10/28/2001 12:00:00 a.m. | nqwmi | | DIS | Admission Date: 8/13/2001 Report Status:
Discharge Date: 2/1/2001
****** DISCHARGE ORDERS ******
SEWER , KIRK H. 737-58-21-7
Parkne
Service: CAR
DISCHARGE PATIENT ON: 9/10/01 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
ZOCOR ( SIMVASTATIN ) 20 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: IN 3 DAYS
FOLLOW UP APPOINTMENT( S ):
Dr. Francisca Urbaniak , cardiology November at 10 am scheduled ,
Dr. Marcelina Strauhal , VCMC October at 2:10 pm scheduled ,
Dr. Tobie Pencil , lipids November at 10 am scheduled ,
ALLERGY: Reglan ( metoclopramide hcl ) , Phenothiazines
ADMIT DIAGNOSIS:
cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
nqwmi
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) hypercholesterolemia ( elevated
cholesterol ) chronic lower back pain ( low back pain ) sleep apnea
( sleep apnea ) gerd ( gastroesophageal reflux disease ) Legionella
lyme disease ( Lyme disease )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cardiac cath 5/10/01 showed patent D1 stent and unchanged coronaries
since last cath 99
BRIEF RESUME OF HOSPITAL COURSE:
50 year-old with CAD history of PTCA with stent to 1st diag in 1999 , also with
chronic lower back pain with intrathecal morphine pump. Presents with
chest pain in context of 12 hours nausea/vomiting/dry heave likely
secondary to morphine withdrawal from malfunctioning pump. Chest pain
relieved with sublingual NTG x3. Enzyme leak , troponin 1.3 at outside hospital
--> NQWMI. patient transferred for cath to evaluate stent. Cath 5/10/01
showed patent D1 stent , 50% LAD , 60% PDA with likely accelerated
idioventricular rhythm post cath. He was transferred to cards
for evaluation of rhythm and optimization of cardiac management.
patient has been asymptomatic on morphine PCA ( pending arrival of
intrathecal pump infusion per pain service ). HTN was controlled with
clonidine , and his ECG normalized. Chest pain was thought
to be secondary to increased demand during acute withdrawal. Will
Pump was refilled per pain service , and his cardiac regimen was
optimized. Outpatient cardiology follow up with stress test to risk
stratify was arranged. Patient's urine output was marginal on 3/16/01 .
He was hydrated with modest response. BUN and creatinine were stable.
ADDITIONAL COMMENTS: Call your doctor or go to emergency room if you develop chest pain ,
lightheadedness , worsening shortness of breath , or palpitations. Follow
-up appointments have ben scheduled for cardiology , cholesterol
management , and primary care.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: CREAN , RAY T. , M.D. ( GM454 ) 9/10/01 @ 10:02 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 544
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
- |
755769119 | PUO | 08406058 | | 896070 | 10/3/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/5/1992 Report Status: Signed
Discharge Date: 10/7/1992
ADMISSION DIAGNOSIS: STATUS POST MYOCARDIAL INFARCTION. PROBLEMS
WERE SCHIZO-AFFECTIVE DISORDER AND COLITIS.
HISTORY OF PRESENT ILLNESS: Patient is a 47 year old man
transferred from Put Wathern Hospital
after an acute anterior myocardial infarction. Approximately one
week prior to admission , patient noted a three month history of
substernal chest pain. Exercise tolerance test done at Forestblan Conwake Hospital
three days prior to admission was positive for ischemia and patient
was admitted to Pagham University Of for cardiac
catheterization.
PHYSICAL EXAMINATION: On admission showed a clear chest , cardiac
with regular rate and rhythm , distant heart
sounds , and no rub or gallop , abdomen was obese , and trace pedal
edema.
HOSPITAL COURSE: Patient underwent cardiac catheterization which
showed a 95% tight proximal left anterior
descending lesion. This was on 8/2/92 . On 9/5/92 , patient
underwent atherectomy with good results of this proximal left
anterior descending lesion. There were no complications and
patient was discharged in excellent condition.
DISPOSITION: DISCHARGE MEDICATIONS: Nifedipine XL 30 mg every day ,
Azulfidine two grams twice a day , Lopressor 100 mg three times a day ,
Prozac 40 mg twice a day , Isordil 10 mg twice a day , Ecotrin one every day ,
Mevacor 20 mg every day , Stelazine 2 mg bi.d. , and Clonopin orally three times a day
Patient is discharged to home.
QZ694/6444
EARNESTINE M. FIERMONTE , M.D. TM8 XU4 D: 11/15/92
Batch: 7490 Report: O1464L3 T: 6/29/92
Dictated By: KAM R. ISA , M.D.
cc: 1. ROSSIE MANKOSKI , M.D./
Norri Hospital
Nolouis
Document id: 545
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
- |
N |
109080323 | PUO | 62974095 | | 711252 | 10/3/2000 12:00:00 a.m. | GASTRO INTESTINAL BLEEDING | Signed | DIS | Admission Date: 1/20/2000 Report Status: Signed
Discharge Date: 2/27/2000
CHIEF COMPLAINT: Weakness , shortness of breath , worsening over one
month.
HISTORY OF PRESENT ILLNESS: THis is a 71 year old male with
diabetes mellitus , asthma , history of
guaiac positive stool , history of angina now with increased
weakness and shortness of breath progressive over one month. He
has required increased metered dose inhalers for "asthma" over the
past two weeks and has become progressively short of breath over
one block where he used to be able to walk "all the way into town."
He denied dizziness , myalgias , no fevers , chills , nausea , vomiting
or diarrhea but did complain of a decreased appetite and ten pound
weight loss over the past month. He said he has had black stools
times three weeks with constipation and said that he stopped his
iron pills about a month ago because he just had too many pills to
take. He also denied dysuria , hematuria or any bright red blood
per rectum. He denied cough , rhinorrhea. He did have a sore
throat but no recent contact and got his Pneumovax and flu shot
this year. The patient denied any orthopnea or paroxysmal
nocturnal dyspnea or peripheral edema. The patient was last
admitted in 4/10 for malaise and shortness of breath and found to
have a right lower lobe pneumonia at the time , also in atrial
fibrillation and flutter , hyperglycemia and guaiac positive stools
attributed to diverticulosis.
PAST MEDICAL HISTORY; 1. Significant for history of angina.
The patient had an exercise echocardiogram
in 2/14 which showed normal systolic function and no wall motion
abnormalities , no ischemia. He went three minutes and stopped
secondary to fatigue with max heart rate of 79 which is 52% of
predicted. He was beta blocked with blood pressure of 130/80 and
no ST changes. 2. Diabetes mellitus , 3. Asthma. In 11/1 , PFTs
showed FEC 88% of predicted , FEV of 74% of predicted , FEV1/FEC
ratio of 85% of predicted and total lung capacity 88% of predicted
functional , residual capacity and 83% of predicted. 4. Sigmoid
diverticulosis/polyps , 5. History of renal stones , 6. History of
atrial fibrillation and flutter in 4/10 when admitted with
pneumonia. 7. Ataxic gait and intermittent dementia noted on the
4/10 admission. 8. Guaiac positive stool noted on the 4/10
admission. 9. Also , history of gastritis and history of GI bleed
at Pande Memorial Hospital in 1/24 . Attempt was made to gather
information at discharge from Pande Memorial Hospital but we were
unable to obtain records. 10. History of left hydrocele. 11.
Hypertension and hypercholesterolemia. 12. Anxiety disorder.
PAST SURGICAL HISTORY: The patient said he had some operation for
kidney stones.
ALLERGIES: Unknown.
MEDICATIONS: Humulin NPH 20 twice a day , Isordil 20 twice a day , Cardizem 30
three times a day , Mevacor 20 every day , Klonopin 0.5 twice a day , Paxil
20 every day , Albuterol two puffs four times a day , Azmacort four puffs twice a day
and Zantac 150 twice a day
SOCIAL HISTORY: Positive tobacco pack per day , ETOH occasionally
and he lives with his wife. He doesn't work.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: On admission , the patient was afebrile at
97.8 with heart rate of 80 , blood pressure
110/50 , lying down and sitting up heart rate of 88 and blood
pressure of 120/50. He was satting 97% on room air. GENERAL: He
was awake , alert , irish speaking male , poor historian. HEENT:
NC/AT , EOMI , PERRLA. OROPHARYNX: Negative with moist mucous
membranes. NECK: He had no JVP. CORONARY: Regular rate , no
murmurs , rubs or gallops. LUNGS; Crackles bilaterally at bases.
ABDOMEN: Soft , non-tender , tympanic with good bowel sounds and no
peritoneal signs. RECTAL: Showed guaiac positive brown stool.
EXTREMITIES: Warm , dry but poorly palpable peripheral pulses.
Cranial nerves examination showed II/XII grossly intact and motor
and sensory exams were without gross deficit.
LABORATORY: His EKG showed normal sinus rhythm with first degree
AV block , rate of 78 , PR of 212 , QRS of 96 and QT 448
with axis of 57. He had some flat Ts in AVL and T wave inversion
in V1. His chest x-ray had no infiltrate , no effusion and no
evidence of failure. Laboratory revealed sodium of 138 , potassium
of 4.1 , chloride 103 and bicarbonate of 25 with BUN of 17 and
creatinine 1.2. His baseline was 0.7 in 4/10 . Glucose was 186 and
anion gap of 10. He had a white count of 8.2 , hematocrit of 17.9
which his baseline was 39.5 in 4/10 , platelets of 280 and MCV of
68. He had 66 neutrophils , 21 lymphs and 8 monos and physical therapy of 12.1 ,
PTT of 21.3 and INR of 1.0. His CK was 47 and Troponin was 21.9.
His amylase was 28 and lipase was 187.
HOSPITAL COURSE: By problem list: Heme: He had a hematocrit of
17.9 down from baseline of 39.5. He was
transfused three packed red blood cells and his hematocrit
responded appropriately. It was 34.5 by the day of discharge. He
also had iron studies sent off that showed a total iron binding
capacity of 324 and ferritin of 20 consistent with iron deficiency
anemia. He was restarted on Niferex.
GI: Given this guaiac positive stool and history of guaiac
positive stool in 1999 , he was thought to have an acute on chronic
GI bleed questionably secondary to diverticulosis or cancer. He
also has history of gastritis. We kept him NPO. GI consult was
obtained. He underwent initially an esophagogastroduodenoscopy
which was completely normal. Esophagus had no varices , no
esophagitis. Stomach was normal; no ulcer , no erosion or end NSAID
gastropathy. His duodenum to D3 was normal with small
periampullary diverticulum. Colonoscopy was then performed which
found sigmoid diverticulosis , 4 millimeter non-bleeding sessile
polyp which was removed by snare cautery and some mild oozing after
the polypectomy but good hemostasis was achieved. Small , internal
hemorrhoids were present but no active bleeding sites were found.
On pathology , it was found to be a hyperplastic polyp. GI team
recommended small bowel follow through to rule out small bowel
source for bleeding as an outpatient. The patient was kept on his
Zantac 150 twice a day for history of gastritis. The patient was sent
home on Tylenol for pain and told to avoid taking aspirin or any
other NSAIDs given his GI bleed.
Renal: Creatinine was 1.2 on admission. His baseline was 0.9. He
received some intravenous fluids as he was NPO for his GI studies and his
creatinine came down to 0.9. So , it was likely that he was
slightly volume depleted on admission.
Cardiovascular: The patient had a history of angina but no recent
chest pain and no cardiac complaints. With his hematocrit of 18 ,
he had a flat CK and Troponin of 0.19 and had no further cardiac
issues during this hospital course. He was kept off aspirin given
his GI bleeding. THe patient also has hypertension and was on
Isordil and Cardizem for that. His blood pressure meds were held
initially on admission and were re-added back at the time of
discharge as well as his Mevacor.
Endocrine: The patient was maintained on his Humulin NPH and
covered with sliding scale during this admission. His blood sugars
remained in the 160 to 180 range.
Pulmonary: The patient was kept on his Albuterol and Azmacort
metered dose inhalers and by the time of discharge , was without
wheezes and satting well at 96% on room air.
Neuro: The patient was kept on his Klonopin and Paxil for anxiety.
Fluid , electrolytes and nutrition: The patient was started on
magnesium oxide for low magnesium during his hospital course.
DISCHARGE MEDICATIONS: Are as follows: 1. Tylenol 650 mg orally every 4
as needed headache , 2. Isordil 20 mg orally
twice a day , 3. Cardizem 30 mg orally three times a day , 4. Mevacor 20 mg orally every day ,
5. Humulin 20 units subcutaneously twice a day , 6. Klonopin 0.5 mg orally twice a day ,
7. Paxil 20 mg orally every day. 8. Magnesium oxide 420 mg orally twice a day ,
9. Niferex 150 mg orally twice a day , 10. Zantac 150 mg orally twice a day , 11.
Albuterol inhaler , 12. Azmacort inhaler.
FOLLOW-UP; He is to follow-up with Dr. Bye in a week.
CONDITION ON DISCHARGE: THe patient was discharged home in stable
condition.
Dictated By: VONNIE F. CHANT , M.D. TU84
Attending: NATHANIAL BYE , M.D. WI41 GE677/6862
Batch: 65100 Index No. W8RJ6135AN D: 3/30
T: 10/17
Document id: 546
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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874486955 | PUO | 72680439 | | 621733 | 7/8/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/11/1994 Report Status: Signed
Discharge Date: 2/10/1994
PRINCIPLE DIAGNOSIS: 1. BRADYARRHYTHMIA.
SECONDARY DIAGNOSIS: 1. SYNCOPE.
PROCEDURES: Pacemaker insertion , 24 of November .
IDENTIFICATION: Sixty year old black female who has a chief
complaint of dizziness and syncope. The source of
history was the patient , who was a moderate historian and the old
chart. HISTORY OF PRESENT ILLNESS: According to the patient , she
first presented to the medical system in 1989. At that time she
was walking at home and became dizzy. She was taken to Pe Valley Health in Dence She was told that she had a heart
attack and was placed on a monitor when she was noted to have an
episode of asystole on the monitor. This led to emergent pacer
insertion. After pacer placement , the dizziness never recurred
until a few months ago. This led to hospitalization on May , 1994
at Pagham University Of . She was seen by the pacer service
who interrogated her pacer and found it functioning normally.
However , the pacer lead type ( MECHRONIC 4012 ) is felt to have a
high failure rate , necessitating a new pacer insertion.
Unfortunately , the patient left AMA before the procedure could be
performed.
Today , the patient got out of bed and preceded to the bathroom ,
where she had a normal bowel movement without any symptoms. She
got up from the toilet and while walking back to bed became dizzy
again. She subsequently passed out for an undetermined time.
After waking up she knew exactly where she was and had no
post-ictal symptoms. She fell to the floor , but denies any trauma.
She also denied urinary/fecal incontinence during this episode.
She adamantly denies chest pain , shortness of breath or significant
palpitations. She presented today to the ER for evaluation.
Medications on admission - None. No known drug allergies. PAST
MEDICAL HISTORY: None. HABITS: No tobacco , no alcohol. SOCIAL
HISTORY: Unemployed , divorced , mother of six children. FAMILY
HISTORY: Positive for hypertension. No seizure disorder in the
family and her mother and two aunts have pacemakers inserted.
PHYSICAL EXAMINATION: Admission - Morbidly obese black female in
no acute distress without complaints
presently. T 98.3 , blood pressure lying down 120/80 , sitting up
133/82 , heart rate lying down 72 , heart rate sitting up 80 ,
respiratory rate is 16 , O2 sat is 98% on room air. HEENT -
Anicteric. Clear oropharynx. Neck is supple. Lungs are clear.
Back - Without spinal or cvat. Cardiovascular - Regular rate and
rhythm. No jugular venous distention. Normal S1 and S2 , no S3 or
S4 , no murmurs. Carotids with normal upstrokes and no bruits.
Abdomen - Positive bowel sounds , obese , soft , nontender , no
organomegaly. Extremities - No pitting edema. 2+ radial and DP
pulses bilaterally. Neuro - Alert and oriented times three.
Cranial nerves III-XII are tested and are intact. Sensation is
grossly intact. Motor strength - Normal gait , not tested.
Reflexes are 1-2+ patella and biceps reflexes , symmetrically.
LABORATORY DATA: K 3.9 , mag 2.1 , Hematocrit 38.9. Chest x-ray
is negative. Costophrenic angles were not
visualized well secondary to her large habitus. EKG showed normal
sinus rhythm at 72 , first degree AV block , PR interval of 0.30 ,
left ventricular hypertrophy.
HOSPITAL COURSE: The patient was admitted to the unit. Her story
was most consistent with an arrhythmia induced
syncope. Considering her history , it was felt that she certainly
had a symptomatic bradycardic episode. Because her current
pacemaker had a very high failure rate , we recommended changing the
pacemaker and the patient agreed. She was placed on the cardiac
monitor without any event over her hospital stay.
As part of her prepacer work-up , she had a right upper extremity
venogram which showed patent vessels on that side. The patient had
a pacemaker insertedon 24 of November in the OR without any complications.
The reason it was done in the OR was because of her large size and
the strength of the table. After pacer insertion , the patient did
very well without any further symptoms of dizziness or syncope. She
was discharged to home the following day in good condition.
DISPOSITION: Discharge medications - Keflex 500 mg every 8 hours for nine
doses , Percocet 1-2 orally every 6 hours as needed pain. Follow-up
will be in the Pacemaker Clinic.
Dictated By: IRVING ESCALANTE , M.D. FB73
Attending: LEOLA C. MUSICH , M.D. AW13 GV931/6913
Batch: 749 Index No. QMNG3O06FG D: 9/20/94
T: 9/20/94
Document id: 547
| Target |
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| output/system_textual_annotation.xml | textual |
U |
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U |
U |
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U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
015243975 | PUO | 83968701 | | 923689 | 1/3/1994 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 7/28/1994 Report Status: Unsigned
Discharge Date: 8/12/1994
DISCHARGE DIAGNOSIS: LEFT LEG WOUND INFECTION.
HISTORY OF PRESENT ILLNESS: Ms. Peshlakai is a 67-year-old female
with a history of diabetes , who
underwent a coronary artery bypass graft on 26 of October for unstable
angina with non-Q wave myocardial infection. She did well
postoperatively and was discharged home in good condition. About
two weeks after her operation , she began to notice some swelling
and erythema around her left thigh saphenous vein graft harvest
site. This increased and she came to the Emergency Room on
17 of March . She denied any fever , chills , night sweats , nausea , or
vomiting. She stated there was a small amount of purulent
appearing liquid draining from the wound.
PAST MEDICAL HISTORY: Significant for noninsulin dependent
diabetes , hypertension , coronary artery disease ,
hypercholesterolemia , supraventricular tachycardia , hiatal hernia ,
osteoarthritis , chronic right ear abscess , and schizophrenia.
PAST SURGICAL HISTORY: Significant for coronary artery bypass
grafting x3 with the left internal mammary artery to the left
anterior descending artery , and saphenous vein grafts to the
posterior descending artery and the obtuse marginal artery.
PHYSICAL EXAMINATION: Temperature 100.4 , with her other vital
signs stable. Her heart rate was regular
with a regular rhythm and no murmur. Her heart rate was 98 , and
her blood pressure was 104/58. Her lungs were clear to
auscultation , and her sternum was stable. Her left thigh was
erythematous around the wound , with a large area of induration.
She had good distal pulses , and her left foot was warm. The thigh
wound had an area of necrotic appearing skin.
HOSPITAL COURSE: The staples were removed in this area ,
and a large amount of pus was extracted.
Some of this was sent for culture. The areas of necrotic skin were
debrided and after copious irrigation , the wound was packed with
sterile gauze soaked in normal saline. She was started on
Vancomycin and gentamicin intravenously , and was admitted to the
hospital for intravenous antibiotics and dressing changes. Her cultures
grew out staph aureus which was methacillin resistant , but
sensative to gentamicin and vancomycin , as well as citrobacter ,
which was sensative to gentamicin and vancomycin.
She remained hemodynamically stable , and her white count came down
from 14 to a stable level of 7-8. Her temperature on the second
day after admission was 99.6 , and never rose higher than that. The
erythema in the area of her wound decreased markedly , and she
remained pain free. The wound began to granulate very well , and
the lower portion of the wound remained clean and dry , while the
upper portion required three different debridements over her
hospital course. After this , however , the entire wound remained
clean and well granulated.
The dressing changes were continued and the patient was screened
for the Rehabilitation Service to follow up with some strengthening
and intravenous antibiotics and dressing changes. A follow-up culture was
obtained after one of the dressing changes , which grew out e. coli ,
which was sensative to Cipro , ofloxacin , citrobacter , and
enterococci. All species have been sensitive to ciprofloxacin.
The patient was changed from vancomyin and gentamicin to vancomyin
intravenous and ciprofloxacin orally She will receive a total of 14 days of
vancomycin , and seven days of ciprofloxacin , after seven days of
gentamicin.
She was accepted for rehabilitation by Todler Fieldount General Medical Center , and on 25 of September , she was discharged to Todler Fieldount General Medical Center in good condition. She will continue on an
1800 calorie ADA diet , and her discharge medications include
aspirin 325 mg orally every day , atenolol 100 mg every day , Librium 10 mg
orally twice a day , Cipro 500 mg orally twice a day x3 days , vancomycin 1000 mg
intravenous every 24 hours x3 days , Colace 100 mg orally three times a day , iron sulfate 300
mg orally three times a day , Verapamil 60 mg orally three times a day , Prolixin LA 12.5 mg
intramuscularly every two weeks. She should have dressing changes
with wet to dry normal saline gauze to her left thigh wound three
times each day , as well as wound inspections to make sure that it
continues healing as well as it is now. She will follow-up with
Dr. Barrette and with her own cardiologist.
Dictated By: ERMA BESS , M.D. RR65
Attending: GENNY S. BARRETTE , M.D. GV1 TN580/9958
Batch: 222 Index No. BYPF336UBI D: 9/6/94
T: 9/6/94
CC: 1. FAX TO TODLER FIELDOUNT GENERAL MEDICAL CENTER
Document id: 548
| Target |
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Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
U |
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U |
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U |
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U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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Y |
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N |
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Y |
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402990568 | PUO | 69687681 | | 733531 | 8/12/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/14/1994 Report Status: Signed
Discharge Date: 10/2/1994
PRIMARY DIAGNOSIS: 1. RIGHT LOWER EXTREMITY CLAUDICATION
PROCEDURE PERFORMED: RIGHT FEMORAL POPLITEAL BYPASS
HISTORY OF PRESENT ILLNESS: This patient is a 54-year-old woman
with a history of hypertension ,
coronary artery disease , chronic obstructive pulmonary disease and
adult onset diabetes , who now presents for right lower extremity
revascularization. The patient was admitted to Pagham University Of with severe chest pain on 1/5/92 . At that time , the
patient emergently underwent a coronary artery bypass graft after
dissection of her right coronary artery during angioplasty. She
had a coronary artery bypass graft times three ( LIMA to the LAD ,
saphenous vein graft to RCA times two ). Postoperatively , she had
an intra-aortic balloon pump placed. Immediately postoperatively ,
the patient lost pulses in her right lower extremity. She
underwent an emergent fem-fem bypass graft with return of her
pulses. The patient's postoperative course was uneventful.
Since that time , the patient has had persistent lower extremity
claudication symptoms in her right lower extremity. She underwent
angioplasty of her right SFA on 4/10 with resolution of the
angiographically evident stenosis , however , she has had persistent
symptoms. The patient now presents with right lower extremity
claudication after 10 feet. She denies any chest pain or rest
pain. She denies any shortness of breath and dyspnea on exertion.
PAST MEDICAL HISTORY: 1. Significant for hypertension. 2.
Coronary artery disease. 3. Peptic ulcer
disease. 4. Adult onset diabetes. 5. Chronic obstructive
pulmonary disease. PAST SURGICAL HISTORY: The patient is status
post coronary artery bypass graft in 1992 , status post
fem-fem bypass graft in 1992 , status post angioplasty in 4/10 .
MEDICATIONS: Pepcid 20 mg twice a day , Procardia XL 60 mg every day ,
Lopressor 50 in the morning , 25 at noon and 50 at night , Glucotrol
7.5 mg every day before noon , an aspirin a day 500 mg every day before noon , Hydrochlorothiazide
25 mg every day , Elavil 50 mg every bedtime , and K-Dur 20 mg every day ALLERGIES:
The patient has a reaction to Amoxicillin. SOCIAL HISTORY:
Cigarettes one pack a day times 35 years and the patient is still
smoking.
LABORATORY STUDIES: Electrolytes were within normal limits. BUN
of 9 and creatinine of .9. LFTs were within
normal limits. White count of 8 , hematocrit of 50. physical therapy and PTT
were within normal limits. Chest x-ray showed no acute disease.
EKG showed normal sinus rhythm with no acute disease. Noninvasive
vasculars showed no DP on the right , physical therapy of .56for an ABI. DP on
the left was .8 and physical therapy was .9.
PHYSICAL EXAMINATION: The patient was a pleasant woman in no
apparent distress. Head/neck examination
were unremarkable. Lungs were clear to auscultation. Cardiac
examination was unremarkable. Abdomen was obese , soft , non-tender
and non-distended and bowel sounds were positive. There was a
palpable fem-fem graft with a positive thrill. Extremities showed
left groin site without hematoma , 2+ femoral pulses with 2+ left
sided DP and physical therapy pulses , 1+ DP palpable. The physical therapy was dopplerable on
monophasic.
HOSPITAL COURSE: The patient was admitted after angio which she
tolerated without difficulty. There was no
hematoma on her left groin. The patient was seen by Cardiology who
cleared for the revascularization recommending monitored bed and
serial EKGs and CPKs postoperatively. The patient was taken to the
Operating Room on 3/7/94 for right lower extremity
revascularization. At that time , the patient underwent a right
fem-pop bypass graft without complication. There were no
complications. For details of the operation , please see the
dictated Operative Note.
The patient's postoperative course was unremarkable. She was
afebrile and vital signs were within normal limits. The patient
had a dopplerable pulse on postoperative day #1 and for the
remainder of her hospital course. The patient's wound from her
groin had persistent serous drainage for which the patient had
three times a day dressing changes while in the hospital. She will be
discharged to home with VNA for twice a day dressing changes because of
the serous drainage has been persistent. In the upper aspect of
the patient's wound , there was some erythema for which she was
maintained on I.V. antibiotics during her hospital stay and will be
discharged on orally antibiotics. There was no active purulent
drainage from any of the wound sites. The patient was ambulating
without difficulty. She was tolerating a regular diet and
urinating and having normal bowel movements. The staples were left
intact at the time of discharge because of the patient's diabetes.
DISPOSITION: The patient will be discharged to home on 2/9/94
with VNA for twice a day dressing changes. MEDICATIONS ON
DISCHARGE: Keflex 500 mg four times a day times five days days , Percocet 1
to 2 tablets every 3 to 4 h as needed pain. The patient is to resume taking
all her previous medications as normally scheduled. FOLLOW-UP
CARE: The patient is to follow up with Dr. Abson in 1 to 2
weeks for evaluation.
Dictated By: GENNY BARRETTE , M.D. EV52
Attending: NATHAN J. ABSON , M.D. RA17 IZ473/9527
Batch: 6329 Index No. NEHG5G5B4Q D: 2/9/94
T: 10/13/94
Document id: 549
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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994785515 | PUO | 33070418 | | 6550230 | 10/4/2005 12:00:00 a.m. | CHRONIC HEART FAILURE , PNEUMONIA | Signed | DIS | Admission Date: 1/18/2005 Report Status: Signed
Discharge Date: 8/10/2005
ATTENDING: DEPSKY , GWYNETH ALMEDA MD
PRINCIPAL DIAGNOSES: Endocarditis , urinary tract infection.
SECONDARY DIAGNOSES: Mitral regurgitation , diabetes ,
hypertension , congestive heart failure , recurrent UTIs , uterine
prolapse , hyperlipidemia , hiatal hernia , right breast nodule.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old with a
history of severe mitral regurgitation , history of congestive
heart failure with an ejection fraction of 60% in 6/8 , chronic
abdominal discomfort , history of recurrent UTIs , and uterine
prolapse , who one week prior to admission developed increased
nausea , decreased appetite , weakness , fatigue and increased low
back pain. No vomiting , diarrhea , cough , or dysuria. On
presentation , the patient was found to be hypotensive , in septic
shock , with bacteremia in urinary tract infection and admitted to
the Medical ICU for pressure support.
ADMISSION PHYSICAL EXAMINATION: Notable for heart rate of 94 ,
blood pressure of 80-90/50. Notable for heart exam with regular
rate and rhythm , normal S1 and S2 , with 3/6 systolic crescendo
murmur and decrescendo murmur at the right upper sternal border
radiating to the clavicles and carotids , and 3/6 holosystolic
murmur at the apex radiating to the axilla , and an apical heave.
JVP flat. Chest with crackles in the right middle lung fields and
leg basilar crackles. Abdominal exam was benign. Guaiac
negative. Extremities with no clubbing , cyanosis , or edema and
1+ dorsalis pedis pulses bilaterally.
RELEVANT STUDIES AND TESTS: Blood culture on 10/13
Streptococcus viridans , levofloxacin sensitive , penicillin MIC
0.19. Urine culture on 10/13 Greater than 100 , 000 Klebsiella
pneumoniae , ampicillin resistant , gentamicin sensitive , and
levofloxacin sensitive. TEE on 10/17 Severe mitral
regurgitation , posterior leaflet with mitral calcifications and
linear density concerning for endocarditis.
HOSPITAL COURSE:
IMPRESSION: A 76-year-old female with mitral regurgitation ,
history of CHF , history of recurrent UTI , who presented with
nausea and chills , had hypotension requiring a medical ICU stay x
2 days , with Streptococcus viridans bacteremia and mitral
calcifications in linear density concerning for endocarditis plus
Klebsiella UTI.
1. Infectious disease: The patient presented with chills and
hypotension and was admitted to the MICU from the ED for
treatment of septic shock. Her mean arterial pressures were kept
above 65 with Levophed. She initially was treated with
levofloxacin and vancomycin to treat Gram-positive cocci
bacteremia and UTI. Blood culture from 5/15 , grew out
Streptococcus viridans , levofloxacin sensitive , penicillin MIC
0.19. Urine culture was positive for Klebsiella , ampicillin
resistant , gentamicin and levofloxacin sensitive. On 1/11 ,
antibiotics were changed to penicillin 3 million units intravenous every 4 hours
and gentamicin 50 mg intravenous every 8 hours ATEE on 5/29 showed severe mitral
regurgitation with posterior leaflet calcifications and linear
density concerning for endocarditis. Therefore , a PICC line was
placed on 10/11 for continuation of a six-week course of
penicillin 3 million units intravenous every 4 hours until 1/3 and two-week
course of gentamicin 50 mg intravenous every 8 hours until 9/12 . She will follow
up in the Infectious Disease Clinic with Dr. Rossie Mankoski on
1/5/05 at 8 a.m.
2. Cardiovascular: Ischemia: The patient was maintained on
aspirin. Lipitor was initially helped for an initial
transaminitis presumed to be secondary to shock liver , that at
the time of discharge her liver enzymes had normalized and she
was restarted on her Lipitor. Pump: The patient has a history
of congestive heart failure , with an ejection fraction 60% in
6/8 . She had hypotension , requiring Levophed until 2/5 . She
had an episode of flash pulmonary edema on 6/16 in the setting
of fluid bolus and one unit of packed red blood cells. She has a
very attenuatus balance between preload dependence and overload.
Her Lasix and ACE-I were held while she was hypotensive. Because
her systolic blood pressure continued to be low in the 90s and
low 100s , attempt was not made to re-add the ACE while in the
hospital. It is anticipated that her cardiologist and outpatient
physicians will attempt to add the ACE back onto her medical
regimen for better afterload reduction as her blood pressure
tolerates. The patient also has a very severe mitral
regurgitation , which would be one of the reasons that an ACE on
her medication regimen would be beneficial. Rhythm: The patient
was maintained on telemetry , and was found to be a normal sinus
rhythm with ectopy , including short once of nonsustained
ventricular tachycardia. She was started on Lopressor 12.5 mg
three times a day on 1/11 , and this was increased to 25 mg twice a day at
discharge , with her heart rates continuing to be between the 70s
and the 90s , however , with less episodes of ectopy. Her
electrolytes were also well repleted.
3. Gastrointestinal: The patient had evidence of shock liver
( 4/10 with an ALT of 135 , AST of 177 , alkaline phosphatase of
251 , and T bili of 1.7 ) that is now resolving. Lipitor was held ,
and was started as a transaminitis resolved. Non-contrast CT of
the abdomen showed biliary sludge and gallstones , no evidence of
acute cholecystitis. Right upper quadrant ultrasound confirmed
the CT findings. Colon cancer is a concern with the patient's
anemia being new since 5/8 . Her last colonoscopy was in 2000 ,
and she will benefit from repeat colonoscopy as an outpatient.
She was continued on Nexium for prophylaxis. Heme: The patient
had guaiac positive stools in the medical ICU , her hematocrit was
stable around 33%. She has a microcytic anemia with an MCV of
79 , her iron studies ( iron of 10 , TIBC of 191 , ferritin is 744 )
suggesting anemia of chronic disease with possibly overlying iron
deficiency.
4. Endocrine: The patient had a normal random cortisol level of
35.3. She had an uncertain diagnosis of diabetes and was on the
Portland protocol in the medical ICU. Hemoglobin A1c , however ,
was 6.5. Therefore , she was maintained thereafter only on
insulin sliding scale and rarely required any coverage.
5. Prophylaxis: The patient was kept on Lovenox and Protonix.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily , iron sulfate 325 mg
daily , gentamicin sulfate 50 mg intravenous every 8 hours until 9/12 for a
two-week course , penicillin G potassium 3 million units intravenous every 4 hours
until 1/3 for a six-week course , Lopressor 25 mg twice a day ,
Caltrate plus D2 tablets orally daily , Lipitor 10 mg daily , and
Protonix 40 mg daily. The patient has not been restarted on her
home Lasix and lisinopril secondary to persistently low blood
pressures between the 90s and 100s. It is anticipated that
especially her Lisinopril and her Lasix will be added back on to
her medical regimen as her blood pressure tolerates. Given that
she was no longer on Lasix , she was also taken potassium
chloride.
DISPOSITION: The patient is to be discharged to rehabilitation
at Sa Pehall in order to be able to get her antibiotic
therapy. She was discharged on stable condition.
PHYSICIANS FOLLOW-UP: The patient has been following follow-up
appointments:
1. Stress test in 2/6/05 at 3 p.m.
2. Dr. Germaine Blackgoat ( general cardiology ) on 7/10/05 at 10 a.m.
3. Dr. Gaye Franza 3/22/05 at 12 p.m.
4. Dr. Rossie Mankoski ( infectious disease ) 1/5/05 at 8 a.m.
The patient will follow up regarding the success of her
antibiotic therapy. It is also anticipated that her cardiologist
will re-add back on her ACE for better afterload reduction as her
blood pressures tolerates , and potentially we will add her back
on to the Lasix as well. She will require weekly lab draws to
check her electrolytes and CBC while she is on the antibiotics.
CONSULTANTS: Infectious disease , Dr. Delpha Wantuck , pager
number 55866.
PRIMARY CARE PHYSICIAN: Dr. Gaye Franza .
The patient is full code. Her family is aware of the situation.
eScription document: 3-2383763 CSSten Tel
CC: Gaye Franza M.D.
KTDUOO , Pagham University Of
Ka Parkway , Ox , Rhode Island 24469
CC: Germaine Blackgoat
Pagham University Of
Pemoorl Pkwy , Vale In
CC: Rossie Mankoski MD
Yanewworcelake Roton
Dictated By: BLACKGOAT , GERMAINE LAVONNE KATE
Attending: DEPSKY , GWYNETH ALMEDA
Dictation ID 3901301
D: 1/12/05
T: 1/24/05
Document id: 550
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
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OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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512432449 | PUO | 81520819 | | 2021476 | 8/18/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/7/2005 Report Status: Signed
Discharge Date: 9/7/2005
ATTENDING: BARNABA , CARA CHANCE MD
SERVICE: Cardiology Team Mahuntjack Por O
PRIMARY CARE PHYSICIAN: Dessie R. Arendz MD , PHD.
PRINCIPAL DIAGNOSIS: Congestive heart failure.
LIST OF PROBLEMS/DIAGNOSES: Coronary artery disease , status post
myocardial infarction; diabetes mellitus; hypertension;
hypothyroidism; and anxiety.
HISTORY OF PRESENT ILLNESS: Briefly , this is an 82-year-old male
with a history of CHF with an EF 10% to 15% who is status post
MI , history of hypertension , diabetes mellitus , and
hypothyroidism. There is also a question of a history of atrial
fibrillation as well.
In the past 2 months , the patient had complaints of increasing
dyspnea on exertion with being unable to walk from one end of the
room to the other without becoming short of breath; a mild weight
gain of 3 pounds as well; and a stable , 2-pillow orthopnea.
On August , 2005 , the patient awakened from sleep with a sudden
onset of shortness of breath and chest pressure associated with
nausea and vomiting. The patient presented to an outside
hospital emergency department where his blood pressure was
stable , and he was saturating 94% on room air. He was treated
with intravenous Lopressor and nitroglycerin , sublingual and topical. He
was admitted at that hospital , and Cardiology was consulted who
diagnosed him with a mild CHF by his physical examination. A
chest x-ray was with bibasilar opacities that were more likely
atelectasis. The patient was ruled out for an MI at that
hospital and treated with Lasix at the home doses of Lasix 40 mg
orally twice a day with stable systolic blood pressures of 100s to 110s.
His course at that hospital was complicated by a nonsustained
ventricular tachycardia through which he was asymptomatic. He
was started on Lovenox twice a day for a low EF.
The patient was transferred to the Pagham University Of
on May , 2005 , for elective placement of an AICD.
PAST MEDICAL HISTORY: Atrial fibrillation , anxiety , CHF with an
EF of 10% to 15% , MI , diabetes mellitus , hypertension ,
hypothyroidism , status post cholecystectomy for cholelithiasis ,
and a history of probable prostate ??___??.
MEDICATIONS: The patient's home medications had included Lasix
40 mg orally twice a day , KCl 10 mEq every day , glyburide 7.5 mg every day ,
Levoxyl 150 mcg every day , Zocor 20 mg orally every day , digoxin 0.125 mg
every day , lisinopril 40 mg orally every day , atenelol 25 mg orally every day ,
trazodone 50 mg to 100 mg every bedtime as needed insomnia , and Ativan 0.5
mg as needed
Transfer medications include digoxin 0.125 mg every day , levothyroxine
150 mcg every day , glyburide 7.5 mg every day , Lasix 40 mg twice a day , Zocor 20
mg orally every day , Imdur 30 mg orally every day , lisinopril 40 mg orally every day ,
atenelol 25 mg orally every day , aspirin 325 mg orally every day , KCl 10 mEq
orally every day , trazodone 50 mg orally every bedtime , and Ativan 0.5 mg orally
every bedtime , and there is a question whether the patient was currently
on Lovenox 100 mg subcutaneously twice a day
SOCIAL HISTORY: The patient is an ex-smoker and quit smoking
greater than 20 years ago. He lives with his wife.
FAMILY HSITORY: Both the parents of the patient are with a CAD
in their 70s.
PHYSICAL EXAMIANTION: The patient's vital signs upon arriving on
the floor; temperature was 94.5 , pulse was 64 , blood pressure was
120/60 , respirations were 20 , and he was saturating 98% on room
air. Examination was remarkable for JVP at his jaw and moist
mucous membranes. Heart had a regular rate and rhythm with
frequent ectopy and S1 , S2 , S3 , and S4. The lungs were with a
faint left bibasilar crackles. Abdomen was benign. The
extremities were with no pitting edema but slightly cool
bilaterally. Neurological examination is nonfocal.
ADMISSION LABORATORY DATA: Remarkable for a creatinine of 0.9.
CBC was unremarkable. BNP was 2035. INR was 1.3 , and PTT was
37.4.
Of note , an echocardiogram performed at the outside hospital on
July , 2005 , showed an EF of 10% to 15% , moderate left atrial
enlargement , right atrial enlargement , mild to moderate aortic
regurgitation , mild MR and mild TR , and pulmonary artery
pressures of 45.
An ETT myoview performed at the outside hospital showed a large
fixed defect inferiorly and inferolaterally as well as a mild
ischemia in the lateral wall.
EKG at the outside hospital performed on July , 2005 , was with
sinus rhythm; right bundle-branch block with T wave inversion in
V1 through V4; Q waves in II , III , and aVF; first-degree AV
block; and a question of a left anterior fascicular block.
A chest x-ray at the outside hospital on August , 2005 , was with
bibasilar opacities with a question of atelectasis versus
pneumonia.
Admission EKG here on May , 2005 , was unchanged from the
outside hospital.
Admission chest x-ray on done on May , 2005 , showed
cardiomegaly and mild bilateral costophrenic angle blunting.
HOSPITAL COURSE: Subjectively , this is an 82-year-old male with
a history of congestive heart failure with an ejection fraction
of 10% to 15% status post myocardial infarction , hypertension ,
diabetes mellitus , and hypothyroidism who was transferred to the
Pagham University Of for an elective automatic
implantable cardioverter-defibrillator placement.
1. Cardiovascular: Ischemia. The patient had no active
ischemia. He does have a history of a myocardial infarction ,
which was inferior in area. His ETT-MIBI was with mild lateral
wall ischemia with a large fixed inferior and inferolateral
defect. The patient was continued on aspirin , ACE inhibitor , and
statin and restarted on his beta-blocker. A catheterization was
performed on May , 2005 , which demonstrated a left dominant
system and no significant left main or left anterior descending
artery lesions. A left posterior descending artery had an 80%
lesion in the mid posterior descending artery. Ejection fraction
was estimated at 15% with global hypokinesis and dilated left
atrium and dilated left ventricle. The patient had elevated
wedge pressure of 42 and 2+ mitral regurgitation.
2. Pump: The patient has a history of ischemic cardiomyopathy.
On admission , he was volume overloaded with a BNP of 2035. On
admission , the patient was treated with Lasix , Isordil , ACE
inhibitor , and digoxin. Hydralazine was added. A
catheterization on May , 2005 , demonstrated elevated left
heart-filling pressures. The patient was diuresed subsequently
with more than 4 liters and was euvolemic upon discharge. The
patient is currently euvolemic on orally Lasix to being slightly
dry. Given increased CO2 but a normal BUN and creatinine , we
have changed the patient's Lasix dose to 60 mg orally every day before noon and 40
mg orally every afternoon upon discharge. Given the systolic blood
pressures in the 90s and 100s , the patient's lisinopril was
changed to 20 mg orally every day The patient is to be followed by VNA
at home to monitor blood pressure.
3. Rhythm: The patient was followed by EP. His admission
electrocardiogram showed a right bundle-branch block with a
question of left anterior fascicular block and a first-degree
arteriovenous block. On October , 2005 , the patient became
suddenly bradycardic to the 30s and 40s with nonsustained
ventricular tachycardia x30 beats and a new second-degree
arteriovenous block type 1. The patient was asymptomatic
throughout this. Zoll pads were placed , and atropine was put at
the bedside. On August , 2005 , the patient appeared to be back in
normal sinus rhythm. On August , 2005 , a pacemaker with automatic
implantable cardioverter-defibrillator was placed with cardiac
resynchronization therapy as well. This was interrogated on June , 2005 , and the ??___?? were confined. The patient will follow
up with Dr. Schoeppner in EP on July , 2005 , at 10:20 a.m. The
patient is to avoid vigorous activity.
4. Endocrine: The patient is with diabetes mellitus and was
covered with regular insulin sliding scale here. He was advised
to restart on his home dose of glyburide 7.5 mg every day upon
discharge. The patients' history of hypothyroidism and thyroid
function test is consistent with sick euthyroid syndrome. He was
continued on levothyroxine at his home dose.
5. Psychiatry: The patient is given trazodone and Ativan every bedtime
as needed The patient's mental status was somewhat decreased on the
night of August , 2005 , status post automatic implantable
cardioverter-defibrillator placement. He was not oriented to
time. This later resolved by the evening of September , 2005.
6. Genitourinary: The patient was noted to have bloody urine
after receiving heparin during the catheterization thought
secondary to Foley trauma. There were no clots; however , given
significant hematuria , ??___?? Foley was placed and bladder
irrigation was started. Urinalysis was negative. Urine was pink
colored by the night of September , 2005. The Foley was discontinued
due to a leakage. This was not replaced given good urine output ,
continued pink-colored urine , and no clots. The patient's
hematocrit was stable throughout this.
7. Prophylaxis: The patient was given pneumoboots given the new
automatic implantable cardioverter-defibrillator placement and
hematuria.
8. Infectious Disease: The patient is to be on clindamycin for
7 days status post pacemaker placement.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally every day , atenolol 12.5 mg
orally every day , clindamycin 300 mg orally four times a day through May , 2005 ,
digoxin 0.125 mg orally every day , Lasix 60 mg orally every day before noon and Lasix 40
mg orally every afternoon , hydralazine 10 mg orally three times a day , levothyroxine 150
mcg orally every day , lisinopril 20 mg orally every day , Ativan 0.5 mg orally
every bedtime as needed insomnia , trazodone 50 mg orally every bedtime as needed
insomnia , Zocor 20 mg orally every bedtime , Imdur 30 mg orally every day ,
glyburide 7.5 mg orally every day , magnesium oxide 800 mg orally twice a day ,
and KCl slow release 20 mEq orally every day
DIET: The patient's diet on discharge; the patient should
measure weight daily; continue a low-cholesterol , low-fat , and
low-sodium diet , ADA 2100 calories per day.
ACTIVITIES: No vigorous activity of the left arm for 1 month and
no lifting of the left arm above the shoulder. The patient
should not drive until a followup appointment.
FOLLOWUP APPOINTMENTS: The patient is to see Dr. Stan Meckley
and Glinda Bancourt , nurse practitioner. The clinic will call the
patient with his appointment time. The patient is to see Dr.
Ava Schoeppner on July , 2005 , at 10:20 a.m. at the Pagham University Of .
eScription document: 1-0931615 SS
CC: Dessie Rosana Arendz MD , PHD
O Pla
Dictated By: GIRARDI , ABE
Attending: BARNABA , CARA CHANCE
Dictation ID 9736094
D: 8/9/05
T: 9/1/05
Document id: 551
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OSA |
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921778812 | PUO | 49448215 | | 852834 | 10/2/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/2/1994 Report Status: Signed
Discharge Date: 8/6/1994
PRINCIPAL DIAGNOSIS: 1. CHEST PAIN
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old , black
female with a history of coronary
artery disease , inferior infarct , mitral valve replacement ,
hypertension , atrial flutter who presented with six hours of chest
pain. The patient has had episodes of chest pain in the past.
Today the pain spread to her epigastrium and made her nauseated and
diaphoretic. She was very short of breath. She stood up , became
dizzy and vomited once. She was brought by a neighbor to the
Emergency Room. In the Emergency Room she received sublingual
Nitroglycerin x 3 and 2 mg of Morphine , 2" of Nitropaste with
relief of her chest pain. Her EKG had no changes going from pain
to pain free. She was admitted for rule out of myocardial
infarction. PAST MEDICAL HISTORY: Is significant for rheumatic
heart disease diagnosed at age 30. In 1965 she had a mitral valve
commissurotomy and in 1981 she had an mitral valve replacement with
St. Jude valve. In October of 1992 she was noted to have atrial
flutter and she was started on Clonidine , switched to Quinidine and
then put on Pravastatin. She has been cardioverted three times
most recently in October of 1994. History of congestive heart
failure , deep venous thrombosis x 2 , adult onset diabetes on NPH 10
units every day before noon , rheumatoid arthritis , question of cerebrovascular
accident and thyroid nodule , status post Iodine treatment. PAST
SURGICAL HISTORY: As above. ALLERGIES: PENICILLIN. She develops
anaphylaxis; ASPIRIN she gets a rash. MEDICATIONS ON ADMISSION:
Were Lopressor , Coumadin , Lasix , Pravastatin , Plaquenil and
Insulin. SOCIAL HISTORY: She lives alone. No alcohol , tobacco or
drug use. FAMILY HISTORY: She had a mother , brother and son all
who are notable for having irregular heart beats.
PHYSICAL EXAMINATION: On admission she was afebrile. Blood
pressure was 200/palpable to 130/85. Her
saturation was 98%. Physical examination was unremarkable. Her
chest had bilateral crackles , left greater than right. On cardiac
examination her heart showed regular rate and rhythm , S-1 , S-2 with
slight S-1 snap. No rubs or gallops. Belly was soft. No
hepatosplenomegaly. Pulses were intact. She was neurologically
intact.
LABORATORY DATA: Significant for an elevated Chloride and an uric
acid of 7.8. Her first CK was 5.4.
HOSPITAL COURSE: The patient was admitted for rule out myocardial
infarction. She was started on Heparin ,
Lopressor and Nitropaste. Her Insulin was continued with four times a day
finger sticks and she was continued on her Pravastatin and her
Coumadin was held at this time. The patient remained stable with
subsequent CK's being 54 , 55 and 46. The patient's Lopressor was
increased to increase her rate control during her admission and
then her Coumadin was restarted. A Cardiology consultation was
obtained and the patient was begun on Isordil 10 mg three times a day with
adequate blood pressure tolerance. Her Lopressor was increased to
100 twice a day to improve symptomatic control. During her admission
the patient had experienced some chest pain on hospital day number
three. There were no EKG changes at that time and the pain
resolved spontaneously. The Cardiology Team at this point
recommended continuing medical management as the patient was in
reasonably good control of her pain and was not particularly
interested in more aggressive intervention at this time. She did
have a MIBI that was performed , however , that was equivical
secondary to cardiac rotation in a setting of atypical chest pain.
The Cardiology Team felt that it was not necessary to cath this
patient , however , they did recommend noninvasive studies of her
legs , PVR's and AVI's as an outpatient to evaluate possible
claudication.
DISPOSITION: The patient was discharged on March , 1994.
MEDICATIONS ON DISCHARGE: Lopressor 100 mg twice a day and
Isordil 10 mg three times a day; Insulin 10 units NPH , every day before noon. FOLLOW-UP CARE:
The attending on the case was Dr. Aspacio and the patient is to
follow-up with Dr. Shalonda Aspacio in KTDUOO Clinic.
Dictated By: ELLA TACKE , M.D. AS36
Attending: SHALONDA ASPACIO , M.D. WE9 ZY670/7082
Batch: 4046 Index No. Y0FJQ331Z0 D: 5/25/95
T: 5/25/95
Document id: 552
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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335530998 | PUO | 01416153 | | 4560429 | 8/27/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/27/2006 Report Status: Signed
Discharge Date:
ATTENDING: NAKAI , RHEBA MD
PRIMARY CARE PHYSICIAN: Dr. Bryan Gaar , 390-986-6828
CHIEF COMPLAINT: Sepsis.
HISTORY OF PRESENT ILLNESS: Ms. Flow is an 83-year-old woman
with multiple medical problems including CAD status post CABG ,
diabetes mellitus , CHF ( EF 55% ) and atrial fibrillation who
presented with hypotension , likely secondary to sepsis from right
lower extremity cellulitis. She developed the right lower
extremity cellulitis one month ago. Two days prior to
admission , patient developed worsening erythema , edema and tenderness
along with chills and sweats. She was brought into the emergency
room on 8/7/06 and was found to be hypotensive with a systolic
blood pressure in the 80s. She was given intravenous fluids and started
on vancomycin , aztreonam , and clindamycin , but remained
hypotensive. She was started on dopamine , Levophed and
vasopressin as well as Decadron. Surgery was consulted for biopsy as to rule
out the possibility of necrotizing fascitis. A
CT of her lower extremity was done in the ED and she was admitted to the MICU.
patient's blood cultures grew group A streptococcus. Her wound culture grew
group A strep and E. coli. patient was also dx with a klebseilla UTI. Her
antibiotics were changed to vancomycin , levofloxacin , and Flagyl.
Her blood pressure improved and on the day of transfer to the
floor on 3/9/06 , she was noted to be oliguric , presumably
due ATN secondary to hypotension. Her urine
output continued to drop and she developed a metabolic acidosis
with a bicarbonate of 10. Her lactic acid at that point was 4.4. Her ABG was:
7. 9/23/98 and she was transferred back to the
MICU.
From a renal perspective , ARF was less likely to be post-streptococcal
glomerulonephritis because of the timing of her strep infection.
She had no hypertension or WBC casts. The UA was
positive for hematuria. She had low complement levels , so there
was some question of HUS after group B strep infection ,
although there were no schistocytes on her smear. The patient was
aneuric on admission to the MICU and she started renal
replacement therapy. Her urine output recovered and
was greater than 800 mL daily while in the ICU.
However , by the day of transfer to the floor on 4/30/06 , her urine output
started to decrease and she started intermittent
dialysis via a tunneled LIJ catheter. The renal team followed her closely and
her meds were renally dosed. Her vancomycin was dosed by level.
In terms of her hypertension , her blood pressure has normalized and
her beta-blocker is being titrated upwards.
From a cardiac perspective , the patient's troponin hit a high of
0.87 in the setting of septic shock. She was evaluated by MMC
cardiology , and this was felt to be consistent with demand
ischemia. She has actually been asymptomatic from a cardiac
standpoint. She was continued on daily aspirin. Her LDL was 63
and a statin was started. She will actually need her fasting
lipids checked once her acute illness has passed and her LDL goal
is less than 70. The patient has a history of AFIB on Coumadin.
Her INR goal is 2-3. Her INR is drifting down. She is off of
Coumadin because she has several lines that needed to be pulled ,
including a right subclavian. The hemodialysis catheter will either be
removed , if she has improved urine output , or a more permanent type of access
will be placed. She will be on prophylactic heparin three times a day for DVT
prophylaxis when her INR hits 1.5.
From a hematologic perspective , the patient initially had thrombocytopenia on
admission. There was some concern for DIC , as there was a very quick rise in
her INR. Fibrinogen; however , was normal and the INR has since stabilized. She
has persistent thrombocytopenia , although her platelet count is recovering.
Her platelet factor 4 antibody was negative.
There was no clear precipitant other than sepsis. She has a
normocytic anemia with a large drop in hematocrit since admission and
there was some concern for hemolysis with the rising
bilirubin , low haptoglobin with multiple immature erythrocytes ,
but no schistocytes were seen on manual diff. She did require
two units of packed red blood cells on this admission. Her
hematocrit and platelets did drop on 2/27/06 as the steroids were being
tapered off. Her direct Coombs was negative. Haptoglobin
was within normal limits. Medications causing her
thrombocytopenia like Seroquel and heparin were stopped.
From a pulmonary standpoint , she is oxygenating and ventilating
well and not requiring any supplemental O2. She started tube
feeds on 11/9/06 with some marked hyperglycemia and also
steroids for her hypotension contributing to her hyperglycemia.
She was actually started on an intravenous insulin protocol in the ICU for better
control and then was transitioned to NPH insulin plus regular
insulin as well as a regular insulin sliding scale with good effect.
Her home regimen was previously Lantus 25 units subcutaneously daily. Her
TSH was within normal limits and she will continue levothyroxine.
The patient developed a pain in her left fourth finger during this admission
and the PIP joint was tapped on 2/27/06 by rheumatology. The
appearance of the fluid was consistent with gout. She improved with steroids.
Her right shoulder ultrasound showed a small effusion , which was unlikely to be
infectious per radiology. She was started on Decadron 4 mg orally every 6 hours , and only
has mild , residual pain.
From a GI perspective , patient's LFTs rose on 8/27/06
with peak ALT of 122 , T bili of 8.7 , and alkaline phosphatase of
196. She had a rising INR ( off of Coumadin ) consistent with
hepatic injury and hepatocellular dysfunction. Her abdominal CT was
unremarkable. GI was consulted. The etiology was unclear and the differential
diagnosis was drug related liver injury versus infection or shock liver , and
less likely , fatty liver disease. Her hepatitis serologies are
negative and Tylenol has been held since 8/27/06 . Flagyl
and clindamycin were discontinued on 11/9/06 , and her LFTs
trended down. AMA was negative. ASMA was pending at the time of this
dictation.
From a neurologic point of view , the patient initially required
Dilaudid PCA for pain with her legs. Now , she is comfortable on a fentanyl
patch with Dilaudid boluses. Seroquel was started for sedation
and that was actually stopped because of thrombocytopenia.
From a dermatologic standpoint , she has had left lower extremity
venostasis ulcers. She has a right lower extremity arterial
insufficiency ulcer. She was seen by wound care. Vascular
surgery requested that she have ABIs and assessment of her vascular
flow once her acute illness has passed.
For nutrition , the patient started tube feeds through an NG tube given her
prolonged sedation. She will need to continue to improve her nutritional
status. A speech and swallow evaluation was done on 10/27/07
and she has been approved for orally , soft diet.
In terms of access , patient has a right subclavian left IJ hemodialysis catheter.
She had a left radial artery line that was discontinued on 1/3/06 . The right
subclavian will be removed when her INR is 1.5 and the
hemodialysis catheter will either be removed or replaced with
more permanent access depending on her urine output.
For prophylaxis , she is on Nexium. She does not have
pneumo boots on because of cellulitis and heparin was held with
thrombocytopenia , now will be restarted on 10/27/07 or when her
INR is 1.5 rather.
PAST MEDICAL HISTORY: Diabetes mellitus type II on insulin , CAD
status post CABG ( 1998 ). The right saphenous vein was harvested
for surgery. Since that time , she has had baseline swelling and
edema in the right lower extremity , CHF with diastolic
dysfunction , EF 55% in July 2004 , dry weight is 150 pounds per
the patient. Atrial fibrillation on Coumadin. Sick sinus
syndrome , status post permanent pacemaker placement in October 2006
complicated by hemothorax requiring thoracoscopy. Chronic renal
insufficiency with a baseline creatinine of 1.7 , gout ,
osteoarthritis , status post left total knee replacement in 1995 ,
status post right total knee replacement in 1990 , hypothyroid ,
osteoporosis , and chronic hearing loss.
HOME MEDICATIONS: Lantus 25 units subcutaneously every day before noon , NovoLog sliding
scale , aspirin 81 mg orally daily , prednisone taper ( started
11/29/06 ) half tab daily x2 weeks , then half tab every other day
x2 weeks , torsemide 20 mg 2-3 tabs orally daily depending on
weight , metoprolol 12.5 orally twice a day Coumadin? 1 mg orally nightly ,
fentanyl 25 mcg per hour every 72 hours , potassium , levothyroxine 75 mcg
orally daily.
ALLERGIES: Penicillin causes red welts. This is the only
allergy that the patient endorses. Cephalosporin , unknown
reaction. Question for quinolones , unknown reaction , but the
patient have been taking levofloxacin and ciprofloxacin in the
past without a problem. Sulfa and Bactrim , unknown reaction.
Codeine unknown reaction.
SOCIAL HISTORY: The patient lives with her daughter and five
grandchildren , ranging in age from 7 to the 20s. She is a former
healthcare worker and a union organizer. At baseline , she uses a
walker. She never smoked tobacco. She very rarely drinks
alcohol and never used any drugs.
FAMILY HISTORY: Parents: Does not know the family history of
her parents or siblings. She has a son with a history of
diabetes.
ADMISSION PHYSICAL EXAMINATION: Temperature 98.7 , heart rate 98 ,
blood pressure 171/85 , respiratory rate 19-23 , satting 97%-98% on
2 L ( this is the ICU admission from 3/9/06 ). In general , she
was moaning in pain , slightly drowsy , but easily arouseable.
Oriented to person , " Pagham University Of " , and " April ".
Speaking in full sentences. ENT remarkable for slightly
sluggishly reactive pupils bilaterally. Her oropharynx notable
for dry mucous membranes. Neck was supple. Lungs were clear
with decreased breath sounds at the bases bilaterally.
Cardiovascular exam was tachycardic , regular with the distant S1
and S2. Her abdomen remarkable for normal bowel sounds ,
otherwise nontender and nondistended. Extremities , pain with
movement of her upper extremities. She had baseline
osteoarthritis in the shoulders , right greater than left. Right
lower extremity had erythema , warmth and 2+ edema with exquisite
tenderness 1 cm below the knee. The lateral distal lower
extremity had 3 cm very dark black plaque near the biopsy site.
She had a right foot that was cool with 1+ dorsalis pedis pulses.
Left lower extremity with 2+ edema , 1+ dorsalis pedis pulse.
Left hand , fourth and fifth digit MCP-PIP with erythema and
warmth. Neurologic , cranial nerves II through XII are grossly
intact. Moving all extremities. Full strength exams precluded
by pain.
Her EKG showed V pacing. Chest x-ray on 8/7/06 showed
cardiomegaly , a right IJ in place ( placed in the ED ) , no focal
consolidation. No overt pulmonary edema or pneumothorax. CT of
the right lower extremity showed cellulitis without gas. Echo in
July 2004 , EF of 55% , no regional wall motion abnormalities. RV
was dilated with normal function. She had diastolic septal
flattening consistent with RV volume overload by atrial
enlargement , mild-to-moderate MR , PAP , 17+ RA.
LABORATORY DATA: Remarkable for bicarbonate 21 , BUN 49 ,
creatinine 1.6 ( baseline 1.7 ) , glucose of 204 , magnesium 1.3 ,
lactic acid was 6.5 going to 6.2 , T bili was 1.5 , AST 45. INR
1.4. Hematocrit 43.2 , platelets of 156 , 000 , white count of 9.8
with 84% neutrophils , 14% bands , 1 lymph , 1 mono. Cardiac
enzymes were positive at 9 p.m. on 3/9/06 with the troponin of
0.26.
MICROBIOLOGY DATA: Blood culture on 8/7/06 positive for beta
hemolytic group A strep. Urine on 8/7/06 , greater than 100 , 000
klebsiella ( pansensitive ). Blood cultures on 11/22/06 positive
for beta hemolytic group A strep. Blood cultures 3/9/06 , no
growth. Joint fluid on 6/7/06 from the right knee , no growth ,
rare polys , no organisms seen on Gram stain. Blood cultures from
1/4/06 , 12 , and 11/6/06 , all no growth to date at the time of this
dictation. Stool culture negative for C. diff. Left fourth
finger fluid negative for organisms on Gram stain or culture on
2/27/06 . Sputum culture on 9/14/07 , 1+ suspected orally flora.
Chest x-ray on 9/14/07 , hazy opacification within the left lower
hemithorax due to atelectasis , unchanged from 6/10/06 . Right
lower extremity fascial biopsy on 8/7/06 , dense fibroconnective
tissue , no acute inflammation present.
IMPRESSION: Ms. Flow is an 83-year-old woman with multiple
medical problems presenting with hypotension likely secondary to
sepsis from her right lower extremity cellulitis and a klebsiella UTI.
PLAN:
1. ID: The patient had group A strep bacteremia likely due to
cellulitis. She was treated empirically with vancomycin x6
weeks. Day one was 11/22/06 . Vancomycin was being dosed bilevel
as the patient was requiring hemodialysis and had decreased urine
output. Echocardiogram was unremarkable for vegetations. Second
echo was pending on 10/27/07 at the time of this dictation to
rule out any kind of vegetation. She did have some spots on her
toes that looked like possible Janeway lesions. Klebsiella UTI
was treated with levofloxacin.
2. Renal: The patient is oliguric acute renal failure on
chronic with question of either a result of sepsis and
vasodilatation and hypotension versus a true ATN. She has been
requiring hemodialysis. Last dialysis was 10/27/07 . Urine
output and improving. The patient may have a permanent tunneled
catheter placed depending on how her urine output recovers. We
will use Lasix as needed to manage volume.
3. Cardiovascular: The patient had demand ischemia with a peak
troponin of 0.87 with septic. Her LDL was 63 and a statin was
started. She will continue her aspirin and beta-blocker. We
will recheck her fasting lipids when the acute illness has
resolved as an outpatient. The patient now has normal blood
pressure with titrating her beta-blocker up and considering
adding a second agent to normalize her hypotension. We are
avoiding Ace inhibitors because of her acute renal failure. She
has AFIB , sick sinus syndrome. She is on Coumadin as an
outpatient , has a permanent pacemaker. We are holding her
Coumadin for now and this can be resumed once decision has been
made about hemodialysis access. She had an elevated INR in the
ICU , presumably due to shock liver , as her other LFTs are
also increased simultaneously.
4. Endocrine: The patient has diabetes mellitus. She has
elevated blood sugars on tube feeds and steroids. We are
titrating up her insulin. Her home regimen is Lantus. the tube
feeds were discontinued on 10/27/07 as the patient was cleared to
eat a diabetic diet and we will transition her insulin
accordingly. She is hypothyroid and we should continue her home
Levoxyl.
5. Rheumatology: The patient had a gout flare in her left hand ,
right shoulder , and right knee. Taps were consistent with gout.
The cultures were no growth to date. She is on a dexamethasone
taper , however decreasing to 1 mg intravenous every 12 hours on 7/9/07 per
rheumatology.
6. Heme: The patient had persistently low platelets and anemia.
Initially , it was a concern for DIC , but the fibrinogen was
normal. There was some concern for hemolysis. Her hematocrit
and platelets dropped in the setting of tapering her steroids and
she actually did require two units of packed red cells on
2/27/06 . Her dexamethasone was then increased. In response to
that , heparin was stopped. Her platelet factor intravenous antibody is
negative. We will continue to follow her counts as we taper the
steroids. It could be possible that the changes in her
hematocrit and platelets are due to sepsis.
7. GI on 8/27/06 , she developed elevated LFTs. We continued to
follow the trend of her LFTs and they have decreasing at the time
of this dictation.
8. Neurology: The patient has severe pain from gout. She is on
a Dilaudid PCA initially , now is on her home fentanyl patch with
Dilaudid boluses as needed
9. Dermatology: The patient has a history of venostasis ulcers
and right arterial lower extremity insufficiency. She was seen
by wound care and vascular surgery , were continued to follow
their recommendations and when she is an outpatient , she should
have ABIs. She could not have an MRI to study flow to those legs
as she has a pacemaker.
10. FEN: The patient is on a mechanical soft diet with thin
liquids on 10/27/07 . Nutrition is following.
11. Prophylaxis: The patient will need DVT prophylaxis when INR
hits 1.5. She is on a PPI while she is on steroids.
DISPOSITION: Rehabilitation. She has a right subclavian line
that should be removed prior to discharge , and a decision about
the hemodialysis catheter should be made.
Her healthcare proxy is her daughter , Beierschmitt , her cell number
893-303-8108 , home number is 356-871-0612.
CODE: DNR/DNI.
CONTINUED CARE PLAN:
1. Follow up the results of all cultures to resolution.
2. Remove right subclavian line.
3. Make a decision about whether or not the patient will need
intermittent hemodialysis and if so , through what access.
4. Resume Coumadin once that access has been placed or once all lines have
been removed.
5. Recheck lipids as an outpatient.
6. ABIs for both legs and followup of chronic , non-healing wound.
7. Continue vancomycin.
eScription document: 4-3005822 CSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: NAKAI , RHEBA
Dictation ID 9945944
D: 10/27/07
T: 7/9/07
Document id: 553
| Target |
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DM |
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GER |
Gou |
HC |
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OA |
Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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151658119 | PUO | 01757560 | | 6139337 | 2/20/2005 12:00:00 a.m. | musculoskeletal pain | | DIS | Admission Date: 11/14/2005 Report Status:
Discharge Date: 10/2/2005
****** FINAL DISCHARGE ORDERS ******
HEDLEY , SOOK 990-79-59-1
Boise Ven Ci
Service: CAR
DISCHARGE PATIENT ON: 7/7/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PETTINGER , DOUGLASS N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Stay with Family , Friends with services
DISCHARGE MEDICATIONS:
ENALAPRIL MALEATE 20 MG orally every day
HYDROCHLOROTHIAZIDE 25 MG orally every day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 75 MCG orally every day
ATIVAN ( LORAZEPAM ) 0.5 MG orally three times a day as needed Anxiety
PAXIL ( PAROXETINE ) 10 MG orally every day
ALPHAGAN ( BRIMONIDINE TARTRATE ) 1 DROP each eye twice a day
Number of Doses Required ( approximate ): 3
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours
SPIRIVA ( TIOTROPIUM ) 18 MCG NEB every day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain
ATENOLOL 25 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Viray 9/8/05 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
musculoskeletal pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pulonary fibrosis ( pulmonary fibrosis ) hypothyroid ( hypothyroidism )
OA ( osteoarthritis ) osteoporosis
( osteoporosis ) GERD ( gastroesophageal reflux disease ) hyperlipidemia
( hyperlipidemia ) Past EtOH abuse ( history of alcohol abuse ) Cervical cancer
( cervical cancer ) HTN ( hypertension )
OPERATIONS AND PROCEDURES:
none.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none.
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
HPI: 73 year-old female with history of interstitial pneumonitis history of VATS in 8/3 ,
readmitted 7/7 for persistent pain at vats site. patient returned to ED on
day of admission with chest pain x 2 days , substernal towards left and
along her left rib cage. No radiation to the back , neck or arms. patient is
unable to characterize the pain well. +nausea. patient is hypoxic at
baseline , with home o2 requirement. patient had troponin leak to 0.16 in
the ED and was admitted to cardiology.
----------------------------------------------------------
PMH: ipf , history of vats , home o2 requirement , hypothyroid , copd , oa ,
osteoporsis , gerd , hyperlipidemia , history of cervical ca , htn , post etoh
abuse , anxiety
------------------------------------
Meds on admission: atenolol 25 every day , colace 100 twice a day , enalapril 20 every day , hctz
25 every day , synthroid 75 mcg every day , oxydoone 5-10 mg every 4 hours as needed pain , omeprazole
20 every day , duoneb every 6 hours , lidoderm patch , ativan 0.5 orally three times a day , paxil 10 every day ,
alphagan , spiriva 18 mcg every day
----------------------------------
All: NKDA
--------------------------------------
Exam on admission: heart rate 63 , blood pressure 151/88 , rr 18 , sat 99% on 3L , +strabismus
with R esotropia at rest , tongue with white plaque , jvp 8 cm , cv rrr no
m/r/g , pulm: scattered crackes at bases , abd benign , ext: 2+ dp
pulses , no edema , + clubbing EKG: nsr at 73 , nl axis nl intervals , no
changes from prior
------------------------------------
studies/tests: Persantine MIBI: negative for any ischemia
------------------------------------
Problem List
Ischemia: Patient was admitted with troponin leak of 0.16 , no ekg
changes. Patient's subsequent troponins were <assay. Patient's story is
unlikely to be cardiac chest pain. Persantine MIBI was done to rule out
any ischemia. MIBI was negative. Pain could be due to patient's VATS
procedure. Patient was initially placed on heparin , asa , bblocker , ace ,
high dose statin. Heparin was discontinued and patient was d/c'd on her
outpatient cardiac medications.
Pump: BP's elevated in ER to 177/95. It is unclear whether patient had
been taking cardiac meds during the week. When patient was placed back
on her outpatient cardiac blood pressure medicines she was well controlled with blood pressure
130s/80s.
Rhythm: The patient remained in nsr during the hospitalization.
Pulmonary: newly diagnosed interstitial pulmonary fibrosis. She was
continued on her home regimen of duonebs , o2 by nasal canula
( 2-4L ).
FEN/GI: Nexium for GI prophylaxis
Endo: history of hypothyroid last tsh 2.9. Patient was continued on synthroid.
Pain control: The patient has a history of admission for Chest wall pain
for VATS. VATs procedure done 3 weeks ago and per outpatient
pulmonologist , patient had been requiring large doses of opioids per her
family members. The patient , however , did not complain of
increased pain at her outpatient visit. During this admission , the
patient did not request any as needed pain medication and was comfortable with
regular heart rate throughout the admission. The patient should no
longer require opioids for pain due to the VATS procedure. We are
recommending that the patient take tylenol for pain and follow up with
her primary care physician if this is unable to control the pain.
Exam at discharge: NAD , JVP flat , crackes at bases , otherwise CTA b/l ,
rrr , s1 , s2 , no m/r/g. No tenderness to palpation over left ribs/VATS
site. Abdomen benign. Extremities without edema. +clubbing
Labs at discharge: troponin <assay , electrolytes wnl , bun 5 , cr 0.6 , wbc
6.0 , hct 37.6 , plts 374 , chol 191 , tri 107 , hdl 42 , ldl 128 , vldl 21
ADDITIONAL COMMENTS: Please take tylenol for your chest pain. See your primary care physician at the Bulls Asn Hospital this monday. Take your medications as prescribed.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up lipids. Patient was placed on zocor for better cholesterol
control. Follow up pain and requirment for pain medications.
No dictated summary
ENTERED BY: MUNDT , SUMMER M. , M.D. ( DY980 ) 7/7/05 @ 06:35 PM
****** END OF DISCHARGE ORDERS ******
Document id: 554
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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517077919 | PUO | 45227626 | | 8233077 | 10/10/2006 12:00:00 a.m. | Gout | | DIS | Admission Date: 2/27/2006 Report Status:
Discharge Date: 3/26/2006
****** FINAL DISCHARGE ORDERS ******
KISHIMOTO , BRIANA 104-13-35-2
New Hampshire
Service: MED
DISCHARGE PATIENT ON: 2/3/06 AT 06:30 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: INGRAM , ANDREE OSWALDO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
COLCHICINE 0.6 MG orally every 3 days Starting Today August
DIGOXIN 0.125 MG orally every day
Alert overridden: Override added on 10/7/06 by
LARZELERE , GAYLE C. , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: md aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally twice a day
Starting Today August Food/Drug Interaction Instruction
Avoid milk and antacid
LEVOTHYROXINE SODIUM 75 MCG orally every day
Override Notice: Override added on 10/7/06 by LARZELERE , GAYLE C S. , M.D. on order for DIGOXIN orally ( ref # 047444057 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: md aware
Previous override information:
Override added on 6/16/06 by GORRELL , JULIETTE D. , M.D.
on order for COUMADIN orally ( ref # 742822357 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: aware Previous override information:
Override added on 8/19/06 by PERSONIUS , SVETLANA B GIOVANNA , M.D. , M.P.H.
on order for COUMADIN orally ( ref # 492018544 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: will follow
REGLAN ( METOCLOPRAMIDE HCL ) 5 MG orally three times a day
Starting Today August
OXYCODONE 5-10 MG orally every 6 hours as needed Pain HOLD IF: oversedated
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
THIAMINE HCL 100 MG orally every day
TRAZODONE 50 MG orally HS as needed Insomnia
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting NOW August
Instructions: Except on Wednesdays and Saturdays , adjusted
as per MMC Coumadin Clinic instruction
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 6/16/06 by
GORRELL , JULIETTE D. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
Alert overridden: Override added on 8/19/06 by
PERSONIUS , SVETLANA BART , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
75 MG orally every day Starting Today August
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
NEURONTIN ( GABAPENTIN ) 200 MG orally every day
K-DUR ( KCL SLOW RELEASE ) 40 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
TORSEMIDE 100 MG orally twice a day Starting Today August
COZAAR ( LOSARTAN ) 50 MG orally every day Starting Today August
Number of Doses Required ( approximate ): 5
LEVOCARNITINE 1 GM orally every day
Number of Doses Required ( approximate ): 5
CELEXA ( CITALOPRAM ) 20 MG orally every day Starting Today August
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LANTUS ( INSULIN GLARGINE ) 58 UNITS subcutaneously every afternoon
Starting ON 5/14/07 )
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
NOVOLOG ( INSULIN ASPART ) 6 UNITS subcutaneously before meals
Starting Today August
PREDNISONE Taper orally Give 10 mg every 24 hours X 3 dose( s ) , then
Give 5 mg every 24 hours X 3 dose( s ) , then
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 2/3/06 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB orally Q5MIN
as needed Chest Pain
ACETYLSALICYLIC ACID 81 MG orally every day
Alert overridden: Override added on 2/3/06 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware
CALCITRIOL 0.25 MCG orally 3x/Week M-W-F
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: On Wednesdays and Saturdays only.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/3/06 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
METOLAZONE 2.5 MG orally every day on Wednesday and Saturday
Instructions: Give 30 minutes prior torsemide
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
SIMETHICONE 80 MG orally four times a day
DIET: Patient should measure weight daily
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
DR KISTNER MMC Vi Perv Quernaas ( 216 ) 917-8318 2/10/06 @ 2:10 PM scheduled ,
DR BIRCH 10/12/06 AT 10:40AM scheduled ,
Arrange INR to be drawn on 6/20/06 with f/u INR's to be drawn every
14 days. INR's will be followed by MMC Coumadin Clinic
ALLERGY: SHRIMP
ADMIT DIAGNOSIS:
hand pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Gout
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Adriamycin induced CMP HTN IDDM Sarcoid
Left Breast CA- history of lumpect and XRT/Adria-'84 hypercholesterolemia
? GI origin of epigastric pain dvt ( deep venous thrombosis )
osteoarthritis ( unspecified or generalized OA ) hypothyroid
( hypothyroidism ) cad ( )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: left hand swelling
HPI: 61yoF with DM , gout history of dvt , history of right mastectomy for DCIS who
p/with one week of left hand erythema and welling and pain. This
started in her thumb and spread to wrist along with DIP , MCP
of first finger , now with pain/tenderness of left elbow. DM control
has been poor since sx started. Denies trauma , bites , cuts , no f/c ,
no cough , no anorexia/n/v. In ED writted for nafcillin.
PMH: DM , gout , CRI , AICD , HTN , CAD , COPD on home
oxygen , OSA , GERD , depression , right mastectomy
All: shrimp
SH: lives in assisted living , no tob/etoh/drugs
PE: T97.7 , hr80 , bp95/62 , r20 , sat100%ra
Gen: aox3 , speaks slowly , nad , obese h/n: perrl , eomi , mmm , jvp 7cm
water Chest: CTAB , right mast scar Cor: RRR nl s1s2 , no
mrg Abd: obese , soft , ntnd , nabs ext: swollen ankle nonpitting , tender
over left hand DIPS , 1st/2nd MCPs , elbow pain with active movt Xray: soft
tissue swelling of left wrist , no effusion no
fracture
Labs: Cr 2.3 , Gluc 442 , dimer 394 , wbc 7.4 , hct 39
EKG: NSR with 1deg avb at 73bpm , old antlat infarction
****************Hospital Course******************
61yoF with history of DM , gout , CRI here with an inflammatory polyarthritis
of the left hand/wrist with overlying swelling. No evidence of
systemic illness at this time. Most likely etiology is gout , given lack
of other clinical signs or risk factors for septic joint.
1. RHEUM: Patient refused left wrist tap. She was followed closely by
rheumatology , who recommended starting steroids and continuing colchicine
for sx relief. Colchicine was decreased to 0.6mg every other day given renal
function. Patient was discharged home to finish 1 week steroid taper. At
time of discharge , hand pain and swelling was mildly improved.
2. ID: no signs of septic joint.
3. HEME: Patient was continued on home coumadin.
4. RENAL: Cr at 2.3 near baseline , renally dose medications
5. ENDO: Patient was admitted with hyperglycemia , no evidence of HONK ,
likely related to infection. Hyperglycemia was further worsened by
administration of steroids , as expected. Patient's insulin requirements
were quantified and standing novolog increased qAC in addition to sliding
scale. Lantus was continued at home dose. Blood glucose was under
improved control at time of discharge. Patient was discharged home with
home lantus/novolog with a sliding scale written out for her. She will
have VNA to help her with glucose management. Thyroid replacement was
continued.
6. FULL CODE
Please note , medication list at discharge was verified against medications
list administered by Conchap Un Memorial Medical Center and is updated as to what patient
has been and is currently receiving.
ADDITIONAL COMMENTS: Please seek medical attention for worsening hand pain , blood glucose
greater than 300 , fever , shortness of breath , chest pain , or any other
concerns.
Please continue all home medications. You have one new medication:
prednisone , 10mg ( 2 pills ) for 3 days followed by 5mg ( 1 pill ) for 3
days , then stop this medication.
Please administer insulin sliding scale as per sheet given to you.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Check blood glucose before each meal and apply sliding scale per handout.
Call your doctor with any blood glucose reading >250-300.
No dictated summary
ENTERED BY: LENEAVE , JETTA , M.D. ( KQ022 ) 2/3/06 @ 06:09 PM
****** END OF DISCHARGE ORDERS ******
Document id: 555
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
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- |
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N |
N |
546539207 | PUO | 65571399 | | 9246492 | 6/13/2004 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 7/10/2004 Report Status: Signed
Discharge Date: 10/19/2004
ATTENDING: RASHEEDA BRAGAS MD
ADMITTING DIAGNOSIS: CHF exacerbation.
LIST OF PROBLEMS AND DIAGNOSES:
1. CHF.
2. CAD status post CABG in 1988.
3. Chronic renal insufficiency.
4. Type II diabetes.
5. Glaucoma.
6. Hypercholesterolemia.
7. History of bowel resection for diverticulitis.
8. Question of TIA in the past with right-sided numbness.
BRIEF HISTORY OF PRESENT ILLNESS:
Ms. Tin is an 83-year-old africaan-speaking female with history
of CAD , distant three-vessel CABG , CRI , NSTEMI in 10/29 ,
treated with just medications , EF of 75% in 10/29 , who
presented one week of PND , dyspnea on exertion , and chest
heaviness. This chest sensation did not radiate and was
unassociated with nausea , vomiting , diaphoresis or
lightheadedness. The patient also had cough with green sputum x1
year , no fevers or chills , no sick contacts. EMS gave Lasix and
Nitrospray. In the ED , she was briefly on a nonrebreather mask ,
responded to 80 mg of intravenous Lasix , K was 5.8 and got Kayexalate.
She became comfortable , sitting at 75 degrees , chest pain-free.
Also , noted no change in bowel/bladder habits , no change in meds
and no dietary changes. She had positive progressive lower
extremity edema x2 weeks.
ALLERGIES:
Lisinopril leading to hyperkalemia.
SOCIAL HISTORY:
Retired textile worker from Westwark Scond Ston , lives with daughter , and is
portugese speaking.
HOME MEDICATIONS:
Aspirin , metoprolol , allopurinol , valsartan , glipizide , Lipitor ,
and nifedipine.
PHYSICAL EXAMINATION ON ADMISSION:
Temperature was 96 , pulse was 70 , blood pressure was 148/56 ,
respiratory rate was 20 , and saturating 100% on nonrebreather and
eventually in the high 90s on a couple of liters of oxygen. In
general , she was in no acute distress , JVP 12 cm with positive
hepatojugular reflux , soft bibasilar rales , regular rate and
rhythm , 2-3/6 systolic murmur , loudest at the left upper sternal
border , ( mild AS on echo from 1/26 ). Abdomen was soft ,
nontender , and nondistended , bowel sounds positive. Extremities
showed 3+ bilateral pitting ankle edema with weak distal pulses.
LABORATORY DATA:
Showed a sodium of 129 , potassium of 5.7 , creatinine of 2.8 with
a baseline anywhere between 2 and 3.5 , cardiac enzymes negative
x1 , BNP of 1448. EKG showed normal sinus rhythm at 73 , septal
Qs , QTC of 456. Chest x-ray showed cardiomegaly , small bilateral
effusions , no infiltrate.
HOSPITAL COURSE BY PROBLEMS:
1. Cardiovascular: Ischemia: Rule out MI by enzymes and EKG
with a full set negative. Continued her aspirin , beta-blockers ,
and statin for coronary artery disease. Pump: CHF flare with
elevated BNP , volume overload , diuresed with Lasix and Diuril;
salt/water restricted , kept strict I/O with moderate diuresis.
After load reduced with ARB , weaned off her previous home calcium
channel blocker. Rhythm: Telemetry showing transient new atrial
fibrillation with a maximum heart rate of less than 70 , which
spontaneously resolved after several hours. An echo showed
stable aortic stenosis without any acute worsening. She also had
a rhythm strip on the telemetry showing a regular focus of
ventricular ectopy , also spontaneously resolving. This was
treated with continued beta-blockers. At the time of discharge ,
she was in normal sinus rhythm.
2. Renal: Chronic renal insufficiency with baseline creatinine
of 2.8 to 3.3 , with acute worsening in-house , most likely
secondary to over diuresis with Diuril/Lasix , also some prerenal
component secondary to fluid restriction. Her potassium was
elevated initially , got Kayexalate , and then was low/low normal
after Lasix. Creatinine peaked at 4.1 , Lasix and ARBs were held.
Urine study showed a prerenal component , also showed some
proteinuria. Her creatinine eventually improved to 3.3 , and her
bicarb improved from 17 to 23 with the closing of her acid gap
from 17 to 11. Potassium was 4.5 at the time of discharge. The
patient will need to follow up with Dr. Younker , her
nephrologist , and she was set up for an appointment on 2/18/04 .
3. Endocrine: DM-2 , she was treated with regular sliding scale
insulin with good blood sugar control. Her glipizide was held
given that her creatinine clearance was worsening. We did not
restart her glipizide at the time of discharge until follow up
with Dr. Goud given her overall worsening creatinine
clearance.
4. Rheumatology: History of gout , change her allopurinol to
every 72 hours from every other day secondary to creatinine clearance. She did
complain of some left heel pain and left foot pain , thought
secondary to her gout. This improved at the time of discharge.
5. Heme: Hematocrit dropped from 29 to 25 , her guaiac was
negative on the 2/5/04 . She also has epistaxis at night for
four to five days. She was placed on humidified room air given
nasal saline sprays and Afrin. Because of her coronary artery
disease , she was transfused total of 3 units over the course of
her hospital stay to keep her hematocrit greater than 30. She
was given Lasix after her transfusions. An ENT evaluation showed
a small area of ulceration in her posterior nasopharynx , which
will need a follow up possibly with a CT as an outpatient to rule
out malignancy. At the time of her discharge , her hematocrit was
36. Initially , Coumadin was started given her new onset of
atrial fibrillation. After consideration of risks versus benefit
of anticoagulation , her transient atrial fibrillation which
resolved spontaneously , it was decided to continue any further
anticoagulation and send her out just on aspirin. She did
receive subcutaneous heparin for DVT prophylaxis while in-house.
GI: The patient initially had some constipation , which was
relieved with stool softeners. The patient's stool was guaiac
negative. The patient received the PPI.
DISPOSITION:
The daughter who is the patient's healthcare proxy was made aware
of the patient's status and disposition throughout her hospital
course. A physical therapy evaluation indicated that the patient would benefit
from a period of re-stay at rehab , however the patient family
preferred the patient to go home and was constant that they would
be able to provide 24/7 support over the next week as the patient
will need help in navigating her home which included two flights
of stairs. physical therapy was comfortable with this and this was explained
thoroughly to the patient and her family with regard to the risks
versus benefit of going home versus going to rehab. The patient
will follow up with Dr. Goud in one to two weeks , which has
not been scheduled , and with Dr. Younker with Nephrology which
has been scheduled for 2/18/04 . Communication was made with Dr.
Goud regarding her admission here. The patient will be sent
home with VNA support to follow up on her weights and fluid
status , she will also have home physical therapy.
CODE STATUS:
Full code.
MEDICATIONS:
1. Lasix 20 mg orally every day
2. Lipitor 80 mg orally every day
3. Metoprolol sustained release 100 mg orally twice a day
4. Colace 100 mg orally twice a day as needed for constipation.
5. Allopurinol 100 mg orally every 72 hours
4. Aspirin 325 mg orally every day
5. Valsartan 160 mg orally every day
PRIMARY CARE PHYSICIAN:
Julissa Goud , M.D.
eScription document: 8-1392625 BFFocus
Dictated By: CRIDGE , LORRETTA
Attending: BRAGAS , RASHEEDA
Dictation ID 7407155
D: 7/27/04
T: 4/13/04
Document id: 556
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887833478 | PUO | 26367322 | | 5922658 | 3/3/2002 12:00:00 a.m. | CAD , mild CHF. | | DIS | Admission Date: 3/3/2002 Report Status:
Discharge Date: 10/30/2002
****** DISCHARGE ORDERS ******
SANDMANN , CONTESSA 167-38-69-6
Wapines Roche Pems
Service: MED
DISCHARGE PATIENT ON: 4/4/02 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARRECA , EMERALD M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
DIGOXIN 0.125 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
TNG 0.4 MG ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 as needed chest pain
LOSARTAN 25 MG orally every day
Number of Doses Required ( approximate ): 10
LEVOFLOXACIN 250 MG orally every day X 4 Days
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
ATENOLOL 25 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Toni ( KTDUOO ) 4/6/03 ,
Cardiology clinic , Dr. Rimando . 047 384 5484 ,
No Known Allergies
ADMIT DIAGNOSIS:
r/o mi
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD , mild CHF.
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) history of CABG ( history of cardiac bypass graft
surgery ) HTN ( hypertension ) hyperlipidemia ( elevated cholesterol )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
echo.
BRIEF RESUME OF HOSPITAL COURSE:
patient is 71F p/with cough and SOB x 4mts.
She is a swedish-speaking woman who just moved to Alesaia from Valle A Nor ,
with PMHx sig for CAD: ( AMI 1995 ->stent LAD-> in stent restenosis ->
2VCABG: SVG->LAD , SVG -> RCA. 1997
SVG-LAD stent->stenosis->restent. 1998 3rd svg-LAD
stent placed. ICD placed for low EF. Other cardiac
RF are HTN and hyperlipidemia. She has had 4
month history of worsening DOE ( 2o to SOB and leg
weakness ) , cough prod of white sputum ( since starting captopril ).
+Orthopnea , Neg PND. Occ LE edema , but no recent increase or
weight change. She has no current CP , but does
have history of stable angina , last 3 weeks ago , r/b sublingual
tng x1. In Lem Ter Dale , Virginia 67774 , the resp Sx
were tx'd with steroids , nebs , abx with no
improvement. ROS also sig for dysuria. Occ night sweats ,
poor appetite.
EXAM: afeb , 69 155/85 99%RA. gen: overweight pleasant woman in NAD.
JVP 8-9cm. lungs clear b/l. card S1S2 RRR , 2/6 sus murmur at apex. Abd
benign. 1+ LE edema.
LABS/TESTS: CK , Troponin flat x2. BNP 94. U/A WBC TNTC. ECG: ST
elevation V1-V4. CXR mild pulm edema.
COURSE: 1. CV: rhythm: patient has ICD for low EF.
No arrythymia seen on tele. She was formerly
on lopressor 50qd. Changed to atenolol upon d/c.
pump:There was concern that this ST elevation ( new since 1998 ) was 2o
apical aneurysm , howeve echo 11/3 was neg for aneurysm; showed EF 35%
septal AK , inf/ant distal AK , inf HK , post dist HK. ( Official results
pending at time of d/c ) She will follow up with Terence Rimando in cardiac
clinic
for mgmt of her cardiac disease. She was also thought to be mildly
fluid overloaded , given lasix 40 IVx1 , then continued
on outpt dose of 40 orally every day Afterload
reduction: changed from ACEI ( report of cough in past )
to ARB. Should be titrated up as tol as outpt.
Cont dig 0.125 every day , level pending at time of discharge.
ischemia: r/o'd MI. Consider outpt dobut Mibi. Lipid profile pending
at time of d/c.
ID: UTI: levo x5d. Remained afebrile. Flu shot given.
DISPO: new primary care physician Dr. Toni in KTDUOO . F/u in cards clinic with Dr. Rimando .
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Call for an appointment in cardiology clinic 180 106 1853. Do not
continue taking captopril.
No dictated summary
ENTERED BY: HANSBERRY , SHAN ROBERTA , M.D. ( WD511 ) 4/4/02 @ 01:15 PM
****** END OF DISCHARGE ORDERS ******
Document id: 557
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816576315 | PUO | 22240846 | | 3141750 | 2/23/2005 12:00:00 a.m. | RESPIRATORY DISTRESS | Signed | DIS | Admission Date: 9/3/2005 Report Status: Signed
Discharge Date: 10/6/2005
ATTENDING: FERNANDE RANDY PREWER MD
Of note , the patient was admitted to the CCU and then transferred
over to the Heart Failure Service mid admission.
PRINCIPAL DIAGNOSIS: Respiratory distress.
OTHER DIAGNOSES: CHF , hypertension , bronchospastic asthma ,
nonischemic cardiomyopathy , and pulmonary hypertension.
BRIEF HISTORY OF PRESENT ILLNESS: A 63-year-old female with
hypertension , asthma with baseline PAF , peak flows of 150 to 175 ,
and history of previous nonischemic cardiomyopathy with most
recent EF of 55% on 4/11/04 as well as pulmonary hypertension
with the pulmonary artery systolic pressure of 96 mmHg , who was
in her usual state of health until three or four days prior to
admission when she developed cough and symptoms of an upper
respiratory infection. She had no reported fevers or chills. On
the day of admission , the patient was at her friend's house.
When she became acutely short of breath , EMS was called and per
report , the patient was in a tripod position , sweaty , and felt to
be in respiratory distress. In the ED , she was given 80 mg IVF
Lasix , several nebulizer treatments , and actually that was done
in field. Shortly after arrival to the ED , the patient appeared
to be in worsening distress and she desaturated in terms of her
oxygen saturation to the 70% to 80%. She was urgently intubated
and at the time of intubation , there were significant amount of
secretions/emesis in the secretions. She was given 120 mg IVF
Lasix. Chest x-ray at that time showed an infiltrate on the left
consistent with pulmonary congestion. Her BNP on admission was
591 , up from 204 on 4/11/04 . The notable labs were CK of 115
and MB fraction of 2.8 , a troponin of 0.62 , and a white blood
cell count of 11.7. Her ABG post intubation was 7.4/54/453 .
PAST MEDICAL HISTORY: As above. Hypertension , asthma , tobacco
use , nonischemic cardiomyopathy , and pulmonary hypertension.
MEDICATIONS ON ADMISSION: Albuterol , atorvastatin , aspirin 325
mg , Flovent twice a day , potassium 20 mEq three times a day , Lasix 200 mg twice a day ,
lisinopril 40 mg every day , magnesium oxide , multivitamins , Norvasc 10
mg every day , Serevent two puffs twice a day , and Valium.
ALLERGIES: Metoprolol to which she gets bronchospasm.
SOCIAL HISTORY: She presently smokes cigarettes approximately
half a pack to one pack per day x 30 years , unknown whether she
drinks alcohol.
PHYSICAL EXAMINATION ON ARRIVAL: Temperature of 100.1 , she had a
heart rate of 53 in sinus , blood pressure 150/90 , and initial
vent settings included assist control with a tidal volume of 500 ,
breathing at 12 with an FIO2 of 100% , 93%. Exam notable for a
JVP of 8 and 9 , reactive pupils , diffuse expiratory wheezes on
pulmonary exam , irregular tachycardia , S1 , S2 , 3/6 holosystolic
murmur at the left upper sternal border , soft abdomen with
positive bowel sounds , warm extremities , 1+ pitting edema , and
notable labs were as above.
Her CCU course can be summarized by the following:
1. Cardiovascular: In terms of her pump , she as noted had
pulmonary congestion on chest x-ray and during her CCU stay ,
diuresed approximately 4.7 liters and her weight went down 6 kg.
On transfer to the floor of Cardiology Heart Failure Service , she
still appeared somewhat volume overloaded to despite 100 mg intravenous
Lasix every day. In terms of her rate , she was normal. On transfer
from the CCU , she had normal sinus rhythm with occasional signs
of paroxysmal atrial fibrillation , which was thought possibly due
to her pulmonary process. In terms of her ischemia , she had some
troponin leak , it was thought to be in the setting of CHF , but
that was trending downward and her blood pressure was difficult
to control likely due to medical noncompliance , longstanding
hypertension at home. She was on captopril , hydralazine , and
amlodipine.
2. In terms o her pulmonary status , there was a question of a
left infiltrate on her chest x-ray , so she was started on
levofloxacin and she was continued to be treated with Solu-Medrol
intravenous with switching to prednisone 60 mg orally Her ABG showed mild
retention that would be expected in the setting and we continued
levalbuterol nebulizers every 4 hours as well as Atrovent nebulizers
every 4 hours and did not start a steroid taper.
She was transferred from the CCU to the floor on the ACE , October
2005 , after five-day stay in the CCU.
Briefly , summarized her floor course by the following problems:
1. Cardiovascular: In terms of her pump , she was continued to
be diuresed down to what was thought to be a goal dry weight
between 82 and 84 kg. We were able to accomplish this diuresis
with Lasix 120 mg twice a day orally and did not need to initiate any
form of drips. We attempted to diurese her down to euvolemic
weight of approximately 84 kg on discharge. Rhythm: On the 30 of August
of October , she developed atrial fibrillation with rapid
ventricular rate into the 130s and was placed on the diltiazem intravenous
drip titrated up to a heart rate below 100 , maximal rate reached
140 to 150. We switched to diltiazem drip over to diltiazem orally
three times a day up to a dose of eventually 150 mg twice a day that was then
sequentially brought down later during the admission. We also
started digoxin orally and started heparin for anticoagulation. It
was at that time decided that electrical cardioversion would not
be optimal in her stay , so it was decided that she would be
chemically cardioverted using the drug dofetilide. Otherwise ,
Tikosyn and we initiated the doses of dofetilide on February ,
2005 , first with the loading dose of 250 mcg and then with 500
mcg twice a day. She was watched carefully with EKGs before every
dose of dofetilide because of the risk of torsade de pointes and
we kept her magnesium well repleted. She tolerated the chemical
cardioversion and went back into mostly sinus rhythm without too
much ectopy or signs of any other arrhythmia , then we were able
to decrease her diltiazem down to 60 mg orally three times a day Ischemia:
She had small troponin leaks that eventually resolved , thought to
be due to failure. In terms of her cardiovascular status , a
right heart cath was done on the March , 2004 , which showed
the following pressures: RA pressures of 10 , pulmonary capillary
wedge pressures of 12 , and pulmonary artery pressures of 60 with
cardiac output of 6. Swan-Ganz catheter readings also showed
similar pressure suggesting that the causes of her respiratory
distress were more respiratory disease in nature as opposed to
CHF heart failure nature. We , of course , continued gentle
diuresis but proceeded to aggressively manage her respiratory
disease. Blood pressure: She was maintained on a regimen and
eventually discharged in regimen of hydralazine 100 mg three times a day ,
Isordil 40 mg three times a day , diltiazem 60 mg three times a day , and lisinopril 20
mg every day As her blood pressures had been hard to control , she
left here with blood pressures in the ranges of 120 to 150s/40s
to 70s.
2. Pulmonary wise , her respiratory distress seem to be more due
to her significant component of bronchospasm and slowly improved
throughout the course of admission. We did not begin the taper
of her prednisone until after she was discharged. She was
discharged on 60 mg orally every day of prednisone and we will begin to
taper after four days to 50 mg every afternoon orally every day and then after
four days of that to 40 mg orally every day , after which the Pulmonology
Service will then determine whether she needs further tapering
and how fast to do it. She is also continued on Flovent 220 mcg
four puffs twice a day as well as Advair 500/50 mcg twice a day inhalers in
addition to her Atrovent inhalers in the morning five puffs. She
will be arranged for followup in the Pulmonary Clinic , 337-8573 ,
for management of her asthma , COPD , and pulmonary hypertension.
The pulmonary fellow input was greatly appreciated.
3. Heme: She was started on heparin because of the risk of clot
formation during her atrial fibrillation with RVR and then
transitioned to Coumadin with a dose of 5 mg of Coumadin. Should
be followed up in the Coumadin Clinic at KTDUOO ( Kernan To Dautedi University Of Of ) who will draw her INR first starting on the
16 of October of October when she has an appointment with her primary care physician. Her
renal issues are creatinine , were initially bumped to 1.9 , but
came down steadily to a discharge level of 1.5. She had good
urine output and no other major electrolyte abnormalities after
her initial low sodiums. She did have persistently elevated
bicarbonate levels as would be expected. Her white count was
somewhat high , but she was on steroids and was not thought to be
infected.
She was visited often by many family members and the following
follow-up appointments were made in terms of her disposition:
She has an appointment with Dr. Sun Leason , her primary care
physician at KTDUOO on January , 2005. She has an appointment
with her primary cardiologist , Dr. Mathew Stautz on September ,
2005. She has an appointment with the Electrophysiology Service
to follow up on her arrhythmia issues on January , 2005 , and
she will be making an appointment with the Pulmonology Service
and to followup in a few weeks for her bronchospastic issues.
She also has visiting nurses' support setup for her as well as
connection with the Coumadin Clinic at KTDUOO . She was discharged
in a stable condition on July , 2005 with followup. Her
exam was essentially improved respiratory wise and unchanged
cardiac wise. She felt ready to leave.
DISCHARGE MEDICATIONS: Albuterol inhaler two puffs every 4 hours ,
Atrovent inhalers two puffs four times a day , Coumadin 5 mg orally
every afternoon , digoxin 0.125 mg orally every day , diltiazem 60 mg orally three times a day ,
enteric-coated aspirin 325 mg orally every day , Flovent 220 mcg inhaled
twice a day , hydralazine 100 mg orally three times a day , Isordil 40 mg orally
three times a day , Lasix 120 mg orally twice a day , lisinopril 20 mg orally every day ,
prednisone 60 mg orally every day before noon , and simvastatin 40 mg orally every bedtime
In terms of disposition , she again needs Pulmonary followup and
appointment , which the fellow said that she will be called form
the Agard Tomw. Medical Center .
eScription document: 9-9264061 ISSten Tel
Dictated By: PHILLEY , DORINDA
Attending: PREWER , FERNANDE RANDY
Dictation ID 8208534
D: 9/15/05
T: 9/15/05
Document id: 558
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876052391 | PUO | 13862165 | | 153102 | 10/12/1998 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 11/10/1998 Report Status: Signed
Discharge Date: 11/10/1998
PRINCIPAL DIAGNOSIS: CHEST PAIN
HISTORY OF HYPERTENSION
HISTORY OF INSULIN DEPENDENT DIABETES
MELLITUS
HISTORY OF CORONARY ARTERY DISEASE
HISTORY OF MYOCARDIAL INFARCTION
HISTORY OF PERIPHERAL VASCULAR DISEASE
HISTORY OF REFLUX DISEASE
STATUS POST RIGHT LOWER LEG BYPASS
HISTORY OF CONGESTIVE HEART FAILURE
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
thai speaking woman with a history
of significant coronary artery disease and other medical problems
as stated above who presented to us in the Emergency Department
complaining of chest pain. The patient was admitted recently on
January for bilateral iliac percutaneous transluminal coronary
angioplasty and received a popliteal to posterior tibial bypass
with saphenous vein on the right lower extremity. This was
complicated by a non-Q wave myocardial infarction with a troponin
level of 12.03 on March . The patient then became stable and
was discharged to rehab on August . On the day of admission ,
around 3 p.m. , the patient complained of 3/10 chest pain , headache
as well as upper extremity pain. The patient received Mylanta at
Thoeaston Healthcare without any relief. She also received
Nitroglycerin sublingual x 2 with some relief. Electrocardiogram
was done at the rehab center at around 4 p.m. with no significant
changes compared to her previous electrocardiograms. Once
transport arrived to pick up patient to go to the Emergency
Department at Pagham University Of , patient became pain
free. She remained pain free for the entire transport as well as
in the Emergency Room. She denies any radiation of her pain. There
was no nausea or vomiting. However , given her significant past
medical history of coronary artery disease as well as a very recent
non-Q wave myocardial infarction , patient was admitted to the
General Medicine Service for rule out myocardial infarction.
PAST MEDICAL HISTORY: Most of it is as stated above. The patient
had a cath in January , 1998 which showed 20% of
LAD stenosis , 70% of diagonal branch stenosis , 95% of the left
circumflex at the OM2 bifurcation and a stent was placed in the
left circumflex. Her echo in July of 1998 showed an ejection
fraction of 60% with mild AS and normal right ventricle function
and size and some left ventricular hypertrophy. The patient has a
coronary artery disease with a MIBI done in September of 1996 which was
notable for inferior ischemia with 5/25 segments. In addition to
her cardiac history and diabetes history , the patient also has a
history of panic attacks.
MEDICATIONS: On admission , the patient arrived with the following
medications: 1. Amlodipine 10 mg every day 2. Enteric
coated aspirin 325 mg every day 3. Atenolol 125 mg twice a day 4.
Captopril 100 mg three times a day 5. Percocet 1-2 tablets every 4-6 hours as needed
pain. 6. Axid 150 mg twice a day 7. Imdur 120 mg twice a day 8.
Nitroglycerin sublingual tablets , 1 tablet every 5 minutes x 3 as needed
chest pain. 9. Ticlid 250 mg orally twice a day
ALLERGIES: Penicillin gives the patient a rash. Patient also
reports an allergic reaction to a flu shot and TB shot.
SOCIAL HISTORY: The patient denies any history of smoking or
alcohol.
PHYSICAL EXAMINATION: In general , patient is a irish speaking
elderly woman who does understand some
English and was resting comfortably in bed in no acute distress.
Vital signs , temperature 99.1 , heart rate 67 , blood pressure
170/90 , respiratory rate 16. Oxygen saturation 98% on 2 liters
nasal cannula. Skin examination warm , dry. HEENT , pupils equal ,
round , reactive to light with extraocular muscles intact. Neck was
supple. She had JVD of about 8 centimeters. Lung examination was
clear to auscultation bilaterally. Cardiac examination reveals
regular rate and rhythm with no murmur , rub or gallop. Abdomen
examination reveals positive bowel sounds , soft , non-tender in
palpation. On extremity examination , the patient has a long scar
on her right lower extremity with stitches in place as evidence of
her recent bypass surgery. The wound appears clean with no
exudates and no erythema. There is some mild edema on the right
lower extremity. There was no edema on the left lower extremity.
HOSPITAL COURSE: The patient was admitted to the General Medicine
Service for rule out myocardial infarction. On
the day of admission , while on the floor , the patient had another
episode of chest pain or chest pressure. However , she reported
that this came on after she had eaten her meal and the pain was
localized to the epigastrium with no radiation. Her
electrocardiogram at that time showed no changes. She was given
some Maalox and this relieved her pain. During this
hospitalization , the patient did not have any cardiac related chest
pain. She was ruled out for myocardial infarction with CK of 48
and then 21 and then 14. On admission , she had a troponin level of
0.17 , however , the patient did have a very recent myocardial
infarction on March with a troponin level of 12.03. It is very
possible that her troponin level of 0.17 is just the tail end of a
recent myocardial infarction and the level is on it's way down.
The patient remained chest pain free and afebrile during this
entire hospital stay. She was stable. Her medical management was
only changed with Hydralazine 10 mg three times a day added to her list of
medications. Per Cardiology , it is okay for patient to go back to
Thoeaston Healthcare with the plan that she will need further
cardiac studies after she is released from her rehab center.
PROCEDURES: The patient did have a chest x-ray on admission
which showed only mild vascular engorgement and
otherwise normal chest x-ray. Her electrocardiogram on the 17 of August
showed ST depressions in the lateral leads as well as T wave
inversion in AVL. It was normal sinus rhythm. This is basically
with no significant changes compared to the electrocardiogram done
on February .
LABORATORY TESTS: Her CBC was normal. Her chem-7 revealed
sodium 134 , potassium 5.0 , chloride 97 , bicarb
26 , BUN 10 , creatinine 0.8. Her CK and troponin level was as
mentioned above.
DISPOSITION: Discharge medications: 1. Enteric coated aspirin
325 mg orally every day 2. Atenolol 125 mg orally twice a day 3.
Captopril 100 mg orally three times a day 4. Colace 100 mg orally twice a day 5.
Hydralazine 10 mg orally three times a day 6. Maalox 15 milliliters orally every 6
hours as needed indigestion. 7. Nitroglycerin sublingual tablets 1 tab
every 5 minutes x 3 as needed chest pain. 8. Percocet 1-2 tablets orally
every 4-6 hours as needed pain. 9. Axid 150 mg orally twice a day 10. Ticlid
250 mg orally twice a day 11. Amlodipine 10 mg orally every day 12. Imdur 120
mg orally twice a day Condition on discharge , stable. The patient is to
be discharged to the Sollic Fredlaer Rehabilitation Hospital Of where she came from prior
to admission. The telephone number at the Sa Pehall is
102-3619. Patient will be followed up by Dr. Jonathan Agliam and
Dr. Zonia Surette at PRMC in about 2 weeks.
Dictated By: AUDRIE ROESLER , M.D. ZK58
Attending: JONATHAN G. AGLIAM , M.D. ZU77 HC345/4230
Batch: 9581 Index No. GHUXLW3I7Q D: 10/20/98
T: 10/20/98
CC: AHOHI
Document id: 559
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128497124 | PUO | 84843297 | | 602961 | 4/14/1997 12:00:00 a.m. | CONGESTIBE HEART FAILURE | Signed | DIS | Admission Date: 4/14/1997 Report Status: Signed
Discharge Date: 8/8/1997
DISCHARGE DIAGNOSES: 1. SHORTNESS OF BREATH.
2. HYPERTENSION.
3. DIABETES.
4. HISTORY OF MITRAL REGURGITATION.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old female
with a history of long standing
hypertension and diabetes who says that she had been doing well
until approximately one week prior to admission when she was in Days Ty for a wedding and during that time she was unable to follow
her normal strict low salt diet. During that time and since the
time back in Co the patient began having increasing shortness
of breath , dyspnea on exertion and paroxysmal nocturnal dyspnea.
The patient on the night prior to admission was unable to sleep
secondary to shortness of breath and sitting up most of the
evening. She went to see her doctor , Dr. Viray in Clinic the
next morning who found her to be in congestive heart failure and
recommended her to go to I Warho Hospital . While in the
Emergency Room the patient was given Procardia XL 20 mg orally x 1
for a systolic blood pressure greater than 200 , Aspirin , Nitropaste
and intravenous Lasix. The patient had significant response to the intravenous Lasix
with complete resolution of her shortness of breath and was
admitted to the Short Stay Unit for evaluation.
PAST MEDICAL HISTORY: As mentioned above and included a stress
echocardiogram in the past which showed
mitral regurgitation , hypokinesis of the septum and AV block on
exertion with an ejection fraction of about 40%.
MEDICATIONS ON ADMISSION: Cardura , Vasotec and Metoprolol.
SOCIAL HISTORY: Denies any tobacco. Lives with her husband.
PHYSICAL EXAMINATION: Temperature was 98.2 , respirations 14. Her
heart rate was 40 , blood pressure 148/70 ,
saturation 95% on room air. She was a pleasant woman , greek
speaking only and was able to speak in full sentences. Neck was
supple with no carotid bruits. Jugular venous pressure was
approximately 8 cm. Lungs clear to auscultation without any
crackles. Heart was in regular rate and rhythm with a II/VI
systolic murmur radiating out to the apex. Abdomen was soft and
nontender. Extremities were without any edema.
LABORATORY DATA: Her electrocardiogram showed bradycardia at 40
with a left bundle branch pattern and she had 2:1
AV block. Her chest x-ray showed an enlarged heart with pleural
effusions and cephalization which was often shown with congestive
heart failure. Her laboratory data SMA-7 was within normal limits.
Her white count was 3.8. Her Hematocrit was 37.9 , Platelet Count
182. Her CPK was within normal limits as were her coagulations.
HOSPITAL COURSE: The patient was admitted to the Short Stay Unit
for further evaluation and was ruled out with
serial CPK's. She was seen by the Cardiology Group who on further
evaluation of her also felt that even with the resolution of her
congestive heart failure she was ready to go home with adjustment
in her blood pressure medications and felt that with her
bradycardia she would not be able to tolerate her Lopressor. It
was felt that the Lopressor was extremely important in her
anti-ischemic regimen and in discussing with her outpatient
Cardiologist , Dr. Trench , it was felt that a pacemaker placement
would be in her best interest. In that way she could have good
control of her heart rate and maximization of her blood pressure
medications and her increased tolerance of beta blockers. The
patient then underwent pacemaker placement without any difficulty
and it was interrogated the day after placement without any
problem. The patient was doing well with only minimal pain at the
incision site.
DISPOSITION: The patient was discharged in stable condition with
no reportable disease and no adverse drug reactions.
MEDICATIONS ON DISCHARGE: Keflex 250 mg orally four times a day for 5 days;
Norvasc 5 mg orally every day; Hydrochlorothiazide 25 mg orally every day and Vasotec
20 mg orally twice a day FOLLOW-UP CARE: The patient will follow-up with
her Cardiologist , Dr. Dong Trench in one week and will probably have
her blood pressure medications further adjusted at that point.
Dictated By: MYRON VANIER , M.D. CW89
Attending: MYRON VANIER , M.D. RH26 WI858/4193
Batch: 81383 Index No. G2LFY7392L D: 2/19/97
T: 11/16/97
Document id: 560
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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186317516 | PUO | 26391547 | | 255871 | 6/23/1998 12:00:00 a.m. | DEGENERATIVE JOINT DISEASE RT. KNEE | Signed | DIS | Admission Date: 4/18/1998 Report Status: Signed
Discharge Date: 9/22/1998
DIAGNOSIS: END-STAGE OSTEOARTHRITIS , RIGHT KNEE.
HISTORY OF PRESENT ILLNESS: Ms. Legions is a 75-year-old woman who
was scheduled for a right total knee
replacement for end-stage osteoarthritis. The patient has had a
long-standing history of progressive knee pain , which has become
disabling over the last six months. The patient has two units of
autologous blood available for this procedure.
PAST MEDICAL HISTORY: Significant for osteoarthritis , borderline
diabetes mellitus , glucose-6-phosphate
dehydrogenase deficiency , and glaucoma.
PAST SURGICAL HISTORY: Significant for cesarean section times
three. She is also status post dental
extractions.
ALLERGIES: Glucose-6-phosphate dehydrogenase deficiency and
erythromycin.
ADMISSION MEDICATIONS: Timoptic-XE one every hour and every day before noon in each
eye , Indocin 25 mg orally as needed , and Tylenol
as needed
SOCIAL HISTORY: The patient denies smoking currently. She quit
25 years ago. She reports drinking alcohol
occasionally. She is on an American Diabetic Association 1 , 300
calorie low sodium diet. The patient is a widow who resides in
Gitang 1 , Win Ph Rangechu
REVIEW OF SYSTEMS: Significant for glasses , history of glaucoma ,
and early cataracts. She has full dentures on
uppers and partial dentures on the bottom. She is deaf in the
right ear. There are no pulmonary problems. Cardiovascular , the
patient denies coronary artery disease , hypertension , chest pain ,
congestive heart failure , or deep venous thrombosis. The patient
has a history of borderline diabetes mellitus with baseline blood
sugars in the 140s.
PHYSICAL EXAMINATION: Her blood pressure was 140/80. She is 4'10"
tall and 168 lb. In general , she ambulated
with an antalgic gait on the right with a cane. She required
assistance to get onto the examination table. Head , eyes , ears ,
nose , and throat were significant for pupils being equal and
reactive to light with extraocular muscles intact , and normal
pharynx. There was no evidence of carotid bruits. Her lungs were
clear to auscultation bilaterally. Her heart was regular in rate
and rhythm with a normal S1 and S2. There was no murmur. Her
abdomen was protuberant , but nontender with no organomegaly. There
was a well healed midline incision consistent with cesarean
section. There were no focal neurological deficits. Examination
of her extremities revealed bilateral varus with the right greater
than the left. Active range of motion of the right knee was from a
15 degree extension deficit to approximately 70 degrees. There was
palpable crepitus. She had positive medial and lateral joint line
tenderness. The knee appeared stable to valgus and varus stresses.
She had a palpable dorsalis pedis and posterior fullness with no
evidence of ulceration. She was neurovascularly intact. She
received 5 mg of Coumadin preoperatively and was instructed to
discontinue use of Indocin.
HOSPITAL COURSE: The patient was brought to the Operating Room on
2/29/98 where she underwent a right total knee
arthroplasty with a Kinemax system. Estimated blood loss was 300
cc. The tourniquet time was 90 minutes. She received
perioperative antibiotics and was continued on Coumadin in the
postoperative period. Her pain was well controlled with the use of
a PCA pump provided by the anesthesiology department. Her
postoperative course was , for the most part , uncomplicated. She
did have some low grade temperatures with a T max up to 101.8
postoperatively. This seemed to be related mostly to atelectasis.
Her hematocrit was kept greater than 30 with the use of autologous
blood transfusions. On postoperative day two , her white blood cell
count was 13.7 , but had decreased by postoperative day three to 12.
Her electrolytes were well controlled. She was made therapeutic on
Coumadin by postoperative day two with a physical therapy of 16.4 and an INR of
2.0. She worked with the physical therapy department along the
total knee arthroplasty pathway. Her skin dressings were taken
down and the wound was noted to be clean , dry , and intact with no
evidence of erythema or discharge. The patient was felt to be
doing well , although a little bit slow in terms of her physical
therapy. It was felt that she would benefit from a short stay at a
rehabilitation hospital and a consult was placed with the Ganeviewe . The patient was discharged to Teran Skinver Careteher Hospital pending bed
availability on 10/10/98 .
DISCHARGE MEDICATIONS: Colace 100 mg orally twice a day , iron sulfate 300
mg orally three times a day times a total of five days ,
Folate 1 mg orally every day , insulin regular ( human ) sliding scale subcutaneously
four times a day , multivitamin one tab orally every day , Timoptic 0.25% one drop
each eye every day before noon , Coumadin to keep physical therapy/INR between 1.5 and 2.0 ,
Tylenol 650-1 , 000 mg orally every 4 hours as needed , Tylenol no. 3 one to two
tabs orally every 4 hours as needed pain , and Benadryl 25-50 mg orally every bedtime
as needed for sleep.
DISPOSITION: The patient is discharged to a rehabilitation hospital.
DISCHARGE INSTRUCTIONS: She is instructed to continue physical
therapy for increased range of motion of
her right knee. She is further instructed to continue taking
Coumadin for a total of six weeks. She is instructed to follow up
with Dr. Caitlin Rademan as an outpatient in five weeks , to call his
office for an appointment.
Dictated By: CARMELITA FOILES , M.D. BM182
Attending: CAITLIN RADEMAN , M.D. CH.B KQ72 RP481/9914
Batch: 1302 Index No. L1UJONKPU D: 10/10/98
T: 10/10/98
Document id: 561
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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767073610 | PUO | 93027999 | | 0402030 | 3/21/2004 12:00:00 a.m. | malignant hypertension | | DIS | Admission Date: 3/21/2004 Report Status:
Discharge Date: 7/1/2004
****** DISCHARGE ORDERS ******
ANCISO , RAMONA 949-15-43-3
Sanmont A O
Service: CAR
DISCHARGE PATIENT ON: 10/17/04 AT 02:00 PM
CONTINGENT UPON ride home
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAMBLET , BRITTANEY NICKI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
Starting Today January
AQUAPHOR TOPICAL TP every day
Instructions: apply to dry patches on arms , hands
LASIX ( FUROSEMIDE ) 60 MG orally every day Starting Today November
LISINOPRIL 40 MG orally every day HOLD IF: sbp <= 120
Alert overridden: Override added on 9/1/04 by
PETRETTI , SEPTEMBER L. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: wil monitor
SARNA TOPICAL TP every day
Instructions: apply to affected areas of hands , arms.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 120 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
GLIPIZIDE XL 10 MG orally every day before noon Starting Today November
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 150 MG orally every day
Starting Today November Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ATORVASTATIN 80 MG orally every day
Instructions: take 40mg pill daily.
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician , KTDUOO , Dr. Contessa Zebley , 9am 6/2/04 scheduled ,
Dr. Coletta Verry , cardiology , PUO , February , 9.30am 10/19/04 scheduled ,
CHF nurse practitioner , Annabel Verfaille , 14 of April , 9am 7/15/04 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
malignant hypertension , chf exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
malignant hypertension
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) DM ( diabetes mellitus ) medication
non-compliance ( noncompliance ) HTN ( hypertension ) glaucoma ( glaucoma )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
stress mibi -> 6minute stress , lvef 38% , no ischemic response , mod
size , severe perfusion defect inferior/inferolateral walls , moderate
reversibility.
echo -> EF20% , global HK with mild regional variation , enlarged RV with
impaired systolic function , increased LA and RA size , aortic valve with
mild thickening , mild MR , normal TV with mod regurg. PA systolic
pressure 54 mm HG. [Previous EF 58%]
BRIEF RESUME OF HOSPITAL COURSE:
56M p/with decompensated CHF from HTN CM history of cad ( history of mi ) , CHF , HTN , Dm2 ,
CRI , glaucoma , cognitive impairment. Not adherent with medication
regimen for past year. His last medication regimen included Norvasc
10QD , HCTZ 25 every day , lisinopril 20 every day , atenolol 50 every day , micronase 5 every day ,
simvastatin , timoptic drops 0.5 every day. Last MD visit was with his primary care physician
Dr. Contessa Zebley in 2001. Presented to ED with CC:testicular swelling.
Also with several months increased cough , especially at night ,
increased orthopnea , PND , decreased exercise tolerance. + LE swelling.
Eats salty food regularly and also adds salt , has not been taking
medications. No recent fevers/chills/night sweats. No n/v/diarrhea.
No ab pain/urine discoloration/melena/brbpr. No rash. In ED
T95.P113 , BP215/123 , SaO2 98% grossly vol overloaded.
given ASA 325 for ekg changes , lasix 40 intravenous , NTG drip. Diuresed
1400cc. On 12B T97 , BP 190/100 , P88 , RR18 , 96%RA aaox3 ,
pleasant , mmm , jvp tragus , no bruits , pmi lateral/diffuse ,
S1 , S2 , S4 at apex; lungs bibasilar faint rales , ab
distended , nt , no hsmg , +BS. no rebound/guarding.+++scrotal/penile
swelling , 3+edema to thighs. multiple excoriations , eczema of left
hand , fingers. ekg: lvh , sinus , rrr , stdep V1 , 5 , 6. old every intramuscular III.
cxr: cardio , megaly , pulmonary edema.
***Assessment and Hospital Course***
56yo gentleman manifesting the results of non-medical intervention
and the natural progression of hypertensive CM
***CV:1. ischemia: patient has hx of NSTEMI and hx of CAD as manifest
by 99% occlusion of RCA which was not intervened upon in 1991 2/2
collaterals and lesion no suspicious for pattern of MI. While here
ruled out for MI. Echo at time of improved but not optimal
hypertension showed EF decrsd to 20% ( 59% 1998 ) ekg changes c/with strain
pattern , ruled out for mi. asa , lipitor , acei. Stress mibi day prior
to discharge showed improved ef to 38% and a small perfusion defect in
the PDA/OM territory with moderate reversibility. Given
significant improvement with conservative medical mngmnt ,
feel confident that patient does not require pci at this
time. 2.pump: at admission grossly volume overloaded , 2/2 malignant
hypertension and chf. echo showed ef of 20% and global HK. aggressive
diuresis with monitor of renal function/lytes was carried out. During
this admission weight was initially 89kg at day of discharge had been
diuresed to 79kg. Improved dramatically from a clinical
standpoint; also , of note , admitted with BNP 1374 , 701 day prior to
discharge. Feel that this is still not his dry weight
and he will go home on 60 lasix every day orally. His htn responded nicely to
isordil , hydral , captopril and diuresis. Once past the acute stage of
his exacerbation we restarted beta blockade , lisinopril , imdur. Will g
o home on lisinopril 40QD. toprol XL 150 every day , imdur 120 orally every day
**Endo: history of Dm with complete nonadherence. EDglucose 320. Started
lispro while in house and then started glipizide 10 qAM with decent con
trol. HbA1c at day of admission was 11. a.m. cortisol and TSH were
normal and did not suggest Cushing syndrome or thyroid disease. He wil
l need ophthalmology follow up asap.
**Renal: creatinine clearance tolerated aggressive diuresis , 24 hour
urine was collected and showed proteinuria and a cortisol level is sti
ll pending.
. **Proph: colace , senna , lovenox. **Code: full **Dispo: will go home
with VNA for medication teaching , and BP check. Will be followed by
sany ody hospital home chf program , will follow up with Annabel E Verfaille CHF NP at PUO , will follow up with pcp Dr. Contessa Zebley , will also
follow up with cardiology. patient will not return to work for an
additional 7 days to learn his new regimen and adjust to side effects
and a new lifestyle.
ADDITIONAL COMMENTS: for home vna to help with medication instruction , teaching daily weight
technique , monitor BP , please draw chem7 on friday and have results
sent to Dr. Contessa Zebley .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: PETRETTI , SEPTEMBER L. , M.D. ( KV36 ) 10/17/04 @ 12:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 562
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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217462843 | PUO | 02980787 | | 0212899 | 1/9/2005 12:00:00 a.m. | NSTEMI | | DIS | Admission Date: 1/9/2005 Report Status:
Discharge Date: 4/20/2005
****** FINAL DISCHARGE ORDERS ******
MARPLES , FRIEDA 943-88-15-1
Oknorlan S Ades
Service: CAR
DISCHARGE PATIENT ON: 4/4/05 AT 08:00 PM
CONTINGENT UPON 7pm dose of lovenox
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BACHMANN , LASHANDA L. , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA 325 MG orally every day
Override Notice: Override added on 6/12/05 by
HIPKINS , ERMA M. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 393256302 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: needs Previous override information:
Override added on 6/26/05 by EMAYO , KRAIG , M.D.
on order for COUMADIN orally 5 MG every afternoon ( ref # 872568511 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: ok Previous override information:
Override added on 6/26/05 by RAMIL , FELIPA C. , M.D.
on order for COUMADIN orally ( ref # 349136668 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ATENOLOL 100 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 6/20/05 by
HIPKINS , ERMA M. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: needs
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 6/12/05 by
HIPKINS , ERMA M. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: needs
LOVENOX ( ENOXAPARIN ) 90 MG subcutaneously twice a day
Alert overridden: Override added on 4/4/05 by
BUCCHERI , FELICE M. , M.D.
SERIOUS INTERACTION: HEPARIN & ENOXAPARIN SODIUM
Reason for override: aware
FLOVENT ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Override Notice: Override added on 6/12/05 by
HIPKINS , ERMA M. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 393256302 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: needs
Previous override information:
Override added on 6/26/05 by EMAYO , KRAIG , M.D.
on order for COUMADIN orally 5 MG every afternoon ( ref # 872568511 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: ok
Previous override information:
Override added on 6/26/05 by RAMIL , FELIPA C. , M.D.
on order for COUMADIN orally ( ref # 349136668 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Starting Tomorrow May
MAGNESIUM OXIDE ( 241 MG ELEMENTAL MG ) 800 MG orally twice a day
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Hammar within 4 weeks ,
primary care physician in 2 weeks ,
Arrange INR to be drawn on 9/25/05 with f/u INR's to be drawn every
3 days. INR's will be followed by MMC anticoagulation service.
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
acute coronary syndrome
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTEMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF CAD
OPERATIONS AND PROCEDURES:
Catheterization: R dominant , ostial OM1 95% culprit lesion , stented with
2.5x13-mm DES; diffuse OM2 70% lesion stented with 2.5x13-mm DES; and LCX
lesion stented with 3.5x13-mm DES , all stented to 0% with TIMI 3 flow.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
ID/CC: 68 year-old retired social worker with cardiac risk factors of obesity ,
hypertension and possible family history admitted with atrial flutter and
found to have ACS.
HPI: patient is fairly inactive at baseline but over the three days prior to
admission had noted shortness of breath with walking even a few steps.
On night prior to admission , she had severe shortness of breath , unable
to breathe in comfortably even sitting bolt upright; this was accompanied
by substernal chest pressure and profuse diaphoresis. She went to MMC
clinic the following morning reporting the shortness of breath was found
to be in atrial flutter with 2:1 block and 2-3mm lateral ST depressions
in V4-V6. The first EKG in the ED showed new deep , symmetrical T-wave
inversions in V4-V6 , 1-mm concave down ST elevation in lead III and
similar contour in II and aVF although not elevated. First TnI 7.39 ,
MB 21.2. Went to cath lab and found to have active thrombus in the OM
distribution; received drug-eluting stents to OM1 , OM2 , and LCX and
monitored overnight in the CCU with 18 hours of post-procedure
eptifibatide.
Home meds: metoprolol , norvasc , combivent
PEx: On transfer to floor , exam notable for faint bibasilar crackles ,
JVP 14 , S1S2 intermittent gallop , no LE edema.
EKG: atrial flutter with variable block , bifascicular block ( LAFB and
RBBB )
Assessment and Hospital Course:
68 year-old woman with non-ST elevation MI and atrial flutter with variable
block , history of facilitated PCI with 3 stents in OM and LCX distribution.
1 ) CV Ischemia: history of NSTEMI: ASA , clopidogrel , atorvastatin 80 , atenolol
100 , captopril converted to lisinopril. Pump: CHF , with atrial flutter
and ACS the likely precipitants. Initially required O2 to
maintain sat > 90 but gradually titrated to off. Diuresed well with Lasix
80 intravenous twice a day , negative 1 L/day for 3 days and then converted to orally lasix 40.
TTE showed normal LV size , concentric LVH , EF 50% , abnormal septal
motion , mild diffuse HK. Nl RV size/function , mild LAE , mild RAE. No AI ,
mild-mod MR , mild TR. PA 29 + RA. Trace pulmonic regurgitation. Nutrition
was consulted regarding low-fat and low-salt diets , as well as fluid
restriction. Rhythm: Initially rate-controlled on beta-blocker and
diltiazem for goal rate in 60s; she will be discharged on atenolol 100 mg
orally every day. She had several 10-14-beat runs of NSVT , treated with aggressive
lyte replacement particularly in light of long QTc. Initiated heparin and
discharged on coumadin with a lovenox bridge. She was not considered an ICD
candidate based on her EF.
2 ) Endo: MMC chart shows a diagnosis of diabetes. No fingersticks were
elevated this admission; a hemoglobin A1C was 6.2%. Likely to have
glucose intolerance and will benefit from weight loss.
3 ) FEN: Standing Mg oxide for long QTc; she will be discharged on 800 mg orally
twice a day;. <2g NaCl , <2L Fluid restriction.
restricted , Cardiac diet.
4 ) Renal: Because of history of HTN , renal arteries were visualized during
catheterization; study revealed 3 left renal arteries , one of which had a
40% lesion , and 2 right renal arteries. No intervention was done.
patient will be discharged home in good condition and will be followed by the
MMC heart failure service.
ADDITIONAL COMMENTS: Take all medicines as directed. DO NOT MISS A SINGLE DOSE OF PLAVIX. THIS
MEDICINE KEEPS YOUR NEW STENTS OPEN AND IS VITALLY IMPORTANT TO YOUR
HEALTH.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HIPKINS , ERMA M. , M.D. , PH.D. ( SE52 ) 4/4/05 @ 12:45 PM
****** END OF DISCHARGE ORDERS ******
Document id: 563
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108201325 | PUO | 73267138 | | 730254 | 1/11/1998 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 8/29/1998 Report Status: Signed
Discharge Date: 8/2/1998
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old woman
with a history of cardiomyopathy who
presents with two weeks of peripheral swelling , shortness of
breath , dyspnea on exertion , and chest pain with exertion. She has
a history of hypertension. She presented in 1991 with shortness of
breath , substernal chest pain , and three pillow orthopnea. She
ruled out for a myocardial infarction back then and was thought to
be in congestive heart failure secondary to hypertension. An echo ,
at that time , showed a moderately dilated left ventricular ,
moderately concentric left ventricular hypertrophy , abnormal septal
motion , and diffuse severe left ventricular contractive function.
She was also noted to have MR , AI , and TR , at that time. An
exercise tolerance test was done and she went for two to three
minutes with no ECG changes , but with chest pain and underwent
cardiac catheterization. Her coronaries were clear , at that time ,
but the catheterization did reveal restrictive etiology with
equilibria of pressures that separated with Valsalva maneuvers.
The patient was also noted to have a hematocrit of 34 with black
tarry stool , at that time , and there was no work up done. The
patient did well for a few years after that and , in 1997 , she had
an echo which showed an ejection fraction of 55%. The patient did
well again until three to four months ago when she began having
shortness of breath. On 9 of October 1998 , she had swelling in her
feet , dyspnea on exertion after half a block or stairs , and chest
pain on exertion. The chest pain was subxiphoid and is a pressure
like pain. The patient also had palpitations on occasions with the
chest pain. The pain did not radiate. After five to 15 minutes of
rest , the pain would go away. The patient does have three pillow
orthopnea , but no paroxysmal nocturnal dyspnea and no syncope. She
has no fevers , chills , nausea , vomiting , diarrhea , or dysuria.
Last Tuesday , she went running for a bus and had shortness of
breath , chest pain , and diaphoresis. After 15 minutes , she felt
better. She came in for a troponin level of 0.01 , she ruled out.
Her cardiac risk factors are diabetes mellitus , hypertension ,
hypercholesterolemia , history of tobacco , obesity , and family
history with mother who died of a heart attack in her 70s. The
patient has new ECG findings with a left bundle branch block.
PHYSICAL EXAMINATION: On examination , the patient's vital signs
were stable with a temperature of 98 , heart
rate 93 , blood pressure 138/90 , and respiratory rate 20. She was
saturating at 100% on two liters of oxygen. Examination showed 12
cm JVD , positive hepatojugular reflex. Lungs were clear. Heart
was tachycardic with regular rhythm , S1 , S2 , and S3 , as well as a
murmur in the left lower sternal border that was II/VI systolic.
LABORATORY DATA: Chest x-ray on admission showed cardiomegaly with
changes consistent with edema. The patient also
had a hematocrit of 26 on admission.
HOSPITAL COURSE: The patient was started on Lasix and also
received two units of blood. The patient
underwent severe diuresis and also had an echo , which showed an
ejection fraction of 35% , diffuse hypokinesis , dysfunction of the
anteroseptal and anterolateral walls , 4+ MR , and 4+ TR , as well as
50 mmHg right systolic pressures greater than diastolic pressures.
The patient improved with transfusion and diuresis. The patient
was also started on digoxin. On discharge , the patient had follow
up appointments with gynecology and GI , as well as her primary care
doctor and the congestive heart failure service.
DISCHARGE MEDICATIONS: Digoxin 0.25 mg orally every day , iron 300 mg
orally three times a day , Lasix 80 mg orally twice a day ,
glyburide 5 mg orally every day , lisinopril 40 mg orally every day , and
Prazosin 2 mg orally twice a day
Dictated By: LALOR
Attending: CARMON E. BOSHERS , M.D. NF1 HK878/6817
Batch: 21172 Index No. K5IKBO6WUU D: 2/4/98
T: 2/4/98
Document id: 564
| Target |
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| output/system_intuitive_annotation.xml | intuitive |
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905672058 | PUO | 13575018 | | 2019655 | 10/4/2005 12:00:00 a.m. | CHF , cardiac ischemia | | DIS | Admission Date: 1/18/2005 Report Status:
Discharge Date: 8/10/2005
****** FINAL DISCHARGE ORDERS ******
ADSIDE , EMELINA 397-36-35-3
Ant Kan Glechueans
Service: CAR
DISCHARGE PATIENT ON: 3/17/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REISMAN , CATHIE MINDI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day Starting Today March
KETOROLAC ( KETOROLAC TROMETHAMINE ) 1 DROP OS four times a day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual every 5 minutes X 3
as needed Chest Pain HOLD IF: SBP < 100
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
LISINOPRIL 10 MG orally every day
Alert overridden: Override added on 3/17/05 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
LASIX ( FUROSEMIDE ) 20 MG orally every day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
150 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lyn ( cardiologist ) 8/10 2:30 pm scheduled ,
Dr. Dewispelaere 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF , cardiac ischemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF , cardiac ischemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM x30 yrs , HTN , high cholesterol , iron deficiency anemia , rectal CA , history of
TAH/BSO
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
PET-CT
BRIEF RESUME OF HOSPITAL COURSE:
80 year-old F c/ CAD transfer from TH for troponin leak ,
demand ischemia , in setting of anemia , colonoscopy , SOB from CHF over
last month.
-----
PMH: CAD , persantine MIBI CVH showing fixed apical , ant
wall defects , reversible septal defect CHF LVEF 29% , severe global
HK DM
HTN Hypercholesterol
Fe-def Anemia ( undergoing outpt with u ) history of TAH/BSO , rectal CA resection
1993
-----
STATUS: GEN: Pleasant ,
NAD NECK: JVP 10 , no
bruits CHEST: tr crackles at base , o/with
CTA CV: Irreg rhythm , soft s4 at apex , s3 at base ,
II/VI SEM NEURO: MS NL ,
nonfocal
------
EVENTS: 10/19 transfer from TH
------
STUDIES: Persantine MIBI as per HHCH , 4/21 at
NMCO 7/4 PET myocardial viability study: 1. A large region of myocardial
scar in the mid-LAD distribution , without residual stress induced
peri-infarct ischemia. 2. Large regions of viable myocardium in the
distribution of the proximal to mid-LAD , left circumflex and RCA coronary
arteries. 3. Moderate global LV systolic dysfunction.
7/4 PM Echo: 25-30% EF with ant/lat wall hypokinesis and ant/basal septum ,
akinesis of mid-distal ant septum and entire apex. RV fx nl. Mild TR.
CXR - diffuse interstitial markings c/with pulm edema
------
CONSULTS: NONE
------
PROBLEM:
--Ischemia: PET viability scan 7/4 to
assess myocardial viability - scar - no reversible defects; on BB , ACEI ,
ASA
--CHF: Echo 7/4 - EF 25-30% - ant/basal hypokinesis , apex akinetic;
started on low dose lasix 20 mg every day on 10/27 . need to follow up labs with Dr.
Lyn .
--Anemia: Difficult to with u in context of transfusion , colonoscopy when as
outpt , now stable.
--FULL CODE
--Dispo: f/u with Dr. Lyn , primary care physician. Given depressed EF and MI , meets MADIT II
criteria for ICD. However , after consideration , this has been deferred to
out-patient cardiologist.
ADDITIONAL COMMENTS: Please measure weights daily. Please avoid salty/sugary food. Please
follow diabetic , heart failure diet. Please follow up with your primary care physician in
1-2 weeks ( need to call him for appointment ) , and Dr. Lyn on 8/10 at
2:30 pm. Please call your doctor or return to the hospital if you
experience increasing shortness of breath ,
chest/arm/jaw/anginal-equivalent pain , diaphoresis , nausea , vomitting ,
increasing lower extremity edema or any other concern.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. physical therapy at home
2. F/u Dr. Lyn on 8/10 2:30 pm ( check electrolytes and volume status )
3. Cardio/pulmonary eval by VNA
4. patient was started on lasix on 10/27 . Will need to have lytes/creatinine
followed by Dr. Lyn .
No dictated summary
ENTERED BY: STRAHL , ROSAURA A. , M.D. , PH.D. ( WP69 ) 3/17/05 @ 12:27 PM
****** END OF DISCHARGE ORDERS ******
Document id: 565
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425993188 | PUO | 70424113 | | 8991729 | 8/14/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/14/2004 Report Status: Signed
Discharge Date:
ATTENDING: ALETA KERTESZ MD
INDICATION FOR SURGERY:
Coronary artery disease.
HISTORY OF PRESENTING ILLNESS:
The patient is a 55-year-old female with a past medical history
of hypertension and diabetes who presented to the ED with two-day
history of epigastric pain and chest pain radiating to her left
arm. The patient states that she had been having on and off
chest pain since about 6/8 and had been diagnosed previously
with gastritis. She presented to the Meon Wellfor Pipebocock Medical Center in April and
again with complaints of chest pain and epigastric pain. At that
time , she was found to have extreme PDA defect by MIBI. She was
also tested and thought to have H. pylori gastritis which
apparently was causing her chronic chest pain. On the day of
admission , the patient began to have chest pain which was not
relieved by Maalox. She described the pain as peristernal
accompanied by nausea and vomiting and some diaphoresis. It was
relieved in the ED by two sublingual nitroglycerins. She had
negative cardiac enzymes x 2 and was admitted for a workup.
Repeat stress MIBI showed reversible LA and circumflex defects
and an EF of 50%. Cardiac cath revealed three-vessel disease and
the patient is now scheduled for CABG. The patient originally
speaks Creole; however , she can speak and understand English.
PREOPERATIVE CARDIAC STATUS:
The patient has a history of class III angina that has not had
any recently accelerated angina , and there is history of class
III heart failure. She is in normal sinus rhythm right now.
PAST MEDICAL HISTORY:
Hypertension , diabetes insulin dependent with history of obesity
with gastritis , neuropathy , and retinopathy secondary to
diabetes , and received immunization as a child in Gu Ra Ven
PAST SURGICAL HISTORY:
None found.
FAMILY HISTORY:
No family history of coronary artery disease.
SOCIAL HISTORY:
Emigrated from Ma Wood And in 1993 , has full freedom , lives with two
daughters. The patient is an employed housekeeper at an outside
hospital.
ALLERGIES:
Metformin caused GI intolerance.
MEDICATIONS:
Lopressor 25 orally four times a day , captopril 6.25 orally three times a day , aspirin 650
mg every day , Lovenox 100 sq. twice a day , atorvastatin 800 mg orally every day ,
NPH 60 units every day before noon and 20 units every afternoon , and Nexium 20 mg orally
every day
PHYSICAL EXAMINATION:
The patient is 5 feet 1 inch tall , 89 kilos , temperature of 98
degree Fahrenheit , heart rate of 71 per minute , and blood
pressure left arm 112/68. HEENT: PERRLA. Dentition is without
evidence of any infection and no carotid bruits. Chest: No
incision. Cardiovascular: Regular rate and rhythm. Pulses 2+
in carotids , radials , and femorals bilaterally. Dorsalis pedis
1+ bilaterally , posterior tibial nonpalpable but dopplerable on
the left and 1+ on the right. Allen's test of the left upper
extremity was normal. Pulse oximetry use right upper extremity
was normal. Pulse oximetry use right slightly sluggish ; the
patient is right handed. Respiratory: Breath sounds clear
bilaterally. Abdomen: Soft , no incisions , no masses noted.
Rectal: Deferred for now. Extremities: Venous striatus
discoloration bilateral lower extremities. Neuro: Alert and
oriented. No focal deficits , 98% on room air.
LABS ON ADMISSION:
Sodium of 136 , potassium of 4.3 , chloride of 101 , bicarb ??___??
Repeat INR , Echocardiogram showed an EF of 36% with mild mitral
??___?? ST elevation ??____?? Moderate LV function was noted.
HOSPITAL COURSE:
??___?? within normal limits so vascular causes of pain in the
right lower extremity was ruled out and they recommended leg
elevation as part of the treatment so Orthopedics was consulted
to delineate the reason for the excruciating right lower
extremity pain which is still pending.
Cardiovascular: She is on Lopressor and captopril , and the
patient apparently had an inferior wall MI postop. Reason seems
to be poor targets , CPK and MBs were cycled continuously for
three more days in the ICU. The MBs finally started trending
down on day #3 with a peak of 140. The CPKs started trending
down along with the MB as high as 2600 , but on day #5 the CK
started rising again to touch a high level of 5000 which was
being worked up at the time of transfer. Otherwise , she is on
captopril , Lopressor , and doxycycline. Interventional Cardiology
is following her and recommended heparin for a possible
microvascular occlusion in the lower extremities and she was
started on heparin on day #5.
Respiratory: No issues. Extubated expeditiously and she was
weaned from oxygen at the time of transfer.
GI: Taking orally and tolerating it well.
Renal: Had issues with urinary infection before , and she had a
blocked Foley on the day of transfer which was flushed and urine
output was normal after that and she got a new Foley after that
and was noted to have a lot of sediments in the urine at that
time which was sent for UA which is still pending at the time of
transfer.
Endocrine: She is a diabetic and Diabetes Service were on board
and the blood sugars were very well control on the 29 of August and on the
15 of September the blood sugars seemed to be out of control and her
NPH was increased according to the Diabetes Service.
Hematology: She is on aspirin and Plavix for poor targets and
coronary artery disease on 81 mg orally every day and Plavix of 75 orally
every day , and she was transferred with 2 units of PRBCs during this
course of the ICU stay. No active issues at the time of
transfer.
ID: She was started on levofloxacin , and she was also started on
vancomycin for a possible urine infection and that has to be
continued for at least 5 days of levofloxacin for a positive UA.
eScription document: 6-9205149 EMSSten Tel
Dictated By: HOULTON , YEA
Attending: KERTESZ , ALETA
Dictation ID 0156050
D: 10/27/04
T: 10/27/04
Document id: 566
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
U |
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U |
U |
U |
U |
U |
U |
U |
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U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
709261733 | PUO | 68543607 | | 8064709 | 4/18/2005 12:00:00 a.m. | ANEMIA | Signed | DIS | Admission Date: 3/18/2005 Report Status: Signed
Discharge Date: 7/6/2005
ATTENDING: SCOVEL , DULCIE MD
ADMISSION DIAGNOSES: Panhypopituitarism , easy bruising , altered
mental status , and lower extremity edema/rash.
HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old female
with a history of craniopharyngioma , status post resection and
XRT 11 years ago complicated by panhypopituitarism and cognitive
impairment. At baseline , the patient has difficulty staying
fully awake , difficulties with reading and writing , and
short-term memory deficits. She also reports easy bruising and
recent nose bleeds that were treated with packing of the nose.
She has had bruising in the arms and feet for about two weeks.
She also reported dyspnea on exertion for about 10 days with some
lightheadedness with standing , and an increase in her lower
extremity edema.
REVIEW OF SYSTEMS: Otherwise negative. She denied cough ,
fevers , chills , abdominal pain , nausea , vomiting , diarrhea , PND ,
orthopnea , or URI symptoms. Her mental status at this point
appeared to be at baseline.
PAST MEDICAL HISTORY: Craniopharyngioma , status post resection
and XRT.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Ritalin-SR 20 mg orally daily.
2. Levoxyl 274 mcg orally daily. The patient reports that this is
on hold.
3. Aviane ( OCP ) 1 tablet orally daily.
4. Cortef 20 mg orally every day before noon
5. DDAVP 0.2 mg orally every day before noon and 0.4 mg orally every bedtime
6. Multivitamin.
7. Melatonin.
8. CPAP.
9. No Doz as needed
10. Provigil 600 mg orally every day before noon
11. Humatrope 40 units every afternoon The patient reports that this too
was on hold.
SOCIAL HISTORY: The patient denies tobacco and alcohol use. She
is a graduate student who lives with her mother.
Of note , her last MRI was in October 2005 that showed a
partially empty sella , otherwise negative.
PHYSICAL EXAMINATION: Vital Signs: Temperature 96 , pulse 18 ,
blood pressure 110/76 , respiratory rate normal , and O2 saturation
99% on room air. General Appearance: Morbidly obese female ,
sleepy , arousable , in no acute distress. HEENT: Anicteric
sclerae , oropharynx was clear. Pupils were equally round and
reactive. Extraocular movement intact. Neck: Supple. Obese.
Chest: Clear to auscultation bilaterally. CVS: Regular rhythm
and bradycardiac. No murmurs , rubs , or gallops. Abdomen:
Benign. Extremities: No cyanosis or clubbing , 1+ pitting edema
to the ankles with some erythematous skin ( baseline ).
LABS AND DIAGNOSTIC STUDIES:
1. Chem-7: Notable for a creatinine of 0.9 , BUN of 28 , and
bicarbonate of 30.
2. CBC: Notable for white blood count of 2.15 , hematocrit 29 ,
and platelets 64.
3. Coagulations: physical therapy 14 , PTT 56 , and INR 1.1.
4. UA: Showed 1-3 white blood cells with 10-15 casts. UHCG was
negative.
5. EKG: Showed sinus bradycardia at a rate of 52 beats per
minute with first-degree AV and nonspecific ST-T wave changes.
6. Chest x-ray: Showed no infiltrate or effusion.
INITIAL ASSESSMENT AND BRIEF SUMMARY: This is a 27-year-old
female with a history of craniopharyngioma , status post resection
and XRT in 1993 with subsequent panhypopituitarism and chronic
sleepiness. She was admitted to the General Medical Service on
1/1/05 with a two-week history of a.m. confusion , visual changes ,
ataxia , tinnitus , bilateral lower extremity edema , and shortness
of breath. She had also had easy bruising and a severe episode
of epistaxis requiring cauterization. Her blood work was notable
for pancytopenia. She then had swelling of her hands and arms as
well as a rash. MRI in 2/17 showed no change or evidence of
tumor recurrence. The patient , while on the General Medical
Service , had an extensive rheumatologic , neurologic , and
hematologic workup , at which point she underwent both bone marrow
biopsy and unsuccessful LP under intravenous conscious sedation. The
patient became unresponsive and hypothermic about 2 hours after
her bone marrow biopsy and was therefore transferred to the MICU
on 10/6/05 for closer observation. She seemed encephalopathic
during this stay and was started empirically on ampicillin ,
cefoxitin , and acyclovir. She was then sent for a CT-guided
lumbar puncture requiring intubation. She was extubated on
4/18/05 . She was then transferred out to the floor where she
continued to improve. Hospital course in more detail by system
below.
HOSPITAL COURSE:
1. The patient has a history of obstructive sleep apnea and uses
CPAP at home. Her outpatient pulmonologist at the Poguary Medical Center
was contacted who confirmed this. On admission , she had a normal
O2 saturation with a relatively clear chest x-ray. However , she
became hypothermic and unresponsive following her bone marrow
biopsy. She also required intubation for CT-guided lumbar
puncture for airway protection in the setting of her excessive
sedation. She was extubated on 4/18/05 and her oxygen was
quickly weaned off. Since then she has been oxygenating and
ventilating well on room air. CPAP was continued at night. She
has had no other pulmonary complications.
2. CVS. The patient has no history of cardiac disease. An
echocardiogram done on 6/1/05 showed normal LV function with
preserved ejection fraction , no wall motion abnormalities ,
moderate tricuspid regurgitation , and mild mitral regurgitation.
In terms of her rhythm , the patient has a resting bradycardia in
the 30s to 40s that is thought to be secondary to increased vagal
tone and has no hemodynamic consequence. She received atropine
while in the ICU at 1 mg x 1 on two separate occasions; in the
first instance for bradycardia to a heart rate of 19 in the
setting of getting vasoconstrictors for a low blood pressure and
the second time when she had a heart rate down to 30. After the
patient was transferred out to the floor , we did obtain a
dedicated EP Service Cardiology consult , who evaluated the
patient. They confirmed that her bradycardia is most likely due
to vagal tone. She responds appropriately with an increase in
her heart rate with exertion. In this young woman , it was deemed
that a pacemaker would not be an appropriate choice. She did
have 3-4 second pauses on one occasion on the floor but had no
recurrence throughout the rest of her stay. If after discharge
she develops further pauses or a syncopal episode , this issue can
be revisited. While she was in house , we did keep atropine and
Zoll pads at the bedside but did not have to use it once she was
transferred out of the ICU. In terms of ischemia , the patient
had a slightly elevated CK-MB on admission , but she has had a
normal echocardiogram and negative troponin since.
3. Renal. The patient developed acute renal failure during the
early part of her stay thought secondary to acyclovir , which had
been given for presumptive meningitis. Her abdominal ultrasound
was negative and urine eosinophils were also negative. Her
creatinine improved with appropriate hydration and was normal at
the time of discharge ( creatinine equal to 1.0 ).
4. The patient does have a history of hypernatremia. Initially ,
her home DDAVP was held for fear that it would be difficult to
diurese her if she became volume overloaded given her somewhat
elevated creatinine. However , her sodium continued to increase
to 155 despite getting free water repletion , so her DDAVP was
restarted on 10/5/05 . She was discharged on her home dose of
DDAVP of 0.2 mg orally every day before noon and 0.4 mg orally every afternoon with one nasal
spray every bedtime Her sodium at the time of discharge was 145. She
has been followed by the Endocrine Service in house for this.
They have recommended that she not increase her home dose ,
instead she will aggressively increase her orally water intake in
order to maintain her normal sodium. She will follow up in two
weeks with Dr. Firestein of Endocrine who will recheck her
electrolytes at that time.
5. Derm/Rheumatology. The patient was evaluated by both of
these services during her stay. She had biopsies done of several
locations that showed nonspecific pathology consistent with mixed
connective tissue disease. However , her serologies have , for the
most part , been negative. She was treated presumptively with
stress-dose and eventually pulse steroids. These were tapered
towards her stay. She will be discharged on a quick taper of
hydrocortisone 20 mg orally twice a day for two days , after which she
will revert to her home dose of 20 mg orally every day before noon and 10 mg orally
every afternoon
6. Endocrine. The patient has panhypopituitarism and was
followed by the Endocrine Service throughout her stay. In terms
of her thyroid function , the patient was continued on her home
dose of Levoxyl. It was difficult to interpret her TSH in the
setting of panhypopituitarism; therefore we followed her T4 , T3 ,
and free T4 levels. These were rechecked towards the end of her
stay once she had recovered from her acute illness and in light
of a slightly decreased free T4 level , her Levoxyl was increased
to 275 mcg orally daily at the time of discharge.
7. Diabetes insipidus. The patient's hypernatremia was
corrected with D5 water and increasing her orally fluid intake.
She was also put back on her home dose of DDAVP.
8. Growth hormone. There was no indication for growth hormone
replacement.
9. Adrenal insufficiency. The patient completed a course of
stress dose steroids for her procedures and then got pulse
steroids per wound for a question of lupus versus mixed
connective tissue disorder. However , this was tapered over her
stay and she will be discharged on a very brief taper. She will
go back to her home regimen of hydrocortisone.
10. Gonadotropins. The patient was continued on Aviane ( OCP )
during her stay.
11. Neurologic. The patient had no clear etiology for her
hypersomnolence. She was followed by the Neurologic Service in
house. She does not appear to be hypercarbic or hypoxic. Her
infectious workup was entirely negative and she was therefore
taken off antibiotics. Her EEG showed nonspecific diffuse
slowing with no seizure foci. The default diagnosis has been
that some of her symptoms , including her altered mental status ,
lower extremity edema , rash , and perhaps even pancytopenia , may
be secondary to Provigil. This was therefore discontinued and
she should not start this once she returns home. Initially , her
stimulants were held for fear that they were contributing to her
pancytopenia. However , her Ritalin was restarted once her counts
started to recover. She was discharged on Ritalin-SR 20 mg orally
twice a day Her mental status seemed to improve on this regimen. At
the time of discharge , she was awake , alert , able to converse
well , and at her baseline.
12. Hematologic. The patient presented with pancytopenia , again
of unclear etiology. Bone marrow biopsy was negative for
leukemia , lymphoma , and myelodysplasia. Rather , it was
consistent with a viral effect or drug effect. Her counts had
resolved by the time of discharge with a white blood count equal
to 9.26 , hematocrit of 27.6 , and platelets of 266. This too may
have been due to Provigil effect.
13. Prophylaxis. The patient was maintained on Pepcid for GI
prophylaxis and heparin for DVT prophylaxis.
14. Code. Full.
15. ID. The patient had multiple blood , urine cultures , and CSF
cultures sent. These were all negative. Of note , stool culture
was positive for C. difficile. She was therefore started on orally
Flagyl 500 mg orally three times a day on 9/20/05 . She will complete a 14-day
course of this antibiotic.
DISPOSITION: Home with VNA services.
CONDITION ON DISCHARGE: Satisfactory.
COMPLICATIONS DURING THIS HOSPITAL STAY: None.
TO DO/FOLLOWUP PLAN:
1. The patient should follow up with her primary care physician in 1-2 weeks.
2. The patient should follow up with Dr. Firestein in the Endocrine
Department in 2-4 weeks. She can be reached at 250-895-0491.
3. The patient should aggressively increase her orally water
intake in order to keep her sodium within normal limits.
4. The patient should call her doctor if she has any changes in
her mental status or if she develops nausea , vomiting , abdominal
pain , rash , shortness of breath , lightheadedness , or any other
worrisome symptoms.
5. Of note , the patient's biopsy sutures on her left abdomen and
right forearm were removed on the day of discharge. These areas
appear to have healed well. Her central line was also removed on
3/9/05 without complications.
DISCHARGE MEDICATIONS:
1. Pepcid 20 mg orally twice a day
2. Hydrocortisone 20 mg orally twice a day x 4 doses starting in the
a.m. of 9/10/05 .
3. Hydrocortisone 20 mg orally every day before noon and 10 mg orally every afternoon
starting on 1/12/05 ( p.m. dose to be given at 4 p.m. )
4. Levoxyl 275 mcg orally daily.
5. Flagyl 500 mg orally three times a day x 13 days.
6. Multivitamin 1 tablet orally daily.
7. DDAVP 0.2 mg orally every day before noon and 0.4 mg orally every afternoon
8. DDAVP nasal spray , 1 spray every bedtime
9. Ritalin-SR 20 mg orally twice a day
10. Aviane 1 tablet orally daily.
11. Miconazole nitrate 2% topical powder applied to affected
areas twice a day
eScription document: 0-8974400 IS
Dictated By: CHAIX , TRISH
Attending: SCOVEL , DULCIE
Dictation ID 1753860
D: 3/1/05
T: 9/13/05
Document id: 567
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
N |
472510821 | PUO | 58706198 | | 1442574 | 8/23/2005 12:00:00 a.m. | volume overload | | DIS | Admission Date: 6/20/2005 Report Status:
Discharge Date: 5/10/2005
****** DISCHARGE ORDERS ******
HUERTES , ANNAMARIE DAMARIS 210-49-59-4
Saca Blvd.
Service: RNM
DISCHARGE PATIENT ON: 6/12/05 AT 05:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BUSSLER , FRAN , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
PHOSLO ( CALCIUM ACETATE ) 667 MG orally three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
GLIPIZIDE 10 MG orally every day before noon and Q5PM
HEPARIN 5 , 000 UNITS subcutaneously three times a day
LISINOPRIL 10 MG orally every day HOLD IF: sbp<100 and call ho
REGLAN ( METOCLOPRAMIDE HCL ) 5 MG orally every 6 hours
OXYCODONE 2.5-5 MG orally every 6 hours as needed Pain
Instructions: Given lower dose first with Tylenol. Try
remaining 2.5mg if no relief.
SENNA TABLETS 2 TAB orally twice a day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
HOLD IF: sbp<100 , heart rate<55 and call
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
HOLD IF: sbp<100 and call ho
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 11/19/05 by LALATA , JOHNETTA B JOLYN , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware.
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
CELEXA ( CITALOPRAM ) 10 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 6/12/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: MDA
DIET: Fluid restriction: 1500cc
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Mordhorst Please call for appointment after discharge from rehabilitation. ,
ALLERGY: intravenous Contrast , METHYLDOPA , Penicillins , PRAZOSIN
ADMIT DIAGNOSIS:
volume overload; CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
volume overload
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM history of RLE DVT ( calf ) HTN ABDOMINAL PAIN EXT HEMORRHOIDS MS CHEST
PAIN cad ( coronary artery disease ) history of CABG ( history of cardiac bypass graft
surgery ) history of appy ( history of appendectomy ) history of ccy ( history of
cholecystectomy ) ESRD on HD ( end stage renal disease ) Afib with RVR
( atrial fibrillation ) hyperchol ( elevated
cholesterol ) chf ( congestive heart failure ) vitiligo
( vitiligo ) obesity ( obesity ) history of MRSA pneumonia ( history of pneumonia )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
72 year old woman with history of CAD history of CABG , CHF , DM , ESRD x 5
yrs admitted for 1 month worsening n/v/d/abd pain and increasing
weakness. Patient history of 2 admissions in past month for mild CHF as well as
n/v/d. Had negative stool studies and negative Abd CT as well
as EGD 7/7 which was negative except for chemical gastritis. D/C
home on 1/7 and represented with CP ( pleuritic ) and SOB. Sx came on
in 1 hour. ROS: No CP SOB , fever , chills , hematochezia ,
melena , hematemasis , coffegrounds.
PMH: ESRD x 5 yrs , CAD history of 3v CABG ,
CHF EF 40% , HTN , Hyperchol , PAF with RVR , history of MRSA pna ,
depression , history of CCY , history of DVT 10/10 . ALL: intravenous contrast , PCN ,
prazosin
SocHx: from Do
IN ED: T95.8 P90 160/100 RR16 98%RA. cardiac enzymes , elvated BNP ,
D-Dimer 648. EXAM: PERRL , OP MMM , L carotid Bruit; RRR s1s2 no R/R/M;
bibasilar crackles 1/2 way up; abd soft with diffuse tenderness , +BS; ext
WWP , no edema; neuro intact
LABS: wbc 17.06; hct 33.5 , CE's negative x 1 , LFT's wnl; D-Dimer 648; BNP
3900; INR 1.2 CXR: no acute cardiopulm process
EKG: no significant changes , long QTc at baseline
IMP: 72 year old woman with MMP , depression/FTT , presents with
pleuritic chest pain and increase WBC.
FEN/RENAL: HD TuThSat , continued current regimen of HD. Renal will plan
to remove more volume at HD in future given representation with volume
overload. Electrolytes were followed and repleted as needed. Kept strict
I/O's and patient restricted to 1500cc. Continued diabetic/cardiac diet.
Patient did require single dose torsemide on non-dialysis day.
GI: ? gastorparesis , on decreased reglan per prior admission and patient
doing well from abdominal pain standpoint. Still consider gastric
emptying study outpatient. Stool studies negative. Outpatient
colonoscopy for history of guaiac positive stools. I have spoke with primary care physician.
Stable LFTs.
CV: ( i ) Continued current regimen. Low prob ACS with this readmission.
She was ruled out for MI. ( p ) fluid up , patient needs more fluid off in
HD and will have goal weight adjusted per renal. Did require single
dose torsemide as patient does make some urine and had symptomatic
relief. ( r ) Run of aberrant conduction on telemetry self resolving.
Followed on telemetry and patient ruled out for MI. No other events
noted and patient asymptomatic at time of telemetry event.
PULM: Due to contrast allergy V/Q scan done to rule out PE given
pleuritic nature of pain and increased WBC with SOB. V/Q scan read as low
probability per Dr. Ramonez . Pain resolved after dialysis and removal of
excess volume.
ENDO: Continued glipizide and novolog. Glipizide changed to Q5PM given
early morning hypoglycemia. Patient in the future may require NPH insulin
for tighter glucose control.
PPX: heparin , PPI
Code: FULL
Neuro/Psych/Social: I have spoken with Laverriere , social worker who
knows the patient and family from multiple admissions. Psychiatry has
seen the patient in the past per her and felt there was some overlying
secondary gain from hospitalizations given her depression. The patient
had declined medication for depression in the past but on last admission
clexa was started. This medication will need to be increased after
discharge. It was felt that the patient would benefit from rehab per physical therapy
and that this would give time for her home situation to improve. Patient
lives on top floor and has difficulty leaving. She is in for alternative
housing.
Dispo: Placement in rehab as FTT at home and requires rehabilitation as
physical therapy finds her below functional capacity.
ADDITIONAL COMMENTS: 1. Please return to the hospital with any urgent concerns such as
shortness of breath , chest pain , or other symptoms that concern you.
2. Take your medications as instructed.
3. Please call your primary care physician for follow up appointment at the time of
discharge from rehabilitation.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Return to hospital with any urgent concerns , otherwise seek the care
of you primary care physician.
2. You will need to follow up with your primary care physician for increasing in Celexa.
3. Call you primary care physician for follow up appointment and to schedule outpatient
colonoscopy.
No dictated summary
ENTERED BY: STAYNER , FALLON I. , M.D. ( HJ57 ) 6/12/05 @ 03:02 PM
****** END OF DISCHARGE ORDERS ******
Document id: 568
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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472510821 | PUO | 58706198 | | 2756623 | 11/18/2004 12:00:00 a.m. | FEVER , END STAGE RENAL DISEASE | Signed | DIS | Admission Date: 10/1/2004 Report Status: Signed
Discharge Date: 7/10/2004
ATTENDING: ISAAC BOOKER VAUSE M.D.
ADMISSION DIAGNOSIS:
Bronchitis and volume overload.
PRINCIPAL DISCHARGE DIAGNOSES:
1. End-stage renal disease.
2. Diabetes.
3. Bronchitis.
4. Hypertension.
HISTORY OF PRESENT ILLNESS:
Ms. Huertes is a 71-year-old woman with end-stage renal disease
who presents after being discharged from two recent admission to
Pagham University Of 24 hours after she went to
rehabilitation with fevers , diffuse body pains , and hypertension.
She was admitted from 8/1/2003 to 11/12/2004 for volume
overload treated to the hemodialysis as well as antibiotics ,
vancomycin , gentamicin , and azithromycin for pneumonia. From the
1/27/2004 through 10/4/2004 she was readmitted and presented
with increased lipase , right upper quadrant pain , shortness of
breath , nausea , and decreased orally intake. She was dialyzed and
the lipase was felt to be elevated from poor renal clearance. An
MRI was obtained at that time , which revealed no acute
abnormalities. Transesophageal echocardiogram was also obtained
at that time because of the prior positive blood culture and it
was negative for vegetation or severe valve disease. A chest CT
during this previous admission showed a resolved right pleural
effusion and some improved interstitial pulmonary edema.
On the day prior to admission , she woke up sick and tired at
rehab. She developed a nonproductive cough and some mild
pleuritic chest pain. In addition , she experienced some right
upper and right lower quadrant pain , which she had also had
during her most recent hospitalization. At Ahohi , her heart rate was 94 , blood pressure 183/81 , and
she was 94% on 2 liters of nasal cannula. She was febrile to
102.5 and was experiencing chills. She was brought into the
emergency department where she was found to have blood pressure
of 134/67. She received 2 mg of morphine approximately a liter
of normal saline and some Tylenol. A CT scan of her abdomen
revealed a fibroid uterus and left kidney cystic lesion.
PHYSICAL EXAMINATION:
Her admission physical examination was significant for
temperature of 100.2 , blood pressure of 102/53 , and saturating
98% on 2 liters. The patient was mildly anxious. She was
normocephalic and atraumatic and had surgical pupils bilaterally.
Her neck was supple and her jugular venous pressure was 8 cm.
She had decreased breath sounds throughout and had fine scattered
rales throughout her lung fields. Heart was regular rate and
rhythm with normal S1 and S2 with a 2/6 systolic ejection murmur
at the right upper sternal border without any radiation. Her
abdomen was obese , soft , nontender , and nondistended with good
bowel sounds. Her extremities revealed no clubbing , cyanosis , or
edema. She did have a right arm fistula for hemodialysis with a
good thrill. Neurologically , she was alert and oriented x3
and had a steady gait with a walker.
LABORATORY DATA:
Her admission laboratory data was significant for a uremia
related to her end-stage renal disease , normal LFTs , cardiac
enzymes less than assay , and a white count of 17.2 up from 9.2
just two days earlier. Her hematocrit is at baseline of 30.1.
Her UA revealed 2 to 4 white cells , 1+ bacteria , and 8 to 10
hyaline casts. Chest x-ray revealed cardiomegaly with no
effusions and some mildly prominent pulmonary vasculature. EKG
revealed normal sinus rhythm and T-wave inversions at 5 and 6 as
well as 1 and AVR , which are old.
HOSPITAL COURSE:
1. Renal: Ms. Huertes was maintained on hemodialysis Tuesday ,
Thursday , and Saturdays while in hospital and was followed by the
renal service daily. She was maintained on PhosLo calcium
carbonate and Nephrocaps for optimum mineral balance while on
dialysis. Her right arm fistula had a good thrill throughout.
On her very first day of admission , she became hypertensive
during dialysis , but had a normal blood pressure again after
receiving back the ultrafiltration fluid that had been taken off.
Also of note during her hospital stay , given her fevers and
unrevealing infectious workup , an MRI was completed with a renal
protocol to evaluate this left renal cyst. The cyst was
complicated and appeared to have septations. However , it did not
enhance and upon review with the radiologist it was deemed very
unlikely that this cyst would represent a renal cell carcinoma.
However , her UA did have 1 to 2+ positive blood on repeat in the
hospital without a Foley. At the time of discharge her urine
cytology was pending at the time of discharge.
2. Infectious disease: Given the fact that Ms. Huertes presented
with intermittent fevers all the way up to 102 , some mild
hypertension associated with dialysis , and previous positive
blood cultures , an infectious disease consult was called. After
extensive infectious disease workup including blood cultures ,
urine cultures , abdomen CTs , as well as induced sputum , no source
for infection was revealed. However , it was felt that Ms. Huertes
may have had a viral upper respiratory tract infection and/or
bronchitis which was not treated. She received a single dose of
vancomycin and gentamicin upon admission for her hypertension and
fever , but received no further antibiotics during her hospital
stay. She was afebrile during the last seven days and had a
stable white count and no left shift. Workup
for infectious disease included an HIV test , which was negative.
She was PPD negative. Her induced sputum was negative for
fungus , mycoplasma , and primary care physician. Her abdominal CT revealed no
obvious abscess and urine analysis was negative. Blood cultures
x2 as well as cultures from previous admissions were held for
fungal and hacek organisms , all of which were negative.
3. Pulmonary: Ms. Huertes 's only stable complaint from her
previous hospital stays has been mild dyspnea. She experienced
dyspnea on exertion after walking 10 to 15 feet. A chest CT from
her last admission revealed no interstitial lung disease , no
significant pulmonary edema , and no infiltrative disease. She
had a set of PSP on 3/11/2003 , which revealed a restrictive
physiology , but may not have had sufficient effort. The
pulmonary consult was called. Of note , the patient had an
echocardiogram from 9/1 , which revealed a pulmonary artery
systolic pressure of 59. It was felt that this may have been
spurious as the previous echocardiogram revealed aortic pressure
in the 30s. She received a repeat an transthoracic
echocardiogram which showed a pulmonary artery systolic pressure
of 36% in right atrium. This is her baseline pressure. The
previous pressure was probably artificially elevated because of
volume overload. This means that it is unlikely that pulmonary
hypertension is causing her shortness of breath. Overnight pulse
oximetry revealed no desaturations and there is a very low
probability of sleep apnea despite habitus and a low probability
based on her history. She does not report any daytime
somnolence. It is possible that outpatient pulmonary function
test and sleep studies will be considered if this dyspnea
continues. There was no need for a right heart catheterization
nor was there any need to pursue further imaging to think about
chronic thromboembolic pulmonary hypertension. By the time she
was discharged and working with physical therapy regularly , Ms. Huertes 's
dyspnea was significantly improved. It is still unclear why she
was no dyspneic and may be a combination of deconditioning ,
repeated hospitalizations , and will be improved with
rehabilitation.
4. Cardiovascular: Ms. Huertes is exhibiting no signs or
ischemia. Her EKG showed chronic lateral T-wave inversions. Her
cardiac enzymes were negative. She was maintained on the baby
aspirin as well as beta-blocker throughout her hospital stay.
Ms. Huertes did have a transthoracic echocardiogram which revealed
an estimated ejection fraction of 45 to 50% , some mid septal and
lateral hypokinesis which was old , some mildly thickened aortic
valve with no aortic insufficiency , mildly thickened mitral valve
with mild mitral regurgitation. Her tricuspid valve revealed
there as mild TR and a tricuspid jet of 3 meters per second ,
which was translated into a pulmonary artery systolic pressure of
36 mmHg right atrial pressure. Also , of note she had biatrial
enlargement and normal right ventricle size and function. After
the initial episode of hypertension and hemodialysis , Ms. Huertes
was normotensive throughout the remainder of her hospital stay
and was discharged on a beta-blocker as well as ACE inhibitor.
5. FEN/GI: Ms. Huertes 's abdominal pain resolved on day two of
hospitalization and given a negative CT , normal movements , and no
further abdominal pain , nausea , or vomiting , it was felt that
this may have been related to either due to either viral
gastroenteritis or irritable bowel syndrome. The patient was
maintained on proton pump inhibition and while inhouse had a low
sodium diabetic diet with 1800 calories as well as low potassium
for her renal care.
6. Disposition: Physical therapy consulted early in Ms.
Bartleson hospital stay and agreed that she would benefit from
subacute rehabilitation to get her strength back after these
multiple hospitalizations. She was given a walker and could walk
with assistance on a rolling walker. Unfortunately , her home has
stairs and is ill equipped for such a transition from walker to
home so she will benefit from rehabilitation. Ms. Huertes was
discharged in stable condition and will follow up with her
primary care doctor Dr. Knecht at KTDUOO Clinic.
ALLERGIES:
1. intravenous contrast dye.
2. Penicillins.
3. Methyldopa.
4. Prazosin.
5. Micronase.
6. Dyazide.
7. Enalapril.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally every day
2. PhosLo 1334 mg orally three times a day
3. Colace 100 mg orally twice a day
4. Glipizide 5 mg orally every day
5. Lisinopril 10 mg orally every day
7. Senna 2 tablets orally twice a day
8. Simvastatin 40 mg orally every bedtime
9. Tessalon Perles 100 mg orally three times a day as needed cough.
10. Nephrocaps 1 tablet orally every day
11. Calcium carbonate 1000 mg orally every bedtime
12. Nexium 40 mg orally every day
13. Toprol XL 50 mg orally every day , hold if systolic blood pressure
less than 100 or heart rate less than 55. Also hold on the
mornings of dialysis until after dialysis.
FOLLOW UP:
Ms. Huertes with follow up with Dr. Martine Knecht at Kernan To Dautedi University Of Of and that can be reached at
338-823-2634.
She will resume dialysis at the P Therford Hospital under the care of Dr. Tabatha Hollway .
eScription document: 1-9130066 EMSSten Tel
Dictated By: FIGURA , CAREY
Attending: WERNER REGINIA CASEBIER , M.D. YQ0
Dictation ID 0794412
D: 1/9/04
T: 1/9/04
Document id: 569
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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098812026 | PUO | 57870793 | | 778036 | 10/22/2002 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 1/21/2002 Report Status:
Discharge Date: 10/24/2002
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Hendba , Missouri 13056
Service: MED
DISCHARGE PATIENT ON: 9/5/02 AT 03:30 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GASIOROWSKI , ZACHARIAH BRITTNI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL #3 ( ACETAMINOPHEN W/CODEINE 30MG )
1-2 TAB orally Q4-6H as needed pain
ATENOLOL 100 MG orally every day
PREMARIN ( CONJUGATED ESTROGENS ) 1.25 MG orally every day
PROZAC ( FLUOXETINE HCL ) 20 MG orally four times a day
Override Notice: Override added on 2/17/02 by THRONEBURG , FLORETTA M C. on order for HCTZ orally ( ref # 97260836 )
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
HYDROCHLOROTHIAZIDE Reason for override: Aware
Previous override information:
Override added on 2/17/02 by THRONEBURG , FLORETTA M.
on order for LASIX intravenous ( ref # 91768797 )
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
FUROSEMIDE , INJ Reason for override: Aware
HCTZ ( HYDROCHLOROTHIAZIDE ) 12.5 MG orally every day
Alert overridden: Override added on 2/17/02 by
THRONEBURG , FLORETTA M.
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
HYDROCHLOROTHIAZIDE Reason for override: Aware
LISINOPRIL 40 MG orally every day
Alert overridden: Override added on 12/10/02 by
THRONEBURG , FLORETTA M.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: Aware
AMLODIPINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEURONTIN ( GABAPENTIN ) 800 MG orally four times a day
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 3
CELEBREX ( CELECOXIB ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 12/10/02 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to NSAID'S
POSSIBLE ALLERGY ( OR SENSITIVITY ) to NSAID'S
DEFINITE ALLERGY ( OR SENSITIVITY ) to NSAID'S
Reason for override: patient Takes regularly
LASIX ( FUROSEMIDE ) 40 MG every day before noon; 20 MG every afternoon orally every day 40 MG every day before noon
20 MG every afternoon Starting Today July
Alert overridden: Override added on 12/10/02 by :
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
FUROSEMIDE Reason for override: patient takes regulary; Aware
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
ALBUTEROL INHALER 2 PUFF inhaled four times a day
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG NEB four times a day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
OSCAL 500 + D ( CALCIUM CARB + D ( 500MG ELEM C... )
1 TAB orally four times a day
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Gasiorowski 9/21/02 scheduled ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) restrictive lung disease ( restrictive pulmonary
disease ) chf ( congestive heart failure ) fibromyalgia
( fibromyalgia ) von willebrand's ( hemophilia ) sleep apnea ( sleep
apnea ) iron deficiency anemia ( iron deficiency anemia ) hypoxia
( hypoxia ) GERD , history of TAH/BSO , PICA. ? central hypoventilation syndrome.
OA.
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
44 year-old f with complex medical hx including CHF secondary to diastolic
dysfucnction and Obstructive sleep apnea/RLD of obesity and von
Willibrand's Disease presented to Stowna Medical Center with worsening
SOB and pedal edema and increased O2 requirement to 8L last night from
baseline 4L requirement. She denies F/C/N/V but reports increased
yellow sputum production for the last 1-2 mo. patient denies any dietary
indescretion. She has a history of noncompliance with her medications
but reports taking them faithfully for the last month--she brought all
of her medications ( several bottles empty , several unopened ). She
reports palpitations but reports that she has had this for a lon time
and associates it with her anemia. She also reports CP traveling under
L. breast with coughing , deep inspiration.
PMH:( 1 ) Obesity ( 2 )Obstructive Sleep Apena ( 3 ) Central
Hypoventilation ( 4 )Restrictive lung dz. secondary to obesity , OSA ( 5 )
Fybromylgia/ pain syndrome ( 6 )von Willibrand dz. ( 7 )Stress Incontinence
( 8 ) GERD ( 9 ) PICA
A&P: 44 year-old f with MMP and multiple admissions in the past for volume
overload presents with likely CHF flare ( likely secondary to medical
noncompliance ).
1. CV-CHF-JVP 9-10 on admission with CXR demonstrating vascular
congestion , 8L O2 requirement; Patient was aggressively diuresed with
Lasix with O2 requirement returning to 4L baseline. Ischemia -- patient
without history of MI/high cholesterol/DM. +smoking with 15 packyr smoking. Lipid
panel sent and pending on discharge. Dobutamine MIBI completed
showing moderate size anterior septal wall defect consistent with a
diagonal lesion. Due to the patient's size , this was a technically
very limited study and these results could only be stated with medium
probability. patient unable to start ASA B/C of vWD but is already
medically managed with atenolol and lisinopril. Will need outpatient
follow up. HTN -- controlled on outpatient regimen of ATenolol 100
mg every day , Lisinopril 40 mg every day , Amlodipine 10 mg every day with SBP 120-150.
2. Heme - vWD. history of iron deficiency. Not anemic on this admission.
3. Pulmonary -- Patient respiratory status improved with diuresis with
admission 8L O2 requirement weaned to 3-4L with O2 91-92 which is her
baseline4.
4. I/D -- afebrile throughout stay; U/A negative; no evidence of pul
monary infection
5. Endocrine - TSH checked as possible CHF stimulus; pending at time
of discharge.
6. Psych consult attained. patient with traumatic youth and evidence of
dependant personality. Thought to have insight into medical condition
but lack of faith in medications. Poor compliance is by choice. May
benefit from outpatient social work/psychology follow up as outpatient
as is somewhat resistant to psychiatry. Re. belief that cannot touch
metal without pain and question of delusions , patient not thought to be
delusio nal or psychotic.
7. Patient discharged to home with VNA visits twice weekly and
transportation arrainged for future office visits.
ADDITIONAL COMMENTS: Please take oll of your previously prescribed medications. Only your
lasix has bee changed: please take 40 mg in the morning and 20 mg in
the evening. Please call this week for follow-up appointment to see
your primary care physician , Dr. Gasiorowski , in 3 weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
For VNA: Please emphasize med compliance ( has been chronically
noncompliant ). Also , focus on cardiopulmonary assess , volume status.
Please draw electrolytes at first visit next week and inform Dr.
Gasiorowski of results.
No dictated summary
ENTERED BY: SPILLETT , SILVA A. , M.D. ( ZN585 ) 9/5/02 @ 01:07 PM
****** END OF DISCHARGE ORDERS ******
Document id: 570
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
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HTN |
HTG |
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Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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474838388 | PUO | 91766942 | | 6700039 | 4/10/2007 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/6/2007 Report Status: Signed
Discharge Date:
ATTENDING: OGDEN , LATORIA M.D.
REASON FOR ADMISSION: Ms. Vissman was a transfer from Put Wathern Hospital for further management of severe hypertension.
HISTORY OF PRESENT ILLNESS: Ms. Vissman is a 72-year-old woman
with a history of diabetes , hypertension , hyperlipidemia ,
peripheral vascular disease , carotid stenosis status post
bilateral carotid endarterectomies in 1996 , chronic kidney
disease , and renal artery stenosis , with a history of multiple
strokes in the past and recent admission to Totin Hospital And Clinic
in October for evaluation of multiple embolic strokes after
presenting with weakness. She had an extensive evaluation at
that time given her history of multiple strokes including: Echo
with bubble study ( negative for PFO or intraventricular clot ) , EF
60-65% , no transesophageal echo was done at that time , CRP and
ESR were elevated , and she has been worked up for vasculitis in
the past , which had been nonrevealing. She was started on niacin
given her elevated lipoprotein A. There was no clear
etiology found for her multiple CVAs. She was discharged to
rehab on 9/18/07 where she had been able to ambulate with a
walker.
On 3/3/07 , Physical Therapy came to the patient's bedside at
rehab and found her unresponsive. Blood pressure was found to be
elevated at 210/120. Clonidine 0.2 mg and Lopressor 25 mg were
given and her blood pressure remained elevated at 200/100. She
was transferred to the Emergency Department at Put Wathern Hospital .
At that time , she denied any lightheadedness , chest pain ,
palpitations or shortness of breath prior to this episode and she
did not remember the episode. No focal weakness or changes in
sensation , no vision changes.
On review of systems , she denied any fevers or chills ,
diaphoresis , recent URI , nausea , vomiting or diarrhea , abdominal
pain or dysuria. Head CT at outside hospital reportedly revealed
an old left PCA distribution infarct. Brain MRI revealed tiny
foci of restricted diffusion in the high left frontal region ,
which was thought could indicate a small acute embolic infarct.
Extensive periventricular white matter changes and an old left
PCA infarct were seen. There was no hemorrhage. MRA was normal.
Neck MRI 8/29/07 without contrast revealed moderate focal
stenosis in the proximal left ICA , question small thrombus within
the proximal right ICA. Cardiology , Neurology , Renal and
Vascular Surgery consultations were obtained at the outside
hospital. She had severe hypertension during her admission
there , which was difficult to control and headache that was
treated with Tylenol , Motrin , and morphine intravenous. Systolic blood
pressures ranged between 117 and 220. Her medications were
adjusted and during that admission , she was started on topical
nitroglycerin , Lopressor , minoxidil and Norvasc. She was
transferred to Pagham University Of for further
evaluation given that most of her recent prior medical care had
been here.
PAST MEDICAL HISTORY:
1. History of stroke.
2. Hypertension ,
3. Diabetes.
4. Hyperlipidemia:
5. Peripheral vascular disease including carotid stenosis status
post carotid endarterectomy in 1996. She had a fem-fem bypass in
1994 and an ax-fem bypass in 2005. She has renal artery
stenosis and had a left renal artery stent placed in 8/4 .
6. Chronic kidney disease.
7. Question of dementia.
8. Hypothyroidism.
9. Recent smoking history , quit in 10/6 .
10. Left adrenal adenoma.
11. Pulmonary adenoma.
12. Osteoporosis.
13. Depression.
14. History of breast cancer in 4/9 , lymph node negative ,
status post XRT and chemotherapy.
15. Question of coronary artery disease with a negative
adenosine MIBI in 2004.
16. Spinal stenosis and degenerative disk disease status post
laminectomy in 1991.
MEDICATIONS ON TRANSFER:
1. Nicoderm patch 7 mg daily.
2. Morphine sulfate 2-5 mg intravenous every 2-4h. as needed
3. Nitroglycerin 2 inches topically every 6 hours
4. Lopressor 50 mg orally twice a day
5. Lasix 20 mg orally daily.
6. Nexium 20 mg orally daily.
7. Catapres 0.2 mg orally twice a day
8. Levoxyl 150 mcg orally daily.
9. Minoxidil 2.5 mg orally twice a day
10. Niaspan 1000 mg orally every bedtime.
11. Norvasc 5 mg orally twice a day
12. Humulin N 10 units subcutaneously every day before noon
13. Humulin N 5 units subcutaneously every afternoon
14. Plavix 75 mg orally daily.
15. Zocor 40 mg orally every bedtime.
16. Ecotrin 325 mg orally daily.
17. Wellbutrin 75 mg orally every day before noon and 37.5 mg orally every afternoon
18. Zetia 10 mg orally daily.
19. Humulin R sliding scale before meals and at bedtime
ALLERGIES: The patient has several allergies documented. These
include:
1. Calcium channel blockers cause tremor and palpitations.
2. Percocet causes an itch.
3. Codeine causes nausea and vomiting.
4. Losartan causes shakiness.
5. Tramadol causes confusion.
6. Lisinopril causes irritability and abdominal pain.
7. NSAIDs cause GI upset.
8. Isosorbide dinitrate causes headache and palpitations.
9. Fluvastatin causes myalgias.
10. Histamine H2 inhibitors cause possible diarrhea.
11. Hydrochlorothiazide causes elevated creatinine.
12. Enalapril causes cough.
13. Oxycodone plus APAP causes hives.
14. Gabapentin causes lethargy.
15. Latex unknown.
16. Fluoxetine increased depression.
FAMILY HISTORY: Colon polyps.
SOCIAL HISTORY: She is divorced and lives with her daughter.
She is a former secretary and she denies alcohol. She has a long
smoking history , smoked two packs per day for 50 years ,
quit in 10/6 .
ADMISSION PHYSICAL EXAMINATION: Vital Signs: Temperature was
96.7 , heart rate 74 , blood pressure 170/86 , respiratory rate 16 ,
oxygen saturation 99% on 2 L. In general , she is awake and
alert , lying in bed in no acute distress. HEENT: pupils
equal , round and reactive to light. Extraocular movements were
intact. She was not able to cooperate with visual field exam.
Oropharynx was clear. Neck revealed carotid bruits bilaterally.
Her JVP was flat. She had normal carotid upstrokes. Lungs were
clear. Cardiovascular , regular rate and rhythm , 2/6 holosystolic
murmur at her right upper sternal border. Abdomen was obese ,
soft , nontender , nondistended. There was no abdominal bruit.
Extremities showed trace lower extremity edema and 2+ dorsalis
pedis pulses. Skin: No rash. Neurologic: She knew her name ,
the Kernan To Dautedi University Of Of , Cihollgrove Mont De and that it was 5/3 . She was unable to
identify the date or the day of the week. She knew the
president. She was able to spell world backwards and forwards
correctly. She could identify presidents in the past as well.
She was able to name a pen and a watch. She was able to salute
bilaterally. Her strength was 5/5 bilaterally in her deltoids.
Her right triceps were 4/5 , left triceps 4+/5 , biceps 4+/5
bilaterally. Strength was 4-/5 in her bilateral hip flexors ,
dorsi and plantar flexion. She had no hyperreflexia in her
biceps or her patella. She had some right-sided dysmetria on
finger-nose-finger.
LABS ON ADMISSION: Sodium was 133 , potassium 3.5 , chloride 104 ,
bicarbonate 21 , BUN 30 , creatinine was elevated at 2.6. Her
creatinine had been 1.8 in 8/4 , glucose 217 , white count was
7.35 with 63% neutrophils , 26% lymphocytes , 5% monocytes and 6%
eosinophils. Hematocrit was 34 , which was increased from 27 in
October . Platelets were elevated at 503 , 000. They had been
509 , 000 in October as well. LFTs were within normal limits.
Albumin was 3.6 , which is increased from 3 in October . EKG
revealed normal sinus rhythm with a rate of 75. There was no
change from prior.
Chest x-ray on admission revealed a linear opacity in the lower
third of the left lung that is consistent with scarring. Lungs
otherwise well expanded and clear , no significant effusions were
seen and the cardiomediastinal contours were stable with a normal
size heart , calcification in the arch the aorta and mildly
tortuous descending aorta.
The patient had had an echo in the past , 3/6/07 , that revealed
an ejection fraction of 60-65% with evidence of impaired
relaxation. She had an echo on 10/6/07 that was negative for
any intracardiac shunt. She had also had a Holter monitor in
October that revealed a few short runs of SVT that were most
likely atrial tachycardias , but there was no atrial fibrillation.
STUDIES DONE SINCE ADMISSION: Carotid ultrasound 11/23/07 . This
revealed an 80-85% stenosis of mid right internal carotid artery.
There was no evidence of hemodynamically significant disease in
the left carotid artery.
MR brain 6/28/07 . This revealed:
1. Multifocal peripheral cortical infarcts of different ages and
bilateral anterior and posterior circulations with newly
developed foci of acute infarct between 1 and 14 days days old
that suggests ongoing embolism. Cardiac , aortic or carotid
source of emboli should be considered.
2. Focal moderate stenosis or thrombus in the proximal right
ICA. Cervical CTA to evaluate further if indicated.
3. Moderate focal stenosis of the proximal left subclavian
artery and left vertebral artery origin as described , no
visualization of the proximal and mid segment of the nondominant
right vertebral artery as described.
8/20/07 echocardiogram: the left ventricle is normal in size ,
overall left ventricular function is normal. The estimated
ejection fraction is 55-60%. There were no regional wall motion
abnormalities. There was no left ventricular thrombus detected.
The aortic root size was normal. There was no cardiac source of
embolus identified and compared with prior study on 4/18/07 and
10/6/07 , there was no significant change.
HOSPITAL COURSE: Ms. Vissman is a 72-year-old woman with
multiple medical problems including severe vasculopathy ( carotid
stenosis and renal artery stenosis status post renal artery stent
placement in 8/4 ) , diabetes , hypertension , hyperlipidemia and
multiple strokes. She was admitted to an outside hospital with
unresponsiveness. She was transferred here for management of her
severe hypertension and worsening kidney function. During this
hospital admission , her medications were adjusted. Initially ,
the nitro paste was stopped. The Lasix was held. Her minoxidil
was also stopped as well. She was continued on clonidine 0.2 mg
orally twice a day and Norvasc 10 mg orally daily. Lopressor was also
stopped during this hospital admission and labetalol was started ,
which was titrated up by the time of this dictation. Her
antihypertensives include labetalol 300 mg orally every 8 hours , Norvasc
10 mg orally daily and clonidine 0.2 mg orally twice a day It is very
important that the patient receive her medications at their
scheduled times or her blood pressure will rise. She continued
to complain of headache , particularly on the right side and as
detailed above carotid ultrasound revealed a tight right internal
carotid artery stenosis. Vascular Surgery was consulted and she
is currently scheduled to have a left endarterectomy on Friday ,
1/21/07 after which point she will be cared for by the Vascular
Surgery Service. Given the patient's kidney disease and severe
hypertension in addition to recent renal artery stent placement ,
Nephrology was consulted as well during her hospital stay. It
was felt that there was no need for intervention regarding her
renal arteries or visualization of her kidneys at this time.
They agreed with holding the furosemide and changing Lopressor to
labetalol and titrating up labetalol as needed. Her clonidine
could also be titrated up by 0.1 mg increments should she need
more blood pressure control in the future , if her heart rate
does not tolerate higher doses of labetalol. The patient's
creatinine on admission was 2.6 , which subsequently decreased to
2 , however , at the time of this dictation has increased to 2.6
and it is thought that this may be a result of improved blood
pressure control and may be a new baseline; her creatinine will
need to be followed. The patient also has a history of diabetes
and is on insulin and her insulin regimen including NPH and before meals
coverage were titrated during this hospital admission.
Hemoglobin A1c was checked during this hospital admission and it
was 6.4. TSH was checked as well and it was within normal
limits.
CONTACT NUMBERS: Contact numbers for the patient's family
members are:
1. Healthcare proxy , daughter Burton Santulli , 452-378-1260.
2. Daughter , Sheldon Vissman , 505-204-1733.
3. Son , Sheldon Vissman , 119-743-8502.
Discharge medications and the remainder of the patient's hospital
course will be dictated by the covering team at that time.
CODE: The patient was full code at the time of transfer.
eScription document: 0-2521469 CSSten Tel
Dictated By: BAILLEU , ARA
Attending: OGDEN , LATORIA
Dictation ID 0189670
D: 9/18/07
T: 9/18/07
Document id: 571
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
Y |
Y |
N |
- |
N |
Y |
Y |
N |
N |
N |
N |
- |
N |
448866901 | PUO | 37071809 | | 307904 | 10/9/2000 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 1/22/2000 Report Status: Signed
Discharge Date: 6/7/2000
PRINCIPAL DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
PROBLEM LIST:
1. HYPERTENSION.
2. NON-INSULIN DEPENDENT DIABETES MELLITUS.
3. HYPERCHOLESTEROLEMIA.
4. PERIPHERAL VASCULAR DISEASE.
5. PARKINSONISM.
HISTORY OF PRESENT ILLNESS: This is a 72 year old woman with a
history of hypertension , non-insulin
dependent diabetes mellitus , high cholesterol , who presents with
chest pain. She is status post a coronary artery bypass grafting
in 1992 and catheterizations in 1993 and 1998 and has had a long
history of stable angina. This angina is approximately once per
week , always responds to one sublingual nitroglycerin. It is
usually diffuse pain in the front of her chest and across her back.
The morning of admission she experienced shortness of breath and
chest pain which decreased after one sublingual nitroglycerin.
After lunch she had a repeated episode which was not relieved by
nitroglycerin. She came to the emergency room at the I Warho Hospital . Electrocardiogram there showed lateral changes.
The patient has been recently undergoing a work up for a weight
loss of 40-50 pounds over only a couple of months. An ERCP in
5/12 showed narrowing in the common bile duct. This narrow was
stented and brushings were taken. These brushings were sent for
cytology and pathological analysis and they were not diagnostic.
This course status post ERCP was complicated by pancreatitis.
Echocardiogram in 7/16/98 showed an ejection fraction of 40-45%
with 2+ mitral regurgitation. The most recent catheterization in
1998 showed the SVG to OM1 graft patent , the SVG to RCA graft
patent , LAD was totally occluded , the RCA was 40-50% occluded , PDA
had an ostial 80% lesion that was rotabladed. This was complicated
by a perforation. She had a short stay in the CCU after this
procedure.
ALLERGIES: Dilaudid which makes her dizzy.
PAST MEDICAL HISTORY:
1. Coronary artery bypass grafting 1992.
2. Two catheterizations , 1993 and 1998.
3. Hypertension.
4. Non-insulin dependent diabetes mellitus.
5. High cholesterol.
6. Peripheral vascular disease , status post fem/pop and fem
thrombectomy.
7. Weight loss with constriction of the common bile ducts , status
post ERCP.
8. Pancreatitis post ERCP.
9. Parkinsonism.
MEDICATIONS ON ADMISSION: Aspirin 325 mg orally every day; atenolol 25
mg once a day; Lisinopril 2.5 mg once a
day; Imdur 60 mg once a day; Metformin 500 mg twice a day; sinemet
25/100 twice a day; Zantac 150 mg twice a day; Zoloft 25 mg once a
day.
SOCIAL HISTORY: No drinking , no smoking. She is a widow. She is
quite active , reports that she goes to a lot of
parties.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.3 , pulse 66 ,
blood pressure 144/60 , breathing comfortably
on room air. GENERAL: This is a , comfortable , friendly
female. CHEST: Clear to auscultation. CARDIOVASCULAR: Present
S1S2 , regular rate and rhythm , positive II/VI systolic ejection
murmur heard best at the left lower sternal border. ABDOMEN:
Benign. There is no edema. Neurologic exam notable for tremor ( baseline
per patient , and otherwise nonfocal ).
LABORATORY DATA: SM-7 normal with a creatinine of 0.8 , white count
5.11 , hematocrit 36.4 , platelets 243 , CK 30 ,
Troponin-I 0.02 , lipase 276 , albumin 4.2.
HOSPITAL COURSE: She was admitted for rule out myocardial
infarction. She ruled out for the myocardial
infarction and had no further chest pain or electrocardiogram
changes. She had an exercise MIBI. On the exercise she went on a
modified Bruce for 6 minutes 25 seconds with a maximum heart rate
of 150. There were nondiagnostic ST changes during exercise and
she stopped due to fatigue. MIBI images showed the following:
There was a mixed transmural and nontransmural myocardial
infarction involving four cardiac segments in the inferior lateral
and lateral wall. There was moderate peri-infarct ischemia
involving additional segments. There was mild to moderate
ischemia involving three cardiac segments in the high lateral wall.
There was mild anterior septal ischemia. She went for cardiac
catheterization which showed the following: A right dominant
system with a left anterior descending that had lesions that were
40% and 50%. Diagonal had a 70% lesion that was stented to 20%.
Left circ was occluded with saphenous vein graft to the OM patent
and the saphenous vein graft to the RCA patent. There was in
addition a large 10 millimeter pseudoaneurysm at the site of the
previous PDA rotablation which was thrombosed with a coil. The
procedure was accomplished without complications. She had some
mild chest pain after the procedure which was reproducible with
palpation of her anterior ribs. The electrocardiogram did not show
change. The patient was discharged to follow up with Dr. Carlton J Abshear .
DISPOSITION: She was discharged to home in stable condition.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally.every day; atenolol 25 mg
once a day; bacitracin topically once a
day; Lisinopril 2.5 mg once a day; omeprazole 20 mg once a day;
Sinemet 25/100 orally 1 tablet twice a day; Zoloft 25 mg once a day;
Imdur 60 mg once a day; Glucophage 500 mg twice a day; nitroglycerin
as needed , take as instructed; lipid lowering study medication as instructed
Dictated By: AGUSTINA RESNIK , M.D. JK68
Attending: ABE E. GIRARDI , M.D. QO19 GY950/1415
Batch: 46239 Index No. WMLI329TZG D: 10/17
T: 1/18
CC: 1. CARLTON J. ABSHEAR , M.D. RM7
2. DERICK YAN , M.D. IW32
Document id: 572
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
- |
Y |
- |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
- |
415842495 | PUO | 78560075 | | 4472204 | 10/10/2006 12:00:00 a.m. | pulmonary embolism | | DIS | Admission Date: 8/13/2006 Report Status:
Discharge Date: 3/4/2006
****** FINAL DISCHARGE ORDERS ******
DEARTH , DEIRDRE T. 104-60-01-0
Omong Buffnoo
Service: ONC
DISCHARGE PATIENT ON: 10/19/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE G. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
GLIPIZIDE 5 MG orally twice a day
GUAIFENESIN 10 MILLILITERS orally every 4 hours as needed Other:cough
IBUPROFEN 600 MG orally three times a day as needed Pain
Food/Drug Interaction Instruction Take with food
LACTULOSE 30 MILLILITERS orally four times a day as needed Constipation
OXYCODONE 5 MG orally every 4 hours HOLD IF: oversedated , RR<10
Instructions: patient may refuse
SENNA LIQUID 1 TSP orally HS
TRAZODONE 50 MG orally HS
ZOLOFT ( SERTRALINE ) 50 MG orally every day
Override Notice: Override added on 9/13/06 by GOLDFEDER , MAXINE H R. , M.D. , M.S.C. on order for GEODON orally ( ref # 479891740 )
SERIOUS INTERACTION: SERTRALINE HCL & ZIPRASIDONE HCL
Reason for override: ok
COMPAZINE ( PROCHLORPERAZINE ) 10 MG orally every 6 hours as needed Nausea
LOVENOX ( ENOXAPARIN ) 75 MG subcutaneously twice a day
FLOVENT ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
Starting Today June
SEROQUEL ( QUETIAPINE ) 25 MG orally three times a day
Starting Today June as needed Anxiety
Override Notice: Override added on 9/13/06 by GOLDFEDER , MAXINE H R. , M.D. , M.S.C. on order for GEODON orally ( ref # 479891740 )
SERIOUS INTERACTION: QUETIAPINE FUMARATE & ZIPRASIDONE HCL
Reason for override: ok
Number of Doses Required ( approximate ): 10
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
30 MG orally every day Starting Today June
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
GEODON ( ZIPRASIDONE ) 80 MG orally every bedtime
Starting Today June
Alert overridden: Override added on 9/13/06 by GOLDFEDER , MAXINE H R. , M.D. , M.S.C.
SERIOUS INTERACTION: SERTRALINE HCL & ZIPRASIDONE HCL
SERIOUS INTERACTION: QUETIAPINE FUMARATE & ZIPRASIDONE HCL
Reason for override: ok
ARANESP ( DARBEPOETIN ALFA ) 200 MCG subcutaneously Q3WEEKS
Reason for ordering: Oncology - Chemotherapy Induced Anemia
Last known Hgb level at time of order: 9.1 g/dL on
10/14/06 at PUO
Diagnosis: Anemia in Neoplastic Disease 285.22
Treatment Cycle: Maintenance
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Bibi Triggs , Dr. Cole Emanuelson 11/17/06 , 2:00pm scheduled ,
Dr. Leone Bonnie 8/25/06 , 3:45pm scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
pulmonary embolism
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pulmonary embolism
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
iddm ( diabetes mellitus ) , hypercholesterolemia ( elevated cholesterol ) ,
htn ( hypertension ) , asthma ( asthma ) , arthritis ( arthritis ) , obesity
( obesity ) , history of ccy ( history of cholecystectomy ) , metastatic breast ca
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
HPI: 58 year-old F history of widely metastatic breast cancer with metastasis to brain
currently undergoing whole-brain XRT , bone , lung , and mediastinum
including the right side of her ribs , p/with to ED yesterday c/o of rib pain
upon lifting laundry. Pain is pleuritic and worsens with movement. Got
some relief with Tylenol and codeine. PECT initially read as negative ,
and patient was discharged home with follow up to primary oncologist. However ,
today , PECT was read this am as positive although only with small
subsegmental embolus in RLL. Of note , patient has chronic intermittent leg
pain and paresthesias , but PECT was neg for any leg DVT. patient was called to
come back , and is currently in stable condition. patient denies SOB , chest
pain , palpitations. ROS as above; in addition , patient has constipation and
has not had BM since 10/17/06 .
PHYSICAL EXAM:
VS: T 97.7 , P 86 , BP 137/80 , R 15 , O2 98% 2L , Wt 100 kg
GEN: Morbidly obese , drowsy history of pain medication , but oriented.
HEENT: NCAT , MMM , PERRL.
NECK: JVP difficult to assess. No LAD.
CV: Distant heart sounds. RRR , no m/r/g.
CHEST: Lungs CTAB. R costal margin bony TTP.
ABD: Morbidly obese. BS decreased. NTND. No Murphy's sign.
EXT: Warm. Pulses 1+ B BR/DP. Tr non-pitting edema.
STUDIES:
- EKG: NSR. No RV strain pattern , no ST/TW change.
- PECT as above.
-----------
HOSPITAL COURSE:
* HEME: PE - Anticoagulation with lovenox , anti-factor Xa level reasonably
in range at 1.03. Avoided coumadin as patient with brain metastasis undergoing
XRT. Cont iron supplementation. Aranesp.
* ONC: Metastatic breast cancer. Will defer to primary oncology for
treatment regimen; giving aranesp , zometa , cont XRT.
* CV: ISCHEMIA - no active issues , cont ASA. PUMP - HTN , cont nifedipine.
* RESP: Asthma - albuterol , flovent , guaifenesin as needed
* ENDO: DM - cont avandia , glipizide. Hypercholesterolemia - cont lipitor.
* GI: Morbid obesity - nutrition consulted. Cont bowel regimen for
constipation.
* PSYCH/PAIN: Cont geodon , seroquel as needed , trazodone. Pain regimen per
primary oncologist.
* PPX: Treatment dose Lovenox for PE.
ADDITIONAL COMMENTS: you have been hospitalized for starting treatment for a clot in your
lungs. please keep your appointments as scheduled. please call your MD or
return to the ED if you should have increased pain or shortness of
breath.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
cont lovenox
keep f/u appts
physical therapy
No dictated summary
ENTERED BY: POLO , MALINDA M. , M.D. , M.S.C. ( UY57 ) 10/19/06 @ 02:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 573
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
- |
N |
N |
Y |
Y |
- |
Y |
856450649 | PUO | 99098383 | | 572070 | 6/3/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/3/1999 Report Status: Signed
Discharge Date: 6/3/1999
PRINCIPAL DIAGNOSIS: BILATERAL LOWER EXTREMITY WEAKNESS
OTHER PROBLEMS:
1. HISTORY OF MORBID OBESITY.
2. OBSTRUCTIVE SLEEP APNEA.
3. ATRIAL FIBRILLATION.
4. HISTORY OF CELLULITIS.
5. EJECTION FRACTION OF 40 PERCENT WITH LEFT ATRIAL ENLARGEMENT.
6. URINARY TRACT INFECTION.
CHIEF COMPLAINT: Mr. Cubeta is a very pleasant 59 year-old man who
presents with a history of morbid obesity ,
paroxysmal atrial fibrillation and ejection fraction of 40 percent
who presents status post a fall and with increasing urinary
frequency.
HISTORY OF PRESENT ILLNESS: Mr. Cubeta has morbid obesity and is
currently at a weight of 450 pounds
and also has a history of fluctuating weight with decrease in
weight to 200 pounds with dieting. He also has obstructive sleep
apnea on continuous positive airway pressure , history of atrial
fibrillation and is not anticoagulated per his primary care
physician. He has a mildly decreased ejection fraction with mitral
regurgitation and a history of cellulitis. He presented in 4/5
for a short stay unit admission with progressive lower extremity
weakness bilaterally and urinary incontinence. It was felt at that
time by neurosurgery and neurology to be multifactorial and no
consistent with disk or cord impingement. There was a work up at
that time including B12 , ANA and HIV all of which were negative.
EMG showed decreased recruitment in the tibialis anterior and
gastrocnemius bilaterally. His rectus femoris were normal
bilaterally. He was treated for a urinary tract infection at that
time with Bactrim for resolution of his incontinence and he was not
anticoagulated by his primary care physician. Since discharge he
noted continued right greater than left lower extremity weakness
otherwise at baseline health until two weeks prior to admission
when he noted some lumbar and sacral pain , nonradiating , worse
while moving his right leg. Over the past few days he noted also
increasing urinary frequency without burning or urinary
incontinence , no fever or chills and no costovertebral angle
tenderness or pain. No bowel incontinence or perianal numbness or
pain. The night of admission , at 7:30 p.m. while getting up from a
chair , his right leg gave out and he fell to the floor "gracefully"
without injury or head trauma , no loss of consciousness. He had no
preceeding dizziness , chest pain , shortness of breath or
paresthesia and presented to the Emergency Room at the Pagham University Of .
PAST MEDICAL HISTORY: As above.
ALLERGIES: Penicillin gives him hives.
SOCIAL HISTORY: He is a psychology Professor , therapist , former
illicit drug use including LSD. No history of
tobacco use , currently. Rare alcohol use and lives with his wife
of 15 years.
FAMILY HISTORY: Varicose veins , early coronary artery disease in a
brother who was 50 years old. His parents passed
away in a motor vehicle accident. No history of clots.
PHYSICAL EXAM: The patient is a morbidly obese man in no acute
distress , sitting in a chair. Vital signs showed
temperature of 97.1 , pulse 80 , blood pressure 148/90 , oxygen
saturation 96% on room air with a respiratory rate of 20. HEENT:
Obese neck. Pupils equal , round and reactive to light and
accommodation. No conjunctivitis. Oropharynx is clear. Mucous
membranes were moist. Jugular venous distention not appreciated.
CHEST: Clear to auscultation bilaterally. HEART: II/VI systolic
ejection murmur at the apex radiating to the axilla. Irregular ,
irregular rhythm. No S3 or S4. ABDOMEN: Obese , soft and
nontender. ABDOMEN: Obese , soft and nontender. Nondistended with
positive bowel sounds and a significant rash of his pannus.
RECTAL: Strong rectal tone. EXTREMITIES: Right calf was with a
shallow , erythematous dry ulcer which was chronic with changes
consistent with venous insufficiency and varicose veins.
NEUROLOGICAL: Nonfocal. Strength in the right hip flexor was
decreased to 4/5 and on the right his plantar dorsiflexion strength
was 4/5 bilaterally. Sensation was grossly intact to touch.
Finger-to-nose was normal.
LABORATORY DATA ON ADMISSION: Sodium 140 , potassium 4.5 , chloride
102 , bicarbonate 26 , BUN 20 ,
creatinine 0.9 , glucose 101. He had a white blood cell count of 9
with 76 polys , 4 bands , hematocrit 37.6 and a platelet count of
236. His urinalysis showed 3+ blood and positive leukocyte
esterase with 15-20 white blood cells , one plus bacteria and one
plus squamous cells.
HOSPITAL COURSE: 1. Neurological: The neurology service came by
to see the patient in the Emergency Room and felt
that there was no acute neurologic change but if the patient was
unable to walk he should be sent to rehabilitation. They saw no
new acute change and he should continue to be followed by neurology
in clinic.
2. Cardiac: He does have a history of paroxysmal atrial
fibrillation and echocardiogram with decreased ejection fraction
was noted previously. He will be started on a trial of Lasix orally
every day to decrease his peripheral edema to help him with
rehabilitation and his primary care physician will continue to
follow him for his atrial fibrillation and he does elect not to
anticoagulate him at the moment though Coumadin should be a
consideration given his risk of stroke.
3. Skin care: Right calf demonstrates a pressure ulcer and the
patient should apply Nystatin powder for his pannus rash.
4. Infectious disease: His urinary tract infection will be
treated with seven days of Bactrim and follow urine cultures.
DISPOSITION ON DISCHARGE: The patient will be discharged to
rehabilitation care for leg
strengthening.
MEDICATIONS ON DISCHARGE: Aspirin 325 mg orally every day , Colace 100
mg orally twice a day , Lasix 40 mg orally every day before noon ,
Indomethacin 25 mg orally three times a day as needed pain , Lisinopril 15 mg orally every
day , multivitamin one tablet orally every day , Bactrim DS one tablet orally
three times a day , Tamsulosin 0.4 mg orally every day , Miconazole 2% topical powder
twice a day
CONDITION ON DISCHARGE: Stable.
Dictated By: MARIA COWART , M.D. CP56
Attending: BOBBY LOVERO , M.D. SX60 MK517/8095
Batch: 4548 Index No. B6RH7I56WG D: 8/28/99
T: 8/28/99
Document id: 574
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
097238564 | PUO | 45875883 | | 9418937 | 4/5/2003 12:00:00 a.m. | PREGNANCY , 371/2 WEEKS , HYPERTENSION | Signed | DIS | Admission Date: 11/10/2003 Report Status: Signed
Discharge Date: 10/27/2003
Date of Discharge: 10/27/2003
ATTENDING: TYLER BEUERLE MD
ATTENDING PHYSICIAN: Tyler Beuerle , M.D.
PRINCIPAL DIAGNOSES:
1. Hypertension.
2. Type 2 diabetes.
3. Severe preeclampsia.
4. Status post primary cesarean section.
HISTORY OF PRESENT ILLNESS: This is a 42-year-old , G3 , P0 who
presented to Labor and Delivery on 11/10/2003 at 32-4/7 weeks
gestation , dated by a 7-week ultrasound with class B diabetes
mellitus and an increased blood pressure. The patient denied
headaches , visual changes , and epigastric pain. She did report a
16-pound weight gain over the past two weeks and she had 4+
protein on urine dip in the clinic that day. The patient is
treated with insulin for her class B diabetes mellitus during
pregnancy. The patient's prenatal screens are notable for Rh
positive , antibody negative , RPR nonreactive , Gonorrhea and
Chlamydia negative , hemoglobin electrophoresis AA , hepatitis B
surface antigen negative , TSH was 2.02 , hemoglobin A1C on
9/28/2002 was 8.7 , on 3/2/2002 was 9.4 and a chorionic villus
sampling procedure revealing normal chromosomes. As stated
above , the patient is dated by a 7-week ultrasound. Her current
pregnancy has been followed by Dr. Damon Krinsky in the Diabetes
Clinic from 8 weeks of gestation. Her prenatal course is notable
for a history of chronic hypertension. Her blood pressure was
122/70 , range of blood pressures during pregnancy was 100/60 to
130/80. The patient did not require medications during this
pregnancy for blood pressure control. Today in clinic , the
patient had a blood pressure of 158/90 with 4+ protein on dip.
She denied signs and symptoms of preeclampsia. The patient's
second prenatal issue is a history of class B type2 diabetes
mellitus , on insulin. Her most recent hemoglobin A1C was 6.6 on
2/2/2003 . The patient's baseline 24-hour urine protein was 59
mg. The patient had good fetal growth on ultrasound. At a
25-week scan , fetal weight was estimated to be 973 g in the 91st
percentile with a normal survey. At 28 weeks , the fetus was
1 , 370 g in the 86th percentile with normal Dopplers. At 32
weeks , the fetus was 1 , 976 g on 11/10/2003 in the 66th percentile
with normal fluids , anterior placenta , vertex position , normal
Dopplers and normal survey. The patient's third issue in the
pregnancy was morbid obesity with a high BMI. The patient's
fourth issue was advanced maternal age. She is status post a
chorionic villus sampling for normal chromosomes.
PAST MEDICAL HISTORY: Hypertension , type 2 diabetes mellitus ,
diagnosed 2 years ago. The patient was treated with orally
glyburide until 6 weeks pregnant and then switched to insulin.
PAST SURGICAL HISTORY: Excision of right facial sebaceous cyst ,
therapeutic abortion x 2.
PAST OB HISTORY: G3 , P0020. Therapeutic TAB in the first
trimester at age 16 , therapeutic TAB in the second trimester at
age 18.
ALLERGIES: No known drug allergies.
MEDICATIONS: NPH and Humalog insulin , regimen adjusted according
to blood sugars and prenatal vitamins.
PHYSICAL EXAMINATION UPON ADMISSION: Blood pressure 160/80 ,
afebrile , no acute distress. Heart: Regular rate and rhythm.
Lungs: Clear to auscultation bilaterally. Abdomen: Soft ,
obese , nontender and gravid. Extremities: Showed 3+ edema with
2+ deep tendon reflexes. Fetal heart tones were 140s and
reactive , vertex position for the fetus by Leopold and
ultrasound.
HOSPITAL COURSE: The patient was admitted to Labor and Delivery
for rule out preeclampsia. Her initial laboratory studies
revealed a creatinine of 0.8 , platelets of 323 , ALT 39 , AST 30 ,
uric acid 5.6 , 24-hour urine protein was 2 , 995 mg. The patient
was managed on the labor floor , ruling in for preeclampsia. She
was started on magnesium sulfate therapy for seizure prophylaxis
and she was begun on betamethasone treatment for fetal lung
maturity. Her glucose levels were watched carefully after the
administration of betamethasone. She remained stable. After the
patient was betamethasone complete on 1/24/2003 , an induction of
labor was started using cervical ripening agents. The patient
received Cervidil x 1 , Cytotec x 4 , Foley bulb mechanical
dilatation and low dose Pitocin. After this , she reached 1 cm
dilatation , 25% effacement , -3 station. At this point on
5/2/2003 , due to the failure of initiating labor with cervical
ripening agents and Foley bulb , a decision was made to proceed
with laminaria to mechanically dilate the cervix further. On
5/2/2003 , 28 laminaria were placed in the patient's cervix and
the patient was restarted on Pitocin. The laminaria were
discontinued and the patient was examined and found to be 3-4 cm ,
50% with a high station. She was continued on Pitocin for
protocol and her cervix did not change. Therefore , the patient
was consented for cesarean section for failure to progress with
induction of labor and severe preeclampsia. The patient had
remained stable in regards to her preeclampsia with stable blood
pressures. On 3/25/2003 , the patient underwent a primary
cesarean section , low transverse for delivery of a 3 pound 7
ounce vigorous infant at 4:35 a.m. , 3/25/2003 . Apgars were 7 at
1 minute and 8 at 5 minutes respectively. The patient tolerated
the procedure well. A JP drain was placed in the subcutaneous
tissue due to the patient's morbid obesity. The patient's
postpartum course was notable for restarting the patient on orally
antihypertensives and continuing to monitor her fingerstick blood
glucose levels. The patient was started on hydrochlorothiazide
and lisinopril , which she had been taking prior to pregnancy.
Her fingersticks were checked and she was covered with a Humalog
sliding scale. She was on subcutaneous heparin for DVT
prophylaxis. The patient's Jackson-Pratt drain was discontinued
prior to her discharge and staples were to remain in place for 10
days. The patient was discharged to home with Visiting Nurse
Services to monitor her blood pressure and her fingersticks. The
patient was to followup with Dr. Damon Krinsky for further
management of her diabetes and hypertension.
DISPOSITION: Home Health Services.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Colace 100 mg orally twice a day , ibuprofen 600
mg orally every 6 hours as needed for pain , prenatal vitamins , Percocet 1-2
tablets orally every 4 hours as needed for pain , lisinopril 25 mg orally every day ,
hydrochlorothiazide 50 mg orally every day , and Niferex one capsule orally
twice a day
DISCHARGE INSTRUCTIONS: The patient was instructed to have her
fingersticks checked by Visiting Nurse Services throughout the
weekend. She will show these sugar values to Dr. Damon Krinsky for
evaluation. She will follow up with Dr. Damon Krinsky in 10 days
for staple removal. The patient is instructed to have nothing
per vagina for 6 weeks. No tampons , no sexual intercourse , no
douching , no heavy lifting for two weeks. The patient was
instructed to call for fever , heavy vaginal bleeding and severe
abdominal pain or any concerns about her incision.
LABORATORY STUDIES UPON DISCHARGE: Glucose 86 , BUN 13 ,
creatinine 0.9 , sodium 141 , potassium 4.6 , chloride 103 ,
bicarbonate 28 , ALT 20 , AST 18 , alkaline phosphatase 92 , total
bilirubin 0.3 , calcium of 9.2 , and hematocrit 29.9.
eScription document: 9-7801134 TFFocus
Dictated By: GIRARDI , ABE
Attending: BEUERLE , TYLER
Dictation ID 1162780
D: 10/13/03
T: 1/23/03
Document id: 575
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
144089827 | PUO | 43364462 | | 4653527 | 10/30/2007 12:00:00 a.m. | Atypical chest pain | | DIS | Admission Date: 9/29/2007 Report Status:
Discharge Date: 1/3/2007
****** FINAL DISCHARGE ORDERS ******
LICANO , TEMPIE M 762-84-14-5
S
Service: CAR
DISCHARGE PATIENT ON: 3/20/07 AT 12:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCPECK , REYES DALE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. AMLODIPINE 10 MG orally every day
2. ACETYLSALICYLIC ACID 81 MG orally
3. ISOSORBIDE MONONITRATE ( SR ) 30 MG orally every day
4. SIMVASTATIN 20 MG orally every day
5. METOPROLOL SUCCINATE EXTENDED RELEASE 75 MG orally every day
6. FUROSEMIDE 20 MG orally every day
7. DOCUSATE SODIUM 100 MG orally twice a day
8. OMEPRAZOLE 20 MG orally every day
9. ALTRAM 25 MG orally every 6 hours
10. SENNOSIDES 1 TAB orally every day
11. SOLIFENACIN 5 MG orally every day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today May
Alert overridden: Override added on 8/1/07 by :
on order for ACETYLSALICYLIC ACID orally ( ref # 397455486 )
patient has a PROBABLE allergy to ROFECOXIB; reaction is
constipated. Reason for override: takes aspirin at home
NORVASC ( AMLODIPINE ) 5 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LEXAPRO ( ESCITALOPRAM ) 10 MG orally DAILY
Override Notice: Override added on 8/1/07 by
COONE , TERESITA R. , M.D.
on order for ULTRAM orally ( ref # 289671072 )
POTENTIALLY SERIOUS INTERACTION: ESCITALOPRAM OXALATE &
TRAMADOL HCL Reason for override: mda
Number of Doses Required ( approximate ): 3
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
GLYBURIDE 2.5 MG orally DAILY
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally DAILY
HOLD IF: for sbp < 100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
ATIVAN ( LORAZEPAM ) 0.25 MG orally every 6 hours as needed Anxiety
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
75 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 3/20/07 by :
on order for TOPROL XL orally ( ref # 716642706 )
patient has a PROBABLE allergy to ATENOLOL; reaction is
FATIGUE WITH ALL B-BLOCKERS. Reason for override:
tolerates at home
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 1-2 TAB orally twice a day
as needed Constipation
SIMVASTATIN 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ULTRAM ( TRAMADOL ) 25 MG orally every 6 hours as needed Pain
Alert overridden: Override added on 8/1/07 by
COONE , TERESITA R. , M.D.
on order for ULTRAM orally ( ref # 289671072 )
patient has a PROBABLE allergy to FENTANYL; reaction is nausea.
patient has a PROBABLE allergy to OXYCODONE CONTROLLED
RELEASE; reaction is vomiting. Reason for override:
patient takes at home Previous Alert overridden
Override added on 8/1/07 by COONE , TERESITA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: ESCITALOPRAM OXALATE &
TRAMADOL HCL Reason for override: mda
Number of Doses Required ( approximate ): 2
VESICARE 5 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Sana Azua ( please follow-up with Dr. Pidro in 1-2wks ) ,
Dr. Carlton Abshear 10/9/07 at 10:40 scheduled ,
ALLERGY: ETHYL ALCOHOL , PROCHLORPERAZINE , LISINOPRIL , ATENOLOL ,
PIMOZIDE , FENTANYL , zophran , ROFECOXIB ,
OXYCODONE CONTROLLED RELEASE
ADMIT DIAGNOSIS:
Atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Hx sick sinus Rx=DDD pacer Hx Hodgkins Rx with ABVDx13
Hx of BOOP from bleomycin NIDDM recurrent rest chest pain known CAD
HTN history of PTCA RCA distant tobac hypercholosterolemia
imaging PVD with history of claudication history of hysterectomy history of spinal stenosis
depression October , RCA50 , OM1-70 ETTs , mult , all ( - ) ECHO
10/11 , LVH , LAE , 1MR
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
*****
HPI: 86yo F with CAD history of PCI , AS history of AVR '03 , SSS history of PPM '93 and
diastolic heart failure who p/with chest pressure that came on at rest
and resolved with SLN. Chest pressure began at rest in setting of fear ,
radiated to R shoulder was associated with diaphresis and sob , no n/v.
Pain releived with SLN. patient has had 3-4 episodes of similar chest pressure
over last 2 months , admitted 6/12 and r/o for MI. Adenosine MIBI 6/19
positive for sm reversible perfusion defect in DIAG territory. patient
also reports increased sob x 2-3 months worsened over last week with
orthopnea , no wt gain or PND. In the ED , patient was given ASA , BB and
admitted for r/o MI.
***
PMH: CAD history of PCI to RCA , AVR '03 c/b CVA ( without residual defects ) , SSS
history of PPM ( '93 ) , HTN , DM , Hodgkins lymphoma history of radiotherapy ( '93 ) ,
Bladder Ca history of transurethral resection , Depression , spinal
stenosis , bowel perforation history of colectomy , R pleural lung nodule
( increasing in size ) , PVD.
***
Home Medications: Norvasc 10mg daily , ASA 81mg daily , colace 100mg
twice a day , Lexapro 10mg daily , lasix 20mg daily , imdur 30mg daily , toprol
75mg daily , prilosec 20mg daily , zocor 20mg daily , SLN , altram
25mg every 6 hours as needed , senna 1 tab daily as needed , vesicare 5mg daily.
***
All: EtOH - facial swelling , Procholorperazine - altered mental
status , Lisniopril - angioedema , Atenolol - fatigue , dimozide -
altered MS
***
SH: lives alone , quit smoking 30 years ago , no etOH
***
PE: 97.2 65 156/64 16 100% RA NAD
PERRL , EOMI , dry MM , B carotid bruits
RRR , nl s1/s2 , III/VI murmur at RUSB
Decreased BS at bases bilaterally
soft , nt/nd , stoma c/d/i no peripheral edema
1+ dp pulses , wwp
A+Ox3 , non-focal neuro exam
***
Labs: wbc 8.33 , hct 39.2 , plt 296 , INR 1.0 , bun 18 , Cr
0.9 , Cardiac biomarkers negative x 3.
***
Results:
Echo 7/12 borderline concentric LVH , EF 60-65% , no RWMAm , paradoxical
septal motion , abn diastolic function , trace AR , aortic valve gradient
of 19 , mild MR , mild TR , no effusions
Cath 5/10 no LM , mid 45% LAD , DIAG 1 35% , DIAG 2 45% , multipl 40-50%
RCA lesions.
CXR 5/25 R sided PPM , small R pleural effusion ( unchanged from prior ) ,
no acute CPP.
MIBI 11/25 sm area of mild reversible perfusion defect in Diag territory ,
nl systolic fxn. Chest CT 2/15 increase in size of pulm nodule in LLL ,
enlargement of R para-tracheal node.
***
A/P 86 year-old F with CAD history of PCI , AS history of AVR , sss history of PPM with several episodes
of CP in last 2 months that come on with fear and anxiety and worsening
DOE now p/with another episode of chest pressure at rest. Ddx anxiety , ACS ,
diastolic heart failure , bioprosthetic vavle dysfunction.
*CVI: Known CAD , MIBI with perfusion defect , chest pressure at rest with no
new EKG changes. The history is suggestive of non-cardiac chest pain
( comes on with anxiety/fear , occurs at rest , no chest pain with exertion ).
The patient ruled out for MI with 3 sets of negative cardiac enzymes.
She remained chest pain free throught course of admission , however , did
have occasional shortness anxiety attacks with shortness of breath that
relieved with low dose ativan. The patient will continue ASA , BB ,
zocor. Lipids ( chol 119 , Tri 142 , HDL 135 , LDL 56 ). We increased her dose
of imdur for better blood pressure control and symptomatic relief of angina ( although
likley not having true angina ). She will follow-up with her cardiologist
Dr. Carlton Abshear .
*CVP: Known diastolic HF with DOE over last several months. Recently
admitted for volume overload requiring diuresis. Durnig this
admission the patient appeared euvolemic. We continued her home dose of
lasix. The patient did have some hypertension with sbp in 150s. We split
her norvasc into twice a day dosing for tighter control and increased imdur. May
need to have anti-hypertensive up-titrated as outpatient. Patient is not
on an ACE inhibitor because of angioedema. An echo cardiogram pending
at time of discharge and should be followed up as OP.
*CVR: no issues
*Pulm: ***HIGH SUSPICION FOR LUNG CA*** given smoking hx and
recent enlarging pulmonary nodule in RLL with sm R pleural effusion. Needs
to have an further outpatient workup. Patient also has a hx of BOOP 2/2
bleomycin and diastolic heart failure all of which may contribute to her
DOE.
*GI: history of bowel perforation history of colectomy with colostomy. Stoma appeared
C/D/I. Continued homebowel regimen
*GU: Overactive bladder , followed by GU as an outpatient. Recently
started vesicare with good effect
*Endo: DM on glyburide at home. Kept on SSI. Her HGA1C was ***
*PPI: lovenox , ppi
FULL CODE
ADDITIONAL COMMENTS: To Patient: You were admitted to the hospital to rule out a heart attack
as the cause for your chest pain. Based on our evaluation we feel that
your chest pain is atypical and most likely not related to your heart.
We have made a few changes to your medications. We increased your dose
of imdur from 30mg to 60mg , we changed your norvasc from 10mg daily to
5mg twice per day and we added ativan on an as needed basis for anxiety
and agitation. If you develope recurrent chest pain , shortness of breath
or other concerning symptoms please contact a physician. You may try
taking ativan when you have chest pain especially if the chest pain is
brought on by fear or anxiety. Please follow-up with your primary care physician in the
next 1-2 weeks to be sure that you are tolerating the changes in
medications well.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
***ENLARGING PULM NODULE W/ PLUERAL EFFUSION*** High suspicion for Ca and
needs further OP work-up
*Up-titrate blood pressure medications for better control
*Have patient follow-up with Dr. Abshear ( cardiology )
No dictated summary
ENTERED BY: DESJARDIN , RENDA S MD ( WL26 ) 3/20/07 @ 03:28 PM
****** END OF DISCHARGE ORDERS ******
Document id: 576
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182796277 | PUO | 05941893 | | 339302 | 10/25/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/12/1995 Report Status: Signed
Discharge Date: 8/8/1995
DISCHARGE DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
SECONDARY DIAGNOSES INCLUDE: 1. CHRONIC ATRIAL FIBRILLATION.
2. HYPERTENSION.
3. NON-INSULIN DEPENDENT DIABETES
MELLITUS.
4. PNEUMONIA
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old woman
with a history of chronic atrial
fibrillation who was admitted with fever , rapid atrial
fibrillation , shortness of breath , and chest pain. She has had
atrial fibrillation for one and a half years and she had been rate
controlled with Digoxin , Lopressor , and Diltiazem in the past. She
had been poorly compliant with her medications. In 9/19 , she had
a MIBI which was negative for reversible perfusion defect and in
6/10 , she had an echo that showed normal left ventricular size and
left ventricular ejection fraction of 50 to 55% with a large left
atrium. She had moderate distal hypokinesis and trace tricuspid
regurgitation and mitral regurgitation. In 7/13 , she had a Holter
that showed atrial fibrillation/atrial flutter at a rate of 70 to
185. In 4/3 , she was admitted to Pagham University Of
with substernal chest pain and increasing shortness of breath. A
chest X-Ray at this time showed pulmonary edema. She was treated
with intravenous Lopressor and Lasix and ruled out for a myocardial
infarction. One day prior to admission , the patient noted the
onset of increasing shortness of breath and wheezing. She had a
cough productive of yellow sputum. She was seen in the Emergency
Room and at that time , was afebrile with an O2 saturation of 93% on
room air. She was in atrial fibrillation at 100 and her
laboratories were within normal limits. She was discharged to
home. She returned to the Emergency Ward several hours later with
persistent shortness of breath now complaining of substernal chest
pain. She did have a temperature of 101 at this point and she was
admitted for further evaluation. She was given Lasix 20 mg
intravenously in the Emergency Room.
PAST MEDICAL HISTORY: Notable for: 1 ) Chronic atrial
fibrillation. 2 ) Hypertension. 3 )
Non-Insulin dependent diabetes mellitus. 4 ) Diverticulitis status
post sigmoid colectomy. 5 ) Status post ventral hernia repair. 6 )
Status post right carpal-tunnel release.
CURRENT MEDICATIONS: Coumadin 2.5 mg , Restoril as needed , Atenolol 50
mg orally every day , Lasix 20 mg orally every day ,
sublingual Nitroglycerin as needed , and Digoxin. She does not smoke
or drink any alcohol.
ALLERGIES: She is allergic to Penicillin.
PHYSICAL EXAMINATION: She was a Hispanic woman in no apparent
distress. Her temperature was 101.6 , blood
pressure 122/70 , heart rate 110 , she was saturating 99% on two
liters. HEENT: Examination was within normal limits. NECK:
Supple with no lymphadenopathy and no jugular venous distention.
CHEST: Showed diffuse expiratory wheezes with crackles at the left
base. CARDIAC: Examination showed an S1 and S2 with an irregular
heartbeat , there were no murmurs , and her carotids were 2+ without
bruits. ABDOMEN: Soft , non-tender , and non-distended.
EXTREMITIES: Showed no cyanosis , clubbing , or edema.
NEUROLOGICAL: Examination was within normal limits.
LABORATORY EXAMINATION: Chest X-Ray showed pulmonary edema with
question of an infiltrate at the left base
in addition. EKG showed atrial fibrillation at a rate of 111 and
she had no T wave or ST segment changes. Her SMA 7 was within
normal limits , her white blood cell count was 8.7 , her hematocrit
was 42 , her platelets were 201 , her liver function tests were
within normal limits , her INR on admission was 1.7 , and her digoxin
level was 0.4.
HOSPITAL COURSE: The patient was admitted for possible pneumonia
and rule out myocardial infarction as well as
congestive heart failure. She was started on Cefotaxime
intravenously and put on nebulized inhalers. All cultures , blood
and sputum cultures , were negative and her chest X-Ray the next day
was clear suggesting that the patient most likely had a
tracheobronchitis rather than an actual pneumonia. From a cardiac
standpoint , she was admitted for rule out myocardial infarction
protocol. She ruled out , she was given increased diuresis , and her
rales and wheezes improved. Over the next several days , she did
well , however , she did have still some evidence of congestive heart
failure on examination. An echo was obtained which showed an
ejection fraction of 50 to 55% with normal left ventricular size.
The patient was therefore changed from Digoxin to Diltiazem 60
three times a day for her rate control for atrial fibrillation. Her Lasix
dose was also increased to 40 mg orally every day The Atenolol was
discontinued. The patient did very well on this regimen. She had
no further evidence of rales or wheezing and her congestive heart
failure seemed to be in much better control. Her heart rate was
well controlled on the Diltiazem at a rate of 60 to 70 with blood
pressures of 120/70. Her initial complaints of cough also
resolved. She was changed to orally antibiotics and was sent home to
complete a ten day course for presumed pneumonia.
DISPOSITION: The patient is discharged in good condition on
7/18/95 . She is to follow-up with Dr. Noblin , her
primary medical doctor , on Monday , 4/13/95 at his walk-in clinic.
DISCHARGE: Aspirin 325 mg orally every day , Beclovent four puffs inhaled
twice a day , Cephradine 500 mg orally twice a day for five days , Diltiazem 60
mg orally three times a day , Lasix 40 mg orally every day , Robitussin cough medicine
as needed , Atrovent Inhaler two puffs inhaled four times a day , and Coumadin 2.5
mg orally every day
Dictated By: CARLY CALABRETTA , M.D. BZ47
Attending: RUFUS BERNAS , M.D. PM48 VE102/2044
Batch: 8531 Index No. QRDVOP02P3 D: 7/18/95
T: 7/16/95
Document id: 577
| Target |
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314282883 | PUO | 39500472 | | 1261209 | 6/12/2005 12:00:00 a.m. | CAD | | DIS | Admission Date: 4/20/2005 Report Status:
Discharge Date: 11/1/2005
****** FINAL DISCHARGE ORDERS ******
KAEMMERLING , NIDA 697-79-95-0
Ma Lo A
Service: CAR
DISCHARGE PATIENT ON: 2/24/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PETTINGER , DOUGLASS N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 6/4/05 by
ECKLER , ROLANDA , M.D.
on order for ECASA orally 325 MG every day ( ref # 91551122 )
patient has a DEFINITE allergy to Aspirin; reaction is GI
BLEED. Reason for override: Its ok.
DILTIAZEM 30 MG orally three times a day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 6/4/05 by
ECKLER , ROLANDA , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: We know.
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 2/29/05 by
ECKLER , ROLANDA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: HTN
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CLOPIDOGREL 75 MG orally every day Starting IN a.m. June
Override Notice: Override added on 6/4/05 by
ECKLER , ROLANDA , M.D.
on order for NAPROXEN orally ( ref # 32868264 )
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
NAPROXEN Reason for override: md aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally every day Starting Today September
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 2/24/05 by :
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: htn
GLIPIZIDE 5.0 MG every day before noon; 2.5 MG every afternoon orally 5.0 MG every day before noon
2.5 MG every afternoon
METFORMIN EXTENDED RELEASE 500 MG orally twice a day
DIET: Patient should measure weight daily
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Genny Barrette 1/12/2005 2:24PM scheduled ,
Dr. Laquita Overstrom 8/12/05 at 11:15am scheduled ,
ALLERGY: Aspirin , Codeine , HYDROMORPHONE HCL , CAPTOPRIL
ADMIT DIAGNOSIS:
Chest Pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) HTN ( hypertension ) Hyperlipidemia
( hyperlipidemia ) Diabetes Mellitus Type 2 ( diabetes mellitus type
2 ) PUD ( peptic ulcer disease ) Hx GI bleeding ( history of upper GI bleeding )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Sestamibi - adenosine cardiac stress test
Cardiac echocardiograph
BRIEF RESUME OF HOSPITAL COURSE:
*CC: Chest , shoulder pain
*HPI: 43y diabetic man with 3vD , discharged from PUO on 4/11 after
3vCABG , initially manifested as chest tightness and L shoulder pain.
CABG was notable for complex anatomy ( LIMA-LAD , LRad-Ao-OM1 ,
LVB/SVG-PDA ) with small-caliber grafts and a postop course complicated by
MI and pneumonia. Mr. Schroader currently presents with 12 hours continuous
6/10 chest pressure at rest , also sharp L shoulder pain. In the ED , his
pain was relieved by NTG/narcotic. His EKG and cardiac enzymes suggested
against an acute coronary syndrome. He was admitted with suspicion of
pericarditis / pericardial effusion based on history and exam.
He was afebrile and hemodynamically stable in - house but noted to be
hypervolemic with JVP 12cm , clear lungs , and s4 gallop without rub on
cardiac exam , and displaying mild peripheral edema. A sestamibi -
adenosine stress study displayed a small inferobasal area of reversible
perfusion defect without wall motion abnormality. A cardiac
echocardiogram showed a mildly dilated left ventricle with inferior
hypokinesis , an EF of 70% and free of effusion. These tests were
unchanged or improved verses similar tests performed during his prior
admission.
Mr. Schroader was diuresed with 20mg Lasix intravenous x1 followed by 20mg Lasix orally
x1 to which he responded well. At the time of discharge , his chest pain
had complety resolved and he was nearly euvolemic. Also on this
admission , he was noted to develop a bad taste in his mouth as a result of
captopril use. He was then switched to lisinopril with resolution of
symptoms.
Of note during this admission , Mr. Schroader agreed to see a consultant from
the PUO department of Psychiatry for numerous issues within his personal
life which have been causing him distress. Formal recommendations from
psychiatry after extended conversions with Mr. Schroader include a referral
to Family Services at I Temedma Doch Health University And Hospital for couple's
therapy for him and his wife as well as referral to PUO outpatient
psychiatry for individual and possibly pharmacologic therapy.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Consider Cardiac Rehabilitation program as outpatient
No dictated summary
ENTERED BY: ECKLER , ROLANDA , M.D. ( FY73 ) 2/24/05 @ 02:20 PM
****** END OF DISCHARGE ORDERS ******
Document id: 578
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516422342 | PUO | 68996694 | | 0467704 | 7/5/2005 12:00:00 a.m. | LEFT HIP INFECTION | Signed | DIS | Admission Date: 8/29/2005 Report Status: Signed
Discharge Date: 4/5/2005
ATTENDING: RUFUS BERNAS MD
PRINCIPAL DIAGNOSIS:
Left hip infection.
HISTORY OF PRESENT ILLNESS:
This is a 60-year-old female who sustained a mechanical fall out
of bed on 11/8/04 and suffered a left subtrochanteric fracture
for which she underwent left intramedullary nailing at Pagham University Of by Dr. Verna Eckloff . Some weeks later ,
she returned with a left hip infection with drainage noted from
her wound. An irrigation and debridement was performed at an
outside hospital where concern for sepsis had developed in the
context of hypotension. Cultures from this procedure grew out
Methicillin-resistant staphylococcus aureus. She was transferred
to the Pagham University Of for further management; and
on 5/29/05 , another irrigation and debridement was performed by
Dr. Eckloff . Vancomycin and rifampin were begun at this time.
She was discharged to rehabilitation , had convalesced , and
returned home. Not four days later , she was found on follow up
to have continued drainage from the wound and increased pain in
her left hip. She was admitted for treatment of continued left
hip infection. The patient arrived with a PICC line in place on
vancomycin for MRSA infection.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Polymyositis.
3. Fibromyalgia.
4. Asthma.
5. GERD.
6. Hypertension.
7. Osteoarthritis.
8. Depression.
MEDICATIONS:
1. Vancomycin 1000 mg intravenous every 24 hours
2. Lovenox 40 mg subcutaneous daily.
3. Prilosec 20 mg orally daily.
4. Lopressor 25 mg orally three times a day
5. Amitriptyline 100 mg orally every bedtime
6. DuoNeb every 6 hours as needed wheeze.
7. Prozac 40 mg orally daily.
8. Prednisone 7.5 mg orally daily.
9. Benadryl as needed
10. Vicodin as needed
ALLERGIES:
No known drug allergies.
PHYSICAL EXAM ON ADMISSION:
Afebrile , heart rate stable , serosanguineous drainage from left
hip wound , range of motion decreased secondary to pain. Left
lower extremity warm and well perfused. Sensation intact to
light touch in all distributions.
HOSPITAL COURSE:
The patient was admitting from clinic for further evaluation and
management of the suspected left hip infection. A CT scan was
performed which revealed a 12 cm x 7 cm x 4.5 cm fluid collection
lateral to the hip extending into the surrounding soft tissues
with question of contiguity with the nail/intramedullary space.
Given the patient's history with general anesthesia including
desaturations and difficulty with ventilation experienced on
irrigation and debridement in April 2004 management aims were
directed towards the conservative if at all possible. CFH
Radiology was consulted for potential IR drainage of the
collection and anesthesiology was consulted of her previous
events under sedation. On 3/3/05 , the patient underwent a
CT-guided drainage of fluid collection with placement of a
drainage catheter. A 10 cc of pus was immediately aspirated upon
introduction of the guiding needle. A gram stain revealed 4+
PMNs and no growth on aerobic or anaerobic cultures. Blood
cultures drawn the following day also showed no growth. The
Infectious Disease Service continued to follow the patient in
house with recommendations to continue vancomycin without
rifampin that had been suggested upon previous discharge and
despite her itchiness with infusions since no other signs of
symptoms of allergic or anaphylactic reaction had occurred. Her
vancomycin regimen was changed to 1000 mg intravenous every 12 hours and slightly
higher trough levels were tolerated by the ID Service due to the
patient's renal function and the persistence of the patient's
infection. Continued monitoring of vancomycin levels were
therefore not recommended.
Due to continued drainage from the catheterized wound , the
decision was made for treatment of the hip by a multistage
procedure , in which the hardware would be removed and antibiotics
spacer placed temporarily while longterm intravenous antibiotic treatment
was pursued for at least six weeks and finally the hip replaced
with total arthroplasty , once evidence suggested that infection
had been cleared.
On 11/29/05 , the patient underwent removal of the intramedullary
nail , Girdlestone procedure , and placement of antibiotic beads.
Please see the operative note for further details. The procedure
proceeded without complication including any anesthetic events as
had occurred in the past. She was transfused 2 units of packed
red blood cells due to a postoperative hematocrit of 24
experiencing an appropriate rise following transfusion. Gram
stain from intramedullary reamings showed 2+ polys with no
organisms and cultures revealed no growth. She described minimal
pain and was able to weightbear as tolerated on the left lower
extremity without difficulty. A urinary tract infection was
found on preoperative evaluation for the second stage operation
and she was treated with a seven-day course of levofloxacin.
On 4/23/05 , the patient returned to the OR for removal of
antibiotic beads and placement of an antibiotic spacer , please
see the operative note for further details. This too proceeded
without intraoperative complications , however , postoperatively ,
it was found that the spacer head was slightly dislocated. This
was tolerated and the patient was allowed to weightbear. She did
this minimally secondary to increased pain. She was also again
transfused with 2 units of packed red blood cells due to a
hematocrit of 24 with an appropriate rise in her hematocrit
falling. Given the increased pain , the obvious shortening of the
leg with external rotation and without neurovascular compromise
the patient was counseled that operative exploration and
replacement of the spacer would be recommended. While the
patient did understand the need for this , she became more
depressed at the prospect of what described a "set back."
Psychiatry was consulted for support and potential change in
medications if they deemed fit. They did not recommend any
changes in her current antidepressant regimen but did suggest
continued support by social work. This was indeed the case.
By 10/3/05 , the patient was at the peace with the decision for
further surgery and she returned to the OR. Please see the
operative note for further details. The patient underwent a left
antibiotic space replacement with fusion of the head in the
socket. The patient tolerated the procedure well. Her
postoperative course was unremarkable. She did complain of some
pain with movement of her left hip but this was to be expected
given the fusion of the spacer head with the socket and this pain
did improve with time. She also noted some difficulty with
ambulation given her shorter left leg , a left leg lift was
therefore provided to her. By the time of discharge , she was
voiding , tolerating regular diet , and ambulating with assistance.
Physical therapy did work with her for weightbearing as
tolerated on the left lower extremity with posterior precautions.
She was discharged in stable condition to a rehabilitation
facility for further subacute care and with instructions to
continue intravenous vancomycin for another six weeks ( starting date
9/15/05 ). She was also instructed to follow up with Dr. Ibey
in one to two weeks. The patient will followed by the Infectious
Disease Service when she returns in house and the service is
reconsulted at that time.
The patient arrived on the prednisone taper which was eventually
discontinued per patient wishes and agreement with her
rheumatologist , her last dose was on 7/30/05 and she will not
continue with prednisone thereafter.
DISCHARGE INSTRUCTIONS:
1. Please follow electrolytes and vancomycin trough level at
least twice weekly.
2. The patient may shower with assistance , keep incision clean
and dry with dry gauze dressings , changed daily.
3. Continue vancomycin for a six-week course starting on
9/15/05 . A trough up to 30 should be tolerated , please hold for
a creatinine of greater than 1.3 , adjust and hold according to
renal function.
4. Physical therapy , weightbearing as tolerated on the left
lower extremity , leg lift posterior precautions. Follow up with
Dr. Ibey of Orthopedic Surgery in one to two weeks.
DISCHARGE MEDICATIONS:
1. Amitriptyline 100 mg orally every bedtime
2. Valium 1 mg orally every 8 hours as needed muscle spasm.
3. Benadryl 25 mg orally every 6 hours as needed itching.
4. Colace 100 mg orally twice a day as needed constipation.
5. Prozac 40 mg orally daily.
6. Lopressor 25 mg orally three times a day
7. Nubain 10 mg intravenous every 6 hours as needed itching.
8. Oxycodone 5-10 mg orally every 4 hours as needed pain.
9. Lovenox 40 mg subcutaneus daily.
10. Esomeprazole 40 mg orally daily.
11. DuoNeb 3/0.5 mg nebulizer every 6 hours as needed wheeze or shortness
of breath.
12. Vancomycin 1000 mg intravenous every 12 hours premedicated with Benadryl for
itching. Tolerate trough up to 30 hold for creatinine greater
than 1.3.
eScription document: 4-4927050 EMSSten Tel
Dictated By: BREINES , AZALEE
Attending: BERNAS , RUFUS
Dictation ID 4300908
D: 7/30/05
T: 7/30/05
Document id: 579
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
Y |
Y |
N |
Y |
Y |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
245876836 | PUO | 99067599 | | 8123193 | 10/13/2006 12:00:00 a.m. | NSTEMI history of catheterization with DES placed | | DIS | Admission Date: 4/28/2006 Report Status:
Discharge Date: 1/18/2006
****** FINAL DISCHARGE ORDERS ******
DEBNAR , LANITA 202-70-31-3
Ph Ter Do
Service: CAR
DISCHARGE PATIENT ON: 7/25/06 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BLACKGOAT , GERMAINE LAVONNE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally every other day
ECASA 325 MG orally every day
PROZAC ( FLUOXETINE HCL ) 40 MG orally every day
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
2 PUFF inhaled four times a day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Override Notice: Override added on 1/4/06 by
PAMA , WILLIAMS , M.D.
on order for NEPHROCAPS orally ( ref # 656479135 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: will monitor
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 1/4/06 by
PAMA , WILLIAMS , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: will monitor
LANTUS ( INSULIN GLARGINE ) 16 UNITS subcutaneously every bedtime
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LISINOPRIL 2.5 MG orally every day
ACIPHEX ( RABEPRAZOLE ) 20 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally three times a day
Starting Today November
Instructions: This is an increased dose of the lopressor
that you have at home ( do not take your home lopressor
anymore ). Your only other new medications are
PLAVIX , LISINOPRIL and LIPITOR.
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Avril Taplin at KTDUOO 9/22/06 at 10:45AM scheduled ,
Dr. Carri Katcsmorak at PUO Cardiology 10/1/06 at 12:00PM scheduled ,
Dr. Derick In at PUO 9/22/06 at 1:15PM scheduled ,
P Therford Hospital Hemodialysis 10/10/06 at your usual dialysis time ,
ALLERGY: Penicillins , Morphine , Codeine
ADMIT DIAGNOSIS:
NSTEMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTEMI history of catheterization with DES placed
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN DEPRESSION OBESITY TAH/BSO
Diastolic CHF ( EF 60 , LVH , 3+MR ) ( congestive heart failure ) atypical
angina ( neg dobutamine 4/4 ) ( angina ) insulin-resistant DM ( diabetes
mellitus ) GERD ( esophageal reflux ) gout
( gout ) CRI ( creatinine increase from 3 6/29 to 6 6/8 ) ( 4 ) COPD
( chronic obstructive pulmonary disease ) OSA ( sleep
apnea ) anemia ( anemia ) ESRD ( end stage renal
disease ) multiple failed AV fistula placements
OPERATIONS AND PROCEDURES:
cardiac catheterization
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: NSTEMI , troponin 2.98
=================================================
HPI: 74F with ESRD , DM2 , HTN , COPD ( 2L O2 at night ) , diastolic CHF , mild
mitral stenosis , anemia who developed SSCP at rest at 7pm on night PTA
8/10 , persisted until a.m. when she came to ED , found to have troponin
2.98 , CP resolved with NTG drops started for BP control , got ASA , heparin
bolus/drops in ED.
=================================================
PMH:ESRD ( 2/2 DM2 started 11/3 ) / HTN / IDDM2 / diastolic dysfunction
/ GERD / anemia of CKD / mild mitral stenosis
=================================================
MEDS: ASA 325 / cardizem 60 three times a day / lopressor 50 three times a day / proac 40 /
nephrocaps / aciphex 20 / isordil 40 three times a day / lantus 18U HS / albuterol
inhaled four times a day as needed / atrovent inhaled four times a day / allopurinol 100 Tu , Th , Sa / valium 5
q12 as needed / ambien 10 bedtime
====================================================
ALL: PCN->tongue swelling , codeine/morphine-> MS changes
===================================================
EXAM:
98 180/80 ->130/70 with NTG drops 20 100%RA JVP 5-6 / RRR 3/6 SM at
mitral/tric area / CTA / obese / no edema , faint dp , patient pulses
bilateral both feet , ( cool ).
LABS:troponin 2.98 / MB 5.5 ECHO: 6/24/06 EF 45-50% / septal inf HK /
mild LAE / mild MS ( grad 7 ) / mod to severe MR / mild TR
EKG: NSR at 100 , nl axis , LVH , no STTW changes CXR: cardiomegaly ,
clear ( bilateral pleural effusions improved )
=============================================***
HOSPITAL COURSE:
1. CV. The patient was felt to be high risk for CAD on presentation
with her ESRD and DM. Will typical chest pain and a positive troponin
she was felt to have NSTEMI and was immediately placed on Reopro and
Heparin drops , as well as nitro drops for BP and pain control. She did well
overnight and went to hemodialysis and then directly to catheterization
the next morning. She was found to have a 70% LAD lesion which was
stented with a DES. She was started on ACEI , lipitor , ASA , plavix and
her oupatient lopressor was increased. She did well post-cath ,
complaining only of mild numbness/tingling in the lateral R thigh thought
to be a mild compression neuropathy from laying flat for hours post-cath.
Her groin was stable without hematoma and she had good peripheral
pulses. She was discharged to home to continue her cardiac medications
and follow-up with her cardiologist , Dr. Katcsmorak , and her primary care physician. Her BP was
well controlled and she had no rhythm issues throughout the
hospitalization.
2. ESRD. She was followed by the renal team throughout hospitalization
for hemodialysis and had no issues. Per the renal team she received
pre-cath mucomyst as she still makes some urine , and she was started on
lisinopril. She continued on nephrocaps. She will continue HD at
Norap Valley Hospital every MWF after discharge.
3. GOUT: She was continued on her outpatient allopurinol.
4. DM. She was continued on her outpatient insulin regimen with good
FSBG control.
5. COPD. She was continued on her outpatient atrovent with as needed
albuterol and she has oxygen at home.
FULL CODE
ADDITIONAL COMMENTS: Your chest pain was caused by decreased flow to your heart muscle which
was corrected with a metal stent to keep the blood vessel in your heart
open. It is VERY important that you NEVER miss a day of your new
medication PLAVIX because this medication keeps that metal stent open.
Call Dr. Katcsmorak or Dr. Hazinski if you have any chest pain , shortness of
breath or any other worrisome symptoms. Keep eating a heart-healthy
diet , gradually increase your exercise back to your baseline and take all
of your med
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: BORRIELLO , SACHIKO S. , M.D. ( EP65 ) 7/25/06 @ 11:44 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 580
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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567631637 | PUO | 50929184 | | 1716266 | 11/28/2006 12:00:00 a.m. | FEVER | Signed | DIS | Admission Date: 10/20/2006 Report Status: Signed
Discharge Date: 1/16/2006
ATTENDING: MOLTER , ROXANNA MD
CHIEF COMPLAINT:
The patient came in with chief complaint of altered mental status
and questionable fever.
HISTORY OF PRESENT ILLNESS:
This is an 82-year-old male with multiple medical problems ,
coronary artery disease status post CABG , congestive heart
failure with EF of 30% in 2005 , diabetes , and renal insufficiency
with several recent hospitalizations who is discharged from the
hospital on 8/24/06 status post a CHF exacerbation , and a
pneumonia , and an UTI in the previous admission was complicated with Pseudomonas
and was treated with ceftriaxone , but then later on cefepime. Of note ,
Since then , the patient had a progressive changes in
mental status and increasing confusion with difficulty balancing
and becoming lethargic. Thus , prompted the patient to come to the
emergency room. In the ED , on 11/8/06 , the patient was
afebrile , vital signs stable , who was received vancomycin ,
ceftazidime and levofloxacin. At that point in time , a 1 liter
of normal saline.
PHYSICAL EXAMINATION ON ADMISSION:
Temperature was 97.6 , heart rate in the 60s , blood pressure was
stable at 120/60 and 96% on 2 liters. The patient , otherwise ,
cardiac exam has a systolic murmur , which is right upper sternal
border. Abdominal exam was soft , mildly distended and hypoactive
with bowel sounds. The patient's extremities , on the right lower
extremity was noted to be amputated of metatarsals and in the
left extremity , posterior distal 5-cm area has a erythematous ,
warm area of pus muscle and fascia exposed , no bone area of overt
necrosis. No evidence of exposure of bone or no exposed bone or
any areas of overt necrosis.
LABORATORY DATA:
At that point , his lab was significant for creatinine 1.4 and BUN
of 25 , total bilirubin of 1.6 , and he has a 10.7 white blood
count and 37 of hematocrit. The patient's chest x-ray show
questionable right pulmonary edema versus pneumonia and the
patient also had received an echo in the past , which shows an EF
30% , an LVH , hypokinesis of the anterior wall and a mild MR. EKG
was sinus and mild left axis on admission day.
HOSPITAL COURSE BY SYSTEM:
1. Infectious Disease: The patient has this open ulcer on the left
lower extremity on the posterior thigh shows a 5-8 cm area of
erythematous fascia and muscle exposed likely may be cellulitis ,
but at the time of admission , there was no pus drainage , but
erythema was noted with given patient's history of diabetes and
recent hospitalization and also pseudomonal infection from the wound , so the
patient will start to treat with vancomycin and Zosyn. However ,
culture shows a Staph , Pseudomonas and Gram-negative rods on
vancomycin and Zosyn , so we changed to ceftazidime and ultimately
changed to imipenem and vancomycin because of sensitivities.
Plastic surgery was consulted and asked for wet-to-dry dressing
and MRI was also achieved and shows no signs of osteomyelitis and
Plastic also thinks that the wound has been well taken care of
during his stay at the hospital , and the lesion has been stable.
The patient should be continued on vancomycin and imipenem as an outpatient and
should be followed by his primary care , Dr. Erma Bess , in 2 weeks
for wound care as well as for infectious disease follow up.
Plastic , also recommended that the patient should have to
continue his wet-to-dry dressings for wound care. Plastic , also
recommended a cream called Ethezyme , which was instructed to
apply in the lower and upper margin of the ulcer and for daily bandage
changes.
2. Pulmonary: There were no active issues. There was a
questionable pneumonia , however , it was resolved spontaneously
with antibiotic treatment and chest x-ray has been unremarkable
with his following chest x-ray. The last chest x-ray that he
received was on 2/5/06 prior to discharge and it shows moderate
degenerative changes of the mid thoracic spine , but no
significant infiltrates was noted and no focal area of
consolidations. The patient had stable moderate cardiomegaly and
satisfactory positioning of the right central venous catheter ,
which is his PICC for the intravenous antibiotics. No acute
cardiopulmonary diseases were noted on chest x-ray.
3. Cardiovascular: The patient had a history of coronary artery
disease status post a CABG and a congestive heart failure with EF
of 30% status post recent admission for CHF on exacerbation. The
patient was admitted to the hospital with the monitoring of
strict Ins and Outs with daily weight but no apparent active
issues during the hospital stay. The patient has a fluid
restricted diet of less tan 1500 mL and the patient was on
antihypertensive , aspirin , Plavix , as well as on a cardiovascular
diet. Of note , the patient's captopril 12.5 mg orally every 8 hours was
changed to lisinopril 5 mg orally daily. So , we had to increase
his Lasix to 80 mg orally twice a day at the beginning because of mildly
elevated BNP , however , we decreased a Lasix to 40 mg daily due to
over diuresis and the patient has been doing well for with
negative diuresis of about 1 liter.
4. Hematology: The patient hematocrit has been stable , however ,
that has been stable at 37 and on discharge it was 32 ( please refer to GI for
details ).
5. GI: The patient had a blood cards , has been no issues of
irregular bowel movement about once every two days has been on a
bowel regimen. However , about 2 days prior to discharge on
6/17/06 early morning the patient had a bowel.
HOSPITAL COURSE:
Gastroenterology: The patient has no active GI issues during
this whole hospital stay. However , on 6/17/06 , early morning ,
the patient had a one huge bowel movement which included blood
clots that were witnessed by nursing. At that point in time , we
got a hematocrit back and it was 33 , and previous patient's
hematocrit was 37. Due to this event , the patient was asked to
stay in the hospital for one more night for further evaluation.
A GI consult was called from Berlcal Hospital , Dr. Jerabek ,
and Dr. Jerabek reveals that that the patient actually had a
colonoscopy about a year ago , which shows diverticuli ,
hemorrhoids as well as a cecal AVM that is not actively bleeding.
Dr. Gumina , who was the attending at this point in time ,
recommended that we should follow up one more set of labs to make
sure that the patient was not actively bleeding prior to
discharge , and the patient's hematocrit on 11/12/06 , morning , was
32 as well as on 8/16/05 , morning , was 33 and it was stable.
Overnight , the patient did not have any bowel movement.
Renal: In terms of renal , the patient's creatinine has been
stable between 1 to 1.2. The patient's admission creatinine was
1.4 , which has slowly dropped between 1 to 1.2. The patient does
in the past have elevated creatinine which resolved
spontaneously.
Endocrine: In terms of endocrine , the patient is a type II
diabetic , which was covered by sliding scale , and the patient
does have elevated TSH , low TFTs , and due to the patient's
history of lithium use , there is no need for Synthroid currently.
The patient's glucose has been well controlled in the hospital
with Lantus of 10 units , and it has been ranging between 110 to
140. The patient will need regular fingerstick of before meals and at
bedtime before meal time and also at night to ensure that the
patient is covered by enough insulin.
Neurology: In terms of neurology exam , the patient had a CT scan
that was negative , and talking to family members , the patient
actually has returned back to his original mental status. The
patient does have some hearing problem , so it is extremely
important to speak to the patient clearly and may be at times
have to whisper to the patient's ears for him to able to
understand the communication. The patient had negative CT scan ,
but however , his physical is consistent with Parkinson's disease.
During the evening time as well as early morning time , the
patient does have waxing and waning episodes where the patient
starts to get confused in terms of times and day as well as
place. However , usually after breakfast , the patient will become
alert and oriented x3 again.
Prophylaxis: The patient is on PPI and Lovenox.
The patient was going to be discharged home on antibiotics. The
patient has completed his 10 days of imipenem antibiotics and
vancomycin of 13 days and the patient will continue antibiotics
for the next one to two weeks and will follow up with Dr. Erma D Bess , and his clinic number is 198-465-2543. The patient was
discharged home with following medications and they are aspirin
81 mg orally daily , albuterol nebulizer 2.5 mg nebs every 4 hours and
as needed for shortness of breath , Dulcolax 10 mg PR daily as needed
for constipation , Celexa 20 mg orally daily , Plavix 75 mg orally
daily , Colace 100 mg orally twice a day , enoxaparin , which is the
Lovenox , 30 mg subcutaneously for prophylaxis , Nexium 20 mg orally
daily for prophylaxis , Ethezyme one applicator topical twice a day ,
that will be applied on his wound on the upper and the lower
edges of the ulcerated region and also he would need dressing
change in association with the application of the cream , folic
acid 1 mg orally daily , Lasix 40 mg orally daily , and imipenem 500 mg
intravenous every 8 hours He is on Lantus 10 units subcutaneous every afternoon , and he
is also covered with Insulin Regular sliding scale. If insulin
is less than 125 , should not give any units , if it is between 125
and 150 , give 2 units , if it is between 151 and 200 , should given
3 units subcutaneously , if it is between 201 and 250 , should give
4 units , if it is between 251 and 300 , should give 6 units , and
if it is between 301 to 350 , should give 8 units , and if higher
than 350 , should give 10 units. The patient is also on Imdur 90
mg orally daily , hold if systolic pressure less than 100 and heart
rate less than 55 , lactulose 30 mL twice a day as needed for
constipation , Synthroid 137 mcg orally daily , lisinopril 5 mg orally
daily , and Maalox tablets one to two tablets orally every 6 hours as needed
for upset stomach , he will not be discharged to rehabilitation
center with magnesium , Zaroxolyn 2.5 mg twice weekly , Lopressor
12.5 mg orally twice a day , Zyprexa 2.5 mg orally as needed for anxiety and
usually given at bedtime , oxycodone 5 mg orally every 6 hours as needed for
pain , senna , which is a tablet for his GI , two tablets orally
twice a day as needed for constipation , multivitamins one tablet orally
daily , and vancomycin 1 g intravenous every 12 hours
DISCHARGE CONDITION:
Stable.
CODE STATUS:
DNR. No CRP , no defibrillation , and no intubation.
DISCHARGE INSTRUCTIONS:
1. The patient will continue antibiotics , imipenem and
vancomycin. The patient had 10 days of completed imipenem at the
hospital and vancomycin of 13 days , and the patient will be
continued on imipenem and vancomycin until further notice by his
primary care doctor , Dr. Erma Bess , in two weeks.
2. The patient will continue to have dressing changes twice a day
wet-to-dry on his left lower extremity with Ethezyme cream
applied on the lower upper edges of the ulcerated lesion.
3. The patient should continue to have a before meals and at bedtime
blood glucose monitoring for the rehab stay. The patient will
continue to have blood glucose checked as a continued basis. In
terms of endocrine at this point in time , the patient is covered
by Lantus 10 units and covered by sliding scale. The patient
should also continue to have strict ins and outs and also daily
weights after discharge.
eScription document: 1-1367056 EMSSten Tel
Dictated By: LAPATRA , LETA
Attending: MOLTER , ROXANNA
Dictation ID 7403730
D: 11/12/06 \.br&.br\: 11/12/06
Document id: 581
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
N |
N |
- |
N |
745179229 | PUO | 17981485 | | 977705 | 2/29/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 2/29/1990 Report Status: Unsigned
Discharge Date: 10/18/1990
DISCHARGE DIAGNOSIS: 1 )MYOCARDIAL INFARCTION.
2 )CONGESTIVE HEART FAILURE.
3 )HYPERTENSION.
HISTORY OF PRESENT ILLNESS: This patient is a 60-year-old white
male who presented with a two week
history of paroxysmal nocturnal dyspnea and dyspnea on exertion
admitted with new EKG changes consistent with myocardial infarction
for rule out MI. The patient's cardiac risk factors are diabetes ,
hypertension , distant smoking history. There is no history of
increased cholesterol and no family history of heart disease. The
patient noted the onset of exertional shortness of breath around
the beginning of 10 of October . At that time the patient was experiencing
increased stress because of the recent death of the patient's
sister-in-law. The patient consulted his local physician , Dr.
Cole Emanuelson , on 14 of October . An EKG at that time showed no change
from an EKG of a year earlier. Over the next week the patient
reported feeling weak , general malaise , experienced occasional
chills with continuing dyspnea on exertion. There was one event on
7 of July where the patient experienced chest pain with severe
diaphoresis and a chill which he attributed to the flu although the
patient did not seek medical attention at that time. Over the last
10 to 14 days prior to admission the patient noted increasing
exertional dyspnea , three episodes of paroxysmal nocturnal dyspnea
associated with right chest discomfort. There was no nausea ,
vomiting , diaphoresis , cyanosis. The patient also noted edema in
his lower extremities over the last two weeks. The last episode of
paroxysmal nocturnal dyspnea was this past weekend. On the day of
admission the patient saw Dr. Pidro once again and EKG
demonstrated marked anterolateral changes that were new since the
EKG taken on 14 of October . The patient presented to the Pagham University Of Emergency Ward. PAST MEDICAL HISTORY: Significant
for hypertension of approximately 10 years , non-insulin dependent
diabetes mellitus of approximately 12 years , left Bell's palsy in
1985 treated with prednisone , type intravenous hypolipoproteinemia. The
patient was also admitted for right face and arm pain at the
Kernan To Dautedi University Of Of in 21 of April . This was attributed to TIA. Carotid
non-invasives at that time along with a head CT were reportedly
negative. The patient also had a right cranial nerve III palsy in
30 of August . MEDICATIONS: Micronase 10 mg orally twice a day , Persantine 60 mg orally
three times a day , aspirin one orally every day , Lisinopril 5 mg orally every day , and Atenolol 50 mg
orally every day ALLERGIES: None known. SOCIAL HISTORY: There is
approximately 20 pack year history of smoking. The patient quit
cigarettes 20 years ago. Ethanol history was social. The patient
is married , has two grown children. He currently works in a short
term storage warehouse office , apparently recently lost his tobacco
shop business and there is certainly a potential stress regarding
his employment situation and recent death of his sister-in-law
following a prolonged illness. FAMILY HISTORY: The patient reports
his parents are still living , has single sibling who is alive and
well. He denies family history of coronary artery disease ,
hypertension or diabetes. REVIEW OF SYSTEMS: Non-contributory.
PHYSICAL EXAMINATION: The patient was a thin white male in no
acute distress sitting up on the stretcher.
Vital signs demonstrated he was afebrile , blood pressure 140/90 ,
pulse 88 , respirations 18. His room air O2 sat was 96%. HEENT
exam normocephalic , atraumatic. Left pupil was 5 mm and contracted
to 3; right pupil was 4 mm and contracted to 3. His extraocular
movements were intact. Fundi were poorly visualized secondary to
possible partial cataract. Oropharynx was only remarkable for
extensive upper bridge work. Neck was supple , no adenopathy. His
carotids were 1+ bilaterally without bruits. His chest exam was
remarkable for decreased breath sounds halfway up , right greater
than left , with absent breath sounds at the bases. The chest was
dull to percussion halfway up , however , there were no rales ,
wheezes or rhonchi noted. Cardiac exam revealed jugular venous
pulse was approximately 7 cm at 30 degrees , regular rate and
rhythm , S1 and S2 with loud S4 , otherwise no murmur or rub.
Abdominal exam demonstrated bowel sounds were present , non-tender ,
liver span 8 cm in midclavicular line. There was no spleen tip
palpable. Rectal exam normal tone with a firm prostate without
masses and stool was guaiac negative. Back exam revealed no spinal
or CVA tenderness noted. There was slight buffalo hump present ,
however. Extremities - Radial pulses 3+ , femoral 2+ , posterior
tibial 2+ on the right and 1+ on the left , dorsal pedis 1+
bilaterally. There are no femoral bruits. There was 1+ pitting
ankle edema bilaterally. Neuro exam was non-focal.
LABORATORY DATA: On admission sodium 141 , potassium 4.6 , chloride
105 , CO2 24 , BUN 19 , creatinine 0.9 , glucose 178.
ALT 20 , AST 18 , LDH 177. CK 107. Alk phos 98 , bili total 0.5 ,
direct 0.2. Cholesterol 236 , triglycerides 320. Total protein
7.0 , globulin 4.6 , albumin 2.4 , calcium 9.9 , phosphate 3.8. White
count 6.6 , Hct 39.8 , platelets 260 , 000 , three point differential
revealed 26% lymphocytes , 5.8% monocytes , 68.2% granulocytes. physical therapy
was 12.6 , PTT 31.0. UA was pending. EKG showed normal sinus
rhythm at a rate of 84 , PR interval 160 , QRS 84 , QTC 0.44 , axis
+30. The EKG was remarkable for Q wave in T and F and extensively
across the precordium , T wave inversions in 1 , 2 , and R. ST
elevations of 2 to 3 mm in V2 , V3 , and V4 with T wave inversion in
V2 through V6 , all of these changes new since 21 of April . Portable
chest x-ray demonstrated bilateral pleural effusions with fluid in
the minor fissures , question of cardiomegaly , increasing pulmonary
vascular redistribution consistent with congestive heart failure.
HOSPITAL COURSE: The patient was admitted to the General Medical
Service Ing Si Ho and subsequently ruled out for MI
by enzymes. His initial CK was 107. Eight hours later his CK
drawn was 45 and final CK was 89. However , the patient underwent
echocardiography and the echocardiogram demonstrated a moderately
dilated left ventricle with decreased global contractile function ,
roughly estimated at around 25%. There were extensive wall motion
abnormalities with mid to distal septal akinesis , anterior ,
anterolateral , and septal apex dyskinesis consistent with a large
anterior myocardial infarction. However , there was no mural
thrombus seen although occult thrombi could not be excluded at that
time. Because of the echocardiogram result and the fact that the
patient ruled out for a recent MI the clinical picture was
consistent with an evolved myocardial infarction within the time
between the patient's initial presentation to Dr. Pidro in 10 of October
and the patient's presentation in 16 of October . Consequently the plan was
made to manage the patient with gentle Lasix diuresis. The
patient's beta blocker was held because of the concern for wall
motion abnormalities and possible aneurysm formation. The patient
was anticoagulated on heparin and subsequently was loaded on
Coumadin. In addition the patient's afterload reduction was
increased and changed to Captopril. In addition the patient
underwent an exercise tolerance test with thallium scan on
1 of November . During this procedure the patient exercised for 6
minutes on modified Bruce protocol. The test was stopped secondary
to leg fatigue. The patient's heart rate rose from 98 to 150 ,
blood pressure rose from 126/72 to 148/76. The patient had no
chest pain. There was no evidence for ischemia. Thallium images
showed a moderately severe perfusion defect at the apex sustained
to the low anterior wall , inferolateral wall , and septum. This
defect was unchanged on late images. There were , therefore , no
signs of ischemia , however , there was some mild transient loss of
uptake consistent with CHF. The overall impression was of a fixed
defect consistent with an evolved myocardial infarction. Because
of the evidence for an evolved myocardial infarction the decision
was made that this patient would not be a candidate for coronary
artery bypass grafting and so cardiac catheterization was deferred
at this time. The patient was discharged to home on 16 of April . At
the time of discharge a UA and sediment were pending.
DISPOSITION: DISCHARGE MEDICATIONS: Lasix 40 mg orally every day , Captopril
37.5 mg orally three times a day , Ecotrin 325 mg orally every day , Coumadin 5 mg
orally every bedtime , magnesium oxide two tablets orally every day , Isordil 10 mg orally three times a day
with meals , and Micronase 10 mg orally twice a day CONDITION ON DISCHARGE:
Stable. FOLLOW-UP: With Dr. Cole Emanuelson in his office on
Tuesday , 9 of August , at 3 p.m.
________________________________ LL290/4971
COLE D. EMANUELSON , M.D. ER8 D: 10/15/90
Batch: 9533 Report: G0589N8 T: 2/18/90
Dictated By: DION POLLIO VVX5
cc: 1. BRITTANEY HAMBLET , M.D.
Document id: 582
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
N |
N |
Y |
Y |
N |
N |
570822487 | PUO | 60118630 | | 664375 | 10/27/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/5/1996 Report Status: Signed
Discharge Date: 8/30/1996
ADMITTING DIAGNOSIS: DEEP VENOUS THROMBOSIS OF THE RIGHT.
OTHER DIAGNOSES: CHRONIC DYSURIA.
OBSTRUCTIVE SLEEP APNEA.
MENORRHEA.
INSULIN-DEPENDENT DIABETES MELLITUS.
GASTROESOPHAGEAL REFLUX DISEASE.
DEPRESSION.
HYPERTENSION.
IDENTIFICATION: This is a 35-year-old woman who presented with
left lower extremity pain.
HISTORY OF PRESENT ILLNESS: She is a 35-year-old , morbidly obese
woman who has a history of diabetes
as well as sleep apnea , who now presents two days after persistent
left lower extremity throbbing , cramping , calf pain. She was very
non-mobile , spending most of her time in bed secondary to
non-motivation. She denies any leg swelling , trauma , or recent
travel. She also denies pleuritic pain and swelling. She also had
previous left lower extremity pain and had a negative LENIs in
1993. She had a recent right lower extremity cellulitis and she
was treated in October 1996 with Keflex and Zovirax.
PAST MEDICAL HISTORY: Chronic urea. She is status past
appendectomy. She has had incidence of
diabetes. She has gastroesophageal reflux disease , as well as
hemorrhoids. She has a history of depression , hypertension ,
obstructive sleep apnea , as well as amenorrhea.
ALLERGIES: She is allergic to penicillin and Bactrim , which gives
her a rash.
ADMISSION MEDICATIONS: Keflex four times a day , Zovirax 500 five times a
day , Bentyl 20 every 6 hours as needed , Provera and
trazodone 150 every bedtime , Elavil 25 every bedtime , Prozac 60 every day before noon , Insulin
70/30 which gets 35 in the morning and 25 at night , lisinopril 215
once a day , CPAP , as well as Percocet as needed
PHYSICAL EXAMINATION: Her temperature was 99.7 , pulse 90 ,
respiratory rate 18 , blood pressure
110/palp. She is a morbidly obese , white woman who was lying in
bed in no apparent distress. Her HEENT examination was benign.
Chest was clear to auscultation bilaterally. Cardiac examination
was without distant heart sounds. Abdomen was soft , obese ,
non-tender , and non-distended. Extremities had positive left shin
sebaceous non-healing ulcer that measured 61 mm on the calf. She
had a positive Homans , positive calf tenderness , but no palpable
pulse. Her right side showed a healing ulcer and covered 60 cm.
Rectal examination was guaiac negative.
HOSPITAL COURSE: The patient was admitted to the hospital with the
presenting diagnosis of deep venous thrombosis of
the left lower extremity. She underwent LENIs which showed that
markedly poor examination due to the patient's body habitus , there
was no obstructive thrombus identified in the left common femoral
popliteal vein at the knee and sebaceous wound was not identified.
The patient was treated because she did have the signs of deep
venous thrombus with intravenous heparin , as well as Coumadin. It took a
lot of heparin and Coumadin to get her therapeutic so that by the
time of discharge , her INR was 1.8. So she is being discharged on
10 mg of Coumadin a night with the plan for her to follow up
tomorrow morning where she will be checked for INR once again.
There were no other complications during this hospitalization. Her
other problems were all treated with the medications that she was
on and no other changes were made.
DISCHARGE MEDICATIONS: Elavil 10 mg every bedtime , Benzal 20 mg twice a day ,
Colace 100 mg twice a day , Prozac 50 mg orally
every day before noon , lisinopril 25 mg orally every day , Provera 40 mg orally every day ,
Coumadin 10 mg orally every bedtime , Reglan 10 mg orally every day , trazodone 100
mg orally every bedtime , and insulin 70/30 35 units every day before noon and 25 units
every afternoon
DISCHARGE CONDITION: Stable condition.
FOLLOW-UP: She is planned to follow up with Dr. Sic at CHH on
3/7/96 .
Dictated By: MARIKO DYKHOFF , M.D. BK5
Attending: DERICK D. YAN , M.D. MJ24 DE437/9769
Batch: 02264 Index No. I2YRZZAA0 D: 10/15/96
T: 6/24/96
Document id: 583
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
- |
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- |
- |
- |
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- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
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518371046 | PUO | 58113739 | | 238628 | 8/24/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/14/1996 Report Status: Signed
Discharge Date: 2/2/1996
PRINCIPAL DIAGNOSIS: UNSTABLE ANGINA.
HISTORY OF PRESENT ILLNESS: Bao Zupfer is a
68-year-old psychiatrist with a
history of hypertension , recent positive exercise test several
weeks prior to admission who now presented with increasing
frequency of chest pain with exertion , as well as at rest. The
patient is admitted for cardiac catheterization.
The patient states that he has been in good health all of his life ,
with history of some hypertension and sinus tachycardia. He is
followed by Drs. Clint Eboni Defore . A routine exercise stress test had
been reported as equivocal for coronary artery disease. Records of
this test are currently unavailable. Since 1995 , the patient has
done well without any anginal symptoms until February 1996 when he
was admitted to the Pagham University Of for rule out
myocardial infarction after experiencing recurrent palpitations and
sudden feelings of hunger associated with chest pressure. At that
time , there were no EKG changes. His CK and troponin levels were
flat. No arrhythmias were noted during the brief hospitalization.
He was discharged on a beta blocker , as well as a calcium channel
blocker. In September 1996 , the patient underwent a repeat annual
exercise stress test. This time , he was able to go only 4.4
minutes , stopped with fatigue , shortness of breath , and
palpitations , noted to correlate with atrial premature beats. He also
developed 4/10 chest pressure that was relieved with rest and
nitroglycerin. His maximum heart rate was 127 , maximum blood
pressure 120/60. EKGs during exercise revealed 2 mm ST depressions
in leads II , III , AVF , and V4 , and 1 mm depressions in leads V3 ,
V5 , and V6. These EKG changes persisted into 30 minutes of
recovery.
In the four weeks following this positive ETT , the patient noted a
drastic decrease in his exercise capacity and he developed onset of
substernal chest pain with exertion. This discomfort was
associated with shortness of breath , no clear radiation. There was
never any nausea , vomiting , diaphoresis , or palpitations associated
with this chest pain. In the two weeks prior to admission , the
patient developed similar substernal chest pain at rest on several
occasions. All of these were relieved with sublingual
nitroglycerin.
On the evening prior to admission , the patient developed substernal
chest pain during a music concert. This occurred at rest and
lasted approximately 10 minutes , relieved with one sublingual
nitroglycerin. The next morning , the patient notified his primary
cardiologist about the increased frequency of his chest pain , and
he was , therefore , admitted for cardiac catheterization.
The patient on admission , was chest pain-free , denies palpitations ,
and shortness of breath. His cardiac risk factors include his age ,
sex , smoking history , positive family history , and elevated
cholesterol level. The patient denies orthopnea , paroxysmal
nocturnal dyspnea , and ankle edema. He has no pleuritic chest pain
and no calf tenderness.
PAST MEDICAL HISTORY: 1. Hypertension. 2. "Palpitations" ,
question of premature atrial contractions.
3. Benign prostatic hypertrophy. 4. Depression.
ALLERGIES: The patient is allergic to horse serum which causes a
rash.
ADMISSION MEDICATIONS: 1. Sular 10 mg every day. 2. Zebeta 5 mg
every day. 3. Zoloft 50 mg every day. 4. Enteric
coated aspirin 325 mg every day.
FAMILY HISTORY: The patient's mother suffered a myocardial
infarction in her 70s , also history of strokes.
The patient's father had a stroke and died of a cerebral
hemorrhage.
SOCIAL HISTORY: The patient is married and lives with his wife in
Fullsonxing He is currently still
practicing as a psychiatrist. He has a 25 year smoking history , up
to three packs per day. He quit five years ago. He denies alcohol
use.
PHYSICAL EXAMINATION: The patient is a pleasant , well built ,
white male lying in bed in no
apparent distress. His temperature was 97.6 , pulse 56 , blood
pressure 110/64 , and respiratory rate 20. HEENT examination was
anicteric. Oropharynx had no lesions. Neck was supple with no
lymphadenopathy. There were brisk carotid upstrokes , but with no
bruits. His JVP was around 6 cm. His lungs were clear to
auscultation. There was no costovertebral angle tenderness. His
heart examination had a regular rate and rhythm with a I/VI
systolic ejection murmur at the left upper sternal border. His
abdomen was soft , nontender , with normal bowel sounds. There was
no hepatosplenomegaly. Femoral pulses were 2+ bilaterally without
bruits. His extremities revealed no clubbing , cyanosis , or edema.
He had 2+ DP and physical therapy pulses. Neurologic examination was nonfocal.
His deep tendon reflexes were reduced to 0-1+ bilaterally.
LABORATORY DATA: Sodium was 144 , potassium 4.5 , chloride 104 ,
bicarbonate 23 , BUN 20 , and creatinine 1.4.
Liver function tests were all within normal limits. His CBC
revealed a white count of 6.10 , hematocrit 37.9 , and platelet count
285 , 000. His physical therapy was 11.8 , PTT 28.5. His fasting cholesterol , done
prior to admission , revealed a triglyceride of 121 , HDL 43 , and LDL
131. Urinalysis was negative. His EKG , on admission , revealed a
normal sinus rhythm at 59 beats per minute and axis up to 68
degrees with normal intervals. There was poor R wave progression
with large R waves in V1 and V2 consistent with an old posterior
infarct. There were occasional APVs with two different physical therapy/T wave
morphologies. His chest x-ray , on admission , revealed no acute
cardiopulmonary process , unchanged from prior film.
ASSESSMENT: The patient is a 68-year-old man with history of
hypertension , positive exercise tolerance test several
weeks prior to admission , now presenting with crescendo angina for
cardiac catheterization.
HOSPITAL COURSE: The patient was taken to the catheterization
laboratory for cardiac catheterization on the
second day of admission. The catheterization revealed a 60%-70%
proximal stenosis of his LAD and a 40% proximal stenosis of his
RCA. His left circumflex appeared normal. After an extensive
discussion with Dr. Frehse , Dr. Kush , and Dr. Ventresca , the decision
was made to stent the LAD lesion. The LAD was subsequently
successfully stented with a 0% residual stenosis. Following the
successful PTCA , the patient was placed on heparin and Ticlid for
48 hours. During this period of time , the patient had one episode
of mild chest discomfort which was epigastric in nature , and was
relieved with Maalox. There were no associated EKG changes. At
the end of the 48 hours of heparin and Ticlid , the patient was
discharged home to complete a total of 28 days of Ticlid. On the
day of discharge , the patient was started on fluvastatin for his
elevated LDL level. He is to follow up with Dr. Kush for furtther
management.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Sular 10 mg every day , Zebeta 5 mg every day ,
Zoloft 50 mg every day , enteric coated aspirin
325 mg every day , Ticlid 250 mg twice a day times 28 days , fluvastatin 20 mg
every bedtime , Sarna topical as needed for pruritus.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow up
with Dr. Kush and to get every other week
blood draws for check of his white count for six weeks.
FOLLOW-UP: The patient was to follow up with Dr. Kush in
the week following his discharge.
Dictated By: JOANA I. ZERBE , M.D. NH8
Attending: QUINN J. KUSH , M.D. NE5 IH195/0822
Batch: 00254 Index No. T4WDWHMSF D: 6/23/96
T: 3/25/96
CC: 1. QUINN J. KUSH , M.D. PQ5
2. Clint Defore , M.D.
Document id: 584
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
- |
- |
- |
- |
- |
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- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
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275517606 | PUO | 86700356 | | 932716 | 1/13/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/13/1991 Report Status: Signed
Discharge Date: 9/20/1991
DISCHARGE DIAGNOSES: UNSTABLE ANGINA , ADMITTED FOR
PERCUTANEOUS TRANSLUMINAL CORONARY
ANGIOPLASTY.
HYPERTENSION.
BILATERAL RENAL ARTERY STENOSIS.
STATUS POST ONE EPISODE OF ATRIAL
FIBRILLATION ON 13 of October , WITH
SPONTANEOUS RESOLUTION.
HISTORY OF PRESENT ILLNESS: The patient was a 50 year old white
male transferred from
Akcare Hospital after an episode of atrial fibrillation on
13 of October , and unstable angina. Cardiac risk factors included
hypertension , smoking , family history. He had a myocardial
infarction in 1970 , and had been basically pain-free until 1985 ,
when he began experiencing stable angina , requiring one sublingual
nitroglycerin every 2 weeks. His typical anginal equivalent is
bilateral wrist tingling , plus some left arm or chest pressure. The
pain is brought on by exertion , relieved by nitroglycerin and rest.
His last exercise tolerance test with thallium was in 26 of September , when
he went 5 minutes on a standard Bruce protocol , and stopped because
of fatigue. Maximal blood pressure was 165/85 , heart rate 95 , rate
pressure product 15675. He experienced his typical wrist
discomfort , an his electrocardiogram showed left ventricular
hypertrophy with strain , focal premature ventricular contractions
and ventricular bigeminy. There was no evidence of ischemia on the
thallium images. On 13 of October , the patient experienced a left arm
dull ache radiating to the left side of his chest , unlike his usual
angina equivalent. It was not relieved by nitroglycerin or by
rest. He called his Carna Home Hospital physician and
went to his local hospital. He denied palpitations , shortness of
breath , nausea , vomiting , diaphoresis. On presentation , he was
found to be in atrial fibrillation with ventricular rate 140. He
spontaneously converted to normal sinus rhythm and sinus
bradycardia to 55. He had no previous history of atrial
fibrillation. The patient ruled out for a myocardial infarction ,
and while in the hospital experienced 3 to 4 episodes of his usual
anginal equivalent of wrist pain , relieved by 1 nitroglycerin each
time. It was unclear whether these symptoms were associated with
electrocardiogram changes. He received intravenous
trinitroglycerin at some point , and he was transferred here for
further evaluation of his rest pain. PAST MEDICAL HISTORY revealed
hypertension , ischemic heart disease as above , peptic ulcer
disease , hiatal hernia. MEDICATIONS ON ADMISSION at the time of
transfer were diltiazem 90 milligrams by mouth 4 times a day ,
Lopressor 25 milligrams by mouth twice a day , Isordil 40 milligrams
by mouth twice a day , Lisinopril 5 milligrams by mouth twice a day ,
Zantac 150 milligrams by mouth at hour of sleep , digoxin .25
milligrams by mouth per day. ALLERGIES included no known drug
allergies. FAMILY HISTORY was positive for coronary artery
disease. SOCIAL HISTORY revealed the patient has a desk job at a
furniture store. He used to smoke 3 packs per day , quit 6 years
ago. He drinks 3 beers a week. He lives with his wife and one son
at home , and 2 other grown children. REVIEW OF SYSTEMS was
negative.
PHYSICAL EXAMINATION: Blood pressure was 190/90 , pulse 60 and
regular , respiratory rate 16 , no acute
distress. Head and neck examination was unremarkable , jugular
venous pressure flat. Chest showed diminished breath sounds
diffusely , no wheezes or crackles. Cardiovascular examination
showed a III/VI systolic ejection murmur loudest at the aortic
area , and a II/VI systolic murmur at the apex radiating halfway to
the axilla. Abdomen was soft , benign. Femoral pulses were 2+
bilaterally with bruits left greater than right. Extremities
showed no cyanosis , clubbing or edema , palpable pedal pulses.
Neurologic examination was nonfocal.
LABORATORY EXAMINATION: An echocardiogram at the outside hospital
on 9 of September , showed left atrium size 42
millimeters , mild left ventricular hypertrophy , posterior
hypokinesis , preserved systolic function , aortic sclerosis with a
peak pressure gradient of 36 mm/HG , read as moderate aortic
stenosis with mild aortic regurgitation. The electrocardiogram
showed sinus rhythm at 70 , left axis deviation , left ventricular
hypertrophy , left atrial enlargement , T-wave inversion in I and
AVL , V5 and V6 , strain pattern. Chest x-ray was unremarkable.
SMA-7 was within normal limits , blood urea nitrogen 13 , creatinine
1.1.
HOSPITAL COURSE: While in the hospital , the patient underwent
cardiac catheterization with percutaneous
transluminal coronary angioplasty of the left circumflex and right
coronary artery on 18 of May , and bilateral renal artery angioplasty
on 20 of February . The patient remained in normal sinus rhythm. He
experienced angina on 2 of February , with ischemic changes
anterolaterally. He underwent percutaneous transluminal coronary
angioplasty on 18 of May , and his 90% stenosis of the obtuse marginal
branch #2 was reduced to 30% and the 90% right coronary artery
distal lesion was reduced to a 30% residual. He tolerated the
procedure well with no complications. He also underwent renal
angiography , which showed bilateral renal artery stenosis , and for
this he underwent bilateral renal artery angioplasty on 20 of February ,
which he also tolerated well.
Renal arteriography and angioplasty were performed becuase of drug-resistant
hypertension and continued hypokalemia requiring K repletion even
when off diuretics. Prior work-up had revealed no evidence for
hyperaldosteronism.
DISPOSITION: CONDITION ON DISCHARGE was good. MEDICATIONS ON
DISCHARGE were Isordil 30 milligrams by mouth 3 times
a day , Zantac 150 milligrams by mouth at hour of sleep , Ecotrin 1
by mouth per day , K-Dur 40 mEq by mouth twice a day , Nifedipine 30
milligrams by mouth 3 times a day , digoxin .25 milligrams by mouth
per day , Lopressor 100 milligrams by mouth twice a day. It was
felt that in time his antihypertensives can be adjusted as
necessary.
VH327/5150
CARA BARNABA , M.D. HL86 D: 9/5/91
Batch: 5066 Report: T5952T0 T: 3/9/91
Dictated By: CAROYLN REIDHERD , M.D.
cc: 1. MELDA IVASKA , M.D.
Document id: 585
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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510033746 | PUO | 08075191 | | 2406971 | 10/25/2007 12:00:00 a.m. | intraabdominal abscess | Signed | DIS | Admission Date: 9/25/2007 Report Status: Signed
Discharge Date: 3/14/2007
ATTENDING: MARCOTT , DESIRAE MD
PRIMARY CARE PHYSICIAN: September Petretti , MD
SERVICE: Nessinee Ker Hospital Medical Center Surgery.
PRINCIPAL DIAGNOSIS: Wound infection.
LIST OF PROBLEMS:
1. Wound infection.
2. Coronary artery disease.
3. Diabetes mellitus.
4. Hypertension.
5. Asthma.
6. Obstructive sleep apnea.
7. Morbid obesity.
8. Depression.
9. Peripheral vascular disease.
10. History of cerebrovascular accident.
HISTORY OF PRESENT ILLNESS: This is a 51-year-old female with
recurrent incisional hernia , status post repair x2 by Dr. Gravatt ,
who now presents with five days of abdominal pain , fever to 103 ,
vomiting two days ago , and dizziness. She denies constipation or
diarrhea , urinary symptoms and nausea. The pain is constant and
sharp over her previous incision. Last bowel movement was in the
morning of her admission.
PAST MEDICAL HISTORY: Coronary artery disease status post PCI in
2003 of the right coronary artery , insulin-dependant diabetes
mellitus , hypertension , history of cerebrovascular accident , in
detail , right thalamic infarct , left temporal watershed with
residual right-sided weakness , peripheral vascular disease status
post right saphenous artery stent , GERD , gastritis , erosive
esophagitis , asthma with an FEV of 2.2 and an FEV-FVC ratio of
82% , sleep apnea , morbid obesity , currently undergoing outpatient
evaluation for gastric bypass surgery , depression , and
fibromyalgia.
PAST SURGICAL HISTORY: Cholecystectomy; repair of ventral
hernias x2 , last one in 2001 by Dr. Gravatt ; total abdominal
hysterectomy , oophorectomy , and tubal ligation.
MEDICATIONS AT HOME: Aspirin 81 mg orally daily , albuterol inhaler
2 puffs four times a day as needed , amitriptyline 25 mg orally at
bedtime , atenolol 50 mg orally daily , Lipitor 40 mg orally daily ,
Caltrate 600 plus D one tablet orally daily , Plavix 75 mg orally
daily , Diltiazem sustained release 120 mg orally daily , Nexium 40
mg orally daily , ferrous sulfate 325 mg three times a day , Prozac
80 mg orally daily , Advair Diskus 550 one puff twice a day ,
glyburide 5 mg orally daily , hydrochlorothiazide 25 mg orally daily ,
insulin NPH Humulin 70 units subcutaneously every morning , 60
units subcutaneously every evening , Insulin Regular Humulin 5
units subcutaneously every morning , Insulin Regular Humulin 80
units subcutaneously before meals , Imdur ER 60 mg orally daily , lisinopril
40 mg orally daily , and oxycodone 5 mg orally every six hours as
needed for pain.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: She is a 34-pack-year smoker that quit one year
ago. Denies ETOH or intravenous drug use.
PHYSICAL EXAMINATION: On admission , her abdomen was both soft
and obese. Tender above the midline incision with induration.
There was no overlying erythema.
LABS: Notable for high white blood cell
count of 20.5 as well as a troponin of 0.16.
Imaging: CT scan of the abdomen and pelvis showed a
6.1 x 6-cm loculated abscess adjacent to her current hernia , not
communicating with small bowel , also showed no obstruction.
The patient was admitted to the Nessinee Ker Hospital Medical Center Surgery Service. After
reviewing once more the imaging , it was determined that the
abscess was involving the mesh placed during the last ventral
hernia repair. The decision to proceed with an
Interventional Radiology guided percutaneous drainage of the
abscess was done. 98 mL of dark brown
and bloody discharge was extruded from this procedure and sent to microbiology ,
two drains were left in place. Eventually , 2+ Klebsiella pneumoniae grew
sensitive to several
antibiotics , for which her antibiotic therapy was redirected to
levofloxacin. On 10/2/07 , the patient was taken
to the operating room to remove the infected mesh. A Cardiology
consult had been obtained because of her troponin leak. The event was
determined to be ischemic in nature;
however , given her surgical indication , Cardiology did not
recommend an intervention at the Cath Lab at the moment; however ,
they do recommend that she is followed as an outpatient. The
patient was then taken to the operating room for an abdominal
wound exploration and removal of mesh.
HOSPITAL COURSE BY SYSTEMS:
1. Neuro: The patient did well with as needed morphine and
eventually as needed oxycodone to control her pain. She has a
history of depression , so a Social Work consult was obtained ,
which provided emotional support for the patient.
2. Cardiovascular: She was initially given intravenous Lopressor
perioperatively and eventually she was restarted on her home
cardiovascular medications. Cardiology continued to follow and
her troponin trended down.
3. Pulmonary: There were no issues.
4. GI: Her diet was going to be advanced , however , on
postoperative day #2 , unfortunately bile was noted to be
seeping out of her abdominal wound , which was interpreted as the
development an enterocutaneous fistula. This was treated with
bowel rest and wet-to-dry dressings initially. Eventually , a VAC
sponge was placed , which after three days was removed and healthy
granulation tissue was appreciated underneath its original place. A new VAC
sponge will be placed once transferred to rehab.
5. GU: Maintenance IVF as needed
6. FEN: A PICC line was placed and TPN was initiated after the
enterocutaneous fistula was identified. TPN is now at goal.
7. Heme: Subcutaneous heparin.
8. Endocrine: Diabetes Service was consulted and a insulin
regimen was initially difficult to achieve due to high blood
glucose measurements initially and brief episodes of hypoglycemia
two days before her discharge. However , her insulin regimen now
appears to be optimal.
9. ID: Initially received vancomycin , levofloxacin , and Flagyl
since her admission; however , once the above results were noted ,
this antibiotic regimen was tailored down to a levofloxacin. She
is now being discharged on no antibiotics.
DISCHARGE MEDICATION: Tylenol 650 mg orally every 4 hours as needed for
headache or fever to greater than 101 , aspirin 81 mg orally daily ,
albuterol nebulizer 2.5 mg nebs every four hours as needed for
shortness of breath , amitriptyline 25 mg orally at bedtime as
needed for insomnia , Plavix 75 mg orally daily , Diltiazem Extended
Release 120 mg orally daily , Nexium 20 mg orally daily , Prozac 80 mg
orally daily , Advair Diskus 550 one puff twice a day , heparin 5000
units subcutaneously every eight hours , insulin NPH Humulin 25
units every morning and 25 units every evening , Insulin Regular
Humulin sliding scale every four hours , Imdur ER 60 mg orally
daily , lisinopril 40 mg orally daily , Lopressor 50 mg orally twice a
day , naftifine topical daily , octreotide acetate 100 mcg
subcutaneously twice a day , oxycodone 5 to 10 mg orally every four
hours as needed for pain , and simvastatin 80 mg orally at bedtime.
DISPOSITION: Rehabilitation facility.
FOLLOWUP PLANS: The patient should contact Dr. Gravatt for a
followup appointment.
CODE STATUS: The patient is full code.
eScription document: 3-1065072 CSSten Tel
Dictated By: GUSTOVICH , MARLO HELENE
Attending: GRAVATT , JEFFRY
Dictation ID 6620153
D: 4/7/07
T: 4/7/07
Document id: 586
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
Y |
Y |
N |
N |
Y |
Y |
Y |
N |
N |
N |
N |
N |
N |
052748736 | PUO | 82180280 | | 399416 | 6/9/2001 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 10/26/2001 Report Status: Signed
Discharge Date: 5/14/2001
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old gentleman
with a history of aortic stenosis ,
non-insulin dependent diabetes mellitus , hypertension and
hypercholesterolemia who is preop for a cardiac catheterization and
aortic valve replacement to be admitted on September , 2001. He
has had an echocardiogram which demonstrates severe aortic stenosis
with mitral annular calcification , left ventricular hypertrophy and
1+ aortic insufficiency , also mild tricuspid regurgitation and
ejection fraction of 55%.
PAST MEDICAL HISTORY: Notable for non-insulin dependent diabetes
mellitus , depression , hypertension ,
hypercholesterolemia , and gout.
ALLERGIES: The patient had no known drug allergies.
MEDICATIONS ON ADMISSION: 1 ) Simvastatin. 2 ) Lopressor 50 mg
orally twice a day 3 ) Allopurinol 300 mg once
a day. 4 ) Lasix 40 mg three times a day. 5 ) Captopril. 6 )
Potassium replacement. 7 ) Multivitamin.
PHYSICAL EXAMINATION: His examination is unremarkable. He has a
right carotid bruit and palpable distal
pulses. CHEST: Clear. ABDOMEN: Soft. EXTREMITY: No lower
extremity edema.
HOSPITAL COURSE: He is seen in consultation by Oral Medicine for
carious teeth since he is preopped for aortic
valve replacement and he was cleared by the dentist for this
procedure. He went to the cardiac catheterization laboratory where
he underwent coronary arteriography on November , 2001. His
aortic valve area had been calculated at echocardiogram at 0.7 cm
squared. His coronary arteriogram demonstrated a 50% lesion of his
left anterior descending coronary artery , 60% second diagonal and a
60% lesion of the right coronary artery. He underwent preop
carotid ultrasound for the carotid bruit that was noted and he had
insignificant carotid disease by doppler. He went to the operating
room on September , 2001 where he underwent aortic valve
replacement with a #23 Carpentier-Edwards bioprosthetic valve and
coronary artery bypass grafting times two with saphenous vein graft
to the left anterior descending coronary artery and the saphenous
vein graft to the posterior descending. The intraoperative course
was unremarkable. His postoperative course was complicated only by
mild confusion which has cleared and the patient is alert and
oriented. He is to be discharged to rehabilitation in good
condition on the following medications.
MEDICATIONS ON DISCHARGE: 1 ) Enteric coated aspirin 325 mg orally
every day. 2 ) Lithium 300 mg twice a day.
3 ) Potassium supplementation 20 mEq once a day. 4 ) Pravachol 40
mg once a day. 5 ) Glyburide 1.25 mg twice a day. 6 ) Parnate 10
mg twice a day. 7 ) Lasix 20 mg once a day.
FOLLOW-UP: The patient is to be discharged to the care of Dr. Alexandra T Popovic , Cardiovascular Division at Pagham University Of .
Dictated By: CHRISTY CLARDY , M.D.
Attending: LOIDA F. GOLEBIOWSKI , M.D. QO2 SG673/0273
Batch: 7400 Index No. PGYSKD84WX D: 6/16/01
T: 6/16/01
CC: ALEXANDRA T. POPOVIC , M.D. ZU1
NINA SURACE , M.D. , Paulpeake Rage Nix
Document id: 587
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
- |
Y |
N |
Y |
Y |
N |
N |
N |
015634120 | PUO | 59679705 | | 243269 | 11/9/1998 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 11/9/1998 Report Status: Signed
Discharge Date: 6/9/1998
PRIMARY DIAGNOSIS: SYNCOPE.
OTHER DIAGNOSIS:
1. INSULIN DEPENDENT DIABETES MELLITUS.
2. HYPERTENSION.
3. OSTEOARTHRITIS.
4. OBESITY.
5. HISTORY OF PNEUMONIA.
6. HISTORY OF COLONIC POLYPS AND GUAIAC POSITIVE STOOL.
7. STATUS POST TOTAL KNEE REPLACEMENT IN 3/17 .
8. BELL'S PALSY TIMES 20 YEARS.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old Native
American female with history of
diabetes , hypertension , chronic low back pain who had a syncopal
episode on the night prior to admission. The patient was at home
sitting on the bed and go up to go outside. The patient felt pain
in her lower back and numbness and tingling in legs similar to her
chronic low back pain. The patient walked to the top of the stairs
to go down and last remembered grabbing onto the bannister. The
patient passed out and fell down 17 stairs. The patient does not
remember falling and according to her family , she was not
unconscious for more than 2 to 3 seconds at the bottom of the
stairs. When the patient woke up , she states she felt her heart
racing and was diaphoretic with shortness of breath. The patient
denies preceding chest pain , dizziness , vertigo or any other
symptoms prior to her syncopal episode. The patient also denies
headache , vomiting , loss of bowel and bladder function. The
patient states that she has passed out one or two times in the past
but does not remember the circumstances surrounding the events.
The patient went to the KTDUOO clinic the next day and from there was
sent to the emergency department. The patient states that she has
chest tightness/pressure on occasion that is often associated with
shortness of breath and diaphoresis. She states the pain radiates
to her arms on occasions. She experiences this pain both at rest
and with exertion. She states she has occasional leg swelling but
denies orthopnea or paroxysmal nocturnal dyspnea. The patient's
risk factors for coronary artery disease include hypertension ,
insulin dependent diabetes mellitus and strong family history of
heart disease.
PAST MEDICAL HISTORY: As stated above.
ALLERGIES: The patient has had a reaction to contrast dye in the
past that resulted in hives. THe patient has
questionable allergy to an unknown antibiotic which causes a rash.
The patient is also reportedly allergic to Bactrim.
MEDICATIONS: Lopid 600 twice a day , Axid 150 twice a day , Captopril 75
twice a day , Cardizem 180 every day , Lasix 40 every day , Insulin 70/30
80 in the am and 40 in the pm.
SOCIAL HISTORY: The patient is a housekeeper originally from
Che Rham Son She denies tobacco or alcohol use. The
patient lives with her son who is blind and also her granddaughter.
FAMILY HISTORY: The patient's father died of MI at age 81; mother
died of MI at age 73. The patient has a brother
who died of MI at age 38.
PHYSICAL EXAMINATION: The patient is comfortable in no acute
distress. It is noted that the patient is
morbidly obese. Vital signs; Pulse 120 , blood pressure 180/80 ,
temperature 99.5 , respiratory rate 16 , O2 sats 96% at room air.
HEENT: Pupils are equal , round and reactive to light; Extraocular
muscles are intact. Oropharynx is clear. Mucous membranes are
moist. NECK: Supple without lymphadenopathy. CARDIOVASCULAR: S1 ,
S2 no murmurs , rubs or gallops appreciated. The patient has
diminished dorsalis pedis pulse on the left side; otherwise ,
peripheral pulses are intact. CHEST: Clear to auscultation
bilaterally; crackles bilaterally at the bases. ABDOMEN: Obese ,
soft , non-tender. EXTREMITIES: No clubbing , cyanosis or edema
noted. There is a 1 cm abrasion at the right shin , bruising over
the right shin and dorsal aspect of the foot. NEURO: Alert and
oriented times three. There is a right lower facial droop;
otherwise cranial nerves II through XII intact. Motor is 5/5 in
all extremities; sensory is intact throughout to light touch.
LABORATORY: Sodium 138 , potassium 4.6 , chloride 100 , bicarb 26 ,
BUN 16 , creatinine 0.8 , glucose 305. WBC 12.7 ,
hematocrit 36.1 , platelets 327. Troponin I is 0; CK 216. Chest
x-ray is negative. CT of head is negative. EKG shows normal sinus
rhythm at rate of 117. There is a right bundle branch block and
left anterior fascicular block present. There are also Q waves in
lateral leads V4 through V6.
HOSPITAL COURSE: The patient was admitted to the general medical
service for evaluation of syncope. She was
monitored over the weekend and no arrhythmias were picked up on
cardiac monitor. The patient underwent echocardiography which
showed mild left ventricular hypertrophy and ejection fraction of
80%. There were no wall motion abnormalities. There was also noted
mild left atrial enlargement and mild aortic valve sclerosis. Due
to the worrisome nature of patient's history of angina-like
symptoms , she went directly to cardiac catheterization , which
revealed heavily calcified LAD and RCA. The LAD showed proximal
stenosis of 30 to 40% , circumflex showed proximal stenosis of 30%
and the RCA showed proximal stenosis of 30%. It was felt that this
represented mild CAD and most likely could not explain the source
of the patient's syncopal episode. The patient also underwent
electrophysiology study which showed no evidence for ventricular
arrhythmias or bradyarrhythmias as cause of syncope. The patient
continued to have no arrhythmic events on cardiac monitor
throughout her hospital stay. The patient tolerated the cardiac
cath well and did well during the postprocedure period. The
patient's diltiazem was discontinued thinking that it may
contribute to heart block given the fact that she has a
bifascicular block. THe patient was started on nifedipine XL. The
patient was discharged home with close follow-up with her primary
care physician , Dr. Seguin .
MEDICATIONS: On discharge , Captopril 75 twice a day , Nifedipine XL 90 every
d , Lopid 600 twice a day , Axid 150 twice a day , Lasix 40 every day ,
INsulin 70/30 80 every day before noon and 40 every afternoon
Dictated By:
Attending: AVRIL FIDELIA TAPLIN , M.D. BS9 RA963/0798
Batch: 32257 Index No. K1XDPV007O D: 10/21/98
T: 3/9/98
CC: DR. DIMPLE D GILDA F. HAZINSKI , M.D. TN38
Document id: 588
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
896890694 | PUO | 49034699 | | 493218 | 7/8/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/15/1993 Report Status: Signed
Discharge Date: 8/4/1993
HISTORY OF PRESENT ILLNESS: Mr. Marzella is a 43-year-old status
post coronary artery bypass graft who
presents complaining of left arm and hand numbness with tingling
for twenty-four hours. The patient has a long history of coronary
artery disease starting with development of angina in 1989.
Ultimately , in 27 of June of 1991 , he underwent angioplasty of the lad which
re-stenosed. In 25 of June of 1992 , he had an myocardial infarction and
ultimately underwent a exercise tolerance test which was negative
and he was not catheterized and it was treated with Coumadin for
clot. In 16 of March of 1992 , he had a non-Q wave myocardial infarction with
a peak CK of 231 , 6% MB. A catheterization at that time showed
100% LAD with right to left collateralization , an 80% circ and a
70% OM2. He under coronary artery bypass graft with a saphenous to
the OM1 and OM2 and a LIMA to the LAD. The coronary artery bypass
graft was complicated by ventricular fibrillation arrest and he did
have EPS done at that time. Two months later , an echocardiogram
showed an akinetic septum and akinetic apex and decreased left
ventricular function with an ejection fraction of about 40%. Since
his coronary artery bypass graft , the patient denies any chest
pain , shortness of breath or paroxysmal nocturnal dyspnea. He is
fairly active , walking a reasonable amount per day but has not yet
returned to work. Last evening after playing a video arcade game ,
the patient noted a pins and needle sensation from the elbow to the
left hand along the lateral side of the arm and a sense of
clumsiness with the left hand. He went to sleep but this feeling
persisted in the morning and he called the CENH . He was evaluated
there and sent for carotid noninvasives in the area which showed a
15% left and a 60% right ICA stenosis by report and was transferred
to the Pagham University Of Emergency Room. In the
Emergency Room , he was thought to have proximal hand weakness and
upgoing toe on that same side and EKG changes so he was admitted.
Presently , the patient complains of decreased tingling in the hand
but still some numbness less so on the forearm. He denies
headache , nausea , vomiting or visual changes. PAST MEDICAL
HISTORY: The patient's past medical history is significant for
noninsulin dependent diabetes mellitus , coronary artery disease as
above , gout , proteinuria with 2.4 grams of protein in a 24-hour
urine in 1989 , morbid obesity. MEDICATIONS ON ADMISSION:
Lopressor 12.5 mg orally twice a day and an aspirin a day. ALLERGIES: He
has no known drug allergies. SOCIAL HISTORY: He is a mechanic
though not currently working. He is married. He was a smoker
until 1992 , when he quit. He also drank significant amounts of
alcohol until 1992 , when she also quit.
PHYSICAL EXAMINATION: The patient is an obese white male in no
apparent distress. Blood pressure 142/76.
Pulse: 79 and afebrile. The physical examination showed the head
and neck examination that was unremarkable with fundi that showed
no palpable edema. The lungs were clear to auscultations. The
cardiac examination was unremarkable. The abdomen examination was
obese but had no masses or tenderness. He had trace lower
extremity edema , left greater than the right , consistent with
saphenous vein harvest site with good peripheral pulses. He was
guaiac negative on rectal exam. His neurological examination
showed alert and oriented times three. His cranial nerves were
intact. His discs were sharp bilaterally. He had a question of
mild pronator drift on the left. His strength was 5 out of 5
except for 4 out of 5 interossei on the left. He was able to do
rapid alternating movements. The finger-to-nose within normal
limits. No objective sensory changes to light touch and pin prick.
He did not extinguish to double simulanteous stimuli in his hands
of feet. His gait was within normal limits.
LABORATORIES ON ADMISSION: His white count was 9.9 , hematocrit
43.9 , platelets of 245 , glucose 115 ,
BUN/creatinine 24/0.7 , EKG normal sinus at 70. He
pseudonormalization of T-waves in V2 through V6 , 1 and L. The
chest X-ray showed no acute changes. A CT of the head showed a
very vague and subtle area of decreased attenuation in the
posterior right frontal lobe. There was no mass effect or no
blood.
HOSPITAL COURSE: The patient was admitted for presumed new stroke.
He was begun on Heparin and ultimately once the
Heparin was therapeutic , he was begun on a Coumadin load. His
symptoms of numbness and weakness in the left hand gradually
improved over the course of his hospital stay and he had no other
new significant symptoms. A repeat head CT at seventy-two hours
showed essentially the same vague density as seen on the previous
CT. In addition , he underwent a repeat echocardiogram which showed
no significant changes and no evidence of clot.
DISPOSITION: The patient was discharged to home in stable
condition on 8/26/93 . MEDICATIONS ON DISCHARGE: Discharge
medications include Lopressor 12.5 mg orally twice a day and enteric coating
aspirin one orally every day and Coumadin 10 mg orally bedtime FOLLOW-UP: He is
to follow up with his CHH primary doctor of a physical therapy check a couple of
days after the discharge.
Dictated By: DENISHA H. MCRORIE , M.D. AX6
Attending: SERENA DENCH , M.D. YK32 KRCGI/5679
Batch: 9141 Index No. DLVBKR0931 D: 10/20/93
T: 10/20/93
Document id: 589
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
- |
Y |
N |
N |
- |
965013582 | PUO | 44411101 | | 7784867 | 10/3/2005 12:00:00 a.m. | PERFORATED DUODUNUM | Signed | DIS | Admission Date: 10/3/2005 Report Status: Signed
Discharge Date: 5/10/2006
ATTENDING: MUSICH , LEOLA M.D.
PRINCIPAL DIAGNOSES:
1. Pulmonary embolism.
2. Enterobacter pneumonia.
3. MRSA pneumonia.
4. Respiratory failure requiring tracheostomy.
HISTORY OF PRESENT ILLNESS:
This is a 68-year-old female with diastolic heart failure ,
hypertension , and diabetes , who is status post a perforated
duodenal ulcer repaired on 8/13/05 at an outside hospital. The
patient's course at the outside hospital was complicated by
respiratory failure requiring mechanical ventilation and
hypotension that required pressor support with Neo-Synephrine.
After aggressive diureses , she was extubated and on 5/29/05 , the
patient was transferred to Pagham University Of on
facemask. On 4/29/05 , the patient was found to have a left
upper lobe pulmonary embolism on chest CT and was started on
heparin drip. At that time , a chest tube was placed for removal of left
pleural effusion. Upon manipulation of the chest tubes , the
patient was noted to desaturate and required intubation.
Bronchoscopy was performed with copious secretions.
Echocardiogram on 4/29/05 showed moderate pericardial effusion
and evidence of right ventricular strain. At this time , the
patient was transferred to the CCU for further care.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Diastolic heart failure.
3. Hypertension.
4. Hyperlipidemia.
5. Osteoarthritis.
6. Peptic ulcer disease status post gram patch for perforated
duodenal ulcer on 8/13/05 .
7. Obesity.
8. Cervical stenosis.
MEDICATIONS AT THE TIME OF TRANSFER TO THE CCU:
Fentanyl drip , versed drip , heparin drip , insulin drip ,
vancomycin , Flagyl , levofloxacin , Lopressor 5 mg intravenous every 6 hours ,
Dilaudid , albuterol , Atrovent , Nexium 20 mg orally twice a day
twice a day
ALLERGIES:
No known drug allergies.
FAMILY HISTORY:
Noncontributory.
SOCIAL HISTORY:
Noncontributory.
VITALS AT THE TIME OF TRANSFER TO THE CCU:
Temperature 102 , pulse 100-113 , blood pressure 86-125/39-50. The
patient was ventilated on assist control , tidal volume 400 ,
respiratory rate of 14 , overbreathing at 27 , PEEP of 10 with PIP
of 33 , saturating 92% on 95% FiO2. Physical examination revealed
a patient who was intubated and only mildly responsive to
stimuli. The patient's cardiac exam revealed a normal S1 and S2 ,
a possible S4 with no evidence of murmur. Her JVP was not
assessable at the time of transfer. Pulmonary exam revealed the
lungs that were clear to auscultation bilaterally. Her abdomen
was soft. The patient grimaces with deep palpation to the right
lower quadrant. Her extremities were warm with no evidence of
rash and good pulses.
LABORATORY DATA:
Labs at the time of transfer to the CCU revealed a white cell
count of 13.3 , hematocrit of 30.8 , a platelet count of 200 , 000.
Sodium 141 , potassium 4.5 , bicarbonate 31 , BUN 13 , creatinine of
0.5 , and glucose 131. PTT was 32.6 , INR 1.4. LFTs were normal
other than a mildly elevated total bilirubin at 1.1. CK was 27.
MB was 0.4. Troponin was 0.22.
STUDIES PERFORMED DURING THIS HOSPITALIZATION:
The patient had a chest CT on 4/29/05 that revealed left upper
lobe and lingular branch pulmonary embolism , but no evidence of
DVT. Her most recent chest CT done on 6/21/06 revealed
segmental atelectasis involving the posterior basal
and lateral basal segments of the left lower lobe , minimal
left-sided effusion , and slight improvement of opacities in
the upper lobe due to improving pneumonia. Abdominal CT
on 4/29/05 , revealed no evidence of free intraperitoneal gas or
extravasation of orally contrast to suggest persistent bowel
perforation. There was a small to moderate amount of ascites
with a more localized 2.5 cm phlegmonous area in the right
pericolic gutter , not amenable to percutaneous drainage. Follow
up abdominal CT on 9/6/06 , revealed decreased splenic
subcapsular hematoma and enlarged bilateral ovaries.
Transvaginal ultrasound on 8/26/06 revealed mildly enlarged and
lobular right ovary with the size of 3 x 3 x 2.7 cm.
IMPRESSION:
A 68-year-old woman with diabetes , hypertension , who presented to
an outside hospital with duodenal bleed on 9/29/06 , requiring
gram patch repair , complicated postoperatively by volume
overload , hypotension , pulmonary embolism , Enterobacter
pneumonia , and coag-negative Staph bacteremia.
HOSPITAL COURSE BY ISSUE:
1. Infectious disease:
A. Enterobacter pneumonia: The patient completed a 14-day
course of imipenem for Enterobacter pneumonia. Chest CT on
10/22/05 showed resolving pneumonia. Sputum culture from
8/7/06 , revealed Enterobacter and MRSA. The sputum cultures
through 7/21/06 showed persistent Enterobacter. As the patient
was persistently febrile and repeat CT showed new left upper lobe
atelectasis with a question of infiltrate and bilateral ground
glass opacities , the patient was restarted on imipenem with the
addition of linezolid per recommendation of the Infectious
Disease consult team. The patient completed a full course of
imipenem on 4/5/06 , and a full course of linezolid on 1/1/06 .
Chest x-ray performed on 1/10/06 revealed no evidence of
consolidation.
B. Pseudomonas pneumonia: The patient had a urine culture on
7/21/06 that grew 100 , 000 colonies of Pseudomonas aeruginosa.
The patient was initially placed on gentamicin; however , this was
switched to levofloxacin on 10/6/06 and then ciprofloxacin on
7/25/06 based on microbiologic susceptibilities. The patient
completed a full course of ciprofloxacin on 4/5/06 .
C. Enterococcus bacteremia: Blood culture on 10/19/06 grew
vancomycin susceptible Enterococcus. The patient completed a
14-day course of linezolid.
D. Candidal intertrigo: The patient was put on topical
antifungals with failure to improve candidal skin infection. She
was started on fluconazole 100 mg orally daily on 8/26/06 . She
will complete a seven-day course on 10/28/06 .
2. Pulmonary: The patient had a prolonged course of ventilator
dependence. A tracheostomy was performed on 6/26/05 . The
patient was successfully weaned to trach collar on 7/25/06 . Her
trach collar was capped on 1/10/06 and the patient has been
tolerating oxygen via nasal cannula since that point.
3. Heme:
A. Pulmonary embolism: The patient was found to have left upper
lobe and lingular branch pulmonary emboli. As discussed above ,
she was initially on heparin , which was discontinued on 8/7/06 .
The patient was found to be subtherapeutic on her Coumadin on
7/23/06 , and was initiated on Lovenox as a bridge at that time.
Lovenox was continued until 4/5/06 . At the time of discharge ,
the patient's Coumadin dose is 3 mg orally at bedtime. Her INR was
2.7 on 1/1/06 . Please continue to monitor and adjust dose
accordingly. There was some concern for possible right upper
extremity DVT during this hospitalization given the appearance of
right upper extremity swelling. Non-invasive studies were
negative for evidence of DVT in the right upper extremity.
B. Iron deficiency anemia: The patient was found to have an
iron less than assay on 8/6/06 , a TIBC of 181 , and ferritin of
828. She was started on ferrous sulfate. Her hematocrit has
been stable with the transfusion goal less than 27.
4. Cardiovascular:
A. Ischemia: No active issues.
B. Pump: The patient had an echocardiogram done on 4/13/05 ,
revealing normal LV function and size , and an ejection fraction
of 55-60% , no akinesis , mild right ventricular enlargement ,
moderate right ventricular global dysfunction , normal left
atrium , and right atrium , normal valves , and small circumscribed
pericardial effusion. The patient had evidence of fluid overload
on transfer to this hospital. She has been successfully diuresed
down to her dry weight of 100 kg. She was recently on
torsemide 100 mg orally three times a day that has been weaned off due to
concerns of increasing BUN and bicarbonate in the setting of
aggressive diureses. Please continue to monitor weights and dose
torsemide for concern of worsening fluid overload.
C. Rhythm: The patient has had a tachycardia , thought to be
secondary to fever and pulmonary embolism. Her heart rate the
day prior to discharge was 87-104.
5. Gynecologic: The patient has bilateral enlarged ovaries on
abdominal CT , confirmed by transvaginal ultrasound on 8/26/06 ,
revealing a mildly enlarged and lobular right ovary with the size
of 3 x 3 x 2.7 cm. The patient has a known history of enlarged
ovary , and comparison will need to be made with prior pelvic
ultrasounds as an outpatient. Recommended further outpatient
evaluations to rule out ovarian malignancy.
6. Fluids , electrolytes , and nutrition: The patient was
switched on 8/26/06 , on tube feeds of Jevity to increase the
fiber per recommendations of the nutrition consult team. We have
been continuing the free water boluses for mild hypernatremia.
The patient has a history of mild pill dysphagia and esophagogram
during this hospitalization revealed mild-to-moderate esophageal
dysmotility.
7. Endocrine: The patient has been followed by the Endocrine
consult team during the hospitalization for monitoring of blood
sugars. She has a tendency to become hypoglycemic when her tube
feeds are turned off. Please continue to monitor glucose
fingersticks every six hours.
8. Neurologic: We added Zyprexa 5 mg orally at bedtime and as
needed for anxiety or agitation. We also have added Klonopin 1
mg orally at bedtime.
9. Renal: As noted above , the patient has an elevated BUN to
creatinine ratio consistent with prerenal azotemia. We have held
all diuretic agents , this will need to be monitored in the rehab
setting.
10. GI: The patient is constipated. She is on a bowel regimen
of Colace and senna with as needed lactulose. She was disimpacted
1/10/06 . She has a chronic pill dysphagia as discussed above.
11. The patient seen by the Dermatology consult service on
4/5/06 for concern of a blanching erythematous rash on her mid
back , buttocks , upper thighs , groin area , and around her pannus.
The Dermatology consult team felt that this was most consistent
with a drug hypersensitivity eruption. As the timing of the
rash was unclear , it makes it difficult to determine the
offending agents. The patient has been on multiple antibiotics ,
which are likely offenders and has been discontinued as the
courses were completed. The rash is fairly limited and appears
to be improving at the time of discharge. Please continue
clobetasol 0.05% cream twice a day to the effected areas with
pramoxine 1% lotion three times a day , and Sarna lotion as needed
for pruritus. Okay to stop these medications when the rash has
resolved. The patient is in satisfactory condition at the time
of discharge. She is full code.
DISCHARGE LABORATORY DATA:
At the time of discharge , her laboratories were as follows:
Sodium 135 , potassium 3.8 , bicarbonate 39 , BUN 80 , creatinine
0.7 , and glucose 60. She had normal LFTs with the exception of a
mildly elevated alkaline phosphatase at 134. Calcium is 9.5 ,
magnesium 2.6. White cell count 17.5 , with a normal differential
hematocrit to 28.2 and stable , platelets 471 , 000. All blood
cultures have been negative for greater than a week. The patient
had a maximum temperature of 100 on the day prior to discharge
and continues to have low-grade fevers. As discussed above , her
INR is 2.7 at the time of discharge. Please continue to monitor
and adjust Coumadin accordingly.
DISCHARGE MEDICATIONS:
Medications at the time of discharge include , Tylenol 500-1000 mg
per NG tube every four hours as needed for pain , headache , or
temperature greater than 101 , not to exceed 4 g daily , albuterol
nebulizer 2.5 mg every four hours as needed for wheezing ,
Dulcolax 20 mg per rectum once a day as needed for constipation ,
Klonopin 1 mg per NG tube at bedtime , hold if oversedated , Colace
100 mg orally twice a day , fentanyl patch 50 mcg per hour topically
every 72 hours , fluconazole 100 mg orally daily; to be completed on
10/28/06 , Regular Insulin sliding scale , regular insulin 13 units
subcutaneous every 6 hours , Atrovent inhaler , eight puffs inhaled four times a day
four times per day as needed for shortness of breath and
wheezing , lactulose 30 mL per NG tube twice a day as needed or as needed
for constipation , hold if greater than two bowel movements per
day , Lopressor 25 mg orally every 6 hours , artificial saliva one bottle
orally daily as needed for dry mucous membranes , pramoxine 1%
topical three times per day for drug hypersensitivity rash on mid
back , buttocks , upper thighs , groin area , and around pannus ,
Sarna topically applied once per day as needed for itching , senna
tablets two tablets orally twice a day , ocean nasal spray two sprays
twice per day , as needed for nasal drainage , Coumadin 3 mg orally
every afternoon , multivitamin 5 mL per NG tube daily , Clobetazole 0.05%
cream twice a day for drug hypersensitivity , drug rash , on midback ,
buttocks , upper thighs , groin area , and round pannus , Zyprexa 5
mg orally at bedtime , miconazole nitrate 2% powder topically twice
per day , albuterol eight puffs inhaled four times a day and
needed every two hours for wheezing , Caltrate plus D one tablet
orally three times a day , Nexium 40 mg orally daily , Lantus 52 units
subcutaneous every day before noon , Zydis 5 mg G-tube daily as needed for
anxiety , XenoDerm topically applied twice per day to bottom ,
ferrous sulfate orally liquid 300 mg G-tube three times a day , torsemide 100
mg orally daily as needed for weight gain greater than 5 pounds.
eScription document: 2-4140357 EMSSten Tel
Dictated By: MANKOSKI , ROSSIE
Attending: MUSICH , LEOLA
Dictation ID 2191865
D: 1/1/06
T: 1/1/06
Document id: 590
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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434197864 | PUO | 41085865 | | 9410463 | 2/7/2007 12:00:00 a.m. | Asthma flair | | DIS | Admission Date: 10/7/2007 Report Status:
Discharge Date: 8/26/2007
****** FINAL DISCHARGE ORDERS ******
TROWERY , DEDE C 032-72-55-8
Norf
Service: MED
DISCHARGE PATIENT ON: 7/11/07 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VACEK , WALTON JANELLA , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ALBUTEROL AND IPRATROPIUM NEBULIZER 3/0.5 MG NEB every 4 hours
2. ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
3. DIVALPROEX SODIUM 500 MG orally twice a day
4. DOCUSATE SODIUM 100 MG orally twice a day
5. HYDROCHLOROTHIAZIDE 12.5 MG orally every day
6. INSULIN NPH HUMAN 26 UNITS subcutaneously twice a day
7. INSULIN REGULAR HUMAN 10 UNITS subcutaneously twice a day
8. LACTULOSE 15-30 MILLILITERS orally four times a day
9. LISINOPRIL 20 MG orally every day
10. OXYCODONE 10 MG orally every 4 hours
11. PREDNISONE 60 MG orally every day
12. RISPERIDONE 3 MG orally every day
13. SENNOSIDES 2 TAB orally twice a day
14. TRAZODONE 300 MG orally HS
15. ABILIFY 15 MG orally every bedtime
16. INSULIN SYRINGES 1 CC subcutaneously twice a day
17. ONE TOUCH ULTRA SOFT LANCETS
18. ONE TOUCH ULTRA TEST STRIPS
MEDICATIONS ON DISCHARGE:
ALBUTEROL AND IPRATROPIUM NEBULIZER 3/0.5 MG NEB every 4 hours
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
ZYRTEC ( CETIRIZINE ) 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DEPAKOTE ( DIVALPROEX SODIUM ) 500 MG orally twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally DAILY
Alert overridden: Override added on 8/10/07 by :
POTENTIALLY SERIOUS INTERACTION: OMEPRAZOLE & FAMOTIDINE
Reason for override: Omeprazole discontinued
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY nasal DAILY
Instructions: 2 sprays in each nostril once a day
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
HYDROCHLOROTHIAZIDE 12.5 MG orally DAILY
INSULIN NPH HUMAN 28 UNITS subcutaneously twice a day Starting Today February
HOLD IF: If not eating take half dose
INSULIN REGULAR HUMAN 10 UNITS subcutaneously twice a day
LACTULOSE 30 MILLILITERS orally four times a day as needed Constipation
LISINOPRIL 20 MG orally DAILY
Override Notice: Override added on 11/19/07 by
LENEAVE , JETTA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
771039577 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
OXYCODONE 10 MG orally every 4 hours as needed Pain
PREDNISONE Taper orally Give 60 mg every 24 hours X 2 dose( s ) , then
Give 40 mg every 24 hours X 3 dose( s ) , then
Give 20 mg every 24 hours X 3 dose( s ) , then Starting Today November
RISPERDAL ( RISPERIDONE ) 3 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
TRAZODONE 300 MG orally BEDTIME
ABILIFY 15 MG orally BEDTIME
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Flo Titterness primary care physician phone 041-877-2543 11/1 at noon scheduled ,
Dr. Chilo Psych 6/12 at 10am scheduled ,
Dr. Bedatsky Pulmonology phone 947-164-2074 10/25 at 1pm scheduled ,
Pulmonary Function Testing phone 588.572.8489 10/25 at 11am scheduled ,
ALLERGY: Aspirin , NSAIDs , Penicillins , ACETAMINOPHEN
ADMIT DIAGNOSIS:
asthma
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Asthma flair
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NSVD x 4 Asthma , history of ~15 intubations ( asthma ) diabetes
( ) vocal cord dysfunction-Addunction syndrome schizoaffective
disorder bipolar subtype morbid obesity
( obesity ) HTN ( hypertension ) Sleep Apnea
OPERATIONS AND PROCEDURES:
see discharge summary
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
see discharge summary
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
HPI: 33 year-old F with history of asthma history of 15 intubations who was
discharged on 11/23/07 after a 5 days hospitalization for an asthma flair.
The patient reports that she was fine at home initially but that by
Saturday evening approx 2:30AM , she noted worsening SOB and gradual onset
of CP. The pain in her chest was diffuse approx 9/10 in severity without
radiation and worse with movement or inspiratory effort. The SOB did not
abate despite constant albuterol nebs and taking her dose of Prednisone
60mg that morning. She reports that her peak flow was 300 at home and in
the ED. Her baseline is 500. Consequently , she decided to return to the
PUO ED. In the short interim since her discharge she reports being
compliant with all of her medications. She stayed at home during this
interval without any clear precipitating trigger including exertion ,
cold air , URI , respiratory irritants such as cleaning products or
perfumes or significant emotional stress. She recently had her carpets
cleaned.
PMH:
1. Asthma , history of 15 intubations , Last intubation last year , since age
12 , 10+ flares/year requiring steroids. ( 2005 PFT FEV1 90s , FVC 90 ,
FEV/FVC90 )
2. HTN
3. IDDM
4. Schizoaffective d/o bipolar subtype
5. Morbid obesity
6. laryngeal adduction syndrome
7. TTE: EF 60% 2005
PSH
1. Appendectomy 2003
2. C-section 1997
ALL: NSAIDs , ASA - angioedema , Tylenol - hives , PCN - hives
Meds on Admission:
DUONEB 3/0.5 MG every 4 hours , ALBUTEROL 2.5 MG every 2 hours as needed SOB , Wheezing , DEPAKOTE
500Mg twice a day , HCTZ 12.5 MG every day , LISINOPRIL 20 MG every day , OXYCODONE 10MG every 4 hours
as needed Pain , PREDNISONE 60MG every day taper , RISPERDAL 3MG every day , INSULIN NPH HUMAN
26 UNITS twice a day , INSULIN REGULAR HUMAN 10 UNITS twice a day , LACTULOSE 15-30ML four times a day
as needed Constipation , TRAZODONE 300MG every bedtime , ABILIFY 15 MG every bedtime , Pepcid 20mg
every day , Senna/Colace
Meds on Discharge
DUONEB 3/0.5 MG every 4 hours , ALBUTEROL 2.5 MG every 2 hours as needed SOB , Wheezing , DEPAKOTE
500Mg twice a day , HCTZ 12.5 MG every day , LISINOPRIL 20 MG every day , OXYCODONE 10MG every 4 hours
as needed Pain , PREDNISONE 60MG every day taper , RISPERDAL 3MG every day , INSULIN NPH HUMAN
26 UNITS twice a day , INSULIN REGULAR HUMAN 10 UNITS twice a day , LACTULOSE 15-30ML four times a day
as needed Constipation , TRAZODONE 300MG every bedtime , ABILIFY 15 MG every bedtime , Pepcid 20mg
every day , Senna/Colace , Singulair 10mg every day , Advair inhaled 500/50 twice a day , Zyrtec 10mg
every day , Flonase Nasal Spray 2 puffs in each nostril every day
Physical Exam
Tm/c 97.9/97.1 HR 85-95 BP 94-114/50-60 RR 18 O2Sat 99% RA
General: Morbidly obese woman lying comfortably in bed able to speak in
full sentences
HEENT: NCAT. PERRLA at 3mm , VFFC , sclera anicteric. Oropharynx is clear
without erythema , exudates or lesions. Mucous membranes moist
Neck: No LAD noted. Trachea midline , no carotid bruits appreciated.
Thyroid not enlarged and without nodules.
Heart: RRR. nl S1 and S2 , no MGR. JVP is 5cm
Pulm: Distant breath sounds equal b/l. No wheezes were heard. Not using
accessory muscles for respiration.
Abd: NTND , NABS. No masses. No HSM. Well healed surgical scar.
Spine/Ext: No vertebral or paravertebral tenderness appreciated. DPs are
2+ throughout with no CCE
Neuro: CN II-XII intact. Motor -5/5 throughout. Sensation: Symmetric to
PP , temp and vibration throughout. Proprioception is intact.
Coordination
is unremarkable. DTRs 2+ throughout. MS AOx 3.
Imaging
1. Chest radiograph: normal study unchanged from patient's previous
studies
2. PE CT: suboptimal study due to obesity. No evidence of central PE or
large DVT.
Hospital Course:
1. Pulm: H/o severe asthma with recent asthma flare , readmitted
after one day at home with worsneing SOB despite being on Prednisone 60mg
every day and Albuteral Nebs. Acutely in the ED , the patient was stable without
significant wheezing , tachypnea , low 02 sats , use of accessory muscles
for inspiration. CXR clear. Triggers were reviewed with the patient.
There were no clear precipitating triggers to this flare other than
carpet cleaning at home. On the floor , the patient received solumedrol x
1 dose then was transitioned back to prednisone. Breath sounds were
diminished but no wheezing was evident. She was continued on duoneb and
albuterol nebulizers for SOB. Singulair was added to her medication
regimen for maximum possible pharmacological coverage. The patient's
outpatient pulmonologist was consulted , recommended continued CPAP and
outpatient follow up including PFTs. Peak flows improved from 300 to 530
on Hospital day 3. Arrangements were made for her to have CPAP at home
and for outpatient Pulmonary follow up. She will start zyrtec and
flonase for possible allergic component to asthma. On hospital day 2 , her
PPD was read as negative.
2. CV: The patient was continued on Lisinopril and HCTZ for BP
control. Her JVP was not elevated. A routine EKG showed no changes from
previous exam and nothing to suggest cardiac ischemia. CP
appeared musculoskeletal in origin and the patient was maintained on
oxycodone for pain control.
3. GI: The patient's bowel regimen was continued for constipation ,
and will be continued at discharge.
4. Psych: We continued all home meds for treatment of her
schizoaffective disorder. An appointment for outpatient follow up was
made with her psychiatrist Dr. Chilo .
5. FEN: The patient was stable. ADA diet. Replete K and MG
6. PPX: Lovenox was used for DVT prophylaxis while an inpatient
but was discontinued on discharge. She should remain on a PPI while on
steroids
7. Code: full
8. Dispo: home
Of note , patient left the hospital prior to receiving discharge
paperworka nd prescriptions.
ADDITIONAL COMMENTS: Your medications have been changed in the following ways:
1. ) You have 3 new medications: Zyrtec to take once a day , flonase nasal
spray once a day , and pepcid to take twice a day.
2. ) Your NPH has been increased from 26 units to 28 units per day. You
will need to follow up with your primary care physician for further adjustments.
3. ) Continue the prednisone taper that you have at home.
4. ) While on oxycodone , you should take a strong bowel regimen to prevent
constipation including colace and lactulose.
5. ) Continue all other home medications as prescribed.
*Please follow up with Dr. Bedatsky . Obtain pulmonary function tests as
scheduled prior to your appointment ,
*Please seek medical attention for difficulty breathing , chest pain ,
fever , worsening cough , or any other concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. The patient has been instructed to resume her Advair inhaler while
she
finishes her orally steroid taper.
2. Pulmonology: Appt with Dr. Bedatsky . Full PFTs scheduled
prior to visit. Please make recommendations for disease management.
3. primary care physician: Follow up patient after steroid taper. Management of DM and HTN.
Please emphasize the need for weight-loss and life style modification.
4. Psych Please manage schizoaffective disorder. Please consider ativan
as needed for anxiety. Since we consider anxiety to a be a possible trigger of
the patient's respiratory problems.
No dictated summary
ENTERED BY: LENEAVE , JETTA , M.D. ( KQ022 ) 7/11/07 @ 04:05 PM
****** END OF DISCHARGE ORDERS ******
Document id: 591
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
N |
U |
N |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
Y |
N |
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Y |
N |
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N |
381512640 | PUO | 40525214 | | 123198 | 7/15/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/12/1990 Report Status: Unsigned
Discharge Date: 4/2/1990
HISTORY OF PRESENT ILLNESS: This is a 56-year-old gentleman with a
history of chest pain and atrial
fibrillation. His cardiac risk factors included hypertension ,
cigarette smoking and a family history; no diabetes or cholesterol.
In 3/23 , he sustained an IMI complicated by V-tach , cardiogenic
shock and Dresler's. He was discharged on digoxin and Lasix. He
subsequently did well with chest pain only on extreme exertion
characterized by retrosternal burning which radiated to his left
arm with shortness of breath. It did not occur at rest. He saw
Dr. Schwerd who prescribed Isordil with much decrement in symptoms.
In 8/13 , he was found to be hypertensive with decrease in T-4. He
was treated with captopril and Synthroid. In 6/8 , he had new
onset of atrial fibrillation. He was treated with Quinaglute. In
7/4 , he noted dizziness with decreased vision episodically. He
was treated with the discontinuation of captopril and digoxin was
begun. Atrial fibrillation was again documented on a Holter.
On 6/8/90 , he was admitted to Bussadd Southrys Community Hospital with atrial
fibrillation. The quinidine level was 1.6 and digoxin level 0.8 ,
T-4 9.2. The heart rate was 64 , blood pressure 110/90. He ruled
out for an MI. He was treated with an increase in his quinidine
sulfate. His course was complicated by a five second pause. A DDD
pacer was placed. He continued to have light-headedness without
associated arrhythmias. An echo revealed an ejection fraction of
30% with inferior akinesis , left ventricular hypertrophy and a
small pericardial effusion. While in the hospital , he had two
episodes of chest pain which were abated by nitroglycerin. There
were no brady or tachy arrhythmias noted at the times of the chest
pain. He was off Isordil. The chest pain occurred with walking.
There was no chest pain since restarting Isordil. On the monitor
he was noted to be in normal sinus rhythm with a first degree heart
block and occasional atrial fibrillation. The T-4 value was 9.2.
PAST HISTORY: Cholecystectomy in 1983; hypertension; decreased
T-4; meningitis as a child. ALLERGIES: None known.
PHYSICAL EXAMINATION: Heart rate 65; blood pressure 120/90;
temperature 97.5. The HEENT exam was
unremarkable. Carotids 2+ with normal upstrokes and no bruits.
The lungs were clear. The cardiac exam revealed a regular rate and
rhythm; S1 and S2; no S3; II/VI systolic murmur at the left upper
sternal border radiating to the apex; no rubs; PMI nondisplaced;
JVD 6 cm. The abdomen revealed a cholecystectomy scar. The
extremities revealed strong pulses and no bruits. The neuro exam
was nonfocal.
LABORATORY EXAMINATION: White count 9.4; hematocrit 42;
platelets 390; sodium 143; potassium 5.2;
chloride 107; CO2 30; BUN 26; creatinine 1.8; glucose 90; physical therapy 12.6;
PTT 29.8; quinidine level 3; calcium 9.2. The EKG revealed dual
chamber 100% paced; no atrial activity; rate 65; intervals 0.16 ,
0.20 and 0.50. An EKG from 10/7 revealed sinus brady at 50;
intervals 0.22 , 0.12; appropriate QTC; left atrial hypertrophy.
Urinalysis was notable for a specific gravity of 1.025 , pH 5 ,
presence of urate crystals. The chest x-ray showed no CHF or
infiltrate; cardiomegaly as well as a dual chamber pacer present.
HOSPITAL COURSE: The patient was admitted to the cardiology Spoonhino Tonshoore Ln
team. The Potwood Kinlis Wellscajohns Health Center team preferred to stop the
Quinidex at this time and observe him for recurrence of atrial
fibrillation with plans to start Norpace if this occurred. There
was no recurrence of atrial fibrillation while in-house. The DDD
remained in place with settings as per the admission note. He had
a cardiac work up consisting of an echocardiogram revealing an
ejection fraction of 30% with inferior and apical hypokinesis
consistent with location of the old MI. He was maintained on
Isordil and atenolol as part of his admission regimen without
symptoms while in-house. On the prior to discharge , he underwent a
standard Bruce ETT. He exercised nine minutes stopping secondary
to fatigue with a peak heart rate of 105; blood pressure increased
from 100/80 to 124/78. There were no ST-T wave changes from
baseline. He was thought to be maximally medicated. His pulse
pressure product at rest was excellent and well maintained , and he
was asymptomatic. He was maintained on his current cardiac
regimen.
He was noted to have a mildly elevated BUN at 26 and creatinine 1.8
on admission. He was found to have urate crystals in his urine.
His BUN decreased to 23 and creatinine 1.3 prior to discharge. We
will consider alkalyzing his urine if we suspect a true urate
nephropathy.
DISPOSITION: He was discharged to home on 1/19/90 . MEDICATIONS ON
DISCHARGE: Isordil 10 mg orally three times a day; atenolol 50 mg
orally twice a day
DISCHARGE DIAGNOSES: 1. CORONARY ARTERY DISEASE.
2. ATRIAL FIBRILLATION.
3. ASYSTOLE.
4. QUESTION OF URIC ACID NEPHROPATHY.
UD634/2156
FRANCISCA A. URBANIAK , M.D. MS1 D: 1/7/91
Batch: 7641 Report: N8227M0 T: 4/6/91
Dictated By: RAY CREAN , M.D.
Document id: 592
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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356637867 | PUO | 54795665 | | 3733434 | 8/3/2005 12:00:00 a.m. | RULE OUT MYCOCARDIAL INFARCTION | Signed | DIS | Admission Date: 6/12/2005 Report Status: Signed
Discharge Date: 9/27/2005
ATTENDING: TONI , CARMELITA M.D.
DATE OF SURGERY:
3/1/05 .
HISTORY AND PHYSICAL:
This is a 74-year-old gentleman with a history on
insulin-dependent diabetes mellitus , hypertension , coronary
artery disease , with substernal chest pain on exertion , which had
been increasing for the month prior to surgery. He denies any
shortness of breath , PND or orthopnea. He has a history of
three-vessel disease on catheterization back in 1996 , status post
angioplasty without stenting. He reportedly had an abnormal
exercise tolerance test in 1996 and in 1999. He was admitted via
his primary care physician's office on 7/16/05 with substernal
chest pain and T wave inversions in leads V3 and V4. Enzymes
were cycled and they were negative x4. The patient went to the
cath on 2/7/05 and was found to have coronary artery disease.
He was scheduled for CABG.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes mellitus , on insulin therapy.
3. Hypercholesterolemia.
PAST SURGICAL HISTORY:
Unknown.
MEDICATIONS ON ADMISSION:
1. Lopressor 50 mg orally three times a day
2. Lisinopril 40 mg orally daily.
3. Aspirin 325 mg orally daily.
4. Hydrochlorothiazide/triamterene one tablet daily.
5. Atorvastatin 80 mg orally daily.
6. Lantus 50 cc daily.
ALLERGIES:
The patient has no known drug allergies.
SOCIAL HISTORY:
No known social history.
FAMILY HISTORY:
No family history of coronary artery disease.
PHYSICAL EXAMINATION:
The patient stands 5 feet 6 inches tall , weighs 97.9 kg.
Temperature was 97 , heart rate was 62 , and blood pressure was
110/64. He was on a face mask with an oxygen saturation at 95%.
On physical examination , he was alert and oriented , with no focal
deficits. HEENT showed PERRLA. No teeth , both upper and lower
dentures. No carotid bruits. Cardiovascular: Regular rate and
rhythm , with no murmurs , rubs or gallops. His Allen's test on
the left upper extremity was normal , on the right upper extremity
was normal. Respiratory: He had clear breath sounds
bilaterally. Adomen: Soft , nontender , no masses , noted to be
obese. Extremities: Without scarring , varicosities or edema.
Pulses , carotid left and right were 2+ , radial left and right
were 2+ , femoral left and right were 2+ , dorsalis pedis were left
and right present by Doppler , and posterior tibial were left and
right present by Doppler.
ADMISSION LABORATORY VALUES:
Sodium of 137 , K of 4.2 , BUN of 35 , and creatinine of 1.3. White
blood cell count was 7 , hematocrit was 38 , and platelet count was
179 , 000. INR was 1.1. His UA was described as contaminated.
Cardiac cath from 2/7/05 , which was performed at the Kernan To Dautedi University Of Of ,
showed a 95% ostial LAD lesion , a 60% mid LAD lesion , an 80%
distal LAD lesion , a 70% proximal D1 lesion , a 40% proximal
circumflex lesion , a 90% ostial OM1 lesion , a 100% proximal RCA
lesion , and a right dominant circulation. Echo from 9/10/05
showed a 60% ejection fraction , with trace to mild mitral
regurgitation , no wall motion abnormalities. An EKG on 2/7/05
showed a normal sinus rhythm with a rate of 52 , inverted T waves
in V3 , V4 , V5 and V6. A chest x-ray from 11/22/05 was read out
as normal.
HOSPITAL COURSE:
The patient was taken to Surgery on 3/1/05 . The preoperative diagnosis was
unstable angina , three-vessel disease and morbid obesity. The procedure was a
CABG x3. The patient had an anaphylactoid response to aprotinin and
subsequently had an all vein CABG. There was a Y graft , SVG1 connecting SVG2
to the LAD , SVG2 connecting the aorta to OM1 , and SVG3 connecting to PDA. The
patient was brought up from the operating room to the Cardiac Surgery
Intensive Care Unit in stable condition. He was extubated on postoperative
day #1. He did well over the next several days. He had some intermittent
confusion , but neuro exam was essentially nonfocal , and the patient was
transferred to the Step-Down Unit on postoperative day #4. At that time ,
neurologically , he was intact. Of note , he had a ventricular fibrillation
arrest in the operating room because of the aprotinin reaction in the
operating room with systolic pressures in the 40s. Open cardiac massage was
required , and he was defibrillated. They used lidocaine and amiodarone during
the code. His CK-MB rose to 37.5 , and his CK was 1646. After his procedure ,
the patient did wake up and was neurologically intact. The patient was on a
regular diet. He had had problems with abdominal distention , but this had
resolved. The patient had also been noted to have an increased creatinine.
However , this also resolved. The patient was a known diabetic and was on
NovoLog sliding scale , and also receiving Lantus. The patient has no
infectious disease issues at that time. The patient was in the Step-Down Unit ,
and on postoperative day #5 , he was noted to spike. Cultures were sent off
which grew out 3+ Gram-native rods. He was started on Flagyl for presumed
aspiration pneumonia. He also is noted to have a positive UTI and was started
on levofloxacin at that time. He also was noted to have a rise in his
creatinine and this was followed as well. On postoperative day #8 , the
patient was again spiked up to 101. Pancultures were sent out as well. He was
found to have a beta-lactamase-resistant E. coli in his urine. This prompted
an ID consult , and the patient was started on nitrofurantoin. Also , at this
time , around postoperative day #9 , it was noted that the patient began to have
some serous drainage from his sternal wound. He was followed by Infectious
Disease at that time , and over the course of the next several days , it was
discovered that the wound grew out Gram-negative rods. A Plastic Surgery
consult was obtained for the patient after a CT scan showed some nonunion of
the sternal table and collection of fluid underneath the sternum. On
postoperative day #11 , it was decided that the patient would benefit from
incision and drainage plus pectoral flap or omental flap for sternal wound
infection , so the patient was taken back to the operating room on 1/25/05 for
incision and drainage of a deep sternal wound infection. At the time of
surgery , a purulent liquid material was expressed through the skin. The
incision was made. The sternum was noted to be totally separated with most of
the wires having been pulled through. The wound was irrigated , and an omental
flap with pectoral advancement was performed. The patient returned from the
operating room to the Surgery Intensive Care Unit where he was again confused ,
however , was able to be easily returned to baseline. Following these
recommendations , the nitrofurantoin was discontinued and the patient was
started on imipenem. Also , the patient was noted to be growing Enterobacter
in his urine and he was started no ceftazidime. The patient did well in the
ICU. He improved from a neuro status. His chest wound healed without
difficulty. He had one brief episode of atrial fibrillation during a coughing
spell , but this also resolved , and the patient was continued on his
antihypertensive medication. The patient was deemed fit for transfer on a
postoperative day #18 back from the ICU once again to the Step-Down Unit.
SUMMARY BY SYSTEM:
1. Neurologically , the patient is portugese-speaking only. He is
intact , moving all extremities , getting in and out of bed , and
very independent.
2. Cardiovascular: The patient's heart rate is in 70 to 80 ,
sinus. Blood pressure is 100s to 150s , means are 70s to 100s.
He is on Lopressor 25 mg every 6 hours and on amlodipine 5 mg twice a day
3. Respiratory: The patient is on room air , saturating 98%.
4. GI: The patient is advanced diet as tolerated , having bowel
movements , on a diabetic diet.
5. Renal: The patient's Foley is out , running negative 340 for
the day before , on Lasix 20 mg orally twice a day Recommendations would
be to have an extra dose or so of Lasix since chest x-ray this
morning was noted to be slightly wet.
6. Endocrine: He is a diabetic. He is on Lantus , NovoLog ,
insulin , and Diabetes Management is following.
7. Heme: The patient is on aspirin and atorvastatin. He still
has chest drains , which are being followed by Plastics who wants
to keep them in.
8. ID: He has got a deep sternal infection with E. coli and is status post a
pectus as well as a omental flap closure. Imipenem was started on 11/19/05 per
ID's recommendation , needs to continue for six weeks. UTI growing out
Klebsiella and Enterobacter. Imipenem was stared on 11/19/05 , again , this will
need to be continued for six weeks. The patient is also on vancomycin for his
sternal wound infection. This was started on 1/25/05 and needs to continue
for six weeks. Currently , the patient is afebrile. White blood cell count is
10. The chest wound was noted to have a small area of erythema , however , it is
intact , and he is being followed by Plastics.
The rest of the dictation will follow when the patient is
discharged.
eScription document: 9-7198670 EMS
Dictated By: FJESETH , JOHNSIE
Attending: TONI , CARMELITA
Dictation ID 7373195
D: 5/10/05
T: 5/10/05
Document id: 593
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
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N |
723981072 | PUO | 82448458 | | 7711979 | 2/22/2005 12:00:00 a.m. | SHORTNESS OF BREATH , CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/22/2005 Report Status: Signed
Discharge Date: 7/25/2005
ATTENDING: DEANDRA LAZARO GILFOY MD
ADMITTING DIAGNOSIS: CHF exacerbation.
DISCHARGE DIAGNOSIS: CHF exacerbation.
DISCHARGE CONDITION: Stable.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
gentleman with a history of nonischemic cardiomyopathy with a
baseline ejection fraction recently estimated at 10-15% in
September of this year. History of polysubstance abuse including
intravenous drug abuse , internasal cocaine , history of hepatitis C ,
history of depression , celiac sprue , history of insulin-dependent
diabetes mellitus , chronic renal insufficiency with a baseline
creatinine ranging from 1.8-2.4 , history of bipolar disorder ,
history of non-ST elevation MI with a negative stress test in
10/29 , who presents on May , 2005 after sustaining a fall
at home. Patient lives on the third floor of his building and
has difficulty secondary to dyspnea on exertion with ambulation
up steps. Per patient , patient was walking up steps and felt
increasing dyspneic and secondary experience a fall. EMS was
notified and patient was brought to the Pagham University Of . Upon presentation to the Kernan To Dautedi University Of Of , patient reports
other additional symptoms of CHF exacerbation including
progressive dyspnea on exertion , orthopnea , paroxysmal nocturnal
dyspnea and cough productive of yellow phlegm dating back to most
recent discharge from hospital on March , 2004 when patient
was admitted for similar complaint of CHF exacerbation. Patient
with multiple , multiple admissions in the last year to two years
secondary to CHF exacerbation with exacerbations felt to be
secondary to medication noncompliance as well as dietary
discretion.
PAST MEDICAL HISTORY: As stated.
MEDICATIONS ON ADMISSION: Include Lasix 100 mg three times a day , Regular
Insulin sliding scale , lisinopril 7.5 mg orally every day , Ativan 0.5 mg
every bedtime as needed insomnia , spironolactone
25 mg orally every day , amlodipine 10 mg orally every day , Plavix 75 mg orally
every day , Lantus 15 units subcutaneously every bedtime , Protonix 400 mg orally every day
ALLERGIES: Patient with allergies to multiple medications
including aspirin , codeine , tetracycline , NSAIDs , ibuprofen ,
Benadryl , Compazine , penicillin. Additionally of note , patient
should not receive beta-blockage given history of cocaine abuse
and ongoing cocaine use.
SOCIAL HISTORY: Patient lives on the third floor of his
apartment building. Former tobacco user. Patient refused to
discuss polysubstance abuse at the time of admission.
FAMILY HISTORY: Noncontributory.
VITAL SIGNS ON ADMISSION: Patient was afebrile at 96 , pulse of
84 , blood pressure 150/99 , respiratory rate of 20 , O2 sat 100% on
room air. Patient was quite combative on admission , though it is
unclear exactly the etiology of the patient's agitation.
PHYSICAL EXAMINATION ON ADMISSION: Remarkable for elevated
jugular venous pressure with pulsation observant the ear at 90
degrees , estimated approximately 18 cm of water. Patient
addition with rales approximately one-half to two-thirds up
bilaterally on chest exam. Cardiac exam: Patient regular rate
and rhythm , no murmurs , rubs or gallops were appropriated.
Patient's lower extremities were felt to be warm and
well-perfused with 2+ lower extremity edema to the hips
bilaterally.
LABORATORY VALUES ON ADMISSION: Remarkable for sodium of 127 ,
hyponatremia felt to be secondary to chronic CHF exacerbation.
Potassium of 5.1 , bicarb of 19 , creatinine elevated at 2.6 up
from baseline of 1.8 , glucose elevated at 377 , hematocrit stable
at 34.5 and BNP was recorded on admission at greater than assay.
EKG on admission revealed normal sinus rhythm with a heart rate
of approximately
80 with T-wave inversion in V5-V6 which were similar to prior
echocardiograms. Chest x-ray obtained on admission revealed
pulmonary vascular congestion with flank pulmonary edema and
bilateral pleural effusions. No infiltrate was appreciated. As
such , patient was admitted for evaluation and management of CHF
exacerbation. CHF was felt to be secondary to medication and
dietary noncompliance as previously mentioned.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular:
A. Ischemia: Patient with no evidence for chest pain or
ischemic injury. At the time of admission , CHF exacerbation not
felt to be due to recurrent ischemia but rather medication
indiscretion. Of note , patient with multiple prior troponin
leaks ranging from 0.10 to 0.12 on prior admissions. Not felt to
be secondary to ischemia necessarily but rather due secondary to
elevated filling pressures.
B. Pump: Patient with decompensated heart failure on admission
not felt to be in a low cardiac output state but rather just
volume overloaded. Patient was subsequently diuresed using both
intravenous Lasix and orally torsemide. At the time of discharge , patient
felt to be relatively euvolemic though will likely require
further outpatient evaluation and ongoing diuresis given his
continued congestive heart failure. Patient with difficulty
adhering to a 2 liter per day fluid-restriction diet , would
recommend further nutritional outpatient evaluation and
counseling regarding his fluid status given poor cardiac
function. At the time of discharge , patient on 100 mg of
torsemide twice a day with relatively good urine output and I/O of
approximately negative 0.5 to 1 kg per day , would recommend
intensive outpatient CHF management including multidisciplinary
approach using heart failure nursing. Patient advised to use
scale and record daily weight , that there have been issues in the
past with compliance. Additionally , patient's Aldactone was
discontinued secondary to hyperkalemia and instead patient was
started on Isordil/hydralazine for hemodynamic support.
C. Rhythm: Patient stable from the perspective , maintained on
tele monitoring with no events over his hospital course.
2. Renal: Patient with acute renal failure on admission with
creatinine elevated to 2.6. With ongoing diuresis and correction
of volume overload , patient's creatinine corrected to a baseline
value. At the time of discharge , patient's creatinine was 2.0.
Recommend rehab monitoring of renal function including creatinine
and BUN every three days until patient on a stable dose of
torsemide and felt to be euvolemic , given concern or risk for
acute renal failure during ongoing diuresis.
3. Endocrine: Patient with a history of insulin-dependent
diabetes maintained on Lantus with Regular Insulin sliding scale
per outpatient regimen.
4. Psych: Patient with a history of bipolar disorder ,
maintained on Depakote. Additionally , patient with a history of
insomnia managed with Ativan 0.5 mg orally every bedtime as needed
Patient with a history of bipolar disorder treated with Depakote
per outpatient regimen.
MEDICATIONS AT TIME OF DISCHARGE: Include hydralazine 10 mg orally
four times a day with a hold parameter for systolic blood pressure less
than 100 mmHg. Regular Insulin sliding scale , Isordil 10 mg orally
three times a day , multivitamin , Norvasc 10 mg orally every day , torsemide 100 mg
orally twice a day , Plavix 75 mg orally every day given aspirin allergy ,
Depakote ER 250 mg orally every bedtime , Nexium 40 mg orally every day with
appropriate substitution for formulary PPI , Lantus
20 units subcutaneously every bedtime P.r.n. medications to include Tylenol , Ativan
0.5 mg orally every bedtime as needed insomnia , Atrovent neb 0.5 mg neb
three times a day as needed shortness of breath , Ultram 50 mg orally every 8 hours as needed
pain.
ONGOING MEDICAL ISSUES AND OUTPATIENT ISSUES:
1. Patient will require further aggressive outpatient CHF
management including ongoing diuresis using orally torsemide.
Patient does put out well to orally torsemide , though of note he
does have compliance issues with regards to daily fluid intake.
2. Additionally , would recommend further titration of
hydralazine and Isordil to maximize hemodynamic support.
3. Additionally , given hyperkalemia on admission with peak
potassium reaching 6.0 , patient's lisinopril and spironolactone
held at the time of discharge. Would recommend reinstitution of
patient's ACE inhibitor particularly as an outpatient with
low-dose lisinopril perhaps starting at 2.5 mg orally every day with
intensive monitoring of potassium.
4. Additionally , would recommend further diabetic teaching as an
outpatient given patient's poor compliance.
5. Strongly feel patient would benefit from involvement in a CHF
program either through Kernan To Dautedi University Of Of or
through other program.
FOLLOW-UP APPOINTMENT: Patient to follow up with primary care
physician , Dr. Cole Aini , at the Pagham University Of . Please call for follow-up appointment.
eScription document: 3-6842411 LMSSten Tel
Dictated By: GORGLIONE , JEANNETTE
Attending: GILFOY , DEANDRA LAZARO
Dictation ID 7130658
D: 8/7/05
T: 8/7/05
Document id: 594
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
805053407 | PUO | 90043314 | | 3353209 | 1/25/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/21/2005 Report Status: Signed
Discharge Date:
ATTENDING: CASSEM , JERAMY M.D.
PRELIMINARY DISCHARGE SUMMARY.
PRINCIPAL DIAGNOSIS ON DISCHARGE: Aspiration pneumonia , line
infection , refractor asthma.
HISTORY OF PRESENT ILLNESS: This is a 59-year-old female well
known to the team on admission with a history of COPD/asthma ,
history of intubation , CHF ( EF of 30% ) , diabetes , schizoaffective
disorder who presents with worsening shortness of breath and
dyspnea as well as night sweats from Sa Pehall . She was
discharged from GMS to rehab on January after being admitted
for shortness of breath and treated as a COPD flare with one week
of azithromycin , prednisone taper and nebulizer treatments. She
was discharged with good O2 sats in the 90s on two liters ( her
home O2 requirement is 2 liters ). Now she presents with
worsening shortness of breath , night sweats and cough which is
productive. She denies chest pain , palpitations ,
lightheadedness , nausea , vomiting , diarrhea. She also finished a
course of levofloxacin after an admit from July to 2 of May for
similar symptoms.
She was transferred from the Sa Pehall to P Therford Hospital ED with
vital signs at that time were 99.5 , heart rate of 120 , blood
pressure of 105/35 , and a respiratory rate of 36 , and 81% on room
air and 86% on 5 liters. She received 1 mg of Ativan , 5 duonebs ,
500 mg intravenous of clindamycin , 500 mg of levofloxacin. Her ABG at
that time was 7.32/82/113 . Her troponin was 0.13 and her BNP was
29. It was thought that she required ICU care and since no beds
were available at Norap Valley Hospital , she was transferred to the
Kernan To Dautedi University Of Of . Her vital signs on admission include a heart rate of
110 , a blood pressure of 190/55 , respiratory rate of 32 and sats
87 to 89% on 4 liters , going up to 95% on 6 liters. She received
vancomycin 1.5 intravenous x1 , albuterol and Atrovent nebs stack as well
as aspirin.
PAST MEDICAL HISTORY: Remarkable for COPD/asthma with last
pulmonary function tests in October 2005 showing an FVC of 41% ,
FEV1 of 0.74 liters , 33% , and a ratio of FEV1/FVC of 83%. Also ,
schizoaffective disorder/questionable bipolar , GERD , diabetes ,
CHF with EF of 30% , and an echo in October 2005 , hypertension
and steroid myopathy.
MEDICATIONS ON ADMISSION:
1. Aspirin 325.
2. Dig 0.25.
3. Colace 100 twice a day
4. Guaifenesin 10 ml every 4 as needed for cough.
5. Insulin NPH 56/12.
6. Isordil 10 three times a day
7. Lactulose 15.
8. Lisinopril 5.
9. Ativan 0.5 mg every 6 as needed for anxiety.
10. Milk of Magnesia 30 as needed constipation.
11. Robaxin 1 , 500 three times a day
12. Nystatin 5 four times a day
13. Prednisone 10.
14. MDI Atrovent every 4.
15. Risperdal 3.
16. Miconazole powder topical twice a day
17. Seroquel 200/600.
18. Singulair 10.
19. Vitamin D 3-400.
20. Trileptal 75 twice a day
21. Depakote 250.
22. Advair 1 puff twice a day
23. Caltrate Plus D.
24. Duonebs as needed
25. ??_____?? Insulin 6 before every meal
26. Levalbuterol 1.25 three times a day
27. Lasix 80.
ALLERGIES: Penicillin , sulfa.
SOCIAL HISTORY: She lives alone but has husband who is involved
in her care. Attends Geri-day program three times per week.
PHYSICAL EXAMINATION ON ADMISSION: Heart rate of 105 , blood
pressure 98/64. Sat of 94% on six liters. On general exam , she
was morbidly obese , working to breathe , speaking in phrases.
Wanting water. Respiratory distress. HEENT: Tearing eyes.
Sclerae anicteric. Extraocular muscles intact. Oropharynx was
clear. Chest with very poor air movement. It was end expiratory
wheezes throughout. Her cardiovascular: JVP not visualized
secondary to body habitus. Tachycardic. Distant heart sounds.
Abdomen was soft , obese , nontender , nondistended. Her
extremities: There was 2+ edema to the knee level.
LABS: Remarkable labs on admission include a creatinine of 1.7 ,
a bicarb of 38 , her BNP was 29 , troponin was 0.13. Her crit was
32.4 , white blood count 7.6 , and platelets 267. On the
differential her white blood count was 93 polys , no bands. Coags
were within normal limits. Her UA was ??__??. EKG showed sinus
tachycardia 106 , some T-wave inversions in lead 1 , some
flattening in lead 5 , but essentially unchanged from prior.
Chest x-ray: Portable AP view with stable cardiomegaly ,
questionable of lower lobe infiltrate but no evidence of CHF.
ANALYSIS AND PLAN: On admission , this is a 59-year-old female
with history of recent COPD and asthma exacerbation , diabetes ,
CHF , who presents with worsening shortness of breath and
suspected right middle lobe pneumonia.
HOSPITAL COURSE BY PROBLEM:
1. Pulmonary: The patient presented with hypercarbic , hypoxemic
respiratory distress , most likely secondary to a recurrent
pneumonia in the setting of her baseline obstructive/restrictive
pulmonary disease. She was not found to be volume overloaded on
admission , and she had a D-Dimer that was negative as well. Her
restrictive lung disease is most likely secondary to her body
habitus leading to obesity hyperventilation syndrome and her
obstructive disease have components of asthma since has
responsive bronchodilation after beta-agonist. The management of
her respiratory status involved initially starting on steroids ,
prednisone 60 mg , frequent nebs , as well as continuing her Advair
and Singulair. It was also planned to use BiPAP since she might
have sleep apnea component despite no objective data supporting
that. She on second day of hospital stay , was under increased
respiratory distress. A repeat blood gas showed a pH of 7.27 , a
PCO2 of 88 , and a PO2 of 82 on 50% of O2. Since clinically
patient was deteriorating , it was decided that she would benefit
of intubation. The patient was intubated on May and was
placed on before meals mode. On ventilation , the patient initially
required before meals since she was not able to maintain good total volumes
on pressure support. Multiple times that it was attempted to
wean her off the ventilator , she developed increased respiratory
distress and decreased total volume with ventilator mechanics
showing increased airway resistance. Despite frequent nebs , she
was unable to be weaned off the ventilator. On January , after
multiple attempts , it was decided that she would benefit from
longterm ventilatory support. She underwent a PEG and
tracheostomy placement by Dr. Bancourt with no complications. Since
January , her ventilatory settings were decreased to pressure
support with peep of 5 and a pressure support of 10. She had two
recurrent episodes of increased respiratory distress when moved
in bed. It was suspected that her respiratory distress was
related to a mechanical obstruction of her tracheostomy and prior
to discharge , she will be getting a different trach recommended
by surgery which will minimize this mechanical obstruction.
Otherwise , she is currently on 40% of FIO2 and a peep of 5 ,
pressure support of 12 and at those settings she is getting tidal
volumes in the range from 380 to 450 and O2 sats between 98 and
100%.
2. ID: Her chest x-ray had a suspected right middle lobe
infiltrate in addition to the fever and increased white blood
count. It was decided that she would benefit from nosocomial
pneumonia coverage. Her first course of antibiotics included
levo , clinda. , as well as vancomycin. Cultures of her sputum and
blood were sent , were negative. Her sputum cultures just grew
orally flora and her blood cultures initially were all negative but
on January , she had a positive culture for staph. , guaiac
negative , in the setting of a central venous line. It was
thought at that moment that she had secondary infection which was
MSSE line infection and all lines were pulled and she was
continued on vancomycin for another 14 days. Her antibiotics
were switched to ceftaz. , azithromycin , clindamycin and
vancomycin. She received a total of 21 days of antibiotics and
prior to discharge had finished her ceftaz. and Flagyl. She also
received a 14 day course of vancomycin after the central venous
lines were removed and since then she has been afebrile and all
blood cultures after October have been negative , so about 10
days with negative blood cultures and sputum cultures.
Just prior to discharge , her left IJ line will be removed since
she just finished her course of antibiotics as well as her
peripheral A line.
Endocrine: The patient received high dose of steroids ,
prednisone 60 mg , for about two weeks and had a couple of
attempts to decrease the prednisone but responded with increased
broncho-resistance on ventilator measurements and it was decided
to keep her at a higher dose. The week prior to admission , a
slow tapering was started with 50 mg for 5 days , then 50 mg for
another 4 days and on discharge , she was on the transition point
to 30 mg. She was getting calcium carbonate and vitamin D for
osteoporosis prevention. Her diabetes was managed with Lantus
100 units a day with Portland Insulin Protocol on initial ICU
stay transitioned to Regular Insulin scale. She was not needing
any extra insulin units prior to discharge.
Cardiovascular:
A. Ischemia: The patient had recent workup for CAD including
Cath which was negative , but she did have an elevation troponin
which was likely secondary to demand ischemia with spontaneous
resolution. She was continued on aspirin. There was no angina
or new changes in EKG during this admission.
B. Pump: She looked slightly volume overloaded on admission.
She received Lasix
80 intravenous twice a day and her diuretic regimen was titrated and she might
need , once discharged ,
a standing dose of Lasix to maintain her I's and O's goal even.
Her blood pressure off the ACE inhibitor on hospital stay ranged
between 112 and 130. We plan to restart her on a small-dose ACE
inhibitor prior to discharge with the objective of better blood
pressure control as well as renal protection from her diabetes.
We will not restart Isordil since patient had no evidence of
coronary artery disease.
Psych: We will continue home regimen of Trileptal , Depakote as
well as Risperdal.
Heme: Her hematocrit has remained stable during this admission.
Since she was getting multiple blood draws , she received about 2
units of packed red blood cells and all her workup for a source
of anemia was negative including vitamin B12 , including iron
studies as well. Her heme ?__? panel was also negative.
Musculoskeletal: Patient had an infiltrative ?___? on her left
arm around her peripheral intravenous access. The infiltration lead to a
large ulcer which was managed by Plastics. They recommended only
twice a day dressing changes. There were no signs of evident
infection in the site and healing since that event has been quite
good. There are some signs of granulation tissue in the ulcer
base but no erythema or pus around it. Physical Therapy has
been involved in the case and have been doing tremendous work in
putting her sitting upright , as well as gaining increased
strength on her extremity. She is still unable to raise her arm
against gravity but she has 2/5 muscle strength throughout and
she will likely need intensive rehab once she is discharged.
FEN: She had a metabolic test performed which yielded a measure
resting energy expender of 2121 kilocalories a day and a
predicted basal metabolic rate of 1771 kilocalories a day. Those
results yielded to an increase in her tube feedings which are
consisted of Osmolite 1.2 at 70 cc an hour.
eScription document: 2-9694555 MCS
Dictated By: ALSPAUGH , KERRY
Attending: CASSEM , JERAMY
Dictation ID 8716547
D: 3/8/05
T: 3/8/05
Document id: 595
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
- |
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- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
- |
162833261 | PUO | 88950853 | | 493749 | 2/18/1999 12:00:00 a.m. | VENTRICULAR TACHYCARDIA | Signed | DIS | Admission Date: 3/25/1999 Report Status: Signed
Discharge Date: 9/25/1999
PRINCIPAL DIAGNOSIS: ATRIAL FIBRILLATION
PROBLEM LIST:
1. Gout.
2. Hypertension.
3. Abdominal aortic aneurysm status post repair.
4. Prostate carcinoma.
5. Status post aortic valve replacement.
CHIEF COMPLAINT: This is an 81 year old gentleman with a history
of hypertension status post aortic valve
replacement , congestive heart failure , abdominal aortic aneurysm ,
atrial fibrillation who presents status post syncopal episode on
9/23/99 .
HISTORY OF PRESENT ILLNESS: Mr. Houghton is an 81 year old gentleman
with a history of hypertension , aortic
insufficiency status post aortic valve replacement , congestive
heart failure and abdominal aortic aneurysm repair who was stable
with baseline dyspnea on exertion until the day prior to admission
when he went out to take the garbage. He states that he stepped
off the curb and passed out. He denies any prodrome syndrome and
denies loss of bowel or bladder function. No fever or chills. He
did not recall the event but remembers coming to and his neighbor
calling the ambulance. He denies any chest pain , shortness of
breath , palpitations , associated with the incident and denies any
similar event in the past. He landed on his left side , face first.
Mr. Houghton has been treated with propafenone for his atrial
fibrillation and two weeks prior to admission was increased from
150 mg three times a day to 300 mg three times a day Of note , he had been on
procainamide which was changed to propafenone secondary to an
increasingly positive ANA. During his last visit with his
cardiologist , Dr. Raabe , he was noted to be in atrial fibrillation.
His propafenone was doubled and was to be followed. At Norap Valley Hospital , the patient had a work up which included a head CT that
was negative. His INR was found to be 5.4 and electrocardiograms
revealed baseline left bundle branch block/widening of the QRS and
underlying atrial fibrillation. He was also found to have a left
lower lobe pneumonia and was treated with antibiotics. He was
transferred here for further evaluation. On 3/7/99 , he was noted
to have a wide complex tachycardia in the 150 beats per minute
range.
PAST MEDICAL HISTORY: 1. Prostate cancer treated with hormone
therapy 7-8 years ago. 2. Gout. 3.
Hypertension. 4. Abdominal aortic aneurysm status post repair.
5. Status post aortic valve replacement. 6. Status post
cholecystectomy.
MEDICATIONS ON ADMISSION: Propafenone 300 mg orally three times a day , Coumadin
daily , Colchicine 0.6 mg orally twice a day ,
Allopurinol 200 mg every day , Pepcid 20 mg orally twice a day , Captopril 25 mg
three times a day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco. One drink of alcohol per day. He
lives with his wife.
PHYSICAL EXAM: Temperature 98.0 , pulse 80 , blood pressure 138/82 ,
respiratory rate 20 , room air oxygen saturation 90
percent. Baseline weight is 193 pounds. GENERAL: This is an
elderly gentleman with multiple ecchymoses on the face with a
packed nose. He is mildly anxious. HEENT: Notable for facial
bruises , lacerations on the bridge of the nose with left naris
packing. Pupils equal , round and reactive to light and
accommodation. Tympanic membranes clear. Oropharynx is clear.
NECK: Reveals jugular venous pressure about 10 centimeters , 2+
carotids , no bruits. LUNGS: Bibasilar crackles , poor air
movement. CARDIAC: Irregularly irregular with a normal S1 and S2
with a I/VI systolic ejection murmur heard best at the right lower
sternal border and a II/VI systolic ejection murmur heard best at
the right upper sternal border. ABDOMEN: Soft , nontender. Good
bowel sounds. No hepatosplenomegaly. No costovertebral angle
tenderness and no spinal tenderness. EXTREMITIES: Cool ,
adequately perfused with 1+ dorsalis pedis pulses. NEUROLOGICAL:
He is alert and oriented times three. Motor strength is 5/5
throughout. Reflexes are 1+ and symmetric. GAIT: Within normal
limits.
LABORATORY DATA ON ADMISSION: White blood cell count 7.6 ,
hematocrit 40.5 , platelets 139 ,
sodium 139 , potassium 4.5 , chloride 104 , bicarbonate 22 , BUN 52 ,
creatinine 1.3 , glucose 98 , magnesium 2.0 , physical therapy 22.2 , PTT 54.7 , INR
3.4.
Electrocardiogram revealed atrial flutter with rapid response or an
accelerated junctional rhythm at a rate of 85.
IMPRESSION: This is an 81 year old gentleman with no known history
of coronary artery disease who was status post aortic
valve replacement with homograft repair of the abdominal aortic
aneurysm on Propafenone for atrial fibrillation. Now presenting
with a syncopal episode of presumptive cardiac etiology. Given his
baseline supraventricular tachycardia , the most likely explanation
was a rapid ventricular response to atrial fibrillation/flutter
with a widened QRS secondary to propafenone.
HOSPITAL COURSE: 1. Cardiovascular: Initially his Propafenone
was held given its' ability to increase the QRS
interval. His Coumadin was also held given his supratherapeutic
INR and recent facial traumas. His hematological status was
followed carefully with serial hematocrit checks. He was evaluated
early on by the electrophysiology service and was started on a low
dose beta blocker to prevent him from going back into atrial
fibrillation while off the anticoagulation. An EP study was
planned , however on 7/17/99 the patient had an episode of
nonsustained ventricular tachycardia which appeared to be different
from his baseline atrial fibrillation. In addition this was not
likely to be a bundle branch re-entry pattern and therefore the
utility of an EP study was thought to be very low. Given this the
EP service favored placement of a DDDR/AIDC post cardiac
catheterization to rule out any coronary disease. Cardiac
catheterization was performed on 5/13/99 and he was found to have
no coronary artery disease. He went for his DDDR/AICD placement on
5/13/99 and this was done successfully. He was continued on his
Captopril and Lopressor and in addition , Amiodarone was started at
400 mg orally twice a day Two days after pacemaker placement he developed
a temperature to 101.1 and was cultured. The pacer site looked
clean and was not thought to be infected. He received AICD
teaching by the EP service prior to discharge. He will be
continued on his Ancef as an outpatient as well.
2. Hematology: His anticoagulation was held given that he was in
normal sinus rhythm and he had extensive facial fractures and
wounds. He remained out of atrial fibrillation and was not
anticoagulated. His hematocrit and platelets remained stable.
3. ENT: The patient had received nasal packing to his left naris
at Norap Valley Hospital and this remained in place for six days. He
was followed by the ENT service here at Pagham University Of
and their recommendation was for follow up maxillofacial CT scan.
This revealed multiple facial fractures but no orbital floor
fracture. The ophthalmology service was consulted and their
opinion was that he had a normal examination and no evidence of
ocular muscle entrapment , optic neuropathy or globe malposition.
Therefore no operative intervention was required for his
periorbital fractures. He is to follow up in the Pagham University Of eye clinic upon discharge.
He was also seen by the dental service and noted to have infected teeth. He had
a fever the day following his dental exam. This needs to be carefully managed
as he also has a prosthetic valve.
4. Neurological: The patient's mental status was
at time somewhat worrisome because he became very sleepy and lethargic , however
according to his outpatient cardiologist , Dr. Raabe , he is often
this way. Concern was raised for a subdural hematoma given his
recent trauma. However his mental status waxed and waned
periodically and he was also alert and oriented times three.
DISPOSITION ON DISCHARGE: The patient will be discharged to
Silvtonla Health .
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE: Allopurinol 100 mg orally twice a day ,
Amiodarone 400 mg orally twice a day , Captopril
12.5 mg orally three times a day , Clindamycin 300 mg orally four times a day , Colchicine 0.6
mg orally every day , Colace 100 mg orally twice a day , Lopressor 25 mg orally
three times a day , Zantac 150 mg orally twice a day
DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr.
Teas as an outpatient and with the
Pagham University Of ophthalmology group. His amiodarone
dose will need to be decreased to 200 mg every day in about two weeks
as an outpatient.
Dictated By: WERNER SCHMIDTKE , M.D. VU17
Attending: MARGARETT TEAS , M.D. YQ81 DC613/1102
Batch: 9312 Index No. F3AEVC09ID D: 5/12/99
T: 5/12/99
CC: SUNSHINE D. RAABE , M.D. HR28
Document id: 596
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
- |
N |
N |
- |
156883837 | PUO | 43767623 | | 9201197 | 5/7/2004 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 9/24/2004 Report Status:
Discharge Date: 4/10/2004
****** DISCHARGE ORDERS ******
WAYMAN , CECILIA 155-40-90-2
Ine Chat
Service: CAR
DISCHARGE PATIENT ON: 7/15/04 AT 01:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BLACKGOAT , GERMAINE LAVONNE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
ROCALTROL ( CALCITRIOL ) 0.25 MCG orally QMWF
PHOSLO ( CALCIUM ACETATE ) 667 MG orally three times a day
CLONIDINE HCL 0.1 MG/DAY TP Q168H
PROCRIT ( EPOETIN ALFA ) 10 , 000 UNITS subcutaneously QWEEK
Reason for ordering: Renal Disease
Last known Hgb level at time of order: 10.3 g/dL on
3/20/04 at PUO Symptoms: Fatigue , SOB ,
Diagnosis: Chronic Renal Failure 219
Treatment Cycle: Initiation
LASIX ( FUROSEMIDE ) 100 MG orally twice a day Starting IN a.m. September
LABETALOL HCL 800 MG orally three times a day HOLD IF: sbp<90 or heart rate<55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 40 MG orally every day HOLD IF: sbp<100
MUPIROCIN TOPICAL TP twice a day Instructions: apply to shin
NIFEREX-150 150 MG orally twice a day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 6/11/04 by
FIGURA , CAREY T. , M.D.
on order for SIMVASTATIN orally ( ref # 50676916 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 6/11/04 by
FIGURA , CAREY T. , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
NORVASC ( AMLODIPINE ) 10 MG orally every day HOLD IF: sbp<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 360 MG orally every day
Starting Today October HOLD IF: sbp<90
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
FLOVENT ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
LAMICTAL ( LAMOTRIGINE ) 150 MG orally twice a day
Number of Doses Required ( approximate ): 4
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
TRILEPTAL ( OXCARBAZEPINE ) 300 MG orally twice a day
LANTUS ( INSULIN GLARGINE ) 46 UNITS subcutaneously every day
Starting Today April Instructions: half his home dose
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
DIET: Patient should measure weight daily
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Marola ( PMD ) January @1:30 pm scheduled ,
Dr. Vause ( Kidney ) March 2:30 pm scheduled ,
Dr. Stautz ( CHF ) January @ 4:20 pm scheduled ,
ALLERGY: Tape
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) htn ( hypertension ) bipolar ( bipolar
disease ) panic ( panic disorder ) renal insufficiency ( renal
insufficiency ) congestive heart failure ( congestive heart failure )
copd ( chronic obstructive pulmonary disease ) cad ( coronary artery
disease ) nephrotic syndrome ( nephrotic syndrome )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous diuretics , vein graft mapping
BRIEF RESUME OF HOSPITAL COURSE:
64 year-old male hx of CHF , CAD , CRI , nephrotic syndrome , COPD DM2 ( ID ) ,
bipolar d/o , history of stent of PDA in 8/10 , presents with 1 week of
progressive SOB , DOE , orthopnea , lower extremity leg swelling , and
chest burning. patient with recent 5/9 admission for CHF , doing baseline
after d/c but had hotdogs with beans 1 week ago , 1 day prior to
symptom onset. patient also with decreased exercise tolerance ( 1/5 blocks
walk to DOE with shaving ). Burning in chest with activity ( band like ,
radiating to both shoulders ) releived promptly with rest. Cath in
11/18 stening of PDA , LAD 40% , LCx 40%.
Stress echo in 11/1 - 55%EF , atypical CP with infusion.
Vitals HR 80 , BP 155/90 , Afebrile , RR 20 , 94% RA.
Gen: Sitting , labored breathing
Heent: JVP 10-11 , no carotid bruis ,
CV: s3 ( ?split s2 ) , 2/6 SEm LUSB ,
Pulm: Rales diffuse , decreased BS LL bases , egophany on R lower base
Abd: Soft , obese , NT , +BS , ext: 2+ pit edema bilat- good
DP/s WWp , left anterior shin transdermal ulcer
( new ).
************** Hospital Course***************
1 ) ISCHEMIA: patient with prior CAD/stent , likely angina 2nd to demand
ischemia on decompenasted HF. cont meds , patient not on Plavix on
admission. Doubt primary angina as couse of CHF/RHF.
2 ) PUMP: patient with ?dyastolic HF with
acute decomp/exacerbation ( with dietary
indiscretion )- as well as renal failure as poss source of
volume overload. Change to intravenous lasix 100 twice a day and
strict I/Os , weights. October patient has responded to BMP diuresis in past.
Restarted here on BMP with limited response. patient achieved -500 ml every day but
continued to have weight gain. I suspect that fluids were not being acc
urately accounted for. At this time patient is no longer being effect
ively diuresed and will require dialysis for volume overload in a
short period of time.
3 ) RHYTHM: No signs of arhtymias
4 ) RENAL: physical therapy with stage 4 CRI and nephrotic
synd. May be volume overload 2nd to renal failure
in addition to CHF decomp/exacer. Cr. 4 at admission but elevated to
5.3. Given patient's current condition , dialysis seems
imminent. October patient went for vein mapping but patient remained uncertain if
he will accept dialysis as a treatment option. At time of d/c
creatnine now 5.0. patient will have creatnine checked in 2 days and
called in to following physician. Will HD plan accordingly.
5 ) GI: GI bleed in past , Guaiac neg in ED
6 ) ENDO: DM2- will on 1/2 dose lantus in house with RISS , HA1C-5.7
subclinical hypothyroid , TSH-3.235
7 )HEME: microcytic anemia ? FE vs.
chronic disease , patient with transfusion from ED , unable
to send FE studies at this time. Started on Procrit per renal.
8 ) PSYCH: Bipolar d/o- cont meds
9 )patient with poor ox sat- f/u CT for structural causes of poor
oxygenation.
10 ) FULL Code CODE
ADDITIONAL COMMENTS: Please note that we have made the following changes to your
medications: Simvostatin increased to 40 every day , Lisinopril now 40 every day ,
Imdur increased to 180 every day we have also started Rocaltrol m/with f; phoslo
three times a day , procrit ( will be administered by Dr. Vause ) , Mupirocin ( apply to
open soar 2x/day ). Also , please return to the hospital if you have
chest pain or excessive shortness of breath. You should weigh yourself
daily. If you are losing more than 1 kg/day ( 2.2 lbs ) skip your evening
lasix.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Make sure you get your blood drawn before going to your CHF
appointment on June at 4:20 pm.
No dictated summary
ENTERED BY: INGRAM , ANDREE OSWALDO , M.D. ( RM850 ) 7/15/04 @ 01:06 PM
****** END OF DISCHARGE ORDERS ******
Document id: 597
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
Y |
N |
- |
Y |
N |
- |
N |
N |
- |
N |
226221953 | PUO | 68155720 | | 3579077 | 5/29/2006 12:00:00 a.m. | chf exacerbation | | DIS | Admission Date: 5/7/2006 Report Status:
Discharge Date: 11/19/2006
****** FINAL DISCHARGE ORDERS ******
EISENZIMMER , ANTONIETTA 581-42-71-1
Charlme Vi Birm
Service: MED
DISCHARGE PATIENT ON: 1/29/06 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. A. L.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ATORVASTATIN 80 MG orally DAILY
COREG ( CARVEDILOL ) 3.125 MG orally twice a day
HOLD IF: SBP<90 or P<55
Instructions: if held , please call HO
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 6
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
LASIX ( FUROSEMIDE ) 80 MG orally DAILY Starting IN a.m. May
INSULIN 70/30 HUMAN 50 UNITS every day before noon; 35 UNITS every afternoon subcutaneously
50 UNITS every day before noon 35 UNITS every afternoon
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally DAILY
Starting IN a.m. January Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 10 MG orally DAILY HOLD IF: SBP < 90 and call HO
Alert overridden: Override added on 3/9/06 by
DUTCH , CAROLYNN F , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: SPIRONOLACTONE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: monitor
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally DAILY
SPIRONOLACTONE 50 MG orally DAILY HOLD IF: SBP<90
Food/Drug Interaction Instruction Give with meals
Override Notice: Override added on 3/9/06 by
DUTCH , CAROLYNN F , M.D. , M.P.H.
on order for LISINOPRIL orally ( ref # 944000507 )
POTENTIALLY SERIOUS INTERACTION: SPIRONOLACTONE &
LISINOPRIL Reason for override: monitor
Previous override information:
Override added on 3/9/06 by GERZ , JEANNA L. , M.D. , M.P.H.
on order for KCL IMMEDIATE RELEASE orally ( ref #
109658399 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: monitored
Previous override information:
Override added on 10/8/06 by DUTCH , CAROLYNN F , M.D. , M.P.H.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
171914695 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: monitor Previous override information:
Override added on 10/8/06 by BLACKGOAT , GERMAINE L. , M.D. , PH.D.
on order for CAPTOPRIL orally ( ref # 451579411 )
POTENTIALLY SERIOUS INTERACTION: SPIRONOLACTONE & CAPTOPRIL
Reason for override: aware
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
cardiology dr hanagami 158.668.8770 1-4 weeks ,
pcp dr chadwick rochat 444-844-8841 2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chf , unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf exacerbation
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
echo 7/25 -with EF 20-25% , wall motion abnl , dil ivc , tr , mr. evidence of
atrial septal defect noted.
Mibi/PET-CT 9/2 test results are abnormal and c/with the following:
1. A medium sized region of myocardial scar without residual
ischemia or viability in the distribution of the mid-LAD coronary
artery.
2. A small region of myocardial scar without residual ischemia
or viability in the distribution of the PDA coronary artery.
3. Moderate global LV systolic dysfunction.
BRIEF RESUME OF HOSPITAL COURSE:
CC- sent in by pcp for chest pressure
HPI-66yo M from A 11/27 had labs drawn at
spi ian university hospital . 5/9 saw pcp , reported sig.cardiac hx. and over the past
few months has had an increase in chest pressure , nonradiating , initially
sx on exertion , most recently at rest. On sunday ,
he was lying on couch when the sx started , took two nitro with good
resolution. no sob , no n/v/diaphoresis/fevers. he has also noted
worsening LE edema and weight gain of 30lbs over this time period. He
admits to missing his meds and to eating a lot of salt.
He was worked up at Stone Chastorgscienceceville Hospital in Lansaint for several months to
try and determine how to best treat his cardiac disease. Per the patient , they
said they couldn't do anything for him.
In ED , afebrile heart rate 60s , BP 110s sat 100%RA. . Tx with lasix 80iiv , asa
325 , coreg
6.25 , inuslin 8u. each eye 1500. CXR c/with pulm edema
Exam
Gen- resting comfortably in bed , no c/o
HEENT- jvp to jaw
Pulm- b/l crackles at bases
Abd- soft , NT , ND
Ext- c/o rt foot pain , no signs of trauma. slight edema , b/l , c/o ttp
along top of left. DPs not palpable
Home meds
plavix75
asa81
carnitidine ( ? ) 150 twice a day
imdur 30
digitek 0.125
lasix 80
coreg 6.25
spironolactone 50
insulin 70/30 50qam , 35 every afternoon
NKDA
PMH
mi x3 ( 1993 ) - ? cath , ?inoperable , knows he has 3v
dz
htn
chf
gerd
dm
Shx
from Taca Hwy , Losalling Mo Merlum Mong , New Hampshire 65116
exsmoker quit 5y pta
no etoh , no ivdu
FHx
brother died of MI 5/15 in 50s
parents died of CAD in 70s/80s
htn , dm
studies
cxr 10/2 cardiomegaly , increased interstitial marking c/with pulm edema
ekg- nsr 1 degree avblock , nl axis , every in v1-v3 , poor r waves in v4-v5 , T
inversion 3 , avf , biphasic Ts and mild depression ( <0.5mm ) in v5
echo 7/25 -with EF 20-25% , wall motion abnl , dil ivc , tr , mr. evidence of
ASD seen.
Mibi 9/2 no evidence of reversible ischemia
assessment and plan
66yo with cad/mi , dm , chf , admitted for chf exacerbation and r/o MI
1. CV-
a. ischemia- sig cad with hx of chest presure at rest , ce -x2. ekg
abnl without priors , concerning for unstable angina. given asa , carvedilol
( changed to lisinopril 7/26 ) , lipitor , plavix and started on lovenox 100
sq. Lovenox was stopped when ce neg x3 on 7/25 . Lipid panel ok , continue
on lipitor 80. Has been CP free since Sunday. Stressed on 7/26 , results
show no evidence of reversible ischemia and patient has had no CP while in the
hospital.
b. pump - chf exacerbation , likely 2/2 not taking meds and poor diet
control. will txc with lasix 40iv twice a day , goals -1liter/day. patient already
improving- good diuresis with lasix 40iv. continue home spironolactone ,
restarted on home imdur. ACEi started and increased to 10mg every day fluid
restricted to 2L.
echo 7/25 with EF 20-25% , wall motion abnl , dil ivc , tr , mr. Patient has
diuresed well during his time in house with a weight on dc of 82
kg. Continue on lasix 80po daily.
c. rhythm- sinus , on tele. long Pr interval noted , dig stopped to
avoid any additional PR prolongation. may need EP workup in the future.
2. pulm- cardiogenic pulm edema , imprving. sat stable on RA.
continue diuresis. On room air throughout his time in house , appears very
comfortable.
3. GI- mild transaminitis- decreased over the course of his time
here and normal AST/ALT/Tbili on day of discharge. Alk phos contiues to
be elevated at 175. Will need pcp follow up evaluation , but no abdominal
complaints.
4. Heme- on lovenox for UA , transitioned to subcutaneously DVT ppx dosing on
7/25 , on plavix for ? stent. Will continue on plavix and asa as outpt.
5. endo- nph 18 twice a day for now ( inc from home 10 ) , 6u before meals and ss. hgb
a1c 10.4- indicating need for tighter glucose control. He will go home on
an increased dose on NPH and advised to keep tight control over his blood
sugar.
6. msk- c/o left foot pain , unclear source. xray final read shows
degenerative changes. able to doppler DPs. ? claudication? Patient is
pain free now.
7. fen- ada , cardiac diet. Lytes repleted while in house , all normal
on discharge.
8. Patient is staible for discharge home. He will need to followup
with cardiology as an outpt.
ADDITIONAL COMMENTS: 1. take all your medications as directed.
2. Weigh yourself daily , if you start to gain weight ( even 5 pounds ) , you
need to contact your doctor about increasing your lasix dose.
3. Follow up with cardiology as directed.
4. check you blood sugars in the morning and with meals. adjust your
insulin as needed. dr chadwick rochat at spi ian university hospital will be following his
blood sugars.
5. get a recheck of your lfts as an outpt , your Alk Phos and GGT were
elevated.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. take all your medications as directed.
2. Weigh yourself daily , if you start to gain weight ( even 5 pounds ) , you
need to contact your doctor about increasing your lasix dose.
3. Follow up with cardiology as directed.
No dictated summary
ENTERED BY: DUTCH , CAROLYNN F , M.D. , M.P.H. ( FM112 ) 1/29/06 @ 12:54 PM
****** END OF DISCHARGE ORDERS ******
Document id: 598
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
Y |
- |
Y |
- |
Y |
N |
N |
N |
- |
268068689 | PUO | 70466694 | | 7018304 | 11/10/2006 12:00:00 a.m. | CHEST PAIN | Signed | DIS | Admission Date: 11/10/2006 Report Status: Signed
Discharge Date: 1/16/2007
ATTENDING: MANKOSKI , ROSSIE MD
ADMITTING DIAGNOSIS: Coronary artery disease.
BRIEF HISTORY: The patient is an 81-year-old Italian-speaking
gentleman with a past medical history significant for diabetes ,
hypertension , and COPD who was admitted to an outside hospital
with rise in his chest pain. At that time , there were no EKG
changes and the chest CT PE protocol was reportedly negative.
Several hours later , the patient developed left-sided chest pain
with ST elevations in V2 , V4 and enzyme leak. On
11/27/06 , the patient was transferred to Pagham University Of where he underwent a cardiac catheterization , which
revealed three-vessel disease.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Hyperglyceridemia.
4. COPD.
5. BPH.
6. Seizures.
7. Blindness in the right eye.
PAST SURGICAL HISTORY:
1. Bilateral knee replacement.
2. Right knee re-operated for infection.
3. Bilateral inguinal hernia repair.
4. Right eye enucleation.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: Italian speaking , lives at home , is accompanied
with his son. The patient is a retired farm worker.
ALLERGIES: The patient is allergic to Ciprofloxacin , Ceftin , and
Singulair.
ADMISSION MEDICATIONS:
1. Lopressor 25 orally every 6 hours
2. Diltiazem 125 mg orally daily.
3. Aspirin 325 mg orally daily.
4. Furosemide 20 mg orally daily.
5. Methylprednisolone 30 mg intravenous every 8 hours
6. Atorvastatin 80 mg orally daily.
7. Allopurinol 100 mg orally daily.
8. Ativan 0.5 mg orally at bedtime.
9. Nexium 20 mg orally daily.
10. Proscar 5 mg orally every night.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs were as follows.
Temperature 97.1 , heart rate 73 , blood pressure on the right arm
108/59 , and oxygen saturation 98%. HEENT , PERRLA , dentition
without evidence of infection , no carotid bruits. On chest
examination , no incisions. Cardiovascular , regular rate and
rhythm without murmurs. Respiratory , breath sounds are clear
bilaterally. On abdominal exam , bilateral inguinal hernia
incisions and enlarged right groin hematoma from previous cardiac
catheterization. On extremities , bilateral lower extremity
varicosities. Neuro exam , the patient was alert and oriented
without focal deficits.
Cardiac catheterization performed at Pagham University Of
on 11/2/06 revealed 30% mid RCA occlusion , 40% distal RCA , 90%
ostial OM1 , 90% mid CX , 80% proximal LAD , 99% mid LAD , and 60%
mid LM. EKG on 5/5/06 showed a normal sinus rhythm at 76 and
an incomplete right bundle-branch block. A chest x-ray on
11/2/06 was consistent with congestive heart failure.
HOSPITAL COURSE: The patient's hospital course is as follows by
systems.
1. Neurologic: Agitation and delirium. In the immediate
postoperative period , the patient was on alcohol drip , given a
preop history of alcohol use. The patient's neurologic status
improved with the patient being more alert during the day ,
particularly with family members present. Haldol was used as needed
for agitation during the hospital course.
2. Cardiovascular: On 11/27/06 , the patient was taken to the
operating room and underwent coronary artery bypass grafting x1
with LIMA to LAD , with incomplete revascularization due to
inadequate conduit. The patient tolerated the procedure well and
after a period of observation , was transferred to the Cardiac
Surgery Intensive Care Unit. Subsequently , during the hospital
stay , the patient was started on beta-blockers and statins.
Later during the hospital stay , the patient became hypotensive , requiring
fluid resuscitation and vasopressor administration.
3. Respiratory: The patient was extubated on postoperative day
two , but he was reintubated for acute respiratory failure later during the day
with subsequent re-extubation on 2/16/07 . During the hospital stay ,
the patient had two additional re-intubations for acute respiratory failure
events , one on 11/21/07 followed by extubation on the next day , on 11/17/07 and
the second one on 4/18/07 followed by extubation on 3/23/07 .
4. GI: It was characterized by nutrition deficiency , although
the patient was able to tolerate soft mechanical diet , the intake
was limited. The puff tubes were placed multiple times for
additional nutrition , but were frequently removed by the patient ,
given the delirium and agitation.
5. Renal: The patient had good urine output and the electrolyte
and creatinine levels were closely monitored.
6. Endocrine: Tight glycemic control was maintained with
Portland protocol in the immediate postop period and subsequently
with subcutaneously insulin. The patient was also on prednisone with the
preop indications for COPD and given his postop frequent
bronchospastic events.
7. Hematologic: The patient was started on aspirin and also on
Plavix , given the incomplete coronary vascularization.
Hematocrit and platelets were stable.
8. Infectious disease: The course was complicated by: A )
Sternal wound infection for which the patient underwent
pericardial strip advancement on 11/21/07 and omental flap and
wound closure on 10/1/07 . The wound was reopened at the bedside
on 7/28/07 by Plastic Surgery due to increased drainage and a
VAC sponge was placed. Wound cultures were sent and appropriate
antibiotic treatment was instituted. B ) Pneumonias. Treated
initially empirically and subsequently with specific antibiotics
after culture results became available. C ) Fever , later in the
hospital course , the patient experienced fever without
leukocytosis despite negative cultures. Throughout the hospital
course , Infectious Disease Service and Pulmonary Service were
consulted and they followed the patient continuously.
9. Other: Incidental radiologic finding of a renal mass
consistent with renal cell carcinoma. Urology Service was
consulted and the recommendations were made for no intervention
at this time.
After excessive discussion with the very supportive patient's family with
regards to the patient's prognosis , family decision was made to withdraw
medical care and discharge the patient to home with hospice services. Thus , on
4/18/07 , the patient was discharged to home after hospice services were
arranged.
MEDICATIONS AT DISCHARGE: Were the following.
1. Tylenol suppository 650 mg every 6 hours
2. Toradol orally 10 mg every 4 hours as needed for pain.
3. Haldol liquid 1 to 3 mg orally every 4 hours as needed for
agitation.
4. Nexium 20 mg everyday.
5. Morphine liquid 5 to 20 mg orally every 2 hours as needed for
pain and for shortness of breath.
Support for the patient's family was provided throughout the
hospital course , and the patient's family was instructed to call
house officer on call if any question might arise.
eScription document: 7-5678913 CSSten Tel
Dictated By: SHOMER , DOTTY
Attending: MANKOSKI , ROSSIE
Dictation ID 5160061
D: 5/20/07
T: 5/20/07
Document id: 599
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
- |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
433461314 | PUO | 49848971 | | 177233 | 2/28/2002 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 8/18/2002 Report Status: Signed
Discharge Date: 3/4/2002
SERVICE: The patient was taken care of on the Cardiology Sanoa Troit Prings
Service.
PRINCIPAL DISCHARGE DIAGNOSIS: UNSTABLE ANGINA.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old man with
hypertension , hypercholesterol ,
diabetes mellitus , coronary artery disease status post coronary
artery bypass graft , PTCA , with known exertional angina , who now
presents with episodes of chest pressure , shortness of breath
lasting approximately one hour and occurring at rest. The patient
was taken to an outside hospital where his pain dissipated only
after sublingual nitroglycerin , then intravenous nitroglycerin , Lopressor ,
Plavix , enoxaparin , and aspirin. At the outside hospital , the CK
was found to be 400 with an MB fraction of 4 percent. A Troponin T
was found to be 0.099 , creatinine was 2.2. Upon arrival to the
Kernan To Dautedi University Of Of , the patient had 1/10 chest pain and a blood pressure of
195/98 which improved with TNG to 170 systolic and after after
Lopressor to 130 systolic.
PAST MEDICAL HISTORY: Coronary artery disease status post MI in
1994 and 1995 , status post CABG seven years
ago , hypertension , diabetes mellitus , hypercholesterolemia.
ALLERGIES: Penicillin.
MEDICATIONS: Aspirin 81 mg orally every day , Lopressor 25 mg orally twice a day ,
Zestril 5 mg orally twice a day , Zocor 80 mg orally every day ,
Lasix 40 mg every day , insulin 70/30 40 mg twice a day
SOCIAL HISTORY: The patient was a former smoker who quit 40 years
ago but has an 80 pack year history. He drinks
alcohol occasionally. He lives with his wife in Ca ,
As
FAMILY HISTORY: His family history is negative for coronary artery
disease , however , he does have a family history of
diabetes mellitus.
PHYSICAL EXAMINATION: On physical examination , vital signs were a
temperature of 96.3 , heart rate 80 , blood
pressure 195/95 , respiratory rate 18 , O2 sats 100 percent on 3
liters of oxygen. General , the patient appeared comfortable , in no
apparent distress. HEENT , the pupils are equal , round , reactive to
light , extraocular movements are intact , mucous membranes are
moist. The lungs are clear to auscultation bilaterally , crackles
in the lower half of the lung fields bilaterally , no wheezes.
Cardiovascular , regular rate and rhythm , S1 and S2 normal , no S3 or
S4 , positive 2/6 systolic ejection murmur. The abdomen is soft ,
nontender , nondistended , positive bowel sounds. Extremities , no
clubbing , cyanosis , or edema , 2+ DP and physical therapy pulses bilaterally.
Neurological exam , nonfocal.
LABORATORY DATA: Pertinent labs at the time of admission , the
patient has a creatinine of 2.2 up slightly from
a baseline of 1.8. He had a hematocrit of 36.8. CK equal to 417 ,
MB equal to 15 , Troponin T equal to 0.09. EKG showed normal sinus
rhythm , first-degree AV block , left axis deviation , T wave
inversion in aVL , and T wave flattening in lead 1.
HOSPITAL COURSE BY SYSTEM: Cardiovascular: The patient was
started on aspirin , Plavix , Lopressor ,
Zocor , heparin , and a 2B3A inhibitor before cardiac
catheterization. Zestril was held secondary to marginal renal
function. Cardiac catheterization on September revealed occlusion
of SVG to RCA and SVG to OM. These lesions were treated with a
total of five stents. The last OM manipulation resulted in
showering of plaque and subsequent chest pain and EKG changes ( ST
elevation in precordial leads ). Following cardiac catheterization
the patient had no further episodes of chest pain and remained
hemodynamically stable throughout his hospital course. He was
successfully diuresed following his acute renal failure.
Renal/GU: The patient has a baseline chronic renal insufficiency
with a creatinine of 1.8. Following cardiac catheterization the
patient developed acute renal failure secondary to intravenous contrast with
a creatinine peaking at 6.8 , and then improving gradually to 4.2
upon discharge. While in the hospital the patient was followed by
Renal and Urology consult team. The patient had developed
hematuria while on aspirin , Plavix , heparin , and 2B3A inhibitor.
His hematuria resolved gradually. A renal ultrasound demonstrated
no evidence of obstruction , but did show several simple cysts , as
well as a calcified cyst which was further evaluated by CT scan ,
which demonstrated a likely hyperdense cyst , but follow-up MRI was
recommended to more definitively rule out the possibility of a
neoplasm. Ultrasound showed no evidence of clots in the bladder.
Electrolytes were closely followed and adjusted appropriately
during the hospital course. The acute renal failure was
complicated by moderate volume overload in the setting of depressed
EF. The patient was continued on Lasix 40 mg orally every day Urology
also recommended an outpatient cystoscopy to rule out tumor versus
Foley trauma as the cause of the patient's hematuria.
Heme: Following cardiac catheterization , the patient developed
epistaxis , frank hematuria , and coffee-ground emesis ( secondary to
swallowing blood and not a GI bleed ). The hematocrit fell to 29
and the patient was transfused with one unit of packed red blood
cells. Heparin and Tegralen were stopped , the patient was
continued on aspirin and Plavix. The hematuria resolved , and no
clots were seen on abdominal ultrasound. The hematocrit remained
stable throughout the rest of the patient's hospital course.
Endocrine: For his diabetes , the patient was maintained on TZI
sliding scale while in-house , later was restarted on his home
regimen of insulin 70/30 , and was discharged on this home regimen.
DISPOSITION: At the time of discharge the patient was ambulating ,
and arrangement were made for the patient to receive
a walker for assistance with ambulation.
DISCHARGE MEDICATIONS: Discharge medications include aspirin 325
mg orally every day , Lasix 40 mg orally every day ,
hydralazine 30 mg orally four times a day , Isordil 20 mg orally three times a day , Lopressor
100 mg orally twice a day , nitroglycerin 1/150 0.4 mg sublingual every 5 minutes x 3
as needed chest pain , Zocor 80 mg orally every bedtime , insulin 70/30 40 units
s.c. twice a day , Plavix 75 mg orally every day , Zantac 150 mg orally every day
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: Follow-up includes an appointment with Dr. Sojka on
3/29/02 , cystoscopy with Dr. Tonsil on 6/17/02 ,
abdominal MRI on 3/14/02 , and an appointment with Dr. Meduna
within one month.
Dictated By: LORETTA VALORIE GEMMELL , M.D. QV06
Attending: LEOLA C. MUSICH , M.D. ZS40 MI273/854098
Batch: 25323 Index No. O0KU110FPG D: 2/24/02
T: 2/24/02
CC: 1. DR. SOJKA , FAX NUMBER 143 870-8885.
Document id: 600
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
- |
847442317 | PUO | 82161933 | | 016989 | 11/22/1999 12:00:00 a.m. | SEPSIS | Signed | DIS | Admission Date: 11/22/1999 Report Status: Signed
Discharge Date: 1/3/1999
PRINCIPAL DIAGNOSIS: Sepsis related to Streptococcal laryngitis
( culture positive ).
OTHER SIGNIFICANT DIAGNOSES: Status post heart transplant in 1989
for viral myocarditis and hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a charming 28-year-old
woman who was diagnosed with viral
myocardial myopathy in 8/2 and received a heart transplant at
Bussadd Southrys Community Hospital at that time. She did very well with only one
episode of rejection in 1995 , which was treated with OKT-3. She
also successfully carried out a pregnancy. The patient's husband
reports that she began complaining of sore throat approximately two
days prior to admission and then one day prior to admission
developed fever in early morning of 102.2 with myalgias. She had
poor orally intake throughout the weekend and had no nausea and
vomiting at home but developed some in the emergency room. She had
however , had some diarrhea with loose stools , no blood. She felt
dizzy and weak today while getting into the car. She took
over-the-counter medications at home. Her daughter was ill
approximately two months ago and the patient works at a child day
care center where many of the children are ill. She had some lower
abdominal pain but no dysuria or hematuria , no cough , no recent
travel , mild diffuse headache without nystagmus or photophobia. In
the emergency room the patient was afebrile , temperature 99.1 , but
was noted to be hypotensive with a blood pressure of 71/33 ,
tachycardic to 136 , respirations of 16 and 96% O2 saturated on room
air. She received two grams of ceftriaxone , 500 mg of levofloxacin
and 1 gram of vancomycin as well as three liters of normal saline ,
intravenous fluid rapid infusion. Her blood pressure was still
marginal from the 80s to 90s systolic. Neo was started at 40 mcg
through peripheral intravenous line and she was admitted to the
Coronary Care Unit.
PAST MEDICAL HISTORY: In addition to the previously mentioned
viral myocarditis and heart transplant in
1989 , with rejection in 1995 treated with OKT-3. She also had
chronic renal insufficiency with a baseline creatinine from 1.3 to
2.1 , usually in the 1.5 area. She has hypertension. She is
gravida 1 , para 1 , complicated by toxemia requiring Cesarean
section. She also had hyperlipidemia and obesity.
MEDICATIONS ON ADMIT: Included cyclophosphamide 100 mg twice a day ,
Cardura 10 mg every day , Imuran 75 mg every day ,
prednisone 10 mg every day , Vasotec 5 mg every day , Pravachol 40 mg every day
ALLERGIES: To penicillin and Sulfa which resulted in rashes.
Allergy to intravenous contrast dye which resulted in
pruritic hives. Morphine causing nausea and vomiting and
succinylcholine which the patient reports resulted in respiratory
arrest.
PHYSICAL EXAMINATION: On admission to the Coronary Care Unit , the
patient's temperature was noted to be 102.6.
She was in sinus tachycardia to the 130s , slightly tachypneic up
to 24 , blood pressure of 98/40 , already on 40 mcg of Neo
intravenously. General: Drowsy , ill-appearing , flush young woman.
Pupils equal , round and reactive to light bilaterally. Extraocular
movements intact. Oropharynx was erythematous with some slight
white exudate on the tonsils and pharynx bilaterally. Mucous
membranes were dry with some white , red exudate on the tongue. She
had some tender cervical chains but not discrete palpable
lymphadenopathy with no neck stiffness , no sinus tenderness.
Lungs: Clear to auscultation bilaterally. There was no dullness
to percussion. Cardiovascular: Revealed rapid but regular rhythm ,
normal S1 and S2 , with positive S3 at the apex. Abdomen: Soft ,
nondistended , normal bowel sounds , diffuse , mild tenderness
throughout. Extremities: Warm with 2+ dorsalis pedis pulses
bilaterally. Hands pale with cold fingers. Neurologic: Alert but
drowsy and oriented times four. She was grossly nonfocal.
Examination was limited secondary to the patient's discomfort.
LABORATORY/X-RAY STUDIES: Sodium 137 , potassium 5.0 , chloride 103 ,
bicarbonate 23 , BUN 46 , creatinine 2.8
which was increased from her previous baseline of 1.7 , glucose 92 ,
CK 22 , with troponin 0.07. Last cyclosporine level was 140s to
260s. White blood cells 7.6 with 68 polys and 25 bands.
Hemoglobin 11.3 , hematocrit 32.4 , platelets 157 , 000. physical therapy 12.9 , INR
1.2 , PTT 33. EKG on admission was sinus tachycardia at 130 with a
normal axis incomplete right bundle branch block with Qs in III and
AVF , no ST-T wave changes and low volts across. Portable chest
x-ray on admission was clear. Blood cultures , throat cultures and
fungal isolators were sent off as well as EBV , CMV-IgM. Throat
culture grew out group A Strep. The patient had some improvement
with levofloxacin and briefly received vancomycin and gentamicin as
well prior to her culture growing out. The patient had worsening
renal function , likely due to acute tubular necrosis secondary to
prerenal azotemia from her initial hypotensive episodes.
HOSPITAL COURSE: The patient was treated briefly with vancomycin
and gentamicin. Throat culture grew out group A
Streptococcus. She improved on levofloxacin. Renal function
worsened likely due to acute tubular necrosis of prerenal azotemia
secondary to her initial hypotensive episodes on admission. She
gradually improved to a creatinine of 1.7 on the day of discharge.
During her hospitalization , she had some mild to moderate pulmonary
edema secondary to vigorous intravenous fluid resuscitation and
support of her blood pressure. She was diuresed with Lasix 20 to
40 mg intravenously every day for two days with excellent response and
was discharged below her dry weight. Her diarrhea with nausea and
vomiting was presumptively treated with Flagyl. However ,
Clostridium difficile was negative times two. Ova and parasites ,
fecaliths and stool cultures were all negative. She received
symptomatic relief with Compazine and Imodium. The patient's
baseline hypertension reappeared after her blood pressures had
stabilized and she was restarted on her outpatient regimen of
Vasotec and Cardura. Her baseline tachycardia was found to have
been evidently longstanding and well tolerated with heart rate of
100 to 120s.
DISPOSITION: The patient was discharged to home in good condition
on day #5 of a ten-day course of levofloxacin at
renal dose , 250 mg orally every day and she also continued her usual
immunosuppressive regimen with a cyclosporine level of 454. She
had a follow-up appointment with Dr. Duenwald in one week after
discharge. Discharge medications included Imuran 75 mg orally every day ,
Sandimmune 100 mg twice a day , Vasotec 5 mg twice a day , Miracle Cream
topically every day , prednisone 10 mg every day before noon , Zantac 150 mg twice a day ,
Cardura 10 mg every day , Compazine 5 to 10 mg every 4-6h. as needed nausea and
vomiting , Pepto-Bismol 30 ml every 1h. as needed diarrhea up to a total of
eight doses in 24 hours , levofloxacin 250 mg every day times a total of
ten-day course , Imodium 2 mg every 6 hours as needed diarrhea , Lasix 20 mg every day
as needed increased weight by two pounds above her baseline weight of
99 kg.
Dictated By: DULCIE SCOVEL , M.D. FM37
Attending:
DI181/5082
Batch: 29736 Index No. I5RI2D5523 D: 11/1
T: 8/25
Document id: 601
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
- |
Y |
N |
N |
Y |
Y |
N |
N |
N |
Y |
N |
N |
020464834 | PUO | 87319524 | | 0678772 | 10/10/2005 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 3/4/2005 Report Status:
Discharge Date: 11/5/2005
****** FINAL DISCHARGE ORDERS ******
DOUTHETT , JR , CANDIE 765-82-95-4
Troit Di
Service: MED
DISCHARGE PATIENT ON: 3/30/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ROMIG , PEGGY KELLEY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
LISINOPRIL 10 MG orally every day
Override Notice: Override added on 9/1/05 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
41405334 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
200 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally HS
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally every day As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 3/30/05 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
DIET: Patient should measure weight daily
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Goud as regularly scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
AMI ( myocardial infarction ) insulin resistance HTN
( hypertension ) nephrolithiasis ( kidney stone ) history of R colectomy for
colon CA ( 7 )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
-CC: 69M with ischemic cardiomyopathy ( 4/3 EF 30% ) admitted from TH
after a dizzy spell on toilet earlier that day. He began feeling dizzy
and lightheaded while on toilet after bowel movement. Felt diaphoretic
and had single episode of nausea/vomiting. Denied any chest pain ( this
was unlike his MI during which he had bilateral shoulder pain ). Mild SOB.
No chest pain or SOB prior to this episode. Took 3 Nitro tabs with out
improvement or worsening of sx. At baseline exercise tolerance since MI
( has been doing cardiac rehab ). Recently ate fried clams and ham/cheese
sandwhich. Takes daily weights and denies weight gain. Be was brought to
Plantdan Camchild Hospital where given K supplementation for hypokalemia ( 3.1 ) ,
Lasix 40mg , and first set of cardiac enzymes negative. Transferred to
PUO .
-PMHx: ischemic cardiomyopathy , CAD ( multivessel ) history of ant MI 2/17 , HTN ,
dyslipidemia , OSA ( on CPAP intermittently for 3 wks ) , nephrolithiasis ,
history of partial colectomy 2/2 colon CA , history of CCY.
-Meds: ASA , lasix , lipitor , lisinopril , toprol , plavix , nexium , nitro ,
ambiem , prozac ( taking occasionally ).
-All: NKDA
-Physical Exam: Vital signs stable. O2sat 97% on 2L. Not in respiratory
distress , taking in full sentences. JVP 7cm at 30 degrees with out
significant abdominojugular reflex. Normal S1+S2 , no murmurs. Regular
rhythm. Coarse rhonci at bases bilaterally. No significant edema.
-Neurologically intact.
-Labs: Chem7 normal except for mild hypokalemia ( 3.4 ). Mg 1.8. Normal
CBC. Cardiac enzymes negative x 3 sets ( 1 at TH , 2 at PUO ). BNP 524 at
TH , 1371 at PUO .
- HOSPITAL COURSE
Most likely cause for event was a vagal reaction in the setting
of borderline failure due to recent Na intake. Known EF 30%. BNP elevated.
He ruled-out for MI. No evidence of arrhythmia.
1. CV - Received lasix at TH . No evidence of florid CHF on exam or CXR.
Treatment with fluid restriction and afterload reduction with home meds.
During ROMI was maintained on telemetry , ASA , and beta-blocker. No
evidence of arrhythmia. He did have some bradycardia in 50s during the
night. Support plan for placement of ICD in the near future. Mg and K
supplementation. Will add K supplement to outpatient regimen.
2. Pulm: He is a former smoker with no known COPD. Coarse breath sounds at
lung bases - most likely mild edema. Follow O2sats. Recent
dx of OSA , occas uses CPAP , but doesn't know settings. CXR pending at BMCH .
3. FEN: replete lytes , fluid restrict , follow labs.
4. PPX: lovenox
FULL CODE
ADDITIONAL COMMENTS: please continue all you medications as written. Please increase the
amount of potassium that you take to... Please call Dr. Goud for an
appointment within one month.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
please continue your usual medications. Please continue to measure your
weight every day and limit your salt intake. Please increase the amount
of potassium you take to ...
No dictated summary
ENTERED BY: BIRDETTE , KATHARYN Z. , M.D. , PH.D. ( BG51 ) 3/30/05 @ 11:19 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 602
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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135358408 | PUO | 11671436 | | 696914 | 8/18/1997 12:00:00 a.m. | CARDIOMYOPATHY | Signed | DIS | Admission Date: 4/12/1997 Report Status: Signed
Discharge Date: 2/16/1997
PRINCIPAL DIAGNOSES: 1 ) DILATED CARDIOMYOPATHY.
2 ) HYPOTENSION.
3 ) RENAL FAILURE.
4 ) PANCREATITIS.
HISTORY OF PRESENT ILLNESS: Ms. Montecillo is a 45 year-old female with
dilated cardiomyopathy and a reported
history of myocarditis approximately fifteen years ago with a long
history of ethanol abuse. In October , 1995 , she was admitted to
Pagham University Of with upper respiratory symptoms and
progressive shortness of breath with cardiomegaly. An
echocardiogram at that time revealed an ejection fraction of 15%
with global hypokinesis , two to three plus mitral regurgitation and
a normal right ventricle. She underwent catheterization which
showed a right dominates and no coronary artery disease. An
exercise treadmill test scan show maximal VO2 of 12.6 milliliters
per kilogram per minute. More recently an echocardiogram in
October , 1997 , show an injections fraction of 20% with moderate
mitral regurgitation and left atrial enlargement. She has been
managed on Digoxin , diuretics and ACE inhibitors. On this regimen
she continued to have orthopnea , paroxysmal nocturnal dyspnea and
dyspnea on excretion. She was recently seen by Dr. Board in early
February , 1997 , and give a prescription for Zaroxolyn 2.5 mg. She
did not take this medication until two days before her admission
and subsequently had brisk diuresis. Over the last week prior to
her admission she experienced mild abdominal pain without
radiation. She had no change in her bowel movements. No bleeding
per rectum and no melena but had frequent vomiting. She presented
to the Car University Medical Center on July , 1997 , with the same
symptoms. Her creatinine was 1.3. Amylase was normal. An
abdominal CT was consistent with pancreatitis. Laboratory studies
were notable for an increased glucose , creatinine of 3.2 on
hospital day number two and then subsequently creatinine of 5.5.
She continued to have decrease in systolic blood pressure to the
70's and was urgently transferred to the Pagham University Of on a Dopamine and Insulin drip.
PAST MEDICAL HISTORY: Significant for the following: 1 ) Dilated
cardiomyopathy , 2 ) Adult onset diabetes
mellitus , 3 ) History of appendectomy and 4 ) History of ovarian cyst
removal.
ALLERGIES: The patient is allergic to Penicillin.
MEDICATIONS ON ADMISSION: 1 ) Digoxin .375 every day , 2 ) Lasix 160
twice a day , 3 ) Captopril 2.5 twice a
day , 4 ) K-Dur 40 twice a day , 5 ) Magnesium oxide 1 gram three
times a day , 6 ) Aspirin once per day , 7 ) DiaBeta 10 twice a day
and 8 ) Zaroxolyn.
SOCIAL HISTORY: The patient has a 19 year-old son with
cardiomyopathy. The patient is a smoker and
drinks three glasses of Rum per day.
PHYSICAL EXAMINATION: Blood pressure was 40 on Doppler , heart rate
in the 150's , respiratory rate 16 , oxygen
saturation 96% , 100% with face mask. She was transferred on
Dopamine drip of 20 micrograms per kilograms per minute and Insulin
10 units per hour. Heent: Extraocular movements were intact.
Pupils were equal , round and reactive to light. Neck: Right
interna jugular triple-lumen catheter. Chest: Clear to
auscultation anteriorly and laterally. Cardiovascular: Regular
rhythm , tachycardic , no murmurs. Abdomen: Soft , diffusely tender.
Positive bowel sounds. No guarding or rebounds. Extremities: No
edema , cold , clammy and no distal pulses. Abdominal CT report from
the Car University Medical Center showed some degree of fatty
infiltration and diffused enlargement of pancreas with some
infiltration of the inferior peripancreatic border. No pseudocyst.
Chest x-ray: No congestive heart failure. PA catheter in good
condition. PA catheterization readings: Pulmonary artery
pressures 20 , Pulmonary capillary wedge 13 , central venous pressure
8. EKG sinus tachycardia at 162 beats per minutes. Axis 35
degrees , 1 millimeter ST depressions in V4 through V6 , and 1 ST
elevation in V1 through V3 with a left bundle branch block.
LABORATORY: Sodium 120 , potassium 3.0 , chloride 69 , bicarbonate
18 , BUN 67 , creatinine 5.5 , glucose 961 , GAP 33 ,
amylase 212 , lipase 1 , 704 , ALT 9 , AST 33 , CK 673 , CKMB 6.3 , left
ventricular hypertrophy 709 , alkaline phosphate 47 , direct
bilirubin 0.3 , total bilirubin 1.9 , total protein 64 , albumin 2.3 ,
globulin 4.1 , calcium less then assayed , phosphorus 6.6 , magnesium
2.4 , cholesterol 57 , triglycerides 59. Digoxin 2.1. Urine like
sodium 71 , potassium 4.5 , chloride 79 , creatinine 78. Calculated
FENA of fractional secretion of sodium 2.15%. White blood cell
count 12.19 , hematocrit 41.4 , platelets 66. Differential 12
leukocytes , 11 monocytes , 76 neutrophils , no eosinophils , 0.3
basophils. physical therapy 15.3 , PTT 34.4 , fibrin products less then 0.5 ,
fibrinogen 372 , INR 1.7.
HOSPITAL COURSE: The patient was treated for a dilated
cardiomyopathy and severe pancreatitis. She
was vigorously hydrated for pancreatitis and had few complications.
In setting of her increased abdominal distension and development
of pleural effusion as well as sudation for ethanol withdrawal she
required intubation. Throughout her Intensive Care Unit admission
she had a high fever. An abdominal CT with intravenous contrast on August , 1997 , was negative for pancreatic necrosis and no tapable fluids
collection. She continued to be febrile as mentioned before
despite therapy with Ceftazidime , gentamicin , Vancomycin and
Flagyl. She intermittently had coagulate negative staphylococcal
cultures from her lines which were changed as well as Xanthomonas
maltophilia for which she received Bactrim. At the time of her
transfer from the Intensive Care Unit to the General Medical
Service she was usually linked with a baseline heart rate in the
120's and a systolic blood pressure in the 90's. The plan was to
restart her at low doses of a ACE inhibitor for after load
reduction , as tolerated. With careful surveillance of her fluid
status and maintenance of weight between 73 and 74 kilograms.
Pulmonary wise she was treated for seven days with Bactrim for the
Xanthomonas infection as well as chest physical therapy daily. Her renal
function was at her baseline at the time of transfer. Infectious
Diseases as stated above she was treated with Bactrim for seven
days with a plan to reculture if her fever spikes. The patient was
transferred on total parenteral nutrition until she could tolerate
a orally diet.
REVIEW OF SYSTEMS: 1 ) Cardiovascular: The patient's congestive
heart failure improved and she was eubolemic
after extensive diuresis. She was started on high doses of Lasix
and then decreased to 80 mg orally every day with her weight being stable
in the 67 kilogram range. She remained tachycardic in the 110's to
120's with a systolic pressure in the 80's. She was able to
tolerate 6.25 mg of Captopril and thus was discharged on a dose of
2.5 mg of the Lisinopril daily.
2 ) Pulmonary: The patient's shortness of breath resolved as her
fluid status stabilized. At the time of discharge her lungs were
clear to auscultation and her oxygen saturation was in the high
90's on room air.
3 ) Gastrointestinal: Pancreatitis resolved with lipase at the
time of discharge of 302. Amylase was normal. She had no further
abdominal pain. She declined a nasal gastric feeding tube but was
able to advance her diet. Nutrition was consulted and suggested
nutrition supplements which the patient was reluctant to take.
4 ) Infectious Diseases: The patient was not on any antibiotics at
the time of discharge and remained afebrile.
5 ) Physical Condition: The patient was able to walk and tolerate
light exercise. She had been orthostatic , dropping her blood
pressure to the 60's on standing up but was without symptoms. Her
orthostasis improved with decreasing the amount of diuresis. She
was scheduled to have Physical Therapy at home after discharge from
the hospital.
6 ) Mental Status: The patient's base lines at the beginning of
her admission was lethargic and confused. Her mental status
improved as her hemodynamic and cardiovascular status improved.
CONDITION ON DISCHARGE: At the time of discharge the patient was
alert and oriented times three and in
good condition. The patient was very clear about her wishes not to
go to Rehabilitation Hospital and elected to go home with careful
VNA and Physical Therapy follow-up.
LABORATORY: Glucose 172 , BUN 32 , creatinine 1.7 , sodium 137 ,
potassium 5.0 , chloride 94 , CO2 27 , ALT 17 , AST 20 ,
LDH 230 , alkaline phosphates 74 , total bilirubin 0.5 , direct
bilirubin 0.2 , lipase 251 , albumin 4.1 , calcium 10.2 , magnesium
2.4 , cholesterol 196 , triglycerides 300. White blood cell count
6.4 , hematocrit 33.1 , platelets 517 , physical therapy 12.4 , PTT 25.6 , INR 1.1.
Clostrieium difficile toxin negative on January , 1997. Cortisol
21.2 , a.m. cortisol on May , 1997.
MEDICATIONS ON DISCHARGE: 1 ) Nystatin powder topical , 2 ) Digoxin
0.25 mg orally every day , 3 ) Colace 100 mg
orally twice a day , 4 ) Folate 1 mg orally every day , 5 ) Lasix 80 mg orally every day ,
6 ) Insulin finger sticks four times a day with regular insulin sliding scale
coverage , 7 ) Ativan 1 to 2 mg orally every 4 hours for agitation , 8 )
Multi-vitamin , 9 ) Thiamine 100 mg orally every day , 10 ) Lisinopril 2.5
mg every day
Dictated By: EVELYNE TEPPER , M.D. RM45
Attending: KATHIE M. BOARD , M.D. RR5 AH928/9436
Batch: 26360 Index No. FBXJZ50O1C D: 3/30/97
T: 2/19/97
Document id: 603
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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820143912 | PUO | 93386292 | | 5951665 | 8/12/2006 12:00:00 a.m. | RESPIRATORY DISTRESS | Signed | DIS | Admission Date: 10/27/2006 Report Status: Signed
Discharge Date: 4/7/2006
ATTENDING: FRERICKS , CHRISTIN MD
DIAGNOSIS:
Respiratory failure , fluid overload.
SERVICE:
Medical Intensive Care Unit.
HISTORY OF PRESENT ILLNESS:
Mr. Kohles is a 67-year-old man with history of multifactorial
hypercarbic/hypoxemic respiratory failure with a recent prolonged
stay at the Pagham University Of Medical Intensive Care
Unit ( 8/1/06 - 3/10/06 ) who was discharged to Asidea Rehabilitation Hospital with tracheostomy and PEG on 3/10/06 . The
patient had done well at rehab with significant improvement in
his pulmonary status to the point that he was off the ventilator
using a nasal cannula for supplementary oxygen only. He also had
significant improvement in his functional status with ability to
stand and ambulate for short distances as well as improvement in
his mental status back to baseline. However , over the several
days prior to this admission his respiratory status had been
deteriorating with an increasing respiratory rate , increased work
of breathing , and falling oxygen saturations. For the last two
nights prior to admission , the patient had to be bagged overnight
and was not able to maintain saturations above the high 80s. He
had been afebrile with no change in cough or secretions. He
denied any abdominal pain , vomiting , or diarrhea. He was started
on empiric levofloxacin on the day prior to admission as well as
some increased diuresis with an increase in his standing Lasix
dose to 40 mg intravenous every 8 hours According to the patient's wife , this
did improve his respiratory status somewhat; however , he was
still unable to remain oxygen saturation above 90%. The patient
also received 2 units of packed red blood cells for a hematocrit
of 25 the day prior to admission. The morning of admission to
Pagham University Of it was felt that the patient's
respiratory distress and poor oxygenation were such that he
needed to return to ventilator assistance. The patient was then
transferred to the Pagham University Of Emergency
Department where on arrival his vitals were notable for a heart
rate of 76 , blood pressure 123/62 , respirations 28 , oxygen
saturation of 92% by nasal cannula. He was placed on the
ventilator at pressure support with 10 of pressure support and 5
of peak with an FIO2 of 50%. Arterial blood gas at this time was
7.38 , 66 , and 63.
PAST MEDICAL HISTORY:
1. Diabetes mellitus ( hemoglobin A1c of approximately 10 ).
2. Morbid obesity , likely obesity-hypoventilation syndrome.
3. Status post tracheostomy and PEG placement after PUO MICU
stay for hypercarbic/hypoxemic respiratory failure , 8/1/06 to
3/10/06 .
4. Status post crush injury to bilateral lower extremities ,
followed by right below the knee amputation and surgical
reconstruction of the left lower extremity.
5. L3 radiculopathy.
6. Hypertension.
7. Left internal capsule CVA in 1997 with residual chronic fine
motor deficits of the left hand , chronic mild word-finding
difficulty , short-term memory loss , mild left lower extremity
weakness and left foot drop.
8. Right lower extremity prosthesis.
9. History of left DVT on Coumadin.
10. Chronic shortness of breath.
11. Likely sleep apnea.
12. Urinary frequency.
13. Iritis: Right eye recurrent episodes , negative
rheumatologic workup.
14. Central blindness , left eye , since childhood.
MEDICATIONS ON TRANSFER TO PAGHAM UNIVERSITY OF :
Levofloxacin 750 mg orally daily started 5/23/06 , Coumadin 3 mg at
bedtime , Lasix 40 mg intravenous three times a day started 5/23/06 , labetalol 200 mg
three times a day , simvastatin 80 mg at bedtime , aspirin 325 mg orally daily ,
amlodipine 10 mg orally daily , Lantus 56 units at bedtime ,
tiotropium 18 mcg daily , Flovent one puff twice a day , sodium chloride
nasal spray four times a day , albuterol nebulizers as needed , Mucomyst
nebulizers as needed , senna , bisacodyl suppository 10 PR daily ,
nystatin swish and spit four times a day , Ramelton 8 mg at bedtime , Haldol
5 mg per G-tube at bedtime as needed and Haldol 1 mg every 6 hours as needed
ALLERGIES:
The patient has no known drug allergies.
SOCIAL HISTORY:
The patient has lived with his wife though he has been at rehab
since 3/10/06 . He is a former longshoreman. He is
self-educated and an avid reader. His wife is a neonatal
intensive care unit attending physician at Pande Memorial Hospital .
The patient quit use of tobacco in 1995 and does not drink
alcohol. He denies use of any illicit drugs.
PHYSICAL EXAMINATION:
On arrival to PUO MICU , was notable for temperature of 97.3 ,
heart rate 68 and normal sinus rhythm , blood pressure 140/56 ,
respiratory rate in the 30s , oxygen saturation 92% on pressure
support 10 and 5 with an FiO2 of 50%. The patient was an obese
alert man in no acute distress. Physical exam notable for coarse
breath sounds anteriorly and diminished breath sounds at
bilateral bases , distant heart sounds. Right lower extremity has
a BKA. Left lower extremity with 2+ edema with some chronic
color change suggestive of venous insufficiency. Distal pulse
not palpable.
Chest x-ray revealed tracheostomy tube in position , a right
pleural effusion , somewhat difficult to evaluate lung bases.
Echocardiogram 8/1/06 revealed normal size and function of the
left ventricle , normal right ventricle , and a trivial pericardial
effusion.
LABORATORY DATA:
At the time of admission , were notable for a creatinine of 1.3
improved from 1.5 at the time of discharge on 3/10/06 .
Urinalysis revealed 50-100 red blood cells but 0-2 white blood
cells. White blood count was 9.1 with 75 polyps , 14 lymphs , and
8 monos. Hematocrit was 30.7 , which is at baseline.
EKG revealed normal sinus rhythm at 77 , normal axis , normal
intervals and less than 1-mm of ST depression in leads 2 , 3 , V4
through V6.
HOSPITAL COURSE BY SYSTEM AND PROBLEM:
1. Hypoxemic respiratory failure , likely multifactorial from
obesity-hypoventilation syndrome , sleep apnea , question COPD.
Recurrent decompensation was thought to be precipitated by volume
overload and subsequent pleural effusion. The patient improved
dramatically with aggressive diuresis and he was able to
successfully transition back to use of trache collar during the
day , however , it seems that he does better with ventilatory
support overnight and current permanent plan of care is to
transition patient to home ventilator support such that he will
supplemental oxygen either by nasal cannula or trache collar
during the day and be able to use the ventilator at night. The
patient was also continued on inhaled steroids and nebulizers.
2. Positive blood culture , 1/4 bottles from blood cultures drawn
on 7/26/06 were positive for Gram-positive cocci and clusters;
however , he was afebrile and with no clinical evidence of
infection , so this was thought likely to be contaminant and no
treatment was given.
3. Fluid overload. As noted , the patient responded very well to
diuresis. He was transitioned to a new stable dose of orally Lasix
namely 60 mg orally twice a day This will need to be adjusted as
needed.
4. Hypertension. The patient was continued on his home regimen
of labetalol and amlodipine on which he did well.
5. Diabetes. The patient was continued on home regimen of
Lantus , however , this was titrated up somewhat due to some
elevated sugars the last few days of his admission. He is sent
out on Lantus 60 mg subcutaneously at bedtime as well as a
regular insulin sliding scale.
6. Nutrition. The patient should follow a cardiac , diabetic
salt restricted and fluid restricted orally diet. He does have a
PEG tube for supplemental feeding should he be unable to take
orally but at the time of discharge he is doing well with a
mechanical soft diet with the above restrictions.
7. The patient is therapeutically anticoagulated on Coumadin.
Indication is history of DVT. He will be continued on a dose of
3 mg at bedtime. Coumadin should be drawn every two days
initially until it is clear that this is the correct stable dose
for him. It may need to be titrated up or down.
CODE STATUS:
The patient is full code.
MEDICATIONS AT THE TIME OF DISCHARGE:
Aspirin 325 mg orally daily , Lasix 60 mg orally twice a day , labetalol 200
mg orally three times a day , amlodipine 10 mg orally daily , simvastatin 80 mg
orally at bedtime , Coumadin 3 mg orally at bedtime , Lantus 60 mg
subcutaneously at bedtime , regular insulin sliding scale ,
Pulmicort 0.25 mg nebulizers every 12 hours , albuterol 2.5 mg nebulized
every 4 hours , Combivent MDI two puffs inhaled every 4 hours , Ocean spray two
sprays four times a day to nostrils , Colace 100 mg orally twice a day , senna one
teaspoon orally at bedtime , bisacodyl 10 mg per rectum daily , K-Dur
20 mEq orally daily , magnesium oxide 500 mg orally three times a day , nystatin
suspension 5 ml swish and spit four times a day , Haldol 5 mg orally at
bedtime as needed and Haldol 1 mg orally every 6 hours as needed
The patient is discharged in stable condition to Hodi Anbarre University Hospital on 6/3/06 .
eScription document: 3-0831269 EMSSten Tel
Dictated By: CHAIX , TRISH
Attending: FRERICKS , CHRISTIN
Dictation ID 6610044
D: 6/3/06
T: 6/3/06
Document id: 604
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
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Y |
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| output/system_intuitive_annotation.xml | intuitive |
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572637890 | PUO | 63025378 | | 2442855 | 6/10/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/1/2005 Report Status: Signed
Discharge Date:
ATTENDING: FREHSE , MARILYN MD
ADMITTING SERVICE:
General Surgery Service.
HISTORY OF PRESENT ILLNESS:
This is a 47-year-old female with a history of relapsing
polychondritis and morbid obesity , who presented six weeks prior
to admission with admission of choledocholithiasis and acute
cholecystitis. The patient was treated with a percutaneous
cholecystostomy tube as bridging therapy; however , the patient's
cholecystostomy tube was subsequently accidentally pulled out in
the weeks preceding her current admission. In the interim , the
patient denied any associated nausea , vomiting , fever , or
diarrhea. She was subsequently scheduled for an exploratory
laparotomy with an open cholecystectomy , which took place on
6/25/2005 . In order to fully address concerns related to her
history of polychondritis , the patient was scheduled for a
preoperative admission and pulmonary evaluation and was
subsequently admitted to the General Surgery Service on the
direction of Dr. Marilyn Frehse on 5/13 .
PAST MEDICAL HISTORY:
Relapsing polychondritis with associated interstitial lung
disease , tracheal , ear cartilage and nose involvement , managed
with dapsone , adalimumab , and steroids at home; morbid obesity;
COPD/OSA on CPAP at home; osteoporosis; bilateral avascular
necrosis of the hip; depression.
PAST SURGICAL HISTORY:
Notable for prior sinus surgery , bilateral carpal tunnel surgery.
HOME MEDICATIONS ON ADMISSION:
Included levofloxacin 500 mg orally daily , Flagyl 500 mg orally
daily , prednisone 10 mg orally every day before noon , trazodone , Effexor ,
Neurontin , quinine , Seroquel , Flexeril , OxyContin , DuoNeb ,
Advair , Caltrate plus vitamin D , Colace , esomeprazole.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
The patient has no notable alcohol , tobacco or intravenous drug use
history. The patient is married with two daughters , is
wheelchair bound and lives in Eans Pe
PHYSICAL EXAMINATION UPON ADMISSION:
Temperature 97.4 , heart rate 80 , blood pressure 110/90 ,
respiratory rate 20 , and saturating 95% on 4 liters. The
patient's general exam is notable for a morbidly obese ,
middle-aged female. HEENT exam demonstrated pupils equal , round
and reactive to light and accommodation. The patient
demonstrated no evidence of cranial nerve dysfunction.
Respiratory exam demonstrated lungs clear to auscultation
bilaterally , but distant breath sound secondary to her habitus.
Cardiovascular exam demonstrated normal S1 and S2 with regular
rate and rhythm. Abdomen was noted to morbidly obese , soft ,
nondistended with mild tenderness in the right upper quadrant.
Extremities noted to demonstrate mild peripheral edema with warm
and well-perfused clinical examination and no evidence of acute
run of ischemia.
LABORATORY EXAMS UPON ADMISSION:
Sodium 142 , potassium 3.8 , chloride 106 , bicarbonate 32 , BUN 8 ,
creatinine 0.9 , glucose 120. ALT 69 , AST 37 , alkaline
phosphatase 147 , total bili 0.7 , amylase 20 , lipase 15 , total
protein 6.4 , albumin 3.3 , calcium 8.1 , white blood cell count
5.7 , hematocrit 29.6 , platelets 152 , physical therapy 14.7 , PTT 26.3 , and INR
is 1.1. UA was noted to be clear without evidence of urinary
tract infection.
EKG was notable for normal sinus rhythm at 62 beats per minute
without evidence of acute ischemia. Preoperative plain film of
the chest demonstrated unremarkable sinus and no acute
cardiopulmonary process seen.
HOSPITAL COURSE:
The patient was admitted to the General Surgery Service on the
direction of Dr. Marilyn Frehse on 1/1/2005 . As mentioned
previously , her admission was scheduled several days prior to a
planned surgery in order to permit adequate evaluation by the
Pulmonary , Thoracic Surgery and Rheumatology Services in order to
clear for her planned surgical intervention given her history of
polychondritis. Following extensive review by the above-named
services , the patient was cleared for operative intervention and
subsequently underwent an open cholecystectomy on 6/25/2005 .
For detailed description of the patient's operative procedure ,
please see the relevant operative report.
The patient tolerated the procedure well and was subsequently
transferred to the Surgical Intensive Care Unit for further
evaluation and management postoperatively. Given concerns about
her airway and for continuous monitoring given concerns about her
body habitus. While in the Intensive Care Unit , the patient
could rest well clinically without acute events. She remained
stable from a cardiovascular standpoint and her pulmonary status
was noted to be stable through the duration of her initial
admission to the Intensive Care Unit. Following closed
observation in the ICU , the patient was subsequently cleared for
transfer to the regular patient floor on postoperative day number
one , 4/1/2005 . While on the regular floor , the patient
initially progressed well clinically. She was successfully
weaned from intravenous analgesia and was transitioned to orally pain
medications without complications. She initially remained stable
from a cardiovascular perspective and was noted to demonstrate a
stable wound exam with declining liver function studies through
postoperative day #2 , 2005.
At this point , once the patient was deemed stable for discharge
to home , she demonstrated an acute episode of increased work of
breathing and shortness of breath with an abrupt increase in her
oxygen requirements. Despite aggressive attempts to improve
oxygenation through noninvasive means , the patient proved to
unable to achieve oxygenation status with these measures and was
transferred emergently to the Intensive Care Unit for intubation.
Of note , arterial blood gas drawn in the context of this episode
demonstrated a widened A-a gradient concerning for a possible
coronary embolus. Given the patient's habitus and her weight ,
however , she was deemed inappropriate for a PE protocol scanning
and was treated presumptively for pulmonary embolus. The
remainder of the patient's admission was spent in the Intensive
Care Unit and was punctuated by respiratory failure , suspected
pulmonary embolus requiring ongoing heparin therapy , development
of intraabdominal bile leak requiring repeat exploratory
laparotomy and drainage procedure.
The subjects of the patient's admission will be further described
by system as follows:
1. Neurological: For the duration of her extended stay in the
Intensive Care Unit , the patient remained adequately sedated with
intravenous agents including fentanyl and Versed. Of note , the patient
was noted to demonstrate massive requirements of sedating
analgesic agents in order to provide adequate comfort. Despite
this , however , she was successfully weaned to a regimen of
intermittent opioid dosing via her G-tube , which she was noted to
tolerate without complication. With gradual withdrawal of her
sedating agents , the patient was noted to be appropriate and
responsive and demonstrated no evidence of neurological
compromise. Of note , the patient at no demonstrated any evidence
of acute neurological events or cerebrovascular accidents
necessitating further evaluation from a neurological perspective.
At the time of this dictation , the patient is noted to be alert ,
oriented and comfortable on an analgesia regimen consisting of
stable fentanyl infusion and as needed oxycodone. She was noted to
move all extremities to command , noted to be appropriate to
questioning , demonstrates no evidence of neurological compromise
on gross exam.
2. Cardiovascular: The patient's Intensive Care Unit stay was
punctuated by progressive septic physiology requiring ongoing
pressor support for a period of several weeks in order to
maintain adequate profusion pressures. As her intraabdominal
process progressed , the patient was noted to require increasing
support with multiple agents including neosynephrine and
vasopressin; however , following appropriate surgical debridement
of her intraabdominal bile collection , she was gradually
successfully weaned from pressor agents and at no point
afterwards required further aggressive pressure therapy in order
to maintain adequate pressures. She at no point demonstrated any
evidence of acute myocardial ischemia despite multiple rule out
protocols in the setting of hypertensive episodes. Serial
bedside echocardiograms demonstrated no evidence of acute
myocardial dysfunction or diminution of ejection fraction and she
subsequently was noted to stabilize from cardiovascular
perspective. Of note , over the course of her admission , the
patient was noted to demonstrate periodic episodes of idiopathic
bradycardia unrelated to oxygenation status; however , she at no
point required external pacing or atropine therapy in order to
treat such episodes and was noted on all occasions as
spontaneously resolved her bradycardic episodes. At the time of
this dictation , the patient is noted to be stable with regular
rate and rhythm and no evidence of acute myocardial dysfunction.
She is free of pressor support and continues on a standing
regimen of Lopressor 25 mg per J-tube every 6 hours without complication.
Followup EKG demonstrated no evidence of myocardial ischemia and
she has been free of episodes of bradycardia for at least the
past 10 days.
3. Pulmonary: As described above , the inciting events for the
patient's return to the Intensive Care Unit on postoperative day
#2 was noted to be acute respiratory distress secondary to
presumed pulmonary embolus. Unfortunately , the patient's body
habitus precluded her from a definitive pulmonary embolus
protocol CT scan and she was therefore started empirically on intravenous
heparin therapy in order to provide adequate anticoagulation.
Her weight incidentally also precluded her from additional
studies to evaluate for evidence of pulmonary embolus including a
VQ scan , thus her PE treatment regimen was based on empiric
evidence only. Following institution of heparin therapy , the
patient's oxygenation status was noted to gradually improve ,
although her pulmonary status was noted to decline with
subsequent increase in fluid requirements given her septic
physiology. Serial day x-rays performed in Intensive Care Unit
demonstrated evidence of fluid overload through the course of her
stay , which also likely compromised her oxygen status initially.
Given her ongoing requirement for pressor therapy while following
the development of her intraabdominal pathology , the patient was
recommended for a tracheostomy procedure given the expectation of
prolonged mechanical ventilation requirements. She therefore
underwent PEG placement on 3/11/2005 following an extensive
discussion with the patient's family regarding her likely
prognosis. For a detailed discussion of this procedure in the
context of a concomitant repeat exploratory laparotomy and
J-tube/G-tube insertion , please see relevant operative report.
Following placement of this tracheostomy , the patient progressed
well clinically from respiratory perspective. Following drainage
of her intraabdominal bile leak , the patient's septic physiology
was noted to gradually resolve and she was successfully weaned
from pressor therapy. With cessation of her pressors , adequate
diuresis was rendered possible and the patient was effectively
fluid oscillated for the duration of her Intensive Care Unit
stay.
With the fluid oscillating , the patient's respiratory status
continued to improve as such her serial chest x-ray demonstrated
gradually resolving over load. With diuresis , the patient was
subsequently gradually weaned from pressor support to successful
trach collar trials , which she accomplished without complication.
As the time of this dictation , the patient is noted to be
tolerating to the extended trach collar trials during the day
with planned ventilatory arrest at night. Her respiratory exam
demonstrated lungs were clear to auscultation bilaterally with
mild bibasilar crackles and no additional evidence of acute
respiratory failure. Her trach site is clean , dry , and intact
with no evidence of cuff leak. The patient is successfully
tolerating trials of a Passe Muir valve , which has provided her
with ability to vocalize while on her trach collar trials. A
potential plan for trach tube downsizing has been deferred for
the movement given concerns about the risk of returning the
patient to the operating room for this procedure. Given the lack
of acute indication for such a procedure , it has been deemed best
to defer such an intervention until such surgery deemed
absolutely necessary.
4. GI: Shortly , following the patient's readmission to the
Intensive Care Unit , she was noted to demonstrate gradually
increasing liver function studies suggestive for potential repeat
biliary obstruction. The GI Service was , therefore , enlisted to
come and tell me potential appropriateness of an ERCP. Following
extensive discussions with the Gastroenterology Service , the
patient was subsequently recommended for an ERCP to be performed
in the operating room , which subsequently took place on
3/11/2005 . This selection of the operating room as the site for
intervention was informed on the basis of her inability to be
effectively scoped in the Radiology suite given her body habitus.
In the operating room , the patient underwent successful
placement of a biliary stent with liberation of a mild amount of
bilious fluid from the common bile duct. No sphincterotomy was
performed at this point. Following placement of the stent and
successful prominence of the ERCP , the patient was initially
noted to improve clinically with a transient diminish in her
biliary studies. However , shortly following , she again noted
gradual increase in her biliary studies and gradual worsening in
her general clinical exam associated with increasing fevers and
septic physiology. Serial abdominal exams were notable for
gradual increasing abdominal distension , necessitating a return
to the operating room on 3/11/2005 for a combined tracheotomy ,
exploratory laparotomy , drain placement , G-tube/J-tube placement ,
and biliary drainage procedure. For a detailed description of
the patient's operative procedure , please see a relevant
operative report. Of note , the patient was noted to demonstrate
a 3-liter bile collection intraoperatively with no evidence of
bowel injury or ischemia upon performing of this procedure.
Multiple intraabdominal drains were placed and no evidence of
active bile leak was noted at the time of this procedure.
Postoperatively , the patient progressed well clinically. Her
biliary function studies were noted to gradually normalize
following the drainage procedure and her abdominal exam remained
stable for the duration of her posterior course. Following
effective drainage of this collection , the patient's septic
physiology was noted to gradually correct , allowing effective
weaning of her pressor support and marked in all organ system
functions. She thereafter successfully started no tube feeds for
nutritional supplementation , which she tolerated without
complication. At all times , effective GI prophylaxis was
provided by Pepcid and PPI therapy. At the time of this
dictation , the patient's GI exam remained stable. Her abdomen
was soft , nondistended and nontender with evidence of morbid
obesity per her baseline exam. Her surgical incisions were noted
to be clean , dry and intact with staples in place. Of note , her
midline incision was left partially opened in order to promote
adequate wean drainage postoperatively and to permit healing by
secondary intervention; this incision has continued to remain
stable with no evidence of active infection postoperatively. Her
drain output has gradually diminished over her postoperative
course , permitting removal of one of her JP drains. Her G-tube
and J-tube sites remained clean , dry and intact with her tubes
remaining in place and functional. The patient is currently
running tube feeds at goal via her J-tube without complication.
Her G-tube continuous to vent appropriately without incident.
5. GU: Following transfer , the patient to the Intensive Care
Unit her urinary output continued to be monitored on a continuous
basis in order to reassess her hydration status. Through the
course of her time of septic physiology , the patient demonstrated
variable urine output correlated approximately with her blood
pressures. With resolution of her septic physiology , however ,
the patient was noted to be exuberantly responsive to efforts at
diuresis and was quickly noted to be independently productive of
large amounts of urine without diuretic therapy. She
successfully oscillated her fluids through the duration of her
admission , at no point demonstrated any evidence of acute renal
failure or electrolyte abnormalities. She at no point
demonstrated any evidence of a hemodialysis requirement during
the course of her admission. At the time of this dictation , the
patient remained independently productive of adequate amounts of
urine in order of 700 cc per hour via her Foley catheter. Her
electrolytes remained stable and BUN and creatinine demonstrate
no evidence of acute renal failure.
6. Heme: As stated previously , the presumed etiology of the
patient's return to the Intensive Care Unit was thought to be an
acute , hemodynamically stable pulmonary embolism. The patient
was immediately started on heparin therapy , which continued for
the duration of her ICU stay until the point of transition to
Coumadin therapy. Of note , the patient required large doses of
heparin in order to provide a therapeutic PTT with hourly
infusion rate in order of 2000-2500 units of heparin per hour.
Following prolonged heparin invasion and gradual stabilization of
her clinical status , the patient was gradually transitioned to
Coumadin therapy via her J-tube without complication. At the
time of this dictation , the patient remained borderline
therapeutic on Coumadin with an INR of 1.7 on a daily dose of
Coumadin 5 mg per day. She at no point has demonstrated any
evidence of postoperative hemorrhage or bleeding instability; her
platelet count has likewise remained stable for the duration of
her stay. Although , the potential for placement of an IVC filter
was discussed on several occasions during the duration of her
current admission , the patient's body habitus precludes her from
effective radiological placement of such a filter and such
intervention is therefore been deferred at least for the time
being.
7. ID: Following transfer of the patient to the Intensive Care
Unit , she was noted to demonstrate gradually worsening septic
physiology associated with spiking fevers for much of her initial
Intensive Care Unit stay. Serial cultures of blood , sputum ,
urine and biliary drainage were notable for evidence of near
pan-resistant pseudomonas in her biliary drainage site. An
Infectious Disease consultation was therefore obtained. The
patient was recommended for broad-spectrum antibiotic therapy
consisting of linezolid , ceftazidime , Flagyl and colistin. With
gradual worsening of her clinical condition , the patient was
subsequently started on a course of Xigris for a 96-hour period
per Xigris protocol. While on Xigris , the patient did not
demonstrate any appreciable improvement in her septic status and
she was therefore recommended for operative intervention on
3/11/2005 as described above. Following drainage of her
abdominal bile collection , the patient was noted to gradual
improve clinically with slow resolution of her septic state.
Followup cultures continued to demonstrate evidence of biliary
pseudomonas colonization necessitating ongoing colistin therapy.
With further speciation of her cultures , the patient was
subsequently weaned from all antibiotics except for colistin and
underwent placement of a PICC line for planned prolonged colistin
therapy. With stabilization of her clinical status , the patient
was subsequently restarted on her home dapsone regimen in order
to promote primary care physician prophylaxis given her home immunosuppressive and
steroid regimen. At the time of this discharge , the patient
remains afebrile with stable white blood cell count and no
additional culture information suggested for ongoing infection.
She has a stable and appropriately positioned upper extremity
PICC line , which is functional and continues to permit adequate
dosage of her standing colistin antibiotic regimen. As of this
dictation , the patient is planned for ongoing colistin therapy
for several weeks pending modification by the Infectious Disease
Service.
8. Endocrine: In the context of her ICU readmission , the
patient was noted to demonstrate widely fluctuant blood sugars
requiring continues therapy with a Portland protocol insulin
schedule. Following successful resolution of her septic
physiology , however , the patient was successfully weaned from
insulin therapy without complication and was noted to demonstrate
stable blood sugars for the duration of her stay. Given her home
steroid requirement for her chronic polychondritis , the patient
was placed on a steroid taper for the duration of her Intensive
Care Unit stay , which she continues at the time of this
dictation. At no point did she demonstrate any evidence of acute
adrenal insufficiency or thyroid dysfunction in the course of her
admission.
At the time of his dictation , the patient remains under
evaluation for planned transfer to a vented rehabilitation
facility. The remainder of the patient's hospital course and her
discharge medication regimen will be dictated at the time of her
transfer by an appropriate member of the Intensive Care Unit
team.
eScription document: 0-3953140 EMS
Dictated By: VACEK , WALTON
Attending: FREHSE , MARILYN
Dictation ID 2710004
D: 3/5/05
T: 3/5/05
Document id: 605
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DM |
Gs |
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OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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351667992 | PUO | 22298869 | | 943469 | 6/2/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/25/1995 Report Status: Signed
Discharge Date: 7/21/1995
PRINCIPAL DIAGNOSIS: LEFT LOWER EXTREMITY WOUND INFECTION
HISTORY OF PRESENT ILLNESS: This is a 54 year old gentleman
who is status post a four vessel
coronary artery bypass graft on 6/15/95 at an outside hospital.
The patient's postoperative course was complicated by respiratory
failure secondary to presumed phrenic nerve injury. The patient
also developed congestive heart failure. In addition , the patient
had undergone embolectomy and left lower extremity fasciotomy for
left lower extremity ischemia on 5/25/95 . The patient now presents
to Dr. Burston with infected left lower leg pressure ulcer with
open and gangrenous muscle exposed through this posterior wound.
The patient was at the rehabilitation center prior to this transfer
to the Pagham University Of . The patient had no documented
febrile episodes.
PAST MEDICAL HISTORY: Significant for insulin dependent
diabetes mellitus , peripheral vascular
disease , coronary artery disease , congestive heart failure , history
of atrial fibrillation/flutter , right sacroiliac joint decubitus
ulcer.
PAST SURGICAL HISTORY: As above. Coronary artery bypass graft
on 7/23/95 . Left lower extremity
fasciotomy on 5/25/95 .
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg orally every day
2. Digoxin 0.325 mg orally every day
3. Azmacort 6 puffs inhaled twice a day
4. Heparin 5000 units subcutaneously twice a day
5. Zantac 150 mg orally twice a day
6. Lasix 40 mg orally every day
7. Capoten 25 mg every 8
8. Albuterol nebulizers 0.5 cc in 2.5 cc normal saline four times a day
9. NPH insulin 38 units subcutaneously twice a day
10. Nystatin swish and swallow 5 cc orally four times a day
11. Bactrim DS one tab orally twice a day
THE PATIENT HAS NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: Significant for 100 pack/year history.
PHYSICAL EXAMINATION: Temperature 100. Blood pressure 120/47 ,
pulse 103 , sinus tachycardia. In
general , the patient was trached and in no acute distress. The
patient's skin revealed mottled distal extremities. HEENT:
normocephalic , atraumatic head. Trach was in place with a collar.
Lungs: bilateral inspiratory wheezes , scattered throughout.
Heart: regular rhythm with sinus tachycardia. Distant heart
sounds. No S3 or S4 were noted. The patient had no obvious
murmurs. Abdomen: positive bowel sounds. The patient was obese.
Abdomen was nontender , nondistended with no palpable masses. The
patient had multiple ecchymoses. Neurologic: the patient was
alert and oriented times three. Cranial nerves II through XII
grossly intact. Extremities: right buttock with approximately a
10 square centimeter decubitus ulcer. The patient's right lower
extremity revealed a previous harvest scar with about a 2 cm
incision and breakdown over the calf area. Distal foot has a
mottled appearance but has Dopplerable posterior tibial and
dorsalis pedis pulses. The toes are cool and insensate. Left
lower extremity revealed three open ulcers with marked gangrenous
muscle exposure. The patient had a Dopplerable posterior tibial
with cold pulses but no Dopplerable dorsalis pedis pulse. The
patient was insensate distally from the region of the wounds down
to the feet.
HOSPITAL COURSE: The patient was taken to the Operating Room
on 9/11/95 for a preoperative diagnosis of a
left lower extremity infected pressure sore. Intraoperatively , the
patient was noted to have necrosis of both heads of the
gastrocnemius muscle including the soleus and also a portion of the
lateral compartment. The muscle appeared black and necrotic and
there was a marked amount of purulence. Aerobic and anaerobic
cultures were obtained at this time and sent to Microbiology for
gram stains and cultures. All of the visibly blackened and
necrotic muscle was removed and the wound was irrigated with
copious amounts of antibiotic-containing solution. The patient
appeared to tolerate the procedure well and was sent to the
Intensive Care Unit , given the patient's cardiac history as well as
his ventilator dependence.
The patient was seen by the Infectious Disease service and was
started on Ampicillin , Gentamicin and Flagyl empirically until
culture results returned. The patient was taken back on 2/8/95
for a second irrigation and debridement procedure. During this
procedure , some necrotic skin , subcutaneous tissue and fascia were
noted and were sharply debrided free. The wound was relatively
clean upon completion of the procedure with no apparent loculations
or collections or purulence. The muscle also at this time appeared
viable and it was considered that the wound may heal on its own.
The patient was seen by the Vascular Surgery service as well for
his history of left lower extremity ischemia and for his loss of
his dorsalis pedis pulse on his left foot. The left foot remained
cool and insensate with no motor function. The patient did however
have flexion and extension at the knee.
After adequate irrigation and debridement , it was felt that the
patient would not require amputation of his lower extremity given
the viability of the muscle.
NEUROLOGIC. The patient was alert and awake postoperatively. The
patient was appropriate in his neurologic status. The patient
however did appear to have some episodes of anxiety for which he
was placed on Klonopin 1 mg orally three times a day The patient continued to do
well and had his pain adequately controlled with orally Percocet.
RESPIRATORY. The patient was initially weaned off the ventilator
to continue his positive airway pressure with 5 of PEEP and 5 of
pressure support with 50% FIO2. The patient's tidal volumes were
consistently elevated over 600 and the patient had no subjective
complaints of shortness of breath. However , on postoperative day
#4 and #2 , the patient noted some difficulty catching his breath.
Pressure support was increased back up to 10. This inability of
the patient to maintain his spontaneous tidal volumes was
consistent with a respiratory fatigue secondary to his
diaphragmatic dysfunction. However because the patient appeared to
be weaning from the ventilator initially postop , it was decided
that the patient should have his diaphragmatic function assessed to
see if there had been any change.
The patient underwent a fluoroscopy study to assess his
diaphragmatic excursions on 10/29/95 . The test revealed no
diaphragmatic excursion consistent with phrenic nerve injury. It
was decided at this time that the patient would remain on his
previous ventilator settings of 10 of pressure support and 5 of
CPAP and 50% FIO2 and no further weaning would be attempted.
GASTROINTESTINAL. The patient arrived on tube feedings of Promote.
Because we do not have this at our institution , the patient was
started on a similar formula of full strength Ensure High Protein
at 105 cc/hour. This meets the patient's full nutritional
requirements.
However , because the patient appears to have no reason for not
encouraging his orally intake , the patient's tube feeds were
decreased to 50 cc/hour throughout the day for a 12 hour period and
orally intake at this time was encouraged. The patient then received
12 hours of his tube feeds at 105 from 7 p.m. to 7 a.m. The
patient was placed back on his normal subcutaneous doses of insulin
NPH 38 units in the morning and 38 units at night.
The patient has been treated intermittently with insulin drip for
control of his blood sugars during the times he was taken to and
from the Operating Room. Our goal for this patient is to attempt
to encourage his orally intake and to cycle his tube feeds only at
night. The patient should have 24 hour calorie counts initiated to
assess the adequacy of this orally intake.
GU. The patient has a Foley catheter in place and has good urine
output. The patient has excoriations around his inner thighs which
prevented us from removing his Foley in case the patient has episodes of
urinary incontinence. Once the patient's inner thighs heal , the
patient may have the Foley removed and the patient may be able to
void on his own in either a bedside urinal or with a condom cath in
place. The patient is receiving his Lasix 40 mg a day.
CARDIOVASCULAR. The patient was initially ruled out for a
myocardial infarction following his first operative procedure. The
patient has had no complaints of chest pain. The patient's
cardiovascular status has been stable with CVP's running in the 12
to 13 range. The patient had no episodes of hypotension and has
been continued on his Capoten.
HEMATOLOGIC. The patient has been stable with no issues. The
patient continues on subcutaneous heparin.
INFECTIOUS DISEASE. The patient was treated with Ampicillin ,
Gentamicin and Flagyl. The patient's intraoperative cultures from
his left leg ulcer grew out E. coli , sensitive to Ampicillin and
Ofloxacin. The patient also grew out Enterococcus , sensitive also
to Ampicillin and Ofloxacin and Enterobacter cloacae , sensitive to
Gentamicin and Ofloxacin. The patient was switched over from
Gentamicin to Ofloxacin to continue his antibiotic course. The
patient has been followed by the Infectious Disease service.
Because of the time of operation , it was considered that the
infectious tissue was completely debrided , and the patient does not
need to continue on an extensive antibiotic course.
The patient will receive 7 more days of orally Ofloxacin as an
outpatient as per the ID service. The patient will have received ,
prior to discharge , a total of 7 days of intravenous Ampicillin and
Ofloxacin. The Flagyl was discontinued after day #6.
TUBES/LINES/DRAINS. The patient had a triple lumen catheter in
place which was removed on the day prior to discharge. The patient
had a peripheral intravenous placed in instead. The patient will not be
receiving any intravenous medications and will continue on orally antibiotic
dosings.
ADDENDUM
DISCHARGE MEDICATIONS: The patient's medication upon discharge
which include: 1 ) Tylenol 650 mg orally every 4 hours
as needed headache. 2 ) Aspirin 81 mg orally every day 3 ) Albuterol nebulizer
0.5 cc in 2.5 cc of normal saline four times a day 4 ) Capoten 25 mg orally every hour
5 ) Chloral hydrate 500 mg orally every bedtime as needed insomnia. 6 ) Clonopin
1 mg orally three times a day 7 ) Digoxin 0.375 mg orally every day 8 ) Colace 100 mg orally
twice a day 9 ) Lasix 40 mg orally every day 10 ) Heparin 5000 units subcutaneously twice a day
11 ) Insulin NPH 38 units subcutaneously twice a day 12 ) Milk of Magnesia 30 cc
orally every day as needed constipation. 13 ) Multivitamins one capsule orally every day
14 ) Mycostatin 5 cc orally four times a day 15 ) Percocet one or two tabs orally
q3-4h as needed pain. 16 ) Metamucil one packet orally every day 17 ) Azmacort
six puffs inhaled twice a day 18 ) Axid 150 mg orally twice a day 19 ) Ofloxacin
200 mg orally twice a day x 7 days.
Dictated By: GERMAINE L. BLACKGOAT , M.D. XV68
Attending: SCOTTIE BURSTON , M.D. EL37 FU131/0524
Batch: 138 Index No. ONDAH63ZO1 D: 10/28/95
T: 10/28/95
CC: 1. SCOTTIE BURSTON , M.D. NQ12
2. GENNY S. BARRETTE , M.D. SE6
3. LEOLA C. MUSICH , M.D. GF37
4. PRINGRYSHIRE LIHART HOSPITAL
Document id: 606
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
956575530 | PUO | 82335153 | | 7060992 | 11/21/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 6/24/2006 Report Status: Signed
Discharge Date: 11/28/2006
ATTENDING: STUKOWSKI , JANAY MD
SERVICE:
Cardiac Surgical Service.
HISTORY OF PRESENT ILLNESS:
Mr. Shabel is a 73-year-old male from Tlandmempsa Tiville Grand who is a retired
professor of physiology. He noted that he had "extra beats" by
his primary care physician approximately one year ago. The
patient had a Holter monitor placed , which reportedly showed many
PVCs as well as episodes of AV block. He then underwent stress
testing and eventual cardiac catheterization in Lanbockter Worce Ma in 2005 ,
which revealed 3-vessel coronary artery disease. The patient was
referred to Dr. Stukowski for coronary revascularization.
PAST MEDICAL HISTORY:
Hypertension , stroke , diabetes mellitus , hyperlipidemia , benign
prostatic hypertrophy , and osteoarthritis of both knees.
PAST SURGICAL HISTORY:
Appendectomy in 1955 , open cholecystectomy in 1989 , and TURP in
1998.
FAMILY HISTORY:
No history of coronary artery disease.
SOCIAL HISTORY:
A 35-pack-year cigarette smoking history. Rare history of
alcohol use.
ALLERGIES:
Atenolol which caused near syncope.
PREOPERATIVE MEDICATIONS:
Amlodipine 5 mg orally twice a day , ramipril 5 mg orally every other day ,
aspirin 325 mg orally daily , torsemide 20 mg orally daily , HCTZ 12.5
mg orally daily , atorvastatin 10 mg orally daily , metformin 500 mg
orally daily , Amaryl 2 mg orally daily , Lantus 20 units nightly , and
Ambien 5 mg orally nightly.
PHYSICAL EXAMINATION:
Vital Signs: Temperature 97.8 , heart rate 76 , blood pressure in
the right arm 128/52 , blood pressure in the left arm 122/50.
HEENT: Dentition without evidence of infection , no carotid
bruit. Cardiovascular: Slightly irregular rhythm without
murmur. Peripheral pulses are all 2+ include the carotid ,
radial , femoral , dorsalis pedis , posterior tibial. Respiratory:
Breath sounds clear bilaterally. Extremities: Without scarring ,
varicosities or edema. Neuro: Alert and oriented with visual
field cuts lateral field of both eyes.
PREOPERATIVE LABS:
Sodium 138 , potassium 4.1 , chloride 103 , carbon dioxide 25 , BUN
25 , creatinine 1.5 , glucose 74 , white blood cells 7.44 ,
hematocrit 36.8 , hemoglobin 12.3 , platelets 212 , 000 , physical therapy 13.3 , INR
of 1 , PTT of 23.2.
Cardiac catheterization data performed on 2/10/06 , coronary
anatomy 70% proximal LAD , 70% mid OM1 , 30% ostial OM1 , 90%
proximal RCA , 100% mid RCA , 90% proximal ramus , right dominant
circulation.
ECG on 7/9/06 showed normal sinus rhythm at 77 with multiple
PVCs , left anterior hemiblock and right bundle-branch block.
Chest x-ray on 7/9/06 was read as normal.
HOSPITAL COURSE:
BRIEF OPERATIVE NOTE:
DATE OF SURGERY:
9/27/06 .
PREOPERATIVE DIAGNOSIS:
Coronary artery disease.
POSTOPERATIVE DIAGNOSIS:
Coronary artery disease.
PROCEDURE:
CABG x4 , sequential graft , SVG1 connects aorta to ramus and then
OM1 , LIMA to LAD , SVG2 to RCA.
BYPASS TIME:
93 minutes.
CROSSCLAMP TIME:
79 minutes.
One ventricular wire , two pericardial tubes , one left pleural
tube placed. The patient came off cardiopulmonary bypass on 4 of
insulin.
COMPLICATIONS:
None.
While in the Cardiac Intensive Care Unit , his course was
complicated by the following:
1. Although the patient had an allergy of syncope caused by
atenolol , he was started on another beta-blocker Lopressor.
He has not had any complications from this
medication. He was later transitioned to Toprol in anticipation
of his discharge.
2. He also had a low hematocrit while in the cardiac intensive
care unit and was transfused 2 units of packed red blood cells.
Since that time , his hematocrit has remained stable. He was
transferred to the Cardiac Step-Down Unit on postoperative day
#2. While on the Cardiac Step-Down Unit , his course was
complicated by the following:
1. The patient was initially hypertensive upon transfer to
cardiac step-down unit and started on captopril. His
hypertension appears to be under control at this time.
Otherwise , all epicardial pacing wires and chest tubes were
removed without complication and he was weaned from his oxygen
requirement and diuresed to approximately her preoperative
weight.
He will be discharged to rehabilitation on postoperative day #5
on the following medications:
DISCHARGE MEDICATIONS: Amlodipine 5 mg orally daily , captopril
6.25 mg orally three times a day , Colace 100 mg orally twice a day , aspirin 325 mg
orally daily , Amaryl 2 mg orally daily , HCTZ 12.5 mg orally daily ,
NovoLog sliding scale please see attached sliding scale , Lantus
20 units subcutaneous nightly , Toprol-XL 100 mg orally daily ,
Niferex 150 mg orally twice a day , oxycodone 5-10 mg orally every 4 hours as needed
pain , atorvastatin 10 mg orally daily.
Mr. Shabel will follow up with Dr. Stukowski , cardiac surgeon , in
six weeks and Dr. Frehse , the patient's cardiologist in two
weeks.
eScription document: 9-7410635 EMSSten Tel
Dictated By: TRIARSI , VERDA
Attending: STUKOWSKI , JANAY
Dictation ID 0346028
D: 9/6/06
T: 9/6/06
Document id: 607
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995493955 | PUO | 25782688 | | 1248392 | 4/13/2005 12:00:00 a.m. | CHEST PAIN | Signed | DIS | Admission Date: 5/19/2005 Report Status: Signed
Discharge Date: 10/26/2005
ATTENDING: STUKOWSKI , JANAY MD
PRINCIPAL DIAGNOSIS:
Coronary artery disease.
HISTORY OF PRESENT ILLNESS:
A 66-year-old gentleman with a medical history significant for
coronary artery disease and two prior MIs. He is also status
post angioplasty and an LAD stent , he has hypertension ,
hyperlipidemia , and diabetes mellitus , and presents now with
chest pain. The patient had been in his usual state of health
when on the day prior to admission , he developed substernal chest
pain while walking and lasted 2-3 hours and was relieved by rest
and sublingual nitroglycerin. He denies shortness of breath ,
nausea , or diaphoresis. He presented to Menlandlourdes Medical Center Urgent Care where he was evaluated and sent to the
Pagham University Of emergency department , where he was
found to have a troponin of 5.6 , which peaked at 6.7. He was
admitted , and cardiac catheterization revealed diffuse disease.
He is being evaluated for possible surgical intervention.
PAST MEDICAL HISTORY:
Hypertension , insulin-dependent diabetes mellitus ,
hypothyroidism , hypercholesterolemia , B12 deficiency sleep apnea ,
on home CPAP , nephrolithiasis , restless legs syndrome , and
diabetic retinopathy.
PAST SURGICAL HISTORY:
Congenital Schatzki's ring , status post dilation via EGD.
SOCIAL HISTORY:
Positive for a rare alcohol use. The patient has three children ,
and is semi-retired as an architect.
ALLERGIES:
Sulfa causing rash and joint swelling , and enalaprilat causing
cough.
MEDICATIONS ON ADMISSION:
Lopressor 50 mg orally four times a day , valsartan 160 mg orally daily , aspirin
325 mg orally daily , atorvastatin 80 mg orally daily , B12 100 mcg
orally daily , Colace 100 mg orally twice a day , folate , Levoxyl , Nexium ,
Lantus , and NovoLog insulin.
PHYSICAL EXAMINATION:
Height 5 feet 7 inches tall , weight 67 kg. Vital signs: Not
listed. HEENT: PERRL. Oropharynx is benign. Neck: Without
carotid bruits. Chest: Without incisions. Cardiovascular:
Regular rate and rhythm , no murmurs. Respiratory: Breath sounds
are clear bilaterally. Abdomen: No incisions , soft , no masses.
Rectal: Normal tone , no masses , guaiac negative. Extremities:
Without scarring , varicosities or edema. Pedal pulses are 1+
bilaterally. Radial pulses are 2+ bilaterally. Allen's test in
the left upper extremity is normal by pulse oximeter. Neuro:
Alert and oriented , grossly nonfocal exam , although there is
slightly decreased light touch sensation in the lower extremities
around the great toe bilaterally.
LABORATORY VALUES ON ADMISSION:
Include sodium of 139 , potassium of 4.3. BUN of 12 , creatinine
of 1.2 , and glucose of 106. Hematology includes white blood cell
count of 7.4 , hematocrit of 33 , INR of 1 , PTT of 104. Cardiac
catheterization data: EKG , normal sinus rhythm at 67 with a
nonspecific T-wave abnormality in 1 , aVL , V5 , and V6. Chest
x-ray is without acute disease.
HOSPITAL COURSE:
The patient was admitted on 8/17/05 and underwent cardiac
catheterization the following day , which revealed 90% proximal
LAD stenosis , 90% mid LAD and 100% distal LAD stenosis , 100% mid
LVB1 , 80% mid circumflex , 70% proximal D1 , 70% proximal PDA , and
a right dominant circulation. There is diffuse coronary
calcification and extensive diffuse disease with small distal
vessels. LAD in stent restenosis. There is collateral flow
diffusely small left main. The patient was taken to the
operating room on 11/7/05 and underwent CABG x4 with SVG1 to
RCA , and sequential graft of SVG2 to D1 and then OM1. The
patient also had LIMA to LAD and an LAD endarterectomy. The
patient was taken to the Intensive Care Unit following surgery in
stable condition. He was given 150 mg of Plavix on arrival to
the ICU , and a second dose 6 hours later. He was also started on
heparin 500 units for 48 hours and given aspirin that same night.
The patient was extubated the following day and was noted to
require the transfusion of a unit of packed red blood cells. He
required neosynephrine transiently , which was weaned off on
postoperative day #2. That same day , he transferred to the
Step-Down Unit , neurologically intact , with pain well controlled ,
hemodynamically stable , started on aspirin , Lopressor , and
Plavix. The patient was also on 2 liters of oxygen at the time
of transfer , and had chest tube in that still had output. The
patient's diet was being advanced , and he was being diuresed with
Lasix with good effect. Perioperatively , he was also followed by
the Diabetes Management Service for blood sugar control and was
transitioned from intravenous insulin to subcutaneous insulin
postoperatively. The patient was noted to have a preoperative
urinary tract infection of E. coli for which he was started on
levofloxacin on 4/30/05 and treated for five days. On
postoperative day #3 , his wires , chest tubes and Foley were
removed. He was noted to have loose lower front teeth following
his difficult intubation , and the Dental Service was called to
see the patient. The recommendation was simply to avoid putting
pressure on those teeth and they advised that this would allow
the teeth to retighten in the jaw over the next couple of weeks.
The patient continued to do well , remained in sinus rhythm , and
was weaned off oxygen , saturating well on room air. He
progressed daily and walked first with assistance and then
steadily on his own. He is discharged to home in good condition
on postoperative day #7 on the following medications:
Enteric-coated aspirin 325 mg orally daily , atenolol 75 mg orally
daily , Colace 100 mg orally three times a day , oxycodone 5 mg to 10 mg orally
every 6 hours as needed pain , Plavix 75 mg orally daily , Lantus 38 units
subcutaneously at bedtime , NovoLog 18 units subcutaneous every day before noon ,
NovoLog 12 units subcutaneously with lunch and supper , and
atorvastatin 80 mg orally daily. He is to have a follow-up
appointment with his cardiologist , Dr. Pederzani , in one to two weeks ,
and with his cardiac surgeon , Dr. Stukowski , in four to six weeks.
eScription document: 2-5945178 EMSFocus transcriptionists
Dictated By: JACOBSON , CHRISTEEN
Attending: STUKOWSKI , JANAY
Dictation ID 1291708
D: 10/27/05
T: 10/27/05
Document id: 608
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718175239 | PUO | 85554562 | | 1236617 | 7/5/2006 12:00:00 a.m. | HIP FRACTURE , STATUS POST HEART TRANSPLANT | Signed | DIS | Admission Date: 8/7/2006 Report Status: Signed
Discharge Date: 2/3/2006
ATTENDING: PETTINGER , DOUGLASS MD
CHIEF COMPLAINT: Right Hip fracture.
BRIEF ADMISSION HISTORY: Ms. Englebert is a 67-year-old lady who
received a heart transplant in October 2006 for idiopathic
dilated cardiomyopathy and who was transferred from an outside hospital after
sutaining a right hip fracture. She had been in good health
until one day prior to admission to Pagham University Of
when she tripped over the carpet in her house and fell to the
ground and fractured her right hip. There was no loss of
consciousness or head trauma nor were there any preceding
symptoms such as chest pain , shortness of breath , or
palpitations. She has a history of osteoarthritis as well as
known bilateral hip insufficiency fractures for which she has
been evaluated in the past. She was transferred to Pagham University Of for orthopedic surgery.
REVIEW OF SYSTEMS: The patient has felt in good health with no
recent fevers , chills , or night sweats. She is able to do her
daily activities as well as low intensity aerobic activities
without significant dyspnea on exertion. She notes no recent
cough , nausea , vomiting , diarrhea , dysuria , or lower extremity
swelling.
PAST MEDICAL HISTORY:
1. Idiopathic dilated cardiomyopathy , status post heart
transplant on 5/10/2006 . She is status post biventricular
assist device x6 months and AICD , now both removed.
2. Chronic renal insufficiency with a baseline creatinine of
1.1-1.2.
3. Osteoarthritis in both hips.
4. Osteoporosis with bilateral femoral neck insufficiency fractures.
5. Hypercholesterolemia.
6. History of recurring C. difficile colitis.
MEDICATIONS ON ADMISSION: Neoral 150 mg twice a day , prednisone 8 mg
daily , CellCept 1500 mg twice a day , Protonix 20 mg daily , Pravachol
40 mg daily , diltiazem 360 mg daily , multivitamin one daily ,
magnesium oxide 400 mg daily , calcium and vitamin D 1800 mg
daily , Fosamax weekly on Mondays , Colace 100 mg daily , Zocor 20
mg daily , Dulcolax 10 mg as needed for constipation , vitamin E
400 units daily , and vitamin C 500 mg twice a day
ALLERGIES: The patient has a history of heparin-induced
thrombocytopenia. Penicillin causes a rash.
ADMISSION PHYSICAL EXAMINATION: She was afebrile , 98.6 , pulse
115 , blood pressure 118/80 , respiratory rate 18 , and oxygen
saturation 95% on room air. She was a well-appearing lady in no
acute distress who rated her pain as 2/10 at rest and yet 8/10
upon movement of her lower extremities. On head and neck exam ,
her JVP was flat. Her oropharynx was without erythema or
exudates. Her lungs were clear bilaterally. On examination of
the heart , she had a regular rhythm and was tachycardic. S1 and
S2 were clearly audible. There was no rub or murmur or gallop.
Her abdominal exam was benign , and her extremities were warm and
without edema. Her right leg was shortened and externally
rotated.
LABORATORIES ON ADMISSION: Significant for sodium of 146 ,
potassium of 4.2 , chloride of 111 , bicarbonates of 24 , BUN 39 ,
creatinine 1.4 , PTT 26.2 , and INR 1.1.
Plain films of the hip revealed a nondisplaced right femoral
fracture.
EKG showed sinus tachycardia. Echocardiogram performed on
7/25/2006 revealed LVEF of 55-60% without wall motion
abnormality and no evidence of diastolic dysfunction. Her RV was
mildly enlarged , mild left atrial enlargement , no AR , and mild
TR. There was no aortic regurgitation , mild mitral
regurgitation , and trace tricuspid regurgitation.
Most recent right heart catheterization results performed in April
2006 showed normal right-sided filling pressures with a right
atrial pressure of 3 mmHg , RV 4 , PA 24 , and pulmonary capillary
wedge pressure of 9.
HOSPITAL COURSE BY SYSTEMS: In summary , Ms. Englebert is a
67-year-old female status post heart transplant in October 2006
who was stable from a
cardiac standpoint when she tripped and sustained a
right hip fracture. She was transferred from outside hospital in Xand for
surgical evaluation.
Musculoskeletal: The patient is status post right hip fracture.
She went to the OR on hospital day #2 and received a dynamic hip
screw. The procedure was uncomplicated , and the patient was able
to begin weightbearing on postoperative day #1. She worked with
physical therapy and upon discharge was able to ambulate around
the Ron with a walker. She should continue aspirin 325 mg daily
for four weeks after the surgery. There is no indication for
systemic anticoagulation after this particular procedure. She
will receive oxycodone as needed.
Cardiovascular: She is status post transplant with the last
echocardiogram revealing ejection fraction of 60%. She was
continued on her standard immunosuppressive medications. There
was no evidence of ischemia throughout the hospital stay. She
was euvolemic with no evidence of congestive heart failure. She was in sinus
rhythm on telemetry throughout her hospital stay.
Hematology: The patient has a history of heparin-induced
thrombocytopenia. She was treated with fondaparinux daily prior
to the procedure and then discharged on aspirin for four weeks
postprocedure. Her hematocrit dropped from 33.5% to 24.9% after
the surgery. She was transfused with 2 units of packed red blood
cells on the day after surgery with appropriate hematocrit rise.
She received additional 2 units of packed red blood cells prior
to discharge , and her hematocrit was 30.4% on the day of
discharge. Stools were guaiac negative , and it was thought that
his hematocrit drop was due to the postoperative blood loss as
well as potential hematoma formation at the site of the surgery.
Her hematocrit will be followed closely as an outpatient.
DISCHARGE MEDICATIONS: Tylenol 650 mg every four hours as needed
for pain , aspirin 325 mg daily for four weeks after the surgery ,
Fosamax 70 mg weekly , Dulcolax p.r. 10 mg as needed for
constipation , Caltrate plus D one tablet daily , Neoral
( cyclosporine ) 150 mg twice a day , diltiazem extended release 360 mg
daily , Colace 100 mg twice a day , magnesium oxide 420 mg daily ,
CellCept 1500 mg twice a day , oxycodone 5-10 mg every six hours as
needed for pain , Protonix 40 mg daily , Pravachol 40 mg daily ,
prednisone 8 mg every morning , and multivitamin one tablet daily.
FOLLOWUP PLANS: The patient will continue her home medication
regimen. In addition , she should be maintained on aspirin 325 mg
for four weeks to prevent clot formation postsurgery. She should
take oxycodone as needed for pain. She has a followup
appointment with orthopedic surgery. The attending who performed
her procedure was Dr. Ibey . Her appointment is scheduled for
11/4/2006 at 09:15 a.m. She should followup with her primary
care doctor within 1-2 weeks of discharge and will also be
closely followed by transplant clinic. She was instructed to
have her blood drawn on Monday after discharge , 7/12/2006 , to be
reviewed by her primary care doctor.
eScription document: 4-9352078 HFFocus
Dictated By: WALTERS , ELIZABET
Attending: PETTINGER , DOUGLASS
Dictation ID 6066074
D: 10/24/06
T: 1/6/06
Document id: 609
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918345620 | PUO | 81370631 | | 1093220 | 4/18/2004 12:00:00 a.m. | CORONARY ARTERY DISEASE , AORTIC STENOSIS | Signed | DIS | Admission Date: 10/27/2004 Report Status: Signed
Discharge Date: 6/4/2004
ATTENDING: ISABELLE EVON COLASAMTE MD
CARDIAC SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: Mr. Rude is a 67-year-old male who
has had known aortic stenosis for approximately seven years. He
recently presented with chest burning while walking uphill as
well as having problems with mild fatigue. He subsequently
received a more extensive cardiac workup and was found to have
coronary artery disease as well on a heart cath. This is in
addition to his aortic stenosis , which was found to have a peak
gradient of 112 and an aortic valve area of 0.6.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes controlled with dietary treatment only.
3. Coronary artery disease.
4. Aortic stenosis.
PAST SURGICAL HISTORY: Right knee arthroscopy in 2002.
FAMILY HISTORY: Patient's father died of an injury at work.
Patient's mother is still alive. He has a sister who is 65 years
old with arrhythmia problems and a son with diabetes and coronary
artery disease.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Diltiazem 300 mg orally every day
2. Lisinopril 10 mg orally every day
3. Xanax 0.5 mg orally as needed
PHYSICAL EXAM: The patient's height is 6 feet 1 inches. Weight
is 91.8 kilograms. Heart rate is 88. Blood pressure is 118/68
in the right arm , 116/72 in the left arm. HEENT: Pupils equal ,
round , and reactive to light. Extraocular movements intact.
Mucous membranes are moist. Oropharynx is clear. There are no
carotid bruits. He does have a cardiac murmur that does radiate
into the neck. Chest: There are no incisions. Cardiovascular:
Regular rate and rhythm with a 4/6 systolic murmur heard
throughout the precardium. Pulses: Carotid , radial , femoral ,
dorsalis pedis and posterior tibialis pulses are 2+ bilaterally.
Respiratory: Breath sounds are clear bilaterally. Abdomen: Soft ,
nontender , nondistended with normoactive bowel sounds.
Extremities: The patient has no varicosities or edema. Neuro:
Patient is alert and oriented and has no focal deficits.
LABS UPON ADMISSION: Sodium is 137 , potassium 3.9 , chloride 103 ,
bicarbonate 24 , BUN 19 , creatinine 1 , glucose 185 , magnesium 2 ,
white count 6.7 , hematocrit 41 , hemoglobin 14.6 , platelets
224 , 000 , physical therapy 14.5 , INR 1.1 , PTT is 34.7.
HOSPITAL COURSE: The patient was admitted to the hospital on
2/14/04 and was taken to the OR the same day where he received
an aortic valve replacement using a 25 mm Carpentier Edwards
pericardial valve. He also received a 2-vessel CABG in which the
left internal mammary artery was grafted to the left anterior
descending artery and a saphenous vein was sewn to the first
obtuse marginal artery. Postoperatively , he was hemodynamically
stable and was taken to the cardiac intensive care unit. He was
quickly weaned off of the ventilator and was extubated. He was
then started on beta-blockade and on postoperative day 1 he was
transferred to the floor. Over the next few days , he was
diuresed. He later developed atrial fibrillation. He was
hemodynamically stable with this. However , his rate was in the
120s. Rate control was achieved using Diltiazem and Lopressor.
He was subsequently anticoagulated with Coumadin. On the day of
discharge , he remained alert and oriented , ambulating quite well
without assistance , hemodynamically stable with heart rate in the
70s. He was eating well and having a bowel movement and had been
diuresed quite well. He was felt to be fit for discharge and was
sent home in good condition. He will be seen by a visiting
nurse. Follow up will be initially with Dr. Pindell who will
also manage his anticoagulation. He will see Dr. Colasamte in four
to six weeks.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours as needed pain.
2. Xanax 0.5 mg orally three times a day as needed for anxiety as the patient
was taking preoperatively.
3. Aspirin enteric coated 81 mg orally every day
4. Diltiazem 30 mg orally three times a day
5. Colace 100 mg orally three times a day as needed for constipation.
6. Lasix 40 mg orally twice a day
7. Ibuprofen 200 to 800 mg orally every 6 hours as needed for pain.
8. Lopressor 75 mg orally four times a day
9. Niferex 150 mg orally twice a day
10. Percocet one tab orally every 6 hours as needed for pain.
11. Coumadin. This dose will be adjusted by the anticoagulation
service for Dr. Pindell . Tonight he will receive 3 mg.
12. K-Dur 20 mEq orally twice a day
13. Glucophage extended release 500 mg orally every day
14. Atorvastatin 20 mg orally every day
DISCHARGE DIAGNOSES:
1. Aortic valve stenosis status post aortic valve replacement.
2. Coronary artery disease status post coronary artery bypass
grafting.
3. Hypertension.
4. Diabetes mellitus.
eScription document: 8-1621944 EMSSten Tel
Dictated By: MARCOTT , DESIRAE
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 0293774
D: 4/6/04
T: 4/6/04
Document id: 610
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145554788 | PUO | 77162931 | | 645641 | 9/18/1995 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 2/12/1995 Report Status: Unsigned
Discharge Date: 3/10/1995
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old man with
unstable angina who was referred to
the Pagham University Of for cardiac catheterization and
coronary artery bypass grafting. The patient has a four-year
history of coronary artery disease who presented with left-sided
chest pain four days prior to admission. He describes episodes of
chest pain occurring approximately every two months as well as
evidence of shortness of breath although he has a noted picture of
chronic obstructive pulmonary disease.
ETT in 1989 was negative and he recently described progressively
poor exercise tolerance to the point that he was taking sublingual
NTG on a twice daily basis for exertional angina. One week prior
to admission he developed severe substernal chest discomfort at
rest , lasting approximately 10 minutes. Then , after taking a
sublingual NTG , he reported loss of consciousness for a duration of
20 to 30 seconds at which point he was taken to the Daonredd Cison Community Memorial Hospital by
an EMT. At the clinic he received intravenous NTG , heparin and
Diltiazem.
An ETT Thallium demonstrated reperfusion abnormalities in the
inferior and anterior walls. He left the Daonredd Cison Community Memorial Hospital AMA to see
his cardiologist on the 11th who referred him to the Pagham University Of for elective catheterization. At the time of
presentation he denied chest pain or shortness of breath. Cardiac
risk factors are notably an 80-pack year smoking history , family
history of heart disease , hypercholesterolemia and non
insulin-dependent diabetes mellitus.
PAST MEDICAL HISTORY: Notable for history of interstitial lung
disease , hyperlipidemia , GE reflux , chronic bronchitis and
obstructive sleep apnea. MEDICATIONS ON ADMIT: Cardizem 120mg
orally.twice a day , Mevacor 20mg orally.twice a day , Pepcid 40mg orally.every day , Ventolin
and Seldane taken on a as needed basis. ALLERGIES: NKDA.
PHYSICAL EXAMINATION: Six centimeters of JVD , normal cardiac
examination with intact distal pulses.
Diminished breath sounds bilaterally.
LABORATORY EVALUATION: Unremarkable.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service and underwent cardiac catheterization
demonstrating 80% distal stenosis of the left main as well as the
origin of the LAD with additional occlusion of the midportion of
the LAD and distal carotid , 80% stenosis of midportion of left
circumflex and proximal occlusion of the right coronary. Previous
pulmonary function tests performed in October included an FEV-1 of
2.53 , FEV-1/FVC of 83 , FVC 3.05. He was seen preoperatively by the
Dental Service. He was felt to have a possible periodontal abscess
of tooth #32 for which a course of orally penicillin was recommended
and completed.
On the 13 of November , the patient received double coronary artery bypass
graft including pedicle LIMA bypass to the LAD and LAD patch
angioplasty with a single aortocoronary saphenous vein bypass graft
to the obtuse marginal. He tolerated the procedure well. He was
admitted to the Cardiac Surgery Intensive Care Unit in routine
fashion without complications. He was stable in sinus rhythm. He
had a somewhat higher than normal O2 requirement which diminished
with diuresis.
His hospital course proceeded without complications although he did
demonstrate a low-grade fever and leukocytosis up to 20 , 000 for
which he was started on an empiric course of cefuroxime for
radiographic infiltrate although his sputum cultures were not
definitive. He was evaluated by the ID Service and cultured
appropriately with continuation of empiric antibiotics. He
continued to demonstate low-grade fevers during the course of his
hospital stay with persistent leukocytosis in the range of 14 to
16K prior to discharge. No definite source of infection was
identified.
All of his wound sites looked clean and cultures remained negative.
He was weaned off oxygen for some time. He had no productive
cough. On the 28 of November we discharged him to home AMA , although
encouraged a stay for further evaluation of his fever and
leukocytosis.
DISPOSITION: Aspirin 325mg every day , Diltiazem 120mg orally.three times a day ,
Colace 100mg three times a day , iron sulfate 300mg three times a day , Lasix
80mg orally.twice a day , Mevacor 20mg orally.twice a day , MVI one orally.every day ,
Percocet one to two tabs. every 4 as needed , KCl 40mil/eq orally.twice a day and
ciprofloxacin 500mg orally.twice a day X 10 days taken with clindamycin
300mg orally.four times a day He was encouraged to see his cardiologist for
follow-up over the following week and should return to
Dr. Genny Barrette office during this interval prior to completion
of his antibiotics.
Dictated By: GAYLENE G. FANIEL , M.D. RQ51
Attending: GENNY S. BARRETTE , M.D. HK9 ED912/8456
Batch: 74157 Index No. WVXIZW806B D: 5/12/95
T: 5/12/95
Document id: 611
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773096589 | PUO | 31995211 | | 6301350 | 8/27/2006 12:00:00 a.m. | PULMONARY EDEMA | Signed | DIS | Admission Date: 8/27/2006 Report Status: Signed
Discharge Date: 7/5/2006
ATTENDING: KERTESZ , ALETA M.D.
OPERATIONS:
1. CABG x3 ( Y-graft sequential: LIMA connects aorta to LAD ,
sequential SVG1 connects LIMA to OM1 and then PDA )/left atrial
appendage resection.
2. Insertion of a pacemaker on 2/19/2006 .
HISTORY OF PRESENT ILLNESS: Mr. Eklov is a 76-year-old man with
history of atrial fibrillation who is admitted to Osri Medical Center last month with atrial fibrillation with rapid
ventricular response. At that time , he also had arm pain and
pulmonary edema. This resolved once his heart rate was
controlled. He has had atrial fibrillation for the past 30 years
and has been on Coumadin for the past 20. The patient has been
on amiodarone therapy in the past and has biopsy-demonstrated
cirrhosis as a consequence of this therapy , which has resolved
following the discontinuation of the medication. He has been
rate controlled since that time but is very sensitive even with
slight delay in his rate-slowing medications with heart rate
becoming rapid associated with a sensation of aching in his arms.
He also has a history of peripheral vascular disease with
endarterectomy of the external iliac , common femoral , and TSA
with patch angioplasty on the left in April 2000 at PUO . He
also has a cerebrovascular disease with MRI a few years ago also
showing evidence of old small infarcts involving the right
inferior cerebellum and the old lacuna in the left anterior pons
and some patchy areas of the bilateral pons , small areas of
ischemia. He was thought to have basilar artery disease by
neurology. He complains that right side is less sensitive to
temperatures and touch than the left side but no difference in
motor activities is noted. He also has a history of coronary
artery disease. As an outpatient , MIBI in September 2006 showed
1-mm ST depression but no ischemia on imaging. Left ventricular
ejection fraction was noted to be 45% without any regional wall
motion abnormalities. Elective catheterization showed
three-vessel disease and was admitted to the Pagham University Of for CABG.
PREOPERATIVE CARDIAC STATUS: Urgent. The patient presented with
critical coronary anatomy. There is a history of class III heart
failure. The patient is in atrial fibrillation.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: None.
PAST MEDICAL HISTORY: Hypertension , peripheral vascular disease
of the lower extremities , status post endarterectomy of the
external iliac , common femoral , and TSA with patchy angioplasty
on the left in April 2000 , diabetes mellitus with insulin
therapy , hypercholesterolemia , migraine headache , and bilateral
lower extremity neuropathy due to diabetes.
PAST SURGICAL HISTORY: Surgery for a torn right rotator cuff ,
August 2006 , and as above.
FAMILY HISTORY: Father had a stroke.
SOCIAL HISTORY: History of tobacco use , cigarette smoking
history but quit smoking many years ago.
ALLERGIES: Penicillin - skin edema , quinidine - rash , and
amiodarone - cirrhosis of the liver.
ADMISSION MEDICATIONS:
1. Diltiazem 360 orally daily.
2. Lisinopril 10 mg orally daily.
3. Aspirin 81 mg orally daily.
4. Coumadin orally as directed.
5. Lasix 20 mg orally daily.
6. Simvastatin 80 mg orally daily.
7. Metformin 500 mg twice a day
8. Insulin.
CARDIAC CATHETERIZATION DATA: Coronary anatomy: 95% mid LM , 60%
ostial LAD , 50% proximal circumflex , 100% proximal RCA , right
dominant circulation , and marginal diffuse 99%.
ECG: Atrial fibrillation at 90 beats per minute , nonspecific
intraventricular delay , Q-waves in V3 , poor R wave progression ,
precordial leads , and ST elevation in V2 and V3.
CHEST X-RAY: Normal , atherosclerotic aortic knob.
HOSPITAL COURSE: The patient was admitted to the intensive care
unit following an uncomplicated coronary artery bypass graft as
described above as well as a left atrial appendage resection.
His bypass time was 106 minutes with cross-clamp time of 61
minutes. One ventricular wire and one pericardial tube was
placed. A retrosternal tube and a right pleural tube were also
placed. Please see dictated operative note for details.
Following his operation , he was transferred to the ICU for
further care and management. The patient was extubated on
postoperative day #1 and was given supplemental O2 nasal cannula
at that time. On postoperative day #2 , the patient's chest tubes
were removed , and his pacing wires were left in place since the
patient was found to be asystolic as an underlying rhythm. The
patient remained in atrial fibrillation and alternated with sinus
rhythm with first-degree AV block. His atrial fibrillation was
difficult to control in the acute postoperative setting , and
cardiology consult was obtained for further care and management
of the patient. On postoperative day #3 , the patient had
shortness of breath and was given Lasix for diuresis. He was 2
liters negative on postoperative day #3 , though he was still
increased from his preoperative weight. His pacing wires were
discontinued on postoperative day #3 as the patient was found to
have return of his underlying rhythm. He was started on
Lopressor and on diltiazem at that time. On postoperative day
#4 , the patient's diltiazem was changed to diltiazem CD 360 mg
and atenolol 50 mg daily per Dr. Bachmann . The patient was
given a physical therapy consult for home safety evaluation on that day. On
postoperative day #8 , the patient had an episode of symptomatic
sinus bradycardia and as a result received a transvenous
pacemaker by the electrophysiology service for the control of the
sinus bradycardia , and on the day of discharge from the ICU , the
patient was taken for permanent pacemaker placement by the
electrophysiology team.
The patient's pain was controlled with Tylenol without
significant pain requirement issues. He was intact
neurologically on day of discharge , moving all four extremities ,
and appropriate. From a cardiovascular standpoint , the patient
was given his pacemaker and was still in atrial fibrillation as
his underlying rhythm. He was given 50 of atenolol as well as
extended release of diltiazem 360 daily. He was on room satting
appropriately and was given Atrovent on a as needed basis. He was
tolerating POs and getting Nexium and Colace from a GI
perspective. The patient was receiving diuresis with Lasix of 40
orally twice a day , and his electrolytes were supplemented. From a
hematologic standpoint , he was given aspirin 81 mg , and his
Coumadin will be restarted. He had no significant infectious
disease issues on the day of discharge. From endocrine
perspective , the patient was given NPH 24 units every day before noon and 20
units every afternoon and his baseline sliding scale in addition to NovoLog
10 units as a standing order.
DISPOSITION: The patient was discharged to the cardiac step-down
unit.
DISCHARGE CONDITION: Good.
FOLLOWUP: The patient was instructed to follow up with his
attending physician , Dr. Kertesz , in 1-2 weeks following
discharge.
eScription document: 0-2999224 HFFocus
Dictated By: CRITTLE , AMANDA
Attending: KERTESZ , ALETA
Dictation ID 1715630
D: 7/15/06
T: 7/15/06
Document id: 612
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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880628308 | PUO | 49275058 | | 6730688 | 10/30/2005 12:00:00 a.m. | ALTERED MENTAL STATUS | Signed | DIS | Admission Date: 4/25/2005 Report Status: Signed
Discharge Date: 2/10/2005
ATTENDING: AABY , WALDO OPHELIA MD
SERVICE: General Medical Service.
PRINCIPAL DIAGNOSIS: Altered mental status and dyspnea.
LIST OF PROBLEMS: Coronary artery disease status post stenting ,
congestive heart failure and head and neck squamous cell
carcinoma.
HISTORY OF PRESENT ILLNESS: Mr. Cogswell is a 70-year-old man
with coronary artery disease status post stenting in September of this
year , congestive heart failure and head and neck squamous cell
carcinoma treated with chemotherapy and radiation therapy earlier
this year , presenting with a change in mental status and dyspnea.
After his stents in September of this year , he went to the cardiac
rehab and then home where he was mostly in bed on tube feeds.
His methadone dose ( for pain control ) was increased from 2.5
twice a day to 4. in the morning and 5 in the evening and he was
noticed to have increased lethargy. So , he self discontinued his
methadone for two days. He also had increased cough and tan
sputum. Of note , he just completed 14-day course of vancomycin ,
cefpodoxime and Flagyl for aspiration pneumonia. He also has a
G-tube for failed Speech and Swallow test previously. In the
emergency room , he received vancomycin , levofloxacin and Flagyl.
He had no other complaints on review of system.
PAST MEDICAL HISTORY: Coronary artery disease status post three
stents in January of 2005 for an NSTEMI , right hip placement. He
had a recent aspiration pneumonia , discharged from the Kernan To Dautedi University Of Of on
4/30/05 . He has type 2 diabetes , left carotid endarterectomy ,
hypertension , hypercholesterolemia , congestive heart failure with
most recent ejection fraction of 20% and squamous cell carcinoma
originally treated in 1989 in the head and neck and relapsed in
2005. He is status post carbotaxol and radiation therapy.
ALLERGIES: He has no known drug allergies.
MEDICATIONS: Include ECASA 325 daily , Plavix 75 daily , metformin
850 twice a day , Zocor 40 mg once a day , paroxetine 2.5 mg once a
day , atenolol 25 mg once a day , methadone 5 mg twice a day ,
Zofran as needed , Lasix 20 once a day , lisinopril 20 mg orally once a
day , pyridoxine 5 mg once a day.
FAMILY AND SOCIAL HISTORY: His father died of an MI. He lives
in Mon Vi Ce He smokes half a pack per day for unknown
number of years.
PHYSICAL EXAM: He was afebrile. His heart rate was 62 , blood
pressure 110/60 , breathing at 20 breaths per minute with an O2
saturation of 97%. He appeared tired with dry mucous membranes.
He had diffuse rhonchi on his chest exam. He had a 2/6 systolic
murmur heard best at the apex with a regular rate and rhythm.
His abdomen was soft and nontender with his G-tube site clean.
His extremities were warm. He was alert and oriented x3 on
initial exam but this waxed and waned during his inpatient stay.
PERTINENT LABS: Include glucose originally of 429 brought down
with insulin to 85 , cardiac enzymes which were negative , a white
count of 17.3 and hematocrit of 31.2 , but his baseline is in the
30s. Chest x-ray on admission showed a right lower lobe
ill-defined opacity concerned for atelectasis versus pneumonia.
A head CT showed no acute intracranial abnormality. EKG showed
normal sinus rhythm with a borderline QT interval of 490 , left
ventricular hypertrophy and deep T-wave inversions in the lateral
leads but the same as previous EKGs.
HOSPITAL COURSE: This is a 70-year-old man with multiple medical
problems including CAD , CHF and cancer with head and neck
presenting with change in mental status possibly due to his
methadone dosage versus infectious etiology namely pneumonia.
Hyperglycemia at admission may have been contributory.
Pulmonary: Blood cultures were negative for growth. He was
initially placed on cefotaxime and Flagyl and was changed to orally
meds , per G-tube meds Flagyl and cefpodoxime. He was continued
on his albuterol nebulizer , Atrovent and a repeat chest x-ray
after intravenous fluids revealed slight improvement. He , from
the respiratory standpoint , gradually improved with marked
increase in activity and alertness by the day of discharge.
Neuro and Psych: His change in mental status was thought to be
due in large part to his methadone changes in dose. He was taken
off the methadone and was eventually placed on Zyprexa 2.5 mg at
night and 2.5 mg at noon. He did wax and wane in terms of his
orientation sometimes thinking he was not at the hospital but he
always had the correct date , correct season and knew generally
what the current events at that time.
Cardiovascularly , he was diuresed gently but otherwise has no
change in status.
Palliative care: Palliative Care made numerous recommendations
that we followed , one was to treat with Zyprexa 2.5 mg at night
and at noon to stabilize his mental status fluctuations. This
came with uncertain effect as at discharge but overall his
functionality had improved and the amount of time he was aware
and communicative was overall lengthened. We also started him on
fluconazole intravenous and changed per G-tube upon discharge for
treatment of orally thrush.
Endocrine: He was placed on Regular Insulin sliding scale while
on his tube feeds. We also added insulin NPH standing order for
8 units at morning.
Code status: The possibility of DNR/DNI was discussed at length
with the patient and with his family and they repeatedly and
ultimately decided to have Mr. Cogswell be DNR/DNI at this point.
They understand the ramifications of this and are comfortable
with this decision.
DISPOSITION: Mr. Cogswell is being discharged to rehab at Sa Pehall and he will follow up with Dr. Lebario , his oncologist.
FOLLOWING PHYSICIAN: Alexandra Lebario , MD
eScription document: 7-2325767 CS
CC: Oview Covant Memorial Hospital
CC: Alexandra Lebario M.D.
Medical Oncology , Skill Snerkernfairmri Rehab
In Berkehai Gocoln
Dictated By: HARKLEY , JACQULYN
Attending: AABY , WALDO OPHELIA
Dictation ID 0346333
D: 5/7/05
T: 5/7/05
Document id: 613
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074981892 | PUO | 65633683 | | 792356 | 11/21/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/3/1995 Report Status: Signed
Discharge Date: 2/10/1995
PRINCIPAL DIAGNOSIS: POST MYOCARDIAL INFARCTION ANGINA
SIGNIFICANT PROBLEMS: 1. Coronary artery disease
2. Hypertension
3. Non-insulin dependent diabetes
mellitus
HISTORY OF PRESENT ILLNESS: Patient is a 72 year old white male
Status post recent myocardial
infarction who was admitted for recurrent chest discomfort.
On the 17 of April , the patient noticed a "uncomfortable chest
sensation" as he was driving. He experienced diaphoresis at that
time , but no shortness of breath and no nausea or vomiting. He was
seen at an outside hospital and noted to have 2-3 mm ST elevations
in leads 2 , 3 , FV5 and V6 ( Stusri Medical Center ). The patient was given
TPA , Heparin intravenous and aspirin. His peak CPK was noted to be
5 , 742 with an MB fraction of 199. The patient's hospital stay was
complicated by frequent PVCs on cardiac monitor , for which he was
temporarily treated with Lidocaine. Immediately after the TPA
infusion , the patient noted that his chest discomfort which was
located primarily on the left side , across the midline , to the
right. An echocardiogram that was performed , showed an ejection
fraction of 60% with posterolateral dyssynergia. On the 3 of July of
September , the patient was discharged from Stusri Medical Center after a submax
ETT. He reached a heart rate of 95 and blood pressure 168/90.
On the 26 of September , the patient noted that he had a recurrence of
this vague chest discomfort as he was sitting and talking to
friends. He took a sublingual Nitroglycerin without relief. This
chest discomfort episode resolved spontaneously after approximately
ten minutes.
On the 20 of May , the patient was at a party and , again ,
developed a similar anxious sensation which was similar to the
feeling that he experienced prior to his myocardial infarction. He
took two sublingual Nitroglycerin again , without relief , and his
discomfort resolved after two hours. Patient denies PND ,
orthopnea , or edema. The patient was admitted on the 20 of May
for cardiac catheterization to evaluate post myocardial infarction
angina.
ALLERGIES: Include Penicillin and Toprol which leads to an itch.
PAST MEDICAL HISTORY: Significant for hypertension for five to
six years and diet controlled diabetes
mellitus times four years.
ADMISSION MEDICINES: Ecotrin , Vasotec 20 mg orally every day Atenolol 50
mg orally every day Nitropatch which was to be
continued the day of admission.
SOCIAL HISTORY: The patient has never smoked and he denies
alcohol use.
FAMILY HISTORY: His father died at the age of 48 with the
history of coronary artery disease. The mother
died at the age of 80 secondary to congestive heart failure. His
brother died of a myocardial infarction in his 60s.
ADMITTING PHYSICAL EXAM: BP 120/80. Heart rate 54. Temperature
97.2 , with 95% room air saturation.
Patient is a well-developed elderly male , lying in bed in no acute
distress. HEENT exam reveals pupils are equal , round , reactive to
light and accommodation , oropharynx is within normal limits. Neck
exam is supple with jugular venous pressure 4 cm and carotids
without bruits. Heart exam shows S1 and S2 with a positive S4 , 1/6
systolic murmur heard at the left lower sternal border. Chest is
clear to auscultation bilaterally. Abdominal exam is benign with
positive bowel sounds , soft and non-tender and is non-distended.
Extremities exam shows no clubbing , cyanosis , or edema , with +2
pulses bilaterally at the femoral deep tendon , and posterior tibial
sites. Rectal exam is guaiac negative. Neurological exam is
non-focal , with down-going toes bilaterally , and 2+ reflexes
bilaterally.
ADMISSION LAB: Sodium 139 , potassium 4.9 , chloride 190 ,
bicarbonate 26 , BUN 23 , creatinine 1.4 , glucose
183 , white count 9.3 , hematocrit 36 with platelets of 274 , CK 219 ,
LDH 407. Urinalysis negative. Electrocardiogram showed sinus
rhythm 55 , axis 20 , normal intervals , biphasic V4 through V6 and 1
mm ST elevation in V5 and V6. chest x-ray was within normal
limits.
HOSPITAL COURSE: The physical therapy was started on Heparin
immediately after admission for presumed post
myocardial infarction angina. He underwent cardiac catheterization
the morning following admission. This demonstrated a proximal 100%
occluded left circ lesion which was easily angio-positive to 20%
residual. This was complicated by a small dissection. An LV gram
demonstrated inferior hypokinesis. The patient tolerated the
procedure well without significant decrease in hematocrit or
increase in creatinine. He was heparinized for a full forty-eight
hours post cardiac catheterization procedure. At the time of
discharge , he was ambulating. At no time during this admission did
he develop chest discomfort.
The patient was discharged to home in good condition and will be
followed by his cardiologist in one week post discharge.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day Atenolol 50 mg orally
every day Vasotec 20 mg orally every day Sublingual
Nitroglycerin as needed
Dictated By: EDGARDO J. CISTRUNK , M.D. UK56
Attending: CHRISTINE DARIO , M.D. NG36 YD888/7169
Batch: 3779 Index No. W8ABXF1HZW D: 4/8/95
T: 4/8/95
Document id: 614
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CHF |
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470665576 | PUO | 75985858 | | 2568836 | 5/6/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/22/2005 Report Status: Signed
Discharge Date:
ATTENDING: BARNABA , CARA CHANCE MD
DISCHARGE DATE:
To be determined.
SERVICE:
Cardiology Linwhite Pkwy. , Beau Pro , Nevada 98896
ADMISSION WEIGHT:
139.4 kg.
DISCHARGE WEIGHT:
130.3 kg.
CHIEF COMPLAINT:
Increasing dyspnea on exertion.
HISTORY OF PRESENT ILLNESS:
This 59-year-old woman with two weeks of dyspnea on exertion ,
increased pedal edema presents to the Emergency Department. She
reports that over the past 3-4 weeks she has had a slow increase
in her lower extremity edema and gradual increase in her weight
and moderate increase in dyspnea on exertion. She has taken
increased Bumex and also tried Zaroxolyn at home without effect.
She reports strict adherence to a diet and fluid restriction and
her medications. She urinates clear urine multiple times a day
and at night. She reports no orthopnea , no PND , less shortness
of breath at rest , no chest pain , no fevers , chills , nausea ,
vomiting , or diaphoresis. She does report increased facial
edema , increased swelling in her hands , and increased abdominal
girth.
PAST MEDICAL HISTORY:
1. CHF ( diastolic dysfunction , EF of 60% on biweekly outpatient
nesiritide ).
2. Insulin-dependent diabetes mellitus complicated by
gastroparesis , chronic renal insufficiency , and retinopathy.
3. Chronic renal insufficiency ( baseline creatinine 3.2 to 4.6 ).
4. Depression.
5. Recent Mallory-Weiss tear.
6. Morbid obesity.
7. Anemia.
8. Hypercholesterolemia
9. Right leg superficial femoral thrombus extending into the
deep vein system on Coumadin ( diagnosed in 4/9 ).
10. Nephrotic syndrome.
11. Chronic back pain from spinal stenosis.
ALLERGIES:
Sulfa drugs have given an unknown reaction.
MEDICATIONS ON ADMISSION:
Avapro 300 mg every day , metoprolol XL 300 mg every day , aspirin 81 mg
every day , Respirdal 1 mg as needed , epoetin 20 , 000 every week , Norvasc 20
mg twice a day , Coumadin 6 mg once a day , Nexium 40 mg every day , clonidine
0.3 mg twice a day , Colace 100 mg twice a day , iron sulfate 325 mg twice a day ,
NPH insulin 35 units subcutaneously twice a day , meclizine 25 mg twice a day , Senna
two tablets twice a day , Paxil 30 mg every day , Zocor 80 mg every day , Bumex 2
mg orally twice a day , and Zaroxolyn ( unknown dose ).
FAMILY HISTORY:
No known history of coronary artery disease , positive family
history of diabetes mellitus.
SOCIAL HISTORY:
Quit smoking one year ago previously smoked 20 pack years , no
alcohol , no reported intravenous drug use. Lives in Delp alone , has
no social supports but does have VNA at home , has three sisters
and three brothers.
PHYSICAL EXAMINATION:
On physical exam , temperature 98 , pulse 87 , blood pressure
140/80 , respirations 18 , and 97% on room air. She is in no
apparent distress. Pupils are equal and reactive. Extraocular
movements are intact. Mucous membranes moist. JVP is
approximately 5 cm. Heart is regular rate and rhythm , no
murmurs , gallops , or rubs. Chest is clear to auscultation with
no wheezes. Abdomen is obese with positive bowel sounds.
Extremities shows 3+ , lower extremity edema and tenderness to the
touch. Neuro is alert and oriented x3. Cranial nerves are
intact. Skin shows no rashes.
LABORATORY EXAMS:
Initial BMP was 36 , sodium 135 , potassium 3.4 , chloride 98 ,
bicarbonate 27 , BUN 74 , creatinine 4.4 , white blood cell 6 ,
hematocrit 36 , platelets 155 , 000 , troponin I less than assay , CK
146 , MB 2.3.
Chest x-ray , no changes from 2003. EKG normal sinus rhythm at
71. Left axis deviation. Question of left anterior hemiblock.
Echo in 8/14 showed normal valves. EF of 65% to 70%. Mild LVH.
Normal pulmonary artery systolic pressure.
HOSPITAL COURSE:
This 59-year-old female with multiple medical problems including
morbid obesity , diabetes , CHF with diastolic dysfunction , and
chronic renal insufficiency secondary to diabetes is on home
nesiritide infusions and comes in with total body volume
overload. She was aggressively diuresed during this
hospitalization.
COURSE BY SYSTEM:
Cardiovascular:
1. Ischemia: The patient did not have any positive cardiac
enzymes and no evidence of ischemia. She was maintained on
aspirin , a beta-blocker , and a statin.
2. Pump: The patient was diuresed aggressively. She was
started on a continuous BNP drip along with Lasix 160 mg intravenous
twice a day plus metolazone as needed to help diurese approximately 1
liter per day. The patient did not respond to orally Lasix. The
patient was variably responsive to diuretics , but at the time of
discharge , had diuresed down the 130.3 kg a drop of approximately
10 kg or approximately 22 pounds. The patient's BNP at the time
of discharge was 8 and she was not felt to be in heart failure.
She continued to have lower extremity edema that was felt likely
secondary to venous stasis and lack of mobilization. Therefore ,
she was encouraged to mobilize and given compression stockings to
help mobilize the fluid in her legs. At the time of discharge ,
she was diuresing well to orally Bumex and she was maintained on
Bumex in order to keep her ins and outs even each days.
3. Rhythm: The patient did not have issues from a rhythm
perspective.
Renal: The patient had a creatinine that climbed as high as 5.8 ,
during her hospitalization. She was felt to have an underlying
diabetic nephropathy. The Renal Service ( Dr. Werner Casebier ) was
consulted and felt that the patient would likely eventually need
outpatient dialysis , however , there was no emergent indication
for dialysis at this time. The patient has seen Dr. Rossie K Mankoski , at Pagham University Of , Vascular Surgery prior to
this for consideration of a fistula placement and she will
continue to follow up with Dr. Loerwald following discharge.
Hematology: The patient was maintained on Coumadin for her
history of a clot in the right and left superficial femoral vein ,
which was diagnosed in 4/9 and was noted to be extending
towards the deep venous system. The patient was also continued
on iron for her underlying anemia.
Endocrine: The patient had diabetes and was maintained on her
NPH plus a regular insulin sliding scale to control her blood
sugars and her blood sugars were reasonably well controlled and
generally below 200.
Musculoskeletal: The patient was complaining of increasing
cramps in her calves a few days prior to discharge. Therefore ,
lower extremity noninvasive ultrasound tests were repeated and
these ruled out recurrent deep venous thrombosis. A CK was
checked and this was normal and therefore , it was felt that the
patient did not have any evidence of rhabdomyolysis or a
compartment syndrome. It was felt that these pains were most
likely secondary to venous pooling in the legs combined with
inactivity. The patient was treated symptomatically with
oxycodone and encouraged to ambulate to help mobilize the fluid
out of her legs.
FINAL MEDICATIONS:
The final medications will be dictated at the time of discharge.
eScription document: 9-6117100 EMS
Dictated By: TUOMALA , HERMINA
Attending: BARNABA , CARA CHANCE
Dictation ID 4324424
D: 10/2/05
T: 10/2/05
Document id: 615
| Target |
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DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
Y |
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Y |
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N |
N |
189350399 | PUO | 02584657 | | 0896201 | 6/26/2007 12:00:00 a.m. | rheumatoid arthritis | Unsigned | DIS | Admission Date: 7/4/2007 Report Status: Unsigned
Discharge Date: 5/27/2007
ATTENDING: MOOSE , BUCK M.D.
PRINCIPAL DIAGNOSIS: The diagnosis responsible for causing the
admission is rheumatoid arthritis flare.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female
with a history of rheumatoid and gouty arthritis ,
insulin-dependent diabetes , hypertension , sickle cell trait and
chronic kidney disease ( baseline creatinine of 1.9 ). For her
rheumatoid and gouty arthritis , she had been long treated with
methotrexate and allopurinol. In 5/3 , due to worsening renal
insufficiency , her methotrexate was discontinued. Following
this , she was seen by her rheumatologist with complaints of
worsening joint pains and body aches , for which she was started
on Plaquenil on 7/25/07 . On 10/3/07 , she presented to the
Pagham University Of Emergency Department complaining of
total body pain. In particular , she said that her left groin was
very painful , although when asked , she said that every joint and
muscle group was causing discomfort. She denied fevers , chills ,
loose stools , urinary symptoms , nausea , vomiting or other
constitutional symptoms aside from a headache on the day of
admission. Her pain especially in her hip was so severe at the
time of admission that she felt that she was not able to walk.
PAST MEDICAL HISTORY:
1. Rheumatoid and gouty arthritis: Previously on methotrexate
and allopurinol , but due to worsening renal insufficiency ,
methotrexate was stopped in 5/3 , and Plaquenil was started in
7/21 .
2. Insulin-dependent diabetes.
3. Hypertension.
4. Sickle cell trait.
5. Multinodular goiter.
6. Status post CVA , with mild residual right hemiparesis.
7. Chronic kidney disease , baseline creatinine of 1.9 ( ?of
whether this is due to renal tubular acidosis or diabetes ).
MEDICATIONS AT HOME:
1. NPH.
2. Plaquenil 200 mg twice a day
3. Allopurinol 100 mg daily.
4. Lisinopril 40 mg daily.
5. Paxil.
6. Hydralazine 50 mg four times a day
7. Toprol 50 mg daily.
8. Aspirin 81 mg.
9. Imdur 30 mg.
10. Prilosec 20 mg ,
11. Hydrochlorothiazide 25 mg once a day.
12. Calcitriol 0.25 mg twice a day
13. Lipitor 20 mg once a day.
ALLERGIES: To metoclopramide , which causes dystonia.
SOCIAL HISTORY: She has prior tobacco history.
FAMILY HISTORY: Her mom passed away at age 79 and had coronary
artery disease and diabetes. Her father passed away at the age
of 66 from an aneurysm.
PHYSICAL EXAMINATION ON ADMISSION: Her temperature was 97.7 ,
pulse of 93 , respirations 16 , blood pressure 151/69 , satting 99%
on room air. In general , she was awake , alert , oriented ,
conversant , but in pain. HEENT: Extraocular muscles were
intact , mucous membranes are moist , neck was supple , JVP was not
noticeably elevated. Cardiovascular: Regular rate and rhythm.
Lungs: Clear to auscultation bilaterally. Abdomen: Soft ,
diffusely tender especially in the left and right lower
quadrants , with a question of rebound in these distributions as
well. Extremities: Warm and well perfused , no
cyanosis/clubbing/edema. Extremities: Exquisite tenderness to
palpation over the left hip ( due to severe pain , the patient
could not be positioned in lateral decubitus position to
accurately assess for bursal pain ) , positive left hip pain on
internal and external rotation of the hip , and positive left
elbow pain , along with pain in multiple other areas , without
obvious erythema , effusion , warmth or trauma.
LABORATORY STUDIES ON ADMISSION: Her sodium was 130 , potassium
of 4.1 , chloride of 99 , bicarb of 22 , BUN of 78 , creatinine of
2.3 ( baseline creatinine 1.9-2.5 ) , glucose of 227. Her white
count was 11.8 , hematocrit of 26.9 ( baseline hematocrit of
29-30 ) , platelets of 378 , 000. Her ALT was 12 , AST was 12 ,
alkaline phosphatase of 98 , total bilirubin 0.2 , albumin was 3.1
and globulin was 4.2. Her ESR was 103 , CRP was 151.
OTHER PERTINENT LABS DURING THE COURSE OF HER HOSPITALIZATION:
Her initial urine sodium was 34 , urine creatinine 58.2 , urine BUN
555; urine eosinophils negative; urinalysis showed 2+ protein , 23
white cells , 1 red blood cell , 1+ bacteria and 2+ squamous cells.
On 10/3/07 , urine cultures and blood cultures negative;
8/28/07 urine culture positive for MRSA , sensitive to Bactrim.
On 3/8/07 , left hip washing and aspiration Gram-stain negative
and culture negative. On 7/25/07 , C. difficile negative.
HER RELEVANT STUDIES ARE AS FOLLOWS: On 10/3/07 , pelvic and hip
x-rays demonstrated right hip rheumatoid arthritis , narrowing of
the right SI joint; no acute abnormality or effusion in the left
hip. On 10/3/07 , lower extremity noninvasive studies negative.
On 10/3/07 , KUB showing gastric antral gas. On 10/3/07
abdominal CAT scan notable for bilateral peri renal straining
( old ) , mesenteric stranding ( old ) , left phlebolith. On 3/8/07
echocardiogram , EF of 60% , concentric left ventricular
hypertrophy , mild mitral regurgitation , mild tricuspid
regurgitation , pulmonary artery systolic pressure of 38 plus
right atrial pressure , trace effusion.
ASSESSMENT AND PLAN: A 65-year-old female with a history of
rheumatoid and gouty arthritis , diabetes , sickle cell trait and
chronic kidney disease ( baseline creatinine of 1.9 ) , admitted for
diffuse body aches and pains , most likely attributable to a
rheumatoid arthritis flare.
HOSPITAL COURSE:
1. Body aches and joint pains: The differential diagnosis for
the patient's body aches and joint pains initially included a
rheumatoid arthritis flare , septic joint , crystal joint disease ,
intra-abdominal process or Plaquenil reaction. Her abdominal CAT
scan showed stable peri-renal standing and mesenteric stranding.
Her creatinine kinase was normal. Her urine culture from the
second day of hospitalization was notable for MRSA. A left hip
aspiration was attempted by Interventional Radiology; no fluid
was obtainable , so a washing followed by drainage was performed ,
which had a negative Gram-stain and negative cultures.
Similarly , blood cultures were negative , and an echocardiogram
revealed no evidence of endocarditis as an explanation for her
MRSA urinary tract infection. By process of elimination ,
therefore , the etiology of her body aches and joint pains was
therefore thought to be rheumatoid arthritis flare , although of
note , her ESR and CRP were a bit higher than would be expected
for a rheumatoid arthritis flare. She was seen by the
Rheumatology Consult Service , who stated that the Plaquenil would
take a few weeks to exert its effect. As a result , she was
started on prednisone and uptitrated per symptoms. In addition ,
she was started on leflunomide. Initially , there were plans to
start Enbrel , and a PPD placed was negative; however , due to her
concomitant MRSA urinary tract infection , such plans have been
deferred to the outpatient setting.
2. MRSA urinary tract infection: As discussed above , her urine
culture day after admission was notable for MRSA , sensitive to
Bactrim. Due to hip pain and one mild fever to the range of
100.6-100.9 with persistent leukocytosis in the range of 11 to
15 , Interventional Radiology did a hip wash and aspirate that was
negative , as well as a transthoracic echo that was negative for
evidence of endocarditis. Surveillance blood cultures similarly
were negative. She was started on vancomycin , with plans to
change to Bactrim upon discharge.
3. Pain control: The patient was on standing and as needed
Dilaudid , along with OxyContin three times a day , the latter of which she
refused due to nausea. She was , therefore , started on a fentanyl
patch with standing and as needed Dilaudid. She did well on this
standing and as needed Dilaudid. As of discharge , she has done well
on this regimen.
4. Hypertension: The patient was hypertensive with systolic
blood pressures in the range of 170s at multiple times during her
hospitalization. This is partly from pain , and partly from poor
control of her central hypertension. She was maintained on
Toprol , Imdur , hydralazine and amlodipine , which were titrated
for a maximum effect. Because of refractory hypertension , we
recommend that she undergo renal artery imaging as an outpatient.
5. Diabetes: The patient was started on NPH , short-acting
prandial insulin and a sliding scale , all of which were up
titrated while she was inhouse.
6. Acute on chronic renal insufficiency: The patient had acute
on chronic renal insufficiency ( creatinine on admission 2.3 ,
baseline of 1.9 ). This was thought to be predominantly prerenal.
Through her hospitalization , her creatinine gradually decreased
to her baseline of 1.9.
MEDICATIONS ON DISCHARGE: A separate dictation for medication
list will be supplied when the patient is ready for discharge.
eScription document: 1-6921026 CSSten Tel
Dictated By: BLACKGOAT , GERMAINE
Attending: MOOSE , BUCK
Dictation ID 7400200
D: 7/28/07
T: 7/28/07
Document id: 616
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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110132746 | PUO | 12605164 | | 9497000 | 9/25/2007 12:00:00 a.m. | CONGESTIVE HEART FAILURE EXACERBATION | Unsigned | DIS | Admission Date: 10/22/2007 Report Status: Unsigned
Discharge Date: 7/21/2007
ATTENDING: SVENNINGSEN , CHRISTIAN VIVAN MD
CHIEF COMPLAINT: Status post fall.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman with
severe pulmonary hypertension secondary to chronic PEs , OSA ,
gout , bilateral hip replacements who presents with two falls in
the past two days. The day prior to admission , the patient fell
while he was standing at the sink. He has poor recall of events
but thinks he landed on his leg. On the day of admission , he
fell after getting out of the shower. He grabbed a chair , but
slipped and landed on his buttocks , then he fell backwards and
hit the back of his head. He denies any loss of consciousness.
EMS was called and brought him to the Emergency Department. He
did note a brief episode of chest pain after the fall. He says he is compliant
with his medication regimen and denies dietary indiscretion.
REVIEW OF SYSTEMS: Review of systems also notable for complaints
of more labored breathing , increased swelling , especially in the
left lower extremity as well as worsening orthopnea over the past
several days. He uses BiPAP at home at baseline.
PAST MEDICAL HISTORY: Significant for pulmonary hypertension ,
last catheterization was in September 2005 , which showed no
obstructive lesions , PASP of 104. He has OSA and is on BiPAP , he has
history of DVTs , history of lower extremity ulcers and cellulitis ,
hypertriglyceridemia , gout , hypertension , obesity. He is status
post bilateral hip replacement as well as knee
replacement.
ALLERGIES: He is allergic to Versed.
SOCIAL HISTORY: He lives in Lo A part of the year and owns a car
dealership. No tobacco.
PHYSICAL EXAMINATION ON ADMISSION: He was afebrile , heart rate
94 , blood pressure 126/60 , 92% on room air. Head atraumatic , no
nuchal rigidity. JVP was 10. Lungs were clear with distant
breath sounds. Cardiovascular exam: Tachycardic with a loud S2.
Extremities showed swelling over the right wrist without warmth.
Lower extremities had brawny skin changes bilaterally with
2+ edema in the legs to the mid shin. Neuro exam: cranial nerves
II-XII were grossly intact. He had 4/5 strength at the left hip flexor ,
5/5 otherwise in the lower extremities.
LABORATORY DATA ON ADMISSION: Included a hematocrit of 58.7
within the patient's baseline of 53 to 58 , creatinine of 1 , INR
4.4 , troponin 0.04. EKG showed normal sinus rhythm with left
atrial enlargement and right atrial enlargement. Head CT was
negative. Plain films of the pelvis were negative for fracture.
Hardware was in place. Right wrist showed no fracture , but did
show erosive changes suggestive of crystal deposition.
Chest x-ray showed no pulmonary edema. Additional studies
included a repeat head CT , which was again negative.
HOSPITAL COURSE BY PROBLEM: In summary , this is a 61-year-old
gentleman with a history of pulmonary history of hypertension and
chronic PEs on anticoagulation who presents after falls in the
setting of worsening lower extremity edema as well as orthopnea.
CARDIAC: ISCHEMIA: he was ruled out for MI. His last
catheterization was negative in September 2005. He was continued
on his beta-blocker and he was anticoagulated on Coumadin.
PUMP: The patient has severe pulmonary hypertension. The
NDH team followed this patient carefully. He was diuresed
with a daily goal of negative 500 to 1 L with intravenous Lasix once
or twice a day as needed. His home dose of Lasix is 160 mg orally He responded
very well to two doses of 160 mg intravenous twice per day , but this was titrated down
to 160 once a day given the goal of keeping the patient approximately 500 mL to
1 L negative per day to minimize fluid and electrolyte shifts. His weight on
admission was 440 pounds. At discharge ,
his weight was 429. His dry weight according to his primary
cardiologist's notes suggest a dry weight of 419 pounds. He was
otherwise maintained on his home regimen of Procardia ,
hydrochlorothiazide , Revatio , and Toprol. He will need to follow
up with Dr. Lamia , his cardiologist , on 3/10/07 .
2. Rhythm: The patient was in normal sinus rhythm. He did have
an episode of missed beats , likely Wenckebach on 7/20/07 as well
as some ectopy. These were thought secondary to fluid shifts.
His electrolytes were thus repleted aggressively and he was
monitored on telemetry.
3. Pulmonary: His baseline room air oxygen saturation was
90-93%. He should use oxygen as treatment for his pulmonary
hypertension. He should also be provided with oxygen at home
when he is discharged. Chest x-ray was clear. In addition , he
uses BiPAP at night and this should be continued while he is at
rehabilitation and after he is discharged.
4. Heme: The patient has a history of DVT with PEs. He is on
Coumadin with an INR goal of 2.5. Initially , he was
supertherapeutic on admission , but his regimen was restarted after holding 2
doses. Of note , on 7/21 , he did miss a dose of Coumadin inadvertently , but
he should be continued on his home regimen , which is 11 mg on
Monday , Wednesday and Friday and 12 mg the other days of the
week. In addition , because of the patient's asymmetric lower
extremity edema , LENIS were obtained and were negative. The
patient's elevated hematocrit was likely secondary to pulmonary
hypertension and hypoxia and was within his baseline.
5. Fluids , electrolytes and nutrition: The patient was
maintained on K and mag scales. He was also on a 2 L fluid
restriction. The patient refused a cardiac diet; however , he was
willing to accept a diet that was had no added salt.
6. Neurologic: The patient's neuro exam was completely
nonfocal. He had a repeat head CT , which was also negative.
This was on 4/20/07 .
7. Musculoskeletal: The patient was seen by Physical Therapy.
He was treated for his hip pain initially with oxycodone. This
was changed to Dilaudid for better pain control. He said that he
would like to be changed back to his home dose of oxycodone when
he is discharged , as he feels the Dilaudid is fairly strong.
X-rays were negative for any fracture.
8. Rheumatological: The patient has a history of gout. This
appeared to be exacerbated with diuresis. His gouty pain was
initially in his right wrist. He also describes pain in his
right knee. He is on his home doses of allopurinol and
colchicine. Indocin was added and at discharge , the patient had
received two days of Indocin. We would like him to receive a
total of three days of Indocin. Tylenol and narcotics as
previously described can be used to help with his gouty pain.
9. GI: The patient takes Nexium at home and he was continued on
Prilosec while an inpatient. He should be switched back to
Nexium when he is discharged from rehabilitation.
PHYSICAL EXAMINATION AT DISCHARGE: At discharge , the patient was
afebrile. His blood pressure was between 110-140 over 66-80 ,
heart rate is between 76 and 87. His room air saturation was 91%
on room air. He was breathing very comfortably and complained
only of right wrist pain. His lungs were clear. JVP is less
than 10. His cardiac exam was tachy with a regular rhythm and a
loud S2.
LABORATORY DATA ON DISCHARGE: Include a creatinine of 1 and
include a hematocrit of 53.1 and INR of 2.3. Potassium was 3.9
and magnesium was 2.0.
DISPOSITION: The patient is being discharged to rehab.
FOLLOWUP: He should follow up with his cardiologist , Dr.
Lamia . He also has an appointment scheduled with
Endocrinology in the near future.
DISCHARGE MEDICATIONS: Coumadin 11 mg Monday , Wednesday and
Friday and 12 mg nightly on Tuesdays , Thursdays , Saturday and
Sunday , Diovan 320 a day , multivitamin 1 tab daily , Toprol-XL 50
once a day , nifedipine extended release 30 once a day , Revatio 20
mg 3 times a day , hydrochlorothiazide 25 once a day , Lasix 160 intravenous
once per day , allopurinol 200 once per day , colchicine 0.6 once
per day , Colace , Prilosec 20 once a day , Dilaudid 2 mg every 4 hours
orally as needed pain , Tylenol 500-1000 mg orally every 6 hours as needed pain not
to exceed 4 gm total from all sources in a 24-hour period , Ambien
10 mg orally nightly as needed insomnia.
eScription document: 9-4025147 CSSten Tel
Dictated By: HENDY , CLARETHA
Attending: SVENNINGSEN , CHRISTIAN VIVAN
Dictation ID 6369989
D: 3/19/07
T: 3/19/07
Document id: 617
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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368229044 | PUO | 43763152 | | 7252740 | 3/18/2007 12:00:00 a.m. | Pneumonia | | DIS | Admission Date: 5/29/2007 Report Status:
Discharge Date: 7/26/2007
****** FINAL DISCHARGE ORDERS ******
POOYOUMA , ANIBAL 069-56-41-8
Wa Stonri Ra Cin
Service: MED
DISCHARGE PATIENT ON: 2/19/07 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. GLYBURIDE 5 MG orally twice a day
2. SIMVASTATIN 20 MG orally every day
3. ACETYLSALICYLIC ACID 81 MG orally every day
4. LISINOPRIL 10 MG orally every day
5. METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally every day
6. METFORMIN 500 MG orally twice a day
7. ALENDRONATE UNKNOWN orally QWEEK
8. ROSIGLITAZONE 4 MG orally every day
9. HYDROCHLOROTHIAZIDE 25 MG orally every day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ALBUTEROL INHALER 2 PUFF inhaled every 6 hours Starting Today February
Instructions: please instruct patient how to use with spacer
FOSAMAX ( ALENDRONATE ) 70 MG orally QWEEK
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
AZITHROMYCIN 250 MG orally DAILY Starting IN a.m. February
Food/Drug Interaction Instruction Avoid antacids
Take with food
Alert overridden: Override added on 2/22/07 by
DUSSAULT , LARAINE , M.D.
SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
Reason for override: aware
GLYBURIDE 5 MG orally twice a day
Alert overridden: Override added on 2/19/07 by :
on order for GLYBURIDE orally ( ref # 427265724 )
patient has a POSSIBLE allergy to FUROSEMIDE; reaction is Rash.
Reason for override: patient takes regularly
ROBITUSSIN ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours
as needed Other:Cough
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
Alert overridden: Override added on 2/22/07 by
ENTEL , BOK S.
on order for HYDROCHLOROTHIAZIDE orally ( ref # 579316224 )
patient has a POSSIBLE allergy to FUROSEMIDE; reaction is Rash.
Reason for override: Patient takes regularly
LISINOPRIL 40 MG orally DAILY
Override Notice: Override added on 2/22/07 by
ENTEL , BOK S.
on order for POTASSIUM CHLORIDE intravenous ( ref # 306805180 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 2/22/07 by ENTEL , BOK S.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
085455299 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override:
METFORMIN 500 MG orally twice a day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
AVANDIA ( ROSIGLITAZONE ) 4 MG orally DAILY
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 2/22/07 by
DUSSAULT , LARAINE , M.D.
on order for AZITHROMYCIN orally ( ref # 119959760 )
SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Your primary care physician Dr. Walth in 1 week ,
ALLERGY: FUROSEMIDE
ADMIT DIAGNOSIS:
Dyspnea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
aortic stenosis ( aortic stenosis ) diabetes ( diabetes mellitus type
2 ) sleep apnea ( sleep apnea ) pace maker
( pacemaker ) sick sinus rhtyhm ( sick sinus syndrome )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: cough , fever , shortness of breath
===================================================
HPI: 75 year-old F history of AS , DM , SSS history of PM , HTN , restrictive lung dz presenting
with productive cough , fever , and shortness of breath for the past three
days. patient was in USOH until 3 days PTA when patient developed dry cough. Over
the next two days cough worsened producing green sputum. patient also had a
fever of 101 F one day PTA along with wheezing , and increasing shortness
of breath. Denies any N/V/D , sore throat , sick contacts , or exposures.
No associated CP , palpitations , light headedness , headaches , photophobia ,
edema , orthopnea , sleep apnea , weight changes. She received a flu
vaccine this year. She made an appointment to see her primary care physician today , but
when her primary care physician heard her on the phone he told her to see him first thing
this morning. At the appointment she received an x-ray which was
negative for pneumonia and she was sent to the ED for further workup of
her worsening SOB.
Of note patient reported that she had 4 falls in the past 2 months , most
recently 1 month ago. And she had a negative workup by her primary care physician ,
pulmonologist , and cardiologist.
ED:
In ED patient was afebrile Temp 98.5 and tachypneic breathing at 28/min
sating 88% at room air and 97% on 4L NC. She was hemodynamically stable
HR 96 BP 130/70. Labs notable for a D dimmer of 540 and PE-CT was
performed which was negative for PE and pneumonia. She was given
ceftriaxone 1000 mg and azithromycin 500 mg , and duonebx3 with
improvement of SOB.
ROS:
Patient denies anorexia , weight changes , recent travel , change in
medications
===================================================
CARDS HX: Aortic stenosis , DM2 , SSS history of PM , HTN , hypercholesterolemia ,
elective cath performed on 4/9 showed minimal CAD and mildly elevated
aortic valve gradient
===================================================
OTHER PMH: Sleep apnea , restrictive lung disease secondary to paralysis
of right hemidiaphragm diagnosed 5 years ago.
===================================================
HOME MEDS: Glyburide 5 mg twice a day , Zocor 20 mg every day , ASA 81 mg every day ,
lisinopril 40 mg every day , Toprol XL 50 mg every day , Metformin 500 mg twice a day ,
Fosomax qweek , Avandia 4mg every day , hctz 25 mg every day
===================================================
ADMISSION EXAM:
VS: Temp: 98.5
Supine: HR: 96 BP: 136/70 ( Baseline 130's/70's per patient )
Standing: HR: 100 BP: 142/72
RR: 24 O2 Sat: 88% RA 97% 4L
Gen: Fatigued appearing , tachypneic , obese woman lying in bed , pleasant ,
A&Ox3 in NAD
HEENT: nl conjunctiva , anicteric , no sinus tenderness , PERRLA , EOMI , mmm ,
oropharynx clear
Neck: JVP 9 cm , trachea midline , neck supple , thyroid no palpable , no LAD
CV: nl S1 S2 , RRR , 2/6 high pitched crescendo decrescendo systolic murmur
loudest at upper left sternal border ( old ) , no rubs or gallops
Lung: decreased fremitus and dullness to percussion on the right to mid
lung , rhonchi heard throughout , no wheezing , no accessory muscle use ,
good air movement
Abd: +BS , soft , NT , ND
Ext: WWP , no CCE ,
Neuro: MSE nl , CNII-XII intact , able to ambulate , negative Romberg
===================================================
STUDIES:
Chest CT
1. No evidence of pulmonary embolus to the lobar level. Limited
assessment of smaller vessels. No evidence of or deep venous
thrombosis.
2. Mediastinal and mild upper abdominal lymphadenopathy may
warrant further evaluation or follow-up imaging.
3. Elevation of right hemidiaphragm with associated atelectasis
unchanged from prior studies.
===================================================
CONSULTS: None
===================================================
ASSESSMENT:
75 year-old F with history of AS , SSS history of PM , DM2 , restrictive lung disease presenting
with acute onset of cough , fever , and worsening shortness of breath over
the past three days.
patient has a long history of SOB and recently several episodes of falls
managed by her primary care physician , cardiologist , and pulmonologist. Workup has thus far
been negative for cardiac causes including new arrhythmias ,
malfunctioning pacemaker or worsening AS per echo done 8/18/07 at TH .
Elective cath done on 10/15/07 at PUO showed minimal CAD. The most
recent visit to her pulmonolgist two months ago revealed stable pulmonary
function. Recent CXRs done at TH suggest there may be a component of
pulmonary edema , her presentation at this admission not consistent with
worsening pulmonary edema from heart failure of valvular disease.
An atypical presenation for MI was also ruled out by enzymes.
Given her acute onset of cough with a fever , the most likely etiology is
infectious exacerbated by her poor pulmonary reserve.
=============================================
HOSPITAL COURSE:
--------------
1 ) PULMONARY: patient kept on ceftriaxone and azithromycin despite a negative
CXR and chest physical therapy because of concern for CAP in patient with poor pulmonary
reserve. Presentation most consistent with a viral etiology. Symptoms
responded well to duonebs and robitussin as needed On HD#2 , patient's
breathing markedly improved and was able to wean off of O2 able to sat
95% on room air. patient was able to ambulate on room air without dropping O2
saturation below 90%. Patient was d/c to home on azithromycin and
albuterol inhaler.
2 ) CV: Cariac enzymes were negative. Patient was kept on her home
regimen of ASA , toprol , lisinopril , hctz.
3 ) DM2: Oral meds were held on admission and patient switched to NPH +
prandial aspart.
4 ) FEN: low fat , low cholesterol diet , K/Mg scales. Tolerated orally's
5 ) Ppx: DVT prophylaxis with Lovenox 40 mg subcutaneously every day
===================================================
CODE STATUS: FULL
===================================================
ADDITIONAL COMMENTS: - We have added an antibiotic , Azithromycin 250 mg , that you should take
once a day for two days.
- Please take your home medications as you were doing.
- Please schedule an appointment with Dr. Walth in wone week.
- Please return if you experience increasing shortness of breath ,
pain with deep inspiration , swelling in your legs , chest pain , fever ,
chills , or with any other questions or concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- Please follow up on new mediastinal and abdominal lymphadenopathy on CT
scan
No dictated summary
ENTERED BY: DUSSAULT , LARAINE , M.D. ( YJ28 ) 2/19/07 @ 03:22 PM
****** END OF DISCHARGE ORDERS ******
Document id: 618
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
Y |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
129779394 | PUO | 33011684 | | 436209 | 10/26/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/6/1995 Report Status: Signed
Discharge Date: 9/13/1995
DISCHARGE DIAGNOSIS: 1. Unstable angina.
HISTORY OF PRESENT ILLNESS: Mr. Chauvette is a 59 year old gentleman
with a history of coronary artery
disease , status post PTCA in 1990 who present with recurrent
uncontrolled chest pain. He had a positive exercise tolerance test
in October of 1990 which led to a catheterization which showed 100
% proximal right coronary artery and 60 % OMB-2. He had successful
PTCA of his right coronary artery. His chest pain recurred in
February of 1990 and he had another positive stress test ,
catheterization showed restenosis at the PTCA site and a second
PTCA was performed successfully. He has done well with negative
stress test , most recently in 6/7 .
Over the last several weeks to months , he has noted increasing
chest pain with less and less exertion and now presents with on and
off chest pain over the last 18 hours prior to admission. He was
treated in the I Warho Hospital emergency room with beta
blockers and intravenous TNG which was limited by low blood pressure and
bradycardia. Because of ongoing chest pain with EKG changes , the
patient was taken directly to the cath lab and found to have a 70 %
left main , 80 % proximal LAD , 60 % OMB 2 , and minor irregularities
at the right coronary artery PTCA site.
Because of his continuing chest pain in the cath lab , an
intra-aortic balloon pump was placed and the patient was
transferred to the CCU. His past medical history is significant
for coronary artery disease , hypertension , depression. He has no
past surgical history.
MEDICATIONS: His medications on admission include Diltiazem ,
Naprosyn , aspirin , Prozac.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION: He is a white gentleman in moderate
distress. His heart rate is 54 , blood
pressure of 100/60 , jugular venous distention to 8 cm. with no
carotid bruits. Chest is clear to auscultation. The heart rate is
regular with a regular rhythm and no murmur. The abdomen is
benign. Neurologically , is grossly intact. His EKG on admission
shows sinus bradycardia with lateral ST and T wave abnormalities.
HOSPITAL COURSE: The patient was admitted to the hospital and
underwent emergent catheterization as above
requiring an intra-aortic balloon pump and was then taken for
urgent surgery. On 7/28/95 , he was taken to the operating room
where he underwent a coronary artery bypass grafting x 3 utilizing
the left internal mammary artery to the left anterior descending
coronary artery , and saphenous vein grafts to the obtuse marginal ,
ramus , under general endotracheal anesthesia and cardiopulmonary
bypass. This was performed by Dr. Marcott and there were no
complications and the patient tolerated the procedure well. He was
taken to the post surgical intensive care unit in stable condition.
He remained hemodynamically stable over the first postoperative
night and was extubated without any problem. His intra-aortic
balloon pump was weaned down as tolerated and removed at the bed
side. He was started on Lopressor and aspirin and continued on
Ancef perioperatively. He was given Lasix for diuresis and
responded well. He progressed well and had his chest tubes removed
and was ambulating and tolerating a regular diet well. By
postoperative day five , a moderate amount of tan drainage was
noticed at the lower portion of his sternal wound. The sternum was
only slightly unstable and the wires all appeared intact on chest
x-ray. He was started no Vancomycin. By postoperative day seven ,
he continued to be afebrile and hemodynamically stable , saturating
at 95 % on room air. His sternal wound remained clean and he was
discharged home to be followed up by VNA with dressing changes and
monitored closely.
DISCHARGE MEDICATIONS: Include enteric coated aspirin once a
day , Prozac twice a day , Lopressor 25 mg.
twice a day , Tylox one to two capsules every three to four hours as needed pain ,
Cipro 500 mg. twice a day for five days.
He will follow up with Dr. Marcott and with his local physician.
Dictated By: ERMA D. BESS , M.D. RR65
Attending: CARLTON J. ABSHEAR , M.D. DY0 HY755/1810
Batch: 6185 Index No. 9ZUQM97Y0B D: 2/22/95
T: 4/24/95
Document id: 619
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
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- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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729903734 | PUO | 03707858 | | 649556 | 6/7/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/7/1991 Report Status: Signed
Discharge Date: 8/25/1991
DISCHARGE DIAGNOSIS: ANEURYSM REPAIR.
AUTOMATIC IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR PATCH PLACEMENT.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old white
female , status post large anterior
myocardial infarction complicated by ventricular tachycardia ,
ventricular fibrillation arrest and aneurysm , admitted for surgical
repair and AICD ( automatic implantable cardioverter defibrillator )
placement. The patient's cardiac risk factors included
hypertension , increased cholesterol , adult-onset diabetes mellitus ,
positive family history , positive previous myocardial infarction.
Her cardiac course was notable for a large anterior myocardial
infarction on 2 of November . The patient received recombinant tissue
plasminogen activator and underwent emergent percutaneous
transluminal coronary angioplasty. A left ventriculogram showed
anterior septal dyskinesis and ejection fraction was approximately
20%. The patient had postoperative tamponade requiring
pericardiocentesis. On 2 of November , the patient suffered worsening
congestive heart failure , tachyarrhythmia and required emergent
cardioversion and subsequent medical therapy. She had recurrent
ventricular tachycardia treated with Lidocaine. In 17 of March ,
electrophysiologic studies were performed and the patient was
started on Amiodarone. The patient also underwent transplant
evaluation with cardiac catheterization showing occluded left
anterior descending coronary artery at S1 , right dominant system ,
marked left ventricular dilatation with anterior septal dilatation
and ejection fraction 18%. Right atrial pressures were 60/12/11 ,
right ventricular pressures 56/14 , pulmonary capillary wedge
pressure 34 , cardiac index 31. An echocardiogram showed left
atrium 4.9 centimeters , left ventricle with normal wall thickness ,
plus thrombus and mild pericardial effusion , anterior septal
akinesis , hypokinetic left ventricle , 1+ tricuspid regurgitation ,
2+ mitral regurgitation. The patient was admitted at this time for
aneurysm repair. PAST MEDICAL HISTORY revealed coronary artery
disease as above , hiatal hernia , adult-onset diabetes mellitus ,
hypertension , status post total abdominal hysterectomy and
bilateral salpingo-oophorectomy , status post appendectomy , status
post cholecystectomy. MEDICATIONS ON ADMISSION included Micronase
5 milligrams by mouth each day , Amiodarone 200 milligrams by mouth
each day , captopril 37.5 milligrams by mouth 3 times a day ,
Coumadin 2 milligrams by mouth each day. ALLERGIES were to
Halcion , which causes hallucinations. SOCIAL HISTORY revealed the
patient is married with 5 children , 7 grandchildren.
PHYSICAL EXAMINATION: On admission , the patient was a pleasant ,
middle-aged , white female in no acute
distress. The patient was afebrile , blood pressure 98/60 ,
temperature 98 , respiratory rate 24 , oxygen saturation on room air
was 92%. Skin was without lesions. Head , eyes , ears , nose and
throat examination was within normal limits. Neck was supple
without lymphadenopathy , carotids 2+ without bruits , no jugular
venous distention. Chest examination was significant for rales
about 1/3 of the way up from the bases. Cardiac examination
revealed S1 and S2 , positive S3 , II/VI systolic murmur was heard at
the left upper sternal border radiating to the apex. Abdomen was
soft , nontender , nondistended , no organomegaly. Extremities
revealed 2+ pitting edema. Neurologic examination was nonfocal.
Rectal examination revealed normal tone , guaiac negative stool.
LABORATORY EXAMINATION: Chest x-ray on admission revealed
cardiomegaly , left pleural effusion versus
scarring , mild pulmonary vascular redistribution. The
electrocardiogram showed normal sinus rhythm at 85 , left atrial
enlargement , low voltages , no change compared to old study of
previous admission. Other laboratory data on admission was
unremarkable.
HOSPITAL COURSE: The patient was admitted on 10 of March , to the
Surgery Service and the procedure was performed
on 29 of January . Please see the operation note for description of the
aneurysmectomy and AICD patch placement. The patient was managed
postoperatively on the Surgical Service without complications , and
transferred to the Medical Service 2 days prior to discharge. On
the Medical Service , treatment included removal of the patient's
chest tube , removal of her pacing wires , and captopril was
increased to a final dose of 37.5 milligrams.
DISPOSITION: The patient was discharged to home. MEDICATIONS ON
DISCHARGE included Coumadin 2 milligrams by mouth
each day , Bactrim-Double-Strength 1 by mouth twice a day times 6
days , Amiodarone 200 milligrams by mouth each day , Micronase 5
milligrams by mouth each day , captopril 37.5 milligrams by mouth 3
times a day. CONDITION ON DISCHARGE was stable. The patient was
to FOLLOW-UP with Dr. Sheryl Goldkamp in 4 weeks , and with Dr. Isabelle E. J Colasamte . The patient was to have her prothrombin time and partial
thromboplastin time checked at her local Coumadin Clinic.
ZC844/3152
CARLTON J. ABSHEAR , M.D. RM7 D: 5/26/92
Batch: 4915 Report: U6806Y12 T: 9/13/92
Dictated By: WENDI B. NEWAND , M.D.
Document id: 620
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
- |
381198717 | PUO | 10920045 | | 135518 | 3/24/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/10/1995 Report Status: Signed
Discharge Date: 10/16/1995
PRINCIPAL DIAGNOSIS: ATRIAL FLUTTER.
SECONDARY DIAGNOSIS: 1. HYPERTENSION.
2. LVH.
3. HYPERCHOLESTEROLEMIA.
4. ASTHMA.
5. BORDERLINE DIABETES MELLITUS.
6. OBESITY.
7. GASTRITIS.
8. ALLERGIC RHINITIS.
9. DEPRESSION.
10. OSTEOARTHRITIS.
11. RIGHT KNEE EFFUSION.
12. IMPOTENCE , STATUS POST IMPLANT.
HISTORY OF PRESENT ILLNESS: This is a 60 year old , black male
who initially presented for an injured
knee , which occurred three days ago at work. He was noted in
triage to have a blood pressure of 210/130 and was triaged to
urgent. The patient has had a long-standing history of
hypertension and he stopped his medications actually about two
months ago when he ran out of prescriptions. Following this the
patient began to note some difficulty with dyspnea on exertion and
has also noted some altered sensations in his chest during the week
prior to admission , which lasted approximately one to two seconds
and occurred primarily at rest. These occurred across his chest
but did not radiate. The patient stated his shortness of breath
has become progressively worse. He has had no orthopnea.
Basically , over the past three weeks the patient has noted ( 1 ) his
irregular heart beat , as if he is missing beats , although he does
not note any tachycardia , ( 2 ) dyspnea on exertion , including
orthopnea and paroxysmal nocturnal dyspnea , and ( 3 ) intermittent
substernal chest pain which occurs only at rest and not with
exertion. He described this as an ache and stated it did not
radiate. The episodes lasted , at the most , four to five minutes ,
and resolved on their own without any other symptoms. He denies
any syncope or presyncope. Four years ago , as mentioned , he
slipped at work , bending his right leg , and has subsequently had
increased swelling of his right knee , foot and calf , also with some
calf pain. Today was a holiday and he had off from work , so he
came to the Emergency Ward , primarily for evaluation of his knee
and his dyspnea. At that time they found that he was in atrial
flutter.
PAST MEDICAL HISTORY: His past medical history includes
hypertension , LVH , asthma , increased
cholesterol , borderline diabetes mellitus , obesity , gastritis ,
allergic rhinitis , depression , osteoarthritis , chronic right knee
effusion , and impotence , status post penile implant.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: His medications include Procardia XL
60 mg every day , Hydrochlorothiazide 25 mg every
day , Mevacor 40 mg every day , Ventolin and Beconase inhalers , Seldane
as needed , Zantac 150 mg twice a day , Elavil 25 mg bedtime , and Paxil 20 mg every
day. He has not taken these in the past two months.
SOCIAL HISTORY: He is married and lives with his wife. He is a
bulldozer operator. He does not smoke , drink or
use any drugs.
FAMILY HISTORY: His family history is negative for coronary artery
disease.
PHYSICAL EXAMINATION: His physical examination showed a black
male in no acute distress. His pressure at
the time of admission examination was 170/100. His heart rate was
in the 50 to 80 range. Respirations were 16. Temperature was
98.7. He was satting 98 percent on room air. Heent was benign.
Neck was supple without lymphadenopathy. The lungs had some
bibasilar crackles and slight wheezes on the left. The heart was
irregularly irregular with an S1 , S2 and S4. There were no
murmurs. The abdomen had normal bowel sounds and was soft , mildly
obese and non-tender. There was no hepatosplenomegaly. Rectal was
heme negative per Emergency Ward. Extremities showed 1+ right
edema and some trace , left sided , lower extremity edema. Right
knee was very swollen and he had right calf tenderness but no cord.
On neurological examination he was alert and oriented times three.
Examination was non-focal.
LABORATORY DATA: Labs showed a sodium of 142 , potassium 4.4 ,
chloride of 102 , bicarbonate of 26 , BUN 14 ,
creatinine 1.1 , and blood glucose was 122. Magnesium was 1.6. CK
was 385 and MB was 2.9. White cell count was 7.8 , hematocrit 43.7 ,
and platelets were 234 , 000. His physical therapy was 12.7 , PTT 24.4. Chest
x-ray showed increased cardiac silhouette , PVR , and there were no
infiltrates. The knee film showed a large effusion , which was
present in the past , and some osteoarthritis but no sign of
fracture. The patient had lower extremity non invasives which were
negative and a VQ scan which was read as between low and
intermediate probability.
ASSESSMENT: This is a 60 year old man with long-standing
hypertension , now off medications for two months. He
presented with new atrial fibrillation , mild congestive heart
failure and intermittent atypical chest pain. Given symptoms were
predated by a leg injury , his lower extremity non invasives were
negative and VQ scan was low to intermediate probability , the
possibility of pulmonary embolism was not further pursued. Likely
mechanism is poorly controlled hypertension and conduction system
disease causing atrial flutter and congestive heart failure. His
low rate is worrisome for intrinsic conduction disease and it was
considered that there was no need for anticoagulation for atrial
flutter.
HOSPITAL COURSE: As noted , the patient had lower extremity non
invasives and VQ scans which were essentially
negative and he was not treated for pulmonary embolism , as it was
considered to be ruled out. He had an echocardiogram during his
admission which showed 50 percent ejection fraction with inferior
hypokinesis and left atrial size of 4 cm. The patient remained in
atrial flutter during his admission and was coumadinized for the
concern he may be slipping from atrial flutter to atrial
fibrillation occasionally. He was also started on Digoxin. The
patient remained stable and did well. He ruled out for myocardial
infarction. He was then discharged for follow up with Dr.
Rothery for his general medical concerns and will have an
appointment with Dr. Overstrom for cardioversion and an exercise
tolerance test. The patient's Dig levels and physical therapy will be checked as
an outpatient by the VNA services and these will also be called to
Dr. Rothery . The patient's admission was without complication.
MEDICATIONS ON DISCHARGE: The patient's discharge medications
and dosing were Ventolin two puffs
four times a day as needed shortness of breath , Ecasa 325 mg orally every day , Digoxin
0.25 mg orally every day , Prozac 20 mg orally every day , Lisinopril 30 mg orally
every day , Mevacor 20 mg orally every bedtime , naproxen 325 mg orally twice a day
as needed pain , Procardia XL 90 mg orally every day , Azmacort six puffs
twice a day , Axid 150 mg orally twice a day , Serevent two puffs inhaler twice a day ,
Coumadin 5 mg orally every bedtime
DISPOSITION: CONDITION ON DISCHARGE: The patient's condition on
discharge was stable. Disposition was to home with
services. DISABILITY: Estimated disability was mild.
Dictated By: CAITLIN L. RADEMAN , M.D. XF50
Attending: QUEEN LINSEY ROTHERY , M.D. YD77 UY619/1596
Batch: 44937 Index No. N7SHO2688Y D: 10/22/95
T: 10/8/95
CC: 1. QUEEN ROTHERY , M.D. NY84
LAQUITA TAMIKO OVERSTROM , M.D. NF54
Document id: 621
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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348349961 | PUO | 20253314 | | 257943 | 6/15/1998 12:00:00 a.m. | DEHYDRATION | Signed | DIS | Admission Date: 2/10/1998 Report Status: Signed
Discharge Date: 10/21/1998
FINAL DIAGNOSIS: ( 1 ) CORONARY ARTERY DISEASE
( 2 ) HYPERTENSION
( 3 ) OBESITY
( 4 ) DIABETES , INSULIN REQUIRING
( 5 ) DEPRESSION
( 6 ) GOUT
( 7 ) CHRONIC HEARING LOSS
( 8 ) HISTORY OF CHOLECYSTECTOMY AND APPENDECTOMY
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old woman
with insulin requiring diabetes
mellitus , hypertension , and known coronary artery disease who
presented on the day of admission after having a fall at home. She
was noted in the emergency room to have new ECG changes. The
patient was recently catheterized in October of 1998 at which time
she was found to have a 100% left anterior descending artery
lesion , a 100% right coronary artery lesion , and a 40% obtuse
marginal 1 lesion. Her left anterior descending artery and right
coronary artery territories were being served by collaterals and
the decision was made to manage her medically on enteric coated
aspirin , Atenolol 50 mg every day , Lisinopril 30 mg every day , and Pravacid
at 20 mg every day Her Bumex dose was recently increased from 1 to 2
every day on 1/12/98 . She was recently admitted from 11/7/98 to 8/10/98
for increasing shortness of breath and some chest pain and had
catheterization with results as described above. She was
discharged to home on an increase in her medical regimen. Her last
echocardiogram was done in February of 1997 and this showed a
moderately dilated left ventricle with septal akinesis , inferior
hypokinesis , and an ejection fraction of 35%. Her right
ventricular size and function were normal. There was mild left
atrial enlargement , mild mitral regurgitation , mild tricuspid
regurgitation , and trivial aortic insufficiency. Since discharge
she has been followed in Kernan To Dautedi University Of Of by Dr.
Mccullen , as well as by Dr. Abshear of cardiology. Her Bumex dose as
described above was increased on 1/12/98 because of fluid overload.
Of note , she has had very poor glycemic control over the two months
prior to admission with blood sugars in the 300 to 400 range. Her
last A1C was 12.3 on 1/12/98 . It had been 6.0 on 9/20/97 . On the
day of admission after standing up to get her insulin , she felt
lightheaded and fell backwards , landing on her coccyx into a chair
but the chair fell backwards and so she fell backwards as well.
She reported that for two or three days prior to admission she had
been having some lightheadedness. She denied any visual changes or
weakness , loss of consciousness or head injury. She denied any
seizure or seizure history or loss of urine. She was unable to get
up and called for help and an ambulance brought her to the
emergency room department.
REVIEW OF SYSTEMS: She reported occasional diarrhea and
constipation. She had no fever or chills. No
cough. No urinary symptoms. She also denied any dietary
indiscretion or non-compliance with her insulin. She reports that
she has chest pain approximately two times per week but denied
having any chest pain on the day of admission.
MEDICATIONS: Enteric coated aspirin 325 mg every day , Atenolol 50 mg
every day , Isordil 20 mg three times a day , Lisinopril 30 mg every day ,
Bumex 2 mg every day since 1/12/98 , Pravastatin 20 mg every day , Omeprazole
20 mg every day , insulin NPH 75 every day before noon and 35 every afternoon , regular 25 every day before noon
and 15 every afternoon , Trazadone 100 mg every bedtime as needed , Allegra 60 mg twice a day ,
Proventil 2 twice a day
PAST MEDICAL HISTORY: Coronary artery disease as noted above.
Hypertension. Obesity. Insulin-dependent
diabetes mellitus. Depression. Gout. Chronic hearing loss
requiring hearing aids bilaterally. History of cholecystectomy
and appendectomy in past.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: The patient lives alone and has a visiting nurse.
She use to work in housekeeping at the
Kendsonre Ale Ater Hospital . She has a remote history of
smoking but does not drink any alcohol.
PHYSICAL EXAMINATION: She is an obese woman in no acute distress.
Temperature 98.3 degrees , pulse 95 , blood
pressure 109/63. Her room air saturation was 95%. She was not
orthostatic. HEENT: Unremarkable. Jugular venous distension
difficult to assess because of her habitus. Heart: Regular rate
and rhythm. S1 and S2 distant. No murmurs , rubs , or gallops.
Lungs clear with exception of question of some rales at bases.
This was also difficult to assess due to poor inspiratory effort.
Abdomen: Benign. Extremities: 1+ edema at feet only.
Neurologic: Nonfocal. The patient was an appropriate historian
but had difficulty hearing some of the questions.
LABORATORY DATA: Normal set of electrolytes with BUN 58 ,
creatinine 2.4. Blood sugar 435. Anion gap 16.
Arterial blood gas on room air: pH 7.4 , pCO2 40 , pO2 69 , oxygen
saturation 94%. The first CK done in the emergency room department
was 194. An ACE test was positive but beta hydroxybutyrate was
negative with triponin of 0. WBC 7 , hematocrit 37 , platelet count
167. Coagulase was within normal limits. Urinalysis was
remarkable for 3+ glucose with no ketones , 1+ esterace , negative
nitrite , 20 to 25 white blood cells , 2 to 3 red blood cells , 2+
bacteria , and 1+ yeast. Urine culture was sent and came back
negative. ECG was normal sinus rhythm at rate of 92 with intervals
of 0.15 , 0.1 , and 0.324 , an axis of 32 , and left atrial
enlargement. There were new T-wave inversions in leads 1 and L
with biphasic T-waves in V4 through V6 compared with her ECG of
4/13/97 .
ASSESSMENT: In short , this is a 65 year old woman with known two
vessel coronary artery disease , hypertension , and
insulin-dependent diabetes mellitus under poor glycemic control
recently , now presenting with hyperglycemia , dehydration , and new
ECG changes suggestive of lateral ischemia. She was admitted for
rule out of myocardial infarction and monitoring.
HOSPITAL COURSE: Cardiovascular: The patient was admitted and
placed on a cardiac monitor. She ruled out for
myocardial infarction by enzymes and her ECG continued to show new
lateral T-wave changes. There was no evolution or change in these
throughout the course of the admission. On 10/22/98 the patient
underwent a Dobutamine MIBI study after discussion with her primary
care physician and cardiologist , Dr. Abshear , who felt that this
would be a helpful study , given her difficult history and known
underlying coronary artery disease. The results of the Dobutamine
study were that she had no ECG changes and the MIBI images showed
lateral and inferior infarcts but no active ischemia.
Over the course of the first couple of days of the admission , the
patient's blood pressure was noted to be lower than her usual
baseline. Her diuretics were held with the thought that her
elevated creatinine , lightheadedness , and general malaise were
probably due to dehydration , given that her Bumex dose had recently
been increased. She was gently hydrated with a total of about 3
liters and her blood pressure increased somewhat. A follow-up
chest x-ray was done which did not show any evidence of congestive
heart failure. The patient had no other active cardiac issues
during this admission.
Renal: At the time of the admission the patient's creatinine was
2.5. It subsequently bumped to a maximum of 2.9 in the setting of
her dehydration. Her blood pressure medications were held and she
was gently rehydrated. With this treatment , her creatinine
returned to its baseline of approximately 1.5 to 1.6. At the time
of admission there was some question as to whether she might have a
urinary tract infection given her urinalysis; however , a urine
culture came back negative. The white blood cells in her urine on
admission were not present on a subsequent specimen which was
obtained by straight catheterization and the thought was that the
initial pyuria was probably related to vaginal candidiasis.
Pulmonary: Over the course of the first three or four days of
admission , the patient developed a somewhat increasing oxygen
requirement for unclear reasons. Her need for oxygen waxed and
waned but , because of her habitus and her general complaints of
dyspnea over the last several months , there was some concern that
she may be having chronic pulmonary embolus. For this reason she
was taken to VQ scan on 1/18/98 . This study was read as low
probability. She was transiently anticoagulated while awaiting the
results of the scan but the heparin was subsequently discontinued.
The reasons for her increase in oxygen requirement during the
course of this admission remained somewhat unclear. It is possible
that she has sleep apnea given her body habitus and this would
warrant follow-up as an outpatient. Her oxygen saturation at the
time of discharge is approximately 92% on room air.
Endocrine: At the time of admission the patient had blood sugars
in the range of 400 to 500. Her insulin doses were increased in
order to obtain better glycemic control. The reason for her sudden
increase in insulin needs remains elusive.
Orthopedics: At the time of the admission the patient had a set of
lumbosacral spine films done in order to rule out injuries related
to her fall. The films were read as showing a potential subtle
fracture of the coccyx. The patient had a significant amount of
pain in this area over the course of admission and it was thought
likely that she did , indeed , have a fracture. She has been working
with physical therapy in order to increase her mobility.
Gastrointestinal: The patient had been complaining over this
admission of some burning in her esophagus , as well as some
epigastric tenderness. It seems from review of her records that
this has been a chronic problem. She was started on Cisapride for
presumptive element of diabetic gastroparesis , in addition to being
maintained on her Prilosec. Of note , she had recently undergone
endoscopy and been diagnosed with a question of Helicobacter pylori
infection which has now been treated. However , her symptoms
continue. In addition , she had recently had a barium study in April
of 1996 that showed no abnormalities. It was decided that this
study did not warrant repeating at this point.
Neurologic: On several occasions during this admission the patient
became acutely confused. At these times she was not noted to have
a focal neurological examination. These instances appeared
questionably related to dosing of her Compazine and also all seemed
to occur in the evening. It was thought that she was probably
sundowning and , during her clearer moments , she reported having
similar problems at home.
Infectious disease: The patient began having some low grade fevers
on approximately hospital day #4. Blood and urine cultures at that
time were negative. Because of the low grade fevers and her
decreased oxygen saturation intermittently , chest x-ray and VQ scan
were done. The VQ scan was read as low probability. The chest
x-ray was read as having some atelectasis in the left lower lobe.
There was a question of whether this was atelectasis versus an
infiltrate. However , since the patient remained with a normal WBC
and no purulent sputum , it was thought unlikely that she had
pneumonia. She also reported having some congestion and it was
thought that she might be having low grade fevers from a upper
respiratory infection.
DISPOSITION: DISCHARGE MEDICATIONS: Albuterol inhaler 2 puffs
four times a day , Enteric coated aspirin 325 mg every day , Atenolol
25 mg every day , Colace 100 mg twice a day , NPH insulin 95 every day before noon and 45
every afternoon , sliding scale insulin every before meals and every bedtime , regular insulin 30
every day before noon and 20 every afternoon , Atrovent inhaler 2 puffs four times a day , Isordil 10
mg three times a day- hold for systolic blood pressure less than 100 ,
Lisinopril 30 mg orally every day- hold for systolic blood pressure less
than 100 , Prilosec 20 mg every day , Cisapride 10 mg four times a day , Pravastatin
20 mg every bedtime , Allegra 60 mg twice a day The patient is discharged to
rehabilitation because of her difficulty with walking. FOLLOWUP:
She will follow-up in clinic with her cardiologist , Dr. Abshear , and
with her primary care physician , Dr. Hisako Mciver .
Dictated By: KATIA POPPELL , M.D. MA60
Attending: GENNY BARRETTE , M.D. DB07 MR006/8163
Batch: 6397 Index No. AKKUBM13TK D: 8/10/98
T: 8/10/98
Document id: 622
| Target |
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853811314 | PUO | 34637505 | | 0327687 | 1/22/2007 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 10/18/2007 Report Status: Signed
Discharge Date: 11/3/2007
ATTENDING: THEILING , BREE MD
DISCHARGE DIAGNOSIS: CAD status post cardiac catheterization.
HISTORY OF PRESENT ILLNESS: A 68-year-old male with history of
CAD status post three-vessel CABG , hypertension , peripheral
vascular disease , COPD who had an episode of chest pain one week
prior to admission , presenting with left arm tingling that
resolved after 1 sublingual nitro. Later , on 10/18/2007 , his
blood pressure was noted to be in systolic blood pressure range
of 220s , was asymptomatic. Called his primary care physician and was told to go to
the hospital. Since 10/18/2007 was in the ED observation
section , had completed a rule out MI , which was negative for MI ,
and had undergone a stress MIBI on 7/1/2007 which showed
reversible area of septal ischemia. The patient was admitted for
further workup.
PAST MEDICAL HISTORY: COPD , hep C with a negative viral load
after interferon and RBV treatment , hyperlipidemia , renal artery
stenosis status post renal stenting , functional quadriplegic due
to motor vehicle accident in the past , TIA in 1975 status post
left carotid endarterectomy , left common iliac artery angioplasty
in 1994 , CABG 3-vessel 11/26 .
MEDICATIONS AT HOME: Toprol-XL 12.5 daily , Lipitor , Atrovent ,
aspirin 81 mg daily , Prevacid , thiamine , multivitamin , Valium ,
Neurontin.
ALLERGIES: Baclofen and Bactrim.
PHYSICAL EXAMINATION: Afebrile , vital signs were stable , in no
apparent distress , no JVD. Lungs were clear. Regular rate and
rhythm , no murmurs , rubs or gallops. Soft , nontender , and
nondistended. No lower extremity edema , chest x-ray was
unremarkable.
HOSPITAL COURSE: A 68-year-old male with history of CAD status
post three-vessel CABG , hypertension , peripheral vascular
disease , admitted for workup of chest pain , ruled out for MI. An
exercise stress test that showed evidence of reversible ischemia.
The patient was admitted for further workup and cardiac
catheterization.
1. CAD. The patient underwent cardiac catheterization which
revealed three-vessel CAD with patent grafts to the right
circumflex and LAD. Proximal LAD to diagonals were not bypassed.
The decision was made by the clinical team and the referring
physician for further medical management controlling blood
pressure and return for repeat cardiac catheterization PCI of the
protected left main , approximately the two diagonals if symptoms
recur. The patient was continued on aspirin , statin ,
beta-blocker and lisinopril was started. The patient had no
evidence of heart failure. He had an echo in September of 2006 which
showed preserved ejection fraction. The patient had been
admitted on hydrocortisone which had been started secondary to
anomic dysfunction. Given that the patient presented with severe
hypertension the fludrocortisone was discontinued. His blood
pressure was titrated by adding lisinopril to his regimen.
During his hospitalization , the patient was monitored on tele and
no events were noted.
2. GI. The patient was continued on his Prevacid for GERD.
3. Neuro. The patient was continued on Neurontin for
neuropathic pain.
4. Psych. The patient had several episodes of confusion during
the evening slightly thought to be due to sundowning that
worsened after he got Ambien for insomnia. Per the family , the
patient has had several episodes of confusion and paranoia during
prior hospitalizations. During these episodes the patient was
alert and oriented x3 but exhibited paranoid behavior. Chest
x-ray and urinalysis were sent to rule out infectious process
actually to explain his confusion and these were unremarkable.
The patient was treated with Seroquel 25 mg nightly as needed in the
short-term for sundowning which he responded well to.
5. Pulmonary. History of COPD , was stable during this
hospitalization and continued on his home regimen.
6. Renal. The patient was pretreated with Mucomyst and
bicarbonate pre and post cardiac catheterization.
7. FEN. The patient was maintained on a cardiac diet and
electrolytes were repeated as needed. The patient's code status
is full code during this hospitalization.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily , Colace 100 mg orally
twice a day , Neurontin 300 mg orally three times a day , Atrovent inhaler 2 puffs
four times a day , Prevacid 30 mg daily , lisinopril 5 mg daily , Toprol-XL 25
mg daily , MiraLax 17 grams orally daily as needed constipation ,
Seroquel 25 mg orally bedtime as needed for agitation , Zocor 20 mg
daily , and thiamine 100 mg daily.
PRIMARY CARE PHYSICIAN:
1. Follow up blood pressure and titrate medications as needed.
2. Optimize medical management of CAD , diagnostic results showed
3-vessel CAD , with patent grafts , proximal LAD and two diagonals
are not bypassed. Decision is for medical management. If the
patient continues to experience symptoms , further consideration
for a repeat cardiac catheterization and PCI if necessary.
3. The patient was complaining of chronic blurry vision which he
had prior to this hospitalization; we recommend further follow up
with ophthalmology as an outpatient.
DISCHARGE LABORATORY DATA: BUN 31 , creatinine 1.1 , sodium 139 ,
potassium 4.4 , chloride 102 , bicarbonate 25. LFTs within normal
limits. Calcium 9.7 , magnesium 1.9. White blood cell count 6 ,
hematocrit 39.3 , platelets 212 , normal differential. INR 1.1.
eScription document: 6-4760487 IFFocus
Dictated By: GETTINGS , OTELIA
Attending: THEILING , BREE
Dictation ID 4523425
D: 2/19/07
T: 2/19/07
Document id: 623
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
U |
Y |
U |
Y |
U |
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Y |
U |
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U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
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076954946 | PUO | 61732093 | | 815438 | 2/30/1999 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 2/30/1999 Report Status: Signed
Discharge Date: 5/18/1999
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old male with
known coronary artery disease status
post myocardial infarction who presented with new onset of dyspnea
on exertion. The cardiac catheterization revealed three vessel
disease and the patient presented for coronary artery bypass
grafting.
PAST MEDICAL HISTORY: Significant for hypertension , diabetes
mellitus , gastroesophageal reflux disease ,
peripheral vascular disease , and peripheral neuropathy. No
strictures and no bleeding.
MEDICATIONS ON ADMISSION: Lasix 40 mg twice a day , Norvasc 10 mg every
day , Imdur 30 mg every day , Aldactone 25 mg
every day , Atenolol 75 mg every day , ranitidine 150 mg twice a day , Zocor 40 mg
every day , insulin 26 units of NPH in the morning , 14 of regular
insulin in the morning , 26 of NPH in the evening and 14 of regular
in the evening.
TESTS/STUDIES: Cardiac catheterization showed left anterior
descending coronary artery with 100 percent
stenosis , left circumflex at the origin with 50 percent stenosis ,
obtuse marginal 100 percent , obtuse marginal two 90 percent , obtuse
marginal three diffuse disease , right coronary artery proximal
30-40 percent , mid 90 percent , ramus 100 percent. Ejection fraction
on echocardiogram was 35 percent , severe apical hypokinesis and
lateral hypokinesis , inferior diskinesis , trace mitral
regurgitation , mild tricuspid regurgitation. Electrocardiogram
showed normal sinus rhythm with anterior infarct. BUN and
creatinine was 1.9 and 1.6.
PHYSICAL EXAM: The patient was awake , alert and oriented times
three. Good orally hygiene. No carotid bruits.
HEART: Regular rate and rhythm. No murmurs , rubs or gallops.
CHEST: Clear to auscultation to the bases. ABDOMEN: Soft ,
nontender and nondistended , normal active bowel sounds.
Dopplerable dorsalis pedis pulses.
HOSPITAL COURSE: The patient was informed consented of all the
risks and benefits of the procedure and the
patient was adequate prepared preoperative before the actual
surgery. For more details of the actual surgery please refer to
Dr. Marcott ' operative note on 5/15/99 . Immediately postoperatively
the patient was taken to the cardiac surgery intensive care unit
where he was admitted without difficulty. The patient woke up
appropriately and was extubated. The patient had cardiac index of
2.3 , was kept on Neoral and epinephrine for pressor support. The
patient was advancing his diet as tolerated after extubation and
was making adequate urine output. The patient was tolerating wean
from epinephrine on postoperative day number one. The patient
received consultation from the electrophysiology service , as it
appeared that the patient had a transient block at the level of the
AV-node. The patient continued to be followed in the cardiac
surgery intensive care unit and an echocardiogram was done that
showed a 30 percent ejection fraction and global hypokinesis. The
patient had a nonfocal neurological exam. The patient was weaning
down on dopamine and Neoral however still continued to need this
drip. The patient also had a Lasix drip of 10 per hour. The
patient was breathing well on the face mask. The patient was kept
NPO at this time as he was not able to tolerate orally intake without
nausea. The patient continued to have an elevated creatinine of
1.7 , down from 1.9 earlier and a hematocrit of 32.8 with no signs
of bleeding. The patient continue to have Ancef for chest tube
coverage.
The patient was again seen by the electrophysiology service for
possible change in his rhythm. The rhythm was Wenckebach and the
patient was evaluated for a possible pacemaker. On postoperative
day number three the patient was hemodynamically stable weaning of
of Neoral but still on Dopamine and still requiring a Lasix drip at
10 per hour. The patient was still in Wenckebach and the patient
continued to breathe well however remained at 70%. The patient
remained NPO as his respiratory needs took precidence over his
eating and the risk of aspiration was high. The patient continued
to make good urine output however was dependent on the Lasix.
Chest tubes were discontinued on this day. The patient was
re-evaluated by the electrophysiology service again. On
postoperative day number four the patient received a pacemaker and
Lasix was discontinued on postoperative day number four. The
pacemaker was placed by Dr. Dominguez . For more details of this
surgery please refer to his operative note. A Medtronic lead was
placed.
On postoperative day number five the patient continued to do
extremely well. The patient was AV-paced on the pacemaker at a
rate of 80 with a good blood pressure of 155/70. He weaned down
off of all of his drips and pressure support. The patient was able
to come down to four liters and was able to advance on his diet.
The patient made good urine output with only orally Lasix and the
Lasix drip was discontinued. The patient was continued on Kefzol
for perioperative AICD placement and transfer to the floor. On
postoperative day six and seven the patient continued to do
extremely well with no change in his management. The patient
continued on his Lasix , Lopressor and aspirin and Keflex. An
echocardiogram was done that showed an ejection fraction of 30-40
percent. There was no change in his management. The patient
continued to do well advancing in all areas. No instability of his
heart. He advanced to a full house diet making good urine output
with minimal use of Lasix. The patient was therefore discharged
without complications and with placement of the pacemaker on
2/8/99 .
MEDICATIONS ON ADMISSION: Aspirin 81 mg orally every day , Colace 100 mg
orally three times a day , Lasix 20 mg orally twice a day ,
NPH Humulin insulin 20 units subcutaneously every day before noon , insulin 10
units regular at night , 7 units of regular twice a day , Niferex 150
mg orally twice a day , Percocet 1-2 tablets orally every 4 hours as needed pain , Zantac
150 mg orally twice a day , Coumadin to check with the Coumadin clinic
for strict follow up , potassium slow release 10 mEq orally every day and
Zocor 40 mg every night.
DISCHARGE INSTRUCTIONS: The patient will be discharged to home
with home services to follow up strictly
on his Coumadin dosing. The patient is also to follow up with Dr.
Desirae Marcott in 2-4 weeks and cardiology in one week in the Coumadin
clinic on the next day.
Dictated By: CANDY RILLER , M.D. SR62
Attending: DESIRAE R. MARCOTT , M.D. PW1 HS266/9112
Batch: 73695 Index No. M2ID0F49RP D: 4/14/99
T: 6/26/99
Document id: 624
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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921680499 | PUO | 79951974 | | 439148 | 11/10/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/7/1994 Report Status: Signed
Discharge Date: 10/11/1994
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE. PROBLEM LIST
INCLUDES:
1 ) HYPERTENSION.
2 ) ASTHMA.
3 ) DEGENERATIVE JOINT DISEASE.
HISTORY OF PRESENT ILLNESS: This is a 73 year old gentleman with a
past medical history of hypertension
who presented to Dr. Cassetty at the Osri Medical Center on
9/1/94 after a couple of episodes of heavy diaphoresis and
nausea , an identifiable precipitant. His EKG there revealed new T
wave inversions in the inferior leads and he was admitted to the
Osri Medical Center where he ruled out for myocardial infarction.
While at Merla Medical Center , his EKG alternated between left anterior
hemi-block and left posterior hemi-block. In addition , he had
further episodes of nausea and diaphoresis. Because of his
baseline conduction system disease , an exercise tolerance test
could not be performed and the patient was sent for an exercise
tolerance test thallium. However , prior to the test , the patient
became diaphoretic and nauseous with a non-palpable blood pressure.
He was treated with an intravenous fluid bolus with subsequent
improvement. Because he was felt too unstable to undergo a nuclear
imaging , he was transferred to the Pagham University Of to
undergo cardiac catheterization. The patient denied any paroxysmal
nocturnal dyspnea , orthopnea , or peripheral edema. He also denied
any recent change in exercise tolerance. PAST MEDICAL HISTORY:
Significant for a history of rectal fissure , a small bowel
obstruction , microhematuria of uncertain etiology despite an
extensive work-up , diverticulosis , and hemorrhoids. He also has a
history of degenerative joint disease and a history of mild asthma.
His coronary risk factors include hypertension , obesity , gender ,
and age. ALLERGIES: None. CURRENT MEDICATIONS: Calan SR 240
orally every day , Beconase two puffs twice a day , Brethaire two puffs four times a day ,
Azmacort four puffs twice a day , Feldene 20 mg orally every day , and Aspirin
one orally every day
PHYSICAL EXAMINATION: This was a well-developed pleasant male in
no apparent distress with a blood pressure
of 154/82 , heart rate 74 , and respirations 14. HEENT:
Normocephalic , atraumatic , pupils equally round and reactive to
light and accommodation , extraocular movements intact , and
oropharynx was benign. NECK: Supple with no jugular venous
distention and he had a left carotid bruit , however , his carotid
upstrokes were normal. LUNGS: Clear to auscultation bilaterally.
CARDIAC: Examination revealed a very quiet precordium with a
regular rate and rhythm without any murmurs , gallops , or rubs.
EXTREMITIES: Revealed femoral pulses 2+ without bruits , dorsalis
pedis and posterior tibial pulses 1+ bilaterally , and he had no
clubbing , cyanosis , or edema.
LABORATORY EXAMINATION: Significant for a sodium of 140 , a
potassium of 4.4 , BUN of 28 , creatinine
1.7 , glucose of 110 , white count was 6.4 , hematocrit was 47.6 ,
platelets were 137 , 000 , his physical therapy was 13.6 , and his PTT was 47.3. His
chest X-Ray at Osri Medical Center revealed an enlarged heart with
no pulmonary infiltrates , his EKG from 3/6/94 at the Osri Medical Center revealed sinus bradycardia at 56 , left posterior
hemi-block with non-specific intraventricular conduction delay , and
poor R wave progression across his precordium. He had deep T wave
inversion in III and F , this EKG was also notable for a pattern of
alternating conduction delay with alternating pattern of left
anterior and left posterior hemi-block.
HOSPITAL COURSE: The patient underwent a cardiac catheterization
on 10/16/94 which revealed hemodynamics of a
right atrial mean of 6 , a right ventricular pressure of 28/6 , a
pulmonary capillary mean pressure of 14 , he had a totally occluded
mid left anterior descending lesion , a tight second diagonal
lesion , a totally occluded OM1 lesion , and a 70% distal right
coronary artery lesion. His left ventriculogram revealed
anteroapical hypokinesis. On further analysis of the patient's
EKG , it was felt that he alternated between left anterior
hemi-block and left posterior hemi-block. It was felt that his
symptoms may be an indication of more advanced conduction system
disease that would possibly justify a pacer. At this point , the
decision was to monitor the patient with Holter monitoring and to
perform a stress MIBI examination to assess if he degenerated to
more severe conduction disease. Holter monitoring on 1/6
revealed sinus rhythm between 40 and 85 , he had 14 hours of
occasional atrial premature beats , two hours of occasional
ventricular premature beats , each lasting less than a minute , as
well as intermittent intraventricular conduction delay. He had no
symptoms during the 24 hours of Holter monitoring. He exercise
tolerance test MIBI examination revealed a modified Bruce protocol
on which he went twelve minutes stopping secondary to leg fatigue ,
he had no chest pain , his maximum heart rate was 112 , his maximum
blood pressure was 195/95 , he had no change in his baseline EKG as
well as no ST changes , and no arrhythmias. His MIBI evaluation
revealed a fixed inferior defect extending to the posterior septum.
Given the above information , particularly the fact that the patient
did not degenerate to more severe conduction system disease with
exercise , it was felt that a pacer would not be necessary at this
time. Moreover , the patient had no provokeable ischemia by MIBI
evaluation and it was felt that revascularization was unnecessary.
The decision then was to send the patient home on an adequate
medical regimen which was achieved during his hospital course via
the addition of Captopril to his medical regimen to provide him
with adequate blood pressure control. It is noteworthy that the
patient had no episodes of nausea or diaphoresis during his
hospitalization , that is ambulating without assistance with no
symptoms whatsoever. He is therefore felt to be stable for
discharge and is being discharged to home.
OPERATIONS AND PROCEDURES: Cardiac catheterization on 10/16/94
with complications none.
DISPOSITION: DISCHARGE MEDICATIONS: Captopril 25 mg orally three times a day ,
Verapamil SR 180 mg orally twice a day , Ocean Spray two
puffs inhaler twice a day , Ecotrin 325 mg orally every day , Beconase two puffs
inhaler four times a day , Ventolin two puffs inhaler four times a day , and Azmacort
four puffs inhaler twice a day CONDITION ON DISCHARGE: Stable. The
patient is being discharged to home for follow-up with Dr. Regena M Cassetty on O Chatogrand A in Otte in one week's time.
Dictated By: FLORETTA THRONEBURG , M.D. JD63
Attending: FLOYD T. LYN , M.D. FR5 CR259/2651
Batch: 0358 Index No. VLEZBA4SE1 D: 10/10/94
T: 11/14/94
Document id: 625
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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682375294 | PUO | 07250267 | | 792275 | 1/9/2001 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 8/21/2001 Report Status: Signed
Discharge Date: 7/29/2001
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male
with a two week history of orthopnea ,
dyspnea on exertion , increasing pedal edema , and increased
abdominal girth.
The patient's past medical history included coronary artery
disease , status post coronary artery bypass graft in 1994 ,
including saphenous vein graft to LAD , PLV , and OM1 diagonal ,
paroxysmal atrial fibrillation , on Coumadin , cerebrovascular
accident in 1991 without residual deficits.
Briefly again , this is an 81-year-old gentleman with a history of
coronary artery disease , status post coronary artery bypass graft ,
here with gradual onset over the past month of increased lower
extremity swelling and increased dyspnea on exertion. He had no
prior episode. He sleeps on one pillow. He is able to walk 3/10
of one mile without difficulty. The patient is only able to walk
up one flight of stairs , but with some difficulty today secondary
to shortness of breath. The patient noted low grade fever since
ten days ago to about 100.5. The patient denied any chills. The
patient denied any abdominal and there was no nausea , vomiting or
diarrhea. The patient recently began antibiotics after a dental
procedure and was recently worked up for a left greater than right
lower extremity swelling one week ago with negative ultrasound
work-up of his lower extremities.
ALLERGIES: The patient is allergic to codeine , reaction unknown.
MEDICATIONS ON ADMISSION: At the time of admission , the patient
was on Coumadin , Micronase , and baby
aspirin.
SOCIAL HISTORY: Social history was negative for tobacco use and
positive for occasional alcohol use. The patient
works as an engineer and lives with his wife.
FAMILY HISTORY: The patient's family history was non-contributory.
ASSESSMENT: This is an 81-year-old gentleman with known coronary
artery disease , status post coronary artery bypass
graft , presenting with low grade fevers and right greater than left
congestive heart failure.
PLAN:
1. Diuresis , aggressively.
2. Repletion of electrolytes when diuresing.
3. Cardiac monitoring , telemetry , and rule out myocardial
infarction.
4. Work-up for etiology of right congestive heart failure.
LABORATORY DATA: Laboratory data at the time of discharge revealed
sodium 137 , potassium 3.7 , chloride 95 , bicarb
30 , BUN 45 , creatinine 1.2 , glucose 154 , calcium 9.4 , magnesium
2.1 , white count 9.7 , hematocrit 42.2 , and platelets 282.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on aspirin , captopril 50 mg orally
three times a day , Colace , Lasix 80 mg orally twice a day , Isordil 10 mg orally three times a day ,
Lopressor 12.5 mg orally twice a day , Coumadin 2 mg orally every day , and
Timoptic.
HOSPITAL COURSE:
Cardiovascular: The goal heart rate and blood pressure were
achieved. The goal heart rate was in the 70s-80s
with a blood pressure in the 110s-130s systolic. The patient was
diuresed over 10 kilograms and diuresed about 1-2 liters daily.
The patient was stable on orally Lasix regimen. After diuresis , the
patient underwent an adenosine MIBI for work-up of his ischemic
disease. Results were pending at the time of this dictation.
Also , the patient underwent a chest CT scan to rule out pulmonary
embolism , which was negative. The patient was discharged in stable
condition on April , 2001 without complications. Of note , the
patient did undergo a fall , likely related to decreased blood
pressure while in the hospital. He sustained no injury and the
fall was recorded by the nurses in the incident report. Again ,
there were no traumatic complications of this.
Dictated By: PHOEBE MACVICAR , M.D. HU03
Attending: RUFUS C. BERNAS, M.D. CS32 IW362/605511
Batch: 90159 Index No. GXOXRX4991 D: 10/19/01
T: 10/19/01
Document id: 626
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
- |
040983013 | PUO | 21723084 | | 1256885 | 8/9/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 7/10/2006 Report Status: Unsigned
Discharge Date: 4/6/2006
ATTENDING: STUKOWSKI , JANAY MD
SERVICE:
Cardiac Surgery Service.
PRINCIPAL DIAGNOSIS:
1. Coronary artery disease.
2. Status post RCA stent placement ( 10/24/05 )
SECONDARY DIAGNOSES:
1. Hypertension.
2. Dyslipidemia.
3. Obesity.
4. Status post left knee arthroscopy ( 1999 ).
5. Status post left TKR ( 1999 ).
6. Status post right ankle fracture and pinning ( 20 years ago ).
7. History left extremity DVT ( 1999 ).
8. Status post radical prostatectomy ( 1995 ).
9. 25-pack-year cigarette smoking history.
HISTORY OF PRESENT ILLNESS:
Mr. Mardirossian is a 65-year-old male with past medical history
as above , admitted to Akcare Hospital with chest pain in 10/5
and subsequently diagnosed with acute inferior ST elevation MI
with Q waves in leads II , III and AVF. Cardiac catheterization
was done at Ranor Healthcare on 10/24/05 with RCA stented at
that time for 85% occlusion. Cardiac catheterization also
demonstrated 70% proximal occlusion of the LAD and proximal
circumflex with 85% distal circumflex lesion. Ventriculogram
estimated ejection fraction to be 60%. He now presents to Pagham University Of for elective surgical correction of his
coronary artery disease. In the interim , he denies continued
chest pain , shortness of breath , palpitations , nausea , vomiting ,
diaphoresis or syncope.
PAST MEDICAL HISTORY:
As above.
PAST SURGICAL HISTORY:
As above.
FAMILY HISTORY:
Positive for CAD. One brother with prior CABG , one brother with
myocardial infarction history.
SOCIAL HISTORY:
A 25-pack-year cigarette smoking history. Runs a paper company ,
currently employed full-time.
ALLERGIES:
No known drug allergies.
PREOPERATIVE HOME MEDICATIONS:
Include the following: Lopressor 50 mg orally twice a day , lisinopril
20 mg orally daily , isosorbide 30 mg orally three times a day , aspirin 325 mg ,
Plavix 75 mg orally daily , atorvastatin 80 mg orally daily ,
multivitamin daily.
PREOPERATIVE LABORATORY DATA:
Obtained on 10/14/06 , sodium 141 , potassium 4 , BUN 20 , creatinine
0.8 , glucose 87 , magnesium 2 , white blood cell count 7.2 ,
hematocrit 39.3 , platelet count 311 , 000 , INR 1.1 , and PTT 27.6.
PROCEDURE:
Mr. Mardirossian was admitted to the Pagham University Of
on 2/18/06 and on the same day underwent elective coronary
artery bypass graft x3 with LIMA to LAD and SVG1 to ramus to OM1
( sequential graft ).
BYPASS TIME:
58 minutes.
CROSSCLAMP TIME:
50 minutes.
INTRAOPERATIVE FINDINGS:
Included good LV contractility , good quality conduit and targets.
Please refer to operative note for details.
HOSPITAL COURSE:
Mr. Mardirossian was transferred to the Cardiac Surgery Intensive
Care Unit in the immediate postoperative period , hemodynamically
stable , intubated and sedated on Precedex. Following weaning
of sedation , the patient was found to neurologically stable ,
moving all four extremities well. He remained in normal sinus
rhythm throughout the perioperative period with stable blood
pressure and tolerated well initiation of low-dose beta-blocker
in the form of Lopressor. He was extubated in the evening of
surgery without difficulty and subsequently weaned to
supplemental oxygen by nasal cannula without difficulty.
Following extubation , diet was advanced as tolerated with the
patient administered GI prophylaxis in the form of Nexium orally
daily. Creatinine remained stable at baseline level of 0.7
perioperatively with the patient tolerating well low-dose
diuretic in the form of Lasix 20 mg orally twice a day Perioperative
hyperglycemia was managed by the Diabetes Management Services ,
with the patient requiring Portland Protocol intravenous insulin infusion
postoperatively for glucose management with goal of glucose value
less than 125. Following advancement of diet , NovoLog sliding
scale was administered with meals. The patient remained afebrile
throughout the perioperative course with white blood cell count
stable at 8 to 9. Routine perioperative antibiotic prophylaxis
was administered in the form of vancomycin intravenous x2 doses. Mild
postoperative anemia required no transfusion of blood , with the
patient's hematocrit having improved to 27.9 by day of discharge
on Niferex orally twice a day White count remained stable with INR and
PTT stable at preoperative levels. Plavix 75 mg orally daily was
resumed in the postoperative course for preoperative RCA
stenting. Additionally , the patient was begun on enteric-coated
aspirin 325 mg orally daily without difficulty. Mr. Mardirossian
followed a routine postoperative course with his temporary
epicardial pacing wires and chest tubes discontinued on
postoperative day #2. The patient subsequently continued to
increase his activity level , ambulating around the Olk
with nursing assistance on room air. He was transferred to the
Cardiac Surgery Step-Down Unit on postoperative day #3 in normal
sinus rhythm , tolerating well low-dose beta-blocker , diuretic ,
Plavix , and aspirin. While in the step-down unit , he continued
to increase his activity , now ambulating ad lib on room air , in
normal sinus rhythm with stable blood pressure on Lopressor 50 mg
orally four times a day and diuresing well on Lasix 20 mg orally twice a day Mr.
Mardirossian is discharged home in the morning of postoperative day
#5 , hemodynamically stable with normal creatinine and stable
hematocrit.
PHYSICAL EXAMINATION ON DAY OF DISCHARGE:
The patient is an obese male , alert and oriented x3 in no acute
distress. Vital signs are as follows: Temperature 97.8 degrees
Fahrenheit , heart rate 72 sinus rhythm , blood pressure 110/64 ,
and oxygen saturation 99% on room air. Today's weight listed as
2.3 kilograms above his preoperative weight of 131 kilograms.
HEENT: PERRL. No carotid bruits or JVD appreciated. Pulmonary:
Lungs are clear to auscultation bilaterally. Coronary: Regular
rate and rhythm , normal S1 and S2 , no murmurs or gallops
appreciated. Abdomen: Obese , soft , nontender , nondistended ,
positive bowel sounds. Extremities: Trace edema at bilateral
lower extremities to mid calves , 2+ pulses at all extremities
bilaterally. Skin: Midline sternotomy incision well approximated
and healing well with no erythema or drainage present , no sternal
click elicited on examination. Right lower extremity endoscopic
SVG harvest site incision well-approximated and healing well with
no erythema or drainage present. Mild ecchymosis present at right
thigh , soft , nontender. Neuro: intact , nonfocal examination.
LABORATORY DATA ON DISCHARGE:
On 10/6/06 , sodium 137 , potassium 4.2 , BUN 19 , creatinine 0.7 ,
glucose 98 , calcium 8.9 , magnesium 1.9 , white blood count 9.2 ,
hematocrit 27.9 , platelet count 237 , 000 , INR 1.1 , and PTT 29.2.
Microbiology negative for VRE and MRSA on routine surveillance
screen on 2/18/06 . Pathology: no specimens received
DIAGNOSTIC IMAGING:
Chest x-ray PA and lateral view obtained on 7/21/06 demonstrated
stable cardiomegaly with subsegmental atelectasis of the left
lower lobe , small bilateral pleural effusions , mild bilateral
pulmonary edema , no areas of pneumothorax or consolidation
present.
DISPOSITION:
Mr. Mardirossian is discharged home on postoperative day #5
following elective coronary artery bypass graft procedure. He
has recovered very well following his revascularization and is
expected to continue to make excellent recovery following
discharge with continued close follow up by his primary care
physician and cardiologist. Mr. Mardirossian has been advised
to call to schedule follow-up appointment with his cardiac
surgeon , Dr. Janay Stukowski , in six to eight weeks. Additionally ,
he will follow up with his primary care physician , Dr. Coppler ,
in one to two weeks and with his cardiologist , Dr. Squibb , in
two to four weeks. He will follow up with his primary care
physician for continued evaluation and management of
hypertension , dyslipidemia , osteoarthritis and for continued
support regarding weight loss. Plavix is to continue for no less
than six months postoperatively for RCA stent placed 10/24/05 and
for bypass graft protection. He has been advised to follow up with
his cardiologist for continued evaluation and management of blood
pressure , heart rate , heart rhythm , lipid levels , and for possible
future adjustment of medications. Mr. Mardirossian has been advised
to continue to monitor his incisions for signs of infection and to
take all medications as directed.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Include the following: Acetaminophen 325 mg to 650 mg orally every 6
h. as needed pain or temperature greater than 101 degrees
Fahrenheit , enteric-coated aspirin 325 mg orally daily , Colace 100
mg orally three times a day as needed constipation , Lasix 20 mg orally daily x7
days , ibuprofen 400 mg to 800 mg orally every 8 hours as needed pain , Niferex
150 mg orally twice a day , multivitamin with minerals one tablet orally
daily , Toprol-XL 100 mg orally twice a day , K-Dur 10 mEq orally daily x7
days , Plavix 75 mg orally daily for preoperative stent of RCA to
continue until otherwise directed by cardiologist ( to continue
for no less than six months following stent placement ) , and
atorvastatin 80 mg orally daily.
Mr. Mardirossian has recovered very well following his coronary
revascularization. He is anticipated to continue to make full
recovery to his preoperative independent level of functioning.
Thank you for referring this patient to our service. Please do
not hesitate to call with questions or concerns.
eScription document: 8-9658638 EMSSten Tel
CC: Gaylene Faniel M.D.
A Ro
CC: Vernon Randklev M.D.
Bea Duna Medical Center
Ey T Ing
Dictated By: SURGEON , PRICILLA
Attending: STUKOWSKI , JANAY
Dictation ID 5069892
D: 4/5/06
T: 4/5/06
Document id: 627
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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163945084 | PUO | 46428492 | | 1949280 | 8/6/2006 12:00:00 a.m. | LEFT IST TOE INFECTION | Signed | DIS | Admission Date: 8/6/2006 Report Status: Signed
Discharge Date: 8/29/2006
ATTENDING: VAREL , ASHLI C. L. C.
ADMITTING DIAGNOSIS:
Peripheral vascular disease.
LIST OF PROBLEMS AND DIAGNOSES:
Chronic kidney disease , diabetes , peripheral vascular disease ,
congestive heart failure , aortic stenosis , coronary artery
disease status post CABG , anemia , hypertension.
HISTORY OF PRESENT ILLNESS:
A 79-year-old male with history of non-insulin dependent
diabetes , coronary artery disease , congestive heart failure ,
hypertension , chronic renal failure , recently 1.5 months status
post left toe amputation on 5/26/06 complicated by acute on
chronic renal failure and delirium requiring postoperative
dialysis from 8/18/06 through 4/30/06 . The patient presented
on 5/5/05 for a nonhealing ulcer for three weeks' duration ,
exposed bone on the left great toe and was admitted for
debridement and antibiotics. An MRA on 9/10/06 demonstrated on
the right a multifocal high-grade stenosis of the proximal ,
anterior tibial , the tibioperoneal trunk and the proximal ,
posterior tibial arteries and included peroneal artery at the
midcalf , two-vessel runoff and on the left diffuse high-grade
stenoses of the anterior tibial , posterior tibial arteries and
occlusion of the peroneal artery in the dorsalis pedis. The
patient now presents with bleeding from the site of the left toe
amputation beginning two weeks ago associated with throbbing
pain , soreness , erythema and swelling and exacerbated blood
pressure when walking and only treated by narcotics.
PAST MEDICAL HISTORY:
Stage intravenous chronic kidney disease secondary to diabetes with the
baseline creatinine of 2.3 , non-insulin-dependent diabetes since
1998 , peripheral vascular disease , congestive heart failure with
an EF of 55% on 1/1/06 , aortic stenosis status post AVR ,
coronary artery disease status post CABG , anemia and
hypertension.
PAST SURGICAL HISTORY:
Aortic valve replacement with a Carpentier-Edwards valve ,
pulmonary hypertension prior to the AVR , status post ablation for
atrioventricular nodal reentry , tachycardia , CABG x4 , and PFO
closure 1/1/06 status post left first toe amputation 9/10/06
complicated by delirium and acute renal dysfunction.
MEDICATIONS:
Aspirin , Lopressor , Norvasc , Zocor , Plavix , PhosLo , Prandin ,
Nephrocaps , Epogen , Calcitriol.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
Lives alone , separated from wife , retired firefighter. Former
smoker with a distant history of five-pack years. Seldom alcohol
use.
FAMILY HISTORY:
Diabetes in the father and the daughter. Father had diabetes ,
was a smoker and an alcoholic and died of a myocardial infarction
at age 65.
PHYSICAL EXAMINATION ON ADMISSION:
VITAL SIGNS: Temperature 99.8 , heart rate 79 , blood pressure
170/90 , respiratory rate 20 , oxygen saturation 100% on room air.
On exam , in general , elderly man in no acute distress.
HEENT: Normocephalic , atraumatic. No scleral icterus.
NEURO: Alert and oriented x3.
CARDIAC: Regular rate and rhythm. Split S2 , mild systolic
murmur , 2/6 radiating to the carotids bilaterally , heard best at
the right second intercostal space. No bruits bilaterally.
RESPIRATORY: Clear to auscultation bilaterally , no rales ,
wheezing or rhonchi.
GI: Soft , nontender , firm , nondistended , positive bowel sounds ,
no rebound , no guarding , no masses.
EXTREMITIES: 2+ edema bilaterally. No clubbing , no cyanosis. A
cold right foot , left lower extremity great toe amputation site
bandage with bloody drainage. Radial pulses 2+ bilaterally.
Femoral pulses 2+ bilaterally. physical therapy pulse palpable , DP pulse
palpable on the right and the left physical therapy pulse 1+ and DP pulse was
not palpable.
EKG: Left axis deviation with left ventricular hypertrophy ,
question of lateral ischemia.
HOSPITAL COURSE AND PROCEDURES:
Procedures: 7/25/06 , Irrigation and debridement of the left
great toe with extension of amputation to the transmetatarsal
joint. 1/10/06 and 5/29/06 , left toe I&D with left popliteal
bypass graft to the anterior tibial artery with right saphenous
vein graft and Vac placement. Serial debridements on 4/29/06 ,
2/4/06 and 10/2/06 . Foot had been debrided so that the
amputation on the first and second toes are down to the level of
the tarsometatarsal joint.
HOSPITAL COURSE:
The patient was admitted on 7/5/06 for treatment with intravenous
antibiotics and presumed operative intervention.
Neuro and Psych: The patient has delirium postoperatively for
which he was placed on soft restraints and received Zyprexa.
This resolved quickly. Did well for the duration of admission in
terms of mental status. Alert and oriented x3 at the time of
discharge.
Cardiac: Upon admission , potassium was noted to be elevated and
the patient had EKG changes associated with hyperkalemia. Both
the Renal and Cardiology services were consulted and assisted
with his perioperative management in terms of cardioprotection
and possible need for dialysis. No further events. The
hyperkalemia resolved. He remained hemodynamically stable. He
received aspirin and Zocor for coronary artery disease related
event prophylaxis. Blood pressure was controlled with isosorbide
dinitrate , Norvasc , lisinopril , and Lopressor.
Pulmonary: No events. Maintained oxygen saturation greater than
90% on room air.
Renal: Creatinine was stable in the mid 3s and trended down to
2.6 at the time of discharge below his baseline of 4-5. Voiding
without difficulty at the time of discharge. Maintained on his
renal medications.
FEN/GI: Tolerated regular diet. Lactulose and Colace to prevent
constipation while taking narcotics , also had Dulcolax as needed
Zinc and vitamin C was started per the Nutrition consult.
Hematology: He received heparin for DVT prophylaxis. His
hematocrit remained stable. He had some oozing from the right
thigh but this resolved with a pressure dressing.
ID: He was treated throughout his hospitalization with
vancomycin , levofloxacin and Flagyl for methicillin-resistant
Staphylococcus aureus that grew from the wound after the first
and second irrigation and debridement. The levofloxacin and
Flagyl were discontinued prior to discharge. He will continue
his vancomycin at the time of discharge. Please see addendum for
antibiotic plan.
Endocrine: Diabetes controlled. He was maintained on his
Prandin and insulin sliding scale for glycemic control. He also
received vitamin D.
His incision remained clean , dry and intact without erythema or
exudate. He was afebrile with stable signs at the time of
discharge.
ACTIVITY INSTRUCTIONS:
He is nonweightbearing on the left lower extremity to protect the
open toe.
COMPLICATIONS:
None.
DISCHARGE LABS:
Laboratory tests at the time of discharge include sodium 138 ,
potassium 4.1 , chloride 111 , bicarbonate 21 , BUN 35 , creatinine
2.6 , calcium 9.0 , magnesium 1.9 , vancomycin 19.5 , white blood
cell count 7.3 , hemoglobin 9.9 , hematocrit 30.2 , platelets 221.
DISCHARGE MEDICATIONS:
His medications at discharge include aspirin 325 mg orally daily ,
vitamin C 500 mg orally twice a day , calcitriol 0.5 mcg orally daily ,
Colace 100 mg orally daily , heparin 5000 units subcutaneous three times a day ,
isosorbide dinitrate 10 mg orally three times a day , lactulose 30 mL orally
three times a day , lisinopril 50 mg orally daily , Lopressor 50 mg orally every 6 hours
Simethicone 80 mg orally four times a day , vancomycin 1 g intravenous every other day ,
zinc sulfate 220 mg orally daily for two weeks , Zocor 80 mg orally
daily , Norvasc 10 mg orally daily , Nephro-Vite one tab orally daily ,
Prandin 0.5 mg orally with each meal , Aranesp 40 mcg subcutaneous
every week , sliding scale insulin , insulin aspart 4 units
subcutaneous with breakfast and dinner , Dulcolax 10 mg PR daily ,
Tylenol as needed , Dilaudid 2-4 mg orally every 4 hours as needed for pain ,
milk of magnesia as needed for constipation , Reglan for nausea ,
oxycodone for pain 5-10 mg orally every 4 hours hours as needed for pain ,
Zyprexa 5 mg orally every 8 hours as needed for anxiety or agitation ,
Maalox as needed upset stomach.
DISPOSITION:
To rehabilitation.
PHYSICIAN FOLLOWUP:
The patient will follow up with Dr. Varel at 931-223-3069. To
call Dr. Varel to be seen within one to two weeks after
discharge.
eScription document: 2-7322866 EMSSten Tel
Dictated By: VANKILSDONK , MARLYN
Attending: VAREL , ASHLI
Dictation ID 4000384
D: 11/27/06
T: 11/27/06
Document id: 628
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
081887025 | PUO | 98395102 | | 366263 | 5/28/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/18/1992 Report Status: Signed
Discharge Date: 4/7/1992
DIAGNOSIS: CORONARY ARTERY DISEASE.
NON-INSULIN-DEPENDENT DIABETES
MELLITUS.
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old gentleman
who was admitted to Pagham University Of for exertion-related substernal chest pain , which
had increased recently. He had a past history of adult-onset
diabetes mellitus and was admitted at this time for work-up of his
chest pain. PAST MEDICAL HISTORY was significant for history of
non-insulin-dependent diabetes mellitus , status post back surgery.
ALLERGIES were no known drug allergies.
HOSPITAL COURSE: The patient underwent work-up on the Medical
Service. He was found to have a positive
exercise tolerance test with ischemic electrocardiogram changes in
the inferior lateral leads. The patient was treated with
intravenous heparin when he developed recurrent chest pain episode
and underwent cardiac catheterization on 28 of November . This study
revealed a 80% stenosis of the ostial left main , 80% at the origin
of the left anterior descending coronary artery and 60% of the mid
left anterior descending coronary artery , 60% first diagonal , 90%
first obtuse marginal branch , and left ventricular function study
was not obtained. After the cardiac catheterization , the patient
was transferred to the Cardiac Surgery Service for operative
treatment of his coronary artery disease. After the usual
preparation , he underwent triple coronary artery bypass grafting on
28 of November . The patient tolerated the procedure well.
Postoperatively , he was hemodynamically stable. He was diuresed to
his preoperative weight. The further postoperative course was
without complications. The patient recovered remarkably fast from
his operation , and could be discharged home on 6 of August .
DISPOSITION: The patient was discharged to home. CONDITION ON
DISCHARGE was good. MEDICATIONS ON DISCHARGE
included Tylenol #3 1 to 2 tablets by mouth every 4 to 6 hours as
needed for pain , Lopressor 75 milligrams by mouth twice a day ,
Micronase 5 milligrams by mouth each day , Ecotrin 1 tablet by mouth
each day. The patient will FOLLOW-UP with his cardiologist the
week following discharge. The patient had an appointment with Dr.
Genny S. Barrette 4 weeks after discharge for his cardiac surgical
FOLLOW-UP.
WI827/3789
GENNY S. BARRETTE , M.D. ZD6 D: 10/30/92
Batch: 3151 Report: F8711U05 T: 7/7/92
Dictated By: HORACIO FOERSCHLER , M.D.
Document id: 629
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
N |
N |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
Y |
U |
Y |
Y |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
Y |
- |
N |
N |
- |
N |
N |
Y |
N |
Y |
Y |
N |
Y |
Y |
270751876 | PUO | 52092119 | | 3920159 | 10/8/2006 12:00:00 a.m. | SHORTNESS OF BREATH | Signed | DIS | Admission Date: 6/24/2006 Report Status: Signed
Discharge Date: 10/21/2006
ATTENDING: DELMENDO , CRISTINE M.D.
CHIEF COMPLAINT:
The patient was admitted for a chief complaint of abdominal pain.
BRIEF HISTORY OF PRESENT ILLNESS:
This is a 70-year-old female with a history of CHF , nonischemic
hypertension , diverticulosis , complaining of two days of
pressure-like abdominal pain starting suddenly on the morning of
1/1/06 . She had nausea , gas , with no vomiting , pain through
entire abdomen , new diarrhea felt like water in her belly ,
complained of tachypnea with bowel movements , no bright red blood
per rectum. She had occasional dark stools , none on the day of
admission. She was currently getting better. Subjective fevers
at home. She had bowel movement daily. She has a history of
constipation with no bowel movement on day of admission. She had
no dysuria. She also has complained of a cough for two days and
she had blood-tinged sputum. She had ECG in the past.
Significantly her aunt died of tuberculosis 15 years ago. She
had right breast pain with cough. She had no pleuritic pain. No
night sweats. She has baseline three-pillow orthopnea. She had
no weight
gain over the last week and she had increased leg pain. She is
compliant with her medications and she complains of anxiety since
being sick. She eats daily. She has had no vaginal bleeding.
No dysphagia.
PAST MEDICAL HISTORY:
Significant for CHF. She had a echo in 9/19 , which showed an EF
of 50%-55%. She has severe tricuspid regurgitation. She has
LVH. She had a catheterization in 2001 that showed no evidence
of coronary artery disease. She has atrial fibrillation that is
rate controlled and she has hypertension , history of hypothyroid
secondary to amiodarone. She is obese. She is status post
bilateral knee replacements at the Greene Lidonimill Medical Center
in 1993 and 1994. This was done for osteoarthritis. She has a
history of anxiety , PVD , diverticulosis status post partial
colectomy in 1997 also done at the Greene Lidonimill Medical Center .
PAST SURGICAL HISTORY:
Significant for bilateral total knee replacements and the colon
resections.
ALLERGIES:
She is allergic to no known drugs.
MEDICATIONS AT HOME:
Xanax 1.5 mg every day before noon , Zoloft 50 mg every day before noon , Coumadin 2 mg every afternoon ,
Cozaar 15 mg daily , atenolol 40 mg daily , Lasix 40 mg daily ,
Protonix 20 mg daily , and Percocet as needed for pain.
SOCIAL HISTORY:
She lives alone divorced. She smoked for 20 years ago and quit
20 years ago. She does not use illicit drugs.
PHYSICAL EXAMINATION:
Upon admission here , physical exam was significant for that she
was afebrile , pulse was 93 , blood pressure of 111/77 , respiratory
rate of 16 , she was satting well on 4 L nasal cannula started at
96% with 2 L nasal cannula. In general , she was anxious ,
tearful , obese , and does not look ill. HEENT: She was PERRL.
Her OP was clear. She had no thyroid enlargement. Her JVP was
11 cm , although it was difficult to assess. With regard to her
cardiovascular status , she was tacky. She had regular rate.
There was no S3-S4 appreciated. She had normal S1-S2 and there
were no murmurs appreciated. Her chest exam was significant for
diffuse wheezing on both inspiratory and expiratory movements.
She had no rales or rhonchi. Her abdominal exam was significant
for very obese midline scar. She is diffusely mildly tender with
no peritoneal signs. No palpable abdominal aorta. She had no
bruits. Extremities: She has positive venostasis signs and no
traces of edema. Neurological exam: She is alert and oriented
x3 and cranial nerves II through XII were grossly intact. Her
stool is guaiac negative in the emergency room.
Her EKG was significant for multiple beats of ectopy and on
telemetry she was found to be in atrial fibrillation with the
rate in 80s to 90s with multiple runs of five to six beats of V
tach and quite a bit of ectopy. This has been described at
multiple previous visits while in the hospital by systems.
Assessment was that this is a 70-year-old female with no
nonischemic CHF presenting with diffuse symptoms including cough ,
shortness of breath , abdominal pain , and anxiety. Her exam was
consistent with volume overload and possibly cardiac asthma. No
history of COPD or history of asthma or patient frequent
wheezing. Trigger for exacerbation could be bronchitis versus
abdominal process.
HOSPITAL COURSE BY SYSTEMS:
With regard to her cardiovascular status , pump , she was volume
overloaded per the physical exam. She was diuresed to her dry
weight. With regards to her rhythm , she was rate controlled with
beta-blocker now well controlled. No evidence of current
ischemia , cardiac enzymes were negative. Pulmonary status: She
has stacked nebs with levobuterol , prednisone given in the
emergency room. She was also given a course of azithromycin.
Her sputum and Gram stain culture was negative. With regard to
her abdominal complaints: Her belly pain was of unclear
etiology. She had a negative abdominal CT question constipation.
No evidence of AAA on abdominal CT. Bowel moves regular. She
was provided with a PPI inhouse. All stools were negative for
old blood. With regard to her psychiatric condition , she has
anxiety. This was treated with Zantac and as needed Ativan.
Musculoskeletal system: She was tender in muscles likely related
from obesity. With regard to infectious disease status , she had
a negative chest CT. Her cough is productive of blood , tinged
sputum secondary to chronic cough and elevated INR. Gram
staining culture were negative. A course of azithromycin was
completed. She was also started on prednisone to help with her
wheezing. She was transitioned back from her diuretic Lasix dose
to her usual home dose of Lasix and her beta-blocker was changed
to a long-acting. Coumadin dose was adjusted to maintain her INR
at therapeutic range and she is being discharged to rehab as
physical therapist evaluation felt that she is very unsteady on
her feet.
There were no complications of this hospital admission. The
patient did well , is improving , she will be discharged on a
prednisone taper and nebulization. Her bowel regimen was
discontinued because she was having a little bit of diarrhea.
She should follow up with her primary care physician and
cardiologist within two weeks of discharge from rehabilitation.
There will be an addendum to this discharge summary with final
follow up and medication list.
eScription document: 3-1920700 EMSSten Tel
Dictated By: DELAGLIO , CHRISTIANA
Attending: DELMENDO , CRISTINE
Dictation ID 5077481
D: 1/21/06
T: 1/21/06
Document id: 630
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PVD |
VI |
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278353436 | PUO | 51253594 | | 9613392 | 10/24/2006 12:00:00 a.m. | URINARY TRACT INFECTION | Signed | DIS | Admission Date: 10/11/2006 Report Status: Signed
Discharge Date: 6/2/2006
ATTENDING: DELMENDO , CRISTINE M.D.
PRINCIPAL DIAGNOSIS: Left MCA cerebral vascular accident.
LIST OF PROBLEMS/DIAGNOSES: Urosepsis , candiduria.
BRIEF HISTORY OF PRESENT ILLNESS: This is an 83-year-old man
with a history of diabetes , peripheral vascular disease ,
bilateral above the knee amputations , dementia who presented on
1/1/06 to the Totin Hospital And Clinic Emergency Department with
mental status changes including increased confusion and decreased
responsiveness over the past two to three days. He had some
degree of baseline dementia but there was a definite change in
his mental changes according to his son. His son also reports
that the patient had decreased urine output over the past two
days with decreased orally intake as well. Although , the patient
did not complain of nausea , vomiting , fevers , diarrhea , chest
pain , or shortness of breath. He arrived in the emergency
department obtunded , responsive to pain only.
PAST MEDICAL HISTORY: Peripheral vascular disease , status post
bilateral above the knee amputations , diabetes mellitus , insulin
dependent , dementia , hyperlipidemia , hypertension , anemia or
chronic disease , traumatic brain injury in October 2002 , which
included a subdural hematoma and a subarachnoid hemorrhage , also
congestive heart failure with the ejection fraction of 28%
measured in September of 2002 , history of C. diff colitis and
polymyalgia rheumatica and hypertension.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS: Include Lantus , lisinopril , Ritalin.
SOCIAL HISTORY: Denied tobacco and alcohol per the patient's
son. The patient lives with his son.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Unable to be performed because the patient
was obtunded.
BRIEF ADMISSION PHYSICAL EXAM: On admission , he had a
temperature of 96.5 , heart rate is 60 , blood pressure of 138/86 ,
respiratory rate of 14 , he is sating 97% on room air. He was
obtunded and responded to the pain by localizing with his left
hand. His skin was dry and cold to the touch. He had dry mucous
membranes. He had no jugular venous distention. His heart had
regular rate and rhythm with normal S1 and S2 heart sounds. He
did have a 2/6 systolic ejection murmur. His lungs were clear to
auscultation bilaterally. His abdomen was soft and nondistended ,
positive bowel sounds. Rectal exam was deferred. Bilateral
above the knee amputations with no signs of infection from the
past surgical site. He had 2+ radial pulses. His neuro exam , he
was obtunded. His pupils were equal and reactive to light. He
had no thorough reflex. On initial examination , he had increased
tone in his upper left extremity and he was moving his left upper
extremity but not his right.
LABORATORY DATA: On admission , his Chem-7 was pertinent for a
glucose of 242 , a creatinine of 1.5 , and a BUN of 40. His white
count was 11.1 with a crit of 31.6 and platelets of 314 , 000. His
physical therapy was 13.8 and INR of 1.1 and a PTT of 29.3. His EKG showed
sinus bradycardia with T-wave inversions in I , aVL , V3 through V6
with no ST changes. Compared to a prior EKG in July of 2004 ,
there were no acute changes. His initial set of cardiac enzymes
was negative. A Foley catheter was placed with frank pus
expressed into the Foley catheter bag. A UA was sent from that
specimen , which showed greater than 200 white blood cells , 3+
leuk esterase , negative nitrites , and 2+ bacteria.
HOSPITAL COURSE:
ID: The patient was admitted initially with the diagnosis of
mental status changes and urosepsis given the grossly positive
urine in the Foley and a positive UA. Urine culture was sent.
He was started on levofloxacin for a total course of five days.
He was fluid hydrated with normal saline bolus of 500 mL in a
rate of 100 mL per hour after that. He was also given a dose of
vancomycin and ceftriaxone in the emergency department , which
were discontinued on admission to the floor. The urine culture
eventually did not grow out any bacteria , but did grow out
greater than 100 , 000 candida. He was started on fluconazole intravenous
and that was discontinued after one day and he was switched
instead to an amphotericin bladder washout with 50 mg going into
a 1 L sterile water bag , which was infused into the bladder at 42
mL an hour continuously over the course of 24 hours. Further
into his hospital course , he again spiked the temperature on
5/23/06 to 101.6 degrees with transient hypertension with the
systolics into the 80s. At that point , he was started on
vancomycin , Flagyl , and gentamicin. Another urine culture , blood
culture and chest x-ray were done at that time. Blood cultures
eventually did not grow out anything as well as the urine , which
was also negative. His blood pressure improved with the fluid
bolus and over the next few days , he remained afebrile with a
stable blood pressure. On the night before discharge , the
patient's intravenous infiltrated and we were unable to replace the intravenous to
administer a one-time dose of gentamicin of 350 mg intravenous , which is
the extended interval dosing. At that time , we had conversation
with the patient's healthcare proxy who is Daryl Buol who
agreed that no further attempts at intravenous should be made and we
should continue to not have a Foley catheter in place. On
discharge , the patient will be sent home without antibiotics and
without a Foley catheter and the family is aware and agrees with
this plan.
Neuro: After the initial course of antibiotics in the emergency
department , we expected the patient's mental status to be vastly
improved. On exam the next morning , he continued to be obtunded
and did not seem to be moving his right arm. We therefore got a
head CT , which showed a large new left MCA territorial infarct.
We started aspirin and we consulted neurology. Neurology at
first recommended that we do an MRI , MRA and a lumbar puncture to
further investigate the mental status changes , but these studies
were deferred given the lack of interventions available to us
given the patient's decreased functional status. We did however
obtained a transthoracic echocardiogram , which showed an ejection
fraction of 30% and no thrombus , which could have been the nadirs
for the stroke. We also got carotid ultrasounds , which did show
75% stenosis in the right ICA and 1% to 25% stenosis on the left ,
which would not explain the stroke on the left side. We also
checked a lipid panel and started a low dose of simvastatin to
prevent further stroke evaluation and formation. Neurology had
signed off and he has a neurology follow-up appointment with Dr.
Paulk as an outpatient if needed.
Cardiovascular: He has a presumed history of coronary artery
disease given his low ejection fraction and regional wall motion
abnormalities seen on the echocardiogram. We started a low dose
of atenolol with hold parameters as well as lisinopril and as
mentioned before , we continued aspirin.
Endocrine: We continued the patient's Lantus dose and titrated
it as necessary. On discharge , he is going home with Lantus 6
units daily with the NovoLog scale for additional coverage.
FEN: At first , we kept the patient npo given his obtunded
state. We got a speech and swallow consult , which evaluated his
swallowing mechanisms and agreed that he could tolerate orally and
okayed him for nectar-thick pureed diet. He did not take a lot
of orally during his hospital course and was only able to be fed by
members of his family with any real efficacy. The topic of
placing a percutaneous endoscopic gastrostomy tube was broached
with the family , but given that the patient is taking some orally ,
they wanted to defer PEG tube placement given his low functional
capacity and high rate of mortality over the next year.
END OF LIFE: The patient came in with a code that is of DNR/DNI.
Given the patient's new large left MCA stroke , which has left him
functionally debilitated , several end of life care discussions
were held with the patient's healthcare proxy Daryl Buol and
as well as with the patient's son who seemed to be his primary
care giver. They have all come to the agreement that the patient
would not wants to have aggressive interventions done , which
include CPR , intubation , pressors , and at this point as well they
feel that interventions such as intravenous fluids or Foley catheters are
not in order as well. The patient is being discharged home where
the family has arranged a certain level of home healthcare with
their primary physician. The patient already has a home
healthcare aid who works 40 hours a week during the day and his
son takes care of him the rest of the time. They are working on
arrangements to further supplement his care with the home
healthcare aid , which will be able to cover the nights and
provide him 24 hours to provision as which he needs. Several
discussions were held about whether the patient should be placed
in a skilled nursing facility because of his extraordinary
healthcare needs and that he needs to be fed , he needs to have
his diaper changed , and his hygiene looked after , but given that
the patient's wishes were to go home , the family felt
that they would try to take him home and feed him themselves and
see how he does and if that did not workout well , they would opt
for a more structured living facility for the patient. The
patient's family is aware of the large amount of working effort
that this patient will require in the future and they have agreed
to take on this task. We have offered our social services to
help with establishing further home healthcare needs , but the
family has actually done this independently with the primary care
physician.
COMPLICATIONS: There were no complications for this hospital
stay.
PHYSICAL EXAM AT DISCHARGE: On discharge , the patient was
afebrile with the temperature of 98.1 , his heart rate is 68 ,
blood pressure was 130/60 , respirations were 20 , and he is sating
94% to 99% on room air. On exam , he was awake and looking
around. He was nonverbal. He was moving his left upper
extremity but not his right using it to scratch his face and
forehead. His heart was regular rate and rhythm with normal S1
and S2 , no murmurs appreciated. His lungs were clear to
auscultation bilaterally. His abdomen was nondistended and soft
and nontender.
DISCHARGE MEDICATIONS: Include Tylenol 650 mg orally every 4 hours as needed ,
aspirin 325 mg orally daily , atenolol 25 mg orally daily , Dulcolax 10
mg per rectum daily as needed for constipation , Colace 100 mg orally
twice a day , milk of magnesia 30 mL orally twice a day as needed for
constipation , Ritalin 5 mg orally every day before noon , simvastatin 20 mg orally
every bedtime , Lantus 6 units subcutaneously daily.
DISPOSITION: The patient's disposition is to home. He has home
healthcare arranged through his family and through his primary
care physician. He has some blood cultures , which have been no
growth to date , but final cultures are pending and if they are
grossly abnormal , these results will be telephoned to him by the
microbiology lab.
PHYSICIAN FOLLOW-UP APPOINTMENTS: He has an appointment with Dr.
Paulk of neurology on 9/6/06 at 8 a.m. An appointment was
attempted with his primary care physician who is Brooke D Lemmen whose phone number is 768-474-9098. Unfortunately ,
his office was closed and an appointment was not able to be
schedule before discharge. The appointment will be scheduled;
the date and time of the scheduled appointment will be telephoned
to the healthcare proxy or to the patient's son.
eScription document: 6-8031232 CSSten Tel
CC: Brooke Lemmen MD
Athens Mi Ponce Street
Villevos Highway , E Gilb West , Minnesota 30002
CC: Cristine Delmendo M.D.
E Acon
Dictated By: SCHUYLER , EVIA
Attending: DELMENDO , CRISTINE
Dictation ID 1164924
D: 8/21/06
T: 8/21/06
Document id: 631
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437039023 | PUO | 87891930 | | 1925805 | 10/21/2005 12:00:00 a.m. | HYPOKALEMIA | Unsigned | DIS | Admission Date: 10/21/2005 Report Status: Unsigned
Discharge Date: 6/18/2005
ATTENDING: GUMINA , MARJORY SHELA MD
ADMISSION DIAGNOSES:
1. Weakness.
2. Congestive heart failure.
DISCHARGE DIAGNOSES:
1. Bacteremia.
2. Giant cell arteritis.
3. Congestive heart failure.
CONSULTS: Neurology on 9/23/05 .
PROCEDURE: Attempted lumbar puncture on 9/23/05
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male
with history of diabetes mellitus , hypertension , atrial
fibrillation , giant cell arteritis , and congestive heart failure
with preserved systolic function , who presents with generalized
weakness. On the day of admission , the patient's children and
VNA were unable to get in touch with him and came to his house ,
where he was sitting too weak to answer the door. At that time ,
he was apparently confused and disoriented. The patient reports
feeling poorly for about two years since his diagnosis with giant
cell arteritis , but denied any acute change over the past several
days prior to admission. He denied focal weakness , slurred
speech , bowel or bladder incontinence , loss of consciousness and
had no witnessed seizure activity. He also denied chest pain , palpitations ,
shortness of breath , increased dyspnea on exertion , orthopnea ,
and also had no report of fever , cough , dysuria , urinary
frequency , diarrhea , abdominal pain , jaw claudication , calf
tenderness , or vision loss. He did think that he had recently
lost weight and has chronic lower extremity edema and chronic
right shoulder pain. In the ED , he was afebrile with pulse of
78 , blood pressure 124/60 , and breathing 16 times per minute.
His potassium was noted to be low. Chest x-ray showed pulmonary
edema and head CT was negative. He received potassium and
magnesium repletion as well as oxycodone for right shoulder pain
and was admitted for weakness in the setting of hypokalemia and
volume overload.
PAST MEDICAL HISTORY: Congestive heart failure with preserved
systolic function , chronic lower extremity edema , diabetes
mellitus type 2 , history of atrial fibrillation history of DC cardioversion ,
hypertension , hypercholesterolemia , giant cell arteritis , chronic renal
insufficiency , history of spinal stenosis , gout , depression , and
status post recent left thigh ulcer excision.
ADMISSION MEDICATIONS: Coumadin 2.5 mg orally daily , Zocor 20 mg
orally daily , atenolol 100 mg orally twice a day , Lasix 80 mg orally twice a day ,
lisinopril 40 mg orally daily , Medrol 10 mg daily , glyburide 10 mg
orally twice a day , potassium chloride 10 mg orally twice a day , and
multivitamin 1 tab orally daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone with a cat. His son
visits him daily. He denies tobacco use but reports alcohol use
of one drink a day.
ADMISSION PHYSICAL EXAMINATION: Vitals - afebrile , pulse 74 ,
blood pressure 105/51 , respirations 18 , and sats 92% on room air.
GEN - NAD , pleasant elderly gentleman. HEENT - MMM , oropharynx
was clear. Neck - JVP is 12 cm. PULM - poor inspiratory effort
on exam , left side mostly clear with decreased breath sounds and
rales at the right base. CV - regular rate with early beats and
no murmurs , gallops , or rubs appreciated. ABD - soft , nontender ,
and nondistended with positive bowel sounds. EXT - 1+ pitting
edema to knees , faint distal pulses , left thigh sutures with mild
surrounding erythema. Neuro - cranial nerves II through XII
grossly intact , motor strength is 5/5 throughout except the right
deltoid , which is limited by pain and hip flexors , which were 4/5
bilaterally.
ADMISSION EKG: Normal sinus rhythm with a rate of 78 , T wave
inversions in aVL , which were old.
HOSPITAL COURSE:
1. ID - The patient developed hypotension on the morning of
9/23/05 . He was given intravenous fluids , stress dose steroids , and
started on broader antibiotic coverage ( vancomycin and
levofloxacin ). He was also started on acyclovir with concern for
encephalopathy in the setting of increased lethargy and
right-sided deficits reported earlier that morning. He responded
to intravenous fluids and did not require pressor support. A lumbar
puncture was attempted and was unsuccessful. His blood cultures
from 9/23/05 in the a.m. grew gram-negative rods and antibiotics
which were changed to ceftriaxone and levofloxacin for double
gram-negative coverage. The other cultures grew one out of four
pansensitive pseudomonas and one out of four Bacteroides fragilis
and his antibiotics were changed to ceftazidime , levofloxacin ,
and Flagyl. The acyclovir was stopped. Blood cultures were
repeated on the evening of 9/23/05 and were negative. He was
discharged home with a PICC line to complete a 14-day course of
antibiotics. At the time of discharge , the patient was afebrile
and vital signs were stable. His white blood cell count was
elevated likely secondary to steroids. The source of his
bacteremia was unclear , but most likely a bowel origin given its
species and would consider microperforation as the possibility.
A follow-up colonoscopy may be considered as an outpatient.
Other sources include sinusitis and recent removal of a left leg
ulcer , but were unlikely to result in pseudomonas and
Bacteroides.
2. Neuro - The patient presented with generalized nonfocal
weakness. On the morning of 9/23/05 , he developed focal
right-sided weakness , aphasia , and lethargy/confusion. Stat head
CT/CTA and neuro consult were done and the patient was started on
acyclovir for concern of CNS infection. Lumbar puncture was
attempted but was unsuccessful. CTA was negative for acute stroke
and MRI/MRA was also done and was negative. The patient's
right-sided deficits were transient and the patient's mental
status also improved during the rest of his hospitalization. The
cause of his acute symptoms were unclear , but included giant cell
arteritis exacerbation , recrudescence of previous stroke ,
transient hypotension from sepsis and TIA. Interestingly , on
review of his chart , it was also found that the initial ED
nursing note per EMS reported right-sided weakness , which must
have been transient as well because the ED physician note was
without focality.
3. CV/Pulm - ( I ) The patient denied chest pain and troponin was
negative x 2. He was continued on aspirin and statin and
restarted on beta-blocker when his blood pressures improved.
( P ) - The patient has a history of diastolic congestive heart
failure and was admitted with mild pulmonary edema on chest
x-ray. He was initially given Lasix , but was discontinued on the
morning 9/23/05 in the setting of hypertension. He also
complained of shortness of breath at that time , but chest x-ray
was repeated , which showed clear lungs. His sats were 94 to 95%
on two to three liters of oxygen. He required aggressive fluid
resuscitation for his hypotension , which he tolerated well. He
again became short of breath on the morning of 2/27/05 and was
thought to be mildly volume overloaded. He was given intravenous Lasix and
restarted on daily orally Lasix. He was discharged on 40 mg orally
twice a day Lasix.
( R ) - The patient has a history of atrial fibrillation and status
post DC cardioversion. He presented in sinus rhythm. He did
require intravenous Lopressor and verapamil for rapid rate atrial flutter
on 5/25/05 to 2/27/05 , which was somewhat refractory to
treatment. However , his rate quickly improved on placement of a
Foley in the setting of difficulty voiding and a large bladder
residual. At the time of discharge , he was restarted on his home
dose of atenolol.
4. Renal - The patient presented with chronic renal
insufficiency , which remained stable during his hospitalization.
His creatinine ranged from 1.5 to 1.9. The patient's Foley
catheter was removed on 5/25/05 and the patient began to
complain of urinary frequency and urgency on 2/27/05 .
Urinalysis and urine culture were negative. However , postvoid
residual was one liter and his Foley was replaced. On discharge ,
he was given a trial to void , which was not completed. It was
recommended that the patient be discharged with a Foley , but was
declined. The patient and his family were informed of our recommendation. He
has VNA services scheduled who are aware
of his urinary difficulty and should check postvoid residual and replace the
Foley or teach straight cath as needed.
5. Heme - The patient has a history of atrial fibrillation and
was previously on Coumadin anticoagulation. However , his
Coumadin was stopped several days prior to admission for left leg
ulcer excision and presented subtherapeutic with an INR of 1.2.
His Coumadin was held during his stay in the MICU , but was
restarted prior to discharge. He will be followed by MMC
Anticoagulation and should be closely monitored in the setting of
antibiotics. On discharge , his INR was 1.6.
6. Derm - The patient had a left leg ulcer excision several days
prior to admission. The patient should have sutures removed
after discharge at two weeks post excision. The site was an
unlikely source of his bacteremia.
7. Rheum/Endocrine- The patient has a history of giant cell
arteritis. ESR was elevated to 99 on admission. The patient was
initially continued on home dose Medrol. However , on the morning
of 9/23/05 , in the setting of right-sided weakness , mental
status change , and hypotension , the patient was changed to
high-dose Solu-Medrol with concern for his GCA
exacerbation/vasculitis. When the cultures grew preliminary
gram-negative rods and MRI of the brain was negative for
vasculitis , he was changed to stress dose hydrocortisone.
Steroids were tapered during hospitalization and the patient was
discharged on a continued taper back over one week to his home dose Medrol 10
mg per day. The patient was also on glyburide as an outpatient
for diabetes mellitus. As an inpatient , he was given insulin for
more aggressive control. On discharge , the patient was to
continue on twice per day insulin 70/30 while recovering and
tapering steroids. As an outpatient , it may be considered to
resume his orally agents in place of insulin.
8. Access- The patient had a right internal jugular central
venous line placed in the MICU , which was discontinued prior to
discharge. A PICC line was placed for home antibiotics.
9. FEN- The patient presented with hypokalemia to 2.9 and required
multiple doses of repletion. At the time of discharge , his
potassium was 3.1 and received additional potassium on that day.
He was discharged on a regimen of 40 mEq of potassium chloride
per day. He will need his potassium to be rechecked as an
outpatient in the setting of receiving daily Lasix. However ,
there was concern for more aggressive outpatient repletion in the
setting of chronic renal insufficiency.
10. Prophylaxis- The patient was given Nexium and Lovenox.
RADIOLOGICAL STUDIES:
1. CT head on 2/7/05 - no acute intracranial abnormality ,
bilateral maxillary and ethmoid sinus mucosal thickening.
2. Portable chest x-ray on 2/7/05 - mild pulmonary edema.
3. PA and lateral chest x-ray on 2/7/05 - stable with mild
cardiomegaly , no acute pulmonary process.
4. CTA head , 9/23/05 - paraventricular white matter changes
consistent with small vessel ischemia; mild-to-moderate atrophy
with compensatory ventricular megaly , mild- to-moderate proximal
right internal carotid artery stenosis with calcification and
atheroma; calcifications of the bilateral segments at the
internal carotid arteries as well as the bifurcation of the
proximal left internal carotid artery with no appreciable
stenosis and calcification and mild narrowing of the origin of
the right vertebral artery; complete opacification of bilateral
maxillary sinus , mucosal thickening of the bilateral ethmoid and
sphenoid sinuses; degenerative changes at the cervical spine.
5. Portable chest x-ray , 9/23/05 - no change in cardiac
silhouette or pulmonary parenchyma from 2/7/05 .
6. Portable chest x-ray , 9/23/05 - improved aeration of the
right lung base allowing visualization of the right
hemidiaphragm; placement of right jugular central venous catheter
with tip in the SVC; no pneumothorax.
7. MR of the brain with and without contrast , 9/23/05 - no
evidence of acute infarction , no intracranial collections of mass
lesions; mild involutional changes present.
8. Portable chest x-ray , 7/5/05 , bibasilar opacities due at
least in part to atelectasis; right jugular central venous
catheter was stable in position; no evidence for substantial
pleural effusion or pneumothorax.
CARDIOLOGY STUDIES: Echocardiogram on 7/5/05 - normal LV size ,
EF 55% to 60% , no wall motion abnormalities; normal RV; atrial
size normal; trace to mild MR; mild TR , PAP 38.
MICROBIOLOGICAL STUDY:
1. Blood cultures , 9/23/05 admission - one out of four
Bacteroides fragilis , one out of four pansensitive Pseudomonas
aeruginosa.
2. Blood cultures , 9/23/05 , in the evening - no growth.
3. Urine culture , 9/23/05 - no growth.
4. Urine culture , 2/27/05 - negative with total colony count of
1000 yeast.
5. VRE and MRSA screen on 9/23/05 - negative.
6. C. diff screen on 2/27/05 - negative.
DISPOSITION: The patient is to be discharged on 9/19/05 in
stable condition to home with services.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed headache.
2. Enteric-coated aspirin 81 mg orally daily.
3. Atenolol 100 mg orally twice a day
4. Ceftazidime 1000 mg intravenous every 24 hours with the last dose on 3/23/05 .
5. Colace 100 mg orally twice a day
6. Lasix 40 mg orally twice a day
7. Medrol taper 12 mg every 12 hours x4 doses , then 10 mg every
12 hours x4 days , then 8 mg every 12 hours x4 doses , then 6 mg
every 12 hours x4 doses , and then continue methylprednisolone
orally at 10 mg every 24 hours indefinitely.
8. Flagyl 500 mg orally three times a day
9. Coumadin 1.25 mg orally every afternoon
10. Zocor 20 mg orally every bedtime
11. Insulin 70/30 , 20 units subcutaneously every day before noon and 12 units subcutaneously
every afternoon
12. Levofloxacin 250 mg orally daily to end on 3/23/05 .
13. Flomax 0.4 mg orally daily.
14. Insulin sliding scale , subcutaneously twice a day only at breakfast and
dinner.
15. Potassium chloride 40 mEq orally daily.
TO DO/PLAN:
1. Medication changes: holding lisinopril and glyburide; reducing
Lasix from 80 mg twice per day to 40 mg twice per day; Coumadin
dose halved on antibiotics ( MMC Anticoagulation may adjust this
based on lab values ); steroid taper over the week following
discharge to his original dose; last dose of antibiotics on
3/23/05 , the PICC line can be removed when his course of
ceftazidime is complete.
2. The patient is on insulin two times per day while recovering.
Possibility to return to glyburide should be discussed with his
primary care physician once steroid taper and antibiotics completed.
3. It was recommended that the patient be discharged with the
Foley catheter given his difficulty voiding , however , he
declined. His ability to void should be assessed by the VNA
Services and the patient should be straight cathed as necessary.
4. The patient should record daily weights and keep a
glucose log , which should be presented at his primary care physician follow-up.
5. The patient should follow up with his primary care physician within one week and
have lytes checked at that time.
6. The VNA Services should check a Chem-7 on Sunday following
discharge. INR is to be followed by MMC Anticoagulation Clinic
at 831-963-5333.
eScription document: 6-1059921 CSSten Tel
Dictated By: WATERHOUSE , IGNACIA
Attending: GUMINA , MARJORY SHELA
Dictation ID 8189505
D: 5/29/05
T: 5/29/05
Document id: 632
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
- |
N |
Y |
N |
- |
N |
063416560 | PUO | 00531446 | | 6606323 | 1/1/2004 12:00:00 a.m. | atrial fibrillation , calcaneous fracture | | DIS | Admission Date: 1/1/2004 Report Status:
Discharge Date: 8/5/2004
****** DISCHARGE ORDERS ******
BACULPO , ROBERTA D. 653-77-60-2
Ponce Milanceatl
Service: CAR
DISCHARGE PATIENT ON: 4/11/04 AT 07:00 PM
CONTINGENT UPON CT scan
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LAMIA , SHAINA CHIA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 5/28/04 by
SUGIMOTO , ARDELL PABLO , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: heart
VITAMIN B12 ( CYANOCOBALAMIN ) 1 , 000 MCG orally every day
Number of Doses Required ( approximate ): 5
DIGOXIN 0.25 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 60 MG orally twice a day
HOLD IF: sbp<105 and call HO
OXYCODONE 5 MG orally every 6 hours as needed Pain
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting Today May Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 5/28/04 by
SUGIMOTO , ARDELL PABLO , M.D. , M.P.H.
on order for ECASA orally ( ref # 73842873 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: heart Previous override information:
Override added on 5/28/04 by SUGIMOTO , ARDELL P STANTON , M.D. , M.P.H.
on order for LIPITOR orally ( ref # 55088460 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: home 40mg
METOPROLOL ( SUST. REL. ) 300 MG orally every day
HOLD IF: sbp<100 , heart rate<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 5/28/04 by
SUGIMOTO , ARDELL PABLO , M.D. , M.P.H.
on order for DILTIAZEM orally ( ref # 15684628 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: home med
Previous override information:
Override added on 5/28/04 by SUGIMOTO , ARDELL P STANTON , M.D. , M.P.H.
on order for TIAZAC orally ( ref # 98595353 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: home med
Previous override information:
Override added on 5/28/04 by SUGIMOTO , ARDELL P STANTON , M.D. , M.P.H.
on order for DILTIAZEM SUSTAINED RELEASE orally ( ref #
40951343 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: home emd
Number of Doses Required ( approximate ): 5
ACCUPRIL ( QUINAPRIL ) 20 MG orally every day
HOLD IF: sbp<105 and call HO
Number of Doses Required ( approximate ): 4
TIAZAC ( DILTIAZEM EXTENDED RELEASE ) 240 MG orally every day before noon
Starting IN a.m. May Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 5/28/04 by
SUGIMOTO , ARDELL PABLO , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: home med
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Alert overridden: Override added on 5/28/04 by
SUGIMOTO , ARDELL PABLO , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: home 40mg
NIASPAN ( NICOTINIC ACID SUSTAINED RELEASE ) 1 GM orally every bedtime
Override Notice: Override added on 5/28/04 by
SUGIMOTO , ARDELL PABLO , M.D. , M.P.H.
on order for LIPITOR orally ( ref # 55088460 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: home 40mg
LANTUS ( INSULIN GLARGINE ) 66 UNITS subcutaneously every afternoon
INSULIN LISPRO MIX 75/25 74 UNITS subcutaneously every day before noon
INSULIN LISPRO MIX 75/25 54 UNITS subcutaneously every afternoon
GLUCOMETER 1 EA subcutaneously x1
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Partial weight-bearing: no weight on Lt foot. Use air cast.
FOLLOW UP APPOINTMENT( S ):
Orthopedics , first week February 062 426-5178 ,
Dr. klaus primary care physician June ,
Arrange INR to be drawn on 2/15/04 with f/u INR's to be drawn every
30 days. INR's will be followed by Dr. Klaus
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
atrial fibrillation'
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atrial fibrillation , calcaneous fracture
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes , HTN , hypercholesterolemia ,
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT foot , Plain film foot 3views
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Baculpo is a 64yo man with T2DM , HTN , chronic
afib , and several hospital admissions for CHF who presents after
becoming dizzy while shovelling snow. The pateint had not taken his
rate control medications this a.m. , and was shovelling snow
when he experienced dizziness/lightheadedness and
fell to his kness. No loss of consciousness , no head trauma.
Did expereince generalized weakness , but no
slurred speech , focal weakness , or incontinence. No
chest pain , no SOB , no orthopnea , no PND , no
palpitation s. EMS-HR 140s-160s , BP 190/90 , in ED
rate controlled with intravenous metoprolol and diltiazem.
HR 100s , SBP 100s.
Exam JVP 8-10 , chest CTA , CV irreg , no MRG , Abd obese , LE trace edema ,
possible absent left DP. Labs creat 2.1 ( base~1.7 ) , dig 0.8 , trop 0.1 ,
ckmb 10.5 , ck 383.
****HOSP COURSE***
1. CV Isch: Most c/with demand ischemia. Gave
ASA , continue rate control with home meds ,
continue lipitor/niacin ( incr lipitor 40-->80 ). INR 3.3
so no heparin. Enzymes trended down from 0/1->0.24->0.23.
Pump: Mildly incr JVP , trace edema;
continue lasix , 60 twice a day ( was 40po three times a day at
home ) Telemetry
2. Endo: Continue home insulin. Provided diabetes education. Provided
glucometer. 3. Renal: CRI , stable
4. Pulm: Low susp PE , given INR 3.3 and no pain or asym LE
swelling 5.MSK:sustained fall to Lt heel during presyncope. Initially p
ain with ambulation. On HD 2 difficulty with weight bearting.
Tenderness over tallus. Plain films showed question of anterior cal
caneous and tallus fracture. Discussed with orthopedics. Provided
hard boot. told to not bear full weight on left foot. CT performed
with reconstitutions to rule out avulsion. Patient was stable to be
discharged with outpatient regimen with follow up one week from
discharge with orthopedics ambulatory clinic. Code: FULL CODE
ADDITIONAL COMMENTS: Please take all medications as indicated. Please call orthopedics for
your appointment. You need to be seen next week to evaluate your foot
fracture 385 505 6200. Please take your blood sugar as you were
taught here. Please follow up with yoru cardiologist within 2 weeks of
discharge.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: JUSTESEN , IRISH A. , M.D. , M.PHIL. ( SQ531 ) 4/11/04 @ 05:27 PM
****** END OF DISCHARGE ORDERS ******
Document id: 633
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
945062144 | PUO | 82603231 | | 118208 | 8/7/1992 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/4/1992 Report Status: Unsigned
Discharge Date: 1/26/1992
HISTORY OF PRESENT ILLNESS: Chief complaint is coronary artery
disease. Patient is a 71 year old
white male with a history of coronary artery disease , angina , and
dyspnea on exertion who presents for coronary artery bypass
grafting. Patient reports angina since 4/26 described as chest
fullness. Patient denies shortness of breath , chest pressure , or
syncope. Patient notes dyspnea on exertion while in Own Day nine
months ago. Exercise tolerance tests were performed which revealed
five minutes of exertion , however , was stopped prior to ST segment
changes. Cardiac catheterization in 4/26 revealed a 30% left
main , 40% left anterior descending , 50% circumflex , 100% mid right
coronary artery , and a 90% right coronary artery lesion.
Angioplasty was attempted of the proximal right coronary artery
lesion. A dissection resulted and total occlusion of the proximal
right coronary artery without EKG changes or chest pain. Cardiac
risk factors include a family history , no tobacco , hypertension ,
diabetes , and hypercholesterolemia. PAST MEDICAL HISTORY:
Significant for adult onset diabetes , diet controlled , and a
question of a gout with no history in the past. PAST SURGICAL
HISTORY: Significant for tonsillectomy and adenoidectomy and
appendectomy as a child. CURRENT MEDICATIONS: Levatol 30 mg orally
every day , Procardia XL 30 mg orally every day , Colchicine 0.6 mg orally every day ,
Pepcid 40 mg orally every 6 hours , and Aspirin one tablet orally every day
ALLERGIES: Patient has an allergy to Penicillin.
PHYSICAL EXAMINATION: Grossly within normal limits.
HOSPITAL COURSE: Patient was admitted to the Cardiac Surgical
Service and was taken to the Operating Room on
5/3/92 where he underwent a three-vessel coronary artery bypass
grafting. Patient tolerated the procedure well and was taken to
the Cardiac Surgical Intensive Care Unit post-operatively.
Patient's post-operative course from this point on was
uncomplicated. Patient was successfully extubated on
post-operative day number one and was diuresed back to
pre-operative weight through the subsequent post-operative days.
Patient ruled out for a myocardial infarction perioperatively.
Patient continues to do very well and plan is to discharge the
patient home on post-operative day number seven from coronary
artery bypass grafting.
DISPOSITION: DISCHARGE MEDICATIONS: Pepcid 20 mg orally twice a day ,
Procardia XL 30 mg orally every day , Levatol 10 mg orally
every day , Colchicine , and Ciprofloxacin. Patient is instructed to
follow-up with Dr. Golebiowski in the Cardiac Surgical Clinic. CONDITION
ON DISCHARGE: Good.
QV836/8939
LOIDA F. GOLEBIOWSKI , M.D. MC6 D: 4/29/92
Batch: 9107 Report: H3021C2 T: 5/23/92
Dictated By: CLARETHA ABDEL , M.D. WX59
Document id: 634
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
528594855 | PUO | 38124863 | | 2695418 | 10/21/2006 12:00:00 a.m. | Atypical chest pain | | DIS | Admission Date: 2/2/2006 Report Status:
Discharge Date: 1/9/2006
****** FINAL DISCHARGE ORDERS ******
LAVALETTE , CORINNE 958-08-78-6
Perv
Service: MED
DISCHARGE PATIENT ON: 7/12/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOHANAN , SHEA K. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
AMITRIPTYLINE HCL 50 MG orally BEDTIME
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY
ATENOLOL 50 MG every day before noon; 25 MG every afternoon orally 50 MG every day before noon 25 MG every afternoon
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
2 TAB orally DAILY
FLUOXETINE HCL 20 MG orally DAILY
LISINOPRIL 20 MG orally DAILY HOLD IF: o
Override Notice: Override added on 1/18/06 by
CLAYBURN , NIKI , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
610081846 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
METFORMIN 1 , 000 MG orally twice a day
AVADIA 8 UNIT DAILY
GLYBURIDE 10 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please scedule an appointment with your primary care ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) NIDDM ( diabetes mellitus ) sleep apnea ( sleep
apnea ) obesity ( obesity )
OPERATIONS AND PROCEDURES:
ETT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Atypical Chest pain
****
HPI: 54 hispanic woman with morbid obesity , HTN , NIDDM , sleep apnea
on CPAP , who presented with one week history of intermittent left arm
pain while washing dishes , lasting 15 minutes , sometimes
radiating to her left chest , positional , no associated with SOB ,
N/V/D. Responds to sublingual NTG ( however within 5-10min ). She has history
of atypical chest pain , last ETT 1998 , walked 3min , HR-128 , non
ischemic. Cardiac risk factors: Age , HTN , DM , Obesity ,
FH. In ED pain free , no changes in EKG , first set of cardiac enzymes
is negative. Received ASA , Heparin drops started.
****
PMH:
1. NIDDM
2. HTN
3. Morbid obesity
4. OSA ->Home CPAP
5. Chronic back pain.
****
Home meds: Atenolol 50AM/25PM , Avadia 8 , Fluoxetine 20 , Metformin 1gm
twice a day , Glyburide 10BID , Lisinopril 20 , CaCO3 1200QD , Amitriptyline
50QHS
****
Exam: T- 98.6 HR-86R , BP-117/55 , RA-18 ,
97%RA General: Obese ,
NAD HEENT:MMM ,
PEEEL CV: Flat JVP , RRR , S1 , S2 , no
MRG Lungs: CTA
B/L Abdomen: soft , NTND , +BS.
Ext: Warm , no edema
****
Hospital course:
54F with multiple cardiac risk factors admitted
with atypical chest pain , no evidence for ACS.
*CV:
( I ) Completed ROMI , ETT walked for 2 minutes and 33 sec , 75% MPHR ,
stopped due to fatigue , no EKG changes. Can continue home ASA , BB ,
Risk stratification: Lipid profile , A1C are pending.
( P ) ETT in ED with EF-55% , not in failure , htn controlled with BB , ACEI
( R ) No events
*Endo: RISS , return to home meds , A1C pending
ADDITIONAL COMMENTS: 1. You did not have heart attack!!
2. Continue all your medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. follow up A1C , lipid profile.
2. Weight reduction
No dictated summary
ENTERED BY: DUSSAULT , LARAINE , M.D. ( YJ28 ) 7/12/06 @ 12:00 PM
****** END OF DISCHARGE ORDERS ******
Document id: 635
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
N |
- |
N |
740965499 | PUO | 76805268 | | 9816584 | 6/21/2006 12:00:00 a.m. | unstable angina | | DIS | Admission Date: 4/12/2006 Report Status:
Discharge Date: 7/22/2006
****** FINAL DISCHARGE ORDERS ******
MARITATO , BERNIE 836-28-79-5
Gner Parkway , T Palis
Service: CAR
DISCHARGE PATIENT ON: 1/8/06 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAMBLET , BRITTANEY NICKI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECOTRIN ( ASPIRIN ENTERIC COATED ) 325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 10 MG orally DAILY
Starting Today July
Override Notice: Override added on 9/16/06 by HEIDERMAN , LEISA E H. , M.D. on order for TRICOR orally ( ref # 789845147 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
FENOFIBRATE , MICRONIZED Reason for override: aware
BACLOFEN 10 MG orally every afternoon
CARBAMAZEPINE 200 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day before noon
TRICOR ( FENOFIBRATE ( TRICOR ) ) 48 MG orally every afternoon
Alert overridden: Override added on 9/16/06 by
HEIDERMAN , LEISA E. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
FENOFIBRATE , MICRONIZED Reason for override: aware
Number of Doses Required ( approximate ): 4
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
GLIPIZIDE 5 MG orally every day before noon
ISOSORBIDE MONONITRATE ( SR ) 30 MG orally every afternoon
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 10 MG orally every day before noon HOLD IF: sbp<100
Alert overridden: Override added on 9/16/06 by
HEIDERMAN , LEISA E. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
150 MG orally every day before noon HOLD IF: sbp<100 or heart rate<55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain
PRILOSEC ( OMEPRAZOLE ) 40 MG orally every afternoon
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr. Lemmings in Delpnecrest Ce Medical Center 739-777-1180 Thurs September at 2pm ,
Dr. Hermina Tuomala at Nessinee Ker Hospital Medical Center - call to schedule appointment within 2 wks of discharge scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
unstable angina
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
dm ( diabetes mellitus ) cad ( coronary artery disease ) history of cva ( history of
cerebrovascular accident ) hyperlipidemia
( hyperlipidemia ) htn ( hypertension ) seizure disorder ( ) history of PE ( )
OPERATIONS AND PROCEDURES:
left heart catheterization
history of PCI with 2 microdriver stents to the PLV and the retrograde limb of
the PLV extending into the distal RCA
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
***CC: chest pain in patient with known CAD history of CABG + PCI's
***HPI: patient is a 74 year-old male with history of CAD history of CABG 1998 ( lima-lad ,
svg-rca , svg-om1 , svg-diag1 ) with subsequent PCI to the svg-diag1
( 11/3 ) and the SVG-RCA ( 5/27 ) both with bare metal stents ,
CVA , HTN , DM. At baseline , he lives at home alone. He had been
reasonably active with ADLs and had been chest pain free for over 1 year.
On the night prior to admission , patient experienced sharp substernal chest
pain 5/10 , non-radiating. He had no associated symptoms.
His CP improved with 2 NTGN. On the day of admission , he had
more episodes of stuttering chest pain relieved by nitroglycerin.
He presented to PUO for furthter evaluation and management.
Of note: The patient's last cardiac cathterization in 1/13
was unchanged compared to a 11/1 cath ( 3 of 4 grafts were patent. The
SVG-OM has a known 100% complex occlusion ). The patient's last ECHO in 11/1
showed an EF 30% with global hypokinesis and mild-mod MR.
***ED course: Afeb , HR 68 , BP 128/69 , O2sat 100%RA. Enzymes negative. EKG
with inferior TW flattening. CTA was negative for
dissection. patient was treated with ASA , nitro sublingual ,
morphine 2mg x1 , and a heparin drops with bolus.
************
PMH:
*CVA
*PE ( previously on coumadin )
*CAD history of CABG 98 ( LIMa --> LAD , SVG --> RCA , SVG --> OM , SVG --> diag )
PCI + stent to SVG --> dig 2002 and SVG --> RCA 2004. SVG --> OM with known
occlusion not intervened upon
*CHF with EF 30% 11/1
*HTN
*GERD
*history of ccy
*diverticulosis
*DM
***HOME MEDICATIONS: carbamazepine 200mg orally twice a day , lasix 40mg orally daily ,
glipizide 5mg orally
every day before noon , lisinopril 10mg orally every day before noon , toprol xl 150mg every day before noon , ecotrin 325 daily ,
plavix 75mg every day before noon , prilosec 40mg every afternoon , tricor 48mg every afternoon , lipitor 10mg orally every afternoon ,
baclofen 10mg orally every afternoon , isosorbide mononitrate 30mg orally every afternoon
***ALL: none
***SH: Widow. Wife died 2 months ago. Quit smoking 30 yrs ago. No etoh.
***ADMISSION EXAM: afebrile P 64 SBP 103 sat 96% RA; NAD; a+o x 3; L sided
weakness , lungs clear; S1S2 2/6 HSM at apex , ab soft NTl ext warm
***ADMISSION LABS: Cr 1.6 ( baseline 1.4 ) hct 36.9 ( baseline ) , lipase 119 ,
ddimer 262 , BNP 260
***STUDIES:
*CXR - no acute CP process
*CTA + CT abd/pelvis- official read pending;
prelim read of CTA describes sternotomy clips , vascular calcification ,
non-specific LN in mediastinum , mild dilation of trahepatic bile duct , mild
L >R perinephric stranding , L hypodense kidney lesion , diverticulosis , no
dissection
*EKG - nsr , 1st degr avb , ivcd L bundaloid , qtc 416 , II TWI , III , avF
flattening , I + AvL + v5-6 TWI
*cardiac cath: R dom , occlusion of native vessels including LAD , diag , Lcx ,
RCA , and PLV. Patent LIMA to LAD.
Patent stented SVG to diag and SVG to RCA. Known occlusion of SVG to OM.
*ECHO: prelim EF 35-40%
***HOSPITAL COURSE BY SYSTEM and PROBLEM:
CV:
*CAD history of CABG + stents to 2/4 grafts* patient presented with unstable angina.
He was treated with ASA , plavix , statin , tricor , bb , acei , and hep drops
He underwent cardiac cathterization as described above which revealed native
3vd , 3/4 patent grafts , and a new PLV occlusion which was stented.
Also had overlapping stent to distal RCA. patient was treated with integrillin x 18
hours. He was discharged on his home cardiac ischemia regimen.
*dyslipidemia* Lipids were checked and were TC 117 , HDL 32 , LDL 54 , Tri 153.
LDL is in excellent range. HDL is still low despite tricor. One could
consider titrating up tricor on an outpt basis. LFTs and CKs would
require close monitoring.
*EF 30%* patient appeared euvolemic. He was continued on his home bb , acei ,
lasix and nitrate. A repeat ECHO was ordered , prelim shows EF 35-40%
*NSR*
NEURO: *CVA* patient was continued on carbamazepine for tingling pain.
PULM: *history of PE* patient is no longer on coumadin. Ddimer in ED was positive.
CTA showed no central PE. No further imaging was pursued given
that clinical hx and exam not consistent with PE. Abnormal lab will
require outpt f/u. Issue of ongoing coumadin for history of PE should
be readdressed on outpt basis.
GI: *GERD* patient continued on PPI
*diverticulosis* Inactive
*dilation of intrahepatic bile ducts* Incidentally discovered on abdominal
imaging. WIll require outpt f/u and perhaps reimaging.
RENAL: *CRI* Cr improved from 1.6 on admission to 1.4 on discharge.
patient received mucomyst and alkalinized fluid pre _+ post cath.
Ab imaging incidentally revealed L >R perinephric stranding.
This is of an unclear etiology. patient showed no clinical symptoms or signs of
kidney infection. patient will require outpt f/u and perhaps repeat imaging
ONC: *nonspecific med LN , L hypodense kidney lesion* Incidental finding
on abdominal imaging. These will require outpt f/u and possibly repeat
imaging.
HEME: *anemia* patient's hct ranged from 37 on admission to 33 on discharge.
He should have oupt f/u for anemia + possible colonoscopy.
ENDO: *DM* patient's glipizide was held. He was treated with novolog while
hospitalized. He was discharged on his home glypizide.
PROPH: hep drops/nexium
***DISCHARGE STATUS: Exam unchanged from admission save for new mild
bruising R groin. R LE warm with R pulses dopplerable. Labs with hct 33 , Cr 1.5
***DISPOSITION: patient is being discharged to home without services. He should
follow up with his primary care physician and cardiologist.
ADDITIONAL COMMENTS: TO physical therapy:
-You were admitted with chest pain. You were found to have a blockage
in one of the arteries around your heart and this blockage was preventing
your heart from getting enough oxygen. You underwent cardiac
catheterization and a stent was placed to keep this blocked artery open.
You should take all your medications and follow up with your doctors as
directed.
-Return to the emergency room or call your doctor if you have chest pain
or pressure , shortness of breath , palpitations , lightheadedness , nausea ,
vomiting , diarrhea , abdominal pain , fevers , or any other concerning
symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
primary care physician/cards:
-F/u official read of ECHo
-f/u official read of CTA + ab/pelv CT
consider repeat imaging to eval abnormalities including nonspecific
mediastinal LN , mild dilation of intrahepatic bile duct , L>R perinephric
stranding , and hypodense L kidney lesion
-Consider repeat ddimer ( abnormal here , but low prob for PE , no central
PE on CTA )
-Consider repeat lipase ( abnormal here , no clinical evidence of
pancreatitis )
-f/u anemia and consider colonoscopy
No dictated summary
ENTERED BY: TROOP , WILFREDO V. , M.D. ( HK24 ) 1/8/06 @ 11:50 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 636
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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009560203 | PUO | 78023769 | | 1042030 | 10/14/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/22/2005 Report Status: Signed
Discharge Date:
ATTENDING: POPOVIC , ALEXANDRA MD
SERVICE: Cardiology.
PRINCIPAL DIAGNOSES: Pulmonary edema , hypertensive urgency ,
non-ST-elevation myocardial infarction , status post
catheterization.
LIST OF PROBLEMS AND DIAGNOSES:
1. Hypertension since at least 1995.
2. Diabetes.
3. Hyperlipidemia.
4. Obstructive sleep apnea , on CPAP.
5. Status post cerebrovascular accident.
6. Pneumonia.
HISTORY OF PRESENT ILLNESS: The patient , Mr. Raver is a
44-year-old married Hispanic male with a history of diabetes;
hypertension; hypercholesterolemia; and obstructive sleep apnea ,
on CPAP , who presented to the P Therford Hospital Emergency Room on November ,
2005 , with complaint of shortness of breath. His wife reported
that he has been experiencing gradually worsening shortness of
breath since the afternoon of October , 2005 , without any chest
pain. He has increased dyspnea on exertion , needing to use a
CPAP at night. He was found to be hypertensive to the 200/100 ,
with florid pulmonary edema and hypertensive encephalopathy. The
patient was then intubated for airway protection and oxygenation
and admitted to the P Therford Hospital ICU where he was diuresed
aggressively. The patient's hypertension was difficult to
control , requiring labetalol initially and then a successful
regimen of intravenous nitroglycerin , nitroprusside , hydralazine , and
Lopressor. The patient received a TEE on November , 2005 , which
showed concentric LVH , no wall motion abnormalities , and EF of
45%. There was a concern for aortic dissection on
echocardiogram , but an MRI/MRA revealed no dissection. The
patient was also frequently agitated requiring increasing doses
of Versed and fentanyl as well as as needed Haldol and Zyprexa.
During the admission to P Therford Hospital , he had lateral ST segment
depressions on multiple EKGs and a non-ST-elevation MI ( NSTEMI )
with a peak troponin of 20 on November , 2005 , a peak CK of 430 ,
and a peak MB of 20. He was started on ASA , heparin ,
beta-blocker , statin , and Integrilin and transferred to the TTHC
on March , 2005 , for management for possible catheterization.
At the P Therford Hospital ICU , the patient also had marked hyperglycemia
and was put on a ??___?? protocol.
At the Kernan To Dautedi University Of Of CCU , he was found to have a cardiac enzyme leak
with a peak CK of 286 , CK-MB of 6.2 , and troponin of 13.8 , which
trended down. His EKG showed signs of evolving anterior MI. The
patient was continued to be maintained on aspirin , Plavix , and
Lipitor while Integrilin was discontinued on CCU day #2 as the
patient was not stable for cardiac catheterization. His blood
pressure continued to be very difficult to control. The patient
came in from the TTHC with a nitroglycerin drip , which was weaned
and transitioned to Norvasc 5 mg every day , captopril 25 three times a day ,
Lopressor 100 four times a day , and hydralazine 50 four times a day However , his
blood pressure continued to rise ??___?? on CCU day #4 and
Nipride drip was initiated. This increase was in the setting of
confusion ??___??. His Nipride was weaned on day #5 and his orally
blood pressure medications were restarted with systolic blood
pressure goal of 140. The patient also had an episode of sinus
pause of greater than 2.5 seconds on September , 2005 , with no
symptoms. intravenous labetalol was discontinued after that episode.
CCU course was complicated by the patient spiking a fever to
104.1 on CCU day #3 , and he was started on broad spectrum
antibiotics for presumptive ICU pneumonia. He was started on
vancomycin , ceftazidime , and levofloxacin was added. The CCU
course was also complicated by the patient developing left-sided
weakness in the left lower extremity on ICU day #5 , which was
concerning for CVA. An MRI/MRA was obtained which showed small
vessel disease consistent with hypertension-induced
cerebrovascular accident and no evidence of embolism. An
echocardiogram was obtained and was negative for any cardiac
sources and emboli and with a negative bubble study. Secondary
to the patient's mental status and question of inability to
swallow , an NG tube was placed; however , it was self-discontinued
by the patient on September , 2005. The patient was transferred to
the cardiology team on January , 2005 , for further medical
management prior to cardiac catheterization for the
non-ST-elevation MI.
REVIEW OF SYSTEMS: Negative for chest pain , shortness of breath ,
dyspnea on exertion , abdominal pain , nausea , vomiting , fevers ,
chills , and dysuria.
PAST MEDICAL HISTORY:
1. Hypertension. Difficult to control on multiple regimen and
follow at LMHO .
2. Diabetes , also very difficult to control. His last
hemoglobin A1c was 11.4 on August , 2005.
3. Obstructive sleep apnea , on CPAP.
4. Hypercholesterolemia.
5. Status post cerebrovascular accident secondary to
hypertension.
6. Status post ICU pneumonia.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Home Medications: Metformin 1 g twice a day; Actos 30 every day;
TriCor 145 every day; Aceon 8 mg every day; acetabutolol 400 mg twice a day;
Lasix 60 mg orally twice a day; Tiazac 420 every day; Crestor 20 every day; and
Catapres-2 patch.
2. Medications On Transfer: Aspirin 325 every day; Plavix 75 every day;
Lipitor 80 every day; Lopressor 50 three times a day; captopril 50 three times a day;
hydralazine 20 four times a day; famotidine 20 twice a day; Colace 100 twice a day;
senna; heparin subcutaneously 5000 units three times a day; vancomycin 1 g
every 12 hours day #10; ceftazidime 2 g every 8 hours day #7; and levofloxacin
750 every day day #4.
SOCIAL HISTORY: The patient works in shipping. He lives with
his wife and three kids. Positive history of tobacco , no
alcohol , and no intravenous drug use.
PHYSICAL EXAMINATION: Vital Signs: T-max and T-current are
100.9; blood pressure is 138 to 190/72 to 102; pulse is 62 to 79;
respiratory rate 18 to 20; and O2 saturations 96% to 98% on 2
liters. General: The patient was slightly confused and
agitated , but answers in English and remembering his anniversary.
HEENT: PERRL. Positive subconjunctival hemorrhage , right
greater than left. Pulmonary: Some mild wheezes and upper
airway breath sounds bilaterally at the base; otherwise , clear.
CV: Regular rate and rhythm. S1 and s2. Mild systolic murmur
at the left lower sternal border. Abdomen: Soft , nontender , and
nondistended. Positive bowel sounds. Obese. Extremities: No
clubbing , cyanosis , or edema; 2+ DP pulses. Neurologic: Slight
left-sided weakness , 4/5 , in the upper and lower extremities.
Deep tendon reflex 2+ and symmetric.
LABORATORY DATA: His labs are significant for sodium 142 ,
potassium 4.0 , chloride 111 , bicarbonate 27 , BUN 26 , and
creatinine 1.2. His blood sugar is 172. His white count is 8.6 ,
hematocrit 29.2 , and platelets 200.
STUDIES:
1. On March , 2005 , his EKG showed ST abnormality and possible
lateral subendocardial injury.
2. On February , 2005 , echocardiogram showed LV mildly dilated
concentric hypertrophy. Function is normal. EF was 55% with no
wall motion abnormalities.
3. MRI/MRA with multiple small vessel infarctions; one in the
left cerebellum noted in the posterior corpus callosum , multiple
in the centrum semiovale on the right hemisphere.
4. Renal ultrasound , which showed bilaterally symmetric kidneys
with no hydronephrosis.
5. EEG abnormal consistent with moderate to diffuse cerebral
dysfunction , possibly secondary to toxic metabolic
encephalopathy. No definite epileptiform abnormalities.
6. Chest x-ray showing cardiomegaly and vascular congestion.
7. All his blood cultures and urine cultures had no growth to
date.
ASSESSMENT AND PLAN: This is a 44-year-old male with history of
hypertension , diabetes , high cholesterol , and obstructive sleep
apnea presenting with hypertensive crisis , pulmonary edema ,
status post ICU stay complicated by multiple strokes and
left-sided weakness , non-ST-elevation myocardial infarction
likely demand ischemia secondary to hypertension and agitation ,
hyperglycemia requiring ??___?? protocol , and question of
ICU-acquired pneumonia with spiking fever needing the use of
broad spectrum antibiotics. The patient is now transferred to
the floor for further management prior to catheterization.
HOSPITAL COURSE BY SYSTEMS:
1. CV: Ischemia: EKG showing sign of an evolving anterior MI.
The patient continued to be on aspirin , Plavix , and Lipitor. The
patient received a catheterization on August , 2005 , which shows
left oblique marginal #1 with 90% discrete lesion that was
stented to 0 with a DES stent and RCA with 80% discrete lesion
stented to 0. The patient was stable postcatheterization.
Pump: The patient's blood pressure continued to be high on the
floor. He was started on captopril 50 three times a day , eventually
increased to 100 three times a day; hydralazine 20 four times a day intravenous , eventually
switching over to 50 orally four times a day The patient was restarted on
home medication of clonidine patch as discontinuation can cause
labile hypertension. He was also started on Lasix 80 mg orally
twice a day During the catheterization , the patient was found to have
a pulmonary wedge pressure of 17 , which is elevated. He was
given intravenous Lasix to diurese. He diuresed very well with the orally
and intravenous dose.
Rhythm: The patient had two episodes of sinus pause greater than
3 seconds on September , 2005 , with no episodes since September ,
2005. It could be secondary to obstructive sleep apnea versus
conduction abnormality. Electrophysiology service was consulted.
The EP service encouraged the patient to wear a CPAP device
during the day. His beta-blocker was held secondary to the sinus
pause. However , after the catheterization and with the result of
obstructive lesion , the patient was restarted on low-dose
beta-blocker with atenolol 25 mg every day
2. Pulmonary: When transferred , the patient's sedation was
weaned and he was without any pressure on CCU day #4. He had
received Lasix for pulmonary edema. He continued to diuresed on
the floor with 80 mg orally of Lasix.
3. ID: The patient had spiked a fever to 104.1 on March ,
2005 , with a question of pneumonia. He was continued on his
vancomycin , ceftazidime , and levofloxacin for a 14-day course.
His vancomycin will be completed on discharge while he will need
to continue on ceftazidime and levofloxacin during
rehabilitation. The patient was MRSA negative. He continues to
have low-grade fever , but no frank fever over 100.4. The patient
continued to improve and does not complain of any subjective
fever.
4. GI: The patient received an NG tube on September , 2005 , but it
was self-discontinued. He had speech and swallow test , which he
passed and was started on the house diet. The patient received a
nutrition consult for his diabetes and was put on a cardiac and
diabetic diet. His magnesium and potassium were repleted.
5. Renal: On admission , his creatinine was 1.6 and trended down
to 1.2 and 1.1 prior to discharge. We thought that his
increasing creatinine is likely secondary from hypertensive
injury. The patient was given Mucomyst prior and after
catheterization. He tolerated the ACE inhibition with no rise in
creatinine.
6. Neurologic: On CCU day #5 , the patient developed weakness in
the left upper and lower extremity with concern for CVA.
Neurologic consult was initiated and MRI and MRA were obtained.
MRI/MRA showed small vessel disease consistent with
hypertension-induced CVA. He had a negative echocardiogram and
negative bubble study. The patient was given some physical
therapy and will likely need rehabilitation.
7. Endocrine: The patient takes Humalog 75/25 50 units before
breakfast and 20 units before dinner , NPH 20 at bedtime , and also
Actos and metformin. Here , the patient was given a NovoLog
sliding scale with 14 units of NovoLog before every meal and Lantus 35
every bedtime He will be continued on these doses and will need to be
transitioned to his home medications once he goes home.
8. Prophylaxis: The patient will receive PPI and heparin for
prophylaxis.
CODE: Full.
DISPOSITION: The patient will likely need rehabilitation for his
prolonged ICU course and also for his stroke.
DISCHARGE MEDICATIONS: The discharge medications will be
dictated as an addendum pending discharge.
eScription document: 4-9866651 SSSten Tel
CC: Sheri Unikel
Ainam Iro Hospital
Min Ral S
CC: Alexandra Popovic MD
Blodelersa Perv
CC: Kam Isa , MD , Ph.D. ,
Pande Memorial Hospital
Dictated By: STRAHL , ROSAURA
Attending: POPOVIC , ALEXANDRA
Dictation ID 8390481
D: 5/25/05
T: 5/25/05
Document id: 637
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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749366744 | PUO | 03259164 | | 0201680 | 11/6/2005 12:00:00 a.m. | RIGHT LOWER LOBE PNEUMONIA | Signed | DIS | Admission Date: 9/21/2005 Report Status: Signed
Discharge Date: 1/29/2005
ATTENDING: FILOMENA DONEHOO MD
ADMISSION DIAGNOSIS: Change in mental status.
DISCHARGE DIAGNOSIS: Hypercarbic respiratory failure and
aspiration pneumonia.
BRIEF HISTORY OF PRESENTATION: The patient is a 74-year-old
woman with a past medical history significant for rectosigmoid
cancer complicated with vesicular vaginal fistula status post
total pelvic exenteration , cystectomy with ileal loop diversion
on February 2004 , obesity , hypoventilation syndrome with chronic
respiratory acidosis status post gluteal sacral abscess who was
brought to the Emergency Department from a skilled nursing
facility with change in mental status and sacral wound infection.
In the Emergency Department at 4 p.m. her vitals were noted to
be a temperature 98 , heart rate 73 , blood pressure 145/63 , and
she was breathing 90% on 4 liters nasal cannula. She was noted
to have no orientation to place and ABG showed a pH of 7.2 , PCO2
103 and a PO2 of 249. At 5:30 p.m. the patient became
diaphoretic. Blood cultures were drawn and her mental status was
worsening. She was started on 100% nonrebreather and subsequent
ABG was 7.17 , PCO2 of 109 , PO2 of 217. With Bipap initiation her
ABG improved to a pH of 7.21 , PCO2 of 87 , PO2 of 87. Then , she
was subsequently intubated , started on assist control ventilation
with an ABG of 7.37 , PCO2 of 59 , PO2 141. She was a difficult
intubation , required fiberoptic assistance. Her vitals at that
time , she had a blood pressure of 80-90/60s , that slowly returned
to 110s/60s. In the Emergency Department , a head CT , PE protocol
CT and chest abdominal CT showed right lower lobe opacification.
She had a head CT that showed no acute intracranial abnormality.
An abdominal CT showed an air fluid collection in the pelvis and
some cholelithiasis and a CT PE showed no evidence of PE though
admittedly the study was limited and there was a small bilateral
pleural effusion and right lower lobe consolidative paucity
possibly representing an early pneumonia. She was started on
Levo Flagyl and Vanc and received 1-2 liters intravenous fluid. In
addition , she had elevated K which was treated with insulin D5
calcium gluconate. She had an EKG which showed T wave inversions
of V2-V4 and flat T waves in V5. She was admitted to the Medical
Intensive Care Unit where she was intubated and sedated with
Versed and Fentanyl , and at that time she was hemodynamically
stable.
PAST MEDICAL HISTORY: The patient's past medical history is
notable locally advanced rectosigmoid cancer T4 M1 metastatic
diagnosed in 2003. It was diagnosed in the context of diarrhea
and rectal bleeding and passing stool in the vagina and bladder.
She had vesicular and vaginal fistulas at that time. She is
status post total pelvic exenteration with ileal loop diversion
in February 2004 , status post XRT in July and September 2004 , status
post gluteal sacral abscess August 2004 , status post c-dif
colitis in August 2004 , status post e. coli MSS bacteremia in
August 2004 , obesity , hypoventilation syndrome. She normally
sats in the 80s on room air. She has iron deficiency anemia ,
GERD , osteoarthritis. An echo April 2004 showed normal left
ventricular function with an EF of 60% with question of elevated
right-sided pressures , LVH and she suffered immobility secondary
to XRT with back pain and lower extremity edema , status post
total abdominal hysterectomy in August 2001 , and had a
pulmonary evaluation in February 2004 in which she was assessed to
have obesity , hypoventilation syndrome , nocturnal oxygen
desaturation , chronic respiratory acidosis complicated with
longstanding obesity hypoventilation syndrome.
MEDICATIONS: The patient takes Tylenol as needed pain , vitamin C
500 twice a day , zinc sulfate 220 daily , iron sulfate 325 three times a day ,
oxycodone 5 every 4 hours as needed pain though she does not require that
very often , Toprol XL 50 daily , Lovenox 40 subcutaneously daily , Remeron
7.5 every bedtime , Xalantan 7 drops each eye , Seroquel 25 every bedtime , Nexium 20
daily , Mag oxide 800 twice a day
ALLERGIES: Erythromycin causes GI upset , penicillin causes mouth
sores.
SOCIAL HISTORY: She has two children , she is divorced , lives at
a skilled nursing facility , prior smoker but does not drink
alcohol and no history of intravenous drug use.
FAMILY HISTORY: Complicated with obesity. Father died at age of
83 of colon cancer. Mother had dementia.
PHYSICAL EXAMINATION: The patient is a morbidly obese woman who
at the time of the document exam was intubated , vented and
sedated. She was asleep , did not open her eyes. Her neck was
supple. Chest: There were coarse breath sounds with diffuse
wheezes. Her cardiac exam was notable for an S1 , S2 , regular
rate and rhythm and the JVP was difficult to assess. Abdominal
exam was notable for a colostomy. Her abdomen was soft ,
nontender , and no bowel sounds were appreciated. Her extremities
were warm and well perfused. Neurologically , she was sedated.
Skin was not notable for any rashes or petechiae.
HOSPITAL COURSE: By system:
1. Pulmonary: The patient was in the Medical Intensive Care
Unit from the 29 of March to the 25 of May of October . She has known obesity
hypoventilation syndrome. She was weaned from assist control to
pressure support ventilation. On the 25 of May , the patient self
extubated , was put on bipap and then quickly transitioned to
nasal cannula. The patient did report needing bipap at night at
one point though later on it was felt that she was not on bipap
at night normally. She has an elevated right hemidiaphragm seen
on chest x-ray and at baseline sats 90-93% on 2 liters. On the
floor , she was seen by pulmonary consult about management of her
obesity ventilation syndrome. At the time of discharge the
patient is to sleep on bipap 10/0. Those parameters will need to
be optimized with a sleep study after discharge and , in addition ,
the patient will have to be observed at night with sats being
monitored to qualify her for bipap at night. In the hospital we
did monitor her sats overnight and she satted 85-87% on 2 liters
of nasal cannula when she was sleeping at night.
2. Infectious Disease: The patient had a right lower lobe
pneumonia treated with levofloxacin and Flagyl that was started
in the Emergency Department on November , 2005. She will
complete a 14 day course of those antibiotics. The patient was
consistently afebrile and the thought was the patient had
aspiration right lower lobe pneumonia. The patient did receive a
few doses of Vancomycin which was later discontinued. The
patient was also treated by Diflucan and Flagyl to cover BV/yeast
infection as the patient was noted to have some vaginal
discharge. The vaginal discharge ultimately had negative
cultures. The patient also had a known stage intravenous decubitus in her
sacral area that did not appear to be infected.
3. Cardiovascular: The patient was volume overloaded after
receiving significant fluids when she first presented. She had a
left pleural effusion on subsequent chest x-rays. She was
diuresed aggressively with Lasix. Typical doses were 40 mg intravenous
and at the time of discharge the patient could comfortably lie
flat on her back without any discomfort. The patient also was
noted to have some ectopy. Her lytes were repleted. An
echocardiogram was checked which showed normal EF moderate right
ventricular dysfunction and no wall motion abnormalities. This
did not demonstrate any change from prior.
4. Neuropsych: The patient had an altered mental status likely
related to hypercarbic respiratory failure and also hypoxemia at
the time of present admission. She was weaned off sedation. She
had a negative head CT. When she was extubated , the patient was
alert and oriented and returned back to baseline mental status.
5. Heme: The patient was immobile at baseline and is high risk
for PET protocol. CT at the time of admission was negative and
the patient was treated with Lovenox prophylaxis. The patient
was also continued on her iron pills.
6. Renal: The patient has metabolic compensation for
respiratory acidosis which resolved during the ICU stay , and the
patient's creatinine return to baseline during her
hospitalization.
7. GI: The patient received tube feeds through her OG tube and
was transitioned to orally's.
8. Surgery/GYN: The patient has a known colonic vaginal fistula
with purulent vaginal discharge. She was seen by surgery and GYN
who evaluated her and looked at her abdominal CT and felt that
this was not a clinically significant fistula and was not in fact
a source of infection.
9. Disposition: The patient will be discharged to a skilled
nursing facility/rehab facility. She requires intensive
rehabilitation and nursing given her body habitus and her limited
mobility.
DISCHARGE MEDICATIONS: The patient will be discharged on vitamin
C 500 twice a day , calcium carbonate 500 three times a day , Colace 100 twice a day ,
Pepcid 20 twice a day , iron sulfate 325 three times a day , mag oxide 840 twice a day ,
mag sliding scale , Flagyl 500 orally three times a day to finish on November , zinc sulfate 220 mg orally daily , Lovenox 40 mg subcutaneously daily ,
Xalantan 1 drop each eye every afternoon , levofloxacin 500 mg orally daily to
finish on August , miconazole nitrate 2% topical powder
twice a day , Combivent neb 2 puffs four times a day as needed , Promod 2 scoops
orally daily , Maalax every 6 hours as needed upset stomach.
eScription document: 1-3935274 DBSSten Tel
Dictated By: ESANNASON , BELINDA
Attending: DONEHOO , FILOMENA
Dictation ID 7537071
D: 8/30/05
T: 8/30/05
Document id: 638
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
045911026 | PUO | 32796229 | | 283892 | 7/19/2002 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 7/16/2002 Report Status: Signed
Discharge Date: 9/1/2002
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE EXACERBATION.
PROBLEMS: 1. CHRONIC ATRIAL FIBRILLATION.
2. CONGESTIVE HEART FAILURE WITH AN EJECTION FRACTION
OF 40%.
3. CORONARY ARTERY DISEASE STATUS POST 2-VESSEL CABG
IN June 2001 , STATUS POST MYOCARDIAL INFARCTION
IN June 2001.
4. DIABETES MELLITUS X10 YEARS.
5. HYPERTENSION.
6. PERIPHEROVASCULAR DISEASE.
7. HISTORY OF BLADDER CANCER STATUS POST RESECTION.
8. HYPERCHOLESTEROLEMIA.
9. LUMBAR STENOSIS.
10. CHRONIC RENAL INSUFFICIENCY , BASELINE CREATININE
1.1-1.4.
OPERATIONS/PROCEDURES: Intubation and central venous line
placement.
COMPLICATIONS: None.
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman
with a history of coronary artery
disease , congestive heart failure , chronic atrial fibrillation ,
multiple cardiac risk factors , who presented with 2-3 days of
increased shortness of breath , orthopnea , weight gain and
peripheral edema. The patient admits to some dietary indiscretion ,
having been eating Chinese food but reports good compliance with
all her medications. She denied chest pain , diaphoresis. Weight
gain was 2 pounds , going from 184 to 186 pounds. She also reported
severe fatigue and considerable dyspnea.
PAST MEDICAL HISTORY: As listed above.
MEDICATIONS ON ADMISSION: Lasix 120 mg twice a day , NPH insulin 42
units in the morning , 8 units in the
evening , Coumadin 4 mg Monday , Wednesday and Friday , 3 mg Tuesday ,
Thursday , Saturday and Sunday , amiodarone 300 mg every day , cozor 40 mg
every day , Lopressor 50 mg twice a day , Niferex 150 mg twice a day ,
multivitamins , nitroglycerin sublingual as needed chest pain.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives alone but her daughter is next door.
Denies alcohol use. Quit smoking 20 years ago.
PHYSICAL EXAMINATION: In the emergency room the patient was
afebrile with a heart rate of 105 , blood
pressure 123/72 , breathing at a rate of 20 , satting 88% on room
air , increased to 95% on 2 L nasal cannula. The patient jugular
venous pressure to her ear. LUNGS: Decreased breath sounds
one-third of the way up bilaterally with scattered crackles.
HEART: Irregularly irregular without murmurs reported. The
patient has a 2/6 diamond shaped early peaking systolic ejection
murmur at the right upper sternal border consistent with her
diagnosis of aortic stenosis/sclerosis. ABDOMEN: Soft , nontender.
Left greater than right 1+ pitting edema to the ankles.
LABORATORY STUDIES: Chemistries notable for creatinine of 1.7 ,
BUN 34 , hematocrit 48.1 , CK flat at 33 ,
troponin 0.02. Chest x-ray showed bilateral pleural effusions and
pulmonary edema. ECG compared with April 2001 showed no
ischemic changes.
HOSPITAL COURSE: CARDIOVASCULAR: The patient was given
increasing doses of Lopressor for rate control of
her atrial fibrillation up to 100 mg orally four times a day On 2/6/02 the
patient was found with a heart rate in the 30s. It was then
decreased to the 20s and the patient was presyncopal. A code blue
was called. The patient was treated with atropine and
transthoracic pacing and Dopamine for hypotension. The patient was
intubated for airway protection. She weaned slowly off the vent in
the cardiac care unit , was extubated on 9/14/02 and transferred to
the floor on 3/20/02 . On the floor the patient was convalescing ,
diuresing with Lasix 40 mg intravenous as needed for a goal of 500-1 , 000 cc
negative each day. This intravenous dose was changed to 80 mg orally twice a day
The patient's Captopril was titrated up as her blood pressure
tolerated and this was changed to zestril 40 mg before discharge.
The patient continued on amiodarone 200 mg orally every day , which was
changed to 300 mg orally every day on discharge. The patient remained in
sinus rhythm with a heart rate ranging from 48 to the high 60s.
The patient was not symptomatic with this relative bradycardia but
it was noted that in the future if this persists , a pacemaker
should be considered.
PULMONARY: The patient had fever and hypoxia in the cardiac care
unit. Sputum was cultured and grew pansensitive pneumococcus. The
patient was started on ampicillin which was changed to amoxicillin
on day seven of antibiotics. The patient was also placed
temporarily on albuterol and Atrovent nebs which were discontinued
on 11/28/02 .
FEN/GI: The patient had a mild hypernatremia up to 152 and
contraction on glyc improved with regard to correcting her
intravascular volume status. She was maintained on low salt diet
and lytes were repleted as needed The patient was kept on regular NPH
doses with CZI sliding scale as needed Although morning sugars ranged
in the 60-70s , afternoon glucoses were often in the mid 200s. Mrs.
Dreesman primary care physician may want to consider adding a
midday dose of regular insulin.
DERMATOLOGY: The patient had palmar and plantar lesions diagnosed
by dermatology as palmoplantar keratoderma that was treated with
miconazole.
Physical therapy was consulted and gave recommendations about
oxygen use at home as well as use of a walker and home safety.
DISPOSITION: The patient was discharged to home with VNA
services and home oxygen in place through the MMC
care coordination.
DISCHARGE MEDICATIONS: Amiodarone 300 mg orally every day , amoxicillin
875 mg orally twice a day x6 days , buffered
aspirin 81 mg orally every day , Lasix 80 mg orally twice a day , insulin NPH 42
units subcutaneously every day before noon , 8 units subcutaneously every afternoon , zestril 40 mg orally every day ,
cozor 40 mg orally every bedtime , Niferex 150 mg orally twice a day , Coumadin 4 mg
orally every Monday , Wednesday , Friday , Coumadin 3 mg orally every Tuesday ,
Thursday , Saturday , Sunday.
CONDITION ON DISCHARGE: Good.
Dictated By: DESIRAE R. MARCOTT , M.D. JM20
Attending: DENISHA H. MCRORIE , M.D. RZ9 JI397/871291
Batch: 17994 Index No. A2TDVF5US8 D: 6/20/02
T: 6/20/02
CC: 1. ROSSIE MANKOSKI , M.D.
Document id: 639
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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924541354 | PUO | 20578241 | | 7360686 | 8/14/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/14/2004 Report Status: Signed
Discharge Date:
ATTENDING: JACKSON PART MD
DISCHARGE DATE: 2/18/04 , anticipated.
PRINCIPAL DIAGNOSIS: Coronary artery disease.
SECONDARY DIAGNOSIS: Aortic stenosis , COPD , cough , diabetes ,
history of DVT , hypertension , GERD.
HISTORY OF PRESENT ILLNESS: This is a 78-year-old man with a
history of coronary artery disease , COPD , end-stage renal disease
on hemodialysis , and ischemic cardiomyopathy presenting as a
transfer from Osri Medical Center for management of ischemic
cardiomyopathy and aortic stenosis. Briefly , he was admitted to
Osri Medical Center on 7/16/04 , with varied symptoms including
a nonproductive cough , bronchospasm , and shortness of breath. He
also was hypoglycemic with a glucose of 34 , likely due to
anorexia and continued used of regular amounts of insulin. He
was found to have positive cardiac enzymes as well with a
troponin peaking at approximately 4.3 , and was seen by
Cardiology , Renal Services in consultation. Concurrently , he was
treated with a course of azithromycin and ceftriaxone for
presumed bronchitis. The initial plan recommended by Cardiology
included an echocardiogram , which was read at that time ,
indicated decreased ejection fraction of only about 15% to 20%.
This represented a change from prior. The next step intended was
for a cardiac catheterization , but there was concern regarding
his aortic stenosis which despite a gradient of only 14% on
echocardiogram , was concerning , as this might represent an
underestimation. He was transferred to Pagham University Of for further evaluation of both the need for aortic valve
replacement and this new reduced ejection fraction , felt to
likely be ischemic cardiomyopathy , with a demand related
non-ST-elevation MI.
Of note , he also had a pulmonary artery pressure of 68 on his
prior echo. He has had a cardiac cath in 2000 showing
well-preserved ventricular function , overall EF 60% , with LAD 30%
to 40% , 60% diagonal , 100% RCA , 60% OMB , and diffuse circumflex
disease.
Shortly before transfer , he was hemodialyzed as regularly
scheduled. He had been placed on a prednisone taper for
questionable COPD exacerbation.
At this time , he denies any chest pain or chest heaviness now or
prior to admission. He has no back or jaw pain. He does have
shortness of breath with a nonproductive cough and wheezes. No
fevers , chills , nausea , vomiting. No orthopnea. Increased lower
extremity edema and increased salty food intake immediately prior
to Merla Medical Center hospitalization. He was feeling well one week
prior to admission at Osri Medical Center .
PAST MEDICAL HISTORY: Diabetes mellitus , insulin dependent ,
end-stage renal disease on hemodialysis x 2 years ( Monday ,
Wednesday , Friday ) , coronary artery disease , known three-vessel
disease , possible history of MI 20 years ago , hypertension ,
ischemic cardiomyopathy , DVT status post IVC filter placement ,
possibly two filters , removed , hyperlipidemia , COPD , home O2
requirement of 3 liters , sats 97% , prostate cancer , status post
XRT , GERD , depression.
MEDICATIONS AT HOME: Insulin NPH 14 units every day before noon , 10 units
every afternoon , 10 units regular insulin every day before noon , insulin sliding scale ,
quinine 325 mg orally before dialysis , captopril 25 mg orally three times a day ,
nitroglycerin patch , Serevent , Flovent , Flomax 0.4 mg , Lipitor 20
mg every bedtime , Protonix 40 mg orally , albuterol and Atrovent nebulizer
treatments , Paxil 10 mg every day , Senokot twice a day , PhosLo two
capsules three times a day , Coumadin 2.5 mg orally every day.
MEDICATIONS ON TRANSFER: Prednisone 10 mg , Serevent , quinine 325
mg , captopril 25 mg three times a day , Flovent twice a day , Flomax 0.4 mg every day ,
Lipitor 20 mg every day , Protonix 40 mg every day , Paxil 10 mg every day ,
aspirin 325 mg every day , albuterol nebulizers , PhosLo two tablets
three times a day , nitroglycerin paste , Nephrocaps , azithromycin ,
last dose 10/26/04 , NPH insulin 10 units twice a day , Epogen 14K units
every Sunday , heparin.
ALLERGIES: Demerol.
SOCIAL HISTORY: A retired boiler worker , lives in Roville Sas Ta with
his wife. No living children. Not currently smoker. Rare
alcohol use.
FAMILY MEDICAL HISTORY: Son died at age 44 of renal cancer.
PHYSICAL EXAMINATION: Notable for O2 sat of 96% on 4 liters ,
coughing but no distress , blood pressure 106/56. JVP , 6 cm.
Diminished second sound , 3/6 mid peaking systolic ejection
murmur , high pitched , audible at apex , left lower sternal border ,
and aortic ausculatory area. Abdomen: Moderately obese , soft ,
nontender , no bruits. Femoral pulses: Weak , no distal pulses , no
edema. Extremities: Warm.
EKG: Sinus is 74 , LVH , left atrial enlargement , old inferior MI
with Q waves in III and aVF.
LABS: Notable for a creatinine of 7.4 , INR of 1.7 , hematocrit of
34.8 , white count of 11.9. Chest x-ray , clear.
ASSESSMENT AND PLAN: A 78-year-old man with coronary artery
disease , diabetes , end-stage renal disease , COPD , aortic
stenosis , here with shortness of breath , and increased troponins.
The most concerning feature was interval decrease in ejection
fraction from 60% to 10% to 15% over a four-year interval.
Slightly ischemic concerning with old inferior MI and with
elevated troponins.
COURSE BY SYSTEM:
1. Cardiovascular: He was maintained on aspirin , statin , and
ACE ( renally dosed ). Beta-blocker held secondary to
bronchospasm. His echo was reevaluated and felt to be close at
30% ejection fraction. He had a diagnostic cardiac
catheterization to assess his aortic stenosis on 9/10/04 . The
findings were an aortic valve area of 1.2 to 1.6 cm2 with aortic
gradient of 21.1. His pulmonary artery pressure was peak of 61 ,
mean of 35. His vessels showed an LAD ostial 70% lesion , and LAD
proximal to mid 70% tubular lesion , a large marginal 80% lesion
left circumflex , a 100% occluded right coronary artery , with left
to right collaterals. It was also found to have a difficult
placing a right IJ catheter , likely occluded.
2. Cardiac surgery was consulted and these findings were
discussed. It was felt that he was a better candidate for
percutaneous stenting rather than immediate surgery given the
balance between his only mild-to-moderate aortic stenosis and the
high risks of surgery. Accordingly , he was observed over the
weekend and had a repeat catheterization on 2/12/04 with
stenting of the left circumflex marginal lesion from 99% to 0%
with a drug-eluting stent. He tolerated this procedure well
without hematoma and with maintenance of dopplerable pedal
pulses.
3. Pulmonary: He continued to have good oxygen saturations on 4
liters. After several days , he was tapered to 0 mg of
prednisone; he continued to have severe cough that gradually
improved , nonproductive throughout. He was on antitussive
medications as needed. He completed a course of azithromycin
that had been started at Osri Medical Center . Chest x-rays were
clear x 2. He attempted PFTs , but his vital capacity was
severely limited by cough. However , his FEV1 was 0.89 , 40% of
predicted.
4. Hematologic: His Coumadin was held given the unclear need
for acute anticoagulation ( remote DVT , already protected by IVC
filter ) and the concern that he might need an intervention. This
was started shortly before discharge with the expectation he
would follow up as prior to admission with his INRs.
5. Renal: He was seen by the Renal Team and dialyzed to his dry
weight on a Monday , Wednesday , Friday schedule.
6. Endocrine: His blood sugars were somewhat labile ranging
from the 300s to the 40s. This was complicated by the use of
prednisone. Post prednisone , he was placed on home regimen of 14
units every day before noon , 8 units every afternoon of NPH , and 8 units regular every day before noon
eScription document: 1-3838758 ISSten Tel
Dictated By: RADEMAN , CAITLIN
Attending: PART , JACKSON
Dictation ID 4408064
D: 10/11/04
T: 10/11/04
Document id: 640
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
- |
Y |
N |
N |
Y |
- |
N |
N |
Y |
N |
N |
- |
630372501 | PUO | 76001088 | | 1456979 | 2/15/2006 12:00:00 a.m. | noncardiac chest pain | | DIS | Admission Date: 2/15/2006 Report Status:
Discharge Date: 10/28/2007
****** FINAL DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 673-14-60-6
Caro Euadie
Service: MED
DISCHARGE PATIENT ON: 7/9/07 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAKAI , RHEBA ROSINA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALPRAZOLAM 1 MG orally every 4 hours as needed Anxiety
Instructions: on every 4 hours at home
ASCORBIC ACID 500 MG orally twice a day
ASPIRIN ENTERIC COATED 325 MG orally DAILY
Alert overridden: Override added on 11/6/06 by
FRIES , SPENCER L. , M.D.
on order for ASPIRIN ENTERIC COATED orally ( ref #
205193630 )
patient has a POSSIBLE allergy to IBUPROFEN; reaction is GI
upset.
patient has a POSSIBLE allergy to KETOROLAC TROMETHAMINE;
reactions are Rash , GI upset.
patient has a POSSIBLE allergy to NSAIDs; reactions are GI
upset , patient tolerates home asa. Reason for override: patient needs
DULCOLAX ( BISACODYL ) 10 MG orally DAILY as needed Constipation
CLOPIDOGREL 75 MG orally DAILY
DIGOXIN 0.125 MG orally DAILY HOLD IF: sbp<100 , heart rate<60
Alert overridden: Override added on 11/6/06 by
FRIES , SPENCER L. , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: will monitor
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FUROSEMIDE 80 MG orally DAILY
Alert overridden: Override added on 11/6/06 by
FRIES , SPENCER L. , M.D.
on order for FUROSEMIDE orally ( ref # 156435839 )
patient has a POSSIBLE allergy to DYAZIDE; reaction is SOB.
Reason for override: will monitor
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally DAILY
HOLD IF: SBP<100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LEVOTHYROXINE SODIUM 50 MCG orally DAILY
Override Notice: Override added on 11/6/06 by
FRIES , SPENCER L. , M.D.
on order for DIGOXIN orally ( ref # 094825439 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: will monitor
LIDOCAINE 5% PATCH TOPICAL TP DAILY
Instructions: on for 12 hours , off for 12 hours - on 2
patches at home
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 30 MG orally twice a day
HOLD IF: oversedation , RR<10
OXYCODONE 30 MG orally every 4 hours as needed Pain
HOLD IF: lethargic , rr<20
PREGABALIN 150 MG orally twice a day
Alert overridden: Override added on 11/6/06 by
FRIES , SPENCER L. , M.D.
on order for PREGABALIN orally ( ref # 904747047 )
patient has a POSSIBLE allergy to GABAPENTIN; reaction is
alopecia. Reason for override: patient tolerates at home
Number of Doses Required ( approximate ): 10
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally BEDTIME
HOLD IF: diarrhea
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
SODIUM CHLORIDE 3 GM orally three times a day
VANCOMYCIN HCL 1 GM intravenous every 12 hours Instructions: last day 6/25/07
ZINC SULFATE 220 MG orally twice a day
Food/Drug Interaction Instruction
Take 1 hour before or 2 hours after meals.
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lapin , ID clinic , PUO Oklahoma , 507-978-7612 July at 2pm scheduled ,
Dr. Lero , MMC , 168-515-7171 June at 2:40pm scheduled ,
Dr. Eckloff ( spine clinic Massachusetts ) January @8:30am ,
ALLERGY: DYAZIDE , Penicillins , NSAIDs , Erythromycins ,
AZITHROMYCIN , Tape , IBUPROFEN , KETOROLAC TROMETHAMINE ,
BUPROPION HCL , GABAPENTIN
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
noncardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
fibromyalgia ( fibromyalgia ) htn ( hypertension ) history of gastric bypass
( history of gastric bypass surgery ) obesity
( obesity ) anemia ( anemia ) spinal stenosi ( spinal
stenosis ) CAD history of MI ( coronary artery disease ) history of coronary stent
( history of coronary stent ) pacemaker
( pacemaker ) Hyperlipidemia ( hyperlipidemia ) anxiety
( anxiety ) TAH ( hysterectomy ) ccy ( cholecystectomy )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
**CC: chest pain
**HPI: 58F history of gastric bypass , fibromyalgia , HTN , DM , history of recent
laminectomy and washout for infected seroma and washout. She's had
frequent admissions for atypical chest pain at multiple
hospitals. On DOA , noted that at exactly 1:30 PM had sudden onset of
sscp 10/10 which she described as someone sitting on her chest and
stabbing her. This pain lasted through 2 episodes of nitro sublingual , a 3rd
dose in the ED , and was finally relieved by morphine.
**In ED: 60 , 18 124/71 , 99%RA given morphine 2mg intravenous x 3 , then morphine
4 mg intravenous x 3 , then lopressor x 1 , then xanax x 1. Pain relieved 4 hours
after start of pain.
*****
PMHx: cath in 10/22 with occlusion of LAD history of cypher stent. laminectomy.
chronic pain. fibromyalgia. DM , HTN , obese , anemia , hyponatremia ,
tobacco use
*****
PE: 68 18 141/73 99% RA GEN: obese woman , tearful , anxious , heent:
mmm , cn ii-xii intact , symmetric. no bruit , jvp 7-8cm ,
pulm: cta bilatearlly , Cor: rrr , no m/r/g. abd obese history of surgery.
ext: bronzing LE , +2 pulses. neuro intact ( decreased sensation
bilateral lower extremities )
*****
Labs: CK: 89 CKMB: 7.9 TNI <0.10 WBC 10 , HCT 33 => ruled out on
5/3 CXR: nothing acute - L sided pacer , R sided PICC In
SVC PE-CT: neg for PE. unable to assess for
DVT EKG: most vpaced but one in nsr with TWI laterally.
( new in v3-v6 ).
*****
Events: 5/3 ruled out for MI. Subsequently c/o frequent episodes of
chest pain that she says are relieved by NTG and morphine , suspect
noncardiac.
MIBI results 4/20/07 : normal perfusion and normal EF , area of abnormal
uptake in L axilla , recommended mammogram
*****
IMPRESSION: Ms. Huitink is a 58F with a history of diabetes , CAD history of stent to
LAD in 2004 , permanent pacemaker for ?afib/SSS , who was admitted with
chest pain that she described as exactly like her MI with ckmb elevated.
However she also stated that her chest pain had never really resolved
after her cath in 2004. Complicating factors include multiple admissions
for chest pain , chronic pain syndrome , and narcotic dependence.
**CV: i: Initially there was concern b/c her CKMB fraction was
elevated , and there were T wave inversions in V3-V6 that seemed new in a
non-paced EKG that was captured. She received one dose of therapeutic
lovenox , which was discontinued when she ruled out. She continued to
complain of chest pain throughout her admission , which typically would be
relieved by morphine. Suspicion for cardiac chest pain is low , but a
MIBI was obtained to determine her baseline. The MIBI
revealed normal perfusion and normal EF. There was abnormal uptake in the
left axilla , and obtaining a mammogram was recommended.
**NEURO: High pain med requirements secondary to chronic pain , and
surgical interventions. She was maintained on regimen as outlined in
last d/c summary , including MS Contin 30mg twice a day and oxycodone 30mg orally every 4 hours
as needed pain. Pain service was called but did not see her in house and
recommended outpatient follow up with either rheumatology or psychiatry
re her chronic pain syndrome and fibromyalgia. Bladder training can be
considered given her urinary incontinence.
**ORTHO: recent procedure ( 10/24 L3-L5 laminectomy for cauda equina ,
I&D for seroma 7/8 . Orthopedics followed while she was in house. She
was noted to have a small protrusion likely muscle herniation in the site
of the recent procedure. Dr. Lapin ID saw the patient and will see
her in follow up. She is to continue the vancomycin through 6/25/07 , and
then the vancomycin and the PICC should be discontinued. She will follow up
with Dr. Eckloff on July .
Full code
ADDITIONAL COMMENTS: You were admitted to Pagham University Of with chest pain. Your
blood was checked and you did not have a heart attack. You should follow
up with your primary care doctor , Dr. Lero , at the scheduled
appointment. You should also follow up with Dr. Lapin , infectious
disease specialist , at the scheduled appointment.
Call your doctor or return to the Emergency Department if you have any
severe chest pain , shortness of breath , fainting , or any other concerning
symptoms.
You need to have a mammogram done as an outpatient. Please ask your
primary doctor to order this
Vancomycin stops 1/2/06 . PICC line needs to be taken out.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) consider psychiatric or rheumatologic follow-up re her chronic pain
and fibromyalgia
2 ) consider outpatient bladder training re her urinary incontinence
3 ) please order mammogram , abnormal uptake in L axilla on MIBI
No dictated summary
ENTERED BY: KILLIN , ALMEDA V. , M.D. ( XS81 ) 7/9/07 @ 12:57 PM
****** END OF DISCHARGE ORDERS ******
Document id: 641
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
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Obe |
OSA |
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| output/system_textual_annotation.xml | textual |
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152307321 | PUO | 82935889 | | 2729236 | 9/7/2003 12:00:00 a.m. | SVT , CHF with pulmonary edema | | DIS | Admission Date: 9/22/2003 Report Status:
Discharge Date: 10/28/2003
****** DISCHARGE ORDERS ******
KODADEK , ROY K 770-62-37-9
Sawauirv Riirv Sland , Nebraska 87578
Service: MED
DISCHARGE PATIENT ON: 4/19/03 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 1/2/03 by
GORT , NANCI , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
Reason for override: will follow
LASIX ( FUROSEMIDE ) 40 MG orally every day before noon Starting Today October
Alert overridden: Override added on 1/2/03 by
GORT , NANCI , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: will follow
METOPROLOL TARTRATE 12.5 MG orally twice a day HOLD IF: sbp<90 , heart rate<60
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
TERAZOSIN HCL 2 MG orally every day
Number of Doses Required ( approximate ): 4
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOVENT ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
MMC primary care physician 1-2 weeks ,
ALLERGY: Quinine ( quinine sulfate ) , Sulfa , G6pd deficiency
ADMIT DIAGNOSIS:
SVT , pulm edema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
SVT , CHF with pulmonary edema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
atrial fibrillation ( atrial fibrillation ) hypertension ( hypertension )
glaucoma ( glaucoma ) copd ( chronic obstructive pulmonary
disease ) cholesterol ( elevated cholesterol ) asthma
( asthma ) gout ( gout ) cerebrovascular disease ( cerebrovascular disease )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT scan chest: resolving L lingular/LUL opacities/consolidative
process. Slight residual lingular atelectasis , resolvins.
No edema.
Echo: normal aortic root; LA normal RA mod enlarged; RVH , enlarged ,
mild HK; concentric , mild LVH with EF 55%; no MR , no AR , no AS; LV
diastolic dysfunction; mild TR with markedly elevated PA systolic
pressure ( 63mmHg+RA pressure ).
BRIEF RESUME OF HOSPITAL COURSE:
71M COPD on home O2 , diastolic dysfuntion , PAF ,
admitted with narrow complex SVT , decompensated heart failure. patient
presented after several days of SOB , orthopnea , DOE with few steps.
Denies CP/palpitations. In ED , HR 140s , converted to
SR with 6 adenosine. CXR showed pulmonary
edema. IMP: Likely CHF exacerbation with unclear etiology ,
infectious vs. ischemic vs. acute volume overload ( dietary
noncompliance ) vs. medical noncompliance. COURSE/PLAN: CV: ROMI was
negative. ECHO showed markedly elevated R heart pressures , LV
diastolic dysfunction. Fluid
restriction in hospital. Diuresis with lasix. patient diuresed negative
1.5 liters
and symptomatically was much improved on HD#2. MIBI as outpatient.
PULM: ? COPD exacerbation. duonebs ,
prednisone. Stopping prednisone on d/c. ID: no evidence of
infection. RENAL: follow bun/cr. DISPO:
Decompensated CHF likely in setting of dietary/medicine non-compliance.
Will counsel patient with regard to dietary regulation of fluid
balance.
ADDITIONAL COMMENTS: Use home oxygen for shortness of breath. Take medicines as directed.
Weigh yourself daily and report any weight
gain or weight loss to your physician. Limit daily salt intake as this
may cause fluid to build up in your lungs. Use inhaler on schedule to
help breathing.
Resume normal activity as you tolerate , advancing activity slowly.
Patient will require MIBI cardiac stress test as outpatient.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Monitor your sodium intake , and weight daily , make sure you are not
gaining weight from day to day. Take medicines as directed. Schedule
follow up appointment with MMC primary care physician in 1-2 weeks for follow up. Use
home O2 as needed for comfort. You will need a cardiac stress test as
an outpatient.
No dictated summary
ENTERED BY: DEVAUGHAN , MAMMIE M. , M.D. ( ME531 ) 4/19/03 @ 02:25 PM
****** END OF DISCHARGE ORDERS ******
Document id: 642
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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OA |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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Y |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
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724162269 | PUO | 53976075 | | 880602 | 5/18/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/8/1996 Report Status: Signed
Discharge Date: 4/5/1996
PRINCIPAL DIAGNOSIS: CARDIOMYOPATHY.
SIGNIFICANT PROBLEMS: 1. Coronary artery disease. 2.
Hyperlipidemia.
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old gentleman
with a history of CAD dating back to
1991 when the cath showed one vessel disease. He was not
angioplastied. The patient had an MI at that time which was
medically managed. The patient did well until July of 1995 when
the patient had another anterior MI , massive , treated with
thrombolytics. Cardiac catheterization at that time revealed a 99%
proximal RCA and serial 70% LAD lesions. The patient also was
noted to have a severe LV dysfunction with an ejection fraction of
28% and his MI was complicated by a complete heart block and a dual
chamber pacemaker was placed. At that time the patient was
considered to be a surgical candidate secondary to high risk. In
August of 1995 the patient was admitted for non Q wave MI with a
peak CK of 798 , positive MB fraction , and was again treated with
thrombolysis with TPA. The patient did well with no anginal
symptoms but has had primarily symptoms of CHF with dyspnea upon
exertion , progressive shortness of breath , and limited exercise
tolerance since that time. In July of 1996 the patient had an
exercise tolerance test with oxygen consumption measured at 11.8
ml/kg. The patient exercised for 6 minutes and reached a maximal
heart rate of 114 and stopped secondary to dyspnea. Given the
patient's poor functional status he presented for cardiac
catheterization and complete workup for cardiac transplant. The
patient admits no shortness of breath at rest but with 1-2 flights
of steps. He also becomes short of breath with ten minutes of
light labor. The patient also has daily angina with neck pain
radiating to his head which is relieved with rest.
PAST MEDICAL HISTORY: 1. CAD , as above status post MI times three
in 1991 and 1995 twice. 2. CHF , ischemic
cardiomyopathy with ejection fraction of 28% since July of 1995.
3. Hyperlipidemia with a cholesterol in the 300s.
FAMILY HISTORY: Positive for coronary artery disease paternal
uncle , died at that age of 39 of an MI. Sister
died at the age of 66 of an MI. Brother had an MI at the age of
55. Positive for diabetes mellitus in a paternal uncle. Positive
for hypertension in his mother. Father died of emphysema.
SOCIAL HISTORY: Positive for tobacco , four packs per day times 20
years , quit in 1991. Ethanol , one glass of wine
per day , quit in 1995. Married times 27 years , three children ages
21 to 25. Retired merchandise wholesaler , currently on disability.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Digoxin 0.125 mg orally every day , Lasix 80 mg orally
every day , Lopressor 25 mg orally twice a day , Captopril
6.25 mg orally three times a day , Mevacor 40 mg orally every day , Coumadin 2.5
alternating with 5 mg orally every day , and Nitro patch.
PHYSICAL EXAMINATION: Blood pressure 101/78 , pulse 69 ,
respirations rate of 18 , T max was 97.6. In
general a middle aged male in no acute distress. HEENT: Pupils
equal , round , and reactive to light , extraocular movements intact ,
poor dentition. Neck was supple with a JVD of 9 cm. Positive
jugular reflux , no bruits. CARDIAC: Regular rate and rhythm , S1
and S2 , positive S3 , no murmurs. LUNGS: Clear to auscultation.
ABDOMEN: Positive bowel sounds , no masses , non-tender.
EXTREMITIES: 2+ pulses , no edema. NEUROLOGIC: Alert and oriented
times three. Cranial nerves 2-12 intact , nonfocal. RECTAL:
Guaiac negative. Prostate no nodules.
LABORATORY EXAMINATION: Sodium of 145 , potassium 4.9 , chloride
102 , bicarb 28 , BUN 24 , creatinine 1.5 ,
glucose of 90. Calcium of 9.9 , phosphorus 3.4 , cholesterol 178 ,
triglycerides 129. Hematocrit 54 , white count of 5.5 , platelet
count of 188 , 000. physical therapy 1.3 , PTT of 30.5. LFTs: AST 54 , ALT 39.
EKG showed a left bundle branch block with Q waves in V1 and V3 ,
biatrial enlargement , inverted T waves in II , III , and AVF. Chest
x-ray revealed cardiomegaly , DDD pacer wires in position , lungs
clear.
HOSPITAL COURSE: The patient was admitted originally for a workup
for cardiac transplant. The patient had a
cardiac transplant labs drawn , had a PPD placed , which was negative
with positive controls. The patient had a psychiatry consult.
Hepatitis serology for hepatitis B and C were negative. The
patient was kept on heparin at therapeutic levels and was diuresed
with Lasix. His Captopril was also increased. The patient was
also treated with Isordil. At this point the patient was
reassessed and it was thought that he might be a candidate for a
revascularization. With this in mind , the patient was scheduled
for a ETT Thallium which if positive for ischemia he would go for a
cardiac catheterization. In the meantime the patient was medically
managed , diuresed of three to four liters over the several days of
admission. His Isordil was increased and he was continued on aspirin and
digoxin , on Mevacor. Further transplant labs revealed a TSH of
2.8 , T3 of 159 , T4 of 7.8. Urine 24 hour collection total volume
was 4200 cc , creatinine of 29 , urine protein less than assay. The
patient had his ETT Thallium which showed a question of septal
ischemia with a fixed apical defect. The patient went 6 minutes on
a standard Bruce protocol with a maximum heart rate of 156 , stopped
secondary to chest pain and 1 mm ST segment depressions. The
patient went to cardiac catheterization the following day. The
patient's cardiac catheterization revealed three vessel disease
with a 100% LAD. His catheterization film was evaluated by cardiac
surgery , Dr. Colasamte who believed that the patient would not benefit
from a CABG. Given this , the patient received a continued
transplant workup of a CT of the abdomen , as well as a dental
consult , with a planned tooth extraction , with appropriate
premedication with amoxicillin , and holding of his heparin. The
patient tolerated this well. Preliminary report on the CT of the
abdomen showed a small single less than 1 cm hepatic lesion. The
patient was medically stable on discharge.
The patient was found to have increasing LFT's upon discharge. Subsequently ,
his mevacor was dicontinued and LFT's returned to norma. DISCHARGE
MEDICATIONS: Captopril 25 mg orally three times a day , digoxin 0.125 mg orally every day , Lasix
80 mg orally twice a day , Isordil 20 mg orally three times a day , Mevacor 40 mg orally every day
( Discontinued immediately after discharge ) , Coumadin to be taken for 5 mg
every bedtime for four days and then to resume the 2.5 mg
with 5 mg every other day
FOLLOW-UP: The patient is to follow-up with the Cardiomyopathy
Service. The patient will be followed up to see how he
is tolerating his new medical regimen and be further evaluated for
cardiac transplant.
Dictated By: FRANSISCA W. LUEHRS , M.D. AH35
Attending: SACHIKO S. BORRIELLO , M.D. LV2 YZ241/8792
Batch: 97719 Index No. Z1OOBX8NTK D: 2/19/96
T: 3/1/96
Document id: 643
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
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U |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
N |
747683306 | PUO | 99239194 | | 115537 | 11/27/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/25/1994 Report Status: Signed
Discharge Date: 6/22/1994
DISCHARGE DIAGNOSIS: ATRIAL FIBRILLATION.
SECONDARY DIAGNOSES INCLUDE: 1. ASTHMA.
2. MORBID OBESITY.
3. ALCOHOL ABUSE.
HISTORY OF PRESENT ILLNESS: Ms. Kundla is a 50 year old woman with a
long history of asthma who presented
with shortness of breath and palpitations. Her asthma is
characterized by multiple short admissions for flares , last in
October 1993 , and multiple courses of steroid tapers. At home , she
uses Ventolin and Theophylline. Her other medical problems include
morbid obesity and a history of alcohol abuse. She has had
palpitations in the past and a Holter in 4/19 showed only three
episodes of supraventricular tachycardia. She has also had a
stress test in February 1992 which was a nine minute arm cycle
stress test with maximal heart rate of 128 and systolic blood
pressure of 120. The test was negative for ischemic changes. She
has never had an EKG showing atrial fibrillation. She came into
the Emergency Ward on 8/22/94 complaining of two weeks of
intermittent palpitations as well as shortness of breath. She used
increased doses of her Ventolin inhaler for this and continued on
her Theophylline. She felt her heart fluttering quite a bit and
intermittently , these palpitations would go away. She never took
her heart rate during these episodes nor could she characterize her
heart as being irregular. Prior to the palpitations beginning , she
had gone on a drinking binge and had drank a half a pint of brandy.
She has had a cough productive of whitish sputum but no change in
the sputum character chronically. Her asthma has been slightly
increasing with increased wheezing and she has been using her
inhaler more. In the Emergency Ward , her EKG showed atrial
fibrillation with a heart rate in the 130 range. She was
controlled with intravenous Diltiazem and admitted for new onset
atrial fibrillation. PAST MEDICAL HISTORY: As above and also
including degenerative joint disease of the knees and ankles.
CURRENT MEDICATIONS: Slo-phyllin and Ventolin Inhaler. ALLERGIES:
She had no known drug allergies. SOCIAL HISTORY: She lives with
her two children , has used alcohol in binges , and does not smoke.
FAMILY HISTORY: She has a family history of coronary artery
disease with a mother who died of a myocardial infarction in her
fifties.
PHYSICAL EXAMINATION: She was a morbidly obese black female in no
acute distress. Her temperature was 98.2 ,
heart rate 108 , blood pressure 110/68 , and O2 saturations 96% on
two liters. HEAD/NECK: Examinations were negative , her jugular
venous pressure was not visible secondary to obesity , and her
carotids were 1+ bilaterally. LUNGS: Showed scant wheezing at the
left base otherwise were clear. CARDIAC: Examination was
irregularly irregular , she had distant S1 and S2 , and no murmurs.
ABDOMEN: Obese , soft , non-tender , and no organomegaly.
EXTREMITIES: Without definite edema. RECTAL: Examination was OB
negative with decreased tone. NEUROLOGICAL: Examination was
essentially non-focal.
LABORATORY EXAMINATION: Notable on admission were a theophylline
level of 23.6 which was elevated , an SMA 7
which was within normal limits with the exception of a potassium of
3.8 , BUN and creatinine of 5 and 0.9 , and CBC showed a white count
of 6.1 , hematocrit 40.8 , and platelets of 288. An EKG showed
atrial fibrillation at 136 with low voltage and poor R wave
progression. Chest X-Ray showed no infiltrates or effusions.
HOSPITAL COURSE: The patient was admitted to the Medical Service.
Her rate was controlled with intravenous
Diltiazem drip which was changed over to 90 mg orally every day In
addition , she was started on Digoxin and her rate was controlled to
the seventies and eighties. She was also heparinized and
coumadinized and an ACE consultation was obtained given her history
of alcohol abuse. She was not interested in further out-patient
care for this matter but has the number and will call if she
desires it. Also , a Nutrition consultation was obtained given her
obesity and she will follow-up with them as an out-patient.
DISPOSITION: She is followed in KTDUOO Clinic by Dr. Tomeka Haugland
and he will see her as an out-patient in one week at
which time he will schedule her an admission for elective
cardioversion after she has been anti-coagulated for at least three
weeks. DISCHARGE MEDICATIONS: Coumadin 5 mg orally every day , Diltiazem
SR 180 mg orally twice a day , Beclovent Inhaler two puffs inhaled four times a day ,
Atrovent Inhaler two puffs inhaled four times a day , and Nitroglycerin
sublingually as needed
Dictated By: DEANDRA L. GILFOY , M.D. HC88
Attending: BRITTANEY N. HAMBLET , M.D. QX8 WS652/7514
Batch: 2721 Index No. KITK2U7M4G D: 11/11/94
T: 3/2/94
Document id: 644
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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344979897 | PUO | 56655452 | | 0059078 | 11/12/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/1/2005 Report Status: Signed
Discharge Date:
ATTENDING: STUKOWSKI , JANAY MD
INTERIM DISCHARGE SUMMARY
This is a dictation of the patient's Cardiac ICU stay in Ropines Fre Delp
This is an interim dictation covering postoperative days #1-#10.
Date of admission 6/11/05 . Date of discharge from the Cardiac
ICU 11/4/05 . The remainder will be dictated by the PA on the
floor prior to patient's discharge to home including discharge
medications and additional hospital course.
SERVICE:
Cardiac Surgery Service.
ADMISSION DIAGNOSIS:
Coronary artery disease , three-vessel.
DISCHARGE DIAGNOSIS:
Three-vessel coronary artery disease status post CABG x4.
OPERATIONS:
On 10/2/05 , CABG x4 , sequential graft , SVG1 ( aorta to OM1 and
OM2 , LIMA to LAD , SVG to PDA ).
OTHER PROCEDURES NOT IN THE OPERATING ROOM:
Video swallow on 6/17/05 .
HISTORY OF PRESENT ILLNESS:
The patient is a 68-year-old male with a history of non-insulin
dependent diabetes , hypertension , atrial fibrillation , status
post cardioversion ( on orally amiodarone since 11/13 ) ,
nephrolithiasis , lung cancer status post XRT , and right lower
lobectomy in 1996 , presenting with six-month history of
exertional chest pain when climbing greater than one flight of
stairs or walking up hills , relieved with 30 seconds to 1 minute
of rest. The patient describes pain as "burning , " pain in left
chest , nonradiating , not associated with nausea , vomiting , or
diaphoresis. He denies rest pain. The pain has not been
accelerating or progressive in nature. The patient had a
positive exercise tolerance test at A Triaded Health , limited by
reduced exercise tolerance and shortness of breath ( blood
pressure elevated , no EKG changes ) , so went on to have MIBI on
6/18/05 showing moderate size defect in inferolateral and
inferobasal segments with near complete reversibility , normal LV
ejection fraction of 70% , no regional wall motion abnormalities.
Cardiac catheterization done on 6/11/05 , at PUO showed
three-vessel coronary artery disease with occluded RCA , focal
severe proximal LAD stenosis , and significant disease of OM1 and
OM2. He presents for a CABG.
PREOPERATIVE CARDIAC STATUS:
Elective. The patient presented with critical coronary anatomy.
The patient has a history of class II angina ( slight limitation
of coronary activity ). There has been no recent angina. The
patient does not have symptomatic heart failure. The patient is
in first-degree AV block. The patient has a history of
AF/flutter treated with amiodarone 200 mg orally daily after
cardioversion in 1997.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST MEDICAL HISTORY:
Hypertension , diabetes; on orally agents , hypothyroidism ,
hypercholesterolemia , COPD; on bronchodilator therapy , chest
radiation to right lung , nephrolithiasis , childhood polio , atrial
fibrillation status post cardioversion ( on amiodarone 200 mg orally
daily since 11/13 ) , lung cancer status post XRT , and right lower
lobe lobectomy in 1996 , mild peripheral neuropathy ( diabetic ) ,
diabetic retinopathy , cataracts , colonic polyps , hypothyroidism ,
CAD , angina , asthma , and radiation bronchiectasis.
PAST SURGICAL HISTORY:
Status bronchoscopy , right thoracotomy , right lower lobe
lobectomy with radical lymph node dissection on 10/15/96 , status
post bronchoscopy and cervical mediastinoscopy 10/1/96 , status
post attempted extraction of kidney stones with left flank
incision in 1960.
FAMILY HISTORY:
Coronary artery disease , father with MI at age 64.
SOCIAL HISTORY:
History of tobacco use , 100-pack-year cigarette smoking history ,
history of occasional alcohol use. The patient is retired
manager for Y Mont and drives rental cars now.
ALLERGIES:
Sulfa , unknown reaction.
ADMISSION MEDICATIONS:
Lopressor 50 mg orally twice a day , amlodipine 5 mg orally daily ,
lisinopril 40 mg orally daily , amiodarone 200 mg orally daily ,
isosorbide 60 mg orally daily , aspirin 325 mg orally daily ,
hydrochlorothiazide 25 mg orally daily , albuterol two puffs four times a day ,
fluticasone two puffs twice a day , Lipitor 20 mg orally daily , Avapro
150 mg orally daily , Levoxyl 112 mcg orally daily , glyburide
one-quarter tablet of 5 mg tablet orally daily.
PHYSICAL EXAMINATON:
Height and Weight: 5 feet 9 inches , 69.1 kg. Vital Signs:
Temperature 96.9 , heart rate 62 , blood pressure on the right
145/82 and on the left 142/79 , satting 95% on room air. HEENT:
Pupils are equal and reactive , dentition without evidence of
infection. No carotid bruits. Chest: Right thoracotomy
incision , well healed. Cardiovascular: Right: Regular rate and
rhythm , no murmurs. Allen's test , left upper extremity normal ,
right upper extremity normal. Pulses , 2+ carotid , radial ,
femoral , dorsalis pedis , posterior tibials bilaterally.
Respiratory: Clear to auscultation bilaterally. Prolonged
expiration , scattered mild rhonchi , diffusely on the left ,
decreased breath sounds , right base. Abdomen: Well-healed left
flank incision , soft , no masses. Extremities: With scarring ,
varicosities , or edema. Neuro: Alert and oriented.
PREOPERATIVE LABS:
Notable for creatinine of 1.3 , hematocrit of 37.2 , and platelets
257 , 000. Cardiac catheterization data , 6/11/05 , 70% proximal
LAD lesion , 100% mid OM1 lesion , 70% ostial OM2 lesion , 100%
ostial RCA lesion , 70% distal RCA lesion , right dominant
circulation , collateral flow , SEP2 to right PDA , collateral flow
OM1 to OM1 , normal left circumflex , LEVF of 70% with no regional
wall motion abnormalities , no renal artery stenosis.
Ventriculogram , 70% ejection fraction. EKG: First-degree AV
block at 55 , inverted Ts in AVR , first-degree AV block in
postcatheterization EKG. Chest x-ray on 6/11/05 with evidence
of prior right lobe lobectomy. Lungs are clear no effusions.
Trachea is slightly deviated to the right.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:
The patient was admitted on 6/11/05 following cardiac
catheterization showing three-vessel coronary artery disease with
occluded RCA , focal severe proximal LAD stenosis , significant
disease of OM1 and OM2. He was assessed preoperatively for
coronary artery bypass surgery. He was taken to the operating
room on 10/2/05 where he underwent CABG x4 with the sequential
graft with saphenous vein graft , one connecting the aorta to OM1
then OM2 , LIMA to LAD , saphenous graft 2 to PDA. The patient was
then bypassed for 108 minutes. He left the operating room with
one ventricular wire , two pericardial tubes ( Blake drains ) , and
one left pleural tube ( Blake drain ). For further details , please
see the dictated operative note. The patient was taken to the
cardiac surgery ICU on Ve following surgery.
ICU COURSE BY SYSTEM:
Neuro: The patient was alert and oriented x3 throughout his ICU
stay. Following extubation , the patient had marginal respiratory
status , so pain control was accomplished with intravenous Dilaudid. The
patient had a history of chronic renal insufficiency , so Toradol
was avoided. When the patient was taking orally's , Dilaudid was
changed to orally Dilaudid. Pain control was good with orally
Dilaudid throughout his ICU stay.
Cardiovascular: The patient was in normal sinus rhythm on
postoperative day #1 through #3. However , the patient flipped
into atrial fibrillation in the 110s to 120s at 0100 on
postoperative day #3. He was started initially on his home dose
of 200 mg orally daily of amiodarone. However , later on
postoperative day #3 , this was changed to an amiodarone drip.
The patient was continued on amiodarone drip at 1 for six hours
and later decreased to 0.5 of amiodarone drip. Amiodarone drip
continued from postoperative day #4 to #5. The patient remained
in atrial fibrillation , so on postoperative day #3 at 1:00 a.m.
to postoperative day #6 , when he converted to sinus rhythm at
0500. The patient was transitioned to 200 mg orally daily of
amiodarone , which she was continued on at home after receiving
one full day of 400 mg orally three times a day amiodarone. He was
transferred out of the unit on 200 mg orally daily of amiodarone.
The patient was started on 50 mg orally four times a day of Lopressor. Since
postoperative day #6 , the patient has remained in rate controlled
sinus rhythm without any episodes of atrial fibrillation. The
patient is also on aspirin and Zocor.
Respiratory: The patient is status post right lower lobectomy in
1996 for lung cancer and has a 100-year smoking history. His
respiratory status was marginal following extubation at 0400 on
postoperative day #1. The patient remained on 100% high flow
oxygen from postoperative day #2 to #4. The patient required
every 2 hours nasotracheal suctioning and every 1h. chest physical therapy in order to keep
him from being re-intubated. From postoperative day #2 to #4 , on
chest x-ray , the patient's right middle lobe appeared to be
collapsed. There was a question of atelectasis versus pneumonia.
The patient was started on levofloxacin on 9/30/05 on
postoperative day #2 , for questionable right middle lobe
pneumonia , as lobe is collapsed and the patient had extremely
thick secretions. The patient was continued on aggressive chest
physical therapy and pulmonary toilet. He had a strong cough and was able to
cough up thick secretions on his own. The patient was unable on
postoperative day #2 to #3 to remove mask without desats into the
70s to 80s. He was started on his nebulizers around the clock on
Atrovent and mucomyst nebs , as well as his home inhalers of
fluticasone and albuterol. The patient appeared to be tiring
early in the morning on postoperative day #3 and Anesthesia was
called for an evaluation but the patient continued to struggle
along on 100% oxygen for two more days between BiPAP and 100%
high flow oxygen. With BiPAP , patient's pO2 on his gas was
improved. ABGs continued improved as the patient was able to
mobilize more. The patient is diuresed with the Lasix drip with
improvement in his respiratory status as well. The goal is to
keep patient 1 liter negative in order to improve his pulmonary
status. The patient had an episode on postoperative day #3 of
20-second loss of consciousness while getting nasotracheal
suction around 2300 on 8/28/05 . This was initially thought to
be hypoxic in origin. However , the patient had two further
episodes with strong cough on postoperative day #5 and #6 of 20
to 30-second losses of consciousness with no signs of a vagal
origin on cardiac monitor.
By postoperative day #5 to #6 , the patient's respiratory status
had improved. Diuresis was continued. The patient was given a
dedicated triple-lumen catheter with a dedicated TPN line on
8/20/05 , postoperative day #4 , as it was unclear whether the
patient would turn the corner and avoid intubation , and the
patient was also without nutrition for several days at this
point. The patient continued to improve in terms of his
respiratory status with diuresis. By postoperative day #6 , the
patient's right middle lobe appeared to be re-expanding on chest
x-ray. It continued to be re-expanded from postoperative day #6
to #10 on transfer from the unit on 11/4/05 . The patient is
continued on three times a day Lasix after his drip was turned off on
10/22/05 . Goal was to keep the patient negative in order to
maximize his pulmonary status. The patient has marginal
pulmonary reserve. The patient also continues on levofloxacin
for a total of an 11-day course for prophylaxis against
pneumonia.
GI: The patient is on a minced diet on transfer from the unit.
The patient was evaluated by Speech and Swallow. On
postoperative day #5 , 6/17/05 , a bedside evaluation was
performed and a video swallow was done. The patient at this time
was cleared for puree and thin liquids with a chin tuck. This
was changed to a minced diet on postoperative day #8 , as the
patient was thought to find this more palatable. The patient was
started on Nexium following extubation. TPN was started through
a dedicated port after a line change on postoperative day #4.
This was done , so the patient could continue getting nutrition
despite his marginal respiratory status. TPN was still continued
on discharge from the unit on 11/4/05 , as the patient had been
having calorie counts performed by nursing in order to make sure
that the patient was taking in adequate nutrition prior to
discontinuation of TPN. The patient continues to be in
aspiration risk , as he has very poor pulmonary status at
baseline. Continue calorie counts on discharge from the unit and
Nutrition will recommend stopping TPN when the patient is taking
enough in calories orally
Renal: The patient's baseline creatinine was 1.3. His
creatinine has been stable around the 1.6 to 1.8 , postop
following diuresis with Lasix. The patient was started on a
Lasix drip on postoperative day #1 in order to gently diurese
him. He was continued on a Lasix drip until postoperative day #9
with adjustments to keep him negative and per chest x-ray every
morning. The patient was transitioned to 20 mg intravenous three times a day Lasix
on 10/22/05 , on postoperative day #9. This was increased on
postoperative day #10 , 11/4/05 , to 40 mg intravenous three times a day prior to
transfer from the unit , as the patient looked wet on chest x-ray.
The patient's right middle lobe appeared re-expanded on
postoperative day #6 to #10. This is critical for patient's
pulmonary reserve. Goal will be to keep the patient negative in
terms of his fluid balance in order to maximize his pulmonary
status. His creatinine has continued to remain stable. The
patient is urinating well and responds well to Lasix.
Endocrine: The patient was initially placed on a Portland
protocol and transitioned after postoperative day #3 to NovoLog
sliding scales with meals. At the time of transfer from the ICU ,
he continues on glipizide 5 mg orally twice a day and then NovoLog
sliding scale with meals and nightly. He is also on NovoLog 8
units subcutaneously with meals. This will be continued on transfer.
Sugar control has been good with these agents. The patient
remains on Levoxyl 112 mcg orally daily for his hypothyroidism.
Heme: The patient was started on aspirin on postoperative day #0
through his orogastric tube. This was continued on postoperative
with ECASA 325 mg orally daily , the patient's hematocrit and
platelets have been postop requiring no transfusions.
ID: The patient was started on levofloxacin on 9/30/05 ,
postoperative day #2 , for question of pneumonia with right middle
lobe collapse versus pneumonia on chest x-ray. This was
continued for a total of 11 days. The patient self medicates
with levofloxacin at home for bronchiectasis and chronic
bronchitis when his secretions become thick and troublesome.
eScription document: 5-4456674 EMSFocus transcriptionists
Dictated By: CISTRUNK , EDGARDO
Attending: STUKOWSKI , JANAY
Dictation ID 6534084
D: 8/29/05
T: 8/29/05
Document id: 645
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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- |
906128280 | PUO | 93229960 | | 4273057 | 10/10/2005 12:00:00 a.m. | CHF flare | | DIS | Admission Date: 3/4/2005 Report Status:
Discharge Date: 4/19/2005
****** FINAL DISCHARGE ORDERS ******
STINGLE , ASIA 829-70-24-1
Lo
Service: MED
DISCHARGE PATIENT ON: 2/21/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOVA , DOUGLASS V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
Override Notice: Override added on 9/1/05 by
STAPLINS , TEISHA S , M.D.
on order for COUMADIN orally ( ref # 32664506 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
ATENOLOL 50 MG orally every day before noon Starting Today September
ENALAPRIL MALEATE 10 MG orally every day
LASIX ( FUROSEMIDE ) 80 MG orally every day Starting Today August
HOLD IF: sbp < 100
NPH INSULIN HUMAN ( INSULIN NPH HUMAN ) 60 UNITS subcutaneously every day before noon
Starting Today September
NPH INSULIN HUMAN ( INSULIN NPH HUMAN ) 60 UNITS subcutaneously every afternoon
Starting Today August
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting NOW August
Instructions: Take every Monday , Wed , Fri , Sat , Sun.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 9/1/05 by
STAPLINS , TEISHA S , M.D.
on order for SIMVASTATIN orally ( ref # 48105465 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: mda Previous override information:
Override added on 9/1/05 by STAPLINS , TEISHA S , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
PAXIL ( PAROXETINE ) 50 MG orally every day
SEROQUEL ( QUETIAPINE ) 800 MG orally every afternoon
Number of Doses Required ( approximate ): 4
DEPAKOTE ER ( DIVALPROEX SODIUM ER ) 1 , 000 MG orally every afternoon
LIPITOR ( ATORVASTATIN ) 60 MG orally every day
Alert overridden: Override added on 2/3/05 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: mda
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Annabel Verfaille August 2:30 PM scheduled ,
Dr. Sylvia Oniell February scheduled ,
Arrange INR to be drawn on 9/6/05 with f/u INR's to be drawn every
7 days. INR's will be followed by Dr. Sylvia Oniell
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Aflutter with RVR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF flare
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) history of MI 2000 ( history of myocardial infarction )
PE ( pulmonary embolism ) Schizophrenia
( schizophrenia ) gut malrotation ( 3 ) Atrial fibrillation ( atrial
fibrillation ) IDDM ( diabetes mellitus type 2 ) HTN
( hypertension ) dysfunctional uterine bleeding ( dysfunctional uterine
bleeding ) uterine fibroid ( uterine fibroids ) history of rheumatic fever ( history of
rheumatic fever ) history of c-section x2 ( history of cesarean section )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CXR - clear
EKG - Aflutter
Lower Extremity Vascular Ultrasound - negative for DVT bilaterally
BRIEF RESUME OF HOSPITAL COURSE:
---
ID: 52 year old woman ---
CC: SOB , weight gain ---
DX: CHF
HPI: 52 yr old woman with a history of of rheumatic heart disease , CHF , HTN ,
Type 2 DM on insulin , CAD , history of MI 2000 , and A fib/flutter , who
presents with 2 days of increasing SOB and weight gain. Per patient -
came in to ED because CHF nurse noted weight gain. patient also
describes 2 days of swelling in her legs and an increasing SOB. patient
had to sleep with 3 pillows , rather than her usual 2. 1 day PTA
patient developed pain in her L lower leg , described as a "knot in
her calf." Day of admission , patient weight was noticed to be +10 lbs
and she was recommended to come to the ED. Patient has
+orthopnea , PND , fatigue. At baseline patient becomes SOB when
climbing 2 stairs. She denies any palpitations , cp , n/v/d. Admits
auditory and visual hallucinations ( men and women crawling on the
wall saying things about
me ). PMH: Htn , CAD history of MI 2000 , Rheumatic Fever c valve dz ,
CHF , IDDM , Depression , Schizophrenia , Afib/flutter , Fibroids ,
Dysfunctional Uterine Bleeding , history of PE , history of domestic violence
--- EVENTS:
In the ED , EKG showed the patient to be in A flutter with HR in the
110s. She was given 25 mg orally Lopressor x 2 , which brought her HR down
to the 80s. Patient described a period of chest pain while in the
ED , which lasted for seconds. The pain was described as sharp ,
midline , and pleuritic.
7/5 - no O/N events 4/21 - no O/N
events ---
STATUS: VS: T: 97.1 , HR 80 , BP 106/67 , RR 18 , O2sat 98% on RA GEN:
breathing comfortably ,
NAD NECK: JVP
flat PULM:
CTAB CV: NL S1 and S2. No
MRG's ABD: obese. soft. NT. mild distention. +BS. No masses
or bruits EXT: DP and TP 2+ , 1+ pitting edema bilaterally.
Left calf , ankle tender anteriorly and posteriorly. + Homan's
sign. ---
STUDIES/TESTS: 5/12/05 CXR: mild kyphosis , no effusion , moderate
cardiomegaly no change since 11/5/05 8 EKG: HR 118 , A flutter.
Previous EKG ( 7/20/05 ) showed A fib , which was changed from a
previous A flutter.
4/21 - Bilat Lenis - neg for DVT ---
PROBLEM LIST: 1 ) Pulm - Currently treating this as a CHF exacerbation
- etiology likely diet non-compliance. Very
mild BLE edema , inc abd girth and wt gain. Ischemia ruled
out. 2 ) CV - I: ruled out with enzymes x3. Continue ASA , Metop ,
Statin , ACE P - CHF , likely minor flare
2/2 diet non-compliance. Continue Lasix R: patient appears to have history
of Afib/flutter , unclear if goes in and out , but patient states always in
Afib. Rate control with BB , coumadin - last INR
2.8. 3 ) Endo - history of DM - FS high on HD1 , now 140s -150s after
increased NPH dose to 60 every day before noon and every afternoon - cont RISS. 4 ) Psych - history of
schizophrenia , with active aud and vis hallucinations ( chronic , for
years ). ALso , was issue of domestic violence from first husband but per
social work - this appears to be remote. SW spoke with patient in ED.
No psych consult at this
time as psych issues appear to be at baseline. Social Work is
seeing patient regarding getting her section 8 housing. 5 ) FEN -
Monitor Lytes , replace Mg , K as needed. 6 ) Ppx - on
Coumadin 7 ) CODE - Full
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
follow up with Annabel Verfaille , the CHF nurse.
it is very important that you maintain your careful low salt diet and do
not drink too many fluids. Otherwise you will end up back in the
hospital. Continue to measure your daily weights. Be very strict about
taking your insulin.
Seek medical attention if you develop worsening shortness of breath ,
chest pain , lightheadedness , dizziness , or any other concerning symptoms.
No dictated summary
ENTERED BY: STAPLINS , TEISHA S , M.D. ( PO959 ) 2/21/05 @ 10:56 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 646
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
- |
N |
N |
N |
Y |
N |
N |
N |
579817978 | PUO | 25198085 | | 804794 | 1/29/2002 12:00:00 a.m. | VULVAR ABSCESS | Signed | DIS | Admission Date: 5/24/2002 Report Status: Signed
Discharge Date: 5/3/2002
ADMISSION DIAGNOSES: VULVAR ABSCESS , DIABETES.
PRINCIPAL DISCHARGE DIAGNOSES: VULVAR ABSCESS , DIABETES , CORONARY
ARTERY DISEASE , LEFT VENTRICULAR
SYSTOLIC FUNCTION.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old obese
woman with a long history of poorly
controlled IDDM , and recurrent abscesses. She presents with one
week of left groin pain and enlarging palpable mass. She first
noticed a tender bump six days prior to admission and was seen in
GYN clinic three days prior to admission at which time she was
afebrile with a white count of 10.6 and was prescribed a ten-day
course of Levaquin. Her symptoms persisted and she had the onset
of chills so she returned to the GYN clinic the day of admission ,
was afebrile with a 5 x 3 cm vulvar mass and the finger stick of
390. She was admitted to the I Warho Hospital for intravenous
antibiotics and diabetic control with the plan for I&D by GYN.
PAST MEDICAL/SURGICAL HISTORY: Insulin-dependent diabetes mellitus
diagnosed in 1987 , bilateral
peripheral neuropathy , depression with recently discontinued Paxil ,
history of asthma , no current medications , no recent flares or
intubations , hemorrhoids , status post I&D for left thigh and
buttock abscesses , status post TAH-LSO , status post surgery for
ectopic pregnancy , status post RSO for ovarian abscess , status post
excision of lingular mass ( hemorrhagic infarct , no malignant
cells ) , status post systemic biopsy for mild chronic gastritis.
MEDICATIONS ON ADMISSION: Insulin 70/30 70 units twice a day; Nexium 40
every day; Diflucan 100 every day; DesOwen
lotion; Lac-Hydrin lotion; Endocet 5/325 twice a day; Levaquin 500 every day
x 10 days.
ALLERGIES: Codeine which causes constipation; Demerol which causes
hallucinations; penicillin which causes hives.
FAMILY HISTORY: Breast cancer in her mother and sister , ovarian
cancer in her paternal grandmother. Coronary
artery disease and borderline diabetes in her mother.
SOCIAL HISTORY: She is a positive one pack a day smoker x 36
years , denies alcohol or drug use. She has a
large extended family in the area. A history of noncompliance with
diabetes management.
REVIEW OF SYSTEMS: Twenty-five pound intentional weight loss over
the past two months , decreased energy ,
shortness of breath on climbing one flight of stairs. Pain in legs
with exercise. Recent polyuria , polydipsia , and noted blood on the
underwear in the distant past , believed it to be hemorrhoids.
PHYSICAL EXAMINATION: On admission. VITAL SIGNS: Afebrile ,
temperature 98.2 , heart rate 97 , blood
pressure 140/88 , respirations 18 , oxygen saturation 99% on room
air. GENERAL: Obese , middle-aged woman in no acute distress.
HEENT: PERRL. EOMI. Oropharynx clear. Moist mucous membranes.
Positive upper dentures. NECK: No LAD , thyroid not palpable.
CHEST: Clear to auscultation bilaterally. HEART: S1S2 , no
murmurs , rubs or gallops. JVP at 8.0 cm. ABDOMEN: Soft ,
nontender , nondistended , positive bowel sounds , no
hepatosplenomegaly , no masses. EXTREMITIES: Tender , 3.0 cm , firm
mobile , nonfixed , nonerythematous question flocculent mass in her
left groin without associated lymphadenopathy. She did not have
palpable lower extremity pulses , though her extremities were warm
with less than 2 second capillary refill. NEURO: Alert and
oriented x 3. Cranial nerves intact. 5/5 strength bilaterally
upper and lower extremities. Sensation grossly intact upper and
lower extremities , thought some subjective altered sensation in the
lower extremities bilaterally.
IMPRESSION: A 48-year-old female with a long history of poorly
controlled insulin-dependent diabetes , initially admitted
for an I&D left vulvar abscess , control of her diabetes in the
setting of infection , though she developed acute pulmonary edema
after being on the insulin drip and ultimately had a cardiac workup
which revealed severe left systolic dysfunction with an EF of 30%
and a 2-3 coronary vessel disease.
HOSPITAL COURSE: 1 ) Infectious Disease: She had a vulvar
abscess , received gentamicin ( dosing per levels )
and clindamycin for the duration of her hospital course. Her
cultures revealed 1+ vaginal flora , anaerobic culture revealed
bacteroides , pepto Strep and Propionibacterium. She is status post
an I&D of the vulvar abscess on hospital day #2 which throughout
the hospital course showed no signs or symptoms of further
infection and the plan is for her to follow up with Dr. Stepler as an
outpatient and for her to go home on clindamycin to complete a
fourteen-day course.
2 ) Diabetes mellitus: On admission her finger sticks were 600.
She at that time received a 15 unit bolus with subsequent insulin
drip until the OR. She transitioned to subcutaneously insulin on hospital
day #3 and when her diet returned she returned to NPH similar to
home dosing of 50 twice a day and Regular 14 moved up to 17 units twice a day
with a sliding scale to cover. Her sugars were in the high
100s-low 200s on this regimen. Her discharge sugars were about the
same and she was discharged on her original outpatient dose of
70/30 70 units twice a day
3 ) Cardiopulmonary: On hospital day #1 the patient started with
complaints of cough and shortness of breath with sort of a
plus/minus response to nebs , given her history of asthma and
smoking. She had a chest x-ray that showed pulmonary edema with
small effusions which was felt to be due to the fluid from the
insulin drip. She had an EKG with a left bundle branch block which
was new from an EKG in 2000. She then was placed on a rule out
protocol with flat enzymes. An echocardiogram that revealed a 30%
ejection fraction , global hypokinesis , moderate to severe decrease
in systolic function , moderate MR , trace TR. She underwent an
adenosine MIBI stress test to show a small reversible perfusion
defect ( diagonal coronary artery distribution ) , severe global
hypokinesis. She was placed on aspirin and simvastatin ( LDL 160s ) ,
Lopressor , and Captopril. She was diuresed with Lasix intravenous. She
underwent a cardiac catheterization on October which revealed LAD
long 80% stenosis , 50% RCA stenosis , and a pulmonary wedge pressure
of 27. A coronary artery bypass graft was recommended by
cardiology and after a family meeting they decided on discharge
with follow up for CABG decision and planning.
4 ) GI: Low salt fluid restricted diet in-house and started on
Nexium for a history of gastritis.
5 ) Renal: BUN and creatinine was turning upward after the
titration of her ACE inhibitor , this was monitored and stabilized.
6 ) Pulmonary: Pulmonary wedge pressure of 27 , the patient with
pulmonary hypertension likely due to left volume overload. She was
going home with Lasix 40 mg orally.every day and lisinopril 20 twice a day
The discharge plan was for her to be discharged medically optimized
for cardiac surgery , if she makes the decision to go in that
direction. She has follow up appointments with both her primary
care physician Dr. Katheryn Gruntz and GYN Dr. Stepler .
DISCHARGE MEDICATIONS: Clindamycin 300 mg four times a day; simvastatin 20
mg every day; lisinopril 20 mg twice a day; atenolol
25 mg every day; Lasix 40 mg every day; aspirin 325 mg every day; insulin 70/30 70
units twice a day subcutaneously
DISCHARGE FOLLOWUP: Dr. Stepler , for her to call and make an
appointment in two weeks. Primary care
physician Dr. Katheryn Gruntz , make an appointment within one week.
Dictated By: GAYE FRANZA , M.D. XF08
Attending: ROXANNA E. MOLTER , M.D. NM7 VS852/163316
Batch: 97090 Index No. RCSFP178JI D: 1/4/02
T: 1/4/02
CC: 1. EVELIA STEPLER , M.D.
2. KATHERYN SATURNINA GRUNTZ , M.D.
Document id: 647
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
- |
N |
Y |
Y |
Y |
N |
N |
098812026 | PUO | 57870793 | | 4453094 | 6/19/2005 12:00:00 a.m. | Congestive heart failure | | DIS | Admission Date: 10/3/2005 Report Status:
Discharge Date: 1/24/2005
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Beth
Service: CAR
DISCHARGE PATIENT ON: 5/11/05 AT 07:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SERVICE , QUINN STEPANIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ATENOLOL 100 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 500 MG orally three times a day
HYDROCHLOROTHIAZIDE 50 MG orally every day
LISINOPRIL 5 MG orally every day
Override Notice: Override added on 4/5/05 by
RICCIARDONE , NELLY , M.D. , PH.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
55934602 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: Aware
Previous override information:
Override added on 6/26/05 by RYDALCH , SARAH K. , M.D.
on order for KCL SLOW RELEASE orally ( ref # 94151825 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 6/26/05 by RYDALCH , SARAH K. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 73757664 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day
RHINOCORT ( BUDESONIDE NASAL INHALER ) 2 SPRAY nasal twice a day
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: To inframammary area.
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 10
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG every day before noon; 10 MG every afternoon orally every day 40 MG every day before noon
10 MG every afternoon Starting Today November
ALDACTONE ( SPIRONOLACTONE ) 12.5 MG orally every day
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 7/8/05 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: MD aware
DIET: Fluid restriction: 2 liters
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Meghann Christenson 11/29/05 scheduled ,
Dr. Lizbeth Maphis 10/24/05 scheduled ,
Dr. Verdell Pee 6/28/05 at 9 am scheduled ,
ALLERGY: Aspirin , IRON DERIVATIVES , NSAIDs , FERROUS SULFATE
ADMIT DIAGNOSIS:
Congestive Heart Failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) restrictive lung disease ( restrictive pulmonary
disease ) chf ( congestive heart failure ) fibromyalgia
( fibromyalgia ) von willebrand's ( hemophilia ) sleep apnea ( sleep
apnea ) iron deficiency anemia ( iron deficiency anemia ) hypoxia
( hypoxia ) GERD , history of TAH/BSO , PICA. ? central hypoventilation syndrome.
OA.
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: I can't sleep without sitting up
HPI: Pendarvis is a 47 year-old woman with history of OSA , Pulm HTN , morbid
obesity , on home 02 ( 5L at baseline ) presenting with 1 week of
orthopnea , cough productive of yellow sputum , and increased dyspnea on
exertion. At baseline , becomes SOB with only 10 feet of ambulation; on
admit , can only go a few feet without dyspnea. No fevers/chills.
Has occasional crampy SSCP-->bilateral breasts ( for yrs ) that is
unrelated to exertion and is not accompanied by palpitations ,
SOB , light-headedness , or diaphoresis. Also complains of increased
bilateral arm and hand pain with occasional paresthesias of left hand.
ROS +for wt gain ( 100 lbs since 29 of March when she was d/c'd from Ranor Healthcare ) , fatigue. No change in bm's , urine.
T 96.7 , P 60 , BP 120/80 , RR 22 , SpO2 93% on 5L
Obese , mildly increased work of breathing , lungs CTAB , jvp not
appreciable 2/2 to impressive neck adiposity , RRR S1 S2 no mrg
appreciated , 1+ edema of LE b/l.
PMH: OSA , restrictive lung disease , von Willebrand's disease ,
pulmonary hypertension , congestive heart failure , hemorrhoids , iron
deficiency anemia
Meds: Detrol 2 twice a day , Atenolol 100 every day , lisinopril 5 every day , calcium 300
three times a day , hctz 50 every day , metamucil , duonebs as needed
SocHx: 50 pack year smoking hx , no EtOH , history of sexual abuse at
hands of uncle when a child
Labs: HCO3 35 , chems wnl. TnI < assay , bnp 32. WBC nl with slight
left shift. UA with large blood , small LE.
*********************************************
CV-I-+mibi in '02 diag dist. cont BB , ACE-I. lipids good in
6 of April . -P-?mild volume overload , although not evident on exam. BNP li
kely artificially low in this morbidly obese patient. Diuresis with
intravenous lasix. Re-echo to re-eval pulm pressures while in-house. patient
refusing Card MRI , CTA of pulm bed 2/2 inability to lie flat. Send home
with Lasix 40 mg orally every day before noon/10 mg orally every afternoon and aldactone 12.5 mg orally every day with
adjustments
via VNA and Dr. Pee .
-R-history of SVT-currently sinus brady , stable
PULM-likely increased DOE , "orthopnea" 2/2 increased abd pressure
causing worsening of restrictive pulm pattern +/- Pickwickian
syndrome. BIPAP at night. Cough could be 2/2 post-nasal
drip/GERD. Rhinocort. Nebs , guifenisin as needed To provide Rx for second
BIPAP machine so that patient can use during the day.
GI-history of bleeding hemorrhoids. Continue metamucil ( patient refuses colace ,
will only take metamucil ).
ENDO- Nutrition consult for wt loss. HbA1c.
HEME-history of iron deficiency anemia with intolerance to orally iron.
Iron studies wnl during this stay.
RENAL-Bun/Cr wnl. UA with TNTC RBCs.
ID-Induced sputum culture , UCx.
PAIN-avoid resp depressants
( opiates ) , NSAIDs/ASA ( history of VWBs ). Tx with tylenol. patient refusing SSRI
for fibromyalgia.
CODE-full
ADDITIONAL COMMENTS: Please wear your bipap as often as possible at night. Discuss your
needs with your pulmonary doctor , Dr. Leuga when you have your
appointment. Continue taking your medicines as directed.
-The most important thing is for you to work on your weight. Please
work with your visiting nurse and PCA to establish an appropriate diet.
Remember that fruit juice has a lot of calories and is not very
satisfying.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
Visiting nurse should check your weight , as well as do blood draws
twice per week or as needed for potassium and creatinine to help guide
appropriate diuretic therapy ( please make sure potassium is checked 3
days after discharge on 7/18/05 . Weights and labs should be
transmitted to Dr. Meghann Christenson and
to Dr. Pee ( 900-027-6729 ) for management of therapy. There will need
to be significant reinforcement of dietary goals--calorie , salt and
fluid restriction.
No dictated summary
ENTERED BY: WOHLFORD , CECILY , M.D. , PH.D. ( ZA48 ) 7/8/05 @ 01:37 PM
****** END OF DISCHARGE ORDERS ******
Document id: 648
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| output/system_intuitive_annotation.xml | intuitive |
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935717561 | PUO | 73655237 | | 7088654 | 7/5/2006 12:00:00 a.m. | fluid overload 2/2 CKD | | DIS | Admission Date: 7/5/2006 Report Status:
Discharge Date: 10/28/2007
****** FINAL DISCHARGE ORDERS ******
LEICHNER , EFREN S 812-26-05-1
Chand
Service: MED
DISCHARGE PATIENT ON: 7/9/07 AT 03:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 7/9/07 by :
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override:
CIPROFLOXACIN 500 MG orally every 24 hours X 10 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ARANESP ( NON-ONCOLOGY ) ( DARBEPOETIN ALFA ( NON... )
40 MCG subcutaneously QWEEK
TRICOR ( FENOFIBRATE ( TRICOR ) ) 145 MG orally DAILY
Starting Today November
Alert overridden: Override added on 4/30/06 by
VEAZIE , OK E. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN &
FENOFIBRATE , MICRONIZED Reason for override: will monitor
Number of Doses Required ( approximate ): 5
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 80 MG orally every day before noon
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
NOVOLOG ( INSULIN ASPART ) 3 UNITS subcutaneously before meals
Starting Today November
Instructions: or resume your prior sliding scale as
directed
LANTUS ( INSULIN GLARGINE ) 48 UNITS subcutaneously DAILY
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled twice a day Food/Drug Interaction Instruction
Contraindicated in Patients with Peanut , Soya or Soyabean
Allergy
AVAPRO ( IRBESARTAN ) 300 MG orally DAILY
Number of Doses Required ( approximate ): 5
LABETALOL HCL 200 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
Alert overridden: Override added on 4/30/06 by
VEAZIE , OK E. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
ADALAT CC ( NIFEDIPINE ( EXTENDED RELEASE ) )
120 MG orally DAILY Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr. Debold Tuesday 7/18 at 1:30PM scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
fluid overload
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
fluid overload 2/2 CKD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CRI; DM; HTN; obesity; smoking history; COPD; anemia
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: shortness of breath
*****************
HPI: 67 year-old man with a history of DM , HTN , CRI ( 2/2 DM nephropathy )
and COPD who presented to the ED on 5/3 with shortness of breath
worsened by exerction. He denied chest pain , orthopnea , or PND. He did
note increased lower extremity edema and abdominal girth. He reports
taking his lasix 80mg orally daily at home but with dietary indescretion and
increased salt intake ( lots of bacon and canned soup ).
******************
PMH: CRI , DM , HTN , hyperlipidemia , COPD , hx CVA 2002 with residual L arm
numbness , anemia , history of L hip replacement
MEDS: combivent twice a day , lantus 48U every day before noon , novolog SS qAC , lasix 80mg daily ,
nifedipine 90mg daily , avapro 300mg daily , atenolol 25mg daily , labetalol
100mg twice a day , plavix 75mg daily , ASA 81mg daily , lipitor 40mg daily , tricor
145mg daily , nephrocaps 1 tab daily
ALL: NKDA
SH: retired SW at PMH , lives with wife , daughter , granddaughter
HRB: quit tobacco 25 years prior , no etoch
FH: father with CHF and MI at age 65
*********************
ADMIT EXAM: 97.1 , 60 , 122/60 , 24 , 97%4L NC , wt 262lbs
Well appearing , JVP 8 , distant heart sounds , crackles bilaterally in
lower 1/3 of lungs , +BS , obese distended abdomen , 2+ edema to knees
*********************
DISCHARGE EXAM: 98.8 , 65 , 130/60 , 20 , 94RA , weight 241lb. No peripheral
edema. Lungs clear to ascultation.
*********************
DATA: admit labs notable for K 5.3 , BUN 92 , Cr 3.8 , Hct 27.4 , WBC 8.8 ,
cardiac enzymes negative , HbA1C 6.3. WBC peak 11. Hct nadir 26. BUN/Cr
stable. D/C K 4.5. TSH pending.
EKG: NSR 60 , RBBB ( old ) , LAD ( old ) , unchanged from prior
CXR: low lung volumes , + pulmonary vascular congestion
ECHO: LVH , LVEF 60% , RV mild enlargement , no valvular abnormalities
UCX: 100K pansensitive Ecoli
**********************
HOSPITAL COURSE
67M with fluid overload from CKD/dietary indiscretion.
1 ) SOB: felt to be from fluid overload as opposed to COPD exacerbation or
MI. Ruled out for MI. Diuresed with intravenous lasix to dry weight 241lb then
transitioned to orally lasix prior home dose.
2 ) CARDS( P ): BP goal <130 given CKD , DM. Unclear why patient was on 2 BB
so stopped atenolol and titrated up labetalol. Also titrated up
nifedipine and added HCTZ to get at BP goal. Diuresed with intravenous lasix as
above.
3 ) CARDS( I ): ruled out for MI , no EKG changes. Maintained on ASA ,
statin , BB , ARB , plavix ( for stroke ).
4 ) CARDS( R ): no issues with rate
5 ) DM: maintained on lantus 48U qAM with novalog sliding scale for meals.
Added 3U novalog before each meal. HbA1C acceptable <7.
6 ) CRI: stable CRI , Cr did not change with aggressive diuresis.
Continued ARB , nephrocaps.
7 ) HEME: picture consistent with iron def anemia + anemia of chronic
disease. Started on three times a day iron and darbepoein qWeek. Discharge Hct still
27.
8 ) UTI: patient developed foley related UTI , with low grade temp and WBC
11. Pansenstive Ecol which were treated with ciprofloxacin at renal
dosing for a 10 day course.
9 ) physical therapy: physical therapy evaluated the patient and recommended a walker
which was given and home physical therapy assessment.
10 ) FEN: 2g nasal , 2L fluid restriction , ADA , low fat diet
11 ) PROPHY: heparin
12 ) DISPO: home with services ( VNA , physical therapy )
****************
ADDITIONAL COMMENTS: 1 ) Home physical therapy: please do home physical therapy eval and assist with patient's use of
walker ( new device for him )
2 ) VNA: please measure patient's weight and BP and report any weight gain
over 3lbs ( dry weight 240lbs ) or BP>140 or <100 to primary care physician Dr. Debold at
154.937.4668
3 ) Mr. Leichner : please do not eat more than 2g of salt a day or drink more
than 2L of fluid per day. Please eat a low fat , low cholesterol diet.
Please measure your weight every day and call your doctor if your weight
goes up by more than 3lbs.
4 ) Mr. Leichner : please note your new medications are ciprofloxacin ( for 10
days only ) , iron , darbepoetin shots , and HCTZ. Your atenolol has been
stopped. Your labetalol and nifedipine doses have been increased.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) New meds are cipro ( 10 day course ) , iron , darbepoetin ( started on 10/28 ,
will see you in the office 7/18 and you can decide whether to continue
qWk ) , and HCTZ
2 ) Meds stopped: atenolol ( patient was on 2 beta blockers )
3 ) Meds changed: labetalol up titrated to 200mg twice a day , nifedipine up
titrated to 120mg daily
4 ) Please uptitrate lasix as needed
No dictated summary
ENTERED BY: HOSTIN , KALLIE L. , M.D. ( CJ00 ) 7/9/07 @ 03:36 PM
****** END OF DISCHARGE ORDERS ******
Document id: 649
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
Y |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
840096369 | PUO | 72721697 | | 7276506 | 7/29/2006 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 5/4/2006 Report Status: Signed
Discharge Date: 2/29/2006
ATTENDING: GOLEBIOWSKI , LOIDA MD
DISCHARGE DIAGNOSIS: Critical aortic stenosis , coronary artery
disease.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
gentleman with a history of insulin-dependent diabetes ,
hypertension and coronary artery disease who had a prior CABG in
1995 and had been followed for his aortic stenosis. He had been experiencing
increased shortness of breath and syncopal episodes including a fall on
10/17/06 . The patient has been followed by his cardiologist , Dr. Viviana M Newbert , at Put Wathern Hospital , who referred the patient to Dr. Golebiowski
for aortic valve replacement.
PREVIOUS CARDIOVASCULAR INTERVENTION: At Kendsonre Ale Ater Hospital in 1995 , CABG x4.
PAST MEDICAL HISTORY: Hypertension , TIA , insulin-dependent
diabetes , hypothyroidism , BPH , Parkinson's disease , bilateral
carotid artery stenosis , depression , irritable bladder , question
of dysphagia to solid foods.
PAST SURGICAL HISTORY: Appendectomy , cholecystectomy , cataract
surgery and CABG x4 in 1995.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient has a five-pack year history of
cigarette smoking. The patient rarely drinks alcohol. He is a retired board
of director of multiple companies and owns a nursing home , which he runs with
his daughter.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS: Atenolol 25 mg daily , lisinopril 40 mg
daily , aspirin 325 mg daily , furosemide 20 mg daily , Sinemet
50/200 mg daily , milk of magnesia , Tylenol , Colace , Novolin 5
units every day before noon and 10 units every afternoon , levothyroxine 112 mcg daily ,
Ditropan 2.5 mg twice a day , trazodone , Senokot , Flomax 0.4 mg daily ,
Celexa 10 mg daily , Avodart 0.5 mg daily.
PHYSICAL EXAMINATION: Vital Signs: Temperature 99 degrees ,
heart rate 88 , right arm blood pressure 160/88 and left arm blood
pressure 146/84 , O2 saturation 96% on room air. HEENT: PERRLA ,
dentition without evidence of infection , left and right carotid
bruits. Chest: Healed midline sternotomy. Cardiovascular:
Regular rate and rhythm , systolic murmur heard throughout
precordium. Respiratory: Rales present bilaterally. Abdomen:
Soft , no masses , scars noted from prior appendectomy and
cholecystectomy. Extremities: Multiple small abrasions and
bruises over both legs. Neurologic: Alert and oriented.
Cranial nerves grossly intact except for tongue , which deviates
to the left. Strength 5/5 in the upper and lower extremities.
Sensation and reflexes symmetric and equal. Pulses 2+
bilaterally at carotids , radials , femorals and PTs , present by
Doppler at DPs bilaterally. Allen's test of the left and right
upper extremities both normal.
PREOPERATIVE LABS: Sodium 139 , potassium 4.5 , chloride 101 ,
bicarb 29 , BUN 23 , creatinine 1.3 , glucose 298. White blood cell
count 6.0 , hematocrit 42.9 , hemoglobin 13.8 , platelets 237 , 000 ,
physical therapy 15.9 , INR 1.3 , PTT 29.6. Urinalysis was normal.
CAROTID IMAGING: The patient had less than 25% stenosis of the
right internal and left internal carotid arteries. MR angiogram
of the left internal carotid artery showed 60% occlusion and 50%
occlusion of the right internal carotid artery. Cardiac
catheterization performed on 4/7/06 at Pagham University Of revealed 100% ostial LAD stenosis , 100% proximal
circumflex stenosis , 70% ostial left main stenosis , 75% mid RCA
stenosis , 50% proximal RT LV-BR stenosis , and proximal stenosis of the
right PDA. CABG grafts from prior bypass surgery were all
patent.
Echocardiogram on 6/5/06 showed an ejection fraction of 60% ,
aortic stenosis with a mean gradient of 38 mmHg and peak gradient
of 67 mmHg , calculated valve area was estimated at 0.7 sq cm.
There was mild mitral valve insufficiency. An EKG on 5/27/06
showed first-degree AV block with a heart rate of 62 and inverted
T waves in leads I , aVL and V4 through V6.
Chest x-ray on 7/6/06 was consistent with congestive heart
failure and revealed aortic calcifications and left lower lobe
atelectasis.
HOSPITAL COURSE: The patient was admitted on 7/6/06 for
completion of his preoperative workup. He was brought to the
operating room on 10/22/06 where Dr. Golebiowski performed a reoperative
sternotomy and a minimally invasive aortic valve replacement
using a 23-mm Carpentier-Edwards Magna valve. The
cardiopulmonary bypass time was 186 minutes and the aortic
cross-clamp time was 77 minutes. The patient tolerated the
procedure well and was transferred to the Cardiac Surgery
Intensive Care Unit in hemodynamically stable condition. Over
the next few days , the patient was extubated. He had episodes of
uncontrolled hypertension and was placed on a nitroglycerin drip.
By postoperative day #4 , the patient had been weaned off his
drips and his blood pressure was well controlled. He had been
hemodynamically stable and afebrile in the Intensive Care Unit.
He was ready for transfer to the regular hospital floor for the
remainder of his recovery. At that point , the patient demonstrated
postoperative confusion , particularly at night. The
patient's neurological exam was otherwise normal. The patient
was started on cardiac medications including captopril , Lopressor
and aspirin. He had been extubated without complication and was
oxygenating well with the support of 1 liter of oxygen via nasal
cannula. He had no respiratory issues. The patient was seen by
the Speech and Swallow Service for his history of dysphagia and
was cleared for mechanical soft diet with nectar-thick liquids
and crushed pills. The patient's diet was advanced as tolerated.
He exhibited adequate urine output with diuretics
postoperatively for fluid retention. The patient was followed by
the Diabetes Management Service in the postoperative period for
his history of diabetes. He was initially on an insulin drip and
then weaned to a NovoLog sliding scale with supplemental Lantus
insulin in the evenings. The patient's hematocrit had dropped to
22 on postoperative operative day #3 and he was transfused one
unit of packed red blood cells with an appropriate hematocrit
bumped to 26. On postoperative days #4 through #6 , the patient
continued his slow steady progress. The neurology team who had
visited him after surgery after his mental status changes
recommended holding his Sinemet and only to restart if his
Parkinson symptoms reoccur. Otherwise , the patient
experienced some hypertension and his blood pressure medications
were titrated accordingly. The patient remained in a sinus
rhythm. By postoperative day #6 , his blood pressure was stable.
He was oxygenating well on room air and was ambulating
comfortably in the halls. He had a sitter accompany him in his
room for impulsivity , however , this became unnecessary after
postoperative day #6. A PA and lateral chest x-ray looked clear
with no infiltrates and no pneumothorax. He had returned to his
baseline mental status and he was deemed ready for discharge to
the rehabilitation facility , which is owned by his daughter.
On the day of discharge , the patient's vital signs were
temperature 97.7 degrees , heart rate 65 in sinus rhythm , blood
pressure 104/60 , O2 saturation 97% on room air. Respiratory rate
20. The patient was still several kilograms above his
preoperative weight. A urinalysis had suggested a low-level
infection and his urine culture was growing proteus 5000 CFUs and
he was started on a seven day course of ciprofloxacin.
LABORATORY DATA: On the day of discharge , sodium 143 , potassium
4.2 , chloride 102 , bicarbonate 34 , BUN 33 , creatinine 1.2 ,
glucose 102 , magnesium 2.4 , white blood cell count 11.6 ,
hematocrit 28.0 , hemoglobin 9.1 , platelets 297 , 000. physical therapy 16.2 , INR
1.3 , PTT 28.1.
DISCHARGE CONDITION: Stable.
DISPOSITION: Discharged to a rehabilitation facility.
DISCHARGE DIET: A low-cholesterol , low-saturated fat ,
2100-calorie per day ADA diet.
ACTIVITY: The patient should be walking as tolerated. The
patient should arrange followup appointments with his
cardiologist , Dr. Viviana Newbert , at 629-907-2791 in one to two
weeks after discharge and with his cardiac surgeon , Dr. Loida F Golebiowski , at 117-219-4079 in four to six weeks after discharge.
DISCHARGE INSTRUCTIONS: The patient was instructed to shower
daily and keep his incisions clean and dry. He should continue
to ambulate frequently. The patient should be weighed daily and
the physician should be contacted if the patient's weight ,
peripheral edema or work of breathing is noted to be increasing.
The patient should also continue his ciprofloxacin for a total of
one week for a proteus UTI.
DISCHARGE MEDICATIONS: For the rehabilitation facility include
the following: Tylenol 325 to 650 mg orally every 4 hours as needed pain ,
Norvasc 10 mg daily , Artificial Tears two drops each eye three times a day ,
vitamin C 500 mg orally twice a day , enteric-coated aspirin 325 mg
daily , Dulcolax 10 mg per rectum daily as needed constipation ,
ciprofloxacin 500 mg orally every 12 hours times a total of 14 doses ,
Celexa 10 mg orally daily , Colace 100 mg orally three times a day , Avodart 0.5
mg orally daily , Nexium 20 mg orally daily , folate 1 mg orally daily ,
Lasix 40 mg orally daily , ibuprofen 400 mg orally every 8 hours as needed pain ,
insulin Aspart 6 units subcutaneously with meals and please hold
if the patient is npo , NovoLog sliding scale at mealtime and
at bedtime , insulin Glargine 26 units subcutaneously at bedtime ,
Atrovent nebulizers 0.5 mg nebulizer four times a day , K-Dur 20 mEq orally
daily , Synthroid 112 mcg orally daily , lisinopril 40 mg orally daily ,
milk of magnesia 30 mL orally daily as needed constipation , Toprol-XL
100 mg orally daily , Niferex-150 150 mg orally twice a day to be taken for
one month after surgery for postoperative anemia , Ditropan 2.5 mg
orally twice a day , simvastatin 20 mg orally at bedtime , Flomax 0.4 mg
orally daily , multivitamin one tablet orally daily , and thiamine
hydrochloride 100 mg orally daily.
eScription document: 8-8319968 CSSten Tel
CC: Loida Golebiowski MD
DIVISION OF CARDIAC SURGERY
Te
CC: Viviana Newbert M.D.
Put Wathern Hospital
Land Tuc A
Dictated By: MUMMA , MARYLOU
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 2790796
D: 10/18/06
T: 10/18/06
Document id: 650
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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537124853 | PUO | 72340071 | | 2818552 | 2/27/2005 12:00:00 a.m. | hypoventilation due to obesity , upper respiratory infection | | DIS | Admission Date: 9/8/2005 Report Status:
Discharge Date: 10/13/2005
****** DISCHARGE ORDERS ******
DUMMERMUTH , KARIMA 513-82-96-4
Ried Boulevard
Service: MED
DISCHARGE PATIENT ON: 6/9/05 AT 09:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALBUTEROL INHALER 4 PUFF inhaled every 2 hours Starting Today September
as needed Shortness of Breath
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally every day
ADVIL ( IBUPROFEN ) 600 MG orally every 6 hours
Food/Drug Interaction Instruction Take with food
LISINOPRIL 40 MG orally every day HOLD IF: sbp<110 , call HO
Override Notice: Override added on 11/27/05 by
CLAYBURN , NIKI , M.D.
on order for KCL intravenous ( ref # 97012998 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally three times a day
HOLD IF: sbp<110 , ht<55 - call HO if held
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
FLOVENT ( FLUTICASONE PROPIONATE ) 880 MCG inhaled twice a day
MICONAZOLE 200MG VAGINAL SUPP 1 SUPP PV every bedtime X 5 doses
Instructions: total 7 day course ( started 3/2 )
LEVOFLOXACIN 750 MG orally every day
Instructions: 14 day course; started 7/18/05
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: apply to affected areas
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
GLYBURIDE 5 MG orally every day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day as needed Shortness of Breath , Wheezing
ROBITUSSIN DM ( GUAIFENESIN DM ) 10 MILLILITERS orally every 6 hours
as needed Other:cough
DIET: House / Low chol/low sat. fat
ACTIVITY: ambulate with rolling walker and assistance
FOLLOW UP APPOINTMENT( S ):
primary care physician , Dr. Jubilee , call 486-705-2610 for f/u appt in 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hypercarbic respiratory failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hypoventilation due to obesity , upper respiratory infection
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) history of TAH ( history of hysterectomy ) diastolic
CHF HTN ( hypertension ) OA ( osteoarthritis ) chronic L ankle edema
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intubation/ventilatory support , BiPAP , antibiotics , diuresis
BRIEF RESUME OF HOSPITAL COURSE:
CC: hypercarbic respiratory failure
HPI: 53 F with history of morbid obesity , diastolic CHF , HTN p/with respiratory
distress. Developed URI and DOE over week PTA. Presented to primary care physician 4/7 with
SOB- sats 80% RA->94% 4L NC. Sent to P Therford Hospital and
given solumedrol and nebs; ABG 7.18/90/58 -->
intubated ( FIBEROPTICALLY ) and transferred to PUO MICU.
In ICU , patient felt to be suffering from
obesity hypoventilation syndrome with decompensastion
2/2 URI; +/- compnent of volume overload.
Steroids stopped; Abx and gentle diuretics given.
Extubated 3/2 with nl PH and PCO2 70s ( presumed
baseline ). Unable to tolerate BiPAP in
ICU. PE: 97.6 , 63 , 144/75 , RR 15 , 95% 1L.
Morbidly obese middle-aged female in NAD , able to
complete full sentences , OP clear , MMM ,
poor dentition , lungs poor air
movement/coarse expiratory wheezes , distant heart sounds ,
S1S2 , could not hear m/r/g , abd c well-healed
midline scar , abd obese , soft , NT/ND , no HSM
appreciated , large/swollen ext , NT with no pitting
edema , baseline per patient , neuro non-focal.
PMH: diastolic CHG , history of TAH/hernia repair , HTN , OA , chronic L ankle
edema MEDS: ECASA , Lasix 40 , Lisinopril 40 , Lopressor
25 four times a day , Lovenox subcutaneously , Levoflox 750 every day , Lantus 5 subcutaneously
every day ALL:
NKDA PLAN:
1 ) PULM: continued on levo for CAP x 14 days; Gentle O2 to support O2
sats with goal sat ~92%; patient tolerated BiPAP on floor and will be
continued on home BiPAP for hypoventilation 2/2 morbid obesity;
d/c'd with Abx , lasix for maintenance of euvolemia , inhalers , O2; MS no
rmal on d/c
2 ) ID: levo x 14 days; no positive micro data
3 ) CV: No ischemic or rhythm issues; lasix to
keep euvolemic history of diuresis in ICU
4 ) ENDO: lantus/NPH during hospital course; d/c'd on glyburide- adjust
and further DM work-up as an outpatient DM
5 ) FEN: low fat/low salt diet
6 ) DISPO: seen by physical therapy; resistant to pulmonary rehab; OK for d/c home
with home O2 and BiPAP; lives with son
FULL CODE
ADDITIONAL COMMENTS: Please follow-up with your primary care physician; see a physician for shortness of
breath , fever , increased cough , excessive sleepiness , or other
concerning symptoms.
VNA: please assist with meds; please provide with home physical therapy ( ambulate with
rolling walker ); please provide home O2 and home BiPAP ( setting 10/5 );
please assess respiratory and volume status each visit
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with primary care physician; weight loss interventions; home BiPAP and O2
No dictated summary
ENTERED BY: COSE , LATASHIA C. , M.D. , M.B.A. ( JU10 ) 6/9/05 @ 11:22 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 651
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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881373464 | PUO | 04291228 | | 4218045 | 10/1/2006 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 10/1/2006 Report Status: Signed
Discharge Date: 10/5/2006
ATTENDING: KERTESZ , ALETA M.D.
PRINCIPAL DIAGNOSIS: Aortic valve stenosis.
HISTORY OF PRESENT ILLNESS: A 75-year-old gentleman with a
history of coronary artery disease who is status post CABG in
1983 who has recently experienced unstable angina and was
admitted in April of 2006 to Sertneervilleall Rop Fortchoc Health Care for
workup and was found to have an aortic valve area of 0.8 and
significant vein graft disease to OM1. The patient received
coronary stents to OM1 and the native circumflex at Ouf County General Hospital in April of 2006. Of note , the right coronary artery was
seen to be occluded at that time as was the vein graft to that
coronary. The vein graft to the LAD had been priorly stented and
was noted to be patent. The patient began developing shortness
of breath and symptoms of aortic stenosis , which were complicated
by anemia , which was thought to have developed due to some AV
malformations of the foregut. In view of the patient's
progressive symptoms , it was decided to proceed with aortic valve
replacement , which was first scheduled for September , but then
rescheduled when the patient was noted to have coughing and
hemoptysis. The patient was treated for pneumonia surgery
rescheduled and he is admitted to Pagham University Of
for reoperation aortic valve replacement.
PAST MEDICAL HISTORY: Hypertension , hypercholesterolemia , gout ,
GERD , congestive heart failure , anemia and BPH.
PAST SURGICAL HISTORY: Prostate surgery , left hip replacement ,
right total knee replacement , cholecystectomy and tonsillectomy.
FAMILY HISTORY: Negative for coronary artery disease.
SOCIAL HISTORY: A 60-pack-year smoking history , two glasses of
wine every evening. The patient is a widower , lives alone , four
children live in the area.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Atenolol 50 mg orally daily.
2. Aspirin 81 mg orally daily.
3. Lasix 40 mg orally daily.
4. Atorvastatin 80 mg orally daily.
5. Allopurinol 300 mg orally daily.
6. Protonix 40 mg orally daily.
7. Multivitamin.
8. Iron daily.
PHYSICAL EXAMINATION: 5 feet 6 inches tall , 82 kg , temperature
96 , heart rate 70 , blood pressure 124/60 and oxygen saturation is
100% on room air. HEENT , PERRLA. Oropharynx benign. Neck
without carotid bruits. Chest with a midline sternotomy.
Cardiovascular , regular rate and rhythm , systolic ejection
murmur. Respiratory , breath sounds clear bilaterally. Abdomen ,
cholecystectomy scar well-healed , soft , no masses. Extremities
without scarring , varicosities or edema , 2+ pedal and radial
pulses bilaterally. Allen's test in both upper extremities
normal by pulse oximeter. Neuro , alert and oriented , grossly
nonfocal exam.
LABORATORY DATA: Preop laboratory chemistries include BUN of 21
and creatinine of 0.8. White blood cell count is 5.8 , hematocrit
35 and INR is 1.0. Carotid imaging , left internal carotid artery
1 to 25% occluded , right internal carotid artery 25% to 49%
occluded. Cardiac catheterization data from 2/29/06 performed
at outside hospital reveals the following: 60% left main , 100%
RCA , 100% mid LAD , 100% SVG1 to LAD , 100% SVG3 to circumflex.
There is borderline LV function. Estimated ejection fraction is
35%. There is inferior hypokinesia , global hypokinesia , vein
graft occlusion of 100% to the right coronary artery , widely
patent saphenous graft , inside of prior standing to OM1 and OM2 ,
widely patent saphenous vein graft to the LAD , patent prior
stents placed in native LAD and left main. Echo from 2/29/06
estimates ejection fraction of 55% , finds aortic valve stenosis
with mean gradient of 53 mmHg and a peak gradient of 82 mmHg and
calculated valve area of 0.8 cm2 , mild aortic valve
insufficiency , mild mitral insufficiency , mild tricuspid
insufficiency , aortic valve was thickened with diminished cusp
mobility. The left atrium is enlarged. There is mitral annular
calcification , normal mitral leaflet excursion. Left ventricle
demonstrates concentric hypertrophy. There is normal right
systolic function. Right atrium is dilated. Right ventricle is
normal. Tricuspid valve was normal. There is severe aortic
valve stenosis. EKG , normal sinus rhythm at 68 with ST
elevations in V1 and V2 , inverted Ts in leads 1 , 2 , AVF , AVR , AVL
and V1 through V6. Chest x-ray is normal , but reveals aortic
calcification.
HOSPITAL COURSE: The patient was taken to the operating room on
4/29/06 and underwent reoperation minimally invasive aortic
valve replacement with a 21-mm Carpentier-Edwards Magna valve.
The patient was taken to the Intensive Care Unit following
surgery on Levophed and epinephrine drips. He was noted to be
hypotensive following surgery , which was refractory to pressors
and volume requiring pressor boluses and transient application of
chest compressions and the patient underwent placement of an
intraaortic balloon pump. The balloon pump was weaned and
removed by postoperative day 2 and pressors were weaned by
postoperative day 3. The patient transferred to the Step-Down
Unit later on postoperative day #3 and continued to progress
daily. His diet was advanced to full house diet and was well
tolerated. The patient was started on beta-blockade , aspirin and
statin for his coronary artery disease and a course of
antibiotics was completed for a preoperative urinary tract
infection The patient was followed perioperatively by the
Diabetes Management Service for tight glycemic control. The
patient was weaned off of supplemental oxygen with ongoing
diuresis and he remained in sinus rhythm and saturated well on
room air for the remainder of his stay. The patient's
preoperative Flomax was restarted following the removal of Foley
catheter. The patient initially had difficulty voiding and then
voided without difficulty. He has been instructed to follow up
with his home neurologist within the next few weeks and earlier
if he has difficulties. The remainder of his postoperative stay
was uncomplicated and he is discharged to Rehab in good condition
on postoperative day #6.
At time of discharge , laboratory chemistries include the
following , sodium of 135 , potassium of 4.3 , BUN of 18 and
creatinine of 0.8. White blood cell count is 5.7 , hematocrit
27.5 and INR is 1.1.
He is discharged to Rehab on the following medications.
1. Flomax 0.4 mg orally daily.
2. Oxycodone 5 to 10 mg orally every 6 hours as needed pain.
3. Niferex 150 mg orally twice a day
4. Toprol-XL 50 mg orally daily.
5. Allopurinol 300 mg orally daily.
6. Enteric-coated aspirin 325 mg orally daily.
7. Atorvastatin 80 mg orally daily.
8. Colace 100 mg orally every 8 hours as needed constipation.
9. Lasix 40 mg orally daily.
10. Potassium slow release 20 mEq orally daily.
11. Glucophage-XR 500 mg orally every 8 hours
12. NovoLog sliding scale before every meal as needed.
The patient will follow up appointments with his cardiologist ,
Dr. Dominguez in one to two weeks and with his cardiac surgeon , Dr.
Kertesz in four to six weeks. He will also follow up with his
urologist , Dr. Trelles in three to four weeks.
eScription document: 5-5056369 CSSten Tel
Dictated By: JACOBSON , CHRISTEEN
Attending: KERTESZ , ALETA
Dictation ID 4455044
D: 2/4/06
T: 2/4/06
Document id: 652
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
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Y |
N |
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N |
047657566 | PUO | 70437680 | | 9601842 | 9/13/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/9/2005 Report Status: Signed
Discharge Date:
ATTENDING: TONI , CARMELITA M.D.
SERVICE:
Cardiac Surgery Service.
PRINCIPAL DIAGNOSIS:
Symptomatic critical aortic stenosis.
HISTORY OF PRESENT ILLNESS:
This is a 56-year-old smoker status post renal transplant in January
of this year complicated by delayed graft function and sepsis who
presented two days prior to admission with shortness of breath
and chest pain. The patient was found to have critical aortic
stenosis with a valve area of 0.7 cm2 an EF of 60%. The patient
does have a history of positive stress test for which a cardiac
catheterization was performed in 6/29 . At that time , he was
found to have 40% lesion of the LAD. On admission to the
Kernan To Dautedi University Of Of , on 10/12/05 , cardiac enzymes were drawn and this showed
a troponin level of 0.21. EKG showed no acute changes. The
patient was placed ACS protocol and initially admitted to the
Cardiology Service. The Cardiac Surgery Service was consulted
for emergent aortic valve repair and potential coronary artery
bypass grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. End-stage renal disease secondary to hypertension , status
post cadaveric renal transplant in 5/13 complicated by delayed
graft function and sepsis , baseline creatinine 2.2-2.4.
3. Diabetes mellitus.
4. Hypercholesterolemia.
5. Status post right upper extremity AV fistula.
MEDICATIONS ON ADMISSION:
1. Diltiazem 240 mg orally daily.
2. Prednisone 10 mg orally daily.
3. FK506 , dose according to level.
4. CellCept , dose according to level.
5. Acyclovir.
6. Rocaltrol.
7. Bactrim.
8. NPH.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
A 40-pack-year cigarette history. The patient is a painter and
is still working.
FAMILY HISTORY:
Father on dialysis , mother with hypertension , and sister is with
diabetes mellitus.
ADMISSION PHYSICAL EXAM:
Height 6 foot 1 inch and weight 100 kg. Temperature 98.0
degrees , heart rate 82 and sinus , blood pressure right arm
126/60 , blood pressure left arm 130/68 , and oxygen saturation
97%. No carotid bruits , regular rate and rhythm with a loud 4-6
systolic murmur along the right upper sternal border , bilateral
rales. Soft , nontender , and nondistended abdomen. Extremities
with 2+ edema bilaterally. Pulses , 2+ femoral bilaterally.
Pedal pulses are present by Doppler bilaterally.
LABORATORY DATA:
Admission labs are significant for BUN of 49 , creatinine of 2.8 ,
glucose of 203 , white blood cell count of 9660 , hematocrit of
35% , and platelets 269 , 000.
IMAGING:
1. Cardiac catheterization on 1/11/04 performed at Kernan To Dautedi University Of Of , 40%
proximal LAD lesion , codominant circulation.
2. Echocardiogram on 5/13 , aortic stenosis with mean gradient
62 mmHg , peak gradient of 82 mmHg , calculated valve area 0.7 cm2 ,
mild aortic insufficiency , trivial mitral insufficiency , LVH EF
of 50%.
3. EKG on 10/21/05 , normal sinus rhythm at 70 with first-degree
AV block , evidence of left ventricular hypertrophy.
4. Chest x-ray on 10/21/05 , interstitial pulmonary edema.
HOSPITAL COURSE:
On 10/17/05 , the patient was brought to the operating room for
critical aortic stenosis , acute coronary syndrome and acute
pulmonary edema. He underwent an aortic valve replacement with a
#21 Carpentier-Edwards magna valve , as well as a coronary artery
bypass graft x1 with LIMA to LAD. Bypass time was 120 minutes
and crossclamp time 90 minutes. Two atrial wires and one
ventricular wire was placed. Please see the operative note for
further details. The patient tolerated the procedure well. He
was extubated with without incident on postoperative day #1. His
neurologic status was in time and he did not suffer any delirium
as witnessed after his initial emergence from anesthesia during
the renal transplantation. He was noted to have significant orally
secretions , but these were clear and thin. On postoperative day
#1 , his femoral arterial line was removed and his renal
transplantation medications restarted. His CK-MB peaked at 46
and did trend down thereafter. On postoperative day #2 , he had
begun to be diuresed in light persistent pulmonary edema and seen
by chest x-ray. His chest tubes were removed without incident.
On postoperative day #3 , he was hemodynamically stable. His FK
levels were noted to be low , as is historically the case with
him. Renal Transplant Medicine was following and did titrated
his medications as necessary. On postoperative day #4 , his final
left chest tube was removed. Post-pull chest x-ray showed the
lung to be well expanded. He was found to be hyponatremic with a
sodium of approximately 130. He was begun on fluid restriction
of 1.5 liters for hematocrit of 21. A 1 unit of packed red blood
cells was also given at this time and he was continued on
diuresis. On postoperative day #5 , as his preoperatively weight
had been reached , he was taken off of diuresis. His renal
transplantation medications discontinue. The patient was up out
of bed and ambulating well. The patient was also noted to have a
large sacral decubitus ulcer , without exposure of bone. This
ulcer was the result of the previous admission in January after
renal transplantation. The Plastic Surgery Service was consulted
and their recommendations included appropriate therapeutic
support surface , frequent turning with minimization of being in
the seated position , optimization of nutrition , and wet-to-dry
dressings to the wound. The service is still following the
patient and will consider VAC dressing and the later time.
SUMMARY BY SYSTEMS:
Neuro: The patient was alert , oriented , and intact. P.r.n.
narcotic pain medications as tolerated. Please avoid NSAIDs and
nephrotoxic drugs for pain control.
Cardiovascular: Lopressor increased to 37.5 mg orally four times a day. To
be titrated to goal systolic blood pressure of less than 140 and
heart rate in the 70's. Diltiazem , currently on hold , per Dr.
Toni . Renal Transplant Medicine is aware and in an agreement.
Respiratory: The patient is saturating well on room air. Chest
x-ray with mild pulmonary edema , improving each day. Continue
pulmonary toilet and activity.
GI: On cardiac/renal/ADA diet. Nexium , continued to offer
nutritional supplementation to optimize status in light of wound
healing needs.
Renal: Status post renal transplantation in 5/13 with Renal
Transplant Medicine Service following. The patient currently is
on prednisone , Prograf , CellCept , as directed by the transplant
team. Transplant team will follow and make recommendations. The
patient also was hyponatremia , on 1500 mL fluid restriction at
the time of transfer. Sodium level to be followed.
Endocrine: The patient on NovoLog sliding scale Diabetes
Management Service following.
Heme: The patient transfused on 11/4/05 for a hematocrit of 21.
Current hematocrit 25.4%. Follow hematocrit also on aspirin.
ID: No issues.
Wound: The Plastic Surgery Service following for potential VAC
placement later on in this admission.
eScription document: 0-2428362 EMSSten Tel
Dictated By: BREINES , AZALEE
Attending: TONI , CARMELITA
Dictation ID 6807634
D: 11/16/05
T: 11/16/05
Document id: 653
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
U |
U |
U |
U |
Y |
- |
Y |
U |
Y |
Y |
Y |
U |
Y |
| output/system_intuitive_annotation.xml | intuitive |
Y |
- |
Y |
N |
N |
N |
N |
Y |
- |
Y |
N |
Y |
Y |
Y |
N |
Y |
110132746 | PUO | 12605164 | | 5547245 | 3/3/2004 12:00:00 a.m. | FAILED LT. TOTAL HIP REPLACEMENT | Signed | DIS | Admission Date: 3/3/2004 Report Status: Signed
Discharge Date: 4/4/2004
ATTENDING: BROOKE LEMMEN M.D.
DIAGNOSIS: Status post left total hip revision , status post
right total hip primary.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old male
with morbid obesity and complicated past medical history
including multiple DVTs and PEs , pulmonary hypertension ,
congestive heart failure , obstructive sleep apnea , asthma , status
post IVC filter , gout , recurrent cellulitis presenting for left
total hip revision after a failed left total hip arthroplasty
previously. Additionally , the patient was having pain in his
right hip due to his morbid obesity and osteoarthritis and wants
to have that done as well.
PAST MEDICAL HISTORY: Hypertension , DVT/PE in 1983 , 1987 , 1997 ,
status post TPA for PE , status post cath 1997 , venous stasis
dermatitis , pulmonary hypertension , gout , morbid obesity ,
recurrent left lower extremity cellulitis , OA , congestive heart
failure , EF 40% , obstructive sleep apnea , asthma.
PAST SURGICAL HISTORY: IVC filter 2/16 left total knee
replacement status post left knee arthroscopy 1998 , status post
left total hip arthroplasty , status post appendectomy , status
post exploratory laparotomy 14 years ago for unclear reasons.
PHYSICAL EXAMINATION ON ADMISSION: Afebrile , vital signs stable.
Lungs clear to auscultation bilaterally. Regular rate and
rhythm , normal S1 , S2. Abdomen obese , nontender , nondistended.
Incision was clean , dry and intact from the left side.
MEDICATIONS ON PRESENTATION: Diovan 160 every day before noon , Lotrel 5/25
every day before noon , Naproxen 500 twice a day , allopurinol 200 every day before noon , Lasix 120
every day before noon , atenolol 50 every day before noon , colchicine 1.2 twice a day , Zaroxylyn 25
every Monday , Wednesday , Friday , Coumadin every afternoon , oxycodone 5-10
as needed
HOSPITAL COURSE: The patient was admitted to the Intensive Care
Unit after his first operation on 2/3/2004 which was revision
left total hip arthroplasty. It went without complications but
because of his pulmonary hypertension and need for a central line
monitoring he was admitted for the ICU. He did quite well in the
ICU and was discharged the next day to the floor. On the floor
he received pain control , antibiotic prophylaxis for 48 hours and
was started on Lovenox right away in anticipation of surgery next
week for his right total hip. He mobilized his physical therapy
and did well. There were no signs of infection over the course
of the week or DVT. One week later he went on to a right total
hip replacement which also went without complications but did not
require an ICU stay. Again , he was given antibiotics
perioperatively for 48 hours. His was started on Coumadin the
night of the surgery to maintain an INR of 2-3 for 14 days with
Lovenox which he was given right away and then to maintain an INR
of 3-4 after the initial 14 days postoperatively. He did well
with physical therapy , was getting out of bed. His incisions
were clean , dry and intact bilaterally. The remainder of his
postop course was uncomplicated.
PLAN:
1. INR of 2-3 with Lovenox 40 mg twice a day for the first 14 days
postoperatively. After that , Coumadin should be maintained at
3-4 and dosed daily.
2. The patient has absorbable sutures that do not need to be
removed.
3. The patient may shower when the incision is dry. He may bath
after his first 14 days and there is no drainage.
4. The patient is weightbearing as tolerated bilaterally on his
total hip replacements with posterior hip dislocation precautions
bilaterally.
5. The patient should have a follow up appointment with Dr.
Lemmen in four weeks status post discharge from I Warho Hospital . He should call for an appointment.
6. The patient should resume all preoperative medications.
eScription document: 2-4826001 DBSSten Tel
Dictated By: IVASKA , MELDA
Attending: LEMMEN , BROOKE
Dictation ID 7357384
D: 2/12/04
T: 2/12/04
Document id: 654
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
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Y |
U |
U |
U |
U |
- |
U |
U |
- |
Y |
U |
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| output/system_intuitive_annotation.xml | intuitive |
N |
N |
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Y |
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N |
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- |
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094143304 | PUO | 39961189 | | 0609249 | 8/13/2006 12:00:00 a.m. | SEPSIS | Signed | DIS | Admission Date: 4/29/2006 Report Status: Signed
Discharge Date: 5/21/2006
ATTENDING: DEPSKY , GWYNETH MD
PRINCIPAL DIAGNOSIS:
Urosepsis.
LIST OF PROBLEMS:
1. Urosepsis.
2. Hypoxic respiratory failure.
3. Pneumonia.
4. Aspiration.
5. Pulmonary embolism.
6. Diabetes.
7. Obstructive sleep apnea.
8. Spinal sarcoidosis.
HISTORY OF PRESENT ILLNESS:
The patient is a 66-year-old man with a history of spinal
sarcoidosis with secondary paraplegia who presented with altered
mental status , hypoxemic respiratory failure and hypotension. He
was doing well until the morning of 4/29/2006 when he complained
of difficulty breathing and his wife placed him on home CPAP
machine that he usually uses at night. Despite being placed on
the machine , he was still having air hunger and complaining of
feeling unwell. His wife also noted him to have increasing
lethargy and decreased responsiveness and called EMS to have him
brought to the emergency room. He also was noted to have a
decreased urine output from his chronic suprapubic catheter x2
days. In the emergency room , he was found to be unresponsive ,
grunting , and in respiratory distress. His initial room air
saturation was in the high 60's to low 70's. He was placed on
100% nonrebreather with some improvement of his saturations in
the low 90's and an ABG of 7.37/43/77 on 100% nonrebreather. He
was therefore intubated for hypoxic respiratory failure. He
became hypotensive with intubation despite using etomidate with
blood pressures in the 60's/40's , and an initial CVP of 16 , so he
was started on Levophed with a systolic blood pressure in the
130's on 7 to 10 of Levophed. He received 1 liter of intravenous fluid.
He received a head CT without contrast that showed no acute
bleeding or acute infarction. He had a chest x-ray that showed
no obvious infiltrate. His INR was found to be elevated. Given
the CT of his abdomen without contrast that showed a suprapubic
catheter obstruction with bilateral hydronephrosis and distended
bladder. His creatinine was 2.9 , elevated from his baseline of
0.9. Urology was consulted to change the suprapubic catheter
tube and pus was noted to be aspirated from the suprapubic
catheter. He was started on vancomycin , gentamicin , Flagyl , and
stress dose steroids , and blood and urine cultures were sent in
the emergency and he was transferred to the MICU.
PAST MEDICAL HISTORY:
Sarcoid disease 20 years ago , paraplegia x18 years , chronic
suprapubic catheter/ostomy for 12 years , diabetes type II , right
DVT , on Coumadin , status post chronic UTI , and CPAP at night for
obstructive sleep apnea.
HOME MEDICATIONS:
Include Regular Insulin sliding scale before meals and at bedtime , NPH 54
units in the morning and 68 units in the night , baclofen 10 mg
three times a day , amitriptyline 25 mg at bedtime , oxybutynin 5 mg three times a day ,
gabapentin 300 mg three times a day , iron sulfate 325 mg three times a day , vitamin C
500 mg daily , magnesium 420 mg three times a day , Coumadin 5 mg daily ,
ranitidine 150 mg twice a day , and calcium 950 mg daily.
ALLERGIES:
No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION:
His temperature was 97.4 , heart rate 105 , blood pressure 136/67 ,
his O2 saturation was 100% on before meals 700 with PEEP of 5. In general ,
he was intubated and responsive to simple commands. HEENT:
Sluggish pupils. His lungs were clear anteriorly. His heart was
in regular rate and rhythm with no murmurs , rubs or gallops. His
abdomen was obese , large , soft , nondistended and nontender , with
positive bowel sounds. His extremities had chronic venous stasis
changes of right and lower extremities with areas of no skin
breakdown. He had a large sacral decubitus ulcer with bone
exposed that was foul smelling on his sacrum. He was
neurologically moving all four extremities and following
commands. He had an ostomy and suprapubic catheter in place.
LABORATORY STUDIES:
Notable for an elevated creatinine of 2.9 , otherwise , his Chem-7
was within normal limits. His LFTs were within normal limits.
His hematocrit was 34.6 , his white count was 9.4 , and his
platelets were 343 , 000. He had negative cardiac enzymes. His
urine and blood tox screens were negative. His UA was
significant for 3+ protein , trace glucose , negative ketones , 3+
leukocyte esterase , negative nitrites , 4-10 red blood cells , 4+
bacteria , and 3+ triple phosphate crystals. His EKG was in
normal sinus rhythm with an old right bundle-branch block and
left axis deviation , first-degree AV block. His chest x-ray
showed retrocardiac opacity that was thought to be aspiration
versus pneumonia. Abdominal and chest CT showed bibasilar
airspace opacities , left greater than right , with aspiration
versus pneumonia , bilateral hydronephrosis , severe decubitus
ulcers , and large gastrohepatic lymph nodes slightly enlarged and
calcified.
ASSESSMENT:
This is a 66-year-old man with spinal sarcoidosis and secondary
paraplegia , who presented with altered mental status , hypoxemic
respiratory failure , and hypotension , who had urosepsis and
pneumonia and found later on admission to have pulmonary
embolism.
HOSPITAL COURSE BY PROBLEM:
1. Hypoxemia: He was intubated at the time of admission and
extubated a day later on 5/7/2006. BiPAP was used at night as
he had used at home for a sleep apnea with O2 saturations in the
high 90's on room air during the day. He was initially treated
for pneumonia with ceftazidime , levofloxacin , and vancomycin.
The vancomycin was discontinued on 3/18/2006 , and the
ceftazidime was discontinued on 10/8/206. His levofloxacin was
continued at 500 mg per day for a total 10-day course on
5/3/2006. This is to be used for a UTI and pneumonia. On
11/8/2006 , the patient was supposed to go home and found to have
a desaturation to high 80's on room air. He was found to have a
chest x-ray within normal limits. A pulmonary embolism CT was
done that demonstrated a small nonocclusive pulmonary embolism in
the posterobasilar segment of the right lower lobe with involving
right lower lobe infarct suggestive that he had had a PE that was
resolving. At this time , his INR had been subtherapeutic for
three days at 1.7 to 1.9 and he was continued on his Coumadin.
The following day , his INR was therapeutic at 2 , and on the day
of discharge , it was 2.2. It was thought that the PE was in the
setting of a subtherapeutic INR. His oxygen requirement was back
to baseline at the time of discharge , and his goal INR was to be
on the higher end of the 2 to 3 range , which was goal previously.
He was also given nebulizer treatments throughout his
hospitalization.
2. ID: His urine was found to have Proteus , resistant to
Macrobid , and Klebsiella , resistant to ampicillin. Levofloxacin
was started for this and for the presumed pneumonia seen on chest
x-ray for a total of a 10-day course. Sputum and blood cultures
have been no growth to date. He had no fevers and no elevated
white counts.
3. Cardiac: He was thought to have an element of autonomic
insufficiency secondary to sarcoid with episodes of hypo and
hypertension in the MICU. His cortisol stim test was within
normal limits , it was 14.5 before stim and 23.6 after stim , so he
was not treated with steroids. His blood pressure was in the
30's to 160's with pauses in the 100's on the floor with frequent
bigeminy and trigeminy and many PVCs , so he was started on 12.5
twice a day metoprolol on 7/6/2006 with good results. He continued
to have ectopy and continued to be hypertensive , and given his
diabetes , he was started on a low dose of captopril on 6/20/2006
with no complications and was able to maintain blood pressures in
ideal ranges.
4. GU: Urology replaces suprapubic catheter early on admission.
He was continued to have bladder irrigation with good effect ,
and Urology signed off on 7/13/2007.
5. Endocrine: The patient was given NPH 20 twice a day through his
hospitalization and Regular Insulin sliding scale. His sugars
were high on this reduced regimen and so he was placed on his
home NPH doses for discharge.
6. Decubitus ulcer: Plastic Surgery was consulted on 4/29/2006
and the wound did not look infected. It was debrided and
wet-to-dry three times a day dressing changes were recommended as well as
Panafil three times a day dressing changes. He was prescribed Panafil to go
home on.
7. Renal: The creatinine was initially 2.7 , and after receiving
intravenous fluids , it came down to 1.2. He likely had acute renal
failure secondary to postrenal obstructive etiology. His
creatinine was stable at around 1 for the remainder of his
admission.
8. Heme: The patient has a history of DVT. Initially , his INR
was found to be therapeutic and he was placed on levofloxacin , so
the plan was that he should have half of his home Coumadin dose
while he was on levofloxacin , so he was given half of dose and
his INRs came down to a nadir of 1.7. His INR was subtherapeutic
for three days , and at that time , a PE was found , his INR was
1.8. The day after this , his INR was 2 and then came up to 2.2
on the day of discharge. He was discharged on Coumadin 5 mg ,
which is his home dose to follow up at his Coumadin Clinic.
9. FEN: He was placed on maintenance intravenous fluids until cleared to
eat by Speech and Swallow. Speech and Swallow estimates having
baseline aspiration risk and he was known to cough and aspirate
at home. He had been recently worked up at the Landhi Terblack Ebro Medical Center
on a recent admission for aspiration pneumonia. They recommended
thickened puree diets and felt that even this he was likely to
aspirate. The risks and benefits of eating were explained to his
wife and him and he decided to continue to eat as there was no
ideal option.
10. Pain: He continued gabapentin , oxybutynin , and
amitriptyline as at home.
11. Prophylaxis: He was given Nexium and Coumadin.
12. Code status: He was full code , which was discussed with his
wife.
PHYSICAL EXAMINATION AT DISCHARGE:
The current temperature was 98 , the heart rate was 91 to 114 ,
blood pressure 100-114/54-70 , respiratory rate of 20 , and
saturating 97-100% on 1-2 liters. In general , he was responsive ,
alert , and appropriate. His lungs were clear to auscultation
bilaterally. His heart had normal S1 and S2 , soft systolic
ejection murmur at the right upper sternal border. His abdomen
had positive bowel sounds , distended , soft and nontender. He had
a suprapubic catheter as well as an ostomy that were clean , dry
and intact. Extremities , he had 2+ peripheral edema that was
stable with no skin breakdown.
LABORATORY VALUES:
His labs at the time of discharge were stable. His hematocrit
was 27.2 , down from 29 , which was closed to his baseline of 34.
His INR was 2.1 at the time discharge.
DISCHARGE MEDICATIONS:
Amitriptyline 25 mg orally at bedtime , vitamin C 500 mg orally daily ,
baclofen 10 mg orally three times a day , Caltrate 600 Plus D one tablet orally
twice a day , ferrous sulfate 325 mg orally three times a day , gabapentin 300 mg
orally three times a day , NPH human insulin 54 units in the morning , 68 units
in the evening , Regular Insulin sliding scale , levofloxacin 500
mg orally daily , to end on 11/23/2006 for a total course of 10
days , magnesium oxide 420 mg orally three times a day , metoprolol 12.5 mg orally
twice a day , oxybutynin 5 mg orally three times a day , Panafil ointment three times a day ,
ranitidine 500 mg orally twice a day , and Coumadin 5 mg orally daily.
FOLLOW UP:
The patient will follow up his primary care physician , Dr. Whitmore The appointment
with Dr. Wildt will be within the next week , and the
appointment with the Coumadin Clinic will be tomorrow or the next
day.
ISSUES FOR FOLLOW UP:
Include following up on his aspiration risk and continuing to
discourage thin liquids as well as encourage him sitting upright
when eating and being observed and stopping when he coughs. He
will need continuous blood pressure and heart rate monitoring
given the new beta-blocker and the ACE inhibitor as well as
assessment of his frequent PVCs. We will continue to follow his
diabetes and continue to follow his INR with a goal being 2 to 3
with ideal goal on the higher end 8 range.
eScription document: 9-9307817 EMSSten Tel
Dictated By: ALEXIS , LEAH
Attending: DEPSKY , GWYNETH
Dictation ID 5796555
D: 5/26/06
T: 5/26/06
Document id: 655
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
- |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
- |
Y |
Y |
N |
N |
Y |
N |
N |
- |
936165609 | PUO | 35322508 | | 041434 | 11/6/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/6/1995 Report Status: Signed
Discharge Date: 11/4/1995
SERVICE: GENERAL MEDICAL SERVICE TEAM VIII.
PRINCIPAL DIAGNOSIS: 1. UNSTABLE ANGINA.
SIGNIFICANT PROBLEMS: 2. HYPERTENSION.
3. HIGH CHOLESTEROL.
4. KNOWN CORONARY ARTERY DISEASE.
5. STATUS POST ANGIOPLASTY X 3.
HISTORY OF PRESENT ILLNESS : This is a 64-year-old male complaining
of chest pain at rest. The patient
has a history of known coronary artery disease , angioplasty x 3 ,
hypertension , high cholesterol.
8/5 - Substernal chest pain at rest accompanied by nausea which
worsened with exertion. EKG showed ST segment elevation
inferiorly. Cardiac catheterization at Pagham University Of showed 90% stenosis of right coronary artery , 90% stenosis
of OM1 , 20% stenosis of second diagonal branch , ejection fraction
of 78%. Post angioplasty - 20% stenosis right coronary artery , 10%
stenosis of OM1. Good resolution of symptoms.
1/95 - Exercise Tolerance Test: 4 minutes 12 seconds , maximum
heart rate 102 , maximum blood pressure 256/120 , no EKG changes.
4/95 - Substernal chest pain at rest , unrelieved by three
nitroglycerin tablets. EKG normal. Cardiac Catheterization: 90%
stenosis of right coronary artery , 80% stenosis of OM1. Post
angioplasty - 30% stenosis of right coronary artery , 20% stenosis
of OM1. Good resolution of symptoms.
6/95 - Substernal chest pain at rest , relieved by two nitroglycerin
tablets. EKG normal. Cardiac Catheterization: 90% stenosis of
right coronary artery distal to original PICA site , 90% stenosis of
second diagonal branch. Post angioplasty - 10% stenosis of right
coronary artery. Some acute visual changes during catheterization
and received heparin. Visual symptoms resolved. Post angioplasty
there was good resolution of cardiac symptoms.
7/95 - Exercise tolerance test - decreased tolerance secondary to
hypertension , no chest pain , no ST changes.
9/95 - The patient began to develop chest pain , described as "band
of pressure" around chest , occurring at rest without radiation.
The chest pain was relieved by sitting up and taking deep breaths.
The patient also found relief approximately 20 minutes after taking
two nitroglycerin tablets. Frequency of chest pain has increased
since February . It is now occurring every day and awakening the
patient approximately 2-3 times per night. The patient saw primary
provider on 11/9 who arranged admission for cardiac
catheterization. At admission , the patient had no shortness of
breath , no nausea or vomiting , no dizziness , no diaphoresis , no
orthopnea , no exertional dyspnea. The patient has distant smoking
history ( quit 1968 ) and alcohol , approximately 3-4 drinks per night
every 2-3 days.
PAST MEDICAL HISTORY : Hypertension , high cholesterol , coronary
artery disease ( as above ) , gout.
MEDICATIONS ON ADMISSION : Atenolol 25 mg orally every day; and nifedipine
XL 30 mg orally every day
ALLERGIES : No known drug allergies.
FAMILY HISTORY : Father with myocardial infarction at 90 , mother
with myocardial infarction at 88 , brother with
colon cancer.
SOCIAL HISTORY : Retired police officer; semiretired attorney;
lives in Mawar Nash Himo with wife and has four
children. Smoking , alcohol as above.
PHYSICAL EXAMINATION : Obese , well appearing white male in no
apparent distress. Vital Signs:
Temperature 97.3 , pulse 88 and regular , respirations 12 and
unlabored , 02 saturation 97% on room air , blood pressure 164/96.
HEENT: Pupils equal , round , reactive to light; conjunctivae clear;
orally mucosa and pharynx clear. Neck: Supple , no adenopathy , no
jugular venous distention , no bruits. Lungs: Clear to
auscultation bilaterally , no wheezes , crackles , or rales. Cardiac:
Regular rate and rhythm , normal S1 and S2; no murmurs , rubs , or
gallops. Chest: Gynecomastia bilaterally. Abdomen: Obese; large
ventral wall hernia; soft; nontender; nondistended; no masses; no
HSM. Extremities: Radial/DP pulses - 2+ bilaterally; mild 1+
pitting edema two-thirds of way to knee bilaterally; no clubbing or
cyanosis. Rectal ( in Emergency Room ): Positive for hemorrhoids ,
guaiac negative.
DATA ON ADMISSION : Electrolytes within normal limits. CK 110 ,
Magnesium 2.3 , WBC 8.6 , normal differential , hematocrit 41.4 ,
physical therapy/PTT - 12.3/26.7. UA: 2+ protein , trace blood , trace leukocytes
esterase , sediment negative. Chest X-ray: Mild right pleural
effusion , mild increase in interstitial markings , no infiltrates.
EKG: Normal sinus rhythm at 52 beats per minute , 0.15/0.084/0.418 ,
poor R-wave progression , no change from 6/10/95; Q in III , aVF seen
on 7/28/95 , nonspecific ST flattening V2 through V6.
HOSPITAL COURSE : Admitted 11/9 and was stable overnight. On
8/15 the patient underwent cardiac
catheterization where 90% stenosis of right coronary artery at
former PTCA site was noted. There was 20% stenosis of OM1 at
former PTCA site. Stent was placed to RCA site. Procedure
completed without complications. Patient started on intravenous heparin and
10 mg Coumadin for anticoagulation. The patient did well , without
chest pain , shortness of breath , hematoma , or infection at groin
catheterization insertion site. On 6/19 the patient's INR was 2.5
and the patient was discharged to home.
DISCHARGE MEDICATIONS : Atenolol 50 mg twice a day; nifedipine XL 30 mg
orally.every day; aspirin 81 mg orally every day;
simvastatin 20 mg orally every bedtime; nitroglycerin tablets 1/125 one tab
sublingual every 5min. x 3 for chest pain; Coumadin 5 mg orally every day
DISPOSITION : Patient discharged to home in stable condition.
Patient to follow up with primary care provider , Dr.
Machi , at Carna Home Hospital on 11/9 for physical therapy/PTT check.
Patient to follow up with Dr. Theiling at Carna Home Hospital in one month.
Dictated By: MARCELINA STRAUHAL , M.D LBMH
Attending: GWYNETH A. DEPSKY , M.D. NVH
OJ735/9217
Batch: 19443 Index No. ZJWLYV14TL October
T: 1/14/95
CC: 1. SANTINA MACHI , M.D. IRRH
2. BREE M. THEILING , M.D. TTH
3. GWYNETH A. DEPSKY , M.D. NVH
4. MARCELINA M. STRAUHAL , M.D. LBMH
Document id: 656
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
Y |
Y |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
Y |
Y |
Y |
Y |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
405790389 | PUO | 03299884 | | 445114 | 7/11/1998 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 4/2/1998 Report Status: Signed
Discharge Date: 4/7/1998
PRINCIPAL DIAGNOSIS: RULE OUT UNSTABLE ANGINA.
SIGNIFICANT PROBLEMS: 1 ) Rule out pulmonary embolus. 2 ) Mitral
valve prolapse. 3 ) Asthma. 4 )
Gastroesophageal reflux disease.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female
with a history of pulmonary embolus in
1992. She had been well until July , 1998 , when she
experienced her first episode of chest pain. The pain was
described as substernal in location , sharp , radiating into the left
arm , occurring at rest and lasting about five minutes. The pain
was on and off all day long. It was accompanied by shortness of
breath and exertional dyspnea , nausea , and diaphoresis. The pain
had no relation to deep breathing. In the recent three days , the
chest pain had become more constant and had the characteristic of
pressure over the precordia , and the patient had more diaphoresis ,
poor appetite and nausea. She visited her primary care physician
and was referred to the Pagham University Of for further
evaluation. Her coronary artery risk factors include positive for
obesity , hyperlipidemia with triglycerides of 237. She didn't have
hypertension , diabetes mellitus and she did not smoke. She is
still menstruating.
PAST MEDICAL HISTORY: ( 1 ) The patient has a history of
palpitations since 1988.
( 2 ) Mitral valve prolapse , diagnosed in 1988.
( 3 ) Spindle cell tumor of the forehead ,
diagnosed and removed in October of
1998.
( 4 ) Asthma , diagnosed in 1990 , with a peak
flow rate of about 240 , and has been
treated on and off with bronchodilators.
( 5 ) Gastroesophageal reflux disease
diagnosed in 1992.
( 6 ) Dysfunctional uterine bleeding in 1992.
( 7 ) Severe pulmonary embolus in 1992.
( 8 ) Cholecystectomy.
( 9 ) Floating kidney fixation.
( 10 ) Tubal ligation
( 11 ) Appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: 1 ) Atenolol 100 mg every day; Zoloft
25.0 mg every day; enteric-coated
aspirin 81.0 mg every day; vitamin E; multivitamin; Tums
one tablet three times a day
PERSONAL HISTORY: The patient is married and has three children ,
all alive and well. She is still menstruating.
SOCIAL HISTORY: The patient is working as a secretary. She denied
tobacco and alcohol use.
FAMILY HISTORY: The patient's father died of diabetes and
congestive heart failure. Her mother died of a
myocardial infarction at the age of 62.
REVIEW OF SYSTEMS: The patient had a nocturnal cough , paroxysmal
nocturnal dyspnea , plus/minus exertional
dyspnea , leg edema. There was no melena. There was no dysuria.
There was no hematuria. There was no hemoptysis.
PHYSICAL EXAMINATION: The patient was a middle-aged white female
who was lying in bed in mildly acute
distress. The temperature was 98.1 degrees. The blood pressure
was 150/75 at the Emergency Department , but it was only 90/60 when
measured on the floor. The pulse rate was 72. The respiratory
rate was 18. The oxygen saturation was 97% on two liters. The
conjunctiva were pale. The sclera were icteric. The pupils had
light reflexes , prompt and symmetric. The mouth examination
revealed the mucous membranes to be moist. The neck was supple.
The jugular venous distention was 4.0 cm. There was no parotid
fluid. The thyroid was not enlarged. On chest examination , there
was symmetric expansion. Breath sounds were clear. There were no
basilar crackles. On heart examination , there was a regular heart
beat. There was no split S-2. There was no increased P-2. There
was no heart murmur heard. On the abdominal examination , the
abdomen was soft and was slightly distended. The liver and the
spleen were not palpable. The bowel sounds were normo-active. The
extremities were freely moveable. There was mild pitting edema.
There was no cyanosis , and there was no clubbing of fingers. The
Homans' sign was negative. There was no palpable cord of the legs.
The left calf was slightly tender , but the dorsalis pedis pulse was
positive on both sides , although slightly less on the left side
than on the right side. On neurological examination , there were no
focal neurological signs.
LABORATORY DATA: The sodium was 141. The potassium was 4.0. The
chloride was 106. The bicarbonate was 27.0. The
BUN was 19.0. The creatinine was 0.6. The blood sugar was 91.0.
The CK was normal times three. The troponin-I was 0.05. The CKMB
was not measured because of normal. The CBC showed a WBC of 9.78 ,
a hematocrit of 37.8 , a platelet count of 315.
A chest x-ray revealed no cardiomegaly and no pulmonary congestion.
An EKG originally showed normal sinus , with no acute ST-T changes.
The ABGs with two liters oxygen showed a PO2 of 74.0 , an SO2 of
94.4 , a pH of 7.37 , a PCO2 of 39.0.
Other studies included a cardiac echo which showed normal left
ventricular size and normal systolic function. The ejection
fraction was 54%. There was normal right ventricular size and
function. There was no acute right heart overload. There was no
significant valvular dysfunction , and there was no pericardial
effusion. The V-Q scan on April , showed intermediate
probability for PE. The cardiac catheterization on April ,
showed normal coronary arteries and normal pulmonary pressures.
Leni's studies on April showed no evidence of deep venous
thrombosis. A pulmonary angiogram on August showed no
evidence of pulmonary embolism.
HOSPITAL COURSE: After the patient was admitted to the Floor , she
developed hypotension , with the blood pressure
Pdown to 80/50. The hypotension was responsive to normal saline
challenge , 2.0 liters. The arterial blood gases showed a large AO2
gradient. After three hours on the Floor , the EKG showed Q-R-S and
ST-T changes at Lead 3 and AVF , suggestive of right ventricular
strain , so right ventricular infarction was suspected. Emergency
cardiac echo showed that there was no acute right heart overload ,
and that both chambers of the heart were normal. Cardiac
catheterization was normal. Leni's showed no evidence of deep
venous thrombosis. A pulmonary angiogram was done , and it showed
no evidence of pulmonary embolism. Other causes of epigastric pain
such as pancreatitis and hepatitis was ruled out because of normal
levels of amylase , lipase and liver function. The patient's chest
pain was partially relieved with Motrin.
MEDICATIONS ON DISCHARGE: Include enteric-coated aspirin , 81.0
mg orally every day; Atenolol 50.0 mg orally every day;
TUMS , 1 , 250 mg orally three times a day; Motrin 800 mg orally every 6 hours; Maalox 15.0 ml
orally every 6 hours as needed for indigestion; multivitamin , one tablet orally every day;
Zoloft 25.0 mg orally every day; Axid 150 mg orally twice a day
DISPOSITION: The patient was discharged in stable condition , and
she will be followed at her primary care physician's
office and cardiologist for a scheduled visit in one week. The
patient has also had study about ANA and lupus screen as well as a
rheumatoid arthritis screen. These results will be followed up as
an outpatient. The patient's thyroid function was totally normal.
Dictated By: CAITLIN PIACENTE , M.D. IB
Attending: BREE M. THEILING , M.D. TTH
FJ696/2327
Batch: 70953 Index No. BINUH39Z6M May
August
Document id: 657
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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209096147 | PUO | 08723508 | | 4787551 | 5/26/2005 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 5/26/2005 Report Status: Signed
Discharge Date: 11/7/2005
ATTENDING: STUKOWSKI , JANAY MD
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Betsy Defont is a 79-year-old gentleman with extensive history of
coronary artery disease who has previously undergone a coronary
artery bypass graft x2. Also , several percutaneous transluminal
coronary angioplasties and stents of his saphenous vein graft to
his first diagonal coronary artery in 1999. He also received a
stent to his left subclavian due to total occlusion and a stent
and angioplasty of the left brachial artery. He has a history of
atrial fibrillation , chronic renal failure , peripheral vascular
disease. He is also status post bilateral carotid
endarterectomies as well as a longstanding history of
insulin-dependent diabetes mellitus. The patient recently had
been experiencing increasing shortness of breath , dyspnea on
exertion , paroxysmal nocturnal dyspnea and more frequent episodes
of substernal chest pressure. Aortic valve area had reached the
value of 0.4 cm2. During her previous admission in September 2005 ,
he underwent cardiac catheterization , which revealed left main
coronary artery disease and three vessels with evidence of
restenosis. At that time , he underwent successful stenting to
his left main coronary artery and a successful PTCA and stenting
two saphenous vein graft to the posterior descending coronary
artery. Echocardiogram revealed an ejection fraction of 50% ,
aortic stenosis with a mean gradient of 23 mmHg , a peak gradient
of 38 mmHg , calculated valve area of 0.8 cm2 , trivial aortic
insufficiency , mild mitral insufficiency , and moderate tricuspid
insufficiency.
PAST MEDICAL HISTORY/PAST SURGICAL HISTORY:
Significant for myocardial infarction in 1999 , history of class
intravenous heart failure with inability to carry on any physical
activity , recent signs and symptoms of congestive heart failure
including paroxysmal nocturnal dyspnea , dyspnea on exertion ,
pulmonary edema on chest x-ray , and pedal edema. He is status
post a coronary artery bypass graft x4 in 1989 with the left
internal mammary artery to left anterior descending coronary
artery , saphenous vein graft to the first diagonal coronary
artery , saphenous vein graft to the posterior descending coronary
artery , saphenous vein graft to the third obtuse marginal
coronary artery and also reoperation in 1992 for coronary artery
bypass graft x2 with a saphenous vein graft to the posterior
descending coronary artery , and saphenous vein graft to left
circumflex coronary artery. He is also status post a PTCA and
atherectomy in 1996 and 1997 and stent placement in 1999 and most
recently as stated above he has history of hypertension ,
peripheral vascular disease , claudication bilaterally with
insulin-dependent diabetes mellitus. The patient is also status
post a right fem-pop bypass. He has a history of dyslipidemia ,
renal failure status post left carotid endarterectomy and right
carotid endarterectomy , peripheral vascular angioplasty to the
left subclavian and left brachial arteries , a peripheral vascular
stent placement of the left subclavian and left brachial
arteries. He is status post a cholecystectomy and hernia repair.
ALLERGIES:
The patient has allergies to Quinaglute , lisinopril , verapamil ,
where he develops GI upset.
MEDICATIONS ON TRANSFER:
Atenolol 25 mg once a day , amlodipine 5 mg once a day , losartan
50 mg once a day , baby aspirin 80 mg once a day , Plavix 75 mg
once a day , Coumadin , Lasix 80 mg once a day , atorvastatin 40 mg
once a day , Actos 30 mg once a day , Mucomyst , colchicine 0.6 mg
once a day , insulin NPH Humulin 25 units and 8 units and regular
insulin , Humulin of 4 units , Proscar 5 mg once a day , and
potassium chloride slow release 20 mEq once a day.
PHYSICAL EXAMINATION:
Cardiac exam: Irregularly irregular rhythm. Peripheral vascular
2+ pulses bilaterally in the carotid , radial pulses , 1+ left
femoral , nonpalpable right femoral and nonpalpable bilaterally in
the dorsalis pedis and posterior tibialis pulses. Respiratory:
Breath sounds clear bilaterally. Extremities: 3+ edema on both
legs , is otherwise noncontributory.
ADMISSION LABORATORY DATA:
Sodium of 141 , potassium 3.7 , chloride of 106 , CO2 29 , BUN of 45 ,
creatinine 1.5 , glucose of 88 , magnesium 1.9. WBC 6.02 ,
hematocrit 27.2 , hemoglobin 8.4 , platelets of 239 , 000. physical therapy of 36
and physical therapy/INR of 3.6.
HOSPITAL COURSE:
Betsy Defont was brought to the operating room on 1/14/05 where he
underwent an elective reoperation aortic valve replacement with a
23 mm Mosaic valve. Total bypass time was 119 minutes , total
crossclamp time was 69 minutes. Intraoperatively , the patient
was cannulated via the right axillary artery and left femoral
vein. A sternotomy was performed while on coronary pulmonary
bypass without incident. He was found to have a trileaflet
calcified aortic valve , which was excised after transverse
aortotomy. The patient did well intraoperatively , came off
bypass without incident , was brought up to the Intensive Care
Unit in normal sinus rhythm and stable condition.
Postoperatively , the patient did very well. He was extubated and
transferred to Step-Down Unit on postoperative day #1. He did
receive transfusion of 2 units packed red blood cells for
postoperative anemia. His Plavix , aspirin and Coumadin was
restarted for his atrial fibrillation. Betsy Defont was also found
to have an air leak from his chest tube and also did begin to
have some postoperative confusion on postoperative day #2. His
narcotics were discontinued. His chest tube air leak resolved ,
and the chest tubes were removed without incident. Post-pull
chest x-ray showed no pneumothorax. On postoperative day #3 , the
patient continued with his confusion requiring a sitter.
Psychiatry was consulted and recommended to restart his
preoperative benzodiazepine and Haldol in the evening. He was
also seen by the Infectious Disease Service for shingles and
was started on a seven-day course of acyclovir for
post-herpetic neuralgia. He required vigorous diuresis and
pulmonary toilet with Mucomyst and vigorous chest physical
therapy. The patient's mental status cleared. He no longer
required a sitter. He was screened by rehab and was accepted for
transfer to rehab on postoperative day #11. The patient also
received additionally a unit of packed red blood cells for
hematocrit of 23 with good result. Betsy Defont was also started on
Lovenox on 4/4/05 as a bridge to Coumadin until his INR
increases to 2.0 for his atrial fibrillation , atrial flutter.
DISCHARGE MEDICATIONS:
The discharge medications for Betsy Defont is as follows: Baby
aspirin 81 mg once a day , Klonopin 0.5 mg in the evening ,
colchicine 0.6 mg once a day , Colace 100 mg three times a day ,
Lasix 60 mg three times a day , Haldol 0.5 mg in the evening ,
insulin NPH 16 units in the evening at 10:00 p.m. and 20 units in
the morning , Lopressor 50 mg every six hours , Niferex 150 mg
twice a day , Proscar 5 mg once a day , Lovenox subcutaneously every 12 hours
until INR reaches 2.0 or greater , potassium chloride slow release
20 mEq twice a day , Plavix 75 mg once a day , Nexium 40 mg once a
day , DuoNebs inhaler every two hours as needed for wheezing ,
NovoLog sliding scale before meals and every bedtime , NovoLog insulin 8 units
with breakfast and 2 units with lunch and 4 units with dinner ,
Lipitor 40 mg once a day , and Coumadin. The patient received 6
mg of Coumadin this evening , and his Coumadin dosing will be
followed by Pagham University Of Anticoagulation Service
at ( 405 ) 082-3371 for his atrial fibrillation for target INR of
2.0-3.0. Betsy Defont will follow up with Dr. Janay Stukowski in six
weeks and Dr. Reyes Mcpeck in one week , his cardiologist.
DISCHARGE LABS:
The discharge labs for Betsy Defont is as follows: Glucose of 113 ,
BUN of 35 , creatinine 1.3 , sodium 139 , potassium 4.1 , chloride of
106 , CO2 27 , magnesium 2.2 , WBC 7.67 , hemoglobin 8.1 , hematocrit
25.8 , platelets of 281 , 000. physical therapy/INR 19.7 , physical therapy/INR of 1.7.
DISPOSITION:
Mr. Defont will be transferred to Geme Leafount Healthcare in Las E Da
CONDITION ON DISCHARGE:
He is discharged in stable condition.
eScription document: 9-0563057 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: STUKOWSKI , JANAY
Dictation ID 5211915
D: 1/21/05
T: 1/21/05
Document id: 658
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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U |
U |
U |
- |
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U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
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Y |
N |
N |
N |
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Y |
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- |
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N |
N |
N |
381800224 | PUO | 26149384 | | 1108801 | 11/7/2004 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 4/7/2004 Report Status: Signed
Discharge Date: 10/28/2004
ATTENDING: GAYLENE GRACE FANIEL MD
PRINCIPAL DISCHARGE DIAGNOSIS: Status post AVR , CABG x3.
OTHER DIAGNOSIS: Diagnoses hypertension , diabetes mellitus type
I , dyslipidemia , COPD and asthma.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old female who was
admitted to Osri Medical Center on 8/14/04 complaining of chest
pain on exertion and was ruled in for NSTEMI by enzymes peaking
on 10/5/04. CK 381 and TNI 0.18. No acute EKG changes were
noted. The patient was transferred to Pagham University Of for catheterization and possible CABG. Preoperative
cardiac status myocardial infarction 8/14/04 requiring
hospitalization associated with prolonged chest pain. Peak CK
389 , troponin 0.18.
PREOPERATIVE CARDIAC STATUS: The patient has a history of class
II angina. There has been no recent angina. There is history of
class II heart failure. The patient is in normal sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: None.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus , insulin
therapy , dyslipidemia , COPD , bronchodilator therapy , asthma for
the last 7-10 years.
PAST SURGICAL HISTORY: Knees bilateral arthroscopy 3/17 ,
10/10
FAMILY HISTORY: Family history of coronary artery disease.
Mother with MI. Father died at an early age due to questionable
PE.
SOCIAL HISTORY: A history of tobacco use 70-pack-year cigarette
smoking history , quit smoking 30 years ago. Single , lives with
her children.
ALLERGIES: To lisinopril and metformin.
PREOP MEDICATIONS: Verapamil 80 mg twice a day , Avapro 150 mg every day ,
aspirin 325 mg every day intravenous heparin , hydrochlorothiazide 50 mg every day ,
albuterol 2 puffs twice a day , fluticasone 2 puffs four times a day ,
atorvastatin 10 mg every day , Celexa 20 mg every day , ibuprofen 800 mg
twice a day NPH insulin 30 units twice a day
PHYSICAL EXAMINATION: Height and weight: 5 feet 1 inches , 103
kilograms. Vital signs: Temperature 96 , heart rate 80 , BP right
arm 140/80. HEENT: PERRLA , dentition without evidence of
infection , left carotid bruits , right carotid bruit. Carotid
bruits hard to distinguish from radiated systolic murmur into
carotids. Chest: No incisions. Cardiovascular: Regular rate
and rhythm , systolic III/VI murmur radiating to carotids.
Pulses: Carotid 2+ bilaterally , femoral 2+ bilaterally , radial
2+ bilaterally , dorsalis pedis present by Doppler bilaterally ,
posterior tibial present by Doppler bilaterally. Allen's test
left upper extremity normal , right upper extremity normal , left
handed patient. Please use right forearm for graft takedown.
Respiratory: Breath sounds clear bilaterally. Abdomen: No
incisions , soft , no masses. Extremities without scarring ,
varicosities or edema. Neuro: Alert and oriented , no focal
deficits.
LABORATORY DATA: Chemistry sodium 138 , potassium 3.9 , chloride
103 , CO2 26 , BUN 16 , creatinine 0.7 , glucose 164. Hematology WBC
9.58 , hematocrit 30.9 , hemoglobin 10.7 , platelets 287 , physical therapy 13.6 ,
INR 1.0 , PTT 36.9. Carotid imaging: CNIS Ultrasound left
internal carotid artery , zero percent occlusion , right internal
carotid artery zero percent occlusion. Cardiac catheterization
data from 9/12/04 showed coronary anatomy , 95% osteo LAD , 40%
proximal LAD , 60% proximal ramus , 90% mid circumflex , 90% mid
OM1 , right dominant circulation. Echo from 7/27/04 showed 57%
ejection fraction , aortic stenosis mean gradient 22 mmHg , peak
gradient 37 mmHg , calculated valve area of 1 cm2 , mild mitral
insufficiency , trivial tricuspid insufficiency , mid and inferior
septal hypokinesis , normal RV function. EKG from 9/12/04 showed
normal sinus rhythm rate of 69 , ST depression in I , V4 , V5 , V6 ,
inverted T's in I AVL , V4 , V5 , V6. Chest x-ray from 9/12/04
showed increased pulmonary vascular markings , otherwise clear.
Right ICA proximal 65-70% stenosis , left ICA proximal 75-80%
stenosis. The patient was admitted to our service and stabilized
for surgery. Date of surgery 3/12/04.
PREOPERATIVE STATUS: Urgent. The patient presented with AMI
critical coronary anatomy , rest angina , valve dysfunction.
PREOPERATIVE DIAGNOSIS: CAD , aortic stenosis.
PROCEDURE: An AVR with a 21 Carpentier-Edwards pericardial valve
and a CABG x3 LIMA to LAD , SVG1 to PDA , SVG2-OM2 with a Robichek
closure. Bypass time 201 minutes , crossclamp time 156 minutes.
FINDINGS: Obesity , heart fused pericardium which had severe
calcification , adhesions between heart and pericardium taken down
on CPB. There are no complications. The patient was transferred
to the unit in stable fashion with lines and tubes intact.
HOSPITAL COURSE: Initial postoperative period: Miquel Fry was
extubated without difficulty and had reasonable saturations on
nasal cannula. Chest x-ray appeared wet and diuresis was
increased. The history of COPD and thus preoperative COPD
medications were restarted. She was in sinus rhythm with a
systolic blood pressure of 110 and started on beta-blocker. She
was given Toradol initially for pain and Percocet for break
through pain. Gentle diuresis was initiated and in the initial
postoperative period she was on the Portland protocol for
elevated postoperative blood sugars. She was transferred to the
step-down unit on 2/14/04 where she continued to improve.
Diuresis was continued and increased as needed. She was on 96%
saturation with 3 liters of oxygen delivered via nasal cannula.
Her hematocrit postoperative fluctuated between 23-25 and the
patient was asymptomatic. She continued to be followed by
cardiology for the duration of her hospital course. Gentle
ambulation was increased. She remained in sinus rhythm in the
80's and pressure was stable 120's/80's and oxygen was
progressively weaned. Her temporary pacing wires were DC'd
without incident on 1/19/04. She was followed by Diabetes
Management Service for the duration of her hospital course.
Chest tubes were DC'd without incident on 6/26/04. Physical
therapy was consulted and they cleared her for home discharge
secondary to elevated white count and low-grade temperatures on
5/20/04. She was pan cultured. Resultant culture showed a UTI
and all cultures were negative. Wounds were stable. Diuresis
was continued and increased. Miquel Fry had a postoperative
echocardiogram on 6/13/04 which showed an ejection fraction of
55-60% , trace MR , trace TR and no AI and no regional wall motion
abnormalities. She continued to progress well and was evaluated
by cardiac surgery service to be stable to discharge to home with
VNA service on 6/17/04 with the following discharge instructions.
Diet: Low-cholesterol low saturated fat , ADA 2100 calories per
day.
FOLLOWUP APPOINTMENTS: With Dr. Huitron 178 324-4586 in 5-6 weeks ,
Dr. Stayner 771-077-6316 in 1-2 weeks , and Dr. Bess 787-041-7197
in 1-2 weeks.
ADDITIONAL COMMENTS: Please have primary care physician/cardiologist draw CBC at
first office visit and repeat UA and culture to determine need
for treatment of possible UTI , is completing antibiotic course as
outpatient.
TO DO PLAN: Make all follow up appointments. Local wound care:
Wash all wounds daily with soap and water. Watch all wounds for
signs of infection , redness , drainage , pain , swelling , fever.
Keep legs elevated while sitting/in bed. Call primary care physician/cardiologist
or Pagham University Of cardiac surgery service
117-219-4079 with any questions.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 325 mg every day , Lasix
60 mg twice a day for 3 days then 40 mg twice a day for 3 days , ibuprofen
600 mg every 6 hours as needed pain , Lopressor 50 mg three times a day , niferex 150 150
mg twice a day , simvastatin 20 mg every bedtime , K-Dur 30 mEq twice a day and then
20 mEq twice a day , fluticasone 44 mcg inhaled twice a day , levofloxacin
500 mg every day for 2 days to complete course for UTI , Humalog ,
insulin on sliding scale , Humalog insulin 12 units subcutaneously with
lunch and dinner , Humalog insulin 16 units subcutaneous with
breakfast , Celexa 20 mg every day , Combivent 2 puffs inhaled four times a day ,
Nexium 20 mg every day , and Lantus insulin 62 units subcutaneous
every bedtime
eScription document: 3-4122942 DBSSten Tel
Dictated By: CRIDGE , LORRETTA PA
Attending: HUITRON , SHERRY CATRICE
Dictation ID 9562384
D: 9/2/04
T: 9/2/04
Document id: 659
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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682349409 | PUO | 25903098 | | 6049287 | 6/24/2005 12:00:00 a.m. | HEART FAILURE , HYPONATREMIA | Signed | DIS | Admission Date: 10/16/2005 Report Status: Signed
Discharge Date: 10/2/2005
ATTENDING: BOARD , KATHIE MIREYA MD
ADMITTING DIAGNOSIS:
Decompensated heart failure and hyponatremia.
DISCHARGE DIAGNOSIS:
Congestive heart failure.
CHIEF COMPLAINT:
Transfer from outside hospital for decompensated heart failure
and hyponatremia.
HISTORY OF PRESENT ILLNESS:
This is a 65-year-old female with nonischemic cardiomyopathy ,
diabetes , obesity with ICD/biventricular pacer , CHF with EF of
15% was admitted to an outside hospital initially for a fall and
was subsequently found to have decompensated heart failure and
hyponatremia. The patient was then transferred to Totin Hospital And Clinic for further treatment. At the time of the fall , the
patient was not presyncopal , likely due to possibly feeling weak.
At the hospital , the patient received orally Lasix and then intravenous
Lasix with little success in treating CHF. The patient was found
to have sodium level of 117 , hydrochlorothiazide was then
withheld and the patient was restricted on fluids. Of note , the
patient comes in on Coumadin therapy secondary to having a CVA in
10/5 with no residual symptoms while off Coumadin. The
patient denies any history of chest pain , shortness of breath ,
palpitations , however , the patient knows that he has had
increasing dyspnea on exertion and weakness. She also notes some
swelling and difficulty lying completely flat.
PAST MEDICAL HISTORY:
1. CHF with EF of 15% with biventricular pacer and ICD on an
anticoagulation.
2. CVA in 7/17
3. Diabetes.
4. Hypertension.
5. Chronic back pain treated with Neurontin , Xanax , and
oxycodone.
6. Agoraphobic/anxiety disorder.
7. Hypercholesterolemia.
ALLERGIES:
No known drug allergies.
MEDICATIONS:
1. Hydrochlorothiazide 25 mg once daily.
2. Digoxin 0.125 mg once daily.
3. Lasix 80 mg twice daily.
4. Isordil 30 mg orally daily.
5. Xanax 0.5 mg orally every 6 hours as needed
6. Potassium 60 mEq orally twice a day
7. Vicodin every 6 hours as needed
8. Coumadin 5 mg Monday , Wednesday , Friday.
9. Neurontin 100 mg orally three times a day
PHYSICAL EXAM AT ADMISSION:
Vital signs: Temperature 96.6 , blood pressure 98/60 , respiratory
rate 18 , O2 sat 95% , pulse 70. General appearance: No apparent
distress. Awake , alert , and oriented to place and person x2 ,
somewhat oriented to time , knows ear and month. Lungs: Crackles
at the bases bilaterally to mid lung fields. HEENT: Extraocular
movements intact. Pupils equal , round , and reactive.
Cardiovascular: S1 , S2 , 3/6 systolic ejection murmur. JVP 18 cm ,
regular rate and rhythm. Abdominal exam: Soft , nontender ,
nondistended. Positive bowel sounds. Extremities: Trace edema
bilaterally 1+ , 2+ pulses bilaterally. No calf tenderness.
Neurologic exam: Remembers 2/3 objects at 5 minutes , alert and
oriented x2-3 , follows commands , slurred speech , a little bit
drowsy but alert. No facial droop. No ptosis. 4/5 strength
bilaterally.
LABORATORY DATA ON ADMISSION:
Sodium 120 , creatinine 0.9 , potassium 4.8 , magnesium 1.9 , white
count 6.9 , hematocrit 42.5 , INR 2.1.
EKG: V paced , sinus rhythm , no ischemic changes.
Chest x-ray: Pleural effusions bilaterally , no infiltrates , CHF.
HOSPITAL COURSE:
This is a 65-year-old female with non-ischemic cardiomyopathy ,
CHF with EF of 15% and on a biventricular pacer , ICD , diabetes ,
obesity , admitted from outside hospital for treatment of
hyponatremia and decompensated heart failure.
1. Cardiovascular:
A. Pump: The patient initially was in significant decompensated
heart failure. As a result , the patient was immediately started
on diuretics with torsemide intravenous 100 mg twice a day with a goal of
-1 to -2 liters daily. Daily weights and strict I & Os were
monitored daily. The patient was also placed on 1 liter free
water restriction and 2 liters fluid restriction. Digoxin levels
were shown to be in normal range. The patient was continued on
digoxin , Isordil , and thiazides were held secondary to patient's
hyponatremia. Over the hospital course , the patient's
hyponatremia improved significantly and gradually back up in to
the 130s. The patient continued to diurese well initially with a
weight of 83.5 kilograms. At the time of discharge , the
patient's weight was approximately 273 kilograms. The patient
also continued to show much improvement in terms of energy level.
Subjectively , the patient felt better. Zestril was also slowly
added to patient's CHF regimen. At the time of discharge ,
Zestril 10 mg per day was added. A beta-blocker was also added ,
specifically Coreg at 3.125 mg twice daily , Aldactone 25 mg once
daily was also added to the regimen. In terms of diuresis
initially , the patient was on 100 mg twice a day orally torsemide and at
one point was switched to Lasix drip as the patient was not
responding to diuretics. Eventually the patient was transitioned
back to an orally regimen with torsemide ultimately at 50 mg orally
twice a day
Echocardiogram was also performed which showed significant mitral
regurgitation with reversal of flow in the pulmonary venous
system. As a result , there was consideration and discussion
about mitral valve replacement. The patient is amenable to
procedure performed by Dr. Perch This will be discussed and
coordinated by his office and him. This will be a percutaneous
procedure possibly.
The patient's electrolytes were monitored twice daily as the
patient was actively being diuresed. Electrolytes were repleted
as needed
B. Rhythm: The patient has no active arrhythmias. However , the
patient's ICD and biventricular pacemaker was found to be towards
end of life and required replacement. As a result , although not
urgent during this admission , ICD/biventricular pacer was
replaced by Dr. Dominguez on 4/20/05. The patient tolerated the
procedure very well with no complications. The patient's ICD
pocket was checked for any signs of pocket hematoma or other
complications. The patient is stable and new ICD/pacer is
functioning properly. No signs of bleeding or infection.
C. Ischemia: There are no active issues. EKGs demonstrated no
signs of cardiac ischemia. The patient was chest pain free
throughout the hospitalization.
2. Endocrine: The patient's home regimen was held and the
patient was continued only on a insulin sliding scale after meals
and at bedtime. Fingersticks demonstrated good sugar control.
Fingersticks were managed mostly between 100 and 120.
3. FEN: The patient was on diabetic diet. The patient was also
checked twice daily for electrolytes and repleted for magnesium
and potassium scale. Sodium was also monitored as the patient
was initially admitted for hyponatremia. As a result , all
thiazides were held.
4. Hematology: The patient had a home dose of Coumadin 5 mg
Monday , Wednesday , Friday. The patient's regimen was continued
as inpatient and was slightly modified eventually to
approximately 2 to 2.5 mg once daily. INR was maintained
therapeutic throughout the hospitalization. ICD replacement
procedure per Dr. Brumet The patient was continued with the
foal INR between 2.0 to 2.5.
5. Psyche/Neuro: Continued patient's home regimen of Xanax ,
Neurontin and pain medication to control chronic back pain.
6. Prophylaxis: For DVT prophylaxis , the patient was on Coumadin
with therapeutic INR. For GI prophylaxis , the patient was placed
on Nexium.
Physical therapy consult was also called to evaluate the
patient's functional status. The patient also underwent regular
physical therapy sessions inhouse to improve functional status.
ID: The patient's UA demonstrated possible evidence for urinary
tract infection. This may also have contributed to patient's
decompensated heart failure and also initial complaints of
feeling weak. Urine culture demonstrated that the patient had
citrobacter that was sensitive to ciprofloxacin. As a result ,
the patient was started on a course of ciprofloxacin. The
patient was also placed in isolation as the strain was resistant
to gentamicin. The patient after treatment was taken off contact
isolation. The patient was afebrile. Vital signs were stable
with no complaints of dysuria , chills , or fevers throughout
hospitalization. Subsequent UA demonstrated evidence that
urinary tract infection was adequately treated.
DISPOSITION:
The patient to follow up with home cardiologist within one to two
weeks. After discharge , the patient will also follow up with Dr.
Service to discuss further treatment of mitral valve
regurgitation. After Coumadin follow up and INR blood draws , the
patient will follow up with primary care doctor.
eScription document: 2-7777026 EMSSten Tel
Dictated By: DURRETTE , SEYMOUR
Attending: BOARD , KATHIE MIREYA
Dictation ID 2985592
D: 1/13/05
T: 1/13/05
Document id: 660
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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063586499 | PUO | 71740995 | | 1175278 | 8/29/2005 12:00:00 a.m. | CARDIOMYOPATHY | Signed | DIS | Admission Date: 6/26/2005 Report Status: Signed
Discharge Date: 10/9/2005
ATTENDING: DOUGLASS PETTINGER MD
PRIMARY MEDICAL DIAGNOSIS:
Congestive heart failure.
OTHER MEDICAL DIAGNOSES:
Morbid obesity , hypothyroidism , hypertension , history of poor
adherence to medical regimen.
BRIEF HISTORY OF PRESENT ILLNESS:
The patient is a 58-year-old woman with medical history as
mentioned above and history of idiopathic cardiomyopathy with her
last echocardiogram in 6/22 showing ejection fraction of 35-45%.
She presents with approximately 1.5 weeks of increasing
shortness of breath and dyspnea on exertion. The patient denies
chest pain , fevers or chills but does say that she has had sore
throat and a cough for approximately one week. The cough is
productive of clear frothy sputum. The patient reports
compliance with most of her medicines but states that she is not
taking Synthroid and lisinopril because these medications make
her feel bad. She also reports eating submarine sandwiches for
the past week secondary to difficulty shopping and doing her
cooking at home. She does not measure her daily weights. She
states that in addition to the Synthroid and lisinopril , she is
unsure of her other medical regimen as she has run out of some of
her medicines at home.
PAST MEDICAL HISTORY:
As above.
ALLERGIES:
Ampicillin causes a rash.
SOCIAL HISTORY:
The patient has two adult children at home and reports that she
drinks approximately 1/2-1 pint of ethanol over 2-3 days and
binges that occur approximately two times per month.
ADMISSION DATA:
Vital signs: Temperature 97 , pulse 76 , blood pressure 150s/80s.
note that one read with a small cuff read a blood pressure of
200/100 , this was believed to be secondary to inefficient cuff
size. Oxygen saturation 94% on room air. In general , the
patient is morbidly obese , in no acute distress , slowly
responsive to questions with frequent staring episodes. HEENT
exam was significant for mild pharyngeal erythema without
exudates. Neck exam was significant for no lymphadenopathy.
Jugular venous pressure was elevated although it is difficult to
assess secondary to body habitus. Lungs showed clear breath
sounds although a few crackles were present at the left base.
Abdomen was morbidly obese but did have active bowel sounds and
was nontender. Extremities showed significant subcutaneous fatty
tissue , however , there was no pitting edema. Extremities were
warm throughout. Dermatologic exam was significant for dry skin
and thin eyebrows. Neuro exam revealed 3+ biceps reflexes
bilaterally. There was a question of slow relaxation phase.
Chest x-ray showed mild pulmonary redistribution. EKG was
unchanged from prior , and showed normal sinus rhythm with a first
degree AV block , left axis deviation , left ventricular
hypertrophy with poor R-wave progression and nonspecific T-wave
abnormalities.
Laboratory values on admission was significant for creatinine of
0.8 , D-dimer was negative at 306 , BNP 2. White blood cell 6.9 ,
hematocrit 43.6 , platelets 170 , 000 , magnesium 1.7 , potassium 3.2 ,
INR 0.9 , PTT 29.3.
INITIAL IMPRESSION:
This is a 58-year-old woman with morbid obesity , dilated
cardiomyopathy and hypothyroidism in the setting of poor medical
compliance , admitted with likely multifactorial dyspnea on
exertion and mild congestive heart failure and decompensation.
SUMMARY OF HOSPITAL COURSE:
1. Cardiovascular:
Pump: The patient presented with an elevated JVP in the setting
of a negative BNP. However the clinical exam was more consistent
with mild failure and the patient was diuresed with 80 mg of intravenous
Lasix. She responded to this dose with good urine output and
stable renal function test. However , secondary to stress
incontinence and difficulty measuring JVP , the patient was
slightly over diuresed while inhouse resulting in an increasing
BUN to creatinine ratio. On her final day of her
hospitalization , all diuretics were held and the patient was
discharged on her usual regimen of diuretics including Lasix 80
mg once per day. The patient had been noncompliant with her
lisinopril secondary to throat symptoms and reportedly some
lightheadedness. Therefore she was changed to Cozaar 50 mg at
the time of discharge. The patient's discharge weight was 141.5
kg and this was estimated to be dry weight for the patient at
this time.
Rhythm: The patient had first degree AV block that was stable
from old EKGs. She was monitored on telemetry throughout her
hospital stay. There were no significant events on telemetry
during this hospitalization.
Ischemia: Rule out MI protocol was initiated in the ED secondary
to vague symptoms. This was continued and the patient ruled out
with serial negative cardiac enzymes x 3. there was no
suggestion of ischemic by ECG criteria as well.
2. Endocrine: The patient has a long history of noncompliance
with her thyroid hormone replacement and was clearly hypothyroid
on this admission. However , secondary to difficulty with blood
draws , thyroid function tests that were ordered were not obtained
on this admission and should be obtained as an outpatient in the
near future. the patient was encouraged to continue taking her
thyroid medicine as this may help improve her overall functional
status in addition to her cardiomyopathy.
DISCHARGE MEDICATIONS:
Lasix 80 mg orally every day , folate 1 mg orally every day , potassium chloride
20 mEq orally every day , Prozac 10 mg orally every day , Ventolin 2 puffs
aerosol as needed , levothyroxine 225 mcg orally every day , multivitamin tablet
orally every day , Protonix 40 mg orally every day , Colace 100 mg
orally twice a day , aspirin 81 mg orally every day , Flonase 1-2 puffs in the
nose twice a day , Advair Diskus one puff twice a day , Aldactone
one tablet orally every day , atenolol 25 mg orally every day
FOLLOWUP PLANS:
The patient will have a followup in KTDUOO clinic with her primary
care provider , the day following discharge , since Wednesday
8/6/05. at this time , routine chem-7 can be obtained to
evaluate for improvement in renal function and electrolyte
status. The patient will followup with her cardiologist , Dr.
Stautz at her regularly scheduled intervals. Tests pending at the
time of discharge , the patient had a transthoracic echocardiogram
performed which is pending at the time of this dictation. The
patient is discharged to home with services in good condition.
eScription document: 8-6143830 EMSSten Tel
Dictated By: BIRDETTE , KATHARYN
Attending: PETTINGER , DOUGLASS
Dictation ID 5427028
D: 1/5/05
T: 1/5/05
Document id: 661
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
Y |
- |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
- |
N |
N |
Y |
N |
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N |
600101831 | PUO | 62698226 | | 9643504 | 9/18/2003 12:00:00 a.m. | ISCHEMIC HEART FAILURE | Signed | DIS | Admission Date: 5/2/2003 Report Status: Signed
Discharge Date: 7/15/2003
HISTORY OF PRESENT ILLNESS: This patient is a 72-year-old woman
with ischemic cardiomyopathy status
post CABG in 1995 who presented with palpitations. The patient
said her symptoms developed about a month ago. She has had stress
for the last few months. Her husband died six months ago from
pancreatic cancer. When her palpitations developed she assumed
that they were related to anxiety. She said that she would feel a
rapid heart rate that would last about thirty minutes at a time and
occurred several times a week. She denied any chest pain or
syncope with these episodes. She presented to cardiology clinic to
see Dr. Lyn where an electrocardiogram was done and she was found
to have a heart rate of 162. Her blood pressure at that time was
100/60. She was admitted to the cardiology service for further
evaluation.
PAST MEDICAL HISTORY: 1. Coronary artery disease , status post
coronary artery bypass graft ( CABG ) in April ,
1995. Vessels bypassed were the LIMA/LAD , SVG/PDA. Her CABG was
preceded by her first MI in October 1995 where she was found to
have stenosis in her stenosis in her LAD , RCA. She had PCI to both
vessels in the intervening period. She had unstable angina and was
recathed which showed restenosis leading up to her CABG. Her last
echocardiogram was in September , 2001 that showed an ejection fraction of
20%. 2. Type 2 diabetes which is complicated by peripheral
neuropathy. 3. Hypertension. 4. Gout. 5. Anxiety and
depression.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Pravachol 10 mg orally.every day; Elavil 20 mg
orally once a day; allopurinol 3 x week;
Toprol 25 mg once a day; Lasix 40 mg once a day; Accupril 10 mg
once a day; digoxin 0.125 mg once a day; Xanax three times a day as needed
SOCIAL HISTORY: The patient's husband died six months ago of
pancreatic cancer. He was a retired Kigan Parkway
policeman. She has a long history of heavy smoking but is not
currently smoking. She denies any alcohol use. She lives alone on
the Tonpaulhunt Hamp Geaus but has a daughter who lives in Orl Rocheda Saltprocra
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6 , heart rate
104 , blood pressure 100/60 , satting 96% on
room air , breathing 18. GENERAL: She is in no acute distress.
HEENT: Extraocular movements intact. Pupils equally round and
reactive to light and accommodation. JVP flat at 45 degrees.
CARDIOVASCULAR: She had a laterally displaced PMI , normal S1 ,
split S2. LUNGS: Clear to auscultation bilaterally. ABDOMEN:
Soft , nontender , nondistended , positive bowel sounds. EXTREMITIES:
Lower extremities were warm with 1+ edema bilaterally. NEURO:
Cranial nerves II-XII were intact.
Electrocardiogram on admission showed normal sinus rhythm with left
atrial enlargement and left bundle branch block. Her
electrocardiogram in clinic showed a wide complex tachycardia and a
left bundle branch block. Her chest x-ray showed no pulmonary
edema or infiltrate.
HOSPITAL COURSE: This patient is a 72-year-old woman with a
significant ischemic heart disease who was
admitted with wide complex tachycardia.
1 ) Cardiovascular - Ischemia: The patient's abnormal rhythm was
presumed to be ventricular tachycardia given her history of severe
ischemic heart disease. Once her tachycardia was stabilized she
was taken to catheterization which showed patent grafts. She did
have a small increase in her troponin but this was thought to be
related to demand. She did not have any complaints of chest pain
during the hospitalization. We continued her on her beta blocker
and initially held her digoxin while we were controlling her
rhythm. She was slightly hypotensive during her episodes of
tachycardia so we initially held her Accupril as well , but her
medications were resumed a few days before discharge.
Pump: At the time of admission the patient was classified as
having Class II heart failure although she did admit to not being
very active and it was felt that if the patient exerted herself
more she would have more symptoms. On her catheterization her
pulmonary capillary wedge pressure was found to be 31 with a normal
right atrial pressure. She also had a repeat echocardiogram which
showed an ejection fraction of 15% with 1+ MR and a thick aortic
and mitral valve. She did not exhibit any signs of volume overload
during her hospitalization and we continued her home dose of Lasix.
We also kept her on a two liter fluid restriction but her
creatinine soon began to increase from a baseline level of 1.4 to a
peak of 2.1. The patient did admit that she drank a significantly
larger amount of fluid at home and so she was quite hypovolemic in
comparison to what she was normally used to. As a result we
liberalized her fluid restriction and her creatinine normalized.
Rhythm: When the patient arrived her tachycardia resolved and she
was in normal sinus rhythm. However , later that evening she went
back into ventricular tachycardia. She had stayed in ventricular
tachycardia with her heart rate often reaching the 130s for several
minutes at a time. Her blood pressure was always stable in the
90s/50s. She denied any chest pain. She was given an amiodarone
load of 150 mg intravenous x 1 over 20 minutes and also started on a orally
load of 400 mg orally three times a day Over the next two days she continued to
have episodes of sustained ventricular tachycardia for five minutes
at a time and ultimately her ventricular tachycardia progressed so
that she would have episodes of 10-15 minutes at a time. When she
became symptomatic she was started on an amiodarone drip. This was
done through a peripheral line and after several hours the patient
developed a mild phlebitis. She was taken off the drip and placed
again on orally amiodarone. Her VTAC was thought to be primarily due
to her ischemic cardiomyopathy and we discussed the need for an ICD
with her. She was reluctant but ultimately agreed. We did also
discuss the possibility of an EP study and ablation but the patient
preferred the least invasive method possible. While the patient
was currently in compensated heart failure , as mentioned previously
it was felt that this was because she did not exert herself any
further , and that it was likely that she would within the next year
or two , decompensate and have more symptoms of congestive heart
failure. Because of the severity of her disease a dual-chamber
pacemaker was also placed at the same time as the ICD. The patient
tolerated the procedure well. By the time of discharge her
amiodarone was decreased to 200 twice a day This will likely be
decreased to 200 every day as an outpatient. She did not have any more
episodes of VTAC.
2 ) Endocrinology: We kept the patient on her same insulin regimen
of 60 units in the morning and in the evening and covered her with
an insulin sliding scale.
3 ) Pulmonary: The patient will have pulmonary function tests as
an outpatient given her therapy with amiodarone. At baseline she
did not have any pulmonary complaints.
4 ) ID: When the patient was given intravenous amiodarone she did develop
phlebitis. Despite the fact that the amiodarone was quickly
discontinued , she did develop what appeared to be a mild
cellulitis. She was started on Keflex and her cellulitis resolved.
During the hospitalization she also had a urinary tract infection
with E. coli. We were limited in the antibiotics that we could
choose. We did not want to use levofloxacin because of the
potential to prolong her QT given that she was taking amiodarone
and Elavil. She had an allergy to Bactrim which had a reported
history of renal failure. We were not able to find out any more
details on this reaction. As a result we gave her a seven-day
course of cefpodoxime given that the UTI was speciated to E. coli.
5 ) Rheumatology: The patient has a history of gout. We continued
her allopurinol.
DISPOSITION: The patient was sent home with her daughter. We did
offer for her to have VNA but she refused and felt
that her needs would be met at her daughter's house. At the time
of discharge she was not sure whether she was going to move back to
her home eventually in the Iga or whether she was going to
sell her home and move closer to family.
FOLLOWUP: The patient has follow up appointments with Dr. Dobrich
and Dr. Gaskell She will have pulmonary function tests.
DISCHARGE MEDICATIONS: Pravachol 10 mg orally once a day; Elavil 20
mg orally.every day; NPH 60 mg every day before noon and every afternoon;
allopurinol 300 mg Monday , Wednesday , Friday; Glucotrol 10 mg orally
once a day; Toprol 25 mg once a day; Lasix 40 mg once a day;
Accupril 10 mg once a day; digoxin 0.0625 once a day; amiodarone
200 mg twice a day; Keflex 250 mg orally x 2 doses; cefpodoxime 100
mg orally.every day x 2 days. Please note that we decreased the patient's
digoxin dose from 0.125 to 0.0625 given the addition of amiodarone.
Dictated By: ARIE L. TELES , M.D. NTTJMC
Attending: FERNANDE R. PREWER , M.D. RJLH
AZ409/737376
Batch: 92864 Index No. QDKY5H9YW3 March
August
Document id: 662
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
- |
- |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
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Y |
N |
N |
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Y |
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- |
N |
N |
906128280 | PUO | 93229960 | | 8325239 | 8/12/2005 12:00:00 a.m. | PALPITATIONS | Signed | DIS | Admission Date: 8/12/2005 Report Status: Signed
Discharge Date: 7/25/2005
ATTENDING: TIBOLLA , MADISON M.D.
PRIMARY CARE PHYSICIAN: Dr. Risien
PRINCIPAL DIAGNOSIS: CHF.
LIST OF PROBLEMS: Coronary artery disease status post MI in
2000 , PE , schizophrenia , gut malrotation , atrial fibrillation ,
IDDM , hypertension , dysfunctional uterine bleeding , uterine
fibroids , history of rheumatic fever status post C-section x2 ,
depression , domestic abuse , CHF , and hypercholesterolemia.
HISTORY OF PRESENT ILLNESS: This is a 52-year-old female with
multiple medical problems who presented with palpitation ,
shortness of breath , and retrosternal chest pain ( 9/14 )
nonradiating , no response to sublingual nitro , food or position
x1 week. The patient reported running out her Toprol and
Enalapril just prior to onset of symptoms. Symptoms were
associated with nausea , stable two-pillow orthopnea , question
slightly increased frequency of PND episodes but weight stable at
about 240 pounds. Four weeks prior to admission , the patient
weighed 237.5. The patient had negative cardiac CT in October
of 2005. VNA noted the patient's persistent tachycardia over the
last few days and referred her to the ED. The patient denies any
fever , chills , any sweats , abdominal pain , diarrhea ,
constipation , and reports black stools ( on iron ).
ALLERGIES: Clozaril.
PHYSICAL EXAMINATION: On admission , afebrile , heart rate 83 ,
blood pressure 113/77 , respiratory rate 18 , O2 sat 95% on room
air. General , middle-aged African-American obese female , laying
on stretcher in no acute distress. HEENT , anicteric , oropharynx
with dry mucous membranes , no JVD discernible but difficult to
examine given neck girth , no carotid bruits. Lungs , clear to
auscultation bilaterally. CV , tachycardia , irregularly
irregular. No murmurs , rubs , or gallops , distant heart sounds.
Abdomen , obese , soft , nontender , slightly distended , positive
bowel sounds , negative fluid wave. Extremities , warm , trace
ankle edema bilaterally. Skin , no rash. Neuro , nonfocal.
DATA: D-dimer less than 200. Cardiac enzymes negative x2. BNP
48. EKG aflutter at 115 , RAD. Chest x-ray , cardiomegaly , no
pulmonary edema , no effusion.
HOSPITAL COURSE:
1. CV: Blood pressure was controlled with enalapril and Toprol.
The patient was initially duiresed with intravenous lasix during her
hospitalization , but required increasingly higher doses and then the
addition of diuril to maintain a negative fluid balance. For many days
her weight did not change and it was suspected that she was not being
compliant with her fluid restriction. Her weight on admission was 247. She
was diuresed to a weight of 238.9 on the day of discharge with using doses of
lasix 160 twice a day with diuril. She was placed on 1 liter fluid restriction.
The patient is being followed by Lynwood Keitel in the Ashore Cleod Health
The patient was ruled out for MI by EKG and enzymes.
Atrial flutter rate controlled in the 60s-80s.
2. Heme: The patient continued on Coumadin for her atrial
flutter with INR goal rate of 2 to 3. INR on the day of
discharge was 3. The patient will follow up at the Shalti Arv Ler Hospital for INR.
3. Endocrine: The patient's hemoglobin A1c was 10.4. Her NPH
was adjusted to 80 units in the a.m. and 70 units in the p.m.
with NovoLog sliding scale and 4 units before every meal.
4. Pulmonary: The patient had an episodic desaturation to the
mid 80s on room air. It was corrected with deep breath. The
patient has most likely OSA and/or obesity-hypoventilation syndrome and an
outpatient sleep study is recommended.
DISCHARGE MEDICATIONS:
Klonopin 0.5 mg orally three times a day , Depakote 1000 mg orally at bedtime ,
Colace 100 mg orally twice a day , enalapril 5 mg orally daily , NPH 70
units subcutaneous at bedtime and 80 units subcutaneous every day before noon ,
oxybutynin chloride 5 mg orally twice a day , oxycodone 5 mg orally every 4 hours
as needed pain , quinine sulfate 260 mg orally at bedtime , thiamine HCl
50 mg orally daily , Coumadin 6 mg orally every afternoon , Paxil 50 mg orally
daily , Toprol-XL 150 mg orally every day before noon , KCl 20 mEq orally every day before noon ,
Lipitor 80 mg orally daily , Seroquel 800 mg at bedtime , Protonix 40
mg orally daily , and Lasix 200 mg orally every day before noon and 100 mg orally
every afternoon
FOLLOW-UP APPOINTMENTS:
The patient has a follow-up appointment in the Ashore Cleod Health on 10/4/05 at 3 p.m. and with Dr. Cwalinski on
1/27/05. Arrange for INR to be drawn on 1/20/05 in the
Shalti Arv Ler Hospital , INR to be drawn every three days.
CODE STATUS:
The patient is full code.
PRIMARY CARE PHYSICIAN:
Dr. Risien
eScription document: 0-7583971 CSSten Tel
Dictated By: NICKLIN , MOIRA
Attending: TIBOLLA , MADISON
Dictation ID 7298711
D: 7/13/05
T: 7/13/05
Document id: 663
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
132781378 | PUO | 96108627 | | 6057874 | 6/20/2006 12:00:00 a.m. | PRE-SYNCOPE | Unsigned | DIS | Admission Date: 1/30/2006 Report Status: Unsigned
Discharge Date: 1/29/2006
ATTENDING: COCOMAZZI , REA M.D.
ADMITTING DIAGNOSIS: Mechanical fall.
DISCHARGE DIAGNOSIS: Mechanical fall.
SECONDARY DIAGNOSES:
1. Hypertension.
2. Bradycardia.
3. Osteoarthritis , status post left total knee replacement.
4. Spinal stenosis.
HISTORY OF PRESENT ILLNESS: Mrs. Mcguffee is a 73-year-old woman
with a history of coronary artery disease , hypertension ,
dyslipidemia , and arthritis who presents with a fall. The
patient has a history of pulmonary embolism in 2000 , treated with
Lovenox and Coumadin. The patient also has a history of coronary
artery disease , status post non-ST elevation myocardial
infarction. She presented with chest pain in 2001 and had a
troponin I , which peaked at 25. Cardiac catheterization revealed
a left-sided occlusion and percutaneous coronary intervention was
unsuccessful. A subsequent adenosine mibi in September 2002
revealed normal left ventricular function and no perfusion
defects. The patient has since been admitted for left chest
pain , last in February 2005 , which has been attributed to her
shoulder arthritis. She ruled out for myocardial infarction at
that time and chest CT scans were also negative. Today , the
patient was talking to her son on the phone when she went to
retrieve a pen and her left knee gave out and she suffered a
mechanical fall to the floor. She struck her left forehead
against a dresser. She did not have any loss of consciousness
and also denied chest pain , shortness of breath , or palpitations.
There were no focal neurological deficits and no actively
inflamed joints. She says that her left lower extremity ,
especially her left knee is chronically unstable and weak. In
the emergency department , the patient was afebrile. Her heart
rate was 70. Her systolic blood pressure was initially 190 mmHg ,
but subsequently came down to 150 mmHg without any intervention.
A head CT was negative for bleed and a chest x-ray was negative
for infiltrate or effusions. She was admitted to Medicine for
further evaluation.
PAST MEDICAL HISTORY: Coronary artery disease , hypertension ,
hypercholesterolemia , osteoarthritis , polyarthritis with positive
rheumatoid factor , and a positive ANA , spinal stenosis , pulmonary
embolism in 2001 , obesity , pseudogout , status post left total
knee replacement , history of right foot cellulitis ,
gastroesophageal reflux disease , and history of colonic adenomas.
ALLERGIES: The patient is allergic to Bactrim and shellfish.
MEDICATIONS ON ADMISSION: Include aspirin 325 mg , atenolol 25
mg , Plaquenil 400 mg daily , lisinopril 60 mg daily , nifedipine 90
mg daily , meloxicam 7.5 mg daily , hydrochlorothiazide 25 mg
daily , Lipitor 40 mg daily , Protonix 40 mg daily , and Colace 100
mg as needed
PHYSICAL EXAMINATION: The patient's temperature was 96.2
degrees , heart rate was 52 beats per minute , blood pressure was
142/70 , respiratory rate was 18 breaths per minute , and the
patient's oxygen saturation was 97% on room air. On physical
exam , the patient was lying in bed in no apparent distress and
was alert and oriented. The extraocular movements were intact.
There is no scleral icterus with a mild proptosis and some
periorbital induration around her right eye , which was tender to
palpation. The jugular venous pressure was 8 cm of water. The
lungs were clear to auscultation bilaterally. On her cardiac
exam , the patient had a regular rate and rhythm , a normal S1 with
physiological split S2 and a 2/6 systolic murmur , best heard at
the base. Abdomen was soft and nontender , with active bowel
sounds. The patient's extremities were warm and well perfused
without edema. On strength testing , the patient had 4/5 strength
in her left knee extensors and left hip flexors; otherwise , all
other muscle groups in her lower extremities were 5/5. The
patient reports that her left lower extremity weakness is
chronic. There were no effusions on either knee. Skin was
without rashes.
INITIAL LABORATORY DATA: Her sodium was 143 , potassium 3.4 ,
chloride 107 , bicarb 28 , BUN 16 , creatinine 0.9 , with glucose of
160. The patient had a white blood cell count of 5300 ,
hematocrit was 35.7 , and platelets were 217 , 000. Her INR was 0.9
and a PTT was 27.8. The patient's initial CK was 177 , CK-MB was
3.7 , and troponin I was less than assay. An EKG showed sinus
bradycardia with normal axes and no T-wave changes , no Q waves ,
and no ST changes. Chest x-ray showed no acute cardiopulmonary
process and a head CT was negative for mass or bleed.
HOSPITAL COURSE: The patient was admitted due to a mechanical
fall and ruled out for myocardial infarction by serial CKs and
troponins drawn 8 hours apart for three sets. Her EKGs remained
unchanged throughout her hospitalization and the patient had no
chest pain , shortness of breath , or any other cardiac symptoms.
Her troponin values were all less than assay. The patient
ambulated with physical therapy the morning after her admission without
difficulty , navigating stairs , and also walking around the pond
without any difficulty whatsoever. The patient also had plain
films taken of her left knee , which showed that her left knee
prosthesis was well seated without any evidence of instability or
fusion or fracture of the joint. The patient was noted during
her hospitalization to be bradycardiac to the mid 40s while
sleeping. It was recommended that the patient follow up with the
primary care physician to assess whether she needs to continue on
her atenolol due to bradycardia noted on telemetry. The patient
will also follow up with her orthopedist regarding her proceed
instability of her left knee joint. The patient's orthopedist is
Dr. Babula of the Loring Medical Center and her primary care
physician is Dr. Tobolski in Sa Pehall The patient will call
for follow-up appointment with her physicians. The patient was
discharged with her son to home on the evening of 8/19/06 to
continue her admission medications. There were no changes made
to her medications listed above.
eScription document: 8-4387827 CSSten Tel
Dictated By: ARUIZU , JULIANNE MARIE
Attending: COCOMAZZI , REA
Dictation ID 6613420
D: 8/19/06
T: 11/19/06
Document id: 664
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262260684 | PUO | 44536773 | | 0865860 | 3/10/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/29/2005 Report Status: Signed
Discharge Date: 5/29/2005
ATTENDING: KATHERYN GRUNTZ MD
PROCEDURES DURING ADMISSION:
1. Insertion of a pacemaker , 8/16/05.
2. Electrophysiology study , 8/16/05.
3. Cardiac catheterization , 2/5/05.
ADMITTING DIAGNOSES:
1. Third-degree heart block.
2. Syncope.
3. Status post motor vehicle collision.
4. Rule out stroke.
PRINCIPAL DISCHARGE DIAGNOSES:
1. Third-degree heart block; resolved.
2. Status post motor vehicle collision.
3. Lateral and medial menisci tears , left knee.
4. Old CVA.
SECONDARY DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Diabetes.
3. Hypertension.
HISTORY OF PRESENT ILLNESS:
Mr. Vlasak is a 73-year-old gentleman who is a restrained driver
in a single car motor vehicle collision , in which the car went
off the road at a moderate rate of speed ( approximately 45 miles
an hour ) , and struck a telephone pole. There are no skin marks
noted at the scene. There was airbag deployment , and the patient
was wearing a seatbelt. The patient reports feeling "fine" prior
to the motor vehicle collision. However , he has no recollection
of the motor vehicle collision itself , and the next thing he
remembers is waking up and finding the airbag is deployed , and
being in severe pain. He does remember EMS arriving.
Upon arrival of the EMS , he was found to have a heart rate of 30
in a third-degree AV block. The patient denies any chest pain ,
shortness of breath , nausea or vomiting before the motor vehicle
collision. He also denies any fevers , chills , night sweats ,
shortness of breath , headaches or visual changes either before or
after. He had no recent changes in any doses of his medications.
He was also complaining of knee pain.
ED COURSE: In the Emergency Department , he was seen by the
Trauma Team. A full dictation of the Emergency Department
courses has been completed. Please see the computer for further
details of this dictation. However , in brief , he had numerous
CAT scans performed while in the Emergency Department. These
included a CAT scan of the abdomen and pelvis , head , and chest.
There was also a CT of the cervicothoracic and lumbar spine , with
reconstructions performed. As well as plain x-rays films of the
lower extremity as well a pelvis , C-spine , and chest. Of
significance , the plain films of the knee were negative. The CAT
scan of the chest demonstrated a right frontal periventricular
hypodensity , which was thought to represent a subacute infarct.
He was subsequently admitted to the Cardiac Step-Down Floor. He
was seen by the Neurology Service ( Dr. Richmann , who is the
Neurology resident ) , who initially saw him.
PAST MEDICAL HISTORY:
1. Significant for myocardial infarction , eight years ago. He
received cardiac stents at that time.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes.
5. Renal cyst.
6. Cataract.
PAST SURGICAL HISTORY:
1. Significant for coronary stenting; two were placed eight
years ago during his MI , and he had an additional two stents
placed in September of 2004.
2. Cataract removal.
MEDICATIONS AT HOME:
1. Glyburide 100 mg orally twice a day
2. Metformin 500 mg orally twice a day
3. Aspirin 81 mg orally every day.
4. Zocor 80 mg orally every day.
5. Plavix 75 mg orally every day.
6. Prilosec 20 mg orally every day.
7. Isosorbide dinitrate 40 mg orally three times a day
8. Atenolol 100 mg orally every day.
ALLERGIES:
He has no known allergies.
PHYSICAL EXAMINATION UPON ADMISSION:
Blood pressure of 123/51 , heart rate of 48 , respiratory rate of
16. General appearance: He is a well-developed , well-nourished ,
and well-hydrated male , in mildly acute distress. HEENT:
Normocephalic and atraumatic. Extraocular motions are intact.
Pupils are equal , round , and reactive to light and accommodation
at 4 mm. The conjunctivae are pink and the sclera is anicteric.
The oropharynx is significant for a slight bite mark on the
tongue , without any active bleeding. There are moist mucosal
membranes. The neck is supple , and there is no midline
tenderness. There is no JVD. The chest is clear to
auscultation. There is tenderness over the right ribs , as well
as mild sternal tenderness. The heart is regular rhythm ,
although markedly bradycardiac. The abdomen is soft , nontender ,
and nondistended. There are good bowel sounds in all four
quadrants. There is no CVA tenderness. The pelvis is stable to
rock. Extremities: There is tenderness in the abrasions over
the left knee. The left knee is in an immobilizer , at the time
of admission to the floor. He has full range of motion in
ankles , shoulders , and elbows bilaterally. There is decreased
range of motion in the left knee. There is no bony tenderness
along any of the long bones of the upper or lower extremities ,
with exception of the knee. Peripheral vascular , dorsalis pedis ,
posterior , tibial , and radial pulses are all equal bilaterally.
Neuro exam: He is awake , alert , and oriented x3. Cranial nerves
II-XII are intact. Motor is 5/5 in the upper and lower
extremities bilaterally. Sensation is equal bilaterally , in the
upper extremities , lower extremities , and face. There is no
dysmetria or dysarthria. Finger-to-nose is fast and accurate
bilaterally. There is no drift. Skin is warm , dry , and
well-perfused.
LABORATORY DATA UPON ADMISSION:
CT C-spine negative. CT head shows a right frontal subacute
infarct. CT chest shows anterior fifth rib fractures
bilaterally. There was also some supraclavicular stranding along
the left side , without any evidence of vessel injury. CT of the
abdomen and pelvis is negative , except for a ruptured renal cyst.
He was also incidentally noted to show diverticulosis , without
any diverticulitis. The CT of the thoracic and lumbar spines
also demonstrated no fractures , although there were incidentally
noted to be anterior osteophytes in numerous levels. CT of the
chest demonstrated the rib fractures , but was otherwise negative.
Laboratory , sodium 138 , potassium 4.4 , chloride 103 , bicarbonate
25 , BUN 28 , creatinine 1.3 , glucose 185 , and anion gap is 10 , AST
and ALT are 20 and 25 respectively. Alkaline phosphatase is 80.
Lipase is 51. Calcium is 8.8 , the albumin is 4.6 , the CK is 89 ,
CKMB is 3.6 , and troponin was less than assay. His serum
toxicology screen was negative for aspirin , Tylenol ,
benzodiazepine , barbiturates , and tricyclics. Urine drug screen
is also negative. physical therapy , PTT , and INR were 13 , 25.8 , and 0.9
respectively. CBC was significant for white count of 12.0 ,
hemoglobin and hematocrit were 14.6 and 42.2 , and platelets are
250. Urinalysis was negative.
Review of the prehospital EKG demonstrated a complete
( third-degree ) heart block. However , EKG done immediately upon
admission to the Trauma Bay demonstrated a bifascicular block ,
with a rate in the 40s.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: He was admitted to the Cardiac Step-Down
Unit. He had Zoll pacer pads were placed upon his chest , and
atropine remained at his bedside. He also had an additional Zoll
pacer pads , as well as the pacemaker standby at the bedside ,
however , these were not needed , as he has completed asymptomatic
with his bifascicular block. He had serial enzymes , which were
performed , he was ruled out for myocardial infarction. He went
to the Cardiac Cath Lab , which demonstrated some coronary artery
disease. Please see the dictated cardiology reports for the
findings of the Cath Lab. It was felt , however , this was
unchanged from prior studies. He also went to the
Electrophysiology Lab. They were unable to induce any
ventricular tachycardia or other dysrhythmias during the
prolonged EP studies. He had a pacemaker inserted. The
pacemaker was followed by the Electrophysiology Service , and was
found to be working adequately. The attending was Dr. Ava Schoeppner ,
with the Electrophysiology Service. Dr. Gruntz with the
Cardiology Service saw him and was attending on record.
2. Neurology: He was seen by the Neurology Service. So , this
was under Dr. Fiona Authur , the attending neurologist on the
case. He had an MRI/MRA performed of his head and neck. The
diffusion-weighted images demonstrated no evidence of any
abnormality. There was a region of increase signal intensity on
the T2 and FLAIR images , involving the vasoganglion , extending
the corona radiata. Therefore , given the fact that signal was
seen on the T2 and FLAIR , not on the diffusion-weighted , it was
felt that this was at least 10 days old. Therefore , this was not
felt to be either the cause nor an affect of the motor vehicle
collision. It was most likely represented an old CVA , which was
not previously detected. Given the fact that the patient
remained asymptomatic , and had a normal neurological exam , and
radiographic data demonstrated that this infarct was more than 10
days old , and this was not further addressed. An MRA of his head
and neck demonstrated tortuous vertebrobasilar system. The
MRI/MRA of the neck was essentially normal , however , the left
bifurcation was thought to be without any significant stenosis.
The right bifurcation is probably without significant stenosis ,
however , could not be completed excluded. Given artifact , this
could be further followed up with an outpatient venous duplex of
the carotid arteries.
3. Musculoskeletal: He was seen by the Orthopedic Service in
the Emergency Department at the time of the trauma , he ultimately
had an MRI that was performed of his knee. This showed tears of
the medial and lateral menisci. There was no evidence of
fracture. He remained in a knee immobilizer. He saw Physical
Therapy , which felt that further therapy would be indicated.
With the impression of the Orthopedic Service that no acute
intervention was needed , and that he should follow-up with Sports
Medicine or Orthopedics in approximately 3-4 weeks. In addition ,
he was noted to have several rib fractures. The rib fractures
were felt to be the source of his pain , he continue to complain
of some inspiratory pain throughout his chest. However , he
adamantly denied any pain throughout his chest wall upon
inspiring. It was therefore felt that given the negative enzymes
and the negative Cath , and the known rib fractures that the chest
pain was strictly a result of a musculoskeletal pain. This pain
was well controlled with the combination of Dilaudid and
oxycodone. He was encouraged to take several deep breaths per
hour to reduce the risk of atelectasis or pneumonia.
4. Infectious Disease: There was no evidence of any acute
infection. Of note , his white count was trending upwards , on the
last two days of admission. It was felt that this probably
represented stress , given all the recent procedures that were
done , including the catheterization and the electrophysiology
studies , rather than A2 infection. The chest x-ray was performed
on the 25th , which demonstrated no infiltrate. This was reviewed
with an attending radiologist who reported low lung volumes.
Otherwise , it was essentially negative. In addition , a repeat
urinalysis was performed. The results are pending at the time of
dictation , however , will be followed up prior to the patient's
discharge from the hospital. The patient appears well , and
states that he is feeling at his best since the accident.
However , further workup for his white count is not performed at
the present time , however , the patient is informed , as the Ni Medical Center and the discharge summary , which show that the patient
seem to develop any evidence of infection that he should be
reevaluated by a physician.
5. Nutrition: The patient is able to eat without any
difficulty. He was eating regular house diabetic/cardiac diet.
6. Hypercholesterolemia: He was continued on his Zocor
throughout the hospitalization.
7. Prophylaxis: He was initially treated with Lovenox 40 mg
sub-Q. every day for a prophylaxis against DVTs. He is also on
aspirin and Plavix for secondary cardiac and neurological
prophylaxis. The Lovenox is discontinued , at the request of the
Electrophysiology Service on the 24th.
8. Endocrine: Given the numerous contrast studies , initially
his metformin was held. However , he was later restarted on this.
In addition , he was continued on his glyburide and covered with
sliding scale insulin. His blood sugar was never any significant
problem during his hospitalization.
9. Disposition: The patient will be going to Yale-&licgnu Hospital , in
stable condition. At the Rehab , he will continue to get physical
therapy , which he has received in the hospital. It was felt that
a short course of rehab would benefit the patient to allow him to
go back living independently again. He will be discharged to the
Rehab in stable condition.
MEDICATIONS AT DISCHARGE:
1. Tylenol 650 mg orally every 4 hours as needed pain.
2. Aspirin 81 mg orally every day.
3. Atenolol 100 mg orally every day.
4. Colace 100 mg orally twice a day
5. Glyburide 5 mg orally twice a day
6. Dilaudid 1-2 mg intravenous every 4 hours as needed pain.
7. Isosorbide dinitrate 40 mg orally three times a day
8. Ativan 1-2 mg intravenous as needed anxiety.
9. Oxycodone 5-10 mg orally every 6 hours as needed pain.
10. Senna tablets 2 orally twice a day
11. Keflex 250 mg orally four times a day x12 doses. Keflex should be
completed on Monday night.
12. Zocor 80 mg orally every bedtime
13. Ambien 5 mg orally every bedtime
14. Tessalon 100 mg orally three times a day as needed cough.
15. Plavix 75 mg orally every day.
16. Novalog slides.
17. Prilosec 20 mg orally twice a day
18. Maalox 1-2 tabs orally every 6 hours as needed pain.
The patient has following discharge appointments. He has
appointments with Dr. Rosalyn Mcalmond , with Sports Medicine , Dr.
Ava Schoeppner in 10-14 days , and Dr. Victor Money in one
week. Appointment with Dr. Mcalmond is in 3 weeks.
ADDENDUM:
Mr. Vlasak had this pacemaker placed and was recovering
uneventfully. However , it was noted that he started having
increasing white count. It was felt this was perhaps due to a
mild urine infection and was started on Levaquin. However , he
started the next day complaining increasing pain in his knee. At
this time , his white count had risen to 23 , 000. The knee was
obviously a concern for possible infection. His knee was warm ,
was tender and was erythematous , compared to the contralateral
side. As a result , the Orthopedic Service was again consulted.
An arthrocentesis was performed on his left knee , this was a dry
tap; no fluid was able to be obtained. The subsequent day , he
was complaining of increasing pain , and the sed rate returned in
the 99 with a CRP of 190. The EP Service again evaluated the
patient , and felt that there was no evidence of any clear
infection from the pacer site. He continued to have no erythema
or tenderness around the pacer site. His chest x-ray was
essentially unremarkable. The next day ( 10/9/05 ) , he was seen
by the Rheumatology Service , under Dr. Strite who also felt this
was most likely to be prepatellar bursitis , probably septic in
nature , with a hematoma. He was asked to seen by the Infectious
Disease Service , under Dr. Lamorte and Abe Girardi
He was started on Ancef 1 gm every 8 hours A PICC line will be placed
later today on the 5/15/05 and he will be discharged to rehab.
Of note , he has been afebrile for more than 48 hours while on the
Ancef , and his white count has improved dramatically , into the
approximately 10000 range. He will continue to get intravenous Ancef
every 8 hours for an additional 12 days. New consultants on the case ,
again Dr. Lamorte and Dr. Abe Girardi with Infectious
Disease , Dr Brannigan and Dr. Claretha Hendy with Orthopedics and Dr.
Strite with Rheumatology.
eScription document: 6-7522492 IS
CC: Rosalyn Mcalmond M.D.
Kernan To Dautedi University Of Of Medicine
CC: Victor Money MD
Cean
Mississippi
CC: Rossie Mankoski M.D.
Tall
CC: Jeannette Lackner MD
Juanblo
Shingpids Cord
CC: Ava Schoeppner MD
Cardiac Arrhythmia Service Pagham University Of
Ona Highway
Dexing Rham Newlico
CC: Katheryn Gruntz MD
Na Ge Pe
Mon Kerka A , Michigan 63979
Dictated By: MANKOSKI , ROSSIE
Attending: GRUNTZ , KATHERYN
Dictation ID 2448399
D: 5/2/05
T: 10/1/05
Document id: 665
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GER |
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744135337 | PUO | 95637816 | | 0393443 | 1/10/2006 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 5/25/2006 Report Status: Unsigned
Discharge Date:
ATTENDING: MANKOSKI , ROSSIE M.D.
INTERIM DISCHARGE SUMMARY
SERVICE: Bozeerbi Hospital Service.
PRINCIPAL DIAGNOSIS: Volume overload.
HISTORY OF PRESENT ILLNESS: Ms. Stewardson is a 74-year-old female
with congestive heart failure , aortic stenosis , obesity ,
hypoventilation syndrome on BiPAP at night , diabetes who presents
from rehabilitation with a 12 kg weight gain since the end of
October 2006. Her last admission to Pagham University Of was complicated by a pCO2 of 80 requiring an ICU stay
and noninvasive ventilation. Moreover , the patient had a
gastrointestinal bleed and hematocrit to a level of 24. GI
consultant felt that due to the patient's comorbidities and
difficulty intubating the patient , she would not be a candidate
for either colonoscopy or EGD.
PAST MEDICAL HISTORY:
1. Chronic renal insufficiency ( baseline creatinine 1.2-1.7 ).
2. Crohn's in remission.
3. Gastrointestinal bleed on Coumadin.
4. Congestive heart failure.
5. Aortic stenosis.
6. Restrictive lung disease likely secondary to obesity.
7. Diabetes.
8. Arthritis.
9. Spinal stenosis.
PAST SURGICAL HISTORY:
1. Right mastectomy.
2. Two knee replacements.
3. Two laminectomies.
4. Gallbladder removal.
5. Exploratory laparotomy for chronic abdominal pain without
findings.
6. D&C.
ALLERGIES:
1. Heparin ( heparin-induced thrombocytopenia ).
2. Aspirin.
3. Demerol.
4. Codeine.
5. Dilaudid.
6. Ciprofloxacin.
7. Macrodantin.
8. Penicillin.
PREVIOUS STUDIES:
1. Echocardiogram 7/7/2005: Ejection fraction 65-70% , mild
concentric left ventricular hypertrophy , aortic valve was
thickened , stenotic , peak gradient 58 ( mean 33 ) , AVA 0.74 , mild
mitral regurgitation , mild-to-moderate tricuspid regurgitation
( regurgitant velocity 3.2 m/s , pulmonary artery systolic pressure
40+ right atrial pressure ) , trace-to-mild pulmonic regurgitation.
2. Pulmonary function test 2/8/2006: FVC 31% , FEV1 23
percent , FEV1/FVC 77%.
PHYSICAL EXAMINATION:
On admission , 5/25/2006 , the patient's weight on admission was
130 kg. Her vital signs are as follows , temperature 95.8 , pulse
67 in atrial fibrillation , blood pressure 126/Doppler , the
patient had respiratory rate of 20 and an O2 saturation 95% on 4
liters. In general , the patient was in no acute distress ,
speaking in full sentences. Examination of the neck revealed JVP
to the ear , weak/weight carotid upstrokes , no bruits.
Cardiovascular examination revealed an irregular rhythm with an
S1 and weak S2. A 4/6 crescendo-decrescendo systolic murmur was
heard best at the right upper sternal border radiating to the
carotids. Lung examination revealed crackles that heard at the
way up bilaterally with decreased breath sounds throughout. The
patient's abdomen was obese , but soft and nontender. Examination
of her extremities revealed a parvus at tardus. Lower extremity
pulses could not be palpated due to edema. The patient had 4+
lower extremity edema. Examination of the left shin showed
erythema , pain , swelling with a 2 x 2 cm ulcer on the left
anterior shin. The ulcer appeared clean , dry and intact with no
drainage.
STUDIES AT OIUH:
1. EKG on 5/25/2006 showed atrial fibrillation at 63 beats per
minute with a normal axis and poor R-wave progression.
HOSPITAL COURSE:
1. The patient presented in gross volume overload: We attempted
to diurese the patient with intravenous torsemide. Gradually ,
the dose of torsemide was increased from 100 twice a day to 200
twice a day. At the time of this dictation; however , the
patient's weight had decreased only to 124.6 kg. Her admission
weight on 7/15/2006 was 130 kg. However , this weight was
recorded in the bed ( not standing ). Her first standing weight
was recorded on 8/19/2006 at 125 kg. Her lower extremity edema
only mildly improved , however , at the time of this dictation , the
patient was able to put her shoes on , which she was unable to do
prior to admission. During this diuresis , the patient's
potassium was repleted twice a day. She was also maintained on
Aldactone and acetazolamide ( for elevated CO2 levels ). The
patient's lipid profile was measured during this hospitalization
and she had an LDL of 64. She was maintained on Zocor. Aspirin
cannot be administered due to the patient's drug allergy profile.
From a rhythm standpoint , the patient remained in atrial
fibrillation during this hospitalization through 5/18/2006. She
was not anticoagulation , given her history of HIT and history of
gastrointestinal bleed on Coumadin.
2. Pulmonary: The patient was maintained on BiPAP and Flonase
throughout her hospitalization. Her mental status was monitored
closely given her previous MICU stay during her last admission
for an elevated pCO2. However , the patient was alert and
oriented x3 during her hospitalization.
3. Renal: The patient's creatinine was stable at approximately
1.1 during her diuresis through 10/30/2006.
4. Gastrointestinal: The patient was maintained on Nexium
during her hospitalization. Her hematocrit remained stable at
approximately 32.4.
5. Endocrinology: The patient was maintained on Levoxyl and her
home NPH regimen.
6. Infectious disease: The patient was given vancomycin for
cellulitis on her left shin , which appeared to be improving as
the erythematous area was decreasing from 5/4/206 to
10/30/2006. She was also started on gentamicin on 10/11/2006 for
asymptomatic bacteriuria. The patient's urine culture on
8/19/2006 greater than 100 , 000 colonies of pseudomonas.
CODE STATUS: During this hospitalization , the patient reiterated
that she is a full code. It was discussed with her that she is
difficult and in fact possibly and possible intubation. She was
one time intubated nasally. In any event , she wants all life
saving measures performed. At the time of this dictation , she is
a full code ( healthcare proxy Debbie Hambleton , phone number ( 700 ) 752-4501 ).
eScription document: 9-7446509 BFFocus
Dictated By: IVASKA , MELDA
Attending: MANKOSKI , ROSSIE
Dictation ID 9375881
D: 3/3/06
T: 11/26/06
Document id: 666
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
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PVD |
VI |
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012425438 | PUO | 28507921 | | 6683222 | 3/16/2004 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 8/5/2004 Report Status: Signed
Discharge Date: 4/25/2004
ATTENDING: CARRI KATCSMORAK MD
SPEAKER NAME: Abe Girardi , M.D.
ADMITTING DIAGNOSIS:
Congestive heart failure.
DISCHARGE DIAGNOSES:
Congestive heart failure , mitral regurgitation , and atrial
fibrillation.
CHIEF COMPLAINT:
Chest pain x 3 months and shortness of breath.
HISTORY OF PRESENT ILLNESS:
This is a 75-year-old female with no previous cardiac disease who
presented this morning with chest pain and shortness of breath ,
which had been limiting her over the last month. She had
gastrointestinal surgery earlier this year , complicated by need
for wound infection with revision and debridement.
Before her surgery , she could walk 20 minutes every morning , and
was very active. Over the last month , she has been limited by
shortness of breath , substernal chest pressure , and an overall
decrease in exercise tolerance. She cannot walk across the room
without difficulty now. The pressure in her chest is
nonradiating , is like a pressure rather than sharp , comes
unpredictably with exertion , and is relieved by rest. The
shortness of breath accompanies the pain. The symptoms have been
becoming more severe , and last night , she had rest shortness of
breath and chest pain. This morning she came to the emergency
department because her visiting nurse for her wound care told her
she looked worse and more short of breath and that she should
come to the hospital. She has never had chest pain or shortness
of breath until a little over a month ago , but does take
beta-blockers for a few isolated episodes of nonsustained
ventricular tachycardia that she had during her surgery
admission. She sleeps on two pillows every night , which is
chronic but does not get short of breath when flat. She denies
PND , palpitations , weight gain , swelling , or syncopal episodes.
She is a nonsmoker , nondiabetic without high cholesterol that she
knows of. Her chest pain is 2/10 upon admission to the emergency
department and is now 0/10 with nitroglycerin. In the emergency
room , she was given heparin , Plavix , aspirin , beta-blocker ,
Plavix 300 , and oxygen.
REVIEW OF SYSTEM:
She does not have any gastrointestinal symptoms. Her pain is
unrelated to eating. She has no cough , sputum production , and no
history of blood clots. She does not have calf pain , and she has
no neurologic symptoms.
PAST MEDICAL HISTORY:
Status post bowel resection for diverticulitis , status post
ileostomy take down in 7/21 , status post closure of wound
8/19/04 , and nonsustained ventricular tachycardia during last
hospitalization.
FAMILY HISTORY:
Brother with angina at age less than 55.
SOCIAL HISTORY:
No tobacco. No ETOH.
MEDICATIONS:
1. Aspirin 325 mg orally every day
2. Beta-blocker ( the patient does not know dose ).
ALLERGIES:
Bactrim.
PHYSICAL EXAMINATION:
Vital signs: Afebrile , heart rate 83 , blood pressure 113/72 ,
respirations of 18 , and saturation 98% on room air. In general ,
the patient was sitting up comfortable , in no acute distress ,
breathing comfortably. Coronary exam: Regular rate and rhythm.
Normal S1 and S2. Slight murmur diastolic in the axilla. Heart
sounds were distant. Jugular venous pressure at 8 cm.
Pulmonary: Faint crackles inferiorly bilaterally superior 2/3rd
clear to auscultation bilaterally. Abdominal exam: Positive
bowel sounds. Wound was covered , some small amount of drainage
on the dressing , nontender , and nondistended. Extremities: 2+
pulses bilaterally , 1+ pretibial edema bilaterally. Neck exam
was significant for loud carotid bruits bilaterally.
ADMIT LABS:
White blood cell count 9.5 , hemoglobin 12.3 , hematocrit 38 ,
platelets 213 , 000 , calcium 8.2 , magnesium 1.6 , sodium 134 ,
potassium 4.3 , chloride 104 , bicarbonate 22 , BUN 19 , creatinine
0.8 , and blood glucose of 151. Troponins upon admission: CK-MB
1.4 , CK 63 , and troponin less than 0.10 , d-dimer 1408 , which is
high , physical therapy , PTT , and INR: physical therapy was 17.1 and INR 29.1. ECG normal
sinus rhythm. No ST changes. No Q waves. Chest x-ray: No
evidence of infiltrate. No evidence of congestive heart failure
such as hilar prominence or effusion. Cardiac axilla was
slightly enlarged which is unchanged from her 10/29 films.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular:
Ischemia: The patient was thought to have acute coronary
syndrome and was sent to have a left heart catheterization. At
catheterization , she was found to have a large dyskinetic heart and
severe mitral regurgitation but no angiographically significant
coronary artery disease.
Cardiovascular/pump: Echocardiogram on hospital day 2 showed mild to
moderate left ventricular enlargement with moderate mitral
regurgitation and left atrial enlargement. There was only mild
structural mitral valve disease with MAC and leaflet thickening. Left
ventricular systolic function was moderately to severely impaired.
Management for congestive heart failure was pursued with the intention to
reassess LV size , function and MR after optimizing medical therapy. We
began diuresis at this time with 40 mg of intravenous Lasix. The patient came in
at 64 kilograms and discharge weight and dry weight is 58.0 kilograms.
The patient was also started on ACE inhibitor and beta-blocker as well as
every day orally Lasix.
Rhythm: The patient developed atrial fibrillation and atrial
flutter during this hospitalization with rapid ventricular
response. Heart rate was often into the 150s-160s. We were able
to eventually obtain control with Toprol XL 200 mg orally every day ,
diltiazem orally 30 mg three times a day , which was then converted to 45 mg
twice a day for an outpatient dosing. The patient was also started on
Coumadin while in hospital. She will follow up in Coumadin
Clinic. The day after discharge , she will have labs drawn to
check her INR. She will be on Lovenox 60 mg subcutaneous twice a day
until INR becomes therapeutic.
2. Wound care: The patient has open abdominal wound
approximately 2 cm x 2 cm that is followed by Dr. Authur , Fiona Surgery came by to see Mrs. Iannalo in hospital and made
recommendations for wound care. CT scan showed no evidence of entero-
cutaneous fistula. The patient will get follow up wound care at home with
visiting nurses.
FOLLOW-UP APPOINTMENT:
Include cardiology with Dr. Harkley at Pagham University Of , Tuesday 2/14/04 at 3 o'clock p.m. phone number is
527-424-0072. The patient will have an echocardiogram at Pagham University Of on 11/15/04 at 10 o'clock a.m. The patient
has a follow-up appointment with a new primary care doctor Dr.
Jeannette Gorglione at the KTDUOO at Pagham University Of phone
number is 497-635-1653. This appointment is 11/15/04 at 2:10 in
the afternoon. Last appointment will be follow up with Dr.
Fiona Authur , phone number 679-827-8734 , and we are still
waiting for call back on when this appointment will be. The
patient needs follow up with general surgery Dr. Samuelson Also ,
the patient will have visiting nurses come for wound care. The
patient has follow up in the Ashore Cleod Health INR will be drawn
tomorrow that is 5/24/04 and at the Andsmi Community Medical Center ,
phone number is 132-202-5576.
DISCHARGE MEDICATIONS:
Include:
1. Enteric-coated aspirin ECASA 325 mg orally every day
2. Digoxin 0.125 mg orally every other day , which is every other day.
3. Lasix 40 mg orally every day
4. Lisinopril 10 mg orally every day
5. Coumadin 5 mg orally every afternoon
6. Toprol XL 200 mg orally every day
7. Lovenox 60 mg subcutaneous every 12 hours and this medication will be
continued until INR becomes therapeutic.
8. Celexa 20 mg orally every day
9. Diltiazem 45 mg orally twice a day
eScription document: 2-3628053 EMSSten Tel
Dictated By: GORGLIONE , JEANNETTE
Attending: KATCSMORAK , CARRI
Dictation ID 8814754
D: 9/9/04
T: 9/9/04
Document id: 667
| Target |
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245876836 | PUO | 99067599 | | 8176167 | 2/15/2006 12:00:00 a.m. | CELLULITIS RIGHT FOOT | Signed | DIS | Admission Date: 8/5/2006 Report Status: Signed
Discharge Date: 3/10/2006
ATTENDING: LOERWALD , PENNIE MICHEAL MD
PRINCIPAL DIAGNOSIS: Chronic peripheral vascular disease
complicated by atheroemboli , status post cardiac catheterization.
PROCEDURES:
1. 6/28/2006 , aortogram bilateral lower extremity runoff Dr.
Burghard
2. 9/22/2006 left femoral to dorsalis pedis bypass graft , Dr.
Seefried
HISTORY OF PRESENT ILLNESS: This is a 75-year-old former smoker
with hypertension , diabetes , end-stage renal disease on
hemodialysis , CAD status post coronary catheterization in October
2006 and October 2006 who presented in clinic with progressively
worsening bilateral foot pain , foot mottling and new ulcerations.
Concern for atheroembolization was raised following cardiac
catheterization. In followup , the patient appeared to have
persistent ulcerations as well as erythema. Pedal signals by
Doppler , however , were present. She was admitted from clinic for
cellulitis and further evaluation of her vascular anatomy. At
the time of admission , she denied chest pain , shortness of breath
or fever , chills. She described the pain as burning in both her
feet with some relief obtained when dangling the feet off the
bed.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis Monday , Wednesday ,
Friday.
a. 5/19/2004 , status post left radiocephalic AV fistula by Dr.
Seefried
b. 3/18/2005 , status post left AV fistula cephalic
transposition by Dr. Seefried
c. 1/13/2006 , status post left AVF revision by Dr. Seefried
d. 9/17/2006 , status post right IJ tunneled hemodialysis
catheter.
2. CAD.
a. History of non-ST elevation MI.
b. status post catheterization on 1/13/2006 with 80% proximal
LAD stenosis status post drug-eluting stent of the LAD.
c. Status post catheterization 8/6/2006 with left circumflex
and right coronary artery disease , noncritical.
3. CHF with diastolic dysfunction.
a. 2/14/2006 , Echo showing concentric left ventricular
hypertrophy , EF of 45-50% which was reduced from 2004. Septal
and inferior wall hypokinesis , mild left atrial enlargement ,
moderate to severe MR , mild TR.
4. COPD , on intermittent home oxygen.
5. Obstructive sleep apnea.
6. Diabetes mellitus.
7. Hypertension.
8. Dyslipidemia.
9. Gout.
10. GERD.
11. History of right pleural effusion.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg orally daily.
2. Plavix 75 mg orally daily.
3. Cardizem 60 mg orally three times a day
4. Lipitor 80 mg daily.
5. Atrovent 2 puffs four times a day.
6. Albuterol 2 puffs twice a day
7. Renagel 806 mg orally every meal.
8. Allopurinol 100 mg orally daily.
9. Zaroxylyn 2.5 mg orally daily as needed overload.
10. Lantus 10 units subcutaneous nightly.
11. Regular insulin sliding scale.
12. Valium 5 mg orally twice a day as needed
13. Isordil 40 mg orally three times a day
14. Hydralazine 20 mg orally three times a day
15. Lopressor 75 mg orally three times a day
16. Zantac 150 mg orally twice a day
17. Aciphex 20 mg orally daily.
18. Neurontin 300 mg orally post-dialysis.
19. Metamucil.
20. Nitroglycerine as needed
21. Procrit 40 , 000 units subcutaneously every week.
22. Lilly insulin pen , unknown dosage 20 units every morning and
10 units every evening.
23. Loperamide 2 tabs orally four times a day.
24. Ambien 10 mg orally nightly as needed
ALLERGIES:
1. Penicillin causing tongue swelling.
2. Morphine causing mental status changes.
3. Codeine causing mental status change.
4. Dilaudid causing mental status change , added on this
admission.
SOCIAL HISTORY:
1. Tobacco , 80-pack-year history , quit in 1990.
2. No alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Notable for temperature of
99.2 , heart rate of 121 in sinus tachycardia , blood pressure
116/60 , saturating 98% on room air. She was noted to have a 2/6
systolic murmur at the apex. Lungs were clear bilaterally.
Pulse exam showed no palpable femoral pulses and biphasic
dopplerable pulses bilaterally , DP and physical therapy. Extremities showed
bilateral mottling of all toes and an open 0.5 cm ulceration at
the base of the left fourth toe. All toes are exquisitely tender
to palpation. Sensation is decreased but equal bilaterally.
HOSPITAL COURSE: This 75-year-old female vasculopath was
admitted for further evaluation of her peripheral vascular
disease which was suspected to be contributing to her new
ulcerations and progressively worsening wrist pain as an
exacerbating factor to likely atheroembolic phenomenon , status
post coronary catheterizations earlier in the year. She was
placed on broad-spectrum antibiotics and plan was made for an MRA
to evaluate her anatomy. Unfortunately , the patient was unable
to tolerate the MR and did experience some mental status changes
that prevented further noninvasive imaging , when she received
some narcotic following her hemodialysis round. Over the ensuing
days she required rather significant doses of Zyprexa and Haldol
to contain agitation and delirium , as the patient would also get
physical and violent. This appeared to sedate her sufficiently
and over the following days , she did manage to calm significantly
and returned to her baseline mental status. She did appear very
emotionally labile throughout the rest of her stay and incredibly
remorseful for previous events. On 6/28/2006 , she was offered
an angiogram to delineate aortic and bilateral lower extremity
runoff anatomy. She did tolerate this well under simple intravenous
conscious sedation. This showed chronic disease with
collateralization and very poor inflow to the bilateral feet with
essentially one vessel run off on either side. After extensive
discussions with the patient and the patient's family , the
patient did agree to a left femoral to dorsalis pedis bypass
graft which was performed on 9/22/2006 without complication.
Please see the operative note for further details. The patient
did tolerate the procedure well. By time of discharge , she was
tolerating a regular diet and ambulating at baseline with her
rolling walker. The pain was well controlled with minimal
analgesics that were not narcotic based. Cardiology was
consulted during this time to optimize her prior to the OR. Her
primary cardiologist , Dr. Katcsmorak did make some recommendations
including an echocardiogram that showed preserved ejection
fraction and no wall motion abnormalities. Her beta blockade was
titrated up and she was instructed to follow up with cardiology.
She did tolerate hemodialysis throughout this time without undue
difficulty. She did on one occasion experience dyspnea following
hemodialysis that resolved of its own accord , no cardiac events
or in evidence by EKG or by following cardiac enzymes. As the
patient was in stable condition and back to her baseline level of
activity with very strong support at home , she was discharged to
home with services for wound checks and home safety evaluation.
She was instructed to follow up with Dr. Loerwald in one to two
weeks.
DISCHARGE INSTRUCTIONS:
1. Touchdown weightbearing on the left heel. The patient should
not keep legs in dependent position for more than 10 minutes at a
time. She was to use the walker and a cane as instructed by
physical therapy.
2. Legs are to be elevated as much as possible while sitting or
lying down.
3. All home medications were to be resumed except for Lopressor ,
the dose of which had been changed by Dr. Katcsmorak to 50 mg orally three times a day
4. VNA was ordered to assist with wound care including Betadine
paint to incisions daily.
5. Showering only , no bathing or immersion in water for
prolonged periods of time.
6. Follow-up visit to be scheduled with Dr. Loerwald in one to two
weeks and Dr. Hazinski primary care physician in one week.
DISCHARGE MEDICATIONS:
1. Tylenol 325 mg orally every four hours as needed pain.
2. Albuterol inhaler 2 puffs twice a day
3. Allopurinol 100 mg orally daily.
4. Aspirin 325 mg orally daily.
5. Calcitriol 1.5 mcg orally every Monday and every Friday.
6. Plavix 75 mg orally daily.
7. Darbepoetin alfa 100 mcg subcutaneous every week.
8. Ferrous sulfate 325 mg orally three times a day
9. Prozac 40 mg orally daily.
10. Neurontin 300 mg orally post-dialysis.
11. Motrin 400 mg orally every eight hours as needed pain.
12. Lantus 10 units subcutaneous nightly.
13. Insulin regular sliding scale. See discharge order for
scale.
14. Atrovent 2 puffs four times a day.
15. Lopressor 50 mg orally three times a day Do not take with
lightheadedness or dizziness.
16. Metamucil 1 packet orally daily.
17. Sevelamer 800 mg orally three times a day
18. Lipitor 80 mg orally nightly.
eScription document: 9-9082218 HFFocus
Dictated By: BREINES , AZALEE
Attending: LOERWALD , PENNIE MICHEAL
Dictation ID 9252782
D: 5/28/06
T: 5/28/06
Document id: 668
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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| output/system_intuitive_annotation.xml | intuitive |
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461385149 | PUO | 02258900 | | 985988 | 5/4/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/24/1996 Report Status: Signed
Discharge Date: 10/17/1996
PRINCIPAL DIAGNOSIS: NECK PAIN.
ADDITIONAL DIAGNOSIS:
1. LEFT BUNDLE BRANCH BLOCK ON ELECTROCARDIOGRAM.
2. NON-INSULIN-DEPENDENT DIABETES MELLITUS.
3. HYPERTENSION.
4. HYPERCHOLESTEROLEMIA.
5. CHRONIC NECK PAIN.
6. IMPOTENCE.
HISTORY OF PRESENT ILLNESS: Mr. Biddleman is a 63-year-old man with a
history of non-insulin-dependent
diabetes mellitus , hypertension , and chronic neck and shoulder pain
who presented with a near syncopal episode and a new left bundle
branch block on EKG. He has a history of intermittent episodes of
sudden onset of an ill defined , non-painful sensation that shoots
from the region of his left shoulder , up his left neck , and then
across his head bilaterally. The episodes are usually
instantaneous. He does not know how often he has them , but does
not think that he has had more of these episodes recently. He has
previously been worked up for chronic neck and left shoulder pain
that is attributed , in part , to a history of trauma. X-rays have
shown degenerative arthritis in the cervical spine , especially in
the region of C6 and C7 with evidence of foraminal narrowing and
nerve root impingement. He also has evidence of multiple
osteophytes in his cervical spine and in the region of his left
shoulder. He has had a normal head CT in 7/17 This pain has
been responsive to physical therapy and traction in the past.
Today , he had a similar such episode while turning his head to the
right while driving his car. The shooting sensation from his
shoulder up to his head was accompanied by a near loss of
consciousness and was followed immediately by flushing with
diaphoresis and then weakness and dizziness that persisted for
about 5-10 minutes. He did feel nauseated , but did not vomit. He
denied any chest pain , shortness of breath , or palpitations. He
pulled his car over to the side of the road and had his friend
drive him to TTHC. He continued to feel weak. He was noted at
TTHC to have a left bundle branch block on his EKG that was new
compared to an EKG obtained in 8/3 He was , therefore , referred
to Pagham University Of for further evaluation and
management. On system review , he gives a history of dyspnea on
exertion and exertional fatigue with shortness of breath that is
relieved by rest. This has not changed recently and seems stable.
He also had stable three pillow orthopnea. He denied any
paroxysmal nocturnal dyspnea or swelling of lower extremities. His
cardiac risk factors include diabetes mellitus , hypertension , a
positive family history , hypercholesterolemia , and he is a former
smoker.
PAST MEDICAL HISTORY: 1. Non-insulin-dependent diabetes mellitus ,
diagnosed in 1992 , last glycosylated
hemoglobin was was 12.7 in 6/18 2. Possible coronary artery
disease , last exercise tolerance test in 6/10 was without any
evidence of EKG changes. 3. Hypertension diagnosed in 1992. 4.
Hypercholesterolemia with baseline cholesterol 251 , LDL 175 , HDL
32 , and triglycerides 262. 5. Chronic neck and left shoulder pain
as above. 6. History of headaches , possible migraine headache
versus cluster headaches. 7. Probable gastroesophageal reflux
disease by history. 8. History of a right sided pneumonia and
empyema status post right sided chest tube four weeks , now with
chronic pleural changes. 9. Benign prostatic hypertrophy , last PSA
was 2.88 in 3/22 10. Impotence , normal prolactin and
testosterone levels. 11. History of balanitis. 12. History of
psoriasis.
ADMISSION MEDICATIONS: 1. Glipizide 5 mg orally every day. 2.
Hydrochlorothiazide 25 mg orally every day. 3.
Aspirin. 4. Terazosin 2 mg orally every day. 5. Zantac 150 mg orally
twice a day 6. Ativan as needed 7. Percocet as needed
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Notable for coronary artery disease in his
father who died of a myocardial infarction at age
66. There is no family history of diabetes mellitus or
hypertension.
SOCIAL HISTORY: The patient is a retired custodian. His wife died
in the last year , just after having undergone a
coronary arterial bypass graft. He has three children who lives in
the area. He claims he quit smoking in 1990 after a 40 pack year
history.
PHYSICAL EXAMINATION: His temperature was 98.5 , heart rate between
90 and 100 , blood pressure 144/96 ,
respiratory rate 16 , and oxygen saturation 95% on two liters by
nasal cannula. He appeared to be a middle aged man who was
comfortable lying in bed. HEENT examination was notable for a 5 mm
nodule on the palpebral margin of his right upper eyelid. Sclera
were anicteric. Pupils were equal , round , and reactive to light.
Extraocular muscles were intact. Oropharynx was without any
evidence of lesions or without any adenopathy or masses. There was
no jugular venous distention apparent and no bruits heard. His
neck was nontender to palpation. His back was nontender to
palpation. No muscle spasm was palpable. His lungs were clear to
auscultation bilaterally. His heart rate sounded somewhat fast ,
but was regular. His heart sounds were distant with an indistinct
first heart sound , but a second heart sound without evidence of
splitting. No S3 was heard. There was a question of a fourth
heart sound. There was also question of a grade I/VI systolic
murmur at the left sternal border and apex. He had good radial and
dorsalis pedis pulses. His abdomen appeared obese with active
bowel sounds. It was soft and nontender. His liver span was
estimated at 6 cm by percussion. He did not have any splenomegaly.
His stool was heme occult negative. Extremities were without any
evidence of cyanosis , clubbing , or edema. His skin was warm and
moist without any lesions. Neurologic examination showed an alert
and oriented man with fluent speech and 5/5 motor strength in his
upper extremities and lower extremities bilaterally. His touch
sensation was intact in his lower extremities bilaterally. He had
normal biceps and patellar deep tendon reflexes bilaterally. His
toes were downgoing on Babinski's test bilaterally.
LABORATORY DATA: Electrolytes were within normal limits with BUN
24 and creatinine 1.2. Serum glucose was 204.
His white blood cell count was 7 , 900 , hematocrit 42% , and platelets
282 , 000. His prothrombin time and partial thromboplastin times
were normal. His liver function tests were normal. His
cholesterol was 227 with triglycerides 311. His cardiac troponin
was 0.0. EKG , on admission , showed sinus rhythm at a rate of 30
with the left bundle branch pattern that was new compared with an
EKG from 8/3 His axis and intervals were normal. A chest x-ray
demonstrated a right lower lobe opacity and bilateral pleural
thickening , no acute infiltrate , and no evidence of congestive
heart failure.
HOSPITAL COURSE: The etiology of his symptoms was unclear , but he
was admitted to rule out myocardial infarction ,
given the fact that he had a left bundle branch block pattern on
his EKG that was new compared to a previous EKG. It was not known
whether this new EKG finding was acute or whether this had occurred
sometime between 3/16 and the present time. He was started on
heparin for the possibility of an acute myocardial infarction. He
was maintained on aspirin and started on a beta blocker. His
hydrochlorothiazide was discontinued. He was started on
simvastatin given his hypercholesterolemia. He ruled out for an
acute myocardial infarction with cardiac enzymes. He had an
echocardiogram on 2/9/96 which demonstrated borderline left
ventricular hypertrophy with low normal systolic function and an
estimated ejection fraction of 45%-50%. No regional wall motion
abnormalities were noted. He had mild left atrial enlargement ,
mild mitral regurgitation , and mild tricuspid regurgitation. A
Holter monitor on 2/9/96 showed a predominant rhythm of normal
sinus rhythm with a few atrial premature beats and ventricular
premature contractions. There was no evidence of high grade
ventricular ectopy. Because of his uninterpretable EKG , he
underwent exercise testing with MIBI imaging on 3/2/96. He
exercised for 6 minutes on a standard Bruce protocol. This was
discontinued due to fatigue. His heart rate increased from
baseline 58 to a peak of 94 , and his blood pressure changed from
130/60 at rest to 140/50 at peak. His peak rate pressure product
was 13 , 200. His EKG was notable for left bundle branch pattern
with 1 mm ST depressions. MIBI imaging demonstrated small apical
and septal rift consistent with mild ischemia. Because he remained
asymptomatic , and because his exercise test was without evidence of
large areas of myocardium at risk , he was discharged home on
3/2/96. He will follow up with his cardiologist for further
evaluation as indicated. His medication regimen was optimized
during his hospital stay.
DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg orally
every day. 2. Atenolol 100 mg orally every day. 3.
Hytrin 1 mg orally every bedtime 4. Glipizide 10 mg orally every day before noon and 5 mg
orally every bedtime 5. Zantac 150 mg orally every bedtime 6. Simvastatin 10 mg
orally every day. 7. Nitroglycerin 0.4 mg sublingually every 5 minutes as
needed for chest pain.
DISCHARGE DISPOSITION: He was discharged home on a low
cholesterol , low saturated fat diet.
FOLLOW-UP: He will follow up with his primary physician and
cardiologist in the next week.
Dictated By: LEOLA C. MUSICH , M.D. CHOA
Attending: CARMON E. BOSHERS , M.D. CH
DH419/9554
Batch: 90107 Index No. W7TKWP0QUW July
April
Document id: 669
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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800843851 | PUO | 29407184 | | 892850 | 4/6/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/6/1992 Report Status: Signed
Discharge Date: 1/3/1992
DIAGNOSIS: CORONARY ARTERY DISEASE.
ALBINISM.
HISTORY OF GOUT.
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old Mexican
male with a history of coronary artery
disease , who is status post coronary artery bypass grafting and
presented with severe left-sided chest pain radiating to the back
and arm occurring 7 hours previously. The patient's history of c
coronary artery disease began in 20 of June , when he developed substernal
chest pain and underwent cardiac catheterization showing a 100%
right coronary artery occlusion and 80% left anterior descending
occlusion , 70% proximal mid-left anterior descending lesion.
Angioplasty was attempted , but was unsuccessful. In 1 of January , the
patient underwent a 2-vessel coronary artery bypass grafting by Dr.
Golebiowski at Pagham University Of with a left internal mammary
artery graft to the left anterior descending and right internal
mammary artery graft to the posterior descending artery. However ,
the patient had persistent incisional-type pain after his coronary
artery bypass grafting , but reported absence of his angina pain
post-CABG. The patient underwent an echocardiogram post-CABG
showing normal left ventricular function with no regional wall
motion abnormalities , moderate effusion and mild left atrial
enlargement 4.8 centimeters. The patient did well for 2 years
post-CABG and underwent an exercise tolerance test in 15 of September ,
exercising for 10 minutes and 0 seconds , maximum blood pressure
170/100 , without chest pain or electrocardiogram changes ,
considered to be a negative test. Since then , the patient has only
had sharp incisional pain not related to exertion , and he suffers
no exertional angina and has no exercise limitation. Over the past
several months , the patient has gradually developed increasing
exertional chest pain , increasing in both intensity and frequency ,
to the point where it was occurring daily 1 week prior to
admission. The patient had been tried on multiple medications as
an outpatient , however , because of issues of
noncompliance/alternative belief system , it was unclear as to what
medications the patient was actually taking. On the day of
admission at 1:30 pm , the patient experienced severe 8 out of 10
substernal chest pain radiating to the left arm with numbness and
neck tightness , associated with dizziness and numbness on the
scalp. The patient had no nausea , vomiting or shortness of breath ,
but did suffer pleuritic pain in addition. The pain lasted 30
minutes and was somewhat alleviated with rest and sitting in the
supine position on the way to the emergency room. At the Pagham University Of emergency room , the patient had worsening of
the severity of his pain and was treated with sublingual
nitroglycerin without relief , then morphine sulfate 4 milligrams
times 2 , Lopressor 5 milligrams times 1 , Nitro-Paste 1 inch with
complete relief. An electrocardiogram on admission showed normal
sinus rhythm , rate 80 , axis normal , no ST or T-wave abnormalities ,
no Q-waves. The patient was admitted to the Ano Sonprai Rotonards Team.
PAST MEDICAL HISTORY was notable for albinism , he denies ulcers or
gastrointestinal bleeds , he has a history of gout. HABITS included
former heavy alcohol use , however , he denies use in the last 6
months. The patient smoked cigarettes until 5 years ago.
ALLERGIES were no known drug allergies. FAMILY HISTORY was
negative. SOCIAL HISTORY revealed the patient is an appliance
technician , he is married with 3 children. MEDICATIONS ON
ADMISSION revealed that the patient reported using Nifedipine-XL 30
milligrams by mouth each day , enteric-coated aspirin 1 per day ,
occasional Indocin and colchicine. His Carna Home Hospital prescription also included Lisinopril 20 milligrams by mouth
per day , and Isordil 20 milligrams by mouth 3 times , but the
patient denied taking these.
PHYSICAL EXAMINATION: The patient was mildly diaphoretic in no
apparent distress. Temperature was 97 ,
heart rate 78 , blood pressure 140/90 , respiratory rate 20 on 2
liters of oxygen with 97% saturation. Skin was pale with red hair.
Oropharynx was clear , extraocular movements were intact , pupils
were equal , round , reactive to light and accommodation. Carotids
were II+ bilaterally , there was a sternotomy scar on the chest , no
evidence of infection. Lungs were clear to auscultation and
percussion without rales. Cardiac examination showed a soft S2 , S1
was normal , no murmurs , rubs or gallops. Abdomen was soft ,
nontender , no hepatosplenomegaly. Rectal examination showed normal
tone , normal prostate , guaiac negative. Femoral pulses were I+
bilaterally without bruits. Extremities showed II+ pulses in the
dorsalis pedis , no edema , the deep tendon reflexes were normal.
Neurologic examination was nonfocal.
LABORATORY EXAMINATION: Chest x-ray showed clear lungs and no
pneumonia or congestive heart failure.
The electrocardiogram was as noted above. Sodium was 141 ,
potassium 4.7 , chloride 112 , bicarbonate 24 , blood urea nitrogen
26 , creatinine 1.8 , of note his baseline is 1.4 in 5-90 , glucose
85 , white blood cell count 3.59 , platelets 125 , 000 , hematocrit
44.5 , prothrombin time 12.7 , partial thromboplastin time 33.9 ,
creatinine kinase 1 , 010 with 20 myocardial bands , LDH 222.
Urinalysis was notable for 4+ proteinuria , no white cells , no red
cells , 1 to 2 hyaline casts.
HOSPITAL COURSE: The initial impression was the patient had
probable coronary disease and probable unstable
angina. He was admitted for intensive cardiac monitoring and
cardiac catheterization. The patient was started on heparin at
1 , 000 units per hour after bolus and sliding scale Nitro-Paste ,
aspirin and Lopressor , and continued on Nifedipine. On the first
day of admission , the patient suffered 2 episodes of substernal
chest pain and he was taken somewhat emergently to cardiac
catheterization which revealed a patent left internal mammary
artery graft to the left anterior descending , a patent right
internal mammary artery graft except for small vessel disease in
the graft , and an essentially occluded posterior descending artery.
The native coronary arteries showed occluded left anterior
descending proximally with filling from the left anterior
descending , circumflex showed a long 70% proximal lesion at the
second obtuse marginal branch with 90% distal lesion. The right
coronary artery was occluded proximally with right-to-right
collaterals and left-to-right collaterals from the left anterior
descending. The patient was planned for a 2-step angioplasty and
was returned to the floor for stabilization while awaiting his
angioplasty. However , the patient suffered 2 episodes of
substernal chest pain despite being on intravenous heparin and
intravenous nitroglycerin was initiated and the patient was
transferred to the Coronary Intensive Care Unit. The patient
remained pain-free until he underwent angioplasty of the right
coronary artery lesions with a result of 20% residual stenosis. Of
note , the patient's creatinine kinase levels continued to trend
downward with the initial creatinine kinase being 1 , 010 being his
maximal value. The patient had no further chest pain after his
angioplasty , except for the baseline incisional pain which was
unrelated to exertion. The patient was monitored closely for 2
days after angioplasty. Nitroglycerin was tapered off and the
patient was discharged on 9 of January Of note , the 4+ proteinuria
was unresolved at the time of discharge , because of his unstable
course and transfers between the Intensive Care Unit and the floor ,
we were unable to complete a 24-hour urine collection. This issue
will be addressed further.
DISPOSITION: The patient will be discharged to home. MEDICATIONS
ON DISCHARGE were aspirin 325 milligrams by mouth
each day , Lopressor 100 milligrams by mouth twice a day. CONDITION
ON DISCHARGE was stable. The patient will FOLLOW-UP with Dr. Rufus Bernas in the Healtship Ron Offa Memorial Medical Center
Estimated disability is none.
Dictated By: ROSSIE K. MANKOSKI , M.D. Ford Pidssaint Sca
Attending: RUFUS C. BERNAS , M.D. Leigh Lin Do
DF535/30-7
Batch: 0367 Index No. YLVHP28K4B April
November
CC: JACKQUELINE A. PLAYER , M.D. Ale Portberke Ing
Document id: 670
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407116017 | PUO | 74918141 | | 291097 | 9/12/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/4/1993 Report Status: Signed
Discharge Date: 10/8/1993
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old woman
with a history of coronary artery
disease , presenting with progressive symptoms for cardiac
catheterization. Her cardiac history began in 20 of April , when she
presented with new substernal chest pain. She ruled in for a
non-Q-wave myocardial infarction , was treated with medical therapy
and did well , until 5 of October , when she had progressive exertional chest
heaviness and shortness of breath. An exercise tolerance test was
positive at that time , and echocardiogram showed good left
ventricular function. She had a cardiac catheterization which
showed a 90% left anterior descending , 75% first diagonal , 75%
second diagonal. The cardiac catheterization was complicated by
foot cellulitis , sepsis and deep vein thrombosis and she was in and
out of the hospital for several months recovering. Given this , she
was hesitant to undergo further procedures and was treated with
medical therapy. The patient did fairly well with stable angina
and shortness of breath , until 1 year prior to admission when she
had slowly progressive increase in her chest heaviness and
shortness of breath , limiting her activities. Her anginal pattern
has not changed recently in a significant manner , but over the last
several months her pain has been extremely limiting to her
activities , and thus she presented for cardiac catheterization and
a question of revascularization. The patient has stable 2-pillow
orthopnea , she has claudication with a 10-minute walk relieved with
rest. The patient denied paroxysmal nocturnal dyspnea. Her chest
pain is not associated with diaphoresis , nausea , vomiting ,
radiation , or syncope. It is associated with upper chest
heaviness , shortness of breath and warmth in the chest and neck.
PAST MEDICAL HISTORY was significant for coronary artery disease as
above , diabetes times 20 years on insulin for the last 10 years ,
complicated by neuropathy and retinopathy , hypertension ,
hypercholesterolemia , breast cancer status post left mastectomy and
radiation therapy in 1979 , peripheral vascular disease ,
musculoskeletal pain syndrome , she had a positive ANA previously on
work-up , but her symptoms are fluctuant and easily controlled.
History also included deep vein thrombosis during her previous
cardiac catheterization , cataracts , status post cholecystectomy and
appendectomy. MEDICATIONS ON ADMISSION were Nifedipine-XL 60
milligrams each day , Inderal 20 milligrams by mouth 3 times a day ,
insulin 45 units of NPH each morning , sublingual trinitroglycerin
as needed. FAMILY HISTORY was negative for coronary artery disease
and diabetes. ALLERGIES were no known drug allergies. SOCIAL
HISTORY revealed the patient lives with her daughter in Lan , she does not smoke nor drink.
PHYSICAL EXAMINATION: On admission , she was in no apparent
distress. Vital signs were within normal
limits. Head and neck examination was unremarkable. Lungs were
clear to auscultation. Cardiac examination revealed regular rate
and rhythm with a I/VI systolic ejection murmur , no S3 , no S4 , no
jugular venous distension. Abdominal examination was nontender ,
nondistended , no hepatosplenomegaly , normoactive bowel sounds , no
masses. Extremities showed no clubbing , cyanosis or edema.
Neurologic examination was within normal limits.
LABORATORY EXAMINATION: On admission , platelets were 318 , 000 ,
hematocrit 41.7 , white count within normal
limits , prothrombin time 11.2 , partial thromboplastin time 31.1 ,
electrolytes were unremarkable. Chest x-ray showed no infiltrates
or effusions. The electrocardiogram had normal sinus rhythm at 70
with axis 0 , intervals within normal limits , left atrial
enlargement , T-wave inversion in III , but no acute ST-T wave
changes.
HOSPITAL COURSE: The patient was admitted and underwent cardiac
catheterization which showed a 90% proximal left
anterior descending stenosis , 70% mid-left anterior descending , 90%
first diagonal , 70% second diagonal and 100% obtuse marginal branch
stenosis. The right coronary artery was not cannulated , but looked
normal with what dye could be injected. A percutaneous
transluminal coronary angioplasty was planned the following day for
dilatation of her serial left anterior descending lesions , however ,
the patient had significant bleeding the night before , when arising
after her cardiac catheterization and the decision was made to wait
until over the weekend to do the percutaneous transluminal coronary
angioplasty. On Monday , the patient underwent percutaneous
transluminal coronary angioplasty with successful dilatation of the
serial left anterior descending lesions , both down to 30% , and did
well. Sheaths were removed the next day and the patient was
discharged.
DISPOSITION: The patient will be discharged to home. CONDITION ON
DISCHARGE was stable. The patient is to FOLLOW-UP
with her Carna Home Hospital cardiologist. MEDICATIONS
ON DISCHARGE were the same as her admission medications.
Dictated By: DENISHA H. MCRORIE , M.D. Pro
Attending: KATHERYN SATURNINA GRUNTZ , M.D. Ahuntsonnews Ral Ra
WL315/8160
Batch: 0461 Index No. PWVGOOGFM January
January
Document id: 671
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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326043009 | PUO | 82489284 | | 521826 | 4/25/1997 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 7/5/1997 Report Status: Signed
Discharge Date: 10/7/1997
PRINCIPAL DIAGNOSIS: DILATED CARDIOMYOPATHY.
PROBLEM LIST: 1 ) CARDIOMYOPATHY.
2 ) STATUS POST MULTIPLE INJURIES.
3 ) HISTORY OF HEPATITIS B.
HISTORY OF PRESENT ILLNESS: The patient is a 42 year-old gentleman
with dilated cardiomyopathy with
worsening functional status. He was admitted for transplant
work-up , right heart catheterization and optimization of his
medical treatment. He initially developed symptoms approximately
six years prior to admission with complaints of dyspnea and
orthopnea. His chest x-ray at that time demonstrated cardiomegaly
and ultimately an echocardiogram demonstrated dilated
cardiomyopathy. In 1992 , a catheterization was performed with
clean coronary arteries by report. In February of 1994 , he had a
"cerebrovascular accident". He was on Coumadin at that time. His
symptoms included right hand and face anesthesia and hemiplegia
which lasted only a few seconds and were self resolved. A CT was
negative by report. He was started on Coumadin subsequently. In
February of 1994 , he had an echocardiogram which demonstrated a
left ventricular end diastolic diameter of 6.2 cm and ejection
fraction of 20%. There was no thrombus seen. There was 2+ mitral
regurgitation. There were no regional wall motion abnormalities.
He was doing fairly well at home with medical management without
any admissions for congestive heart failure until earlier this
year. He began to have worsening symptoms following a viral
illness in October of 1997. At that time an echocardiogram in
October of 1997 demonstrated a probably left ventricular thrombus
and ejection fraction of 12%. His Lasix dose was increased and his
Atenolol dose was decreased. He improved and in October of 1997 , he
was able to participate in activities such as sledding and skating
with only occasional chest pressure and dyspnea on exertion. In
October of 1997 , an exercise tolerance test was performed which he
went 11 minutes. Maximum heart rate was 148. His rate pressure
product was 18 , 000 and the peak oxygen consumption was 20.4. At
the time nitrates were added to his regimen. His Atenolol was
increased. However , nitrates were discontinued because of headache
and insomnia. Now , over the prior one to two months , proceeding
admission , he has had worsening symptoms with orthopnea , dyspnea on
minimal exertion with less than one flight of stairs , decreased
appetite. His weight is stable , but it is felt to be a decrease in
the body amount with an increase in fluid weight. He has nocturnal
shortness of breath and dyspnea. There is no syncope. He was seen
by Dr. Fernande Prewer and was felt to be at that time a class four
on the Auhan St. . His Lasix was increased and he
was referred for admission.
REVIEW OF SYSTEMS: Positive for orthopnea as well as paroxysmal
nocturnal dyspnea four out of seven nights.
There is no nocturia. His exercise tolerance is approximately one
flight of stairs with moderate shortness of breath. He complains
of nausea and anorexia without vomiting. He also has insomnia and
erectile difficulties. He has a 6 lb. weight loss over the week
prior to admission following an increase in outpatient diuretic
use. His baseline weight was 175 lbs. One month ago , it was 165
lbs. and the day of admission , it is 155 lbs.
PAST MEDICAL HISTORY: Notable for cardiomyopathy as above , gunshot
wound to his chest and head at the age of 14
and motor vehicle accident , Hepatitis B. He has had four
colonoscopies in the past and has had no polyps.
PAST SURGICAL HISTORY: Notable for appendectomy and a ganglion
cyst in his right wrist.
MEDICATIONS ON ADMISSION: 1 ) Enalapril 10 mg orally twice a day 2 )
Atenolol 12.5 mg orally every day. 3 )
Coumadin 5 mg orally every day. 4 ) Lasix 80 mg orally twice a day 5 )
Digoxin 0.25 mg orally every day. 6 ) Kay Ciel 10 mg orally every day. 7 )
Multivitamins one orally every day.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: He is a sales representative for a food broker.
He lives with his wife and three daughters in
Do Ga Falls He was a former smoker who quit in 1984. Previously , he
had smoked one to two packs per day for twelve years. He continues
to use alcohol and drinks approximately six beers per week.
FAMILY HISTORY: His father is 70 years old. His mother is 68. He
has a sister with colon polyps and a brother who
is healthy. His family history is otherwise notable for familial
colon cancer and polyposis.
PHYSICAL EXAMINATION: Vital signs: Weight 72 kg , afebrile , heart
rate 78 , blood pressure 95/71 , respiratory
rate 18 , oxygen saturation 98% on room air. HEENT is
normocephalic , atraumatic. Oropharynx revealed multiple fillings ,
but there is no abnormality. His neck is supple with no
thyromegaly , carotid bruits or jugular venous distension. His
jugular venous pressure is 6 cm. His chest is clear. His cardiac
examination is regular rate and rhythm with an S3 as well as right
ventricular impulse palpable and audible. His abdomen was soft ,
non-tender with normal active bowel sounds. He had no bruits. His
liver is 12-14 cm and 1 cm below the right costal margin. There
are no masses. His extremities were warm and well perfused.
Neurological examination revealed a mild right facial asymmetry ,
but otherwise , his neurological examination is non-focal.
LABORATORY: Laboratory evaluation on admission was notable for a
sodium of 133 , creatinine 1.2. Liver function tests
are notable for a bilirubin of 1.7 and 0.7. His complete blood
count is unremarkable. His INR was 1.4. His urinalysis was
unremarkable. Pulmonary function tests on admission included an
FVC of 81% of predicted and FEV1 of 78% of predicted and an
FEV1/FVC ratio of 97% of predicted. His DLCO is 90% of predicted.
EKG demonstrated sinus rhythm at 80 with first degree
atrioventricular block. His PR interval is 0.226. His QRS
interval is 0.10 and his QTC is 0.401. There was a left anterior
hemi-block. His axis is -49 degrees. There was left atrial
enlargement. There was poor R-wave progression. There were
flipped T-waves across the precordium. There was an increase in
left atrial size since October of 1997 , otherwise no acute changes.
HOSPITAL COURSE: This is a 42 year-old gentleman with idiopathic
dilated cardiomyopathy now presented with
worsening functional status over the past few months as well as
recent fluid overload necessitating increase in Lasix. There was a
question of patient non-compliance especially given his current
alcohol use which raises the question of psychologic readiness for
cardiac transplant at this time. Following admission , the patient
underwent a right heart catheterization which demonstrated right
atrial pressure of 7 , right ventricular pressure of 55/12 , PA
pressures of 58/32 , mean wedge pressure of 30 , arterial pressure at
the time was 113/74 with a mean of 90. Additionally , by Fick , his
cardiac output was 2.85 with a cardiac index of 1.49 , pulmonary
venous resistance of 280 and a systemic venous resistance of 2 , 330.
Because of this markedly high SVR and a borderline PVR , he was
started on intravenous nitrates with intravenous Nitroprusside with
a significant decrease in his SVR as well as his PA pressures.
This was felt to be a significant enough reduction in his pressures
to suggest that he would be a successful transplant candidate.
Therefore , he was transitioned to orally nitrates and started on
Isordil by mouth. However , he developed intolerance to nitrates
with severe headaches and ultimately all nitrates were
discontinued. He was subsequently managed only on afterload
reduction. His Analopril was held and he was started on Captopril
which was titrated up with good maintenance of his decrease in
pressure. Additionally , he was started on Losartan for further
afterload reduction which he tolerated well without orthostatic
symptoms. His Lasix was gradually increased and he continued to
have quite a significant improvement symptomatically with no
further orthopnea in the hospital. Further parts of the cardiac
transplant work-up were undertaken including PPD and controls which
were placed. There was no reaction to either PPDs or controls at
72 hours. He had a B12 and folate level drawn which were within
normal limits. His thyroid function test demonstrated a TSH of 1.9
and all other parameters were within normal limits. Digoxin level
on discharge was maintained in a therapeutic range. Hepatitis
panel was sent and he was negative for Hepatitis B antigen or
antibody as well as Hepatitis C antibodies. 24 hour urine
collection was obtained for creatinine and his creatinine clearance
was at 88 at 24 hours. Pulmonary function tests were as noted
above. He was seen by Dental Consult and was felt to have a few
minor restorative needs which could be taken care of by his
outpatient dentist , but he was dentally cleared otherwise for a
transplant. Subsequent to his medical changes and his transplant
work-up , he was restarted on his Coumadin and was discharged when
his INR had become greater than 2 with a target range of 2 to 2.5
planned. Echocardiogram was performed on October , 1997 which
demonstrated 1+ tricuspid regurgitation , 2+ mitral regurgitation ,
severely dilated left ventricle with an ejection fraction of 20%.
There was diffuse severe hypokinesis and apical akinesis. There
was evidence of echo contrast within the left ventricle suggesting
a clot. There was moderate left atrial enlargement.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition. He was markedly improved from
a symptomatic point of view on discharge.
FOLLOW-UP: The patient is to follow-up with Dr. Fernande Prewer in
the Ashore Cleod Health
MEDICATIONS ON DISCHARGE: 1 ) Captopril 75 mg orally four times a day 2 )
Potassium Slow Release 10 mEq orally q.
day. 3 ) Lasix 80 mg orally every day. 4 ) Multivitamins one orally q.
day. 5 ) Coumadin 5 mg orally every day. 6 ) Losartan 15 mg orally q.
day. 7 ) Digoxin 0.25 mg orally every day on even days and 0.125 mg
orally every day on odd days.
DISPOSITION: The patient was discharged to home.
Dictated By: GAYE GUSMAR , M.D.
Attending: HA I. OTANI , M.D. O
SN201/9589
Batch: 24363 Index No. VVLK8X5EPL D: 4/4/97
T: 10/10/97
Document id: 672
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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433461314 | PUO | 49848971 | | 9352684 | 9/4/2004 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 6/29/2004 Report Status: Signed
Discharge Date: 5/11/2004
ATTENDING: LEOLA CLARISA MUSICH
ADMISSION DIAGNOSIS:
Congestive heart failure.
PRINCIPAL DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Diastolic dysfunction.
3. Hypertension.
4. Diabetes mellitus.
5. Serratia UTI.
6. Chronic renal dysfunction.
7. Dyslipidemia.
8. Coronary artery disease.
9. Mild pulmonary hypertension.
10. Mitral regurgitation.
ALLERGIES:
Penicillins.
BRIEF HISTORY OF PRESENT ILLNESS:
The patient is a pleasant 78-year-old gentleman who presents with
shortness of breath and paroxysmal nocturnal dyspnea for
approximately three weeks. He has a history of coronary artery
disease with an MI in 1994 and four-vessel CABG with subsequently
placed five stents in 2002 for graft and native vessel stenosis ,
hypertension , chronic renal insufficiency with a baseline
creatinine of 2.8 , diabetes mellitus ( insulin dependent ) ,
hyperlipidemia , and a pace maker for symptomatic bradycardia. He
is presented with three weeks of increasing orthopnea , dyspnea ,
and paroxysmal nocturnal dyspnea with rare chest tightness
without radiation and onset of symptoms mainly while recumbent.
He presents after coming to an outside hospital with three to
four days of these worsening symptoms. He was transferred to
Pagham University Of where he received most of his
cardiac care. The patient had these worsening heart failure
symptoms after a trip to Tempe Leah Cu , some dietary indiscretion and
a five-pound weight gain. He has had no syncope , palpitations ,
but has had some mild nausea without emesis. At the outside
hospital when he presented , his EKG showed a baseline left
bundle-branch block and had a troponin of 0.13. He was given
some Lasix and had echocardiogram , had initially revealed an
ejection fraction of 35%. He was transferred to Pagham University Of , started on a nitroglycerin drip as well as a
heparin drip for presumed coronary artery disease , a repeat
echocardiogram showed an ejection fraction of 50% , anterior wall
distal dyskinesis from an old myocardial infarction and
moderate-to-severe mitral regurgitation. This is consistent with
an echocardiogram that he received in 1/8 . Upon
presentation , the patient was afebrile , had a heart rate of 82 ,
blood pressure of 138/64 and was sating 96% on 5 liters of nasal
canula. His jugular venous pressure was 7 cm. His lungs had
rales bilaterally , approximately half way up. He had no
dullness. His heart was regular rate and rhythm with a 3/6
holosystolic murmur at the apex with radiation to the left
axilla. He had no S3 , and no S4. His abdomen was mildly
distended. He had no fluid waves and positive bowel sounds. His
extremities were warm. He had no pedal edema and 1+ dorsalis
pedis pulses bilaterally. EKG at Pagham University Of
revealed a dual chamber pacemaker with left bundle-branch pattern
and no significant ST wave changes and an occasional PVC.
ADMISSION LABORATORIES:
Significant for a creatinine of 3.1 , a BUN of 76 , potassium of
5.3 , his hematocrit was 29.4 , and physical therapy-T was 56 on heparin drip.
BRIEF RESUME OF HOSPITAL COURSE:
1. Ischemia. The patient has an extensive history of coronary
artery disease. He is maintained on aspirin , Plavix , low dose
beta-blocker with carvedilol as well as ACE inhibitor and statin.
He initially came in with a troponin of 0.13 , which was felt as
demand ischemia related to systemic hypertension and pulmonary
hypertension. His enzymes trended down and were negative after
the initial check. Eventually , the patient received 48 hours of
intravenous heparin as well as intravenous nitroglycerin and was chest
pain free. At this point , he received an Adenosine MIBI nuclear
study , which revealed a known distal anterior wall scar with a
very small surrounding region of reversible ischemia that was
felt to be nonrevascularizable. He was maintained on optimum
medical management with the caveat that cardiac catheterization
in this gentleman who had already had previous history of renal
dysfunction with a creatinine rise to nearly 7 with a dye load
was not warranted nor indicated at this time. By discharge , he
was ambulating halls and was chest tightness free. Coronary
artery disease was felt to be a noncontributory factor to his CHF
exacerbation.
2. Pump. The patient had an ejection fraction of 45% upon
admission with moderate-to-severe mitral regurgitation. He was
initially diuresed approximately 3 liters with a combination of
Lasix and Natrecor. At this point , his pulmonary edema had
resolved and his oxygen requirement was decreased. Given the
fact of his tenuous renal status , we wanted to avoid further
diuresis or after-load reduction until we knew exactly what his
right and left heart filling pressures were. The patient was
taken to the Cardiovascular Diagnostic Laboratory and received a
right heart catheterization. His pulmonary capillary wedge
pressure was determined to be 16 and his pulmonary artery
pressure 56/18. His RA pressure was 8. There was some initial
false elevation because of inadequate sedation while in the cath
lab , and the patient was transferred for 48 hours of tailored
therapy to the Cardiac Care Unit where he had a pulmonary artery
catheter in place. At this point , his after-load reduction was
maximized with combination of hydralazine and Isordil with good
effect. His creatinine decreased with after-load reduction to
2.7. His symptoms improved and we were able to diurese another 2
liters of the patient. By discharge , the patient was actually
becoming hypertensive again and he was started on amlodipine , a
calcium channel blocker , which he has tolerated in the past. Of
note , the patient has been exposed to ACE inhibition in the past
and is currently not on an ACE inhibitor. In the past , he had
had a rise in his potassium to 5.5 on ACE inhibition. On an
outpatient basis in the future , we would suggest the patient have
a trial of ACE or ARB to optimize his after-load reduction and
neurohormonal activation with his heart failure. The patient's
heart failure regimen includes standing Lasix , carvedilol ,
Isordil and hydralazine , as well as digoxin for symptomatic
improvement.
3. Rhythm. The patient has a dual-chambered pacemaker. He was
maintained on telemetry throughout his hospital stay. His
electrolytes were replete and he is on a low-dose beta-blocker.
He had a few rounds of nonsustained ventricular tachycardia less
than 8 beats every time during his hospital stay. The patient is
not at this time a candidate for resynchronization biventricular
pacer therapy because his ejection fraction of 45% , even if his
QRS interval is greater than 150 ms.
4. Pulmonary. Given the fact that the patient had a normal
pulmonary capillary wedge pressure and elevated pulmonary artery
pressures , a brief investigation of pulmonary parenchymal disease
was undertaken. He had a high resolution chest CT , which showed
mild ground glass infiltrate at the bases consistent with
pulmonary edema and no evidence of interstitial process. He also
had pulmonary function tests. Pulmonary function tests revealed
an FVC of 1.88 liters and an FEV1 of 1.33 liters. This gives an
FEV1 to FVC percent of 71%. He has both decreased FVC and FEV1 ,
but an FEV1 and FVC percent that is most consistent with a mild
restriction. His lung volumes are approximately 50% predicted
suggestive of a restrictive process and his DLCO both corrected
and uncorrected are 50% predicted. His corrected DLCO is 13.5.
It is unclear if the patient has underlying restrictive lung
disease given the absence of definitive interstitial process on
high resolution chest CT. A more likely explanation for these
findings is a residual pulmonary edema relating to inadequate
diuresis with his congestive heart failure. The patient was
sating 98% on room air at the time of discharge.
5. Endocrine. The patient has very difficult to control
diabetes mellitus , and was maintained on both NPH and Lispro
sliding scale while in house. He was briefly hypoglycemic during
his initial hospital course because of a urinary tract infection.
This resolved after approximately 24 hours of holding his
long-acting insulin and giving him glucose replacement therapy.
He was euglycemic on 15 and 10 of NPH in the a.m. and p.m.
respectively as well as a Lispro scale at the time of discharge.
Furthermore , the patient was found to have a TSH of 0.219 as well
as a normal T4 , this is suggestive of clinical hypothyroidism ,
which is consistent with over replacement with Synthroid such as
maintenance Synthroid dose is decreased from 75 mcg to 60.5 mcg
and we recommend a TSH to be checked in late February 2004.
6. Renal. The patient has baseline chronic renal insufficiency
presumably due to a combination of diabetes and hypertension. He
has had adverse reaction to contrast dye in the past with a
creatinine bump to nearly 7. We wanted to avoid as much contrast
dye as possible during this hospital stay because of his renal
insufficiency. We ended up re-dosing his digoxin to three times
weekly from every other day because of the dig level of 0.19.
His creatinine was 2.7 and falling at the time of discharge and
his BUN was 67. He was making good urine and had no evidence of
residual urinary tract infection.
7. Infectious disease. Upon presentation , the patient after a
Foley was placed became a little delirious and hypoglycemic.
Urine cultures grew out greater than 100 , 000 colonies of Serratia
marcescens and he was given a 14-day course of renally dosed
levofloxacin with good resolution of his symptoms.
8. Neuropsych. The patient has a history of depression and had
some mild delirium in the setting of urinary tract infection ,
which resolved with as needed Zyprexa as well as treating of the
underlying condition. Psychiatric Service was consulted and felt
like he had a resolving medical delirium and there is no
indication for further pharmacal or psychodynamic therapy at this
time. ( His mild subclinical hyperthyroidism may have contributed
to his low mood as apathetic hyperthyroidism in a gentleman of
this age is not uncommon. )
9. Prophylaxis. The patient was maintained on Nexium for GI
prophylaxis and subcutaneous heparin for DVT prophylaxis.
CODE STATUS:
The patient is full code.
The patient was consulted by both Physical Therapy and
Occupational Therapy who felt that acute rehabilitation would be
warranted at this time.
DISPOSITION:
The patient was discharged in stable condition on room air and
was chest pain free to the Dea Health The patient's health care proxy is his wife , Mrs.
Malcolm Swartzbaugh , whose phone number is ( 291 ) 861-3520. He will
be followed by Dr. Leola Musich at Pagham University Of
Schedule appointments with Dr. Meduna ( 603 ) 398-0769. The patient's primary care physician is Dr. Genoveva Stidman at ( 544 ) 366-7578. The patient should be maintained on a
fluid-restricted diet of less than 2 liters of fluid total. He
should have low-cholesterol , low-saturated fat as well as a
diabetic diet with ADA 2100 calories per day. He should also be
sodium restricted to less than 2 g daily. Activity to be guided
by Physical Therapy at Go Ale Belle , 22260
TO DO:
1. Titrate amlodipine as needed The patient has tolerated up to 10
mg amlodipine in the past.
2. Consider outpatient trial of ACE inhibitor or ARB in the
future with close monitoring of potassium.
3. Recheck TSH late February 2004.
4. Complete former days of antibiotics for Serratia urinary
tract infection.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed headache.
2. Vitamin C 500 mg orally three times a day ( to help with iron absorption ).
3. Enteric-coated aspirin 325 mg orally every day
4. Digoxin 0.125 mg orally every Monday , Wednesday and Friday.
5. Colace 100 mg orally twice a day
6. Procrit 40 , 000 units subcutaneously every 2 weeks ( for chronic
renal disease ).
7. Iron ( ferrous sulfate ) 325 mg orally three times a day
8. Lasix 40 mg orally twice a day
9. Heparin 5000 units subcutaneously three times a day
10. Hydralazine 100 mg orally four times a day , hold for systolic blood
pressure less than 100.
11. NPH Humulin Insulin 15 units every day before noon , 10 units every afternoon
subcutaneously , hold if fasting sugars less than 100 , please give
half dose of npo
12. Isordil 60 mg orally three times a day
13. Lactulose 30 ml orally four times a day ( hold if diarrhea ).
14. Synthroid 62.5 mcg orally every day ( recheck TSH late February 2004 ).
15. Milk of magnesia 30 ml orally every day as needed constipation.
16. Nitroglycerin 0.4 mg one tablet subcutaneously every 5 minutes x
3 as needed chest pain , hold if SVT less than 100.
17. Senna two tablets orally twice a day as needed constipation.
18. Proscar 5 mg orally every day
19. Zocor 80 mg orally every bedtime
20. Amlodipine 5 mg orally every day , hold if systolic blood pressure
less than 100.
21. Zyprexa 2.5 mg orally every bedtime as needed insomnia.
22. Carvedilol 3.125 mg orally twice a day
23. Levofloxacin 250 mg orally every 48 hours x 2 more doses ( 4 more days
total ).
24. Nephrocaps one tablet orally every day
25. Lispro ( Insulin Lispro sliding scale ) subcutaneously before every meal ,
if blood sugar is less than 125 then give 0 units subcutaneously ,
if blood sugar is 125-150 then give 2 units subcutaneously , if
blood sugar is 151-200 then give 3 units subcutaneously , if blood
sugar is 201-250 then give 4 units subcutaneously , if blood sugar
is 251-300 then give 6 units subcutaneously , if blood sugar is
301-350 then give 8 units subcutaneously , if blood sugar is
351-400 then give 10 units subcutaneously and notify covering
physician.
26. Flomax 0.4 mg orally every day
27. Nexium 20 mg orally every day
28. Maalox 1-2 tablets orally every 6 hours as needed upset stomach.
eScription document: 5-6481860 EMSSten Tel
Dictated By: FIGURA , CAREY
Attending: MUSICH , LEOLA
Dictation ID 8845442
D: 9/23/04
T: 9/23/04
Document id: 673
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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672618901 | PUO | 36220243 | | 8593379 | 9/25/2006 12:00:00 a.m. | CHF , sleep apnea , obesity hypoventilation syndrome | | DIS | Admission Date: 1/8/2006 Report Status:
Discharge Date: 1/15/2006
****** FINAL DISCHARGE ORDERS ******
FAWCETT , ALBERTA 039-63-44-8
E89 Room: 10R-930
Service: MED
DISCHARGE PATIENT ON: 6/13/06 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ATENOLOL 50 MG orally DAILY HOLD IF: SBP <100 or HR <60
CATAPRES ( CLONIDINE HCL ) 0.2 MG/DAY TP Q168H
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 120 MG orally every day before noon HOLD IF: SBP<100
LASIX ( FUROSEMIDE ) 80 MG orally every afternoon HOLD IF: SBP <100
GEMFIBROZIL 600 MG orally twice a day
SALINE NASAL DROP ( SODIUM CHLORIDE 0.65% ) 2 SPRAY nasal four times a day
as needed Other:nasal dryness
SINGULAIR ( MONTELUKAST ) 10 MG orally DAILY
LANTUS ( INSULIN GLARGINE ) 10 UNITS subcutaneously DAILY
Starting Today ( 9/18 )
Instructions: patient's wife states he takes 100 units
daily , not clear
that this is actual dose and was hypoglycemic on
admit , advised to restart home dose
ACETAZOLAMIDE 250 MG orally BEDTIME
DIET: House / 2 gm Na / ADA 2000 cals/day / Low saturated fat
low cholesterol
ACTIVITY: activity as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician DR TETRICK ( 315 ) 043-2962 10/26/06 @ 11:00 a.m. ,
SLEEP STUDY ( 215 ) 591-0556 ( REISLING ) CLINIC WILL CALL DITH DATE AND TIME ,
ALLERGY: Penicillins , ACE Inhibitor
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF , sleep apnea , obesity hypoventilation syndrome
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF , sleep apnea
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: leg swelling
-----
HPI: 71 year-old male with history of DM , HTN , and poss CHF
( patient denies and unclear from documenation ) here with 2 weeks of LE
edema. Of note patient was difficult to obtain a history from and there
is little consistency between his story on admission and what
was recorded by his primary care physician in his MMC chart. patient states he has had
increasing LE swelling for 2 weeks despite taking all of his
medications. patient states that he has not increased his Na intake
recently. patient repeatedly denied SOB , increased abd girth , and PND.
patient did note that he sleeps on 2 pillows at night but his breathing
his fine when he is lying flat.
Next day spoke with patient's wife who confirmed story documented by primary care physician
including increasing shorntness of breath and orthopnea.
ED: lasix 120 intravenous x 1 ROS: no fevers , chills , or night sweats. No
ST , hearing problems , or visual problems. No SOB , but
does note non-productive cough x 1 day. No CP , palpitations ,
orthopnea , or PND. No abd pain , N/V , diarrhea , BRBPR. patient does
endorse nocturia stating that he gets up 6-7 times/night to urinate.
No dysuria or hematuria. No joint pains or rashes.
-----
PMH:
OSA
DM-on insulin
HTN
Anemia
H/o DVT-on coumadin
?CHF-per old MMC notes
H/o pituitary adenoma and hyperprolactinemia
BPH
-----
ALL: AceI-->angioedema ( required trach ) , PCN-->rash
-----
MEDS: ( per MMC note , unclear what he's actually taking , if any )
Atenolol 100mg orally daily
Protonix 40mg orally daily
Catapres 0.2mg tp daily ( although no patch on body )
Lasix 120mg orally twice a day
Norvasc 10mg orally daily
Lantus ( dose unknown )
Singulair 10mg orally daily
Beconase aq 1 spray/nostril three times a day
-----
SH: patient lives with wife. No tob , EtOH , or drug use.
-----
FH: non-contributory
-----
PE on Admit:
VS: 96.4 63 138/74 24 96% on 2.5LNC
Gen: A&O , NAD , comfortable breathing while lying flat , loud breathing
HEENT: PERRL , EOMI , OP clear , MM dry
Neck: lot of redundant neck tissue , could not appreciate JVP , supple
CV: nl s1 s2 , no m/r/g
Lungs: CTA-bilat , no crackles , no dullness
Abd: obese , NT/ND , quiet BS , lg midline surgical scar with other
surrounding scars
Extrem: 1-2+ pitting edema to knees , WWP , no cyanosis
-----
PROC/TESTS:
CXR: negative ( prelim )
Echo( 4/3 )-marked LVH , otherwise nl , EF 55-70%
Echo( 3/22 )-mod LVH , EF 60-65% , no WMAs , suggestive of diastolic
dysfunction , trace TR
-----
CONSULTS: Pulmonary Medicine ( Dr. Piontkowski )
-----
IMP: 71 year-old male with history of DM , HTN , and poss history of CHF who presents with
2 weeks of LE edema.
-----
PLAN:
CARDS:
I: No known history of CAD-little concern for ACS with no sxs except LE
edema -unclear why not on ASA , no history of GI bleed or ulcer. Will start ASA
for primary/secondary prevention. Checked lipid profile , trigs very
elevated at 482 and HDL 24. LDL could not be peformed b/c trigs were so
high. Started gemfibrozil , patient can have repeat lipid profile as outpt and
statin at discretion of primary care physician. patient was continued on BB but dose was
decreased to 50mg orally daily as patient having asymptomatic bradycardia to 40's
while sleeping.
P: patient's MMC notes list CHF as dx , patient denies any history of LE edema or CHF
before 2 weeks ago but is on lasix twice a day at home. Last echo in 4/3
showed LVH with preserved EF. patient with likely diastolic dysfunction. patient on
exam has only LE edema , but received 120 intravenous lasix in ED. patient's
presentation c/with CHF exacerbation but BNP of 13 is unusual. Continued
to diurese patient with intravenous lasix and once he was approaching euvolemia
switched him back over to home dose. patient's LE edema likely multifactorial
due to CHF and some component of chronic venous stasis. LENIs were
checked and were negative for DVTS. Discontinued patient's CCB as may be
contributing to LE edema. Echo was repeated this admit which
showed EF 60-65% and signs of diastolic dysfunction.
HTN: BP was controlled this admit. patient was continued on BB , norvasc , &
catapres
R: no issues this admit
ENDO: patient has history of DM and patient states he is taking insulin at home ( unclear
dose ). patient was started on Lantus with SS novolog and his sugars were
somewhat elevated. Advised patient to restart home insulin regimen after d/c.
Sent HgA1C but was still pending at the time of discharge.
RENAL: patient appears to have CKD per MMC recs -baseline 1.4-1.6 , renally
dose meds
NEURO: patient's wife noted that patient has intermittently been confused at home.
She describes episodes when he wakes up at night and doesn't know where
he is. This is likely due to hypoxia as patient has severe sleep apnea and
rarely wears cpap at home. patient was alert and oriented during this admit.
Sent labs to evaluate for secondary cause of dementia and they were
negative. Suggested that patient f/u with primary care physician if these episodes persist.
PULM: patient with history of sleep apnea. Per 2003 sleep study patient's sleep apnea
was central and not obstructive although this is difficult to believe
based on patient's body habitus and redundant neck tissue. patient evaluated by
pulmonary after RA ABG showed PaO2 50's. patient pulse ox was monitored and
when he fell asleep without his cpap he desatted to low 60's and high
50's. patient satted in mid 90's on RA while awake and upright. Pulmonary
thought patient likely with obesity hypoventilation syndrome and sleep apnea
( central +/- obstructive ). patient tried on empiric bipap ( 4/9 ) the night
prior to d/c and felt that he slept much better. Of note patient used the
nasal mask in house but has the full mask at home. Tried to set up patient
for home bipap but is not eligible unless has another sleep study.
Communicated this with patient's primary care physician who will set up repeat sleep study in
near future. patient also started on empiric every bedtime acetazolamide per pulmonary
recs based on recent data showing that it improves symptoms in patient's with
central sleep apnea and heart failure.
PPx: lovenox
CODE: FULL
FULL
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: RANDKLEV , VERNON E. , M.D. ( LF02 ) 6/13/06 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 674
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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961677284 | PUO | 29991274 | | 463337 | 3/14/2000 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/16/2000 Report Status: Signed
Discharge Date: 2/27/2000
PRINCIPAL DIAGNOSIS: STREPTOCOCCAL TRICUSPID VALVE ENDOCARDITIS
SECONDARY DIAGNOSES: 1. LEFT OPHTHALMITIS
2. SEPTIC POLYARTHRITIS
3. PACEMAKER MALFUNCTION
4. DIABETES MELLITUS TYPE II
5. CORONARY ARTERY DISEASE STATUS POST
CORONARY ARTERY BYPASS GRAFTING
6. PACEMAKER PLACEMENT
7. PULMONARY HYPERTENSION
8. OBESITY
9. OBSTRUCTIVE SLEEP APNEA
PROCEDURES: SEE HOSPITAL COURSE
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old gentleman
with a past medical history
significant for diabetes mellitus , obesity , coronary artery disease
status post coronary artery bypass grafting and pacemaker placement
in 1996 and 1999 respectively , who presented on 7/16/2000 with a
four day history of cough , fevers , chills , myalgias and left eye
pain. The patient also noted over the course of four days prior to
admission , that his orally intake had been decreasing. He had been
experiencing nausea and vomiting without diarrhea and fevers to 103
degrees. On the day of admission the patient noted the sudden
onset of vision loss in his left eye associated with redness and
pain. In the Emergency Room the patient was given Diamox , aspirin
and nitropaste in response to T-wave inversions anteriorly on his
electrocardiogram. In addition , the patient was cultured and
started on broad spectrum antibiotics including Ceftriaxone ,
azithromycin and Gentamycin.
PHYSICAL EXAM: VITAL SIGNS: Temperature 99.2 , heart rate 60 ,
blood pressure 118/78 , 98% oxygen saturation on 100
percent face mask. HEENT: OS with hazy , edematous cornea ,
moderately dilated fixed pupil with erythema and injected
conjunctiva. NECK: Supple without lymphadenopathy , no carotid
bruits and no jugular venous distention. LUNGS: Bibasilar scant
crackles. CHEST: Distant heart sounds. Regular rate and rhythm.
No murmurs , rubs or gallops. S3 , loud S2. EXTREMITIES: Minimal
edema , no cyanosis. 2 plus peripheral pulses. ABDOMEN: Obese ,
soft , nontender and nondistended. Normal bowel sounds. Difficult
to assess. NEUROLOGICAL: Nonfocal. RECTAL: Guaiac negative
brown stool.
LABORATORY DATA ON ADMISSION: Chemistry panel showed BUN 74 ,
creatinine 2.8 ( baseline 1.0 ) ,
otherwise normal. Albumen 2.4 , liver function studies otherwise
normal. CK 169 , troponin 1.7 , CBC showed a white blood cell count
of 5.5 , hematocrit 33 , platelets 51. Electrocardiogram showed
paced rate of 60 with T-wave inversions of V1-V6. Chest x-ray
showed cardiomegaly with vascular redistribution. No focal
infiltrates noted. CT of the head showed no evidence of acute
bleed. Urinalysis essentially negative.
HOSPITAL COURSE: 1. Infectious disease: The patient was
initially treated with broad spectrum antibiotics
in the Emergency Room and was rapidly noted to be hypotensive with
a systolic blood pressure in the 72. The patient was hydrated
aggressively and consistently pan cultured. The patient began to
spike fevers from 100 to 101 range. On the second hospital day ,
the patient grew 4/4 bottles of what turned out to be Group B streptococcus.
The patient's antibiotics were changed to Penicillin and Gentamycin. A
transesophageal echocardiogram was performed on the day of
admission and did not demonstrate any vegetation , however with
persistent high spiking fevers , sepsis and 4/4 blood culture
bottles , repeated blood cultures growing GBS the patient had repeat
transesophageal echocardiogram. This demonstrated a 1.5x1.0
centimeter vegetation on the anterior annulus of the tricuspid
valve and it was also noted to be hitting the pacemaker wire though
not fixed to it. Of note , the bubble study on the echocardiogram
was negative for patent foramen ovale.
The patient presented complaining of left eye pain and loss of
vision on the night of admission in the Emergency Room , the
ophthalmologist saw the patient and determined that the patient had
an elevated pressure. The elevated pressure was treated and he
responded well by the following day. At that time the patient's
eye was aspirated and noted to also be infected by GBS. The
patient was injected intraocular with Vancomycin at that time.
Unfortunately the patient continued to spike fever despite
appropriate therapy for his GBS and his eye appeared to be
worsening with continued erythema , conjunctival edema and a
purulent exudate. It was determined that the patient would require
enucleation which he underwent on 5/10/2000.
The patient also had a right lower extremity cellulitis during his
hospital course. This was treated with a ten day course of
dicloxacillin and resolved without complications. The patient's
course was complicated by persistent fevers despite appropriate
antibiotic therapy and left eye enucleation. An extensive work up
was undertaken to evaluate the fevers including evaluation for
possible epidural abscess , psoas abscess and infected joints. None
of these proved to be a source. The patient underwent multiple
joint aspirations ( see musculoskeletal section below ) without clear
evidence of infection. The patient also underwent a tagged white
blood cell scan which demonstrated increased uptake in the left
shoulder , manubrium , right knee , left ankle and mid shaft of the
left tibia. These were interpreted both on the initial views and
delayed views as consistent with acute inflammation but not
diagnostic of infection. As mentioned above the patient was also
treated for cellulitis and underwent left eye enucleation. The
patient's fever curve trended down throughout the hospital stay and
on the day prior to admission , the patient underwent a repeat
transesophageal echocardiogram to ensure that there was no
myocardial abscess. There was no evidence of any abscess and the
vegetation was no longer visible. It was felt that the low grade
fevers were secondary to ongoing inflammation but no acute
infectious process at the time of discharge. The patient's last
positive blood culture was 4/3/2000.
Of note , there was concern that the patient's fever could be
secondary to a drug reaction. Therefore once the infectious work
up was completed , the Penicillin was changed to Vancomycin. His
gram positive coverage will need to be continued for four weeks
after his left eye enucleation.
2. Ophthalmology: As described above , the patient presented with
left eye pain and vision loss. It was felt from the time of
presentation that the patient would not recover vision in his left
eye. The patient was treated initially for his elevated pressure
and then the following day his eye was aspirated and injected with
Vancomycin. Ultimately the patient had left eye enucleation. The
patient's eye healed well through the remainder of his hospital
course and does not appear to be a source of infection thereafter.
The patient's extraocular muscles were left intact with the thought
of placing a prosthesis at a later date.
3. Cardiovascular: On admission the patient was noted to have
T-wave inversions anteriorly on his electrocardiogram. However it
rapidly became clear that his pacemaker was malfunctioning
demonstrating only occasional pacing spikes. By 6/24/2000 the
pacemaker was no longer capturing or sensing. As mentioned above ,
the wire did not appear to be incorporated in the vegetation noted
on the tricuspid valve however it did appear that the vegetation
was hitting the pacemaker wire with systole and diastole. On
6/13/2000 the patient underwent pacemaker explantation without
complications.
The indication for pacemaker placement had been for bradycardia.
There was some concern throughout the patient's hospital course
that the patient would become bradycardic without his pacemaker in
place however this never manifested as a problem. He did
demonstrate some runs of ventricular tachycardia during the early
phase of his hospital course but this resolved as his sepsis
resolved. He did have one episode of supraventricular tachycardia
thought to be 1-1 conduction of his atrial arrhythmia. His
Lopressor was increased in response to this and the patient was
tolerating this dose without episodes of bradycardia or
hypotension.
The patient as mentioned above , underwent a transesophageal
echocardiogram at the time of admission which demonstrated an
ejection fraction of 35 percent , apical hypokinesis , moderately
dilated right ventricle with moderately depressed systolic
function. Mild inferior vena cava dilatation consistent with
elevated right heart filling pressures. The patient's cardiac
function appeared to be stable throughout his hospitalization. he
did rule out for myocardial infarction at the time of admission.
4. Musculoskeletal: One of the patient's major presenting
complaints was significant arthralgia and myalgia. It was though
that along with left ophthalmitis , the patient could have septic
polyarthritis. The patient underwent several arthrocentesis by the
rheumatology service. Though the fluid did demonstrate elevated
white blood cell count it was never clear that these were acutely
infected. There were no bacteria on gram stain or culture. The
patient's right knee continued to be tender , erythematous and warm
during the initial part of the hospitalization. Therefore the
patient went to arthroscopic examination on 7/16/2000. The
patient's knee was lavaged with 9 liters of sterile saline prior to
closing all of the effusion was drained. There were no
complications. The patient continued to have symptoms of right knee
effusion and pain and therefore returned to the operating room on
10/28/2000 for repeat arthrocentesis. Since that time the right
knee has reaccumulated a moderate sized effusion but the patient
has tolerated physical therapy and has regained a moderate amount
of his range of motion. It was determined that the patient should
not have this effusion drained again because it was no longer warm
or erythematous.
The left shoulder was also quite tender during the initial hospital
stay. The patient underwent multiple joint aspirations of the
glenohumeral and acromioclavicular joints , both at the bed side and
under fluoroscopic examination. Again , this joint demonstrated
elevated white blood cell count but never any clear evidence that
it was a septic joint.
The patient after his left eye enucleation , was noted to have an
elevated CK of 1522. It was thought that this was an insignificant
MB fraction. It was not felt that there was enough manipulation to
skeletal muscles during the enucleation to warrant this. This rise
in CK did coincide with increased muscle aches. It was felt that
the patient perhaps had a mild episode of rhabdomyolysis which
resolved quickly to a CK of 177 five days later.
At the time of discharge the patient is experiencing no myalgias or
arthralgias with the exception of the right knee which is still
somewhat limited in its range of motion and demonstrates an
effusion but is responding well to rehabilitation.
5. Pulmonary: The patient was quite stable from a pulmonary
standpoint throughout his hospitalization. The patient was
initially maintained in the Emergency Room on high flow oxygen
however was quickly weaned to nasal cannula and then room air. The
patient does have obstructive sleep apnea and used his BIPAP at
night throughout his hospitalization.
6. Hematology: On admission the patient demonstrated a
thrombocytopenia with a nadir of 51. This has improved throughout
his hospital course and on the day of discharge his platelets were
noted to be 538.
The patient was noted to have hematocrit that trended down and
corresponded to some guaiac positive stools with anticoagulation.
The patient received a total of four units of packed red blood
cells. His hematocrit has remained stable with a good reticulocyte
count at the time of discharge.
The patient was anticoagulated for his atrial fibrillation
initially with Heparin and then ultimately with Coumadin 10 mg orally
every HS. The patient's INR has been therapeutic in the 2-3 range for
approximately five days.
7. Renal: On admission the patient was noted to have an elevated
creatinine from his baseline of 1.0. This was thought to be
secondary to dehydration and prerenal azotemia. The patient's
creatinine reached a peak of 3.0 and stabilized at 1.3 at the time
of discharge. This appears to have resolved entirely with
resolution of sepsis and rehydration.
8. Fluids/electrolytes/nutrition: The patient was significant
dehydrated at the time of admission. This responded rapidly to in
vitro fertilization. He also regained his appetite as his sepsis
resolved. The patient is noted however to have a very poor
albumen , which is 2.3 at the time of discharge. The patient will
require improved nutrition at rehabilitation and after discharge
from rehabilitation. The patient's electrolytes were relatively
stable throughout his hospital stay.
9. Endocrine: The patient has a long standing history of type II
diabetes mellitus. On admission , he was taking metformin 1000 mg
orally twice a day , regular insulin 10 every day before noon and 10 every afternoon , NPH insulin
25 every day before noon and 20 every afternoon His hemoglobin A1-C was noted to be
elevated at 8.1 in 11/15 The patient's metformin was held
throughout his hospital stay with the anticipation of possible
invasive procedures. He is maintained and NPH insulin as well as
sliding scale insulin. The patient was restarted on his metformin
prior to discharge and increased dose of NPH insulin. This will
likely need to be adjusted as the patient recovers further.
10. Gastrointestinal: The patient did develop guaiac positive
stools during his anticoagulation for atrial fibrillation. This
will need to be followed up as an outpatient once the patient has
made a full recovery from the acute event. Also the patient did
demonstrate a mild transaminitis during his hospital stay and this
appears to have resolved with the transition from Penicillin to
Vancomycin for his antibiotic regimen.
MEDICATIONS ON DISCHARGE: Colace 100 mg orally twice a day , Ilotycin
0.5% topical three times a day over left eyelid ,
Lasix 160 mg orally twice a day ( 8:00 a.m. and 3:00 p.m. ) , NPH insulin 50
units every day before noon and 35 units every afternoon , regular insulin 15 units every day before noon
and every HS. Regular insulin sliding scale every before meals and HS. Metoprolol
50 mg orally four times a day , Metamucil two packets orally twice a day , multivitamin
with minerals one tablet orally every day , Vancomycin 1000 mg
intravenously every 12 hours , Coumadin 10 mg orally every day , Norvasc 5 mg
orally every day ( hold if systolic blood pressure less than 110 ) ,
metformin 1000 mg orally twice a day , trandolapril orally twice a day ( hold if
systolic blood pressure less than 110 ) , miconazole 2% powder
topical twice a day , Tylenol 650 mg orally every 4 hours as needed headache ,
Droperidol 0.625 mg intravenously every 6 hours as needed nausea ,
nitroglycerin 1/150 one tablet sublingual every 5 minutes times 3
as needed chest pain , Serax 15-30 mg orally every HS as needed insomnia ,
Percocet 1-2 tablets orally every 4 hours as needed pain , Senna syrup 2 teaspoons
orally every HS as needed constipation.
ACTIVITY: Per rehabilitation.
DIET: ADA 2200 calorie diet , low saturated fat and low
cholesterol.
DISPOSITION ON DISCHARGE: The patient is discharged to the
rehabilitation facility.
Dictated By: HYMAN CARPENTIER , M.D. GI52
Attending: LEOLA C. MUSICH , M.D. WZ94
OK423/3980
Batch: 0026 Index No. F0SM6Q33U4 D: 8/10
T: 8/10
CC: TIARA RENETTA WILLOW BUSALACCHI
Document id: 675
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
- |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
887470647 | PUO | 84597502 | | 9309343 | 10/5/2005 12:00:00 a.m. | chest pain | | DIS | Admission Date: 7/4/2005 Report Status:
Discharge Date: 3/21/2005
****** DISCHARGE ORDERS ******
PIGGIE , RANEE 248-24-05-6
F92 Room: 46J-662
Service: MED
DISCHARGE PATIENT ON: 11/22/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCCULLEN , CORRINE ULYSSES , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
PEPCID ( FAMOTIDINE ) 20 MG orally every day
GLYBURIDE 5 MG orally twice a day
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 9/10/05 by
MUNDWILLER , MORA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
METFORMIN 850 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Mccullen , January , 2005 at 2:30 pm scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes , hypertension
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT , Echocardiogram
BRIEF RESUME OF HOSPITAL COURSE:
60M with DM , HTN + FH for CAD p/with CP. patient awoke early on morning of
admission with CP radiating to top of left head and left arm ,
assoc with palpitations but not SOB/LH/N/DIAPH. patient also had a cold
recently. No history of anginal sx's , fairly active individual at baseline.
In ED CP resolved p 2 hrs total with SLTNG x 3 and MSO4 intravenous x 2.
Exam: VS in ED notable for hypertension ( SBP 160 ) resolved to 136/60 on
floor , 2/6 sys murm at
base. EKG: sinus 60's with TWI in
v3. Labs: neg cardiac enzymes x 1. D-dimer
neg.
***********Hospital Course***************
60M with atypical CP syndrome but risk factors. Likely MSK
chostochondritis 2/2 cold sx's or GERD.
*CV: The patient ruled out for MI with serial enzymes and EKGs. He had
an echocardiogram which showed an ejection fraction of 60% ( unchanged
from prior echo from 1995 ) and sluggesh LV wall motion. He had an ETT on
the second hospital day which was negative. His a.m. lipids were notable
for a total cholesterol of 138 , triglycerides of 77 , an HDL of 33 and an
LDL of 105. The decision was made not to start him on a statin but to
instead advise dietary modifications. However , this will be followed by
his outpatient primary care physician , Dr. Mccullen , who was also the attending physician
during his hospitalization.
*DM The patient's metformin was held in case he needed catheterization or
nuclear imaging. It was restarted at the time of discharge. He was kept
on his glyburide , an covered with a RISS.
*GI: The patient was started on Pepcid for possible reflux causing his
symptoms.
*The patient was also advised he can take NSAIDS for probable
costochondritis 2/2 his recent URI.
The patient was FULL CODE
He was discharged to home with a follow-up appointment with his primary care physician , Dr.
Mccullen , in one month.
ADDITIONAL COMMENTS: Call your doctor right away if you have further chest pain , shortness of
breath or other worrisome symptoms.
If your chest pain does not go away with nitroglycerin under the tongue ,
please call 911 for an ambulance to take you to the hospital.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MUNDWILLER , MORA H. , M.D. ( HF693 ) 11/22/05 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 676
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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663917208 | PUO | 66936113 | | 4701222 | 5/16/2004 12:00:00 a.m. | history of Rt TKR | | DIS | Admission Date: 6/19/2004 Report Status:
Discharge Date: 7/10/2004
****** DISCHARGE ORDERS ******
LAVALETTE , CORINNE 585-65-79-4
Sonnas Own
Service: ORT
DISCHARGE PATIENT ON: 9/22/04 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RADEMAN , CAITLIN LAQUITA , M.D.
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650-1 , 000 MG orally every 6 hours as needed Pain
HOLD IF: Temp >101.5; and notify the HO
TYLENOL #3 ( ACETAMINOPHEN W/CODEINE 30MG ) 2 TAB orally Q4-6H
Number of Doses Required ( approximate ): 16
ATENOLOL 50 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 500 MG orally every day
BENADRYL ( DIPHENHYDRAMINE HCL ) 25-50 MG orally HS
as needed Insomnia
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FAMOTIDINE 20 MG orally twice a day
FES04 ( FERROUS SULFATE ) 300 MG orally three times a day X 5 Days
FOLATE ( FOLIC ACID ) 1 MG orally every day X 4 Days
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
MVI ( MULTIVITAMINS ) 1 TAB orally every day
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day as needed
Instructions: may be given with the patients choice of
beverage
COUMADIN ( WARFARIN SODIUM ) CHECK W/HO orally every day
Starting Today ( 5/25 )
Instructions: Monitor physical therapy/INR & dose for goal INR 2.0-2.5
DVT prophylaxis is planned X 6 weeks
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/11/04 by RADEMAN , CAITLIN LAQUITA , M.D. SERIOUS INTERACTION: SULFAMETHOXAZOLE & WARFARIN
Reason for override: md
CHOLECALCIFEROL 400 UNITS orally every day
DIET: No Restrictions
ACTIVITY: Partial weight-bearing
FOLLOW UP APPOINTMENT( S ):
Dr Rademan 10/12/04 Xray at 1:15pm Appt at 2:15pm 8/21/04 scheduled ,
PATC 4/18/04 at 10:20am 5/10/04 scheduled ,
Arrange INR to be drawn on 10/26/04 with f/u INR's to be drawn every
Mon/Thurs days. INR's will be followed by PUO Anticogulation Service
No Known Allergies
ADMIT DIAGNOSIS:
Bilateral Knee OA
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of Rt TKR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Osteoarthritis , LBP history of Laminectomy , Iron Deficiency Anemia , history of PE 71/88
OPERATIONS AND PROCEDURES:
5/11/04 RADEMAN , CAITLIN LAQUITA , M.D.
RIGHT TOTAL KNEE REPLACEMENT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
N/A
BRIEF RESUME OF HOSPITAL COURSE:
patient underwent a Rt TKR on 5/29/04 for endstage OA. The patient tolerated
the procedure well and had an uncomplicated postoperative course on
the TKR pathway. patient was HD stable but did require transfusion with 2
units of PRBC's on POD 3 for Hct of 27.9. Standard care with femoral
nerve catheter for acute pain management/CPM , prophylactic Abx until
all tubes/drains were d/c'd , and coumadin/TEDS/P-boots for DVT
prophylaxis. Wound clean and healing. patient slow to progress with physical therapy and
sustained a fall on the morning of POD 3 when sitting at EOB and
slightly confused. patient had no head trauma or LOC , or extremity injury.
Mental status has cleared since that time , but patient still requiring
mod assist with functional activities. patient stable for transfer to rehab
on POD 4.
ADDITIONAL COMMENTS: DSD every day The wound may be left OTA when dry. Staples may be removed in
rehab or by VNA as of 1/18/04 , please sterristrip the wound. When the
patient is discharged home please arrange biweekly blood draws for
physical therapy/INR every Mon/Thurs with results called to the PUO Anticoagulation
Service at 132-202-5576. Goal INR is 2.0-2.5. DVT prophylaxis is
planned X 6 weeks. Please notify the Anticoagulation Service when the
patient is discharged home.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Arrange biweekly blood draws for physical therapy/INR every Mon/Thurs with results called
to 988-605-5355 for outpatient anticoagulation management
Notify the Anticoagulation Service when the patient is discharged home
Staple removal 1/18/04
Followup with Dr Rademan as scheduled
No dictated summary
ENTERED BY: SCOVEL , DULCIE ( XP60 ) 9/22/04 @ 07:15 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 677
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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536815366 | PUO | 34000260 | | 0565941 | 9/27/2002 12:00:00 a.m. | history of lap chole | | DIS | Admission Date: 9/27/2002 Report Status:
Discharge Date: 10/6/2002
****** DISCHARGE ORDERS ******
GRIEF , FELICA 110-54-09-4
Jose And Ransfieldmo
Service: GGI
DISCHARGE PATIENT ON: 10/10/02 AT 12:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: QUELLA , STACEY J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
IMURAN ( AZATHIOPRINE ) 50 MG orally every day
CYCLOSPORINE ( SANDIMMUNE ) 100 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Alert overridden: Override added on 4/26/02 by
ALUQDAH , SELMA DELORSE , M.S.
POTENTIALLY SERIOUS INTERACTION: OXYCODONE & CYCLOSPORINE
Reason for override: needs cyclosporin
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLIC ACID 1 MG orally every day
DILAUDID ( HYDROMORPHONE HCL ) 2-4 MG orally Q4-6H as needed pain
PREDNISONE 5 MG orally every day before noon
SIMETHICONE 80 MG orally four times a day
PROCARDIA XL ( NIFEDIPINE ( SUSTAINED RELEASE ) )
90 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Quella 1 Week ,
No Known Allergies
ADMIT DIAGNOSIS:
heart transplant , gallstonesw
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of lap chole
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CARDIOMYOPATHY ? AETIOLOGY NIDDM history of PTB history of CCF R/O MI COMPLETED
OPERATIONS AND PROCEDURES:
4/26/02 QUELLA , STACEY J. , M.D.
LAPOROSCOPIC CHOLELITHIASIS
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
63 yoF history of cardiac transplnat for cardiomyopathy presenting with
epigastric pain and multiple gallstones. patient brought to the OR for
uneventufll lap chole. patient in the postop period with positive postop
course regaining adequate orally intake , ambulation , and pain control. patient
on POD 2 is deemed suitable for d/c home in stable condition.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please make follow-up appointment with Dr. Quella in 1 week.
No dictated summary
ENTERED BY: SUGIMOTO , ARDELL , M.D. ( VD67 ) 10/10/02 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 678
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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708551358 | PUO | 86674530 | | 1389744 | 8/16/2004 12:00:00 a.m. | Left carotid stenosis | | DIS | Admission Date: 10/10/2004 Report Status:
Discharge Date: 10/26/2004
****** DISCHARGE ORDERS ******
BOCKENSTEDT , MERNA 209-17-26-6
Den S Noo
Service: VAS
DISCHARGE PATIENT ON: 8/11/04 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MANKOSKI , ROSSIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting post OP DAY 1
Instructions: Begin morning of POD #1
ATENOLOL 25 MG orally every day before noon
ENALAPRIL MALEATE 2.5 MG orally every day
HEPARIN 5 , 000 UNITS subcutaneously twice a day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
Instructions: Please take for sympoms of constipation while
taking percocet.
PERCOCET 1-2 TAB orally every 6 hours Starting Today ( 4/24 ) as needed Pain
Instructions: Do not drive while taking percocet
DIET: House / ADA 2100 cals/dy
ACTIVITY: Partial weight-bearing: Do not lift more than 10 lbs until follow up
FOLLOW UP APPOINTMENT( S ):
Dr. Derham 1 week , call office to set up appt ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Severe Left Carotid Stenosis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Left carotid stenosis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , HTN , hyperlipidemia , PVD , tinnitus , NIDDM , osteoarthritis
OPERATIONS AND PROCEDURES:
4/11/04 MANKOSKI , ROSSIE , M.D.
LEFT CAROTID ENDTARTERECTOMY WITH PATCH ANGIOPLASTY
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
75 year old male with 95 stenosis of Left ICA underwent uncomplicated
Left Carotid Endarterectomy as described in operative reoport.
Patient had a post-operative course marked by hypertension which was
controlled with intravenous hydralazine and Labetolol. Otherwise , patient's
post-operative course was uneventful and patient's JP drainage tube
was removed on POD#1. Patient was tolerating
full diet , pain was controlled on orally medications , and patient was
ambulating at time of discharge.
ADDITIONAL COMMENTS: - Call office if wound has marked increase in redness , swelling , or
develops purulent drainage. Call for Temps 101.5
- Go directly to ER if develops any stroke symptoms -- paralysis ,
inability to walk , altered change in mental status.
- Do not immerse wound - no tub baths , swimming , or hot tubs. OK to
shower on Saturday night
- Do not drive while taking oxycodone
- Resume all home meds and ensure that patient takes 325 mg aspirin
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-call office to set up follow-up appt.
No dictated summary
ENTERED BY: CROCKET , CHARLESETTA DOT , M.D. , PH.D. ( HE65 ) 8/11/04 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 679
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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376950295 | PUO | 84780901 | | 6573873 | 6/21/2006 12:00:00 a.m. | MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/12/2006 Report Status: Signed
Discharge Date: 1/10/2006
ATTENDING: HARTSELL , DANILLE L. MD
The patient is a 76-year-old male with a history of diabetes ,
hypertension , CAD status post MI in 2000 who presented with an ST
elevation MI to the Emergency Room on 10/13/06. He was brought
to Cath where he was found to have in-stent thrombosis in his LAD
which was aspirated and bare-metal stent was placed in his LAD
and another stent was placed in his diag-2. He had been arrested
multiple times in V-Tach requiring CPR and cardioversion. In the
Cath Lab , he was given bicarb , placed on the epi drip , given
Lasix and was intubated. He was thought to aspirate at the time
of intubation secondary to vomiting. A bedside echo revealed
global hypokinesis with an EF of 35%. He , at that time , was
placed on a balloon pump , dopamine 16 , amio 1 , propofol 1 , and
Integrilin and brought to the floor. On the floor , his blood
pressures were difficult to control and his ??___?? readings
indicated a wedge pressure of 47. His MAPs to keep them over 60
required max dopamine , max Levophed , epinephrine and dobutamine.
His family was aware of his prognosis and was there at the time
of his arrest at 3:30 in the morning. CPR was initiated , and
ACLS was done until the family decided to terminate the ACLS and
the time of death was 3:47 a.m. on 10/13/06. At that time , exam
revealed no breath sounds , no heart sounds , and nonreactive
pupils. The cause of death was thought to be cardiogenic shock
secondary to ST elevation MI.
eScription document: 8-2199247 EMSSten Tel
Dictated By: ALEXIS , LEAH
Attending: HARTSELL , DANILLE L.
Dictation ID 8723980
D: 8/23/06
T: 8/23/06
Document id: 680
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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000012052 | PUO | 18541153 | | 4446633 | 7/28/2006 12:00:00 a.m. | pna | | DIS | Admission Date: 1/16/2006 Report Status:
Discharge Date: 10/10/2006
****** FINAL DISCHARGE ORDERS ******
BACHMAN , LEONIE K. 390-11-18-0
War Scot Derdjo
Service: CAR
DISCHARGE PATIENT ON: 7/10/06 AT 03:00 PM
CONTINGENT UPON Home services
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
AMITRIPTYLINE HCL 30 MG orally BEDTIME
Override Notice: Override added on 7/10/06 by
DUMAY , JAYNE B. , M.D.
on order for LEVOFLOXACIN orally ( ref # 416526652 )
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: ok
NORVASC ( AMLODIPINE ) 10 MG orally DAILY HOLD IF: sbp <90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CRESTOR 40 MG DAILY
Instructions: this is patient's outpatient medication
PROCRIT ( EPOETIN ALFA ) 10 , 000 UNITS subcutaneously Q2WEEKS
Instructions: MMC will instruct patient on teaching and
provide first dose.
FERROUS SULFATE 325 MG orally three times a day
Instructions: at home every day dosing
Food/Drug Interaction Instruction Avoid milk and antacid
PROZAC ( FLUOXETINE HCL ) 40 MG orally DAILY
Override Notice: Override added on 7/10/06 by
DUMAY , JAYNE B. , M.D.
on order for LEVOFLOXACIN orally ( ref # 416526652 )
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
LEVOFLOXACIN Reason for override: ok
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 11/12/06 by
DUMAY , JAYNE B. , M.D.
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
GEMFIBROZIL Reason for override: home med
ASPART ( INSULIN ASPART ) 7 UNITS subcutaneously before meals HOLD IF: if NPO
LANTUS ( INSULIN GLARGINE ) 30 UNITS subcutaneously every afternoon
HOLD IF: 1/2 dose if NPO
IRBESARTAN 375 MG orally DAILY
Number of Doses Required ( approximate ): 8
ISOSORBIDE MONONITRATE ( SR ) 90 MG orally DAILY
HOLD IF: sbp <100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LEVOFLOXACIN 750 MG orally every 48 hours X 7 doses
Starting Today ( 1/12 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 7/10/06 by
DUMAY , JAYNE B. , M.D.
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
LEVOFLOXACIN Reason for override: ok
ATIVAN ( LORAZEPAM ) 0.5-1 MG orally every 6 hours as needed Anxiety
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
HOLD IF: if >2 bm
ATENOLOL 100 MG orally DAILY
VICODIN ( HYDROCODONE 5 MG + APAP 500MG ) 1 TAB orally every 4 hours
as needed Pain
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Sasnett : call for appointment ,
Dr. Mandry : renal , call for appointment ,
ALLERGY: ORPHENADRINE CITRATE ,
ANGIOTENSIN CONVERTING ENZYME INHIBITOR
ADMIT DIAGNOSIS:
sob
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pna
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
?CARDIOMYOPATHY EF=39%( 1989 HTN
SEVERE HYPERCHOL/HYPER TG POORLY CONTROLLED DM history of
CHOLE/APPY/TAH DIFFUSE ABDOMINAL PAIN ELEVATED
LIPASE ALLG: SULFA/AMOXICILLIN
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: sob , jaw pain
HPI: 67F , history of CAD history of RCA PTCA x 2 in 1994 with a recent MIBI 1/13
notable for reversible defect in mid/basal inferior wall ( PDA
territory ) , hypercholesterolemia , htn , CRI , obesity , and smoking , p/with
chest pain and ARF on CRI. Has 6 month history of increasing sob , now at rest ,
new orthopnea and pnd. No chest pain but frequent 4-5 x/day bilateral
jaw pain relieved with 3 slng each. Went to cardiology 8/5 and noted
more prominant st dep/twi laterally. Direct admit for ischemia workup with
possible cath pending renal fx. Last echo EF 60%. On ROS: denies any
fever , cough , URI sx.
PMH:
CAD: RCA PCA x 2 1994. small rev PDA territory defect 1/13
HTN
DM
Hypercholesterolemia
CRI baseline 2.9 4/6 LBP
Crhonic Pain Depression
Former smoker
----
STUDIES: ECG:sb at 56. 1st AVB. TWI with ST dep laterally i ,
ii , L , V2-6. CXR: hilar prominance. RLL opa ? pna.
Chest CT: multiple righ lobe consolidations thought to be most
consistent with pna. Repeat MIBI: mild myocardial ischemia in PDA , fairly
unchanged from 1/13 prior.
---- C
Status: AF. HR50s BP 144/86 98% RA. TAB. ---
Impression: Pneumonia. Stable PDA territory ischemia per MIBI. CRI.
PLAN:
1. CV:
I: Enzymes negative x 3 with no changes in ECG. Repeat MIBI showed
stable PDA territory reversible ischemia. Decision made not to cath
given CRI , stable MIBI , and no unstable angina per symptoms.
Discharged on asa , isosorbide , norvasc , statin , irbestartan , beta blocker
and gemfibrizide.
P: euvolemic. Resume home dose lasix 40 orally every day
R: SR with first degree AVB , no events on telemetry.
Other : CUS: difficult to assess right side due to neck habitus but prox
ICA 0-25% plaque. Left side clean. VNA to do blood pressure , heart rate checks until seen by
primary care physician.
2. Renal: Creatinine stable at 2.8. Will start procrit as CKD with
anemia. On iron. patient to get procrit teachign by Daniella Woeste at MMC
463 663 1153. To f/u with outpatient renal doctor Gaylene Faniel
3. HEME: Admit hct 27 , recieved 1 u , with HCT 29.7. Iron 108 , TIBC , b12 ,
folate normal levels. To get procrit as described above. Have HCT checked
by primary care physician in 1 week.
4. ENDO: Resume home dose insulin: lantus 30 every day , April before meals. stools ,
anemia lab with u pending. HCT 27.
5. ID/Pulm: Chest CT showed R pneumonia likely community acquired , no
prior CT for comparison. Clinically patient was afebrile , wbc 10K.
Discharged on levofloxacin 750 every other day x 7 doses with instructions for primary care physician to
f/u with repeat Chest ct in several months. primary care physician to follow qtc given
levofloxacin.
ADDITIONAL COMMENTS: Resume all home medications.
In addition you need to be on procrit which your primary care doctor will
provide. They will call you for your first dose which will be given at
the clinic.
Take levofloxacin 750 every other day for 7 doses.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Take levofloxacin for 7 doses for pneumonia. Have your QT checked at
primary care physician.
2. Will need procrit from primary care physician: arranged through MMC Daniella Woeste
3. Have your HCT checked next week at MMC
No dictated summary
ENTERED BY: DUMAY , JAYNE B. , M.D. ( UW216 ) 7/10/06 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 681
| Target |
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CHF |
Dp |
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GER |
Gou |
HC |
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OSA |
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784490540 | PUO | 21871093 | | 9010793 | 3/21/2004 12:00:00 a.m. | Sigmoid stricture | Signed | DIS | Admission Date: 3/21/2004 Report Status: Signed
Discharge Date: 6/3/2004
ATTENDING: LOVELLA CIVALE MD
SERVICE:
Toaud Hospital Service.
PRINCIPAL DIAGNOSIS:
Colonic stricture status post sigmoid colectomy.
LIST OF PROBLEMS AND OTHER DIAGNOSES:
1. History of diverticulitis.
2. History of questionable inflammatory bowel disease.
3. GERD.
4. Depression and chronic pain.
5. History of breast cancer.
PAST SURGICAL HISTORY:
1. Sigmoid colectomy in 2003.
2. Right breast lumpectomy in 1998.
3. Multiple Port-a-Cath placements.
4. Right axillary lymph node dissection in 1998.
5. History of endoscopy.
HOSPITAL COURSE:
This is a 41-year-old female with a history of diverticulitis and
questionable inflammatory bowel disease with a known colonic
stricture since 4/5 The patient has had attempted to dilatation
without success. The patient has also recent history
of ribbon like stools and complains of difficulty with bladder
function as well as a sense of urgency to urinate. Her past
medical history is significant for diverticulitis , questionable
inflammatory bowel disease , GERD , depression , chronic pain , and
history of breast cancer. Her surgical history is significant
for sigmoid colectomy in 2003 , right breast lumpectomy , axillary
lymph node dissection in 1998 , as well as multiple Port-a-Cath
placements , and endoscopic treatment. She was admitted on
7/20/04 and taken to the OR for a sigmoid colectomy; the procedure
was complicated by a left ureteral injury for which Urology was
consulted intraoperatively. Urology placed a left ureteral stent
intraoperatively and made recommendations to maintain stent for a
total of six weeks after which time it would be removed on an
outpatient basis ( Dr. Cridge will be following this case ). In
addition , they recommended maintaining Foley for five days. The
EBL during the case was 2500 cc necessitating transfusion of 4
units of packed red blood cells. She was extubated and taken to
the PACU in stable condition with an epidural in place on
perioperative antibiotics of clindamycin and with NG tube in
place. On
postoperative day #1 , it was noted that the patient was
increasingly becoming confused and anxious as well as remained
tachycardic despite what was thought to be adequate volume
resuscitation and she was transferred to the unit at this point.
More specifically , in addition to being tachycardic later that
day on postoperative day #1 , she became tachypneic with noted
hypoxemia and mental status changes in need of intubation. Of
note , the patient was saturating at 96% on 100% oxygen via
facemask. It is also notable that the patient in the 24-hour
perioperative window received 14-liter of fluid resuscitation.
The night of postoperative day #1 , as mentioned earlier , the
patient was increasingly agitated before she was transferred to
the unit and although discontinued her NG tube it was thought at
this time that she may have aspirated. She also removed her
supplemental oxygen and was noted to have saturations in the 85%
range with tachycardia in the 140 range. A PE protocol CT was
obtained that was negative for emboli or DVT but was positive for
right upper lobe posterior segment consolidation that was
consistent with an aspiration event. She was subsequently
transferred on the night of postoperative day #1 to the ICU ,
intubated , and had a right IJ central line placed. Overnight ,
between postoperative day #1 and postoperative day #2 , her blood
pressure would drop requiring multiple fluid boluses in addition
to the administration of an additional unit of packed red blood
cells for a hematocrit of 23. She also received albumin. Of
note , the CT also did not reveal any evidence of acute bleed;
however , this was a noncontrast study. She was placed on Versed
and propofol , intubated in the unit with a fentanyl patch ,
remained tachycardic , the origin of which was unclear. It was
thought initially that there was some type of narcotic control
that may be responsible for this tachycardia. However , it was
also speculated that she may be bleeding from an unknown source.
She was intubated , NPO , NG tube in place with intravenous fluid
resuscitation , Foley in place per Urology as noted above , on subcutaneously
heparin with close monitoring of the hematocrit with transfusions
to be given as necessary placed on a triple regimen of
clindamycin , levo , and Flagyl. On postoperative day #3 , the
patient in the unit with hypertension , anemia , tachycardia , the
patient's hematocrit was still 23 and she received 2 additional
units of red blood cells and hematocrit rose to 30 at this time.
She was poorly responsive on postoperative day #3 and it was
thought that she had better be weaned off of Versed which
happened to be replaced with haloperidol. In addition , clonidine
was added to her regimen as well as Lopressor secondary to her
tachycardia. There was close examination of her mental status
during this time. On postoperative day #4 , the patient was still
persistently tachycardic and hypertensive. JP was discontinued
on the day and , in addition , as noted above , Haldol and clonidine
were added to her regimen. She continued to be agitated and
there was a question raised then that there was an unclear
history that was not previously diagnosed of alcoholism and this
may have been an alcohol withdrawal phenomenon. So , her Versed
actually was increased then for a questionable alcohol withdrawal
and she was given multivitamins , thiamine and folate and in
addition for her hypertension Lopressor 5 every 4 was continued. She
was still intubated with goals of weaning off ventilation , NPO ,
NG tube to low suction , the question of TPN was raised , levo and
Flagyl for aspiration pneumonia which would be continued for
10-14 days. By postoperative day #5 , it was clear that this was
a problem of drug or alcohol withdrawal at least that was what
was thought. Her neuro regimen was changing at this time with
various measures using Versed , then using Ativan , and Apresodex
to changing her fentanyl regimen as well as adding morphine to
her regimen as needed all with goals of increasing the general
relaxation. Psych was consulted on postoperative day #5 and
concluded that this woman had a history of polysubstance abuse ,
alcohol and likely opiates , and chronic abdominal pain due to
stricture which probably was related to her opioid abuse; I
believe the delirium was likely multifactorial in etiology ,
postoperative delirium that was notable for significant fluid
shifts , there was the question of aspiration pneumonia in
addition to possible opiate and alcohol withdrawal. They
recommended starting with Zyprexa if the patient was sedated in
the a.m. with a DC a.m. dose of Zyprexa and just use it in the
evening and agreed to taper off the Versed minimizing the use of
opiates as tolerated by the patient and encouraged the family to
reorient the patient to keep her awake during the day. On
postoperative day #6 , her mental status was gradually clearing.
Patient goal was to wean off sedation for a possible extubation.
Her blood pressure as well as heart rate were stabilizing and
tube feeds were also started at this point with multivitamins and
mineral replacement. In addition , urine output continued to be
good. Her hematocrit was stable. Her cultures were at this
point negative , but the antibiotic Flagyl-levo regimen was
continued. Of note , her stoma would gradually start to produce
fluid and her incision during this leg of her course remained
clean , dry , and intact. On postoperative day #6 , she was also
consulted by Addiction Psychiatry who concluded similar results
to recommendations concluded earlier. They would agree with the
Zyprexa and also recommended restarting Ativan , as I said ,
additionally agreeing with the taper off of the Versed with the
use of Ativan only for cases of agitation and additionally
recommended to the discontinue the Celexa and BuSpar the patient
was on until the delirium cleared to avoid a polypharmacy. Of
note , Psyche was able to speak with the husband who confirmed the
patient's longstanding history of alcohol dependence that likely
predated the 10 years that he had known her. It is important to
note that the patient was consuming approximately a quart of
Vodka a day as well as Peppermint Schnapps daily up until her
surgery last April . After that procedure , she continued to
drink presumably about 3 beers a day. However , the husband since
he was working so much was unable to really adequately guage just
how much alcohol she was drinking. In addition , she was noted to
have , this is per the husband , undergone multiple detoxes at
treatment facilities for alcohol dependence and believed that she
had experience withdrawal seizures in the past. On postoperative
day #7 , the patient's mental status was gradually improving with
weaning off of her Versed with intravenous Ativan and low doses as
tolerated and as needed She , in addition , this day was tolerating
her tube feeds; however , she did pull her NG tube again. Her Foley
was taken out at this time. The ureteral injury believed to be
resolved at this point , continued on her levo and Flagyl with
question of whether or not to stop her antibiotic regimen. On
postoperative day #8 , mental status continued to improve and she
was started on sips which she tolerated well. Her intravenous was hep
locked and she was seen fit to be transferred to the floor. Of
note , also on postoperative day #8 , the patient had some low
blood pressure which was treated with volume resuscitation in the
form of normal saline boluses that stabilized right after her
transfer to the floor. On postoperative day #9 , it was noted
that the patient had some red stool in the ostomy bag. The
patient was hemodynamically stable this was afternoon of
postoperative day #9. Her labs were checked , CBC , and found to
be within normal limits and her ibuprofen which she was taking
was discontinued. On postoperative day #10 , with mental status
improving greatly , the patient had her central line discontinued.
Over the last couple of days , she had made attempts to walk and
was walking with physical therapy. Her diet over the last couple of days had
been advanced without any problems and she was converted to a
house diet on postoperative day #10. On postoperative day #11 ,
her mental status seemingly completely resolved on regular diet ,
out of bed. It was noted though that she had some erythema of
the mid portion of her wound , three staples were removed from
this portion of the wound and serosanguinous exudate was
expressed , minimal amount of fluid. The wound was explored and
there was found to be no fascial defect. Cultures were taken at
this time and the wound was packed with wet-to-dry dressing with
instructions given to the patient and nursing for wet-to-dry
dressing changes three times a day On postoperative day #11 , the patient
was seen fit to be discharged home. Her mental status had
completely resolved. She was afebrile and hemodynamically
stable , tolerating a regular diet , and fully ambulatory. She was
to be discharged home with VNA Services. Medicine Team that had
been seeing her did agree that she needed to contact her
psychiatrist to provide an update of the current admission to
update her on her medical regimen inhouse and she is to schedule
an appointment to follow up with her psychiatrist. The Medicine
Team also recommended continuing her psyche medications she was
taking prior to admission that includes Celexa 4 mg every day , BuSpar
10 mg three times a day , nortriptyline will be started by her psychiatrist.
Also recommended to continue Ativan taper as followed with 1 mg
three times a day today , 1 mg twice a day the next day which would have been
5/29 , and then 1 mg every day before noon on Wednesday 6/26, and then stop
taking the Ativan with instructions of no refills on the Ativan.
The Medicine Team also strongly enforced , reminded her not to
drink while taking the Ativan.
ALLERGIES AND MEDICINE REACTIONS:
intravenous Keflex gives her a rash.
OPERATIONS AND PROCEDURES:
On 7/20/04 , the patient received a sigmoid colectomy , a
diverting ostomy.
HOSPITAL COURSE BY PROBLEM:
See HPI.
COMPLICATIONS:
1. Intraoperative complication of left ureteral injury.
2. Alcohol opiate withdrawal.
DISCHARGE MEDICATIONS:
BuSpar 10 mg orally three times a day , fentanyl patch 100 mcg/h. and topical
every 72 hours , folic acid 1 mg orally every day , Dilaudid 2-4 mg orally every 4 hours
as needed pain , thiamine , HCl 100 mg orally every day , Celexa 40 mg orally
every day , Ativan with a tapered dose of 1 mg orally twice a day to be
tapered on the following day to 1 mg orally every day and then on day #3
to just 1 mg in the a.m. , Protonix 40 mg orally every day , Neurontin 600
mg orally three times a day , and clonodine 0.2 mg orally every weekly.
DISPOSITION:
Home with VNA Services.
eScription document: 1-6943513 EMSSten Tel
Dictated By: MCRORIE , DENISHA
Attending: CIVALE , LOVELLA
Dictation ID 3070207
D: 3/18/04
T: 2/5/04
Document id: 682
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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392986061 | PUO | 09031082 | | 2863060 | 10/22/2006 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 2/17/2006 Report Status: Unsigned
Discharge Date:
ATTENDING: GABHART , DORTHY M.D.
SERVICE: General Medicine Pauler
ADMIT DIAGNOSIS: DKA and uremia.
OTHER DIAGNOSES: Hypertension , diabetes , end-stage renal
failure , history of polysubstance abuse.
OPERATIONS AND PROCEDURES: The patient was intubated on 10/14/06
and also underwent an extubation 5/7/06. The patient had
removal of his right IJ tunneled catheter.
OTHER TREATMENTS AND PROCEDURES: An MRI and multiple
hemodialysis.
HISTORY OF PRESENT ILLNESS: Mr. Merles is a 53-year-old man with
end-stage renal disease on hemodialysis , also past medical
history of diabetes type 1 , hypertension , hepatitis C , alcohol
and polysubstance abuse who was found unconscious on 10/14/06
with a blood pressure of 140/80 , heart rate in the 80's and
satting in the mid 90's and a glucose of 320.
REVIEW OF SYSTEMS: Upon finding Mr. Merles it was notable of the
fact that he had missed hemodialysis the previous week. He was
intubated for airway protection. A head CT was normal on his
arrival to the hospital and his potassium of 6.9 was treated with
calcium , insulin bicarbonate and glucose. He received
Vancomycin , levofloxacin and Flagyl. He was admitted to the
Medical ICU. In the Medical ICU the metabolic acidosis was
thought to be secondary to diabetic ketoacidosis combined with
uremia. A tox screen was negative. An EEG showed diffuse
slowing. The patient was reinitiated on hemodialysis. Sputum
from his lungs grew out serratia that was pan sensitive and the
patient was put on Vancomycin and Ceftaz after spiking fevers.
His right internal jugular tunneled catheter was removed even
though his fistula was partly infiltrated. The patient was
extubated on 8/7/06 , his mental status improved , and the
patient was sent to the floor.
eScription document: 4-5309005 DBSSten Tel
Dictated By: EISENHAVER , KAREN
Attending: GABHART , DORTHY
Dictation ID 3318592
D: 6/13/06
June
Document id: 683
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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Obe |
OSA |
PVD |
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461171537 | PUO | 89762298 | | 2266652 | 9/20/2005 12:00:00 a.m. | hereditary angioedema | | DIS | Admission Date: 10/13/2005 Report Status:
Discharge Date: 10/6/2005
****** DISCHARGE ORDERS ******
BLANN , GLENNA A. 009-06-32-4
Ville Room: Poring
Service: MED
DISCHARGE PATIENT ON: 9/15/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GILFOY , DEANDRA LAZARO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
VIT C ( ASCORBIC ACID ) 500 MG orally twice a day
ATENOLOL 75 MG orally every day HOLD IF: sbp<100 , heart rate<60
DIGOXIN 0.125 MG orally every other day Instructions: Sun , Tues , Thurs
Override Notice: Override added on 10/22/05 by
MUNDWILLER , MORA H. , M.D.
on order for SYNTHROID orally ( ref # 88144153 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: will monitor
DIGOXIN 0.1875 MG orally every other day Instructions: On M , W , F , Sat
Alert overridden: Override added on 10/22/05 by
MUNDWILLER , MORA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: will monitor
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
PEPCID ( FAMOTIDINE ) 20 MG orally every day
Instructions: therapeutic interchange
LASIX ( FUROSEMIDE ) 20 MG orally every day
Alert overridden: Override added on 10/22/05 by
MUNDWILLER , MORA H. , M.D.
on order for LASIX orally ( ref # 01606876 )
patient has a POSSIBLE allergy to Sulfa; reaction is RASH.
Reason for override: tolerates at home
SYNTHROID ( LEVOTHYROXINE SODIUM ) 50 MCG orally every day
Override Notice: Override added on 10/22/05 by
MUNDWILLER , MORA H. , M.D.
on order for DIGOXIN orally ( ref # 38708275 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: will monitor
Previous override information:
Override added on 10/22/05 by MUNDWILLER , MORA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: will monitor
SENNA TABLETS 2 TAB orally twice a day as needed Constipation
STANOZOLOL 4 MG orally every day Starting IN a.m. ( 11/29 )
VIT E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
KEFLEX ( CEPHALEXIN ) 500 MG orally four times a day X 28 doses
Starting Today ( 6/11 )
Alert overridden: Override added on 10/22/05 by
MUNDWILLER , MORA H. , M.D.
on order for KEFLEX orally ( ref # 68155828 )
patient has a POSSIBLE allergy to Penicillins; reaction is
RASH. Reason for override: patient has tolerated in past ok
RHINOCORT ( BUDESONIDE NASAL INHALER ) 2 SPRAY nasal twice a day
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Aspacio 1-2 weeks ,
Dr. Rolson or Dr. Biggins 1-2 weeks ,
ALLERGY: intravenous Contrast , Sulfa , Penicillins , QUINIDINE SULFATE ,
LEVOFLOXACIN , LISINOPRIL , NITROFURANTOIN , STANAZOL ,
PROCAINE HCL , Dairy Products , WHEAT/GLUTEN ,
NITROFURANTOIN MACROCRYSTAL
ADMIT DIAGNOSIS:
hereditary angioedema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hereditary angioedema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HEREDITARY ANGIOEDEMA AFIB - lodose Coum/ASA HYPOTHY
history of SUBDURAL ON COUM history of APPY , TAH tracheostomies x
3 multiple intubations DVT , ivc filter in place GERD polycythemia
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
83 year-old F with hereditary angioedema presents with
abdominal pain. patient had URI one week ago , which resolved , but then
woke up on day of admission with severe abd pain. patient has had multiple
admits in past for GI sx 2/2 hereditary angioedema ,
and pain on day of admit same as these episodes.
Was not relieved by stanazolol. Also had
diarrhea , N/V , sweats and decreased POs. Admitted for
FFP rx , which usually resolves her
sx. Baseline PE: 98.1 85 94/80 20 94%
RA Very distended , tender abdomen and decreased
bowel sounds
Impression: Hereditary angioedema flare with GI manifestations
HOSPITAL COURSE: ALLERGY: The patient received 6 units FFP with
premedication with intravenous Benadryl on the first night of her
hospitalization. She was also given Stanazolol 4 mg every 4 hours overnight , wh
ich was changed to twice a day on the second hospital day. She was continued
on her outpatient dose of rhinocort and allegra PAIN: The
patient's pain was controlled with Dilaudid. CV: The patient was c
ontinued on her home cardiac meds , no changes ENDO: The patient was
continued on her home dose of synthroid for hypothyroid GI: The
patient was maintained on Zantac and Stanazolol. PPX: Lovenox FULL
CODE
The patient was discharged with instructions to follow up with allergy.
ADDITIONAL COMMENTS: Please call your doctor right away if you develop fevers , worsening of
your abdominal pain , or other concerning symptoms.
Please call Dr. Aspacio and Dr. Rolson 's offices tomorrow to make follow u
p appointments for 1-2 weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MUNDWILLER , MORA H. , M.D. ( HF693 ) 9/15/05 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 684
| Target |
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CHF |
Dp |
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GER |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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620524588 | PUO | 97359826 | | 7181693 | 6/17/2006 12:00:00 a.m. | history of Lt THA | | DIS | Admission Date: 11/19/2006 Report Status:
Discharge Date: 2/25/2006
****** FINAL DISCHARGE ORDERS ******
SCHNEEKLOTH , LAVONNA 333-46-87-7
Ra Ce Room: Dilumra Dale Ster
Service: ORT
DISCHARGE PATIENT ON: 6/28/06 AT 11:00 a.m.
CONTINGENT UPON Cleared by physical therapy
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
Starting Today ( 5/29 ) as needed Pain
Instructions: Do not exceed 4000mg in 24 hours
BACLOFEN 20 MG orally four times a day
FIORICET ( BUTALBITAL+APAP+CAFFEINE ) 2 TAB orally every 6 hours
as needed Headache
Override Notice: Override added on 10/22/06 by
CASSA , MARITZA R. , M.D.
on order for COUMADIN orally ( ref # 701786646 )
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
Reason for override: every day inr Previous override information:
Override added on 7/26/06 by CASSA , MARITZA R. , M.D.
on order for COUMADIN orally 3 MG x1 ( ref # 620635771 )
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
Reason for override: wm Previous override information:
Override added on 5/4/06 by CASSA , MARITZA R. , M.D.
on order for COUMADIN orally 3 MG x1 ( ref # 996297324 )
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
Reason for override: wm Previous override information:
Override added on 5/27/06 by CASSA , MARITZA R. , M.D.
on order for COUMADIN orally 2 MG every afternoon ( ref # 916085073 )
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
Reason for override: wm Previous override information:
Override added on 5/27/06 by CASSA , MARITZA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & BUTALBITAL
Reason for override: wm
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
GLIPIZIDE XL 10 MG orally DAILY Starting IN a.m. ( 2/24 )
LISINOPRIL 5 MG orally DAILY
METFORMIN 1 , 000 MG orally twice a day
METHADONE 40 MG orally 5x daily Starting Today ( 5/29 )
Instructions: #70 40mg tablets dispensed
METHADONE 5 MG orally every 6 hours Starting Today ( 5/29 ) as needed Pain
Instructions: #60 5mg tablets dispensed
MVI ( MULTIVITAMINS ) 1 TAB orally DAILY
COUMADIN ( WARFARIN SODIUM ) 2.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Or as directed by the Anticoagulation Service
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/22/06 by
CASSA , MARITZA R. , M.D.
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: BUTALBITAL & WARFARIN
Reason for override: every day inr
DIET: No Restrictions
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr Gaylene Faniel 6/8/06 Xray at 9:15am Appt at 10:15am 11/5/06 scheduled ,
Arrange INR to be drawn on 8/26/06 with f/u INR's to be drawn every
Mon/Thurs days. INR's will be followed by PUO Anticoagulation Service
ALLERGY: PROCHLORPERAZINE
ADMIT DIAGNOSIS:
Osteoarthritis Lt Hip
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of Lt THA
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Legg-Calve-Perthes Disease , Diabetes Mellitus , Anemia , history of
Parathyroidectomy , Migraine Headaches , history of Cellulitis Lt Leg ,
Hypercalcemia
OPERATIONS AND PROCEDURES:
5/27/06 FANIEL , GAYLENE , M.D.
LT.TOTAL HIP REPLACWEMENT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Transfusion PRBC x 2 units
BRIEF RESUME OF HOSPITAL COURSE:
Patient has hx of Legg-Calve-Perthes disease history of chiari osteotomy
complicated by septic arthritis x 2. Recent radiographic studies
revealed end stage osteoarthritis of L hip with cystic changes noted in
femoral head. patient was taken to the OR on 9/22/06 for Lt total hip
replacement. The patient tolerated the procedure well , and there were no
complications. Routine peri-op intravenous antibiotics were given. Acute pain
management with PCA until POD2 , when the patient transitioned to orally pain
medications. Patient steadily with daily physical therapy. Patient was
made PWB ( 50% ) on LLE with functional abduction only , and posterior hip
dislocation precautions. The dressing was changed on POD2 and on discharge
the incision was clean/dry/intact with no erythema. HCT was noted to be 23
on POD#1 and patient received transfusion of 2 units PRBC. Upon discharge ,
the patient was afebrile with stable vital signs and intact neurovascular
status in the operative extremity. Coumadin/TEDs/pneumoboots for DVT
prophylaxis. INR was 2.0 on the day of discharge and should receive 2.5
mg of coumadin on the evening of discharge.
ADDITIONAL COMMENTS: Call or return to ER for fever >101.5 , increased redness , swelling or
discharge from incision , chest pain , shortness of breath , or anything
else that is troubling you. OK to shower but do not soak incision in
tub/pools/etc. for at least two weeks. Partial weight bearing ( 50% ) LLE ,
functional abduction as per physical therapy page 3 until cleared at follow-up.
Posterior hip dislocation precautions. Do not drive or drink alcohol
while taking narcotic pain medications. Resume all home medications.
Follow-up as scheduled with surgeon. Follow-up with your primary care
physician within one month for reassessment of home medications post
surgery. Coumadin x 4 weeks. Goal INR 1.5-2.5. Please call or fax
results to PUO anticoagulation service at 689-1096 f1 . Blood draws for
physical therapy/INR the day after discharge , then every Mon/Thurs. Any outpatient
anticoagulation issues , or action values should be called to the
Anticoagulation Service. Suture removal as of 2/4/06 , by VNA. Contact
your primary care physician for pain medication renewals.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Blood draws for physical therapy/INR the day after discharge , then every Mon/Thurs with
results called to 765-060-3001 jys 9 for outpatient
anticoagulation management
Suture Removal 2/4/06
Home services for nursing/wound assessment , physical therapy , & phlebotomy
Follow up with Dr Aspen as scheduled
Contact your primary care physician for medication refills
No dictated summary
ENTERED BY: SCOVEL , DULCIE , PA-C ( XP60 ) 6/28/06 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 685
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
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Y |
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U |
U |
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| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
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N |
705817406 | PUO | 72914456 | | 3616127 | 3/8/2004 12:00:00 a.m. | Angina , sp elective PCI to LAD | | DIS | Admission Date: 6/9/2004 Report Status:
Discharge Date: 7/10/2004
****** DISCHARGE ORDERS ******
RODRIGUES , MARYROSE 624-72-45-1
Di S Ston Room: Leigh Co Scot
Service: CAR
DISCHARGE PATIENT ON: 7/22/04 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TYACKE , MACKENZIE , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Shortness of Breath
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
GLYBURIDE 5 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOVENT ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
FLONASE ( FLUTICASONE NASAL SPRAY ) 1-2 SPRAY inhaled every day
Number of Doses Required ( approximate ): 5
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
GLUCOPHAGE ( METFORMIN ) 1 , 000 MG orally twice a day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Tyacke 4 wk ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
history of cath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Angina , sp elective PCI to LAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM ( diabetes mellitus ) HTN ( hypertension )
hyperchol ( elevated cholesterol ) CAD ( coronary artery disease )
OPERATIONS AND PROCEDURES:
PCI with cypher stents x2 to two discrete LAD lesions , please see full
cath report for details
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
54yo admitted for elective cath , sp PCI x2 to LAD.
patient with HTN , hyperchol and DM to primary care physician with 6wk angina , ETT showed rev
isch in LAD. Cath this a.m. showed diffuse LAD disease without sig
lesions in other territories. patient got two cypher stents
to two prox LAD lesions. Tolerated procedure
well , and had good rediographic
results. EXG: NSR without
isch/infartion Exam: JVP flat , lungs clear , RRR with
s4s1s2
Hospital course
Angiography revealed several LAD lesions with two potential cultprits
in the proximal portion. These were both stenteed with cypher stents
with good radiographic results. He was able to ambulate pain free on
d/c. He sould f/u with Dr. Tyacke in 1-2wk , and remain on ASA and
planvix indefinitley.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: HIENS , FLORANCE MELANY , M.D. , PH.D. ( AV136 ) 7/22/04 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 686
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
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| output/system_textual_annotation.xml | textual |
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054171831 | PUO | 17914981 | | 202187 | 8/29/2001 12:00:00 a.m. | GERD | | DIS | Admission Date: 9/9/2001 Report Status:
Discharge Date: 5/2/2001
****** DISCHARGE ORDERS ******
OELZE , MARCHELLE 868-80-82-8
Co Ve Room: Seatmin Grovewestham
Service: MED
DISCHARGE PATIENT ON: 3/3/01 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: AABY , WALDO OPHELIA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
GEMFIBROZIL 600 MG orally twice a day
Override Notice: Override added on 3/23/01 by
SIX , ETTA E. , M.D. , PH.D.
on order for ZOCOR orally ( ref # 63659750 )
SERIOUS INTERACTION: GEMFIBROZIL & SIMVASTATIN
Reason for override: patient req
GLYBURIDE 10 MG orally twice a day
MAALOX PLUS EXTRA STRENGTH 15 ML orally every 6 hours as needed Indigestion
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 3/23/01 by
SIX , ETTA E. , M.D. , PH.D.
SERIOUS INTERACTION: GEMFIBROZIL & SIMVASTATIN
Reason for override: patient req
AVANDIA ( ROSIGLITAZONE ) 4 MG orally twice a day
OCUFLOX ( OFLOXACIN 0.3% OPH SOLUTION ) 1 DROP OS four times a day
Number of Doses Required ( approximate ): 4
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
GLUCOPHAGE ( METFORMIN ) 1 , 000 MG orally twice a day
ALTACE ( RAMIPRIL ) 2.5 MG orally every day
Alert overridden: Override added on 3/3/01 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL Reason for override: aware
LOVENOX ( ENOXAPARIN ) 40 MG subcutaneously every 12 hours X 14 Days
Starting Today ( 10/21 )
LOVENOX ( ENOXAPARIN ) 40 MG subcutaneously every day X 90 Days
Starting 2 WEEKS
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Carlton Abshear 1 week ,
Dr. Violet Greigo 4/26/01 scheduled ,
ALLERGY: Procardia ( nifedipine ( immed. release ) ) , Isordil ,
Benadryl ( diphenhydramine hcl )
ADMIT DIAGNOSIS:
abdominal pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
GERD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , NIDDM , Hypercholesterolemia , history of DVT/PE , history of RLL pneumonia , GERD ,
cva ( cerebrovascular accident ) , cabg ( cardiac bypass graft surgery )
pvd ( peripheral vascular disease )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
This is a 63 year old M with history of CAD , MI , history of CABGx4 , history of PE , history of CVA
on coumadin , NIDDM and history of recent pneumonia ( 4/25 ) who now presents
with intermittent epigastric pain associated with nausea , diaphoresis
and SOB x 2 days which he notes is his anginal equivalent. He
denied any associated CP , fevers/chills/sweats ,
diarrhea/constipation. Exam was notable only for mild epigastric
tenderness. Labs were notable for Na 133 and Cr 1.7 , negative
tropnin ( 0.00 ) and CK 53 , LFTs normal. RUQ ultrasound was notable for
normal gall bladder with a fatty liver and gallstones and no
sonographic Murphy's. ECG showed NSR at 80 with flat T in I and
flipped T waves in 2 , 3 ( all old ) and new T wave inversions V5/V6. V/Q
scan was intermediate probability likely secondary to recent pne
umonia , but d-dimer 800. patient had +LENI's. Given his history of CVA on
anticoagulation , Dr. Cser was consulted and reccomended
starting the patient on reduced dose lovenox ( 50mg subcutaneously twice a day x 2 wk and
40mg subcutaneously x 3 mo ). Checked heparin level ( 0.9 ) so reduced dose of
lovenox to lovenox 40mg subcutaneously twice a day LENIS to be repeated in 3 months prior
to d/c
lovenox. MI and was ruled out. He underwent adenosine-MIBI which was
without change vs his dobutamine-MIBI '00. He was felt to have mild
gastritis/GERD and was discharged on his regular medications as well as
Prilosec 20 twice a day and Lovenox as above. He was discharged in stable
condition and will follow-up with Dr. Carlton Abshear and his primary care
doctor.
ADDITIONAL COMMENTS: 1. Please set up a follow-up appointment with your primary care doctor
within 1-2 weeks for re-assessment of GI distress.
2. Follow-up with Dr. Carlton Abshear within 1 week.
3. Take lovenox as directed.
4. Please return to the emergency department with worsening symptoms or
new fevers/chills/sweats , chest pain , difficulty breathing.
5. VNA for lovenox teaching/compliance. Medication compliance.
6. VNA to draw serum potassium 11/3 and send result into Dr. Carlton Abshear
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Continue home meds.
2. VNA for assistance with Lovenox and meds.
3. Lovenox as directed.
4. Follow-up LENIS in 3 months before d/c lovenox.
5. Follow-up with Dr. Carlton Abshear AND pcp.
No dictated summary
ENTERED BY: SIX , ETTA E. , M.D. , PH.D. ( SW3 ) 3/3/01 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 687
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
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N |
060907716 | PUO | 56225750 | | 680051 | 11/10/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 6/17/1990 Report Status: Unsigned
Discharge Date: 4/25/1990
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old female
with severe dysmenorrhea and
menorrhagia and fibroids. PAST MEDICAL HISTORY: Asthma. She has
current use of intravenous heroin. PAST OBSTETRICAL HISTORY: Gravida intravenous ,
para III , AB I. Status post three prior ceserean sections.
MEDICATIONS: On admission include Uniphyl , 400 mg orally every bedtime;
Ventolin inhaler , as needed; heroin. ALLERGIES: NO KNOWN DRUG
ALLERGIES.
PHYSICAL EXAMINATION: On admission revealed a well-developed ,
obese female. Uterus was retroverted.
Cul-de-sac was nodular. Small introitus. Premenstrual bloating.
HOSPITAL COURSE: The patient was admitted as a same day surgical
patient on 2/14/90. She underwent a total
abdominal hysterectomy and bilateral salpingo-oophorectomy under
general anesthesia. The findings included a fibroid uterus with
normal ovaries. Estimated blood loss was 600 cc. Postoperatively ,
the patient was placed on an aminophylline drip and treated with
Alupent. She was treated with intramuscular narcotics with her history of intravenous
drug abuse. Postoperative hematocrit was 27.5 down from 28
preoperatively. A Foley was kept in for five postoperative days.
On the fifth postoperative day it was removed and the patient
voided without difficulty. She otherwise did well and was
discharged home on postoperative day number seven. Final pathology
returned chronic cervicitis with squamous metaplasia , proliferative
endometrium , endometrial polyp , multiple leimyomas , negative serosa
and slight paraovarian adhesion.
DISPOSITION: The patient was discharged to home in stable
condition. MEDICATIONS: On discharge included
Percocet ( 30 ); Uniphyl , 400 mg orally every bedtime; Alupent inhaler; iron and
Estraderm patch.
________________________________ IY498/7757
ISAAC BOOKER VAUSE , M.D. D: 1/10/90
Batch: 1453 Report: J5407Q2 T: 9/4/90
Dictated By: ARNULFO MACKLER , M.D. FV7
Document id: 688
| Target |
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DM |
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GER |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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461171537 | PUO | 89762298 | | 028299 | 11/15/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/6/1995 Report Status: Signed
Discharge Date: 8/26/1995
PRINCIPAL DIAGNOSIS: DEEP VENOUS THROMBOSIS
SECONDARY DIAGNOSIS: HEREDITARY ANGIOEDEMA
HISTORY OF PRESENT ILLNESS: This is a 73 year old white female with
hereditary angioedema with recent
abdominal surgery presents with 30 hours of severe abdominal pain
and tightness , typical of her hereditary angioedema attacks. The
patient has had HAE since childhood and recalls having a ring cut
off her finger as a child during an attack. She has had three
tracheostomies , the last one over 20 years ago for laryngeal edema.
Symptoms include throat tightness , difficulty talking and
swallowing and abdominal pain. She often has attacks at local
trauma sites. Over the past several years she has received Human
C1 esterase inhibitor as part of a study conducted at CTMC by Dr.
Zonia Surette She has done very well with these treatments for acute
attacks until recently when she states the inhibitor has stopped
working as well as previously. Dr. Alycia Pitney has told her she
may have an antibody to the inhibitor and her recent events include
4/17 admitted with severe abdominal pain , flare of HAE , apparently
became hypotensive and acidemic and went to laparotomy emergently ,
on pressors without bowel preparation. Colostomy was done for bowel
wall edema and was complicated by postoperative abscess requiring
drainage. One month ago she had her colostomy taken down which has
been complicated by incontinence of stool requiring Depends. At
baseline , C4 is 6-10 , normal being 16-34 , C1 inhibitor 5-9 , normal
being 25-83. On 8/20/95 at 1:30 p.m. she developed the onset of
typical HAE attack with crescendo abdominal pain and throat
tightness. She took extra stanozolol but the abdominal pain
persisted to where it was intolerable and she presented to the EW
with nausea and vomiting. Last bowel movement was 8/20/95 ,
slightly loose , normal urine. In the EW she was given Demerol ,
Solu Medrol , Zantac and Benadryl. PAST MEDICAL HISTORY: Includes
cholecystectomy , appendectomy , hysterectomy for fibroid , but not
bilateral salpingo-oophorectomy. She has a history of renal
calculi , history of abnormal liver function tests , unknown cause ,
history of AF , now controlled with DIG and Verapamil. She is
status post subdural hematoma on Coumadin at therapeutic levels ,
hypothyroid on replacement , history of right deep venous
thrombosis , history of carpal tunnel syndrome , severe
osteoarthritis with cervical spine , lumbosacral spine and right
knee involvement. History of cerebrovascular accident , right
hemiparesis , now at 90% of baseline , left iridectomy , left drop
foot , left thigh numbness and tingling , dizziness and
disequilibrium. FAMILY/SOCIAL HISTORY: She has a son and two
grandchildren with HAE , three daughterse not effected , lives with
husband , daughter , lives upstairs. She uses no tobacco , rare ETOH.
MEDICATIONS: Digoxin .125 mg every day , Verapamil 60 mg twice a day ,
Coumadin 1 mg every day , aspirin 80 mg every day , Synthroid 0.05 mg every day ,
Stanozolol 2 mg every day with increased dose as needed. ALLERGIES:
Quinidine causes nausea; intravenous contrast causes rash; propafenone ,
migraines; penicillin rash; sulfa rash; novocaine throat swelling.
Food allergies are wheat , dairy , chocolate , walnuts and
strawberries.
PHYSICAL EXAMINATION: On admission this is an ill-appearing woman
with a raspy voice. Vital signs , 99.1 , heart
rate 116 in atrial fibrillation , blood pressure 132/84 , respiratory
rate 18. Head and neck examination , normocephalic , atraumatic ,
status post iridectomy on left. The oropharynx is clear , no
stridor. Neck , supple , carotids 2+ , stigmata of old thyroid
tracheostomy. Lungs , clear to auscultation. Heart , irregularly
irregular , tachycardia , I/VI early systolic murmur at left lower
sternal border without radiation. Abdomen , recent midline incision ,
healing , normal bowel sounds , soft but exquisitely tender to
palpation or percussion. There is positive rebound tenderness ,
positive shake tenderness. Rectal , guaiac positive per EW.
Extremities , no clubbing , cyanosis or edema , pulses are 2+
peripherally. She has positive pain to passive motion right knee ,
neck not examined. Neuro , alert and oriented x 3 , cranial nerves
are intact. Motor is 5/5 throughout except left foot without
extension. Sensory , decreased light touch on the left lateral
thigh , deep tendon reflexes 2+ throughout , toes right upgoing , left
downgoing.
LABORATORY DATA: White count 10.2 , hematocrit 41.3 , platelets
377 , sodium 140 , potassium 3.8 , chloride 100 ,
bicarb 30 , BUN 14 , creatinine 1.5 , glucose 140 , liver function
tests normal. physical therapy 13.5 , PTT 24.5. Chest x-ray and KUB without
infiltrates , no free air , no ileus , no obstruction. EKG , atrial
fibrillation at 117 , normal QRS and QT , unchanged from 10/10 , DIG
effect is present.
HOSPITAL COURSE: The patient improved dramatically over the first
day of admission with decreased abdominal pain ,
improving appetite and was started on clear liquids on 3/5/95 late
in the day. Initial treatment included Solu Medrol 125 mg intravenous bolus
in the emergency room and Stanozolol 2 mg four times a day when first sent to
the floor. She also had intravenous Zantac 50 mg q8 for the first three days
of admission. The patient's symptoms continued to improve and diet
was advanced over the next several days. Further concerns on this
hospitalization were whether or not she would ever be a candidate
for further C1 esterase inhibitor replacement , the question being
was her hypotension during the last treatment leading to bowel
surgery caused by the disease itself or as a response to the
inhibitor. As of discharge this question has yet to be settled with
Dr. Tunget The patient developed left pedal edema by 10/6/95 and
although on low dose Coumadin , note is made of past subdurals on
therapeutic Coumadin. The patient had a lower extremity noninvasive
revealing a left leg deep venous thrombosis located at the
bifurcation of the left common and superficial femorals. Given the
patient's complications on Coumadin in the past and risk of
pulmonary embolus , she was sent for filter placement which was done
on 2/14/95. The patient also had the complication of bright red
blood per rectum , she said this happens occasionally at home and on
examination had moderate external hemorrhoids , no sign of recent
bleeding , no internal hemorrhoids , no gross blood on examination.
At this point she had normal coagulation studies and her hematocrit
was 29.8 on 10/26/95. The patient was kept overnight with stable
hematocrit and discharged on 11/7/95.
DISPOSITION: The patient was discharged to home. MEDICATIONS:
Aspirin 81 mg orally every day; Digoxin .125 mg orally every day;
Synthroid 50 micrograms orally every day; Verapamil 60 mg orally three times a day;
Coumadin 1 mg orally every day; Stanozolol 2 mg orally twice a day The patient
will followup by telephone with Dr. Annette Schoultz CONDITION ON
DISCHARGE: Good.
Dictated By: SIOBHAN DICKHAUT , M.D. ME66
Attending: ANNETTE SCHOULTZ , M.D. JW7
FT919/1398
Batch: 4966 Index No. NCJDOBMS6 D: 8/8/95
T: 10/5/95
Document id: 689
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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373092506 | PUO | 66257495 | | 5966977 | 10/7/2006 12:00:00 a.m. | history of panniculectomy | | DIS | Admission Date: 8/30/2006 Report Status:
Discharge Date: 9/28/2006
****** FINAL DISCHARGE ORDERS ******
HAWF , KATE 684-96-57-9
De
Service: PLA
DISCHARGE PATIENT ON: 5/26/06 AT 12:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CARTIER , EARLENE CARLO , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 1 , 000 MG orally every 6 hours
KEFLEX ( CEPHALEXIN ) 500 MG orally four times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally twice a day
DILAUDID ( HYDROMORPHONE HCL ) 2-4 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 2/8/06 by
CADARETTE , MINERVA , M.D.
on order for DILAUDID orally ( ref # 301679877 )
patient has a PROBABLE allergy to Morphine; reaction is GI
Intolerance. Reason for override: will watch
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously every 4 hours Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
Please give at the same time and in addition to standing
mealtime insulin
LEVOTHYROXINE SODIUM 75 MCG orally DAILY
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
METOCLOPRAMIDE HCL 10 MG intravenous every 8 hours as needed Nausea
QUINAPRIL 20 MG orally DAILY
Number of Doses Required ( approximate ): 5
SIMETHICONE 40 MG orally four times a day as needed Upset Stomach , Other:gas
STYKER PAIN PUMP ( BUPIVACAINE 0.5% )
400 MILLILITERS intravenous every 24 hours Instructions: Rate = 4ml/heart rate
Bolus dose = 4ml Lockout interval = 60 minutes
DIET: No Restrictions
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Breanna Caridine 063-025-7685 5-7 days ,
ALLERGY: Morphine
ADMIT DIAGNOSIS:
abdominal laxity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of panniculectomy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
none
OPERATIONS AND PROCEDURES:
2/8/06 CARTIER , EARLENE CARLO , M.D.
PANNICULECTOMY
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Drain care - monitor/record drain output , when less than 30 cc in 24
hours patient may call for appointment for removal. Change drain sponges
daily. Strip drains twice daily.
Wound check every day - DSD to incision if spotting.
BRIEF RESUME OF HOSPITAL COURSE:
56 year-old morbidly obese female with abdominal skin laxity 2/2 massive
weight loss after gastric bypass , admitted to plastics on 6/10/05 for
panniculectomy. patient tolerated all procedures without difficulty. post-op
period has been uneventful. at discharge patient is afebrile with stable
vitals , taking orally's/voiding every shift. has ambulated independently but
with some difficulty given body habitus. pain generally
has been well managed. Incisions are clean , dry and intact. Jp's with
moderate serosanguinous output remain in place. patient is discharged to rehab
in stable condition . instructions given. Services arranged
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Continue your antibiotics as long as you have drain/s in place.
Drain care - monitor/record drain output , when less than 30 cc in 24
hours , call for appointment for removal. Change drain sponges daily.
Strip drains twice daily.
Activity - sponge baths only while drains are in place. Walking as
tolerated. No lifting more than 10 pounds. No jogging , swimming , or
aerobics x 4-6 weeks. Monitor/return for signs of infection which may
include: increased pain , swelling , redness , fever , drainage , problems
with incisions , or other concerns. If you have any questions , please
call Dr. Breanna Caridine 063-025-7685 or Santina Slagel NP at 974 904-1742
pager 89810 or pager 51537.
No dictated summary
ENTERED BY: SLAGEL , SANTINA M. , N.P. ( ) 5/26/06 @ 11:28 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 690
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
Y |
- |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
- |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
- |
- |
N |
N |
N |
- |
Y |
- |
Y |
N |
Y |
- |
N |
- |
N |
767129253 | PUO | 56620872 | | 981149 | 4/15/1999 12:00:00 a.m. | RT. LUNG CARCINOMA | Signed | DIS | Admission Date: 4/15/1999 Report Status: Signed
Discharge Date: 9/9/1999
HISTORY OF PRESENT ILLNESS: Seventy-year-old woman with a
complex past medical history which
includes cerebrovascular accident x two in 1980s without deficits ,
seizure history probably secondary to ETOH withdrawal ( none since
1993 ) , hypertension x 30 years , asthma , gout , status post repair of
subclavian artery stenosis in 1993. The patient presented to the
Pagham University Of on 1/2 with severe chest pain. The
patient ruled out for myocardial infarction but chest x-ray showed
a right lung mass. A chest CT on 2/15 revealed a 2.3 x 2.8 cm
lobulated mass in the right lower lobe involving the pleura. There
were extensive hilar and mediastinal constitutions consistent with
prior granulomatous disease. Tests were positive for multiple
precarinal and right peritracheal areas of adenopathy recent from
metastatic disease.
PAST MEDICAL HISTORY: Cerebrovascular accident x without versus
reversal ischemic neurological deficits in
1987 , history of ETOH withdrawal , B12 deficiency , hypertension ,
gout , E. coli , sepsis in 1990 , status post myocardial infarction
( per M.D. note , the patient denies ) , asthma.
PAST SURGICAL HISTORY: Right total knee replacement in 1982 ,
innominate and left subclavian artery
stenosis - bypassed ( with re-op in 1993 ) , left total knee
replacement in 1994 , ovarian cyst excision.
ALLERGIES: Aspirin causes epistaxis ( this was in combination
with Motrin ).
MEDICATIONS: Adalat 200 mg orally twice a day , Zantac 150 mg orally twice a day ,
Magnesium Oxide 40 mg three times a day , Ultram 300 mg every day ,
Trazodone 100 mg every bedtime , Azmacort 80 mg as needed , aspirin 81 mg every day ,
Dyazide 25 mg every day , nose spray twice a day , calcium chloride pills every day ,
Colchicine 600 mg every day , cyproheptadine hydrochloride 4 mg twice a day
every bedtime , anticholesterol med.
PHYSICAL EXAMINATION: Clinic - Blood pressure 146/78 , pulse 76 ,
respiratory rate 16. In general , the
patient was in no acute distress. Normocephalic , atraumatic. The
patient's emotions were intact. Heart in regular rate and rhythm
with no murmurs , gallops or rubs. Lungs had fine crackles
posterior chest. The bases were clear to auscultation. The
abdomen was obese , soft , non-tender without hepatosplenomegaly. No
costovertebral angle tenderness. Extremities were without
clubbing , cyanosis or edema. The patient was alert and oriented x
three. Non-focal. Speech was fluent.
LABORATORY DATA: White blood cell count 9.03 , hematocrit 38.2 ,
platelets 215. Coagulation status was normal
with INR of 1.2. Sodium of 41 , potassium 3.8 , BUN/creatinine
16/0.8 , glucose 126.
HOSPITAL COURSE: The patient admitted to the Thoracic Surgery
Service on 6/29/99 and taken to the Operating
Room for a video assisted thorascopic right lower lobe lobectomy by
Dr. Speaker The procedure went without complications.
Postoperatively , the patient did well. The chest tube that was
placed intraoperatively did not have a leak. The patient was
followed by the Internal Medicine Service. The patient went into
rapid atrial fibrillation postoperatively. She was placed on a
rule out myocardial infarction and seen by the Cardiology Service.
The patient was successfully converted into a normal sinus rhythm
using Diltiazem intravenous. This was converted to orally Diltiazem. The
patient's postoperative course was largely unremarkable but for
dysrhythmia. She was on no antibiotics. She required diuresis
with Lasix 40 every day for home. The patient's pain was well
controlled with orally pain medications , Percocet.
Final pathology was read as squamous cell carcinoma , 4.0 cm. ,
moderately differentiated with focal characterization with
extensive necrosis. No lymphatic or vascularization was
identified. Tumor abuts but did not invade the pleura.
DISPOSITION: The patient was discharged to home.
FOLLOW-UP: With Thoracic Surgery Service as has been arranged
as well as with primary care physician and Cardiology
as needed.
DISCHARGE MEDICATIONS: Albuterol nebulizers 250 mg every 4 hours ,
Allopurinol 300 mg every day , Colchicine 0.6 mg
every day , cyproheptadine hydrochloride by mouth 400 mg every day , Digoxin
0.125 mg every day , Diltiazem 30 mg three times a day , Colace 100 mg three times a day , Lasix
40 mg orally every day , Percocet 1-2 tablets orally every 4 hours as needed , Dilantin
200 mg orally twice a day , Trazodone 100 mg orally every bedtime
DISCHARGE DIAGNOSIS: SQUAMOUS CELL CARCINOMA OF THE LUNG.
Dictated By:
Attending: DERICK D. YAN , M.D. MR7
QC773/6432
Batch: 18144 Index No. R0RJ5QDER4 D: 3/9/99
T: 5/16/99
Document id: 691
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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OA |
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OSA |
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VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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953868385 | PUO | 00804167 | | 1258378 | 8/13/2003 12:00:00 a.m. | myocardial infarction | | DIS | Admission Date: 10/10/2003 Report Status:
Discharge Date: 9/23/2003
****** DISCHARGE ORDERS ******
MERIWEATHER , AI 734-82-23-4
Georgia
Service: CAR
DISCHARGE PATIENT ON: 6/13/03 AT 12:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VERRY , COLETTA F. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
GLYBURIDE 7.5 MG every day before noon; 2.5 MG every afternoon orally 7.5 MG every day before noon
2.5 MG every afternoon
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
METFORMIN 1 , 000 MG orally twice a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Instructions: Please continue to take Plavix x 90 days
unless told otherwise by your cardiologist.
PREVACID ( LANSOPRAZOLE ) 30 MG orally twice a day
ATORVASTATIN 40 MG orally every day
ATENOLOL 25 MG orally every day
HYDROCORTISONE 1% -TOPICAL CREAM TP twice a day
Instructions: Apply to affected eczematous areas twice a
day.
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Verry June , 11AM scheduled ,
Dr. Murthy August , 2:50 ,
ALLERGY: Lisinopril
ADMIT DIAGNOSIS:
Chest Pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
myocardial infarction
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , hypercholesterolemia
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cath: Two vessel coronary artery disease
Successful PTCA/Stenting - Marg 1 to 0% with drug eluting stent
Successful Primary Stenting - CX to 0% with bare metal stent
Successful Angioplasty - distal tru CX to 0%Sheath Management - Sutured
in site , in right groin - RFA
Echo: Estimated ejection fraction is 55-60%. There is very mild
inferior hypokinesis present , trace TR.
BRIEF RESUME OF HOSPITAL COURSE:
57 year-old F with NIDDM , HTN , hyperchol , 30 pk yr hx
tob use , and GERD who presents with 10/10 CP x 36 hrs. CP burning in
left ant chest radiating with tingling feeling to neck , down L arm and
to L leg , waxing and waning over 1.5 days. She
remembers having this type of pain once before about 8
yrs ago , but not as severe. Walking made pain
better. She had some diaphoresis and nausea , but no SOB.
Denies PND , orthopnea , LE swelling , DOE , palpitations , claudication ,
recent ingestion or drug use. On exam , patient tachy to 115 , BP
144/85 , 98% RA , JVP 6 , CTAB , RRR , S1 , S2 , S4. weak
R femoral pulse , no bruits. EKG with 0.5 mm ST elevations in V5 , 6. TnI
.82 , CKMB-. In ED: heparin ggt , nitro , ativan , MSO4 , Maalox.
Hospital course by system:
1. CV: The patient had emergent catheterization on 5/15/03 for acute
MI. She was found to have no significant LAD or LM disease , 70% lesion
in proximal LCX , stented with a bare metal stent to 0% and a discrete
90% lesion in the OM1 which was stented with a drug eluting stent. The
patient tolerated the procedure well , with no post-procedure chest
pain. She had no hematoma or bruit in the right femoral artery at the
site of insertion. The following day the patient had an echo that
showed EF 50-55% with very mild inferior hypokinesis and trace TR. She
was discharged on ASA , beta blocker , and as needed NTG for chest pain. Her
cholesterol was total 169 , triglycerides 167 , HDL 43 , cLDL 93. She
was continued on her statin. She has had ?angioedema to ACE in past ,
but will likely start on ARB as outpatient. She was given information
on smoking cessation and will be referred to the smoking cessation
program by her primary care physician.
2. Endo: Glucose was >300 during her event ,
continued to be high off her metformin on admission. Her HbA1c was
13.2%. She will follow up DM with her primary care physician and was given some DM and
nutrition teaching in house.
She will be given a nutrition referral by her primary care physician
3. Renal: Metformin was stopped for her intravenous contrast during cath
procedure and patient received one dose of mucormist prior to cath and
2 doses afterwards as well as hydration. Her creatinine on discharge
was 0.8.
4. Dispo: She was discharged home in stable condition without chest
pain , SOB or discomfort. She will follow up with Dr. Verry on June.
ADDITIONAL COMMENTS: Please call your primary doctor with any chest pain , shortness of
breath , fainting , lower extremity swelling.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr. Murthy and Dr. Bonefont
No dictated summary
ENTERED BY: MURTHY , OLIMPIA DEMETRA , M.D. ( ML96 ) 6/13/03 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 692
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
- |
460188248 | PUO | 87946910 | | 1783857 | 10/18/2006 12:00:00 a.m. | STATUS POST RENAL TRANSPLANT | Unsigned | DIS | Admission Date: 2/5/2006 Report Status: Unsigned
Discharge Date: 10/16/2006
ATTENDING: NORSETH , ARDELLA M.D.
ADMITTING DIAGNOSES: GI bleed , dyspnea , ESRD status post renal
transplant.
DISCHARGE DIAGNOSIS: Deceased.
SERVICE: The patient has been admitted to the renal PA service.
Throughout the patient's hospital course , the patient had
multiple consults including Hematology , Infectious Disease ,
Nutrition , Physical Therapy , Social Work , and Cardiology.
CHIEF COMPLAINT ON ADMISSION: Epistaxis , melena , shortness of
breath.
HISTORY OF PRESENT ILLNESS: The patient was a 53-year-old white
female. The recent renal transplant highly sensitized the
patient who was undergoing plasmapheresis for antibody mediated
projection. The patient had a history of rheumatic heart
disease , status post AVR , MVR with St. Jude valve. She had
initially presented with three days of epistaxis , black tarry
stools , and shortness of breath in the setting of the
subtherapeutic INR. Her hematocrit upon admission was 14 , but
she was hemodynamically stable with tremendously elevated
troponin. Her recent hospital course had been complicated by
episodes of atrial fibrillation and flutter with RVR ,
gram-positive cocci bacteremia and hypertension , positive for
bacteriemia and endocarditis. The patient had a long course in
the medical intensive care unit following admission.
MEDICATIONS UPON TRANSFER: Vancomycin 1 g intravenous every 12 hours start date
of 7/6 , levofloxacin 500 mg intravenous every 48 hours start date of 7/6 ,
Flagyl 500 mg intravenous three times a day with the start date of 7/6 , CellCept
750 mg orally three times a day , intravenous heparin 500 units per hour , diltiazem 30
mg four times a day , calcitriol 0.25 mcg orally daily , Nexium , Solu-Medrol 20
mg intravenous every 8 hours , insulin sliding scale twice a day , Prograf 1 mg twice a day ,
Compazine as needed , Bactrim single strength every other day ,
Valcyte 450 mg orally every week. , Coumadin 5 mg orally daily , rifampin ,
which was discontinued on 1/26/06 and changed to rifabutin 300
mg daily on 4/10/06.
PHYSICAL EXAMINATION UPON ADMISSION: Temperature 95.6 , pulse 97 ,
BP 109/51 , respirations in the 20s , oxygen saturations in the 98%
on 2L. Generally , she was in no acute distress and alert.
HEENT , JVP increased to 9 cm. Pulmonary , bilateral rales to
bases. Cor , regular rate and rhythm. No murmurs. Abdomen ,
moderate , distended , but nontender. Good bowel sounds.
Extremities , 2+ edema bilaterally. Neurologically , moved all
extremities.
HOSPITAL COURSE BY SYSTEMS:
1. Anemia. The patient's hematocrit on admission was 14 in the
setting of subtherapeutic INR , on Coumadin. Her epistaxis now
has resolved and now with a stable hematocrit of greater than 30 ,
status post 7 units packed red blood cells. ENT was consulted
for epistaxis.
2. Fluid collection in the abdomen. The patient had IR guided
drainage of fluid collection done on 4/23 continued to drain
greater than 700 mL per day. She had a repeat CAT scan on
2/13/06 , which indicated large amount of ascites in the abdomen
and pelvis. Fluid pockets where IR drain was placed were no
longer present. IR drain was planned to be removed by CIS.
3. Melena. Upper endoscopy was consisted with evidence of small
shallow pyloric ulcers. No evidence of bleeding source. The
patient was advanced to a full diet and was placed on a proton
pump inhibitor and H. pylori were found.
4. CVS.
a. Elevated troponin , history of hypertension , no known coronary
artery disease , no chest pain , but does have dyspnea on exertion
likely secondary to severe anemia , demand ischemia ,
ST-depressions on EKG since with the demand ischemia. This
patient's serial troponins had been trending downward with
aggressive rate control. She had a second episode of atrial
fibrillation over the weekend of 11/20/06. The patient had an
episode which was converted with amiodarone. The patient had
elevated troponins that as stated above were turning down and
some ST-depressions on EKG , which was most likely secondary to
demand ischemia. The patient had an echocardiogram while
inhouse , which showed normal left ventricular function. No
regional wall motion abnormalities.
b. AVR , MVR. Heparin was stopped for therapeutic INR on
Coumadin.
c. Endocarditis. TEE. The patient had a transesophageal
echocardiogram which was consistent with small vegetation on the
aortic valve. She was placed on intravenous vancomycin , rifabutin , and
Linezolid. She had positive cultures on 3/12/06 and then again
on 2/6/06 both blood cultures from PICC line grew gram-negative
cocci in clusters. PICC line was removed. She had ongoing
bacteremia. She had a repeat TEE on 4/8/06 , they indicated no
vegetation seen on the aortic valve; however , she continued to be
bacteremic. She was then continued on vancomycin and daptomycin
per ID. Linezolid was discontinued on 5/2/06 per ID. She
maintained negative blood cultures since 5/6/06.
d. Atrial fibrillation. The patient is in atrial fibrillation
with rates of 130s on 7/20/06 , was given diltiazem 10 mg x2 then
started on intravenous amiodarone. She converted to sinus rhythm with
amiodarone , finished intravenous load , and continued on 200 mg daily. It
was planned for her to taper from there.
5. Renal. Status post renal transplant on FK , CellCept , and
prednisone. The patient had a renal ultrasound , which was
negative for hydronephrosis , obstruction or infarct. She had a
renal transplant biopsy on 3/3/06 , which results indicative
mild tubular damage and capillaritis suggestive of humeral
rejection. She received IVIG x2 , pulse steroids. She progressed
to have an increase in her creatinine to 5.7 and decreased urine
output. The patient was initiated on dialysis on 5/5/06 , again
on 1/27/06 , 4/3/06 , and 7/13/06. She then was maintained on
Monday , Wednesday , and Friday schedule for dialysis and was
placed on Renagel for increased phosphate.
6. GI. The patient throughout her hospital course had
increasing abdominal fluid collection with increasing shortness
of breath. She had an abdominal ultrasound to assess her amount
of fluids and marked for paracentesis. CIS marked the patient
for paracentesis. Paracentesis was attempted at the bedside with
only 700 mL of bloody gastric ascites. The patient had minimal
improvement of discomfort. The fluid was sent for gram stain ,
LDH , albumin , white blood cell count , and differential. CT of
the abdomen was consistent with moderate amount of ascites on the
right side of the abdomen mildly distended small bowel , question
of an ileus , which began to improve as of 10/26/06.
7. Neurologically , the patient had a new onset of psychiatric
manic disorder versus organic dementia. Her mood and behavior
had seemed to improve on 6/24/06 ; however , the patient
verbalized multiple concerns from 3/25/06 to 10/10/06 about
impending , worsening of condition , and possibility of death.
8. Pulmonary. The patient continued to spike fevers about 103
on 11/24/06. Chest x-ray had showed left lower lobe pneumonia.
ID was consulted. The patient was given ceftazidime 2 g intravenous x1.
On 2/15/06 , the patient was transferred out of the MICU. She
was hypotensive; however , her CVP line showed a blood pressure of
15-20 points higher systolic then what were showing on her
peripheral blood pressure cuff. She had nosocomial pneumonia ,
which had improved. Her ceftazidime was stopped and aztreonam
was stopped. Her ileus seemed to be improving. She had a bowel
movement. She also developed hyperbilirubinemia and therefore
amiodarone was stopped. Her NG tube was removed. Her abdomen
remained tight from fluid overload. Her dialysis alternating
with ultrafiltration. Fluid form her abdomen grew E. coli , on
vancomycin. She was on Nexium orally Her feeding tube was
placed secondary to malnutrition and third spacing. She was
started on Mepron 10 mL per hour , meropenem was started on
10/10/06 for a question of spontaneous bacterial peritonitis.
Plan was for paracentesis on 7/25/06. Renally , the patient
remained anuric and dialysis dependent. FK was continued and
CellCept was discontinued on 1/17/06. The patient continued to
have thrombocytopenia , neutropenia , and anemia. In the early
morning of 5/28/06 , the patient began having large volume emesis
with aspiration. She was transferred to the medical intensive
care unit and resulted in respiratory arrest , pulses , electrical
activity arrest. A code was initiated with intubation. The
patient decompensated and became very hypotensive. Despite the
efforts of CPR , the patient became profoundly bradycardiac and
advanced to PA again , not responding. After 1.5 hour FR code ,
efforts were discontinued. The patient was pronounced at 8
o'clock a.m. deceased.
eScription document: 0-2917224 CSSten Tel
Dictated By: REIDHERD , CAROYLN
Attending: NORSETH , ARDELLA
Dictation ID 8043791
D: 9/27/06
T: 10/27/06
Document id: 693
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727288776 | PUO | 81812239 | | 939742 | 10/19/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/30/1991 Report Status: Signed
Discharge Date:
ADDENDUM: Please see prior dictation. This is an addendum to the
previous discharge summary dictated on 4/28/91 .
On postoperative day number five , as the patient was being prepared
for discharge to the Habra Raco Hospital , she spiked to 101.7 and then to
102.2. A complete fever workup was done which included negative
blood cultures , a urine culture positive for 10 , 000 Enterococci
consistent with a mild urinary tract infection. Of note , the
patient had no evidence of pyelonephritis without any CVA
tenderness. She had a chest x-ray performed which showed only
atelectasis. Careful examination of the lower extremity showed no
evidence of deep venous thrombosis. The most likely source of
fever in this morbidly obese woman was a wound infection. Thus ,
the patient's staples were removed , and the wound was carefully
examined. The following day , after heat had been applied to the
wound , one small area in the wound separated , and a seroma
containing some serosanguineous fluid was drained. The wound was
then deeply probed , and extended very deeply. The fascia was
completely intact. A Penrose drain was placed through the opening
in the incision to allow the serosa to completely drain. The
following day , on postoperative day number eight , the drain was
removed , and the wound was packed deeply with Nu-Gauze soaked in
half strength hydrogen peroxide. Wet-to-dry dressing changes were
performed for several days , and the wound continued to remain clean
with healthy appearing tissue. Wound culture revealed Staphylococcus
coagulase negative. She had been started on orally Ampicillin for enterococcal
UTI. The
patient became afebrile immediately after the wound drained and had no further
elevations in her temperature. A chest film showed only
atelectasis , and thus she was vigorously ambulated and received
more chest physical therapy , and Albuterol nebulized treatment. Of
note , the patient's white count rose to 16 with a fever again
probably associated with the patient's wound infection. The
patient is thus discharged home on 8/1/91 , postoperative day 12 in
stable condition. She will be followed very closely by the
Visiting Nurses Association with frequent dressing changes and
wound care. She will also be followed very closely by Dr. Kristin Due as an outpatient. The patient is thus discharged home in
stable condition , following a complication of her surgery , a wound
separation.
CJ622/9692
KRISTIN S. DUE , M.D. DO8 D: 9/24/91
Batch: 0123 Report: C0218E0 T: 10/10/91
Dictated By: RIVA A. RIIS , M.D. LW23
Document id: 694
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
N |
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- |
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- |
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N |
888805676 | PUO | 02423099 | | 7840998 | 7/28/2006 12:00:00 a.m. | STEMI | | DIS | Admission Date: 1/16/2006 Report Status:
Discharge Date: 10/10/2006
****** FINAL DISCHARGE ORDERS ******
MASELLA , DOVIE 768-61-65-1
D64 Room: 08Z-126
Service: CAR
DISCHARGE PATIENT ON: 7/10/06 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REEDY , LILIA DOMINGA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 10/16/06 by
TOLLEFSON , AHMED , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
373786714 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: mda
Previous override information:
Override added on 11/12/06 by DUMAY , JAYNE B. , M.D.
on order for LIPITOR orally ( ref # 413036701 )
patient has a DEFINITE allergy to ATORVASTATIN; reaction is
Unknown. Reason for override: not allergic
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 6/16 )
Override Notice: Override added on 10/16/06 by
DUMAY , JAYNE B. , M.D.
on order for IBUPROFEN orally ( ref # 082613666 )
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
IBUPROFEN Reason for override: ok
ENTERIC COATED ASA 325 MG orally DAILY
LISINOPRIL 5 MG orally DAILY HOLD IF: sbp < 100 or heart rate < 55
Alert overridden: Override added on 7/10/06 by
DUMAY , JAYNE B. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: ok
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 1
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Pain
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Marvella Lindloff call office for appointment ,
No Known Allergies
ADMIT DIAGNOSIS:
ST elevation myocardial infarction
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
STEMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ST elevation MI hypercholesterolemia smoker etoh
OPERATIONS AND PROCEDURES:
Catherization: L coronaries clean. 100% ostial RCA thrombotic lesion
which was stented to 0% with TIMI flow 3.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Reason for Admit: transfer from Osri Medical Center for STEMI and
urgent catherization
HPI: Mr. Masella is a 47M , with a history of obesity , active smoking ,
moderate alcohol use and uncontrolled dyslipidemia , who presented to
UOSH after 2 episodes of substernal chest pain radiating to neck and L
arm at rest in the late afternoon of 8/24 At the TH , he had transient
STEMI note at 2am with initial troponin of 0.06. He was treated
with asa , heparin , plavix loaded ( 300 mg x 1 ) , morphine and transferred
to PUO for urgent catherization. Cath showed clean left side , ostial RCA
thromus 100% which was PTCA and stented successful with good TIMI flow.
patient had transient post procedure chest pain with no ECG changes relieved
with oxycodone. patient had difficulty laying flat , fem stop temporarily
placed.
-----
Home meds: lipitor 20 , not taking regularly
-----
Status: afebrile heart rate 72 , blood pressure 124/82 , 18 96RA. NAD. Lungs clear. no m/g.
Moderate size groin ecchymosis with no hematoma , no bruit.
----
Studies:
1. CXR: LLL atelectasis
2. CUS: L clean. R prox and mid ICA 0-25%; 25-49% plaque
3. AAA CT: prelim read negative for aneurysm
4. Echo: EF 60% , no regional wall motion abnormalities
----
Impression: Inferior STEMI history of rca stent
Plan:
CV: Troponin peak to 6 at 7pm 24 hours after event. Received infliximab x
24 hours. Discharged on asa 325 for life , plavix 75 mg orally every day x 30 days
minimal , toprol 100 , lisinopril 5 , lipitor 80 ( LDL 119 at admission ). At
time of discharge , patient euvolemic , sinus rhythm. ECG at discharge: every
waves inferiorly with TWI in III , AFL. Will f/u with outpatient
primary care doctor and cardiology. Provided smoking cessation and
alcohol counseling. Patient concerned about impotence while taking
betablocker , instructed on importance of bb in improving morbidity and
mortality. patient to f/u with Dr. Hamblet at NVH and Dr. Poyser primary care physician KAAH .
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: DUMAY , JAYNE B. , M.D. ( UW216) 7/10/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 695
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745216306 | PUO | 88775779 | | 306210 | 2/26/1999 12:00:00 a.m. | PANCREATITIS | Signed | DIS | Admission Date: 5/25/1999 Report Status: Signed
Discharge Date: 4/20/1999
IDENTIFICATION: This is a 40-year-old Hispanic female with
history of HIV who is admitted for pancreatitis.
HISTORY OF PRESENT ILLNESS: Mrs. Houpt is a 40-year-old female
diagnosed with HIV in 1990 , last viral
load was 2/3 , which was less than 400 , who presents with one day
history of severe mid-epigastric pain. Current history begins
approximately one week ago when Mrs. Houpt was discharged from
Bridgesnecrest Memorial Hospital after four day admission for pancreatitis.
Her records from Sa Pehall are not available. The patient
describes an abdominal CT consistent with pancreatitis , as well as
endoscopy performed which showed gastritis. Pain was treated with
Demerol and morphine. The patient states she awoke this morning in
her usual state of good health. In about 30 minutes , after taking
a crushed tablet of DDI , she began to experience severe
mid-epigastric pain , which radiated to the right upper quaddrant.
She took Maalox without relief. She presented to Niland Rawee Hospital
and took her every daily dose , however , the pain continued to increase
and she presented herself to I Warho Hospital Emergency
Room for further evaluation. Pain is described as a stabbing 10/10
pain without any relationship to position. Nothing makes it
better. It radiates to the right upper quadrant and bores straight
to the back. This is exactly similar to the pain that she had when
she presented to Sa Pehall
ALLERGIES: Compazine , which causes tardive dyskinesia.
MEDICATIONS: DDI; d4t , Indinavir , Serax; hydroxyurea; Dilantin , 300 mg. every day;
Zoloft; methadone , 100 mg. every day; Klonopin , 1 mg.
four times a day; Proventil; Percocet.
PAST MEDICAL HISTORY: Significant for 1. Pancreatis; 2. Peptic
ulcer disease; 3. HIV diagnosed in 1990;
4. Hepatitis C virus; 5. History of seizure disorder; 6. Positive
RPR and positive MHATP in 9/19/98.
SOCIAL HISTORY: Significant for HIV contact via sexual
intercourse; history of heroine use , which she
describes beginning to use after contracting HIV. She states she
has not used in over five years. She has no tobacco or alcohol
history.
PHYSICAL EXAM: Temperature 99.7 , heart rate 115 , blood pressure
150/90; satting at 98% on room air. She is a
middle-aged Hispanic female who is writhing in pain , who is alert
and responsive. Head and neck exam: Poor dentitia , pupils equal ,
round and reactive to light. Sclera anicteric. Neck supple.
Chest is bilaterally clear to auscultation. Cardiovascular exam ,
tachycardic , normal S1 , S2 , no murmurs , rubs or gallops. Abdominal
exam is distended with bowel sounds. There is severe tenderness in
the epigastric region to light palpation. There is no pain on
palpation to lower abdomen. There is no Grey Turner's sign.
Extremities , there is no cyanosis. 2+ dorsalis pedis and posterior
tibialis.
LABORATORY DATA: Sodium 153 , potassium 5.2 , chloride 99 , bicarb
27 , BUN 15 , creatinine 0.4 , glucose 127. She has
a white blood cell count of 5.5 , hematocrit 41.5 , platelet count
100 , MCV 103.1 , RDW 17.0 , ALT 38 , AST 113 , alk phos 13 , amylase
307 , lipase 3 , 522. Total bili 0.7 , direct bili 0.4. physical therapy 13.1 , PTT
28.8 , INR 1.2. Urine , HCG negative. Abdominal ultrasound was
performed in the Emergency Room and showed an enlarged common bile
duct without interhepatic dilatation. This was limited to body
habitus.
ASSESSMENT: This 40-year-old female with HIV who was admitted to
the I Warho Hospital after recent discharge
from Sa Pehall with pancreatitis flare , second lifetime episode ,
most likely secondary to her HIV medication.
HOSPITAL COURSE: Mrs. Houpt was admitted to the General Medicine
Service Team. She was immediately placed NPO and
was aggressively fluid hydrated with normal saline. Pain Service
was consulted and placed the patient on a morphine PCA pump. Given
the patient's history of seizure disorders , Demerol was used very
sparingly for pain , only used once with good effect. However , the
patient continued to complain of mid-epigastric abdominal pain ,
10/10 even while on the morphine PCA. On hospital day #2 , the Pain
Service changed her over to a Dilaudid PCA with excellent effect.
By hospital day #3 , she was hungry and wanted to eat. Her diet was
advanced to clear sips and then advanced to full liquids , which she
tolerated well. The Dilaudid PCA was stopped and patient was
placed on orally Percocet for pain with good effect. Her pancreatic
enzymes decreased from a high of 3522 down to 1495 , then to 1125.
By 9/17 , they were 682; by 5/8 , they were 884. Triglycerides on
admission were 77. The patient was also taken off all of her HIV
medications. By the date of admission on 10/6 , the patient does not
complain of any abdominal pain. Pain is well controlled with
Percocet and she is tolerating orally.s well. There were episodes of
agitation during this hospitalization. On admission , the patient
was taken off of her Klonopin; however , when Klonopin was
reinstituted by hospital day #3 , the patient became less agitated.
She was continued on Dilantin throughout her hospitalization; there
was no seizure activity. She will follow-up with her primary care
doctor on Monday , Shonna Saber She will not be discharged on any
HIV medications. This will be added on a later date by the
Infectious Disease Team. She will continue on her methadone
maintenance at 100 mg. a day. Patient is unaware of her dosage of
methadone.
DISCHARGE MEDICATIONS: She will be discharged on Klonopin , 1 mg.
orally four times a day; methadone , 100 mg. orally every day ,
patient is not to be identified of the dosage of methadone;
Dilantin , 100 mg. orally three times a day; Zoloft , 75 mg. orally every day;
Percocet , one to two tabs orally every 4-6 h. as needed pain. She will also
continue on her Proventil. Patient will follow up in Dr. Sollars 's clinic next
week to carefully review an alternative regiment.
Dictated By: JODY CROLL , M.D. SY76
Attending: DORETHA D. VANEGAS , M.D. WT39
DA470/0618
Batch: 06395 Index No. RINZPG10DI D: 11/24/99
T: 7/6/99
cc: Kelsi Sollars M.D. Infectious Disease Clinic
Document id: 696
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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634558876 | PUO | 44368745 | | 4546134 | 10/15/2006 12:00:00 a.m. | HO evaluation | | DIS | Admission Date: 11/28/2006 Report Status:
Discharge Date: 2/10/2006
****** FINAL DISCHARGE ORDERS ******
CADORETTE , KEISHA E 064-12-47-0
Beaupherclaer
Service: GGI
DISCHARGE PATIENT ON: 6/21/06 AT 09:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
LANTUS ( INSULIN GLARGINE ) 60 UNITS subcutaneously DAILY
Starting Today ( 1/25 ) HOLD IF: npo
ROXICET ORAL SOLUTION ( OXYCODONE+APAP LIQUID )
5-10 MILLILITERS orally every 4 hours as needed Pain
ZANTAC SYRUP ( RANITIDINE HCL SYRUP ) 150 MG orally twice a day
ACTIGALL ( URSODIOL ) 300 MG orally twice a day
Instructions: if gallbladder still in- start taking 2
weeks after discharge
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally DAILY
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 6/21/06 by :
POTENTIALLY SERIOUS INTERACTION: PROCHLORPERAZINE &
LEVOFLOXACIN Reason for override: aware
DIET: stage II bypass diet
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please call Dr. Hornbeak immediately to schedule follow-up appiontment ,
Please follow-up with primary care doctor for blood sugar check ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
HO evaluation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
none
OPERATIONS AND PROCEDURES:
laparoscopic roux-en-y gastric bypass
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to the Toott Hospital surgery service after undergoing
LRYGB. No concerning intraoperative events occurred; please see dictated
operative note for details. Patient was transferred to the floor from
the PACU in stable condition. Patient had adequate pain control and no
issues overnight into POD1. The patient had an UGI on POD1 that was
negative for obstruction or leak , at that time was started on a Stage I
diet which was tolerated well. The following day the patient was started
on a Stage II diet that was tolerated as well , but patient
initially struggled to have adequate intake. Incision erytematous , with
serous discharge by POD 2 requiring multiple but decreasing dressing
changes. Continued
dressing wound , DSD with improvement. Sugars remained high in 200's
during admission. patient seen by Endocrine service and sugars finally
improving with lantus 60 subcutaneously bedtime She also had some difficulties
with urination on POD4 and required a foley catheter for about a day. Her
foley was d/c'd the a.m. before she was d/c'd and she urinated without
incident. Patient was noted to have a UTI at discharge and was started on
three day course of levaquin. Remainder of hospital course
unremarkable , and the
pateint was discharged in stable condition , tolerating stage II diet well ,
ambulating , voiding
independently , and with adequate pain control. The patient was given
explicit instructions to follow-up in clinic with Dr. Hornbeak in 1-2 weeks.
patient sent home with VNA for wound checks and close sugar control with
instructions to f/u with Lynnette Robards by phone and record fingersticks.
She should f/u with her primary care physician if she has further probelms with urination.
ADDITIONAL COMMENTS: -You may shower , but do not bathe , swim or otherwise immerse your
incision.
-Do not lift anything heavier than a phone book.
-Do not drive or drink alcohol while taking narcotic pain medication.
-Resume all of your home medications.
-If you have fevers > 101.5 F , vomiting , or increased redness , swelling ,
or discharge from your incision , call your doctor or go to the nearest
emergency room.
-VNA: please check blood sugar daily and call results into MD
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KONEN , GENOVEVA M. , M.D. ( SH710 ) 6/21/06 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 697
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
N |
N |
- |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
797900970 | PUO | 47203512 | | 8119776 | 10/10/2003 12:00:00 a.m. | history of Rouex en Y Gastric Bypass / Open Cholecystecomy | | DIS | Admission Date: 6/10/2003 Report Status:
Discharge Date: 10/25/2003
****** DISCHARGE ORDERS ******
MALANEY , SHAWNA 853-13-69-7
SACMCOA Room: 08Z-126
Service: GGI
DISCHARGE PATIENT ON: 6/27/03 AT 11:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ROXICET ELIXIR ( OXYCODONE+APAP LIQUID ) 5 ML orally Q3-4H
Starting when EPIDURAL IS CAPPED as needed PAIN
Alert overridden: Override added on 3/9/03 by
ALUQDAH , SELMA DELORSE , M.S.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
PHENANTHRENES Reason for override: pain control will monitor
ZANTAC ELIXIR ( RANITIDINE HCL SYRUP ) 150 MG orally twice a day
DIET: Gastric Bypass Stage 2
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Hornbeak 1-2 weeks ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
Morbid Obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of Rouex en Y Gastric Bypass / Open Cholecystecomy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
depression ( depression ) drug overdose ( drug overdose ) PE ( pulmonary
embolism )
OPERATIONS AND PROCEDURES:
3/9/03 HORNBEAK , LAUREL I. , M.D.
ROUX EN Y GASTRIC BYPASS
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
40F with morbid obesity underwent rouex-en-y gastric bypass. Tolerated
procedure well. Uncomplicated postop course. patient was tachycardic on
POD#1 and maintained HR in low 100's or high 90's. Abdomen was
benign. patient tolerating Stage 2 diet. Ambulating. CBC WNL. patient discharged
on POD#3.
ADDITIONAL COMMENTS: Please call MD or return to hospital if you develop fevers/chills ,
persistent nausea/vomitting , concerning abdominal pain , or any other
concerning symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: RODARMEL , DONYA MITZIE , M.D. ( AM78 ) 6/27/03 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 698
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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618283162 | PUO | 09342280 | | 625082 | 11/3/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/11/1990 Report Status: Unsigned
Discharge Date: 10/8/1990
HISTORY OF PRESENT ILLNESS: The patient was an essentially healthy
79 year old retired garment industry
worker , followed by Dr. Douglass N. Pettinger , the internist at
Pagham University Of for the question of transient ischemic
attacks. On the evening of admission , the patient and his wife
noted fatigue , light-headedness and 3 episodes of diaphoresis. The
patient took 1 to 2 ounces of ethanol for relaxation and several
hours later while attempting to climb stairs fell and was unable to
get up. Soon after , he had one episode of melenotic soft stool in
large volume without frank blood and then a moderate amount of
coffee ground emesis. The emergency medical technicians were
called , and in the ambulance the patient had a blood pressure of
110/68 , heart rate 110. At the Pagham University Of
emergency ward , his blood pressure had dropped to 95/60 and he was
symptomatically orthostatic. Esophagogastroduodenoscopy was
performed in the emergency ward , which showed an actively bleeding
1 cm antral lesion in the greater curvature , which was cauterized.
This was thought to be consistent with a pancreatic cyst or
leiomyoma , or less likely a metastatic lesion , along with some mild
esophagitis. He had no previous history of peptic ulcer disease.
The patient takes aspirin 1 to 2 tablets per day for several months
as question treatment for transient ischemic attack and for his hip
pain. He also has daily ingestion of ethenol , approximately 2 to 3
ounces , for many years. There was no history of nausea , vomiting ,
diarrhea , weight loss , abdominal pain , anorexia or any other
constitutional symptoms. There is a remote history of abdominal
pain and spastic colon with a negative work-up in 1976 , including a
Barium enema , upper gastrointestinal series and abdominal
ultrasound. He was admitted to the Pagham University Of
Medical Intensive Care Unit , where his course was notable for a
5-unit packed red blood cell transfusion with stabilization of his
hematocrit and vital signs. The initial hematocrit was 21 and he
was transfused up to the 37 range. MEDICATIONS ON ADMISSION
included aspirin 2 orally every day and Westcort Cream for psoriasis. PAST
MEDICAL HISTORY was notable for chronic psoriasis , vertigo question
transient ischemic attack , status post multiple excisions for basal
cell skin carcinoma , history of hiatal hernia with a question of
reflux esophagitis , status post suprapubic prostatectomy for benign
prostatic hypertrophy , status post herniorrhaphy , status post
appendectomy , question of glucose intolerance diet controlled ,
status post right cataract surgery with lens implantation. FAMILY
HISTORY is notable for multiple siblings healthy in their late
80's , one brother with pancreatic carcinoma , hypertension in mother
and sister , no history of other systemic illnesses. SOCIAL HISTORY
reveals the patient is a retired woman's clothing manufacturer , who
lives in Ter Hou Le S Di with his wife , who is a Pagham University Of employee. REVIEW OF SYSTEMS is negative , except for the
vertigo and occasional episodes of diaphoresis.
PHYSICAL EXAMINATION: The patient was a 79 year old man looking
remarkably well and fit. He was afebrile ,
pulse 60 , blood pressure 130/72. His skin was well tanned with
multiple psoriatic patches on the lower extremities. Head , eyes ,
ears , nose and throat examination was unremarkable. Neck was
normal. Chest was clear. Cardiac examination showed S4 , S1 and
S2 , no S3 , the murmur heard at admission was absent. Abdomen was
soft , flat , without hepatosplenomegaly. Extremities showed pulses
to be intact without clubbing , cynosis or edema. Neurologic
examination was nonfocal.
LABORATORY EXAMINATION: The electrocardiogram was normal. Chest
x-ray was normal. Urinalysis showed mild
pyuria and hematuria , which will be followed. Laboratory values of
note included a normal SMA-20 , except for a globulin of 1.6.
Hematocrit was 37 , with a normal differential.
HOSPITAL COURSE: The patient underwent several diagnostic studies ,
including a repeat upper gastrointestinal
endoscopy , which showed the 1-cm gastric antral lesion. It also
showed some thickened folds within the stomach , which were
biopsied. The lesion was not biopsied for fear of rebleeding. The
patient also underwent an abdominal computerized tomography , which
showed a 1 to 2 cm cystic appearing lesion felt to be consistent
with either dilated pancreatic duct or a small pancreatic
pseudocyst. There was no evidence of intra-abdominal malignancy.
The patient also underwent an upper gastrointestinal series , which
was unremarkable. On 22 of July , the patient developed a tender left
big toe , which was initially thought to be gout or another
inflammatory arthritis , for example psoriatic arthritis , and he was
evaluated by the Rheumatology Service. The patient underwent a
joint tap , the findings of which were unremarkable. He also had
some erythematous changes on the forefoot , and the picture was
thought to be consistent with a mild cellulitis , with perhaps the
portal of entry being a psoriatic plaque. He was treated with
intravenous Kefzol and the erythema resolved overnight. The other
complicating issue is a mild elevation in liver enzymes noted on
the day before admission. This needs to be followed.
DISPOSITION: MEDICATIONS ON DISCHARGE include Pepcid 20 mg orally twice a day
( this may be the cause of elevated liver function
tests ) , Velosef 500 mg orally four times a day times 7 days , Westcort Cream.
Disposition is to home. CONDITION ON DISCHARGE is good. FOLLOW-UP
care is to be provided by Dr. Douglass N. Pettinger at the Pagham University Of , and Dr. Lacy Mcausland in the Division of
Gastroenterology at the Pagham University Of .
________________________________ JZ380/1408
SACHIKO S. BORRIELLO , M.D. WP8 D: 9/17/90 Batch: 9243 Report: X3949N4 T: 5/11/90
Dictated By: SVETLANA S. SALLINGS , M.D. MX95
cc: SVETLANA S. SALLINGS , M.D.
DOUGLASS N. PETTINGER , M.D.
LACY L. MCAUSLAND , M.D.
Document id: 699
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798415987 | PUO | 34920670 | | 1673870 | 10/10/2004 12:00:00 a.m. | unstable angina | | DIS | Admission Date: 7/6/2004 Report Status:
Discharge Date: 9/22/2004
****** DISCHARGE ORDERS ******
ROLLAG , BENNY E. 106-94-89-6
X68 Room: 26O-650
Service: CAR
DISCHARGE PATIENT ON: 10/22/04 AT 04:00 PM
CONTINGENT UPON ambulatory O2 sat >90%
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
Alert overridden: Override added on 3/18/04 by
INNARELLI , DONNETTE BETTY , M.D.
on order for ENTERIC COATED ASA orally 325 MG every day ( ref #
82001532 )
patient has a POSSIBLE allergy to NSAIDs; reaction is Unknown.
Reason for override: tolerates Previous Alert overridden
Override added on 6/28/04 by INNARELLI , DONNETTE BETTY , M.D.
on order for ENTERIC COATED ASA orally 325 MG every day ( ref #
86115564 )
patient has a POSSIBLE allergy to NSAIDs; reaction is Unknown.
Reason for override: has tolerated Previous override reason:
Override added on 10/30/04 by GREENFELDER , SILVIA VINCE , M.D. , PH.D.
on order for ECASA orally 325 MG every day ( ref # 37577909 )
patient has a POSSIBLE allergy to NSAIDs; reaction is Unknown.
Reason for override: patient takes at home
INSULIN NPH HUMAN 36 UNITS every day before noon; 40 UNITS every afternoon subcutaneously
36 UNITS every day before noon 40 UNITS every afternoon
NEURONTIN ( GABAPENTIN ) 600 MG orally twice a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ZETIA ( EZETIMIBE ) 10 MG orally every day
LISINOPRIL 40 MG orally every day
HYDROCHLOROTHIAZIDE 25 MG orally every day
PREVACID ( LANSOPRAZOLE ) 30 MG orally every day
GLUCOPHAGE ( METFORMIN ) 1 , 000 MG orally twice a day
IBUPROFEN 600-800 MG orally every 6 hours as needed Pain
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 10/22/04 by :
on order for IBUPROFEN orally ( ref # 93940110 )
patient has a PROBABLE allergy to NSAIDs; reaction is Unknown.
Reason for override: Patient has tolerated in past
Previous Alert overridden Override added on 10/22/04 by :
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
IBUPROFEN Reason for override: Monitoring HCT
ATENOLOL 25 MG orally every day
Instructions: take 1/2 your regular home dose until you
see your cardiologist/primary care physician
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Tyminski his office will call you re: appointment in 2 weeks ,
Dr. Wurth 's office is setting up right leg ultrasound for 2-4 weeks ,
ALLERGY: SIMVASTATIN , NSAIDs , SHELLFISH , Codeine
ADMIT DIAGNOSIS:
unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
unstable angina
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) history of stent placement ( history of angioplasty )
high cholesterol ( elevated cholesterol ) htn
( hypertension ) fibromyalgia ( fibromyalgia ) gallstones ( biliary stones )
OPERATIONS AND PROCEDURES:
6/28/04 Cardiac cath
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
64 year-old F with DM , CAD history of OM1 stent '99 , with 1 month history of worsened
exertional angina ( jaw tightness ) , and 2 day history of worsening
intermittent jaw pain , SOB , presented after 2nd episode of pain at rest
to TH ED. Initial enzymes were negative , patient was heparinized for
EKG changes and transferred to PUO ED where B-set TnI positive; TWI
in anterior leads. Cath results below.
Initial exam - BP 140s , HR 50s , afebrile , soft systolic murmur , clear
lungs. EKG- NSR , TWI in anterior leads , Troponin 0.67 , MB 7.4 , CK 303 ,
CK 303. HCT 39.1
PMHx: DM , CAD history of Om1 stent , hyperlipidemia , HTN , fibromyalgia , history of
CCY , spinal stenosis , obesity , history of TAH
**Hospital Course**
CV/HEME:
Patient underwent cardiac cath on 6/28/04 - LAD 90% lesion and OM2 99%
lesion both successfully stented with cypher. Remaining 100% PDA.
Following cath , patient had bradycardia to 20-30's in setting of
femoral hematoma. BP initially measured in 60s , thought to be vagal 2/2
femoral hematoma. Received atropine x 1 and Fem stop placed over cath
site for compression - BP dropped again with bradycardia- transferred
to CCU and briefly on dopamine. CT ruled out retroperitoneal
bleed. Hct stable. Transferred back to floor within 24 hours.
Patient also noted occasional mild abdominal discomfort , but had
negative LFTs and lipase. She also noted right calf pain and was found
to have a below-the knee right tibial vein DVT , was not anticoagulated
for this below-the knee clot because of low risk of embolization and he
r recent HCT drop/hematoma. LENI was repeated on day of discharge
and showed no progression. One the two days prior to admission ,
her HCT dropped from 32 to 26 , and she was trandfused 2 U PRBC
with HCT bump to 34.1. Repeat CT showed shrinkage of hematoma , so
patient is being discharged with plans to have primary care physician recheck HCT at home
in 2 days.
MSK: Patient complained of left knee pain after fall one week prior.
X-ray shoed only osteoarthritis , although knee was somewhat warm.
There was no clear effusion , so patient is being given
ibuprofen as needed for now.
______
Anti-ischemic regimen at discharge: ASA , Plavix , Atenolol , Lisinopril.
( no Statin because of muscle pain hx ). Will continue home diabetic
regimen and followup with primary care physician/cardiology.
ADDITIONAL COMMENTS: You should return to the hospital or call your doctor if you have chest
pain or difficulty breathing.
Dr. Wurth 's office will send someone to your home on Sunday 8/17 to
draw your blood levels. Your hematocrit on discharge today is 34.1
DISCHARGE CONDITION: Stable
TO DO/PLAN:
You should have a repeat right leg ultrasound test ( "LENI" ) to follow
the small blood clot in your leg. You will need to schedule this test
to occur in the next 3-4 weeks through Dr. Brendan Wurth office.
No dictated summary
ENTERED BY: MALADY , CASSONDRA F. , M.D. , M.S. ( JZ49 ) 10/22/04 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 700
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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U |
Y |
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U |
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U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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707826215 | PUO | 17768471 | | 0291136 | 1/21/2005 12:00:00 a.m. | Viral syndrome | | DIS | Admission Date: 1/21/2005 Report Status:
Discharge Date: 9/23/2005
****** FINAL DISCHARGE ORDERS ******
TORRELL , JAMAL 728-74-26-8
Irv
Service: MED
DISCHARGE PATIENT ON: 10/27/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
CEPACOL 1-2 LOZENGE orally every 4 hours as needed Other:sore throat
VITAMIN B12 ( CYANOCOBALAMIN ) 1 , 000 MCG intramuscular every day X 3 doses
DIPYRIDAMOLE 25 MG orally every afternoon
LASIX ( FUROSEMIDE ) 10 MG orally every day
ISORDIL ( ISOSORBIDE DINITRATE ) 30 MG orally three times a day
ATIVAN ( LORAZEPAM ) 3.5 MG orally every bedtime as needed Insomnia
INDERAL ( PROPRANOLOL HCL ) 10 MG orally four times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NORVASC ( AMLODIPINE ) 2.5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NITROGLYCERIN 0.2% TOPICAL TP twice a day Instructions: 1 inch ,
ZETIA ( EZETIMIBE ) 10 MG orally every day
AZITHROMYCIN 500 MG PACK 500 MG orally every day X 4 doses
Alert overridden: Override added on 10/27/05 by :
POTENTIALLY SERIOUS INTERACTION: LORAZEPAM & AZITHROMYCIN
POTENTIALLY SERIOUS INTERACTION: AMLODIPINE BESYLATE &
CALCIUM PHOSPHATE , ORAL Reason for override: aware
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Gruntz within 2 wks ,
Dr. Piontkowski ,
ALLERGY: Penicillins , Aspirin
ADMIT DIAGNOSIS:
Viral syndrome
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Viral syndrome
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn elev chol bph , history of turp x4 history of partial gastrectomy IMI '73 CAD
history of CABG x3 ( history of cardiac bypass graft surgery )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Sore throat , cough , weakness
---------------
DDX: 83yo man with ho CAD , IMI , CABG ( 2000 ) , HTN ,
hyperlipidemia , stable angina , recently d/c'd from PUO 6/24 after
being r/o'd for MI with negative MIBI p/with 2 days viral syndrome with
sore throat , cough , weakness , sweats.
---------------
HPI: patient came to PUO ED with 2 days weakness , fatigue , diziness , sore
throat and cough. No CP , SOB. Appetite ok , drinking plenty of
fluids. No weight loss. Has several month history of weight loss. In
ED , given 500 azithro. He was observed O/N and then admitted to
medicine because of FTT. Of note , patient c/o very depressed mood. Had a
break in at his apartment 6/24 , everythign stolen. Son also
recently dx'd with metastatic prostate ca.
----------------
STATUS: Afebrile ( though 101.9 O/N in ED ) VSS , NAD , no
cough. CTAB , RRR , normal S1/S2 , no murmurs , Abd benign , no edema.
AOx3. - EKG:A-paced at 69 , IMI , normal axis , no acute
iscmeic changes
----------------
STUDIES:
- MIBI ( 1/13 ): EF 45% , noted to have multiple pulmonary nodules
- CXR ( 10/7 ): negative
- CT Chest ( 7/13 ): several pulmonary nodules in RUL
inferiorly , largest 0.6cm. Also tiny nodules in upper
lobes bilaterally , 2-3mm. Several small nodes in
mediastinum. No LAD. C/W inflammatory changes ,
including possible TB or atypical mycobacterium.
----------------
HOSPITAL COURSE BY PROBLEMS:
----------------
1 ) ID - No significant fever or WBC. Symptoms were already improved on
admission; no cough. patient was observed O/N with IVF. Improved in the
morning. Will be D/C'd on azithromycin x 5 days.
----------------
2 ) PULMONARY NODULES: Had been seen on prior MIBI. CT c/with pulmonary
nodules. No clinical signs of TB , but did have night sweats for
several months. Will f/u with Dr. Piontkowski as outpatient for with u.
-----------------
3 ) HEME: Given anemia , iron studies , B12 , folate sent. Got B12 1000ug intramuscular
x 1. patient refuses all VNA services , so patient was instructed to f/u with
doctors office to get injectiosn for 2 more days , then monthly. Likely
2/2 gastrectomy.
-----------------
4 ) DEPRESSION: patient seems severely depressed , admits to depressed
mood. patient declines psych consult at this time.
---------------
FULL CODE
ADDITIONAL COMMENTS: Please call your doctor if you continue to feel unwell , or return to the
hosptial. If you would like to receive your B12 injections , please go to
the doctors office on Thursday and Friday to receive the injections.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- continue azithro x 4 days
- B12 1000ug every day for 2 more days , the every month.
No dictated summary
ENTERED BY: PANCHO , MARJORIE , M.D. ( VG21 ) 10/27/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 701
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GER |
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838440387 | PUO | 59556390 | | 8800598 | 9/25/2003 12:00:00 a.m. | labs , ekg | | DIS | Admission Date: 11/20/2003 Report Status:
Discharge Date: 10/13/2003
****** DISCHARGE ORDERS ******
ROTHMAN , BAILEY 329-84-06-2
More Sey Room: Bootl Stockph Navwhitelyn Boulevard , Clark Westnashaspo Moines , Kansas 66500
Service: CAR
DISCHARGE PATIENT ON: 5/15/03 AT 10:30 a.m.
CONTINGENT UPON echo , BP
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MENDONSA , JEANNETTE CONSTANCE , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
EC ASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
GLYBURIDE 2.5 MG orally every day
ZAROXOLYN ( METOLAZONE ) 5 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5 MIN X 3
as needed Chest Pain
ZOCOR ( SIMVASTATIN ) 10 MG orally every bedtime Starting Today ( 6/18 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
ACCUPRIL ( QUINAPRIL ) 40 MG orally every day
Alert overridden:
Override added on 3/20/03 by POLLIO , DION D. , MB , BS , PHD
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
QUINAPRIL HCL Reason for override: patient takes both
Number of Doses Required ( approximate ): 4
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 60 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KCL SLOW RELEASE 20 MEQ X 1 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 3/20/03 by POLLIO , DION D. , MB , BS , PHD on order for ACCUPRIL orally ( ref # 78783676 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
QUINAPRIL HCL Reason for override: patient takes both
CLOPIDOGREL 75 MG orally every day Starting START THE NEXT DAY
NORVASC ( AMLODIPINE ) 5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
ACTIVITY: no heavy lifting or driving for 2 days
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
john smith call for apt ,
No Known Allergies
ADMIT DIAGNOSIS:
ischemic heart disease
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
labs , ekg
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension , hypercholesterol , PVD
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cath
BRIEF RESUME OF HOSPITAL COURSE:
79 year-old lady CABG X 2 most recent 1991 LIMA to LAD ,
SVG to RCA and SVG to OM1. Other problems of HT , NIDDM and
claudication. Admitted to put wathern hospital with chest pain , ECG
changes and small enzy , e rise transferred to PUO for cath.
Angiogram showed severe native coronary artery
disease occluded LAD , OM and RCA. Patent LIMA to LAD ,
SVG to OM2 3 and SVG to RCA. Left renal
artery stenosis with significant gradient stented
with 6.0 x 18 mm omnilink stent. Groin closed with 6F
pe rclose vein manually
compressed. Addendum-patient would get angina when hypertensive
to 200 in the lab , so susupect small vessel
disease responsible for her chest pain. will need
to watch BP given renal stenting , but if
still hypertensive tomorrow PM will need to increase
BP meds. Janet Piltz 5/8/03
Overnight patient developed Cp with HTN and EKG changes which was relieved
with Sl NTG and intravenous Lopressor.NO bump in enzymes. NO CP since last
night. Started Norvasc 5mg and Imdur 60mg. Echo today with EF
60% and no WMA. Will continue to follow
today monitoring BP and CP Likely d/c in
am.
8/10/03
patient stable today with no CP and BP well controlled. Ready for d/c
ADDITIONAL COMMENTS: -you will need to to take plavix for at least 3 months and aspirin for
life
-call if you have any concerns
-Call Dr. Reedy for appointment within the next two weeks
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STRAUHAL , MARCELINA ( ) 5/15/03 @ 08:07 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 702
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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141445265 | PUO | 18125885 | | 9583156 | 5/20/2005 12:00:00 a.m. | history of cath | | DIS | Admission Date: 10/3/2005 Report Status:
Discharge Date: 6/10/2005
****** DISCHARGE ORDERS ******
LAZARINI , ALEJANDRINA E. 579-93-49-2
Greenstam Room: Daleaette
Service: CAR
DISCHARGE PATIENT ON: 1/12/05 AT 10:00 a.m.
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: JOURNEAY , WINFRED TENESHA , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
ENALAPRIL MALEATE 5 MG orally twice a day
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
HUMULIN 70/30 ( INSULIN 70/30 ( HUMAN ) ) 37 UNITS subcutaneously every afternoon
Number of Doses Required ( approximate ): 4
HUMULIN 70/30 ( INSULIN 70/30 ( HUMAN ) ) 57 UNITS subcutaneously every day before noon
Starting IN a.m. ( 2/23 )
Number of Doses Required ( approximate ): 4
HUMULIN 70/30 ( INSULIN 70/30 ( HUMAN ) ) 27 UNITS subcutaneously x1
Number of Doses Required ( approximate ): 1
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 2
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
CELEXA ( CITALOPRAM ) 20 MG orally every day
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
denisha mcrorie 1-2 weeks ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
history of cardiac catheterization
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of cath
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) CAD ( coronary artery disease ) history of cabg ( history of
cardiac bypass graft surgery ) IDDM
( ) hypercholesterolemia ( elevated cholesterol ) peripheral neuropathy ( )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cath
BRIEF RESUME OF HOSPITAL COURSE:
63 year old male with hypertension , diabetes
mellitus , hypercholesterolemia , history of CABG , presents with
typical angina , a positive adenosine MIBI , and today a cath his
anatomy is unchanged-no intervention performed. The right
femoral artery was sealed , distal pulses present by doppler as before
procedure. CABG 2002 @ TEVH --LIMA -->LAD , SVG-->LAD ,
SVG-->rtPDA , SVG-->D1. 2003 grafts patent , 2.5x13 Cypher to OM2.
9/9 Adenosine MIBI with inf/inflat ischemia. Med hx: htn ,
hyperchol , type 2 dm , glaucoma. Meds: see
orders Allergies:
codeine Plan: Admit to interventional service for
observation , will be discharged to home when arrangements can be made
with his sister ( caregiver ). 3/21 and ready for dc.
ADDITIONAL COMMENTS: -please continue all of your current medications and see dr journeay in a
week or two. call if you have any concerns before then.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: LALATA , JOHNETTA , PA-C ( ) 1/12/05 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 703
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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707016140 | PUO | 91535309 | | 4305773 | 6/27/2004 12:00:00 a.m. | pre-syncope , non-cardiac | | DIS | Admission Date: 2/24/2004 Report Status:
Discharge Date: 11/24/2004
****** DISCHARGE ORDERS ******
BECKENDORF , ALLA 616-86-08-5
Ce Ster S Room: A
Service: MED
DISCHARGE PATIENT ON: 6/8/04 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALBUTEROL INHALER 2 PUFF inhaled four times a day Starting Today ( 6/7 )
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
ATENOLOL 25 MG orally twice a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 75 MCG orally every day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 3/3/04 by
LEPPANEN , ALFREDA , M.D.
on order for ZOCOR orally ( ref # 05341906 )
patient has a PROBABLE allergy to ATORVASTATIN; reaction is
unknown. Reason for override: aware
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
CELEBREX ( CELECOXIB ) 200 MG orally every day
Food/Drug Interaction Instruction Take with food
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Tabbaa , patient to call for appt 1-2 weeks ,
ALLERGY: ATORVASTATIN
ADMIT DIAGNOSIS:
Pre-syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pre-syncope , non-cardiac
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) asthma ( asthma ) hypothyroidism
( hypothyroidism ) elevated cholesterol ( elevated cholesterol ) varicose
veins ( varicose veins ) UTIs ( urinary tract infection )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
75 year-old africaan speaking F with HTN , high cholesterol ,
hypothyroidism , asthma , presents with pre-syncope.
*********
Seen by primary care physician 3d PTA for L hip pain , HA , polyarthralgias. EKG then
showed sinus brady. TSH noted to be mildly elevated at that visit at
5.3 , RF and ANA neg. Now p/with 1-2 days
presyncopal episodes x2 , one while walking then this am
at church while seated. No SOB , CP , palps , no LOC ,
no f/s/c , wt loss , + dec 'd orally's x2 days
2/2 n/dyspepsia , also +BRBPR with minimal blood
x1-2d. +chronic L>R hip pain. In ED: afeb ,
normotensive , rec'd. CXR: clear. EKG: NSR 51. Has been
taking meds as
directed. PE: 98.5 65 147/80 12 99%RA , NAD , mm dry ,
OP clear , JVP flat , CTAB , rrr , no m/g/r , ABd
soft , NT/ND , heme pos brown stool , +ext hemorrhoids ,
TR edema bilat , 2+ pulses , +L>R trochanteric
bursa point tenderness , neuro
non-focal LABS: cardiac enzymes neg x1 , UA neg , TSH
5.3 , otherwise unremarkable , Hct 40 at
baseline.
*****HOSP COURSE*******
CV: unlikely cardiac origin of presyncope , more likely mild
hypovolemia. R/R: monitored on tele , noted to brady to low 50s after ta
king atenolol , which could be a contributing factor. ISCHEMIA: R/o'd
for MI by enzymes. LDL elevated , vague rxn to lipitor. Started zocor ,
aspirin. Cont'd BB , imdur. aMIBI 6/21 showed: small reversible defect of
mild intensity in distal ant wall and apex c/with small area ischemia in
distal LAD. patient reports prior history of blood in stool while on ASA. Advised
of benefits of ASA for her , and started on 81mg every day , advised to try this
and discuss further with her primary care physician.
PUMP: gave 500cc NS. patient with no further episodes on ambulation. Unable to
perform echo prior to discharge but may pursue this as an outpatient.
patient noted to be hypertensive to 180 SBP 20-24h after atenolol dose.
Therefore switched to twice a day frequency with 1/2 dose ( 25mg ) given
bradycardia. May consider increasing imdur if persistent hypertension.
GI: dyspepsia. Started PPI , chk'd H.pylori. May benefit from EGD as
outpt. D/c'd on H2 blker
ENDO: mildly subtherapeutic on levoxyl , increased to 75mcg every day
MSK: trochanteric bursitis. Rx'd with
NSAIDS , d/c'd on celebrex , but may consider changing to hi dose
ibuprofen
PULM: asthma , cont'd albuterol inhaled as needed
PPX: lovenox for DVT ppx
ADDITIONAL COMMENTS: It is important that you call Dr. Tabbaa for a follow up appointment
within the next 1-2 weeks. You should take all medications on the
discharge list at the doses specified. It is important that you stay
well hydrated. If you feel lightheaded , fall , or lose consciousness ,
call your doctor or seek attention at the nearest emergency room.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: NETTI , DARNELL TATIANA , M.D. ( JC301 ) 6/8/04 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 704
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
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450006899 | PUO | 77741572 | | 4237179 | 9/19/2005 12:00:00 a.m. | RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 11/2/2005 Report Status: Signed
Discharge Date: 5/24/2005
ATTENDING: MONDELL , MELINA MD
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old female
transferred from the Internal Medicine Service for acute
cholecystitis. The patient presented with abdominal pain for
five days , nausea , vomiting and shortness of breath. The patient
was originally admitted to the Internal Medicine Service where
she received a cardiac rule out. A CT scan was obtained on
11/2/2005 , which showed an inflamed gallbladder , which
corresponded to patient's ongoing right upper quadrant pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Diabetes mellitus type 2 ( untreated ).
OUTPATIENT MEDICATIONS: Atenolol 50 mg orally daily ,
hydrochlorothiazide 25 mg orally daily , Nexium 40 mg orally daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vitals: 98.4 , heart rate 101 , pulse 82 ,
blood pressure 92/60 , respirations 20 , 96% on room air.
Appearance: Comfortable , in no acute distress. Cardiovascular:
Regular S1 , S2. No gallops , rubs or murmurs. Pulmonary: Clear
to auscultation bilaterally. No wheezes or crackles. Abdomen:
Soft , mildly distended , right upper quadrant tenderness with
guarding , positive Murphy's , no rebound , positive bowel sounds ,
no peritoneal signs. Extremities: No clubbing , cyanosis or
edema. Rectal: Guaiac negative , no masses.
IMAGING: CT of the abdomen , distended gallbladder with
gallbladder wall thickening , pericholecystic fluid , bile duct
within normal limits.
HOSPITAL COURSE BY PROBLEMS:
1. Acute cholecystitis: The patient was taken to the operating
room on 6/9/2005 for open cholecystectomy. There were no
complications and the patient was moved to the general surgical
floor and continued to recover without complication. By
postoperative day #6 , she was tolerating a regular diet and
ambulatory. However , the patient developed productive cough and
a chest x-ray was obtained , which failed to show any infiltrate
and she remained afebrile throughout her hospital stay. She was
discharged with Robitussin A-C and instruction to call or return
to the hospital if she developed worsening cough , fever , vomiting
or had any other concerns. In addition , she was instructed to
follow up with Dr. Mondell for staple removal and wound check as
well as her primary care doctor.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally daily , atenolol 50 mg
orally daily , hydrochlorothiazide 25 mg orally daily , Lipitor 40 mg
orally daily.
DISCHARGE RECOMMENDATIONS AND FOLLOWUP:
1. The patient was instructed to follow up with Dr. Mondell in
one week for wound check and staple removal.
2. The patient was instructed to follow up with her primary care
doctor. An appointment was scheduled for Dr. Augustine Milholland on
10/17/2005 at 11:30 a.m. The patient was notified that she
likely has untreated diabetes and needs to be started on new
medications.
eScription document: 3-3236372 RFFocus
Dictated By: MANKOSKI , ROSSIE
Attending: MONDELL , MELINA
Dictation ID 3207666
D: 4/4/05
T: 4/4/05
Document id: 705
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
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601453381 | PUO | 58735436 | | 7701444 | 6/20/2003 12:00:00 a.m. | FEVER | Signed | DIS | Admission Date: 9/17/2003 Report Status: Signed
Discharge Date: 4/19/2003
CHIEF COMPLAINT: Mr. Rude is a 55-year-old gentleman with a
history of end stage renal disease on
hemodialysis , who presents with fevers.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old gentleman with
end stage renal disease on
hemodialysis , hepatitis C positive , history of MRSA bacteremia ,
hypertension , CAD , status post MI , and sick sinus syndrome , status
post pacemaker in 1998 , who presents with fevers , chills , and a
question of an infected pacemaker pocket site. In October 2003 , he
had debridement of the pacemaker pocket and was doing fine , and
then over the week leading up to this admission , he developed
itching and tenderness of his right chest at the pacemaker site.
He was sent to the emergency room from hemodialysis today for
evaluation of his infected site. The pacemaker at that point was
scheduled to be removed on 9/17/03 , and when he was seen in the
emergency room , he denied any chest pain , shortness of breath ,
nausea , vomiting , diarrhea , cough , sputum production.
PAST MEDICAL/SURGICAL HISTORY: End stage renal disease on
hemodialysis , hepatitis C , history
of MRSA bacteremia , hypertension , CAD , status post MI , sick sinus
syndrome , status post pacemaker in 1998 , history of closed head
injury with subsequent mental retardation , history of
hyperparathyroids , status post parathyroidectomy , status post
partial gastrectomy for a peptic ulcer disease.
MEDICATIONS: Fosamax 70 mg every week , calcium , Zoloft , Vasotec ,
Risperdal , diltiazem , Lopressor , aspirin , Zantac ,
Colace , Nephrocaps.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives at home with a roommate. His uncle is his
healthcare proxy. He has a past history of
smoking for two years , although quit a long time ago. He uses
alcohol occasionally. No intravenous drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.8 , heart rate
80 , blood pressure 130/80 , satting 97% on
room air. GENERAL: He was generally comfortable-appearing in no
acute distress. HEENT: Pupils equal , round , and reactive to
light , sclerae nonicteric , moist mucous membranes , OP clear. NECK:
No lymphadenopathy , no JVD , supple. LUNGS: Clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm , no murmurs , rubs , or
gallops. ABDOMEN: Soft , non-tender , non-distended , with positive
bowel sounds. EXTREMITIES: Warm , DPs 2+. CHEST: Positive right
upper outer quadrant of chest over pacemaker site , with area of
erythema and fluctuance. NEURO: Alert and oriented x2 , non-focal
exam.
LABORATORY DATA: Include white blood cell count 7.3 , hematocrit
31 , platelets 256 , MCV of 113. Sodium 140 ,
potassium 4.2 , chloride 100 , bicarb 31 , BUN 23 , creatinine 6.1 ,
glucose 101 , calcium 8.3 , magnesium 1.9 , albumin 3.5 , total protein
9.2 , phos 2.0. Chest x-ray no infiltrate. EKG normal sinus
rhythm , no ST segment changes , left axis deviation and LVH , no
pacemaker spikes noted.
HOSPITAL COURSE/ASSESSMENT AND PLAN: 1. ID - Candida non-albicans
grew out of his cultures from
his hemodialysis center. He was started on amphotericin-B with an
ID consult , and will complete a four week course on 2/18/03. His
cultures here at the Kernan To Dautedi University Of Of remain negative. They removed his
infected pacemaker , as well as his Hickman catheter. He has been
afebrile here for the last several weeks , 2-3 weeks prior to
discharge.
2. Cardiovascular - ( A ) Rhythm - His pacemaker was removed. It
had been interrogated not long prior to his admission here and had
not been firing , and therefore , did not appear to be needed anyway.
He had to return to the EP lab a second time for a lead extraction ,
as they were unable to pull out the leads on the first attempt. By
his repeat echoes , however , he appears to have a retained pacemaker
wire although EP believes that they removed the entire wire for all
intents and purposes. It should be assumed that he does have a
retained wire , however. Also , the patient had episodes of atrial
flutter with rapid ventricular response and a decreased blood
pressure after his pacemaker was removed. He was ultimately
treated with amiodarone with excellent control over his weight and
rhythm , and has been in normal sinus rhythm for the last week or so
prior to discharge. There are no plans for pacemaker placement at
this time. ( B ) Ischemia - He complained of chest pain while he was
here and ruled out for a MI. ( C ) Pump - Hypertensive while in
atrial flutter and then again during an episode of acute blood
loss. Since both issues have resolved , his blood pressures have
been very stable. He is to be continued on his Vasotec and
Lopressor. ( D ) Vascular - He had a traumatic left groin line
attempt. Vascular , subsequently , performed a groin exploration ,
hematoma evacuation , and sutured his vascular laceration. The
patient continued to lose a significant amount of blood into his
thigh , requiring several units of blood and one unit of platelets.
His hematocrit , however , has now been stable for one week prior to
discharge. He has a follow-up appointment with vascular on
11/20/03.
3. FEN/GU - Hemodialysis patent , very poor access. After removal
of his possibly infected hemodialysis catheter , IR was completely
unable to place an IJ or subclavian catheter on either side.
Ultimately , they had to place a tunnelled right groin line which is
very poor long-term option. He has a followup in vascular clinic with Dr Loerwald
on 11/10/03 to address his access issue , for possible creatine of a groin
AVfistula or graft.
4. Heme - Hematocrit now stable , high 20s , low 30s. B12 and
folate are normal.
5. Disposition - The patient is to be discharged to rehab on
10/11/03 in stable condition. He has become very deconditioned
while he was here in the hospital as he was unable to get much physical therapy
here given both his groin hematoma and some of his groin access
issues. Now there are no restrictions on his activity as his right
groin line is tunnelled.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed headache ,
amiodarone 200 mg orally every day , amphotericin
125 mg intravenous every 24 hours to be given with 100 mg of hydrocortisone intravenous prior
to his amphotericin , also should be treated with 1 mg intravenous of
morphine prior to his amphotericin administration , Phoslo 2 tabs
orally before every meal and every bedtime , Cepacol 1-2 lozenges orally every 4 hours as needed
throat pain , Cepacol 1 lozenge orally three times a day , Colace 100 mg orally
twice a day , Vasotec 40 mg orally every day , hydrocortisone 100 mg intravenous every day ,
Lopressor 50 mg orally three times a day , Percocet 1 tab orally every 6 hours , low dose
because he is a hemodialysis patient , Zoloft 50 mg orally every day ,
Risperdal 1 mg orally every bedtime , Nephrocaps 1 tab orally every day , calcium
carbonate plus vitamin D 2 tabs orally twice a day away from meals , Nexium
40 mg orally every day , ondansetron 4 mg intravenous as needed emesis.
FOLLOW-UP APPOINTMENTS: ( 1 ) Include 11/10/03 at 1:15 p.m. with
Dr. Loerwald , vascular surgery clinic at the
I Warho Hospital . This is for both a left postop groin
check , as well as to address his access problems. ( 2 ) He has
hemodialysis three times a week.
Dictated By: BERNA O. RUKA , M.D. RS18
Attending: ANNALEE DITOMMASO , M.D. JJ1
IC268/253692
Batch: 8651 Index No. GAFV7Z08M5 D: 8/10/03
T: 8/10/03
Document id: 706
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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921778812 | PUO | 49448215 | | 3595863 | 10/23/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: Report Status: Signed
Discharge Date: 10/23/2003
Date of Discharge: 10/23/2003
ATTENDING: MARILYN FREHSE MD
The patient was on the Arvai Sonprince Hospital
PRINCIPAL DIAGNOSIS: Small bowel obstruction.
HISTORY OF PRESENT ILLNESS: This is an 80-year-old woman with a
past medical history of incarcerated umbilical hernia. She also
has a history of coronary artery disease. She presented with one
day of substernal chest pain , shortness of breath , and nausea.
The patient has normal angina pain , which is usually treated with
nitroglycerin , but she had run out. The chest pain had resolved
with nitroglycerin given in the ambulance. The patient also
complained of having abdominal pain for the past few days with
some nausea. Her last bowel movement was two days before
admission with no flatus for the past two days as well. The
abdominal pain was worst today. The patient was felt to have a
partial small bowel obstruction in the emergency room and was
evaluated by both the surgical service and the medical service.
PAST MEDICAL HISTORY: Incarcerated umbilical hernia and a mitral
valve replacement with a St. Jude valve in 1990. She had
coronary artery disease with a clean catheterization in 2001 ,
hypertension , diabetes , diverticulitis , status post a sigmoid
colectomy , and atrial fibrillation controlled with Coumadin 3.5
mg every day
MEDICATIONS: Lasix 80 mg every day , Glyburide 5 mg every day , Lisinopril
20 mg every day , Norvasc 10 mg every day , Coumadin 3.5 mg every day , Isordil 20
mg three times a day , amiodarone 200 mg once a day.
ALLERGIES: She has allergies to aspirin , penicillin , and
sotalol.
SOCIAL HISTORY: She lives alone with no smoking and no alcohol
use.
ADMISSION PHYSICAL EXAM: Vital signs: Temperature was 96.8 ,
heart rate was 76 , respiratory rate was 18 , blood pressure
152/79 , O2 saturation was 94% on two liters. In general , she was
in no acute distress and pleasant. Cardiovascular exam: She had
an irregular rhythm with audible S1 and S2. No S3 was heard. No
murmurs. No jugular venous distension. Chest was clear to
auscultation bilaterally. Her abdomen had increased bowel
sounds , was tympanitic , was diffusely tender. Her extremities
had no edema.
LABS: She had a white blood cell count of 14 , hematocrit of 42 ,
platelets of 221 , 000 , sodium of 144 , potassium of 4 , chloride of
109 , bicarb of 28 , BUN of 20 , creatinine of 1.6 , blood glucose of
200 , troponin I was less than assay , CK was 118 , INR of 2.6. KUB
x-ray showed dilated loops of small bowel consistent with small
bowel obstruction. EKG showed atrial fibrillation at 78 beats
per minute with an incomplete right bundle branch block , an old
inferior MI with loss of anterior fossa.
HOSPITAL COURSE: The patient's abdominal pain was most likely
due to small bowel obstruction secondary to a ventral hernia. It
was decided by the surgical service that the ventral hernia
should be fixed operatively. The medical service evaluated the
patient , decided that her chest pain was her normal baseline
angina and she had no acute coronary syndrome at the time of
admission. Recommendations were made to discontinue her
Coumadin , allow her INR to fall to 1.8 before operating. The
patient was also to be given generous boluses of normal saline
preoperatively to avoid hypotension and tight blood sugar control
during her hospital course. The patient was admitted to the
medical floor before her operation and was scheduled for ventral
hernia repair several days later. During her stay on the
surgical ward , the patient had developed complaints of new visual
changes described as objects of floating in her visual field. At
this point , a CT scan of the head was done to rule out an acute
cerebral avascular accident. Head CT was initially read as
normal. No acute bleed. However re-read as showing a left-sided
sub acute thalamic infarct of 10 days to 2 weeks age. At this
point , a neurological consultation was obtained. The neurology
consultant recommended an MRI/MRA of the head and neck to
evaluate for possible hidden acute stroke and a carotid
ultrasound to assess her carotid artery patency. The MRI/MRA of
her head was negative , a carotid ultrasound was done which was
also negative with no lesions similar to her previous carotid
artery ultrasound of 10/1 A transthoracic echocardiogram was
also done to evaluate for atrial clots. Her echocardiogram was
largely unchanged from her previous echocardiogram of 2002. She
had normal left ventricular function with an ejection fraction of
55% and moderate tricuspid regurgitation. Given this negative
workup for any acute stroke , it was decided to obtain an
ophthalmology consult to evaluate the patient's visual changes.
The ophthalmology consultant attributed her visual changes to
vitreous humor particulate matter , which is very common in older
people. It was most likely the cause of her visual changes. The
ophthalmology consultant recommended every day Pred Forte drops in
each eye for her status post corneal transplant.
The patient was finally taken to the operating room on hospital
day 7 for ventral hernia repair. The operation was uncomplicated
with minimal blood loss. Postoperatively , the patient's course
progressed well with good pain control , good progression of diet
and good ambulation. Postoperatively , the patient was restarted
on Coumadin and placed on intravenous heparin for prophylaxis secondary to
her mitral valve prosthetic. The patient remained in the
hospital for seven days after her operation for adequate
anticoagulation with Coumadin. On postop day 3 , the patient was
noticed to have bright red blood in her urine. A urological
consult was obtained for evaluation of gross hematuria. CAT scan
showed several centimeters of calcified bladder wall , which is
indicative of infection versus tumor. However no gross tumor
mass was observed and the remainder of her collecting system was
normal. The urological consult recommended follow up in Urology
Clinic in two to four weeks. The patient was then discharged on
postop day 7 to the Sa Pehall for continued physical therapy.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Amiodarone 200 mg orally every day , vitamin B12
15 mcg orally every day , Colace 100 mg orally twice a day , Folate 1 mg orally
every day , glipizide 2.5 mg orally every day , Isordil 20 mg orally three times a day ,
lisinopril 20 mg orally every day , Pred Forte Ophthalmic one drop each
eye every day for seven days , vitamin B6 50 mg orally every day , Coumadin 7.5
mg every afternoon , Norvasc 10 mg orally every day
DISPOSITION: The patient will follow up with Dr. Frehse in
Surgery Clinic in one week and the patient will follow up in
Urology Clinic in two to four weeks.
eScription document: 7-5032989 EMSSten Tel
Dictated By: BARRETTE , GENNY
Attending: FREHSE , MARILYN
Dictation ID 3911210
D: 11/11/03
T: 11/11/03
Document id: 707
| Target |
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Gs |
GER |
Gou |
HC |
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Obe |
OSA |
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| output/system_textual_annotation.xml | textual |
U |
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Y |
U |
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U |
Y |
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U |
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Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
N |
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N |
344200926 | PUO | 90744314 | | 846573 | 4/8/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/14/1991 Report Status: Signed
Discharge Date: 11/2/1991
ADMISSION DIAGNOSES: 1 ) ATYPICAL CHEST PAIN.
2 ) HYPERTENSION.
3 ) DIABETES.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old white
male with a history of chest pain ,
hypertension , diabetes , Duke C colon carcinoma who presents with a
three day history of worsening chest pain and shortness of breath.
His cardiac risk factors include hypertension , diabetes , positive
family history , and hypercholesterolemia. The patient does not
smoke. The patient had a screening echocardiogram in 30 of November in
Aman Y Sidfro Community Medical Center which revealed normal LV function , trace
AI , question of aortic valve prolapse. The patient has been doing
well and notes that beginning in early 1990 began to have what was
described as stable exertional angina. An ETT in 13 of October was
consistent with but not diagnostic of ischemia. The patient
reports that approximately six months ago he noticed some slight
DOE and fatigue at work. The patient also reports that he has
frequent chest pain in the morning , described as substernal without
any radiation. The pain is associated with shortness of breath but
no nausea , vomiting or diaphoresis , palpatations or dizziness. This
pain usually lasts approximately 15 to 20 minutes and the patient
did not take nitroglycerin for these pains. Two days prior to
admission the patient reports having a similar episode of a.m.
chest pain , worse than usual , he decided to take nitroglycerin ,
however , his nitroglycerin was over six months old and were without
effect. On the day of admission the patient reports feeling severe
chest pain after vigorous exercise and this pain radiates to his
jaw. This pain persisted until he went to his KTDUOO appointment at
2 p.m. with Dr. Jeramy Cassem , and Dr. Cassem sent the patient to the
EW. The patient's pain was relieved in the EW with Nitro Paste ,
TNG sublingual , MSO4 , and intravenous TNG. The pain lasted a total of approximately
three hours. The patient was admitted to the HYT and was
noticeably diaphoretic on arrival and complaining of some recurrent
chest pain which was relieved with a single sublingual TNG. A finger stick
revealed a glucose of 60 at the time. The patient denies PND ,
lower extremity edema , claudication or orthopnea. He admits to
taking both is a.m. and p.m. insulin doses at one time in the
morning , and reports that he ate two doughnuts and had some coffee
in the morning and had nothing else for the rest of the day. PAST
MEDICAL HISTORY: Includes hypertension , diabetes , peripheral
neuropathy , hypercholesterolemia , Dukes C colon cancer , status post
ileocolostomy in 1979 , negative colonoscopy in 20 of June , CVA in 1977
with residual slight left arm weakness , nasal polypectomy
approximately four years ago , UTI with negative IVP in 1987.
MEDICATIONS: On admission included Atenolol 100 mg orally every day , Isordil
10 mg orally three times a day , aspirin one a day , Enalopril 10 mg orally twice a day ,
hydrochlorothiazide 25 mg orally twice a day , NPH insulin 45 units every day before noon and
15 units every afternoon , Elavil 25 mg orally every day ALLERGIES: Penicillin -
Hives and rash. FAMILY HISTORY: Positive for myocardial
infarction , the patient's father died of an MI at age of 59. SOCIAL
HISTORY: Patient does not smoke , patient admits to ETOH abuse , he
quit drinking approximately two years ago.
PHYSICAL EXAMINATION: The patient was a slightly obese 60-year-old
male lying in no acute distress , slightly
anxious. Vital signs - Temperature afebrile , pulse 60 ,
respirations 20 , blood pressure 110/80. Neck without JVD , 2+
carotids with normal upstroke , no bruits. Chest CTA. Heart RRR ,
S1 and S2 , no murmurs. Abdomen benign. Extremities without edema ,
2+ femoral pulses without bruits , 2+ distal pulses
LABORATORY DATA: The patient's admitting electrolytes were
significant for a potassium of 3.4 , BUN and
creatinine of 23 and 1.3 , glucose of 69. The patient's CKs were
N208 with 6 MBs , 130 , and 104. The patient's WBC was 9.7 , Hct 45 ,
PLT 228 , 000. Coags were WN L.
HOSPITAL COURSE: The patient had no recurrent chest pain since
admission. Cardiac catheterization on 3 of June
revealed only a 40% mid LAD stenosis and slight anterior wall
hypokinesis. It appeared that the patient's chest pain was not
cardiac in origin with clean coronaries and negative CKs. It was
decided to discharge the patient on 17 of July with follow-up in KTDUOO
Clinic with Dr. Eustolia Lawrentz
DISPOSITION: DISCHARGE MEDICATIONS: Included Vaseretic 1 of January
one tablet orally twice a day , Atenolol 50 mg orally every day , Elavil 25
mg orally every day , Ecotrin one orally every day , NPH insulin 45 units sub Q every day before noon
CONDITION: Good. The patient is discharged to home with follow-up
in KTDUOO Clinic with Dr. Jeramy Cassem , the patient will have an
appointment with the nurse in A Ancechi Leni County General Hospital in approximately
one week to check his blood pressure and glucose.
FN512/8475
VITO E. HOLTMANN , M.D. VM0 D: 6/29/91
Batch: 3050 Report: L6026B0 T: 11/19/91
Dictated By: ALYSE HOLDA , M.D.
Document id: 708
| Target |
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| output/system_intuitive_annotation.xml | intuitive |
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210032808 | PUO | 20003943 | | 8179157 | 11/9/2007 12:00:00 a.m. | upper respiratory tract infection/reactive airways | | DIS | Admission Date: 5/27/2007 Report Status:
Discharge Date: 10/16/2007
****** FINAL DISCHARGE ORDERS ******
RANNO , ROMONA 347-43-78-7
Hi Garl Prings
Service: MED
DISCHARGE PATIENT ON: 10/28/07 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GILFOY , DEANDRA LAZARO , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
MEDICATIONS ON ADMISSION:
1. AMLODIPINE 10 MG orally every day
2. BENZTROPINE MESYLATE 1 MG orally twice a day
3. ASPIRIN ENTERIC COATED 81 MG orally every day
4. HYDROXYZINE HCL 50 MG orally twice a day
5. ATORVASTATIN 20 MG orally every bedtime
6. METFORMIN 1000 MG orally twice a day
7. OMEPRAZOLE 40 MG orally every day
8. CHLORPROMAZINE HCL 100 MG orally every bedtime
9. TRAZODONE 100 MG orally every bedtime
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ALBUTEROL INHALER HFA 2 PUFF inhaled four times a day as needed Wheezing
AMLODIPINE 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
COGENTIN ( BENZTROPINE MESYLATE ) 1 MG orally twice a day
THORAZINE ( CHLORPROMAZINE HCL ) 100 MG orally BEDTIME
Alert overridden: Override added on 10/28/07 by :
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
HYDROXYZINE HCL 50 MG orally twice a day as needed Itching
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
2 PUFF inhaled three times a day
Instructions: Take until cold/cough/wheezing symptoms have
completely resolved Food/Drug Interaction Instruction
Contraindicated in Patients with Peanut , Soya or Soyabean
Allergy
METFORMIN 1 , 000 MG orally twice a day
OMEPRAZOLE 40 MG orally DAILY
PNEUMOCOCCAL VAC. POLYVALENT 0.5 MILLILITERS intramuscular x1
Instructions: per Physician Approved Order and Nursing
Screening Form for Inpatient Pneumococcal Immunization.
TRAZODONE 100-200 MG orally BEDTIME Starting Today ( 3/22 )
as needed Insomnia
DIET: House / Carbohydrate Controlled / Low saturated fat
low cholesterol
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Ellena Schuneman 2-4 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
wheezing
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
upper respiratory tract infection/reactive airways
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Coronary artery disease , hyperlipidemia , mild aortic stenosis
DM-II , Goiter , HTN , schizoaffective disorder , GERD.
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
HPI:
71F diabetic with hx of HTN , schizoaffective disorder here with
wheezing/DOE. Has had 2 weeks of congestion , productive cough--clear
sputum-- worsening wheeze over last day. No history of
asthma/tobacco. Daughter had bad URI 2wks ago. No CP/pressure. No
fever/chills/NS. No N/V/D. Responded very well to Nebs in ED.
-------
PMHx: NIDDM , HTN , mild AS ( AVA 1.6 ) , +dipyrimadole PET--small
rev defect LCx/OM1 territory , hyperlipidemia , schizoaffective.
FHx: mother/sister with cardiac death in 60s , diabetes.
SHx: nonsmoker ( quit >15yrs ago ) , no EtOH , no drugs
-------
Physical Exam: T: AF , BP108/70 , P 80s , R18 , Sat 96-98% on RA
Gen: A&Ox3 , well appearing. Resp: no wheezes. CTAB.
CV: RRR , 3/6 early peaking systolic murmur , obscuring S1. S2 wnl , no
gallops/rubs. Abd: obese , soft , NT , ND , NABS
Ext: 2+ distal pulses , no edema.
--------
Labs: WBC 7 , Hgb 12.4 , Enzymes negative. CXR: trace bibasilar
atalectasis , no infiltrate/effusion.
EKG: NSR @85 , 1st degree AV block , otherwise nl.
--------
Hospital Course/A&P:
71F diabetic here with reactive airways 2/2 to URI , markedly improved
post bronchodilators , doing well.
1. Pulm: --> start MDI albuterol/atrovent.
-->given steroids in ED , will discontinue given marked improvement , no
smoking hx , no COPD on CXR.
-->No indication for antibiotics/no evidence pneumonia.
2. CV ( I/R )--No active issues. Cont ASA , lipitor , amlodipine.
( P ) BP stable , well controlled on home meds.
3. Schizoaffective: continue cogentin , trazodone and thorazine every bedtime
MS stable , mood level.
4. Diabetes: continued metformin--not switched to
insulin given minimal illness , plan for rapid D/C.
5. Hx of anemia--HCT near normal. Continue Iron vit.
6. Ppx: omeprazole , ambulating , colace.
ADDITIONAL COMMENTS: Your wheezing has improved rapidly after starting inhalers. These
medicines help open up the airways in your lungs.
Take atrovent , 2 puffs , 4 times daily until your cold symptoms have
completely resolved.
Take albuterol , 2 puffs as needed up to four times daily if you
still have wheezing or shortness of breath in spite of the atrovent
inhaler.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Followup resolution of wheezing. Can likely discontinue atrovent
inhaler--keep albuterol as as needed in the event of recurrent URI trigger.
2. Ongoing management of psych meds.
3. Cardiovascular/diabetes followup.
No dictated summary
ENTERED BY: JOURNEAY , WINFRED T. , M.D. ( ZO641 ) 10/28/07 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 709
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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449325050 | PUO | 44544705 | | 1238555 | 2/10/2005 12:00:00 a.m. | Cardiomyopathy , LV thrombus | | DIS | Admission Date: 2/8/2005 Report Status:
Discharge Date: 2/14/2005
****** DISCHARGE ORDERS ******
LABRE , MANUELA 542-30-17-1
Spo Gu Room: En Heim Za , New Jersey 75832
Service: MED
DISCHARGE PATIENT ON: 11/28/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
DIGOXIN 0.25 MG orally every day
ENALAPRIL MALEATE 20 MG orally every day Starting IN a.m. ( 4/16 )
Override Notice: Override added on 4/10/05 by
FIGURA , CAREY T. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
79423334 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: aware
Previous override information:
Override added on 4/18/05 by FIGURA , CAREY T. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
ENALAPRIL MALEATE Reason for override: aware
LASIX ( FUROSEMIDE ) 80 MG orally every day
GLIPIZIDE 5 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 7.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally every day Starting IN a.m. ( 4/16 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
GABAPENTIN 100 MG orally three times a day
LOVENOX ( ENOXAPARIN ) 60 MG subcutaneously every 12 hours
LANTUS ( INSULIN GLARGINE ) 12 UNITS subcutaneously every day
ARANESP ( DARBEPOETIN ALFA ) 300 MCG subcutaneously Q2WEEKS
Reason for ordering: Oncology - Chemotherapy Induced Anemia
Last known Hgb level at time of order: 12.0 g/dL on
4/18/05 at PUO Symptoms: SOB ,
Diagnosis: Anemia in Neoplastic Disease 285.22
Treatment Cycle: Maintenance
NOVOLOG ( INSULIN ASPART ) 5 UNITS subcutaneously before meals
DIET: Patient should measure weight daily
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Katheryn Gruntz full; Dr. will call patient to set up ,
Dr. Elinore Prazak full until 3/23 Dr. will call patient to set up earlier appt ,
Dr. Julieann Geeding at MMC Shingathens Lietperv March , 12:00 PM scheduled ,
Arrange INR to be drawn on 1/13/05 with f/u INR's to be drawn every
2 days. INR's will be followed by Dr. Julieann Geeding
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
New cardiomyopathy , LV thrombus
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Cardiomyopathy , LV thrombus
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CMP ( cardiomyopathy ) HTN ( hypertension ) DM ( diabetes
mellitus ) breast cancer ( breast cancer )
OPERATIONS AND PROCEDURES:
Adenosine-MIBI
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
71yoF with history of recurrent breast cancer history of 2 cycles
taxol , one year of herceptin , history of DM , HTN who p/with one month worsening
fatigue and DOE found to have new cardiomyopathy with EF 15% and LV
mural thrombus. Fatigue began around a month ago when
taxol therapy started. No CP/PND/orthopnea , no LE edema increasing
abd girth or palpitations. patient denies URI sx , no n/v/d , no f/c. Can
walk barely one flight before DOE , no claudication sx.
Patient sleep on side with one pillow. Noted cardiomegaly and
pleural effusion on CT 8/22 ( brca staging ) , subsequent with u included
echo at Tulok 4/25 as described above. In ED patient had a negative I
+head CT to r/o mets , guaiac negative , started heparin drip with
bolus. PMH: Brca ( originally dx 1986 , her2 positive ) , HTN ,
DM , history of fibroids Meds at home: lantus , metformin , glyburide ,
enalapril , protonix , aranesp q2wk , zometa. PE: T96.8 , hr99 , bp102/60 ,
r20 , sat 99%3LNC Gen: aox3 , nad , H/N: jvp 10cm water , no thyroid
masses , chest few bibasilar rales , heart RRR +s3 , abd soft ntnd nabs ,
ext wwp , trace pedal edema. Labs: Na 130 , K3.5 , gluc 379 , WBC 1.95
with 30% pmn , hct 36 , plt 403 , inr 1.2 , ck/mb/tni
negative. EKG: NSR at 96bpm , nl volts , no acute STTW
changes. Head CT negative; CXR small left effusion ,
cardiomegaly.
**************hospital course******************
1 ) Heme: L ventricular mural apical thrombus , confirmed by Echo PUO
7/20/05. Head CT on admission showed no evidence of brain mets. On
therapeutic heparin drops , goal PTT 60-80 sec , bridging to Coumadin
starting at 5 mg orally every day , following INR for goal 2-3. INR curr 1.4 ,
bridging with Lovenox until therapeutic; will set up f/u with
Coumadin Clinic.
2 ) Pump: New dilated cardiomyopathy , EF 15% , BNP 230. CMP likely
due to Herceptin; however , actively ruling out other possible causes ,
esp ischemic. Adenosine-MIBI 6/8/05 converted to planar imaging
due to patient claustrophobia/movement , decreased sens/spec c/with MIBI
but no obvious concerning perfusion defects on wet read; however ,
official read was 'non-diagnostic.' Consider Cath or PET
as an outpatient. ACE , SPEP/UPEP pending. Fe studies show iron
deficiency , which rules out hemochromatosis. TSH decreased at 0.333 ,
?hyperthyroidism; T4 wnl , THBR slightly elev. Slightly volume
overloaded , on Lasix 80 mg orally every day , checking daily I/O's , goal is neg
0.5-1 L daily TBB. On Enalapril , low-dose Lopressor ,
Digoxin 3 ) ID: WBC 1.9 on admission , polys 16% ` ANC
~400. Neutropenic on admission , still on precautions , WBC
increasing steadily and ANC improving. CIS T>100.5. 4 ) Ischemia:
Appreciate Cardiology consult Dr. Katheryn Gruntz ( MMC ).
Toscine Medical Center ( avoiding cath given neutropenia ) on Tuesday 6/8/05
to assess for CAD was non-diagnostic. Lopressor ,
Enalapril 5 ) Endo: DM , HbA1c 8.2%. On Lantus 12 mg subcutaneously every day ,
Novolog 5 mg subcutaneously before every meal , Glipizide 5 mg orally every day , Novolog sliding scale.
TSH 0.3 , T4 7.7 , THBR 1.29. Holding Metformin.
6 ) Renal: Cr 1.0 on admission , history of DM and HTN , on ACE for renal
protection
7 ) Onc: Per Oncology recommendations , continue to
hold Herceptin given current EF 15%.
8 ) PPx: Nexium for GI , heparin.
9 ) Dispo: Follow-up with Dr. Katheryn Gruntz ( MMC Cards ) , Dr. Elinore Prazak
( MMC Onc ) , Dr. Julieann Geeding ( MMC primary care physician ).
for LV thrombus and prevention of DVT.
FULL
CODE
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow-up with Dr. Katheryn Gruntz ( Bea Duna Medical Center ) , Dr. Elinore Prazak ( MMC
Onc ) , Dr. Julieann Geeding ( MMC primary care physician ).
Note to primary care physician: patient is now on Coumadin , needs close INR f/u for the
immediate future. patient lives in Quarpat Highway but has a Vi Els Mahunt Lab near home.
F/u with Onc re change of chemotherapy regimen ( holding Herceptin as
likely cause of CMP ).
No dictated summary
ENTERED BY: FIGURA , CAREY T. , M.D. ( VT32 ) 11/28/05 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 710
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
N |
Y |
Y |
N |
- |
Y |
Y |
- |
- |
N |
Y |
N |
N |
- |
510916525 | PUO | 07122247 | | 5156600 | 4/19/2003 12:00:00 a.m. | history of ureteral stent | | DIS | Admission Date: 4/19/2003 Report Status:
Discharge Date: 2/16/2003
****** DISCHARGE ORDERS ******
FULVIO , ANGILA P 456-02-11-5
Orl Au , Hawaii 18977 Room: Son Chulinownettesalt Seatza Mont
Service: URO
DISCHARGE PATIENT ON: 10/19/03 AT 09:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MANKOSKI , ROSSIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally every day
ELAVIL ( AMITRIPTYLINE HCL ) 25 MG orally every bedtime
Override Notice: Override added on 2/26/03 by RICHINS , MARLANA YUKI , M.D.
on order for LEVOFLOXACIN orally 250 MG every day ( ref # 95302735 )
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: will monitor
Previous override information:
Override added on 4/30/03 by RICHINS , MARLANA YUKI , M.D.
on order for LEVOFLOXACIN orally ( ref # 01736061 )
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: will monitor
ATENOLOL 100 MG orally every day Starting Today ( 1/13 )
COLCHICINE 0.6 MG orally twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally twice a day Starting Today ( 1/13 )
GLIPIZIDE 5 MG orally every day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
NIFEREX-150 150 MG orally twice a day
Instructions: separate from Levoflox dose by two hours
Alert overridden: Override added on 2/26/03 by
TAAL , DARLA TOSHIA , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
POLYSACCHARIDE IRON COMPLEX Reason for override:
will separate doses by 2 hours Previous Alert overridden
Override added on 2/26/03 by TAAL , DARLA TOSHIA , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
POLYSACCHARIDE IRON COMPLEX Reason for override: ok
PERCOCET 1 TAB orally every 6 hours as needed Pain
SIMVASTATIN 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ISOSORBIDE MONONITRATE 60 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 9
ACARBOSE 25 MG orally three times a day
Number of Doses Required ( approximate ): 5
LEVOFLOXACIN 250 MG orally every day
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 2/26/03 by
TAAL , DARLA TOSHIA , M.D.
on order for NIFEREX-150 orally 150 MG twice a day ( ref # 36242341 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
POLYSACCHARIDE IRON COMPLEX Reason for override:
will separate doses by 2 hours
Previous override information:
Override added on 2/26/03 by RICHINS , MARLANA YUKI , M.D.
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: will monitor
Previous Alert overridden
Override added on 4/30/03 by RICHINS , MARLANA YUKI , M.D.
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: will monitor
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
FENOFIBRATE 54 MG orally every day
Number of Doses Required ( approximate ): 5
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
URISED 2 TAB orally four times a day as needed Pain
DIET: No Restrictions
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lorean Kadow , call to scheudle appointment 2-3 weeks ,
Dr. Derham , call to schedule appointment as directed ,
Dr. Spillett call to schedule appointment next week ,
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
Forniceal Rupture
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of ureteral stent
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
lad stent 2/14 dm ( diabetes mellitus ) obesity
( obesity ) hyperchol ( elevated cholesterol ) gout
( gout ) emphysema ( chronic obstructive pulmonary disease ) renal
insufficiency ( chronic renal dysfunction ) sick sinus syndrome ( sick
sinus syndrome ) pacemaker ( pacemaker )
OPERATIONS AND PROCEDURES:
Placement right ureteral stent by Dr. Lorean Kadow
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
69M with known AAA present three days from ureteroscopy at TH
complicated by forniceal rupture with flank and groin pain. To OR on
HD#2 for ureteral stent placement. Procedure without complications.
Patient tolerated well. Stent was noted to drain bloody fluid during
procedure. Post-op patient had mild flank discomfort consistent with
stent placement. POD#1 patient has eposide of hypertension to 90/45
systolic with mild postural dizziness. Sx and signs resoved with Po
fluids and holding one dose atenolol. At time of discharge on POD#2
patient was comfortable , tolerating orally and without dizziness or
hypotension.
ADDITIONAL COMMENTS: You may experience soem flank and groin discomfort from the stent. Take
pain medications as needed. If you esperience severe abdominal or back
pain come to the emergency department. Call Urology clinic for
questions or concerns related to the stent. Schedule follow-up with Dr.
Bucknor regarding treatment of your aneurysm.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KNOWER , ANGELIA ROSLYN , M.D. ( ZK82 ) 10/19/03 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 711
| Target |
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GER |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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881672314 | PUO | 10211516 | | 7557994 | 10/8/2005 12:00:00 a.m. | same | | DIS | Admission Date: 10/8/2005 Report Status:
Discharge Date: 8/12/2005
****** FINAL DISCHARGE ORDERS ******
BETSILL , DALILA L 202-19-19-5
Burg , Illinois 11747 Room: Pa Rham Son
Service: URO
DISCHARGE PATIENT ON: 1/20/05 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CRIDGE , LORRETTA PA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
CAPSAICIN 0.025 % TP twice a day Instructions: apply to legs
LASIX ( FUROSEMIDE ) 40 MG orally every day
MICRONASE ( GLYBURIDE ) 2.5 MG orally every day
L-THYROXINE ( LEVOTHYROXINE SODIUM ) 50 MCG orally every day
Alert overridden: Override added on 9/19/05 by
RANNELLS , ADDIE JEFFEREY , M.D.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: home
PYRIDIUM ( PHENAZOPYRIDINE HCL ) 100 MG orally three times a day
as needed Other:bladder/stent pain
PROBENECID 1 , 500 MG orally twice a day
COZAAR ( LOSARTAN ) 75 MG orally every day HOLD IF: sbp <100
Number of Doses Required ( approximate ): 5
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
BACTRIM DS ( TRIMETHOPRIM/SULFAMETHOXAZOLE DOU... )
1 TAB orally every 24 hours
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Cridge at 163-566-5922 Please call office for follow-up appointment ,
ALLERGY: Aspirin , Morphine , ALLOPURINOL , ALENDRONATE ,
FOSINOPRIL , Codeine , CARBAMAZEPINE
ADMIT DIAGNOSIS:
nephrolithiasis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , gout , OA , Afib , Diverticulitis , nephrolithiasis , CRI , sleep apnea.
OPERATIONS AND PROCEDURES:
cystoscopy , L ureteroscopy , L retrograde pyelogram , Laser lithotripsy and
L stent placement.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none.
BRIEF RESUME OF HOSPITAL COURSE:
This is a 79 yoM with a 1 cm L renal stone that was stable for years but
caused left hip and flank pain with nausea and vomiting. Patient was
admitted to PUO on 6/25/05. With hx of Afib , patient's cardiologist Dr.
Meduna was consulted and coumadin was helf for operation. It was
orginally planned to reverse INR with FFP but patient felt throat
tightness after 5 min of FFP transfusion and FFP was stopped. Patient
underwent laser lithotripsy and stent placement on 11/17/50 and he
tolerated the procedure well. Immediate post-op , patient had frequent PVC
but cardiac enzyme was negative. Foley was removed on POD1 midnight and
patient voided without difficulties with post void residue 120 cc.
Patient was noticed to have an enlarged prostate during procedure and
need to follow up with Dr. Cridge for further management. On POD2 , patient
tolerated regular diet , and was ready to be discharged home with Bactrim
and low dose Coumadin. He is to follow up with his primary care physician for INR check and
Coumadin dose adjustment.
ADDITIONAL COMMENTS: Please start taking Coumadin at 3 mg for tonight and tomorrow night and
resume your regular coumadine dose schedule. Call your Coumadin clinic on
Monday for follow up regarding to blood check and coumadin dosage
adjustment. No lifting more that 10 lbs. No driving while on narcotics.
Please call for fever > 101.5 , unable to urinate , shortness of breath or
any other concerning symptoms. Call Urology office 163-566-5922 for
appointment and questions.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GALASHAW , DORIAN , M.D. , PH.D. ( HU80 ) 1/20/05 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 712
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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856450649 | PUO | 99098383 | | 5648542 | 5/9/2003 12:00:00 a.m. | CHF | | DIS | Admission Date: 5/30/2003 Report Status:
Discharge Date: 3/2/2003
****** DISCHARGE ORDERS ******
CUBETA , LEOLA T 685-91-92-4
M A Ba Room: Go Alb Virg
Service: MED
DISCHARGE PATIENT ON: 7/29/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
ALLOPURINOL 300 MG orally every day
LISINOPRIL 20 MG orally twice a day
Override Notice: Override added on 1/5/03 by
BLANDING , JOHNETTE TERESA , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 64128907 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
LEVOFLOXACIN 500 MG orally every day
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
CELEXA ( CITALOPRAM ) 20 MG orally every day
VIOXX ( ROFECOXIB ) 25 MG orally every day
Food/Drug Interaction Instruction Take with food
TORSEMIDE 20 MG orally twice a day
TRAZODONE 50 MG orally HS
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
METROGEL 0.75% ( METRONIDAZOLE ) TOPICAL TP twice a day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Timbrook 2-3 weeks ,
Dr. Reyes Mcpeck urology 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid Obesitiy atrial fibrilation ( atrial fibrillation ) anxiety
( anxiety ) depression ( depression ) sleep apnea ( sleep
apnea ) copd ( chronic obstructive pulmonary disease ) chf ( congestive
heart failure ) gout ( gout ) anemia ( anemia ) osteoarthritis
( osteoarthritis ) pancreatitis ( pancreatitis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
63 year-old M with morbid obesity , hx OSA , CHF , chronic venous statis ulcer
presents with progressive SOB , DOE. patient had been recently cutting back
on dose of torsemide since he had been experiencing episodes of
incontinence. In addition , patient had c/o 3 day hx fevers/chills , and
cough with sputum production. CXR found RLL infiltrate by report ( film
done at TH ) as well as vascular congestion. patient also with venous stasis
ulcer on R tibia , has been growing in size over past 6 weeks , VNA
doing wet to dry dressings at home. In ED febrile to 100.3 , exam
significant for some ronchi at R base , rales bialterally at bases ,
large ( 10cm ) area of macerated skin RLE , dressed.
Hospital Course:
1. CV- patient in CHF from CXR findings , hypoxia , foley inserted and
started on lasix 60mg intravenous twice a day The patient had an excellent diuretic
response to this regimen , diuresing up to 1.5 L neg per day over the
first three days of admission. Endpoint of diuresis difficult to
assess , but patient was converted back to orally diuretics on 4/18/03. patient last
had echo over 2 yrs ago , repeated echo showed EF 60-65% with mild MR and
calcified mitral annulus. Initial EKG thought to be afib probably not
afib since it showed a regular rhythm , but may be junctional rhythm.
2. ID- Presumed RLL PNA , started on levofloxacin , will repeat CXR here
since no film available for viewing from TH .
3. Skin/wounds- large venous stasis ulcer on R tibial region , also patient
has decub skin breakdown- consulted skin care nurse to recommend
appropriate therapy , nurses will follow skin care instructions for
Ag dressings and duoderm , will continue dressings with VNA assistance
4. Pulm- patient with OSA , CPAP at night , cont to titrate O2 to SaO2 > 92%
5. GU- patient had been c/o significant incontinence over the past 1-2
weeks and requested to see urology while in house- urology recommended
keeping foley in until decub ulcers heal and patient can have proper eval as
outpatient
6. Disposition- patient discharged to home with VNA services for dressing
changes and foley care , physical therapy. patient will f/u with his primary care
physician and and urology as an outpatient
ADDITIONAL COMMENTS: 1. Please call your primary care physician for an appointment within
the next 2-3 weeks.
2. You should call Dr. Reyes Mcpeck from urology for an appointment , the
phone number is 163-566-5922
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. patient needs VNA nursing services for dressing changes and foley care
2. patient should have CXR followed as outpt , 3cm opacity noted in RLL on
film done 1/4 ( per patient , has barium in R lung from prior barium
aspiration )
No dictated summary
ENTERED BY: ARUIZU , JULIANNE MARIE , M.D. ( QS40 ) 7/29/03 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 713
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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101792361 | PUO | 27336536 | | 0808503 | 3/9/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/14/2006 Report Status: Signed
Discharge Date:
ATTENDING: GUMINA , MARJORY SHELA MD
ADMISSION DIAGNOSES:
Urinary retention and leg pain.
DISCHARGE DIAGNOSES:
Urinary retention and leg pain.
HISTORY OF PRESENT ILLNESS:
Mr. Glembocki is a 48-year-old man with history of bipolar disorder ,
seizure disorder , type 2 diabetes , antiphospholipid antibody
syndrome , on Coumadin anticoagulation , presents with history of
recent URI five weeks prior that developed to sinusitis and has
been on amoxicillin for this. He has had multiple ENT visits for
this. He has noticed abdominal pain , nausea , vomiting but no
diarrhea and he also notes decrease in appetite and generalized
weakness. He also had some right lower extremity pain and was
evaluated by Orthopedics prior with full workup which on
diagnosis no fracture evident. In the emergency room , he had
calf pain so he was evaluated for DVT and LENIS were performed
which showed no clots. He presented also expressing concern of
inability to void with suprapubic tenderness noted. Foley was
placed and removed 1 liter of urine.
PAST MEDICAL HISTORY:
Antiphospholipid antibody syndrome. He has had a left MCA stroke
in 1996 , type II diabetes , seizure disorder , bipolar disorder ,
severe pneumonia in 5/22 , and gout.
MEDICATIONS ON ADMISSION:
1. Depakote extended release 1500 mg nightly.
2. Effexor 150 mg twice a day
3. Lamictal 50 mg orally twice a day
4. Magnesium oxide 400 mg orally twice a day
5. Nexium 20 mg orally daily.
6. Multivitamin one tab daily.
7. Colchicine 0.6 mg orally daily.
8. Glipizide 5 mg orally twice a day
9. Synthroid 50 mcg orally daily.
10. Coumadin 4-6 mg nightly , titrate to INR 2-3.
11. Toprol-XL 50 mg daily.
12. Pravachol 40 mg every bedtime
ALLERGIES:
He is intolerant to Tegretol and to erythromycin , unclear what
the reaction is.
FAMILY HISTORY:
He has a great aunt with seizure disorder and a history of
hypercoagulable disorders in his family.
SOCIAL HISTORY:
He does not smoke or drink or use intravenous drugs. He lives with his
mother.
PHYSICAL EXAMINATION:
He was afebrile 96.6 , heart rate 112 , blood pressure 161/82 ,
respiratory rate 18 , satting 95% on room air. He was awake ,
alert with a flat affect with slow responses and poor eye
contact. He was alert and oriented x2 at the time without
knowing the date. His pupils are equal , round , and reactive. Mucous
membranes are dry. JVP was normal. He had no thyromegaly. His
chest was clear to auscultation bilaterally. His heart was
tachycardic with no murmurs , rubs , or gallops. Abdomen was soft ,
obese with bowel sounds , some mild suprapubic discomfort.
Extremities , he had 2+ DP and physical therapy pulses. He was alert; his neurologic
exam was otherwise nonfocal. He has slight dry
blood in his rectal exam with a boggy prostate , normal rectal
tone.
ADMISSION LABS:
Significant for white count of 8 , hematocrit of 43 , platelets of
322 , 000 , potassium 4.6 , creatinine 0.9 , TSH 3.8 , INR 6.7 , calcium
9.8 , magnesium 1.4. Urinalysis showed a specific gravity of
1.025% with 1+ ketone , 2+ blood. Chest x-ray showed no acute
process.
HOSPITAL COURSE:
In summary , this is a 48-year-old man with a history of bipolar disorder ,
seizure disorder presenting with supratherapeutic INR and signs of
urinary retention.
Genitourinary: Given his prostate exam and history of BPH it was
thought that his urinary retention was due to a large prostate
complicated by taking opiates for his right leg pain and
potentially also contributing from his psychiatric medications.
He did well with a voiding trial after starting Flomax and he has
not had a Foley in since hospital day #2.
Right lower extremity pain: He had a negative noninvasive lower
extremity ultrasound with no cords palpated. He had prior a
orthopaedic workup that was negative. He is receiving oxycodone.
There has been some thought that maybe his hypomagnesemia is
exacerbating his pain possibly in the form of leg cramps. He is
being repleted with mag with increasing doses of standing
magnesium. However , exam is most consistent with underlying diabetic
neuropathy and he was started on Neurontin 300 every bedtime , which will need to be
titrated as outpatient.
Diabetes: He is a diabetic on orally agents. His orally medications
were held while in house and he was given NPH and sliding scale. Oral
medications were reinstituted for the last 5 days of his hospitalization.
Anticoagulation: He has history of antiphospholipid antibody
with history of stroke from mitral clot. He was supratherapeutic
on his Coumadin , upon arrival he was reversed with vitamin K and
is now subtherapeutic being bridged with Lovenox until his
Coumadin is at least 2. His Coumadin should be titrated
according to INRs that are checked every other day until for a
goal of INR 2-3.
Psychiatric: For his bipolar disorder and seizure disorder , he
was continued on his home meds.
Neurological: He had a brief episode of delirium over the
weekend which was likely thought to be metabolic and has now
resolved. He is at his baseline. He should avoid opiates when
possible.
Disposition: He was discharged to home on new medications which
include increased magnesium , flomax , neurontin. He should
continue his antibiotics for his sinusitis history , to be finished on 5/15/06.
DISCHARGE MEDICATIONS:
1. Citracal 950 mg orally daily.
2. Colchicine 0.6 mg orally daily.
3. Colace 100 mg orally twice a day
4. Folate 1 mg orally daily.
5. Synthroid 50 mcg orally daily.
6. Magnesium gluconate sliding scale orally daily.
7. Lopressor 25 mg orally twice a day
8. Ocean nasal spray two sprays nasally daily.
9. Thiamine 100 mg orally daily.
10. Coumadin 5 mg orally every afternoon , titrate Coumadin dose to INR goal
of 2-3.
11. Multivitamin one tab orally daily.
12. Zocor 40 mg orally every bedtime
13. Lovenox 100 mg subcutaneous twice a day until INR is greater than
2.
14. KCl scale.
15. Flonase two sprays inhaled daily.
16. Lamictal 50 mg orally twice a day
17. Flomax 0.4 mg orally daily.
18. Augmentin 875/125 one tab orally three times a day , course dictated by
his ENT physicians to end on 10/23/06 ( for sinusitis ).
19. Effexor extended release 150 mg orally twice a day
20. Depakote extended release 1500 mg orally at bedtime.
21. Nexium 20 mg orally daily.
22. Glipizide 5 mg orally twice a day
23. Magnesium oxide 1600 mg orally twice a day
24. Metformin 850 mg orally twice a day
ADDENDUM: The patient should follow up with his primary care
physician and ENT physician.
eScription document: 3-5609845 EMSSten Tel
Dictated By: HARKLEY , JACQULYN
Attending: GUMINA , MARJORY SHELA
Dictation ID 6337186
D: 10/16/06
T: 10/16/06
Document id: 714
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
469354752 | PUO | 65339223 | | 0902429 | 10/10/2007 12:00:00 a.m. | Seroma | | DIS | Admission Date: 10/17/2007 Report Status:
Discharge Date: 8/1/2007
****** FINAL DISCHARGE ORDERS ******
MALANEY , SHAWNA 127-55-98-7
Balt Room: Rance Ster
Service: ONC
DISCHARGE PATIENT ON: 8/8/07 AT 04:30 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CURLL , TRISHA K. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ACETAMINOPHEN 650 MG orally every 4 hours
2. HYDROMORPHONE HCL 2 MG orally every afternoon
3. IBUPROFEN 600 MG orally three times a day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
IBUPROFEN 600 MG orally every 6 hours as needed Pain
Food/Drug Interaction Instruction Take with food
MSIR ( MORPHINE IMMEDIATE RELEASE ) 5-10 MG orally every 4 hours
as needed Pain
DIET: No Restrictions
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Fulco ,
Gaylene Faniel ( Ortho Oncology ) ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Uterine cancer , iliopsoas seroma
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Seroma
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of clear cell uterine cancer
OPERATIONS AND PROCEDURES:
Iliopsoas Drain Placement
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI/MRV of the abdomen
BRIEF RESUME OF HOSPITAL COURSE:
HPI: Patient is a 64 year-old woman with clear cell uterine CA originally
diagnosed in 9/22 - now status post hysterectomy , radiation , cycles of
carboplatin and taxol and then single agent doxil given myelosupression
and thrombocytopenia. She presents with progression of left lower
extremity edema and groin pain. Multiple studies have revleaed an
iliopsoas fluid collection which was drained recently and
previously revelaed atypical cells and were thought consistet with
radiation effect. On 8/28 she underwent an U/S of the LLE which was
negative for DVT , but a cystic struction was again noted in the
iliopsoas and the patient noted that her leg increased in size and she
had worsening groin pain. She was admitted for drainage , pain control
and imaging. ---
PMH: hypercholesterolemia , OA -----
Meds: Ibuprofen as needed , tylenol as needed , dilaudid
as needed -----
Allergies: NKDA -------
Status: afebrile , VSS , LLE edematous and tense , RRR , CTA b/l. abd
benign. Drain left groin draining serosanguinous fluid.
--------
Key studies:
U/S 8/28 11.5x5.5x2.7 cyctic structure in left iliopsoas
MRA/MRV/MRI: MRA: Normal aorta , proximal segments of celiac trunk , SMA ,
bilateral solitary renal arteries are widely patient. The common external ,
internal iliac arteries wiedely patent , IMA not well visualized.
MRV: IVC , bilateral renal veins , bilateral iliac and femoral veins are
patient. Left iliac and proximal superficial femoral vein are small in
caliber due to compression by ?seroma. No thrombus idenitified
Other finding: Liver , spleen , bilateral adrenal glands are unremarkable.
Kidneys are normal in size , symmetric perfusion. Large fluid collection
in the L iliopsoas from the sacroiliac joint to the insertion of the
iliopsoas.
------
Hospital course/A&P
1. LLE edema and groin pain: Given pain and fluid reaccumulation drain
placed by IR 9/9 and removed 11/8 Fluid was sterile with no evidence of
infection. Drain was removed due to a concern for the risk of infection
of a sterile fluid collection , particularly given it's relative proximity
to a joint and the risks that could be associated with a joint infection
in this woman. As per IR's recommendations , we asked our colleagues in
orthopedics to participate in this patient's care. They had no
recommendations for the short term given that her fluid collection had
been drained and she was pain free. Recommended that she could follow up
with Dr. Gaylene Faniel in Orthopedic Oncology if her pain/fluid collection
recurs.
2. Pain control: Patient's pain was well controlled by intravenous morphine ( 2mg
Q4-6 hrs ) after drain placement- only required one day of intravenous morphine.
Following drainage of the fluid collection she noted that she was much
more comfortable and was well controlled with ibuprofen and low dose MSIR
( minimal requirement ). Will be discharged with prescription for MSIR
should her pain recur.
3. Prophylaxis: Patient received one dose of therapeutically dosed
lovenox pending the read of the MRI - then switched to prophylactic dosed
lovenox.
Patient remained full code throughout this hospitalization
ADDITIONAL COMMENTS: If you have worsening of your leg/groin pain , you should contact your
oncologist.
If you have fevers or chill , nausea/vomiting , or shortness of breath , you
should contct your physician
You were treated for a seroma/hematoma adjacent to your iliopsoas muscle.
There was no evidence of infection based on the fluid collected from this
drainage. If the pain you were having recurs , or your leg edema worsens ,
you should contact your primary oncologist to determine the future
treatment plan. You were seen by Orthopedic Surgery during this admission
- their recommendation was that nothing needed to be done acutely and that
you could follow up with Dr. Gaylene Faniel for further evaluation if you
are interested.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
F/U with Gaylene Faniel - ortho onc if needed. F/u final results of
cytology/gram stain for drained fluid.
No dictated summary
ENTERED BY: POK , LIZETTE W. , M.D. ( LV48 ) 8/8/07 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 715
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979471841 | PUO | 51095484 | | 2770091 | 11/7/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 10/1/2006 Report Status: Signed
Discharge Date: 11/28/2006
ATTENDING: KERTESZ , ALETA M.D.
SERVICE:
Cardiac Surgery Service.
ADMITTING DIAGNOSES:
Coronary artery disease and aortic stenosis.
HISTORY OF PRESENT ILLNESS:
This is a 79-year-old male status post stenting of the PDA and
PTCA , radioablation and stenting of his LAD in 2000. He had
recurrent ischemic symptoms four months later and cardiac
catheterization showed restenosis of his LAD with an 80% lesion
at D3. He had brachytherapy and repeat PTCA. Since then , he has
done well but he had increasing dyspnea from CR. Exercise
thallium test , which showed increasing LV filling pressures
during exercise and inferior apical ischemia. He was admitted
for cardiac catheterization , which was done on 2/13/06 and the
patient was found to have a 45% proximal right coronary artery
disease , 50% distal left main disease , and 95% mid LAD disease.
PAST MEDICAL HISTORY:
Significant for hypertension , dyslipidemia , and chest radiation ,
prostate cancer , osteoporosis , and urinary incontinence.
HOSPITAL COURSE:
He was admitted , made ready for surgery. He was taken to the
operating room on 1/5/06. At which time , he underwent a CABG
x3 with a LIMA to the LAD , a saphenous vein graft to the PDA and
a saphenous vein graft to the obtuse marginal. The patient's
aortic valve was only found to be mildly stenotic with the valve
area of 1.4 and a peak gradient of 30. This was discussed with
his cardiologist , Dr. Buck Moose and a combined decision was made
not to replace the aortic valve at this time. The patient's
immediate postoperative course was uncomplicated. He was
transferred to the Intensive Care Unit in a stable fashion. He
was found to have an inferior lateral ischemia on EKG , therefore ,
he was taken to the cath lab , all grafts were found to be patent
and there was resolution of ischemia. He was weaned off his pressors and he
was extubated.
He was found to be hemodynamically
stable. He was started on Lopressor and gentle diuresis. On
postoperative day #3 , we titrated up his Lopressor and started on
his Norvasc and transferred him to the Step-Down Unit. On
postoperative day #4 , he was slightly tachycardic with ambulation
and we titrated up on his beta-blockers. PA and chest x-ray look
good. Physical therapy was consulted to decide whether the
patient would benefit from rehabilitation. He was started on
empiric levofloxacin for questionable pneumonia. He was found
suitable for discharge on postoperative day #5 , however , the
patient had isolated temperature and his white count was found to
be trending and he was hypertensive. The patient was found to
have a positive blood culture from when he had been in the
Intensive Care Unit and he was continued on levofloxacin. The
patient was discovered to have left leg cellulitis at the knee
where his saphenous vein graft was harvested from. He was
started on vancomycin. This area continued to be watched while
the patient remained on intravenous antibiotics. He was afebrile. His
white blood cell count was 12. The patient remained stable but
he continued to have a white count and left
leg ultrasound finally done on postoperative day #10 , revealed a
fluid collection above the knee to the mid calf mostly behind his
knee where the area of erythema was and his white blood cell
count went up to 15. Therefore , on 9/6/06 , the patient was
taken to the operating room , at which time , he underwent a
drainage and irrigation of his left lower extremity saphenous
vein donor site , moderate amount of fluid were expressed , and
cultures were taken. The patient was transferred back to the
Step-Down Unit after this procedure. Please see the continuing
dictation done by Pricilla Surgeon for the rest of the patient's
hospital course and discharge status.
eScription document: 9-3105124 EMSSten Tel
Dictated By: VERRY , COLETTA
Attending: KERTESZ , ALETA
Dictation ID 2952697
D: 7/12/06
T: 7/12/06
Document id: 716
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945311621 | PUO | 21473420 | | 5360575 | 7/4/2005 12:00:00 a.m. | viral URI , pulmonary HTN | | DIS | Admission Date: 5/18/2005 Report Status:
Discharge Date: 3/28/2005
****** FINAL DISCHARGE ORDERS ******
HIDVEGI , MICHALE 477-88-86-7
Wa Valesa Dallford
Service: CAR
DISCHARGE PATIENT ON: 2/21/05 AT 08:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LAMIA , SHAINA CHIA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 5/25/05 by
BORGESE , LAKISHA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 160 MG orally twice a day
GLIPIZIDE 10 MG orally twice a day
OCEAN SPRAY ( SODIUM CHLORIDE 0.65% ) 2 SPRAY nasal four times a day
as needed Other:dried nasal mucosa
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 5/25/05 by
BORGESE , LAKISHA , M.D. on order for ECASA orally ( ref # 57806803 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware
ZOLOFT ( SERTRALINE ) 150 MG orally every day
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally every bedtime
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KCL SLOW RELEASE 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
ATROVENT NASAL 0.06% ( IPRATROPIUM NASAL 0.06% )
2 SPRAY nasal three times a day
Number of Doses Required ( approximate ): 10
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
TRACLEER ( BOSENTAN ) 125 MG orally twice a day
Number of Doses Required ( approximate ): 10
VENTAVIS 1 neb NEB every 3 hours Instructions: during wake hours
ALBUTEROL INHALER 2 PUFF inhaled every 4 hours
as needed Shortness of Breath , Wheezing
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
NDH per NDH team ,
Arrange INR to be drawn on 2/3/05 with f/u INR's to be drawn every
perclinic days. INR's will be followed by prior clinic
ALLERGY: Cephalosporins , ACE Inhibitor
ADMIT DIAGNOSIS:
Viral infection , severe pulmonary hypertension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
viral URI , pulmonary HTN
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN history of PUD dm ( diabetes
mellitus ) pulmonary hypertension ( pulmonary hypertension ) osa ( sleep
apnea ) gerd ( gastroesophageal reflux disease )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
HPI: 51 F with history of severe pulmonary HTN , DM , OSA , obesity , on chronic
home O2 ( 8L NC ). She is followed by the NDH service , at
her baseline until about one week ago , having returned
from A Pend S two weeks ago , she began to experience dyspnea on
exertion and chest tightness. She also reports productive cough
( greenish ) , rhinorrhea , sinus tenderness , N/V , malaise. She denies
palpitations or radiating chest pain. The day PTA , VNA found the
patient to desat to 82% with exertion. She went to Akcare Hospital ,
where she was found to have an SpO2 of 99% on 8L , no EKG
changes , NAD on CXR.
She was hospitalized in September 2005 at PUO with simlar SOB. At this
time , she underwent a RHC which showed PA pressures 70-80% ( 110/40/60-65 )
of sytemic pressures. She also had a negative MIBI , negative
swallowing study. Since discharge , she reports being med compliant , and
diet compliant. Her weight has been stable at 238 lbs. She feels that
her depression has been worse of late. ALL: ACEi ,
cephalopsporins
MEDS: K-Dur 20 twice a day , Nexium 20 , lasix 160 twice a day ,
tracleer 125 twice a day , Glipizide 80 twice a day , Coumadin 5/7.5 , ECASA 81 , Zoloft
100 , MVI , Oceanspray , Ambien 10 every bedtime , Ventavis nebs
every 3 hours
PE:96.8 , 83 , 114/76 , 97-98% on 8L
NC. JVP 14 , RRR , loud P2 , no M. CTA. Obese.
Labs: K 3.5 , Cr 1.4 , WBC 8.2 , CK/TNI neg , BNP 443.
****************Hospital Course******************
A/P 51F with sever pHTN , OSA , DM , obesity , p/with SOB and URI-type Sx.
Near pulmonary baseline.
1. Pulm: Severe pHTN with very elevated PA pressures. Likely subjective
SOB in the context of viral URI. Cont Ilprost , home O2 , tracleer ,
albuterol. Pulmonary status stable , but patient is uneasy with going
home , and so will stay - stable enought to go home.
2. CV: Recent ECHO , Cath , probably no need to do further with u. ROMI by
serial enzymes/EKG. Continue Lasix , KCl , ASA 81.
3. Psych: history of depression. Inpatient psych consult. Cont. zoloft , ambien.
4. DM: Will follow FSBS.
5. Heme: Coumadin for pulmonary microclots on Bx in
past. WIll increase Coumadin since INR 1.9 , recheck every day.
6. FEN: low salt , low fat diet.
7. ID: Likely viral URI. BCx taken.
WIll recheck CXR if clinically
warranted.
8. GI: GERD , nexium prophylaxis.
ADDITIONAL COMMENTS: Call you doctor if you become more short of breath.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: HOLLIDAY , CASSAUNDRA C. , M.D. ( ZP01 ) 2/21/05 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 717
| Target |
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| output/system_textual_annotation.xml | textual |
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U |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
228929386 | PUO | 26756252 | | 104505 | 5/25/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/25/1992 Report Status: Signed
Discharge Date: 3/27/1992
SERVICE: GENERAL MEDICAL SERVICE 8.
PRINCIPAL DIAGNOSIS: 1. ASTHMA/CHRONIC OBSTRUCTIVE PULMONARY
DISEASE EXACERBATION.
2. STABLE ANGINA.
HISTORY OF THE PRESENT ILLNESS: The patient is a 60 year old
female with a history of coronary
artery disease , asthma , and tobacco use , who presented with a one
week history of cough , yellow sputum production , and increasing
shortness of breath. The patient stated that she has needed to use
her Proventil inhaler with increasing frequency this past week.
The night prior to admission , the patient described using her
inhaler every half hour to one hour with little or no relief. The
patient also complained of "cold" symptoms of rhinitis , sore
throat , and increased cough with yellow sputum production , plus
chills. There was no fever , nausea , or vomiting , no melena or
hematochezia. No dysuria. Plus increased urinary frequency. Plus
headaches. No dizziness. Good orally intake. The patient arrived at
the Pagham University Of Emergency Ward and was unable to
perform peak flow. She had an 02 saturation on admission of 96%.
After three nebulizers , the patient was able to perform a peak flow
of 145. She was also given Solu-Medrol 80 mg intravenous times one in the
Emergency Ward. PAST MEDICAL HISTORY: ( 1 ) Asthma/chronic
obstructive pulmonary disease. The patient experiences
approximately one flare per year. She has never been intubated.
She was hospitalized once for asthma in 11/9 and kept approximately
one week. ( 2 ) Stable angina. The patient complains of a history
of angina times three years , presented with substernal burning. The
angina has been stable recently with approximately one episode
every two weeks , always relieved with one sublingual Nitroglycerin.
The angina would also occur when ascending approximately two
flights of stairs. The patient has a history of positive ETT with
thallium in 8/30 , but a cardiac catheterization in 6/8 showed
clean coronaries. The patient also complains of three pillow
orthopnea and paroxysmal nocturnal dyspnea. CARDIAC RISK FACTORS:
Hypertension and tobacco. No cholesterol , diabetes , or myocardial
infarction history. Questionable family history. ( 3 ) Enlarged
kidney. SOCIAL HISTORY: Tobacco: One pack every three days times
43 years. No alcohol. Retired. FAMILY HISTORY: Mother died of
asthma at a young age. No cardiac history. ALLERGIES: There are
no known drug allergies. MEDICATIONS ON ADMISSION: Verapamil SR
240 mg q-day , Isordil 40 mg orally three times a day , and Proventil two puffs
twice a day , Atrovent two puffs twice a day , enteric coated aspirin one orally
q-day , Valium as needed , and Lasix 20 mg orally q-day as needed
PHYSICAL EXAMINATION: This is a 60 year old female in no acute
distress. Vital signs reveal a temperature
of 98.4 , blood pressure 140/90 , heart rate 82 and regular ,
respiratory rate of 20 , 02 saturation of 96% on room air. HEENT:
PERRLA , EOMI , oropharynx clear , naries clear. Right tympanic
membrane with fluid , without erythema. Neck: No jugular venous
distension , no bruits , no LAD. Lungs: Poor air movement with
expiratory wheezes throughout , and no rales. Cor: Regular rate
and rhythm , plus S4. Back: No vertebral CVA tenderness. The
abdomen was soft , nontender , plus bowel sounds. Pulses: Radial ,
carotid , femoral , and DP pulses were 2+ bilaterally. Lower
extremities: 1+ pitting edema bilateral. Neurological exam was
nonfocal. Rectal: No masses , guaiac negative.
LABORATORY DATA: The chest x-ray showed no infiltrates , plus
bronchial wall thickening consistent with
bronchitis EKG showed normal sinus rhythm at 81 , PR interval
0.16 , QRS 0.0 , 72 , at 30 degrees. Inverted T-waves in V1 , V4-V6 ,
biphasic T-waves in V3 , and no significant change since 4/10 On
admission , there were normal electrolytes. WBC: 5.4 thousand ,
hematocrit 42 , and platelets 254 , 000.
HOSPITAL COURSE: The patient was admitted to the stepdown unit on
9-B and given Solu-Medrol 80 mg intravenous every 8 hours and
Albuterol nebulizer q1 hour treatments. She was also given Bactrim
DS one orally twice a day for presumed bronchitis. The patient did well
over the hospital course with increasing peak flow to over 200 on
discharge. Her lung exam was also much improved with better air
movement on discharge. Immediately after admission , the patient
complained of one episode of burning , substernal chest relieved
with one sublingual Nitroglycerin. She did have EKG changes with
new upright T-waves throughout the precordium and in I , different
from admission. She was ruled out for a myocardial infarction and
had flat CK's. Her upright T-waves in I and V3-V6 continued
throughout the hospital course. This was thought to be secondary
to labile Q-waves as noted in the past. The patient was discharged
on four days of Bactrim and a Prednisone taper.
DISPOSITION: CONDITION ON DISCHARGE: Stable. MEDICATIONS ON
DISCHARGE: Atrovent inhaler two puffs four times a day ,
Clinoril 150 mg orally twice a day , enteric coated aspirin one orally
q-day , Bactrim DS one orally twice a day times four days , Verapamil Sr 240
mg orally every day before noon and 180 mg orally every afternoon , Azmacort inhaler two puffs
twice a day , Isordil 40 mg orally three times a day , Albuterol inhaler two puffs
four times a day , Prednisone 60 mg orally q-day wean to off in two weeks ,
Valium 5 mg orally four times a day as needed , and Colace 100 mg orally three times a day
as needed FOLLOWUP CARE: With Dr. Peggy Romig to be arranged by the
patient within two weeks of discharge. DIET: Low salt , low
cholesterol. ACTIVITY: As tolerated.
Dictated By: JACK T. TIMPSON , M.D. EX11
Attending: PEGGY K. ROMIG , M.D. AB14
KY631/4550
Batch: 7002 Index No. INPFDA4JT1 D: 6/11/92
T: 8/19/92
Document id: 718
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009846710 | PUO | 50140079 | | 775598 | 11/13/1997 12:00:00 a.m. | UNSTABLE ANGINA | Unsigned | DIS | Admission Date: 3/27/1997 Report Status: Unsigned
Discharge Date: 1/28/1997
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
PROCEDURE: CORONARY ARTERY BYPASS GRAFT ON February , 1997.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old gentleman
with a ten year history of diabetes
mellitus , peripheral vascular disease , hypertension and increased
cholesterol who was admitted ten days following discharge from the
hospital following treatment for an infected left thigh wound. The
patient ran out morphine three days prior to his admission and
presents with a two day history of chest heaviness and shortness of
breath. The patient originally presented in September of 1997 with a
right foot cellulitis and claudication at 50 yards. This was
treated with debridement and broad spectrum antibiotics and
subsequently treated with amputation of his right toe. On October ,
1997 , the patient underwent a right femoral popliteal bypass. He
was subsequently readmitted in January of 1997 for a left femoral
popliteal bypass and a split thickness skin graft to his fifth toe.
He was admitted again in the end of January through the beginning of
April with a question of a left thigh wound graft infection for
which he was treated with intravenous antibiotics. He was
discharged to home and is now readmitted with chest pain and
heaviness.
PAST MEDICAL HISTORY: Significant for the above with the addition
of hypertension , peripheral vascular
disease , non-insulin dependent diabetes mellitus and depression.
MEDICATIONS ON ADMISSION: 1 ) Wellbutrin 75 mg orally every day. 2 )
Vasotec 5 mg orally every day. 3 ) Glyburide
5 mg orally every day. 4 ) Tylenol 650 mg orally every 6 hours as needed 5 )
Nafcillin 2 mg intravenously every 4 hours 6 ) Morphine.
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.9 degrees ,
heart rate 92 , blood pressure 122/60.
Pupils were equal , round and reactive to light. His neck
demonstrated a right carotid bruit. There was no lymphadenopathy.
There was no jugular venous distension. Auscultation of the chest
revealed bibasilar rales. Cardiac examination revealed a regular
rate and rhythm without murmurs , gallops or rubs. There was a
normal S1 and S2. Abdominal examination revealed positive bowel
sounds , soft , non-tender , non-distended abdomen. Extremities
demonstrated bilateral groin scars and the left medial thigh wound
which was open for a length of approximately 5 cm with wound
packing. The base of the wound looked well granulated. There was
bilateral ankle edema. Pulses were 2+ dorsalis pedis bilaterally.
LABORATORY: Admission laboratory data revealed that the
electrolytes were normal. His white blood cell count
was 13.9. Liver function tests were within normal limits. CK was
70 and the Troponin I was 0.0.
HOSPITAL COURSE: The patient was admitted to the Medicine Service
where he ruled out for myocardial infarction
with CKs of 39 and 70. His EKGs however demonstrated marked T-wave
inversion in the precordial leads. The chest pressure and
tightness resolved with sublingual nitroglycerin and Lopressor.
His initial presentation was complicated by the fact that it was
thought he was undergoing withdrawal from narcotics which he was
using perioperatively. However , he ultimately underwent a cardiac
catheterization on June , 1997 which demonstrated a 40% mid LAD
lesion and 50% distal LAD lesion , 50% proximal second diagonal
lesion and 99% OM1 lesion with slow flow , along with an 80% OM2
lesion and a 99% RCA lesion. Ejection fraction at that time was
noted to be 40%. Given the patient's presentation , he was booked
for coronary artery bypass grafting which he underwent on February ,
1997. The patient tolerated the procedure well and was transferred
to the Intensive Care Unit postoperatively and had an uneventful
postoperative recovery. He was maintained on Diltiazem for his
radial artery graft. His course was only complicated by
intermittent episodes of atrial fibrillation and flutter. His
thigh wound appeared clean with wet to dry dressing changes and
there was no further evidence of active infection. The patient was
followed by the Miter Highway , Field , Idaho 39369 Service ( the drug abuse service ) as well as the
Plastic Surgery Service throughout his hospital stay. Plastic
Surgery felt that his hand was well perfused at the time of
discharge. The patient remained in a normal sinus rhythm after
that brief episode of atrial fibrillation and he was not maintained
on Coumadin at the time of discharge.
MEDICATIONS ON DISCHARGE: 1 ) Enteric coated aspirin 325 mg orally
every day. 2 ) Wellbutrin 75 mg orally q.
day. 3 ) Captopril 25 mg orally three times a day 4 ) Diltiazem 30 mg orally
three times a day 5 ) Lopressor 50 mg orally three times a day 6 ) Glyburide 5 mg orally q.
day. 7 ) Simvastatin 20 mg orally every bedtime 8 ) Percocet 1-2 tablets
orally every 4 hours as needed pain. 9 ) Nafcillin 2 mg intravenously every 4 hours 10 )
Lasix 80 mg orally twice a day times five days. 11 ) Potassium 40 mEq
orally twice a day times five days.
DIET: Diabetic diet at 1800 kilocalorie.
ACTIVITY: As tolerated.
FOLLOW-UP: The patient is to follow-up with Dr. Pittinger in six
weeks , along with the cardiologist in one week ( Dr.
Fiermonte ) , Dr. Burston on October , 1997 of Plastic Surgery and
the Ri Gene Team in two weeks.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISPOSITION: The patient was discharged home with VNA services.
Dictated By: LORRETTA P. CRIDGE , M.D. RZ
Attending: DILLON C. PITTINGER , M.D. II8
GG419/8760
Batch: 32833 Index No. DLET1X7M40 D: 5/5/97
T: 5/4/97
Document id: 719
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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317582123 | PUO | 04593167 | 1913347 | 10/12/2005 12:00:00 a.m. | bleeding AV-fistula , anemia | | DIS | Admission Date: 10/11/2005 Report Status:
Discharge Date: 9/10/2005
****** FINAL DISCHARGE ORDERS ******
CAVAIANI , IRENA REBECCA 801-85-73-2
Io Room: Athens
Service: RNM
DISCHARGE PATIENT ON: 10/21/05 AT 06:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PILLING , WEI NYLA , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally every day
CEPACOL 1-2 LOZENGE orally every 4 hours as needed Other:sore throat
FOLIC ACID 1 MG orally every day
HYDRALAZINE HCL 40 MG orally four times a day HOLD IF: sbp < 100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ISORDIL ( ISOSORBIDE DINITRATE ) 30 MG orally three times a day
HOLD IF: sbp < 100
LISINOPRIL 40 MG orally every day HOLD IF: sbp < 100
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally three times a day
HOLD IF: sbp < 100 , HR < 55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NYSTATIN SUSPENSION 5 MILLILITERS orally four times a day
Instructions: swish and swallow
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/1/05 by
GUSTOVICH , MARLO , M.D. , PH.D.
on order for NEPHROCAPS orally ( ref # 88999733 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: mda
NORVASC ( AMLODIPINE ) 10 MG orally every day HOLD IF: sbp < 100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
MAALOX/BEN/LIDO 1:1:1 15 MILLILITERS SWISH & SWALLOW three times a day
Instructions: for sore throat. patient may refuse.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 1/1/05 by
GUSTOVICH , MARLO , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: mda
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day Starting IN a.m. ( 2/14 )
HOLD IF: if patient starts to bleed from fistula site
KEPPRA ( LEVETIRACETAM ) 500 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
LANTUS ( INSULIN GLARGINE ) 6 UNITS subcutaneously every bedtime
Starting Today ( 4/24 )
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously and
call HO Call HO if BS is greater than 400
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally x1
as needed Upset Stomach
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Partial weight-bearing: as tolerated.
Full weight-bearing: as tolerated.
FOLLOW UP APPOINTMENT( S ):
Diabetes clinic with dr Hubert Lahr 11/18/05 8AM scheduled ,
Cardiology/arrhythmia with dr Jacklyn Grinstead 11/18/05 2PM scheduled ,
ALLERGY: TETRACYCLINE ANALOGUES
ADMIT DIAGNOSIS:
bleeding AV-fistula , ROMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bleeding AV-fistula , anemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ESRD IDDM-hypo/hyperglycemic seizures history of AV fistula
1/25 chronic pancreatitis HTN
alcoholic cardiomyopathy beta-thal trait alcoholic
gastritis Hep B/Hep C depression
+ PPD narcotic seeking history of penectomy history of infected penile
implant history of post-ant tibial bypass surgery history of GI bleed , unknown
source 3/10 VT ( ventricular
tachycardia ) long qt seizure disorder ( seizure
disorder ) penile amputation
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
4/6/05 HD in a.m.
BRIEF RESUME OF HOSPITAL COURSE:
Attending: Vanmarter , Alfredo
--------------
CC: 54M with ESRD+MMP has bleeding from fistula HPI
HTN , ESRD on HD , history of NSTEMI 2003 , alcoholic CMP , severe PVD , long QTc
syndrome ( history of recent torsades ) present with spontaneous bleeding from AV
fistula. Bleeding stopped with 1ht of pressure in ED , but patient developed
pleuritic CP , subtle TW changes. Pain resolved after lopressor. Only
other recent complaint is sore throat with swallowing.
---------
PMHx: DMI , ESRD on HD , CAD history of MI and stent , EtOH CM , PVD history of
L BKA and R fem-tib bypass , sz d/o , long QT history of recent torsades
episode , ? NPH with MS delta , +PPD hx , Hep B & C , chronic pancreatitis ,
penisectomy , b-thal trait.
----------------
Daily status: Afebrile , Alert , oriented x 2 , conversant , RRR ,
CTA , abd soft , NT with +BS , no edema , fistula patent - bandaged and
not oozing.
-----------
EVENTS:
5/22/05 fistula bleed and CP
4/6/05 HD in a.m. , received 1uPRBCs in PM.
11/29/05 received 1uPRBCs
---------------
Studies: Cath 10/6 showed complete distal RCA , 65% ramus , no other
significant dz. Echo: LVH , EF 55%
************
HOSPITAL COURSE:
This is a 54 year-old man with ESRD+MMP who was admitted for one episode of
spontaneous bleeding from his AVF. PMH sig for brittle DMI , HTN , ESRD
on HD , history of NSTEMI 2003 , alcoholic CMP , severe PVD , long QTc syndrome ( history of
recent torsades ). patient also c/o pleuritic CP , with subtle TW changes.
1 ) CV: Rhythm: recent torsades , on tele , no events. Repleted lytes as needed
Pump: Echo showed EF 55% , severe LVH. continue HTN meds as outpt ,
including lisinopril , norvasc , and hydralazine , nitrite. Ischemia: subtle
EKG changes but no repeat CP since admission. cardiac enzymes negative , EKG
changes resolved somewhat by end of admission. cont ASA , BB , statin , and
restart plavix as patient's hct was stable on discharge ( 34.6 ). patient had been
hemodynamically stable throughout hospitalization.
-patient has f/u appt with cardiology Dr Jacklyn Grinstead 9/30/5 at 4pm ,
575-803-4363 , Atl Cu Di Lingwest Tal/ Hospital , Rance
2 ) RENAL: ESRD on HD MWF , last 6/22/05. Fistula patent and working well
per renal team. resume outpt HD schedule MWF.
3 ) HEME: patient with fistula bleed , likely compounded by plavix use. Hct at
30% ( low end of baseline ). Bleed stopped after prolonged pressure. HD
without difficulty in a.m. 4/6/05 , but because patient had a 6 unit drop ( from
30 to 24 ) , patient was kept for observation and was transfused 1 unit of PRBCs.
patient received an additional unit of PRBCs 2/22/05. patient was dicharged back to
rehab with no further bleeding on PM of 7/23/05.
4 ) GI: patient had episodes of guaiac+ stool on and off during this
hospitalization , but never frank melena or BRBPR. the GI consult was
informally consulted and felt that as long as patient was hemodynamically
stable , this was not an inpatient issue to urgently pursue at this time.
patient's Hct on discharge ( 34.6 ) was around his baseline. the renal team agreed
with GI's assessment.
-patient has outpt GI appt on 6/20/05 at 10AM with Dr Reinstein ( 970-634-1887 )
4 ) PULM: No active issues.
5 ) NEURO: Sz d/o on Keppra. Mental status improved compared to prior
admission description. A&O x 3 , responds appropriately to questions.
6 ) ID: sore throat with ? esophagitis , nystatin S&S.
7 ) ENDO: DM with hypo/hyperglycemic episodes in past. Prev followed by
endocrine for labile sugars. On home lantus + 3 units qAC + SS novolog.
increased home lantus dose to 15u every bedtime but am sugar 26 on 8/28 , and low
sugars again on a.m. 2/30/05 , so will send out on lantus 6 every bedtime and should
closely monitor bs and titrate lantus/novolog SS qAC appropriately. patient will
most likely require a bedtime snack to avoid his early morning hypoglycemic
episodes.
-f/u appt with endocrine clinic ( 125-634-8399 ) 9/29/05 at 11AM , Gle Lingwest Tal/ Hospital , Lan Chii Do
8 ) FEN: Repleted lytes , esp Mg given recent hx of torsades. patient with prior
aspiration risk , but was tolerating POs well at time of d/c.
9 ) Ppx: PPI , subcutaneously heparin
10 ) dispo: to rehab when Hct stable ( d/c Hct at 34.6 ) , 2/30/05
-----------
CODE: FULL
ADDITIONAL COMMENTS: please follow up with the diabetes clinic and the cardiology clinic , both
appointments on monday 6/22/05. come back to the ED if the fistula starts
to bleed again.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
follow serial Hcts. monitor AVF for future bleeds. please closely monitor
patient's sugar levels--he needs a bedtime snack to avoid bottoming out in the
early mornings. patient has f/u appointments for cardiology , diabetes , and
GI--please make sure that he makes it or they will most likely drop him
from their patient lists ( 2/2 multiple no-shows ). thanks.
No dictated summary
ENTERED BY: SCHUNEMAN , ELLENA M. , M.D. , PH.D. ( EK34 ) 10/21/05 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 720
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
Y |
- |
N |
N |
N |
N |
N |
N |
N |
N |
N |
737023301 | PUO | 82038223 | | 970264 | 11/22/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 3/27/1990 Report Status: Unsigned
Discharge Date: 2/10/1990
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old woman ,
status post CABG times three in 7/6 ,
status post inferior myocardial infarction in 2/10 with a peak CPK
of 714. She has a history of chest pain since the CABG. The CABG
consisted of a LIMA to the LAD , saphenous vein grafts to the OMB-2
and RCA. In 9/16 , she had been cathed and a 70% RCA occlusion with
a question of thrombus was seen. A 90% OMB-2 was seen; a
circumflex of 60% was seen; an LAD of 70% was seen. An LV-gram
showed inferior akinesis and posterior hypokinesis with a left
ventricular ejection fraction of 78%. Post CABG at baseline , she
had substernal chest pain at rest with rare use of sublingual
nitroglycerin. She has a history of peptic ulcer disease which was
a duodenal ulcer with melena. She had an EGD in 5/20 which showed
mild antral gastritis without ulcers. She is status post
colonoscopy in 9/16 which showed diverticulitis. She has a history
of anemia with a hematocrit of 29 , MCV of 68. She was treated with
iron sulfate and H2 blockers. She noted a history in two months of
a 20 pound weight loss. One week prior to admission , she had
melena of loose stool. She felt light-headed. She had a cough and
nocturia. Three days prior to admission , she noted a stabbing
periodic epigastric pain with nausea and vomiting twice; no coffee
grounds or hematemesis. She had dysphagia for months to liquids
and solids with the sensation of aspiration on swallowing. She had
a sharp pain radiating to the left arm and shortness of breath.
The pain was similar to the inferior MI in 1988. On 2/4 , she came
to the emergency ward , where her blood pressure was found to be
110/68 lying and 90/palp sitting. O2 sat was 97% on room air. Her
JVP was 9 cm with crackles at the right base. She was given three
sublingual nitroglycerins and Maalox. Her hematocrit was 20.8.
She was given 10 mg of intravenous Lopressor from which she became
hypotensive , but this resolved. She was transfused three units of
packed red blood cells , given Lasix and intravenous H2 blockers. She went
to the unit and ruled out for an MI by EKG and enzymes. The A-set
revealed a CPK of 54; B-set was 48; C-set was 36. An ABG was 132 ,
99 , 7.43 , 33. Potassium was 4.2 , BUN 20 , creatinine 0.9.
ALLERGIES: None known.
PHYSICAL EXAMINATION: JVD was 9 cm on admission and decreased;
scar at the left base of the neck secondary
to a basal cell resection; II/VI systolic ejection murmur at the
left sternal border without gallop. The lungs revealed crackles at
the right base one quarter. She had a kyphoscoliosis. The abdomen
was benign. The neuro exam was nonfocal , though she had some past
pointing secondary to poor eyesight.
HOSPITAL COURSE: On 7/5 , she was transferred to the floor. She
complained of some left arm pain secondary to her
intravenous , but she had no EKG changes and this improved with hot
compresses. She was guaiac negative. On the evening of 4/21 , she
was noted to be trace guaiac positive in the stool. On 7/6 at 7:30
a.m. , she complained of substernal chest pain which radiated to both
upper extremities with tingling bilaterally. This did not resolve ,
even after giving Maalox , four sublinguals and 12 mg of morphine
and three inches of Nitropaste. Her blood pressure was stable at
130/80 , heart rate was 68 , and she was afebrile. Her substernal
chest pain ranged between 7-3 , and she was given 20 mEq of Kay
Ciel. Her potassium was 3.8 , hematocrit 32.8 and stable. She was
given two more units of packed red blood cells after having been
given two more units of packed red blood cells between 7/5 and 10/27
intravenous nitroglycerin 50 units was started after one hour and 15 minutes
of pain. This was increased to 100 units. EKG changes were noted
as a flattening in V4 through V6 with no ST depressions , and she
had a T wave down in V3 which was new since admission. On 7/6 , she
was transferred to the unit. Her CKs were negative; A-set was 27 ,
B-set was 29 , C-set was 57 and D-set was 65. A catheterization
showed right atrial pressures of 12 , PCWP of 16 , SVR 1 , 000 , PVR 76 ,
PA 34/14 , cardiac output 6.8. Grafts from the aorta to the OM ,
aorta to the RCA and LIMA to the LAD were all patent. LAD showed
100% proximal occlusion , LAD diagonal showed a 50% long proximal
and circumflex showed a 50% proximal , OM-2 showed a 70% occlusion
at the origin. There was a mild increase in right and left sided
pressures. She was readmitted to the floor and watched. Her
hematocrit remained stable. She had an endoscopy done on the
morning of 7/10 , and the impression was of a large hiatal hernia
with no evidence of GI bleeding at this time. It was recommended
that she had an upper GI and small bowel follow through or repeat
colonoscopy in the future as an outpatient. Her hematocrit
remained stable at approximately 33 for the past four days. The
sed rate was 25 , physical therapy and PTT within normal limits , potassium 4.2 ,
iron 182 , TIBC 432 , vitamin B-12 371 , folate 3.9 , ferritin 16 ,
cholesterol 153 , triglyceride 112
DISPOSITION: The patient was discharged home in stable condition.
MEDICATIONS ON DISCHARGE: Pepcid 20 mg orally twice a day;
metoprolol 50 mg orally twice a day; nitroglycerin 1/150 0.4 mg sublingual
as needed FOLLOW UP will be with Dr. Barnaba and with the GI service.
DISCHARGE DIAGNOSES: 1. UPPER GASTROINTESTINAL BLEED.
2. CORONARY ARTERY DISEASE , STATUS POST
CORONARY ARTERY BYPASS GRAFTING.
3. PEPTIC ULCER DISEASE.
4. IRON DEFICIENCY ANEMIA.
5. HISTORY OF CHOLELITHIASIS.
________________________________ UQ363/6286
CARA BARNABA , M.D. HL86 D: 8/9/90
Batch: 7437 Report: B7363C3 T: 7/2/90
Dictated By: JOHNSIE FJESETH , M.D.
Document id: 721
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
U |
- |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
Y |
N |
N |
- |
N |
N |
N |
N |
Y |
N |
902260517 | PUO | 05373993 | | 5291920 | 5/12/2003 12:00:00 a.m. | CHF | | DIS | Admission Date: 11/5/2003 Report Status:
Discharge Date: 10/14/2003
****** DISCHARGE ORDERS ******
MASELLA , DOVIE 565-56-05-5
Therorf Pkwy
Service: MED
DISCHARGE PATIENT ON: 8/12/03 AT 05:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MARREEL , ANNAMARIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 5 UNITS subcutaneously every day before noon
Starting IN a.m. on 9/8/03
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 8/24/03 by
RUBIANO , ELIZ JASPER , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
LOVENOX ( ENOXAPARIN ) 60 MG subcutaneously twice a day
ZESTRIL ( LISINOPRIL ) 10 MG orally every day Starting Today ( 10/5 )
Alert overridden: Override added on 8/24/03 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: monitoring
CARVEDILOL 3.125 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LASIX ( FUROSEMIDE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Contessa Zebley in KTDUOO as previously scheduled 1 week following discharge ,
INR check in KTDUOO ; mondays and thursdays start next week ,
EP service , Dr. Boera 1/20/03 scheduled ,
Arrange INR to be drawn on 3/20/03 with f/u INR's to be drawn every
tobedetermined days. INR's will be followed by Darin Jeffirs in KTDUOO ( Monday/Thursday draws )
No Known Allergies
ADMIT DIAGNOSIS:
chest pain , sob
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
?CAD congenital heart block etoh'ism htn
history of PACER PLCT 1980 history of SILENT IMI history of l
nephrectomy history of appy history of spinal stenosis
l3-4 ge reflux , nl ugi 8/13 heme + stool anemia
resolving thrombocytopenia resolving rhabdo new onset
DM resolving pancreatitis DM 2/2 pancreatitis
OPERATIONS AND PROCEDURES:
cardiac cath 9/8/03
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
65M with history of CAD history of IMI 1988 , CHF , DM , a/with 1-2
weeks of progressive dyspnea , increased anginal frequency. At recent
basline , patient reports exertional angina and dyspnea walking ~1 block , 1-2
pillow orthopnea. Over the past week , patient
reports increased anginal frequency , occasionally
at rest , and development of dyspnea at rest.
+PND and dietary indiscretion , no palps , LH. In
ED received NTG , Lasix , Lisinopril which
produced some mod improvement. Cardiac hx notable for
TTE 1998 with EF 50% ( incr from 35% in '97 ) , inf
HK. ETT-MIBI '97 for 9 min ( modified Bruce ) with
inf defect and mild ischemia. CXR showed mod
pulm edema. PE notable for BP 132/70 , P82 , 94%
4L , bilateral crackles 1/3 up , JVP 9-10 cm , RRR
2/ 6 SM apex , ext without edema. Labs notable for
ALT 59 , AST 69 , first set enzymes flat. EKG
with atrial flutter , v-paced. ROS notable for +cocaine
use 2-3 days ago , +recent EtOH use.
HOSPITAL COURSE:
CV:
1. ISCHEMIA: History concerning for ischemia , given subacute
increase in sxs of angina and dyspnea in patient with CAD , DM , PVD. Persistent
CP at rest , started Heparin , NTG drops Changed BB to CCB for +cocaine
tox , but d/c'd CCB 2/2 HOTN. MIBI 7/26 showed small fixed inferior
defect in PDA territory ( c/with old IMI ) , no ischemia , EF 28% , global LV
dysfxn , worst inferiorly. Cards recommended cath 1/27 to r/o ischemia
as cause of newly decreased EF ( see below ) -> nonobstructive CAD
( diag30% ) , NL L heart filling pressures. Continued ASA/Capto/statin;
d/c'd asa/statin when no CAD demonstrated. 2. PUMP: Clearly volume
overloaded on admission , but showed marked
improvement following diuresis with Lasix. TTE 7/9 EF 25% , global HK ,
most severe inf/post/IS walls from base to apex , tr AI , mild MR/TR ,
secundum-type ASD with L->R shunt , possible veg vs thrombus on one of
pacing wires. Eval'd by EP service for pacer thrombus vs. veggie ,
recommended heparin while in house -> changed to Lovenox to Coumadin
bridge at time of discharge , especially in light of stroke risk with newl
y-discovered ASD. Etiology of CMP not certain , but patient has significant
EtOH as well as cocaine history. Iron studies normal , TSH low , free T4
normal. Will aim for lower therapeutic INR given prob with compliance.
3.RHYTHM: S/p PPM , history of paroxysmal Afib/flutter , needs consideration of
longterm anticoagulation for atrial arrythmia but will be determined
as outpatient , since currently patient needs to be anticoagulated regardl
ess for pacer lead thrombus.
GI: Followed serial LFTs , resolved to
normal with diuresis.
ID: Initially started empiric Naf/gent 7/25 for ?veggie on pacer wire ,
but no clinical e/o endocarditis and blood cx's ( pre-abx ) all
NGTD. D/c'd abx 7/26 , followed surveillance cx's ( all NGTD at time of
discharge ).
SUBSTANCE ABUSE: Admits to inhaled cocaine in
last week , denies IVDU or recent EtOH. Eval'd by
GRH team , and refused referral for EtOH/drug
abuse counseling.
ADDITIONAL COMMENTS: Call your doctor if you have any chest pain , shortness of breath , or
any other concerning symptoms. It is extremely important that you
follow-up about your INR to adjust your Coumadin doses; stop taking
coumadin if you are unable to keep your clinic appointments. You need
to check coumadin every monday and thursday in KTDUOO clinic and fol
low-up with Darin Jeffirs in KTDUOO at 268-445-9819. Weigh
yourself daily; if your weight changes by more than 3 pounds , call your
doctor.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
per hospital course; vna for meds compliance , home safety , inr/Chem 7
check Thurs , 10/22 Call Darin Jeffirs at KTDUOO 537-738-6908 with INR
results ( to be drawn thursday , and then scheduled at KTDUOO mondays and
thursdays ). Call Dr. Contessa Zebley at KTDUOO with Chem 7 results. patient's home
phone is 835-574-5251
No dictated summary
ENTERED BY: OSDOBA , JEANA , M.D. ( WZ98 ) 8/12/03 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 722
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
042580388 | PUO | 02169523 | | 0172255 | 8/16/2004 12:00:00 a.m. | heart failure | | DIS | Admission Date: 10/10/2004 Report Status:
Discharge Date: 10/8/2004
****** DISCHARGE ORDERS ******
SHAMEL , GEMMA 375-11-88-7
Burg H Li
Service: MED
DISCHARGE PATIENT ON: 4/16/04 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LALATA , JOHNETTA BEN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ATENOLOL 100 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally three times a day
Instructions: Give with warm water , separately from other
pills before meals. Thanks ,
COUMADIN ( WARFARIN SODIUM ) 3.75 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 10/26 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/21/04 by
ESANNASON , BELINDA , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware.
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 2/21/04 by
ESANNASON , BELINDA , M.D. , PH.D.
on order for COUMADIN orally ( ref # 77365546 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware. Previous override information:
Override added on 4/11/04 by BREZNAY , MATILDE EMOGENE , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
INSULIN 70/30 ( HUMAN ) 10 UNITS every day before noon; 0 UNITS every afternoon subcutaneously
10 UNITS every day before noon 0 UNITS every afternoon
COZAAR ( LOSARTAN ) 100 MG orally every day
Number of Doses Required ( approximate ): 10
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
cisar 1-2 weeks ,
Arrange INR to be drawn on 6/27/04 with f/u INR's to be drawn every
7 days. INR's will be followed by contreraz
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
idiopathic dilated CM hx asthma hx CVA
( hemorrhage ) IDDM ( diabetes mellitus ) Nephrotic Syndrome 2/2 DM
( nephrotic syndrome ) AICD ( for history of VT ) ( ventricular
tachycardia ) CAD ( coronary artery disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
56F with hx. of idiopathic cmp ( ef 25% ) , presents with dyspnea on
exertion , orthopnea , lower extermity edema.
HPI: reports 1 wk history of increasing lower extermity edema ,
orthopnea. Has been taking all meds but has recently had multiple
dietary indiscretions including chicken noodle soup and grilled ham
cheese sandwich. In addition patient has episodes of nausea and also
hypoglycemia when she discontinues her medications. No chest pain , no
palpitations , dyspnea on exertion with stairs.
In emergency department d , 70 / 138/87/ 100%
CXR: mod. pulm edema , L small pleural effusion and LLL opacity
PE: jvp 10 chest: crackles 1/4 bases b/l cv: enlarged pmi , rv heave ,
3/6 hsm lsb , apex , no gallops abd: no organomegaly; ext: warm 3+ LE
edema
PMH: cardiomyopathy , Asthma , cva/brain aneurysm , AICD for VT , DM ,
dvt R.leg , gerd , chronic leg swelling , Hypertension
SH: lives with son , 1 cig/day , no etoh
EKG: nsr nl axis , qtc 473 lae , lvh , lat twi , st elev , v1 , v2--old
LABS: bnp: 3726 ck 937 mb 7.3 tn<assay echo:
ECHO: 10/14/03 severe global lvhk 20% lae , decraesed rv f( x ) , MR , mild
tr , pasp 28
Assessment 56 female idiopathic CMP. Presents with CHF exacerbation 2/2
dietary indiscretion
*************************Hospital Course********************
1.CV ISCH: Elevated ck , tni ( - ) , ckmb low , ruled out X3 cont.
Beta Blocker , ASA , non-occlusive 2vd on cath.
PUMP: warm and wet; the patient was diresed approximately 6 Liters to
her dry weight of 149 kilograms. At dry weight patient had a BNP
of 3700. In house her ACE was switched to Cozaar secondary to cough.
Beta Blocker was changed to once a day Atenolol. An echo on 8/28
revealed EF 21% mV moderate mr , incomplete closure , TV: moderate tr ,
incomplete closure;LV globak HK , rv mildly to moderately decreased ,
incomplete study due to patient not fully cooperating. On the patients
final day in the hospital she was noted to have symptomatic dehydra
tion and was orthostatic - symptoms resoved with a 500 cc NS bolus.
2.ENDO : the patient's insulin regiment was modified and she was dc'd
on insulin 70/30 10 am. THe patient's admission regimine of Lantus 40 every
d was causing both hyper and hypoglycemia in house. Her hospital course
was notable for a few episodes of hypoglycemia resulting in down
titration of insulin a.m. and PM doses. THe patient was noted to be
extremely hypoglycmeic on 8 units of 70/30 in the PM and the PM
insulin was discontinued for the time being. It was decided that the
patient's diet at home would have higher glucose and carbohydrate
content and her Fs's will need further with up as outpatient. We reccomend
titrating the 70/30 insulin up as needed.
3.GI: she complained of mild epigastric pain after meals , and said it
is thought that this represents diabetic gastroparesis. Her reglan
dose was increased to 10 and she tolerated orally's better subsequently and
was less symptomatic.
4.HEME: cont coumadin
5.PROPHYLAXIS: coumadin , nexium
6.CODE full
ADDITIONAL COMMENTS: 1. Please followup with Dr. Unterkofler in 1-2 weeks
2. Please switch your insulin to 10 units of 70/30 insulin the morning.
Your primary doctor may make changes in your insulin regimin
based on your recorded blood sugars.
3. Please stop taking Metoprolol and Lisinopril.
4. Please start taking Cozaar and Atenolol. Your Reglan dose is
increased.
5. VNA for diabetes management , CHF management , and medical compliance.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ESANNASON , BELINDA , M.D. , PH.D. ( OK00 ) 4/16/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 723
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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402105256 | PUO | 89357151 | | 7016353 | 6/23/2006 12:00:00 a.m. | internal hemorrhoids , nonbleeding diverticuli , gastritis | | DIS | Admission Date: 3/24/2006 Report Status:
Discharge Date: 7/27/2006
****** FINAL DISCHARGE ORDERS ******
FORSLUND , ERICKA E 640-32-71-6
Warkpem Ank ,
Service: MED
DISCHARGE PATIENT ON: 4/3/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 200 MG orally DAILY
CALCITRIOL 0.25 MCG orally DAILY
DICLOXACILLIN 500 MG orally four times a day X 7 Days
Starting Today ( 7/21 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 200 MG orally every day before noon
MAGNESIUM GLUCONATE 500 MG orally twice a day
ZAROXOLYN ( METOLAZONE ) 2.5 MG orally DAILY
METOPROLOL TARTRATE 50 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXYCODONE 5 MG orally every 8 hours as needed Pain
PHENOBARBITAL 64.8 MG orally three times a day
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 20 MG orally every 12 hours
LANTUS ( INSULIN GLARGINE ) 37 UNITS subcutaneously every afternoon
Starting Today ( 7/21 )
LIPITOR ( ATORVASTATIN ) 10 MG orally BEDTIME
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
COLCHICINE 0.6 MG orally EVERY OTHER DAY
COUMADIN ( WARFARIN SODIUM ) 12.5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Monday , Wednesday , Friday
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/3/06 by :
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: md aware md aware
COUMADIN ( WARFARIN SODIUM ) 10 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Tuesday , Thursday , Saturday , Sunday
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/3/06 by :
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: md aware
ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally DAILY
Alert overridden: Override added on 4/3/06 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: md aware
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
HUMALOG INSULIN ( INSULIN LISPRO )
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day as needed Constipation
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FOLLOW UP APPOINTMENT( S ):
Dr Jack Timpson pcp 3/25 @ 2 ,
Coumadin level Tues and Fri ,
Arrange INR to be drawn on 12/10/06 with f/u INR's to be drawn every
4 days. INR's will be followed by Dr. Lins
ALLERGY: MEPERIDINE HCL , SILDENAFIL CITRATE , GABAPENTIN ,
SPIRONOLACTONE , NITRATE , DIGOXIN , AMLODIPINE , ACE Inhibitor
ADMIT DIAGNOSIS:
lower GI bleed
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
internal hemorrhoids , nonbleeding diverticuli , gastritis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
VV pacer ( pacemaker ) CAD history of CABG ( coronary artery disease ) CHF
( congestive heart failure ) Afib ( atrial
fibrillation ) CVA ( cerebrovascular accident ) IDDM ( diabetes
mellitus ) Peripheral neuropathy ( peripheral neuropathy ) Obesity
( obesity ) PVD ( peripheral vascular disease ) CRI ( chronic renal
dysfunction )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
EGD/colonscopy-no active bleeding , atrophic gastritis , scattered
diverticuli , small non bleeding sessile smooth polyps in sigmoid ,
transverse colon , descending and ascending colon , moderate internal
hemmorrhoids; inadequate prep , small polyps cannot be r/o , outpatient
screening colonscopy should be repeated 2years with 2 day prep
BRIEF RESUME OF HOSPITAL COURSE:
CC: HALCOMB
HPI:71 year-old male with extensive history of cv disease on coumadin for afib ,
with recent colonscopy 4/3 depicting diverticuli , polyps and
internal hemorrhoids who presents with several week history of
rectal bleeding with bowel movements with several episodes of large
volume bloody discharge , painless , not associated with BM over the
past week. patient denies associated symptoms no sob , cp ,
fevers or chills. Increasingly constipated since starting iron ,
noticed dark stools. No history of GIB or dyspepsia or vomiting or coughing
up blood. Admission
Status: ED:given 250 cc NS; internal hemmorhoids seen on
anoscopy Vitals:74 vpaced , 148/82 , 16 , 98
RA Exam:obese , well appearing , nad , mmm , jvp not
appreciated , lungs clear , obese , rotund abd , bs present , rectal guiaic
positive , no BRBPR , tender on exam , 1+edema chronic L>R ( chronic ) ,
pulses nonpalpable , mult ulcers of R shin erythematous ,
mildly tender to palpation Studies:
-EKG vpaced at 75 unchanged A/P: Likely diverticular vrs hemorrhoidal
bleed on coumadin , hemodynamically stable , no further
bleeding , Hct stable , needs inpatient f/u secondary to
anticoagulation ,
Problem List: CV-Ischemia ASA held , Cont BB ,
Lasix Pump EF
50% Rhythm monitor on
telemetry Resp-no actives
issues Renal-Cr function at
baseline GI-2 large bore IVS , T and H; GI consulted ,
recommend colonscopy on 8/4 history of colonscopy described above , will need
repeat study in 2 years , also primary care physician will f/u EGD biopsy , cont nexium
40bowel regimen at home , outpatient GI
f/u Heme-Hct 41.1 on admission c/with prior; repeat Hct
stable; INR therapeutic on admission at 3 , given Vit K 5mg times one
to reverse given unclear severity of bleeding at onset , on coumadin
for afib , patient followed in coumadin clinic at PUO with blood draws at Abois Che Memorial Hospital , verified with coumadin clinic , will need twice weekly draws
pending stabilization of level , restarted coumadin at d/c
Endo-1/2 lantus while
npo ID-R LE ulcers concerning for developing cellulitis ,
started on doxycycline will complete 10 day course FEN-npo with gentle
IVF Pain-oxycodone ,
allopurinol Neuro- history of seizure disorder on phenobarbital , level
therapeutic , cont PPx-PPI , pneumoboots ,
TEDS Dispo-home
Code-FC
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with primary care physician as scheduled
INR checked at Osri Medical Center on Tues and Fri
Your primary care physician will follow results
EGD biopsy rsulted followe by primary care physician
Return to ED or call primary care physician with heavy bleeding or concerning symptoms such
as dizzyness or abdominal pain
Repeat colonoscopy in 2 years
Follow electrolytes with primary care physician
primary care physician will follow progression of cellulitis on antibiotic , return to Ed
with fevers or chills or increasing redness or pain
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( HT541 ) 4/3/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 724
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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991635846 | PUO | 69053105 | | 6933311 | 11/11/2006 12:00:00 a.m. | asthma exacerbation | | DIS | Admission Date: 2/12/2006 Report Status:
Discharge Date: 11/10/2006
****** FINAL DISCHARGE ORDERS ******
BECKENDORF , ALLA 818-87-74-3
Derd Asouthvu Codown
Service: MED
DISCHARGE PATIENT ON: 5/23/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
Starting Today ( 11/19 ) as needed Shortness of Breath , Wheezing
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled three times a day
LISINOPRIL 20 MG orally DAILY
Override Notice: Override added on 10/24/06 by
NETTI , DARNELL TATIANA , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
351532487 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
SINGULAIR ( MONTELUKAST ) 10 MG orally DAILY
PREDNISONE Taper orally Give 60 mg every 24 hours X 2 dose( s ) , then
Give 50 mg every 24 hours X 3 dose( s ) , then
Give 40 mg every 24 hours X 3 dose( s ) , then
Give 30 mg every 24 hours X 3 dose( s ) , then
Give 20 mg every 24 hours X 3 dose( s ) , then
Give 10 mg every 24 hours X 2 dose( s ) , then Starting IN a.m. ( 11/25 )
DIET: 2 gram Sodium
ACTIVITY: Activity as tolerated
FOLLOW UP APPOINTMENT( S ):
Please arrange to see Dr. Lero by the end of the week. ,
ALLERGY: AMOX./CLAV.ACID 250/125 , Codeine
ADMIT DIAGNOSIS:
Asthma exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
asthma exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma ( asthma ) HTN ( hypertension ) obesity
( obesity ) HTN ( hypertension ) hyperglycemia on steriods ( elevated
glucose ) hirsutism ( hirsutism ) spinal stenosis ( spinal
stenosis ) LBP ( low back pain ) chiari
malformation spinal syrinx C3-T2 ( 8 )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
42 year-old F with history of asthma p/with SOB in setting of recent asthma flare
******************
patient was in her USOH until 1wk PTA when experienced URI sx , productive
cough and low grade fevers. Seen at Mountford Wilkes-perescosautiesglens where rx'd with
nebs , steroids and d/c'd on pred taper starting at 40mg every day patient was told
that her CXR was c/with PNA. Also rx'd Z-pack which she has completed.
Cough and URI sx have improved but she has had persistent DOE. Peak flow
has been 150 , decreased from baseline of 300-350. Seen in MMC
urgent care today where reportedly she was hypertensive and O2 sat
94-95% on RA , referred to COASTPRI CYPRESSJEFF E TIA VERLRO GENERAL HOSPITAL for asthma flare refractory to current
treatment. No CP , HA or focal neurological deficits. patient c/o +increased
LE edema L>R , +orthopnea , and +PND. No sick contacts.
****
ED: 97.4 p126 181/95 30 94% RA , CXR and EKG performed , rx'd
prednisone 60mg x1 , nebs.
**************
PMH: Asthma - no history of intubation , multiple admissions and courses of
steroids , HTN , Obesity , Hyperlipidemia , Hyperglycemia - when on steroids ,
Hirsutism , Chiari Malformation - history of decompression , Spinal Stenosis ,
Spinal Syrinx - C3-T2 , Low back pain - history of multiple epidural steroid
injections
*************
MEDS: prednisone 30mg every day ( taper ) , advair , albuterol , combivent ,
singulair , lisinopril
***********
EXAM: Afeb p104 199/104 rr25 96% 2L
patient appeared in mild respiratory distress , sitting up reading a
book , very pleasant obese woman
HEENT: JVP not elevated
LUNGS: prolonged expiratory phase
CVS: rrr , nl S1S2 , no m/g/r
ABD: obese , BS+ , NT/ND
EXT: TR to 1+ edema to mid calf bilat , L>R
***************
LABS: WBC 14
STUDIES:
EKG: sinus tach 104
CXR( : linear opacity in RLL most c/with platelike atelectasis but cannot r/o
resolving or new PNA
***************
HOSITAL COURSE:
42 year-old F with asthma and tobacco use presents with asthma/COPD flare
refractory to initial treatment
* PULM: SOB most likely 2/2 reactive airway disease.
Substantial smoking history raises question of COPD as
contributor or dominant factor in her pulmonary disease.
patient was treated with duonebs every 4 hours with Albuterol every 2 hours as needed patient was continued
on advair , singulair. She was started on Prednisone 60 daily for 4 days
and then slowy tapered. No abx at this time as she just completed course.
WBC elevation likely 2/2 steroids. At D/C , peak flow had improved to 250
and ambulating O2 sat was 92-94%. patient's breathing had significantly
improved. Smoking cessation encouraged. patient was interested in trying
nicotine patch.
* CV: PUMP: HTN: Lisinopril was increased to 20mg daily due to
hypertension. No evidence of end-organ damage in with u. UA neg
for proteinuria.
* PPX: lovenox
CODE: full
ADDITIONAL COMMENTS: 1. ) Continue all of your home medications. Your lisinopril was increased
to 20mg daily.
2. ) Take prednisone 60mg daily for 2 days ( starting tomorrow ) , then 50mg
daily x 3days , then 40mg daily x3 days , then 30mg daily x 3days , then
20mg daily x3 days , and then 10mg daily x2 days and stop.
3. ) Please arrnge to see Dr. Lero by the end of the week. She will
advise you of any change in your prednisone taper.
4. ) Call Dr. Lero or come back to the emergency room if you experience
worsening of your breathing or fever.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
** Dr. Genovese **
Please taper prednisone as tolerated by patient.
No dictated summary
ENTERED BY: OSMERS , TESSA M ( YZ90 ) 5/23/06 @ 12:40 PM
****** END OF DISCHARGE ORDERS ******
Document id: 725
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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997044127 | PUO | 54837690 | | 580360 | 7/16/2001 12:00:00 a.m. | SOB , incisional hernia | | DIS | Admission Date: 1/23/2001 Report Status:
Discharge Date: 5/16/2001
****** DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
Ichi Highway , Dale , Colorado Room: 14D-195
Service: MED
DISCHARGE PATIENT ON: 5/21/01 AT 06:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REMLEY , EVALYN AMANDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ATENOLOL 50 MG orally every day Starting Today ( 3/5 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
KLONOPIN ( CLONAZEPAM ) 1 MG orally three times a day
Override Notice: Override added on 5/21/01 by
BIALY , ELENA
on order for AZITHROMYCIN orally ( ref # 34254014 )
POTENTIALLY SERIOUS INTERACTION: CLONAZEPAM & AZITHROMYCIN
Reason for override: Monitor
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
ZESTRIL ( LISINOPRIL ) 10 MG orally every day
NIFEREX-150 150 MG orally twice a day
PERCOCET 1-2 TAB orally every 4 hours as needed pain
PREDNISONE Taper orally every day before noon
Give 60 mg every day X 1 day( s ) ( 5/21/01 8/13/01 ) , then ---done
Give 40 mg every day X 1 day( s ) ( 10/24/01 6/13/01 ) , then ---done
Give 20 mg every day X 2 day( s ) ( 2/2/01 10/13/01 ) , then ---done
Starting Today ( 3/5 )
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours as needed SOB
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG NEB four times a day
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
KTDUOO clinic nurse 9/30/01 ,
Dr. Cohens 2 wks ,
No Known Allergies
ADMIT DIAGNOSIS:
SOB
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
SOB , incisional hernia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1 obesity
obstructive sleep apnea psoriasis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
37 year-old with history of multiple admissions for atypical chest pain , PMH of
morbid obesity , history of gastric bypass 3/23 sleep apnea , borderline HTN ,
p/with asthma flare , SOB. Had cath 2/30/01 with clean coronaries. D/c'd 2/20
with
alb and atr inhalers as well as prednisone taper and azithromycin for
dx of tracheobronchitis. Since d/c reports worsening cough prod of
scant white sputum and incr. SOB. Also noted painful diastasis bulge
along gastric bypass incision. SOB responded to Nebs in ED.
Pts respiratory status at baseline ( PFR here 250 , at home 200-250 per
patient ). Main complaint
seemed to be incisional hernia. Was seen by surgery who will follow patient
Soc svcs were consulted , and patient will f/u with PMD in KTDUOO clinic and
with KTDUOO nsg. patient will f/u with Dr. COHENS of Surgery in TWO WEEKs.
( Ms. Harkenreader may call Dr. Cohens 's office at 783-027-6947 to choose
the best time for her schedule on 11/27/01 ).
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GEKAS , CLEORA CIERRA , M.D. ( OI99 ) 5/21/01 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 726
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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364617096 | PUO | 93272592 | | 8459899 | 5/22/2007 12:00:00 a.m. | CHF | | DIS | Admission Date: 5/25/2007 Report Status:
Discharge Date: 1/26/2007
****** FINAL DISCHARGE ORDERS ******
FINEMAN , BLAKE 740-86-75-4
Angelesbofordsi Sade Room: Pro
Service: MED
DISCHARGE PATIENT ON: 11/17/07 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAKAI , RHEBA ROSINA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA 81 MG orally DAILY
Alert overridden: Override added on 7/11/07 by
IMHOFF , JACOB , M.D.
on order for ASA orally 81 MG every day ( ref # 785068915 )
patient has a PROBABLE allergy to SALSALATE; reaction is
Unknown.
patient has a PROBABLE allergy to CELECOXIB; reaction is
Unknown. Reason for override: patient tolerates
ATENOLOL 50 MG orally DAILY Starting Today ( 4/25 )
HOLD IF: SBP<100 , HR<55
Override Notice: Override added on 11/17/07 by
KILLIN , ALMEDA V. , M.D.
on order for TIAZAC orally OTHER every day ( ref # 382224616 )
POTENTIALLY SERIOUS INTERACTION: ATENOLOL & DILTIAZEM HCL
Reason for override: aware Previous override information:
Override added on 11/17/07 by KILLIN , ALMEDA V. , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & ATENOLOL
Reason for override: home med
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
VITAMIN B12 ( CYANOCOBALAMIN ) 50 MCG orally DAILY
Number of Doses Required ( approximate ): 5
CARDIZEM CD ( DILTIAZEM CD ( 24 HR CAPS ) ) 240 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 11/17/07 by :
POTENTIALLY SERIOUS INTERACTION: ATENOLOL & DILTIAZEM HCL
Reason for override: home med
LASIX ( FUROSEMIDE ) 40 MG orally DAILY HOLD IF: SBP<100
Alert overridden: Override added on 11/17/07 by
KILLIN , ALMEDA V. , M.D.
on order for LASIX orally ( ref # 501204710 )
patient has a POSSIBLE allergy to CELECOXIB; reaction is
Unknown. Reason for override: home med
INSULIN NPH HUMAN 16 UNITS subcutaneously DAILY
Starting Today ( 4/25 )
Instructions: take in evening as you always have
AVAPRO ( IRBESARTAN ) 300 MG orally DAILY HOLD IF: sbp<100
Alert overridden: Override added on 7/11/07 by
IMHOFF , JACOB , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN Reason for override: patient tolerates
Number of Doses Required ( approximate ): 5
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 300 MG orally DAILY
HOLD IF: SBP<100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
METFORMIN 500 MG orally three times a day
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
AVANDIA ( ROSIGLITAZONE ) 8 MG orally DAILY
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Bernas -please call for appt in 1 month ,
primary care physician please call for appt in 1-2 weeks ,
ALLERGY: Penicillins , ACE Inhibitor , Erythromycins , GABAPENTIN ,
TETANUS , SALSALATE , CELECOXIB , AMIDE ANESTHETICS
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , Diabetes , OSA
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
diuresis with intravenous lasix
echocardiogram
BRIEF RESUME OF HOSPITAL COURSE:
CC: shortness of breath
HPI: 73 year-old f with CAD and CHF-lmtd baseline ex capacity. Increasine DOE
and difficulty performing ADLs since 9/5 Stable orthopnea , new PND.
Also p/with some throat fullness and chst tightness on L-not
anginal equivalent..at rest , last 2 hours , relief 20min p NTG. Has
missed 2 doses of lasix but is otherwise compliant. Last ECHO
2003-mild LAE , 1-2+MR , mild-mod inf HK. Last cath 2005-LAD 40%prox
and 30%mid , RCA 100%mid-old since 2001 , LAD PDA collaterals. In ED
97% RA. PMH: HTN , CHF , hyperthyroidism , history of monoclonal
gammopathy , CAD history of cx stent 2001 , OSA on CPAP , DM , nephrolithiasis ,
CKD 1.3 , spinal stneosis ALL: PCN , ACE , emycin , neurotin , tetanus ,
salsalate , celebrex , amide
anesthetics HOME MEDS: asa 81 , nph 16 , imdur 300 , cardizem 240 ,
plvix 75 , atenolol 75 , lasix 40 , lipitor 20 , metformin 500 three times a day ,
avandia 8 , avapro 300 , B12
**********************
ADMIT STATUS: 97% RA , 140.60 HR 49 oriented , abd benign , ctab , 2/6 sys
m at apex , chronic LE edema
************************
STUDIES: CXR cardiomegaly
stable EKG 1st AV block , old inf
qs ECHO 7/18 , MR , mild-mon inf HK , EF 55% , unchanged from
prior
*********************
HOSPITAL COURSE:
1.DYSPNEA: The patient presented with increased dyspnea on exertion ,
likely secondary to CHF with preserved ejection fraction. Her EKG was
without changes from prior and her cardiac enzymes were cycled and
negative x3. She was given 40mg intravenous lasix with approx 2L diuresis daily.
Her weight at discharge was 127.3kg. Her admission weight was 131.5kg.
She had an ECHO which showed an EF of 55% and 1-2+MR with slightly
elevated PA pressure. This was unchanged from her previous ECHO in 2003.
Her CXR did not show any acute process. She had a DDimer of 2300. LENIS
showed no evidence of a DVT and on 7/18 she had a CT with PE protocol which
showed no evidence of a DVT or PE. She was given mucomyst for this for
renal protection. She was continued on her CPAP for OSA.
2. HTN: The patient was continued on her avapro and Imdur. Her diltiazem
and atenolol doses were decreased as she was having bradycardia with rates
in the 40s on the first day of her hospital stay.
3. CAD: The patient was continued on her imdur , beta blocker , and aspirin.
Her plavix was held as she was holding this as an outpatient for upcoming
cataract surgery. Her last stent was 2001 and she was given permission by
her outpatient cardiologist to hold this.
4. DM: Her avandia and metformin were held and she was continued on her
NPH and a sliding scale.
5. RENAL: Her Cr. was 1.4 at admission and improved to 1.1 with diuresis.
She was given mucomyst for renal protection.
6. FEN: She was maintained on a 2L fluid restriction and 2g Na
restriction.
7.PPX: heparin three times a day
ADDITIONAL COMMENTS: 1. Call your doctor if you have any more shortness of breath or
difficulty doing your daily activities.
2. Resume your usual home dose of lasix , monitor your weight daily and
call your doctor if your weight is increasing. Eat a diet low in salt
( less than 2 grams ).
3. We have decreased the dose of your atenolol to 50mg daily ( 1 pill ).
4. Please have your primary care physician Dr. Walth check your creatinine on Friday November This has been arranged and her office will contact you.
5. Please call Dr. Bernas for a follow up appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please follow patient's Cr. She received contrast for a CT.
2. Please adjust BP meds. Her atenolol dose was decreased because her
heart rate was in the 40s.
3. Please evaluate her anemia. Her Hct was in the low 30s while in the
hospital.
No dictated summary
ENTERED BY: KILLIN , ALMEDA V. , M.D. ( XS81 ) 11/17/07 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 727
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
Y |
N |
- |
N |
N |
N |
N |
158191074 | PUO | 25093021 | | 3645289 | 9/23/2002 12:00:00 a.m. | MITRAL REGURGITATION | Signed | DIS | Admission Date: 9/23/2002 Report Status: Signed
Discharge Date: 2/9/2002
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE AND MITRAL
REGURGITATION.
HISTORY OF PRESENT ILLNESS: 81-year-old white male with
longstanding mitral regurgitation and
congestive heart failure , hypertension , who has been followed with
serial echocardiograms with echocardiogram in September 2001 showing 1
plus mitral regurgitation with ejection fraction of 48% , trace
aortic insufficiency , diastolic diameter 6.6 , systolic diameter
4.9. The patient complains of shortness of breath with dyspnea on
exertion despite losing 20 pounds , notes shortness of breath with
walking up hill , walks 1 mile in 30 minutes daily. Repeat
echocardiogram on July , 2002 showed ejection fraction of
40-45% , 2-3 plus mitral regurgitation , trace aortic regurgitation ,
with hypokinesis of basal inferior wall. Diastolic diameter was 6 ,
systolic diameter of 3. The patient was selected for elective
surgery.
PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: Hypertension , bladder
carcinoma , painful
right shoulder and hand. Status post motor vehicle accident versus
pedestrian at age 7. Bilateral cataract repair in 2000.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 25 mg orally every day , Lasix 80 mg
every day before noon and 40 mg every afternoon , baby aspirin ,
Avapro 300 mg orally every day , Glucosamide chondroitin 400 every day.
HOSPITAL COURSE: The patient was admitted on November , 2002 ,
stabilized for surgery. On March , 2002 the
patient underwent a coronary artery bypass grafting x 5 with left
internal mammary artery to left anterior descending coronary
artery , saphenous vein graft 1 to diagonal one , saphenous vein
graft 2 to ramus , saphenous vein graft 3 to posterior descending
coronary artery , saphenous vein graft 4 to LVB1 and mitral valve
repair with a 30 Cosgrove. Total bypass time was 269 minutes ,
cross clamp time was 214 minutes. For further information
regarding the operation refer to the operative note.
The patient was stabilized and transferred to intensive care unit
with a drip of epinephrine at 4 mcg and nitroglycerin at 5 mcg.
Postoperatively the patient was weaned from oxygen , extubated ,
stabilized and sent to the step down unit after slow dopamine and
vasopressin weaning. The patient was sent to the step down unit on
postoperative day 2 where chest tubes , wires were all pulled out.
The patient was aggressively diuresed. The patient did well. On
postoperative day 5 the patient started having atrial fibrillation
in and out , specifically in the morning time , Lopressor was
increased and digoxin was increased by his cardiologist. The
patient was stabilized and heart rate was in sinus rhythm. During
the hospitalization the patient was also followed by his
cardiologist. The patient was stabilized and sent to
rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE: Enteric coated aspirin 81 mg orally every day ,
Lasix 40 mg orally every day , ibuprofen
400-600 mg orally every 4-6h , Niferex 150 mg orally twice a day , Zantac 150 mg
orally twice a day , Coumadin today 5 mg orally x 1 , for further dose of
Coumadin refer to instructions. Potassium chloride 20 mEq orally every
day , digoxin 0.25 mg orally every day , Lopressor 50 mg orally three times a day
LABORATORY VALUES ON DISCHARGE: Glucose 84 , BUN 30 , creatinine
1.2 , sodium 138 , potassium 4.0 ,
chloride 103 , CO2 24 , magnesium 2.1 , calcium 8 , white blood cell
count 7.86 , hematocrit 28.2 , platelets 284 , 000 , physical therapy 21.8 , INR 1.9.
FOLLOW UP: The patient will follow up with Dr. Colasamte in 6 weeks
and his cardiologist in 1-2 weeks. The patient was
discharged to rehabilitation in stable condition with a heart rate
of 81 , normal sinus rhythm.
Dictated By: SUSANNE NEVIUS , M.D. QU11
Attending: ISABELLE E. COLASAMTE , M.D. CL7
ES803/298005
Batch: 3417 Index No. E8KL74664D D: 1/11/02
T: 1/11/02
Document id: 728
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
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- |
584837428 | PUO | 72498010 | | 6074261 | 9/23/2006 12:00:00 a.m. | cad | | DIS | Admission Date: 4/1/2006 Report Status:
Discharge Date: 9/13/2006
****** FINAL DISCHARGE ORDERS ******
POTANOVIC , REBBECA 813-53-09-5
Ly Aton Charl Room: 34H-217
Service: CAR
DISCHARGE PATIENT ON: 2/26/06 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TALAMANTE , LOGAN BEATRIZ , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
DIGOXIN 0.25 MG orally DAILY
LASIX ( FUROSEMIDE ) 20 MG orally EVERY OTHER DAY
GLYBURIDE 10 MG orally twice a day
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
DILANTIN ( PHENYTOIN ) 200 MG every day before noon; 250 MG every afternoon orally BEDTIME
200 MG every day before noon 250 MG every afternoon Starting Today ( 3/23 )
Instructions: also take 200mg every afternoon
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after )
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
BENAZEPRIL 10 MG orally DAILY
GLUCOPHAGE ( METFORMIN ) 850 MG orally three times a day
Instructions: resume tomorrow 11/14/06
CELONTIN ( METHSUXIMIDE ) 300 MG orally three times a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: no heavy lifting for 3-4 days
FOLLOW UP APPOINTMENT( S ):
Dr. Part call for appointment ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cad
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
dm ( diabetes mellitus ) obesity ( obesity ) dyslipidemia
( dyslipidemia ) htn ( hypertension ) cad ( coronary artery
disease ) chf ( congestive heart failure ) history of cabg ( history of cardiac bypass
graft surgery ) seizure ( seizure disorder )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of cath
BRIEF RESUME OF HOSPITAL COURSE:
ID/CC:
63M transferred from OMC with positive stress test. HPI
Pateint has history of CABG LIMA-D1 , V-OM1 , V-OM2 , V Y-graft to PDA and PLV.
Presented to OMC on Monday with exertional angina. ROMI. Nuclear
stress reveled inferior scar and small area of anterior
ischemia. Transferred to PUO for cath. PMH
Seizure d/o , DM , CHF , CAD , CABG , HTN COPD , Schizo-affecitve disorder ,
dyslipidemia Meds on
transfer: Dilantin300/300/250 , glyburide 10 twice a day , metformin
850 three times a day , toprol 100 Daily , ASA 325 daily , isordil 20tid , lasix 20
every other day , lipitor 40 Daily , neurontin , celondin 300 three times a day , digoxin 0.25
Daily , benazepril 10 daily.
Allergies: None SH: lives
alone
****Hospital Course
1. CV: Cath LIMA-LAD patient. SVG Y graft to PDA and LV mid 50% in
graft stenosis. SVG to both OM branches occluded. RCA 100% , LAD mid
100% , LCx 100%. Patient was found to be ASA resistant will
change to plavix 75 daily. Other meds: Toprol 100 daily , isordil 20
three times a day Lasix 20 every other day. atorva switched to simva in house , benazepril to
lisinopril 10 , digoxin
0.25. 2. DM: will continue to hold metformin , restart
glyburide and start RISS. 3. Staying overnight as he lives alone , has
no way of getting home.
4. Neuro: Cont neurontin 300 three times a day , dilantin 200/200/250 , celondin-
listed on meds on discharge , but not on home meds. It is unclear if
he should be on this or not.
11/20/06
patient stable and ready for d/c
ADDITIONAL COMMENTS: Please take all medications as prescribed.
Call with any questions or concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STRAUHAL , MARCELINA , PA ( NY41 ) 2/26/06 @ 10:50 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 729
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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416683905 | PUO | 89518668 | | 2055104 | 3/10/2002 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/13/2002 Report Status: Signed
Discharge Date:
ADMISSION DIAGNOSIS: LEFT FOURTH TOE GANGRENE.
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old woman
with diabetes and well known to the
Vascular Surgery Service , status post multiple bilateral toe
amputations. She was last here in April of 2002. The patient was
admitted on March , 2002 for a planned left fourth toe
amputation and VAC sponge change by Dr. Kulinski
PAST MEDICAL HISTORY: The patient's past medical history includes
hypertension , coronary artery disease ,
status post myocardial infarction , insulin dependent diabetes
mellitus , history of seizures , status post cerebrovascular
accident , gastroesophageal reflux disease , and asthma.
ALLERGIES: The patient's allergies include penicillin , aspirin ,
NSAIDs , and pentazocine.
MEDICATIONS ON ADMISSION: At the time of admission , the patient
was on Zestril 20 mg every day , Plavix 75 mg
every day , Peri-Colace 30 mg twice a day , Niferex 150 mg twice a day , Gabitril 12
TIT three times a day , Flagyl 500 three times a day , Lantus insulin 80 units every bedtime ,
ceftazidime 1 gm every 8 , vancomycin 1 gm twice a day , esomeprazole 20 mg
every day , Prozac 20 mg every day , folic acid 1 mg every day , Humalog sliding
scale , Lasix 100 mg orally twice a day , Dilaudid as needed , Dulcolax as needed ,
ofloxacin 0.3% ophthalmologic drops one each eye four times a day , Cosopt one drop
each eye twice a day , brimonidine tartrate 0.2% ophthalmologic drops one each eye
four times a day , Pred Forte 0.12 twice a day drops both eyes.
PHYSICAL EXAMINATION: Physical examination revealed temperature to
be 98.7 , heart rate 72 , and blood pressure
154/71. HEENT was negative. The chest was clear. The abdomen was
protuberant , soft , and non-tender. The extremities revealed open
amputations of the bilateral feet with 2+ femoral pulses and
palpable DP and physical therapy pulses bilaterally with right greater than left.
There was no evidence of cellulitis with a necrotic left fourth
toe.
HOSPITAL COURSE:
1. Vascular: The patient was admitted for the left fourth toe
amputation , which occurred on April . This wound
was left open. She tolerated the procedure well with a VAC change
occurring on August at the bedside. At that time , it was noted
that , although , there was pink granulation tissue , the fifth toe
had become ischemic and nonviable. Therefore , the patient was
taken to the operating room on August for a left fifth toe
amputation , which was also left open. That was tolerated well , but
did not seem to be viable secondary to ischemia and infection.
Therefore , on March , 2002 , she was taken to the operating room
for a left transmetatarsal amputation of the third , fourth and
fifth toes. Dressing changes , wet-to-dry , were done. During that
time , it was noted that additional necrotic debris at the lateral
aspect of the foot required more debridement , so she was taken to
surgery on April for debridement and a partial resection of
the left fifth metatarsal. A VAC was placed and changed on
March at the bedside. On October , 2002 , the wound was
felt to be clean enough and a split thickness skin graft was placed
on the left foot , 75 square cm , and the donor site was the left
thigh. This seemed to be taking well. We continued with dressing
changes and a heat lamp to the donor site , which healed well. On
February , 2002 , we took her to the operating room again for
debridement of the left foot. The plantar aspect of the skin graft
had become discolored and we felt the infection required
debridement. Intraoperatively , the bone did not seem to be
involved and , at this point , we had been continuing wet-to-dry
dressing changes and , as of January , 2002 , the plan was to take
the patient to the operating room on January , 2002 for another
skin graft. Now that the wound is clean , she has completed
antibiotics.
2. Neurological: The patient has a history of a seizure disorder ,
which has been stable on Gabitril. She is
status post stroke and is stable. For her depression , she receives
Prozac. Her pain is well controlled on a Fentanyl patch with
oxycodone for as needed pain and Dilaudid for breakthrough pain. The
patient also has occasional dizziness and this is treated with
as needed meclizine.
3. Cardiovascular: The patient has coronary artery disease and is
status post a myocardial infarction , and
hypertension , which is currently well controlled on Lopressor 50 mg
three times a day
4. Respiratory: The patient has asthma that has been stable and
not evidenced in the hospital.
5. GI: The patient has a history of gastroesophageal reflux
disease , which is treated with esomeprazole. She is on a
diabetic diet. She receives Colace , Senna , multivitamins , folic
acid and Niferex.
6. GU: The patient is receiving Lasix 100 mg twice a day at this
moment. Her admission creatinine was 0.7 , peaked at 2.0
on February , at which time we called a renal consultation , who
said she was probably pre-renal acute renal failure secondary to
ace inhibitor , Lasix and a new bunch of antibiotics. At that time
we held the ace inhibitor , held the Lasix , and renally dosed the
antibiotics , at which time her creatinine came down to 1.1 , which
is closer to her baseline. We have slowly restarted Lasix and she
has tolerated that. We have since discontinued her antibiotics.
7. Heme: The patient's admission hematocrit was 25.7 , for which
she received 1 unit of packed red blood cells on
April . She received another unit of packed red blood cells on
November and her most recent hematocrit , on January , was 26.8.
Therefore , she is baseline anemic.
8. Infectious Disease: This has been another major issue for this
patient. Starting from the beginning , on
October , the patient had a urinary tract infection with mixed
flora , for which she was treated with a five day course of Diflucan
for Candida. On April , a wound culture of the left foot
showed Pseudomonas , which was resistant to multiple drugs ,
multidrug resistant E. coli , and methicillin resistant
Staphylococcus aureus , as well as multidrug resistant Klebsiella.
On February , when we went to the operating room for further
debridement of the left foot , we obtained deep cultures from the
operating room and found Pseudomonas diphtheroid and Klebsiella ,
which were sensitive to vancomycin and cefotaxime. Infectious
Disease had consulted on our patient and recommended vancomycin ,
cefepime and Flagyl and a two week course of these antibiotics for
a soft tissue infection. It did not appear in the operating room
again that the bone was involved in the infection. An MRI on
August , however , showed soft tissue swelling in the sinus
tract that was suspicious for osteomyelitis of the fifth
metatarsal , but , in consultation with Infectious Disease , Vascular
Surgery , her operative findings , and clinical picture , we decided
it looked more like a soft tissue infection and treated her for two
weeks with antibiotics.
9. Endocrine: The patient has diabetes mellitus and her blood
sugar control has been an issue throughout her
hospital stay , slowly titrating up to her current Lantus dose of
150 units subcutaneously every bedtime She seems to be doing well with that.
10. Ophthalmology: The patient is status post bilateral cataract
surgery and attempted filter for glaucoma in
the right eye and high pressure with pain , and proliferative
retinopathy with bilateral traction detachment. She was taking the
following medications: Pred Forte , Cosopt , ofloxacin , and Alphagan
for her eyes. On August , she had an Ophthalmology appointment
for floaters and that diagnosis was proliferative diabetic
retinopathy , status post pan retinal phototherapy with vitreous
hemorrhage. On October , she had an appointment with Dr. Raabe at
142-036-0000 , who recommended to add timolol to her eye drops , and
will be following up with her.
11. Dental: The patient had an appointment on July , where
they recommended a root canal of #18 and #19 for
caries. This root canal was done on January . The number of the
clinic is 428-247-1913.
12. Skin: The patient received Lotrimin , miconazole and wound
care to her right foot with Regranex. The left foot is
receiving wet-to-dries every day
13. Tubes , lines and drains: The patient had a right PICC line
placed on October , 2002.
DISCHARGE INSTRUCTIONS:
Neurological: Continue.
Cardiac: Continue.
Respiratory: Continue.
GI: Continue.
GU: Continue with monitoring of creatinine.
Heme: Continue with monitoring of hospital course.
Infectious Disease: No antibiotics needed , but follow left wound
closely and she is positive for methicillin
resistant Staphylococcus aureus , so she will need to be in
isolation.
Endocrine: Blood sugar control.
Ophthalmology: She need follow-up with her ophthalmologist about
her retinopathy , bilateral detachment and glaucoma.
Dental: She had a root canal done and will need follow-up.
Vascular: Will need to follow her bilateral extremity examination
and the skin graft to her left foot to ensure proper
healing. As well , she will be needing rehabilitation secondary to
weakness and decreased mobility after these amputations. She is
heel weight bearing on the left , weight bearing as tolerated on the
right. Goals will be to have bed mobility , transfers , daily
therapy with exercise , and the goal will be to ambulate 25 feet
with the least restrictive device.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was actively on , as of January ,
Lotrimin topical twice a day , Colace 100 mg twice a day , Fentanyl 150 mcg
every 72 hours , Prozac 20 mg every day , folic acid 1 mg orally every day , Lasix
100 mg orally twice a day , heparin 5000 units subcutaneously twice a day , insulin sliding
scale , Lopressor 50 mg three times a day , Niferex 150 mg orally twice a day ,
Pred Forte one drop each eye four times a day , Senna two tablets orally every bedtime ,
Gabitril 12 mg orally twice a day , miconazole powder to groin twice a day ,
Regranex topical twice a day to right foot and cover with loose sterile
dressing , Plavix 75 mg orally every day , Cosopt one drop each eye twice a day ,
ofloxacin 0.3% ophthalmologic solution one drop each eye four times a day ,
esomeprazole 20 orally every day , Lantus 150 units subcutaneously every bedtime , and
Alphagan one drop each eye four times a day She is currently using one touch ultra
glucose pen stick for blood sugar draws. She gets Tylenol as needed ,
Natural Tears as needed , Dilaudid as needed for pain , Milk of Magnesia
as needed , meclizine as needed , and oxycodone as needed
FOLLOW-UP: The patient was instructed to follow-up with Dr. Derham
in two weeks from the date of discharge.
Dictated By: DARLA TAAL , M.D. FE059
Attending: ROSSIE MANKOSKI , M.D. NW98
NP601/912754
Batch: 50279 Index No. FLMH989G68 D: 7/23/02
T: 7/23/02
Document id: 730
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074981892 | PUO | 65633683 | 340816 | 7/1/1997 12:00:00 a.m. | LEFT LOWER EXTREMITY CELLULITIS | Signed | DIS | Admission Date: 7/1/1997 Report Status: Signed
Discharge Date: 3/19/1997
PRINCIPAL DIAGNOSIS: LEFT LOWER EXTREMITY CELLULITIS.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male with
a history of coronary artery disease
status post three vessel coronary artery bypass graft on 1/17/97
complicated by right parietal cerebrovascular accident , who
presents with erythema and swelling of left leg for two days prior
to admission. The patient denies trauma , but actually does admit
to scratching his leg with his hand at night. The patient denies
shortness of breath , chest pain , nausea , vomiting , diarrhea , and
belly pain.
PAST MEDICAL HISTORY: 1. Coronary artery disease status post
myocardial infarction in 1995 , status post
PTCA of left circumflex 10/28 , status post three vessel coronary
artery bypass graft on 11/13/97. 2. Status post right parietal
cerebrovascular accident postoperatively with long postoperative
recovery. 3. Non-insulin-dependent diabetes mellitus , diet
controlled. 4. Hypertension.
ALLERGIES: Penicillin results in joint swelling.
ADMISSION MEDICATIONS: Metoprolol 75 mg orally every day , Norvasc 5 mg
orally twice a day , Cozaar 50 mg orally twice a day ,
Coumadin 3 mg on Monday and Friday and 4 mg on Tuesday , Wednesday ,
Thursday , Saturday , and Sunday , multivitamin one tablet orally every day ,
and hydrocortisone 1% applied to face twice a day as needed.
SOCIAL HISTORY: The patient lives with his wife and daughter. He
does not smoke. He uses alcohol occasionally.
FAMILY HISTORY: Notable for coronary artery disease.
PHYSICAL EXAMINATION: The patient's temperature was 96 , blood
pressure 130/80 , pulse 68 , respirations 18 ,
and O2 saturation 97% on room air. The patient was an alert male
in no acute distress. Chest revealed few bibasilar crackles.
Heart had regular rate and rhythm with no rubs , murmurs , or
gallops. Abdomen was soft , nontender with bowel sounds present.
Extremities revealed left lower extremity with erythema with areas
of prior excoriation. Now , there is increased warmth and there is
onychomycosis present.
LABORATORY DATA: Hematocrit was 41 and white blood cell count 5.5.
INR was 1.8. LENIs were negative for deep venous
thrombosis , but left lower extremity calf veins were not
visualized.
HOSPITAL COURSE: The patient received 1 gm of Ancef intravenous every 8 hours with
improvement in cellulitis. He received 5 mg of
Coumadin while in-house.
DISCHARGE MEDICATIONS: Same as admission medications with the
addition of Keflex 500 mg orally four times a day for
two weeks and Lotrimin , probably twice a day , to feet.
FOLLOW-UP: The patient will have INR checked by VNA on Monday ,
9/23/97.
Dictated By: ANIBAL V. RIGLER , M.D. YN47
Attending: DEANDRA L. GILFOY , M.D. HC88
AA151/9658
Batch: 4118 Index No. P0LOWU1UPV D: 3/25/97
T: 3/25/97
CC: 1. SANA M. AZUA , M.D. IK70
2. FRANCISCA A. URBANIAK , M.D. MS1
Document id: 731
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647903858 | PUO | 76033503 | | 2951560 | 3/2/2007 12:00:00 a.m. | PREGNANCY , 6 WEEKS DIABETIC | Signed | DIS | Admission Date: 1/27/2007 Report Status: Signed
Discharge Date: 5/27/2007
ATTENDING: ASTILLERO , CHERY MD
SERVICE: Obstetrics/Maternal Fetal Medicine.
PRINCIPAL DIAGNOSIS:
1. Pre-gestational diabetes.
2. History of coronary artery disease.
3. Recurrent SABs
4. Hepatitis B.
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old G16 ,
P0-0-15-0 , who presented at 6 and 4/7 weeks by LMP
consistent with ultrasound of the day of admission , as a transfer
from the High-Risk Obstetric Clinic , admitted to the Fuller
Antepartum Service for diabetic control. The patient had
presented to the Special OB Clinic as a new patient for prenatal
care. Review of her medical problems revealed that the recent
glucose control had been suboptimal. In view of this and in view
of the fact that the patient had multiple other issues , the
patient was admitted for diabetic control , adjustment of her
insulin regimen and evaluation regarding the other medical
problems.
History of present pregnancy: the patient had a last
menstrual period in the second week of October . Ultrasound on the
day of admission , 9/5/07 , revealed a 6.6-week intrauterine
pregnancy with a fetal heart rate of 110. The estimated date of
confinement is 4/19/07. Prenatal screening labs were pending at
the time of admission. The patient has blood group O +ve.
PAST MEDICAL HISTORY: The patient has a history of ST elevation
myocardial infarction in 2000. The infarct was a presumed
embolism to the left anterior descending and the left circumflex coronary
artery. The complete occlusion of the mid-to-distal left
anterior descending artery , which was thought to be due to
thrombosis , was treated with TPA and angioplasty. The patient had
a normal catheterization in October 2000. The last echocardiogram
revealed an ejection fraction of 45% in 2002; however , the
patient never had a repeat echo since that time. On the day of
admission , the patient reported that she was able to climb four
flights of stairs to her apartment , haveing to pause after two flights of
stairs to catch her breath.
In addition , the patient has a history of diabetes mellitus , diagnosed in 2000.
The patient had a medical admission in 2006 for hypoglycemia when she
incidentally injected Humalog instead of Lantus. On the day of admission , the
patient was on a Humalog 7 units twice a day and Lantus 12 units in
the evening. Her fasting sugars were in the 150s before admission and her
blood sugar measurements were over 200 in the evening. On the day of
admission , the fasting sugar was 123.
In addition , the patient has a history of hepatitis B ,
diagnosed in 2005. The patient had a positive E antigen in 2005.
She had previously been on Epivir 150 mg orally daily , but this
was stopped prior to the current pregnancy.
PAST OB/GYN HISTORY: The patient has a history of a fibroid
uterus , and a history of recurrent miscarriages. In terms of the
fibroid uterus , the patient did report pelvic pain in the
outpatient setting. Ultrasound had shown an 8-10 cm
dominant posterior fibroid. The patient occasionally takes
oxycodone for fibroid pain.
In terms of the patient's recurrent miscarriages , the patient had fifteen SABs
in the past with over 10 dilatation and evacuations , including one molar
pregnancy with subsequent choriocarcinoma. All losses were in the first
trimester , less than 12 weeks' gestation. The patient had been
evaluated previously for a thrombophilia workup , but this had
been negative multiple times aside from a MTHFR gene mutation ,
which was noted on this admission , and it is unclear whether this
has been addressed previously. The patient had previously been
told by a reproductive endocrinologist , that she should consider
adoption or a gestational carrier. Chromosomes on several
pathology specimens from the previous abortions showed
aneuploidy.
The patient currently denies a history of sexually
transmitted infections. She has a history of cervical dysplasia ,
with a history of CIN I and CIN II in 1990 and 1992. She
underwent a LEEP in 1992 , which was consistent with HSIL. All
subsequent Pap smears were either within normal limits. Last Pap
smear done in February 2006 at Kernan To Dautedi University Of Of was insufficient for
analysis. In terms of the patient's history of choriocarcinoma , the patient
had a molar pregnancy , which then developed into a subsequent choriocarcinoma.
For this , the patient was treated with methotrexate , actinomycin D and Cytoxan ,
then VP-16 , cisplatin and bleomycin with presumed cure.
PAST SURGICAL HISTORY: Dilatation and evacuation x10 ,
hysteroscopy for infertility workup , and LEEP.
MEDICATIONS ON ADMISSION: Humalog Insulin 7 units twice a day ,
Lantus 12 units in the evening , aspirin 81 mg orally daily stopped
prior to pregnancy , history of lamivudine/Epivir use , 150 daily
stopped prior to current pregnancy.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Former smoker , given up smoking in 2000 after a
myocardial infarct. No history of alcohol abuse or intravenous drug use.
The patient lives in Van Lanel with her boyfriend , unemployed.
FAMILY HISTORY: No history of GYN malignancies , history of
maternal diabetes , longstanding. Father with coronary artery
disease in his 50s.
HOSPITAL COURSE: The patient was admitted for the primary
purpose of diabetic control.
1. Diabetes mellitus. The patient had reported poor diabetic
control as an outpatient. Therefore , her regimen was continued ,
with the addition of a sliding scale , in order to determine the
additional insulin needs as an outpatient. Over the course of
the admission , the patient's Lantus was increased to 20 units at
nighttime , and she was using 8 units three times a day of insulin
lispro , in addition to a lispro sliding scale. With this
regimen , the fingerstick glucose control improved , and the
fasting blood sugar on the day of discharge was 90. On the day
prior to discharge , the patient had blood sugars in the range
from 93 to 139. An HbA1c was sent , which was 6.7 , during this
admission , the patient also had a Nutrition consult. She will be
followed in the High-Risk Obstetric and Diabetic Clinic by Dr.
Wikins
2. Cardiology. The patient was restarted on her aspirin , given
her history of myocardial infarct at a very early age. In
addition , an echocardiogram was obtained on the day after
admission. This revealed an ejection fraction of 50% as well as
a large left ventricular thrombosis , which was presumed to be a
longstanding. Cardiology was consulted and the impression was
that the thrombosis was likely a combination of her left
ventricular hypokinesia related to the previous infarct , as well
as her hypercoagulable state. Therefore , their recommendation
was to start the patient on Lovenox for the duration of this
pregnancy , which adjusted for her weight was a dose of 90 mg
daily , followed by a transition to Coumadin postpartum , to be
continued for likely long-term , possibly lifelong duration. The
Cardiology Consult Team noted that the MTHFR mutation had not
resulted in elevated homocysteine levels in the past. However ,
they did agree that folate supplementation at high doses was
indicated. The patient will be continued on Lovenox 90 mg daily
subcutaneously , and aspirin 81 mg orally daily as an outpatient.
She will have Cardiology followup with Dr. Brooke Lemmen on
3/6/07. During the entire admission , she was hemodynamically
stable , in sinus rhythm , with no complaints of chest pain ,
shortness of breath or palpitations.
3. Hepatitis B. The patient had liver function tests and a
hepatitis panel on this admission , given her history of active
disease diagnosed in 2005 , with a positive hepatitis E antigen.
On admission , the patient had not been on Epivir , which had been
stopped prior to this current pregnancy. Liver function tests
were checked on this admission and were within normal limits. In
addition , serologies were checked and the hepatitis E antigen and
the E antibody was negative. Hepatitis B surface antigen and hepatitis B
core antigen were reactive. At the time of this dictation , a
hepatitis B viral load was pending. Given the patient's history
of hepatitis B , an outpatient appointment was being arranged at
the time of discharge , with Dr. Banegas , from the Division of
Gastroenterology at the Pagham University Of . It was
decided that the patient should not take any lamivudine until
Gastroenterology followup. During the entire hospital stay , the
patient did not have any GI complaints , was tolerating a regular
diet , and having normal regular bowel movements.
4. history of fibroids , the patient was noted again to have an 8-cm fibroid
on her ultrasound scan. She required rare intermittent doses of
oxycodone as required for pain , which was presumed to be related
to her fibroid uterus.
5. Prenatal care. The patient had her first trimester labs sent
on this admission. GC and chlamydia testing were negative.
Urine culture was negative. The patient was O +ve. Given the
patient's history of MTHFR mutation and the recurrent SABs , the
patient was started on prenatal vitamins , as well as high-dose
folic acid , B12 and B6. In view of the patient's diabetic
history , and a transiently elevated creatinine to 1.2 on hospital
day 2 , which went back to 0.7 on the day of discharge , the
patient had a 24-hour urine collection sent , this returned
negative at 92 mg per 24 hours. It was noted that the patient
had an Ophthalmology retinal exam at an outside hospital health
center this year. For the remainder of this pregnancy , it was
noted that the patient will require ultrasounds at 11 and 17
weeks , as well as a fetal echo , and the recommended testing for
pre-gestational diabetics for the remainder of the pregnancy.
The patient was discharged in a stable condition , with followup
appointments arranged for the various specialties.
DISPOSITION: Home without services.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Lovenox subcutaneously 90 mg daily.
3. Vitamin B12 100 mcg orally daily.
4. Folate 4 mg orally daily.
5. Prenatal vitamins one tablet orally daily.
6. Lantus 20 units subcutaneously every afternoon.
7. Insulin lispro 8 units subcutaneously before meals , as well as lispro
sliding scale , in addition a before meals.
FOLLOW-UP APPOINTMENTS:
1. Special OB on 1/5/07.
2. Dr. Smithmyer , Endocrinology on 1/5/07.
3. Dr. Nina Surace , Cardiology , on 3/6/07.
4. Dr. Banegas , Gastroenterology , the patient will receive
letter with the appointment from GI Clinic.
eScription document: 5-9926778 CSSten Tel
Dictated By: SUGIMOTO , ARDELL
Attending: ASTILLERO , CHERY
Dictation ID 2426054
D: 7/28/07
T: 7/28/07
Document id: 732
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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357007009 | PUO | 73091725 | | 5290544 | 9/10/2006 12:00:00 a.m. | history of VHR with mesh | | DIS | Admission Date: 5/5/2006 Report Status:
Discharge Date: 9/28/2006
****** FINAL DISCHARGE ORDERS ******
LATTEA , NIKITA B. 543-61-60-7
Ale Ran Hou
Service: GGI
DISCHARGE PATIENT ON: 5/26/06 AT 12:00 PM
CONTINGENT UPON pain controlled
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WEINGARTNER , ROBBYN ERIK , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASCORBIC ACID 500 MG orally twice a day Instructions: Take 1 tablet
CALCITRIOL 0.25 MCG orally DAILY Instructions: Take 1 capsule
CALCIUM CARBONATE 1 , 500 MG ( 600 MG ELEM CA )/ VIT D 200 IU
1 TAB orally DAILY
KEFLEX ( CEPHALEXIN ) 500 MG orally twice a day
Starting Today ( 6/29 )
Instructions: continue while drain in place
Alert overridden: Override added on 4/5/06 by
ADAMO , QUEEN , M.D.
on order for KEFLEX orally ( ref # 603558561 )
patient has a POSSIBLE allergy to Penicillins; reactions are
TREMORS , shaking. Reason for override:
tolerates cephalosporins
COLCHICINE 0.6 MG orally DAILY
Alert overridden: Override added on 5/26/06 by
KIELBASA , RUEBEN , PA-C
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & COLCHICINE
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & COLCHICINE
Reason for override: aware
CYCLOSPORINE MICRO ( NEORAL ) 150 MG orally twice a day
Instructions: avoid grapefruit unless MD instructs
otherwise. give with meals
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 5/26/06 by
KIELBASA , RUEBEN , PA-C
on order for COLCHICINE orally ( ref # 925876405 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & COLCHICINE
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & COLCHICINE
Reason for override: aware Previous override information:
Override added on 5/26/06 by KIELBASA , RUEBEN , PA-C
on order for OXYCODONE orally ( ref # 968848698 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & OXYCODONE
HCL Reason for override: aware
Previous override information:
Override added on 4/5/06 by ADAMO , QUEEN , M.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
CYCLOSPORINE Reason for override:
home medication , taking at home
DILTIAZEM EXTENDED RELEASE 300 MG orally DAILY
HOLD IF: SBP less than 110 or HR less than 60 and CALL HO
Instructions: Avoid grapefruit unless MD instructs
otherwise. Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FOLIC ACID 1 MG orally DAILY
INSULIN ASPART 7 UNITS every day before noon subcutaneously 7 UNITS every day before noon
INSULIN ASPART 8 UNITS subcutaneously at lunch
INSULIN ASPART 8 UNITS subcutaneously at dinner
INSULIN GLARGINE 35 UNITS subcutaneously every day before noon
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally DAILY
Instructions: Take 1 tablet
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LEVOTHYROXINE SODIUM 125 MCG orally DAILY
MAGNESIUM OXIDE ( 241 MG ELEMENTAL MG ) 400 MG orally twice a day
METHOTREXATE ( NON ONCOLOGY USE ) 2.5 MG orally QWEEK
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 1 , 500 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 5/26/06 by
KIELBASA , RUEBEN , PA-C
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & OXYCODONE
HCL Reason for override: aware
PRAVASTATIN 20 MG orally BEDTIME
Instructions: Avoid grapefruit unless MD instructs otherise
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 4/5/06 by
ADAMO , QUEEN , M.D.
on order for CYCLOSPORINE MICRO ( NEORAL ) orally ( ref #
982140784 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
CYCLOSPORINE Reason for override:
home medication , taking at home
PREDNISONE 7.5 MG orally every day before noon
TORSEMIDE 40 MG orally DAILY
Instructions: Please check with your cardiologist
regarding dosing of torsemide
DIET: No Restrictions
ACTIVITY: Walking as tolerated
please wear abdominal binder at all times
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Weingartner 1-2 weeks , for JP drain removal , please record output. ,
Primary Care Physician 2-4 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Ventral hernia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of VHR with mesh
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DILATED CMP ( EF 33% ) ATYPICAL CP( midepigastric pain )
NSVT WITH DIZZINESSs/p AICD '98 CLEAN C'S IN 92 Amiodarone-induced
hyperthyroidism thyroid ultra sound: diffuse
enlargement one 6x4x2 mm nodule Pancreatitis 5/11 Renal infarct '92
OPERATIONS AND PROCEDURES:
4/5/06 WEINGARTNER , ROBBYN ERIK , M.D.
VENTRAL HERNIA REPAIR , MESH
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Lattea , Nikita 73091725
HISTORY OF PRESENT ILLNESS: This is a postoperative followup visit. Mr.
Mucha is a very pleasant 46-year-old African-American male who comes
in approximately two weeks after having an open cholecystectomy for
gangrenous cholecystitis. The postoperative course was complicated by a
bile leak from the cystic duct. The patient had an ERCP with a stent
placement by Dr. Gaylene Faniel The patient will have this removed in two
months. Otherwise , the patient is doing well with no fevers , chills , or
sweats. No nausea , vomiting , diarrhea. He is having normal bowel
movements and tolerating a regular diet. He has a midline ventral hearing
in the subxiphoid region near his cardiac transplant incision site. For
which he got operative managment.
PHYSICAL EXAM: Today , the abdomen is soft , nontender , nondistended. The
incision is healing well and the staples are taken out. He has a midline
ventral hernia in the subxiphoid region near his cardiac transplant
incision site. The hernia is somewhat symptomatic but the defect was very
large. We have elected to repair this in the fall as the patient has
several obligations in the next couple of months.
PAST SURGICAL HISTORY: Heart transplant and status post cholecystectomy.
PAST MEDICAL HISTORY: Also includes diabetes , congestive heart failure ,
and gout.
MEDICATIONS:
1. Vitamin C ( Ascorbic Acid ) orally twice a day
unit strength: 500MG form: TABLET take: 1 Tablet( s )
2. Calcitriol ( Rocaltrol ) orally every day
unit strength: 0.25MCG form: CAPSULE take: 1
3. Calcium Carbonate 1500 Mg ( 600 Mg Elem Ca )/ Vit D 200 Iu ( Caltrate
600 + D ) orally 1 TAB every day
4. Colchicine orally every day as needed
unit strength: 0.6MG form: TABLET take: 0.5
5. Cyclosporine Micro ( Neoral ) ( Neoral Cyclosporine ) orally 150 MG twice a day
Avoid grapefruit unless MD instructs otherwise. Give with
meals
6. Diltiazem Extended Release ( Cartia Xt ) orally 300 MG every day
Avoid grapefruit unless MD instructs otherwise.
7. Esomeprazole ( Nexium ) orally 40 MG every day
8. Folic Acid orally 1 MG every day
9. Insulin Aspart ( Novolog ) subcutaneously 7 units a.m.
8 units at lunch and 8 units at dinner
10. Insulin Glargine ( Lantus ) subcutaneously 35UNITS every day before noon
11. K-Dur ( Kcl Slow Release ) orally every day
unit strength: 20MEQ form: TABLET CR take: 1 Tablet( s )
12. Levothyroxine Sodium ( Synthroid ) orally 125 MCG every day
1 DAILY
13. Magnesium Oxide ( 241 Mg Elemental Mg ) orally 400 MG twice a day
14. Methotrexate ( Non Oncology Use ) orally 2.5 MG QWEEK
15. Mycophenolate Mofetil ( Cellcept ) orally 1500 MG twice a day
16. Pravastatin orally 20 MG every bedtime
Avoid grapefruit unless MD instructs otherwise.
17. Prednisone orally 7.5 MG every day before noon
18. Torsemide orally 40 MG every day
Please check with your cardiologist regarding dosing of
torsemide
ALLERGIES: Has allergies to medications include penicillin - > tremors
SOCIAL HISTORY: He does not smoke and does not drink.
patient admitted on 9/10/2006 , underwent ventral hernia repair with mesh , jp
drain. Please see operative note for details of procedure. patient sent to
PACU in stable condition. Admitted to surgical service for observation ,
2/2 pain issues.
N: PCA dilaudid providing adequate pain control. patient transitioned to orally
pain medications in am POD 1 , controlled well.
CV: history of cardiac transplant , no issues , all home meds re-started , vitals
wnl. .
P: weaned oxygen , on room air.
GI: Tolerating Regular diet. Blake Drain intact with strict output
recorded. Sent home with VNA and antibiotics.
GU: no issues , voiding.
Heme: subcutaneously heparin , usual proph.
ID: Keflex orally 500mg twice a day ( adjusted for renal disfunction ) while on Blake
drain. VNA for blake drain.
- f/u appt in 1-2 weeks and f/u for drain removal when output < 30 cc /
24 hrs.
ADDITIONAL COMMENTS: Seek immediate medical attention for fever >101.5 , chills , increased
redness , swelling or discharge from incision , chest pain , shortness of
breath , or anything else that is troubling you. OK to shower but do not
soak incision until follow up appointment , at least. Please leave white
band aid strips on until they fall off. No strenuous exercise or heavy
lifting until follow up appointment , at least. Do not drive or drink
alcohol while taking narcotic pain medications. Resume all home
medications. Call Dr. Weingartner to make follow up appointment. VNA to
help with JP drain care. Please measure outptu and call Dr. Weingartner when
less than 30cc in 24 hour period. Continue keflex ( antibiotic ) until
Drain is out.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KIELBASA , RUEBEN , PA-C ( HP50 ) 5/26/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 733
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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- |
736473937 | PUO | 87757880 | | 041080 | 8/14/1996 12:00:00 a.m. | NEW ONSET ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 1/17/1996 Report Status: Signed
Discharge Date: 10/27/1996
DISCHARGE DIAGNOSIS: SUPRAVENTRICULAR TACHYCARDIA/PAROXYSMAL
ATRIAL FIBRILLATION.
HISTORY OF PRESENT ILLNESS: Patient is a 54 year old man status
post AVR admitted for tachycardia.
Patient is a 54 year old with history of high blood pressure and
status post aortic valve replacement with homograft for chronic AI
from bicuspid aortic valve. His postoperative course was
complicated by prolonged fevers , he had multiple blood cultures
drawn and only one culture grew Hemophilus parahaemolyticus in the
sputum , and only one out of many blood cultures grew coagulase
negative Staphylococcus. He was discharged from the surgical
service on July , 1996 on Lopressor and Percocet. He was sent
home feeling well except for persistent low grade temperatures.
One day prior to admission , patient had mild shortness of breath
but denied orthopnea and paroxysmal nocturnal dyspnea with no chest
pain. He awoke the morning of admission with no complaints but was
found by VNA to have a rapid heart rate and was sent to the
Emergency Room. Patient denied shortness of breath , dyspnea on
exertion , cough , pleuritic chest pain , dizziness , and palpitations.
PAST MEDICAL HISTORY: Included: 1 ) Status post AVR for AI from
bicuspid aortic valve as above. 2 ) History
of polio in 1955. 3 ) Hypertension. 4 ) History of knee surgery.
ALLERGIES: He had no known drug allergies.
CURRENT MEDICATIONS: Lopressor 25 twice a day and enteric coated
aspirin 325 a day.
SOCIAL HISTORY: He was married with children , worked in the
clothing industry , and denied cigarette and
alcohol use.
FAMILY HISTORY: Negative for coronary artery disease and negative
for cardiomyopathy , deep venous thrombosis , and
pulmonary embolus.
PHYSICAL EXAMINATION: He was a healthy appearing male alert in no
apparent distress. Temperature was 99.1 ,
blood pressure 118/70 , pulse of 90 , and 97% O2 saturations on two
liters of oxygen. HEENT: Oropharynx was clear with pupils equally
round and reactive to light and extraocular movements intact.
NECK: Supple with no lymphadenopathy , no jugular venous
distention , and carotids were 2+ bilaterally with no bruits.
CARDIOVASCULAR: Regular rate and rhythm without murmurs , rubs , or
gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN:
Soft , good bowel sounds , nontender , nondistended , and no
hepatosplenomegaly. RECTAL: Examination was negative for blood.
EXTREMITIES: No edema. NEUROLOGICAL: Examination was nonfocal.
LABORATORY EXAMINATION: On admission , SMA 7 significant for
potassium of 4.6 , BUN of 19 , and
creatinine 0.9 , white count was 10 , hematocrit of 33.6 , platelet
count of 377 , physical therapy 13.8 with INR of 1.3 , and PTT of 23.6. Chest
x-ray showed no infiltrate and no effusion. EKG showed atrial
flutter at 156 , borderline left ventricular hypertrophy initially
then after 5 mg of intravenous Verapamil , he converted to atrial
fibrillation at 100 , and there were no specific ST-T wave changes.
He also underwent VQ scan which showed high intermediate
probability scan.
HOSPITAL COURSE: The patient was admitted to the cardiology B
service for management of atrial
fibrillation/atrial flutter and question of pulmonary embolus. He
was heparinized and was continued on Lopressor for rate control.
He was placed on cardiac monitor. In addition because of the low
grade fevers , more blood cultures were obtained. He underwent a PA
gram on January , 1996 which showed no evidence of pulmonary
embolism , normal right heart pressures , and bibasilar subsegmental
atelectasis. Patient was begun on Coumadin and he was also seen by
infectious disease consultation who felt that he should be off all
antibiotics. He also underwent a transesophageal echo on January ,
1996 which showed mildly dilated left ventricle with low normal
systolic function , aortic homograft with no vegetation or fluid
collection around the annulus , trace aortic insufficiency was
present , mitral valve was mildly thickened with 1+ mitral
regurgitation but no obvious vegetations , tricuspid and pulmonic
valves were normal with no vegetations , and left atrium was also
normal with no thrombus. Patient continued to have low grade
fevers with no obvious evidence of infection and infectious disease
consultation service suggested that patient be discharged to home
off all antibiotics and be followed closely at home with
instructions to return to the hospital with any signs of increasing
fevers , chills , or any problems with the incision site.
DISPOSITION: Patient is discharged to home on May , 1996 in
good condition.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
diltiazem 30 mg orally three times a day , and Coumadin
10 mg orally every day
FOLLOW-UP: Patient has follow-up with Dr. Fournier
Dictated By: KEN WESTFALL , M.D. AK5
Attending: SHAVONNE D. MAINER , M.D. QP3
SA851/2148
Batch: 14349 Index No. LNBF834IQD D: 11/10/97
T: 6/10/97
Document id: 734
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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007269174 | PUO | 78290430 | | 6480632 | 12/10/2005 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 12/10/2005 Report Status:
Discharge Date: 11/5/2005
****** FINAL DISCHARGE ORDERS ******
BOMBICH , ARNOLDO C 494-23-93-8
Peteseve Ln Room: Po Ra O
Service: CAR
DISCHARGE PATIENT ON: 6/20/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TYACKE , MACKENZIE , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Assisted living
DISCHARGE MEDICATIONS:
ECOTRIN ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day
FERRO-SEQUELS 1 TAB orally every day
LISINOPRIL 30 MG orally every day
PRAVACHOL ( PRAVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NORVASC ( AMLODIPINE ) 5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 120 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
PILOCARPINE 2% 1 DROP each eye twice a day
BACTRIM DS ( TRIMETHOPRIM/SULFAMETHOXAZOLE DOU... )
1 TAB orally twice a day X 12 doses Starting Today ( 5/29 )
Instructions: started on 10/12 , continue until 3/1 a.m.
CLOBETASOL PROPIONATE 0.05% CREAM TP twice a day
Instructions: please apply to affected areas.
Number of Doses Required ( approximate ): 10
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 6/12/05 by BLACKGOAT , GERMAINE LAVONNE KATE , M.D.
on order for ALLEGRA orally ( ref # 075161838 )
patient has a PROBABLE allergy to DIPHENHYDRAMINE ; reaction
is agitation. Reason for override: patient takes at home
ALPHAGAN ( BRIMONIDINE TARTRATE ) 1 DROP each eye twice a day
Number of Doses Required ( approximate ): 10
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
CALCIUM CARBONATE 1 , 500 MG ( 600 MG ELEM CA )/ VIT D 200 IU
1 TAB orally every day
ZETIA ( EZETIMIBE ) 10 MG orally every day
METFORMIN 250 MG orally twice a day
ACIPHEX ( RABEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Cassem in October scheduled ,
ALLERGY: epinephrine eye drops , LEVOFLOXACIN , intravenous Contrast ,
DIPHENHYDRAMINE , Penicillins , BACITRICIN OINTMENT ,
OXYBUTININ
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
'93LIMA-LAD;SVGs-PDA , D1 , OM1 ?USA glaucoma esophageal spasm NIDDM , diet
controlled fibrocystic mastitis peripheral
neuropathy OA , DJD history of duodenal ulcer lumbar spinal stenosis HTN
hypercholesterolemia history of carpal tunnel release hyponatremia
( hyponatremia ) MI ( myocardial infarction ) ?cauda equina
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
REASON FOR ADMIT: substernal CP
HPI: 83yoF with CAD history of 4 vessel CABG 1993 history of L main and diagonal PTCA
with cypher stent 8/13 followed by bare metal stent in diagonal for
recurrent CP , p/with substernal epigastric pain. Has had multiple
admissions for chest pain , last in 9/8 with MIBI that was improved
from prior. Woke up at 5am with substernal epigastric pain , unclear if
angina or esophageal spasm. Took maalox and 3 ntg with pain
relief. Then CP radiated to left arm which is more typical of
anginal pain. Called lame medical center and came in. Had some vague symptoms in ED
that responded to nitro , BP dropped 140s to 90s but came right back
up. First set neg. EKG no changes. PE unremarkable.
***********************
PMH: CAD history of 4v CABG history of Lmain and diagonal cypher stent and diagonal BMT
8/13 , htn , hyperchol , fibrocystic mastitis , history of type intravenous RTADM , eophageal
spasm , glaucoma , peripheral neuropathy , OA , DJD , history of duodenal ulcer ,
lumbar spinal stenosis , history of carpal tunnel releaseplease see problem list
***********************
Cardiac studies
-Cath 8/13 LM stent patent. LAD 100% lesion with patent LIMA. diagonal 80%
lesion with cypher stent , another bare metal stent placed distally , LCx
100% RCA 100% with patent SVG->RAMUS , LIMA->LAD , SVG->D2 , SVG->PDA
-MIBI 9/8 mod sized severe perfusion defect in LCx/OM! territory
throughout inferolateral and basal inferior wall with mild reversibility ,
improved since 4/9
************************
ADMISSION MEDS: lisinopril 20mg daily , calcium 600+D daily , isosorbide
120mg daily , metformin 250mg twice a day , allegra 60mg daily , asa 325mg daily ,
alphagam gtts twice a day , pilocarpine 2% twice a day , clobetizol cream 0.5mg twice a day ,
pravachol 80mg every bedtime , zetia 10mg every bedtime , norvasc 5mg daily , atenolol 50mg
daily , ferrex 1/day , acephex 20mg daily , plavix 75mg every bedtime , ntg as needed
ALLERGIES: epi eyedrops , intravenous contrast , levo ,
penicillin , bacitracin ointment , oxybutinin SH: lives at Bend Arlpring Padayert
assisted living. HCP is niece Dia Riemenschneid 014 837 9228. no
tob/etoh/ivdu.
*************************
ADMISSION PE: VS afeb 61 146/67 16 100%2L
HEENT: anicteric , eomi , surgical pupils b/l , op clear NECK: supple ,
carotid 2+ without bruits , no lan , jvp 7 LUNGS: ctab , occ wheezes CV: rr , nl
s1 s2 , no m/r/g ABD: nl bs , soft , mild tender in LLQ to deep palpation ,
no masses , no hsm EXT: trace edema , warm , dp/patient 1+ b/l SKIN: diffuse
erythematous nodular skin lesions. left elbow with abrasion NEURO: a&ox3 ,
moves all extremities
*************************
LABS/STUDIES
--labs on admission: Ca 10.9.
--cardiac enzymes x 3 neg
--UA 1+ LE , neg nitrite , 10-15 WBC , 4+ bact
--UCx >100 , 000 enteric gram neg rods , mucoid , sens pnding
--EKG sinus @55 , LAD , TWI III ( new ) , TW flattening I/avF ( old ) , V5-V6
lateral flattening ( old ) no ST changes , poor RWP
--CXR ( portable ): clear
*************************
A/P CV:
--ischemia: Given cardiac history patient admitted for r/o MI , although
from story discomfort could also have been 2/2 esophageal spasm. Patient
ruled out for MI with 3 sets of neg cardiac enzymes and no EKG changes.
Did not have recurrence of her chest discomfort or left arm tingling at
rest or with ambulation. On good cardiac regimen , and continued on ASA ,
plavix , BB , ACE , statin , zetia. lipid panel good with total chol
163 and ldl 86 hdl 43. uptitrated ACE to optimize BP , increased to 30mg
daily with improved BP with SBP in 110s.
--pump: no e/o overload. cont on home BP meds.
--rhythm: tele with out events
GI: history of esophageal spasm , cont PPI. likely source of chest discomfort.
NEURO: left arm tingling did not recur but if recurs in the future may
consider carotid ultrasound or neck imaging.
HEME: history of Fed anemia , cont iron. Hct stable in low 30s , 32.6 at d/c.
ENDO: on lantus , novolog prandial , and novolog sliding scale here ,
restarted on home metformin at d/c.
ID: UTI. Started on Bactrim for 7 day course.
DERM: cont steroid ointment
HEENT: cont eyedrops.
FEN: cardiac , diabetic diet. watch Ca.
PPx: lovenox , PPI
CODE: DNR/DNI ----- >
HCP niece Dia Riemenschneid 174 973 9606
ADDITIONAL COMMENTS: *Please call our Dr. or return to the ED if you have any more episodes of
chest discomfort
*Your lisinopril has been increased to 30mg daily. You have been started
on Bactrim for 7 days for a urinary tract infection. All other
medications are the same
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*monitor BP with uptitration of ACE
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE KATE , M.D. ( ZE37 ) 6/20/05 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 735
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
288431774 | PUO | 41739484 | | 3376748 | 3/28/2005 12:00:00 a.m. | PULMONARY EMBOLISM | Signed | DIS | Admission Date: 8/8/2005 Report Status: Signed
Discharge Date: 8/8/2005
ATTENDING: ISABELLE EVON COLASAMTE MD
This discharge summary summarizes his Intensive Care Unit course
from March , 2005 to July , 2005.
HISTORY OF PRESENT ILLNESS: Briefly , Mr. Harajly is a 69-year-old
African-American male who is postoperative day 11 from a
reoperative aortic valve replacement and mitral valve repair for
endocarditis. His postoperative course was complicated by
Mobitz's type II heart block and long sinuses pauses for which he
was transferred to the ICU on account of snow storm making
staffing issues difficult to take care of him on the floor. He
remained in the Intensive Care Unit one day.
HOSPITAL COURSE: His Intensive Care Unit course by system is:
1. Neurologic: The patient was complaining of pain at his
Quintin catheter insertion site for which he was treated with
oxycodone.
2. Cardiovascular: The patient was initially transferred to the
Intensive Care Unit with bradycardia and Mobitz's type II heart
block and 6-7 second sinus pauses. He was asymptomatic for all
of these events with good hemodynamics. However , given the large
snow storm and short staffing , it was felt that he would be
better off in the Intensive Care Unit for closer monitoring. He
had no major issues in the Intensive Care Unit. He was switched
from labetalol and amlodipine as well as his beta blocker eye
drops so as to not exacerbate his heart block. He did have some
difficult to control hypertension which was treated with
hydralazine which was titrated up to 80 four times a day with good result.
In addition , he was maintained on Losartan and Lisinopril. He
was followed by the Electrophysiology Service who came to the
conclusion that the patient does need a permanent pacemaker;
however , the issue of when and how to place the pacemaker has yet
to be resolved as the patient has difficult venous access issues
given his multiple clotted AV fistulas and poor venous access
sites. The Electrophysiology Service and Dr. Colasamte are in the
process of deciding what the best approach for his pacemaker is.
Hew as in a sinus rhythm with occasional asymptomatic bradycardia
in the 40s but otherwise stable rhythm.
3. Respiratory: No issues.
4. GI: He is on a renal diet which he tolerated. He is also on
a bowel regimen and on 2 liter fluid restriction per the Renal
Team.
5. Renal: The patient is followed by renal medicine. He is
anuric and he is dialyzed Saturday , Tuesday , Thursday. He had no
acute renal issues although his potassium was somewhat on the
high side between 4.8 and 5.0 but trended down by the next day.
He was followed by the Vascular Surgery Service who have
determined that his right AV fistula is not salvageable. They
plan to do a left AV fistula on an outpatient basis once the
patient's current cardiac issues have resolved and he is
discharged from the hospital.
6. Endocrine: No issues.
7. Heme: No issues. The patient is on an aspirin 81 mg a day.
8. ID: The patient came in to the Intensive Care Unit on
Vancomycin , Gentamicin and Rifampin for presumed endocarditis
although all of his cultures have been negative. He has
continued on these in the hospital. He is afebrile without a
white count.
eScription document: 5-8753849 DBSSten Tel
Dictated By: ZITZOW , NICOLAS MERRIE
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 8985776
D: 6/11/05
T: 6/11/05
Document id: 736
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
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- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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816645569 | PUO | 32646255 | | 3738317 | 2/17/2005 12:00:00 a.m. | asthma exacerbation | | DIS | Admission Date: 2/23/2005 Report Status:
Discharge Date: 1/9/2005
****** DISCHARGE ORDERS ******
RODIBAUGH , ISADORA 289-67-53-5
T Li Spogle
Service: MED
DISCHARGE PATIENT ON: 7/18/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ALBOR , SANA L. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
Instructions: patient can refuse if not SOB
CLINDAMYCIN HCL 300 MG orally four times a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
PREDNISONE Taper orally Give 60 mg every 24 hours X 1 dose( s ) , then
Give 40 mg every 24 hours X 2 dose( s ) , then
Give 30 mg every 24 hours X 2 dose( s ) , then
Give 20 mg every 24 hours X 2 dose( s ) , then
Give 10 mg every 24 hours X 2 dose( s ) , then
ZOLOFT ( SERTRALINE ) 200 MG orally every day
METFORMIN 850 MG orally three times a day
LEVOFLOXACIN 500 MG orally every day
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 10/3/05 by
IVASKA , MELDA X. , M.D. , M.S.C.
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: Will monitor
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 10/3/05 by
IVASKA , MELDA X. , M.D. , M.S.C.
on order for LEVOFLOXACIN orally ( ref # 63392383 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: Will monitor
LASIX ( FUROSEMIDE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Nuessle July , 1:50 pm ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
asthma
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
asthma exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma ( asthma ) niddm ( diabetes mellitus type 2 )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
HPI: This 36 year-old woman has a history of asthma and obestity. She presents
with SOB and URI sx. She has previously been hospitalized for asthma , but
never intubated , and has never required ICU care. She was last treated
for an asthma flare one month ago. She has been unable to refill her
advair due to social pressures ( children at home ). She works as a pre-
school teacher and has been in frequent contact with sick children. For
the past week she has had increasing SOB , cough productive of white
sputum , and DOE after 1 block. Peak flow about 450 at baseline , 250 today.
Seen in urgent care and found to de-sat to 85% on RA on ambulation.
Referred to ED. There , VS 96.1 97 149/75 20 89 on RA. Treated with nebs ,
prednisone , lasix for pulmonary congestion seen on CXR , and levofloxacin
for possible RLL infiltrate on CXR.
ROS: postive for lightheadedness , blurred vision , chest fluttering. No
history of calf pain.
PMH: Asthma , NIDDM , history of c-section , tubal ligation , teratoma
removal. Meds: Albuterol , atrovent , metformin , zoloft , advair
All: NKDA
Soc Hx: Married , two children , no tob , no Etoh
Fam Hx: PE , father
Admission exam: 96.4 79 140/90 20 97% RA
Obese woman , speaking in complete sentences , NAD. RRR no MGR. Mild rhonchi
at RLL , otherwise infrequent wheezing. +BS s , nt , nd. 1+ edema in le's ,
ulcer on R shin with erythema tracking down leg. Neuro non-focal.
Labs: Nl Chem 7. WBC 9.3 HCT 31 Plt 289 D-dimer 1132
A/P: 36 year-old woman with history of asthma , presents with SOB , URI sx , de-sat on
ambulation. Asthma flare most likely , though d-dimer concerning for
DVT/PE.
Hospital Course: The patient was treated with albuterol/advair nebulizers
and prednisone with rapid improvement. She was restarted on Advair , and
written for a prednisone taper for discharge. LENIS were performed which
excluded the diagnosis of DVT. The patient has no further hypoxia and
does not complain of pleuritic chest pain , and the diagnosis of PE is
low probability. She was also treated with 40mg intravenous lasix for pulmonary
edema seen on her CXR. Her BNP is 24 , which makes systolic dysfunction
unlikely ( recent ECHO shows EF 60% ). She should be followed as an outpt
for serial examinations and placed on lasix if she continues to have
signs of right heart failure suggesting diastolic dysfunction.
Finally , the patient is discharged on levofloxacin + clindamycin as
coverage for her LE cellulitis and RLL infiltrate.
She is encouraged to lose weight , and to follow up with her primary care
physician to obtain nutrition consultation and a plan for exercise to
achieve this aim.
ADDITIONAL COMMENTS: 1. you have had a viral infection that worsened your asthma. You
should take Advair daily and albuterol only as you need it for
shortness of breath
2. you are being treated with antibiotics for 10 days for your
leg skin infection. You should keep your leg elevated as much as
possible over the next 10 days.
3. You should work with your primary care physician to help lose weight
to improve your breathing , fluid retention , and diabetes
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. take advair as scheduled
2. f/u wt gain with pcp
No dictated summary
ENTERED BY: IVASKA , MELDA X. , M.D. , M.S.C. ( NY01 ) 7/18/05 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 737
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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281676199 | PUO | 45516411 | | 013643 | 11/23/2000 12:00:00 a.m. | ABDOMINAL PAIN | Signed | DIS | Admission Date: 8/6/2000 Report Status: Signed
Discharge Date: 6/9/2000
SERVICE: Ne
PRINCIPAL DIAGNOSIS: Pyelonephritis.
SECONDARY DIAGNOSES: Urinary tract infection. Bilateral adnexal
masses. Diabetes mellitus.
HISTORY OF PRESENT ILLNESS: Ethelyn Athmann is a 53 year old woman
with a history of diabetes mellitus
who presents with abdominal pain and fevers over two weeks
duration. Two weeks prior to admission , the patient had headaches ,
nausea , vomiting , presyncope , anorexia with mild periumbilical
pain. She also had fevers to 101 degrees F. with associated chills
and diaphoresis. The patient presented to her primary care
physician three days before admission and was found to have
elevated liver function tests with AST of 39 , ALT of 108. At that
time , the patient was presumed to have a viral syndrome. Two days
prior to admission , the patient developed worsening abdominal pain.
The pain was described as sharp , constant in character with
radiation to the back. The pain was more intense in the right
lower quadrant. The pain was also noted to be in the lower flanks
and the costovertebral angle area. The patient has noted no change
in her usual bowel habits of one stool per week. She has had no
diarrhea , constipation , melena , or hematochezia. She has had no
hematemesis. She denies any urinary symptoms but only has
nocturia. Of note , the patient had menopause approximately eight
years ago , but in each of the last three months she has noticed
monthly vaginal bleeding which she believes are a resumption of
menstrual cycles. The last episode was about one month ago. The
patient also has a history of nephrolithiasis but feels that this
current pain is different from the one she has had in the past.
PAST MEDICAL HISTORY: Significant for hypertension , diabetes
mellitus diagnosed two years ago , obesity ,
obstructive sleep apnea , nephrolithiasis , osteoarthritis , glaucoma.
PAST SURGICAL HISTORY: Notable for cesarean section 20 years ago
that was complicated by pulmonary embolism.
MEDICATIONS ON ADMISSION: 1. Lasix 60 mg every day. 2. Glyburide 5 mg
every day. 3. Labetalol 200 mg twice a day
4. Timoptic , Xylatan drops for glaucoma.
ALLERGIES: Lidocaine leads to rash. Lisinopril leads to cough.
Diltiazem leads to edema. Nifedipine leads to edema.
Intravenous contrast leads to hives.
FAMILY HISTORY: Significant for cardiovascular disease.
SOCIAL HISTORY: The patient is married and has two children. She
denies any use of alcohol or tobacco.
PHYSICAL EXAMINATION: Temperature 102 , heart rate 90 , respiratory
rate 34 , blood pressure 143/48. Oxygen
saturation 91% on 2 liters nasal cannula. HEENT: Pupils equal ,
round , reactive to light and accommodation. Extraocular muscles
intact. Anicteric sclerae. Oropharynx clear. No jugular venous
distension. CHEST: Clear to auscultation bilaterally. HEART:
Regular rate and rhythm. Normal S1 , S2 , no murmurs. ABDOMEN:
Obese and fairly firm. Diffusely tender to palpation. Increased
right lower quadrant pain. Rebound tenderness and mild guarding.
Bowel sounds are present but decreased. BACK: No costovertebral
angle tenderness. CERVIX: Cervical motion tenderness is present.
NEUROLOGIC: The patient is alert and oriented x3.
LABORATORY: Chemistries revealed sodium 132 , potassium 4.2 ,
chloride 94 , CO2 32 , BUN 13 , creatinine 1. Glucose
315 , calcium 9.9. Liver function tests showed ALT 58 , AST 23 , ALK
127 , total bilirubin 1.2 , albumin 4.6 , globulin 3.1 , amylase 28 ,
lipase 145 , total protein 7.7. The complete blood cell count
revealed a white blood cell count of 23.91 , hemoglobin 14.1 ,
hematocrit 41.8 , platelets 520. The differential showed 77 polys ,
7 bands , 6 lymphocytes , and 6 monocytes. The urinalysis was
notable for pH 5.5 , protein 1+ , glucose 1+ , leukocytes 1+ , nitrite
positive , trace ketones , and no blood. Sediments showed white
blood cells 45 - 50 , 4+ bacteria , 1+ squamous epithelial cells , 1 -
2 casts. Abdominal CT was notable for a 7 x 8 cm low density fluid
collection in the region of the right adnexa and a 4 x 8 cm low
density fluid collection in the left adnexa. A UCG was negative.
PROCEDURES: September , 2000 , endometrial biopsy. The procedure
was limited due to the patient's body habitus. The
biopsy revealed no evidence of malignancy. Complications none.
HOSPITAL COURSE: By systems:
1. GENITOURINARY. The patient's presenting
symptoms and abdominal CT findings of bilateral adnexal masses were
suspicious for a tubo-ovarian abscess. However , the patient did
not have any of the associated risk factors , given that the patient
is not sexually active and denied introducing any foreign objects
into the vagina. The patient was initially managed on triple
antibiotics , ampicillin , gentamicin , and Clindamycin. Since a CT
scan is not the optimal test to evaluate the adnexa , a transvaginal
ultrasound was ordered which revealed endometrial thickness of 3.6
mm and bilateral cystic masses. The patient's right upper quadrant
pain and tenderness persisted for several days during the admission
with periodic exacerbations and was increasingly suspicious for
cholelithiasis or pancreatitis. The patient then had an abdominal
ultrasound which was essentially was within normal limits and
showed no abnormal viscera. The bilateral adnexal masses continued
to be of major concern , and interventional radiology was consulted
for possible aspiration. Given that the etiology of the masses was
unclear and the risk of malignancy in a post menopausal woman , it
was decided that the best approach would be open tissue sampling.
It was then decided to postpone this procedure pending further
evaluation of the patient. Of note , the patient had a CA-125 drawn
which 77. Serum HCG was negative. The patient's report of new
onset of post menopausal bleeding was concerning. Considering the
high likelihood of malignancy , the patient was being followed by
the gynecology oncology service and underwent endometrial biopsy
for tissue sampling. The biopsy revealed no evidence of
malignancy. The patient had a repeat CT scan on hospital day
number seven which was essentially unchanged from admission showing
persistent bilateral adnexal masses and no free fluid. The
patient's symptoms of right lower quadrant pain persisted but
became more responsive to treatment toward the end of the
admission. Throughout the admission the actual etiology of the
bilateral adnexal masses was never discerned. As a result , the
patient was referred to the gynecology oncology service for
continued follow up as an outpatient.
2. INFECTIOUS DISEASE. The patient's presentation of fevers ,
chills , and diaphoresis was certainly suspicious for infectious
process. Initially the patient was covered with ampicillin ,
gentamicin , and Clindamycin for empiric antimicrobial coverage.
The urine culture was notable for greater than 100 , 000 Escherichia
coli which was pan sensitive. All blood cultures at initial
presentation had been negative. On October , the creatinine
level increased to 1.8. As a result , gentamicin was then switched
to Levofloxacin. The patient's fever initially defervesced from
102.2 to 99.3 , but spiked to 100.1 after six days of antibiotics.
Her white blood cell count remained elevated and ranged from 24 to
32. However , by discharge the white blood cell count was 10.
Because of the patient's initial minimal response to antibiotics ,
repeat blood cultures and urine cultures were sent which were
negative. In addition , ID was consulted to provide further
guidance regarding antimicrobial management. They recommended to
continue ampicillin and Levofloxacin. Clindamycin was changed to
Flagyl. By discharge , the patient was afebrile.
3. CARDIOVASCULAR. By hospital day number two , the patient was
noted to have increased lower extremity swelling and new bibasilar
crackles. The symptoms were suggestive of volume overload and
possibly congestive heart failure. A chest x-ray was notable for
bilateral atelectasis in the lower lobes but no pulmonary edema or
pleural effusions. A cardiac echocardiogram revealed normal
systolic function with ejection fraction of approximately 60% and
mild left ventricular hypertrophy. The patient was treated with
Lasix and was aggressively diuresed. She responded well to
treatment.
4. NEUROLOGIC. The patient presented with abdominal pain and was
initially with Demerol and Vistaril. Initially the patient was
only minimally responsive to treatment , but over time she became
more responsive. By discharge , the patient was without pain.
MEDICATIONS ON DISCHARGE: Lasix 60 mg orally four times a day Glyburide 5 mg
orally every day. Labetalol 200 mg orally
twice a day Flagyl 500 mg orally every 8 hours Levofloxacin 500 mg orally every
24 hours. Xalatan 1 drop each eye every afternoon Timoptic 0.5% 1 drop OS every day.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient was discharged to home and required no
services.
DISCHARGE INSTRUCTIONS: The patient was advised to call her
primary care physician for fevers greater
than 100.5 , chills , nausea , vomiting , abdominal pain. The patient
was also advised to take her temperature every day. The patient
was scheduled to follow up with her primary care physician in one
week. She will also follow up with the gynecology oncology service
for further evaluation of bilateral adnexal masses and post
menopausal bleeding.
Dictated By: TROOP , TWILA SADIE ERICA
Attending: AVRIL F. TAPLIN , M.D. QI3
FW138/9274
Batch: 58545 Index No. JDSHEA4HI4 D: 5/11
T: 5/11
Document id: 738
| Target |
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474382460 | PUO | 05214753 | | 632613 | 1/20/1998 12:00:00 a.m. | STATUS POST MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 6/7/1998 Report Status: Signed
Discharge Date: 10/2/1998
DIAGNOSES: 1. MYOCARDIAL INFARCTION.
2. HERPES ZOSTER.
BRIEF HISTORY: The patient is an 80-year-old man with a history
of coronary artery disease , who was transferred to
I Warho Hospital two days following an acute myocardial
infarction , for post myocardial infarction management. The patient
has known coronary artery disease , and is status post myocardial
infarction in 1998. At this time he underwent a two-vessel CABG
with a saphenous vein graft to the RCA and to the LAD. Since then ,
he claims that he has done very well with rare angina
( approximately two times a year ) which responds well to sublingual
nitroglycerin.
He underwent an exercise treadmill test in 1997 , that showed
inferolateral ST depressions with exercise , that were considered
non-diagnostic , secondary to LVH and some resting EKG
abnormalities.
On August , the patient noted 10 out of 10 chest pain while walking
with his family. He took sublingual nitroglycerin times three with
no relief. He was taken to Thasstoncheripigapema Memorial Hospital where an EKG
showed ST depressions in leads V2 through V4 , and T wave flattening
in V1 and V5. He also had T wave inversions in V2 through V4. The
patient was treated with intravenous heparin , intravenous
nitroglycerin , and beta blockers. He remained pain free after this
treatment. He eventually developed a Q wave in V1. During his
hospitalization at Mery Hospital , the patient was noted to have
an 11 beat run of V-tach on August , and was started on a lidocaine
drip. The lidocaine drip was stopped on September , and the
intravenous nitroglycerin was weaned. He was placed on nitro paste
on September , and his intravenous heparin was then stopped on January .
The patient was transferred to I Warho Hospital on January
because he preferred to receive his care from his primary
cardiologist. He denies having any chest pain since his initial
pain on the seventh. He also denies shortness of breath ,
orthopnea , paroxysmal nocturnal dyspnea , swelling , nausea ,
vomiting , or diaphoresis. He has been tolerating a regular diet.
PAST MEDICAL HISTORY: 1. Coronary artery disease status post MI
in 1998 , and two-vessel CABG in 1998.
2. Exercise induced atrial fibrillation
noted in 1990 with no recurrence.
3. Prostate carcinoma status post
prostatectomy in 1986.
4. Malaria in 1944.
MEDICATIONS: Enteric coated aspirin 325 mg every day , atenolol 25 mg
every day , nitro paste started at the outside hospital.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient was recently widowed approximately
two months ago , and has been grieving. He is
close with his daughter. He denies any use of tobacco or alcohol.
CARDIAC RISK FACTORS: No tobacco , no hypertension , no family
history of significant cardiac disease , and
no known history of hypercholesterolemia.
PHYSICAL EXAMINATION: He was a pleasant elderly man in no acute
distress , who was sitting up in bed. Vital
signs: the patient was afebrile with blood pressure 115/60. Heart
rate was 67. Respiration was 18. Room air saturation was 94%.
HEENT exam showed the patient to be anicteric , with intact
extraocular movements , and moist mucus membranes. The neck was
supple with jugular venous pressure noted , approximately 8
centimeters. The chest was clear to auscultation bilaterally with
no rales or wheezes.
The coronary exam showed regular rate and rhythm , with a 1/6
midsystolic murmur at the left sternal border , and no S3.
The abdominal examination showed a flat abdomen with active bowel
sounds , and a well-healed midline low abdominal scar consistent
with his prior prostatectomy. No masses or hepatosplenomegaly were
noted.
The extremity exam showed no edema , with 2+ femoral and posterior
tibial pulses bilaterally , and 1+ dorsalis pedis pulses
bilaterally.
On neurologic exam , the patient was alert and oriented times three
with cranial nerves III through XII intact and symmetric. The
motor examination was 5/5 throughout , with 1+ deep tendon reflexes
and downgoing toes bilaterally.
LABORATORIES AT THE OUTSIDE HOSPITAL: CPK at admission was 2611 ,
with an MB fraction of 260.
Sodium 139 , potassium 4.9 , chloride 100 , CO2 30 , BUN 20 , creatinine
1.0 , glucose 123. The white blood cell count was 8.4 , with a
hematocrit of 40 , and platelets of 160. LDH is 162. AST is 26.
The EKG showed normal sinus rhythm , with normal intervals. The
prior ST depressions had resolved , and there were Q waves in V1 and
V2. The T waves were flattened in V5 and V6.
HOSPITAL COURSE: Cardiac: the patient remained off of his heparin
drip and on his nitro paste , and had no further
episodes of chest pain or shortness of breath. He underwent an
echocardiogram , which revealed an ejection fraction of 45 to 50% ,
and posterior/lateral hypokinesis in the left ventricle. There
were no valvular abnormalities. Because the patient had no further
episodes of chest pain , he did not undergo further evaluation , and
was discharged home. The plan is for him to undergo another
exercise test in approximately 3 to 4 weeks.
ID: The patient developed a temperature of 101.1 on his first day
of admission. He presented with a Foley catheter in place , which
was removed. A urinalysis and culture were negative. Blood
cultures were drawn and were negative , and a chest x-ray was normal
as well.
On hospital day number three , the patient was noted to have a
non-pruritic , non-painful , erythematous rash on the back of his
lower right buttock and the back of his right leg. The patient
claimed that this rash was completely asymptomatic , and he would
not know about it if no one had pointed it out.
On hospital day number four , it was noted that this rash had filled
up a dermatomal pattern on the back of his right leg , and it was
felt that this most likely represented an acute outbreak of herpes
zoster. The patient was not treated specifically for herpes , given
that he was asymptomatic , and we did not have any proven diagnosis.
However , we were confident enough of this that we felt that it
would explain his low grade temperatures.
Psych: The patient spoke openly about his sadness following the
loss of his wife , two months ago. He was seen by Social Services ,
as well as by the Survtheast Centex Health Care , who thought that the patient
was appropriately grieving , and appropriately sad. It was felt
that at the time of discharge , that the patient had proper social
support at home , and was properly responding to the death of his
wife. It was therefore felt that he did not need any acute
psychiatric evaluation.
DISPOSITION: The patient was discharged home , in stable condition
on hospital day four. He will follow-up with his
cardiologist , Dr. Dario , in approximately 5 days. He will be seen
by the Visiting Nurses Association , approximately two times a week ,
to check both his blood pressure and cardiac status , as well to
help insure that he is not developing a more severe depression.
DISCHARGE MEDICATIONS: The discharge medications include atenolol
25 mg orally every day before noon and 12.5 mg orally q.
p.m. , enteric coated aspirin 325 mg orally every day , lisinopril 2.5 mg
orally every evening , and Pravachol 10 mg orally every bedtime
The patient had been tolerating this regiment of medications at the
time of discharge.
Dictated By: GERALDO CONCILIO , M.D. SD91
Attending: CHRISTINE DARIO , M.D. AW87
IQ640/1341
Batch: 72059 Index No. GLTSWO1221 D: 2/13/98
T: 11/5/98
Document id: 739
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PVD |
VI |
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985342959 | PUO | 56964284 | | 910093 | 7/16/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/6/1995 Report Status: Signed
Discharge Date: 11/12/1995
CHIEF COMPLAINT: SLURRED SPEECH AND RIGHT SIDED WEAKNESS
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old right
handed female with a history of
hypertension who was in her usual state of health until 10 a.m.
when she noted , while in a seated position , after bending over to
pick up articles from the floor , had a sudden headache described as
a bifrontal burning sensation. Afterwards , she noted mucus from
the nose which lasted two to three minutes. She thought it was a
"sinus headache". Over the next half hour , she noticed while
talking to her self , she had some slurred speech. She attempted to
walk and found that the right side of her body felt "wobbly" and it
was difficult to walk but she was able to walk into the kitchen and
get a glass of water. The slurred speech and right side body
weakness lasted for approximately one hour and improved until
"normal levels".
For approximately five to six hours later , the slurred speech
returned and family members who arrived that her face was twisted
and she had slurred speech , and that she had to lift her right leg
up with her hands in order to get into the car. She ultimated that
with the first event , she had headache and nausea only with the
second event. She denied any vomiting or light headedness or
dizziness. There was no visual change such as diplopia.
PAST MEDICAL HISTORY: Occasional lower back pain and right foot
surgery secondary to trauma. MEDICATION:
Hydrochlorothiazide 100 mg orally every day. ALLERGIES; NO KNOWN DRUG
ALLERGIES.
SOCIAL HISTORY: Tobacco; ten pack year history. There is
no history of alcohol or intravenous drug
abuse. The patient has three children , one son , two daughters , and
she is currently married. She is currently unemployed and has a
sixth grade education. She grew up in Prai Apines Ri
FAMILY HISTORY: There is a positive family history of a
stroke in her father.
PHYSICAL EXAMINATION: The patient appeared stated age. Vital
signs showed a blood pressure of 158/108 ,
temperature of 98.2 , heart rate of 88 , respiratory rate 16. The
neck was supple with meningismus. The lungs were clear. The heart
showed a regular rate and rhythm without murmur. The abdomen was
benign. The extremities showed no clubbing , cyanosis , or edema.
On neurologic examination the patient was awake , alert , and
oriented times three , attention with difficulty with days of the
week , and month of the year. Speech was spontaneous and fluent
with dysarthria. The patient refused to read or write. She has
normal naming repetition , and comprehension. There was no right or
left confusion. Calculation was poor , believed to be secondary to
her poor educational status. The cranial nerves not tested. The
bilateral visual fields were full , discs were sharp , fundus clear ,
pupils 4 mm reactive bilaterally to light and accommodation , and
were consentual. There was positive nystagmus on right gaze. She
has normal facial sensation with a right facial paresis in the
upper motor neuron distribution. She had normal palate and uvula.
Sternocleidomastoids were strong. The tongue was midline. On
motor examination the patient had mild increased tone of her right
body , no tremor and a positive drift of the right upper extremity.
Strength of the left upper and lower extremities displayed 5/5
strength in all major muscle groups. The left upper extremity had
upper motor neuron distribution weakness with decreased strength
and upper extremity extensors with strength being 4 minus of the
lower extremity with decreased flexor strength with EHL being 4
minus also. The deep tendon reflexes were slightly more brisk on
the right with 2+ with out going right toe. The left upper
extremity and right lower extremity were 2 and toe down going.
Sensory exam was normal to light touch and pin prick , temperature ,
position , and normal double simultaneous stimulation.
Coordination; The patient has normal finger to nose , heel to shin ,
and the right was not out of proportion to the weakness. Gait was
remarkable for decreased swing , positive for circumduction on the
right and Romberg was negative.
LABORATORY DATA; Sodium 141 , potassium 3.6 , chloride 98 ,
Bicarb 26 , BUN and creatinine 9 and 0.6
respectively , glucose 104 , white count 7.3 , hematocrit 45.2 ,
hemoglobin 14.3 , platelets 250 , physical therapy 12.9 , PTT 38.8 , MCV 86.4. CT of
the brain was negative for any mass lesions noted; no shift , no
hemorrhage , no lacune. ELECTROCARDIOGRAM showed normal sinus
rhythm , 75; large left atrium with normal axis and intervals; no
ST-T wave changes.
HOSPITAL COURSE: The patient was admitted to the neurology
service and started on one aspirin per
day. The patient was then ordered to have a cardiac echocardiogram
and MRI of the head. Throughout her hospital course her clinical
symptoms improved tremendously , and the patient proved that she was
90% of her baseline. MRI was remarkable for small pontine lacuna
infarct on the left which corresponds highly with the patient's
clinical examination. A cardiac echocardiogram was normal. MRA
also showed small common carotid disease which will be followed up
with carotid Doppler ultrasound as an outpatient.
DISPOSITION: The patient was discharged to home.
CONDITION ON DISCHARGE: Improved.
DISCHARGE MEDICATIONS: hydrochlorothiazide 100 mg orally every day ,
aspirin 1 tablet orally every day. The patient is to follow up with
myself in one month and to follow up with her primary care
physician in two or three weeks. The patient is to have cardiac
Doppler study of her neck on August , 1995 at 9:30 a.m. and she was
advised to call for any problems or concerns regarding any
component of her health care.
FINAL DIAGNOSIS: 1. LEFT PONTINE STROKE
2. HYPERTENSION
Dictated By: ROSANNE S. VERNET , M.D. PC92
Attending: CARA NEVA KENEKHAM , M.D. VQ6
QC025/7175
Batch: 8197 Index No. ERYEBS646G D: 7/21/95
T: 4/11/95
Document id: 740
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CHF |
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DM |
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GER |
Gou |
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OSA |
PVD |
VI |
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611623444 | PUO | 66926606 | | 6513463 | 2/28/2005 12:00:00 a.m. | hyperglycemia , urinary tract infection | | DIS | Admission Date: 3/21/2005 Report Status:
Discharge Date: 4/23/2005
****** DISCHARGE ORDERS ******
HYKES , EDYTH 704-38-09-2
Green Er Room: Sas Pora A
Service: MED
DISCHARGE PATIENT ON: 6/5/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 10/30/05 by
FIGURA , CAREY T. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
METFORMIN 1 , 000 MG orally twice a day
LEVOFLOXACIN 250 MG orally every day X 1 doses
Starting Today ( 1/19 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously every day
Starting Today ( 1/19 )
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Ida Gildner , Pagham University Of Endocrine and Diabetes Clinic , Et Ri 2/13/05 , 1:00 PM scheduled ,
Please call Flinspach at PUO Physician Referral for a primary care physician , 7- 975-829-9912 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hyperglycemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hyperglycemia , urinary tract infection
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
urinary tract infection obesity ( obesity ) type 2 DM ( diabetes mellitus )
?OSA ( ? sleep apnea )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Hyperglycemia ( 400s ) , not in DKA
HPI: 31 F with a history of Type 2 DM ( diagnosed 6 years ago ) , morbid
obesity , and borderline HTN who was referred to PUO ED after being
found to be hyperglylcemic ( 440 mg/dl ) at Tempson Neistone Ino Hospital She has not checked her blood sugar or taken any medications
for diabetes for an entire year , secondary to being very involved
with the care of her handicapped mother ( who passed away
this year at 50 years old of complications from diabetes ). She has
had symptoms of polydipsia and polyuria , tingling in her fingers and
toes , and worsening vision. Also has had several days of UTI
symptoms. In PUO ED , her blood sugar remained in the 400s despite
Regular insulin 18 units , Lantus 20 units , and Novolog 6 units.
Admitted for treatment of hyperglycemia and optimizing her
diabetes medication regimen. --
PMH:
Type 2 DM - diagnosed 6 years ago. Was previously
on insulin and checking sugars three times a day. No self-FSBG checks or diabetes
medications for 1 year.
Morbid obesity
Borderline HTN
HOME MEDS: None
ALL: None --
EXAM: T98.1 P84 BP130/57 R18 O2sat96%RA General: Pleasant , morbidly
obese woman in NAD HEENT: EOMI , PERRL. Fundus exam limited. Dry
O/P. Neck: Acanthosis nigricans , no LAN
CV: RRR , II/VI HSM @ LLSB. No m/r/g. Apical auscultation limited by
intervening tissue.
Lungs: CTAB
Abdomen: S , obese , NT , ND , NABS
Extremities: No C/C/E. No wounds on
feet. Neuro: Decreased pinprick medial feet b/l and
hands ( esp ulnar distribution ). --
CHEM: 138 / 4.0 / 104 / 29 / 14 / 0.9 < 331 Anion gap 5 , pH
7.41 Blood glucose: 473 , 427 , 331 ,
421 CBC: 12.2 > 38.8 < 428
EKG: NSR @96. Normal intervals , axis. Deep pathologic Q waves in
III , aVF that are present in EKG from 2000. No ST/T waves changes
suggestive of ischemia
************HOSPITAL COURSE*************
31 F with a history of Type 2 DM ( diagnosed 6 years ago ) , morbid obesity , and
borderline HTN who presents with hyperglycemia in 400s with
hyperglycemia , ~1 year of poor diabetes management , symptoms of
microvascular damage , and EKG suggestive of old inferior MI , not in DKA.
Also has had several days of UTI symptoms.
ENDO: Primary goals of admission are blood glucose <200 mg/dl , diabetes
education , diabetes home medication regimen / glucometer / test strips ,
and setting the patient up with a primary care physician. Check HgA1c. Check FSBG before every meal.
Blood sugar was 308 at 6 pm last night , 340 at 7 am this morning.
Increase Lantus to 25 mg subcutaneously every day. Increase Metformin to 1000 mg orally twice a day .
Consult Diabetes teaching program in a.m.. Set up follow-up with primary care physician , +/-
ophthalmology.
ISCHEMIA: Admission EKG and EKG in 2000 with Q-waves in III , F suggesting
old inferior infarct. No CP/SOB. Lipid profile: Chol 160 , Tri 187 , HDL
38 , LDL 94
HTN: Lisinopril 5 mg orally every day
ID: UTI. Levofloxacin 250 mg orally every day x 2 doses ( already treated for 2
days ). F/u Urine cultureHEME: Microcytic anemia , likely iron
deficiency. Fe 43 , TIBC 300 , Ferr pending.
F/E/N: KCl orally replacement scale. MgSulfate sliding scale.GI: Colace
as needed , MOM prnDISPO: Goal blood glucose is <200 mg/dl.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Endocrinologist/Diabetes doctor at Pagham University Of
Test fingerstick blood glucose 3 times daily ( including in the morning
before eating ) , and keep a log/record of the values.
Take your insulin and metformin as prescribed.
Decrease your intake of food with high saturated fat and cholesterol.
Take a 30-45 min walk at least 5 times per week.
No dictated summary
ENTERED BY: FIGURA , CAREY T. , M.D. ( VT32 ) 6/5/05 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 741
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893002240 | PUO | 93176817 | | 568138 | 10/10/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/22/1994 Report Status: Signed
Discharge Date: 1/28/1994
PRINCIPAL DIAGNOSIS: 1. RIGHT-SIDED CEREBROVASCULAR ACCIDENT.
OTHER DIAGNOSES: 1. TYPE II DIABETES.
2. HYPERTENSION.
3. RIGHT SHOULDER PAIN.
4. HOOK WORM ENTERITIS.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old Hispanic
man with a history of a left-sided
cerebrovascular accident , with a dense right hemiparesis , who
presented to the Emergency Room at Pagham University Of on
17 of September , complaining of left-sided facial numbness , and left upper
extremity numbness since awakening that morning. The patient has a
history of non-insulin dependent diabetes mellitus , hypertension
and hyperlipidemia , as well as a past history of a left hemispheric
stroke with a right-sided hemiparesis , who awoke the morning of
admission with left lip numbness. Over the subsequent few hours ,
the patient's numbness progressed to include the entire left
one-half of his face. By 10 o'clock in the morning , his entire
left arm was also numb. His left lower extremity was also
involved. In the Emergency Room , an EKG was done , and revealed
subtle ST segment depressions in leads II , and V4 through V6 , as
well as .5 mm of ST depression in lead I. There were no comparison
EKGs available. The patient denied any chest pain , shortness of
breath , nausea , vomiting or diaphoresis. Given his history of
myocardial infarction that he states may have occurred in the past ,
as well as numerous coronary risk factors , he was admitted for rule
out of myocardial infarction and evaluation of his left-sided
numbness.
MEDICATIONS ON ADMISSION: Included Procardia XL 30 mg orally every day ,
Glyburide 5 mg orally twice a day , Dyazide.
PAST MEDICAL HISTORY: Significant for: ( 1 ) Left-sided
cerebrovascular accident in 1989. ( 2 )
Hypertension. ( 3 ) Chronic right upper extremity pain after his
initial cerebrovascular accident. ( 4 ) Type II diabetes.
ALLERGIES: Penicillin , with unknown reaction.
SOCIAL HISTORY: The patient is a resident of Nebraska ,
Sta S E , New Mexico 47475 . He denies alcohol or tobacco use.
PHYSICAL EXAMINATION: The patient was a thin , Hispanic male in no
acute distress , and pleasant. His vital
signs were: Blood pressure 150/88 , with a pulse of 86 , and a
respiratory rate of 20. His saturation was 96% on room air. His
temperature was 98.4. HEENT: Pupils equal , round , reactive to
light and accommodation; extraocular muscles intact. Pharynx was
clear. Neck was supple without adenopathy. There was no increased
jugular venous pressure. Lungs were clear to auscultation
bilaterally , with the exception of mild bibasilar crackles.
Cardiac exam showed regular rate and rhythm with a II/VI systolic
ejection murmur at the left lower sternal border , with radiation to
the left axilla. Abdomen was soft , non-tender , with positive bowel
sounds. Extremities were without cyanosis , clubbing or edema.
There were no cords and no Homan's sign was present. On
neurological exam , the patient showed cranial nerves II through XII
grossly intact. The patient did , however , have loss of the right
shoulder shrug. On motor exam , the patient was 5/5 in all major
muscle groups on the left-hand side , and 4/5 in all major muscle
groups on the right-hand side. The patient was also somewhat
hyperreflexic on the right upper and lower extremities. Babinski
was down going on the right , and withdrawal on the left. On
sensory exam , the patient had decreased pin prick on the left
aspect of the fact , from V1 to V3 , and numbness of the left upper
extremity. Light touch was intact bilaterally. Proprioception was
also intact bilaterally.
LABORATORY DATA ( on admission ): Included a potassium of 3.4 , a BUN
of 13 , a creatinine of 0.8 , a
glucose of 226. His white blood cell count was 6.3; his hematocrit
was 44.9 , and his platelet count was 196. AST and ALT were 21 and
31 , respectively. LDH was 155. Total bilirubin was 0.5.
Cholesterol was 201. Calcium was 10.2 , with an albumin of 4.7.
EKG demonstrated normal sinus rhythm at 75 , with .5 mm of ST
segment depression in lead I , and 1 mm of ST depression in leads II
and V4 through V6. Chest x-ray was clear bilaterally. There was
cardiomegaly present. There was question of a left lower lobe
opacity. There were no signs of congestive heart failure. Head CT
without contrast showed an old left centrum semiovale lesion ,
consistent with with a watershed infarct. There was no evidence of
acute bleed.
HOSPITAL COURSE: The patient is a 63 year-old Hispanic male with
the following important medical issues to be
managed:
( 1 ) Cardiovascular. The patient presented without chest pain , but
EKG changes , including .5 mm of ST segment depression in lead I ,
and 1 mm of ST segment depression in leads II , and V4 through V6.
There was no prior EKG for comparison. Given his multiple cardiac
risk factors , a decision was made to rule the patient out for
myocardial infarction. His serial creatinine kinase levels were
67/74/115. Given the low levels , there was no MB fractionation
done. The patient also was placed on Holter monitor to attempt to
rule out a dysrhythmic etiology of his deficit. Holter showed
predominantly a normal sinus rhythm at a rate of 442 to 98. There
were 7 atrial premature beats , and 5 ventricular premature beats ,
as well as a 12-beat run of supraventricular tachycardia at a rate
of 125 , and a 6-beat run of ventricular tachycardia at 144. All of
these were asymptomatic. The patient underwent transthoracic
echocardiography while an inpatient , to rule out a vegetative
source of emboli , which may have resulted in his change in
sensation. Echocardiogram demonstrated concentric left ventricular
hypertrophy with an ejection fraction of 65%. There was a
thickened aortic leaflet with calcification of the right and left
coronary cusps of the aortic valve. No shunt was visualized. The
patient had no occurrence of chest pain or shortness of breath
while admitted to the Pagham University Of . These events
were thought to be entirely non-cardiac in nature , and he was
removed from Telemetry. The patient's hypertension was managed
with Nifedipine 10 mg orally three times a day during this admission , and
switched to 30 mg of Nifedipine XL orally every day as an outpatient. His
blood pressure should be followed as an outpatient , and additions
and adjustments made accordingly.
( 2 ) Neurologic. The patient was admitted with what appeared to be
a purse sensory defect of the right hemisphere , resulting in left
facial and upper extremity numbness. He was seen in consultation
by the Neurology Service. CT scan of the head without contrast in
the Emergency Room was negative for acute bleed. In the Emergency
Room , the patient received one enteric coated aspirin , and he was
not started on intravenous heparinization. It was unclear ,
initially , whether the etiology of this patient's change in
neurological status was secondary to embolic phenomena or possibly
a second watershed infarct. Given his negative echocardiogram of
the heart , as well as a negative Holter monitor , it was thought
that the etiology of this patient's left-sided facial numbness was
not cardiac in nature. It was the feeling of the Neurology Service
that the patient had experienced a right-sided subcortical infarct ,
probably in the right thalamus region. He was also noted to have
risk factors for small vessel disease , including hypertension and
diabetes. His numbness appeared to be resolving on aspirin alone;
however , on the second day of admission , the patient began to
develop dysarthria. There was concern that the patient was having
an evolving cerebrovascular accident that was involving the
brainstem , given tongue involvement. He was thus started on
intravenous heparinization. His dysarthria promptly resolved. He
underwent MRI with and without contrast of the head , three days
after the initial event , which demonstrated only right-sided small
vessel disease. There was no evidence of acute bleed or underlying
vascular abnormality. Given the small vessel disease in this
patient , he was taken off intravenous heparin and continued on one
aspirin a day. He did well during the remainder of his stay. He
was seen in consultation by Physical Therapy and Occupational
Therapy , who , in conjunction with the patient's family , believed
that he was at a somewhat decreased level of functioning from his
baseline , given his sensory changes. He is thus to be sent for
inpatient rehabilitation for his new cerebrovascular accident , and
then to be followed as an outpatient in Dr. Pashal 's clinic. He
will continue on one aspirin a day for life. His right-sided
scapular and shoulder pain is chronic , after sustaining his initial
left-sided cerebrovascular accident. It should be treated with
physical therapy , including ultrasound and stretching maneuvers.
The patient was also placed on Naproxen for pain relief.
Muscle relaxants may be tried as an outpatient if the above stated
efforts do not help reduce this patient's pain.
( 3 ) Infectious disease. This patient had no infectious
complications while hospitalized. He was , however , found to have a
slight peripheral eosinophilia during this admission , and was
evaluated by O&P of the stool. Stool evaluation showed moderate
hook worm eggs , as well as rare Trichuris trichiura eggs. He was
treated with three days of Mebendazole.
( 4 ) Endocrine. The patient has a history of Type II diabetes , on
Diabeta. The patient's blood glucose levels were checked by finger
stick four times daily , and were in the 190's to 240's range during
this admission. He was covered with a CZI sliding scale of regular
insulin. The patient was advised by Dietary on the American
Diabetic Association diet. He is to continue as an outpatient on
Glyburide 5 mg orally twice a day
MEDICATIONS ON DISCHARGE: Enteric coated aspirin 325 mg orally every day;
Colace 100 mg orally twice a day; Glyburide 5
mg orally twice a day; Naprosyn 375 mg orally twice a day , with meals; Nifedipine
XL 30 mg orally every day; sublingual nitroglycerin 1/150 , one tablet
sublingually every 5 minutes times three , then call M.D.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient was discharged on 19 of July to
rehabilitation at Howood Medical Center .
FOLLOW UP: He is to follow up in clinic with Dr. Pashal in KTDUOO ,
at his first available appointment.
COMPLICATIONS: There were no complications during this stay.
Dictated By: BRIDGETT PASHAL , M.D.
Attending: VERDA A. TRIARSI , M.D. CM80
AG300/5801
Batch: 037 Index No. NLLE15795D D: 4/16/94
T: 4/16/94
CC: HOWOOD MEDICAL CENTER
Document id: 742
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DM |
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439543912 | PUO | 78614353 | | 047620 | 5/25/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/19/1993 Report Status: Signed
Discharge Date: 2/10/1993
ADMISSION DIAGNOSIS: COMPLETE HEART BLOCK.
HISTORY OF PRESENT ILLNESS: Mr. Oberdick is a 43 year old male
with Down's syndrome who was admitted
with multiple episodes of syncope over the prior 8-10 years. These
were characterized by emesis followed by loss of consciousness with
a question of seizure like activity. This had occurred on a yearly
basis for 8-10 years. Such an episode occurred on May At that
time , his mother brought him to the Gle Ra Csylv Valley Medical Center Emergency Room
because he developed a facial hematoma after one of these episodes.
PHYSICAL EXAMINATION: In the Emergency Room he was noted to be
somewhat groggy with a brief episode of
apparent loss of consciousness with a question of apnea. He was
sent to head CT for a scan and at that time he vomiting with loss
of consciousness and a decrease in heart rate to 30 beats per
minute. He was intubated in the CT scan room , sedated and paralyzed
while the study was completed. When he arrived in the Intensive
Care Unit , he had a heart beat in the 20s with complete heart
block , which was transient and with subsequent return to normal
sinus rhythm. The remainder of his exam was remarkable for an S4
and I/VI systolic ejection murmur. NEURO: The neurological exam was
nonfocal.
LABORATORY DATA: Electrolytes were normal. His EKG showed sinus
tachycardia with an axis of 0 , ST flattening in
leads V5 and V6 , I in L and a question of a Q in III. Chest X-ray
raised the question of an infiltrate in the left base. The head CT
was negative. His course in the MICU was as follows: He ruled out
for myocardial infarction , despite an elevated CK. The MB fraction
was negative on electrophoresis. On the morning of February , he
spiked a temperature to 102.3 and was begun on Penicillin. Later on
February he had an episode of complete heart block with asystole for
9 seconds. Otherwise , he alternated sinus tachycardia and second
degree heart block with runs of bradycardia at the rate of 30-40
and also tachycardia.
HOSPITAL COURSE: A temporary pacemaker was placed on February
through the left subclavian approach. At that
time , he was hemodynamically stable , except for intermittent
hypertension , which was treated with Nifedipine. He was
transferred to the Cardiology Waistan Tavi Whiterow Dr , Anting Huntgeux Rochelis , Oklahoma 24268 on January , 1993 to await
pacemaker placement. He was switched from Nifedipine to Captopril
for treatment of his hypertension and his fever was treated with
Cefotetan for presumed aspiration pneumonia. This has resulted in a
delay in his pacemaker placement. He intermittently had a
pericardial friction rub on physical examination that was thought
to be most likely due to myocardial irritation by the pacing wire
implantation. One echocardiogram in a series did reveal a regional
wall motion abnormality that may have been a function of the
pacemaker wire as well. He remained afebrile and completed a course
of antibiotics for his presumed aspiration pneumonia , although
subsequent chest x-rays did not support that diagnosis. He
required replacement of his temporary pacemaker wire while awaiting
permanent pacemaker placement to decrease the risk of infection.
He underwent permanent pacemaker placement in the Operating Room
with anesthesia backup in case there was need for intubation
because the patient had difficulty remaining still. The pacemaker
replacement was performed on July , 1993. Intubation was not
necessary.
DISPOSITION: He tolerated the procedure well and was discharged to
home on May , 1993. MEDICATIONS: The medications at
discharge were: Kefzol 500mg four times a day for 3 days , and Lisinopril 10mg
orally every day. He will followup with Dr. Jacquet on March , 1993 and in
KTDUOO with Dr. Denisha Mcrorie Secondary Diagnoses were pacemaker
placement and Down's syndrome.
Dictated By: LULA A. MOUN , M.D. EC27
Attending: VERDA A. TRIARSI , M.D. GY7
YP322/5981
Batch: 4976 Index No. M1VFXY00W1 D: 3/8/93
T: 3/8/93
Document id: 743
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
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573219258 | PUO | 21946948 | | 5279998 | 5/1/2005 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 7/7/2005 Report Status:
Discharge Date: 7/1/2005
****** FINAL DISCHARGE ORDERS ******
RASMUS , LENORA Y 864-38-46-8
Seat
Service: MED
DISCHARGE PATIENT ON: 9/23/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VACEK , WALTON JANELLA , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 7/7 )
NICOTINE TRANSDERMAL SYSTEM 14 MG/DAY TP every 24 hours
Number of Doses Required ( approximate ): 2
NOVOLOG ( INSULIN ASPART ) 2 UNIT subcutaneously before meals
Starting Today ( 7/7 )
Instructions: please administer 2 units novolog insulin if
your blood sugar ( before a meal ) is more than 200
ATENOLOL 25 MG orally every day
ZYBAN ( BUPROPION HCL SUSTAINED RELEASE ) 150 MG orally twice a day
OMEPRAZOLE 20 MG orally every day
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
METFORMIN EXTENDED RELEASE 500 MG orally every day
LANTUS ( INSULIN GLARGINE ) 8 UNITS subcutaneously every bedtime
Starting Today ( 7/7 )
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
DR. BYSE , INGER ( Primary Care: Kernan To Dautedi University Of Of , 160 450 7566 3/4 , 3:10pm scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , DMII
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT
BRIEF RESUME OF HOSPITAL COURSE:
CC: CHEST PAIN
IDENTIFIER/DX: r/o MI PMH: 51 y M presents with 3 day history of
substernal chest pressure occurring only at night , no medical
care since 1989 ( ETT neg. with good effort , 1989 ) , feels as if "someone
sitting on his chest" , 7/10 SSCP occurring only while lying prone at
night , waking him from sleep , no radiation , no SOB , no nausea ,
vomiting , or diaphoresis , no association with exertion , respiration ,
motion. Alleviation with standing , Motri. Duration usually 30 minutes.
No associated sourbrash.
patient is a smoker , 1ppd , interested in cessation , works as
custodian/janitor , frequent heavy lifting without SOB or CP. No
medications , no allergies. In ED BP 203/88 , pulse 96 , exam
unremarkable , A set enzumes negative , received ASA 325 , 2L O2 , BP
decreased with nitropaste no EKG findings , random blood glucose noted to
be 260. Pain free for duration of ED stay.
Risk factors ( + ) smoking ( + )FH , ? of undiagnosed diabetes and
hypertension
---------
ROS: positive for polyuria/polydipsia
---------
EXAM: 97.6 54 137/67 16 96-99% ( 2L )
HEENT: NC/AT , PERRL , anicteric , EOMI , MMM without exudates.
Neck: supple , NT , full ROM , 2+ carotid pulses without bruits , no LAD
Lungs: CTAB , no c/with r
CV: RR , S1 , S2 , no m/r/g , JVP
Abd: soft , NT/ND , nl BS , no HSM , no masses
Ext: no c/c/e; 2+ DP/ physical therapy pulses b/l
Skin: no rashes
Neuro: A and O x 3 , CN II through XII intact
---------
LABS:
-CBC , CMP unremarkable except glucose 260
-A set , B set , C set cardiac enzymes all negative
-Hgba1c >9 ,
-LDL-cholesterol 138
---------
DAILY EVENTS:
---------
STUDIES/PROCEDURES: EKG ( 11/10 ): NSR , borderline RAD
CXR ( 11/10 ): No acute cardiopulmonary process
---------
---------
ACTIVE PROBLEMS:
( 1 )Chest pain
( 2 )Hypertension
( 3 )Hyperglycemia
---------
---------
HOSPITAL COURSE:
( 1 ) CV: Poor story for ACS but significant risk factors for CAD , ruled out
for MI with negative ckmb/troponin I x 3 , fasting lipids elevated ,
maintained on asa , metoprolol , changed to atenolol prior to discharge with
addition of zocor. ETT obtained after rule out completed - patient went 9
minutes with nonspecific ST segment changes. Consider starting ACE in
outpatient setting if hyperkalemia subsides. Euvolemic , on tele in NSR
( 2 ) RESP: Intially on 2L O2 during rule out. Smoking cessation consult ,
zyban/Nicorette started prior to discharge. Possible OSA , consider sleep
studies as outpatient.
( 3 ) GI: Nighttime SSCP associated with flat position likely for GERD ,
on PPI as inpt , will extend into outpatient trial. Given age , screening
colonoscopy appropriate as outpatient.
( 4 ) RENAL: Microalbumin negative , high normal potassium.
( 5 ) ENDO: Newly diagnosed DM , very responsive to insulin therapy , on low
novolog sliding scale during hospital stay , with addition of low-dose
nasal lantus every bedtime and low dose metformin added prior to discharge , to be
uptitrated with goal of orally therapy alone in the outpatient setting.
( 6 ) PPX: Nexium , lovenox
( 7 ) FEN: Good orally intake , cardiac/diabetic diet
( 8 ) CODE: full
ADDITIONAL COMMENTS: Your chest pain was not a heart attack , and is more likely to repsresent
dyspepsia/esophageal reflux than any cardiac disease , and we have given
you a trial of medicine for this , you should also try elevating the head
of your bed and avoiding onions , alcohol , and fatty foods. You do have a
new diagnosis of diabetes , high blood pressure , and high cholesterol ,
however , and are at risk for heart disease , so we have started you on a
regimen of diabetes , blood pressure , and cholesterol reducing medicines ,
and it is important to follow up with your primary care physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
--follow up with primary care physician in 2 weeks
--assess patient's performance with new diabetes regimen , statin , BB , PPI ,
at that time
--check LFTs , basic metabolic panel on new medication
--f/u lipid profile in three months , f/u Hgb a1c at that time
--f/u smoking cessation: referral , patch , zyban
--f/u nutrition changes
--appropriate for screening colonoscopy as outpatient
--in need of full preventive health assessment in outpatient context
No dictated summary
ENTERED BY: DIVELBISS , LONNY O. , M.D. , PH.D. ( RE075 ) 9/23/05 @ 06
****** END OF DISCHARGE ORDERS ******
Document id: 744
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DM |
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GER |
Gou |
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117775138 | PUO | 35185417 | | 671032 | 5/23/1999 12:00:00 a.m. | ISCHEMIA RT. LEG | Signed | DIS | Admission Date: 9/2/1999 Report Status: Signed
Discharge Date: 8/27/1999
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old gentleman
who has a past medical history of
non-insulin dependent diabetes mellitus , coronary artery disease ,
and peripheral vascular disease who had a revascularization
procedure with a left femoral popliteal bypass graft in August of
1998. Since that time his foot has become cool and the graft has
been noted to be occluded. He presents for a re-operation for
revascularization.
PAST MEDICAL HISTORY: Non-insulin dependent diabetes mellitus.
Coronary artery disease status post coronary
artery bypass graft in 1991 and series of angioplasties prior to
the coronary artery bypass graft. Gastroesophageal reflux disease.
Non-healing left foot ulcer with no osteomyelitis. Hypertension.
Peripheral vascular disease.
MEDICATIONS: Glyburide 5 mg orally every day before noon , Glucophage 850 mg orally
three times a day , Lisinopril 5 mg orally every day , Lopressor 50 mg
orally every day , enteric coated aspirin 325 mg orally every day , Simvastatin 10
mg orally every day , and NPH 10 units subcutaneously every afternoon
PAST SURGICAL HISTORY: In 1991 he had a coronary artery bypass
graft. His postoperative course was
complicated only by atrial fibrillation which was medically managed
and he has been without recurrence since that time. In August of
1998 he had a left superficial femoral artery to anterior tibial
artery bypass graft with non-reversed greater saphenous vein and
left common femoral endarterectomy with Dacron patch angioplasty ,
as well as debridement of the left lateral foot wound. After this
surgery , he had an uncomplicated postoperative course.
SOCIAL HISTORY: The patient quit smoking in the fall of 1998 and
does not use alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: He has had no chest pain , shortness of breath ,
or angina since the time of his bypass. Just
prior to his admission , he was seen by Dr. Lashanda Bachmann of Carna Home Hospital cardiology and was cleared from a cardiac
standpoint saying that he was an average risk for surgery as he has
done well from his prior surgeries and has had no symptoms since
his bypass surgery. Additionally , his preoperative angiogram
showed his superficial femoral artery graft to be proximally
occluded with mid to distal reconstitution. Above the knee
popliteal artery , there was mild diffuse disease. Below the knee
popliteal was patent. There was diffuse proximal disease in the
peroneal and posterior tibial arteries. The posterior tibial
occludes above the knee and there is high grade focal stenosis at
the anterior tibial origin. The dorsalis pedis is patent.
HOSPITAL COURSE: On 2/10/99 the patient was brought to the
operating room where Dr. Derham performed a left
femoral above-the-knee popliteal bypass graft. This went without
complications. The type of graft used as a 6 mm Dalcron graft.
The immediate postoperative pulse examination was notable for a
palpable femoral popliteal and graft pulse with a Dopplerable
dorsalis pedis pulse and posterior tibial pulse on left side. The
patient had an ECG postoperatively that showed no significant
change to his preoperative ECG. He was started on heparin at 8
p.m. the day of surgery.
Of note , on postoperative day #1 , the patient got very diaphoretic
and nauseous. At that time an ECG was done that showed no
significant change and , throughout that episode , he had no
hemodynamic instability. This was likely secondary to having
gotten up rather quickly and likely a vasovagal event.
Throughout the rest of his hospitalization course the patient was
mobilized with physical therapy. He had a Dopplerable dorsalis
pedis pulse , posterior tibial pulse , and peroneal pulse on left
side throughout his entire hospital course. However , the graft was
no longer palpable by postoperative day #2 but it was strongly
Dopplerable.
The patient was continued on heparin until his Coumadin reached the
high 1 level which was achieved on 1/25/99 when his INR was 1.6. At
this time his heparin was discontinued. The anticoagulation is on
for keeping the graft patent and not for any cardiac or stroke
reasons. The goal on his INR will be approximately 2 to 2.5. On
1/25/99 the patient was stable for discharge. His pulse examination
was notable for Dopplerable dorsalis pedis pulse and posterior
tibial pulse and peroneal pulse.
The patient's record of Coumadin in response with INR is as
follows: On 2/10/99 the patient was started on Coumadin at which
point his INR was 1.0. On that day he got 5 mg of Coumadin. The
following day , 5/27/99 , his INR was 1.1 and he got another 5 mg of
Coumadin. On 8/17/99 the patient's INR was 1.2 and he got another 5
mg of Coumadin. On 10/15/99 the patient got 7.5 mg of Coumadin and
his INR was 1.2 at that time. On 6/8/99 the patient got 10 mg of
Coumadin and his INR was 1.6 the following day on the day of
discharge , 1/3/99. On the day of discharge , 1/25/99 , the patient
will get 7.5 mg of Coumadin and his predicted daily dose will be
roughly 7.5 mg of Coumadin orally every day
DISPOSITION: DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg
orally every day ( this is a critical medicine and he should
be on this at all times despite being on Coumadin ) , Colace 100 mg
orally three times a day , iron 300 mg orally three times a day , Glyburide 5 mg orally three times a day ,
NPH insulin 15 units subcutaneously every day before noon , CZI insulin sliding scale to get
4 units of regular insulin for blood sugar over 201 to 250 , 6 units
of regular insulin for blood sugar of 251 to 300 , 8 units of
regular insulin for blood sugar of 301 to 350 , and 10 units for
blood sugar 351 to 400 and , greater than 400 , house officer is to
be called. Lisinopril 5 mg orally every day , Demerol 50 to 100 mg orally
every 4 hours as needed pain , Lopressor 50 mg orally twice a day , Glucophage 850 mg
orally three times a day , and Coumadin orally every day to be dosed according to daily
anticoagulation tests as stated previously with INR goal of 2 to
2.5.
Dictated By: SILVA SPILLETT , M.D. VF22
Attending: ROSSIE MANKOSKI , M.D. NW98
NI387/9931
Batch: 6659 Index No. DRIVGA3U41 D: 9/1/99
T: 9/1/99
CC: 1. REHABILITATION HOSPITAL ( 602 ) 299-2321
Document id: 745
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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682582454 | PUO | 74601423 | | 133484 | 10/3/2002 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 10/30/2002 Report Status: Signed
Discharge Date: 9/3/2002
PRINCIPAL DIAGNOSIS: SYNCOPE.
PROBLEMS: 1. SYNCOPE.
2. ORTHOSTATIC HYPOTENSION.
3. ISCHEMIC CARDIOMYOPATHY.
4. DIABETES MELLITUS.
5. CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: This is a 62-year-old white male with
insulin dependent diabetes mellitus ,
coronary artery disease and ischemic cardiomyopathy who was
admitted with syncope. He is status post myocardial infarction in
1979 and 1985 as well as a coronary artery bypass graft in 1987
with a LIMA to LAD , SVG to RCA , SVG to OMB. Over the past ten
years he has complained of increasing CHF symptoms including
dyspnea on exertion , fatigue , chest tightness and has had multiple
admits for exacerbations , the most recent from November to
March , 2001 for progressive fatigue. At that time a right
heart catheterization revealed high filling pressures and he was
treated with aggressive diuresis. Angiography revealed occluded
SVGs and a patent LIMA. Dobutamine radionuclide study revealed
inferior and inferolateral infarct. There was no evidence of
revascularization. Evaluation for heart transplant found cirrhosis
by liver spleen scan which ruled out the possibility of transplant.
He reported light-headedness and dizziness and was seen by the
Electrophysiology Service who performed an EP study which was
negative for provokable VT and since he is not a transplant
candidate it was felt that empiric ICD placement would not be in
his best interest. His light-headedness and presyncope worsened.
His captopril dose was reduced from 37.5 mg to 25 mg three times a day with
marked improvement in his energy and less dizziness. Over the past
weeks his dizziness and light-headedness recurred and worsened with
episodes of presyncope and frank syncope. On the day of admission
he was scheduled for a clinic appointment. On arrival he felt
dizzy and "crumpled" with loss of consciousness and therefore was
admitted for further evaluation.
PAST MEDICAL HISTORY: Ischemic cardiomyopathy with an ejection
fraction of 15% to 20% in February of 2001 ,
status post anterior MI in 1980 and 1986 , three vessel CABG in 1987
with LIMA to LAD , SVG to OM and SVG to PDA , type 2 diabetes
mellitus , insulin dependent , hypothyroidism , nephrolithiasis ,
gallstones , cardiac cirrhosis which is mild and was diagnosed in
February 2001 by abdominal ultrasound and liver scan , IBS , psoriasis.
ADMISSION MEDICATIONS: Captopril 25 mg orally three times a day , Isordil 40 mg
orally three times a day , Lipitor 20 mg orally every day , NPH
insulin 65 units subcutaneously twice a day , Xanax as needed , torsemide 120 mg orally
every day before noon , torsemide 80 mg orally every afternoon , digoxin 0.125 mg orally every day ,
Synthroid 250 mcg orally every day , Prozac 20 mg orally every day
ALLERGIES: No known drug allergies.
ADMISSION PHYSICAL EXAMINATION: Vital signs: Lying blood pressure
94/58 , heart rate 70 , oxygen
saturation 97% on room air. Sitting blood pressure 78/54. Patient
could not stand secondary to light-headedness to complete
orthostatic vital signs. Afebrile. General: Appearing
comfortable in a supine position. No acute distress.
Cardiovascular: Regular. Normal S1 , S2. No S3. JVP
approximately 5 cm. A II/VI holosystolic murmur at apex. Lungs:
Clear to auscultation bilaterally. Abdomen: Soft , non-tender ,
nondistended. No hepatosplenomegaly. Extremities: No edema.
ADMISSION LABORATORY DATA: Sodium 128 , potassium 4.2 , chloride 91 ,
bicarbonate 22 , BUN 64 , creatinine 2.6 ,
glucose 348. White blood cell count 17.9 , hematocrit 37.6 ,
platelets 286.
OPERATIONS AND PROCEDURES: None.
HOSPITAL COURSE: This is a 62-year-old white male with history of
insulin dependent diabetes mellitus , coronary
artery disease and ischemic cardiomyopathy and probably cardiac
cirrhosis who presents with presyncope and syncope. The arrhythmia
was considered possible and there has been none documented and he
was not inducible two years prior to admission. Given his
orthostatic vital signs it was felt that his volume status and
medications were responsible for his symptoms. In addition his
elevated BUN and creatinine were consistent with volume depletion.
He improved off diuretics , nitrates and ACE inhibitor as well as
liberalization of his diet regarding salt and fluid intake. There
were no arrhythmias noted on his telemetry monitor. An endocrine
consult was called to evaluate for possible contribution of
autonomic insufficiency secondary to his diabetes mellitus. They
recommended decreasing his Synthroid dose due to a suppressed TSH
as well as more aggressive blood sugar control , however , they were
unable to document orthostatic hypotension and felt that his
episodes of presyncope and syncope were related to his volume
status and medications rather than autonomic insufficiency.
DISCHARGE MEDICATIONS: To be dictated on the actual day of
discharge.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home with services.
FOLLOW-UP: Primary care provider and cardiologist , Dr. Virgina Negrin
Dictated By: SANDY MERAS , M.D. VX90
Attending: SEPTEMBER L. PETRETTI , M.D. ND75
MN724/947092
Batch: 8864 Index No. I5QOCR6JKC D: 11/20/02
T: 11/20/02
Document id: 746
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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506204373 | PUO | 74372820 | | 1597827 | 1/24/2006 12:00:00 a.m. | INFECTED MESH IN ABDOMINAL | Signed | DIS | Admission Date: 4/17/2006 Report Status: Signed
Discharge Date: 10/12/2006
ATTENDING: CIVALE , LOVELLA MD
PRINCIPAL DIAGNOSIS: MRSA-infected abdominal mesh.
HISTORY OF PRESENT ILLNESS: This is a 90+-year-old male with a
complex past medical history including CAD status post stent x2 ,
hypertension , CHF with an EF of 10-20% , AF , on chronic
anticoagulation , status post pacer placement , and diabetes
mellitus who presented to the SICU status post exploratory
laparotomy for removal of chronically MRSA-infected mesh from
prior abdominal surgery. He was admitted to the ICU for
careful monitoring and fluid volume management
postoperatively. He has had multiple abdominal surgeries. The
mesh was originally placed for ventral hernia repair in 2005. He
had since developed draining sinus tracts for which cultures have
grown out MRSA. He was admitted preoperatively for reversal of
anticoagulation and semi-urgent removal of the mesh. In the
operating room , he underwent an exploratory laparotomy , lysis of
adhesions and removal of the abdominal mesh. He was closed and
one Jackson-Pratt drain was left in place. During the procedure ,
he was intubated with etomidate , succinylcholine and kept sedated
with Versed and fentanyl. He received intraoperative vancomycin
and levofloxacin as well as 2200 mL of lactated Ringer's. In an
attempt to reverse anticoagulation , one unit of FFP was begun but
then aborted due to hypotension , which resolved with epinephrine
injection , likely due to transfusion reaction. Another unit of
FFP was hung and tolerated well. EBL was 300 mL. Urine output
was 410 mL for the four-hour case. He was extubated uneventfully
and transferred to the ICU in stable condition.
PAST MEDICAL HISTORY:
1. Colon cancer , status post colonoscopy in 2005 that was
negative.
2. Prostate cancer.
3. History of CVA with a left occipital infarct thought to be
due to embolic phenomenon.
4. History of TIAs.
5. Osteoarthritis of the cervical spine.
6. Chronic atrial fibrillation , on Coumadin for anticoagulation.
7. Sick sinus syndrome , status post pacer placement.
8. CAD status post MI in 2005 , status post stenting of LAD and
RCA.
9. CHF.
10 Spindle-cell tumors from lung.
11. Hypothyroidism.
12. MRSA wound infection/mesh infection.
13. Status post Mallory-Weiss tear.
14. Hiatal hernia.
15. Status post debridement of skin and subcutaneous tissue with
partial excision of mesh and wound vac on 8/19/05
16. Status post ex lap ventral hernia repair with Sepramesh ,
2/29/05.
17. Status post right colectomy in 2002 complicated by fascial
dehiscence requiring ex lap and repair of fascial dehiscence.
18. Status post prostatectomy.
19. Status post right VATS and wedge resection.
20. Status post fusion of cervical spine.
21. Status post TNA.
22. Status post appendectomy.
OUTPATIENT MEDICATIONS:
1. Amiodarone 200 mg by mouth daily.
2. Calcium.
3. Colace 100 mg by mouth three times a day
4. Coumadin alternating doses of 4 mg and 3 mg.
5. Diltiazem CD 360 mg orally daily.
6. Aspirin 81 mg orally daily.
7. Folate 1 mg orally daily.
8. Lisinopril 10 mg orally daily.
9. Metamucil as needed
10. Clopidogrel 75 mg orally daily.
11. Potassium.
12. Protonix 40 mg orally daily.
13. Simvastatin 80 mg orally daily.
14. Synthroid 25 mcg orally daily.
15. Thiamine 100 mg orally daily.
16. Metoprolol SR 100 mg orally twice a day
17. Zyprexa 2.5 mg at bedtime as needed
ALLERGIES: Ether.
SOCIAL HISTORY: No alcohol or tobacco use. Married , lives with
wife , retired 25 years ago.
ADMISSION LABS: Remarkable for creatinine of 1 , hematocrit of
30.1% , INR of 1.7. EKG V-paced at 60 , no ST-T wave abnormalities
compared to preop.
PHYSICAL EXAMINATION: Vital Signs: On admission , temperature
98 , pulse 60 and V-paced , blood pressure 140/85 , saturating 96%
on 3 L nasal cannula. Neuro: Awake , alert , appropriate.
Pulmonary: Clear to auscultation bilaterally , no rales , no
wheezes. Cardiovascular: Regular rate and rhythm , no murmurs ,
rubs or gallops. Abdomen: Soft , nondistended , mildly tender
midline incision with dressing clean , dry and intact. JP in
midline with sanguinous drainage. Lax abdominal wall with
protuberance but soft. Extremities: Warm and well perfused.
IMAGING: Chest x-ray negative for acute disease and
cardiomegaly.
HOSPITAL COURSE: This is a 90+-year-old gentleman with a complex
past medical history including CAD status post MI and stent x2 ,
CHF was admitted to the SICU , status post ex lap for removal of
MRSA-infected mesh for careful monitoring and fluid resuscitation
in light of cardiac status. His postoperative course was
remarkable for bleeding with sanguinous output from the JP drain ,
a question of an abdominal hematoma and a progressive drop in his
hematocrit. The heparin drip , which was initiated given the
patient's chronic AF , was discontinued and FFP administered.
Platelets were also given at the request of the Plastic Surgery
Team in light of aspirin and Plavix , which were continued due to
the patient's cardiac stents. Despite bolus Lasix , the patient
did develop CHF with symptomatic pulmonary edema and increased
oxygen requirement. Concomitantly , the patient also became
delirious , as is his historical pattern with significant agitation.
He developed hypertension refractory to beta-blockade , calcium
channel blockers and intravenous ACE inhibitors in this setting. The
patient was thus placed on a nitroglycerin drip , a furosemide
drip with ginger blood product resuscitation to address bleeding
and an elevated INR. He responded well to this regimen and
aggressive pulmonary toilet. Both the patient's primary care physician , Dr.
Holihan , and his cardiologist , Dr. Holtmann , did follow the
patient. His oxygenation never suffered during this time and he
did not have significant hypercarbia. He was eventually weaned
back to nasal cannula. He did have a mild transient elevation in
creatinine while on the Lasix drip but has since recovered back
to baseline off of the Lasix drip. His nasogastric tube was
removed on 5/18/06 and he tolerated ice chips without
difficulty. His home cardiac medications were restarted on
6/10/06. The patient was out of bed and ambulating without
difficulty. At the time of dictation , his nitroglycerin drip was
being weaned with the assistance of nitro paste. He is
anticipated to be transferred to the floor once he receives a red
blood cell transfusion and once the nitroglycerin drip is off.
PLAN:
Neuro:
1. The patient does sundown at home and has done so while in
the ICU. He has been much more calm and appropriate over the
past 24 to 36 hours.
2. He does experience more significant delirium with morphine
and less so with sparing Dilaudid as needed
3. We will continue with sparing Dilaudid as needed , and Zyprexa
2.5 at bedtime as needed per home regimen. Haldol is written as needed
as needed.
Cardiovascular:
1. CAD status post stent x2 , AF on chronic anticoagulation , CHF ,
status post pacer for sick sinus syndrome , currently V paced.
2. Outpatient systolic blood pressure 150 to 180 , current goal
of SBP 140 to 160.
3. Weaning off nitroglycerin drip , nitro paste added.
4. Diltiazem CD 360 orally daily , Lopressor SR 100 mg orally twice a day ,
lisinopril 10 mg orally daily , amiodarone 200 mg orally daily ,
restarted per home regimen.
5. Aspirin and Plavix to continue for cardiac stents.
6. Watch for overload.
Pulmonary:
1. Pulmonary edema with improving chest x-ray , currently
saturating well on 4 L of nasal cannula.
2. Aggressive pulmonary toilet , nebs , out of bed and ambulation.
3. Lasix with blood.
GI:
1. Patient advanced to clear liquids only.
2. All orally meds.
3. Nexium.
GU:
1. Good urine output off Lasix.
2. Creatinine back to baseline of 1.
3. Lasix to be given with blood as well as potassium.
4. Slowly trending back to preop weight , would recommend gentle
diuresis as needed and careful observance of potassium.
Heme:
1. Hematocrit 25% today , we will give one unit of packed red
blood cells with Lasix and potassium.
2. Continue with subcutaneous heparin for now and Coumadin to restart
at discretion of primary team.
ID:
1. Vancomycin for MRSA-infected mesh.
2. PICC line consult ordered for anticipated long-term
vancomycin.
Endocrine:
1. Synthroid at home dose.
2. RISS.
SERVICES FOLLOWING THE PATIENT:
1. Medicine , Dr. Holihan , patient's primary care physician.
2. Cardiology , Dr. Nakamatsu
3. Plastic Surgery , Dr. Samuelson
Patient anticipated to be transferred to the floor on 6/10/06.
eScription document: 2-3779758 CSSten Tel
Dictated By: BREINES , AZALEE
Attending: CIVALE , LOVELLA
Dictation ID 1551066
D: 9/22/06
T: 9/22/06
Document id: 747
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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837733940 | PUO | 41922973 | | 6163276 | 1/7/2006 12:00:00 a.m. | liver cyst | | DIS | Admission Date: 8/18/2006 Report Status:
Discharge Date: 7/6/2006
****** FINAL DISCHARGE ORDERS ******
MILFORD , VONDA E 507-73-93-5
Orl Own Beau
Service: MED
DISCHARGE PATIENT ON: 8/10/06 AT 06:00 PM
CONTINGENT UPON Stress test
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
CHLORHEXIDINE MOUTHWASH 0.12% 15 MILLILITERS twice a day
NEURONTIN ( GABAPENTIN ) 1 , 200 MG orally twice a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 25 MCG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXAZEPAM 20 MG orally BEDTIME
OXYBUTYNIN CHLORIDE 5 MG orally twice a day
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Primary care 1-2 weeks ,
Dr. Barnaba , cardiology as scheduled previously. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
rule out MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
liver cyst
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pneumonia , diet-controlled DM , depression/anxiety , hypothyroidism
dyspepsia , postmenopausal bleeding , hereditary spherocytosis ,
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
RUQ ultrasound , MRI of abdomen , MIBI , Cardiac enzymes and telemetry
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest/abd pressure
HPI: patient is obese 73 year-old female with past tob , MIBI positive for reversible
defect in LAD territory 6/8 ( conservatively managed ). Had chest pressure
after dinner lasting 15min with SOB. Called EMS.
Pain in abdominal/epigastric/substernal area. Reports cough , congestion
x1 wk , ASA+nitro , zofran given in ED. No night sweats , no changes in urine
or stool , mild SOB. Pain onset shortly after eating sandwich. Known
history gallstones.
****************
PMH: DM , obesity , dyslipedemia , hypothyroid , depression , irritable
bowel , GERD , bipolar , hemolytic anemia , hepatic cyst.
****************
Pre-admission Medication List for MILFORD , VONDA E 41922973 ( PUO ) 73 F
1. Acetylsalicylic Acid orally 81 MG every day
2. Apap 500mg + Diphenhydramine 25mg ( Tylenol Pm ) orally 1 TAB every bedtime as needed
insomnia
3. Gabapentin orally 1200 MG twice a day
4. Levothyroxine Sodium ( Levoxyl ) orally 25 MCG every day
please restart your home dose
5. Metoprolol Succinate Extended Release ( Toprol Xl ) GTUBE 25 MG every day
6. Oxazepam ( Serax ) orally 20 MG every bedtime
7. Oxybutynin Chloride orally 5 MG twice a day
8. Simvastatin ( Zocor ) orally 40 MG every bedtime
*****************
PE: T97.1 , HR 81 , BP 162/68 , O2 sat 99%.
A&Ox3 , EOMI , PERRL
Lungs CTA b/l.
Heart RRR , no M/R/G
Abd: Obese , RUQ mildly tender , Ext: no C/C/E
*****************
Labs: Hct 33.9 , cardiac enz neg x3
RUQ u/s large complex liver cyst
MRI: 8 cm complex cystic hepatic lesion with mild enhancement. Despite
the peripheral location , the most likely diagnosis would be a biliary
cystadenoma. Other entities remained in the differential , however ,
including biliary cystadenocarcinoma , a thrombosed hemangioma , cystic
metastases , and infection ( hydatid or abscess ). If available , access to
any prior outside imaging would be helpful to distinguish these.
Otherwise , follow-up or biopsy could be considered. Nonenhancing cystic
lesion in the spleen , likely a splenic cyst or hemangioma.
*****************
Hospital Course:
73 year-old with probable CAD , presents with abd/chest pressure. Was ruled out
for MI , and f/u MIBI actually demonstrated interval improvement in cardiac
disease. As the pain was epigastric in location , pursued further imaging
of liver cyst.
1. CV: R/o by negative enzymes x 3 , ASA , statin , BB. No recurrence of the
pain following admission. Stress PET on 6/26 did not demonstrate any
reversible perfusion defect ( unlike prior study 6/8 ). Will continue
current medications. Given elevated BP on admission ( and control on 25
lopressor three times a day ) , will increase toprol from 25 to 50mg orally daily. patient should
followup with primary care physician and cardiologist for further adjustments as needed. Dr.
Barnaba was notified of the patient's admission.
2. Abd pain. Pain appeared to have abdominal component , and given absence
of cardiac disease , pain may have more likely originated may be biliary or
hepatic area. Patient was continued on PPI. A RUQ u/s demonstrated small
gallstones and a sizable hepatic cyst ( previously known ). The cyst was
then characterized by MRI , which revealed likely
cystadenoma per preliminary report. This lesion should be closely
followed , and surgical options should be evaluated. Furthermore , the
possibility of biliary pain should be considered given presence of small
gallstones and timing of pain. Referral for elective laproscopic
cholecystectomy should be considered.
3. Psych. depression/anxiety/bipolar. Continued home medications with no
changes during the hospital stay.
4. Heme. Anemia , chronic at baseline. Should be followed as outpatient.
5. Reported history of diabetes. A1C was 4.5. No treatment was given.
6. Hyperthyroidism. Continued levoxyl. TSH 2.808.
7. Periodontal pain. Patient reported pain in gums , ? infection. The
patient was offered chlorhexidine mouthwash and encouraged to followup
with her dentist as soon as possible for evaluation.
Full Code
ADDITIONAL COMMENTS: 1. Cardiac tests were normal. Continue to take all of your medications as
prior , except for Toprol XL , which you should take at a slightly higher
dose until talking with your primary doctor.
2. You have a cyst in your liver and should follow-up with your primary care physician to
discuss further evaluation.
3. If you have chest pain , worsening shortness of breath , nausea ,
vomiting or abdominal pain , please call your doctor or seek medical
attention
4. Seek follow up with your dentist for pain in gums.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Hepatobiliary cystadenoma: could consider surgical excision. Consider
gallbladder removal
2. Follow BP , as Toprol XL increased from 25 to 50mg daily.
No dictated summary
ENTERED BY: WAFULA , KARMA A. , M.D. , PH.D. ( BC90 ) 8/10/06 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 748
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
- |
U |
Y |
U |
U |
U |
Y |
Y |
U |
- |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
- |
N |
Y |
Y |
- |
- |
N |
N |
N |
N |
435169739 | PUO | 21701223 | | 477871 | 2/7/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/18/1993 Report Status: Signed
Discharge Date: 4/19/1993
PRINCIPAL DIAGNOSIS: INFERIOR MYOCARDIAL INFARCTION.
PSORIASIS.
CERVICAL DEGENERATIVE JOINT DISEASE.
STATUS POST COLECTOMY.
STATUS POST RIGHT HERNIA REPAIR.
KNOWN CORONARY ARTERY DISEASE.
STATUS POST NON Q WAVE MYOCARDIAL INFARCTION
IN 1989.
STATUS POST LEFT ANTERIOR DESCENDING
PTCA IN 1989.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old white
male with known cardiac disease ,
status post non Q wave myocardial infarction in 1989 , status post
left anterior descending PTCA in 1989 , who was admitted following
an episode of post myocardial infarction chest pain from an outside
hospital. Cardiac risk factors include adult onset diabetes ,
hypertension , hypercholesterolemia , history of tobacco , history of
myocardial infarction. Cardiac history dates back to 3/21 when the
patient experienced substernal chest discomfort and ruled in for
non Q wave myocardial infarction. A cardiac catheterization showed
95% left anterior descending lesion , left circumflex 70% lesion and
diffuse right coronary artery disease. He had PTCA of the left
anterior descending lesion and did well for approximately two
months but was readmitted at that time in 6/11 with recurrent chest
discomfort. A cardiac catheterization at that time revealed 30%
left anterior descending lesion , 40% circumflex lesion and 80% OMB3
lesion and 50% mid and distal RCA stenoses. He had no angina until
approximately two days prior to admission when he presented to an
outside hospital with substernal chest discomfort. He rule in for
an inferior myocardial infarction with CK peaking at 2316. He was
treated with morphine , intravenous nitroglycerin , aspirin , heparin and intravenous
streptokinase. He had recurrent chest discomfort post myocardial
infarction and was transferred to Pagham University Of .
HOSPITAL COURSE: On admission , the patient's medications were
optimized to increase his beta blockade.
Eventually , the patient was weaned from intravenous nitroglycerin and intravenous
heparin to orally nitrates. The patient had no further chest
discomfort during the admission and had a predischarged modified
Bruce protocol exercise tolerance test. He did have some episodes
of shortness of breath secondary to congestive heart failure ,
however , this resolved with Lasix. EKG was consistent with
inferior myocardial infarction on transfer. On 6/9 , he had a
modified Bruce protocol stress test for which he went nine minutes
without chest discomfort or shortness of breath. This was read as
evidence of no ischemia. The patient was discharged home on
5/19/93.
DISPOSITION: The patient was discharged to home in stable
condition. MEDICATIONS: On discharge included
diltiazem , 120 mg orally twice a day; metoprolol , 75 mg orally twice a day; Isordil ,
20 mg orally three times a day; aspirin , 325 mg orally every day; Glyburide , 25 mg orally every
day; gemfibrosol , 600 mg orally twice a day; omeprazole , 20 mg orally every day.
Dictated By: LATORIA C. OGDEN , M.D. TG42
Attending: GAYLENE G. FANIEL , M.D. KE29
ML126/7163
Batch: 5131 Index No. KMUBUJV8Y D: 1/1/93
T: 10/28/93
Document id: 749
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
719243531 | PUO | 24802754 | | 058033 | 1/11/1997 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 10/17/1997 Report Status: Signed
Discharge Date: 8/26/1997
FINAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old female
with history of coronary artery
disease who had a PTCA in 1980 who presented to the emergency room
department with worsening chest pain. She was admitted and treated
for unstable angina.
PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.
Diabetes mellitus. Coronary artery disease.
Chronic angina for ten years.
MEDICATIONS: Metoprolol , Captopril , Nitrol paste , aspirin ,
heparin , insulin.
PHYSICAL EXAMINATION: GENERAL: She was pale and in moderate
distress. No jugular venous distension or
lymph nodes palpable. LUNGS: Clear. HEART: Regular rate and
rhythm. No gallop. 2/6 systolic ejection murmur. S1 and S2 and
S3. No S4. ABDOMEN: Soft.
LABORATORY DATA: CBC and chemistry were normal. The first CPK was
156. Her first ECG showed normal sinus rhythm ,
Q-wave in 1 and aVL , left hemiblock that was with pain. She had a
second ECG done. This showed 2 , 3 , and aVF with flipped Ts , V4 ,
V5 , and V6 with flipped Ts , and V3 was flat.
HOSPITAL COURSE: The patient underwent a cardiac catheterization
on 3/21/97 which showed 40 percent left anterior
descending artery , 90 percent obtuse marginal 1 , 90 percent obtuse
marginal 2 , 90 percent proximal right coronary artery , 80 percent
mid and distal right coronary artery. The PTCA was performed. The
right coronary artery had two stents placed. She had an episode of
hypotension following this which required some Dopamine and then
responded to that. She had more hypotension. She was transferred
to HTHH at 10/5/97. She did well after that until she was ready for
discharge. She was discharged in fair condition on 1/13/97.
DISPOSITION: DISCHARGE MEDICATIONS: She went home on Captopril 50
mg orally three times a day , Imdur 30 mg orally every day , and Lopressor
25 mg orally three times a day The patient was discharged to home. She will
have services at home.
Dictated By: KALEIGH E. IMRIE , M.D. CP35
Attending: RONA J. GRAP , M.D. JR0
XB024/6797
Batch: 07714 Index No. KDEW6BP7H7 D: 8/24
T: 2/17
Document id: 750
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
921778812 | PUO | 49448215 | | 398096 | 7/10/2001 12:00:00 a.m. | CERBRAL VASCULAR ACCIDENT | Signed | DIS | Admission Date: 2/18/2001 Report Status: Signed
Discharge Date: 2/1/2001
CHIEF COMPLAINT: LEFT LOWER EXTREMITY NUMBNESS.
HISTORY OF PRESENT ILLNESS: Cristal Lippman is a 78-year-old
African American female with a
significant cardiac history , including hypertension , congestive
heart failure , history of afib -- patient is on Coumadin , CAD ,
status post MI , mitral valve replacement in 1995 or so , who was in
her usual state of health until the morning of admission , when she
says she awoke in a sweat , had a headache , and noticed she could
not stand. She felt that her left lower extremity was "asleep" and
weak. She called 911 , came to KAAH . The patient also noted that
her speech seemed slurred at the time that she was unable to get
up. She denied any weakness or numbness in her other extremities
or face. She denied any chest pain , shortness of breath , or visual
changes. She says she did note transient heart palpitations. She
denied fever , chills , nausea , and vomiting. In the ER the patient
was noted to have 2/5 left lower extremity power. She had no
apparent sensory deficits at that time.
PAST MEDICAL HISTORY: As above , and including noninsulin dependent
diabetes mellitus , a status post left hip
replacement , history of DVT , status post mitral valve replacement
for mitral stenosis approximately eight years ago ( patient says she
has a history of rheumatic fever ) , and bilateral cataracts.
MEDICATIONS ON ADMISSION: Norvasc 10 mg every day , amiodarone 200 mg
every day , Isordil 20 mg three times a day , Lasix 40
mg every day , Coumadin 5 mg Monday , Wednesday , and Friday and 2.5 mg
Tuesday , Thursday , Saturday , and Sunday , Lomotil 1-2 mg four times a day
as needed , glyburide 5 mg twice a day , and Prinivil 20 mg every day.
SOCIAL HISTORY: Patient denied any history of tobacco , ethanol , or
illicit drug use. She lives alone and says she is
a very private person. She does all of her own activities of daily
living and walks with a cane.
FAMILY HISTORY: The patient's mother died of an MI and her father
apparently died of a PE. She has a son that died
of an MI as well.
ALLERGIES: The patient has an allergy to penicillin , sulfa drugs ,
and aspirin.
REVIEW OF SYSTEMS: As per HPI.
PHYSICAL EXAMINATION: On being admitted to the hospital , the
patient was afebrile at 97.4 degrees
Fahrenheit , with a pulse of 68 , blood pressure of 190/90 , and
satting 98% on room air. Patient's exam showed that she had no
carotid bruits or JVD. Her heart exam was notable for a regular
rate and rhythm , as well as prosthetic S1. Her lungs were clear to
auscultation bilaterally and abdominal exam was benign.
Extremities showed cool fingers on the right , with a 1+ pulse , and
warm well perfused fingers on the left , with a 2+ radial pulse.
Apparently , these extremity changes are long-standing and not new.
She had 2+ pulses in her posterior tibial pulses and trace pulses
in her dorsalis pedes pulses bilaterally. On neuro exam the
patient was alert and oriented x three. She exhibited good naming ,
comprehension , reading , and fluency. Cranial nerves II-XII were
intact bilaterally. On motor exam the patient had 5/5 power
everywhere except for the left lower extremity , with knee flexors ,
knee extensors , ankle flexors , and ankle extensors being 3+/5 and
hip flexors and hip extensors being 4-/5. Her tone was slightly
increased in her left lower extremity. On sensory exam she had
slightly reduced sensation to pinprick , light touch , and
temperature in both extremities to the hip. Deep tendon reflexes
were symmetric and 2+ throughout , with downgoing toes bilaterally.
Pertinent labs on admission showed a slightly increased creatinine
at 1.7 and a BUN of 31. The patient had a TSH of 1.09 and a total
cholesterol of 197 , with an LDL of 131. Her sed. rate was 14 and
her hematocrit was 40.2. INR was noted to be 1.7. CKs were flat
and the patient was ruled out for an MI.
IMPRESSION:
1. Neurologic: Given the patient's significant cardiac history
and subtherapeutic INR , it was considered that her left lower
extremity weakness that was transient was likely a transient
ischemic attack. The patient's motor deficits quickly improved
over her hospital stay and she felt she was back to baseline on the
day of discharge. Head CT and head MRI and MRA were negative for
any acute changes , including hemorrhage and infarction. On MRA the
patient was noted to have some proximal stenosis of her right
intracranial carotid and had also some atherosclerotic changes of
her PCAs bilaterally. The patient also had ATTE with a bubble
study that was negative for PFO. The patient was continued on her
Coumadin at 5 mg every bedtime until her INR was therapeutic. During this
interval she was started on heparin and was therapeutic on that.
The patient is to follow up in the Coumadin clinic as well as
neurology clinic in one month. She is to have her Coumadin drawn
at three days after discharge to ensure that her INR is above 2.
Her Coumadin dosing regimen was slightly changed , with her taking
four doses of 5 mg a week and three doses of 2.5 mg a week. The
patient was seen by physical therapy , who cleared her to go home
and felt that she was okay to walk stairs with her walker.
2. Cardiovascular: The patient has an extensive cardiac history
as detailed above. Her systolic blood pressure was calculated
between 120 and 160 during the first day of her hospital stay , as
it was unclear whether she had a serious carotid stenosis or not.
Her blood pressure meds were gradually added back. The patient had
several episodes of atypical chest pain , for which she was ruled
out with telemetry and enzymes , which were flat.
3. Endocrine: The patient was placed on a diabetic diet and was
continued on her glyburide. A hemoglobin A1C is pending at the
time of this dictation. She was covered with sliding scale insulin
during her hospital stay.
MEDICATIONS ON DISCHARGE: Amiodarone 200 mg every day , Norvasc 10 mg
every day , Isordil 20 mg three times a day , Lasix 40
mg every day , Coumadin 5 mg Monday , Wednesday , Friday , and Sunday , and
2.5 mg Tuesday , Thursday , and Saturday , glyburide 5 mg twice a day ,
Lasix 40 mg every day , and Prinivil 20 mg every day.
Dictated By: PATTIE FLINSPACH , M.D. BX483
Attending: CLEVELAND BENNINGFIELD , M.D. BC8
XN988/677896
Batch: 63601 Index No. KNCZR001IP D: 2/10/01
T: 7/26/01
Document id: 751
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
Y |
N |
N |
N |
N |
N |
Y |
Y |
N |
N |
N |
354230748 | PUO | 93387199 | | 645184 | 11/7/1998 12:00:00 a.m. | FAILED LT. KNEE | Signed | DIS | Admission Date: 2/10/1998 Report Status: Signed
Discharge Date: 4/10/1998
DIAGNOSIS: FAILED LEFT TOTAL KNEE REPLACEMENT.
HISTORY OF PRESENT ILLNESS: Mrs. Harbin is an 80-year-old woman who
had a left primary total knee
replacement performed in 1976 for psoriatic arthritis. The patient
did well up until last fall when she developed pain and swelling
and occasional symptoms of catching. Radiographs showed failure of
her femoral component with evidence of polyethylene wear.
PAST MEDICAL HISTORY: Significant for psoriatic arthritis
and noninsulin dependent diabetes
mellitus which is diet controlled.
PAST SURGICAL HISTORY: Status post bilateral total knee
replacements in 1976. Status post
right total hip replacement in 1992. Status post left total hip
replacement in 1988. Status post bilateral metacarpophalangeal and
proximal interphalangeal arthroplasties. Status post
cholecystectomy. Status post total abdominal hysterectomy with
umbilical hernia in the past.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS: Voltaren as needed
SOCIAL HISTORY: The patient denies a history of
cigarette smoking or alcohol use. She
is on an 1800 ADA diet. The patient is a widow who resides in
S Down Wood , and plans to be discharged to
rehabilitation.
REVIEW OF SYSTEMS: The patient wears bifocals. The
patient has a remote history of
migraine headaches. The patient has a history of tuberculosis in
childhood but no positive chest x-ray findings. The patient has a
history of shortness of breath with exertion but no history of
coronary artery disease , myocardial infarction , chest pain ,
congestive heart failure , or deep vein thrombosis. The patient has
a history of noninsulin dependent diabetes mellitus which is diet
controlled. Her primary care physician is Dr. Devin Brady of
A
PHYSICAL EXAMINATION: On physical examination blood pressure
is 150/80 with a pulse of 62 , height is
5'3" and weight is 170 lbs. In general the patient is an obese
woman with an antalgic gait on the left without an assistive
device. Examination of her lymph nodes showed no lymphadenopathy.
HEENT revealed pupils equal , round , and reactive to light with
extraocular movements intact and normal pharynx. Her lungs were
clear to auscultation bilaterally. Her heart was regular rate and
rhythm with a normal S1 and S2 and no murmur. Her abdomen was
obese , soft , nontender , and nondistended. Neurologically there
were no focal findings. Extremities , the left knee revealed a
medial parapatellar incision which was well healed. She had active
range of motion with a 10 degree extension deficit and flexion to
90 degrees. She had a palpable dorsalis pedis and posterior tibial
pulse and was neurovascularly intact distally. The patient was
instructed to discontinue her NSAIDs and was given a prescription
for Coumadin 5 mg orally on the evening prior to her surgery.
HOSPITAL COURSE: On 12 of November the patient underwent
revision of left total knee
replacement. She tolerated the procedure well with no
intraoperative complications. She received perioperative
antibiotics and was continued on Coumadin postoperatively. On
postoperative day one the patient was noted to be doing quite well.
Her Hemovac put out a total of 540 cc initially plus 60 cc more
overnight , and the Hemovac was discontinued. She was continued on
the Ancef , Coumadin , and given pain medicines.
On postoperative day two the patient was having a difficult time
cooperating with the nursing staff. She was refusing treatments ,
medications , and blood draws. Later in the day the patient seemed
to be doing better , perhaps due to the arrival of her daughters.
She became more compliant.
On postoperative day three the patient's mental status improved and
she was compliant. She was doing quite well on the CPM with range
of motion of 0-50 degrees. Views of the left knee were obtained by
x-ray. On 10 of March the patient was noted to be doing well. The
incision was noted to be clean and dry with no evidence of
infection. Plans were made for her to be discharged to
rehabilitation.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every four hours
as needed headache , Benadryl 25-50 mg orally
every bedtime as needed sleep , Colace 100 mg orally twice a day , iron sulfate 300
mg orally three times a day times five days , Folate 1 mg orally every day times four
days , multivitamin one tablet orally every day , Percocet 1-2 capsules orally
every 3-4 hours as needed pain , Metamucil as needed , Sorna topical lotion
every day as needed itch , Coumadin to keep the physical therapy INR between 1.5 and 2.0
for a total of six weeks , and nizatidine 150 mg orally twice a day
ADDITIONAL INSTRUCTIONS: The patient was instructed to keep the
incision clean and dry for five more
days , and then she may begin showering as long as there is no
evidence of a discharge. The patient was instructed not to take
baths. A dry sterile dressing may be applied on a as needed basis.
The patient is to continue working with physical therapy for range
of motion and gait training per the Total Knee Replacement
protocol.
COMPLICATIONS DURING ADMISSION: None.
DISPOSITION: To rehabilitation.
CONDITION UPON DISCHARGE: Stable.
Dictated By: PRECIOUS KNUTESON , M.D. BM182
Attending: SOFIA DEPALO , M.D. IE3
TH450/1120
Batch: 4887 Index No. XTYZRE92VK D: 1/17/98
T: 1/17/98
Document id: 752
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
Y |
N |
- |
N |
- |
Y |
N |
N |
N |
N |
- |
- |
269462644 | PUO | 90673833 | | 2369715 | 7/16/2006 12:00:00 a.m. | RIGHT UPPER LOBE PNEUMONIA | Signed | DIS | Admission Date: 5/10/2006 Report Status: Signed
Discharge Date: 6/10/2006
ATTENDING: PILLING , WEI M.D.
DISCHARGE DIAGNOSIS: Community acquired pneumonia.
CHIEF COMPLAINT: Cough and shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old woman with
end-stage renal disease on hemodialysis , hypertension , diabetes ,
prior stroke as well as a non-ST elevation MI with a right
coronary artery stent placed in April of 2005 who presents
with a one week history of cough and shortness of breath. On the
day of admission the patient experienced approximately 25
minutes of chest pain that was 5/10 in severity while she was at
dialysis. The patient describes this chest pain to be
right-sided and pleuritic in nature. She denies fevers , chills ,
nausea , vomiting , abdominal pain or diarrhea or lightheadedness.
She also denies orthopnea or paroxysmal nocturnal dyspnea. Of
note , at baseline , the patient does have slow speech with some
right lower extremity weakness from her prior stroke in April
of 2005. The EMS Service was called and noted that
she had a large amount of
secretions. On presentation to the emergency department , the
patient received aspirin , Plavix , azithromycin ,
cefpodoxime , vancomycin , captopril and
Trileptal. She had a chest x-ray consistent with a right upper
lobe pneumonia.
PAST MEDICAL HISTORY: Hypertension , coronary artery disease ,
end-stage renal disease on hemodialysis Monday , Wednesday ,
Friday , status post cardiac catheterization with three-vessel
disease , diabetes , atrial fibrillation , stroke , seizure disorder ,
right subclavian vein thrombosis with a status post SVC stent.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION Zocor 40 mg orally once a day , aspirin 81
mg orally once a day , Toprol-XL 150 mg twice a day , Nephrocaps one
tablet orally once a day , Plavix 75 mg orally once a day , Trileptal
300 mg orally once every morning , 450 mg orally once every evening ,
Nexium 20 mg orally once a day , Sensipar 60 mg orally once a day ,
Norvasc 10 mg orally once a day , Prozac 20 mg orally once a day ,
captopril 50 mg orally three times a day.
SOCIAL HISTORY: The patient has a history of alcohol use in the
past but none currently. She denies tobacco or intravenous drug use. She
lives in a rehab and has two children who live in Garmsion Ln
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97 , heart rate
53 , blood pressure 143/52 , respiratory rate 20 and satting 100%
on room air. General: The patient was in no apparent distress ,
alert and oriented x3 with slow speech and a mild right-sided
facial droop. HEENT: Pupils were equal , round and reactive to
light , extraocular muscles intact , moist mucous membranes , JVP at
8 cm. Cardiovascular: Significant for 3/6 harsh systolic
ejection murmur at the right upper sternal border heard to the
carotids and also at the apex. Chest: Decreased respiratory
effort. No egophony , no crackles , no rhonchi. Abdomen soft ,
nontender , nondistended , normoactive bowel sounds. Back: The
patient has a decubitus ulcer on the sacrum. Extremities warm
and well perfused with 1+ pedal edema. Neurologic examination:
Cranial nerves II-XII intact , she did have some right lower
extremity weakness that has been chronic. Sensation testing was
intact throughout.
LABORATORY DATA: significant for potassium 3.3 ,
BUN 13 , creatinine od 2 , BNP 7900. One set of negative cardiac
enzymes. White blood cell count 3.1 , hematocrit 36 , platelets
248 , INR 1.2 , EKG showed some new ST depressions in the inferior
and lateral leads that were new from prior. Chest x-ray; PA and
lateral showed a new ill-defined opacity in the right upper lobe
likely representing pneumonia. Chest CT without contrast showed
no evidence of cavitary lesion within the lungs , a small area of
consolidation within the right upper lobe consistent with
possible pneumonia. A nodule in the right upper lobe that was 8
mm in size and stable from 2005 , but should be followed up
approximately every 6 months with follow up with CAT scan of the
chest. There were coronary calcifications.
HOSPITAL COURSE BY SYSTEM:
1. Infectious disease , the patient was admitted with a right
upper lobe pneumonia somewhat concerning for aspiration
pneumonia , pneumonia given that she was found to have a large
amount of secretions upon admission. She was initially treated
with vancomycin to cover for MRSA as well as ceftriaxone and
azithromycin. She had nasal swabs that were negative for
influenza A&P. She also had a PPD placed on May , 2006 ,
that was negative. She had two sputum cultures that were sent
for AFB smears that were negative for acid fast bacilli. Her
vancomycin was discontinued after 24 hours. She has completed a
5-day course of azithromycin. She has to complete another 5
doses of cefpodoxime have outpatient that should be admitted
administered three times a week after hemodialysis. The patient
had a chest CT that showed no evidence for a cavitary lesion.
She does however have a pulmonary nodule in the right upper lobe
that should be followed with interval CAT scans as an outpatient.
The patient also had a beta glucan and serum tests that are
currently pending. The patient has had negative culture data.
She was initially placed on tuberculosis precautions , however ,
given the absence of cavitary lesion on chest CT , negative PPD
and negative sputum cultures , the likelihood of TB was thought to
be extremely low and her precautions were discontinued.
2. Fluids , electrolytes and nutrition: The patient had a speech
and swallow evaluation for concern of aspiration. She was placed
on mechanical soft honey thick liquid diet that she should
continue upon discharge. She will likely need a repeat speech
and swallow evaluation while at rehabilitation and may possibly
need a video swallow examination if she continues to show signs
of aspiration. In addition , the head of her bed should be kept
elevated. The patient was also noted to have hypercalcemia
during this admission. The patient should have a serum protein
electrophoresis as an outpatient for further evaluation.
Currently , her calcium supplementation during dialysis has been
discontinued. In addition , her PTH level is currently pending
and should be followed up as an outpatient.
3. Renal: The patient has end-stage renal disease on
hemodialysis. She undergoes hemodialysis Monday , Wednesday and
Friday and she should continue this upon discharge at the Lesum On- Community Hospital
at E , 367 907 7801. She was
admitted to the renal service. She continues on Nephrocaps.
4. Cardiovascular: The patient had three sets of negative
cardiac enzymes and ruled out for myocardial infarction. The
patient is status post recent non-ST elevation MI was continued
on aspirin , Plavix , statin , ACE inhibitor , Beta-blocker. She
appeared euvolemic on examination.
5. GI: The patient was placed on a bowel regimen.
6. Prophylaxis: The patient received PPI and heparin for DVT
prophylaxis.
7. Wound care: The patient was seen by the wound care consult
service for a stage 2 sacral decubitus ulcer. She should have
DuoDERM dressing applied to this ulcer every three days. She
also benefits from an air mattress and vitamin C supplementation
as well.
8. Endocrine: The patient's TSH was normal at 1.12.
9. Hematology: The patient had evidence of anemia of chronic
disease. Folate was normal , B12 was normal.
10. Psych: The patient continued on Prozac for depression.
11. Neuro: The patient continued on Trileptal for her seizure
disorder.
CODE STATUS: The patient is full-code and her health care proxy
is her son.
DISCHARGE MEDICATIONS Tylenol 650 mg orally every six hours , as
needed for pain , not to exceed 4 grams a day , aspirin 81 mg orally
once a day , albuterol nebulizer 2.5 mg nebs every 4 hours ,
Norvasc 10 mg orally once a day , vitamin C 250 mg orally twice a day ,
captopril 50 mg orally three times a day , cefpodoxime 400 mg orally
three times a week after hemodialysis for 5 more doses , Plavix 75
mg orally once a day , Colace 100 mg orally twice a day , Nexium 40 mg
orally once a day , Prilosec 20 mg orally once a day , Toprol-XL 150 mg
orally twice a day , Nephrocaps one tablet orally once a day ,
Trileptal 300 mg orally once every morning and 450 mg orally once
every afternoon , senna two tablets orally twice a day , hold if
loose stool , Zocor 40 mg orally at bedtime , Zinc sulfate 220 mg
orally once daily for fourteen doses.
TO DO LIST:
1. Continue wound care for sacral decubitus ulcer.
2. Follow up with primary care provider to have serum protein
electrophoresis as outpatient as well as monitoring of her right
upper lobe pulmonary nodule seen on chest CT.
3. Please have repeat speech and swallow evaluation at
rehabilitation to assess for aspiration.
4. Please continue current plan for hemodialysis every Monday ,
Wednesday and Friday.
eScription document: 9-4613950 RSSten Tel
CC: Normand Maryland Bennes MD , DRPH
Grove Pro
Woodley
Dictated By: JERRETT , RACHEAL
Attending: PILLING , WEI
Dictation ID 9058139
D: 4/10/06
T: 4/10/06
Document id: 753
| Target |
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CHF |
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Gou |
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| output/system_intuitive_annotation.xml | intuitive |
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553809697 | PUO | 30439070 | | 6718372 | 9/17/2006 12:00:00 a.m. | PYLMETHRIGIS | Unsigned | DIS | Admission Date: 4/6/2006 Report Status: Unsigned
Discharge Date: 5/10/2006
ATTENDING: NAJI , COLIN MD
CHIEF COMPLAINT: Inability to ambulate and abdominal pain.
HISTORY OF PRESENT ILLNESS: A 63-year-old female with history of
diabetes , hypertension , congestive heart failure with an ejection
fraction of 45% , and recurrent UTI , who was recently admitted for
hypoglycemia secondary to insulin overdose , comes in with 24
hours left lower quadrant pain , flank discomfort , low-grade
temperatures , dysuria , pain radiating down both legs to below the
knee. She was just DC'd 6/21/06 , during admission grew Proteus
resistant to Cipro. She denies diarrhea , vomiting , nausea , point
tenderness to the costophrenic angle , chest pain , and shortness
of breath. In ED , she received 1 g of Ceptaz , fluids , and was
admitted to GMS floor on 9/18/06.
PAST MEDICAL HISTORY: Hypertension , abdominal hernia , asthma ,
obesity , high cholesterol , peripheral neuropathy , chronic renal
insufficiency , lower extremity edema , and diabetes mellitus type
II.
ALLERGIES: Enalapril.
ADMISSION MEDICATIONS: Aspirin 325 once a day , Cefradox 200 mg
twice a day , Colace 100 mg twice a day , Prozac 40 mg once a day ,
Lasix 80 mg twice a day , hydroxyzine 25 mg twice a day ,
metolazone 2.5 mg twice a week , Monday and Thursday , oxycodone
5-10 mg every 4 hours if pain , Neurontin 800 mg three times a day , Lantus
90 units every bedtime , Novolog 20 units before meals , Lipitor 40 mg
once a day , Protonix 40 mg once a day.
PHYSICAL EXAMINATION:
Vital Signs: Temperature of 99.2 , heart rate 78 , blood pressure
119/58 , respiratory rate 18 , oxygen 98 on room air.
General: No acute distress , unable to sit up , oriented x3.
HEENT: Drowsy CHEIRS , NIGEL
Neck: Supple , JVP below 10 cm , no lymph nodes.
Chest: CTAB.
COR: Regular rate and rhythm with 1/6 systolic murmur at right
upper sternal border.
Abdomen: Mild tenderness with left lower quadrant pain. Bowel
sounds were present. No guarding or rebound.
Extremities: No edema , 1+ pulse bilaterally.
Neuro: 2+ DTR , decreased sensation to light touch in feet ,
unable to lift legs against gravity.
LABORATORY DATA: Pertinent positive , potassium 5.4 , BUN 69 ,
creatinine 2.3 , glucose 214 , hematocrit 32.3 at baseline.
Urinalysis , 50-60 white blood cells , 1+ bacteria , and cloudy
urine. On specification in prior hospital admission , Proteus
mirabilis sensitive to cephalosporins and resistance to
ciprofloxacin.
HOSPITAL COURSE BY PROBLEM: The patient was admitted on
9/18/06. She had 10/10 bilateral leg pain which required change
of pain medication from oxycodone to Dilaudid , first as needed doses
every 4 hours were allowed with 1-2 mg then this was augmented to
as needed every 2 hours of 2-4 mg. Per pain consult , we changed
Neurontin to Lyrica 100 three times a day Over the next two days , patient's
pain symptoms improved tremendously on this regimen. She
decreased using the as needed pain medications until she reached a
plateau of two usages of 2 mg Dilaudid orally a day next to her
methadone 5 mg three times a day.
UTI: During prehospital course , she ________ Bactrim and
ciprofloxacin , we put her on ceftriaxone 2 g once daily
intravenously for which her symptoms improved rapidly over the
next two or three days. She denies currently any abdominal pain ,
flank pain , dysuria , and urinary tract infection has clinically
resolved. Please continue intravenous medication for at least
another seven days until 3/11/06.
FUTURE CARE PLAN:
Neuropathic pain: The patient has diabetic neuropathy. The
patient is on Lyrica 100 mg three times a day , methadone 5 mg
three times a day , and Dilaudid as needed orally Per pain consult , it
was suggested to change her antidepressant Prozac to Cymbalta 60
mg , this should be done with a taper of the Prozac and increasing
doses of Cymbalta. First start with 40 mg of Prozac and 10 mg of
Cymbalta then gradually increase the Cymbalta and decrease the
Prozac , to 30-20 , 20-30 , 10-40 , and then finally 60 mg Cymbalta.
Cymbalta has significant effects on diabetic neuropathic pain and
the patient would benefit largely from these measures. The
patient has pain consult setup with Dr. Bossert at the Pain Clinic
here in the Pagham University Of on 8/11/06.
Obesity: The patient currently is morbid obese with a BMI of 50
which inhibits her abilities to care for herself , cleaning , and
going to the toilet , mobilization is difficult. The patient
would benefit from drastic dietetic weight loss programs/consider
GI surgical intervention to reduce appetite and help losing
weight.
DISCHARGE MEDICATION: Tylenol 1 mg orally every 6 hours as needed pain ,
aspirin 81 mg orally once a day , Dulcolax 10 mg per rectum once
daily as needed constipation , Captopril 6.25 mg orally three times
daily , please check potassium and creatinine , ceftriaxone 1 g intravenous
once daily , Benadryl 25 mg orally every bedtime , Colace 100 mg orally twice
a day , Prozac 40 mg orally once a day , Lasix 80 mg orally twice a
day , heparin 5000 units subcutaneous three times a day , Dilaudid
2-4 mg orally every 2 hours as needed pain , Ativan 0.5 mg orally every 6 hours as needed
pain and anxiety , milk of magnesia 30 mL orally once daily as needed
constipation , methadone 5 mg orally three times daily , metolazone
2.5 mg orally twice weekly , senna tablets two tablets orally twice a
day , Fleet Enema one bottle p.r. daily as needed constipation ,
trazodone 25 mg orally every bedtime as needed insomnia , simvastatin 40 mg
orally daily , Nexium 40 mg orally daily , Lantus 70 units subcutaneous
daily , beware of hypoglycemic episodes in the morning , reduced
Lantus from 100 to 70 units over hospital course , insulin as per
sliding scale subcutaneous before meals , insulin as per 20 units
subcutaneous before meals , Maalox tablets quick dissolve one to
two tablets orally every 6 hours as needed upset stomach , Lyrica 100 mg orally
three times a day
eScription document: 4-0766406 EMSSten Tel
Dictated By: DAURIZIO , GINNY
Attending: NAJI , COLIN
Dictation ID 3569627
D: 1/1/06
T: 1/1/06
Document id: 754
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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OSA |
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486555786 | PUO | 76780305 | | 928524 | 10/4/2002 12:00:00 a.m. | CELLULITIS | Signed | DIS | Admission Date: 11/13/2002 Report Status: Signed
Discharge Date: 6/11/2002
ADMISSION DIAGNOSIS: LOWER EXTREMITY VENOUS STASIS WITH
SUPERIMPOSED CELLULITIS.
DISCHARGE DIAGNOSIS: LOWER EXTREMITY VENOUS STASIS WITH
SUPERIMPOSED CELLULITIS , RESOLVED.
SERVICE: GENERAL MEDICAL Myby Boulevard
CONSULTS OBTAINED: Infectious Disease and Dermatology.
HISTORY: The patient is a 56 year old woman with chronic venous
stasis complicated by Psychiatric history , chronic
noncompliance , and visits to multiple care providers , readmitted
for painful , swollen , red , right lower extremity. The patient had
a previous episode of cellulitis of the right lower extremity in
July of 2002 treated at Norap Valley Hospital with clindamycin ,
leading to a clostridium difficile colitis; previous episodes
resolved entirely. The patient now returned with a one week
history of increasing symptoms of the right lower extremity. She
reported positive subjective fevers as well as chills. She denied
nausea , vomiting , bright red blood per rectum , melena or chest
pain. The patient does report chronic abdominal pain , positive
dyspnea on exertion , but no dysuria.
PHYSICAL EXAMINATION: Temperature is 98.2 , pulse 87 , blood
pressure 134/69 , respirations 20/minute ,
oxygen saturation 95% on room air. Physical examination reveals a
morbidly obese middle aged female in no acute distress. The
patient is alert and oriented. Speech , however , is pressured and
tangential. The left lower extremity is remarkable for 1+ edema
and brawny hyperpigmentation below the knee. The right lower
extremity is erythematous and shiny below the knee with 2+ edema.
The extremity is very tender to the touch. On admission white
blood cell 8.6 , urinalysis 4+ squamous. A right lower extremity
x-ray revealed no bony abnormalities. Chest x-ray showed no
infiltrates.
HOSPITAL COURSE: From an I.D. standpoint , cellulitis was treated
with Ancef without improvement. Based on input
from the Infectious Disease Service the patient was switched to
intravenous vancomycin on August Blood cultures were negative
from February A repeat urinalysis was negative. A dermatology
consult was obtained on March and gave an impression of
cellulitis secondary to venous insufficiency and obesity and
possible tinea pedis. The consult recommended discontinuing
nystatin and triamcinolone with use of Spectazole and miconazole
between the toes on lower legs and inframammary twice a day On October Infectious Disease saw the patient and confirmed the impression
of cellulitis. They also voiced concern for adequate dosing of
vancomycin given the patient's size and to properly cover non
staphylococcal etiologies. The vancomycin dose was increased to
1.5 gram intravenous every 12 hours and then to every eight hours. On the 4 of October of
February the dorsum of the left foot was draining a serous fluid. At
the time a CT was also obtained which was negative for any fluid
collections. Debridement was not recommended at that time. The
patient at that time was still receiving levaquin. Dermatology saw
the patient on May once more and supported the diagnosis of
chronic venous stasis. From a hematologic standpoint , the
beginning of this day , the patient received lower extremity ,
noninvasive imaging to rule out deep venous thrombosis. These were
negative for deep venous thrombosis. From a psychiatric standpoint
the patient has an undifferentiated psychiatric disorder , most
possibly bipolar with a manic component but refused to see Psych
and instead insisted on taking Dexedrine for a claimed diagnosis of
narcolepsy. In the absence of prescription , the patient reportedly
took her own medications while in the hospital. The mental status
examination is significant for pressured speech , tangential in
nature and evidence of poor short-term memory. The patient lacks
any suicidal or homicidal ideation and does not appear to have any
psychotic component. From a cardiovascular and fluid standpoint ,
Lasix diuresis was attempted and a Foley catheter was placed.
Given that all of the involved sources believed that the most
fundamental cause for the patient's symptoms was fluid overload and
venous insufficiency in the lower extremities , aggressive diuresis
was continued , leading ultimately to a dose of 80 mg of Lasix
twice a day An echocardiogram on May showed right ventricular
dilatation without any compromise in function. From a
musculoskeletal standpoint the patient did suffer a fall while
standing on September She had no head trauma. She did complain
of some right knee pain without functional impairment. There was
no instability in the joint. The patient also later complained of
pain in the right foot , which he complained resulted from the fall.
However three views from the foot showed no evidence of fracture of
significant soft tissue disease. A chronic issue during the
patient's stay was her refusal to look forward to discharge despite
evidence that her acute issues had corrected and that improvement
of her chronic underlying condition would require comprehensive
therapy on a home and outpatient basis. By the 29 of October the
patient's cellulitis had resolved and this had been confirmed by
Infectious Disease reconsult. At that point only stasis dermatitis
continued. The vancomycin was therefore discontinued after
adequate antibiotic course. On September the lower extremity
continued to show improvement. On August the patient was
deemed ready for discharge. She was advanced to continue Lasix at
80 mg orally twice a day with potassium at 60 meq orally per day to replace
any losses. Other meds were prescribed as before. The patient was
also sent home with ketoconazole for a short course and a small
supply of oxycodone to control her pain until she could follow-up
wit her new outpatient provider Dr. Duva at A Triaded Health The
plan was to leave the patient's Foley catheter in because she had
persistent problems with urinary incontinence which predates this
hospital admission. The patient plans to see Urogynecologist , Dr.
Baumohl for this problem. We arranged outpatient follow-up
appointments for the patient with both of these doctors , Dr. Duva
and Dr. Baumohl on November All of the information was
communicated verbally to the patient. The patient was advised to
take all medications as directed. We emphasized that it's very
important for her to elevate her legs regularly and to try to limit
soft drink intake as this was likely contributing to the swelling
in her legs. She was instructed to weight herself daily and to
contact her primary care physician if her weight was steadily
increasing. We advised her to seek medical attention for fever ,
increased redness or new pronounced swelling in her legs , any
numbness or tingling in her legs , new skin ulcers or any other
concerns.
MEDICATIONS ON DISCHARGE: Betoptic S eye drops 0.25% to the right
eye one drop twice a day , Klonopin 1 mg orally
every bedtime , Lasix 80 mg orally twice a day , potassium chloride slow release 60
mEq orally daily , albuterol and ipratropium nebulizer inhaler 3/0.5
mg every 4-6h as needed shortness of breath or wheezing.
Dictated By: ROSSIE KAYCEE MANKOSKI , M.D. LG484
Attending: AVRIL TAPLIN , M.D. FW48
BD494/569980
Batch: 89015 Index No. Z3RK29D3A2 D: 2/5/02
T: 10/18/02
CC: Dr. Duva , A Triaded Health
Document id: 755
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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000597448 | PUO | 96398256 | | 7356384 | 4/9/2006 12:00:00 a.m. | multilobar pneumonia and congestive heart failure | | DIS | Admission Date: 6/10/2006 Report Status:
Discharge Date: 3/10/2006
****** FINAL DISCHARGE ORDERS ******
ELIA , MARQUITTA 973-71-82-4
Field Ox Room: Ard Ano Peeye
Service: MED
DISCHARGE PATIENT ON: 1/4/06 AT 12:00 PM
CONTINGENT UPON Home services
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GILFOY , DEANDRA LAZARO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 325 MG orally DAILY
DULCOLAX ( BISACODYL ) 10 MG orally DAILY as needed Constipation
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LOVENOX ( ENOXAPARIN ) 80 MG subcutaneously twice a day
FENOFIBRATE 145 MG orally DAILY
Override Notice: Override added on 10/29/06 by
BUCCHERI , FELICE M. , M.D.
on order for ZOCOR orally OTHER every bedtime ( ref # 878586821 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
SIMVASTATIN Reason for override: aware
Number of Doses Required ( approximate ): 30
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally DAILY
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
NOVOLOG ( INSULIN ASPART ) 12 UNITS subcutaneously before meals
Starting Today ( 3/23 )
LANTUS ( INSULIN GLARGINE ) 44 UNITS subcutaneously every afternoon
Starting Today ( 3/23 )
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG NEB four times a day
KEPPRA ( LEVETIRACETAM ) 500 MG orally twice a day
LISINOPRIL 20 MG orally DAILY HOLD IF: SBP < 100
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
200 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 10/29/06 by
BUCCHERI , FELICE M. , M.D.
on order for ZOCOR orally OTHER every bedtime ( ref # 878586821 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
Previous override information:
Override added on 7/9/06 by ALESNA , MYRNA S. , M.D.
on order for ZOCOR orally ( ref # 236600715 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: will monitor
Previous override information:
Override added on 4/10/06 by KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 10/25/06 by :
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: md aware
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
September Petretti 2/22/06 13:30 scheduled ,
Barbagallo 7/14/06 15:15 scheduled ,
Dr. Fiermonte 8/18/06 14:00 scheduled ,
ALLERGY: PHENYTOIN SODIUM , PHENYTOIN
ADMIT DIAGNOSIS:
hypoxia , hypotension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
multilobar pneumonia and congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CVA DM CAD GERD HTN history of CABG and Ley Rotal University Medical Center MVR hyperlipidemia
sacral decub ( decubitus ulcer )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
antibiotics , diuresis
BRIEF RESUME OF HOSPITAL COURSE:
cc: multilobar pna , hypotension , MICU call-out
***
HPI: 66 year-old male with CAD , HTN , DMII , hyperlipid , ischemic CMP ( EF
35% ) , history of CVA's. Recent admit 4/25 for RML pna , 2 day hosp. Has
felt fine , but some waxing and waning. Increased cough , rigors ,
difficulty walking/speaking , fever to 101 , SOB , blue lips/hands per
family. EMS called and O2 sat 80% -> 97% on 100% NRB. EKG on admit
showed new LBBB but cath lab did declined to intervene saying
likely 2ary demand. Hypotensive in ED required fluids , SCL line
placed. PMH: CAD ( 3V CAD history of CABG X 1 in 1999 ( SVG to RCA ) ,
NSTEMI 11/19 with cypher to 70% prox LAD and pixel to 70% ostial D1 ,
NSTEMI 11/1 , new cypher to D1 instent restenosis , diffuse LCx
disease; HTN , DMII ( on orally agents ) , hyperlipid , MR history of Ley Rotal University Medical Center 33mm
in 1999 , ischemic CMP EF35% , multiple CVA's ( on Rx dose lovenox ) , SDH
in setting of coumadin 9s/p Burr hole drainage in 1999 ) , seizure d/o;
history of carotid stenosis history of L CEA 2002 , GERD; sacral decubits
ulcer
***
Admit meds ASA 325 , Toprol 200 , lisinopril 20 , lovenox 80 twice a day ,
fenofibrate 145 , lipitor 40 , glipizide 10 twice a day , keppra 500 twice a day ,
benadryl 25 twice a day as needed itching , MBI , FeSO4 325 every day , trazadone 50 , zantac
150 twice a day , miconazole
TP
***
All: dilantin - desquam rash
***
On admission: T 96.7 HR 75 BP 98/54 RR 14 97% 4L NAD , anicteric , OP
clear Pulm - crackles , dec. BS at bases , no
wheezes RRR , distant HS , mechanical S1 , JVP to
jaw +BS , obese , soft
NT warm , dry no
rashes awake , but not cooperative , L sided facial droop , L
forearm flexed , moving all four extrem
****
Admit CXR - diffuse B airspace dz , R>L , no effussion , c/with diffuse
multilobar pna Echo 9/8 LVEF 35% with akinesis of septum , inf wall ,
apical lat segment , mechanical MV EKG in MICU - sinus
76
***
Consults Cards - demand ischemia , no need to stress inpatient ,
stop tracking troponins , can stress as o/p as indicated , f/u with
Fiermonte , add Lasix 20 mg every day
***
1. ID - ? Multilobar pneumonia. On empiric ceftriaxone , azithro ,
vanco in MICU. D/c vanco 4/10 Await BCx for possible speciation.
Afebrile. On 2L NC. CXR cleared quickly , so may have been more
component of CHF. Completed short 7 day course of azithro
2. CV - I: Extensive CAD , elevated CK , troponin and new LBBB in settin
of hypoTN. Initially thought to be demand ischemia. Trended enzymes ,
with troponin remaining elevated at 5 , but CK mb decreased from 18 to 2.
Consulted cards who felt that demand ischemia ( LBBB rate dependent ). ASA ,
Bblocker ( ? ) , statin , fibrate. ON therapeutic lovenox for CVA.
P: HypoTN in unit now resolved ( was febrile in ED , but unclear source of
infection as all cultures negative , ? component of flash pulm edema ) ,
appears euvolemic to slightly volume up. Will send on 20 mg Lasix daily.
EF stable at 35% , no changes on echo
R: New LBBB in setting of tachycardia , but resolves with decreased rate.
3 ) Heme - Had oozing from L subclavian site in setting of
anticoagulation , now appears resolved. Line removed on 4/28 in a.m..
4. Renal - CRI , Cr at baseline 1.2-1.5.
5. Neuro - history of multiple CVAs - on Rx dose lovenox , sz disorder - On
Keppra. Sundowning - on zyprexa twice a day.
6. Endo - DM. Home glipizide held. On lantus , lispro SS. Blood sugar very
elevated during admission , so d/c'ed glipizide and sending on Lantus with
before meals novolog.
8. Prophy - Therapeutic lovenox , nexium.
9. Code - FULL CODE.
ADDITIONAL COMMENTS: Take all medications as prescribed. Check weight daily and avoid high
salt foods - if your weight increases by > 2 lbs in 2 days or 5 lbs in
one week , contact your physician to consider increasing your lasix dose.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- Continue treatment dose lovenox at home
No dictated summary
ENTERED BY: MARTER , BRYON M. , M.D. , PH.D. ( VD96 ) 10/25/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 756
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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513604071 | PUO | 05855004 | | 1783089 | 8/15/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/5/2005 Report Status: Signed
Discharge Date:
ATTENDING: COLASAMTE , ISABELLE EVON MD
DATE OF TRANSFER FROM INTENSIVE CARE UNIT: February , 2005.
VASCULAR SURGEON: Dr. Rossie Mankoski
PROCEDURES PERFORMED: On January , 2005 , open amputation of right
fourth toe and on November , 2005 , CABG x 4 ( LIMA to LAD , SVG1 to
acute marginal; sequential graft: Left radial connecting LIMA to
ramus and circumflex ).
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male
with a history of uncontrolled diabetes mellitus and a
longstanding history of peripheral vascular disease. He
presented to an outside hospital on October , 2005 , complaining of a
nonhealing ulcer of his right foot for one year. At the outside
hospital ABI showed 0.32 on the right and 0.43 on the left with
PVRs normal only at the thigh. The patient also underwent a
cardiac workup at the outside hospital. MIBI showed reversible
ischemia involving the basal , mid , and apical segments of the
anterior wall. Echocardiogram showed an ejection fraction of 45%
with possible septal hypokinesis. The patient was transferred to
Pagham University Of for further management. The patient
was seen by the Vascular Surgery Service and underwent amputation
of his right fourth toe on January , 2005. Cardiology and
Cardiovascular Surgery were also consulted for the findings of
cardiac workup at the outside hospital. The patient underwent a
cardiac catheterization on April , 2005 , which showed left main
disease with three-vessel disease. Lower extremity angiogram was
also completed on April , 2005 , which showed a totally occluded
right external iliac artery with reconstitution of the right
common femoral artery; right hypogastric collaterals perfusing
the leg; right profunda femoral artery with proximal disease and
distal reconstitution; right superficial femoral artery with
severe mid vessel focal stenosis , and 2 vessel runoff. The plan
was for coronary bypass to be followed a right lower extremity
revascularization at a later time. The patient also underwent
carotid ultrasound on February , 2005 , preoperatively , which showed
no hemodynamically significant disease in the right carotid
artery and a 55% stenosis in the left carotid artery.
PREOPERATIVE CARDIAC STATUS: Class II heart failure.
Preoperatively , the patient was in normal sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: None.
PAST MEDICAL HISTORY: Hypertension; diabetes mellitus;
rheumatoid arthritis; multiple right foot bone injury secondary
to football.
PAST SURGICAL HISTORY: Bilateral mastoidectomy; penile surgery
in childhood; and sebaceous cyst removal.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: Eighty-pack-year cigarette smoking history , quit
in 1980; positive history of ETOH , quit in 1993 , has been
attending AA since that time; history of heroin , speed , and
barbiturate use , quit in 1993; previously worked for a moving
company , currently on disability; single , lives alone.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS: No home medications.
INHOSPITAL MEDICATIONS: At the time of evaluation on July ,
2005 , Lopressor 25 mg orally twice a day; nitroglycerin infusion at 100
mcg per minute; aspirin 325 mg orally daily; vancomycin;
levofloxacin; and Flagyl.
PREOPERATIVE PHYSICAL EXAMINATION: Height 5 feet 8 inches ,
weight 81.8 kilograms.
Vital signs: Temperature 97 , heart rate 78 , blood pressure
150/86 , and oxygen saturation 99%.
HEENT: Pupils equal , round and reactive to light and
accommodation; dentition without evidence of infection; and no
carotid bruits.
Chest: No incisions.
Cardiovascular: Regular rate and rhythm without any murmurs;
pulses 2+ bilaterally in the carotids and radials; on the left 1+
femoral , absent DP signal , positive physical therapy signal; on the right ,
positive signals in the femoral DP and physical therapy; normal Allen's test
bilaterally with a questionable noncompressible vessel on the
right.
Respiratory: Breath sounds clear bilaterally.
Abdomen: No incisions , soft , no masses.
Rectal: Deferred.
Extremities: Open wound right foot.
Neurologic: Alert and oriented , without any focal deficits.
PREOPERATIVE LABORATORY RESULTS: Sodium 139 , potassium 3.9 ,
chloride 105 , bicarbonate 28 , BUN 9 , creatinine 0.8 , glucose 138 ,
magnesium 1.5 , white blood cell count 10 , hematocrit 37.5 ,
hemoglobin 13.1 , and platelets 263. physical therapy 14.9 , INR 1.1 , PTT 26.2 ,
and hemoglobin A1c 10.6. UA was consistent with infection.
Cardiac catheterization performed at Pagham University Of
on April , 2005 , showed 60% distal left main; 80% proximal LAD;
90% proximal circumflex; 70% ostial OM1; and 90% mid RCA.
Echocardiogram on March , 2005 , showed an ejection fraction of 45%
with trivial mitral insufficiency , trivial tricuspid
insufficiency , and a pulmonary pressure of 24 mmHg.
Preoperative EKG on April , 2005 , showed normal sinus rhythm at
75 beats per minute.
Chest x-ray on November , 2005 , showed clear lung fields.
The patient underwent CABG x 4 ( LIMA to LAD , SVG1 to acute
marginal; sequential graft: left radial connects LIMA to ramus
and circumflex ).
INTENSIVE CARE UNIT COURSE BY SYSTEM:
Neurologic: The patient remained neurologically intact
throughout his ICU course. He was receiving Tylenol , ibuprofen ,
and Toradol as needed for pain.
Cardiovascular: The patient required external pacing for
bradycardia on postoperative day #0. His intrinsic heart rate
increased. On the day of transfer , his heart rate was in the
60's sinus rhythm with blood pressures 120s to 180s over 70s to
80s. He was receiving diltiazem 30 mg orally three times a day for the radial
artery graft and his Lopressor was being titrated. At the time
of transfer , he was receiving Lopressor 18.75 mg orally four times a day The
patient was transferred from the ICU with his atrial and
ventricular pacing wires in place.
Respiratory: The patient was extubated on postoperative day #0.
At the time of transfer , he was receiving oxygen 2 liters per
minute via nasal cannula with an O2 saturation of 98%.
GI: The patient had a gastric dilation on chest x-ray in the
morning of postoperative day #1. This was asymptomatic and
resolved spontaneously. On the day of transfer , he was
tolerating orally's. and his diet was being advanced. He was
receiving Pepcid for GI prophylaxis.
Renal: The patient's fluid balance on the day prior to transfer
was negative 187 cc. His sodium was 138 on the day of transfer
with a potassium of 4.1 , BUN 11 , and creatinine 0.8. He was
receiving Lasix 20 mg orally four times a day
Endocrine: The patient was on a Portland protocol while in the
ICU. At the time of transfer , he had no insulin requirement.
The patient was being followed by the Diabetes Management
Service.
Heme: On the day of transfer , the patient's hematocrit was 30.7
with a platelet count of 225 and an INR of 1.4. He was receiving
aspirin and Zocor.
ID: Postoperatively , the patient was continued on vancomycin ,
levofloxacin , and Flagyl for his history of right toe gangrene.
The patient was ambulating on his heels. Wet-to-dry dressing was
being done to the right foot three times a day On the day prior to
transfer , the patient's T-max was 98.3 with a white blood cell
count of 14. His chest tubes had an output of 360 cc the day
prior to transfer. The patient's radial artery JP was
discontinued prior to transfer , however , his chest tubes were
left in place.
eScription document: 7-0748321 ISFocus transcriptionists
Dictated By: PETEET , JOYA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 3749517
D: 7/5/05
T: 7/5/05
Document id: 757
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| output/system_intuitive_annotation.xml | intuitive |
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849420538 | PUO | 24466939 | | 440276 | 10/9/2000 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 11/8/2000 Report Status: Signed
Discharge Date: 6/10/2000
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: Mrs. Mira Sickafoose , whose past medical
history includes diabetes ,
hypertension , and multiple prior coronary interventions
( ballooned ) , presents in a stable state for elective coronary
artery bypass graft , after a cardiac catheterization showed two
vessel disease.
HOSPITAL COURSE: On 23 of November the patient underwent coronary artery
bypass grafting , left internal mammary artery to
left anterior descending , saphenous vein graft to left coronary
artery and then to obtuse marginal. After surgery the patient
became hypotensive and ischemic. A new angiogram was performed
which showed three vessel coronary artery disease , an occluded
sequential venous graft to obtuse marginal and left coronary
artery , and a patent left internal mammary artery graft.
The patient was reoperated; a new coronary artery bypass graft was
performed on 23 of June , a new vein graft was placed to the right
posterior descending artery and another one to the obtuse marginal.
An intra-aortic balloon pump had been previously placed and was
removed three days later.
OTHER EVENTS DURING HOSPITAL STAY: 1. Volume over-load for
which the patient has still
some fluid retention and is still being on diuretics.
2. The patient underwent multiple interventions in her groins ,
mostly for placement of arterial lines and intra-aortic balloon
pump. Some hematoma developed but it never worsened. Vascular
Surgery was consulted but no further intervention was done.
3. A very dubious diagnosis of cellulitis was done just after her
surgery for a redness and swelling in her leg and feet. Infectious
Disease was consulted and they ruled out the idea of cellulitis as
the patient has lichen ruber planus and Infectious Disease said
that this was the reason for her redness. In the last two days of
her stay in our hospital , the redness became a little bit more
visible , and there was some question of increased white blood
cells , so it was decided to start her on Ancef and it should be
continued for about seven more days.
4. The patient is on three days of levofloxacen treatment for a
urinary tract infection.
5. When the diagnosis of cellulitis was hypothized the first time ,
a Doppler study of her lower extremity was done that showed no
obstruction to venous flow.
6. The patient also went for a period in atrial fibrillation and
was treated and converted to normal sinus rhythm with beta
blockers , namely Lopressor.
CURRENT CONDITION: At present the patient is in stable condition ,
afebrile , heart rate 81 in sinus , blood
pressure 120/60 , respiratory rate 20 , with a saturation of 96% in
room air. Her blood sugar is 189 , BUN 10 , creatinine 0.8 , sodium
137 , potassium 4.5 , bicarbonate 151 , white blood cells 10.7 ,
hematocrit 28.4 , and INR 1.4.
The list of medications is included in the discharge summary.
Thank you for accepting this patient.
Dictated By: LATOYA BARGERON , M.D. XT89
Attending: JANAY D. STUKOWSKI , M.D. JX47
KJ083/7604
Batch: 20489 Index No. WKOY2J7SYB D: 11/8
T: 11/8
Document id: 758
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041529309 | PUO | 81159403 | | 174717 | 9/18/1997 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 9/18/1997 Report Status: Signed
Discharge Date: 10/14/1997
PRINCIPAL DIAGNOSIS: CHEST PAIN AND PRESYNCOPE.
SECONDARY DIAGNOSES: ( 1 ) HYPERTENSION.
( 2 ) ELEVATED CHOLESTEROL.
( 3 ) CORONARY ARTERY DISEASE STATUS POST
CORONARY ARTERY BYPASS GRAFT SURGERY ON
10/13/97.
( 4 ) STATUS POST BLADDER SUSPENSION SURGERY.
( 5 ) PAROXYSMAL ATRIAL FIBRILLATION.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old woman
with a history of coronary artery
disease who was admitted on 2/9/97 for bladder suspension surgery
to Akcare Hospital The plan at that time was for a laparoscopic
procedure , but because of bladder puncture , it was converted to an
open procedure. She had ST depressions on EKG intraoperatively ,
and was admitted to the ICU there. She was treated for a
myocardial infarction and developed postmyocardial angina with EKG
changes which were unrelieved by sublingual nitroglycerin. For
this reason , she was started on intravenous TNG and transferred to I Warho Hospital for cardiac catheterization. She underwent cardiac
catheterization on 1/10/97 and this revealed three vessel disease.
She underwent coronary artery bypass grafting on 3/4/97 with a
LIMA to LAD , SVG to PDA , and SVG to OM1. Her postoperative course
was complicated by paroxysmal atrial fibrillation , with which she
was symptomatic. She was started on procainamide during the
admission and was discharged home on 1/4/97 with a subtherapeutic
proc/nepa level ( 3.0-4.5 ). She arrived home at 4:30 p.m. and felt
well until approximately 7:00 p.m. , when she developed acute onset
of 8 out of 10 chest pain across her entire chest radiating down
the left arm and associated with light-headedness and visual
changes. She reported this was similar to a prior anginal episode.
She took three sublingual nitroglycerin at home and had no relief.
EMTs were called and found the patient pale , diaphoretic , with
blood pressure 90/palp , and a heart rate of 150. She was treated
with more nitroglycerin and improved somewhat in terms of her pain.
She was taken to Akcare Hospital where EKG showed rapid atrial
fibrillation with ST depressions globally. She was given intravenous fluids
and 750 mg of procainamide , as well as 20 mg of intravenous Cardizem and
nitroglycerin. Her pain resolved. Her systolic blood pressure
came up to the 110 range and her atrial fibrillation rate decreased
to the 80s. Subsequently , she converted into normal sinus rhythm
with a rate in the 60s and was transferred to the I Warho Hospital for further treatment. Her pain lasted for approximately
one hour in total. On arrival to the I Warho Hospital on
the floor , she had 3 out of 10 chest pain , without shortness of
breath , presyncope or palpitations. This pain radiates to the back
and was reproducible with left-sided sternal pressure unlike her
prior anginal episodes.
PAST MEDICAL HISTORY: ( 1 ) Hypertension; ( 2 ) High cholesterol;
( 3 ) Coronary artery disease status post CABG
on 3/4/97 with anatomy as described above; ( 4 ) Bladder suspension
surgery in 1995 and 1997; ( 5 ) Paroxysmal atrial fibrillation
perioperatively.
ALLERGIES: No known drug allergies.
MEDICATIONS: ( 1 ) Atenolol 100 mg orally twice a day; ( 2 ) Percocet 1-2
tabs orally every 4 hours as needed; ( 3 ) Coumadin; ( 4 ) Axid 150 mg
orally twice a day; ( 5 ) cephradine 500 mg orally four times a day x7 days for wound
infection in the vein harvest site; ( 6 ) procainamide 750 mg orally
four times a day ( she was receiving 500 mg orally four times a day in hospital prior to
discharge ).
FAMILY HISTORY: History of a son with a myocardial infarction at
age 39 , brother with an MI at age 64 , and a mother
with an MI at age 64.
SOCIAL HISTORY: She lives with her husband at home and does not
smoke tobacco.
PHYSICAL EXAMINATION: VITAL SIGNS - Heart rate 59 , BP 100/60 ,
respiratory rate 20 , sat 98 on three liters
with temp 97.7. GENERAL - She was an elderly woman in no acute
distress. HEENT - Oropharynx is benign. NECK - She has normal
jugular venous pressure at approximately 8 cm. CHEST - Clear to
auscultation and percussion. HEART - Remarkable for S1 and S2.
Regular rhythm , no murmurs. She had a surgical scar in the midline
which is healing without any pus or signs of inflammation. ABDOMEN
- Benign. She had a midline scar which was healing without
erythema or pus. EXTREMITIES - Revealed a left lower extremity
medial scar with erythema but no pus. She had left-sided edema , 2+
to the mid shin , but there was no edema on the right side. She had
1-2+ decreased pulses bilaterally. Her feet were cool but her
neurologic function was intact. She had normal capillary refill.
NEURO - Non-focal.
LABORATORY DATA: BUN 18 , creatinine 1.0 , with normal electrolytes.
She had a white count 15 and hematocrit 40. Her
LFTs were within normal limits , and her CK was 55. EKG , at the
time of admission here , showed normal sinus rhythm at a rate of 59 ,
with intervals of 0.2 , 0.08 , and 484. She had a left axis of -34
degrees and evidence of an old inferior MI. She had T-wave
inversions in lead I , L , V2-V6 , and II , and she had ST elevations
( slight ) in leads III and F ). These were unchanged during her
episode of chest pain upon arrival compared with her EKG from the
morning of discharge.
HOSPITAL COURSE: In short , this was a 72-year-old woman who was
status post coronary artery bypass grafting 12
days prior to admission , who was now readmitted within four hours
of discharge because of rapid atrial fibrillation and chest pain
lasting for an hour.
She was admitted and found to be in normal sinus rhythm at the time
of admission. Her procainamide was increased to 750 mg orally four times a day
given that her levels of proc/nepa were subtherapeutic at the time
of discharge earlier in the day. Given her history of one hour of
chest pain , she was ruled out for myocardial infarction with serial
CKs which were flat. However , her troponin came back at 5.1 the
following morning. It rapidly trended downward , and so it was
unclear as to whether she had actually suffered any myocardial
damage. Other possible explanations for her chest pain included:
Question of pericarditic , post-pericardiotomy pain vs. coronary
disease vs non-cardiac causes. In addition , at the time of
admission , she had an Infectious Disease issue and her white blood
cell count was elevated at the outside hospital , and there was some
erythema around her left leg site.
On hospital day #2 , she had an episode of atrial fibrillation at a
rate of 140-150 with symptoms of palpitation but no chest pain.
Her proc and nepa levels were therapeutic at this time ( 6.0-9.0 ).
On the following day , she had an episode of atypical chest pain
without EKG changes and which was different from her prior angina.
The following evening , she had an additional episode of chest pain.
At this time , she had a heart rate of approximately 160 and was
found to be in atrial fibrillation with no ST-T wave changes. This
episode resolved with 2.5 mg of intravenous Lopressor within 10 minutes.
On 11/17/97 , she underwent an echocardiogram which showed a normal
LV size , with mild concentric hypertrophy. There was normal
systolic function and an ejection fraction of 66% , with inferior
hypokinesis. Based on this information , it was decided that the
patient probably did not have an MI. At this time , the decision
was made that she had failed procainamide , as she had now broke
through several times with atrial fibrillation , well therapeutic on
the procainamide. The procainamide was discontinued and she was
loaded on amiodarone at a dosage of 600 mg orally three times a day x13 doses.
On 10/10/97 , she underwent an ETT MIBI which showed mild
peri-infarct ischemia but no ST-T wave changes and the patient had
no symptoms at nine minutes on a submax Bruce.
At the time of discharge , she remained on amiodarone at a dose of
200 mg orally every day and she has been restarted on her Coumadin for
which she will be followed by the Anticoagulation Service. At the
time of discharge , she has been in normal sinus rhythm for over 36
hours. Her other issues during this hospitalization having
included infectious disease for which she was on cephradine because
of some wound site erythema and an elevated white blood cell count
at an outside hospital. She was treated with five days of
cephradine and remained afebrile. In addition , she was started on
levofloxacin for concern about a UTI , given her complaints of
urinary frequency. However , it is more likely that this urinary
frequency is related to her underlying urologic problems. In terms
of her anticoagulation , she was maintained on a intravenous heparin while
not on Coumadin. She is restarting with careful recoumadinization
given the fact that she is now on amiodarone.
DISCHARGE MEDICATIONS: ( 1 ) Aspirin 81 mg orally every day; ( 2 ) amiodarone
200 mg orally every day; ( 3 ) atenolol 100 mg orally
every day; ( 4 ) Isordil 10 mg orally three times a day; ( 5 ) sublingual nitroglycerin
as needed; ( 6 ) Coumadin as directed; ( 7 ) Axid 150 mg orally twice a day;
( 8 ) Ativan 0.25 mg orally twice a day as needed anxiety; ( 9 ) Premarin
0.625 mg orally every day; ( 10 ) Pravachol 10 mg orally every bedtime She has now
been in sinus rhythm for over 36 hours. It seems likely that she
will not require long-term amiodarone or Coumadin.
DISCHARGE FOLLOW-UP: The patient will follow-up with her
cardiologist , Dr. Jackson Part , so that the
decision can be made as to when she may stop taking her amiodarone
and Coumadin.
DISCHARGE DISPOSITION: The patient was discharged to home on
4/2/97.
CONDITION ON DISCHARGE: Stable condition.
Dictated By: KATIA POPPELL , M.D. MA60
Attending: JACKSON PART , M.D. IZ71
BR973/8488
Batch: 67833 Index No. HSEHQC0HFM D: 3/1/97
T: 2/29/97
CC: 1. JACKSON PART , M.D. IZ71
2. JACKSON E. PART , M.D. RM7
Document id: 759
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925996229 | PUO | 14065099 | | 6353111 | 9/20/2003 12:00:00 a.m. | MITRAL REGURGITATION | Signed | DIS | Admission Date: 10/20/2003 Report Status: Signed
Discharge Date: 10/20/2003
Date of Discharge: 10/20/2003
ATTENDING: LOIDA GOLEBIOWSKI MD
PRIMARY DIAGNOSIS: Mitral valve regurgitation.
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old female
with a past medical history significant for Hodgkin's lymphoma
requiring chemotherapy and radiation therapy , as well as a
history of splenectomy , asthma , and history of tobacco use , who
presents to our service with symptoms of congestive heart failure
including dyspnea on exertion , lower extremity bilateral edema ,
and decrease exercise tolerance. On the day of admission ,
2/22/03 , she underwent cardiac catheterization , which revealed
clean coronary arteries. On August , 2003 , she then
underwent an elective mitral valvuloplasty , 26 Carpentier-Edwards
pericardial , with size 26 Cosgrove-Edwards ring and vegectomy.
In the immediate postoperative period , she was transferred to the
Cardiac Surgery Intensive Care Unit initially requiring 0.5 of
epinephrine to maintain proper pressure. Epinephrine was weaned
to off on postoperative day #1. She was extubated in the evening
of the day of surgery and epinephrine was subsequently weaned to
off. Gentle diuresis was begun on postoperative day #1 as well
as low dose beta blocker , which she tolerated well. She was
transferred to the Cardiac Surgery Step Down Unit on
postoperative day #1 , where diuresis was increased. Baby aspirin
was begun , and the patient continued to make excellent
cardiovascular progress. On February , 2003 , she began to
complain of some persistent numbness and tingling of the left
lower extremity , which she felt to be interrupting her attempts
to stand and maintain balance. For further treatment , a
Neurology consult was obtained. Per Neurology , she was found to
have no weakness at the left lower leg and foot , although when
pressure was exerted on the foot , she reported an uncomfortable
tingling throughout the leg. She reported no back pain and no
change in bowel or bladder control. Sensory examination was
found to be intact , however , soft touch and pin sensation tested
in the lateral leg below the knee caused a spreading tingling
sensation throughout the left lower extremity. Per Neurology
recommendations , Neurontin 300 mg every day was begun and it was
recommended that she follow up with the Department of Neurology
following discharge if the tingling sensation has not improved.
With aggressive diuresis , the patient was able to regain her
postoperative weight and by the day of discharge was 1.7
kilograms below her preoperative weight. She has made excellent
cardiovascular progress following this surgery and is anticipated
to continue her rehabilitation at home with VNA System.
PHYSICAL EXAMINATION: The patient is an obese young woman alert
and oriented x 3. HEENT: No carotid bruits or JVD present.
Pulmonary: Lungs are clear to auscultation bilaterally.
Coronary: Regular rate and rhythm. Normal S1 , S2. No murmurs ,
rubs , or gallops appreciated. Abdomen: Obese , nontender , and
nondistended. Positive bowel sounds. Extremities: 2+ pulses at
all extremities bilaterally. Trace edema at the bilateral lower
extremities to mid calf. Skin: Midline sternotomy incision well
approximated , healing well. No areas of erythema or drainage
noted.
LABORATORY DATA: On the day of discharge , sodium 141 , potassium
4.2 , BUN 17 , creatinine 1.0 , calcium 8.9 , magnesium 2.6 , white
blood cell count 11.3 , hematocrit 33.5 , platelets 361 , and INR
1.0.
PROCEDURES: On 6/2/2003 , elective mitral valvuloplasty , 26
Cosgrove-Edwards ring with vegectomy , small sterile vegetations
on A2 and P2 debrided , and found by lab testing to be sterile
vegetations. Cross clamp times were confirmed by Gram stain as
sterile and debrided intraoperatively. Please refer to operative
note for details.
CONSULT: Consulted Department of Neurology with followup
recommendations implemented during this patient's stay.
DISPOSITION: The patient will be discharged today to her home
with VNA assistance.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 81 mg orally every day ,
Colace 100 mg orally twice a day x 7 days , Lasix 60 mg orally every day ,
ibuprofen 800 mg orally every 8 hours as needed pain , Lopressor 25 mg orally
three times a day , Niferex 150 mg orally twice a day , Atrovent nebulizer 0.5 mg
nebulized four times a day , Neurontin 300 mg orally every day , K-Dur 30 mEq orally
every day to be discontinued or decreased if Lasix dose is changed ,
and Flovent 44 mcg/inhaled twice a day
The patient has been instructed to call to schedule follow up
appointments with Pagham University Of Department of
Cardiac Surgery , Dr. Loida Golebiowski , within 6-8 weeks following
discharge as well as her primary care physician , Dr. Trish Chaix in approximately 1-2 weeks as well as with her
Cardiologist , Dr. Christeen Jacobson in 1-2 weeks. She will
call on recommendation from her primary care physician to
schedule follow up appointment with Pagham University Of
Department of Neurology should her left lower extremity tingling
not resolve. At that time , she would be advised to pursue EMG
testing for further workup of dysasthesia. The patient has made
excellent progress following her mitral valvuloplasty surgery and
is anticipated that she will return to her full preoperative
level of independent functioning with continued cardiovascular
rehabilitation and VNA assistance.
Please call if further questions or concerns.
Thank you for referring this patient to our service.
eScription document: 1-5890310 ISSten Tel
CC: Christeen Jacobson M.D.
SVG QV4 , Pagham University Of
Ron Terdilake Lis Di
Go Ville Green
CC: Loida Golebiowski MD
DIVISION OF CARDIAC SURGERY
E Mifran Van
Ra Que Fre
CC: Trish Chaix M.D.
DELJ COUNTY MEDICAL CENTER
S Son Si
Louis , Hawaii 54738
Dictated By: SURGEON , PRICILLA
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 6977837
D: 10/2/03
T: 8/21/03
Document id: 760
| Target |
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PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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511502857 | PUO | 69460401 | | 0407430 | 5/3/2005 12:00:00 a.m. | Diabetes | | DIS | Admission Date: 7/1/2005 Report Status:
Discharge Date: 10/4/2005
****** FINAL DISCHARGE ORDERS ******
MOREMAN , MONTY AMPARO 452-32-47-7
War
Service: MED
DISCHARGE PATIENT ON: 2/18/05 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: IN , DERICK T , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
INSULIN NPH HUMAN 40 UNITS subcutaneously every day before noon Starting Today ( 8/3 )
INSULIN NPH HUMAN 40 UNITS subcutaneously every afternoon Starting Today ( 8/3 )
INSULIN REGULAR HUMAN 15 UNITS subcutaneously every day before noon
Starting Today ( 8/3 )
Instructions: can give with am dose of nph
GLUCOMETER 1 EA subcutaneously x1
INSULIN REGULAR HUMAN 20 UNITS subcutaneously every afternoon
INSULIN REGULAR HUMAN 10 UNITS subcutaneously before meals
Instructions: Take if pre-lunch FS > 180
METFORMIN 500 MG orally twice a day
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Cistrunk ( new primary care physician ) 4/6/05 @ 2:50pm scheduled ,
Dr. Heupel ( Endocrine ) 10/28/05 @ 7:30pm scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Diabetic Ketoacidosis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Diabetes
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Diabetes ( diabetes mellitus ) obesity ( obesity )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
23 year-old M with morbid obesity p/with 1 wk of polyuria and polydypsia and 3 days
of nausea and vomiting. Mr. Fullenwider was in his usual state of health
until one week ago when he started to have a decreased apetitie , polyuria
and polydypsia. He would wake up every 2 hours at night to urinate. He
was drinking vitamin water and Gatorade to keep from being too
dehydrated. He denies any URI symptoms , cough , SOB , dysuria , abdominal
pain or diarrhea during the past couple of weeks. He does however
complain of some DOE in the past week. 3 days ago , he developed morning
nausea and vomiting. The vomit was nonbilious , nonbloody vomit and no
associated abdominal pain or diarrhea. He denies any HA , visual changes ,
changes in mental status or dizziness. He also denies sick contacts. He
has not had any change in weight.
PMH:
Morbid obesity
MEDICATIONS:
Pepcid before meals every bedtime
ALLERGIES: NKDA
SH: Marital Status: not married. Lives with girlfriend. Not working.
TOB negative; ETOH negative; ILLICITS negative
FH: Maternal grandmother with DM/Htn
ROS: See HPI for pertinent positives
PHYSICAL EXAM ON ADMISSION: VS: T 97.5 , HR 103 , BP 110/60 , RR 20 , O2sat
96%RA. GENERAL: Morbidly obese young man , lying in bed , comfortable NAD.
HEENT: NCAT , sclera anicteric; mucous membranes are dry , OP without
erythema or thrush. Fundi with clear margins. CHEST:CTAB
CV: RRR , audible S1 and S2 , no m/r/g. 2+ and symmetric radial , 2+ and
symmetric pedal pulses. ABD: Positive bowel sounds. Obese abdomen.
Nontender , non-distended. Hepatic margin , soft , palpable just under the
costal margin. NEURO: AOx3. CNII-XII intact. Strenght: UE 5/5 , LE 5/5
bilaterally. Sensation intact to light touch and temperature. Reflexes 1+
brachial , brachioradialis and patellar.
DATA:
Chemistry On admission:
Chem7: 131/4/92/22/11/1.1/440
ABG: PO2 82 , PH 7.39 , PCO2 35
TP 8.5 , Alb 4.8 , AST 42 , ALT 76 , Bt 0.5 , Alk 80
UA: pH5 , 3+ gluc , 2+ ketones , neg bili , 1+ blood , neg Leuks , neg nitrite
RADIOLOGY:
Chest Xray: no signs of an acute cardiopulm process.
EKG:
HR 100bpm , normal sinus rhythm , normal PR , QRS and QT intervals. No ST-T
wave abnormalities. J-point elevations in v2-v6.
ASSESSMENT/HOSPITAL COURSE:
23 year-old M with morbid obesity who p/with polyuria , polydypsia , nausea and
vomiting. Given presentation and lab values , patient is in diabetic
ketoacidosis: BS>200 , ketonuria , pH<7.4.
1. DKA: New diagnosis of diabetes. Unclear what the trigger was for the
DKA - no signs/symptoms of infection. No history of of stress in recent weeks.
a. Corrected hyperglycemia and acidosis with insulin - anion gap resolved
by HD#2.
b. Repleted volume and electrolytes: whole body potassium depleted -
started NS with 20mEQ of KCl ` give 2L of fluid in total. Until gap
normalized and potassium became stable at 4.
c. Blood sugars were erratic during entire Hospital stay. Difficult
to control on high levels of NPH and regular alone. Adequate control
to BS = 200s achieved with: Metformin 500mg twice a day; a.m. -- NPH 40u , reg 15u;
lunch -- Reg 10u if BS>180; PM NPH 40u , reg 20u. Endocrine was consulted
and agreed with plan. Antibodies for ?typeI DM sent. F/U with endocrine
scheduled.
d. Patient was placed on a diabetic diet , received a nutrition consult
with diabetes education. He also received education on finger sticks and
insulin administration. The importance of health care and compliance was
asserted. Regular exercise and only 3 meals a day with limitation of snacks
was encouraged.
e. Follow up appointments with Dr. Cistrunk and Endocrine were obtained.
--------------------
FULL CODE
ADDITIONAL COMMENTS: -Be sure to continue compliance with a diabetic diet -- 3 meals a day.
=Take your insulin at the designated times
-Take Metformin once a day.
-Continue regular exercise
-Be aware of potential low blood sugar levels and symptoms
-Folow up with your primary care physician Dr. Cistrunk in April
-Follow up with Endocrine clinic -- Dr. Heupel -- on February
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-Diabetic insulin regimen:
every day before noon: 40u NPH , 15u reg
@noon: 10u reg if BS>180
every afternoon: 40u NPH , 20u reg
Metformin 500mg twice a day
-Patient to attempt 3meals a day of diabetic diet; check BS four times a day;
administer insulin as recommended; have regular exercise.
-F/U with primary care physician and Endocrine at designated appointments.
No dictated summary
ENTERED BY: JULIUSSON , LAVELLE A , M.D. ( YB68 ) 2/18/05 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 761
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
279285965 | PUO | 99914311 | | 8665638 | 6/2/2005 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 5/30/2005 Report Status: Signed
Discharge Date: 1/12/2005
ATTENDING: GUMINA , MARJORY SHELA MD
SERVICE:
Aga Fay Hamp
PRIMARY CARE PHYSICIAN:
Rufus Bernas , M.D.
ADMISSION DIAGNOSIS:
Aspiration pneumonia.
ADDITIONAL PROBLEMS:
Thalamic stroke , left hemiparesis , hypertension , diabetes ,
expressive aphasia status post VP shunt.
HISTORY OF PRESENT ILLNESS:
The patient is a 69-year-old man with a history of a recent right
hemorrhagic stroke in 8/21 now with minimal purposeful activity
who follows simple commands and lives in a nursing home who
presents with a likely aspiration pneumonia. He was noted to be
hypoxic after a vomiting episode at his nursing home. He was
unable to provide a history but the events were recounted by the
nursing home staff. On 10/9/05 , he had fevers to 101.5 and
congestion throughout the day despite getting nebs and oxygen ,
his condition did not improve , he vomited twice and was noted to
be hypoxic to an oxygen saturation of 84% on 5 liters of O2 , he
also had a temperature of 101.6 , a heart rate of 127 , a blood
pressure of 140/80 and was sent to the Pagham University Of Emergency Department. In the Emergency Department , the
patient's vital signs showed a temperature of 102.6 , heart rate
of 133 , respiratory rate of 24 , blood pressure 155/72 and 93%
oxygen saturation on nasal cannula. His EKG initially showed ST
elevations inferiorly. He was evaluated by Cardiology who felt
that given his comorbidities and poor functional status he was
not a candidate for cardiac catheterization. His EKGs
spontaneously normalized without intervention. His first set of
cardiac enzymes was negative. His chest x-ray showed a
left-sided pneumonia and he had a white blood cell count of 34.
He received 2 liters of normal saline , cefotaxime , and Flagyl.
He also received Lopressor and aspirin. Of note , the patient had
been given Flagyl in the nursing home , which was started on
10/4/05.
PAST MEDICAL HISTORY:
Of note , the patient had a recent medical history significant for
a right thalamic hemorrhagic stroke , which resulted in left
hemiparesis on an admission 7/14/05 to 1/29/05 during which a
VP shunt was placed that hospitalization was complicated by an
aspiration pneumonia. He was readmitted on 2/6/05 to 10/21/05
for a change in mental status during which he was given
antibiotics on and off for the VP shunt. He resolved during this
hospitalization to baseline and was discharged to the nursing
home. Past medical history is also significant for history of
aspiration pneumonia status post a PEG tube 10/27 , diabetes ,
hypertension , aortic stenosis , colon cancer and spinal fusion in
2002.
MEDICATIONS ON ADMISSION:
Clonidine 0.2 every day before noon , 0.4 every afternoon , Lopressor 12.5 twice a day , HCTZ 25
daily , Lantus 70 , lisinopril 40 daily , Norvasc 10 daily , Keppra
1000 at bedtime , terazosin 2 at bedtime , omeprazole 20 daily ,
Jevity 1.2 at 90 mL per hour with free water bolus of 240 mL
four times a day , Colace , Senna , MVI.
SOCIAL HISTORY:
He lives alone , no smoking , no alcohol by report. Currently
lives a Wa Van
LABORATORY DATA:
Labs on admission were significant for a white count of 36 ,
hematocrit 45 , platelets of 327 , 000 , creatinine of 1.2 up from
baseline of 0.7 , remainder of his Chem-7 was normal. His cardiac
enzymes on admission showed a CK of 79 , CK-MB of 1.3 and troponin
less than assay. His UA was negative. Chest x-ray showed left
mid lung hazy opacity. Abdomen and pelvis CT showed no acute
processes. Head CT showed a right VP shunt and no acute changes.
EKG as described above.
CONSULTANTS DURING THIS HOSPITALIZATION:
Included Cardiology for question of cardiac catheterization as
described above.
HOSPITAL COURSE BY PROBLEM:
1. Pneumonia: The patient was thought to have a likely
aspiration pneumonia despite his PEG tube because of reported
vomiting at the nursing home. He was put on broad antibiotic
coverage of vancomycin , ceftazidime , and Flagyl. He was
continued on a 14-day course of antibiotics with clinical
improvement. His antibiotics were discontinued after 14 days and
he remained afebrile with the normal white count. Of note , on
2/16/05 , he had another episode of vomiting , which was thought
to result in another aspiration event. However , repeat chest
x-rays showed no additional pneumonia and given that he was
treated with a full two-week course of antibiotics it was decided
to end his course of antibiotics and he remained afebrile with a
normal white blood cell count.
2. Cardiovascular: The patient initially had ST elevations
normalized. This was thought likely to be due to demand ischemia
given its complete resolution. Per Cardiology recommendations ,
he was not a candidate for long-term anticoagulation or cardiac
catheterization. He was continued on medical management without
further incident.
3. Hypertension: The patient was persistently hypertensive and
his blood pressure medications were titrated up and additional
medications were added as described in discharge medication list.
4. Diabetes: The patient's insulin regimen was titrated up to
cover persistently high morning blood sugars given tube feeds
overnight.
5. Neurological: The patient had a baseline aphasia and was
difficult to communicate with , however , as his pneumonia
resolved , his mental status improved and he was able to
communicate with short phrases and answer yes or no questions.
6. FEN: He was receiving tube feeds overnight per Nutrition
recommendations. He was also receiving NPH and regular insulin
as described in discharge medications.
7. C. difficile: The patient had some diarrhea and was tested
for C. diff. This returned positive and he was continued on
Flagyl for a total of 3-4-week course as determined by the rehab
facility.
CODE STATUS:
Full code.
Because of difficulty communication with the patient , it was
unclear what his exact code status was so he remained full code.
His mother is his next of kin but due to her own medical problems
and a recent hospitalization , she was unreachable and it was
unclear whether she had capacity for decision making. There was
an ethics consult meeting on 4/4/05 to determine the goals of
care. Per discussion at that meeting which is documented in the
medical chart , It was decided that he remain full code. This
will need to be readdressed with Mr. Josic at some point when it
can be determined if he is competent for making this decision.
Please see the chart for further details on the results of this
ethics consult. Further questions regarding this can be
addressed to Dr. Gumina , the attending physician.
DISCHARGE PHYSICAL EXAM:
Significant for persistent aphasia , ability to answer questions
yes or no with occasional short phrases. A 3/6 holosystolic
murmur heard loudest at the left upper sternal border and the
remainder of the exam was unremarkable.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Atenolol 50 mg every day before noon
3. Atenolol 25 mg every afternoon
4. Clonidine 0.2 mg every day before noon
5. Clonidine 0.5 mg every afternoon
6. Colace 100 mg orally twice a day
7. Insulin NPH subcutaneous 30 units every day before noon
8. Insulin NPH 104 units subcutaneous every afternoon
9. Regular insulin sliding scale every 6 hours
10. Lisinopril 30 mg twice a day
11. Flagyl 500 mg orally three times a day
12. Terazosin 2 mg at bedtime.
13. Simvastatin 20 mg at bedtime.
14. Norvasc 10 mg daily.
15. Lovenox 40 mg subcutaneous daily.
16. Miconazole nitrate 2% powder topical twice a day
17. Keppra 1000 mg at bedtime.
18. Esomeprazole 40 mg orally daily.
19. Tylenol 650 mg orally every 4 hours as needed
20. Albuterol 2.5 mg every 2 hours as needed
21. Dulcolax 5-10 mg orally daily as needed
22. Dulcolax 10 mg orally daily as needed constipation.
23. Robitussin 1-2 teaspoons orally every 4 hours as needed cough.
24. Reglan 10 mg intravenous every 6 hours as needed nausea.
25. Oxycodone 5 mg orally every 6 hours as needed pain.
eScription document: 5-8001185 EMSSten Tel
CC: Rufus Bernas M.D.
Bo Community Hospital
Di
Kan Vu Ale
Dictated By: PANCHO , MARJORIE
Attending: GUMINA , MARJORY SHELA
Dictation ID 6667961
D: 6/13/05
T: 6/13/05
Document id: 762
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
Y |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
Y |
- |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
789882744 | PUO | 49201190 | | 4670646 | 8/29/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/23/2005 Report Status: Signed
Discharge Date:
ATTENDING: DOUGLASS PETTINGER MD
ADMITTING DIAGNOSIS: Congestive iheart failure.
DISCHARGE DIAGNOSIS: Pending.
CHIEF COMPLAINT: Bloating , abdominal distention.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman with a
history of an idiopathic cardiomyopathy with an EF of 15% who
presents with bloating , abdominal distention , and fatigue. The
patient's idiopathic cardiomyopathy was diagnosed in 1990. The
patient had a Chronicle device to monitor filling pressures
placed in 2001 , which has been nonfunctional since 2004. The
patient had worsening symptoms in September 2004 , which led to an
admission for diuresis. She showed evidence of fluid overload on
admission of diuresis with intravenous Lasix and intravenous dobutamine. The
patient developed a Chronicle device lead thrombus and was
started on anticoagulation. The patient underwent a right heart
cath in September 2004 , which showed an artery pressure of 10 , wedge
pressure of 25 , SVR 2074 , PVR 326 , and CI of 1.5. Post-diuresis
after addition of hydralazine and Isordil , the patient's RA
pressures were RA=8 , pulmonary artery=50/24 , cardiac index of 2.4
with SVR of 1205. The patient's most recent admission was in
August 2004 with decompensated heart failure , during which time
she was diuresed with intravenous Lasix , metolazone , and dobutamine and
diuresed 11 liters. The patient also began workup for cardiac
transplant at that time. The patient on this admission describes
one week of abdominal distention , lower extremity edema , and
stable two-pillow orthopnea. The patient describes no PND ,
shortness of breath , or palpitations. She also denies dietary or
med noncompliance.
PAST MEDICAL HISTORY: As above.
MEDICATIONS ON ADMISSION:
1. Glyburide 10 in the a.m. and 5 in the p.m.
2. Digoxin 0.125 every day
3. Probenecid 500 every day
4. Multivitamin one tab every day
5. KCL 20 mEq every day
6. Celexa 20 mg every day
7. Hydralazine 100 mg orally three times a day
8. Ativan 0.5 three times a day
9. Coumadin 5 every afternoon
10. Isordil 40 three times a day
11. Torsemide 200 twice a day
12. Lisinopril 2.5 every day
SOCIAL HISTORY: The patient lives with three daughters. She is
an ex-custodian with past tobacco use but no ethanol use. The
patient's family has no history of cardiomyopathy.
SIGNIFICANT LABS ON ADMISSION: Normal renal function with a BNP
of 1018 and no evidence of bandemia. EKG on admission shows
sinus tachycardia at 105 with normal axis , widened QRS , normal
PR , and no evidence left atrial enlargement , and no change since
1/25 Left heart cath in 1990.
HOSPITAL COURSE:
1. Cardiovascular:
Ischemia: The patient has no known CAD. She had a troponin at
admission of 0.12 , which subsequently went down to 0.10 less than
assay. It is thought to be secondary to right ventricular strain
with volume overload. The patient was initially started on
aspirin and a statin; however , given her no evidence of CAD and a
normal cholesterol panel , both aspirin and statin were
discontinued.
Pump: The patient presented as "cold and wet" with poor forward
flows secondary to systolic dysfunction and likely increased SVR.
The patient was started on dobutamine for improved inotrope.
The patient was also put on a Lasix strip for diuresis after a
loading dose. The patient was maintained on Isordil and
hydralazine for pre and afterload reduction. Her ACE inhibitor
was held while on the Lasix strip. Metolazone also was used to
improve diuresis , and the patient was maintained on digoxin with
level checks every three days. The patient underwent an echo ,
which showed an EF of 15% , global akinesis with
moderate-to-severe MR , moderate TR , and no evidence of
dyssynchrony. The patient had moderate-to-severe RV dysfunction.
Rhythm: The patient was maintained on telemetry , especially
given the fact that she had no ICD in place. EP was consulted
and evaluated the patient for both an ICD and biventricular pacer
given no evidence of dyssynchrony on echo , it was decided that
the patient would undergo ICD placement only.
2. Renal: The patient's creatinine was 1.1 on admission and was
monitored closely with diuresis. On admission , she had a normal
UA.
3. Heme: The patient was placed on heparin instead of Coumadin
for Chronicle device lead thrombus with a PTT goal of 60-80. The
patient's platelets dropped from 222 to 166 during this admission
and tests were ordered for the HIT antibody. The patient's
platelets normalized , but unfortunately , the PF4 was positive.
It was felt that this was a false positive and this was confirmed
with a Heme consult. Heme recommended rechecking the PF4 in
three to four weeks and holding heparin products until the PF4
was rechecked. The patient would be restarted on Coumadin after
her ICD placement.
4. Endocrine: The patient was maintained on sliding scale
insulin and Lantus for diabetes management.
5. GI: The patient had right upper quadrant pain on admission
likely related to a congested liver. A right upper quadrant
ultrasound showed a normal liver with thickened gall bladder
walls and ascites , and her symptoms were improved with diuresis.
The patient was maintained on Nexium for prophylaxis.
6. Psych: The patient was continued on citalopram and Ativan
for depression and anxiety. Psych was consulted for assistance
with management.
7. Musculoskeletal: The patient was maintained on probenecid
for gout.
8. Prophylaxis: The patient was on PPI and heparin until she
was on the HIT positive and was placed on Pneumoboots for
prophylaxis.
DISCHARGE MEDICATIONS: To be determined at the time of
discharge.
eScription document: 4-8884824 IB
Dictated By: BORDA , ANIKA
Attending: PETTINGER , DOUGLASS
Dictation ID 7833841
D: 10/9/05
T: 1/27/05
Document id: 763
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
621063612 | PUO | 35230079 | | 982079 | 7/10/1997 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 7/10/1997 Report Status: Signed
Discharge Date: 3/15/1997
PRINCIPAL DIAGNOSIS: Gastroenteritis , resolved. Atypical chest
pain , GI versus cardiac.
HISTORY OF PRESENT ILLNESS: Ms. Benulis is a 60 year woman with
past medical history significant for
diabetes , hypertension , hypercholesterolemia , smoking ,
gastroesophageal reflux and hypertension. Two days prior to
admission , she ate some Chinese food in the evening and felt some
mild stomach upset. One day prior to admission , she ate the
leftovers of this Chinese food and again , felt stomach upset. A
short time later , she began vomiting food and water but no blood.
This continued , up to and including the day of admission. She
developed some left sided epigastric pain under her left ribs and
in her left upper quadrant. This radiated to her back but nowhere
else. She cannot describe the pain other than to say it is "really
bad."
REVIEW OF SYSTEMS: Notable for shortness of breath walking up her
15 stairs and shortness of breath with doing
dishes , requiring a break every fifteen minutes.
In the emergency department , she continued to have emesis of small
amounts of clear fluid and food. She had one episode of witnessed
emesis of small clumps of red blood in the emergency department.
During one episode of emesis , she had abdominal pain which she
described as radiating also to her left chest and this was relieved
with two sublingual nitroglycerin.
PAST MEDICAL HISTORY: As above , plus remote history of peptic
ulcer disease.
FAMILY HISTORY: Positive for diabetes.
SOCIAL HISTORY: The patient came to this country from E Ra Tampchi
when she was 38 years old. She is a retired
domestic worker. She is widowed and lives with her daughter. She
has a home health aid three times a week. The patient has smoked
one pack per day of cigarettes for twenty years.
ALLERGIES: Contrast dye causes a rash and itching.
MEDICATIONS ON ADMISSION: Insulin NPH 44 units every day before noon , 22 units
every afternoon , Insulin regular 14 units q.
a.m. , 5 units every afternoon , Mevacor 10 mg orally every day , Lisinopril 20 mg
orally every day.
PHYSICAL EXAMINATION ON ADMISSION: Afebrile , pulse 66 , blood
pressure 142/50 , respiratory
rate of 12 , oxygen saturation 98% on two liters. In general , the
patient is a comfortable , mildly heavy woman. She has moist mucous
membranes. There is no jugular venous distention. Her lungs are
clear in all fields. Her heart is in a regular rate and rhythm ,
with somewhat distant heart sounds. There is no murmur heard.
Her abdomen is completely benign , with good bowel sounds. Her
liver and spleen are not palpable. There is no peripheral edema.
LABORATORIES: Admission EKG revealed a normal axis , normal sinus
rhythm , with some mild T-wave flattening in V5 and
V6. Chest x-ray on admission was normal.
HOSPITAL COURSE: Cardiovascular: The patient was started on
intravenous Heparin in the emergency department
and written for rule out MI protocol. Her CKs were mildly
elevated , between 500 and 600 , with normal MB fractions. Her
troponin levels did not reveal any evidence of cardiac ischemia or
injury. The Heparin was stopped after she ruled out for myocardial
infarction. She continued to have some mild abdominal pain ,
however these episodes were always associated with concurrent
nausea and vomiting. The abdominal pain was immediately relieved
after she vomited. This resolved after three days , and she was
scheduled for an exercise treadmill test with MIBI. The patient
went six minutes on a manual protocol treadmill. She went at a
slow rate and did not complete stage one. She had 1/2 to 1 mm SP
depressions which were flat in one to two leads. She had some
vague chest heaviness , which technically qualified as symptomatic ,
however the technician stated that there suspicion was that it was
more fatigue. Because the chest was formally positive but with
still no suspicion for significant ischemia , a MIBI scan was
performed. This demonstrated mild ischemia with exercise in 4 of
25 inferior segments only. After her GI distress resolved , the
patient had no further episodes of chest pain. Although the
patient may have some coronary artery disease , it is not felt that
this is actively symptomatic in her. She will be followed up in
clinic and started on beta-blocker and/or nitrates if she has clear
symptoms of anginal pain.
Gastrointestinal: The patient was admitted with obvious
gastroenteritis. She did not have any diarrhea with these
episodes. She was treated with a mild diet and antiemetics as
needed. Her GI symptoms resolved after three days and she is
eating well at the time of discharge. She was started on
omeprazole 20 mg orally every day for her heartburn pain.
Diabetes: The patient was followed during this admission by Dr.
Cafagno , her primary endocrinologist. Her blood sugar controls
while here were excellent. She was given a container for a routine
24 hour urine collection for protein , to be completed as an
outpatient.
Health Maintenance: The patient was started on Nicoderm patches
and advised to stop smoking. She received her flu shot while here.
MEDICATIONS: Enteric coated aspirin 325 mg orally every day. Insulin
NPH 35 units every day before noon , 18 units every afternoon. Insulin
regular sliding scale before every meal and every bedtime. Insulin regular 12
units every day before noon , 5 units every afternoon. Mevacor 10 mg orally every day.
omeprazole 20 mg orally every day. Lisinopril 20 mg orally every day.
Nicotine patch seven mg per day.
DISCHARGE CONDITION: Good.
DISPOSITION: The patient is discharged to home with ongoing VNA
services.
FOLLOW UP: She will follow up in my clinic on 8/15/97 at 9:40
a.m.
Dictated By: DIA RIEMENSCHNEID , M.D. OI60
Attending: WENDI B. NEWAND , M.D. PE39
HO943/3503
Batch: 25029 Index No. VYPZWY3YLI D: 5/16/97
T: 4/26/97
Document id: 764
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
- |
Y |
N |
N |
N |
- |
N |
N |
Y |
N |
N |
Y |
N |
N |
- |
222272560 | PUO | 06355535 | | 656190 | 11/19/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/13/1992 Report Status: Signed
Discharge Date: 5/17/1992
DISCHARGE DIAGNOSIS: 1. CONGESTIVE HEART FAILURE.
2. HYPERTENSION.
3. ASTHMA.
4. URINARY TRACT INFECTION.
5. HISTORY OF MELENA.
6. LOW BACK PAIN.
HISTORY OF PRESENT ILLNESS: This is a 62-year-old black female
with a past history of hypertension
and congestive heart failure who presented to the emergency room
with increasing shortness of breath. In April 1991 , the patient
states that she had a bout of a cold with coughing and chills and
some substernal chest pressure. In October 1992 , the patient had
one 10-minute episode of substernal chest pain associated with
nausea , sweating and shortness of breath. Since then , she relates
increasing shortness of breath on exertion , paroxysmal nocturnal
dyspnea , orthopnea and ankle edema. She also has been coughing up
more mucus and at times , blood-stained. She also complains of
dysuria for approximately the past month without hematuria. In
October 1992 , she had one episode of melena which lasted two
weeks. There is no history of peptic ulcer disease. PAST MEDICAL
HISTORY: Past medical history is remarkable for:
1. Asthma since early 20's. She was intubated once for asthma
in her early 20's.
2. Hypertension since she was a child.
3. History of congestive heart failure.
4. Hysterectomy secondary to fibroids at approximately age 20.
TAH , BSO.
5. Question of chronic renal insufficiency.
Medications at the time of admission are Lisinopril , Procardia ,
Albuterol nebulizer. Allergies are to IVP contrast. Family
history is positive for hypertension. Social history - she lives
with a 23-year-old son and just suffered a family tragedy in the
death of her youngest son who was shot to death three years ago.
Habits - she smokes 1/2 pack a day. She has over a 30-pack year
smoking history. She does not drink or engage in illicit drug use.
Review of systems is otherwise negative.
PHYSICAL EXAMINATION: On admission , this is a moderately obese
black female in moderate respiratory
distress. Temperature is afebrile , blood pressure 160/90 , pulse
84 , respiratory rat 32 , O2 saturation 97% on two liters nasal
prong. Head and neck exam showed significant jugular venous
distention. Chest showed diffuse expiratory wheezes , some use of
accessory muscles. Cardiovascular exam had an S1 and S2 with no
murmur. The abdomen was obese , otherwise benign. The liver edge
was 12.0 - 14.0 cm by percussion. Rectal exam was guaiac negative.
Extremities had no cyanosis or clubbing but 1+ bilateral ankle
edema. Neurological exam was grossly nonfocal. Musculoskeletal
exam - there was an area of left paravertebral tenderness in the
lumbar sacral spine area.
LABORATORY DATA: On admission , hematocrit 35.1 , platelet
count 246 , 000 , white count 9000 with 65%
polys , 1% bands. ABG on unclear FIO-2 was pH 7.48/37/73/95.5%
saturation. SMA-7 was significant for a BUN 19 , creatinine 1.4. physical therapy
12.3 , PTT 31.7. Urinalysis was positive for traced blood and
leukocytes , too numerous to count white blood cells , 7-10 red blood
cells and 4% bacteria on microscopy. Urine culture grew klebsiella
sensitive to Bactrim. EKG was sinus at a rate of 80 , axis -29
degrees , intervals of .196/.116/.1478 , marked left ventricular
hypertrophy with left atrial abnormality with strain pattern in
V3-V6. Chest X-ray was significant for moderate pulmonary edema.
Lumbar sacral plain films showed no significant bony disease. An
Echocardiogram showed a severe left ventricular hypertrophy ,
preserved systolic function , possible diastolic dysfunction and new
posterior wall hypokinesis consistent with coronary artery disease.
HOSPITAL COURSE: Renal ultrasound showed both kidneys to
be approximately 11.0 cm in size. No
renal artery stenosis was seen though it was a limited study due to
body habitus. Flexible sigmoidoscopy was carried out by the GI
service and no significant lesions were found. The patient was
diuresed for congestive heart failure to which she responded well.
Her breathing was significantly improved by the second hospital
day. It is felt that her hypertension has contributed to at least
clinical evidence of her failure. While in the hospital , the blood
pressure was difficult to control and eventually required the use
of three medications. At the time of discharge , she was running
blood pressures in the range of 140-150 systolic and diastolic of
90 which is much improved for her. A repeat urine culture was
negative and the antibiotics were stopped. Her low back pain was
felt to be muscular in origin and she was given Flexeril for this.
She has no history of peptic ulcer disease but it has been decided
to institute a trial of H2 blocker therapy and reevaluate the need
for upper GI endoscopy in three weeks time. Her asthma was
relatively quiescent but it has been stressed to her that she
should continue to use her puffers.
DISPOSITION: CONDITION ON DISCHARGE is stable.
MEDICATIONS at the time of discharge are
Beclovent 4 puffs twice a day , Ventolin 2 puffs four times a day , Pepcid 20 mg
orally twice a day , Habitrol nicotine patch every day , Procardia XL 90 mg
orally every day , Lisinopril 40 mg orally every day , Labetalol 200 mg orally
twice a day , Flexeril 10 mg orally three times a day and Lasix 40 mg orally every day. The
patient will follow up at Wa Hospital on 1/26/92 at 6:10
p.m. She also has an appointment with GI clinic here on 11/10/92
at 2:30 p.m.
AK732/3980
DAMON B. KRINSKY , M.D. YX1 D: 9/13/92
Batch: 3913 Report: H2258P97 T: 11/10/92
Dictated By: CAROYLN REIDHERD , M.D.
Document id: 765
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
Y |
Y |
Y |
N |
N |
961515206 | PUO | 47409541 | | 0229515 | 3/20/2003 12:00:00 a.m. | bronchitis | | DIS | Admission Date: 3/15/2003 Report Status:
Discharge Date: 3/7/2003
****** DISCHARGE ORDERS ******
DEBNAR , LANITA 026-99-98-9
Windman Dr , Cin Leigh , Utah 73515
Service: MED
DISCHARGE PATIENT ON: 8/20/03 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOYNES , TALITHA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 5/5/03 by
HENRIKSEN , LANE , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
DEFINITE ALLERGY ( OR SENSITIVITY ) to NSAID'S
DEFINITE ALLERGY ( OR SENSITIVITY ) to SALICYLATES
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
Reason for override: awware takes at home
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
HOLD IF: sbp < 90 and call ho
Alert overridden: Override added on 5/5/03 by
HENRIKSEN , LANE , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: aware has tol Previous Alert overridden
Override added on 5/5/03 by HENRIKSEN , LANE , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates at home
ROBITUSSIN ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours as needed cough
NIFEREX-150 150 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
VITAMIN B 6 ( PYRIDOXINE HCL ) 100 MG orally every day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 5/5/03 by
HENRIKSEN , LANE , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: tol at home
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 5/5/03 by
HENRIKSEN , LANE , M.D.
on order for MVI THERAPEUTIC orally ( ref # 81248850 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: tol at home
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
HOLD IF: sbp < 100 , heart rate <55 and call ho
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally twice a day
HOLD IF: sbp < 100 and call ho
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIOVAN ( VALSARTAN ) 160 MG orally every day
HOLD IF: sbp < 100 and call ho
Number of Doses Required ( approximate ): 5
ALLEGRA ( FEXOFENADINE HCL ) 180 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
POTASSIUM CHLORIDE SUSTAINED RELEASE 10 MEQ orally every day
Ingredients contain 10 MEQ KCL every day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LANTUS ( INSULIN GLARGINE ) 60 UNITS subcutaneously every day
Starting Today ( 4/24 )
Instructions: please check your fingerstick glucose prior
to meals and bedtime.
METAMUCIL ( PSYLLIUM ) 1 TSP orally every day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
HUMALOG ( INSULIN LISPRO ) subcutaneously
HUMALOG ( INSULIN LISPRO ) 6 UNITS subcutaneously every day before noon
Instructions: and use humalog as your sliding scale as you
have been doing at home
ZAROXOLYN ( METOLAZONE ) 2.5 MG orally every day
Alert overridden: Override added on 4/5/03 by :
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: aware takes at home
VIT C ( ASCORBIC ACID ) 500 MG orally every day
VIT E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
AZITHROMYCIN 250 MG orally every day X 4 Days
Food/Drug Interaction Instruction Avoid antacids
Take with food
Alert overridden: Override added on 8/20/03 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
Reason for override: aware
DIET: House / 2 gm Na / ADA 2000 cals/day / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Keetan , your primary care doctor , PUO 802 077 8923 , call for an appointment for within 2 weeks of discharge ,
Radiology ( mammogram ) March , 9:15 am scheduled ,
ALLERGY: Percocet , Reglan ( metoclopramide hcl ) ,
Gantrisin ( sulfisoxazole ) , Cephalosporins , G6pd deficiency ,
Lidocaine ( antihistamines ) , Iv contrast dyes , Aspirin , Codeine ,
Neggram ( nalidixic acid ) , Lestrill , Keflex , Sulfa , Penicillins ,
Flagyl , Lidocaine , Codeine
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bronchitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Asthma HTN RAD G6PD DEF ?history of CHF IDDM
history of ischemic colitis Arthritis DJD Allergic rhinitis Glaucoma
Bursitis history of appy , TAH , Zenker's divertic removal
hx dvt 1988 obstructive sleep apnea
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
75F with CHF 2/2 diasystolic dysfxn , possible asthma , HTN , DM , CAD , p/with
wheeze/dyspnea & SSCP & diarrhea , likely with mild vol. overload &
bronchitis , hemodyn. stable , 7/28 & 8/25 on room air , ambulating
without issue , symptomatically much improved , to followup as outpt for
further management of her CHF and baseline restrictive lung disease.
HPI:
-see problem list for past med hx ( extensive ) -patient last seen
PUO 2/10 ( 3 days PTA ) with substernal chest pressure ( SSCP ) & sob , with
diffuse wheezes , RA sat 100%-> nebs , Po pred , d/c from obs with in
24 hrs with short pred taper. Over next 3
days , breathing got worse , developed cough ( + ) yellow
sputum , no FEVER , ( + ) diarrhea ( watery , no blood , c/with chronic colitis
diarrhea ) & polyuria , & chest pressure worse with cough better with SLNTG.
patient also has had increasing LE edema , recently
had lasix dose increased by CHF nurse. On DOA ,
per VNA- BS in 200s , BP 134/60 ( baseline sbp 100s ) ,
wt 5 lb decrease 1 night ( 218-> 213 ) so sent patient
to ED. VS T 98.6 HR 92 BP 120/53 RA 96%; ( + )
diffuse wheezes & rhonchi-> alb neb , 40 mg intravenous lasix ,
6u reg. insulin 4 glc 336. EKG & Cxray with no
new significant changes
PROBLEM LIST:
( 1 ) PULM- per pulm eval as outpt , including PFTs , no
asthma , likely CHF causing wheezes & patient got no benefit from steroids
( a ) d/c steroids 4/8 ( b ) continued outpt advair , combivent , as needed nebs
( c ) chest patient twice a day ( d ) cpap every bedtime as per home ( e ) 4/8 diuresis ( 2.5
L neg ) ( f ) 7/28 o2 sat 95% RA , with her usual baseline wheezes on exam
( g ) may need high resolution chest ct as outpt to evaluate lung
parenchyma to explain baseline wheezes
( 2 ) CV: ( i ) ischemia-( a ) ruled out for MI by cardiac enzymes , no ekg
changes. ( b ) cont cardiac meds ( asa , statin , bb , nitrates ) and no
further ischemic issues during this admit. ( ii ) pump- 4/8 jvp hard to
assess 2/2 neck obesity but euvol to mildly wet ( a ) 7/28 goal i<0 1-2
L , met goal ( 2.5L ) -> 7/28 nearly orthostatic ( lying sbp 100 , heart rate 95->
standing sbp 110 , heart rate 112 )-> change to home orally lasix ( 80 orally twice a day ) with as needed
intravenous as needed for I=O or slightly neg 500 cc.
( b ) cardiac diet , fluid restriction. patient being discharged near
euvolemia on orally lasix for f/u of weights , electrolytes , and lasix
titration per CHF clinic/nurse as outpt.
( iii ) rhythm: tele until r/o'd , NSR without further issues
3 ) RENAL: cr at baseline 4/8 2.1 ( a ) f/u cr history of diuresis 7/28 stable
2.0 ( b ) replete lytes as needed as no scales , final CR 2.2
( 4 ) GI-protonix , bowel regimen ( b ) if diarrhea , cx and send stool
leuks however on 7/28 formed BMs with no further issues
( 5 ) ENDO- 4/8 tsh 0.097 - levoxyl DC'd , recommend f/u as o/p to
determine TSH levels of thyroid replacement.
b ) Diabetes - Her Lantus was increased to 60 U every day due to persistent
hyperglycemia even off steroids. Her fingerstick glucoses ranged in
the mid 200s to lower 300s prior to the increase. Her glucose
control should continue to be monitored as an outpatient.
( 6 ) HEME-cont fe & guaiac stools 7/28 hct stable , 33.4 ( 7 ) FULL code
for this admission
( 8 ) Health maintenance - mammogram rescheduled for March at 9:15 am.
( 9 ) ID - Azithromycin Z-Pack started 8/25 for probable sinusitis.
Multiple U/A's this admission , all normal or contaminated/poor
specimen. Final repeat pending ( sent for LGF ).
ADDITIONAL COMMENTS: Call your doctor or return to ED if any of your symptoms , such as
cough , wheeze , shortness of breath , dizziness , falling , diarrhea , chest
pain , return , worsen or change in any way concerning to you. ( 2 ) Take
your medications and see your doctor as instructed above; note that
levoxyl has been discontinued.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
( 1 ) Follow for resolution of sinusitis , bronchitis. ( 2 ) F/u volume
status , daily wts on current lasix dose , adjust as needed. ( 3 ) F/u
electrolytes with lasix diuresis as outpt. ( 4 ) consider high resolution
CT scan of chest to eval. lung parenchyma re: chronic wheezes. ( 5 )
Repeat TSH , as levoxy was d/c while here. ( 6 ) TO VNA-
Assess o2 sats , volume status , orthostatics , blood sugars , home safety ,
orally intake , bowel movements , and medication compliance. ( 7 ) patient may benefit
from home physical therapy
No dictated summary
ENTERED BY: POLO , MALINDA MINDA , M.D. -HEME ONC ( XL83 ) 8/20/03 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 766
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
473896717 | PUO | 99960572 | | 2180595 | 9/6/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/10/2005 Report Status: Signed
Discharge Date: 10/4/2005
ATTENDING: DOUGLASS BOVA M.D.
SERVICE: Terirvson
PRINCIPAL DIAGNOSIS: Non-ST elevation MI.
SECONDARY DIAGNOSES: Congestive heart failure , COPD ,
hypertension , diabetes mellitus , gout , hypercholesterolemia.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female
with a history of hypertension , renal artery stenosis , diabetes ,
chronic renal insufficiency , and COPD who presents with 3 days of
increasing shortness of breath. The patient reports that over
the 3 days prior to admission. She had increased shortness of
breath and worsening dyspnea on exertion. At baseline , she can
usually walk a block before becoming short of breath and over
these past few days , she can no longer walk several feet. She
also reports that she has a productive cough with whitish sputum
and recently recovered from an upper respiratory tract infection
3 weeks ago. She denies any chest pain , palpitations , or
lightheadedness , nausea , vomiting , and diaphoresis. She has had
stable 3-pillow orthopnea for many years with no recent increase
in lower extremity edema. She does note a 5-pound weight gain
over the past week prior to admission. The patient had been
followed recently as an outpatient by both cardiology and renal
for her hypertension and chronic renal insufficiency. She has
known renal artery stenosis by MRI in February 2004 and recently
had an episode of acute renal insufficiency with an increase in
her creatinine from 1.6 to 2.7 in the setting of Lasix and
nonsteroidal antiinflammatory drugs. The patient has been taking
extra Lasix. So in the week prior to admission , she had run out
of this medication. In the emergency room , the patient was
hypertensive and in mild respiratory distress ( 92% on room air ).
She was given nebulizers and Lasix 80 mg intravenous with a diuresis of
1.5 liters. In the emergency room , she describes some left-sided
chest pain , worse with inspiration , which lasted a few minutes
with some associated nausea and vomiting. An EKG showed ST
depressions in leads V2 through V6.
PAST MEDICAL HISTORY: Congestive heart failure , hypertension ,
diabetes mellitus , COPD , anemia , osteoarthritis , gout , peripheral
vascular disease , and hypercholesterolemia.
MEDICATIONS: Allopurinol 100 every day , Alupent 2 puffs four times a day
as needed , aspirin 325 every day , atorvastatin 40 mg orally every bedtime ,
Atrovent 2 puffs four times a day , Clonidine 0.6 every week , Imdur 180 every day ,
iron gluconate 27 mg twice a day , Lantus 62 units every day before noon , Lasix 80 mg
orally every day , lisinopril 40 mg every day , magnesium oxide 400 mg orally
every day , minoxidil 5 mg orally every day , nicardipine SR 60 mg orally twice a day ,
Pulmicort 1 puff twice a day , nitroglycerin sublingual as needed chest
pain.
ALLERGIES: Rofecoxib causes wheezing and NSAIDs cause acute
renal failure.
SOCIAL HISTORY: The patient lives with her 3 great grandchildren
between the ages of 9 and 12 for whom she cares for herself at
home. She has a history of tobacco , 30-pack-year and quit in
1968. She denies alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97 , pulse 59 ,
blood pressure 160/70 , respirations 20 , O2 sat 99% on 2 liters.
The patient was alert and in no acute distress. JVP 8 cm.
Pupils equal and reactive to light. Extraocular movements
intact. Oropharynx clear. Neck is supple. Cardiovascular: 2/6
systolic murmur at the left lower sternal border. Respiratory:
Left-sided crackle. Abdomen is soft , nontender , nondistended
with normal active bowel sounds. Extremities: Trace pedal
edema. Neurovascular: The patient was alert and oriented x3
with a nonfocal neurologic exam.
LABS ON ADMISSION: Remarkable for a BUN of 40 and a creatinine
of 1.6 ( this is decreased from 2.7 in October 2005 ). BNP was 95.
CK 95 , troponin negative. EKG showed normal sinus rhythm with
PACs. Normal axis , ST depressions in V2 through V6. Chest x-ray
showed a left lower lobe infiltrate/opacity. No effusions , no
edema.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Ischemia. The patient with shortness of
breath on admission and ST depression in V2 through V6. The
patient had an episode of chest pain at rest on the floor with a
positive troponin to 10.8 on 7/26/2005. No progression of the
EKG changes seen in the emergency room. The patient was started
on intravenous heparin and cardiology was called to arrange for cardiac
catheterization. However , the patient was noted to have a
decrease in her hematocrit from 30 to 23. She was guaiac
negative. Cath was initially put on hold for the patient to be
transfused. The patient then became chest pain free starting
10/7/2005. Her enzymes trended down. intravenous heparin was
discontinued on 6/18/2005. The patient had a MIBI on
5/1/2005 , which showed areas of ischemia in the distal LAD and
OM territories. The patient underwent catheterization on
1/23/2005 , which showed chronically occluded RCA with collateral
50% LAD lesion , 95% tubular proximal D1 lesion , 50% tubular OM1
lesion; no stents were placed. She was continued on aspirin ,
beta-blocker , statin , and ACE inhibitor. The patient had one
additional episode of chest pain on 1/21/2005. In this instance
chest pain was pleuritic with no associated ischemic symptoms and
EKG remained unchanged. This was thought unlikely to be of
ischemic origin. The patient has no chest pain or shortness of
breath since this time up until the time of discharge. Pump:
The patient was felt to be volume overloaded on admission
( secondary to Lasix noncompliance. The patient was initially
given 80 mg of intravenous Lasix with a diuresis of 1.5 liters. Diuresis
was then more gentle with an I/O goal of even to negative 500 cc
per day. Lasix was held prior to cath. The patient was thought
to be dry status post her large diuresis. The patient will
resume her Lasix at a lower dose of 40 mg every day on discharge. A
transthoracic echo on 10/9/2005 showed an EF of 65-70% , mild
hypokinesis of the distal anterior and septal walls , trace MR ,
mild AI and aortic stenosis ( aortic valve area 0.9 to 1.0 ). The
patient also has a history of hypertension with known unilateral
renal artery stenosis. The patient was initially on lisinopril ,
nicardipine , clonidine patch , and Imdur. The patient's ACE
inhibitor was held prior to cath because she was persistently
hyperkalemic. Her systolic blood pressure remained between
130-160. The patient will be discharged on a lower dose of
lisinopril ( with close followup by her primary care physician ).
Rhythm: The patient was monitored on telemetry. She showed
sinus bradycardia in the 40s to 60s with first-degree block. The
patient was asymptomatic.
2. Pulmonary: Shortness of breath on admission thought to be a
combination of COPD , recent upper respiratory infection with
question of a left lower lobe infiltrate on chest x-ray as well
as volume overload. The patient was continued on her nebulizers.
She was also diuresed. She also completed a course of
azithromycin/cefotaxime for community-acquired pneumonia. Her
shortness of breath greatly improved since the time of admission.
Her oxygen saturation was 99-100% on room air ( and with
ambulation ) at the time of discharge.
2. Renal: The patient has a history of chronic renal
insufficiency , microalbuminuria , and renal artery stenosis. She
had a recent episode of acute renal failure in the setting of
nonsteroidal antiinflammatory drugs. Her creatinine was 1.8 to
2.0 through most of this admission. She underwent renal artery
angiography on 1/23/2005 , which shows moderate stenosis of the
right renal artery. No stent was placed. She was given
Kayexalate as needed for hyperkalemia. Her ACE inhibitor was
held temporarily and restarted at a lower dose given
hyperkalemia. Her K was 4.6 at the time of discharge. In
addition to the patient's ACE inhibitor , Lasix , allopurinol , and
colchicine were held prior to cardiac catheterization. She was
given Mucomyst and intravenous fluids around the time of her
catheterization. Her creatinine improved after cath hydration to
1.6 on the day of discharge.
3. Endocrine: The patient has a history of diabetes. She was
continued on Lantus with an insulin sliding scale.
4. Musculoskeletal: The patient complained of right great toe
pain. This was thought to be a bunion versus the patient's gout.
Given increased redness , warmth , and swelling the patient was
treated for a gout flare. She was given colchicine ( renally
dosed ) and continued on her prophylactic allopurinol. Both of
these medications were held prior to cath. NSAIDs were avoided
given renal insufficiency. The patient was given Tylenol for
pain with good effect. The patient showed decreased pain and
swelling of her right great toe over the course of this admission
and this was resolved on discharge. The patient will be
continued on renally dose prophylactic allopurinol.
5. Heme: The patient had a drop in hematocrit on 9/30 from 30
to 23. She was guaiac negative. She was transfused and then
maintained to hematocrit of approximately 30 since 10/7/2005.
Her post cath hematocrit was 27.9 ( repeated at 28.9 ). Her groin
site was clean , dry , and intact. No tenderness over the abdomen
and flank.
6. Prophylaxis: Nexium and subcutaneously heparin.
7. Code was full.
DISPOSITION: The patient will be discharged to home. She will
follow up with her primary care physician. She was also
instructed to avoid foods that were high in salt and potassium.
She was instructed to keep track of her daily weight.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Tylenol 325-650 mg orally every 6 hours as needed
pain , aspirin 81 mg orally every day , clonidine 0.6 every week , Colace 100
mg orally twice a day , nicardipine 60 mg orally twice a day , sublingual
nitroglycerin as needed chest pain , Senna 2 tabs orally twice a day , Imdur
180 mg orally every day , atorvastatin 80 mg orally every day , Lantus 60 units
subcutaneously every day , allopurinol 100 mg orally every day , Toprol XL 25 mg orally
every day , Alupent inhaler 2 puffs every 6 hours , Atrovent inhaler 2 puffs
four times a day , Pulmicort 1 puff twice a day , albuterol inhaler 2 puffs every 4 hours
as needed shortness of breath and wheezing , Lasix 40 mg orally every day ,
lisinopril 5 mg orally every day
eScription document: 4-2874995 PFFocus
CC: Carmon Boshers M.D.
DELJ COUNTY MEDICAL CENTER
Ank Arv Ca
Etjacksa
Dictated By: CONEDY , ARMINDA
Attending: BOVA , DOUGLASS
Dictation ID 3130035
D: 5/14/05
T: 5/14/05
Document id: 767
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803287069 | PUO | 64744160 | | 2865811 | 7/23/2006 12:00:00 a.m. | chest pain | | DIS | Admission Date: 7/25/2006 Report Status:
Discharge Date: 1/26/2006
****** FINAL DISCHARGE ORDERS ******
KREITZER , CHELSEA E 450-94-58-6
Rie Ti Ville
Service: CAR
DISCHARGE PATIENT ON: 2/18/06 AT 06:00 PM
CONTINGENT UPON Neuro recs , physical therapy
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MAINER , SHAVONNE D. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA 325 MG orally DAILY Starting Today ( 10/22 )
Instructions: Do NOT stop this medication. It prevents
blood clots in your stents
Override Notice: Override added on 3/25/06 by
WESTBERG , KAMALA M. , M.D. , PH.D.
on order for TORADOL intravenous ( ref # 684528464 )
SERIOUS INTERACTION: IBUPROFEN & KETOROLAC TROMETHAMINE ,
INJ Reason for override: aware
ATENOLOL 12.5 MG orally DAILY Starting Today ( 10/22 )
Instructions: For blood pressure and heart rate
LISINOPRIL 5 MG orally DAILY Starting Today ( 10/22 )
Instructions: For blood pressure and heart
Alert overridden: Override added on 2/18/06 by
WESTBERG , KAMALA M. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
BLEPH-10 ( SULFACETAMIDE 10% ) OINTMENT TP four times a day
Instructions: to L eye x 10 days.
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Starting Today ( 10/22 ) Instructions: For your cholesterol.
CLOPIDOGREL 75 MG orally DAILY Starting IN a.m. ( 7/21 )
Instructions: Do NOT stop this medication. It prevents
blood clots in your stents
Override Notice: Override added on 3/25/06 by
WESTBERG , KAMALA M. , M.D. , PH.D.
on order for TORADOL intravenous ( ref # 684528464 )
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
KETOROLAC TROMETHAMINE , INJ Reason for override: aware
Previous override information:
Override added on 3/25/06 by WESTBERG , KAMALA M. , M.D. , PH.D.
on order for MOTRIN orally ( ref # 376433780 )
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
IBUPROFEN Reason for override: aware
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
OMEGA-3-FATTY ACIDS 1 , 000 MG orally three times a day
Instructions: For your cholesterol
NIASPAN ( NICOTINIC ACID SUSTAINED RELEASE )
0.5 GM orally BEDTIME
Instructions: Take at bedtime. Take your aspirin 30
minutes before to prevent your face from flushing
Alert overridden: Override added on 2/18/06 by :
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: monitering
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
RETURN TO WORK: 1 week
FOLLOW UP APPOINTMENT( S ):
Dr. Virgen Yueh , Cardiology February , at 4 PM scheduled ,
Dr. Louie Ayyad , Primary Care ,
ALLERGY: Penicillins , PHENOTHIAZINES ,
PROCHLORPERAZINE EDISYLATE , VERAPAMIL SUSTAINED RELEASE ,
AMITRIPTYLINE HCL
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
menorrhagia htn
obesity ( obesity ) GERD ( gastroesophageal reflux disease ) Plantar
faciatis ( plantar fasciitis ) diffuse arthralgia ( arthralgias )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cypher stent to LAD
BRIEF RESUME OF HOSPITAL COURSE:
49F Nigerian F with HTN , hyperchol , presented with CP
6/28/06 history of PCI with DES to RCA x 4. Here for stuttering but
persistent x 3 weeks , typical CP , unresponsive to NTG ( has used 30 in
past 3 weeks ) and Percocet at home. Pain is
5/10 , tightness/pressure , substernal , radiating to back and L arm ,
pleuritic , assoc with SOB , n/diaphoresis , palps , indigestion. +DOE
with 5 mins walking , +PND , no orthopnea , no LE edema
+lightheadedness no syncope. In ED , EKG with STE in V2 ,
pseudonormalization of V3 , with RBBB ( old ). Dynamic in V3. 1st set enzs
neg. Got ASA , Plavix , Lipitor , Heparin drops , Nitro drops and morphine.
Pain still 3/10 on Nitro 45 mcg/min. ( No BB , for
BPs )
***
PMHx: Menopausal since 2000 All: PCN- rash ,
compazine-dyskinesia Home Meds:Coreg 3.125 mg orally twice a day , Zocor ? , Plavix
75 mg orally daily , ASA 81 mg orally daily , Dyazide 37.5/25 orally
daily , Percocet 5/325 as needed , NTG as needed , Nexium 40 mg orally daily
***
Exam: 98.1 66 140/90 16 100% 2L NC L conjunctivitis , JVP 5 cm , +S4 , no
bruits
***
Labs: BUN/Cr 12/0.9 , HCT 33.8 , 1set card enzs neg
***
Studies: EKG: NSR , 70's , RBBB ( old ) , LAD , TWI II , III , AVF ( new
since 4/3 but old as of 8/27 ) , TWI V3-V6 , dynamic in V2 and V3 with
STE in V2 and pseudonormalization in V3.
CXR: nml ECHO 6/28/06 ( TH ): EF 55% , mild LAE , mild MR , no
WMA
Cath 6/28/06 : EF 35% , 100% occlusion to RCA and 4 x
DES to prox and mid RCA , +L-> R collateralization. akinesis
infero-basal wall , mod abnml LV func.
CT abd/pelv 3/10/06 : No
hematoma/retroperitoneal bleed.
Cath 8/18/06 : tubular 50-55% , hazy appearing lesion , D1 ostial 50% ,
small S2 70% , prox LCx 45% lesion. Cypher placed in prox LAD.
ECHO 3/10/06 : EF 45-50%. Inf wall is akinetic , post wall is
hypokinetic. mild LAE , mild AI , mild MR , tr TR , PAP 19.5 mmHg
***
Hospital Course: 1. CV- I: dynamic ST changes V2-V3 noticed in ED.
+episode of acute chest pain on the floor , 5-6/10 , substernal ,
non-radiating , same quality as prior. EKG with normalization of
V4-V6 where they had been inverted before. Enzs neg in ED , started on
Heparin drops ( PTT 60-80 ) in the ER and continued until cath. Started Nitro
drops in ED and stopped later on the floor for headache and because her
pain was not completely relieved ( 5-6/10->2/10 ). During acute CP episode ,
received sublingual NTG x 2 before had relief. patient complained of positional pain
( worse with sitting upright ) and lack of total relief with Nitro drops
suggested possible pericardial etiology. CP gone after cath , no NSAIDS
given. Lipid profile with high Trigs ( 192 ) and low
HDL ( 22 ) , LDL 53. Cont ASA , Lipitor , Plavix. Will go on Atenolol.
Initially held Ace and diuretic for lowish BPs , restarted Captopril and
tolerated well with BPs 120's/130's so will go on Lisinopril. P:ECHO
showed EF 45-50% , inf wall is akinetic , post wall hypokinetic. R: NSR , 1
episode of 5 beats of VT ( had nausea with this ) on tele 4/11 , lytes were
normal , patient was post-cath. Got Compazine ( error- not ordered by MD , patient has
known dystonic rexn to this med ) No reaction noted. patient informed and
incident report filed.
2. GI- Nexium for GERD
3. Heme- Iron studies normal , patient has hx of HCT 30-35.
4. ID-conjunctivitis. Bleph-10 to L eye x 10 days.
5. PPX- Was on heparin drops , nexium.
6. Neuro- L leg numbness and paresis immediately post-cath. Was unable to
move entire L leg , had numbness in all aspects of leg and across lower L
abdomen. Complained of lower back pain on L. Down going toes on R , mute
toes on L , unable to elicit patellar reflex B/L , normal pedal pulses and
no hematoma/oozing at groin site. CT Abd/pelv neg for retroperitoneal
bleed. 12 h later , was able to dorsiflex and plantar flex foot. 24h later ,
was able to walk with assistance , able to go up on heels and toes , able to
flex knee with difficulty , unable to flex hip while in bed , able to abduct
hip. 1+ patellar reflex and toes down at that time. Evaluated by Neuro
consult service and felt to be elaborating her deficits. patient may contact
Dr. Texiera 733-564-9814 if she has further complaints.
7. physical therapy recs walker and cane with outpt physical therapy. Outpt cardiology should eval
for cardiac rehab.
8. Dispo home with VNA , home physical therapy.
Full Code
ADDITIONAL COMMENTS: You have been diagnosed with chest pain and left leg weakness. A stent
has been placed in your coronary artery. You MUST take Aspirin and Plavix
to prevent blood clots in your stents. Your medications have been
changed. Please follow-up with your doctors or call to reschedule. Return
to the ER if you have trouble breathing , chest pain , or any other
concerning symptoms.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Follow-up neuro deficits of L leg
2. BP and Med check , consider uptitrating BB and Ace
3. Check LFTs on statin , niaspan
4. patient recommends cardiac rehab , please eval at her cards appointment.
No dictated summary
ENTERED BY: WESTBERG , KAMALA M. , M.D. , PH.D. ( QE231 ) 2/18/06 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 768
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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073178719 | PUO | 99310817 | | 905920 | 11/13/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/13/1996 Report Status: Signed
Discharge Date: 2/1/1996
PRINCIPAL DIAGNOSIS: ABDOMINAL PAIN.
SECONDARY DIAGNOSES: 1 ) INTRAUTERINE PREGNANCY AT 33.2 WEEKS
GESTATION.
2 ) NO PRENATAL CARE.
3 ) MORBID OBESITY.
4 ) Trichomonas VAGINITIS.
CHIEF COMPLAINT: The patient is a 35 year-old G7 , P3-1-2-3 with
unknown last menstrual period , a 33.2 weeks
gestation at the time of presentation by an ultrasound who
presented to the Emergency Room with abdominal pain. Her dating is
by a last menstrual period which is unknown. She has a positive
pregnancy test on October , 1996 which will give her an EDC of
November , 1997 at 27 and 6/7th weeks gestation. An ultrasound
done on the Labor Floor revealed an EDC of May , 1997 at 29
and 6/7th weeks gestation and an ultrasound done formally revealed
an 33.2 weeks gestation. Prenatal screen is A positive , Hepatitis
negative.
HISTORY OF PRESENT ILLNESS: The patient states that she was in her
usual state of health until about
11:00 on the day of presentation when she began to have abdominal
pain which she described as diffuse , constant , crampy and
occasionally getting worse. She gets no relief from position
changes or bowel movements. The patient also describes the pain as
somewhat like grasp pains but it is different in that it is
constant. The patient denies fevers , chills , nausea , vomiting and
diarrhea. She reports slightly decreased appetite over the past
three days. She has no dysuria , no hematuria. She has been
constipated in the past. She had a recent cold with upper
respiratory infection symptoms. The patient reports no
contractions , no leakage of fluid and no bleeding per vagina. She
does report fetal movement.
PAST MEDICAL HISTORY: Obesity and a pilonidal cyst in the past.
PAST SURGICAL HISTORY: None.
PAST GYN HISTORY: Significant for Trichomonas in 1994.
PAST OBSTETRICAL HISTORY: Full term normal spontaneous vaginal
delivery times three , one miscarriage
and two therapeutic abortions.
MEDICATIONS ON ADMISSION: The patient is on no medications.
ALLERGIES: The patient is allergic to seaweed.
SOCIAL HISTORY: Reveals smoking of one pack per day , occasional
alcohol , no intravenous drugs.
PHYSICAL EXAMINATION: The patient is an obese female in some
discomfort , belching. Vital signs:
Temperature 98.4 degrees , blood pressure 162/60 which then became
152/85 and then 145/85 , heart rate 88-108 , respiratory rate 20 ,
oxygen saturation 96% on room air. The patient has numerous dental
caries. She has anicteric sclera. Her lungs were clear to
auscultation. Heart was regular rate and rhythm with normal heart
sounds. She is obese , gravid with positive bowel sounds. She is
generally tender to deep palpation , slightly right greater than
left , no rebound or guarding. Extremities reveal no clubbing ,
cyanosis or edema. Neurological examination was 1-2+ throughout.
Cervix was 1 cm , closed and posterior. Rectal examination revealed
normal tone , guaiac negative. Fetal heart rate was in the 140-150s
with average variability , not formally reactive. She had no
contractions on the monitor.
LABORATORY: Admission laboratory studies revealed a white blood
cell count of 17.7 , hematocrit 37.1 , platelets 289.
SMA-7 was within normal limits. Liver function tests was within
normal limits. Amylase 55 , lipase 23 , calcium 8.9 , uric acid 2.3.
A urinalysis clean catch revealed 3+ protein , trace glucose with
30-35 white blood cells , 1-2 red blood cells , 2+ bacteria and 1+
squamous epithelial cells. Urine tox was negative. Floor
ultrasound with anterior placenta , BPP six out of eight.
ASSESSMENT AND PLAN: This is a 35 year-old female , G7 , P3-1-2-3 at
33.2 weeks by a formal ultrasound is admitted
with abdominal pain.
HOSPITAL COURSE: 1 ) Abdominal pain: Because the patient had
anorexia , abdominal pain and also some nausea
as well as increased white blood cell count , a Surgery consult was
obtained. They suggested that the patient remain NPO with
intravenous hydration and to follow her serial white counts as well
as serial examinations to rule out appendicitis. The patient was
hungry on the evening of admission. She was given a diet and was
tolerating without any problems. At the time her abdominal
examination was benign. Her white blood cell count went from a
high of 17.7 down to 11.9. At the time of dictation , the current
one is still pending. There does not appear to be any evidence of
appendicitis. There also does not appear to be any evidence of
preterm labor.
2 ) Rule out PET: We do not have the patient's book in blood
pressures since she had no prenatal care , however no admission her
initial blood pressure was 162/60 and with 3+ protein , the patient
was assessed regarding rule out pre-eclampsia. She had no symptoms
during the admission , however did report some headaches recently
and maybe some spotty vision. However , it is reassuring that she
had none of these complaints during the admission. Her blood
pressures on the floor have been reassuring with a blood pressure
maximum when she is on the Fuller Service of 140/70. The patient's
PET laboratory studies were reassuring and the baby has normal
fluid. The patient is currently undergoing 24 hour urine protein
and further determination will be made from then. It is expected
that the patient will be discharged , feeling that the proteinuria
is from her vaginitis.
3 ) No prenatal care: The patient had her initial prenatal
laboratory studies drawn and also a glucose loading test done on
this admission. The results are pending at this time. The patient
will be discharged to the regular OB clinic for an appointment in
the next one to two days.
4 ) Trichomonas vaginitis: A straight catheter urinalysis was
resent which revealed 60-65 white blood cells , 4+ Trichomonas as
well as hyfe and 2+ squamous epithelial cells. The patient was
given 2 grams of Flagyl times one. She is advised to tell her
partner so that he may receive some medical care and receive
treatment also. She is advised not to have intercourse with him
until he is treated.
5 ) Contraception: The patient desired postpartum sterilization
and during this admission signed PPS forms.
6 ) Morbid obesity: The patient will need an Anesthesia consult as
an outpatient secondary to her body habitus.
7 ) Social work: The patient revealed that she did not want her
husband to know that she was pregnant. We had a social worker come
and discuss with her regarding further plans.
MEDICATIONS ON DISCHARGE: Prenatal vitamins.
Dictated By: CARMELITA M. TONI , M.D. DX05
Attending: MOHAMMAD CASEBOLT , M.D. ZK4
WM191/0686
Batch: 15074 Index No. MVPAWDO8E D: 10/26/96
T: 4/10/96
Document id: 769
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
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946845360 | PUO | 39737797 | | 675375 | 2/28/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/2/1992 Report Status: Signed
Discharge Date: 10/7/1992
DISCHARGE DIAGNOSIS: TRANSIENT ISCHEMIC ATTACK. PROBLEM LIST
INCLUDES HISTORY OF LEFT HEMISPHERIC
CEREBROVASCULAR ACCIDENT RESULTING IN
SHORTTERM MEMORY LOSS AND RIGHT SIDED
WEAKNESS , LEFT GREATER THAN RIGHT , WHICH
OCCURRED IN 1981 , PERIPHERAL VASCULAR DISEASE
STATUS POST RIGHT FEMOROPOPLITEAL BYPASS
ANGIOPLASTY TIMES THREE IN 1989 , HISTORY OF
CHRONIC OBSTRUCTIVE PULMONARY DISEASE , AND
HISTORY OF ATYPICAL CHEST PAIN.
HISTORY OF PRESENT ILLNESS: This is a 58 year old white male with
a history of peripheral vascular
disease and old left hemispheric cerebrovascular accident who
presents with a right sided arm weakness and numbness. In 1981 ,
the patient suffered a left hemispheric cerebrovascular accident
which resulted in shortterm memory loss and right sided weakness ,
leg greater than arm. The right sided deficit eventually resolved ,
however , his lower leg remained numbness and weak , distal greater
than proximal. Ten days prior to admission , the patient
experienced a transient episode of loss of vision in his right eye.
He states that he felt as if his lid was closed over his right eye
and he asked his wife whether this was actually the case.
Approximately ten to fifteen seconds later , the "blindness"
disappeared and his normal vision returned. Two days prior to
admission , patient began to experience chest pain and subsequently
took sublingual Nitroglycerin. He states that his pain briefly
improved but would then recur much more severely. This complex
event occurred three times before the pain began to subside.
Immediately following the second episode , the patient states that
he began to feel increasing weakness in his right hand. The
sensation increased over the course of the entire day and became
so bothersome at night that he had trouble sleeping. He then
became concerned that he might have had a stroke ( the weakness
reminded him of his previous cerebrovascular accident ) and he
decided to come to the Pagham University Of for evaluation.
In the Emergency Room , he had a head CT done which was negative and
also an EKG which showed normal sinus rhythm. He denies
dysarthria , loss of consciousness , and/or dizziness. PAST MEDICAL
HISTORY: In 1981 , as stated , peripheral vascular disease , status
post right femoropopliteal bypass angioplasty times three in 1989 ,
status post L5-L6 discectomy in 1984 , persistent lumbar disc , EMG
consistent with mild to moderate denervation of lower extremity
muscles , left greater than right , consistent with polyradiculopathy
or spinal stenosis , history of esophageal reflux and esophageal
spasm , history of atypical chest pain , angina , reportedly had
negative coronary catheterization , status post bilateral knee
surgery for a history of osteoarthritis , status post
cholecystectomy , status post small bowel obstruction times two with
enterolysis , and history of chronic obstructive pulmonary disease.
CURRENT MEDICATIONS: Calan SR 120 mg every day , Tagamet , sublingual
Nitroglycerin as needed , and Azmacort. ALLERGIES: Penicillin.
FAMILY HISTORY: Negative for diabetes and hypertension but
positive for increased cholesterol and heart disease. He has a
sixty pack year history of smoking , no history of alcohol or
intravenous drug abuse. SOCIAL HISTORY: He is a married retired
auto mechanic.
PHYSICAL EXAMINATION: He was a pleasant male , he was lying in bed ,
and appeared older than his stated age.
Vital signs showed temperature 98.7 , pulse 82 , blood pressure
144/90 , and respirations 18. LUNGS: Clear bilaterally with
distant breath sounds bilaterally. HEART: Regular rate and rhythm
with no murmurs. No carotid , ophthalmic , vertebral , or temporal
bruits auscultated. ABDOMEN: Soft and non-tender with scar in
right upper quadrant consistent with old cholecystectomy.
NEUROLOGICAL: Examination showed mental status with patient alert
and oriented times three , attention showed digit repetition of five
forward , forward , backward , language with spontaneous speech ,
normal fluency , and normal comprehension , and patient pointed to
objects in sequence good. Yes and no questions normal , word and
sentence repetition normal , naming and word finding normal , reading
normal , writing normal , and memory showed immediate recall good and
remote memory three out of three events , new learning ability , and
four out of four objects at five minutes. Numered construction
ability and clock were normal , cube unable to reproduce , and
cranial nerves showed II with bilateral horizontal nystagmus of
about ten beats noted bilaterally. VII nerve showed right sided
nasolabial fold droop and mild ptosis. Patient had a history of
Bell's palsy. All other cranial nerves were normal , motor
examination was showed tone normall throughout , bulk was normal
throughout , and his upper extremities showed right upper extremity
with deltoid of 5 , triceps 5 , biceps 5 , wrist extensors 4+ , wrist
flexors 4+ , finger extension 4+ , and finger flexion 4+. Upper
extremity on the left side showed deltoids 5 , triceps 5 , biceps 5 ,
wrist extensors 5 , wrist flexors 5 , finger extension 5 , and finger
flexion 5. Lower extremities showed , on the right iliopsoas of 5 ,
hamstring 5 , quadriceps 4+ , gracilis 4+ , AT 4+ , and EHL 4+ with , on
the left iliopsoas 4 minus , hamstring 4 minus , quadriceps 4 minus ,
gracilis 4 minus , AT 4 minus , and EHL 4 minus. Sensory
examination of the upper extremity right normal light touch , pain ,
and temperature except for some decreased joint position about the
right finger and left upper extremity showed normal joint position ,
light touch , pain , and temperature. Lower extremity joint position
was decreased about the ankle on the right and also decreased on
the left , light touch was decreased , and pain and temperature were
decreased all in the same distribution on the right and the area
where a graft had been taken. There was normal on the left side
for light touch , pain , and temperature. Reflexes in the upper
extremity were 2 throughout , reflexes in the lower extremity was 1
throughout , Babinski not present bilaterally , normal
finger-to-nose , and gait was not tested.
LABORATORY EXAMINATION: On admission , he had a white count of 9 ,
hemoglobin 14.6 , hematocrit 40.9 , MCV
88.4 , platelets 221 , his physical therapy was 12 , and PTT was 35. His urine was
clear and clean and SMA 7 was normal.
HOSPITAL COURSE: The patient was ruled out for myocardial
infarction with cardiac enzymes. During his
hospitalization course , patient was heparinized and PTT was kept
therapeutic. Patient had an MRA angiography on 10/6/92 of the
head which showed a left area of enhancement in the left pons. He
had an echo which was normal except for an echodense lesion about a
cm above the aorta , possibly an atherosclerotic plaque , and he had
carotid dopplers which were normal. The discharge impression was lacunar
disease , but embolism ( of unclear origin ) could not be ruled out.
DISPOSITION: DISCHARGE MEDICATIONS: Calan SR 120 mg every day , Tagamet
at 400 mg three times a day , and Aspirin 325 mg every day The
patient is sent home with follow-up with Dr. Shetz in two weeks.
AU355/4353
WALDO O. AABY , M.D. GB4 D: 3/26/92
Batch: 1339 Report: L0137M3 T: 7/11/92
Dictated By: GAYLENE FANIEL , M.D.
Document id: 770
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172100234 | PUO | 34013384 | | 1267882 | 1/17/2005 12:00:00 a.m. | diastolic heart failure | | DIS | Admission Date: 10/15/2005 Report Status:
Discharge Date: 10/17/2005
****** DISCHARGE ORDERS ******
KAZUNAS , JULIET 292-57-27-6
Li Room: Ph Y Mond
Service: MED
DISCHARGE PATIENT ON: 8/26/05 AT 06:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Pain
Instructions: Please limit tylenol to <4grams per day.
Alert overridden: Override added on 8/29/05 by
STIDMAN , GENOVEVA , M.D.
on order for TYLENOL orally ( ref # 78822893 )
patient has a PROBABLE allergy to ACETAMINOPHEN W/CODEINE
15MG; reaction is NAUSEA. Reason for override: for pain
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
ATENOLOL 100 MG orally twice a day Starting Today ( 7/18 ) HOLD IF:
ZESTRIL ( LISINOPRIL ) 40 MG orally twice a day HOLD IF: SBP<100
Override Notice: Override added on 10/18/05 by
ANESTOS , MISHA J. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 44492817 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: following
Previous override information:
Override added on 10/18/05 by WYNDHAM , MAXIE
on order for KLOR-CON orally ( ref # 79558175 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override:
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
HOLD IF: sedation , RR<15
Alert overridden: Override added on 4/20/05 by
GORGLIONE , JEANNETTE , M.D.
on order for OXYCODONE orally ( ref # 68594613 )
patient has a PROBABLE allergy to ACETAMINOPHEN W/CODEINE
15MG; reaction is NAUSEA. Reason for override: aware
AVANDIA ( ROSIGLITAZONE ) 8 MG orally twice a day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
LIPITOR ( ATORVASTATIN ) 40 MG orally every bedtime
NIFEREX-150 150 MG orally twice a day
ASCORBIC ACID 500 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally every day
KLOR-CON ( KCL SLOW RELEASE ) 20 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 8/26/05 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override:
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please call Bryon Marter , MD ( 506 )153-9513 to make an appointment to be seen within one week. ,
Please arrange for a new primary care physician in the area using KTDUOO 121-826-6583. ,
ALLERGY: Erythromycins , Penicillins ,
ACETAMINOPHEN W/CODEINE 15MG , CLINDAMYCIN
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
diastolic heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of IMI Non-cardiac chest pain Lumbosacral disc
dz Chronic pain syndrome Migraines HTN Anxiety
Depression ALLERG:PCN , Erythro , Tetracy
history of PTCA 1/11 FOR OCC RCA POSITIVE ETT/MIBI 93: ANT/LAT WALL ISCHEMIA
OPERATIONS AND PROCEDURES:
NONE.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE.
BRIEF RESUME OF HOSPITAL COURSE:
*HPI:58 year-old F with chest pain , known CAD ( history of inferior wall MI '91 ) , multiple
cardiac RF ( HTN , DM2 , HChol , recent smoker , Fam Hx ) , also with hiatal
hernia , ?breast cysts , chronic pain syndrome. patient presents with stabbing
chest pain with radiation down L arm ( which is unlike her anginal CP ) ,
feeling of chest "tightness" and ?diaphoresis and SOB. This pain has been
persistent for 1.5 weeks , worsening/persistent x 24 hours.
*PMH: CAD history of PCI 1992 , HTN , DM , dyslipidemia , gastritis , depression , OA ,
hiatal hernia , chronic pain syndrome
*MEDS: avandia 8 mg orally twice a day , atenolol 100 mg orally twice a day , lipitor 20 mg orally every bedtime ,
zestril 40 mg orally every day , asa 81 mg orally every day , percocet as needed
*ALLERGIES: erythromycin , pcn , motrin?
*SH: d/c smoking 3 yrs ago , no etoh , no ivdu/recreational drugs , lives with
her husband
*PE on admission: remarkable for marked chest wall tenderness , and mild
fluid overload by JVP of ~10cm , S4 on cardiac auscultation , 1+ peripheral
edema , and dyspnea with occasional expiratory wheezing.
*LABS/STUDIES: Admission studies showed BNP of 809; CXR wnl , EKG unchanged
from previous , negative cardiac enzymes x3.
**********HOSPITAL COURSE************
*Chest discomfort: It was felt that her chest symptoms were not angina but
possibly represented bronchospasm , or fluid overload secondary to
diastolic dysfunction. TTE was therefore performed on 6/21 and showed ED
60% , LVH , and small area of HK on inferior wall. Dipyridamole-PET done
4/19 showed small severe fixed perfusion defect in inferior wall , but was
otherwise unremarkable. Given the patient's fluid overload and possible
diastolic dysfunction , she was given a total of 60 mg intravenous Lasix and over
10/13/4 diuresed approximately 1 L negative. Clinical improvement was
observed on 6/10 To treat possible bronchospasm she was given
atrovent/albuterol by MDI four times a day On 11/16 improvement was noted with respect
to her dyspnea , wheezing , and chest "tightness" , and she was switched to
orally Lasix 80 mg. She was discharged with instructions to monitor daily
weights and take orally Lasix 40 mg , with followup with her primary care physician/outpatient
cardiologist Dr. Woller
*Secondary prevention: the patient's admission lipid profile returned LDL
of 107; her statin dose was increased to Simvastatin 80 mg ( and she was
discharged with Lipitor 40 mg ). Her blood pressure remained within
normal limits after increasing her lisinopril dose to 40 twice a day , she was
discharged with this new dose. The patient remained on telemetry over
her hospital course with no issues.
*Anemia: The patient's admission Hct was 32.8 ( baseline of 40 ) and the
patient was asymptomatic from this standpoint. Iron studies were sent and
showed low-normal serum iron of 38 , with iron sat of 12%. She was
discharged with Niferex 150 mg twice a day and ascorbic acid 500 mg twice a day x 1month ,
to be followed up with her primary care physician.
*Pain: Throughout her hospital course , the patient's chronic pain ,
headache , and chest pain was managed with her home regimen of Percocet
5/325 four times a day and acetaminophen as needed
*Endo: Her blood sugars remained in excellent control with home dose of
Avandia 8 twice a day A mildly enlarged thyroid was noted but her TSH was wnl at
0.715.
ADDITIONAL COMMENTS: Please call your doctor or return to the emergency room if you are
experiencing persistent chest pain , shortness of breath ,
lightheadedness/dizziness , and/or palpitations.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
*Please keep your appointments ( or call to reschedule ) with Dr. Rebelo
( 208-745-9232 ).
*Please arrange for a new primary care physician with KTDUOO ( your doctor in the hospital was
Dr. Ma Yeagley , but you can arrange for follow-up with any available
doctor ). Their number is ( 316 ) 042-7495.
*Please remember to measure your weights every day. If your weight
increases and/or you are feeling more short of breath or notice more
swelling in your legs , please call your doctor.
No dictated summary
ENTERED BY: ANESTOS , MISHA J. , M.D. ( RL398 ) 8/26/05 @ 06
****** END OF DISCHARGE ORDERS ******
Document id: 771
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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OA |
Obe |
OSA |
PVD |
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| output/system_intuitive_annotation.xml | intuitive |
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510916525 | PUO | 07122247 | | 7763144 | 6/24/2006 12:00:00 a.m. | not applicable | | DIS | Admission Date: 9/9/2006 Report Status:
Discharge Date: 8/1/2006
****** FINAL DISCHARGE ORDERS ******
FULVIO , ANGILA P 456-02-11-5
Awest Drive , Natuccotroit E Rouge , Florida 28166
Service: RNM
DISCHARGE PATIENT ON: 10/8/06 AT 02:30 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PILLING , WEI NYLA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL NEBULIZER 2.5 MG inhaled every 4 hours
as needed Shortness of Breath
ALLOPURINOL 300 MG orally DAILY
ATENOLOL 100 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally twice a day
VITAMIN D3 ( CHOLECALCIFEROL ) 400 UNITS orally DAILY
PEPCID ( FAMOTIDINE ) 20 MG orally BEDTIME
LASIX ( FUROSEMIDE ) 120 MG orally twice a day
AMARYL ( GLIMEPIRIDE ) 4 MG orally DAILY
Number of Doses Required ( approximate ): 4
LANTUS ( INSULIN GLARGINE ) 31 UNITS subcutaneously DAILY
METOLAZONE 2.5 MG orally DAILY
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 500 MG orally three times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
NIFEREX-150 150 MG orally twice a day
TACROLIMUS 1 MG orally every 12 hours Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
SPIRIVA ( TIOTROPIUM ) 18 MCG inhaled DAILY
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally EVERY OTHER DAY
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Norseth - renal transplant Monday 2/18/06 at 9:00 am scheduled ,
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
acute renal failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
not applicable
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pain hypotension
CAD ( coronary artery disease ) CHF ( congestive heart failure ) diabetes
( diabetes mellitus type 2 ) renal transplant ( kidney
transplant ) AAA repair ( abdominal aortic aneurysm ) open chole
( cholelithiasis ) hypertension ( hypertension ) gout
( gout ) a fib ( atrial fibrillation ) copd ( chronic obstructive
pulmonary disease ) obstructive sleep apnea ( sleep
apnea ) gerd ( gastroesophageal reflux disease ) hyperlipidemia
( hyperlipidemia )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ultrasound guided renal transplant biopsy
BRIEF RESUME OF HOSPITAL COURSE:
CC: elevated creatinine
HPI: 72 year-old male with ESRD history of living unrelated renal transplant
11/15 , and diastolic dysfunction who presented to clinic today with
slow , progressive rise in creatinine. This has been
thought to be secondary to his extensive diuresis for CHF , however
his creatinine is now up to 2.6. He will be admitted for a renal
transplant biopsy to r/o rejection vs. polyoma virus vs. medication
toxicity vs. ATN.
********************************************
PMH/PSH:
1. ESRD 2/2 FSGS
- on HD x 3 mos via L AVF
- LURTx 6/13/04 ( from best friend ) , baseline Cr 1.4-1.6 range
- admission 5/25 with hypertension , ARF while on ACE inhibitor
2. Type 2 DM
3. HTN
4. Gout - started pre-Tx
- L and R toes , Rx as needed with steroids
5. Obesity
6. A-fib - on coumadin
7. CAD f/b Dr. Isaac Vause
- PPM for SSS 1999 , but not currently pacer-dependent - for pacemaker
generator change 5/15
- PTCA x 1 to LAD 1997 , PTCA x 2 to RCA 2001
- 10/18 sestamibi 6.2 mets , no evidence ischemia at mod workload ( but
did get jaw pain ) , EF 60% no WMA
- 2003 2D echo EF 45%
8. COPD , FEV1 1.3 , 60% predicted
9. Obstructive sleep apnea - on CPAP x 5yrs
10. fibromyalgia
11. infrarenal AAA repair 8/4
12. cholecystitis and cholecystectomy
13. history of forniceal rupture with R ureteral stent 9/24
14. Hx LGIB with cautery to AVM in asc colon and removal of polyp 2002
15. GERD
16. Hyperlipidemia
*******************************************
Medications on admission:
Immunosuppression
1. Tacrolimus 1 mg twice a day 2. Cellcept 500 mg three times a day
Other meds:
1. Atenolol 100 mg every day
2. ASA 325 mg every day ( off for 2 weeks )
3. Plavix 75 mg every day ( off for 2 weeks )
4. Pepcid 20 mg twice a day
5. CaCarb 500 mg twice a day
6. Lipitor 40 mg every day
7. Lasix 120 mg twice a day
8. Allopurinol 300 mg every day
9. Vitamin D 400 units every day
10. Niferex 150 mg twice a day
11. Amaryl 4 mg every day
12. Quinine 325 mg as needed
13. Prednisone 10 mg as needed gout flare
14. Bactrim SS M/W/F
15. Lantus 31 units every day
16. Coumadin ( off for 2 weeks )
17. Spiriva MDI
18. Albuterol MDI
19. Metolozone 2.5 mg every day
*********************************************
Physical Exam: Vitals: T98.6 P62 BP 120/50 O2 98% Sat RA
General: well appearing male , NAD
HEENT: oropharynx clear , neck supple , no lymphadenopathy
CVS: distant heart sounds , +S1/S2 , no m/r/g , mild JVD
Lungs: mild b/l expiratory wheeze , no rales
Abdomen: +BS , obese ,
Allograft: RIF , mildly tender , incision well healed
Ext: teds in place , 2+ bilateral lower extremity edema
MSK: FROM throughout Neuro: grossly intact
*********************************************
Hospital Course: Mr. Fulvio is a 72 year old male history of renal transplant
2004 with history of diastolic dysfunction presented to clinic with
elevated creatinine 2.6 from baseline 1.7. Patient was admitted for renal
transplant biopsy.
1. Renal - Mr. Fulvio underwent a ultrasound guided renal
transplant biopsy on 3/18/06. Biopsy without complication. Post biopsy
hematocrit stable. Preliminary results of biopsy indicate chronic
allograft nephropathy. Final results will be followed as an out patient.
2. Immunosuppression - He was maintained on his out patient
immunosuppression regimen.
3. Mr. Fulvio was discharged to home in stable condition. He will
follow up with Dr. Norseth in renal transplant clinic on 9/3/06.
ADDITIONAL COMMENTS: 1. Please return to the emergency room if you have pain over transplant
kidney , blood in your urine , lightheadedness , or dizziness.
2. Please call clinic with any further questions.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ROBARDS , LYNNETTE I. , PA-C ( ZW96 ) 10/8/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 772
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
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OSA |
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065762049 | PUO | 48943933 | | 348097 | 6/2/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/25/1995 Report Status: Signed
Discharge Date: 6/14/1995
IDENTIFICATION: This is a 65 year old woman with a history of
insulin dependent diabetes mellitus and
cerebrovascular accident , admitted with new onset renal failure.
HISTORY OF PRESENT ILLNESS: This is a 65 year old woman with a
history of insulin dependent diabetes
mellitus , cerebrovascular accident , and congestive heart failure.
She went for a regular clinic appointment the day of admission and
vomited. Primary M.D. diagnosed hypotension and dehydration and
referred her to Pagham University Of Emergency Room. On
arrival to the Emergency Room she complained of loose stools per
her ostomy times three weeks. She had a diverting transverse
colostomy secondary to a perirectal abscess. She also was passing
loose stool per rectum. She vomited two times in the week prior to
admission. Creatinine was noted to be 5.0 with a history of
creatinine of 3.3 in January of 1995 and 1.5 in February of 1994. She
notes her urine output has not changed in the past few weeks. She
reports having Foley in place for about a month after surgery for
the perirectal abscess , in October of 1995. She had pain and
bleeding after discontinuation of the Foley. In the winter of 1994
the patient had increasing creatinine and was seen at Nashawn Systems/enmark Memorial Hospital And Health Systems She was told she had NSAID
induced acute renal failure. Creatinine decreased after Motrin was
discontinued.
PAST MEDICAL HISTORY: She has a past medical history of
hypertension since 1978 , insulin dependent
diabetes mellitus , initially treated with orally medication ,
cerebrovascular accident in 1994 , a right posterior parietal , right
frontal lobe , bilateral cerebellar attenuation , arthritis , history
of Motrin use which was discontinued in the winter of 1994 , a
questionable history of arrhythmias , positive PPD diagnosed in 1993
which was treated with inhaled , history of bilateral deep venous
thrombosis in May of 1995 , secondary to postoperative bedrest , an
ostomy for perirectal abscess in October of 1995 , and history of
congestive heart failure in October of 1995 , for which she was
intubated.
MEDICATIONS: Medications include Cardizem 120 every day ,
Hydrochlorothiazide 50 every day , Vasotec 20 twice a day ,
Clonidine 0.5 twice a day , NPH 18 units every day before noon , and Coumadin 3 mg orally
every bedtime
SOCIAL HISTORY: She has no history of tobacco or alcohol use.
She lives with her daughter and has VNA and Home
Health Aide every day.
FAMILY HISTORY: Her father died of a myocardial infarction at
40 years of age , positive hypertension and
diabetes. Mother died of alcohol abuse and cirrhosis.
PHYSICAL EXAMINATION: Temperature is 96 , heart rate 68 ,
respiratory rate 16 , blood pressure 96/54 ,
and she was 98 percent on room air. Significant findings on
physical examination included her chest being clear to
auscultation. Her cardiac examination showed a regular rate and
rhythm with no murmurs , rubs or gallops. Abdominal examination was
soft , non-tender , non-distended , and obese with good bowel sounds.
Colostomy was in place , pink and bag had loose stool. Rectal was
guaiac negative. Extremities showed trace pedal edema.
Neurological was grossly intact. Strength in her upper extremities
was 3/5 and lower extremities was 4/5.
LABORATORY DATA: Labs on admission showed a sodium of 139 ,
potassium of 4.5 , chloride of 105 , bicarbonate
14 , BUN 102 , and creatinine of 4.7. Anion gap was 20. White count
was 7 , hematocrit 39 , and platelets were 283 , 000. EKG showed a
normal sinus rhythm at 75 with normal intervals and no acute ST-T
wave changes. Chest x-ray showed no congestive heart failure.
HOSPITAL COURSE: ( 1 ) Acute renal failure - This was felt to be
secondary , most likely , to dehydration from viral
enteritis , superimposed on chronic renal insufficiency , secondary
to hypertension and diabetes. Her Hydrochlorothiazide and Vasotec
were discontinued. She was given gentle intravenous hydration with half
normal saline. Creatinine was seen to be decreasing. The
patient's creatinine gradually decreased and was 1.6 at discharge.
This was to be followed up as an outpatient. ( 2 ) GI - It was felt
that the patient had viral enteritis. Stool cultures were all
negative. Gradually the patient began to have less diarrhea and
was able to take good orally intake. This was stable at discharge.
( 3 ) Deep venous thrombosis - The patient's INR on admission was
4.8. Therefore , her Coumadin was held for several days and at
discharge her INR was 2.2. ( 4 ) Surgery - The patient was evaluated
by Service while in the hospital and it was felt that
eventually the patient would have a take-down of her colostomy and
would reevaluate once the patient was medically stable as an
outpatient.
MEDICATIONS ON DISCHARGE: Discharge medications included
Cardizem CD 120 mg every day , NPH insulin 9
units subcutaneous every day before noon , Clonidine 0.5 mg orally every day , cisapride
10 mg orally four times a day , Vasotec 20 mg orally twice a day , and Coumadin 3 mg
orally every bedtime
DISPOSITION: The patient was discharged to follow up in
Tempson Neistone Ino Hospital with Dr. Martinelli
Dictated By: DULCIE SCOVEL , M.D. UM52
Attending: JEFFERY C. D. HUFF , M.D. IN4
EC520/1520
Batch: 19526 Index No. X1CBSB3KEU D: 5/9/95
T: 8/10/95
Document id: 773
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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266108089 | PUO | 32848205 | | 704631 | 1/4/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/29/1992 Report Status: Signed
Discharge Date: 7/10/1992
DISCHARGE DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: Ms. Katke is a 32 year old woman who
presented with intermittent chest pain
and shortness of breath of two days duration. Her cardiac risk
factors include a positive family history but no diabetes , no
cholesterol , no hypertension , and no history of tobacco use. The
patient was in good health until two days prior to admission. At
that time , she noted 2/10 substernal chest pain radiating to the
left arm accompanied by shortness of breath and dizziness. There
was no nausea , vomiting , or diaphoresis. The pain lasted
approximately 45 minutes and did not change with activity or
position. The pain and shortness of breath recurred approximately
two times that day. She had a fourth episode on the morning of
admission while watching television. She went to the Healtstone Hospital where there was no improvement. An EKG there showed
flipped T waves across her precordium. The patient improved with
oxygen there. The pain recurred during an ambulance ride to the
Pagham University Of where it was again relieved with
oxygen. The patient has no prior history of chest pain ,
palpitations , or shortness of breath. She denies orthopnea ,
paroxysmal nocturnal dyspnea , edema , or previous dyspnea on
exertion. PAST MEDICAL HISTORY: Chronic low back pain. PAST
SURGICAL HISTORY: Status post cesarean section in 1986. CURRENT
MEDICATIONS: None. ALLERGIES: Tylenol with Codeine. FAMILY
HISTORY: Both her mother and father died of myocardial infarction ,
the mother at age 50 and the father at age 74. The patient has a
sister who underwent a coronary artery bypass graft at age 37. The
patient denies alcohol , tobacco use , and drug use.
PHYSICAL EXAMINATION: The patient was an obese Hispanic woman who
was in no acute distress. Her blood
pressure was 110/80 and her pulse was 100 and regular. HEENT:
Examination was within normal limits. NECK: Supple. CHEST: Clear
to auscultation and percussion. CARDIOVASCULAR: Examination
showed no jugular venous distention , S1 and S2 were regular with no
S3 , S4 , or murmur , and carotids were 2+/2+ with no bruits. ABDOMEN:
Obese , soft , and non-tender with good bowel sounds. EXTREMITIES:
Femorals showed no ruits , there was no cyanosis , clubbing , or
edema , and there were 2+/2+ dorsalis pedis and posterior tibial
pulses bilaterally. NEUROLOGICAL: The patient was alert and
oriented , cranial nerves II-XII were intact , and strength and
reflexes were symmetric.
LABORATORY EXAMINATION: On admission , cholesterol was 202 ,
triglycerides 316 , BUN 12 , creatinine 1.3 ,
hematocrit 42.2. EKG on admission showed normal sinus rhythm at a
rate of 92 and an axis of negative 12. Intervals were 0.17 , 0.07 ,
and 0.35. There was evidence of poor R wave progression and
flipped T in leads V1 through V6.
HOSPITAL COURSE: This is a 32 year old woman with no prior cardiac
history who presents with chest pain at rest. She
has a strong family history and high triglycerides which makes us
question if there is a genetic predisposition for coronary artery
disease. Her EKG is clearly abnormal , however , it is unclear if
these are new or old changes. Patient was put on a rule out
myocardial infarction protocol and started on Nitrol Paste ,
Lopressor , and Aspirin. Her CPK initially were 243 with 2 MB and
later decreased to 202 , 141 , 132 , and 88. An echocardiogram done
during this admission showed an ejection fraction of 60% , mild
hypokinesis of the inferoposterior walls , and slight apical
hypokinesis of the right ventricle with a question of prior
infarction. The patient underwent an initial exercise test during
which she went three minutes and 23 seconds on a standard Bruce
protocol. There was no evidence of ischemia. On a second exercise
test , the patient completed seven minutes of a Bruce protocol
stopping secondary to dyspnea and leg fatigue. An EKG during the
protocol showed minimal ST depressions in the inferior leads with
recovery and flipped T in the anterior leads. The impression was
that there was no evidence for ischemia although the patient did
not achieve a maximal heart rate. There appeared to be diminished
exercise tolerance. Patient was discharged with a follow-up
appointment in the KTDUOO Clinic.
DISPOSITION: DISCHARGE MEDICATIONS: Isordil 10 mg orally three times a day ,
Lopressor 100 mg orally twice a day , Ecotrin 325 mg one
every day , Micronase 5 mg orally every day , and sublingual Nitroglycerin as needed
chest pain.
GO615/1511
EVELYNE TEPPER , M.D. ML3 D: 1/9/92
Batch: 1548 Report: L4881Y31 T: 2/6/92
Dictated By: STACIE C. HALECHKO , M.D.
Document id: 774
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
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N |
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N |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
359699199 | PUO | 79728386 | | 752227 | 1/21/2000 12:00:00 a.m. | ANGINA | Signed | DIS | Admission Date: 3/27/2000 Report Status: Signed
Discharge Date: 7/24/2000
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION.
SIGNIFICANT PROBLEMS: 1. CORONARY ARTERY DISEASE.
2. HYPERCHOLESTEROLEMIA.
3. HYPERTENSION.
4. ANEMIA.
HISTORY OF PRESENT ILLNESS: Ms. Chalfin is an 80 year old female who
presents to an outside hospital with
chest pain. She states the night prior to admission she felt some
shortness of breath and tightness in her chest upon laying down.
She took one sublingual Nitroglycerin without relief. Thirty
minutes later took another sublingual Nitroglycerin , again without
relief. Shortness of breath was accompanied with increasing
feeling of chest tightness rated approximately 8/10. Took a third
Nitroglycerin without relief and felt her breathing became wheezy.
She then drove herself to an outside hospital for evaluation. She
was there treated with intravenous Lasix , morphine and
Nitroglycerin with resolution of her pain. EKG at outside hospital
showed anterolateral ST depression and her enzymes were negative
ruling out for myocardial infarction. She has cardiac risk factors
of hypertension , hypercholesterolemia and age. Her cardiac
symptomatology began in the fall of 1999 when she began to
experience chest discomfort with exertion and rest. Evaluation by
Dr. Lorean Kadow showed high cholesterol with an LDL 141 , EKG with LVH
and nonspecific T wave flattening. A Thallium stress test in
August of 1999 was three minutes , fifty-two seconds duration ,
stopped secondary to shortness of breath , and there were
inferolateral ST depressions with inferior apical ischemia on
imaging. She had her symptoms managed medically with cholesterol
lowering and antihypertensive therapy.
PAST MEDICAL HISTORY: Significant for hypertension ,
hypercholesterolemia , angina , Paget's
disease , anemia , osteoarthritis.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She is widowed , she lives alone. Has many friends
and support in the area. Owns her own store. No
tobacco , no alcohol , no drug use.
REVIEW OF SYSTEMS: Positive for orthopnea increasing over the
past month. No palpitations. No claudication.
No lower extremity edema. No syncope. No melena , diarrhea ,
hemoptysis or bright red blood per rectum.
ALLERGIES: No known drug allergies.
ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS - She is afebrile at
98.3 degrees , heart rate 52 , blood
pressure 160/68 , oxygen saturation 97% on room air. GENERAL - She
is a petite , elderly woman sitting in bed in no apparent distress.
HEENT - Pupils are equally round and reactive to light. Oropharynx
is clear. NECK - JV pressure approximately 6 cm of water , 2+
carotids , no bruits. LUNGS - Crackles bilaterally at the bases , no
wheezing. HEART: Distant heart sounds. S1 , S2. Soft grade I/VI
systolic ejection murmur. No gallop. ABDOMEN - Soft , non-tender ,
nondistended. Normal bowel sounds. No masses , guarding or
rebound. EXTREMITIES: Warm. No clubbing , cyanosis or edema , 1+
dorsalis pedis pulses bilaterally. NEURO: Nonfocal.
ADMISSION LABORATORY DATA: Significant for a sodium of 140 ,
potassium of 4.4 , BUN of 40 , creatinine
of 1.6. CK of 459 with an MB of 28.7. White blood cell count of
8 , 000 , hematocrit 26.9 , platelet count 238. Urinalysis was
negative. EKG on admission showed normal sinus rhythm at 60 beats
per minute with ST segment depression V4 through V6 approximately 1
mm and approximately 1 mm ST depression in lead II.
HOSPITAL COURSE: Ms. Chalfin was admitted to Pagham University Of for evaluation of her angina after
ruling out at an outside hospital , however , on presentation her
laboratory values were consistent with a myocardial infarction and
her hospital course is summarized as follows.
1. CARDIOVASCULAR: Ms. Chalfin ruled in for a myocardial infarction
with a peak CK of 459 with an MB of 28.7. This decreased to 328
with an MB of 15.4 the following morning. Her troponin was 15.
She , however , remained asymptomatic and pain free throughout her
hospitalization. She underwent cardiac catheterization on April , 2000 which showed an okay left main , LAD with proximal 90%
stenosis , which underwent PTCA and stenting with good result , an
osteal D-1 80% lesion which underwent PTCA with good result , a
totally occluded proximal left circumflex and a right coronary with
a proximal 30% to 40% stenosis. She tolerated this procedure well
and without complications. Her medical regimen was altered to
include beta blockade , ACE inhibition and antihypertensives and
ischemics , as outlined below. Of note , left ventriculogram on her
catheterization showed anterior hypokinesis with 3+ mitral
regurgitation.
2. ANEMIA: Ms. Chalfin has a known normochromic , normocytic anemia
which was worked up during this hospitalization. She had a
hematocrit of 26.9 on admission for which she was transfused one
unit of packed red blood cells. Her workup showed an iron of 74 , a
TIBC of 244 , a ferritin of 224 , B-12 of 241 ( borderline low ).
Folate and Epogen levels were pending at the time of discharge.
She also had a TSH which was normal at 2.86 , reticulocyte count of
3% and a pending serum protein electrophoresis. She was seen by
the Hematology Consult Service and was scheduled for follow-up with
Dr. Donehoo in the Hematology Clinic. Her hematocrit at the time
of discharge was 30.
Ms. Chalfin was stable for discharge on February , 2000. Follow-up
with Dr. Shavonne Mainer in PRMC Cardiovascular Group on March at
1:00 p.m. and with Dr. Filomena Donehoo in the Skill Snerkernfairmri Rehab Hematology Clinic.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily , iron 300 mg three
times a day , Hydrochlorothiazide 25 mg
daily , Lisinopril 5 mg daily , multivitamin one daily , Relafen 500
mg orally a day , Imdur 60 mg orally a day , Plavix 75 mg daily for
29 days , Lipitor 40 mg daily , Atenolol 25 mg orally a day ,
magnesium oxide 420 mg daily.
Dictated By: GENNY BARRETTE , M.D. SS2
Attending: EARNESTINE M. FIERMONTE , M.D. ND6
WB156/5651
Batch: 85008 Index No. Q0HT4W96OW D: 6/23
T: 6/23
CC: 1. EARNESTINE M. FIERMONTE , M.D. ND6
2. SHAVONNE D. MAINER , M.D. QP3
3. FILOMENA M. DONEHOO , M.D. AQ7
4. DR. NERI , none
Document id: 775
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
N |
N |
N |
- |
N |
N |
N |
N |
N |
N |
N |
593491386 | PUO | 67745627 | | 7249862 | 5/1/2005 12:00:00 a.m. | ? ISCHEMIA | Signed | DIS | Admission Date: 7/7/2005 Report Status: Signed
Discharge Date: 6/26/2005
ATTENDING: KATCSMORAK , CARRI MD
ADMISSION DIAGNOSIS: Chest pain/SOB.
HISTORY OF PRESENT ILLNESS: In brief , this is an 85-year-old man
with ischemic cardiomyopathy , atrial fibrillation , CRI , and prior
mitral valve replacement , and bioprosthesis presented with DE
compensated heart failure , increasing shortness of breath , and
chest pain. He has complex cardiovascular history and
progressive symptoms of heart failure. He had CABG in 1980 and
1990 and multiple PCI most recently in 6/29 with intervention on
SVG to the PDA. He had MVR in 1980 with bioprosthesis. He had
implantation of a CRT pacemaker with ICV function in 3/7 His
history of heart failure dates back ten years , but he has had
more marked decline over the past two years currently has SOB
typically , does not have orthopnea , PND , or leg edema. He has
been admitted to the Osri Medical Center several times for
management of CHF in 1/14 After diuresis he states he could
walk up to 30 yards on a flat surface , but could not walk up
steps. He was at baseline until 3/29/05 when he had recurrent
episodes of chest pain respondive to sublingual nitroglycerin
associated with diaphoresis , nausea , palpitations , and
lightheadedness. On 10/17/05 , he had acute onset of shortness of
breath at rest after eating. He was admitted to the Osri Medical Center and treated with diuresis and anticoagulation. MI was
excluded by serial enzymes. He was noted to be anemic. Other
lab values were consistent with hemolysis. As a part of his
workup , during ETT MIBI , he was able to walk 2 minutes 52 seconds
on the standard Bruce protocol , peak HR 94 , echo showed a dilated
LV , EF of 34% , mild global hypokinesis , and septal and apical
akinesis , enlarged dixed defect in the inferior apical wall with
moderate fixed defect in the inferior apical segment , and a small
amount of reversibility was noted in a mild inferior lateral
defect. Echocardiogram at PUO on 5/13 showed EF of 35% , septal
and apical akinesis , with normal RV function , mitral
bioprosthesis , mildly elevated antegrade velocities , mild
perivalvular regurgitation , moderate TR , moderate pulmonary
hypertension , SVP of 48 mmHg and PA plus RA pressure , transferred
for evaluation and management of chest pain at Osri Medical Center with ? need for catheterization.
PAST MEDICAL HISTORY: CHF , EF is 25% , atrial fibrillation ,
chronic renal insufficiency with baseline creatinine of 1.5 , mild
COPD , status post AAA repair in 1995 , BPH , TIA/CVA , anemia , on
home O2 , status post AICD , pacer , status post sinus arrest in
1993 , ischemic cardiomyopathy , CAD , status post mitral valve
replacement , porcine valve placed in 1980 , and status post CABG
x2. Please see HPI for further information.
MEDICATIONS: At home , Flomax 0.4 , Proscar 5 mg daily , Lipitor 80
mg daily , Toprol 50 mg daily , Lasix 40 mg twice a day , aspirin 81 mg
daily , and Imdur 90 mg daily , Plavix 75 mg daily , hydralazine 10
mg three times a day , Coumadin , Advair , and Combivent.
TRANSFER MEDICATIONS: As above plus Lasix increased to 80 mg
twice a day , and Imdur to 120 daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married and lives with wife. Family very
involved. A former smoker , quit in 1980.
FAMILY HISTORY: Alcohol: No history of abuse. He is retired
supervisor in water department. Family history is otherwise
noncontributory.
PHYSICAL EXAMINATION: NAD , 60s to 70s , afebrile , and BP is 100
to 110 over 50 to 60. Saturating at 89% on two liters , 94% on
four liters , JVD 12 , mild HJR , bronchial breath sounds , dullness
at bases , and no rales. Cardiac is irregularly regular 2/6 mid
peaking SVM , and 2/6 HSM at apex. Abdomen: Benign. No HSM.
Extremities are warm without edema.
LABORATORY DATA: EKG underlying atrial fibrillation with
ventricular pacing at 70. Labs of note , hematocrit 27 , BUN 38 ,
creatinine 1.8 , sodium 140 , BNP brain natriuretic peptide 482 , CK
61 , troponin 0.1 , haptoglobin less than assay , reticulocyte count
6.2 , and LDH 679.
HOSPITAL COURSE BY SYSTEM:
Cardiovascular: An 84-year-old man with complex medical issues
elderly and debilitated currently with last three to four heart
failures secondary to ischemic cardiomyopathy. He has undergone
multiples attempts of revascularization including CABG x2 ,
repeated PCI , most recently in 6/29 with intervention on SVG.
Revascularization options at this point are quite limited , the
amount of active ischemic burden suggested by his recent
submaximal MIBI ETT is unlikely to account for the severity of
the symptoms that he is experiencing. Unfortunately , his overall
debilitated state makes surgical intervention unlikely to be
tolerated. He was moderately overloaded at the time of arrival
and was aggressively diuresed. An echocardiogram was performed
on 7/24/05 , which showed moderate known perivalvular mitral
valve leakage and an EF of 30%. A right heart catheterization
was performed on 8/23/05 which showed RA pressure 7/7 , mean 5;
RV 52/1 , mean 4; PA 54/17 , mean 34; and PW 21/40 , mean 23. In
summary , overall dry after aggressive diuresis; however , with
large amounts of mitral regurgitation. For this reason , it was
discussed with the family possible clamping for his mitral valve
as he is not a candidate for mitral valve replacement given his
end-stage heart and generally frail state. Plan as of the time
of this dictation is to undergo TEE on 2/18/05 to evaluate
whether clamping of the mitral valve would be possible and then
to have mitral valve clamping later this week. The patient was
diuresed effectively with Lasix 200 mg intravenous twice a day with metolazone.
The patient was also started on digoxin and Aldactone. He had a
bump in his creatinine to 2.2 on 10/3/05 and then it continued
to rise and for this reason diuresis was held as of 2/10/05. As
for rhythm , paced , normal sinus rhythm , on telemetry. O 2/6/05
brief round of V-tach , paced out of it. An AICD and pacer in
place.
Pulmonary: COPD. On O2 at home , however , with increased
desaturation here in the hospital to mid 80s while walking ,
thought secondary to his extreme mitral valve regurgitation. On
Advair , Combivent , and albuterol nebulizer.
Renal: Elevated creatinine in mid 2s , baseline CRI creatinine
1.5 , and all medications were renally dosed.
FEN: Potassium and Magnesium scales , twice a day electrolytes given
diuresis.
Heme: Hemolytic anemia with bilirubin of 3.0 likely secondary to
mitral valve regurgitation , not surgical candidate , baseline
unknown. Given transfusion on 2/7/05. Transfuse for
hematocrit less than 30. PTT goal of 60 to 80 on heparin. He
will eventually be put on Coumadin.
CODE: Code status was changed during the time of this admission
to DNR/DNI/no pressors.
This is an interval dictation , please see addendum for remaining
hospital course and for discharge medications.
eScription document: 1-2260161 ISSten Tel
CC: Jackson Part M.D.
Pla
Wa Falls Greenchdi
Ta Ox Terb
Dictated By: GIRARDI , ABE
Attending: KATCSMORAK , CARRI
Dictation ID 5444930
D: 2/18/05
T: 2/18/05
Document id: 776
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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983279178 | PUO | 04309927 | | 9958894 | 10/9/2005 12:00:00 a.m. | RIGHT KNEE EFFUSION | Signed | DIS | Admission Date: 3/21/2005 Report Status: Signed
Discharge Date: 11/14/2005
ATTENDING: IN , DERICK M.D.
PRINCIPAL DIAGNOSES:
1. Knee pain.
2. Chronic venous stasis.
3. Lithium toxicity.
4. Obesity.
HISTORY OF PRESENT ILLNESS:
This is a 50-year-old female with a history of hypertension ,
diabetes , obesity , as well as a schizophrenia and bipolar
disorder , presents with right knee swelling , redness and pain for
one week. The patient lives alone at home and has two brothers
who periodically check in on her. She was visited by her brother
yesterday and found that her right knee had been swollen red and
tender for about a week. After he noted this , he brought her to
the emergency department. The patient states that the leg has
made it impossible for her to ambulate. She denies trauma to the
area recently. She also denies fevers , chills , shortness of
breath or chest pain. There is no nausea , vomiting , constipation
or diarrhea.
PAST MEDICAL HISTORY:
1. Ovarian cystadenofibroma , status post TAH-BSO in 8/18
2. Obesity.
3. Hypertension.
4. Diabetes.
5. Hyperlipidemia.
6. Schizophrenia.
7. Bipolar disorder.
8. Obstructive sleep apnea , on home BiPAP.
9. History of laparoscopy for infertility.
ALLERGIES:
No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lisinopril 10 mg daily.
2. Lipitor 40 mg daily.
3. Klonopin.
4. MetroGel orally at bedtime.
5. Lithium 900 mg at bedtime.
6. Acebutolol 200 mg daily.
7. Risperdal 0.5 mg at bedtime.
SOCIAL HISTORY:
The patient lives at home alone. She smokes tobacco , but denies
ethanol. She does drink several bottles of soda per day. Her
brother , Telma Fausett , did involve in her care; his phone number
is 932-691-5659 , he can also be reached at 490-726-2635. Her
other brother , Telma Fausett , is also involved in her care and can
be reached at 211-311-6940.
PHYSICAL EXAMINATION:
Temperature 97.5 , pulse 42 , blood pressure 107/58 , respirations
20 , and oxygen saturation 97%. In general , this is an obese
female , she is thai-speaking mostly. She appears unkempt and
in discomfort somewhat because of her right knee pain. She is no
acute distress. Cardiovascular exam shows bradycardia , with
normal S1 and S2 , and 2/6 systolic ejection murmur heard best at
the left upper sternal border. Her chest exam showed some low
soft rumbling sounds with inspiration and expiration , otherwise ,
clear to auscultation bilaterally. Abdomen was distended and
obese. There are positive bowel sounds , and no palpable liver
and spleen. Extremity exam showed uncut nails on upper and lower
extremities bilaterally. Her right leg was greater in size than
her left , however , both show significant 2-3+ pitting edema. On
the right ankle area , there appears to be chronic venous stasis
changes with hyperpigmented patch on the lower extremity. There
are less chronic venous stasis changes on the left lower
extremity. There was some mild erythema around the right knee.
This area of redness was poorly demarcated and mildly blanching.
There was painful passive motion on her right knee. Neuro exam
was grossly intact and nonfocal. She did have a coarse tremor in
her upper and lower extremities when asked to use these
extremities for motion.
DIAGNOSTIC DATA:
Electrolytes were significant for a potassium of 5.8 and a
creatinine of 1.6 that was raised from previous creatinine in
2004 of 1.0. Her liver enzymes were unremarkable. Her
hematocrit was 45.5. A UA done on admission was bland , however ,
urine cultures grew greater than a 1000 CFU/mL of coag-negative
Staphylococcus. Her right knee film showed mild effusion , no
fracture. This effusion was tapped and showed 20 white blood
cells , 810 red blood cells. Of the white blood cells , 21% were
PMNs and 75% were lymphocytes. There were no crystals seen.
There were no organisms seen.
ASSESSMENT:
Ms. Fausett is a 50-year-old female with a history of bipolar
disorder , schizophrenia , obstructive sleep apnea , hypertension ,
and diabetes , was admitted for one week of worsening right knee
redness , swelling and pain causing immobility.
HOSPITAL COURSE BY SYSTEM/PROBLEM:
1. Leg swelling: The differential diagnosis that was considered
for her leg swelling included deep venous thrombosis versus
cellulitis versus septic joints versus gout versus chronic
lymphedema with an acute worsening. Infectious causes were
considered less likely given the fact that the patient's white
count was not significantly elevated , ( it was 10.5 with 75%
polys , and 80% lymphs ) , and in fact that she has not had any
fever. The patient was treated empirically , however , as this
diagnosis was unable to be ruled out initially with vancomycin
and Unasyn and then with levofloxacin. The patient was treated
with therapeutic doses of heparin because of the concern of pain
and swelling asymmetrically of the lower extremities. This
continued until lower extremity Doppler studies showed no deep
venous thrombosis in the right femoral or left popliteal veins.
Uric acid levels were checked and shown to be elevated at 8.6 and
again at 8.0. These values suggest that gout may be involved in
this problem , however , there are no crystals and the synovial
fluid making this diagnosis also less likely. Over her hospital
course , the swelling , tenderness and redness of the right knee
decreased significantly. However , the patient's left knee began
to cause her significant pain , requiring oxycodone , Tylenol and
lidocaine patch. Because of concerning renal function with a
creatinine of 1.6 from 1.0 , NSAIDs were held initially , however ,
her creatinine trended down to 1.2 on the day of discharge , and
so she will be discharged with NSAIDs , which are expected to help
her musculoskeletal pain. While in the hospital , she received
Physical Therapy who evaluated the patient and suggested that the
patient would benefit from continued direct physical therapy to
address functional mobility retraining. Short-terms goals
included ambulate 50 feet with minimal assistance with
restrictive device , and to tolerate out of bed to chair for 30
minutes with reports of fatigue.
2. Lithium toxicity: Because of the patient's coarse tremor ,
bradycardia , hypotension , and the fact that she was taking
lithium , encouraged her lithium level to be checked which came
back elevated at 2.7 , ( normal levels between 0.5 and 1.3 ). This
level was concerning because lithium has a very narrow
therapeutic window. Her lithium was held and she was treated
with intravenous fluids , which allowed her creatinine to decrease. It was
thought that she was also somewhat dehydrated on presentation to
the emergency department. Her lithium toxicity could in part
explain for her bradycardia and hypotension as well as her
hypokalemia and renal failure. A psych consult was obtained to
address the question of when and how to restart the lithium. The
psych consultant suggested to check lithium levels daily until
they fell below 0.5 and then should restart the lithium at 300 mg
at bedtime. On the day of discharge , her lithium level was at
1.12. This level should be checked at the nursing facility and
lithium should be restarted at 300 mg at bedtime when the level
is 0.5 or below.
3. Cardiovascular: From a pump standpoint , the patient was
hypovolemic and hypotensive on presentation to the emergency
department. She responded well to normal saline fluid boluses
and given a total of 3 liters over her hospital course. From a
rhythm standpoint , the patient's bradycardia was resolved of
either over beta blockade or lithium toxicity. Her beta-blocker
was held as well as her lithium and her heart rate improved to
the 50 and 60s. We would recommend holding the beta-blocker
until follow up at her primary care physician's office for her
next appointment. From an ischemia standpoint , EKG was performed
which was a poor study that showed perhaps some T-wave inversions
in aVL. However , ACS is unlikely at this time. The patient had
no chest pain.
4. Renal: Acute renal failure on presentation with a creatinine
of 1.6 and 1.0 is likely prerenal versus lithium toxicity versus
a combination of these. A creatinine improved to 1.2 on the day
of discharge.
5. Endocrinology: The patient had a history of diabetes
according to her medical records. Her glucose while admitted
here was in between 90 and 132. These were random glucose draws.
Hemoglobin A1c was checked which came back at 6.2. At this
time , diabetes may or may not be an appropriate diagnosis for her
and she should follow up with her primary care physician with a
fasting blood glucose test.
6. Infectious disease: On initial presentation , the patient
presented with hypotension in the setting of bradycardia and beta
blockade with decreased volume status. There was a concern
initially that this may be cellulitis and she was covered broadly
with Unasyn and vancomycin. However , as she improved , and the
redness and swelling decreased , she was switched to levofloxacin
and committed to complete a seven-day course. She will complete
six more days after discharge from the hospital of levofloxacin.
7. Deconditioning: As mentioned above , Physical Therapy was
consulted and the patient will go to nursing facility for a
temporary rehabilitation. Upon discharge to her home from rehab ,
home safety evaluation should take place to make sure that the
patient is okay to go back home and can give the services that
she needs.
MEDICATIONS ON DISCHARGE:
1. Tylenol 650 mg orally every 4 hours as needed pain.
2. Klonopin 1 mg orally at bedtime.
3. Oxycodone 5 mg to 10 mg orally every 4 hours as needed pain , please hold
if respiration rate is less than 12.
4. Risperdal 0.5 mg orally at bedtime.
5. Levofloxacin 500 mg orally daily for six days after the day of
discharge from Pagham University Of on 3/18/05.
6. Ibuprofen 600 mg every 6 hours as needed pain.
DISCHARGE DISPOSITION:
The patient was discharged in stable condition to a nursing
facility. Please draw blood for lithium level checks daily until
it is below 0.5 , at which time , she should be restarted on
lithium 300 mg orally at bedtime. She will follow up with her
primary care physician , Dr. Buck Diego Moose at Chlais University Hospital , phone number is 271-077-8750. A message
was left in the voice mail of her physician's office to schedule
her an appointment and to contact her brother , Telma Fausett , at
phone number 932-691-5659 or 719-745-4406 , or Telma Fausett at
969-614-1360 to inform them at when the appointment will be. It
was requested that she be seen within two to three weeks.
eScription document: 6-3264224 EMSSten Tel
CC: Buck Moose M.D.
Ter Den Fre
Valelake Rich Ri
CC: Cornelia Zable MD
Verlce Orstamhunt And
Ine Lasla Hou
Dictated By: DESJARDIN , RENDA
Attending: IN , DERICK
Dictation ID 8388485
D: 10/21/05
T: 10/21/05
Document id: 777
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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302833316 | PUO | 14368263 | | 9443849 | 6/27/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/23/2006 Report Status: Signed
Discharge Date:
ATTENDING: STEVINSON , DEE M.D.
ADMISSION DIAGNOSIS: Cardiac arrest.
DISCHARGE DIAGNOSIS: Sepsis/line infection , end-stage renal
disease on hemodialysis.
HISTORY OF PRESENT ILLNESS: This is a 54-year-old female with a
history of cardiomyopathy , hypertension , diabetes type 2 ,
end-stage renal disease on hemodialysis who had a reported
cardiac arrest while receiving dialysis on 3/25/06 in her
outpatient clinic at Des She began to feel nauseated and
then vomited. The patient then reportedly went into VFib and was
shocked once by EMS , resulting in a narrow QRS complex rhythm.
She was intubated , received amiodarone and dopamine , as her BP was
approximately 70s systolic over palpable diastolic. In the ED , a portable
chest x-ray revealed diffuse bilateral opacities , risk of pulmonary edema and
ABG showed respiratory acidosis. patient was transferred to the ICU for further
management.
Of note , she was recently hospitalized at Totin Hospital And Clinic on 7/1/06
through 10/11/07 for initiation of dialysis after her BUN and creatinine
had risen remarkably from baseline. She was then asymptomatic at
that time. A fistulogram and angioplasty of her right AV fistula
was performed on 7/6/06 with prednisone premedication but it
was unsuccessful and therefore a left IJ tunneled dialysis
catheter was inserted on 1/18/06 with the tip ending in the
right atrium. She has since received dialysis treatments with no
complication.
PAST MEDICAL HISTORY: Coronary artery disease ,
CHF , echo in July of 1999 shows moderate left ventricular
hypertrophy of about 65% , diabetes type 2 20 years including with
retinopathy , nephropathy and neuropathic pain , hypertension for
the past 20 years , hypercholesterolemia , status post medullary
CVA July 1999 , right PICA resulting Wallenberg's syndrome ,
morbid obesity , left knee degenerative joint disease ,
iron-deficiency anemia.
ALLERGIES: intravenous contrast , which gives her anaphylaxis ,
tetracycline to an unknown reaction , lisinopril.
HOME MEDICATIONS: At the time of admission include amitriptyline
25 mg orally bedtime , enteric-coated aspirin 325 mg orally daily ,
enalapril 20 mg orally twice a day , Lasix 200 mg orally twice a day , Losartan
50 mg orally daily , Toprol-XL 200 mg orally twice a day , Advair Diskus
250/50 one puff inhaler twice a day , insulin NPH 50 units every day before noon subcutaneously
and 25 units every afternoon subcutaneously , insulin lispro 18 units subcutaneously at
dinner time , Protonix 40 mg orally daily , sevelamer 1200 mg orally
three times a day , tramadol 25 mg orally every 6 hours as needed pain.
SOCIAL HISTORY: This patient is single and has one son and one
grandson. Tashia Sobe is the healthcare proxy and is her son.
She worked 30 years for Sonale Longwood and is currently retired.
PHYSICAL EXAMINATION ON ADMISSION: Her vital signs were
temperature 97.6 , heart rate 72 , BP of 115/66 with mean arterial
pressure of 83 , respiratory 14 , sating 100% on 60% inspired FiO2.
Her CVP at admission was 17 to 20. The patient is an obese woman who was
intubated and responded to voice. Her pupils were 3 to 2 mm
bilaterally. Her extraocular movements were intact. Her chest
exam was notable for diffuse crackles throughout with good air
movement. Cardiac auscultation revealed regular rate and rhythm
with no murmurs , rubs or gallops. Her abdomen was soft ,
nontender and nondistended with normal active bowel sounds.
Extremities showed no edema. Distal pulses were not palpable
bilaterally. She has thickened hyperpigmented skin
changes on both feet.
LABORATORY DATA: Significant labs on admission included a sodium
of 141 , potassium 4.1 , chloride of 102 , bicarb of 31 , BUN 33 ,
creatinine 4.2 with a glucose of 156. Her hematocrit was 32.
An ABG at 10 p.m. of admission on FiO2 of 60% revealed a pH of 7.36 , pCO2 of
52 , pO2 91. Her first set of cardiac enzyme revealed a
creatinine kinase of 116 and the MB fraction of 0.7 and troponin
T of less than assay and lactate of 1.8. Tox screen was
negative. Urinalysis was remarkable for 2+ protein , 3+ blood and
positive for nitrates , and negative for leuks , 4 to 10 white
blood cells , 15 to 25 red blood cells , 2+ bacteria , 1+ squamous
epithelial cells.
IMAGING: Significant imaging at admission was an x-ray for chest
x-ray revealing diffuse bilateral opacities , possible pulmonary
edema versus aspiration pneumonia , an EKG showing normal sinus
rhythm 100 beats per minute with no acute ST changes and old
T-wave inversion in V2.
ASSESSMENT: This is a 55-year-old female with end-stage renal
disease on hemodialysis secondary to diabetes who had an apparent
VFib arrest at hemodialysis on 7/8/06 and was shocked and
admitted to the CCU after being intubated in the Kernan To Dautedi University Of Of ED. The
patient had difficulty weaning from vent and was finally
extubated on 11/11/06. The CCU course was also complicated by
coag-negative Staph grown from a Quinton catheter blood draw.
The catheter was changed to over a wire on 11/11/06. Blood
cultures on 10/24/06 revealed likely Staph aureus growth for
which the patient received continuous vancomycin.
HOSPITAL COURSE BY PROBLEMS:
1. Question of VFib arrest. Whether or not the patient actually
had a VFib arrest seems to be in some doubt as she never had an
arrhythmia on tele here by report and her troponin when peaked at
0.14 on 3/25/06 after receiving one external defibrillator shock
at hemodialysis. We believe what likely happened was a vagal event during
hemodialysis , possibly including a pause misread at VF by the defibrillator.
This explantation is supported by the observation that she has been
continuously having nausea with dialysis and her known a history
of vasovagal episodes in the past. Echo on 3/25/06 shows an EF
of 60 to 65% with mild concentric left ventricular hypertrophy
and no wall motion abnormalities. The patient was continued on
telemetry and treated with her home dose of beta-blocker with
good response.
2. Volume status. The patient is very close to her dry weight
upon discharge , which she gives at 354 pounds by wet scale. She
has been continued on hemodialysis with good results.
3. Possibly infected hemodialysis catheter. The patient had a
single set of coag-negative Staph positive blood cultures from
Quinton catheter on 11/12/06. Line was changed over wire
7/28/06 and was treated with vancomycin dose by renal levels.
The patient continued to grow out coag-negative Staph , positive
blood cultures from 2 out of 2 sets drawn on 8/30/06.
4. Anemia. In the setting of end-stage renal disease her
baseline hematocrit is about 30 and stable.
5. Diabetes type 2. She was treated with a Portland protocol
during her ICU course wand was switched to a long and
short-acting subcutaneous insulin approaching her home dose of NPH twice a day.
6. FEN. The patient was gradually advanced to an orally diet with
no signs of aspiration status post extubation.
7. Prophylaxis. The patient received heparin subcutaneously and
Nexium.
8. Code. The patient is full code. Her healthcare proxy is her
son Tashia Sobe , 633-221-1708.
DISPOSITION: This patient will likely need rehab and is being
screened by physical therapy and OT and will likely be discharged to rehab when
bed is available.
eScription document: 4-3803639 CSSten Tel
Dictated By: DASE , ANNABEL
Attending: STEVINSON , DEE
Dictation ID 1116761
D: 1/17/06
T: 1/17/06
Document id: 778
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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182796277 | PUO | 05941893 | | 196000 | 11/27/2001 12:00:00 a.m. | CHF | | DIS | Admission Date: 7/7/2001 Report Status:
Discharge Date: 9/22/2001
****** DISCHARGE ORDERS ******
CURTSINGER , BEE 070-83-52-9
A Ave , A , 55831
Service: MED
DISCHARGE PATIENT ON: 9/6/01 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: UNTERKOFLER , AL MARYJO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
Override Notice: Override added on 9/6/01 by
GAHRING , DULCIE EVELIA , M.D.
on order for COUMADIN orally ( ref # 14833358 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will follow
Previous override information:
Override added on 2/24/01 by NEGLIO , TABITHA , M.D.
on order for COUMADIN orally ( ref # 43087045 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will follow
ATENOLOL 25 MG orally every day Starting Today ( 8/18 ) HOLD IF:
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 60 MG orally every day Starting Today ( 8/18 )
Instructions: Take 60mg per day for 3 days and then change
dose as per Dr. Neal Kruel instructions
ZESTRIL ( LISINOPRIL ) 7.5 MG orally every day
Starting Today ( 8/18 ) HOLD IF:
Override Notice: Override added on 2/24/01 by
NEGLIO , TABITHA , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 55811989 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
Previous override information:
Override added on 2/24/01 by NEGLIO , TABITHA , M.D.
on order for KCL SLOW REL. orally ( ref # 25306124 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 9/6/01 by
GAHRING , DULCIE EVELIA , M.D.
on order for ZOCOR orally ( ref # 90470435 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will follow
Previous override information:
Override added on 2/24/01 by NEGLIO , TABITHA , M.D.
on order for ZOCOR orally ( ref # 23126506 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will follow
Previous override information:
Override added on 2/24/01 by NEGLIO , TABITHA , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will follow
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/6/01 by
GAHRING , DULCIE EVELIA , M.D.
on order for ERYTHROMYCIN TP ( ref # 69712135 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN &
ERYTHROMYCIN , TOPICAL OR OPHTHALMIC Reason for override:
will follow Previous override information:
Override added on 9/6/01 by GAHRING , DULCIE EVELIA , M.D.
on order for COUMADIN orally ( ref # 14833358 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will follow
Previous override information:
Override added on 2/24/01 by NEGLIO , TABITHA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will follow
METFORMIN 1 , 000 MG orally twice a day Starting Today ( 8/18 )
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
Alert overridden: Override added on 2/7/01 by :
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & OMEPRAZOLE
Reason for override: indicated
VALACYCLOVIR 1 , 000 MG orally every 8 hours X 7 Days
DIET: House / ADA 1800 cals/dy
FOLLOW UP APPOINTMENT( S ):
Dr. Taps on wenesday at PRMC 2/21/01 scheduled ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chronic Afib G-E Reflux HTN
NIDDM , DIET CTRL CHF ( EF 65% ) ( congestive heart failure ) history of
colectomy for diverticulitis ( history of colectomy ) history of ventral hernia
repair ( history of hernia repair ) history of carpal tunnel release ( history of carpal
tunnel repair )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
75 year-old admitted for cHF exacerbation , incr SOB
over past few days , orthopnea and PND. JVP 7 cm , minimal pedal edema ,
L sided failure with diastolic dysfunction. intravenous lasix 40 in ED ,
patient diruesed well and decreased SOB. patient also with
L subcostal pain likely musculoskeltal in
orgin , chronic. No ekg changes , enzymes flat.
CXR enlarged heart with minimal pulm engorgement ,
no pulm edema. Comparison with old CXR
shows increase in size of heart--echo done and shows EF 55% mod MR and
severe TR , slight worsening of MR/TR from old echo , still increased
right sided pressures as well. Plan is for patient to go home on 60 mg
lasix every day and see Dr. viray on wed. as well as daily weights. Back
lesions vesicular and c/with herpes zoster.
ADDITIONAL COMMENTS: please weigh yourself every day. If you gain more than 2 lbs , please
call Dr. Ridgill Your baseline "dry" weight is 185. Please weigh
yourself on scale as soon as you get home to have accurate baseline wei
gt and compare all values to first weight at home. You have herpes
zoster on your back. Call Dr. Kruel if you can't control your pain
with Tylenol. Please page Dr. Galashaw about your eye pain and come to the ED
if pain worse. VNA:page Dr. Taps when he/she sees ms. Curtsinger ( 669 ) 979-2642 OM 32233 and leave call back number.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: REFFITT , LAVETA GUILLERMINA , M.D. ( PV74 ) 2/7/01 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 779
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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628567699 | PUO | 85842554 | | 3664842 | 5/26/2007 12:00:00 a.m. | Gemella morbillorum bacteremia and possible endocarditis | | DIS | Admission Date: 2/21/2007 Report Status:
Discharge Date: 9/29/2007
****** FINAL DISCHARGE ORDERS ******
CYNOVA , JAKE D 491-68-62-3
MI
Service: MED
DISCHARGE PATIENT ON: 1/15/07 AT 03:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE G. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
MEDICATIONS ON ADMISSION:
1. ACETAMINOPHEN 650 MG orally every 6 hours
2. ACETYLSALICYLIC ACID 325 MG orally every day
3. ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
4. DOCUSATE SODIUM 100 MG orally twice a day
5. FLUTICASONE NASAL SPRAY 2 SPRAY nasal every day
6. HEPARIN 5000 UNITS subcutaneously every 8 hours
7. INSULIN GLARGINE 32 UNITS subcutaneously every bedtime
8. KCL SLOW RELEASE TAB 40 MEQ orally twice a day
9. NIFEREX 150 150 MG orally twice a day
10. PANTOPRAZOLE 40 MG orally Q12
11. SENNOSIDES 2 TAB orally twice a day
12. SIMVASTATIN 40 MG orally every bedtime
13. ALBUTEROL NEBULIZER 2.5 MG NEB every 12 hours
14. SARNA UNKNOWN TOP UNKNOWN
15. FUROSEMIDE 80 MG orally every day before noon
16. FLUTICASONE PROPIONATE 110 MCG ORAL INHALER 2 PUFFS inhaled twice a day
17. INSULIN LISPRO SLIDING SCALE subcutaneously
18. LOSARTAN 50 MG orally every day
19. THERAPEUTIC MULTIVITAMINS 1 TAB orally every day
20. MAALOX EXTRA STRENGTH UNKNOWN orally UNKNOWN
21. POLYETHYLENE GLYCOL 17 GM orally every day
22. DIPHENHYDRAMINE 25 MG orally UNKNOWN
23. BISACODYL UNKNOWN orally UNKNOWN
MEDICATIONS ON DISCHARGE:
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: apply to pannus
ACETYLSALICYLIC ACID 325 MG orally DAILY
ALBUTEROL NEBULIZER 2.5 MG NEB every 6 hours as needed Wheezing
ALBUTEROL NEBULIZER 2.5 MG NEB every 12 hours
NEOMYCIN/POLY B/BACITRACIN OINTMENT ( BACITRAC... )
TOPICAL TP DAILY Instructions: apply to right hand lesion
Alert overridden: Override added on 3/10/07 by :
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & NEOMYCIN
SULFATE , TOPICAL OR OPHTH Reason for override: aware
DULCOLAX ( BISACODYL ) 5 MG orally DAILY as needed Constipation
CEFTRIAXONE 2 , 000 MG intravenous DAILY Starting Today ( 5/2 )
Instructions: to end 11/7/07
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FLUTICASONE NASAL SPRAY 1 SPRAY nasal twice a day
FLOVENT HFA ( FLUTICASONE PROPIONATE inhaled )
110 MCG inhaled twice a day
LASIX ( FUROSEMIDE ) 80 MG orally every day before noon Starting IN a.m. ( 7/26 )
Alert overridden: Override added on 7/25/07 by
HORA , LATARSHA T. , M.D. , M.P.H.
on order for LASIX orally ( ref # 533742872 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: no reaction Previous Alert overridden
Override added on 7/25/07 by HORA , LATARSHA T. , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: GENTAMICIN SULFATE &
FUROSEMIDE Reason for override: aware
GENTAMICIN SULFATE 80 MG intravenous DAILY Starting Today ( 5/2 )
Instructions: to continue at least for 2 weeks ( until
11/27/07 )
Override Notice: Override added on 7/25/07 by
HORA , LATARSHA T. , M.D. , M.P.H.
on order for LASIX orally ( ref # 533742872 )
POTENTIALLY SERIOUS INTERACTION: GENTAMICIN SULFATE &
FUROSEMIDE Reason for override: aware
Previous override information:
Override added on 7/25/07 by HORA , LATARSHA T. , M.D. , M.P.H.
on order for LASIX INJ intravenous ( ref # 914108730 )
POTENTIALLY SERIOUS INTERACTION: GENTAMICIN SULFATE &
FUROSEMIDE , INJ Reason for override: aware
HEPARIN 5 , 000 UNITS subcutaneously every 8 hours
Instructions: please give as instructed until patient out of
bed and ambulatory.
LANTUS ( INSULIN GLARGINE ) 36 UNITS subcutaneously BEDTIME
HOLD IF: please give 1/2 dose if NPO
LISPRO ( INSULIN LISPRO )
Sliding Scale ( subcutaneous ) subcutaneously before meals Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
If ordered before every meal administer at same time as , and in addition
to ,
standing insulin aspart order. If ordered HS administer
alone
K-DUR ( KCL SLOW RELEASE TAB ) 40 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
NIFEREX 150 150 MG orally twice a day
PANTOPRAZOLE 40 MG orally every 12 hours
MIRALAX ( POLYETHYLENE GLYCOL ) 17 GM orally DAILY
as needed Constipation Number of Doses Required ( approximate ): 4
SARNA TOPICAL TP DAILY as needed Itching
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 11/18/07 by
CHANT , VONNIE F. , M.D. , M.P.H.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
294155663 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: md aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 11/18/07 by
CHANT , VONNIE F. , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: md aware
DIET: Fluid restriction
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Chanelle Tikkanen 10/29/07 12:45PM scheduled ,
Dr. Dulcie Scovel ( Infectious Disease Clinic ) 7/19/07 8am scheduled ,
Dr. Christine Dario , please call for follow up upon discharge from rehab ,
ALLERGY: Sulfa , TETRACYCLINE
ADMIT DIAGNOSIS:
bacteremia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Gemella morbillorum bacteremia and possible endocarditis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) dm ( diabetes mellitus ) cad ( coronary
artery disease ) af ( atrial
fibrillation ) htn ( hypertension ) hypercholesterolemia ( elevated
cholesterol )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
TEE 6/18/07
BRIEF RESUME OF HOSPITAL COURSE:
CC: fever , +blood cx , r/o endocarditis
--------
HPI:
82 year old man with PMH s/f AVR for aortic stenosis ( August , 2007 ) ,
HTN , hyperlipidemia , CAD history of CABG , CHF ( ef 60% 6/12 ) , atrial
fibrillation with SVR , IDDM , Fe def anemia and hemorrahgic stroke ( ~6
months ago ) who was transferred from Whitein Bapdell Medical Center due to fever ( 2
days prior to presentation ) and positive UA and blood culture
significant for gram positive cocci in clusters. Concern that
patient may have endocarditis. No other systemic signs or
symptoms.
-------
PMH: history of AVR ( 11/29 ) , htn , hyperlipidemia , cad with cabg x3 , a fib with
svr , iddm , anemia , history of hemorrhagic stroke 9/21 , bph , history of suprapubic
cath placement
--------
HOME MEDS:albuterol , asa , sarna , colace ,
fluticasone , lasix 80 every day before noon , lispro SS , lantus 32u every bedtime , simvastatin ,
tylenol as needed , senna , losartan , mvi iron , kcl , protonix , maalox ,
dulcolax , benadryl , miralax
-------
ALL: sulfa--swelling;
tetracycline--swelling
-------
ADMIT EXAM: VS: 98.5F , heart rate 49 , bp160/56 , sat
99%ra gen-nad; heent-o/p clear , no icterius; neck-fupple ,
no lan , fvp to ear; cv-brady irreg irreg , 4/8 sem at lusb;
pulm-crackles at bases b/l; abd-benign; no stigmata of endocarditis;
extr-1+ pitting edema to ankles b/l , 1+pulses b/l ,
wwp
-----
ADMIT LABS: CR 1.9 ( baseline 1.3 ) , hct 31 ( baseline 29 ) , wbc
8
-------
DATA:
CXR: improved L pleural effusion
EKG: a fib@44 , lad , rbbb , old q's inf ( unchanged from prior )
From Rehab: 10/22 gpc in chains ( ?2/4 bottles )
Echo ( TTE ) 1/8 EF 60-65% mild LVH with restrictive filling defect , mild
LAE/RAE , AoV peak grad 52mmHg , mean 2mmHg , peak AoV velocity 3.6 m/s
( elevated but stable )trace MR , Trace TR , PAP 31 +RAP , no veg.
U/A: 3+LE , 7wbc , 1+bact
UCx: 10 , 000 colonies probable pseudomonas
9/16 BCx: Gemella morbillorum ( pansensitive ) , PCN MIC 0.125
( intermediate )
Wound Cx of suprapubic cath insertion site: rare MRSA , few CNS , rare
enterococci
TEE: negative for ring abscess or valvular vegetation.
-------
A/P: 8 Y/O M with mult med problems , history of recent AVR , transferred from
rehab with fever , +U/A , +blood cx's , with concern for
endocarditis given recent AVR. Patient was started on ceftaz and vanco
empirically , then was changed to ceftriaxone and gentamycin once Gemella
morbillorum was identified on in-house blood cultures. Patient remained
afebrile in-house and did not exhibit any significant leukocytosis , or
stigmata of endocardititis. Surveillance cultures drawn after starting
antibiotics have remained negative to date.
--------
1. Cardiovascular ischemia: No CP/CT/CD. Hx of CAD history of CABG continue
with aspirin 325mg orally every day rhythm: patient with hx of AF with SVR. Patient placed
on telemetry for observation. Is bradycardic at
baseline , asymptomatic has refused PPM in the past per report. Some runs
NSVT up to 14 beats , checking twice a day lytes keep Mg>2 and K.4 , no nodal
agents given bradycardia. Pump: hx CHF documented , last EF 60%. patient
appears fluid up , responded well to 60 intravenous lasix x1. patient then appeared
euvolemic and lasix was held , for sev days and became hypervolemic ,
lasix 60mg intravenous repeated and patient restarted on home lasix dose ( 80mg
every day before noon ). Patient's discharge weight is 96.7kg. His dry weight is
approximately 93KG. Discharge weight is 96.7kg. His in/out goal is 500cc
neg daily. -TTE neg for veg , but given high risk , TEE obtained on 7/4
to assess for possible endocarditis. Was negative for ring abscess or
valvular vegetationn. patient will still require treatement for
endocarditis as cannot be entirely ruled out. Held losartan
due to acute worsening of renal function as well as initiation of
gentamycin. patient can resume use once gent is discontinued.
2. Renal: Cr slightly elevated above
baseline ( 1.1-1.3 ) on admit , likely 2/2 CHF and poor forward flow has
declined to near baseline and was 1.4 at time of d/c.
3. GU: patient has hx of BPH and has a suprapubic cathether that was inserted
at the time of surgery due to difficulty to pass foley. At TH patient has
been clamped repeatedly over the last week with PVR checked. patient
without difficulty in house with PVR of 50cc. Urology consulted and
suprapubic catheter pulled without difficulty. Cont dry sterile dressing
daily to wound.
3. ID-Gemella morbillorum in blood , Pseudomonas in urine although
only 10k colonies. patient treated with 5 days of ceftaz , and 4 days
vanc. Decision was made to d/c ceftaz given only 10K colonies
Pseudomonas in urine and some coverage with ceftriaxone and gent ( started
10/8 ) d/c'd vanc 10/24 Will need 6 wks ctx and at least 2 wks gent for
presumed endocarditis. PICC placed 10/8
4. GI -continue protonix 40 Q12 all stools guaiac negative in house.
5. Endocrine -hx of IDDM will titrate up insulin to 36U every bedtime
with insluin aspart SS
6. FEN -cardiac diet -cont MVI -twice a day lytes with goal to keep K/Mg March
7. GI -continue senna and colace
8. Pulm -cont flovent 2 puffs twice a day and albuterol every 12 hours
9. Heme: cont niferex twice a day for iron deficiency anemia. patient also with mild
eosinophilia on diff , should be monitored.
10. Derm: skin tear on right hand , placing neomycin ointment and sterile
dry dressing daily.
Prophylaxis-cont heparin 5000 three times a day -cont protonix 40Q12h
FULL CODE
ADDITIONAL COMMENTS: You were admitted to the hospital with a bacterial blood infection and
possible heart valve infection. You were treated with intravenous
antibiotics and improved.
PLAN:
1. Continue ceftriaxone for 6 weeks to end 11/7/07 and gentamycin to
continue for at least 2 weeks ( at least until 11/27/07 )
2. Please go to your follow up appointment with Dr. Dulcie Scovel in the
infectious disease clinic at the Kernan To Dautedi University Of Of on 7/19/07 at 8AM.
3. Please go to your follow up appointment with Dr. Tikkanen on 10/29/07 at
12:45PM.
4. Please call Dr. Neal Kruel office for follow up upon discharge from rehab.
5. Please stop taking your home losartan medicine while you are on
antibiotics. Dr. Dario can decide when to restart this medicine.
6. After leaving rehab , if you are still on antibiotics , please have your
blood drawn twice a week. Your results will be sent to Dr. Sabal
7. If you have fever , sweats chills , rash , worsening shortness of breath ,
or chest pain please contact your physician or return to the ER.
8. Continue all other home meds.
9. Continue low salt , low fat , low cholesterol diet , continue to restrict
all fluids to 2 liters daily.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please check basic metabolic panel twice daily while actively
diuresing on lasix. Then check basic metabilic panel twice weekly to be to
follow lytes and creatinine while on antibiotics.
2. Please draw CBC with differential once weekly while on gent and
ceftriaxone.
3. Please draw gent trough once weekly and adjust gent dose as needed.
4. Infectious Disease consultant to determine whether gentamicin should be
continued beyond 2 weeks
5. Consider surveillance blood cultures 1 week after completing
antibiotic therapy to document clearance.
6. Please place neomycin ointment to right hand lesion daily and cover with
dry sterile dressing once daily.
7. Cont dry sterile dressing to suprpubic cath site daily until healed.
8. Consider repeat urine cultures 2 weeks after d/c to document clearance
of pseudomonas.
9. Consider restarting losartan after gentamicin is discontinued given
underlying renal insufficiency.
10. Please follow up pending blood cultures ( no growth to date at time of
discharge. )
11. Please do daily weights on patient.
No dictated summary
ENTERED BY: HORA , LATARSHA T. , M.D. , M.P.H. ( LZ161 ) 8/1/07 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 780
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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OSA |
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787149547 | PUO | 17262458 | | 7449979 | 3/24/2003 12:00:00 a.m. | unstable angina , coronary artery disease | | DIS | Admission Date: 10/23/2003 Report Status:
Discharge Date: 5/11/2003
****** DISCHARGE ORDERS ******
HAMMETT , FREDERICA 917-62-64-1
Lertage Pkwy. , Ville U , Vermont 25226
Service: CAR
DISCHARGE PATIENT ON: 7/26/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MAINER , SHAVONNE DEVONA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting Today ( 9/14 )
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 as needed Chest Pain
BACTRIM DS ( TRIMETHOPRIM /SULFAMETHOXAZOLE DO... )
1 TAB orally Qweds and sun
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day Starting Today ( 3/18 )
Instructions: continue indefinitely
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Starting Today ( 9/14 )
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 150 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 2.5 MG orally every day
Alert overridden: Override added on 11/19/03 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Irving Escalante ( in 1 week ) ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
unstable angina , coronary artery disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , COPD , AAA repair , MI X 2 , multiple UTIs , CAP , elevated cholesterol
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
The patient is an 80 year-old woman with a hx of CAD history of MI in 1988 , 1991 , HTN
who presents with chest pain. She had prior MI , last in 1991 and since
then has been chest pain free. The day of admission , she had severe
retrosternal chest pain ( as she reports , similar to her prior angina
but not as severe ) and went to a local hospital. EKG and enzymes
negative , but CXR showed widened mediastinum. There was concern for
dissection , so she underwent CT which was read as positive for
dissection in ascending aorta. She was transferred to PUO CCU for
further care. Repeat CT here showed no dissection but did show
extensive calficiations and luminal disease of the aorta. She was chest
pain free here until 6/9 a.m. when she had chest pain again with ST
depressions in V3-V6 at rest. She was made pain free with nitro and
heparin and transferred to the cardiology floor with presumed unstable
angina given her anginal pain , EKG ischemia changes , but lack of
elevated cardiac enzymes. Echo 6/22/03 demonstrated EF 65% with no
RWMA , no aortic root dissection , no effusion , and normal RV function.
1. CV: On 11/19/03 , cardiac catheterization was performed via radial
approach which revealed 3 vessel coronary disease with 90%
proximal LAD lesion followed by aneursymal segment and subsequent
90% lesion , diffuse non critical LAD disease distally , occluded
and collateralized D1 , occluded and collateralized OM2 , anterior
takeoff RCA with serial non-critical lesions and a mid 70% lesion.
The LAD was stented with a 18mm X 2.5mm Cypher stent with good
results. Patient will be continued on ASA , plavix , statin , metoprolol ,
and lisinopril will be started here ( nitrates will be discontinued ).
Integrillin was also give pericatheterization for 16 hours. Fasting
lipid profile on 3/18 revealed Triglycerides of 122 , HDL 28 ( low ) and
normal cholesterol ( 122 ) , CLDL , VLDL
2. Renal: Patient received mucomyst prior to the contrast CT here which
was continued for her cardiac catheterization. Her renal function
remained stable and normal throughout her hospital stay.
3. GU: She has a history of recurrent UTIs and has been on bactrim
prophylaxis here. Urine cultures on 6/9 and 10/19 have been negative.
4. Dispo: She is being discharged in stable condition with instruction
to follow up with her primary care physician ( Dr. Irving Escalante ).
ADDITIONAL COMMENTS: VNA instruction for BP checks and Physical Therapy
For patient: please continue to take plavix for at least 1 year and
work with primary care physician/Cardiologist whether or not to continue indefinitely
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: EBERLIN , AMAL M. , M.D. ( TS77 ) 7/26/03 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 781
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
N |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
- |
343144868 | PUO | 04432477 | | 181456 | 10/15/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/15/1996 Report Status: Signed
Discharge Date: 10/12/1997
PRINCIPAL DIAGNOSIS: UNSTABLE ANGINA.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old woman
with adult onset diabetes mellitus ,
hypertension admitted with chest pain , bradycardia , decreased blood
pressure , no previous history of chest symptoms. Risk factors
include positive adult onset diabetes mellitus , hypertension ,
smoker , elevated cholesterol , no family history. Her present
history is notable for mid sternal chest pressure at three out of
ten while sitting and watching television. The pain did not
radiate. There was no shortness of breath , diaphoresis or nausea ,
except for pressure on left side of neck which is typical for her
when her blood pressure is elevated. The patient took Nifedipine
without relief and went to the bedroom to rest. There the pressure
became pain , three to four out of ten. She took Cardizem without
relief. She called EMS. The pain was relieved with the EMTs gave
nitroglycerin times two. This lasted 30 minutes. EMTs found her
to have blood pressure of 190/100 , heart rate 76 , normal sinus
rhythm. They gave two nitrospray , blood pressure decreased to
150/80 , heart rate 76 and after two minutes in the vehicle , she had
sinus bradycardia at 30-40 , blood pressure 120/80. She was given
0.5 mg of Atropine times one without any affect. She was brought
to the Pagham University Of , but initially she was
normotensive with a systolic blood pressure of 100. Then suddenly
she had bradycardia with heart rate of 30-40 and systolic blood
pressure of 75. She was given intravenous fluids and Atropine 0.5
mg times one. This lead to an increase in her blood pressure
systolic of 100 and her heart rate increased to 60. On transfer to
the floor , she was without chest pain , normotensive and in normal
sinus rhythm.
REVIEW OF SYSTEMS: She denies lower extremity edema , orthopnea ,
paroxysmal nocturnal dyspnea , fever , chills ,
cough , abdominal pain.
PAST MEDICAL HISTORY: 1 ) Adult onset diabetes mellitus on
Glucotrol. 2 ) Hypertension. 3 )
Palpitations. 4 ) Cerebrovascular accident about four months ago.
The history of this is unclear. She is followed by Dovie Binns
at the Bussadd Southrys Community Hospital
MEDICATIONS ON ADMISSION: 1 ) Nifedipine 10 mg orally as needed for
elevated blood pressure. 2 ) Lasix 20
mg orally every day. 3 ) Glucotrol 15 mg orally every day. 4 ) Cardizem 300
mg orally every day. 5 ) Coumadin 3.75 mg orally every day. 6 ) Colace 100
mg orally twice a day 7 ) Iron 325 mg orally every day.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: The patient lives in Hien , Nevada 09848 She is
married. She is unemployed. She has eight
children. She has no alcohol use. She was a smoker , discontinued
three months ago. She smoked three cigarettes per day times 43
years.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.9 degrees ,
heart rate 62 , blood pressure 144/86 , SAO2
96% on two liters. General: Well appearing , greek speaking
woman in no apparent distress. HEENT was normocephalic ,
atraumatic. Pupils were equal , round and reactive to light.
Oropharynx revealed lower and upper dentures. Neck with full range
of motion , supple , jugular venous pressure 8 cm , carotids 2+ , no
bruits. Chest revealed basilar rales bilaterally. Cardiovascular
was regular rate and rhythm , normal S1 and S2 , no murmurs. Abdomen
was non-tender , no hepatosplenomegaly , positive bowel sounds.
Extremities revealed no clubbing , cyanosis or edema , 2+ dorsalis
pedis and posterior tibial pulses bilaterally. Neurological
revealed motor in upper extremities and lower extremities at five
out of five. The patient was alert and oriented times three.
LABORATORY: Laboratory studies revealed a sodium of 143 , potassium
4.1 , chloride 100 , bicarbonate 47 , BUN 26 , creatinine
1.1 , glucose 244 , white blood cell count 9 , hematocrit 33.9 ,
platelets 276. Troponin was 0.0. CK was 75. physical therapy 14.7 , INR 1.5 ,
PTT 32. Chest x-ray showed cardiomegaly , no congestive heart
failure , no infiltrates. EKG revealed sinus bradycardia at 58 ,
0.158/092/0.47 , no ST or T-wave changes , no Q-waves , no old EKG for
comparison at the time of admission.
HOSPITAL COURSE: The patient underwent exercise tolerance test on
a standard Bruce protocol. She completed 6
minutes , 32 seconds but stopped secondary to leg fatigue. She has
no chest pain. EKG was without changes during exercise , but at
recovery , developed EKG changes in both inferior and lateral leads.
This was consistent but not diagnostic of ischemia. She underwent
angiography which showed left main OK , LAD proximal 20% , D2 60% ,
ostial 90% mid , left circumflex mid 30% , OM2 distal 60-70% , OM1
mild diffuse disease. She underwent PTCA of her diagonal two which
went from 90% to 0% stenosis. She received Heparin overnight and
the sheaths were pulled on the following day. In addition , she
underwent modification of her medical regimen. She was given
aspirin , Beta blocker , Isordil , and ACE inhibitor.
MEDICATIONS ON DISCHARGE: 1 ) Aspirin 325 mg orally every day. 2 )
Atenolol 50 mg orally every day. 3 )
Lisinopril 10 mg orally every day. 4 ) Pravachol 20 mg orally every day. 5 )
Glucotrol XL 15 mg orally every day before noon. 6 ) Lasix 20 mg orally every day. 7 )
Nitroglycerin tablets sublingual as needed chest pain.
FOLLOW-UP: The patient is to follow-up in the KTDUOO Clinic with Dr.
Ulysses Geldrich
Dictated By: GERARD MUHLSTEIN , M.D. TZ80
Attending: JACKSON PART , M.D. IZ71
EW247/5259
Batch: 65137 Index No. RSLQ9O9E7Z D: 5/2/97
T: 3/15/97
Document id: 782
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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593109802 | PUO | 52570701 | | 4237716 | 2/8/2004 12:00:00 a.m. | Non cardiac chest pain | | DIS | Admission Date: 2/8/2004 Report Status:
Discharge Date: 6/18/2004
****** DISCHARGE ORDERS ******
RAVER , KATHERYN 691-15-40-8
Mermontpla Innewlista Juan
Service: MED
DISCHARGE PATIENT ON: 11/8/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SHOPBELL , MYRIAM P. , M.D.
CODE STATUS:
No CPR / No defib / No intubation / No pressors /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
as needed Shortness of Breath , Wheezing
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PROZAC ( FLUOXETINE HCL ) 40 MG orally every day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
INSULIN NPH HUMAN 118 UNITS every day before noon; 24 UNITS every afternoon subcutaneously
118 UNITS every day before noon 24 UNITS every afternoon
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally three times a day
HOLD IF: heart rate<55 or sbp<100 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 4/15/04 by BUBERT , PASTY N. , M.D.
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override:
aware
VERAPAMIL SUSTAINED RELEAS 240 MG orally every day HOLD IF: sbp<95
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 4/15/04 by BUBERT , PASTY N. , M.D. on order for LOPRESSOR orally ( ref # 81413461 )
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL ,
SUSTAINED-REL & METOPROLOL TARTRATE Reason for override:
aware
SIMVASTATIN 10 MG orally every bedtime Starting Today ( 3/2 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOVENT ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
DIOVAN ( VALSARTAN ) 160 MG orally every day HOLD IF: sbp<95
Number of Doses Required ( approximate ): 3
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 3
ALPHAGAN ( BRIMONIDINE TARTRATE ) 1 DROP each eye every 8 hours
Number of Doses Required ( approximate ): 4
SEREVENT DISKUS ( SALMETEROL DISKUS ) 1 PUFF inhaled twice a day
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Goud 1/16/04 scheduled ,
ALLERGY: ACE Inhibitor
ADMIT DIAGNOSIS:
Rule out MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD DM HTN OBESITY CHF likely restrictive lung disease asthma
OPERATIONS AND PROCEDURES:
Myocardial dobutamine PET scan
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
69 year-old woman with CAD history of 4v-CABG , asthma , obesity and likely
consequent restrictive lung disease , OSA , diastolic dysfunction , IDDM
with retinopathy , presenting with 1 week increased SOB and 3 days of
pleuritic chest pain. SOB at 1 step is increased from baseline DOE
over the last week. Also with deep substernal chest pain x 3days which
may have been pleuritic and was necessarily exertional. Different pain
than anginal pain. Always slightly orthopneic , +LEE bilaterally. No
f/c/s. Some cough nonproductive . No sore throat or sick contacts. In
ED 97.8 70 150/70 100%2LNC.
Pain completely resolved with NTG x3 and ASA. Exam: Obese , midline
ventral hernia. JVP 11.
?lower lobe crackles. 2+ bilat LEE ( slight L>R ). Cr 1.4 baseline.
Hct 34 baseline. WBC 8.2. enzymes neg x2. BNP 108 EKG with no changes
( ?old every wave ). CXR hard to interpret.
The differential diagnosis of the patient's chest pain included
cardiac ischemia , GI and PE. We ruled out ischemia and PE as causes dur
ing this admission , the patient attributes her symptoms to large vental
hernia , making it difficult for her to breathe.
PULM: She had a PE
CT with no large PE or large
DVT , possible brewing infiltrate in LLL vs atelectasis ( poor study
due to obesity ). LENI negative.
CV: Ruled out for MI by serial markers and EKGs. ECHO 10/3 multiple
areas of HK , EF 45% ( compared to 55%
on revious echo 8/24 ) , same MR ( mild/mod ) and trace TR. A cardiac PET
scan with dobutamine ( due to asthma ) on 3/2 showed mod sized area of
prior MI in OM/PDA territory ( consistent with area of old infarct ).
--Pump: JVP up: started lasix intravenous with goal negative 1L per day. W
e diuresed the patient and resumed her home meds ( we switched
diovan to 80 twice a day , from 160 every day on discharge ).
--FEN: diuresis. Follow lytes and volume status
--CODE: DNR/DNI during this admission per her discussion with our
team and with her primary care physician ( addressed during outpatient appointment ).
--GI: we continued the patient on a PPI
She was discharged home with physical therapy and VNA.
ADDITIONAL COMMENTS: Please return to the Emergency room if you have any chest pain ,
shortness of breath or faint. Please follow up with Dr. Goud on
discharge.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: PAMA , WILLIAMS , M.D. ( CL00 ) 11/8/04 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 783
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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050164302 | PUO | 25737458 | | 640674 | 6/5/1998 12:00:00 a.m. | ASTHMA | Unsigned | DIS | Admission Date: 8/13/1998 Report Status: Unsigned
Discharge Date: 9/23/1998
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old obese
gentleman who has a history of asthma
and hypertension. No known history of coronary artery disease.
The patient presented with acute onset of wheezing on the morning
of admission. He was in his usual state of health until he
developed this shortness of breath while driving which he is
believed is secondary to an asthma flare. He received Albuterol
and Atrovent nebulizers in the emergency room , as well as intravenous
Solu-Medrol for oxygen saturation in the 80s , with some
improvement. He was also noted to have an elevated triponin level
at 0.12. The CK was 241 with MB of 0. Subsequent CK was 393 with
MB of 50.1. He was transferred to the cardiology service for rule
out myocardial infarction and for further evaluation and treatment.
At that time he denied any chest pain or radiation of pain.
SOCIAL HISTORY: Remarkable for tobacco use of one to two cigars a
day. Ethanol use.
PAST MEDICAL HISTORY: Hypertension. Asthma. Nephrotic
proteinuria. Insulin-dependent diabetes
mellitus. Elevated cholesterol.
PAST SURGICAL HISTORY: Status post thoracotomy in 1986 for
retrocardiac/atrial cystic mass. Status
post vasectomy.
ALLERGIES: Penicillin.
MEDICATIONS: Metformin 500 mg orally twice a day , insulin NPH 33 units
subcutaneously every day before noon and 15 units subcutaneously every afternoon , Lisinopril 20
mg every day , Losartan 100 mg every day , Zocor 20 mg every day , Lasix 160 mg orally
twice a day , Colchicine 0.6 mg twice a day as needed , and Indomethicine 25 mg
as needed , as well as Beclomethicine multidose inhalers 4 puffs twice a day
as needed wheeze.
PHYSICAL EXAMINATION: Obese gentleman in mild distress.
Extraocular movements intact. Pupils equal ,
round , and reactive to light and accommodation. He had bibasilar
crackles , as well as wheezes , throughout. Heart: Regular rate and
rhythm. No murmurs , rubs , or gallops. Abdomen: Large , obese.
Tympanitic. Good bowel sounds. Extremities: No edema.
LABORATORY DATA: Electrolytes were within normal limits. Serum
glucose 269. CBC: WBC 12 , hematocrit 49 ,
platelet count 261.
HOSPITAL COURSE: He was admitted for rule out myocardial
infarction and he , indeed , was found to rule in
for a myocardial infarction with triponin of 7.77. He had an
echocardiogram which revealed inferior septal hypokinesis , left
ventricular ejection fraction of approximately 40%. He had normal
PA systolic pressures. He underwent cardiac catheterization on
7/1/98 which revealed stenosis of the left anterior descending
artery of 90% and left circumflex artery of 90% and right coronary
artery total occlusion. It also showed ejection fraction of 25%.
Based on these catheterization results and his ruling in for
myocardial infarction , he was taken to the operating room on
4/8/98 for an elective coronary artery bypass graft.
The left internal mammary artery was grafted to the left anterior
descending artery. The saphenous vein graft and radial artery were
used to graft the aorta to the obtuse marginal and to the posterior
descending artery. At the time of the procedure there was drainage
of a bronchogenic cyst which was identified by echocardiogram. The
contents of the cyst were found to be sterile. During the
procedure he had an intra-aortic balloon pump placed.
Postoperatively he had some bleeding from his chest tubes. The
chest was left open postoperatively and covered with Esmarch
bandage. Several hours postoperatively he had some bleeding and
required re-exploration of the chest. We removed a small amount of
bleeding from the cavity. One pack was left in.
He remained on several inatropes and pressors and remained on an
intra-aortic balloon pump. He was transfused with multiple blood
products , including platelets and fresh frozen plasma for continued
leaking. He remained intubated and was gradually weaned off of
pressors. He also remained on a Lasix drip for diuresis and he
continued to receive multiple units of blood products.
On 4/3/98 he underwent sternal closure in the operating room. The
patient tolerated the procedure well. He was again taken to
Intensive Care Unit. He remained intubated and on an intra-aortic
balloon pump. On 10/21/98 the patient had been extubated and
intra-aortic balloon pump had been removed. Gradually his cardiac
drips were weaned. Postoperatively he had atrial fibrillation and
he was begun on Coumadin. He had an atrial arrhythmia which was
controlled medically. He continued to progress slowly and was
begun on orally medications as his drips were weaned.
The patient was noted to have a 3 cm upper sternal opening which
was initially thought to be possibly infected and this was opened
as concern for his diabetes mellitus and possible infection.
Plastic surgery was consulted and there was no gross infection to
be found. He had gram stain and culture obtained of the wound.
The gram stain revealed sterile wound and culture had grown out
nothing. The plastic surgery recommended two week course of intravenous
Vancomycin to cover possible organisms; however , there was no
clinical evidence of infection. The patient had a PICC line placed
for long term antibiotics and he is being discharged on Vancomycin
intravenous at a dose of 1 mg intravenous q18h with peak and trough to be checked at
rehabilitation facility. He will also continue with wet to dry
dressing changes on the sternal wound three times a day
DISPOSITION: DISCHARGE MEDICATIONS: Tylenol #3 1 to 2 tablets
orally q3 - 4h as needed pain , Albuterol nebulizers 2.5 mg
nebulizers every 4 hours , Beclovent 4 puffs inhaled twice a day , Digoxin 0.25 mg
orally every day , Diltiazem 30 mg orally three times a day , Colace 100 mg orally three times a day ,
Lasix 80 mg orally three times a day His preoperative dosage of insulin , as
well as Lisinopril.
Dictated By: DENISHA MCRORIE , M.D. SS37
Attending: JANAY D. STUKOWSKI , M.D. JX47
HB339/5317
Batch: 4939 Index No. FSAETI666D D: 8/25/98
T: 8/25/98
Document id: 784
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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416949358 | PUO | 98617103 | | 042519 | 7/26/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/24/1994 Report Status: Signed
Discharge Date: 1/28/1994
PRINCIPAL DIAGNOSIS: 1. RULE OUT MYOCARDIAL INFARCTION
SECONDARY DIAGNOSES: 2. UNSTABLE ANGINA
3. HYPERTENSION
4. HYPERCHOLESTEROLEMIA
5. STATUS POST CORONARY ARTERY
BYPASS GRAFT
PROCEDURES: CARDIAC CATHETERIZATION AND PTCA
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male
status post coronary artery bypass
graft in 1988 who presents with unstable angina. In 9/5 , he had
an episode of substernal chest pain and an EKG done was positive.
Catheterization revealed 95% mid LAD , 50% diagonal LAD , 80% D1 , 80%
left circ , 80% OM1 , OM2 , and diffuse RCA. Attempted PTCA was
complicated by substernal chest pain and a CK peaked to 1920. He
required an intra-aortic balloon pump and emergent coronary artery
bypass graft times three. The coronary artery bypass graft
included SVG to LAG , SVG to OM1 , SVG to OM2. In 1990 , he underwent
another exercise test with one millimeter ST depression thought
secondary to fatigue. In 2/16 , he had further substernal chest
pain and shortness of breath and another positive ETT. He ruled
out for myocardial infarction at that time. Catheterization
revealed SPT to LAD patent , SPT to OM1 patent , SPT to OM2 patent.
Leading LAD , OM1 , OM2 , and OM3 100% acquitted. RC s OM3 80% , 80% ,
80% lesions were PTCA'd and reduced to 20% , 20% , and 30% serial
lesions.
In October of 1994 , an exercise tolerance test was predictive of
ischemia ( exercise 9 minutes on standard Bruce with typical
substernal chest pain ). His heart rate was 131 , blood pressure
230/90 , 1 millimeter ST depression. In September of 1994 , he was
admitted with recurrent substernal chest pain which was relieved
with sublingual Nitroglycerin. He ruled out for myocardial
infarction. A catheterization at that time revealed restenosis of
proximal RCA 90% lesion. He underwent successful PTCA of RCA
lesion. Other grafts were patent. On July , 1994 , he
exercised on standard Bruce protocol six minutes and 20 seconds
with chest pain five out of ten. He had two depressions
infralaterally and was seen at CHH with question of restenosis. It
was felt they should increase his Diltiazem. He was intolerant of a
beta blocker. He now presents with one week of additional
substernal chest pain. On the night prior to admission , he had
substernal chest pain at rest times two which were immediately
relieved with sublingual Nitroglycerin.
PAST MEDICAL HISTORY: His pat medical history is significant for a
duodenal ulcer ( upper GI bleed , 1988 ) , ankylosing spondylitis ,
adult onset diabetes mellitus , juvenile rheumatoid arthritis ,
hyperglyceremia , hypertension. SOCIAL HISTORY: Tobacco - he quit
in 1988 - with 80 pack year history. No alcohol use. FAMILY
HISTORY: His brother is status post coronary artery bypass graft.
His other brother died at age 60 of myocardial infarction. He has
a brother with CEA. SOCIAL HISTORY: He is a letter carrier. He
is married and four children , two at home who are healthy.
MEDICATIONS: His medications on admission are Tagamet , Diltiazem
CD 240 mg orally every day , ECSA every other day , Cholespol 5 grams twice a day , and Axid.
PHYSICAL EXAMINATION: The patient had a temperature of 97.2 ,
pulse 54 and regular , respirations 20 ,
blood pressure 140/60 , O2 saturation on 2 liters 99%. HEENT - His
pupils are equal , round , and reactive to light. Oropharynx was
clear. His carotids were two plus bilaterally. He had no
lymphadenopathy. His thyroid was nonpalpable. Jugular venous
pressure approximately 8 centimeters. He had fine rales
bilaterally at bases of his lungs. He had a regular rate and
rhythm. S-1 and S-2 are normal. There was no S-3 , no S-4 , and no
murmurs. PMI non-displaced. Mediastinum - He had an old scar.
Abdomen - He has no scars. His abdomen is soft and non-tender and
no hepatosplenomegaly. Extremities: He has femoral scars
bilaterally , 2 plus pulses , no bruits. His rectal was guaiac
negative per Emergency Room. Neurological - His reflexes are two
plus upper extremities , one plus lower extremities , toes downgoing.
Cranial nerves II-XII in tact. Motor sensory grossly intact. He
was alert and oriented times three. LABORATORY DATA: His
hematocrit was 47.4 , white cont 7.2 , platelets 241 , sodium 143 ,
potassium 4.2 , BUN 10 , creatinine 0.9 , glucose 213 , cholesterol
233 , triglycerides 278 , calcium 9.7 , albumen 4.4. All other labs
were within normal limits.
HOSPITAL COURSE: The patient was admitted for
evaluation of unstable angina with a
markedly positive exercise tolerance test at CHH for cardiac
catheterization. He ruled out for myocardial infarction with CPKs
of 158 , 143 , 132. EKGs were without any significant change and he
had no further episodes of chest burning or discomfort on the day
following admission. DIET: He was continued on his his
medications prior to admission and was also started on an ADA diet
given his diabetes. On 6/23/94 , the patient had an episode of
chest pain which required sublingual Nitroglycerin and intravenous Heparin
for resolution. He described this as chest pressure radiating
bilaterally to his neck and complained of gas like sensations.
EKGs revealed ST change in 1 and inverted T in AVL and he was
started on intravenous Heparin. He was also given Serax. intravenous TNG was
started and titrated to obtain a blood pressure greater than 100.
His symptoms resolved. An EKG following a resolution of symptoms
showed resolution of EKG changes. Duration of chest pain was
approximately 40 minutes. A cardiac catheterization on 10/17/94
showed preliminary results of 80% stenosis in mid RCA which was
successfully dilated to 20% with PTCA , an occluded LAD , an occluded
OMB1 and OMB2 and 50% left circ. , patent SVG to LAD , patent SVG to
OMB2 , occluded SBG to OMB. His wedge was 13 , RA 9 , RV 28/10 , PA
28/14 , arterial pressure 110/70. He remained comfortable
throughout the remainder of his hospitalization status PTCA and RCA
without further episodes of chest pain or pressure. His
medications were increased for better blood pressure control.
DISPOSITION: MEDICATIONS: He was discharged on 1/25/94 to
follow-up with Dr. Tyacke at CHH on
June Medications at the time of discharge were EPSA 325
mg orally every other day , Diltiazem CD 300 mg orally every day , Tagamet 150 mg orally
twice a day , Colestipol 5 grams orally twice a day , Sublingual Nitroglycerin
1/150 every 5 minutes x 3 as needed chest pain.
Dictated By: VONNIE CHANT , M.D. RR59
Attending: MACKENZIE TYACKE , M.D. KC8
MF422/0287
Batch: 3872 Index No. S3GS6X0DI5 D: 9/18/94
T: 7/17/94
Document id: 785
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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909702719 | PUO | 18940613 | | 115014 | 10/15/2000 12:00:00 a.m. | ASTHMA EXACERBATION | Signed | DIS | Admission Date: 7/14/2000 Report Status: Signed
Discharge Date: 5/6/2000
PRINCIPAL DIAGNOSIS: ASTHMA EXACERBATION.
SECONDARY DIAGNOSES: 1 ) MORBID OBESITY.
2 ) HISTORY OF RECURRENT DEEP VENOUS
THROMBOSES/PULMONARY EMBOLUS.
HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old woman
with a long-standing history of asthma
and chronic obstructive pulmonary disease who now presents with
cough , shortness of breath , increased wheezing times three days.
The patient is a morbidly obese woman with a long-standing history
of asthma since childhood. Her most recent pulmonary function
tests in October of 1998 revealed an FVC of 2.6 and FEV1 of 1.43
and an FEV1/FVC of 66%. Her most recent hospitalization for an
asthma exacerbation was October of 2000 at the Pagham University Of She has no history of intubations , no medical intensive
care unit admissions , no home oxygen. She also has a history of
repeated deep venous thromboses , particularly to the left lower
extremity and a history of pulmonary embolus in 1975 and 1991. She
has been on Coumadin since 1991 with her last admission for a deep
venous thrombosis in 1997. Three days prior to this admission , the
patient noted that she felt unwell with a cough productive of
yellow sputum , increased shortness of breath and wheezing. She
attributed the cough and wheeze to exposure to dust and mold on
Monday at the nursing facility at which she lives. The patient was
diagnosed with an upper respiratory infection at the skilled
nursing facility at which resides and she received one dose of
Doxycycline 100 mg on the night prior to admission. She was
transferred to the Pagham University Of on August , 2000 for
increased shortness of breath , cough and wheezing , not relieved by
two Ventolin nebulizers. She notes no associated symptoms , no sore
throat , nausea , vomiting , diarrhea , fever or hemoptysis. She has
been afebrile with no known ill contacts. In the emergency room ,
she had a peak flow of 180 with a normal peak flow of 350. In the
emergency department , she received an Albuterol nebulizer , Atrovent
nebulizer times one , Levofloxacin 500 mg times one , Prednisone 60
mg times one and was admitted for further management.
PAST MEDICAL HISTORY: 1 ) As above with a history of asthma and
chronic obstructive pulmonary disease. She
was admitted for pneumonia in 1997. 2 ) Deep venous thromboses
which have been recurrent since age 21 with left lower extremity
swelling. 3 ) Pulmonary embolus in 1975 and 1991. 4 )
Abortion/placental infarction. 5 ) Vaginal bleeding. 6 ) Obesity.
7 ) Allergic rhinitis.
MEDICATIONS ON ADMISSION: 1 ) Colace 100 mg orally twice a day 2 )
Xenical 120 mg orally twice a day 3 ) Diazide
one tablet orally every day. 4 ) Uniphyl 800 mg orally twice a day 5 ) TUMS
625 mg orally twice a day 6 ) Lasix 100 mg orally twice a day 7 ) Pyridoxine 50
mg orally every day. 8 ) Folate 3 mg orally every day. 9 ) Celebrex 100 mg
twice a day 10 ) Wellbutrin 200 mg orally twice a day 11 ) Iron 325 mg orally
three times a day 12 ) Coumadin 8 mg orally twice a day 13 ) Albuterol nebulizers
90 mg inhaler , 2 puffs four times a day as needed 14 ) Albuterol nebulizers
every 4 hours 15 ) Prednisone 60 mg orally three times a day 16 ) Levofloxacin 500 mg
orally every day. 17 ) Magnesium oxide 840 mg orally twice a day 18 ) Flovent
660 mcg orally twice a day 19 ) Serevent 20 mcg inhaled 2 puffs twice a day
ALLERGIES: The patient is allergic to horse serum which leads to
anaphylaxis.
FAMILY HISTORY: Father had a cerebrovascular accident at age 35 ,
history of arterial thromboses. Mother has breast
cancer. Both parents are still living.
SOCIAL HISTORY: The patient lives in a nursing home separated from
her husband. She smokes three to four cigarettes
a day which is down from one pack per day. No significant alcohol
history.
PHYSICAL EXAMINATION: On physical examination , the patient was a
morbidly obese woman breathing with
difficulty lying in bed. Her vital signs included a temperature of
98.5 degrees , heart rate 98 , blood pressure 110/80 with a
respiratory rate of 20 , oxygen saturation 96% on room air. Her
physical examination was significant for the following: Her skin
had no rashes , no cyanosis. She was normocephalic , atraumatic with
no nasal discharge , no sinus tenderness , moist , pink , mucous
membranes with no exudate or erythema. Her neck was supple and
non-tender with no lymphadenopathy , no jugular venous distension
and no thyromegaly. Her chest examination revealed diffuse
inspiratory and expiratory wheezes bilaterally with a prolonged
expiratory phase , no crackles or rales. Her diaphragm elevated
symmetrically on expiration. Cardiac examination was regular rate
and rhythm with a normal S1 and S2 , no murmurs , gallops or rubs.
Her abdomen was soft , obese , non-tender with positive bowel sounds ,
no masses were palpated. Her examination was limited secondary to
obesity. Her extremities were warm with no clubbing or cyanosis.
She had marked edema of the lower extremities bilaterally with left
greater than right. Dorsalis pedis pulses were trace bilaterally.
LABORATORY: Laboratory studies were notable a white blood cell
count of 11.3 , hematocrit 36.7 and platelet count 317.
physical therapy was elevated at 23.5 , PTT 42.2 , INR 3.8. Electrolytes included
a sodium of 141 , potassium 2.6 , chloride 102 , bicarbonate 26 , BUN
17 , creatinine 0.9 and a glucose of 108. Calcium was 9.6 ,
magnesium 1.9. Theophylline level was 14.7. Her EKG showed normal
sinus rhythm with 95 beats per minute. PR , QRS and QTC intervals
were all within normal limits. Her chest x-ray , PA and lateral ,
showed low lung volumes but no pneumonia or congestive heart
failure.
HOSPITAL COURSE: 1 ) Respiratory: The patient's symptoms were
most likely secondary to asthma in the setting of
bronchitis given her long-standing history of asthma and chronic
obstructive pulmonary disease and her recent exposure to mold and
dust. A pulmonary embolus was deemed less likely given her INR of
3.8 and her oxygen saturation of 96% on room air. She was started
on Prednisone 60 mg orally three times a day and her medical regimen included
Uniphyl 800 mg twice a day , Lasix 100 mg orally twice a day , Albuterol
nebulizers 2.5 mg every 4 hours and every 1h. as needed , Flovent 660 mcg twice a day ,
Flonase 1-2 sprays every day , Serevent 2 puffs twice a day and Atrovent
nebulizers four times a day The patient was also placed on Levofloxacin 500
mg every day for her infection. The patient remains afebrile
throughout her course. Her sputum culture grew out 4+ polys ,
moderate gram , positive variable cocci in clusters and few gram
negative rods. The patient continued to improve on her medical
regimen with continued cough and sputum production. She was placed
on two liters oxygen nasal cannula on August , 2000 overnight for
comfort. Her peak flow was less than 120 on admission and improved
to 240 on May , 2000 , 230 on October , 2000 and peak flow of 320 on
May , 2000. The patient remained short of breath although this
improved over her course and she also improved in movement with
diminished wheezing. On discharge , the patient had a peak flow of
320 , saturating 97% on room air with a respiratory rate of 20. The
patient was discharged today to her nursing home , continuing on her
nebulizers and inhalers as well as the Prednisone 60 mg three times a day
today , day five and then continuing a slow taper thereafter with 50
mg three times a day times five days , then 40 mg three times a day times five days , 30 mg
three times a day times five days , 20 mg three times a day times five days and 10 mg
three times a day times five days.
2 ) Infectious disease: The patient is on Levofloxacin 500 mg orally
every day. Today is day number five and she will complete a seven day
course of Levofloxacin at her nursing home.
3 ) Hematology: The patient had an INR of 3.8 on 9 mg twice a day of
Coumadin upon admission. In the past , she has been known to have
an increased INR with the addition of antibiotics due to decreased
Coumadin clearance. Thus , on admission , we decreased her Coumadin
dose to 8 mg twice a day However , on January , 2000 , her INR climbed to
5.0 , so we again reduced her Coumadin to 6 mg twice a day Her evening
dose of Coumadin was held as well. The patient's INR was noted to
be 2.0 on October , 2000 and the Coumadin dose was again raised to 9
mg twice a day On May , 2000 , the patient's INR was 4.5. The
patient's a.m. dose of Coumadin was ordered to be held and her
Coumadin dose was readjusted to 7 mg in the a.m. and 8 mg in the PM
while on the antibiotics. She was ordered for two more days of
Levofloxacin and then two days after she stopped the Levofloxacin ,
INR should be rechecked and Coumadin dose readjusted to 9 mg twice a day
with INR being checked every day.
4 ) Fluids , electrolytes and nutrition: The patient continued on
her weight reduction medications including Xenical 120 mg twice a day
and Adipex 30 mg every day. The Phentermine was discontinued to be
restarted at the nursing home. The patient's weight was noted to
be 395.2 pounds.
MEDICATIONS ON DISCHARGE: 1 ) Albuterol nebulizers 2.5 mg every 4 hours
2 ) Albuterol nebulizers 2.5 mg every 1h.
as needed wheezing or shortness of breath. 3 ) TUMS 625 mg orally
three times a day 4 ) Diazide one capsule orally every day , hold if systolic blood
pressure lower than 100. 5 ) Ferrous sulfate 325 mg orally three times a day
6 ) Folate 3 mg orally every day. 7 ) Lasix 100 mg orally twice a day 8 )
Magnesium oxide 840 mg orally twice a day 9 ) Prednisone 60 mg orally
three times a day 10 ) Pyridoxine 50 mg orally every day. 11 ) Uniphyl 800 mg
orally twice a day 12 ) Coumadin 8 mg orally every day before noon , 7 mg orally every PM. After
two days off antibiotics , will change dose back to 9 mg orally twice a day
13 ) Atrovent nebulizers 0.5 mg four times a day 14 ) Serevent 2 puffs
inhaler twice a day 15 ) Flovent 660 mcg inhaler twice a day 16 ) Flonase
1-2 sprays inhaled every day to each nostril. 17 ) Levofloxacin 500
mg orally every day times three days starting today. 18 ) Wellbutrin
200 mg orally twice a day 19 ) Celebrex 100 mg orally twice a day 20 ) Xenical
120 mg orally twice a day 21 ) Adipex 30 mg orally every day. 22 ) Potassium
chloride slow release 20 mEq times two orally three times a day
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
FOLLOW-UP: The patient is to have a follow-up appointment with
Dr. Buckman on March , 2000 which is scheduled and a
follow-up appointment with Dr. Burle on May , 2000 which is also
scheduled.
Dictated By: CALVIN III , EVELIA SHANE
Attending: AVRIL F. TAPLIN , M.D. QI3
RD779/0686
Batch: 8754 Index No. MDYL489WSS D: 6/3
T: 6/3
CC: WAYNEPARK HEALTH , Sli Brid
LORRETTA P. CRIDGE , M.D. LY42
DR. PRIBBENO ,
MAGALY CONWRIGHT , M.D. MG7
Document id: 786
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
Y |
N |
Y |
N |
045911026 | PUO | 32796229 | | 7330944 | 11/23/2006 12:00:00 a.m. | ATRIAL FIBRILLATION | Unsigned | DIS | Admission Date: 10/21/2006 Report Status: Unsigned
Discharge Date: 3/26/2006
ATTENDING: GRUNTZ , KATHERYN MD
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female
with history of coronary artery disease , hypertension , AFib ,
diabetes , chronic renal insufficiency , status post permanent
pacemaker , presenting with exertional shortness of breath x 1
week , orthopnea , and runs of NSVT. Shortness of breath started 1
week ago. The patient was found to be in AFib and started on
Lopressor by primary care physician; however , shortness of breath worsened , patient
began sleeping upright in her recliner with worsening shortness
of breath. Denies any chest pain , nausea , vomiting , diaphoresis ,
or radiating pain. Patient also reports decreased activities of
daily living over the past week secondary to fatigue.
PAST MEDICAL HISTORY: August 2001 , status post two-vessel CABG
and NSTEMI; 3/2 , found to have an EF of 30% to 35%. Echo in
2003 notable for mild left ventricular dilatation , EF of 35% to
40% with global hypokinesis with hypokinesis of the anterior
septum , mid inferior-posterior basal septum , aortic valve area of
0.9 , MR , left atrial enlargement , TR , and PAP of 38. Patient
also has a history of chronic renal insufficiency; hypertension;
AFib , on Coumadin; status post permanent pacemaker; anemia;
status post bladder resection secondary to cancer;
insulin-dependent diabetes; aortic stenosis; hypothyroidism;
peripheral vascular disease.
ALLERGIES: Patient has no known allergies.
MEDICATIONS: Coumadin 1 mg; insulin , Lantus , 30 units every bedtime;
aspirin 325 mg; lisinopril 40 mg; Levoxyl 100 mcg; amiodarone 200
mg; Zocor 80 mg; Lopressor 50 mg twice a day; Lasix 120 mg twice a day ,
Multivitamin; calcium carbonate.
SOCIAL HISTORY: The patient lives in in-law apartment with
family. No tobacco or alcohol use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Notable for no fever , chills , nausea ,
vomiting , diarrhea , or chest pain. Patient does report a viral
syndrome 1 month ago. No new cough. Patient reports she last
felt well 1 month ago.
PHYSICAL EXAMINATION: Physical exam in the ED notable for T-Max
97.1 , heart rate 68 , BP 95 to 122/61 to 83 , respiratory rate of
20. O2 sat 94 on room air. Patient was in no acute distress ,
sitting upright , and virtually speaking in full sentences.
Mucous membranes moist. JVP at the earlobes 18 to 20. Rhonchi
in her right base with an irregularly irregular rhythm , S1 and
S2 , 2/6 systolic ejection murmur at the right upper sternal
border. Abdomen was obese , nontender , nondistended. Positive
bowel sounds. No hepatosplenomegaly. Extremities were warm ,
dry , and intact. No edema. DP , physical therapy 1+ bilaterally. Skin was
warm , dry , and intact. No rashes. Patient was alert and oriented
x 3. Cranial nerves II through XII grossly intact. Moving all
extremities.
LABORATORY DATA: Admission labs Notable for creatinine of 2.1
from baseline of 1.4 to 1.6. Potassium 4.7 , magnesium 2.7 , white
count 7.47 , hematocrit 46.3 from baseline 37 to 39. First set of
enzymes were negative. BNP 365 , INR of 3.3. Chest x-ray
consistent with pulmonary edema. EKG notable for atrial
fibrillation with nonspecific ST changes and a paced rhythm.
In summary , this is an 83-year-old female with a history of
coronary artery disease , hypertension , CHF , aortic valve
stenosis , paroxysmal AFib , status post permanent pacemaker with
recent conversion into AFib 1 week ago. Started on beta-blocker
by primary care physician , presenting with CHF exacerbation concerning for ischemia.
Telemetry also notable for multiple runs of NSVT concerning for
ongoing ischemia.
CARDIOVASCULAR: Patient has an EF of 35%. When last examined in
2003 , on presentation , was volume overloaded. However , BP was
well controlled. Patient was diuresed with intravenous Lasix and then
converted to an orally regimen. Blood pressure was titrated as
well as heart rate for improved rate control. ACE inhibitor was
initially held in the setting of worsening renal function ,
however , restarted prior to discharge. A repeat echo on 7/25
revealed an EF of 35% with an akinetic septal and inferior wall;
hypokinetic anterior lateral and posterior wall as well as left
atrial enlargement. Aortic valve stenosis with a gradient of 17
and mean of 10 with moderate AF , MR , TR with a peak AP of 29 and
the right atrial pressure similar to the prior study in 2003.
Ischemia , patient also has a history notable for coronary artery
disease status post CABG. Although the patient denied ongoing
chest pain , given history of diabetes , we were concerned for
ongoing ischemia. However , enzymes were negative x 3 with
telemetry notable for multiple runs of NSVT , stretching 20 to 30
beats , concerning for ongoing ischemia. Patient underwent
cardiac cath on 5/25 , which was notable for a left main 70%
stenosed and LAD 100% stenosed , circumflex 90% stenosed , RCA 100%
stenosed , large one 100% stenosed with an intact LIMA to LAD
graft as well as an intact SVT to OM graft. Patient underwent
Rotablator and balloon to the left circumflex and the OM lesions
and the LAD , left circumflex , and OM were stented. Patient was
continued on aspirin , beta-blocker , and statin. Patient was
started on Plavix. Patient was instructed to remain on Plavix
until further notice. Patient has baseline AFib with runs of
NSVT , which improved significantly status post revascularization.
Rate control was improved with a regimen of beta-blocker and
amiodarone. Patient will be continued to be monitored on
telemetry.
PULMONARY: Patient oxygenated well throughout her hospital stay.
Patient was carefully diuresed in the setting of acute on
chronic renal insufficiency in the setting of a dye load. On
discharge , she is oxygenating well on room air.
HEME: Hematocrit remained stable throughout her hospital course.
Coumadin was initially discontinued to proceed with cardiac
cath; however , patient was restarted on Coumadin with primary care physician
followup to follow INR. At the time of discharge , the patient has
mild thrombocytopenia. primary care physician will continue to monitor.
ENDOCRINE: Patient has a history of diabetes mellitus , on
insulin , was continued during her hospital stay , increased her
Lantus dose secondary to suboptimal blood sugar control.
Hemoglobin A1c in April was noted to be 6 , indicative of good
control. Patient also has a history of hypothyroidism. TSH
within normal limits and she was continued on her current dose of
Levoxyl.
RENAL: Patient has acute on chronic renal failure , baseline
creatinine of 1.4 to 1.6 , likely secondary to poor forward flow.
Creatinine improved with diuresis. At the time of discharge ,
creatinine was in the range of 1.8. Currently , she will be
continued to be followed as an outpatient. Patient will be
started back on ACE inhibitor prior to discharge. Prior to
cardiac cath , the patient did receive bicarb and Mucomyst to aid
in renal protection. At p.m. , patient was maintained on a
cardiac food-restricted diet.
NEURO , OPHTHO: Status post cardiac cath , patient complained of
left blurry vision. Patient was evaluated by neurology and
ophthalmology , which revealed a left corneal abrasion. They
recommended no further imaging studies , however , one may consider
carotid ultrasound as an outpatient to further evaluate.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Aspirin 325 mg every day , amiodarone 200 mg
every day , Lopressor 337.5 orally three times a day , Levoxyl 100 mcg orally every day ,
Multivitamin 1 tab orally every day , Zocor 80 mg orally every bedtime , Caltrate
Plus D 1 tab orally every day , Lantus 30 units every day , Coumadin 2 mg
every bedtime , Lasix 180 mg orally twice a day , Plavix 75 mg orally every day ,
lisinopril 20 mg orally every day Patient will follow up with primary care physician , Dr
Spuhler , on 1/27/06 at 2:40 p.m. INR will be drawn on 4/10 and
followed by Dr Feezell Patient has home VNA for BP checks and
volume status. Any questions may be directed at Dr Fisch
eScription document: 5-4328406 HF
Dictated By: YEAGLEY , MA
Attending: GRUNTZ , KATHERYN
Dictation ID 8819692
D: 2/3/06
T: 2/3/06
Document id: 787
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195619812 | PUO | 33640513 | | 2791995 | 9/23/2007 12:00:00 a.m. | history of angioplasty and stenting | | DIS | Admission Date: 6/17/2007 Report Status:
Discharge Date: 11/17/2007
****** FINAL DISCHARGE ORDERS ******
SAKAL , KARLY K. 974-03-12-0
Hassperv Ry Sa
Service: CAR
DISCHARGE PATIENT ON: 2/23/07 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LYN , JR , FLOYD T. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ASPIRIN ENTERIC COATED 325 MG orally every day
2. CLOPIDOGREL 75 MG orally every day
3. FENOFIBRATE ( TRICOR ) 48 MG orally every day
4. MYCOPHENOLATE MOFETIL 1000 MG orally twice a day
5. OXYBUTYNIN CHLORIDE XL 10 MG orally every day
6. PRAVASTATIN 40 MG orally every bedtime
7. INSULIN GLARGINE 20 UNITS subcutaneously every day before noon
8. FUROSEMIDE orally every day
9. THERAPEUTIC MULTIVITAMINS 1 TAB orally every day
10. PREDNISONE 5 MG orally every day
11. CYCLOSPORINE ( SANDIMMUNE ) 75 MG orally twice a day
12. METOPROLOL SUCCINATE EXTENDED RELEASE 50 MG orally every day
MEDICATIONS ON DISCHARGE:
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
ENTERIC COATED ASA 325 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 10/9 )
CYCLOSPORINE ( SANDIMMUNE ) 75 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 5/26/07 by BLACKGOAT , GERMAINE L. , M.D. on order for PRAVACHOL orally ( ref # 031920652 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
PRAVASTATIN SODIUM Reason for override:
patient taking as outpatient Previous override information:
Override added on 5/26/07 by BLACKGOAT , GERMAINE L. , M.D.
on order for TRICOR orally ( ref # 660022708 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
FENOFIBRATE , MICRONIZED Reason for override:
patient taking as outpatient
TRICOR ( FENOFIBRATE ( TRICOR ) ) 48 MG orally DAILY
Override Notice: Override added on 5/26/07 by BLACKGOAT , GERMAINE L. , M.D. on order for PRAVACHOL orally ( ref # 031920652 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
PRAVASTATIN SODIUM Reason for override:
patient taking as outpatient Previous override information:
Override added on 5/26/07 by BLACKGOAT , GERMAINE L. , M.D.
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
FENOFIBRATE , MICRONIZED Reason for override:
patient taking as outpatient
Number of Doses Required ( approximate ): 1
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously every day before noon
Starting Today ( 10/27 )
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 1 , 000 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
DITROPAN XL ( OXYBUTYNIN CHLORIDE XL ) 10 MG orally DAILY
Number of Doses Required ( approximate ): 1
PRAVACHOL ( PRAVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 5/26/07 by
BLACKGOAT , GERMAINE L. , M.D.
on order for PRAVACHOL orally ( ref # 031920652 )
patient has a PROBABLE allergy to SIMVASTATIN; reaction is
muscle aches. Reason for override:
patient tolerates pravastatin Previous Alert overridden
Override added on 5/26/07 by BLACKGOAT , GERMAINE L. , M.D.
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
PRAVASTATIN SODIUM
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
PRAVASTATIN SODIUM Reason for override:
patient taking as outpatient
PREDNISONE 5 MG orally every day before noon
DIET: House / Low chol/low sat. fat
ACTIVITY: light activity , no heavy lifting or driving x 2 days. ok to shower , no swimming or bathing x 5 days
Lift restrictions: Do not lift greater then 10-15 pounds
FOLLOW UP APPOINTMENT( S ):
Heart transplant Clinic 2-4 weeks ,
ALLERGY: SIMVASTATIN
ADMIT DIAGNOSIS:
CAD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of angioplasty and stenting
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of cardiac transplant 1992 ( history of cardiac transplant ) Diabetes mellitus
type II ( diabetes mellitus type 2 ) Trochanteric bursitis ( trochanteric
bursitis ) Dyslipidemia ( dyslipidemia ) DJD spine ( OA of cervical
spine ) Hx vocal cord injury postop Hx gastritis with UGIB ( history of upper
GI bleeding ) Hx postop seizure
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of angioplasty and stenting
BRIEF RESUME OF HOSPITAL COURSE:
HISTORY OF PRESENT ILLNESS: Karly Sakal is a
71-year-old white female who underwent cardiac transplantation on
1/27/1992. She has had a variety of important posttransplant
medical issues including diabetes , obesity , and spinal stenosis.
She has also had significant vascular disease including allograft
coronary artery disease and bilateral carotid artery disease. She
underwent stenting of the right internal carotid artery in
9/6 and stenting of the left internal carotid artery in 5/2
In addition , in 9/6 , she underwent stenting of the left
circumflex coronary artery and in 2/20 , she underwent stenting of
the left anterior descending coronary artery. At the time of her
catheterization in July , it was noted that she had additional
disease in the left circumflex and the posterior descending coronary
artery and the decision was made to perform an additional procedure
for some or all of these lesions. The patient now returns for repeat
intervention in the left circumflex PCI Notes---
Complicated bifurcation lesion of mLCX involving OM1 and OM2.
Bifurcation ultimately treated with "coulotte" stenting with 2.5( 28 )
Cypher in lower branch and 2.5( 18 ) Cypher in upper branch. Kissing
balloon inflations performed at the end of the procedure. There was
a dissection in the mid portion of the lower OM at the end of the
case. Likely due to coronary guidewire that had to be
placed in a tortous vessel. Given distal nature of dissection , we
elected not to treat further at this time. Patient tolerated
procedure well without complaints.
Started integrilin at the end of the case for 18 hours.
She should remain on aspirin for life and clopidogrel indefinitely.
She will have her CK's checked as well as Cr. in a.m..
SSI coverage. Mucomyst and
IVF Manual 8Fr sheath removed from Rt
CFA.
7/26
patient did well overnight. groin stable without hematoma , bruit. denies any
groin/flank pain. blood pressure stable. ck's flat. hct noted to be decreased to 26
from 32- likely related to prlonged procedure. will repeat to make ure
stable prior to d/c.
ADDITIONAL COMMENTS: -you must take aspirin for life
-you must take plavix for a minimum of 1 year
DO NOT STOP ASPIRIN OR PLAVIX FOR ANY REASON UNLESS SPEAK WITH YOUR
CARDIOLOGIST!
-resume other medications at usual doses
-continue iron supplements at usual dose and report any lightheadedness ,
weakness , dizziness immediately
-call with questions or concerns
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STAHLHUT , DALIA K. , PA-C ( RV67 ) 2/23/07 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 788
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376293581 | PUO | 43568987 | | 6250257 | 7/19/2006 12:00:00 a.m. | UNSTABLE ANGINA | Unsigned | DIS | Admission Date: 9/17/2006 Report Status: Unsigned
Discharge Date: 6/13/2006
ATTENDING: COLASAMTE , ISABELLE EVON MD
SERVICE:
Cardiac Surgical Service.
HISTORY OF PRESENT ILLNESS:
Ms. Shearer is a 65-year-old female with a known history of
coronary artery disease. Most recently admitted with shortness
of breath and abdominal tightness. At the time of admission , she
did have a troponin leak of 0.46. She had cardiac
catheterization , which revealed three-vessel coronary artery
disease. She was referred to Dr. Colasamte for coronary
revascularization.
PAST MEDICAL HISTORY:
Hypertension , hyperlipidemia , anxiety disorder.
PAST SURGICAL HISTORY:
Tonsillectomy , cholecystectomy , PTCA in 1998.
FAMILY HISTORY:
No history of coronary artery disease.
SOCIAL HISTORY:
A 20-pack-year cigarette smoking history.
ALLERGIES:
No known drug allergies.
PREOPERATIVE MEDICATIONS:
Lopressor 25 mg orally three times a day , amlodipine 5 mg orally daily ,
lisinopril 40 mg orally daily , isosorbide 60 mg orally daily , and
atorvastatin 80 mg orally daily.
PHYSICAL EXAMINATION:
Vital Signs: Temperature 98.3 , heart rate 56 , blood pressure in
the right arm 110/64 , blood pressure in left arm 116/66. HEENT:
Dentition without evidence of infection , no carotid bruit.
Cardiovascular: Regular rate and rhythm with 3/6 systolic
murmur. Peripheral pulses are 2+ and include the carotid ,
radial , femoral , dorsalis pedis , and posterior tibial. Allen's
test left upper extremity is normal as is the right upper
extremity. Respiratory: Breath sounds clear bilaterally.
Extremities: Without scarring , varicosities or edema. Neuro:
Alert and oriented with no focal deficits.
PREOPERATIVE LABS:
Sodium 140 , potassium 3.6 , chloride 104 , carbon dioxide 26 , BUN
19 , creatinine 0.7 , glucose 124 , magnesium 1.8 , white blood cells
6.92 , hematocrit 45.9 , hemoglobin 13.1 , platelets 192 , 000 , physical therapy
13.3 , INR 1 , PTT 101.4. Cardiac catheterization data on
1/25/06 , coronary anatomy , 80% distal RCA , 70% mid RTLV branch ,
90% proximal LAD , 90% mid circumflex , 70% proximal D2.
Echocardiogram on 10/13/06 , 60% ejection fraction. Aortic
stenosis with a mean gradient of 12 mmHg and peak gradient of 26
mmHg. Calculated valve area of 2.2 cm2. ECG on 11/8/06 normal
sinus rhythm at 52 with Q-waves in leads II , III and AVF. Chest
x-ray on 1/25/06 was read as normal.
HOSPITAL COURSE:
BRIEF OPERATIVE NOTE:
DATE OF SURGERY:
4/7/06.
PREOPERATIVE DIAGNOSIS:
Coronary artery disease.
POSTOPERATIVE DIAGNOSIS:
Coronary artery disease.
PROCEDURE:
CABG x5 , sequential graft SVG1 connects aorta to the PDA and then
LVB1 , left radial connects SVG1 to D2 and then OM3 , LIMA to the
LAD.
BYPASS TIME:
144 minutes.
CROSSCLAMP TIME:
114 minutes.
One ventricular wire , two pericardial tubes , two left pleural
tubes were placed.
COMPLICATIONS:
None.
DESCRIPTION OF THE OPERATION:
The patient was transferred in stable condition to the Cardiac
Intensive Care Unit. While on the Cardiac Intensive Care Unit ,
her course was complicated by the following:
1. Initially felt that she had ST inferior lead changes. It has
turned out to be artifactual.
2. She has pericardial changes that resolved approximately 2
days after the operation.
She was transferred to the Cardiac Step-Down Unit on
postoperative day #2. While on the Cardiac Step-Down Unit ,
course was complicated by the following:
1. Initially the cardiac surgical team had trouble diuresing Ms.
Pepe She was initially diuresed with intravenous Lasix until she was
approximately 500 mL to 1000 mL negative per day. She was
eventually converted to orally Lasix and will be discharged on orally
Lasix. She was weaned from her oxygen requirement and there are
no gross effusions on her chest x-ray at the time of discharge.
2. On the day prior to discharge , physical therapist felt that
Ms. Shearer would benefit from rehabilitation stay as she was
unsteady in her gait on the stairs. However , Ms. Shearer will
only have to climb approximately 2-4 stairs to get into her home
and her bedroom as well as bathroom will be on the first four.
Physical therapy did clear her for discharge to home as long as
she is on the first floor with a physical therapy evaluation when
she is at home. Otherwise , Ms. Shearer has done well.
DISCHARGE MEDICATIONS:
She will be discharged home on the following medications:
Diltiazem 30 mg orally three times a day , Colace 100 mg orally twice a day , aspirin
325 mg orally daily , Lasix 60 mg orally daily , K-Dur 30 mEq orally
daily , Glucophage 500 mg orally twice a day , Niferex 150 mg orally twice a day ,
oxycodone 5-10 mg orally every 4 hours as needed pain , Zocor 40 mg orally
daily , Toprol-XL 25 mg orally daily. Ms. Shearer will follow up
with Dr. Colasamte , cardiac surgeon , in six weeks and Dr. Sasnett ,
cardiologist , in four weeks and Dr. Dilella , patient's primary
care physician , in one to two weeks.
eScription document: 8-9247618 EMSSten Tel
Dictated By: TRIARSI , VERDA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 8294922
D: 2/5/06
T: 2/5/06
Document id: 789
| Target |
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DM |
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GER |
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| output/system_textual_annotation.xml | textual |
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U |
U |
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| output/system_intuitive_annotation.xml | intuitive |
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680159882 | PUO | 61129049 | | 154481 | 1/5/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/16/1995 Report Status: Signed
Discharge Date: 11/19/1995
PRINCIPAL DIAGNOSIS: Coronary artery disease
CHIEF COMPLAINT: This is a 76-year-old male without previous
cardiac history who is admitted with chest pain.
HISTORY OF PRESENT ILLNESS: Cardiac risk factors include tobacco
smoking , hypertension and diabetes.
He has no family history , no history of hypercholesterolemia. He
had a negative stress test 10-12 years ago. Usual activity level
is to walk about a block a day. He has a history of severe
osteoarthritis of his neck. Today on the date of admission the
patient had a steroid injection in his cervical spine , which he
tolerated well. He did well until 5:30 p.m. when , while resting in
bed , he noted left-sided chest pain radiating to his left upper
arm , no shortness of breath , diaphoresis or palpitations. He did
not try any particular treatment and came to the emergency room.
The pain had increased in intensity to 10/10. In the emergency
room initial EKG showed T compression in V3-V6 , three lead. With 3
sublingual nitroglycerin and 2/10 , 5 mg intravenous Lopressor made him pain
free. There was no resolution of his ST changes. He had
recurrence of chest pain two hours later in the emergency room.
Left-sided chest pressure was similar quality to the previous while
lying on the stretcher. His EKG showed flattened T wave changes in
V4-V6 , ST depression 1 mm V4-V6 , evolved he had a T wave inversion
in V3-V6 when pain free. He was started on heparin and intravenous
nitroglycerin.
PAST MEDICAL HISTORY: Includes hypertension , adult onset diabetes
mellitus , history of renal calculi , benign
prostatic hypertrophy , increased triglycerides , history of malaria
and typhus and dengue fever , history of proteinuria.
MEDICATIONS ON ADMISSION: Captopril , Micronase and Darvon as needed
ALLERGIES: Penicillin , which makes him itch.
SOCIAL HISTORY: Lives with his wife. He is a cigar smoker , rarely
drinks alcohol , no family history of cardiac
disease.
PHYSICAL EXAMINATION: Shows a vigorous white male who looks
younger than his stated age. Pulse 54 ,
blood pressure 107/53 , sat of 95% on room air. Physical exam was
notable only for a regular rate and rhythm , normal S1 , S2 , with
positive S4.
ADMITTING LABORATORY: Significant only for CK of 210. His CKs
never got higher than 210; however , cardiac
component of 1.7 , it was considered that the patient had ruled in
for non Q wave myocardial infarction.
HOSPITAL COURSE: On 11/10/95 the patient underwent cardiac
catheterization. He had mildly elevated
right-sided pressures and showed three vessel disease of the 70%
proximal left anterior descending , 90% apical stenosis. He had a
30% proximal left circumflex lesion and two serial 95% distal left
circumflex stenoses. His OM1 had a 30-40% diffuse luminal
irregularity. His right coronary artery was also noted to have
luminal irregularities. Posterior descending artery was noted to
have a 90% mid stenosis. Systolic function showed EF of 71%. On
11/10/95 the patient underwent successful balloon angioplasty of the
proximal 95% stenosis of the left circumflex. On 8/4 the patient
complained of chest pressure , underwent an exercise tolerance test ,
5 minutes and 1 second , stopping secondary to leg fatigue. He had
2 mm ST segment depressions consistent with severe coronary artery
disease. On 11/1/95 the patient underwent a second cardiac
catheterization followed by successful angioplasty of his mid
posterior descending artery lesion with 30% residual stenosis and a
small intimal dissection of the inferior margin of the vessel. The
patient did well following this and was discharged home on the
following medications.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day; Micronase 5 mg
orally every day; nitroglycerin tabs 1/150 one
tab sublingual every 5 minutes; enoxaparin , study drug for TME-11 , 60
mg subcutaneously every 12 hours; Lisinopril 7.5 mg orally every day; Atenolol 75 mg orally every
day.
FOLLOW-UP: He will be following up with Dr. Defore , his primary
physician , and with Dr. Meduna , cardiology.
Dictated By: ROMANA ARORA , M.D.
Attending: LEOLA C. MUSICH , M.D. VG64
IT920/1303
Batch: 54164 Index No. U7BNNB1NO D: 10/1/96
T: 4/10/96
Document id: 790
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
U |
Y |
Y |
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U |
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U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
N |
709998647 | PUO | 89509775 | | 7680124 | 5/14/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 7/13/2005 Report Status: Unsigned
Discharge Date: 10/3/2005
ATTENDING: KERTESZ , ALETA M.D.
PRINCIPAL DIAGNOSIS:
Coronary artery disease.
HISTORY OF PRESENT ILLNESS: 80-year-old woman with history of
diabetes , hypertension , and COPD who was seen at Norap Valley Hospital on 1/9/05 reporting a two day history of increasing
shortness of breath and orthopnea. She was admitted with non-ST
elevation MI and congestive heart failure. Peak troponin level
was 5.72. The patient underwent cardiac catheterization , which
revealed severe two vessel disease and she was transferred to
Pagham University Of for cardiac surgery evaluation.
PAST MEDICAL HISTORY:
Hypertension , diabetes mellitus on orally agent ,
hypercholesterolemia , COPD , history of breast cancer treated with
XRT 10 years ago and osteoarthritis.
PAST SURGICAL HISTORY: Cholecystectomy.
FAMILY HISTORY:
Positive for coronary artery disease.
SOCIAL HISTORY:
Positive for 20-pack-year smoking history.
ALLERGIES:
No known drug allergies.
ADMISSION MEDICATIONS: Atenolol , amlodipine , atorvastatin , and
Glucotrol , patient is unsure of doses.
PHYSICAL EXAMINATION:
VITAL SIGNS: 5 feet 2 inches tall , 66 kilos. Temperature 99.2 ,
heart rate 89 , blood pressure 147/57 in right arm , 147/53 in left
arm. Oxygen saturation is 98% on room air. HEENT: PERRL.
Oropharynx benign. Neck without carotid bruits. There is a bruit
over the left subclavian area of the chest. Chest is without
incisions , breast biopsy site is noted. Cardiovascular: Regular
rate and rhythm , no murmurs. Respiratory: Inspiratory crackles
bilaterally. No wheezes. Abdomen: Right-sided vertical
cholecystectomy scar , soft , no masses. Extremities: Mild
varicosities , 1+ pedal pulses bilaterally , 2+ radial pulses
bilaterally. Allen's test in both upper extremities are normal
by pulse oximeter. Neuro: Alert and oriented , grossly nonfocal
exam.
LABORATORY DATA:
Pre-op chemistries include sodium of 134 , BUN of 24 , creatinine
of 1. Hematology includes white blood cell count of 13 ,
hematocrit of 29.
Cardiac catheterization data performed at
outside hospital reveals the following: 70% left main , 90%
circumflex , 30% LAD , 60% D1 , 40% RCA and a right dominant
circulation.
Echocardiogram from 5/28/05 estimates ejection
fraction at 60% , notes mild aortic insufficiency. EKG normal
sinus rhythm at 83 with ST depressions in V4 and V5 , inverted
T-waves. Chest x-ray is consistent with congestive heart failure
and cardiomegaly.
HOSPITAL COURSE:
The patient was taken to the operating room on 3/22/05 and
underwent CABG x2 with a Y graft , LIMA connects SVG1 to LAD and
SVG1 connects aorta to OM1. The patient was taken to the
Intensive Care Unit following surgery in stable condition. She
was extubated on her operative day without difficulties and was
hemodynamically stable postoperatively with adequate urine
output. The patient was started on a beta-blocker and was
followed by Diabetes Management Service for glycemic control.
She was transferred to the Step-Down Unit on postoperative day #2
in good condition; neurologically intact and hemodynamically
stable , saturating well on 2 liters of oxygen by nasal cannula ,
her diet was advanced and well tolerated. Her urine output was
brisk on diuretics. She was started on aspirin. White blood
cell count was noted to be elevated postoperatively , but the
patient remained afebrile and her white blood cell count trended
down for the remainder of her hospital stay. She was noted to
have a urinary tract infection for which she was treated with
ciprofloxacin and she continued to progress daily with mobility
and ambulation. The remainder of her hospital stay was
uncomplicated and she is discharged to home in good condition on
postoperative day #5. At time of discharge , her laboratory
chemistries include the following: sodium of 134 , potassium of
4.4 , BUN of 26 , creatinine of 0.9. Her white blood cell count has
steadily declined during the postoperative period and her white
blood cell count is 14 at time of discharge. The patient's hematocrit is
stable at 35 , and INR is 1.1.
DISCHARGE MEDICATIONS:
Tylenol 650 mg orally every 6 hours as needed pain ,
enteric-coated aspirin 325 mg orally daily , atenolol 100 mg orally
twice a day , ciprofloxacin 250 mg orally every 12 hours x2 doses , this will
complete 3 days treatment for urinary tract infection , Colace 100
mg orally three times a day as needed constipation , Niferex 150 mg orally twice a day
Combivent 2 puffs inhaled four times a day as needed shortness of breath and
wheezing , Lantus insulin 20 units subcutaneously every bedtime , and
atorvastatin 10 mg orally daily
She is to have follow-up appointments with her cardiologist , Dr.
Peaks in one to two weeks and with her cardiac surgeon , Dr.
Kertesz in four to six weeks.
eScription document: 6-3424911 EEeScription
Dictated By: JACOBSON , CHRISTEEN
Attending: KERTESZ , ALETA
Dictation ID 0783777
D: 5/29/05
T: 5/29/05
Document id: 791
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388530584 | PUO | 02419606 | | 173979 | 6/6/1998 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/2/1998 Report Status: Signed
Discharge Date: 11/27/1998
DISCHARGE DIAGNOSIS: WIDE COMPLEX TACHYCARDIA POST EXERCISE
TOLERANCE TEST RECOVERY.
SECONDARY DIAGNOSES:
1 ) HYPERCOAGULABILITY STATE WITH NEGATIVE SERUM WORK-UP.
2 ) RULE OUT RENAL CELL CARCINOMA ON THE LEFT ( CT PENDING ).
3 ) HISTORY OF PPD POSITIVITY WITH CHEST X-RAY NEGATIVE.
4 ) GOUT.
5 ) CHRONIC OBSTRUCTIVE PULMONARY DISEASE STATUS POST UNILATERAL
ORCHIECTOMY.
6 ) HISTORY OF HEPATITIS A.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old man with
coronary risk factors of hypertension ,
borderline hypercholesterolemia , remote tobacco with a history of
hypercoagulability ( negative work-up for protein C , S , activated
protein C , factor V lydin , antithrombin III , anticardiolipin
antibody , and homocystine level ) , and multiple deep venous
thromboses/pulmonary emboli requiring chronic anticoagulation and
placement of an IVC filter in 11/20 He reportedly had a history
of chronic shortness of breath and negative stress test for
ischemia in 6/10 through 3/11/98. A Holter monitor in 4/17
showed frequent premature ventricular contractions , 21 couplets ,
and no other arrhythmias. An echo in 10/28 showed an ejection
fraction of 55% , left ventricular hypertrophy , mitral valve
prolapse with 2-3+ mitral regurgitation , and trace aortic
insufficiency. A repeat Holter in 3/15 showed numerous premature
ventricular contractions , PM bradycardia , sinus tachycardia , a rate
of 113 , six triplets , and 172 couplets. On a stress test in 4/4 ,
the patient lasted two minutes and stopped secondary to atypical
chest pain with a peak heart rate of 79% of predicted and a peak
blood pressure of 170. There were no signs of definite ischemic
and no clinically significant rhythm disturbance. The patient
reported a vague history of arrhythmia in the Wa Lo
for which he was supposedly due to have a pacemaker placed. He
denied ever being symptomatic with these arrhythmias. Over the
last week , he had reported increasing fatigue and shortness of
breath. The day of admission on his way to the clinic for an INR
check , he reported chest tightness that was different from his
previous pulmonary emboli , apparently 10/10 on presentation though
he denied it after the fact associated with shortness of breath and
fatigue with "heavy heart beats". He denied associated symptoms of
nausea , vomiting , diaphoresis , light headedness , and palpitations.
He denied congestive heart failure and syncopal symptoms over the
last few weeks. In the Emergency Room , he had flat CK and a 0
troponin I and a stress test lasting three minutes and fifteen
seconds. Patient stopped secondary to fatigue and not chest pain ,
however , three to five minutes after recovery , he developed a
couple of episodes of nonmonomorphic wide complex tachycardia at a
rate of about 150 lasting twenty to thirty beats during which time
he was reportedly asymptomatic. The patient was admitted for
evaluation of this possible ventricular tachycardia.
PAST MEDICAL HISTORY: History of multiple pulmonary emboli/deep
venous thromboses with number one in 11/17 ,
status post TPA when echo showed right ventricular strain , number
two in 6/28 , number three in 6/10 after one year of Coumadin , and
number four in 2/11 status post IVC filter placement when patient
bled into left renal cyst with goal INR of 3 to 3.8. Patient had a
negative hypercoagulability work-up , question of renal cell
carcinoma which must be evaluated in the next two months , history
of PPD positivity of 2 cm and negative chest x-ray , mitral valve
prolapse and MR on echo , hypertensive borderline
hypercholesterolemia , gout , chronic obstructive pulmonary disease ,
status post unilateral orchiectomy , restrictive lung disease ,
history of a duplex 5 cm adrenal mass , negative 17
hydroxyketosteroids and VMA , and history of hepatitis A virus.
CURRENT MEDICATIONS: Lopressor 25 mg orally twice a day , amlodipine 10 mg
orally every day , Cardura 2.5 mg orally every day , Axid 150
mg orally twice a day , Coumadin 6 mg orally every day , and indomethacin every 4 hours
ALLERGIES: Patient had no known drug allergies
( hydrochlorothiazide was thought to cause gout
exacerbations and ace inhibitor thought to cause cough , and beta
blocker with urinary retention ).
FAMILY HISTORY: Patient had a family history of cancer and no
history of premature coronary disease ,
palpitations , or sudden death.
SOCIAL HISTORY: The patient immigrated from the Mil
with his wife a few years ago , had a remote
history of tobacco , occasional alcohol , and no drugs. He was a
previous factory worker.
REVIEW OF SYSTEMS: Negative.
HOSPITAL COURSE: The patient is a 70 year old with a history of
hypertensive borderline hypercholesterolemia , and
hypercoagulability with multiple pulmonary emboli in the past who
presented asymptomatically with a wide complex tachycardia that
could not rule out ventricular tachycardia in the recovery phase of
a full Bruce exercise tolerance test. The patient was admitted for
Holter monitoring times 48 hours. He was ruled out for a
myocardial infarction. He was started on a cholesterol lowering
agent , his Coumadin was held , and Heparin was started in the case
of an invasive procedure. On 10/15/98 , the patient had an exercise
tolerance test MIBI on an increased dose of beta blocker of 50 mg
of Lopressor every 8 hours which showed that the patient exercised three
minutes and fifteen seconds stopping secondary to leg pain from his
deep venous thrombosis with a peak heart rate of 106 , peak blood
pressure 150/80 , frequent premature ventricular contractions in
couplets , no ST or T wave changes , and no chest pain. The patient
then had an adenosine MIBI with a maximum heart rate of 81 and a
maximum blood pressure of 180/70. He did have chest pain after the
infusion with T wave inversions in V5 through V6 and occasional
premature ventricular contractions that were consistent with but
not diagnostic of ischemia. The MIBI images showed mild
nonspecific inferior wall changes with some reversibility
suggestive with but not conclusive of ischemia. The patient was
discharged the following day on his usual out-patient medicines
with the addition of an ace inhibitor , Lisinopril 10 mg orally every day ,
given his mitral regurgitation. He will continue his beta blocker
at an increased dose , Atenolol 50 mg orally every day , in addition to his
Cardura and amlodipine. He was started on Zocor at 10 mg orally every day
DISPOSITION: He will need out-patient echos to follow his mitral
regurgitation and will need to be observed the higher
risk of developing atrial fibrillation. He will also need a repeat
stress test in the next couple of months when his leg pain
completely resolves. From a hypercoagulability standpoint , his
Coumadin was started at his usual out-patient dose of 6 mg orally
every afternoon with enoxaparin used as a bridge to anticoagulation until
his INR is at least 3. His goal INR is between 3 and 3.8. He will
have visiting nurse teach him to use the enoxaparin and will come
to Coumadin Clinic at KTDUOO every two to three days to have his INR
level checked. A pelvic CT was scheduled on 8/14/98 at 2 p.m. to
reevaluate his kidneys and rule out renal cell carcinoma.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally every day , Lisinopril 10 mg
orally every day , Atenolol 50 mg orally every day ,
amlodipine 10 mg orally every day , Cardura 1 mg orally every bedtime , nitroglycerin
sublingual tablets 0.4 mg every 5 minutes as needed chest pain ,
indomethacin 25 mg orally every 6 hours , Axid 150 mg orally twice a day , Zocor 10 mg
orally every bedtime , enoxaparin 60 mg subcutaneously every 12 hours until INR 3 ,
and Coumadin 6 mg orally every afternoon
FOLLOW-UP: The patient will follow-up with Dr. Ulysses Geldrich
next week and was in stable condition upon discharge.
Dictated By: MAGALY CONWRIGHT , M.D. MG7
Attending: DESIRAE R. MARCOTT , M.D. BB18
RM479/3254
Batch: 38485 Index No. LETWMC4UAC D: 10/7/98
T: 5/25/98
CC: 1. ULYSSES C. GELDRICH , M.D. HD87
Document id: 792
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847442317 | PUO | 82161933 | | 413158 | 2/20/2000 12:00:00 a.m. | ABDOMINAL PAIN | Signed | DIS | Admission Date: 2/20/2000 Report Status: Signed
Discharge Date: 1/21/2001
CHIEF COMPLAINT: A 29-year-old G 3 P 2 admitted on postoperative
day #19 , status post a STAT cesarean section at
29 weeks for fetal bradycardia following laparoscopic
cholecystectomy. She was readmitted for wound infection.
HISTORY OF PRESENT ILLNESS: The patient's past medical history
is significant for cardiac transplant
in 1989 for a dilated cardiomyopathy. The patient is on multiple
immunosuppressants. The patient had several episodes of acute
cholecystitis and underwent laparoscopic cholecystectomy nineteen
days prior to admission. Fetal bradycardia developed immediately
following the cholecystectomy and a STAT cesarean section was
performed. The patient was returned to the Cardiology Service for
further management of fluid status and mild congestive heart failure.
She was discharged on postoperative day #7. On 3/3 the patient
was seen in the MFM practice and a wound hematoma on the left side was
noted. It was and drained with normal , healthy tissue identified.
She had twice a day dressing changes with a visiting nurse. On the day of
admission the patient noted a temperature to 100.0 , slightly foul-smelling
discharge from the wound. She denied abdominal pain. The patient
also noted that the right foot pain present at the time of surgery
had been worsening over the course of the day and was noted to be
swollen and erythematous at the time of admission.
PAST MEDICAL HISTORY: Viral cardiomyopathy , now status post
transplant , hypertension , chronic renal
insufficiency with a baseline creatinine of 1.4-1.8 ,
hyperlipidemia , obesity , history of group A Strep sepsis in 1998.
PAST SURGICAL HISTORY: Cesarean section x 2 in 1998 and 2001 ,
laparoscopic cholecystectomy on 10/24 ,
D&E for SAb in 11 of November , status post eye surgery in 1973.
MEDICATIONS: Imuran 75 mg orally twice a day; cyclosporin 125 mg orally
every day; prednisone 10 mg orally every day; pravastatin 10 mg
orally every bedtime; quinidine sulfate 25 mg orally three times a day; Kaopectate 30
mg orally every i.d.; Zantac 150 mg orally twice a day; miconazole topical 2%
as needed; Tylenol #3 1-2 orally every 4-6h as needed pain.
ALLERGIES: Sulfa , penicillin , IVP dye all cause pink rash ,
succinylcholine resulted in respiratory arrest.
PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.6 ,
blood pressure 120/60 ,
respirations 18 , pulse 74. HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese ,
nontender , nondistended , incision was open at two sites. There was
gray , malodorous fluid draining from the wound. The wound tracked
superiorly on the left. The fascia was intact. There was no
evidence of necrotic tissue. EXTREMITIES: Distal extremities had
trace edema , right greater than left with erythema and tenderness
on the dorsal surface of the right ankle.
HOSPITAL COURSE: 1 ) Wound infection: An Infectious Disease
consult was obtained at the time of admission and
the patient was sent for immediate intraoperative treatment and
wound debridement. Surgery was consulted intraoperatively to
confirm healthy tissue and no evidence of necrosis. The patient
was started on levofloxacin and clindamycin intravenous and three times a day dressing
changes. Blood cultures obtained prior to antibiotic therapy were
negative for bacteremia. Cultures of the wound were consistent
with Strep and diphtheroids with obvious polymicrobial involvement.
On hospital day #3 blood cultures which had been drawn from the
patient's indwelling line returned with 2/4 bottles positive for
gram-positive cocci in clusters. The central line was discontinued.
The patient began treatment on vancomycin 1 gram intravenous every 12 hours , levofloxacin
was continued and the Flagyl was started 500 mg orally three times a day The
patient remained afebrile throughout this time. A CT of the abdomen
and pelvis was obtained per Infectious Disease recommendation and it
confirmed that there was no intraabdominal abscess. The patient was
continued on intravenous vancomycin with orally Flagyl and levofloxacin until
4/14/01 , hospital day #8. At that point the patient was discharged to
home with visiting nurse and continued intravenous and orally antibiotics x 14
days. Cultures obtained following discontinuation of her central
line returned as negative. On hospital day #6 the patient had
a significant yeast infection surrounding the lower aspect of the
incision as well as in the intertriginous areas. This was treated
with topical nystatin.
2 ) Cardiovascular: The patient's cardiac standpoint remained
stable throughout the admission with no evidence of congestive
heart failure. Routine echo was performed on 5/25/01 as scheduled
per her transplant protocol. There were no other cardiovascular
issues during the patient's admission.
3 ) Renal: The patient had a baseline history of renal
insufficiency as described above with a creatinine of 2.1 on
admission. Creatinine increased during her admission to a maximum
of 3.1. She was also noted to have decreasing urine output at that
time. Adjustments were made in vancomycin and cyclosporin levels
and the patient's creatinine slowly returned to baseline with
significant improvement of urine output.
4 ) GI: The patient had no difficulties with bowel function until
hospital day #5 when patient was noting increasingly loose
stools. C. diff. was obtained x 2 and were negative. She was
treated with Imodium as needed
5 ) Rheumatology: The patient had initially right ankle pain and
swelling noted at the time of admission. A Rheumatology consult
was obtained and the joint was tapped and there was no evidence of
infection at that time. The patient was continued to be followed
by Rheumatology and , based on Rheumatology and Transplant Team
recommendations , was treated with colchicine for the diagnosis of
gout on immunosuppressant medications. The possibility of plantar
fasciitis was raised during admission and treatment was pain
medication , continued colchicine and physical therapy. The patient
was able to ambulate at the time of discharge.
DISCHARGE MEDICATIONS: Vancomycin 750 mg intravenous every 12 hours; levofloxacin
500 mg orally every day; Flagyl 500 mg orally three times a day
x 14 days; Percocet 1-2 orally every 3-4h as needed pain.
The patient had a visiting nurse established for continued twice a day
dressing changes at home and to obtain vancomycin and cyclosporin
levels as needed.
FOLLOWUP: She will be followed by her cardiac transplant team to
follow her antibiotic and immunosuppressant levels. She
was scheduled for routine follow up with the cardiac transplant
team with no changes in appointment time , follow up with OB/GYN in
two weeks' time.
Dictated By: KUM BINGLEY , M.D. SK18
Attending: ANASTACIA M. DEBROCK , M.D. SK0
TP525/1669
Batch: 17448 Index No. USULFV26RB D: 10/13/01
T: 9/30/01
Document id: 793
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209514778 | PUO | 19125161 | | 9818062 | 5/18/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE , ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 8/28/2006 Report Status: Signed
Discharge Date: 1/6/2006
ATTENDING: PETTINGER , DOUGLASS MD
HISTORY OF PRESENT ILLNESS:
The patient was admitted for an elective right heart
catheterization and reassessment of refractory CHF and atrial fibrillation He
is a 62-year-old man with
a history of nonischemic cardiomyopathy with an EF of 30% who was diagnosed
about ten years ago and has been stable with medical management
until this past year when he started developing worsening dyspnea
on exertion , orthopnea , palpitations , and PND. His functional
status has declined significantly since then. In 11/26 , he was
admitted for decompensated heart failure and diuresed back to dry
weight. An ICD was placed at that time. Following discharge , he
developed AFib with rapid ventricular response and underwent DC
cardioversion with Dr. Norine Dehl however , relapsed shortly ,
thereafter. He was started on amiodarone , but developed a
question of pulmonary toxicity with significant dry coughing. He
was continued to be in atrial fibrillation with rapid ventricular
response despite maximal carvedilol and digoxin. He is now being
electively admitted for right heart catheterization , diuresis ,
and possible repeat cardioversion versus amiodarone challenge ,
and completion of his transplant evaluation.
PAST MEDICAL HISTORY:
Nonischemic cardiomyopathy , EF of 30% , atrial fibrillation status
post ICD placement , echo in 2/10 with an EF of 30-35% with a
dilated LV and anterior wall and septal hypokinesis , mild mitral
regurgitation , hypertension , hyperlipidemia , and diabetes.
MEDICATIONS AT HOME:
Include aspirin 325 mg daily , carvedilol 25 mg twice a day , digoxin
0.125 mg daily , Lasix 60 mg orally daily , lisinopril 20 mg orally
daily , Vytorin 10 mg orally daily , Protonix 40 mg orally daily ,
metformin 500 mg orally twice a day , glyburide 2.5 mg orally twice a day ,
Coumadin , iron sulfate 325 mg daily , and magnesium gluconate 500
mg orally twice a day
ALLERGIES:
He has a questionable allergy to amiodarone.
SOCIAL HISTORY:
Lives on Fay , Maine 25284 He does not drink , smoke , or use any other
drugs.
PHYSICAL EXAM ON ADMISSION:
He was afebrile with a heart rate of 106 in atrial fibrillation.
His blood pressure is 102/78 and satting 98% on room air. He was
in no distress. His JVP was approximately 12 cm. He had a right
ventricular heave. His rate was irregularly irregular with an
S3 , no murmurs. Chest is clear to auscultation. He had a
palpable pulsatile liver tip , but otherwise , his abdomen was
benign. He had no lower extremity edema.
HOSPITAL COURSE BY SYSTEM:
He is a 62-year-old man with nonischemic cardiomyopathy , EF 30% ,
awaiting transplant who is now admitted for right heart
catheterization and diuresis for volume overload and possible
amiodarone challenge versus cardioversion , rate and rhythm
control atrial fibrillation.
Cardiovascular: The patient had no evidence of ischemia. He was
mildly volume overloaded and was gently diuresed with orally Lasix
and eventually twice a day orally torsemide at 60 mg twice a day He was
diuresed onto his dry weight of 70 kilograms. He underwent
exercise stress testing and was able to go for 7 minutes without
any ischemic changes. His rhythm rate was in atrial fibrillation
throughout. He has peak oxygen uptake with above is anaerobic
threshold and his peak respiratory exchange ratio was 1.44. He
underwent a chest CT , which showed no evidence of amiodarone
pneumonitis or interstitial disease , and then was subsequently
started on amiodarone challenge in attempts to rhythm and rate
control of atrial fibrillation. He was resistant to the
amiodarone in terms of rate and rhythm control; however , began
developing elevated LFTs consistent with amiodarone hepatitis as
well as a persistent dry cough concerning for amiodarone
pulmonary toxicity. The amiodarone was stopped and he was
started on dofetilide at 125 mg orally twice a day for correcting for
his creatinine clearance. After 2 doses of dofetilide , he
converted to normal sinus rhythm and was rate controlled in the
70s and 80s. His QTc was followed twice a day and did not show
any signs of prolongation. He was finally being discharged on
dofetilide for rate and rhythm control as he is now in normal
sinus rhythm. He will also go home on torsemide 60 mg orally
twice a day to maintain his dry weight. He has been instructed to
continue taking his glyburide , but not his metformin given his
poor creatinine clearance being discharged with a creatinine of
1.6 and the fact that he is on metformin. He will see his
primary care doctor and will either likely be started on low-dose
insulin or another orally hypoglycemic agent. He will follow up
with his primary care doctor and Dr. Pettinger for continued
transplant evaluation.
DISCHARGE MEDICATIONS:
Include carvedilol 25 mg orally twice a day , darbepoetin 100 mcg
subcutaneous every week , digoxin 0.125 mg orally every other day ,
dofetilide 125 mcg orally twice a day , Vytorin one tab orally daily , iron
sulfate 325 mg orally twice a day , glyburide 5 mg orally twice a day , potassium
40 mEq orally daily , lisinopril 10 mg orally daily , Protonix 40 mg
orally daily , torsemide 50 mg orally twice a day , Coumadin 2 mg orally
every afternoon
FINAL ADDENDUM:
The patient will continue taking his Coumadin for goal INR of 2-3
and follow up at the Kernan To Dautedi University Of Of Coumadin Clinic , in addition , he
received one unit of packed red blood cells for anemia of chronic
disease and was given intravenous iron therapy and will continue the
patient on orally iron replacement.
eScription document: 4-8582198 EMSSten Tel
Dictated By: MANGANELLI , ADELINA
Attending: PETTINGER , DOUGLASS
Dictation ID 0588299
D: 3/9/06
T: 3/9/06
Document id: 794
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009189075 | PUO | 55313086 | | 8496143 | 9/11/2002 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 9/11/2002 Report Status:
Discharge Date: 10/8/2002
****** DISCHARGE ORDERS ******
WOLSEY , JENNEFER 154-11-50-8
Georgia
Service: CAR
DISCHARGE PATIENT ON: 9/11/02 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: STAUTZ , MATHEW SAMMY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 1 , 250 MG orally twice a day
DIGOXIN 0.125 MG orally every day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 20 UNITS subcutaneously every day before noon
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 5 UNITS subcutaneously every afternoon
LISINOPRIL 2.5 MG orally every day
Alert overridden: Override added on 6/17/02 by
PRINCE , DARLA VELLA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
ATIVAN ( LORAZEPAM ) 1 MG orally every bedtime
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
TORSEMIDE 80 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
ALBUTEROL AND IPRATROPIUM NEBULIZER 3/0.5 MG inhaled every 6 hours
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: 4 gram Sodium
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Lyn ( cardiology ) 1-2 weeks ,
Dr. Newhard ( primary care physician ) 1-2 weeks ,
Arrange INR to be drawn on 10/2/02 with f/u INR's to be drawn every
7 days. INR's will be followed by dia riemenschneid
ALLERGY: Benadryl ( diphenhydramine hcl ) ,
Atarax ( hydroxyzine hcl ) , Penicillins
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
rheumatic heart dz ( rheumatic heart disease ) MVR/AVR history of replacement
with Ley Rotal University Medical Center ( cardiac valve replacement ) history of tricuspid repair CHF
( congestive heart failure ) IDDM ( diabetes
mellitus ) afib ( atrial fibrillation ) esophageal ulcer
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
patient is 61yoF urdu speaking A , poor
historian , with hx of MMP including CHF , history of triple valve repair who
presents with ? SOB. Hx is variable depending on the interview , but
it appears that patient had completed
outpatient rx for bronchitis with good result approx 5
days PTA. patient then developed some ?shortness of
breath which may have been secondary to medical
non compliance. On ROS , patient denies CP ,
n/v/d , orthopnea/ PND , admits to wt gain , 3lbs
over 1 week and cough with clear
sputum. PE: 97.9 66 18 136/61 99% on
2l HEENT -NCAT , JVP
8cm PULM - Rhonchorus through both lung
fields CARD- Irregular , 3/6 SEM , mechanical
HS ABD-+BS , soft , nt ,
nd EXT-no c/c/ , trace
edema CXR- COPD , small l effusion ,
A+P - 61yoF with hx of mutiple medical problems , difficult historian ,
who presents with ? SOB 1 ) CARDS - patient has been diueresed in the ED.
She soes not appear to be volume overloaded , either
by CXR or PE. Will continue her home dose
Dig , torsemide , with small additional intravenous lasix for
goal neg 1-2L. No evidence for
ischemia 2 )ENDO- Continue home
NPH 3 )PAIN- Percocet
as needed 4 )GI- Nexium
20 5 )FEN-Continue
supplements 6 )HEME-Continue
coumadin 7 )ID-Afebrile , no WBC. nothing for
now
Hospital course: patient was diuresed with intravenous torsemide , 1-2 L/day. Her CXR
and JVP markedly improved. She was started on an ACE inhibitor and her
betablocker was converted to once a day. She remained afebrile. Repeat
CXR's did not show any evidence of pneumonia.
ADDITIONAL COMMENTS: ** Call 575-803-4363 to make an appointment with your cardiologist for
1-2 weeks from now. **
- Measure your weight every day - if it goes up by more than 2 pounds ,
call your cardiologist and he will make adjustments in your
medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please have VNA draw INR and check fluid status , diabetes check , med
compliance.
No dictated summary
ENTERED BY: SWANDA , VERLIE , M.D. ( EF73 ) 9/11/02 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 795
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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509221029 | PUO | 25145895 | | 341820 | 5/22/2001 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/14/2001 Report Status: Signed
Discharge Date:
PRINCIPAL DIAGNOSIS: HEART FAILURE.
SIGNIFICANT PROBLEMS: AORTIC INSUFFICIENCY.
VALVULAR CARDIOMYOPATHY.
MITRAL REGURGITATION.
TRICUSPID REGURGITATION.
HYPERTENSION.
HEMOLYTIC ANEMIA.
CHRONIC RENAL INSUFFICIENCY.
HISTORY OF PRESENT ILLNESS: This is a 50 year-old man with
valvular cardiomyopathy , status post
three aortic valve replacements who presents with no acute
complaints but progressive decline in daily function. Mr. Nemani 's
history begins in January of 1995 when he presented with shortness of
breath , dyspnea on exertion and orthopnea in the setting of
medication ( Lasix and/or Procardia for hypertension ).
Noncompliant , he was found by echo to have severe aortic
insufficiency with moderate mitral regurgitation , left ventricular
hypokinesis and ejection fraction of 45%. He subsequently
underwent aortic valve replacement along with a mitral valve
repair , aortic valve pathology showed myxomatous degeneration. One
month post surgery he required repeat aortic valve replacement with
dehiscence and was documented to have an annular abscess with
cultures positive for yeast. At this time he also required
coronary artery reimplantation and annular repair.
HOSPITAL COURSE: His hospital course was additionally complicated
by the development of third degree heart block
necessitating the implantation of a permanent pacemaker. After
discharge Mr. Nemani did generally well for the following years
until October of 1999 when he again presented with increasing
shortness of breath. Echo then revealed moderate to severe aortic
insufficiency with moderate mitral regurgitation. Cardiac
catheterization showed clear coronary arteries. At this time his
aortic valve was again replaced with a St. Jude valve. Again
following discharge Mr. Nemani did generally well until October of
2001 when again he presented with shortness of breath. At that
time echo showed at least mild paravalvular aortic regurgitation
with left ventricular dilatation ( systolic diameter 6.1 cm ) along
with 1+ mitral regurgitation , 2+ tricuspid regurgitation and an
ejection fraction of 15 to 20%. Stress testing at this time showed
a physical work capacity of 15.1. It is not documented what was
done at this time but apparently his Lasix was increased from 40
twice a day to 80 twice a day with good effect.
Regarding this admission , Mr. Nemani reports that he has been
feeling fine and has been in the hospital because his doctors want
to replace his valve , or if that doesn't work to give him a new
heart. He reports no increasing dyspnea , fatigue , ankle edema or
abdominal girth. He sleeps on three pillows at night and has not
recently been shortness of breath when lying flat. He is able to
do chores around the house without getting shortness of breath but
usually does get shortness of breath after one flight of stairs.
He doesn't complain of significant disability or quality of life
impairment as a result of his heart condition. He notes that he
has not been able to participate in the marching band over the last
year but that he is still able to play seated.
Mr. Nemani attributes his disease to having been noncompliant with
Procardia following a cerebrovascular accident in 1993. He says
that "he brought on his heart problems himself".
PAST MEDICAL HISTORY: Otherwise notable for hypertension , a
cerebrovascular accident in 1993 , an
embolism to the left foot in 1998 and chronic renal insufficiency
with a creatinine of 1.4 to 2.2 in September of 1999.
ALLERGIES: He is allergic to Zestril which gives him perioral
angioedema.
MEDICATIONS ON ADMISSION: Lasix 80 mg twice a day , Atenolol 50 mg
every day , Avapro 150 mg every day , Coumadin 5
mg every day , Zantac 150 mg twice a day , Niferex 150 mg every day.
FAMILY HISTORY: Negative for heart disease.
SOCIAL HISTORY: He has a 35 pack/year smoking history and drinks
only occasionally. Mr. Nemani is on permanent
disability leave from his job at Go Ster Nasson which involved a lot of
heavy lifting. He lives at home with his wife and son and spends
most of his day there. He is active in a Son where he
likes to play the base drum.
PHYSICAL EXAMINATION: Mr. Jacinto is a thin , healthy appearing
black man in no apparent distress. Heart
rate is 65 , blood pressure 120/170. Oxygen saturation 98% on room
air. His carotid pulse was normal in volume. Jugular venous
pressure is 7 cm. His lungs were clear. His PMI was vibratory
and quality and prominent lateral to the anterior axillary line.
He had a normal S1 with an ejection sound and loud prosthetic S2 as
well as a 3/6 systolic murmur at the right upper sternal border and
a 3/4 holodiastolic murmur at the left lower sternal border
radiating to the right upper sternal border. His abdomen was
nondistended with no organomegaly. His extremities were warm with
faint pulses.
LABORATORY DATA: Labs were remarkable for a creatinine of 2.3 ,
hematocrit of 33.5 with an MCV of 83.5. RBW was
28.8 , reticulocyte count of 6.6 and LDH of 1 , 777.
Mr. Nemani had an echo here that showed severe aortic insufficiency
with a severely dilated left ventricle ( and diastolic diameter of
7.0 and systolic diameter of 6.3 ) as well as mild to moderate
mitral and tricuspid regurgitation and ejection fraction of 20 to
25%. Exercise testing showed an oxygen uptake of 12.7. On cath
his pulmonary artery pressure , wedge pressure and pulmonary
vascular resistance were 47/16 , 13 and 379 which fell to 26/4 , 5
and 137 respectively with Nipride. His systemic vascular
resistance was markedly elevated to 2400 and his thick cardiac
output and cardiac index was 3.62 and 2.31.
Amlodipine was then started and Lasix was increased in an effort to
increase systemic vascular resistance and pulmonary wedge
pressures. The remainder of the transplant workup results were
unremarkable except for a significantly reduced diffusing capacity
of 59% corrected. A creatinine clearance of 48.4 and a PSA of
18.1 , prostate biopsy and bone scan were both negative.
His admission was otherwise notable for an elevated creatinine of
3.0 in the setting of perioperative levofloxacin and gentamicin as
well as aggressive vasodilator therapy. His creatine was back
down to his baseline of low 2's before discharge. Mr. Nemani was
discharged home in stable condition on the following medications.
DISCHARGE MEDICATIONS: Atenolol 25 every day , Lasix 120 twice a day ,
Coumadin 5 mg every day , amlodipine 2.5 mg q.
day , Avapro 150 mg every day , Niferex 150 mg every day and ranitidine 150
mg twice a day
FOLLOW-UP: Mr. Nemani will follow-up with Dr. Mathew Stautz in two
weeks.
Dictated By: ETTA SIX , MD ROCHELL TYNDALL
Attending: SUNSHINE D. RAABE , M.D. HR28
QJ699/288936
Batch: 37700 Index No. H7VPYQM028 D: 6/13/01
T: 7/29/01
CC: 1. MATHEW STAUTZ , M.D. ZZ69
2. DESIRAE MARCOTT , M.D. AA4
3. MARCELA JONE , AKCARE HOSPITAL
Document id: 796
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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799534280 | PUO | 62210422 | | 5663423 | 9/27/2002 12:00:00 a.m. | LEFT ATRIAL MYXOMA | Signed | DIS | Admission Date: 9/27/2002 Report Status: Signed
Discharge Date: 11/28/2002
HISTORY OF PRESENT ILLNESS: Mr. Orduna is a 70-year-old
gentleman who went to see primary care
physician and presented with aphasia. MRI was sent at that time ,
which revealed a left parietal infarct. A transesophageal
echocardiogram was done , which revealed a large left atrial myxoma
with prolapse across the mitral valve into the left ventricle with
a pedunculated stock. The patient does not have symptomatic heart
failure and is normal sinus rhythm.
PAST MEDICAL/SURGICAL HISTORY: Significant for percutaneous
transluminal coronary angiography
and atherectomy with stent placement , history of recent
cerebrovascular accident , diabetes mellitus , orally agent treatment ,
chronic obstructive pulmonary disease , remote history of gout ,
chronic renal insufficiency , status post angioplasty and stenting
procedures , and anemia. He is status post a right nephrectomy in
1999 , with renal cell carcinoma and right knee replacement in 2001 ,
and a laparoscopic cholecystectomy in the year 2001. The patient
underwent cardiac catheterization on 4/26/02 , which revealed a
left anterior descending coronary artery with a 40% stenosis , first
obtuse marginal coronary artery with a 60% stenosis , a right
coronary artery with a 60% stenosis and a right dominant
circulation , ejection fraction of 50%. The patient underwent an
echocardiogram on 1/9/02 which revealed the following: ( 1 ) Left
ventricular cavity size with wall thickness and systolic function
appeared normal with an ejection fraction of 55% , with no akinetic
areas seen. ( 2 ) The right ventricle appears normal in size and
systolic function. ( 3 ) The aortic valve is trileaflet without
evidence of dysfunction. ( 4 ) The mitral leaflets appear mildly
thickened. There is light retrace mitral regurgitation. The left
atrium is enlarged. ( 5 ) A large heterogeneous multilobulated mass
is seen within the atrium. It appears to be attached by a stalk to
the interatrial septum. The mass measures approximately 7 x 3.5 cm
and prolapses to the mitral valve and to the left ventricle. The
distal portion of this mass has more mobile element. A mild amount
of inflow obstruction is noted , and there is also mild valvular
incompetence. The appearance of the mass is most consistent with
myxoma , although other primary and secondary neoplasms are also
possible. Thrombus is seen much likely , but superimposed thrombus
formation overlying the main mass is possible. ( 6 ) The tricuspid
valve leaflets are mildly thickened. There is trace tricuspid
regurgitation with peak velocity of 2.7 m/sec predicting pulmonary
artery systolic pressures of 29 mmHg plus right atrial pressure.
( 7 ) There is no evident pericardial effusion. ( 8 ) No prior studies
are available for comparison. ( 9 ) Findings reviewed with clinical
team. The patient also underwent a MRI of the brain which revealed
the following: ( 1 ) Left parietal infarct. ( 2 ) Bilateral posterior
communicating arteries. Otherwise , normal vasculature. The
patient was seen by the neurology service who recommended that the
patient did not proceed with his cardiac surgery at this time. He
will be discharged to home and be readmitted on 2/19/02 in the
year 2002 for his cardiac surgery. He has otherwise had an
uneventful hospital course and will be discharged to home in stable
condition.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: Celexa 40 mg every day , atenolol 100 mg every day , allopurinol
100 mg every day , glyburide 5 mg every day before noon and Lipitor 10 mg
in the evening.
PHYSICAL EXAMINATION: CARDIAC: Regular rate and rhythm , with no
murmurs , rubs or heaves. RESPIRATORY:
Breath sounds clear bilaterally. NEURO: Alert and oriented with
an expressive aphasia.
DISCHARGE LABORATORY DATA: Glucose 88 , BUN 23 , creatinine 1.7 ,
sodium 140 , potassium 4.6 , chloride
102 , CO2 27. WBC 8.12 , hemoglobin 9.0 , hematocrit 28.6 , platelets
262. ESR 87.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 325 mg 1 orally every day
atenolol 100 mg every day , Lipitor 10 mg q.
evening , allopurinol 100 mg every day , glyburide 5 mg every morning , Celexa
40 mg every day
Mr. Orduna will be discharged to home in stable condition.
Dictated By: PRISCILLA BARBELLA , P.A.
Attending: GAYLENE G. FANIEL , M.D. HK34
OD276/088799
Batch: 13617 Index No. JURC4XC6M6 D: 11/18/02
T: 7/18/02
Document id: 797
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
- |
Y |
N |
N |
N |
N |
N |
Y |
N |
- |
Y |
Y |
N |
N |
094513064 | PUO | 19651095 | | 5728943 | 10/14/2005 12:00:00 a.m. | Attending evaluation | | DIS | Admission Date: 10/22/2005 Report Status:
Discharge Date: 9/20/2005
****** FINAL DISCHARGE ORDERS ******
ROCHE , OLIN 214-43-79-6
Ryi Ln. , Fran , Connecticut 31193
Service: MED
DISCHARGE PATIENT ON: 10/10/05 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WAGNON , DENNA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Shortness of Breath
ALBUTEROL NEBULIZER 2.5 MG NEB four times a day as needed Wheezing
AUGMENTIN 250/125 ( AMOX./CLAV.ACID 250/125 ) 1 TAB orally three times a day
Food/Drug Interaction Instruction
May be taken without regard to meals
VASOTEC ( ENALAPRIL MALEATE ) 20 MG orally every day
Override Notice: Override added on 10/10/05 by
CULTON , DANA
on order for KCL SLOW RELEASE orally ( ref # 03434978 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override:
aware , good renal function , low K with lasix
Previous override information:
Override added on 7/14/05 by CULTON , DANA
on order for KCL IMMEDIATE RELEASE orally ( ref # 62421236 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: aware
LASIX ( FUROSEMIDE ) 60 MG orally every day
HYDROCHLOROTHIAZIDE 25 MG orally every day
NIZORAL ( KETOCONAZOLE ) CREAM TP after shower
Instructions: Apply under breasts after shower , or every day
( most frequent )
Override Notice: Override added on 7/14/05 by
SCOLNIK , WILBUR J. , M.D. , PH.D.
on order for ATIVAN orally ( ref # 51090785 )
POTENTIALLY SERIOUS INTERACTION: KETOCONAZOLE , ORAL &
LORAZEPAM Reason for override: aware
MG GLUCONATE ( MAGNESIUM GLUCONATE ) 500 MG orally twice a day
METHADONE HCL 20 MG orally three times a day
HOLD IF: patient appears somnolent , RR<10
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
PREDNISONE 40 MG orally every day before noon
KCL SLOW RELEASE 20 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 10/10/05 by
CULTON , DANA
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override:
aware , good renal function , low K with lasix
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
CALTRATE + D ( CALCIUM CARBONATE 1 , 500 MG ( 600 ... )
1 TAB orally every day
ESOMEPRAZOLE 40 MG orally every day
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB four times a day as needed Wheezing
BACTRIM DS ( TRIMETHOPRIM/SULFAMETHOXAZOLE DOU... )
1 TAB orally 3x/Week M-W-F
DILTIAZEM EXTENDED RELEASE 90 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Schlesener within 1 month ,
ALLERGY: LOBSTER , FLOWERS , STUFFED ANIMALS , THEOPHYLLINE ,
LORATADINE , FEXOFENADINE HCL , MONTELUKAST
ADMIT DIAGNOSIS:
SOB , Cellulitis , Syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Attending evaluation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) OSA ( sleep apnea ) Morbid obesity
( obesity ) Depression ( depression ) Rx opioid abuse ( substance
abuse ) Asthma ( asthma ) LBP ( low back
pain ) Adhesive capsulitis ( adhesive capsulitis ) Bilat rotator cuff
tear ( rotator cuff tear )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
1. PFTs: results pending
2. TnI ( - ) x2
BRIEF RESUME OF HOSPITAL COURSE:
CC: 51 year-old morbidly obese woman with cellulitis , ?
syncope , SOB
DDx: SOB-restrictive ( body habitus ) +asthma
Syncope-vasovagal vs. hypotension 2/2 steroid
taper
HPI: 51 o African-American , morbidly obese woman with cellulitis on
abdomen tx with 10d course of Keflex with improvement but not complete
resolution. C/o subjective fevers , chills at home. Syncopal episode
( 3dPTA ) after getting out of car on very hot day. Unclear memory of
event , but denies CP/SOB. Many previous mechanical falls. Of note , patient
c/o of worsening LE edema over past month. patient has HTN.
60mg every day prednisone for last several months 2/2 SOB. Began
taper on 11/19 , now on 40qd. Has had 4 MICU admissions for SOB , no
intubations.
Vitals in the ED were 98.1 HR 86 RR18 BP
148/90 O2Sat94% RA. She received 60 mg orally Lasix and 1g intravenous
Cefazolin.
----------PHYSICAL EXAM------------------
VS: Tm97.8 Tc97.7 HR 70-90 BP115-152/60-80 RR20 O2sat96RA
Gen: pleasant , somnolent but arousable , morbidly obese
HEENT: EOMI , but L eye drifts outward with somnolence
CHEST: CTAB , no wheezes but distant breath sounds
COR: RRR , nml S1 , S2 , no M/R/G
Abd: Mild erythema on inferior edge of pannus , stable since yesterday.
Scattered blanching spots of erythema underneath breasts with white
crusting
Ext: 2+ edema to mid-shins , = bilaterally. Some blanching erythema on
ant surface bilaterally. No tenderness , 2+DP pulses
---------INVESTIGATIONS-----------
NOTE: WBC elevated at baseline 2/2 steroid use CK: 471 ( =baseline )
TnI#1<assay Echo ( 5/30 EF 70% , no wall motion abnormality ,
trace MR PFTs ( '01 ): FVC:74% , FEV1: 72 , FEV1/FVC:97
CXR( 8/9/05 ):Stable interstitial prominence ( ? vasc engorgement )
Wrist: ( 5/20/05 ) No acute fracture , interval healing of old fx.
EKG: NSR
PFTs: Pending at time of dicharge summary
----------ASSESSMENT/PLAN--------------
1. Syncope: Likely orthostasis by history. TnI( - )x2 , EKG NSR , metabolic
panel wnl
2. ID: Cellulitis not impressive. Cefazolin x2d , switch to Augmentin for
7 d total course
3. Pulm: history of severe "asthma" , but PFTs c/with restrictive picture. PFts
repeated , f/u as outpt with pulm
4. CV: Likely some LHF 2/2 HTN and RHF 2/2 chronic lung disease.
Diltiazem added for HTN/diastolic dysfunction. Lasix increased to 60 mg
orally with improvement in breathing.
5. Neuro: Continue chronic pain meds
6. Electrolytes: Long-acting K+ to supplement with increase Lasix. God
renal function
************ADDENDUM***************
patient left room several timse afte rattempts to do PFTs. Spoke with Dr. Brobeck
who said patient had been noncompliant with appts in the past.
ADDITIONAL COMMENTS: Please restart all of your previous home medications EXCEPT for the
following changes:
1. Augmentin: Please take Augmentin 3x per day for 5 days after discharge
2. Lasix: We have increased your dose to 60 mg every day
3. Diltiazem: For BP and heart failure. Take a 30mg tablet , 3x per day
4. Slow release Potassium to supplement
5. Continue your steroid taper as you ad Dr. Hampon discussed
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Finish course of Augmentin
2. Follow up with Pulmonologist
No dictated summary
ENTERED BY: CULTON , DANA ( ) 4/19/05 @ 12:11 PM
****** END OF DISCHARGE ORDERS ******
Document id: 798
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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- |
207236795 | PUO | 75909774 | | 7863149 | 8/8/2005 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed
Discharge Date: 10/20/2005
ATTENDING: THEILING , BREE MARLYN MD
ATTENDING PHYSICIANS: Shizuko Pederzani , MD and Bree Marlyn Theiling ,
M.D.
DISCHARGE DIAGNOSIS: Non-ST elevation myocardial infarction.
CHIEF COMPLAINT: Referred by primary care physician for EKG
changes and exertional symptoms.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old woman
with a history of type 2 diabetes , hypertension , COPD , who was at
her primary care physician's office today , and presented with
diaphoresis and weakness. She was found to be hypoglycemic with
a glucose in the 50s. The patient had an EKG , which showed new
anterior Q waves. For the past six months , the patient reports
having left-sided arm pain radiating to her right arm upon heavy
walking that has worsened recently. The pain lasted 15 minutes
and abates with rest. She also reports dyspnea on exertion over
the same time period.
PAST MEDICAL HISTORY: Non-insulin-dependent diabetes mellitus ,
hypertension , chronic obstructive pulmonary disease ,
osteoporosis , osteoarthritis , status post appendectomy , status
post tonsillectomy , gout , coronary artery disease , question of
TIA in 2001.
MEDICATIONS ON ADMISSION: Aspirin 81 mg once a day , Norvasc 5 mg
once a day , lisinopril 40 mg once a day , atenolol 50 mg once a
day , hydrochlorothiazide 25 mg once a day , allopurinol 200 mg
once a day , Fosamax 70 mg once a week , glyburide 2.5 mg twice a
day , metformin 500 mg twice a day , multivitamin.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for coronary artery disease in her
father and brother; also significant for diabetes and
hypertension. Uterine cancer in her mother.
SOCIAL HISTORY: The patient has a 40-pack-year smoking history
and quit in 1991. She reports occasional alcohol use. She is
single. Worked as a secretary and lives in assisted living.
PHYSICAL EXAMINATION: Vital signs on admission: Temperature
97.1 , heart rate 63 , blood pressure 120/58 , respiratory rate 20 ,
satting 98% on 2 liters. Physical examination significant for:
Jugular venous pulse at 6 cm , bilateral carotid bruits.
Cardiovascular: S1 S2 , normal regular rate and rhythm , no
murmurs , rubs or gallops , PMI nondisplaced , no right ventricular
heave. Lungs: Clear to auscultation bilaterally. Abdomen:
Soft , nontender , nondistended with good bowel sounds.
Extremities: Warm and well perfused with no peripheral edema.
LABORATORY DATA: Troponin of 0.29. EKG revealed new Q waves
anteriorly.
STUDIES:
Cardiac MRI , 4/25/2005 , revealed scar tissue in the
mid-to-distal LAD region.
Left heart catheterization , 7/15/2005 , revealed severe
three-vessel disease with 50% to 60% stenosis of LM , 95% stenosis
of LAD , a tight calcified RCA and OM1.
Cardiac echo , 7/15/2005 , ejection fraction of 35% to 40% , septal
hypokinesis , mild mitral regurgitation.
Stress MIBI with PET viability , 6/15/2005 , revealed viable
myocardium.
PROCEDURES: Carotid duplex study , 6/15/2005 : Showed no
significant disease of the carotid arteries.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: Ischemia-The patient had a stable anginal
pattern , but had new Q waves in the anterior leads and a troponin
leak. She was admitted with non-ST-elevation myocardial
infarction and continued on aspirin , beta-blocker , and initially
on heparin drip. The cardiac catheterization showed severe
three-vessel disease and a question of viable myocardium. A
stress MIBI with PET viability on 6/15/2005 showed viable
myocardium; however , cardiac MRI with gadolinium showed scarred
tissue in the LAD territory. A CT Surgery consult was obtained
to consider CABG versus PCI. After reviewing the radiology
studies , it was determined that the patient would benefit from a
CABG. She was on a schedule to have CABG during this admission;
however , due to scheduling constraints , will be discharged home
and then return to the hospital , 11/5/2005 , for CABG to be
performed by Dr. Garced Her cardiac enzymes trended down during
the admission. She will be discharged with a prescription for
nitroglycerin sublingually as needed for chest pain and
instructed to call her physician/911 , if she experiences any
chest pain. Pump - an echocardiogram on 7/15/2005 revealed an
ejection fraction of 35% to 40%. The patient was euvolemic on
her exam. She continued on her lisinopril , Imdur , Lopressor
while in-house.
2. Endocrine: The patient has a history of type 2 diabetes.
The patient's orally hypoglycemic medications were held during the
admission and she was given standing NPH insulin , standing
prandial NovoLog with scale coverage. She will be discharged
home on her glyburide and Avandia. Her metformin will be held
given her increased creatinine upon admission.
3. Renal: The patient had a creatinine of 1.4 on admission.
Her fractional excretion of sodium was calculated to be 0.45% ,
and she was thought to be prerenal. Prior to discharge , her
creatinine normalized to 1.1.
4. FEN: The patient tolerated a low-sodium , no-caffeine diet.
5. Psychiatry: The patient continued on her amitriptyline for a
history of depression.
6. Medication changes: The patient will not continue on her
Norvasc and metformin. She will continue on her aspirin ,
lisinopril , hydrochlorothiazide , allopurinol , Fosamax ,
multivitamin , and amitriptyline. She will start on Imdur ,
high-dose Lipitor and Avandia. Her glyburide was changed to
once-a-day dosing , and her atenolol was changed to Toprol-XL 75
mg orally once a day.
TO DO/PLAN: The patient was instructed to return to the hospital
if she experienced any chest pain , shortness of breath , worsening
leg swelling , nausea , vomiting , sweating or fevers. The patient
will return to the hospital on 11/5/2005 for CABG with Dr.
Garced She is also scheduled for a followup appointment with
Dr. Rehnborg , 231-760-9777 on 7/7/2005 at 4:40 p.m. The patient
was instructed to return to the hospital two hours before her
scheduled surgery on 9/5/2005.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally once a day ,
allopurinol 200 mg orally once a day , amitriptyline 5 mg orally once
every evening , hydrochlorothiazide 25 mg orally once a day ,
lisinopril 40 mg orally once a day , magnesium gluconate 500 mg orally
twice a day , Imdur 30 mg orally once a day , Fosamax 70 mg orally once
a week , Lipitor 80 mg orally once a day , Toprol-XL 75 mg orally once
a day , glyburide 2.5 mg orally once a day , Avandia 4 mg orally once a
day , nitroglycerin 0.4 mg 1 tablet sublingually every 5 minutes
x3 doses as needed for chest pain , multivitamin 1 tablet orally
daily.
eScription document: 1-6326435 BFFocus
CC: Bree Marlyn Theiling MD
O
Yorkchi Pla Mongton-obrokereve
CC: Rema Rehnborg MD
Ville Tl Xing ST.
Cla Ston Inena
CC: Aleta Kertesz MD
Division of Cardiac Surgery , Pagham University Of
Valleson E
Ant Pines Ey
Dictated By: JERRETT , RACHEAL
Attending: THEILING , BREE MARLYN
Dictation ID 9874785
D: 2/3/05
T: 2/21/05
Document id: 799
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516880662 | PUO | 11923443 | | 9469371 | 10/22/2003 12:00:00 a.m. | HYPERGLYCEMIA | Signed | DIS | Admission Date: 10/22/2003 Report Status: Signed
Discharge Date: 2/23/2003
ATTENDING: AMIE SALLY HEIDELBERG MD
HISTORY OF PRESENT ILLNESS: Patient is a 48-year-old female with
morbid obesity , insulin-dependent diabetes , CAD status post
NQWMI , OSA , mild pulmonary hypertension , was well until two days
prior to admission when she sustained a mechanical fall. In the
ensuing two days noted increased extremity swelling. On
10/6/2003 , patient reported increased shortness of breath and
pleuritic chest pain , called EMS. On arrival to hospital , had an
O2 sat of 51% on room air , improved to 90% on 100% face mask , was
then placed on BiPAP. An ABG was drawn , was found to be
7.23/65/97 , blood sugar of 536. Also noted to have a UA of 4+
bacteria , 2+ lower extremity edema , left greater than right , and
was admitted to the MICU with hypercarbic respiratory failure.
Patient denies fevers , cough , abdominal pain , nausea , vomiting.
Does report one day of urinary burning and frequency. Reports
compliance with medications. Fingersticks not checked at home.
PAST MEDICAL HISTORY: Includes:
1. Morbid obesity.
2. Insulin-dependent diabetes , history of DKA.
3. Diabetic retinopathy.
4. CAD status post non-Q-wave MI.
5. OSA. Last echo 11/28 showed an EF of 50-55% , hypokinesis of
inferior septum , mild right ventricular dysfunction , mild MR plus
TR , mild pulmonary hypertension.
6. Asthma.
7. Lumbar DJD and chronic back pain.
8. Status post TAH/BSO.
9. History of urosepsis.
10. Hypercholesterolemia.
11. History of lower extremity DVT.
MEDICATIONS UPON ADMISSION: NPH 40 units every afternoon , Regular Insulin
sliding scale , aspirin 81 mg orally every day , Toprol 200 mg every day ,
Lipitor 10 mg every day , diazepam 10 mg four times a day as needed anxiety , Vicodin
1 tab every day as needed pain , Percocet 1-2 tabs as needed pain.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with husband. Minimally ambulatory , uses a
scooter. No tabacco , alcohol or recreational drug use.
PHYSICAL EXAMINATION ON ADMISSION: She had T-max to 98.1 , heart
rate 75 , blood pressure 136/60 , O2 sat 99% on BiPAP 20/5 , FIO2
40% , tidal volume 300-400 , respirations 17-30. Generally: She is
a morbidly obese woman , sleepy but easily arousable. HEENT:
Pupils about 1 cm bilaterally , but reactive on BiPAP. Neck:
Unable to assess , JVP. Lungs: Distant breath sounds , no wheezes
or crackles. CV: Distant heart sounds but regular , no murmurs.
Abdomen: Obese , distant bowel sounds , nontender , no masses.
Extremities: Bilateral lower extremity edema , 1+ on right and 2+
on left. Left lower extremity warm and foot erythematous , fungal
infection of left foot , 2+ DPs bilaterally , bilaterally upper
extremity swelling. Neurologically: Patient sleepy but
arousable , follows commands , wiggles toes , squeezes hands.
LABORATORY FINDINGS ON ADMISSION: Sodium 133 , potassium 5.7 ,
chloride 98 , bicarb 24 , BUN 32 , creatinine 1.6 , glucose 536 ,
calcium 7.6 , magnesium 2. albumin 3. ALT 99 , AST 54 , alkaline
phosphatase 229 , total bilirubin 0.3 , amylase 16 , lipase 20 , CK
218 , MB 4.3 , troponin less than assay. Second set of enzymes
were CK 327 , MB 6.1 , troponin less than assay , serum OSM 329.
White count of 10.06 , hematocrit 41.5 , platelets 274 , physical therapy 13 , PTT
27 , INR 1.0. D-dimer greater than 4000. ABG: On BiPAP , was
7.23 , 65 , 97. Urine tox showed barbiturates , benzos and opioids.
UA 1.025/5.5/2+ protein , 3+ glucose , trace ketones , 1+ blood , +
nitrate , 5-8 white blood cells , 2-4 red blood cells , 4+ bacteria ,
0-2 epithelial cells. EKG: Showed sinus rhythm at 90 , normal
axis , normal intervals , flat Ts in precordium , Q and III
unchanged from 3/20 Chest x-ray was limited due to soft
tissue , left upper lung clear , rest of study non-diagnostic.
HOSPITAL COURSE BY SYSTEM:
1. Pulmonary: Maintained on BiPAP and nasal canula with sats and
the ABG improving on transfer from MICU. On 10/11/2003 , ABG at
the time showed , was 7.31/74/71 , consistent with chronic
hypercarbia. Given the asymmetric leg swelling , PE and DVT was
suspected , however , unable to obtain further imaging due to
patient's size. D-dimer greater than 4000 , empirically
anticoagulated with Lovenox. Ten-A levels were supratherapeutic
initially trending down. PICC line placed in order to obtain
more regular Ten-A levels but then had to be removed ( see below ).
Given patient's size and risk for DVT , patient sent to rehab on
Lovenox.
2. CV-Ischemia: The patient had a troponin bump to 1.09 on third
set of enzymes without EKG changes. Thought to be secondary to
pulmonary disease , ? right heart strain in setting of PE.
Troponin trending down on second assay. Aspirin , beta-blocker ,
statin continued.
Pump: Echo showed an EF of 65% with moderate right ventricular
stain consistent with prior echo and pulmonary hypertension ,
evidence of fluid overload , patient diuresed on intravenous Lasix with
good improvement.
Rhythm: No active issues.
3. Heme: Anticoagulated empirically for presumed DVT/PE on
Lovenox. Hematocrit stable.
4. Infectious Disease: UA was 4+ bacteria initially on
levofloxacin , Foley removed 8/29/2003.
5. Endocrine: Initially maintained on insulin drip in MICU ,
transported to floor and maintained on NPH/RISS. Blood sugars
remained 150s-250s on stable NPH regimen.
6. Renal: 10/19/2003 with high bicarb , 37 , in setting of heavy
diuresis , suspect contraction alkalosis. Spironolactone added to
regimen with good effect.
7. Pain: Patient has chronic pain medications , left on home
doses of Vicodin , and diazepam and Percocet.
8. Access: PICC line placed 10/11/2003 for lab access , unable to
get reliable access , but arm swelling on 6/2/2003 , removed PICC
line , patient started on Keflex , 5-day course , for
thrombophlebitis , question cellulitis , suspected in setting of
left arm swelling greater than right and tenderness.
9. Disposition: physical therapy/OT feels patient unsafe to go home. Patient
needs consistent exercise , diet regimen , in addition to greif
counseling ( patient lost 15-year-old son two years ago and
reports increased weight gain after his death , in addition to
symptoms of depression ).
DISCHARGE MEDICATIONS: Patient discharged on the following
medications: Aspirin 81 mg orally every day , Dulcolax 5-10 mg orally
twice a day as needed constipation , captopril 25 mg orally three times a day , Colace
100 mg orally twice a day , Pepcid 20 mg orally twice a day , Lasix 40 mg orally
every day , NPH insulin 25 units subcutaneously every afternoon , NPH insulin 70 units subcutaneously
every day before noon , Regular Insulin sliding scale , Immodium 2 mg orally
every 6 hours as needed diarrhea , Lopressor 75 mg orally three times a day , Percocet
1-3 tabs orally every 6 hours as needed pain or headache , spironolactone 25
mg orally every day , Keflex 500 mg orally four times a day x 3 days starting today ,
2/23/2003 ; Vicodin 1 tab orally every 4-6hours as needed pain; Lovenox 80
mg subcutaneously every 12 hours , K-Dur 20 mEq x 1 orally every day , miconazole nitrate
2% powder topical twice a day to apply to affected areas.
FOLLOW-UP APPOINTMENT: Patient to follow up with primary care
physician in
1-2 weeks after discharge from rehabilitation hospital.
eScription document: 9-6331100 LMSSten Tel
Dictated By: MAGLIONE , KRISTIAN
Attending: HEIDELBERG , AMIE SALLY
Dictation ID 3358108
D: 10/19/03
T: 10/19/03
Document id: 800
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585843377 | PUO | 62142260 | | 897367 | 9/14/1995 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 6/29/1995 Report Status: Unsigned
Discharge Date: 6/11/1995
PRELIMINARY DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
white male status post anterior wall
myocardial infarction , status post TPA who presented with
post-infarct angina and three-vessel disease by catheterization.
The patient's cardiac risk factors include diabetes , hypertension ,
and positive family history. The patient denies cigarettes. The
patient is a very noncooperative historian.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for diabetes of 20 years
without neurological or retinopathy treated with orally
hypoglycemics. The patient has long-standing hypotension of 30 to
40 years. The patient , in 1985 , had a percutaneous transluminal
coronary angioplasty at the Pagham University Of and has
had rule outs since for myocardial infarction with the last one
approximately in 1990 at Pagham University Of . The
patient , however , has been able to work and climb stairs and walk
about a mile without difficulty. Several days to admission , the
patient reports pain and ache over the lower back and flanks as
well as substernal chest pain with radiation to the upper left arm.
The patient is unable to describe any further symptoms. The
patient denied nausea or vomiting but says he was diaphoretic. The
patient took four to five Nitroglycerins without relief. The
patient subsequently was admitted to Put Wathern Hospital and had at
least 3 hours of pain at Put Wathern Hospital . The patient was ruled
in for anterior wall myocardial infarction with ST elevations 4 to
5 mm in V1. Blood pressure was 152/95. The patient received
front-loaded TPA , Heparin , Aspirin , Morphine sulfate and
Nifedipine. At 1:00 a.m. , the patient had recurrent chest pain
with elevations in V1 through 6 , Lead , 1 , AVL and the patient was
subsequently transferred to the Pagham University Of . At
the Pagham University Of , the patient was cathed and had
100% stenotic mid left anterior descending , 90% ulcerated obtuse
marginal first branch , 60 to 70% stenotic right coronary artery and
anterior apical aneurysm was noted. The patient was placed on an
intra-aortic balloon pump in preparation for coronary artery bypass
surgery.
PAST MEDICAL HISTORY: The patient's past medical history is
inclusive of status post percutaneous
transluminal coronary angioplasty in '85 at Pagham University Of , coronary artery disease , diabetes , hypertension and
ruptured appendectomy 25 years prior to admission.
MEDICATIONS ON ADMISSION: The patient was admitted on the
following medications: Diltiazem 60
three times a day , Glyburide , Lisinopril 20 orally every day.
ALLERGIES: The patient has no known drug
allergies.
PHYSICAL EXAMINATION: On physical examination , the
patient's temperature is 98.1 , heart
rate 66 , sinus 137/57 , saturating at 97% and 100% face mask who is
in no acute distress lying in bed with an intra-aortic balloon
pump. HEENT: Pupils are equal and reactive to light and
accommodation. Intraocular muscles intact. Oropharynx clear.
Neck: Jugular venous pressure was about 8 cm. There was no
hepatojugular reflux. No thyromegaly. No lymphadenopathy.
Carotids were 2+ without bruits. Heart: A balloon pump was in
place. Regular rate and rhythm. Normal S1 , S2. No murmurs
appreciated. Abdomen was soft , nontender , nondistended with
positive bowel sounds. Extremities: No clubbing , cyanosis or
edema. The patient had 2+ dorsalis and posterior tibial pulses
bilaterally and on the right femoral artery had a right
intra-aortic balloon pump in place. There were no varices noted.
HOSPITAL COURSE: The patient went to the Operating
Room on 9/29 , had a coronary artery
bypass graft x three with a saphenous vein graft to the LAD , first
branch of the obtuse marginal and the posterior descending artery.
The patient tolerated the procedure well and was transferred to the
Cardiac Surgery Unit in stable condition. On postoperative day #1 ,
the patient self-extubated himself and resultantly had an adequate
arterial blood gas , thus not requiring emergent intubation. The
patient's intra-aortic balloon pump was subsequently removed
without further incident , and the patient was subsequently
transferred to the floor in stable condition. On postoperative day
#3 , the patient had atrial fibrillation which was treated and
controlled pharmacologically , and also the patient was treated with
prophylactic anticoagulation with Coumadin. The remainder of the
hospital stay , the patient remained afebrile , tolerated his diet ,
was ambulatory , had his chest tube and cordis and Foley catheters
removed. On postoperative day #6 , the patient converted to sinus
rhythm , and the patient had planned discharge for 24 hours after
that which would have been on 10/2 However , the patient
requested to be discharged to home. The condition was discussed
with the patient and the patient's wife which required continued
observation until the morning for removal of epicardial wires.
However , the patient refused to stay. He experienced a desire to
go home stating that he does not like the food here and is unable
to sleep and does not want further medical intervention. The risks
of the discharge including rhythm , abnormalities and complications
related to pacing wires were reviewed with the patient and his
wife.
DISPOSITION: Despite understanding potential risks
for discharge , the patient expressed
desire for leaving against medical advice. The above condition was
discussed with Dr. Barrette , the attending surgeon. The patient was
subsequently found to have left the hospital by taxi with intravenous
Heplocks , wires and Telemetry intact. The patient was called at
home , and condition of his discharge and recommendations were given
which were to return to the hospital to have intravenous's , wires and
Telemetry removed. The patient refused , however. He refused to
have the Visiting Nurse Association to come in to remove his intravenous's.
The patient was encouraged to return for clipping of the epicardial
pacing wires; however , he refused. The patient's wife was sent
with prescriptions and risk management was also informed. The
patient was requested to return today , the 10 of October , to have
pacing wires and Telemetry removed as well as intravenous's. The patient
returned for an hour , had pacing wires removed and Telemetry box
also removed. The patient just left on his own accord. The
patient requested to follow-up with Dr. Barrette in 6 weeks and his
cardiologist in 2 weeks.
Dictated By: SHERELL HOOE , M.D. PT80
Attending: GENNY S. BARRETTE , M.D. ZD6
JK023/6132
Batch: 9176 Index No. E6MRY607GS D: 4/3/95
T: 4/3/95
Document id: 801
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190913023 | PUO | 90499272 | | 541255 | 7/16/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/4/1993 Report Status: Signed
Discharge Date: 6/20/1993
DISCHARGE DIAGNOSIS: LEGIONNAIRES' DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old woman
with no significant past medical
history who presented with fevers , chills , sweats , shortness of
breath , pleuritic chest pain , cough inducing vomiting of white to
yellow fluid , myalgias , burning epigastric pain , and diarrhea all
over the last five days. The source was the patient via japanese
interpreter , the patient was a poor historian , and her old chart
was missing at the time of admission. She denied any cardiac or
pulmonary history though she did have an admission to the Pagham University Of in 2/10 for shortness of breath. Clinical
diagnosis was apparently flash pulmonary edema as she had a normal
admission chest X-Ray which later revealed mild pulmonary vascular
redistribution consistent with congestive heart failure. She was
ruled out for a myocardial infarction and had an exercise tolerance
test which was negative for ischemic disease. She says she has had
increasing dyspnea on exertion over the past six weeks with
substernal chest pain after climbing two flights of stairs.
Several weeks ago and again the day of admission , she has had
two-pillow orthopnea and paroxysmal nocturnal dyspnea. She was
well overall until five days ago when she started developing the
following symptoms: 1 ) "Bone pain" first in her hands and then
all over. 2 ) Fevers ( although she did not take her temperature ).
3 ) Chills. 4 ) Drenching sweats. 5 ) Anorexia. 6 ) Increasing
shortness of breath worsening over the week. 7 ) Pleuritic chest
pain worse with inspiration and laying on her left side. 8 ) Cough
and/or white vomitus ( one apparently induces the other but the
patient cannot distinguish which ). 9 ) Nose bleeds. 10 ) Neck
pain. 11 ) Sore throat. 12 ) Burning epigastric pain. 13 )
Abdominal bloating and diarrhea. 14 ) Black stools times one day.
15 ) Overall malaise. She denies hemoptysis , weight loss ,
photophobia , neck stiffness , runny nose , sneezing , radiation of
chest pain , dysuria , lower extremity edema , bright red blood per
rectum , or melena. PAST MEDICAL HISTORY: Negative for asthma ,
tuberculosis , or HIV risk factors. It is otherwise significant for
one episode of pulmonary edema of unclear etiology as noted above.
Her echo at that time was significant for a left ventricular
ejection fraction of 54% with increased left atrial size and mild
mitral regurgitation/aortic insufficiency. Her exercise tolerance
test was significant for not going nine minutes on a standard Bruce
protocol with a peak heart rate of 150 stopping secondary to
fatigue with blood pressure of 170/80 and no chest pain or ischemic
changes. CURRENT MEDICATIONS: Tylenol as needed ALLERGIES: No
known drug allergies. FAMILY HISTORY: Father with hypertension in
his sixties , mother died of a vaginal cancer at a young age ,
daughter has asthma , and brother has hypertension. SOCIAL HISTORY:
She is separated , lives with three of five children , works as a
cleaning lady in various buildings in Ence Na A Chi Valepit , no tobacco , last
smoked at the age of 14 , and no alcohol or intravenous drug use.
She did have a history of exposure to typhus in her family
recently. REVIEW OF SYSTEMS: She had a weight gain of two pounds
over the past two months , her last period was during the week prior
to admission , and was shorter than usual.
PHYSICAL EXAMINATION: The patient had a temperature of 100.8 , a
heart rate of 150 , blood pressure of 120/80 ,
respiratory rate of 30 to 35 , and O2 saturations of 93 to 96% on
three liters. She was mildly orthostatic on admission. GENERAL:
She was a tachypneic thai speaking woman in moderate respiratory
distress. HEENT: Remarkable for dry mucous membranes and a white
coating over her tongue but no erythema or exudate of her posterior
pharynx. NECK: Supple with tender submandibular shotty adenopathy
bilaterally. No jugular venous distention or thyromegaly. LUNGS:
Remarkable for diffuse crackles scattered throughout both lung
fields , louder in the mid and lower lung fields bilaterally , and no
egophony or dullness. HEART: Remarkable for tachycardia and
normal S1 and S2 without murmurs , rubs , or gallops. BACK:
Revealed mild tenderness to palpation at both costovertebral angles
and there was no spinal tenderness. ABDOMEN: Soft with moderate
tenderness to deep palpation in the epigastrium , there was no
rebound or guarding , she had normal bowel sounds , no
hepatosplenomegaly , no Murphy's sign , and no masses. EXTREMITIES:
No cyanosis , clubbing , or edema. SKIN: Without rash.
NEUROLOGICAL: Examination showed her to be alert and oriented
times three , cranial nerves II-XII were intact , and motor and
sensory examinations were intact. There were no cerebellar
findings and her reflexes were 1+ of the upper extremities and 0 at
the knees with toes downgoing bilaterally.
LABORATORY EXAMINATION: On admission , sodium was 137 , potassium
4.2 , chloride 102 , bicarbonate 24 , BUN 15 ,
creatinine 0.9 , and glucose 145. Her white blood cell count was
20.7 with 71 polys , 14 bands , 9 lymphocytes , 4 monocytes , and 2
metamyelocytes. Her hematocrit was 45% and her platelet count was
322 , 000. Her room air blood gas revealed a pO2 of 66 , O2
saturation of 94.1% , pH of 7.46 , pCO2 of 34 , and an HCO3 of 25.
EKG was remarkable for sinus tachycardia at 152 beats per minute
with flat T waves in her limb leads and V5 and V6 , there were no
acute ST or T wave changes. When compared with prior EKG from
2/10 , the rhythm was much faster but in sinus. Her chest X-Ray
was remarkable for diffuse interstitial lung disease , increased
compared with a prior chest X-Ray of 10/3 Her liver function
tests were unremarkable on admission.
HOSPITAL COURSE: After admission , the patient was started on
intravenous Bactrim and intravenous Erythromycin
in Legionella doses to cover her broadly for this interstitial
pneumonia. Sputum inductions were done for toluidine blue , gram
stain , and culture and sensitivity which were negative. An HIV
test was sent which was also negative making the diagnosis of primary care physician
very unlikely. She had Legionella antibody and urine antigens
sent. Although the urine antigens are pending , the Legionella
antibody came back positive at 1:256. At this titer , the diagnosis
of legionnaires' disease was made. Until this titer came back ,
however , the diagnosis was not as clear and the patient had a PPD
planted with anergy panel. This PPD was negative and the patient
was not anergic. Pulmonary consultation was obtaind to consider
bronchoscopy as the patient could not produce sputum for the first
several days of her admission. As she was improving , the decision
was made to hold off on bronchoscopy. A typhus antibody was sent
given her possible exposure to typhus and that is still pending
although unlikely to be the case given her improvement on Bactrim
and Erythromycin and the fact that she has a positive Legionella
titer. Her gastrointestinal symptoms initially were felt to be
probably gastrointestinal complaints related to Legionella
legionnaires' disease. Stool cultures were sent and eventually
came back negative and she was started on intravenous Pepcid later
switched to orally Pepcid. She was also vigorously hydrated for her
losses in her diarrhea. The cause of her marked sinus tachycardia
was unclear although it was probably secondary to stress. Her
heart rate eventually came down with fluids although she was not
markedly orthostatic on admission. With fluid repletion , her heart
rate did come down and subsequent EKG revealed that she was not in
AV flutter with a 2:1 block but indeed was in sinus tachycardia.
Over the subsequent days , her heart rate eventually normalized.
Her O2 saturations initially were in the low nineties with three
liters. With Erythromycin , her hypoxia markedly improved and by
the time of discharge , she was 98% on room air. As noted over the
subsequent days , she became afebrile with stable blood pressure and
improving respiratory rate and O2 saturations. This improvement ,
however , took at least two to three days before it became clear
that she was heading in the right direction. During her early
course , she started to have some abdominal distention with marked
discomfort in her belly. A nasogastric tube was placed with
suction and she was made NPO. Her amylase and lipase were normal.
Meanwhile , her white count did markedly improve and it appeared
that all of these symptoms were probably secondary to her primary
legionnaires' disease. Cold agglutinins eventually came back
negative and her Mycoplasma titers are pending. Subsequent chest
X-Ray revealed that patient's process was at least radiographically
stable although she was clinically better. As noted above , her
white count improved and she remained afebrile except for single
episode of low grade fevers on 1/3 immediately prior to
discharge. She was thus watched for an additional day and was
discharged afebrile feeling well. Her course was also remarkable
for an increase in her ALT to 100 from a normal baseline probably
on the basis of Bactrim toxicity. After her Legionella titers came
back as well as her HIV being negative , her Bactrim was stopped and
she was switched from intravenous to orally Erythromycin. She
tolerated the switch well without any complications. She received
a total of seven days of intravenous Erythromycin and was
discharged with a two week course of orally Erythromycin.
DISPOSITION: Patient will follow-up in Mi Lakeield Sonme Clinic in two weeks
for follow-up of her Legionella pneumonia. DISCHARGE
MEDICATIONS: Pepcid 20 mg orally twice a day times four weeks ,
Erythromycin 500 mg orally four times a day times two weeks , Tylenol 650 mg
orally every 6 hours as needed , and Maalox 30 cc orally every 6 hours as needed
Dictated By: DENISHA H. MCRORIE , M.D. MH9
Attending: MAXIMA M. LOEWE , M.D. FR5
CP609/0372
Batch: 8743 Index No. TBYPB53S5M D: 5/24/93
T: 1/26/93
Document id: 802
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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024363780 | PUO | 59554677 | | 7459826 | 11/2/2003 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 4/21/2003 Report Status: Signed
Discharge Date: 7/3/2003
ADMITTING DIAGNOSIS: MITRAL REGURGITATION AND MILD AORTIC
STENOSIS.
HISTORY OF PRESENT ILLNESS: An 80-year-old female with known
rheumatic heart disease , with mitral
regurgitation , paroxysmal atrial fibrillation , who underwent an AV
ablation and post ablation requiring a permanent pacemaker , who now
complains about progressive shortness of breath , orthopnea , and
ankle edema , and referred for surgery.
PAST MEDICAL HISTORY: Past medical history is significant for
venous stasis changes with ankle edema ,
mitral regurgitation , as well as mild aortic stenosis , with history
of rheumatic heart disease , hypertension , hypothyroidism , AV nodal
ablation as mentioned above requiring permanent pacemaker , chronic
pain to her right heel , degenerative joint disease.
PAST SURGICAL HISTORY: Past surgical history is significant for
right knee surgery , right hip replacement
in 2002 , appendectomy , hernia repair , AV ablation , and permanent
pacemaker.
FAMILY HISTORY: No significant family history of coronary artery
disease.
SOCIAL HISTORY: No tobacco use.
ALLERGIES: Penicillin ( no reaction documented ).
MEDICATIONS: Toprol 60 mg orally once a day , Coumadin 4 mg orally
every day , furosemide 80 mg orally once a day , Levoxyl 50 mcg
orally every day , Protonix 40 mg orally once a day , propoxyphene , and
multivitamin.
PHYSICAL EXAM ON ADMISSION: Temperature of 96.1 , heart rate of 70 ,
blood pressure of 120/60 in the right
arm. HEENT: PERRLA , dentition without evidence of infection , no
carotid bruits. CHEST: No incision. CARDIOVASCULAR: Regular
rate and rhythm , with a systolic murmur with also a diastolic
rumble component , pulses 2+ throughout. RESPIRATORY: Rales
present bilaterally. Does not indicate how far up. ABDOMEN: Cyst
palpable liver , no mass noted , soft. RECTAL: Deferred.
EXTREMITIES: 2+ edema , with bilateral venous stasis ulcer , with no
signs of active infection. NEURO: Alert and oriented , with no
focal deficits.
LABORATORY VALUES ON ADMISSION: Sodium of 141 , K of 4.5 , chloride
of 105 , CO2 of 26 , BUN of 32 ,
creatinine of 1.2 , glucose of 110 , magnesium of 2.2. HEMATOLOGY:
White count of 7.5 , hematocrit of 32.3 , platelets of 216 , physical therapy of 13 ,
with an INR of 1.1 , a PTT of 59.3. Cardiac catheterization was
done on 6/12/03 , which showed a 30% proximal LAD , right dominant
circulation , ventriculogram of 49 , PA mean of 30 , pulmonary
capillary wedge of 15 , cardiac output of 3.7 , and cardiac index of
2.2.
Patient was admitted to the Cardiac Surgery Service on 6/12/03 ,
needed a pre-op echo , which was obtained on 7/7/03 , which showed
mild LV hypertrophy with preserved overall systolic function , EF of
about 55% , with right ventricle with normal size and function ,
aortic valve mildly thickened; however , leaflet excursion is good ,
the peak transaortic velocity is 2 mm per second consistent with a
peak instantaneous gradient of 60 mmHg. The mitral annulus is
thickened and calcified. There is mild to moderate mitral
regurgitation. The peak antegrade mitral velocity is 1.8 ,
consistent with a maximal gradient of approximately 12. The valve
area is estimated at approximately 1.8 cm2. Mild tricuspid
regurgitation was noted , with a regurgitant velocity of 2.5 ,
consistent with normal pulmonary systolic pressures. Due to her
nonhealing ulcer for which she has been evaluated by Derm for over
a year , patient was seen by Vascular Surgery to evaluate for
vascular compromise as a component of these nonhealing ulcers.
ABIs were obtained , which showed both left and right ABIs greater
than 1 , also PVRs were normal throughout and it was felt that there
was no vascular component to these nonhealing ulcers , and they
recommended that it was due to venous stasis changes and chronic
edema and felt local wound care and leg elevation would be the
treatment of choice at this point. Patient , with some evidence of
poor dentition , was seen by the Dental Team , which felt that there
was no evidence of active infection at this time that needed
further dental treatment prior to her surgery. Due to her plan for
valve replacement , patient was empirically started on vancomycin ,
levofloxacin , and Flagyl for coverage of these nonhealing ulcers.
Patient was also seen by Dermatology , who felt these were venous
stasis ulcers and recommended Hibiclens wash , as well as Silvadene
dressing with Xeroform gauze , and leg elevation , and also
recommended lower noninvasive to rule out DVT , which was obtained
on 4/25/03 which showed no evidence of DVT. On 8/11 patient was
taken down to the operating room and underwent a mitral valve
replacement , with preservation of the posterior mitral leaflet , and
had a Hancock porcine valve placed. Total cardiopulmonary bypass
time was 126 minutes. Cross-clamp time was 89 minutes. Patient
came off the heart-lung machine on Levophed and was paced with an
internal pacer and was started on some intravenous amiodarone for
uncontrolled A fib immediately coming off the heart-lung machine.
Over the next few hours , patient had frequent ectopy over the pacer
and the Cardiology Team was consulted. With interrogation of the
pacer , they felt that she was having frequent infranodal ectopy ,
but the pacer itself with the AV function was functioning normally.
The AF suppression was temporarily turned off , which they felt may
stabilize the rate and decrease the amount of ectopy that was seen
on the monitor. Over the next several days , patient with the
amiodarone drip had better rate control , with suppression of also
the intrinsic A fib that she had preoperatively , and on post-op day
#3 was switched over to Lopressor from amiodarone , per
recommendation of Cardiology. Patient was extubated on post-op day
#1 and required heavy diuresis over the next several days to wean
off her O2 , but by day of discharge was weaned off O2. Chest x-ray
looked slightly wet , so patient will continue on diuresis at the
rehab center. The patient with improvement of her venous stasis
ulcers; however , they are still open , and with discussion with the
Cardiac Surgery chief fellow it was discussed that until they were
healed with new valves in place that they would like to continue
the triple antibiotics of vancomycin , levofloxacin , and Flagyl , and
will be discharged to the rehab with those antibiotics. The
levofloxacin and Flagyl can be as orally and vancomycin as intravenous. The
patient also had a PICC line placed for poor venous access , which
by x-ray was in good position and 43 cm in length.
The patient by post-op day #10 was in stable condition to be
transferred to the rehab facility , and will be discharged with the
following medications: Colace 100 mg orally three times a day as needed
constipation , Lasix 40 mg orally three times a day x 5 days and to reassess
further Lasix dosing , ibuprofen 200-800 mg orally every 4-6h. as needed
pain , Levoxyl 50 mcg orally every day , Lopressor 25 mg orally three times a day , Flagyl
500 mg orally three times a day until improvement of leg ulcer , Niferex 150 mg
orally twice a day , Darvocet 100 one tablet every 6 hours as needed pain , Silvadene
1% topical twice a day to the venous stasis ulcer , vancomycin 1 g every 12 hours
( hold for vancomycin trough >15 ) , Coumadin , to check with hold every day
to target INR between 2 to 3 , Coumadin will be 5 mg dose tonight ,
K-Dur 20 mEq orally three times a day x 5 days while on the current Lasix
dosing , levofloxacin 250 mg orally once a day , and Carraklenz one
application topical twice a day as needed for dressing changes.
Patient to follow up with her cardiologist , Dr. Dominguez , phone
number 265-633-5715 , in 1-2 weeks; patient to follow up with Dr.
Golebiowski , 117-219-4079 , in 6 weeks for post surgical eval; and patient
to follow up with his Coumadin dosing with Dr. Cumberlander ,
telephone number 016-503-0251 , for further Coumadin dosing once
discharged from the rehab center.
Dictated By: TOMIKA AFZAL , P.A.
Attending: LOIDA F. GOLEBIOWSKI , M.D. MC6
JA104/370307
Batch: 2772 Index No. VZJSFG3J5H D: 7/22/03
T: 7/22/03
CC: 1. Rehab Center via fax.
Document id: 803
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
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PVD |
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| output/system_textual_annotation.xml | textual |
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Y |
U |
U |
Y |
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| output/system_intuitive_annotation.xml | intuitive |
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427934481 | PUO | 02809933 | | 2251382 | 8/3/2005 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 7/13/2005 Report Status: Signed
Discharge Date: 10/24/2005
ATTENDING: STAUTZ , MATHEW MD
SERVICE: Ny Full Dence
PRINCIPAL DIAGNOSES: Acute and chronic renal failure and
congestive heart failure.
OTHER PROBLEMS AND DIAGNOSES CONSIDERED: Type 2 diabetes ,
hyperlipidemia , acute and chronic renal insufficiency , upper GI
bleed with gastritis , ischemic cardiomyopathy , gout , sacral
decubitus ulcer.
BRIEF HISTORY OF PRESENT ILLNESS: Mr. Marsingill is a 60-year-old
man with a known history of ischemic cardiomyopathy and CHF , EF
of 35% , status post CABG in 1990 with redo in September 2005 , as well
as mitral and tricuspid valve repair and left atrial
reconstruction in September 2005. He presented asymptomatic from home
after being called by his primary cardiologist as the lab result
showed elevated BUN and creatinine at 244/4.1. This all occurred
in the setting of increased diuresis on torsemide , increasing the
dose from 100 mg by mouth twice daily to 150 mg by mouth twice
daily as well as a recent addition of Keflex for sacral decubitus
ulcer. On further questioning , Mr. Marsingill reported symptoms of
increasing dyspnea on exertion with decreased exercise tolerance
as well as chronic loose stools with a history of C-diff
positivity but negative on last testing. He denied any chest
pain , pleurisy , nausea , vomiting , abdominal pain , and both he and
his family denied any change in mental status as well as
hematuria or dysuria , although he did complain of mild urinary
hesitancy. Prior to presentation , he was directed to hold his
diuretics , included torsemide as well as all other nephrotoxic
agents including allopurinol , colchicine , digoxin , and
lisinopril.
His allergies include heparin to which he has heparin-induced
thrombocytopenia.
In terms of medication reactions during this hospitalization , he
was placed on H. pylori treatment with amoxicillin ,
clarithromycin , and Nexium twice daily; and in reaction to this ,
he had mild elevation of his liver function tests.
BRIEF ADMISSION PHYSICAL: Mr. Marsingill is A&O x3 with a BP of
90/60 , heart rate of 84. His lungs are bilaterally clear. His
heart exam shows a regular S1 , S2. Faint S3 with a 1/6
holosystolic murmur heard best at the apex with a JVD of 12 cm
plus V waves. His abdomen is benign. Extremities show no edema ,
but a left lower extremity petechial rash. He is found to be
heme positive with tarry stool , and he has a stable stage 4
sacral decubitus ulcer , well granulated without clear evidence of
infection.
Admission labs are significant for creatinine of 3.6 , BUN of 239 ,
potassium of 5.8 , digoxin of 1.7 , hematocrit of 29.3 , INR 4.1.
Admission EKG showed sinus rhythm with a first degree AV block.
Stable Q's in II , III , aVF , as well as V4 to V6. Left axis
deviation and right bundle branch block and an unchanged ST
depression in V2.
OPERATIONS AND PROCEDURES: 11/19/2005 , right heart
catheterization with PA line removal on 6/1/2005. 9/10/2005 ,
upper endoscopy and colonoscopy. 6/12/2005 , echocardiogram.
6/12/2005 , renal ultrasound.
HOSPPITAL COURSE:
1. Mr. Marsingill presented with acute and chronic renal failure
with baseline BUN and creatinine at approximately 66/2.4 with a
rapid rise between presentation and the last noted value on
11/15/2005. Although , he was asymptomatic and did not have any
EKG changes , he was treated with Kayexalate and sodium
bicarbonate which resulted in rapid normalization of potassium.
The superelevation of his BUN was thought in part to be due to
possible over diuresis but also complicated by the fact that he
had Hemoccult positive stool as suspicious for a GI bleed as a
source of increased nitrogen. The renal service was consulted
and initial treatment of his acute renal failure included the
above plus removal of all fluid restriction and diuresis in order
to reverse any potential prerenal state. Essentially , all urine
and renal studies including eosinophils and renal ultrasound were
negative with a renal ultrasound showing normal kidneys without
hydronephrosis but without increased resistance in the feet
bilaterally. At the time of discharge , his creatinine and BUN
had fallen to 1.9/81 respectively and remained stable over days.
The initial renal diet restrictions imposed during the
hospitalization were removed towards the end of the stay with
persistently stable values as well.
2. From a cardiovascular standpoint , a repeat echo on 9/12
showed an EF of 35 to 40 with inferior wall and inferior septal
severe hypo to akinesis as well as posterior wall severe
hypokinesis with trace aortic insufficiency , 1+ mitral valve
regurgitation , 2+ tricuspid valve regurgitation but normal left
ventricular size and thickness as well as normal right
ventricular size function. In order to better assess his filling
pressures and fluid status and attempt to optimize his renal
function , Mr. Marsingill underwent a right heart cath with PA line
placement on 11/19/2005 which revealed elevating filling
pressures including right atrium at 26 to 27 , right ventricle
65/13 , PA 64/32 , wedge 36. Pulmonary artery sat 39% , SVR 1568 ,
and pulmonary vascular resistance 221. His cardiac output and
index were both reduced. The PA line was left in for tailor
therapy , and he was initially placed on nesiritide drip at 0.005
as well as a Lasix drip with good urine output and increase in
his cardiac output and index and decrease in his elevated
systemic vascular resistance. On 10/6/2005 , the nesiritide drip
was discontinued and Lasix continued with the addition of
short-acting nitrates in the form of Isordil. Eventually , he was
transferred from the Lasix drip to torsemide reaching optimal
dose of 100 mg orally twice a day on 2/10/2005 , and further tailoring
with Imdur 30 and hydralazine 10 mg orally three times a day for further
afterload reduction were preformed. Lisinopril previously used
on admission was continuously held given the recent acute renal
failure.
3. From an ischemic standpoint , there were no active issues
during the hospitalization. His beta blocker was reduced to 12.5
briefly , but his normal dose of 25 once a day was resumed prior
to discharge. In terms of his rate , it was well controlled on
the above regimen , but his rhythm showed frequent ectopy without
response to diuresis or beta blockade. He does have an ICD in
place which never fired during the course of the hospitalization.
Upon discharge , he was close to euvolemia with an approximate
discharge weight of 67.6 kg.
4. From a GI standpoint , his initial presentation included
heme-positive tarry stools with elevated BUN. He was seen by the
GI service and underwent a colonscopy and upper EGD which were
significant for gastritis without signs of active bleeding as
well as internal hemorrhoids. H. pylori serologies were
positive , and he was initially started on clarithromycin ,
amoxicillin , and Nexium twice a day , but this regimen was changed to
amoxicillin , Flagyl , and Nexium twice a day given an elevation of his
LFTs on the prior regimen. There was no overt GI bleeding , and
he tolerated the procedure without complication.
5. From a nutrition standpoint , Mr. Marsingill was seen by a
nutrition specialist who confirmed suspicion of suboptimal
caloric intake meeting his total caloric needs about only 60% and
total protein needs are 85% despite labilization of his diet and
the addition of Megace. His nutritional goals were even more
important given his large stage 4 sacral decubitus ulcer with
poor healing since January 2005. Despite encouragement and the
addition of appetite stimulants with vitamin C , zinc , mineral ,
multivitamins , and the addition of supplements , he presently fell
short of his goals but refused other means of diet
supplementation including NG tube placement and PEG placement and
is determined to provide adequate orally intake by mouth. He and
his family met with a registered dietitian and understand the
importance of his caloric intakes.
6. From a musculoskeletal point of view , he has stage 4 sacral
decubitus ulcer which is followed by plastic surgery and
frequently debrided as an outpatient , Dr. Authur and his team ,
followed the patient while inhouse , and it was treated as per
protocol with twice a day dressing changes with Panafil and wet-to-dry
dressings. Initially , he was started on Keflex for suspicion of
infection in the wound , and this was changed to vancomycin given
MRSA growth in the wound and further Klebsiella growth which was
treated with levofloxacin , but these were all discontinued on
10/6/2005 as per plastic recommendations given the high
probability colonization. It was also felt that these
antibiotics would provide appropriate coverage for the possible
right lower lobe infiltrate questioned on x-ray.
7. From an endocrinology standpoint , he has a history of diabetes
type 2 , and he was continued on his Lantus and NovoLog insulin
sliding scale with titration of optimal glucose control in order
to promote wound healing. He was followed by the diabetes
management team.
8. From rheumatologic standpoint , he has a history of gout , and
he was maintained on allopurinol , renal dosing , but colchicine
helps. On about 1/6/2005 , he developed symptoms of podagra ,
and a prednisone taper starting at 15 mg was started with quick
resolution of symptoms.
9. From hematologic standpoint , he has anemia baseline and takes
Procrit once a week as an outpatient. He received 1 unit of
packed red blood cell transfusion on 8/18 and maintained his
hematocrit throughout the remainder of the hospitalization. He
was also maintained on darbepoetin as an inpatient.
Laboratory data showed no evidence of hemolysis with a normal
haptoglobin and LDH , but evidence of decreased iron saturation.
He was started on iron supplementation , and his Coumadin was held
for the supratherapeutic levels on admission and optimize prior
to discharge.
PERTINENT EXAM ON DISCHARGE: Patient was afebrile with stable
vital signs. He did have decreased breath sounds at the right
base know to correspond with his small right basilar opacity with
atelectasis. Other than that , his heart exam remained unchanged
with a regular rhythm , S1 and S2 , S3 , with a 1/6 holosystolic
murmur at the apex. His JVD was 11 cm , and he had no peripheral
edema.
Discharge lab showed a creatinine of 1.9 with a BUN of 81 ,
potassium of 3.6 , hematocrit 32.1 , white blood cell count 9000.
His digoxin level was normal at 0.8 , and his INR was 3.
CONSULTATNTS: Dr. Loewe from Sason , Dr. Wojnowski from GI , Dr.
Authur from plastic surgery , Lael Calicott from nutrition , as
well as the diabetic management service.
DISCARGE MEDICATIONS: Aspirin 81 mg by mouth daily , albuterol 2
puffs inhale 4 times a day as needed for shortness of breath
relieving , allopurinol 150 mg by mouth daily , amoxicillin 1000 mg
by mouth twice a day for a total of 14 days , vitamin C 500 mg by
mouth twice a day , digoxin 0.0625 mg by mouth daily , Colace 100
mg by mouth twice a day , iron 150 mg by mouth twice a day ,
hydralazine 10 mg by mouth 3 times a day , Megace 40 mg by mouth
daily , Reglan 10 mg by mouth 4 times a day as needed for nausea ,
oxycodone 5 to 10 mg by mouth every 4 hours as needed for pain.
Prednisone taper , to complete the following course , 15 mg by
mouth daily for 3 days , 10 mg by mouth daily for 3 days , and then
5 mg by mouth daily for 3 days , to be administered sequentially.
Multivitamin with minerals 1 table by mouth daily , Coumadin 3 mg
by mouth every evening , zinc sulfate 220 mg by mouth daily ,
Toprol XL 25 mg by mouth daily , Imdur 30 mg by mouth daily ,
torsemide 100 mg by mouth twice daily , Nexium 40 mg by mouth
twice daily , Lantus 40 units subcutaneously nightly , NovoLog 14
units subcutaneously 5 mL , Flagyl 500 mg by mouth 4 times a day
for a total of 14 days , potasium chloride slow release tablets 40
mEq by mouth daily , and Procrit 40 , 000 units subcutaneously
weekly.
He was discharged in a stable condition. There were no pending
tests or followup tests needed. He will follow with Dr. Raisa Cervetti He is full code.
PRIMARY CARE PHSYICAIAN/HEALTH OFFICICER: Miyoko Ibrahim ,
M.D.
eScription document: 7-6318285 GP
Dictated By: IBRAHIM , MIYOKO
Attending: STAUTZ , MATHEW
Dictation ID 1355234
D: 10/21/05
T: 2/18/05
Document id: 804
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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Y |
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Y |
U |
U |
Y |
Y |
Y |
U |
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U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
N |
Y |
N |
- |
Y |
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Y |
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- |
766300449 | PUO | 89531955 | | 4782089 | 2/14/2006 12:00:00 a.m. | AORTIC STENOSIS , CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 12/10/2006 Report Status: Signed
Discharge Date: 5/4/2006
ATTENDING: KERTESZ , ALETA M.D.
PATIENT OF: Aleta Kertesz , M.D.
SERVICE: Cardiac Surgery Service.
DISPOSITION:
To home with VNA service.
PRINCIPAL DISCHARGE DIAGNOSIS:
Status post CABG x3/LIMA , AVR with a 23 St. Jude medical
mechanical valve.
OTHER DIAGNOSES:
Hypertension , diabetes mellitus type II , hypothyroidism ,
hypercholesterolemia , renal failure/nephrotic syndrome , COPD , and
( bronchodilator therapy ) PE/thrombosis in 1991 , hypothyroidism ,
and gout.
HISTORY AND PHYSICAL HISTORY OF PRESENT ILLNESS:
The patient is a 69-year-old male with known aortic stenosis with
recent increase in frequency of chest pain and shortness of
breath on exertion.
PREOPERATIVE CARDIAC STATUS:
Elective. The patient presented with critical coronary
anatomy/valve dysfunction. The patient has a history of class
III angina. There has been no recent angina. There is a history
of class 3 heart failure.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST SURGICAL HISTORY:
Status post bilateral cataract repair 10 years ago , status post
kidney biopsy in 1990 , status post prostate biopsy in 1996 and
2002.
FAMILY HISTORY:
Father died of CVA at age 70 , brother died at 84 status post
valve repair.
SOCIAL HISTORY:
History of tobacco use , history of cigar smoking , history of
alcohol use , and last drink 22 years ago. The patient is a
retired house painter.
ALLERGIES:
All soaps ??___?? , perfumes/PCN rash and possible erythromycin
rash.
PREOP MEDICATIONS:
Atenolol 25 mg daily , Avapro 450 mg daily , aspirin 81 mg daily ,
Coumadin , Lovenox 40 units subcutaneously daily , Lasix 40 mg daily ,
albuterol 2 puffs twice a day , Flovent 4 puffs twice a day , atorvastatin 60
mg daily , allopurinol 200 mg daily , Levoxyl 0.05 daily , Nasonex 2
sprays daily , ranitidine 300 mg daily , Prandin 0.5 mg daily , Tums
as needed , multivitamins one tab daily , and Colace 100 mg twice a day
PHYSICAL EXAMINATION:
Height and weight 5 feet 6 inches , 72 kilos. Vital signs:
Temperature 97 , heart rate 66 , BP right arm 108/58 , left arm
110/60 , and oxygen saturation 98% on room air. HEENT:
PERRLA/dentition without evidence of infection/no carotid bruits.
Chest , no incisions. Cardiovascular , 4/6 throughout , radiates
to carotids. All distal pulses intact. Allen's test left upper
extremity normal , right upper extremity normal. Respiratory:
Breath sounds clear bilaterally. Abdomen: No incisions , soft ,
no masses. Extremities: Trace pedal edema , few varicosities.
Neuro: Alert and oriented , no focal deficits.
LABORATORY DATA:
Chemistry: Sodium 139 , potassium 4.4 , chloride 108 , CO2 26 , BUN
49 , creatinine 1.4 , glucose 75. Hematology: WBC 9 , hematocrit
38.8 , hemoglobin 13.2 , platelets 256 , physical therapy 15.5 , INR 1.2 , PTT 31.4 ,
UA was contaminated. Cardiac catheterization data from 2/12/06
performed at PUO showed coronary anatomy 50% proximal RCA
stenosis , 70% proximal LAD , 60% ostial D1 , 50% proximal OM1 , 40%
proximal LAD , 45% mid circumflex. Echo from 10/18/06 shows 75%
ejection fraction , aortic stenosis , mean gradient 61 mmHg , peak
gradient 106 mmHg , calculated valve area 0.7 cm2 , trivial aortic
insufficiency. EKG from 10/18/06 showed normal sinus rhythm rate
of 66. Chest x-ray from 10/18/06 was normal. The patient was
admitted to CSS and stabilized for surgery.
DATE OF SURGERY: 9/29/06.
PREOPERATIVE DIAGNOSES:
Aortic stenosis , coronary artery disease.
PROCEDURE: AVR with a 23 St. Jude region valve/CABG x3 with LIMA
to LAD , SVG1 to OM1 , SVG2 to PA.
BYPASS TIME:
221 minutes.
CROSSCLAMP TIME:
184 minutes , calcified aortic valve , antegrade and retrograde
cardioplegia.
The patient was transferred to the unit in stable fashion with
lines and tubes intact. Postop day #1 , no pressors , heparin at
500 an hour , hemodynamically stable. Postop day #2 , no pressors ,
heparin 500 an hour , hemodynamically stable. Transferred to
Step-Down Unit on postoperative day #2.
SUMMARY BY SYSTEM:
Neurologic: No neurologic deficit. Pain well controlled.
Cardiovascular: Cardiac meds , aspirin , and Lopressor continuing
cardiac monitoring.
Respiratory: Weaning O2 as tolerated , chest physical therapy ambulation as
tolerated , continuing DuoNeb , had been extubated on postop day
#1.
GI advancing diet as tolerated. GI prophylaxis.
Renal: Maintain adequate urine output , monitor BMP , and replace
electrolytes as needed Diuresis as tolerated when stable , has
underlying renal insufficiency for ??___?? with diuretics.
Endocrine: Tight glycemic control.
Hematology: Anticoagulated with aspirin monitoring H&H
transfusing as needed keeping on heparin drip at 500 units an hour
without titration. Giving Coumadin 5 mg night of transfer and
then checking physical therapy/INR.
ID: No antibiotics. The patient stable for transferred to
Step-Down Unit While in the Step-Down Unit , he proceeded to
progress well. Postop day #3 , Keeping heparin at 500 units an
hour , INR 1.5 , wires cut chest tubes out , the patient ambulating.
Postop day #4 , ??___?? 90s on 2-4 liters , increased heparin 600
units an hour , PTT 57.1 , INR 1.8 , creatinine up to 1.6. Good
urine output. Ambulating independently. Postop day #5 , the
patient now one or for left lower extremity fascial biopsy to
rule out necrotizing fasciitis.
General Surgery , ID and derm involved continuing to give
vancomycin. Creatinine increased to 1.7 from baseline of 1.4 ,
BUN of 70 , came down on Lasix and Diuril ??___??4 units FFP prior
to going to OR. The patient still very volume overloaded cards
following. Positive UTI with greater than 1000 gram-negative
rods , started Cipro. Postop day #6 , sinus rhythm. Heart rate
elevated at high 90s. Increase Lopressor 75 mg four times a day , BP stable
remains on two liters O2 , continuing to aggressively diuresed.
Biopsy from yesterday stripped or to rule necrotizing fasciitis
shows only neutrophils on past sampled per report , nonspecific
per general surgery/I discontinued Flagyl. The patient remains
on levofloxacin for UTI and vancomycin for gram-positive
coverage. Anticipate treating with vancomycin while inpatient
than discharge , the patient had short course of levofloxacin to
cover both UTI and cellulitic dermatitis. Dermatology feels
delay on left lower extremity , likely secondary to edema and
nephrotic history , punctured left dorsal blister for pressure
release since sterile culture for culture and sensitivity , wound
graft with Xeroform and Kerlix. Heparin/Coumadin bridge for St.
Jude AVR , PTT slightly low this a.m. increase heparin 600 to 650.
??___?? negative , platelets 282. Postop day #7 , sinus rhythm ,
hemodynamically stable , remains on 2.5 liters of O2 which tends
2+ bilateral lower extremity and penile/scrotal edema.
Creatinine rising currently 1.8 on Lasix 40 mg twice a day
Discontinue Diuril , today given low sodium , renal following today
has no pending. ??___?? vancomycin/levofloxacin for left lower
extremity cellulitis and UTI coverage. Anticipate treating
cellulitis with vancomycin while inpatient and discharging on
short course of levofloxacin to cover both UTI and cellulitis ,
has two new blisters on left foot , ankle , and toe dressing with
Xeroform and DSD. All blisters postop thought to be secondary to
edema and history of nephrotic syndrome. ID/derm/general surgery
have signed off. Heparin/Coumadin bridge for St. Jude AVR.
Hematocrit improving slowly with diuresis , no prbc's , ??___??
negative. Postop day #8 , sinus rhythm , BP stable now on room
air , remains very volume overloaded tense bilateral edema at
lower extremity in addition to penile/scrotal edema. Foley
remains in place due to significant penile edema , diuresing well
on Lasix 40 mg twice a day , creatinine stable 1.8 renal following.
Sodium slightly improved on Diuril , remains on
vancomycin/levofloxacin for left lower extremity cellulitis and
UTI coverage. Anticipate treating cellulitis with vancomycin
while inpatient , and then discharged in a short course of
levofloxacin. Dressing blisters on left lower extremity with
Xeroform and DSD. Heparin discontinue today with INR of 2.3.
Postop day #9 , in sinus rhythm , BP stable , ambulating well on
room air. Hematocrit down to 24.6 despite diuresis giving 1 unit
packed red blood cells , remains very volume overloaded.
Creatinine down plateau 1.8-1.7 on Lasix 40 mg twice a day with
negative fluid balance daily. Lower extremities with improved
edema , although still 1 to 2 plus , also still has significant
penile/scrotal edema with full remaining in place. Renal has
been following , but no recent note. Cards also following. INR
therapeutic for ST. Jude AVR of heparin , holding Coumadin tonight
for INR upto 3.7. Postop day #10 , creatinine down with 1.6 ,
hematocrit 28.7 , left leg with multiple healing blisters , dusky
areas onto toes on left foot , good peripheral pulses , continue
antibiotics. Postop day #11 continuing antibiotics. Wounds on
left leg appear clean and dry without erythema afebrile. White
count 10.6 , creatinine only 1.6. Plan home on antibiotics one to
two days. Postop day #12 left dorsal foot blister without
erythema. Left medial foot blister broke this afternoon , clear
drainage , no erythema , getting Xeroform dressing to dorsal foot ,
skin starting to get macerated. Anterior left lower leg
cellulitis with increased erythema from vein harvest site
reevaluating. INR 1.8 and not holding Coumadin , kept Lasix at
twice a day added Zaroxolyn 800 mL negative so far , penile edema
slightly improved , albumin 2.2 , gave intravenous albumin and started high
protein ??___?? three times a day Spoke with general surgery again
discontinued left thigh sutures on Thursday. Left leg with
increasing edema , ??___?? not done ambulating home when ready.
Postop day #13 , sinus rhythm/room air showing slow improvement ,
increase Zaroxolyn twice a day to improve diuresis. Cold renal to
revisit the patient , they will see him , but agree with the
current treatment. Ordered 24 hour urine protein and creatinine.
??___?? negative for lower extremity DVT , although exam was
limited by edema. The patient ambulating well on volts.
Excellent nursing care with dressing changes of lower extremity
wounds and blisters. On 4/5/06 , sinus rhythm/room air , stopped
intravenous antibiotics as they were making little difference in wound
healing. ID reconsulted for right lower leg cellulitis and
further management. Dermatology called back for results of skin
biopsy. Sub-epidural fasciculation with abundant eosinophils
versus possible bullous pemphigoid. The patient ambulating
frequently and continuing to diurese. Postop day #15 , sinus
rhythm/room air continues to diurese. ID running fever and
erythema around ??___?? "stab and grab" site is that patient
??___?? allergic reaction to Ethibond ties and bands. We will
try Benadryl to see if this helps revolve symptoms. The
patient's erythema in legs is dependent , looked much better
today , legs elevated and ??____?? with ambulation. Lower
extremity and penile edema improving daily. Blisters on feet
continue to receive excellent care from nursing. Derm cyst
bullous pemphigoid very unlikely because of distribution of
blisters likely from extreme edema/inflammation per renal , start
ACE inhibitor when patient back to dry weight , beginning
discontinue planning. Postop day 16 , physical therapy screening erythema/SVG
site erythema the same ambulating with assistance diuresing still
up 7 kilos by weight. Postop day #17 , 24-hour urine protein
pending , left leg SVG sites slowly improving of antibiotics ,
ambulating with assistance , sinus rhythm with/room air , stable ,
continuing diuresis. The patient was evaluated by Cardiac
Surgery Service to be stable to discharge to home with VNA
service on postop day #18 with the following discharge
instructions.
DIET:
The patient should measure weights daily. House ,
low-cholesterol , low saturated fat , ADA 2100 calories per day.
FOLLOW-UP APPOINTMENTS: Dr. Kertesz , 117-219-4079 in five to six
weeks , Dr. Theiling 860-067-7792 in one to two weeks and Dr.
Mentgen 098-462-4721 in one to two weeks.
TO DO PLAN:
Make all follow-up appointments , local wound care , wash wounds
daily with soap and water , watch all wounds for signs of
infection , ( redness , swelling , fever , pain , discharge ). Keep
legs elevated while sitting/in bed. Call primary care physician/cardiologist or PUO
Cardiac Surgery Service at 117-219-4079 with any questions. INR
goal of 2-3 for mechanical aortic valve.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS: Acetaminophen 500 mg every 4 hours as needed pain ,
allopurinol 200 mg daily , vitamin C 500 mg twice a day , enteric-coated
aspirin 81 mg daily , atorvastatin 60 mg daily , Benadryl 25 mg
every 6 hours as needed skin allergy , Colace 100 mg twice a day as needed
constipation , Zetia 10 mg daily , Flovent 88 mcg twice a day , Lasix 40
mg daily , K-Dur 20 mEq daily , Levoxyl 50 mcg daily , Zaroxolyn 5
mg daily , with instructions to give just prior to administering
Lasix , Toprol-XL 150 mg twice a day , Nasonex sprays daily , oxycodone 5
mg every 6 hours as needed breakthrough pain , Prandin 1 mg three times a day ,
multivitamin therapeutic one tab daily , and Coumadin with
variable dosage to be determined based on INR.
eScription document: 5-1922117 EMSSten Tel
Dictated By: CRIDGE , LORRETTA PA
Attending: KERTESZ , ALETA
Dictation ID 6187152
D: 11/16/06
T: 2/29/06
Document id: 805
| Target |
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773981468 | PUO | 11147158 | | 9141268 | 6/20/2006 12:00:00 a.m. | WEAKNESS | Signed | DIS | Admission Date: 1/30/2006 Report Status: Signed
Discharge Date: 2/2/2006
ATTENDING: THEILING , BREE MD
DATE AND TIME OF DEATH: 1/18/06 at 2:20 p.m.
CHIEF COMPLAINT: The patient was admitted on 2/12/06 with a
chief complaint of weakness and confusion.
HISTORY OF PRESENT ILLNESS: This was a 70-year-old female with
CHF , coronary artery disease , diabetes , peripheral vascular
disease , and chronic renal insufficiency that was admitted on
2/12/06 for weakness and confusion. She had been recently
hospitalized on 3/25/06 through 10/28/06 and 10/16/06 through
9/4/06 for CHF exacerbation requiring aggressive diuresis.
Her weight on discharge on 9/4/06 was 85 kg. She did well
initially at home after discharge , but two days prior to
admission , had increasing somnolence and confusion with global
weakness causing the patient to fall without head trauma or loss
of consciousness. The patient had decreased orally intake and was
febrile to 99.5. On admission , her weight was 83.9 kg. She was
hypotensive with blood pressures of 100/50. Her JVP was elevated to
15 and 3+ pitting edema. She had a BNP of 2321 and a white cell
count of 18.9.
Assessment: An assessment on admission suggested that the
patient possibly had hypoperfusion secondary to over diuresis or
worsening heart failure secondary to a cardiac event with a note
of having a troponin of 2.61.
Hospital Course: Her hospital course after admission on 2/12/06 was
complicated by worsening cardiac function with minimal improvement on milrinone
and decreasing urine output despite diuretics and also gross gastrointestinal
bleeding with melanotic stool while she was on Coumadin for atrial
fibrillation. In addition , there was concern for sepsis. The patient was on
antibiotics with levofloxacin , Flagyl , and vancomycin. She required a transfer
to the Cardiac Care Unit on 11/19/06 for further medical therapy for poor
cardiac output , a
possible need for CVVH , given volume overload in the setting of renal failure ,
and work-up of GIB. Her code status was DNR/DNI during her admission into the
CCU on 7/25/06. The patient reversed her status to DNR , but allowed for
elective intubation on 11/19/06 , given her increasing GI bleed and the
worsening renal failure. The patient was electively intubated on 10/30/06
without any complications. For her GI bleed , she had an EGD and colonoscopy ,
which found a
gross large ascending colorectal mass with ulcerations , which likely
contributed to her gross GI bleed. Given the patient's wishes to
be DNR/DNI and given her new finding for a large mass in the
ascending colon , the patient's code status was changed to comfort
measures only on 4/20/06. In addition , her colorectal mass pathology returned
showing poorly differentiated tumor with lymphoma versus adenocarcinoma being
most likely as the diagnosis. For the above reason , the patient was also made
CMO.
Being CMO status , she was removed of all pressors and
antibiotics in the morning of 4/20/06. She was made comfortable sedated on
fentanyl and Versed. She was then extubated for comfort with family present.
She had agonal breathing with episodes of apnea and was given additional
sedation for comfort. The patient drew her last breath at 2:20 p.m. Her
family was present at bedside. The attending was aware.
On assessment , the patient had no spontaneous breathing , no corneal reflex ,
and no peripheral pulses. The patient's eyes were dilated and no heart
sounds or breath sounds were appreciated. Given the CMO status ,
no CPR was undertaken. The patient was pronounced dead at 2:20
p.m. on 4/20/06. Family declined autopsy.
eScription document: 7-7352812 CSSten Tel
Dictated By: CHRISTAL , OLIN
Attending: THEILING , BREE
Dictation ID 3575124
D: 1/18/06
T: 1/18/06
Document id: 806
| Target |
Ast |
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CHF |
Dp |
DM |
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GER |
Gou |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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Y |
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U |
Y |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
Y |
N |
950416379 | PUO | 82557278 | | 321703 | 8/3/1997 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/8/1997 Report Status: Signed
Discharge Date: 10/29/1997
PRINCIPAL DISCHARGE DIAGNOSIS: Rule out myocardial infarction.
ADDITIONAL DIAGNOSES:
1. Hypertension.
2. Peripheral vascular disease.
HISTORY OF PRESENT ILLNESS: Mr. Hanners is a 59-year-old gentleman
with no known history of cardiac
disease who presented with substernal chest pain. Mr. Hanners was in
his usual state of health with known cardiac risk factors of
hypertension , peripheral vascular disease family history , and
history of smoking cigarettes who presented with steady course of
substernal chest pain beginning the day of admission. The patient
noted that after lunch he felt the left-sided chest pressure
described as crushing which was intermittent. He continued with
his activities during the day and went to a baseball game in the
evening and the symptoms continued and were then associated with
right shoulder and arm tingling and achiness. He left the game and
on the way home , he had increasing substernal chest pain rating
6-7/10 which was associated with perfuse diaphoresis. At that
point , the patient came to the Emergency Department. He denied
shortness of breath , nausea , vomiting , or palpitations. He had a
similar episode with a rule out MI two years ago at which time he
had a negative workup per patient report. He denied any orthopnea ,
PND , or peripheral edema as well as fevers or chills. Upon arrival
in the Emergency Department , the patient received sublingual
Nitroglycerin as well as Lopressor , Nitropaste , and Aspirin with
resolution of symptoms.
PAST MEDICAL HISTORY:
1. Hiatal hernia.
2. Hypertension.
3. Peripheral vascular disease with claudication , noted worsening
over the past month , decreasing from 1 mile to inability to
do treadmill for any amount of time.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Nadolol 50 mg orally every day
2. Pepcid before meals 1 twice a day
SOCIAL HISTORY: He is the owner of a furniture store. He is
married and lives with his wife. He admits to
1-1/2 pack per day of cigarettes for 45 years , but is currently
cutting down. He denies alcohol or intravenous drug use.
FAMILY HISTORY: His father has a history of coronary artery
disease in his late 50s.
REVIEW OF SYSTEMS: Noncontributory.
PHYSICAL EXAM: In general , the patient was a well-appearing
elderly male in no acute distress. His heart rate
was 65-70 beats per minutes , blood pressure 140/90 , O2 saturation
96% on room air , and respiratory rate 16. HEENT exam was within
normal limits. The neck was supple with no JVD. The heart is
regular rate and rhythm without murmur or gallops , and positive S4.
The lungs were clear bilaterally. The abdomen was benign. The
extremities were with no edema. Neurological exam was grossly
nonfocal.
LABORATORY: The patient's CKA sed was 40 , CKB sed 33 , troponin 0 ,
cholesterol 265. Chest x-ray was negative. EKG
showed J point elevation in V1-V2 with no ST or T wave changes
compared with prior EKGs. He had a normal sinus rhythm at 62 with
normal intervals and a normal axis.
IMPRESSION: This is a 59-year-old gentleman with substernal
chest pain and symptoms , and multiple cardiac risk
factors who is admitted to the Short-Stay Unit for rule out
myocardial infarction protocol.
HOSPITAL COURSE: The patient was admitted and ruled out for
myocardial infarction with normal CK and EKG.
The patient had no further episodes of chest pain while in-house
and underwent a exercise stress test with arm ergometry secondary
to his history of claudication. The patient exercised 8 minutes
using ergometry and stopped secondary to fatigue. His maximum
blood pressure was 212/102 and maximum heart rate was 101. He had
no chest pain , no ST or T wave changes , and no evidence of ectopy.
His heart rate was less than 80% of predicted maximum , but he is on
a beta blocker. There was no evidence for ischemia. Because of
the test result , the patient ruled out for myocardial infarction
and was discharged to home.
FOLLOW-UP PLAN: Patient will have follow-up with his Primary
Care Physician.
DISCHARGE MEDICATIONS:
1. Nadolol 50 mg orally every day
2. Simvastatin 5 mg orally every bedtime
3. Axid 150 mg orally twice a day
4. Nitroglycerin 1:150 sublingual tablets , 1 tablet q5min x3
as needed chest pain.
Dictated By:
Attending: DIONNE G. MONSOUR , M.D. MJ66
TO713/8469
Batch: 96625 Index No. E5NR9O3O2 D: 10/12/97
T: 11/9/97
Document id: 807
| Target |
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CHF |
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Gs |
GER |
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967188139 | PUO | 89831429 | | 9505196 | 3/28/2005 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 10/1/2005 Report Status: Signed
Discharge Date: 10/15/2005
ATTENDING: LACKNER , JEANNETTE MD
ADMITTING DIAGNOSES:
1. Hypoxia.
2. Acute renal failure.
3. Congestive heart failure.
DISCHARGE DIAGNOSES:
1. Hypoxia.
2. Acute renal failure.
3. Congestive heart failure.
CHIEF COMPLAINT:
Shortness of breath , ____ MS.
HISTORY OF PRESENT ILLNESS:
The patient is a 61-year-old female with end-stage renal disease ,
not yet on hemodialysis; hypertension; insulin-dependent diabetes
mellitus , who is legally blind; hypothyroidism. The patient of
note had a recent AV fistula placed. The patient was admitted to
the Pagham University Of initially on 3/9/04 through
5/14/05 for hypoglycemic arrest , during at which time she was
resuscitated with full mental recovery. The patient was
subsequently discharged to the Griffcoo Nonster Hospital ,
and was readmitted on 9/16/05 through 10/10/05 for left toe
ulceration , which required operating room debridement , and
intravenous antibiotics , including vancomycin , levofloxacin and
Flagyl. The patient was subsequently transitioned to orally
clindamycin at the time of discharge , and discharged back to the
Futage Tervpa Ili Ycoast University Medical Center The patient subsequently
presented on 9/30/05 per the report of the HTH
The patient was noted to have intermittent confusion and hypoxias
to 85% on room air on the morning of admission. The patient was
sent to the Totin Hospital And Clinic emergency room where she was
found to be normotensive at 138/83 , with an O2 saturation of 88%
on room air , augmented to 100% on nonrebreather. Physical
examination at the time of admission was remarkable for bilateral
crackles , two-thirds of the way up bilaterally. Chest is
remarkable for vascular congestion , question of right lower lobe
infiltrate. Of note , laboratory values on admission were
remarkable for BUN of 18 , and the creatinine up of 54 , elevated
from prior creatinine reading on 10/10/05 of 2.7. Her brain
natriuretic peptide on admission was measured at 2200. The
patient was subsequently admitted to General Medical Service
under the attending physician , Dr. Jeannette Manie Lackner , for further
evaluation and management.
PAST MEDICAL HISTORY:
Remarkable for end-stage renal disease. The patient with the
right AV fistula in place , not yet on hemodialysis , hypertension ,
and insulin-dependent diabetes mellitus. The patient is legally
blind , the patient with hypothyroidism , the patient with recent
right toe ulceration , requiring operating room debridement; the
patient with a history of hypoglycemia.
MEDICATIONS ON ADMISSION:
Include aspirin , atenolol , calcitriol , PhosLo , calcium carbonate ,
Colace , heparin , NPH , Regular Insulin sliding scale ,
levothyroxine , oxycodone as needed , timolol , amlodipine , Dilantin ,
Protonix , clindamycin , Cozaar , and Lasix.
ALLERGIES ON ADMISSION:
Include penicillin and metolazone.
SOCIAL HISTORY:
Not significant. The patient was previously residing at the
Griffcoo Nonster Hospital
LABORATORY DATA:
Full laboratory panel on admission includes sodium of 133 ,
potassium of 5.4 , chloride of 103 , bicarbonate of 21 , BUN of 80 ,
elevated from 53 of several days prior; creatinine of 5.4 ,
elevated from 2.7 of several days prior; glucose of 43; white
count of 10.5; hematocrit of 25.4 , down from 28.9 of several days
prior; platelets of 315 , 000; INR of 1.5. Cardiac enzymes were
negative for any evidence of coronary insufficiency. Chest film
as mentioned previously demonstrated prominent bibasilar
pulmonary vasculature , mild cardiomegaly , and question of right
lower lobe infiltrate. EKG was unremarkable.
HOSPITAL COURSE BY SYSTEMS:
1. Renal: The patient presented with acute and chronic renal
insufficiency. Prior creatinine measured at 2-3. At the time of
admission , the creatinine was 5.4. Peak creatinine was measured
at 6.0. The patient was seen by the Renal Consult Service for
further evaluation of his acute renal failure. The patient was
felt to have gadolinium-induced nephropathy given her prior
chronic renal insufficiency and recent MRA , which had been
obtained to evaluate for peripheral vascular disease. Over the
time of admission , the patient was felt to be significantly
volume overloaded secondary to this acute renal failure , with
patient's weight up approximately 50 pounds from her baseline
value , and given her chest x-ray consistent with acute pulmonary
congestion , the patient was started on a Lasix drip with Diuril
support with significant improvement in her volume status. The
patient diuresed significantly over the time of admission.
Admission weight was recorded at 129.9 kg. At the time of
discharge , the patient had diuresed down to a dry weight of 95.6
kg , felt to be her dry weight. The patient was subsequently
restarted on her outpatient dose of Lasix 40 mg orally daily.
Recommend further outpatient titration and Lasix dosing as
required to maintain her ins and outs at approximately even.
Additionally , the patient on a fluid-restricted diet of 2.5
liters per day. The patient to follow up with her outpatient
nephrologist at the Kendsonre Ale Ater Hospital as per the discharge
instructions.
2. Cardiovascular: The patient with significant volume overload
secondary to acute renal failure. The patient was diuresed of
the hospital course as previously described. Recommend
outpatient evaluation as required.
3. Pulmonary: The patient with hypoxia on admission secondary
to acute pulmonary congestion. With significant diuresis , the
patient's hypoxia resolved. At the time of discharge , the
patient was on room air with O2 saturation greater than 92%. Of
note , the patient with occasional desaturation occurring at night
while sleeping , felt to be secondary to peripheral obstructive
sleep apnea. Recommend further outpatient evaluation and
supplemental oxygenation as required at night.
4. Heme: The patient with significant anemia secondary to both
iron deficiency and chronic renal insufficiency. The patient was
maintained on Epogen and iron supplementation. Additionally ,
given a significant bilateral lower extremity edema on admission
with hypoxia , concern for lower extremity deep venous thrombosis.
Lower extremity noninvasive ultrasound is negative for any
evidence of clot.
5. Endocrine: The patient with significant hypothyroidism ,
maintained on Levoxyl. Recommend outpatient evaluation as
required. Additionally , the patient with a history of
insulin-dependent diabetes mellitus , maintained on NPH twice a day
with Regular Insulin sliding scale supplementation. At the time
of discharge , the patient's NPH was at 12 units subcutaneous
twice a day with Regular Insulin sliding scale supplementation before every meal
at bedtime. Recommend titration as required to an A1c less than
7.5. Of note , the patient with significant hypoglycemia in the
past , particularly in the setting of infection or low orally
intake , so we would recommend caution.
6. Prophylaxis: The patient was on subcutaneous heparin 5000
units three times a day for DVT prophylaxis in addition to Protonix 40 mg.
7. Musculoskeletal: Recommend physical therapy rehabilitation
as tolerated.
8. Code status: The patient adamantly DNR/DNI per her own
wishes.
9. Infectious disease: The patient noted to have persistent
diarrhea with minor abdominal pain at the time of admission. C.
diff colitis was found to be positive. The patient was therefore
treated with two-week course of orally Flagyl 500 mg every 8 hours x14
days , and given concern initially for right lower lobe pneumonia ,
the patient was treated with a 14-course of levofloxacin ,
titrated to her renal function. At the time of discharge , the
patient was afebrile. Vital signs were stable. The patient was
tolerating food and physical therapy at baseline level. The
patient to be transferred back to the Griffcoo Nonster Hospital for further physical therapy rehabilitation.
FOLLOW UP:
The patient to follow up with her primary care physician , Dr.
Bench at the KAAH T Clinic. In addition , the patient is
scheduled for follow-up appointment with KAAH Nephrology , Dr.
Caroyln Reidherd , scheduled for 10/3/05 at 11 a.m.
eScription document: 4-3729600 EMS
Dictated By: GORGLIONE , JEANNETTE
Attending: LACKNER , JEANNETTE
Dictation ID 0970970
D: 8/29/05
T: 8/29/05
Document id: 808
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| output/system_textual_annotation.xml | textual |
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430684242 | PUO | 55241867 | | 9958906 | 3/10/2005 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 8/21/2005 Report Status: Signed
Discharge Date: 4/16/2005
ATTENDING: REMLEY , EVALYN M.D.
SERVICE: Medicine.
ADMISSION DIAGNOSIS: Pneumonia , COPD.
CHIEF COMPLAINT: A 48-year-old female with history of CHF , COPD
and breast cancer with increased shortness of breath for one
month.
HISTORY OF PRESENT ILLNESS: The patient had three weeks of cold
like symptoms , which progressively worsened. Initially , she had
a sore throat and mild headache that progressed to a
sputum-productive cough. She has been in orthopnea at baseline
but has become increasingly short of breath and requiring more
frequent inhaler treatments. She went to her primary care
physician last week and got azithromycin for presumed pulmonary
infection. She completed antibiotic course but over the past few
days has felt even more short of breath. She works at a hospital
and yesterday measured her O2 saturation , which was 76% under
mild exertion. She then came to the Emergency Department today
for evaluation and treatment.
REVIEW OF SYSTEMS: Significant for cough with yellow sputum and
dyspnea on exertion. She has mild subjective fevers but no
chills or no night sweats. No chest pain. She does have
headaches and baseline orthopnea with no PND.
PAST MEDICAL HISTORY: Significant for COPD with a FEV1/FVC of
81% of predicted in February of 2004. She was hospitalized for
three weeks and intubated for past pneumonia. She did have home
O2 following that hospital course. CHF. Hypertension.
Diabetes. Left breast cancer 18 months ago status post radiation
and surgery complicated by MRSA wound infection. Hypothyroidism.
MEDICATIONS: Lasix 40 daily , levothyroxine 225 mcg daily ,
lisinopril 10 mg daily , Xanax one tablet three times a day , Motrin as needed ,
Combivent , B12 , and potassium chloride 20 mEq daily.
ALLERGIES: Erythromycin and Flexeril.
SOCIAL HISTORY: 30-pack history of tobacco use. She works at
E
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM: Vital signs , temperature 99.2 , heart rate 86 ,
blood pressure 153/88 , respiratory rate 24 , O2 saturation 86%.
Exam , general , in no apparent distress , pleasant middle-aged
woman sitting in a wheelchair. HEENT , PERRL , no scleral icterus.
Face flushed with spider angioma. Mucosal membranes moist.
Neck , JVP approximately 7 cm. CV , regular rate and rhythm , 2/6
systolic murmur apex radiating to axilla and laterally displaced
PMI. Chest , no wheezes after nebulizers. Mild crackles at right
base. Abdomen , soft , nondistended , nontender , modestly obese.
Extremities , 2+ pulses , mild lower extremity bilaterally. Edema
in the upper extremities , left greater than right.
LABORATORY DATA: On admission , sodium 139 , potassium 4.6 ,
chloride 97 , bicarb 31 , BUN 14 , creatinine 0.6 , glucose 105 , WBC
4.6 , hematocrit 45.8 , platelets 256. LFTs within normal limits.
Coags within normal limits. BNP 46 , CK-MB 0.9 , troponins
negative. EKG showed normal sinus rhythm , T-wave inversions , V3
through V5. Chest x-ray shows enlarged heart with right middle
lobe opacity.
HOSPITAL COURSE:
1. Pulmonary: The patient with possible right middle lobe
pneumonia versus CHF versus exacerbation versus COPD versus PE.
The patient is found to have pneumonia. She is afebrile with
normal white blood cell counts but continues to be hypoxic to the
mid 80s on room air. Sputum cultures were sent and the patient
was treated empirically with Levaquin. Levaquin was given for a
total of 8 doses in-house and the patient will continue for a
total of 14-day course. The patient had a PECT , which was
initially read was positive , however , the final read was negative
for PE. The patient initially received a dose of Lovenox 100 mg
twice a day but was discontinued given negative PE. The patient was
seen by Pulmonary Service who performed the bronchoscopy on
6/14/05 , which showed a copious blood-tinged mucosa and
collapsed right middle lobe lung with narrow orifice. Brushings
and cytology were taken and sent to Pathology and the results are
still pending. The patient's pulmonary function test showed
severe obstructive disease with the FEV of 0.9 with some aspects
of restrictive disease. She also underwent a bubble study , which
was negative for heart septal defects. The PA pressure was
estimated at 42. The patient then underwent a right heart
catheterization to check for vasodilator response and heart
function. This was performed on 10/10/05 , which showed high
right-sided heart pressures and a pulmonary wedge pressure of
16-18 and suggested that the patient was not in acute left heart
failure. The patient was also seen by the Da ,
Pulmonary Hypertension Consult Service , whose impressions were
that the patient's poor pulmonary function is due to COPD and
pectus cavernosum as well as radiation for breast cancer and is
chronic condition. No indication was present for treatment with
primary pulmonary antihypertensive agents. The patient then had
a repeat chest x-ray on 10/10/05 to evaluate for the right middle
lobe , which continues to be collapsed. The patient was stable on
2-3 L of nasal cannula oxygen , saturating at about middle 90s.
The patient was re-evaluated by physical therapy on 3/29/05 and
was found to not need any particular treatments at home. The
patient was discharged to home with home O2 2-3 nasal cannula and
instructed to keep O2 saturations above 88%. The patient does
work in the hospital. The patient's work situation and
disability regarding her lung condition was discussed by the
attending physician.
2. Cardiovascular: The patient is stable with no evidence of
acute CHF , complicating dyspnea. The BNP was normal and JVP
remained relatively flat throughout her hospital course. The
patient was continued on her outpatient hypertensive medications ,
which was captopril and that was given three times a day with good control.
The patient was also on Lasix 40 mg daily , which was then
increased to 60 on day of discharge to encourage gentle diuresis.
3. Endocrine: The patient has diet-controlled diabetes at home.
She was on insulin sliding scale and house and required only
several units of insulin a day. Her blood sugars remained in the
mid 100s.
The patient was on Levoxyl 225 mcg daily in-house and was found
to have a increased TSH of 10.5 , therefore dose of Levoxyl was
increased to 250 mcg. The patient is instructed to follow up
with her primary care provider and her endocrinologist in two
weeks to recheck a TSH.
4. Musculoskeletal: The patient complaining of leg cramps ,
chest spasms , and back pain. Back pain appears chronic. Chest
spasms appeared to be musculoskeletal in etiology and not
cardiac. The patient was on oxycodone 5 mg every 4 hours as needed and then
transitioned to OxyContin 10 mg twice a day with good pain control.
5. Social Services: The patient was seen by Social Services
regarding prescription coverage , ability to handle copayments.
Additionally , her concerns regarding short-term disability and
long-term disability for work were addressed. The patient is to
inquire with her benefit office to determine for services.
DISCHARGE CONDITION: Stable.
DISCHARGE DISPOSITION: Discharged to home with home O2.
DISCHARGE MEDICATIONS: Levaquin 500 mg daily for six more days ,
captopril 12.5 mg orally three times a day , Lasix 60 mg orally daily ,
levothyroxine 250 mcg orally daily , Xanax 0.25 mg three times a day as needed ,
OxyContin 10 mg orally every 12 hours , Combivent 1-2 puffs four times a day
DISCHARGE INSTRUCTIONS: The patient to call if becoming short of
breath , has chest pain , fever over 100.5 or any other concerns or
questions.
FOLLOW-UP APPOINTMENTS: Include 10/17/05 at Put Wathern Hospital for
sleep study where the patient is to arrive before 09:00 p.m. that
night , 10/25/05 with Dr. Ketola at 02:30 p.m. for primary care
follow-up , Dr. Burle on 7/18/05 at 04:00 p.m. for follow-up of
pulmonary issues and a two weeks' time follow-up with her
endocrinologist regarding her thyroid condition.
DISCHARGE DIAGNOSIS: COPD , pneumonia , secondary pulmonary hypertension ,
hypothyroidism , hypertension , non-insulin-dependent diabetes.
eScription document: 2-1331094 CS
CC: Evalyn Remley M.D.
Norap Valley Hospital
Sto Ins A
Chatau Ton Me
CC: Lorretta Cridge M.D.
Pulmonary Division , Pagham University Of
Van Ty Ton
More
CC: Ketola her primary care provider
Dictated By: MUNGIN , AIDE
Attending: REMLEY , EVALYN
Dictation ID 0639363
D: 4/19/05
T: 4/19/05
Document id: 809
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CHF |
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GER |
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HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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748718858 | PUO | 63349134 | | 802967 | 2/14/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/11/1994 Report Status: Signed
Discharge Date: 6/29/1994
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old male
without significant past medical
history who presented to Norap Valley Hospital with chest pain , ruled
in for an acute myocardial infarction and received thrombolysis.
The patient had persistent chest pain and was transferred to the
Pagham University Of for further evaluation. Cardiac risk
factors include no family history , no diabetes , no
hypercholesterolemia , very distant smoking history , male , and no
hypertension. The patient developed 6/10 substernal chest pain
radiating to his left arm , associated with nausea and shortness of
breath while he was sitting in his car on the morning of admission.
An hour later , he reached Norap Valley Hospital where his vital signs
revealed a blood pressure of 170/90 , heart rate was 85 , lungs were
clear to auscultation and an EKG which showed anterior ST
elevations with peak T waves. He was treated with front loaded
TPA , intravenous Heparin , intravenous Nitroglycerin , aspirin , Lopressor , but
continued to have substernal chest pain and ST elevations. He was
treated with Morphine and managed to sleep intermittently but every
time woke up with persistent pain. An echocardiogram performed at
the Norap Valley Hospital revealed a normal ejection fraction ,
inferior , posterior and septal hypokinesis. Given his persistent
chest discomfort , he was transferred to the Pagham University Of for post-thrombolysis , angioplasty.
The patient went directly to cardiac catheterization which revealed
the following; he had a right dominant system with two serial 90%
stenosis in the mid LAD , no abnormalities in the RCA , or left
circumflex artery , hemodynamics revealed an LVEDP of 14. LV gram
revealed apical hypokinesis with otherwise normal left ventricular
size , and function , right after that he underwent angioplasty of
his left anterior descending artery with successful results
( stenosis 90% down to 30 and 20% respectively ). Of note , he did
have TIMI grade 2 to 3 flow prior to angioplasty. The patient was
then transferred to the CCU without chest pain. PAST MEDICAL
HISTORY: This is notable for benign prostatic hypertrophy , status
post TURP , he is also status post an appendectomy. HABITS: The
patient is an x-smoker with a 48 pack year history , quite 30 years
ago. He drinks alcohol socially. MEDICATIONS ON ADMISSION: At
the time of admission , the patient was on no medications at home ,
however , medications on transfer were; Lopressor 50 mg orally twice a day ,
aspirin 160 orally every day , intravenous Nitroglycerin at 50 micrograms an hour ,
Heparin at 1000 units an hour. ALLERGIES: The patient has no
known drug allergies. FAMILY HISTORY: There is no known coronary
artery disease. SOCIAL HISTORY: The patient use to work in
construction , he lives with his wife and has two children. His
granddaughter is a nurse at Pagham University Of .
PHYSICAL EXAMINATION: On admission , the patient was an elderly
male , sleepy , no apparent distress. His
blood pressure was 110/80 , heart rate was 62 , respiratory rate was
18. 93% oxygen saturation on six liters. The HEENT examination
showed extraocular movements were intact , pupils equal , round and
reactive to light and accommodation , oropharynx was benign. Neck
was supple without lymphadenopathy. There was no thyromegaly.
Chest was clear to auscultation. Cardiac carotids were 2+ without
bruits. There was a regular rate and rhythm , S1 , S2 , there was a
soft S4. There was no S3 , no murmurs. Abdomen soft with good
bowel sounds , no hepatosplenomegaly. Rectal was guaiac negative at
Norap Valley Hospital . The patient's extremities showed no edema ,
pedal pulses were intact bilaterally. Right femoral sheath in
place.
LABORATORY DATA: On admission , the patient's potassium was 3.8 ,
creatinine was 1.2 , creatinine kinase 960 with 99
MBs , white count was 9 , hematocrit 34.3 , physical therapy and PTT was greater
than 110. EKG revealed normal sinus rhythm at 80 , left axis
deviation , negative 35 , first degree heart block , 2 mm ST
elevations in V2 to 3 , Q waves in V1 to 5 , and small inferior Q
waves. Chest x-ray revealed bilateral low lung volume with mild
pulmonary edema. His cholesterol was 173.
HOSPITAL COURSE: In summary , this is a 78-year-old man who is
status post an acute myocardial infarction treated
with front loaded TPA with persistent chest pain and ST elevations
now status post acute angioplasty of his LAD , admitted to the CCU
for further management. He was continued on intravenous Heparin and intravenous
Nitroglycerin , Lopressor , and aspirin. The patient was pain free
following angioplasty and his EKG post-angioplasty , showed
improvement in his anterior ST segments with evolution consistent
with an anterior myocardial infarction. The patient's post-MI
course was relatively uncomplicated with a peak CK of 960 , with 99
MBs ( with which he presented on admission ). By hospital day two ,
he had a CK of 336 , and 19 MBs. The patient was continued on intravenous
Nitroglycerin for 48 hours and was weaned to Nitropaste and
continued on intravenous Heparin for a total of five days. The patient was
also diuresed gently and within a few days had good oxygenation on
room air. The patient had a submaximal ETT MIBI prior to discharge
on hospital day seven , and went 9 minutes on a modified Bruce
without chest pain or dyspnea. The patient's maximal heart rate
was 120 , and maximal blood pressure was 180. EKG showed
normalization of his T-waves but no other diagnostic changes
consistent with ischemia. MIBI images revealed very mild
reversible ischemia in the apex , and apical portion of the inferior
wall. The patient will be discharged on a cardiac regimen which
includes Lopressor , aspirin , Captopril which was initiated a few
days prior to discharge , he will also be given sublingual
Nitroglycerin as needed The patient is scheduled to follow up with a
full Bruce ETT MIBI on 29 of November , to complete his risk ratification.
He is also scheduled for an echocardiogram the same day. The
patient will follow-up with Dr. Buck Moose in Cardiology at the
Pagham University Of and Dr. Vanhauen at Norap Valley Hospital .
Of note , the patient complained of significant dysphagia while
lying supine status post cardiac catheterization and upon more
complete history it became apparent that he has had dysphagia for
quite some time. The patient denied significant weight loss but
has had trouble with both solids and liquids. A video swallow was
obtained which revealed no aspiration and normal swallowing
mechanism and a barium swallow was noted for significant esophageal
dismotility and tertiary contractions. These results have been
communicated to his primary physician ( Dr. Vanhauen who will follow ).
DISPOSITION: CONDITION ON DISCHARGE: At the time of discharge ,
the patient was stable. MEDICATIONS ON DISCHARGE:
At the time of discharge , the patient was on Lopressor 50 mg four times a day ,
aspirin 325 mg every day , Captopril 6.25 mg three times a day , sublingual Nitroglycerin
as needed
DISCHARGE DIAGNOSES: 1. ACUTE ANTERIOR MYOCARDIAL INFARCTION
2. CORONARY ARTERY DISEASE
3. ESOPHAGEAL DISMOTILITY
PROCEDURE PERFORMED: 1. Cardiac catheterization , angioplasty.
Dictated By: LATKO
Attending: DANILLE LACY HARTSELL , M.D. BV3
WA620/8148
Batch: 3836 Index No. C1ZM8E8283 D: 7/10/94
T: 3/19/94
CC: 1. PENNIE LOERWALD , M.D. Ville
Cinponcecean Salt Na
Document id: 810
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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069368881 | PUO | 43005496 | | 5325596 | 10/20/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/20/2003 Report Status: Signed
Discharge Date:
ATTENDING: ROSSIE MANKOSKI M.D.
PRINCIPAL DIAGNOSIS:
Dilated cardiomyopathy.
SECONDARY DIAGNOSES:
Right foot osteomylitis , left calf ulcer , hypertension ,
peripheral vascular disease , nonsustained VT , gout , occipital
CVA , atrial fibrillation , left vocal cord paralysis , and renal
failure.
HISTORY OF PRESENT ILLNESS:
The patient is a 54-year-old man with nonischemic dilated
cardiomyopathy who presents with weight gain , weakness , and
azotemia. The patient has known cardiomyopathy thought to be
secondary to alcohol with incomplete cardiology follow up.
Cardiac catheterization performed in 1998 showed a right atrial
pressure of 16 , PA pressure 49 of 28 , pulmonary capillary wedge
pressure of 26 , cardiac output of 4 , cardiac stress done in 2002 ,
he lasted 5 minutes 30 seconds did not read anaerobic threshold
with a ZO2 of 11.1. The patient was admitted in February 2003 with
decompensated heart failure. An echo showed LV EDD of 65 and
ejection fraction of 25% with moderate MR and severe TR treated
with dobutamine , seretide , and diuretics with good effect.
Course complicated by left leg cellulitis and worsening renal
functioning on ACE inhibitor. Two weeks prior to presentation ,
the patient was seen in clinic with fluid retention , diuretics
were increased , then had worsening renal function , so diuretics
was held and now presented with fatigue , leg edema , and draining
foot wound.
PAST MEDICAL HISTORY:
Hypertension , diabetes , peripheral vasculare disease , status post
transmetatarsal amputations , osteomyelitis , and VT. The patient
declined ICD , gout , occipital CVA , and atrial fibrillation.
MEDICATIONS ON ADMISSION:
Digoxin 0.125 mg every other day , Imdur 30 mg every day , hydralazine 25 mg
three times a day , torsemide was being held , Coumadin 1 mg every day , carvedilol
3.125 mg twice a day , allopurinol 100 mg every day , Glucophage , and
glyburide.
FAMILY HISTORY:
Father with coronary artery disease in 80s.
SOCIAL HISTORY:
He currently lives with a roommate. Family is somewhat strange ,
although recently more involved with the patient. No tobacco use
and moderate alcohol consumption per patient.
ALLERGIES:
No known drug allergies.
PHYSICAL EXAMINATION:
A tired older man lying at 30 degrees with profound fatigue.
Blood pressure 84/60 , pulse 100 and regular , weight 102.4 kg , and
temperature 99.4. Mild pallor. No scleral icterus. JVP to the
angle of jaw. Coarse breath sounds bilaterally without wheeze.
Cardiac irregular and soft systolic murmur at the left sternal
border. No S3 , gallop , or rub. Abdomen reveals decreased bowel
sounds. Liver - four fingerbreadths below right costal margin ,
nonpulsatile. No guarding or rebound. Extremities: Warm with 3+
edema to thighs.
LABORATORY DATA ON ADMISSION:
Sodium 129 , potassium 4.2 , BUN 133 , creatinine 1.2 , hematocrit
31.9 , white blood cell count 15.8 with 89% polys , 8 bands , and
INR 4.6 , albumin 2.7 and total bilirubin 3.4 , and normal
transaminases. ECG showed atrial fibrillation at 90 per minute ,
low voltage , poor R-wave progression with QRS widening , and
nonspecific T-wave abnormality.
HOSPITAL COURSE:
The patient was admitted to Cardiology Service for continued
management of his volume overload , dilated cardiomyopathy , and
lower extremity infections. This hospital course will be
summarized briefly by dates.
1. On 11/21/03 , the patient was found to have progression of his
right lower extremity infection and was taken to the OR for
debridement.
2. On 10/8/03 , Diuril was added to his regimen and his
creatinine was noted to increase from 2.6 to 3.6 and diuretics
were subsequently held.
3. On 6/25/03 , the patient retuned to the OR for revision of
right wound infection and underwent a further transmetatarsal
amputation.
4. On 5/5/03 , the patient noted nausea , fatigue , and malaise
coincident with 20-beat run of VT followed by syncope in the
stetting of dobutamine. The VT terminated spontaneously. The
patient was loaded on amiodarone , unfortunately still required
low dose dobutamine to maintain his cardiac output.
5. On 11/2/03 , the patient returned to the OR for debridement
and was noted to be hypotensive with baseline systolic blood
pressures of 80s going to 60s over palp with decrease urine
output. He was transferred to the CCU briefly and did well on
ionotropes and diuretics. He was transferred back to the floor
and continued to have decrease urine output on maximal diuretic
doses and ionotropes.
6. On 6/5/03 , the renal surgery recommended that the dobutamine
be stopped in order to enhance renal perfusion and Lasix be
increased to 80 mg per hour. The patient promptly developed
cardiogenic shock with discontinuation of dobutamine and was
again transferred to the CCU with systolic blood pressures in the
60s. He was ashen and cold. Subsequently , he has required
dobutamine between 1 and 2.5 mcg/kg/minute to maintain his
cardiac output as well as CVVH for volume management. He has
tolerated the FL rates between 15 and 200.
7. On 4/28/03 , the patient noted hoarseness. Otolaryngology
evaluation demonstrated paralyzed left vocal cords thought to be
secondary to left atrial enlargement or potentially the placement
of a left IJ catheter.
8. On 5/6/03 , a tunneled catheter was placed for hemodialysis
and CVVH access with plan initiation of hemodialysis.
9. On 10/30/03 , he had first course of hemodialysis and he
tolerated this procedure well. A PICC line was placed. The
patient was given a pneumococcal vaccine.
10. Cardiovascular:
a. Pump: The patient with advanced dilated cardiomyopathy with
poor overall prognosis , was admitted for aggressive diuresis in
order to improve his position on the ?? ?? curve. This was
performed by CVVH and is now being transitioned to hemodialysis.
He has beyond less invasive measures such as digoxin and ACE
inhibitors , and he is now dobutamine dependent.
b. Ischemia: The patient without any history of ischemic heart
disease and no symptoms suggestive of any incorporate lesions.
c. Rhythm: Chronic AF and occasional ectopy and VT on
dobutamine , currently loaded on amiodarone without any further
events.
11. Infectious Disease: The patient with chronic osteomylitis ,
currently in a six-week course of ceftazidime , vancomycin ,
Flagyl , and Diflucan for complicated osteomyelitis , end date is
on 9/27/03. He was given pneumococcal vaccine. He is
up-to-date on his flu vaccine.
12. Renal: The patient has had progressive renal failure likely
secondary to low flow to the kidneys. This has been exacerbated
by ACE inhibitors in the past. In addition , increasing doses of
diuretics have been ineffective that the patient is able to
obtain increased amounts of cardiac output. As he comes on
strongly through , he may regain some renal function , however , it
is predicted that he will require hemodialysis for remainder of
the life. He has tolerated this. A tunneled catheter was placed
for access on 10/20/03.
13. Vascular: The patient with peripheral vascular disease now
status post transmetatarsal amputation. He remains with a open
wound in his left foot and a calf ulcer. The patient is planned
to be evaluated by Plastic Surgery prior to discharge for final
plans whether a flap or healing by secondary retention.
14. Psychiatry: The patient is depressed with frequent periods
of anxiety , exceedingly fearful of dying , and unable to sleep
with light off or with drapes pole secondary to believe that if
he falls asleep , he will no longer wake up. He was seen by
Psychiatry , who suggested starting low dose of Zyprexa in the
evening. This has greatly improved his mood and he is doing well
from this regard.
15. Endocrine: The patient failed a course of stimulation test
and was started on hydrocortisone. When this was tapered down ,
he had some periods of hypotension and this was increased again.
He remains on maintenance doses of hydrocortisone. Etiology of
his adrenal insufficieny is unclear. Additionally , the patient
has diabetes. He was on orally hypoglycemic as an outpatient ,
however , now this renal function , he has been transitioned over
to insulin with his standing doses of Lantus with a lispro
sliding scale.
16. FEN: The patient was started on TPN for quite severe
malnutrition. He now has increasing albumin with increased
appetite , and he is tolerating more food. He has been placed on
nectar thick liquids for secondary to left vocal cord paralysis
and visualized aspiration on barium swallow by ENT.
DISPOSITION:
The patient currently is stable.
PLAN:
At this point , would be discharge with home dobutamine and
frequent and careful follow up by his primary cardiologist Dr.
Schafer
eScription document: 8-8046944 EMS
Dictated By: INNARELLI , DONNETTE
Attending: MANKOSKI , ROSSIE
Dictation ID 4966608
D: 10/30/03
T: 8/25/03
Document id: 811
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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847442317 | PUO | 82161933 | | 4851171 | 7/14/2005 12:00:00 a.m. | Atrial fibrilation | | DIS | Admission Date: 4/4/2005 Report Status:
Discharge Date: 10/3/2005
****** DISCHARGE ORDERS ******
ABO , RON P. 721-75-63-2
Gacoll Oaks
Service: CAR
DISCHARGE PATIENT ON: 11/29/05 AT 11:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PETTINGER , DOUGLASS N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
Override Notice: Override added on 9/13/05 by
FANIEL , GAYLENE G. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 17032720 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 200 MG orally every day
Override Notice: Override added on 9/13/05 by
FANIEL , GAYLENE G. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 17032720 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
KLONOPIN ( CLONAZEPAM ) 1 MG orally twice a day as needed Insomnia , Anxiety
COLCHICINE 0.3 MG orally every day
Override Notice: Override added on 9/13/05 by
FANIEL , GAYLENE G. , M.D. , PH.D.
on order for RAPAMYCIN orally ( ref # 29701624 )
POTENTIALLY SERIOUS INTERACTION: COLCHICINE & SIROLIMUS
POTENTIALLY SERIOUS INTERACTION: COLCHICINE & SIROLIMUS
Reason for override: aware - on as stable home med.
DOBUTAMINE HCL intravenous 2 mcg/kg/min in D5W continuous intravenous
HYDRALAZINE HCL 25 MG orally twice a day HOLD IF: SBP<80
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally twice a day
PREDNISONE 10 MG orally every day
ALDACTONE ( SPIRONOLACTONE ) 25 MG orally every day
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 9/13/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: patient requires
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting NOW ( 9/10 )
Instructions: WITHIN HOUR OF PHARMACY APPROVAL
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/13/05 by
FANIEL , GAYLENE G. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/13/05 by
FANIEL , GAYLENE G. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 17032720 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 9/13/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for ALDACTONE orally ( ref # 07373572 )
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: patient requires
TORSEMIDE 80 MG orally every day
Alert overridden: Override added on 9/13/05 by
COSE , LATASHIA C. , M.D. , M.B.A.
on order for TORSEMIDE orally ( ref # 76543121 )
patient has a POSSIBLE allergy to Sulfa; reaction is Rash.
Reason for override: patient tolerates
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 500 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
NIFEREX TABLET 150 MG orally twice a day
Number of Doses Required ( approximate ): 6
RAPAMYCIN ( SIROLIMUS ) 0.5 MG orally every day
Alert overridden: Override added on 9/13/05 by
FANIEL , GAYLENE G. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: COLCHICINE & SIROLIMUS
POTENTIALLY SERIOUS INTERACTION: COLCHICINE & SIROLIMUS
Reason for override: aware - on as stable home med.
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Please follow up with the PUO Heart Failure Service as scheduled ,
Arrange INR to be drawn on 4/16/05 with f/u INR's to be drawn every
4-7 days. INR's will be followed by PUO Anticoagulation clinic
ALLERGY: Sulfa , Penicillins , SUCCINYLCHOLINE CHLORIDE ,
intravenous Contrast , Morphine
ADMIT DIAGNOSIS:
Atrial fibrilation with RVR.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atrial fibrilation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of cardiac transplant htn obesity CRI
gout ( gout ) history of ccy ( history of cholecystectomy ) pulm amiodarone toxicity
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
anticoagulation , Management of CHF
BRIEF RESUME OF HOSPITAL COURSE:
HPI: The patient is a 33-year-old female with a history
of cardiac transplant and declining ventricular function is admitted
from Heart Failure Clinic after presenting for follow up eval and
noted to have new atrial fibrillation with VR of 130. Mrs. Abo is
known to the service and was recently discharged following a CHF
admission requiring intravenous diuresis and pressor support. She was
discharged on dobutamine 2mcg/kg/min and orally torsamide. In the
intervening period she has been feeling well. She has been quite
active. She has had no dizziness / lightheadedness. No syncope.
Denies any feeling of palpitations. Her weight has been
stable. ROS: No F/C/NS. Change in wt. + LE swelling. + SOB.
Decreased exercise tolerance. Orthopnea PND. No cough. No URI sx.
No change in bowel habits. No urgency , dysuria or frequency. No
nocturia. No arthralgias or
myalgias PMH:
1. Dilated cardiomyopathy status post cardiac transplant 1989.
2. Episode of rejection of her graft in 1995. 3. Deterioration of LV
function in 2000 4. On annual surveillance , 75% RCA lesion was noted on
prior cath and was subsequently stented. 5. Prior admission complicated
by esophagitis believed to be secondary to immediate-release potassium.
6. Chronic renal insufficiency with baseline creatinine of
1.5. 7. SVT. 8. Gout. 9. Amiodarone pulmonary toxicity.
10. Status post cholecystectomy.
MEDS: ( on D/C )
1. Aspirin 325 mg orally daily.
2. Allopurinol 200 mg orally daily.
3. Colchicine 0.3 mg daily.
4. Dobutamine intravenous drip 2 mcg/kg/min
5. Pepcid 20 mg orally daily.
6. Hydralazine 25 mg twice a day.
7. Isordil 40 mg twice daily.
8. Prednisone 10 mg every day before noon
9. K-Dur 20 mEq twice daily
10. Aldactone 25 mg orally daily.
11. Zocor 40 mg every bedtime
12. Torsemide 80 mg orally daily.
13. CellCept 500 mg orally twice a day.
14. Niferex tablets 150 mg orally twice daily.
15. Nexium 40 mg orally daily.
16. Tylenol 325-650 mg orally every 6 hours for pain as needed
17. Clonopin 1 mg orally twice a day as needed anxiety.
18. Rapamycin 0.5mg daily ALLERGIES: intravenous contrast - hives ( has
tolerated contrast when treated with Benadryl ) , penicillin - rash.
Sulfa - rash.
SOCIAL HISTORY: The patient is married and lives at home with her
husband and two children , 6 and 4 years of age. She denies tobacco
use. Denies ethanol use. FAMILY HISTORY: Mother has a history of
Crohn's disease.
EXAM: VS: T97 , P128 , BP120/20 , RR 18 , 98 O2Sat
RA Gen: patient in bed , Alert ,
NAD HEENT: Anicteric , PERRLA , EOMI , MMM , OP
Clear Neck: Supple , No LAD , JVP approx
10cm CV: Tachycardic , regular , Nml s1s2 , Prominent gallop
( difficult to termine s3 vs s4 given rate. Pulm: CTA with mild
decrease in BS at RLB Abd: Obese , Soft , NT/ND No HSM or mass
appreciated. + striea and
echymosis. Ext: No C/C , No Edema , DP pulses 2+
Bilat Neuro: Grossly
Nml. LABS:
Pending STUDIES:
EKG: AFIB with rate 138 , RBB and LAFB. 1/28/05 , echo showed an EF of
30% bilaterally decreased ventricular function and bilateral
atrial enlargement
with severe TR and MR , PIT estimated 11. 8/30/05 ,
exercise tolerance test ( dobutamine ) no EKG changes ,
baseline hypokinesis , no changes in wall motion abnormality.
10/10/05 , cardiac catheterization - left main , left circumflex , right
coronary artery without significant lesions. A 60% mid LAD lesion.
RA 22 , PCW 25 with V waves - 35.
IMPRESSION:
Mrs Abo is a 33 F history of cardiac transplant 1989 with allograft CAD
and declining ventricular function and on ionotropic support now with
new A Fib. Given tenuous function A Fib likely will be poorly
tolerated. PLAN:
1 )CV a. Isch - Cont. ASA , Statin , hydral and nitrate.
No evidence of active ischemia. b. Pump - Cont dobutamine at 2
MCG/KG/MIN. Cont orally torsamide c. Rhyth - On tele - with AF. Goal
to rate control , though underlying hypotention may be limiting. Will
start Heparin for anticoagulation with goal 50-70 PTT. EP consulted re:
rhythem control. Given past Amiodarone toxicity it is felt that
antiarhythmic therapy will likely not be of benifit. Will
anticoagulate and send out on coumadin. Will f/u with Dr. Fiermonte in
coumadin clinic.
2 ) Pulm - Will check CXR for pulm process as inciting cause. -> negative
3 ) Renal - Baseline CRI. Will follow closely
4 ) ID - No issues
5 ) Rheum - history of gout. Will cont allopurinol and Colchacine ( low dose )
6 ) GI - history of esophagitis. NO IR KCL. Cont pepcid and nexium.
7 ) Immune - Cont Cellcept , prednisone and rapamycin. Will check
rapa level give past high levels. Will start transplant eval while in
house.
8 ) Heme - Heparin for new Afib. Goal 50-70. Will start coumadin
and get to goal INR of 2.0 prior to d/c..
9 ) Endo - Will check TSH -> returned normal.
10 )Neuro/Psych - Cont clonapin 1 as needed
11 ) PPX - On heparin and PPI
12 ) FULL CODE
Discharged to home with services on dobutamine as before and on coumadin
for new PAF
ADDITIONAL COMMENTS: Please take all of your medications as prescribed. If there is a
discontinuation of you dobutamine for any reason please contact your
cardiologist immediately. You have been started on coumadin for your
atrial fibrilation. Blood draws to follow your INR will be
necessary. If you notice weight gain , increased lower extremity swelling
or increased SOB contact your cardiologist. If you have worsening
palpitations , chest pain , dizziness or lightheadedness please seek
medical attention.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
You will need blood draws starting 4/16/05 to measure your INR now that
you are taking coumadin. It is essential that the VNA service call in
the INR results to the PUO Anticoagulation Clinic at 132-202-5576.
Alternatively it can be faxed to 545-904-2410. You will be contacted
later in the same same day ( or following day if results obtained late )
with instructions for your coumadin dosing.
No dictated summary
ENTERED BY: FANIEL , GAYLENE G. , M.D. , PH.D. ( LG397 ) 11/29/05 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 812
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
135358408 | PUO | 11671436 | | 749781 | 2/10/2000 12:00:00 a.m. | DILATED CARDIOMYOPATHY | Signed | DIS | Admission Date: 5/30/2000 Report Status: Signed
Discharge Date: 1/20/2000
PRINCIPAL DIAGNOSIS: DILATION CARDIOMYOPATHY WITH HEART FAILURE.
SIGNIFICANT PROBLEMS:
1. FAMILIAL DILATED CARDIOMYOPATHY.
2. DIET CONTROLLED DIABETES MELLITUS.
3. HISTORY OF ACUTE PANCREATITIS.
4. HISTORY OF ATRIAL FIBRILLATION.
5. HEPATITIS B HISTORY.
6. PSORIASIS.
7. HISTORY OF ALCOHOLISM.
8. STATUS POST APPENDECTOMY.
9. STATUS POST OVARIAN CYSTECTOMY.
10. CHRONIC RENAL INSUFFICIENCY.
11. G V P VI.
HISTORY OF PRESENT ILLNESS: This 49 year old lady was admitted
with increasing shortness of breath
and increasing abdominal girth in a setting of known dilated
cardiomyopathy on the cardiac transplant list.
Her history extends back to 1995 when she was fist admitted with
shortness of breath and an ejection fraction of 15% with 3+ mitral
regurgitation in a setting of excessive alcohol use. Her
cardioangiogram at that time showed right dominant system without
coronary artery disease and her exercise stress test revealed a VO2
of 12.6. The presumptive diagnosis at that time was alcoholic
relation dilatation cardiomyopathy. In 11/18 she represented with
an ejection fraction of 20% with moderate mitral regurgitation and
left atrial enlargement and she was treated with digoxin , diuretics
and ace inhibitors. It subsequently was revealed that there was a
strong family history of dilated cardiomyopathy and , in fact ,
subsequently two of her sons , ages 13 years old , were diagnosed
with dilated cardiomyopathy and her diagnosis was therefore altered
from alcoholic to familial cardiomyopathy. In 10/22 she was
admitted with acute pancreatitis and developed acute renal failure
requiring intubation. Her stay was complicated by Staphylococcal
bacteremia. She recovered but presented again in 11/13 with a
history of progressive shortness of breath , dyspnea on exertion ,
orthopnea , PND and abdominal pain , nausea and vomiting and
anorexia. She required dobutamine and intravenous Lasix and had an episode
of nonsustained ventricular tachycardia. In 11/10 she presented
with syncope in the presence of a potassium of 2.4 and was
diagnosed with Torsades de Pointes in the setting of hypokalemia
and acute TC of 0.68. In 3/14 she represented with an ejection
fraction of 20% with a left ventricular hypokinesis to akinesis and
required intravenous diuresis. In 3/26 she had a laparoscopic
cholecystectomy for multiple gallstones. In 1/20 she was admitted
for cardiac transplant evaluation and found to a VO2 of 9.2 , a DLCL
of 62% predicted and she was negative for PPD. She was admitted in
9/18 for intravenous diuresis and potassium repletion , and again in 5/12
with abdominal distention and orthopnea. Pancreatitis was ruled
out at that stage and she was again treated with intravenous Lasix. She
represented on her last admission on 23 of September with congestive heart
failure requiring intravenous Lasix , Aldactone , Diuril and
Zaroxolyn , ultimately requiring dobutamine for inotropic support
for a short period of time.
On this admission she gives a history of two days of increased
shortness of breath with orthopnea and mild PND with diminished
exercise tolerance. She has been reluctant to combine torsemide
and her regular intravenous Lasix at home which was given to her by
the VNA and feeling increasingly shortness of breath she was taken
to the emergency department at Stusri Medical Center There she was
treated with 200 mg of intravenous Lasix and had a 1.2 liter diuresis , felt
better , and was transferred to this hospital for further evaluation
and management.
SOCIAL HISTORY: She is married with four children and she is
an ex-smoker for the last year , previously 10
cigarettes a day for life and previously a heavy drinker up to 1-2
liters of spirits per day.
FAMILY HISTORY: As above shows strong family history of dilated
cardiomyopathy , with her mother dying at the age
of 36 from a sudden cardiac death , her grandmother dying at the age
of 52 from what appears to have been cardiomyopathy , and two of her
brothers dying at the age of 32 and 42 with heart related problems.
Two of her sons as I mentioned were diagnosed with dilated
cardiomyopathy , one of whom remains quite unwell.
MEDICATIONS ON ADMISSION: Amiodarone 200 mg once a day; Diuril
500 mg once a day; digoxin 0.625 mg once
a day; Colace 100 mg twice a day; Aldactone 25 mg once a day;
Torsemide 100 mg in the morning , 15 mg in the p.m.; K-Dur 100 q.
a.m.
PHYSICAL EXAMINATION: GENERAL: Alert and oriented , in no
distress. She was comfortable. Evidence of
labored breathing. Her pulse was tachycardic at 103 with
respiratory rate of 20 and blood pressure of 84/58. Her
temperature was 98.2. She had diminished radial pulses
bilaterally. She had borderline proptosis with a jugular venous
distention at the angle of the jaw. She had no bruits and no
thyromegaly. She had a loud S3 and S4 with a dynamic precordium
and a displaced PMI with a quiet MR. She had a palpable S4. Her
respiratory examination showed her lungs were markedly clear to
percussion and auscultation without wheeze. Abdomen was mildly
distended without evidence of shifting dullness. Bowel sounds were
normal. She had an inverted umbilicus. She had no peripheral
edema and good peripheral pulses.
Chest x-ray showed a large globular heart without fluid in the
bases with mild upper lobe venous diversion. Electrocardiogram
showed normal sinus rhythm with a left axis and ventricular
conduction defect and left ventricular hypertrophy high voltage.
LABORATORY DATA: Sodium 140 , potassium 3.6 , white count 6.6 ,
hematocrit 37.9. Cardiac enzymes were normal. I
note her right catheterization results of 4/22/99 showed a mean
right atrial pressure of 12 , right ventricular pressure of 38/14 , a
mean pulmonary capillary wedge pressure of 21 with a cardiac index
of 2.88 , and a cardiac output of 4.93 and an SVO of 1022.
IMPRESSION: This was a 49 year old lady with dilated
cardiomyopathy , probably familial in nature , with
increased abdominal girth and shortness of breath , on the
transplant list , admitted for diuresis , plus or minus optimization
therapy.
HOSPITAL COURSE: She was initially treated with twice a day Lasix 200
mg intravenous and had an excellent diuresis on this
regimen. We increased her Aldactone to 50 mg once a day to try and
obtain better potassium control and eventually we added metolazone
at 2.5 mg in the morning. During her admission she had a very
significant improvement with negative diuresis of almost 2 liters
every day for the past 3 days. She had a cortisol stimulation
tests which revealed normal synthetic adrenal function and she had
a normal TSH. She required extensive potassium repletion during
her stay and she is discharged on 120 total of K-Dur per day.
During her hospital stay her glucoses were over 250 for a short
period of time and it was felt that it was probably appropriate to
start her on orally hypoglycemics. However in the setting of
changing her diuretic medications and a hospital diet , this was
considered this could be delayed until her next outpatient visit
with Dr. Gasaway
DISCHARGE MEDICATIONS: Colace 100 mg twice a day; amiodarone 200 mg
every day; digoxin 0.0625 mg every day; M.V.I.
therapeutic 1 tablet every day; K-Dur 14 mEq three times a day; Aldactone 50 mg
every day; Torsemide 100 mg twice a day; Zaroxolyn 2.5 mg every o.d.; Coumadin 5
mg every bedtime
CONDITION UPON DISCHARGE: Stable.
DISPOSITION: To home with VNA for Coumadin , potassium checks and
intravenous 200 mg of Lasix as needed
FOLLOWUP: She will follow up with Dr. Board next Wednesday and
she will have her potassium checked tomorrow in the VH
laboratory , result of which will be forwarded to Dr. Board and any
necessary change to her K-Dur therapy will be managed therefrom.
Dictated By: CASSANDRA ASAKURA , M.D. VS61
Attending: SUNSHINE D. RAABE , M.D. HR28
EG508/7371
Batch: 12928 Index No. NYHU9K2ABG D: 9/8
T: 8/28
CC: 1. GAYLENE G. FANIEL , M.D. LU3
2. SUNSHINE D. RAABE , M.D. HR28
3. MEDICAL RECORD DEPT STUSRI MEDICAL CENTER
Document id: 813
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
N |
Y |
N |
785782309 | PUO | 70951924 | | 1528076 | 6/26/2003 12:00:00 a.m. | CHF | | DIS | Admission Date: 4/23/2003 Report Status:
Discharge Date: 1/26/2003
****** DISCHARGE ORDERS ******
VERGES , BENTON D HERIBERTO 506-16-04-7
Ba
Service: CAR
DISCHARGE PATIENT ON: 10/7/03 AT 11:00 a.m.
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KUSH , QUINN JAKE , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
DIGOXIN 0.125 MG orally every day
LISINOPRIL 10 MG every day before noon; 5 MG every afternoon orally 10 MG every day before noon 5 MG every afternoon
Override Notice: Override added on 4/3/03 by EBERLIN , AMAL M. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
96268242 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
PROSCAR ( FINASTERIDE ) 5 MG orally every day
Number of Doses Required ( approximate ): 8
BISOPROLOL FUMARATE 2.5 MG orally every day HOLD IF: SBP<90; HR<55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
HUMALOG ( INSULIN LISPRO ) 0 CFU subcutaneously before meals
Instructions: please use scale for fsbg 120-130 2u;
130-140 3u; 140-150 4u; 150-160 5u;160-170 6u; 170-180 7u;
180-190 8u; 190-200 10u; 200-210 12u; 210-220 13u;
220-230 14u; >230 15u and page HO
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
LANTUS ( INSULIN GLARGINE ) 40 UNITS subcutaneously every bedtime
Starting Today ( 10/5 )
WELCHOL ( COLESEVELAM ) 2 TAB orally three times a day
Number of Doses Required ( approximate ): 12
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 8/23/03 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
Instructions: This dose will be adjusted by Dr. Kush as an
outpatient.
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Kush - he will schedule 1-2 weeks ,
Arrange INR to be drawn on 11/4/03 with f/u INR's to be drawn every
3 days. INR's will be followed by Kush
ALLERGY: Iv contrast dyes
ADMIT DIAGNOSIS:
cad
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) hypertension ( hypertension ) cad
( coronary artery disease ) mi ( myocardial
infarction ) cabg ( cardiac bypass graft surgery ) pvd ( peripheral
vascular disease ) femoral ( femoral popliteal
bypass ) hypercholesterol ( elevated cholesterol ) afib ( atrial
fibrillation ) chf ( congestive heart failure )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
left heart catheterization
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old man with CAD ( history of CABGx2 , PCI in 8/17 ) , PVD ,
IDDM , afib , htn admitted for catheterization after abnl
dobutamine-MRI. Admitted in 8/17 with symptoms of angina and dyspnea
on exertion , cardiac MRI showed ischemia and patient underwent
cath with LMCA and SBG to RtPDA stented. On discharge
no longer had angina but increased
pulmonary congestion and cough. Moderate improvement
with increased lasix. On 6/5/03 had
elective dobutamine-MRI which led to angina and
reversible ischemia in RCA/LCx territory. Plan was to
cath but elevated INR and rhonchorous. Admit to
diurese and reverse
anticoagulation. Exam: rhonchi throughout both
lung fields , bilateral carotid bruits ,
S1+S2+S3 ( visible +
audible ) , protuberant abdomen , left femoral bruit ,
faint left dp pulse; nonpalpable r dp pulse.
Ext lukewarm.
*****************************************
Ischemic heart disease. We continued ASA , bb , wellchol , ace. Held
coumadin prior to LHC as supratherapeutic ( afib ); gave 1mg vit K.
Catheterization revealed no change from prior with patent LM stent and
stent within SVG to PLV graft. Concluded that symptoms likely due to
CHF. Will have future stress-imaging study to correlate.
CHF: Diuresed with home lasix + lasix intravenous. PCWP 26 suggesting increasing
diuretic regimen advisable. Rhonchi decreased considerably with
diuresis.
DM: A humalog scale +lantus combination was used effectively for
glycemic control.
ADDITIONAL COMMENTS: Please contact primary care physician if shortness of breath , weight gain >3lb , chest
pain. Monitor your diet to avoid salty foods and too much fluid.
Please work with your doctor to develop ideal diuretic regimen.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Adjust diuretic and cardiac regimen as outpatient per primary
cardiologist ( Kush ).
No dictated summary
ENTERED BY: ITSON , YOLANDE LOISE , M.D. ( RT19 ) 10/7/03 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 814
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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918345620 | PUO | 81370631 | | 4738000 | 3/1/2004 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 3/1/2004 Report Status: Signed
Discharge Date: 8/29/2005
ATTENDING: GERARD MUHLSTEIN MD
SERVICE:
General Medical Service Vi Ster Nas
ADMISSION DIAGNOSIS:
Pneumonia.
DISCHARGE DIAGNOSIS:
Pneumonia associated with PICC line bacteremia.
CHIEF COMPLAINT:
Diaphoresis and shortness of breath.
HISTORY OF PRESENT ILLNESS:
Mr. Rude is a 68-year-old gentleman with known coronary artery
disease status post 2-vessel coronary artery bypass grafting in
5/4 , hypertension , atrial fibrillation status post
cardioversion on Coumadin , hypercholesterolemia , aortic stenosis ,
status post aortic valve replacement with bioprosthetic valve ,
diabetes mellitus , cervical stenosis , as well as a recent
admission to the Pagham University Of for bilateral
brachial plexopathy of unknown etiology , who is receiving three
weeks of intravenous cefotaxime as empiric Lyme treatment as a
possible cause for his plexopathy , who presents with shortness of
breath. While at the Wanor Troitreal Community Hospital , the
patient developed shortness of breath one-and-a-half day prior to
admission. This was associated with significant diaphoresis and
fevers intermittently for four days prior to admission. Of note ,
the patient denied any dysuria , cough , sinus pain , diarrhea , ear
pain , pleuritic chest pain , calf pain , paroxysmal nocturnal
dyspnea , or orthopnea. The patient was taken to the emergency
department where a chest x-ray demonstrated a new right upper
lobe pneumonia. The patient was treated with levofloxacin in the
emergency department and admitted to the inpatient medical
service.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post 2-vessel coronary artery
bypass grafting in 4/5
2. Hypertension.
3. Atrial fibrillation status post cardioversion on Coumadin.
4. Hypercholesterolemia.
5. Aortic stenosis , status post aortic valve replacement
( bioprosthesis ).
6. Diabetes mellitus.
7. Bilateral brachial plexopathy of unknown etiology , but
attributed to Lyme disease. The patient was being treated four
with three weeks of intravenous cefotaxime. This brachial plexopathy had
improved to the point where the patient was able to lift his arms
and do his own ADLs. When he first presented with this
condition , the patient had a near complete paralysis of his motor
function in his upper extremities without loss of his sensory
function , per report.
8. Cervical stenosis and foraminal stenosis , as well as
congestive heart failure with an ejection fraction of 45%.
ALLERGIES: No known drug allergies.
MEDICATIONS: Metformin 1000 mg orally every day before noon and 500 mg orally
every afternoon , simvastatin 5 mg orally every Monday , Wednesday , and Friday ,
Neurontin 300 mg twice a day , which had been tapered down to 300 mg
every day , and then plan for discontinuation , Nexium 20 mg orally
twice a day , Colace 100 mg orally twice a day , aspirin 81 mg orally twice a day ,
amiodarone 200 mg orally every day , Atenolol 50 mg orally every day , Senna ,
Coumadin 5 mg orally every day , methadone 5 mg orally as needed pain , and
regular insulin sliding scale , and cefotaxime 2 g intravenous injections
three times a day ( final dose on the day of admission ).
SOCIAL HISTORY: Resident at the Longro Ana Dara for the past three
weeks. He is married. Tobacco history , one-and-a-half packs per
day , smoking x40 years but has quit. No alcohol use. Over the
past seven years.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Upon admission , afebrile , pulse 80s , blood
pressure 126/72 , and oxygen saturation 96% on 2 liters. General
appearance: Not acutely in distress , talking in full sentences ,
ruddy appearing in the face , but stable per the patient. Head
and neck exam revealed pupils that were equally round and
reactive to light. Extraocular movements were intact. No sinus
tenderness. JVP was around 9 cm , no lymphadenopathy.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2 , 2/6
systolic ejection murmur at the upper sternal border. Chest
exam: Bibasilar crackles and right-sided bronchial breath sounds
and question focal wheeze. Abdomen: Soft , nontender , and
nondistended. Bowel sounds are present. Extremities: No edema.
Warm and well perfused.
LABORATORY DATA:
Admission laboratory values included a Chem-7 within normal
limits with a creatinine of 0.8 and glucose of 181. White blood
cell count of 9.8 , hematocrit of 33.6 , and platelets of 222 with
a differential of 88% neutrophils. Liver function tests are
significant AST of 45 , ALT of 65 , alkaline phosphatase 153 , and
total bilirubin 0.5 , yet these liver function tests quickly
corrected the next morning of an AST of 21 , ALT of 47 , alkaline
phosphatase 123 , total bilirubin 0.5 , CK of 31 , CK-MB of 1.7 ,
troponin of less than assay , and amylase of 23. Chest x-ray
showing a right upper lobe wedge-shaped infiltrate , mild
cardiomegaly , and mild pulmonary edema. Electrocardiogram was
consistent with an old EKG from 2004 , normal sinus rhythm at 82 ,
now with slightly increased widening of the QRS complex in a left
bundle-branch block pattern , hyperacute T waves in V4 and V3.
IMPRESSION:
A 68-year-old gentleman with multiple medical problems and
bilateral brachial plexopathy of unclear etiology , now improving ,
who presents with new right upper lobe infiltrate in the presence
of having an indwelling PICC line in place for intravenous antibiotics
over the past three weeks as well as a bioprosthetic valve.
HOSPITAL COURSE BY SYSTEM:
1. Infectious disease: The patient was admitted for likely
hospital-acquired pneumonia given his long hospitalization and
rehabilitation stays recently. The patient was pancultured. The
PICC line was discontinued and the tip was cultured. The patient
was covered broadly initially with vancomycin , as well as
ceftazidime. On further review of the culture data during the
hospital course , the patient began to grow coagulase-negative
Staphylococcus that was resistant to methicillin from both the
PICC line culture , as well his blood cultures from 11/10/05. His
chest CT was significant for an extensive area of ground glass
opacity in the right upper lobe with smaller areas in other
lobes. Bilateral mediastinal adenopathy was noted. Infection
was thought to be the most likely diagnosis in view of the
rapidity of the chest film changes. Other possibilities included
bronchoalveolar cell carcinoma or lymphoma per the radiologic
read , but was not consistent with the clinical presentation. Per
infectious disease consultation , the pneumonia could be
attributed to the MRSE PICC line bacteremia with secondary
seating. A subsequent transthoracic echocardiogram revealed an
ejection fraction of 55%-60% , but with abnormal paradoxical
motion consistent with his postoperative status after aortic
valve replacement. The entire anterior wall was hypokinetic.
The right ventricular systolic function appeared to be normal.
The left atrial size was mildly dilated at 4.6 cm. The aortic
valve appeared to be normal functioning with trace aortic
regurgitation. Other valvular function appeared to be within
normal limits with exception of moderate-to-severe tricuspid
regurgitation and peak systolic pulmonary artery pressures of 31
mmHg plus right atrial pressure. No pericardial effusion was
seen and no evidence of endocarditis was observed. On follow up
chest x-rays throughout the hospital course , the patient's
infiltrate resolved with a chest x-ray on 5/11/05 showing clear
lungs and only prior cardiac surgery evident without worsening or
continued presence of the right upper lobe infiltrate. A new
PICC line was placed per infectious disease service
recommendations for continued intravenous treatment with
vancomycin for 7 to 10 days starting 48 hours after the last
blood culture was negative. Therefore , the last dose of his intravenous
antibiotics should be given on 2/18/05. To cover other
gram-negative sources for his pneumonia , the Infectious Disease
Service also suggested continuing and ceftazidime treatment as
well. Therefore , the patient will be discharged on both
intravenous vancomycin as well as intravenous ceftazidime
treatment. Because of the patient's inability to pay for the
visiting nurses to administer intravenous antibiotics at home , the patient
will be discharged to a rehabilitation center.
2. Cardiovascular:
Ischemia: Given the patient's history of diabetes and shortness
of breath , the patient was ruled out for myocardial infarction
with three negative cardiac enzymes. The patient was continued
on his anti-ischemic regimen including aspirin , statin , as well
as beta blockade. In the future , the patient should be
transitioned back to once a day dosing of beta blockade as an
outpatient.
Pump: The patient initially presented in mild volume overload.
The patient was maintained on his home dosing of Lasix with good
volume response. By the end of his hospitalization , the patient
was not requiring any oxygen supplementally and was discharged
with euvolemia.
Rhythm: The patient was admitted initially in normal sinus
rhythm status post cardioversion for atrial fibrillation. He
remained on Coumadin. He was placed on telemetry given some
increased widened intervals of his QRS complexes. Early in the
course of his hospitalization , the patient converted back to
atrial fibrillation. His rate was controlled with beta blockade.
The Na Memorial Hospital was asked to comment. The patient
was maintained on both beta blockade as well as digoxin. He also
continued on anticoagulation with Coumadin. Interestingly , the
Cardiovascular Service suggested that possibly some ground-glass
opacities on the patient's chest CT could be attributed to
amiodarone lung toxicity. Because of this finding , it was
recommended that the patient stop the amiodarone , which was
indeed discontinued through this hospitalization. He should
follow up with his cardiovascular group as an outpatient to
determine further course of treatment for his atrial
fibrillation.
Anticoagulation: The patient will continue to be treated with
Coumadin for goal INR between 2 to 3. By the end of this
hospitalization , the patient's INR was 1.7 on a dose of Coumadin
7 mg orally every bedtime That dose was increased to 7.5 mg orally every bedtime
The patient should have his INR checked within two days after
discharge and have his Coumadin dose changed appropriately.
3. Neurologic: The patient was admitted on a previous
hospitalization with a history of bilateral brachioplexopathy.
It had been attributed to possible line infection given a history
of a tick bite. He was treated empirically with three weeks of
intravenous cefotaxime with moderate improvement of motor function while
at rehabilitation. Interestingly , upon further review of Lyme
disease workup , the patient apparently had a negative serology
for Treponema pallidum IgG. Confirmatory tests , which included a
Lyme disease titer was still marked as pending in our computer
system at the Pagham University Of . Despite multiple
attempts to try to contact the laboratory , which runs this
particular tests , we were unable to confirm or deny the presence
of past Lyme infection. Therefore , at this time , we can only
state that his bilateral brachioplexopathy was secondary to an
unknown and unclear etiology. Fortunately , with physical therapy
and with time and possibly with infusion of the intravenous cefotaxime ,
the patient's motor function has improved. At the time of this
discharge , the patient's overall upper extremity motor strength
was 4+/5 symmetrically. The patient should follow up very
closely with his primary care physician as well as his
neurologist in one month. At that time , his neurologist should
confirm or negate the possibility that the patient's neurologic
symptoms may have been caused by Lyme disease. The patient
should continue physical therapy at rehabilitation and as an
outpatient. In addition , the patient should continue his
Neurontin taper. He currently is on 100 mg orally three times a day and
should be tapered to nothing by the end of his hospitalization
and rehabilitation. He will continue on methadone for his
chronic pain. In addition , he suffers from significant anxiety.
He will be discharged on as needed Ativan at low-dose , as higher
doses tend to make him sleepier and oversedated.
4. Endocrine: The patient was admitted with diabetes mellitus.
He was initially admitted with taking metformin 1000 mg orally
every day before noon and 500 mg orally every bedtime Because of his hospitalization and
multiple studies , this was discontinued transiently and he was
placed on a regular insulin sliding scale. At the end of this
hospitalization , he will be placed back on those home doses of
metformin. In addition , he will continue his ACE inhibitor for
his diabetes , as well as for his significant cardiac disease.
5. Pulmonary: Much of his pulmonary process can be attributed
to his pneumonia as treated in the statements above. In
addition , he will continue on as needed Atrovent and albuterol
nebulizer treatment for possible wheezing during his
hospitalization. In addition , it is hoped that the Ativan as needed
dosing also contribute to less subjective shortness of breath
secondary to alleviation of his anxiety.
6. Gastrointestinal: The patient , periodically , throughout his
hospitalization complained of mild epigastric pain. A KUB showed
no perforation and no obvious obstruction , but with many loops of
bowel with stool. He was placed on a bowel regimen including
Colace , senna , and Dulcolax as needed By the end of this
hospitalization , he appeared to be less symptomatic. In
addition , he will continue his trial of simethicone as needed for
abdominal gas and bloating. He will continue on his proton pump
inhibitor , Nexium 40 mg orally every day
CODE STATUS:
He remains full code throughout his hospitalization.
DISPOSITION:
The patient will be discharged to rehabilitation where he will
continue intravenous antibiotic support for until 2/18/05. He should
also continue physical therapy for his upper extremity motor
dysfunction. He should follow up with his primary care physician
as well as his neurologist as stated in his discharge summary.
DISCHARGE MEDICATIONS:
Include Tylenol 650 mg orally every 4 hours as needed headache , aspirin 325 mg
orally every day , albuterol nebulizer treatment 2.5 mg nebulizer
treatment every 4 hours as needed shortness of breath or wheeze , Dulcolax 5
mg orally every day as needed constipation , ceftazidime 1000 mg intravenous every 8 hours ,
to continue until 1/28/05 , digoxin 0.125 mg orally every day , Colace
100 mg orally twice a day , Lasix 40 mg orally every day , Robitussin every 4 hours
as needed cough , Regular Insulin sliding scale before every meal and every bedtime ,
lisinopril 5 mg orally every day , Ativan 0.25 mg to 0.5 mg orally every 8 hours
as needed insomnia or anxiety , hold if respiration rate is less than
8 or somnolent , methadone 5 mg orally every 8 hours as needed pain; hold if
oversedated or respiration rate less than 8 , Lopressor 50 mg orally
three times a day; hold if heart rate is less than 55 or systolic blood
pressure less than 100 , senna two tabs orally twice a day; hold for
loose stools , simethicone 80 mg orally four times a day as needed gas bloating
or abdominal discomfort , trazodone 25 mg orally every bedtime as needed
insomnia , vancomycin 1000 mg intravenous every 12 hours; last doses on 1/28/05 ,
Coumadin 7.5 mg orally every afternoon; please draw INR within the next one
to two days and dose the Coumadin appropriately for INR goal 2 to
3 , simvastatin 5 mg orally every other day , Neurontin 100 mg orally three times a day;
please continue to wean until completely off , Nexium 40 mg orally
every day , Atrovent nebulizer treatment 0.5 mg nebulizer treatment
every 6 hours hour as needed shortness of breath or wheeze , and metformin
1000 mg every day before noon and 500 mg every afternoon
eScription document: 8-1384317 EMSSten Tel
Dictated By: GELLINGER , WAYLON
Attending: MUHLSTEIN , GERARD
Dictation ID 7059631
D: 5/2/05
T: 5/2/05
Document id: 815
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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834899235 | PUO | 99686864 | | 037230 | 2/8/2000 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 6/15/2000 Report Status: Signed
Discharge Date: 10/6/2000
SERVICE: CARDIAC SURGERY.
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
BRIEF HISTORY: This patient is a 57-year-old black male with a
history of hypertension and coronary artery disease
admitted 25 of May with episodes of chest pain. In July 1993 ,
the patient presented with a lateral wall myocardial infarction and
was treated with angioplasty of the ramus branch. His course was
complicated by severe hypertension and pulmonary edema. Preserved
left ventricular function with mitral regurgitation were noted. He
presented again in October 1996 with recurrent pulmonary edema in
the setting of non-compliance and extreme hypertension. The
cardiac catheterization was remarkable for a 70% occlusion of the
mid-left anterior descending artery , an 80% of the diagonal 1 , an
occluded ramus , a 70% of the obtuse marginal 1 , diffuse disease of
the right coronary artery with a 70% at the posterior descending
origin , moderate mitral regurgitation , and preserved ejection
fraction. A coronary artery bypass graft was recommended but
refused at the time , and the patient was treated medically. In the
interval , the patient has had intermittent compliance with
medications. Over the last month , he has had calf claudication at
two to three city blocks , sometimes followed by chest pain. He
presented to the Emergency Room on May , 2000 , and on the
standard Bruce exercise tolerance test , went 5.9 and stopped with
right leg pain and chest pain. The EKG showed ST elevations in
leads V1-4. The patient was given aspirin and nitroglycerin. He
refused admission and further work-up. He again presented
25 of May after a walk in the park and incidentally noted markedly
elevated blood pressure , followed by chest pain. He came to the
Emergency Room. He had not taken his medications that morning.
MEDICATIONS ON ADMISSION: The home medications included
lisinopril , Lipitor , Imdur , labetalol ,
and aspirin.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Sleep apnea , CPAP-intolerant; hypertension.
SOCIAL HISTORY: Alcohol abuse. He has used one-half to one
pack per day of tobacco since age 18. No alcohol
for the last ten years. The patient is married with grown
children. He is on disability.
PHYSICAL EXAMINATION: On physical examination , the patient is a
middle-aged black male in no acute distress. The blood pressure is
128/88 in the right arm , 126/76 in the left arm , the pulse 80 with
low upstrokes , brisk , without bruits. The oropharynx is clear.
The thyroid is not palpable. The lungs are clear. An S4 is heard
as well as a faint systolic murmur at the apex. The abdomen is
unremarkable without bruit. There is a 1+ right femoral pulse with
a bruit. The left femoral pulse is 2+. The distal pulses are
normal on the left and diminished on the right. There is no edema.
HOSPITAL COURSE: A coronary catheterization 29 of April showed
left ventricular anterior basilar hypokinesis and
1+ mitral regurgitation. The left main coronary artery was okay.
The left anterior descending showed serial proximal 90% and 80%
stenoses. The circumflex obtuse marginal 1 showed a mid-70% and
distal 80%. The right coronary artery showed a mid-99% and a
distal serial 80%-70%. A renal angiogram showed a right femoral
artery stenosis at 4-5 cm proximal to the femoral head.
On 21 of January , the patient had an operative procedure , a
three-vessel coronary artery bypass graft using the left internal
mammary artery and saphenous vein grafts. The patient was
transferred to the Intensive Care Unit on Burglewest Mont A He was then
transferred to the Step-Down Unit on postoperative day 1. A
Vascular Surgery consultation was obtained for the right femoral
artery stenosis. Chest tubes and pacing wires were removed on
postoperative day 3. Laboratory studies on 26 of April included a
sodium of 141 , a potassium of 4.1 , a chloride of 104 , a bicarbonate
of 26 , a BUN of 15 , a creatinine of 0.8 , platelets of 114 , 000 , a
magnesium of 1.9 , a white count of 7 , 400 , an hematocrit of 40.3 ,
platelets of 206 , 000 , an INR of 0.8 , and a prothrombin time of
11.0.
DISCHARGE MEDICATIONS: The patient will go home on the following
medications: enteric-coated aspirin 325 mg
orally every day , Captopril 6.25 mg orally three times a day , Colace 100 mg orally
twice a day , Lasix 20 mg orally twice a day for three days , Glyburide 5 mg orally
every day , ibuprofen 600 mg orally every 6 hours , Lopressor 50 mg orally three times a day ,
Prilosec 20 mg orally every day , Percocet one to two tablets orally every 4 hours
as needed pain , atorvastatin 20 mg orally every day , and Atrovent inhaler two
puffs inhaled four times a day
FOLLOW-UP: The patient will follow up with Vascular Surgery in
four weeks ( Dr. Reedy ); with Cardiac Surgery ( Dr.
Huitron ) in six weeks; and with Cardiology ( Dr. Raabe ) in one to two
weeks.
Dictated By: BATHRICK , SHERELL K.
Attending: GAYLENE G. FANIEL , M.D. HK34
DZ323/0792
Batch: 39879 Index No. PRKH192456 D: 1/30
T: 6/24
Document id: 816
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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335530998 | PUO | 01416153 | | 6723652 | 1/13/2004 12:00:00 a.m. | Congestive Heart Failure | | DIS | Admission Date: 4/25/2004 Report Status:
Discharge Date: 10/7/2004
****** DISCHARGE ORDERS ******
FLOW , SANORA K 099-46-77-9
Down
Service: MED
DISCHARGE PATIENT ON: 5/24/04 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
Override Notice: Override added on 5/24/04 by
HEIT , JANE , M.D.
on order for COUMADIN orally ( ref # 72146538 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware , will follow. patient has tolerated
this regimen
DIGOXIN 0.125 MG orally every day
Override Notice: Override added on 5/24/04 by
HEIT , JANE , M.D.
on order for SYNTHROID orally ( ref # 51893275 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: aware. will follow
ENALAPRIL MALEATE 20 MG orally every day before noon
LASIX ( FUROSEMIDE ) 80 MG orally every day before noon
Alert overridden: Override added on 9/9/04 by
HEIT , JANE , M.D.
on order for LASIX orally ( ref # 16819140 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
patient has a POSSIBLE allergy to
TRIMETHOPRIM/SULFAMETHOXAZOLE; reaction is Unknown.
Reason for override: patient has already tolerated med
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
Alert overridden: Override added on 5/24/04 by
HEIT , JANE , M.D.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: aware. will follow
COUMADIN ( WARFARIN SODIUM ) 6 MG orally x1
Starting ON 3/5/04 ( 8/25 ) Instructions: ON IN EVENING OF
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 5/24/04 by
HEIT , JANE , M.D.
on order for SYNTHROID orally ( ref # 51893275 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware. will follow
Previous override information:
Override added on 5/24/04 by HEIT , JANE , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware , will follow. patient has tolerated
this regimen
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
NEURONTIN ( GABAPENTIN ) 200 MG orally every afternoon
LISPRO ( INSULIN LISPRO )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LANTUS ( INSULIN GLARGINE ) 77 UNITS subcutaneously every day before noon
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 8/25 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/24/04 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: md aware. patient is closely monitored.
DIET: House / 2 gm Na / ADA 1800 cals/day / Low saturated fat
low cholesterol
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please Call your nurse to set up INR check on monday. 11/21/04 ,
Your primary care doctor. Please call to schedule 1-2 weeks ,
Arrange INR to be drawn on 1/2/04 with f/u INR's to be drawn every
3 days. INR's will be followed by LMC CHF/ Cards nurse
ALLERGY: Penicillins , Cephalosporins , Sulfa ,
TRIMETHOPRIM/SULFAMETHOXAZOLE , TRIMETHOPRIM , Codeine
ADMIT DIAGNOSIS:
Congestive Heart Failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive Heart Failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) diastolic dysfunction hypothyroidism
( hypothyroidism ) obesity ( obesity ) cri ( chronic renal
dysfunction ) diabetes ( Type 2 diabetes ) cad ( coronary artery
disease ) history of cabg x4 ( history of cardiac bypass graft surgery )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Gentle diuresis
maximization of medications
BRIEF RESUME OF HOSPITAL COURSE:
CC: Increasing DOE
HPI: 81 year-old F with history of CHF/CAD history of CABG , with worsening dyspnea on
exertion since past 2-3 days. patient notes weight inc to 157 , and dropped
to 147 with augmented diuresis. patient target weight =152-154. patient notes no
change in baseline orthopnea , but does note increasing LEE an
periorbital edema. patient has fatigue even with minimal exertion , like
going to bathroom. patient had an episode of unstable AF with CHF lat
month and was managed as an outpt with med adjustment. PMH:Afib , CHF ,
CAD , DM type I , hearing loss , hypothyroidism , osteoporoisis ,
perihperal neuropathy. PSH: history of CABG.
A: Mild CHF , here for treatment maximization.
HOSPITAL COURSE BY SYSTEM
CV:ischemia- ruled out for MI with serial enzymes. cont ACEI ,
Betablocker. Lipid
panel wnl. Pump-daily weights , lasix for gentle diuresis of goal 500c-
1L net negative. Rhythm: afib/Aflutter , rate control with BBlocker
Renal:CRI , cr at baseline. Normal , renal dose meds FEN: follow
lytes/K/Mg. Diet-low fat/chol. Fluid restriction to 2
L/day. Endo: Hypothyroid- levoxyl , checked TSH , pending at time of disc
harge. DMtypeI- lantus 77u every day before noon , lispro subcutaneously Heme: Daily physical therapy/PTT- low
INR. Increased coumadin dose with outpt follow-up. patient returned home in
improved condition , and has a
slight change in outpatient medication regimen- namely Toprol XL incre
ased to 25mg twice a day , digoxin 0.125 mg every day.
ADDITIONAL COMMENTS: If you notice rapid weight gain , increasing shortness of breath , chest
pain , light headedness , extreme fatigue , or any other symptom
concerning to you , please immediately alert your MD or present to the
nearest ED.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
TSH pending ,
Check INR on monday 10/29/04.
No dictated summary
ENTERED BY: KUHLS , GREGORY T. , M.D. ( UC57 ) 5/24/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 817
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| output/system_textual_annotation.xml | textual |
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490615097 | PUO | 67095171 | | 8069078 | 10/6/2007 12:00:00 a.m. | ABDOMINAL PAIN; RENAL FAILURE , PULIMONARY EDEMA | Signed | DIS | Admission Date: 10/19/2007 Report Status: Signed
Discharge Date: 1/18/2007
ATTENDING: ISA , KAM MD
ADMISSION DIAGNOSIS: Abdominal pain.
DISCHARGE DIAGNOSIS: Pneumonia.
HISTORY OF PRESENT ILLNESS: An 86-year-old female with past
medical history significant for atrial fibrillation , diastolic
CHF , rheumatic heart disease status post mitral valve
replacement and tricuspid repair , chronic renal insufficiency , prior small-bowel
obstruction and GI bleeding who presented with abdominal pain.
The patient reports sudden onset of abdominal pain approximately
one day prior to admission , which became progressively worse.
The patient was noted to have nausea and vomiting at home with
green/yellow fluid. The patient was suspected to have an
aspiration event per the patient's daughter. The patient denies
fever or chills. Denies dysuria. Denies shortness of breath or
cough. No recent antibiotics. No sick contacts.
EMERGENCY DEPARTMENT COURSE: Temperature 97.5 , heart rate 74 ,
blood pressure 183/65 improved to 128/56 , respiratory rate 16 ,
oxygen saturation 96% on room air , subsequently decreased to 92%
on room air and improved to 96% on 2 L nasal cannula. On exam ,
patient was noted to have positive jugular venous distension , 3/6
systolic murmur at the left upper sternal border , right lower
quadrant tenderness to palpation , abdomen soft and without
rebound tenderness. A chest x-ray was performed and a right
lower lobe infiltrate and moderate pulmonary edema was noted. A
KUB was also performed , which did not show any evidence of
obstruction. An abdominal CT demonstrated mild diffuse small
bowel thickening concerning for infection versus ischemia. The
patient was given ceftriaxone , azithromycin and Flagyl intravenous as well
as Lasix 40 mg intravenous x1.
PAST MEDICAL HISTORY: Hypertension , atrial fibrillation on
Coumadin , rheumatic heart disease status post bioprosthetic
mitral valve replacement and tricuspid valve repair ( 2000 ) , mild
aortic stenosis , diastolic heart failure , chronic renal
insufficiency with baseline creatinine=2.6 , history of
small-bowel obstruction , history of GI bleed. ( Totin Hospital And Clinic admission in 7/8 with capsule study demonstrating small
bowel lymphangiectasias and angiectasis , colonoscopy
demonstrating sessile polyps and diverticulitis , questionable
history of mesenteric ischemia , status post right total hip
replacement , status post CVA at age 55 , no history of MI.
ADMISSION MEDICATIONS:
1. Renagel one tablet with dinner.
2. Diovan 120 mg daily.
3. Procrit 5000 units subcutaneous every week.
4. Norvasc 5 mg every day before noon
5. Norvasc 2.5 mg every afternoon
6. Imdur 30 mg twice daily.
7. NovoLog 4/4/5 plus sliding scale insulin.
8. Lantus 8 units nightly.
9. Nexium 40 mg twice daily.
10. Coumadin 4 mg orally every afternoon
11. Caltrate plus D one tab twice daily.
12. Iron sulfate 325 mg twice daily.
13. Lasix 80 mg orally every day before noon plus 40 mg orally every afternoon
ALLERGIES: Codeine and Benadryl.
ADMISSION PHYSICAL EXAMINATION: Temperature 96.6 , heart rate 62 ,
blood pressure 108/60 , respiratory rate 20 and oxygen saturation
95% on 2 l. Chest with bilateral dullness and right basilar
rales. Positive egophony at right base. Heart with regular rate
and rhythm , and a 3/6 systolic mid peaking murmur at left upper
sternal border heard throughout. Normal S1 and S2. Abdomen is
soft , nontender and nondistended. Positive bowel sounds. Guaiac
negative.
ADMISSION LABORATORY DATA: Sodium 141 , potassium 4.5 , chloride
101 , bicarbonate 25 , BUN 111 , creatinine 2.7 and glucose 206.
WBC 6.29 , hematocrit 37.7 ( 38.5 at last check ) , platelets
260 , 000 , INR 2.8. LFTs normal , amylase 80 , lipase 18 , total
bilirubin 0.8 , albumin 3.7 , lactate 1.7. Urinalysis 1+ protein ,
WBC 2 , RBC 0.
STUDIES:
1. Chest x-ray ( 2/12/07 ): Cardiomegaly , mediastinal wires ,
positive cephalization and Kerley B lines consistent with
moderate pulmonary edema , right lower lobe opacification.
2. KUB ( 2/12/07 ): Nonspecific gas pattern without evidence of
obstruction or free air. Calcified aorta and iliac.
3. CT abdomen ( 1/14/070 : 1bilateral infiltrates consistent
with pneumonia , questionable mild diffuse small-bowel thickening ,
no appendicitis , no obstruction , no perforation , positive
gallstones , positive gallbladder distension without wall
thickening or pericholecystic fluid.
4. EKG ( 2/12/07 ): Atrial fibrillation at 71 beats per minute ,
pseudonormalized.
CONSULTING SERVICES:
1. Gastroenterology.
2. Surgery.
HOSPITAL COURSE BY PROBLEM:
1. Abdominal pain: Unclear etiology of abdominal pain on
presentation , but given history of mesenteric ischemia and
questionable small-bowel thickening on CT , the initial concern
GI and Surgical Services were consulted and followed the patient over
Hospital day #1. Serial CBC , lactate and anion gaps were
followed and showed no evidence of ischemia. By the evening of
hospital day #1 , the patient's abdominal pain had fully resolved
and the patient was initiated on clears. By the morning of
hospital day #2 , the patient was tolerating a regular diet.
Although no clear diagnosis could be made , the rapid resolution
of the patient's abdominal pain was thought to be most consistent
with viral enteritis. Given the patient's history of
atherosclerosis , further imaging of the abdominal vessels by MRA
during followup was recommended by the GI Service.
2. Pneumonia: Bilateral infiltrates consistent with aspiration
pneumonia. The patient was initially treated empirically with
ceftriaxone , azithromycin and Flagyl intravenous , which was switched to
cefpodoxime plus Flagyl orally on hospital day #2. The patient
became febrile on HD#4 ( 3/7/07 ) up to 101.9 and as such was switched
back to ceftriaxone , Flagyl and azithromycin intravenous after
which the patient remained afebrile throughout the remainder of
her admission. The patient was discharged on 10/25/07 with
instructions to complete an additional six days of cefpodoxime ,
Flagyl and azithromycin orally for a total of 14 days of antibiotic
therapy. The patient was also given lactobacillus as a probiotic
agent.
3. Hypoxemia: The patient was noted in the ED to have a mild
oxygen requirement with an oxygen saturation of 92% on room air ,
which improved to 97% on 2 L nasal cannula. The differential
diagnosis for the patient's hypoxemia included pulmonary edema
( seen on chest x-ray ) and pneumonia. The patient was given 40 mg
intravenous Lasix in the Emergency Department and was treated for
pneumonia as above. On Hospital day #2 , the patient's at rest
room air oxygen saturation was noted to be 95-97% , but decreased
to 85% with ambulation on room air. The patient was still
thought to be mildly hypervolemic and was gently diuresed. On
the day of discharge , the patient was noted to have a room air
saturation of 100% at rest and 95% with ambulation. The patient
was instructed to continue gentle orally diuresis at home and VNA
services were arranged to monitor her oxygen saturations and daily weight.
4. Anemia: History of GI bleeding , chronic renal insufficiency.
The patient's hematocrit was stable at baseline 33-36 throughout
her hospital admission. The patient was guaiac negative on
admission. An active type and screen was maintained throughout
admission. No evidence of GI bleeding throughout
hospitalization. The patient's hematocrit was 37.7 on admission
and 33.5 at discharge. The patient was given her weekly Procrit
5000 units subcutaneous injection on 10/25/07 prior to discharge.
The patient was instructed to resume iron supplementation after
discharge.
5. CHF: The patient's admission chest x-ray was suggestive of
pulmonary edema , possibly secondary to elevated blood pressure in
the setting of abdominal pain versus insufficient diuresis at
home. There was no evidence of acute ischemia on EKG. The
patient was gently diuresed during her admission. The patient's
dry weight is 57 kg. The patient's weight at discharge was 61
kg. Repeat chest x-ray on the morning of discharge still showed
evidence of pulmonary congestion and interstitial edema. As
such , the patient was thought to be still mildly hypervolemic at
the time of her discharge and was instructed to continue gentle
diuresis at home. The patient was discharged on Lasix 80 mg orally
twice daily , which is a slight increase from her home dose of 80
mg every day before noon and 40 mg every afternoon The patient was instructed to measure
her weights daily and to follow up with her cardiologist , Dr.
Meduna , for further titration of her diuretic dose.
6. Hypertension: The patient's blood pressure was elevated in
the ED up to 183/65 in the setting of abdominal pain and improved
over several hours to the 110-120s/60s-70s. On hospital day #2 ,
the patient's blood pressure was noted to be slightly elevated
from 130s-150s/70s. As such , the patient's valsartan and Norvasc
were restarted on hospital day #2. The patient's Imdur was
restarted on hospital day #4. The patient's blood pressure
remained well controlled during the remainder of her admission
ranging from 100-122/46-71 on her home regimen.
7. Atrial fibrillation: With pseudoregularization. The
patient's rate was noted to be well controlled. The patient's
Coumadin was held in the setting of a supratherapeutic INR likely
secondary to concurrent antibiotic use. The
patient's INR trended down to 2.1 on hospital day #4 and she was
restarted on a reduced dose of Coumadin. The patient's INR was
2.7 on the a.m. of discharge on Coumadin 1 mg nightly while still
on antibiotics as above. VNA Services were arranged to measure
her INR on 7/11/07 and to send the results to the PUO Coumadin Clinic ,
132-202-5576.
7. Chronic renal insufficiency: The patient's creatinine was
noted to be at baseline 2.7 on admission and slightly
increased creatinine to 3.2 at the time of discharge. In
contrast , the patient's BUN was 83 at discharge , down from 111 on
admission. The patient did not show evidence of contraction
alkalosis with bicarbonate=22 on a.m. of discharge. The
patient's BUN , creatinine and bicarbonate were to be rechecked on
7/11/07 with the results sent to Dr Meduna ( Cardiology ) and
Dr. Norseth ( nephrology ) for further titration of her medications
as needed.
8. Diabetes: The patient was initially continued on home dose
Lantus and sliding scale insulin. Standing NovoLog insulin
before every meal was reinitiated as the patient's orally intake improved.
The patient's Lantus dose was titrated up to improve glucose
control during admission. However , the patient experienced
intermittent hypoglycemia at increased doses of Lantus and was
returned to her home dose of 8 units subcutaneously nightly. At the time
of discharge , the patient was returned to her home insulin
regimen of Lantus 8 units nightly plus NovoLog 4 units with
breakfast , 4 units with lunch and 5 units with dinner plus
sliding scale insulin. The patient was instructed to continue to
monitor her blood glucose with meals.
PROPHYLAXIS: TEDs/Coumadin , PPI.
CODE STATUS: Full code.
CONTACT: Almeda Leveto , daughter/healthcare proxy , cell
847-204-5636 , home 172-103-4039.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Afebrile , heart
rate 65 , blood pressure 122/46 , oxygen saturation 96% room air.
General: Breathing comfortably on room air in no acute distress.
Chest: Bilateral BASILAR Rales right greater than left. Heart:
Regular rate and rhythm , 3/6 mid peaking murmur at left upper
sternal border heard throughout , external jugular venous
distention. Abdomen: Soft , nontender and nondistended.
Positive bowel sounds. Extremities: Trace bilateral pedal
edema , positive pigmentation changes of shins consistent with
venous stasis.
DISCHARGE MEDICATIONS:
1. Norvasc 5 mg orally every day before noon
2. Norvasc 2.5 mg every afternoon
3. Azithromycin 250 mg orally daily x6 doses.
4. Caltrate 600 plus D one tablet orally twice daily.
5. Cefpodoxime 200 mg orally daily x6 doses.
6. Colace 100 mg orally twice daily as needed , constipation.
7. Procrit 5000 units subcutaneous every week.
8. Nexium 40 mg orally daily.
9. Ferrous sulfate 325 mg orally twice a day
10. Lasix 80 mg twice daily.
11. NovoLog sliding scale subcutaneous with meals.
12. NovoLog 4 units subcutaneous with breakfast and with lunch ,
5 units with dinner.
13. Insulin , glargine 8 units subcutaneous daily.
14. Isosorbide mononitrate 30 mg orally twice daily.
15. Lactobacillus two tablets orally three times daily x25 doses.
16. Flagyl 500 mg orally every 8 hours x19 doses.
17. Senna tablets one tablet orally twice daily as needed for
constipation.
18. Sevelamer 400 mg orally every afternoon
19. Diovan 120 mg orally daily.
20. Coumadin 1 mg orally every afternoon ( levels to be followed by the PUO
Coumadin Clinic ).
DISCHARGE CONDITION: Stable.
eScription document: 1-2120934 CSSten Tel
Dictated By: BARRETTE , GENNY
Attending: ISA , KAM
Dictation ID 7410100
D: 11/9/07
T: 11/9/07
Document id: 818
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
- |
- |
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Y |
Y |
N |
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N |
350457905 | PUO | 34112342 | | 961209 | 11/29/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/15/2000 Report Status: Signed
Discharge Date: 6/2/2000
SERVICE: GENERAL MEDICINE TEAM Ville
PRINCIPAL DIAGNOSES: 1. CONGESTIVE HEART FAILURE.
2. REACTIVE AIRWAY DISEASE.
3. HYPERTENSION.
4. MORBID OBESITY.
BRIEF HISTORY: This patient is a 60-year-old African-American
female with a recent , eleven-day hospitalization at
the Pagham University Of for a congestive heart failure
flare. The patient presents now with two days of progressively
worsening shortness of breath at rehabilitation. The patient
presented initially with chest pain and CHF , and was ruled out for
a myocardial infarction , in early October . An echocardiogram then
revealed mild to moderate left ventricular dysfunction and abnormal
septal motion , with septal apical hypokinesis and minimal mitral
regurgitation. An exercise treadmill test at that time was without
ischemia , though her target heart rate was not achieved. During
the hospitalization at that time , the patient was slowly diuresed
and then discharged to rehabilitation. At rehabilitation , she has
been chest-pain-free , but she has had increasing shortness of
breath and wheezing. In the emergency department , she was found to
be in congestive heart failure by chest x-ray. The oxygen
saturations were 93% on 2 liters. She was given albuterol and
Atrovent nebulizers and intravenous Solu-Medrol , and was also given a dose
of 120 mg of intravenous Lasix.
PAST MEDICAL HISTORY: Please see the Problem List.
PAST SURGICAL HISTORY: The patient has had the following
surgeries: ( 1 ) A cholecystectomy; ( 2 ) Two
Caesarean sections.
MEDICATIONS ON ADMISSION: Ventolin two puffs orally four times a day ,
Azmacort four puffs twice a day , Rhinocort
two puffs twice a day , enteric-coated aspirin 325 mg orally every day , atenolol
25 mg orally every day , Lasix 40 mg orally every day , Motrin 800 mg orally every day ,
Isordil 10 mg orally three times a day , Claritin 10 mg orally every day , Cozaar 75 mg
orally every day , Pepcid 20 mg orally twice a day , simvastatin 20 mg orally every day ,
and nitroglycerin sublingually as needed
LISTED ALLERGIES: Lisinopril gives her a cough.
SOCIAL HISTORY: No tobacco or alcohol use and no intravenous drug abuse.
The patient works in the Ro Birm Xingchenaheights at
the Pagham University Of .
PHYSICAL EXAMINATION: On admission , the vital signs include the
following: the temperature is 98.0 degrees
F. , the pulse 87 , the blood pressure 180/110 , and the respirations
24. The oxygen saturation is 92% on 2 liters. In general , the
patient is a morbidly obese female in mild to moderate distress.
The neck is supple , without bruits; the jugular venous pressure
cannot be assessed secondary to the patient's body habitus. The
cardiovascular examination shows a regular rate and rhythm with an
S1 , an S2 , and an S3 , and a 2/6 systolic ejection murmur at the
right upper sternal border and a 2/6 murmur at the left upper
sternal border. Examination of the lungs is significant for rales
bilaterally in one-third of the lung fields. She also has
inspiratory and expiratory wheezing and a prolonged expiratory
phase. The abdomen is soft , non-tender , and non-distended , with no
masses. The extremities show 2+ pitting edema in both lower
extremities and the pulses are 2+ in the dorsalis pedis and
posterior tibial arteries. On neurological examination , the
patient is alert and oriented times four. The neurologic
examination is otherwise non-focal.
DATA BASE: The admission chest x-ray showed moderate congestive
heart failure with moderate pulmonary edema but no
acute infiltrate. The EKG revealed a normal sinus rhythm with a
rate of 60 , a normal axis , and no ST-T wave changes when compared
to prior EKGs from October 2000. The admission laboratory studies
were as follows. The sodium was 140 , the potassium 4.0 , the
chloride 99 , the CO2 39 , the BUN 23 , the creatinine 0.9 , the
glucose 78 , the CK 114 , the troponin 0.00. The white count was
8 , 200 , the hematocrit 44 , and the platelets 315 , 000. The physical therapy was
11.8 , the PTT 23.1. The cholesterol level was 206.
HOSPITAL COURSE: By problems:
1. CARDIOVASCULAR. The patient was re-admitted to the Pagham University Of with worsening congestive heart failure on a dose
of Lasix of 40 mg orally every day She received 120 mg intravenous Lasix in the
emergency department and her diuresis was continued with aggressive
intravenous Lasix until two days prior to discharge , when she was
switched to orally Lasix. She was started initially on 120 mg of intravenous
Lasix once a day , which resulted in a diuresis of 1-2 liters every
twenty-four-hour period. The patient was ruled out for myocardial
infarction by serial enzymes and EKGs. The decision had been made
during the last hospitalization to manage her coronary artery
disease medically. The patient did not desire cardiac
catheterization at this point. She was eventually switched to orally
Lasix at a dose of 60 mg by mouth twice a day.
2. RESPIRATORY. The patient was admitted to the hospital for
congestive heart failure but also had evidence of reactive airway
disease on clinical examination. She had profound inspiratory and
expiratory wheezes and shortness of breath. Due to the history of
reactive airway disease , the patient was started on intravenous
Solu-Medrol , albuterol , Atrovent , and Serevent. She was given
supplemental O2 to maintain her oxygen saturations greater than
93%. She was continued on her intravenous steroids throughout the
hospitalization , and these were eventually switched to orally
prednisone near the end of the hospitalization and were to be
tapered on an outpatient basis. Her shortness of breath resolved
by the time of discharge.
3. FLUIDS AND ELECTROLYTES. Due to the aggressive diuresis , the
patient developed a contraction alkalosis during the course of
hospitalization. Her bicarbonate rose to a level of 43 , with a BUN
of 34. At this time , the diuresis was withdrawn slightly and the
patient's electrolytes normalized.
DISCHARGE MEDICATIONS: Albuterol inhaler two puffs four times a day ,
enteric-coated aspirin 325 mg orally every day ,
Lasix 60 mg orally twice a day , Robitussin with codeine 5 ml orally every 4 hours ,
Atrovent inhaler two puffs inhaled four times a day , Isordil 20 mg orally
three times a day , Lopressor 25 mg orally three times a day , nitroglycerin 0.4 mg
sublingually as needed , Zantac 150 mg orally twice a day , Zocor 20 mg orally
every bedtime , Norvasc 5 mg orally every day , Serevent two puffs inhaled twice a day ,
Claritin 10 mg orally every day , Flovent 220 micrograms inhaled twice a day ,
Cozaar 100 mg orally every day , and a prednisone taper with 60 mg orally
every day for three days , then 50 mg orally every day for three days , then 40
mg orally every day for three days , then 30 mg orally every day for three days ,
then 20 mg orally every day for three days , then 10 mg orally every day for three
days.
DISCHARGE CONDITION: Improved.
DISPOSITION: The patient was discharged home.
Dictated By: KALEIGH E. IMRIE , M.D. TG15
Attending: ELOIS K. POLCOVICH , M.D. YM8
DV637/7122
Batch: 80374 Index No. GDSX6059Y4 D: 3/13
T: 6/3
Document id: 819
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
Y |
Y |
N |
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N |
N |
N |
N |
987234569 | PUO | 94878180 | | 9777384 | 11/19/2004 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 4/2/2004 Report Status: Signed
Discharge Date: 2/24/2004
ATTENDING: ISABELLE EVON COLASAMTE MD
HISTORY OF PRESENT ILLNESS:
The patient is a 66-year-old gentleman who was noted to have an
abnormal electrocardiogram during preoperative testing for his
right shoulder surgery. The patient underwent stress test , which
showed areas of ischemia. The patient underwent cardiac
catheterization on 8/28/04 which revealed a left anterior
descending coronary artery with an osteal 90% stenosis , the ramus
coronary artery with an ostial 70% stenosis , first diagonal
coronary artery with a mid 90% stenosis , a 3rd diagonal coronary
artery with an ostial 80% stenosis , left circumflex coronary
artery with a proximal 75% stenosis , right coronary artery with a
50% ostial stenosis , posterior descending coronary artery with a
proximal 90% stenosis , a right dominant circulation and right
renal artery stenosis of 75 80%. Echocardiogram on 4/6/04
revealed an ejection fraction of 60% , mild mitral insufficiency ,
trivial tricuspid insufficiency , low normal to borderline reduced
overall left ventricular systolic function , not quantified. The
patient has a history of atrial fibrillation which was treated in
the past with propafenone which is currently resolved and he has
history of myocardial infarction. He also has a history of class
III heart failure with marked limitation of physical activity.
PAST MEDICAL AND SURGICAL HISTORY:
Significant for hypertension , non-insulin-dependent diabetes
mellitus , dyslipidemia , chronic obstructive pulmonary disease ,
benign prostatic hypertrophy and paroxysmal atrial fibrillation ,
no known episodes since 1995 , nephrolithiasis , and bursitis of
his right shoulder. History of hepatitis type unknown and renal
artery stenosis and renal insufficiency. He is status post left
rotator cuff repair in 1991.
ALLERGIES:
The patient has allergies to procainamide which causes diarrhea
and arthralgias and verapamil which causes difficulty
concentrating and constipation.
MEDICATIONS ON ADMISSION:
Toprol 25 mg once a day , lisinopril 10 mg once a day , propafenone
150 mg once a day enteric-coated aspirin 325 mg once a day ,
Rhinocort , simvastatin 20 mg once a day , metformin 500 mg once a
day , and glyburide 5 mg twice a day.
PHYSICAL EXAMINATION:
Cardiac exam regular rate and rhythm with no murmurs , rubs or
heaves , peripheral vascular 2+ pulses bilaterally throughout.
Respiratory breath sounds clear bilaterally , is otherwise
noncontributory.
HOSPITAL COURSE:
The patient was brought to the operating room on 10/19/04 where
he underwent an urgent coronary artery bypass graft x5 with left
internal mammary to left anterior descending coronary artery
saphenous vein graft to the first diagonal coronary artery. A
right internal mammary artery to the ramus coronary artery , a
left radial artery to the second left ventricular branch and
sequential to the first left ventricular branch. Total bypass
time was 159 minutes , total cross clamp time 110 minutes. The
patient did well intraoperatively , came off bypass without
incident , was brought to the Intensive Care Unit in normal sinus
rhythm and stable condition with intravenous insulin.
Postoperatively , the patient did show his atrial fibrillation and
atrial flutter which was treated Lopressor , diltiazem ,
propafenone. He was extubated and placed on his preoperative
inhalers for his chronic obstructive pulmonary disease. He did
have a left-sided pleural effusion which was tapped on 1100 cc of
bloody fluid on 3/26/04. Post-tap chest x-ray revealed a small
left residual effusion and no pneumothorax. The patient was
slightly hypertensive due to renal artery stenosis and initially
low urine output. Renal ultrasound revealed equal size kidneys
and no hydronephrosis. His oliguria was blood pressure dependent
and he did resume urination without use of diuretics. The
patient was also followed by the diabetes mellitus service for
his non-insulin-dependent diabetes mellitus and was put back on
his preoperative dose of glipizide. The patient was transferred
to the step-down unit on postoperative day #6. He did complain
on 5/11/04 of left eye black spot in the middle of his left eye.
The patient was seen by the ophthalmology service which was felt
that this was due to his diabetic retinopathy. The patient will
follow up as an outpatient with his local ophthalmologist; his
symptoms have resolved. The patient required vigorous diuresis
and was sent home on Lasix 20 mg once a day for 5 days.
DISCHARGE LABS:
For the patient on 3/3/04 are as follows: Glucose 147 , BUN of
16 , creatinine 1.3 , sodium 139 , potassium 4.2 , chloride of 106 ,
CO2 25 , magnesium 2.2 , WBC 9.27 , hemoglobin 10 , hematocrit 30.5 ,
platelets of 294 , physical therapy INR 1.3.
DISCHARGE MEDICATIONS:
Diltiazem 15 mg 3 times a day for his radial artery harvesting
and Lasix 20 mg once a day for 5 days , glipizide 10 mg in the
morning and 10 in the evening , lisinopril 10 mg once a day ,
niferex 150 mg twice a day. Propafenone hydrochloride 150 mg 3
times a day , Toprol XL 25 mg once a day , potassium chloride slow
release 10 mEq once a day for 5 days and Nexium 40 mg once a day ,
full strength aspirin 325 mg once a day , simvastatin 20 mg once
in the evening.
DISPOSITION:
The patient will follow up with Dr. Isabelle Colasamte in 6 weeks ,
his cardiologist Dr. Lashanda Bachmann in 3-4 weeks and his
primary care physician , Dr. Arnulfo Mackler in 1 week and his local
ophthalmologist in approximately 3-4 weeks. He is discharged to
home in stable condition with visiting nurse.
eScription document: 8-8634301 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 0688291
D: 3/3/04
T: 6/8/04
Document id: 820
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797255323 | PUO | 14020021 | | 626351 | 2/28/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/10/1991 Report Status: Signed
Discharge Date: 3/23/1991
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old man
from Ins , with a his-
tory of ischemic cardiomyopathy and congestive heart failure , who
was transferred to the Totin Hospital And Clinic for transplant evalua-
tion. In 1975 , he suffered a myocardial infarction and subse-
quently had exertional angina. In 2 of March he suffered a second MI
and underwent three-vessel coronary artery bypass graft in 8 of May
At that time his ejection fraction was 21%. Over the ensuing
months , the patient noted markedly worsening symptoms of CHF with
orthopnea , paroxysmal nocturnal dyspnea , and dyspnea on exertion.
One week prior to transfer , the patient was admitted to Cock Dia Medical Center for management of his congestive heart failure. He was
initially treated with afterload reduction , digoxin and Lasix.
On this regimen , a PA line was placed with the following read-
ings: RA 8 , RV 76/4 , TA 80/36 , pulmonary capillary wedge pres-
sure 34 , and cardiac index 1.49. Echocardiogram revealed dilated
left ventricle with global hypokinesis , tricuspid regurgitation ,
and PA systolic pressure 80mmHg. The patient was treated with
dobutamine , intravenous TNG , and nitroprusside with symptomatic
relief and hemodynamic stabilization with wedge pressure falling
to 18. TNG and Nipride were successfully weaned. However , the
patient remained dobutamine dependent.
The patient was transferred to the Totin Hospital And Clinic for evalu-
ation for transplantation. At the time of admission he noted
dyspnea on minimal exertion but not at rest. He denied chest
pain , palpitations , lightheadedness , or syncope. The patient is
married , and worked as a janitor until October of 1991. He is
married with seven children and lives in Ver Racho .
The patient's PAST MEDICAL HISTORY is significant for severe
abdominal trauma many years ago , having been gored by a bull.
PHYSICAL EXAMINATION: Discharge physical examination is nota-
ble for a blood pressure of 100/50 , a
heart rate of between 100 and 110 , a respiratory rate of 18 , a
blood pressure of 112/66 , a temperature of 97.1 , and a weight of
80.4 kilograms. The patient is in normal sinus rhythm with occa-
sional short bursts of ventricular tachycardia last two days
prior to discharge. LUNGS: Occasional crackles. HEART: Sounds
distant. ABDOMEN: Benign. EXTREMITIES: Trace edema.
LABORATORY DATA: Discharge sodium 134 , potassium 4.2 , BUN
32 , creatinine 1.4. White count 9.8 ,
hematocrit 29.2 , platelets 253. ALT 14 , AST 8 , LDH 223 , total
bilirubin 0.6 , direct bilirubin 0.3 , albumin 2.8 , total protein
5.9 , cholesterol 106.
MEDICATIONS at time of discharge include dobutamine at 15 mcg per
kilogram per minute; captopril 25 mg orally three times a day; digoxin 0.125
mg orally every day; Lasix 160 mg orally twice a day; potassium chloride 20 mEq
orally twice a day; Coumadin 1 mg orally every day; Atrovent , two puffs four times a day;
Azmacort , eight puffs twice a day; Pepcid 20 mg orally twice a day; Colace
100 mg orally three times a day; vancomycin 1 gm every 12 , discontinued 9-23 a.m.
after 14 days; ampicillin 2 gm intravenous every 6 ( 27 of June equals day number
five ); Halcion 0.125 orally every bedtime as needed; Serax 15 mg orally every 6 hours
as needed
HOSPITAL COURSE: 1. Transplant Listing: The patient has
been listed for cardiac transplant ,
has had all the necessary preoperative workup including pulmonary
function tests and tissue typing. Should a heart become avail-
able , he could be Medivacked back to the Pagham University Of for surgery.
The patient's hospital course was significant for the following
workup: He had a catheterization 27 of January , which showed patent
grafts and occluded native left anterior descending and obtuse
marginal branch. An echocardiogram on 15 of July showed mitral regurg-
itation , an ejection fraction of less than 20% , and no vegeta-
tions on the valve.
The patient's most significant problem during his hospital course
included temperatures. On 26 of November , he had an increased temperature
to 101 and increased white count with left shift. His central
line was pulled , and the tip grew gram positive cocci. The
patient also grew gram positive cocci from two blood cultures.
He was started on vancomycin and defervesced , and has been
afebrile for four days.
Subsequently , the patient again became febrile approximately one
week into his vancomycin course. At this point he was recul-
tured , and those cultures grew gram negative rods in one out of
four blood culture specimens. These were gram negative enteric
rods , pan-sensitive , for which the patient was started on
ampicillin 2 gm intravenous every 6. This was felt most likely secondary to
a urinary tract infection from the Foley catheter , which has been
discontinued.
At the time of discharge , the patient is stable , dobutamine
dependent , without chest pain , able to ambulate from chair to
commode without shortness of breath , palpitations , or light-
headedness. He is eager to be transferred back to the Paul Wa , Georgia 88247 area to await heart transplant.
With any questions , please contact Doctor Loan Kuharik Pagham University Of 138-8931 , beeper number 1693 , the patient's
medical intern.
The patient's condition at time of discharge is fair.
DISPOSITION: Continuing care in the coronary care
unit of the hospital inpatient near
patient's home. The patient will be under the care of a Doctor
Gaylene Faniel
Dictated By: CHRISTIN FRERICKS , M.D. SB41
EF045/5852
JACKSON ERICKA PART , M.D. RM7 D: 5/1/91
T: 5/1/91
Batch: M529 Report: UI277B57 T:
Document id: 821
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313615200 | PUO | 85677707 | | 7012460 | 10/10/2003 12:00:00 a.m. | RT. ANKLE OSTEOARTHRITIS | Signed | DIS | Admission Date: 8/25/2003 Report Status: Signed
Discharge Date: 11/1/2003
Date of Discharge: 11/1/2003
ATTENDING: DOUGLASS PETTINGER MD
ADMISSION DIAGNOSIS: Right ankle fusion.
DISCHARGE DIAGNOSIS: Status post right ankle fusion and
pneumonia.
SECONDARY DIAGNOSES: Cleared history of heart transplant ,
history of rheumatic fever , diabetes mellitus type 1 ,
gastroesophageal reflux disease , chronic renal insufficiency , and
osteoporosis.
HISTORY: The patient is a 65-year-old woman with history of
rheumatic heart disease and endocarditis ultimately requiring
heart transplant in August of 1993 , diabetes mellitus type #1 ,
and chronic renal insufficiency with baseline creatinine of 1.8.
He was admitted on February , 2003 , for elective right ankle
fusion. About 1 year prior to admission , she fell down stairs
and had a right pilon fracture initially treated with cast
immobilization. The patient noted persistent right lower leg and
ankle deformity and daily aching pain and decided with her
orthopedic surgeon to have an elective right ankle fusion. After
surgery , her vitals were 100.3 , 111 , respiratory rate of 18 ,
oxygen saturation of 98% upon 70% face mask. Exam was notable
for decreased breath sounds with wheezing with a positive S4.
JVP was difficult to assess. Extremities were warm with pitting
edema. Labs were notable for cyclosporin levels 133. EKG showed
no significant change consistent with June , 2003. She was
started on intravenous Lasix diuresis for proper fluid overload , as she
had received 4 L intraoperatively. She developed low-grade fever
and then up to 102 , and had left calf pain on palpation. A
spiral CT was sent that was negative for PE , DVT , or CHF , but
positive for atelectasis. The BUN to creatinine ratio trended
upwards up to 31/2.3 from 29/1.7 on admission and then she was
transferred to cardiology 3 for management of hypoxia , fever ,
acute and chronic renal failure , and developing hypertension to
the 90s , systolic from a baseline of 105. She was transferred to
cardiology on May , 2003. Her vitals on transfer were T
max 100.4 to current 99.2 , pulse 99 to 108 , currently 99 , blood
pressure was ranging to 90 to 102 over doppler to 60.
Respiratory rate of 18 , 97% on high flow of 100% oxygen. On
physical exam , she had bibasilar inspiratory crackles , left
greater than right and tachycardia around 100. Extremities were
warm with trace edema in the left lower extremity. Her labs at
that time were notable for white count of only 6.5. Creatinine
of 4.1 from 2.3 , and BUN of 41. She had a portable chest x-ray
that showed cardiomegaly and bilateral atelectasis with focal
opacity at the left lung base. EKG showed normal sinus rhythm
with 97 beats per minute. No ST changes , Q wave inversions in V1
and V3 , with RSR prime pattern. V1 that showed RS duration of 80
milliseconds , not significantly changed from February , 2003.
Echocardiogram on January , 2003 , had shown an ejection
fraction of 50% to 55% with mild left ventricular enlargement and
preserved systolic function , mild posterior and lateral
hypokinesis , normal right ventricular size and function , mitral
valves mildly thickened with mild MR. Stress echocardiogram on
February 2003 , showed no inducible ischemia. There was a
dobutamine protocol. Right heart cath in February of 2003 ,
showed a right atrial pressure of 21 , PCWP is 28. This time , she
was started on Lasix 40 mg orally every day , The labs were negative for
rejection.
PAST MEDICAL HISTORY: As noted above , rheumatic heart disease
status post heart transplant in 1993 , diabetes mellitus type 1 ,
GERD , chronic renal insufficiency , baseline creatinine of 1.8.
In 1985 , had septic stroke with brain abscess postoperative
status post MVR. History of MRSA , osteoporosis. Status post
cholecystectomy.
OUTPATIENT MEDICATIONS: Mag oxide , Tums as needed , Niferex ,
Lexapro , multivitamin , Colace , Nexium , Lasix , Cyclosporin ,
prednisone , Imuran , Cozaar , Cardizem , aspirin , Nephrox ,
Pravachol , Fosamax , NPH 60 units every day before noon 10 units every afternoon
ALLERGIES: Penicillin causes rash , codeine causes severe nausea
and vomiting.
SOCIAL HISTORY: Quit smoking in 1978 , rare alcohol , no intravenous drug
use.
PHYSICAL EXAMINATION: On admission , vitals were notable for
oxygen saturation in the 84% range on room air and tachycardia.
HOSPITAL COURSE:
Musculoskeletal: The operation was without complications with
minimal bleeding. She had a right leg cast placed after the
procedure. She has been followed by the orthopedic surgery team
initially on their service and then as a consulting team , once
she was transferred to medicine. She was able to move her toes
with the splint in place and there were no orthopedic
complications from the procedure. She will follow up with Dr.
Goodnow on March , 2003. She also worked with physical
therapy to peripheral functional status and will need physical
therapy as an outpatient 3 to 5 times per week. Her motion is
limited by decreased strength in the upper extremities , which
prevents her from performing NWB gait.
Cardiovascular: Initially it was difficult to assess whether she
was volume overloaded or euvolemic given the hypotension , but
elevated right heart filling pressure before the admission and a
chest x-ray that also revealed fluid in the fissure on the right.
She had poor urine output as well so she was given Lasix 120 mg
intravenous twice a day , to which she did not respond and the Lasix drip was
started. She was transferred to the CCU for possible sepsis
because her blood pressure continued to drop to the 60 and 70
systolic and required Dopamine intravenous. Once she was transferred to
the CCU , a Swan-Ganz catheter was placed , which revealed SVR of
689 , and cardiac output of 5.8 consistent with sepsis. The right
heart filling pressures were high also. She was continued on intravenous
Lasix with good urine output response in the MICU and then was
subsequently transferred back to the cardiac team when her
hemodynamic status was improved. For ischemia , she was given
aspirin and her home Pravachol for her ischemic risk factors
including diabetes and high cholesterol. When she returned to
the floor , her diuresis remained good off the Lasix , possibly
related to post ATN diuresis and her ins and outs remained
negative. She was given her home prednisone 5 mg every day as well as
her home cyclosporin. She was also continued on Imuran.
Infectious Disease. Given the chest x-ray findings , she was
treated for pneumonia initially with broad covers with
vancomycin , azithromycin , and levofloxacin. All the blood and
urine cultures were negative. The workup for her infection was
negative and was presumed that she had community-acquired
pneumonia , and it responded well to levofloxacin 10-day course.
The vancomycin was discontinued in the MICU and the Ceptaz was
continued when she was transferred back the floor. On physical
exam on the day of discharge was improved with only faint
inspiratory crackles at the right base. She had two MRSA nares
cultures that were negative and a third one was pending on the
day of discharge. Stool cultures were sent that were negative as
well as sputum Gram stain and culture that was negative.
Renal: In the postoperative course , her creatinine rose
dramatically to the 5 range , also the possible etiology was
multifactorial including dye load with the CT , spiral , as well as
history of chronic renal insufficiency likely from diabetes and
chronic cyclosporin use. She was seen by renal consult and
during the course of the MICU stay , her renal function improved
dramatically back to the baseline and in the interim , she was
given Sevelamer for high phosphorus , but it was discontinued when
the phosphorus level came back normal.
Gastrointestinal: She was continued on Nexium , Lactulose , and
did not report any GI discomfort.
Hematology: She was given subcutaneously heparin for prophylaxis and
Niferex.
Endocrine: During the period of hypotension , she was given test
dose steroids with hydrocortisone , and she responded well to this
and when she returned to the cardiology floor , her hydrocortisone
was tapered and she was then placed back on her home prednisone.
She was continued on her home NPH 60 units in the morning and 10
units at night. She did develop some hypoglycemic episodes that
were asymptomatic , the lowest glucose was 37 , so the evening dose
of NPH was reduced to 4 units. She was also covered with insulin
sliding scale while on steroids.
Respiratory: She was breathing comfortably on room on the day of
discharge.
Neurology: She did have some waxing and waning of her mental
status during the setting of hypotension and fever , although she
had a baseline slowed response to questioning. She was markedly
slower to respond to questioning but normally oriented to place
and person. By the time she was discharged she was back to her
baseline mental status as confirmed by her husband at bedside.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally every day , Imuran 15 mg
orally every day , Colace 100 mg orally twice a day , Heparin 5000 units subcutaneously
twice a day , NPH human insulin 60 units subcutaneously every day before noon NPH human insulin
40 units subcutaneously every afternoon regular insulin sliding scale subcutaneously before every meal
and bedtime , Lactulose 30 mg orally every day , Niferex 150 mg orally twice a day ,
Nystatin cream topical twice a day , prednisone 5 mg orally every day before noon ,
Pravachol 40 mg orally every bedtime , cyclosporin 15 mg orally twice a day ,
Diltiazem Extended Release 300 mg orally every day , Miconazole Nitrate
2% topical twice a day , Nexium 40 mg orally every day , Magnesium oxide 400 mg
orally every day , Combivent 2 puffs inhaled four times a day , as needed shortness of
breath , Lexapro 20 mg orally every day , Fosamax 70 mg orally every week.
DISCHARGE CONDITION: Stable.
DISCHARGE INSTRUCTIONS: The patient will follow up with
orthopedics Dr. Goodnow on March , 2003. Physical therapy
needs to work with the patient 3 to 5 times a week to improve her
mobility and functional status as per physical therapy
recommendations during her stay here. Please call Totin Hospital And Clinic or look in the medical records to see what her third MRSA
culture report is for nares culture , if it is negative , then she
has had 3 negative MRSA cultures and does not need to be in MRSA
precautions any longer.
She needs to follow up with the heart transplant service in 2 to
4 weeks at Pagham University Of .
eScription document: 0-6121501 ISSten Tel
CC: Orval Goodnow M.D.
I Warho Hospital
Fort
Ville
CC: Douglass Pettinger MD
Sta Bayleighcam Bi
Ent O Louis
CC: Gaylene Faniel
Cou
Ville Cuse Napeo
Dictated By: BAUCHSPIES , REFUGIA
Attending: PETTINGER , DOUGLASS
Dictation ID 2669120
D: 4/7/03
T: 4/7/03
Document id: 822
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664176081 | PUO | 55283816 | | 1956944 | 9/14/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/13/2005 Report Status: Signed
Discharge Date:
ATTENDING: MARJORY SHELA GUMINA MD
ADMISSION DIAGNOSIS: Bradycardia.
DISCHARGE DIAGNOSES: Include bradycardia , diverticulosis and
plantar fasciitis. Other diagnoses treated over the patient's
hospitalization includes insulin dependent diabetes mellitus ,
hypertension , obstructive sleep apnea.
OPERATIONS AND PROCEDURES: Operations and procedures over her
course include colonoscopy. No other procedures were performed.
HISTORY OF PRESENT ILLNESS: In brief , the patient is an
82-year-old woman with a history of insulin dependent diabetes
and hypertension who is in her usual state of health until the
morning of presentation when she was sitting at breakfast she
felt an increased in drowsiness and faintness with gradual onset
over ten minutes while seated. She felt as if she was going to
collapse but had no visual or motor deficit. She called her
daughter. Per report , the patient experienced no dysarthria or
confusion , no focal motor deficit. She stood and walked outside
noting no changes with standing. She denies fall or loss of
consciousness. She had some shortness of breath as well as
dyspnea on exertion. At baseline , she has poor exercise
tolerance to less than 30 feet without shortness of breath. On
the day of presentation this was reduced to less than ten feet.
She had no chest pain or palpitations , no cough but mild URI
symptoms. No fevers , chills , nausea or vomiting. She did have
one subjective temperature the day prior to admission , no change
in stools. She had some feeling of urinary frequency but no
burning , no leg pain or falls. She has had no recent change in
orally intake. Of note , the patient has had multiple presentations
to her primary care physician in the past for symptomatic
bradycardia for which her medication regimen has been repeatedly
changed. Of note , she was recently started on Clonidine for her
hypertension.
PAST MEDICAL HISTORY: Past medical history is notable for
insulin dependent diabetes , hypertension , a history of a urinary
tract infection in the past , bradycardia , chronic edema in her
legs , obstructive sleep apnea. She has a history of a positive
PPD. She is allergic to Lisinopril which gives her angioedema as
well as CT contrast dye.
MEDICATIONS ON ADMISSION: Her medications at the time of
admission include Avapro 75 mg twice a day , Clonidine 0.2 mg orally
twice a day , atenolol 100 mg orally daily , Norvasc 10 mg orally daily ,
insulin NPH 20 twice a day , Flonase , Lasix 40 twice a day She denies
tobacco or alcohol use.
FAMILY HISTORY: Negative for cardiovascular or lung disease.
PHYSICAL EXAMINATION: Her exam showed a temperature of 95.5 , a
heart rate of 40 , blood pressure of 140/60 , respiratory rate of
18 , oxygen saturation 99% on room air. She is comfortable. She
is fatigued with no acute distress. Her extraocular movements
are intact. She has no scleral icterus. Her neck is supple with
a JVP of approximately 12. Her heart is regular rate and rhythm ,
S1 and S2 are normal. She is bradycardic. She has no murmurs ,
rubs or gallops. Lungs are clear bilaterally without wheezes or
rales. Her abdomen is obese but soft , nontender , no pulsatile
liver is appreciated. Extremities are warm and well perfused
with 3+ edema to the knees. She is alert and oriented x3. Her
reflexes are 2+ bilaterally , 5/5 strength in bilateral upper and
lower extremities. Her cranial nerves are all intact.
ADMISSION LABS: Admission labs are notable for a hematocrit of
35.8 , a BUN of 21 , and a creatinine of 1.4 which is essentially
at the patient's baseline. The patient had three sets of cardiac
enzymes which were all negative for ischemia. She had blood
cultures drawn which have returned no growth to date. Her TSH at
time of admission was 2.55 within the range of normal. Chest
x-ray showed low lung volumes , cardiomegaly without effusion or
consolidation. EKG was sinus rhythm 40 bpm , no Q waves , no T
wave inversions , no new ST segment elevation or depression. Her
QT corrected is 431 milliseconds. She had an echo January ,
2004 showing an ejection fraction of 65% and normal valves.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: The patient was admitted for workup and
treatment of her symptomatic bradycardia. On reviewing the
patient's past medical records , it was noted that she had
experienced similar symptoms with episodes of bradycardia related
to medications in the past. She was noted to be on atenolol
which had been a longstanding medication for her as well as
Clonidine which had only been started in the preceding 2-3 days.
Atenolol was discontinued at the time of admission as it had
nodal blocking properties. Additionally , Clonidine was also
discontinued for its potential rare adverse reaction of causing
bradycardia and at times heart block. Her heart rate gradually
improved over the course of her admission and by the time of
dictation her heart rate ranged from 60-75 at rest. The patient
was evaluated while inhouse. The patient had no loss of
consciousness , anginal chest symptoms or worsening of her
hypertension during this period. She was evaluated by the
Cardiology Service at I Warho Hospital on the day
following admission who found the patient likely not to require
pacemaker. The recommendation of the Cardiology Service
additionally recommended to hold Clonidine and consider
restarting atenolol at a low dose of 25 mg orally daily. The
patient was subsequently re-evaluated by the Electrophysiology
Service at the I Warho Hospital which assessed the
patient to likely not require a pacemaker given her improvement
of her bradycardia with the discontinuation of her nodally active
medications. The patient was maintained on telemetry over the
course of her hospitalization with no new or dangerous
arrhythmias noted. In terms of ischemia , the patient had a
negative workup for cardiac ischemia by enzymes x3 and had no
further anginal symptoms or changes in her EKG to indicate
myocardial ischemia or infarction. In terms of her pump
function , the patient was assessed to be volume up at the time of
admission and treated with one dose of Lasix 40 intravenous. She was
subsequently continued on her outpatient dose of Lasix 40 orally
and will be discharged on Lasix 40 orally twice a day She was noted to
have some improvement in her lower extremity edema over her
hospital course but it was assessed to be chronic and likely not
an issue to be further assessed by her outpatient physician. In
summary , the patient will be discharged to home without further
use of atenolol. The recommendation of the hospital team is that
the patient continue on her discharge medications for
hypertensive control. These will be Avapro 75 mg orally twice a day as
well as Norvasc 10 mg daily. It is recommended that if the
patient has poorly controlled hypertension as an outpatient , she
will undergo a trial with an agent that has no activity at the
sinoatrial node. Our recommended agent would be doxazosin. If
the patient continues to have bradycardia related to medications
and is unable to have her hypertension controlled by medications
that do not cause bradycardia , she may need to be re-evaluated by
the electrophysiology service for placement of a pacemaker. At
this time though , there is no recommended electrophysiologic
workup remaining for the patient.
2. Gastrointestinal: At the time of admission , the patient had
a known history of diverticulosis by colonoscopy as well as
barium enema , but had no history of acute bright red blood per
rectum. She suddenly developed acute bleeding from her rectum on
the evening of November , 2005 to a volume of approximately 1.5
- 2 liters. The patient was clearly orthostatic and unable to
stand without dizziness. She had no pain with this bleeding and
had no evidence of hematemesis. The patient was transfused to a
total of four units of packed red blood cells with her hematocrit
stabilizing in the low 30s following a drop to 28.8. She was
evaluated by the Gastroenterology Service at I Warho Hospital who took the patient to colonscopy on March . She
was found on colonoscopy to have nonbleeding diverticuli as well
as evidence of fresh blood in the sigmoid colon. The diagnosis
was thus made that the patient had had a sigmoid diverticular
bleed but was currently stable hemodynamically. The patient was
also assessed by surgery who felt the patient not to be an urgent
surgical candidate but recommended nasogastric lavage if the
patient were to rebleed and further consultation with surgery in
that event. The patient was observed to be hemodynamically
stable over the remainder of her hospitalization with no evidence
of drop in blood pressure or new blood per rectum. Her
hematocrit remained stable in the range of 30 at time of
discharge. She is recommended to follow up with her primary care
physician for observation and is instructed to return to the
Emergency Department immediately if there are any signs of
gastrointestinal bleeding and either vomiting of blood or blood
in her stool. She is maintained on Nexium for gastrointestinal
prophylaxis over her course.
3. Endocrine: The patient has a known history of insulin
dependent mellitus and she was maintained on NPH insulin at a
dose of 10 units subcutaneously twice a day following blood sugars
which was reduced from her outpatient dose following blood sugars
in the range of 50-60 on day of admission. She was also
maintained on an insulin sliding scale. During her
hospitalization , the patient's history of refractory hypertension
was concerning for the possibility that she may have some degree
of underlying renovascular hypertension. She has subsequently
underwent a secondary hypertension workup which included an a.m.
cortisol level which was 10.8 which was in the low range of
normal. She had an aldosterone level which was 2.8 which was low
and a plasmin renin activity 0.1 which is low. She completed a
24 hour urine collection and the urine levels of cortisol
metanephrines and normetanephrines are still outstanding. It is
recommended that she follow up these levels with her outpatient
physician. As stated above , the patient's blood pressure was
well controlled on Norvasc and Avapro and on the morning of
dictation her systolic blood pressure was 120 mmHg.
4. Musculoskeletal: Beginning on January , the patient began
to complain of bilateral foot cramps worse in the plantar aspect
of her foot but also on the dorsum of her foot which were
exacerbated by dorsi and plantar flexion. She also described
vague pain in her right lateral calves. She subsequently
underwent lower extremity noninvasive ultrasound studies which
demonstrated no evidence of venous clots in either of her legs.
On exam , her legs demonstrated no tenderness to palpation over
her major joints and no evidence of frank inflammation. She was
assessed to likely have plantar fasciitis on the basis of
examination. The case was discussed with Rheumatology who
recommended Tylenol as well as hot or cold packs. The patient
subsequently received these treatments with improvement of her
symptoms. At the time of discharge though she continues to have
some left foot pain and Rheumatology has been consulted to
evaluate the patient more fully. Their recommendations are
pending at time of dictation. The patient complained of
difficulty walking secondary to this bilateral foot pain and will
be discharged to a rehabilitation facility for further care.
5. Infectious disease: The patient had a urinalysis at the time
of admission as well as blood cultures , both of which were
negative. Her chest x-ray at time of admission was without
infiltrate.
6. ENT: The patient was continued on her Flonase at her
outpatient dose , stable without new complaints at time of
dictation.
7. Prophylaxis: The patient was maintained on Lovenox for DVT
prophylaxis which was subsequently discontinued following her
diverticular bleed. She is maintained on Nexium for
gastrointestinal prophylaxis. She will be discharged to a
rehabilitation facility in stable condition.
FOLLOW UP PLAN: Follow up plan for her is with her primary care
physician , Dr. Kleinschmidt Dr. Krommes is advised to follow the
patient's urinary cortisol as well as her 24 hour urine
metanephrines and normetanephrine levels. It is recommended that
he continue to follow his hypertension closely as he has been and
use whenever possible agents without sinoatrial nodal activity.
Recommended next agent if the patient continues to have
refractory hypertension would be doxazosin. The patient is
advised to pursue a high fiber diet in the context of her
diverticulitis and is advised to return to medical care
immediately if there are any new signs of gastrointestinal
bleeding or vomiting of blood. Again , the patient is not
assessed to be a candidate for a pacemaker at this time due to
the likely medication related bradycardia that she experienced
although she continues to have new symptomatic bradycardia. It
is recommended that she return for re-evaluation to the
Electrophysiology Service. She is recommended to follow up with
physical therapy as an inpatient at a rehabilitation facility and
then follow up with Podiatry if indicated. Please note the
patient's NPH insulin dosing was decreased from her outpatient
level from 20 to 14 units subcutaneously twice a day given the
patient's episodes of hypoglycemia on the day of admission during
which she was receiving 20 units subcutaneously. It is advised
that her rehabilitation facility check daily fingersticks with
meals and adjust her NPH dosing as appropriate.
DISCHARGE MEDICATIONS: Discharge medications will include Colace
100 mg orally twice a day , Lasix 40 mg orally twice a day , NPH insulin 14 units
subcutaneously twice a day , Norvasc 10 mg orally daily , Flonase 1-2
sprays daily , Avapro 75 mg orally twice a day , Tylenol 650 mg orally every 6 hours
eScription document: 0-0071167 DBSSten Tel
Dictated By: BERNAS , RUFUS
Attending: GUMINA , MARJORY SHELA
Dictation ID 6244099
D: 10/24/05
T: 10/24/05
Document id: 823
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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581312753 | PUO | 77634248 | | 5593546 | 6/21/2006 12:00:00 a.m. | acute on chronic renal failure | | DIS | Admission Date: 4/12/2006 Report Status:
Discharge Date: 7/22/2006
****** FINAL DISCHARGE ORDERS ******
BONING , FREDDA F 207-67-77-5
Sto
Service: CAR
DISCHARGE PATIENT ON: 1/8/06 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAMBLET , BRITTANEY NICKI , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Override Notice: Override added on 9/16/06 by NOAKES , MARLEEN D , M.D. on order for COUMADIN orally ( ref # 803720751 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: md aware
ALLOPURINOL 100 MG orally DAILY
Override Notice: Override added on 9/16/06 by NOAKES , MARLEEN D , M.D. on order for COUMADIN orally ( ref # 803720751 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: md aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
GLIPIZIDE 5 MG orally twice a day
ISOSORBIDE DINITRATE 5 MG orally three times a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
Override Notice: Override added on 9/16/06 by NOAKES , MARLEEN D , M.D. on order for COUMADIN orally ( ref # 803720751 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: md aware
ATIVAN ( LORAZEPAM ) 0.5 MG orally twice a day as needed Anxiety
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRAVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/16/06 by NOAKES , MARLEEN D , M.D. on order for COUMADIN orally ( ref # 803720751 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: md aware
Previous override information:
Override added on 9/16/06 by NOAKES , MARLEEN D , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
PRAVASTATIN SODIUM Reason for override: nd aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 9/16/06 by NOAKES , MARLEEN D , M.D. on order for PRAVASTATIN orally ( ref # 394993335 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
PRAVASTATIN SODIUM Reason for override: nd aware
TORSEMIDE 40 MG orally twice a day Starting Today ( 9/21 )
COUMADIN ( WARFARIN SODIUM ) 1 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/16/06 by
NOAKES , MARLEEN D , M.D.
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: md aware
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Kum Pidro primary care physician ( 916 ) 897-5795 June at 12:15pm scheduled ,
Dr. Coletta Verry 575-803-4363 PUO Cardiology June at 11am scheduled ,
Dr. Earnest Alicia 079-250-0210 PUO Thoracic Surgery November at 4pm scheduled ,
Dr. Rossie Mankoski ( 579 ) 822-3056 SSR Thoracic Oncology November at 3pm scheduled ,
Arrange INR to be drawn on 4/29 with f/u INR's to be drawn every
3 days. INR's will be followed by primary care physician Kum Pidro
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hyperkalemia , acute on chronic renal failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
acute on chronic renal failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF ( congestive heart failure ) cad ( coronary artery disease ) htn
( hypertension ) dm ( diabetes mellitus ) gerd ( gastroesophageal reflux
disease ) hypothyroidism ( hypothyroidism ) mitral regurgitation
( 2 ) lung ca history of RUL lobectomy and RLL wedge resection ( lung cancer )
endometrial ca history of TAH/BSO
( endometrial cancer ) basal cell ca ( basal cell
carcinoma ) CRI ( chronic renal dysfunction ) renal artery stenosis history of
L stent ( renal artery stenosis ) recurrent flash pulm edema ( pulmonary
edema )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
***CC: hyperkalemia in setting of worsening renal insufficiency
***HPI: patient is a 75 F with multiple medical problems including CAD history of PCI
to OM1 '91 , LAD '97 , LCx '01 , RCA '02 , dyslipidemia , CHF with an EF 30-35%
in 9/21 ( dry weight 158lbs ) , MV repair 8/27 , HTN , afib on
coumadin , pericardial effusion history of window 6/10 ,
RAS history of left renal artery stent , and CRI with a baseline Cr 1.9-2.2. At
baseline , she lives at home. She is alert and oriented.
She receives assistance from VNA. 1 day prior to admission , patient was seen
in cardiology clinic by Dr. Marlo Bonefont Her Cr was noted to
be 2.3 and her potassium 5.3. The following day , patient was instructed to
have her basic metabolic panel rechecked. Her Cr was noted to be 2.6 and
her potassium 5.5. She was advised to present to the PUO ED for further
evaluation and management of hyperkalemia in the setting
of worsening renal insufficiency.
****PMHx:
*CAD history of PCI to OM1 '91 , LAD '97 , Lcx '01 , RCA '02 , OM1 '91
*dyslipidemia
*CHF EF 30-35% 9/21
*HTN
*MV repair 8/27
*afib on coumadin
*NSVT
*pericardial effusion history of pericardial window 6/10
*RAS history of L renal artery stent
*CRI baseline Cr 1.9-2.2
*GERD
*PVD history of R 5th toe amputation
*iron deficiency anemia
*bronchoalveolar lung cancer history of RUL lobectomy and RLL wedge resection ,
*uterine CA history of TAH/BSO
*BCC L upper lip
*hypothyroidism
*NIDDM
****HOME MEDS:torsemide 60 orally twice a day , synthroid 100 , glipizide 5
twice a day , iron 325 twice a day , allopurinol 100mg daily , ASA 325 , ativan 0.5 twice a day as needed ,
coumadin 1mg orally every bedtime , toprol xl 100mg daily , metolazone 2.5mg as needed , nexium
20mg daily , K 20 meq twice a day , pravastatin 40mg , colace 100 mg orally twice a day
****ALL: NKDA
****SOC HX: Married. lives in Rhode Island Quit smoking 10 yrs ago. ( + )60 pk-yr.
No EtOH or drugs.
****ADMISSION EXAM:
T 97.5 HR Irreg 76 BP 124/56 O2sat 97% RA
Gen: NAD
HEENT: L surgical pupil. EOMI. MMM. OP clear.
CV: JVP 6cm , irreg , no m/r/g
Pulm: crackles RLL
Abd: soft , umbilical hernia , NTND. +BS
Ext: trace edema LLE , distal pulses not palpable. extremities warm. soft
nodule over left shin likely lipoma , no clubbing/cyanosis.
****ADMISSION LABS: Cr 2.7 , K 4.4 , Hct 37.3 , BNP 896 ( 644-781 ) , INR 1.5
****STUDIES:
EKG - afib 90 , LBBB morphology , L axis deviation , loss of anterior forces
inferior + precordial leads , Qtc 515
CXR - lobectomy staples in RUL , ill defined R basilar opacity ,
mild pulm edema vs. PNA
Renal U/s - nl
ECHO - EF 30% , LVH , inf/post/apical AK + HK of remaining walls ,
RV function low nl , mild LAE , trace to mild MR , mild TR
****
HOSPITAL COURSE BY SYSTEMS and PROBLEMS:
RENAL: *worsening renal insufficiency* patient was admitted with worsening
renal insufficiency. A UA was dirty and urine culture was sent.
patient was not treated with antibiotics , as she was afebrile , asymptomatic ,
and without leukocytosis. Her FeBun was 35.9 , not consistent with
intravascular depletion. On exam , she appeared euvolemic.
A repeat ECHO revealed relatively unchanged systolic function.
A renal ultrasound was within normal limits. It is unclear what
caused the patient's vacillation in renal function. She likely has
a narrow range with respect to ideal volume status. She was continued on her
home torsemide dose while in house. Her weight on discharge was 72.5 kg ( 159
lbs ) , very close to her admission weight of 72.7 kg and to her designated dry
weight of 159 lbs. Her creatinine improved on its own from 2.7 on admission
to 1.9 on the day of discharge. 1.9 represents a value within her
baselne creatinine range of 1.8 to 2.2. She will need close follow up of
her renal function
*hyperkalemia* patient presented with hyperkalemia in setting of worsening renal
insufficiency. Her peak creatinine was 5.5. She recevied kayex on the day of
admission. Subsequent creatinine measurements were in the 4's without
k-binding treatment on the one hand or K supplementation on the other.
patient had been on k supplementation at home. Her orally supplements are being
held on discharge. She will need close follow up of her potassium and
may need to resume supplementation on an outpatient basis.
CV:
*CAD history of multiple PCI* patient was continued on ASA , bb , statin. She was
also started on low dose isordil. Her BP will need close monitoring on this
new medication.
*BP* patient was continued on bb and started on isordil , as above.
On the day of discharge , her standing SBP dropped to 92 from 118 sitting.
Her HR remained in the 70s. She was asymptomatic. In light of these changes ,
she was discharged on torsemide 40 mg orally twice a day , lower than her home dose and
in-hospital dose of 60 mg pO twice a day She was instructed not to walk without
supervision and to stand up slowly from seated position.
*CHF* patient was thought to be clinically euvolemic on exam. Her BNP was in the
800s. Her repeat ECHo showed an EF of 30% , relatively unchanged from
previous ECHO 3/24 She was continued on her home torsemide dose while in
house and discharged on a lower dose of torsemide as described above.
*MVR* Stable.
*afib* patient was rate controlled with bb. Her INR was subtherapeutic on
admission. In light of this , her coumadin dose was increased from 1 to 2
while in house. Her INR rose to 1.9 on discharge. Her coumadin dose was
downgraded to 1. She will need close follow up of her INR.
HEME:
*iron deficiency anemia* patient was continued on iron. Colonoscopy could
be considered but may not be indicated given patient's prognosis from known
lung malignancy.
ONC:
*lung CA* patient has CXR findings likely related to her known
malignancy. She will f/u with her outpatient oncologist.
PULM:
*o2 requirement* patient was noted to desat to 87% while ambulating.
Home O2 was arranged. Etiology of patient's new oxygen requirement likely
relates to underlying lung malignancy , and perhaps to her CHF - although
she appears compensated from that standpoint.
ENDO: *DM* patient was treated with SSI while in house and was discharged on
her home glipizide. She was continued on her home levoxyl.
RHEUM: *gout* patient was continued on her prophylactic allopurinol.
PROPH: nexium/coumadin
****DISCHARGE STATUS: On discharge , patient is afebrile , P 70s SBP 90s-110s
satting 95% 2L. Exam unchanged from admission. hct 31 , Cr 1.9 , INR 1.9
****DISPOSITION: patient is being discharged to home with VNA services
ADDITIONAL COMMENTS: TO physical therapy:
-You were admitted with worsening kidney function. An ultrasound of your
kidneys was normal and your kidney function improved.
-During this hospitalization , we added a new medication called isordil 5
mg three times per day. We decreased your dose of torsemide to 40 mg
two times per day. In addition , we stopped your medication
called potassium. You will have your potassium levels checked and your
outpatient physicians will decide on whether you need to restart potassium
and at what level.
-We arranged for you to have home oxygen. Use it while sleeping and
when you feel short of breath. Do not smoke or cook on the stove while
using oxygen. Stay away from open flames.
-Do not stand up quickly from a seated position and do not
walk without supervision. We noticed your blood pressure is lower
when you stand and we do not want you to get dizzy and fall , especially as
you are on coumadin. Do not drive.
-Return to the emergency room or call your doctor if you have increasing
shortness of breath , weight gain , chest pressure or jaw pain , dizziness ,
lightheadedness , palpitations , abdominal pain , vomiting , or diarrhea.
-Take prescription for blood draw to PUO on 11/25 Have INR , chem 7 , and
magnesium checked. As per script , results should be faxed both to Dr. Kum Pidro fax 934-555-1526 and to Dr. Coletta Verry tel 575-803-4363
To VNA:
-monitor O2 sat on home O2
- do heart rate and blood pressure check
- check weight - notify Dr. Coletta Verry 575-803-4363 if weight
increases or decreases by 2 pounds in 3 days
DISCHARGE CONDITION: Fair
TO DO/PLAN:
primary care physician/cards:
-Monitor creatinine. patient's creatinine improved from 2.7 to 1.9. Baseline
1.8-2.2 in past. FeBUN was 35.9% and BUN/Cr ratio was 20. We continued
torsemide 60mg orally twice a day Renal ultrasound was normal bilaterally.
-Monitor potassium. patient's K decreased from 5.5 to 4.1. She did not
require potassium supplementation while in the hospital. Her outpatient
dose of potassium was held. This may need to be restarted if her potassium
decreases below 4.
-F/u official results of urine culture , send secondary to dirty UA.
patient not treated as afebrile , asymptomatic , nl wbc count.
-Monitor hct - stable in low 30s. patient has known iron deficiency anemia
and is on iron.
-Monitor INR on coumadin. Goal INR is 2-3. patient had been on 1 mg orally every day
coumadin at home. Her INR on admission was 1.5. She was treated with
coumadin 2 mg orally every day Her INR rose to 1.9 on the day of discharge. She was
discharged again on coumadin 1 mg orally every day VNA should draw her INR on 4/29
and fax results to her primary care physician.
-Monitor blood pressure on isordil. On low dose 5mg orally three times a day currently.
-Monitor SOB on home o2. patient desatted to 87% while ambulating on RA. Her
subjective shortness of breath improves tremendously on 2L. PET scan
suggests progressive lung CA.
-Patient is DNR/DNI and her healthcare proxy is her husband.
No dictated summary
ENTERED BY: TROOP , WILFREDO V. , M.D. ( HK24 ) 1/8/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 824
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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117585063 | PUO | 19549965 | | 099734 | 6/2/1999 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 1/10/1999 Report Status: Signed
Discharge Date: 6/6/1999
PRINCIPAL DIAGNOSIS: Atrial flutter.
PROBLEMS: Coronary artery disease. New atrial fibrillation..
HISTORY OF PRESENT ILLNESS: Mr. Berne is a 50 year old
gentleman with a history of coronary
artery disease status post two vessel coronary artery bypass graft
( CABG ) performed at I Warho Hospital two weeks prior to
his admission. He presents with three days of palpitations. On
18 of June , Mr. Berne underwent cardiac catheterization which showed
100% occlusion of the proximal LAD and 70% occlusion of the
circumflex. He subsequently had a two vessel CABG at I Warho Hospital with attachment of the LIMA to the LAD and the left
radial artery to the circumflex. Postoperatively he went into
atrial fibrillation which later converted to normal sinus rhythm ,
and he was discharged in stable condition on 24 of August on a medical
regimen of aspirin 325 mg every day , diltiazem 30 mg three times a day to prevent
vasospasm of radial artery , Atenolol 25 twice a day Three days prior to
this admission , the patient noted palpitations of his heart with
fluttering of the neck associated with clamminess and diaphoresis.
He felt no chest pain , no nausea , vomiting , or shortness of breath ,
but VNA noted that his 150 beats per minute. The patient presented
to the Stusri Medical Center emergency room on 10 of June where EKG showed
him to be in atrial fibrillation alternating with atrial flutter
with a two-to-one block. An echocardiogram performed in the
emergency room showed an ejection fraction of 54% with a mild
pericardial effusion. By report from Stusri Medical Center , the
patient converted to normal sinus rhythm. He was sent home on his
previous medical regimen of Atenolol and aspirin with an increased
dose of diltiazem to 60 three times a day The patient felt well on discharge
with no chest pain , shortness of breath , abdominal pain , and no
syncope. Laboratory studies in the Kernan To Dautedi University Of Of emergency room showed
low CK of 31 with troponin of 0.3 , magnesium 2.4. On the morning
of admission , 17 of May , the patient noted palpitations again with a
rapid heart rate to 140 to 150. He presented to the Gle Ra Csylv Valley Medical Center emergency room. As previously , the patient denied
associated symptoms of chest pain , shortness of breath , nausea ,
vomiting , abdominal pain , back pain , PND , or orthopnea.
PAST MEDICAL HISTORY: 1. Status post myocardial infarction 1994.
2. Coronary artery disease.
3. Parathyroidectomy 1978 for parathyroid nodule. 4. Status post
CABG January , 1999. 5. Status post arthroscopic knee surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg every day. Diltiazem 60 mg
three times a day Atenolol 25 mg twice a day Percocet
one to two every day as needed pain. Pravachol 40 mg every bedtime
SOCIAL HISTORY: The patient is a former medical assistant who
lives with his wife. He has a four to five pack
year smoking history having quit 25 years ago and drinks occasional
alcohol. No intravenous drug use.
FAMILY HISTORY: Positive for an uncle who died of myocardial
infarction at an early age.
PHYSICAL EXAMINATION: Temperature 100.1 F , heart rate 130 to 140
regular , blood pressure 108/74 , respiratory
rate 16. O2 saturation 96% on room air. The patient was an obese
Caucasian male in no apparent distress. HEENT exam revealed pupils
equal , round , and reactive to light. Extraocular muscles intact.
Oropharynx clear with no exudate or erythema. Neck supple with no
cervical or supraclavicular lymphadenopathy , no thyroid
enlargement. Chest - full , symmetric expansion. Clear to
auscultation with no rales or wheezes. Well healed sternal
surgical scar. Cardiovascular exam - jugular venous pressure at 8
cm. Normal S1 and S2. Rhythm irregularly irregular. No murmur ,
S3 , or S4. Carotid pulses 2+ bilaterally , no bruits. Abdominal
exam , soft , nontender , nondistended , no organomegaly , plus bowel
sounds. Extremities , no cyanosis , edema , or tenderness , warm and
well perfused with 2+ dorsalis pedis pulses bilaterally.
Neurological exam , alert and oriented X3. Cranial nerves II
through XII intact. Motor and sensory exam normal with 2+ patellar
reflexes , toes down going.
LABORATORY: On admission showed sodium 142 , potassium 4.4 ,
chloride 102 , CO2 26 , BUN 13 , creatinine 0.9 , glucose
104. White blood cell count 6.68 , hematocrit 31.0 , platelets 299.
18% lymphocytes , 71.8% neutrophils. physical therapy 12.9 , INR 1.2 , PTT 24.4.
CK on admission 28. CT 0.08.
Chest x-ray showed a right pleural effusion but no evidence of
congestive heart failure or infiltrate.
EKG showed atrial fibrillation at 130 beats per minute. Normal
axis with Q waves in 3 , AVF , V1 through V4. Unchanged from
previous EKG.
Calcium 8.7 with an albumin of 3.4.
HOSPITAL COURSE: The patient was treated with a medical regimen on
admission of increased Atenolol to 50 twice a day ,
continued diltiazem at 30 mg three times a day , continued aspirin. Was loaded
with heparin bolus of 5000 , and loaded with procainamide at a rate
of 750 mg every 6 hours Despite loading with procainamide for a total
of 5.25 grams over 36 hours , the patient maintained rhythm of
atrial flutter with two to one block throughout his hospital course
with occasional variable conduction of three to one block
alternating with two to one block , occasional breaks to atrial
fibrillation. An echocardiogram was performed in hospital on
27 of February which showed an ejection fraction of 30% decreased from 45%
on his last Gle Ra Csylv Valley Medical Center echocardiogram dated October , 1999.
The echocardiogram from 27 of February also showed left ventricle normal
in size with moderate concentric LVH , reduced LV function , left
atrium enlargement , with no evidence of thrombus. Normal valves
with a small pericardial effusion. Other causes for atrial
fibrillation were considered. TSH came back normal at 3.1. New
onset atrial fibrillation and atrial flutter was felt to be
consistent with pericardial inflammation post surgery. The patient
was maintained on procainamide throughout duration of stay. Dose
was increased on 16 of November to procainamide SR 1000 mg four times a day
However , this attempt at pharmacological cardioversion did not
succeed in attaining normal sinus rhythm. The patient was
presented with option of two to three weeks anticoagulation as an
out patient with rate control on Atenolol and diltiazem to be
followed by elective DC cardioversion at the end of three weeks.
Also discussed was the option of performing a transesophageal echo
followed by in house DC cardioversion. The patient and Dr.
Meduna chose the first option. The patient was started on
Coumadin and attained INR of 1.7 by the day of discharge , 8 of May
Although patient had maintained atrial flutter rhythm throughout
hospital stay , hemodynamically had been stable with pulse ranging
between 76 to 110 with occasional tachycardia during activity and
during the morning hours ranging from 120 to 130. Blood pressure
ranged between 90 to 110 systolic pressure. There was a
significant concern regarding the patient's decreased ejection
fraction to 30% from preoperative 45% , felt to be possibly
secondary to negative inotropic medications as well as atrial
fibrillation with rapid ventricular response. However , could not
rule out possibility of new infarct or ischemia causing decreased
LV function. In addition to his previous medications , the patient
was discharged on Digoxin .25 mg every day and with instructions to
follow up with Dr. Meduna regarding his dose of procainamide
as well as the possibility of adding a low dose ace inhibitor.
Patient will be followed by VNA Services and by Anticoagulation
Service managed by Cora Chilo for INR monitoring and will return
to I Warho Hospital in two to three weeks for elective DC
cardioversion.
MEDICATIONS ON DISCHARGE: Aspirin 325 mg every day. Atenolol 50 mg
twice a day Diltiazem 30 mg three times a day
Procainamide SR 1000 mg four times a day Coumadin 5 mg every bedtime Pravachol 40
mg every bedtime Digoxin 0.25 mg every day. Colace 100 mg every day. Captopril
12.5 mg every day to be filled only on specific instructions by Dr.
Stroder
FOLLOW UP: The patient will follow up with Dr. Meduna on
Monday , 8 of April , by phone regarding medication changes
and will return to I Warho Hospital in two to three weeks
for DC cardioversion.
The patient and his wife will continue to monitor heart rate and
blood pressure with home blood pressure cuff to follow vital signs
and have been instructed to call Dr. Meduna if heart rate
exceeds 140 beats per minute or if patient experiences symptoms of
chest pain , shortness of breath , or increased palpitations , as well
as sign of blood in stools or excessive bruising.
The patient was discharged to home with VNA services in stable
condition.
Dictated By: AMIEE DELK , H.M.S.3
Attending: LEOLA C. MUSICH , M.D. VG64
LL440/0970
Batch: 29503 Index No. TGGTU47R8S D: 3/11/99
T: 10/2/99
CC: 1. MALINDA M. POLO , M.D. PH8
2. LEOLA C. MUSICH , M.D. VG64
3. ROBIN JARRARD , M.D. Ri Kee Villemerlos
Document id: 825
| Target |
Ast |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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958458341 | PUO | 53494999 | | 607945 | 2/6/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/29/1996 Report Status: Signed
Discharge Date: 4/16/1996
PRINCIPAL DIAGNOSIS: NON Q WAVE MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old woman with mild
mental retardation , schizophrenia , and
borderline diabetes mellitus who was transferred from Whid Downdoc Rehabilitation Of for further cardiac evaluation after a non Q wave
myocardial infarction. She was in her usual state of health until
August 1995 when her family reports she began to have
intermittent abdominal pain and shortness of breath. It continued
to worsen until October 1996 when she presented to her primary
medical doctor and was diagnosed with a upper respiratory infection
and treated with antibiotics and Theo-Dur. At that time , the
family noticed she had an increasing shortness of breath , lethargy ,
and now significant weight gain. They reported about 35 lb per
week. On the date of admission to the Whid Downdoc Rehabilitation Of , she was
ambulating , but became extremely short of breath with severe
abdominal pain. They took her to the hospital and she was admitted
for what they thought was primary gastrointestinal process , but
they noted increasing GGTs without alkaline phosphatase changes in
her laboratory panel. She was placed on a rule out myocardial
infarction protocol and subsequently ruled in for a non Q wave
myocardial infarction with CKs of 235 , 6.3% , 246 , 7.7% MBs and 197 ,
7.6% MBs. Her EKG showed anterolateral myocardial
infarction/ischemic myocardial infarction. Her echo at Whid Downdoc Rehabilitation Of showed decreased LV function per report. Since admission
there , she had had repeated episodes of chest pain/abdominal
discomfort from 7/11/96 to 5/25/96 , and she was transferred to
the Pagham University Of for further evaluation.
PAST MEDICAL HISTORY: Mild mental retardation , schizophrenia ,
borderline diabetes mellitus , and morbid
obesity.
FAMILY HISTORY: The patient has had a history of thyroid problems
in her family. She has a history of coronary
artery disease in her family. She lives with her sister. Her
daughters are in the area. Her cardiac risk factors include family
history , borderline hypertension. She does not smoke or drink.
PHYSICAL EXAMINATION: The patient is an obese woman in no obvious
distress. The patient had dry mucous
membranes. Her neck and JVP were difficult to assess secondary to
body habitus. She had a left IJ catheter in place. She had
distant heart sounds without murmurs , rubs , or gallops. Lungs had
crackles 1/4 of the way up bilaterally. Abdomen was markedly obese
with a right upper quadrant tenderness to deep palpation. She had
edema from her feet up to her abdominal canis. She had 4+ edema to
her hips. There were 2+ pulses DP and physical therapy. Femoral pulses were
difficult to assess. The patient was alert and oriented times
three and able to understand questions , but she had decreased
verbal skills.
LABORATORY DATA: SMA-20 and CBC were within normal range. Her
LDH was slightly elevated at 419 , alkaline
phosphatase elevated at 746. Total protein was decreased at 6.4 ,
albumin decreased at 3.6. Her digoxin level was 0.4. She was on
heparin with a PTT of 58.8. EKG showed a sinus rhythm of 89 , poor
R wave progression , old ischemic myocardial infarction , T wave
inversions in 1 , L , and V5-V6. Chest x-ray , by report from Whid Downdoc Rehabilitation Of , showed mild cardiomegaly , pulmonary venous
hypertension , elevated right hemidiaphragm.
HOSPITAL COURSE: On transfer , the patient was evaluated with an
echocardiogram which showed global hypokinesis
with an ejection fraction of 20% and severely dilated heart.
Cardiac catheterization was contemplated to rule out ischemia as
her source of cardiomyopathy , but given that catheterization would
likely require intubation secondary to sedation given her psych
issues , the decision was made to pursue a more conservative course
with treatment of medication. She was aggressively treated for
congestive heart failure with digoxin , Ace inhibitor , and intravenous Lasix
and she continued to get intravenous Lasix twice a day 40 mg. She remained
stable while in the hospital and , after several days of diuresis ,
her edema slowly improved. Her breathing improved and she began to
ambulate. She lost approximately 8 kg while in hospital.
Her second issue was gastrointestinal. She continued to have , on
admission , an elevated LDH and alkaline phosphatase in the absence
of significant transaminases , it was not consistent with passive
congestion alone. We continued to follow them and they eventually
drifted down. The source of her elevations were never clear. We
checked the ammonia level which was normal and a sedimentation rate
which was normal.
Her third issue was Infectious Disease. Her urine , by report at
Whid Downdoc Rehabilitation Of , had greater than 10-15 E.coli. She was not
treated with antibiotics. We repeated the urinalysis here and
began ampicillin on orally for a urinary tract infection , which she
continued for a full 10 day course. They felt that her urinary
tract infection was secondary to limited ambulation and her body
habitus.
The fourth issue was fluids , electrolytes , and nutrition. She had
total body edema and anasarca with slightly decreased protein and
albumin , but most likely secondary to severe congestive heart
failure. Her mucous membranes were dry , but felt this was
secondary to her breathing and possible intervascular depletion.
All of these issues cleared as she was diuresed.
The fifth issue was psych. We continued her medications and
contacted her family for support while she was in the hospital.
The patient did well and once she was able to walk around with
physical therapy , she was discharged on Lasix , digoxin , and with
VNA.
DISCHARGE MEDICATIONS: Elavil 50 mg orally every bedtime , aspirin ECASA
325 mg orally every day , Cogentin 1 mg orally
twice a day , digoxin 0.125 mg orally every day , Lasix 60 mg orally twice a day ,
Haldol 10 mg orally every day , Ativan 1 mg orally twice a day , and lisinopril 20
mg orally twice a day
DISCHARGE CONDITION: She is being discharged in stable condition
with VNA follow up.
Dictated By: GWYNETH A. DEPSKY , M.D. AS80
Attending: IRVING M. ESCALANTE , M.D. NL16
GD879/8759
Batch: 83812 Index No. Y7TYYK3NJH D: 1/2/96
T: 8/25/96
CC: 1. SWISS , SHONNA LAVONA G. NL16
2. FANIEL none
Document id: 826
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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545309959 | PUO | 87447111 | | 564292 | 11/26/1997 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | Signed | DIS | Admission Date: 10/20/1997 Report Status: Signed
Discharge Date: 2/3/1997
ADMITTING DIAGNOSIS: ASTHMA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE
FLARE.
DISCHARGE DIAGNOSIS: ASTHMA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE
FLARE.
CORONARY ARTERY DISEASE , STATUS POST CORONARY
ARTERY BYPASS GRAFT IN 1994.
INSULIN DEPENDENT DIABETES MELLITUS.
PAROXYSMAL ATRIAL FIBRILLATION.
DEGENERATIVE JOINT DISEASE.
STATUS POST BILATERAL TOTAL KNEE REPLACEMENT.
STATUS POST PARATHYROIDECTOMY.
CHRONIC RENAL INSUFFICIENCY.
BILATERAL CATARACTS.
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old female ,
with a history of coronary artery
disease , chronic obstructive pulmonary disease , and diabetes , who
presented with chest tightness and a nonproductive cough. The
patient basically complained of a two to three day history of
cough , congestion , and wheezing. She had a productive cough
productive of white clear sputum. The patient also stated that her
respirations were accompanied by chest tightness , different from
her angina equivalent. The patient denied fevers , chills , night
sweats , or dizziness. She had no diarrhea , nausea , or vomiting.
The patient initially presented to Akcare Hospital where chest
x-ray was clear , without evidence of infiltrate. The patient was
transferred to I Warho Hospital Emergency Department for
further evaluation. In the Emergency Department at PUO , it was
felt that the patient deserved admission to the Short Stay Unit for
very mild congestive heart failure exacerbation and bronchospastic
episode. The patient was given one dose of Solu-Medrol 80 mg
intravenously and transferred up on Albuterol and Atrovent
nebulizers. Of note , the patient had a history of increased
glucose intolerance on steroids. She also had pulmonary function
tests on 10 of February which demonstrated an FEV1 of 1.27 which was 69%
of predicted and an FVC of 1.75 which was 75% of predicted.
Echocardiogram in September 1994 demonstrated mild to moderate decreased
left ventricular function with regional wall motion abnormality
consistent with her old apical septal and inferobasilar infarcts.
Ejection fraction at that time was 45%. The patient had previously
been treated with Biaxin and then switched to Augmentin in the
Short Stay Unit for treatment of possible bronchitis. Other issues
in the Short Stay Unit were a question of an infection of the left
great toe with a history of diabetes. The patient was transferred
to Grand on 6 of February in stable condition.
PAST MEDICAL HISTORY: 1 ) History of congestive heart failure.
2 ) Coronary artery disease , status post
coronary artery bypass graft in 1994 , LIMA to LAD and an SVG graft
to OM1 , distal OM1 and RCA. 3 ) Insulin dependent diabetes.
4 ) Paroxysmal atrial fibrillation. 5 ) Degenerative joint disease.
6 ) Asthma/chronic obstructive pulmonary disease. 7 ) Status post
bilateral total knee replacements. 8 ) Status post
parathyroidectomy for hyperparathyroidism. 9 ) Chronic renal
insufficiency. 10 ) Status post brown tumor excision of the right
radius. 11 ) Constipation. 12 ) Rectocele repair in February 1997.
13 ) Cataracts.
ALLERGIES: The patient is allergic to Bactrim which causes rash.
MEDICATIONS: Medications on transfer from the Short Stay Unit
included Atrovent nebulizers .5 every 4 hours , Mevacor 20 mg
every day , Premarin .625 mg every day , Cardizem CD 300 mg per day , Vasotec
7.5 mg every day , enteric coated aspirin 81 mg every day , calcium carbonate
625 mg every day , Colace 100 mg twice a day , vitamin C 500 mg per day ,
Prednisone 40 mg per day , sliding scale insulin NPH 12 units in the
morning and 5 units at night , Lasix 20 mg per day , Albuterol
nebulizer 2.5 mg every 3 hours , Augmentin 250/125 mg three times a day , and Lotrimin
1%.
SOCIAL HISTORY: The patient lives with her husband and grown
children in Riry Street , Green Xing Tempe The patient denied tobacco
or ethanol history.
PHYSICAL EXAMINATION: On admission , this was an elderly female
sitting in a chair in no apparent distress.
Vital signs included temperature of 97.1 , heart rate 84 , blood
pressure 128/78 , and breathing of 99% on 3 liters. HEENT: Pupils
were equal , round , and reactive to light. Extraocular movements
were intact. Moist mucous membranes were noted. Oropharynx was
clear , without lesions. Neck had 2+ carotid pulses bilaterally
without bruits. Jugular venous pressure was estimated at
approximately 5 cm. Lungs had a few end expiratory wheezes
bilaterally at the bases. Heart revealed a regular rate and rhythm
with normal S1 and S2 and no rubs , gallops , or murmurs. Abdominal
exam was soft , with positive bowel sounds , nontender , nondistended ,
with no hepatosplenomegaly. Extremities demonstrated 1+ peripheral
pulses bilaterally. Status post bilateral total knee replacement
scars were notable. There were 1+ femoral pulses. She had a left
great toe with tenderness and erythema. No lymphangitic changes
were appreciated.
LABS ON TRANSFER: Sodium was 137 , potassium 4.4 , chloride 105 ,
bicarbonate 23 , BUN 49 , creatinine 1.6 , glucose
129. Iron was 76 , ferritin 236. White count was 16.5 , hematocrit
33.3 , and platelets 255 , with an MCV of 89.7. Chest x-ray
demonstrated elevated left hemidiaphragm with minimal atelectasis
at the left base. Lungs were clear. She was status post coronary
artery bypass grafting. Pulmonary vasculature was normal. She had
notable degenerative joint disease of the thoracic spine. There
was no evidence of acute disease. ECG demonstrated normal sinus
rhythm at 70 beats per minute with left atrial enlargement , poor R
wave progression , old Q's in 3 , and no acute ST-T wave changes.
ASSESSMENT: The assessment for this woman was an acute chronic
obstructive pulmonary disease/bronchospastic airway
disease exacerbation , as well as left great toe infection.
HOSPITAL COURSE: 1 ) Pulmonary: The patient was initially admitted
on 21 of September to the Short Stay Unit as stated in
the history of present illness and received one dose of Solu-Medrol
intravenously in the Emergency Department and then started on
Prednisone 40 mg orally every day She was also placed on Atrovent and
Albuterol nebulizers. The patient noted slow improvement in
symptoms , as well as peak flows. Peak flow initially on admission
was around 200 and on transfer from the Short Stay Unit was about
250. Once the patient was transferred to the floor , she had noted
significant improvement , requiring decreased 02 , essentially to
require no 02 on 11 of April with an 02 saturation of 96%. The
patient was changed to metered dose inhalers with Aerochamber on
11 of April which consisted of Serevent two puffs twice a day , Vanceril
four puffs twice a day , and Albuterol two puffs four times a day , with noted
improvement. The patient was also continued on 40 mg of Prednisone
orally every day , as well as Augmentin for question of bronchitis. On
26 of July the patient was found to have slight scattered end
expiratory wheezes , however , was moving good air. It was decided
to discharge the patient from a pulmonary standpoint on Vanceril
four puffs twice a day , Serevent two puffs twice a day , and Albuterol two
puffs four times a day for seven days , then as needed The patient's peak flow
on the day of discharge was approximately 250 as well , however ,
notable symptomatic improvement was achieved. The patient is to
follow-up with Dr. Burle in one week.
2 ) Left great toe cellulitis. An infectious disease consult was
obtained , and it was felt that bone films would be in order to rule
out any evidence of chronic osteomyelitis as well as to continue
on Augmentin 250 mg three times a day Bone films were obtained which were
negative for any evidence of chronic osteomyelitis. Subsequently ,
ESR was checked which was elevated at 73. As well , a bone scan
obtained to rule out chronic osteomyelitis of the left great toe ,
the results of which on the preliminary reading were as follows.
The right foot was diffusely hyperemic. The left foot potentially
could be underperfused in relation to the right foot secondary to
diabetic vascular changes. On the delayed images , the right second
proximal phalanx had a slight prominence. The left second
metatarsophalangeal joint had a slight prominence. She also
demonstrated an abnormal right mid foot at the proximal
metatarsophalangeal joints of the medial three metatarsals ,
possibly consistent with neuropathic joint. There was also a
prominence of bilateral tibial components of the knees which could
be suggestive of prosthetic loosening , however , this was not
confirmed by clinical exam. In essence , there was no evidence of
chronic osteomyelitic changes. Therefore , it was decided to
continue a total of a 14 day course of Augmentin 250 mg three times a day
for this issue. If symptoms were to worsen or not improve fully ,
the patient is to follow-up again with her primary medical doctors ,
Dr. Heam or Dr. Burle , as well as potentially setting her up in
the Infectious Disease Clinic for further follow-up.
3 ) Miscellaneous. As to the remainder of her medical issues , the
patient was maintained on her home medications and demonstrated no
issues. Therefore , the patient was discharged on 26 of July in
stable condition.
FOLLOW-UP: The patient is to make an appointment and follow-up
with Dr. Burle for her chronic obstructive pulmonary
disease/asthma flare. She is also to follow-up with Dr. Heam in
three weeks to one month for her endocrinologic issues. VNA will
check glucose measurements twice a week , the results of which are
to be called in to her endocrinologist.
DISCHARGE MEDICATIONS: Augmentin 250 mg orally three times a day with food
times 11 more days , enteric coated aspirin
81 mg every day , calcium carbonate 625 mg every day , Cardizem CD 300 mg per
day , Premarin .625 mg every day , Mevacor 20 mg at night , Proventil MDI
with spacer two puffs four times a day times seven days then as needed , Colace
100 mg twice a day , vitamin C 500 mg every day , Prednisone taper 40 mg times
one day then 30 mg times three days then 20 mg times three days
then 10 mg times three days , NPH Insulin 12 units subcutaneously
every day before noon and 5 units subcutaneously every afternoon , regular insulin 4 units
subcutaneously every day before noon and 6 units subcutaneously every lunch and 4
units subcutaneously every afternoon , Lasix 20 mg every day , Serevent two puffs
orally twice a day , Vanceril four puffs twice a day , and Lotrimin 1% Cream.
DIET: Low salt , low fat , low cholesterol , ADA.
ACTIVITIES: As tolerated.
Dictated By: ANJELICA SWARTZBECK , M.D. FW96
Attending: GENNY S. BARRETTE , M.D. CE9
OW888/0489
Batch: 39586 Index No. V3CYPG10PO D: 1/10/97
T: 3/25/97
Document id: 827
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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593109802 | PUO | 52570701 | | 115127 | 4/24/1997 12:00:00 a.m. | UNSTABLE ANGINA | Unsigned | DIS | Admission Date: 4/26/1997 Report Status: Unsigned
Discharge Date: 5/23/1997
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
PROCEDURE PERFORMED: Four vessel coronary artery bypass graft.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old woman
with a history of chronic renal
failure , hypertension , diabetes mellitus and morbid obesity with a
long history of coronary artery disease and angina. The patient
presented to the hospital with recurrent chest tightness with
radiation to her left arm associated with shortness of breath ,
nausea , vomiting and headache. The patient had similar episodes in
the same prior to presentation. These are not associated with
exercise which was new for her.
In the emergency room the patient received aspirin and nitro-paste
along with beta blockers. Her EKG at that time demonstrated 2 to 3
mm ST depressions in her lateral leads. CK at that time was 634
with an MB of 30. Her troponin I came back at 12.8. The patient
was admitted at that time with a diagnosis of nonQ-wave myocardial
infarction.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes mellitus.
Hypertension. Morbid obesity. Cataract
surgery. Coronary artery disease. Angina ( As above ).
MEDICATIONS: Hytrin 20 mg every bedtime , Humulin NPH 175 mg every day before noon ,
45 every afternoon , Regular 45 every day before noon , 10 every afternoon ,
lisinopril 40 mg every day , Micronase 10 mg twice a day , Verapamil SR 240 mg
twice a day
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: She was a morbidly obese woman in no
apparent distress. Blood pressure 142/74 ,
pulse 78 , respiratory rate 20 , temperature 99.9 , sats are 97% on
four liters. HEAD , EYES , EARS , NOSE AND THROAT: No dental
pathology. Oropharynx is clear. Sclerae are anicteric. Neck -
Supple with full range of motion. There is no jugular venous
distention. No carotid bruits. Cardiac - Revealed a regular rate
and rhythm , normal S1 and S2 without murmurs , rubs or gallops.
Lungs are clear to auscultation bilaterally with minimal crackles
at the bases. Abdomen - Benign with positive bowel sounds and no
masses identified. Extremities - Without edema and without venous
varicosities. Distal pulses were 2+ bilaterally. Neurological -
Nonfocal. Rectal - Guaiac negative.
LABORATORY DATA: Admission - Significant for a glucose elevated
at 211 , but otherwise normal.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service and ruled in for nonQ-wave myocardial
infarction. She underwent cardiac catheterization 7 of February where a
100% proximal dominant circumflex artery stenosis was noted along
with 60% proximal LAD and 80% RCA stenosis.
The patient underwent PCA of her circumflex which at that time was
not successful. Postoperatively she did well , but had persistent
chest pain. She did underwent cardiac catheterization 27 of June
which revealed 40% residual stenosis of the dominant left
circumflex. At that time , coronary steps were placed. The patient
however , continued to experience substernal chest pain and dyspnea
over the ensuing days. The patient also experienced flash
pulmonary edema and was transferred to the Coronary Care Unit. At
that time it was decided that her attempts at angioplasty were
unsuccessful. She was evaluated for coronary artery bypass
grafting.
She was taken to the operating room on 3 of September where she underwent
four vessel bypass ( LIMA to LAD , saphenous vein graft to R1 and
then jumped to OM and lastly saphenous vein graft to PDA ). She
tolerated this procedure well and was transferred to the Cardiac
Intensive Care Unit. She was maintained on triple antibiotics to
cover the potential sequela of a superficial cordis site skin
infection. Sputum sent from postoperative day #1 demonstrated
Pseudomonas in her sputum. Chest x-ray showed the evolution of a
right basilar consolidation. She was placed on ofloxacin and
piperacillin to cover the Pseudomonas. She was slow to extubate
but ultimately did on 18 of May The rest of her postoperative course
was significant for steady wean of her oxygen requirement with
concomitant aggressive diuresis. She was covered with ofloxacin
and piperacillin throughout the rest of her hospital course with
resolution of her right lower lobe pneumonia demonstrated on chest
x-ray. She experienced no further substernal chest pain during her
hospitalization.
In the immediate postoperative period , she did experience some
confusion but this resolved spontaneously and her neurological exam
was completely nonfocal.
The patient was evaluated by physical therapy and it was their
assessment that she was somewhat unable and given her living
situation , she was recommended for rehabilitation.
Additionally , her leg wounds and her chest wound have continued to
drain somewhat throughout the hospital course. There is no
apparent evidence of significant infection in either site. If some
minor infection were to develop , it should be covered adequately
with the ofloxacin or piperacillin that she is currently taking.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Colace 100 mg orally three times a day , insulin NPH 60
units in the morning , 20 units in the evening , lisinopril 10 mg
every day , Percocet 1-2 tabs orally q3-4h , Verapamil 80 mg three times a day ,
piperacillin 3 grams intravenous every 4 hours for an additional four days from the
time of discharge. Ofloxacin 400 mg orally twice a day for an additional
four days , Lopressor 25 mg orally twice a day , Albuterol inhalers two
puffs three times a day as needed wheezing.
DIET: Low fat ADA diet , 1800 calories a day.
ACTIVITIES: As tolerated.
FOLLOW-UP: Dr. Colasamte in four weeks , cardiologist in one week.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To rehabilitation.
Dictated By: LORRETTA P. CRIDGE , M.D. UO87
Attending: ISABELLE E. COLASAMTE , M.D. CL7
RQ854/1636
Batch: 6247 Index No. LDWV2Q42OI D: 6/9/97
T: 6/9/97
Document id: 828
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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864945124 | PUO | 81278338 | | 132143 | 8/18/1997 12:00:00 a.m. | FAMILIAL CARDIOMYOPATHY | Signed | DIS | Admission Date: 4/12/1997 Report Status: Signed
Discharge Date: 7/26/1997
SERVICE: Pro Cin Co
PRINCIPAL DIAGNOSIS: CARDIOMYOPATHY.
OTHER SIGNIFICANT PROBLEMS: None.
CHIEF COMPLAINT: The patient was admitted with a one month history
of increasing shortness of breath , decrease in
exercise tolerance , and two week history of indigestion , diarrhea ,
and mild abdominal discomfort.
HISTORY OF PRESENT ILLNESS: Mr. Kinkle is a 29 year old
gentleman with familial cardiomyopathy
diagnosed at age 18. Cardiac catheterization in 1987 revealed a
PCWP 13 , CI 3.8 , no coronary artery disease or valvular problems ,
and a moderately enlarged diffusely hypokinetic left ventricle , EF
31%. , RA 8 , PA 27/12 , SVR 779. Approximately four to six years
ago , he began having increased shortness of breath and was started
on digoxin , Lasix , and Vasotec at that time. A follow-up echo in
1993 revealed an EF of 25% to 30% with moderate dilation of all
four heart chambers , left atrial size of 4.2 with 2+ TR and 3+ MR.
ETT on August 1994 was 9 minutes and 4 seconds in duration
revealing only nonspecific 1 mm ST depression , V4 through V6 , and
MV O2 of 17.0 ml/min/kg. He continued on his medical regimen until three
months prior to this hospital admission when he began to lose
weight ( approximately 35 lbs. at this time by the patient's
report ) , and one month ago , he noticed that he was increasingly
short of breath. He has two pillow orthopnea which has not
changed. He has occasional paroxysmal nocturnal dyspnea and
occasional palpitations. He denies any chest pain or peripheral
edema. He also notes that his exercise tolerance has been greatly
decreased. His Lasix dose was increased recently in clinic as
well. Furthermore , beginning approximately two weeks prior to
admission , he began to complain of indigestion , diarrhea ,
intermittent nausea and vomiting , and abdominal pain. He has had
multiple watery brown stools each day without hematochezia , melena
or fevers. He presented to the Emergency Department four days
prior to admission with these complaints with negative workup at
that time. Most recent Echo on October revealed EF at 24%
with global decreased function , 3+ TR , 4+ MR , left atrial size 5.7 ,
right ventricular enlargement with peak RV pressure greater than
58 , and no thrombus. Last ETT on 5/25 was 7 minutes and 31 seconds
in duration. MV O2 of 15.9 with peak uptake above the anaerobic
threshold.
PAST MEDICAL HISTORY: As above , also status post appendectomy and
tonsillectomy in the past.
MEDICATIONS: Vasotec 5 every day; Lasix 80 mg every day: digoxin 0.25 mg
every day.
ALLERGIES: NKDA.
HABITS: Occasional ETOH on weekends , approximately three to four
beers. Positive tobacco use approximately one pack per
day times ten years which he reports to have stopped two weeks ago.
Also history of marijuana use which he has stopped two weeks ago.
FAMILY HISTORY: Notable for a mother , sister , brother , and
numerous other relatives with cardiomyopathy.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: He is a thin white male in no acute
distress. Blood pressure 108/80 , pulse 89
and regular , respirations 22 , temperature 99.3. O2 sat 95% on room
air. Weight 70.5 kg. HEENT: Benign. NECK: CVP is 10 cm;
however pulses are 2+ without bruit. LUNGS: Clear to auscultation
bilaterally. HEART: Notable for regular rate and rhythm; III/VI
holosystolic murmur radiating to the axilla; S3 and S4 present;
apical end pulses inferolaterally displaced and enlarged. ABDOMEN:
Palpable pulsatile liver which is 3 cm below the costal margin ,
nontender. Abdomen is nontender , nondistended with good bowel
sounds present. No splenomegaly. EXTREMITIES: No edema present.
Extremities warm and dry with 2+ pulses bilaterally. Tinea
infection present in the axilla and groin. NEUROLOGIC: Alert and
oriented time three. Cranial nerves III-XII were grossly intact.
Motor strength was 5/5 throughout. Toes are downgoing bilaterally.
LABORATORY STUDIES: Sodium 137 , potassium 4.1 , chloride 99 ,
bicarbonate of 28 , BUN 18 , creatinine 1 ,
glucose 91 , ALT 249 , AST 140 , LDH 228 , alk phos 48 , total bilirubin 1.2 ,
direct bilirubin 0.6. White blood cell count 5.4 , hematocrit 35.2 ,
platelets 186. Albumin 3.2 , uric acid 10.3. EKG is normal sinus
rhythm at 97. No ST changes or Q waves present. Positive LVH.
Chest x-ray was without edema or infiltrate. Cardiomegaly is
present. Enlarged pulmonary arteries. Cardiac catheterization
revealed pulmonary capillary wedge pressure at 28 , pulmonary artery
70/30 , RV 70/8 , right atrium 12 , mixed venous saturation 45% , SVC
saturation 95%.
HOSPITAL COURSE: Following cardiac catheterization , Mr. Mclaney
was admitted for tailored therapy , and was
started on nitroprusside in addition to intravenous diuresis with Lasix ,
Captopril , and Isordil. Digoxin was continued , and he was sodium
and fluid restricted. He was also admitted for a transplant
evaluation. As part of his workup , hepatitis serologies were sent ,
as well as out of concern for his elevated LFTs. These were
negative , except for a borderline hepatitis B antibody. LFTs
gradually decreased throughout his hospitalization , and were likely
elevated due to passive congestion due to heart failure. Also
alcohol use is possible but less likely due to the pattern of
elevated LFTs.
By the next day following nitroprusside therapy overnight , his SVR
had decreased to 1000 with cardiac output of 4.71 , CVP was
decreased to 9 , and he had significant diuresis as further
evidenced by his weight loss. Captopril and Isordil doses were
increased while weaning nitroprusside for a goal systolic blood
pressure greater than 80 to 90 and SVR less than 1200. His GI
complaints resolved immediately upon admission. He had no further
episodes of diarrhea , abdominal pain , nausea or vomiting. Thus , no
further workup was done at this time. Of note , he was on Fannie
Rippel protocol and was randomized to hemodynamic therapy.
Captopril was increased to final dose of 50 mg four times a day with Isordil
increased to 20 mg three times a day Nitroprusside was weaned off on 1/16/97.
intravenous Lasix was switched to orally on 1/16/97.
By 10/15/97 , he continued to feel very well without any complaints
of dyspnea on exertion , light-headedness , dizziness , or shortness
of breath. He did begin to complain of cough , possibly productive
of clear sputum , beginning on this day. He did have one episode of
a four beat run of asymptomatic nonsustained V-tach which was
well-tolerated.
On January , he had a repeat ETT which he completed in 5 minutes and 40
seconds. It was stopped secondary to leg fatigue with a max heart of 132.
EKG was without changes on exercise. Peak V. O2 of 14.3 and without ischemia.
Lasix dose was optimized with final dose of 40 mg orally Cough continued , and a
chest x-ray was obtained which was negative for infiltrate. Sputum was sent
and was also negative. He felt that the symptom might be due to post nasal
drip which he has had in the past , and this symptom will have to be followed.
As part of his transplant workup , an abdominal ultrasound was negative ,
although of note , his gallbladder could not be optimally visualized due to a
contraction of the gallbladder. A repeat ETT was as mentioned above.
Echocardiogram revealed LV dilatation with severe LV dysfunction , EF 15% ,
global hypokinesis , right ventricular dilatation with mild-to-moderate
dysfunction , left atrial enlargement , 3+ MR , 2+ TR with a peak velocity of 3.2
consistent with pulmonary artery systolic pressure of 40 mm greater than right
atrial pressure. Pulmonary function tests revealed SVC of 3.35 , 67% ( FEV1 of
2.78 , 67% ) , FEV1/FVC of 83% , FEF 25-75 68% , FVL CO corrected 85% as predicted.
Hepatitis studies , as mentioned above. CMV: IgG positive , IgM negative. EBV:
IgG positive , IgM negative. Mumps positive , VZV positive. Toxoplasma IgG
borderline , low positive; IgM negative. PPD with mumps and Candida control
were placed on 9/20/97 , and the patient was to return to the hospital on
8/16/97 to be examined.
By May , 1997 , the patient was feeling extremely well , and
ambulating without difficulty. He had improved energy and
appetite , and was afebrile. He denied any shortness of breath ,
chest pains , palpitations , and was felt to be stable for discharge.
PROCEDURES: He underwent an echocardiogram on 9/20/97 , ETT
9/20/97 , abdominal ultrasound 9/20/97 , pulmonary
function test 11/3/97 , cardiac catheterization 4/28/97.
DISCHARGE MEDICATIONS: Captopril 50 mg orally four times a day; Isordil 20 mg
orally three times a day; Lasix 40 mg orally every day with
instructions that if his weight increased by three to four pounds ,
he should take 80 mg of Lasix that day; Lotrimin 1% cream topical
twice a day; and digoxin 0.25 mg orally every day.
DIET: He was also discharged on a 2 gram sodium diet with 2 liter
fluid restriction.
FOLLOW-UP: He will return to the hospital on 8/16/97 to have his
PPD and controls read by myself. He will also
follow-up with Dr. Borriello in clinic in two weeks.
Dictated By: KAM R. ISA , M.D. GA069
Attending: SACHIKO BORRIELLO , M.D. EO3
HX507/5693
Batch: 00160 Index No. ULWHX40JRM D: 10/28/97
T: 10/28/97
Document id: 829
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OSA |
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| output/system_textual_annotation.xml | textual |
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381610558 | PUO | 20125977 | | 6973767 | 5/3/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 7/1/2005 Report Status: Signed
Discharge Date: 7/15/2005
ATTENDING: COLASAMTE , ISABELLE EVON MD
DISCHARGE DIAGNOSIS: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
gentleman with a history of coronary artery disease and
angioplasty in 1991. However , he had no history of myocardial
infarction or congestive heart failure. The patient's history
also is notable for severe depression and anxiety. He had been
fine with medical management of his coronary artery disease until
three to four months prior to admission when he began feeling
tightness in the chest and midsternal chest pain on admission. A
stress test performed in October showed abnormalities in the septal
and apical segments and an ejection fraction of 60%. During the
last several months , the patient experienced increasing frequency
of his anginal episodes and on 11/4/05 he was admitted to
Pagham University Of because of complaints of chest pain
and high blood pressure up to 230/130. The patient did
experience relief with sublingual nitroglycerin. His EKG showed
changes positive for ischemia and a troponin leak of 0.15. He
was scheduled for cardiac catheterization performed on 9/23/05 ,
which revealed left main coronary artery stenosis , LAD stenosis ,
and a long RCA stenosis. The patient was then referred for
surgical revascularization of his coronary arteries.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus treated
with diet , hypercholesterolemia , COPD , asthma , ruptured disk x2
at age 20 , GERD , depression with three recent hospitalizations.
PAST SURGICAL HISTORY: Right breast biopsy 14 years ago revealed
to be benign.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Denies tobacco use.
ALLERGIES: To beestings. Penicillin causes a rash and Demerol
causes dizziness.
ADMISSION MEDICATIONS: Atenolol 50 mg daily , lisinopril 30 mg
daily , aspirin 81 mg daily , Nexium 40 mg daily , Cymbalta 80 mg
daily , Seroquel 100 mg daily.
PHYSICAL EXAM: Height 5 feet 8 inches , weight 7.05 kg. Vital
signs , temperature 96 degrees , heart rate 77 , O2 saturation 98%.
HEENT , PERRLA , dentition without evidence of infection , no
carotid bruits. Cardiovascular , regular rate and rhythm , no
murmurs. Respiratory , breath sounds clear bilaterally. Abdomen ,
no incisions. Extremities , without scarring , varicosities or
edema. Neuro , alert and oriented , no focal deficits. Pulses 2+
bilaterally throughout. Allen's test of the right and left upper
extremity revealed normal.
PREOPERATIVE LAB: Sodium 133 , potassium 4.1 , chloride 100 ,
bicarb 26 , BUN 20 , creatinine 1.1 , glucose 230. White blood cell
count 5 , hemoglobin 12.5 , hematocrit 38.1 , platelets 165. physical therapy
14.1 , INR 1 , PTT 37.7. Urinalysis was normal.
Cardiac catheterization performed on 9/23/05 at Pagham University Of 90% proximal left main , 100% proximal LAD , 85%
ostial OM-1 , 75% RCA with right dominant circulation. EKG on
2/21/05 showed normal sinus rhythm at 79 with a left bundle
branch block. Chest x-ray on 2/21/05 was normal.
HOSPITAL COURSE: Cardiac catheterization was performed on
9/23/05 which revealed critical coronary artery disease and the
patient was referred for immediate surgery. The following
morning , the patient was brought to the operating room where Dr.
Colasamte performed a CABG x5 using a LIMA to the LAD and sequential
graft connecting the aorta to the acute marginal and then the PDA
using saphenous vein graft. A second saphenous vein graft
connected the aorta to the OMA-1 and then the OM-2. The aortic
cross-clamp time was 68 minutes and the total cardiopulmonary
bypass time was 119 minutes. The patient tolerated the procedure
well and was transferred postoperatively to the Intensive Care
Unit in hemodynamically stable condition. On postoperatively day
1 , the patient was extubated , he was found to be anxious and the
psychiatric medications were restarted. By postoperative day 2 ,
the patient complained of pain , which was highly related to
anxiety. The patient had borderline hypotension , which responded
well to fluid. By the third day after surgery , the patient had
remained hemodynamically stable and was ready for transfer to the
Step-Down Unit for the remainder of his recovery. The patient's
chest tubes and pacer wires were removed and a follow-up chest
x-ray showed no pleural effusion , pneumothoraces , and only
minimal pulmonary congestion , which responded well to diuretics.
The patient's postoperative EKGs showed a bundle-branch block
that had existed preoperatively and his cardiologist advised that
the patient could continue a beta-blocker as tolerated. During
the last several days of his hospital stay , the patient required
a lot of reassurance regarding his excellent recovery. He was
ambulating comfortably in the hallways and had remained in the
sinus rhythm with rate in the 70s and stable blood pressure. A
repeat chest x-ray showed resolution of any pulmonary congestion.
By postoperative day 7 , the patient was ready for discharge home
with his wife who is a nurse.
DISCHARGE PHYSICAL EXAM: On the day of discharge , the patient's
vital signs were as follows: Temperature 97.3 degrees , heart
rate 84 and sinus rhythm , blood pressure 126/70 , respiratory rate
20 , and the patient was oxygenating well on room air.
DISCHARGE LABORATORY DATA: Sodium 137 , potassium 4.1 , chloride
103 , bicarb 27 , BUN 21 , creatinine 1 , glucose 107 , calcium 8.6 ,
magnesium 1.7 , white blood cell count 7 , hemoglobin 9.9 ,
hematocrit 29.8 , platelets 244.
DISCHARGE CONDITION: Stable.
DISPOSITION: Discharged home with VNA services.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 325 mg daily ,
diltiazem 30 mg three times a day , Colace 100 mg three times a
day , ibuprofen 400 mg every 8 hours as needed pain , Ativan 1 mg orally every 6 hours
as needed anxiety , atenolol 50 mg daily , Niferex 150 mg orally twice a day ,
oxycodone 5 mg orally every 6 hours as needed pain , glipizide XL 5 mg orally
daily , Seroquel 100 mg daily , Nexium 40 mg daily , duloxetine 80
mg daily.
DISCHARGE FOLLOW-UP: The patient is to follow-up with the
following people; his primary care physician , Dr. Stacie Halechko
at 787-208-9850 , in one to two weeks , his cardiologist , Dr.
Alyse Holda at 312-062-3692 , in two to four weeks , and with his
cardiac surgeon , Dr. Isabelle Colasamte , at 117-219-4079 in four to
six weeks.
eScription document: 9-2913760 CSSten Tel
CC: Isabelle Colasamte M.D.
Division of Cardiac Surgery Pagham University Of
Vu Ette Perv
Brid
Dictated By: MUMMA , MARYLOU
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 1116673
D: 9/13/05
T: 9/13/05
Document id: 830
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
842373955 | PUO | 60095707 | | 335697 | 6/29/1999 12:00:00 a.m. | DEHYDRATION | Signed | DIS | Admission Date: 1/11/1999 Report Status: Signed
Discharge Date: 2/28/1999
DISCHARGE DIAGNOSIS: 1. ISCHEMIC HEPATOCELLULAR INJURY.
2. ALCOHOL ABUSE.
3. ALCOHOLIC CARDIOMYOPATHY.
CHIEF COMPLAINT: Vomiting , fever , and chills for 18 hours prior to
admission and a cough.
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
African-American female with a history
of long-standing alcohol abuse with two episodes of alcoholic
pancreatitis in the past. She is status post T2 , N1 floor of the
mouth squamous cell carcinoma. This was treated with resection and
XRT. She presents with vomiting x 18 hours. The patient was in
her usual state of health until two days prior to admission when
she began to develop upper respiratory infection symptoms with
congestion and a productive cough. The cough was initially
productive of white sputum and then later which turned dark in
color. She denies any blood tinged sputum or rust colored sputum.
The patient's cough and upper respiratory infection symptoms
progressed and she began to feel weak. On the morning prior to
admission , the patient awoke from sleep with a coughing fit and
subsequently vomited. She denies any hematemesis at that time.
She repeatedly had episodes of vomiting over the next 28 hours
prior to admission and was unable to drink liquids without
vomiting. She reports that she took approximately eight to ten
Tylenol 500 mg tablets prior to admission for her symptoms. She
became progressively light-headed and dizzy , especially with
standing up. She reports subjective fevers although she did not
take her temperature , and also night sweats. She had one episode
of diarrhea which was nonbloody and loose. Her son , who is an
employee of the Pagham University Of cafeteria , went to
visit her and urged her to go to the emergency room.
In the emergency room , the patient was initially triaged to the
emergent side of the EW , was found to have a blood pressure of
77/50 with a pulse of 138. She was transferred to the acute side
for management.
PAST MEDICAL HISTORY: 1. Notable of alcohol pancreatitis in September
of 1998 and April of 1997. 2. Squamous cell
carcinoma of the head and neck , as previously noted , status post
excision in 1994 with XRT and hyperbaric oxygen therapy. She is
also status post multiple dental extractions and one flap revision.
3. History of total abdominal hysterectomy and bilateral
salpingo-oophorectomy in 1985. 4. History of small bowel
obstruction , status post lysis of adhesions , getting an exploratory
laparotomy in September 1997.
ALLERGIES: She has no known drug allergies.
MEDICATIONS: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: One to three cigarettes per day and one-half to
one pint of brandy each day for "a long time."
REVIEW OF SYSTEMS: As per history of present illness. She denies
any orthopnea , paroxysmal nocturnal dyspnea ,
lower extremity edema , chest pain , or shortness of breath. As far
as she knows , she has no known cardiac history.
PHYSICAL EXAMINATION: She was relatively well-appearing in no
apparent distress. Her temperature was
98.0. Her blood pressure was 110/84 , her pulse was 101. Her
respiratory rate was 16 and oxygen saturation was 95% on room air.
HEENT: Pupils equal , round and reactive to light and
accommodation; extraocular muscles intact; sclera were muddy
without icterus. Oropharynx was notable for postsurgical changes
on the right side and with dry mucous membranes. Neck: Notable
for no meningismus and jugular venous pressure of approximately 5
cm. The lungs were clear to auscultation bilaterally. Heart:
Regular rate and rhythm without murmurs , gallops , or rubs
auscultated and a nondisplaced point of maximal intensity.
Abdomen: Soft with mild left upper quadrant tenderness , but no
hepatic tenderness. The liver edge was nonpalpable. There was no
spleen tip palpable and bowel sounds were present. The extremities
were notable for no clubbing , cyanosis , or edema and were warm and
perfuse. Neurologically , she was alert and oriented x 3 with
intact cranial nerve. Her strength and sensation were grossly
intact , 5/5 in the upper and lower extremities. Her toes were
down-going bilaterally and her reflexes were symmetric in the upper
and lower extremities. Rectal examination was guaiac negative.
DATA: Laboratory values upon admission showed electrolytes within
normal limits. Magnesium was 1.1. White count 6.5 ,
hematocrit 48 , platelets 200. Differential: 78 polys , 1 band , 12
lymphs and 8 monos. MCV was 104. RDW was 14. ALT 140 , AST 605 ,
alkaline phosphatase 119 , and total bilirubin was 2.6 with a direct
fraction of 1.5. Lipase was 319 , amylase was 44. Her INRs were
1.1 and her prothrombin time was 19.9 Troponin was 0.22.
Chest x-ray was notable for no infiltrates or evidence of heart
failure.
EKG was notable for sinus tachycardia at 117 with a Q-wave of 3 and
Q-wave in V2 and V3. Q-wave inversions were noted in V3 and V6
with no chest pain.
Urinalysis was notable for 2+ protein , trace keto , 3+ blood , 2+
leukocyte esterase , 28 to 30 whites and 2+ squamous cells.
ASSESSMENT: In the emergency room , the patient was acutely treated
for presumed sepsis and received a dose of ceftriaxone
and clindamycin. Urinalysis results indicated that she had a
potential urinary tract infection at that time. Blood cultures
were drawn and the patient received intravenous hydration. Her EKG was
noted to have new T-wave inversions as compared to previously with
an indeterminate troponin. She was admitted to medicine for
management.
HOSPITAL COURSE: The patient's hospital course can be summarized
as follows:
1. Cardiovascular: The patient has no known cardiac history. Her
cardiac risk factors include cigarette smoking and postmenopausal
female , age 51. No diabetes mellitus. No known
hypercholesterolemia. No known family history. She does , however ,
drink heavily and has done so for a number of years. She has no
known cardiotoxic effect secondary to alcohol.
The T-wave inversions were noted with an indeterminate troponin.
The patient was admitted in a rule out protocol. She ruled out for
an myocardial infarction with serial CKs which were all below 50.
Her T-wave inversions persisted despite resolution of her sinus
tachycardia. An echocardiogram was obtained which demonstrated
dilated left ventricle of 5.6 cm and an ejection fraction of 25 to
30% with inferoseptal and inferoseptal apical akinesis. No
ventricular thrombus was noted.
Cardiology consultation service was asked to see the patient to
evaluation her in the setting of her new depressed ejection
fraction and focal wall motion abnormalities. Initially , she was
presumed to have coronary disease which had been clinically silent
prior to this. She was treated with aspirin , Lopressor and
Captopril 6.25 mg three times a day. Unfortunately , the patient's
blood pressure did not tolerate this antihypotensive regimen and ,
despite efforts to scale it back in dosages , the majority of the
medicines were held. Nevertheless , the patient's heart rate slowed
to the 60s. She experienced one episode of burning chest pain on
the night of admission which was alleved with Maalox. There were
no EKG changes associated with that pain.
The patient was taken to the cardiac catheterization lab on September
The cardiac catheterization was notable for a right atrial
pressure of 5. Right ventricular pressure of 36/10. Pulmonary
artery pressure was 35/13 , and the pulmonary capillary wedge
pressure was 16. Her cardiac output was 6.13 with an index of
3.69. The left heart catheterization noted normal coronary
arteries without evidence of significant coronary disease. Her
left ventriculogram also noted a preserved ejection fraction with
no focal wall motion abnormalities. Dr. Christeen Jacobson of the
cardiac consultation service followed the patient in house and felt
that the reversal of her wall motion abnormalities could be
attributable to the acute effects of alcoholic cardiotoxicity. The
patient will be discharged on aspirin for primary prevention of
coronary disease , as her other medications were discontinued. The
patient was heparinized for her apical wall motion abnormality and
low ejection fraction while in house and the heparin was
discontinued at the time of catheterization.
2. GI: The patient presented with an acute elevation of her
transaminases. The patient's transaminases were noted to be less
than 10 in September of 1998. Initially , it was felt that these
transaminases might reflect alcoholic hepatitis given her
significant alcohol history. The patient reports that her last
drink was on Sunday prior to admission. She drinks about a pint of
brandy every day. The patient's transaminases continued to rise ,
however. The diagnosis of acute Tylenol toxicity superimposed upon
hepatocellular damage from alcoholic hepatitis was also
entertained. She was empirically started on naphthyl cystine and
received approximately two to three doses , however , that medication
was discontinued upon GI consultation. The patient's transaminases
rose to a level of approximately 4000 AST and 1000 ALT , and the GI
service was consulted. The patient's hepatitic serologies were
sent and were notable for positive hepatitis B core antigen ,
whereas the rest of her hepatitis serologies including hepatitis C ,
hepatitis A and hepatitis B surface antigen were negative. The GI
service felt that her hepatocellular injury was most likely
attributable to an ischemic "shock liver" condition. She had a
right upper quadrant ultrasound as well which demonstrated a
dilatation of the common bile duct to 1 cm with some biliary
sludging but no evidence of obstructive lesions. Given the
patient's isolated increase in AST and ALT and bilirubin without an
increase in alkaline phosphatase , the diagnosis of ischemic
hepatotoxicity was entertained by the GI service. On the date of
discharge , the patient's ALT had fallen to 221 and her AST had
fallen to 50. Her total bilirubin had fallen to 1.1. The patient
was asymptomatic from hepatic perspective throughout her
hospitalization without any evidence of encephalopathy or
asterixis. An isolated ammonia level was sent and it was 45.
3. Infectious disease: The patient had a repeat urinalysis that
was sent on the morning following admission which was indicative of
urinary tract infection. Urine culture eventually indicated an
infection with Enterococcus. The patient received seven days of
ampicillin while in house , following her initial first day dosing
of ceftriaxone and clindamycin. The patient's urinary tract
infection clear symptomatically. She developed a yeast infection
in her vulvar area secondary to antibiotic therapy and this was
treated with topical Nystatin. The patient was not discharged on
antibiotics as she clinically cleared her infection.
4. FVN: The patient had persistent hypomagnesemia while in house
and required significant magnesium repletion. The etiology of this
hypomagnesemia was unclear; however , it was attributable to her
chronic alcohol use and depletion of total magnesium stores. Her
electrolytes clearly need to be followed closely as an outpatient.
5. Hematologic: The patient's INR slightly increased while in
house but this is attributable to heparin bolus and
supratherapeutic prothrombin time. Upon discharge , the patient's
INR had normalized. She received vitamin K 10 mg x 3 days as
empiric treatment for vitamin K depletion secondary to chronic
alcoholism as well as the possibility for hepatic synthetic
dysfunction.
6. Hypotension: The patient's initial presentation for
hypotension was attributable to dehydration; however , it became
clear that the patient normally exists with a low normal blood
pressure of approximately 80 to 100 systolic. It was stressed to
the patient that she must maintain adequate orally intake to maintain
her circulating blood volume , as she seemed to be intolerant to the
antihypotensive medicines that were used for cardioprotection. A
random cortisol was drawn and was normal. The issue of potential
renal insufficiency was most likely excluded. The patient will
follow-up on endocrine and electrolyte issues with her primary
doctor.
DISCHARGE MEDICATIONS: Folic acid 1 mg orally every day , Nystatin
topical cream , Zantac 150 mg orally twice a day ,
multivitamin one every day and aspirin 325 mg orally every day.
FOLLOW-UP: The patient will follow-up with Dr. Sana Albor in
KTDUOO on March . Dr. Sugimoto was involved in the
patient's hospitalization and will provide excellent continuity of
care as an outpatient.
Dictated By: SHELLEY STARNAULD , M.D. AH89
Attending: DOUGLASS N. PETTINGER , M.D. JB3
VG550/4065
Batch: 23311 Index No. J8KQZD64UX D: 11/15/99
T: 10/16/99
Document id: 831
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Dp |
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Obe |
OSA |
PVD |
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785782309 | PUO | 70951924 | | 7361251 | 9/11/2006 12:00:00 a.m. | CHF decompensation , hypoxia , cyanosis , coronary artery disease | | DIS | Admission Date: 9/11/2006 Report Status:
Discharge Date: 10/6/2006
****** FINAL DISCHARGE ORDERS ******
VERGES , JR , BENTON D. 506-16-04-7
A
Service: CAR
DISCHARGE PATIENT ON: 5/12/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KUSH , QUINN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Override Notice: Override added on 5/12/06 by BONTON , DANIELL L. , M.D.
on order for COUMADIN orally 6 MG every afternoon ( ref # 593466576 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: patient needs Previous override information:
Override added on 2/13/06 by BONTON , DANIELL L. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: patient needs
BISOPROLOL FUMARATE 5 MG orally DAILY
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
DIGOXIN 0.125 MG orally DAILY
FINASTERIDE 5 MG orally DAILY
Number of Doses Required ( approximate ): 3
FOLIC ACID 1 MG orally DAILY
FUROSEMIDE 80 MG orally DAILY
Instructions: continue your original outpatient lasix scale
INSULIN ASPART Insulin Scale ( subcutaneous ) subcutaneously before meals
Instructions: Continue your original outpatient insulin
sliding scale High Scale Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 2 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 7 units subcutaneously
If BS is 301-350 , then give 10 units subcutaneously
If BS is 351-400 , then give 12 units subcutaneously
Call HO if BS is greater than 350
If ordered before every meal administer at same time as , and in addition
to ,
standing insulin aspart order. If ordered HS administer
alone
LANTUS ( INSULIN GLARGINE ) 68 UNITS subcutaneously BEDTIME
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally twice a day
Starting Today ( 2/12 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
K-DUR ( KCL SLOW RELEASE ) 40 MEQ orally DAILY
Starting Today ( 2/12 )
Instructions: continue your original outpatient potassium
sliding scale As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 2/13/06 by BONTON , DANIELL L. , M.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
MAGNESIUM OXIDE ( 241 MG ELEMENTAL MG ) 400 MG orally DAILY
as needed Other:leg cramps
NITROGLYCERIN 0.4MG/SPRAY 1-2 SPRAY orally x1 as needed Chest Pain
PREDNISONE 10 MG orally every day before noon
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally DAILY
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: take 6 mg tonight , then follow up with your
coumadin clinic Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/12/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: patient needs Previous Override Notice
Override added on 2/13/06 by BONTON , DANIELL L. , M.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 741061912 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: patient needs
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Kush , as scheduled ,
ALLERGY: intravenous Contrast , Iodine contrast dye
ADMIT DIAGNOSIS:
CHF decompensation , hypoxia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF decompensation , hypoxia , cyanosis , coronary artery disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) hypertension ( hypertension ) cad
( coronary artery disease ) mi ( myocardial
infarction ) cabg ( cardiac bypass graft surgery ) pvd ( peripheral
vascular disease ) femoral ( femoral popliteal
bypass ) hypercholesterol ( elevated cholesterol ) afib ( atrial
fibrillation ) chf ( congestive heart failure )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: dyspnea , hypoxia
HPI: 73 year-old Mwith CAD history of multiple CABG and PCI , iCMP ( EF 25-30% ) ,
PVD , hyperlipidemia , and PAF on coumadin presents with acute
worsening of shortness of breath and cyanosis. He has had
progressively worsening dyspnea and weight gain over the past
several months. Dry weight 175 , now 181. He has stable orthopnea and
sleeps with his head raised to 30 degrees. Increasing abdominal
girth. Stable nocturia ( 1-2 times per night ). Dry persistent
cough for past several months. He complains of dry mouth and takes a
lot of ice chips. However , he does restrict his fluid intake to less
than 2 quarts daily. The am of admission , the patient was
acutely short of breath upon waking. He was noted to by cyanotic
( hands and face ) by his wife. He was given supplemental oxygen by his
wife , and his oxygen saturation was in the high 80s. He does not
use oxygen at baseline. He has baseline angina ( nonradiating
substerna chest pain relived by nitro spray ).
*************
PMHx:
CAD history of CABG 1981 ( 3v ) , 1993 ( 5v ). history of PCI with DES to LM and SVG to PLV
Ischemic CMP ( EF 30% )
PAF
ICD placed 10/25
Hyperlipidemia
Mild AI
IDDM
PMR on prednisone
S/p Bilateral CEA 1995 ,
PVD with claudication ,
S/p Bilateral
Fem-Pop bypass 1995 ,
Central retinal artery occlusion resultant blindness OD ,
Lumbar laminectomy ,
Hx Bladder Ca
***************
ALL: iodine contrast
MEDS:
Aspirin 325 mg every day , Plavix 75 mg every day , Bisoprolol 5 mg every day , Digoxin 0.125 mg
every day , Furosemide scale 60-80 every day , Imdur 30 mg twice a day , Lantus 50 units +
Humulin SS , Proscar 5 mg every day , Folic acid 1 mg daily , Vitamin E 400 units
daily , MVI , Prednisone 10 mg every day , Coumadin 5 mg every day , Mg++ 120-240 mg HS ,
Nitroglycerin spray
***************
ADMISSION EXAM
Afeb , 79 NSR , 129/61 , 20 , 94% 2L Weight 79.8 kg
Coarse rales 1/2 up
Diffuse/Lat PMI , 3/6 HSM to axilla , 2/6 SEM at LUSB , occasional S3.
***************
STUDIES:
9/16 CXR ( port ) - no pulm edema
9/16 EKG NSR 75. 1 mm ST dep and TWI II , III , aVF. J elev V2. ( unchanged
per Kush )
2/12 CXR ( PA/Lat ) - cardiomegaly , fluid in minor fissure on R.
***************
HOSPITAL COURSE
73 year-old M with known CAD ( history of multiple CABG and PCI ) , ischemic CMP ( EF
25-30% ) , hyperlipidemia , PVD , IDDM and worsening dyspnea presents with
acute shortness of breath and cyanosis.
1. CV/Pump: iCMP ( EF 25-30% ) NYHA class III. S/p ICD placement. Patient
with progressive volume overload uncontrolled as outpatient. Admitted
with acute decompensation with hypoxia and cyanosis. JVP elevated on
exam. Will diurese aggressively with goal of dry weight ( 175 pounds ). Not
currently on spironolactone or ACEI. The patient responded to diuresis
with lasix 60 mg intravenous twice a day. Weight on discharge down to goal of 175 pounds.
Starting a new afternoon sliding scale for diuretics. For each pound over
175 , he will take 20 mg lasix.
2. CV/Ischemia: known severe CAD history of multiple CABG and PCI with stable
angina at baseline. Episode the morning of admission was his baseline
angina. However , Tn became elevated to 0.33 , but was downtrending. This
is likely demand in the setting of hypoxia/respiratory distress.
His ST depressions on admission were not much changed from baseline , and
resolved by the morning. His ASA and plavix was continued. He is
intolerant of statins.
3. CV/Rhythm: PAF on coumadin. Currently in NSR. Digoxin level 0.4.
4. Pulm: hypoxia likely due to pulmonary edema and worsening CHF. However
CXR with little evidence of edema. His saturation improved to 95% on RA
prior to discharge. He felt symptomatically better.
5. Renal: ARF with baseline Cr 1.2. Likely 2/2 DM. UA and urine
protein/creatinine pending on discharge
6. Heme: anticoagulation with coumadin for atrial fibrillation ( Goal INR
2.0 to 3.0 )
7. Vascular: PVD history of revascularization. Magnesium for leg cramps.
8. FEN: low fat , low cholesterol , 2 gm sodium , 2L fluid restriction.
Replacing electrolytes aggressively. Has sliding scalre K replacement at
home.
ADDITIONAL COMMENTS: Continue to take your lasix and potassium on your sliding scale as you
were before admission.
Continue your original insulin sliding scale.
Weigh yourself daily.
Continue your original outpatient medications
***********
NEW AFTERNOON LASIX SCALE
Take your afternoon weight.
For every pound over 175 , take 20 mg lasix.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Monitor electrolytes while on lasix.
2. Monitor daily weights. Patient is on sliding scale diuretics.
3. Consider other options for lipid lowering ( ie ezetimibe ,
cholestryramine )
4. Consider tighter diabetes control as outpatient fingersticks are 80s
to 300s at home.
5. Consider adding back ACEI when tolerable
6. Consider spironolactone for class III CHF and for K retention.
7. Monitor INR and titrate coumadin
8. f/u HbA1c
No dictated summary
ENTERED BY: BONTON , DANIELL L. , M.D. ( PC41 ) 5/12/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 832
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
437560059 | PUO | 11693097 | | 7642439 | 7/6/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 6/2/2006 Report Status: Unsigned
Discharge Date: 2/5/2006
ATTENDING: STUKOWSKI , JANAY MD
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Mr. Verjan is a 65-year-old gentleman with history of
non-insulin-dependent diabetes mellitus , hypertension ,
dyslipidemia , and peripheral vascular disease who presented to
Norap Valley Hospital on 5/23/06 with unstable angina. The patient
reports that he had been having intermittent left-sided chest
pressure at rest over the past three days associated with
shortness of breath , each episode lasting approximately 10
minutes. EKG on admission revealed sinus tachycardia with a new
incomplete left bundle-branch block and downsloping 1-1.5 mm ST
depressions in V3 through V6 and 1 mm depression in aVL. The
patient was deemed to have a NSTEMI and unstable angina. He was
not heparinized due to the fact that he was on Coumadin for
peripheral vascular disease with a therapeutic INR. On 11/26/06 , the patient
underwent cardiac catheterization , which revealed the following: Left
circumflex coronary artery with an ostial 100% stenosis , left
anterior descending coronary artery with a proximal 60% stenosis
and a mid 50% stenosis , right coronary artery with a proximal 80%
stenosis and a mid 60% stenosis , right dominant circulation ,
ejection fraction of 30% , collateral flow from the second
diagonal to the third marginal in the right posterior left
ventricular branch to the second marginal , left ventricular
hypokinesis , severe inferior and apical.
PAST MEDICAL AND SURGICAL HISTORY:
Significant for myocardial infarction with a peak CK of 87 ,
troponin 0.48 , history of class intravenous angina with inability to carry
on any physical activity , history of class II heart failure with
slight limitation of physical activity , congestive heart failure ,
paroxysmal nocturnal dyspnea , dyspnea on exertion , hypertension ,
peripheral vascular disease , status post bilateral fem-pop bypass
and status post bilateral transmetatarsal amputations ,
non-insulin-dependent diabetes mellitus , dyslipidemia , history of
gastrointestinal bleeding , anxiety disorder , eosinophilia ,
chronic back pain , anemia.
ALLERGIES:
The patient has no known drug allergies.
MEDICATIONS AT TIME OF ADMISSION:
Lopressor 37.5 mg twice a day , aspirin 325 mg daily , Colace 100 mg
twice a day , Pepcid 20 mg intravenous every 12 hours , insulin sliding scale ,
atorvastatin 80 mg daily , glipizide , Avandia , Zestril , metformin ,
meclizine , lactulose , vitamin C , Protonix , Niaspan , Neurontin ,
Zincate , Coumadin for peripheral vascular disease.
PHYSICAL EXAMINATION:
Cardiac exam: Regular rate and rhythm with no murmurs , lifts or
heaves. Peripheral vascular 2+ pulses bilaterally in the
carotid , radial , femoral pulses and 1+ bilaterally in the
dorsalis pedis and posterior tibialis pulses. Respiratory:
Breath sounds clear bilaterally. Allen's test of the left
upper extremity , abnormal intermittent waveform with radial
occluded using a pulse oximeter , right upper extremity
abnormal poor intermittent wave form with the radial occluded ,
also with a pulse oximeter. Physical exam otherwise is
noncontributory.
ADMISSION LABS:
Sodium 128 , potassium 4.2 , chloride of 99 , CO2 21 , BUN of 23 ,
creatinine 1.1 , glucose of 201 , magnesium 1.7 , WBC 5.81 ,
hematocrit 28.6 , hemoglobin 10.2 , platelets of 132 , physical therapy of 18.2 ,
physical therapy/INR 1.5 , PTT of 33.7.
HOSPITAL COURSE:
Mr. Verjan was brought to the operating room on 3/26/06 where he
underwent a coronary artery bypass graft x3 with left internal
mammary artery to left anterior descending coronary artery , a
sequential graft and a vein graft connecting from the aorta to
the second obtuse marginal coronary artery and then to the left
ventricular branch. Total bypass time was 55 minutes , total
crossclamp time was 46 minutes. The patient did well
intraoperatively , came off bypass without incident , was brought
to the Intensive Care Unit in normal sinus rhythm and in stable
condition. Postoperatively , the patient did well. His CK-MB
trended down and EKG normalized. The patient's postop chest x-ray
revealed moderate-to-severe pulmonary venous congestion bibasally
requiring vigorous pulmonary toilet. The patient was extubated on
1/5/06. The patient was also followed by the Diabetes Mellitus
Service for his non-insulin-dependent diabetes mellitus. His
blood glucoses were well controlled. He was started back on his
orally medication of glipizide 5 mg and was covered with a NovoLog
sliding scale. The patient was transfused 3 units of packed red
blood cells postoperatively , and was re-started on Coumadin for his
peripheral vascular disease. The patient's platelet count
dropped to as low as 59 , 000. He had a HIT panel sent off which
came back negative and platelets trended up at time of discharge
to 143 , 000. Mr. Verjan was transferred to the Step-Down Unit on
postoperative day #3. His pacing wires were removed , and he was
screened for rehabilitation for discharge. The patient also had
some urinary retention postoperatively and did require Foley
reinsertion and was started on Flomax 0.4 mg once a day. He
failed a second voiding trial and will be discharged with a leg
bag and follow up in the Urology Clinic in one week and continue
on his Flomax until that time.
DISCHARGE LABS:
The discharge labs for Mr. Verjan were as follows: Glucose of
150 , BUN of 39 , creatinine 1.2 , sodium 138 , potassium 3.6 ,
chloride 103 , CO2 23 , magnesium 1.9 , WBC 8.6 , hemoglobin 11 ,
hematocrit 31.4 , platelets of 143 , physical therapy of 17.1 , physical therapy/INR of 1.4.
Urinalysis from 6/2/06 was negative. Urine culture is no
growth so far at time of discharge.
DISCHARGE MEDICATIONS:
Enteric-coated aspirin 81 mg every day , Colace 100 mg twice a day
while taking Dilaudid , Lasix 40 mg every day x3 doses , glipizide 5 mg
daily , Dilaudid 2-4 mg every three hours as needed pain , lisinopril
2.5 mg daily , Niferex 150 mg twice a day , Toprol-XL 150 mg every day ,
Lipitor 80 mg daily , Flomax 0.4 mg every day , potassium chloride slow
release 10 mEq every day x3 doses with Lasix and Coumadin every day per INR result. The
patient will receive 4 mg of Coumadin this evening for his
peripheral vascular disease. His Coumadin dosing will be
followed by Dr. Brooke Lemmen at ( 808 ) 092-4081.
FOLLOW-UP PLANS:
He will follow up with Dr. Janay Stukowski in six weeks , his
cardiologist Dr. Chadwick Rochat in one week , his heart failure
cardiologist Dr. Cathie Reisman on 2/6/06 at 1:30 in the
afternoon , and Urology Clinic at the Pagham University Of
for his urinary retention in one week. Clinic number ( 196 ) 973-8374.
DISPOSITION:
Mr. Verjan is discharged to rehab in stable condition.
eScription document: 2-6426281 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: STUKOWSKI , JANAY
Dictation ID 9939177
D: 11/19/06
T: 11/19/06
Document id: 833
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
584256383 | PUO | 79394275 | | 6416201 | 4/12/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 5/27/2006 Report Status: Signed
Discharge Date: 7/4/2006
Date of Admission: 5/27/2006
ATTENDING: STUKOWSKI , JANAY MD
SERVICE: Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS: Ms. Zazueta is a
54-year-old female who was found to have an abnormal EKG during a
preoperative evaluation for partial thyroidectomy , which prompted
a cardiac workup. Stress test revealed ischemic changes and
followup cardiac catheterization revealed mid right coronary
artery stenosis of 70% , proximal right coronary artery with 80%
and the left anterior descending coronary artery with a proximal
60% stenosis , left main coronary artery with a mid 70% stenosis ,
left circumflex coronary artery with a proximal 80% stenosis and
a mid 50% stenosis and a right dominant circulation.
Echocardiogram revealed an ejection fraction of 55% with trivial
mitral insufficiency and trivial tricuspid insufficiency.
Carotid noninvasives revealed that the left internal
carotid artery could not be assessed due to the patient's body habitus and
large goiter , but did reveal relatively diminished diastolic flow in the right
common carotid artery with a velocity 69 cm per second proximally and 62 cm per
second mid , 53 cm per second distally. Velocities in the left
common carotid artery 92 cm per second approximately , 62 cm per
second mid , and 73 cm per second distally. CT
angiogram of the neck on 10/10/06 revealed the following:
1. High-grade stenosis or possible complete occlusion of the
right cervical ICA at origin , the possibility of a very small
caliber residual voluminous suggested catheterization.
Angiography is recommended for further assessment.
2. Very high-grade narrowing of the left proximal ICA at its
origin by complex calcified and likely ulcerative plaque.
3. Internal carotid artery cavernous segment stenosis on the
left is likely mild-to-moderate.
4. Mild proximal basilar artery stenosis.
5. Vertebral artery origin stenosis cannot be excluded. They
are not well evaluated due to beam hardening related to body
habitus.
6. Large neurogenous thyroid lesions are most suggestive of
goiter , although more aggressive lesions cannot be completely
excluded. Clinical correlation and thyroid ultrasound could be
performed for further evaluation if indicated.
7. Cervical spine degenerative disease and stenosis in the lower
C-spine. The patient underwent repeat CT of the head and neck.
Final report is not available at this time.
PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: Significant for
class III heart failure with marked limitation of physical
activity , hypothyroidism , dyslipidemia , status post brain tumor
in 1973; pathology unknown , remote seizure disorder , migraines ,
goiter status post left partial thyroidectomy preoperative for a
right thyroidectomy after her coronary artery bypass grafting.
She is status post a partial oophorectomy and as stated above
craniotomy for tumor resection in 1973 and status post left
partial thyroidectomy and right breast biopsy.
ALLERGIES: The patient has allergies to penicillin where she
develops hives.
MEDICATIONS ON ADMISSION: Atenolol 100 mg daily , aspirin 81 mg
daily , simvastatin 40 mg daily , vitamin C one tab daily , woman's
wellness natural hormone balance two tablets a day and Pepcid-before meals
one tab as needed.
PHYSICAL EXAMINATION: Five feet six inches , 145.44 kg ,
temperature 98.6 , heart rate 70 and regular , blood pressure right
arm 140/70 , left arm 146/74. Oxygen saturation 96% on room air.
Cardiovascular , regular rate and rhythm with no murmurs , rubs or
heaves. Peripheral vascular 2+ pulses bilaterally in the
carotid , radial , femoral pulses 1+ bilaterally in the dorsalis
pedis and posterior tibialis pulses. Respiratory , breath sounds
clear bilaterally , is otherwise noncontributory.
ADMISSION LABS: Sodium 140 , potassium 3.9 , chloride of 103 , CO2
29 , BUN of 13 , creatinine 0.9 , glucose 205 , magnesium 1.9 , and
BNP is 62 , WBC 7.51 , hematocrit 38.4 , hemoglobin 12.4 , platelets
of 312 , physical therapy 14.9 , physical therapy/INR of 1.2 , and PTT of 26.3.
HOSPITAL COURSE: The patient underwent left carotid artery stent
placement on 4/18/06. Coronary artery bypass grafting was
canceled due to the high-grade carotid stenosis. Operative
report is not available at this time. Postoperatively , the patient had
developed diplopia and a distant visual disturbance. CT of the
head was negative for any acute event. Neurologically , the patient's mental
status was intact , alert , oriented. The patient's neurologic
symptoms improved and she was transferred to the Step-Down Unit
on 7/6/2006 and was cleared for discharge to home on 11/27/06.
Mrs. Zazueta will follow up with the vascular surgeon , Dr.
Youngberg , in two weeks and Dr. Stukowski will perform her coronary artery bypass
graft in four weeks. She is discharged to home in stable condition.
DISCHARGE MEDICATIONS: Plavix 75 mg , enteric-coated aspirin 325
mg a day , Motrin 400-800 mg every 6 hours as needed pain , Toprol-XL 100 mg
daily , simvastatin 40 mg nightly.
DISCHARGE LABS: Glucose 101 , BUN of 11 , creatinine 1 , sodium
139 , potassium 4.4 , chloride of 102 , CO2 28 , magnesium 1.9 , WBC
is 7.07 , hemoglobin 11 , hematocrit 33.3 , platelets of 274.
DISPOSITION: Ms. Zazueta will be discharged to home in
stable condition , will follow up with Dr. Janay Stukowski for her
coronary artery bypass grafting next month and Dr. Youngberg as
stated above in two weeks for her postoperative left carotid
artery stent placement.
eScription document: 6-1305501 CSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: STUKOWSKI , JANAY
Dictation ID 0579550
D: 10/13/06
T: 3/27/06
Document id: 834
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
- |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
Y |
Y |
N |
N |
N |
Y |
Y |
N |
Y |
N |
- |
N |
N |
618580599 | PUO | 54917192 | | 7666885 | 9/29/2005 12:00:00 a.m. | COPD flare , right heart failure | | DIS | Admission Date: 9/10/2005 Report Status:
Discharge Date: 10/6/2005
****** FINAL DISCHARGE ORDERS ******
HOTZE , KURTIS 789-80-40-4
Ceni
Service: MED
DISCHARGE PATIENT ON: 8/4/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHOULTZ , ANNETTE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day Starting IN a.m. ( 8/14 )
ELAVIL ( AMITRIPTYLINE HCL ) 10 MG orally every bedtime
ATENOLOL 25 MG orally every day Starting IN a.m. ( 8/14 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FUROSEMIDE 20 MG orally every day Starting Today ( 9/19 )
GUAIFENESIN 10 MILLILITERS orally three times a day Starting Today ( 9/19 )
as needed Other:cough
OXYCODONE 5 MG orally three times a day Starting Today ( 9/19 ) as needed Pain
Instructions: please give am and pm dose with his doses of
morphine. midday dose 2-3pm.thank you.
QUININE SULFATE 325 MG orally HS Starting Today ( 9/19 )
Food/Drug Interaction Instruction Take with food
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 10/2/05 by
KOETS , FRIEDA N. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/2/05 by
KOETS , FRIEDA N. , M.D.
on order for MVI THERAPEUTIC orally ( ref # 69033580 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
MORPHINE CONTROLLED RELEASE 15 MG orally every 12 hours
FELODIPINE 5 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Number of Doses Required ( approximate ): 5
FLONASE ( FLUTICASONE NASAL SPRAY ) 1 SPRAY inhaled every day
Number of Doses Required ( approximate ): 5
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
CALTRATE + D ( CALCIUM CARBONATE 1 , 500 MG ( 600 ... )
1 TAB orally twice a day
NOVOLOG MIX 70/30 ( INSULIN ASPART 70/30 )
35 UNITS every day before noon; 22 UNITS every afternoon subcutaneously 35 UNITS every day before noon 22 UNITS every afternoon
PREDNISONE Taper orally Give 60 mg every 24 hours X 5 dose( s ) , then
Give 50 mg every 24 hours X 3 dose( s ) , then
Give 40 mg every 24 hours X 3 dose( s ) , then
Give 30 mg every 24 hours X 3 dose( s ) , then
Give 20 mg every 24 hours X 3 dose( s ) , then
Give 10 mg every 24 hours X 3 dose( s ) , then
Give 5 mg every 24 hours X 3 dose( s ) , then Starting Today ( 9/19 )
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please schedule appointment with primary care doctor at the WH early next week ,
ALLERGY: Erythromycins
ADMIT DIAGNOSIS:
pneumonia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
COPD flare , right heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
prostate CA , DM , hypertension , R breast cancer , recurrent
pneumothorax , COPD on home O2 , hypercholesterolemia , OA , chronic pain
BPH , peripheral neuopathy
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cardiac MR
v/every scan
BRIEF RESUME OF HOSPITAL COURSE:
--HPI: Mr. Tortorella is a 77yo African American male with PMH notable for COPD ,
HTN , NIDDM and recent PNA who presented to PUO ED on 4/15/05 via EMS with a
CC of SOB x 3d. He was seen 2 days earlier at the Landhi Terblack Ebro Medical Center where he
was diagosed with pneumonia and given Azithromycin. The day of admissio
he said his breathing felt more labored and he contacted EMS to take him to
the PUO ED. He also reported worsening exercise tolerance and an increase
in bilateral lower extremity edema over the past few months , accompanied by
a 20lb weight gain. He also noted left sided pleuritic pain made worse by
physical movement and deep breathing. He was treated in the ED with
supplemental O2 and Levofloxacin and admitted with a diagnosis of COPD flare
and right heart failure.
--Home meds: atenolol 25mg orally every day , HCTZ 25mg orally every day , felodipine 5mg orally every day ,
zocor 20mg orally every bedtime , ASA 81mg orally every day , Advair 1 puff twice a day , Combivent 2 puffs
four times a day , loratidine 10mg orally every day , guqifenesin 600mg orally every 12 hours , morphine 15mg orally
q8-12h , Percocet 1-2 tab orally every 6 hours , quinine sulfate 325mg orally every bedtime , Colace
100mg orally twice a day , Senna 2 tab orally every day , calcium+vim D 125 units orally every day , Elavil
10mg orally every bedtime
--Allergies: NKDA
--Social Hx: veteran and retired school bus driver. lives with close friend
in Indiana son checks in on him multiple times during the week.
--PE upon admission: afebrile , P 101 , R 28 , BP 150/70 , O2 sat 99% 2L NC
Pulm- labored breathing , accessory muscle use , rhonchi and expiratory
wheezes present throughout both lung fields. egophony in LLL.
CV- normal PMI , no RV heave. RRR. Unable to appreciate heart sounds. weak
peripheral pulses. 12cm JVD.
Abd- +BS , nontender , nondistended. hepatomegaly.
Ext- 2+ bilateral pitting edema.
Neuro- AAOx3. CN intact. strength 5/5 , symmetric. unable to elicit
reflexes.
--Sig labs and tests upon admission: BUN 17 , Cr 1.4 , Glucose 179. WBC 8.7 ,
Hct 38 , MCV 84. LFTs normal. Albumin 4.3 , Amylast 83 , Lipase 33. Cardiac
enzymes- negative.
CXR showed old RLL infiltrate unchanged from previous tests.
ECG demonstrated nonspecific ST changes unchanged from previous tests.
--Hospital course:
1. ) Pulm- patient treated for COPD flare with supplemental O2 , DuoNebs , and
steroids. Since he reported left sided pleuritic chest pain , we evaluated
the possibility of PE with a V/Q scan that reported a low probability of PE.
2. ) CV- patient's physical exam demonstrated signs of right-sided heart failure ,
notably 12 cm JVD , hepatomegaly and later hepatojugular reflex , and 2+
bilateral lower extremity pitting edema. We proceeded to treat his heart
failure by diuresis with Lasix , initially orally and then intravenous. Overall , he
diuresed approximately 1L fluid. To further evaluate his heart failure , a
cardiac MRI was obtained and demonstrated normal cardiac anatomy and
function. His LVEF was 73% and he had no valvular dysfunction.
3. ) ID- Sputum was cultured which showed few polys , moderate cocci , 2+
suspected orally flora. Since he remained afebrile and did not demonstrate an
elevated WBC , we did not treat with antibiotics.
4. ) Endo- His diabetes was managed with his home regimen of Novolog.
Steroids may have contributed to his elevated blood sugars. In a previous
discharge summary , it was noted that he had an elevated TSH level. We
followed up on this by rechecking his TSH , which was normal.
5. ) Renal- He an elevated baseline level of Cr. We monitored his Cr and
BUN for an increase with diuresis. While the BUN increased to the low 30s ,
his Cr was stable.
6. ) Prophylaxis- Chronic pain and insomnia were managed with his out-patient
regimen of morphine and oxycodone. He was given Elavil for sleep. Because
of his history of cancer , he was placed on Lovenox for anticoagulation.
ADDITIONAL COMMENTS: Please use your home oxygen when you are sleeping at night. We have added
combivent inhalers and a steroid taper to your medicines. Please stop the
hydrochlorathiazide ( hctz ) 25mg. Instead you will be taking lasix 20mg
once a day.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
- Continue Lasix 40mg orally every day at home and D/C home HTCZ.
- Slow Prednisone taper over next 20 days.
- Have primary care physician address management of HTN medications and OSA. Check lytes on
new dose of lasix. Consider adding ACE inhibitor considering hx of NIDDM.
Episodic hypoxia while sleeping may contribute to pulmonary HTN and signs
of right heart failure observed.
No dictated summary
ENTERED BY: HOLLIDAY , CASSAUNDRA C. , M.D. ( ZP01 ) 8/4/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 835
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
N |
Y |
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Y |
N |
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N |
472205463 | PUO | 29439805 | | 053963 | 10/14/1997 12:00:00 a.m. | MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/14/1997 Report Status: Signed
Discharge Date: 5/16/1998
ADMISSION DIAGNOSIS: CHEST PAIN.
PROBLEM LIST: 1 ) CORONARY ARTERY DISEASE.
2 ) HYPOTHYROIDISM.
3 ) PEPTIC ULCER DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old woman who
had coronary artery bypass graft in
1993 who presents with ten minutes of acute chest pain today. In
August of 1992 , she had quadruple bypass surgery with LIMA to the
LAD and saphenous vein graft to the PDA , OM2 and diagonal branch.
She was feeling generally well until the beginning of April at
home. From June , 1997 to January , 1997 , she was in
A O and began to experience intermittent episodes of diaphoresis.
These tended to occur with ambulation on a flat surface , although
she did have one episode that awakened her from sleep. The second
time this happened , she went to the Ow. Rehabilitation Hospital Of there in Lub Na Hunt
with the complaints of diaphoresis and some nausea , although she
did not have chest pain , shortness of breath , vomiting or
palpitations. No EKG was done at the time. She said that she was
definitely more comfortable lying or sitting than standing. It is
of note that she had had her Beta blocker , Pendalol decreased from
5 mg to 2.5 mg prior to this trip to Speckwolf Dr , Ver Ba , South Carolina 16074 On return to the
Tage S Montakor Ver , Wisconsin 02911 , she had upper respiratory and pharyngeal symptoms
with low grade fevers and a cough productive of a green sputum.
This was treated with Amoxicillin given to her by her son who is a
pharmacist. These symptoms gradually resolved and she saw Dr.
Hamblet on March , 1997 and was given a clean bill of health.
At this visit , he did start her on Prinivil. Since she had been
home from Quezon Boulevard , La More E , Kentucky 57872 , she really had not had repeat episodes of
diaphoresis. Then on the day of admission when she went shopping
and had a recurrent episode of diaphoresis while carrying bags ,
this time with substernal chest pain that radiated down both arms.
She also had a general sense of heaviness across her chest. She
drove home and took a sublingual nitroglycerin that completely
resolved her pain. She describes this pain as exactly like the
anginal pain that she had prior to her coronary artery bypass
graft. The total duration of this episode was approximately ten
minutes. By the time she presented to the Emergency Room , she had
no diaphoresis and no chest pain and was feeling perfectly normal.
The latest echocardiogram in April of 1997 showed an ejection
fraction of 35% with mid to distal septal and apical akinesis and
inferior akinesis with mild mitral regurgitation. In July of
1997 , she went 4 minutes and 18 seconds on an exercise tolerance
test with Thallium which showed only fixed defects , no reversible
defects.
PAST MEDICAL HISTORY: Significant for coronary artery disease and
coronary artery bypass graft with cardiac
risk factors of hypertension , family history and high cholesterol ,
hypothyroidism and remote peptic ulcer disease with history of
cholecystectomy and appendectomy.
MEDICATIONS ON ADMISSION: 1 ) Zocor 5 mg orally every bedtime 2 ) Prinivil
5 mg orally every day. 3 ) Pendalol 2.5 mg
orally every day. 4 ) Aspirin 325 mg orally every day. 5 ) Synthroid 0.100
mg orally every Monday , Wednesday and Friday and 0.12 mg orally Tuesday ,
Thursday , Saturday and Sunday. 6 ) Pepcid as needed
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: The patient lives in Sni Ard Cla with her husband and
has two married sons. She does not smoke and
drinks wine occasionally.
FAMILY HISTORY: Mother died of a myocardial infarction at age 58
and her brother had a coronary artery bypass graft
at age 79 and she has a sister with Alzheimer's disease.
PHYSICAL EXAMINATION: The patient is a pleasant , elderly woman in
no apparent distress. Vital signs:
Temperature 99.4 degrees , heart rate 87 , blood pressure 115/78 ,
respiratory rate 18 , oxygen saturation 98% on room air. The rest
of the physical examination was significant for a clear oropharynx.
Lungs were clear to auscultation bilaterally. Cardiovascular
examination was regular rate and rhythm , S1 and S2 and a two out of
six systolic ejection murmur at the left upper sternal border with
no gallop or rub. Abdomen was soft with good bowel sounds.
Extremities revealed no edema. Neurological examination was
non-focal. Rectal examination was guaiac negative with no masses.
LABORATORY: Laboratory studies were significant for a white blood
cell count of 5.46 , hematocrit 40.1 , platelets 190.
Cardiac Troponin I was 0.0. CK was 102. Urinalysis was negative.
Chest x-ray was clear with no infiltrates. EKG was normal sinus
rhythm with normal intervals and normal axis with a left bundle
branch block pattern and first degree atrioventricular block with
no change compared to an EKG done on March , 1997.
HOSPITAL COURSE: The impression on admission was that this is a
woman with known coronary artery disease status
post coronary artery bypass graft who is now experiencing unstable
angina with diaphoretic episodes , both at rest and exertion and now
substernal chest pain. She ruled out for a myocardial infarction.
On April , 1998 , she had a standard Bruce exercise tolerance
test in which she went 3 minutes , 30 seconds and stopped because of
chest pain. This was typical of anginal pain and resolved eight
minutes into recovery. The EKG had no changes with a left bundle
branch block at baseline and this was considered to be consistent
with but not diagnostic of ischemia. She subsequently underwent
cardiac catheterization which revealed patent grafts with her known
underlying native disease. Her right atrial pressure was 4 , right
ventricular 46/8 , PA 42/22 , pulmonary capillary wedge pressure 19.
From here , she was managed medically with increases in her ACE
inhibitor , Statin and the addition of nitrates. After the cardiac
catheterization , she developed a large right groin hematoma at the
puncture site and a bruit was noted. An ultrasound was done that
revealed a pseudoaneurysm of the common femoral artery. She was
followed by Vascular Surgery and on May , 1998 , had a
follow-up ultrasound which confirmed the presence of a
pseudoaneurysm in her common femoral artery measuring 2 X 1.5 cm
surrounded by a large hematoma. On May , 1998 , the patient
underwent surgical repair of the pseudoaneurysm without any
complications and she was discharged on March , 1998 with
follow-up with both Dr. Loerwald of Vascular Surgery and Dr. Hamblet ,
her cardiologist.
MEDICATIONS ON DISCHARGE: 1 ) Aspirin 325 mg orally every day. 2 )
Colace 100 mg orally twice a day 3 ) Synthroid
100 mcg orally every Monday , Wednesday and Friday , 112 mcg orally q.
Tuesday , Thursday , Saturday and Sunday. 4 ) Lisinopril 10 mg orally
every day. 5 ) Beclomethasone diproprionate double strength spray to
each nostril twice a day 6 ) Zocor 20 mg orally every bedtime 7 ) Toprol XL 75
mg orally every day. 8 ) Imdur 30 mg orally every day. 9 ) Augmentin one
tablet orally every day for seven additional days.
Dictated By: DESIRAE MARCOTT , M.D. ZG13
Attending: JACKSON PART , M.D. IZ71
WB023/5453
Batch: 78809 Index No. ICGIQH684U D: 3/10/98
T: 3/10/98
Document id: 836
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
- |
348893917 | PUO | 00979234 | | 3999446 | 11/25/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/6/2005 Report Status: Signed
Discharge Date: 1/9/2005
ATTENDING: SHOPBELL , MYRIAM M.D.
SERVICE: Son
PRINCIPAL DIAGNOSIS: Cardiomyopathy , coronary artery disease.
PROBLEM LIST AND DIAGNOSIS:
1. Morbid obesity.
2. Diabetes.
3. Hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old woman
with morbid obesity ( greater than 330 pounds ) , hypertension ,
diabetes mellitus who presents with one week of increasing
dyspnea on exertion. She notes that she can no longer walk from
room to room without resting and she used to be able to walk
around her house. She also notes a frequent need to "get air"
which also wakes her from sleep. She often opens the window ,
turns on the air conditioning , etc. when she feels short of
breath. She started sleeping on two pillows over the past few
weeks. She also reports an intermittent increase in her leg
swelling and a cough productive of scant clear to whitish sputum.
She was unable to name her home medications , but stated that she
took four medications plus insulin which is in accordance with
her LMR notes. She has not been able to check her fingerstick
blood glucose levels recently because her machine has been
broken. She denies chest pain , tightness except with coughing.
She denies pleuritic pain , any recent illness , any sick contacts ,
any change in urinary or bowel habits , any nausea or vomiting ,
night sweats , diaphoresis or pain in her jaw or arms. Of note ,
her KTDUOO primary care physician , Dr. Alverta Burvine , note from
September 2004 noted tachycardia greater than 100 with decreased
exercise tolerance , inability to lie flat , and snoring and
daytime sleepiness. At this time , an echocardiogram performed in
January 2004 revealed an EF of 60 to 65% , trace PR and no regional
wall motion abnormality.
PAST MEDICAL HISTORY: Significant for hypertension. Bilateral
DVTs in 1972. The patient is not currently on anticoagulation.
She was on Coumadin for one year following this event.
Dysfunctional vaginal bleeding. Fibroids. Type II diabetes
mellitus. Morbid obesity. Pituitary microadenoma.
HOME MEDICATIONS: ( Per LMR - the patient confirms these as best
she can recollect ).
1. HCTZ 25 mg daily.
2. Glucophage 500 mg orally twice a day
3. NPH insulin 60 every day before noon , 20 every afternoon
4. Lisinopril 40 mg.
5. Iron supplements.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies tobacco use , alcohol use ,
drugs. She lives with her daughter who is one of her four
children , and eight of her 14 grandchildren in Cuse A Wa
She does not work.
FAMILY HISTORY: Hypertension , diabetes mellitus. No known MI's.
ADMISSION PHYSICAL EXAMINATION: Temperature 98.8. Heart rate
137 , down to 98 with 5 mg of intravenous Lopressor in the Emergency
Department. Blood pressure 156/98 , satting 95% on room air. In
general , the patient is an obese , pleasant woman in no apparent
distress. HEENT: Extraocular muscles are intact. Mucous
membranes moist. No JVD. Cardiovascular exam reveals
tachycardia , S1 , S2. No murmurs , rubs or gallops but heart
sounds are distant and difficult to assess. Lungs: Decreased
breath sounds throughout secondary to body habitus , but no
crackles or wheeze noted. Abdomen: Soft , nontender ,
nondistended. Extremities warm and well perfused. Bilateral
pitting edema to shins. Derm: No ulcers or lesions.
Hyperpigmentation noted around neck and under breasts. GU exam:
Very trace guaiac positive stool.
ADMISSION LABORATORY RESULTS: Notable for a blood glucose of
190 , BNP of 271 , and hematocrit of 32. ??_____?? EKG: Sinus
tachycardia at 118 with no ST or T-wave abnormalities. Chest
x-ray revealed mild cardiomegaly. No pulmonary edema. No
infiltrate. PE protocol CT ruled out central PE and showed a
small right pleural effusion.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular:
Ischemia: The patient had cycled electrocardiograms and
biomarkers. These were negative for myocardial ischemia or any
acute change. The patient was maintained on aspirin , Lipitor 80
mg , beta-blocker , and ACE inhibitor. The patient underwent
cardiac catheterization on 8/10/05 which revealed a 50% LAD
lesion , a 70% D1 lesion. These lesions were not intervened upon
at the time of dictation. This patient is awaiting viability
study.
Pump: The patient underwent echocardiography on 5/19/05. The
findings of that study were very concerning revealing ejection
fraction of 20 to 25% , sharply decreased from EF of 60 to 65% in
January 2004. In addition , the study revealed global hypokinesis
with septal akinesis.
Rhythm: The patient has remained tachycardic and has been
monitored on tele with no noted abnormalities. On the night of
8/10/05 following cardiac catheterization , the patient had a 13
beat run of nonsustained V. tach on telemetry. She received
electrolyte optimization and close monitoring. Following this
episode , the patient's cycled cardiac biomarkers revealed a
troponin of 7.25 , MB fraction of 31 , CK of 283. As noted above ,
she will undergo cardiac viability study on 4/30/05 and may
receive evaluation by the Electrophysiology Service.
2. Pulmonary: The patient's initial presentation was suspicious
for pulmonary embolism given her distant past medical history of
DVT's. However , when she was admitted , she exhibited only
tachycardia without evidence of tachypnea or hypoxia and her
clinical course thus far , as well as her PE protocol CT is not
suggestive of this diagnosis. She has had a minimal oxygen
requirement over the course of her hospital stay. She does
experience dyspnea on exertion , however , has not been hypoxic at
any point.
3. Endocrine: TSH was normal. The patient was continued on her
orally hypoglycemic as well as an adjusted insulin regimen which
will be further altered prior to the patient's discharge. In
addition , she will be discharged with a prescription for a new
blood glucose monitor. Her last hemoglobin A1c check was close
to 12. Given her concerning findings of coronary artery disease ,
she will need to maintain much tighter control of her blood
glucose in the future. At the time of dictation , the patient is
being maintained on scheduled NPH as well as regular insulin
sliding scale.
4. Hematologic: Baseline anemia with admission hematocrit
improved from prior infectious diseases. The patient's
productive cough was thought to be not due to infection. The
patient has remained afebrile with normal white blood cell count
over the course of her hospital stay.
The remainder of this patient's hospital course and her discharge
medications will be dictated in a future addendum.
eScription document: 1-1756178 MCSFocus transcriptionists
Dictated By: SURGEON , PRICILLA
Attending: SHOPBELL , MYRIAM
Dictation ID 5430527
D: 9/15/05
T: 9/15/05
Document id: 837
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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590003036 | PUO | 91379789 | | 251306 | 5/14/2001 12:00:00 a.m. | POSITIVE EXERCISE TOLERANCE TEST | Signed | DIS | Admission Date: 5/14/2001 Report Status: Signed
Discharge Date: 8/15/2001
Mr. Birkett is a 58-year-old gentleman , who was admitted to
I Warho Hospital on 6/9/01 with coronary artery
disease. He went to the cardiac cath lab on 6/9/01 for elective
cardiac catheterization. Primary indication was a positive stress
test and known coronary artery disease. He has a past medical
history that includes diabetes mellitus , insulin dependent for 30
years , a former smoker and also has asthma and chronic obstructive
pulmonary disease. His coronary angiography demonstrated a 60%
discrete left main coronary artery lesion. No significant left
anterior descending coronary lesions were identified. He had a
discrete 50% lesion of the second diagonal. No significant
circumflex lesions and no significant right coronary lesions. He
was referred for coronary artery bypass grafting and was seen in
consultation by the cardiac surgical service. He has a prior
history of coronary artery disease and had undergone percutaneous
angioplasty in 1993. His surgical history includes a right lower
lobe wedge resection for a ____________. His medication on
admission are Cardizem 180 mg once a day , Avapro 150 mg once a day ,
Allegra 180 mg once a day , Lipitor 40 mg once a day , Pulmicort
twice a day , Rhinocort , Proventil inhalers , also Lente Insulin ,
Humalog as needed and doxycycline as needed , multivitamins , vitamin E
and enteric-coated aspirin 81 mg. He has no known drug allergies.
His physical exam is unremarkable. His neck is supple. He has no
carotid bruits. His cardiac exam is regular rhythm. Normal S1/S2
without murmur. Lungs are clear to auscultation bilaterally.
Abdomen is soft and nontender. Extremities with no lower extremity
edema , varicose veins. Peripheral pulses are intact.
Labs on admission include a glucose of 267 , BUN and creatinine of
16/1.0 , white blood cell count 9.5 , hematocrit of 43.6 , platelets
252. His liver function tests were within normal limits and his
urinalysis negative. Chest x-ray was clear. EKG demonstrated
sinus rhythm , 55 beats/minute and no ST-T wave changes. He had had
a SPECT on 8/25/01 , which demonstrated post stress ejection
fraction of 47% with moderate inferior wall hypokinesis , mid to
distal anterior and anteroseptal wall hypokinesis.
He was seen in consultation with the plastic surgery service for
potential left radial artery harvest for his bypass grafting. His
Allen's test by plastics for his left hand demonstrated a good
pulse and he was determined to be a good candidate for left radial
harvesting. He went to the operating room on 6/2/01 , where he
underwent coronary artery bypass grafting x3 with a left internal
mammary artery to left anterior descending coronary artery. A left
radial to the first diagonal and a left radial has a skip to the
obtuse marginal #1. His intraoperative course was unremarkable.
Postoperative course was unremarkable. He was placed on a Portland
protocol for blood sugar control and the diabetic management
service was consulted to help in his diabetic management. He was
extubated on the evening of surgery and his inhalers were restarted
for his asthma control. He continued to do well and began his own
blood sugar management along with the diabetic service. Blood
sugars remained between 123-250 on his Lente and Humalog regimen.
He did have a temperature of 101 briefly on postop day four.
Cultures were negative. His wounds all are clear and well healing
on postop day six. Half of the staples in his radial artery
harvest site are removed; the other half to be removed on Friday by
the visiting nurse association on Friday , 11/10
He is to be discharged in good condition on the following
medications: Lopressor 25 mg three times a day , diltiazem 30 mg three times a day for his
radial artery , to be continued throughout his postop course ,
potassium supplementation 10 mEq three tablets , one tablet once a
day for three days along with Lasix 20 mg one tablet once a day for
three days , enteric-coated aspirin 325 mg once a day , Rhinocort two
sprays four times a day as needed , Pulmicort inhaler two puffs
twice a day , ibuprofen 600 mg one tablet every six hours as needed
for pain , Proventil inhaler two puffs four times a day as needed
for wheezing , Lipitor 40 mg once a day at bedtime , Allegra 180 mg
once a day , and Avapro 150 mg once a day. He is to be discharged
to the care of Dr. Genoveva Stidman on Monew
Dictated By: CHRISTY CLARDY , P.A.
Attending: JANAY D. STUKOWSKI , M.D. JX47
UM942/056649
Batch: 71566 Index No. QLPVYW8F9Q D: 9/10/01
T: 9/10/01
CC: 1. GENOVEVA STIDMAN , M.D. VX46
Document id: 838
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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682349409 | PUO | 25903098 | | 129249 | 9/10/1997 12:00:00 a.m. | DILATED CARDIOMYOPATHY | Signed | DIS | Admission Date: 7/19/1997 Report Status: Signed
Discharge Date: 6/7/1997
PRINCIPAL DIAGNOSIS: CARDIOMYOPATHY.
SIGNIFICANT PROBLEM: NON-INSULIN DEPENDENT DIABETES MELLITUS.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old female
with dilated cardiomyopathy who is
admitted for transplant evaluation. The patient initially
presented in 1991 with substernal chest pain. At that time , it was
thought that she was having a myocardial infarction and
Streptokinase was given; however details are not known. An
echocardiogram at that time showed that her ejection fraction was
35-40% with evidence an anteroseptal myocardial infarction. An ETT
Thallium showed fixed anteroseptal and apical defects. Cardiac
catheterization showed clean coronaries. The patient was referred
to Pagham University Of where an exercise bicycle test
showed 6 minutes and 22 seconds of exercise. Her peak heart rate
was 113 with a peak blood pressure of 140/60 and a peak VO2 of 11.6
ml per kg per minute. The patient apparently did well until about
a year prior to admission when she noted a gradual decrease in her
exercise tolerance. At an outside , she was hospitalized for
congestive heart failure symptoms. Lately , the patient noticed
that she is unable to walk without becoming short of breath. In
January of 1997 , the patient was able to walk one mile , but is now
unable to do so. The patient reports stopping several times while
trying to climb one flight of stairs. She does report orthopnea as
well as paroxysmal nocturnal dyspnea , no light headedness or
syncope. She does have some palpitations as well as complaints of
twinges under left breast that occur randomly. She does not
experience any leg swelling. The patient saw Dr. Borriello on
September , 1997 at which time an echocardiogram showed a
massively dilated left ventricle with severely depressed systolic
function and an ejection fraction of 15%. All walls were severely
hypokinetic. There was moderate left atrial enlargement and
moderate mitral regurgitation. There was normal right ventricular
size and function and no thrombus or pericardial effusion. The
patient underwent a bicycle test for which achieved 5 minutes and
33 seconds with a maximal heart rate of 108 and a VO2 of 6.4 ml per
kg per minute.
PAST MEDICAL HISTORY: Significant for 1 ) History of bronchitis.
2 ) History of cardiomyopathy as above. 3 )
Non-insulin dependent diabetes mellitus. 4 ) Status post
hysterectomy at age 40. 5 ) Status post cholecystectomy. 6 )
Status post appendectomy. 7 ) History of panic disorders. 8 )
History of agoraphobia. 9 ) History of alcohol use.
MEDICATIONS ON ADMISSION: 1 ) Coumadin 2.5 mg orally four times a
week and 5 mg orally three times a week.
2 ) Digoxin 0.125 mg orally every day. 3 ) Enalapril 10 mg orally twice a day
4 ) Micronase 2.5 mg orally every day. 5 ) Multivitamins one tablet
orally every day. 6 ) Lasix 40 mg orally twice a day 7 ) Xanax 0.5 mg orally
four times a day as needed
ALLERGIES: The patient had no known drug allergies.
FAMILY HISTORY: Her parents both died with cardiac problems with
coronary artery disease ( father at age 42 , mother
at age 62 ).
SOCIAL HISTORY: The patient lives alone with an apartment next to
her son. She has worked as a house cleaner. She
has an 18 pack year history of cigarette smoking; she quit smoking
30 years ago. She does have a history of heavy alcohol use. She
is recently divorced.
PHYSICAL EXAMINATION: The patient is pleasant in no apparent
distress. The patient is afebrile with a
blood pressure of 110/76 , heart rate 70 and a respiratory rate of
20 with oxygen saturation of 97% on room air. Her head examination
is remarkable for upper dentures. Neck shows jugular venous
pressure of 7 cm. Carotid upstrokes are decreased and without
bruits. There was no lymphadenopathy. Lungs show occasional
bibasilar rales. Heart shows regular rate and rhythm with distant
heart sounds. There is a left ventricular heave and an S3 present.
The abdomen is obese with bowel sounds present , soft , non-tender
without masses. The extremities show 1+ pitting edema bilaterally.
Pulses are intact bilaterally and the extremities are warm.
Neurological examination is non-focal with intact sensation and
motor examination. Deep tendon reflexes are symmetric and 2+
bilaterally with downgoing toes bilaterally.
HOSPITAL COURSE: The patient was admitted for a transplantation
work-up. She was catheterized on February ,
1997. The catheterization showed no coronary artery disease noted.
The atrium showed 16 mm of mercury mean pressure. The right
ventricle showed 48/18 mm of mercury. The PA showed 48/34 mm of
mercury with a mean pressure of 39 mm of mercury. The pulmonary
capillary wedge pressure showed a mean of 30 mm of mercury.
Cardiac output and cardiac index showed 4.4 liters per minute and
2.2 liters per minute per meter squared. The patient was briefly
transferred to the Coronary Care Unit secondary to her elevated
pulmonary capillary wedge pressure and the presence of her
Swan-Ganz catheter. The patient was diuresed with good response.
She was transferred back to the General Medicine Team where
diuresis with intravenous Lasix was continued. She tolerated
Enalapril and Lasix well. By the end of her hospitalization , she
was taking 12.5 mg of Enalapril twice a day and 40 mg of Lasix orally
twice a day She had been taken off her Coumadin and had been placed on
Heparin during this hospitalization. The patient did experience
some hematuria toward the end of her hospitalization which was felt
to be secondary to Foley trauma while she was in the Coronary Care
Unit.
As part of the patient's transplant evaluation , she had a PPD with
controls placed which showed that her PPD was negative and her
controls were positive. The patient underwent a Dental consult as
well as a Psychiatric consult. The Psychiatric evaluation was
favorable for transplantation. The Dental consult involved the
patient having panoramic x-rays. Thyrology showed a
cytomegalovirus IgG being positive , a cytomegalovirus IgM being
equivocal , and Epstein-Barr virus anti-VCA IgG at 640 , an
Epstein-Barr virus anti-VCA IgM being less than 10 and a mucal
screen being greater than or equal to 32 , a varicella zoster titer
of 512 , a Toxoplasma IgG being positive , a Toxoplasma IgM being
negative. Abdominal ultrasound showed a mildly dilated common bile
and pancreatic duct and showed that this patient was status post
cholecystectomy.
While the patient maybe a good transplant candidate , it was felt
that her weight was a negative factor in her potential for
transplant. The patient will be pursuing cardiac rehabilitation
and weight loss if she is to be considered for transplant in the
future. The patient was discharged.
MEDICATIONS ON DISCHARGE: 1 ) Tylenol 650 mg orally every 4 hours as needed
headache. 2 ) Xanax 0.5 mg orally four times a day
3 ) Digoxin 0.125 mg orally every day. 4 ) Enalapril 12.5 mg orally
twice a day 5 ) Lasix 40 mg orally twice a day 6 ) Micronase 1.25 mg orally q.
day. 7 ) Multivitamins one tablet orally every day. 8 ) Coumadin 2.5
mg orally every day on even days and 5 mg orally every day on odd days.
INSTRUCTIONS: The patient was instructed that she should increase
her diuresis at home if she noticed an increase in
her weight and was instructed to see a physician for continued for
weight increases due to fluid accumulation.
Dictated By: TERENCE NICKOLAS , M.D. TD62
Attending: SACHIKO BORRIELLO , M.D. EO3
MT288/1120
Batch: 74735 Index No. NRTYW3BEN D: 10/10/97
T: 2/20/97
Document id: 839
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
Y |
Y |
N |
- |
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N |
313615200 | PUO | 85677707 | | 5892053 | 11/20/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/20/2005 Report Status: Signed
Discharge Date: 10/15/2005
ATTENDING: RAABE , SUNSHINE M.D.
PRINCIPAL DIAGNOSIS: Heart failure.
LISTS OF PROBLEMS AND DIAGNOSES: Status post cardiac transplant
in 1993 , obesity , chronic obstructive pulmonary disease ,
insulin-dependent diabetes mellitus , chronic renal insufficiency
with a baseline of creatinine of 1.5 , hepatitis B , hypertension ,
osteoporosis , status post L3 compression fracture , status post
left hip fracture with replacement in September 2005 , complicated by
infection necessitating removal , debridement , and deconditioning.
BRIEF HISTORY OF PRESENT ILLNESS: Ms. Pinnette is a 67-year-old
female with multiple medical comorbidities and a past medical
history significant for cardiac transplant in 1993 , and hip
replacement in September 2005 , complicated by wound infection , and need
for prolonged rehabilitation who presented from Oswe Mastook Hospital to Car University Medical Center with three days of
progressive worsening shortness of breath. Her chest x-ray was
consistent with congestive heart failure , and she was transferred
to Pagham University Of with the request of her daughter
for further management of her heart failure. Here , her mental
status was borderline upon admission , but it improved with
discontinuation of standing analgesic and decreasing of her
clonazepam. A head CT showed no acute processes. She had a
right upper arm cellulitis and urinary tract infection on
screening urinalysis. She was anemic. She was found to be
vancomycin resistant Enterococcus positive , but repeated cultures
demonstrated MRSA negative. Her inpatient issues included
management of her heart failure , right upper extremity
cellulitis , urinary tract infection , chronic anemia , diabetes ,
and evaluation of her hip by orthopedics.
ALLERGIES: She had allergies to penicillin and codeine , but the
reactions are unknown.
MEDICATIONS ON ADMISSION: Vitamin C , Imuran , PhosLo , iron
sulfate , Deltasone , Coumadin , Aranesp , Dilaudid for pain ,
lactulose , Reglan , Sarna topical , Senokot , Ambien for sleep ,
miconazole powder , cyclosporine , Celexa , and Lasix 80 mg once per
day.
PHYSICAL EXAMINATION: She was afebrile. Her blood pressure was
130/57 , and her pulse 120 in sinus tachycardia. She was 95%
saturated on 3 liters. Physical exam was significant for
bibasilar crackles in her lungs. 2+ edema in her legs to her
knees. A 5 cm x 5 cm area of warm erythema in her right upper
extremity and a left hip wound with packing in place granulation
tissue.
OPERATIONS AND PROCEDURES: CT of her head , which showed no acute
processes. Echocardiogram of her heart showed an ejection
fraction of 55%. Normal right ventricle and structure with mild
to moderately reduced systolic function in her right ventricle.
Moderately dilated left atrium , moderately dilated right atrium ,
normal aortic valve , mild to moderate mitral regurgitation , and
structurally normal tricuspid valve. Right upper arm ultrasound ,
which showed no evidence of venous obstruction.
HOSPITAL COURSE BY PROBLEM: Ms. Pinnette 's inpatient issues
included management of her heart failure , right upper arm
extremity cellulitis , urinary tract infection , chronic anemia ,
diabetes and evaluation of her hip by orthopedics. For her heart
failure , she was diuresed with intravenous and transitioned to orally
torsemide and they entered discharge dose of torsemide 200 mg
orally twice per day. Her admission weight was 133 kg and her
discharge weight 122 kg. She should continue on her current
torsemide and limit her daily salt intake , and restrict herself
to 2 liters per day for her right upper extremity cellulitis.
She was given a five-day course of levofloxacin ( used to address
recurrent UTI ) and then a two-day course of Ancef , her cellulitis
cleared with this regimen. For her urinary tract infection , she
was initially treated with levofloxacin and transitioned to
Bactrim based on antibiogram sensitivities. A long-term Foley
catheter was removed. Repeat cultures showed bacteria in her
urine; however , she was clinically asymptomatic , it was felt that
this is more consistent with colonization and no further
treatment was instituted. If needed for further antibiotics , a
PICC line was placed on May , 2005 , after her prior PICC
line clotted. Prior to discharge , a new Foley catheter was
placed and she was incontinent of urine and overall more
comfortable with catheter in place. While on Bactrim for her
UTI , her creatinine rose to a peak of 2.0 , it was unclear whether
this raise was due to diuresis or the antibiotic. With cessation
of the antibiotic , her creatinine trended downward to her
baseline at 1.6. For her chronic anemia , the patient was
continued on iron ( which was increased to three times per day )
and darbepoetin , folate was added. She was asymptomatic from her
chronic anemia. She was given two units of packed red blood
cells in May , 2005 , and two more units on February ,
2005 , and she responded appropriately to this. Her discharge
hematocrit was 30. Her hip was evaluated by orthopedics. They
felt her hip was healing well. She should be continued on
wet-to-dry dressings. No further orthopedic intervention is
planned. She can bear her full weight on her hip. At discharge ,
the patient was hemodynamically stable , afebrile , and breathing
comfortably on three liters of oxygen. She was discharged to
Hona Barn Medical Center and should work aggressively towards
reconditioning.
DISCHARGE MEDICATIONS: Vitamin C 500 mg twice per day , Imuran 25
mg daily , PhosLo 667 mg three times per day , clonazepam 0.25 mg
twice per day , cyclosporine 50 mg twice daily , Colace 100 mg
twice daily , iron sulfate 325 mg three times per day , folate 1 mg
daily , Dilaudid 2 mg every six hours as needed for pain , please
hold this sedated for respirations less than 10 per minute ,
insulin NPH 14 units every evening , insulin NPH 46 units every
morning , lactulose 30 mL four times per day as needed for
constipation , prednisone 5 mg every morning , Sarna topical every
day apply to affected areas , multivitamin daily , Coumadin 2.5 mg
daily , goal INR 2 to 3 , zinc sulfate 220 mg daily , Ambien 5 mg
before bed as needed for insomnia , torsemide 200 mg by mouth two
times per day , Fosamax 70 mg once per week , miconazole nitrate 2%
powder topical two times per day apply to affected areas as
needed , Advair Diskus 250/50 one puff inhaled twice per day ,
esomeprazole 20 mg once per day , DuoNeb 3/0.5 mg inhaled every
six hours as needed for shortness of breath , Aranesp 50 mcg
subcutaneously once per week , NovoLog sliding scale before meals ,
Lexapro 20 mg once per day , Maalox one to two tablets every six
hours as needed for upset stomach , and Lipitor 20 mg once per
day.
OUTSTANDING ISSUES: Include following INR the goal of 2 to 3 ,
following weight and clinical signs of volume overload , following
up on loose stools for possible Clostridium difficile infection.
Following clinical signs for evidence of urinary tract infection
treating with antibiotics as necessary.
PRIMARY CARE PHYSICIAN: Dr. Gaylene Faniel
eScription document: 7-2388267 SSSten Tel
CC: Gaylene Faniel M.D.
Bay Ing Son
Ak
Dictated By: THEILING , BREE
Attending: RAABE , SUNSHINE
Dictation ID 5048135
D: 10/4/05
T: 10/4/05
Document id: 840
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
Y |
N |
U |
U |
U |
U |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
- |
- |
N |
N |
N |
N |
- |
Y |
N |
Y |
Y |
Y |
N |
N |
083126973 | PUO | 90337024 | | 8279150 | 10/28/2005 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 1/17/2005 Report Status: Signed
Discharge Date: 4/9/2005
ATTENDING: SHANNON , JULIANA O.
MEDICAL SERVICE:
Gard Worce Oard
PRINCIPAL DIAGNOSES:
Acute renal failure , anemia.
LIST OF PROBLEMS/DIAGNOSES:
Hypertension , family history of CAD , degenerative joint disease ,
depression , obstructive sleep apnea , pulmonary hypertension and
morbid obesity.
HISTORY OF PRESENT ILLNESS:
A 60-year-old morbidly obese female with a history of
hypertension , obstructive sleep apnea , degenerative joint
disease , and recent falls , now in rehab since 7/18 , most
recently at Ley Rotal University Medical Center , who presented with acute renal failure
found on routine labs , the morning of admission. The creatinine
was 3.6 on admission up from 1 in 6/29 and up from 2.2 in 6/8
BUN was elevated at 96. Labs were also notable for hematocrit
of 24 down from a baseline of 44 in 2001. The patient reports
being told that she had chronic kidney disease during an
admission to TH in 7/18 , attributed to heavy NSAID use in the
setting of degenerative joint disease. The patient stopped using
NSAIDs in 6/8 Prior to September , she reports decreased orally intake
in the setting of feeling like she was retaining fluid. Today ,
she complains of diffuse swelling and increased shortness of
breath x2-3 weeks. Denies chest pain , orthopnea or PND. Also ,
reports dysuria in the setting of indwelling Foley since 6/8
Denies fever , chills , nausea , vomiting , abdominal pain , no melena
or bright red blood per rectum in the last six months but reports
melena and bright red blood per rectum intermittently in 2003 in
the setting of colonoscopy that was positive for diverticula.
ADMISSION PHYSICAL EXAM:
The patient was afebrile with a heart rate ranging from 60-90 ,
systolic blood pressure of 120-140 , respiratory rate of 18 , she
was satting 95% on 2-4 liters. The patient was obese nonmobile ,
alert and oriented x3 and in no apparent distress. Pupils were
equal round and reactive to light. Sclerae were anicteric. She
had no conjunctival pallor. JVP could not be assessed due to
body habitus. She had a regular rate and rhythm , normal S1 and
S2. She had a II/VI systolic ejection murmur audible at the left
upper sternal border. Lungs were notable for crackles at the
left base on anterior lung exam , they were otherwise clear. Her
abdomen was obese , she had positive bowel sound. It was soft ,
nondistended and nontender. Extremities were warm and well
perfused. She had 2+ pitting edema to the knee bilaterally.
Pertinent lab results as mentioned in the HPI.
OPERATIONS AND PROCEDURES DURING THE ADMISSION:
1/13/05 creation of left arm AV fistula; 7/7/05 EGD.
HOSPITAL COURSE BY PROBLEM:
In summary , this is a 60-year-old morbidly obese woman who
presented with acute and chronic renal failure and anemia.
PROBLEM:
1. Renal: Renal failure initially thought to be secondary to
prerenal etiology in the setting of elevated BUN/creatinine ratio
and FENA less than 1% in the setting of Lasix and FEBUN of 19%
and because of the presence of abundant granular casts. ATN also
possibility but urine sodium was 29. Postrenal etiology was
ruled out with a renal ultrasound without evidence of
hydronephrosis. The patient was aggressively hydrated once
outside hospital records confirmed an ejection fraction of 60%.
However , the patient initially appeared to fail volume challenge
with no acute change in creatinine past 3.2 from 10/18/05 to
4/20/05. At that time , Vascular Surgery was consulted for AV
fistula placement in the setting of GFR of approximately 17 that
was not improving. AV fistula was placed on 1/13/05 in the left
arm without complication. Renal function was waxing and waning
throughout hospital course with creatinine at time of discharge
of 3.1. Daily urine output usually approximately 600-700 mL.
All diuretics and ACE inhibitor was held throughout hospital
course and blood pressure well controlled. The patient should
not be restarted on these medications because it will precipitate
worsening kidney failure.
2. GI: Colonoscopy in 2001/2003 notable for diverticula. Stool
was guaiac throughout hospital course and generally guaiac
positive brown stool. Hematocrit did not bump appropriately
after transfusion of 4 units. It went from 23.3-30. GI was
consulted in this setting and plans were made for EGD and
colonoscopy to look for a source of GI bleed. Both procedures
were scheduled in OR and attempted on 2/22/05. EGD successfully
performed with evidence of gastritis , nonbleeding ulcer , and
duodenal mass with gastric heterotopia. H. pylori stool antigen
and H. pylori biopsies negative. Patient continued on Nexium 40
mg daily. Colonoscopy not obtained unable to get past the rectum
in the setting of required general anesthesia/ETT in patient's
thighs.
3. Cardiovascular/Pump - ECHO with EF equal to 65% here ,
moderate diastolic dysfunction and moderate pulmonary
hypertension. No rhythm or ischemia issues during hospital
course , low HDL , started on statin.
4. Heme/normocytic anemia , likely secondary to GI bleed with
evidence of iron deficiency. Iron stores repleted with intravenous iron ,
also possible anemia in setting of low EPO. EPO level checked
low and normal , may ultimately benefit from Epogen. On Coumadin
for DVT prophylaxis/paroxysmal a-fib prior to arrival.
Supratherapeutic on admission , so Coumadin held in the setting of
GI bleed until INR 1.5 , then patient was covered with
subcutaneous heparin for DVT prophylaxis. However , acute drop in
platelets in the setting of heparin from the 200s to the 30s , so
heparin stopped. PF4 antibody negative x1 and borderline x1.
PF4 antibody pending at the time of discharge , but all heparin
products including flush is held. The patient restarted on
Coumadin after EGD at 12.5 mg a day. Status post three doses ,
INR was 2. Target INR is 2-2.5 and the patient will be followed
at the Pagham University Of Anticoagulation Clinic , phone
number is 132-202-5576. INRs can be faxed to clinic from rehab
and adjustments in doses can be made accordingly.
5. Endo: TSH within normal limits. Hemoglobin A1c 5.5 , so no
evidence of diabetes.
6. ID: UTI/proteus , levofloxacin renally dosed. Repeat urine
dirty , so orally Cipro started for empiric treatment of UTI in
setting of indwelling Foley. Two days prior to discharge , the
patient with low-grade temp to max 100.4. Chest x-ray unchanged
but only portable chest x-ray was obtained due to patient's
immobility , blood cultures and urine cultures were negative.
Empirically treating for nosocomial pneumonia with orally
levo/cefpodox/azithro x10 days , PICC line in place at time of
discharge. However , it should be discontinued by 11/19/05 to
prevent infection.
7. Allergy: Postnasal drip. Rhinorrhea. Continued Claritin
and Flonase.
8. Psyche: Zoloft continued for depression.
9. Pulmonary: Intermittent , the patient intermittently
desaturates on room air to 80s but always resolved with
repositioning and O2. Likely secondary to respiratory muscle
deconditioning and to restrictive lung disease in the setting of
morbid obesity. Continuing Flovent for asthma and albuterol nebs
as needed for wheezing. Continue CPAP at night for obstructive
sleep apnea.
10. Oncology: History of breast mass last evaluated in 4/20 at
which time the risk of surgery would determine to be greater than
the possible risk of breast cancer. Oncology not able to see
patient during inpatient stay but will schedule outpatient
followup regarding the issue of possible treatment with
tamoxifen.
11. FEN: Gentle bowel regimen , renal diet.
CODE STATUS:
Full.
KEY FEATURES OF PHYSICAL EXAM AT THE TIME OF DISCHARGE:
Essentially unchanged from admission.
DISCHARGE MEDICATIONS:
Include Tylenol 650 mg orally every 4 hours as needed , albuterol nebulizer 2.5
mg inhaled every 6 hours as needed for shortness of breath and wheezing ,
ECASA 81 mg orally daily , PhosLo 667 mg orally three times a day , Catapres 0.1
mg per day every weekly , Colace 100 mg orally twice a day , metoprolol
tartarate 25 mg orally twice a day , senna tablets two tabs orally twice a day
as needed for constipation , ocean spray two sprays inhaled four times a day
as needed for dry nose , Coumadin 12.5 mg orally every afternoon , Zoloft 50 mg
orally every day before noon , azithromycin 250 mg orally daily x10 days , simvastatin
20 mg orally at bedtime , doxazosin 2 mg orally twice a day , Norvasc 5 mg
orally daily , Claritin 10 mg orally daily , Flovent 110 mcg inhaled
twice a day , cefpodoxime proxetil 200 mg orally twice a day x10 days , Flonase
one spray daily , levofloxacin 250 mg orally every 24 x10 doses , and
Nexium 40 mg orally twice a day
DISPOSITION:
To rehab facility.
FOLLOWUP:
Follow up with patient's primary care doctor , Dr. Lorraine , and
oncologist to be arranged , dates of appointments will be
forwarded to rehab facility.
eScription document: 1-0262818 EMSSten Tel
CC: Domenic Lorraine M.D.
Dictated By: PARDON , HALEY
Attending: SHANNON , JULIANA
Dictation ID 1939694
D: 1/20/05
T: 1/20/05
Document id: 841
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
- |
- |
- |
- |
804845454 | PUO | 53934814 | | 2766636 | 9/16/2006 12:00:00 a.m. | transaminitis , CBD dilitation , pancreatic duct dilitation history of stenting , history of sphinterectomy | | DIS | Admission Date: 3/30/2006 Report Status:
Discharge Date: 2/2/2006
****** FINAL DISCHARGE ORDERS ******
MCGUFFEE , THOMAS J 021-75-25-6
J50 Room: Ren Sta Vi Ford
Service: MED
DISCHARGE PATIENT ON: 1/18/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ELLZEY , OREN R. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ENTERIC COATED ASPIRIN ( BABY ) ( ASPIRIN ENTERI... )
162 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 10 MG orally DAILY
Alert overridden: Override added on 1/18/06 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: md aware
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
INSULIN 70/30 HUMAN 20 UNITS subcutaneously every day before noon
AVAPRO ( IRBESARTAN ) 150 MG orally DAILY
Alert overridden: Override added on 7/6/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN Reason for override: md Previous Alert overridden
Override added on 7/6/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN Reason for override: aware
Previous Alert overridden
Override added on 10/30/06 by ALSPAUGH , KERRY Y. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
IRBESARTAN Reason for override: aware
Previous override reason:
Override added on 10/30/06 by THEPBANTHAO , DARCI H. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
487614228 )
POTENTIALLY SERIOUS INTERACTION: IRBESARTAN & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 10/30/06 by THEPBANTHAO , DARCI H. , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 493463126 )
POTENTIALLY SERIOUS INTERACTION: IRBESARTAN & POTASSIUM
CHLORIDE Reason for override: md aware
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally every 48 hours
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally three times a day
Starting Today ( 10/24 ) HOLD IF: HR<55 OR SBP<110
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PILOCARPINE 0.5% 2 DROP OS four times a day Starting Today ( 10/24 )
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally DAILY
ALPHAGAN ( BRIMONIDINE TARTRATE ) 1 DROP each eye twice a day
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician as scheduled on 4/11 1:30 ,
Stent removal Dr Krinsky 7/20 1:30 endoscopy ,
GI Dr Cujas 8/10 9am ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
abdominal pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
transaminitis , CBD dilitation , pancreatic duct dilitation history of stenting , history of sphinterectomy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , HTN , Esophageal Ca , glaucoma , PPM
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of ercp stenting and sphinterotomy on 9/17/06
BRIEF RESUME OF HOSPITAL COURSE:
CC: Abd Pain / GNR bacteremia
***
HPI: 88F with DM , HTN , history of PPM , history of esoph CA history of resxn p/with acute onset
diffuse abd pain , somewhat stronger in LLQ , sharp , a/with nausea. Pain
worse with eating. Had loose BMs x 3-4 days , no fevers , some chills.
No CP , no palps , chronic stable DOE. In ED , Abd
CT , U/S , HIDA scan all unremarkble , but 2/4 BCx with GNRs , and was
given Levo/Flagyl.
***
PMH: DM , HTN , TIA/CVA , history of esoph CA history of resection , history of
PPM
***
ALL: NKDA
***
HOME MEDS: Lipitor 10 , Vit E 400 , Pilocarpine , Timolol , Insulin 70/30
20 every day before noon , HCTZ 25 , PPI , Lopressor 50 twice a day , Avapro ,
ASA
***
PEx: T96.9 P56 140/46 Sats ok on RA. NAD. Lungs clear , RRR S1/S2.
Abd S/ND. Very mild tenderness , somewhat localized over LLQ.
Hyperactive BS. Ext WWP. NONTOXIC
looking.
***
STUDIES: Abd CT: GB wall thickening , dilatation of
pancreatic duct. HIDA: neg for CBD
dist RUQ U/S: GB
sludge
***
NOTABLE LABS: AST 1425 , ALT 1259 , AlkPhos 198 , TB 1.9 , Amy 90.
Chem 7 / CBC unremarkable. No anion gap. BCx with 2/4
GNRs.
***
A/P: 88F with abd pain of unclear etiology on admission with transaminitis ,
abd pain and suspected bile duct stones and sludge. Underwent ERCP which
demonstrated dilated main pancreatitic duct history of stenting , dilated CBD
with sludge history of sphinterectomy. Transaminitis and abd pain have continued
to improve.
***
ID: Given GNR bacteremia , emperically covered with Levo / Ceftaz.
Cx grew pansensitive Kleb , and coverage was narrowed to Levo
to complete a 14 day course. Surveillance cx negative.
GI: Marked transaminitis. No
recent new meds. Hepatitis serologies negative , U/S with Doppler to
r/o Budd-Chiari esp given acute onset negative , Lactate + guaiac for
? mesenteric ischemia( but no gap )negative. No indication for surgery.
GI consulted recommended ERC , results as above. LFTs trending
down history of sphinterotomy and ERCP. Will f/u with GI in 2 weeks for repeat
ERCP at PUO .
CV: Cont Lipitor , HCTZ , Lopressor , Avapro , ASA. No
signs of ischemia , failure. Uptitrated avapro given
persistent HTN , appears to be near maximally BB in terms of heart
rate
OPHTH: Cont eye drops
ENDO: history of DM , cont insulin + scale.
FEN: Npo pending ercp , adv to clears history of procedure well tolerated , K/Mg
scales.
Ppx: Nexium / Lovenox
Full Code
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*f/u with primary care physician and Gi as scheduled
*return to ED with worsening symptoms of abd pain or if unable to tolera
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( HT541 ) 1/18/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 842
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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Y |
Y |
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| output/system_intuitive_annotation.xml | intuitive |
N |
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112891928 | PUO | 22763512 | | 2530911 | 1/21/2005 12:00:00 a.m. | GASTROINTESTINAL BLEED | Signed | DIS | Admission Date: 1/21/2005 Report Status: Signed
Discharge Date: 7/25/2005
ATTENDING: BRUDERER , SHERYL J.
The patient was admitted to the Survtheast Centex Health Care .
PRINCIPAL DIAGNOSIS:
Lower GI bleed.
LIST OF DIAGNOSES:
The patient has a history of diverticulosis for which she had a
colectomy approximately 30 years ago , high blood pressure ,
gastroesophageal reflux , hypothyroidism , supraventricular
tachycardia , and mitral valve prolapse.
HISTORY OF PRESENT ILLNESS:
This is a 76-year-old female admitted from Asidea Rehabilitation Hospital
with a lower GI bleed. She was on the Medicine Service and got a
tagged red blood cell can in that angiography with embolization
of the middle colic artery , but she continued to rebleed. She
had a second angiography procedure , which did not show any
source , but continued to bleed. She had large amounts of red
blood clot and a low blood pressure , so she was taken to the
operating room for a colectomy and ileostomy. The case was
technically very difficult due to the adhesions. The initial
incision was performed through the incision from her previous
colectomy. She also had an open cholecystectomy.
PAST MEDICAL HISTORY:
As above.
MEDICATIONS:
The patient takes Protonix , atenolol , levothyroxine , and
dalteparin.
PAST SURGICAL HISTORY:
The patient had a hysterectomy and cholecystectomy.
ALLERGIES:
Allergic to tramadol , Celebrex , Neurontin , and tolterodine.
PHYSICAL EXAMINATION ON ADMISSION:
Blood pressure 114/62 , heart rate at 78 , respirations 20 , and
saturating 96% on room air. General: The patient is in no acute
distress. Cardiovascular exam: The patient had regular rate ,
normal rhythm , with an audible murmur. Lungs are clear to
auscultation bilaterally. Abdomen: Positive bowel sounds ,
midline surgical scar , nontender to palpation , nondistended.
Rectal exam: The patient has external hemorrhoids. The patient
is guaiac positive.
INITIAL LABORATORY STUDIES:
Chem-7: 129 , 4.1 , 97 , 22 , 27 , 1.1 , and glucose of 178. ABG
showed a pH of 7.41 , PCO2 of 34 , TCO2 of 22 , O2 saturation of
99% , PO2 of 92 , and base excess is -3. ALT of 6 , AST of 12 , CK
of 13 , alkaline phosphatase of 43 , amylase of 25 , T-bili of 0.5 ,
and lipase of 20. Cardiac markers: CK of 13 , CK-MB of 0.1 ,
troponin less than assay. White blood cells 22.55 , hemoglobin of
11 , hematocrit 32.2 , and platelets 581 , 000.
HOSPITAL COURSE:
The patient had a complete abdominal colectomy in the operating
room performed on 6/13/05 by Dr. Sterba This is done for
diverticulosis and colonic hemorrhage. There were no
complications during the procedure. The patient was initially
admitted to the PACE team. Both surgery and gastroenterology
were consulted. The patient did receive and tolerate multiple
blood transfusions. The patient was taken to the operating room
on 6/13/05 , which was day #3 of her hospital admission , and was
subsequently admitted to the Survtheast Centex Health Care . Her postoperative
course was uncomplicated. The patient was extubated after the
surgery and was sent to the general floor. The Foley was removed
on postoperative day #3. The patient was tolerating a clear diet
and thus was advanced to a house diet. The patient had a history
of left total knee replacement , performed on 5/5/05 at Kendsonre Ale Ater Hospital The staples were removed during this hospital
stay on postoperative day #3 as well. The patient was discharged
to Wilc Ple Hospital on 50 mg of atenolol orally daily , 125
mcg of Synthroid orally daily , spironolactone 50 mg orally twice a day ,
and oxycodone 10 mg orally every 6 hours as needed pain. The patient was
discharged in stable condition to Wilc Ple Hospital on
5/23/05. There were no pending labs or studies at this time.
The patient is to follow up in Surgery Clinic and has been
instructed to follow up with her orthopedic surgeon regarding the
left knee replacement.
eScription document: 2-8528404 EMSSten Tel
Dictated By: TIBOLLA , MADISON
Attending: BRUDERER , SHERYL
Dictation ID 1016205
D: 9/4/05
T: 9/4/05
Document id: 843
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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171486426 | PUO | 43712082 | | 8650647 | 10/21/2005 12:00:00 a.m. | right MCA stroke | | DIS | Admission Date: 10/21/2005 Report Status:
Discharge Date: 6/18/2005
****** FINAL DISCHARGE ORDERS ******
SIPHO , GRETTA 607-02-83-0
Suwind Ln.
Service: NEU
DISCHARGE PATIENT ON: 9/19/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WANTUCK , DELPHA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
CIPROFLOXACIN 500 MG orally every 12 hours X 10 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
DEXTROAMPHETAMINE SULFATE 10 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously three times a day
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LEVOTHYROXINE SODIUM 125 MCG orally every day
ATIVAN ( LORAZEPAM ) 0.5 MG orally every 4 hours as needed Anxiety
METOPROLOL TARTRATE 12.5 MG orally twice a day HOLD IF: SBP<120
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
REMERON ( MIRTAZAPINE ) 7.5 MG orally every bedtime
Number of Doses Required ( approximate ): 5
LAMICTAL ( LAMOTRIGINE ) 200 MG orally twice a day
Number of Doses Required ( approximate ): 5
CLOPIDOGREL 75 MG orally every day Starting Today ( 11/24 )
HOLD IF: plt count < 100
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours as needed Shortness of Breath
NIASPAN ( NICOTINIC ACID SUSTAINED RELEASE ) 0.5 GM orally every bedtime
Starting Today ( 11/24 ) HOLD IF: myalgias
Alert overridden: Override added on 9/19/05 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
SALT TABLET ( SODIUM CHLORIDE ) 1 GM orally twice a day
DIET: Mechanical Soft/Thin ( no consistency restriction ) (FDI)
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Attkisson , WH 222-523-7329 2 weeks ,
primary care physician Dr. Defore 433-586-6650 3-4 weeks ,
Neurologist Dr. Pasqualetti ASAP ,
Oncologist Dr. Enamorado as previously determined ,
ALLERGY: Demerol , Penicillins , Codeine , Sulfa , intravenous Contrast ,
LEVETIRACETAM , DIVALPROEX SODIUM
ADMIT DIAGNOSIS:
stroke
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
right MCA stroke
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
severe right internal carotid artery stenosis
non-small cell lung cancer , pancytopenia secondary to chemotherapy
hypertension , dyslipidemia , type 2 diabetes mellitus epilepsy
chronic obstructive pulmonary disease hypothyroidism ( post-Graves' disease )
SIADH
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI/MRA head and neck
CT/CTA head and neck
noncontrast head CT x 4
video swallowing study
transthoracic echocardiogram
BRIEF RESUME OF HOSPITAL COURSE:
This 64 year-old right-handed woman presented after being found down and
weak on the left. She has a recent diagnosis of non-small cell lung
cancer and has been receiving chemotherapy and radiation therapy
treatments. She presented outside the window for thrombolysis or
intervention. Exam revealed plegia of the left face and arm , paresis of
the left leg , and an incomplete neglect syndrome. MRI/MRA revealed
partial right MCA territory stroke and suggested severe proximal right
ICA stenosis; she was placed on heparin. Antihypertensives , aside from
low-dose metoprolol , were held. CT/CTA head and neck the following day
confirmed a severe proximal right ICA stenosis and revealed evolution of
the stroke to involve much of the right MCA territory. The heparin was
discontinued and the patient placed back on clopidogrel. The Grismi Boisran Hospital
under Dr. Attkisson evaluated the patient and recommended a follow-up
appointment with him two weeks after discharge.
Laboratory work-up pertinent to stroke revealed a normal homocysteine ,
normal TSH , lipid profile with LDL 108 , HDL 52 , TG 131 , and Lp( a )
lipoprotein elevated at 93. She was continued on a statin , and low-dose
niacin added to the regimen because of the Lp( a ) results. Her hemoglobin
A1c and random blood sugars were elevated; she received an insulin
sliding scale. Echocardiogram showed normal LVEF and size , no wall motion
abnormalities , + evidence of diastolic dysfunction , and normal LA size.
Her cell counts trended downward in an expected fashion given the timing
of her most recent chemotherapy. She was placed on neutropenic
precautions. Her oncologist Dr. Enamorado recommended administering
prophylactic ciprofloxacin and a single dose of long-acting G-CSF. She is
not planned to receive any additional chemotherapeutic or radiation
therapy treatments in the near future.
Her neurological examination remained stable. Repeat head CTs done to
assess for edema following the stroke revealed some effacement of the
right lateral ventricle , but no threatening mass effect.
Her serum sodium trended down throughout admission; it is recommended
that she not receive hypotonic fluids at rehab and that she be water
restricted to 1L per day , and take salt as directed.
Given her thrombocytopenia , it is recommended that antiplatelet therapy
with clopidogrel be held until her platelet count rises over 100. It is
also recommended that anticoagulation with therapeutic low-molecular
weight heparin as bridge to warfarin with target INR 2-3 be restarted 2
weeks after her stroke , on 2/16/05. She should follow up for
neurological issues with Dr. Attkisson of neurosurgery as well as her
outpatient neurologist , Dr. Rossie Mankoski , at Tonsta Ean Villebaxt Hospital
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Fair
TO DO/PLAN:
1. hold clopidogrel until plt > 100k
2. start low-molecular weight heparin as a bridge to warfarin ( target INR
2-3 ) and discontinue clopidogrel 7/1/05
3. Free water restrict 1L per day , follow serum sodium.
4. Follow up with Dr. Attkisson in 2 weeks.
No dictated summary
ENTERED BY: MARATRE , BRYAN RUBIE , M.D. ( HA75 ) 9/19/05 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 844
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
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N |
N |
639951950 | PUO | 53695647 | | 216145 | 7/15/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/6/1996 Report Status: Signed
Discharge Date: 11/8/1996
PRINCIPAL DIAGNOSIS: LEFT RENAL CELL CARCINOMA , STATUS POST LEFT
PARTIAL NEPHRECTOMY.
HISTORY OF PRESENT ILLNESS: Patient is a 48 year old female who
presented to primary care provider ,
Dr. Padron in KTDUOO in July of this year complaining of rectal
bleeding. The workup was negative by colonoscopy with a negative
rectal biopsy. An abdominal CT revealed a 2 cm solid enhancing
mass , most certainly a renal cell carcinoma , new since CT done in
7/14 Also , it showed a probable liver hemangioma which had been
previously identified on the 1995 CT. Patient also reported a new
onset of non insulin dependent diabetes with a 25 pound weight loss
over the past five weeks , but she had no history of fever , night
sweats , change in bowel or bladder habits , and she's had no rectal
bleeding.
PAST MEDICAL HISTORY: Significant for atypical chest pain in January
of 1996 but had a negative workup in KAAH .
She's also had a history of non insulin dependent diabetes for
which she takes glyburide 5 mg orally twice a day She also had a negative
colonoscopy in January of 1996 for the history of rectal bleeding ,
with a rectal biopsy that was negative. She's had a remote tubal
ligation and also history of a right ankle fracture 1 1/2 years
ago.
MEDICATIONS: Glyburide 5 mg orally twice a day
ALLERGIES: Question of allergy to CT scan dye gives her chest
wall tightness. Also , lidocaine products reportedly
give her an altered mental status.
LABORATORY EXAM ON ADMISSION: White blood cell count was 3.5 ,
hematocrit of 37.5 , platelets of
212. Sodium was 139 , potassium 4.1 , chloride 104 , bicarb of 22 ,
BUN 12 , creatinine 0.9 and glucose of 231. Her liver function
tests showed a total bilirubin of 0.6 , AST 13 , ALT 28 , alkaline
phosphatase 94.
HOSPITAL COURSE: Patient underwent a left partial nephrectomy
on November , 1996. The pathology came back as a
renal cell carcinoma , Stage I to II with negative margins and no
capsular invasion. There were no complications from the procedure
and patient had no complications postoperatively. Patient was
discharged on Percocet 1-2 tabs orally every 3 hours as needed pain , Colace 100
mg orally twice a day to take while she's taking her Percocet. Milk of
Magnesia 30 cc orally every bedtime as needed constipation , Augmentin 250 mg
orally three times a day ( this is day 3 of a 7-day course for reported history
of sinusitis ). Patient was discharged to home with followup. She
is to return to Urology Clinic on Tuesday , April 30th to have her
staples removed and she is to follow up in 4-6 weeks with Urology
Clinic for a followup appointment.
Dictated By: GAYE S. GUSMAR , M.D. GI62
Attending: ROSSIE MANKOSKI , M.D. AP34
NW092/6720
Batch: 47937 Index No. H3RDV44R14 D: 9/6/96
T: 10/25/96
CC: 1. CARMON E. BOSHERS , M.D. CH
Document id: 845
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
- |
N |
N |
N |
- |
059853281 | PUO | 34790858 | | 4691794 | 5/30/2006 12:00:00 a.m. | NPH | | DIS | Admission Date: 5/28/2006 Report Status:
Discharge Date: 3/18/2006
****** FINAL DISCHARGE ORDERS ******
KLUEMPER , VELVET 191-37-89-0
Portomi Spo Son
Service: NSU
DISCHARGE PATIENT ON: 5/28/06 AT 09:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KWASNICKI , HUI KATHI , M.D. , PH.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
FOSAMAX ( ALENDRONATE ) 70 MG orally QWEEK
Starting ON 10/3 ( 11/12 )
Instructions: Give tablet on an empty stomach with a full
glass of water , then wait 30 minutes before the patient eats
or lies down ( to promote absorption and avoid distress ).
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
Number of Doses Required ( approximate ): 3
CALCIUM CARBONATE 1 , 500 MG ( 600 MG ELEM CA )/ VIT D 200 IU
1 TAB orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
HOLD IF: SBP <100 or HR <50
ZESTRIL ( LISINOPRIL ) 40 MG orally DAILY HOLD IF: SBP < 100
Instructions: Not recent home meds
Override Notice: Override added on 5/28/06 by
AMIRAULT , ERVIN A. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
541690390 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: needed
Previous override information:
Override added on 8/27/06 by FANIEL , GAYLENE , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
003405876 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: .
Previous override information:
Override added on 8/27/06 by FANIEL , GAYLENE , M.D. , PH.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
704188600 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: .
Previous override information:
Override added on 8/27/06 by FANIEL , GAYLENE , M.D. , PH.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
707998110 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: .
Previous override information:
Override added on 8/27/06 by AMIRAULT , ERVIN A. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
700257609 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: needed
LOSARTAN 100 MG orally DAILY HOLD IF: SBP <100 or HR<50
Override Notice: Override added on 5/28/06 by
AMIRAULT , ERVIN A. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
541690390 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: needed
Previous override information:
Override added on 8/27/06 by FANIEL , GAYLENE , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
003405876 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: .
Previous override information:
Override added on 8/27/06 by FANIEL , GAYLENE , M.D. , PH.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
704188600 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: .
Previous override information:
Override added on 8/27/06 by FANIEL , GAYLENE , M.D. , PH.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
707998110 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: .
Previous override information:
Override added on 8/27/06 by AMIRAULT , ERVIN A. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
700257609 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: needed
Number of Doses Required ( approximate ): 7
METFORMIN 500 MG orally twice a day
METOPROLOL TARTRATE 150 MG orally DAILY
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 11/9/06 by
LIPSETT , TREVA , P.A.
on order for LIDOCAINE HCL 2% subcutaneously ( ref # 192666479 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
LIDOCAINE HCL , LOCAL-INJ Reason for override:
OXYCODONE 5 MG orally every 4 hours as needed Pain
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 4/24/06 by SWEATT , KAYLEE GAYE , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: Will Follow
SALT TABLET ( SODIUM CHLORIDE ) 4 GM orally three times a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 4/24/06 by SWEATT , KAYLEE GAYE , M.D.
on order for SIMVASTATIN orally ( ref # 636621966 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: Will Follow
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
call 476-448-2351 for follow up with dr. oey , 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
NPH
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NPH
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN DM
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
lumbar drain 2/21/06
BRIEF RESUME OF HOSPITAL COURSE:
HPI: 75 year-old F with hx/o of urinary incontince , memory loss , and difficulty
walking who presents for a lumbar drain. patient was involved in an MVA in
6/8 after which she had difficulty walking. Over the last year she had
had a syndrome of progressive memory deficits , gait difficulty , and
urinary incontinence. Head CT was performed which demonstrated
ventriculomegaly. Lumbar puncture was done here at the Kernan To Dautedi University Of Of where
thee opening pressure was 23 and 20 cc were drained. Following the LP
there was very clear but short lived improvement in her symptoms.
PMH: HTN , DM , arthritis , peripheral edema , hyperlipidemia , no history of
cancer or heart disease
PSH: Bilateral cataracts
Medications: NPH 2 Units qAM , NPH 60 Units qAM , Metoprolol 100 mg every day ,
Metformin 500 mg twice a day , Fosamax 70 mg qwk , Calcium 600 mg every day , MVI , Losartan
100 mg every day , HCTZ 25 mg every day , Simvastatin 40 mg every day
Allergies: NKDA
SHX: Speaks Hindi , family is very helpful and cooperative - they
translate for patient. Retired teacher of fashion , Married with 8 kids ,
No smoking or ETOH
PE:
97.5 74 180/90 18 100%RA
HEENT: Neck supple , NAD
CV: rrr , nl S1/S2 , no 2/6 systolic murmur
Resp: LCTAB , no adventitious sounds
Abd: Soft , NT , ND , +BS x4
Neuro: Awake , A+Ox3 with fluent speech , following commands appropriately.
PERRL , EOMI , FS , TM. No pronator drift was noted on examination. The patient
is moving all extremities well with 4/5 strength x4. Sensation to light
touch is grossly intact throughout. patient's gait is unsteady and wide based.
patient was able to remember only 2/3 objects after 5 minute delay.
HOSPITAL COURSE:This patient was admitted to the hospital in the evening on
2/14 through direct admit. Her labs revealed low sodium. She was
started on salt tabs and her sodium was monitored closely.
After other labs were reviewed and antibiotics were
hung , the lumbar drain was inserted at the bedside. The patient tolerated the
procedure well. She was evaluated by physical therapy and the drain was opened to drain
approximately 10cc/day. She was evalated daily by physical therapy and the
neurosurgery team.
ADDITIONAL COMMENTS: Please do not drive while taking pain meds. Sutures will be removed upon
follow up in the clinic in 7-14 days. If fever>101.5 , new weakness , new
numbness , vomiting , increasing headache , wound redness/discharge , then
please call office.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: AMIRAULT , ERVIN A. , M.D. ( MT1 ) 5/28/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 846
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392986061 | PUO | 09031082 | | 5451041 | 3/28/2006 12:00:00 a.m. | HTN EMERGENCY | Signed | DIS | Admission Date: 7/23/2006 Report Status: Signed
Discharge Date: 8/2/2006
ATTENDING: STEVINSON , DEE H.
SERVICE: Pids Heim
PRINCIPAL DIAGNOSIS: Pneumonia.
LIST OF OTHER PROBLEMS/DIAGNOSES: Altered mental status ,
seizure , hypertensive emergency , end-stage renal disease and
hepatitis C.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old man
with type 1 diabetes , end-stage renal disease on hemodialysis ,
history of polysubstance abuse and hepatitis C who was in his
usual state of health until hemodialysis on 2/18/06 , when he was
noted to be lethargic after hemodialysis. He came to the
emergency room where he also complained of headache and chest
pain. He was noted to have blood pressure of 202/91 and lateral
ST depression on EKG and a mild troponin leak. He was given
nitroglycerin paste , labetolol 10 mg intravenous with resolution of the
headache , chest pain and decrease of the blood pressure into the
160s. On chest x-ray , he was also noted to have bilateral lower
lobe pneumonia. The patient remained lethargic. The head CT was
negative. Of note , the patient has a recent admission to the
Norap Valley Hospital with hypoglycemia , pneumonia and C. difficile
colitis for which he is completing a course of vancomycin ,
Levaquin and Flagyl. The patient lives in a nursing home. The
records show that his baseline blood pressure is 160-180
systolic. He has had hypertension to the 200s for a week prior
to admission.
PAST MEDICAL HISTORY: Notable for end-stage renal disease on
hemodialysis , type 1 diabetes for 30 years , poorly-controlled
hypertension , hepatitis B and C with previous treatment with
interferon , possible ethanol-related liver disease , asthma ,
peptic ulcer disease and peripheral vascular disease with history
of toe amputation.
SOCIAL HISTORY: The patient lives alone , although recently he
has been living in a nursing home. He is separated from his wife
and children who live out of state. He is a former smoker and
alcohol abuser. He has a history of heroin use and cocaine use
but currently not abusing either.
ALLERGIES: The patient is noted to have an allergy to aspirin
with the reaction being epistaxis , although this is not a true
allergy.
PHYSICAL EXAMINATION: On admission , notable findings were an
altered mental status. The patient was somnolent and confused
but was without other significant physical findings.
HOSPITAL COURSE:
1. Cardiovascular: The patient was admitted with hypertensive
emergency with mild troponin leak likely secondary to demand
ischemia. Labetolol 200 mg orally twice a day was added to his
antihypertensive regimen this admission and the patient's blood
pressure was reasonably well controlled throughout the admission.
2. Infectious disease: The patient is being empirically treated
for likely cavitary pneumonia that was observed upon chest CT.
The patient has clinically improved on ciprofloxacin 500 mg orally
every day and will be discharged on a 7-day course of the same. The
patient also has a history of C. difficile colitis and has been
treated with Flagyl 500 mg orally three times a day during this admission and
was discharged on a 14-day course of the same. Blood cultures
during this admission have been negative to date. The patient
was PPD negative and induced sputum was negative by acid fast
tests for evidence of tuberculosis.
3. GI: The patient complained of left lower quadrant pain prior
to dialysis on 10/30 and some involuntary guarding was apparently
appreciated. CT of the abdomen ruled out
an acute abdominal process and the patient has been without
abdominal pain throughout the rest of the hospitalization. The
patient's laboratory studies are notable for an elevated alkaline phosphatase
with unclear etiology. The patient has no Murphy
sign or other signs of cholecystitis that could be appreciated.
4. Neurology: The patient presented with altered mental status
on admission. He was confused and somnolent. Within 2 days of admission , he
was much improved and was alert and oriented x3.
The altered mental status was most likely secondary to pneumonia.
The patient reportedly had a tonic-clonic seizure in
hemodialysis on 11/12/06. Neurology was consulted and thought
this was most likely secondary to fluid , electrolytes shifts in
dialysis. The patient had both EEG and brain MRI , which were
normal during this admission.
5. Renal. The patient has end-stage renal disease on
hemodialysis and dialysis was continued Monday , Wednesday and
Friday according to his usual schedule.
6. Endocrine. The patient is a brittle type 1 diabetic and
early in his hospital course , he had frequent episode of
hypoglycemia which responded to an AMP of D50. the patient's
insulin regimen at the time of discharge , on which his sugars were
reasonably well controlled without episodes of hypoglycemia , was
Lantus 4 units every day before noon Lantus 4 units every afternoon with NovoLog 3 units
with breakfast and 3 units with lunch and NovoLog 2 units with
dinner and sliding scale NovaLog used only when fingersticks were
greater than 400.
7. Pulmonology The patient has left lower lobe cavitary
lesion observed on chest CT that may be malignant , although it
most likely represented pneumonia. He needs to follow up chest
CT in 6-8 weeks to confirm if this lesion was pneumonia and that
it has completely resolved.
The patient had a history of COPD/asthma and continued on Advair during this
admission.
At the time of discharge , the patient was afebrile with heart rate
in the 90s , systolic pressure ranging from 140-160/60-80 and
saturating 97% to 100% on room air.
DISCHARGE MEDICATIONS: Include aspirin 81 mg orally every day , Lipitor
80 mg orally every day , ciprofloxacin 500 mg orally every 24 hours for a 7-day
course after discharge , esomeprazole 20 mg orally every day , Advair
Diskus 100/50 mcg 1 puff in inhaled twice a day , folic acid 1 mg orally
every day , NovoLog 3 units subcutaneously with breakfast , NovoLog 3 units subcutaneously
with lunch , NovoLog 2 units subcutaneously with dinner , Lantus 4 units
subcutaneously every day before noon , Lantus 4 units subcutaneously every afternoon and NovoLog sliding
scale if the fingersticks greater than 400 , labetolol 200 mg orally
twice a day , lisinopril 80 mg orally every day , Flagyl 500 mg orally three times a day for
14 days following discharge , Nephrocaps 1 tab orally every day ,
nifedipine XL 30 mg orally every day and Sevelamer 2.4 g orally three times a day
DISCHARGE INSTRUCTIONS: Regarding followup tests that are needed
after discharge , the patient should schedule to have a CT of the
chest 6-8 weeks following discharge to rule out malignancy in the
left lower lobe. The patient should continue on regular Monday ,
Wednesday , Friday dialysis according to his usual regimen. The patient should
complete the 7 day course of Ciprofloxacin that was prescribed. The patient
should complete the 14 day course of Flagyl as prescribed. The
patient should follow up with his primary care physician within 2
days of discharge. The patient should be discharged to skilled
nursing facility from which he was admitted.
eScription document: 7-2099271 BFFocus
Dictated By: WOLFENSPERGER , NAOMI
Attending: STEVINSON , DEE
Dictation ID 2980757
D: 1/17/06
T: 1/17/06
Document id: 847
| Target |
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446066240 | PUO | 53255941 | | 0695015 | 11/27/2004 12:00:00 a.m. | Atypical Chest Pain | | DIS | Admission Date: 3/22/2004 Report Status:
Discharge Date: 7/18/2004
****** DISCHARGE ORDERS ******
KINSTLER , ALBINA 128-91-50-9
U
Service: MED
DISCHARGE PATIENT ON: 7/14/04 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOVA , DOUGLASS V. , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 3/3 )
ATIVAN ( LORAZEPAM ) 0.5 MG orally twice a day as needed Anxiety
ZYPREXA ( OLANZAPINE ) 5 MG orally every bedtime
Number of Doses Required ( approximate ): 4
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
PROTONIX ( PANTOPRAZOLE ) 20 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally three times a day
Starting Today ( 5/20 ) HOLD IF: SBP<85 , HR<55
Instructions: May titrate dose to keep patient's HR btw 60-90
bpm. Eventually , if patient tolerates , may change to
patient's home med of Atenolol 25 mg every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LEVOFLOXACIN 500 MG orally every day X 6 Days
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please follow-up with Dr. Madison Tibolla on June , 2004 at 2:30 p.m. ,
Dr. Shelley Starnauld , Gastroenterology , 604.894.9654 , on 10/28/04 at 9:15 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Atypical Chest Pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical Chest Pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
gastritis ( gastritis ) esophagitis ( esophagitis ) hypertension
( hypertension ) hyperlipidemia ( hyperlipidemia ) history of colonic adenoma
( history of adenomatous polyp ) remote history of alcohol ( history of alcohol abuse )
depression , history of suicide attempt ( depression )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Adenosine mibi 11/10/04 , no ischemia , no ECG changes , small region mild
stress-induced ischemia.
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old F c esophagitis , HTN , hyperlipidemia who presented with SSCP
intermittent over 8 hours. Episodes lasted 8-10 minutes. The pain was
non-radiating and 3/10. Associated nausea , mild diaphoresis. Noted some
epigastric pain , similar to prior bouts of gastritis. Better when
lying down and with pepto-bismol. patient had similar sx 2 days PTA after a
large meal. ROS + for night sweats but no F/C or weight loss. At home
patient is on b-blocker , statin , ASA. patient had echo in '94 that showed EF 60% ,
mild LVH. VS in ED T99 , WF41 , BP120/p , o2 97RA. Got ASA 325 , heparin
drops , MSO4 2mg , NTG 0.4mg sublingual. patient became pain-free 15 min after taking
NTG. **PE CV RRR s m/r/g lungs clear , abd soft , ext c trace pedal
edema. neuro: patient c mild confusion , flat affect. Admit labs nL c K 3.2.
A&B sets negative , EKG normal s ST changes.
**HOSPITAL COURSE: 1 ) SSCP: patient went for ETT but was unable to complete
2/2 dizziness. EKG c/with but not diagnostic of ischemia. patient found to be
hypotensive to 100/70 , orthostatic. patient's hx of gastritis and reflux
places GI causes high on ddx list , in addition patient had v low grade fever
on admit ( to 100 ) and c/o sore throat. patient had a-mibi 7/20 , overall no
nonischemic c small area stress-induced ischemic change. Over
hospital course , patient c decreased orthostasis but after team d/ced b-bl
ocker on 7/20 patient has had sinus tach to 100s c 130-150 on exertion.
Run SVT in am 2/30 BP increased to 130s/80s , titrating lopressor to
decrease HR. Of note , patient was found to have am cortisol of 9.2 ( at 8:30
am , checked as part of orthostasis with u ) and may need cortictropin sti
m test as o/p.
2 ) history of GASTRITIS AND ESOPHAGITIS: continuing on ppi , as needed maalox , has
appt c GI 10/28/04
3 ) NEURO/PSYCH: patient c v. flat affect and history of depression. Continue
Zyprexa and pr Ativan.
4 ) FEN: patient taking orally
ADDITIONAL COMMENTS: Please note that we have intended to make no changes in your home
medications except the following: Take 25 mg lopressor 3 times daily.
Take levofloxacin daily for 6 more days. It is critical that you
continue to be followed by your primary physicians , including Dr. Madison Tibolla on June as outlined for further evaluation. Seek
medical attention immediately if you develop anything of concern. Drink
plenty of liquids.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MENIETTO , WYATT M. , M.D. ( SA88 ) 6/24/04 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 848
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| output/system_textual_annotation.xml | textual |
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461171537 | PUO | 89762298 | | 9282677 | 10/22/2003 12:00:00 a.m. | Hereditary angioedema | | DIS | Admission Date: 10/10/2003 Report Status:
Discharge Date: 10/10/2003
****** DISCHARGE ORDERS ******
BLANN , GLENNA A. 009-06-32-4
Son Pahar Tamp
Service: MED
DISCHARGE PATIENT ON: 5/30/03 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DEPSKY , GWYNETH ALMEDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ENTERIC COATED ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 5/30/03 by
KNECHT , MARTINE , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to G6PD DEFICIENCY
Reason for override: on as outpt
ATENOLOL 75 MG orally every day
DANAZOL 200 MG orally three times a day Starting Today ( 9/19 )
Instructions: For 3 days then , 200 mg by mouth twice a day
for 2 days , then alternating 200 mg once a day and 200 mg
twice a day thereafter.
DIGOXIN 0.125 MG orally every other day
Instructions: 0.125 on ttss and on MWF take one and half
tabs
Alert overridden: Override added on 5/30/03 by
KNECHT , MARTINE , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: patient on as oupt
SYNTHROID ( LEVOTHYROXINE SODIUM ) 50 MCG orally every day
Override Notice: Override added on 5/30/03 by
KNECHT , MARTINE , M.D.
on order for DIGOXIN orally ( ref # 14260557 )
POTENTIALLY SERIOUS INTERACTION: LEVOTHYROXINE SODIUM &
DIGOXIN Reason for override: patient on as oupt
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: no wheat and no dairy (FDI)
ACTIVITY: Resume regular exercise
ambulation c walker
FOLLOW UP APPOINTMENT( S ):
Dr. Earp please call for a follow up appt this afternoon or tomorrwow- 095-419-1798 ,
Dr. Xuan Monninger please call for a follow up appointment this afternoon for an appointment next week to check you blood- 977-673-0310 ,
ALLERGY: Iv contrast dyes , Sulfa , Penicillins ,
Quinidine ( quinidine sulfate ) , Levofloxacin , Lisinopril ,
Quinidine ( quinidine sulfate ) ,
Macrodantin ( nitrofurantoin ) , Stanazol ,
Novocain 1% ( procaine hcl 1% ) , Dairy products , Wheat/gluten
ADMIT DIAGNOSIS:
Hereditary Angioedema-exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hereditary angioedema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HEREDITARY ANGIOEDEMA AFIB - lodose Coum/ASA HYPOTHY
history of SUBDURAL ON COUM history of APPY , TAH tracheostomies x
3 multiple intubations DVT , ivc filter in place CAD history of MI CAF
history of DVT c IVC filter Hypercholesterolemia HTN Hypotension Polycythemia
GERD polycythemia
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
2 units FFP
BRIEF RESUME OF HOSPITAL COURSE:
81 year-old womanc with multiple medical problems including CAD history of 2 mi
and Hereditary angioedema admitted from the ED c c/o , n , v , abdominal
tenderness and chest discomfort. She did not identify any
precipitant to what she called exacerbation of her Her. Angioedema-
No sob , no DOE , no radiations. No BRBPR , no incontinence. She was
treated in the ED with lopressor and SLNT c minimal relief.
EXAM- LCTA , nl s1s2 , afib , diffuse abd tenderness , guaic - , Labs- LFT
wnl , Cardiac enzymes-neg. Baseline Hct and Cr. CXR neg and no acute
changes on EKG. t was admitted for an exacerbation of Hereditary
angiodedem and
treated with 2 units FFP for which she responded well and reported a
decrease in sx of n , v , d. on 8/13 she cont to have mild diffuse abd
pain , but no episodes of diarrhea.
ALLERGY
Allergy was consulted and determined
the likely etiology to be her Hereditary Angioedema and changed her
Danazol regiment ( see d/c instruction ).
CAD- Due to her reports of chest
discomfort. Cardiac enzymes were drawn and all were within normal
limits- not indicating cardiac ischemia and patient did not complain of
chest discomfort or shortness of breath after admission to the
hospital.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
To follow up with Dr. Sue ( allergy ) and is to call for an
appointment- She is to cont. her Danazol according to Allergy
recommendations-see d/c sheet-
To Follow up with primary care physician Dr. Aspacio for monitoring of CK and LFT's- patient to
call for follow up appointment-
No dictated summary
ENTERED BY: POLO , MALINDA M. , M.D. ( BC164 ) 5/30/03 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 849
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054171831 | PUO | 17914981 | | 228466 | 11/4/1994 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/20/1994 Report Status: Unsigned
Discharge Date: 11/18/1994
ADMITTING DIAGNOSIS: UNSTABLE ANGINA
DISCHARGE DIAGNOSIS: UNSTABLE ANGINA
OPERATIONS/PROCEDURES: CORONARY ARTERY BYPASS GRAFTING , FOUR
VESSEL , BY DR. STUER , , 7/18/94
STERNAL REWIRING , BY DR. STUER , , 11/8/94
BRIEF HISTORY OF PRESENT ILLNESS: Mr. Oelze is a 56 year old
gentleman , with a history of
myocardial infarction , who presents with unstable angina. Cardiac
history is significant for echocardiogram , which revealed inferior
myocardial infarction , three vessel disease , unstable angina , mild
LV dysfunction , and an ejection fraction of 40%. Cardiac
catheterization reveals preliminary ejection fraction of 35% , 70%
RCA , 70% PDA , 70% LAD , 70% D-2 , and mid left circumflex.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia ,
pulmonary embolism in 1987 ,
peripherovascular disease in the 70's , non-insulin dependent
diabetes , history of hepatitis B , and left shoulder fracture.
PAST SURGICAL HISTORY: PTCA of the LAD and left circumflex in
1986.
ALLERGIES: Isordil , which causes nausea.
MEDICATIONS ON ADMISSION: Lopressor 100 mg. orally every day ,
nitroglycerin sublingual , glyburide
2.5 mg. orally every day , and Ecotrin one tablet orally every day ,
HOSPITAL COURSE: Mr. Oelze was admitted to the hospital on the 30 of October , 1994. He was taken to the operating
room on the 28 of April , 1994 , where he underwent a four vessel
coronary artery bypass grafting. The patient tolerated the
procedure well. His postoperative course has been complicated by
the following: ( 1 ) Unstable sternum , diagnosed at the bedside.
The patient was taken back to the operating room on the 6 of September , 1994 , where he underwent sternal rewiring. The patient has
been stable from a cardiac standpoint.
( 2 ) A hemorrhoid and rectal prolapse was noted when the patient was
straining to use the restroom. A General Surgery consult was
initiated , with Dr. Parrow He felt that the patient's condition
was stable for discharge today , and that he would be medically
managed with Metamucil , Colace , sitz baths , and Anusol HC per
rectum twice a day. The patient will followup with Dr. Parrow It
will also be discussed whether patient will benefit from a
colonoscopy to rule out the chance that a polyp is associated with
his rectal prolapse.
DISPOSITION: The patient is discharged to home , with his family ,
in stable condition.
DISCHARGE MEDICATIONS: Glyburide 2.5 mg. orally every day , Lopressor
25 mg. orally twice a day , Ecotrin 325 mg. orally
every day , Lasix 20 mg. orally every day , KCL 20 mEq. orally every day , Metamucil
two packs orally twice a day , Anusol HC one suppository per rectum twice a day ,
sitz baths twice a day , and Motrin 600 mg. orally four times a day
Dictated By: ROSANNE CALLARI , M.D. UM6
Attending: JANAY D. STUKOWSKI , M.D. JX47
UX065/0214
Batch: 6017 Index No. PCYY3H6SDV D: 9/21/94
T: 9/21/94
Document id: 850
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144495155 | PUO | 29799067 | | 8730812 | 5/1/2005 12:00:00 a.m. | endometrial caRCINOMA | Signed | DIS | Admission Date: 7/7/2005 Report Status: Signed
Discharge Date: 7/15/2005
ATTENDING: SCOVEL , DULCIE M.D.
SERVICE: Gynecologic Oncology.
DIAGNOSIS: Endometrial cancer.
HISTORY OF PRESENT ILLNESS: Ms. Newmeyer is a 76-year-old G6 , P3
with postmenopausal bleeding. Endometrial biopsy revealed grade
II endometrioid-type adenocarcinoma of the endometrium. She had
no other symptoms. She opted for surgical management.
PAST OB HISTORY: She is G6 , P3 , she has had three spontaneous
vaginal deliveries and three spontaneous abortions. She has been
postmenopausal since age 55. No STD. No history of cervical
dysplasia.
PAST MEDICAL HISTORY: Diabetes , hypertension , CHF with diastolic
dysfunction , arthritis and obesity.
PAST SURGICAL HISTORY: She had a CABG in April , a
cholecystectomy , and umbilical hernia repair.
MEDICATIONS: Glyburide 10 mg orally twice a day , metformin 1 g twice a day ,
lisinopril 40 mg daily , Toprol-XL 200 mg daily , Lasix 40 mg
daily , Zocor 80 mg nightly.
ALLERGIES: None.
SOCIAL HISTORY: No tobacco or drugs. Occasional alcohol.
FAMILY HISTORY: No GYN cancers.
HOSPITAL COURSE: The patient was taken to the operating room on
7/7/2005 , underwent a total abdominal hysterectomy , bilateral
salpingo-oophorectomy and staging. Intraoperative , she is
diagnosed with ovarian cancer. Estimated blood loss was 600 mL.
Please see Dr. Neal Kruel separate dictation for full details.
POSTOPERATIVE COURSE: Relatively uncomplicated. She did have
the development of an ileus. An NG tube was placed on
10/4/2005 , she became tachypneic , tachycardic , and developed
cough. Chest x-ray was suspicious for pneumonia and she was
started on antibiotics with levofloxacin and clindamycin. She
did have a small oxygen requirement of 3 liters of O2. During
her hospitalization , we did have the Diabetes Service to evaluate
her and make recommendations regarding her blood sugars. On
postop day #8 , she did have some wound drainage. Two staples
were removed. She had some serous drainage. Wound was not
packed , wound was further opened and packed with sterile gauze ,
soaked in saline. She was discharged to home with VNA for twice a day
wound packing. She was sent home on new medications namely NPH
insulin 20 units twice a day with recommendation of an early follow up
with her primary care physician. Her primary care physician and was notified of the
change in medications.
DISCHARGE MEDICATIONS: Lasix 20 mg orally day , insulin NPH human
20 units twice a day , lisinopril 40 mg daily , and Flagyl 500 mg orally
twice a day , this is renally dosed , oxycodone 5-10 mg orally every 4 hours
as needed pain , Zocor 80 mg orally nightly , Atrovent nebulizers
as needed , Ambien 5 mg orally nightly. as needed , levofloxacin 750 mg
orally daily. This is also renally dose and Toprol-XL 100 mg orally
daily. She is to follow up with Dr. Loeffelholz and her nurse for
staple removal and then routine postop follow up with Dr. Loeffelholz
within two to three weeks in follow up with primary care
physician early next week to review her diabetes medications and
blood sugars.
DISCHARGE INSTRUCTIONS: The patient was given written discharge
instructions with phone numbers to contact in case of questions
or concerns.
eScription document: 8-2067241 BFFocus
Dictated By: VANHORN , TISA
Attending: LOEFFELHOLZ , DEETTA
Dictation ID 5324271
D: 7/18/05
T: 7/18/05
Document id: 851
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378576931 | PUO | 59506466 | | 6515296 | 6/13/2005 12:00:00 a.m. | INTRA ABDOMINAL ABCESS | Signed | DIS | Admission Date: 8/25/2005 Report Status: Signed
Discharge Date: 10/17/2005
ATTENDING: MARILYN VENA FREHSE
PRINCIPAL DIAGNOSIS: History of abdominal abscess , now with
persistent nausea and vomiting and abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a 66-year-old
africaan-speaking female. She was seen earlier today in Dr.
Fallow office for follow up and status post IR placement for
unresolved abdominal abscess. The patient is complaining of
persistent nausea and vomiting after eating and decreased
appetite , mild-to-moderate abdominal pain located in left upper
quadrant and right lower quadrant. She denies fever or chills
and has continued lethargy. No other symptom associated.
Patient has history of an unresolved abdominal abscess status
post appendectomy for a perforated appendicitis. She had
appendectomy on 9/21 and then returned on 11/10/04 with
increasing abdominal pain and CT showed abscess leaks and
perforated appendiceal stump. She was treated with amoxicillin ,
Flagyl and fluconazole , IR drain placed and patient discharged.
It was later removed and patient returned on 10/24/05 with a CT
showing reaccumulation of abscess fluid. Another IR drain was
placed and the patient was treated with intravenous antibiotics. Cultures
reported 4+ enterococci and 2+ Staph aureus , Bacteroides
thetaiotamicron , bifidobacterium species. Patient discharged on
2/9/05.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Treated for pneumonia at P Therford Hospital a month
ago , afib. , hypertension , diabetes , dyslipidemia , hypothyroidism ,
CAD , diverticulitis , peripheral edema.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs stable , afebrile ,
regular. Cardiovascular , regular rate and rhythm. Lungs clear
to auscultation bilaterally. Abdomen obese , soft , nontender ,
nondistended , mild tenderness to palpation in the right lower
quadrant and left upper quadrant. IR drain in place and intact.
Extremities: No edema.
HOSPITAL COURSE: Patient was admitted to Survtheast Centex Health Care for intravenous
antibiotics , vancomycin , ceftazadime and Flagyl which were soon
discontinued postop after hospital day #1. A new CT scan with
orally contrast showed no reaccumulation of abscess but minimal air
and leakage of contrast in the area of the drain. It was
recommended by IR to eventually perform an abscessogram when the
output of the drain was less than 10 cc per two days. Patient
was also evaluated by Psych and diagnosed with adjustment
reaction with depression features and Wellbutrin was started.
Upon discharge , the patient was tolerating orally's , ambulating ,
using a walker , voiding , vital signs were stable. She is
discharged in stable condition. Follow up with Dr. Neal Kruel in
two weeks as well as Interventional Radiology. Patient has
remained in the hospital awaiting rehab.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed headache ,
baby aspirin 81 mg orally every day , atenolol 100 mg orally twice a day ,
Colace 100 mg orally twice a day , Pepcid 20 mg orally every day , Lasix 60 mg
orally every day , Atrovent inhaler 2 puffs inhaled four times a day as needed shortness
of breath , Simvastatin 20 mg orally every bedtime , Diltiazem extended
release 120 mg orally every day , regular insulin Humulin sliding scale
before meals and bedtime blood sugar less than 125 give 0 , blood sugar
125-150 2 units subcutaneously , 150-200 3 units , 201-250 4 units , 251-300
6 units , 301-350 8 units and 351-400 10 units , Reglan 10 mg orally
four times a day , Lovenox 80 mg subcutaneously every 12 hours , Wellbutrin SR 100 mg orally
every day , Milk of Magnesia 30 ml orally every day as needed constipation ,
Serax 15-30 mg orally every bedtime as needed insomnia.
FOLLOW UP: The patient will follow up with Dr. Frehse in 1-2
weeks as well as her primary care physician and Interventional Radiology , phone
number 916-307-8446 , in 1-2 weeks for IR drain. Drain output on
follow up should be recorded every day. Drain does not need to
be flushed. The patient is instructed is instructed to return
sooner for follow up with any increasing abdominal pain , nausea ,
vomiting , fever or chills.
eScription document: 0-1047087 EMSSten Tel
Dictated By: WINTERMANTEL , GRANT
Attending: FREHSE , MARILYN
Dictation ID 0421174
D: 10/24/05
T: 10/24/05
Document id: 852
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461171537 | PUO | 89762298 | | 853477 | 6/15/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/5/1993 Report Status: Signed
Discharge Date: 6/20/1993
ssssDIAGNOSIS: HEREDITARY ANGIOEDEMA CRISIS.
PAROXYSMAL ATRIAL FIBRILLATION.
SHOCK.
C1 ESTERASE INHIBITOR DEFICIENCY
( HEREDITARY ANGIOEDEMA ).
OSTEOARTHRITIS.
HYPOTHYROIDISM.
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old with a
long history of hereditary angioedema ,
history of paroxysmal atrial fibrillation , who presented with
sudden onset of abdominal pain , shock and atrial fibrillation. The
patient has a long history of C1 esterase inhibitor deficiency ,
status post emergent tracheostomy times 3 in the distant past , as
well as a history of paroxysmal atrial fibrillation in the recent
past. She has failed Quinidine and Propafenone in the past , and
she is maintained in normal sinus rhythm on Sotalol. The patient
was admitted for paroxysmal atrial fibrillation with increased
ventricular response and was treated with an increased Sotalol dose
and converted to normal sinus rhythm without electrical
cardioversion. The patient was most recently discharged on
10 of January Three days prior to this admission , the patient presented
with a flu-like illness with a temperature of 103 orally , and she
stayed in bed. The next day , she was afebrile and felt better. On
the day of admission , the patient awoke at 7:00 am with sudden
onset of excruciating abdominal pain and she called Bussadd Southrys Community Hospital She went by ambulance there. She said this pain is
typical of her attacks , except was much worse than ever before. On
arrival at Bussadd Southrys Community Hospital , the patient was found to be
hypotensive , clammy , and she was given C1 esterase inhibitor , but
remained persistently hypotensive and was transferred to Pagham University Of Her she had a systolic blood pressure of 60
and was found to be in atrial fibrillation. A CVL groin line was
placed and she was given vigorous intravenous fluid hydration. The
patient was started on Vancomycin , gentamicin and Flagyl to cover a
possible bowel source for sepsis. The pains rapidly decreased over
the next 2 hours , typical of her attacks , but still persisted
mildly. Her blood pressure stabilized and she remained afebrile.
PAST MEDICAL HISTORY included the C1 esterase inhibitor deficiency ,
hereditary angioedema , paroxysmal atrial fibrillation , history of
subdural hematoma secondary to Coumadin , status post appendectomy ,
status post total abdominal hysterectomy , osteoarthritis.
ALLERGIES included multiple foods , sulfa , PCN , Novacaine.
PHYSICAL EXAMINATION: On admission , her temperature was 95.8 ,
blood pressure 90/palpable , heart rate in
the 120's and irregularly irregular. Head , eyes , ears , nose and
throat examination showed pupils were equal , round , reactive to
light , extraocular movements were intact. Neck was without
swelling , without stridor , no adenopathy. Lungs were clear. Heart
had S1 , S2 , irregularly irregular. Abdomen was diffusely tender ,
positive bowel sounds , no rebound , slightly distended. Rectal
examination was guaiac negative. Neurologic examination showed she
was alert and oriented times 3 , cranial nerves intact.
LABORATORY EXAMINATION: Significant values included blood urea
nitrogen 21 , creatinine 1.3 , white count
11 , hematocrit 53.2 , arterial blood gases were pH 7.4 , oxygen 413 ,
PCO2 32 , on 100% face mask. Abdominal computerized tomography scan
showed some thickening and some mild edema of her bowel wall , and
moderate to large amount of ascites with no evidence of
perforation. Chest x-ray was clear. The electrocardiogram showed
atrial fibrillation at 150 , normal axis and intervals , no ischemic
changes.
HOSPITAL COURSE: The patient was admitted and given vigorous
intravenous fluids. Her Sotalol dose of 120
milligrams twice a day was increased to 160 milligrams twice a day.
Her Stanzolol dose of 2 milligrams by mouth every other day was
increased to 2 milligrams by mouth every 6 hours The patient was
monitored very carefully , ruled out for myocardial infarction with
flat creatinine phosphokinase levels. Her abdominal pain was gone
by the next hospital day , and her electrolytes normalized. The
patient had some mild diarrhea , which slowly resolved , and she
remained in atrial fibrillation on the increased Sotalol dose. On
22 of July , the patient underwent DC-cardioversion and was given 100
joules times 2 , and then converted with 200 joules. She remained
in normal sinus rhythm. Her QTC was .467 on her increased dose of
Sotalol , and so she was maintained on this. The patient was
discharged in excellent condition.
DISPOSITION: The patient will be discharged to home. MEDICATIONS
ON DISCHARGE were Sotalol 160 milligrams by mouth
twice a day , Stanzolol 2 milligrams by mouth each day , Synthroid 15
micrograms by mouth each day , aspirin 1 by mouth each day. The
patient is to FOLLOW-UP with Dr. Annette Schoultz
Dictated By: KAM R. ISA , M.D. JY58
Attending: ANNETTE SCHOULTZ , M.D. JW7
TK879/0043
Batch: 3771 Index No. NVZSK7UIE D: 5/24/93
T: 1/26/93
CC: ROSALIA M. ROLSON , M.D. RA3
Document id: 853
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272505350 | PUO | 00947633 | | 310665 | 3/27/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/30/1992 Report Status: Signed
Discharge Date: 7/28/1992
PRINCIPAL DIAGNOSIS: APPENDICITIS.
SECONDARY DIAGNOSIS: GRAVES' DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old woman
with a history of Graves' disease and
known cholelithiasis who presented to the Pagham University Of Emergency Room with a 12 hour history of increasing right
upper quadrant and right lower quadrant abdominal pain , nausea ,
vomiting and a fever. She had one normal bowel movement on the day
of admission. She denied pyuria , anorexia. PAST MEDICAL HISTORY:
Graves' disease. PAST SURGICAL HISTORY: None. MEDICATIONS: On
admission included , 10 mg orally twice a day; Inderal , 40 mg orally
twice a day ALLERGIES: NO KNOWN DRUG ALLERGIES. HABITS: Negative
smoking history. No alcohol intake.
PHYSICAL EXAMINATION: On admission revealed an ill appearing
female in moderate distress. Lungs were
clear to auscultation bilaterally. Cardiac exam revealed a regular
rate and rhythm. Abdomen was soft , nondistended , right lower
quadrant and right upper quadrant tenderness , lower greater than
upper , positive bowel sounds , negative Murphy's sign. No shake or
peritoneal signs. Rectal exam revealed normal tone , no masses ,
nontender , no stool in vault.
LABORATORY DATA: On admission included a white blood cell
count of 14.33. Hematocrit 36.3. Urinalysis
revealed 15-20 red cells.
PROCEDURES: EXPLORATORY LAPAROTOMY.
APPENDECTOMY.
HOSPITAL COURSE: The patient was admitted to the floor. There ,
she had a temperature of 102.2 and a pulse of
152. She continued to experience right upper and right lower
quadrant pain , lower greater than upper. Because of a known
cholelithiasis , differential of her right sided abdominal pain
included , primarily , cholecystitis and appendicitis. She thus
underwent abdominal ultrasound. Ultrasound revealed right upper
quadrant gallbladder with mildly thickened walls , gallstones , but
no common duct dilatation or pericholecystic fluid. The right
lower quadrant revealed thickened small bowel walls but peristalsis
was also identifiable. Using the ultrasound probe , the right lower
quadrant was certainly more tender than the right upper quadrant.
On serial examinations , her abdominal pain and tenderness became
gradually worse and her temperature continued to remain high
spiking to 101 to 102. She was thus brought to the Operating Room
for an exploratory laparotomy. A paramedian incision was made and
appendicitis noted. The gallbladder appeared grossly normal. She
tolerated the procedure well without any complications.
Postoperatively , she continued to have high temperature spiking
over 103 degrees. She also became tachycardic to approximately
150. Because she had not been taking her medications for a few
days preoperatively as well as because she had tremor ,
hyperreflexia , fever , and tachycardia she was suspected to be
thyrotoxic. Of note , she had been in atrial fibrillation one month
prior to admission. Endocrinology consult was obtained and based
on their recommendations , she was restarted on , 15 mg orally every
six hours; Inderal , 40 mg orally every six hours; SSKI , one-third of 1 cc
orally three times a day Thyroid function tests were sent. She gradually
defervesced. Her heart rate diminished and her ambulation was
rapidly advanced. Her wound was noted to be slightly erythematous
and she was thus started on Velosef.
DISPOSITION: MEDICATIONS: On discharge included Percocet , one
to two tablets orally every four hours as needed; Inderal , 40 mg
orally every six hours; SSKI , one-third cc orally three times a day; , 10 mg orally
three times a day; Velosef , 500 mg orally four times a day times seven days.
EO799/32 -2
SEPTEMBER PETRETTI , M.D. HF8 D: 7/25/92
Batch: 5007 Report: B4682C86 T: 11/14/92
Dictated By: ROSSIE MANKOSKI , M.D.
Document id: 854
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047657566 | PUO | 70437680 | | 7864630 | 7/16/2006 12:00:00 a.m. | syncope , NOS | | DIS | Admission Date: 7/16/2006 Report Status:
Discharge Date: 10/21/2006
****** FINAL DISCHARGE ORDERS ******
HYKES , EDYTH 233-36-36-2
Ahass
Service: RNM
DISCHARGE PATIENT ON: 7/25/06 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PILLING , WEI NYLA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
INSULIN NPH HUMAN 10 UNITS subcutaneously twice a day
INSULIN REGULAR HUMAN 4 UNITS subcutaneously three times a day
Instructions: before meals
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously three times a day Medium Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 3 units subcutaneously
If BS is 251-300 , then give 5 units subcutaneously
If BS is 301-350 , then give 7 units subcutaneously
If BS is 351-400 , then give 8 units subcutaneously
Call HO if BS is greater than 350
Please give at the same time and in addition to standing
mealtime insulin
METOPROLOL TARTRATE 12.5 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
PRILOSEC ( OMEPRAZOLE ) 40 MG orally twice a day
PREDNISONE Taper orally Give 60 mg every 24 hours X 3 dose( s ) , then
Give 50 mg every 24 hours X 7 dose( s ) , then
Give 40 mg every 24 hours X 7 dose( s ) , then
Give 30 mg every 24 hours X 7 dose( s ) , then
Give 20 mg every 24 hours X 7 dose( s ) , then
After taper , continue PREDNISONE at 10 mg every 24 hours
Starting Today ( 5/14 )
FLOMAX ( TAMSULOSIN ) 0.4 MG orally DAILY
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
XENADERM ( TRYPSIN - BALSAM PERU - CASTOR OIL ... )
TOPICAL TP twice a day
Instructions: Please apply to affected area.
DIET: House / Renal diet (FDI)
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
at dialysis ,
primary care physician Dr Feddersen 3/21 @ 350 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
anemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
syncope , NOS
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of RML pneumonia recalcitrant smoker history of chronic
hematuria Acute renal failure 11/13 NIDDM
( ) HTN ( hypertension ) ESRD on HD
( ) CAD ( ) history of renal transplant ( history of kidney transplant )
OPERATIONS AND PROCEDURES:
EGD
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Dialysis
BRIEF RESUME OF HOSPITAL COURSE:
CC: syncope
HPI: 58M with ESRD
history of renal allograft complicated by cellular rejection on HD MWF ,
DMII , HTN , aortic stenosis history of AVR ( porcine ) with simultaneous single
vessel CABG LIMA->LAD. patient reports eating breakfast and taking morning
medications and then feeling lightheaded , diaphoretic , with his heart
racing. His symptoms began while he was sitting , but he stood up to
walk across the room and felt his symptoms worsen. He
remembers feeling more "dizzy" and "unsteady" and then remembers
being on the ground. He does not remember falling or lowering
himself , but he denies loss of consciousness. EMS was called to take
him to the
ED. On the ambulance he felt some substernal heaviness
and discomfort that lasted less than 1 hours. The feeling resolved
after receiving oxygen. He denies chest pain prior to fainting.
He has not felt well since his renal transplant complaining of
shortness of breath. He however notes increasing shortness of breath ,
cough , and fatigue over the past weeks. Denies fever , chills ,
edema , melena , bright red blood per rectum , hematochezia , dysuria ,
hematuria. He did feel nauseas after he
fainted.
In ED seen by renal fellow and sent to dialysis where he received 2
units PRBC for Hct of 24.
PMH ESRD 2/2 DMII history of renal transplant complicated
allograft rejection on HD MWF. AVR with simultaneous single vessel
cabg for nonobstructive cad in
9/21/05 HTN
DM2 - on insulin history of
CHF Hypercholesterolemia
Large sacral wound ( slowly healing ) recurrent
UTIs
All: NKDA
Events: 11/3 22 beat VT , EP consulted started metop 12.5
HR BP R O2
sat Pupils pinpoint , mmm , neck supple no LAD , JVP
~10 Lungs tubular sounds over right mid lung field ,
course breath sounds at left base Heart RRR s1 loud s2 systolic murmur
at RUSB radiates to carotid , systolic murmur at apex
radiating to axilla. Abdomen , soft , renal allograft
tenderness. Ext
1+edema. BUN 60 , CRE 9.8 CK 61 , CK-MB 1.5 , TROP-I
<0.10. WBC 12.48 , HCT 24.01.2 , PTT
41.1 ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Studies: CXR 11.15.2006 Stable mild pulmonary edema
( unofficial ). EKG sinus rhythm nonspecific twave abnormalities in
I , II , avf , avl , twi in v5 and v6 unchanged from prior in September
2006. Echo 11/3 valves and EF
OK ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Consults: GI Rader , Yael 74610 , Renal is primary team.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Impression:
58M with ESRD history of renal allograft rejection here for syncope , likely
symptomatic anemia. ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Plan: Renal - by history sounds volume overloaded will
likely need more frequent dialysis to remove excess fluid.
Nephrocaps. On steroid taper for rejection.
CV-I: nonobstructive CAD history of LIMA to LAD , patient has been on ASA in past ,
unclear why stopped will consider adding asa after consultation with
primary care physician. Will ROMI with enzymes as patient admitted for
sycope.given NSVT may need ischemic eval. CV-P: volume up by symptoms
and xray , will need more frequent dialysis , will consider repeating
echo as part of the evalution for syncope - specifically to evaluate
aortic prosthesis function. Echo
OK. CV-R: monitor on tele , BB for
VT Heme: patient anemia with Hct of 24 , on high doses of
Epo and intravenous iron at HD , this suggests blood loss. Will guiaic stools ,
monitor hct , renal ultrasound today to evaluate for hemorrhage into
allograft. Received 2 units PRBC at HD.GI consulted and
planning EGD on Monday. Pulm: chronic cough likely secondary to
cigarette smoking , recent worsening likely represents
pulmonary edema , will monitor respiratory status. ID: WBC 12 , with no
evidence of infection , monitor fever curve and culture if
spikes. Endo: DM on vague sliding scale at home , Will start
with NPH 10 twice a day , Regular 4 before meals with sliding scale for additional
coverage and titrate to requirements.
GI: guiac + stools. EGD uremarkable here. Nexium for
gerd. GU: cystoscopy as outpt , urine cytology , for
intermittent hematuria. PPX: Nexium , Hep subcutaneously
three times a day. Full
code
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
followup at dialysis
No dictated summary
ENTERED BY: DEBROCK , ANASTACIA ( ) 7/25/06 @ 01:43 PM
****** END OF DISCHARGE ORDERS ******
Document id: 855
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GER |
Gou |
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OSA |
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568910472 | PUO | 53420604 | | 8612557 | 9/10/2006 12:00:00 a.m. | Pumlmonary Embolism | | DIS | Admission Date: 4/23/2006 Report Status:
Discharge Date: 3/17/2006
****** FINAL DISCHARGE ORDERS ******
LAWVER , DANIEL 679-23-32-6
Ge Grovecleardowneans Ha
Service: CAR
DISCHARGE PATIENT ON: 2/12/06 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRUNTZ , KATHERYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 8/19/06 by
MCQUISTON , PAMELIA T. , M.D.
on order for COUMADIN orally ( ref # 342651028 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/18/06 by MCQUISTON , PAMELIA T. , M.D.
on order for COUMADIN orally ( ref # 366420351 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: AWARE
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
IBUPROFEN 400-800 MG orally every 6 hours as needed Pain
Food/Drug Interaction Instruction Take with food
ASACOL ( MESALAMINE TABLET ) 800 MG orally twice a day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
150 MG orally twice a day Instructions: patient takes twice a day at home.
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
OXYCODONE 5 MG orally every 6 hours as needed Pain
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 8/19/06 by
MCQUISTON , PAMELIA T. , M.D.
on order for COUMADIN orally ( ref # 342651028 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 10/18/06 by MCQUISTON , PAMELIA T. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: AWARE
TRAZODONE 25 MG orally BEDTIME as needed Insomnia
COUMADIN ( WARFARIN SODIUM ) 8 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 8/19/06 by
MCQUISTON , PAMELIA T. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
DIET: Patient should measure weight daily
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care doctor 1 week ,
Dr. Gruntz 11/22 at 4:30 scheduled ,
Arrange INR to be drawn on 2/4/06 with f/u INR's to be drawn every
3 days. INR's will be followed by VNS
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Dyspnea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pumlmonary Embolism
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) dysliipds
former smoker ( past smoking ) ulcerative colitis ( ulcerative colitis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
HPI: Daniel Lawver is a 66 year old male with PMHx sig for CAD history of 2
vessel CABG 10/19 , HTN , UC who was admitted for cc of SOB. patient was
discharged history of CABG on 6 of August That evening , patient had SOB while trying to
sleep. SOB was worse with lying down , patient was unable to sleep. Sunday 3/10
patient was seen by VNS who suggested he come into ED for eval. In ED patient had
nml CXR , but dropped 02 sat while sleeping to 91% on RA. Was placed on
CPAP with ltd relief. 6/2 CTA showed multiple small embolic PE. patient was
INR was 1.8 ( down from 2.1 3/10 ) and he was given 120mg lovenox at 5PM
6/2 in the ED.
On the floor patient states SOB improved. Denies chest pain , calf pain , cough ,
dyspnea , n/v/d. patient has no history or family history of clots.
PMHx:
CABG 7/29/2006 LIMA to LAD , saphenous to first diagonal
EF 60-65% 9/30
Afib
HTN
Hyperlipdemia
GERD
Ulcerative colitis
Obesity
Osteoarthritis of knees
Medcations:
Asa 81
Lipitor 40mg qday
Lasix 40mg qday
KCL 20meq day
Asacol 800mg twice a day
Toprol 150mg twice a day
Coumadin 8mg qday
Oxycodone 5-10mg q6 as needed
Allergies: NKDA
Social: lives at home with wife. No ETOH , no smoking.
FHx: no history of clots
PE:
Vitals: T97.7 BP 118/70 HR 79 02 sat 97% 3L Weight 155 kg
Gen: friendly male , NAD , A&0x3
HEENT: PERRLA bil , anicteric , noninjected. MMM , no lesions.
Neck: supple , no adenopathy , no thyromegaly
CV: JVP flat , ireggulyar rate , nml s1 , s2
Lungs: crackles at lower lobes bilaterally
Ab: obese , soft , NT , ND , noromactive BS , no hepatosplenomegaly
Ext: WWP , no edema , no cords , no calf tenderness
Derm: no rashes
Neuro: CN II-XII intact , sensory and motor grossly intact
Labs remarkable for INR of 2.1 , then 1.8
ECG: premature atrial complexes , rate 70 ,
CTA 9/25 Mult bil pulm emboli , segmental and subsegmental
Expected post surgical anterior mediastinal hematoma , posterior fluid
collection
Hospital course:
Pulmonary: Patient was found to have mult small PE. On HD 2 was started on
heparin Bridge. His coumadin was increased to 10mg every bedtime HD 3 INR was 2.8.
patient remained hemodynamically stable and was continued on 3L of 02 with 02
sat 95%. He will be discharged on home 02. Will decrease coumadin to 8mg
every bedtime with close follow up with VNS.
ADDITIONAL COMMENTS: Please check INR in 1-2 days.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Check INR in 1-2 days.
No dictated summary
ENTERED BY: MCQUISTON , PAMELIA T. , M.D. ( PT36 ) 2/12/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 856
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618283162 | PUO | 09342280 | | 5755266 | 9/23/2006 12:00:00 a.m. | ABDOMINAL PAIN | Signed | DIS | Admission Date: 7/21/2006 Report Status: Signed
Discharge Date: 1/18/2006
ATTENDING: PETTINGER , DOUGLASS M.D.
HISTORY OF PRESENT ILLNESS: This is a 90+-year-old man with
multiple medical problems , who was recently admitted for a delta
MS and found to have multiple posterior circulation infarcts ,
likely embolic in nature. He was discharged yesterday and now
presents with fevers , chills , shaking , and increasing abdominal
distention. On admission also , noted to have increased sputum
production and therefore question aspiration event was considered
while at rehab. At his recent hospital stay , he was evaluated
for PFO , which was found to be negative , had no paroxysmal atrial
fibrillation , had hypertensive episodes to systolic blood
pressure of 240 , which responded well to hydralazine. Had a
troponin leak to peak of 1.94 , which trended down and was
considered to be demand related. At baseline , the patient lives
with his wife at home , walks with a walker , and requires
assistance with ADLs. On arrival on the floor , the patient had a
temperature of 101.3 , axillary , heart rate 80s to 90s , blood
pressure 180s/80s , and O2 saturation of 97% on three liters. His
abdomen was found to be quite distended , however not rigid and
had no peritoneal signs.
PAST MEDICAL HISTORY:
1. Right hip fracture status post right hemiarthroplasty.
2. Non insulin-dependent diabetes.
3. Depression.
4. Psoriasis.
5. Leiomyoma.
6. Hypertension.
7. SVT.
8. History of GI bleed.
9. Chronic renal insufficiency with baseline creatinine of 1.3
to 1.6.
10. Embolic stroke in October of 2006.
IMPORTANT STUDIES:
1. Chest PA and lateral dated 1/10/06 , increased opacification
seen on the lateral view over the lung base concerning for
pneumonia , which is probably in the left lower lobe , atelectasis
was seen in the right lung , tiny bilateral pleural effusions are
possible , and heart size is normal.
2. Abdominal ultrasound on 3/1/06 : 1 ) Contracted gallbladder
with gallstones. No sonographic evidence for acute
cholecystitis. 2 ) Bilateral pleural effusions.
3. KUB dated 4/5/06 , no subdiaphragmatic air is seen , no
high-grade obstruction , and limited study due to motion artifact.
4. Urine culture on 4/5/06 , greater than 100 , 000 pansensitive
E. coli.
HOSPITAL COURSE:
1. The patient was found to have a pansensitive E. coli UTI and a
questionable left lower lobe pneumonia , which would have likely
been due to aspiration given the patient's recent stroke and
documented aspiration by Speech and Swallow on previous
admission. The patient's white count , which was initially 19.8
on the day of admission trended down over the first three days of
his admission as he was treated with Levaquin. The Levaquin ,
which will cover both the urinary tract infection and the
possibility of aspiration pneumonia will be continued for a total
of a 14-day course to end on 11/16/06. The patient's blood
cultures showed no growth.
2. GU , the patient was found to have 1.5 mL of urine in his
bladder when he was admitted indicating significant urinary
retention. A Foley was placed and the patient drained the urine.
The patient was started on Flomax to improve his recovery from
the urethral obstruction. Most likely , the patient has
underlying urinary retention that was exacerbated by his recent
Foley placement during his previous admission. Then when he went
to rehab without the Foley ( note he did void several times prior
to discharge from the hospital ). The patient developed urinary
obstruction likely contributing to his urinary tract infection
and requiring readmission. The Foley was kept in place until
hospital day four. When the Foley was taken out , the patient did
not void at all. A bladder scan ten hours after the Foley was
taken out revealed 432 mL of urine in his bladder. A Foley was
replaced in his bladder and Urology was consulted. Urology
recommended bladder rest for seven days meaning that the Foley
should be left in place for seven days and then he is to follow
up with Dr. Haley Tonsil with the Foley still in place for a
voiding trial within a week after discharge.
3. Renal , the patient's creatinine at admission was 2.2 , which
is significantly above his baseline. This was attributed to
acute renal failure secondary to the urinary obstruction. When
the Foley was placed , his creatinine steadily declined , and on
the day prior to discharge was 1.2 , which is within his normal
range.
4. Cardiovascular , the patient continued to be hypertensive with
SBPs greater than 200 , particularly at night. Therefore , during
his hospital course , his blood pressure regimen was titrated up
such that at the time of discharge , his blood pressure regimen is
Lopressor 50 four times a day and Norvasc 10 daily. Blood pressures during
24 hours prior to discharge ranged from 110 to 140/70s and his
heart rate ranged 64 to 82.
5. Endocrine , the patient was treated with insulin and his orally
regimen while inhouse and this can be continued at rehab. He
will be discharged on Lantus 12 , NovoLog sliding scale , and
tolbutamide 500 daily.
6. GI , the patient had a steadily rising alk phos through the
course of his hospital stay. At admission , it was 206 and it
rose to 508. A GGT was drawn and found to also be elevated at
119 , therefore a right upper quadrant ultrasound was completed ,
which showed a contracted gallbladder with gallstones but no
acute cholecystitis. The patient was found to be constipated on
the day prior to discharge and was given a Dulcolax suppository ,
which had worked in the past.
7. Prophylaxis , the patient received Lovenox subcutaneously daily.
CODE STATUS: The patient is DNI though he would want to be
resuscitated with CPR , defibrillated , and given pressors.
CONTACT INFORMATION: His son , Dr. Kamala Litteer , can be contacted
at 559-049-8783 or 759-360-1703. His wife can be contacted at
011-647-5438.
FINAL DIAGNOSIS: Urinary retention leading to urinary tract
infection , possible aspiration pneumonia.
MEDICATIONS AT DISCHARGE TO REHAB: Tylenol 325 mg orally every 6 hours
as needed pain , aspirin 325 mg orally daily , Dulcolax 10 mg p.r.
twice a day as needed constipation , Colace 100 mg orally twice a day , Mag
sulfate sliding scale intravenous daily , Lopressor 50 orally four times a day , Senna
one tablet orally twice a day , tolbutamide 500 mg orally daily ,
triamcinolone topical daily , Zocor 20 orally every bedtime , Norvasc 10
orally daily , Lovenox 30 subcutaneously daily , risperidone 1 mg orally
every bedtime , Dovonex ointment topical twice a day , Remeron 15 orally every bedtime ,
Zyprexa 2.5 mg sublingual every bedtime as needed anxiety or agitation ,
levofloxacin 250 mg orally daily x5 doses to finish on 2/24/06 ,
Flomax 0.4 mg orally daily , Lantus 12 units subcutaneously daily , DuoNeb
3/3.5 nebs every 6 hours as needed shortness of breath or wheezing , NovoLog
sliding scale before meals and nighttime.
FOLLOWUP APPOINTMENT: Dr. Sarabando on 8/13/06 at 2:15.
Thank you for the opportunity to take part in the care of your
patient.
eScription document: 1-0244463 CSSten Tel
Dictated By: INGRAM , ANDREE
Attending: PETTINGER , DOUGLASS
Dictation ID 9737009
D: 3/1/06
T: 3/1/06
Document id: 857
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042580388 | PUO | 02169523 | | 0435272 | 11/2/2007 12:00:00 a.m. | CARDIOGENIC SHOCK | Signed | DIS | Admission Date: 5/28/2007 Report Status: Signed
Discharge Date: 1/26/2007
ATTENDING: PART , JACKSON MD
SERVICE: Coronary Care Unit.
BRIEF HISTORY OF PRESENT ILLNESS: Ms. Bruscino was a 58-year-old
woman with a history of non-ischemic cardiomyopathy and ejection
fraction of 15% who was initially admitted to the Pagham University Of following a cardiac arrest. On arrival in the
emergency department she was found to have recurrent ventricular
tachycardia and was defibrillated. She required an intraaortic
balloon pump to maintain her blood pressure.
PAST MEDICAL HISTORY: Significant for non-ischemic
cardiomyopathy. She has a pacemaker/ICD. She has a history of
chronic kidney disease , deep venous thrombosis , history of
cerebrovascular accident , history of hypercholesterolemia ,
history of coronary artery disease , history of diabetes , history
of GI bleed and history of chronic hepatitis C.
HOSPITAL COURSE BY PROBLEMS: Ms. Bruscino had a complicated
course in the hospital and her care was related primarily to
recurrent ventricular tachycardia and prolonged anoxic injury
affecting multiple organ systems. During her hospital course ,
she required pressor medications , an intraaortic balloon pump ,
and ventilator support. Of note , the patient had noted , prior to her
admission , that she would never want to be dependent upon "machines." Due to
poor neurological status and poor
prognosis , and in conjunction with the patient's previously expressed wishes ,
medical care was withdrawn on 4/25 after many discussions with family. The
patient's primary care physician , Dr Vermillion , was involved with these
discussions. The intraaortic balloon pump was turned off. Pressure medications
were held and the mechanical ventilator was stopped. The patient passed away
on 11/17/07 shortly after removal of mechanical support.
eScription document: 6-9754791 CSSten Tel
Dictated By: FEDDERSEN , AUGUSTINE
Attending: PART , JACKSON
Dictation ID 4513773
D: 11/17/07
T: 10/18/07
Document id: 858
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830228439 | PUO | 30858406 | | 150190 | 1/18/1998 12:00:00 a.m. | MENOMETRORRHAGIA , FIBROID UTERUS | Signed | DIS | Admission Date: 7/2/1998 Report Status: Signed
Discharge Date: 10/13/1998
PRINCIPAL PROCEDURES: Total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old gravida
5 , para 4 , with long-standing history
of menometrorrhagia with a known fibroid uterus. The patient has
been bleeding per vagina nearly everyday since 1994 , so heavily
such that in 11/16 , she presented to the I Warho Hospital
with heavy bleeding and chest pain. At that time , her hematocrit
was 18 and she actually ruled in for a mild myocardial infarction.
She continues with heavy bleeding and she has a large cervical
fibroid that makes an endometrial biopsy impossible to perform in
the clinic. The patient was thus scheduled for a bilateral total
abdominal hysterectomy and bilateral salpingo-oophorectomy as she
does not desire to retain her ovaries.
PAST MEDICAL HISTORY: ( 1 ) Iron-deficiency anemia; ( 2 ) She is status
post MI as above. Her cardiac risk factors
are smoking and mild obesity.
PAST SURGICAL HISTORY: She has had a history of bilateral tubal
ligations.
PAST OB/GYN HISTORY: G 5 , P 4 , status post bilateral BTL. She has
had four normal spontaneous vaginal
deliveries.
MEDICATIONS: Iron sulfate 300 mg orally every day; aspirin 325 mg orally
every day; atenolol 50 mg orally every day; Axid 150 mg orally
twice a day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a smoker. She does not drink
alcohol or use any other drugs. The patient's
primary care provider is Dr. Elmer Sic
PHYSICAL EXAMINATION: GENERAL - The patient is a well-appearing
morning who speaks English as a secondary
language. Her primary language is africaan. NECK - No thyromegaly ,
no lymphadenopathy. LUNGS - Clear to auscultation bilaterally.
HEART - Regular rate and rhythm , without murmurs , gallop , or rubs.
BACK - No spinous tenderness , no CVA tenderness. ABDOMEN - Soft ,
non-tender. There is a lower abdominal mass midline approximately
10 weeks size. PELVIC - She has a normal external genitalia ,
normal vaginal with some blood in the vault. The cervix is widened
and on bimanual exam , there is a number of fibroids palpated in
this 8-10 weeks size uterus.
LABORATORY DATA: Hematocrit 40 on 11/8/97 , white count 7.0 ,
platelets 531. PAP in 10/20/97 was within normal
limits. An echo in 7/19 revealed mild left ventricular hypertrophy
with good systolic function.
HOSPITAL COURSE: The patient was admitted thus for a TAH/BSO on
10/2/98 , which was performed without
complications and a minimal EBL of 150.
Postoperatively , in the PACU , she had several PVCs on the monitor
and electrolytes were checked , as well as CBC , and she was ruled
out for MI. Her potassium returned to 4.6 , mag 1.9 , and hematocrit
34. She was given 2 gm of magnesium sulfate and she was felt to be
stable. She ruled out for MI over the ensuing 24 hours with CKs of
70 , 117 , and 170. She had no symptoms of chest pain , jaw pain , or
left arm pain at any point during this admission.
She continued to do well in the hospital and by postoperative day
#3 , she was ambulatory , voiding spontaneously , tolerating a full
diet and passing flatus. She was discharged home on 1/26/98 on the
following medications:
DISCHARGE MEDICATIONS: Motrin 600 mg orally every 4-6h. as needed pain;
Axid 150 mg orally twice a day; atenolol 12.5 mg
orally every day; Peri-Colace 1 orally twice a day; ECASA 325 mg orally every day;
Premarin 0.625 mg orally every day
DISCHARGE FOLLOW-UP: The patient will follow-up with her primary
GYN doctor , Dr. Baris , and her
primary medical doctor , Dr. Carmelita Toni in the chief resident clinic
postoperatively in two weeks. She will see Dr. Toni or Dr. Hein
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: ARLYNE ROIS , M.D. QE09
Attending: HAYWOOD STAKES , M.D. CI70
GE736/4466
Batch: 51575 Index No. EOHSJP1S6O D: 10/14/98
T: 10/14/98
Document id: 859
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780021795 | PUO | 75045835 | | 010035 | 10/6/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/12/1991 Report Status: Signed
Discharge Date: 3/6/1991
PRIMARY DIAGNOSIS: RIGHT PATELLA TENDON RUPTURE.
SECONDARY DIAGNOSIS: ETOH.
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old black
male who was mugged on Friday ,
5/3/91. He states that he bumped his head , however , denies loss
of consciousness. He was also knocked in the chest. He does not
know how his right knee was injured. His chief complaint on
presentation was right knee pain. He was taken to the Emergency
Room and was evaluated and noted to have a right patella tendon
rupture. He now presents for surgical repair electively. PAST
MEDICAL HISTORY: Is only significant for pneumonia as a child. He
had incision and drainage to his left anterior tibia. He also has
had bilateral hernia repairs. He was on no medications on
admission. He has no known drug allergies. He does have a history
of ethanol use and tobacco use.
PHYSICAL EXAMINATION: He is a well developed , well nourished male
in no apparent distress. His skin was warm.
His HEENT exam was unremarkable. His chest was clear. His heart
had a regular rate and rhythm with a normal S1 and S2 , and no
murmurs. His pulses were 2+ and symmetric throughout. There were
no bruits present. His right lower extremity revealed a swollen
right knee. He was unable to do a straight leg raise and had a
range of motion of approximately 60 degrees. His ACL was intact.
His sensation was intact. He had no paresthesias. He had 1+
laxiety laterally. His neurological examination was nonfocal.
HOSPITAL COURSE: The patient was admitted to the Orthopedic
Surgery Service under Dr. Gilbreth He was taken to
the operating room on 2/14/91. There , he underwent the repair of a
right patella tendon. The patient tolerated the procedure well.
There were no complications. Postoperatively , the patient did very
well. He was advanced gradually on his continuous passive motion
and range of motion exercise with physical therapy. By the time of
discharge on 10/4/91 , he had partial weight bearing and
approximately 90 degrees range of motion. He will have followup
with Dr. Rademan in approximately 2-4 weeks.
DISPOSITION: MEDICATIONS ON DISCHARGE: Motrin 800 mg orally q6-8
as needed
BE461/1307
CAITLIN RADEMAN , M.D. MW29 D: 1/1/91
Batch: 9534 Report: A1623Q0 T: 6/20/91
Dictated By: BUCK MOOSE , M.D.
Document id: 860
| Target |
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CHF |
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Gs |
GER |
Gou |
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Obe |
OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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141445265 | PUO | 18125885 | | 1470925 | 8/13/2005 12:00:00 a.m. | likely non-cardiac chest pain | | DIS | Admission Date: 8/13/2005 Report Status:
Discharge Date: 6/4/2005
****** FINAL DISCHARGE ORDERS ******
LAZARINI , ALEJANDRINA E. 579-93-49-2
Ok
Service: CAR
DISCHARGE PATIENT ON: 11/14/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BACHMANN , LASHANDA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
ENALAPRIL MALEATE 2.5 MG orally every day Starting Today ( 10/20 )
LASIX ( FUROSEMIDE ) 20 MG orally every day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 25 MCG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain
PREDNISOLONE 1% 1 DROP each eye four times a day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
CITALOPRAM 40 MG orally every day
VYTORIN 10/40 ( EZETIMIBE 10 MG - SIMVASTATIN ... )
1 TAB orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
ISOSORBIDE DINITRATE 5 MG orally twice a day
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Please avoid exercise or strenuous activity until you see your local physician.
FOLLOW UP APPOINTMENT( S ):
LMC CHF nurse practitioner in 1 wekk 6/12/05 scheduled ,
Dr. Sakumoto 1/10/06 scheduled ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
likely non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) CAD ( coronary artery disease ) history of cabg ( history of
cardiac bypass graft surgery ) IDDM
( ) hypercholesterolemia ( elevated cholesterol ) peripheral neuropathy ( )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: SSCP
HPI:64 M with CAD history of CABGx4 ( 2002 ) history of MI 2002 , htn , hypercholesterolemia ,
IDDM p/with 10/14 CP @ LMC clinic that resolved with rest. There was no
radiation , n/v , SOB , diaphoresis. He was given asa 325 , sublingual ntg at LMC
and transferred to PUO . At PUO VS were: T 96.1 , HR 70 , BP 156/56 , 18 ,
98/RA. His exam was normal except for his obesity. Enzymes/CXR were
negative. EKG showed 1 to 1.5 mm ST-depressions in V2-V5 which were old.
He was started on heparin and transferred to the floor for ROMI and
further management.
PMH:
CABG x 4 ( 3/16 )
LIMA-LAD , SVG-distal LAD , SVG-diag 1 , SVG-RCA
Cath 2/17
LAD 99% , 80%; patent LIMA-LAD , LCx patent , RCA-100% , SVG-RT PDA patent;
SVG-Diag1 50% prox , 40% distal
Dipyridamole PET 5/22 mild basolateral ischemia
Echo 3/14 EF 45% with E->A reversal
htn , IDDM , hypercholesterolemia , peripheral neuropathy , hypothyroid
---------------------------------------------------
Admission PE: T 96.1 , P 70 , BP 106/56 , O2sat 96% RA.
Obese; NAD; CTAB; RRR nl S1/S2 , +S4 , JVP difficult to interpret;
Extremities warm and well perfused , 1+ bilateral pedal edema.
-----------------------------------------------------------------------
Hospital Course:
CV:
ishemia:There was a low probabilty of ACS. The patient had negative
enzymes x 3. EKGs were unchanged from previous EKGs. He was discharged
on his home medicatino regimen. However , his nexium was increased to twice a day
to eliminate GI contribution to frequent chest pain episodes. Further
work-up was deferred due to recent extensive work-up including cath 7/13
The patient was discharged on all of his other home medications.
Endo-Patient was taken off orally diabetic regimen , but was restarted on
these medications on discharge. Of note , his novolin 70/30 is pre-filled
by an LMC nurse and the exact dosing is not available in the chart.
ADDITIONAL COMMENTS: Please continue to have your novolin syringes pre-filled by the LMC
nurse.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please take all of your medications.
Follow up with the CHF NP in 1 week.
Follow up with Dr. Sakumoto , your cardiologist , in one month.
Return to the hosptial if you experience any chest pain.
No dictated summary
ENTERED BY: WARRELL , KRYSTIN D. , M.D. , PH.D. ( FO61 ) 11/14/05 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 861
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
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| output/system_textual_annotation.xml | textual |
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600192717 | PUO | 08849650 | | 6542246 | 7/24/2007 12:00:00 a.m. | Asthmatic flare | | DIS | Admission Date: 11/22/2007 Report Status:
Discharge Date: 9/25/2007
****** FINAL DISCHARGE ORDERS ******
STOLTZ , JESENIA 164-83-05-6
La Lene
Service: MED
DISCHARGE PATIENT ON: 3/26/07 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOSSERT , CHAROLETTE S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. AMLODIPINE 10 MG orally every day
2. GABAPENTIN 300 MG orally three times a day
3. HYDROCHLOROTHIAZIDE 25 MG orally every day
4. PHENYTOIN 250 MG orally twice a day
5. SIMVASTATIN 20 MG orally every bedtime
6. LISINOPRIL 40 MG orally every day
7. ALBUTEROL INHALER 2 PUFF inhaled every 4 hours
8. FLUTICASONE PROPIONATE 110 MCG ORAL INHALER 2 PUFFS inhaled twice a day
9. CITALOPRAM 20 MG orally every day
MEDICATIONS ON DISCHARGE:
ALBUTEROL INHALER 2 PUFF inhaled every 4 hours as needed Wheezing
NORVASC ( AMLODIPINE ) 10 MG orally DAILY HOLD IF: SBP<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CIPROFLOXACIN 250 MG orally every 12 hours X 3 doses
Starting Today ( 3/10 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
CITALOPRAM 20 MG orally DAILY
FLOVENT HFA ( FLUTICASONE PROPIONATE inhaled )
110 MCG inhaled twice a day Instructions: 2 puffs twice daily
NEURONTIN ( GABAPENTIN ) 600 MG orally three times a day
HYDROCHLOROTHIAZIDE 25 MG orally DAILY HOLD IF: SBP<90
LISINOPRIL 40 MG orally DAILY HOLD IF: SBP<90
DILANTIN ( PHENYTOIN ) 230 MG every day before noon; 200 MG every afternoon orally
230 MG every day before noon 200 MG every afternoon Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after )
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
REPLIVA 9/30 TABLET 15-200-1 1 TAB orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Titterness ( neurologist ) please call to set up within next 1-2 weeks ,
Dr. Camak ) outpt pulmonologist ) Thursday October , 2007 at 1:40PM scheduled ,
Dr. Musgraves ( primary care physician ) June , 2007 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Hypoxemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Asthmatic flare
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Acute Asthma Flare
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Echocardiogram 9/25/07
BRIEF RESUME OF HOSPITAL COURSE:
CC: seizures , hypoxemia
HPI: 53F history of sarcoid , seizure disorder within the last year , possible
cardiomyopathy , asthma , smoking , HTN , and obesity p/with seizure activity
at home and then later in the ED. Has a history of intermittent
non-adherence to prescribed dilantin regimen. Treated acutely with
ativan , found to be subtherapeutic on dilantin so re-loaded with
dilantin to achieve therapeutic levels. Observed in ED overnight with
plans for morning discharge , but became questionably hypoxemic ( O2 sat
low 90s ) and somewhat subjectively dyspneic. The physicians in the
emergency room thought that the patient was having
an asthma exacerbation and gave the patient prednisone 60mg x 1 ,
combivent/albuterol nebulizer treatment , levofloxacin/clindamycin
for possible aspiration pneumonia , and admitted her to the medical floor
for further evaluation and treatment.
Hospital Course:
1 ) Pulmonary. On admission to the floor , the patient was found to have
normal oxygen saturations in the mid 90s on room air and was not thought to
have any concurrent bronchospasm or focal sounds of a pneumonia. Her chest
x ray was negative , she was not having fevers and her white blood count was
normal. Her steroids and levofloxacin/clindamycin were therefore
discontinued and she received her home inhalers and nebulizers only. She
remained stable on this regimen throughout her hospital stay. Her breath
sounds and heart sounds were admittedly a bit distant and she may have an
element of undiagnosed COPD , so pulmonary function tests were recommended
as an outpatient. Additionally , the patient may benefit from a sleep study
as an outpatient given her component of desaturation while asymptomatic and
sleeping during the night of admission.
2 ) Infectious disease. The patient did have an apparent urinary tract
infection and so was treated with ciprofloxacin 250mg twice daily for three
days.
3 ) Cardiovascular. The patient did report some symptoms of PND and orthopnea ,
which appeared to be stable for the last several years. She was not volume
overloaded on exam. She received an echocardiogram to investigate possible
cardiomyopathy or congestive failure , and this showed a normal ejection
fraction without obvious structural abnormalities except for mild bilateral
atrial dilatation.
4 ) Neurological. The inpatient medical team communicated with the pts
outpatient neurologist to discuss continued seizures in the context of
questionable intermittent noncompliance. Per the instructions of her
neurologist , the pts dilantin was increased to 230mg orally every day before noon and 200mg orally
every afternoon with plans to check another dilantin level on Friday March ( five
days after increasing dose ). Her neurontin dose was also increased to 600mg
three times daily.
ADDITIONAL COMMENTS: 1 ) Please draw dilantin level on Friday 4/3/07 and send results to
outpatient primary care physician and outpatient neurologist.
2 ) Please help patient with medication teaching , especially as regards
anti-epileptics ( dilantin , neurontin ) in order to improve outpt
compliance and reduce frequency of seizures.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Please follow up dilantin level to be drawn by VNA on Friday 10/21/07.
2 ) Consider PFTs/sleep study as outpt.
No dictated summary
ENTERED BY: DUREPO , JR , JESSI T. , M.D. ( NS56 ) 3/26/07 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 862
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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352571489 | PUO | 59749742 | | 1464707 | 2/12/2006 12:00:00 a.m. | ischemic foot | Signed | DIS | Admission Date: 11/10/2006 Report Status: Signed
Discharge Date: 9/3/2006
ATTENDING: DERHAM , ROSALINA CORIE
VASCULAR SURGERY
PRINCIPAL DIAGNOSIS: Right foot gangrene.
DISCHARGE DIAGNOSIS: Right foot gangrene.
OTHER MEDICAL ISSUES CONSIDERED AT THIS TIME: Diabetes type 2 ,
peripheral vascular occlusive disease , congestive heart failure ,
coronary artery disease , status post left knee amputation ,
depression , and dementia.
BRIEF HISTORY OF PHYSICAL ILLNESS: The patient is a 90+-year-old
female with multiple medical problems including dementia ,
coronary artery disease , diabetes , and PVOD , who presented to the
Leyo Ault University Health Center Department on 5/23/06 for
an intermittently cold and blue foot. Gangrene was noticed in the second
and third right lower extremity toes. She was admitted for
possible amputation.
PAST MEDICAL HISTORY: Significant for diabetes type 2 , coronary
artery disease status post myocardial infarction , anemia ,
congestive heart failure , asthma , depression , neurogenic bladder ,
and dementia.
PAST SURGICAL HISTORY: Significant for left above-knee
amputation in 10/5 , left superficial femoral artery to peroneal
artery bypass with graft on 3/14 , a right hip arthroplasty in
11/20 , and a remote history of cholecystectomy and appendectomy.
HOME MEDICATIONS:
1. Trazodone 50 mg nightly.
2. Celexa 20 mg daily.
3. Lactulose 30 mg every day before noon
4. FiberCon one tablet.
5. Hydrochlorothiazide 25 mg daily.
6. MVI daily.
7. Synthroid 25 mcg daily.
8. Colace 100 mg twice a day
9. Novolin 30 units every day before noon , 7 units every afternoon
10. Novolin sliding scale.
11. Hydrochlorothiazide 25 mg daily.
12. Zyprexa 2.5 mg nightly.
ALLERGIES: She has an allergy to penicillin and
fluoroquinolones.
SOCIAL HISTORY: She lives in a nursing home. She has not been
ambulatory at baseline status post her left AKA. She is
wheelchair bound.
PHYSICAL EXAMINATION: At the time of admission , she was
bradycardic to 47 , otherwise blood pressure and vital signs were
stable. In general , she was confused , alert and oriented x0 but
in no acute distress. On her extremities , on the left she had an
above-knee amputation with stump intact without ulcers. Her
right foot was cool to the mid foot proximally. There was bluish
discoloration of toes one , two , and three. Pulses , there was 2+
femoral pulses bilaterally and monophasic physical therapy on the right. The
DP was not dopplerable.
HOSPITAL COURSE: The patient underwent and tolerated a right AKA on 5/30/06
without any complications , and after recovery from anesthesia was
admitted to the general care floor. Diet was advanced as
tolerated. The pain was well controlled with orally pain
medications. The patient was evaluated by physical therapy. Her
stump wound was healing with mild erythema around the drainage
site for which she was treated with perioperative ancef and
switched to one week of orally linezolid just prior to discharge.
At the time of the discharge , the patient was discharged afebrile
with vital signs stable and the wound , clean , dry and intact.
There were no complications encountered in this hospital stay.
At the time of discharge , the patient was afebrile , vital signs
stable , with the right AKA stump well healed and with mild
erythema inferior to the incision.
DISCHARGE MEDICATIONS:
1. Tylenol Elixir 1000 mg orally every 6 hours as needed pain.
2. Citalopram 20 mg orally daily.
3. Colace 100 mg orally twice a day
4. Hydrochlorothiazide 25 mg orally daily.
5. Novolog sliding scale. Please see the discharge summary for
the scale doses.
6. Lantus 20 units subcutaneously every day before noon
7. Lactulose 30 mL orally daily as needed constipation.
8. Synthroid 25 mcg orally daily.
9. Linezolid 600 mg orally every 12 hours x10 doses starting today ,
11/16/06.
10. Zyprexa 2.5 mg orally every afternoon
DISPOSITION: The patient is to be discharged to her skilled
nursing facility. Plan is for her to follow up with Dr. Derham
in one to two weeks and with her primary care physician in one to
two weeks.
ADVANCED DIRECTIVES: The patient is DNR/DNI.
eScription document: 4-6637108 CSSten Tel
CC: Rossie Mankoski MD
Pagham University Of
Neean St.
Ak No Fay
Dictated By: HALLFORD , DARBY
Attending: MANKOSKI , ROSSIE
Dictation ID 5288035
D: 11/5/06
T: 11/5/06
Document id: 863
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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761622641 | PUO | 80826409 | | 239600 | 5/13/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/12/1995 Report Status: Signed
Discharge Date: 11/9/1995
Service is GYN oncology.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old T3 , P3 ,
status post TAH , BSO , on April , for a left complex pelvic mass which was consistent with a
left ovarian adenofibroma benign , who presents now with abdominal
pain , nausea and vomiting , since 12:30 a.m. The patient doing well
at home until 12:30 a.m. on the day of admission. She was
tolerating a regular diet and taking good orally's , last meal 7 to 8
p.m. at which time she had normal bowel movement , was passing gas.
Went to sleep , awoke at 3:30 vomiting food with abdominal pain , no
urinary symptoms , no fever. The patient has had abdominal since at
least once a day for the last week , no melena , no bright red blood
per rectum. No hematemesis.
PAST MEDICAL HISTORY: Significant for
1. Polymyositis with vasculitis , steroid
dependent.
2. Insulin dependent diabetes.
3. Hypertension.
4. History of Graves' disease on no
medications.
5. Lichen simplex chronicus.
PAST SURGICAL HISTORY: 1. Deltoid muscle biopsy.
2. TAH , BSO as above.
3. Direct laryngoscopy.
MEDICATIONS ON ADMISSION: 60 units of NPH every day before noon , 10 units of NPH
every afternoon , Procardia XL 60 mg. every day , Axid
150 mg. twice a day , Prednisone 10 mg. orally every day , as well as Bactrim Double
Strength one twice a day
ALLERGIES: Include Ansaid and aspirin , the patient reports
a rash.
PHYSICAL EXAMINATION: On admission , temperature was 99 , blood
pressure of 160/80 , heart rate was in the
90's , respiratory rate of 18. Her lungs were clear bilaterally.
The heart exam was regular rate and rhythm. No murmurs , rubs or
gallops. Abdomen was diffusely tender to deep palpation , however ,
soft active bowel sounds , no rebound , no peritoneal findings. Well
healed midline incision , no drainage , no erythema. Extremities are
nontender without edema.
LABS ON ADMISSION: Included a sodium of 145 , a K of 4.5 , chloride
of 99 , bicarb of 31 , and BUN and creatinine of
9/0.7 and a glucose of 103 , white count of 10.9 , with platelet
count of 508 and a hematocrit of 41.6. Her UA showed 5 to 10 white
cells , 3 to 7 red cells and 1 + grams. KUB showed a large amount
of stool in the large bowel , no free air , a few air fluid levels ,
overall picture was not consistent with small bowel obstruction.
The patient was admitted with a question of gastroenteritis vs.
partial small bowel obstruction , which would be early. She was
admitted and kept NPO for bowel rash to receive the intravenous fluids. No
NG tube was placed. On hospital day one , the patient was
complaining of abdominal crampiness and feeling nauseated. She had
a small amount of emesis. She had spiked a temperature of 101.2.
This was felt to still either be consistent with the flu , or ileus.
A fever work up was then begun. She had blood cultures that were
sent , repeat KUB and a repeat CBC. By the afternoon , the patient
was feeling a little bit better.
Her CBC that was drawn early in the morning , had a white count of
10.38 , a hematocrit of 38.4 , and a platelet count of 422. She had
a normal amylase at 57 , normal lipase at 15 , normal LFT's with an
ALT of 18 , ASC of 20 , and LVH of 290 and alk. phos. of 81 and total
and direct bilirubin of .3 and .2. Her SMA 7 showed the sodium of
138 and a K of 4.3. Her BUN and creatinine of 8/.8 , bicarb of 28
and a glucose of 107. Her KUB and upright that was repeated still
showed a large amount of stool in the large bowel , few air fluid
levels but no change from the earlier exam.
On hospital day three , the patient's fever curve had improved. The
cultures that were previously sent were no growth so far and these
remained negative throughout the course of the hospitalization. She
was tolerating clears over the course of the morning. However ,
later on in the day , her pain returned , mainly in the right upper
quadrant , right lower quadrant. At this point , the decision was
made to check a CT scan. Of note , when the patient was admitted and
had a temperature spike , she was placed on stress post steroids
given her history of Prednisone. This was maintained throughout
her hospitalization.
Her CT scan showed that there was contrast seen through the small
bowel and colon to the rectum. There was a small section of small
bowel with wall thickening at the paraumbilical level with fluid
around it and no absence of small bowel obstruction. No edema in
the colon , with a small amount of free fluid around the liver and
the pericolic gutters. This raised concern although these findings
could be consistent with small bowl obstruction , to erase concern
about ischemia. However , the patient's exam had improved
remarkably by the morning of the 22 of June Her abdomen was soft , with
active bowel sounds and the patient was only mildly tender. Given
that the exam was not quite consistent with the CT readings , other
things were considered in the differential. Of note , the patient
had a couple of loose stools and stool cultures were sent. He does
have a history of salmonella in the past. These cultures were
negative and included SSYC and C. diff.
The concern was raised on the 24 of June that if this was not consistent
with ischemic bowel , that perhaps this was an exacerbation of her
vasculitis and could represent vasculitic changes in her SMA
circulation which had improved because the patient was placed on
stress post steroids. An angiogram was performed and the findings
were as followed: The aortoiliac artery and SMA were normal in
appearance. There was no evidence of microaneurysm , narrowing or
dilation. Because of these findings , it was felt that this was
not a picture consistent with vasculitis. She was switched from
her Hydrocortisone to her usual Prednisone dose of 10 mg. every day on
the 5 of August , the day prior to discharge.
The patient did well overnight , tolerated clears in the morning ,
and by lunch time , was able to eat a full diet. Of note , the
patient the night prior to discharge , had a complaint of some calf
pain which was transient in nature. However , although her exam was
unremarkable , lower extremity noninvasives were done and these were
negative. So the patient is being discharged home in good
condition. She is tolerating a regular diet.
MEDICATIONS ON DISCHARGE: Include Insulin , Procardia XL 60 mg. every
d , Axid 150 mg. twice a day , Prednisone 10 mg.
every day
Dictated By: SHANDA BARIS , M.D. BG4
Attending: GERRI S. JIAU , M.D. VR99
MK658/3064
Batch: 0427 Index No. 7EWAVL912E D: 4/5/95
T: 1/19/95
Document id: 864
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
N |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
- |
- |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
601453381 | PUO | 58735436 | | 688357 | 3/11/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/29/1994 Report Status: Signed
Discharge Date: 2/29/1994
PRINCIPLE DIAGNOSIS: HYPOTENSIVE EPISODE.
SIGNIFICANT PROBLEMS: 1. End stage renal disease on chronic
hemodialysis. 2. Mild mental retardation.
3. Movement disorder ( tics ). 4. Status post parathyroidectomy.
5. Partial thyroidectomy. 6. Status post partial gastrectomy for
peptic ulcer disease. 7. History of MRSA from wound in 1988.
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
gentleman with end stage renal disease
on chronic hemodialysis who was admitted status post fall and
seizure. The patient's end stage renal disease is thought to be
secondary to hypertension , although he has never had a renal
biopsy. He has been on hemodialysis since 1987 , having dialysis
three times a week. His dry weight is about 85 to 86 kilos. His
dialysis has been complicated by multiple episodes in the past of
hypotension and seizure activity occurring after dialysis. These
episodes occur about once a month.
On the day of admission , the patient came home from routine
hemodialysis where he was ultrafiltered 5.5 kilograms of fluid and
his final blood pressure after dialysis was 100/60. At noon , the
patient went home , ate lunch and went up to his room. At that time
he complained of feeling dizzy and sitting on the edge of the bed
told his uncle that he was not feeling well and then slumped onto
the floor. He does not believe that he hurt himself , i.e. , did not
hurt his head , although he did complain of some right foot pain.
He was still conscious as his uncle lifted him back to bed and then
an ambulance was called.
After a few minutes , the patient lost consciousness , rolling his
eyes back with some facial twitching bilaterally and tongue
retraction. This episode lasted about five minutes. There was no
tongue biting , no urinary incontinence or bowel incontinence. The
patient gained full recovery of his alertness upon waking up but
was a bit diaphoretic. His aunt checked his vital signs which were
blood pressure 70/40 , pulse 79. The patient had also complained of
chest pain for a few minutes prior to his episode. When the EMTs
arrived , the patient was alert and oriented times three , cold and
clammy , temperature 98.6 , pulse 89 , respirations 26 , blood pressure
82/60.
The patient was brought to the emergency room and was orthostatic
by blood pressure ( 10 points ) from lying to sitting. He was given
500 ccs of normal saline and was no longer orthostatic , comfortably
sitting up in the bed. At about 9:00 p.m. he complained of feeling
dizzy and became diaphoretic while trying to stand up. The patient
was again brought into bed. He became unresponsive for one minute
with his eyes rolled up and some bilateral face twitching. This
episode only lasted about one minute. The patient was admitted for
observation.
Past medical history reveals the following: 1 ) Mild mental
retardation since about 10 years ago. 2 ) Movement disorder ( tics )
on Stelazine. 3 ) End stage renal disease thought to be secondary
to hypertension. 4 ) Status post parathyroidectomy for secondary
hyperparathyroidism. 5 ) Partial thyroidectomy for goiter
incidentally found at surgery. 6 ) Status post partial gastrectomy
for peptic ulcer disease in the 1960's. 7 ) History of MRSA from
wound in 1988. 8 ) Hepatitis B surface antibody positive and
hepatitis C virus positive. Medications on admission: Calcium
carbonate , 1250 mg orally three times a day; nephrocaps , 1 orally every day; DHT , 0.2 mg orally every day;
Stelazine , 2 mg orally three times a day There are no known allergies. Social
history: The patient was a former smoker and has a history of
alcohol abuse but no intravenous drug use. He lives with his aunt and uncle
and is mildly retarded.
PHYSICAL EXAMINATION: On physical examination , vital signs
showed a lying blood pressure of 96/60 ,
pulse 80 , sitting up blood pressure 104/70 , pulse 96 , temperature
97.5 , O2 sat 95% on room air. The patient was a well nourished ,
black male in no apparent distress. HEENT exam was unremarkable.
Neck showed JVD of 4 cms. No lymphadenopathy. Chest was clear to
auscultation. Heart revealed S1 , S2 , normal rate and rhythm with a
1/6 systolic murmur best heard at the left upper sternal border.
No CVA tenderness. Abdomen was soft , nontender , no masses. Bowel
sounds were positive. The patient was guaiac negative with brown
stool. Extremities revealed a tender , edematous dorsal aspect of
right foot , with full range of motion at the ankle joint. Left
extremity benign. Neuro exam was grossly nonfocal.
LABORATORY DATA: On admission , sodium 142 , potassium 4.8 ,
chloride 94 , bicarb 32 , BUN 38 , creatinine 8.6 ,
glucose 168. A CBC revealed white count of 8.82 , hematocrit 35 ,
platelets 246. Calcium was 9.7. Chest x-ray revealed mild
pulmonary vascular redistribution with no significant CHF and no
infiltrates. Ankle x-rays on the right revealed no fracture or
dislocation. EKG revealed normal sinus rhythm at a rate of 76 ,
axis 2 degrees , some 1 mm ST elevations in I and AVL , T-waves flat
in lead III. The slight elevations in ST were consistent with EKG
on 1/9/94.
HOSPITAL COURSE: The patient was observed overnight and put on
an orally renal diet , checking orthostatics
frequently. The patient remained asymptomatic throughout his
hospital course and remained hemodynamically stable with no
orthostasis. The patient was evaluated by the renal service who
assessed that this episode was most likely secondary to the
extensive fluid removal from dialysis leading to a low blood
pressure. In addition , they noted that seizures and orthostasis
are often seen status post dialysis in some patients. They
recommended no further work up of this seizure episode and
recommended no prophylaxis with an antiepileptic. The patient
underwent dialysis again on 6/5/94 per schedule. After this
dialysis , the patient was asymptomatic , not orthostatic and did not
complain of any light headedness.
As the patient complained of right foot pain , right foot films were
obtained which revealed nondisplaced fractures of the second ,
third , fourth and fifth metatarsal bones. Orthopaedic service was
consulted who put the patient in a bivalve cast with a toe plate.
Physical therapy was consulted. The patient was allowed to sit in
a chair and engage in nonweight bearing activities. His foot was
elevated on three pillows for 72 hours. The patient remained
hemodynamically stable and now awaits placement into a skilled
nursing facility for rehabilitation , given his casted right lower
leg.
DISPOSITION: The patient will be discharged on his medications
from admission which include: 1 ) Nephrocaps , 1 orally
every day 2 ) Calcium carbonate , 1250 mg orally three times a day 3 ) DHT , 0.2 mg orally every day
4 ) Stelazine , 2 mg orally three times a day The patient will be seen again in
orthopaedics clinic on Friday , 5/13/94 at 9:15 a.m. The patient is
discharged in stable condition to a rehab/skilled nursing facility
per wishes of patient , family and per recommendation of physical
therapy.
Dictated By: COLLEEN TOHER , M.D.
Attending: CHARLEEN A. IVEL , M.D. UM17
AP881/2794
Batch: 068 Index No. HSVC241ZGI D: 5/6/94
T: 5/6/94
Document id: 865
| Target |
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| output/system_intuitive_annotation.xml | intuitive |
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753663912 | PUO | 24902443 | | 6644550 | 10/17/2006 12:00:00 a.m. | noncardiac chest pain , poorly controlled DM | | DIS | Admission Date: 3/17/2006 Report Status:
Discharge Date: 7/23/2006
****** FINAL DISCHARGE ORDERS ******
HERTZBERG , DEON 702-66-74-8
Shing
Service: MED
DISCHARGE PATIENT ON: 2/18/06 AT 03:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
ATENOLOL 50 MG orally DAILY HOLD IF: SBP<100 , HR<60
DOVONEX OINT 0.005% ( CALCIPOTRIENE 0.005% ) CREAM TP twice a day
Instructions: apply to psoriatic lesions
Number of Doses Required ( approximate ): 5
LANTUS ( INSULIN GLARGINE ) 35 UNITS subcutaneously every day before noon
Starting Today ( 2/29 )
LISINOPRIL 5 MG orally DAILY HOLD IF: SBP < 100
ATIVAN ( LORAZEPAM ) 0.5 MG orally every 6 hours as needed Insomnia , Anxiety
METFORMIN 1 , 000 MG orally twice a day
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Starting Today ( 2/29 ) Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/18/06 by
KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 2/18/06 by
KATZER , CALANDRA , M.D. on order for ZOCOR orally ( ref # 804702147 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician DR RASPOTNIK ( 113 ) 358-0410 7/17/06 @ 10:40 a.m. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
noncardiac chest pain , poorly controlled DM
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , poorly controlled type II DM x 10 years , psoriasis
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Exercise Stress Test
BRIEF RESUME OF HOSPITAL COURSE:
CC: high sugars/atypical chest pain
--
HPI: 56 year-old DM male with poorly controlled sugars
presents with atypical CP and hyperglycemia x several months. The
patient was in his USH when , around noon the day of admission , he
found his blood sugar to be 520. He had no symptoms such as
sweating , tremor , blurry vision , HA , N/V. In addition , over the past
several months , he has had chest pain which does not radiate several
days a week. The pain usually comes on in the morning/at
rest and has not increased in frequency. It is not associated with
N/V/diaphoresis. He has HTn , but does not smoke , has no family hx of
ACS , and is not known to have hyperchol In the ED , his VSS and
BS was 400s. EKG was WNL. He was give nitro , ASA , lopressor , insulin ,
ativan and mag gluconate in the ED and sent to the floor.
--
PMH:HTN , psoriasis , DM II x 10 yrs
--
SHx: former janitor. From Dataarv 3-4 beers 1-2x/week , no smoking , no
drugs
--
Fam Hx: sister-DM , no CAD
--
All: NKDA
--
Meds on admission: ASA 81 , metformin 1000 twice a day , vit B1 , atenolol 50
every day , vit E , lantus 30U qAM , ativan 0.5 mg every bedtime as needed insomnia , dovonex
0.005% cream
--
Daily status VS: 98.1 76 142/90 20 98% RA Gen: NAD CV: S1 , S2 , S4. No
M/R/G Pulm: CTA B Abd:soft , NT , ND , +BS Ext: WWP. No C/C/E
--
Labs/Tests: Cardiac enzymes neg , besides sugar , other labs WNL
CXR: old L. sided rib fxs. ?new left rib fx. No acute cardiopulm.
process
EKG: NSR.
--
A/P 56 year-old Type II DM with poorly controlled sugars with atypical CP
and asymtomatic hyperglycemia to 520. On ETT , able to exercise only 2'42"
on Standard Bruce protocol , achieving HR of 130 ( on atenolol )--stopped
due to leg fatigue and shortness of breath , no chest pain , no EKG
changes.
--
1.CV ( P ) ?LVH on cardiac exam. no signs of CHF. Continued b-blocker. ( I )
CP atypical for ACS. EKG wnl. Ruled out for MI. Added ACE and statin to
regimen , given ongoing cardiac risk factors , poorly controlled DM. ( R )
no issues.
2. Endo - Type II DM with poorly controlled sugars. Lantus lowered first
night because NPO ( 30 U ). Gave insulin SS and 4 mg qAC. Continued
metformin. Will discharge on 35U lantus qAM , will need to f/u with primary care physician
Dr. Raspotnik for further titration.
3. Skin - continue dovonex for psoriasis
4. Neuro - ?anxiety. continue ativan as needed for insomnia. No evidence of EtOH
withdrawal during hospitalization.
6.FEN - low salt , ADA diet.
7. Ppx - lovenox
Contact: 1444387749 ( family member number )
FULL CODE
ADDITIONAL COMMENTS: Regresa al hospital para presion o dolor del pecho.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KATZER , CALANDRA , M.D. ( TR28 ) 2/18/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 866
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
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873524333 | PUO | 65864379 | | 070527 | 10/14/2001 12:00:00 a.m. | FAILED BYPASS GRAFT | Signed | DIS | Admission Date: 8/4/2001 Report Status: Signed
Discharge Date: 9/30/2001
PROCEDURE: Left lower extremity revascularization.
HISTORY OF PRESENT ILLNESS: This is a 63 year old male with a
history of peripheral vascular disease
status post a left femoral to peroneal bypass graft on 4/19/01 for
left lower extremity rest pain. He presents with eleven days of
left lower extremity swelling. Over the prior eight days the
patient noticed pain and pinkish discoloration of the left foot.
The patient also noticed occasional left foot coldness which was
relieved with dependent positioning.
PAST MEDICAL HISTORY: Peripheral vascular disease. Hypertension.
Diabetes mellitus. Aortic stenosis.
PAST SURGICAL HISTORY: Left femoral to peroneal bypass in July of
2001. Right femoral to peroneal bypass in
September of 1999. Right fifth toe amputation in September of 1999. Multiple
wrist surgeries , including a failed left wrist fusion.
ALLERGIES: No known drug allergies.
MEDICATIONS: He is on outpatient medications of Lopressor 25 mg
orally twice a day , Hydrochlorothiazide 50 mg orally every day ,
Glipizide 10 mg every day before noon and 5 mg every afternoon , Simvastatin 10 mg orally every bedtime ,
Amlodipine 5 mg orally every day , aspirin 325 mg orally every day , Colace 100 mg
orally twice a day , and as needed Percocet.
HOSPITAL COURSE: The patient was admitted on 10/21/01 for presumed
failed left femoral to peroneal bypass graft.
The patient was preopped for revision of his bypass graft and , on
1/26/01 , the patient was taken to the operating room for a femoral
to posterior tibial bypass graft. The patient tolerated the
procedure well but immediately postoperatively the patient was
noted to have non-Dopplerable signals in his left foot. The
patient was brought back to the operating room at which time the
significant sized clot was found in the distal anastomosis of the
graft which was removed. Again , the patient was returned to the
recovery room and , in the ensuing hours , the patient again lost all
Dopplerable signals in his left foot. On postoperative day #1 the
patient returned one more time to the operating room for revision
of his left bypass graft. The patient tolerated the procedure well
and had strong Dopplerable dorsalis pedis pulse and posterior
tibial pulse throughout the remainder of his hospital stay. The
patient was kept on perioperative Ancef antibiotics.
On postoperative day #0 the patient was found to be in respiratory
distress. Chest x-ray revealed flash pulmonary edema. Cardiology
consult was obtained at that time and an echocardiogram revealed an
ejection fraction of 35 percent with moderate aortic stenosis and
regurgitation. The patient ruled in by enzymes for a myocardial
infarction. The patient was kept on beta blocker for goal heart
rate less than 75 and was started on Digoxin. Cardiology also
recommended the addition of an Ace inhibitor for further blood
pressure control. The patient remained stable. He remained in the
Surgical Intensive Care Unit for the first three days
postoperatively at which time the patient was medically stable and
transferred to a surgical floor and monitored bed. Repeat
echocardiogram on postoperative day #4 and #3 was unchanged from
his prior echocardiogram , again , revealing an ejection fraction of
35 percent with global hypokinesis , severe aortic stenosis , and
moderate aortic regurgitation. Cardiology continued to follow the
patient throughout his hospital stay. They recommended the patient
return for cardiac catheterization following a short stay in acute
rehabilitation. Otherwise the patient progressed well. He did
develop a small amount of erythema in his left lower extremity
incision site. He was restarted on antibiotics and the erythema
slowly regressed over the ensuing three days. Otherwise the
patient's incisions to his right arm , left leg , and right leg all
were clean , dry , and intact with staples.
Physical therapy consult was obtained and the patient was able to
ambulate with the assistance of a walker. The patient continued to
progress well. He tolerated a regular diet and ambulated and
voided without difficulty. On postoperative days #9 and #8 , the
patient was accepted to acute rehabilitation at which time he was
transferred. The patient is in stable condition.
DISPOSITION: LEVEL OF ACTIVITY: He should continue working with
physical therapy to increase his mobility. DIET: He
has no restrictons of diet. Please keep his left lower extremity
elevated when he is resting in bed or in chair. Please call
I Warho Hospital if he experiences fevers , chills , or
redness or discharge from the surgical site. FOLLOWUP: The
patient is to follow-up with Dr. Abson in the vascular clinic.
Please call I Warho Hospital vascular clinic to arrange
for an appointment. DISCHARGE MEDICATIONS: He is discharged on
enteric coated aspirin 325 mg orally every day , Captopril 25 mg orally
three times a day , Digoxin 0.25 mg orally every day , Glipizide 10 mg orally every day before noon and
5 mg orally every afternoon , Hydrochlorothiazide 50 mg orally every day , Motrin 600
mg orally every 6 hours as needed pain , Lopressor 50 mg orally three times a day , Percocet 1 to
2 tablets orally q3 - 4h as needed pain , Zantac 150 mg orally twice a day ,
Simvastatin 10 mg orally every bedtime , Oxycontin 40 mg orally every 12 hours , Keflex 500
mg orally four times a day for three additional days.
Dictated By: GAYLENE FANIEL , M.D. PS42
Attending: NATHAN J. ABSON , M.D. YL03
XM249/1002
Batch: 5667 Index No. TVVSEJ5LJ3 D: 2/8/01
T: 2/8/01
Document id: 867
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
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OSA |
PVD |
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750395034 | PUO | 51756156 | | 183898 | 10/29/2002 12:00:00 a.m. | HEPATIC ENCEPHALOPATHY | Signed | DIS | Admission Date: 11/18/2002 Report Status: Signed
Discharge Date: 9/1/2002
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old status
post a massive gastrointestinal bleed
in April of 2001 who was transferred to the Totin Hospital And Clinic
Hospital for a TIPS procedure which failed. She proceeded to go to
surgery at that time for a splenorenal shunt. She was recently
discharged from the Pagham University Of on August ,
2002. During the hospitalization , she had a complicating course
with encephalopathy , but she was able to be controlled with
lactulose and discharged to rehabilitation. She at that time also
had complications with infections for which she completed a course
of antibiotics. At rehabilitation , she was doing fairly well , but
her ammonia had been high. The highest was 196 on March ,
2002. The patient has also had increased confusion , increased
abdominal girth. When the daughters went in to visit her today ,
she was completely disoriented , complaining of abdominal pain. The
daughters also report subjective fevers and chills. At the
rehabilitation , her vital signs were notable for a blood pressure
of 94/60 , temperature 99.2. Per the daughters , the diet had not
been followed at rehabilitation and she was eating hot dogs. She
was also given benzodiazepines for sleep , up to 60-75 mg every day of
Oxazepam. Per report , she had increased confusion and more acutely
in the last two days. In the emergency room on arrival , her blood
pressure was in the 120s , 98% on room air , she was febrile. She
was given levofloxacin , Flagyl and ampicillin. A Gastrointestinal
consult was called.
PAST MEDICAL HISTORY: Cirrhosis secondary to hepatitis C , grade 4
esophageal varices , encephalopathy , status
post a frontal craniotomy , status post a motor vehicle accident
with a subdural hematoma , peptic ulcer disease.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER: Spironolactone 100 mg orally twice a day ,
olanzapine unknown dose , Flagyl which she
had completed her course for Clostridium difficile , albuterol and
Atrovent nebulizers , lactulose 120 mg every 6 hours , Lopressor 50 mg
three times a day , Serax 30 mg , Duragesic patch , Neomycin 2 grams four times a day ,
Oxazepam 30 mg every bedtime and 15 mg every 8 hours as needed
SOCIAL HISTORY: The patient lives with one of her daughters. She
has a remarkable history of tobacco for 30 years ,
one pack per day , recently quit.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.1 , heart rate
99-120 , blood pressure 94-149/55-71 , oxygen
saturation 99% on room air. GENERAL: She was a well-nourished ,
well-developed lady who was confused and agitated. HEENT:
Remarkable for icteric sclera. LUNGS: Clear. CARDIOVASCULAR:
She had a regular rate and rhythm , S1 and S2 normal. Jugular
venous pressure was flat. ABDOMEN: Positive for bowel sounds ,
soft , but distended. She reports tenderness on palpation. RECTAL:
Guaiac-positive per emergency department. EXTREMITIES: Her right
lower extremity had erythema , painful to the touch , no warmth and
no cords. NEUROLOGICAL: Positive for asterixis. She was alert
and oriented to person , but not to time and confused about the
place. She was unable to carry on a conversation and unable to
keep attentive. Her strength was 5/5 and her sensation was intact.
LABORATORY: Laboratory data was remarkable for a sodium of 130 ,
potassium 4.9 , chloride 102 , bicarbonate 17 , BUN 9 ,
creatinine 0.8 and glucose 100. Her ALT was 16 , AST 72 , alkaline
phosphatase 118 , amylase 15 and lipase 33. Her ammonia level was
45 , albumin 3.2 , total bilirubin 2.4. Her hematocrit was 29.1.
Her INR was 1.4. EKG was normal sinus rhythm. Abdominal CT scan
showed that she had no abscess , no obstruction , no acute abdominal
process.
HOSPITAL COURSE: 1 ) Gastrointestinal: At the time of admission ,
it was a confusing picture for increased
abdominal girth , however the CT scan showed that she had very
little ascites and on examination , little tenderness. Therefore ,
she got a paracentesis which was negative for spontaneous bacterial
peritonitis. The patient was treated with cefotaxime and Flagyl
for possible spontaneous bacterial peritonitis , continued on the
lactulose and her diuretics. However , the patient much improved
from the gastrointestinal standpoint and after resolution of her
infectious picture ( see below ) , the patient was doing incredibly
well with spironolactone and Lasix. She has not been able to
tolerate her beta blocker secondary to hypotension. During her
hospitalization , her hematocrit has been stable. A
gastrointestinal consult was obtained. I appreciate their input.
They recommend to follow up with the Transplant Team. She has an
appointment to see the Transplant Team on July , 2002. At this
time , it is recommended that she begin to get work-up for a liver
transplant. However , her hematocrit and her INR remained stable
throughout the hospitalization.
2 ) Infectious disease: The patient was negative for spontaneous
bacterial peritonitis , however on the second day of
hospitalization , she grew out 4/4 bottles with gram positive cocci
in pairs which speciated to be Streptococcus Group B. Therefore ,
the antibiotics were tailored and she was started on nafcillin
intravenously. The patient then had a PICC line placed and she
will continue treatment of two weeks with intravenous penicillin.
The patient has been doing very well with resolution of her
erythema. Infectious Disease Service consult was obtained. I
appreciate their input. They suggested two weeks of intravenous
penicillin.
3 ) Cardiovascular/hematology: Given the swelling of the leg , the
patient had lower extremity ultrasounds which were negative for
clot. Otherwise , she remained in normal sinus rhythm and no
symptoms of congestive heart failure.
4 ) Psychiatry: The patient was very confused , most likely
delirium. Psychiatry input was greatly appreciated. Another
reason for her confusion was the fact that she was getting much
benzodiazepines at her rehabilitation before. She was weaned off
her benzodiazepines and started on olanzapine and titrated up as
tolerated. Therefore , we highly recommend avoiding benzodiazepines
in this patient and continue with olanzapine which can take as needed
as well as needed.
5 ) Vascular: Vascular Surgery followed this patient during her
hospitalization and deemed that her splenorenal shunt was working
well with no evidence of leak.
DISPOSITION: The patient is sent to rehabilitation for further
treatment and finishing of her antibiotic course. At
this point , she has requested a new primary care physician and this
will be myself. I will follow her with an appointment in July ,
which I have scheduled for her.
MEDICATIONS ON DISCHARGE: Nexium 20 mg orally every day , olanzapine 5
mg orally every PM and olanzapine 2.5 mg orally
every 8 hours as needed , Atrovent inhalers , Azmacort , spironolactone 100 mg
orally twice a day , penicillin 3 million units intravenously every 4 hours for a
complete course of two weeks , Nico-Derm 14 mg a day topical ,
Lopressor 50 mg orally three times a day which is to be held if her systolic
blood pressure is less than 100 , lactulose 30 ml orally three times a day ,
Motrin as needed for pain and Lasix 40 mg orally every day.
Dictated By: ENA MARLATT , M.D. UJ77
Attending: DEANDRA L. GILFOY , M.D. HC88
HL267/511640
Batch: 8014 Index No. IPJKOC2G96 D: 10/12/02
T: 10/12/02
Document id: 868
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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496796627 | PUO | 21962485 | | 427949 | 2/23/2001 12:00:00 a.m. | dvt , pseudogout | | DIS | Admission Date: 10/19/2001 Report Status:
Discharge Date: 6/17/2001
****** DISCHARGE ORDERS ******
ANCISO , RAMONA 352-11-58-6
La Ave , Des , Mississippi 89963
Service: MED
DISCHARGE PATIENT ON: 10/10/01 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RESTER , TIEN TILDA , M.D.
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
as needed headache , joint pain
ALLOPURINOL 100 MG orally every day
ATENOLOL 50 MG orally twice a day HOLD IF: sbp<90 , heart rate<60
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HEPARIN 5 , 000 U subcutaneously twice a day
NPH INSULIN HUMAN ( INSULIN NPH HUMAN ) 15 U subcutaneously every day before noon
REG INSULIN HUMAN ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously twice a day Call HO If BS > 400
For BS < 200 give 0 Units reg subcutaneously
For BS from 201 to 250 give 0 Units reg subcutaneously
For BS from 251 to 300 give 0 Units reg subcutaneously
For BS from 301 to 350 give 8 Units reg subcutaneously
For BS from 351 to 400 give 10 Units reg subcutaneously HOLD IF: fs<300
Instructions: please check fs twice a day
OMEPRAZOLE 40 MG orally twice a day
PREDNISONE Taper orally
Give 15 mg every day X 1 day( s ) ( 5/17/01 -01 ) , then ---done
Give 10 mg every day X 1 day( s ) ( 4/29/01 -01 ) , then ---done
Give 5 mg every day X 1 day( s ) ( 9/4/01 -01 ) , then ---done
GLUCOTROL XL ( GLIPIZIDE XL ) 10 MG orally every day
Starting Today ( 6/11 ) HOLD IF: npo
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: Not Applicable
ALLERGY: Penicillins , Aspirin , Nsaid's
ADMIT DIAGNOSIS:
pseudogout , dvt
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
dvt , pseudogout
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ugib ( duod ulcer second to nsaid's ) non-sustained v-tah gout and
hyperuricemia htn , ?cad history of chole arthritis periph neuropathy
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
84 year-old M with hx iddm , htn , gout , recent ugib
secondary to duod. ulcer now p/with R DVT and polyarticuar arthritis. On
10/25 patient presented to TH with UGIB secondary to duod. ulcer
secondary to vioxx use , ulcer was cauterized. During his
hospitalization his allopurinol was d/c. He also had incr R knee and
elbow pain and swelling.
He was d/c to rehab fascilitiy where his bs
were difficutl to control. He was admitted to the
PUO for further management. Leni's revleaed
R peroneal DVT. His knee was tapped for
straw colored fluid c/with pseudo-gout. WBC=17.
Pseudo-gout: . Rx with prednisone taper and therapeutic tap of knee jo
int. He has minimal pain now , is able to weight bear on R knee. DVT:
will manage conservatively secondary to recent UGIB. Follow-up
LE u/s on 9/27 and 6/26 have shown no extension of the DVT.
Treat prophylactically with heparin subcutaneously , pneumoboot to lle. DM: Mr. Karima Dummermuth has had elevated blood sugars while on the prednisone taper.
He was initially managed with nph and czi ss but his prior orally
agent of Glucotrol XL was re-started and supplemented with am nph. His
glucophage is being held secondary to renal insufficency
( creatnine=1.3 ). Urinary sx's- Ua wnl , uculture is pending.
ADDITIONAL COMMENTS: patient's DVT is being managed with out anti-coagulation secondary to recent
UGIB. Serial u/s have shown no extension of DVT. If patient ambulating without
ut incr LE symptoms will not need additional LE u/s. patient's insulin
regimen will need to be adjusted at rehab as he was on prednisone here
which affected his sugars.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: PETRUCCELLI , LEAN LIZZIE , M.D. ( ZX64 ) 10/10/01 @ 08
****** END OF DISCHARGE ORDERS ******
Document id: 869
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
197067870 | PUO | 51185078 | | 8774437 | 6/21/2006 12:00:00 a.m. | same | | DIS | Admission Date: 1/1/2006 Report Status:
Discharge Date: 9/7/2006
****** FINAL DISCHARGE ORDERS ******
FUSI , HORTENSIA 400-71-92-1
A
Service: OTO
DISCHARGE PATIENT ON: 10/24/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BRAUNSTEIN , MAUREEN TOBIAS
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
as needed Pain , Headache , Temperature greater than:101.4
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
as needed Shortness of Breath
DILTIAZEM EXTENDED RELEASE 360 MG orally DAILY
HOLD IF: SBP<110 , HR<60 Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY Starting IN a.m. ( 7/28 )
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally DAILY
HOLD IF: potassium > 4.5
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 1/7/06 by
LANGSETH , MURIEL N. , M.D.
on order for LISINOPRIL orally ( ref # 076262319 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: home meds
LISINOPRIL 40 MG orally DAILY HOLD IF: SBP<100
Alert overridden: Override added on 1/7/06 by
LANGSETH , MURIEL N. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: home meds
METFORMIN 850 MG orally twice a day
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
PREDNISONE 30 MG orally every day before noon
DIET: No Restrictions
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Braunstein 1 week ,
ALLERGY: Cephalosporins , CEFAZOLIN SODIUM
ADMIT DIAGNOSIS:
Paraphargyngeal mass
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
sleep apnea ( sleep apnea ) asthma ( asthma ) obestity
gerd ( esophageal reflux ) obstructive lung disease htn
( hypertension ) dm ( diabetes mellitus ) migraine ( migraine
headache ) asthma ( asthma )
OPERATIONS AND PROCEDURES:
1/7/06 BRAUNSTEIN , MAUREEN TOBIAS
TOTAL PAROTIDECTOMY FACIAL NERVE DISSECTION
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Removal of JP
D/C staples
BRIEF RESUME OF HOSPITAL COURSE:
49yoF presented to PUO on 1/7/06 for transcervical excision of deep lobe
parotid mass and left submandibular gland. The patient tolerated all
procedures without complication , for details please see operative note.
The post-operative period has been uneventful. Patient received periop
antibiotic prophylaxis and DVT prophylaxis throughout hospitilization. patient
was placed on home CPAP setting , diet was advanced as tolerated and the
JP drain and staples were removed on POD3. Patient is being discharged:
afebrile , tolerating regular diet without nausea/vomiting , pain well
controlled on orally medication , voiding , incision clean , dry and intact ,
and ambulating well. Currently and on POD3 , patient and staff agree patient is
ready for discharge home with f/u with Dr. Braunstein in 1-2 weeks.
ADDITIONAL COMMENTS: Resume all home medications. Seek immediate medical attention for fever
>101.5 , chills , increased redness , swelling , bleeding or discharge from
incision , chest pain , shortness of breath , difficulty breathing , severe
headache , increasing neurological deficit , or anything else that is
troubling you. No strenuous exercise or heavy lifting until follow up
appointment , at least. Do not drive or drink alcohol while taking
narcotic pain medications. Call your surgeon to make follow up
appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WANKUM , SHERISE AYANNA ( VS19 ) 10/24/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 870
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
- |
- |
N |
N |
N |
Y |
Y |
N |
Y |
N |
Y |
N |
N |
172100234 | PUO | 34013384 | | 3230656 | 7/20/2005 12:00:00 a.m. | back pain , UTI | | DIS | Admission Date: 2/7/2005 Report Status:
Discharge Date: 7/13/2005
****** FINAL DISCHARGE ORDERS ******
KAZUNAS , JULIET 292-57-27-6
Noo
Service: MED
DISCHARGE PATIENT ON: 3/22/05 AT 12:30 PM
CONTINGENT UPON ekg
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHNURBUSCH , JEFFERSON J. , M.D. , J.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day Starting Today ( 5/30 )
Instructions: FOR YOUR HEART
Alert overridden: Override added on 5/28/05 by CISTRUNK , EDGARDO JUAN , M.D. , PH.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 738890921 )
patient has a POSSIBLE allergy to IBUPROFEN; reaction is Hives.
Reason for override: md aware
CIPROFLOXACIN 250 MG orally every 12 hours X 5 Days
Starting Today ( 5/30 )
Instructions: FINISH ANTIBIOTICS TO TREAT YOUR URINARY
TRACT INFECTION Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
Starting Today ( 5/30 ) Instructions: STOOL SOFTNER
FOLATE ( FOLIC ACID ) 1 MG orally every day
GLIPIZIDE 5 MG orally every 12 hours
Starting AT 9:00 PM ON 9/26 ( 5/30 )
Instructions: for your diabetes
LISINOPRIL 20 MG orally every 12 hours
Override Notice: Override added on 5/28/05 by
GIRARDI , ABE E. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
581856845 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: monitoring
Previous override information:
Override added on 5/28/05 by GIRARDI , ABE E. , M.D.
on order for KCL intravenous ( ref # 298025072 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: monitoring
Previous override information:
Override added on 5/28/05 by LALATA , JOHNETTA B. , M.D.
on order for KCL SLOW RELEASE orally ( ref # 541180602 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 5/28/05 by CISTRUNK , EDGARDO JUAN , M.D. , PH.D.
on order for K-LOR orally ( ref # 666225592 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 5/28/05 by LALATA , JOHNETTA B. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
NIFEREX-150 150 MG orally twice a day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 5/28/05 by LALATA , JOHNETTA B. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: requires
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally every 24 hours Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KCL SLOW RELEASE 20 MEQ orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 5/28/05 by LALATA , JOHNETTA B. , M.D. on order for LISINOPRIL orally ( ref # 436043190 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
LIPITOR ( ATORVASTATIN ) 40 MG orally every bedtime
Starting Today ( 5/30 ) Instructions: for your cholesterol
Override Notice: Override added on 5/28/05 by LALATA , JOHNETTA B. , M.D.
on order for MVI THERAPEUTIC orally ( ref # 818823542 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: requires
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day Starting IN a.m. ( 7/10 )
Instructions: to prevent blood clots
CANDESARTAN 16 MG orally every day Starting Today ( 5/30 )
Instructions: for your blood pressure
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day Starting Today ( 5/30 )
Instructions: for your breathing
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
Instructions: FOR LEG SWELLING
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 45 MG orally every 12 hours
Starting AT 5:00 PM ON 5/10/05 ( 5/30 )
Instructions: for pain
PERCOCET 1 TAB orally Q4-6 hours as needed Pain
Instructions: for breakthrough pain not managed by
oxycontin
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
Instructions: for your breathing
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours as needed Wheezing
Instructions: for your breathing
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1-2 PACKET orally every day as needed Constipation
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain
Instructions: if pain is not relieved by nitro , call 911.
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Er, Health office will call you. If you do not hear from the office , call: 161-856-3442 ,
Dr. Neale , Renal 7/9 at 3PM scheduled ,
Dr. Reisman , Cardiology 8/10 at 12:30 PM scheduled ,
ALLERGY: Erythromycins , Penicillins , CLINDAMYCIN , IBUPROFEN
ADMIT DIAGNOSIS:
nephrolithiasis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
back pain , UTI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of IMI Non-cardiac chest pain , Lumbosacral disc dz Chronic pain syndrome
Migraines , HTN , Anxiety Depression ALLERG:PCN , Erythro , Tetracy
history of PTCA 1/11 FOR OCC RCA POSITIVE ETT/MIBI 93: ANT/LAT WALL ISCHEMIA
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT abd
BRIEF RESUME OF HOSPITAL COURSE:
CC: 59F with CAD recently RCA/OM1 stent admitted with
nephrolithiasis for pain control. HPI: hx chronic pain syndrome on
percocet and morphine ( also for OA ) , who recently had R heart
cath and PCI 1 wks ago. During that admission , was noted to have
hematuria --> renal f/u. C/O L flank pain x 2 days , planned for CT.
In Cards clinic on DOA , noted poor pain control. admitted by ED for
pain control. Got ASA , no IVF. morphine. PMH: chronic pain syndrome ,
FM on mscontin three times a day CHF , diastolic dysfunction. OSA , CPAP. HTN , CAD ,
chol , mult MI , stent x 3 1 wk ----------
EVENTS: in ED OBS appeared comfortable on dilaudid and
morphine. ----------
STATUS: resumed on home pain regimen , required additional 25 mg oxycodone
overnight.
--------- STUDIES:
I- CT showed: kidney stones on R , by CT ureter in ED , no hydro.
stones are old , not clear that this is causing her current pain.
-------- IMP: 59F with CAD and recent PCI now with
nephrolithiasis and pain control problems. PLAN:
1. CV: gave lasix to increase filtration and UOP , while
increasing IVF to keep up with euvolemic state.
- cont outpt regimen - asa , statin , bb , acei. 2. GU/RENAL: increase
UOP with IVF and Lasix. 3. ID: does not appear to have systemic
infection. Inflammation of ureter. tx UTI ( UA+ ) with cipro 250 mg orally x 7
days. Started 4/23 , ending 3/6
4. FEN: Diabetic , low salt , low fat/cholesterol diet 5. Pain control with
home regimen of MScontin and
oxycodone. Switched to 45 mg oxycontin orally every 12 hours instead of MS contin upon
discharge as patient requiring frequent as needed for breakthrough. Of note ,
back pain crosses lumbosacrum , radiates down legs bilaterally , and to
groin bilaterally. This distribution is consistent with a
more mucskuloskeletal etiology of pain , rather than R-sided
nephrolithiasis.
ADDITIONAL COMMENTS: You must continue your medications , especially aspirin and plavix to
protect your stent. Continue the Ciprrfloxacin for your UTI. Follow up
with your doctors or call to reschedule the appointments. Call your
doctor or return to the ER if you have fever , chills , sweats , worsening
shortness of breath , chest pain , or any other problems.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow-up U/A.
2. Consider CT scan to R/O renal CA given hx of microscopic hematuria
3. Consider cystoscopy to R/O bladder CA given above.
4. Med check
No dictated summary
ENTERED BY: WESTBERG , KAMALA M. , M.D. , PH.D. ( QE231 ) 3/22/05 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 871
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
921778812 | PUO | 49448215 | | 871599 | 11/23/2000 12:00:00 a.m. | Syncope | | DIS | Admission Date: 8/6/2000 Report Status:
Discharge Date: 9/14/2000
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
Co Ri Walklare
Service: MED
DISCHARGE PATIENT ON: 8/11 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650-1 , 000 MG orally every 4 hours as needed pain
AMIODARONE 200 MG orally every day
Override Notice: Override added on 7/19 by HALLFORD , DARBY H. on order for COUMADIN orally ( ref # 45975969 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: md aware Previous override information:
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
on order for COUMADIN orally VARIABLE ( ref # 31980411 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: tolerates
Previous override information:
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: tolerates Previous Alert overridden
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: tolerates/monitored
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
Alert overridden: Override added on 7/5 by
BUCKMAN , CLAUDIA ILA , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates Previous Alert overridden
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates Previous Alert overridden
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates
MICRONASE ( GLYBURIDE ) 10 MG orally twice a day
Alert overridden: Override added on 7/5 by
BUCKMAN , CLAUDIA ILA , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates Previous Alert overridden
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates Previous Alert overridden
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates
PLAQUENIL ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Give with meals
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally three times a day
HOLD IF: sbp <90
LISINOPRIL 20 MG orally twice a day HOLD IF: sbp <100
Override Notice: Override added on 7/5 by
BUCKMAN , CLAUDIA ILA , M.D.
on order for KCL IMMEDIATE REL. orally SCALE every day ( ref #
48554686 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: tolerates
Previous override information:
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: tolerates
Previous Override Notice
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 48554686 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: monitored
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally twice a day
HOLD IF: sbp <100 HR 60 Food/Drug Interaction Instruction
Take with food
Alert overridden: Override added on 7/5 by
BUCKMAN , CLAUDIA ILA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to BETA-BLOCKERS
Reason for override: tolerates Previous Alert overridden
Override added on 7/5 by BUCKMAN , CLAUDIA ILA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to BETA-BLOCKERS
Reason for override: monitored
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
COUMADIN ( WARFARIN SODIUM )
EVEN days: 5 MG qTTHSat; ODD days: 2.5 MG qMWF orally every day
Starting Today ( 8/3 )
HOLD IF: INR >3.0 and call primary doctor
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 7/19 by HALLFORD , DARBY H.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: md aware
NORVASC ( AMLODIPINE ) 10 MG orally every day HOLD IF: sbp <100
LOVENOX ( ENOXAPARIN ) 70 MG subcutaneously every 12 hours X 4 Days
Starting Today ( 8/3 ) HOLD IF: INR is 2-3
Instructions: Please give first dose today and provide
teaching. Would have her visiting nurse give the injections
if INR is not 2-3
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Annette Schoultz 1-2 weeks , patient to call for an appointment ,
Dr. Shonna Saber , Cardiology 2-3 weeks , patient to call for appointment ,
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
Syncope , R/O MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Syncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
*** 7/19 ***
7/9 78F with HTN , PAFon amiodarone , MS history of MVR
on coumadin , ?CAD/IMI with clean coronaries on
cath '91 , history of CHF , now presenting with 2 episodes
of ?syncope. First episode while sitting ,
?LOC , second episode while leaning over , likely no
LOC , both episodes without pre- or
post-syncopal SOB/palpitations/lightheadedness/confusion
or other sx. In ED had Lleg/armpain and HA.
Had negative Head CT , neg Lextremity films.
Meds noteable for extensive cardiac regimen
including lopressor , coumadin ,
amio , norvasc , lisinopril , lasix , isordil. CXR showed mild CHF
?Lbase effusion. ECHO 18 of January EF65% , EKG old inferior
MI changes/primary AVblock. Noted bradycardia to
30s while asleep on night of
admission CV: unclear etiology of syncopal episodes but
CV likely given her history. Will call Cards
consult in a.m. Important to assess specific
etiology given need for coumadin for MVR versus fall
risk with the syncopal episodes. Orthostatics
negative. Cardiology consulted , and recommended an event monitor to
assess for specific rhythms while she is symptomatic. Over her hospital
course , she had one episode of near-syncope similar to her weekend
symptoms. There was no typical rhythm noted on telemetry at that time.
Cardiology recommended monitoring HR and BP and consider d/c'ing
Lopressor if it is excessively low and correlating with symptoms.
Would follow up on event monitor to determine need for further
intervention.
Neuro: Head MR negative; ruled out intracranial
ischemia/bleed. Heme: INR 4.3 on admission and restarted after holding
for one day. Restarted coumadin at usual home dosing. On 7/10 INR was
2.1 so arranged for 4days of Lovenox to be given if INR is not
therapeutic.
Follow up plan: Event monitor to be ordered. Patient to follow up with
Dr. Aspacio and Dr. Odea in 1-2 weeks. Visiting nurse to do home safety
eval , and monitor INR/administer Lovenox if needed , and check
BP/HR/symptoms.
ADDITIONAL COMMENTS: For visiting nurse: Please draw blood every day for 5 days to check INR. If it
is less than 2 please give the Lovenox injections for the day. If it
remains in 2-3 range , just continue the regular Coumadin dosing. Please
check BP and heart rate and call primary doctor Dr. Aspacio if it is
excessively low or high and patient is complaining of symptoms. Please
ensure she is wearing her event monitor.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HALLFORD , DARBY H. , M.D. ( EW07 ) 8/11 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 872
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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415352296 | PUO | 32764707 | | 4434944 | 4/4/2006 12:00:00 a.m. | R femur neck fracture | | DIS | Admission Date: 9/19/2006 Report Status:
Discharge Date: 8/30/2006
****** FINAL DISCHARGE ORDERS ******
HOTZE , KURTIS 938-44-43-5
Scot Rich Ing
Service: ORT
DISCHARGE PATIENT ON: 10/13/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COMPONO , JIM , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
Starting Today ( 1/30 )
Instructions: take for 2 days and then only as needed; do
not take
any additional tylenol or vicodin ( contains tylenol ).
Alert overridden: Override added on 1/25/06 by
KREATSOULAS , CHRISTINIA , M.D.
POTENTIALLY SERIOUS INTERACTION: ACETAMINOPHEN &
ACETAMINOPHEN Reason for override: will monitor
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
325 MG orally DAILY
ATENOLOL 25 MG orally DAILY
DULCOLAX RECTAL ( BISACODYL RECTAL ) 10 MG PR DAILY
as needed Constipation
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
NOVOLOG ( INSULIN ASPART ) 7 UNITS subcutaneously before meals
HOLD IF: npo , fs < 60
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
INSULIN NPH HUMAN 43 UNITS every day before noon; 12 UNITS every afternoon subcutaneously
43 UNITS every day before noon 12 UNITS every afternoon
Instructions: do not give half dose for npo
LACTULOSE 30 MILLILITERS orally every 6 hours as needed Constipation
Instructions: titrate to BMs
LISINOPRIL 10 MG orally DAILY
Alert overridden: Override added on 10/28/06 by KURTZ , CARLOTTA J , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally four times a day
HOLD IF: diarrhea
PHENERGAN ( PROMETHAZINE HCL ) 25 MG orally four times a day as needed Nausea
ZOCOR ( SIMVASTATIN ) 80 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/25/06 by
KREATSOULAS , CHRISTINIA , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
807647135 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 1/25/06 by
KREATSOULAS , CHRISTINIA , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
ULTRAM ( TRAMADOL ) 50 MG orally q4-6 Starting Today ( 1/30 )
as needed Pain HOLD IF: RR <9 , sedation , O2 sat < 93%
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
1 TAB orally twice a day
DIET: House / ADA 2100 cals/dy
ACTIVITY: weight bearing as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Compono , call 936-006-6214 for appointment 2-3 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
R femur neck fracture
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
R femur neck fracture
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD HTN high cholesterol IDDM history of BKA L
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
physical therapy
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Plassman is a 56 year-old malel with a history of IDDM , peripheral vascular disease ,
CAD , hypercholesterolemia , hypertension , history of BKA on L who tripped over
rolled carpet at home/garage , fell and broke R femur/neck. He was
transferred here from an outside hospital on 5/4/06. Medicine ,
cardiology , and endocrinology was consulted for preoperative optimization
of care and risk stratification. He was taken the OR on 1/8/06 by Dr.
Compono for R hip pinning. See full operative note for details. He
tolerated the procedure well. Postoperatively , he did well also. His
postoperative course was notable for pulmonary edema which responded very
well to diuresis. He went from 100% face mask on POD 1 to RA within 2
days with monitored diuresis and electrolyte replacement. He had no
cardiac symptoms and remained hemodynamically stable. Endocrinology
followed him and made recommendations daily for adjustment of his insulin
regimen. They also recommended continuing his caltrate + vitamin D. He
also had some emesis postop which did not respond to zofran but did to
phenergan. Today he tolerated lunch well and by dinner , wife and patient
feel comfortable and in fact prefer to go home today. He is afebrile ,
vital signs within normal , 95% on RA. He has RRR , lungs CTAB. R hip
incision clean , dry , intact with staples. STrenght 5/5 RLE and sensation
intact. He has prosthesis on left LLE. He has been cleared by physical therapy if
ambulance takes him home and he has 24hrs supervision which he has. He is
abulatory with walker and cane. He has special commode ordered. He will
return to see Dr. Handerson in clinic in 2 weeks. He is being
discharged home with reglan and phenergan for nausea. He will have VNA and
home physical therapy.
ADDITIONAL COMMENTS: 1 ) keep incision clean and dry 2 ) you are weight bearing as tolerated but
use walker for now and have 24hrs supervision at all times 3 ) call for
redness , fever > 101 , drainage from incision or if vomiting continues for
more than 3 days , if you stop passing stool or flatus.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KREATSOULAS , CHRISTINIA , M.D. ( LV86 ) 10/13/06 @ 06
****** END OF DISCHARGE ORDERS ******
Document id: 873
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
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- |
- |
869841894 | PUO | 04096805 | | 0174532 | 9/7/2004 12:00:00 a.m. | Dementia | | DIS | Admission Date: 11/7/2004 Report Status:
Discharge Date: 10/27/2004
****** DISCHARGE ORDERS ******
HAMMETT , FREDERICA 929-50-68-6
Antawinsan Chank El Room: La , Alaska 78484
Service: NEU
DISCHARGE PATIENT ON: 2/14/04 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCGONIGLE , VONDA EDWIN , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
GLUCOTROL ( GLIPIZIDE ) 10 MG orally twice a day HOLD IF: BS< 100
PRAVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
ALTACE ( RAMIPRIL ) 5 MG orally every day
ARICEPT ( DONEPEZIL HCL ) 5 MG orally every day
Number of Doses Required ( approximate ): 5
SEROQUEL ( QUETIAPINE ) 25 MG orally every bedtime
Number of Doses Required ( approximate ): 1
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Sana Albor April at 1:40pm scheduled ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Dementia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Dementia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) hx mi ( history of myocardial infarction ) hx
chf ( history of congestive heart failure ) hx cva ( history of cerebrovascular
accident ) reflux ( gastroesophageal reflux disease ) history of L nephrectomy
( history of nephrectomy ) ? meningioma on scan ( ?
meningioma ) gallstones ( gallstones )
OPERATIONS AND PROCEDURES:
MRI brain
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Patient is a 80 year-old female with hx of CAD , DM , HTN , left PICA stroke
who presented to the ED after a fall. SHe was admitted after being
found to be demented and unclear if this was a new or old diagnosis.
Basic labs for dementia were sent including TSH , B12 , folate which were
normal. MRI revealed a mennigioma and old PICA infarct. LIkely
diagnosis is Alzheimer's Disease. She was started on Aricept and
Seroquel. physical therapy/OT evaluated her and felt that she was safe to be d/c home
with services. SW was consulted to arrange for this. Her family was
contacted and expressed concern for her safety at home. Patient was
resistent to home care and did not feel that she needs any help in the
home. Psychiatry was consulted to determine if she has the capacity to
make decisions regarding her care. They did feel that she has
diminished capacity but felt that she would be safe to return to her
home. She was d/c home with services.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: AFONSO , DUSTIN ISOBEL , M.D. ( FB96 ) 2/14/04 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 874
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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417262154 | PUO | 86403383 | | 3068121 | 7/27/2004 12:00:00 a.m. | atypical right sided chest pain | | DIS | Admission Date: 7/27/2004 Report Status:
Discharge Date: 5/1/2004
****** DISCHARGE ORDERS ******
BRICKNER , AUDRIA 030-56-45-0
Gardlooptress Hwy.
Service: MED
DISCHARGE PATIENT ON: 10/14/04 AT 04:00 PM
CONTINGENT UPON ETT results.
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
CLONAZEPAM 1 MG orally three times a day
CYCLOBENZAPRINE HCL 10 MG orally three times a day
Number of Doses Required ( approximate ): 3
DICLOXACILLIN 500 MG orally four times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
FLUOXETINE ( FLUOXETINE HCL ) 60 MG orally every day
LEVOTHYROXINE SODIUM 175 MCG orally every day
Starting Today ( 7/18 )
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
BACTRIM DS ( TRIMETHOPRIM /SULFAMETHOXAZOLE DO... )
1 TAB orally every 12 hours X 6 doses
LAMICTAL ( LAMOTRIGINE ) 25 MG orally twice a day
Number of Doses Required ( approximate ): 2
EVISTA ( RALOXIFENE ) 60 MG orally every day
SEROQUEL ( QUETIAPINE ) 200 MG orally every afternoon
Number of Doses Required ( approximate ): 2
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
to be scheduled with primary care physician ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
R/O MI , syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical right sided chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypothyroidism ( hypothyroidism ) depression ( depression )
OPERATIONS AND PROCEDURES:
Got an ETT Bruce Protocol on 9/30/04 that was negative for ischemia.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
58yoF history of hypothyroidism , depression , anxiety ,
recurrent R sided CP who p/with 9/10 R upper chest pain x 24hrs that
began while lying on the couch watching TV day prior to admission.
Not associated with SOB/palp/diaph/n/v , but did
have some right arm numbness. She noted that the
pain was worse with deep inspiration. Also of
note last Tuesday patient had syncope episode
without prodrome/co/osb while shopping at a grocery
store. She has noted intermittent R sided CP ever
since the death of her son 5 yrs ago. She sees
a psychiatrist , is on multiple psychoactive
meds , denies SI/HI but is tearful talking about her
son. Never exercises , can walk one flight without
DOE , no claudication. In the ED she received
aspiring , nitro and morphine with resolution of her chest
a pain. portugese SPEAKING ONLY
PMH: hypothyroidism , depression Meds: levoxyl , lamictal , seroquel ,
clnazepam , cyclobenzaprine , evista , prozac. All: NKDA , no
TOB/eoth. PE: T98.4 , hr68 , bp119/66 , 18 , 96% on
2lnc aox3 , nad , jvp<6cm , CTAB , RRR no MRN nl s1s2 ,
abd soft obese , ntnd +bs , ext no c/c/e , 1+
distal pulses.
Labs: cr 0.8 , hct 40.5 , wbc 6.5 , nl lfts , d-dimer 442 , ck/mb/tn
negative , inr 1.0 , alb 4.4. EKG: nsr at 60 , TWI 1 and avl ( no old
for comparison ) CXR without acute pulmonary
process.
***************hospital course********************
1. CV: ischemia: Aspirin , lopressor , statin , ntg as needed MSO4 for chest
pain. Serial cardiac enzymes and EKG negative for MI. No events on
telemetry. Got ETT Bruce protocol negative for ischemia. Cholesterol
and triglycerides found to be
elevated , put on Zocor 20mg orally every bedtime. 2. PULM: doubt PE given history and
negative D-dimer.
3. Psych: history of depression/anxiety , no si/hi , continue outpatient psych
regimen. 4. Cellulitis:On dicloxacillin 500mg four times a day x7days
5. UTI: on Bactrim x3days
6. Endocrine:TSH elevated at 6.866 , but on 10/5 TSH was 2.510. Will keep
current levothyroxine dose and f/u with primary care physician.
6. PPX: lovenox for dvt , ppi for
gi 7. FULL
CODE
ADDITIONAL COMMENTS: Follow-up with primary care physician to check TSH level in about 3 weeks. Follow-up with
primary care physician in about 1 week to assess resolution of cellulitis and UTI.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. f/u TFTs in 4-6 wks
No dictated summary
ENTERED BY: FIGURA , CAREY T. , M.D. ( VT32 ) 10/14/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 875
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
- |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
- |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
N |
N |
N |
- |
759584010 | PUO | 47947002 | | 297604 | 6/11/2000 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 9/18/2000 Report Status: Signed
Discharge Date: 2/13/2000
PRINCIPAL DIAGNOSIS: LEGIONELLA PNEUMONIA , BILATERAL PLEURAL
EFFUSIONS.
HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-old
female with a distant history of
ovarian cancer , rheumatoid arthritis with systemic lupus
erythematosus features , and history of TTP , status post
splenectomy , who was admitted with fever , shortness of breath and
pleuritic chest pain. She was in her usual state of health until
October of this year , when she began to experience dyspnea on
exertion , shortness of breath one week after her husband died.
Initially she thought it was anxiety secondary to her husband's
death , but this shortness of breath began to increase and occurred
on rest. She also reports that she has had a recent history of
orthopnea and says that for the past few months she has had
bilateral lower extremity edema with gradual onset. She also has
had a dry , non productive cough for the past month and three days
ago began to have fevers up to 102 , chills , nausea , dry heaves ,
headache and diarrhea. The shortness of breath has increased in
intensity and yesterday she began to experience sharp pleuritic
right chest pain. She denied productive cough , neck stiffness ,
photophobia , sick contacts , chest pain , palpitations , or recent
travel. Of note , the patient had been on Plaquenil previously but
she self discontinued this three months ago because she has been
feeling well. She has had no recurrence of her rheumatoid
arthritis symptoms , which for her include arthritis in her hands.
PAST MEDICAL HISTORY: Past medical history is significant for
diabetes type 2 , hypertension , TTP , history
of splenectomy , history of Haemophilus influenzae and pneumococcal
sepsis , rheumatoid arthritis with systemic lupus erythematosus
features , history of osteomyelitis in the right ankle , history of
ovarian cancer in 1989 , status post chemotherapy , total abdominal
hysterectomy and bilateral salpingo-oophorectomy.
ALLERGIES: She has no known drug allergies.
MEDICATIONS: Her medications include diltiazem 240 mg a day ,
lisinopril 40 mg a day , Naprosyn 500 mg twice a day , NPH
insulin 24 units subcutaneously every day before noon , Entex-LA.
SOCIAL HISTORY: She lives with her son. Her husband recently
died in October of this year with esophageal
cancer. She has no alcohol or tobacco use. She is an elementary
school teacher.
FAMILY HISTORY: Family history is significant for coronary artery
disease as well as breast carcinoma.
PHYSICAL EXAMINATION: On physical examination , the patient was
afebrile with a temperature of 98 , pulse in
the 100s , blood pressure 182/99. The patient's oxygen saturation
was 92% on 5 liters. She was alert and oriented , in mild
respiratory distress. The skin was without rash. HEENT: Not
significant. NECK: The neck was supple with no lymphadenopathy or
thyromegaly. CARDIOVASCULAR: Tachycardic , regular rhythm , without
murmurs , gallops or rubs. She had no jugular venous distention.
LUNGS: The lungs revealed markedly decreased breath sounds at the
bases and faint crackles at the bases on the right. ABDOMEN:
Abdominal examination was completely benign. No hepatomegaly or
masses. She did have a scar from the splenectomy. EXTREMITIES:
The extremities showed 1+ edema bilaterally. There were no cords.
Negative Homans' sign. There was no clubbing or cyanosis.
NEUROLOGICAL: The neurological examination was intact.
LABORATORY DATA: Significant laboratory studies included a
sodium of 137 , white blood cell count of 19.5
with 2 bands and 86 polys as well as Howell-Jolly bodies.
Hematocrit was 38.6 , platelets 495 , 000. CK was 50 , troponin was 0.
D-dimer was greater than 1 , 000. Chest x-ray revealed large
bilateral pleural effusions , left greater than right. She had a CT
scan which was a limited study that showed no evidence of a
pulmonary embolism. It showed a questionable infiltrate in the
right lung versus compressive atelectasis.
HOSPITAL COURSE: In summary , this is a 57-year-old female with a
distant history of ovarian cancer and TTP , who
was admitted with likely community acquired pneumonia and bilateral
moderate to large pleural effusions. Initially the patient was
given cefuroxime and levofloxacin in the emergency department for a
presumed community acquired pneumonia. She also was given Lasix
for diuresis , given there was a question of whether or not she was
having any heart failure. Given her elevated D-dimer , she had a
spiral CT scan of the chest which did not reveal any evidence of
pulmonary embolus and also had lower extremity Dopplers which were
negative. However , there was a continuous Doppler wave form on the
study which raised the suspicion of a more proximal venous
compression. Therefore , she underwent abdominal CT scan , which did
not show any evidence of venous obstruction as well as lymphatic
obstruction.
1 ) INFECTIOUS DISEASE: The patient was admitted and treated for
what was thought to initially be just a community acquired
pneumonia with large effusions , likely peripneumonic in nature.
She initially was started on cefuroxime and azithromycin by the
General Medicine team. She was pancultured as well as had
Legionella urine antigen sent. Subsequently her Legionella urine
antigen became positive and repeat test again revealed that this
was in fact positive. At that time , levofloxacin was added given
recommendations from the Infectious Disease Service. She was
continued on azithromycin; however , cefuroxime was discontinued as
there was no evidence of other etiology of her pneumonia. She
underwent thoracentesis late the evening of her admission , which
revealed a transudate. Cytology was sent on this and was negative
as well as all cultures were negative from this. She underwent
multiple bilateral therapeutic pleuracentesis , given that the
effusions were quite large. Ultrasound revealed multiple
loculations on the right side and she had to undergo right sided
ultrasound guided thoracentesis to remove fluid. In addition , the
patient was aggressively diuresed with Lasix to help with the
effusions.
The patient continued to have a high oxygen requirement throughout
the hospitalization despite aggressive thoracentesis. However , as
she was diuresed aggressively , her oxygen requirement was down from
initially 5 to 6 liters per nasal cannula. Prior to discharge , she
was off of O2 except that she had desaturations to 86% with
ambulation. Therefore , she was discharged home with as needed oxygen.
She remained afebrile throughout the rest of the hospitalization
and her pulmonary status continued to improve prior to discharge.
Other complications during the hospitalization included an elevated
platelet count up to 800. This was thought likely to be acute
phase reactant secondary to infection and fever and this will be
followed as an outpatient. In addition to this , she had an
elevated CA-125 level. This was discussed with her GYN oncologist
and he felt that this was likely from the effusions , but again
should be followed as an outpatient to make sure that this resolves
as the effusions continue to resolve. Abdominal CT scan , which was
done to rule out more proximal venous compression did not reveal
any recurrence of ovarian cancer.
The patient was discharged to home on October , 2000 , with services
as well as as needed oxygen. She was in stable condition. She had no
problems with her diabetes , hypertension , rheumatoid arthritis
throughout the rest of her hospitalization.
DISCHARGE MEDICATIONS: Her discharge medications include Lasix
80 mg twice a day , insulin sliding scale ,
lisinopril 40 mg a day , levofloxacin 500 mg times 14 days ,
Cardizem-CD 240 mg orally every day
FOLLOW-UP: She is to follow-up with Dr. Blacknall in one week and
she is to have her platelets checked as well as a
CA-125 as her Legionella pneumonia resolves.
Dictated By: MA YEAGLEY , M.D. AE12
Attending: DEANDRA L. GILFOY , M.D. HC88
JY848/1957
Batch: 32245 Index No. Z6VU8K9CNG D: 7/6
T: 11/1
CC: 1. CORDELIA D. BLACKNALL , M.D. DB91
Document id: 876
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| output/system_intuitive_annotation.xml | intuitive |
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878696591 | PUO | 75926089 | | 5050637 | 11/28/2003 12:00:00 a.m. | Acute rejection of Renal Transplant | | DIS | Admission Date: 7/10/2003 Report Status:
Discharge Date: 11/19/2003
****** DISCHARGE ORDERS ******
BALAS , MITCHELL M 647-44-74-0
Man Dence
Service: RNM
DISCHARGE PATIENT ON: 1/20/03 AT 04:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PILLING , WEI NYLA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FLUOXETINE HCL 20 MG orally every day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
28 UNITS every day before noon; 8 UNITS every afternoon subcutaneously 28 UNITS every day before noon 8 UNITS every afternoon
HUMAN INSULIN REG ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously ( subcutaneously ) before every meal & HS
If BS is less than 200 , then give 0 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
METOPROLOL TARTRATE 50 MG every day before noon; 25 MG every afternoon orally 50 MG every day before noon
25 MG every afternoon Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PREDNISONE 5 MG orally every day before noon
PROGRAF ( TACROLIMUS ) 3 MG orally every 12 hours
Starting Today ( 7/10 )
Instructions: Take 3mg for next two days , then decrease
the dose to 1mg every day Go to the Samfairm Oakmiss Sack Center to
get blood drawn Monday Morning.
Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
CELLCEPT ( MYCOPHENOLATE MOFETIL ) 500 MG orally every 12 hours
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Food decreases peak by up to 40%
REMERON ( MIRTAZAPINE ) 30 MG orally every bedtime
Number of Doses Required ( approximate ): 10
RAPAMUNE ( SIROLIMUS ) 4 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
AMBIEN ( ZOLPIDEM TARTRATE ) 5 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIET: House / Renal diet (FDI)
ACTIVITY: Partial weight-bearing: As per your Orthopedic Surgeon.
FOLLOW UP APPOINTMENT( S ):
Renal Transplant for blood draw Monday , 8am scheduled ,
Dr. Goodnow , Orthopedics , 007-586-0134 , 9:45am , please bring X-rays 10/30/03 scheduled ,
Dr. Sembrat , Rheumatology 123-112-2058 , 9am 3/10/03 scheduled ,
ALLERGY: Dilaudid ( hydromorphone hcl )
ADMIT DIAGNOSIS:
Renal Failure , Possible rejection of Kidney Transplant.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Acute rejection of Renal Transplant
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CMV colitis HTN , IDDM , ESRD , history of Renal Tx history of Wilm's Tumor ( age 3 ) history of
thyroid CA , history of resect +CMV donor history of hyperthyroid on T4 history of AFib ,
pulm HTN/fibrosis ( XRT-rel ) history of incr PTH , gout ( gout )
hypertriglyceridemia , history of appendectomy history of cataract surgery history of R eye
embolus with central VF defect , small
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Renal Biopsy 1/20/03
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Balas is a 48 year-old admitted for a renal biopsy. patient is history of renal
transplant x 2 ( 1997 , 2001 ) who presented to renal clinic on 9/30
complaining of night sweats and fatigue. His creatinine at that time
was 3.5 ( up from 3.2 in 8/23 ). At that time , his Prograf was reduced
from 4 mg twice a day to 3 mg twice a day. There was concern at this time over possibl
e rejection of his renal transplant and he was admitted 6/23 for
elective renal biopsy to evaluate for rejection.
PE on Admission: 97.5 , 110/66 , P90 , RR18 97% on RA. Gen: Flat affect ,
but conversant. Pulm: CTAB , no wheeze. CV: RRR , s1 , s2 , +s3.
Holosystolic murmur , 3/6. Diastolic murmur present. Abd: well healed
surgical scars , soft , NT/ND. Ext: Charcot joint left foot , right foot
in brace for navicular fracture.
A/P:
1 ) Renal: Renal failure 2/2 radiation therapy as child for Wilm's
tumor , transplanted 1997 , 2001 , continue immunosuppressant regimen.
Renal bx 9/26 , showed acute rejection , likely resolving. Will follow
up with renal transplant on 9/21
2 ) Heme: Prolongued PTT , inhibitor screen negative , lupus
anticoagulant negative. Thrombin time , anticardiolipin ab pending.
3 ) Endocrine: Diabetes history of transplant , on NPH/SSI.
4 ) Rheum: history of Gout , intermittantly treated with Colchicine , has follow
up scheduled with Rheumatology on 3/10/03 , 9am. Dr. Genny Barrette
5 ) Ortho: Navicular fracture in right foot , 8 days ago , x-rays obtained
at La Ditl Would like second opinion re: management from St.ri County Health Center Ortho consulted informally re: recommendations.
Appointment scheduled with Dr. Goodnow on 9/16 , 9:45am. Will need to
bring X-rays.
6 ) Psych: Will continue remeron and prozac.
ADDITIONAL COMMENTS: Please decrease dose of FK to 1mg twice a day after two days and follow up with
renal transplant on Monday to have your blood drawn. Appointments
scheduled for both Rheumatology and Orthopedics.
Call for temp>100.4 , increased pain in feet , decreased urinary output ,
chest pain , shortness of breath or anything concerning to you.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TOMASELLO , CHUNG KARLENE , M.D. ( DY08 ) 1/20/03 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 877
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| output/system_intuitive_annotation.xml | intuitive |
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380075158 | PUO | 43908087 | | 5019915 | 10/2/2004 12:00:00 a.m. | research study | | DIS | Admission Date: 8/4/2004 Report Status:
Discharge Date: 3/3/2004
****** DISCHARGE ORDERS ******
TOMA , AYAKO 113-98-54-8
Ster Na Ce Hi
Service: MED
DISCHARGE PATIENT ON: 6/1/04 AT 08:00 a.m.
CONTINGENT UPON completion of study protocol
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SPILLETT , SILVA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
DIET: House / study diet
ACTIVITY: activity as tolerated
NO FOLLOW APPOINTMRNT REQUIRED
No Known Allergies
ADMIT DIAGNOSIS:
research
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
research study
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
dm ( diabetes mellitus ) htn ( hypertension ) sleep apnea ( sleep
apnea ) gout ( gout ) depression
( depression ) obesity ( obesity ) left total hip replacement
OPERATIONS AND PROCEDURES:
n/a
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
as per study protocol
BRIEF RESUME OF HOSPITAL COURSE:
patient admitted for research study.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MCMILLAN , TWILA C. , M.D. ( AF37 ) 6/1/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 878
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
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OSA |
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| output/system_intuitive_annotation.xml | intuitive |
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808769538 | PUO | 26659638 | | 4003747 | 5/5/2005 12:00:00 a.m. | CHF Exacerbation , NSTEMI | | DIS | Admission Date: 5/5/2005 Report Status:
Discharge Date: 10/9/2005
****** FINAL DISCHARGE ORDERS ******
WASZAK , KATELYNN 958-59-75-0
Cape Stockotempe Ux
Service: MED
DISCHARGE PATIENT ON: 1/8/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOHANAN , SHEA K. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
Alert overridden: Override added on 2/8/05 by GOBRECHT , ALVERTA O. , M.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 817262278 )
patient has a POSSIBLE allergy to NAPROXEN ; reaction is
muscle cramps. Reason for override: outpt med
CATAPRES ( CLONIDINE HCL ) 0.4 MG TP Q168H
Instructions: please place 2 of the 0.2mg patches on her
for the week.
HYDROCHLOROTHIAZIDE 25 MG orally every day
Alert overridden: Override added on 11/18/05 by GOBRECHT , ALVERTA O. , M.D.
on order for HYDROCHLOROTHIAZIDE orally ( ref # 538543898 )
patient has a DEFINITE allergy to HYDROCHLOROTHIAZIDE;
reaction is URIN HESITANCY. Reason for override: patient needs
PRAVACHOL ( PRAVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/8/05 by GOBRECHT , ALVERTA O. , M.D. on order for PRAVACHOL orally ( ref # 521448961 )
patient has a PROBABLE allergy to LOVASTATIN; reaction is
Muscle cramps.
patient has a PROBABLE allergy to ATORVASTATIN; reaction is
leg cramps. Reason for override: out patient med
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/8/05 by GOBRECHT , ALVERTA O. , M.D. on order for NORVASC orally ( ref # 727784833 )
patient has a PROBABLE allergy to NIFEDIPINE; reaction is
CONSTIPATION. Reason for override: outpt med
IMDUR ( ISOSORBIDE MONONITRATE ( SR ) ) 90 MG orally every day
Starting Today ( 6/22 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIOVAN ( VALSARTAN ) 160 MG orally twice a day
Alert overridden: Override added on 2/8/05 by GOBRECHT , ALVERTA O. , M.D. on order for DIOVAN orally ( ref # 289946511 )
patient has a PROBABLE allergy to LOSARTAN POTASSIUM;
reactions are facial swelling , FACIAL SWELLING/ITCH.
Reason for override: outpt med
Number of Doses Required ( approximate ): 1000
BECONASE AQ ( BECLOMETHASONE DIPROPIONATE NASAL )
1 SPRAY inhaled twice a day
LANTUS ( INSULIN GLARGINE ) 40 UNITS subcutaneously every day before noon
ACULAR 0.5% ( KETOROLAC TROMETHAMINE ) 1 DROP OS every 6 hours
Alert overridden: Override added on 10/19/05 by :
on order for ACULAR 0.5% OS ( ref # 490072712 )
patient has a PROBABLE allergy to NAPROXEN ; reaction is
muscle cramps. Reason for override:
patient has used these eyedrops without side effect
CLOPIDOGREL 75 MG orally every day X 90 doses
ATENOLOL 100 MG orally twice a day
CARDURA ( DOXAZOSIN ) 0.5 MG orally every day
LORATADINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) ) 1 TAB sublingual Q5MIN
Starting Today ( 9/24 ) as needed Chest Pain
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:cough
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Ranno 9/24 @ 9:30am ,
Dr. Ienco 10/13 @ 1pm ,
Dr. Nerissa Robblee , Mac Hospital ( Cardiology ) 9/1 @4:20 scheduled ,
ALLERGY: Penicillins , CARBAMAZEPINE , LOSARTAN POTASSIUM ,
ENALAPRIL MALEATE , FAMOTIDINE , NIFEDIPINE , LOVASTATIN ,
ATORVASTATIN , NAPROXEN , nutrasweet
ADMIT DIAGNOSIS:
CHF Exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF Exacerbation , NSTEMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) IDDM ( diabetes mellitus ) PVD ( peripheral vascular
disease ) cri ( chronic renal dysfunction ) NQWMI ( myocardial
infarction ) history of 2v CABG ( history of cardiac bypass graft surgery ) history of CVA
( history of cerebrovascular accident ) chronic leukocytosis ( high white
count ) history of TAH/BSO ( history of hysterectomy )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Adenosine MIBI , Echocardiogram , Cardiac Catheterization with Circumflex
and LAD Stent Placement , Renal Angiogram
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
******************
HPI: 78F c hx/o CAD , history of MI in 1998 , CHF c EF 40-45% as of 1998 , HTN ,
DM and atypical chest pain who p/with CHF exacerbation x 3 days likely
2/2 self-d/c of HTN meds for past 2 days.
Assc sxs include productive cough c clr sputum , weakness , dizziness ,
night sweats , and worsening bilat CP. Upon arrival of EMS , she was
afeb c BP of 180/100 , P 80 , RR 50 , and O2 sats of 98%. In the ED ,
she was given captopril , lasix , NTG , c some resolution of her SOB and
no resolution of her CP.
******************
PMH: MI/CABG 1998 , CHF , HTN , Hypercholesterolemia , DM c
retinopathy/nephropathy , PVD , OA , Leukocytosis. MEDS: ASA 325 orally every day ,
Atenolol 50 mg orally twice a day , Beconase 42 mcg inhaled twice a day , Cardura .5 mg orally every day ,
Diovan 160mg orally twice a day , HCTZ 25mg orally every day , Imdur ER 60mg orally every day , Lantus
40mg subcutaneously every day , Loratidine 10mg orally every day , Neurontin 100mg orally three times a day , NTG .4mg
as needed CP , Norvasc 10mg orally every day , Pavachol 80mg orally every day.
ALL: PCN - rash , Carbamazepine rash , Losartan facial swelling rash ,
Nutrasweet throat swelling , Enalapril cough , Famotidine dry mouth ,
Nifedipine constipation , HCTZ urinary hesitancy , Lovastatin
muscle cramps , Atorvastatin leg cramps , Naproxen muscle
cramps
******************
STATUS ( PHYS EXAM ): T98 P 65 BP 146/60 RR 22 O2 sat
98 NAD c SOB , no JVD , lungs CTAB , RRR , no M/R/G , abd
NT/ND , no peripheral edema , peripheral pulses in LE weak , DTR 2+
bilat , CN II-XII intact.
******************
DATA: LABS - BNP 673; TNI neg , CR 0.9; WBC 22 , K 5.2 CXR - pulmonary
edema EKG - LBBB ,
NSR
******************
HOSPITAL COURSE: 1. CV: i - The patient presented c worsening atypical
chest pain , first set of cardiac enzymes neg , second set pos
( TNI-2.93 ) anticoagulated with subcutaneously lovenox , third set of enzymes
trending down. Adenosine MIBI on 11/10 , reversible inferolateral
ischemia and patient underwent cardiac catheterization with
concurrent renal angiogram for difficult to control HTN which showed
three vessel CAD ( LMCA 70% , LAD 100% , CX 70-80% , RCA 90% with 1/2
grafts patent ). Stents placed in CX and LAD. history of cath , HCT dropped to 29
( 39 on admission ) and Creatinine was 1.3 ( .9 on admission ). Patient given
mucomyst with discharge HCT 32 and Cr of 1.1. P- The patient
was diuresed for CHF exacerbation effectively with 20mg intravenous boluses of
Lasix with excellent UOP. Euvolemic at discharge and no longer
requiring lasix. HTN- BP was difficult to control. Titrated up
lopressor to 100 every 6 hours Also added 25mg HCTZ and hydral as needed to cover very
high SBP spikes to 180. Renal angiogram , 50% bilateral renal artery
stenosis. Patient will follow-up outpatient with Dr. Nerissa Robblee on 10/14
Echo showed EF 60-65% with mild concentric LVH consistent with diastolic
dysfunction. 2. PULM: SOB improved with diuresis and
nebs. O2 transiently inc , however patient now weaned. 3. RENAL: Cr
stable. 4. ID: Leukocytosis - WBC 22 on admission c no signs
of infxn and hx of chronic leukocytosis. WBC 17 on 10/5 , c temp of
100.3 , inc SOB and productive cough so Levoquin started for possible
PNA. WBC 12 on 8/17 5. ENDO: on home lantus 40U.
SS CODE:
FULL
ADDITIONAL COMMENTS: Please take your medicines as you were before coming to the hospital
noting the following changes ( Imdur 90mg every day , Plavix 75mg each day
for at least ninety days , Atenolol 150mg twice per day. Please take two
more doses of Levaquin every other day.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: QUIETT , ALLA M. ( ) 1/8/05 @ 12:04 PM
****** END OF DISCHARGE ORDERS ******
Document id: 879
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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381869583 | PUO | 95849811 | | 1489170 | 6/4/2005 12:00:00 a.m. | GRAFT VS HOST DISEASE , history of BONE MARROW TRANSPLANT | Signed | DIS | Admission Date: 4/1/2005 Report Status: Signed
Discharge Date: 10/15/2005
ATTENDING: KATCSMORAK , CARRI GARY LAWANDA
PRINCIPAL DIAGNOSIS:
Graft versus host disease.
HISTORY OF PRESENT ILLNESS:
The patient in 1/25 developed right breast cancer , stage III.
Treatment included lumpectomy and chemotherapy. The patient had
persistent pancytopenia , which was evaluated in 10/4 with bone
marrow aspirate biopsy , which showed multiple cytogenetic
abnormalities with findings consistent with myelodysplastic
syndrome. In 8/14 , she had a nonmyeloblative peripheral blood
stem cell transplant for a match unrelated donor. In 10/18 , she
had lymphocyte infusion. On 5/8 , chimerism study showed 58%
donor origin. Repeat chimerism on 8/23/05 showed 100%
chimerism. The patient prior to admission for two weeks had
diarrhea , watery in nature. She denied sick contacts , had GI
biopsy in middle of 5/24 that showed focal colitis , without
signs of GVHD. The patient was given prescription for steroids
three days prior to admission , but did not complete or fill the
prescription , was admitted from the clinic with significant skin
rash that was consistent with graft versus host disease.
PAST MEDICAL HISTORY:
Includes breast cancer in 1/25 , myelodysplastic syndrome ,
hypertension , and hypercholesterolemia. The patient had isolated
complicated migraine headache and has aortic valvular disease
with aortic insufficiency.
ALLERGIES:
She describes no allergies to medications.
SOCIAL HISTORY:
She is divorced with one son , denies alcohol or illicit drug
intake.
FAMILY HISTORY:
Noncontributory.
PHYSICAL FINDINGS:
On exam vital signs were stable. The patient had dry
maculopapular rash over the upper chest and face , also including
the upper extremities , abdomen , and upper thighs bilaterally ,
flat , slightly erythematous. HEENT exam was normal. She had dry
mucous membranes. Chest is clear to percussion and auscultation.
Cardiac exam: There is a 2/6 systolic ejection murmur heard
best in the aortic area. Abdomen is soft and nontender. There
is no hepatosplenomegaly appreciated on clinical exam. She has
large external hemorrhoids. There is no clubbing , cyanosis , or
edema. Neurological exam is nonfocal.
HOSPITAL COURSE:
1. Oncology: The patient has a history of MDS , 11 months status
post nonmyeloablative transplant. The patient was very slow to
engraft and required donor lymphocyte infusion. Most recent
chimerism studies on 8/23/05 showed a 100% donor origin. The
patient had stage III skin GVH confirmed by biopsy on 6/15/05.
She had moderate improvement response to Solu-Medrol , which was
started on 8/5/05 ( switched to prednisone on 6/11/05 ) and
Elidel started on 5/22/05. There has been even more improvement
in the skin GVH since initiating rapamycin on 8/6
Gut GVH/diarrhea. GI biopsy done on 5/10/05 showed grade II
graft versus host disease in left transverse colon , grade I graft
versus host disease in rectum , with no viral cytopathic changes.
The patient had no significant decrease in the amount of stools
with Solu-Medrol , marginal response to rapamycin , now with some
improvement status post three doses of ONTAK. ONTAK was given on
6/17/05 , 9/6/05 , and 10/22/05 without adverse events. The
patient was premedicated with Pepcid , steroids , Benadryl , and
Tylenol. The only side effect is marked increase in left upper
extremity edema ( see cardiovascular section for more details ).
Solu-Medrol intravenous was started 2 mg/kg/day , started on 8/5/05 ,
changed to 2 mg/kg by mouth orally steroids on 6/13/05. Began
tapering with steroids at 100 mg twice a day on 11/18/05 , decreased to
80 mg on 8/20/05 , and down to 60 mg twice daily on 10/24/05.
Rapamycin was started on 10/10/05 , goal level between 3 and 12.
The patient has been therapeutic since initiating therapy. She
remains on GVH diet , coordinating with dietary and kitchen for
correct menu. She also has been on lactose-restricted diet that
has helped the stool volume as well.
2. Hematology: The patient with no active bleeding was
transfused for hematocrit less than 26 and platelets less than
20. She did have intermittent bright red blood and clots in
stool , most recently on 10/2/05 and 8/25/05. This was
attributed to have large hemorrhoids that were found on
colonoscopy. She remained hemodynamically stable throughout.
3. Infectious disease: The patient remained afebrile throughout
her hospitalization , maintained on prophylactic medication of
Mepron and acyclovir. Cytomegalovirus viral load on 2/7/05 ,
8/5/05 , 5/10/05 , and 10/10/05 , all negative. CMV viral load
on 9/6/05 was pending at the time of this dictation. The
patient is to remain on acyclovir and Mepron once transferred.
4. Cardiovascular: The patient remained hemodynamically stable ,
did not get hypotensive throughout the admission.
5. Extremities: The patient had left upper extremity swelling ,
markedly worsened , starting on tacrolimus , as this is known to
cause capillary leak syndrome due to an ultrasound of the left
upper extremity on 11/28/05 , which is negative for DVT. Etiology
is likely due to lymphedema secondary to axillary resection when
the patient had breast cancer and capillary leak syndrome
associated with ONTAK. The patient had an echocardiogram to
assess the etiology of peripheral edema , which showed an ejection
fraction of 60% , mild aortic insufficiency , and aortic stenosis ,
borderline diastolic dysfunction , normal right heart , and minimal
pericardial effusion.
6. Pulmonary: The patient had one episode of dyspnea when
speaking on 11/16/05 , which resolved without further symptoms
throughout the admission. The patient had chest x-ray on
10/6/05 , which showed small left pleural effusion without other
abnormalities.
7. Gastrointestinal: Mouth , the patient had dry mouth , likely a
component of graft versus host disease using ice chips and mouth
coat is helpful to her. She should continue this throughout.
8. Gut: The patient had persistent loose stools improved ( see
oncology section ). Clostridium difficile testing sent on
8/26/05 and 3/5/05 were negative. She had intermittent bright
red blood per rectum that was related to external hemorrhoids , as
stated above in GI section.
Colonoscopy on 5/10/05 revealed stage II GVHD on biopsy with no
gross visual evidence of bleed. As the fact now , the patient was
admitted on 7/16/05 with bright red blood. The colonoscopy was
notable for large hemorrhagic mucosa , intubating internal
hemorrhoids , and at that time biopsies were negative for graft
versus host disease. This was on 3/5/05. Liver transaminitis
on 8/29/05 , likely due to ONTAK would be followed as an
outpatient. The patient also had transient LFT abnormalities
when first admitted and has since resolved since discontinuing
Bactrim. The bilirubin remained normal. The patient was
asymptomatic.
9. Rectum: The patient had Anusol as needed for hemorrhoids.
She was not a candidate for surgical intervention due to
immunosuppression and infection risk.
10. Renal: The patient repeated increasing creatinine to 1.3.
She maintained a level of 0.9 to 1.2 throughout the last few
weeks before discharge.
11. Fluids , electrolytes , and nutrition: The patient has marked
peripheral edema. Diureses worked well. The patient was up to
18 kg above admit weight and now she is only 3 kg up from the
admit weight on 10/24/05. She is on Lasix 40 mg twice daily by
mouth. This is likely secondary to combination to venous
insufficiency , steroids , and low albumin. In the setting of
ONTAK , she was given albumin and Lasix three times daily , which
is no longer needed now that she that would not be pursuing ONTAK
therapy until an outpatient attending decides , otherwise. She
should have a goal I/O negative to 1 to 1.5 liters a day.
Monitor hemodynamics closely if the patient has been noted to be
dehydrated. Encouraged ambulation and for elevation we were
using Ace bandage like wraps. The patient had electrolytes
monitored and repleaded as needed. Nutrition was following.
12. Endocrine: The patient's fingerstick blood sugars were 134
and 163 , improved since steroids taper initiated. She remained
on the sliding scale as needed , likely this is due to steroids.
13. Dermatology: The patient upon admission had significant
involvement of skin due to GVH greater than 80% body surface area
involved. It is improved significantly , as the exam revealed
less erythema , darkening rash , and decreased distribution. The
patient is on GVH medication , as stated in Oncology section. She
also came in with macerated areas under both breast and was
treated with miconazole powder and had improved by the day of
discharge.
14. Access: The patient had double lumen Hickman catheter ,
which is erythematous surrounding exit site. The cuff has been
exposed for months , although the patient has had no fevers , not
tender , outpatient attending requested to keep it lying in.
SOCIAL DISPOSITION:
The patient accepted at Thoeaston Healthcare We had family
meeting on 8/20/05 with all siblings and patient's son agreed on
once the patient is at home , need for increased support ,
medication compliance , Jeana Osdoba , social worker from Setlake Caardlin County Medical Center is following Dr. Alyea
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Include acyclovir , Anusol , Bactroban , prednisone 60 mg by mouth
twice daily , Mepron 750 mg twice daily , Celexa , sirolimus 4 mg by
mouth once daily , Caltrate , vitamin D , and Nexium , tacrolimus 1%
lotion twice daily to affected skin GVHD areas , and Lasix 40 mg
by mouth twice daily.
eScription document: 1-1995789 EMS
Dictated By: QUITEDO , MELODIE
Attending: KATCSMORAK , CARRI GARY
Dictation ID 8388157
D: 8/29/05
T: 8/29/05
Document id: 880
| Target |
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532988550 | PUO | 73050951 | | 524579 | 5/2/2000 12:00:00 a.m. | RT. KNEE CHONDRAL INJURY , MEDIAL FEMORAL CONDYLE , PATELLOFEMORAL MALTRACKING | Signed | DIS | Admission Date: 5/2/2000 Report Status: Signed
Discharge Date: 1/30/2000
PRINCIPAL DIAGNOSIS: RIGHT KNEE CHONDRAL DEFECT.
ASSOCIATED DIAGNOSES: 1. PATELLOFEMORAL MALTRACKING.
2. CHRONIC RENAL INSUFFICIENCY.
3. ACUTE ON CHRONIC RENAL INSUFFICIENCY.
HISTORY OF PRESENT ILLNESS: Mr. Danielski is a 42-year-old
gentleman who underwent multiple
procedures on his right knee , who presents for right knee
autologous chondrocyte implantation for a right knee medial femoral
condyle defect. He also presents for an anteromedialization of the
tibial tubercle for patellofemoral maltracking.
PAST MEDICAL HISTORY: His past medical history is notable for
glomerulonephritis with chronic renal
insufficiency , for renal induced hypertension , for insomnia , for
asthma , and for gastroesophageal reflux disease.
PAST SURGICAL HISTORY: His past surgical history is notable for
gastric bypass surgery , as well as a
perianal abscess that was treated with intravenous antibiotics , left knee
autologous chondrocyte implantation in August of 1999 , and right
knee osteochondral mosaic plasty in the past in August of 1998.
MEDICATION ALLERGIES: None.
ADMISSION MEDICATIONS INCLUDE: Atenolol 100 mg every day before noon , verapamil
180 mg every day , Zaroxolyn 5 mg every day before noon ,
doxepin 150 mg every bedtime , Valium 10 mg twice a day , Percocet , Oxycontin 20
mg twice a day , and Lasix 2.5 mg every day
SOCIAL HISTORY: He lives with his family , he is engaged and works
for the Vi Roll Dencedastin
PHYSICAL EXAMINATION: Exam of his right knee shows that his
incisions are well-healed. There is a mild
effusion. Neurologic exam was intact. He had tenderness over the
medial femoral condyle.
HOSPITAL COURSE: The patient was admitted on 3/5 For
details of the procedure he underwent , please see
the operative note. In brief , a chondral defect of his right knee
and patellofemoral maltracking were noted. He then subsequently
underwent a decompression of his patellofemoral joint via a 4%
Fulkerson procedure. He also underwent autologous chondrocyte
implantation to his right knee medial femoral condyle defects. He
tolerated this procedure well. Postoperatively his neurovascular
status of his limb remained intact. A drain was left in place , and
care was taken to evaluate for compartment syndrome. No
compartment syndrome did develop. He did receive Coumadin
anticoagulation for DVT prophylaxis. He received perioperative
antibiotics. It was noted that the lateral skin flap over his
anterior knee wound was erythematous and he was restarted on Keflex
after his intravenous antibiotics were discontinued. His postoperative
course was notable for a worsening and acute onset of renal failure
on top of his chronic renal insufficiency. He was evaluated very
closely and followed by the Renal Consult Service. His creatinine
did rise from a baseline of around 4 up to 6.7. At the time of
discharge , his creatinine had begun to fall and his renal status
had stabilized.
He was seen by Physical Therapy , and he was placed in a continuous
passive motion machine to maintain knee motion. He was ambulated
touch down weightbearing on his right leg. He was to undergo no
active extension of his right knee. He was ready for discharge on
10/28/01. Discharge condition stable.
DISCHARGE INSTRUCTIONS:
1. Follow-up with Dr. Birgit Konstantinidi
2. Coumadin anticoagulation for DVT prophylaxis for an INR goal of
1.5 to 2.0.
3. A course of orally Keflex.
4. Home CPM.
5. Touch down weightbearing with crutches for his right leg.
6. Active assisted range of motion and flexion of his knee , no
active extension.
7. Follow-up with his primary nephrologist regarding his renal
insufficiency.
Dictated By: CALLIE CERDAN , M.D. FI12
Attending: BIRGIT KONSTANTINIDI , M.D. BO74
US348/558184
Batch: 38000 Index No. L6EFLT9Z37 D: 10/19/01
T: 10/19/01
Document id: 881
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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323306313 | PUO | 79972291 | | 7372997 | 8/17/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/15/2003 Report Status: Signed
Discharge Date:
PRINCIPAL DISCHARGE DIAGNOSIS: PANNICULITIS.
ASSOCIATED DISCHARGE DIAGNOSES: 1. ACUTE RENAL FAILURE.
2. DEPRESSION/PERSONALITY
DISORDER.
3. DIABETES.
4. PROTEIN CALORIE MALNUTRITION.
HISTORY OF PRESENT ILLNESS: This is a 36-year-old woman with a
history of morbid obesity and diabetes
mellitus with recently diagnosed abdominal wall cellulitis status
post a three week stay at Kendsonre Ale Ater Hospital . The patient left
AMA from Kendsonre Ale Ater Hospital the day of current admission and
after spending several hours at home called the ambulance after she
slipped and fell out of her chair and was unable to get up. She
denies loss of consciousness , she was found on the floor lying on
her back. She denies fever or chills. She does have abdominal
pain , denies nausea or vomiting , diarrhea , increased urinary
frequency or dysuria.
PAST MEDICAL HISTORY: Her past medical history is significant for
obesity and diabetes.
MEDICATIONS ON ADMISSION INCLUDE: Insulin , lisinopril , cephalexin ,
Lipitor , cimetidine , Paxil ,
metformin.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: No tobacco or alcohol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature of 96.2 , blood
pressure of 121/64 , pulse of
124 , respirations 18 , saturation of 97 percent on room air. In
general , she is obese , tachypneic , and uncooperative. HEENT ,
supple neck , no jaundice , moist orally mucosa. CV , tachycardic
without murmur. Lungs , CTA anteriorly. Abdomen , lower abdominal
wall with extensive areas of erythema and induration with an open
wound 5 x 7 cm , no pus or drainage , tender to palpation.
Extremities , bilateral swelling , warmth , and erythema with
tenderness. Neurologic , uncooperative for exam , grossly nonfocal.
LABORATORY DATA: laboratories on admission are significant for a
white count of 10.57 , hematocrit of 32.7 ,
platelets of 437. Chem-7 showed a sodium of 135 , potassium of 4.3 ,
chloride of 108 , CO2 of 15 , BUN of 6 , creatinine of 1.2 , glucose of
92 , calcium is 7.5. ESR 75 , INR 1.5 , physical therapy 17.3 , PTT 36.1. UA showed
3 to 5 white blood cells , 2 to 3 red blood cells , positive
leukocyte esterase , positive nitrates. EKG showed sinus
tachycardia with a Q-wave in aVF and questionable Q in V4 through
V5 , left axis deviation , a flat T-wave in V2 through V6 , inverted
T-wave in 3 , all unchanged from previous. Chest x-ray showed no
infiltrates. An abdominal CT done at KAAH on 1/10 showed stranding
and fluid and gas along the anterior aspect of the abdominal wall
without evidence of abscess. An echo done at KAAH showed normal
left ventricular function without valvular disease , with an EF of
64 percent. A surgical pathology report at KAAH showed cellulitis
with ulceration and fat necrosis. Blood cultures at KAAH were never
positive. Lower extremity Doppler on admission negative for clots
above the knee. CT done at KAAH was negative for PE.
HOSPITAL COURSE BY SYSTEMS: ID: The patient was assessed by
general surgery in the emergency room
and plastic surgery followed the patient while in-house. It was
thought that the patient did not require any further surgical
debridement , she is status post two surgical debridements at KAAH .
It was recommended that she undergo wet-to-dry dressing changes.
Originally upon admission to the Kernan To Dautedi University Of Of she was given nafcillin ,
however , after coming up to the floor she was changed to a regimen
of vancomycin , Cefotan and Flagyl as per ID recommendation at KAAH ,
this is the regimen the patient was receiving at KAAH . Her blood
cultures , of note , were never positive. It was recommended by the
ID service that the patient does need an abdominal CT to rule out
an abscess given the stranding seen on prior CT at KAAH , however ,
the patient was too large for the CT table at the Kernan To Dautedi University Of Of , as well
as for an MRI table , it will have to be assessed as to whether the
patient may be transferred to another facility for abdominal
imaging to rule out abscess , until that time wet-to-dry dressings
will continue to the wound and antibiotics will be continued intravenous.
Endocrine: The patient was given a regimen of NPH 14 units twice a day
and an insulin sliding scale with excellent control of blood sugar.
FEN: The patient has severe protein calorie malnutrition , and a
nutrition consult was obtained and extensive conversations were
carried out concerning whether or not to institute TPN or tube
feeds in this patient. The patient originally refused tube feeds
and it was explained to her the risks and benefits of TPN , and a
PICC was placed to institute TPN. However , on 6/6 the patient
attempted to leave AMA and was declared incompetent to make medical
decisions , so while TPN was instituted to help support the patient
nutritionally , at some point a feeding tube including a permanent
PEG will have to be reconsidered , as this is the best way to feed
the patient. Her admission albumin was 1.5 , indicative of severe
protein calorie malnutrition , and her severe malnutrition was also
thought to be the contributing , if not causative , factor to the
patient's renal failure.
Renal: The patient's admission creatinine was 1.2 with an increase
to 1.9 overnight , and continued to rise to a level of 3 throughout
her admission. A renal consult was obtained. FENA was less than 1
percent , so renal felt that the patient's acute renal failure was
most likely prerenal secondary to the patient's severe protein
calorie malnutrition at third spacing , so it was thought that the
patient would benefit from transfusions of blood products and/or
albumin to help pull fluid intravascularly. There was some thought
that perhaps her renal failure could have been due AIN from
nafcillin , however , her urine eos were negative. The patient did
have polyuria from yeast but this was thought to be colonization
and not actual infection. The patient did continue to receive intravenous
fluids throughout this hospitalization , and her electrolytes were
monitored and repleted as necessary.
GI: The patient did have some diarrhea , a C. diff was sent and is
currently negative.
Psychiatry: There were severe behavior problems with the patient
at KAAH resulting in the necessity of maintain an elaborate care
contract with the patient that details each behavior that was
expected of the patient. However , throughout her stay at KAAH ,
though she was thought to have a severely regressed personality
disorder , she was deemed competent to make medical decisions and
thus left AMA from that facility. Upon arrival to I Warho Hospital , she did express suicidal ideations to her niece , so a
psychiatric consult was obtained. However , psychiatry felt like
her suicidal ideation was most likely indicative of a borderline
type personality disorder , so it was not thought that she was
actively suicidal and did not require a one to one sitter.
However , she did continue to have manipulative behavior and severe
medical noncompliance , refusing all care including basic hygienic
care as well as wound dressings , medications , and interviews with
care providers and other medically necessary interventions. The
patient refused multiple evaluations by psychiatry to evaluate for
competence as the patient often did not want to listen when
attempts to explain to her her medical problems and the
consequences concerning medical decisions were attempted. Finally
on October , the patient did try to leave AMA during the night ,
and on the morning of March another psychiatric evaluation was
performed and the patient was declared incompetent by psychiatry ,
and the decision was made to proceed with medically necessary care
despite the patient's unwillingness to comply , and we have begun
the pursuit of her guardianship for this patient. The patient's
sister has agreed to pursue the role as her guardian. Until that
time , the patient will be restrained physically or chemically as
necessary for medically necessary intervention. Psychiatry is
continuing to follow.
CURRENT MEDICATIONS INCLUDE: Flagyl 500 mg intravenous every 8. , Cefotan 1 g intravenous
every 24. , vancomycin dose by levels ,
heparin 5000 units subcutaneously three times a day , NPH insulin 14 units subcutaneously twice a day ,
regular insulin sliding scale , Zofran 8 mg intravenous every 8 hours as needed nausea ,
Paxil 10 mg orally every day , miconazole powder topically twice a day , Nexium
40 mg orally every day , Serax 15 to 30 mg as needed insomnia , Ambien 5 mg
orally every bedtime as needed insomnia , and total parenteral nutrition.
ENTERED BY: FLORETTA MARK THRONEBURG , M.D. YC34
Attending: MARA RAMONEZ , M.D. IT38
DW204/518036
Batch: 30461 Index No. P7NPWF35E6 D: 10/5/03
T: 10/5/03
Document id: 882
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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032466553 | PUO | 02488758 | | 8944061 | 5/8/2006 12:00:00 a.m. | left sided weakness , gait disturbance , ROMI , | | DIS | Admission Date: 5/9/2006 Report Status:
Discharge Date: 5/11/2006
****** FINAL DISCHARGE ORDERS ******
ARRAS , GREG 075-97-18-9
O74 Room: 93P-737
Service: MED
DISCHARGE PATIENT ON: 3/7/06 AT 01:50 PM
CONTINGENT UPON AMA with HOME SERVICES
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PERSONIUS , SVETLANA BART , M.D. , M.P.H.
CODE STATUS:
Other - undefined
DISPOSITION: AMA
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
ATENOLOL 25 MG orally DAILY
CELEXA ( CITALOPRAM ) 20 MG orally DAILY
KLONOPIN ( CLONAZEPAM ) 1 MG orally three times a day
DEPAKOTE ( DIVALPROEX SODIUM ) 500 MG orally twice a day
LISINOPRIL 40 MG orally DAILY HOLD IF: sbp<90
Alert overridden: Override added on 4/17/06 by
TROKEY , CLARITA K. , PA
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MD aware
Previous Alert overridden
Override added on 4/17/06 by TROKEY , CLARITA K. , PA
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MD aware , takes at baseline
RISPERDAL ( RISPERIDONE ) 1 MG orally twice a day
SIMVASTATIN 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Carbohydrate Controlled / Low saturated fat
low cholesterol (FDI)
ACTIVITY: Walking as tolerated
per physical therapy recs
FOLLOW UP APPOINTMENT( S ):
primary care physician as needed at Brook Mepa Community Hospital ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
left sided weakness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
left sided weakness , gait disturbance , ROMI ,
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , CAD , history of MI 2000 , NIDDM
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: dizziness/pre-syncopal episode
***
HPI: 55 F with history of HTN , NIDDM , CAD history of MI in 2000 presents with
episodes of dizziness x 2 days "room spinning around me" with mosr
recent episode one hour prior to presentation from ED. patient was in L+D
visiting her post partum DA when she began to feel dizzy again with
associated 4/10 HA ( reported to be intermittent since 9/11 ) , minimal
sob , and unsteady gait. Unsteady gait has been present x 2 weeks per
patient Patient reports postural dizziness when sitting up since then
with mild HA. Denies diaphoresis , fevers , chills , chest pain. No
nausea/vomiting/PND/orthopnea. patient does report poor orally intake 2/2
inability to cook and care for self at times. Positive weight gain
of 25 lbs in past year. Reports compiance with all meds , last seen
by primary care physician about 2 weeks ago ( Asyth Shorehuy Hospital ) *In ED , vss , none
orthostatic , however noted to have increased weakness on left on
ambulation only with unsteady gait. EKG with new more profound TWI
diffusely t/o leads with inferior/lateral ST depressions V4-V6 ( 1mm )
when c/with TH 2000 records. A set enzymes flat , head CT neg , CXR
pending
***
PMH: Bipolar , NIDDM , HTN , CAD history of MI in 2000 ( Bussadd Southrys Community Hospital ) ,
Depression
***
SH: lives alone , "no help from friends/family" takes care of self ,
unemployed; +tobacco use ( 10 cigs per day ) , denies ETOH/ilicit drug
use
***
Home Medications: klonopin 1mg three times a day , depakote 500 twice a day , risperdal 1
twice a day , cardia 300 every day , metformin 1000 twice a day , celexa 20 every day , lisinopril 40
every day , lipitor 10 every day ( clarified with S&S pharmacy ( 442 ) 995-7682 on
10/20 )
***
ALL: NKDA
***
PE on Admission: VS: Afeb
98.6 67 126/88 16 100%RA Gen: NAD/NARD , sitting up on
stretcher with HEENT: NCAT , anicteric sclera , EOMI , PERRL , mmm , OP
clear Neck: supple , no JVD , no carotid bruits CV: RRR S1S2 , no m/g/r
appreciated Lungs: ctab Abd:obese , +BS , soft , NTND , no HSM , no
RT/G Ext: wwp , 2+ DPs b/l , no edema , no atrophy/asymetry Neuro:Left sided
weakness with +hypoflexia on Left , left sided grip mildly weaker than
right , A+O x 3; + gait disturbance favoring R/falling to left side
***
Imaging: Head CT - negative per prelim rads
read CXR - moderate
cardiomegaly
***
Hospital Course: 55 F with NIDDM , HTN , and CAD history of MI 2000 admitted
with dizziness/presyncopal symptoms in the setting of concerning EKG
changes ( more profound TWI and ST depression in inferior/lateral
leads ) for ROMI and likely cerebellar CVA despite neg prelim head
CT
1. ) Syncope/CV: cycle B+C set with serial EKG's , tele monitoring , per
neuro recs ordered MRI/A yet patient refused , neuro reconsulted on 10/20 and
patient to get carotid dopplers neg ( patent b/l ) , ECHO with EF 60% LVH trace
MR , ASA 325 every day , lopressor 25 three times a day ( given atenolol 25 on AMA ) , checked
lipid panel/restarted on increased dose statin; restarted on ACE.
Unsteady gait: Nuero consulted on admit for + Neuro deficits/gait
disturbance/left sideed weakness , likely central/brain stem CVA , physical therapy and
OT evals obtained , fall precautions , serial neuro exam
2. ) ENDO: NIDDM on metformin at baseline , reports not taking FSBS 2/2
broken glucometer , check AIC , DM protocol , teaching , monitor BS qAC
and HS adjust coverage as needed
4. ) FEN: euvolemic , monitor lytes/replete as needed , carbo controlled cardiac
diet
5. ) Psych: history of bipolar and profound depression on multi drug reg
( continued baseline regimen per psych recs ) Social worker followed patient 2/2
multi social/family issues. patient declared competent at time of signing AMA
papers
6. ) Smoking cessation: nicoderm
7. ) PPx: lovenox
FULL CODE
****************Unfortunately patient left AMA on HD#3 2/2 "Feeling better and
awnting to go home****************************************************
ADDITIONAL COMMENTS: HOME SERVICES FOR physical therapy AND VNA
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TROKEY , CLARITA K. MARYBETH ( ZU74 ) 3/7/06 @ 02:38 PM
****** END OF DISCHARGE ORDERS ******
Document id: 883
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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111791933 | PUO | 77130544 | | 5237997 | 1/17/2006 12:00:00 a.m. | PNEUMONIA | Unsigned | DIS | Admission Date: 2/24/2006 Report Status: Unsigned
Discharge Date: 8/9/2006
ATTENDING: SPILLETT , SILVA A.
TEAM: Sville Well
PRINCIPAL DIAGNOSIS: The condition responsible for causing this
admission is pneumonia.
LIST OF OTHER PROBLEMS AND DIAGNOSES: COPD , CAD , diabetes type
2 , hypertension , TIA , TVD , psoriasis.
BRIEF HISTORY OF PRESENT ILLNESS: This is a 70-year-old female
with end-stage renal disease on hemodialysis , COPD , diabetes type
2 who was admitted with dyspnea and tachycardia on the 10/28/06.
The patient reported a history of cough with productive sputum x3
days and chest pain pleuritic in nature. She denied any nausea ,
vomiting , any bowel or bladder symptoms. She denied headache ,
fatigue , anorexia. Per her family , the patient had a fever to
103 and some confusion while reportedly at home. In the
Emergency Department at Kernan To Dautedi University Of Of , she was tachypneic to the 40s
sating upper 80s on room air and had a fingerstick glucose of 30.
An ABG was consistent with a respiratory acidosis , pH of 7.3 ,
pCO2 of 55 , pO2 of 63 , sating 89% on 2 L. An admission chest
x-ray demonstrated an opacity at the left base. An EKG showed
some left-sided strain unchanged from prior. She received
azithromycin and ceftriaxone in the Emergency Department as well
as vancomycin and was started on BiPAP and transferred to the
MICU. In the MICU , she was treated as a COPD flare with
steroids , antibiotics , and nebulizers , however , the patient began
to tire and developed worsening hypercarbic respiratory failure
so was intubated on the night of the admission and extubated five
days later. Over the course of her MICU admission , she developed
AFib and had a troponin leak. Otherwise , the stay was
unremarkable and she extubated without complication and
transferred to the GMS Services on 4/8/06.
PAST MEDICAL HISTORY: End-stage renal disease on hemodialysis
Monday , Wednesday and Friday. The renal failure is secondary to
renal artery stenosis. Hemodialysis began in April 2005.
Diabetes type 2 with hemoglobin A1c of 5.8. COPD , no PFTs are
available. Hypertension. Coronary artery disease with history
of remote MI , diastolic dysfunction/CHF. TIA for which she
receives Coumadin. Bilateral fem-pop bypasses , psoriasis and a
perforated appendix.
HOME MEDICATIONS: Glyburide 5 twice a day , Lipitor 10 , PhosLo 667
three times a day , Zestril 60 nightly , Toprol-XL 200 , Coumadin 4 mg , aspirin
81 , iron three times a day , Paxil 10 , Nephrocaps daily , Flovent and
Combivent doses unknown.
TRANSFER MEDICATIONS TO THE GMS SERVICE: Diltiazem 90 orally
four times a day , Lopressor 37.5 four times a day , aspirin , albuterol , PhosLo ,
Colace , Pepcid , insulin NPH 15 units twice a day , Nicotine patch ,
nystatin , prednisone taper , betamethasone , captopril 50 three times a day ,
Coumadin 2 , simvastatin 20 , an Aspart sliding scale and as needed
lactulose , Zyprexa and Ativan.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She is an active smoker , smokes about a pack and
a half a day for the past 55 years. Lives with her daughter , has
9 children.
PHYSICAL EXAM UPON TRANSFER TO THE GMS SERVICE: Weight 92.9 ,
temperature is 96.2 , heart rate 118 AFib , BP 107/57 , sating 95%
on 2 L. In general , she appeared younger than stated age. She
had a psoriatic rash on her right thigh. Neuro exam , she was
hard of hearing , otherwise her cranial nerves were intact and she
was alert and oriented x3. Head and neck exam notable for JVP of
5 cm of water. Mucous membranes were moist. Her oropharynx was
clear. Her extraocular motions were full. Her cardiac exam , she
had a regular rhythm without appreciable murmurs , rubs or
gallops , no heaves. Lungs , she had expiratory wheezing without
rhonchi or crackles. Abdomen , although distended but soft , no
laparotomy scar , normoactive bowel sounds without guarding. She
had a Port-A-Cath in her right chest that appeared clean , dry and
intact. Extremities , she had TEDs and SCDs , bilateral pedal
edema , they were warm.
HOSPITAL COURSE BY PROBLEM:
1. From a Pulmonary Standpoint: Pneumonia/COPD flare. The patient was
admitted with pneumonia and COPD flare for which she needed to be intubated and
had a short MICU stay. She did well on antibiotics and was
changed from ceftriaxone , azithromycin , and vancomycin to
levofloxacin which she completed a ten-day course. She also
started on steroid taper and will leave with 20 mg of prednisone
for two more days and then 10 mg of prednisone for three days.
Upon transfer to the floor , she was restarted on Combivent and
Flovent and received as needed albuterol nebulizers and albuterol
inhaler on a every 4 basis. Smoking cessation was emphasized with
the patient. Ace consult was called and the nicotine patch was
continued. She was given a flu vaccine while in the hospital.
The blood cultures and sputum cultures were unrevealing and her
O2 saturation was titrated to greater than 93%.
2. From an endocrine perspective she had a history of diabetes
type 2. She was fleetingly placed on Portland protocol while in
MICU and then transferred to NPH 15 twice a day insulin and NovoLog
sliding scale. She should continue her aspirin and ACE inhibitor
as an outpatient and later her hemoglobin A1c was consistent with
very well controlled diabetic.
3. From a cardiovascular standpoint:
A. Ischemia. Her troponin peaked to 0.38 on 11/22/06 while in
the MICU. It was not associated with any dynamic EKG changes ,
however , her EKG does show some evidence of strain versus
infralateral ischemia with T-waves inversions in the inferior and
lateral leads. Her troponin trended down over the course of the
admission and on last check were less than 0.2. There was a
question of whether this leak was due to volume overload versus
infection. Her aspirin , statin , beta-blocker , and ACE were
continued. Her fasting lipid profile was remarkable only for
hypertriglyceridemia and HDL of 38. She is scheduled for a
outpatient nuclear medicine stress test on 8/13/06 at 09:00 a.m.
B. Rate. She was noted to be in AFib on the MICU and rate was
controlled with diltiazem and Lopressor titrated to heart rate of
80 , she was monitored on tele over the course of admission. She
was already in Coumadin for TIAs , however , the new INR goal for
her is between 2 and 3 and Coumadin levels should be checked at
the time of dialysis.
C. Pump. Her EF was 55% on echo that was done while in the
MICU. There is some evidence of aortic sclerosis , otherwise ,
there is no hypokinesis or wall motion abnormalities noted.
4. From a hematologic standpoint , she was started on epopoietin
for anemia of chronic disease. Her baseline hematocrit of 35
dropped to 26 while in the MICU and she received a unit of blood
for that. Following that transfusion , her hematocrit was stable
in the lower to mid 30s. She was also restarted on iron , which
she takes as an outpatient. Her stool is guaiac negative over
the course of the admission.
5. From a GI perspective , the patient had a mild transaminitis
noted while in the MICU thought likely secondary to hepatic
congestion. Viral serologies were drawn including hep B and C ,
which were negative. Her transaminitis resolved on its own.
6. From a dermatologic perspective , the patient has a history of
psoriasis. She was continued on topical steroids with good
effect.
7. From an infectious disease standpoint , this patient has
evidence of pneumonia by clinical exam and chest x-ray on
admisison , which appeared to be resolved. She completed a
ten-day course of levofloxacin. In addition , multiple cultures
were taken while in the MICU including that from the A line which
grew out coag-negative staph thought likely to be a contaminate.
8. Neuro exam , she was alert and oriented and intact upon
transfer to the medical service. For history of TIAs her
Coumadin was continued.
9. FEN. The patient was started on a renal diabetic low-fat
diet and was fluid restricted to 2 L a day.
10. Renal. The patient is on dialysis Monday , Wednesday , and
Friday for end-stage renal disease secondary to RAS. She is
followed by renal and had a renal attending during the course of
this hospitalization. She was started on Neutra-Phos ,
Nephrocaps , and her PhosLo was continued. Her calcium and
phosphorus were monitored every day before noon and her IPTH was checked and was
415.
11. Prophylaxis. Heparin was continued subcutaneously until her INR was
therapeutic. She still is on VRE precautions for a positive
rectal swab.
She was a full code.
Discharge medications will be included as an addendum.
PRIMARY CARE PHYSICIAN: Dr. Skobiak at PMH
eScription document: 2-2637430 CSSten Tel
Dictated By: PFAFF , TENESHA
Attending: SPILLETT , SILVA
Dictation ID 4212733
D: 5/18/06
T: 5/18/06
Document id: 884
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047314877 | PUO | 87499425 | | 9384711 | 3/11/2006 12:00:00 a.m. | morbid obesity | | DIS | Admission Date: 5/25/2006 Report Status:
Discharge Date: 1/12/2006
****** FINAL DISCHARGE ORDERS ******
SPAULDING , WANETA 833-47-84-9
Norf Ak Chu
Service: GGI
DISCHARGE PATIENT ON: 3/15/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COHENS , ANGELINE VICKI , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ROXICET ORAL SOLUTION ( OXYCODONE+APAP LIQUID )
5-10 MILLILITERS orally every 4 hours as needed Pain
PHENERGAN ( PROMETHAZINE HCL ) 25 MG PR every 6 hours as needed Nausea
DIET: stage II
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Cohens 1-2 weeks ,
PcP- to arrange outpatient Exercise Stress test 2 weeks ,
ALLERGY: Unknown
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn , gerd , fibromyalgia
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ugi negative
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to the Tott Hospital surgery service on 3/1/06 after
undergoing laparoscopic gastric banding. Of note patient with demand
ischemia upon induction cardiology consulted and rec to place patient on
r/o otherwise no issues. r/o negative , no chest pain , sob , cardiology rec
outpatient exercise stress test.; please see
dictated operative note for details.
She was transferred to the floor from the PACU in stable condition.
Patient had adequate pain control and no issues overnight into POD1. She
had an UGI on POD1 which was negative for obstruction or leak. At that
time she was started on a Stage I diet which she tolerated. She was then
advanced to clears and discharged to home a Stage II diet. Her incision
was C/D/I , with no evidence of hematoma collection or infection. The
remainder of the hospital course was relatively unremarkable , and she was
discharged in stable condition , ambulating and voiding independently , and
with adequate pain control. She was given explicit instructions to
follow-up in clinic with Dr. Mafalda Canida 1-2 weeks.
ADDITIONAL COMMENTS: May shower 2 days after surgery , but do not tub bathe , swim , soak , or
scrub incision for 2 weeks. Bandage strips will fall off over time.
Seek medical attention for fevers ( temp>101.5 ) , worsening pain , drainage
or excessive bleeding from incision , chest pain , shortness of breath , or
any other symptoms of concern. Follow up with your surgeon in 1-2 weeks.
Please do not drive or consume alcohol while taking pain medications.
Crush pills , open capsules , or take elixirs.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WINTERMANTEL , GRANT DONYA ( CV862 ) 3/15/06 @ 01:00 PM
****** END OF DISCHARGE ORDERS ******
Document id: 885
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530669524 | PUO | 02443118 | | 3788481 | 10/15/2005 12:00:00 a.m. | pyelonephritis , urosepsis | | DIS | Admission Date: 10/15/2005 Report Status:
Discharge Date: 11/28/2005
****** FINAL DISCHARGE ORDERS ******
TRIGUEROS , OLIN K. 393-56-62-0
Geton Frede Thou
Service: MED
DISCHARGE PATIENT ON: 10/25/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
LISINOPRIL 10 MG orally every day Starting Today ( 9/19 )
HOLD IF: sbp<95
Override Notice: Override added on 11/10/05 by
GUEDRY , OLENE A.
on order for KCL SLOW RELEASE orally ( ref # 003862629 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 11/10/05 by BORGESE , LAKISHA , M.D.
on order for LISINOPRIL orally ( ref # 913444678 )
patient has a PROBABLE allergy to ENALAPRIL MALEATE; reactions
are HOT FLASHES , FACIAL FLUSHING. Reason for override:
patient has tolerated
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally twice a day HOLD IF: heart rate<55 , sbp<95
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 11/10/05 by
BORGESE , LAKISHA , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: aware
Number of Doses Required ( approximate ): 6
LANTUS ( INSULIN GLARGINE ) 19 UNITS every day before noon subcutaneously every day before noon
19 UNITS every day before noon Starting Today ( 8/24 )
Instructions: 1/2 dose if patient npo or decreased orally's
WARFARIN SODIUM 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 11/10/05 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: aware
ROSIGLITAZONE 2 MG orally every day
FUROSEMIDE 20 MG orally twice a day Starting Today ( 9/19 )
as needed Other:LE edema
Instructions: Do not use more than 1-2 days per week for
potential toxicity with digoxin.
SIMVASTATIN 10 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 11/10/05 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: already tolerated , home medication ,
aware
CEFPODOXIME PROXETIL 200 MG orally twice a day X 16 doses
Starting Today ( 9/19 ) HOLD IF: rash
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 11/10/05 by :
on order for CEFPODOXIME PROXETIL orally ( ref # 887829190 )
patient has a POSSIBLE allergy to Penicillins; reaction is
RASH. Reason for override: cannot tolerate floroquinolones
and needs gram neg coverage. has
tolerated cefalosporins well in the past.
DIGOXIN 0.125 MG orally every other day
DIET: House / NAS / ADA 2000 cals/day / Low saturated fat
low cholesterol / low vit k foods (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Nussbaum within 1wk ,
ALLERGY: Penicillins , ENALAPRIL MALEATE
ADMIT DIAGNOSIS:
pyelonephritis , urosepsis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pyelonephritis , urosepsis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
AFIB ( atrial fibrillation ) PYELONEPHRITIS ( pyelonephritis ) DM
( diabetes mellitus type 2 ) HTN
( hypertension ) HYPERLIPID ( hyperlipidemia )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
TTE , Adenosine-MIBI , PE protocol CT
BRIEF RESUME OF HOSPITAL COURSE:
77 year old woman admitted with complaint of urinary frequency and AMS.
The patient has positive blood and urine cultures for Klebsiella and her
AFIB became tachy to 140's. She was also noted to have an elevated
troponin to 1.69 which rose to a max of 2.41 with no ekg changes. She was
rate controlled and started on Levofloxacin. Her mental status improved
and fever resolved. She remained tachycardic and nodal block was
supressing blood pressure. She was started on digoxin with excellent
response. HR stayed in 70-80's and up to 100's with exersion. Her cardiac
workup included an echocardiogram with RV dialation and wall akinesis
with apical sparing , a new finding since last echo in '03. Right sided
EKG neg. A PE was then ruled out with PE protocol CT. The following day
the patient had a adenosine MIBI that showed no perfusion defects. Her
INR was increasing due to the levofloxacin effect and was switched to
ceftriaxone consistant with blood culture succeptabilities. Follow up
blood cultures on 3/11 then demostrated gram positive cocci in clusters
and the patient was given 2 doses of vancomycin to cover potential staph
infection. Cultures were found to be skin flora and patient asymptomatic
and antibiotics d/c'd. Repeat cultures were negative. Patient was
discharged in good condition and will return to primary care physician for close follow up.
ADDITIONAL COMMENTS: Call primary care physician with any changes in urinary symptoms , or fever >101.0. Return to
ER if any changes in mental status , chest pain , SOB , or syncope. Complete
the full course of antibiotics which cover the next 8days. F/U with primary care physician
within the next week with INR and digoxin levels. Do not use lasix unless
necessary and contact primary care physician if using more than 1-2 times per week due to
possible toxicity with digoxin use.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA instructions: Please do vital signs checks. Patient needs a digoxin
level and INR checked weekly , and the first set of labs should be drawn
1-2 days after discharge. primary care physician will follow-up labs. Guiac + x 1 needs f/u.
TO THE PATIENT: We have altered cardiac medications for better rate
control. We have cancelled the coreg( carvedelol ) and
Norvasc( amilodipine ) and replaced them with a blood pressure medication ,
Toprol XL( Metoprolol XL ) to better control the rate of your atrial
fibrillation. The digoxin was also added for heart rate control.
No dictated summary
ENTERED BY: BORGESE , LAKISHA , M.D. ( HY78 ) 10/25/05 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 886
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461325320 | PUO | 42567215 | | 036352 | 3/18/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/23/1994 Report Status: Signed
Discharge Date: 10/20/1994
DISCHARGE DIAGNOSES: 1. DIABETIC KETOACIDOSIS
2. DIABETES MELLITUS
3. ENDOMETRIOSIS
4. HYPERCHOLESTEROLEMIA
5. STATUS POST REPAIR OF THE OSTIUM PRIMUM
ATRIAL SEPTAL DEFECT IN 1975
6. MITRAL REGURGITATION
7. HEMATEMESIS SECONDARY TO A MALLORY WEISS
TEAR IN April 1994.
CHIEF COMPLAINT: Ms. Schraub is a 31 year-old black female
with diabetes mellitus ( insulin
requiring ) who is admitted with emesis and diabetic ketoacidosis.
HISTORY OF PRESENT ILLNESS: Diabetes mellitus was diagnosed in
1984 after the patient presented with a
history of polyuria , polydipsia , fatigue. She was treated with
orally hypoglycemics initially. In 1985 she was hospitalized for a
questionable episode of diabetic ketoacidosis with recurrent
polydipsia , polyuria , nausea and vomiting and she was changed to
insulin treatment.
Subsequently , the patient had intermittent compliance , with
occasional dietary indiscretions with greater than 2500 calories
intake and decreased exercise. Her dose of insulin in 1991 was
Humulin N 40 units subcutaneous every day before noon and 20 units every afternoon with regular
insulin 5 units every day before noon and 5 units every afternoon added. In April of 1993 her
glycosylated hemoglobin ( hemoglobin A1C ) was 20.2 and her finger
stick blood glucose was 265. On August , 1993 her finger stick
blood glucose ranged from 96 to 189. In October 1994 her insulin
dosing was 40 units subcutaneous every day before noon and regular 5 units every day before noon , 5
units of regular every noon and 5 units every afternoon
In early October of 1994 her finger stick blood glucoses ranged
between 160 and 240. She indicated she was depressed about her
diabetes. On January she awoke at 5 am and had 10 episodes of
emesis progressing from clear to greenish to black. She noted that
she had felt well the day previous with no dietary indiscretions
and had taken her insulin as usual on the days prior to this
episode. She denied any abdominal pain , there was no history of
fever or chills and no diarrhea. There was also no immediate
complaint of hematemesis. The patient went to Carna Home Hospital Urgent Care unable to hold down her food intake and
blood sugar was noted to be 333. She received 5 units of
subcutaneous insulin and her blood sugar went to 247. She also
received intravenous fluids , 25 mg of Compazine and 0.5 mg of
intravenous Ativan. The patient had serum ketones present and her
serum bicarb was 16 , initially noted at Carna Home Hospital She was transferred to Pagham University Of
Emergency Department for further management. The patient's recent
creatinine clearance in the urine was 70 , her urine total protein
was 177 mg for 24 hours. PAST MEDICAL HISTORY: Notable
for adult onset diabetes mellitus requiring insulin , endometriosis ,
status post exploratory laparotomy in 1990. She was never
pregnant , para 0 , gravida 0. She had a history of dysmenorrhea.
She had a history of yeast vaginitis , history of
hypercholesterolemia and a history of atrial septal defect ,
repaired in 1975. MEDICATIONS ON ADMISSION: At the time of
admission , the patient was on insulin Lente 40 units subcutaneous
every day before noon , regular 5 units subcutaneous every day before noon and 5 units subcutaneous every
noon , 5 units subcutaneous every afternoon; demulon and lupron for 9 months
which was discontinued several days prior to admission. ALLERGIES:
To Penicillin and sulfa drugs , the results of which were not clear.
Also , aspirin caused epistaxis in the past. FAMILY AND SOCIAL
HISTORY: She lives by herself. She works as a lawyer and professor
of law. She noted that her family history is positive for adult
onset diabetes mellitus in her mother and her grandmother as well
as a family history of hypertension. REVIEW OF SYSTEMS: Revealed
metromenorrhagia and increased menstrual flow recently. She also
noted she had decreased her exercise recently.
PHYSICAL EXAMINATION: On physical examination her vital signs were
as follows: Temperature 99.7 , heart rate of
127 , blood pressure and respiratory rate normal. She was a
pleasant , young , black female frequently vomiting. HEENT: Notable
for normal examination. Neck supple. There was brisk carotid
upstrokes , no thyromegaly was noted. Lungs were clear to
auscultation and percussion. Heart was tachycardic. S1 and S2
with a holosystolic murmur heard at the apex radiating to the left
sternal border. There was an early decrescendo diastolic murmur at
the base in the aortic area , the lateral resolved with fluids.
Abdomen was tender in the epigastrium , it was very tender in the
suprapubic area. Extremities were without edema , cord cyanosis or
erythema. Neurological examination was within normal limits on
modalities.
LABORATORY DATA: Sodium 140 , potassium 4.5 , chloride 105 ,
bicarbonate 14 , BUN of 12 , creatinine 0.6 ,
glucose 290. White blood cell count 10.6 , platelets 255 ,
hematocrit 36.1 with a mean corpuscular volume 85.5. Coags were
normal. Arterial blood gas pH 7.24 , pO2 102 , pCO2 of 27 ,
bicarbonate 12. She was acid test positive. Her chest x-ray
showed questionably large pulmonary arteries bilaterally. There
was no infiltrate or effusion noted. KUB noted a large bladder.
There was no bowel gas , we could not rule out ascites. EKG was
notable for sinus tachycardia at 122 , intervals were 0.15 , 0.088
and 0.47.
HOSPITAL COURSE: Ms. Schraub was admitted with a diagnosis of
diabetic ketoacidosis. She was started on
intravenous fluids of D5 normal saline with 40 mEq of potassium per
liter. She also received and insulin drip intravenously. She had
her finger stick blood glucoses checked every 2 hours She also
had her blood electrolytes and acid tests checked frequently.
Given the fact that she was febrile and had presented with
acidosis , had a harsh cardiac murmur , she had blood cultures times
3 drawn. There were no obvious sources of infection.
Regarding her GI bleed , she began to cough up coffee ground emesis
after repeated episodes of wretching throughout the day. The
bleeding was thought to be due to a Mallory-Weiss tear due to the
excessive vomiting. The patient had an NG tube placed for lavage
which quickly lavaged clear after approximately 1 liter of diluant.
A nasal gastric tube was put to Gomco low suction. Additionally ,
the patient had intravenous fluids running and her orthostatics and
hematocrit were checked frequently. She was started on H2 blockers
intravenously and a GI consultation was obtained.
Regarding the diabetic ketoacidosis , the patient obtained
consultation from the Endocrine Division. With intravenous fluids
and insulin drip her ketoacidosis resolved. The endocrinologist
suggested the ultimate regimen of insulin which will be described
below. Notably , the patient indicated that she could not reliably
time the midday lunch schedule. Therefore , the patient was given
some flexibility in terms of dosing of insulin at that hour.
Regarding her cardiac workup , the patient was noted to have a loud
systolic murmur. She was evaluated by the Aer Spihungwalt Syssas Medical Center
who recommended echocardiography. The results of the
echocardiogram were as described below. The echocardiogram was
obtained on 2 of July , the results were as follows: The left atrium
was mildly dilated. The tricuspid valve leaflet excursion was
mildly increased with tricuspid regurgitation measured as 2+ out of
4+ with a peak velocity of 2.5. It was thought that she had a
mildly dilated right atrium and a mildly concentric hypertrophied
left ventricle. Mitral regurgitation was 3+ out of 4+. Left
ventricular wall thickness was upper limits of normal with
preserved left ventricular systolic function ejection fraction of
65 percent. The patient abnormalities of her atrial ventricular
canal noted consistent with ostium primum. Her left and right
atrial ventricular grooves inserted at the same level of the
intraventricular septum. There was some evidence of flow reversal
in the pulmonary veins as well as the mitral regurgitation noted
above. There was a high flow velocity jet seen in the paramembrane
of intraventricular septum , moving from left to right , consistent
with residual ventricular septal defect. There was no atrial
septal defect seen status post surgical repair. There was a small
echocardiogram bright density at the left ventricular site of the
paramembranous septum thought to be an anomalous cord attachment
from the mitral valve versus endocarditis.
On January , the patient underwent a transesophageal echocardiogram
to evaluate this abnormality seen above. There was no evidence of
residual atrial septal defect or ventricular septal defect. There
was an anomalous chordal attachment to the base of the interior
leaflet of the mitral valve and no endocarditis vegetations were
seen.
The patient was noted to have hypertension and was started on
Lisinopril , nifedipine was transiently given but was discontinued.
The patient was discharged in satisfactory condition on October ,
1994. There were no complications of the hospitalization.
Operations and procedures of the hospitalization were an esophageal
gastroduodenoscopy by Dr. Prey on July , 1994.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on Lisinopril 20 mg orally every day; insulin
12 units plus a regular scale every day before noon before breakfast , insulin 8 units
plus the scale of regular insulin every noon before lunch , insulin 8
units of regular plus a scale of regular every afternoon before supper , insulin
NPH 15 units subcutaneous every bedtime The scale of regular insulin was as
follows: Less than 80 , drink orange juice; greater than 80 , 1 unit;
greater than the 120 , 2 units; greater than the 160 , 3 units;
greater than 200 , 4 units; greater than 500 , 5 units; greater than
300 , notify medical doctor.
FOLLOW UP CARE: The patient was to follow-up with the following
physicians: Dr. Ellena Schuneman at the Healtship Ron Offa Memorial Medical Center , also Dr. Rossie Mankoski in the Ted Kingston No Got Hospital and Dr. Bastain in the Endocrinology
Clinic. The patient was to schedule these appointments herself.
ESTIMATED DISABILITY: None.
DISCHARGE CONDITION: Satisfactory.
Dictated By: DESIRAE MARCOTT , M.D. JM29
Attending: ELLENA M. SCHUNEMAN , M.D. VF5
FH030/5666
Batch: 1927 Index No. EJTJ4L3VE8 D: 9/16/94
T: 10/6/94
1. ROSSIE K. MANKOSKI , M.D. ZC89
2. MIRNA C. BABULA , M.D. GQ19
Hospital
Document id: 887
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
- |
N |
Y |
Y |
Y |
Y |
N |
N |
N |
N |
N |
N |
336377410 | PUO | 49618388 | | 1891648 | 11/10/2005 12:00:00 a.m. | CAD , ESRD | | DIS | Admission Date: 11/10/2005 Report Status:
Discharge Date: 7/6/2005
****** FINAL DISCHARGE ORDERS ******
NORDHOFF , MONIQUE 557-29-59-9
Ehiny
Service: CAR
DISCHARGE PATIENT ON: 2/27/05 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA 325 MG orally every day
ROCALTROL ( CALCITRIOL ) 0.25 MCG orally every day
PHOSLO ( CALCIUM ACETATE ( 1 TABLET=667 MG ) )
1 , 334 MG orally three times a day
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally twice a day
Starting Today ( 7/13 ) HOLD IF: sbp<100 , heart rate<55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally every day
HOLD IF: sbp<100 , heart rate<55 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Alert overridden: Override added on 7/5/05 by
THEPBANTHAO , DARCI H. , M.D.
on order for IMDUR orally ( ref # 892409479 )
patient has a PROBABLE allergy to NITROGLYCERIN I.V.; reaction
is syncope. Reason for override: takes as outpt
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Override Notice: Override added on 7/5/05 by
THEPBANTHAO , DARCI H. , M.D.
on order for NEPHRO-VIT RX orally ( ref # 170500639 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
NEPHRO-VIT RX 1 TAB orally every day
Alert overridden: Override added on 7/5/05 by
THEPBANTHAO , DARCI H. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Starting Tomorrow ( 10/24 )
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
GLIPIZIDE 7.5 MG orally every day
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally every day As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
DIET: House / Adv. as tol. / NAS / ADA 2500 cals/day / Low saturated fat
low cholesterol / Renal diet (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dialysis Saturday 12 of February scheduled ,
Dr. Tyacke (Cardiology ) 27 of February at 11:15 a.m. at LMC Irv Mintamp Au scheduled ,
ALLERGY: NITROGLYCERIN I.V.
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD , ESRD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of CABG history of POLYPECTOMY '92 history of
NEPHROLITHIASIS history of chronic renal insufficiency ( history of chronic renal
dysfunction ) gout ( gout ) history of gastritis/duodenitis ( history of
gastritis ) history of hiatal hernia ( history of hiatal hernia ) history of GERD ( history of
esophageal reflux ) history of hypercholesterolemia ( history of elevated
cholesterol ) htn ( hypertension ) CAD history of cabg
OPERATIONS AND PROCEDURES:
Cardiac catheterization
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
HPI: 76 year old man with CAD history of CABG , ESRD , previously stable angina
with +MIBI in 2004 , gib , Fe-def anemia , who was admitted for increasing
angina and worsening MIBI. During hospitalization he underwent cardiac
catheterization with bare metal stent placement and began hemodialysis.
-----------
STUDIES:
5/22 Echo EF 50% , dil LV , mild conc LVH , no WMA , + paradoxical wall
motion
1/8 MIBI: med sized defect of severe intensity
in med and basal ant and anterolat wall with mod reversibility
11/9 CATH: Only LIMA to LAD patent of grafts , RCA stented with bare
metal
------------
EKG: NSR , 1AVG , LBBB
------------
Admission PE: Vitals 96.6 , 62 , 166/70 , 20 , 98% on RA
Gen: NAD , pale
Heart: JVP to ear , RRR with systolic murmur at RUSB
Lungs: clear
Abd: soft , NTND
Ext: Bouchard's nodes , 2+ DPs , palp thrill in LUE AV fistula
Groin: without hematoma.
-----------
Hospital Course by System:
1. CV: I: Patient underwent cardiac cath on 24 of November which revealed 100%
occlusion of LAD , 100% occlusion of Proximal LCx , Rt LV-BR mid 70% ,
LIMA- LAD patent. Stented RCA with bare metal stent. TPW placed , then
removed. Patient was treated with ASA , plavix , statin , beta-blocker. a.m.
lipid panel was drawn and was pending at time of d/c. Patient will
follow-up with cardiology as outpatient.
P: history of HTN , continued on beta-blocker , ccb and nitrate. Held lasix
since started dialysis.
R: Patient was monitored on telemetry with no active issues
2. Renal: Patient was started on dialysis during hospitalization. He is
to attend dialysis on 8 of January
3. Endo: Kept on ISS , changed back to home glipizide prior to discharge.
4. Heme: Anemic , Fe def , continued niferex per home regimen
5. FEN: Electrolytes were monitored and replaced as needed Maintained on
phoslo , nephrovite , calcitriol. Renal , cardiac diet
6. Ppx: subcutaneously hep
7. Dispo: Patient was discharged to home in stable condition.
He is to follow-up with dialysis on Friday and Dr. Tyacke in cardiology
on 10 of October at 11:15 a.m.
ADDITIONAL COMMENTS: Please take all prescribed medications and attend dialysis on Friday as
well as cardiology follow-up as scheduled. Return to hospital if you
develop chest pain , shortness of breath , nausea , vomiting , or any other
symptoms that you find concerning.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MORGUSON , SHONNA A. , M.D. , PH.D. ( XP22 ) 2/27/05 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 888
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
- |
N |
N |
N |
N |
N |
445620391 | PUO | 08719699 | | 7687881 | 3/18/2005 12:00:00 a.m. | history of ICD | | DIS | Admission Date: 8/18/2005 Report Status:
Discharge Date: 3/21/2005
****** FINAL DISCHARGE ORDERS ******
SIGNS , CANDICE 770-80-72-7
Arizona
Service: CAR
DISCHARGE PATIENT ON: 10/23/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: THEILING , BREE MARLYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
Alert overridden: Override added on 6/6/05 by
HASKO , ROSALIND D. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: needs both
INSULIN NPH HUMAN 10 UNITS subcutaneously twice a day
LISINOPRIL 10 MG orally every day
OXYCODONE 5-10 MG orally every 6 hours as needed Pain
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 6/6/05 by
HASKO , ROSALIND D. , M.D.
on order for TRICOR orally ( ref # 95176619 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & FENOFIBRATE ,
MICRONIZED Reason for override: monitoring INR
Previous override information:
Override added on 6/6/05 by HASKO , ROSALIND D. , M.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 76673508 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: needs both
KEFLEX ( CEPHALEXIN ) 250 MG orally four times a day X 12 doses
Starting when intravenous ANTIBIOTICS END
Number of Doses Required ( approximate ): 20
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
TRICOR ( FENOFIBRATE ) 145 MG orally every day
Alert overridden: Override added on 6/6/05 by
HASKO , ROSALIND D. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & FENOFIBRATE ,
MICRONIZED Reason for override: monitoring INR
Number of Doses Required ( approximate ): 2
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: No heavy lifting and do not lift L elbow above L shoulder x 1 month
FOLLOW UP APPOINTMENT( S ):
Dr. Schoeppner November 10:40am scheduled ,
Arrange INR to be drawn on 11/18/05 with f/u INR's to be drawn every
4-7 days. INR's will be followed by primary care physician
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
history of ICD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of ICD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF ( congestive heart failure ) CAD ( coronary artery disease ) history of CABG
( history of cardiac bypass graft surgery ) dm ( diabetes
mellitus ) htn ( hypertension ) hyperchol ( elevated
cholesterol ) cri ( chronic renal dysfunction )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of dual chamber ICD
BRIEF RESUME OF HOSPITAL COURSE:
69 year-old man with ischemic CMP ( EF 25-30% ) , recent
admit for atrial flutter , history of ablation , and NSVT. Primary prevention
ICD placed without complicaiton. Had short runs of AF during
procedure. For coumadin , baby ASA. Also history of HTN , DM , CRI ,
CHF.
ADDITIONAL COMMENTS: Continue coumadin 5mg each night. Have your INR/coumadin level checked
on Monday , May
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KONTOS , LEANDRA S. , PA-C ( KB76 ) 10/23/05 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 889
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
569777259 | PUO | 17815143 | | 508010 | 8/6/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/4/1993 Report Status: Signed
Discharge Date: 2/15/1993
HISTORY OF PRESENT ILLNESS: Mr. Raheem is a 44 year old man with a
history of hypertension and a family
history of coronary artery disease who presents with new onset of
chest pain. He has been previously treated at the ONCMC for
hypertension. He has no cardiac history , no prior history of chest
pain. He ran out of his blood pressure medicines approximately one
week prior to presentation. He was feeling well until the day of
admission while at work when he noted onset of substernal chest
pain while seated. He was diaphoretic , nauseated , but had no
vomiting. He also had some shortness of breath but no
palpitations. He went to CHH with the same pain and an
electrocardiogram showed LVH with strain. He was given oxygen and
sublingual Nitroglycerin without relief. He was sent to the
I Warho Hospital emergency room. There , he was treated
with Magnesium Sulfate , intravenous Lopressor , intravenous Nitroglycerin , and
sublingual Nifedipine. His blood pressure at CHH had been 210/150.
His pain then resolved with a total of approximately five hours.
He was entirely pain-free since his treatment in the emergency
room. PAST MEDICAL HISTORY: Significant for only hypertension. He
was on three medications which he is unsure of , including
Captopril. He apparently had good blood pressure control with his
blood pressure medication. ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Captopril of unknown dose; Hydrochloro-
thiazide 15 mg orally every day; Diltiazem of unknown dose. FAMILY
HISTORY: Significant for his father who died of myocardial
infarction at age 50. SOCIAL HISTORY: He works as a plumber at
Delpgenebrid Dence U He does not drink and does not smoke.
PHYSICAL EXAMINATION: He is a middle-aged , black man , in no
apparent distress. His blood pressure was
140/100 , pulse 76 , afebrile. Head and neck exam showed PERRL ,
oropharynx was benign. Neck was supple and no adenopathy. Lungs
were clear to auscultation. His cardiovascular exam revealed a
regular rate and rhythm , normal S1 and S2 , an S4 gallop. No
murmurs or rubs , no jugular venous distention , and his carotids
were 2+ bilaterally. Abdomen; good bowel sounds , no hepato-
splenomegaly , no masses. Extremities; no clubbing , cyanosis , or
edema. Neurologic exam was non-focal.
LABORATORY EVALUATION: potassium 4.9 , BUN 11 , creatinine 1.1 ,
glucose 134 , hematocrit 44.6 , white count of
11 , and platelets of 223. CK was 215. physical therapy was 12.1 , PTT 30.1. His
electrocardiogram showed him to be in normal sinus rhythm at 83
beats per minute , normal intervals , axis was -29. He did have LVH
with strain. His chest x-ray showed no pulmonary vascular
redistribution , no effusions or infiltrates.
HOSPITAL COURSE: Patient was admitted to the coronary care unit
and ruled in for a myocardial infarction. His
peak CK was 453 with MB fraction of 16.5. He was in the coronary
care unit for one day , after which he was transferred to the floor.
He had no arrhythmias or complications of his myocardial
infarction. Echocardiogram was obtained which showed moderate
concentric LVH with moderate chamber enlargement , posterolateral
hypokinesis , and ejection fraction of 45% , and moderate mitral
regurgitation with thickened mitral valve leaflets. His
hypertension was initially controlled with Lopressor 150 mg three
times a day. He was then changed to Atenolol and Captopril. With
these medications , he had good blood pressure control. One week
after his myocardial infarction , he underwent an exercise tolerance
test MIBI. He went for 9 minutes on his exercise tolerance test
and stopped due to completion of his protocol. He had no chest
pain or shortness of breath and no ischemic changes on his EKG , and
reached a peak blood pressure of 180/85 and a peak pulse of 94.
His MIBI images showed a fixed defect in the apical anterior
lateral wall , but no reversible changes , consistent with myocardial
infarction but no ischemia. He is discharged to home in stable
condition.
DISPOSITION: MEDICATIONS: Atenolol 100 mg orally every day , aspirin
325 mg orally every day , Lisinopril 10 mg orally every day ,
sublingual Nitroglycerin 1/150 one tablet sublingual x3 every 5 minutes
as needed chest pain. He will have follow-up with Dr. Heslop at
CHH I Re Ale , and with Cardiology , Dr. Nanci Gort
Dictated By: TRISH CHAIX , M.D.
Attending: CARA C. BARNABA , M.D. HL86
PM660/9306
Batch: 8230 Index No. XFTFN10JZF D: 10/16/93
T: 11/13/93
Document id: 890
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
851544510 | PUO | 74695281 | | 456772 | 9/17/2001 12:00:00 a.m. | non-cardiac chest pain | | DIS | Admission Date: 7/2/2001 Report Status:
Discharge Date: 7/16/2001
****** DISCHARGE ORDERS ******
BROFFT , BELINDA 792-10-08-2
De Oak N
Service: CAR
DISCHARGE PATIENT ON: 7/20/01 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 7/20/01 by
SENGBUSCH , SHALANDA Y. , M.D.
on order for COUMADIN orally ( ref # 00489643 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
CAPTOPRIL 12.5 MG orally three times a day HOLD IF: SBP < 100 AND CALL HO
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Override Notice: Override added on 2/21/01 by
KINABREW , MARGIT H. , M.D.
on order for ALDACTONE orally ( ref # 25569998 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & SPIRONOLACTONE
Reason for override: AWARE Previous override information:
Override added on 2/21/01 by KINABREW , MARGIT H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
CAPTOPRIL Reason for override: AWARE
DIGOXIN 0.125 MG orally every other day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
NIFEREX-150 150 MG orally twice a day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
ALDACTONE ( SPIRONOLACTONE ) 25 MG orally every day
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 2/21/01 by
KINABREW , MARGIT H. , M.D.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & SPIRONOLACTONE
Reason for override: AWARE
COUMADIN ( WARFARIN SODIUM ) 6 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 7/20/01 by
SENGBUSCH , SHALANDA Y. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
CARVEDILOL 3.125 MG orally twice a day HOLD IF: SBP < 100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 5
CELEXA ( CITALOPRAM ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Cara Barnaba within 1-2 weeks ,
Dr. Cadoff within one week ,
ALLERGY: Iv contrast dyes
ADMIT DIAGNOSIS:
chest pain , R/O MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Chronic AF since 11/27 , HTN , BPH , ventricular pacemaker , history of CHF , left
buttock hematoma , history of TURP , history of TV , MV repair 3/19 , ischemic
cardiomyopathy
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
78 year-old man who presents with 2 episodes of SSCP. Recently had MV and TV
repair with SVG to OM1. Reported to have 80% diag , 70% LCX from a cath
in Ohio in 3/1 Also history of HTN , DM 2 ( diet controlled ) , AF ,
ventricular pacemaker , ischemic CMP , EF 30%. CP occurred while at
rest , no radiation and no associated symptoms. 1st episode was 10/8 ,
resolved spontaneously. Came to ED , EKG was paced , CK flat , TnI
elevated at 0.17 , similar to value on 4/21 when patient came in for a TIA.
Mr. Brofft was sent home with sublingual nitro. Pain occurred again while
watching TV , resolved with one sublingual nitro. Was admitted for workup of
possible ischemia. Currently CP free.
1. CV: Ischemia: ruled out for MI , added isordil to regimen , ASA.
Continue carvedilol , captopril. Likely to have CAD , Adenosine MIBI
revealed fixed inf/lat defect , consistent with LCX disease. No
reversible defects. Since chest pain is unlikely to be cardiac in
origin , will stop nitrates. patient was able to amubulate without SOB or CP
CHF: euvolemic. continue lasix , aldactone , digoxin.
2. Endo: DM 2 , diet controlled. HbA1C 5.8%
3. Renal: baseline Cr 2.0
4. Neuro: recent history of TIA , on coumadin , may not want to reverse
anticoagulation for possibility of cath.
5. Heme: coumadin was held for possible cath , but was restarted on day
of discharge.
ADDITIONAL COMMENTS: You were admitted to the hospital for chest pain , and we have made sure
that you are not and did not have a heart attack. We also did a
perfusion test to make sure that your heart muscle is receiving
adequate amounts of blood flow. If your chest pain recurrs , gets
worse , or you become short of breath , please call you cardiologist and
return to the emergency department.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Make appointment with Dr. Barnaba within the next 1-2 weeks.
VNA: Please oversee medications , check vitals , and draw physical therapy/INR once a
week , starting Thrusday 1/20/01.
physical therapy: Please help Mr. Brofft regain strength , flexibility and range of
motion.
No dictated summary
ENTERED BY: SENGBUSCH , SHALANDA Y. , M.D. ( UG29 ) 7/20/01 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 891
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
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787057427 | PUO | 28206506 | | 7663792 | 7/29/2006 12:00:00 a.m. | PANCREATITIS | Signed | DIS | Admission Date: 9/17/2006 Report Status: Signed
Discharge Date: 10/17/2006
ATTENDING: HEIDELBERG , AMIE SALLY JANUARY
DATE OF ADMISSION: 1/1/2006.
DATE OF DISCHARGE: 10/7/2006.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old female with a
history of hypertension and blindness who presents with three
days of acute abdominal pain , nausea , and vomiting. She
presented in this manner to her LMC Clinic on the date of
admission , and was sent immediately for an abdominal CT , which
was noted to have findings consistent with pancreatitis. At that
time , she was transferred to the Pagham University Of
emergency department. The patient reports that the pain began in
her upper abdomen three days prior to admission with radiation
throughout the entire abdomen. She was eating soup when she
first noted the acute onset of this pain and then had an episode
of emesis. Since then , she has not been feeling well , and not
been eating much , but did not have any further episodes of
emesis. She did have chills overnight , but no sweats or no
fevers and no diarrhea. Her last bowel movement was three days
prior to admission. The pain was more cramping and burning than
sharp pain. She had never had prior episode like this. She is a
rare drinker , mostly on holidays. Has not had any recent viral
illnesses , although did have a recent flu shot. Did not have any
sick contact. In the Pagham University Of emergency
department , she received 1 liter of normal saline through her intravenous ,
2 mg of morphine intravenous , and potassium replacement.
REVIEW OF SYSTEMS: She also endorsed a small amount of an
intentional weight loss and denied any chest pain , shortness of
breath , cough , or symptoms suggestive of fluid overload.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Legal blindness , likely secondary to macular degeneration.
3. Obesity.
4. Osteoarthritis.
5. Status post total hip replacement.
6. Peripheral neuropathy.
7. Status post TAHBSO for fibroids.
MEDICATIONS ON ADMISSION:
1. Diovan 80 mg orally daily.
2. Premarin 0.9 mg orally daily.
3. Norvasc 10 mg orally daily.
ALLERGIES: Lisinopril causes angioedema.
SOCIAL HISTORY: The patient lives alone and is retired , but
previously worked for an epilepsy foundation. She has never
smoked tobacco. Does occasionally drink alcohol and has never
used any illicit drugs.
FAMILY HISTORY: She does have a sister with a history of a
dropped foot , but does not have any family history of diabetes ,
coronary artery disease , cancer , or pancreatitis.
PHYSICAL EXAMINATION ON ADMISSION: The temperature was 100.3 ,
heart rate 95-110 , blood pressure 124-151/60-77 , respiratory rate
of 18 , oxygen saturation of 97% on room air. In general , she was
comfortable and in no acute distress. HEENT , she has chronic
injection on the left conjunctiva , but her oropharynx was clear.
Pupils were equal , round , and reactive , and extraocular movements
were intact. Her neck showed no thyromegaly , no lymphadenopathy ,
and her JVP was flat. Chest with slight bibasilar crackles.
Heart with a regular rate and rhythm , and a 2/6 systolic murmur
at the right upper sternal border without radiation. Abdomen was
soft with decreased bowel sounds throughout and diffuse moderate
tenderness to palpation without rebound , guarding , or Murphy.
Extremities showed trace bilateral pitting edema to the mid shin
that were warm and well perfused with 2+ pulses. Skin showed no
rashes. Neuro exam was alert and oriented x3 and was grossly
nonfocal.
LABORATORY VALUES ON ADMISSION: Significant for chem-7 with
potassium of 2.7 , bicarbonate of 29 with a normal creatinine of
0.7. CBC showed a white blood cell count of 11.7 with 74%
neutrophils , hematocrit of 36.2 , increased from a baseline of 32 ,
platelets of 326 , and MCV was 85. LFTs were slightly elevated
with an AST of 69 , ALT of 92 , alkaline phosphatase of 148 , a
total bilirubin of 1.1. Amylase was 133 , lipase was 86 , albumin
was 3.7 , and a urinalysis showed 2+ ketones , a specific gravity
of 1.112 , no white blood cells , and 2+ squamous epithelial cells.
IMAGING: An EKG showed no change from her prior diffuse T-wave
flattening and T-wave inversion with normal sinus rhythm at 96
beats per minute. Chest x-ray showed tiny bilateral pleural
effusion and a slightly globular heart that was otherwise normal.
An abdominal CT was consistent with pancreatitis with
peripancreatic stranding , and there was stones seen in the
gallbladder; however , there was no common bile duct dilatation
and no pseudocyst or evidence of necrosis in the pancreas.
ASSESSMENT: This is a 70-year-old woman with a history of
hypertension who presented with acute abdominal pain and an
abdominal CT consistent with pancreatitis with gallstones in the
gallbladder , but without evidence of obstruction.
HOSPITAL COURSE BY PROBLEM:
1. GI: Pancreatitis diagnosed by clinical picture. Laboratory
values on CT findings on admission with no evidence of pseudocyst
or necrosis or other surgical complications of pancreatitis.
Though likely etiology for pancreatitis was gallstone given that
there were gallstones seen on her abdominal CT and that she had
elevation of some of her LFTs. She did go on to have a right
upper quadrant ultrasound to reevaluate. The common bile duct
looked not dilated , but right at the upper limits of normal.
Given this borderline values she was also sent for MRCP to rule
out CBD dilatation in the event that she may need cholecystectomy
in the future. The MRCP showed again no evidence of obstruction
of the duct and no evidence of cholecystitis. She was treated
with aggressive intravenous fluid hydration for the first several days of
admission. Pain controlled with morphine , and was kept npo
for several days until her pain improved. At this time , her intravenous
fluids were gradually decreased , and her diet was gradually
advanced as tolerated. By the time of discharge , she was
tolerating a regular diet without any recurrence of her abdominal
pain , nausea , or vomiting , and was not requiring any further pain
medication. Her LFTs , amylase , and lipase normalized within a
few days of treatment early in the hospitalization. She was also
maintained on intravenous twice a day H2 blocker , and then discharged to home
on orally Pepcid. Given her stated history of heartburn. She was
given an appointment to follow up with the LMC General Surgery
Clinic for evaluation for likely cholecystectomy and instructed
that this would be her plan of care after discharge.
2. Cardiovascular. In terms of ischemia , the patient did have
some T-wave flattening diffusely on her EKG; however , had no
chest pain. This is likely related to her hypokalemia on
presentation. She did rule out for an MI with 3 sets of negative
enzymes and had no EKG changes or telemetry changes concerning
for ischemia and no bouts of chest pain throughout her admission.
In terms of pump , she was aggressively fluid rehydrated , given
her dehydration on admission , and her diagnosis of pancreatitis ,
but did not have any signs of fluid overload at any point during
her hospitalization , and was returned to all orally diet without
need for intravenous fluids prior to discharge. Her blood pressure was
well controlled originally with her home medication of Norvasc
and then with a change to Lopressor in order to obtain good rate
control as well without bouts of hypertension throughout this
admission. In terms of rhythm , the patient did have some
episodes of likely atrial fibrillation versus multifocal atrial
tachycardia on telemetry early in her admission. These episodes
would last only a few seconds and resolved spontaneously and the
patient did not have symptoms from these. This was thought to be
likely related to her acute illness and her hypokalemia on
admission. However , she was started on Lopressor for better rate
control , which was up titrated as needed with good effect. By
the time of discharge , she had had no events on telemetry for
greater than 36 hours. She was discharged on new medication of
Toprol to control her rate and also taking the place of her
Norvasc for her blood pressure control.
3. ID. The patient did have a low-grade temperature on
admission , but this was likely related to her inflammation.
Blood cultures x2 drawn at the time of admission were negative.
The chest x-ray was negative for any growth and finalized before
discharge. Chest x-ray was negative for any evidence of
pneumonia and a urinalysis was negative. She was not started on
any antibiotics throughout the admission.
4. Hematology. The patient has underlying anemia with an
unclear baseline hematocrit given her infrequent labs at this
institution. Her hematocrit was stable between 31 and 36
throughout her hospitalization here and recommended that she
follows up with her primary care provider for further
instructions on her anemia.
5. Fluids , electrolytes , nutrition. The patient was initially
aggressively fluid rehydrated and then changed to maintenance intravenous
fluids. Thus , her diet was advanced. Potassium and magnesium
were repeated as needed with electrolytes originally checked
twice per day until stabilized. She was originally maintained
npo and then her diet was gradually advanced as her symptoms
tolerated to a house diet before discharge.
6. Prophylaxis. The patient was maintained on intravenous twice a day , Pepcid
for GI prophylaxis , and Lovenox for DVT prophylaxis.
7. Code status. The patient is DNR/DNI.
DISCHARGE PLAN: The patient is discharged to home with a
visiting nurse to check in on her for medication management ,
nutrition , and home safety evaluation. She has followup
appointments with her primary care provider , Dr. Grillette , and
also with the LMC General Surgery Clinic regarding possible
cholecystectomy. She was instructed not to take her Norvasc any
more and to take instead the Toprol. Also , she was instructed to
call her physician for any new bouts of abdominal pain , fevers ,
or any other worrisome symptoms.
DISCHARGE MEDICATIONS:
1. Toprol-XL 100 mg per day.
2. Pepcid 20 mg orally twice a day
3. Diovan 80 mg orally daily.
4. Premarin 0.9 mg orally daily ( however , it is recommended that
her primary care physician consider weaning off this medication given its known
risks and recent evidence-based literature , and also given the
possible risk of gallstones of this medication ).
eScription document: 6-1803809 NFFocus
Dictated By: YEAGLEY , MA
Attending: HEIDELBERG , AMIE SALLY
Dictation ID 3579623
D: 8/7/06
T: 2/18/06
Document id: 892
| Target |
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237841533 | PUO | 71822819 | | 196250 | 5/9/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 2/27/1991 Report Status: Unsigned
Discharge Date: 4/10/1991
PROBLEM LIST: ACUTE MYOCARDIAL INFARCTION.
POST MYOCARDIAL INFARCTION ANGINA.
LAD CLOT.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old white
male who has no known cardiac risk
factors. On 6/15/91 , he had one hour of substernal chest pressure
which resolved spontaneously while at work. The next day while
taking a nap , he awakened from sleep with heavy dull substernal
pain with some pleuritic quality , maximum pain was 7-8/10 with
diaphoresis but no shortness of breath. He went to Ro General Hospital , the pain subsided shortly after arrival after
sublingual nitroglycerin , oxygen and morphine. The total duration
of the pain was approximately two hours. EKG showed 2 mm ST
elevations in I and AVL. He was not given PTA because of his past
history of hematuria. He was taken to the Coronary Care Unit on intravenous
heparin , TNG and diltiazem. He ruled in with peak CK of 441 with
18% MB's. His EKG's have shown ST returning to baseline and T wave
inversions in I , L , V2-V6. On 5/13 , he had recurrent 1/10 chest
pain. On 10/8 , he had recurrent 7/10 chest pain for 90 minutes. He
was transferred to Pagham University Of shortly after the
chest pain resolved. PAST MEDICAL HISTORY: Hematuria with
multiple cystoscopies and IVP procedures negative. MEDICATIONS: On
transfer included nitroglycerin , diltiazem and propanolol. HABITS:
The patient does not smoke or drink. FAMILY HISTORY: Significant
for paternal grandfather who died of a myocardial infarction at 55
years of age. His father died at 85. His mother died at age 90.
SOCIAL HISTORY: He is Chief of Custodial Services at South Ton Au He is married and lives with his wife.
PHYSICAL EXAMINATION: On admission revealed a temperature of
99.4. Blood pressure was 110/70. Pulse was
77. Respiratory rate was 18. Examination was significant for
bibasilar rales which cleared with coughing. Cardiac exam revealed
S4 , S1 , S2 , no murmurs or rubs. There was no jugular venous
distention. There were good peripheral pulses.
LABORATORY DATA: On admission included a hematocrit of 38.5.
PTT was 51.5. CK was 270.
HOSPITAL COURSE: The patient was admitted five days after his
first myocardial infarction with a new CK bump
felt to be a second anterolateral myocardial infarction. He was
treated with heparin and beta blockers. He was taken to cardiac
catheterization on the following day which revealed normal
pressures , cardiac output of 6 , cardiac index of 2.9 , thrombus in
the proximal LAD , 90% D1 and 30% proximal RCA lesion. He had
anterior hypokinesis with an LV ejection fraction of 72%. The
patient was treated with five days of heparin and then went down
again to the catheterization laboratory for PTCA of his LAD lesion
which was successful. The patient has had no recurrent chest pain
during this hospitalization. The PTCA was complicated by a small ,
4 x 3 cm right groin hematoma but he had good peripheral pulses and
no bruits. The patient was discharged to home in good condition.
DISPOSITION: MEDICATIONS: On discharge included Lopressor , 100
mg orally twice a day; aspirin , one orally every day and
nitroglycerin , as needed He will follow-up with his CHH internist
and a cardiologist at Joyma Parkway , Ne Me , Kansas 32630 CHH .
OB535/8072
BREE THEILING , M.D. IY1 D: 9/12/91
Batch: 6319 Report: B8202A53 T: 1/7/91
Dictated By: MARCELINE G. NEWYEAR , M.D.
Document id: 893
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043383235 | PUO | 41550960 | | 9294497 | 11/28/2006 12:00:00 a.m. | morbid obesity | | DIS | Admission Date: 10/20/2006 Report Status:
Discharge Date: 9/17/2006
****** FINAL DISCHARGE ORDERS ******
TINDOL , SHARI 406-74-95-0
Landbeth Tuc
Service: GGI
DISCHARGE PATIENT ON: 1/25/06 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MONDELL , MELINA RACHAEL , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
AUGMENTIN SUSP. 250MG/62.5 MG ( 5ML ) ( AMOXICIL... )
5 MILLILITERS orally three times a day X 15 doses
Food/Drug Interaction Instruction
May be taken without regard to meals
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF NEB four times a day as needed Wheezing
Override Notice: Override added on 11/8/06 by
MOOSE , BUCK , M.D.
on order for PROCHLORPERAZINE PR 25 MG every 12 hours ( ref #
209404735 )
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROCHLORPERAZINE Reason for override: AWARE
Previous override information:
Override added on 11/8/06 by MOOSE , BUCK , M.D.
on order for PHENERGAN intravenous 25 MG every 4 hours ( ref # 128489091 )
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROMETHAZINE Reason for override: AWARE
COZAAR ( LOSARTAN ) 25 MG orally DAILY Instructions: crush
PROCHLORPERAZINE 25 MG PR every 12 hours as needed Other:emesis
Alert overridden: Override added on 11/8/06 by
MOOSE , BUCK , M.D.
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROCHLORPERAZINE Reason for override: AWARE
DIET: stage II gastric bypass
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please call Dr. Mondell immediately to schedule follow-up appointment ,
Diabetes Clinic via phone- 877 090 9068 if necessary for high sugars ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , OSA , asthma , DM
OPERATIONS AND PROCEDURES:
laparoscopic adjustable gastric band
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to the Wayne Ravilleston , Massachusetts 01406 on 2/19/06 after
undergoing laparoscopic gastric banding. No concerning intraoperative
events occurred; please see dictated operative note for details. The
patient was transferred to the floor from the PACU in stable condition.
Patient had adequate pain control and no issues overnight into POD1. UGI
on POD1 was negative for obstruction or leak and the patient was started
on a Stage I diet which was tolerated well. The patient was then
advanced to clears and discharged to home a Stage II diet. Her incisions
were without evidence of hematoma collection or infection. The
remainder of the hospital course was relatively unremarkable , and she was
discharged in stable condition , ambulating and voiding independently , and
with adequate pain control. The patient was given explicit instructions
to follow-up in clinic with Dr. Mondell in 1-2 weeks.
ADDITIONAL COMMENTS: You may shower 2 days after surgery , but do not tub bathe , swim , soak , or
scrub incision for 2 weeks. Bandage strips will fall off over time.
Seek medical attention for fevers ( temp>101.5 ) , worsening pain , drainage
or excessive bleeding from incision , chest pain , shortness of breath , or
any other symptoms of concern. Follow up with your surgeon in 1-2 weeks.
Please do not drive or consume alcohol while taking pain medications.
Please follow diet instructions. Resume home medications as instructed.
Please crush pills , open capsules , or take elixirs. Resume metformin also.
Call Diabetes Service if necessary if any problems.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KIELBASA , RUEBEN , PA-C ( HP50 ) 1/25/06 @ 06
****** END OF DISCHARGE ORDERS ******
Document id: 894
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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486594125 | PUO | 84611000 | | 936672 | 8/23/1999 12:00:00 a.m. | PULMONARY EMBOLUS | Signed | DIS | Admission Date: 5/3/1999 Report Status: Signed
Discharge Date: 1/20/1999
PRINCIPAL DIAGNOSIS: SHORTNESS OF BREATH.
PROBLEMS DURING ADMISSION: 1 ) MIGRAINE HEADACHE.
2 ) NONSPECIFIC ABDOMINAL PAIN.
HISTORY OF PRESENT ILLNESS: The patient is a 35 year old female
who carries a diagnosis of lupus for
seven years , recently discharged with a pulmonary embolism and deep
vein thrombosis , on Coumadin and Lovenox , now returns with a
complaint of new onset chest pain and sob. Previously the patient has been
stable with her SLE but had started Plaquenil recently. On
9/28/99 she presented to her rheumatologist complaining of
intermittent leg swelling for the past year and was found to have
left superficial femoral and gastrocnemius DVT. She was about to
begin Lovenox when she mentioned that she had also experienced
occasional pleuritic chest pain over the last five years. She then had a V/Q
scan which was read as intermediate probability for PE. For definitive
diagnosis , a pulmonary angiogram was done on 2/28/99 showing bilateral apical
small pulmonary emboli. She was treated with intravenous heparin and was started on
Coumadin to a therapeutic INR of 2.0. She also had an unremarkable
echocardiogram at that time. On 2/30/99 , the patient returned
with increasing wheezing and shortness of breath. Her INR was 1.8.
Work up revealed an intermediate probability right-sided V/Q
mismatch with a probable new PE. Repeat echocardiogram showed no right
heart strain. It was thought that she had had a recurrent PE in
the setting of subtherapeutic INR. LE DVT was stable on the LENIs.
She was discharged on Lovenox and Coumadin to obtain a goal INR of
3.0. Unfortunately , two days prior to admission , the patient again
noted increased dyspnea on exertion. She has otherwise been
active , feeling well over the past week. She denies chest pain ,
leg pain , wheezing. V/Q scan performed on the morning of admission
showed new mismatched lesions at the left posterior base and right
anterior base. She notes stomach upset for the previous four days ,
recently had an upper GI work up , including an EGD which was
negative by patient's report. She denies any melena , nausea ,
vomiting , BRPPR. She has been tolerating orally
PAST MEDICAL HISTORY: 1 ) SLE x 7 years , on Plaquenil recently.
2 ) Migraine headaches. 3 ) History of DVT.
4 ) Status post laparoscopic cholecystectomy. 5 ) Status post
cesarean section.
ALLERGIES: Bactrim causing diarrhea , Ceftin causing diarrhea.
MEDICATIONS ON ADMISSION: Tylenol as needed; Plaquenil 200 mg every day;
Coumadin 7 mg orally every day; Lovenox for
the previous 6 days; Allegra; Albuterol MDI; Cipro; Heptadine.
FAMILY HISTORY: No history of clotting or bleeding disorders.
Her father died of leukemia. She has two sisters
with arthritis and one sister with ulcerative colitis.
SOCIAL HISTORY: The patient has been married for 10 years and has
an eight-year-old daughter. She is an office
worker in Park Stasti Ence and has not worked for the past month. She
quit smoking on 9/28/99 at the time of her first admission. She
has 10-15 pack years and denies any history of alcohol or IVDU.
PHYSICAL EXAMINATION: An obese , pleasant , female in no acute
distress. Pulse 87. Blood pressure 118/50.
Saturation 97 percent on room air. Afebrile. HEENT: Oropharynx
is clear. Neck is supple without lymphadenopathy or thyromegaly or
JVD. Lungs are clear to auscultation except scattered rales at the
right base. Heart normal S1 and S2. A II/VI systolic ejection
murmur at the left upper sternal border. Abdomen - large , obese ,
nontender , nondistended. Extremities - no palpable cords or edema.
Neurologic - alert and oriented , no focal deficits.
LABORATORY DATA: Creatinine 0.7 , WBC 105 , hematocrit 40 , platelets
307. Electrocardiogram normal sinus rhythm at
86. Normal intervals and axis. No ST-T wave abnormalities.
HISTORY OF PRESENT ILLNESS: , The patient was
placed on intravenous heparin and the Lovenox and Coumadin were
discontinued in anticipation for an IVC filter placement the
following morning. She also received intravenous dihydroergotamine
for migraine headaches with good effect by the following morning.
The following morning , the patient received 2 units of FFP because
her INR was 3.0. The decision to place a filter was postponed and
instead a pulmonary angiogram was performed. This revealed no
obvious recurrent pulmonary embolism. The morning
of 10/27/99 , prior to the angiogram , two
events occurred. First event , the patient was walking to the
bathroom and her heart rate was noted to go at 140 beats per minute
and was approximately sinus tachycardia or supraventricular
tachycardia. This resolved after 45 seconds without intervention
and did not recur and there were no associated symptoms and the
patient was unaware of the event. The second event occurred about
one hour later and the patient noted approximately 5/10 sharp right
lower sternal border chest pain which was not pleuritic and not
positional and resolved spontaneously over the next 5 minutes and
did not recur. She also had some abdominal pain. She tolerated orally's without
any gastrointestinal
symptoms throughout and the pain was mild with a benign abdominal
exam. This will be pursued by her outpatient physician , if
indicated. The patient was resumed on Coumadin 10 mg orally every bedtime
as well as Lovenox in the interim 100 mg subcutaneously twice a day until she
achieves a therapeutic INR which was determined by Cardiology to be , 3.5 ,
given that she has not
had a recurrent PE. Throughout her stay she remained afebrile and
with a saturation of approximately 94-95 percent on room air ,
breathing comfortably.
FOLLOWUP: She will follow up with her primary care doctor and have
her INR checked in two days.
DISCHARGE MEDICATIONS: Cipro heptadine 4 mg orally twice a day;
Plaquenil 200 mg orally every day; Coumadin 10 mg
orally every bedtime; Lovenox 100 mg subcutaneously every 12 hours.
DISPOSITION: The patient is discharged home. She will follow up
with her primary care doctor within one week.
Dictated By: JOSEFINA KOUGH , M.D. UM87
Attending: MARJORY GUMINA , M.D. PO16
CC: MATHEW STAUTZ MD primary care physician
Batch: 46334 Index No. DIDZP16M0C D: 4/28/99
T: 6/24/99
Document id: 895
| Target |
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423657954 | PUO | 64891866 | | 2448600 | 10/13/2003 12:00:00 a.m. | L foot gout | | DIS | Admission Date: 3/29/2003 Report Status:
Discharge Date: 6/2/2003
****** DISCHARGE ORDERS ******
PETRUS , ALLEN C. 396-09-30-3
Sterlans Irv Layork
Service: MED
DISCHARGE PATIENT ON: 9/6/03 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
COLCHICINE 0.6 MG orally twice a day
LOPID ( GEMFIBROZIL ) 600 MG orally twice a day
Alert overridden: Override added on 8/19/03 by
THRONEBURG , FLORETTA MARK , M.D. , M.S.
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
GLIPIZIDE 10 MG orally twice a day
LISINOPRIL 40 MG orally every day
Override Notice: Override added on 8/19/03 by
FONTENO , LILIAN W. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 68230954 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: patient not on potassium-sparing
diuretic
NADOLOL 40 MG orally every 24 hours Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 8/19/03 by
THRONEBURG , FLORETTA MARK , M.D. , M.S.
on order for LOPID orally ( ref # 73139051 )
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
METFORMIN 500 MG orally twice a day
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: apply to L foot in between toes
PERCOCET 1 TAB orally Q4-6H as needed Pain
Instructions: Do not drink alcohol , drive a vehicle , or
operate heavy machinery while taking this medication as it
may cause drowsiness.
Alert overridden: Override added on 9/6/03 by :
POTENTIALLY SERIOUS INTERACTION: ACETAMINOPHEN &
ACETAMINOPHEN Reason for override: aware , will warn patient
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Tibbals ( Dr Verbasco office ) Tue 8/15 at 10:30am scheduled ,
No Known Allergies
ADMIT DIAGNOSIS:
L foot cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
L foot gout
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) dm ( diabetes mellitus ) high chol
( elevated cholesterol ) cva ( cerebrovascular
accident ) recurrent UTI psa ( elevated prostate specific antigen )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Colchicine and indomethacin for gout. Re-instated HCTZ upon discharge.
Indomethacin not prescribed on discharge given mild Cr elevation. Needs
to be re-checked. SBP slightly elevated ( 130-170s ) - ?HCTZ interruption
or need for increased B-blockade. Insulin sliding scale for blood
sugars ( 200-350 FS ) in hospital while on same home regimen.
BRIEF RESUME OF HOSPITAL COURSE:
72y/o M with NIDDM who presented with L foot pain/mild erythema and
inability to bear weight due to pain. Xray without fracture or evidence of
osteomyelitis. Treated with abx in ED and for HD#1 without improvement.
patient afebrile with normal WBC. Suspicious for gout. Treated with one dose of
Medrol ( blood sugars monitored and insulin sliding scale coverage ) and
then aggressively with Colchicine/Indomethacin with marked , fast
improvememt. Able to bear weight and ambulating at discharge.
Indomethacin d/c given Cr bump from 1.2 to 1.5. HCTZ reinstated at d/c.
ADDITIONAL COMMENTS: Do not drink alcohol , drive a vehicle or operate heavy machinery while
taking Percocet as this medication may cause drowsiness. Do not take
with Tylenol or other Tylenol ( acetaminophen ) containing medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Pls have your blood sugar , BP and Cr checked by Dr. Lagard
No dictated summary
ENTERED BY: LACKNER , JEANNETTE M. , M.D. ( OK1 ) 9/6/03 @ 02
REVIEWED BY: LACKNER , JEANNETTE M. , M.D.
****** END OF DISCHARGE ORDERS ******
Document id: 896
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
- |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
733752326 | PUO | 76521396 | | 878455 | 10/11/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/23/1995 Report Status: Signed
Discharge Date: 6/20/1995
HISTORY: Ms. Corp is a 63-year-old woman with peripheral vascular
disease who recently underwent revision of her left
superior femoral artery anterior tibial bypass graft , who now
presents with a cool , ischemic left foot.
Mrs. Corp is a 63-year-old , insulin-dependent diabetic with a long
history of peripheral vascular disease as well as multiple surgical
procedures. She underwent a right transmetatarsal amputation in
1990 and subsequently underwent a right femorla distal saphenous
vein bypass graft in 1991 which was later revised in 1992. She
seems to be doing well with the left side until September of this year ,
at which time she underwent a left superficial femoral artery to
anterior tibial artery bypass using non-reversed basilic vein
harvested from the right arm. She , however , had a large great toe
ulcer , possibly attributed to hammertoe , which subsequently
underwent a left great toe amputation performed on the 16 of November . After this time , she was discharged to the Bloduck Memorial Hospital in
Ron , where she was making progress in physical therapy and
rehabilitation. On the day prior to admission , she was exercising
with 4 pound weights on her legs with the physical therapist when
she described a cool sensation in her foot. She reported that her
foot had been blue , and there were no Dopplerable pulses. Color
later returned. The absence of pulses persisted over the course of
the night , after which point she was referred back to Pagham University Of for evaluation. She denies any significant pain
or any other complications.
PAST MEDICAL HISTORY: Remarkable for history of insulin-dependent
diabetes , history of coronary artery
disease , history of hypertension , cataracts , MRSA from her toe
wound on the 3 of March .
PAST SURGICAL HISTORY: Notable for the above , as well as
debridements of her toe amputation wound
site.
ADMISSION MEDICATIONS: Colace 100 mg twice a day , insulin Lente 12
units subcutaneously every afternoon supplemented by sliding
scale regular insulin scale , Isordil 30 mg three times a day , Zestril 5 mg every
d , Lopressor 50 mg twice a day , Axid 150 mg twice a day , Ofloxacin 200 mg
orally every 12 , Ecotrin 225 mg every day , Vancomycin 1250 mg every 24. She
reports an allergy to codeine and iodine.
ADMISSION EXAMINATION: Remarkable for the following findings:
She was afebrile , heart rate 72 , blood
pressure 140/70. Her right lower extremity was characterized by a
well-healed transmetatarsal amputation site. The foot was warm and
pink. The left side , however , was cool in comparison , although
remained pink with adequate capillary refill. Both femoral pulses
were easily palpable , as well as dorsal pedal pulse on the right.
Her right posterior tibial pulse was additionally biphasic by
Doppler. On the left , she had a biphasic Doppler graft pulse and
dorsopedal , although she had no identifiable posterior tibial
pulse. The remainder of the examination was unremarkable.
Admission labs were likewise unremarkable.
HOSPITAL COURSE: Mrs. Corp was admitted and placed on intravenous
Heparin until the following morning , at which
time she proceeded to the Angiography Suite. She was found to have
two 95% stenosis in a long segment of the left SFA and the left
distal SFA and anterior tibial vein graft was completely
thrombosed. She was successfully treated with stent placement and
received heparin and urokinase in the Intensive Care Unit overnight
with a turn-over pulses of the left leg Doppler. The following
day , her stents were removed. During the remainder of the hospital
course , her left foot remained pink and warm. Her wound had an
infection of exposed bone , but otherwise appeared to be granulating
well. Although left transmetatarsal amputation being considered ,
it was felt that she had a good chance of healing the wound
appropriately. She had a single temperature spike , although all
cultures remained negative. She had continuation of her Heparin
while she was started on a course of Coumadin to reserve patency of
her graft. The remainder of the hospital course was unremarkable.
On the 25 of May , she was discharged back to the Lakesmi Sonno Memorial Hospital in Ter Bellea Irv
DISCHARGE MEDICATIONS: Vancomycin 1250 mg intravenous every day , Ofloxacin 200
mg orally twice a day ( both antibiotics to
continue for an additional two week course ) , Coumadin with target
INR of 2.0 , last target 1.6 , then received 10 mg in evening x 2.
Additionally , Percocet 1-2 tablets orally every 4 as needed , Colace 100 mg orally
twice a day , insulin NPH 10 units subcutaneously twice a day , sliding scale insulin
subcutaneously every 4 , Isordil 30 mg three times a day , Zestril 5 mg every day , Lopressor 50 mg
twice a day , Axid 150 mg orally twice a day She will follow with Dr. Derham in
one to two weeks.
Dictated By: GAYLENE G. FANIEL , M.D. RQ51
Attending: ROSSIE MANKOSKI , M.D. NW98
OL936/5591
Batch: 050 Index No. B5CED7O3K D: 10/10/95
T: 10/10/95
Document id: 897
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
137405889 | PUO | 22505494 | | 509598 | 1/10/2001 12:00:00 a.m. | chf | | DIS | Admission Date: 1/10/2001 Report Status:
Discharge Date: 10/5/2001
****** DISCHARGE ORDERS ******
EVITTS , GRETTA 805-73-07-3
Sbay
Service: CAR
DISCHARGE PATIENT ON: 1/24/01 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HOLDA , ALYSE ANGELES , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
Override Notice: Override added on 6/25/01 by
BERNHART , CLORINDA P. , M.D.
on order for COUMADIN orally ( ref # 35354067 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
ALLOPURINOL 300 MG orally every day
DIGOXIN 0.25 MG orally every day
FOLIC ACID 1 MG orally every day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
ATIVAN ( LORAZEPAM ) 1 MG orally twice a day as needed anxiety or insomnia
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally twice a day
HOLD IF: sbp<90 , heart rate<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
THIAMINE ( THIAMINE HCL ) 100 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 6/25/01 by
BERNHART , CLORINDA P. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: will monitor
INSULIN 70/30 ( HUMAN ) 30 UNITS subcutaneously twice a day HOLD IF: fsg<60
Number of Doses Required ( approximate ): 10
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 60 MG orally every day
HOLD IF: sbp<90 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KCL SLOW REL. 20 MEQ X 1 orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LEVOFLOXACIN 250 MG orally every day Starting IN a.m. ( 11/3 )
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 6/25/01 by
BERNHART , CLORINDA P. , M.D.
on order for COUMADIN orally ( ref # 35354067 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: will monitor
AVAPRO ( IRBESARTAN ) 300 MG orally every day HOLD IF: sbp<90
Number of Doses Required ( approximate ): 5
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Alert overridden: Override added on 1/24/01 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: known
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Holda 1 weeks ,
Dr. Dominguez 10/18/01 scheduled ,
No Known Allergies
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
RECURRENT VT/VFIB CAD ( coronary artery disease ) history of MI ( history of
myocardial infarction ) history of CABG x4 ( history of cardiac bypass graft
surgery ) history of AICD ( history of implanted cardiac defibrillator ) history of sternal
wound infection ( history of wound infection ) history of sternum
resection IDDM ( diabetes mellitus ) chronic anemia
( anemia ) atrial fibrillation ( atrial fibrillation ) dyslipidemia
( dyslipidemia ) ?amiodarone toxicity
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
60 year-old M with ischemic CMP and AFib dx 5 weeks ago. He
was started on coumadin then , and last Tues , was cardioverted ( via the
AICD ). Later that night , he developed SOB , this became severe and
assoc with fever to 102.4 yesterday. Today , went to local
ED ( in RI ). Got lasix and Rocephin ( due to
bibasilar infiltrates on CXR ). WBC elevated at 12.2 ,
Bcx's pending. patient was sent to PUO at his request.
Here , low grade fever; requires FM O2; vitals
stable; mild-mod fluid overload. Will treat
empirically with levofloxacin ( ?aspiration , ?comm acq
PNA ). Will diurese ( well perfused ) and finally will
need to assess underlying rhythm ( not all beats
paced , need to see if back in AFib ). Repeat CXR and
F/U on cx's from
TH . 10/18 cx's from TH NGTD. CXR showed interval improvement from
past films. has bilateral small effusions that are stable and ?
aspiration in right base , but overall interval improvement. BCxs from
TH are neg at 3 days and ECHO is pending at time of discharge.
discharged on orally diuretics and 14 day course of levoflox.
sating well on RA at time of discharge.
ADDITIONAL COMMENTS: Patient should seek immediate medical attention if he develops chest
pain , shortness of breath , lightheadedness , fever , chills ,
palpitations , or falls.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: RACZ , MIREILLE N. , M.D. ( UQ96 ) 1/24/01 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 898
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
094513064 | PUO | 19651095 | | 4612676 | 3/19/2004 12:00:00 a.m. | Fever | | DIS | Admission Date: 11/12/2004 Report Status:
Discharge Date: 4/8/2004
****** DISCHARGE ORDERS ******
ROCHE , OLIN 214-43-79-6
Sundna Hwy
Service: MED
DISCHARGE PATIENT ON: 7/5/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GILFOY , DEANDRA LAZARO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
VASOTEC ( ENALAPRIL MALEATE ) 20 MG orally every day HOLD IF: sbp<100
Override Notice: Override added on 5/11/04 by
THRONEBURG , FLORETTA MARK , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
45156833 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: aware
MOTRIN ( IBUPROFEN ) 600 MG orally three times a day
Food/Drug Interaction Instruction Take with food
METHADONE HCL 20 MG orally three times a day
PERCOCET 1-2 TAB orally three times a day as needed Pain
NORVASC ( AMLODIPINE ) 5 MG orally every day HOLD IF: sbp<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: to affected areas
CELEXA ( CITALOPRAM ) 40 MG orally every day
ADVAIR DISKUS 100/50 ( FLUTICASONE PROPIONATE/... )
2 PUFF inhaled twice a day
CALCIUM CARB + D ( 600MG ELEM CA + VIT D/200 IU )
1 TAB orally twice a day
HYDROCHLOROTHIAZIDE 25 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
as needed Shortness of Breath
PREDNISONE Taper orally
Give 30 mg every 24 hours X 7 day( s ) ( 7/5/04 1/11/04 ) , then
Give 20 mg every 24 hours X 7 day( s ) ( 10/27/04 3/11/04 ) , then
Give 10 mg every 24 hours X 7 day( s ) ( 7/14/04 1/24/04 ) , then
Give 5 mg every 24 hours X 7 day( s ) ( 10/26/04 8/11/04 ) , then
DIET: House / ADA 2100 cals/dy
FOLLOW UP APPOINTMENT( S ):
Dr. Tressa Schlesener 10:00 a.m. 10/7/04 scheduled ,
Dr. Andreas Frankenberry 3:10 PM 4/18/04 scheduled ,
ALLERGY: LOBSTER , FLOWERS , STUFFED ANIMALS , THEOPHYLLINE ,
FLOWERS
ADMIT DIAGNOSIS:
fever
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Fever
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) obesity ( obesity ) OSA ( sleep
apnea ) asthma ( asthma ) low back pain ( low back
pain ) adhesive capsulitis ( left shoulder ) ( musculoskeletal pain )
rotator cuff tear , bilateral ( rotator cuff tear ) depression
heavy prescription opioid use
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
51 year-old f with morbid obesity , asthma , on chronic steroids , with 1 day
malaise and sent to ED when found to have T 101.3 by VNA this am
associated with chills. patient notes no localizing signs or Sx , dysuria ,
urgency , abd pain , n/v/d. At baseline non-productive cough which is
unchanged. No SOB. Did c/o bilat hip pain with ambulation over the
past few days. Also states daughter had fever 2 wks ago and grandchild
now infected as well. Also has required chronic steroids for 1 year
2/2 asthma flares with attempted tapers.
T 101.3 HR 84 BP 129/74 R 28 Sats 96%RA
EXAM: morbidly obese OP clear , tachypnic female , alert , cooperative ,
Lungs CTA with good airmovement , RRR no m/g/r , pannus with
maceration and candidial appearance , Abd with +BS and
no tenderness , 2+LE edema , hips with full ROM , mild bilat tenderness
to palp of ischial tuberosities.
UA negative. LABS: WBC 11.4 , all others unremarkable. CXR: poor study
2/2 habitus but no obvious cardiopulm process.
****************COURSE************************
ID: No localizing infection , follow blood Cx. No Abx for now.
Miconazole powder for pannus. O/n observation given chronic
immunosuppression. Cx negative and patient afebrile.
MSK: given motrin for bilat hip pain with improvement of Sx.
FEN: intravenous hydration , replete lytes.
DISPO: Home with VNA.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: BOWARD , SHAINA MURIEL , M.D. ( PB82 ) 7/5/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 899
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
N |
U |
U |
Y |
U |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
Y |
N |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
N |
N |
646616767 | PUO | 01770752 | | 3831156 | 1/24/2005 12:00:00 a.m. | joint pain | | DIS | Admission Date: 4/25/2005 Report Status:
Discharge Date: 3/28/2005
****** FINAL DISCHARGE ORDERS ******
SWARTZBAUGH , MALCOLM 865-22-93-6
Stin
Service: MED
DISCHARGE PATIENT ON: 2/21/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COLLICA , CHANELLE XOCHITL , M.D. , PH.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours
as needed Shortness of Breath , Wheezing
GLIPIZIDE 10 MG orally twice a day
Alert overridden: Override added on 5/25/05 by
HEAPHY , ALLA , M.D. , D.PHIL.
on order for GLIPIZIDE orally ( ref # 88629927 )
patient has a POSSIBLE allergy to
TRIMETHOPRIM/SULFAMETHOXAZOLE; reaction is Unknown.
Reason for override: home medication per family
LISINOPRIL 5 MG orally every day
METFORMIN 850 MG orally twice a day
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
90 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
INDOMETHACIN SUSTAINED RELEASE 75 MG orally every day
Food/Drug Interaction Instruction Take with food
DIET: No Restrictions
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Strite 11/1/05 10am ,
Dermatology Clinic ( to be scheduled - you will get a call from our coordinator at home ) ,
Dr. Jody Croll Kaitlyn Machnik to be scheduled - you will get a call from our coordinator at home ) ,
ALLERGY: TRIMETHOPRIM/SULFAMETHOXAZOLE
ADMIT DIAGNOSIS:
Joint pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
joint pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
joint pain
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI of R hip. Failed tap of L ankle. R trochanteric bursa injection
BRIEF RESUME OF HOSPITAL COURSE:
--CC: R Hip and L ankle pain --> inability to walk
--HPI: 58yo F with polyarthralgias for about 7 months. Initial contact with
rheumatology was 10/24 when admitted for R wrist pain. Dx as "gout" at the
time. PE suggested probable tenosynovitis of the R common flexor tendon
sheath and multiple extensor tendons. No arthrocentesis at the time. MRI:
No fracture. Mild tenosynovitis of the second compartment of the wrist.
Mild synovitis adjacent to the scaphoid. Tiny ganglion ( more likely than
vessel ) along the dorsal and radial aspect of the capitate. F/u with Dr.
Strite as out-patient on 5/13/05 for pain involving R shoulder and R knee , `
started on colchicine and given Depo-medrol 40mg intramuscular. Assessment at that
time was: "Recurrence of crystal arthropathy with a migratory pattern
consistent with intercurrent crystal arthropathy." Recently had tap of R
knee on 9/15 revealed: 2705 WBC ( 82%PMN , 0 Band , 15mono , 2 lymph ) , 2140
RBC without crystals , no micro. patient has now had increasing R hip and L ankle
joint pain for 3 days. patient comes to the hospital today because she is now
unable to walk due to pain in R hip. Pain is 10/10 , sharp and increased
with pressure on affected joints. Has noted night sweats over the same time
course as these arthralgias. Denies fatigue , any fevers , chills , wt loss ,
lightheadedness , or other systemic symptoms. In ED , pain controlled with
motrin , 10mg oxycodone and 4mg morphine. Rheumatology evaluated and
attempted tap of L knee , unsuccessful.
--PMH: DM , HTN , Obesity , asthma
--CONSULTS: RHEUMATOLOGY( Loida Willibrand a22692 )
-------------------------------------------------
HOSPITAL COURSE: --A/P 58yo F with history of migratory polyarthralgias
followed by rheumatology without specific Dx.
--MSK: Plain films notable for mild OA changes , no acute processes.
MRI of R hip performed which was notable for only a small fluid
collection with in the R hip joint. Rheumatology consulted. Seen by Dr.
Loida Willibrand ( a22692 ). L ankle unsuccessfully tapped. Injected 80mg of
depomedrol + 1cc of 1% lidocaine into her R trochanteric bursa on 4/20
RFunit came back at 144 and Anti-CCP > 100. Discussed with rheumatology
fellow-attndg who thought was classic "palandromic rheumatism" ( Caroyln Reidherd attndg ) and plan is to start hydroxychloroquine 400mg orally every day
until she sees Dr Strite as out-patient ( patient made aware of potential retinal
pigmentation side-effect and will need ophtho f/u in future ). F/u HIV ,
ANA , SPEP , UPEP. TSH=normal. HepB and HepC serologies Negative , Lyme
titers pending. Pain control with Indomethacin. Stop Colchicine.
--CV: Ischemia: no history of CAD. Continue lisinopril , nifedipine Pump: ECHO
with mild depressed LV fxn. Currently euvolemic. Follow fluid status.
R&R: Continue nifedipine.
HEME: Given anemia and low MCV , Consider iron replacement as out-patient and
possible colonoscopy.
FEN: Electrolytes replaced as needed ( Mg and K ). MVI orally every day House diet.
ENDO: TSH=nl. DM: continue glipizide and metformin.
NEURO: Ambien and ativan as needed
PPX: nexium , lovenox.
ACCESS: Peripheral intravenous.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Consider colonoscopy and iron replacement as out-patient Consider Checking
PPD status. Follow-up as an out-patient: HIV , lyme titers , ANA , SPEP , UPEP.
No dictated summary
ENTERED BY: HEAPHY , ALLA L. , M.D. , D.PHIL. ( YT43 ) 2/21/05 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 900
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
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OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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702744113 | PUO | 14759295 | | 0437267 | 9/29/2006 12:00:00 a.m. | Revasculization of occluded graft | | DIS | Admission Date: 1/1/2006 Report Status:
Discharge Date: 7/27/2006
****** FINAL DISCHARGE ORDERS ******
HOSCHEK , ELEANORE 100-38-34-9
Inard A
Service: CAR
DISCHARGE PATIENT ON: 3/8/06 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LIPPHARDT , ERMELINDA S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLCYSTEINE 10%( 100 MG/ML ) 600 MG orally twice a day X 3 doses
Starting ON DAY OF PROCEDURE.
ENTERIC COATED ASA 325 MG orally DAILY
CAPTOPRIL 12.5 MG orally three times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Override Notice: Override added on 11/9/06 by
FRIES , SPENCER L. , M.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
060730230 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 10/9 )
DIGOXIN 0.125 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals HOLD IF: npo
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
INSULIN NPH HUMAN 30 UNITS subcutaneously BEDTIME
Instructions: please ck FSG prior to administration
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
METOPROLOL TARTRATE 50 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 2.5 MG orally three times a day
OXYCODONE 5-10 MG orally every 6 hours as needed Pain
ROSIGLITAZONE 8 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
ZOCOR ( SIMVASTATIN ) 40 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
SPIRONOLACTONE 25 MG orally DAILY
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 3/8/06 by :
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & SPIRONOLACTONE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: Patient monitored as outpatient on
this drug regimen
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Christine Dario , MD 1/21/06 at 10am scheduled ,
Karina Winterfeldt , MD after completion of Plavix ,
ALLERGY: VANCOMYCIN HCL
ADMIT DIAGNOSIS:
CAD with nocturnal angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Revasculization of occluded graft
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of CABG 3/15 history of MI 84 , 96; ischemic cardiomyopathy EF 20%
H/o non-sustained VT and complete heart block history of ICD 2003
AAA history of repair 2002 IDDM PVD HTN Hyperlipidemia Spinal stenosis ( severe )
Chronic renal dysfunction
OPERATIONS AND PROCEDURES:
Right and left cardiac catheterization with stent x2 to vein graft
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
76yoM with CAD history of CABG 1997 presented with 2-3 weeks of nocturnal
angina with increased nitroglycerin requirement for relief. Given
limitations of imaging modalities due to his severe spinal stenosis ,
MIBI/ETT were not feasible , so the patient presented for elective
catheterization 5/16/06. Upon catherization , two occlusions were noted in
the PLV: a 90% occlusion , as well as a moderate sized plaque.
Revascularization was achieved with the placement of non-drug alluding
stents to these lesions; the original 90% lesion was stented to 0%
occlusion. During the catheterization , Dr. Surette noted a gradient of
40mmHg from the thoracic aorta to the femoral aorta raising the
possibility of this as an etiology for Mr. Hoschek 's severe lower back pain
and limited ability to ambulate. The catheterization was without
complications. The patient was placed on Plavix x 6 weeks and Aspirin
indefinately following the procedure , and continued on his home regimen
of Captopril , Metoprolol , Isordil , Digoxin , Spironalactone , Insulin ,
Lasix , Zocor and as needed Nitroglycerin. Groin sheaths were removed and the
patient was without hematoma or bruit. He had 2 episodes of chest
pressure several hours following the procedure with negative EKG and
stable vitals; the symptoms resolved with oxycodone and did not recur.
On discharge he was ambulating confortably without chest pain or shortness
of breath.
ADDITIONAL COMMENTS: Please take your Aspirin and Plavix. The Aspirin needs to be taken every
day on a long term basis , and the Plavix must be taken for ATLEAST 6
WEEKS from 10/29
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up with your Cardiologist , Dr. Dario
Please take your Plavix 75mg for 6 weeks ( until atleast 3/12/06 )
Take your Aspirin 325mg indefinately
Please reschedule appointment with Dr. Winterfeldt to receive steroid
injections for spinal stenosis until AFTER your course of Plavix is
complete
No dictated summary
ENTERED BY: UNG , HORTENCIA R. , M.D. ( JZ88 ) 3/8/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 901
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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837738844 | PUO | 92204102 | | 0904409 | 9/9/2004 12:00:00 a.m. | failure to thrive | | DIS | Admission Date: 10/10/2004 Report Status:
Discharge Date: 5/21/2004
****** DISCHARGE ORDERS ******
AREL , ALEXANDRIA 270-00-62-3
Viewird Ln. , South
Service: MED
DISCHARGE PATIENT ON: 4/4/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DANIEL , CORAZON MERTIE , M.D.
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 500 MG orally three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally every day
ISORDIL ( ISOSORBIDE DINITRATE ) 80 MG orally three times a day
HOLD IF: sbp<100
LISINOPRIL 50 MG orally every day
MAALOX PLUS EXTRA STRENGTH 30 MILLILITERS orally every 6 hours as needed Pain
MOM ( MAGNESIUM HYDROXIDE ) 30 milliliters orally every day
as needed Constipation
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally three times a day
HOLD IF: sbp<90 HR<55 and call ho
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DILANTIN ( PHENYTOIN ) 300 MG orally every bedtime
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after )
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 2/23/04 by
SUDA , JEANICE URSULA R. , PH.D.
on order for ZOCOR orally ( ref # 43373681 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
LOVENOX ( ENOXAPARIN ) 30 MG subcutaneously every day
REMERON ( MIRTAZAPINE ) 15 MG orally every bedtime
Number of Doses Required ( approximate ): 6
ZYPREXA ( OLANZAPINE ) 2.5 MG orally every bedtime
Number of Doses Required ( approximate ): 6
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Alert overridden: Override added on 1/3/04 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: will monitor
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Mccullen when ready to leave Pi'ni Manger Ene Frandecrest Can Medical ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
failure to thrive
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) history of a.fib hypertriglyceride ( elevated
lipids ) vertigo ( vertigo ) anxiety disorder
( anxiety ) ( + ) syphillis titers ( syphillis ) history of cataract surgery ( history of
cataract ) dementia ( dementia ) gastritis
( gastritis ) cad ( coronary artery disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
89 F Hampstam woman with CAD history of multiple PCI , CHF , anxiety , GER
D , atrial fibrillation , and profoundly demented at baseline ,
admitted via ED on 6/10/4 with SSCP , mild volume overload and
inability to cope at home. Has had multiple identical admissions over
the past year. Felt not to be a candidate for further
coronary iintervention. Admitted for ROMI , gentle
diuresis and mainly for placement issues.
Course:
1. CV:
-Ischemia: Ruled out by 3 sets of cardiac enzymes. No ischemic
changes on EKG. She was maintained on cardiac regimen: ASA , Isordil ,
statin , BB , ACEI. No further risk stratification was performed as
stated above.
-Pump: Mildly volume overloaded on admission. Was gently diuresed and t
hen changed back to baseline lasix orally dosing.
-Rhythm: Atrial fibrillation intermittently with sinus rhythm. Not
candidate for anticoagulation. Was bradycardic ( HR 40s-60s ) but
asymptomatic during course. Atenolol was changed to three times a day dosing of
lopressor given CRI ( Cr 1.9 ) and worry that renal clearance of drug
was impaired.
2. Psych: Demented at baseline. Continued home meds: remeron , zyprexa ,
dilantin.
3. Prophy: Will continue prophylactic dosing of lovenox at rehab ( not
contraindicated even with CRI ).
4. Dispo: patient will be discharged to skilled nursing facility after
extensive discussions with family. patient should follow up with primary care physician when
ready to leave Pi'ni Manger Ene Frandecrest Can Medical 661-407-7125 Dr. Kleist
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
please make follow-up appt with primary care physician Dr. Mccullen when patient ready to leave
Pi'ni Manger Ene Frandecrest Can Medical 702-493-1296.
No dictated summary
ENTERED BY: POLO , MALINDA M. , M.D. ( SV42 ) 4/4/04 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 902
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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534463969 | PUO | 74680820 | | 7492316 | 6/4/2005 12:00:00 a.m. | NSTEMI/PCI | | DIS | Admission Date: 7/27/2005 Report Status:
Discharge Date: 7/13/2005
****** FINAL DISCHARGE ORDERS ******
PERODDY , LOUANNE 392-43-70-1
Eter Ingmon Cu
Service: CAR
DISCHARGE PATIENT ON: 3/22/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA 325 MG orally every day
LISINOPRIL 2.5 MG orally every day Starting IN a.m. ( 5/30 )
Alert overridden: Override added on 5/28/05 by
ARMLIN , VINA FABIAN , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
75 MG orally every day Starting IN a.m. ( 5/30 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 1
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
GLIPIZIDE 10 MG orally three times a day
METFORMIN 1 , 000 MG orally twice a day
INSULIN NPH HUMAN 6 UNITS subcutaneously twice a day
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Avoid exercise or strenuous activity until you see your primary care physician.
FOLLOW UP APPOINTMENT( S ):
Follow-up with primary care physician Dr. Issacs in 1 week ,
Follow-up with cardiologist , Dr. Meckley , in 3-4 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
NSTEMI/PCI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTEMI/PCI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of cabg/imi CHF 30-35% EF , 10/19 history of suicide attempt NIDDM
non-healing ulcers r/o ostomyelitis history of DVT L pleural effusion
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
PCI
BRIEF RESUME OF HOSPITAL COURSE:
CC: angina
72 M with CAD history of CABG x4 who presenteds with NSTEMI for cardiac
catheterization , now history of PCI with stenting to SVG.
HPI: 3 days PTA , patient had DOE with dry cough , rapid heart rate , anorexia.
No f/c , exertional CP , decreased exercise tolerance , orthopnea , PND. Went
to primary care physician , found to have ST depressions in lateral leads accompanied by mid
abd discomfort. Sent to Merla Medical Center ED , where CK 808 and sent to cath
lab. Cath showed 90% diagonal lesion , 100% om lesion , and 50% PDA grafts
occlusions. Transferred to PUO for PCI.
PMH: Diabetes with retinopathy , PVD , CAD history of CABG x 4 ( 1997 ) with 3
SVGs to Diag 1 , OM , and PDA and LIMA to the LAD , HTN , Hyperlipidema ,
UGIB ( h. pylori positive 1998 ) , Anemia , DVT , Depression with history of
suicide attempt , RBKA ( 5/17 )
Discharge PE:
VS: T 98.9 , HR 68 , BP 90-120/50 , rr 18 , 93% on RA
NAD , PERRL. JVP flat. Lungs clear. RRR , SEM at LUSB. Abd benign. No
edema , 2+ DP pulse on left , history of right BKA , bilateral cath site with no
bruit or hematoma , Aox3 and nonfocal.
STUDIES:
- CXR ( 4/9 ): pending
- EKG ( 4/9 ): ST depressions in II , V4-V6 , flipped T waves in v5-v6 -
Adenosine Mibi ( 7/15/2004 ): EF 21% , severely dilated LV , akinesis of the
apical anterior wall , apex and entire inferior wall , normal RV function.
- Cath ( 4/9 ): R dominant. 90% LM lesion , 100% LAD lesion , 90% Circ
lesion , 100% Marg2 lesion , 100% RCA lesion , 40% SVG-->PDA lesion , 99%
SVG-->RAMUS stented to 0% with Proxis. 3 of 4 grafts patent. Rotor
atherectomy of distal native LM to prox circ.
Echo: 10/11 30-35% , HK/AK inf/infseptal/posterolateral walls ( RCA
distribution ) , minimally changed from 1997
Hospital course:
CAD: history of PCI with stent to SVG and rotor atherectomy to LM`circ.
The patient received standard post-op care. He was discharged on ASA ,
plavix , statin , toprol , and lisinopril. The meds were hemodynamically
tolerated at the discharge doses.
PUMP: The patient was euvolemic on discharge and had no signs of vascular
congestion during his hospital stay. However , his echo revealed a
depressed ejection fraction of ~30-35%.
RHYTHM: The patient was in sinus rhythm on tele with occassional 4-6 beat
runs of NSVT. EP saw the patient and will reassess for AICD insertion in
3 months.
HEME: The patient has a distory of anemia ( DC hematocrit was 31.6 ) and
history of DVT but there were no active issues in the hospital.
DIABETES: On admission to the hospital , the patient's orally diabetes
regimen was discontinued and he was started on NPH 10 U twice a day. His sugar
was well-controlled and he requried ~7-8 U of insulin on RISS per day.
On discharge , he was switched back to his original diabetic regimen. He
was told to follow-up with his primary care physician in one week and discuss his diabetes
regimen with his primary care physician.
Admission Weight 7/1 kgs , Discharge weight 1/1 kgs
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Please take all your medications as outlined in the discharge report ,
especially PLAVIX.
2 ) Please follow-up with your primary care physician Dr. Issacs in 1 week.
3 ) Please follow-up with your cardiologist , Dr. Meckley , in 3-4 weeks.
4 ) Please do not perform any exercise or strenuous activity until you
see your primary care physician Dr. Shepps
No dictated summary
ENTERED BY: WARRELL , KRYSTIN D. S. , PH.D. ( FO61 ) 3/22/05 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 903
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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268425746 | PUO | 81456333 | | 1705908 | 10/29/2004 12:00:00 a.m. | anemia | | DIS | Admission Date: 9/1/2004 Report Status:
Discharge Date: 2/4/2004
****** DISCHARGE ORDERS ******
HUERTO , ANTONETTA 387-98-22-6
Me Ox Au
Service: MED
DISCHARGE PATIENT ON: 7/14/04 AT 04:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
Incomplete Discharge
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Override Notice: Override added on 3/2/04 by
STAYNER , FALLON I. , M.D.
on order for COUMADIN orally ( ref # 76535393 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
DIGOXIN 0.125 MG orally every day
DILTIAZEM SUSTAINED RELEASE 90 MG orally twice a day
HOLD IF: sbp<90 , heart rate<55 , call HO
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 3/2/04 by
STAYNER , FALLON I. , M.D.
on order for TOPROL XL orally ( ref # 94785298 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: aware
Number of Doses Required ( approximate ): 5
IRON ( FERROUS SULFATE ) 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
Override Notice: Override added on 3/2/04 by
CLAYBURN , NIKI , M.D.
on order for LEVOFLOXACIN orally ( ref # 67764580 )
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
LEVOFLOXACIN Reason for override: aware
Previous override information:
Override added on 3/2/04 by STAYNER , FALLON I. , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & FLUOXETINE
HCL Reason for override: aware
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
HOLD IF: sbp<90 , call HO if held
Alert overridden: Override added on 3/2/04 by
STAYNER , FALLON I. , M.D.
on order for LASIX orally ( ref # 80430619 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: aware
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 3/2/04 by
STAYNER , FALLON I. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & GEMFIBROZIL
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
40 UNITS every day before noon; 20 UNITS every afternoon subcutaneously 40 UNITS every day before noon 20 UNITS every afternoon
Instructions: 1/2 dose if NPO
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 3/2/04 by
CLAYBURN , NIKI , M.D.
on order for LEVOFLOXACIN orally ( ref # 67764580 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
Reason for override: aware Previous override information:
Override added on 3/2/04 by STAYNER , FALLON I. , M.D.
on order for GEMFIBROZIL orally ( ref # 30817368 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & GEMFIBROZIL
Reason for override: aware Previous override information:
Override added on 3/2/04 by STAYNER , FALLON I. , M.D.
on order for ZOCOR orally ( ref # 54270352 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware Previous override information:
Override added on 3/2/04 by STAYNER , FALLON I. , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 3/2/04 by
STAYNER , FALLON I. , M.D.
on order for GEMFIBROZIL orally ( ref # 30817368 )
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware Previous override information:
Override added on 3/2/04 by STAYNER , FALLON I. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 25 MG orally every day
HOLD IF: sbp<100 , heart rate<55 , call HO
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 3/2/04 by
STAYNER , FALLON I. , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: aware
Number of Doses Required ( approximate ): 5
LEVOFLOXACIN 250 MG orally every day Starting IN a.m. ( 10/21 )
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 3/2/04 by
CLAYBURN , NIKI , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: FLUOXETINE HCL &
LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 3/2/04 by
CLAYBURN , NIKI , M.D.
on order for LEVOFLOXACIN orally ( ref # 67764580 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: aware
Previous override information:
Override added on 3/2/04 by STAYNER , FALLON I. , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & SALMETEROL
XINAFOATE Reason for override: aware
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: diabetic diet / 2 gm Na / ADA 2000 cals/day / Low saturated fat
low cholesterol (I) (FDI)
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Leola Musich 1 week ,
Vasular lab June ,
Arrange INR to be drawn on 7/12/04 with f/u INR's to be drawn every
3 days. INR's will be followed by Johnetta Lalata
ALLERGY: Penicillins , Sulfa , Codeine
ADMIT DIAGNOSIS:
Fatigue
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
anemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
COPD ( chronic obstructive pulmonary disease ) CAD ( coronary artery
disease ) HTN ( hypertension ) Diabetes ( diabetes
mellitus ) history of cabg ( history of cardiac bypass graft surgery ) renal artery
stenosis ( renal artery stenosis ) history of renal artery
stent afib ( atrial fibrillation ) CHF diastolic dysfn ( congestive
heart failure ) ? IPF glaucoma ( glaucoma )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
73F with mult medical problems including CAD history of CABG and mult PCI's ,
COPD , DM , Afib , who p/with several days of worsening fatigue/malaise.
Only localizing sx is cough productive of blood-streaked sputum and
mild nausea. No cardiac sx's , no med changes , otherwise well.
Meds: asa , lasix , dilt , dig , coumadin , toprol
XL , zocor , plavix , NPH , prozac , advair ,
glucovance , gemfibrozil
SH: 20 pack yr smoking hx , quit 1983. VS: Afebrile ,
VSS PE: notable for JVP 7 , fine crackles B bases ,
2/6 SEM at base , abd benign , no
edema. Labs: WBC 13 , Hct 31 ( baseline ) , Cr 1.7
( from 1.4 ) , LFTs nl , Lipase 177 , INR 2.9 , Dig
1.0 , enzymes
negative. EKG: NSR @ 65 , old inf and anterosept Q's ,
dig effect seen in lateral leads
( unchanged ) CXR: BLL opacities c/with PNA vs. chronic
fibrotic changes.
RUQ U/S: non-obstructing gallstone
Impression: 73F with non-specific nausea and fatigue , ? PNA on CXR ,
mildly elevated lipase suggesting passed stone.
HOSPITAL COURSE:
1 ) Pulm: ? IPF seen on prior CTs , now with productive
cough. Sputum sent , U legionella , started on levoflox x 10d. COnt
antbx for 8 days after d/c. Cont nebs , no steroids. Will have pulmonary
consult today
2 ) CV: cont current regimen , ASA , plavix , BB , statin , CCB , lasix ,
fibrate. Enzymes negative , EKG unchanged , no evidence of ACS.
3 ) Heme: anemia x 2 yrs while on coumadin , unclear of any prior work
up. Fe studies pending. Coumadin dose decrease to 2 while on Levo , will
need to increase back to 5 every day once abx completed.
4 ) GI: mildly elevated lipase on admission at 177. On d/c lipase
decreased to 93 and patient tolerating POs. May need surgery f/u as
outpt to decide on elective cholecystectomy.
5 ) Endo: DM control , d/c'd glucovance given Cr > 1.4 , cont'd insulin
NPH 40/20 , increase as needed
6 ) Dispo: d/c to pulmonary rehab 10/22
ADDITIONAL COMMENTS: Please call your PLCP with any increasing shortness of breath , chest
pain , or difficulty breathing at all. Also , should you have any nausea
or vomiting associated with abdominal pain , then see your primary care physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow up with Pulmonology as outpatient. May need repeat chest CT
and PFT's
2. Follow up with Dr. Howry re: anemia workup. SHould have a colonoscopy
in the future. Has been years since flex sig
3. Vasular studies of legs for claudication planned on June
4. F/U coumadin labs. Dose decreased due to patient being on Levo. Get
INR check on friday , then 7 days after
5. COntinue Levo x8 days after d/c
No dictated summary
ENTERED BY: STAYNER , FALLON I. , M.D. ( PF23 ) 7/14/04 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 904
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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691471421 | PUO | 66485685 | | 684995 | 2/23/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/19/1995 Report Status: Signed
Discharge Date: 3/22/1995
PRINCIPAL DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION
SECONDARY DIAGNOSES: 1. HISTORY OF NONINSULIN DEPENDENT
DIABETES
2. RIGHT GREAT TOE ULCERATION WITH
LYMPHANGITIS
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old male with
a history of noninsulin dependent
diabetes mellitus , a significant heavy smoking history , and he has
a family history of cardiac disease who was admitted with chest
pain and worsening right great toe ulceration with lymphangitis.
In October , Mr. Dyen stubbed his right great toe and
subsequently developed ulceration. He was first seen for this
ulceration when it began to have serosanguineous fluid leakage.
Over the past month he has received several debridements and
completed a course of Cipro yesterday. A few days prior to
admission he began to have left-sided chest pressure on exertion
with the pain resolving with rest. The episode lasted 30 seconds
to two minutes and were accompanied by posterior neck pain and
dizziness.
On the day of admission he developed chills with rigors , nausea and
vomiting of food without blood. He has had 2-3 episodes of soaking
night sweats in the past two weeks. For the past two days he has
noted redness and swelling of his right foot. The patient denies
shortness of breath , dyspnea on exertion , paroxysmal nocturnal
dyspnea , palpitations , weight loss , abdominal pain , diarrhea ,
melena , or hematochezia.
An exercise tolerance test in October of 1995 , was limited by back
pain , a blood pressure in the 220 range , heart rate in 150 range ,
and frequent premature ventricular beats , but was felt to be
negative for ischemia.
The patient was seen at CHH on the day of admission and was given
a dose of oxacillin and sent to the the I Warho Hospital
for intravenous antibiotics and work-up.
PAST MEDICAL HISTORY: ( 1 ) Back trauma with sciatica following back
surgery. ( 2 ) Noninsulin dependent diabetes.
( 3 ) Peripheral neuropathy. ( 4 ) Status post colon carcinoma with
resection in 1981. ( 5 ) Status post appendectomy. ( 6 ) Hearing loss
in his left ear.
MEDICATIONS ON ADMISSION: Tylenol #3 and glyburide 10 mg orally q.
day. No known drug allergies.
SOCIAL & FAMILY HISTORY: The patient has a 40 year history of
smoking four packs per day , currently
smoking 1-1/2 packs per day. No alcohol use. No intravenous drugs. He is
a retired shift chief for a local prison on disability due to back
pain. The patient is married and lives with his wife and a two
year old son. He is active around the house and does seasonal work
with plant care. He has two adult children. He has a brother who
died of a myocardial infarction at the age of 48. A cousin died of
a myocardial infarction in his mid 40s. A sister died of breast
cancer.
PHYSICAL EXAMINATION: Temperature 100.6 , blood pressure 130/80 ,
and pulse 68. NECK: No jugular venous
distention , no bruits , no masses , no lymphadenopathy. LUNGS: Clear
to auscultation and percussion. CARDIAC: Regular rate and rhythm.
Normal S1 and S2. A 1/6 systolic ejection murmur at the left lower
sternal base. No changes with maneuvers. No radiation. No S3 or
S4 auscultated. ABDOMEN: Benign. EXTREMITIES: Trigger finger of
the left fourth digit. A 1 cm deep ulcer with surrounding collar
callous at the tip of the right great toe with erythema. The ulcer
base is red , nonpurulent , and there is trace edema. NEURO: Left
ear with decreased hearing compared to the right. Cranial nerves
II-XII otherwise grossly intact. No sensation to touch below the
knees. DTRs are 2+ and bilaterally symmetric in the upper
extremities. DTRs are zero in the right and left lower
extremities.
LABORATORY DATA: Sodium 135 , potassium 4.0 , chloride 98 , bicarb
22 , BUN 16 , creatinine 1.3 , and glucose 304.
White count 16.14 , 25 bands , 68 polys , and 2 lymphs. Hematocrit
43.2 and platelet count was 180. CK is 486 , MB 5.1. physical therapy/PTT 11.6
and 27.6. INR 0.9.
Chest x-ray was within normal limits. Right foot x-ray shows soft
tissue swelling in the first toe. No bony changes. EKG on
admission showed no ischemic changes.
HOSPITAL COURSE: The patient ruled out for a myocardial infarction
and was treated for right toe cellulitis with intravenous
antibiotics of gentamicin and Clindamycin. The patient was also
placed on atenolol with the dose increased to 75 mg orally every day.
On discharge , the patient was switched from Nitropaste to Isordil
10 mg orally three times a day The patient's glyburide was also increased to
20 mg orally every day.
The patient underwent MIBI which showed a large fixed posterior
lesion with peri-infarct ischemia. The patient was felt to be
medically stable and capable of being managed as an outpatient. He
was discharged to home on 10/30/95.
MEDICATIONS: On discharge included atenolol , 75 mg orally every day ,
aspirin , 325 mg orally every day , Glyburide , 20 mg orally every day , Tylenol #3 ,
two tablets orally x one as needed for pain , sublingual nitroglycerin ,
as needed
The patient is to follow-up with Dr. Heinen as an outpatient and
with Dr. Tyacke of CHH Cardiology.
DISPOSITION: The patient was discharged to home.
Dictated By: JAMEE Z. EBERENZ , M.D. XU84
Attending: DESIRAE R. MARCOTT , M.D. FQ08
LM655/2120
Batch: 45056 Index No. NNOEZU2RRU D: 7/14/95
T: 7/14/95
Document id: 905
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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105408145 | PUO | 86555770 | | 2924892 | 10/21/2005 12:00:00 a.m. | CHF exacerbation , UTI | | DIS | Admission Date: 5/19/2005 Report Status:
Discharge Date: 11/1/2005
****** FINAL DISCHARGE ORDERS ******
MORALE , KARENA Y 090-60-32-4
Har Fay A Di
Service: CAR
DISCHARGE PATIENT ON: 2/24/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TYACKE , MACKENZIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally twice a day
FERROUS SULFATE 325 MG orally every day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 60 MG orally twice a day Starting Today ( 5/20 )
HYDRALAZINE HCL 10 MG orally three times a day HOLD IF: SBP below 90
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: SBP below 90
LISINOPRIL 20 MG orally every day HOLD IF: SBP below 90
Override Notice: Override added on 6/4/05 by POLO , MALINDA M. , M.D. , M.S.C.
on order for KCL IMMEDIATE RELEASE orally ( ref # 97637572 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 6/4/05 by POLO , MALINDA M. , M.D. , M.S.C.
on order for KCL IMMEDIATE RELEASE orally ( ref # 16540770 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 10/14/05 by POLO , MALINDA M. , M.D. , M.S.C.
on order for KCL IMMEDIATE RELEASE orally ( ref # 84523324 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 10/14/05 by POLO , MALINDA M. , M.D. , M.S.C.
on order for KCL IMMEDIATE RELEASE orally ( ref # 02720208 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 10/14/05 by POLO , MALINDA M. , M.D. , M.S.C.
on order for KCL intravenous ( ref # 70028326 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
75 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LEVAQUIN ( LEVOFLOXACIN ) 250 MG orally every day
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
ACETYLSALICYLIC ACID 325 MG orally every day
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Krichbaum ( in for Dr. Walth ) , 486-705-2610 9/11/05 , 11:30a scheduled ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation , UTI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , obesity , anemia , OA , gout , GERD , CRI , CAD , hyperlipidemia
OPERATIONS AND PROCEDURES:
Cardiac catheterization , 5/25/05 ;
Echocardiogram , 5/25/05
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Dyspnea
HPI: 74 year-old AAF history of NYHF III CHF ( EF 45% ) , PHT , HTN-CMP , p/with worsening
fatigue , DOE and orthopnea over 3-4 w. patient presented to clinic on day
of admit and was admitted for acute decompensation. patient
claims compliance to diet but there is some question from the ED of
dietary indiscretion. In addition , patient reports not being able to get
dose of procrit x 3 mo , due to inconvenience in aquiring
it. patient does not require home O2. Denies CP , SOB at rest , PND ,
palpitations , or dizziness. No cough , fever , or sick
contacts. Echo 5/30 nl septal chamber size , mildly enlarged
aL atrium , mild LVH , 1+ MR , mod TR. PE on admit: VS 98.9 96 136/88
100% RA. NECK: JVP to jaw angle with pulsatile v wave. No bruits. CV:
RRR , +s3 , ? systolic murmur at LSB , increased but non displaced pmi.
LUNGS: Crackles to 2/3 of lung B. EXT: Warm , 2+ DP pulse B. 1+
pitting edema 2/3 to B
knees. Labs on admit: Cr 2 , Trop 0.24 , CK 27 , MB 0.6.
CXR: increased heart border , B effusion. BNP 2329. UA 6-10 wbc , 2+
bact. EKG no changes , baseline diffuse flattened
TW.
**************HOSPITAL COURSE*********************
CV: ( P ) NYHA III CHF ( EF 45% ) in acute decompensation. Strict I&Os ,
fluid restriction. Diurese aggressively with lasix 100 twice a day , replete
lytes , keeping in mind CRI. Cont BB , ACEI. Added hydralazine/isordil
on HD3. Repeat Echo on HD3 showed decreased EF 30-35%.
( I ) CAD , hyperlipidemia: BB , ACEI , statin , ASA. Lipids nl. Suspected
ischemic etiology to worsening CHF , given decreased EF on echo. Did cath
on U Jackmonka Bile , Maryland 44561 however without lesions ( although confirming PHT ).
( R ) No issues.
RENAL: CRI with anemia. Given mucomyst post cath.
HEME: Anemia - Given aranesp , FeSO4.
HTN: BB , ACEI. ID: UTI , E coli in Ucx , sensitivities pending.
Empirically tx with Keflex , changed empirically on HD4 to levo.
ENDO: R/o'd Hyperthyroidism with nl TSH.
RHEUM: Gout - allopurinol.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
No dictated summary
ENTERED BY: ZERTUCHE , TAI C. I. ( EC60 ) 2/24/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 906
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
449544819 | PUO | 50477675 | | 000402 | 10/12/1998 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 11/10/1998 Report Status: Unsigned
Discharge Date: 10/10/1998
HISTORY OF PRESENT ILLNESS: Mr. Varona is a 79-year-old man with
a known history of three-vessel
disease , who is status post an intraaortic balloon placement. He
has a history of hypertension , noninsulin dependent diabetes
mellitus , and is a former smoker. The patient presents with a two
to three month history of exertional angina while climbing a hill
or rushing on a flat surface. He also admits to symptoms of
shortness of breath , light headedness , and diaphoresis. He denies
any nausea , vomiting , or palpitations. He was seen by Dr. Floyd Lyn who did an exercise tolerance test. The patient exercised
for 3 minutes and 40 seconds on a modified Bruce protocol with a
heart rate of 99 , which is 70% predicted , a blood pressure of 190
over palp and the test was stopped secondary to typical substernal
chest pressure. An electrocardiogram revealed a 1 millimeters ST
depression in V3 through V5 , and 2:1 second degree AV block. The
patient had catheterization , which revealed a left main
arteriostenosis of 70% , a circumflex coronary artery with an 80-90%
proximal stenosis , a left anterior descending proximal stenosis of
70% , and mid 70% right coronary artery occlusion midway. He had
right iliac tortuous stenosis. He also had intraaortic balloon
pump placed and went straight to the operating room.
PAST MEDICAL HISTORY: Significant for hypertension , noninsulin
dependent diabetes mellitus , irritable bowel
syndrome secondary to a colectomy for colitis , splenomegaly.
PAST SURGICAL HISTORY: Significant for an appendectomy and
cholecystectomy , and as mentioned above ,
colectomy.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Unremarkable.
HOSPITAL COURSE: The patient was brought to the operating room on
July , 1998 , where he went a coronary artery
bypass graft times three with left internal mammary artery to the
left anterior descending artery , and saphenous vein graft to the
obtuse marginal artery , and a saphenous vein graft to the right
coronary artery. The patient did well , came off bypass without
incident , with his right intraaortic balloon pump in place and
was brought up to the Intensive Care Unit in stable condition. The
patient was extubated on postoperative day 1. The intraaortic
balloon pump was weaned on postoperative day 2 and Mr. Varona
went into atrial fibrillation on postoperative day 2 with a
controlled rate. He was treated with intravenous Lopressor and
converted back to sinus rhythm with occasional premature atrial
contractions. The patient continued in atrial fibrillation , atrial
flutter , with a rate in the 90s to 110s , and was unable to be
converted. Pressures remained in the 130/80 range. Mr. Varona
also had some urinary retention , which required him to have a leg
bag Foley catheter after failing bleeding trials. He will follow
up with Urology in about a week , Dr. Lorean Kadow , in the urology
clinic.
DISCHARGE LABORATORY DATA ( September , 1998 ): Glucose of 198 , BUN
of 39 , creatinine
1.4 , sodium 144 , potassium 3.6 , chloride 100 , CO2 32 , magnesium
2.1. White count of 4.23 , hemoglobin 11.7 , hematocrit 35.9 ,
platelets of 82. physical therapy 17.9. PTT 24.8. INR 2.2.
DISCHARGE MEDICATIONS: Xanax 0.5 milligrams every day; Afrin
spray twice a day; Acid 150 milligrams twice a day;
Metamucil 1 packet every day; Glynase 3 milligrams once in the morning;
Norvasc 5 milligrams every day; Coumadin as directed; Hydrin 1
milligrams once at night; Lopressor 25 milligrams three times a day; Lasix 40
milligrams twice a day and potassium 20 milliequivalent twice a day; Percocet
1-2 tablet every 3-4h as needed pain.
DISP: The patient is discharged in stable condition to home with
visiting nurse. He will follow up with Dr. Gaylene Faniel in
six weeks , his cardiologist within the week , and urology within a
week.
Dictated By: PRISCILLA BARBELLA , P.A.
Attending: GAYLENE G. FANIEL , M.D. II8
YQ268/0732
Batch: 74658 Index No. HEBBTV2SY7 D: 1/29/98
T: 1/29/98
Document id: 907
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
Y |
N |
Y |
N |
- |
N |
N |
N |
N |
921778812 | PUO | 49448215 | | 560346 | 10/14/2002 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 6/26/2002 Report Status:
Discharge Date: 2/10/2002
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
Ingosa Auport
Service: MED
DISCHARGE PATIENT ON: 8/19/02 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
Alert overridden: Override added on 11/10/02 by
ESCARCEGA , MERLENE LANIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: aware
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 11/10/02 by
ESCARCEGA , MERLENE LANIE , M.D. , PH.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: aware
MICRONASE ( GLYBURIDE ) 5 MG orally twice a day
Alert overridden: Override added on 11/10/02 by
ESCARCEGA , MERLENE LANIE , M.D. , PH.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: aware
PLAQUENIL ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
LISINOPRIL 20 MG orally every day
Alert overridden: Override added on 11/10/02 by
ESCARCEGA , MERLENE LANIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 11/10/02 by ESCARCEGA , MERLENE LANIE , M.D. , PH.D.
on order for AMIODARONE orally ( ref # 33557001 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: aware
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: House / ADA 1800 cals/dy
FOLLOW UP APPOINTMENT( S ):
Annette Schoultz March , 10am. scheduled ,
Buck Moose - will call you with appointment. ,
Darin Jeffirs - Please call tomorrow ,
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CHF HX SYNCOPE ALL - ASA , PCN RA
history of St. Jude MVR for MS ( history of cardiac valve replacement ) Hx AFib/flutte
r ( history of atrial fibrillation ) history of IMI ( history of myocardial infarction ) NIDDM
( diabetes mellitus ) gout
( gout ) Hx DVT '70 ( history of deep venous thrombosis ) history of appy ( history of
appendectomy ) history of umbilical hernia repair ( history of hernia repair ) history of
sigmoidectomy for diverticulitis history of L hip # '95 ( history of hip
fracture ) Chronic diarrhea ( diarrhea ) PE ( pulmonary embolism )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old female with dm , htn , ra , afib cad , imi
admiited with cp asoc with sob , n , and diaphoresis. In the setting of a
negative cath 10/12 cad unlikely.HD stable on admission with PE sig for
few crackles Left base ( old )rrr with MR click. ROMI -. Case discussed
with primary care physician and with Dr. Odea ( her primary cardiologist ) HD stable on
discharge without pain since admission.
ADDITIONAL COMMENTS: You have been admitted for evaluation of chest pain. Based upon your
most recent studies and evaluation done in the hospital this admission ,
it appears that you did not have a heart attack and it is unlikely that
this pain is coming from your heart. Take your medications as
prescribed and follow-up with your doctors as scheduled. If you have
worrisome symptoms , please seek immediate medical attention. You will
have visiting nurses coming into your home to do a home safety
evaluation and to check your blood pressure. Blood lab INR on 10/21/02.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HUSHON , NIA , M.D. ( IU38 ) 8/19/02 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 908
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
N |
Y |
N |
N |
N |
- |
Y |
N |
N |
N |
Y |
N |
N |
632978559 | PUO | 30760602 | | 4777381 | 5/30/2006 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 5/28/2006 Report Status:
Discharge Date: 8/13/2006
****** FINAL DISCHARGE ORDERS ******
MERRELL , VICENTA 523-62-97-7
Jose
Service: CAR
DISCHARGE PATIENT ON: 8/27/06 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PREWER , FERNANDE RANDY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA 81 MG orally DAILY Starting Today ( 6/28 )
Override Notice: Override added on 4/24/06 by
GUSMAR , GAYE , M.D.
on order for COUMADIN orally ( ref # 973318561 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: ok
LIPITOR ( ATORVASTATIN ) 40 MG orally BEDTIME
Alert overridden: Override added on 8/27/06 by :
POTENTIALLY SERIOUS INTERACTION: ERYTHROMYCIN &
ATORVASTATIN CALCIUM Reason for override: home
DIGOXIN 0.25 MG orally DAILY Starting Today ( 6/28 )
Override Notice: Override added on 4/24/06 by
GUSMAR , GAYE , M.D.
on order for ERYTHROMYCIN OPHTHALMIC OINTMENT each eye ( ref
# 256680077 ) SERIOUS INTERACTION: DIGOXIN & ERYTHROMYCIN
Reason for override: ok
LASIX ( FUROSEMIDE ) 80 MG orally DAILY Starting IN a.m. ( 6/28 )
INSULIN NPH HUMAN 40 UNITS every day before noon; 30 UNITS every afternoon subcutaneously
40 UNITS every day before noon 30 UNITS every afternoon
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 10 MG orally DAILY
Alert overridden: Override added on 8/27/06 by :
POTENTIALLY SERIOUS INTERACTION: SPIRONOLACTONE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MD aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Starting IN a.m. ( 6/28 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 1
ALDACTONE ( SPIRONOLACTONE ) 12.5 MG orally DAILY
Food/Drug Interaction Instruction Give with meals
Override Notice: Override added on 3/8/06 by
ECKLER , ROLANDA , M.D.
on order for LISINOPRIL orally 10 MG every day ( ref # 722939611 )
POTENTIALLY SERIOUS INTERACTION: SPIRONOLACTONE &
LISINOPRIL Reason for override: aware
Previous override information:
Override added on 4/24/06 by GUSMAR , GAYE , M.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: ok
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Mathew Stautz ( PUO Cardiology ) 1/21/06 at 4:40 pm scheduled ,
Dr. Tarsha Prall ( primary care physician ) to be seen in next 2 weeks ,
Totin Hospital And Clinic Endocrinology -you will be contacted on monday 4/12 for an appointmen ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CARDIOMYOPATHY-EF 35% , ASTHMA , CAD , HTN , hx ETOH ABUSE , INSULIN REQ TYPE
II DM
OPERATIONS AND PROCEDURES:
8/6 Left Heart Catherization
9/29 Right Heart Catherization
Please see hospital course for salient details.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
**CC / ADMIT Dx: SOB
**BRIEF HPI:
45M with non-DCM ( EF25% ) , DM2 , HTN p/with CHF exacerbation / hypoxia ( PND ,
dyspnea , cough , ?chest tightness on a.m. of admit ) likely 2/2 to dietary
indiscretion and medical noncompliance. Treated with lasix , aldactone ,
ACE , with improvement from NRB to 2L by NC.
**RELEVANT PMHX:
-DCM ( EtOH ) EF 20-25% ( 5/27 ) followed by Dr. Mathew Stautz history of angiography 1995 with 50% LAD ( no intervention )
-HTN
-DMII
-OSA on CPAP
-Asthma
**ALLERGIES: PCN ( rash )
**HOME MEDS: Lipitor 20 , Dig 0.l25 , ASA , Lasix
80 , Glipizide 5 , Metformin 500 three times a day , Insulin 70/30 40
every day before noon/30 every afternoon , Lisinopril 10 , Toprol 25 , Aldaction 25 , Coumadin 5
**DAILY STATUS/EXAM:
VS 5/14 AF , P70-100 , BP90-110/60-70 , O2 94 on RA PULM:
CTA CV: JVP 8 , distant , RRR , no murmurs noted
ABD: S/NT/ND
EXTR: 1+ edema to mid-calf bilat , warm , 2+ pulses
NEURO: AOx3 , non-focal
**TESTS/PROCEDURES:
8/6 LHC showed worsening 3vd from prior , no intervention
RHC releaved elevated left and right filling pressures , no
transpulmonary gradient.
**CONSULTS: ACE , SS , nutrition
**Hospital Course:
CV/I: Patient was sucessfully ruled out by serial enzymes for a
potential myocardial infarction. The patient was continuedon his home ASA ,
statin , and BB during his hospital course. To rule out concern for ischemia
as a role in the deterioration of his cardiomyopathy , a left heart
catheterization was performed which showed worsening CAD from his prior
study 5 years. The patient has 3vd disease with diffuse lesions in his RT
PDA , RT LV-VR , LAD , Lcx. Given the patient's symptoms and echocardiographic
evidence of cardiomyopathy proceeded the progression of his CAD , it is
likely that his arteriosclerosis was not the primary etiology of his
imparied cardiac performance though may be contributing to his disease at
this time.
CV/P: CXR on admission revealed pulmonary edema. The patient had
an excellent reponse to diuresis on lasix and was weaned to room air on
the day after admission. His home blood pressure medications were
continued , and were well controlled. A right heart catheterization was
performed on 6/3 which showed elevated right and left sided filling
pressures , particularly with a Pcw of 24 and mean RA pressure of 5. The
patient was started on Imdur during this admission. His lisinopril was
continued.
patient CV/R: Patient is undergoing evaulation for ICD. NO ectopy was noted
during full-time telemetric monitoring.
PULM: His OSA was treated with CPAP at 6 cm. No active asthma rx. No
wheezes on exam.
ENDO: Patient was maintained off his orally medications and placed on
insulin alone. On admission , his blood sugars were in the 300s. His Last
A1C was found to be 9.5. While following his blood sugars , his insulin was
titrated up and drug therapy discontinued. He was discharged with twice a day NPH
insulin to replace his previous med/insulin regimen. PUO outpatient
diabetes services follow-up will be arranged for the patient.
HEME: On coumadin with admit INR 1.1. Coumadin was held
during admission and patient instructed to discontinue medication as
outpatient considering no hx of afib , LV throbus , or DVT/clot as well as
questions with medication compliance.
F/E/N: Patient was instructed on proper diabetic and HF diet.
PSYCH/SOCIAL: Hx EtOH abuse , last drink day of admit. LFTs were
unremarkable. Patient
also lives with cocaine-using brother hough patient denies use. UTox was
negative. GRH consult provided listing of japanese AA meetings. Social work
helped arranged a medical bed for patient at home , and to facilitate his
ability to obtain public housing.
The patient was discharged home in stable condition. Followup appts were
arranged with his cardiologist , Dr. Raisa Cervetti Also , outpatient diabetes
management followup will be arranged with the patient by the PUO Endocrine
service. He was also instructed to make an appt with his primary care physician within two
weeks. VNA
services have been obtained to teach and assist him in this new medication
changes..
ADDITIONAL COMMENTS: STOP taking your coumadin.
STOP taking your metformin and gliburide.
CHANGE your insulin to NPH insulin 40 units in the morning and 30 units
before bedtime.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
follow-up with your cardiologist as instructed.
No dictated summary
ENTERED BY: ECKLER , ROLANDA , M.D. ( FY73 ) 8/27/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 909
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
680341752 | PUO | 67038128 | | 5160093 | 8/9/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/12/2005 Report Status: Signed
Discharge Date:
ATTENDING: GUMINA , MARJORY SHELA MD
CHIEF COMPLAINT: Elective right total knee replacement.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old woman
with multiple medical problems including asthma , interstitial
lung disease and autoimmune hepatitis leading to cirrhosis with
varices , hypersplenism and thrombocytopenia. Prior to admission
she lived with her husband and was independent with activities of
daily living. She was limited by right knee pain. She was
admitted to Pagham University Of 9/2/05 for elective
right total knee replacement.
PAST MEDICAL HISTORY: Migraine headaches , interstitial lung
disease , asthma , reflux , hepatitis A , autoimmune hepatitis
leading to cirrhosis with varices , hypersplenism , and
thrombocytopenia , coagulopathy , chronic diarrhea x10 years ,
status post cholecystectomy , osteoporosis , L4 compression
fracture , osteoarthritis.
HOME MEDICATIONS:
1. Valium.
2. Advair.
3. Combivent.
4. Prednisone
5. Nexium.
6. Propranolol.
7. Lasix.
8. Spironolactone.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient does not smoke cigarettes or drink
alcohol. She is married with four children.
ADMISSION LABS: Potassium 4.3 , white blood cell count 9.9 ,
hematocrit 26.3 , platelets 61 , INR 1.3.
ADMISSION EXAM: First documented by the orthopedic team: Alert
and oriented , afebrile. Pulse in the 70s and sinus. Blood
pressure in the 90s/50s. Satting 100% on 2 liters. Thin ,
elderly woman , faint bibasilar crackles. Regular rate and
rhythm. Abdomen: Soft and nontender. Extremities: Warm.
ADMISSION IMAGING: Portable chest x-ray on 10/11/05 with patchy
opacity in the left lung base , likely atelectasis.
ADMISSION EKG: Normal sinus rhythm , normal axis. QTC 464. LVH ,
T-wave inversion in 3 , T-wave flattening in AVF , T-wave
flattening in V3 through V6.
HOSPITAL COURSE BY SYSTEM:
1. Ortho: Right knee replacement. The patient underwent an
uncomplicated right knee replacement on admission. Subsequently
her leg was immobilized as per orthopedic recommendations. The
reason for immobilization was that movement of the right lower
extremity might precipitate skin tears.
2. Skin: The patient incurred a laceration in her left calf
perioperatively. She also incurred a skin tear on 11/29/05 with
turning in the bed. Her skin was noted to be paper thin with
underlying fluid. Wound healing was impaired secondary to low
albumin and chronic steroid use. The patient was seen by the
Plastic Surgery team. This team recommended appropriate
dressings for the patient's skin tears. The team also grafted
the left thigh skin tear. The patient was treated with
supplemental vitamins to promote wound healing including vitamin
A and zinc. She was also treated with antibiotics to prevent
skin infections. Originally she had been on vancomycin for a
urinary tract infection and when the course was complete for the
urinary tract infection , the patient was switched to Keflex for
prophylaxis versus skin infections.
3. GI: End stage liver disease with varices and
thrombocytopenia. The patient's complete metabolic panel and
coags were checked each day. During the course of her
hospitalization , the patient's transaminases were relatively
stable , but her alkaline phosphatase trended upward. On exam ,
the patient had mild right upper quadrant tenderness which she
reported was chronic. On 5/13/05 , the patient underwent an
abdominal ultrasound to evaluate her right upper quadrant
tenderness and elevated alk/phos. This study revealed a 2.0 x
1.6 x 1.6 cm hyperechoic mass in the portahepatis. This study
also showed evidence of cirrhosis as well as common bile duct
dilation and splenomegaly. A CT scan to further evaluate the
portahepatic mass was recommended. For her autoimmune hepatitis ,
the patient was continued on prednisone. For her varices , she
was continued on propranolol. Her Lasix and spironolactone were
held through much of her hospitalization. On 6/19/05 , her Lasix
was restarted in an attempt to remedy her hyponatremia.
4. Low albumin state: The patient has a low prealbumin
suggestive of decreased orally intake versus decreased synthetic
function of the liver. The patient also has chronic diarrhea and
was thought to be wasting protein. The patient refused ??___??
placement for tube feeds. She was initially on a house diet with
Ensure and Boost supplements as well as MVI and lactinex
granules. The patient was not taking in adequate calories. On
6/19/05 , TPN was initiated.
5. Persistent chronic diarrhea: The patient has a history of
chronic diarrhea. Stool studies including C. diff testing was
negative. The patient was also tested for celiac sprue and this
testing , too , came back negative. The patient was treated
symptomatically with Imodium.
6. GERD: This patient was treated with Nexium and as needed
Maalox.
7. Dysphagia: The patient reported trouble swallowing. She was
evaluated by the Speech and Swallow team on 4/6/05. Her
swallowing function was noted to be intact.
8. Infectious Disease:
Postoperative prophylaxis: Immediately postoperatively , the
patient was initially treated with clindamycin for prophylaxis
versus perioperative infection.
Skin Prophylaxis: The patient was initially treated with
vancomycin and switched to Keflex.
Urinary tract infection: The patient had a series of dirty UA's.
She was ultimately treated with vancomycin for a urine culture
that grew out resistant staph species. She finished her course
of vancomycin on 8/7/05. A repeat UA was noted to be positive
for infection. A repeat urine culture is pending.
Odynophagia: The patient reported trouble swallowing. She was
treated empirically with fluconazole and clotrimazole for
esophageal Candida. This treatment did not remedy her pain in
swallowing. The patient then developed mouth sores. HSV swabs
of these sores are pending. The patient was treated
symptomatically with viscous lidocaine.
9. Pulmonary: The patient has a history of interstitial lung
disease and asthma. She was treated with Combivent and standing
nebulizer treatments. On 8/6/05 , the patient was noted to have
a new oxygen requirement of 3 to 4 liters. Differential
diagnosis was PE versus pneumonia versus volume overload. On
8/6/05 , the patient had a chest x-ray which showed left lower
lobe atelectasis. A repeat chest x-ray on 10/17/05 was read as
normal. On 7/15/05 , the patient was weaned down to room air.
10. Neuro:
Pain: The patient was treated with standing codeine sulfate.
Nausea: The patient was treated with as needed Compazine.
11. Cardiovascular:
Pump: The patient has no known heart failure. In terms of her
volume status , she was deemed to be intravascularly depleted as
evidenced by prerenal urine electrolytes. She was thought ,
however , to be total body volume overloaded. It was thought that
in the setting of her low albumin , she was third-spacing fluid.
The patient was intermittently treated with normal saline and
spa. On 6/19/05 , normal saline was held and the patient was
treated with spa in conjunction with Lasix.
Rhythm: The patient had normal sinus rhythm. She was monitored
on telemetry.
Ischemia: The patient has no known history of coronary artery
disease. She had no chest pain. Her cardiac markers were
negative. Her EKG had nonspecific abnormalities. She was
continued on her beta-blocker. She was not on an aspirin given
her thrombocytopenia.
12. Renal: Decreased urine output. From the day of admission
onward , the patient had relative oliguria , 500 to 900 cc of urine
per day approximately. Her creatinine trended downward from a
value of 0.5 on admission down to as low as 0.2. As noted above ,
the patient was intermittently treated with normal saline and spa
versus spa and Lasix.
13. Hyponatremia: The patient developed asymptomatic
hyponatremia. This hyponatremia was not responsive to fluid
restriction. On 6/19/05 , the patient was treated with Lasix and
spa as noted above. TSH , cortisol and uric acid were checked to
rule out other etiologies of hyponatremia. The results of these
studies are pending.
14. Endocrine: The patient has steroid induced diabetes. She was
treated with Lantus and sliding scale insulin.
15. Heme: Anemia: The patient had normal iron studies , B12 and
folate.
16. Thrombocytopenia: The patient's thrombocytopenia is most
likely secondary to splenic sequestration. An antiplatelet
factor 4 test was sent and is pending.
17. Anticoagulation: The patient had two indications for
anticoagulation. The first was right total knee replacement.
The second was a right lower extremity superficial femoral DVT
discovered on 10/16/05. The goal INR for this patient was
determined to be 1.5 to 2. It was thought that the patient was
at bleeding risk with a higher INR given her known varices and
her thrombocytopenia. From 8/21/05 onward , the patient's INR was
supertherapeutic and her Coumadin was held. It was thought that
the supertherapeutic INR could relate to Coumadin effects versus
nutritional deficiencies versus worsening of her function.
18. Musculoskeletal: Osteoporosis: The patient was treated with
cholecalciferol.
19. Physical therapy: The patient was followed by the Physical
Therapy team.
20. Access: The patient had a PIC line in place.
Discharge medications , the remainder of the hospital course and
disposition will be dictated by Dr. Desirae Marcott
eScription document: 3-1130130 YYO
ENTERED BY: TROOP , WILFREDO
Attending: GUMINA , MARJORY SHELA
Dictation ID 4102436
D: 4/10/05
T: 4/10/05
Document id: 910
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
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- |
- |
- |
245876836 | PUO | 99067599 | | 1000334 | 2/12/2005 12:00:00 a.m. | Hyperkalemia , Chest pain r/o MI | | DIS | Admission Date: 10/24/2005 Report Status:
Discharge Date: 8/22/2005
****** FINAL DISCHARGE ORDERS ******
DEBNAR , LANITA 202-70-31-3
Na Ing
Service: MED
DISCHARGE PATIENT ON: 8/23/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
CODE STATUS:
No CPR / No defib / No intubation /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
ALLOPURINOL 100 MG orally every other day
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
CALCITRIOL 1.5 MCG orally twice a day
VALIUM ( DIAZEPAM ) 5 MG orally every 12 hours Starting Today ( 3/28 )
as needed Anxiety
CARDIZEM ( DILTIAZEM ) 60 MG orally three times a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PROZAC ( FLUOXETINE HCL ) 40 MG orally every day
HYDRALAZINE HCL 20 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled every 6 hours
as needed Shortness of Breath , Wheezing
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally three times a day
ZAROXOLYN ( METOLAZONE ) 2.5-5.0 MG orally every day
Starting Today ( 3/28 ) as needed Other:swelling
Instructions: take 30minutes prior to torsemide
BICARBONATE ( SODIUM BICARBONATE ) 325 MG orally three times a day
INSULIN 70/30 HUMAN 15 UNITS subcutaneously every afternoon
Starting Today ( 3/28 )
Instructions: switch to Lantus at the dose prescribed by
your primary care physician ( 8units daily ) when you run out of 70/30 insulin
Number of Doses Required ( approximate ): 2
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally HS as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
TORSEMIDE 150 MG orally every day
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
DIET: 2 gram Sodium
ACTIVITY: as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Ardella Norseth 4/23 as already scheduled scheduled ,
Dr. Katcsmorak 8/6 as already scheduled scheduled ,
ALLERGY: Penicillins , Morphine , Codeine
ADMIT DIAGNOSIS:
1. hyperkalemia 2. Chest pain r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hyperkalemia , Chest pain r/o MI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN DEPRESSION OBESITY TAH/BSO
Diastolic CHF ( EF 60 , LVH , 3+MR ) ( congestive heart failure ) atypical
angina ( neg dobutamine 4/4 ) ( angina ) insulin-resistant DM ( diabetes
mellitus ) GERD ( esophageal reflux ) gout
( gout ) CRI ( creatinine increase from 3 6/29 to 6 6/8 ) ( 4 ) COPD
( chronic obstructive pulmonary disease ) OSA ( sleep
apnea ) anemia ( anemia )
OPERATIONS AND PROCEDURES:
n/a
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
n/a
BRIEF RESUME OF HOSPITAL COURSE:
-CC: HYPERKALEMIA , CHEST PAIN
-HPI: 74 year-old female came in for Epogen shot and was referred to KTDUOO
clinic to eval leg swelling. LENIS=negative. During eval also
reported an incident of chest pressure on 9/21 ( awoke from sleep
at 7a.m. with indigestion-mid chest and rt shoulder pressure two
hours after eating a bowl of cereal without wearing her dentures and
relieved after taking antacids ) and was sent to ER for eval. In
ER , patient noted to be hyperkalemic was treated with Kayexelate and admitted
to PACE team for MI rule out and Hyperkalemia
-PMHx: see problem list
-MEDS:( patient unable take capsules b/c they get stuck in throat , she
does not like taking meds several times/day so she doubles up on
her short acting meds in the a.m. and does not take any more during the
day ) patient was taking Allopurinol 100mg every other day , Ecotrin 325mg every day ,
short acting Cardizem 120mg every day , Hydralazine 40mg every day , Isordil 80mg every day ,
Zaroxolyn 5mg every day-as needed , Spironolactone 25mg every day , Ambien 10mg every bedtime , Calcitriol
1.5mcg twice a day , Valium 5mg q12 as needed , Toresemide 100 or 150mg every day ,
Albuterol-as needed , Atrovent q6prn , 70/30 insulin 15-20units every day , prozac 40mg
every day , Patient is unsure if she takes Lopressor.
-ALL: PCN , Morphine , Codeine
-SH: lives alone , 50pack yr tobacco ( not active ) , no ETOH.
-FH: non-contrib
-ROS: Nl energy but reports exertional dyspnea relieved by wearing home
O2 , exercise tolerance is minimal has an electric cart. No F/C , no
dizziness , no confusion , chronic insomnia
-PE: Afeb , 83 , 148/82 , RR=20 , O2=98% Pleasant , no JVD , RRR , S1S2 , 3/6
systolic murmur at R+LUSB , lungs clr , abd benign , on CVA tenderness , ext
with 1+bilat edema and calf tenderness , neuro nonfocal.
-DATA: K=5.9 , Cr=6.5 , BNP=131 , flat enzymes , UA=WNL , EKG=NSR 87 with nl
axis and LVH , no peaked T's. Chest XR=increased intestitial
markings
-HOSP COURSE:
1. CV: Hemodynamically stable.
*Isch: Chest pain 9/21 sounded GI in etiology , but patient had similar
chest pain this admit on 9/21 while ambulating from bathroom. EKGs
non-ischemic , enzymes neg. patient seen by her primary cardiologist=Dr. Katcsmorak
on 3/22 who did not think symptoms were related to CAD and stated
further CAD assessment was not indicated. Also stated that given medical
co-morbities she would have a high threshhold for invasive therapy.
( Of note patient had a neg MIBI in 9/21 )
Isordil was restarted as ordered not as patient was taking at home. She
continued on Aspirin.
*Pump: Hx of diastolic dysfunction. BNP=131. Dry
wt 223 lbs. 9/21 patient was with out edema but wt=229 lbs. Aldactone was
d/c'd b/c of hyperkalemia. Zaroxolyn 2.5mg daily and Torsemide150mg daily
were given this admit and dypnea improved. D/C weight=226.9 lbs.
Cardizem , Hydral were restarted per outpatient orders not as patient was
taking at home and her BP remained stable.
*Rhythm: NSR. No arrhthmias identified on telemetry.
2. PULM: Dyspnea improved after 2 lb diuresis ( I/O's inaccurate ). Chest
x-ray notable only for increased interstitial markings , unchange from
prior study.
3. GI: ?GERD as cause of chest pain 10/24 Started on
Nexium , will restart Zantac upon d/c , as has taken this in past.
4. RENAL: Admit Cr=6.5 , d/c Cr=6.6. Cr has doubled since 6/29 and will
likely need to start HD. Has f/u appt with Renal 1/14 Started on orally Bicarb
325mg three times a day this admit , to continue upon d/c.
5. ENDO: DM. Cont 70/30 insulin. patient states she will start Lantus at home
as prescribed by primary care physician when her supply of 70/30 runs out.
6. F/E/N: appears euvolemic. Hyperkalemia corrected
after Kayexelate and calcium gluconate given in ER. K+ upon d/c=4.5
7. HEME: HCT dropped from 30.8 to 28.2 this admit. Stool Guaiac neg.
8. MISC: after a lengthy discussion patient was agreeable to taking medications
as prescibed.
CODE: DNR-DNI. patient states HCP is not needed b/c she's DNR
ADDITIONAL COMMENTS: 1. review your med list and medications with the VNA , if anything is
missing call Dr. Hazinski for a prescription
2. review your d/c medication list with Dr. Norseth to see if anything
needs ajustment
3. weigh your self daily and record , bring record to f/u visits
4. if chest pain recurs , call Dr. Katcsmorak or return to emergency room for re-eval
5. If your have Lopressor at home , call Dr. Katcsmorak and ask if you should be
taking it.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
***ATTN VNA***
1. compare d/c med list to actual meds patient has at home and assess for
discrepancies.
2. assess patient for med compliance
3. check vital signs
4. daily weights
5. Draw CBC with diff and BMP , ca , mg on 5/25 and call results to primary care physician=Dr.
Avril Taplin 041-877-2543
No dictated summary
ENTERED BY: HOLLWAY , TABATHA HELAINE ( CW08 ) 8/23/05 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 911
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
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072781784 | PUO | 83375597 | | 682214 | 4/1/1998 12:00:00 a.m. | PANCREATITIS | Signed | DIS | Admission Date: 11/7/1998 Report Status: Signed
Discharge Date: 3/24/1998
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
African-American female with a
history of chronic pancreatitis who was recently admitted to the
Pagham University Of 5 of November to 6 of July for her chronic
pancreatitis who returned on the 20 of August with recurrent abdominal pain
and symptoms consistent with her chronic pancreatitis. Prior
studies by abdominal CT scan had showed findings consistent with
chronic pancreatitis , such as multiple calcifications and the
setting of abdominal pain , swelling and peripancreatic increased
attenuation. Findings consistent with acute pancreatitis. The
patient was admitted initially to the medical service.
On admission , the patient had a low grade temperature of 100.2 , was
tachycardic with a heart rate of 131 , respiratory rate 20 , blood
pressure 132/80. Her exam was remarkable for decreased breath
sounds at the right base and a few scattered rhonchi. Cardiac exam
was significant for tachycardia. There was no murmurs , rubs or
gallops appreciated. Abdominal exam was significant for decreased
bowel sounds. She had abdominal tenderness in the midepigastric
region with guarding. Rectal exam was guaiac negative in the
emergency room.
LABORATORY DATA: Sodium 128 , potassium 4.1 , chloride 95 ,
bicarb 26 , BUN 23 , creatinine 0.8 , glucose 433 ,
WBC 17.8 , hematocrit 33 , platelets 370. Liver function tests had
an alk level of 434 , T-bili was 0.6 , D-bili was 0.2 , lipase was
123 , amylase was 37.
The patient had an ultrasound in the Emergency Department which
showed no gallstones. Gallbladder that was mildly distended. A
common bile duct that was dilated to 7 mm as well as intrahepatic
duct dilatation. In addition a 6 cm cyst was identified in the
region of the pancreatic head. EKG showed her to be in sinus
tachycardia with the rate of 122. She had a left axis deviation in
Qs and V1.
PAST MEDICAL HISTORY: Significant for pancreatitis , asthma ,
insulin dependent diabetes mellitus , history
of vascular necrosis of both hips , status post a total hip
replacement on the right as well as a total hip replacement on the
left. She has known coronary artery disease , history of chronic
obstructive pulmonary disease , history of GI bleed. Status post a
Nissen fundoplication with redo. Hypertension. Alpha thalassemia.
History of congestive heart failure. Chronic low back pain
secondary to spinal stenosis.
MEDICATIONS: Metformin , Atrovent , Albuterol , Flovent , Elavil ,
Cisapride , Flexeril , Axid , NPH insulin , Cardizem CD ,
lisinopril , Lasix , magnesium oxide , Percocet , Premarin , Provera ,
Prilosec , Lipitor , Tums and multi-vitamins.
ALLERGIES: Aspirin causes facial swelling , palpitations ,
reactive airway disease. Ibuprofen causing GI bleed.
meperidine causing itching , prednisone causing myalgias ,
arthralgias , osteoporosis. Penicillin causes edema. Fophonomide
causes itching. Codeine causes itching. Morphine causes itching.
SOCIAL HISTORY: She does not drink or use tobacco. She has two
children. She lives alone.
After admission to the medical service , she was seen by the
surgical service in consultation. Based on clinical findings and
laboratory values , a repeat abdominal CT study was ordered with a
plan for CT guided drainage to rule out a pancreatic abscess. The
CT guided aspirate appeared purulent and was sent for gram and
cultures. Gram stain was positive for gram negative rods and gram
positive cocci in pairs actually growing out Strep viridans and
Klebsiella.
While in the hospital , the patient also developed a urinary tract
infection with yeast , and was started on fluconazole. This too ,
she will be discharged with , to complete a seven-day course. As
well , the patient was felt to have peptic ulcer disease , and was
begun on H. pylori therapy of Biaxin and bismuth , both of which she
will be discharged on to complete a seven-day course. At the time
of discharge , the patient is relatively pain-free , tolerating a
orally diet , and afebrile. The plan is to discharge her to the
Ron -twin- Hospital for rehabilitation on her usual
medications , plus the above-mentioned antibiotics. She will follow
up in the Uass Goldman Valley Medical Center in the next one to two weeks , and
will in addition be followed by her primary care physician , Dr.
Pretty
Dictated By: REYES D. MCPECK , M.D. UI97
Attending: DENISHA H. MCRORIE , M.D. MK57
QL389/2072
Batch: 4554 Index No. TNKXT38VVT D: 2/19/98
T: 2/19/98
Document id: 912
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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896455168 | PUO | 50867619 | | 6025692 | 7/17/2005 12:00:00 a.m. | wound infection | | DIS | Admission Date: 5/15/2005 Report Status:
Discharge Date: 4/6/2005
****** DISCHARGE ORDERS ******
RINALDO , CLEMENT 241-83-16-8
Jo
Service: VAS
DISCHARGE PATIENT ON: 9/1/05 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: YOUNGBERG , JERICA TANYA , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALLOPURINOL 300 MG orally every day
ASA ENTERIC COATED ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally every bedtime
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
HEPARIN 5 , 000 UNITS subcutaneously twice a day
LISINOPRIL 15 MG orally every day HOLD IF: SBP<100
LOPRESSOR ( METOPROLOL TARTRATE ) 100 MG orally four times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
TRICOR ( FENOFIBRATE ) 48 MG orally every day
Number of Doses Required ( approximate ): 10
LANTUS ( INSULIN GLARGINE ) 66 UNITS subcutaneously every afternoon
Instructions: Do not hold even if patient is NPO. Thanks
ARANESP ( DARBEPOETIN ALFA ) 40 MCG subcutaneously QWEEK
Reason for ordering: Renal Disease
Last known Hgb level at time of order: 6.9 g/dL on
2/30/05 at PUO
Diagnosis: Anemia of other Chronic Illness 285.29
Treatment Cycle: Maintenance
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
NOVOLOG ( INSULIN ASPART ) 8 UNITS subcutaneously before meals
Instructions: if BS<100 please give 4U novolog
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously every bedtime
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 0 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 4 units subcutaneously
If BS is 301-350 , then give 6 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LINEZOLID 600 MG orally every 12 hours
Instructions: please continue to take for 10 days; will
need to have platelets checked every week.
Food/Drug Interaction Instruction
No tyramine-containing foods
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
heel weight bearing only
FOLLOW UP APPOINTMENT( S ):
Dr. Youngberg 590-882-9425 1 week , return to hosptial for elective surgery 10/16 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
non healing RLE TMA stump
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
wound infection
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn dm pancreatitis neuropathy
cri ( renal insufficiency ) arf ( acute renal failure ) anemia
( anemia ) hyperchol ( elevated cholesterol ) left toe digit
amputation retinopathy ( retinopathy ) cad ( coronary artery disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
52-year-old man with long standing diabetes and chronic renal
insufficiency who had undergone a right popliteal to posterior tibial
bypass with transmetatarsal amputation for a diabetic foot infection and
vascular insufficiency. Despite revascularization , the TMA site has
never healed with most recent debridement 11/9/05. Returned with fever
to 103 and some minimal increase in swelling and drainage of the R TMA
site , no pain.
PMH Insulin-dependent diabetes mellitus ,
nephropathy , anemia , coronary artery disease , retinopathy ,
hypercholesterolemia , hypertension , gout , arthritis ,
pancreatitis and chronic renal insufficiency.
PSH 1980 pancreatic debridement , 5/20 right ring finger debridement ,
4/10 left fourth and fifth toe amputation , 6/13 right third
and fifth toe amputation and
10/20 right popliteal-posterior tibial bypass graft and completion
TMA.
8/13 , 1/9 TMA debridement
Meds Allopurinol 300 , ASA 81 , Pepcid 20 , Chlorothiadone 12.5 , colace , Fe
325 three times a day , lisinopril 10 Lopressor 100 q6 , Oxycodone as needed , Zocor 20 ,
Neurontin 300 three times a day , Tricor 48 , Lantus 60 every bedtime
Aranesp 40 qwk
ALLERGIES: No known drug allergies.
Exam 98.9 74 139/62 18 99% r/a
looks well no distress
chest clear
cor rrr
abdomen prior midline incision soft and non-tender
pulses fem pop dp patient graft
L 2+ -- dop dop
R 2+ -- dop dop dop
R TMA site with chronic granulation tissue , no fluctuance
R foot and distal leg much warmer than left
no obvious cellulitis , no tenderness
motor ok. sensory diminished. 3+ edema
CXR ok
EKG ok
R Foot plain films -- possible osteo of 1st , 4th and 5th metatarsal
( prelim read by ED Rads )
patient was admitted to Vascular with diagnosis of non-healing TMA site &
osteo despite apparent adequate revascularization. His foot was elevated
R foot , Triple Abx ( Vanc/Levo/Flagyl ) , and he was made NPO/IVF for
possible BKA. His hospital course was unremarkable. He did not go to the
OR. DM management was consulted and optimized his insulin regimen as well
as provided DM teaching. On PJ7 he underwent an MRI of the RLE revealing
extensive OM of the 3rd>4th metatarsal heads , the cuboid , cunioform as
well as the calcaneuos. Blood cultures that were taken grew out MRSA from
6/7. His remaining blood cultures x 2 over 48 hours remained negetive.
The patient's WBC never rose above 7.8 with no left shift. His foot remained
stable with exam revealng chronic diabetic dermopathy and 3+ edema , no
open wound with minimal granulation tissue , no fluctuance , no cellulitis ,
no warmth or TTP. The patient will be dc'd and will return for elective
AKA 4/12 after his LE edema resolves. He will continue on linizolid as an
outpatient. On HD4 after an unremarkable hospital course the patient was seen
fit to be dc'd home with services for WTD dressing changes twice a day. He was
AFVSS , tolerating an ADA diet , and ambulating heel weight bearing only.
ADDITIONAL COMMENTS: patient will be sent home with WTD dressing changes twice a day. Keep leg elevated
while in bed. Will need to continue the linizolid x 10 days; will need
qweekly CBC check for thrombocytopenia. patient should
seek medical attention if there is increasing leg or arm pain , groin
swelling , T>101.5 , redness/puss at the incision site , altered mental
status , symptoms of stroke ( eg HA , change in vision/speech , unilateral
loss of motor/sensation ).
DISCHARGE CONDITION: Stable
TO DO/PLAN:
will return for elective AKA 10/16
No dictated summary
ENTERED BY: NAUMOFF , MICHAL EVA A. ( FI44 ) 9/1/05 @ 08
****** END OF DISCHARGE ORDERS ******
Document id: 913
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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810810890 | PUO | 55986496 | | 2467684 | 7/7/2006 12:00:00 a.m. | diastolic dysfunction-chf | | DIS | Admission Date: 8/13/2006 Report Status:
Discharge Date: 10/16/2006
****** FINAL DISCHARGE ORDERS ******
BICKNESE , LAYNE 704-32-91-0
Valle
Service: CAR
DISCHARGE PATIENT ON: 7/10/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CAOILI , VALERI M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Starting Give at Discharge
Instructions: patient's home med-has prescription
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS GLUCONATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 40 MG orally twice a day
KCL SLOW RELEASE 20 MEQ orally DAILY
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 7/10/06 by
LAUZON , TOMMIE , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
LISINOPRIL 15 MG orally DAILY
Override Notice: Override added on 7/10/06 by
LAUZON , TOMMIE , M.D. , M.P.H.
on order for KCL SLOW RELEASE orally ( ref # 013371860 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 5/28/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: pts home med
Previous Alert overridden Override added on 8/27/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
Previous Override Notice
Override added on 8/27/06 by LAUZON , TOMMIE , M.D. , M.P.H.
on order for KCL IMMEDIATE RELEASE orally ( ref #
802287648 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Starting Today ( 11/9 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 4
PAXIL ( PAROXETINE ) 20 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician-Dr. Aprea 10/10/06 ,
Cardiologist-Dr. Reedy 8/18/06 ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Lightheadedness/shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
diastolic dysfunction-chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) dyslipidemia ( dyslipidemia ) coronary
artery ( coronary artery disease ) tobacco , anxiety
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Stress Test with Oximetry to assess cardiopulmonary status
Echo ( TTE )
BRIEF RESUME OF HOSPITAL COURSE:
CC: Lightheadness and DOE
***
HPI: 78 year-old female with a past medical hx significant for CAD history of CABG in
4/25 ( LIMA to LAD with saphenous vein graft to LM1 and SVG to PDA ). patient
has been having intermittent episodes of DOE , extending back before her
CABG , usually exertional in nature. patient denies CP , however she tends to
hyperventilate during these episodes which makes her lightheaded. patient also
denied syncope , palpitations , changes in vison/hearing , or weakness.
These episodes have recently been increasing in frequency occuring up to
4x/day but she denied any temporal relationship. On the day of
admission , patient had an episode while going from the bed to the bathroom so
she came to the ED.
In the ED , BP 148/67 , HR 72 , SaO2 94 RA.
*************
PMH: 1. CAD history of CABG 4/25
LIMA -> LAD , SVG -> OM , SVG -> PDA
2. HTN
3. hyperlipidemia
4. anxiety
****
Meds on Admission:
Aspirin 325mg every day
Toprol xl 25mg every day
lasix 20mg every day
lisinopril 5mg every day
paxil 20mg every day
****
All: pcn-anaphylaxis
****
FH: neg cad
****
SH:
pcp: dr. diegel , / cardiologist- dr. starrett ,
****
Px on admission
VSS-blood pressure: 128/72 , p: 70 , so2: 96% ra
Gen: well-nourished female lying in bed , NAD
CV: rrr s1/s2 -mrg
resp: ctab
abd: soft non-tender + bs
ext: warm , neg edema
*****
Labs:
wbc: 9.1 , hb: 15 , hct: 35.4 , plt: 280
MCV: low at 76.5-79.5
Romi x 3 negative , trop <assay
EKG: NSR infralateral t wave inversion unchanged from prior
*****
HOSPITAL COURSE:
1. CV - patient was romi x3 neg , kept on tele-however no events , stress test
with oximetry was done on 3/2 , echo 4/12 showed diastolic
dysfunction
HTN: patient had occasional increased blood pressure readings 160/90;
increased lisinopril to 15mg on 10/3 goal blood pressure was < 130/80
2. ENDO - TSH low at 0.439 , t4/t3 normal , hba1c: elevated 8.2
3. PSYCH - continued paxil , have added ativan 0.5mg twice a day as needed
4. Heme: mcv is low , fe: 39 low , tibc 365 ferritin 85; most likely iron
deficiency anemia--given ferrous gluconate/colace on discharge
5. CODE - full
****
Discharge px:
VSS: T: 97.8 , P: 60-82 , BP: 138-160/72-92 , BP at discharge 130/70
SO2: 95-100% RA
Discharge Labs:na: 142 , k 4.O , cl: 107 , co2: 26 , Bun: 19 , creat: 0.8
wbc: 10.5 , hb: 11.8 , hct: 35.8 , plt: 297 , mcv: 78.0
alkp: 120
ADDITIONAL COMMENTS: Ms. Bicknese it was a pleasure to take care of you during your
hospitalization. We have made some changes to your medications. We
increased your blood pressure medication: Lisinopril from 5mg to 15mg
once a day. We started you on a medication for anemia: ferrous
gluconate which you should take 3 times a day along with colace a stool
softener which you should take twice a day. We also increased your lasix
frm 20mg once a day to 40mg twice a day. As discussed with you , your
echocardiogram ( ultrasound of your heart ) showed that you had some
abnormality with the functioning of your heart which may in part explain
your shortness of breath especially on exertion. It is extremely important
to follow up with your primary care physician Dr. Aprea appt 7/12 at
12:10pm and your cardiologist Dr. Reedy on 2/16 at 1:30pm. If you
have trouble breathing , have chest pain please seek medical attention as
soon as possible.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u tsh , t4/t3 , hba1c is elevated; will need hyperglycemic agent
f/u iron studies mcv
f/u alk phos
Event monitor will be sent to patient in 7-10 business days
No dictated summary
ENTERED BY: LAUZON , TOMMIE , M.D. , M.P.H. ( DJ38 ) 7/10/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 914
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
Obe |
OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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921778812 | PUO | 49448215 | | 534363 | 4/6/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/25/1993 Report Status: Signed
Discharge Date: 7/19/1993
PRINCIPAL DIAGNOSIS: ATRIAL FLUTTER.
ASSOCIATED DIAGNOSES: 1. STATUS POST D/C CARDIOVERSION.
2. STATUS POST MITRAL VALVE REPLACEMENT.
3. HISTORY OF RHEUMATIC HEART DISEASE.
HISTORY OF PRESENT ILLNESS: Mrs. Lippman is a 71 year old woman
with a history of mitral valve replacement , atrial fibrillation ,
diabetes mellitus , who presents with light-headedness x 1 day.
Mrs. Lippman has a history of rheumatic heart disease and is
status post commissurotomy in 1965 and a St. Jude's mitral valve
replacement in 1991. In October 1992 she presented in atrial
fibrillation which was well controlled on Quinidine. The Quinidine
was discontinued the following year in April when the patient had a
syncopal episode. At that time , she ruled out for myocardial
infarction and failed Sotalol with increasing PR and QT intervals.
Holter study was negative at that time. Persantine scan showed no
ST changes noted and a fixed defect was present. The patient was
discharged on Lopressor. On August , 1993 she was admitted with
right ankle pain , right lower extremity swelling. Lineis were
negative at that time. On 10/5/93 she was admitted in atrial
flutter with II:I conduction. Trial of procainamide was complicated
by increasing QT intervals. The Procainimide was therefore
discontinued and the Propafenone was begun. The patient underwent
successful DC cardioversion and was discharged on Propafenone 225
three times a day and Lasix 80 every day. Since the morning before admission she
felt light-headed and sweaty. She began to run out of Propafenone
two days before admission and decreased the dose to 150 mg three
times a day. She felt her heart was going slower than normal. This
was worse when standing or walking. However , she had no chest
pain , shortness of breath , loss of consciousness. She had no
diarrhea , no vomiting , her blood sugars have been in the usual
range of 180-200 mg%. PAST MEDICAL HISTORY: As noted above. The
patient has clean coronary arteries by catheterization October
1991.
PHYSICAL EXAMINATION: She is a very pleasant female , appearing
younger than her stated age , in no acute
distress. Her blood pressure is 134/80 without orthostatic change.
Her mouth appears dry but is otherwise unremarkable.
Cardiovascular examination notes a regular rate and rhythm with a
prominent mid-systolic prosthetic valve click. There were
bilateral crackles at the bases. The abdominal and rectal
examinations are normal , stool is guaiac negative. Extremities
showed pigmentation changes in bilateral lower extremities with
well preserved pulses except the dorsalis pedis pulses which are
weak. Neurological examination is unremarkable.
LABORATORY DATA: On admission , EKG showed normal sinus rhythm at
78 beats per minute , axis 145 degrees , PR interval
of 132 milliseconds , no significant change from previous EKG from
February 1993.
HOSPITAL COURSE: The patient was admitted , placed on cardiac
monitor and Holter monitor. On the morning
following admission she was clearly in atrial flutter with II:I
conduction block as confirmed by the Holter monitor. Her
prothrombin time was 25.2 , therefore , on the second hospital day ,
she underwent successful DC cardioversion with 52 joules. The
procedure was carried out without complications; afterwards , the
patient was in normal sinus rhythm with first degree AV block and a
PR interval of 300-320 milliseconds. The patient was observed
through the next day , remained in normal sinus rhythm except for
short periods of SVT with sinus pause. She was asymptomatic and was
able to exercise around the hospital floor and up and down the
stairs. Anticoagulation. The patient is maintained on chronic
Coumadin anticoagulation and at the time of admission she was
continued on her outpatient maintenance of 7.5 mg every bedtime However ,
over the first hospital day prothrombin time increased from 22.3 on
admission to 28.6. Therefore , her Coumadin was held. The
prothrombin time was 29.1. The prothrombin time on discharge was
32 , INR of 3.3 and the patient was instructed to continue on 5 mg
of Coumadin every bedtime and to see Dr. Aspacio in the clinic for physical therapy check in
the next week.
DISPOSITION: MEDICATIONS: Propafenone 225 mg orally three times a day; Colace
100 mg orally twice a day; Colchicine 0.6 mg orally every other day
until May , 1993; Lasix 80 mg orally every day; Plaquenil 200 mg orally
twice a day; NPH Insulin 10 mg subcutaneously every day before noon; Coumadin 5 mg orally every bedtime;
Lopressor 50 mg orally every day; Slo-K 20 mEq orally twice a day CONDITION ON
DISCHARGE: Good. Instructions are given to followup with Dr.
Annette Schoultz in the KTDUOO clinic.
Dictated By: LEOLA MUSICH , M.D. GQ35
Attending: ANNETTE SCHOULTZ , M.D. JW7
KR556/0178
Batch: 3443 Index No. BOBYES73TX D: 10/13/93
T: 2/1/93
Document id: 915
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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058204568 | PUO | 03295339 | | 4746228 | 7/29/2006 12:00:00 a.m. | Volume Overload , Upper GI Bleed | | DIS | Admission Date: 5/4/2006 Report Status:
Discharge Date: 2/21/2006
****** FINAL DISCHARGE ORDERS ******
LANDY , MARINDA 575-71-95-0
Aville
Service: MED
DISCHARGE PATIENT ON: 7/26/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NALBONE , EVIA YONG , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG inhaled every 6 hours
AMITRIPTYLINE HCL 10 MG orally BEDTIME
ARANESP ( DARBEPOETIN ALFA ) 40 MCG subcutaneously QWEEK
Instructions: GIVE QSATURDAY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FLECAINIDE 75 MG orally every 12 hours
LASIX ( FUROSEMIDE ) 160 MG orally twice a day
Starting IN a.m. Sunday ( 1/11 )
Instructions: PLEASE CHECK CREATININE TO MONITOR RENAL
FUNCTION ON INCREASED DOSE OF LASIX.
Alert overridden: Override added on 5/4/06 by
CHAGNON , ANNELIESE J. , M.D. , M.P.H.
on order for LASIX orally ( ref # 254186874 )
patient has a POSSIBLE allergy to CHLOROTHIAZIDE SODIUM;
reaction is Rash. Reason for override: tolerates
HYDROCHLOROTHIAZIDE 12.5 MG orally every day before noon
Alert overridden: Override added on 7/6/06 by
JULIUSSON , LAVELLE A , M.D.
on order for HYDROCHLOROTHIAZIDE orally ( ref # 846221671 )
patient has a PROBABLE allergy to CHLOROTHIAZIDE SODIUM;
reaction is Rash. Reason for override: md aware
VICODIN ( HYDROCODONE 5 MG + APAP 500MG ) 1 TAB orally every 6 hours
as needed Pain
HYDROXYZINE HCL 25 MG orally four times a day Starting Today ( 1/11 )
as needed Itching
INSULIN NPH HUMAN 10 UNITS subcutaneously every day before noon
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LEVOTHYROXINE SODIUM 75 MCG orally DAILY
Override Notice: Override added on 5/4/06 by
CHAGNON , ANNELIESE J. , M.D. , M.P.H.
on order for COUMADIN orally ( ref # 764590001 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: will monitor
Previous override information:
Override added on 5/27/06 by GORT , NANCI , M.D.
on order for COUMADIN orally ( ref # 216058955 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: will monitor
NADOLOL 10 MG orally every day before noon Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 40 MG orally every day before noon
Starting Today ( 1/11 )
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every afternoon
SARNA TOPICAL TP DAILY
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 5/4/06 by
CHAGNON , ANNELIESE J. , M.D. , M.P.H.
on order for COUMADIN orally ( ref # 764590001 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor
Previous override information:
Override added on 5/27/06 by GORT , NANCI , M.D.
on order for COUMADIN orally ( ref # 216058955 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor
SALINE NASAL DROP ( SODIUM CHLORIDE 0.65% ) 2 SPRAY nasal four times a day
as needed Other:nasal dryness , congestion
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/4/06 by
CHAGNON , ANNELIESE J. , M.D. , M.P.H.
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will monitor
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Please call Dr. Derick Yan to schedule an appointment for followup in 1 to 2 months. ,
Dr. Kush , please call 865-556-8789 to schedule an appointment to be seen in 2-4 weeks. ,
Dr. Gaye Gusmar , Thisa Health Center 2/5/06 at 09:30 am ,
Arrange INR to be drawn on 7/26/06 with f/u INR's to be drawn every
4 days. INR's will be followed by KUSH
ALLERGY: LEVOFLOXACIN , CHLOROTHIAZIDE SODIUM
ADMIT DIAGNOSIS:
Volume Overload
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Volume Overload , Upper GI Bleed
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
PVD history of bilat iliac stents ( 10/4 ) ( peripheral vascular disease )
AVR/MVR ( cardiac valve replacement ) AFib ( atrial fibrillation ) CRI
( chronic renal dysfunction ) RHD ( rheumatic heart
disease ) OA ( osteoarthritis ) Diverticulosis history of colectomy
( diverticulosis ) Gout ( gout ) CHF ( congestive heart failure )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
Attg - Krystle Glick outpt cardiologist - Kush
---- CC: low
hct HPI: 77F with history of diverticular GIB on
anticoagulation who presents with a hct drop from baseline 30 to 26
and strongly guiac + stool. The patient is on coumadin for
bioprosthetic MVR and AVR. The patient presented with black , tarry
stools one month ago and was found to have a diverticular
GIB. She was seen in PUO ED the evening PTA for fluid overload. She
was evaluated and discharged on an increased lasix dose.
ROS: trouble starting urination , joint pain , HA , itching since abx ,
weakness PMH: rheumatoid arthritis , CRI , gout , rheumatoid
heart disease , mitral stenosis , aortic stenosis , and regurgitation ,
status post pericardial MVR and AVR in 2000 , type 2 diabetes mellitus ,
NIDDM , hypercholesterolemia ,
osteoporosis , hypothyroidism , peripheral arterial disease , atrial
fibrillation with RVR , history of aspiration pna in 6/19
PSH: history of fem-pop bypass 8/27 c/b allergic abx rxn and damage to vocal
cords. Meds at home: Nexium 40 mg orally
twice a day Flecainide 75 mg orally
every 12 hours Lasix 120 mg orally
twice a day Hydrochlorothiazide 12.5 mg orally
every day before noon Vicodin one tab orally every 6 hours as needed
pain hydroxyzine 10-20 mg orally four times a day as needed
itching NovoLog sliding
Insulin NPH 6 units subcutaneously every day before noon levothyroxine 75 mcg orally
every day before noon nadolol 10 mg orally every day before noon
Sarna topical daily Zocor 20 mg orally
every bedtime Ocean Nasal Spray four times
daily Coumadin 2 mg orally every afternoon
All: levofloxacin->hives , lip swelling ? skin sloughing;
chlorothiazide->rash. SH: no tobacc , no EtOH , no drugs. At rehab since
surgery FH:
nc -----
Daily status: SOB improved , afebrile , JVP @ 9 , 120 lasix intravenous x 1 this
am; I/O goal -500 to -1L; Off plavix; INR 1.8 today ( usu 1.7 per Dr.
Kush ) -----
Admission PE: T97 P64 BP144/58 RR 18 98%2L. NAD , able to speak in
full sentences , Aox3; bilateral crackles to halfway up; CV - RRR ,
III/VI systolic murmur at apex radiating to axilla , II/VI systolic
murmur best heard at LLSB , JVP >15;Abd - hypoactive bowel
sounds , multiple well-healed incisions , distended and firm , with
pitting edema in flanks bilaterally Extr - warm , chronic skin changes ,
2+ pitting edema to thighs bilaterally , 2+ DP and physical therapy pulses
bilaterally -----
ADMIT EKG: NSR 60 bpm , 1st degree AVB. Incomplete RBBB. S in I , small
every in III. -----
A/P: 77F with MMP including RA , CRI , MS , AS history of AVR/MVR , and prior
history of GIB on anticoagulation with coumadin and plavix who
presents with decreased hematocrit 2/2 presumed slow GIB. 1. GI: Patient
has had multiple GIB in past , most recently diverticular bleed 1 month
ago. 2 large bore IVs. Type and crossmatch PRBC. Transfuse for HCT<25.
Check q12hour hcts. Continue PPI twice a day Guiac all stools , has been guaiac
positive throughout this admission but WITHOUT evidence of active bleed.
HCT stable x > 24h , no e/o acute bleed. Continue conservative management.
2. Heme: On coumadin for bioprosthetic MVR and AVR. At goal INR at
present , 1.7-1.9. Held Coumadin initailly , restarted 10/27 once at 1.8 at
2 mg daily. Will hold plavix indefinitely given bleeding risk. Stable hct
@ 27 throughout admission , day of discharge HCT decreased to 25
however felt to not be acute bleed. Repeat value back at baseline.
Checked SPEP and UPEP given anemia , CRI; pending at the time of
discharge this will require follow-up as out-patient for Multiple
Myeloma. 3. CV - ischemia: clean cath in 2000. On plavix for PVD ,
will hold indefinitely given recurrent GIB. - pump: continue nadolol.
Baseline creatinine 1.9-2.3. Appears vol up by exam. Was diuresised
approx 1 L over 48h. Transitioned to orally lasix regimen 7/10 , at increased
dose 160 orally twice a day Most recent echo 6/19 per Dr. Arn Repeat as outpt. -
rhythm: has history of afib with RVR. Continue flecainide. On
telemetry. 4. Endocrine: patient has hypothyroidism. Continue
home dose synthroid. TSH high at 5.5 , FT4 pending at time of discharge.
5. PPX: on coumadin , PPI ----- Code: DNR/DNI
ADDITIONAL COMMENTS: 1 ) Have your INR checked on Monday to ensure an INR goal between 1.7 and
1.9. Please fax the results to Dr. Kush ' office at 132-165-3435.
2 ) Have your Creatinine checked on Monday to ensure that your kidney
function has not decreased on your increased Lasix regimen ( increased to
160mg twice daily from 120 mg twice daily ).
3 ) You had a slow Upper GI bleed while on aspirin , coumadin , and plavix.
STOP taking Plavix. Your baseline HCT falls between 27 and 30.
4 ) Have your primary care physician follow up the results of your SPEP/UPEP and Free T4
tests.
5 ) Have your cardiologist re-evaluate your lasix regimen at your next
visit.
6 ) Your Prilosec dose was increased to 40 mg every day before noon , 20 mg every afternoon.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Have your INR checked on Monday to ensure an INR goal between 1.7 and
1.9. Please fax the results to Dr. Adeline E Napenas at 132-165-3435.
2 ) Have your Creatinine checked on Monday to ensure that your kidney
function has not decreased on your increased Lasix regimen ( increased to
160mg twice daily from 120 mg twice daily ).
3 ) You had a slow Upper GI bleed while on aspirin , coumadin , and plavix.
STOP taking Plavix. Your baseline HCT falls between 27 and 30.
4 ) Have your primary care physician follow up the results of your SPEP/UPEP , Erythropoeitin
and Free T4 levels.
5 ) Have your cardiologist re-evaluate your lasix regimen at your next
visit.
6 ) Your Prilosec dose was increased to 40 mg every day before noon , 20 mg every afternoon.
No dictated summary
ENTERED BY: STOFFREGEN , ZACHERY D. , M.D. , PH.D. ( OC62 ) 7/26/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 916
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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997044127 | PUO | 54837690 | | 292197 | 3/20/2001 12:00:00 a.m. | chest pain | | DIS | Admission Date: 7/14/2001 Report Status:
Discharge Date: 8/23/2001
****** DISCHARGE ORDERS ******
HARKENREADER , NIEVES 867-01-14-6
Man , Wyoming 81856
Service: MED
DISCHARGE PATIENT ON: 9/3/01 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
AMPICILLIN 500 MG orally four times a day X 5 Days
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
KLONOPIN ( CLONAZEPAM ) 1 MG orally three times a day
HOLD IF: resp depression , sedation
FLAGYL ( METRONIDAZOLE ) 500 MG orally three times a day X 5 Days
Food/Drug Interaction Instruction Take with food
PERCOCET 1-2 TAB orally every 6 hours as needed pain HOLD IF: resp depression
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally every day X 5 Days
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
LISINOPRIL 5 MG orally every day
ZANTAC ( RANITIDINE HCL ) 150 MG orally twice a day
Alert overridden: Override added on 9/3/01 by :
POTENTIALLY SERIOUS INTERACTION: OMEPRAZOLE & RANITIDINE
HCL , ORAL Reason for override: prilosec d/c
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Selia 1 week ,
Dr. Angeline Cohens 1 week ,
Nutrition 6/21/01 scheduled ,
CT of abdomen 6/21/01 ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain , r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Borderline HTN Anxiety D/O PPD + history of inhaled G5P4TAB1
morbid obesity ( obesity ) obstructive sleep apnea ( sleep apnea )
psoriasis ( psoriasis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
37F , morbidly obese , history of gastric bypass 2/15/01 ,
c/b splenic infarct ( Rx abx and pain meds ) and odynophagia with poor orally
intake , re-admitted 11/27 after episode of CP concerning for cardiac
source ( with diaphoresis , nausea , palpitation , +/-
SOB , radiation to neck and R arm ). Admit for r/o
MI and pharm MIBI - only with fixed inferior defect - no ischemia.
Also with EF 37% - should echo as outpt to further evaluate.
ADDITIONAL COMMENTS: Please call your MD if you have chest pain , shortness of breath or
other concerns. Please f/u with Dr. Cohens & CT next week per him.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: SPLETZER , ZENAIDA K. , M.D. ( AE12 ) 9/3/01 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 917
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
N |
N |
- |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
789741064 | PUO | 72658175 | | 198757 | 7/15/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/24/1995 Report Status: Signed
Discharge Date: 5/12/1995
PRINCIPAL DIAGNOSIS:
1. New stroke , right sided weakness and confusion.
OTHER DIAGNOSES:
2. Myasthenia gravis.
3. Osteoarthritis.
4. Pernicious anemia.
5. Hypertension , degenerative joint disease.
CHIEF COMPLAINT: Right sided weakness and confusion.
HISTORY OF PRESENT ILLNESS: Ms. Aubrey is an 83 year old woman
with a history of myasthenia gravis ,
arthritis , pernicious anemia and hypertension and degenerative
joint disease with nerve impinging resulting in decreased reflexes
in the left lower extremity. She was in her usual state of health
until when she woke to go to the bathroom at approximately 2 a.m.
on the day of admission. She had difficulty getting up from the
sofa where she sleeps and slipped and fell to her knees. Because
she stated , "her right leg was weak". She started speaking and
talking loudly. Her son heard her , came up to help her. At the
time he arrived , she was crawling around on her hands and knees and
appeared to be mildly confused. He helped her up and assisted her
to the bathroom. She was able to walk with assistance and returned
to bed and did not feel like she needed to call a physician at that
time. She then awoke at approximately six in the morning and was
able to walk without assistance to wash her face and then to eat
breakfast. However , at breakfast , the son noted that she was using
her right hand clumsily cutting pieces of banana onto the floor ,
not adequately reaching her mouth to feed herself and had begun to
use her knife to eat her cereal. He discussed the problem with
her. She agreed that she probably needed to call a doctor about
this. She attempted to get out of the chair and again slipped
forward because of right leg weakness. She contacted her physician
who recommended that she be seen at the Loket A Hospital
When seen there , when leaving , her son noted that she seemed to run
into things on her right side. With entering the car , did not pick
up her right leg well. At the muir yhass hospital , she was found to
have significant right hand weakness and proximal right leg
weakness. She was sent to the Kernan To Dautedi University Of Of for further evaluation.
She denies having had any previous neurologic events similar to
this episode. She has had an episode of dizziness , nausea and
vomiting associated with a severe right occipital headache back in
8/5 at which time she was evaluated at the Kernan To Dautedi University Of Of and was given
diagnosis of benign positional vertigo which since resolved. At
that time , she had a CT scan which showed only periventricular
white matter disease as well as an increased soft tissue density in
the region of the sella. An LP at that time revealed no white
cells and red cells which cleared with successive tubes. She also
six months ago was diagnosed with myasthenia gravis. At that time ,
she had the following symptoms: She had difficulty keeping her
neck up , difficulty swallowing , her eyelids were drooping. These
symptoms resolved quickly with Tensalon injection. She has been
since started on Mestinon and Prednisone with good relief and is
followed by Dr. Joffrion at Loket A Hospital for this problem
and was initially diagnosed by Dr. Dramis at Kendsonre Ale Ater Hospital .
With regards to her current episode , she denies having any
symptoms of chest pain , shortness of breath , nausea , vomiting and
palpitations. She has not had any febrile illness , nausea or
vomiting recently. She has not had any episodes of a shade coming
down before her eyes.
PAST MEDICAL HISTORY: 1. Myasthenia gravis diagnosed by
Dr. Alton Dramis at Kendsonre Ale Ater Hospital
approximately six months ago. Symptoms as described above , good
relief with Mestinon and Prednisone. 2. Pernicious anemia ,
intrinsic factor antibody positive , receives monthly B12
injections. 3. Spine degenerative joint disease , LS spine CT in
1/11 showed most marked deterioration at the L4-L5 vertebra with
spondylolisthesis , bilateral foraminal narrowing and moderate
spinal stenosis. She has long standing decreased reflexes in her
left leg and some decreased sensation to light touch in her left
foot. 4. Hypertension , has taken Reserpine intermittently over the
last 25 years. She has tolerated this well apparently. This is an
outmoded medication however because she has been on it so long , it
has not been discontinued. However , she has been noted to suffer
from some mild depression. 5. Osteoarthritis affecting mostly the
hands and feet followed by Dr. Etta Six at I Warho Hospital 6. Long standing difficulty sleeping , takes
Phenobarbital 15 mg at night as needed for this problem for the last 30
years 7. Frequent UTI's. 8. Episode of benign positional vertigo ,
8/5 as described above. 9. Status post hysterectomy , status post
ovariectomy. 10. Some difficulty with rightward gaze and upward
gaze of the right eye noted as long back as 4/7 11. Hemorrhoids.
12. Right kidney 15 mm simple cyst noted incidentally on the
abdominal CT.
MEDICATIONS AT HOME: Prednisone 12.5 mg every other day , Daypro 600 mg
every day ( arthritis medication ) , Mestinon 60
mg orally four times a day , Reserpine 0.25 mg every day and Phenobarbital 15 mg to
30 mg every bedtime ( for sleep ).
FAMILY HISTORY: Father and two brothers died in World War II.
Mother died of a lung problem.
SOCIAL HISTORY: The patient worked as a lab assistant in the
Do for preventative medicine
and later in pathology. She has been retired since 1968 , currently
volunteers at I Warho Hospital in the gift shop on Tuesday
afternoon. She lives with her husband and one son at home.
EXAM: The patient is an elderly appearing woman with a lively
voice and no apparent distress. She gestures much more
with her left hand compared to her right hand. Vital signs: Temp
97.8 , pulse 84 , blood pressure 110/80 , respirations 18. General
exam: HEENT normocephalic atraumatic. Left palpebral fissure is
slightly smaller than right. Throat without erythema. Neck: Good
range of motion. Chest: Faint end-expiratory wheezes , small
crackles at the right base. Coronary: Regular rate and rhythm ,
possible faint systolic murmur at the left upper sternal border , no
carotid bruits. Abdomen: Soft and nontender. Extremities: Joint
deformities most notable in the hands and feet. Joint deformities
in the hands include the distal interphalangeal joints which is
nonconsistent with rheumatoid arthritis , ulnar deviation of the
hand is present. Neuro exam: Mental status alert , oriented to
April , 1995 at I Warho Hospital , Clinton/Gore ,
cannot remember the previous president , picks Reagan. Language:
Fluent and nondysarthric , good repetition , reading and
comprehension , poor word generation but is better in term than
attention. Patient can span five forward , backwards and misses
rely and tune , possibly mild decreased attention. Memory: Fair
for events leading to hospitalization but some difficulty getting
logical sequence of occurrences , may partly be due to language
difficulties. Visual spacial: Clock shows poor organization ,
writes numbers down the middle of the circle. Cranial nerves II:
Right pupil is slightly larger than left pupil , reactive , visual
fields full to confrontation , 3 , 4 , 6 , possible decreased abduction
and vertical upgaze of the right eye. However , she denies double
vision. VII: Smiles symmetrically. Eyebrows symmetric. There is
possibly decreased left nasolabial fold on the left , however , smile
is symmetric. VIII: Hearing intact , finger rubbing bilaterally.
IX , X: Palate is up bilaterally. Turgor of the mouth is 5/5.
Tongue midline. Motor: No drifts , difficulty with fine finger
movement on the right side which is slightly slower than on the
left , has especially more difficulty on the right side initiating
the movements figuring out what to do. Right rapid alternating
movements of the right hand is slightly slower than the left.
Power: Deltoid , biceps and triceps 5/5 , bilaterally symmetric ,
however does not raise her right deltoid as high. Wrist extensors
on the right are 4+/5 and on the left 5/5. Interossei on the right
5-/5 , on the left 5/5. Lower extremities: Iliopsoas , quads , hams
and gastrocs all 5/5 symmetric. EHL possibly slightly diminished
strength on the right. Has increased difficulty with heel to shin
on the right leg probably suggestive of proximal right lower
extremity weakness not apparent on cognition testing. Sensories
and light touch and pinprick are grossly intact throughout. No
double simultaneously stimulation extension , proprioception intact
in the feet bilaterally. Decreased vibration in the left foot
compared to the right foot , reflexes upper extremities 2+
symmetric , lower extremities - right lower extremity 3+ knee , 2+
ankle. Toes downgoing , left , 1+ knee , 1+ ankle , toe downgoing.
Coordination: Finger to nose within normal limits bilaterally.
Heel to shin slightly worse on the right lower extremity , possibly
secondary to proximal flexor weakness. Gait: Walks quickly but
requires holding onto assistants for balance. Incidentally , she
says it is because she needs shoes for arthritis , marked pronation
of the ankle on small steps.
LABS: Sodium 144 , potassium 3.9 , chloride 106 , C02 25 , BUN 15
and creatinine 0.9 , glucose 125 , calcium 10.5 , magnesium
2.0 , B12 was normal. RPR nonreactive. PFT's normal. Phenobarb
level not detected. Tox screen positive for Benzodiazepine ( this
may have been due to sedation she received for the CT. However , it
is not clear that she received sedation ). Hematocrit 34.6 with MCV
of 80.6 , platelets 217 , white count 9.05 , polys 73 , 18 lymphs , 7
monos , 2 eo and 7 basophils. physical therapy 13.1 , PTT 25.7. CT:
Periventricular white matter disease , slightly increased density
above the sella.
HOSPITAL COURSE: This is an elderly woman with hypertension ,
myasthenia gravis and arthritis who presented
with weakness of her right lower extremity and right hand and some
confusion as evidenced by using a knife to eat her cereal instead
of a spoon. Her exam was notable for mildly impaired attention ,
possibly confused clock difficulty with handwriting and decreased
strength of the right hand and likely probably decreased strength
to the right lower extremity. Hip flexors is based on the relative
difficulty with heel to shin on the right. Old findings on exam
included abnormalities of the right eye muscles , decreased left
palpebral fissure and sensory findings in the left lower
extremities as well as reflexes. Her presentation was consistent
with possible small vessel stroke affecting the arm and leg more
than the face. This could have occurred in the pons area or the
internal capsule. The component of confusion however is less
explainable based on a deep lesion such as this and raised the
possibility of a small cortical insult. MRI showed no territorial
stroke , just T2 intense abnormalities in the periventricular white
matter , corona radiata and centrum semiovalle suggestive of small
vessel disease. Echo and Holter were not suggestive of
cardioembolic disease. Echo showed normal LV size , preserved LV
function with estimated ejection fraction of 80%. There is also
mild LVH , no thrombus was seen. There was aortic sclerosis with
mildly regurgitation , mild thickening of the mitral valve leaflets
with mild mitral regurgitation and bubble study was negative.
Holter was sinus rhythm at 54 to 127 beats per minute. Occasional
frequent APB's , 14 atrial couplets , five runs of SVT ranging from 3
to 10 beats with heart rates 108 to 182 , occasionally only frequent
VPB's at all hours and one ventricular couplet. Carotid
noninvasive studies showed no significant hemodynamic lesions. Of
note on the MRI , the basilar artery appeared to be small caliber
and the carotid showed some calcification. On carotid noninvasive
studies , however , there was only minimal plaque in the carotid
arteries.
In summary , it appears that Ms. Aubrey had a small vessel stroke.
She showed some critical improvement during hospital stay and was
able to walk without assistance on the second hospital day. She
also had improved right hand function and appeared to be less
confused. We recommended starting enteric coated aspirin which she
is to take one per day. In the setting of the acute stroke , we did
not control her blood pressure aggressively. Her pressures ranged
from systolics of 120 to 180 averaging around 140 to 150 with
diastolics usually in the 80's. We have suggested that she
discontinue the use of her Reserpine as intermittent use is
problematic especially with this medication and she admits to
intermittent use as well as the fact that she has suffered from
some mild depression that can be associated with Reserpine. She
will be started on an alternative blood pressure as an out-patient
with Dr. Seaholtz in the next week. We did not wish to start this
medication in the acute setting. She will likely be started on an
Ace inhibitor for blood pressure control. We also suggested that
she discontinue the use of Phenobarbital for sleep as this might
contribute to confusion.
Finally , since she is on Prednisone and Mestinon , we asked the
patient whether she was taking GI prophylaxis. Evidently , she only
does this intermittently as well. She may be on Carefate , however ,
we suggested taking an H2 blocker once in the evening and have
provided her with the prescription for Zantac 150 mg every bedtime She
will follow-up with Dr. Seaholtz , her primary doctor at Ville Ciltlake Community Hospital as well as Dr. Joffrion at the Crit Memorial Hospital
for her myasthenia gravis and stroke. She has an appointment with
Dr. Joffrion next week on Wednesday.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg every day.
2. Prednisone 12.5 mg orally every other day
3. Mestinon 60 mg orally four times a day
4. Daypro one orally every day.
5. Zantac 150 mg every bedtime
6. B12 monthly injections.
7. To be started on a blood pressure medication as an out-patient
by Dr. Motz
Condition on discharge: Stable. Disposition: Home with
occupational therapy visits and blood pressure visits.
Dictated By: GAYE S. FRANZA , M.D.
Attending: DERICK D. YAN , M.D. AZ67
RE382/2946
Batch: 2558 Index No. 7KMWD1W1Z D: 11/12/95
T: 5/30/95
CC: 1. Dr. Seaholtz Tamp Beth Hospital
2. Dr. Joffrion Kass Statesdou Metteil General Hospital
3. Dr. Derick Yan Sherst. Health Care
Document id: 918
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182796277 | PUO | 05941893 | | 249615 | 3/1/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/20/1993 Report Status: Signed
Discharge Date: 8/25/1993
PRINCIPAL DIAGNOSIS: 1. VENTRAL HERNIA
SECONDARY DIAGNOSES: 2. ADULT ONSET DIABETES MELLITUS
3. HISTORY OF DIVERTICULITIS
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old woman
who developed diverticulitis in 16 of May
She underwent bowel resection and had a complicated hospital course
complicated by infection and pain. She remained in the hospital
for approximately 1 1/2 months. After discharge she continued to
have pain. She was seen in the Ashore Cleod Health in 24 of November , with the
diagnosis of ventral hernia. PAST MEDICAL HISTORY: Is significant
hypertension; adult onset diabetes mellitus; diverticulitis. PAST
SURGICAL HISTORY: Sigmoid colectomy in 8 of September right carpal tunnel
release in 1992. MEDICATIONS ON ADMISSION: At the time of
admission , the patient was on Tylenol. ALLERGIES: Penicillin ,
Darvon.
PHYSICAL EXAMINATION: In general , the patient is an obese female
in no acute distress. The vital signs
showed temperature 97.7 , heart rate 84 , blood pressure 100/70 and
respiratory rate 18. The HEENT examination was benign. The lungs
were clear to auscultation bilaterally. The heart was regular rate
and rhythm. The abdomen was obese , soft , non distended , with
periumbilical tenderness , and a palpable umbilical hernia.
HOSPITAL COURSE: The patient was brought to the Operating Room on
17 of February , where she underwent mesh repair of her
midline incisional hernia. She tolerated the procedure well
without complications. Postoperatively , her diet and activity were
increased. She developed very mild erythema around the incision
postoperatively for which she received 3 days of intravenous Vancomycin.
She never developed a high fever or white count. Antibiotic
coverage was converted to Ciprofloxacin and she remained afebrile
for 24 hour and was discharged to home in good condition.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on Ciprofloxacin 500 mg orally twice a day x 5
days , Tylenol #3 1-2 tablets orally every 4 hours as needed CONDITION ON DISCHARGE:
Good. DISPOSITION: To home. FOLLOW UP CARE: In the Ashore Cleod Health in one week for wound check and staple removal.
Dictated By: ROSSIE MANKOSKI , M.D. EO73
Attending: CARYN C. ZANGL , M.D. OK89
IB143/2020
Batch: 9784 Index No. BQTDJ0LQU D: 8/18/93
T: 3/28/93
Document id: 919
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622305015 | PUO | 73874783 | | 509519 | 2/28/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/10/1991 Report Status: Signed
Discharge Date: 3/20/1991
HISTORY: The patient is a 62 year old rug
salesman admitted with increasing
angina. In 1981 he was first diagnosed with exertional chest
pain and hospitalized for a strongly positive stress test
catheterization at Pagham University Of with an 80%
proximal circumflex and 50% left anterior descending coronary
artery.
Since that time he has been managed medically and recently felt
that his angina consisted of chest aching , throat aching and
dryness of the throat. This worsened.
On March , 1991 he had an exercise treadmill test. He went
eight minutes and 0 seconds and attained a peak heart rate of
110 , 70% of predicted and a peak blood pressure of 198/90. The
test was stopped due to 1 mm ST depression in Leads II , III , F
and V4 to V6. He developed chest discomfort. Normal blood
pressure responds to exercise and the ischemic changes were
similar to previous tests on July , 1989 but a lower exercise
capacity. His exercise discomfort is exertional and he used to
notice it when he carried his golf bag up a hill.
Yesterday he noticed more frequent anginal pain , with throat ,
chest and chest pressure and both arms aching with dull pain
while playing golf. He noticed the symptoms around the third
hole. He was then able to play up to the 14th hole walking. He
took one nitroglycerin and was able to finish to the 18th hole.
On the day of admission he noticed some pain at work while moving
around the office , but it did not last long enough for him to
take a nitroglycerin.
Medications on admission; LoPressor 50 mg orally twice a day , Isordil 20
mg orally three times a day , Verapamil 80 mg orally three times a day , Xanax 0.25 mg orally
twice a day as needed , one aspirin every day and as needed nitroglycerin.
HOSPITAL COURSE: The patient ruled out for a myocardial
infarction. On March he had a
percutaneous transluminal coronary angioplasty in which a
proximal circumflex was dilated from 95% to 20%. The only other
lesion was a right coronary artery of 30%.
The patient's post percutaneous transluminal coronary angioplasty
course was complicated by nausea and vomiting. A KUB was non-
specific. The patient's nausea and vomiting resolved over a
course of two days and he remained well and was able to tolerate
orally intake well. Throughout his episodes of nausea and vomiting
the electrocardiogram remained unchanged and he denied any of his
usual anginal symptoms.
DISPOSITION: The patient was discharged home in
excellent condition on LoPressor
50 mg orally twice a day , Isordil 20 mg orally three times a day , Verapamil 80 mg
orally three times a day , one aspirin every day and Pepcid 20 mg orally twice a day
Dictated By: JACKSON PART , M.D. WU86
GQ7 /9996
CARA BARNABA , M.D. HL86 D: 6/28/91
T: 10/10/91
Batch: N668 Report: KL635S63 T:
Document id: 920
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756484975 | PUO | 14374811 | | 3722171 | 9/15/2005 12:00:00 a.m. | febrile illness possibly CAP | | DIS | Admission Date: 5/16/2005 Report Status:
Discharge Date: 11/29/2005
****** DISCHARGE ORDERS ******
RODIBAUGH , ISADORA 716-33-91-2
Awa Greenrhamrie Rie
Service: MED
DISCHARGE PATIENT ON: 2/29/05 AT 03:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
ALBUTEROL ( NEB ) ( ALBUTEROL NEBULIZER ) 2.5 MG NEB every 2 hours
as needed Shortness of Breath , Wheezing
ALLOPURINOL 100 MG orally every day
ATENOLOL 25 MG orally every day
CEPACOL 1 LOZENGE orally every 2 hours as needed Other:cough
DOXYCYCLINE HYCLATE 100 MG orally twice a day Starting Today ( 10/21 )
Instructions: Cont for 7 days after discharge
Food/Drug Interaction Instruction Give with meals
Take 1 hour before or 2 hours after dairy products.
LASIX ( FUROSEMIDE ) 40 MG orally every day
ROBITUSSIN before meals ( GUAIFENESIN before meals ) 5 MILLILITERS orally every 6 hours
as needed Other:cough
HOLD IF: for sedation or altered mental status
PNEUMOCOCCAL VACCINE ( PNEUMOCOCCAL VAC. POLY. )
0.5 ML intramuscular x1 Starting prior to DISCHARGE
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG NEB four times a day
CEFPODOXIME PROXETIL 200 MG orally twice a day
Starting Today ( 10/21 )
Instructions: Cont for 7 days after discharge
Food/Drug Interaction Instruction Give with meals
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Weingartner 1/5/05 @ 12:00 pm @ Hisgate Ln , Wa , Iowa 56983 scheduled ,
ALLERGY: intravenous Contrast , IRON ANALOGUES , Erythromycins ,
LEVOFLOXACIN
ADMIT DIAGNOSIS:
Pneumonia , ARF , COPD , Gout
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
febrile illness possibly CAP
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ASTHMA/COPD aodm history of MI x 2 history of V FIB ARREST history of CABG 1/25 sleep apnea
obesity hypercholesterolemia history of chole history of dvt ->
greenfield aaa repair ( abdominal aortic aneurysm ) diverticular
abscess ( abscess ) gerd ( gastroesophageal reflux
disease ) gout ( gout ) dm neuropathy
( neuropathy ) carpal tunnel ( carpal tunnel syndrome ) chf ( congestive
heart failure ) iron def anemia ( baseline
30 ) cri ( 1.4 to 2 ) history of sigmoid colectomy 2/1 OSA ( sleep apnea ) history of R
CEA
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
73 F with CAD , asthma/COPD , CRI p/with acute onset
fever/chills/rigors. patient was hospitalized one month prior at P Therford Hospital
and completed a one week prednisone taper post-discharge. She has a
hx of multiple COPD exacerbations , but denies
CP/SOB/nv/diarrhea/rash/dysuria. CXR-normal
Labs - Cr-2.2 , K-4.0 , WBC-1.95 , U/A neg , blood/urine cx
pending PMH: CAD history of CABG 1996 , CHF , COPD/Asthma , obst
sleep apnea , CRI ( bcr 1.7 ) , VF arrest , gout , AAA repeair with
greenfield filer , GERD , R CEA , chole/appy , sigmoid
colectomy. Meds: ASA , atenolol , mvi , atrovent nebs ,
cefotaxime , doxy , lasix , allopurinonol , quinine
( held for possible WBC suppression ) All: erythromycin , levofloxacin , intravenous
contrast ,
theophylline SH: 1 ppd
smoker
PE on admission
Gen fatigued ,
somnolent HEENT - no LAD ,
MMM Cor - s1 , s2 2/6 holosystolic murmur @
LLSB Pulm - + bibasilar dry crackles , no
tachypnea Ab- obese , SNTND +BS , +healed surgical
scars Ext no c/c/e , PP
2+ skin - no rash
Hospital Course: Patient was given both doxycycline and cefotaxime. Her
SOB quickly resolved. After one day , the patient seemed to be back to
baseline. Curiously , her WBC < 1. Hematology was consulted. A BM
biopsy was recommended which the patient declined. Her cultures were
negative. For the hematology workup , B12 and cortisol were normal. ANA ,
protein electrophoresis , SPEP and UPEP were pending at discharge. Qunine
was D/C'd as it is one cause of leukopenia. For this , the patient has a
follow-up appointment in the hematology clinic on 4/3 @ 12:00 pm at Balt Sa Shing She also had a Hct of 27 for which she was transfued a
unit of blood. The patient was stable at discharge. She was instructed
to continue her abx for seven days and given her f/u appt information.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Cont Abx for seven days. F/u appt with Hematology: Dr. Weingartner , 1/5/05
@ 12:00 pm , Revesa Pla Ster Heme/Onc , 676 068 6564
No dictated summary
ENTERED BY: WARRELL , KRYSTIN D. , M.D. , PH.D. ( FO61 ) 2/29/05 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 921
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350097830 | PUO | 17449486 | | 045133 | 5/17/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/2/1995 Report Status: Signed
Discharge Date: 3/21/1995
HISTORY OF PRESENT ILLNESS: Patient is a 42 year old female with a
history of variegate porphyria ,
insulin dependent diabetes , coronary artery disease , status post
coronary artery bypass graft , and hypercholesterolemia who had
experienced five days of confusion , weakness , change in bowel
habits , and fatigue with flashing sensations of anxiety with
emotional lability. Patient had a history of variegate porphyria
for about fifteen years , was followed by Dr. Jackson Part , and she
had been relatively free of porphyria attacks with the last major
one approximately twelve years ago with symptoms similar to those
she was experiencing at the time of this admission. In April
1994 , she had a mild porphyria attack which was managed by stopping all
her medications. She intermittently had skin lesions ,
especially with sun exposure. She had never been phlebotomized or
received other treatments. In the past two months , she had been
taking Ativan of 3-4 mg every day for anxiety. She stopped taking
Ativan on January , 1995 and after this abrupt stopping of this
medication , she started to have feelings of disorientation ,
confusion , and fatigue with emotional lability. She also was in
Idaho with extensive sun exposure in the last two weeks. She
contacted Dr. Hazinski who advised her to increase her carbohydrate
intake to about 400 grams a day , however , her symptoms progressed.
Two days prior to admission , she felt weak and while standing , her
legs gave way without losing consciousness. She felt weak
throughout the week before admission with no vertigo , tinnitus , or
ataxia. She also felt paresthesias of the hands and feet but not
perioral and she also experienced episodes of flushing and
tremulousness with a feeling of rushing sensation in the chest with
no tachycardia associated at the time of this symptomatology. She
had no fevers with the sensation of flushing and feeling of burning
up. She had several bouts of diarrhea intermingled with
constipation. On the day of admission , patient became confused and
disoriented while driving and she came to see Dr. Hazinski in the
PRMC Clinic. She was admitted for evaluation of a possible
porphyria attack. Of note , the only new medications that she had
been taking was chloral hydrate for the last five days and
Compazine with one dose.
PAST MEDICAL HISTORY: 1 ) Insulin dependent diabetes. 2 )
Coronary artery disease status post PTCA
times two and a coronary artery bypass graft of the left anterior
descending in 6/25 Exercise tolerance test was noted before
catheterization and she had a catheterization in 1/10 for angina.
She had a patent LIMA graft , 60% proximal left anterior descending
lesion , and 50% right coronary artery stenosis. 3 )
Hypercholesterolemia , did not tolerate cholestyramine. 4 ) Status
post left ulna entrapment release two months ago. 5 )
Hypertension. 6 ) Status post excisional biopsy of the left breast; the
pathology of the lesion was diabetic mastopathy.
ALLERGIES: Morphine which gave her a rash and patient avoided
multiple medications which were known to worsen
porphyria such as sulfa drugs ( not allgergies )
CURRENT MEDICATIONS: At home , patient took insulin NPH 25 units in
the morning with Regular 10 units in the
morning , aspirin 81 mg every day , Lopressor 25 mg twice a day , Compazine 5 mg
every 6 hours as needed anxiety of which she took only one dose , and chloral
hydrate 500 to 1000 mg every bedtime for five days.
SOCIAL HISTORY: Patient was married for fifteen years with one
son and no history of smoking or ethanol use.
PHYSICAL EXAMINATION: Patient was a pale and anxious white female
in no apparent distress with a temperature
of 99.5 , blood pressure 134/70 , heart rate of 92 , respiratory rate
of 18 , and O2 saturation of 97% on room air. HEENT: Examination
was significant for oropharynx with upper dentures and sclerae were
anicteric. NECK: Supple with no jugular venous distention , no
lymphadenopathy , and thyroid was not palpable. CHEST: Clear to
auscultation bilaterally with no costovertebral angle tenderness.
BREASTS: Examination was notable for fully healed scar of the left
breast. CARDIOVASCULAR: Examination showed a regular rate and
rhythm , normal S1 and S2 , and 2/6 systolic murmur heard best at
the apex. ABDOMEN: Soft with good bowel sounds , non-tender , and
non-distended. EXTREMITIES: 1+ pedal pulses bilaterally and no
clubbing , cyanosis , or edema. SKIN: Examination showed a blister
of the left hand fourth and fifth digit interspace and healed
lesions on the right hand. NEUROLOGICAL: Examination showed her
to be alert and oriented times three with a normal mental status
examination with no confusion noted. Cranial nerves were intact ,
motor was symmetric of 3-4/5 on all muscle groups , sensory
examination was significant for decrease to light touch in the
distal feet and hands , deep tendon reflexes were symmetric and 1-2+
throughout , and coordination showed rapid alternating movements and
finger-to-nose both within normal limits. Gait was mildly wide
based with normal heel-to-toe walk , she had no pronator drift , and
Romberg was positive.
LABORATORY EXAMINATION: On admission was significant for a BUN of
17 , creatinine of 1.0 , glucose was 364 ,
liver function tests were within normal limits , white count was
7.2 , hematocrit was 36 , and platelet count was 266.
HOSPITAL COURSE: Patient was admitted for possible porphyria
attack versus Ativan withdrawal symptoms versus
anxiety attack. Neurology consultation was obtained who felt that
patient's peripheral neuropathy was probably secondary to
longstanding diabetes but felt that some of her symptomatology
could be consistent with porphyria. Patient was also seen by
Psychiatry who felt that this episode was consistent with
generalized anxiety disorder separated by post dysthymia and
suggested phenothiazines which are proven to be safe in porphyria
for treatment. She was started on Trilafon 2 to 4 mg orally as needed
every 6 hours for anxiety. The patient was also seen to be orthostatic
which was felt to be secondary to dehydration secondary to poor
orally intake prior to admission. She was also hyperglycemic on
admission which may have contributed to her dehydration. She was
treated with normal saline boluses and her orthostasis improved.
Her Lopressor was also held with this episode of orthostasis. The
Watson-Schwartz test done by Dr. Hazinski on patient very early in the admission
was negative which made an acute porphyria attack very
unlikely. These episodes were felt to be secondary to a
combination of anxiety attack and rapid taper of Ativan which she
had been taking at moderately high doses for the last two months.
Patient also developed urinary tract infection symptoms and her
urine culture showed greater than 100 , 000 colonies of E. coli which
were pansensitive. She was started on Keflex 500 mg orally three times a day
which is shown to be safe in porphyria.
DISPOSITION: Patient is discharged to home on July in good
condition.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally every day , insulin NPH 25
units subcutaneously every day before noon , insulin
regular 10 units subcutaneously every day before noon , Trilafon 2 mg orally every 6 hours ,
and Keflex 500 mg orally three times a day
FOLLOW-UP: Follow-up will be with Dr. Krystle Glick
Dictated By: KEN WESTFALL , M.D. AK5
Attending: JACKSON E. PART , M.D. XH6
UV897/3690 Batch: 56735
Index No. FMRXDT46WO D: 4/18/95
T: 2/26/95
addendum: Her 24 hour urinary porphobilinogen and delta-aminolevulinic acid
were both normal , corroborating the Watson Schwartz test and ruling out an
acute porphyric attack.
ym99
Document id: 922
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864481415 | PUO | 38798383 | | 5837799 | 9/21/2003 12:00:00 a.m. | Costochondritis | | DIS | Admission Date: 9/21/2003 Report Status:
Discharge Date: 9/21/2003
****** DISCHARGE ORDERS ******
DAUTRICH , RON P 148-40-18-4
A Ra Fordyonkers
Service: MED
DISCHARGE PATIENT ON: 6/25/03 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VIOXX ( ROFECOXIB ) 12.5 MG orally every day
Food/Drug Interaction Instruction Take with food
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
Starting Today ( 6/26 )
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Delilah Stamm week ,
ALLERGY: Erythromycins , Ciprofloxacin
ADMIT DIAGNOSIS:
chest pain , heart block
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Costochondritis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Costochondritis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
53 F presenting with 3 days of left sided chest pain.
HPC: The patient was in her USOH until 3 days prior to admission when
she noticed acute-onset left lower anterior chest wakll pain which was
exacerbated by coughing and deep inspiration. There was no associated
SOB , diaphoresis , palpitations. She also denied any relationship of
the pain to food or position. She does however note that she has been
working out more than usual lately and lifting heavier weights than she
is used to. She denies abdominal pain , vomiting , haematemesis , pr
bleeding or melaena.
PMH : Mobitz type I second degree heart block. Duodenal ulcer 2000 ( H.
Pylori positive at that time ). IBS , Type II DBM , Migraines.
DH: Vit D , calcium
FH: Nil of note
SH: Nonsmoker ; occ EtOH
O/E: afebrile , HR 50-60 , BP 108/60 , RR 14 , Sats 98% RA. No jaundice ,
anaemia , cyanosis , clubbing , oedema , or lymphadenopathy. JVP flat. HS
I + II + O. Chest clear. Left anterior chest wall tenderness to
direct pressure. Abdomen soft & nontender.
CXR - Mild L basal atelectasis
ECG: Type II second degree heart block ; Mobitz type I. Nil acutely
ischaemic.
HOSPITAL COURSE AND OUTCOME :
The patient was admitted to general medicine for one night. She ruled
out for MI on enzymes , troponin and ECG. A diagnosis of
musculoskeletal chest pain from costochondritis was made and she was
discharged from hospital on vioxx and nexium. She will followup with
her primary care physician Dr. Stamm in 1 week.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Followup with Dr. Stamm in 1 week
No dictated summary
ENTERED BY: MAGBITANG , BENITA , M.D. ( LV88 ) 6/25/03 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 923
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381967820 | PUO | 02433774 | | 5679374 | 6/21/2006 12:00:00 a.m. | herpetic whitlow , cellulitis | | DIS | Admission Date: 4/12/2006 Report Status:
Discharge Date:
****** FINAL DISCHARGE ORDERS ******
DUNNING , ERNEST 837-01-57-4
NV Lis In Valle , West Virginia 89979
Service: MED
DISCHARGE PATIENT ON: 9/16/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: OGDEN , LATORIA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 500 MG orally every 8 hours
Alert overridden: Override added on 9/16/06 by :
on order for TYLENOL orally ( ref # 000627216 )
patient has a PROBABLE allergy to ACETAMINOPHEN W/CODEINE
30MG; reaction is Unknown. Reason for override:
MD aware , takes tylenol alone at home without problems
ACETYLSALICYLIC ACID 325 MG orally DAILY
FOSAMAX ( ALENDRONATE ) 70 MG orally QWEEK
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 9/16/06 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: MD aware
CALCIUM + D ( 500 ELEM. CA ) ( CALCIUM CARBONATE... )
1 TAB orally three times a day
CLINDAMYCIN HCL 450 MG orally four times a day Instructions: For 10 days.
CLOBETASOL PROPIONATE 0.05% CREAM TP twice a day
ERGOCALCIFEROL 400 UNITS orally DAILY
PLAQUENIL SULFATE ( HYDROXYCHLOROQUINE ) 400 MG orally DAILY
Food/Drug Interaction Instruction Take with food
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day as needed Wheezing
MIDRIN ( ISOMETHEPTENE/DICHLORALPHENAZONE/APAP )
1 CAPSULE orally every 2 hours as needed Headache
Alert overridden: Override added on 9/16/06 by :
on order for MIDRIN orally ( ref # 133529095 )
patient has a PROBABLE allergy to ACETAMINOPHEN W/CODEINE
30MG; reaction is Unknown. Reason for override:
patient takes at home without problems
LEVETIRACETAM 750 MG orally twice a day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 125 MCG orally DAILY
LISINOPRIL 10 MG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
OXCARBAZEPINE 300 MG orally twice a day
PHENOBARBITAL 120 MG orally DAILY
Alert overridden: Override added on 9/16/06 by :
POTENTIALLY SERIOUS INTERACTION: PREDNISONE & PHENOBARBITAL
POTENTIALLY SERIOUS INTERACTION: PREDNISONE & PHENOBARBITAL
Reason for override: MD aware
PRAMOXINE HCL 1% TOPICAL TP three times a day as needed Itching
Instructions: Apply to itching skin
PREDNISONE 5 MG orally every day before noon
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/16/06 by :
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PHENOBARBITAL & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MD aware
DIET: House / Low chol/low sat. fat
ACTIVITY:
Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Sana Albor ( KTDUOO ) 1/5/06 , 3:10 pm scheduled ,
GABISI , DEBROAH LAEL , M.D. ( RHEUM ) 3/9/06 , 10 am scheduled ,
DINGEL , ALESSANDRA E. , M.D. , M.PH. ( DERM ) 10/1/06 , 9:45 am ,
ALLERGY: PHENYTOIN SODIUM , Penicillins ,
ACETAMINOPHEN W/CODEINE 30MG , Morphine
ADMIT DIAGNOSIS:
herpetic whitlow , cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
herpetic whitlow , cellulitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
SLE hypothyroidism ( hypothyroidism ) seizure
( seizure ) osteoporosis ( osteoporosis ) osteogenesis imperfecta
( osteogenesis imperfecta ) hypertension
( hypertension ) history of disseminated VZV PE ( pulmonary
embolism ) CVA ( cerebrovascular accident ) hyperlipidemia ( hyperlipidemia )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Clindamycin 600 mg intravenous X 3 doses
BRIEF RESUME OF HOSPITAL COURSE:
CC: cellulitis , herpetic whitlow
HPI: 56F with SLE c/b lupus nephritis and PE ( on steroids for most of past
30 yrs , now on coumadin ) , disseminated VZV , CAD , history of CVA X3 , seizure d/o ,
who comes to ED with 3 days increasing R middle finger pain and swelling.
patient noted vesicles on medial aspect of affected finger over past few
weeks. 3 days ago , accidentally nicked skin just below these vesicles ,
developed small region of erythema that spread to backside of finger and
back of palm over 48 hrs. Her daughter noted some weeping over the
vesicles evening PTA , so sent patient to ED for eval. Upon arrival patient c/o
10/10 pain in skin and increasing rash. Denied f/c , any other rash ,
inability to use R middle finger , joint pain in affected area. Given 600
mg clindamycin intravenous X2 , seen by Ortho hand who dx'd cellulitic superinfxn
of herpetic whitlow , felt joints not involved , and marked boundaries. Rec
= give intravenous clinda , observe , could send home with 10 days orally clinda if
improved over 8-12 hrs. Given hx SLE + prednisone use and ? of DM2 ( turns
out not to have clear DM after chart Bx ) , patient admitted for observation.
At time of admission , denied f/c , weakness , N/V/D , any residual pain
over R middle finger. Noted that area of redness over finger had
rapidly receeded and joints remained nontender. patient frustrated with long ED
stay and disagreed with DM dx. Strongly opposed to admission given
improvement , asked to go home from ED.
--
PMH: SLE , discoid lupus , hypothyroidism , disseminated VZV , seizure d/o
( since childhood ) , migraines , CAD with HTN/hyperlipidemia , NSTEMI 10/25 , CVA
X3 ( last 2004 ) , osteoperosis , osetogenical imperfecta , depression , history of PE
Home Meds:
Pre-admission Medication List for DUNNING , ERNEST 02433774 ( PUO ) 56 F
Last saved by: BERNO , LUCI D. , M.D. on 4/12/2006 at 13:09
1. Acetaminophen ( Tylenol ) orally 500 MG every 8 hours
for your back pain
2. Acetylsalicylic Acid orally 325 MG every day
3. Alendronate ( Fosamax ) orally 70 MG QWEEK
Give on an empty stomach ( give 1hr before or 2hr after food ) Take
with 8 oz of plain water
4. Atorvastatin ( Lipitor ) orally 40 MG every bedtime
5. Calcium Carbonate ( 500 Mg Elemental Ca++ ) orally 1250 MG three times a day
in between MEALS
6. Clobetasol Propionate 0.05% TOP 1 APPLICATION twice a day
7. Ergocalciferol ( Vitamin D 25-Oh ) orally 400 UNITS every day
8. Hydroxychloroquine ( Plaquenil Sulfate ) orally 200 MG twice a day
Take with food
9. Ipratropium And Albuterol Sulfate ( Combivent ) inhaled 2 PUFF four times a day as needed
Other:shortness of breath
10. Isometheptene/Dichloralphenazone/Apap ( Midrin ) orally 1 CAPSULE Q1H as needed
Headache
Up to 6 capsules per day
11. Levetiracetam ( Keppra ) orally 750 MG twice a day
12. Levothyroxine Sodium orally 125 MCG every day
13. Lisinopril orally 10 MG every day
14. Metoprolol Succinate Extended Release ( Toprol Xl ) orally 50 MG every day
Take consistently with meals or on empty stomach.
15. Omeprazole Otc ( Prilosec Otc ) orally 20 MG every day
16. Oxcarbazepine ( Trileptal ) orally 300 MG twice a day
17. Phenobarbital orally 64.8 MG twice a day
18. Prednisone orally 5 MG every day
19. Simethicone orally 80 MG four times a day as needed Other:gas , indigestion
20. Warfarin Sodium ( Coumadin ) orally 5 MG every afternoon
No high Vitamin-K containing foods
21. Simethicone as needed
Allergies: Phenytoin , PCNs , Percocet , Morphine
--
SHx: Lives with daugther , japanese-speaking. 3 daughters , 2 sons. No tob ,
EtOH , drugs.
FHx: 1 son with epilepsy , sister with SLE , no other autoimmune dz , no CA ,
son and daughter with "heart dz"
ROS: Chronic headache , hungry. Rest negative except as per HPI.
--
EXAM: 97 63 118/78 12 98% RA
Comfortable , arm elevated in sling , eating lunch , A&OX3
OP clear , slightly blue sclera , no LAD , PERRL , EOMI
CTAB
RRR , s1=s2 , no m/r/g
Obese , NT , ND , +BS , no appreciable organomegaly
No c/c/e , 2+ pulses; thining hair over scalp with central alopecia
R hand: confluent vesciles over medial 3rd digit DIP , no TTP over
DIP/PIP/MCP , redness surrounding vesicles without exudate and receeding at
all points from marked boundaries , no soft tissue swelling concerning for
conpartment syndrome
Neuro nonfocal
--
Relevant studies/Labs: None sent from ED
--
HOSPITAL COURSE BY PROBLEM:
Impression: 62F with SLE , CAD , history of disseminated VZV , seizure d/o here with
herpetic whitlow and bacterial superinfection/cellulitis.
1. ID/Cellultis overlying herpetic whitlow--patient's infection appeared to be
markedly improved from ED presentation at time of evaluation by admitting
Medicine team. However , given history of SLE and prednisone use , making patient
functionally immunosupressed , indication for conservative management with
admission and observation reasonable. Per record , patient does not have
official Dx of DM2--?elevated Gluc in past 2/2 steroid use. patient very
resistant to staying in hospital , as she felt her finger was much
improved , pain completely resolved , margins all receeded from marked
borders at admission , no f/c , no joint pain. Reviewed Ortho hand recs ,
plan with Medicine attending and patient As patient displayed excellent understanding
of Dx , indications for return to hospital , and desire for adherence ,
agreed to d/c her home from the ED with orally Clindamycin 450 mg orally four times a day and
close f/u in KTDUOO with primary care physician on 10/17 Given a final dose of Clinda 600
mg intravenous before d/c. Decision made not to provide Rx for herpetic whitlow at
the present time given patient's many allergies and brief literature review ,
which notes controversy over acyclovir Rx , given that most cases resolve
spontaneously in 2-3 wks. patient to readdress at primary care physician visit.
2. SLE--no e/o flare , cont home meds
3. HTN--none in ED , cont home meds
4. Hyperlipidemia--cont home meds
5. Seizure d/o--last seizure 8/24/06 per Neuro outPt record , none in ED.
Cont home meds
6. CAD history of NSTEMI--cont ASA , HTN and lipid control regimen
7. history of PE--no e/o recurrent , cont coumadin
8. history of CVA--Neuro exam nonfocal , cont coumadin
9. Hypothyroidism--cont synthroid
FEN--Cards diet , POs , chem7 every day
Ppx--coumadin , tylenol , dilaudid , bowel regimen
Code--Full
ADDITIONAL COMMENTS: Return to ED for increasing pain in your right hand , worsening swelling ,
fevers , chills , weakness , inability to use your right hand or middle
finger , or other worrisome symptoms. Please take the full course of your
antibiotics.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. take full course of antibiotics
2. follow up with primary care physician on 1/5/06
No dictated summary
ENTERED BY: BERNO , LUCI D. , M.D. ( SZ20 ) 9/16/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 924
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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385601183 | PUO | 28399383 | | 325281 | 10/10/2000 12:00:00 a.m. | non cardiac chest pain | | DIS | Admission Date: 10/10/2000 Report Status:
Discharge Date: 8/14/2000
****** DISCHARGE ORDERS ******
STRAWN , DILLON 447-94-69-6
Lenegas
Service: CAR
DISCHARGE PATIENT ON: 2/3 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LAMIA , SHAINA CHIA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
ATENOLOL 25 MG orally every day Starting Today ( 9/1 )
PREMARIN ( CONJUGATED ESTROGENS ) 0.625 MG orally every day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 50 U subcutaneously twice a day
HOLD IF: if BG <100
PRINIVIL ( LISINOPRIL ) 40 MG orally every day HOLD IF: SBP<90
Override Notice: Override added on 10/30 by DASE , ANNABEL D. , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 11111344 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: monitored
NAPROSYN ( NAPROXEN ) 375 MG orally twice a day as needed pain
Food/Drug Interaction Instruction Take with food
DITROPAN ( OXYBUTYNIN CHLORIDE ) 5 MG orally twice a day
SIMETHICONE 80 MG orally four times a day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
CARDURA ( DOXAZOSIN ) 1 MG orally every bedtime
ADALAT CC ( NIFEDIPINE ( EXTENDED RELEASE ) ) 30 MG orally every day
DIET: No Restrictions
RETURN TO WORK: IN 2 DAYS
FOLLOW UP APPOINTMENT( S ):
Dr. Borders 1 week ,
ALLERGY: Lovastatin , Hctz ( hydrochlorothiazide )
ADMIT DIAGNOSIS:
unstable angina , chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
non cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
GI distress , non cardiac stress pain.
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
53 year-old female with DM , HTN , history of MI 1980 , presenting with crescendo angina
and hypertension. Patient's blood pressure was controlled with
Atenolol 25mg every day , prinivil 40 every day , and adalat CC 30 every day Overnight the
patient was noted to be hypertensive with a pulse in the 45's. Cardura
1mg every bedtime was added for additional control. Patient was taken to cath
which revealed clean coronary arteries and LVH with EF 68%.
ADDITIONAL COMMENTS: call Dr. Danette Borders you experience further chest pain.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
follow up with Dr. Borders regarding further management of BP.
No dictated summary
ENTERED BY: DASE , ANNABEL D. , M.D. ( DR378 ) 2/3 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 925
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
N |
N |
- |
N |
N |
- |
N |
N |
N |
N |
N |
N |
357007009 | PUO | 73091725 | | 023671 | 10/18/1999 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 4/20/1999 Report Status: Signed
Discharge Date: 6/11/1999
DISCHARGE DIAGNOSIS: ATRIAL FIBRILLATION STATUS POST
CARDIOVERSION.
HISTORY OF PRESENT ILLNESS: The patient is an 38-year-old African
American gentleman with a familial
dilated cardiomyopathy with an ejection fraction of approximately
20 percent , history of ventricular tachycardia status post AICD
placement , and recurrent atrial fibrillation status post two prior
attempts at cardioversion. The patient had also previously been
begun on amiodarone for chemical cardioversion , however , he
developed severe hyperthyroidism. The patient also has had several
recent admissions for exacerbations of his congestive heart
failure , most recently in February , 1998 when he was admitted for
tailored therapy. At that time , an echocardiogram demonstrated an
ejection fraction of , approximately , 20 percent with atrial
dimension of 5 centimeters , left ventricular diastolic dimension of
7.7 centimeters , moderate-severe mitral regurgitation , and moderate
tricuspid regurgitation with pulmonary artery pressure of
approximately 40 , plus right atrial pressure. The patient was , at
that time , diuresed to his dry weight , which is approximately 186
pounds. Unfortunately , he was again admitted in February of 1998
with volume overload and was diuresed. At that time , he was noted
to be in atrial fibrillation , and was cardioverted on his
previously implanted AICD.
His most recent admission was on May to March , when
he again was cardioverted by his AICD for atrial fibrillation and
treated for volume overload. In October of 1999 , he had increasing
firing of his AICD both for true ventricular tachycardia , as well
as for atrial fibrillation , and anti-tachycardia pacing. He was
seen in cardiomyopathy clinic on July , and was found to be in
atrial fibrillation and volume overloaded. His diuretics were
increased at that time , as his weight was 207 pounds , and he
diuresed down to a weight of 199 pounds. It was felt that
amiodarone would be the best drug for him in terms of management of
his ventricular and atrial arrhythmias , and so the patient
underwent an elective thyroid ablation with radioactive iodine. He
received 30 mCi of I-131. He now presents today after the thyroid
ablation for amiodarone load and cardioversion. The patient is
feeling relatively well , and is not experiencing any significant
dyspnea on exertion or paroxysmal nocturnal dyspnea. He reports no
increased lower extremity edema. No neck pain. No fever or
chills. No nausea or vomiting.
PAST MEDICAL HISTORY: ( 1 ) Notable for dilated cardiomyopathy
diagnosed in 1992. His most recent V.02 is
19.5 in February of 1995. ( 2 ) AICD placement for ventricular
tachycardia in October of 1998. ( 3 ) Hyperthyroidism secondary to
amiodarone. ( 4 ) History of atrial fibrillation , status post
multiple cardioversions in the past ( see above ). ( 5 ) History of a
left renal infarct. ( 6 ) History of pancreatis.
ALLERGIES: He is allergic to penicillin.
MEDICATIONS: ( 1 ) Captopril 75 milligrams four times a day ( 2 ) Digoxin 0.125
milligrams every day ( 3 ) Isordil 40 milligrams three times a day
( 4 ) Torsemide 200 milligrams twice a day ( 5 ) Coumadin 5 milligrams every day
( 6 ) Prilosec 20 milligrams twice a day ( 7 ) Zaroxolyn as needed
SOCIAL HISTORY: Notable for no tobacco or alcohol use. No history
of intravenous drug use.
FAMILY HISTORY: Notable for a father who died of a myocardial
infarction at age 56 , a brother with
cardiomyopathy who died in the 50s , and another brother with
dilated cardiomyopathy.
PHYSICAL EXAMINATION: The physical examination was notable
for a jugular venous pressure of 10
centimeters. VITAL SIGNS: The patient was afebrile. Pulse was
100 to 120. Blood pressure was 90/75. LUNGS: Clear to
auscultation. CARDIOVASCULAR: Heart rate which is regular ,
irregular with S1 and S2 normal , and intermittent S3 , and a II/VI
holosystolic murmur best auscultated at the apex radiating to this
axilla. ABDOMEN: His belly was soft , nontender , nondistended with
active bowel sounds and a palpable liver , approximately , 1.5
centimeters below the costal margin , which was pulsatile.
EXTREMITIES: His extremities were warm and well perfused. Distal
Pulses were 2+. There was no edema.
LABORATORY DATA ON ADMISSION: BUN of 58. Creatinine of 2.5.
Potassium of 3.8. INR of 5.1.
Hematocrit of 42.8. White count of 8.5.
DIAGNOSTIC STUDIES: His electrocardiogram was notable for atrial
fibrillation of , approximately , 120 with a
zero degree axis and an intraventricular conduction delay; R-wave
progression was poor. He had ST-T wave changes consistent with
digitalis effect. There was no change in this cardiogram compared
to the one in February of 1998.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service , and an amiodarone load was initiated at
400 milligrams four times a day. Endocrinologist Service was
consulted and followed along status post his ablation. The patient
was felt to be euvolemic and slightly hypovolemic upon his
admission , and his diuretics were reduced to 100 twice a day of
Torsemide. After approximately 36 hours with a slight
liberalization of his fluid intake , the patient normalized , and he
became slight hypervolemic. At that time , his diuretic regimen was
returned to his normal outpatient dose of 200 twice a day , and he
received an extra dose of intravenous Torsemide. On the third of
hospitalization , March , 1999 , the patient was cardioverted by
his ICD with 30 joules of synchronous shock , which turned the
patient to sinus rhythm. At this point , he had received three days
of amiodarone at 400 milligrams four times a day. During this
amiodarone load , the patient became markedly nauseated with
episodes of vomiting. It was also noted that he developed some
decreased blood pressure while on the amiodarone attributed to the
negative inotropic effects of the drug. His normal medications
were intermittently held for hypertension , and the patient , at
times , appeared to be quite unwell during his amiodarone load ,
feeling nauseated and relatively hypertensive. However , after the
patient's medicines were given , he returned to a normal blood
pressure and felt well.
The patient was successfully cardioverted to normal sinus rhythm on
March . He will be discharged on amiodarone dose for
maintenance now that his load has been completed. His thyroid
function tests were checked in house subsequent to his ablation ,
and they were notable for a T4 level of 9.6. He is to have his
thyroid function tests rechecked in , approximately , three weeks and
he will be followed in the endocrine clinic as well at that time.
He also is to initiate therapy with Tapazole 10 milligrams a day to
protect the patient from developing hyperthyroidism in the setting
of his amiodarone. The patient's dose of Coumadin was also held in
house as his INR was elevated. It had fallen to a level of 3.0 on
the day of discharge , and he was discharged on a lower dose of
Coumadin to be adjusted as an outpatient by the anticoagulation
team.
The patient's renal function returned to baseline , approximately ,
24 hours after admission when he returned to a euvolemic state.
His slightly elevated creatinine was attributed to pre-renal
dehydration. His creatinine on the day of discharge was 1.6 , and
his baseline is , approximately , 1.6 to 2.0. His baseline
insufficiency can be attributed to poor forward flow.
DISCHARGE MEDICATIONS: ( 1 ) Captopril 75 milligrams four times a day
( 2 ) Digoxin 0.125 milligrams every day
( 3 ) Isordil 40 milligrams three times a day ( 4 ) Amiodarone 200 milligrams
twice a day ( 5 ) Torsemide 200 milligrams twice a day ( 6 ) Prilosec 20
milligrams twice a day ( 7 ) Tapazole 10 milligrams every day to begin on Monday.
( 8 ) K-Dur as per his outpatient medicines. ( 9 ) Coumadin
3 milligrams every day to be adjusted as an outpatient.
FOLLOW UP: The patient will return to the Totin Hospital And Clinic
Hospital early next week to have his electrolytes and
INR checked. He will return in , approximately , three weeks to
have thyroid function tests checked , as previously stated. He has
follow up appointments in both cardiomyopathy clinic and endocrine
clinic , and close follow up with the cardiomyopathy and transplant
team.
Dictated By: SHELLEY STARNAULD , M.D. AH89
Attending: FLOYD T. LYN , M.D. OX2
ZM128/8568
Batch: 35851 Index No. WGXVKX43G4 D: 7/23/99
T: 7/23/99
Document id: 926
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695831179 | PUO | 85228280 | | 1529749 | 7/16/2006 12:00:00 a.m. | FEVER | Unsigned | DIS | Admission Date: 5/10/2006 Report Status: Unsigned
Discharge Date: 5/10/2006
ATTENDING: NAJI , COLIN ELINORE MD
DISPOSITION: Rehab Facility.
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: This is an 86-year-old woman with a
history of diastolic dysfunction , PMR , insulin-dependent
diabetes , adrenal insufficiency , and partial SBO , who is
transferred from Spoli Hospital with recurrence of fever
after a recent discharge from Pagham University Of
during , which she was treated for pneumonia. The patient had a
recent admission to Pagham University Of from 3/25/06 to
4/3/06 , during which she was treated for a urinary tract
infection and pneumonia and discharged to Spoli Hospital
with a PICC line for complete the course of levofloxacin and
vancomycin. She had transient hypertension during that previous
admission , but otherwise did well was initially treated with
ceftriaxone , vancomycin and then levofloxacin and vancomycin and
discharged to rehab. She has been feeling well during the since
then , on the night prior admission , she was noted to have a
temperature of 101.8 with mild nausea. She denied any other
associated symptoms. She is also noted to have an increasing
oxygen requirement at the Rehab Facility increased from baseline
of good saturations of room air up to requirement of 3 L nasal
cannula to maintain her oxygen saturation.
PAST MEDICAL HISTORY:
1. Congestive heart failure. An echocardiogram in September of
2005 showed an ejection fraction of 60% with diastolic
dysfunction. Pulmonary artery systolic pressure of 49 plus a
right atrial pressure and trace regurgitation in all valves.
2. PMR.
3. Hypertension.
4. GERD.
5. Hypothyroidism.
6. History of TIA.
7. Osteoarthritis.
8. Legally blind.
9. Status post cholecystectomy.
10. Depression.
11. History of Nissen fundoplication.
12. Adrenal insufficiency from a history of chronic steroid use
in the past , now maintained on hydrocortisone.
MEDICATIONS ON TRANSFER FROM PORANGECATHEOX MEDICAL CENTER OF ARE AS FOLLOWS:
1. Levofloxacin 500 mg orally every 48 hours
2. Vancomycin 1 gm intravenous every 24 hours
3. Norvasc 5 mg orally daily.
4. Aspirin 81 mg orally daily.
5. Lumigan drops each eye nightly.
6. Dulcolax 5 mg orally daily.
7. Captopril 12.5 mg orally three times a day
8. Colace orally twice a day
9. Insulin NPH 16 units every day before noon and 6 units every afternoon
10. Remeron 15 mg nightly.
11. Synthroid 88 mcg orally daily.
12. Multivitamin.
13. Protonix 40 mg orally daily.
14. Zocor 20 mg orally daily.
15. Iron 325 mg orally daily.
16. Guiatuss 10 mg orally four times a day
17. Allegra 60 mg orally daily.
18. Hydrocortisone 30 mg orally every day before noon
19. Milk of magnesia as needed
20. Epoetin 60 , 000 units subcutaneously every Saturday.
ALLERGIES: Sulfa , azathioprine , sertraline , and metoclopramide.
SOCIAL HISTORY: The patient never smoked , use alcohol or drugs.
Her son is very involved and confirms that the patient is
DNR/DNI.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission , the temperature is 98.6 ,
heart rate 70 , respiratory rate 16 , blood pressure 133/61 , oxygen
saturation was 79% on room air and increased in 94% on 3 L nasal
cannula. In general , the patient appeared comfortable with
pleasant and convulsant and blind. Neck showed a JVP of 7.
Chest exam was with left basilar crackles no wheezes. Heart was
regular rate and rhythm with a 2/6 systolic ejection murmur at
the left upper sternal border. Abdomen was soft , nontender , and
nondistended with normal bowel sounds. Extremities with no
clubbing , cyanosis , or edema.
LABORATORY DATA: On admission were significant for potassium of
4.5 , BUN of 23 , creatinine 1.6 , which is at her baseline of 1.4
to 1.6. White blood cell count of 5.7 , hematocrit 27.3 from a
baseline of 26 to 29 , platelets of 347 , 000. Coagulation studies
were normal. Liver function tests were normal. Cardiac enzymes
were negative. Chest x-ray showed no change in the left lower
lobe infiltrate , since 10/20/06. An EKG showed Q-wave
flattening , but no changes from her prior EKGs. Normal sinus
rhythm.
IMPRESSION: This is an 86-year-old woman with multiple medical
problems including congestive heart failure , diabetes , and
adrenal insufficiency , who presents with recurrent fevers through
levofloxacin and vancomycin.
HOSPITAL COURSE:
1. Infectious Disease. Initially , the source of her repeated
fevers was unclear. Multiple cultures were sent including urine
cultures , stool studies , peripheral blood cultures and blood
cultures from the PICC sputum cultures and induced sputum with
testing for primary care physician , given her history of chronic steroid uses
without primary care physician prophylaxis. All of these came back negative with
the exception of one blood culture from the PICC , which grew
coagulase negative Staphylococcus aureus. So , the PICC line was
discontinued and the tip sent for culture , which was negative.
After discontinuation of the PICC line , the patient did not have
any further fevers. The remainder of her admission , which was
greater than 72 hours. The induced sputum for primary care physician was also
negative and the patient was then started on primary care physician prophylaxis with
Mepron ( given her sulfa allergy ) to be continued until she had
completed her gradual tapper off of steroids. She completed the
levofloxacin and vancomycin courses , which were started on the
previous admission , for pneumonia and did not have any further
fevers after completing these antibiotics. A PPD was placed ,
which was negative.
2. Endocrine. The patient has a history of hypothyroidism ,
adrenal insufficiency secondary to chronic steroids in the past
and insulin-dependent diabetes. Her TSH was checked and was
normal on admission. So , she was continued on her home dose of
Synthroid. Further instructions through her primary care
provider. Her hydrocortisone was slightly decreased and her slow
taper will be further directed by her primary care provider after
discharge. Her insulin regimen was up titrated with the addition
of the before every meal Novalog , given her high fingerstick blood glucoses.
She should continue on this increased regimen after discharge.
3. Pulmonary. On admission , the patient was noted to be hypoxic
on room air with an oxygen saturation of 79% to 80% , which
increased to 93% on 2 L to 3 L of nasal cannula. Given this new
hypoxia and her chronic decreased ambulation , she was sent for a
CT angiogram of the chest , which was negative for PE. The study
also shows small bilateral pleural effusion and mild pulmonary
edema. Resolution of her previous pneumonia and possibly
reactive mediastinal lymphadenopathy. Given this data , she was
restarted on Lasix with diuresis , titrated to 1 L negative per
day and was sound well. Given this data , she was restarted on
Lasix with the diuresis titrated to 1 L negative per day and
responded well. She had decreasing shortness of breath and
improved room air oxygen saturation up to 85% at the time of
discharge. She is continued to be maintained on oxygen of 2 L
nasal cannula with good oxygen saturation and is anticipated to
have a successful gradual wean from oxygen as her diuresis
continue after discharge. The Pulmonary Service was consulted
and followed her agreeing with the diagnosis of pulmonary edema.
They also recommended a followup noncontrast chest CT in 2 to 4
weeks after discharge to reevaluate her mediastinal
lymphadenopathy after a period of diuresis. A followup
appointment was made with Dr. Oberhaus at the Chest Clinic at
Pagham University Of for two weeks following discharge.
Pulmonary function test were completed , which showed a
restrictive defect , which the Pulmonary Service felt could be
attributed to her volume overload. An echo showed an increased
pulmonary artery systolic pressure at 47 plus the right atrial
pressure consistent with previous echo done in September of 2005.
Thus , this was not considered to be new pathology , nor likely
related to her new hypoxia.
4. Hematologic. The patient has a known diagnosis of iron
deficiency anemia as well as anemia of chronic disease and is
maintaining on iron and epoetin as an outpatient. There were no
signs or symptoms of bleeding throughout this admission and she
not required a blood transfusion at any point. She should
continue on her outpatient regimen of iron and epoetin after
discharge. Iron studies done on this admission showed adequate
iron repletion with her current regimen.
5. Cardiovascular. There was no evidence of ischemia throughout
the admission. Given her findings of pulmonary edema on chest CT
and her history of diastolic congestive heart failure , she was
started on Lasix 20 mg intravenous twice a day with effective diuresis noted.
This was transitioned to a orally regimen of 40 mg orally twice a day ,
which will be continued after discharge and titrated to her
weight loss. She was also continued on her outpatient Zocor ,
Norvasc and lisinopril.
6. Renal. The patient has a history of chronic renal
insufficiency. She received Mucomyst and bicarbonate in her intravenous
fluids , prior to her CT angiogram of the chest with prophylaxis
against contrast nephropathy. Her creatinine remained stable at
1.6 for remainder of the admission , which was greater than 72
hours. All mediations were appropriately renally dosed. She
should continue followup with her primary care provider regarding
her chronic renal insufficiency in the future.
7. Fluid , Electrolytes , and Nutrition. The patient was
maintained on any intravenous fluids except as prophylaxis for her CT
angiogram. The potassium and magnesium were repeated as needed
and she was maintained on the renal , cardiac ADA diet.
8. Prophylaxis: She was maintained on three times a day subcutaneously heparin for
DVT prophylaxis and Nexium for GI prophylaxis as well as an
aggressive bowel regimen , given her history of chronic
constipation.
9. Code Status: The patient is DNR/DNI and her son Staci Krochmal , is the healthcare proxy.
DISCHARGE PLAN: The patient will be discharged back to Porangecatheox Medical Center Of to continue physical therapy to regain some independence
with her activities of daily living and more specifically to
regain some independence and the activities , which she enjoys
such as playing the piano. She will have followup with her
primary care provider , Dr. Hoerter regarding general plan for her
care including gradual hydrocortisone taper , her Lasix dosing and
her diabetes management. She will also followup at the chest
clinic with Dr. Oberhaus regarding her primary care physician prophylaxis and the
possibly of repeat chest CT regarding the question of her
mediastinal lymphadenopathy seen on CT during this admission.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg orally daily.
2. Albuterol nebulizer every 4 hours as needed wheezing or shortness of
breath.
3. Norvasc 5 mg orally daily.
4. Mepron 750 mg orally twice a day
5. Lumigan one drop each eye nightly.
6. Dulcolax 5 mg orally daily.
7. Colace 100 mg orally twice a day
8. Nexium 40 mg orally daily.
9. Iron 325 mg orally twice a day
10. Allegra 60 mg orally daily.
11. Lasix 40 mg orally twice a day
12. Neurontin 300 mg orally nightly.
13. Hydrocortisone 20 mg orally every day before noon
14. Aspart insulin sliding scale before every meal
15. Aspart insulin 8 units subcutaneously before every meal
16. NPH insulin 20 units subcutaneously every day before noon and 6 units subcutaneously nightly.
17. Synthroid 88 mcg orally daily.
18. Lisinopril 7.5 mg orally daily.
19. Remeron 15 mg orally nightly.
20. Senna 2 tablets orally twice a day
21. Zocor 20 mg orally nightly.
22. Multivitamin one tablet orally daily.
23. Epoetin 60 , 000 units subcutaneously every Saturday.
eScription document: 5-5176546 CSSten Tel
Dictated By: YEAGLEY , MA
Attending: NAJI , COLIN ELINORE
Dictation ID 6515726
D: 1/5/06
T: 1/5/06
Document id: 927
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CHF |
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OSA |
PVD |
VI |
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695831179 | PUO | 85228280 | | 737297 | 7/15/1998 12:00:00 a.m. | FEVER OF UNKNOWN ORIGIN | Signed | DIS | Admission Date: 7/11/1998 Report Status: Signed
Discharge Date: 10/4/1998
CHIEF COMPLAINT: The patient is a 79 year old female with diabetes
on immunosuppressants with fever x one day of an
unclear source.
HISTORY OF PRESENT ILLNESS: The patient has a history of diabetes
and of PMR , maintained on prednisone
7.5 mg orally every day and Imuran 100 mg orally every day ( begun three weeks
ago ). On 9 of June the patient noticed some blood in the sink after
brushing her teeth and she felt that she had coughed this up. A
chest x-ray was done , which was within normal limits. The patient
had felt tired for the last week. Since yesterday morning , she
felt nauseated , anorexic , had some chills , and took her temperature
later in the day and found a fever of 102. The patient also had a
moderate headache , but has no nuchal rigidity and no difficulty
with moving her head. She also has an occasional cough , which has
been nonproductive , for the past few days. The patient has no
other localizing symptoms - no hemoptysis , no chest pain , no
palpitations , orthopnea , edema , dysphagia , abdominal pain ,
diarrhea , hematuria , dysuria , flank pain , vaginal discharge , edema ,
rash , joint pain , claudication or scalp tenderness. The patient
has no moved her bowels for four days , but this is not unusual for
her.
PHYSICAL EXAMINATION: Mrs. Krochmal is somewhat lethargic , though
appropriate in conversation. Vital signs:
Temperature 103.0 , blood pressure 140/70. HEENT examination:
Anicteric. The extraocular muscles are intact. The pupils were
equal , round and reactive to light. No scalp tenderness. Temporal
arteries are nontender. The oropharynx is dry with no thrush. The
neck is supple. Chest: Crackles at the left base. No jugular
venous distention. Normal S1 and S2. No murmurs , rubs or gallops.
Abdomen: Bowel sounds are positive , soft , nontender , nondistended ,
no hepatosplenomegaly or masses. Rectal examination: Guaiac
negative. Extremities: No edema. No rashes. No tenderness.
Neurological examination: 5/5 strength in all extremities.
PAST MEDICAL HISTORY: Diabetes , PMR , hypothyroidism , peripheral
neuropathy , lower back pain , osteoporosis ,
borderline hypertension , history of stroke ( difficulty playing the
piano with her right hand , mild slurring of speech , but by
discharge her symptoms of wide-based gait and slurring of speech
had resolved. )
CURRENT MEDICATIONS: 1 ) Imuran 100 mg orally every day. 2 ) Prednisone
7.5 mg orally every day. 3 ) Synthroid 0.25 mg orally
every day. 4 ) Glucotrol 10 mg orally every day. 5 ) Lasix 20 mg orally every other
day. 6 ) Fosamax 10 mg orally every day. 7 ) Prilosec 20 mg orally every day.
8 ) Cytotec 400 mg orally three times a day 9 ) Lithium 300 mg orally every day. 10 )
Inderal 20 mg orally every day before noon and 20 mg orally every afternoon and 10 mg orally
every bedtime
ALLERGIES: Sulfa.
SOCIAL HISTORY: The patient is a retired Hebrew teacher. The
patient lives with her husband in a retirement
home. Tobacco - One pack per day for 20 years. Quit 20 years ago.
Alcohol - Occasional.
FAMILY HISTORY: The patient's mother had a stroke in her 60's.
LABORATORY DATA: Laboratory studies on admission showed a white
blood cell count of 8 , 200 , with 15 bands. ALT
18 , AST 26 , alkaline phosphatase 64 , total bilirubin 0.2 , ESR 55 ,
hematocrit 35.8. Sodium 139 , potassium 4.1 , creatinine 1.3.
A spinal tap was done which revealed the gram stain revealed no
organisms , no polys and no epithelial cells. Only one white cell
was noted in the CSF , glucose 92 , protein 46. The patient's
urinalysis showed 5 - 7 white blood cells , 2+ bacteria. The
patient's chest x-ray showed no infiltrates , no free air. KUB
showed no signs of obstruction.
HOSPITAL COURSE: The patient's Imuran was held because it was
thought that this could be a possible cause of
her fever. She was started on Ceftriaxone two grams , Mezlin and
Gentamicin in the Emergency Room. The patient's blood and urine
cultures were all negative , as was the spinal culture. The patient
improved steadily , and the day following admission she had been
afebrile x 24 hours saturating 94% on room air; therefore , the plan
was to discharge her. On the floor the patient received two grams
of Ceftazidime x one and then was taken off of antibiotics.
On the afternoon of 29 of July the patient's oxygen saturation
suddenly dropped. She complained of feeling short of breath and
nauseous. Her room air saturation was 82% when these symptoms
first developed. Over the next 30 minutes the patient
decompensated and her oxygenation was steadily increased; however ,
on 100% nonrebreather face mask her oxygen saturation was less than
80% and her skin appeared mottled. A portable chest x-ray showed
mild congestive heart failure. The patient's EKG showed a normal
sinus rhythm , no axis changes and no ST changes. The patient had
received 100 mg of intravenous Compazine for nausea; otherwise , no new
medications since admission. Her temperature was 100.5 at 2:00
p.m. Because of her rapid decompensation a code green was called
and she was intubated and transferred to the MICU. ABG showed a pH
of 7.35 , a pCO2 of 44 , and a pO2 of 96 following intubation. Blood
pressure remained , during this time , at 130 to 200 over 70 to 90
with heartrates in the 70's to 90's. During her rapid
decompensation the patient was given nebulizers , but with no
effect. The cause of the patient's sudden decompensation was
unclear. During the period of rapid decompensation the patient got
a total of 100 mg of intravenous Lasix. Her lung exam showed some crackles ,
but she did not appear to be all that wet. A chest x-ray three
hours post intubation showed diffuse fluffy infiltrates in the
bilateral lung fields , more central than peripheral. No effusion
was noted. Based on the findings of this chest x-ray , a VQ scan
was not done. It was thought that the rapid decompensation was due
to either pulmonary edema ( the patient had been on 150 cc an hour
of intravenous fluids for approximately 24 hours because she was dehydrated
when she first came in ) , blood , or pneumonia. The patient was
covered with Vancomycin , Ceftazidime ( for Pseudomonas ) ,
Levofloxacin ( for Legionella ) , and Pentamidine ( for primary care physician ). The
patient was also given 50 mg of intravenous Solu-Medrol twice a day Numerous
laboratory studies were sent off including: RSV , influenza ,
parainfluenza , VRE , Legionella , primary care physician , adenovirus , acid-fast bacilli ,
CH50 , and ANA , all of which were negative. Urine and blood
cultures were negative as well. Cardiogenic pulmonary edema was
thought to be an unlikely cause , given that she had a normal left
ventricular size and an ejection fraction of 50% in an
echocardiogram done right after being intubated. There was also no
evidence of any right ventricular dysfunction or RV strain.
She did well over the two days following intubation and was
extubated on 6 of May A bronchoscopy was considered , given the
patient's history of hemoptysis , but as the hemoptysis resolved
over the next couple of days , it was thought to be unnecessary.
The patient's oxygen saturation following extubation was 95% on
three liters nasal cannula and continued to be in the mid 90's once
she was weaned to room air in the subsequent two days. All
antibiotics were stopped while the patient was in the MICU except
for Levofloxacin , which was continued for a seven to ten day
course. The patient was gradually tapered off of the intravenous
Solu-Medrol and put on a orally prednisone taper starting at 80 mg
orally every day. The Pulmonary Consult Team saw her when she was back
on the floor for her continued hemoptysis , but this appeared to
resolve over the next couple of days , and , as a result , it was
decided that this need not be pursued at the present. The patient
did well over the next several days and the day prior to discharge
was saturating at 94% on room air and received 10 mg of orally
prednisone. The etiology of the patient's sudden decompensation
was never entirely clarified , but it appeared that flash pulmonary
edema was probably the most likely explanation , possibly due to a
viral pneumonia in conjunction with fluid overload.
MEDICATIONS ON DISCHARGE: 1 ) Tylenol 650 mg orally every 4 hours as needed
headache. 2 ) Premarin 0.625 mg orally every
day. 3 ) Colace 100 mg orally twice a day 4 ) Lasix 20 mg orally every other
day. 5 ) Glucotrol 10 mg orally every day. 6 ) Synthroid 125 micrograms
orally every day. 7 ) Lithium 300 mg orally every day. 8 ) Cytotec 400
micrograms orally three times a day 9 ) Prilosec 20 mg orally every day. 10 )
Prednisone 10 mg orally every day before noon 11 ) Inderal 20 mg orally every day. 12 )
Fosamax 10 mg orally every day before noon 13 ) Elavil 50 mg orally every bedtime
DISCHARGE DISPOSITION: The patient's discharge disposition is to
home with VNA.
FOLLOW-UP PLANS: The patient is to follow-up with her primary
care doctor , Dr. Elfrieda Winzer , if her weight
increases by more than two pounds , or if she has any further
problems. The patient is also to follow-up with him next week.
The patient is also to follow-up with Dr. Holda from the Cardiology
Group , as needed.
CONDITION ON DISCHARGE: The patient's condition on discharge was
stable.
Dictated By: TABATHA HOLLWAY , M.D. QS4
Attending: ELFRIEDA WINZER , M.D. LP8
KU201/3793
Batch: 07353 Index No. IXUPGW7NX6 D: 6/24/98
T: 10/5/98
Document id: 928
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750457024 | PUO | 24192058 | | 7679935 | 3/10/2004 12:00:00 a.m. | HYPERCALCEMIA | Signed | DIS | Admission Date: 2/23/2004 Report Status: Signed
Discharge Date: 10/24/2004
ATTENDING: CORRINE MCCULLEN M.D.
HISTORY OF PRESENT ILLNESS:
This is a 63-year-old female with type-2 diabetes and
hypertension and history of perihilar mass greater than 4 cm on
the CT scan from Norap Valley Hospital in September 2002 at which time she
refused biopsy. She now presents with nausea and vomiting. The
patient presents with two to three weeks of decrease orally intake
and diminished appetite in the past week. She has also had
nausea , vomiting , and epigastric pain after meals. Vomiting was
nonbloody and nonbilious. The patient has had a 10-pound weight
loss in the past two months. She also complains of myalgias ,
malaise , fatigue , dizziness , occasional shortness of breath ,
dyspnea on exertion , and a nonproductive cough. She denies chest
pain , palpitations , headaches , visual changes , or loss of
consciousness. She presented to her primary care physician on the day prior to
admission. Routine chemistries were checked and calcium was
found to be 14 , potassium 5.7 , and creatinine 4.6. She was
therefore sent to the Kernan To Dautedi University Of Of Emergency Room. In the emergency
room she was afebrile , her heart rate was 56 , her blood pressure
was 147/70 , and she was saturating 98% on room air. Her EKG
showed bradycardia with no ST changes and no big T waves.
PAST MEDICAL HISTORY:
Type-2 diabetes , hypertension , perihilar lung mass greater than 4
cm on CT from September 2002 at Norap Valley Hospital at which time the
patient refused biopsy.
PHYSICAL EXAMINATION:
Temperature 98.4 , heart rate 56 , blood pressure 147/70 , and
saturation 98% on room air. No cervical lymphadenopathy. No
neck masses. No thyromegaly. Chest with bilateral crackles
2/3rd of the way up , which are per primary care physician are chronic.
Cardiovascular , distant heart sounds , S1 , S2. No rubs , murmurs ,
or gallops. JVP flat. No carotid bruits. Abdomen , soft and
nondistended. Epigastrium is tender to palpation. No masses.
No inguinal lymphadenopathy. No peripheral edema , clubbing , or
cyanosis.
HOSPITAL COURSE BY SYSTEM:
1. Hypercalcemia. The patient's initial calcium was 13.2 , a
decrease to the mid 9 range with aggressive intravenous fluids. Studies
sent included PTH = 26 , vitamin D = 27 , TSH = 1.69 , and PTHrP
which is still pending at the time of discharge. The patient had
a negative PPD placed three induced sputum for TB , which were all
negative. SPEP and UPEP had increased gamma globulins , but he
was polyclonal and no end spikes. A chest CT showed large
mediastinal lymphadenopathy with multiple 2-3 cm nodes. No
intraparenchymal disease. A mediastinoscopy for biopsy and
intraoperative BAL were done and the pathology and microbiology
are pending at the time of discharge. Abdominal CT was negative.
2. Renal. Baseline creatinine is 2-3. Creatinine increased to
6 on admission and was down to 3.4 with aggressive hydration by
the time of discharge. There were no casts in her urine. Her
phenol was 11.6% on admission. It was thought that her acute
renal failure was secondary to prerenal azotemia as well as a
component of ATN and tubular damage from the hypercalcemia. Her
creatinine remains stable around 3.4 on discharge.
3. Pulmonary. She did not have any pulmonary symptoms except
for a mild cough that had resolved on admission. She did have
persistent bibasilar crackles , which were old per her primary care physician. She
had no shortness of breath and her saturations remain greater
than 96% on room air throughout admission. Her chest x-ray
showed no evidence of infiltrates , but did show right mediastinal
widening and calcific nodularity in the right upper lobes. Chest
CT showed mediastinal lymphadenopathy as described above and also
a small area of tree-in-bud inflammation. She was ruled out for
TB with induced sputum x 3. Mediastinoscopy biopsy on 1/5/04 ,
results are pending.
4. Heme. Anemia workup. Iron 49 , TIBC 256 , B12 555 , folate
normal , ferritin 102 , reticulocyte 7.9 , and Epogen level 19. She
has a normocytic anemia , but given her chronic renal
insufficiency she has a mild degree of iron deficiency. The
likely etiology of her anemia is secondary to renal disease.
Iron supplementation was started. Hematocrit was stable
throughout admission.
5. Endocrine. The patient has a history of diabetes and was
hypoglycemic on admission. This resolved with hydration. Her
PTH was 26 , her vitamin D was 27 , PTHrP is pending. She was kept
on a regular insulin sliding scale during the admission. She
resumed her NPH dose as an outpatient on discharge. She will
need a close follow up of blood sugars as an outpatient. Her TSH
was 1.69.
6. Skin. The patient had a pruritic rash on her right back ,
which appeared about a week prior to admission. She had a few
scattered 1-2 cm dark nodular regions over the mid right back.
She did not have pustules or discharge from lesions. She also
had areas of postinflammatory hyperpigmentation on her left upper
back.
DISPOSITION.
The patient is discharged home in stable condition. She will
follow up in one week with her primary care physician Dr. Camerena He will need to
discontinue the stitches on her neck and follow up all the
results and arrange treatment as appropriate. Instructions were
given to the patient in dutch.
DISCHARGE MEDICATIONS:
Cardizem SR 240 mg orally every day , metoprolol XL 75 mg every day , NPH at
home doses , iron 325 mg orally twice a day , Percocet one tablet orally
every 6 hours as needed pain for the few days following the mediastinoscopy.
The patient is discharged in stable condition with follow up with
Dr. Raspotnik to be arranged in one week.
eScription document: 8-7985247 EMSSten Tel
Dictated By: FRANKENBERRY , ANDREAS
Attending: MCCULLEN , CORRINE
Dictation ID 8781520
D: 6/7/04
T: 6/6/04
Document id: 929
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696160396 | PUO | 17899982 | | 5260913 | 9/4/2007 12:00:00 a.m. | l catotid stenosis | | DIS | Admission Date: 6/27/2007 Report Status:
Discharge Date: 10/7/2007
****** FINAL DISCHARGE ORDERS ******
PETZOLDT , RACHAEL 226-81-65-2
Au Charl
Service: VAS
DISCHARGE PATIENT ON: 11/19/07 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MANKOSKI , ROSSIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ALENDRONATE 70 MG orally QWEEK
2. ETANERCEPT 50 MG subcutaneously QWK STARTING TUESDAY 3/19/07
3. FOLIC ACID 1 MG orally every day
4. LEVOTHYROXINE SODIUM 100 MCG orally every day
5. METOPROLOL TARTRATE 12.5 MG orally twice a day
6. NIFEREX 150 150 MG orally twice a day
7. PANTOPRAZOLE 40 MG orally every day
8. PREDNISONE 5 MG orally twice a day
9. SIMVASTATIN 80 MG orally every bedtime
10. TRAZODONE 200 MG orally HS
11. METFORMIN UNKNOWN MG orally twice a day
12. ACETYLSALICYLIC ACID 81 MG orally every day
13. INSULIN NPH HUMAN 12 UNITS subcutaneously Q a.m.
14. NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual as needed
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
Starting Today ( 9/8 ) as needed Pain
ECASA 325 MG orally DAILY Starting post OP DAY 1
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ )
1 , 000 MG orally DAILY Starting IN a.m. ( 7/14 )
Override Notice: Override added on 7/9/07 by
ISA , KAM , M.D. , PH.D.
on order for SYNTHROID orally ( ref # 069309809 )
POTENTIALLY SERIOUS INTERACTION: CALCIUM CARBONATE , ORAL &
LEVOTHYROXINE SODIUM Reason for override: aware
FOLIC ACID 1 MG orally DAILY Starting IN a.m. ( 7/14 )
INSULIN NPH HUMAN 12 UNITS subcutaneously every day before noon
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
Alert overridden: Override added on 7/9/07 by
ISA , KAM , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: CALCIUM CARBONATE , ORAL &
LEVOTHYROXINE SODIUM Reason for override: aware
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NIFEREX 150 150 MG orally twice a day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
PREDNISONE 5 MG orally twice a day
ZOCOR ( SIMVASTATIN ) 80 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 7/9/07 by
ISA , KAM , M.D. , PH.D.
SERIOUS INTERACTION: AZITHROMYCIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN & SIMVASTATIN
Reason for override: aware
TRAZODONE 200 MG orally BEDTIME Starting IN a.m. ( 7/14 )
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Derham , call to schedule 7-10d ,
Primary Care Physician , call to schedule 2-3wks ,
ALLERGY: METHOTREXATE
ADMIT DIAGNOSIS:
l carotid stenosis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
l catotid stenosis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ra ( rheumatoid arthritis ) htn ( hypertension ) dm ( diabetes
mellitus ) cad ( coronary artery disease ) ha ( headache )
OPERATIONS AND PROCEDURES:
7/9/07 MANKOSKI , ROSSIE , M.D.
LT. CAROTID ENDARTERECTOMY WITH PATCH ANGIOPLASTY , EEG MONITORING
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
HPI: 77f with neurological changes who now presents for L CEA. On CREST
trial.
PMH: coronary artery disease for which she underwent coronary
angioplasty and a two-vessel coronary bypass grafting procedure 15 years ,
diabetes mellitus , hyperlipidemia and hypertension , iron-deficient anemia
requiring intermittent transfusions , rheumatoid arthritis for which she
is on prednisone , lymphangiectasia , restless leg syndrome , reflux disease
and hypothyroidism
PSH: cholecystectomy , her coronary surgery and a hysterectomy
ALL: NKDA
Home Meds: ASA orally 81 MG every day , Fosamax orally 70 MG QWEEK , Enbrel subcutaneously 50 MG
Qwk , Folate orally 1 MG every day , Insulin Nph Human subcutaneously 12 units Q a.m. , Synthroid orally
100 MCG every day , Metformin orally Unknown MG twice a day , Lopressor orally 12.5 MG twice a day ,
Niferex 150 orally 150 MG twice a day , Nitroglycerin 1/150 ( 0.4 Mg ) ( Ntg 1/150 ) sublingual
1 TAB as needed , Protonix orally 40 MG every day , Prednisone orally 5 MG twice a day , Zocor orally 80 MG
every bedtime , Trazodone orally 200 MG HS
SH: She does not smoke , nor does she drink. She is married and cares for
her husband , who has Alzheimer's
Hospital Course:
Patient tolerated procedure without intra-operative complications.
Patient was extubated in the OR and transferred to the PACU in stable
condition. Patient initially recovered in the PACU before being
transferred to the floor in stable condition. Diet was advanced as
appropriate without complications. Her hospital course was notable for
persistent headaches which were reponsive to oxycodone and tylenol.
Throughout this period her neurologic exam was unremarkable ( CN II-XII
intact , peripheral motor/sensory intact ). On the day of discharge she
was tolerating a regular diet , without headaches , tolerating a regular
diet , and ambulating ad lib. Her incision was clean , dry , and intact.
ADDITIONAL COMMENTS: Seek immediate medical attention for fever >101.5 , chills , increased
redness , swelling or discharge from incision , chest pain , shortness of
breath , or anything else that is troubling you. OK to shower but do not
soak incision until follow up appointment , at least ( ie. no
swimming/bathing/hot tub ). No strenuous exercise or heavy lifting until
follow up appointment , at least. Do not drive or drink alcohol while
taking narcotic pain medications. Resume all home medications. Call Dr.
Derham to make follow up appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ISA , KAM , M.D. , PH.D. ( JH143 ) 11/19/07 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 930
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750424296 | PUO | 13575509 | | 760670 | 7/3/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/16/1990 Report Status: Unsigned
Discharge Date: 5/16/1990
HISTORY OF PRESENT ILLNESS: This is a 22 year old , gravida V para
0314 , at 24 weeks , now with severe
frontal headache and scintillations. Dating is by the last
menstrual period and an early ultrasound which placed her at
approximately 24 weeks. She presented with a three and a half day
history of severe frontal headaches with scintillations. There was
no relief with Tylenol , aspirin or Fioricet. She also stated she
had marked polydipsia for four days. She denied abdominal pain or
swelling. She has a history of preeclampsia with a previous twin
gestation. She does note fetal activity. At this juncture , I
should note that much of this history is as per patient and is
somewhat unreliable. PAST OBSTETRICAL HISTORY: C-section for
twins; previous C-section for singleton; history by patient of
preeclampsia. PAST HISTORY: Initially she admitted to no past
medical problems , however , upon reviewing her chart the following
is obvious: chronic hypertension; seizure disorder following motor
vehicle accident for which she is on valproic acid , no clearly
documented recent seizures; history of asthma for which she takes
medicines as needed; history of behavioral disorders with question of
pseudoseizures in the past; obesity; multiple drug allergies;
cholecystectomy in 1990; appendectomy at age 14; motor vehicle
accident with V-P shunt placement in 1980; facial reconstruction
times three in 1980; superficial vascular surgery in 1989 for
varicosities of the lower extremities. SOCIAL HISTORY: She denies
tobacco , ethanol or drug use.
PHYSICAL EXAMINATION: Revealed an obese white female in mild
distress. The pupils are equal , round and
reactive to light and accommodation; fundi well visualized , no
papilledema. Good facial movements. No orally lesions. The chest
was clear. The heart showed a regular rate and rhythm. The
abdomen was soft and nontender with a fetal heart rate in the
140's. The extremities showed trace edema. The neuro exam showed
cranial nerves II-XII grossly intact. Reflexes were 1+ without
clonus. The strength was reduced to 4/5 in the right upper and
right lower extremities , however , the exam was questionable as she
seemed to have a varying exam depending on the examiner and time of
exam. She also demonstrated decreased fine finger movements on the
right.
HOSPITAL COURSE: Problem #1 ) Headache. The patient has a history
of chronic headaches for which she was maintained
on Fioricet in the past. Over the first week of hospitalization ,
she complained of increasing headache that prevented her from
looking into the light as well as prevented her from ambulating out
of the bed. At times , she complained of intermittent visual
symptoms. These headaches were not completely relieved by Demerol ,
Percocet or Tylenol. She was eventually tried on Fioricet which
apparently produced good relief of the headaches. She was seen by
neurology and noted with a questionably abnormal neuro exam with
findings localized to the right side. Apparently she has a history
of this abnormality in the past. A CT scan revealed what was
apparently old damage from the previous motor vehicle accident. An
MRI was entirely within normal limits. She refused a lumbar
puncture. At this time , the headaches are thought to be either
vascular in origin or psychogenic. She was continued on Fioricet
at the time of discharge. Problem #2 ) Hypertension. She had
elevated blood pressures of 150-160 over as high as 110 upon
admission. She has a history of chronic hypertension in the past
and was at least briefly maintained on hydrochlorothiazide before.
She had a negative work up for PET , including repeat 24 hour urines
and repeat PET labs. As well , she had no physical findings
consistent with PET. Given her history of chronic hypertension , we
felt this was most likely chronic hypertension aggravated by
pregnancy. She was begun on a beta blocker , namely labetolol , with
good control. She was discharged to home on labetolol. Problem
#3 ) History of seizure disorder. She carries the diagnosis of a
seizure disorder , although this is , at least recently , poorly
documented. She has been on valproic acid in the past and has been
taking a small dose of valproic acid apparently on her own
throughout this pregnancy. She has been taking 250 mg a week. She
last noted an obvious seizure three years ago. It is not clear
that this was witnessed by anyone else. While in the hospital , she
had an EEG which suggested some slowing in the right parietal
region. There was no clear seizure activity seen on EEG. She
called us to her room on several episodes which she described as
seizures. These seizures were witnessed by several physicians and
were remarkable for absence of a postictal period as well as
abnormal idiosyncratic behaviors during the events. It was our
feeling that these were not true seizures. Indeed , reviewing her
chart , she has had episodes of what have been called pseudoseizures
similar to these in the past. Given her multiple drug allergies ,
including Dilantin , phenobarb and tegretol , we felt limited in our
therapeutic options. We did elect to increase her dose of valproic
acid as this has apparently been effective in the past. She will
continue this as an outpatient. Problem #4 ) Nausea and vomiting.
She complained of persistent nausea and vomiting during the latter
part of her hospitalization and declined to take anything orally The
etiology of this nausea and vomiting was unclear , although
apparently associated with some diarrhea. As much as was possible ,
work up for an organic cause of the problem was negative. We
elected initially to treat her with intravenous hydration , however ,
she declined further intravenous's. In fact , she became quite vocal in her
demand to go home. She understands our concerns as to the risks of
poor orally intake and insists she will be able to take in orally's at
home. Given her feelings in this regard , we have elected to
discharge her for a trial of outpatient management. Follow up will
be in the clinic. Should she show evidence of compromise or
dehydration , she will be readmitted. Problem #5 ) Psychosocial.
The patient has been seen several times in the past for behavioral
disorders. It is difficult to sort out what part of her
symptomatology is organic and what , if any , is inorganic. She was
seen by psychiatry during her stay here who felt that she had a
significant conflict in her home life. We have counseled her as
much as possible throughout her stay. She has seen both social
services and psychiatry , however , she is at best reluctant to avail
herself of these services. Our plan at the time of discharge is
for follow up with DSS. As well , we have emphasized our
availability to the patient at all times and tried to be as
supportive as possible in these circumstances.
DISPOSITION: The patient was discharged for a trial of management
at home. The etiology of her discomfort is somewhat
obscure , however , we have as best as possible ruled out obvious
major organic pathology , including PET , central CNS processes and
fulminant hypertension.
DISCHARGE DIAGNOSES: 1. INTRAUTERINE PREGNANCY AT 24 WEEKS.
2. HEADACHE.
3. SEIZURE DISORDER.
4. CHRONIC HYPERTENSION.
5. RULE OUT PRE-ECLAMPTIC TOXEMIA.
6. NAUSEA AND VOMITING.
OPERATIONS/PROCEDURES: CT.
MRI.
EEG TIMES TWO.
Batch: 2472 Report: D5569A6 T:
________________________________ MN083/1236
DENISHA MCRORIE , M.D. PQ84 D: 11/7/90
Batch: 6180 Report: Z2547W9 T: 9/17/90
Dictated By: COLE AINI , M.D.
cc: TRISH L. CHAIX , M.D.
Document id: 931
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194522520 | PUO | 87221996 | | 6304551 | 7/4/2003 12:00:00 a.m. | STROKE | Signed | DIS | Admission Date: 7/4/2003 Report Status: Signed
Discharge Date: 8/26/2003
ATTENDING: DERICK DELCIE YAN MD
ADMITTING DIAGNOSIS:
Stented basilar occlusion.
ADDITIONAL DIAGNOSIS:
None , Q-wave myocardial infarction.
OPERATIONS/PROCEDURES:
Cardiac catheterization done on 3/14/03.
HISTORY AND REASON FOR HOSPITALIZATION:
This is a 70-year-old female with a history of coronary artery
disease , diabetes mellitus , hypertension and ____ fibrillation
managed on aspirin and Plavix who presents to the Totin Hospital And Clinic emergency department complaining of lethargy , diplopia
and vertigo. Further information regarding her symptomatology is
not currently available as the patient's initial mental status
was quite poor.
PAST MEDICAL HISTORY:
Significant for hypertension , diabetes , glaucoma ,
hypercholesterolemia , history of alcohol abuse , history of
coronary artery disease.
MEDICATIONS ON ADMISSION:
Not available currently in detail but included aspirin 325 mg and
Plavix 25 mg orally every day
ALLERGIES:
She is allergic to NSAIDs , penicillin and Diltiazem.
PHYSICAL EXAMINATION UPON ADMISSION:
Revealed her to be lethargic , obese. Her face is slightly
asymmetric with some left cheek swelling. Her neck revealed no
bruits. Her heart was irregularly irregular. Her lungs revealed
bibasilar crackles. Her extremities had 1+ pitting edema
bilaterally. Neurologic examination: The only focal findings
were a transient skewed deviation of her eyes. Further
information regarding this is not currently available. Focal
weakness and numbness were not delineated upon initial
evaluation.
SUMMARY OF HOSPITAL COURSE:
The patient was admitted to the Neurology Intensive Care Unit
given her initial imaging findings. These findings were that she
had an occlusion , flat high-grade stenosis of the distal basilar
artery. There was no acute infarction noted. Based on these
findings , she was admitted to the Neurology Intensive Care Unit
and placed on intravenous heparin. Her neurologic status
gradually improved throughout her hospitalization. She did not
complain of diplopia after the first day of her hospitalization.
She also was quite awake after the first day of her
hospitalization. Repeat magnetic resonance imaging done on
10/21/03 revealed a new left cerebellar infarct with persistent
high-grade stenosis of the basilar artery which did appear a bit
more patent than the initial scan done on 10/20/03. At the time
of her discharge , she was being transitioned from heparin to
Coumadin and she was neurologically intact. With regard to her
cardiovascular status , the patient initially ruled in for an MI
based on positive cardiac markers. Her peak troponin-I was 11.02
and her peak CKMB was 18.4. She had lateral T-wave inversions
that were new compared to her old EKGs. She was brought to the
cardiac catheterization laboratory where it was found that she
had multiple moderate stenoses but without any high-grade or
critical stenoses. She was found however to have an elevated
wedge pressure of approximately 30 cm. Echocardiogram done on
10/30/03 revealed an ejection fraction of 60%. She had a mildly
dilated left atrium. It was found that she had moderate
tricuspid regurgitation. Her pulmonary artery pressures were
elevated to 51 mL of mercury. She also is found to have moderate
mitral regurgitation. Based on the findings of her
catheterization and elevated wedge pressures , the patient was
diuresed relatively aggressively. She was also given high doses
of beta-blockade. Her troponin and CKMB levels did decrease
after this. She remained weight controlled with beta-blockade.
There was some discussion of possibly cardioverting her , but
given her recent stroke this will be deferred. With regard to
her blood pressure management , she has been managed while at an
inpatient with hydralazine and Lopressor. A decision was made
not to introduce an ACE inhibitor at this time given her recent
_____ and her baseline renal insufficiency ( 1.8-1.9 ). The
addition of an ACE inhibitor may be indicated at some point in
the near future.
DISCHARGE PLAN:
The patient will be discharged to Howood Medical Center
Hospital.
FOLLOW UP PLANS:
The patient will see her primary care physician , Ma Yeagley ,
at the Department of Medicine on 9/26/04. She will see Dr.
Buck Moose of Neurology on 2/12/03 at 4 p.m. She will see Dr.
Corey Herrmann at the Department of Cardiology on 10/4/04.
DISCHARGE MEDICATIONS:
Aspirin 325 mg orally every day , heparin drip being transitioned to
Coumadin 5 mg orally every day with goal INR of 2-3 , folic acid 1 mg
orally every day , hydralazine 75 mg orally four times a day , metoprolol 125 mg orally
three times a day , simvastatin 20 mg orally every bedtime , Cosopt 1 drop each eye twice a day ,
Nexium 20 mg orally every day , Lasix 40 mg orally twice a day
eScription document: 5-2133269 EMSSten Tel
Dictated By: MOOSE , BUCK
Attending: PAULK , CHANCE YANG
Dictation ID 0127979
D: 1/15/03
T: 1/15/03
Document id: 932
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485453494 | PUO | 50295009 | | 8966060 | 11/29/2005 12:00:00 a.m. | BILATERAL KNEE PAIN | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed
Discharge Date: 8/5/2005
ATTENDING: INNARELLI , DONNETTE M.D.
DIAGNOSIS: Multiple joint sepsis.
HISTORY OF PRESENT ILLNESS: Mr. Rye is a 73-year-old
gentleman who in October of this year developed enterococcus sepsis
of both knees , his right shoulder and left wrist. He was taken
to the operating room in the beginning of July for irrigation
and debridement of the aforementioned joints. The cultures were
significant for enterococcus and he was started on intravenous antibiotics
and discharged to Howood Medical Center . At Mi Lakeield Sonme , he continued to
complain about bilateral knee swelling as well as shoulder and
wrist pain and was therefore brought back for a repeat wash out
and reassessment.
PAST MEDICAL HISTORY: BPH , pacemaker , atrial fibrillation.
PAST SURGICAL HISTORY: Status post bilateral total knee
replacement approximately 10 years ago , status post left ankle
ORIF.
MEDICATIONS ON ADMISSION:
1. Lopressor 50 mg orally twice a day
2. Multivitamin.
3. Lisinopril 7.5 mg orally daily.
4. Colace 100 mg orally twice a day
5. Digoxin 0.25 mg orally daily.
6. Nexium 40 mg orally daily.
7. Unasyn.
8. Gentamicin intravenous.
9. Coumadin 7.5 mg orally every afternoon
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Stable vital signs.
Temperature 97.8. Left wrist tender to examination with
decreased strength of wrist extension , finger flexion and
intrinsics to 3 out of 5. Right shoulder and both knees with
only slightly decreased range of motion and little pain on
passive range of motion. Neurovascularly intact.
HOSPITAL COURSE: The patient was taken to the operating room on
9/3/05 for arthroscopic irrigation and debridement of both knees
as well as the right shoulder. There was a small effusion in
both knees which was aspirated prior to the irrigation and sent
to the laboratory. These cultures show no growth to date with
negative gram stain. The right shoulder was ??_____?? without
effusion. Intraoperative exam: No purulent discharge was
encountered , however there was mild inflammatory response in both
knees and right shoulder. The left wrist was treated with
irrigation and debridement as well as a proximal ??_____??
carpectomy by Dr. Kristian Maglione from hand surgery.
Intraoperative cultures for fluid aspirate as well as bone tissue
from the proximal ??_____?? carpectomy demonstrated coag negative
staph. Postoperatively , the patient was seen by physical therapy
for mobilization and weightbearing as tolerated with free range
of motion of both knees and the right shoulder. He was placed in
an Orthomold splint for the left wrist. On request of the
patient's daughter , Medicine was consulted but had little
recommendations beyond small adjustments of his cardiovascular
medications.
Also , Infectious Disease was consulted and recommended a change
of antibiotics to ampicillin and gentamicin and vancomycin to
treat the coag negative staph in the left wrist aspirate as well
as to continue treatment of the previous enterococcus infection.
No cultures from the current admission have demonstrated
enterococcus. The patient also underwent a transthoracic echo ,
however , the report is pending at the time of discharge.
Finally , the patient was seen by Nutrition who recommended a
??_____?? protein diet with supplements three times a day
Lastly , the patient presents with chronically elevated PTT in a
range of 40 to 70. After discussion with hematology , an
inhibitor screen was sent , however , after the serum was
neutralized , PTT was found to be normal so likely the chronic PTT
elevation was secondary to a hep block in his PICC line.
The patient progressed well and was ambulating with minimal
support at the time of discharge. He has remained afebrile with
benign-appearing incisions. He will be transferred to Howood Medical Center for further mobilization.
DISCHARGE MEDICATIONS:
1. Ampicillin 3000 mg intravenous every 4 hours x6 weeks.
2. Digoxin 0.25 mg orally daily.
3. Colace 100 mg orally twice a day
4. Gentamicin sulfate 400 mg intravenous daily x6 weeks ( please check
gentamicin peak and trough levels ).
5. Lisinopril 10 mg orally daily.
6. Lopressor 50 mg orally three times a day Hold for systolic blood pressure
less than 110 and heart rate less than 55.
7. Senna tablets 2 tablets orally twice a day
8. Multivitamin therapeutic with minerals , 1 tab orally daily.
9. Vancomycin 1 gram intravenous every 12 hours x6 weeks.
10. Coumadin 7.5 mg orally every afternoon with a target INR of 2 to 3 for
atrial fibrillation chronically.
11. Esomeprazole 40 mg orally daily.
12. Oxycodone 5-10 mg orally every 4 hours as needed pain.
PLAN: The patient will be transferred to Howood Medical Center
??_____??. He has a right antecubital PICC line in place which
will be flushed per protocol. He will require intravenous
antibiotics for six weeks' time and during this time will require
at least weekly lab draws with CBC with diff , BUN and creatinine.
He will be followed by Dr. Champeau from Infectious Disease at
Howood Medical Center . He was followed by Dr. Nunziato from Infectious
Disease during his hospitalization at Pagham University Of Mr. Rye will require a hearing test while at
Howood Medical Center due to his longterm gentamicin treatment. He
will require rehab services for mobilization , weightbearing as
tolerated , with free range of motion and no restrictions for both
lower and the right upper extremity. He will remain in his
Orthoplast splint with twice a day dressing changes to the dorsal
wrist incision. Mr. Rye will follow up with Dr. Donnette Innarelli
from Pagham University Of Orthopedics on 7/25 at 9:00 and
with the Hand Service at Pagham University Of on 5/9 at
9:15. He will also follow up with Dr. Fouty from Pagham University Of Gastroenterology for a colonoscopy on 10/17/05 at
9:00 a.m. , also at Pagham University Of on the No La Ter Ri Ver
eScription document: 4-7380246 MCSFocus transcriptionists
Dictated By: SCHROM , CHANELLE
Attending: INNARELLI , DONNETTE
Dictation ID 1706432
D: 9/15/05
T: 9/15/05
Document id: 933
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472510821 | PUO | 58706198 | | 0998472 | 1/14/2005 12:00:00 a.m. | chronic diarrhea , RLQ pain | | DIS | Admission Date: 5/29/2005 Report Status:
Discharge Date: 10/10/2005
****** DISCHARGE ORDERS ******
HUERTES , ANNAMARIE DAMARIS 210-49-59-4
Transa Ln. , Hend , Mississippi 65319 Emi Sta Ence
Service: RNM
DISCHARGE PATIENT ON: 10/25/05 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DRIESENGA , MEE A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
PHOSLO ( CALCIUM ACETATE ) 667 MG orally three times a day
GLIPIZIDE 10 MG orally twice a day
LISINOPRIL 10 MG orally every day HOLD IF: SBP < 100
LOPERAMIDE HCL 2 MG orally every 6 hours as needed Diarrhea
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally every 6 hours as needed Nausea
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
HOLD IF: SBP < 100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Override Notice: Override added on 1/30/05 by
KATZER , CALANDRA , M.D. on order for ZOCOR orally ( ref # 11493003 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
Previous override information:
Override added on 5/15/05 by KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
HOLD IF: SBP < 100 , HR < 55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ATORVASTATIN 10 MG orally every day
Alert overridden: Override added on 1/30/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
IMODIUM ( LOPERAMIDE HCL ) 2 MG orally every 6 hours as needed Diarrhea
DIET: House / 2 gm Na / ADA 1800 cals/day / Low saturated fat
low cholesterol / Renal diet (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Buck Moose , Gastroenterology 10/2/05 scheduled ,
Dr. Carol Mordhorst , primary care physician 7/16/05 scheduled ,
ALLERGY: intravenous Contrast , METHYLDOPA , Penicillins , PRAZOSIN
ADMIT DIAGNOSIS:
nausea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chronic diarrhea , RLQ pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM history of RLE DVT ( calf ) HEMORRHOIDS MS CHEST PAIN cad ( coronary artery
disease ) history of CABG ( history of cardiac bypass graft surgery ) history of appy ( history of
appendectomy ) history of ccy ( history of cholecystectomy ) ESRD on HD ( end stage renal
disease ) Afib with RVR ( atrial fibrillation ) hyperchol ( elevated
cholesterol ) chf ( congestive heart failure ) vitiligo ( vitiligo ) obesity
( obesity ) history of MRSA pneumonia ( history of pneumonia ) HTN
OPERATIONS AND PROCEDURES:
10/15/05 --hemodialysis
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
72F with type II DM , HTN , CAD history of CABG '02 , ESRD on HD , hyperlipidemia p/with 1
month loose stools , 2-3 wks persistent suprapubic/RUQ pain rad to back ,
and intermittent bouts of nausea/vomiting , mild increase in SOB.
Recently admitted 8/13 for similar complaints , C. diff ( - ) , abd CT nl ,
diarrhea resolved spontaneously. 3-4 stools/day , resolving;
suprapubic/RLQ pain rad to back worse with sitting upright , no dysuria ,
hematuria. No F/C , no lightheadedness/syncope , CP , palps , +mild SOB ,
mild decrease in appetite , stable 2 pillow orthopnea , intermittent PND.
Afeb , 169/50 , 65 , 20 , 100% 2L. fatigued , min resp distress , bibasilar
crackles halfway up lung fields , JVP 12-13 cm , minimal tenderness to palp
in suprapubic/RLQ region without rebound/guarding , 1+ pitting edema to
calves bilaterally. Labs: gluc 314 , Cr 5.8 , amylase/lipase nl , LFTs nl ,
albumin 4.6.
***PLAN***
( 1 ) GI: sx control of N/V with reglan , did not require medications for
abdominal pain. Prior stool studies ( - ) , received imodium for symptomatic
relief , sent repeat stool cx--at time of discharge , stool O+P and fecal
leukocytes ( - ). C. diff , stool cultures pending. Had completely normal
abdominal CT 1 month ago for identical symptomatology , only able to
obtain abd CT without contrast due to intravenous dye allergy. Symptoms resolved
spontaneously by time of discharge--will discharge on reglan and imodium
for symptomatic relief , with GI outpatient follow-up at Norap Valley Hospital
on 4/18/05 with Dr. Buck Moose for further evaluation of chronic
diarrhea and mild RLQ tenderness. ?poor sugar control contributing to
symptoms of nausea , abdominal pain. Patient feels that one of the
injections she receives at dialysis contributes to her nausea/vomiting ,
will address with nephrologist Dr. Tabatha Hollway
hemodialysis session. Will continue T/Th/Sat HD at Norap Valley Hospital ;
hemodialysis session. Will continue T/Th/Sat HD at Norap Valley Hospital ;
nephrocaps , phoslo
( 3 ) CV: 3VD history of CABG x 3 in 2002 , ruled out for MI; continued ASA ,
plavix , lisinopril , lopressor , statin , imdur
-P: volume removal at HD , low Na , 1L fluid restriction--received
nutritional counseling to improve compliance with dietary restrictions
-prior TTE with EF 40% , evidence of diastolic CHF
( 4 ) Endo: DM--increased glipizide to 10 twice a day , may need to add insulin for
better control , as HgbA1c always runs high , ?sx of nausea , abd pain
related to hyperglycemia and gastroparesis
-TSH normal at 4.332
( 5 ) Psych: renal service requested psych evaluation for ?secondary gain;
psychiatry felt that patient is lonely/isolated , but not clearly
depressed , probably has some element of PTSD from watching brother-in-law
decapitate an acquaintance when she was 15yo; grandson also died a few
years ago in a house fire--unable to watch news on TV subsequently. No
evidence of secondary gain--felt that moving to assisted living facility
in 1 month will be beneficial for her--no need for any psych meds at this
time. Also evaluated by dutch-speaking social worker , who knows Ms.
Huertes well , extremely helpful in outlining home situation , issues.
( 6 ) PPX: subcutaneously heparin , nexium
( 7 ) Dispo: will d/c home with VNA for monitoring of blood sugars ,
ensuring compliance with medications , low-Na renal diet , 1L fluid
restriction. Patient looking into moving into assisted living
facility--may move as early as next month.
ADDITIONAL COMMENTS: Please go to Norap Valley Hospital Gastroenterology Clinic on 4/18/05 at 1:00
pm for your appointment with Dr. Buck Moose for further evaluation of
your chronic diarrhea and abdominal pain. Please return to the KTDUOO Clinic
on 10/5/05 at 1:30pm for your follow-up appointment with Dr. Carol Mordhorst , your primary care physician.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: KATZER , CALANDRA , M.D. ( TR28 ) 10/25/05 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 934
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283493955 | PUO | 83696554 | | 208654 | 7/14/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/5/1995 Report Status: Signed
Discharge Date: 3/2/1995
PRIMARY DIAGNOSIS: PNEUMONIA , LEFT UPPER LOBE.
OTHER DIAGNOSES: URINARY TRACT INFECTION.
URINARY INCONTINENCE.
HISTORY OF PRESENT ILLNESS: Mr. Kraft is a 70-year-old male
with hypertension , coronary artery
disease , non-insulin-dependent diabetes mellitus , and a
75-pack-year history of tobacco use , who presented on 7/20 at the
Kendsonre Ale Ater Hospital with a four-day history of subjective fever
and nonproductive cough. The patient denied shortness of breath ,
chest pain , orthopnea , or paroxysmal nocturnal dyspnea. He
reported perfuse sweating , usually associated with fever , but
denied history of exposure to tuberculosis or history of
tuberculosis. The patient denied sick contacts and reported having
had an influenza vaccine during this past winter as well as having
a Pneumovax in the past. The patient also reported feeling
fatigued about one week prior to admission and , on the night of
admission , felt his legs collapse under him secondary to weakness.
He denied head trauma. He said he fell on his outstretched arm.
He has no history of seizure disorder and was fully conscious
throughout the event. He called his daughter who brought him to
the Meon Wellfor Pipebocock Medical Center Emergency Room. The patient was seen there and
evaluated , and he was transferred to the Pagham University Of in the early morning hours of 6/15/95 as he is a Pagham patient.
PAST MEDICAL HISTORY: Angina ( none in the past several months ).
Coronary artery disease. Status post
percutaneous transluminal coronary angioplasty in 2/10 at which
time a 99% occlusion of the proximal left anterior descending was
noted , which was 30% after PTCA. Status post PTCA in 1/29 , again
with 99% occlusion of the proximal left anterior descending , which
was 30% after PTCA. Status post PTCA in 2/18 , again with 99%
occlusion of the proximal left anterior descending , which was 30%
after PTCA; there was a small complication in which a focal
dissection of the proximal left anterior descending was noted..
PAST SURGICAL HISTORY: Angioplasty as above.
ADMISSION MEDICATIONS: Sublingual Nitroglycerin as needed Lopressor
50 mg. orally twice a day Cardizem-SR 120 mg.
twice a day Coumadin 2.5 mg. alternating with 3 mg. orally every day.
Lovastatin 20 mg. every day. Glyburide 5 mg. every day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Negative for cardiac disease. His father had lung
cancer.
SOCIAL HISTORY: He is married and lives with wife and daughter.
He has a 75-pack-year history of tobacco use. He
reportedly was smoking until two weeks prior to the onset of
illness. He denies any use of alcohol.
PHYSICAL EXAMINATION: Vital signs at the Kendsonre Ale Ater Hospital
Emergency Room revealed temperature 102 ,
respiratory rate 16 , blood pressure 160/78. At the Pagham University Of Emergency Room , temperature was 100.7 , heart rate
96 , O2 saturations 95% on room air , blood pressure 128/80 ,
respiratory rate 20. This was a well-developed , well-nourished ,
white male who was somnolent but easily arousable. He was very
diaphoretic in the Emergency Room. Neck was supple with full range
of motion and no lymphadenopathy. The JVP was flat. Lungs
revealed anterior bronchial breath sounds in the left upper lung
field. Lungs were clear to auscultation posteriorly.
Cardiovascular exam revealed a regular rate and rhythm with
occasional premature beats. An S1 and S2 were heard. There were
no no murmurs , gallops , or rubs. Abdomen was soft and nontender.
Bowel sounds were present. No masses or hepatosplenomegaly was
noted. On rectal exam , he had heme-negative , brown stool , and he
had a normal tone; this was per the Emergency Room staff.
Extremities revealed no cyanosis , clubbing , or edema. Neurologic
exam revealed cranial nerves III through XII were intact. He was
alert and oriented x three. Motor and sensory exam revealed 5/5
bilaterally. Reflexes were 0 to 1+ bilaterally and symmetrically.
Toes were downgoing. He had normal bulk and tone throughout.
X-RAY: Chest x-ray showed a left upper lobe infiltrate , and this
was per the Kendsonre Ale Ater Hospital . A repeat chest x-ray
here on 5/25/95 again showed extensive left upper lobe pneumonia.
ELECTROCARDIOGRAM: The electrocardiogram revealed a normal sinus
rhythm at 89 with occasional premature
ventricular contractions. He had a Q-wave inversion in lead 3 and
AVF , biphasic V3.
LABORATORY DATA: Fluid balance panel revealed sodium 131 ,
potassium 3.4 , BUN and creatinine 23 and 1.4 ,
chloride and bicarb 98 and 23 , glucose 194. His LDH was elevated
slightly at 259. His other liver function tests were within normal
limits. His total protein was 5.7 , albumin 3.0. His hemoglobin
and hematocrit were 14.4 and 43.3 , respectively. White blood cell
count was 12 , 100 with a differential of 84% polys , 5% bands , 6%
lymphs , and 2% monos. Platelet count was 188 , 000. His urinalysis
was significant for white blood cells and red blood cells that were
too numerous to count. He had 3+ bacteria.
HOSPITAL COURSE:
PROBLEM #1: PNEUMONIA , LEFT UPPER LOBE. The patient received 1 g.
of Cefuroxime at the Kendsonre Ale Ater Hospital and was
transferred to the Pagham University Of where Cefotaxime
1 g. eight hours was begun. The patient continued to spike
temperatures on hospital days #1 and #2 , although blood and urine
cultures remained negative. On hospital day #3 , Erythromycin was
added to his antibiotic regimen as the patient continued to spike
temperatures. The following day , the patient defervesced and
remained afebrile throughout the hospital course. As mentioned
earlier , a repeat chest x-ray here again showed extensive left
upper lobe pneumonia. Clinically , the findings from the physical
exam showed a resolution of the bronchial breath sounds. On the
day of discharge , the patient's lungs were clear to auscultation
bilaterally. The patient had been afebrile for four days and had
been on Erythromycin orally for two days. The intravenous
Cefotaxime was also discontinued two days prior to discharge at
which point the intravenous Erythromycin was changed to orally at
500 mg. four times a day The patient was instructed that he should avoid the
use of tobacco as this would increase his likelihood of
redeveloping pneumonia as well as increase his likelihood of
worsening cardiac disease. A sputum sample was induced , and it was
sent for routine culture and AFB culture and smear. The cultures
were negative , and the AFB smear was negative for mycobacteria.
The cultures were negative on discharge.
PROBLEM #2: URINARY TRACT INFECTION. The patient was treated
with Cefotaxime which was also used for treatment of
his pneumonia. He was noted to have urinary incontinence , and by
report , the incontinence had begun approximately four or five days
prior to admission. It was felt that the incontinence might be
secondary to his ongoing infection. A repeat urinalysis was sent
approximately four days after admission and showed 1 to 2 white
blood cells and 0 bacteria. The patient , at that point , no longer
was having urinary incontinence; however , he was noted to have a
large postvoid residual of 300 cc. It was felt that this might be
related in part to mild benign prostatic hypertrophy. Dr. Cadoff ,
his primary care physician , is aware and will pursue further
work-up as necessary.
PROBLEM #3: ATAXIA. The patient was noted by the family members
to be somewhat ataxic at home. The onset of this
ataxia was in relation to his current illness; however , given the
fact that he was on Coumadin , and due to the fact that he had
sustained a fall in the evening of admission , a CT scan was
performed to rule out a subarachnoid hemorrhage. The CT scan was
negative for hemorrhage and showed age-appropriate atrophy. A
Neurology consult was also requested , and recommendations for the
CT scan , as already discussed , were made. In addition , they
recommended that we check an RPR , B12 , folate , and TSH. The
results are as follows: RPR was nonreactive. The first draw of
B12 was 233 , which is slightly low normal. A repeat B12 was 564 ,
which is within normal limits. His folate was normal at 4.9. His
TSH was slightly low at 0.44. A Physical Therapy consult was also
obtained to assist the patient with exercises to improve his
strength. By discharge , the patient was able to ambulate without
difficulty. He was having no ataxia , whatsoever. We feel , in
part , that some of this ataxia may have been related to generalized
weakness that was associated with his current illness.
PROBLEM #4: DIABETES MELLITUS. On admission , the patient's
glucose was 194. Due to his orally intake , we elected
to hold his Glyburide and to give him insulin subcutaneously on a sliding
scale basis as needed. By hospital day #4 , the patient's orally
intake had improved , and we resumed Glyburide 5 mg. orally every day
with sliding scale as needed We continued Accucheks on a twice a day
basis. His glucose tended to run in the low 200s. His glucose
will need to be followed as an outpatient , and perhaps one might
consider a glucometer for him at home to ensure that he has good
glucose control.
PROBLEM #5: HEMATOLOGIC. The patient was admitted on Coumadin ,
which he takes as follows: 2.5 mg. alternating with
3 mg. On admission , his INR was 1.8. His INR was rechecked on
6/2/95 and was noted to be 4.8. His Coumadin was held for a couple
of days , and his INR was rechecked on the day of discharge; it was
2.4 on the day of discharge. We feel that the elevation in his INR
was probably related to his being on antibiotics. I have mentioned
this to his primary care doctor , Dr. Sroufe He will follow up on
his clinic visit on Monday , 7/22/95.
LABORATORY PENDING ON DISCHARGE: Legionella antigen , obtained on
10/2/95. Repeat stool for
Clostridium difficile toxin on 1/5/95 ; however , the patient's
diarrhea has diminished , and we do not think that this is related
to Clostridium difficile.
DISCHARGE MEDICATIONS: Atenolol 50 mg. orally every day. Cardizem-SR
120 mg. orally twice a day Erythromycin 500 mg.
orally four times a day x eight days. Glyburide 5 mg. orally every day. Lovastatin
20 mg. orally every day. Coumadin 2 mg. orally every day. Nitroglycerin 0.4
mg. tablets sublingual every five minutes x three as needed chest pain;
the patient is to notify the M.D. if the pain fails to resolve
after three tablets or if he should become light-headed while
taking those tablets.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is discharged to home.
FOLLOW-UP: The patient will follow up with Dr. Lindy Cadoff in
clinic on Monday , 7/22/95.
Dictated By: CHIQUITA TARA , M.D.
Attending: LINDY S. CADOFF , M.D. KT06
DI977/3692
Batch: 8551 Index No. HNGNRE1W7X D: 5/10/95
T: 11/14/95
CC: 1. LINDY S. CADOFF , M.D. KT06
Document id: 935
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| output/system_intuitive_annotation.xml | intuitive |
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269173222 | PUO | 28245773 | | 282592 | 4/23/1997 12:00:00 a.m. | RULE OUT MYOCARDIAL INFRACTION | Signed | DIS | Admission Date: 2/8/1997 Report Status: Signed
Discharge Date: 5/9/1997
PRINCIPAL DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old man who
presented with chest pain , nausea , and
vomiting for three hours. His cardiac risk factors include
diabetes mellitus , male gender , and advanced age. He does not
smoke , has no hypertension , and has no family history of coronary
artery disease. The patient has had insulin dependent diabetes
mellitus for 15 years. Over the past few days prior to admission ,
the patient has been feeling poorly and eating less than usual. On
the date of admission , he was eating a sandwich and developed
severe chest tightness with nausea and an urge to vomit. He denied
diaphoresis , shortness of breath , syncope , palpitations , or pain
radiation. The pain lasted for three hours. He came to the
Emergency Department. His initial heart rate was 140 in the
Emergency Department and he received intravenous Lopressor and then was
admitted to 14C ( Short Stay Unit ) pain free.
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus for
15 years , toe amputation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Humulin NPH 12 units every afternoon and insulin
70/30 45 units every day before noon
SOCIAL HISTORY: He does not smoke. He occasionally drinks
alcohol.
FAMILY HISTORY: Negative for coronary artery disease.
PHYSICAL EXAMINATION: Temperature 100 degrees , respiratory rate
16 , heart rate 100 , blood pressure 90/58.
HEENT exam was unremarkable. Lungs were clear to auscultation.
Cardiovascular: Tachycardic; normal S1 and S2; no murmurs.
Abdomen: Positive bowel sounds , soft , nontender , nondistended.
Extremities: No clubbing , cyanosis , or edema. His fourth toe was
amputated.
LABS: White count 6.7 , hematocrit 48.6 , BUN 35 , creatinine 1 ,
liver function tests within normal limits , troponin 0.0 , CPK
660 with an MB of 3.9. EKG showed sinus tachycardia with no
ischemia. Chest x-ray showed no pneumonia or congestive heart
failure.
HOSPITAL COURSE: The patient was admitted to the Medical Short
Stay Unit. He underwent a rule out myocardial
infarction protocol with negative serial CPKs. Exercise test was
done prior to discharge and was negative.
The patient also had evidence of hypovolemia with his hypotension
and tachycardia and poor orally intake for several days. He was
hydrated overnight and felt improved the following day. His
tachycardia and hypotension resolved with hydration.
Also , to evaluate his elevated CPKs , a TSH was checked and is
pending at the time of discharge. Urinalysis also checked in the
Short Stay Unit was negative. After his exercise test , the patient
was discharged to home on his usual medications which include NPH
12 units every afternoon and insulin 70/30 , 45 units every day before noon The patient
will follow up with his primary care physician at Kendsonre Ale Ater Hospital
Dictated By: IRVING M. ESCALANTE , M.D. FB73
Attending: IRVING M. ESCALANTE , M.D. FB73
DQ009/6679
Batch: 1096 Index No. QIMP2Y3X5W D: 6/10/97
T: 6/10/97
CC: 1. DR. WELCH , , KENDSONRE ALE ATER HOSPITAL
Document id: 936
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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045840358 | PUO | 81304558 | | 7284396 | 10/14/2004 12:00:00 a.m. | CHF 2/2 diastolic dysfunction , restrictive pulmonary disease | | DIS | Admission Date: 10/14/2004 Report Status:
Discharge Date: 6/23/2004
****** DISCHARGE ORDERS ******
MALANEY , SHAWNA E. 247-07-03-7
South Dakota
Service: MED
DISCHARGE PATIENT ON: 10/16/04 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COLLICA , CHANELLE XOCHITL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
ELAVIL ( AMITRIPTYLINE HCL ) 25 MG orally every bedtime
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 100 MG orally every day Starting Today ( 2/14 )
BUSPAR ( BUSPIRONE HCL ) 15 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally every day
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals
Starting Today ( 2/14 )
Instructions: Or as directed by your primary providers
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LISINOPRIL 5 MG orally every day
Alert overridden: Override added on 11/8/04 by
LENEAVE , JETTA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
DARVON-N ( PROPOXYPHENE NAPSYLATE ) 100 MG orally every 8 hours as needed Pain
TRAZODONE 50 MG orally HS Starting Today ( 2/14 )
as needed Insomnia
GLARGINE ( INSULIN GLARGINE ) 70 UNITS subcutaneously every bedtime
PROTONIX ( PANTOPRAZOLE ) 40 MG orally twice a day
FOSAMAX ( ALENDRONATE ) 70 MG orally QWEEK
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
ZOLOFT ( SERTRALINE ) 125 MG orally every day Starting Today ( 2/14 )
LASIX ( FUROSEMIDE ) 40 MG orally every day
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
Starting Today ( 2/14 )
Instructions: Please note that the dose is TEN ( 10 ) MG every day ,
not 80 MG as written above per computer default
AMBIEN ( ZOLPIDEM TARTRATE ) 5 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day as needed Shortness of Breath
PREDNISONE 5 MG orally every day before noon
Instructions: AS DIRECTED BY YOUR RHEUMATOLOGIST
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Tressa Schlesener , Pulmonary Clinic , 947-164-2074 4/5 , 2:40pm ,
Dr. Ma Yeagley , primary care physician 11/10 , 1:45pm ,
Dr. Augustine Milholland , Psychiatry , 352-768-3562 1/11/04 scheduled ,
Annabel Verfaille , Heart Failure Clinic At Pagham University Of ( located at Lakli Lane , Na , Mississippi 69364 , Mac Hospital ) 10/19/04 ,
ALLERGY: Codeine , PERCOCET
ADMIT DIAGNOSIS:
CHF 2/2 diastolic dysfunction , restrictive pulmonary disease
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF 2/2 diastolic dysfunction , restrictive pulmonary disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of pneumonia; arthritis; DM Type II; asthma; obesity; depression;
ra ( rheumatoid arthritis ); fibromyalgia ( fibromyalgia ); pud ( peptic
ulcer disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
62 F admitted with 1 month history of increasing dyspnea & chest/neck pressure.
PMH notable for 1 ) CAD history of RCA PTCA/stent 3/17 with repeat cath 9/27
patent without significant obstructive CAF; 2 ) DM on insulin; 3 ) HTN; 4 )
presumed diastolic dysfunction with 2/19 TTE showing LVEF=65-70%
with mild cLVH; 5 ) RA , recently started on low-dose prednisone 5 every day;
6 ) history of asthma per patient; 7 ) depression; 8 ) fibromyalgia; 9 ) gout; 10 )
gastritis/DU; 11 ) history of ventral hernia repair. Now , patient described
subacute chest/neck diffuse discomfort and episodic SOB possibly worse
with exertion though not clearly related to activity , breathing , meals ,
position , nitro and without further associated sxs. Notes medication
non-adherence at times due to depression and not re-filling meds;
includes no lasix x3+ weeks. Seen by primary care physician with SaO2 noted to be 91% on RA
( on home O2 prior but not currently for e/o PNA ) -> admitted.
Overall , evaluated for dyspnea with neck/chest discomfort & hyoxemia of
unclear etiology. Performed ABG to confirm hypoxemia: on 3L NC
7.45/45/79 ( Aa gradient elevated at approximately 158 ).
- Suspected DIASTOLIC DYSFUNCTION in context of ischemic heart dz/HTN
with exacerbation due to med compliance including no recent lasix. This
supported by a ) mild improvement with diuresis with lasix 40 intravenous every day
with resting & ambulatory SaO2s > 93% on 2L and resting SaO2 >90% ( though
decreased to 87% with ambulation ) at time of discharge; b ) underlying
CAD/HTN; c ) repeat TTE with low E/A suggestive of diastolic dyfxn; d )
crackles though no elevated JVD. However admission BNP=102 & still
some hypoxemia at DC & unclear crackles despite diuresis suggesting
additional process:
- PFTs suggest RVD ( ? obesity/CHF v other ); A-mibi without e/o active
ischemia; CXR/CT not suggestive of interstitial
abnormality/thromboembolic dz/PNA; episode of panic with more dypnea
possibly further explaining SOB though not hypoxemia. Outpt
consideration of full PFTS , OSA screen , screen for shunt ( not pursued
given correction with supplemental O2 )
- patient to follow with a ) pulm to see if possible ILD/other despite nl
CT given RVD/hypoxia/RA & consider full PFTs including lung volumes &
consider contribution of possible OSA/hypoventilation; b ) CHF clinic
( discharge weight = 186.4 though no relaible weights established ); c )
primary care physician; d ) psychiatry to enhance mood and med adherence. Established with
home O2 transiently at 2L given borderline hypoxemia with ambulation on
RA and much improved sxs.
ADDITIONAL COMMENTS: Please note that we have intended to make NO changes in your
medications , in case you note any discrepanices , with the following
exception: we increased lisiniopril to 5 mg once a day. It is critical
that you take your medications , including the lasix - seek help from
your pharmacists/primary providers if needed as arrangements including
pill packs may be arranged. It is also critical that you see your
outpatient providers as outlined for continued evaluation though seek
medical attention immediately if you develop anything of concern.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
Consider full PFTS , screen for sleep apnea , adjustment of diuresis
regimen , and TTE with bubble if no improvement ,
No dictated summary
ENTERED BY: CHMURA , AL M. ( NW72 ) 10/16/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 937
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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510330616 | PUO | 27396055 | | 9824910 | 4/25/2005 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 4/25/2005 Report Status:
Discharge Date: 4/25/2005
****** FINAL DISCHARGE ORDERS ******
FALETTI , JULIANNA W 977-67-32-9
Ani Dr
Service: CAR
DISCHARGE PATIENT ON: 9/28/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ABSHEAR , CARLTON JAUNITA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
Override Notice: Override added on 9/28/05 by
MOOSE , BUCK , M.D.
on order for COUMADIN orally ( ref # 86170101 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
CODEINE PHOSPHATE 30 MG orally every 4 hours as needed Pain
MAXZIDE ( TRIAMTERENE 75MG/HYDROCHLOROTHIAZID... )
1 TAB orally every day HOLD IF: SBP <100
Alert overridden: Override added on 9/28/05 by
MOOSE , BUCK , M.D.
on order for MAXZIDE orally ( ref # 62988975 )
patient has a POSSIBLE allergy to Sulfa; reaction is ALOPECIA.
Reason for override: mda Previous Alert overridden
Override added on 9/28/05 by MOOSE , BUCK , M.D.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & TRIAMTERENE
Reason for override: mda
NAPROSYN ( NAPROXEN ) 500 MG orally three times a day as needed Pain
Food/Drug Interaction Instruction Take with food
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 9/28/05 by
MOOSE , BUCK , M.D.
on order for CIPROFLOXACIN orally ( ref # 05632177 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & CIPROFLOXACIN
HCL Reason for override: mda Previous override information:
Override added on 9/28/05 by MOOSE , BUCK , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: mda
FLONASE ( FLUTICASONE NASAL SPRAY ) 1-2 SPRAY nasal every day
as needed Other:nasal congestion
Number of Doses Required ( approximate ): 4
DIOVAN ( VALSARTAN ) 80 MG orally every day HOLD IF: SBP <100
Number of Doses Required ( approximate ): 5
ATENOLOL 25 MG orally twice a day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: House / 2 gm Na / Carbohydrate Controlled / Low saturated fat
low cholesterol (FDI)
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Nuclear Medicine 7/9/05 @8am ,
Dr. Floria Larreta ( covering for Dr. Ellzey ) 2/19/05 @1pm ,
Arrange INR to be drawn on 2/19/05 with f/u INR's to be drawn every
14 days. INR's will be followed by Merissa Tudruj
ALLERGY: Penicillins , Sulfa
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) obesity ( obesity ) history of sarcoid ( history of
sarcoid ) arthritis ( polyarticular arthritis ) diverticulosis
( diverticulosis ) ventral hernia depression
( depression ) unstable angina ( angina )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain
******************************
HPI: 49 year-old woman cx history of recurrent chest pain concerning for unstable
angina but c clean catheterization 2/17 p/with SSCP. She was involved in a
slow velocity MVA ( restrained passenger , hit from behind , no physical
damage done to her , did not hit head ) when she developed SSCP that did
not radiate , but with some diaphoresis. She was seen by EMS on site and
given 4 NTG's , ASA. Her pain resolved after .5 hour. In PUO ED: 138/50 ,
84 , 100%2L; admitted for ROMI , started on Heparin for history of PE's on
Coumadin but with an sub-therapeutic INR now.
********************************
PMH: HTN , morbid obesity , DVT c PE , polyarthritis , Sarcoidosis ,
Diverticulitis , CVA ( right cerebellar ) , colonic polyps , asthma , GERD ,
Ventral Hernia , CCY
MEDS: Naprosyn 500 MG three times a day , ASA 81 MG orally every day , Slow-k 8 MEQ orally every day , Flonase
1-2 SPRAY AER , Coumadin 5 MG orally every day , Maxzide 1 TAB orally every day , Atenolol 25 MG
orally twice a day , Protonix 40 MG orally every day , Diovan 80 MG orally twice a day , Codeine SO4 30 MG orally
twice a day as needed pain
ALLERGIES: Penicillin , Sulfa
*****************************
ADMIT PHYSICAL EXAM:
VS: T 97.6 P: 63 BP: 112/70 RR: 12 O2 Sat: 98%RA
Gen: obese , pleaseant , resting in bed
HEENT: anicteric , MMDry
Neck: JVD 8 cm H2O , no bruits , supple , FROM
CV: distant S1 , S2; no S3/4 , no MRG
Resp: CTAB
Abd: tender over ventral hernia; soft; ND
Ext: no CCE , W/WP
Neuro: grossly non-focal
*********************************
HOSPITAL COURSE:
1 ) CV: Ischemia: Given the patient's cardiac history , she was admitted
for a ROMI. She was continued on her home regimen of BB , ARB , ASA , and
placed on Heparin given her hx/o PE and a subRx INR. O2 NC weaned on
HD#1. She will have a pharmacologic stress test c MIBI imaging as an
outpatient on 7/9/05 to risk stratify and determine if there are any
perfusion abnormalities. Pump: Patient was dry on initial physical exam ,
no signs or sxms of heart failure; was bolused with NS x 1 and continued
on her home antihypertensives with good BP control. Rate: NSR on tele
2 ) Pulm: no hypoxia , low suspicion PE , con't on Heparin with history of PE and
low INR now ( ptt goal 60-80; INR goal 2-3 )
3 ) GI: Given history of polyps , all stools were guaiac neg while on Heparin; history of
GERD , con't PPI.
4 ) Renal: On admission she had new inc. in Cr , follow; check FeNa now but
likely only pre-renal azotemia; bolus now and recheck in a.m.. Cr improved
on a.m. labs.
5 ) FEN: K/Mg scales; was kept NPO until ROMI complete
6 ) PPx: PPI , Heparin intravenous; Flu/Pneunovax
7 ) Full Code
ADDITIONAL COMMENTS: Please continue to take your home medicines as you were before coming to
the hospital. You will have a pharmacologic stress test done on 7/9/05
@ 8am. Please do not eat anything after midnite that morning , also do not
have coffee , decaf or chocolate or anything with caffeine for 24 hours
before 10/27/05. Please bring your PUO card to the nuclear medicine suite
and plan to be there for 4hours. You also have a follow-up appointment
to discuss the results of this test on 6/19 with Dr. Larreta in KTDUOO .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please see instructions
No dictated summary
ENTERED BY: GOBRECHT , ALVERTA O. , M.D. ( UY82 ) 9/28/05 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 938
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
497634108 | PUO | 23712709 | | 254408 | 11/6/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/25/1992 Report Status: Signed
Discharge Date: 7/16/1992
DISCHARGE DIAGNOSIS: RECENT CONGESTIVE HEART FAILURE , HYPOKALEMIA ,
AND HYPERTENSION.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old black
female with a history of diabetes and
hypertension who felt well until October 1992 when she developed an
episode of the flu. Since that time , she has noted persistent
nocturia. Four to five days prior to admission , the patient noted
an increase of shortness of breath requiring her to sleep upright
and increasing peripheral edema. Two days prior to admission the
patient started on Lasix 400 mg twice a day with a dramatic decrease in
her shortness of breath and orthopnea. She was able to sleep in
bed the night of admission. She denies chest pain during any of
these episodes. Blood pressure was in the range of 180/90 without
headache , cognitive changes , or hematuria. Patient was admitted to
Pagham University Of for hypertension and congestive heart
failure evaluation. She states she does follow a low salt diet and
makes her own soups without salt. She does not eat cold cuts , etc.
She denies elicit drug use , birth control use , or heavy alcohol
use. PAST MEDICAL HISTORY: Notable for diabetes mellitus for
fourteen years on an orally hyperglycemic agent and hypertension for
the last three years. PAST SURGICAL HISTORY: Notable for an
appendectomy at age 16 and a hysterectomy at age 47. She has no
children. ALLERGIES: Aspirin which causes gastrointestinal upset.
CURRENT MEDICATIONS: Inderal 40 mg orally three times a day , Lasix 40 mg orally
three times a day times two days , K-Dur 10 mEq every day , Tolazamide 250 mg
orally twice a day , and Hygroton which was stopped one week prior to
admission. SOCIAL HISTORY: Notable for a half a pack of
cigarettes for ten years stopped one month ago and rare alcohol
use. FAMILY HISTORY: Notable for her father with diabetes who
died of a massive heart attack at age 48. Her mother had a brain
tumor and died at age 43. She has three brothers who have a
history of obesity , one brother died during cardiac surgery , and
she has two sisters with gallbladder and kidney disease.
PHYSICAL EXAMINATION: On admission , the patient presented as a
pleasant black female in no apparent
distress. Her blood pressure was 160/96 and she was not
orthostatic. Her pulse was 92 , her respiratory rate was 14 , and
she was afebrile. LUNGS: Examination was clear without wheezes or
rales. CARDIAC: Examination revealed a regular rate and rhythm
with no murmurs. ABDOMEN: Examination was unremarkable.
EXTREMITIES: Revealed 2+ edema to the mid calves and 2+ pulses
palpable. RECTAL: Examination was hemoccult negative.
NEUROLOGICAL: Examination was non-focal.
LABORATORY EXAMINATION: On admission , the patient's potassium was
2.7 , chloride 92 , CO2 33 , and her
magnesium was 1.6. Her white count was 10 , hematocrit 36.4 , and
platelet count was 313. The patient's liver function tests were
within normal limits and her chest X-Ray showed no active disease.
EKG revealed normal sinus rhythm at 96 beats per minute , left
ventricular hypertrophy with strained pattern , and a Q wave in III
as well as flipped T waves in V3 through V6. This was no change
from an EKG in October 1992. The left ventricular hypertrophy was
new since an EKG in February 1987.
HOSPITAL COURSE: The patient had an Endocrine consultation to work
her up for aldosteronemia. The patient had a
24-hour urine which showed no evidence of potassium wasting
bringing some doubt on the hyperaldosterone diagnosis. The
patient's diabetes was well controlled on the basis of fingerstix.
The patient's hypertension was controlled by manipulating her
medications. Thyroid work-up revealed a TCH of 2.9 which was
within normal limits. Her electrolytes were managed with potassium
and magnesium replacement as needed. Her cardiac status was
evaluated as the patient occasionally complained of fluttering
feelings which did not correlate with EKG changes or congestive
heart failure. The patient had an exercise thallium test prior to
discharge which was stopped secondary to fatigue and shortness of
breath. There was no chest pain or EKG changes. The plan was for
the patient to have the patient have a Holter as an out-patient.
She is also to have pulmonary function tests as an out-patient.
The Endocrine Service will follow-up on the possible diagnosis of
hyperaldosteronemia. The patient was considered to be stable for
discharge on May , 1992.
DISPOSITION: DISCHARGE MEDICATIONS: Potassium 40 mEq every day ,
Lopressor 100 mg three times a day , Glyburide 10 mg every day ,
Diltiazem SR 120 mg orally every day , and sublingual Nitrogen 0.3 two to
five minutes apart for smothering feeling. The patient is also
told to maintain a low salt diet. The patient is to follow-up with
Dr. Etta Six in one week. She is also to follow-up with the
Endocrine Service , Dr. Buckman , in two weeks on May .
WW695/9818
ETTA E. SIX , M.D. CR6 D: 4/17/92
Batch: 1461 Report: S0166K85 T: 8/2/92
Dictated By: MARGURITE R. GUILBE , M.D.
Document id: 939
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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741475666 | PUO | 07937307 | | 8923663 | 3/10/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 8/29/2005 Report Status: Signed
Discharge Date: 2/15/2005
ATTENDING: LONGAKER , NATISHA A. MD , PHD
ADDENDUM
Please note this is an addendum to the previously dictated
discharge summary #6296713.
INTERIM HISTORY: In the interim , since the previously dictated
discharge summary , the patient has continued to progress from a
cardiac standpoint.
HOSPITAL COURSE: His hospital course by system from 10/25/05
through the date of discharge is as follows:
1. Ischemia: The patient had continued to remain stable from an
ischemia standpoint. He continues on aspirin and statin. A
beta-blocker has been added back to his regimen and was titrated
to a dose of Lopressor 12.5 mg orally three times a day The patient has not
been started on an ACE inhibitor secondary to his elevated
creatinine at this time. He has had no further episodes of chest
pain.
2. Pump: The patient's congestive heart failure regimen was
titrated. The patient continues on Isordil 20 mg orally three times a day and
hydralazine 50 mg orally three times a day for after load reduction. He was
restarted on a low-dose beta-blocker at 12.5 mg orally three times a day as
well as digoxin at 0.125 mg orally every other day The patient was
aggressively diuresed with intravenous Lasix and Zaroxolyn
followed by conversion to orally diuresis with torsemide at the
time of discharge. The patient will be followed by Dr. Annabel Verfaille in the Doau Hampcacleve as well as by the
CHF Service at Pagham University Of . At the time of
discharge , the patient was felt to be nearing euvolemia with
estimated dry weight of approximately 76 to 77 kg.
3. Rhythm: The patient continued to have atrial flutter with a
block. His heart rate remained in the rate of 100 to 110 at the
time of discharge. He had decreased episodes of more rapid
dysrhythmia following addition of beta-blocker and digoxin to his
medication regimen. He also continues on amiodarone at 200 mg
orally every day As mentioned , the patient was found to have atrial
clot on transesophageal echocardiogram and thus was started on a
heparin drip and transitioned on Coumadin. However , after a
substantial discussion with the Congestive Heart Failure Service
and the patient's outpatient CHF Care Team , it was felt that the
risks of Coumadin in this patient who has a history of
significant noncompliance were greater than the known risk of
thromboembolic disease in the setting of his known atrial clot
and thus the patient was not continued on Coumadin
anticoagulation. Rather , he was given aspirin and Plavix at full
doses. The use of Coumadin in this patient could be re-evaluated
as an outpatient based on the patient's follow-up as deemed
appropriate by his outpatient providers.
4. Endocrine: The patient remained on stable diabetes mellitus
regimen of Lantus 5 units every afternoon and standing NovoLog 3 units
before every meal as well as the NovoLog sliding scale. The patient's
insulin regimen can be adjusted as an outpatient and possibly
orally diabetes medications restarted.
5. Pulmonary: The patient remained stable from the pulmonary
with good oxygen saturations on room air at rest and with
ambulation.
6. Renal: The patient's creatinine on the day prior to
discharge was 1.6 improved from the peak of greater than 2.
Renal toxic medications were avoided. The patient had not been
restarted on ACE inhibitor , which could be done as an outpatient
as his renal function stabilizes. His electrolytes were
monitored and repleted aggressively.
7. Hematology: As mentioned , the decision was made not to
anticoagulate the patient with outpatient Coumadin. He was
started on aspirin and Plavix. Of note , the patient also had
decreased platelets in the setting of heparin anticoagulation and
thus anti-P4 antibody was sent. This test is pending at the time
of the dictation , but should be followed up by the patient's
outpatient providers as it may input further treatment. In the
meantime , recommend no heparin products. As mentioned , the
decision was made by the CHF Team who will be following the
patient as an outpatient not to continue Coumadin
anticoagulation.
8. Neuro: Of note , on the evening of 5/2/05 , the patient
complained of left-sided blurry vision , which was new for the
patient. He does have chronic right visual changes. In light of
the patient's known peripheral atherosclerotic disease and atrial
clot , the patient was seen by the Stroke Team for a question of
acute stroke. He had MRI at that time , which did show multiple
old infarcts in the right frontal , right occipital , left
occipitoparietal , left posterior frontal areas. There was ,
however , no new stroke seen on the MRI. The left internal
carotid artery was not evaluated , not visualized on the MRI and
there was concern for left carotid artery occlusion versus
stenosis. The patient declined any procedure such as carotid
endarterectomy or carotid stenting for his possible carotid
stenosis and due to this denial no workup with the CTA was done.
It was felt that because the patient would decline any
intervention the risk of contrast in the setting of his acute
renal insufficiency would outweigh the benefits of the study.
The patient declined any intervention for his carotid arteries on
several occasions. A carotid noninvasives were ordered and are
pending at the time of this dictation to evaluate the severity of
disease.
9. Social: The patient's sister , Genoveva Grieser , is his health care
proxy. The patient in her presence has declined coronary artery
bypass grafting and heart transplant evaluation. The patient has
also declined further procedure for his probable carotid artery
stenosis.
10. Disposition: The patient will be discharged to the Sa Pehall for further rehabilitation. He will follow up with Dr.
Annabel Verfaille in the Ter E Lo on 8/23/05 at 08:30 a.m. as well
as with Dr. Raina Melvin of Pagham University Of
Cardiology 10/25/05. He also has a follow-up appointment with
KTDUOO primary care physician , Rufus Bernas , on 8/26/05 at 01:50 p.m. The patient
requires substantial social support at this time , which is being
provided by his sister.
MEDICATIONS AT THE TIME OF DISCHARGE:
1. Aspirin 325 mg orally every day
2. Amiodarone 200 mg orally every day
3. Digoxin 0.125 mg orally every other day
4. Colace 100 mg orally twice a day
5. Folate 1 mg orally every day
6. Robitussin A-C 5 mL orally every 4 hours as needed cough.
7. Hydralazine 50 mg orally three times a day
8. Isordil 20 mg orally three times a day
9. Lopressor 12.5 mg orally every 6 hours
10. Simethicone 80 mg orally four times a day as needed upset stomach.
11. Multivitamin one tab orally every day
12. Compazine 5-10 mg orally every 6 hours as needed nausea.
13. Tessalon 100 mg orally three times a day as needed cough.
14. Torsemide 100 mg orally every day
15. Lipitor 80 mg orally every day
16. Plavix 75 mg orally every day
17. Lantus 5 units subcutaneously every afternoon
18. NovoLog 3 units subcutaneously before meals Instructions , give only if food
in room and the patient eating , hold if npo
19. NovoLog sliding scale , please do not give any sliding scale
coverage at bedtime but do record fingerstick blood glucose at bedtime ,
hold if npo
eScription document: 7-3369525 CS
Dictated By: GERZ , JEANNA
Attending: LONGAKER , NATISHA A.
Dictation ID 7280623
D: 5/14/05
T: 5/14/05
Document id: 940
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056735431 | PUO | 67670624 | | 412699 | 10/30/2002 12:00:00 a.m. | POSITIVE EXERCISE TOLERANCE TEST , CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 11/4/2002 Report Status: Signed
Discharge Date: 2/2/2002
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: 61-year-old male status post coronary
stent with severe three-vessel
coronary artery disease. Patient began having substernal chest
pain and shortness of breath on exertion six months ago. At that
time , he underwent cardiac catheterization that revealed 90% RCA ,
60% LAD , and 40% diagonal 1. Stenting and PTCA were performed to
the right coronary artery , with resolution of symptoms; however ,
three months after the stent , they gradually returned. He
currently complains of dyspnea on exertion and shortness of breath
with two flights of stairs occurring about three times a week.
Cardiac catheterization revealed three-vessel coronary artery
disease. Angioplasty was attempted to the restenosis and stent of
RCA without success.
PAST MEDICAL HISTORY: Hypertension , insulin dependent diabetes
mellitus , hypercholesterolemia , Lyme disease
with arthritis and arrhythmia , and BPH.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: History of tobacco use , history of alcohol use.
ALLERGIES: No known drug allergies.
MEDICATIONS: Atenolol 50 mg orally every day , aspirin 325 mg orally every day ,
Hytrin 10 mg orally every day , Protonix 40 mg orally every day ,
Novolin 40 U every day before noon 60 U every afternoon , Wellbutrin 200 mg orally every day ,
metformin 500 mg orally every day , vitamins E , C , glucosamine chondroitin.
PHYSICAL EXAMINATION: Afebrile , heart rate 55 , blood pressure
160/74. HEENT: PERRLA , oropharynx benign.
NECK: Without carotid bruits. CHEST: Without incision.
CARDIOVASCULAR: Regular rate and rhythm , no murmurs. RESPIRATORY:
Breath sounds clear bilaterally. ABDOMEN: Without incisions ,
soft , no masses. EXTREMITIES: Allen's test in the left upper
extremity normal using pulse oximeter , 2+ pedal pulses bilaterally ,
no scarring , varicosities , or edema in lower extremities. NEURO:
Alert and oriented , no focal deficits.
LAB VALUES: Within normal limits , except for a creatinine of 1.3
and a hematocrit of 38. CARDIAC CATH DATA: 70%
proximal LAD , 60% proximal D-1 , 90% mid circumflex , 100% mid RCA ,
right dominant circulation. EKG: Normal sinus rhythm at 60.
CHEST X-RAY: Large heart shadow , otherwise normal.
HOSPITAL COURSE: Patient underwent echocardiography on 11/15/2002 ,
which revealed an ejection fraction of 55% , some
regional wall motion abnormalities in basal anterior septum and
basal posterior appearing slightly hypokinetic. Aortic valve is
slightly thickened , mitral valve with trace MR , tricuspid valve
with mild TR. Other findings: Enlarged left atrium. Patient was
taken to the operating room on 10/24/2002 and underwent CABG x 4 ,
with LIMA to LAD , SVG to D-1 , left radial to OM-2 , and SVG-2 to
PDA. He was taken to the Intensive Care Unit following surgery in
stable condition on 2 mcg of epinephrine and 5 of Levophed.
Amlodipine was started as an antispasmodic for his radial artery.
Diabetes Management Service and cardiology followed him in the
postoperative period. Following chest tube removal , he was found
to have small bilateral pneumothoraces which are stable by chest
x-ray. At time of discharge , the patient has been told he should
have a repeat chest x-ray in one week when he sees his
cardiologist.
He is discharged to home in good condition on postoperative day 5
on the following medications: Enteric coated aspirin 325 mg orally
every day , Colace 100 mg orally three times a day as needed constipation , NPH insulin 30
U every afternoon 50 U every day before noon subcutaneously , Lopressor 25 mg orally three times a day ,
Niferex-150 150 mg orally twice a day , Percocet 1-2 tabs orally every 6-8 h.
as needed pain , simvastatin 20 mg orally every bedtime , amlodipine 2.5 mg orally
every day , Wellbutrin SR 100 mg orally twice a day , Protonix 40 mg orally every day
Patient is to have a follow-up appointment with his cardiologist in
7-10 days and with Dr. Colasamte in 4-6 weeks.
Dictated By: BATHRICK , SHERELL K.
Attending: ISABELLE E. COLASAMTE , M.D. CL7
LN811/106895
Batch: 46765 Index No. XHFUT5819G D: 1/24/02
T: 1/24/02
Document id: 941
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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517077919 | PUO | 45227626 | | 9034384 | 10/12/2005 12:00:00 a.m. | CHF , pneumonia | | DIS | Admission Date: 10/11/2005 Report Status:
Discharge Date: 4/30/2005
****** FINAL DISCHARGE ORDERS ******
KISHIMOTO , BRIANA 104-13-35-2
Ca
Service: MED
DISCHARGE PATIENT ON: 1/13/05 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Assisted Living
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
Override Notice: Override added on 10/21/05 by
OSMERS , TESSA M.
on order for COUMADIN orally ( ref # 02821923 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 1/1/05 by SCINTO , GARNETT MITTIE , M.D.
on order for COUMADIN orally ( ref # 67196694 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
DIGOXIN 0.125 MG orally every day
Override Notice: Override added on 1/1/05 by SCINTO , GARNETT MITTIE , M.D.
on order for LEVOTHYROXINE SODIUM orally ( ref # 35513133 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
MOTRIN ( IBUPROFEN ) 600 MG orally every 8 hours Starting Today ( 2/14 )
as needed Pain Food/Drug Interaction Instruction Take with food
LEVOTHYROXINE SODIUM 75 MCG orally every day
Override Notice: Override added on 10/21/05 by
OSMERS , TESSA M.
on order for COUMADIN orally ( ref # 02821923 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: aware Previous override information:
Override added on 1/1/05 by SCINTO , GARNETT MITTIE , M.D.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware
REGLAN ( METOCLOPRAMIDE HCL ) 5 MG orally before meals
SIMETHICONE 80 MG orally four times a day
VITAMIN B1 ( THIAMINE HCL ) 100 MG orally every day
TRAZODONE 50 MG orally HS
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/21/05 by
OSMERS , TESSA M.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: aware
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 1/1/05 by
SCINTO , GARNETT MITTIE , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
75 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
GABAPENTIN 200 MG orally every day
TORSEMIDE 100 MG orally twice a day
COZAAR ( LOSARTAN ) 50 MG orally every day
Number of Doses Required ( approximate ): 10
LEVOCARNITINE 1 GM orally every day Starting Today ( 4/24 )
Instructions: on 15 ml at home
Number of Doses Required ( approximate ): 10
CITALOPRAM 20 MG orally every day
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 1/1/05 by SCINTO , GARNETT MITTIE , M.D.
on order for LEVOFLOXACIN orally ( ref # 2 of February )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: aware
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LANTUS ( INSULIN GLARGINE ) 60 UNITS subcutaneously every bedtime
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LIPITOR ( ATORVASTATIN ) 10 MG orally every afternoon
Alert overridden: Override added on 10/21/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: aware
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Follow up with you Primary Care Provider within the next two weeks ,
Arrange INR to be drawn on 6/25/05 with f/u INR's to be drawn every
2 days. INR's will be followed by Dr. Caravati LMC
ALLERGY: SHRIMP
ADMIT DIAGNOSIS:
CHF , pneumonia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF , pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Adriamycin induced CMP HTN IDDM Sarcoid
Left Breast CA- history of lumpect and XRT/Adria-'84 hypercholesterolemia
? GI origin of epigastric pain dvt ( deep venous thrombosis )
osteoarthritis ( unspecified or generalized OA ) hypothyroid
( hypothyroidism ) cad ( )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Midline placed on 4/30 for blood draws but did not work. Midline taken
out before discharge.
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
HPI: 61 year-old F with multiple medical problems , including dilated CMP ,
history of chemo and XRT for Breast CA , CAD , history of MI , COPD , on occasional O2 ,
presents with dry cough associated with some SOB x 2 days
and increased DOE as well. At baseline patient is able to walk 1 block
( with walker ) before DOE , now DOE after 1/2 block. patient denies CP. patient
reports orthopnea and PND. patient has chronic abd pain at baseline that
has been evaluated in the past with Abd CT , U/S showing sludge. patient
has a Hx of increased Alk Phos. She reports no change in abd pain at
this time , except increased bloating. No increased leg edema ,
but reports increased in size of L arm. patient also reports wheezing
without increased O2 need at night. No sick contacts , no diarrhea , no
constipation.
****
PE on admission: VS: T97.8 HR73 BP113/71 RR18 O2Sat 92%
Gen: NAD
HEENT: oropharynx clear , no JVD
CV: distant heart sounds , 1/6 SEM
Pulm:ant. endexp wheezes , no crackles
Abd: mild tenderness in epigastrium , RUQ , distended
Ext:Venous stasis , 1+ edema , L arm larger than R arm
*****
Tests: ALK Phos: 627
ALT: 71
AST: 65
Card Enzymes: neg
WBC: 6.4
UA: 1.011 , 1+prot , 5-10WBC , 2+bact
CXR: LLL opacity , seen best on lateral view
EKG: prolonged PR , every in AVL , flat Ts laterally , unchanged from 5/26
RUQ US: sludge , gall bladder wall thickened 8mm , neg sonographic
Murphy's sign , B/L small pleural effusions
1/9 Echo: EF 25% , LV mild to mod dilated at 4.2cm , some RWMA ,
mod-severe MR
4/20 Abd U/S: sludge in gallbladder
1/9 Abd CT: Ascites
1/9 PE protocol CT: mild edema , bilat. effusions , anasarca
**********************************************************************
HOSPITAL COURSE:
61F with LLL PNA and CHF
1. ) ID: patient placed on orally levofloxacin for LLL pneumonia. She received a 7
days course and symptoms resolved. Stable vitals and O2 sats.
2. ) Pulm: HX of CHF. patient's weight 227lbs 2/30/05 ( dry weight ~ 200 ). patient
on torsemide 100mg twice a day at baseline. patient given orally lasix ( in place of
torsemide on admit ) and was increased to 200bid x 2 doses. Then , patient
placed back on torsemide and zaroxyln 5mg orally twice a day x 6 doses was added.
Lytes closely monitored , however , patient was difficult to draw
blood from secondary to poor access. Followed daily weights. On D/C , patient's
breathing was improved and she was ambulating with walker @ her baseline..
Lungs were clear and patient still had BLE edema on d/c.
3. ) GI: Hx of gallbladder sludge , with chronic RUQ pain , with u with CT and
US in the past , but patient not surgical candidate. RUQ US showed just sludge ,
gallbladder wall thickened 8mm , neg sonographic murphy's sign.
4. ) Rheum- 2/3 patient c/o right thumb pain- thumb was
red , warm , and painful to touch at joint. patient has history of gout-
was started on motrin three times a day.
6. ) Endo- BS were high during hospitalization and insulin was adjusted
appropriately. Lantus increased to 60mg every bedtime and novolog 8u before every meal and
sliding scale. patient will be d/c'd home on lantus 60u every bedtime with novolog
sliding scale.
7. ) Heme- patient was restarted on coumadin 5mg orally every day for DVT on
10/3 Follow up INR to be drawn on 2/17 INR on 2/3 was 1.2.
FULL CODE.
ADDITIONAL COMMENTS: 1. ) Primary care follow up to check lytes on torsemide.
2. ) INR checks to be arranged by LMC and coumadin dosing to be called
into Orldence So Ing S Cord Buffa pharmacy.
3. ) Monitor weight 2x/week
4. ) VNA arranged
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. INR to be checked on 8/7 ( goal 2-3 ). patient sent home on coumadin 5mg orally
every bedtime. INR results interepreted by LMC and coumadin dose should be calle
into Cessro Dr. pharmacy 021-481-6945.
2. Continue diuresis with torsemide 100mg twice a day and monitor
weights 2x/week. Keep legs elevated while in bed to help reduce swelling.
3. Please make follow up appointment with Dr. Birch within the
next two weeks. You will need follow up blood work.
4. Take motrin 600mg as needed for your thumb pain. Once pain resolves ,
resume taking your allopurinol 100mg daily for gout prophylaxis.
5. Your lantus insulin dose was increased to 60units at night. Please
continue your sliding scale as usual.
6. You no longer need procrit , as your blood levels were within normal
range. Follow up with your primary care physician for bloodwork monitoring.
7. Contact your primary care provider or come to the emergency room if
you experience difficulty breathing , chest pain , or fever.
No dictated summary
ENTERED BY: OSMERS , TESSA M. ( YZ90 ) 1/13/05 @ 01:29 PM
****** END OF DISCHARGE ORDERS ******
Document id: 942
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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995906475 | PUO | 07554150 | | 852797 | 4/26/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/11/1995 Report Status: Signed
Discharge Date: 12/10/1995
PRINCIPAL DIAGNOSIS: RECURRENT LEFT LOWER EXTREMITY DEEP
VENOUS THROMBOSES ( DVT'S )
SIGNIFICANT PROBLEMS: 1 ) OBSTRUCTIVE SLEEP APNEA
2 ) RESTRICTIVE LUNG DISEASE
3 ) HYPERTENSION
HISTORY OF PRESENT ILLNESS: This is a 50 year old Black female with
a significant past medical history for
multiple DVT's , who came in here complaining of increased left
lower extremity swelling and pain. The patient has a long history
of left lower extremity DVT's. She had her first DVT approximately
ten years ago. She has had approximately one to two DVTs per year
thereafter. According to her report , the DVTs have always been in
the left lower extremity. Also , her record shows that she has only
had DVTs in her left lower extremity. The longest duration of symptoms from a
DVT was approximately for one to two years. She has had
multiple other episodes of left lower extremity swelling and pain. The
patient states that she would not always go to the hospital for
treatment , but instead would self treat herself by raising her leg
when immobile. Nonetheless , she has had approximately four DVTs in
the past year. Her last two admissions for DVTs were as follows:
From 3/6 to 5/1/95 she had left popliteal and greater saphenous
DVTs by lower extremity non invasive testing. She was discharged at
that time but did not fill her Coumadin prescription. She was then
readmitted on 3/23/95 and discharged on 1/1/95 with a left common
femoral DVT by lower extremity non invasive testing.
Since the last admission , the patient adamantly states that she was
very compliant to Coumadin therapy. She states that she has had
increased pain and swelling in the left lower extremity. She also
states that she has been relatively active at home ( she does
gardening , cleans the house , goes for walks ). When not active , the
patient states that she elevates her legs. Despite all of this ,
the patient has noted gradual increase of left lower extremity
swelling and pain which has became intolerable on the day of
presentation.
DVT RISK FACTORS: No trauma to the lower extremities , no prior
surgery to the onset of DVT. No known
hypocoagulable state. No orally contraceptives used. No hormone
replacement therapy. No significant immobilization. The patient is
obese , she has had three miscarriages and she smokes. Also of note
the patient had a factor V level , which was normal. No other
studies have been done by patient report or discharge report.
REVIEW OF SYSTEMS: The patient denies any fevers , chills , sweats ,
nausea or vomiting , diarrhea , bright red blood
per rectum , melena , chest pain , pleuritic chest pain , chest
pressure , cough , or dysuria. However , the patient has had a
significant toothaches bilaterally for the past two weeks. Also , of
particular note , the patient gives a history of sudden onset of
shortness of breath , lasting for approximately 30 minutes or so ,
almost every evening. She states that the shortness of breath is
relieved with oxygen therapy , as she has at home. She never has
pleuritic chest pain or cough with these episodes.
PAST MEDICAL HISTORY: 1 ) Recurrent DVTs x 10 years; 2 ) obesity and
obstructive sleep apnea; 3 ) restrictive lung
disease; 4 ) hypertension; 5 ) atypical chest pain; 6 ) GERD; 7 )
depression; 8 ) status post herniorrhaphy in September of 1994.
PFTs from September of 1994 show an FVC of 1.85 , which is 56%
predicted. FEV-1 of 1.61 , which is 59% predicted. MVC/FEV-1 ratio
of 107% predicted. DLCO corrected 61%. TLC of 3.32 , which is 64% predicted.
ECHO results from 1994 show an ejection fraction of 55% , with a
normal right ventricular function and size.
The patient is on home 02 , approximately two to three liters by
nasal cannula. Her baseline dyspnea on exertion is approximately
five steps or approximately 1/4 block , but always without chest
pain or substernal chest pressure.
PAST OBSTETRICAL HISTORY: She is G VIII , P V with three mis-
carriages in the first trimester.
MEDICATIONS ON ADMISSION: 1 ) Coumadin , 7.5 mg every day; 2 ) Zoloft ,
60 mg every day; 3 ) Lasix , 20 mg every day; 4 )
Axid , 150 mg twice a day
TOBACCO: 30 years x one half pack per day; currently smoking.
ALCOHOL: No alcohol use.
IVDU: Cocaine , no use.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: She has a positive family history for cancer. Her
mother had cancer and died at a young age but she
did not know her mother. Her grandmother had skin cancer. There is
no diabetes mellitus; coronary artery disease , bleeding or clotting
problems or lung problems in her family.
SOCIAL HISTORY: The patient is from Po S Ma and
was raised by her grandmother. She has four living
children and one child who recently passed away. She has been
depressed after the death of her last child. She is now living
with her son in Lare Modehunt Leigh
PHYSICAL EXAM: The patient is a very obese , black female in no
apparent distress. She was not tachypneic.
Temperature 97.3 , blood pressure 112/74 , pulse 64 , respiratory rate
16. Oxygen saturation of 88% on room air , which increased to 93%
on two liters nasal cannula. Skin was warm and dry. There were no
rashes , bruising or petechiae noted. HEENT - pupils equally round
and reactive to light and accommodation. EOMI. Sclera anicteric.
Neck supple with a full range of motion , no lymphadenopathy , no
JVD; oropharynx moist and pink. Tongue midline with a mottled
pigmentation. Tonsils bilaterally enlarged with a small airway
noted. The left upper two molars were tender to minimal palpation.
The right upper molar was also tender. Lungs clear to auscultation
bilaterally but decreased breath sounds in the bases. Heart -
regular rate and rhythm without any murmurs , rubs or gallops.
Abdomen soft , non tender , obese , positive bowel sounds , negative
organomegaly; vertical midline scar , no CVAT. Rectal examination
was hemenegative. Extremities - there was significant left lower
extremity swelling noted up to the thigh with positive pitting
edema to the calf. There was also tenderness on the left inner
thigh anteriorly. There was also marked tenderness on the left
calf. There was no erythema. The left calf measured 41.5 cm.
There was an impressive homan's sign. The right lower extremity
had minimal swelling noted without tenderness , erythema or warmth.
The right calf measured 36.0 cm. Neuro exam non focal.
LABORATORY DATA: Notable for a Bicarbonate of 34 , hematocrit of
48.2 , and RDW of 17.4 and MCV of 75.4; white
blood cell count of 4.9 with a normal differential. Her PTT was
21.6 , INR of 3.2 , PTT of 45.0. Chest x-ray showed no pulmonary
edema or pneumonia. There was bibasilar atelectasis , which was not
changed from prior x-ray. LIMA showed left common femoral vein
DVT , left popliteal vein DVT and distal left saphenous vein DVT.
VQ scan was read as low probability , which was comparable to her
previous VQ scan in September of 1995 , which was low probability.
HOSPITAL COURSE: The patient was evaluated for recurrent DVT and
possible pulmonary embolus and treated with intravenous
heparin. We had a low clinical suspicion for pulmonary embolus and the VQ scan
was also low probability. The patient was seen by the cardiology service to
evaluate if the patient was a candidate for IVC filter placement.
Cardiology felt that the patient was not at risk for pulmonary
embolus and that her recurrent DVTs were of a more result of non
compliance and/or never completing a full course of anticoagulation
therapy. Thus , the plan was to continue to anticoagulate the
patient and follow her as an outpatient. However , the patient
continued to have tooth pain and was seen by the dental service. On
1/17/95 , she had two molars extracted , one on each side of the
upper dentition. Her dental surgery was uncomplicated. After
surgery , she was continued on Heparin and anticoagulated with
Coumadin. The patient continued to do well. However , the patient's
hospital course was notable for multiple episodes of sudden
shortness of breath , usually occurring during the evening. The
shortness of breath would come on suddenly , sometimes when she was
asleep and sometimes when she was awake. The shortness of breath
would last for approximately 30 minutes or so and would be relieved
with oxygen therapy by nasal cannula. The patient states that this
history of sudden shortness of breath is usual for her and has
occurred for several months. There were no associated symptoms of
fevers , chills , sweats , pleuritic chest pain , chest pressure ,
palpitations or cough. We did not suspect that she was having
multiple PE's. The patient was sent home with an INR of 3.2.
In any case , the patient was slow to respond while in house to
anticoagulation with Warfarin. She required approximately six days
of Warfarin at the following doses - 12.5 , 9/14 7.5 and 10 mg of
Coumadin before obtaining an INR greater than 3.
DISCHARGE MEDICATIONS: 1 ) Lasix , 20 mg every day; 2 ) Nifedipine XL , 30
mg every day; 3 ) Zoloft , 50 mg every day; 4 ) Axid ,
150 mg twice a day; 5 ) Coumadin , 7.5 mg alternating with 10 mg orally every
day.
FOLLOW UP: The patient is scheduled to have a follow up
appointment with Dr. Stasko on 7/25/95 at 9:40 a.m.. She is to
have VNA service to her home to check her INR level tomorrow. Her
physical therapy/PTT results will be reported to Caroyln Reidherd , a nurse
practitioner at the Gle Ra Csylv Valley Medical Center KTDUOO Clinic.
Dictated By: DESIRAE MARCOTT , XK7
Attending: CHARLEEN A. IVEL , PH.D IX65
QD758/6796
Batch: 09226 Index No. MRROAO4BVO D: 9/27/95
T: 2/13/95
Document id: 943
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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855931883 | PUO | 06334183 | | 517218 | 1/24/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 7/18/1992 Report Status: Signed
Discharge Date: 10/24/1992
HISTORY: The patient is a 79-year-old black
female with a history of diabetes ,
hypertension and peripheral vascular disease who presented to the
Totin Hospital And Clinic emergency room brought in by the EMTs for
unresponsiveness at home.
Cardiac risk factors were positive for diabetes , hypertension ,
questionable family history and question of a prior MA. She was
relatively well with diabetes and hypertension at her baseline
until approximately 8 of September when she had a left common femoral
angioplasty at Pagham University Of .
In 27 of May , she had a left fem/pop for vascular insufficiency , and
her hospitalization at that time was complicated by some mental
status changes and a fever of unknown etiology.
In 7 of March , she presented to KTDUOO with an upper respiratory infec-
tion and received pneumovax. In 28 of February , she was recurrently seen
in KTDUOO for coughs and colds. In 25 of October , she had a Totin Hospital And Clinic admission for three days of cough , purulent sputum and
shortness of breath.
On admission , she was on her insulin and inhalers. She was
treated with intravenous Cefotetan and intravenous steroids for reactive
airways disease. The patient improved slowly and steadily on a
taper.
On 5 of May , the patient was complaining of increasing lethargy , a
sick feeling , was cold and clammy and called her medical doctor.
Approximately 15 minutes later , the patient was noted by her
family to be unresponsive and EMTs were called. The patient was
found to be hypotensive , diahporetic and nonverbal with a heart
rate in the 20s and EKG that was consistent with complete heart
block.
She was intubated , treated with Atropine in the field and brought
to the Totin Hospital And Clinic emergency room. In the emergency
room , her heart rate was noted to be 20. She appeared to be in
sinus arrest with a ventricular escaped rhythm. An external
pacer was placed. She was paced at 80 , had an increase in her
blood pressure , was given calcium and resuscitated with fluids.
A transvenous pacemaker was placed and captured effectively.
LABORATORY DATA: ing intubated. Her bicarb was eight on
admission. BUN and creatinine were 48 and 2.3. Initial CK was
28. She was given oriing intubated. Her bicarb was eight on
admission. BUN and creatinine were 48 and 2.3. Initial CK was
28. She was given oriing intubated. Her bicarb was eight on
admission. BUN and creatinine were 48 and 2.3. Initial CK was
28. She was given oriing intubated. Her bicarb was eight on
admission. BUN and creatinine were 48 and 2.3. Initial CK was
28. She was given originally , in the emergency room , intravenous insulin
as well and treated with antibiotics including Ceftriaxone ,
Vancomycin and Gentamicin and transferred to the cardiac care
unit because there were no NICU beds available. Allergies: No
known allergies. She does not smoke or drink. She is currently
living with her daughter , one of 11 children. She has 66 grand-
children and 30 great grandchildren. Medications on admission
included Verapamil 40 every day; insulin 30 units NPH a day;
Captopril 25 three times a day; Bactrim DS one tablet orally twice a day; and
Ventolin and Atrovent inhalers.
PAST MEDICAL HISTORY: Notable for hypertension , diabetes ,
multiple rotator cuff injuries in the
past , the femoral and popliteal bypass procedure as noted above
and noted to have an increased globulin in the past.
HOSPITAL COURSE: In the unit , she had intravenous insulin started
for presumed diabetic ketoacidosis. The
sinus arrest was presumed to be metabolic in origin due to her
severe acidosis hyperkalemia secondary to her diabetic ketoaci-
dosis. In addition , she had been on high dose Verapamil with
some question of whether or not this was suppressing her sinus
node.
She was maintained on intravenous insulin for approximately two days but
had a persistent metabolic acidosis. Because of some abdominal
tenderness which was hard to gauge given her decreased mental
status while she was intubated , she underwent an abdominal CT
that was unremarkable , although very mild pancreatitis was noted.
She had a concomitant rise in her amylase and lipase to approxi-
mately 270 and 1 , 290 respectively.
Her LFTs showed a picture consistent with shock liver with her
transaminases going up to approximately 1 , 000-2 , 000 range and the
LDH in the 2 , 000-3 , 000 range. It resolved over time as her blood
pressure returned to normal. Her antibiotics were changed to
Ampicillin , Gentamicin and Flagyl for concern of an abdominal
source despite the negative CT , and her low grade fevers per-
sisted for a few days but then she defervesced.
On 3 of November , she was transferred to the floor after having received
approximately five days of intravenous insulin and a resolution
of her hyperglycemia and ketosis.
Her hospital course on the floor was notable for a titration of
her insulin dose. Of note , her insulin dose was as high as
approximately 30-35 units of NPH every day in a setting of having
received steroids initially on admission and they were continued.
Her steroids were weaned rapidly and , once steroids were stopped
her insulin requirement decreased markedly and she was only on 20
units of NPH a day now.
Of note , she had two episodes of hypoglycemia in the morning with
blood sugars in the 20-30 range , one of which was asymptomatic
but one of which was associated with some shaking that responded
promptly to administration of juice.
From an infectious disease standpoint , she had no obvious source
for any of her fevers , and she defervesced. There was some ques-
tion of aspiration surrounding her original intubation , so she
was maintained on approximately seven days of antibiotics and
then these were stopped. She was watched , and she remained
afebrile throughout her hospitalization.
One day prior to discharge , she complained of some left gum pain.
Exam showed a very mild swelling and some focal tenderness but
was unremarkable. Because of this , she was started on Peni-
cillin 250 mg orally four times a day which will be continued for seven days.
From a renal standpoint , her baseline creatinine was 1.3 to 1.5
range and it bumped to approximately 3.0 during hospitalization.
She was being discharged with her creatinine of approximately
1.7. Her urine output had been excellent.
From a cardiovascular standpoint , within three or four days of
her admission , her sinus arrest resolved in a setting of correc-
tion of her metabolic derangement. Her pacemaker was removed ,
and she had no further cardiac event.
She was being discharged today in stable condition to the Damri Kinli Nonell Hospital with the following discharge medications:
Nifedipine 30 mg orally four times a day; Lasix 20 mg orally every day; Pepcid
20 mg orally every day; Colace 100 mg orally twice a day; Clonidine 0.1 mg
orally twice a day; Ecotrin 325 mg orally every day; Albuterol 0.5 cc and
2.5 cc normal saline every three to four hours as needed; insulin NPH
20 units subcutaneous every day before noon; Penicillin B 250 mg orally four times a day
times one week; Peridex swish and swallow four times a day; and 5 , 000 units
of subcutaneous heparin twice a day as long as she remains somewhat
inactive. She takes an 1 , 800 kilocalorie ADA diet and low-salt
and low-cholesterol diet as well.
DISCHARGE DIAGNOSIS: 1. Diabetic ketoacidosis.
2. Sinus arrest.
3. Diabetes mellitus.
4. Hypertension.
Dictated By: LEOLA CLARISA MUSICH , M.D. NB09
AH342/5017
PEGGY KELLEY ROMIG , M.D. AB14 D: 2/23/92
T: 2/23/92
Batch: C971 Report: UK417C617 T:
Document id: 944
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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816576315 | PUO | 22240846 | | 923108 | 8/18/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/8/1995 Report Status: Signed
Discharge Date: 9/7/1995
The patient received care on the Stercoln Pkwy.
PRINCIPAL DIAGNOSIS: Dilated cardiomyopathy with associated
problems of hypertension and asthma.
CHIEF COMPLAINT: This is a 53 year old female with hypertension x
eight years , who presents with increased dyspnea
on exertion and admitted for left and right heart catheterization ,
and to optimize blood pressure control.
HISTORY OF PRESENT ILLNESS: This is a 53 year old Afro-American
female , first diagnosed with
hypertension in 1987. She presented to the Emergency Room in 1987
with acute atypical chest pain , and was ruled out for a myocardial
infarction. ETT in 1987 demonstrated chest pain during exercise
and suggestive ST T wave changes in the inferolateral leads during
exercise. The patient was discharged from the hospital , and did
relatively well with intermittent chest pain on exertion.
Exercise tolerance test in 1991 demonstrated consistent , but not
diagnostic of ischemia. No chest pain. Echocardiogram in 1992
demonstrated inferior , posterior , and apical hyperkinesis , low to
normal global pattern of systolic contractile function , and a
celionous redundancy of the mitral anterior leaflet , with only
trace mitral regurgitation.
Since 1992 , the patient has developed severe shortness of breath
with positive chest discomfort of pin and needles in the left
chest , which radiates down her left arm. She notes positive
paroxysmal nocturnal dyspnea with the need of sleeping elevated at
45 degrees at some times.
Echocardiogram in 1994 demonstrated moderately dilated left
ventricle with severely depressed systolic function. Ejection
fraction equals 26%. There was 2+ mitral regurgitation and mild
left atrial enlargement also noted. Mild tricuspid regurgitation
with pulmonary artery pressure estimated at approximately 25.
Due to her hypertension and decreased left ventricular function ,
the patient presents to the I Warho Hospital for a left
and right side catheterization , and also for monitoring of her
blood pressure. Her blood pressure ranged , as an outpatient ,
between 170 to 180/100 to 110.
PAST MEDICAL HISTORY: 1. As above.
2. Asthma.
MEDICATIONS ON ADMISSION: 1. Beclovent 4 puffs twice a day
2. Enalapril 4 mg every day
3. Diltiazem 360 mg every day
4. Lasix 40 mg twice a day
ALLERGIES: The patient has no known drug allergies.
HABITS: The patient smokes one-half per day to one pack per day
for the last twenty-five years. Alcohol , occasional.
FAMILY HISTORY: The patient's mother died in her sleep at age 50
of unknown reasons. Her father died due to a
motor vehicle accident. Two brothers and one sister all died at
age 30 to 40 , the patient does not know cause.
SOCIAL HISTORY: The patient has not worked since 1995 due to what
she states as shortness of breath and chest pain.
She has three daughters , all in good health , and four
grandchildren.
PHYSICAL EXAMINATION: On physical examination , this is a 53 year
old female , Afro-American , in no apparent
distress. Vital signs: Temperature 97.6 , blood pressure 134/72
after Hydralazine , heart rate 75 , respiratory rate of 12. HEENT
examination: Extraocular movements are intact. Pupils are equal ,
round , reactive to light. Nasal orally pharynx had no discharge , and
was clear with no exudates. Neck: No adenopathy , no jugular
venous distention , no thyromegaly. Carotids are 2+ with no bruits.
Lungs revealed diffuse expiratory wheezes , prolonged expiratory
phase , no rhonchi or rales. Cardiovascular revealed a regular rate
and rhythm , normal S1 and S2 , positive S4 , with a 2/6 systolic
murmur at the apex. The abdomen was obese , soft , non-tender ,
non-distended , with no obvious hepatosplenomegaly. Extremities
revealed no clubbing , cyanosis , or edema , and no bruits. Pulses
were 2+ throughout. Neurological examination: Alert and oriented
x three , nonfocal examination.
LABORATORY EXAMINATION: Labs upon admission revealed an SMA-7 of
143 , 4.1 , 102 , 28 , 20 , 1.2 , and 93. CBC
of 6.3 , 46.1 , and 280. physical therapy and PTT of 12.5 and 28.4. ALT of 14 ,
AST of 19 , LDH of 197 , alkaline phosphatase of 77 , total bilirubin
of .3 , total protein of 7.9 , albumin of 4.2. Globulins of 3.7 ,
calcium of 9.4 , phosphate of 4.4 , cholesterol of 210 , and
triglyceride of 67.
HOSPITAL COURSE: The patient underwent cardiac catheterization on
hospital day number one which demonstrated no
coronary artery disease disease , right atrium pressure of 12 , PA
pressure of 56/32 with a mean of 38 and pulmonary capillary wedge
pressure of 20. Cardiac output was 5.1 , SVR of 1459 , and PVR of
282. The patient was then admitted to the Floor for workup of her
hypertension. Urine metanephrine and urine VMA were sent. The
patient's Enalapril was discontinued in order to perform the
Captopril Renogram Test. The patient was started on Diltiazem 180
mg every day , Lasix 80 mg twice a day , and Hydralazine 10 mg three times a day
The patient's blood pressure , on hospital day number three , was
130/70 and well-controlled. Her heart rate was 70 to 80. On
hospital day number four , the patient underwent a Captopril
Renogram Test which was negative for renal artery stenosis. Other
hypertension workup Epinephrine , Dopamine , Metanephrine , VMA and
ANA are still pending.
The patient was discharged home on hospital day number five , with
blood pressure being well-controlled throughout her hospital visit
in the 130/70's.
The patient's hypertension control was attributed to the fact that
number one , she stopped smoking during her hospital stay; two , she
was inactive and was on bed rest; and three , the possibility of
strict compliance with medications while in the hospital.
DISCHARGE MEDICATIONS: 1. Diltiazem 180 mg orally every day
2. Enalapril 10 mg orally every day
3. Lasix 80 mg orally twice a day
4. One aspirin per day.
CONDITION ON DISCHARGE: The patient was discharged home in stable
and good condition.
FOLLOW-UP: The patient will have follow-up with KTDUOO on Thursday ,
April , 1995 for check of blood pressure and
frequent blood follow-up with Dr. Amargo on Monday , September ,
1995.
Dictated By: FRAN BUSSLER , M.D.
Attending: JONATHAN AGLIAM , M.D. LM51
QT975/5476
Batch: 8531 Index No. C2RFKQ81MD D: 4/4/95
T: 7/23/95
CC: 1. JONATHAN AGLIAM , M.D. LM51 CARDIOLOGY
2. KATINA AMARGO , M.D. JM29
Document id: 945
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
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| output/system_intuitive_annotation.xml | intuitive |
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472205463 | PUO | 29439805 | | 7503465 | 11/25/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/6/2005 Report Status: Signed
Discharge Date:
ATTENDING: BLANCHETT , MILLY BRITTANI MD
Admitted 10/18/05 to Dr. Denisha Mcrorie
ADMISSION CHIEF COMPLAINT: Poor orally intake and failure to
thrive.
HPI: This 77-year-old female first noted dysphagia beginning in
approximately October 2005. Since then it has persisted and
worsened , and she was seen by a primary care physician. Initial
endoscopy was performed , which was suspicious for malignancy ,
however , the patient was on Coumadin and no biopsy was obtained
at that time. She underwent a repeat upper endoscopy on August ,
2005 at the Ronyscutford Community Hospital The EGD revealed that Ms. Hanners
had Barrett's esophagus as well as a nodule on the distal
esophagus. No evidence of gastritis. A biopsy of the nodule
revealed poorly differentiated invasive adenocarcinoma at 35 cm.
It appeared to be rising in association with Barrett's
esophagitis. She also has a history of ischemic myopathy with an
LVEF of approximately 20% and CAD with a history of bypass graft
in 1992 and a biventricular ICD placed in October 2004. She
underwent an endoscopy on September , 2005 , an EUS revealed that she
had an intramural lesion in the distal esophagus measuring 2 cm
in diameter invading into the muscularis propria , therefore she
was staged and having T3 , N0 , MX , and tumor by EUS. She was seen
at Balltetreatnalbre Medical Center in mid July by both Dr. Jackson Part
from Medial Oncology and Dr. Steinert from Radiation Oncology. It was
felt that she was a reasonable candidate for consideration of
chemoradiation. She therefore began her chemoradiation and
radiotherapy , chemotherapy including Taxol and cisplatin.
Approximately 1 week prior to admission on February , 2005 ,
unfortunately , she reports over the course of the past week , she
has had increasing dysphagia to the point where she is having
trouble swallowing liquids. She presented for her routine
radiation therapy the day prior to admission , with complaints of
severe lightheadedness and difficulty getting off the radiation
table. She was taken to the ED , where she was found to be
dehydrated and weak. She had some chills , but no fever , no
hemoptysis or diarrhea. She has had very poor orally intake and
she notes some weight loss.
PAST MEDICAL HISTORY:
1. CAD , status post CABG , 5 vessel in 1995.
2. CHF with a biventricular pacer placed , EF of 20%.
3. Hypertension.
4. Hyperlipidemia.
5. Diverticulosis.
6. Status post appendectomy.
7. Status post gallbladder removal.
8. A-fib on Coumadin.
9. Esophageal cancer status post chemo on XRT.
10. Hypothyroidism.
11. Peptic ulcer disease.
ALLERGIES: Codeine causes GI upset , morphine and Demerol caused
GI upset , amoxicillin/clavulanic acid caused GI upset , azelastine
causes stinging , and amiodarone causes cold sweats.
MEDICATIONS: Her medications on admission were Lopressor 50
twice a day , Diovan 80 , digoxin 0.125 mg five days a week , Synthroid
0.125 mg , Imdur 30 daily , Lasix 80 daily , Prevacid 30 daily ,
multivitamin , Coumadin 3 mg nightly , and Zocor 5 every other day.
SOCIAL HISTORY: The patient is married and lives with her
husband. She is a homemaker. She does not smoke. She does not
drink except for occasionally.
FAMILY HISTORY: She has a father with melanoma , and a mother
with an MI at the age of 59.
REVIEW OF SYSTEM: She had no abdominal pain , no chest pain , no
shortness of breath , no headache , and no joint pain.
PHYSICAL EXAM: On admission ,
VITAL SIGNS: Her temp was 97.4 , pulse 86 , blood pressure 87/56 ,
respiratory rate 20 , saturating 98% on room air.
GENERAL: She was an alert , oriented , cooperative female , who was
resting comfortably.
HEENT: Her mucous membranes were dry , oropharynx clear. Pupils
were equal , round and reactive to right. Extraocular motions
intact.
LUNGS: Clear to auscultation bilaterally , no crackles or
wheezes.
NECK: There is JVP at 7 cm , low lymphadenopathy. Her neck was
supple.
CARDIOVASCULAR: She was irregularly regular with a 2/6 systolic
ejection murmur loudest at the apex.
ABDOMEN: Soft , nontender , nondistended , with positive bowel
sounds. Her extremities had trace edema with no bruising.
LABORATORY DATA: Her admission labs were notable for potassium
of 2.9 , BUN of 37 and creatinine of 1.6. Her LFTs and CBC were
within normal limits. Her INR on admission was 2.7. Her albumin
was 3.7 , mag 1.5. Her UA was negative. Her EKG showed a right
bundle branch block with A-fib , A-flutter with occasional paced
beats from her pacer. Her chest x-ray was clear.
ASSESSMENT: This 77-year-old female with a history of CAD , CHF
and esophageal cancer presenting with lightheadedness , however ,
having nausea and vomiting , most likely her symptoms are due to
dehydration. Unlikely a cardiac cause given no chest pain , no
palpitation , and obviously decreased orally
PLAN:
1. Lightheadedness: Poor orally intake and dehydration.
Nutrition was consulted to evaluate regarding the possible stent
in esophagus. She will be treated with gentle hydration
overnight , measure orthostatics , holding Lasix.
2. Cardiovascular: History of CHF with an EF of 20% , checking
BNP and monitor on tele for arrhythmia , continue digoxin , Diovan ,
Lopressor , continue Imdur , continue Lasix while hydrating.
3. Esophageal Cancer: Got XRT. On the day of admission , she
will continue XRT.
4. Nausea: Rx for Zofran and replete potassium.
5. Hypothyroidism: Continue Synthroid.
6. GERD: Continue Prevacid.
7. A-fib: Continue Coumadin.
8. Hyperlipidemia: Continue Zocor.
9. FEN: Replete electrolytes as needed , diabetic diet , and
multivitamin.
10. Prophylaxis: Subcutaneous heparin and Prevacid.
11. Full code.
BRIEF HOSPITAL COURSE:
1. Lightheadedness: It was felt that all of her lightheadedness
was most likely due to dehydration. Her lightheadedness improved
with hydration , it was most likely due to poor orally intake.
Nutrition evaluated her and suggested high calorie supplements ,
however , she continued to be nauseated and unable to take good
orally GI was consulted regarding possible stenting of her
esophagus given that she had an intra-esophageal lesion that
could potentially be causing this nausea. She was also ordered
for a barium swallow. On the barium swallow , there was a strict
stenotic lesion of the esophagus , which is not allowed any food
to pass through. An EGD was performed , which showed some food
about a tight stenosis that was unable to be passed. Based upon
this it was felt that she would benefit from a G-tube.
Interventional radiology was consulted and placed a G-tube
without complication. Tube feeds were begun and she tolerated
them well without complication. She has been continued on tube
feeds and is currently at goal of 360 cc four times a day , with a
scoop of promod , these will be continued upon discharge.
2. TIA/CVA: On the evening of 5/24/05 , it was noted that she
had decreased ability to move the left side of her body. Based
upon this , a STAT CT and CTA was performed. The CT showed no
bleeding , and during the CT scan , she regained all function in
the left side , however , the CTA did note a large friable clot
within her right ICA. Based upon her high level of heart disease
and high risk for an operative procedure , it was not felt that
she would be a stent candidate at that time. She was continued
on Lovenox therapy with Coumadin with the plan to discharge her
on medical management for this TIA. However , on the morning of
8/16/05 , she was noted to have a new left-sided facial droop.
She also had some left-sided weakness. A STAT CT , CTA once again
showed no bleed. At this point , the clot was noted to have moved
from the right ICA into the MCA , and to have dissolved somewhat.
Based upon this , it felt that she would have good recovery from
her stroke , and she was not a candidate for any sort of
intervention at that time. She was converted over to heparin
drip with the plan to give her a heparin drip as bridging over
while her Coumadin became therapeutic. She was continued on
heparin drip until her INR was therapeutic. She will be
discharged on Coumadin and continued on Coumadin and aspirin
therapy for life.
3. Esophageal Cancer: She was continued on XRT for the entire
time when she was in the hospital. Conversations between Dr.
Levandoski , Dr. Steinert and the family were had and it was felt that she
was no longer a chemotherapy candidate given her poor status , in
terms of her other issues. She will be continued on XRT after
discharge from the hospital.
4. Acute Renal Failure: On admission , she was noted to have an
increased creatinine; it was felt to be most likely due to
dehydration. However , at the time of admission , she had a BUN of
50% and a renal ultrasound was performed , the renal ultrasound
was normal and showed no further defect over the course of her
hospital stay. Her creatinine continued trending down and was
0.9 on the day prior to discharge.
5. CAD: She has a history of CHF with an EF of 50%. She was
monitored on tele for arrhythmia and no arrhythmia was observed.
She does of note have a right bundle branch block at baseline as
well as biventricular pacer with 1 lead out of place causing a
wide complex rhythm. There were multiple alarms for VT , which
were simply her baseline rhythm. In the hospital , she was
continued on digoxin , Lopressor , and Imdur. Her Lasix was
initially held , while she was being hydrated , however , it was
restarted after the G-tube was placed and she was getting
sufficient feeds. She was also continued on her statin. She had
no other cardiac issues while she was in the hospital.
6. Nausea: She was treated with Zofran for her nausea when she
was admitted and she continued to have good response to this.
7. Urinary Tract Infection: On the 25 of May she noted that she was
having increasing pain on urination and increasing burning , an UA
was done and it was found to be positive for infection. A
culture was performed , which showed enterobacter that was
levo-sensitive. She was started on Levaquin and the Foley , which
had been placed prior was discontinued. She was continued on
Levaquin for a 10-day course and this will be continued for
several days after discharge.
8. Hypothyroidism: She was continued on her Synthroid at her
home dosages while she was in-house.
9. GERD: She was continued on Prevacid while she was in-house.
10. A-fib: She was continued on Coumadin , although it was held
prior to her EGD and G-tube placement. During the time when she
was not therapeutic on her Coumadin she was treated with either
Lovenox subcutaneously or heparin intravenous drip titrated to a PTT of 60 to 80 ,
therefore she was always therapeutic on her anticoagulin during
this hospital stay.
11. She was initially on a full diet , however , she was unable to
take any orally so she was started on tube feeds , which she was
able to make her goal. Nutrition was involved in her care and
she was continued on multivitamin.
12. She was on Lovenox or heparin drip throughout her
hospitalization for DVT prophylaxis. She was also continued on
Prevacid.
CODE STATUS: Full Code , and remained full code throughout her
hospitalization.
COMMUNICATION: There was much communication between her family
throughout this hospitalization in terms of their wishes for her
care and for her discharge , and it was agreed that a rehab would
be a good place for to go at the end of her stay here.
eScription document: 1-0166807 HFFocus transcriptionists
Dictated By: SCOVEL , DULCIE
Attending: BLANCHETT , MILLY BRITTANI
Dictation ID 0014426
D: 11/7/05
T: 11/7/05
Document id: 946
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553809697 | PUO | 30439070 | | 467574 | 5/25/2001 12:00:00 a.m. | NON-HEALING ULCER LT. FOOT | Signed | DIS | Admission Date: 5/25/2001 Report Status: Signed
Discharge Date: 11/1/2001
HISTORY OF PRESENT ILLNESS: Ms. Nellum is a 60-year-old woman with
a history of insulin-dependent
diabetes mellitus as well as hypertension and congestive heart
failure who presented in February of 2001 with pain in the left
lateral aspect of her fifth metatarsophalangeal area without
bleeding. This wound has failed to heal over time.
PAST MEDICAL HISTORY: Insulin-dependent diabetes mellitus times
20 years , obesity , hypertension , depression ,
sleep apnea.
PAST SURGICAL HISTORY: 8/23/94 incision and drainage and
debridement of abdominal wound. 4/6/94 ,
debridement of abdominal wound. 10/26/94 debridement and closure
of abdominal wound. 1/7/96 debridement of a chronically infected
abdominal wound in the right lower quadrant. 4/5/97 debridement
of nonhealing abdominal wound in the right lower quadrant. Ventral
hernia repair and abdominoplasty in 4/27/97. 8/1/97 drainage of
seroma with wound debridement and closure. The patient has also
had an appendectomy in 1994 , cholecystectomy and ventral hernia
repair.
MEDICATIONS AT HOME: Lopressor 50 mg orally every day , Neurontin 600 mg
orally every day , Prozac 40 mg orally every day , Prilosec
20 mg orally every day , Lasix 80 mg orally every day , Trazodone 50 mg orally every
day , Lipitor 20 mg orally every day and magnesium supplementation of an
unknown quantity.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM: Weight 315 pounds , blood pressure 130/70 , pulse 68 ,
respiratory rate 18. GENERAL: She was an obese ,
age appropriate elderly female. HEENT: Extraocular movements
intact. No jugular venous distention and no bruits. HEART: With
a clear distinct S1 and S2. Regular rate and rhythm. No murmurs ,
rubs or gallops. LUNGS: Clear to auscultation with no wheezes ,
rales or rhonchi. ABDOMEN: Obese , nontender , nondistended with
normal active bowel sounds. No hepatosplenomegaly. EXTREMITIES:
Demonstrated no clubbing , cyanosis or edema. She had radial pulses
2 plus right and 2 plus at the left. Femoral pulses 1 plus
bilaterally. Popliteal pulses 1 plus bilaterally. Dorsalis pedis
pulse was biphasic and so was the posterior tibialis bilaterally.
HOSPITAL COURSE: The patient was admitted to the manic vascular
surgery service and she underwent an
uncomplicated debridement of the nonhealing ulcer on the left
lateral aspect of her left forefoot. The patient tolerated the
procedure well and was stable in the immediate postoperative
period. The patient was then transferred to the floor where she
underwent a rapid progressive and uncomplicated course of recovery.
The patient's hospital stay was protracted due to inability of the
patient to mobilize herself with the assistance of physical
therapy. She was screened for rehabilitation placement at this
time but there was some difficulty in placement secondary to bed
non-availability. This immobility is consistent with her
mobilization ambulatory capacity at home as per her own report.
The patient throughout the remainder of her hospital stay had
continued progressive healing of the wound on the lateral aspect of
her left forefoot with wet-to-dry dressing changes. Her finger
stick blood sugars were well controlled. By postoperative day
number seven , June , 2001 the patient was found to have
minimal pain , to be voiding and moving her bowels with ease , to be
ambulating with assistance from physical therapy and a walker , to
demonstrate continued well healing of the ulcer at the lateral
aspect of the left forefoot. She was satting well on room air and
tolerating a diabetic house diet.
A placement in a rehabilitation facility was found and the patient
was discharged to rehabilitation with appropriate follow up and
discharge instructions.
PHYSICAL EXAM ON DISCHARGE: LUNGS: Clear to auscultation
bilaterally with no wheezes , rales or
rhonchi. HEART: Regular rate and rhythm. No murmurs , rubs or
gallops. ABDOMEN: Soft , obese , nontender , nondistended. Normal
active bowel sounds. EXTREMITIES: Pulses at the foot which are
biphasic at the dorsalis pedis pulse and posterior tibialis
bilaterally. The ulcer at the lateral aspect of her left forefoot
was well healing and approximately 0.75 cm in diameter with a well
developed bed of granulation tissue.
MEDICATIONS ON DISCHARGE: Tylenol 650 mg orally every 4 hours as needed pain ,
headaches or temperature greater than
101.0 , Prozac 40 mg every day , NPH insulin 60 units every day before noon and 40 units
every afternoon subcutaneously , insulin regular sliding scale subcutaneously
four times a day , Lopressor 50 mg orally every day , oxycodone 5 mg orally every 4 hours
as needed pain , Senna tablets orally twice a day , Trazodone 50 mg orally
every bedtime , Neurontin 800 mg orally three times a day , Prilosec 20 mg orally every day ,
Lipitor 20 mg orally every day , Lasix 80 mg orally every day.
REMAINING ISSUES: Primarily mobilization. The patient should be
seen by physical therapy to expand her
ambulatory and mobilization capacity. Her wound should be cared
for with wet-to-dry dressing changes twice per day and she should
follow up with Dr. Loerwald in 7-10 days.
Dictated By: AISHA GOON , M.D. YS54
Attending: ROSSIE MANKOSKI , M.D. EX35
RT514/512501
Batch: 8458 Index No. U5WLPS4LUG D: 9/24/01
T: 9/24/01
Document id: 947
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380588962 | PUO | 33723686 | | 667674 | 2/26/2001 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 11/3/2001 Report Status: Signed
Discharge Date: 6/8/2001
ADMISSION DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old gentleman
with a history of progressive angina
over the past several months. The patient had a cardiac
catheterization in September of this year revealing total occlusion of
the RCA and 50% left main disease , with a strong family history of
coronary artery disease with a brother dying at the age of 52 from
a myocardial infarction and another brother who is status post
coronary artery bypass grafting. The patient had a stress
echocardiogram done on September , 2001 , which showed no wall motion
abnormalities , but this was a difficult study due to body habitus.
The patient went for six minutes with minimal ST depressions in the
anterior lateral leads , thought due to fatigue and wrist pain , his
anginal equivalent. Due to the patient's increased symptoms and
family history and history left main disease with total occasional
of his RCA was referred for revascularization with open heart
surgery.
MEDICATIONS ON ADMISSION: At the time of admission , the patient
was on Imdur 120 mg orally every day , Lipitor
80 mg orally every day ( about which I am told he was on this high dose
for about one month ) , Prilosec 20 mg orally every day , enteric coated
aspirin 325 mg orally every day , Imdur 120 mg orally every day before noon and Imdur 60
mg orally every afternoon , nitroglycerin sublingual as needed for chest pain ,
acebutolol 400 mg orally every day , hydrochlorothiazide 25 mg orally q.
day , vitamin C , multivites , Norvasc 10 mg orally every day , Prozac 20 mg
orally every day , and K-Dur 20 mEq orally every day.
PAST MEDICAL HISTORY: The patient's past medical history was
significant for coronary artery disease ,
hypertension , hyperlipidemia , obesity , panic disorder , question of
asthma , not on inhalers currently , gastroesophageal reflux disease ,
some his of rectal bleeding , but had a sigmoidoscope done in
September of 1999 that showed no disease , psoriasis , and right elbow
tendinitis.
PAST SURGICAL HISTORY: The patient's past surgical history was
significant for tonsillectomy and
circumcision one year ago.
SOCIAL HISTORY: The patient's social history was negative for
ETOH. The patient had smoked three packs per day
for six years and quit five years ago.
FAMILY HISTORY: The patient's family history was significant for a
brother who died of an myocardial infarction in
his 50s , a mother with an aneurysm , and a father with emphysema.
PHYSICAL EXAMINATION: Blood pressure on the right was 142/90 , on
the left 150/80. HEENT revealed the patient
to be non-icteric. There was no jugular venous distention. There
were no carotid bruits noted. Cardiovascular examination revealed
a regular rate and rhythm with no murmur , rub , or gallop noted.
The lungs were clear to auscultation without any evidence of
wheezes , rhonchi or rales. The abdomen revealed positive bowel
sounds and was soft , non-tender. It was difficult to assess for
any hepatosplenomegaly due to the patient's size. The extremities
revealed no clubbing , cyanosis or edema. A few varicosities were
noted. The pulses were 2+ throughout. Neurological examination
revealed the patient to be alert and oriented x 3 and the
examination was grossly non-focal.
HOSPITAL COURSE: The patient was admitted on May , 2001 and
and was taken to the operating room for coronary
artery bypass grafting x 3 on January , 2001 with RIMA to the OM1 ,
saphenous vein graft to the RCA , and LIMA to the LAD. The total
cardiopulmonary bypass time was 155 minutes. The total cross-clamp
time was 108 minutes. The patient came off the heart lung machine
without any difficulties and on no drips. The patient was
extubated on postoperative day number one , January , 2001. The
patient remained in the Intensive Care Unit for respiratory reasons
and was there for three days. The patient required only diuresis
for improved oxygenation. On postoperative day number three , wires
and chest tubes were removed without any difficulty.
Postoperatively , it was noted on portable x-ray that the patient
had a small right pneumothorax status post chest tube removal.
Subsequent chest x-ray showed a decrease in pneumo size. The
patient had a PA model chest x-ray today that was pending and we
will decide on follow-up depending on the chest x-ray today. The
patient , otherwise , remained in normal sinus rhythm and was able to
be weaned off the O2 with diuresis. The patient was , otherwise ,
doing well with plans for discharge on postoperative day number
five to home in stable condition.
FOLLOW-UP: The patient was instructed to follow-up with his
cardiologist , Dr. Binetti , in one week. The phone
number is 963-373-5263. The patient will also follow-up with
Dr. Colasamte , telephone number 117-219-4079 , in six weeks for a post
surgical evaluation.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on enteric coated aspirin 325 mg
orally every day , Colace 100 mg orally three times a day , Prozac 20 mg orally every day ,
Lasix 20 mg orally every day x five , Lopressor 50 mg orally three times a day ,
Niferex 150 mg orally twice a day , Percocet 1-2 tablets every 4-6 hours
as needed pain , K-Dur 10 mEq orally every day x five days while on Lasix at
that dose , Prilosec 20 mg orally every day , Lipitor 80 mg orally every day
per his preoperative dose that he has been on for one month , and
multivitamins 1 tablet orally every day.
ADDENDUM: The follow-up chest x-ray today showed no evidence of
pneumo. We would recommend in the postoperative
follow-up with Dr. Binetti to have a follow-up chest x-ray.
Dictated By: BATHRICK , SHERELL K.
Attending: ISABELLE E. COLASAMTE , M.D. CL7
OK828/870867
Batch: 46594 Index No. VYEAPJ2THI D: 2/24/01
T: 2/24/01
CC: 1. DR. HULLINGS ,
Document id: 948
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372560998 | PUO | 10390591 | | 781512 | 7/1/1998 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 9/19/1998 Report Status: Signed
Discharge Date: 7/11/1998
PRINCIPAL DIAGNOSES:
1. Hypertension.
2. Anemia.
3. Congestive heart failure.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old male who
was in his usual state of health until
approximately one to two weeks prior to admission , when the patient
had his antihypertensive medications changed. His nifedipine was
discontinued because of gingival hypertrophy and Atenolol was
replaced. Shortly after that he developed increased dyspnea on
exertion , shortness of breath , especially with walking in the
morning. There was a question of light-headedness. He denied any
chest pain , pressure , or tightness. No jaw , neck or arm symptoms.
No orthopnea or PND. Her also denied visual symptoms or headache.
One day prior to admission the patient was taking a walk and was so
fatigued that he had to stop. On the day of admission the patient
was again taking a walk and was noted by friends to be somewhat
unsteady and diaphoretic. The EMTs were called. The patient was
given Lasix and nitroglycerin with improvement in his symptoms. He
denies cough , fevers , chills , vomiting , melena or hematochezia.
The patient has been taking all of his prescribed medications. No
dietary changes. He notes good appetite , no early satiety. He has
a history of two syncopal episodes in the distant past. On the
morning of the admission the patient has not taken any of his
medications yet.
PAST MEDICAL HISTORY:
1. Hypertension diagnosed in 1969.
2. Chronic renal insufficiency , with a baseline creatinine of 1.8 ,
felt to be hypertensive.
3. Cataracts bilaterally.
4. No history of coronary artery disease.
5. Status post appendectomy in the 1950s.
6. Status post umbilical hernia repair in 1945.
MEDICATIONS:
1. Lisinopril 80 mg every day
2. Atenolol 25 mg every day
3. Aldomet 750 mg three times a day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient quit smoking tobacco approximately 40
years ago. Occasional alcohol use.
FAMILY HISTORY: His brother had a heart attack in his late 50s.
The brother also has diabetes.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98 , blood pressure
190/98 , pulse 48. O2 saturation was 98% on
two liters by nasal cannula. GENERAL: The patient is an elderly
African-American gentleman , sitting up in bed in no acute distress ,
talking in complete sentences. HEENT: The left eye has a
nonreactive pupil. The right eye has a small pupil , approximately
2 mm , with a clear cataract. There is no icterus. The oropharynx
was clear with gingival hypertrophy. NECK: Supple , with full
range of motion. There was no lymphadenopathy. JVP was difficult
to assess because of the large neck. CARDIAC: Regular rate and
rhythm with a 2/6 systolic murmur at the base. The carotids were
without bruits. PULMONARY: The patient had bibasilar rales with
expiratory wheezing and a prolonged expiratory phase. ABDOMEN:
Protuberant , soft , non-tender. Normoactive bowel sounds. No
organs appreciated. EXTREMITIES: Edema 2+. Femoral pulses were
2+. There were bruits. Distal pulses were intact. RECTAL: The
patient was heme-negative.
DIAGNOSTIC STUDIES: Sodium 143 , potassium 4.2 , chloride 104 ,
bicarbonate 24 , BUN 35 , creatinine 2.0 ,
glucose 144. CBC shows WBC 8 , hematocrit 32.9 , platelets 343 , MCV
approximately 80 , RDW approximately 16. Admission CK was 175.
Troponin I was 0.05. Chest x-ray showed a questionable bibasilar
infiltrates. EKG showed sinus bradycardia at 56. The axis was 20
degrees. The intervals were 0.175/10/96/0.471. There was LVH by
voltage criteria , an isolated Q in lead 3 , biphasic T waves in AVL ,
and a flat T in lead 3.
HOSPITAL COURSE: By problems:
Congestive heart failure: The patient underwent a rule out
myocardial infarction protocol and subsequently did rule out.
After that he had an exercise echo. The patient exercised for
three minutes on a modified Bruce , achieving a maximum heart rate
of 97 and a blood pressure of 160. The test was stopped because of
knee pain and shortness of breath. Baseline images prior to
exercise showed mild left ventricular hypertrophy , with overall
normal function. There were no resting wall motion abnormalities.
Stress images obtained after peak exercise showed a suggestion of a
posterobasilar hypokinesis. No other wall motion abnormalities
were noted. It was felt that this findings were questionable for
nonspecific finding or ischemia. It was felt that the EKG portion
of the ETT showed no evidence for ischemia. The patient was
diuresed gently with intravenous Lasix and his shortness of breath improved.
Hypertension: On admission , the patient's blood pressure was
approximately 220/110. The patient was started on intravenous nitroglycerin
and intravenous Labetalol in the Emergency Department. The patient was
subsequently weaned from intravenous nitroglycerin and switched to orally
hydralazine and minoxidil , 100 mg three times a day and 2.5 mg every day ,
respectively. The patient had excellent blood pressure control on
these medications. The patient was discharged with close follow-up
in order to titrate these medications.
Anemia: The patient's admission hematocrit was 32.2. Subsequent
hematocrits were very labile , and there was felt to be some lab
error involved. Follow-up hematocrit was in the mid 20s. This was
repeated and was again in the mid 20s. He was transfused two units
of packed red blood cells and underwent upper endoscopy. The
findings were gastritis , with some small erosions in the antrum and
a subcutaneous nodules , which was biopsied. H. pylori studies were
pending at discharge , as were biopsy results. The patient was
started on Prilosec 20 mg every day and will continue with this for
several weeks. Aspirin was held , as the patient's EGD findings
were felt to be consistent with NSAID gastritis. Iron studies
obtained were not entirely consistent with iron deficient anemia.
The serum iron was low. However , the ferritin and TIBC were within
the normal range. Further workup of the patient's anemia will take
place as an outpatient.
Chronic renal insufficiency: The patient's creatinine increased
from admission value of 2.0 to 2.5. This was felt to be secondary
to diuresis , and the patient's diuretic dose was decreased. The
patient will need to have outpatient follow-up of his creatinine.
DISCHARGE MEDICATIONS:
1. Albuterol inhaler two puffs as needed for shortness of breath
and wheezing.
2. Prilosec 20 mg every day
3. Symvastatin 10 mg every day
4. Nitroglycerin sublingual as needed for chest pain , pressure or
tightness.
5. Aldomet 750 mg three times a day
6. Minoxidil 2.5 mg every day
7. Lisinopril 80 mg every day
8. Hydralazine 100 mg three times a day
9. Lasix 80 mg every day
10. Iron sulfate 300 mg twice a day
DISPOSITION: The patient was discharged to home. He will follow
up with his primary care physician , Dr. Vogelsberg , on
10/1/98 at 9:15 a.m. Condition upon discharge is good.
Dictated By: LONNY DIVELBISS , M.D. RD71
Attending: LASHANDA L. BACHMANN , M.D. XR66
XG847/5564
Batch: 17330 Index No. FNGINS7H8H D: 6/13/98
T: 10/1/98
Document id: 949
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473845822 | PUO | 05055944 | | 0871903 | 10/5/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/5/2005 Report Status: Signed
Discharge Date:
ATTENDING: HAMBLET , BRITTANEY M.D.
ADMISSION DIAGNOSIS: Septic shock from right prosthetic knee ,
infection with MRSA.
HISTORY OF PRESENT ILLNESS: Mr. Halston is an 83-year-old
gentleman with a history of coronary artery disease , congestive
heat failure , diabetes , and chronic renal insufficiency , status
post bilateral knee replacement 10 years prior who presented to
an outside hospital on the February , 2005 , with one day of mild
confusion , fever , and lethargy. He was initially thought to have
left lower lobe pneumonia , but subsequently left knee effusion
was noted and an arthrocentesis was performed with consistent
with septic arthritis. He was admitted to the hospital for
broad-spectrum antibiotics ( cefepime and vancomycin ) and
subsequently developed hypotension requiring vasopressor support
with dopamine as well as an increased oxygen requirement. His
sepsis was also marked by acute renal failure , mental status
changes , and a non-ST elevation MI. He was transferred to
Pagham University Of per family request.
At the time of admission , the patient was lethargic but
interactive , orient to person and place and complained of
fatigue , but denied any pain or chest pain or shortness of
breath.
REVIEW OF SYSTEMS: Obtained from family , disclosed one week of
left leg and hip pain , low grade fevers , lethargy , and increased
high-grade fevers starting the day prior to admission. The
patient had no recent travels , sick contacts , trauma , or
exposures.
PAST MEDICAL HISTORY: Hypertension , coronary artery disease ,
diabetes complicated by neuropathy , retinopathy , and nephropathy ,
congestive heart failure , hyperlipidemia , chronic renal
insufficiency , status post distant left nephrectomy for unclear
reasons , neuroendocrine tumor , status post chemotherapy and
reception , and esophageal reason felt to be cured , status post
bilateral total knee replacement , status post right total hip
replacement , DVT , PE , status post IVC filter , and chronic lower
extremity lymphedema.
MEDICATIONS AT TRANSFER: Vancomycin , cefepime , atenolol , and
lisinopril.
MEDICATIONS AT HOME: Atenolol 50 orally every day , Lipitor , lisinopril
10 mg orally every day , and Lasix 40 mg orally every day
ALLERGIES: NKDA.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with his wife and denies any
tobacco , alcohol , or drug use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.8 , heart rate
80 , blood pressure 91/52 , respirations 18 , and satting 95% on 6
liters of nasal cannula. The patient was noted to be lethargic
but otherwise had no acute distress. He was oriented to person
and place. Lungs examination revealed a few basilar crackles ,
but otherwise was clear. Cardiac examination had a regular rate
and rhythm with 2/6 systolic ejection murmur at left sternal
border nonradiating. Abdomen was unremarkable. His right knee
had a large effusion with erythema , tenderness to palpation , and
limited range of motion.
LABORATORY DATA ON ADMISSION: Notable for a sodium of 132; a
potassium of 5.1; and a creatinine of 4.0 , up from a baseline of
1.5. White count was 11 , hematocrit was 37.6 , and platelets were
217. Lactic acid was 0.8. Troponin was 0.71. LFTs were within
normal limits.
DIAGNOSTIC DATA: Chest x-ray revealed poor inspiratory effort
and question of left lingular infiltrate , mild pulmonary edema ,
and a calcified left anterior descending artery. EKG showed
normal sinus rhythm with incomplete right-bundle branch block , 2
to 3 mm SCD depression in the V3 through V5.
Micro from January , 2005 , Staphylococcus aureus with
sensitivities pending. Blood cultures form January , 2005 ,
Gram-positive cocci , speciation and sensitivities pending.
IMPRESSION: This is an 82-year-old gentleman with septic shock
likely secondary to infection of his right prosthetic knee
complicated by bacteremia , acute renal failure , myocardial
injury , and mental status changes.
HOSPITAL COURSE BY SYSTEMS:
1. Infectious Disease. The patient was found to have MRSA ,
septic arthritis complicated by septic shock , bacteremia and
acute renal failure. He was brought to the operating room with
removal of his prosthetic knee and debridement of his surrounding
area with drain replacement. He was started on a 42-day course
of vancomycin 1 g every 12 hours and is currently on day #18 as of
February , 2005. He was also noted to have pneumonia on the
left side that bronchoscopy was also thought to be MRSA
pneumonia. Per ID consult , he was started the linezolid for
better lung penetration and is currently on day #8 of 14. He has
been afebrile now with negative cultures since then. Of note , on
bronchoscopy , there was cytopathic changes consistent with HSV
infection , and he was treated with a course of acyclovir also per
infectious disease this is probably unnecessary and presented
contamination from an old lesion.
2. Pulmonary. The patient had a nosocomial pneumonia with MRSA
and was intubated for inability to handle secretions and mental
status changes. He had a tracheostomy placed and has been
tolerating that breathing on trach collar during the day and
resting on pressure support of 5 and 5 overnight. BBG are
followed with a PC02 goal of less than 55 and a pH of greater
than 7.30 when these were correlated to his arterial blood gas.
3. Cardiovascular. The patient was noted to be in distributive
shock on Neo-Synephrine with a troponin leak secondary to demand
physiology. He had an echo performed , which demonstrated
diastolic dysfunction and preserved ejection fraction. He also
had an episode of atrial fibrillation with rapid ventricular
response in the setting of an acute septic shock. He is
currently in normal sinus rhythm with cardiac enzymes having
resolved. He has been maintained on aspirin , Lipitor , and
Lopressor for blood pressure and rate control.
4. Renal. The patient was noted to be in acute renal failure ,
which is now resolved and with a creatinine at back to baseline
of 1.2 to 1.5.
5. Hematology. The patient has anemia of chronic disease with
crit at baseline of 30. He should be transfused for transfusion
goal of 26 , although there has been no evidence of acute blood
loss during his hospital course other than perioperative excepted
acute drop in crit which is now resolved.
6. Endocrine. The patient was on 50 units of Lantus as an
outpatient but did have episodes of hypoglycemia in the setting
of sepsis and poor nutritional status. He is currently on Lantus
20 units , which can be slowly increased if his blood sugars are
running high. Additional glucose management can be maintained
with sliding scale insulin.
7. Pain/Psych. The patient had peristent delirium likely the
combination of infection pain , ICU delirium , and treatment with
Versed and fentanyl. He had a head CT , which was negative for
any acute process , and once his intravenous narcotic and
benzodiazepine were stopped , his delirium rapidly cleared over 24
to 48 hours. The patient is now on a fentanyl patch for pain
control , which can be increased as his sensorium clears and
Haldol was effective for agitation as well.
8. Gastrointestinal/FEN. The patient had PEG placement to
supplement nutrition and has been tolerating tube feeds without
difficulty.
9. Prophylaxis. The patient was maintained on Nexium and
subcutaneous Lovenox.
10. Code Status. The patient is full code.
eScription document: 4-2963461 SSSten Tel
Dictated By: BOWARD , SHAINA MURIEL
Attending: HAMBLET , BRITTANEY
Dictation ID 0494443
D: 11/10/05
T: 11/10/05
Document id: 950
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| output/system_intuitive_annotation.xml | intuitive |
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746456498 | PUO | 15046065 | | 455796 | 3/10/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/6/1990 Report Status: Unsigned
Discharge Date: 5/7/1990
CHIEF COMPLAINT: Back pain with radiation to left leg.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old black
female who is status post a motor
vehicle accident in approximately 1968 and then again a fall in
1978. She complained of increasing lower back pain with radiation
to the left lower extremity for several months. This pain is now
accompanied by numbness in the left lateral aspect of the upper
leg , lower leg and foot with increasing pain and weakness. She was
unable to stand for long periods of time secondary to the pain and
the weakness and wears a brace on the leg. A CT scan in 1/11
showed spinal stenosis secondary to a disk bulging and facet joint
degeneration at level L4 to L5 with a grade I L4-5
spondylolisthesis and an L5-S1 central disk herniation with a left
nerve root impingement. PAST HISTORY: Hypertension; cardiomegaly;
total abdominal hysterectomy; tonsillectomy; right toe surgery.
She is gravida 0. MEDICATIONS ON ADMISSION: Isordil 10 mg orally
twice a day; Dyazide 50 mg orally daily. ALLERGIES: Aspirin causes GI
bleeding. SOCIAL HISTORY: She does not smoke; moderate alcohol.
No dietary restrictions. She is a divorced retired laundry worker.
FAMILY HISTORY: Remarkable for hypertension and myocardial
infarction. REVIEW OF SYSTEMS: Unremarkable except for dyspnea on
exertion and paroxysmal nocturnal dyspnea and the complaints noted
above.
PHYSICAL EXAMINATION: Afebrile; vital signs stable; height 5'11";
weight 185 pounds. She presented as a
moderately obese black female in no apparent distress. The skin
was clear. The nodes were normal. The extraocular motions were
intact; pupils equal , round and reactive to light. The oropharynx
was benign. The lungs were clear. The cardiac exam revealed a
regular rate and rhythm; S1 and S2; no rubs , murmurs or gallops.
The peripheral pulses were intact. The abdomen was obese; positive
bowel sounds; no masses or organomegaly noted. Cranial nerves
II-XII were intact. Motor was grossly intact. Sensation was
decreased in the distal left lower extremity. She had global
hyperreflexia. Toes were downgoing bilaterally. She had a
positive left straight leg raise causing lower back pain.
HOSPITAL COURSE: The patient was taken to the operating room on
11/12/90 , where she underwent an L3-4-5 spinal
decompression laminectomy for spinal stenosis. At surgery there
was no any significant disk bulging noted , therefore , a diskectomy
was not performed. Postoperatively she did very well. Her only
significant complaint was of a burning sensation in the left
lateral thigh and occasionally in the right lateral thigh episodic
in nature. She claimed that she had had a burned injury to her
left lateral thigh in the past that had caused these burning
sensations to exist prior to her recent surgery. These sensations
were also relieved somewhat by ambulating , and it was felt that she
may have had some transient pressure on her lateral cutaneous
nerves during surgery and during her bedridden course following the
operation.
DISPOSITION: She was discharged following physical therapy
treatment on 3/11/90. FOLLOW UP will be in three
weeks in the orthopedic clinic with Dr. Xiang MEDICATIONS ON
DISCHARGE: Same as on admission plus Tylenol #3.
________________________________ NX927/2680
EVERETT IRIAS , M.D. XZ9 D: 8/19/90
Batch: 6898 Report: F9855P63 T: 1/10/90
Dictated By: MOSHE J. SHUGRUE , M.D. IH44
Document id: 951
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332233188 | PUO | 25167852 | | 042215 | 11/20/2000 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/27/2000 Report Status: Signed
Discharge Date: 3/26/2000
PRINCIPAL DIAGNOSIS: DYSPNEA.
OTHER DIAGNOSIS: CORONARY ARTERY DISEASE , DIABETES MELLITUS
AND STATUS POST CVA.
CHIEF COMPLAINT: 66 year-old male complaining of shortness of
breath times six months.
HISTORY OF THE PRESENT ILLNESS: At baseline the patient exerts
himself without significant chest
pain or pressure. Last February he recalls the onset of shortness
of breath gradually over several months time. Maximal exertion has
been limited by walking utilization at one-quarter mile with
significant symptoms fatigue. The development of severe shortness
of breath occurred most rapidly eight days prior to admission when
he experienced air starvation while getting into a car associated
with significant difficulty with speech and slurring times two
minutes. There was no muscle weakness , visual change , loss of
consciousness , palpitation , but the patient did feel as if he was
about to lose consciousness. Mr. Maleszka also denied labored
breathing , though his breathing was noted to be shallow and
improved immediately thereafter. There was cough associated with
post nasal drip but not hemoptysis. He admitted to left sided
chest pain lasting 30 seconds which was believed not to be cardiac
by his outpatient cardiologist , Dr. Nanci Gort On 10/20 he
was admitted to Tionmark Hospital for two days where echocardiogram
was performed as well as a chest x-ray and he was ruled out for
myocardial infarction. A VQ scan was then arranged for 5/20 at
which time he also had a Dobutamine Sestamibi scan. The test were
not available at the time of his admission the I Warho Hospital on 11/9 At the time of his admission he denied any
shortness of breath though admitted to shortness of breath with
minimal exertion.
MEDICATION: NPH Insulin , Regular INsulin , Glucophage and Aspirin.
PAST MEDICAL HISTORY: ( 1 ) Coronary artery disease. No history of
myocardial infarction. ( 2 ) Status post
coronary artery bypass graft October , 1995 after acceleration of
anginal chest pain. Catheterization at that time had revealed 60%
proximal left anterior descending lesion , totally occluded circ and
50% ramus with an right coronary artery mid-85% stenosis. Left
ventricular ejection fraction was 61% at that time. Coronary
artery bypass graft in 1995 was LIMA to LAD , SVG to PDA , SVG to
Ramus , SVG to OM. Sestamibi scan performed in July of hte year
2000 demonstrated 5 out of 20 segments of mild inferior ischemia
with increased right ventricular uptake. ( 3 ) Insulin dependent
diabetes mellitus diagnosed in 1980. ( 4 ) Cerebrovascular accident
1997 with residual right lower extremity motor debilitation and
word finding. ( 5 ) P32 , Calcium 45 , Carbon 14 exposure at work.
SOCIAL HISTORY: The patient is a microbiologist at Eepidssun No Sterrock , works on virus in Lan Ma Mer harbor and
lives in Worth He has a tobacco history significant for 35
pack years of pipe and cigarette smoking. He has no significant
alcohol history.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2 , Heart rate
66 , Blood pressure 144/84 , 96% O2 sat on
room air. NECK: JVP was at 8 cm , carotids 2+ bilaterally without
bruit and no lymphadenopathy. HEART: Regular rate and rhythm with
a loud P2 at the left upper sternal border and S4. LUNGS: Clear
to auscultation bilaterally without wheezes or crackles. ABDOMEN:
Obese , nontender , nondistended with normal abdominal bowel sounds
and a palpable liver margin. Right rib cage nontender.
EXTREMITIES: Demonstrated 1+ bilateral pitting edema with palpable
pulses bilaterally , they were cool.
LABORATORY EVALUATION: Normal electrolytes with serum creatinine
of 0.8. White blood count 9.7. Hematocrit
32.2. Platelets 225. Serial CK's were obtained and were 35 , 36 ,
and 31. Dedimer was 411. Troponin I was 0.01. Electrocardiogram
demonstrated atrial flutter with a 4 to 1 block at 65 beats per
minute without ST-T wave changes. He ambulated times four minus
with a D sat from 95% to 90 to 92 %.
HOSPITAL COURSE: This 66 year-old male with coronary disease ,
status post coronary artery bypass graft with an
Insulin dependent diabetes mellitus complained of excellerating
shortness of breath times six months with minimal exertion. After
a presentation with low intermediate pre-test probability for
pulmonary embolus , we obtained a VQ scan that was determiend to be
intermediate probability. The patient was then referred for a
coronary angiography. This was performed on 2/23 and revealed
three vessel native coronary disease and one occluded bypass graft.
Left anterior descending artery had a discrete mid 50 % stenosis
occluded distally. The ramus had a smooth discrete 80% stenosis.
The left circumflex artery was totally occluded proximally. The
right coronary artery was also totally occluded but in the
midportion. Of the graft , the left internal mammary artery to the
left anterior descending was patent. Saphenous vein grafts to the
ramus was totally occluded at the Tessio site. SVG to the right
coronary artery was patent. Lower extremity noninvasive studies
were negative for deep venous thrombosis. The patient's dyspnea on
exertion was deemed to be due to left ventricular diastolic
dysfunction and the patient was discharged on appropriate
anti-hypertensive and ischemic medical regimen for follow up with
his cardiologist , Dr. Cara Barnaba on 5/29 in stable condition.
MEDICATION AT THE TIME OF DISCHARGE: Aspirin 325 mg orally every day ,
Atenolol 50 mg orally every am , NPH
Humulin Insulin 20 units every day before noon , 4 units every bedtime subcutaneously , Regular
Insulin on a sliding scale , lisinopril 10 mg orally every day before noon , Sublingual
Nitroglycerin as needed for chest pain every 5 minutes times 3 ,
Simvastatin 20 mg orally every bedtime , Micforman 1 gram orally twice a day , Plavix 75 mg orally
every day before noon , Lasix 20 mg orally every day before noon
Dictated By: LEOLA MUSICH , M.D. OU90
Attending: GWYNETH A. DEPSKY , M.D. LK79
ZD500/3713
Batch: 45470 Index No. UZJD4L8TX1 D: 9/11
T: 1/6
Document id: 952
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748699567 | PUO | 83028988 | | 7056381 | 4/18/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 4/18/2006 Report Status: Signed
Discharge Date: 10/28/2007
ATTENDING: CASSEM , JERAMY MD
ADMISSION DIAGNOSIS:
The patient is admitted for a right gluteal hematoma.
HISTORY OF PRESENT ILLNESS:
The patient is a 62-year-old man with coronary artery disease
status post recent bare metal stenting in August ,
hypercholesterolemia , CLL and peripheral arterial disease and
admitted for increasing right thigh pain and falling
hematocrit at rehabilitation. The patient had a complicated
hospitalization in August where he presented with a severe
right MRSA infection of his right lower extremity. During
hospitalization , he required a revascularization prior to
undergoing surgery and had a bare metal stent placed to his left
anterior descending artery. After his stenting , he underwent a left BKA to
eradicate his left lower
extremity infection and was later noted to have a
right upper extremity clot associated with central venous catheter. The
patient was discharged from the hospital in August on Lovenox
80 mg twice daily and on Coumadin with the plan that his Lovenox
be stopped at the time of his Coumadin reaching a therapeutic
level. He was also discharged on aspirin and Plavix for his bare
metal stent. On the day prior to admission , the patient was
noted to have a hematocrit of 24 at rehab and on the day of
admission the Hct rechecked and was found to be 18. For this , he was
transferred to the Pagham University Of for further
workup. The patient denies any blood in the stool , melena ,
dizziness or lightheadedness. He does note some pain on his
right side , particularly his right upper thigh and gluteal
area. He denies any recent trauma. He felt some weakness in his
right leg but has had no paresthesias or pain. He states that
his leg has been at all times warm.
ED COURSE:
The patient was noted to be guaiac negative and complained of
some mild abdominal fullness. He received an abdominal CT , which
showed a very large right gluteal hematoma with a fresh fluid
levels suggesting acute bleed. The patient was given packed red
blood cells and was noted to have a potassium level of 5.8 for
which he received Kayexalate.
PAST MEDICAL HISTORY:
Type II diabetes , hypertension , coronary artery disease status
post MI in 1997. He had a nonST elevation MI in 3/29 for
which he underwent catheterization. Catheterization at that time
showed an 80% left anterior descending lesion , which was stented
to 0 with a bare metal stent , 80% diagonal and first diagonal
lesion and a 100% circumflex lesion. The patient has known
significant peripheral vascular disease status post left TMA in
4/3 with fem-pop in 4/3 , left foot debridement in 5/26
and finally a left BKA in 6/26 He has congestive heart
failure with last ejection fraction of 32% , hyperlipidemia , gout ,
CLL status post fludarabine x4 cycles in 2004 in which has been
stable with no evidence of residual or retroperitoneal
lymphadenopathy , BPH , chronic kidney disease with a baseline
creatinine of 2.5 , and glaucoma.
ADMISSION MEDICATIONS:
Include aspirin 325 mg , Niferex 150 mg daily , Lasix 80 mg twice a day ,
Colace 100 mg twice a day , Lovenox 80 mg twice a day , Plavix 75 mg daily ,
diltiazem 60 mg three times a day , hydralazine 20 mg three times a day , Lantus 42 units
at night , NovoLog 10 units with meals , Lopressor 75 mg every 6 hours ,
Zocor 40 mg at night , Flomax 0.4 mg daily , Coumadin 10 mg daily ,
multivitamin , vitamin C , zinc 220 mg daily , Neurontin 100 mg
twice a day , Xalatan one drop in the left eye every evening.
ALLERGIES:
His allergies include codeine.
PHYSICAL EXAMINATION ON ADMISSION:
The patient was in no acute distress. Normocephalic , atraumatic.
His eyes were anicteric. His extraocular membranes were intact.
Mucous membranes were moist without exudates. His neck was
supple , with full range of motion. He had 2+ carotid pulses on
both sides without any evidence of bruits. His jugular venous
pressure was approximately 8 cm of water at 30 degrees of
elevation. His lungs were notable for bibasilar crackles with
left side greater than right. Cardiovascular exam: He had
regular sinus rhythm with normal S1 and S2 , and he had a I/VI
systolic ejection murmur at his base. This seemed to radiate to
his axilla. His abdomen was soft , nontender , and nondistended.
He had normal bowel sounds in all four quadrants , no
hepatosplenomegaly or masses. His extremities are notable for a
right-sided gluteal hematoma with fullness and thickening. He
does have 1+ palpable DP pulse on that side confirmed with
Doppler. Skin was without rash , ecchymosis , or petechiae. His
neurological exam was intact. He was alert and oriented x3.
Cranial nerves II through XII were grossly intact. He had intact
motor and sensation in his right lower extremity along with ,
however , was noted to have a baseline neuropathy with sensory
loss up to his admission.
Admission EKG is normal for normal sinus rhythm , normal axis , old
T-wave inversions in I and aVL and an isolated ST elevation in
lead 2.
Notable studies during this admission included CT of the abdomen
on admission which showed a new right gluteal hematoma with fluid
levels suggesting acute bleed.
ADMISSION LABS:
Potassium 5.8 , creatinine 2.1 , hematocrit of 22.3. He had an MRI
of his brain done on 5/29/06 which showed subacute infarction on
the right anterior internal capsule and chronic occlusion of the
left internal carotid and old left parietal stroke. He had an
echocardiogram done on 10/1/06 with an ejection fraction of
30-35% , trace aortic insufficiency , trace mitral regurgitation ,
trace tricuspid regurgitation and PA systolic pressures of 33+
right atrial pressure.
IMPRESSION:
This is a 62-year-old man admitted for a falling hematocrit with
an evolving right gluteal hematoma secondary to supratherapeutic
anticoagulation.
HOSPITAL COURSE BY PROBLEM IS AS FOLLOWS:
1. Right gluteal hematoma. The patient was admitted for low
hematocrit in the setting of being on multiple anticoagulant and
antiplatelet drugs. He was found to have right gluteal hematoma
which was responsible for his acute hematocrit drop. His
Coumadin , Lovenox , aspirin , and Plavix were initially held. He
received vitamin K and three units of FFP to reverse his
coagulopathy. He was also transfused a total of 6 units of PRBCs
for a goal hematocrit of 30 given his cardiac and neurologic
disease as described below. There was no evidence of further
hematocrit drop. Given that he had been anticoagulated due to
right upper extremity DVT and that the indication for
anticoagulation in the setting and catheter associated clot is
somewhat murky , it was felt that the patient would not benefit
from addition of anticoagulation and therefore his Lovenox and
Coumadin were discontinued. He was restarted on his aspirin and
and his Plavix and his Hct remained stable.
2. Non-ST-elevation MI. The patient was admitted in August
and was known to have three-vessel coronary disease and had
underwent stenting of his LAD with a bare metal stent on
6/28/06. After discussion with the cardiologist , he was stopped
on aspirin and Plavix given the evolution of hematoma and his
acute hematocrit drop. During his lowest hematocrit period , the
patient was noted to have lateral ST depressions and this
corresponded to a troponin leak with a peak troponin of 2.46.
The etiology of this was felt to be demand related to his
profound anemia and on correction of his anemia , the patient's ST
depressions resolved fully and his troponins trended downward.
The patient was known to have a presumed ischemic cardiomyopathy
following his nonST elevation MI. He was found to have an
ejection fraction of 30-35%. He will
need to have a repeat echocardiogram done in one month's time to
assess whether or not he would benefit from an implantable
cardiac defibrillator. The patient's blood pressure medications
were adjusted as follows. His blood pressure medications were
initially held due to his stroke-like symptoms at the time of
admission when his low hematocrit. As detailed below , however ,
they were slowly added back. He tolerated slow titration of
beta-blocker to goal heart rate and also addition of an ACE
inhibitor which was felt to be important given his extensive peripheral
vascular disease and his
low ejection fraction.
3. Recrudescence of stroke-like symptoms in the setting of the
patient's acute hematocrit drop. The patient was noted to have
worsening slurred speech and a right facial droop. He does carry
a history of left internal carotid occlusion and left-sided
stroke in the past. The Neurology team was consulted for these acute deficits
and requested an MRI. The MRI showed basically old known strokes and a
subacute right
internal capsule stroke that was felt to be unrelated to his
current symptomatology. He initially had his
antihypertensives to allow for maximal perfusion pressure. However , as
his coagulopathy resolved , it was felt that the stress that
resulted in the recrudescence of his old stroke-like symptoms was
resolved and he was able tolerate , further addition of his
antihypertensives without further incident.
DISPOSITION:
The patient was seen by physical therapy and given his recent
below the knee amputation , it was felt to be best served by going
back to rehab.
DISCHARGE MEDICATIONS: His discharged medications are as
follows:
1. Tylenol 650 mg every 4 hours as needed pain.
2. Aspirin 325 mg daily.
3. Colace 100 mg twice daily.
4. Lovenox 40 mg subcutaneously daily.
5. Nexium 40 mg daily.
6. Lasix 80 mg in the morning and 40 mg at night which his IO
goals should be about -500 cc of fluid per day.
7. Neurontin 100 mg twice a day
8. Aspart 10 units subcutaneous with meals.
9. Aspart sliding scale.
9. Glargine 42 units daily.
10. Xalatan one drop.
11. Lisinopril 15 mg daily.
12. Toprol-XL 200 mg daily.
13. Niferex 150 mg daily.
14. Zocor 40 mg at night.
15. Flomax 0.4 mg daily.
16. Multivitamin one tablet daily.
17. Zinc 220 mg daily.
18. Plavix 75 mg orally daily
FOLLOW-UP PLAN:
The patient is to call his primary care physician , Dr. Normand Bennes and his cardiologist , Dr. Coddington , following
discharge from rehabilitation. At that time , he should have
repeat echocardiogram to assess his candidacy for an implantable
cardiac defibrillator.
eScription document: 9-0339202 EMSSten Tel
Dictated By: OLDOW , TOMAS
Attending: CASSEM , JERAMY
Dictation ID 4883000
D: 4/30/06
T: 4/30/06
Document id: 953
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254205130 | PUO | 39410221 | | 9583133 | 3/26/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 7/3/2005 Report Status: Signed
Discharge Date: 11/13/2005
ATTENDING: TONI , CARMELITA M.D.
PRINCIPAL DIAGNOSES:
Coronary artery disease and aortic stenosis.
HISTORY OF PRESENT ILLNESS:
A 78-year-old gentleman with a history of hypertension ,
non-insulin-dependent diabetes mellitus and hyperlipidemia who
has had two prior MIs with a history of peripheral vascular
disease , coronary artery disease , hypertension , and diabetes who
presented to an outside hospital on 9/4/05 with shortness of
breath , cough , minimal chest pain , left-sided arm uneasiness ,
nausea , and a single episode of vomiting. His symptoms were
relieved with sublingual nitroglycerin and Lasix. Cardiac
enzymes were noted to be mildly elevated. An echocardiogram was
obtained which estimated his ejection fraction at 20%-25% and
noted aortic stenosis , mitral regurgitation , and a left-to-right
shunt. The patient underwent cardiac catheterization on
4/10/05 , which revealed triple vessel disease. He is
transferred to Pagham University Of on 4/10/05 for
surgical evaluation.
PAST MEDICAL HISTORY:
Coronary artery disease status post MI x2 , hypertension ,
peripheral vascular disease , diabetes mellitus on orally agent ,
hypercholesterolemia , COPD on bronchodilators , ischemic
cardiomyopathy , and peptic ulcer disease , and GERD.
PAST SURGICAL HISTORY:
Includes a left carotid endarterectomy done in 1997 and TURP.
FAMILY HISTORY:
Positive for coronary artery disease.
SOCIAL HISTORY:
Positive for smoking.
ALLERGIES:
Aspirin causing gastritis , Keflex causing hives , and Bactrim
causing hives.
MEDICATIONS ON ADMISSION:
Include Toprol 75 mg orally daily , fosinopril 20 mg orally daily ,
digoxin 0.125 mg orally daily , Plavix 75 mg orally daily , Lasix 40 mg
orally daily , albuterol , ipratropium two puff as needed , atorvastatin
40 mg orally daily , Protonix 40 mg orally daily , glyburide 5 mg orally
every day before noon , and Avandia 8 mg orally daily. The patient is also on
heparin at 500 units an hour on transfer from outside hospital.
PHYSICAL EXAMINATION:
5 feet 5 inches tall , 75 kilos , temperature 98.2 , heart rate 60 ,
blood pressure 110/60 in right arm , 106/54 in left arm. HEENT:
PERRL. Oropharynx benign. The patient has upper dentures the
lower teeth. He has no carotid bruits but his murmur , but his
radiates to his carotids bilaterally. He has a well-healed
incision on his left neck. Chest: Without incisions.
Cardiovascular: Regular rate and rhythm , 3/6 systolic murmur.
Respiratory: Breath sounds are clear bilaterally. Abdomen: No
incisions , soft , no masses. There is mild ecchymosis on the left
side of his abdomen. Extremities: Mild ankle edema bilaterally ,
mild brown discoloration and left lower leg and ankle , bilateral
lower leg varicosities , mild on right , more prominent on the
left , 2+ pedal pulses bilaterally , 2+ radial pulses bilaterally.
Allen's test in the left upper extremity is normal by pulse
oximeter in the right upper extremity is abnormal by pulse
oximeter. Neuro: Alert and oriented , grossly nonfocal exam.
The patient is hard of hearing and uses a hearing aid.
LABORATORY DATA:
Preoperative chemistries include sodium of 138 , potassium of 5 ,
BUN of 24 , creatinine of 1 , and glucose is 176. Glycosylated
hemoglobin is 5.9. White blood cell count is 6.4 , hematocrit 39 ,
INR is 1.1. PTT is 52. Cardiac catheterization data from
4/10/05 performed at outside hospital includes the following:
30% mid left main , 90% mid LAD , 100% proximal circumflex , 100%
proximal RCA , 100% mid RCA and a right dominant circulation.
There is moderate disease at the origin of the diagonal branch.
The circumflex is totally occluded proximally and has there
antegrade collaterals which opacify a large part bifurcating
obtuse marginal branch. RCA is occluded , antegrade collaterals
to acute marginal , distal RCA and PDA collateralized from the
left circulation. LIMA is widely patent. Ventriculogram notes
inferobasal akinesis , apical akinesis , and anterior hypokinesis ,
1-2+ MR. Hemodynamics PCW is 10 and cardiac index is 2.1.
Echocardiogram from 9/4/05 estimates ejection fraction at 20% ,
notes aortic stenosis with a mean gradient of 17 mmHg and a peak
gradient of 32 mmHg , calculated valve area of 1 cm2. There is
trivial aortic insufficiency , moderate mitral insufficiency ,
trivial pulmonic insufficiency , and diffuse hypokinesis most
notably involving the inferoposterior and anteroseptal walls.
There is a dilated left atrium , CVP of 20 , small left-to-right
shunt consistent with ostium secundum ASD. EKG normal sinus
rhythm at 80 , left bundle-branch block with inverted Ts in I ,
aVL , V5 and V6 , sinus arrhythmia with a first-degree block.
Chest x-ray is within normal limits.
HOSPITAL COURSE:
The patient was taken to the operating room on 1/1/05 and
underwent aortic valve replacement with a 23 mm
Carpentier-Edwards Magna valve. He also underwent CABG x4 with a
sequential vein graft connecting the aorta to D1 and then OM1.
He also has a graft , LIMA to the LAD and another vein graft
connecting the aorta to the PDA. He also underwent a PFO
closure. He was taken to the Intensive Care Unit following
surgery in stable condition. Postoperatively , the patient was
noted to have a hematocrit of 26 and was noted to be guaiac
negative. He was transferred to the Step-Down Unit on
postoperative day 3.
SUMMARY BY SYSTEM AS FOLLOW:
Neurologically: No issues , pain control. Cardiovascular: The
patient was restarted on beta-blocker and an ACE inhibitor. He
was followed by his Cardiology perioperatively. Respiratory:
Blake drain discontinued on postoperative day 3. Post-pull chest
x-ray was noted to be stable. GI: No issues. Renal: The
patient was maintained on Lasix with a good urine output to
support diuresis. Endocrine: No issues , the patient was
followed by the Diabetes Management Service perioperatively for
hyperglycemia. Hematology: The patient was transfused on
postoperative day 3 for a hematocrit of 25. The patient was also
restarted on Plavix as patient has an aspirin allergy. On
postoperative day 4 , the patient was weaned off oxygen and
saturated well on room air. He also maintained sinus rhythm for
the duration of his hospital stay. The patient began ambulating ,
it was noted that he was unsteady on his feet and walks with
assistance , physical therapy consult was obtained for evaluation
as well as rehabilitation screening. Later that day , the patient
noted visual disturbances which included blurriness and wavy
vision that lasted two and a half hours. A CT angio scan was
done and was found to be negative for acute pathology. Neurology
team was consulted and a stat CT angio of the patient's head was
obtained. This study revealed no high-grade stenoses and it was
recommended that an ophthalmology consult be obtained. The
ophthalmologist examined the patient and also found no indication
of pathology. The patient had no further visual disturbances for
the remainder during his hospital stay. The patient was noted to
have a brief period of rate controlled atrial fibrillation on
postoperative day #6 , he converted back to sinus rhythm on his
increased beta-blocker dose. He remained in sinus rhythm for the
remainder of his postoperative stay and continued to work with
physical therapy and improved daily. The patient waited three
days for an available rehabilitation bed.
DISPOSITION:
He is discharged to rehab in good condition on postoperative day
11.
DISCHARGE MEDICATIONS:
Discharged on the following medications: Tylenol 650 mg orally
every 6 hours as needed pain , Colace 100 mg orally three times a day as needed constipation ,
Lasix 20 mg orally daily , potassium slow release 10 mEq orally daily ,
glipizide 5 mg orally twice a day , ibuprofen 600 mg orally every 6 hours as needed
pain , lisinopril 2.5 mg orally daily , Plavix 75 mg orally daily ,
Combivent two puffs inhaled twice a day , Glucophage-XR 500 mg
following breakfast and Glucophage-XR 500 mg following supper ,
Zetia 10 mg orally daily , Protonix 40 mg orally daily , atorvastatin
40 mg orally daily , and Toprol-XL 100 mg orally daily.
FOLLOW-UP APPOINTMENTS:
The patient is to have follow-up appointments with his
cardiologist , Dr. Donald , in one to two weeks and with his
cardiac surgeon , Dr. Toni , in four to six weeks.
eScription document: 5-9143996 EMS
Dictated By: JACOBSON , CHRISTEEN
Attending: TONI , CARMELITA
Dictation ID 0667478
D: 10/8/05
T: 10/8/05
Document id: 954
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237778376 | PUO | 81640922 | | 2769086 | 6/9/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/9/2004 Report Status: Signed
Discharge Date:
ATTENDING: DENISHA MCRORIE MD , PHD
The patient is an LMC patient. Her primary cardiologist is Dr.
Kittell
HISTORY OF PRESENT ILLNESS: Ms. Bellucci is a 50-year-old woman
with coronary artery disease and extensive vascular disease who
presented to the ED with worsening chest pain at rest and at
baseline has exertional chest pain. She had been experiencing
increasing chest pain of late and was referred to CT surgery for
surgical evaluation to correct her CAD and ischemia. She had
been at an office visit on the date of admission with Dr. Colasamte
and began to experience terrible chest pain and Dr. Suyama
referred her to the Pagham University Of ED for an urgent
evaluation. In the ED , she was noted to be afebrile with a
temperature of 98 , blood pressure 91/54 , respirations 16 , and
satting 98% on 2 liters. She was noted on EKG to be in normal
sinus rhythm with 2-mm ST depressions in II , III , and aVF V4
through V6. She was given aspirin , morphine , metoprolol ,
Mucomyst , Ativan , nitroglycerin and was made pain-free and was
sent to the cath lab for the concern that her stent to the
diagonal #1 placed 6/21/04 was no longer patent , as a cause for
her unstable angina. She had been recently told that no further
intervention was possible after her stent to the diagonal #1.
PAST MEDICAL HISTORY: Significant for coronary artery disease
status post CABG in 1996 , which involved LIMA to LAD ( free ) and
SVG to OM1. Peripheral vascular disease. Status post FEM-POP and
fem-fem bypass in 2003. End-stage renal disease status post
cadaveric renal transplant in 1987 , currently immunosuppressed.
IDDM , hyperlipidemia , hypertension , retinopathy , TIA , lower GI
bleed , chronic diarrhea , CMV colitis , anemia , and bladder CA ,
recent diagnosis not yet worked up.
MEDICATIONS ON ADMISSION: Aspirin 81 mg , azathioprine 50 mg a
day , calcium carbonate 650 mg twice a day , Colace 150 mg twice a day ,
lispro sliding scale , Lantus , multivitamin , folate , Lopressor 25
mg three times a day , prednisone 5 mg a day , Zocor 80 mg every bedtime , Plavix 75
mg every day as well as Zetia 10 mg a day.
ALLERGIES: Sulfa , Benadryl , penicillin , and Compazine.
SOCIAL HISTORY: She lives with her husband and has two children.
HOSPITAL COURSE: On admission , Ms. Bellucci was taken to the
cardiac catheterization suite where it was found that her
circumflex was 60% , which had been 60% stenosis , now 100%
stenosed. Her diagonal #1 status post stent was now 100%
stenosed and all other native disease and graft disease was
unchanged. Her right heart cath revealed elevated filling
pressures and PTCA and stent was carried out of the occluded
diagonal #1 stent as well as the LAD , but she became hypotensive ,
bradycardic , and developed cardiogenic shock requiring CPR and
intubation. She had an IBP placed and subsequently an echo was
done to rule out effusion and was negative , but had an apparently
low EF. She had suspected transient decrease in flow to her
septal arteries and this likely compounded her acute myocardial
infarction. Following insertion of the intraaortic balloon pump ,
it was noted that she had absent pulses in her right foot , which
was noted also to be cool to touch. She was transferred to the
CCU , intubated and sedated , unresponsive.
PHYSICAL EXAMINATION: Her JVP was elevated. Her lungs had
coarse breath sounds anterolaterally , but without crackles or
wheezes. Her heart was regular , tachycardic with a gallop and a
3/6 harsh systolic murmur at the base of her heart and a 2/6
holosystolic murmur radiating to the axilla. She had somewhat
decreased bowel sounds , but her belly was soft and nondistended.
Her bilateral lower extremities were cool with absent pulses in
her feet to palpation and her right foot was mottled and was
notably cooler without edema.
LABORATORY DATA: Her CK was over 100 , MB 7 , troponin 0.92 , INR
0.9 , and platelets 191 , 000. She later developed acute renal
failure and dialysis was initiated on Monday , Wednesday , and
Friday schedule. Her echo showed an EF of 30% with severe MR as
well as inferoseptal and inferior akinesis. The balloon pump was
eventually taken out , the dopamine drip was discontinued. She
was stabilized and extubated. She was stable for several days ,
but on 9/1/04 in the evening experienced an episode of unstable
VT arrest requiring shock x 1. no further defibrillation was
needed. She stabilized after her V-TACH arrest and shocking and
per Electrophysiology Service , she was loaded with amiodarone and
has been continued on 200 mg orally every 6 hours after being titrated off
her amiodarone drip.
BY SYSTEMS:
1. Cardiovascular:
a. Ischemia: Ms. Bellucci has terrible coronary artery disease
and no further intervention can be offered to her after
discussion with both Dr. Colasamte 's Surgical team and the EP
Service. She should not undergo any further catheterizations or
revascularization. She is currently on Aspirin , Plavix ,
Lopressor , and Zocor. She was briefly on Lipitor , but this was
discontinued after a bump in her LFTs. She is not on an ACE or
an ARB secondary to her acute renal failure and at the time of
this dictation her renal function remains poor and there are no
plans to restart an ACE inhibitor or ARB.
b. Pump: Ms. Bellucci has ischemic cardiomyopathy with severe
MR and she is undergoing ultrafiltration and regularly is getting
several liters per hemodialysis session as her blood pressure
tolerates.
c. Rhythm: Ms. Bellucci had an episode of ischemic and unstable
ventricular tachycardia requiring shocking. Electrophysiology
evaluated her for the possibility of an AICD placement , but this
has been deferred for now and it is unlikely that she will ever
have an AICD placed , certainly not on this hospitalization. She
has been loaded with amiodarone and is currently on 800 mg a day ,
split into 200 mg every 6 hours orally and after 10 days she should be
changed to 200 mg orally twice a day This will take place on February She initially tolerated amiodarone very poorly secondary
to nausea , so her dose was titrated up gradually.
c. Peripheral vascular disease: Ms. Bellucci has extensive
peripheral vascular disease and Vascular Surgery is following her
for a likely compartment syndrome in her right calf secondary to
ischemia upon insertion of intraaortic balloon pump. She is
having the circumferences of her cath measured once or twice a
day and these have not been increasing , have in fact been
decreasing. Also , her creatinine kinase levels have been
followed as a surrogate for compartment syndrome and these have
been decreasing and are currently normal. At the time of this
dictation , her CK was 75 down from the 10 , 000 range. She was on
heparin for some time and although her cath continues to be
tender , the pain has improved and the function has gradually
returned. Her pulses remained poor. She had lower extremity
noninvasive Dopplers to evaluate her arterial venous flow and no
clot was noted in the venous circulation. There was no comment
made on the FEM-FEM graft , however , but no note was made of an
arterial clot. She should have the circumferences of her right
calf followed closely at the place that they are marked on the
right lower extremity.
2. Renal: Ms. Bellucci has acute on chronic renal failure. She
was admitted with a creatinine of 2.7 and her creatinine has been
up and down depending on the timing of her dialysis; however , she
is relatively anuric , but occasionally produces small volumes of
urine and this should be followed carefully as well. She is
continuing on prednisone and azathioprine for her transplant and
she did have one positive UA , but this is not being treated
because it is difficult to assess secondary to her extremely
concentrated urine , but should be followed if she does produce
urine. This may be permanent , but it is not clear at this point
she may be on hemodialysis indefinitely. She is on fluid
restriction per renal recommendations of 1000 cc per day intake
and her ARB is being held for now.
3. ID: Ms. Bellucci spiked on 11/5/04 to 101.8 and she has
been found to have a line infection with a positive triple-lumen
catheter tip as well as positive blood cultures. She was started
on vancomycin on 4/7/04 and this is being dosed according to
her vancomycin troughs , which are drawn once a day. If her
trough is near or below 15 she should be given one dose of
vancomycin and this has turned out to be approximately every
other day.
4. Heme: Ms. Bellucci 's platelets have been dropping from the
100s to the mid 50s since she was started on amiodarone. It is
not clear what the source is. She has had two negative HIT
antibodies , platelet factor intravenous antibodies , and her platelets
seemed to have stabilized in the high 40s , mid 50s and she is not
showing any signs of acute bleed , but this has been communicated
with Electrophysiology Service who is aware of the possibility
that amiodarone may be causing her thrombocytopenia and the
amiodarone has been continued unless her thrombocytopenia worsens
significantly. She is also on a number of other medications that
may cause thrombocytopenia and these will be followed as well ,
however , it was only the amiodarone for which the timing was
coincident with the drop in her platelets.
5. Pulmonary: Ms. Bellucci has a large right pleural effusion;
it was tapped on 10/14/04 , 600 cc were removed. It was noted to
be transudative. The tap was complicated by the patient slipping
off her bed during the procedure. She was caught and did not
fall , but the pleural effusion was not completely drained and she
developed a small hydropneumothorax. This should be followed.
She also had a CT subsequently to rule out hemothorax and there
was no evidence of that. The pleural effusion is evident on her
chest x-rays with underlying consolidation. There has been no
compromise , however , in her apparent pulmonary status and this
should be followed since it will likely reaccumulate after
tapping , but if she becomes more symptomatic it should be tapped.
6. Ms. Bellucci is on prednisone. For her diabetes , she is on
NPH and an insulin sliding scale.
7. She experienced an increase in her LFTs , her transaminases
bumped to several 100s , and her total bilirubin peaked at 1.8 ,
her alkaline phosphatase also bumped , however , this may have been
secondary to the starting Lipitor and this was discontinued.
They have trended down since then. It is not clear exactly the
source of her increase in LFTs. She has been restarted on Zocor
at a very low dose at 10 mg and this should be titrated up as her
LFTs tolerate. She was on Zocor as an outpatient and we hope
that this is not a class effect and that it is not going to be
related to the dose of her Zocor.
8. GI: Her nausea should be treated with as needed Ativan and
Zofran. She has a Compazine allergy.
9. Code status: Ms. Bellucci is DNR/DNI , but family does desire
that if they may help that pressures in shock can be used.
eScription document: 6-8885694 ISSten Tel
Dictated By: DALONZO , TELMA
Attending: MCRORIE , DENISHA
Dictation ID 3071562
D: 6/28/04
T: 6/28/04
Document id: 955
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292554258 | PUO | 63243218 | | 163399 | 10/15/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 5/25/1991 Report Status: Unsigned
Discharge Date: 4/10/1991
HISTORY OF PRESENT ILLNESS: CHIEF COMPLAINT is coronary artery
disease. The patient is a 48 year old
male with new-onset angina and a positive exercise tolerance test ,
admitted at this time for elective cardiac catheterization. The
patient first noted chest tightness while walking in the cold 4
months ago. He subsequently had a positive exercise tolerance test
at a very short period of time. The thallium test showed
reperfusion in the anteroseptal and apex areas. The cardiac
catheterization this admission showed 50% proximal circumflex , 70%
obtuse marginal branch #2 , mid right coronary artery subtotal
occlusion , and 80% left anterior descending. He had hypokinetic
left ventricular function with an ejection fraction of 55%.
ALLERGIES are no known drug allergies. PAST MEDICAL HISTORY
reveals hypertension and adult-onset diabetes with
hypercholesterolism. MEDICATIONS ON DISCHARGE were Diabeta 10
milligrams by mouth each morning , Vasotec 5 milligrams by mouth per
day , atenolol 50 milligrams by mouth twice a day , iron sulfate ,
allopurinol , Colace , aspirin and ciprofloxacin 500 twice a day
times 5 days. The patient is a former smoker.
PHYSICAL EXAMINATION: The patient was an obese male , with
examination otherwise unremarkable , no
cardiac abnormalities , lungs were clear.
LABORATORY EXAMINATION: Electrolytes were normal preoperatively ,
except for sugar in the middle 150's
range.
HOSPITAL COURSE: The patient was taken to surgery on 15 of November ,
where he underwent a coronary artery bypass
grafting times 3 with left internal mammary artery to the left
anterior descending , left saphenous vein graft to the marginal and
to the posterior descending artery. The patient tolerated the
procedure well. The posterior descending artery graft had to be
lengthened intraoperatively as it was somewhat tight at the time of
sternum closure. There were no persistent ST changes.
Postoperatively the patient did well. He had one event , which was
felt to be vasovagal in nature in which he had an episode of chest
tight and shortness of breath with diaphoresis. However , serial
enzymes and electrocardiograms were normal. This episode occurred
immediately after the patient had overheard a Code Blue on the
intercom , awakening him in the middle of the night. The patient
also had his discharge delayed for approximately 36 hours because
of a very low-grade temperature , which resolved prior to discharge.
He had minimal erythema of the proximal saphenous vein harvest
site , for which he was placed on ciprofloxacin 5 days
postoperatively in orally form.
RX459/2806
JANAY D. STUKOWSKI , M.D. JX47 D: 9/22/91
Batch: 9506 Report: P8692R07 T: 4/6/91
Dictated By: MOSHE J. SHUGRUE , M.D. IH44
cc: 1. EARNESTINE FIERMONTE , M.D.
Document id: 956
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356637867 | PUO | 54795665 | | 298253 | 8/8/1999 12:00:00 a.m. | CHOLECYSTITIS | Signed | DIS | Admission Date: 8/20/1999 Report Status: Signed
Discharge Date: 10/9/1999
DISCHARGE DIAGNOSIS: ( 1 ) CHOLOLITHIASIS. ( 2 ) CORONARY ARTERY
DISEASE.
HISTORY OF PRESENT ILLNESS: Mr. Beckfield is a 68-year-old dutch
speaking man with a known history of
coronary artery disease , who was in his usual state of health until
August , 1999 when he began to developed right upper quadrant pain ,
and was seen by his primary care physician and sent to the
emergency room with a diagnosis of possible early acute
cholecystitis. The patient was admitted to the Surgical Service at
Pagham University Of , but managed medically without a
operative procedure with antibiotics including ampicillin ,
gentamicin , and Flagyl. The quality of the patient's right upper
quadrant pain was noted as sharp and constant with nausea but no
vomiting , fevers , chills , back pain , or urinary symptoms. The pain
lasted several hours postprandially and had no radiation. In
addition , the patient denies chest pain or shortness of breath.
PAST MEDICAL HISTORY: ( 1 ) Coronary artery disease.
( 2 ) Hypertension. ( 3 ) Diabetes.
( 4 ) Hyperlipidemia. ( 5 ) History of posterior thoracic abscess ,
removed in April 1995. ( 6 ) History of scrotal abscess with
necrotizing fasciitis in 1992.
ALLERGIES: No known drug allergies.
MEDICATIONS: ( 1 ) Aspirin 325 milligrams orally every day ( 2 ) Lisinopril
40 milligrams every day ( 3 ) Mevacor 40 milligrams every day
( 4 ) Insulin NPH subcutaneous 50 units every day before noon ( 5 ) Regular
insulin subcutaneous 10 units every day before noon ( 6 ) Nitroglycerin sublingual
as needed chest pain. ( 7 ) Atenolol 50 milligrams every day
SOCIAL HISTORY: The patient lives with his wife , and has smoked
one and one-half packs per day for 34 years. He
has minimal alcohol use and , in fact , has not drank alcohol since
1984.
FAMILY HISTORY: The patient has a family history of hypertension.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.7. Pulse 52.
Blood pressure 98/98. Respirations 18.
HEENT: Anicteric. Oropharynx clear. No bruits. LUNGS: Lungs
are clear to auscultation. CARDIOVASCULAR: Cardiac examination
regular rhythm. Normal S1 , S2. No murmurs , rubs , or gallops.
BACK: Back has no costovertebral angle tenderness. No spinal
tenderness. ABDOMEN: Obese with positive bowel sounds. Right
upper quadrant tenderness and guarding but no rebound , and no
Murphy's sign. EXTREMITIES: No cyanosis , clubbing or edema.
NEUROLOGICAL: Examination was intact.
LABORATORY DATA: Sodium 142 , potassium 4.1 , CO2 102 , bicarbonate
30 , BUN 15 , creatinine 1.0 , glucose 247. WBC at
11.2 , hematocrit 41.2 , platelets 258. ALT 122 , AST 172 , alkaline
phosphatase 211 , total bilirubin 0.7 , direct bilirubin 0.2.
Amylase 38 , Albumin 3.7 , calcium 9.2 , phosphate 3.0. Urinalysis
was negative.
DIAGNOSTIC STUDIES: Electrocardiogram normal sinus rhythm at 62
with no signs of acute ischemia.
Chest x-ray is clear.
HOSPITAL COURSE ( by system ): ( 1 ) Gastrointestinal: The patient
was admitted to the Surgical Service
for , likely , cholecystis , and managed medically. He was made
npo , and hydrated with intravenous fluids and started on triple
antibiotics including ampicillin , gentamicin , and Flagyl. The
patient remained afebrile with a normal white blood count
throughout his hospital course on the Surgical Service. However ,
his alkaline phosphatase and total bilirubin became elevated and
the Gastroenterology Medical Service was consulted for
consideration of ERCP. The patient then underwent ERCP on March , 1999 , where a distal common bile duct stone was noted , and an
attempt at removal of the stone was made. However , the stone could
not be extracted. Therefore , the procedure was aborted , and the
patient was transferred to the Medical Service for further
management. The patient's liver function tests remained stable
after the attempt of the common bile duct stone removal , and he
continued to remain pain free and afebrile. Given the observation
of a common bile duct stone , the GI Service thought it appropriate
to take the patient back for repeat ERCP two days later. Repeat
ERCP showed that there was no residual stone , and no additional
stones were noted. The patient was then advanced on his
diet , which he tolerated with no further symptoms. The patient
continued to be followed by the Surgical Service who recommended ,
then , an elective cholecystectomy as an outpatient at a later date.
( 2 ) Cardiovascular: Given the patient's history of coronary artery
disease , a cardiology consult was obtained by the Surgical Service ,
who then continued to follow the patient once he was transferred to
the Medical Service. Preoperative evaluation for possible
cholecystectomy was performed , and it was noted that the patient's
coronary artery disease included the following history: The
patient had a coronary catheterization in 1995 , which revealed a 30
percent left anterior descending artery , proximal as well as mid
stenosis , as well clean circumflex , 70 to 90 percent obtuse
marginal lesion , and a 40 percent , 40 percent , and 70 percent
serial right coronary artery lesions , as well as a 70 percent
posterior descending artery lesion. At that time , obtuse marginal
angioplasty was performed. An left ventriculogram revealed an
ejection fraction of 69 percent at the time. In January 1996 , the
patient had an exercise tolerance test , in which the patient went
six minutes and 30 seconds with 1 millimeter ST depressions , which
were highly predictive of ischemia , but the patient had no
symptoms , and he refused intervention at that time.
The cardiology consult concluded that given the patient's history
of coronary artery disease , a recommendation was made to perform a
nuclear imaging study to assess the patient's ischemic risk for a
cholecystectomy. An exercise tolerance test MIBI was performed , in
which the patient had a good work load. However , moderate to
severe inferoapical ischemia was noted on MIBI images. Given the
urgent need for ERCP during this hospital course , catheterization
was postponed , and the patient remained chest pain free and symptom
free throughout his hospital course from a cardiology perspective.
He was continued on medications , which included Lopressor ,
lisinopril , and Diltiazem. Persistent hypertension was controlled
by increasing the dose of beta blocker with good response. Aspirin
was held secondary to consideration of ERCP and the possibility of
gastrointestinal bleed. Given that the patient remained symptom
free from a cardiac standpoint , cardiology consult decided that the
patient's cardiac catheterization would be deferred until after
this hospitalization , in light of the possible complications of
adding a TB3A antagonist during percutaneous transluminal coronary
angioplasty in the context of possible ERCP. Therefore , the
patient will be followed up in cardiology for elective
catheterization.
( 3 ) Endocrine: The patient's diabetes was well controlled with his
insulin regimen , which was held while he was npo , as well as on
an insulin sliding scale.
( 4 ) Infectious disease: The patient remained afebrile throughout
his hospital course , but was continued on ampicillin , gentamicin ,
and Flagly per surgery recommendations.
DISCHARGE MEDICATIONS: ( 1 ) Aspirin 325 milligrams orally every day
( 2 ) NPH insulin subcutaneous 50 units
every day before noon ( 3 ) Regular insulin subcutaneous 10 units every day before noon
( 4 ) Lisinopril 40 milligrams orally every day ( 5 ) Nitroglycerin 1 tablet
sublingual every 5 minutes times three as needed chest pain.
( 6 ) Procardia XL 90 milligrams orally every day ( 7 ) Atenolol 50
milligrams orally every day
DISCHARGE ACTIVITY: As tolerated.
DISCHARGE DIET: ADA 2 , 000 calories per day , low saturated fat ,
low cholesterol diet.
FOLLOW UP: The patient will follow up with the surgery clinic for
scheduling of elective cholecystectomy on October ,
1999 , as well as follow up with cardiology for an elective
catheterization.
Dictated By: HERMINA TUOMALA , M.D.
Attending: TRISH CHAIX , M.D. CR95
SL239/3046
Batch: 93100 Index No. XPUGCF43KJ D: 10/12/99
T: 5/10/99
Document id: 957
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138816585 | PUO | 88728999 | | 3446184 | 5/29/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/7/2006 Report Status: Signed
Discharge Date:
ATTENDING: TONI , CARMELITA M.D.
ADMITTING DIAGNOSES: Aortic stenosis , mitral regurgitation.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female
with severe aortic stenosis , moderate mitral regurgitation ,
status post CABG x2 1997 ( LIMA to LAD , SVG to Cx ) , PPM 2004 ,
several stents. She has a valve area of 0.9 cm2 on echo , 1.1 cm2
on cath and is increasingly symptomatic over the past three
months and upon presentation is unable to walk a block. Cardiac
catheterization on day of admission shows patent grafts , with 50%
lesion , SVG to Cx. She also has RCA disease. She was
admitted as planned preop for AVR/MVP.
PREOPERATIVE CARDIAC STATUS: Elective. There is history of
class III heart failure ( marked limitation of physical activity ).
The patient is in a paced rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: In 1997 CABG x2 ( LIMA to
LAD , SVG1 to Cx )/2004 off pump univentricular permanent
pacemaker.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus on orally
hypoglycemics , hypothyroidism , hypercholesterolemia. Elevated
creatinine clearance estimated at 46.22 cc per minute.
PAST SURGICAL HISTORY: GI bleed secondary to AV malformation;
status post TAH; CABG x2 in 1997; status post status PPM 2004.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: History of alcohol use. One drink per week.
ALLERGIES: Contrast nephropathy.
ADMISSION MEDICATIONS: Lopressor 25 orally twice a day , Imuran 100 mg
Monday , Wednesday , Friday/200 mg Tuesday , Thursday , Saturday , and
Sunday , atorvastatin 40 mg orally daily , Gemfibrozil 600 mg orally
daily , Zetia 10 mg daily , sucralfate 1 g four times a day , Prevacid 30 mg
daily , Avapro 300 mg daily , glimepiride 2 mg daily , Actos 15 mg
daily , Synthroid 75 mcg daily , Levobunolol 0.5% daily.
PHYSICAL EXAMINATION UPON ADMISSION: The patient is 5 feet 0
inches in height and 81.8 kilograms. Vital signs: Temperature
96.5 , heart rate 60 , blood pressure right arm 90/45 , blood
pressure left arm 92/56 , oxygen saturation 98% on room air.
HEENT: Patient has equal and round pupils that are reactive to
light and accommodation , dentition without evidence of infection ,
no carotid bruits appreciated. Chest: Midline sternotomy scar
that is well healed. Cardiovascular: Regular rate and rhythm ,
diminished ejection systolic murmur. The patient has the
following pulse exam , she has equal 2+ bilateral carotid pulses ,
equal 2+ bilateral radial pulses , equal 2+ bilateral femoral
pulses , equal 2+ bilateral dorsalis pedis pulses , equal bilateral
1+ posterior tibial pulses. Allen's test to the right and left
upper extremities noted to be normal. Respiratory: The patient
is clear to auscultation bilaterally. Abdominal: Soft abdomen
with no palpable masses , with visible well-healed scar status
post TAH. Extremity: Patient is status post a left SVG harvest.
Neuro: Patient is alert and oriented x3 with no focal deficits.
PREOPERATIVE LABORATORY STUDIES: Chemistries: Sodium 139 ,
potassium 5.1 , chloride 106 , bicarbonate 27 , BUN 40 , creatinine
1.4 , glucose 157 , magnesium 2.0.
CBC: 8.1/35.1/243. Coags: 13.9/30.9/1.1. UA: Negative.
Cardiac catheterization data: Exam was performed on 10/28/06 at
Pagham University Of . Coronary anatomy: 100% proximal
LAD/100% mid Cx/80% ostial OMI/70% distal RCA/65% mid RCA/100%
mid LVB1/right dominant circulation/0% LIMA to LAD/50% proximal
SVG1 to Cx/patent stent Cx. Hemodynamically: PA mean pressure
is 34/PCW 25/cardiac output 5.45/cardiac index 3.06/SVR 910/PVR
143 , aortic stenosis with a calculated valve area of 1.1
cm2/severe mitral insufficiency.
Echo: 8/9/06 ,
65% ejection fraction/aortic stenosis/mean gradient of 24 mm Hg/peak gradient
49 mm Hg/calculated valve area of 0.9 cm2/trivial aortic
insufficiency/moderate mitral insufficiency/mild tricuspid
insufficiency/____ 2.97/LVEDP 39 mm/LVFD 11 mm.
EKG: 10/28/06 notable for a paced rhythm at 60 beats per minute.
Chest x-ray: 10/28/06 , consistent with congestive heart
failure/slight cardiomegaly with increased vascular markings.
BRIEF HOSPITAL COURSE: The patient was admitted for elective
surgery on 10/18/06 with a preoperative diagnosis of
atherosclerotic coronary artery disease , tricuspid regurg , mitral
regurgitation , aortic stenosis. The patient underwent the
following procedures: Reop AVR ( 19 Carpentier-Edwards magna )/MVP
( commisuroplasty )/TVP ( annuloplasty-no ring )/CABG x1 ( SVG1 to
RCA ).
NOTABLE OPERATIVE DETAILS: Bypass time was 211 minutes.
Cross-clamp time of 152 minutes. Two atrial wires and one
ventricular wire were placed. One pericardial Blake drain was
placed. One retrosternal Blake drain was placed and one right
pleural tube Blake drain was placed. For full operative details ,
please refer to the operative note.
Immediately after transferring the patient to an ICU bed from the
OR table , the patient went into a VFib arrest. CPCR was briefly
performed until we could charge the external defibrillator. A
single shot of 125 joules lidocaine 60 mg resulted in sinus
rhythm and stabilization of hemodynamics. The patient was
transferred to the ICU for further postoperative care.
ICU COURSE BY SYSTEM:
1. Neuro: The patient received sedation as required during
intubation. After extubation , the patient was weaned off all
sedating medications and is neurologically intact upon transfer
from the unit.
2. Cardiovascular: The patient was externally paced initially
postoperatively with external pacing wires and then was
transferred back to internal pacing with previously placed
device. The patient was noted to be hypotensive on postoperative
day #1 and a levophed/epinephrine drip was initiated and
titrated for appropriate blood pressures. The patient was weaned
off pressors as tolerated and by postoperative day #3 was not
requiring any intravenous pharmacologic intervention with her blood pressure.
The patient was placed on Lopressor perioperatively and also
received intravenous amiodarone for previous arrhythmia. Upon transfer ,
patient is internally rate controlled with a rate of 90 beats per
minute and stable on a dose of Lopressor 12.5 mg orally four times a day as
well as amiodarone 200 mg orally twice a day
3. Respiratory: The patient was weaned to extubation on
postoperative day #1 without complication. The patient is
currently stable on 2 liters nasal cannula upon transfer from the
unit.
4. The patient received perioperative intravenous fluids for blood
pressure maintenance. These have been weaned to off by
postoperative day #3. The patient received electrolyte
replacement as indicated. The patient has begun on diuresis of
40 mg Lasix orally twice a day upon transfer from the unit. Of note ,
creatinine is 1.3 upon discharge from the ICU which is equal to
the patient's baseline creatinine.
5. GI: The patient's diet is advanced as tolerated after
extubation and was begun on Nexium 40 mg orally daily.
6. Hematologic: The patient received blood transfusions as
indicated , which included 1 unit packed red blood cells on
postoperative day #1 for a hematocrit of 25 as well as 3 units of
packed blood cells on postoperative day #2. Platelet count was
noted to be below 50 on postoperative day #2 and a HIT panel was
sent which was negative x1. The patient has second HIT panel
pending upon discharge from the ICU. Platelets have been noted
to increase to 72 after nadir on postoperative day #2.
7 ID: The patient has had no issues and received appropriate
perioperative antibiotic prophylaxis vancomycin.
8. Endocrine: The patient's blood glucose was noted to be
greater than 150 postoperatively. The patient was placed on
sliding scale intravenous insulin per Portland protocol. The patient has
been weaned off intravenous insulin and discharged from the unit and is
receiving a NovoLog sliding scale as well as standing dosage of 6
units of Novolog before every meal The patient has been maintained on an
ADA diet.
9. Tubes , lines and drains: The patient had chest tube
discontinued on postoperative day #3 without complication.
External pacing wires were removed on postoperative day #4 prior
to transfer from the unit.
DISCHARGE MEDICATIONS UPON TRANSFER FROM UNIT TO FLOOR:
1. Tylenol 325-650 mg orally every 4 hours as needed fever.
2. Amiodarone 200 mg orally daily.
3. Vitamin C 500 mg orally twice a day
4. Enteric-coated aspirin 81 mg orally daily.
5. Lasix 40 mg orally twice a day
6. Synthroid 75 mcg orally daily.
7. Magnesium sulfate sliding scale.
8. Lopressor 12 mg orally four times a day
9. Niferex 150 mg orally twice a day
10. Zocor 40 mg orally nightly.
11. Betagan 0.25% 1 g each eye daily.
12. Levofloxacin 500 mg orally every 48 hours
13. Plavix 75 mg orally daily.
14. Nexium 40 mg orally daily.
15. Novolog sliding scale before every meal and at bedtime
16. Novolog 6 units subcutaneously before meals
eScription document: 4-9581430 EMSSten Tel
Dictated By: PECOT , ANETTE
Attending: TONI , CARMELITA
Dictation ID 2039829
D: 2/5/06
T: 2/5/06
Document id: 958
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186894246 | PUO | 57862173 | | 036239 | 7/15/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/21/1999 Report Status: Signed
Discharge Date: 6/24/1999
ADMITTING DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: Thirty-seven-year-old gentleman with
a history of angina in the past. In
1995 , a work-up was negative with a negative stress test and
treated medically two months ago regarding exertional angina and
progression of angina on day of admission. He was admitted to the
Whid Downdoc Rehabilitation Of at which time his EKG showed supraventricular
changes in 2 , 3 , and ABF with T-wave inversions in 1 , AVL , and
V4-6. He was cathed at that time which showed 100% LAD and 40%
proximal mid-RCA and a 50% proximal posterior LV branch. The
patient was transferred over to the Pagham University Of
for further management and surgery.
On 11/9 , the patient underwent an echocardiogram which showed an
ejection fraction of 55% with mild inferior to posterior
hypokinesis , trivial mitral regurgitation. He was cathed with an
attempt to angioplasty the LAD but failed and had a stent placed
and noted to have an LAD dissection. Thus , the patient was
referred for surgical intervention with coronary artery bypass
grafting.
PAST MEDICAL HISTORY: Significant for coronary artery disease ,
hypercholesterolemia , hypertension , motor
vehicle accident in 1983 complicated by contusion with slurred
speech and wrist and rib fractures along with multiple facial
lacerations.
PAST SURGICAL HISTORY: As stated above due to motor vehicle
accident. He had a hematoma of his right
neck which needed to be surgically evacuated.
ALLERGIES: No known drug allergies.
MEDICATIONS: Nitroglycerin 1.5 every 6 hours , Simvastatin 20 mg orally
every bedtime , Lopressor 50 mg orally three times a day , aspirin 325 mg
orally every day On the unit , he was on tirofiban intravenous.
FAMILY HISTORY: Very significant with father dying of a
myocardial infarction in his 40s , four uncles who
died of a myocardial infarction in their 30s to 40s.
SOCIAL HISTORY: Positive for ETOH with one drink per day.
Stopped smoking a month ago one pack a day x 18
years. He stopped on 7/4 , the day of admission.
PHYSICAL EXAMINATION: Afebrile , sinus rhythm 66 , blood pressure
95/60 on room air at 96%. HEENT:
Nonicteric , fair dentition , no orally lesions. Neck: No evidence of
bruits. Scar on the right neck secondary to motor vehicle
accident. Cardiac: Regular rate and rhythm , no evidence of
murmurs , gallops or rubs. Lungs: Clear to auscultation. No
evidence of rales , wheezes , or rhonchi. Abdomen: Positive bowel
sounds , soft , non-tender. No evidence of hepatosplenomegaly.
Extremities: No evidence of edema or varicosities. Scar to the
right knee secondary to laceration. Vascular: 2+ pulses
throughout with a patent Allen on the left hand. Neurological:
Alert and oriented x three. Grossly non-focal.
LABORATORY DATA: Within normal limits. A chest x-ray showed
no acute pulmonary disease. EKG was in normal
sinus rhythm. The patient was referred for coronary artery bypass
grafting.
HOSPITAL COURSE: The patient was admitted on 9/8/99 to the
Coronary Care Unit and was taken down to the
Catheterization Laboratory with attempt to angioplasty his LAD but
failed angioplasty and had a stent placed and noted a dissection of
his LAD. The patient was started on tirofiban , Heparin , and intravenous TNG
and referred to the cardiac surgeons for coronary artery bypass
grafting. The patient was also seen by the Plastic Surgery Service
for evaluation of a radial harvest for graft conduit. The patient
had positive patent arch by Allens on the left. The patient was
right handed so it was consented for a left radial harvest. The
patient was taken to the Operating Room on 10/6 and underwent a
coronary artery bypass grafting x four with a LIMA to the LAD , a
radial artery to the second diagonal , and a saphenous vein graft
sequential to the patent ductus arteriosus and posterior LV branch.
The patient on examination of his LAD was found to have a
dissection in the mid-portion from the previous PTCA about 2.5 to
3.0 cm. Anastomosis was done with the LIMA and the two layers of
the LAD artery was reattached with suture.
The patient came off the heart lung machine with no difficulty and
was taken to the Cardiac Surgery Intensive Care Unit and was
extubated on post-op day number one doing well from cardiopulmonary
standpoint and transferred to the Step-down Unit on post-op day
number four. The patient remained in normal sinus rhythm and had
an uncomplicated post-op course except for temperature spike on
post-op day number four to 101. He was pan-cultured. A chest
x-ray showed a slight posterior effusion with question of
consolidation. Some consolidation on the lung field. Sputum only
grew out oroflora. Blood cultures were negative with no growth so
far and a urinalysis was negative. His temperature was felt to be
due to his lung atelectasis , ?start of pneumonia and the patient
was started on Levofloxacin orally The patient had no further
temperature and remained afebrile for the next 24 hours. The
patient had no evidence of elevation in his white count.
DISPOSITION: The patient was discharged to home on post-op day
number five in stable condition.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally once a
day , Diltiazem 30 mg orally three times a day , Percocet
1-2 tablets every 4 hours as needed pain , Zantac 150 mg orally twice a day ,
Levofloxacin 500 mg every day for 5 days for presumed
atelectasis/pneumonia , Atenolol 25 mg orally every day
DISCHARGE LABS: BUN/creatinine 8/0.9 , sodium 140 , potassium 4.5 ,
and magnesium of 2.2 , hematocrit 29 , white count
5.6 , platelets 304.
FOLLOW-UP: He is to follow-up with his cardiologist in one-two
weeks and to follow-up with Dr. Barrette in four-six weeks
for postsurgical evaluation.
Dictated By: TOMIKA AFZAL , M.D.
Attending: GENNY S. BARRETTE , M.D. ZD6
UJ086/3133
Batch: 83173 Index No. O6GNBK1XJU D: 1/21/99
T: 5/29/99
QF9
Document id: 959
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995493955 | PUO | 25782688 | | 208910 | 10/15/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/9/1996 Report Status: Signed
Discharge Date: 5/21/1996
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION.
ADDITIONAL DIAGNOSES: 1. INSULIN-DEPENDENT DIABETES.
2. HYPERTENSION.
HISTORY OF PRESENT ILLNESS: This is a 56 year old with a
history of insulin-dependent diabetes
mellitus and hypertension , who presents status post an anterior
myocardial infarction , assessed with TPA , with postmyocardial
infarction chest pain. Patient has cardiac risk factors of
diabetes x seven years and hypertension x seven months. He was in
his usual state of good health , with normal low exercise tolerance ,
although under an enormous amount of stress at his job. When he
went to bed on June , 1996 , he had a very fitful sleep and
awoke with 7/10 substernal chest pain radiating to his left arm ,
without any associated symptoms , lasting 20 minutes. Took Tylenol
and lisinopril with relief. He called his Carna Home Hospital Attending , was told to go to Plantdan Camchild Hospital , and there was
found to have ST elevations in the anterior region. He was treated
with TPA , intravenous nitrates , and beta blocker , aspirin. His
pain lasted a total of two hours. Post TPA , he had resolution of
pain and electrocardiogram changes and was in the Coronary Care
Unit in Ken Health Care on intravenous heparin and nitroglycerin pain free
since TPA. His peak CK was 136 , with an MB of 5. His
echocardiogram showed an ejection fraction of 55-60% , with mild
septal hypokinesis. He was transferred to the Pagham University Of for post myocardial infarction care.
PAST MEDICAL HISTORY: 1 ) Hypertension x seven months. 2 )
Diabetes x seven years , on insulin
currently. 3 ) History of nephrolithiasis. 4 ) Possible history
of thalassemia. 5 ) Sleep apnea x seven years , on CPAP 12 cm of
water pressure.
MEDICATIONS: Lisinopril 5 mg orally every day , insulin 25 units of NPH
and 5 units of regular every day before noon , 10 units of NPH q.
day.
ALLERGIES: Sulfur.
FAMILY HISTORY: Both parents are alive and well. No coronary
artery disease or diabetes.
SOCIAL HISTORY: Married , with one daughter. He is currently
self-employed as an architect. No tobacco or
alcohol use.
PHYSICAL EXAMINATION: On admission , he was afebrile at 99.8.
Heart rate was 80. Blood pressure was
114/76. Respiratory rate was 20 , with room air saturation of 96%.
He was a well-developed , well-nourished male in no acute distress ,
with examination significant for clear chest , heart with regular
rate and rhythm , I-II/VI systolic ejection murmur at the apex , flat
jugular venous distention , no carotid bruits , femoral bruits noted ,
and an abdomen that was benign. He did have notable left axillary
lymphadenopathy , 1-2 cm , that was non-tender , and inguinal
adenopathy bilaterally 2 x 1 cm for two nodes. Extremity
examination - No cyanosis , clubbing , or edema , positive peripheral
pulses. Neurologic examination was non-focal.
LABORATORY DATA: Labs on admission were significant for a CK of
46.
HOSPITAL COURSE: 1 ) Cardiovascularly - The patient was
continued on postmyocardial infarction care
initially on heparin and intravenous TNG , with the plan to monitor
via telemetry x 72 hours. He was additionally continued on
medications of aspirin and Lopressor as part of an anti-ischemic
regimen. On the second day of his hospital course , he had
recurrent chest discomfort , and it was decided to perform cardiac
catheterization. Catheterization was performed on March , 1996
and revealed a right dominant system with subtotal D2 occlusion , a
very large vessel. A left ventriculogram showed mild anterior
hypokinesis. He had percutaneous transluminal coronary angioplasty
of the D2 lesion down to a 20% residual , with good result. The
patient had no return of chest pain in-house subsequent to his
percutaneous transluminal coronary angioplasty and was managed on a
medical regimen of atenolol , aspirin , and the addition of clonidine
prior to discharge.
2 ) Anemia - With a severely decreased MCV , thought secondary to
beta-thalassemia. Hematocrit remained in the low 30s ( 34 ) and was
stable in-house.
3 ) Lymphadenopathy - Noted on admission. It was decided that this
would be followed by his outpatient physician , Verdie Macisaac , M.D. ,
in one to two weeks. The patient did not have any complaints or
symptoms of fever , chills , or night sweats.
COMPLICATIONS: None.
DISPOSITION: The patient will be discharged to home.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: In Cardiology with Dr. Bachmann on May , 1996.
He will follow up with Dr. Verdie Macisaac by calling on
Monday to schedule an appointment.
DISCHARGE MEDICATIONS: Atenolol 100 mg twice a day , clonidine 0.1 mg
twice a day , aspirin 325 mg every day ,
nitroglycerin sublingual tabs as needed chest discomfort.
Dictated By: CORRINA CROOKED , M.D. SJ80
Attending: LASHANDA L. BACHMANN , M.D. XR66
QT011/5442
Batch: 91526 Index No. JZCNZL8B77 D: 11/5/96
T: 7/30/96
Document id: 960
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VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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532603315 | PUO | 00022482 | | 540142 | 1/28/1996 12:00:00 a.m. | ATRIAL FLUTTER , CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 1/28/1996 Report Status: Signed
Discharge Date: 5/30/1996
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
SECONDARY DIAGNOSES: 1. CARDIOMYOPATHY.
2. STATUS POST RIGHT CAROTID ENDARTERECTOMY.
3. HYPERTENSION.
4. DIABETES MELLITUS.
5. PAROXYSMAL ATRIAL TACHYCARDIA.
HISTORY OF PRESENT ILLNESS: Patient is a 73 year old male with a
history of hypertension , diabetes
mellitus , congestive heart failure , who has had multiple previous
admissions to Pagham University Of with exacerbations of
his congestive heart failure , most recently 27 of February The patient
was reasonably well until approximately 4-5 weeks ago when he
initially noticed slight worsening of bilateral ankle swelling.
This has progressively worsened until the date of admission when
swelling had progressed up to his waist. In the last 2-3 weeks , he
also noted slow worsening of his exertional dyspnea. Prior to
this , he was rarely limited by shortness of breath , but does not
exert himself much. Recently , however , exercise tolerance has
decreased to 3 to 50 feet on flat ground. Patient denied shortness
of breath at rest until yesterday evening when he noted slight
dyspnea also associated with a vague chest tightness. Patient
subsequently went to bed , slept on his usual two pillows. He woke
suddenly at 4:00 A.M. the morning of admission with severe
shortness of breath , chest tightness , and a sensation of general
fatigue. He was unable to get back to sleep because of worsened
orthopnea. His daughter called the EMTs who took the patient to
the Totin Hospital And Clinic Emergency Room. His initial EKG showed a
rate of 150 and he was loaded with procainamide after no change
after being treated with intravenous adenosine. After treatment with O2 ,
his chest tightness resolved. He denied nausea , vomiting ,
lightheadedness or diaphoresis on presentation. He also denied
palpitations during the past few weeks , but has noted episodic
palpitations in the past. He denies any previous episodes of chest
pain or angina. In addition , he denies syncope and presyncope.
PAST MEDICAL HISTORY: 1. Congestive heart failure/ischemic
cardiomyopathy with recent echo of 10/16 with
an ejection fraction of 20% with antero and inferior apical
hypokinesis. 2. Non insulin dependent diabetes mellitus ,
diagnosed in 1988 , treated with orally agents. 3. Hypertension. 4.
Status post varicose vein surgery of the left leg.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 325 mg every day , digoxin 0.25 mg every day ,
glyburide 2.5 mg every day , lisinopril 10 mg every day , Lasix
40 mg orally twice a day
SOCIAL HISTORY: Patient is a retired ship engineer , immigrated
to the Arv , Kansas 24037 from Verra He lives with
his daughter in Ri Rill Sonelos , originally from Sburb He
smokes 1/2 pack per day x 48 years , stopped when he moved to the
Sasas Beau Ant Alcohol - intermittent binge drinking without
regular heavy consumption.
PHYSICAL EXAMINATION: Heart rate was 120 , blood pressure 90/70 ,
without orthostatic change. HEENT showed
pupils were equal , round , reactive to light. Extracular movements
intact. Oropharynx was clear. Neck showed JVP above the jaw with
a question of A waves. Chest showed decreased breath sounds at the
bases bilaterally with bibasilar crackles. Cardiac exam was
regularly irregular S1 , S2 , + S3 and S4 , 2/6 pansystolic murmur to
the apex. Abdominal exam was soft , nontender , nondistended , with a
palpable liver edge , nonpulsatile. No splenomegaly. Extremities
showed 3+ bilateral pitting edema. Distal pulses were not palpable
bilaterally. Femoral pulses 2+ bilaterally. Neurologic exam was
grossly nonfocal. Chest x-ray revealed cardiomegaly with pulmonary
vascular redistribution and perivascular cuffing. EKG showed
atrial flutter with 2:1 block at a rate of 135 with
intraventricular conduction delay with right bundle branch block
pattern , as well as poor R wave progression.
HOSPITAL COURSE: 1. Cardiovascular. After patient had been
treated with procainamide in the emergency room ,
he became hypotensive and was subsequently cardioverted. His blood
pressure recovered to his baseline of 90 systolic and he was
started on Ace inhibitors. He was also treated with intravenous Lasix and
started on heparin. Because of his disproportionate right
ventricular failure , he did undergo a VQ scan which was low
probability.
Patient had recurrent episodes of atrial tachycardia and was loaded
orally with amiodarone. In addition , he had some short runs of
nonsustained ventricular tachycardia.
After aggressive diuresis , the patient was noted to have an
increasing BUN/creatinine. He was started on intravenous dobutamine on
14 of July and was continued on captopril and Isordil. He diuresed well
on dobutamine and was restarted on digoxin. The dobutamine was
weaned to off on 11 of January He was restarted on intravenous Lasix.
On 25 of August , patient underwent cardiac catheterization which showed a
40% mid LAD lesion , 40% OM , 40% RCA. His pressures showed an RA
pressure of 10 , RV 50/12 , with a mean PA pressure of 34 , a
pulmonary capillary wedge pressure of 22 , cardiac output 3.0 , with
an index of 1.6 , SVR 1800. It was therefore felt that his
cardiomyopathy which had initially been attributed to ischemic
etiology , was likely idiopathic or secondary to alcohol. The
patient was subsequently transferred to the TGLMC with Swan-Ganz
catheter in place. He was again treated with dobutamine and
Isordil and his captopril was titrated upwards. Repeat echo showed
an ejection fraction of 20% with an unstable LV thrombus. He was
subsequently restarted on heparin , followed by loading with
Coumadin. He was transferred back to the floor on 2 of February and
remained hemodynamically stable on captopril , Isordil , amiodarone ,
digoxin and aspirin. His Lasix intravenous was converted to orally
torsemide with good fluid balance.
2. Neurology. The patient was noted to complain of
lightheadedness , vertigo and ringing in his ears after receiving
his doses of captopril. He underwent noninvasive carotids which
showed a subtotal occlusion of his right internal carotid artery.
He underwent combined cardiac catheterization and carotid
angiography on 11 of January Angiography revealed a greater than 90% right
internal carotid stenosis. Following the procedure , he had a
transient 5-10 minute episode of decreased responsiveness and
decreased left hand grip , which resolved completely. On 30 of January ,
he underwent right carotid endarterectomy complicated by a small
right neck hematoma which resolved spontaneously. He had no
further symptoms and was able to tolerate captopril up to 25 mg
three times a day
3. Hematology. The patient was anticoagulated with heparin
followed by Coumadin as above , for his LV thrombus , with a target
INR of 2.5 to 3.
4. Non-insulin dependent diabetes mellitus. Patient's blood
sugars were well controlled on orally glyburide.
5. Renal. Patient's creatinine on admission was 1.4. His
creatinine transiently rose to 2.2 with aggressive diuresis , but
fell to 1.4 on discharge.
The patient was discharged home with VNA services on 23 of March He
was stable on discharge. He is to follow up with Dr. Irving Escalante on 10 of February
DISCHARGE MEDICATIONS: Amiodarone 400 mg orally every day , enteric
coated aspirin 325 mg orally every day ,
captopril 25 mg orally three times a day , digoxin 0.625 every day , Isordil 20 mg
orally three times a day , multivitamin , quinine 325 mg orally every day , torsemide 60
mg orally every day , Coumadin.
Dictated By: MAX Z. BALLER , M.D. OJ18
Attending: EVERETT IRIAS , M.D. CL95
CS878/6480
Batch: 66364 Index No. N8DA3YVOA D: 10/29/97
T: 2/9/97
Document id: 961
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Q |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
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N |
408912427 | PUO | 13937870 | | 564417 | 10/28/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/2/2000 Report Status: Signed
Discharge Date: 10/24/2000
SERVICE: The service on which the patient received care was
Cardiology Ma Avenue , Uxmarearb Cleve Nix , West Virginia 65028
HISTORY OF PRESENT ILLNESS: Mrs. Rusconi is a 54-year-old female
with coronary artery disease status
post inferior myocardial infarction in October of 1997 , with sick
sinus syndrome , status post permanent pacemaker placement , and
paroxysmal atrial fibrillation controlled with amiodarone; also
with history of diabetes mellitus and hypertension. She was
admitted to the Speakey Community Medical Center for severe respiratory
distress on 7/10 The summary of clinical events is as follows.
The evening of 7/11 , the patient was having intercourse and
"collapsed." She was very short of breath with this , and presented
to the Emergency Department via the paramedics. They attempted to
intubate her on the field and found her pulse oxygen to be about 60
percent on bag valve mask. They were unable to do so. She was
described during this episode by her husband as to have been
"gurgling." She began to describe shortness of breath , and took
her inhalers which did not help. She began to cough quite a bit
and coughed up some frothy white sputum. At the Emergency
Department , she was immediately intubated at Hungna Coll Hutzj.ma Beachtl Community Hospital
There was some difficulty intubating her , and she was ultimately
intubated by the attending anesthesiologist there. An
echocardiogram showed an ejection fraction of 25 to 30 percent with
flat CKs. She was diuresed six liters with a stable BUN and
creatinine and was extubated on 10/11 A right heart
catheterization there showed a pulmonary artery pressure of 40/15 ,
wedge of 12 , cardiac output of 5.2. Hemodymanics in the Intensive
Care Unit at Hungna Coll Hutzj.ma Beachtl Community Hospital indicate the patient's cardiac output
was quite dependent on her SVR. Her cardiac index fell into the
high two's when her SVR was in the 1340 range , but jumped up into
the high three's at about 3.8 when her SVR was much lower down in
the 800s. At the outside hospital , a right upper lobe infiltrate
was also noted and she was given gentamicin 250 mg times one , and
clindamycin 600 mg. She was diagnosed with pneumonia and treated
with clindamycin , this caused resolution of her white count at the
outside hospital. She also had an increase in her Lasix and
lisinopril dose there , as well as her amiodarone. She was started
on Solu-Medrol 40 mg intravenous every 6 hours for possible asthma.
She did quite well after her treatment for pneumonia and treatment
for pulmonary edema , and was transferred to the I Warho Hospital for further management.
Her last admission was on 2/7 to the I Warho Hospital
for atypical chest pain , when she had a nondiagnostic exercise
tolerance test. She went 6 minutes and 19 seconds with a maximum
heart rate of 94. Her chest pain then was ultimately attributed to
a gastrointestinal cause.
PAST MEDICAL HISTORY: Coronary artery disease status post inferior
myocardial infarction on 4/27 She was last
admitted , as noted above , on 2/7 to the Kernan To Dautedi University Of Of for atypical
chest pain. The patient has sick sinus syndrome and is status post
dual chamber pacemaker in 6/19 Diabetes mellitus. Hypertension.
Paroxysmal atrial fibrillation , well-controlled in the past on
amiodarone. Past rhythm monitoring has revealed brief runs of
ventricular tachycardia. Negative breast biopsy in 3/13
MEDICATIONS: Home medications include amiodarone 200 mg orally every day ,
Glyburide 5 mg orally every day , Lopressor 50 mg orally
twice a day , Prempro 0.625/2.5 orally every day , lisinopril 40 mg orally every day ,
Coumadin , nitroglycerin sublingual , Zantac , beclomethasone , and
Ventolin.
Medications on transfer , Lovenox 60 mg twice a day , aspirin 325 orally
every day , lisinopril 40 mg orally twice a day , clindamycin 600 intravenous
every 8 , digoxin 0.25 , Lopressor 100 mg twice a day , Zantac , Albuterol ,
Flovent , Solu-Medrol , and amiodarone 300 mg once a day.
ALLERGIES: The patient is allergic to penicillin.
SOCIAL HISTORY: The patient has a ten pack year smoking history
and quit in 1968. No intravenous drug use. She
is retired from Medical Records at LMC . She has three grown
children and she is married.
PHYSICAL EXAMINATION: Physical examination on admission is
significant for a blood pressure of 114/93 ,
this is down from a very high blood pressure on admission at the
outside hospital which was in the 200s. Pulse is 60 , temperature
is 96.5 , saturating 97 percent on two liters. General , this is an
agitated woman in no acute distress. Her neck veins were about 5.0
to 6.0 cm of water. The lung examination showed a few crackles in
the left base with the right one clear. Cardiovascular examination
revealed a split S1 and normal S2 , also a soft S3 , the presence of
a 2/6 systolic ejection murmur at the right upper sternal border
was noted. The abdomen was benign , no hepatosplenomegaly noted.
The extremities showed no edema , with intact distal pulses.
Neurologically , the patient was alert and oriented times three with
no focal deficits , but careful neurologic examination was
impossible due to severe agitation and anxiety.
LABORATORY DATA: Laboratory on admission was significant for a
Troponin of 0.02 , CK of 80 , INR of 1.3 ,
hematocrit of 38.0 , BUN/creatinine of 24/0.6.
HOSPITAL COURSE: Mrs. Rusconi was admitted to the I Warho Hospital and managed by problems as follows.
Flash Pulmonary Edema: The initial concern for Mrs. Rusconi was of
this being an ischemic event causing her to have flash pulmonary
edema. However , coronary catheterization revealed the patient to
have clean coronaries. Echocardiogram revealed a left ventricular
hypertrophy with a low normal systolic function , with an ejection
fraction of 50 to 55 percent. There was akinesis of the inferior
wall present. She had normal right ventricular size and function.
She had 1 to 2+ mitral regurgitation with mild left atrial
enlargement and 1+ tricuspid regurgitation with a regurgitive
velocity of about 2.7 meters per second consistent with minimal
pulmonary systolic pressures. Subsequently the patient was noted
to have had a history of hypothyroidism in the past , and she had
normal TSH recently checked by her primary care physician , Dr.
Sultaire , of LMC . However , with no other etiology present , we
were worried about the patient having had tachyarrhythmia from some
other source causing this. The Electrophysiology Service
interrogated the patient's pacer which revealed a number of
tachyarrhythmias. A TSH panel was checked which revealed a TSH of
less than assay , and T4 free thyroxin index elevated. An
Endocrinology consultation was obtained , and they believed that the
patient's thyrotoxicosis was amiodarone induced. She was started
on Tapazole 10 mg orally twice a day They also suggested prednisone , but
the patient did refuse this. They recommended follow-up with
Endocrine in about four to six weeks. Therefore , the final
etiology for the patient's flash pulmonary edema was amiodarone
induced thyrotoxicosis causing increased susceptibility to
tachyarrhythmia , left ventricular hypertrophy , and possible
diastolic dysfunction , resulting in acute pump dysfunction , causing
flash pulmonary edema. The final therapy for this problem will
consist of heavy nodal blockade. The patient will be blockaded
with calcium channel blockers , as well as Lopressor.
Pneumonia: The patient was treated with clindamycin and did quite
well. Her white count fully resolved and she had no fever or other
symptoms of pneumonia. She will be discharged without any further
antibiotics.
Urinary Tract Infection: She had a lot of uric crystals , therefore
she was placed on Bactrim Double Strength twice a day times a total of
seven days.
Psychiatry: The patient has clearly severe anxiety and was in a
full panic attack on admission. She was treated acutely with
Ativan and her problem resolved quite well , and she became more
comfortable in the hospital.
Diabetes Mellitus: Glyburide was held initially on admission. She
was covered with insulin sliding scale. Glyburide was restarted on
the day of discharge. The patient was noted to have relatively
high blood sugars , and these should be followed as an outpatient.
Blood sugars as high as the mid 300s were noted.
Edema: The patient clearly had some fluid accumulation which
resolved with 20 mg of Lasix orally every day We will continue this and
allow outpatient follow-up to determine whether or not she will
need this in the future.
DISCHARGE MEDICATIONS INCLUDE: Amiodarone 200 mg orally every day ,
lisinopril 40 mg orally twice a day ,
Tapazole 10 mg orally twice a day , Zantac 150 mg orally twice a day , Coumadin 5.0
mg orally every afternoon , Bactrim Double Strength one tablet orally twice a day
times four days after discharge , Prempro 0.625/2.5 mg orally every day ,
Glyburide 5 mg orally every day , Lasix 20 mg orally every day , atenolol 150 mg
orally every day , diltiazem CD 240 mg orally every day
DISPOSITION: The patient was discharged home in good condition.
FINAL DIAGNOSIS: Thyrotoxicosis.
FOLLOW-UP: She will follow-up with Dr. Sultaire on Monday , 9/18
at 9:30 a.m. , and Dr. Buckman of I Warho Hospital Endocrinology at A , on 7/16 at 3:00
p.m.
Dictated By: RUFUS BERNAS , M.D. NN13
Attending: DENISHA H. MCRORIE , M.D. XT0
CW612/9072
Batch: 56403 Index No. J0NB3Y82XG D: 3/10
T: 1/15
CC: 1. EUSTOLIA L. LAWRENTZ , M.D. KG12 , LAME MEDICAL CENTER , Ridolouis
2. CLAUDIA I. BUCKMAN , M.D. AN7
3. MACKENZIE TYACKE , M.D. KC8
Document id: 962
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
N |
N |
Y |
N |
Y |
N |
Y |
N |
N |
N |
N |
694125469 | PUO | 40479272 | | 0902160 | 6/20/2006 12:00:00 a.m. | BILATERAL PULMONARY EMBOLI | Signed | DIS | Admission Date: 6/20/2006 Report Status: Signed
Discharge Date: 2/25/2006
ATTENDING: REEDY , LILIA D. MD
HISTORY OF PRESENT ILLNESS: This is an 85-year-old woman with a
history of paroxysmal atrial fibrillation , type II diabetes , DVTs
in the past , and a right lower lobe lung mass found to be thymoma
on fine needle aspirate biopsy who presents with sharp
right-sided chest pain x1 week , as well as increased dyspnea on
exertion times two days. She denies hemoptysis , cough , fever or
chills. The remainder of her review of systems is negative. She
was seen at her primary care physician's clinic , and was sent for a PE protocol CT
at an outside hospital , which was positive for bilateral
pulmonary emboli. She has no recent history of immobilization or
surgery.
PAST MEDICAL HISTORY: Paroxysmal atrial fibrillation , first
diagnosed in September of 2006 , type II diabetes , hypertension ,
recurrent urinary tract infections , gout , congestive heart
failure with an EF of 35% , osteoarthritis , right lower lobe mass
shown to be a thymoma by a fine needle aspirate , status post
thymoidectomy in 1977 and history of C. difficile.
MEDICATIONS ON ADMISSION: Lasix 20 mg by mouth daily , glipizide
5 mg by mouth daily , Toprol-XL 100 mg by mouth daily , Actos 50 mg
by mouth daily , Ambien 2.5 mg by mouth nightly as needed insomnia.
ALLERGIES: Clindamycin causes rash. Penicillin causes rash.
SOCIAL HISTORY: The patient does not use tobacco. She drinks
three glasses of alcohol per day. She is widowed , and lives at
home in a duplex apartment upstairs from her son-in-law. She has
five children.
FAMILY HISTORY: Significant for mother , father and brother all
of whom died of myocardial infarction.
PHYSICAL EXAMINATION ON ADMISSION: Vital Signs: Temperature
96.0 , heart rate 115-150 , blood pressure 110/70 , respiratory rate
18 and oxygen saturation 95% on room air. General: The patient
is in no acute distress , breathing comfortably seated upright.
Neck: Supple. JVP is 15 cm. Lungs: Crackles at the right lung
base. Otherwise , clear to auscultation. Cardiovascular:
Irregularly irregular. No murmurs , rubs or gallops appreciated.
Abdomen: Soft , nontender , nondistended with active bowel sounds.
Extremities: 1+ edema bilaterally , right greater than left.
Extremities warm and well perfused. Neuro: Alert and oriented
x3 , cranial nerves II-XII intact. Nonfocal neurological exam.
Skin: Erythematous lesions on the back , with scaling.
NOTABLE LABORATORY VALUES ON ADMISSION: Sodium 129 , potassium
5.3 , BUN 47 , creatinine 1.4 , glucose 394. White blood count
11.3 , hematocrit 45.7 , platelets 176.
NOTABLE STUDIES: PE protocol CT performed 10/15/06 at outside
hospital: Bilateral pulmonary emboli. Noninvasive vascular
studies of the lower extremities: On 9/17 Partial DVT in
right posterior tibial and right peroneal veins. Total DVT in
right common femoral , right superficial femoral , and right
popliteal veins. Chest x-ray 10/10/06 : Right lower lobe mass
stable from previous. Otherwise , clear. No fractures
appreciated. Echocardiogram in 10/10/06 : EF of 15% , reduced
from prior , although , atrial fibrillation. Global hypokinesis.
Mild mitral regurgitation. Mild tricuspid regurgitation.
Echocardiogram 12/10/06 : Ejection fraction 20-25% , and global
hypokinesis with regional variation. The right ventricular
systolic function mildly reduced. Mild left atrial enlargement.
Mild pre-dilated right atrium. Moderately thickened aortic
valve. Mildly diffusely thickened mitral valve.
PROCEDURES: On 10/10/06 : IVC filter placement without
complication by Dr. Janet Piltz
HOSPITAL COURSE BY PROBLEM: This is an 85-year-old woman with a
history of prior DVTs and lower lobe lung mass , biopsy shown to
be a thymoma , who presents with bilateral pulmonary emboli and
paroxysmal atrial fibrillation.
Hematology: The patient has bilateral pulmonary emboli as
confirmed by PE protocol CT. The patient was initially
anticoagulated with heparin drip for PTT goal of 60-80 , and was
bridged to Coumadin with an INR goal of 2-2.5. Lower extremity
noninvasive studies showed right leg deep venous thrombosis as
noted above. An IVC filter was placed without complications on
10/18/06. The patient was discharged on a Coumadin dose of 7.5
mg by mouth daily , and her INR will be followed by the Pagham University Of Coumadin Clinic ( Dr. Earnestine Fiermonte ) , after
her discharge from rehabilitation.
Cardiovascular: Rhythm: The patient was initially found to be
in atrial fibrillation with a rapid ventricular response , with a
heart rate of approximately 128 beats per minute. This was felt
likely to be secondary to pulmonary embolus. The patient
required both metoprolol and diltiazem for rate and rhythm
control , and was discharged on both of these medications. She
had several episodes of rapid atrial fibrillation throughout her
hospital course , requiring several boluses to metoprolol intravenous and
diltiazem intravenous. She was discharged on a regimen of metoprolol and
diltiazem orally to maintain her in stable normal sinus.
Pump: The patient had an echocardiogram revealing ejection
fraction of 15% while she was in atrial fibrillation , and
ejection fraction of 25% when the patient was in normal sinus
rhythm. She was diuresed gently with Lasix 20 mg by mouth daily.
She was started on low-dose ACE inhibitor on 8/11/06.
Ischemia: The patient has risk factors for coronary artery
disease , but has no chest pain or significant EKG changes during
this admission. She may be considered for cardiac
catheterization in the future as an outpatient.
Endocrine: The patient has type II diabetes mellitus with a
hemoglobin A1c of 8.2. Oral anti-diabetics were held during this
admission , the patient was given basal and prandial insulin. She
was discharged back on her home diabetes regimen.
Onch: The patient has a right lower lobe lung mass which is
likely thymoma by a fine needle aspirate. The patient was seen
by the Thoracic Surgery Service , as follow up for Dr. Major
who had seen her in clinic , and depending of the services that
surgery was not recommended at this time until cardiovascular and
pulmonary issues were stabilized. Medical oncology was also
consulted , and it was recommended that chemotherapy would not be
pursued at this time for this patient. Both services recommended
a followup CT scan in several weeks to detect the progression of
this right lower lobe lung mass. The decision of whether or not
to treat this lung mass will be deferred until her pulmonary
embolism , cardiovascular , and pulmonary issues are stabilized.
Neuro: The patient has a history of drinking two to four drinks
per day , but the patient did not have any signs or symptoms of
alcohol withdrawal during this admission.
Fluids , electrolytes and nutrition: The patient was repeated
with electrolytes as necessary. She was given a cardiac and
American Diabetes Association Diet.
Prophylaxis: The patient was initially on heparin , which in turn
was bridged to Coumadin.
The patient was full code during this admission.
PLANS: The patient should have regular blood draws to monitor
her INR level while she is taking Coumadin. This will be managed
by the Pagham University Of Coumadin Clinic run by Dr.
Earnestine Fiermonte , phone number 988-605-5355 while the patient is
an outpatient. The patient should have diltiazem weaned off as
tolerated. ACE inhibitor and metoprolol should be titrated
upwards as tolerated by heart rate and blood pressure. The
patient has followup appointments scheduled with Dr. Lilia Reedy at Pagham University Of Cardiology on 4/29/07
at 9:40 a.m. , the phone number 527-424-0072. The patient also
has a followup appointment with Dr. Desirae Marcott at the
Pagham University Of Thoracic Surgery Group on 1/25/07
at 1:00 p.m. Telephone number is 465-102-6791.
DISCHARGE MEDICATIONS: Will be dictated in the discharge summary
addendum.
eScription document: 0-8659777 CSSten Tel
Dictated By: MARCOTT , DESIRAE
Attending: REEDY , LILIA D.
Dictation ID 7180414
D: 11/29/06
T: 11/29/06
Document id: 963
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
782417239 | PUO | 63069288 | | 0343706 | 4/20/2006 12:00:00 a.m. | right quardicept tendon rupture | | DIS | Admission Date: 6/9/2006 Report Status:
Discharge Date: 11/5/2006
****** FINAL DISCHARGE ORDERS ******
FRINGER , BLYTHE J 894-95-81-5
Grand Mode Jack
Service: MED
DISCHARGE PATIENT ON: 10/18/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TROJAN , LUISE R. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 7/7/06 by
KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 301049236 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally 0.5 MG every afternoon ( ref # 706797280 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 132509081 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 100 MG orally DAILY
Override Notice: Override added on 7/7/06 by
KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 301049236 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally 0.5 MG every afternoon ( ref # 706797280 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 132509081 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: aware
AMIODARONE 200 MG orally DAILY
Override Notice: Override added on 7/7/06 by
KATZER , CALANDRA , M.D. on order for ZOCOR orally ( ref # 208351639 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
SIMVASTATIN Reason for override: aware
Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 301049236 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally 0.5 MG every afternoon ( ref # 706797280 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for COUMADIN orally ( ref # 132509081 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: aware Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for AMIODARONE orally ( ref # 445607990 )
patient has a PROBABLE allergy to intravenous Contrast; reaction is
Unknown. Reason for override: aware
CEFPODOXIME PROXETIL 200 MG orally twice a day X 2 doses
Food/Drug Interaction Instruction Give with meals
COLCHICINE 0.6 MG orally EVERY OTHER DAY
VITAMIN B12 ( CYANOCOBALAMIN ) 100 MCG orally DAILY
Number of Doses Required ( approximate ): 10
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 80 MG orally every day before noon
LASIX ( FUROSEMIDE ) 40 MG orally every afternoon
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Override Notice: Override added on 7/7/06 by
KATZER , CALANDRA , M.D.
on order for DIOVAN orally OTHER every day ( ref # 282025861 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: aware
Previous override information:
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: VALSARTAN & POTASSIUM
CHLORIDE Reason for override: aware
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 7/17/06 by :
on order for OXYCODONE orally 5-10 MG every 4 hours ( ref # 299683345 )
patient has a PROBABLE allergy to Codeine; reaction is nausea.
Reason for override: aware Previous Alert overridden
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for OXYCODONE orally ( ref # 857033564 )
patient has a PROBABLE allergy to Codeine; reaction is nausea.
Reason for override: aware
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 7/7/06 by
KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
DETROL LA ( TOLTERODINE TARTRATE LONG ACTING )
2 MG orally DAILY Number of Doses Required ( approximate ): 10
DIOVAN ( VALSARTAN ) 40 MG orally DAILY
Alert overridden: Override added on 7/7/06 by
KATZER , CALANDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: aware
Previous Override Notice
Override added on 7/7/06 by KATZER , CALANDRA , M.D.
on order for K-DUR orally ( ref # 789898532 )
POTENTIALLY SERIOUS INTERACTION: VALSARTAN & POTASSIUM
CHLORIDE Reason for override: aware
Number of Doses Required ( approximate ): 10
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: take 5mg on monday/wednesday/friday and
2.5mg on tues/thursday/saturday/sunday
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/18/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: weight bearing as tolerated on right knee , knee immobilizer to be worn at all times when walking.
FOLLOW UP APPOINTMENT( S ):
Dr. Stouer orthopedics- will call you with the date of your surgery. ,
Follow up with Dr. Seguin after you have surgery. ,
Arrange INR to be drawn on 2/26/06 with f/u INR's to be drawn every
7 days. INR's will be followed by Dr. Hazinski
ALLERGY: THIOPENTAL SODIUM , Codeine , intravenous Contrast , METHYLDOPA ,
AMITRIPTYLINE HCL , AMITRIPTYLINE , LISINOPRIL
ADMIT DIAGNOSIS:
right knee pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
right quardicept tendon rupture
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF ( congestive heart failure ) Afib ( atrial fibrillation ) Decubitus
ulcers ( decubitus ulcer ) HTN
( hypertension ) history of Septic arthritis ( history of septic arthritis ) history of B TKR
( history of total knee replacement ) Gout
( gout ) Chronic vaginal bleed ( dysfunctional uterine bleeding ) history of CCY
( history of cholecystectomy ) Morbid obesity ( obesity )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: R knee pain
-----
HPI: 80 F with gout , OA history of bilateral knee replacement in 1992 , admitted
with acute on chronic R knee pain. Day of admit , she tried to get up to
walk to the bathroom , felt acute sharp pain in her
R. knee , and was unable to ambulate. C/o radiation into posterior knee;
denies any trauma. In ED , afebrile , VSS , knee noted to be mildly
swollen and focally tender. Had R. knee films , which showed a large
joint effusion , lateral subluxation of her patella , no fracture , and
intact prosthetic hardware. Seen by ortho service , who felt that joint
was not septic , recommended pain control and discharge home with
outpatient ortho follow-up. patient was seen by physical therapy service , patient unable to
walk with walker and assistance. They recommended rehab placement but
refused and agreed to inpatient admission at PUO for pain control. At
baseline , patient is able to walk ~30 feet with walker or cane , limited by
diffuse back and knee pain.
-----
PMH: HTN; AF , gout , OA , chronic lower and upper back pain , bilateral
knee pain; history of bilateral knee replacement in 1992; carpal tunnel syndrome
-----
Meds at home: ASA 81mg daily; Toprol XL 50mg daily; amiodarone 200mg
daily; diovan 40mg daily; zocor 40mg every bedtime; NTG 0.4mg tab sublingual as needed; lasix
80mg orally qAM/40mg orally qPM; K-dur 20mEq twice a day; prilosec 20mg
daily; folate 1mg daily; vitamin B12; allopurinol 100mg daily;
colchicine 0.6mg every other day; detrol LA 4mg daily as needed; ibuprofen 800mg three times a day
as needed ( takes almost daily ); allegra 180mg daily as needed; vicodin 2mg
qAM/1mg qPM as needed wrist pain
-----
Allergies: thiopental - hypertension; codeine - nausea; intravenous
contrast , methyldopa - unknown; amitriptyline - lip droop , lisinopril
- cough
-----
ADMIT Exam: 96.1 , 97 , 143/103 , 16 , 100% RA
Gen: NAD , obese , pleasant
Pulm: clear , distant lungs
CV: irregular , tachy , distant , no clear m/r/gs
Abd: soft , obese , slightly firm , NT , +nl BS
Extr: warm , 1-2+ edema bilaterally to thighs , R. knee not warm ,
+effusion , 2 small areas of point tenderness inferior to patella in
midline of knee and in popliteal fossa; able to flex ~90 degrees and
extend fully with some pain
-----
Notable Labs on admission: WBC 5.61 , %POLY-A 66.5 , ESR 16
-----
ASSESSMENT/PLAN:: 80F with hx gout , OA history of bilateral knee replacement in
1992 , admitted with atraumatic acute on chronic R. knee pain.
Inability to extend rt knee c/with with quadriceps extensor tendon rupture per
ortho.
-----
HOSPITAL COURSE:
1. ORTHO: patient has a quadriceps extensor tendon rupture by exam. No
additional imaging required. Ortho consulted and recommended surgical
repair. patient was kept in house in anticipation of tendon repair. She could
not be scheduled within the week so was d/c'd home. Dr. Lemmen will notify
patient of the date of surgery. Physical therapy fit patient for brace
( Matson ) and she is WBAT to R knee. patient was cleared by physical therapy for home. Home
physical therapy arranged. patient given oxycodone as needed pain.
2. CV: *Isch: cont'd ASA. Toprol , and Zocor.
*Pump: cont'd diovan and lasix
*Rhythm: hx AF-RVR , currently AF with rate in 90s Cont'd amiodarone 200mg
daily. Coumadin held 2/2 possible surgery but restarted when surgery
could not be scheduled. Dr. Lemmen will notify patient when to stop
coumadin.
3. RENAL: Baseline cr is 1.7-1.8. Cr increased to 2.0 ( Calc cr cl=17 )
during admit. Suspect Ibuprofen as cause so d/c'd. Cr imprived to 1.9 at
d/c.
4. ID: patient found to have UTI. Urine culture grew >100 , 000 E. Coli
sensitive to CXT. patient given 2 days of CXT and sent home on cefpodoxime x 1
more day.
5. MISC: *Cont'd Allopurinol , Colchicine , PPI , B12 , Folate ,
K-dur *Detrol LA dose reduced from 4 to 2mg daily due to
reduced cr clearance.
*Code: FULL
ADDITIONAL COMMENTS: 1. ) Take oxycodone 5-10mg every 4 hours as needed for knee pain. Make
sure you are also taking colace 100mg twice daily and senna tabs 2
tablets twice daily to prevent constipation while on oxycodone.
2. ) Take all of your previous medications. Do not take ibuprofen at home.
3. ) For your urinary tract infection , take cefpodoxime 200mg tomorrow
morning and tomorrow night.
4. ) Dr. Lemmen will contact you with the date of your surgery. He will
also instruct you on when to stop taking your coumadin.
5. ) Come back to the emergency room if you experience any fever ,
worsening knee pain , or inability to ambulate.
6. ) You must wear your knee immoblizer at all times when you are walking.
Home physical therapy has been arranged.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
** primary care physician **
Monitor INR. Dr. Lemmen will notify patient when she should stop taking it
prior to surgery ,
No dictated summary
ENTERED BY: OSMERS , TESSA M ( YZ90 ) 10/18/06 @ 04:02 PM
****** END OF DISCHARGE ORDERS ******
Document id: 964
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
054222344 | PUO | 85515478 | | 4382543 | 4/2/2005 12:00:00 a.m. | Non cardiac chest pain | | DIS | Admission Date: 4/7/2005 Report Status:
Discharge Date: 10/8/2005
****** DISCHARGE ORDERS ******
BACCA , VALARIE 976-44-85-6
Ledom Rd
Service: MED
DISCHARGE PATIENT ON: 9/9/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KEITEL , LYNWOOD D. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 50 MG orally every day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Defore 1-2 wks scheduled ,
ALLERGY: Sulfa , Cephalosporins , intravenous Contrast
ADMIT DIAGNOSIS:
Atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Non cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , obesity , seasonal allergies
OPERATIONS AND PROCEDURES:
adenosine MIBI ->negative
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: atypical CP
HPI:76F with hyperlipidemia , HTN admitted after 4hrs burning
epigastric pain ( resolved with opiates in ED ). EKG no changes ,
negative cardiac markers x3 but nondiagnostic ETT so admitted for
adenosine MIBI in a.m.. Pain described as substernal burning and pressure
which began after patient had eaten hotdog wine and potato salad and gone to
sleep in recliner chair.
PMH:hyperlipidemia/HTN/hypothyroidism
Meds:toprol xl 50/lipitor 10/synthroid 100 ALL:PCNs , sulfa ,
iodine
EXAM:
96.6 57 102/75 16 98%RA
obese , NAD JVP flat , CTA , RRR ( slow ) , no
edema
Labs:cardiac markers neg x3 EKG:SB no TW/ST changes
CXR:negative
ABD CT:negative except for 3 cm LN in mesentery ? etiology ->recommended
follow up CT in 3 months.
HOSPITAL COURSE
Atypical CP->admitted for adenosine MIBI after non diagnostic
ETT. Adenosine MIBI was negative.
ISCH:low suspicion given history and normal EKG and cardiac
markers. Adenosine MIBI was negative.
RR:no arrhythmias on telemetry
Endo:continued home synthroid
FOLLOW UP:patient had an abdominal CT in the ED which did not elucidate an
etiology of her abdominal pain but did show a 3 cm mesenteric lymph node.
She should have a repeat CT in 3 months.
ADDITIONAL COMMENTS: The stress test of your heart was negative.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
You need to have a repeat abdominal CAT scan in 3 months or so.
No dictated summary
ENTERED BY: PAMA , WILLIAMS , M.D. ( CL00 ) 9/9/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 965
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
Y |
N |
Y |
N |
- |
N |
N |
- |
N |
N |
N |
N |
N |
N |
023364619 | PUO | 28061312 | | 936521 | 2/4/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/26/1995 Report Status: Signed
Discharge Date: 5/14/1995
DISCHARGE DIAGNOSIS: INFECTION/RULE OUT ENDOCARDITIS.
SIGNIFICANT PROBLEMS: 1 ) STATUS POST STAPHYLOCOCCUS ENDOCARDITIS
IN March 1995.
2 ) STATUS POST AORTIC VALVE REPLACEMENT
TIMES THREE WITH ST. JUDE IN April 1995.
3 ) NON-INSULIN DEPENDENT DIABETES MELLITUS.
HISTORY OF PRESENT ILLNESS: This is a 65 year old man with a
history of rheumatic heart disease
status post aortic valve replacement times three who suffered acute
bacterial endocarditis ( Staphylococcus aureus , not MRSA ) in 5/26
He presented with nausea , vomiting times one , "a black out" ,
weakness , and temperature of 101.2 the morning of admission. This
patient was admitted back on 10/5/95 with fever times five days ,
nasal congestion , and change in mental status. He was found in bed
with fecal incontinence and increased confusion at that time. Back
in October 1995 , the initial TE showed no vegetation. He was
treated with Cefotaxime and Vancomycin. Patient subsequently
developed atrial fibrillation with congestive heart failure and the
hypertension. On October , he was intubated at which time a TE
showed aortic vegetations. Blood cultures grew Staphylococcus
aureus and the antibiotics were changed to Oxacillin and
Tobramycin. Patient underwent a high risk redo aortic valve
replacement with St. Jude mechanical valve because of persistent
sepsis. The antibiotics were narrowed to Oxacillin. Patient had a
number of septic embolic events and emboli were thrown to the brain
with a right MCA stroke and the spleen as well as the duodenum. On
2/30 , he had an elevated white count , increasing temperature , and
increasing renal failure. At that time , the CT showed these renal
and splenic abscesses and patient was taken to the Operating Room.
He underwent a splenectomy and was found to have a perforated
duodenal ulcer. He underwent vagotomy with pyeloplasty. The
spleen showed multiple abscesses which grew out Candida. On this
admission , the patient was in his usual state of good health until
one week prior to admission when he experienced fatigue. At
baseline , the patient experienced intermittent sharp chest pain
felt to be musculoskeletal secondary to open thoracic surgery.
Patient also experienced pins and needle feelings felt in both
hands. On the night prior to admission , the patient sneezed
experiencing increased back pain. Later that night , he awoke
diaphoretic with aches and pains in the legs. Patient was sick in
the stomach but believed he would feel better if he ate watermelon
whereupon finishing , he had nausea and vomiting times one. Patient
went back to bed and awoke with joint pain throughout with
temperature at 7 a.m. on 100.1 degrees. Later while sitting in a
chair trying to dress , he stood and things started "to go black".
He walked towards the bathroom , got weak , knew he was going down ,
avoided falling down the stairs , and landed on all fours on his
hands and knees. Patient denied head trauma and suffered no
injury. He had no loss of continence or seizure activity. Patient
got up and moved to the bathroom under his own power. He had a
small bowel movement and felt better. Wife returned home and
temperature at 9 a.m. was 101.2. Patient was taken to Termmark's Tonton Hendhung Community Hospital Urgent Care Center. At CHH , he received blood cultures times
two and blood tests before being brought to the Pagham University Of Emergency Room. Patient denied any recent cough , sore
throat , dysuria , and hematuria but did note increased nasal
congestion and shortness of breath over the past month.
PAST MEDICAL HISTORY: 1 ) History of rheumatic heart disease with
aortic valve replacement times three in
3/26 , 1981 , and 5/26 2 ) Acute Staphylococcus aureus bacterial
endocarditis with septic emboli to brain , kidney , and spleen in
6/8 3 ) Status post splenectomy and Candida cultured out. 4 )
Duodenal ulcer status post resection and gastrectomy with vagotomy.
5 ) Status post multiple cerebrovascular accidents. 6 ) Low back
pain. 7 ) Vertigo on Meclizine. 8 ) Benign prostatic hypertrophy.
9 ) Non-insulin dependent diabetes mellitus. 10 ) Paroxysmal
atrial fibrillation.
CURRENT MEDICATIONS: Beclovent and Ventolin puffers , Lopressor 25
mg twice a day , Glyburide 2.5 mg every day , Hytrin 5 mg
every bedtime , Senokot two tablets twice a day , Colace 100 mg twice a day , and
Coumadin 4 alternating with 5 mg every afternoon
ALLERGIES: Penicillin caused a rash.
SOCIAL HISTORY: Tobacco of three packs per day times thirty years
and alcohol quit fifteen years ago. The patient
was unemployed on disability , he was a painter's rigger , and
married times 24 years with four children from his first wife , now
living with his second wife.
PHYSICAL EXAMINATION: Patient's temperature was 101.6 , blood
pressure 96/60 , pulse 88 , and respirations
28. HEENT: Pupils were equal and reactive to light and
accommodation , extraocular muscles were intact , normal funduscopic
examination , no Roth spots were noted , the oropharynx was benign ,
and no petechiae were noted. NECK: Supple and there was no
lymphadenopathy , his jugular venous distention was absent , an EJ
line was in place , and there was a 2+ carotid with zero bruits.
CHEST: Clear to auscultation bilaterally. HEART: Regular rate
and rhythm , S1 and S2 , and there was a holosystolic II/VI systolic
murmur at the left sternal border with no S3 or S4 noted. There
was a very crisp click from the St. Jude aortic valve. ABDOMEN:
Examination showed positive bowel sounds , soft , non-tender , and
non-distended. RECTAL: Refused by patient. NEUROLOGICAL:
Examination showed that the patient was alert and oriented times
three , cranial nerves II-XII were intact , motor was 5/5 in all four
extremities distally and proximally , sensory was normal to light
touch and proprioception , and the reflexes were equal and
symmetric. Cerebellar was slow , equal repetitive motions , and the
F&F was slow but equal with good tracking grossly.
LABORATORY EXAMINATION: Of note , his white count was 19.1 with 18
bands and 53 polys , hematocrit was 41.8 ,
and the electrolytes were all within normal range. The bilirubins
were 0.8 total , alkaline phosphatase 82 , SGPT of 15 , and his physical therapy was
20.7 with an INR of 3.4. A transthoracic echo obtained upon
admission showed the aortic valve was in place , there was a 2.9
meters per second flow through the aortic valve , and there was no
abscess or vegetation noted. Patient had reportedly gotten two
blood cultures in Hona Barn Medical Center and it turned out later that there
had only been one blood draw. One blood culture was also drawn in
the Emergency Room at the Pagham University Of . Chest
x-ray showed cardiomegaly , no infiltrate , and no congestive heart
failure and his EKG at admission showed normal sinus rhythm at 89
with an axis of minus 20 , intervals were 0.26/0.90/0.36 , there was
a flipped T in lead I , aVL , V5 , and V6 , and there was first degree
AV block.
HOSPITAL COURSE: This is a 65 year old gentleman who had had three
aortic valve replacements and had suffered
overwhelming endocarditis as recently as six months ago in the
replaced St. Jude valve at that time with a high risk valve since
patient was known to be febrile at the time of valve replacement.
Therefore , the number one problem was to rule out endocarditis.
The patient had two blood cultures , one at the Hona Barn Medical Center and one
at Pagham University Of , which were negative times 48 hours
while the patient was maintained on Vancomycin and Gentamicin. It
was judged that a TE would not change our treatment for this
gentleman and it was not obtained. An Infectious Disease
consultation was obtained and Infectious Disease recommended
observing the patient on antibiotics for an extra 24 hours before
deeming him non-bacteremic and then to observe the gentleman off
antibiotics for 24 hours before discharging him. In regards to
anti-coagulation , the patient was targeted for an INR of 3 with a
high risk prosthetic heart valve. This was easily maintained using
the patient's normal alternating 4 and 5 mg every afternoon Coumadin. Final
issue was the patient's fall. It was judged that the patient
actually became weak and went down on all fours controlling his
fall without actual syncope. The weakness could be attributed to
the patient's nausea , vomiting , dehydration , and vasovagal. Final
issue was the non-insulin dependent diabetes mellitus. While the
patient was hospitalized , the Glyburide was held and patient was
maintained on a sliding scale of insulin. Patient's blood cultures
remained negative times three days while patient was treated with
Vancomycin and Gentamicin. As per Infectious Disease
recommendations , the intravenous antibiotics were held on the third
day and then patient was observed for 24 hours off antibiotics. He
continued to remain afebrile through the entire hospitalization and
patient was discharged to home on September .
DISPOSITION: Disposition is to home.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed headache ,
Ventolin two puffs inhaled twice a day ,
Beclovent two puffs inhaled twice a day , Beconase two puffs inhaled
four times a day as needed congestion , Colace 100 mg orally three times a day , Meclizine 25
mg orally three times a day , Lopressor 25 mg orally twice a day , Senokot tablets two
tablets orally every day before noon , Coumadin 4 mg orally every other day alternating with 5
mg orally every other day , every day , patient took either 4 or 5 alternating ,
and Glyburide 2.5 mg orally every day Patient was not discharged on any
antibiotics.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: Arranged with his attending , Dr. Sana Azua for the
following week. Patient was also arranged to have an
MRI scan of his spine on Wednesday , 6/6 , at noon. This is to
rule out possibilities of osteomyelitis since patient had had low
back pain since septic events of 5/26
Dictated By: DESIRAE R. MARCOTT , M.D. AC16
Attending: SANA M. AZUA , M.D. TR24
ON137/4989
Batch: 02447 Index No. MLVUJ957UG D: 6/10/95
T: 8/24/95
Document id: 966
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932367573 | PUO | 12555338 | | 796364 | 8/27/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/4/1996 Report Status: Signed
Discharge Date: 11/10/1996
HISTORY OF PRESENT ILLNESS: Ms. Smolinsky is a 45 year old woman
with hypertensive disease , as well as
diabetes , who presents with sustained chest pain and shortness of
breath. The patient has long standing obesity with moderate to
severe hypertension which has been fairly well controlled and
poorly controlled diabetes , as well as atypical chest pain and
asthma. Over the last four days she has had increased episodes of
rather persistent chest discomfort , shortness of breath. She
generally describes it in her anterior chest wall as pressure , but
there is also some sharp qualities as well. The patient has also
noted increasing shortness of breath and dyspnea without subjective
wheezing and there has been an increase in her orthopnea. The
patient is unsure of whether her shortness of breath correlates
with her chest pressure. Previous evaluation has included several
negative exercise tolerance tests , but there was in 1981 an
exercise tolerance test with Thallium that showed a fixed anterior
profusion defect and an EKG has chronic anterolateral Q wave to
poor R wave progression. An echo in 1991 showed LVH with no
regional wall motion abnormalities. The patient was admitted for
rule out MI three months prior to this admission.
PAST MEDICAL HISTORY: 1. Asthma. 2. Hypertension. 3. Diabetes
mellitus. 4. Obesity. 5. Sleep apnea.
6. Peptic ulcer disease.
ALLERGIES: The patient has an allergy to Codeine which produces
nausea.
CARDIAC RISK FACTORS: 1. Diabetes mellitus. 2. Hypertension.
3. Family history of CAD. 4. No tobacco.
5. No hypercholesterolemia.
PAST SURGICAL HISTORY: Notable for: 1. Hysterectomy vaginally.
2. Status post an umbilical hernia repair.
ADMISSION MEDICATIONS: Azmacort , Proventil , Tagamet , Cardizem 300
every day , insulin NPH 40 units every day before noon and 55
units every PM. , aspirin , Motrin , Maxide 1 per day , Lisinopril 20 mg
orally every day.
PHYSICAL EXAMINATION: The patient was afebrile , heart rate 100 ,
respiratory rate 20 , blood pressure was
140/80 , oxygen saturation was 99% on 2 liters. She was an obese
black female lying in the bed at 45 degrees with nasal cannula in
no acute distress. Her head was normocephalic atraumatic. Pupils
were equal and round to light and accommodation. Her extraocular
movements were full. Cranial nerves were intact. There were no
orally lesions. There was minimal jugular venous distention. Chest
was clear. Heart was regular rate and rhythm with no murmurs ,
rubs , or gallops. There was no CVA tenderness. There was some
chest wall tenderness on the left. The abdomen was obese and
non-tender , with bowel sounds present. There was no cyanosis ,
clubbing , or edema. There was no proprioceptive defects.
LABORATORY DATA: Laboratories on admission showed her to have a
potassium of 3.7 , BUN and creatinine of 11/1.2 ,
creatinine kinase of 148 , troponin of 0.0. Chest x-ray was clear
with no evidence of left ventricular failure. EKG showed normal
sinus rhythm at 90 with Q waves/poor R wave progression in I , III ,
intravenous , which was no acute change from the most recent EKG.
HOSPITAL COURSE: The patient was admitted and ruled out for a
myocardial infarction with serial CPK , as well as
serial troponin , both of which showed 0.0. The patient also
underwent a VQ scan given her sedentary life style to rule out
pulmonary embolus , and in fact it was very low probability. The
patient at that point was managed by the addition of a
gastrointestinal regimen of Prilosec and Cisapride as she had
complained of some worsening of her chest pressure when she laid
back flat and some sour taste in her mouth. The patient reported
that this combination of medications made her feel somewhat better.
The patient finally underwent an exercise tolerance test with MIBI
10/1/96. She went 5 minutes and 0 seconds on a Bruce protocol ,
stopped secondary to chest pain. Her peak heart rate was 140 ,
which is 85% of predicted. Her systolic maximum was 120. The
chest pressure was similar to that on admission and it was somewhat
atypical and ill defined. The patient then had MIBI images which
showed a borderline to minimal anterior reversible defect , but that
was as said borderline. The patient was deemed suitable for
discharge after conversation with Dr. Bachmann of the Cardiology
Service , and the patient will be following up with her primary care
doctor. The medication changes will be the addition of Prilosec
and Cisapride in the place of Axid AND the addition of isordil 10mg orally three times a day
DISCHARGE MEDICATIONS: Proventil 2 puffs inhaler four times a day , enteric
coated aspirin 325 mg orally every day , NPH 40
units every day before noon and 55 units subcutaneously every PM. , Lisinopril 20 mg orally every day ,
Maxide 1 tablet orally every day , nitroglycerin 1/150 1 tablet sublingual
every 5 minutes times three as needed chest pain , Prilosec 20 mg orally
every day , Azmacort 4 puffs inhaler twice a day , Cardizem CD 300 mg orally
every day , Cisapride 10 mg orally four times a day , and isordil 10 mg orally three times a day
Dictated By: GERMAINE BLACKGOAT , M.D. RO02
Attending: KURTIS K. MENTGEN , M.D. PB6
ZI752/8650
Batch: 00298 Index No. U7BBFO37E5 D: 11/10/96
T: 9/26/96
Document id: 967
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
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675044488 | PUO | 59647802 | | 8833468 | 2/28/2005 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 10/26/2005 Report Status: Signed
Discharge Date: 11/24/2005
ATTENDING: POPOVIC , ALEXANDRA MD
CHIEF COMPLAINT: Cough , nausea , vomiting , and chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old female
with a past medical history significant for coronary artery
disease , diabetes , hypertension , CHF , and COPD who was admitted
on 2/21/05 after presenting to the emergency department
complaining of three weeks of feeling unwell. The patient states
that approximately three weeks prior to admission , she developed
increased lower extremity edema. She also noted increased cough
and shortness of breath. Approximately two weeks prior to the
admission , she doubled her Lasix dose without much improvement in
her symptoms. About one week prior to the admission , she began
to have abdominal pain , nausea , and vomiting. She continued to
have cough and shortness of breath at this time. The evening
prior to presentation , she had substernal chest pain , which
radiated to her arm x1 hour. This pain improved after taking two
sublingual nitroglycerin tables. She presented to the emergency
department the following day complaining of shortness of breath
and fatigue.
In the emergency department , the patient's vital signs were noted
to be heart rate of 72 , blood pressure of 94/40 with O2 sat 98%
on room air. She was complaining of shortness of breath and
fatigue. Her blood pressure subsequently decreased further to
77/48. At this time , she was bolused with intravenous fluids ,
approximately 1.5 to 2 liters. Following the fluid bolus , she
developed wheezing and was treated with nebulizers. However , she
became more nauseated and dyspneic and her blood pressure
continued to fall. Dopamine was started for blood pressure
support. When she continued to desaturate into the 80% range and
she was subsequently intubated. An echocardiogram at the bedtime
showed a globally depressed ejection fraction of 25%. In
addition , her labs returned with an elevated troponin of 4.5.
She had a subsequent chest x-ray , which documented pulmonary
edema. She was admitted for flash pulmonary edema and was
transferred directly from the emergency department to the cardiac
cath laboratory. In the cath lab , her bypass grafts of the LIMA
to the LAD and SVG to OMB were noted to be patent. However , all
the other grafts were occluded. No interventions were
undertaken. She was also noted to have elevated right and
left-sided pressures with right atrial pressure of 32 and a mean
pulmonary artery pressure of 51 and a left wedge pressure of 40.
She was subsequently transferred to the CCU where she was also
noted to have a serum creatinine of 2.3 and making very small
amounts of urine. A pH at that time was 7.13. Her cardiac
output , cardiac index ratios were 6.8 to 3. She was treated with
sodium bicarb and Lasix intravenous drip. Overnight , she developed a
brisk diuresis and her hypotension resolved. An echocardiogram
obtained on hospital day two showed an estimated ejection
fraction of 45%. The entire inferior wall was noted to be
akinetic. The posterior wall was moderately hypokinetic. Global
right ventricular systolic function was severely reduced. She
was also note to have a thickened , calcified mitral valve with
severe mitral regurgitation.
Her CCU course was notable for two positive blood cultures , one
drawn on 2/21/05 and the other drawn on 4/10/05 for which she
was started first on vancomycin and then switched to nafcillin
for Coag-negative staph bacteremia. She was also diagnosed with
a UTI and started on levofloxacin. She was eventually extubated
on 11/18/05. She was discharged from the CCU on 10/30/05 , and
was accepted on to the Cards Pines Service.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Diabetes mellitus.
4. Coronary artery disease , status post CABG in 1995 with grafts
from the LIMA to the LAD , SVG to RCA , SVG to OM1 , SVG to OM2 , and
RIMA to the PDA.
5. Paroxysmal A-Fib , on Coumadin.
6. COPD.
7. Non-Q wave MI in 2002.
8. Status post right subtotal repair parotidectomy.
9. Status post tubal ligation.
10. Breast cancer , status post right modified radical
mastectomy.
11. History of CHF.
12. Chronic guaiac-positive stool.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS:
1. Aspirin 81 mg a day.
2. Atenolol 12.5 mg a day.
3. Wellbutrin 100 mg twice a day.
4. Zoloft 225 mg once a day.
5. Imdur 30 mg a day.
6. Lisinopril 10 mg a day.
7. Nitroglycerin as needed
8. Serevent.
9. Flovent 44 mcg twice a day
10. Diltiazem ER 300 mg a day.
11. Pravastatin 40 mg a day.
12. Coumadin 2.5 mg twice a day
13. Senna.
14. Colace.
15. Iron sulfate 300 mg three times a day.
16. K-Dur 20 mEq. a day.
17. Metformin 1 gm twice a day.
18. Lantus 20 mg subcutaneously every bedtime
19. Percocet.
20. Albuterol as needed
21. Folate.
22. Magnesium gluconate 1 gm three times a day.
23. Loratadine 10 mg once a day.
SOCIAL HISTORY: The patient is separated from her husband , and
she has several children who live in the same area. She lives
with her son and grandson in the same house. She is a current
smoker , approximately one-third pack per day. She denies alcohol
and intravenous drug use.
FAMILY HISTORY: Notable for a sone with schizophrenia.
LABORATORY STUDIES ON ADMISSION: CBC showed a white blood cell
count of 6.07 , hematocrit 28.5 , and platelets 274 , 000. INR 2.3.
PTT 42.8 and physical therapy 25.8. Sodium 131 , potassium 4.1 , chloride 87 ,
bicarb 24 , BUN 30 , INR 2.3 , and glucose 173. ALT ??___?? , AST
27 , alkaline phosphatase 66 , and total bili 0.2. CK 141 , MB 8.2 ,
troponin peaked at 4.46 and subsequently trended down.
HOSPITAL COURSE: Following discharge from the Coronary Care
Unit: In summary , the patient is a 64-year-old female , admitted
on 2/21/05 , complaining of subacute progressive symptoms of CHF
in addition to a more acute onset of nausea and vomiting. She
presented to the emergency department hypotensive , which was
probably related to dehydration due to decreased orally intake as
well as continued Lasix use. When given intravenous fluids , she went into
flash pulmonary edema , requiring transfer to the CCU and
intubation. The patient underwent emergent cath , which showed no
new intervenable disease , but did show severe MR. She was
admitted to the CCU where she was aggressively diuresed and
weaned of the vent. She was transferred to the floor on
4/13/05.
Her hospital course by system is as follows.
Cardiac ischemia. The patient underwent catheterization on
2/21/05 , which showed 100% obstruction in the SVG to RCA graft ,
60% obstruction in the RIMA to the marginal 1 graft , patent LIMA
to the LAD , and patent SVG to OM1 and OM2. Note was made of
markedly elevated right and left-sided filling pressures. No
stents were placed. We continued management of her ischemia with
aspirin , beta-blocker , Lipitor , and Imdur. In addition , we
started an ACE inhibitor , which had been initially held due to
her hypotension. This was restarted on 10/30/05 for afterload
reduction , given her severe mitral regurgitation. Over the
course of her CCU stay and her hospital stay on the Cardiac
Service , she continued to clinically improve. We felt that her
mitral regurgitation was likely dynamic , related to her CHF flare
and ischemia. We would recommend outpatient echo for further
follow-up of her mitral regurgitation.
Rhythm. The patient at baseline has paroxysmal atrial
fibrillation , on Coumadin. Here , she was noted to be in normal
sinus rhythm. Her Coumadin dose was held for two nights from
10/30/05 to 6/5/05 for planned TEE echo and a small dose of
vitamin K was given. Subsequently , the TEE was later canceled.
We are therefore restarting the patient on her home dose of
Coumadin , but her INR may rise somewhat slowly due to the vitamin
K. We have asked her to have her labs checked on 9/13/05 for an
INR check.
Infectious disease. The patient was noted to have two positive
cultures for Coag-negative staph , one drawn on 2/21/05 and one
drawn on 5/29/05. She was initially started on vancomycin on
2/30/05 and then switched to nafcillin based on her
sensitivities. The plan was to obtain a TEE to evaluate her for
endocarditis. However , on further review of the sensitivity , we
conclude that two bottles represent two different Coag-negative
staph species. We feel that this most likely represents
contamination rather than true bacteremia. This was discussed
with the ID fellow who agreed with our assessment. Therefore ,
the TEE was discontinued and antibiotics were also discontinued.
We asked that the patient have surveillance blood cultures
checked on 9/13/05 while off all antibiotics.
The patient also had a positive UA while in the CCU and was
started on levofloxacin for a UTI. However , her urine cultures
never grew an organism. So , this was discontinued on 6/16/05.
Pulmonary. The patient has a history of COPD. She was continued
on her home inhalers as well as nebulizers as needed. She
received one course of pulse dose steroids while in the CCU for
presumed COPD infection. This was discontinued prior to her
admission to the floor.
Renal. On presentation , the patient had evidence of acute renal
failure with creatinine elevated at 2.3. However , this improved
with diuresis. She also had an MRI of the kidneys to evaluate
for renal artery stenosis on 6/16/05. This showed severe
diffuse atherosclerotic disease of the abdominal aorta , but no
renal artery stenosis. The radiologist recommends a CT angiogram
for further work if clinically indicated as an outpatient.
Endocrine. The patient has a history of diabetes and is on
Lantus and metformin at home. Here , we held her metformin dose
and treated her instead with insulin sliding scale and Lantus.
We have asked the patient to restart her metformin upon
discharge.
FEN. The patient's goal in's and out's should be even to -500 ml
per day. We increased her home Lasix dose from 80 mg daily to 80
mg in the morning and 40 mg at night. These doses should be
subsequently adjusted to maintain her volume status as an
outpatient.
Code. Status is full code.
DISPOSITION: The patient was discharged home on 1/7/05 with
VNA Services. VNA should assist the patient with her medications
as well as volume status checks , daily weights , and lung exams.
She has a follow-up appointment already scheduled with her
primary care doctor , Dr. Nuessle , on 9/29/05 at 2:30 p.m. In
addition , Dr. Tricoche of the Cardiology Service will see
the patient as an outpatient. The exact appointment time and
date are pending at the time of this dictation. The office has
indicated that they will call the patient for a specific
appointment time.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg orally daily.
2. Ferrous sulfate 325 mg orally three times a day
3. Lasix 80 mg in the morning and 40 mg at night.
4. Magnesium oxide 420 mg orally daily.
5. Zoloft 200 mg orally daily.
6. Imdur 30 mg orally daily.
7. Loratadine 10 mg orally daily.
8. Flovent 440 mcg inhaled twice a day
9. Lipitor 80 mg orally daily.
10. Wellbutrin 100 mg orally twice a day
11. Salmeterol one puff twice a day.
12. Nexium 40 mg a day.
13. Lantus 10 units every evening.
14. Lisinopril 5 mg orally daily.
15. Lasix 40 mg orally every afternoon
16. Metoprolol 150 mg orally daily.
17. Metformin 1000 mg orally twice a day
18. Coumadin 2.5 orally every afternoon
19. Nitroglycerin one tablet sublingual every 5 minutes x3 doses
as needed chest pain.
20. Potassium chloride slow release 20 mEq. orally daily.
The patient's Lantus dose should be adjusted according to the
blood glucose levels at home.
eScription document: 3-7419447 CS
CC: Annalisa Tricoche M.D.
CVD ZS1 , Pagham University Of
Lisey
Memps Min Hass
CC: Alexandra Popovic MD
Ette Rock Juan
Iscond La Si
Dictated By: ONIELL , SYLVIA
Attending: POPOVIC , ALEXANDRA
Dictation ID 0143959
D: 1/7/05
T: 10/13/05
Document id: 968
| Target |
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CHF |
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DM |
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GER |
Gou |
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129188447 | PUO | 59954123 | | 5963925 | 2/10/2003 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 6/26/2003 Report Status: Signed
Discharge Date: 9/29/2003
CHIEF COMPLAINT: CHEST PAIN.
HISTORY OF PRESENT ILLNESS: Ms. Sotos is a 58-year-old female
status post stent to her left
circumflex coronary artery three months prior to admission , with a
history of non-insulin dependent diabetes mellitus , hyperlipidemia ,
hypertension , who presents with left jaw pain for the last several
days. She treated this at home with sublingual nitroglycerin with
partial relief of her pain. She presented to the emergency room
and had full resolution of her jaw pain with three sublingual
nitroglycerin. Of note , when the patient presented with a non-ST
elevation MI approximately three months prior , she also had left
jaw pain. Since this pain was the patient's classic anginal pain ,
heparin was started despite the fact that she had negative cardiac
enzymes and no EKG changes.
PAST MEDICAL HISTORY: Non-insulin dependent diabetes mellitus ,
hypertension , hyperlipidemia , coronary
artery disease status post left circumflex stent in April 2002.
Anxiety , depression , left arm phlebitis associated with blood draws
after her left circumflex stent was placed. Status post
appendectomy , status post tubal ligation.
ALLERGIES: No known drug allergies.
MEDICATIONS: Glucophage , Lipitor , atenolol , aspirin , sublingual
nitroglycerin as needed , Zestril , Celexa , Klonopin ,
Neurontin.
SOCIAL HISTORY: The patient has a daughter who works for Tysvillei Medical Center She does not smoke nor does she drink
alcohol. Her primary language is vietnamese.
FAMILY HISTORY: Positive for coronary artery disease. The
patient's father died of a myocardial infarction
at age 62 and her mother died of a myocardial infarction at age 75.
VITAL SIGNS: Blood pressure 100-137/52-67 , pulse 60-62 ,
respiratory rate 18 , oxygen saturation 97-98% on two
liters nasal cannula.
PHYSICAL EXAMINATION: GENERAL: Well appearing middle-aged female.
NECK: JVP flat. CARDIOVASCULAR: Regular
rate and rhythm with normal S1 and S2. CHEST: Clear to
auscultation bilaterally. ABDOMEN: Soft , nontender , nondistended.
Positive bowel sounds. EXTREMITIES: No lower extremity edema ,
warm. RECTAL: The patient is guaiac negative.
HOSPITAL COURSE BY SYSTEMS: 1. Cardiovascular. The patient was
taken for cardiac catheterization
after she was admitted. Her cardiac catheterization was on
April , 2003. Prior to her catheterization she was enrolled in
the Ven Medical Center This was a blinded trial with Clah inhibitor. In accordance with the trial , the patient was
started on Lovenox 1 mg per kg subcutaneously twice a day Later that
afternoon on April , 2003 , she went for cardiac catheterization.
The cath revealed a right dominant system with no significant left
main lesions , no significant left anterior descending lesions , 70%
diffuse lesion in the left circumflex artery consistent with
instant restenosis of her previously placed PIXEL stent. The right
coronary artery showed a 30% lesion. During this catheterization ,
brachytherapy to the vessel that showed instant restenosis was
attempted , however , it was aborted due to technical malfunction of
the brachytherapy delivery machine. The lesion was , however ,
dilated by balloon angioplasty. After dilatation there was TIMI-3
flow with 10% residual stenosis.
Postcath the patient did well. She was maintained on aspirin ,
Zocor , Lopressor , captopril , Celexa , Klonopin which are her home
medications. The morning after catheterization , the patient had
recurrent chest pain which radiated to her right jaw. The pain was
relieved with sublingual nitroglycerin. The following day , the
patient did well. However , she began to develop a right groin
hematoma in the afternoon on July , 2003. The hematoma was
thought to be rapidly enlarging. Hematocrit checked at that time
revealed a significant drop in blood count to 26. The patient was
transfused two units of packed red blood cells. Her hematoma
continue to expand overnight. The patient was discontinued from
Lovenox at that time. However , she was continued on aspirin and
Plavix. The patient's Lovenox was reversed with protamine.
Over the night , the patient's hematoma continued to expand. She
received , the following morning on March , 2003 , one unit of
fresh frozen plasma as well as a third unit of packed red blood
cells. At that point , her hematoma was marked and it was noted to
be stable from that point on , no longer expanding beyond the bounds
of the marks. Her left arm was noted at that time to also be tense
with hematoma secondary to blood draws. Vascular surgery was
consulted in the morning on March , 2003 , in order to assess the
right groin hematoma as well as the hematoma in the left arm due to
concern for developing compartment syndrome. Vascular surgery saw
the patient and felt that as long as the patient's hematocrit
stabilized , she would not need any surgical intervention. They
could not find any evidence for left upper extremity compartment
syndrome at that time.
Also on the morning of March , 2003 , the patient's platelets
agents including both Plavix and aspirin were discontinued.
Further family history was obtained from the patient that day which
revealed history suspicious for possible bleeding disorder
including the information that the patient's daughter bleeds
heavily with each menstrual period , and that both the patient and
her daughter have very easy bruising with history of several
hematomas secondary to light trauma. The patient also reported
that she had heavy bleeding with childbirth that required extra
hospitalization although it did not require a transfusion.
Hematology was consulted at that point. The patient was thought by
hematology to have these hematomas secondary to over
anticoagulation with Lovenox , Plavix , aspirin and possible BANO AAP HOSPITAL CENTER
trial drug with a Weiss Linddoun Hospital The only familial
coagulation problems that were screened for based on their
recommendations were von Willebrand screen as well as a Factor XIII
screen. The Factor XIII screen eventually turned out normal and
the von Willebrand screen was pending at the time of discharge.
By the morning of August , 2003 , the patient had received a total
of five units of packed red blood cells due to blood loss secondary
to this hematoma. Her hematoma had stabilized at that time. She
was restarted on aspirin on August , 2003. From that point
onward , the patient did quite well and was maintained on aspirin ,
beta-blocker , Zocor and ACE inhibitor.
The remainder of her hospitalization was uncomplicated and after
the patient had a stable hematocrit for several days without any
recurrent jaw pain , she was discharged home on January , 2003.
Neurology. On August , 2003 , the patient developed a headache
which she described as the same as she frequently experiences at
home. Her headaches are usually not responsive to Tylenol or other
analgesics. Given the patient's complications with hematoma and
bleeding , a head CT was obtained that afternoon to rule out
intracerebral hemorrhage. Her head CT was negative for bleeding.
Her headache was treated with Tylenol to which it did not respond
and later with Percocet to which she got some relief.
DISCHARGE MEDICATIONS: Aspirin 81 mg orally every day , Klonopin 0.5 mg
three times a day , glucophage 500 mg twice a day , Celexa
40 mg orally every day , Zestril 2.5 mg every day , atenolol 25 mg orally every day ,
Lipitor 20 mg orally every bedtime
FOLLOW UP: The patient was instructed to follow up with her
primary care physician , Dr. Purkerson
Dictated By: SHANEL PORTNOY , M.D. SE88
Attending: JEANNETTE GORGLIONE , M.D. AF83
GC839/921890
Batch: 11675 Index No. NQZK3F7233 D: 5/5/03
T: 5/5/03
Document id: 969
| Target |
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CHF |
Dp |
DM |
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GER |
Gou |
HC |
HTN |
HTG |
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PVD |
VI |
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510916525 | PUO | 07122247 | | 1154369 | 1/2/2004 12:00:00 a.m. | END STAGE RENAL DISEASE | Signed | DIS | Admission Date: 6/8/2004 Report Status: Signed
Discharge Date: 11/10/2004
ATTENDING: GAYLENE FANIEL MD
SERVICE:
Renal Transplant Service.
PRINCIPAL DIAGNOSIS:
End-stage renal disease. The patient was admitted for a living
unrelated renal transplant.
LIST OF PROBLEM:
1. End-stage renal disease.
2. Atrial fibrillation.
3. Obstructive sleep apnea.
BRIEF HISTORY OF PRESENT ILLNESS:
The patient is a 70-year-old male with a history of coronary
artery disease , hypertension , and end-stage renal disease on
hemodialysis for two months that presented for a living unrelated
renal transplant.
ALLERGIES:
The patient reported vertigo to lisinopril and prednisone.
However , prednisone was given on this admission , and he did not
have a problem.
BRIEF ADMISSION PHYSICAL EXAM BY REPORT:
The patient's temperature was 98.0 , blood pressure 148/60 , pulse
67. In general , a pleasant obese male in no acute distress. His
skin was dry and intact. His HEENT exam demonstrated PERRLA ,
EOMs intact. No icterus , neck was without bruits. He had no
palpable lymph nodes. His heart was regular rate and rhythm
without murmurs. Lungs were clear to auscultation. His abdomen
was obese with a midline incision. His extremities demonstrated
no cyanosis , clubbing , or edema. He had a left forearm
hemodialysis axis. He had 5/5 strength in both his upper and
lower extremities. He had 5/5 strength in his hands. His neuro
exam demonstrated he is alert and oriented x3.
HOSPITAL COURSE BY PROBLEM:
1. The patient was in end-stage renal disease and had a living
unrelated renal transplant from his friend. A detailed
description of the procedure can be found in his dictated
operative report. There were no complications. His kidney had
good urine output during his postoperative course. His
creatinine continued to trend down even on his days of discharge.
His creatinine was within a normal range prior to his discharge.
He had some volume overload secondary to the large amount of intravenous
fluids that he received , however , after minimal diuresis he
responded with high urine outputs. His immunosuppression
included Thymoglobulin , tacrolimus , a steroid taper , and
CellCept. His allograft was functioning well.
2. Atrial fibrillation: The patient was found to be in atrial
fibrillation postoperatively. He was evaluated by the Cardiology
Service. They interrogated his pacer and found that he was in
fact in atrial fibrillation. After 48 hours , the Cardiology
Service considered anticoagulation. Because he had a history of
a GI bleed , it was decided that he would not undergo
anticoagulation. The patient's heart rate throughout this period
was within the normal range because he was V-paced.
3. Obstructive sleep apnea: The patient had a history of apnea
and was given a standard home therapy with CPAP at night.
COMPLICATIONS:
None.
KEY FEATURES OF PHYSICAL EXAM AT DISCHARGE:
The patient was awake and alert in no distress. His neuro exam
was nonfocal. Abdomen: Obese , soft , nondistended , with an
incision that was clean , dry , and intact.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally every day
2. Calcitriol 0.5 mcg orally every day
3. Calcium carbonate 500 mg orally twice a day
4. Pepcid 20 mg orally twice a day
5. Dilaudid 2 mg to 4 mg orally every 4 hours as needed for pain.
6. Tacrolimus 5 mg orally every 12 hours This drug has to be checked
daily with daily draws. The Renal Transplant Service will
adjust his dose accordingly.
7. Bactrim single strength one tab orally every day
8. CellCept 1000 mg orally twice a day
9. Plavix 75 mg orally every day
10. Valcyte 450 mg orally every day
11. TriCor 160 mg orally every day
12. Simvastatin 40 mg orally every bedtime
13. Atenolol 75 mg orally every day
DISPOSITION:
The patient was discharged to his home. He was instructed and
given instructions how to have daily tacrolimus levels drawn.
PHYSICIAN FOLLOW UP PLAN:
The patient is to follow up with renal transplant medicine this
week. He is also to follow up with his own cardiologist.
Attending physician's name is Dr. Gaylene Faniel
The patient's primary care physician is Marybeth Newbury , M.D. at
Pagham University Of .
eScription document: 8-5945737 EMSSten Tel
CC: Marybeth Newbury M.D.
Pagham University Of
Chigreenvirg Go
Dictated By: MOOSE , BUCK
Attending: FANIEL , GAYLENE
Dictation ID 2290559
D: 8/22/04
T: 8/22/04
Document id: 970
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
N |
710780777 | PUO | 52024474 | | 1381368 | 8/6/2003 12:00:00 a.m. | AORTIC INCOMPETENCE | Signed | DIS | Admission Date: 10/17/2003 Report Status: Signed
Discharge Date: 11/11/2003
DISCHARGE DIAGNOSIS: STATUS POST REOPERATIVE SINUS VALSALVA AORTIC
ANEURYSM REPAIR.
OTHER DIAGNOSES: 1. CONGESTIVE HEART FAILURE SECONDARY TO ATRIAL
FIBRILLATION.
2. OSTEOPOROSIS.
3. DEPRESSION/MOOD SWINGS.
4. HISTORY OF BLADDER PROLAPSE AND MARFAN'S
SYNDROME.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old female with
Marfan's syndrome status post mitral
valve replacement in 1997 being followed by Dr. Krinsky of cardiology
with routine echocardiograms. She was recently more dyspneic on
exertion with little exercise tolerance. Preoperative cardiac
status includes a history of class II heart failure. Recent signs
and symptoms of congestive heart failure include dyspnea on
exertion. The patient is in normal sinus rhythm. Previous
cardiovascular interventions include 4/4 mitral valve replacement
( 32 Carpentier-Edwards pericardial )/MVP ( 32 physioring
Carpentier-Edwards ) and cleft repair posterior leaflet.
PAST SURGICAL HISTORY: Vaginal hysterectomy and partial
mastectomy.
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: No history of tobacco use.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Preoperative medications were atenolol 100 mg
orally twice a day , Atacand 60 mg orally every day ,
amiodarone 200 orally every day , furosemide 40 mg orally every day , Wellbutrin
200 mg every day , Prozac 10 mg every day , and Fosamax 70 mg every week.
PHYSICAL EXAMINATION: Height 5'6" , weight 74.99 kg , and vital
signs with a temperature of 96.0 , heart rate
62 , and blood pressure in the right arm 140/78 with left arm of
140/78. HEENT: Pupils equal , round , and reactive to light and
accommodation , dentition without evidence of infection , and no
carotid bruit. CHEST: Midline sternotomy. CARDIOVASCULAR:
Regular rate and rhythm with no murmur. PULSES: Carotid 2+
bilaterally , radial 2+ bilaterally , femoral 2+ bilaterally ,
dorsalis pedis 2+ bilaterally , and posterior tibial 2+ bilaterally.
Allen's test of the right upper extremity was normal. RESPIRATORY:
Breath sounds clear bilaterally. ABDOMEN: No incision , soft , no
masses. EXTREMITIES: Without scarring , varicosities , or edema.
NEUROLOGICAL: Alert and oriented with no focal deficits.
LABORATORY EXAMINATION: Sodium 135 , potassium 4.8 , chloride 101 ,
CO2 28 , BUN 23 , creatinine 1.4 , glucose
106 , and magnesium 2.1. Hematology showed white blood count 8.65 ,
hematocrit 35.0 , hemoglobin 11.6 , platelets 274 , physical therapy 12.4 , INR 1.0 ,
and PTT 24.6. Cardiac catheterization was done on 5/22/03. Echo
from 9/10/03 showed 30% ejection fraction , mild aortic
insufficiency , mild mitral insufficiency , mild tricuspid
insufficiency , and aortic root of 4.9 cm.
HOSPITAL COURSE: Patient was admitted to our service on 5/3/03
and stabilized for surgery. Date of surgery was
5/22/03. Preoperative status was elective. Procedure was a
reoperative sinus of Valsalva aortic aneurysm repair. Bypass time
was 218 minutes and cross-clamp time 154 minutes. Two atrial wires
were placed , one ventricular wire , one pericardial tube , one
retrosternal tube , and one left pleural tube were placed. Findings
were a 4.9 cm sinus of the Valsalva aneurysm. There were no
complications. ____ sparing full root with 32 Hemashield graft ,
moderate to severe aortic insufficiency preoperatively , and trace
aortic insufficiency off bypass. Coming off bypass , patient was
asystolic requiring A-pacing but left operating room in sinus
rhythm. Patient was transferred to the unit in a stable fashion.
All lines and tubes were intact. Patient was extubated in a normal
fashion. 9/1/03 , postoperative day one , patient was transferred
to the stepdown unit with lines and tubes intact. Gentle diuresis
was continued and patient's ambulation was slowly increased.
5/30/03 , postoperative day two , patient's chest tubes were
discontinued and central line catheter was discontinued. 9/9/03 ,
postoperative day three , patient's temporary pacing wires were
removed without incident. Patient's ambulation increased and
oxygen was successfully weaned off to room air. Patient was
saturating at 93%. Patient continued with an uncomplicated
hospital course. Gentle diuresis was continued and ambulation was
increased until the patient was evaluated to be stable to discharge
to home with visiting nurse association services on 3/2/03 with
discharge instructions of diet with no restrictions , follow-up
appointment with Dr. Stukowski , ( 841 )727-4369 , in 5-6 weeks , Dr. Krinsky ,
her cardiologist , in 1-2 weeks , and Dr. Gilberg , ( 778 )683-3773 , in
1-2 weeks.
DISPOSITION: To home with VNA service. To do plan includes local
wound care and make follow-up appointments.
DISCHARGE MEDICATIONS: Amiodarone 200 mg orally every day , Prozac 10 mg
orally every day , Lasix 40 mg orally every day , ibuprofen
600 mg orally every 6 hours as needed pain , metoprolol 25 mg orally four times a day ,
Niferex-150 at 150 mg orally twice a day , K-Dur 20 mEq every day , Wellbutrin SR
200 mg orally every day , and Albuterol inhaler 2 puffs inhaled four times a day
as needed wheeze.
CONDITION ON DISCHARGE: Stable.
Dictated By: LORRETTA PA CRIDGE , P.A.
Attending: JANAY D. STUKOWSKI , M.D. JX47
RF999/058669
Batch: 15013 Index No. XBBO3N11DD D: 3/2/03
T: 3/2/03
Document id: 971
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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744135337 | PUO | 95637816 | | 3266534 | 10/28/2005 12:00:00 a.m. | chf exacerbation | | DIS | Admission Date: 1/17/2005 Report Status:
Discharge Date: 10/11/2005
****** FINAL DISCHARGE ORDERS ******
STEWARDSON , TYRON D. 569-60-85-8
Sto Palme Olk
Service: CAR
DISCHARGE PATIENT ON: 1/1/05 AT 05:30 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOARD , KATHIE MIREYA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 1 , 000 MG orally three times a day as needed Pain
ALLOPURINOL 100 MG orally every day
VITAMIN C ( ASCORBIC ACID ) 1 , 000 MG orally every day
CALCITRIOL 0.25 MCG orally every day
VITAMIN B12 ( CYANOCOBALAMIN ) 1 , 000 MCG orally every day
Number of Doses Required ( approximate ): 15
PROPINE 0.1% ( DIPIVEFRIN 0.1% ) 1 DROP each eye twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLIC ACID 1 MG orally twice a day
ROBITUSSIN ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours
as needed Other:cough , sore throat
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
as needed Wheezing
LEVOTHYROXINE SODIUM 112 MCG orally every day
ZAROXOLYN ( METOLAZONE ) 5 MG orally every day
Instructions: please give 30 minutes before Torsemide
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 1/5/05 by
SHOOP , ALTON M. , M.D. , M.PH.
on order for OXYCODONE orally ( ref # 84170911 )
patient has a PROBABLE allergy to Codeine; reaction is Unknown.
Reason for override: patient takes at home
VITAMIN B6 ( PYRIDOXINE HCL ) 50 MG orally every day
ALDACTONE ( SPIRONOLACTONE ) 25 MG orally twice a day
Food/Drug Interaction Instruction Give with meals
Override Notice: Override added on 10/30/05 by
SHOOP , ALTON M. , M.D. , M.PH.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
47699241 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: aware Previous override information:
Override added on 10/18/05 by SHOOP , ALTON M. , M.D. , M.PH. on order for K-DUR orally ( ref # 83809194 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: aware aware
Previous override information:
Override added on 10/18/05 by SHOOP , ALTON M. , M.D. , M.PH.
on order for POTASSIUM CHLORIDE intravenous ( ref # 99822618 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: aware Previous override information:
Override added on 1/5/05 by SHOOP , ALTON M. , M.D. , M.PH.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 60 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
K-DUR ( KCL SLOW RELEASE ) 40 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 10/18/05 by
SHOOP , ALTON M. , M.D. , M.PH.
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: aware aware
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally twice a day
TORSEMIDE 150 MG orally twice a day
TRUSOPT ( DORZOLAMIDE 2% ) 1 DROP each eye twice a day
Number of Doses Required ( approximate ): 5
FLONASE ( FLUTICASONE NASAL SPRAY ) 2 SPRAY inhaled every day
Number of Doses Required ( approximate ): 5
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 5
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: please apply under breast and in groin area.
thanks.
ALBUTEROL AND IPRATROPIUM NEBULIZER 3/0.5 MG inhaled every 6 hours
as needed Wheezing
FEMARA ( LETROZOLE ) 2.5 MG orally every bedtime
Number of Doses Required ( approximate ): 5
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
HUMULIN L ( INSULIN LENTE HUMAN ) 100 UNITS subcutaneously every bedtime
HUMULIN 70/30 ( INSULIN 70/30 HUMAN ) 70 UNITS subcutaneously every day before noon
INSULIN REGULAR HUMAN 54 UNITS subcutaneously with dinner
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously every day before noon
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Kerwood call friday morning to ,
Hoerter call Friday am to schedule ,
ALLERGY: Penicillins , NITROFURANTOIN MACROCRYSTAL , Codeine ,
CIPROFLOXACIN , OFLOXACIN , NITROFURANTOIN , DIPYRIDAMOLE ,
PENICILLIN V POTASSIUM
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) dm ( diabetes mellitus ) atrial
fibrillation ( atrial fibrillation ) urinary tract infection ( urinary
tract infection ) aortic stenosis ( aortic
stenosis ) syncope ( syncope ) iron deficiency ( iron deficiency
anemia ) pernicious anemia treated GIB ( unspecified GI bleed )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
I. INFORMATION
**Presentation:
73 year-old F with PMH of AS AVA 0.74 cm2 , median gradient 36
mmHg , multiple CHF exacs in past , DM , HTN , clinically in
CHF exacerbation.
PMH: worsening AS AVA 074 cm2 , LVEF 65% , mild TR ,
hypothyroidism , DM on insulin , CKD
Final Diagnosis: CHF exacerbation
Treatment and Response:
Note that it was very difficult to monitor her fluid status -JVP
difficult 2/2 girth of neck , often incontinent so I/O inaccurate , and has
chronic leg edema 2/2 PVD. Therefore , we adjusted diuretic regimen
primarily by how she symptomatically felt and her weights.
Initially treated with Torsemide 200 intravenous twice a day , Zaroxylyn 5 mg orally twice a day
( 30 min before torsemide ) , and Aldactone 25 orally twice a day She diuresed well to
this. Over the course of hospital stay , her creatinine increased
from 1.6 to 2.2 , and though her baseline is 1.6-2.0 , we used this , along
with her symptomatic improvement and return of weight to dry weight of
114.5 kg , to establish euvolemia. For final 3 days of stay on
home regimen of torsemide 150 orally twice a day , zaroxlyn 5 orally every day , and
aldactone 25 orally twice a day and had stable weights.
Relevant Data: Weight at d/c 114.5; VS @ d/c 98.0 , 81 , 106/60 , 20 ,
93 on RA; rales at left base
Brief Hospital Course:
See above for CHF related info
In addition , patient was found to have pan-sensitive E-coli UTI - treated with
Bactrim x 7 days. Two days before discharge her initial cough worsened
in severity and became somewhat productive. She never mounted a WBC ,
never was febrile , and CXR showed no infiltrate. Felt to be 2/2
underlying COPD - improved significantly with nebulizer tx and
Robitussen. During hospital stay , she was evaluated for home 02;
however , her ambulatory 02 sat was 94% and her nocturnal O2 sats ( done by
respiratory therapy ) were 89-93%. Therefore , not discharged on home 02 ,
though may want to consider as outpt.
II Action Plan:
**patient told to contact her primary care physician and cardiologist first thing in am after
discharged ( decision made to d/c after 5 pm so appts could not be
scheduled )
**Medication Changes:
All diuretics and DM medications are the same
Bactrim course completed prior to d/c
New med = robitussen
Patient Status: difficult to
monitor her fluid status b/c JVP diff assess 2/2 morbid obesity ,
incontinent , and weights have been unreliable; today weight up 1 lb ,
I/O -1L , but has increasing cough and O2 requirement ( had been on RA
yesterday am ) ; neurologically intact; Sig Daily events: new cough
and increasing WBC Sig procedures/Tests: CXR pending r/o
PNA CXR: vasc congestion , ( + ) spine
sign; TTE( 10/21/05 ): AS AVA 0.74cm2 , LVEF 65% , mild MR ,
mod TR; Consults: 2/20 Put in for Resp Therapy to do
Nocturnal 02 sats Problem
List: CV-I: ? history of of CAD by previous stress test; nNZ's
( - ) x1; no ASA given history of GI bleed; cont statin; CV-P: CHF likely from
bad AS; try to diurese with intravenous torsemide 100 twice a day and zaroxylyn 5 twice a day;
goal -2L /day; may need BNP or dobutamine drip as needed on
prior admissions; 11/18 BACK ON HOME REGIMEN B/C FEEL overdiuresed:
torsemide 150 orally twice a day , Zaroxylyn 5 mg orally every day , and Aldactone 25 orally
twice a day CV-R: known chronic afib; not coumadin candidate;
no rate control meds needed yet; PULM: OSA- doesn't tolerate CPAP;
Afebrile , cough with increasing WBC , CXR
pending RENAL: known CKD; no ACE or ARB as o/p; baseline cr
1.5-2.3; ENDO: known DM cover with nph 25 twice a day , regular 15
before every meal , and RISS; known hypothyroidism , chech tsh , cont home dose
levoxyl; GI: history of GI bleed; nexium
every day; ID: Has UTI ( most likely E-Coli -on Bactrim
-sensitivities pending ) FEN: 2 L fluid restriction , K
scales; FC;
ADDITIONAL COMMENTS: 1 ) CALL DR. KERWOOD , AND DR. HOERTER's OFFICES IN a.m. TO SCHEDULE APPTS FOR
NEXT WEEK
2 ) You are on the same diuretic regimen and insulin regimen that you came
in on.
3 ) Limit fluid intake to 2L
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: SHOOP , ALTON M. , M.D. , M.PH. ( SW78 ) 1/1/05 @ 08
****** END OF DISCHARGE ORDERS ******
Document id: 972
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
Y |
N |
N |
N |
N |
990585823 | PUO | 43827729 | | 9427069 | 8/17/2004 12:00:00 a.m. | Tachyarrhythmia with atrial fibrillation/flutter | | DIS | Admission Date: 3/19/2004 Report Status:
Discharge Date: 11/12/2004
****** DISCHARGE ORDERS ******
OTEY , ERNEST 484-45-94-9
Na Ker Co Dall York
Service: MED
DISCHARGE PATIENT ON: 5/11/04 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FRANZA , GAYE SARAH , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 4/13/04 by
ULLRICH , MARIAN GUILLERMINA , M.D. , M.P.H.
on order for ECASA orally ( ref # 66192891 )
patient has a POSSIBLE allergy to NSAIDs; reaction is
( naprosyn ).
patient has a POSSIBLE allergy to NAPROXEN; reaction is
Unknown. Reason for override: tolerates
DILTIAZEM 30 MG orally four times a day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 8/13/04 by
HOLLINRAKE , CHER
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override:
Insufficient rate control on one agent.
LASIX ( FUROSEMIDE ) 20 MG orally every day
Alert overridden: Override added on 4/13/04 by
ULLRICH , MARIAN GUILLERMINA , M.D. , M.P.H.
on order for LASIX orally ( ref # 70745235 )
patient has a POSSIBLE allergy to HYDROCHLOROTHIAZIDE;
reaction is rash. Reason for override: tolerates
PREDNISONE 10 MG orally every day before noon
METFORMIN 850 MG orally twice a day
REMERON ( MIRTAZAPINE ) 7.5 MG orally every bedtime
Number of Doses Required ( approximate ): 1
ARICEPT ( DONEPEZIL HCL ) 10 MG orally every day
Number of Doses Required ( approximate ): 1
LEVALBUTEROL 0.63 MG inhaled four times a day
Number of Doses Required ( approximate ): 4
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 100 MG orally every day
Starting Today ( 8/9 ) Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 5/11/04 by :
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override:
patient needs for HR control
FOLATE ( FOLIC ACID ) 1 MG orally every day
VITAMIN B 6 ( PYRIDOXINE HCL ) 50 MG orally every day
VITAMIN B12 ( CYANOCOBALAMIN ) 100 MCG orally every day
DIET: House / ADA 1800 cals/dy
ACTIVITY: Ambulate with assistance
FOLLOW UP APPOINTMENT( S ):
Dr. Netti 9/17/04 at 3:50 p.m. scheduled ,
Dr. Pagliuca ( Cardiology ) 1:30 p.m. 11/10/04 scheduled ,
ALLERGY: HYDROCHLOROTHIAZIDE , Penicillins , NSAIDs , LISINOPRIL ,
NAPROXEN , ACE Inhibitor , SEAFOOD , TOMATOES
ADMIT DIAGNOSIS:
Chest Pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Tachyarrhythmia with atrial fibrillation/flutter
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NIDDM , Htn , Asthma , history of Rheumatic heart disease , Bipolar disorder , history of
Cataract surgery , atrial fibrillation , djd , Temporal Arteritis , CVA
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain
HPI: 69y/o female with MMP , including CHF ( EF=50% 10/6/04 ) , NIDDM , Afib ,
and mult CVAs , was in her USOH until 8am the DOA , when she was observed
to have twitches in her eyes and mouth; during this episode , the patient
was A&OX3/no LOC. Per report , she has not had these sx previously. VS
at the time were stable. At 8:45 am per report , the patient began moaning
and complained of left sided chest pain localized to her breast. Her
skin was noted to be clammy. The patient reports no radiation of sx , SOB ,
N/V , palpitations , or dizziness. Proxy did note that patient had a
"congestive cough" for past week. VS at nursing home durnig episode of
chest pain were P57-92 , BP 104/70 , O2 98%RA. patient then brought to the PUO
ED , where she no longer c/o sx but was found to be tachy in afib with
HR 120s-130s. In ED VS: T 99.2; BP 129/116; RR14; O2 99%RA. PE notable
for cataracts b/l , CN intact , lungs CTA b/l , CVS tachy , ?S4 , abd s/nt ,
ext www , no edema. patient unable to cooperate for full neurological exam.
Labs notable for K of 5.4 , Ca of 8.1 , and WCT of 15.02. EKG:tachy at
111 , reg rhythm ?sinus vs. atrial flutter. .5mm ST depression in V5 , no
TW changes , QW in 3 , aVF ( unchanged ). CXR: No evidence of pulm edema/
infiltrate. patient given 50 mg orally lopressor and 5mg intravenous lopressor X 4 with
persistent tachycardia to the low 100s.
ASSESSMENT: 69 year-old female with history of CHF , DM , tachyarrhythmias , and CVAs
presents with chest pain , facial twitching. patient admitted for stabilization
of HR and r/o MI.
HOSPITAL COURSE:
1 ) CARDS:
Ischemia: patient ruled out by enzymes/EKG X3. Did not complain of CP/ SOB
during admission. On ASA , Beta blocker
Pump: H/o CHF with EF 50-55% in 7/19/04. No evidence of volume overload
by PE , CXR. On lasix 20 mg orally every day Repeat ECHO 11/8/04 showed a mild
interval reduction in LV EF down to 35-40% without significant
valvular abnormalities.
Rhythm: patient tachy to 110s on admission but hemodynamically stable. O/N
HD1 had episode of afib at 130s-140s , desat to 88%. No complaints of
CP. Given diltiazem 10 mg intravenous with return of HR to low 100s ( baseline ).
Started diltiazem 30 mg orally four times a day with drop in HR to 70s-80s , with irregular
rhythm. Per EKG , ?sinus arrhythmia vs ?atrial fibrillation with normal
rate. TSH pending. On HD4 , patient had episode of bradycardia down to 50s
( approximately 1 hour ) asymptomatic with no evidence of heart block.
Toprol XL was restarted at home dose ( 100 mg every day ) , and diltiazem was
kept at four times a day dosing upon discharge. Given the brief episode of
bradycardia and concerns for both bradycardia and heart block , it was
decided to place a continuous loop monitor on the patient. She will
follow up in outpatient cardiology on November and with her primary care physician on
November
2 ) NEURO: Has hx of CVA. Head CT on 8/17/04 shows old infarct , no new
lesion. Per proxy , patient back to baseline mental status upon admission.
No episodes of facial twitching during admission. On aricept.
3 ) ID: WCT 15.03 with 86% PMNs. patient afebrile , no evidence of infection.
Given hx. of cough , a sputum gs/cx were done and were negative. WCT
down to 8.03 by discharge. patient on prednisone for temporal arteritis;
this may have been the cause of the WCT elevation , but this is
unlikely as WCT dropped by discharge.
4 ) ENDO: On metformin 850 mg twice a day for DM. In addition , had patient on
sliding scale insuling during admission.
5 ) FEN: Potassium initially elevated , but down to 3.8 by discharge; No
EKG changes were observed. Ca was low , and was repleted - it may have
been responsible for facial twitches. On ADA diet.
6 ) RHEUM: H/o temporal arteritis. Continued prednisone 10mg every day ESR
rechecked on day of discharge per Dr. Tumey To be followed up
as outpatient.
7 ) CODE: FC. *Per Health proxy , Coletta Ketteringham ( phone
640-243-0279 ) , patient's code status had changed to FC after being years of
DNR/DNI. Code status was revisited this hospitalization , and Ms.
Bonaccorso requested that the patient be full code. Discussed issue
with Dr. Netti , who will revisit this issue with the patient and
proxy at her next appt.
ADDITIONAL COMMENTS: Please continue to take your home medications. We have added a new
medication , Diltiazem , which you need to take four times a day. In
two days , you should receive a portable heart monitor that will record
your heart rhythms continuously for one month.
Please schedule an appt. to see Dr. Weckenborg within 1 week. You should see
Dr. Shon Pagliuca in cardiology on November at 1:30 p.m. and Dr.
Netti on June at 1:50 p.m. If you have chest pain , shortness
of breath , dizziness , weakness , or other symptoms go to the ER.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
patient to follow up with Dr. Netti on 9/17/04 at 3:50 p.m. For HR
control , patient started on diltiazem 30 mg four times a day. Will likely transition to
long-acting diltiazem as an outpatient. patient has been scheduled to see
Dr. Pagliuca in cardiology for consideration of amio for heart rate
control. patient to be sent home with loop monitor for possible
bradycardia/heart block on nodal agents.
No dictated summary
ENTERED BY: ULLRICH , MARIAN GUILLERMINA , M.D. , M.P.H. ( GK28 ) 5/11/04 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 973
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369427641 | PUO | 37113610 | | 8376319 | 10/2/2006 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 2/15/2006 Report Status: Signed
Discharge Date: 7/23/2006
ATTENDING: GRAP , RONA M.D.
ATTENDING SURGEON: Isabelle Colasamte , M.D.
PRINCIPAL DIAGNOSES: Chronic atrial fibrillation and atrial
flutter.
PRINCIPAL DISCHARGE DIAGNOSES: Chronic atrial fibrillation ,
atrial flutter , and ablation.
MEDICATION PROBLEMS: Include ,
1. Atrial fibrillation and atrial flutter left sided , status
post atrial fibrillation ablation attempt x1 , and atrial flutter
ablation x4 , transesophageal echo in 6/24 showed that atrial
appendage thrombus and trace mitral regurgitation.
2. Hyperprolactinemia.
3. Hypercholesterolemia.
4. Chest CT in 9/19 showed multiple tiny nodules in the right
upper lobe that needed to be followed up in 6-12 months.
BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with a history of recurrent atrial fibrillation and atrial
flutter , status post multiple cardioversion and failed ablations ,
admitted electively for repeat ablation of his atrial flutter.
He was initially diagnosed with atrial fibrillation about 12
years ago and had multiple failed cardioversion and medication
trials. He underwent several atrial fibrillation ablations ,
which ultimately all failed. Overtime his atrial fibrillation
has become atrial flutter possibly due to scarring of the atrial
wall and repeated ablations. When he was first diagnosed with
atrial fibrillation he was started on Coumadin , but that gave him
skin necrosis around his right scapular region. He had been all
the anticoagulants until 6/24 when during transesophageal echo
for planned ablation he was found to have a left atrial appendage
clot. He was first started on Lovenox , which caused large
ecchymosis , which prompted him to switch anticoagulation the
fondaparinux. He now lived persistently in atrial flutter. His
weight controlled with acebutolol. His physical activity has
somewhat decreased and he occasionally gets short of breath ,
epigastric discomfort , and palpitations. He was admitted on
7/6/06 for planned atrial flutter ablation by Dr. Grap and
Dr. Gawlas However , a preprocedure transesophageal echo
again demonstrated a left atrial appendage thrombus despite being
on fondaparinux , instead the patient underwent permanent atrial
fibrillation and atrial flutter surgery , which included a fourth
sternotomy and ablation of atrial fibrillation with COX III Maze
with cryoablation and cut and sew resection of the left and right
atrial appendages and closure of a patent foramen ovale.
PREADMISSION MEDICATIONS: Included Lipitor 40 mg orally daily ,
acebutolol 200 mg orally daily , bromocriptine 7.5 mg orally
daily , and fondaparinux 10 mg subcutaneously daily.
SOCIAL HISTORY: The patient has no tobacco use , no alcohol
abuse , and no illicit drug use.
ALLERGIES: The patient has allergies to quinidine , Coumadin to
which he has a skin necrosis allergy , flecainide which he has
questionable syncope , and amiodarone in which he developed
abnormal liver function test.
ADMISSION PHYSICAL EXAM: The patient was alert and oriented x3.
He was in no acute distress. His lungs are clear bilaterally to
auscultation. His cardiovascular exam demonstrated regular rate
and rhythm with a normal S1 and S2. There were no murmurs , rubs ,
or gallops. His abdomen was obese. Bowel sounds are positive.
His abdomen was soft and nontender. His extremities were warm.
There was no edema. Skin: There was no rashes. Neuro exam was
nonfocal.
OPERATIONS AND PROCEDURES: On 1/7/06 , the patient underwent
fourth sternotomy ablation of atrial fibrillation with COX III
Maze with cryoablation and cut and sew resection of the left and
right atrial appendages , closure of patent foramen ovale.
Surgery was performed by Dr. Brooke Lemmen
ADDITIONAL PROCEDURES: The patient underwent cardiac
catheterization on 8/9/06 , which showed that he was right heart
dominant that the left main coronary artery had no significant
lesions. The left anterior descending artery had no significant
lesion. The left circumflex artery proximally showed a tubular
25% lesion and the right coronary artery showed no significant
lesions with a mid tubular 40% lesion in the RTLV-VR.
HOSPITAL COURSE BY PROBLEMS: Cardiovascular: Rhythm for
persistent atrial flutter , the patient was unable to go right
flutter ablation at present given his left atrial appendage clot
on transesophageal echo. Therefore , his rate was controlled with
his home medication acebutolol until surgery was performed on
1/7/06 , which included a fourth sternotomy ablation of atrial
fibrillation with COX III Maze with cryoablation , and cut and sew
resection of the left and right atrial appendages , and closure of
patent foramen ovale. There were no complications after the
surgery. The patient was discharged on 1/3/06.
PHYSICAL EXAM ON DISCHARGE: Temperature was 99.9 , heart rate 58 ,
blood pressure 104/96 , and he was sating 96% on 1.5 liters. He
was in sinus rhythm. Cardiovascular wise: He had regular , rate ,
and rhythm. His lungs were clear bilaterally. His extremities
were warm. There was 1+ ankle edema.
DISCHARGE MEDICATIONS: Included acebutolol 200 mg orally daily ,
bromocriptine 7.5 mg orally daily , aspirin 325 mg orally daily ,
fondaparinux 10 mg subcutaneously daily , calcium chloride slow
release 20 mEq orally twice a day , Lasix 40 mg orally twice a
day , levofloxacin 500 mg orally daily , lisinopril 10 mg orally
daily , Motrin 600 mg orally every 6 hours as needed for pain , and Zocor
40 mg orally at nighttime daily.
DISPOSITION: He was stable upon discharge and had followup with
Dr. Grap in Cardiovascular Clinic , advanced directive. The
patient is full code.
eScription document: 3-1382409 CSSten Tel
Dictated By: CHAIX , TRISH
Attending: GRAP , RONA
Dictation ID 0095800
D: 11/9/06
T: 3/8/06
Document id: 974
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558419608 | PUO | 75822489 | | 2907694 | 3/19/2004 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 8/1/2004 Report Status: Signed
Discharge Date: 11/20/2004
ATTENDING: ALETA KERTESZ MD
ADMITTING DIAGNOSIS:
Coronary artery disease.
PRINCIPAL DISCHARGE DIAGNOSIS:
Coronary artery disease.
HISTORY OF PRESENT ILLNESS:
This is an 83-year-old male with a history of coronary artery
disease , hypertension , diabetes mellitus , and hyperlipidemia. He
recently presented to Clagib Toner Community Hospital on 10/18/04 with loss of
consciousness while driving a motor vehicle. He sustained a
left-sided rib fracture. He denies chest pain , shortness of
breath that time. CT scan of the head performed and was
negative. His EKG was consistent with a right bundle-branch
block , but no acute changes. His Persantine testing was
performed and they suspect reversible anterior wall apical
ischemia. He underwent a cardiac catheterization today , which
showed triple vessel disease. He developed complaints of chest
pain post-catheterization with ST depressions , which resolved
with nitroglycerin and Lopressor. He was started on heparin and
nitroglycerin drip and admitted by the cardiology service. CABG
was scheduled by Dr. Garced Trauma Service was consulted to
clear him for surgery. Urology also was consulted due to recent
onset of hematuria and extensive neurological history.
PAST MEDICAL HISTORY:
Significant for hypertension , diabetes mellitus ,
hypercholesterolemia , triple AAA , coronary artery disease , left
rib fractures , bladder carcinoma , and adrenal adenoma on CT scan
of the abdomen from an outside hospital.
HOSPITAL COURSE:
He was admitted , he was made ready for surgery , and was taken to
the operating room on 10/20/04 , at which time he underwent an off
pump coronary artery bypass graft x2 with LIMA to the LAD ,
saphenous vein graft to the RCA. His intraoperative findings
showed that he would need a stent to his OM2 at a later date. He
also will need an EP study prior to discharge. He also would
need aspirin and Plavix. He is transferred to the Intensive Care
Unit in a stable fashion. He was extubated. He was ready for
transfer to Step-Down Unit by postoperative day #1.
Neurologically , he was intact. Cardiovascular: He was getting
Lopressor 5 mg intravenous every 4 hours His heart rate was 80 to 90. His
systolic blood pressure was 90 to 100. Respiratory: He was
extubated within five hours postoperative. He was on 4 liters
with sats in the high 90s. GI: He was npo pending his speech
and swallowing evaluation due to his age. Renal: He was
diuresing well. Urology was following. He required bladder
flushes and his urine became cloudy and the Foley was to remain
in. He was on aspirin and Plavix was to be started. On
postoperative day #2 , his chest tubes were removed. His
epicardial pacing wires were left in and EP was evaluating him
for an AICD secondary to his preoperative syncopal episodes.
Cardiology was following for his need for his stent , which they
recommended him having done as an outpatient in one month after
discharge. The Foley was still in secondary to his hematuria.
On postoperative day #3 , his wires were removed. He went into
atrial fibrillation a short time later. He was titrating up on
his Lopressor. He spoke with the Urology , and he was cleared to
have a __________ follow up with Dr. Cridge in one to two weeks.
On postoperative day #4 , he had an echo done , which revealed an
EF of 55% with trace MR and trace TR , inferior basal hypokinesis.
On postoperative day #5 , his creatinine was up to 1.6. He was
off Motrin and Lasix. He was decreased to his loading 20 without
difficulty and was sating 91% on room air with ambulation and
started on his preoperative captopril for hypertension to 160
systolically. The patient did well and he was found suitable to
discharge to rehabilitation on 6/23/04.
DISCHARGE MEDICATIONS:
Included Tylenol 650 mg orally every 6 hours , baby aspirin 81 mg orally every day ,
captopril 12.5 mg orally three times a day , Lasix 20 mg orally every day for five
days , glipizide 10 mg orally twice a day , Niferex 150 mg orally twice a day ,
oxycodone 5 mg to 10 mg orally every 4 hours as needed for pain , Proscar 5
mg orally every day , simvastatin 40 mg orally every bedtime , Toprol-XL 200 mg
orally every day , potassium slow release 10 mEq orally every day for five days ,
Humalog sliding scale , Flomax 0.4 mg orally every day , Plavix 75 mg orally
every day , Nexium 20 mg orally every day , Lantus 10 units subcutaneous every bedtime
DIET:
Carbohydrate controlled diet , low-cholesterol , low saturated fat ,
ADA 1800 calories a day.
DISCHARGE INSTRUCTIONS:
Include make follow up appointments with Dr. Kertesz in four to
six weeks , Dr. Journeay from Cardiology in one to two weeks , and
Dr. Pavek his primary care physician in two to four weeks and
Dr. Cridge from Urology in one to two weeks. Other instructions
included that the patient would need a permanent pacemaker
placed , as well as a coronary artery stent to his OM. Cardiology
plans to do stenting one month after surgery. EPS will place
pacemaker at that time.
DISCHARGE CONDITION:
Stable.
DISCHARGE DISPOSITION:
Rehabilitation.
OTHER INSTRUCTIONS:
Include the stent placement by cardiology with AICD permanent
pacemaker placement. Monitor creatinine and urine output and to
follow up with urology , local wound care , continue ambulation ,
shower patient daily , keep legs elevated while seated in a chair
and bed , monitor CV status and continue to monitor blood glucose
levels with a glucometer.
DISCHARGE LABORATORY DATA:
The patient's discharge laboratory values included sodium 134 ,
potassium 4.5 , chloride 98 , CO2 28 , BUN 44 , creatinine 1.5 , and
glucose 127. White blood cell count 8.3 , hematocrit 26.7 ,
platelets were 237 , and INR was 1.1. His discharge PA and
lateral revealed persistent elevation of the left lung base.
eScription document: 1-6383252 EMSSten Tel
Dictated By: VERRY , COLETTA
Attending: KERTESZ , ALETA
Dictation ID 2635732
D: 10/30/04
T: 10/30/04
Document id: 975
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075638407 | PUO | 06862563 | | 1314684 | 5/18/2006 12:00:00 a.m. | POSITIVE EXERCISE TOLERANCE TEST | Signed | DIS | Admission Date: 8/28/2006 Report Status: Signed
Discharge Date: 1/6/2006
ATTENDING: KERTESZ , ALETA M.D.
PRINCIPAL DIAGNOSIS:
Coronary artery disease.
HISTORY OF PRESENT ILLNESS:
65-year-old gentleman with history of insulin-dependent
diabetes mellitus , hypertension , and hypercholesterolemia who
presented to his primary care physician with complaints of
exertional chest tightness for the past one to two months that is
relieved by rest. The patient underwent exercise
tolerance testing that elicited 2 mm diffuse ST depression as well
as a drop in systolic blood pressure and chest pain after 5
minutes of exercise. He was referred for cardiac
catheterization , which revealed 80% left main , 80% OM1 , 80%
diagonal 1 , and 70% serial LAD lesions as well as an 80% LPLV ,
and 70% RCA. He was referred for surgical revascularization.
PAST MEDICAL HISTORY:
Hypertension , diabetes mellitus on insulin therapy , and
hypercholesterolemia.
PAST SURGICAL HISTORY:
None.
FAMILY HISTORY:
May be positive for coronary artery disease. Father died in her
early 50s from multiple medical issues.
SOCIAL HISTORY:
Positive for alcohol use but the patient has not used in recent
months.
ALLERGIES:
Sulfa with unknown reaction.
ADMISSION MEDICATIONS:
Atenolol 50 mg orally daily , lisinopril 40 mg orally daily , aspirin
325 mg orally daily , hydrochlorothiazide 25 mg orally daily ,
simvastatin 80 mg orally daily , and Lantus 50 units subcutaneous
nightly.
PHYSICAL EXAMINATION:
Height 6 feet 0 inches tall , 68 kilos. Vital Signs: Temperature
is 97 , heart rate 53 , blood pressure 140/60 in right arm , 132/60
in left arm , and oxygen saturation is 99% on room air. HEENT:
PERRL. Oropharynx benign. Neck without carotid bruits. Chest:
Without incisions. Cardiovascular: Regular rate and rhythm , no
murmurs. Respiratory: Breath sounds are clear bilaterally.
Abdomen: Without incisions , soft , no masses. Extremities:
Without scarring , varicosities or edema , 2+ pedal and radial
pulses bilaterally. Allen's test in both upper extremities is
normal by pulse oximeter. Neuro: Alert and oriented , grossly
nonfocal exam.
PREOPERATIVE LABORATORY DATA:
Chemistries include sodium of 139 , potassium of 5.0 , BUN of 32 ,
and creatinine of 1.6. Hematology includes white blood cell
count of 6 , hematocrit of 36 , and INR of 1.1.
EKG: Normal sinus rhythm at 47 with ST elevations in V2 and V3
and biphasic T waves and aVL. Chest x-ray is normal.
HOSPITAL COURSE:
The patient was admitted on 8/24/06 and underwent cardiac
catheterization with results as previously described. He also
underwent echocardiogram on 11/8/06 , which estimates ejection
fraction at 60% and finds trivial mitral insufficiency , trivial
tricuspid insufficiency , and mild left atrial enlargement. The
patient was taken to the operating room on 10/13/06 where he
underwent CABG x5 with LIMA to LAD and a sequential graft of SVG1
connecting the aorta to PDA and then LVB1. Left radial artery
connects to D1 and then OM1. The patient was taken to the
Intensive Care Unit following surgery in stable condition. He
was extubated later on his operative day and was noted to have a
slight
rise in his MB fraction. He was started on dopamine on
postoperative day #2 for low blood pressure and low urine output
as well as rising creatinine. His CK-MB was noted to have peaked
and was trending down. Postoperative day #3 , the patient was
weaned off of dopamine and his creatinine began to
trend down. On postoperative operative day 4 , the patient was
off all drips making good urine and given 1 unit of packed red
blood cells for a low hematocrit. He was transferred to the
Step-Down Unit later that day. At time of transfer , he was
hemodynamically stable and had been started on diltiazem for
spasm prophylaxis of his radial artery graft. The plan was to
avoid hypotension for renal perfusion and up titrate
beta-blockade carefully. He was saturating well on room air and
his diet was being advanced and was well tolerated. His
creatinine had fallen at time of transfer to 1.6 from its peak of
2.4 and continued to improve to its baseline levels by time of
discharge. The patient was followed perioperatively by the
Diabetes Management Service for glycemic control. He continued
to progress daily , remained in sinus rhythm and on room air for
the duration of his stay. His creatinine remained at baseline
level of 1.6. He continued to ambulate without problems and
was discharged home in good condition on postoperative day #7 on
the following medications: Diltiazem 30 mg orally three times a day to be
continued for three months postoperatively for radial artery
graft , Colace 100 mg orally three times a day as needed constipation ,
enteric-coated aspirin 325 mg orally daily , NovoLog insulin 8 units
subcutaneously at 8:00 a.m. , Lantus insulin 40 units
subcutaneously at 10:00 p.m. , Toprol-XL 100 mg orally daily ,
Niferex 150 mg orally twice a day , oxycodone 5-10 mg orally every 6 hours as needed
pain , Zocor 80 mg orally nightly , NovoLog insulin 4 units
subcutaneously with lunch and supper.
The patient is to have
follow-up appointments with his cardiologist , Dr. Sasnett , in one to
two weeks and with his cardiac surgeon , Dr. Kertesz , in four to
six weeks.
eScription document: 1-5543423 EMSSten Tel
Dictated By: JACOBSON , CHRISTEEN
Attending: KERTESZ , ALETA
Dictation ID 3519210
D: 9/23/06
T: 9/23/06
Document id: 976
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182796277 | PUO | 05941893 | | 383647 | 6/10/2002 12:00:00 a.m. | SMALL BOWEL OBSTRUCTION | Signed | DIS | Admission Date: 10/10/2002 Report Status: Signed
Discharge Date: 2/2/2002
DISPOSITION: Rehab facility as a vented patient.
PAST MEDICAL HISTORY: The patient is a 77-year-old female with
multiple comorbidity noted to have sudden
onset of diffuse abdominal pain 4 days prior to presentation. She
reported the pain as constant and radiated to the back and the
legs. She had nausea and vomiting on the day of presentation after
eating her lunch. She did notice also some constipation and she
had a small bowel movement on the day of presentation.
PAST MEDICAL HISTORY: Atrial fibrillation. Hypertension.
Noninsulin dependent diabetes. History of
pneumonia. History of sigmoid diverticulitis , status post
colectomy , ventral hernia , status post repair. Congestive heart
failure. Pacemaker placement on July , 2002 for sick sinus
syndrome. Rectal jejunum AVM status post GI bleed. Status post
CVA. History of ascites.
MEDICATIONS: Lasix 60 mg orally twice a day , Atenolol 25 mg orally twice a day ,
Glucotrol 5 mg twice a day , Protonix 40 mg orally every day ,
Zestril 5 mg orally every day , Coumadin for her atrial fibrillation ,
Tylenol #3 for pain and iron supplements.
PHYSICAL EXAMINATION: She was afebrile with temperature of 95.8.
Her heart rate was 93 in atrial
fibrillation. Her blood pressure was 124/77. She was satting 100%
on room air. She had an irregularly irregular rhythm. Lungs clear
to auscultation. Her abdomen was distended with shifting dullness.
She had diffuse tenderness. She has guaiac positive stools. She
had no guarding or rebound.
LABORATORY: Her sodium is 140 , her potassium is 3.7 , her
creatinine was 1.1 , her LFTs were all within normal
range with the exception of a slightly elevated alkaline
phosphatase at 238. Her total bilirubin was 1.4 , her lipase was
25 , amylase was 57 , white count was 5.7 , hematocrit was 30.3 , coags
were notable for an INR of 2.1. Her UA was negative with only two
white cells sediment.
RADIOLOGY: Her KUB showed air fluid level small bowel and dilated
proximal small bowel. Chest film showed a pacer
placement with cardiomegaly and atelectasis at the bilateral basis.
Abdomen CT showed a high grade small bowel obstruction with
isolated cluster of small bowel with a closed loop without signs of
mesenteric ischemia. She also had a small ventral hernia. The
patient was given 6 units of FFP and taken to the operating room
for an exploratory laparotomy.
HOSPITAL COURSE: The patient was taken to the operating after her
anticoagulation was reversed. She had an
exploratory laparotomy , lysis of adhesions , with an obstructed loop of
small bowel , with multiple adhesions around the closed
loop obstruction. There was fecal spillage due to an enterotomy within
a closed loop. All of the bowel was viable , and therefore no resection was
required. A moderately sized bezoar was removed
from the small bowel in the area of the obstruction. The EBL was 400 cc. She
was given two units of FFP in the OR. She had 1 , 500 cc of fluid as
well as two units of packed cells , about 1 liter os ascites was
drained intraoperatively. Her abdomen was closed with sepra mesh.
She was intubated and transferred to the Intensive Care Unit.
Postoperatively , she had fairly stable vital signs with a brief
episode of hypotension immediately postoperatively. She was
sedated with Fentanyl and Versed in terms of her cardiac status.
Her atrial fibrillation was persistent and she was receiving
Lopressor 10 mg intravenous every 6 hours Respiratory , she was intubated and on
pressor support of 15 with a blood gas that showed she was
oxygenating well. For GI , she had an NG tube in and she was
npo , had Zantac. GU , she was continued fluid resuscitation.
I.D. , she was started on ampicillin , levofloxacin , Flagyl for a
three day course.
The patient had a prolonged post-operative course characterized by perisistent
right heart failure , massive edema , several episodes of presumed line sepsis ,
and failure to vean from ventillatory support. Her mental status was also slow
to recover. She maintained normal renal function throughout.
Her GI function recovered by POD #5 , and she was able to tolerate full
nutitional support via NG feedings. She underwent a tracheostomy on POD #15.
She then proceeded to make a slow but steady recovery , with normalization of
her body fluid status , hepatic function , and mental function. At the time of
her discharge , her major issues were ventillatory support , with ongoing
compromise from chronic right heart failure.
Tubes , lines , and drains. She had a left brachial vein PICC Line
placed on November . The line was measured at 45 cm. She had a Foley
in place. She had a #7 portex trach tube. She also had an NG tube
for the duration of her hospital course and she is to continue to
have an NG tube while she is trach for tube feeds.
DISCHARGE DIAGNOSIS: Benzodiazepine overuse and dependence.
Atrial fibrillation. Right heart failure
with secondary ascites. Respiratory failure. Serratia pneumonia.
Status post pacemaker placement for sick sinus syndrome. Small
bowel obstruction. Hyperbilirubinemia of unclear etiology.
Presumed acalculus cholecystitis . Iron deficiency anemia.
Diabetes mellitus. Coag negative staph bacteremia.
DISCHARGE MEDICATIONS: Atrovent and albuterol inhalers every 4 hours ,
natural tears 2 drops each eye three times a day ,
ceftazidime 1 gram intravenous three times a day , cholestyramine 4 grams/NG tube
twice a day , digoxin 0.25 mg/NG tube every day , Epogen 40 , 000 units every
week , iron sulfate 300 mg/NG tube three times a day , Lasix 80 mg/NG tube ,
twice a day , NPH insulin 40 units subcutaneously twice a day , lactulose 30 cc orally/NG
tube every day to be titrated to bowel movements , Reglan 10 mg/NG tube
four times a day , Aldactone 50 mg/NG tube twice a day , Actigall 300 mg/NG tube
three times a day , vancomycin 1 gram intravenous every day until November , 2002 , Zyprexa 5
mg/NG tube every day before noon and 10 mg/NG tube every bedtime , also Ativan 1 mg/NG
tube as needed anxiety.
DISPOSITION: Vented rehab.
FOLLOWUP: Followup is to be with Dr. Zangl in two weeks.
DISCHARGE INSTRUCTIONS: The patient is to remain on trach collar
and vented as needed She is also to continue
her NG tube for tube feeds which are to be full strength 2-cal at
50 cc an hour. She is to receive two scoops of ProMod.
Dictated By: TRISH CHAIX , M.D. XE00
Attending: CARYN ZANGL , M.D. OK89
GS814/733179
Batch: 9694 Index No. NESAV959XU D: 1/24/02
T: 1/24/02
Document id: 977
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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628567699 | PUO | 85842554 | | 6266744 | 10/26/2006 12:00:00 a.m. | Aortic Stenosis | | DIS | Admission Date: 1/7/2006 Report Status:
Discharge Date: 4/5/2006
****** FINAL DISCHARGE ORDERS ******
CYNOVA , JAKE D 491-68-62-3
Ey Chu Na
Service: CAR
DISCHARGE PATIENT ON: 8/20/06 AT 06:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NIZIOL , CHELSEA J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
RHINOCORT AQUA ( BUDESONIDE NASAL INHALER )
2 SPRAY inhaled twice a day
CAPTOPRIL 25 MG orally three times a day Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
Override Notice: Override added on 9/21/06 by
MARTER , BRYON M. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE SLOW REL. orally ( ref #
845114198 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: md aware
Previous override information:
Override added on 9/21/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
CAPTOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
CAPTOPRIL Reason for override: aware
Previous Override Notice
Override added on 9/21/06 by JAKOB , TANDY , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
304005334 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CHLORIDE Reason for override: needsz
Previous override information:
Override added on 9/21/06 by JAKOB , TANDY , M.D.
on order for POTASSIUM CITRATE orally ( ref # 570783565 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CITRATE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CITRATE Reason for override: needs
Previous override information:
Override added on 9/21/06 by JAKOB , TANDY , M.D.
on order for POTASSIUM CITRATE orally ( ref # 603559985 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CITRATE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
CITRATE Reason for override: needs
Previous override information:
Override added on 9/21/06 by JAKOB , TANDY , M.D.
on order for POTASSIUM GLUCONATE orally ( ref # 005952102 )
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
GLUCONATE
POTENTIALLY SERIOUS INTERACTION: CAPTOPRIL & POTASSIUM
GLUCONATE Reason for override: md aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
Alert overridden: Override added on 9/21/06 by
JAKOB , TANDY , M.D.
on order for LASIX orally ( ref # 766988177 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: at home
LANTUS ( INSULIN GLARGINE ) 42 UNITS subcutaneously DAILY
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
METOPROLOL TARTRATE 12.5 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
FLOMAX ( TAMSULOSIN ) 0.4 MG orally DAILY
Alert overridden: Override added on 9/21/06 by
JAKOB , TANDY , M.D.
on order for FLOMAX orally ( ref # 283158425 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: at home
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
9/14 @ 9am for echo in radiology ,
9/14 @ 1pm for carotid US ,
9/14 @ 3:30 for chest CT ,
9/14 @ 4:30 for head CT ,
Dental appt comfirmed for Friday 8/7 @ 2pm call 537-977-4128 to change ,
ALLERGY: Sulfa , TETRACYCLINE
ADMIT DIAGNOSIS:
aortic stenosis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Aortic Stenosis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) dm ( diabetes mellitus ) cad ( coronary
artery disease ) af ( atrial
fibrillation ) htn ( hypertension ) hypercholesterolemia ( elevated
cholesterol )
OPERATIONS AND PROCEDURES:
Cardiac catherization with valve crossing.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: Aortic valve area evaluation HPI
admitted for aortic valve evaluation via catherization. This patient was
scheduled to have cystoscopy and bladder intervention for a possible
bladder cancer as well as TURP at Osri Medical Center on 2/1/2006. His
surgeon wanted a pre-surgical cardiac evaluation given this history of
AS. The patient has had not changes in his functional activity recently.
Of note , his past history is notable for 5/23 with a right hemispheric
ischemic stroke. He has been having a gradual recovery: there is no
sensitivity in the left leg , though the motor deficits have improved and
he is able to walk with a walker. When he really exerts himself , he had
episodes of SOB but no chest pain , palpitations , presyncope or syncope.
He does have an unclear history of orthopnea but it might not be of a
cardiac etiology. Of note his activity has not been limited by any
cardiac complaints.
PMH:1. Chronic atrial fibrillation with slow VR2. Calcified aortic valve
with AS , calculated AVE 0.6 cm2 , 8/22 Moderately reduced LV
systolic function. Estimated LVEF 35-40% 3/3 Complete LBBBc. history of
probable enterococcal endocarditis , 8/2 History of CHF3. History of
CADa. ? status post IMI and septal MI by EKG4. Type 2 diabetes mellitus
5. Hypertension6. Hyperlipidemia
Meds:Lasix 80 mg bidCaptopril 25 mg tidPotassium 20 meq qdMetoprolol 12.5
mg twice a day Aspirin 81 mg qdFlomax 0.4 mg qdRhinocort bidInsulin as directed
Physical Exam: Afebrile , Vital signs stable.
HEENT NCAT
Neck: JVP 8cm
Cor 3/6 sem no s2
Lung CTAB/L
Abd soft obese nt nd
Ext 2+b/l edema 1+
dp
Labs/Studies: Cath 80% LAD lesion , pRCA 90%. PCW21 ,
PA 53/14 , AV gradient 30 , valve area 0.94 low EF 35% CO 4.46
Previous EKG: Atrial fibrillation with complete RBBB and likely pulse
inferior in septal MI.
ECHOCARDIOGRAM 2/3 Aortic valve is calcified with reduced opening
excursion and increased flow velocity to 4 m/s. Estimated peak gradient
64 mmHg , mean 37 mmHg. AVA not calculated. Normal MV with mitral annular
calcification and mild MR by color flow. Normal TV with low velocity TI
at 2 m/s suggestive of normal PASP. Mild LAE and RAE. RV is not well
visualized. LV is not well visualized with normal wall thickness and
normal cavity size and grossly moderate LV systolic dysfunction globally
with estimated LVEF 35-40% , qualified by the quality of the images.
Cath: 80% LAD lesion , 90%pRCA , ++MR , pseunormalisation of AV gradient at
30 and valve area of 0.9
( see ZH cath data for details )
Assessment: 81 year old male here for evaluation of AV for possible AVR
with revascularization.
Plan:
1. Aortic Stenosis: Stable post cath , groin site stable.
- We provided regular post cath care
- We continued patients home medications
- Seen by cardiac surgery who want with u prior to surgery ( see
instructions )
- Asked patient to follow up with Potwood Kinlis Wellscajohns Health Center Cardiology
2. Hypertension:
- We continued patient on home medications
- No issues
3. DM:RISS and Lantus
- Good control.
4. Ppx:
- Nexium , no anticoagulation given bleeding risk.
ADDITIONAL COMMENTS: 1. THERE HAVE BEEN NO CHANGES IN YOUR MEDICATIONS. TAKE ALL THE SAME
MEDICATIONS YOU WERE TAKING BEFORE ADMISSION.
2. Call Dr. Ramcharan office , his assistants name is Liane Barby
117-219-4079 and schedule an appointment after all your tests are done.
3. Make sure you see the dentists: you have a Dental appt comfirmed for
Friday 8/7 @ 2pm at PUO . You can call 537-977-4128 to confirm or change.
PLEASE TAKE 2gms of AMOXICILLIN 2 hours before appointment ( script
given ).
The rest of your appointments are: 9/14 @ 9am for echo in radiology
9/14 @ 1pm for carotid US
9/14 @ 3:30 for chest CT
3. See Dr. Lipphardt at the Land Medical Center for an appointment
within 3-4 weeks. Call them at 545-682-2414 with any questions you may
have.
4. Return to the hospital if you have any chest pain , palpiations , SOB or
feel unwell.
5. Return to hospital if your leg feels cold or painful and if you have
any blood collection near your groin site. It could be a complication of
your cardiac catherization.
9/14 @ 4:30 for head CT
6. Give all medications eeryday
7. Check chemistry and CBC every week and send to Potwood Kinlis Wellscajohns Health Center Cardiology
8. Physical therapy as tolerated
9. Make sure patient makes all appointments
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Please keep your appointment with radiology and dental ( or call to
change as needed )2. Please call Potwood Kinlis Wellscajohns Health Center cardiology and Dr. Garced
No dictated summary
ENTERED BY: JAKOB , TANDY , M.D. ( IY78 ) 8/20/06 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 978
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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998239435 | PUO | 89182260 | | 6777525 | 7/7/2006 12:00:00 a.m. | acute coronary syndrome | | DIS | Admission Date: 8/13/2006 Report Status:
Discharge Date: 3/15/2006
****** FINAL DISCHARGE ORDERS ******
ERBEN , DORETHEA 986-93-81-4
Sterton I Louis Kee Ter
Service: MED
DISCHARGE PATIENT ON: 1/9/06 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VACEK , WALTON JANELLA , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
Starting Today ( 7/4 ) as needed Pain , Other:Back pain
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today ( 7/4 )
ARTIFICIAL TEARS 2 DROP OD three times a day
ATENOLOL 50 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
Starting Today ( 7/4 )
Alert overridden: Override added on 8/27/06 by
JULIUSSON , LAVELLE A , M.D.
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
ATORVASTATIN CALCIUM Reason for override: md aware
LISINOPRIL 5 MG orally DAILY
Alert overridden: Override added on 1/9/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MD aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Summer Truocchio , Urology January , 2pm scheduled ,
Dr. Jeannette Gorglione , Cardiology August , 3pm scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
acute coronary syndrome
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
none
OPERATIONS AND PROCEDURES:
ETT-MIBI 10/17 No signs of reversibe ischemia; basal wall hypokinesis
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
EKG 5/6 12pm: NSR , 1-2mm ST elevations in V1-V3 , T wave inversions in
V4-V6
EKG 5pm: Trigenminy with PVCs , ST elevations in V1-V3 , Twave inversions in
V3 -V6
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest pain and pressure x 3 days
********************
HPI: 61 year-old M with CAD , history of MI with 4 vessel CABG with onset of sx of SS
chest pain and pressure 3 days ago. Pain waxes and wanes , intense
periods lasting 5-15 minutes , variant interludes between episodes ,
the shortest being one hour. radiates to his stomach , but not
arm , back or jaw. Endorses diaphoresis , SOB , lightheadeness , blurry
vision , HA. These symptoms subside without
pain. Denies F/C/N/V. Denies trouble speaking , presyncope
with pain. Denies recent sick contacts , recent travel. He endorses a
dry , scratchy throat last week. Denies reflux or GERD.
He is not on plavix , coumadin or ASA at home. He has not yet followed
up with A cardiologist since his surgery.
history of MI and 4 vessel CABG at TH with harvest of the L saphenous vein
and L cephalic Vein ( assumed since harevst sites are in distal ULE ,
and LLE ). 1x episode of frank hematuria and UTI at TH and was
started on Bactrim. No problems since and denies fruther heamturia at
home. He was d/c'd August and returned to River September
In the ED , the patient was given ASA 325mg , Nitroglycerin x3 with good
effect , lopressor 25mg , morphine 2mg.
***************
Allergies: None
**************
CONSULTS:
Cardiology
Dr. Gribbin , Cardiac Surgeon at Spen Ant Health
*************
Daily Status:
*************
STUDIES:
March EKG at 12pm with 1-2 mm ST elevations in V1-V3 , T wave
inversions in V4-V6 and aVL ,
March EKG at 5pm as above but with new T wave inversions in V3
March CXR: moderate left-sided pleural effusion with associated
sub-segmental atelectasis , small right posterior pleural effusion
**************
Hospital course: 61 year-old M with CAD , history of MI with 4 vessel CABG who presented
presenting with CP and pressure , lightheadedness and SOB x 3days. Sx c/with
unstable angina vs. coronary vasospasm vs. incisional/pleuritic pain history of
CABG.
--CV: Patient admitted with sx of SOB , SSCP and pressure , diaphoresis ,
lightheadedness that lasted 5-15 minutes per episode , did not radiate
other than to abdomen , very concerning for ACS vs. unstable angina ,
especially in the setting of known CAD and recent 4-vessel CABG ( TH : NJGH
-> 1st diagonal and then to LAD , L radial artery anastomosis to distal
RCA , L saphenous vein to left circumflex first major marginal; post
surgery TH echo with EF of 43% and some basilar hypokinesis , patient
started on amiodarone for bigeminy ). Dressler's less likely at this time
out from post-op.
( I ) In the ED , the EKG on admission showed NSR , 1-2 mm ST elevations in
leads V1-V3 , T wave inversions in V4-V6 , concerning for acute cardiac
process. No comparison EKG for baseline so unable to ascertain if new
ischemia or if ACS in setting of sx. Patient rec'd ASA , nitro x3 with
relief and 2 mg morphine in ED. CXR was performed showing bilateral
effusions with L>R. Enzyme set A was negative. Patient was admitted to
floor , where a repeat EKG was done , which showed changes from his prior
EKG , specifically a new T wave inversion in V3 and trigeminy with PVCs.
Patient reported mild pain at this time. Signs & symptoms were
concerning enough for ACS that the patient was started on a heparin drip
of 1000cc/heart rate with a loading bolus of 5000 units and his PTT followed.
Home isosorbide was held to ascertain for pain. Records were requested
from Masan Oak Hospital , where the patient had his surgery 1 month ago.
Patient was put on telemetry and his home Lipitor was increased to 80
mg , and his home lopressor was increased to 37.5 mg three times a day. Overnight he was
pain free , and r/o'd by enzymes x 3. His telemetry showed NSR with
occasional trigeminy and PVCs. Pain may be incisional or anginal ,
lightheadedness most likely patient's anginal equivalent. Cardiology was
consulted to consider the indications for catheterization and risk of ACS.
The patient was asx 10/3 and noted to have some sternal incisional pain
with palpation , no EKG changes observed. Reccomendations were made to send
the patient to ETT-MIBI 4/12 , check fasting am lipids , d/c home amiodarone
from TH for his ? arrythmia. The patient was also started on Lisinopril
5mg at this time and his heparin drip was d/c'd. ETT-MIBI showed no signs
of reversible ischemia , basal wall hypokinesis but which was knwon on
admission. Fasting cholesterol was unable to be sent 2/2 to am MIBI
schedule. Should be tested as outpatient.
( P ): No signs of pump dysfunction though mildly elevated jvp of 6-8cm on
admission , EF post-CABG at TH was 43%. Repeat echo was ordered to assess
function though cancelled in setting of unremarkable MIBI and absence of of
sx and signs failure while in house.
( R ): Alternates between NSR and trigeminy with PVCs. Amiodarone from TH
d/c's as not needed for this rhythym.
--Renal: history of hematuria at TH , microhematuria on U/A and urine sed on
admission. Will require outpatient follow up. Per TH noted he would need
renal bx and follow-up though it does not seem appropriate with history of foley and
hematuria. Cystoscopy seems more relevant. We consulted the patient's primary care physician
and agree to recommend outpatient urology follow-up over renal. Urine
cytology was ordered and collected ( though some lost to collection during
MIBI ). Can be followed as outpatient.
--Pulm: cxr with bilateral effusions L>R but which are consistent with a
setting of recent cardiac surgery. Patient noted + SOB with pain. PE
unlikely as infection. Exam resolved slightly over course of stay.
PPx: patient on heparin drip with ? of ACS on 9/9 , lovenox held. Haprin d/c'd 10/3
in pm. Lovenox held as patient ambulatory and to home on 4/18
Code: Full code
ADDITIONAL COMMENTS: -Please follow-up with Cardiology , Dr. Gorglione
-Please cancel renal follow up and renal biopsy with Dr. Ienco
-Please follow-up with Dr. Truocchio , Urology for hematuria
-Please stop taking Motrin for back pain since it can be dangerous if you
have heart problems
-Please take Tylenol for pain instead
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up urine cytology
Please check fasting lipids
No dictated summary
ENTERED BY: JULIUSSON , LAVELLE A , M.D. ( YB68 ) 1/9/06 @ 06
****** END OF DISCHARGE ORDERS ******
Document id: 979
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
U |
Y |
Y |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
Y |
N |
- |
Y |
N |
N |
- |
N |
N |
N |
973124900 | PUO | 00631450 | | 5742898 | 9/9/2004 12:00:00 a.m. | EXERTIONAL ANGINA | Signed | DIS | Admission Date: 9/9/2004 Report Status: Signed
Discharge Date: 8/14/2004
ATTENDING: ALETA KERTESZ MD
DATE OF OPERATION:
4/1/04.
OPERATIONS PERFORMED:
CABG x3 ( LIMA to LAD , SVG1 to OM1 , SVG1 to RCA ).
INDICATION FOR SURGERY:
Coronary artery disease.
HISTORY OF PRESENT ILLNESS:
The patient is a 67-year-old female with a history of
hypertension , diabetes , dyslipidemia , GERD , hiatal hernia ,
hemorrhoids , and status post ORIF of the right hip following a
motor vehicle accident in 10/15 The patient complains of
intermittent chest pain at a routine check up. Stress test on
4/4/04 was positive for ischemic changes. The patient
underwent cardiac catheterization on 3/24/04.
PREOPERATIVE CARDIAC STATUS:
Class II angina. Class II heart failure. Normal sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST MEDICAL HISTORY:
Hypertension; diabetes; dyslipidemia; GERD; hiatal hernia ( by EGD
5/11 ); hemorrhoids; right hip fracture secondary to motor
vehicle accident status post ORIF ( no difficulty ambulating
currently ).
PAST SURGICAL HISTORY:
ORIF for right hip fracture following motor vehicle accident
6/17 appendectomy; "partial hysterectomy" for uterine fibroid
( "tumor behind bladder causing bleeding every month" ); left
breast fibrous cyst removal; and C-section ( twins ).
FAMILY HISTORY:
Coronary artery disease. Brother with MI. Brother also with
heart surgery and permanent pacemaker; mother with two heart
surgeries , first in age 60s.
SOCIAL HISTORY:
A 15-pack year cigarette smoking history. Quit tobacco eight to
nine years ago; has seven children. Works as a domestic violence
counselor.
ALLERGIES:
No known drug allergies.
MEDICATIONS ON ADMISSION:
Atenolol; lisinopril; aspirin; atorvastatin , metformin; glyburide
5 mg orally twice a day; Lantus 16 units every afternoon; hydrochlorothiazide;
Prilosec; "new medication cannot remember the name."
PHYSICAL EXAMINATION ON ADMISSION:
Height 5 feet 5 inches , weight 70.5 kg. Vital signs:
Temperature 98.4 , heart rate 64 , blood pressure right arm 128/72 ,
blood pressure left arm 132/82. HEENT: Pupils are equal , round ,
and reactive to light and accommodation; dentition without
evidence of infection; no carotid bruits; partial upper teeth.
Chest: No incisions. Cardiovascular: Regular rate and rhythm;
no murmurs; 2+ pulses throughout; Allen's test was normal on the
left. Respiratory: Breath sounds clear bilaterally. Abdomen:
Well healed midline incision; soft , no masses , obese , nontender ,
nondistended , positive bowel sounds. Rectal: Deferred.
Extremities: Without scarring , varicosities or edema. Neuro:
Alert and oriented x3 , no focal deficits.
PREOPERATIVE LABORATORY RESULTS:
Sodium 136 , potassium 3.9 , chloride 99 , bicarbonate 24 , BUN 16 ,
creatinine 0.8 , glucose 187 , BNP 71 , white blood cell count 8 ,
hematocrit 37 , hemoglobin 12.9 , platelets 213 , 000 , physical therapy 13.3 , INR
1.0 , PTT 28.9 , and hemoglobin A1c 8.5. UA: Normal.
Cardiac catheterization on 9/11/04 at Pagham University Of showed a 90% proximal LAD; 70% ostial V1; 85% proximal
circumflex; 90% mid RCA; 70% distal RCA; 50% mid LAD; right
dominant circulation.
EKG on 9/11/04 showed normal sinus rhythm at a rate of 65 beats
per minutes with a nonspecific T-wave abnormality in AVL , V2 ,
MC3; chest x-ray 9/11/04 was normal.
Exercise stress test of 4/4/04 showed 1 to 1.5 mm ST
depressions in lead 2 , 3 , aVF and V4 through V6.
The patient underwent a CABG x3 ( LIMA to LAD , SVG1 to OM1 , SVG1
to RCA ) on 4/1/04.
ICU COURSE BY SYSTEM:
1. Neurologic: The patient remained neurologically intact
throughout her ICU course. She was out of bed and ambulating.
She complained of both incisional pain and back pain. She was
transferred with orders for as needed Tylenol , Motrin , and Dilaudid
orally
2. Cardiovascular: The patient required pressors initially for
hypotension. These were gradually weaned off. Her wires were
removed on postoperative day #3. At that time of transfer , her
heart rate was 90s-100s , sinus rhythm with systolic blood
pressures of 80s-90s. The patient was orthostatic on getting out
of bed on the morning of transfer. She was given a normal saline
250 cc bolus prior to transfer. At the time of transfer , she was
receiving Lopressor 12.5 mg orally every 6 hours
3. Respiratory: The patient was extubated on postoperative day
#0. At the time of transfer , she was receiving supplemental
oxygen 4 liters per minute with an O2 saturation of 94%. Her
chest tubes have been removed the prior day. Post removal chest
x-ray showed a questionable small left pleural effusion. The
lungs were otherwise clear.
4. GI: The patient was tolerating a regular diet at the time of
transfer.
5. Renal: The patient was initially oliguric. She was started
on dopamine while in the ICU. This was gradually weaned off.
The patient had a PA catheter placed on postoperative day #1.
This was removed by postoperative day #2. The day prior to
transfer , the patient had a fluid balance of negative 1300 cc.
Her Foley had been removed. Her urine output for the first seven
hours on the morning of transfer was 1175 cc. She was receiving
Lasix 20 mg orally three times a day
6. Endocrine: The patient was on Portland protocol while in the
ICU. She was followed by the Diabetes Management Service. At
the time of transfer , she was receiving Lantus 20 units every bedtime;
NovoLog 4 units subcutaneously before meals; and NovoLog sliding scale.
7. Heme: The patient was transfused 2 units of packed red blood
cells on postoperative day #1 for hematocrit of 22 with
associated hypotension and oliguria. At the time of transfer ,
the patient was receiving Plavix for poor targets. She was also
receiving aspirin and Zocor.
8. intravenous: The patient received two doses of vancomycin
postoperatively. She remained afebrile throughout the remainder
of her ICU course with a T-max on the day of transfer of 99.4.
At the time of transfer , she was not receiving any antibiotics.
Her chest tubes , Foley , and Cordis have been removed the day
prior. Her white blood cell count was 6.8.
eScription document: 8-0744831 EMSSten Tel
Dictated By: PETEET , JOYA
Attending: KERTESZ , ALETA
Dictation ID 5182936
D: 6/2/04
T: 6/2/04
Document id: 980
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245876836 | PUO | 99067599 | | 734253 | 7/26/2000 12:00:00 a.m. | ACUTE RENAL FAILURE | Signed | DIS | Admission Date: 1/9/2000 Report Status: Signed
Discharge Date: 1/4/2000
PRINCIPAL DIAGNOSIS: DEHYDRATION.
OTHER DIAGNOSES: 1 ) DIABETES MELLITUS.
2 ) HYPERTENSION.
3 ) DIASTOLIC DYSFUNCTION.
4 ) SLEEP APNEA.
5 ) CHRONIC RENAL INSUFFICIENCY.
6 ) GOUT.
7 ) GASTROESOPHAGEAL REFLUX DISEASE.
8 ) ANEMIA OF CHRONIC DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old woman
with a history of heart failure ,
preserved ejection fraction , chronic obstructive pulmonary disease ,
obstructive sleep apnea , mild pulmonary hypertension who had an
increase in Torsemide dose from 100 mg twice a day to 180 mg twice a day She
also was subsequently started on Zaroxolyn two days prior to
admission. She has felt increasingly tired and light headed
without dyspnea. She has had a very dry mouth. She has also noted
a decline in urine output. She is admitted to the short stay unit
on May , 2000 when her BUN and creatinine were 125 and 4.2
respectively. This compared to a baseline creatinine of about 2.0.
She was admitted for intravenous hydration. She continues to
complain of dizziness when she sits up at the time of admission and
her creatinine has declined from 4.6 to 2.1 off all her medications
and with some mild hydration over the first two days of admission.
PAST MEDICAL HISTORY: 1 ) Diabetes mellitus. 2 ) Gastroesophageal
reflux disease. 3 ) Gout. 4 ) Congestive
heart failure secondary diastolic dysfunction. 5 ) Diverticulosis
in 1998. 6 ) Obstructive sleep apnea. 7 ) Hypertension. 8 )
Chronic renal insufficiency , baseline creatinine of about 2.0. 9 )
Anemia of chronic disease.
ALLERGIES: The patient is allergic to Morphine.
SOCIAL HISTORY: The patient is married. She has five children and
two foster children. She quit smoking around nine
years ago. She uses a cane with walking.
PHYSICAL EXAMINATION: Physical examination on admission was
significant for chest examination which was
clear. Cardiac examination was muffled , but you could hear an S4 ,
S1 and S2 with a jugular venous pressure around 7 cm , positive
hepatojugular reflux , 1+ peripheral edema of both legs.
Extremities were warm and well perfused. Abdomen is obese and
soft. There was no cyanosis or clubbing in the extremities.
LABORATORY: EKG showed a left ventricular hypertrophy , first
degree atrioventricular block with a heart rate around
90.
HOSPITAL COURSE: The patient was initially admitted to the short
stay unit and was given fluid for two days and
all of her medications were held. She was admitted to the
Cardiology Service , however on April , 2000 , she had been inhouse
with that being her fourth day. Her cardiac medications were
progressively re-initiated and her Imdur was increased to 120 mg
orally twice a day Her course is notable for progressive decline in her
BUN and creatinine. On April , 2000 we restarted her Lisinopril at
10 mg twice a day She came in on 20 mg twice a day She did fine with this.
The next , however we restarted her Torsemide and increased her dose
of Lisinopril. This resulted in a bump of her BUN and creatinine
back up to around 2.8 from 1.9. Because she diuresed a total of
about 300 cc that day , we presumed this bump was due to increase
dose of Lisinopril. We decreased the dose back to 10 mg twice a day and
continued her Torsemide. The patient's BUN and creatinine
stabilized then at 63 and 2.8. Because of this response to
Lisinopril , we performed a renal artery scan with results pending
at the time of this dictation. The patient also at the time of
discharge clearly at her driest considering the medication regimen
that she is on. She is clearly orthostatic this morning. She will
be discharged on 100 mg orally Torsemide twice a day with before knowledge
that she will drink quite a bit more than she does inhouse. She
will be followed up for her potassium , renal function and renal
artery scan by Dr. Carmon Boshers
MEDICATIONS ON DISCHARGE: 1 ) Albuterol inhaler 2 puffs inhaled
twice a day 2 ) Allopurinol 300 mg orally q.
day. 3 ) Enteric coated aspirin 325 mg orally every day. 4 )
Diclofenac sodium two drop each eye twice a day 5 ) Iron sulfate 300 mg orally
three times a day 6 ) Atrovent inhaler 2 puffs inhaled four times a day 7 ) Prinivil
10 mg orally twice a day 8 ) Pred Forte 1% prednisolone one drop o.s.
four times a day 9 ) Humulin 70/30 85 units subcutaneously every day before noon , 15 units
subcutaneously every PM. 10 ) Imdur 120 mg orally twice a day 11 )
Torsemide 100 mg orally every day. 12 ) Tiazac 360 mg orally every day. 13 )
Flonase 1-2 sprays nasally every day. 14 ) Cyclopentolate
hydrochloride 0.5% two drops o.s. twice a day 15 ) Alphagan two drops
each eye twice a day 16 ) Atenolol 50 mg orally every day. 17 ) Colchicine 0.6
mg orally every day.
DISPOSITION: The patient is discharged to home with services.
CONDITION ON DISCHARGE: The patient was discharged in good
condition.
FOLLOW-UP: The patient is to follow-up with Dr. Carmon Boshers and
Dr. Avril Taplin The patient is discharged with VNA
services for a blood draw this come Friday and Monday for a chem-7
with results forwarded to Dr. Carmon Boshers
Dictated By: RUFUS BERNAS , M.D. NN13
Attending: FLOYD T. LYN , M.D. OX2
XI506/1673
Batch: 10730 Index No. HXSL2J2EI9 D: 5/14
T: 5/14
CC: 1. CARMON BOSHERS , M.D. YW15
2. AVRIL F. TAPLIN , M.D. QI3
Document id: 981
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989822471 | PUO | 34325051 | | 4314972 | 3/12/2004 12:00:00 a.m. | Pneumonia | | DIS | Admission Date: 11/20/2004 Report Status:
Discharge Date: 4/6/2004
****** DISCHARGE ORDERS ******
SALAK , KENNETH 439-59-22-5
Delp Hisseatwood
Service: MED
DISCHARGE PATIENT ON: 10/6/04 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WAGNON , DENNA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 500 MG orally every 6 hours as needed Pain , Headache
ATENOLOL 100 MG orally every day
CALCIUM CITRATE 950 MG orally twice a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
GEMFIBROZIL 600 MG orally twice a day
HYDROCHLOROTHIAZIDE 25 MG orally every day
NPH INSULIN HUMAN ( INSULIN NPH HUMAN )
15 UNITS subcutaneously At 10 p.m. ( bedtime )
LISINOPRIL 40 MG orally every day
Override Notice: Override added on 2/22/04 by
DYSINGER , ROZANNE RANDI , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
12825859 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
Previous override information:
Override added on 2/22/04 by DYSINGER , ROZANNE RANDI , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 35380133 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will follow
NIFEREX-150 150 MG orally twice a day
Override Notice: Override added on 11/15/04 by
HIMEL , YVETTE C.
on order for LEVOFLOXACIN orally ( ref # 49086932 )
POTENTIALLY SERIOUS INTERACTION: POLYSACCHARIDE IRON
COMPLEX & LEVOFLOXACIN Reason for override:
Will separate doses by 2 hours.
Previous override information:
Override added on 2/22/04 by DYSINGER , ROZANNE RANDI , M.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
POLYSACCHARIDE IRON COMPLEX Reason for override: will follow
SIMETHICONE 80 MG orally four times a day as needed Upset Stomach
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 1 , 200 UNITS orally every day
Starting Today ( 11/25 )
VITAMIN B COMPLEX 1 TAB orally every day
TRIAMCINOLONE ACETONIDE 0.5% ( TRIAMCINOLONE A... )
TOPICAL TP four times a day
Instructions: Please apply to affected area in right
axilla four times per day.
LEVOFLOXACIN 500 MG orally every day
Instructions: Please give at least 2 hours before and
after any iron supplements until August
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 11/15/04 by
HIMEL , YVETTE C.
POTENTIALLY SERIOUS INTERACTION: POLYSACCHARIDE IRON
COMPLEX & LEVOFLOXACIN Reason for override:
Will separate doses by 2 hours.
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
METFORMIN XR ( METFORMIN EXTENDED RELEASE ) 2 , 000 MG orally every day
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
PROTONIX ( PANTOPRAZOLE ) 40 MG orally twice a day
DIET: House / NAS / ADA 2100 cals/day / Very low fat ( 20gms/day )
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Ida Gildner 3/18/04 scheduled ,
Dr. Buddy Mcmeen 6/7/04 scheduled ,
ALLERGY: HORSE , tricor
ADMIT DIAGNOSIS:
Shortness of breath , right upper quadrant pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) +H pylori , history of rx ( Helicobacter pylori ) guiac +
stools ( lower GI bleeding ) diverticulosis
( diverticulosis ) polyposis ( colonic polyp ) nephrolithiasis ( kidney
stone ) depression ( depression ) obesity
( obesity ) hypertriglyceridemia ( elevated triglycerides ) OSA ( sleep
apnea ) pneumonia ( pneumonia ) contact dermatitis R axilla ( contact
dermatitis )
OPERATIONS AND PROCEDURES:
Mr. Salak underwent an upper endoscopy on 1/14
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
CC/HPI: 56 year-old man with DM , HTN , hypertryglyceridemia , depression
comes in with 2-day history of increasing
abdominal girth , 1-day history of shortness of breath , pleuritic CP. 7 days
PTA noticed increase in nocturia from 2x to 6x. 2
days PTA became uncomfortable while sleeping , could not take deep
breath without RUQ abdominal pain. No fever/chills , no cough , mild
nausea , no vomiting , no change in bowel habits , no
dysuria. Arrived in ED 8/22 , given intravenous Lasix for
presumed CHF.
PMH: Per problem list. MEDS: Not compliant. Admission - Nexium 40 mg
orally twice a day , HCTZ 25 mg orally every day , Lisinopril 40 mg orally
every day , Tiazac 240 mg orally every day , Metformin XR 2000 mg orally every day
on admission
Allergies: Horse ( unknown ) , TriCort ( rash ) PE 3/26 T 97.5 HR 108 BP
196/112 RR 18 SAT 96% RA AOX3 , no JVD , lungs clear , RRR no M/R/G ,
abdom en obese , distended , without peritoneal signs , +bs ,
no LE
edema. PE 3/1 Tm 99.8 HR 80-90 BP 140-170/80-90
RR 18 - 22 SAT 97% 3L 92-94%
RA AOX3 , no JVD , lungs and heart WNL , abd less
tender HOSPITAL COURSE: 1 ) CV. Ischemia. Cardiac
enzymes flat x 3. No significant EKG changes. Pump.
8/22 BNP 64 , no clinical CHF. Hypertension
poorly controlled in setting of missing home meds
with blood pressure up to 170's/90's. Diltiazem d/c'd in favor of Metoprolol and
uptitrated. 2 ) Pulmonary. Ruled out PE with D-dimer
( <200 ). OSA , likely obesity hypoventilation. Failed 2 CPAP trials.
Had fever to 101.5 , desat on RA , tachypneic , pan-cx , CXR LLL PNA ,
Vanco/Levo/Flagyl begun , Vanco d/c'd since unlikely
nosocomial , Levo/Flagyl changed to orally 3 ) GI. 8/22
Abd CT - fatty liver , pancreas. ALT/AST: 133/98 , others WNL , trending
down , near norma. TG - 2032. Serological liver dz with u neg. Gemfibrozil
begun. presumed dx NASH , EGD - antral erosions , ASA/NSAIDs d/c'd for
6 - 8 wks 4 )END: Metformin , ISS 9/10 15 units NPH added at bedtime am
FSBG 120 , will continue. 5 )RENAL/FEN. Good
renal function , patient on ACE inhibitor. Urine cx likely contaminant ,
6 )NEURO/PSY. patient self-d/c'd Wellbutrin Effexor 7d PTA. Restart as
outpatient.
ADDITIONAL COMMENTS: Please return to the hospital if you feel fever or chills dizziness ,
worsening shortness of breath , persistent nausea/vomiting. Please go
to all follow up appointments , including Dr. Ida Gildner
( Endocrinology ) 8/30 2 p.m. in Rilljack ( 485 ) 724-0306 and
with Dr. Buddy Mcmeen , your Primary Care Doctor , on 9/17/04 at 1:30 p.m..
Please call her office to confirm at ( 072 ) 116-6116. Please take all
medications as prescribed.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1 ) Complete 14-day course of Levofloxacin ( until 10/8/04 ).
2 ) Follow up with Endocrine and primary care physician re diabetes and lipid management.
3 ) Follow up with primary care physician for management of chronic medical
problems , including GERD , gastric erosions , hypertension , obstructive
sleep apnea.
4 ) Follow up with outpatient psychiatrist regarding reinitiation of
medications.
No dictated summary
ENTERED BY: DYSINGER , ROZANNE RANDI , M.D. ( KG52 ) 10/6/04 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 982
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222755927 | PUO | 29577753 | | 6363638 | 8/14/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/27/2006 Report Status: Signed
Discharge Date:
ATTENDING: GABHART , DORTHY M.D.
CHIEF COMPLAINT: Right thigh burn , cellulitis and diabetic
ketoacidosis.
HISTORY OF PRESENT ILLNESS: Ms. Davalos is a 36-year-old woman
with very poorly controlled type 1 diabetes and extensive end
organ damage including end-stage renal disease on hemodialysis ,
right eye blindness , lower extremity neuropathy , gastroparesis
and a history of extensive infections including VRE line sepsis ,
MRSA , abdominal abscesses and chronic dermal ulcers. Due to her
dermal ulcers , she developed left ankle osteomyelitis requiring
below-the-knee amputation. She was transferred from Norap Valley Hospital on 1/24/06 in DKA in the setting of a right thigh burn
and possible infection.
The patient was in her usual state of health until three days
prior to admission when she spilled hot broth on her right thigh
and developed a painful red bullae. She presented to Pande Memorial Hospital two days prior to admission , but still she had an
infection. She was given a prescription for antibiotics , which
she did not fill. The area of swelling in her right leg did not
spread from the original blister area all the way up to her groin
and grossly became more tender and warm. On the day of
admission , she returned to the Norap Valley Hospital Emergency Room
for evaluation. Of note , in going to the emergency room , she
missed her regular hemodialysis. In the Norap Valley Hospital
Emergency room , the following vital signs were noted.
Temperature afebrile , heart rate 60 , blood pressure 150/50 ,
oxygen saturation 95% on room air. WBC 4.3 , hematocrit 38 ,
sodium 126 , potassium 7.9 , glucose 1221 , anion gap 13 , acetone
negative , AST 385 , ALT 127 and alk phos 411. EKG revealed peak Q
waves. The patient was given 20 units of intravenous insulin and then was
started on an insulin drip 8 units per hour. She also received 2
amps of calcium gluconate as well as Kayexalate and albuterol
nebs. A repeat Chem-7 in the P Therford Hospital ED showed a glucose of
1100 and an anion gap of 18 with potassium 5.4. The patient was
transferred to the MICU at PUO for further management. At the
time of her transfer , she noted left-sided headache , a warm
feeling over her right thigh. She denied any recent fever ,
shortness of breath , abdominal pain , nausea , vomiting or
diarrhea. She did note that her last bowel movement was three
days prior to admission.
PAST MEDICAL HISTORY:
1. Poor controlled type 1 diabetes.
2. End-stage renal disease on hemodialysis Monday , Wednesday and
Friday - left chest hemodialysis catheter for access.
3. History of VRE line sepsis.
4. History of MRSA.
5. History of abdominal abscess.
6. Chronic dermal ulcers.
7. CHF.
8. History of cardiac murmur.
9. Seizure disorder.
10. Multiple strokes.
11. Chronic nausea.
12. Personality disorder , deemed not to have capacity - guardian
is Earlean Julias # 942-235-3140.
HOME MEDICATIONS:
1. Lantus 24 units subcutaneously each night.
2. NovoLog sliding scale.
3. PhosLo.
4. Nephrocaps.
5. Vitamin D.
6. Sevelamer 1600 three times a day
7. Toprol 100 mg orally daily.
8. Lisinopril 5 mg orally daily.
9. Plavix 75 mg orally daily.
10. Keppra 500 mg orally twice a day
11. Flovent two puffs twice a day
12. Albuterol as needed
13. Baclofen 5 mg orally three times a day
14. Ambien 10 mg orally at bedtime as needed
TRANSFER MEDICATIONS: None.
ALLERGIES: Aspirin causes tongue swelling. Codeine ,
erythromycin beef , poke and insulin all caused unknown reactions.
SOCIAL HISTORY: The patient lives with a personal care assistant
and her daughter. She has four children ages 5 to 20. She
denies tobacco use or alcohol use. She denies any illegal drug
use. Guardian is Earlean Julias , telephone number 942-235-3140.
Per court order , the patient does not have capacity to make
medical decisions.
FAMILY HISTORY: Noncontributory.
NOTABLE ADMISSION EXAM: Weight 70 kg. General , sleepy , but
arousable A&O x3 , conversant and cooperative. HEENT , blind right
eye , left eye reactive. OP clear with moist mucous membranes.
Neck supple. Chest clear to auscultation bilaterally. No
dullness. Cardiovascular , JVP flat. Regular rate and rhythm.
3/6 systolic ejection murmur at the left upper sternal border
with low rumble at the left lower sternal border radiating to the
apex. No delaying carotid upstrokes. Abdomen distended.
Positive bowel sounds. Nontender. Visible old peritoneal
dialysis site with serosanguinous drainage and granulation ,
otherwise noninflamed and nontender. Extremities , left BKA , well
healed. Right thigh 4 x 5-cm open bullae with clear drainage and
a surrounding tender area of erythema and warmth extending up to
the groin and down to the knee , 2+ dorsalis pedis pulse on the
right. Neurological , A&O x3 , cooperative , anxious about getting
intravenous access. Skin , multiple excoriation , all subcentimeter
macules.
NOTABLE LABS: Sodium 133 , potassium 4.3 , chloride 98 ,
bicarbonate 19 , BUN 47 , creatinine 8.3 , calcium 8.5 , magnesium
2.1 , phosphate 2.9 , anion gap 15 , ALT 84 , AST 186 , alk phos 264 ,
T. bili 1.0 , troponin less than assay , BNP 4900 , amylase and
lipase normal , serum osms 337 , lactate 4.7 , WBC 5.3 , hematocrit
31.6 , platelets 208 , 000 , INR 1.3. ABG 7.28/42/128. EKG normal
sinus rhythm at 74 , normal axis , normal intervals , no ischemia ,
no peak T-waves. Echo in September 2006 , mild LVH , EF 65% to 70% , no
wall motion abnormalities , mildly enlarged right ventricle ,
normal RV outflow tract , mild left atrial enlargement , mild right
atrial enlargement , mild aortic stenosis , trace mitral
regurgitation , trace tricuspid regurgitation , pulmonary artery
pressure of 48 , IVC dilated with diminished respirophasic
variation consistent with markedly elevated right atrial
pressure.
HOSPITAL COURSE:
1. DKA: The patient was stabilized in the MICU on an insulin
drip and was then transferred to General Medicine for further
management. Causes of DKA that were ruled out included the
following - negative cardiac enzymes , unimpressive pancreatic
enzymes , unimpressive lactate , normal LFTs. The patient's DKA
was presumed to be due to her right thigh cellulitis in the
setting of a local burn. She initially was given 500 mL normal
saline boluses and then several 250 mL boluses. As she is
aneuric , her boluses were stopped once the blood sugars were
below 500. She initially was placed on insulin drip that was
then transitioned to NPH and finally to Lantus 24 units subcutaneously
daily. Of note , the patient intermittently refused to take both
her long-acting and her insulin sliding scale. As a result , an
endocrinology consult was called. The patient was noted to be
ordering extra food from the kitchen , which could in part explain
her labile sugars. Despite careful diet and glucose control
efforts , the patient still had sugars at times to the 500s.
Endocrinology continues to leave recommendations about before meals
standing insulin in addition to her NovoLog sliding scale and
Lantus insulin. The patient has a history of gastroparesis and
therefore may not tolerate before meals insulin very well. The patient's
new covering team will continue to follow up with Endocrinology.
2. Right thigh cellulitis: The patient was placed on Augmentin
and intravenous vancomycin. Her area of cellulitis has completely
resolved at the present time with slight sloughing of the
overlying skin. The underlying skin is pink with evidence of
good granulation and no further evidence of infection. Given
that her intravenous access is very difficult , the patient received some
vancomycin , as she finishes hemodialysis every other day.
3. End-stage renal disease: The patient missed her dialysis on
the day of admission. Once in the hospital , her potassium was
very difficult to control in part due to poor adherence with her
renal diet and in part due to her very labile sugars. At times ,
her potassium would rapidly increase to a level higher than 6.5
requiring urgent dialysis. At the present time , the patient has
been dialyzed daily since her admission. She is closely followed
by renal with plans to continue dialysis while in the hospital.
She should not receive any further intravenous fluids unless she
has evidence of recurrent DKA , given her anuric state. Should
she become acidotic , the patient can be managed with sodium
bicarbonate and D5W in small boluses.
4. Cardiovascular: Ischemia , there was no evidence of chest
pain. The patient has showed no EKG signs of ischemia. Her
cardiac enzymes remained negative. Lipids are pending at the
present time. Lipid profile check is pending at the present
time. Pump , the patient has a history of CHF with evidence of
right heart failure likely due to valvular disease in some aspect
of the diastolic dysfunction given her preserved ejection
fraction. Her weight on admission was 70 kg. We did not know
her dry weight. Dialysis is helping to manage her fluids given
her aneuric status. Her O2 sats remained stable on room air
throughout the hospitalization. Her hypertension has been
somewhat poorly controlled and for that reason she was continued
on her home dose of Lopressor 25 four times a day and switched to
Captopril , which we continued to titrate at the present time.
Rhythm , normal sinus rhythm. The patient is currently on
telemetry with no signs of arrhythmia.
5. Fluids , electrolytes , nutrition: The patient was placed on a
cardiac , renal and diabetic diet. She was noted to repeatedly
order extra food from the kitchen supervisor. Nutrition
endocrinology and nursing staff are all aware and are working
diligently to prevent the patient from receiving more than 2000
calories per day as specified by her ADA diet. She is continuing
her Nephrocaps and sevelamer. Prophylaxis , heparin 5000 units
subcutaneously three times a day - the patient has consistently refused her heparin.
6. Consent: All interventions require consent from the
patient's medical guardian , Earlean Julias ( please see number
above ).
7. Code status: The patient is full code and this has been
confirmed with the guardian.
ADDENDUM
Of note , on the night of 10/22/06 , the patient complained of
severe cramping , right lower quadrant pain , which is new. She
noted this pain has increased rapidly in the setting of diarrhea.
Several C. diff studies , which were sent recently have been
negative and the patient has had no blood in her diarrhea.
Presumed cause is Augmentin , which has been stopped. The patient
has continued to eat freely and is passing diarrhea despite her
complaints of 10/10 severe abdominal pain. A CT scan of her
abdomen was ordered , but she refused to take orally or intravenous contrast.
The results of this CT scan are pending and will be followed up
by the new medical team.
eScription document: 4-8400539 CSSten Tel
Dictated By: BERNO , LUCI
Attending: FAITH PANAGOS , M.D. WE00
Dictation ID 3123444
D: 5/17/06
T: 5/17/06
Document id: 983
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659753603 | PUO | 48763358 | | 6016423 | 1/20/2006 12:00:00 a.m. | heart failure | | DIS | Admission Date: 2/10/2006 Report Status:
Discharge Date: 10/20/2006
****** FINAL DISCHARGE ORDERS ******
BRECKENRIDGE , BELKIS N 252-22-80-1
Na Para Ni
Service: CAR
DISCHARGE PATIENT ON: 11/8/06 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PREWER , FERNANDE RANDY , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Hospice
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ATOVAQUONE 1 , 500 MG orally DAILY
Food/Drug Interaction Instruction Give with meals
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
ADVAIR DISKUS 100/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 10/28/06 by
MANGANELLI , ADELINA , M.D.
on order for LEVOFLOXACIN orally ( ref # 899292516 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: will follow
Previous override information:
Override added on 6/21/06 by HANAGAMI , STORMY E. , M.D. , PH.D.
on order for LEVOFLOXACIN orally ( ref # 291607865 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: ok
FOLIC ACID 1 MG orally DAILY
HYDROCHLOROTHIAZIDE 50 MG orally DAILY
INSULIN NPH HUMAN 15 UNITS subcutaneously every day before noon
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LEVOFLOXACIN 500 MG orally DAILY
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 10/28/06 by
MANGANELLI , ADELINA , M.D.
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: will follow
ATIVAN ( LORAZEPAM ) 0.5 MG orally every 6 hours as needed Anxiety
REMERON ( MIRTAZAPINE ) 15 MG orally BEDTIME
Number of Doses Required ( approximate ): 10
MORPHINE ELIXIR ( MORPHINE SOLUTION ) 2-5 MG orally every 2 hours
as needed Pain , Shortness of Breath
MORPHINE ELIXIR ( MORPHINE SOLUTION ) 2 MG orally every 6 hours
PREDNISONE 10 MG orally every day before noon
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
RAPAMUNE ( SIROLIMUS ) 1 MG orally DAILY
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
TORSEMIDE 100 MG orally twice a day
AMBIEN ( ZOLPIDEM TARTRATE ) 5 MG orally BEDTIME as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Prewer if needed ,
ALLERGY: WARFARIN SODIUM , PIOGLITAZONE ,
CYCLOSPORINE ( SANDIMMUNE )
ADMIT DIAGNOSIS:
heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of HEART TRANSPLANT COUGH smoker history of B cataract surg history of PE 1984
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
**CC: CHF
**HPI: 61yoM history of heart transplant in 1985 , now with severe CMP EF
15% , transplant vasculapathy and accerlated CAD , severe rest lung dz ,
and essentially end-stage , transferred here from TH
for med mgmt. patient has had several CHF admission , requiring diuresis ,
and returns shortly with same sx's. Now transferred from TH with vol
overload on Dobutamine and Lasix for med
mgmt.
**PMH: history of heart transplant 1985 , transplant vasculapathy and
accelerated CAD , restrictive lung dz , ICMP EF 15% , DM , hx of GIB ,
thrombocytopenia , CRI
**DAILY STATUS: afeb , BP 100/60 , HR 60's , 97%2L. NAD , JVP 14cm ,
bibasilar rales , RRR S1S2S3 , 1+ bilateral LEE.
*************HOSPITAL COURSE*****************
*CVS: patient now 20yrs post heart transplant with many complications
including accelerated CAD , rest lung dz , ICMP EF15% - he is now end
stage with room for no intervention. Will need optimal medical mgmt ,
then home with HOSPICE. He was diuresed aggressively with Lasix
drip and intravenous Diuril and received inotropic support with
Dobutamine. His was transitioned to orally Torsemide and HCTZ by discharge
once he achieved his dry weight. He received frequent Morphine for
anxiety and SOB , and will continue to do so.
Arrangements for HOME HOSPICE have been made. The patient understands his
prognosis is very poor and that there are no further interventions that
can improve his underlying heart diseas. His volume status was
opitmized , and he will go home with a torsemide/HCTZ and as needed Morphine.
*ID: on Levoflox for UTI
*ENDO: NPH and SS
*********DNR/DNI***********
ADDITIONAL COMMENTS: Please note that your new medictions include Torsemide and
Hydrocholorthiazide for diuresis. You will take Levofloxacin for three
more days. Do not take Coreg any longer. Please use Morphine and Ativan
as needed for anxiety and difficulty breathing.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MANGANELLI , ADELINA , M.D. ( PG98 ) 8/24/06 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 984
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739728642 | PUO | 41684491 | | 1017721 | 3/19/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/19/2004 Report Status: Signed
Discharge Date:
ATTENDING: GERARD MUHLSTEIN MD
ADDENDUM
Date of discharge is to be determined.
SERVICE:
General Medical Service Waen Rd
In summary , this patient is a 73-year-old lady with a history of
low back pain , sciatica , morbid obesity , spinal stenosis ,
hypothyroidism , hypertension , diabetes mellitus , posthepatic
neuralgia , rheumatoid arthritis , renal insufficiency , deep vein
thrombosis , bilateral total knee replacement secondary to
degenerative joint disease , who is admitted on 8/15/04 for
worsening low back pain. The following is a continuation of the
hospital events during her stay.
1. Low back pain: As stated before , she suffers from
debilitating low back pain from morbid obesity , spinal stenosis ,
rheumatoid arthritis , and degenerative joint disease. During her
hospitalization , her pain was treated with narcotics as well as a
steroid/analgesic epidural injection. The Pain Service followed
during her discharge day. Her pain control with narcotics was
titrated with a fentanyl patch along with breakthrough orally
Dilaudid. She was also titrated up on her chronic pain
medications including Neurontin and Elavil. The patient had a
history of sedation with too much narcotics , and her narcotics
should be titrated for mental status changes. During her stay ,
she received intravenous conscious sedation MRI , which showed a normal
spinal cord and spinal stenosis , facet involvement. Orthopedics
surgery was consulted early during the hospitalization and they
determined that there was no surgical indication for orthopedic
surgery. They were also reconsulted later on when the patient
appeared to want to have surgery , and at that time orthopedics
surgery determined that the risk-benefit ratio was not in favor ,
and that she was not a surgical candidate in the context of a
newly developed right lower extremity DVT. As mentioned before ,
the patient had an epidural injection with bupivacaine and
steroids on 7/8/05 with minimal initial response to her pain.
However , later , there was some improvement in her pain. The
patient is to follow at the Pain Clinic in two weeks , as further
appointments in the follow up section for a possible repeat
epidural injection. In addition , she is to follow up with Dr.
Eckloff within four weeks of the Orthopedics Surgery Service for
reevaluation for the orthopedics surgery. In addition , she
received aggressive physical therapy , which slowly enabled her to
improve her range of movement in her lower extremities. She does
have chronic and stable left lower extremity immobility.
However , she is able to move her right leg somewhat and this has
improved slowly over time with aggressive physical therapy. The patient has
very agreeable of recent days to physical therapy and is expected
to continue to improve with continued aggressive physical
therapy. This should be the mainstay of her treatment in
addition to her pain control with her medications. She should be
premedicated with Dilaudid or any pain control medications prior
to any physical therapy session.
2. Cardiovascular: The patient had stable cardiovascular
parameters during her admission and did not require any
significant changes in her outpatient medications. Medications
are as listed in the discharge medications.
3. Endocrine: She has severe diabetes mellitus and insulin
resistence. Her NPH was titrated due to episodes of asymptomatic
hypoglycemia to the range of 45 to 55 in the fasting morning
glucoses of normal need. On discharge , the patient was
maintained on NPH insulin twice a day as well as sliding scale of
regular insulin. He also had a history of hypothyroidism and her
Synthroid was continued. She had a history of renal
insufficiency and received a chronic low dose of prednisone. She
did not have any issues while she was in the hospital.
4. Rheumatology: The patient has rheumatoid arthritis. Her
prednisone was decreased in duration of her stay from prednisone
20 mg orally every day before noon to 10 mg orally every day before noon She also is on as an
outpatient on her home dose of methotrexate 20 mg orally every week ,
which was held during her hospitalization due to her acute
issues. However , the methotrexate , which was prescribed by her
outpatient rheumatology , should be restarted as an outpatient as
soon as possible. She takes 20 mg orally every week.
5. Renal: Initially , the patient had a mild increase in her
creatinine on presentation , but this improved to the normal range
with gentle hydration.
6. Infectious disease: The patient had a fever on 4/22/04 to
101 and on 6/26/05 to 101 degrees Fahrenheit. Cultures were
negative. There were white blood cells in her urine and she was
empirically given levofloxacin. She did have cough and sputum ,
and she was found to have MRSA in her sputum and was known to be
colonized at this point , and was placed on precautions. However ,
her chest x-ray was clear. She did not have a clinical
pneumonia. Her lower extremity appeared red and woody and there
was question of cellulitis , and she received 10 days of orally
Keflex , although it was unlikely she had two cellulitis.
7. Pulmonary: She likely has obstructive sleep apnea with a
mild decrease in O2 saturations at night. However , this was
never clinically significant. Her body habitus and symptoms were
consistent with obstructive sleep apnea. Chest x-rays were also
taken during her course and were unchanged from her prior.
Although , she has had a history of being fitted for a C-PAP mask ,
she refused to use this.
8. Hematology: She was diagnosed with a DVT in her right leg by
ultrasound on 6/26/05 , and was started on a heparin drip , which
was bridged to warfarin with therapeutic INR during the rest of
her stay. The plan is for her to continue six months of
anticoagulation , then reevaluation by her outpatient primary care
physician. Her current dose of Coumadin is 6 mg orally every bedtime and
this should be checked one week after discharge from the hospital
in order to ensure a goal INR of 2 to 3. Until than she will be
maintained on Lovenox 40 mg subu every day in the hospital , and this
can be continued as needed as an outpatient.
9. Physical therapy: As per above , the patient is engaged in
physical therapy and showed improvement over time.
10. GI: The patient has intermittent constipation to her pain
medications and has poor orally intake in general , however , this
improved over the course of admission. She requires an
aggressive bowel regimen to keep her regular bowel movements and
she will be often resonant to have a bowel movement due to the
feeling of vertigo during the bowel movements. This , however ,
improved during time. She should be encouraged to allow herself
to have bowel movement in the rest room if she is able. The goal
will be for her to be able to sit on a toilet potty at the
bedside.
11. Fluids , electrolytes , and nutrition: The patient had
intermittent , non-clinically significant hyperkalemia , which
initially was corrected with Kayexalate and bowel movements.
12. Psychiatric: The patient had intermittent vocalization of
not caring if she lived or died because she had lived her life
and she was in pain. She was seen by the psychiatry multiple
times. She did not think that she was suicidal and only need
emotional support to which she responded well. At the time of
discharge , she was euthymic and hopeful and was eager to continue
to improve her quality of life with aggressive physical therapy
and pain control. She was looking forward to continuing her pain
control management follow up visit with pain service.
13. The patient has declared herself to be DNR/DNI.
TO-DO PLAN , FOLLOW-UP PLAN:
1. Aggressive physical therapy and pain control , as directed by
the pain clinic and her primary care physician.
2. After her discharge from rehabilitation , she should follow up
with her rheumatologist Dr. Gabisi , pain clinic , Dr. Azua ,
which is her primary care physician in Orthopedics.
3. She is also noted to be MRSA colonized and should be on
appropriate precautions. She should continue her Coumadin for
six months for her deep vein thrombosis until otherwise directed
by the physician. The pain clinic will consider additional
therapy for pain including epidural repeat as an outpatient. The
patient should restart her methotrexate as an outpatient.
FOLLOW-UP APPOINTMENTS:
At this time , she has an appointment with Dr. Mcmurry at the
Totin Hospital And Clinic Pain Clinic at Sun E , phone number
378-234-0249 on 7/9/05 at 2:30 p.m. She also has an
appointment with Dr. Eckloff , Orthopedic Surgery at the Pagham University Of Orthopedic Service on the Na Sa
Go Louis at Pagham University Of , phone number
443-202-3796 on 10/1/05 at 10:30 a.m. She should have her INR
drawn in one week after discharge and follow up INR is to be
drawn every seven days until therapeutic. The INR should be
followed by her rehabilitation/nursing facility.
DISCHARGE MEDICATIONS:
Albuterol nebulizer 1.25 mg nebulizer every 4 hours as needed wheezing ,
Elavil 75 mg orally every bedtime , atenolol 50 mg orally every day , bisacodyl 10
mg orally every day , folic acid 1 mg orally every day , Lasix 20 mg orally every day ,
Dilaudid 2 mg to 4 mg orally every 3 hours as needed pain , insulin NPH 30
units subcutaneously every afternoon , insulin NPH human 54 units subcutaneously every day before noon ,
Regular Insulin sliding scale , Synthroid 125 mcg orally every day ,
Lisinopril 20 mg orally every day , milk of magnesia 30 mL orally every day
as needed constipation , prednisone 10 mg orally every day before noon , Sudafed 30 mg
orally every 6 hours as needed , nasal congestion , senna tablets two tabs orally
twice a day , Coumadin 5 mg orally every afternoon , no high vitamin K containing
foods , Imdur 30 mg orally every day sustained release , Lipitor 80 mg
orally every day , fentanyl patch 75 mcg per hour transdermally every 72 hours ,
Neurontin 600 mg orally four times a day , Colace 100 mg orally twice a day , Dulcolox
10 mg 20 mg PR every day as needed constipation , lactulose 15 mL and 30
mL orally four times a day as needed constipation , titrate to one to two bowel
movements per day.
eScription document: 7-2277298 EMSSten Tel
Dictated By: SCHUNEMAN , ELLENA
Attending: MUHLSTEIN , GERARD
Dictation ID 2791626
D: 9/15/05
T: 9/15/05
Document id: 985
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381657432 | PUO | 94165526 | | 465711 | 11/26/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/20/1994 Report Status: Signed
Discharge Date: 2/10/1994
PROBLEMS: 1. CORONARY ARTERY DISEASE AND
STATUS POST ANGIOPLASTY OF RIGHT
CORONARY ARTERY AND LEFT
CIRCUMFLEX ARTERY.
2. HYPERTENSION.
3. HIGH CHOLESTEROL.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year white female
with history of positive exercise
tolerance test MIBI , now presents after 12 hours of stuttering
chest pain. Cardiac risk factors include hypertension and high
cholesterol of 220 to 270's. The patient was generally well until
October 1991 she had an episode of chest pressure. This was a
single episode. On October 1991 , the patient had continued chest
pressure. She had exercise tolerance test MIBI for which she went
3 minutes and 37 seconds with a positive left bundle branch block 3
minutes into exercise. Her MIBI showed a reperfusion defect
anteriorly , inferiorly and septal. A decision was made to
medically manage the patient with beta blockers and sublingual
Nitroglycerins. During this exercise tolerance test MIBI , she was
also noted to have 1 to 2 mm ST depressions in multiple leads. The
patient was active and pain-free until at 10:00 p.m. one day prior
to admission , while walking , she developed pressure across the
chest and between her shoulder blades. She had no shortness of
breath , diaphoresis , nausea or vomiting or light-headedness. She
had no palpitations. She took 100 mg of Atenolol with some relief
and went to bed. On the day of admission at 6:30 a.m. , the patient
awoke with chest pain. She checked her blood pressure at home
which was approximately 200/100. She took 100 mg of Atenolol.
Initially , she had increasing chest pain and then this resolved by
approximately 10:30 a.m. She went to the Emergency Room at 1:00
p.m. She described this pain as the same pain that she had in
1991. She did not take any Nitroglycerin because her prescription
was expired. She has had no history of orthopnea , paroxysmal
nocturnal dyspnea or pedal edema. She has no history of chest
pain. She has a history of shortness of breath after walking
upstairs. In the Emergency Room , she was given one Aspirin and she
was also started on Nitropaste. She was given Nifedipine 10 mg orally
x 1. Her blood pressure decreased from 190/100 to 114/76. PAST
MEDICAL HISTORY: ( 1 ) Cardiac. As above. ( 2 ) Increase in blood
pressure. ( 3 ) Left breast cancer in September 1987 , status post
lumpectomy with negative margins. No XRT. She is followed by Dr.
Binney Her mammography on August 1993 was negative per the
patient at Norap Valley Hospital . ( 4 ) Intermittent left bundle branch
block. MEDICATIONS ON ADMISSION: At the time of admission , the
patient was on Atenolol 100 mg every day x two extra doses in the last
24 hours. This was decreased down to 50 mg every day.
Hydrochlorothiazide was discontinued. Multivitamins with Iron.
Sublingual Nitroglycerin prescribed but never taken by the patient.
ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient
lives with her husband. She has six kids and nine grandchildren.
She is a retired Medical Technician. She has no history of smoking
or alcohol. FAMILY HISTORY: No coronary artery disease. Her
mother had ovarian cancer and died at the age of 80. Her father
died of leukemia. She has no history of breast cancer in her
family.
PHYSICAL EXAMINATION: The patient is an obese elderly female
who is comfortable. Blood pressure is
114/76 and 150/100. Temperature 97.3. Heart rate 60. Respiratory
rate 16 , 96% on room air saturation. HEENT: Pupils equal , round
and reactive to light and accommodation. Extraocular movements were
intact. Oropharynx benign. Neck: No jugular venous distention.
Carotids 2+ without bruits. No lymphadenopathy. Lungs: Trace
bibasilar rales. Heart regular rate and rhythm. No murmurs ,
gallops or rubs. Abdomen soft , non-tender , positive bowel sounds.
No bruits. Groin: Femoral pulses 2+ without bruits. Extremities:
1+ pitting edema bilaterally and 2+ dorsalis pedis and posterior
tibial pulses. Neurological nonfocal. Rectal examination guaiac
negative per Emergency Ward.
LABORATORY DATA: Laboratory examinations on admission
revealed SMA-7 within normal limits.
SMA-20 was notable for calcium of 10.2 and cholesterol of 284 ,
triglycerides 271. WBC was 9. Hematocrit of 48. Platelets 294.
MCV 87. Polys 76. Urinalysis negative. Chest x-ray with no
infiltrates or effusion. EKG showed sinus bradycardia , 84 rate.
Intervals were .19 , .08 and .45. Axes 15 degrees. The patient had
Q-waves in Leads 3 and F , biphasic T's in Leads 1 , L and 2 , flat
T-waves in 3 and F , biphasics in V1 through 6. Old EKG not
available but by report is similar.
HOSPITAL COURSE: ( 1 ) Coronary artery disease , status post
angioplasty. The patient is a 70 year
old female admitted with approximately 12 hours of chest pain. She
ruled in for a myocardial infarction with a CPK peak of 786 and MB
fraction of 52. Her echocardiogram examination was within normal
limits with left ventricular function that was normal. She did ,
however , have inferior posterior hypokinesis. Her ejection
fraction was 55%. The patient was on intravenous Heparin , Aspirin and
Nitropaste as well as a beta blocker. She had no symptoms of chest
pain or shortness of breath. She had exercise tolerance test which
was done approximately 5 to 6 days after her myocardial infarction.
She underwent a modified Bruce protocol for 8 minutes and 40
seconds with chest pain and ST changes. She had 1 minute of left
bundle branch block at the end of her exercise test. The patient's
exercise test was also notable for her having typical chest pain
similar to her angina. She had up to 2 mm ST depressions. The
test was highly predictive of significant coronary disease. This
exercise test was done on March . The patient went to cardiac
catheterization on May . During this , she was noted to have
significant coronary artery disease. Her second diagonal had a 50%
proximal stenosis. Her mid left anterior descending showed 40%
stenosis. Her first obtuse marginal had 50% proximal stenosis.
Her most distal large obtuse marginal has a 100% stenosis and fills
by left to left bridging collaterals and right to left collaterals.
Her right coronary artery has a 50% proximal stenosis followed by
70% mid stenosis. Her left ventriculogram shows mild inferior ,
posterior hypokinesis with overall preserved chamber size and
function. The calculated ejection fraction was 67%. On October , the patient returned to the Cardiac Catheterization Laboratory
for percutaneous transluminal coronary angioplasty of her right
coronary artery lesion which was 60 to 40% proximally and 80 to 20%
distally. She also had percutaneous transluminal coronary
angioplasty of her left circumflex of 100% to 20%. Her sheaths
were removed on April in the morning. The patient was
discharged on April with no further complaints of chest pain.
She was not started on Ace inhibitors because her ejection fraction
was very good. She was continued on her beta blocker and Isordil.
The dietician saw the patient with regards to her diet because of
her high cholesterol. She also had post myocardial infarction
teaching done. She will be followed with Cardiac Rehabilitation at
Abois Che Memorial Hospital ( 2 ) Hypertension. The patient had good
control of her hypertension with Procardia. ( 3 ) High cholesterol.
The patient had cholesterol of 239 with HDL 43 , LDL 158. She had
dietician state to her with regards to her high cholesterol ,
however , if this does not work , the patient should be started on acholesterol l
owering medication as an outpatient.
DISPOSITION: CONDITION ON DISCHARGE: Good.
MEDICATIONS ON DISCHARGE: At the time of
discharge , the patient was on Aspirin orally every day , Atenolol 100 mg
orally every day , Isordil 30 mg orally three times a day , Nifedipine XL 30 mg every day orally ,
Nitroglycerin as needed DISPOSITION: The patient will be discharged to
home. FOLLOW-UP CARE: She will be followed by Cardiac
Rehabilitation at Mi Lakeield Sonme She will be followed by Dr. Annette Schoultz in approximately one month. She should have an exercise
tolerance test in three weeks and also have her cholesterol checked
at this time. She will also have a follow-up appointment with Dr.
Rossie Mankoski of Cardiology in approximately two weeks. DIET:
She is suggested to have a low cholesterol , low saturated fat diet.
Dictated By: CARMELITA TONI , M.D. MI94
Attending: WAYLON M. GELLINGER , M.D. DQ3
reviewed on computer without chart
Batch: 0166 Index No. EKCT6X24K0 D: 6/26/94
T: 7/12/94
CC: 1. Rossie Mankoski , M.D.
2. Annette Schoultz , M.D.
Document id: 986
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
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513736624 | PUO | 84044753 | | 9546453 | 7/25/2005 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 1/24/2005 Report Status: Signed
Discharge Date: 10/15/2005
ATTENDING: DEANDRA LAZARO GILFOY MD
ADMITTING DIAGNOSIS: Pneumonia.
DISCHARGE DIAGNOSIS: NSTEMI , pneumonia.
CHIEF COMPLAINT: Right hip and knee pain.
HISTORY OF PRESENT ILLNESS: This is a 76-year-old woman with a
history of insulin-dependent diabetes mellitus , hypertension ,
three-vessel CAD , lung cancer , status post lobectomy in October
2003 who on the day of admission was getting out of bed at home
and had a mechanical fall due to right leg weakness. The patient
was noted to be pale and diaphoretic at this time. The patient
had recently noticed an increase in her baseline , severe dyspnea
on exertion , there was no loss of consciousness , trauma , or
prodrome associated with this mechanical fall. The patient
denied chest pain on admission to PUO . She had left shoulder
pain and complained of right scapular pain in the emergency room.
The patient had been recently discharged from PUO after
admission for herniated disc at L2 and L3 with right nerve root
impingement. In the emergency room , the chest x-ray was
remarkable for a left lower lobe pneumonia. The patient also had
an elevated troponin at 0.19. The EKG in the emergency room
showed 0.5 mm increase in ST depressions in the inferolateral
leads , which the patient had at baseline.
PAST MEDICAL HISTORY:
1. IDDM.
2. CAD.
3. Hyperlipidemia.
4. Hypertension.
5. Glaucoma.
6. PMR.
7. Spinal stenosis.
8. Disc herniation.
9. Upper GI bleed status post AVM.
10. Lower GI bleed
11. Iron deficiency anemia.
MEDICATIONS ON ADMISSION:
1. Atorvastatin 40 mg orally every bedtime
2. Lisinopril 60 mg every day
3. Metformin 850 mg twice a day
4. NPH.
5. Regular insulin sliding scale.
6. HCTZ 12.5 mg orally every day
7. Toprol 50 mg orally every day
8. Vitamin B12.
9. Fosamax 35 mg orally every week.
10. Protonix.
11. Isordil 40 mg orally three times a day
12. Aspirin 325 mg orally every day
13. Flovent.
ALLERGIES:
1. Diltiazem leads to slow junctional rhythm.
2. Quinine leads to headache.
PHYSICAL EXAM ON ADMISSION: Temperature 97 , blood pressure
106/52 , pulse 63 , respiratory rate 16 , saturation 94% on 2 liters
( the patient desaturated to 84% with minimal movement ). In
general , obese , tachypneic , ill-appearing woman. Neck veins
difficult to assess. CVS , distant heart sounds. Pulmonary ,
bibasilar rales. Abdomen , obese , nontender , nondistended with
positive bowel sounds. Extremities , 1+ bilateral edema. Neuro ,
alert and oriented x3 , no focal deficits.
Labs on admission were significant for white blood cell count
equal to 12 with 25% bands and 56% polys , troponin on admission
0.19.
HOSPITAL COURSE:
1. ID: The patient's decreased O2 saturation , chest x-ray
findings were all consistent with a left lower lobe pneumonia.
The patient was started on Levaquin for a seven-day course. The
patient's Levaquin was discontinued on 1/25/04 after a chest CT
showed no evidence of any further infiltrate in the left lower
lobe. The patient was able to be weaned off of oxygen and was
saturating in the high 90% at the time of discharge. The patient
also underwent urine , blood , and sputum cultures during this
admission , which showed no growth of any organism.
2. Pulmonary: The patient had a history of left upper lobe lung
cancer status post resection. The patient was continued on her
Flovent for management of likely COPD. She underwent a chest CT
during this admission , which showed no evidence a mass or
recurrence of her lung cancer.
3. Ischemia: The patient was found to have a troponin as high
as 23 during this admission and ruled in for a non-NSTEMI in the
setting of hypoxemia. The patient was continued on aspirin ,
statin beta-blocker and Ace inhibitor. She underwent a
dobutamine MIBI on 5/18/05 , which showed areas of periinfarct
ischemia most prominent at the anterior wall. The patient then
underwent a cardiac catheterization on 11/29/05 , which showed
left main disease at 50% as well as tight left circumferential
LAD and a 100% RCA lesion. The patient was then evaluated for
CABG in light of her three-vessel coronary artery disease. Due
to her multiple comorbidities , she underwent a preoperative
evaluation with the chest CT , carotid ultrasound , pulmonary
function test , and echocardiogram. The chest CT revealed no
evidence of lung cancer recurrence. Carotid ultrasound was
significant for bilateral ICA stenosis at 60%-65%. PFT showed an
FEV1 of 1.2 liters or 61% predicted with an FEV1/FVC ratio at 84%
predicted. The echo showed an EF of 55% with mild LVH , mild
hypokinesis of the inferior base and evidence of diastolic
dysfunction. Based on these test results , the patient was deemed
able to undergo CABG. The patient's surgery was scheduled for
6/19/05. The patient underwent preoperative evaluation by the
cardiac surgery team prior to discharged on 4/29/05.
4. Pump. On admission , the patient was thought to be volume
overloaded given her exam and chest x-ray findings. The patient
was given one dose of Lasix at 20 mg intravenous and had an adequate
diuresis. The patient was considered euvolemic during the rest
of her admission and required no additional doses of Lasix.
5. Rhythm. The patient was kept on telemetry during this
admission. There were no significant events and no EKG changes
outside of the increasing ST depression as seen on her admission
EKG.
6. Renal: The patient's initial creatinine on admission was
elevated at 1.6 from her baseline of 1.2. The patient's
creatinine trended down to 1.36 during the admission and remained
around her baseline until the time of discharge. Her creatinine
was closely monitored after cardiac catheterization and she
received mucomyst and intravenous fluids at the time of catheterization.
7. Endocrine: The patient was continued on her NPH and sliding
scale insulin during this admission. She was found to have an
enlarged thyroid on chest CT. Her TSH was found to be normal at
3.125. Her thyroid function should be followed as an outpatient.
8. Rheumatology. The patient has a history of PMR and was
continued on her prednisone dose at 10 mg every day
9. Code status: The patient remained a full code during this
admission.
MEDICATIONS AT DISCHARGE:
1. Tylenol 650 mg orally every 4 hours as needed headache.
2. Aspirin 81 mg orally every day
3. Dulcolax 10 mg orally every day as needed constipation.
4. Colace 100mg orally twice a day
5. Hydralazine 20 mg orally three times a day
6. NPH insulin 30 units , 16 units every afternoon subcutaneous.
7. Lisinopril 60 mg orally every day
8. Prednisone 10 mg orally every day before noon
9. Flovent 44 mcg inhaled twice a day
10. Fosamax 35 mg orally every week.
11. Atorvastatin 80 mg orally every day
12. Imdur 90 mg orally every day
13. Toprol XL 50 mg orally every day
14. Protonix 40 mg orally every day
15. Vicodin one tablet orally every 4 hours as needed back pain.
FOLLOW-UP PLAN: The patient will follow up with cardiac surgery
on 10/24/05 for admission for CABG. The patient will also follow
up with Dr. Gaylene Faniel , her primary care doctor on 6/9/05 at
8.30 a.m.
eScription document: 6-9602552 EMSSten Tel
Dictated By: BORDA , ANIKA
Attending: GILFOY , DEANDRA LAZARO
Dictation ID 2903566
D: 9/15/05
T: 9/15/05
Document id: 987
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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690475341 | PUO | 06815791 | | 4061080 | 8/21/2004 12:00:00 a.m. | SEVERE CARDIOMYOPATHY , CHEST PAIN , POSTIVE THALLIUM STRESS TEST | Signed | DIS | Admission Date: 11/13/2004 Report Status: Signed
Discharge Date: 10/28/2004
ATTENDING: CHRISTINE DARIO MD
DISCHARGE DIAGNOSES:
Anemia , GI bleed and CHF exacerbation.
HISTORY OF PRESENT ILLNESS:
This patient is a 64-year-old gentleman with multiple past
cardiovascular medical issues including hypertension , diabetes ,
hypercholesterolemia , nonobstructive CAD on prior catheterization
of 1993 and idiopathic cardiomyopathy with an ejection fraction
reported at baseline from the Land Medical Center to be
45% , prior echocardiogram in Pagham University Of from
1994 reported at 25 to 30% , question alcoholic cardiomyopathy ,
atrial fibrillation. He is status post right MCA CVA while on
Coumadin for atrial fibrillation and peripheral vascular disease ,
history of GI bleed who presented with increased shortness of
breath and cough x several weeks. He noted initial shortness of
breath and nonproductive cough in the end of 9/24 with a
question infiltrate on chest film at that time and the patient
was treated with a 10-day course of antibiotics of unknown
content question levofloxacin with no improvement. Since late
9/24 , the patient reports progressive shortness of breath ,
dyspnea on exertion particularly with ambulation of steps and
when lying down. Additionally , the patient reports a vague band
like pain discomfort over left anterior chest particularly
associated with ambulation of steps and when lying supine. Chest
pain is associated with shortness of breath , but denies
lightheadedness , diaphoresis or recent nausea and vomiting.
Symptoms of chest pain and shortness of breath are notably worse
over the last one to two weeks through the patient reports
resolution over the last 24 hours with question of a new
medication that he is unable recall. He denies palpitation or
raising heart rate. He does report orthopnea , denies PND , but
does report intermittent lower extremity swelling. He denies
hematochezia , bright red blood per rectum , hematemesis with
question of melanotic stools over the last month. The patient
also with a history of prior GI bleed while in Nah several
years prior for which he was transfused 4 units of packed red
blood cells. EGD colonoscopy at that time revealed both upper
and lower GI lesions including several small AVM and
diverticulosis. Additionally , upper GI endoscopy performed at
that time revealed duodenitis.
The patient was seen in a Land Medical Center today
reportedly in atrial fibrillation and atrial flutter. He had
previously been reported to be in this abnormal rhtyhm that
converted to normal sinus rhythm while on amiodarone. He was
noted to have rapid ventricular response in 120s. He had
appeared pale. Hematocrit obtained at that time reportedly 21.4
and the patient was admitted to the Pagham University Of
for further evaluation.
REVIEW OF SYSTEMS:
Of note , review of systems is positive for recent chills , no
fevers , reports intermittent productive cough and weakness and
fatigue. No weight loss over the last six months.
PAST MEDICAL HISTORY:
As given , hypertension , diabetes , hypercholesterolemia ,
nonobstructive CAD on prior catheterization in 1993 , IDCM with EF
of 30 to 45% , question alcoholic cardiomyopathy , atrial
fibrillation on Coumadin , right MCA CVA in 1999 , PVD , peptic
ulcer disease , history of GI bleed with duodenitis ,
diverticulitis and AVM and right hand partial hemiparesis and
depression.
MEDICATIONS ON ADMISSION:
1. Amiodarone 200 mg orally every day
2. Lasix 80 mg orally every day
3. Digoxin 0.25 mg orally every day
4. Niacin 750 mg orally twice a day
5. Amitriptyline 50 mg orally every day.
6. Folate B6.
7. Prilosec 20 mg orally twice a day
8. Avandia 4 mg orally twice a day
9. Valsartan 160 mg orally every day.
10. Nifedipine 90 mg orally every day.
11. Hydrochlorothiazide 25 mg orally every day
12. Bisoprolol 5 mg orally every day
13. Glucophage 500 mg twice a day
14. Gemfibrozil 600 mg orally every day.
15. Zoloft 50 mg orally every day
16. Ambien 10 mg every bedtime
17. Coumadin as needed.
18. Lisinopril 40 mg orally every day
ALLERGIES:
Reported isosorbide resulting in headache , amlodipine lower
extremity edema , Lopressor erectile dysfunction and Viagra , which
reportedly does not work for the patient.
SOCIAL HISTORY:
The patient has a 50-pack-year smoking history , continues to
smoke several cigarettes a day. Past alcohol abuse though the
patient reports no alcohol in the last 20 years. The patient
currently lives with his girlfriend of 45 years and is local to
Jowests
FAMILY HISTORY:
Family history is noncontributory. No history of a sudden
cardiac death.
PHYSICAL EXAMINATION:
Vital signs on admission include a temperature of 98 , heart rate
of 112 , blood pressure 168/90 , respiratory rate 20 93% on room
air. He was in no acute distress though the patient was seen to
be in shortness of breath when lying at 20 to 30 degrees. JVP on
admission 12 to 15 cm of water , difficult to assess given
habitus. The patient additionally with bibasilar rales ,
one-third to one-half up with poor air movement. No egophony or
consolidation was appreciated. Abdominal exam was unremarkable.
Lower extremities were warm and well perfused. He was able to
move all extremities , 4/5 strength in his right hand. He had
positive peripheral pulses and 1+ lower extremity edema , left
greater than right to mid calf.
LABORATORY DATA:
Laboratory values on admission are significant for creatinine of
1.8 of unknown baseline and glucose of 192. LFTs were within
normal limit. White count of 8.7 , hematocrit of 21.4 , down from
baseline of 30 to 35 and platelets of 351 , 000. MCV on hematocrit
was 84.
EKG on admission showed irregularly regular rhythm at 120 likely
atrial fibrillation versus atrial flutter with variable block , ST
segment depression laterally in V5 through V6 , question demand
ischemia versus digoxin effect , left bundle branch block which is
reportedly the patient's baseline. Chest film with vascular
prominence at the hilum bilaterally , question mass infiltrate
over left lower lobe with no overt effusions.
ASSESSMENT:
The patient is a 64-year-old gentleman with extensive past
cardiac and otherwise medical history presenting to the Pagham University Of with CHF exacerbation , anemia with question
GI bleed with hematocrit in the 20s and question
community-acquired pneumonia.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: The patient with no evidence of acute
coronary syndrome. On admission , the patient was noted to be in
a rapid ventricular response at 120 and with CHF exacerbation.
The patient initially with complaint of chest pressure , which was
concerning for demand ischemia in the setting significant anemia
with increased heart rate and known ventricular dysfunction.
Cardiac enzymes were drawn and serially were elevated with a peak
troponin I of 4. Subsequent serial cardiac enzymes resolved to
baseline values. The patient was initially started on heparin intravenous
drip for concern for unstable plaque , but following consultation
with Dr. Dario in Cardiology , it was recommended anticoagulation
be stopped secondary to recent GI bleed and low concern for acute
coronary syndrome versus demand ischemia. Additionally , the
patient was rate controlled with intravenous following orally Lopressor ,
digoxin and amiodarone. Additionally , the patient's ACE
inhibitor was continued and titrated up to lisinopril 40. The
patient was initially diuresed given significant volume overload
with intravenous Lasix with diuresis of 4 to 8 liters over the hospital
course. Echocardiogram obtained during decompensated episode
revealed EF of 25 to 30% with global hypokinesis and septal
akinesis , was significantly altered from prior echocardiogram of
9/16/03 obtained at the Land Medical Center which had
revealed an EF of 40 to 45% with mild global HK. However , of
note , this echocardiogram was similar to prior echocardiogram in
Pagham University Of system from 1994 with no additional
wall motion abnormalities. The patient's cardiovascular issues
felt to stem secondary to anemia in the setting of increased
ventricular response and tachycardia , which led to demand
ischemia and subsequent troponin leak causing decompensated CHF.
The patient's symptomatology resolved with proper rate control
and resuscitation with intravenous fluids and blood. The patient's heart
rate was well controlled in the 60s to 70s and following intravenous
diuresis , the patient's CHF symptomatology resolved. At the time
of discharge , the patient was ambulating without difficulty with
no oxygen requirement. The patient was transitioned to all orally
regimen.
2. Heme: The patient with recent GI bleed with known both upper
and lower GI lesions including AVM and diverticulosis for which
the patient has been previously treated. The patient's
hematocrit on admission 21.4. The patient received 4 units of
packed red blood cells to stable hematocrit of 29 to 30 x 72
hours. In addition , the patient was never hemodynamically
unstable during admission. GI bleed felt to be a precipitating
etiology. The patient was seen by the GI Service , was
recommended further outpatient evaluation and upper and lower GI
endoscopy evaluation as required. The patient to follow up with
Dr. Dario in the Land Medical Center and outpatient EGD
and colonoscopy to be scheduled for the next week or two to
further evaluate. At the time of discharge , the patient's
hematocrit stable at 29 , no evidence of active GI bleed present.
Additionally , the patient initially held on Coumadin giving
concern for ongoing GI bleed and following stable transfusion ,
the patient's Coumadin was restarted at initially 5 and then
later 3 mg orally every bedtime with INR goal of 2.8. To be further
evaluated as outpatient and INR to be checked on 5/11/04 in Dr.
Kangas office and titration of Coumadin as required.
3. GI: As mentioned prior , the patient with GI bleed , thought
to be precipitating etiology of the patient's current
hospitalization. The patient maintained on intravenous Protonix twice a day
and transitioned to orally Prilosec 40 mg orally twice a day As
mentioned , prior to GI consult , the patient will receive the
outpatient evaluation with EGD and colonoscopy as required for
further management.
4. Pulmonary: The patient with history of productive cough ,
fevers , chills. On admission , previously treated with course of
antibiotics , presumably Levaquin for presumed community-acquired
pneumonia giving ongoing symptomatology , the patient treated
initially with intravenous antibiotics including ceftriaxone and
azithromycin transitioned to cefpodoxime and azithromycin. The
patient to complete full 10-day course of antibiotics for
presumed community-acquired pneumonia. At the time of discharge ,
the patient afebrile , ambulating without difficulty , no dyspnea
on exertion and O2 saturation 95% on room air.
5. Psychiatry: The patient with long tobacco history given
extensive cardiovascular status , the patient received addiction
consultation regarding tobacco cessation. Following
consultation , the patient showing good promise regarding tobacco
cessation. He has expressed interest in doing so. As such , the
patient's antianxiety and depression medications have been
altered. The patient to decrease Zoloft to 25 mg orally every day from
50 and to continue that for seven days , following which time , he
should discontinue his Zoloft. Additionally , the patient started
on Wellbutrin initially 150 mg orally every day x seven days , to
transition up to twice a day as tolerated within seven days time as
Zoloft is discontinued , recommend further outpatient evaluation
as needed. The patient with several episodes of sundowning
during his hospital course , treated with Haldol with no further
incidents.
6. Endocrine: The patient with known diabetes , maintained on
Regular Insulin sliding scale with good blood sugar control. The
patient to continue on outpatient regimen of Avandia and
Glucophage. The patient may require additional anti-glycemic
medications in future as necessary.
7. Renal: The patient with chronicrenal insufficiency on
admission with a creatinine of 1.8 presumed baseline. At the
time of discharge , the patient's creatinine had resolved to 1.3 ,
thought to be secondary to cardiorenal syndrome in the setting of
acute CHF decompensation , recommend further outpatient management
evaluation. The patient to follow up with Dr. Dario in the Land Medical Center on 5/11/04 at 1:00 p.m. at which time ,
recommend further evaluation of hematocrit , INR , electrolyte as
required.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 81 mg orally every day.
2. Amiodarone 200 mg orally every day.
3. Lasix 80 mg p every day.
4. Digoxin 0.25 mg orally every day.
5. Niacin SR 750 mg orally twice a day
6. Amitriptyline 50 mg orally every day.
7. Folate B6.
8. Prilosec 40 mg orally twice a day up from 20 mg orally twice a day
9. Avandia 4 mg orally twice a day
10. Hold valsartan.
11. Hold nifedipine.
12. Hydrochlorothiazide 12.5 mg orally every day down from 25 mg every day.
13. Hold bisoprolol , instead substitute Toprol XL 100 mg orally
every day.
14. Glucophage 500 mg orally twice a day
15. Gemfibrozil 600 mg orally every day.
16. Zoloft 25 mg orally every day x seven days after which time it
should be discontinued.
17. Ambien 10 mg every bedtime
18. Coumadin 3 mg to be titrated outpatient.
19. Lisinopril 40 mg every day.
20. Wellbutrin SR 150 mg every day. x seven days after which time it
should be increased to twice a day
21. Amitriptyline 50 mg every bedtime
22. Nitroglycerin as needed
23. K-Dur 20 mEq every day.
24. Azithromycin 500 mg orally twice a day x five days.
25. Cefpodoxime 200 mg orally twice a day x five days.
As mentioned prior , at the time of discharge , the patient
afebrile and vital signs stable. The patient ambulating without
difficulty and feeling at baseline. The patient's O2 saturation
is greater than 95% with ambulation. The patient is to follow up
with Dr. Dario in the Land Medical Center with further
outpatient evaluation for GI bleed as potential source of anemia
as well as further cardiac work up including cardiac
catheterization at a later time given troponin leak in the
setting of demand ischemia. The patient was transitioned to all
orally regimen.
eScription document: 1-2680060 EMSSten Tel
Dictated By: GORGLIONE , JEANNETTE
Attending: DARIO , CHRISTINE
Dictation ID 0250791
D: 9/2/04
T: 9/2/04
Document id: 988
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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748699567 | PUO | 83028988 | | 502531 | 4/16/1997 12:00:00 a.m. | NON-Q WAVE MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/1/1997 Report Status: Signed
Discharge Date: 3/29/1997
PRINCIPAL DIAGNOSIS: ACUTE MYOCARDIAL INFARCTION.
SIGNIFICANT PROBLEMS: Diabetes mellitus.
HISTORY OF PRESENT ILLNESS: This is a 52 year old male with
insulin dependent diabetes mellitus ,
but no previous coronary artery disease or other cardiac risk
factors , who presented with 24 hours of chest pain he described as
starting on January in the evening , at rest , involving his
entire chest , as well as both arms , without any associated symptoms
of shortness of breath , nausea or vomiting , lightheadedness or
palpitations. He states that the discomfort was constant ,
nonpleuritic and not changed by position. The pain lasted all
night but he was able to sleep through this pain. He had no relief
with Tums on the morning of the 20 of September , and came into the Pagham University Of Emergency Room. At VH , an EKG showed flat to
inverted T waves laterally. In the Totin Hospital And Clinic Emergency
Room , he was given aspirin and oxygen with immediate improvement in
his pain from a 4/10 to 2/10 , and was made pain free after one
sublingual nitroglycerin. Again , he was observed for some time in
the emergency room until his first troponin came back positive at
28 , at which time he was admitted with a diagnosis of myocardial
infarction.
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus
complicated by peripheral neuropathy and
impotence. He also has a history of burns in July of '96
requiring skins grafts. He also has a history of obesity. Again ,
he has no prior coronary artery disease.
MEDICATIONS: NPH insulin 60 units in the morning and 30 units
in the evening.
ALLERGIES: None known.
PHYSICAL EXAMINATION: Patient's temperature is 99.4 , blood
pressure 160/86 , pulse 90. Room air
saturation is 93%. The patient is in no apparent distress. HEENT
exam is unremarkable. Cardiac exam shows a regular rate and
rhythm , no murmurs , rubs or gallops noted. Neck showed no jugular
venous distension. Carotids are 2+ without bruits. Pulmonary exam
is clear to auscultation. Abdomen showed normal active bowel
sounds , soft , nontender , nondistended. Extremities showed no
cyanosis , clubbing or edema noted. Neurologic exam was nonfocal.
On rectal exam , he was guaiac negative.
LABORATORY EVALUATION: CBC showed a white count of 11 , hematocrit
was 44.4 , and platelet count was 219.
Patient's troponin I on admission is 27.7. Peak CK during
admission was 977 with MB fraction of 28.5. Cholesterol was 170
with triglycerides being 134. Sodium was 139 , potassium 4.2 ,
chloride 100 , bicarb 24 , BUN 15 , creatinine 1.0 , glucose 283. EKG
showed normal sinus rhythm at 88 with , again , flat T waves to
interverted T waves in the lateral leads V4-V6. Chest x-ray showed
no active disease , no evidence of infiltrates or cardiomegaly or
effusions.
SOCIAL HISTORY: Patient smoked 1/2 pack per day of cigarettes
and quit in 1991. He occasionally drinks alcohol.
He lives with his family and he works in telecommunications. His
LDL was 123 in October of 1991.
FAMILY HISTORY: His uncle has coronary artery disease. No other
family members have coronary disease.
HOSPITAL COURSE: The patient was admitted on September , 1997 with a
diagnosis of acute non-Q wave MI. He was started
on intravenous heparin which was continued for 48 hours and then
discontinued. He was also started on aspirin , beta blocker.
Initially , Lopressor 25 mg four times a day which was converted to once a day
atenolol. The patient remained chest pain free throughout his
hospital course and developed no evidence of arrhythmia while on
the cardiac monitor. Since the patient had slightly high blood
pressures with systolics in the 160-170 range , he was started on
lisinopril 10 mg every day for his hypertension in a diabetic patient.
He also had nitropaste during his hospital stay. He was up in the
chair on day 3 , started ambulating on day 4. He underwent a submax
ETT prior to discharge , went 9 minutes without any chest pain or
EKG changes and was discharged to home on September , 1997. His
diabetes remained under good control while in the hospital. Also
during the hospital stay , the patient had an echocardiogram which
showed the following results: Ejection fraction was 53% with a low
normal systolic function and some posterior basal akinesis with
inferior hypokinesis and lateral hypokinesis. The plan for the
patient will be to follow up with Dr. Rufus Bernas and to undergo
and full ETT six weeks after his MI. Dr. Bernas will also check
the patient's lipid profile and start him on anticholesterol
medications as indicated.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg every day ,
atenolol 50 mg every day , lisinopril 10 mg
every day , sublingual nitroglycerin as needed chest pain , NPH insulin 60
units in the morning and 30 units in the evening.
Dictated By: JULIEANN R. GEEDING , M.D. ZK29
Attending: RUFUS C. BERNAS , M.D. XS9
HC321/1590
Batch: 36753 Index No. H8MC7QGO6 D: 5/4/97
T: 1/28/97
Document id: 989
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849420538 | PUO | 24466939 | | 6335692 | 9/10/2006 12:00:00 a.m. | OSTEOMYELITIS LT. FOOT | Signed | DIS | Admission Date: 5/5/2006 Report Status: Signed
Discharge Date: 4/11/2006
ATTENDING: MANKOSKI , ROSSIE MD
DATE OF ADMISSION: 4/5/06
DATE OF DISCHARGE: 2/29/06
HISTORY OF PRESENT ILLNESS:
This patient is a 72-year-old female with a left plantar fifth
metatarsal ulcer since 3/14 The patient previously had an
ulcer in the same area , which healed successfully. The patient
had recurrence of her neuropathic ulcer and it has worsened and
deepened with progression to osteomyelitis involving the
metatarsal phalangeal joint. The patient's wound healing has
been confounded by longstanding lower extremity edema and as
well as congestive heart failure and venous stasis. The
ulcer has been previously treated with debridement , however , in
5/23 , it became infected and the patient developed left lower
extremity cellulitis , which progressed to the knee. The patient
was treated with antibiotics and subsequently developed profuse
diarrhea and was found to have a Clostridium difficile infection.
The patient was treated with orally Flagyl and vancomycin. She
presents on admission with continued loose stool. The patient
had previously undergone a three-phase bone scan , which was
positive for osteomyelitis and then confirmed by a gallium scan.
The patient has had decreased sensation from bilateral mid tibia
extending distally and denies pain. The patient is admitted from
a rehabilitation facility where she undergoes physical therapy.
At baseline , the patient has poor ambulation and is wheelchair
bound. The patient's cardiovascular risk factors include her
diabetes , venous stasis , coronary artery disease , hypertension ,
elevated cholesterol , and neuropathy.
PAST MEDICAL HISTORY:
1. Lower extremity edema and venous stasis.
2. Right knee gout.
3. Ischemic cardiomyopathy , requiring AICD.
4. Status post removal of thyroid tumor.
5. Status post triple bypass coronary artery bypass graft
surgery.
6. Status post multiple myocardial infarctions.
7. Status post placement of coronary stents.
MEDICATIONS ON ADMISSION:
Atorvastatin 20 mg orally at night , gabapentin 300 mg orally at
bedtime , allopurinol 150 mg orally daily , torsemide 50 mg orally
twice a day , Lopressor 12.5 mg orally twice a day , fentanyl patch 50 mcg an
hour every 72 hours , potassium chloride 80 mEq daily , omeprazole 20 mg
daily , Colace 100 mg twice a day , vancomycin 250 mg orally three times
a day , Flagyl 500 mg three times a day , NPH insulin 25 units in
the morning , and oxycodone 5 mg every 4 hours as needed pain.
ALLERGIES:
Sulfa causes angioedema.
OPERATIONS AND PROCEDURES:
On 5/5/2006 , the patient underwent debridement of her left foot
and amputation of the left fifth metatarsal phalangeal joint. On
10/19/2006 , the patient underwent closure of her wound.
OTHER TREATMENTS AND PROCEDURES:
CT angiogram:
1. Diffuse atherosclerotic disease with multiple focal areas of
mild-to-moderate stenosis seen in the origin of the SMA ,
bilateral renal arteries , common and superficial femoral arteries
and popliteal arteries.
2. Occlusion of the mid third of the posterior tibial artery
with distal reformation on the right side.
3. Three-vessel run off in the left leg.
HOSPITAL COURSE:
The patient was admitted to the Vascular Surgery Service on
5/5/2006 after undergoing her amputation. No concerning
intraoperative events occurred; please see dictated operative
note for details. She was transferred to the floor from the PACU
in stable condition. The patient had adequate pain control and
was tolerating a regular diet by postoperative day #0. She was
placed on a fluid restriction in light of her congestive heart
failure. The patient's wound was clean with no evidence of
hematoma collection. She underwent wet-to-dry dressing changes
three times a day The patient underwent a CT angiogram to evaluate her
lower extremity vasculature; please see the results noted above
in the procedure section. In summary , the patient's three-vessel
run off to the left lower extremity indicated that she would not
likely need a bypass for wound healing at this time. In
addition , because the patient's wound was clean , Dr. Loerwald deemed
that it is appropriate to proceed the closure of the wound. As a
result , on 10/19/2006 , the patient returned to the operating room
and underwent closure of her wound; please see Dr. Varel 's
dictated operative note for details of this procedure. Following
both of the patient's procedures , her pain was well controlled
with orally pain medications. The patient's cardiovascular status
remained stable postoperatively. She did continue on her
home/rehabilitation facility medication regimen for her
cardiovascular issues. The patient remained stable from a
respiratory standpoint. The patient did continue to have loose
bowel movements during her hospital stay. She continued on her
admission regimen for Clostridium difficile , which consisted of
orally Flagyl and orally vancomycin. There were multiple attempts to
save a stool specimen; either the patient did not save the stool
at times or it was mixed with copious amounts of urine. As a
result , a Clostridium difficile test is pending at the time of
discharge and will need to be followed up for test of cure while
at rehabilitation. The patient's hemodynamic status was
monitored closely as well as her fluid status. The patient was
placed on a 1500 mL fluid restriction due to her CHF. The
patient did have a slight rise in her creatinine from 1.4 to 1.8 ,
at the time of discharge , the patient's creatinine was trending
back down to 1.4. The patient's electrolytes were monitored and
repeated as necessary during her hospital stay. The patient
received subcutaneous heparin for DVT prophylaxis while as an
inpatient. The patient's cultures from the operating room were
positive for MRSA , and as a result , she continued on intravenous
vancomycin. The patient is to continue her intravenous vancomycin regimen
through follow up with Dr. Loerwald in clinic. The patient was seen
by the Diabetes Management Service for evaluation of her diabetes
as her blood sugars were elevated on her admission regimen. As a
result , the Diabetes Management Service recommended a regimen
consisting of 25 units of NPH in the morning , 8 units of NPH at
bedtime , a standing NovoLog regimen of 4 units with meals in
addition a NovoLog sliding scale with meals and at bedtime. The
remainder of the patient's hospital course was relatively
unremarkable and she is to be discharged in stable condition back
to rehabilitation with adequate pain control. The patient was given explicit
instructions to follow up in clinic with Dr. Loerwald in one to two weeks.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours as needed pain.
2. Aspirin 325 mg orally daily.
3. Allopurinol 100 mg orally daily.
4. Atorvastatin 20 mg orally at bedtime.
5. Colace 100 mg orally twice a day
6. Fentanyl patch 50 mcg an hour every 72 hours
7. Gabapentin 300 mg orally at bedtime.
8. NovoLog sliding before meals and at bedtime.
9. NovoLog 4 units before meals
10. NPH insulin 25 units every morning.
11. NPH insulin 8 units at bedtime.
12. Potassium chloride immediate release 40 mEq by mouth twice a
day.
13. Lopressor 12.5 mg twice a day.
14. Flagyl 500 mg orally three times a day.
15. Omeprazole 20 mg orally daily.
16. Oxycodone 5-10 mg orally every 4 hours as needed pain.
17. Torsemide 50 mg orally twice a day
18. Triamcinolone 0.1% topical daily applied bilaterally to the
shin.
19. Vancomycin 1 g intravenous every 24 hours , the patient is to continue this
medication through follow up with Dr. Lavee , at which time , he
will determine the length of treatment.
20. Vancomycin 250 mg orally every 6 hours
PENDING RESULTS:
At the time of dictation , the patient has a stool specimen on the
way to the microbiology lab , which will need to be followed up
for test of cure.
PHYSICIAN FOLLOW-UP PLANS:
The patient is to follow up with Dr. Loerwald in approximately one
to two weeks for evaluation of her wound and length of treatment
with intravenous vancomycin.
DISPOSITION:
The patient is discharged to rehabilitation.
eScription document: 3-6456177 EMSSten Tel
Dictated By: SPRATTE , DESIRE
Attending: MANKOSKI , ROSSIE
Dictation ID 2109648
D: 2/29/06
T: 2/29/06
Document id: 990
| Target |
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CHF |
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HTG |
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OSA |
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| output/system_textual_annotation.xml | textual |
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U |
U |
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U |
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603811453 | PUO | 24311948 | | 8779035 | 3/11/2006 12:00:00 a.m. | CRITICAL AORTIC STENOSIS | Signed | DIS | Admission Date: 5/25/2006 Report Status: Signed
Discharge Date: 7/21/2006
ATTENDING: BARRETTE , GENNY MD
SERVICE: Cardiac Surgery Service.
DISPOSITION: To rehabilitation.
PRINCIPAL DISCHARGE DIAGNOSES: Status post AVR with a 23 CE , MVP
with 38 CE , and CABG x1/LAD endarterectomy.
HISTORY OF PRESENT ILLNESS: Mr. Kubat is an 88-year-old male
with chronic atrial fibrillation , CAD and aortic stenosis since
1989 and being followed by a cardiologist in Ent Mond Des who
presented to Ganeviewe in Bebu Knik St , Conwood on 9/27/06 with chest pain
and shortness breath. Until 3/22 , he had been feeling generally
well without limiting dyspnea , fatigue , or chest pain. Since
then he has had two inpatient admissions in Rance La Sona Ra for
CHF. He complains of marked increase in dyspnea on exertion and
fatigue as well as PND/nocturia for the past three to four
months. He developed chest pressure and shortness of breath in
early morning of 9/27/06 and was subsequently brought by EMS to
Ganeviewe During admission , verapamil and isosorbide were
discontinued and he was started on low-dose beta-blocker. He was
also given diuretics for CHF with net 3 L negative balance. He
was also ruled out for acute myocardial infarction. His echo
showed critical aortic stenosis with a valve area 0.44 sq cm , EF
of 55% , moderate MR with valve area 3 sq cm with TR and moderate
pulmonary hypertension. He was then transferred to PUO for
cardiac catheterization and possible valvuloplasty.
PREOPERATIVE CARDIAC STATUS: Elective. The patient presented
with critical coronary anatomy/valve dysfunction. There is a
history of class III heart failure. Recent signs and symptoms of
congestive heart failure include paroxysmal nocturnal
dyspnea/dyspnea on exertion/pulmonary edema on chest x-ray/pedal
edema. The patient is in atrial fibrillation. The patient has a
history of atrial fibrillation/flutter treated with drugs/beta
blocker.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: Cardiac cath in 1981
reportedly with 40% lesion in an unknown vessel.
PAST SURGICAL HISTORY: Wide excision of melanoma in 1980.
FAMILY HISTORY: No family history of CAD.
SOCIAL HISTORY: Lives with his wife who has macular degeneration
and has children. He quit smoking in 1950s. The patient is a
retired mechanical engineer.
ALLERGIES: No known drug allergies.
PREOP MEDICATIONS: Lopressor 25 mg daily , Coumadin , Lasix 40 mg
twice a day , simvastatin 20 mg daily , Colace , MVI , and folate.
PHYSICAL EXAMINATION: Height and weight , 5 feet 9 inches and 60
kg. Vital Signs: Temperature 99 , heart rate 88 , BP right arm
121/80 , left arm 118/78 , oxygen saturation 100% on room air.
HEENT: PERRLA/dentition without evidence of infection/no carotid
bruits. Chest: No incisions. Cardiovascular: Irregular
rhythm , systolic murmur. All distal pulses are intact.
Respiratory: Rales present bilaterally. Abdomen: No incisions ,
soft , no masses. Extremities: Without scarring , varicosities ,
or edema. Neuro: Alert and oriented , no focal deficits.
PREOPERATIVE LABORATORY DATA: Chemistries: Sodium 134 ,
potassium 4.4 , chloride 102 , CO2 27 , BUN 24 , creatinine 0.6 ,
glucose 113 , and magnesium 2.0. Hematology: WBC 9.43 ,
hematocrit 38.2 , hemoglobin 13.5 , platelets 126 , 000 , physical therapy 15.9 , INR
1.3 , PTT 76.1. UA was normal. Cardiac catheterization data from
5/23/06 performed at PUO showed coronary anatomy 60% proximal
LAD , 70% ostial D1 , left dominant circulation. Echo from
2/21/06 showed 55% ejection fraction , aortic stenosis , mean
gradient 80 mmHg , peak gradient 121 mmHg , calculated valve area
0.4 sq cm , moderate mitral insufficiency , moderate tricuspid
insufficiency , left ventricular enlargement , hypertrophied with
reasonable systolic function , severe aortic stenosis , and
moderate mitral regurgitation. There is a markedly left atrial
enlargement , which is probably secondary to pulmonary
hypertension. EKG from 3/15/06 showed atrial fibrillation rate
of 78 , septal infarct. Chest x-ray from 10/3/06 was consistent
with CHF. The lungs are well expanded , stable. Multiple chamber
cardiac enlargement is seen. The bilateral small pleural
effusions decreased in size. No pneumothorax was identified. No
focal consolidation was seen. The patient was admitted to CSS
and stabilized for surgery.
DATE OF SURGERY: 8/16/06.
PREOPERATIVE DIAGNOSIS: CAD , AS , MR.
PROCEDURE: An ascending aortic resection/AVR with a 23 CE
pericardial valve , MVP with 38 CE ring and ring annuloplasty ,
CABG x1 SVG1 to LAD and LAD endarterectomy.
BYPASS TIME: 303 minutes.
CROSSCLAMP TIME: 225 minutes.
CIRC ARREST: 7 minutes.
There were no complications. The patient was transferred to the
unit in stable fashion with lines and tubes intact. On postop
day #1 in the unit , chest x-ray/EKG within normal limits ,
bilateral lower extremities mottled to stable , good pedal pulses
bilaterally. Continuing to monitor. On postop day #2 ,
hematocrit 25.3 , transfused two units PRBC. Hemodynamically
stable. On postop day #3 , extubated , off pressors. Failed video
swallow evaluation. He was transferred to Step-Down Unit on
postoperative day #3.
SUMMARY BY SYSTEM:
Neurologic: No issues.
Cardiovascular: No issues. On aspirin , Lopressor , and Coumadin.
Respiratory: No issues. Have been extubated on postop day #2.
GI: N.orally Video swallow showed aspiration. Nutrition will
continue to follow with recommendations.
Renal: No issues.
Endocrine: No issues.
Hematology: Anticoagulated with aspirin and Coumadin. Recent
mitral valve repair/atrial fib.
ID: No issues.
Of note , recent video swallow , the patient needs Dobbhoff tubes
for meds orally until Nutrition gives further Rx.
On the Step-Down Unit , starting postop day #3 , no narcotics. An
88-year-old status post circ arrest confused , impulsive and on
sitter , Pacing wire remains in place.
On postop day #4 , rate controlled A fib , hypertensive , added
low-dose captopril to Lopressor 12.5 four times a day , diuresing well ,
remains on 1.5 L O2 , strict npo for aspiration per Speech and
Swallow. On tube feeds via Dobbhoff , confusion improving , no
narcotics/sedatives. UA sent for MS changes , negative for UTI.
Wires discontinued. Coumadin for A fib. Rehabilitation
screening initiated.
On postop day #5 , rate controlled A fib , Coumadin. BP still
hypertensive , increased captopril to 12.5 three times a day Ambulating with
physical therapy on room air. Dobbhoff in place. All meds/nutrition via
Dobbhoff. Postop echo ordered for MVP. Off sitters today , clear
mental status. No narcotics/sedatives. UA clean.
On postop day #6 , rate controlled A fib. BP improved on
captopril. Cards following , recommending to preferentially
increase Lopressor and decrease captopril as tolerated. Of note ,
the patient has been quite hypertensive this week with heart rate
well controlled even low-dose Lopressor. Increased Lopressor to
25 mg four times a day , captopril 12.5 three times a day Creatinine 0.4 , has diuresed
well. Postop echo with an EF of 45% to 50% , moderate LVH ,
hypokinetic anterior septal and inferior wall , normal RV. Severe
LAE and RAE , paravalvular leak seen at AVR with mild AI , trace
MR , mild TR. Also has large left pleural effusion , was seen on
echo. Only small bilateral effusions were seen on chest x-ray.
The patient's main issue now is physical therapy and Speech and Swallow
reassessment. Dobbhoff was repositioned today for tube in
stomach with tip newly pointing upwards into the esophagus.
Post-repositioning KUB shows tip now downwards in stomach. Given
some Reglan to advance. Clear mental status. Junky cough cannot
produce sputum for sample. Afebrile. White count 9.8.
Nutrition and EMS Rx followed , has recovered very well ,
ambulating on room air.
On postop day #7 , repeat video swallow scheduled for Monday.
Coumadin started. Coumadin continued and started Plavix for LAD
endarterectomy , off aspirin. Possible PEG placement pending
video swallow results. Repeat chest x-ray with minimal left
effusion.
On postop day #8 , holding Coumadin for possible PEG next week
pending video swallow on Monday. No heparin for now per Dr.
Verda Triarsi
On postop day #9 , tube feeds off at midnight , getting repeat
video swallow on a.m. for speech and swallow. Holding Coumadin ,
which was given for chronic A fib pending possible PEG placement.
On postop day #10 , A fib/room air. Video swallow study showed
improvement , but patient still silently aspirating. Speech and
swallow recommends PEG and continued work with Speech and Swallow
for eventual goal of patient taking orally's. Contacted Metabolic
Support. They will send someone to evaluate the patient for PEG ,
so the procedure will likely take place on Wednesday or Thursday.
On postop day #11 , A fib/room air , feeding tubes were part way
out , readvanced and got KUB showing good placement. Metabolic
support evaluated the patient , got consent for PEG.
On postop day #12 , A fib/room air , holding tube feeds and
Coumadin for PEG placement , scheduled for 10 a.m. Thursday. No
heparin per Dr. Denmark May go to rehab once INR therapeutic for
A fib. The patient had a four-beat run of VT.
On postop day #13 , he was supposed to have PEG placed today.
Metabolic support said that someone called the OR desk yesterday
and canceled the procedure , so it was rescheduled for Tuesday due
to no OR availability. Otherwise , the patient was supposed to
have repeat video swallow next week. Hemodynamically stable.
Holding Coumadin. Rehabilitation when ready.
On postop day #14 , PEG tube placement rescheduled for next
Tuesday , giving low-dose Coumadin for A fib , at goal tube feeds
through Dobhoff , hemodynamically stable.
On postop day #15 , doing well. General surgery consult called to
try and get PEG placed earlier the next Tuesday. Dr. Verda Triarsi will do it either tomorrow or Monday at the latest.
Otherwise , doing well , npo after midnight. Hopefully , he will
get PEG and can go to rehabilitation.
On postop day #16 , tube feeding restarted. PEG placement
tomorrow. Otherwise , doing well , rate controlled A fib.
Rehabilitation once PEG tube placed.
On postop day #17 , finally received peg today , currently on D5 in
a half at 50 mL an hour , okay to give meds through PEG and can
restart tube feeds tomorrow. NG tube out. Coumadin to restart
tonight. physical therapy/rehabilitation screening.
On postop day #18 , started tube feeds this morning , advancing
rate without difficulty. The patient ambulating with assistance ,
rate controlled A fib/2 L O2 stable. Plan to rehab tomorrow.
The patient was evaluated by Cardiac Surgery Service to be stable
to discharge to rehabilitation on postop day #19 with the
following discharge instructions.
DIET: Tube feeds order as written.
FOLLOWUP APPOINTMENTS: Dr. Barrette 117-219-4079 in five to six
weeks , Dr. Kolich 575-803-4363 in one to two weeks , Dr. Maller
302-287-1135 in one to two weeks.
TO DO PLAN: Make all followup appointments. Wound Care: Wash
wounds daily with soap and water , shower patient daily. PEG Site
Care. Watch all wounds for signs of infection ( redness ,
swelling , fever , pain , discharge ). Keep legs elevated while
sitting/in bed. Call primary care physician/cardiologist or PUO Cardiac Surgery
Service at 766-081-5735. INR goal of 2 to 3 for atrial
fibrillation and prosthetic valve replacement
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325/650 mg orally every 4 hours as needed pain or
temperature greater than 101.
2. Dulcolax 5-10 mg orally daily as needed constipation.
3. Dulcolax rectal 110 mg PR daily as needed constipation.
4. Plavix 75 mg daily.
5. Colace 100 mg three times a day as needed constipation.
6. Nexium 20 mg daily.
7. Folate 1 mg daily.
8. Ibuprofen 200-400 mg every 8 hours as needed pain.
9. Insulin at 4 units subcutaneously every 4 hours
10. Insulin regular human sliding scale every 4 hours
11. Atrovent nebs 0.5 neb four times a day
12. Potassium chloride immediate release 20 mEq daily.
13. Milk of magnesia 30 mL four times a day as needed constipation.
14. Lopressor 12.5 mg four times a day
15. Niferex 100 mg/5 mL 100 mg three times a day
16. Nystatin suspension 5 mL four times a day swish and spit for orally
thrush.
17. Simvastatin 5 mg nightly.
18. Multivitamin therapeutic 5 mL three times a day
19. Thiamine HCL 100 mg daily.
20. Coumadin with variable dosage to be determined based on INR.
21. Enteric-coated aspirin 81 mg daily.
eScription document: 5-6839861 CSSten Tel
Dictated By: CRIDGE , LORRETTA PA
Attending: BARRETTE , GENNY
Dictation ID 3534877
D: 8/24/06
T: 8/24/06
Document id: 991
| Target |
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PVD |
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062547234 | PUO | 39316276 | | 2638315 | 3/23/2005 12:00:00 a.m. | AORTIC STENOSIS , MITRAL REGURGITATION , TRICUSPID INSUFFICIENCY , ?CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 3/23/2005 Report Status: Unsigned
Discharge Date: 11/5/2005
ATTENDING: COLASAMTE , ISABELLE EVON MD
ADMITTING DIAGNOSIS: Aortic insufficiency , mitral insufficiency , tricuspid
insufficiency and atrial fibrillation.
HISTORY OF PRESENT ILLNESS: This 78-year-old male with long
history of moderate mitral regurgitation as well as aortic
regurgitation. He was noted on EKG in 2003 to be in atrial fibrillation
was asymptomatic at that time. The patient also in October of
2005 had an acute MI and at that time underwent angioplasty and
stent placement with a drug-eluting stents of the LAD and the
diagonal arteries. He on admission was not on any Plavix for the
stents. He has been in congestive heart failure with
multivalvular dysfunction now noted to have severe pulmonary
hypertension with estimated PA pressures in 99 mmHg plus RA
pressures and referred for surgical repair of his valves.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for the aortic , mitral , and tricuspid regurgitation as
stated above with high PA pressures as well as atrial
fibrillation also as stated above , status post angioplasty with
drug-eluting stents of his LAD and diagonal arteries. The
patient also has a history of hypercholesterolemia , recent
immunosuppressive therapy with prednisone 20 mg orally twice a day for
ITP. The patient also is in atrial fibrillation with Coumadin
therapy. The patient has history of squamous cell carcinoma of
his left tonsils requiring XRT. His creatinine clearance is
estimated as 55 mL per minute.
PAST SURGICAL HISTORY: Bilateral inguinal hernia repairs in 1960
and 1990 , wisdom teeth extractions in 2/27/05.
FAMILY HISTORY: Coronary artery disease. Father had sudden
death without any obvious cause at the age of 62 and mother died
of colon cancer at the age of 65.
SOCIAL HISTORY: History of tobacco use. History of cigar
smoking.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Toprol 100 mg orally once a day , Mavik 4
mg orally twice a day , aspirin 81 mg orally once a day with Coumadin orally once a day ,
Lasix 80 mg orally once a day , prednisone 20 mg
orally twice a day and Lipitor 10 mg orally once a day , Zantac 150 mg orally
twice a day and Lipitor 10 orally at bedtime.
PHYSICAL EXAMINATION: He is 6 foot 2 inches , 71 kilograms.
Temperature of 98 , heart rate of 78 , blood pressure in the right
arm of 102/62. Blood pressure on the left arm 104/62 , O2 sat of
98. HEENT: PERRLA , dentition without evidence of infection. No
carotid bruit. Chest: No incision. Cardiovascular: Irregular
rhythm with a systolic ejection murmur noted that is
holosystolic. Pulses , 2+ pulses bilaterally of the carotid ,
radial and femoral and 1+ bilaterally of the dorsalis pedis and
posterior tibial. Allen's test of left upper extremity is
indicated as poor waveform as well as the right. Breath sounds
clear bilaterally. Abdomen: Status post bilateral inguinal
hernia repair , soft , no mass noted. Rectal: Deferred.
Extremities: Without scarring , varicosity , or edema. Neuro:
Alert and oriented with no focal deficits.
LABORATORY DATA:
On 10/10/05 , chemistries: Sodium of 135 , K of 4.5 , chloride of
100 , CO2 of 30 , BUN of 44 , creatinine 1.1 , glucose of 124 , and
magnesium of 2.4. Hematology from 11/18/05 , white count of 9.4 ,
hematocrit of 39 , hemoglobin of 13 , platelets of 120 , the physical therapy ,
INR , and PTT from the day before of the 28 of November , the preop values physical therapy
of 16 , INR 1.3 , and PTT of 22.9. Echo on 6/6/05 , left
ventricle was moderately dilated. Overall LV function was low normal ,
the estimated EF of 50-55. The ventricle was
mildly hypokinetic with regional variation and right ventricle
size is mildly enlarged , global right ventricular systolic
function is moderately reduced. The left atrium is moderately
dilated and right atrium is moderately dilated. The aortic valve
is trileaflet calcified and mild-to-moderate aortic regurgitation
as noted. Mitral valve is thickened and mildly retracted with
malcoaptation , moderate-to-severe mitral regurgitation in some
views. The valve does not appear to coapt. Tricuspid valve is
structurally normal , but severe tricuspid regurgitation is noted
with PA pressures of 99 mmHg plus right heart pressures.
Pulmonic valve is indicated as normal with mild pulmonic
regurgitation. Aortic root size is normal measuring 3.6 cm , PA
arteries normal size , inferior vena cava is noted to be dilated ,
but not pulsatile. EKG on 5/25/05 , atrial fibrillation at the
rate of 70. Chest x-ray showed cardiomegaly.
HOSPITAL COURSE: The patient was admitted on 10/10/05 and
underwent a cardiac catheterization which showed 25% proximal
LAD , 30% mid RCA , right dominant circulation. The ventriculogram
showed an ejection fraction of 64%. Hemodynamics PA mean of 22 ,
pulmonary capillary wedge of 7 , cardiac output of 4.0 , cardiac
index of 2.1 and an SVR of 1239 and PVR of 319 with moderate
aortic insufficiency and moderate mitral insufficiency. The
patient was taken to the operating room on 11/18/05 , and
underwent an aortic valve replacement with a 23
Carpentier-Edwards magna valve and a mitral valve repair with a
23 CarboMedics AnnuloFlex ring and a tricuspid valve repair. The
patient also had bilateral maze procedure with also resection of
the left atrial appendage , as well as his right atrial appendage.
The patient had two A-wires and ventricular wire placed and was
initially paced after the maze procedure. The patient came off
the heart lung machine on epinephrine , levo , and
milrinone and was taken up to the Cardiac Intensive Care Unit and
extubated on late postop day #1. The patient's hospital course
by systems ,
Neurological: The patient remained intact with no focal
deficits , however , the patient experienced dysphasia due to his
tonsil cancer status post XRT , failing speech and swallow and
finally requiring a PEG placement for nutritional support.
Cardiovascular: The patient was status post a maze procedure and
initially was paced and found to be in a junctional rhythm at 60
then recovery of normal sinus rhythm , however , postoperatively
had gone into a rate controlled atrial fibrillation requiring
low-dose beta-blocker as well as anticoagulation. However , he
did see few episodes of sinus rhythm and currently on discharges
in sinus rhythm and rate controlled on low-dose beta-blocker.
The patient did have an echo postoperatively to evaluate his
valve replacement and repair and found to have normal LV size and
function with an EF of 55%. The patient had mild RV enlargement ,
mild left atrial enlargement as well as right atrial enlargement.
The aortic valve was noted to be well seated with trace AI ,
mitral valve status post repair showed mild mitral regurgitation ,
tricuspid valve status post repair showed mild tricuspid repair
with PA pressures of 40 mmHg. There was no pericardial effusion
found and patient will be discharged on low-dose beta-blocker as
well as anticoagulation.
Respiratory: Patient was extubated on late postoperative day #1
and patient was on Lasix for diuresis postoperatively. The
patient , however , on postoperative day #10 , was noted to have a
temperature and culture showed that he had enterobacter in his
sputum and is being treated with ceftriaxone for a 14-day course.
His discharge chest x-ray shows no evidence consolidation and
mild atelectasis at the left base , no pulmonary edema noted.
GI: The patient had a history of GERD and was on Zantac
preoperatively and was on proton pump postoperatively and
switched over to Pepcid for GI prophylaxis. The patient also was
closely followed by the speech and swallow team and due to his
dysphagia status post squamous cell carcinoma resection of his
left tongue and XRT , patient continues to have dysphasia , unable
to protect his airway and by postoperative day #14 underwent a
PEG placement and now at goal of 70 mL per hour to see if he is
tolerating without any problems. The patient however was on
diuresis for a period of time and required few doses of fluid
bolus for his volume status.
Renal: The patient had a stable BUN and creatinine throughout
his postoperative course , was on Lasix for diuresis postop
without no elevation in his creatinine.
Endocrine: The patient was on portland protocol intraoperatively
and switched over to sliding scale insulin postoperatively due to his
tube feeds. He is on regular insulin standing now at 6 units
with sliding scale for coverage.
Heme: The patient was noted to have a drop in his platelets
postoperatively. Two hit screens were sent which were found to
be negative and patient had recovery of his platelets with
discharge platelets of 196. The patient will be discharged on
Coumadin for atrial fibrillation. Today's INR is 2.1 and he will
be getting his preop dose of 2.5 mg tonight and to follow closely
with his INR. He is also on baby aspirin for his coronary artery
disease and patient was not on Plavix for his stent
preoperatively and will not be on discharge.
ID: The patient received vancomycin for surgical prophylaxis.
On postoperative day #10 , the patient was noted to have a
temperature of 101 and was cultured. Sputum grew out
enterobacter and patient was started on ceftriaxone and will
complete a 14-day course of ceftriaxone. The patient during that
time received neb treatments , chest physical therapy and is still
continuing to bring up some secretion. The patient was noted
also to have a heel blister on his left heel which was debrided
and now is very clean and dry ulcer that was evaluated by the
skin nurse and felt that Xeroform would be the best treatment at
this time and the legs should be elevated on pillows to relieve
any pressure off of the heel for continual healing and
prevention or breakdown. The patient is in stable condition and
has been accepted to a rehab bed on postoperative day #20 and
will be discharged to the rehab facility in stable condition on
these following medications.
DISCHARGE MEDICATIONS:
Acetaminophen 325 mg to 650 mg orally every 4 hours as needed fever , enteric
coated aspirin 81 mg orally once a day , ceftriaxone 2000 mg intravenous
daily x3 more dose to complete a 14-day course , Colace 100 mg
orally three times a day , Pepcid 20 mg orally twice a day , insulin scale as well as
insulin regular at 6 units subcutaneously every 6 hours , but to hold when tf are off ,
lisinopril 5 mg orally once a day , Lopressor 12.5 mg orally four times a day ,
Niferex 150 mg orally twice a day , prednisone 20 mg orally twice a day , Ocean
spray inhaler four times a day x5 days , DuoNeb inhaler as needed wheezing ,
Lipitor 10 mg orally once a day , Coumadin to take as directed
tonight's dose will be 2.5 mg orally once a day.
FOLLOW-UP APPOINTMENTS:
The patient should follow his Coumadin dosing as he did
preoperatively with his primary care physician , Dr. Brend
His phone number is ( 614 ) 512-3688. The patient should also make
these follow-up appointments with his cardiologist , Dr.
Meduna in two weeks. His phone number is ( 318 ) 792-6534.
If he is unable to make this appointment , he should see his primary care physician ,
Dr. Neblett in two weeks. He should also make an appointment
with his primary care physician in two to four weeks for evaluation. His phone
number is ( 614 ) 512-3688. The patient should follow up with Dr.
Colasamte in six weeks for postsurgical evaluation. His phone
number is ( 934 ) 007-9881.
DISPOSITION:
This is Tomika Afzal , PA , completing a discharge summary on
Dovie Masella who will be discharged to the rehab facility in
stable condition on postop day #20.
eScription document: 1-6682976 JSSten Tel
Dictated By: AFZAL , TOMIKA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 2351700
D: 1/14/05
T: 1/14/05
Document id: 992
| Target |
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938996420 | PUO | 49555188 | | 359807 | 1/10/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/9/1993 Report Status: Signed
Discharge Date: 2/13/1993
SERVICE: MEDICINE
PRINCIPAL DIAGNOSIS: CHRONIC OBSTRUCTIVE PULMONARY DISEASE
EXACERBATION.
PROBLEM LIST: 1. POLYMYALGIA RHEUMATICA.
2. LUMBAR DISK DISEASE.
3. HYPERTENSION.
4. COR PULMONALE.
5. TOBACCO SMOKER.
HISTORY OF THE PRESENT ILLNESS: The patient is a 62 year old woman
with a history of chronic
obstructive pulmonary disease who presented to the Emergency Ward
with a chronic obstructive pulmonary disease exacerbation. She was
intubated for somnolence and worsening respiratory acidosis , and
transferred to the MICU. She had never had any intubations
previously. She is an active smoker with a long history of chronic
obstructive pulmonary disease who is followed by Dr. Reyes Mcpeck
Most recently , she was admitted on 8/5/92 for a chronic
obstructive pulmonary disease exacerbation which was treated with
aggressive bronchodilators. Her baseline ABG on discharge was
7.39 , pC02 51.1 , and a p02 of 66 with 91.3% 02 saturation. She had
a previous sleep apnea study on 5/25 which was negative. Her
most recent thyroid function tests on 8/6 revealed an FEV1 of 38%
and an FVC of 51% , with an FEV1/FVC of less than 80%. This was
felt to be consistent with a mixed obstructive/restrictive pattern.
She has been treated with Theophylline and Proventil as well as
home nebulizers , Lasix , and 02 overnight. She continues to smoke
as well as noted above. She has had frequent episodes of cough and
productive sputum as well as lower extremity edema. She now
presents with one to two weeks of increase in her postnasal drip ,
denying any change in her cough or sputum production although she
did note a slightly increased temperature. She began to become
more short of breath and was taken to the Emergency Ward by her
sister. There , she was found to be cyanotic with an 02 saturation
of 59%. Her first blood gas on 50% was 7.27 , pCO2 79 , p02 78%
saturation after one nebulizer treatment. Her peak flows after
three nebulizers were only 90. She began to become somnolent with
a repeat blood gas showing a pCO2 of 94 , and was therefore
intubated and transferred to the MICU. PAST MEDICAL HISTORY: Was
remarkable for ( 1 ) asthma/COPD , ( 2 ) polymyalgia rheumatica , ( 3 )
borderline hypertension , ( 4 ) lumbar disk disease , ( 5 ) psoriasis ,
( 6 ) right sided heart failure , ( 7 ) spinal stenosis , ( 8 ) sinusitis ,
( 9 ) obesity. PAST SURGICAL HISTORY: Status post cholecystectomy
in 1979 , status post back surgery. MEDICATIONS ON ADMISSION:
Theo-Dur 300 mg orally twice a day , Lasix 80 mg orally every day , KCL , Lodine 300
mg orally twice a day , Proventil nebulizers as needed , supplemental 02 every bedtime
ALLERGIES: SHE IS ALLERGIC TO SULFA WHICH CAUSES HER TO HAVE A
RASH. HABITS: She continues to smoke , and she has a history of 40
pack years. There is no alcohol use. SOCIAL HISTORY: She lives
alone. She has two sons. She is assisted by her sister.
PHYSICAL EXAMINATION: On admission , she was an intubated , obese
female in no acute distress. Her blood
pressure was 140/70 , pulse 70-100 , and temperature of 101.6. HEENT
was unremarkable. Neck: Supple with no jugular venous distention.
Lungs revealed diffuse wheezes with an I:E ratio of 1:4. Heart:
Tachycardiac with a normal S1 , S2 , without murmurs , rubs , or
gallops. Breasts: No masses. Abdomen: Obese , mild tenderness to
deep palpation , normal bowel sounds. Extremities: 2+ edema to her
calves bilaterally , no clubbing. Pulses were 2+ dorsalis pedis
pulses. On neurological exam , she was awake but lethargic and
difficult to arouse , but was able to move all extremities. Her
reflexes were 2+ and symmetric bilaterally.
LABORATORY DATA: On admission , sodium 138 , potassium 4.4 , chloride
98 , bicarbonate 36 , BUN 10 , creatinine 0.6 ,
glucose 113. Her liver function tests were within normal limits.
Her white count was 9.96 , 76 polys , 15 lymphs. Her hematocrit was
47.6% with 265 , 000 platelets. The physical therapy was 11.4 , and the PTT was
30.5. Theophylline level was 5.3. ABG's were as mentioned above.
Post intubation , ABG 7.45 , pCO2 41 , p02 57 , with 91% saturation.
The most recent echocardiogram in 1/11 revealed mild concentric
left ventricular hypertrophy and normal left ventricular function.
The chest x-ray revealed an increased heart size with no
infiltrates. The urinalysis revealed too numerous to count white
blood cells and 4+ bacteria. Cultures eventually grew out E. coli.
EKG revealed normal sinus rhythm with an axis of +8 , right bundle
branch block , inverted T's in V1 and V2 , but no significant change
compared with 11/1
HOSPITAL COURSE: The patient was admitted and continued on the
ventilator until 3/6/93. She was given aggressive
bronchodilator treatment via nebulizers , Albuterol and Atropent.
She was started on intravenous Solu-Medrol dose which was rapidly tapered on
a orally schedule. She also received two days of intravenous Ceftriaxone to
cover a possible tracheobronchitis. She was also continued on her
Ancef as well. Her urinary tract infection was treated via the
Ceftriaxone. She did well over the next two days and essentially
was ready for extubation on this regimen on 3/6/93. She was
watched overnight and did continue to do well , and was transferred
to the floor on 6/14/93. By this time , her 02 saturations were 92%
on two liters. She was afebrile , and her peak flows were improving
with continued Albuterol nebulizers and Atrovent inhaler. Her
polymyalgia rheumatica remained stable during her admission. There
was a question whether or not her urinary tract infection was
adequately treated as she had several repeat cultures growing 5 , 000
colonies of Staph aureus and one also growing diphtheroids. These
were clean catches. She had it repeated one more time as a clean
catch , and this was found to grow probable Pseudomonas species ,
with an exact speciation pending. This last culture on 5/17/93 was
associated with an urinalysis that was without white cells. Because
of this and because of the low cell count , I did not feel that it
was necessary to treat the positive culture until a straight cath
specimen was obtained. The patient was informed that if her
dysuria were to persist that she was to call Dr. Burle immediately ,
but that otherwise , her urine was most likely noninfected. She
also received a sleep study on 1/16/93 which revealed that her
oxygen saturations dropped to 46% during REM sleep. This was at a
point when she appeared not to be breathing , and therefore had an
element of essential sleep apnea. She also during periods of
non-REM sleep alternated between breathing against an obstruction
and not breathing at all. This revealed that she also has a
component of obstructive sleep apnea as well. She was started on
Progesterone as an outpatient and will continue to be followed for
evaluation for possible nasal C-PAP. The patient was discharged on
8/19/93 with a continued good airflow and much fewer wheezes than
previously. There were no complications.
DISPOSITION: DISCHARGE MEDICATIONS: Progesterone 20 mg orally
three times a day , Albuterol 0.5 cc in 2.5 normal saline q4
hours as needed , Atrovent inhaler two puffs orally every 4 hours , Prednisone
taper 50 mg orally every day times two tapering down to 10 mg orally every day
with four days of each dose , continued home 02 at night , Ampicillin
500 mg orally four times a day , Lasix 80 mg orally every day , Lodine 300 mg orally
twice a day , Theo-Dur 300 mg orally three times a day , and KCL 40 mEq orally every day The
patient is to be followed up by Dr. Burle on 3/17/93. The patient
will also have evaluation of her cataracts by Ophthalmology on the
same date.
Dictated By: DENISHA H. MCRORIE , M.D. MH9
Attending: LORRETTA P. CRIDGE , M.D. FU1
YR285/4703
Batch: 1784 Index No. SIVURU3KFP D: 7/5/93
T: 10/24/93
Document id: 993
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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244284915 | PUO | 04533679 | | 9917080 | 1/30/2004 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 5/19/2004 Report Status: Signed
Discharge Date: 4/2/2004
ATTENDING: JANAY STUKOWSKI MD
DISPOSITION:
To home with VNA service.
PRINCIPAL DISCHARGE DIAGNOSIS:
Status post CABG x4.
OTHER DIAGNOSES:
Diabetes mellitus type I , hypercholesterolemia , hypertension ,
asthma , CHF , irritable bowel , anxiety , lumbar disc disease ,
angina , CAD , diverticulosis , history of postpartum DVT/PE.
HISTORY OF PRESENT ILLNESS:
The patient is a 68-year-old female with history of hypertension ,
diabetes mellitus , asthma , postpartum DVT/PE who presented with
chest pain to Norap Valley Hospital . Catheterization on 10/12/04
revealed 3-vessel diseases , tight lesions in RCA and OM
territories. Patient was transferred to the Pagham University Of for CABG. No renewed episode of chest pain since
evening of 10/11/04. The patient denies loss of consciousness ,
palpitations , shortness of breath.
PREOPERATIVE CARDIAC STATUS:
The patient has a history of class II angina. There has been
recent angina unstable with intravenous nitroglycerin and intravenous heparin ,
recently accelerated. There is a history of class II heart
failure. The patient is in normal sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
None.
PAST SURGICAL HISTORY:
Partial hysterectomy in 1972.
FAMILY HISTORY:
Mother's side significant for history of diabetes mellitus.
SOCIAL HISTORY:
No history of tobacco use.
ALLERGIES:
Shellfish causes tracheal swelling , novocaine causes wheezing ,
possible lidocaine cross reaction , however not known for sure ,
Valium causes rash.
PREOP MEDICATIONS:
Atenolol 25 mg orally twice a day , nitroglycerine intravenous , aspirin 81 mg
orally every day , heparin last dose 1000 units an hour subcutaneous ,
Lasix 80 mg/160 mg orally every day , atorvastatin 10 mg orally every day ,
Avandia 4 mg orally twice a day , Prozac 20 mg orally every day , glipizide
XL 10 mg every day , insulin NPH 40 units every afternoon
PHYSICAL EXAMINATION:
Height and weight 5 feet 3 inches , 103.4 kilograms. Vital signs:
Temperature 97.4 , heart rate 67 , BP right arm 134/70. HEENT:
PERRLA/dentition without evidence of infection/no carotid bruits.
Chest: No incisions. Cardiovascular: Regular rate and rhythm ,
no murmurs , all distal pulses intact. Allen's test: Left upper
extremity normal , right upper extremity normal. He has history
of impaired circulation in the hands in cold weather. No history
of Raynaud's disease. Respiratory: Breath sounds clear
bilaterally. Abdomen: Lower abdomen medium hysterectomy scar
well-healed , soft , no masses , possible supraumbilical hernia or
abdominal wall weakness , some protrusion upon sitting up.
Extremities without scarring , varicosities or edema. Neuro:
Alert and oriented , no focal deficits.
LABORATORY DATA:
Chemistries: Sodium 141 , potassium 3.6 , chloride 104 , CO2 27 , BUN
16 , creatinine 0.9 , glucose 131 magnesium 1.9. Hematology: WBC
8.12 , hematocrit 30.9 , hemoglobin 9.8 , platelets 231 , 000. physical therapy
14.1 , INR 1.1 , PTT 74.6. UA was contaminated. Cardiac
catheterization data from 10/12/04 showed coronary anatomy , 70%
proximal LAD , 90% proximal OM1 , 90% proximal RCA , 80% proximal
circumflex codominant circulation , LV and diastolic pressure 36.
EKG from 10/12/04 showed normal sinus rhythm.
The patient was admitted to our service and stabilized for
surgery. Date of surgery was 2/29/04.
PREOPERATIVE STATUS: Urgent. The patient presented with
critical coronary anatomy. Unstable angina , rest angina.
PREOPERATIVE DIAGNOSIS: CAD.
PROCEDURE: CABG x4 with LIMA to LAD , SVG1 to PDA , SVG2 to OM1
and SVG2 to D1. SVG 2 to OM1 and SVG2 to OM` and SVG 2 to D1.
BYPASS TIME: 75 minutes.
CROSSCLAMP TIME: 69 minutes.
FINDINGS: PDA 1 mm vessel grafted distally , B1 sequentially
grafted off SVG to OM. There were no complications. The patient
was transferred to the unit in stable fashion with lines and
tubes intact.
Initial postoperative period , the patient was extubated in normal
fashion without complication and chest x-ray looked very wet.
She was started on gentle diuresis. Chest x-ray showed wet lung
fields. She was weaned to oxygen delivered at 2 liters per
minute via nasal cannula. She was started on beta-blockade which
was titrated and secondary to history of CHF , she was on high
doses of Lasix at home which was restarted and she diuresed well.
She was transferred to the step-down unit on postoperative day
2 , 2/13/04 , with lines and tubes intact where she proceeded to
progress well. Chest tubes were discontinued without incident on
9/6/04. She was followed by diabetes management service for
the duration of her hospital course as well as cardiology. She
was followed by Dr. Cara Barnaba LMC cardiology. She was
weaned successfully to room air oxygen on 10/29/04. She
continued to progress well. She was evaluated by cardiac surgery
service to be stable to discharge to home with VNA service on
10/19/04 with the following discharge instructions.
DIET:
Low-cholesterol low saturated fat ADA 2100 calories per day.
Follow-up appointments with Dr. Stukowski 178 324-4586 in five to
six weeks , Dr. Tetrick her primary care physician in one to two weeks and Dr. Cara Barnaba in one to two weeks.
TO , DO PLAN:
Make all follow-up appointments , local wound care , wash all
wounds daily with soap and water , watch all wounds for signs of
infection , redness , drainage , swelling , pain , fever. Keep legs
elevated while sitting/in bed. Call primary care physician/cardiologist at Pagham University Of cardiac surgery service at 117-219-4079 with
any questions.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Enteric-coated aspirin 325 mg orally every day , Colace 100 mg orally
three times a day as needed constipation , Prozac 20 mg orally every day , Lasix 160
mg orally every day before noon 80 mg orally every afternoon , ibuprofen 600 mg orally
every 6 hours as needed pain , Lopressor 50 mg orally three times a day , Niferex-150 1
50 mg orally twice a day , Percocet 1-2 tabs orally every 4 hours as needed pain ,
simvastatin 20 mg orally every bedtime , potassium slow release 20 mEq x2
every day , glipizide XL 20 mg orally every day , Nexium 20 mg orally every day ,
and Lantus insulin 10 units subcutaneous every bedtime
eScription document: 6-8350377 EMSSten Tel
Dictated By: CRIDGE , LORRETTA PA
Attending: STUKOWSKI , JANAY
Dictation ID 4182080
D: 10/19/04
T: 10/19/04
Document id: 994
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
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U |
| output/system_intuitive_annotation.xml | intuitive |
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Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
588034772 | PUO | 85230269 | | 2500427 | 9/11/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/11/2006 Report Status: Signed
Discharge Date:
ATTENDING: BUSSLER , FRAN M.D.
PRINCIPLE ADMISSION DIAGNOSIS: Bacteremia , peri-sepsis and
apnea.
PRINCIPLE DISCHARGE DIAGNOSIS: Bacteremia , peri-sepsis and
apnea , as well as failure to tolerate orally diets.
HISTORY OF PRESENT ILLNESS: He is an 81-year-old man primarily
Russian-speaking , with a history of multiple medical problems
including coronary artery disease status post an MI in 2004 as
well as a cath at the same time with percutaneous intervention ,
congestive heart failure with an ejection fraction of 45-50% ,
atrial fibrillation on anticoagulation and a partial pacemaker
for sick sinus syndrome , multiple strokes x4 , diabetes mellitus
type 2 and COPD , who was recently admitted to the Kernan To Dautedi University Of Of for
bacteremia with Streptococcus oralis without a clear source. His
white blood cell count had increased to 20. His INR had been
supratherapeutic on admission at that time to 14. At that time ,
he had had a transesophageal echocardiogram which did not show
any vegetations and he was discharged to rehab on 3/15/06 with a
course of intravenous penicillin through a PICC line , as well as orally
Flagyl empirically for an elevated white count. At the rehab
facility where he was placed , the patient was found to have
pulled his PICC line and the patient was complaining of being
short of breath and having some mental status changes. He was
treated with some sublingual nitroglycerin at the outside
facility and brought to the Kernan To Dautedi University Of Of Emergency Room , where a chest
x-ray showed some lack of the PICC line and the short of breath
quickly improved in the emergency room. He was , however ,
lethargic and then at times , apneic in the emergency room. A gas
was performed which showed respiratory alkalosis with a pH of
7.5 , a pCO2 of 34 and a pAO2 of 135. The patient then became
slightly hypotensive with systolic blood pressures to the 90s ,
was given intravenous fluid boluses as well as treated empirically with
vancomycin and ceftazidime , to which his blood pressure responded
by going up to around 100-110/60. Given his apnea , a CPAP was
initiated in the emergency department and his oxygenation issues
quickly resolved. A head CT was performed , which was negative.
A right internal jugular line was placed and gentle rehydration
therapy according to early goal-directed therapy for peri-sepsis
was initiated , given the presumption of repeat bacteremia and
early sepsis. He was admitted to medicine for further
management.
PAST MEDICAL HISTORY: Coronary artery disease status post MI in
2004 and a cath in 2005. He is status post a hip fracture in
2005. He has peripheral vascular disease , diabetes , COPD but not
reported to be on any home oxygenation , dementia , Paget disease ,
atrial fibrillation , BPH , congestive heart failure , EF of 45-50% ,
hypertension , diabetes and hypercholesterolemia.
MEDICATIONS ON ADMISSION included the following: Glucotrol 10 mg
orally twice a day and lisinopril 5 mg orally every day , metformin 500 mg
orally three times a day , Flagyl 500 mg orally three times a day x10 days which was started
on 5/5/06 , sublingual nitroglycerin as needed , nystatin suspension
four times a day , Zyprexa 2.5 mg orally every bedtime , Penicillin G 3 million units
intravenous every 4 hours x7 days , Milk of Magnesia , Tylenol as needed , Dulcolax
as needed , Colace as needed , atenolol 50 mg every day , Lipitor 20 mg q.
day , Senna liquid every bedtime , Flomax 0.4 every day.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He has a history of heavy tobacco use. He quit
40 years ago. He lives at home with a 24-hour attendant and he
rarely uses alcohol.
FAMILY HISTORY: Noncontributory.
ADMISSION PHYSICAL EXAM notable for the following: His
temperature was 95.9 , his heart rate was 60 , his blood pressure
was 110/62. He is satting 98% on a CPAP machine. In general , he
was in no acute distress in restraints. His head and neck exam
was notable for a supple neck. Pupils are equal , round and
reactive. His heart demonstrated a regular rate and rhythm. His
JVP was flat. He did not demonstrate any murmurs , rubs , or
gallops. His pulmonary exam was clear anteriorly. His abdominal
exam was noted for being soft , nontender , and nondistended with
positive bowel sounds and mild tympani. He had good peripheral
pulses with trace lower extremity edema. His neuro exam was
nonfocal.
OPERATIONS: During his hospital stay at this time included a PEG
tube placement which happened on 10/25/06.
HOSPITAL COURSE BY SYSTEM:
1. ID: The patient has a history of recent strep oralis
bacteremia and leukocytosis. He was afebrile at the time of
admission; however , given concern for possible early sepsis given
his blood pressure , he was treated with empiric intravenous fluids and
antibiotics with vancomycin and ceftazidime. His chest x-ray
looked like it might have some aspiration and he was treated with
an empiric 7-day course of Ceptaz and Flagyl for aspiration
pneumonia. This course was completed earlier in his hospital
stay. He was also initially treated with vancomycin. A PICC was
placed on 8/7/06 for further antibiotic management of his
bacteremia. His vancomycin was switched to intravenous penicillin and
this will be continued for a full 3-4 week course on 1/15/07. A
TEE was considered unnecessary given the fact that he was going
to be treated anyway with antibiotics for 4 weeks. All blood ,
urine , sputum cultures and stool cultures remained no growth to
date at the time of discharge.
2. Pulmonary: As mentioned above , the patient demonstrated some
apnea in the Emergency Department which resolved with CPAP;
however , given the fact that the patient was a significant
aspiration risk , a CPAP was considered unnecessary and possibly
would increase the risk of aspiration. Pulmonary was consulted ,
who felt that the patient was demonstrating Cheyne-Stokes
respirations secondary to possible CHF or history of CVAs that he
has had in the past. His ABG , as I mentioned above , demonstrated
respiratory alkalosis with a mild metabolic alkalosis as well.
His repeat ABG showed no significant change , which likely
indicates a chronic process. He did not demonstrate any PEs on
studies that were performed here. No pneumonia was noted and the
desaturations that were detected while the patient was sleeping
overnight on 15 units O2 sat monitor resolved quickly with 2
liters of oxygen by nasal cannula. A plan was made to not
reinitiate CPAP given the aspiration risk. He was initially
diuresed mildly with Lasix. This was eventually discontinued.
The patient should receive nighttime supplemental oxygen ,
particularly if he desaturates to less than 90%.
3. Cardiovascular: The patient is status post an MI , status
post PCI in 2004. His enzymes were negative on this admission
and a repeat EKG was unchanged from previous. The patient was
restarted on his home doses of aspirin , statin , beta blocker 2
pump. The patient's ejection fraction was 45-50% with inferior
wall hypokinesis. Hypotension improved on admission , restarted
his beta blocker and his ACE inhibitor and intravenous fluids at the time
of discharge. Re the patient's history of a-fib , he was in
normal sinus rhythm for the majority of his hospital stay.
Coumadin was held peri-procedure when he was getting his PEG
placed and vitamin K had been administered in view of his
supratherapeutic Coumadin. His Coumadin should be restarted on
2/18/07. Of note as well for rhythm issues , the patient was
kept on potassium and magnesium scales while in hospital and he
has a partial pacemaker placed for his sick sinus syndrome.
4. GI: The patient had a history of constipation. His abdomen
was tympanitic when he first presented. He was given a bowel
regimen and has subsequently begun making good solid stool.
Midway through his hospital course , the patient developed trouble
with eating. He had multiple NG tubes placed which he was
self-discontinuing requiring urgent reconsideration of more
permanent feeding tubes. A discussion was held between our
service and the GI team , who felt that a PEG would be useful for
managing this patient's feeding in the future. On 10/1/06 , GI
endoscopically placed a PEG tube for future feeding. Nutrition
was consulted and tube feeds were re-initiated that evening.
Again , his Coumadin will be held until 9/14/07 so as to promote
appropriate wound healing around the site of the PEG placement.
5. Heme: The patient had a history of anemia but did not
demonstrate any acute hematocrit drops. His INR on admission was
1.9. We had transiently restarted Coumadin but he will have to
restart that again on 9/14/07 , given the fact that it was held
for his PEG placement. He was continued on iron supplements
during his hospital stay.
6. Renal: The patient , as discussed above , has demonstrated a
respiratory alkalosis with a mild metabolic alkalosis as well.
His creatinine was mildly elevated which is secondary to chronic
renal insufficiency for unclear reasons. His creatinine by the
time of discharge had improved dramatically to 0.7.
7. Endocrine: The patient's orally hypoglycemics were held during
this hospital stay. He was started on insulin sliding-scale and
Lantus. As his feeding has increased and his tube feeds have
reached goal , his Lantus has had to be titrated up. He is
currently at 15 units every afternoon He may need more while at the
facility that he is going to.
8. GU: The patient has a history of vesiculous spermatocele or
hydrocele , which is going to be followed by urology as an
outpatient. We had held his Flomax initially given low blood
pressure but we restarted it during his hospital stay here.
9. FEN: As mentioned above , the patient is on aspiration
precautions secondary to speech and swallow evaluation that was
consistent with aspiration. NG tubes were placed multiple times
but were self-discontinued by the patient. Finally , a PEG tube
was placed on 3/2 and tube feeds were reinitiated that evening.
10: Psych: The patient has a history of being mildly agitated.
Zyprexa was initiated here at home doses of 2.5 mg every day and
then titrated up to 2.5 mg twice a day The patient has responded very
nicely to this and is no longer agitated.
11. Prophylaxis: He was kept on TEDS and P-boots. Coumadin as
mentioned above will need to be restarted on 9/14/07 and Nexium
was to continue while he is here.
The patient is full code. His contacts include his son ( 299 ) 288-4842 and Meas , his daughter ( 766 ) 594-1901.
DISCHARGE MEDICATIONS: See addendum
DISCHARGE PHYSICAL EXAM: Notable for a temperature of 98.4 T
max , his current is 96.6. His heart rate is in the 90s. His
blood pressure has been stable in the 110-120s/70-80s. His
respirations have been 18-20 , satting 92-96% on room air. In
general , he is in no acute distress. His lungs are with coarse
bilateral breath sounds. His rate and rhythm were regular
without murmurs. His abdomen is soft and nontender with good
bowel sounds. His extremities are without edema.
He is to be discharged today , 2/27/06 , to rehabilitation where
they will focus primarily on his physical therapy and rehab
needs.
eScription document: 9-6109780 HSSten Tel
Dictated By: GOBRECHT , ALVERTA
Attending: LACY LEOTA MCAUSLAND , M.D. GM2
Dictation ID 4698502
D: 2/27/06
T: 2/27/06
Document id: 995
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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U |
U |
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Y |
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U |
| output/system_intuitive_annotation.xml | intuitive |
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797255323 | PUO | 14020021 | | 883787 | 7/5/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/10/1996 Report Status: Signed
Discharge Date: 3/23/1996
PRINCIPAL DIAGNOSIS: HEMOPTYSIS.
SIGNIFICANT PROBLEMS:
1. SINUSITIS.
2. STATUS POST CARDIAC TRANSPLANTATION.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman
status post cardiac transplant ( 11/27 )
who was transferred to the Pagham University Of with a
history of hemoptysis.
The patient underwent cardiac transplantation in 1991 for severe
ischemic cardiomyopathy. The patient had a rather unremarkable
course except for the development of some graft CAD ( seen on last
catheterization ). The patient was admitted from 11/17/96 to
6/24/96 with a two month history of sputum production. The
patient was empirically started on intravenous cefotaxime and his
cyclosporine was adjusted up to 125 mg orally twice a day The patient's
shortness of breath and respiratory problems subsequently resolved.
A CT of the chest showed prior granulomatous involvement of the
lung and spleen. The patient had AFB times three done: all
negative. The patient did have Mycobacterium avium grow out in his
sputum; however , this organism was not felt to be a pathogen for
him. After the patient was discharged , the patient continued
continued to have persistent ear fullness and pain , and a thick ,
but clear , nasal discharge. Then , approximately one week ago , the
patient noted increasing cough. The patient denies any associated
fevers or chills. On the day prior to admission , the patient noted
his sputum was blood tinged. The patient subsequently coughed up
approximately one quarter cup of bright red blood , which was
apparently witnessed in the Emergency Room at the outside hospital.
The patient apparently had some more hemoptysis ( amount not
documented ) on the night of admission; however , the patient has not
had any further hemoptysis since then ( approximately 20 hours ).
PAST MEDICAL HISTORY: 1. Status post cardiac transplantation in
1991 ( secondary to ischemic cardiomyopathy ).
2. Chronic obstructive pulmonary disease. 3. Status post coronary
artery bypass graft. 4. Status post a left ventral hernia repair.
5. Status post a right ankle fracture. 6. Status post goring by
bull in 1987. 7. Liver laceration. 8. Hypertension. 9. Peripheral
vascular disease.
ADMISSION MEDICATIONS: 1. Cyclosporine 125 mg orally twice a day 2.
Cardizem CD 180 mg orally every day. 3. Imuran
175 mg orally every bedtime
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife in Re The patient was a janitor until 1/19 The
patient smoked a half pack per day times 30 years. The patient
drinks only socially ( occasionally ).
FAMILY HISTORY: Father died of a myocardial infarction at age 78.
Mother alive , but has diabetes mellitus ,
congestive heart failure , and coronary artery disease.
PHYSICAL EXAMINATION: On vitals , temperature was 97.9 , blood
pressure 160/100 , heart rate 106 ,
respirations 20 , and O2 saturation 96% on two liters. The patient
is an elderly gentleman lying in his bed in no acute distress.
HEENT examination was normocephalic , atraumatic. Pupils were
equal , round , and reactive to light and accommodation. Extraocular
muscles were intact. There was no lymphadenopathy. JVP was
approximately 7 cm , with no carotid bruits. Cardiac examination
revealed a regular rate and rhythm , normal S1 , S2 , no murmurs ,
rubs , or gallops. Abdomen had positive bowel sounds , obese ,
nontender , and nondistended. Extremities had 2+ bilateral lower
extremity edema. Neurological examination was grossly nonfocal.
LABORATORY DATA: SMA-7 was notable for glucose 284 , creatinine
1.2. CBC revealed a white count of 4 , hematocrit
35.2 , and platelets 191 , 000. physical therapy was 13 , PTT 28.2.
HOSPITAL COURSE: The patient had no hemoptysis throughout his
Pagham University Of hospitalization.
The patient was scheduled for , and underwent , bronchoscopy on
4/3/96 , which revealed bronchiectasis of the anterior segment of
the left lower lobe ( where the CT abnormalities were seen ).
Purulent secretions were also encountered and sent for appropriate
cultures and tests. No evidence of malignancy was seen. The
Pulmonary team did recommend starting the patient on appropriate
antimicrobial coverage for MAI. Therefore , the patient was started
on clarithromycin and ethambutol. Given that these medications
effect the liver cytochrome P450 system , the patient's cyclosporine dose
required adjustment downward to 100 mg orally twice a day to keep his levels
200-300. The patient also underwent CT scan of his maxillofacial
area on 9/12/96. This scan revealed air levels in both maxillary
sinuses , as well as the sphenoid sinuses. Subtotal opacification
was seen in most of the ethmoid air cells. Also , subtotal
opacification of the mastoid air cells was demonstrated
bilaterally. The frontal sinuses appeared minimally developed; of
the few air cells present , there was complete opacification. The
overall impression was pain and sinus disease with left
otomastoiditis. The patient underwent further evaluation in the
ENT Clinic on 7/24/96 ; their recommendations included Biaxin times
four weeks ( the patient will be on this medication for at least
four weeks for coverage of MAI ). The Infectious Disease team
recommends that the patient's repeat AFBs be followed up and , if
they are followed up , clarithromycin and ethambutol could be
stopped after six weeks versus 18-24 months of therapy. The
Pulmonary team also recommended that the patient be started on
Albuterol and Atrovent inhalers and have a set of pulmonary
function tests obtained as an outpatient. It is also recommended
that the patient be started on a cholesterol lowering agent at his
next Transplant Clinic visit ( LDL came back at 151 after patient's
discharge ).
DISCHARGE MEDICATIONS: Procardia XL 60 mg orally every day before noon ,
cyclosporine 100 mg orally twice a day , ethambutol
1 , 500 mg orally every day , Atrovent metered dose inhaler two puffs
four times a day , Imuran 175 mg orally every bedtime , clarithromycin 500 mg orally
twice a day , Afrin two sprays n.a. twice a day times three days , and Ocean
Spray two sprays n.a. every day.
CONDITION: Fair.
DISPOSITION: To home , follow up appointment in the Transplant
Clinic on 8/26/96 ; the patient also instructed to
arrange a follow up appointment with Dr. Kooy ( Pulmonary ). The
patient should have cyclosporine levels monitored carefully ,
especially over the next week or two.
Dictated By: JACKSON E. PART , M.D. HU31
Attending: SEPTEMBER L. PETRETTI , M.D. ND75
PJ762/5220
Batch: 09076 Index No. Y1PBDYKBF D: 7/4/96
T: 9/17/96
CC: 1. SEPTEMBER L. PETRETTI , M.D. ND75
2. FLOYD T. LYN , M.D. OX2
Document id: 996
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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450909216 | PUO | 15916569 | | 5848785 | 7/6/2003 12:00:00 a.m. | CELLULITIS | Signed | DIS | Admission Date: 7/6/2003 Report Status: Signed
Discharge Date: 6/2/2003
ATTENDING: GENOVEVA STIDMAN MD
SERVICE: GMS Eriknox
DISCHARGE DIAGNOSIS:
1. Osteomyelitis of the left foot.
2. Cellulitis of the right and left foot.
DISCHARGE CONDITION: Stable.
PAST MEDICAL HISTORY:
1. COPD.
2. Asthma.
3. Peripheral vascular disease status post fem pop in 2001 on
left , 1999 fem pop on right ( no known CAD last echocardiogram
7/10 with an ejection fraction of 73% ).
4. Diabetes mellitus ( last hemoglobin A1c prior to admission was
7.7 in 9/18 ).
5. Hypertension.
6. Peripheral neuropathy.
7. Chronic renal insufficiency with baseline creatinine of 1.3 to
1.4.
8. Multiple infections status post incision and drainage and
amputation of the 5th left metatarsal in 10/15 for
osteomyelitis ( tendency toward sepsis treated in the past with
levofloxacin and clindamycin given allergies with success , also
history of multiple cellulitis related to surgical incisions
bilaterally in the thighs ).
9. History of methicillin-resistant staphylococcus aureus.
10. Status post API.
11. Status post cholecystectomy.
12. Status post discectomy and laminectomy. Her podiatrist of
record is Dr. Patella His telephone number is 110-465-5363.
HISTORY OF PRESENT ILLNESS: She is a 66-year-old female with
severe diabetes mellitus type II , autoimmune hemolytic anemia ,
peripheral vascular disease , COPD , asthma , and history of
multiple infections who presents with bilateral lower extremity
area edema , swelling , and pain. She specifically complained of
increasing erythema , swelling , and pain of the right second toe
and left foot x 1 day. She saw her podiatrist on the morning of
admission , 7/6/2003 , and her right toe was drained at that
time , yielding pus. Cultures were drawn and it was noted that
she was have increasing erythema over the right ankle and the
left foot all the way to the shin. She had no fever but did have
chills , no shortness of breath or cough , wheezing , no dizziness
or orthostatic symptoms. She had recently been admitted between
8/7/2003 and 3/2/2003 for a COPD flare , pneumonia , and
anemia. She is known to hemolyze additionally in the setting of
infection. At that time she was treated on steroids and at the
time of this admission , was on a prednisone taper. During that
prior admission , she had also being treated with levofloxacin ,
was transfused 4 units of packed red blood cells , and was also
being treated with Aramis. She had had an abdominal CT during
that admission for left upper quadrant pain , which demonstrated
no evidence of splenic infarct. In the ED on this admission , she
was afebrile , her vital signs were stable , she was started on
levofloxacin , and she had plain films of her right foot , which
were consistent with evidence of chronic versus acute
osteomyelitis of the second toe.
REVIEW OF SYSTEMS: On review of systems , she denied any chest
pain , urinary symptoms , nausea , vomiting , diarrhea , and her
fingerstick , she mentioned , had been running high , to the 250s on
prednisone. She has a left plantar ulcer as well , which she had
planned on having surgery soon for.
ALLERGIES: To Keflex , Ultram , Vancomycin , and Linezolid. With
Linezolid , she gets headaches and hypertension , with Vancomycin
hives , Ultram produces systemic reaction of unclear nature , and
to Keflex her allergy is questionable because she has tolerated
cephalosporins and penicillins in the past by report of the
admitting team.
FAMILY HISTORY: Notable for colon cancer and esophageal cancer
in her father and mother respectively.
SOCIAL HISTORY: She is a former nurse at Pagham University Of She is married and has one daughter. She has a
35-pack year history of smoking but she quit in 1994. No alcohol
use.
PHYSICAL EXAMINATION: Notable for an elevated blood pressure of
150/70 , stable heart rate of 70 , afebrile , saturating 100% on
room air , breathing at 18. Other notable aspects of her physical
examination: Chest: She had a left carotid bruit. Her chest
was clear to auscultation bilaterally with the exception of mild
diffuse inspiratory wheezes. Cardiac: She had a regular rate ,
distant heart sounds on her cardiac examination but no murmurs ,
rubs , or gallops. Abdomen: Benign. Back: No CVA tenderness in
her extremities. Extremities: She had tense edema , left greater
than right. She also had an ulcer on the plantar surface of the
left extremity , which was not fluctuant but did have
serosanguinous drainage and erythema that was circumferential to
the mid-shin. There was more tenderness over the lateral
malleolus. She also had some left calf tenderness with a
questionable palpable cord. In her right lower extremity , she
had erythema over the right second toe with a punctate lesion
draining serosanguinous fluid. Discontinuous erythema over the
interior shin was also noted. She had diffuse onychomycosis and
right intradigital ulceration between the 4th and 5th toe. There
was not right calf tenderness that was noted. Neurological:
Neurological was grossly intact and there were no focal deficits
noted.
HOSPITAL COURSE BY SYSTEM:
1. Infectious Disease: Her blood cultures were positive for
gram-positive cocci , which was resistant to methicillin ,
clindamycin , and levofloxacin. She had an MRI of the lower
extremities bilaterally , which demonstrated no collections but
was notable for acute osteomyelitis of the left 2nd and 3rd
metatarsal as well as chronic osteitis of the calcaneous wounds.
The right phalanges were not visualized well. She was started on
Levaquin initially but this was discontinued when the
sensitivities came back and instead she was started on
dopthromycin. Infectious Disease was consulted at this time and
the antibiotics were changed to Bactrim intravenous and then to orally
Bactrim secondary to an increase in her creatinine. A TTE on
2/21/2003 was negative for any vegetation. She underwent
debridement on 10/19/2003 in the afternoon. The material was
sent for culture. She also complained of sternal discomfort ,
dysphasia , and orally thrush on examination , and it was felt that
she likely had orally candidiasis secondary to her steroid course
and so she was started on Diflucan as well as on a nystatin swish
and swallow. The cultures from her bone tissue were positive
methicillin-resistant staphylococcus aureus as well as
beta-hemolytic streptococcus. Infectious Disease once again felt
that , given her allergies , that orally Bactrim would be the best
way to treat these pathogens. On 3/19/2003 , the Diflucan was
discontinued and she was continued on nystatin swish and swallow
for the orally candidiasis , which has since been improving. She is
also being continued on Bactrim and her creatinine has stabilized
at 1.9 after peaking at 2.2. She has follow ups scheduled with
the Infectious Disease physicians on 1/27/2004 and will be
continuing her Bactrim for a full 6-week course with weekly CBC
checks , which will be monitored by her primary care physician ,
Dr. Annette Schoultz
2. Heme: The patient has a history of autoimmune hemolytic
anemia. Her hematologist of record is Dr. Weidenbach On her
last admission , she required transfusions and was thought to have
hemolyzed in the setting of her pneumonia although her hemolysis
labs at that time were negative. On this admission , her LDH and
bilirubins were normal , her hematocrit steadily decreased from
38.8 to 27 and then increased. She had an increase in her LDH
but no schistocytes were notable on smear. Nevertheless , she was
thought to be hemolyzing and received a total of 6 units of
packed red blood cells , given in doses of 2 units each over the
course of this hospitalization. She was transfused successfully
without any complications or transfusion reactions and her
hematocrit at the time of discharge is 36.0.
3. Pulmonary: The patient's prednisone taper was discontinued
on day 4 because of orally candidiasis. She was continued on nebs ,
however , for intermittent wheezing. She has had no acute COPD
exacerbations but has had increased shortness of breath
periodically , which has been improved with nebulizer treatments.
Chest x-ray on 1/7/2003 demonstrated a small bilateral
effusion. She was thought to be fluid overloaded at this time so
her Lasix was restarted for diuresis. Also of note , the patient
had pain in the left posterior lower lung field , which was
pleuritic in nature. She had LENIs done , which were negative ,
had a PE protocol CT on 1/7/2003 , which was negative. At that
time , she was diuresed and her pleuritic left lower lobe chest
pain resolved with diuresis. She had a recurrence of this pain 2
days prior to discharge after receiving 2 units of packed red
blood cells , which presumably led to a volume overload situation.
However , once again , after diuresis , she had complete resolution
of her symptoms. At this time , the CT scan was reviewed to
ensure that there was no fracture of the ribs as she did have
tenderness in the left lower lung field area. However , the ribs
were visualized well and there was no evidence of any fracture.
4. Cardiovascular: The patient was continued on Toprol and her
Diovan was held secondary to elevated potassium. She had
intermittent chest pain without EKG changes , possibly secondary
to esophageal spasm , which was relieved by nitroglycerine. Her
enzymes were negative for the first episode. Her troponin was
0.25 on random draw. This was likely a false positive and her
enzymes thereafter were negative. She had a preoperative MIBI on
10/11/2003 , which demonstrated a moderate area of reversible
ischemia in the territory of the right coronary artery. The
decision was made , however , to go ahead with the surgery for her
feet with spinal block , not with general anesthesia. Her Toprol
was increased to 75 mg every day given her MIBI findings. Her goal
heart rate was set for the 60s and a low-dose statin was also
added to her regimen. It was felt that the cardiovascular plan
in terms of her coronary artery disease should be to increase her
exercise tolerance during rehab to the point where she may begin
to experience symptoms and then cap at that time can be
considered. Towards the end of the patient's hospitalization ,
she required diuresis , particularly after receiving boluses of
volume with her blood transfusions. It was noted that , when her
volume status went up , she had an increase in swelling of her
lower extremities bilaterally as well as recurrences of her
left-sided back pain in the area of the left lower lung field.
However , as noted before , these improved with diuresis.
5. Renal: Her baseline creatinine is 1.3 to 1.4 , increased on
this admission likely due secondary to the dye load , which she
received prior to scans. Her creatinine peaked at 2.7 with the
intravenous Bactrim but began to trend down after the intravenous Bactrim was
discontinued. Other reasons for which her creatinine likely
increased during this admission were secondary to her
dopthromycin and also secondary to the intravenous Bactrim.
6. Endocrine: The patient's blood sugars have been well
controlled after her prednisone was discontinued and she was
maintained on a regimen of NPH.
7. Ophthalmology: The Ophthalmology team was consulted for a
new left floater. The patient has a history of vitreous
hemorrhages and questionable retinal detachment in the past. The
optic examination was notable for vitreous bleed. In response to
this , the head of the patient's bed was elevated and her symptoms
were stable thereafter. If she has a recurrence of curtains
symptoms or spots or flashes , it is recommended that
Ophthalmology be reconsulted at that time.
8. GI: The patient had complained of right upper quadrant pain
during this admission. Her liver function tests were elevated
when initially checked. It was recommended by Infectious Disease
since these would be monitored with intravenous Bactrim. They have been
trending down since she is status post cholecystectomy and was
initially very tender in her right upper quadrant. Her right
upper quadrant ultrasound on 10/19/2003 was negative except for
an enlarged liver alkaline phosphatase that was thought to be
secondary to osteomyelitis. Her right upper quadrant pain
improved subsequently during this hospital course with continued
diuresis and antibiotic treatment.
DISCHARGE CONDITION: The patient is being discharged at this
time in stable condition to the rehab facility. She is being
discharged on the following medications.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally every day
2. Colace 100 mg orally twice a day
3. Folate1 mg orally twice a day
4. Heparin 5000 units orally twice a day
5. NPH insulin 50 units every day before noon , 20 units every afternoon
6. Nystatin suspension 10 ml orally swish and swallow four times a day
7. Regular insulin sliding scale: If blood sugar less than 200 ,
give 0 units; if blood sugar 201-250 , give 4 units; if blood
sugar 251-300 , give 6 units; if blood sugar 301-350 , give 8
units; if blood sugar 351-400 , give 10 units and call physician.
8. Multivitamin 1 tablet orally every day
9. Zocor 10 mg orally every bedtime
10. Toprol XL 75 mg orally every day
11. Bactrim Double Strength 1 tablet orally three times a day for a full
6-week course , which will end on 9/13/2003.
12. Flovent 200 mcg inhaled twice a day
13. Caltrate plus Vitamin D 1 tablet orally every day
14. Nexium 40 mg orally every day
15. Duonebs 3/0.5 mg nebulized treatments every 6 hours
16. Saline eye drops 2 drops each eye three times a day
17. Lasix 80 mg orally every day
18. Senna 2 tablets orally twice a day
19. Aramis 200 mcg subcutaneous every 2 weeks. Most recent dose
1/7/2003 ; next dose due 4/15/2003.
20. Neurontin 500 mg orally twice a day
21. Artificial Tear Drops 2 drops each eye four times a day
as needed MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours as needed headache.
2. Albuterol nebulized treatments 2.5 mg every 2 hours as needed
shortness of breath and wheezing.
3. Dulcolax 5 mg orally every day as needed constipation.
4. Lactulose 30 mg orally four times a day as needed constipation.
5. Maalox Plus 15 ml orally every 6 hours as needed indigestion.
6. Milk of Magnesia 30 ml orally every day as needed constipation.
7. Dulcolax suppository 10-20 mg p.r. twice a day as needed constipation.
DISCHARGE INSTRUCTIONS:
1. Please follow up with primary care physician , Dr. Annette Schoultz , once a week for checking CBC , BUN , and creatinine. As per
the Infectious Disease team , please FAX these results the
Infectious Disease attending at 725-913-6369.
2. Patient has follow up appointment with the Infectious Disease
Clinic with the attending , Dr. Loan Kuharik , on 1/27/2004 at 3:30
p.m. at Pagham University Of .
3. Patient requires follow up with Orthopedic Surgery with Dr.
Goodnow and she has instructions to call Dr. Goodnow 's office and
set up this appointment.
INTERIM INSTRUCTIONS FOR REHABILITATION FACILITY:
1. Please check patient's daily weight and adjust her Lasix dose
based on changes in her weight and also clinical evidence of
volume overload.
2. Please check patient's CBC , BUN , and creatinine on a weekly
basis. She is receiving Bactrim orally
3. Please monitor patient's feet bilaterally and change
dressings as needed.
eScription document: 7-9046469 VSSten Tel
Dictated By: WYNDHAM , MAXIE
Attending: STIDMAN , GENOVEVA
Dictation ID 5211515
D: 1/21/03
T: 1/21/03
Document id: 997
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996638485 | PUO | 79592041 | | 4813412 | 1/17/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/15/2005 Report Status: Signed
Discharge Date: 9/1/2005
ATTENDING: HALPIN , BRIGETTE MD
ADMISSION DIAGNOSES:
1. Pregnancy at 34 weeks with Di/Di twins , IUFD of one twin.
2. Diabetes.
3. Hypothyroidism.
4. High blood pressure , chronic hypertension.
HISTORY OF PRESENT ILLNESS: Ms. Nilda Fiddler is a 32-year-old
G1 , P0 who presented to obstetrical triage at 34 weeks' gestation
with mono/Di twins with complaints of decreased fetal movement as
well as cough in the setting of nausea and vomiting. In triage ,
the fetal heart tracing on twin #2 was unable to be obtained , so
an ultrasound was quickly brought and showed that twin #1 had FH
100 to 108 with no evidence of FH in twin #2. Given evidence of
an IUFD and possible fetal distress in twin #2 , she was brought
for a stat cesarean section which was ultimately complicated by
multiple factors.
PAST MEDICAL HISTORY:
1. Chronic hypertension.
2. Hypothyroidism.
3. Hypercholesterolemia.
4. Obesity.
5. Diabetes type II.
PAST SURGICAL HISTORY: An appendectomy.
MEDICATIONS UPON ADMISSION:
1. Levoxyl 88 mcg orally daily.
2. NPH as well as insulin managed via sliding scale as well as
NPH given at night and in the morning.
3. Albuterol as needed
ALLERGIES: Latex leading to a rash. Pineapple leading to GI
distress.
SOCIAL HISTORY: Denied any alcohol , tobacco , or drugs.
FAMILY HISTORY: Diabetes in father and grandmother.
HOSPITAL COURSE: Ms. Nilda Fiddler was immediately brought to
the operating room and underwent an uncomplicated stat cesarean
section within 15 minutes of her arrival to obstetrical triage.
For complete details of the surgery that she underwent , please
see the dictation from that day. The preoperative diagnoses were
bradycardia , twin #1 , in triage; absent fetal cardiac activity in
#2; and 34 weeks gestational age with mo/Di twins. Postoperative
diagnoses were listed as chorioamnionitis , diabetes , and demise
of twin #2. The findings were consistent with a live born male
infant Apgars 5 and 8; a stillborn male infant , Apgars 0 and 0;
and intact placenta and a foul-smelling amniotic fluid with light
meconium in twin #1. There were no complications.
Her postpartum course was highly complicated by several issues
that will be dealt with by system. In short , she suffered a Vfib
arrest in the setting of the DIC , potential sepsis , potential
HELLP syndrome , and was admitted to the Medical Intensive Care
Unit and intubated. Ultimately , she was discharged from the
Medical Intensive Care Unit and was monitored on the labor floor
and then was transferred to postpartum where she continued to
recover and regain function until postoperative day #12 when she
was discharged home with VNA in stable condition. Her issues
will be dealt with by system.
1. Cardiology. Within 3 hours following her for stat cesarean
section , she presented with acute onset of shortness of breath ,
chest discomfort in the setting of a postpartum hemorrhage.
Telemetry was applied and had evidence of widening QRS complexes ,
and ultimately , she went into Vfib arrest with pulseless
electrical activity. She underwent aggressive resuscitation in
the form of 2 shocks with epinephrine following the code blue.
She was brought back to the operating room where Chem-7 revealed
potassium of 7 which may have been the etiology of this Vfib
arrest. A pulse was obtained following the 2 shocks and
epinephrine , and she was intubated to clear her airway. She was
then transferred to the medical intensive care unit where cardiac
enzymes were followed for 4 total sets and were found to be
grossly positive. The impression of her positive cardiac enzymes
that did trend downwords was that it was secondary to the
aggressive chest compressions and were felt not likely to lead to
significant myocardial injury. An echocardiogram that was
obtained on postoperative day #2 while she was admitted to the
Medical Intensive Care Unit revealed no evidence of focal wall
motion abnormalities and showed that the overall left ventricular
function was normal with an EF of 55%. Of note , throughout her
MICU admission , she was tachycardic to 120s to 140s , and this
was ascribed to her marked amounts of postpartum hemorrhage in
the setting of possible chorioamnionitis with sepsis. This
tachycardia resolved by postoperative day #6 , and by
postoperative day #12 , she was no longer tachycardia with a heart
rate in the 80's.
Her blood pressure while in the initial postpartum period was
maintained in the normal range , began to become elevated by
postoperative day #8 , and she was started on postoperative day
#10 on her labetalol 200 mg orally twice a day This controlled her
hypertension throughout the remainder of her hospital course , and
she was discharged home on labetalol.
2. Hematology. Following her stat cesarean section , she
underwent a postpartum hemorrhage with an estimated hemorrhage of
5-6 L of blood from her vagina. This dissection itself had only
700 cc blood loss. At this time , her fibrinogen was appreciated
to be 78 and her coags were markedly elevated. In the setting of
DIC , she underwent an aggressive product resuscitation and
ultimately she received 20 units of packed red blood cells , 7
units of fresh frozen plasma , 3 pools of platelets , 1200 mcg of
activated factor 7A , 2 units of cryoprecipitate , 4 units of 5%
albumin , and 1 bag of Hespan within a timeframe of 3 to 6 hours.
With this aggressive resuscitation , her hematocrit dropped to as
low as 26.4 , but we within 2 hours , had increased to 61.3.
Acutely following this episode after her aggressive
resuscitation , her fibrinogen increased from its low of 87 to
337. Her DIC continued to be low-grade , even after being
discharged from the Medical Intensive Care Unit. For this
reason , she was monitored on the labor floor for an additional
day postoperative day #4 , and her coagulation studies ranged from
an INR of 1.2 to 1.4. When she was admitted to postpartum , her
INR was 1.1 , and the day before discharge from the hospital , her
coagulation studies were found to be normal with an INR of 1.1
and fibrinogen of 377.
Her platelets became an area of concern when she presented with a
platelet level that was found to be fluctuating between 90 and
185. In the initial presentation after her postpartum
hemorrhage. Her platelets while in the Medical Intensive Care
Unit went to as low as 57 , and this was felt to be possibly a
component of her HELLP syndrome versus dilution from her blood
product resuscitation also part of her DIC consumptive
coagulopathy. Although her DIC consumptive coagulopathy had
evidence that it had resolved , her platelets remained low and
reached another low postoperative #7 when they became 69. A
hematology consult was obtained to evaluate the possible causes
of her low platelets , and she underwent an extensive evaluation
including a negative anticardiolipin and a negative lupus
anticoagulant. The impression was one of low platelets secondary
to shock liver in addition to DIC in addition to dilution with
marked amounts of blood products , especially in the setting of
the hematocrit ranging from the 49 to 50 range at that time. Her
platelets continued to improve throughout the hospital course and
her platelets upon discharge were 144 and had trended up from the
low of 69.
Her hematocrit initially was found to be very high , upon
presentation at 51. This was consistent with hemoconcentration
with a trough to as low as 26 while in the Medical Intensive Care
Unit. Following her resuscitation , it went to as high as 61. On
postoperative day #7 , however , it dropped from 46 to 40 and then
dropped again to 37.5 upon repeat check. This was of concern but
2 subsequent hematocrits were stable in the 39 range. Her final
hematocrit on the day of discharge was 39.5. This dropping
hematocrit was discovered in the setting of a rectus muscle
hematoma that will be dealt with elsewhere in the dictation but
her hematocrit was stable upon discharge.
3. GI. Upon presentation , Ms. Fiddler had evidence of increasing
LFTs. While in the Medical Intensive Care Unit , she was found to
have an AST of 177 , ALT of 124 , and total bilirubin of 6.2.
These elevated liver enzymes in the setting of her low platelets
was suspicious for possible HELLP syndrome. These LFTs continued
to improve with the AST and ALT dropping down to the normal
limits. Upon discharge , she was appreciated to have an ALT of 37
and AST of 48. Her bilirubin , however , continued to increase
from 6.2 to as high as 11.2. In the setting of her increasing
bilirubin while the other LFTs continued to improve , a GI consul
was obtained , and she underwent a right upper quadrant ultrasound
two times , once while on the labor floor and once while on the
postpartum floor. Both of these revealed a normal liver , normal
biliary tree , as well as normal-sized spleen. In the setting of
a normal nonobstructive picture , the GI consult had the
impression that the increased bilirubin was secondary to her
shock liver as well as the multiple blood transfusions and
possible sepsis. They were confident that this would continued
to improve but would likely take 2 to 3 weeks. Upon discharge ,
her total bilirubin had begun to decrease to 8.2. She did
manifest evidence of jaundice that was improving through the
hospital course.
On postoperative day #9 , Ms. Fiddler developed a marked increase in
her amylase and lipase. This was checked in the setting of
increasing right upper quadrant pain that ultimately resolved.
Her lipase was elevated to as high as 438 to 474. GI was again
reconsulted and had the impression that she did not suffer from
pancreatitis given that she had no nausea or vomiting , was
tolerating a regular diet , and had resolved abdominal pain. They
felt that this was likely secondary to post-surgical change and
was not an aggressive process that may need further treatment.
An abdominal pelvic CT also demonstrated a normal pancreas
without any evidence of stranding or pseudocyst formation.
The overall impression of the Obstetrics team was that her
constellation of acute-onset DIC associated with
hyperbilirubinemia and low platelets was all consistent with a
potential diagnosis of acute fatty liver of pregnancy. This
diagnosis is one that can be best made by a liver biopsy and
discussions with the GI Service revealed that they did not feel
strongly that she needed a liver biopsy. The GI Service was
skeptical with regard to the diagnosis of acute fatty liver of
pregnancy despite the clinical hallmarks being manifest in this
patient. They felt as if her symptoms could be adequately
explained by the degree of shock liver and postpartum hemorrhage
that she experienced. It was unclear as to whether or not she
had acute fatty liver of pregnancy , but given the risk of
recurrence , she will be counseled as an outpatient with regard to
future pregnancies and management of these pregnancies , given her
history of potential acute fatty liver of pregnancy.
4. Incision. On postoperative day #10 , she developed a dark
blood ooze from a 2-mm portion on the right aspect of her
Pfannenstiel incision. This was concerning for a possible
subcutaneous hematoma. So an abdominopelvic CT was obtained on
postoperative day #10 that showed evidence of an 8 x 5 cm right
rectus hematoma that may have had an area of tracking through the
fascia into the subcutaneous space. It was felt that this could
undergo dressing daily , and would ultimately seal up and stop
bleeding. She was discharged home with VNA daily dressing
changes and plan to reassess the incision at her followup
postpartum appointment in 4 days from the date of discharge. Of
note , this right rectus hematoma was diagnosed in the setting of
a drop in her hematocrit from 46 to 40. Her hematocrit remained
stable for 2 additional days at 39.5.
5. Infectious disease. On postoperative day #0 , following her
stat cesarean section. She had a T-Max of 101.9 in the Medical
Intensive Care Unit , and ampicillin , gentamicin , and clindamycin
as well as levoflox ofloxacin were started on intravenous and was
continued for 6 days until ultimately her blood cultures grew out
no organism. The urine cultures were negative and her placenta
culture also demonstrated only staphylococcus coagulase negative
with a Gram's stain showing no organisms. She remained afebrile
for the remainder of her hospital course and was not discharged
on antibiotics.
6. Endocrine. Initially following her Medical Intensive Care
Unit admission , her blood sugar remained low throughout the day
despite her eating habits. Her blood sugars would get as slow as
the 40s and as high as the 80s. This was perplexing as she was
known to be type 2 diabetic who initially been managed on
metformin prepregnancy. An endocrine consult was obtained. The
concern was for possible addisonian crisis and cord stimulation
test was normal as well as a.m. and p.m. cortisol levels were
checked. These remained within normal limits , and the concern
for possible Sheehan syndrome secondary to her massive postpartum
hemorrhage was largely excluded. A TSH as well as an ACTH level
where both drawn , and her TSH was 1.05 in the normal range and
the ACTH test was 51 , within the normal range. Of note , her
blood sugars did trend up near the end of her hospital course.
On postoperative day #10 , she was found to have fasting sugars in
the 120s. She was restarted on NPH 10 units daily. every afternoon and
every day before noon as well as her Humalog sliding scale before meals She was
discharged home with prescriptions for NPH as well as her Humalog
and will follow her sugars. These will be followed up by her
endocrinologist Dr. Bloomingdale within 4 days of this discharge.
7. Renal. While in the Medical Intensive Care Unit , she
suffered acute renal failure with a creatinine that went as high
as 2.1. This improved to 1.0 upon discharge. Of note , she had a
decreased sodium appreciated on postoperative day #7. Urinary
electrolytes were drawn and fractional excretion of sodium was
appreciated to be 0.32 consistent with prerenal , and the urine
osmolality was 400 consistent with concentrated urine that may or
may not have been consistent with syndrome of inappropriate ADH.
She underwent fluid restriction for 3 days and her sodium
improved from 129 to 134 upon discharge.
8. Pulmonary. Immediately following her Vfib arrest , she was
complaining of severe rather shortness of breath and was
intubated on the first attempt. At this time , intubated and
sedated , she was in the MICU and was extubated on postoperative
day #2. She was transitioned to nasal cannula after being on
FiO2 of 80% and ultimately was discharged home sating 99 to 100%
on room air with a good exercise tolerance.
9. Infant. Their baby boy Gosnell was doing very well upon
discharge. He was followed by the pediatric service at Pagham University Of and was discharged home with them.
10. Neuro. Initially , her mental status in the Medical
Intensive Care Unit would wax and wane. She would be
intermittently disoriented. A head CT was obtained postoperative
day #4 , and this was shown to have no focal abnormalities
although there was some indication that there might have been
some stranding between the white and gray matter consistent with
possible edema. This report was not mentioned in the final
report of the head CT. Upon discharge , her mental status was at
baseline with perfect memory of the event leading up to the stat
cesarean section although she had some difficulty remembering
specifics with regards to her Medical Intensive Care Unit
admission , and the ensuing days. She was alert and oriented to
person , place , and time.
11. Physical therapy. She underwent a physical therapy consult
with the impression of improving physical status and exercise.
She was given exercise strategies that she will continue at home.
She was offered home physical therapy but declined as she
thought the visiting VNA would be adequate and that she was able
to be out of bed with her usual exercise tolerance.
DISPOSITION: On postoperative day #11 , status post her stat
cesarean sections for IUFD with twins and postpartum hemorrhage
DIC , she was discharged home with a plan to follow up in the OB
clinic in 4 days with Dr. Tomoko Franckowiak and Dr. Brigette Halpin
She will also be seen by Dr. Aeling of endocrinology. She will
have daily VNA dressing changes and was instructed to call if she
had any fever , chills , nausea , vomiting , increased bleeding from
the incision or if she had any questions.
DISCHARGE MEDICATIONS:
1. Colace 100 mg orally twice a day
2. Levoxyl 75 mcg orally daily.
3. Oxycodone 5 to 10 mg orally every 4 hours as needed pain.
4. Senna tablets 2 tabs orally twice a day
5. Simethicone 80 mg orally four times a day
6. Labetalol 200 mg orally twice a day
7. NPH 10 units every day before noon and every afternoon
8. Humalog sliding scale before meals 5-10 units.
DISCHARGE DIAGNOSES:
1. Pregnancy , status post stat cesarean section for IUFD ,
nonreassuring fetal heart tracing.
2. Vfib arrest.
3. DIC.
4. Severe PET/HELLP.
5. Thrombocytopenia.
6. Elevated liver enzymes.
7. Hypothyroidism.
8. A2 gestational diabetes.
Ultimately she was discharged home with low platelets.
Throughout her hospital course , she was appreciated to have
evidence of low platelets on her first CBC upon presentation to
Pagham University Of as well as chest compressions , and a
pulse was once again obtained. In the triage , she was found to
have evidence of a demised twin as well as evidence of a heart
rate of the second twin in the 90's.
eScription document: 5-1030191 HFFocus transcriptionists
Dictated By: LACK , NAOMA
Attending: FRANCISCA AZZIE URBANIAK , M.D. CX64
Dictation ID 1265443
D: 3/15/05
T: 3/15/05
Document id: 998
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150694226 | PUO | 26369689 | | 883656 | 6/3/1999 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 6/3/1999 Report Status: Signed
Discharge Date: 5/3/1999
HISTORY OF PRESENT ILLNESS: The patient is a 64 year-old gentleman
with a history of chest discomfort ,
dyspnea on exertion and fatigue who was scheduled for a coronary
artery bypass grafting. He had cardiac catheterization at Pagham University Of on August , 1999 which demonstrated a 30%
tapering lesion of the left main coronary artery , 70% proximal
lesion of the left anterior descending coronary artery , 80% lesion
distal to D1 , 100% occlusion of his left circumflex and a 100%
occlusion of his right coronary artery. He is admitted on March , 1999 for coronary artery bypass grafting.
PAST MEDICAL HISTORY: Psoriasis and polymyalgia rheumatica ,
coronary artery disease and wide eye
glaucoma. His echocardiogram demonstrated left ventricular
hypertrophy with a normal ejection fraction. He has a 45 year
history of smoking.
MEDICATIONS ON ADMISSION: 1 ) Prednisone 5 mg orally twice a day 2 )
Lasix 40 mg orally every day. 3 ) Zocor 40
mg orally every day. 4 ) Atenolol 25 mg orally every day. 5 ) Nitropatch.
6 ) Enteric coated aspirin orally every day. 7 ) Timolol eye drops to
his left eye. 8 ) Captopril 18.75 mg orally three times a day. 9 )
Tagamet 50 mg orally twice a day. 10 ) Calcium supplementation.
LABORATORY: Laboratory studies on admission revealed a BUN of 20 ,
creatinine 1.2 , white blood cell count 8.8 , hematocrit
40.2. Chest x-ray revealed no acute disease.
HOSPITAL COURSE: On May , 1999 , he underwent coronary
artery bypass grafting times three with a left
internal mammary artery to the left anterior coronary artery ,
saphenous vein graft to the aorta and a saphenous vein graft from
the obtuse marginal to the aorta. His intraoperative course was
uncomplicated. On postoperative day number one , he was weaned to
extubation and he was treated with stress steroids to prevent
steroid withdrawal. On postoperative day number one , he was taken
back to the operating room for bleeding. After he was extubated ,
he was reintubated and was returned in good and stable condition to
the intensive care unit on renal Dopamine. He was again extubated
and was seen in consultation by the Gastrointestinal Service for a
question of gastrointestinal bleed since there was a clot seen on
the transesophageal echocardiogram probe at its withdrawal from his
first surgery. The Gastrointestinal Service saw any evidence of
any upper gastrointestinal bleed and he was maintained on H2
blockers. He was sent to the step down unit on routine
postoperative day number two and his Captopril was increased for
afterload reduction. His course improved and he was diuresed for a
volume overload still requiring oxygen supplementation on two
liters. His oxygen saturation was only 91% on postoperative day
number three. He continued to improve and continued to have care
for his respiratory situation with continued diuresis and nebulizer
treatments and ambulation. He was screened by rehabilitation and
awaited rehabilitation placement. He did acquire a rehabilitation
bed on postoperative day number six and he is being transferred to
rehabilitation on the following medications.
MEDICATIONS ON DISCHARGE: 1 ) Prednisone 5 mg orally twice a day.
2 ) Enteric coated aspirin 325 mg orally
every day. 3 ) Zantac 150 mg orally twice a day. 4 ) Niferex 150 mg
orally twice a day. 5 ) Atrovent nebulizer 0.5 mg four times a day.
6 ) Timolol eye drops 0.5% one drop in both eyes twice a day. 7 )
Atenolol 25 mg orally twice a day. 8 ) Captopril 12.5 mg orally three
times a day. 9 ) Lasix 40 mg orally every day. 10 ) Potassium SR 20
mEq orally every day. 11 ) Simvastatin 40 mg orally every day. 12 )
Ibuprofen 200-800 mg as needed for pain every 4-6h.
FOLLOW-UP: The patient was discharged to the care of Dr. Bree Theiling at Lame Medical Center ,
Van Caral
Dictated By: CHRISTY CLARDY , M.D.
Attending: GAYLENE G. FANIEL , M.D. HK34
CN870/8426
Batch: 5668 Index No. HIOQ061H5O D: 11/10/99
T: 11/10/99
CC: BREE M. THEILING , M.D. IY1
FLETA MANNIX , MD , LAME MEDICAL CENTER
Document id: 999
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215904272 | PUO | 04510760 | | 047530 | 2/21/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/23/1996 Report Status: Signed
Discharge Date: 8/10/1996
PRINCIPAL DISCHARGE DIAGNOSIS: UNSTABLE ANGINA.
IDENTIFICATION: The patient is a 71 year old gentleman with a
history of severe coronary artery disease who
presented with unstable angina with probable mesenteric ischemia.
HISTORY OF PRESENT ILLNESS: Cardiac risk factors include a history
of hypertension , hypercholesterolemia ,
remote history of smoking , questionable positive family history ,
and no diabetes mellitus. The patient has had a history of
coronary artery disease , is status post multiple myocardial
infarctions. In the 1970s the patient had a myocardial infarction
number 1 and in 1992 he had his second myocardial infarction , non Q
wave MI , refused catheterization. ETT was done and he was treated
with Atenolol and Isordil. In 2/23/93 the patient had an anterior
myocardial infarction and subsequently had a V-tach , V-fib arrest ,
converted with 200 joules at Clagib Toner Community Hospital and received TPA ,
heparin , Lidocaine , and his peak CPK value was 7975. Echo revealed
an ejection fraction of 20% with anterior apical akinesis , left
atrial enlargement. The course was complicated by post MI chest
pain. On 11/27/93 the patient was transferred to I Warho Hospital Cardiac catheterization at that point revealed 90% LAD
lesion and 100% PDA lesion , 90% D1 lesion , and the patient had PTCA
of LAD to a remaining 40% lesion and D1 PTCA with 40% residual.
Post PTCA course was complicated by flash pulmonary edema and
anterior ST elevation which led to emergent cath which revealed a
70% LAD , 100% D1 lesion , and this re-occlusion was treated with
repeat PTCA of LAD and intra-aortic balloon pump. The patient was
given Captopril and Lasix for ischemic cardiomyopathy. Since then ,
the patient was medically managed and in his usual state of health
without any chest pain for the two years until about three days
prior to admission when patient had vague abdominal pain ,
epigastric ache , and cramp occurring intermittently , lasting for
4-6 hour episodes. Occasionally the patient was awaken from sleep.
He denied orthopnea , PND , edema. The patient's pain was similar
to but not identical to peptic ulcer disease pain. The patient
denied chest pain. On 5/25/96 , the patient was seen by Dr. Soshnik
of CHH . The patient continued to have abdominal pain. Patient
had CHF on examination. An EKG revealed new lateral T wave
changes. The patient was sent to Clagib Toner Community Hospital and there the
patient became diaphoretic , was short of breath , improved with
nitroglycerin and therefore was transferred to I Warho Hospital
In the Emergency Room , the patient had shortness of breath , blood
pressure elevated to 210/110 , heart rate of 118 , continued to have
abdominal pain and development of chest pain typical of angina. He
received Lopressor , intravenous TNG , aspirin , no heparin secondary to
increased INR to 2.8 , and his shortness of breath subsequently
improved. Chest pain resolved. His EKG had T wave inversions in
V5 through V6.
PAST MEDICAL HISTORY: 1. Significant for coronary artery disease
as above. Status post multiple myocardial
infarctions. PTCA of LAD. 2. Peptic ulcer disease. 3.
Hypertension. 4. Hypercholesterolemia. 5. Status post
amputation of right third distal phalanx. 6. History of
nephrolithiasis.
ADMISSION MEDICATIONS: Coumadin 3 mg every bedtime , Atenolol 25 mg orally
every day , Captopril 25 mg orally three times a day , Mevacor
20 mg orally every day , Axid 150 mg orally twice a day , Nitro patch , and
sublingual nitroglycerin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with brother. Retired heavy
equipment operator. He smoked 15 pack years and
quit twenty years ago. Alcohol occasionally.
FAMILY HISTORY: Positive coronary artery disease in two sisters
with myocardial infarctions.
PHYSICAL EXAMINATION: Temperature of 98 , heart rate of 72 , blood
pressure of 104/68 , respiratory rate of 16.
Oxygen saturation of 97%. HEENT examination revealed no JVD.
Cardiac examination showed regular rate and rhythm with a 2/6
systolic ejection murmur at left lower sternal border. Chest was
soft bibasilar crackles. Abdomen was soft , non-tender ,
nondistended. No hepatosplenomegaly. A ventral hernia was present
which was easily reducible. Extremities showed no cyanosis ,
clubbing , or edema. Neuro examination was nonfocal. Rectal was
guaiac negative per the Emergency Ward.
LABORATORY EXAMINATION: Sodium of 144 , potassium of 3.5. He had a
hematocrit of 43.6 and white blood count
of 9.8. LFTs were within normal range. physical therapy of 20.2 , PTT of 38.2 ,
INR of 2.8. ABG on 100% face mask revealed 7.33 , 45 , 193 , 99.6% in
the Emergency Room. Abdominal ultrasound in the Emergency Room
revealed right renal stones , but no hydronephrosis , no gallbladder
stones , no evidence of triple A. Chest x-ray showed cardiomegaly ,
low volume lungs without clear evidence of CHF. EKG upon arrival
in the Emergency Ward revealed sinus tachycardia , T wave flattening
in AVL , T wave inversion V4 through V6 which were new , poor R wave
progression which was old. Pain free EKG revealed resolution of T
wave inversion in V4 through V6.
HOSPITAL COURSE: The patient was admitted for the rule out MI
protocol. He actually ruled out for a myocardial
infarction with a CPK of 168 , CPK2 of 138 , and CPK3 of 147.
However on 11/10/96 his T wave inversion in V1 and V2 were noted to
be deeper on C set compared to A set. Subsequently that day the
patient had an episode of flash pulmonary edema. As his intravenous heparin
and TNG were being turned down he became acutely short of breath
with bilateral crackles half way up the lung fields. He was found
to be in flash pulmonary edema which was treated with heparin , intravenous
TNG , and also Lasix. The patient did very well after that and his
troponin level at that point was 0. The patient's CPKs were
recycled and the patient ruled out for myocardial infarction again.
His ABG at that point and during his acute episode of shortness of
breath was 7.37 , 43 , pO2 of 111 on 6 liters , and after diuresis he
was able to be on room air without any difficulty. It was
therefore decided for the patient to have cardiac catheterization.
Cardiac catheterization was performed on 10/4/96 which revealed
proximally occluded LAD , 60-70% lesion of OM1 , and 99% lesion of
proximal PDA , and decreased left ventricular ejection fraction with
extensive anterior apical akinesis and also inferior apical
akinesis. Based on this it was decided that the patient had three
vessel disease. In anticipation of surgical conservation the
patient had a ETT MIBI on 7/11/96 and he was able to go on modified
Bruce protocol 6 minutes. He stopped secondary to fatigue. He did
not achieve target heart rate. His maximum heart rate was 104 and
85% of the predicted value. Subsequently the MIBI results revealed
anterior wall and septum and apex to be nonfunctional , however the
patient had known transmural myocardial infarction in inferior wall
which revealed viable myocardium there and also lateral wall
nonfunctioning wall. These are the preliminary results. It was
decided for the patient to have maximal medical management prior to
consideration for surgery. The patient's Isordil dose was
increased while in hospital and his Coumadin was restarted.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Captopril 25 mg orally three times a day , Isordil 40 mg
orally three times a day , Mevacor 20 mg orally every day , Lopressor 25 mg orally every 8 hours ,
nitroglycerin 1/150 as needed chest pain. Coumadin 20 mg orally every bedtime ,
and Axid 150 mg orally twice a day
CONDITION ON DISCHARGE: The patient is being discharged in good
condition.
FOLLOW-UP: With Dr. Miyanaga The patient is to be seen within one
week with Dr. Gruntz of Sa Pehall for
Cardiology , and Dr. Golebiowski of Thoracic Surgery per Dr. Soshnik
recommendations. The patient has been chest pain free since
11/10/96 , since he had the episode of flash pulmonary edema. His
heparin was discontinued on 1/11/96. The patient remained chest
pain free with good oxygen saturation and was not short of breath.
Dictated By: NORMAND SIGLIN , M.D. BQ9
Attending: RHEBA R. NAKAI , M.D. CV13
GA868/1188
Batch: 46525 Index No. D3LKNG4WLZ D: 1/27/96
T: 1/5/96
CC: 1. CARA NEVA KENEKHAM , M.D. WA5
2. RHEBA R. NAKAI , M.D. CV13
3. COLIN E. NAJI , M.D. RB44
Document id: 1000
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Gou |
HC |
HTN |
HTG |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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750292300 | PUO | 98573926 | | 072164 | 7/20/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/24/1996 Report Status: Signed
Discharge Date: 10/9/1996
DISCHARGE DIAGNOSIS: IDIOPATHIC HYPERTROPHY SUBAORTIC STENOSIS.
RELATED DIAGNOSES: 1 ) INSULIN DEPENDENT DIABETES MELLITUS.
2 ) SYNCOPE.
HISTORY OF PRESENT ILLNESS: Patient is a 79 year old Russian
speaking female who had had a history
of exertional chest pain and no previous documented coronary artery
disease. In July 1995 , patient was admitted to Pagham University Of for symptomatic bradycardia. She ruled out for a
myocardial infarction at that time. Echocardiogram revealed left
ventricular hypertrophy and left ventricular cavity obstruction
with systolic outflow tract gradient of 20-30 mm of mercury. In
September 1995 , patient presented to the Bea Duna Medical Center with complaints
of exertional chest pain with onset after one flight of stairs.
She was started on Atenolol. Echocardiogram at that time revealed
asymmetric septal hypertrophy , anterior movement of mitral valve
during systole , and peak left ventricular outflow tract gradient of
58 mm of mercury. This was consistent with the diagnosis of
idiopathic hypertrophic subaortic stenosis. Patient was continued
on Atenolol , however , given her history of symptomatic bradycardia ,
her dose could not be increased. One week prior to admission , the
patient noted onset of substernal chest pressure described as pain
in her anterior chest radiating to her jaw. This was usually
experienced in the late morning with no obvious relation to
exertion usually accompanied by light headedness. On the day of
admission , patient awoke without pain , however , in the a.m. , she
again noted onset of substernal chest pressure associated with
light headedness. This lasted for a period of about thirty minutes
after which time she had a syncopal event. The patient fell on her
right hip without evidence of head trauma with brief loss of
consciousness. Within seconds , she was awake and conversant. EMT
was alerted and she was brought to Pagham University Of
Emergency Department for further evaluation and management. She
denied any significant shortness of breath , fever , chills , and
sweats.
PAST MEDICAL/SURGICAL HISTORY: Insulin dependent diabetes times
twenty years , status post
pancreatectomy , IHSS , and angina.
CURRENT MEDICATIONS: Atenolol 25 mg orally every day , Nifedipine XL 30 mg
orally every day , Lisinopril 20 mg orally every day ,
aspirin , and 30 units NPH insulin every day before noon
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No family history of IHSS or sudden death
documented.
SOCIAL HISTORY: Patient was originally from the Cadence O Lo , former
teacher , married , and lived with husband. There
was no significant use of alcohol or tobacco.
PHYSICAL EXAMINATION: On admission , patient was a pleasant elderly
female in no acute distress. She was
afebrile with a heart rate of 64 , blood pressure 114/68 ,
respiratory rate 16 , and oxygen saturation 97% on room air. HEENT:
Examination was notable for anisocoria , right pupil status post
previous surgery , and oropharynx clear without lesions. NECK:
Supple without lymphadenopathy , no jugular venous distention ,
carotids were without bruits , and firm mobile mass on anterior
neck. LUNGS: Clear to auscultation bilaterally. HEART: Regular
rate and rhythm , S1 , S2 , and III/VI late systolic murmur best heard
at the left lower sternal border. ABDOMEN: Benign. EXTREMITIES:
Without clubbing , cyanosis , or edema. NEUROLOGICAL: Examination
was non-focal.
LABORATORY EXAMINATION: CBC showed a hematocrit of 43.1 , white
blood count 8.6 , platelets 160 ,
electrolytes within normal limits with a potassium of 4.7 ,
BUN/creatinine 34/0.9 , liver function tests within normal limits ,
INR 1.1 , and CK 68. Urinalysis showed a specific gravity of 1.006 ,
pH 5.5 , and 1+ bacteria , chest x-ray with evidence of tortuous
aorta but no acute pulmonary or cardiac disease , and ECG showed a
sinus rhythm , left ventricular hypertrophy , early repolarization in
V1 to V3 , T wave inversion in lead I , first degree AV block ,
otherwise with normal intervals , and axis minus 39.
HOSPITAL COURSE: Patient is a 79 year old female with a history of
IHSS and insulin dependent diabetes who now
presented with a syncopal episode accompanied by substernal chest
pressure. Given the patient's history of chest pain , she was ruled
out for myocardial infarction with flat CK and cardiac troponin I
of 0.0. She was placed on cardiac monitor. She was noted to have
normal sinus rhythm at a rate in the fifties to sixties increasing
as high as the nineties with exertion. As a result , the patient's
beta blocker dose was increased as tolerated with close monitoring
for possible bradycardia. Given the likelihood that her symptoms
could be related to decreased outflow secondary to IHSS , the
Pacemaker Service was consulted. It was felt that the patient
would benefit from placement of a permanent pacemaker which would
possibly be therapeutic both for IHSS as well as allowing further
titration of beta blocker for her exertional angina. The procedure
was discussed with the patient and her family in detail and her
family requested one additional evening to discuss whether or not
to proceed with pacemaker placement. She remained on cardiac
monitor and remained asymptomatic throughout her hospital course.
Clinically , the patient remained stable. She remained on cardiac
monitor given her history of daily episodes of syncope and chest
pain over the last week prior to admission. Her blood sugar was
followed closely with fingersticks four times a day and she was replaced with
sliding scale Regular insulin in addition to her regular NPH dose.
On 3/7/96 , the patient underwent placement of a permanent
pacemaker , mode DDDR , via her left axillary vein without
complication. The patient remained stable overnight and placement
of pacemaker was confirmed with chest x-ray.
DISPOSITION: Patient is discharged to home in stable condition.
She was instructed to notify her medical doctor for
any worsening of chest pain , light headedness , or pain at the
pacemaker site. In addition , she was instructed to check the
incision site for sign of redness as well as fever and she was told
not to shower for four days status post pacemaker placement.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day , Lisinopril 20 mg
orally every day , Lopressor 25 mg orally every 8 hours , and
Procardia XL 30 mg orally every day She will resume her previous insulin
dosing.
FOLLOW-UP: Patient will follow-up with her primary medical doctor ,
Dr. Destree , and her Cardiologist , Dr. Kittell She will
follow-up , in addition , with Dr. Dominguez in the Pacemaker Clinic in
approximately one month.
Dictated By: CHRISTIN G. FRERICKS , M.D. MM39
Attending: CARA NEVA KENEKHAM , M.D. WA5
XJ857/8512
Batch: 90326 Index No. STYFLH7UIU D: 11/21/96
T: 7/1/96
CC: 1. CARA C. BARNABA , M.D. HL86
2. STACIE C. HALECHKO , M.D. UJ97
Document id: 1001
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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OSA |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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052830400 | PUO | 76356238 | | 307625 | 2/20/1997 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 5/16/1997 Report Status: Signed
Discharge Date: 3/12/1997
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
SIGNIFICANT PROBLEMS:
1. CORONARY ARTERY DISEASE.
2. HYPERCHOLESTEROLEMIA.
3. HYPERTENSION.
4. HISTORY OF CONGESTIVE HEART FAILURE WITH FLASH PULMONARY EDEMA.
5. HISTORY OF DEPRESSION.
6. GLAUCOMA.
7. NON-INSULIN-DEPENDENT DIABETES MELLITUS.
8. MITRAL REGURGITATION.
9. CHRONIC RENAL INSUFFICIENCY.
10. HISTORY OF BREAST CANCER STATUS POST LEFT MASTECTOMY AND
TAMOXIFEN TREATMENT.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female
with known coronary artery disease ,
CRF , and history of flash pulmonary edema , recently admitted to
Nessinee Ker Hospital Medical Center on 6/9/97 after sudden onset of shortness of breath
unrelieved by one sublingual nitroglycerin. This shortness of
breath awakened her from sleep. Her blood pressure in the
Emergency Room was 230/110 without EKG changes. She responded well
to intravenous Lasix and intravenous nitroglycerin , saturating at 99% on 100%
nonrebreather mask. Chest x-ray was consistent with pulmonary
edema. Her blood pressure was stabilized on intravenous nitroglycerin with
resolution of her shortness of breath. She was ruled out for
myocardial infarction. The patient was also recently admitted one
month ago to Bussadd Southrys Community Hospital for flash pulmonary edema without
evidence of myocardial infarction. Echo on admission showed 30%
ejection fraction with anteroapical and posterobasal hypokinesis.
Cardiac catheterization in January 1997 showed a 90% proximal RCA
lesion and diffuse distal LAD disease. During vigorous rehydration
following that cardiac catheterization , she developed recurrent
pulmonary edema requiring intubation from which she was weaned
following diuresis. Because her pulmonary edema was believed to be
ischemia related , she was transferred to the Pagham University Of for RCA angioplasty. On this admission , she denies any
chest pain , shortness of breath , or dizziness. She has three
pillow orthopnea , ankle edema. She denies any paroxysmal nocturnal
dyspnea with the exception of her current presentation. The
patient's coronary risk factors include diabetes mellitus ,
hypertension , hypercholesterolemia , post menopausal status without
hormone replacement therapy , and history of tobacco use. Her
exercise tolerance is such that she develops shortness of breath
with walking one block or one flight of stairs. She reports having
to sit down at every other bench in the mall.
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. Total cholesterol
266 down to 193. 2. Hypertension. 3.
Breast cancer status post left mastectomy seven years ago and
status post five years of Tamoxifen therapy. She has had no other
chemo or radiation treatment. 4. Depression. 5. Hypercalcemia ( no
alkalized syndrome ) 9/13 6. History of recurrent pneumonia. 7.
History of diverticulitis. 8. Glaucoma. 9. Non-insulin-dependent
diabetes mellitus diagnosed one year ago , diet controlled. 10.
Chronic renal insufficiency with a history of pyelonephritis at age
three. 11. Mitral regurgitation. 12. Status post total abdominal
hysterectomy , bilateral salpingo-oophorectomy at age 40 , hormone
replacement therapy for five years which was then discontinued
secondary to her breast cancer. 13. Status post bilateral knee
replacement.
TRANSFER MEDICATIONS: Lopressor 25 mg orally twice a day started three
weeks ago , Axid 150 mg orally twice a day , enteric
coated aspirin 325 mg orally every day , Isordil 30 mg orally four times a day ,
hydralazine 50 mg orally four times a day , Lasix 40 mg orally every day , Timoptic
0.25% one GTT each eye twice a day , Serax 30 mg orally every bedtime as needed insomnia ,
and intravenous heparin at 1 , 300 units per hour.
ALLERGIES: Tagamet causes a rash and adhesive tape.
SOCIAL HISTORY: Notable for a history of tobacco. She quit 17
years ago. She uses no alcohol and no intravenous drug
use. She lives with her husband in Nabiceco and has six children.
FAMILY HISTORY: Her father died of stomach cancer. Mother , two
aunts , and sister have history of myocardial
infarction at ages greater than 60.
REVIEW OF SYSTEMS: The patient has been following her weight since
her last discharge ( pulmonary edema ). She
reports a weight loss from 177 to 175 lb over the last couple of
days. She reports a 12 lb weight loss in the last month. She has
no complaints of dysuria or cough.
PHYSICAL EXAMINATION: The patient is a pleasant female , resting
comfortably in bed. Her temperature was
98.5 , blood pressure 156/68 , pulse 78 , respirations 20 , and 95% on
two liters. There was no JVD. Carotids were 1+ without bruits , no
thyromegaly , and no lymphadenopathy. Lungs revealed right basilar
crackles. She was using accessory muscles for respirations. Heart
revealed regular rate and rhythm , normal S1 and S2. There was a
II-III/VI systolic ejection murmur at the LSB. There was a III/VI
holosystolic murmur at the apex radiating to the axilla. There was
no S3 or S4. Her abdomen was slightly distended with no
hepatosplenomegaly. She was guaiac negative. She had 2+ femoral
pulses bilaterally without bruits and 2+ DP pulses bilaterally.
There was no ankle edema. Neurological examination was grossly
intact.
LABORATORY DATA: BUN was 59 , creatinine 3.9 , hematocrit 28.9 , and
MCV 82.3. Magnesium was 2.4. Chest x-ray from
outside hospital was consistent with pulmonary edema. EKG revealed
normal sinus rhythm at 81 , normal axis and intervals ( QT slightly
increased at 0.46 ) , LVH , LAE. There was T flattening in AVL.
There were no acute ST or T wave changes.
HOSPITAL COURSE:
1. CONGESTIVE HEART FAILURE: The patient was much improved after
successful diuresis with improvement
of her pulmonary examination and no evidence of right sided
failure. She was saturating well on room air. Care was taken to
diurese slowly in order to present a prerenal insult. She remained
symptom free for the duration of her hospital course.
2. CORONARY ARTERY DISEASE: The patient denies ever having had any
chest pain , but had known anatomy with single vessel disease ( RCA ).
Her history is suggestive of possible silent ischemia consistent
with her diabetic status. Her anginal equivalent appears to be
shortness of breath. The patient underwent cardiac catheterization
on 6/2/97 with PTCA plus stent placement to her RCA with a good
result. She is on Ticlid for two weeks. Her blood pressure was
well controlled in her target range of 140-160 systolic blood
pressure on hydralazine , Lasix , and Lopressor. The day following
cardiac catheterization , her hematocrit and creatinine remained
stable at 30.9 and 3.7 , respectively. On 7/4/97 , her creatinine
increased to 4.2. This increase was thought to be due to a
combination of prerenal insult in addition to possible
dinephropathy. She was hydrated gently and her creatinine was
watched for the next two days , stabilizing in the 4.4 to 4.5 range.
3. CHRONIC RENAL INSUFFICIENCY: Etiology was unknown , possibly
secondary to diabetes mellitus or hypertensive nephropathy. She
has history of creatinine rises to high 3s and 4s during recent
hospitalizations. Hospital course is as described above. In
addition , Axid was changed to renal dosing ( every day ) and the patient
was treated for a urinary tract infection. In reviewing the
hospital records , there is no evidence of previous work up for
renal artery stenosis. This patient with history and physical to
control blood pressures and flash pulmonary edema in the setting of
hypertension may benefit from further evaluation of possible renal
artery stenosis. This work up was deferred during this
hospitalization due to management of acute issues.
4. DIABETES MELLITUS: This was stable , diet controlled.
5. ANEMIA: The patient was worked up for her baseline low
hematocrit , found to have an iron deficiency anemia treated with
Niferex 150 mg orally twice a day Given her underlying renal failure ,
there may also be a renally driven component to her anemia and she
may benefit from Epogen as an outpatient.
The patient was discharged to home in stable condition to follow up
with Dr. Hermina Tuomala , her cardiologist , in two weeks , and her
primary care physician in one week based on previously scheduled
appointment.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Lasix 40 mg orally every day , hydralazine 50 mg
orally four times a day , Isordil 30 mg orally three times a day , Lopressor 25 mg orally
twice a day , nitroglycerin 1/150 one tablet sublingual every 5 minutes
times three as needed chest pain , Timoptic 0.25% one drop each eye twice a day ,
Axid 150 mg orally every day , and Ticlid 250 mg orally twice a day for two
weeks. Also , Niferex tablet 150 mg orally twice a day
DISCHARGE INSTRUCTIONS: The patient was instructed to have her
CBC checked at two weeks and four weeks
given her Ticlid therapy.
Dictated By: AUGUSTINA HOOPLE , M.D. GN68
Attending: ROSSIE K. MANKOSKI , M.D. ZC89
UO638/8711
Batch: 09411 Index No. S0WX880A9L D: 10/9/97
T: 11/24/97
Document id: 1002
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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952207224 | PUO | 53059524 | | 002666 | 5/3/1997 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 6/7/1997 Report Status: Signed
Discharge Date: 10/11/1997
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE NOW STATUS POST PTCA
TIMES TWO AND STENT PLACEMENT.
CLINICAL DIAGNOSIS/PROBLEM LIST: Coronary artery disease status
post three vessel CABG in 1981 ,
hypertension , insulin dependent diabetes mellitus ,
hypertriglyceridemia , status post total hip replacement in 1990 ,
status post cholecystectomy , status post triple hernia repair.
HISTORY OF PRESENT ILLNESS: Mr. Raycraft is a 71-year-old white
gentleman who has a history of
coronary artery disease , status post CABG in 1981 at the Pagham University Of who was transferred from Docdrew University Hospital
with unstable angina for further evaluation and treatment.
The patient's coronary risk factors include insulin dependent
diabetes mellitus , dyslipidemia , hypertension , age , male gender ,
remote tobacco smoking and also known coronary artery disease.
The patient's cardiac history dates back to 1981 when he underwent
three vessel CABG at the Pagham University Of . The patient
has been in his usual state of health active in the Rina Cou Gasler until he
noticed progressive chest pain with chest tightness and shortness
of breath , but no light-headedness , nausea or vomiting which has
been progressing over the past few months. The patient did not
occur at rest , but occurred with minimal exertion. The patient had
an EKG as an outpatient which showed ST-T wave abnormalities and he
was advised to come to the hospital.
The patient presented to the Docdrew University Hospital and was heparinized.
At that time his CKs were stable and his EKG did not show any
infarction. The patient had an echocardiogram and a Persantine
thallium stress test which was remarkably positive. The patient
developed substernal chest pain after one minute. The patient was
treated with 100 milligrams of aminophylline and two sublingual
nitroglycerines. His EKG revealed 2.5 millimeter ST depression in
leads 2 , AVf and V3-V6. His thallium images showed profusion
abnormalities in the posterolateral , anterior walls and also the
septum. The septum and apex were nearly completely filling in the
rest of the images.
The patient has now been transferred to the Pagham University Of for further evaluation and intervention.
PAST MEDICAL HISTORY: Included the above. He had a CABG in
1981 and by office report , had an SVG to the
LAD in D1 and also and SVG to the distal RCA on OM1.
ALLERGIES: No known drug allergies.
MEDICATIONS: On transfer , NPH insulin 12 units subcutaneously every bedtime ,
aspirin 81 milligrams orally every day , digoxin 0.25
milligrams orally every day , Glucotrol 10 milligrams orally every day before noon ,
gemfibrozil 600 milligrams orally every bedtime , Atenolol 100 milligrams
orally every day , nitropaste 1" every 8 hours , intravenous heparin 1000 units per hour ,
Colace 100 milligrams two twice a day
SOCIAL HISTORY: The patient works three times a week at the S
and he has a remote history of tobacco with
smoking 1-1-1/2 packs per day for 20 years , but also quit 20 years
ago. The patient drinks infrequently , but used to drink more in
the past.
FAMILY HISTORY: Positive for coronary artery disease in his
sister and his brother. His brother had a CABG
at age 73.
REVIEW OF SYSTEMS: The patient at this time denies any shortness
of breath , paroxysmal nocturnal dyspnea
orthopnea or dyspnea on exertion.
PHYSICAL EXAMINATION: Temperature 98.0 , heart rate 49-53 , blood
pressure 140/70 , respirations 20 , O2
saturation 96% on room air. In general , the patient seemed
comfortable. His sclera were anicteric. JVP was 5 centimeters
with good carotids. Lungs were clear to auscultation bilaterally
from anterior. Cardiovascular: Regular with a II-III/VI harsh
crescendo , decrescendo systolic murmur in the right upper sternal
border , and also a I-II/VI diastolic decrescendo murmur in the left
lower sternal border. Abdomen was soft , nontender and nondistended
with normoactive bowel sounds. Extremities showed 1+ pitting edema
to the mid shins. Neurologically , he was alert and oriented times
three. Extraocular movement are intact. Pupils are equal , round
and reactive to light , 3-4 millimeters bilaterally. Otherwise , his
examination was grossly nonfocal , but he has mild paresthesias
distally. Reflexes are 0 at the ankles , 0 at the ankles , but
symmetric and 2+ in the upper extremities.
LABORATORY: He has a normal SMA-7. His hematocrit is 41 with
WBCs 7.9 , platelet count 163 , 000. His CK is 104. His
LFTs are within normal limits.
His electrocardiogram shows sinus bradycardia at 51 with first
degree AV block and T wave inversions in 1 and L with ST-T wave
abnormalities in V4-V6.
His chest x-ray shows cardiomegaly with mild superior vascular
redistribution.
HOSPITAL COURSE: Mr. Raycraft was taken to the Cardiac
Catheterization Laboratory where a
catheterization revealed a left dominant system with a left main
that was okay and LAD was totally occluded proximally. The left
circumflex had 30% stenosis with 4-50% distal stenosis of the
bifurcation of the left PDA , also with a PDA of 80% lesion with PLV
of 40% and OM1 with a tubular 40% lesion. The RCA was totally
occluded at the ostial region , this was old. SVG to the LAD
looked okay , but the LAD itself distally had 90% lesions. The SVG
to the PDA to OM1 was totally occluded. The SVG to the diagonal
had a 95% ostial lesion. There was no MR. A PTCA was performed
with an SVG to the diagonal also with two 3.5 PS stents placed
resulting in 0% residual.
Also noted by Dr. Malekzadeh , is that the operative notes from Pagham University Of from 1981 says that there are two skip SVG
to the PDA to the OM1 , also SVG to the D1 , to the LAD which is
incorrect. There are actually separate SVGs to LAD and to D1 and a
third SVG must be totally occluded to the PDA to OM1.
After the catheterization , the patient was admitted to the
Cardiology Seypanard Vi Bend Team where he continued to be heparinized and
supported with rate control awaiting a second cardiac
catheterization which was to correct the distal LAD lesions. The
patient had an unremarkable hospital course and underwent his
second cardiac catheterization and PTCA on 10/15/97 which resulted
in the two distal LAD lesions which were each 90%. The patient
underwent PTCA to a residual of 10-20%.
The patient tolerated this procedure well and subsequently had a
very small left groin hematoma , but was otherwise okay. He
remained afebrile with stable vital signs and was discharged on
9/20/97 in good stable condition.
DISPOSITION/FOLLOW UP: The patient was discharged in good and
stable condition on 4/3/97. He will
follow up with Dr. Ruthann Parkos in 1-2 weeks. The patient also
will return to have his blood drawn for a CBC check in two weeks
and also in four weeks because he is discharged on Ticlid.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 milligrams orally
every day , Atenolol 100 milligrams orally every day ,
Captopril 25 milligrams orally three times a day , Gemfibrozil 600 milligrams
orally every bedtime , Glucotrol 10 milligrams orally twice a day , NPH insulin 12
units subcutaneously every bedtime , nitroglycerin 1/150 one tablet sublingually q.
5 minutes times three as needed chest pain , Ticlid 250 milligrams orally
twice a day times 14 days ( this was started on 10/10/97 ).
ACTIVITIES: As tolerated.
DIET: No added salt , low fat/low cholesterol , ADA 1800 calories.
OPERATIONS/PROCEDURES: Status post PTCA and stent placements times
two 10/10/97 and status post PTCA 3/8/97.
Dictated By: KELVIN MIRISOLA , M.D. RG28
Attending: SHAVONNE D. MAINER , M.D. QP3
CN489/7711
Batch: 84538 Index No. CWUBLMCSB D: 8/27/98
T: 4/1/98
Document id: 1003
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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098812026 | PUO | 57870793 | | 2975233 | 9/6/2004 12:00:00 a.m. | obstructive sleep apnea | | DIS | Admission Date: 7/28/2004 Report Status:
Discharge Date: 8/3/2004
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Na Ana
Service: MED
DISCHARGE PATIENT ON: 7/14/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DANIEL , CORAZON MERTIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL #3 ( ACETAMINOPHEN W/CODEINE 30MG )
1-2 TAB orally Q6-8H as needed Pain
OS-CAL ( CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) )
500 MG orally three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 80 MG orally every day Starting Today ( 7/18 )
LISINOPRIL 10 MG orally every day
Override Notice: Override added on 1/25/04 by
FIGURA , CAREY T. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
53123548 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 7/14/04 by DASE , ANNABEL D. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 6
METAMUCIL ( PSYLLIUM ) 1 TSP orally every day
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Dr. Meghann Christenson at Totin Hospital And Clinic to be scheduled by patient ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
obstructive sleep apnea
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) restrictive lung disease ( restrictive pulmonary
disease ) chf ( congestive heart failure ) fibromyalgia
( fibromyalgia ) von willebrand's ( hemophilia ) sleep apnea ( sleep
apnea ) iron deficiency anemia ( iron deficiency anemia ) hypoxia
( hypoxia ) GERD , history of TAH/BSO , PICA. ? central hypoventilation syndrome.
OA.
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
46f with morbid obesity , pulm HTN and OSA with
secondary CHF p/with mild CHF flare. Home o2 requ 4-6L now increased to
7-8L. Here for some diruesis , goal hco3 should not exceed 35.
97% 6L , afebrile , bp150/80 L base decrease sounds with fine
rales 1+ pit edema.
**********************hospital course***************************
1. PULM: admitted with mild worsening of chronic hypoxia related to
restrictive lung disease , obesity hypoventilation and obstructive sleep
apnea. Her baseline home oxygen requirement in 5-6L by nasal cannula
along with nasal BiPAP at night 16/8. She had decompensated to 7-8Lnc
and was complaining of dyspnea , both of which resolved with intravenous lasix
and 2-3liters negative diuresis. She is chronically deconditioned and
obese and refused to go to a rehabilitation facility , even pulmonary
rehab.
2. CV: followed by Dr. Cotey of cardiology; diuresed with intravenous lasix and
diamox with bicard between 30-35 during admission. No active ichemic i
ssue or arrhythmias noted during admission. Discharged on home
diuretic regimen of 80mg lasix orally every day with instructed to take an extra
pill once if she feels like her ankles are swelling or she is
particularly short of breath and no phone her physician.
3. ID: CXR negative for infiltrate , no fever no cough and no evidence
of pneumonia. Ms. Benkert had her influenza vaccination this year
already.
4. Social: SW consulted , patient lives alone , has no support network
and is chronically noncompliant with medical and dietary
recommendations. Cardiac and pulmonary social work have both been
involved in her care in the past. physical therapy consulted and recommended
pulmonary rehab , but patient refused. Her primary support is from an
internet friend who lives in Sterli Lane , Sa , North Carolina 51504 and despite bargaining with staff
about which medicines to take and when to discharge her , she was well
enough to go on her scooter to visit "friends" in the hospital and get
high salt food from Xandter Chosidetempe Ma She was discharged in stable condition with
oxygen back to her baseline levels of 96% on 5l nc and will follow up
with her pcp.
ADDITIONAL COMMENTS: Continue to eat a low salt , low total fluid diet. Follow up with your
primary care physician , you cardiology and your hematologist as
necessary. There are no increased oxygen requirements at this time. If
you feel like your ankles are swelling or you are having trouble
breathing , please take one extra lasix pill and call your physician for
further instructions.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: FIGURA , CAREY T. , M.D. ( VT32 ) 7/14/04 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 1004
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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203498769 | PUO | 62670674 | | 3533143 | 4/3/2004 12:00:00 a.m. | chestpain | | DIS | Admission Date: 11/11/2004 Report Status:
Discharge Date: 11/10/2004
****** DISCHARGE ORDERS ******
GLICK , PARIS 370-64-73-8
Son
Service: CAR
DISCHARGE PATIENT ON: 3/4/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BACHMANN , LASHANDA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled three times a day as needed Shortness of Breath
DILTIAZEM SUSTAINED RELEASE 120 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Number of Doses Required ( approximate ): 1
LASIX ( FUROSEMIDE ) 120 MG every day before noon; 80 MG every afternoon orally 120 MG every day before noon
80 MG every afternoon
LEVOXYL ( LEVOTHYROXINE SODIUM ) 125 MCG orally every day
NIFEREX-150 150 MG orally twice a day
FLOVENT ( FLUTICASONE PROPIONATE ) 44 MCG inhaled twice a day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
DIET: House / 2 gm Na / Low saturated fat
low cholesterol (FDI)
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please schedule an appointment to see your primary care physician in 1-2 weeks ,
You will be contacted with an appointment with Caryn Zangl ( LMC -CHF ) ,
You will be contacted with an appointment for a stress test at LMC ,
ALLERGY: DOXYCYCLINE HYCLATE
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chestpain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CHF with diastolic dysfunction ( congestive heart failure ) htn
( hypertension ) hyperlipidemia ( hyperlipidemia ) gout
( gout ) anemia ( anemia ) ovarian cyst ( ovarian
cyst ) migraine ( migraine headache ) asthma
( asthma ) history of tubal ligation ( history of tubal ligation ) hypothyroidism
( hypothyroidism ) history of thyroid resection ( history of thyroidectomy ) hematuria
( hematuria ) obesity ( obesity ) OSA ( sleep apnea )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Exercise stress test 7/25/04
BRIEF RESUME OF HOSPITAL COURSE:
51 year-old with history of diastolic dysfunction on lasix and no known CAD who
presents with subacute sx of worsening CHF and one day of
intermittent chest presure. She describes a substernal pressure that is
relieved after 10-15 minutes with burping. She also notes mild
associated SOB. She has had similar pain in past several times per
month , now occuring more frequently. patient has also noted worsening
exercise tolerance , orthopnea , and PND in last week. She states she
has been compliant with meds but missed 10/20 PM lasix dose. Also notes
eating 4 meals of chinese food in past week.
PMH: CHF with diastolic dysfunction , HTN , high cholesterol , gout ,
anemia , migraine headaches , asthma , hypothyroidism history of resection ,
obesity , OSA not on therapy
MEDS: same as discharge list with exception of prilosec which is new
ALLERGY: E'mycin --> GI upset
FHX: Mother had MI at 49 YO ,
SHX: no tobacco
EXAM:
VS: 97.0 86 117/77 16 100% RA.
GEN: NAD
NECK: JVD 10
CHEST: CTA
CV: RRR S1 , S2
ABD: soft , NT , ND , bowel sounds present
EXT: warm , no edema
EKG without changes.
LABS: Two sets cardiac enzymes negative.
HOSPITAL COURSE:
The patient was admitted to TVMH where she was diuresed with return
of symptoms to baseline. Underwent ETT which was nondiagnostic: 3'30" ,
patient had chest pain but no EKG changes. Admitted for cardiac PET scan to
r/o ischemia.
CV:
ISCHEMIA: No known CAD. Enzymes negative. She was unable to get PET
scan on D2 of admission. Her rule out was complete and her story was
felt to be low probability. The patient is on a statin and will be
continued. She is discharged with a plan to follow up at LMC for the
next available two day MIBI ( will be contacted ) to assess for
reversible ischemia. Patient was seen by Dr. Greif
PUMP: Symptoms of volume overload. The patient was continued on her
home lasix dose with improvement in symptoms. She is discharged on her
prior home regimen with plan to follow up with Caryn Zangl
( LMC -CHF ) and to follow her daily weights.
RHYTHM: The patient was followed on telemetry with no events.
PULM: H/p asthma , OSA. The patient was stable on her home inhalers
HEME: On Fe for anemia. No acute issues
ENDOCRINE: Patient was continued on levoxyl for hypothyroidism
FEN: Fluid restriction and sodium restriction
PROPH: PPI , lovenox
CODE: FC
DISPOSITION:
The patient is discharged on her prior medical regimen with the
addition of prilosec every day ( covered by her insurance ). She will be
contacted by LMC for the next available two day MIBI and with an
appointment to see Caryn Zangl ( LMC CHF ). She has been instructed
to make an appointment to see her primary care physician in 1-2 weeks. The patient agrees
to this plan
ADDITIONAL COMMENTS: 1. ) Please take your prior home medications
2. ) Please take Prilosec as directed
3. ) Please follow up with your primary care physician in one to two
weeks
4. ) Please return for any concerns but especially if your symptoms
worsen or if you feel short of breath , lightheaded , or increased chest
discomfort
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. ) Please take your medications as directed
2. ) Please weigh yourself when you get home and every morning. Please
call Caryn Zangl if you have any change in weight more then two
pounds.
3. ) Please eat a low sodium diet
4. ) Please return for any worsening symptoms
No dictated summary
ENTERED BY: HEIDELBERGER , LATICIA THADDEUS , M.D. ( VE083 ) 3/4/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1005
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
N |
N |
N |
N |
Y |
N |
- |
Y |
N |
N |
N |
972470178 | PUO | 65505285 | | 656541 | 8/9/2001 12:00:00 a.m. | PULMONARY EDEMA | Signed | DIS | Admission Date: 11/10/2001 Report Status: Signed
Discharge Date: 4/18/2001
PRINCIPAL DIAGNOSIS: CEREBRAL INFARCTIONS.
SECONDARY DIAGNOSES: 1. CONGESTIVE HEART FAILURE.
2. PAROXYSMAL ATRIAL FIBRILLATION.
3. CORONARY ARTERY DISEASE.
4. SICK SINUS SYNDROME STATUS POST DDDR
PACEMAKER.
CHIEF COMPLAINT: Briefly , this is an 80 year-old woman with
coronary history of hypertension , diabetes and
atrial fibrillation admitted to Osri Medical Center on the 12 of September for congestive heart failure and was at the time ,
diagnosed with receptive aphasia and a right hemianopsia. CT of
head was negative at that time and she was diagnosed with right MCA
stroke. She was started on anticoagulation as well as Lasix and
nitrites. Echocardiogram at the outside hospital revealed an
ejection fraction of 40 to 45%. She was transferred to the I Warho Hospital on the 3 of November for further evaluation
here.
PAST MEDICAL HISTORY: Notable for: 1. Sick sinus syndrome ,
complete heart block status post DDDR
pacemaker. 2. Paroxysmal atrial fibrillation. 3. DVT in 1992 ,
4. Right TKA , 5. Coronary artery disease , 6. CHF , 7.
Depression. 8. Diabetes. 9. Hypertension.
ALLERGIES: Include quinidine , procainamide and disopyramide.
MEDICATIONS ON ADMISSION: Include Heparin , Lasix , Insulin , Cozaar ,
Imdur , aspirin , Humulin and sotalol.
PHYSICAL EXAMINATION ON ADMISSION: Was notable for: She had a
temperature of 99.9 , blood
pressure of 108/54 , pulse of 78 , 95% on four liters. She is an
obese , elderly woman in no apparent distress. HEAD AND NECK: Exam
revealed orally mucosa was moist. Normocephalic , atraumatic. NECK:
Notable for JVD of 11 to 12 cm. , no bruits. LUNGS: Crackles 1/3
of the way up bilaterally. She had regular rate and rhythm with no
murmurs , rubs or gallops. ABDOMEN: Soft , benign. She had 1+
edema bilaterally; 1+ pulses. NEURO: Notable for alert and
oriented to time , place and person. Her language is notable for a
receptive aphasia. Her cranial nerves II through XII were intact
except for right hemianopsia. MOTOR: Gait was grossly normal.
Grip strength was 5/5 and symmetric. SENSORY: Grossly normal.
DTRs were 1+ and symmetric throughout. Toes were downgoing
bilaterally.
LABS ON ADMISSION: Were noted before of BUN , creatinine of 26/0.8 ,
K of 2.4. LFTs were within normal limits.
Initial CK was 42. She had an LDL of 42 , HDL of 30. TSH was 1.89 ,
Troponin was 0.12. White count was 10.2 , hematocrit of 31 ,
platelets of 156. Her INR was 1.3 , PTT was 35.7 , urinalysis
revealed 40 to 50 white cells , 1+ bacteria and 2+ leukocyte
esterase. Her chest x-ray was normal.
HOSPITAL COURSE BY ORGAN SYSTEM: 1. Neuro: The patient was
likely to have a left MCA stroke
at the outside hospital. Repeat CT at I Warho Hospital
confirmed these findings. She was continued on anticoagulation
since it was felt that most likely the etiology of stroke was
cardioembolic given her cardiomyopathy and cardiac arrhythmias. Of
note , she remained stable until the evening of the 10 of June when she
was found to have depressed mental status and new left hemiparesis.
Repeated head CT was unchanged and she was felt to have a new right
MCA stroke again due to cardioembolic causes. At this time , the
family made a decision to make her DNR/DNI. She was continued on
aspirin and started on full heparinization. Her neurologic status
remained stable and she has improved slowly. Her swallowing
improved and over the next several days ate normally. She
continued to have a receptive aphasia although this improved and
she was able to repeat although her naming remained poor. Physical
therapy and speech were consulted and followed the patient. She
continues to do well. Follow-up CTs have remained unchanged. She
will undergo a SPECT examination to confirm this stroke but
otherwise she has been transitioned to Coumadin for long-term
anticoagulation.
2. Cardiovascular: She is felt to have , given her new depressed
ejection fraction and Troponin leak , she was felt to possibly have
coronary disease and she was expected to go to coronary angiography
given her progressive neurologic symptoms. This was deferred and
she will be continued on conservative therapy including aspirin and
anticoagulation. She was felt to be in some congestive heart
failure and has been diuresed gently with some improvement in her
oxygenation and cardiac exam. Her rhythm should remain at AV paced
without any services.
DISPOSITION: The patient is to be referred to rehabilitation
center for further rehabilitation.
MEDICATIONS ON DISCHARGE: Include aspirin 81 mg orally every day , Colace
100 mg orally twice a day , Lasix 20 mg orally q.
d , NPH insulin 10 twice a day , Coumadin 5 mg orally every day , Betapace 80 mg
twice a day , Imdur 30 mg orally every day , Lovenox 80 mg subcutaneously every 12 hours , Cozaar
50 mg orally every day
Dictated By: VIOLET GREIGO , M.D. YU52
Attending: DEBERA Z. REPLENSKI , M.D. RS28
GT498/8315
Batch: 7730 Index No. Q9YDP56KA8 D: 9/1/01
T: 9/1/01
Document id: 1006
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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043180959 | PUO | 10481516 | | 917646 | 4/25/1997 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/20/1997 Report Status: Signed
Discharge Date: 10/17/1997
HISTORY OF PRESENT ILLNESS: Patient is a 76 year old woman with
asthma. Presenting problem was
shortness of breath. Problem list included anxiety , status post
cholecystectomy in 1988 , headaches , asthma , hypertension , vertigo ,
question of pneumonia in February 1996. Patient's cardiac risk
factors included a history of hypertension , she had no known
history of elevated cholesterol , she did not smoke , and had no
history of diabetes or family history of cardiac disease. She had
no prior myocardial infarction and no history of angina. The
patient did have a history of asthma with no prior hospitalizations
or steroid tapers. She did take orally Proventil at night and there
were no pulmonary function tests available on record. Two days
prior to admission , the patient noted sudden onset of inability to
sleep secondary to shortness of breath when lying down. The
patient tried her inhaler without relief of symptoms. She also
noted an intermittent nonproductive cough. The patient denied
fevers or chills. She reported that her symptoms did not improve
during the day and the night prior to admission , the patient noted
shortness of breath on exertion. She denied chest pain or chest
pressure. She had no diaphoresis , nausea , vomiting , or light
headedness. The patient presented to Pagham University Of
Emergency Department for persistent inability to sleep. On
evaluation in the Emergency Room , her blood pressure was 136/75
with a pulse of 124 , respiratory rate of 32 , and saturations of 94%
on room air. She was given nebulizers times three then 20 mg of
intravenous Lasix. She put out 600 cc of urine to that Lasix. The
Emergency Department then attempted to give her Verapamil 5 mg
times three to decrease her heart rate which was not effective.
The patient had no prior history of cardiac event. Her last
exercise test was in 1993. She went three minutes and five seconds
on the treadmill and stopped secondary to shortness of breath. Her
maximum heart rate was 130 with a maximum blood pressure of 190/80.
She had a baseline left bundle-branch block and therefore , her EKG
were not interpretable.
ALLERGIES: Patient had no known drug allergies.
CURRENT MEDICATIONS: Meclizine 25 mg three times a day , Proventil tablet 4 mg
orally every bedtime , oxazepam 10 mg orally every 8 hours ,
hydrochlorothiazide 25 mg orally every day , and Flexeril 10 mg orally every 8 hours
SOCIAL HISTORY: Habits included that patient did not drink alcohol
and she did not smoke cigarettes. Patient lived
at home with her family who were very involved with her care.
PHYSICAL EXAMINATION: Patient was an elderly Hispanic woman in no
acute distress. Vital signs included a
temperature of 98.2 , blood pressure 108/59 , pulse 101 , and
respiratory rates of 30 with saturations of 92% on three liters.
HEENT: Examination revealed a jugular venous pressure at 6 cm.
CHEST: Showed bilateral rales two thirds of the way up without
wheezes and no focal findings or egophony. CARDIAC: Examination
showed a regular rate and rhythm , tachycardic with a normal S1 and
S2 , no murmurs , and no S3 or S4. ABDOMEN: Showed a well healed
surgical scar , breath sounds present , no hepatosplenomegaly , and no
hepatojugular reflux. EXTREMITIES: Without edema , clubbing , or
cyanosis and she had 2+ symmetrical distal pulses. NEUROLOGICAL:
Examination was within normal limits.
LABORATORY EXAMINATION: SMA 7 was within normal limits with a BUN
of 15 and a creatinine of 1.0 , CBC showed
a white count of 9.45 , hematocrit of 36.5 , and platelets of 338.
CK was 110 and troponin was 0.0. Chest x-ray showed increased
heart size with bilateral increased interstitial markings
consistent with pulmonary edema and positive pulmonary vascular
redistribution. EKG showed normal sinus rhythm at 106 beats per
minute with normal intervals , an axis of negative 16 , a left
bundle-branch block , and no significant changes since 5/6/97.
HOSPITAL COURSE: Patient was admitted for new onset congestive
heart failure. She was ruled out for myocardial
infarction. On the second day of hospitalization , she underwent an
exercise tolerance test MIBI on which she went four minutes and
eleven seconds on a modified Bruce protocol. She stopped secondary
to fatigue. She denied chest pain , there were no EKG changes , and
she had several bursts of nonsustained supraventricular tachycardia
with exercise. Nuclear images revealed mild fixed reduced uptake
in the inferior wall consistent with a small injury but no evidence
of ongoing ischemia. An echocardiogram was also performed that
revealed a dilated left ventricle with global hypokinesis and an
ejection fraction of 15% to 20%. She had mild mitral calcification
with mild regurgitation , trace tricuspid regurgitation , and a
normal right ventricular size and function. It was determined that
the patient would benefit from afterload reduction and inatropy
given her poor ejection fraction. She was started on Captopril ,
Digoxin , and Isordil in addition to the Lasix she had received upon
presentation for her congestive heart failure. The patient
tolerated these medications well and maintained a systolic blood
pressure of approximately 100 without symptoms of orthostasis.
DISPOSITION: DISCHARGE MEDICATIONS: Proventil tablets 4 mg orally
every bedtime , enteric coated aspirin 325 mg orally every day ,
Flexeril 10 mg orally every 8 hours , Digoxin 0.0625 mg orally every day , Lasix 80 mg
orally every day , Isordil 10 mg orally three times a day , meclizine 25 mg orally three times a day ,
nitroglycerin 1/150 tablets taking one sublingually every 5 minutes
times three as needed chest pain , Serax 10 mg orally every 8 hours , K-Dur 20 mEq
orally every day , and Lisinopril 7.5 mg orally every day
FOLLOW-UP: The patient will follow-up with her primary care
physician , Dr. Squiers , at Masta Medical Center in
Cam Mont Fay Dr. Squiers will adjust her medications as
necessary and will arrange for an out-patient Holter monitor to
follow-up with nonsustained run of supraventricular tachycardia
during her exercise stress test.
Dictated By: FLORETTA M. THRONEBURG , M.D. KU51
Attending: NANCI GORT , M.D. OW2
HB712/8208
Batch: 61685 Index No. IYZF5W11FM D: 11/17/97
T: 6/6/97
Document id: 1007
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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148122316 | PUO | 20024969 | | 0943158 | 10/23/2006 12:00:00 a.m. | Chest pain 2/2 coronary artery disease | | DIS | Admission Date: 1/6/2006 Report Status:
Discharge Date: 8/3/2006
****** FINAL DISCHARGE ORDERS ******
LOTHAMER , DARBY 585-66-40-6
Sno Mi New
Service: CAR
DISCHARGE PATIENT ON: 10/16/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NOLAN , BYRON S.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 6/16 )
ENTERIC COATED ASA 325 MG orally DAILY
GLYBURIDE 2.5 MG orally DAILY
Alert overridden: Override added on 6/17/06 by :
on order for GLYBURIDE orally ( ref # 599820010 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: needs and tolerates at home
LEVOXYL ( LEVOTHYROXINE SODIUM ) 250 MCG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
75 MG orally DAILY Starting Today ( 6/16 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
ZOCOR ( SIMVASTATIN ) 40 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ISORDIL ( ISOSORBIDE DINITRATE ) 30 MG orally three times a day
FLOMAX ( TAMSULOSIN ) 0.4 MG orally DAILY
Alert overridden: Override added on 10/16/06 by :
on order for FLOMAX orally ( ref # 144544627 )
patient has a POSSIBLE allergy to Sulfa; reaction is Unknown.
Reason for override: home med
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
DR. CLAUSEL , HOYT , PUO CARDIOLOGY 8/22 @ 1pm ,
DR. ROSE , , primary care physician Wednesday , October , at 10:30 a.m. ,
ALLERGY: Sulfa
ADMIT DIAGNOSIS:
Chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chest pain 2/2 coronary artery disease
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) aortic stenosis ( aortic stenosis )
diabetes ( diabetes mellitus ) hypothyroidism
( hypothyroidism ) depression ( depression ) prostate cancer ( prostate
cancer )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
6/13/2006 LHC:
1. Right dominant
2. No significant LM lesions
3. LAD ( proximal ) discrete 1005 lesion after D1 origin. D1 widely
patent including prior stent. LAD ( mid ) with a discrete 100% lesion.
4. Cx ( proximal ) with a discrete 100% lesion.
5. RCA ( proximal ) with a discrete 100% lesion.
6. LIMA to LAD patent , but distal LAD occluded ( small vessel
disease )
7. SVG to Marg2 ( distal ) with a tubular 70% lesion
8. SVG to Right PDA ( ostial ) with a discrete 100% lesion.
9. Collateral flow from Marg2 to right PDA.
10. PCI: SVG TO MARG2 TO 0% W/ A 3.5 mm CYPHER POSTDILATED TO 4.0 mm
W/ GOOD RESULT.
BRIEF RESUME OF HOSPITAL COURSE:
IDENTIFICATION: 81M with a history of CAD history of 2-vessel CABG , redo LIMA to LAD ,
and PCIx4 admitted with 2 month history of increasingly frequent exertional CP.
HISTORY OF PRESENT ILLNESS:
Mr. Lothamer reports increasingly frequent exertional CP over the past 2
months that has been occurring about twice daily for the past 2 weeks.
Described as sub-sternal pressure , 5/10 , without radiation , and relieved
within 10-15 minutes of rest. Now occurring with walking 2-3 blocks at a
normal pace. Also describes near daily CP upon waking up , relieved
within 30 minutes of resting. Has not been taking sublingual nitro. CP not
associated with SOB , nausea/vomiting , nor diaphoresis. No PND , orthopnea ,
palpitations , nor LE swelling.
For evaluation of these symptoms , he underwent a cardiac MRI , myocardial
perfusion with adenosine stress that was abnormal. Cardiac cath. was
recommended , but he sought a 2nd opinion at an TH in Tucno Day Inland On
arrival to this TH on 10/27 , he was found to be diaphoretic and
orthostatic with an SBP as low as 70. He was thought to be volume-depleted
and admitted for further evaluation. No EKG changes were noted and
cardiac enzymes were negativex3. It was recommended to proceed to
cardiac cath. at TH . He chose to come to PUO ( b/c all of his cardiac
care in the past has been here ) and was transferred on 10/9 for elective
cardiac cath.
No CP , nor SOB at admission.
PAST MEDICAL HISTORY:
1. CAD history of 2-vessel CABG ( 1995 ) with SVG to Diag2 and OM1; subsequent
re-do LIMA to LAD; and then PCIx4 as follows: 22 of June , Diag1 rotablated;
30 of March Diag1 stented; 15 of May LAD beta-radiated; and 15 of May LCx ballooned
2. Aortic stenosis ( previous AVA 0.8 centimeters squared , peak
gradient 72 mmHg , and mean gradient 46 mmHg ) history of AVR with a
Carpentier-Edwards 23 mm pericardial valve , 2003
3. HTN
4. Type 2 diabetes mellitus
5. GERD
6. Prostate cancer , history of XRT and now on hormonal therapy
7. Hypothyroidism
8. Dyslipidemia
9. Benign prostatic hyperplasia
10. Depression
11. H/o incarcerated inguinal hernia history of repair
ALLERGIES: NKDA
MEDICATIONS:
1. Lasix 40 mg orally every day
2. Glyburide 2.5 mg orally every day
3. Imdur 30 mg orally twice a day
4. Lopressor 100 mg orally twice a day ( recently increased on 10/17/2005 )
5. Flomax 0.4 mg orally every day
6. ASA 325 mg orally every day
7. Levothyroxine 250 micrograms orally every day
8. Casodex and lupron every month for hormonal therapy of prostate cancer
SOCIAL HISTORY: Lives with wife. No EtOH. No smoking.
PHYSICAL EXAMINATION:
P 69; BP 168/80; O2 sat 97% , RA
NAD
JVP difficult to assess given body habits
Bibasilar crackles
RRR. S1 and S2 normal intensity. Grade 2/6 diamond-shaped murmur at RUSB
with minimal radiation.
+BS. Obese. ND/NT.
Trace pitting edema bilaterally in lower extremities
Alert and orientedx3
LABORATORY DATA , 10/28
1. WBC 5.6 ( N 63 , L 24 ); Hct 37.5; PLT 165
2. INR 1.0; PTT 28
3. Na+ 138; K+ 4.0; Cl- 101; CO2 27; BUN 18; creatinine 1.0; glucose
141
4. Mg2+ 2.2
5. Cardiac enzymes
a. CK: 45.57 .58
b. MB: 1.2.1.1.0.9
c. TROPONIN: <0.1.<0.1.<0.1
RELEVANT STUDIES:
1. EKG: Sinus rhythm ( rate 69 ). 1st degree AV block. QRS widened
~100 msec , no LAD. Slightly prolonged Qt at 471 msec.
2. 6/18 CARDIAC MRI:
a. Concentric LVH ( LVEDV 133 mL , LVESV 49 mL ) with normal global LV
systolic function ( LVEF~63% )
b. Small region of distal anterior hypokinesis
c. Basal to mid patchy septal subendocardial delayed enhancement
consistent with myocardial fibrosis or scar
d. On first pass perfusion imaging , mid anterior and basal to mid
inferior and inferolateral walls demonstrate moderate degree of segmental
reversibility c/with inducible ischemia in the mid LAD/diagonal and the RCA
territories.
e. Normal RV size and RV global and systolic function
f. Prosthetic valve in aortic position seen
4. 9/1 ECHO: Left ventricular hypertrophy ( LV posterior wall
thickness 12 mm ) with preserved systolic function. Estimated EF~60% with no
obvious RWMA. LVDD 4.2 cm/ LVSD 2.9 cm. Normal right ventricular size and
function. No AI. Mild MR. Mild TR. Normal pulmonary artery systolic
pressures.
OVERALL ASSESSMENT: 81M with a history of CAD history of 3-vessel CABG and PCIx4
admitted with 2 month history of increasingly frequent exertional CP and abnormal
adenosine-MRI. LHC with 3VD and successful PCI to SVG to Marg2.
HOSPITAL COURSE BY PROBLEM:
1. CARDS ISCHEMIA: Chronic stable angina with negative enzymesx3 and no
EKG changes. Recent abnormal cardiac MRI suggests progression of CAD.
6/13/2006 LHC demonstrated the following:
1. Right dominant
2. No significant LM lesions
3. LAD ( proximal ) discrete 1005 lesion after D1 origin. D1 widely
patent including prior stent. LAD ( mid ) with a discrete 100% lesion.
4. Cx ( proximal ) with a discrete 100% lesion.
5. RCA ( proximal ) with a discrete 100% lesion.
6. LIMA to LAD patent , but distal LAD occluded ( small vessel disease )
7. SVG to Marg2 ( distal ) with a tubular 70% lesion
8. SVG to Right PDA ( ostial ) with a discrete 100% lesion.
9. Collateral flow from Marg2 to right PDA.
10. PCI: SVG TO MARG2 TO 0% W/ A 3.5 mm CYPHER POSTDILATED TO 4.0 mm
W/ GOOD RESULT.
Received ASA and lipitor throughout his course. Briefly on integrillin
drops following catheterization , but discontinued following a
retroperitoneal bleed ( see below ). Had recurrent CP with ambulation on 6/16
- isordil was held in the a.m. , restarted in PM. No EKG changes. Discharged
on isrodil and toprol XL. Should be converted to imdur and uptitrated as
necessary
2. CARDS PUMP: Hypotensive on 10/27 likely 2/2 volume depletion. Was
orthostatic again on 10/5 a.m. following lasix and flomax. Again on 6/16
developed orthostatic hypotension after sustaining blood loss from
retroperitoneal blood; not symptomatic on 4/30 Encouraged orally intake and
held BP medications on 6/16 a.m.. Recommend that flomax be held
indefinitely; have restarted lasix 40 mg orally every day at discharge ( should
restart on 6/16 ).
3. CARDS RHYTHM: No active issues. On telemetry.
4. HEME: Cardiac cath. c/b retroperitoneal bleeding with Hct nadir to
30.8 on 6/16 a.m.. Hct stable at discharge.
5. ENDO
a. Home levoxyl 250 micrograms orally every day. TSH 1.862 and WNL.
b. Held home glyburide. On lantus 10 U subcutaneously every bedtime and RISS while
hospitalized.
6. PPX: PPI and heparin subcutaneously three times a day ( no lovenox in anticipation of cardiac
cath )
7. CODE: FULL
ADDITIONAL COMMENTS: Please take all medications and attend follow-up appointments. Please
seek medical attention again immediately if chest pain returns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
( 1 ) Please restart lasix 40 mg orally every day on 5/29 Have your primary care physician reeval
No dictated summary
ENTERED BY: MORGUSON , SHONNA A. , M.D. , PH.D. ( XP22 ) 10/16/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1008
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
- |
Y |
N |
- |
N |
Y |
Y |
- |
Y |
N |
N |
N |
N |
142676284 | PUO | 26550085 | | 611015 | 9/16/2002 12:00:00 a.m. | Septic R knee joint | | DIS | Admission Date: 10/20/2002 Report Status:
Discharge Date: 11/13/2002
****** DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 006-95-73-0
Son Down
Service: MED
DISCHARGE PATIENT ON: 9/10/02 AT 01:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ELLZEY , OREN R. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
CEFTAZ ( CEFTAZIDIME ) 1 , 000 MG intravenous every 8 hours
NPH INSULIN HUMAN ( INSULIN NPH HUMAN ) 14 UNITS subcutaneously twice a day
Starting Today ( 7/26 )
REG INSULIN HUMAN ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously before every meal & HS Call HO If BS > 400
For BS < 200 give 0 Units reg subcutaneously
For BS from 201 to 250 give 4 Units reg subcutaneously
For BS from 251 to 300 give 6 Units reg subcutaneously
For BS from 301 to 350 give 8 Units reg subcutaneously
For BS from 351 to 400 give 10 Units reg subcutaneously
OXYCODONE 10 MG orally every 4 hours as needed pain
Alert overridden: Override added on 8/15/02 by
DEMASE , JANNET M. , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
PHENANTHRENES Reason for override: will moniter
TOBRAMYCIN SULFATE 80 MG intravenous every 12 hours
PAXIL ( PAROXETINE ) 20 MG orally every day
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
MONOPRIL ( FOSINOPRIL SODIUM ) 40 MG orally every day
Alert overridden: Override added on 4/13/02 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
FOSINOPRIL SODIUM Reason for override: Will d/c potassium.
TRICOR 160 MG orally every day
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Call Dr. Enoch for an appointment in the next few days. ,
Dr. Shonna Saber , ID 11/15/02 ,
Call Thaes Terrah Hospital for a follow up appointment with Dr. Wagnon ,
ALLERGY: Morphine , Nsaid's , Ofloxacin
ADMIT DIAGNOSIS:
Presumed psuedomonas-infected R knee joint / chronic osteomyelitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Septic R knee joint
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
dm ( diabetes mellitus ) htn ( hypertension ) history of ex lap history of mva
( ) history of tkr ( history of total knee replacement ) chronic pseudomonas
osteomyelitis ( ) hypercholesterolemia ( ) chronic knee pain
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Right knee aspiration ( 1/11/02 ).
PICC line placement ( 7/19/02 ) , placement confirmed by CXR.
BRIEF RESUME OF HOSPITAL COURSE:
53F with chronic R knee pseudomonas osteomyelitis , DM , HTN.
patient sustained distal femur fracture in 1974 MVA , and had nonunion of
fracture , history of numerous surgeries , including TKR '97. patient has had
repeated pseudomonal infections of joint treated with ceftazidime &
tobramycin. Most recent surgery 21 of April patient had excision of draining
sinus tracts , and was treated with course of abx. patient did well until August
'01 when developed recurrence of knee swelling with occasional drainage
from knee , and reported more difficulty controlling blood glucose
level. Two days prior to admission , patient had fevers , increased pain , &
increased swelling of knee. Presented with decreased ROM ( from 80
degrees to only 5 degrees , with 2/2 pain ) , and inability to bear
weight.
HOSPITAL COURSE:
1. ID. Tx empirically with 80mg intravenous q12 tobramycin & 1000mg intravenous
q8 ceftazidime for presumed pseudomonal joint infection. At d/c , R knee
markedly improved , with decreased swelling , non-tender to palpation ,
decreased pain , increased ROM from 5 degrees at admit to >40 degrees ,
and now able to bear weight. Last spontaneous drainage from knee was
4/24 Theast Medical Center tapped joint ( prior to abx rec'd ) , which showed 13000WBC's ,
53000RBC's , and 3+polys. No crystals. No orgs on gram stain or on
culture. Knee films show no change from previously. No MRI done.
patient febrile while in hospital , to 103 on 11/10/02. Bcx x2 showed no orgs.
U/A negative. On admission: ESR 24 , CRP 2.57. PICC line was placed
for outpatient antibioitc therapy , and placement was confirmed by
CXR. patient to be treated with a 6wk course of tobramycin and ceftazidime
for a presumed pseudomonal infection of R knee.
2. CV. HTN. Contined on ACE-I with lisinopril while in hospital. BP's
in the 160's. EKG done ( to prepare for possible surgical operation ) was
nl. patient was restarted on usual dose of monopril at discharge.
3. PULM. CXR done to prepare for possible surgical operation. Showed
slightly decreased lung volumes but otherwise nl.
4. GI. Continued on Nexium given past history of GI bleed.
5. ENDO. DM. Given rash on forearm , Avandia held , and patient started on
Insulin NPH 10 Units twice a day , increased to 14U twice a day Needs f/u with
primary care physician for control of blood sugar , esp. since difficult to control in
the presence of intermittent infection.
6. PAIN. Well-controlled with oxycodone and neurontin.
7. HEME. physical therapy/PTT checked in case of operation , and were nl.
8. PSYCH. Continued on Paxil. No mood issues during her admission.
9. DISPO. D/c'ed in stable condition to home with VNA , with PICC line
for 6wk. course abx. Will follow up the Shonna Saber , ID on 1/14 at 11am
and will call primary care physician , Michal Enoch , for follow up in next few days
to evaluate blood glucose and adjust insulin dosing.
ADDITIONAL COMMENTS: Complete 6 wk course of ceftazidime and tobramycin recommendations.
Follow-up with Orthopedics and your infectious disease doctor , Shonna Saber
Your Glyburide 10mg twice a day was changed to NPH 10U twice a day for better control.
You will need to follow with primary care physician for adjustment of your insulin.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Will be d/c'ed with PICC line for 6 weeks of tobra/ceftax
antibiotics. Will f/u with Ortho and ID.
2. HTN controlled with ACE-I , but often in systolic 160's range. May
need further control by primary care physician.
3. Difficulty controlling blood sugars. To mid-200's. Have d/c'ed
glyburide and begun NPH , starting at 10U every day before noon and increased to 14U twice a day
Will d/c on insulin SS. Will need further follow-up and adjustment by
primary care physician.
No dictated summary
ENTERED BY: DEMASE , JANNET M. , M.D. ( ZC03 ) 9/10/02 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1009
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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593491386 | PUO | 67745627 | | 023579 | 10/29/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/10/1995 Report Status: Signed
Discharge Date: 2/18/1995
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE WITH UNSTABLE ANGINA.
SIGNIFICANT PROBLEMS: 1. STATUS POST CORONARY ARTERY BYPASS GRAFT
1980 , 1981.
2. STATUS POST LASER ANGIOPLASTY 1992 ,
1993.
3. STATUS POST MYOCARDIAL INFARCTION , 1978.
4. HYPERTENSION.
5. HYPERCHOLESTEROLEMIA.
6. SEIZURES.
7. DIET CONTROLLED DIABETES MELLITUS.
8. STATUS POST PACEMAKER PLACEMENT , 1993.
9. STATUS POST AAA REPAIR IN 1994.
HISTORY OF PRESENT ILLNESS: This is a 75 year old with a long
history of coronary artery disease who
presents with unstable angina.
The patient has a long history of stable and unstable angina ,
suffered a nonQ-wave myocardial infarction 2 of July
PAST CARDIAC HISTORY: 1978 - myocardial infarction. 1980 -
coronary artery bypass graft with porcine
mitral valve replacement. Saphenous vein grafts were performed on
the LAD , PDA arteries. 1991 - Repeat coronary artery bypass graft
because of recurrent angina , LIMA to LAD graft. 16 of August - Laser
angioplasty. 16 of February - Laser angioplasty. 28 of May - Episodes of TIA ,
seizures and was begun on Coumadin. 1 of May - Abdominal aortic
aneurysm repair , nonQ-wave myocardial infarction by enzymes at
Osri Medical Center .
Since July 1995 he has had worsening of his angina to the point
where he had it several times a week while walking very short
distances. He required prophylactic nitroglycerin before walking.
In the week prior to admission , the angina increased to several
times a day , requiring 2 or 3 nitroglycerins for relief where as
before required only 1.
On the day prior to admission , he had recurrent chest pain which
was unresponsive to nitroglycerin. He presents originally to the
Osri Medical Center ER where he was treated with intravenous nitroglycerin
and heparin and had recurring chest pain.
He was transferred to Pagham University Of for further
management.
At the Pagham University Of he ruled in for myocardial
infarction with CKs in the low 300s , MB of 29.8. He was taken to
the cath lab where an angiography showed an occluded left
circumflex and an occluded LAD path of the first diagonal and
occluded proximal RCA , occluded saphenous vein graft to the LAD and
occluded saphenous vein graft to his OM and patent LIMA to LAD and
saphenous vein graft to the PDA.
PAST MEDICAL HISTORY: As summarized above under significant
problems.
MEDICATIONS ON TRANSFER FROM OSRI MEDICAL CENTER : Isordil 20
three times a day , Lopressor 50 mg twice a day , Dilantin
100 three times a day , proscar 5 mg every day , Hytrin 2 mg every day , intravenous heparin and intravenous
TNG.
ALLERGIES: None known.
SOCIAL HISTORY: He lives with his wife , former employee of the
Clooa Turne Sagcraw Ave.
PHYSICAL EXAMINATION: Admission - Elderly , moderately obese man
in no current distress. Heart rate is 63 to
75 , blood pressure 108/64 , R 10-14. HEENT - Within normal limits.
Neck - No jugular venous distention. CV - Regular rate and rhythm
with a systolic 1/6 murmur at the right upper sternal border.
Lungs - Crackles 1/3 of the way up.
LABORATORY DATA: Admission - Normal electrolytes , creatinine ,
CBC - hematocrit 35 , platelets 43 , 000 , physical therapy/PTT
19.2 and 6.1 , respectively. CK were 311 and 333.
HOSPITAL COURSE: The patient was admitted to the CCU and was taken
to the Cardiac Cath Lab with cardiac
catheterization as detailed above. The decision at that time was
made that his findings were not amenable to angioplasty or to
surgical intervention. He was put on an intra-aortic balloon pump
following catheterization. Medications were increased to relieve
after load and decreased ischemia.
His course in the CCU was notable for continued episodes of chest
pain and difficulty weaning from the intra-aortic balloon pump. He
was seen by the cardiac surgery team and they did not feel he was
amenable to revascularization. In addition , he was not a candidate
for laser revascularization protocol under Dr. Murnane and that
protocol was closed.
On 8 of June the patient was successfully weaned from intra-aortic
balloon pump and did not have further chest pain at that time. He
was at this point using sublingual nitroglycerin prophylactically. On 24 of June
the patient was transferred to Cardiology Park Service.
On the floor , the patient continued to have episodes of chest pain
up to 2 or 3 times a day which were relieved with nitroglycerin sublingual.
On 14 of August he had more severe episode of chest pain refractory to 3
nitroglycerin and eventually improved with 6 mg of morphine and 10
mg of intravenous Lopressor. His pain had occurred at rest and lasted a
total of approximately one hour. After this event , the angioplasty
team was reconsulted concerning the possibility of addressing some
of the patient's cardiac lesions. It was agreed that this is a
high risk procedure but after extensive discussion with him and his
family; both decided to attempt an angioplasty of his LAD lesion.
He was briefly admitted to the UHT for intra-aortic balloon pump
prior to the procedure and subsequently on 26 of November underwent PTCA of
his distal LAD to a 30% residual stenosis. He also underwent PTCA
of his proximal LAD to residual 20% stenosis. He was successfully
and rapidly weaned from the intra-aortic balloon pump and
readmitted to the cardiology Ran Wa Heights service on 16 of August
The patient's subsequent course was characterized by decreasing
episodes of chest pain. He began to ambulate in his room and
subsequently around the Cape A Tempe without chest pain. He continued
throughout final week of hospitalization to have one episode of
chest pain on awakening , always relieved with 1 sublingual nitroglycerin
and occasionally relieved without any nitroglycerin.
On 24 of April , the patient was in good condition without angina ,
walking around the Cho Lu Cordafranfordette and scheduled to be transferred to Nemode Gatu Memorial Hospital He has also undergone anticoagulation
with Coumadin for his dyskinesis. He is discharged with a good
INR. He has upon discharge a 24 hour Holter monitor that is
pending which was performed to evaluate his pacer function.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day , Captopril 50 mg
orally three times a day , digoxin 0.25 mg orally every day ,
Lasix 20 mg orally every day , Isordil 10 mg orally three times a day , Mevacor 40 mg
orally every day , metoprolol 25 mg orally three times a day , sublingual nitroglycerin as
needed , Hytrin 2 mg orally every day , proscar 5 mg orally every day , Coumadin 3
mg orally every day
He is discharged in good condition to the Nemode Gatu Memorial Hospital and he will follow-up with his outpatient cardiologist ,
Dr. Jackson Part at the Osri Medical Center .
Dictated By: VERNON RANDKLEV , M.D. GY38
Attending: LEOLA C. MUSICH , M.D. VG64
WL209/1821
Batch: 052 Index No. BJZMU64HY0 D: 11/10/95
T: 11/10/95
CC: 1. LEOLA C. MUSICH , M.D.
2. SHAVONNE MAINER , M.D.
3. MARIBEL LUDGATE , M.D.
Document id: 1010
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756484975 | PUO | 14374811 | | 814056 | 11/22/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/5/1992 Report Status: Signed
Discharge Date: 10/24/1992
PRINCIPAL DIAGNOSIS: 1. Asthma exacerbation.
SECONDARY DIAGNOSES: 2. Coronary artery disease.
3. Chronic obstructive pulmonary
disease.
4. Sleep apnea.
5. Hypertension.
6. Obesity.
7. Tobacco history.
HISTORY: A 61-year-old female with a long tobacco
history of COPD , and recently diagnosed
sleep apnea is admitted with an asthma flare. In 1981 , she had a
DVT which required IVC filter placement. In 1983 , she had a
nonQ-wave MI and cath at that time showed an 80% proximal LAD
stenosis , 30% RCA stenosis treated medically. In October of 1991 ,
the patient had an exercise test in which she went four minutes
in 28 seconds , stopped because of fatigue and there were no
diagnostic EKG changes. PFT's at that time were reportedly
normal , although details are not available at this time.
In July of 1991 , further evaluation of the patient's dyspnea
included multiple normal EKG's , a low probable VQ scan. She was
treated with steroids and inhalers ( Bronchosol ) with good relief.
In September 1991 , the patient had recurrent dyspnea on exertion. She
ruled out for an MI at I Warho Hospital . Repeat Cath
showed an LAD stenosis of 40% , RCA of 80% and an ejection
fraction of 73%. She was discharged on medical management.
In February of 1991 , the patient was diagnosed with "asthma"/COPD
and had another rule out MI for dyspnea. At that time , she had
another ETT in which she went four minutes and 45 seconds ,
stopped secondary to chest pain , however , the EKG was
nondiagnostic. Thallium showed fixed anterior defects ( although
the effects overlying breast tissue cannot be ruled out ).
Bronchoscopy showed mild bronchitis and , since that time , she was
discharged on a prednisone taper which had gradually been tapered
down to 11 mg a day.
Of note , the patient also has been diagnosed with sleep apnea for
which she is on nasal CPAP. She sleeps in a chair due to
orthopnea and occasionally has paroxysmal nocturnal dyspnea.
The most recent pulmonary function tests ( January 1992 ) showed an
FEV1 of 1.76 , an FVC of 2.5 , ratio of 70% , DLCO of 28.3. A
twenty-four holter was negative for arrhythmias. Exercise test
at that time , she went nine minutes and had no ST changes.
Thallium images were again unremarkable.
One week prior to admission , the patient developed symptoms of
upper respiratory infection including sneezing , rhinorrhea ,
headache and had increased shortness of breath. Steroids were
increased as were nebulizers with symptomatic improvement. Over
the five days prior to admission , the patient had increasing
shortness of breath , wheezing worse at night. She denies fevers ,
chills , sweats , nausea , vomiting , chest pain , abdominal pain ,
cough , rash or joint pain.
In the Emergency Room , the patient was in marked respiratory
distress for which she was given nebulizer and begun on intravenous Solu-
Medrol. Peak flow at that time was 180.
Past medical history , COPD , coronary artery disease status post
nonQ-wave MI 1983. Obesity. Sleep apnea. Allergic rhinitis.
Status post cholecystectomy. Benign breast cyst resection.
History of labyrinthitis. History of Sjogren's disease with a
positive anti DNA antibody. History of DVT status post IVC
filter in 1983.
ALLERGIES: Sulfa has caused swollen mouth ,
Theophylline causes jitteriness.
MEDICATIONS: Albuterol nebulizers three times a day; Kay-Ciel
8 mEq every day; Prednisone 11 mg every day;
Guanfacine 600 mg twice a day; Verapamil 240 SR every day; Lasix 40 mg
twice a day ( every day if feels okay ). Cromolyn nebs every 6 hours ( rarely
uses ); Nasobid inhaler twice a day; Ranitidine every bedtime HABITS:
Tobacco history , quit approximately two years ago , rare alcohol.
PHYSICAL EXAMINATION: Obese , pleasant female in mild shortness
of breath initially but responded to
nebs and steroids. Otopharynx was clear. There was no thrush.
NECK: Supple. Carotids 2+. CARDIOVASCULAR: Regular rate and
rhythm , very distant. LUNGS: Decreased breath sounds at bases ,
scant wheezes , no crackles. ABDOMEN: Soft , nontender.
EXTREMITIES: Obese , no marked edema , although difficult to
assess secondary to obesity. SKIN: No visible lesion.
NEUROLOGICAL: Grossly within normal limits.
LABORATORY DATA: Potassium 3.6 , BUN 16 , creatinine 0.9 ,
white count 15.1 , urinalysis negative.
Chest X-ray , no significant disease except for a question of mild
CHF changes.
HOSPITAL COURSE: The patient was treated with intravenous
steroids , nebulizers , oxygen , and did
quite well. The trigger for her asthma remains illusive. She
underwent an esophageal acid study to rule out subclinical
aspiration ( results pending at the time of discharge ). There was
no infectious component to her exacerbation detected , although
preceding viral illness cannot be excluded. The patient was
treated with subcutaneous Heparin for DVT risks.
On hospital day number four , the patient was converted to
Prednisone without complications. She had no episodes of chest
pain and there was no evidence for ischemic etiology.
At the time of discharge , the patient's peak flows were greater
than 500 and her lung exam had cleared remarkably. She is
transferred to Nyno Ter Paou Medical Center for respiratory
rehabilitation on the following medications: Aspirin one tablet
orally every day; Atrovent puffers two puffs every 4 hours; Beconase nasal
inhaler two puffs every 6 hours; Heparin 10 , 000 units subcutaneous
twice a day; Pepcid 20 mg every bedtime; Prednisone 40 mg orally every day ( taper
as tolerated ); Albuterol nebulized treatments every 4 hours as
needed; Isordil 10 mg orally three times a day; Verapamil SR 240 mg orally every day;
Lasix 40 mg orally every day before noon as needed; Beclovent neb six puffs orally
four times a day
ADDENDUM:
Regarding the patient's esophagram results , the patient had a
48-hour esophageal pH monitor which showed that the patient has
reflux episodes and parameters which are within normal limits;
however , 4/7 cough episodes are correlated with the patient's
cough and asthma flares are possibly related to her reflux
symptoms; however , the study was not completely diagnostic.
Benefit from anti-reflux medications such as Reglan on a
diagnostic and therapeutic trial , we should also consider further
gastroesophageal reflux studies such as manometry as an
outpatient.
Dictated By: VIVIANA NEWBERT , M.D. WEAGRAFF , KATHLINE G.
TE482/0100 /
CARA NEVA KENEKHAM , M.D. WA5 D: 5/12/28
T: 8/6/92
Batch: Y217 Report: OP165U9 T:
Document id: 1011
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CHF |
Dp |
DM |
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GER |
Gou |
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567631637 | PUO | 50929184 | | 1000290 | 3/16/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Unsigned | DIS | Admission Date: 6/1/2006 Report Status: Unsigned
Discharge Date: 5/25/2006
ATTENDING: CADOFF , LINDY MD
PRINCIPAL DIAGNOSES: Urinary tract infection , congestive heart
failure.
LIST OF PROBLEMS/DIAGNOSES: Urinary tract infection , congestive
heart failure , mental status changes.
BRIEF HISTORY OF PRESENT ILLNESS: An 83-year-old man with
history of CHF , CAD , DM , baseline dementia , nonhealing Achilles
ulcer , and BPH transferred from an outside hospital for workup of
CHF flare , UTI , and mental status changes. The patient presented
to outside hospital from VLH with mental status changes ,
agitation , and nontraumatic fall. In the outside hospital ED ,
the patient had a positive UA growing gram-negative rods , an
elevated BNP , and a chest x-ray consistent with CHF exacerbation.
The patient was diuresed with Bumex and started on intravenous
levofloxacin. Subsequent chest x-rays showed improvement in
pulmonary edema. The patient was transferred to Pagham University Of for further workup of congestive heart failure.
PAST MEDICAL HISTORY: Diabetes type 2 , congestive heart failure ,
coronary artery disease , hypertension , depression , hearing loss ,
peripheral vascular disease , atrial fibrillation , neuropathy ,
BPH , hypothyroidism , glaucoma , factor VII deficiency , and anemia.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Smoked up to 5 packs per day beginning in the
teen years , quit in 1980. No history of ethanol or intravenous drug
abuse.
REVIEW OF SYSTEMS: The patient denies orthopnea , PND , headache ,
lightheadedness , fever , chills , nausea , vomiting , or diarrhea.
ALLERGIES: SULFA , rash.
BRIEF ADMISSION PHYSICAL EXAMINATION: Vital signs: Temperature
97.9 , heart rate 80 , blood pressure 96/60 , respiratory rate 18 ,
oxygen saturation 95% on room air. The patient is an elderly
man , well-appearing , in no apparent distress. Alert and oriented
to person , 9/12/2006 at KAAH . Poor historian , has difficulty
answering questions and following some directions. HEENT:
Normal conjunctiva , anicteric. PERRLA , moist mucous membranes ,
elevated JVP at 13-14 cm , positive hepatojugular reflex. Neck:
Trachea midline. Neck supple , no lymphadenopathy , normal
pharynx , no exudates. CV: No right ventricular heave. Normal
PMI , normal S1 , S2. Irregularly irregular rhythm , normal rate ,
no murmurs , rubs , or gallops. Pulmonary: Bibasilar crackles ,
left greater than right. No accessory muscle use , good air
movement throughout. Abdomen: Soft , positive bowel sounds ,
nontender , slightly distended , questionable ascites ,
cholecystectomy scar right upper quadrant. Extremities: Warm ,
well and well-perfused , 1+ pedal edema. No clubbing , no
cyanosis , 2+ DP , no digits on the right lower extremity , bandaged
ulcer on left Achilles. Neuro: No focal deficits. Cranial
nerves II-XII intact , moving all extremities.
PERTINENT LABORATORY DATA: Sodium 138 , potassium 3.5 , chloride
106 , bicarbonate 29 , BUN 33 , creatinine 1.4 , glucose 133 , white
blood cell count 6.5 , hematocrit 30.4 , platelets 185 , calcium
8.8 , BNP 866 , iron 26 , ferritin 31.3 , TSH 2.27 , trans ferritin
260 , TIBC 371 , troponin less than assay x2 , CK 41 and 62 , CK-MB
25. Urinalysis was cloudy , large LE , 3+ bacteria , 40-50 white
blood cells. ECG consistent with atrial fibrillation with a
moderate ventricular response , occasional PVCs apparently
conducted diffuse nonspecific ST-T abnormalities , left axis
deviation , no prior EKG for comparison.
OPERATIONS AND PROCEDURES: Chest x-ray performed on 1/1/2006
by Jacqulyn Harkley showing mild pulmonary edema. Echocardiogram
performed on 1/1/2006 by Nerissa Robblee showing no significant
change from previous done 8/10/2003. Ejection fraction of 25% ,
left atrium 5 cm mildly enlarged , global hypokinesia , no obvious
thrombi , PA SBP 57 mmHg. EEG performed on 5/25/2006 by Gerri Jiau was consistent with mild encephalopathy of toxic ,
metabolic , traumatic , or other origins. No definitive , focal , or
epileptiform features. Previous EEG done on 9/17/2006 revealed
similar findings. Head CT on 5/25/2006 by Shea Bohanan showed
prominent ventricles and sulci that appear appropriate for the
patient's age. No acute intracranial process.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular: The patient was admitted with an elevated
BNP and chest x-ray consistent with CHF flare , likely secondary
to UTI. On arrival to the floor , the patient was hemodynamically
stable and asymptomatic. EKG and one set of cardiac enzymes were
negative for cardiac ischemia and his home cardiac medications
were restarted. On examination , the patient had elevated JVP and
edema , suggesting that he was volume overloaded. The patient
responded to diuresis with torsemide 5 mg intravenous and metolazone 2.5
mg by mouth. He was switched to his home dose of torsemide 30 mg
orally and was euvolemic on discharge. Echocardiogram was
performed on 5/25/2006 to rule out structure etiologies for CHF
flare. Results showed no significant change from previous echo
done on 6/27/2006. The patient was on telemetry during the
hospital course and was noted to have atrial fibrillation with
premature ventricular contractions. He remained asymptomatic and
hemodynamically stable throughout the hospital course.
2. ID: UTI contributing to his CHF flare and MS changes.
Urinalysis was positive and the outside hospital reported
Gram-negative rods. The patient was continued on a 10-day course
of orally Levaquin. TP-IgG was negative.
3. Pulmonary: Chest x-ray on admission was consistent with mild
interstitial pulmonary edema. The patient remained asymptomatic
with no oxygen requirement. The patient responded well to
diuretic therapy for CHF flare.
4. Neurology: The patient's altered mental status was thought
to be secondary to urinary tract infection without metabolic
causes. B12 , folate , TSH , and T4 were within normal limits.
TP-IgG was negative. Iron was slow with small hypochromia on
smear , suggesting mild iron deficiency. EEG was also performed
on 5/25/2006 as this patient displayed fluctuations in cognitive
function that could be related to seizure activity. EEG was
nondiagnostic for epileptiform features. The patient was started
on Keppra 500 mg twice a day. His mental status appeared to be at baseline at
time of discharge
5. Renal: Creatinine 1.4 , baseline creatinine was monitored
during diuresis. Creatinine trended down to 1.3 on discharge.
Gross hematuria was present upon arrival to floor secondary to
patient pulling on catheter in his altered mental state. Bladder
scan ruled out obstruction and the bladder was irrigated to
remove clots. As the patient's mental status improved , he no
longer pulled on the catheter and the hematuria resolved. He
continued to have some bleeding around the catheter secondary to
BPH and the trauma from manipulation of the catheter.
6. Wounds: The patient had a nonhealing ulcer on the left
Achilles , recently seen at I Warho Hospital by Dr.
Authur , Plastic Surgery. He saw the patient and recommended
Panafil spray for the wound and frequent dressing changes. The
patient will follow up with Dr. Authur as an outpatient.
7. GI: Distended abdomen with question of ascites. LFTs
returned within normal limits , no indication for ultrasound.
8. Hematology: Hematuria as described above which resolved with
improved mental status. The patient's hematocrit remained stable
throughout the hospital course. The patient has a history of
elevated INR , resistant to orally and subcutaneous vitamin K.
Records from Flofry Bradlrel Memorial Hospital suggest that the patient has factor
VII deficiency. The patient had no episodes of uncontrollable
bleeding or symptoms suggesting anticoagulative state.
9. Endocrine: Continued the patient's home dose of Synthroid.
Diabetes type 2 covered Lantus 10 units and insulin aspart
sliding scale.
10: Fen: Potassium/magnesium scales. cardiac ,
low salt diet.
11. Prophylaxis: Proton pump inhibitor , Lovenox.
12. Code: The patient is DNR/DNI. There were no complications.
DISCHARGE MEDICATIONS:
Tylenol 650 mg every 4 hours by mouth , aspirin 81 mg once daily
by mouth , Dulcolax 5 mg daily by mouth for constipation , calcium
carbonate 500 mg 3 times a day by mouth , Celexa 20 mg daily , by
mouth , Colace 100 mg twice a day by mouth , Nexium 20 mg daily by
mouth , folate 1 mg daily by mouth , Imdur 30 mg daily by mouth ,
Keppra 500 mg twice a day by mouth , Levaquin 500 mg daily x1 by
mouth , Synthroid 137 mcg daily by mouth , lisinopril 5 mg daily by
mouth , lithium carbonate 150 mg twice a day by mouth , Lopressor
25 mg twice a day by mouth , Niferex 150 mg daily by mouth ,
Nystatin ointment topical twice a day for rash , Zyprexa 2.5 mg by
mouth at bedtime , Panafil spray applied topically to wound twice
a day , Zocor 20 mg by mouth at bedtime , torsemide 30 mg daily by
mouth , and zinc sulfate 220 mg daily by mouth.
DISPOSITION:
Stable. There are no pending tests. The patient will follow up
with primary care physician. He will make an appointment with Dr. Kalama The patient
will see Dr. Authur and Plastic Surgery at Pagham University Of for followup appointment for wound on April at
9:45 a.m. The patient is DNR/DNI. His healthcare proxy is his
daughter , Meg Wilday
eScription document: 1-3930374 PSSten Tel
Dictated By: HAENER , AMINA
Attending: CADOFF , LINDY
Dictation ID 7026710
D: 9/20/06
T: 9/20/06
Document id: 1012
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761661806 | PUO | 21953661 | | 7262722 | 3/12/2006 12:00:00 a.m. | LEFT LEG CELLULITIS | Signed | DIS | Admission Date: 4/8/2006 Report Status: Signed
Discharge Date: 11/8/2006
ATTENDING: EHLER III , DANIAL JADWIGA MD
SERVICE: Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS: Mr. Boreen is a 56-year-old
gentleman who underwent coronary artery bypass grafting x4 on
10/26/06 with left internal mammary artery to left anterior
descending coronary artery , a saphenous vein graft to the ramus
coronary artery , a saphenous vein graft to the second obtuse
marginal coronary artery , and a left radial artery graft to the
right coronary artery. The patient did well postoperatively. He
was discharged to home in stable condition on 10/18/06. The
patient noted his left lower leg to be warm and swollen with
redness and presented to see
Dr. Danial Ehler in clinic. Dr. Ehler placed the patient on
levofloxacin and vancomycin and had him admitted for left lower
leg cellulitis.
PAST MEDICAL AND SURGICAL HISTORY: Significant for hypertension ,
dyslipidemia , lumbar disc disease , nephrolithiasis , status post
cholecystectomy , status post coronary artery bypass graft as
stated above.
ALLERGIES: The patient has allergies to tetanus , where he
develops swelling.
MEDICATIONS ON ADMISSION: Toprol 25 mg daily , diltiazem 30 mg
three times a day , aspirin 325 mg daily , Lasix 40 mg daily , atorvastatin 40
mg daily , Tricor 145 mg daily , Zetia 10 mg daily , metformin 500
mg daily , and potassium chloride slow release 20 mEq daily.
PHYSICAL EXAMINATION: Five feet 10 inches tall , temperature 97 ,
heart rate 52 and regular , blood pressure right arm 142/76 , left
arm 148/76 , oxygen saturation 95% on room air. Cardiovascular:
Regular rate and rhythm with a 2/6 systolic murmur at the right
upper sternal border. Peripheral vascular 2+ pulses bilaterally
throughout. Extremities: Left anterior tibial cellulitis.
ADMISSION LABORATORY DATA: Admission labs , sodium 135 , potassium
4.4 , chloride of 101 , CO2 27 , BUN of 29 , creatinine 1.3 , glucose
of 113 , WBC is 11.62 , hemoglobin 11.9 , hematocrit 34.1 , and
platelets of 573. physical therapy 13.2 , PTT of 31.5 , and physical therapy/INR of 1.0.
Urinalysis was negative for urinary tract infection.
HOSPITAL COURSE: The patient was admitted for a left lower leg
cellulitis and was placed on levofloxacin and vancomycin.
Infectious disease consult was called , and recommendations were
followed , which were to discontinue the vancomycin and
levofloxacin , and change to Ancef 1 gm intravenous every 8 hours and monitor his
wound. The patient remained afebrile. White count trended down
and leg wound improved on exam. On the day of discharge , the
patient was noted to have an improved left lower leg wound , he
remained afebrile , and was evaluated by Dr. Ehler , and cleared
for discharge to home. Infectious disease wanted him to continue
on an orally dose of Augmentin 875/125 mg twice a day for a total of 10
days.
DISCHARGE LABORATORY DATA: Discharge labs are as follows ,
glucose 137 , BUN of 21 , creatinine 1.2 , sodium 136 , potassium
4.2 , chloride of 102 , CO2 of 26 , magnesium 1.8 , WBC is 11.11 ,
hemoglobin 12.6 , hematocrit 36.9 , and platelets of 695.
DISCHARGE MEDICATIONS: Discharge medications are as follows ,
Augmentin 875/125 1 tab twice a day for 10 days , enteric-coated
aspirin 325 mg daily , Lipitor 40 mg daily , diltiazem 30 mg
three times a day , Zetia 10 mg daily , Tricor 145 mg nightly , Diflucan 200 mg
daily for one dose for a penile yeast infection , due to
antibiotic use. Metformin 500 mg every afternoon , Toprol-XL 25 mg daily ,
and oxycodone 5-10 mg every 4 hours as needed pain.
FOLLOWUP: Mr. Boreen will follow up with Dr. Danial Ehler on
9/12/06 at 1 o'clock , Dr. Rossie Mankoski in three-four days , his
primary care physician , and his cardiologist , Dr. Cole Aini
in one to two weeks.
DISCHARGE INSTRUCTIONS: The patient was instructed to monitor
his leg wound and call if he had any increased weight ,
temperature greater than 101 degrees , any drainage from the
wound , redness , swelling or change of any kind in his leg wound.
He was cleared by Infectious Disease Service and discharged to
home in stable condition.
eScription document: 8-2192429 CSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: EHLER III , DANIAL JADWIGA
Dictation ID 4158221
D: 6/20/06
T: 6/20/06
Document id: 1013
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833886231 | PUO | 11020818 | | 759470 | 10/15/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/9/1996 Report Status: Signed
Discharge Date: 5/21/1996
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
OTHER PROBLEMS: 1. Poorly controlled hypertension.
2. Diabetes.
HISTORY OF PRESENT ILLNESS: Mrs. Hirschhorn is a 62-year-old woman with
cardiac risk factors of hypertension ,
diabetes , a positive family history , and coronary disease
documented by a prior myocardial infarction who presented with
increased leg swelling , a 21 lb weight gain over the last three
months and who was seen in Clinic on February , 1996 , by Dr.
Fiermonte , and was admitted for management. She had a myocardial
infarction in 1981 and , in September 1995 , she had a three vessel CABG
which included a LIMA graft to the LAD and two saphenous vein
grafts to the OM and to the PDA. In April 1995 , her postoperative
course had been complicated by loculated left pleural effusion
which required bronchoscopy and a left thoracentesis , as well as a
thorascopic lysis of pleural adhesions , some decortication and
drainage of effusions. At this time , she had also been dyspneic on
exertion along with shortness of breath at rest. On April , 1995 ,
she had an echo which showed an EF of 59% , a mildly dilated left
ventricle , abnormal septal motion secondary to left bundle branch
block , and minimal mitral regurgitation , and mild mitral
calcification above the normal right ventricular size and function.
A Bovie study was also performed and was negative. She also
presented with some biventricular failure and diuresis was
attempted , as well as alkaloid reduction. Over the past two
months , she had increased lower extremity edema , and she gained
approximately 21 lb since February , 1995. She has been quite
active and not limited. However , the edema has been her most
limiting factor. Three nights prior to admission , she had dyspnea
on exertion and some proximal maximal dyspnea , but she had no chest
pain and compression boots were attempted to try to alleviate some
of the edema. She had no orthopnea. She claims to have no dietary
indiscretions , no fevers , no sweats , no chills , no coughs , no chest
pain , no abdominal pain , and no bright red blood per rectum , but
she was more fatigued. On February , 1996 , she was seen in Clinic
by Dr. Fiermonte and was seen to have increased leg edema and
increased dyspnea on exertion with climbing stairs. An echo was
performed and showed decreased left ventricular function within an
EF of about 40% , decreased down from an EF of 59% documented in
April 1995. Her CKs were flat an troponin I level later documented
0.4 , which was negative. Echo report also showed some inferior
posterior hypokinesis , as well as significant tricuspid
insufficiency at 3.2 meters per second , which suggested PA
pressures of about 41 mmHg. The patient was subsequently admitted
for management of her congestive heart failure.
PAST MEDICAL HISTORY: Coronary artery disease , status post
myocardial infarction in 1981 , hypertension
with systolics in the 200s , which has been difficult to control ,
diabetes for which she has been on insulin. She has a history of
an amaurosis fugax in September 1995 and was started on Coumadin in January
1995. She has a history of the loculated pleural effusions and a
history of TIA while being on Coumadin. She also has a history of
kidney stones.
PAST SURGICAL HISTORY: CABG times three in 1995 , right CEA in
1993 , and right mastoid surgery.
ALLERGIES: Penicillin and Ceclor which cause a rash.
ADMISSION MEDICATIONS: Lopressor 50 mg orally four times a day , Coumadin 2.5
mg orally every bedtime , Zocor 20 mg orally every bedtime ,
Lasix 40 mg orally twice a day , Captopril 50 mg orally three times a day , insulin NPH
35 units every day before noon , Zantac 150 mg orally twice a day , Procardia XL 30 mg orally
as needed , and Slow KCl.
FAMILY HISTORY: Significant for mother who had a myocardial
infarction at age 40 and 60. Father died of a
myocardial infarction at age 40.
PHYSICAL EXAMINATION: The patient was a rather obese woman ,
totally edematous , who was slightly short of
breath while talking. Her vitals were 97.3 , 64 , blood pressure
211/100 , respiration rate 20 , and oxygen saturation of 96% on room
air. Her neck examination was significant for a jugular venous
pulse that went up to the angle of her jaw at 30 degrees. Her
carotid pulses were 2+ bilaterally showing no bruits , but there was
a right CEA scar. Her chest examination was significant for few
crackles at bilateral bases. Cardiac examination showed a normal
S1 , S2 , but with a faint S3. Abdominal examination had a positive
fluid wave , positive bowel signs , and she was tender in right upper
quadrant. Extremities showed 3+ pitting edema to knees
bilaterally. DP pulse was 1+ bilaterally and femoral pulses were
unable to be palpated. Her weight , at the time of admission , was
233 lb.
LABORATORY DATA: Laboratory values were unremarkable at the time
of admission. EKG showed normal sinus rhythm of
64 , left bundle branch block , and there was no change essentially
since September 1995. Chest x-ray , on admission , showed increased
interstitial markings bilaterally with perhaps a slight pleural
effusion. There was also some left lower lobe scarring and there
was an elevated left hemidiaphragm , which was consistent with
increased initial pulmonary edema.
HOSPITAL COURSE: The patient was diuresed with intravenous Lasix for the
first three hospital days , during which she lost
approximately 17 lb. She was then switched to orally Lasix on
hospital day four , and continued to diurese. She was placed on
strict fluid and diet restrictions throughout her stay. Her blood
pressure was controlled with a diuretic , as well as with a beta-1
blocker and ACE inhibitor and a small amount of nitrate. Her
calcium blocker was discontinued while we were trying to diurese
her. Her blood sugars ran low with her normal 35 units of NPH
dose , so the dose was held for a couple days and she was controlled
an CZI sliding scale and was resumed on 20 units of NPH. By
hospital day five , the patient was stable on the staple regimen.
DISCHARGE MEDICATIONS: Captopril 50 mg orally three times a day , Lasix 100 mg
orally twice a day , NPH 20 units subcutaneous
every day before noon , Isordil 20 mg orally three times a day , Lopressor 50 mg orally every 6 hours ,
nitroglycerin NTG 1/150 sublingual every 5 minutes times three as needed
chest pain , Coumadin 2.5 mg orally every bedtime , Zocor 20 mg orally every bedtime ,
Zantac 150 mg orally twice a day , KCl slow release 32 mEq orally twice a day ,
ofloxacin 200 mg orally twice a day times three days.
COMPLICATIONS: The patient had irritation of her bladder from her
Foley catheter and produced some bloody urine and
then upon discontinuing the Foley catheter had some burning of her
urine for which a urinalysis was performed. She was placed on
ofloxacin for three days.
DISPOSITION: The patient was stable upon discharge.
FOLLOW-UP: She is to follow up with Dr. Fiermonte on January ,
1996 at 12:30 p.m. during a scheduled appointment. She
is also to follow up with Nadia Wankum , her nurse at Norri Hospital to
follow up on her blood sugar control. The patient will also have a
VNA sent to see her three times a week for vital signs check ,
weight medical , pharmaceutical compliance , and her weights will be
called in to Dr. Fournier She should also improve upon her
physical therapy and increase her abilities for ambulation.
Dictated By: CARYN ZANGL , SDB 0
Attending: ALEXANDRA T. POPOVIC , M.D. ZU1
AV059/5350
Batch: 84944 Index No. Q6LSAU6JKH D: 8/12/96
T: 10/19/96
Document id: 1014
| Target |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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N |
745216306 | PUO | 88775779 | | 5951185 | 5/16/2006 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/11/2006 Report Status: Signed
Discharge Date: 10/20/2006
ATTENDING: TROJAN , LUISE M.D.
CHIEF COMPLAINT:
Chest and left arm pain , and left arm paresthesias.
HISTORY OF PRESENT ILLNESS:
This is a 47-year-old female with a past medical history , which
includes HIV positive , hepatitis C positive , seizures , and
neuropathy , who presented complaining of left hand paresthesias
followed by left hand pain that marches proximally up her left
arm and affecting her left shoulder and chest. Along with these
symptoms , she has associated shortness of breath , palpitations ,
lightheadedness , diaphoresis , and nausea. The patient notes that
these symptoms have been occurring approximately five times per
week over the past two months. She has notified her primary care physician of these
events , however , the etiology has never been identified. Of
note , the patient states that these symptoms have increased in
frequency since having two syncopal events , which occurred three
days prior to admission.
Regarding syncope , the patient recalls her first loss of
consciousness episode occurring three days ago in her bedroom.
There were no antecedent symptoms. She came back to
consciousness while on the ground , called out for help and her
daughter came immediately. There was no witnessed seizure
activity , no postictal confusion , no tongue trauma nor was there
any incontinence. A second episode of syncope occurred two days
prior to arrival while the patient was standing in the bathroom.
There was some preceding lightheadedness this time. The
post-event characteristics were the same. Again , the patient was
found by her son when she called out for help.
The patient denies prior history of syncopal events , however , she
does have a lifelong history of seizures and has not been taking
her Keppra for approximately a year , as her prescription has ran
out and she has failed to keep follow-up appointments with her
primary neurologist , Dr. Mateja Both the patient and her
daughter note that she usually has postictal confusion and that
these syncopal events did not fit that description. Furthermore ,
these episodes did not feel like her occasional hypoglycemic
episodes. Unfortunately , the patient's blood sugars were not
obtained during these syncopal events.
Of note , the patient recently started Flexeril to treat chronic
low back pain.
REVIEW OF SYSTEMS:
The patient admits stable three-pillow orthopnea , but new
paroxysmal nocturnal dyspnea , no lower extremity edema , weight
loss or increased abdominal girth. The patient has stable
four-block ambulation limited by dyspnea. She has had notable
weight loss as she has decreased in dress size from 18-14 over
the past nine months. She denies fevers or chills.
PAST MEDICAL HISTORY:
HIV positive , drug-seeking behavior , parotitis , migraine
headaches , anxiety and panic , depression , hepatitis C , seizures ,
neuropathy , pancreatitis , abnormal Pap smear , diabetes mellitus ,
cerebral aneurysm , herpes simplex type 1 , and chronic low back
pain.
ADMISSION MEDICATIONS:
Flexeril 5 mg daily , clonazepam 1 mg four times a day , Truvada one tablet
daily , Norvir 1400 mg twice a day , glyburide 5 mg every day before noon and 2.5 mg
every afternoon , Lomotil one tablet four times a day as needed , methadone 150 mg daily ,
Zofran 4 mg daily as needed , Percocet 325 mg/5 mg tablets one tablet
every 6 hours as needed , Zantac 150 mg twice a day , Zoloft 100 mg every day before noon , and
trazodone 100 mg nightly.
ALLERGIES:
Compazine , Bactrim , didanosine , gabapentin , cephalosporins ,
penicillin , clindamycin , stavudine , Tylenol No.3 , levofloxacin ,
clindamycin , tetanus , intravenous contrast , ibuprofen , abacavir and
ritonavir.
SOCIAL HISTORY:
The patient is from Irv Lerlong She is living with her daughter
and son. No prior tobacco or smoking history. She has a prior
history of drinking alcohol and intravenous drug use.
FAMILY HISTORY:
Negative for early coronary artery disease. Her father had an MI
at age 74. Her mother had coronary artery disease at age 76.
ADMISSION PHYSICAL EXAMINATION:
Temperature 97.8 , blood pressure 172/80 , heart rate 82 ,
respiratory rate 20 , and saturating 100% on room air. This is a
middle-aged woman appearing older than stated age , complaining of
left hand pain , but otherwise appears comfortable. She has a
disconjugate gaze , has only light vision in her left eye.
Sclerae are anicteric. Oropharynx is benign. She had no orally
ulcers or thrush. Neck is supple , without cervical
lymphadenopathy , no JVD , and no carotid bruits. Lungs are clear
to auscultation. Regular rate and rhythm , S1 and S2 , no murmurs ,
rubs or gallops. Abdomen was obese , soft , nondistended , and
nontender with questionable splenic fullness , no clubbing ,
cyanosis or edema. She had a 4 x 4 ecchymosis on her left
shoulder and a 2 x 2 scab over her left elbow. The soft tissue
extending from the left shoulder to left elbow was tender to
palpation as was the left chest. She had decreased sensation of
bilateral lower extremities and left. Aside from a disconjugate
gaze , cranial nerves were intact. Motor exam was intact. Gait
was slightly wide-based , but sufficient without cane. Negative
Romberg , negative pronator drift , and no dysmetria on
finger-to-nose bilateral , and deep tendon reflexes were 2+
throughout.
ADMISSION LABORATORY VALUES:
Sodium 138 , potassium 3.9 , chloride 103 , CO2 28 , BUN 13 ,
creatinine 0.7 , glucose 179 , calcium 9.2 , magnesium 1.6 , ALT 35 ,
AST 34 , alkaline phosphatase 57 , CK 51 , CK-MB 1.4 , troponin less
than assay , white count of 3.35 , hemoglobin 12.6 , hematocrit
36.7 , physical therapy 14.4 , INR 1.1 , and PTT 29.5.
ADMISSION DATA:
Chest x-ray was within normal limits. EKG was normal sinus
rhythm without ischemic change. CAT scan of the head was within
normal limits. Left shoulder and arm plain films were negative
for fracture or dislocation.
IMPRESSION:
This is a 47-year-old female with a history significant for HIV ,
diabetes , questionable cerebral aneurysm , and seizure disorder
( not taking Keppra for the past year ) , who recently had two
syncopal events without prodrome and without postictal state
( thus unlikely a seizure in etiology ) , who presented for
evaluation of left arm paresthesias and chest pain , with
associated diaphoresis , shortness of breath and nausea , which has
been intermittently occurring over the past two months.
During this admission , the patient had frequent recurrences of
her left arm and chest pain symptoms , which were related to
syncopal events. Thus , the medical team does not think that
these two issues are related. The patient underwent an extensive
syncopal evaluation , however , the etiology was never identified.
The etiology of the patient's left arm and chest symptoms and
syndromes also was not identified during this admission , however ,
the medical team suspects it may be related to a cervical spinous
process , potentially arthritis , disc herniation or nerve root
impingement. Please see below for more details. The remainder
of the dictation will be divided into system:
1. Cardiovascular: The patient underwent an extensive
cardiovascular evaluation , all of which was negative.
a. Pump: Given the patient's history of HIV and taking
antiretroviral , there was a concern about associated
cardiomyopathy. Echocardiogram that was performed was completely
within normal limits. The patient did not exhibit signs of
paroxysmal nocturnal dyspnea or orthopnea during this admission.
Dyspnea on exertion could be related to decondition.
b. Rhythm: The patient's telemetry history on 11/8/2006 was
notable for a nonsustained 5-beat run of wide complex tachycardia
with rates in the 150's. This was immediately followed by a
nonsustained 4-beat run of narrow complex tachycardia.
Cardiology consult was placed to review the telemetry strip and
to assess for referral to EP Service for potential AICD. Given
the negative echocardiogram , the Card Service wanted to rule out
ischemia-induced arrhythmia , so a MIBI was performed , and the
patient was started on low-dose beta-blocker and aspirin. The
adenosine MIBI was within normal limits. The telemetry strip was
reviewed by the EP Service and diagnosed the patient with
nonsustained SVT with aberrancy. The Card Service then advised
that there was no need for AICD. They stated that if tolerated ,
the beta-blocker could be continued and that the patient should
be set up as an outpatient for a loop recorder. This will be
coordinated through the patient's primary care physician. Of note , after starting
metoprolol 12.5 twice a day , the patient had occasional bradycardia to
the high 40's. Thus , it was determined that this medication
should be discontinued as it may be impairing the patient's
exercise tolerance.
c. Ischemia: Coronary disease risk factors include diabetes and
family history. She ruled out for a myocardial infarction , had
no ischemic change on her EKG , and had a negative MIBI. No
further workup for coronary artery disease was indicated. A
lipid panel was completely within normal limits and suggesting
treatment was not indicated.
d. Miscellaneous: On 6/10/2006 , the patient was evaluated for
one of her left arm and chest pain events. The patient was noted
to be diaphoretic and complained of nausea and shortness of
breath. The symptoms occurred while the patient was lying in
bed. Upon arrival by the team , her blood pressure was 90/56 ,
heart rate was 56 , she had poor pallor , was diaphoretic , and
described chest pain radiating up and down her arm. EKG in
telemetry during the event was normal sinus rhythm with any acute
ST or T-wave changes. The event spontaneously resolved in less
than 15 minutes without medical intervention.
2. Neuro: The patient has a history of convulsive seizures and
has been noncompliant with Keppra for the past 12 months because
she failed to keep neuro appointment with Dr. Wantuck and has
been unable to obtain refills. Per the patient , her recent
syncopal events were without prodrome and without postictal
state. Thus , were unlikely prior seizures and unlikely seizure
in focus. An EEG was performed during this admission and
demonstrated no definite focal or epileptiform features. Keppra
was restarted at 250 mg twice a day with a goal to increase to 500 mg
twice a day after 7 days and to 750 mg after another week. There was
a question of a history of cerebral aneurysm , diagnosed at an
outside facility , which was never confirmed by Totin Hospital And Clinic imaging. MRI of the brain and MRA of the head and neck
obtained this admission was negative for hemorrhage , mass , edema ,
hydrocephalus , infarction , and negative for abnormal enhancement.
There was no aneurysm high-flow AVM or stenosis found , and MRA
of the neck had no significant abnormality. The patient's
neurologist , Dr. Wantuck , was aware of this admission. A
follow-up appointment has been made.
3. Endocrine: History of diabetes type II , hemoglobin A1c of
6.1 , reflects excellent outpatient glycemic control , however , the
patient reports becoming diaphoretic with normal glycemic levels
between 80 and 100. Given recent weight loss without glyburide
dose adjustment , the medical team decreased glyburide to 2.5 mg
daily for the patient to begin upon discharge. During this
admission , the all orally agents were held and the patient was
treated with the Kernan To Dautedi University Of Of insulin protocol.
4. Infectious disease: The patient has a history of HIV
positive , CD4 count on 11/21/2006 was 217. The viral load was
less than assay. The patient continued on Truvada and Lexiva.
The patient complained of dysuria on 7/26/2006. Urinalysis was
ordered , but symptoms resolved before specimen could be sent the
lab.
5. Pain: History of chronic pain and lumbar spine herniations.
The methadone dose of 155 mg was confirmed with the outpatient
clinic. No additional regular narcotics were given during this
admission.
6. Heme: The patient has chronic pancytopenia. She has a
normocytic normochromic anemia with normal iron studies , B12 and
folate , and a low reticulocyte index consistent with anemia of
chronic disease , likely from HIV immunosuppression.
7. Miscellaneous: The patient was screened by the Physical
Therapy Service who recommended a home safety evaluation. This
will be coordinated to the Hollankfre Visiting Nurses Association.
Given the liability and predictability of events , the team
implemented a 24-hour urine collection to assess for
pheochromocytoma. The results of the studies are pending at the
time of this discharge. The patient may have autonomic
dysregulation as part of her diabetes. Alternatively , the
medical team speculates that the patient may have cervical spinal
arthritis , lumbar herniation or nerve root impingement
contributing to these symptoms. Of note , the patient states that
these episodes had occurred more frequently inpatient and they
were at home. It was until the day of discharge that it was
noted that the patient was not receiving her Klonopin 1 mg four times a day
as she had prior to admission. In fact , she has only received
three doses of Klonopin over a six-day period. It is unclear
what role anxiety is playing into these events. On the day of
discharge , the patient stated that she was making arrangements to
see an orthopedic specialist at Cloud Hospital for
evaluation of her cervical spine.
FINAL DIAGNOSES:
1. Syncope , not otherwise specified.
2. Left arm pain/left chest pain/left arm paresthesias ( not
otherwise specified ).
DISCHARGE MEDICATIONS:
Ecotrin 81 mg daily , clonazepam 1 mg every 6 hours as needed , Imodium one
to two tablets four times a day as needed for diarrhea , Truvada one tablet
orally daily , Lexiva 1400 mg orally twice a day , glyburide 2.5 mg daily ,
Keppra 500 mg twice a day for 14 doses and then 750 mg twice a day
indefinitely , methadone 155 mg daily , Zantac 150 mg twice a day ,
Zoloft 300 mg daily , trazodone 100 mg at bedtime as needed , and
Zofran 4 mg daily as needed for nausea.
MEDICAL FOLLOW UP:
On 10/24/2006 , the patient is scheduled to see her primary care physician , Dr. Jona Byron On 10/21/2006 , she is scheduled to see her psychiatrist ,
Dr. Latasha Hoisl On 4/8/2006 , she is scheduled to see
her Infectious Disease , Dr. Ghislaine Rafus On 7/6/2006 , she is
scheduled to see her neurologist , Dr. Irwin Mateja In
addition , the patient is going to be followed by the Jer Palm Co VNA
who will do a medication reconciliation and home safety
evaluation.
SPECIFIC INSTRUCTIONS:
1. Take medications as listed , clarify discrepancies with your
primary care physician. This means stop taking Flexeril , ____ glyburide has been
changed to 2.5 mg , and low-dose aspirin has been started.
2. If you faint again , you should return to the ER for
evaluation.
3. If your chest pain symptoms recur and persist longer than the
typical course , call your primary care physician and/or return to the emergency
room.
4. Make an appointment with the Cloud Hospital to evaluate
the cause of her left arm symptoms.
5. Check your blood sugars before meals and at bedtime , record
and bring your results to your follow-up appointment.
SPECIFIC INSTRUCTIONS FOR THE primary care physician:
1. Please arrange for a loop monitor.
2. Follow up on a 24-hour urine studies assessing for
pheochromocytoma.
3. Adjust the patient's diabetes management as needed.
eScription document: 5-3125043 EMSSten Tel
Dictated By: HOLLWAY , TABATHA
Attending: TROJAN , LUISE
Dictation ID 6539644
D: 10/15/06
T: 10/15/06
Document id: 1015
| Target |
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Dp |
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GER |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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948000308 | PUO | 27088839 | | 0391334 | 10/16/2003 12:00:00 a.m. | hypertensive encephalopathy | | DIS | Admission Date: 10/16/2003 Report Status:
Discharge Date: 4/9/2003
****** DISCHARGE ORDERS ******
NOVITSKY , JAYMIE M 201-91-91-0
Jose
Service: NEU
DISCHARGE PATIENT ON: 3/10/03 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAGEL , JOETTE ZADA , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
ATENOLOL 50 MG orally every day Starting IN a.m. ( 4/4 )
HOLD IF: SBP<120 , HR<55
ATORVASTATIN 40 MG orally every day
HYDROCHLOROTHIAZIDE 25 MG orally every day
AMLODIPINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FOLATE ( FOLIC ACID ) 1 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr. Borriello 3-4 weeks ,
carotid ultrasound 5/5/03 scheduled ,
ALLERGY: Losartan , Perfume
ADMIT DIAGNOSIS:
stroke
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hypertensive encephalopathy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HYPERCHOLESTEROLEMIA HTN DEPRESSION CAD history of MI '84 ( coronary artery
disease ) , recurrent left Bell's palsy , obesity ( obesity ) allergic
rhinitis ( allergic rhinitis ) , history of TIA vs. stroke , obstructive
sleep apnea , chronic renal insufficiency
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT head without contrast
BRIEF RESUME OF HOSPITAL COURSE:
59 year-old right-handed woman admitted for suspected acute stroke. Her
PMH includes HTN , hypercholesterolemia , prior TIA vs. stroke 10/26
( manifest as slurred speech , left arm and leg weakness ). prior
myocardial infarction ( 1984 ) , and history of left Bell's palsy x 3 with
chronic weakness of facial expression muscles on the left. She had a
possible patent foramen ovale with agitated saline contrast passage on
valsalva maneuver TTE when she was admitted 11/25 for stroke work-up.
Recently , this woman has had 2-weeks of general fatigue , exertional dys
pnea , frequent headaches , and intermittent blurred vision while driving
followed by a 2-3 second episode of binocular visual loss 4/13/03.
Notably , she ran out of amlodipine and reports obtaining a level of
240/150 on self-monitoring. One day prior to admission she saw her primary care physician
who noted hypertension and referred her to an ophthalmologist , who
obtained a normal exam by report.
She awoke this morning with a more severe right frontal headache with
pain radiating to the right shoulder. She also experienced a problem
with gait , leaning to the right. Her husband phoned EMS because she had
a severe headache and seemed "confused." At present , the patient denies
headache and confusion , as well as diplopia , vertigo , dysphagia , and
dysarthria. She denies recent chest pain , but has had orthopnea.
PMHx: hypertension , hypercholesterolemia , prior TIA versus stroke ,
prior myocardial infarction ( 1984 ) , obstructive sleep apnea , recurrent
left Bell's palsy , allergic rhinitis , chronic renal insufficiency
( baseline creatinine around 1.5 )
Meds: ASA 81 , HCTZ , atenolol , amlodipine , atorvastatin , loratadine , as needed
albuterol
All: iodinated contrast , losartan
VS: T 97.2 HR 57 BP 150/90
GEN obese woman , comfortable HEENT sclerae anicteric , orally mucosa moist
NECK: no bruits
HEART mild bradycardia , regular rhythm , II/VI SEM at USB ABD soft ,
nontender , nondistended EXT: no cyanosis , clubbing , or edema; radial
and dorsalis pedis pulses 2+
NEURO: MS significant for no deficits on orientation , attention , langua
ge , memory , and praxis. CN exam significant for right hypertropic skew ,
left facial droop , mostly lower face but with weak eyebrow raise as
well. Motor exam with normal tone , no pronator drift , strength 5/5 in
all muscle groups in upper and lower extremities. Coordination exam
with slightly slowed fine finger movements , right hand , normal
performance on finger-nose-finger and heel-knee-shin , sensory exam
without deficits in light touch , temperature , vibratory sensation ,
reflexes 2 throughout except for 1 in the ankles , toes downgoing
bilaterally. GAIT slightly wided based but stable gait with upright
posture , normal arm-swing. No difficulty with heel , or toe walk. Falls
to left on tandem gait.
Non-contrast head CT negative for evidence of stroke or hemorrhage.
Hospital course: the patient was admitted with hypertension and recent
headaches , visual changes ( blurred vision ) , change in gait ( inability
to walk in heels ) , and recent confusion. Neurologic exam was
significant for right hypertropic skew without diplopia , left facial
weakness that is old per patient and LMR notes , mild slowing of right fine
finger movements , and tendency to fall towards the left on tandem gait.
These findings do not localize well and the differential diagnosis
was felt to include cerebral ischemia/infarction and hypertensive
encephalopathy. The patient had recent poorly-controlled
hypertension as well as symptoms of possible heart failure including
exertional dyspnea and orthopnea.
An MRI was ordered to evaluate for possible stroke or hypertensive
encephalopathy. Unfortunately , the patient was not able to tolerate the
procedure , citing claustrophobia from a traumatic childhood experience
as a prohibitive factor. Her atenolol was continued and she was placed
on aspirin 325 mg every day for stroke and heart prophylaxis. Her blood
pressures remained well-controlled throughout admission and she
remained asymptomatic , without recurrent headache , confusion , and
weakness. Her fine finger movements with the right hand were improved
by hospital day 2. She continued to have difficulty with tandem gait ,
falling to the left. Her lipid profile revealed elevated total
cholesterol and LDL. Her homocysteine level was slightly elevated at
14. She was instructed to raise her dose of atorvastatin as well as
supplement her diet with folic acid. She has an outpt appointment for
carotid non-invasive studies 10/25/03.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Fair
TO DO/PLAN:
The patient should take a full dose of aspirin ( 325 mg ). She should take
folate supplementation. She should also discuss raising her dose of
atorvastatin ( Lipitor ) with her primary care physician , because her cholesterol and LDL
were elevated this admission.
No dictated summary
ENTERED BY: MARATRE , BRYAN RUBIE , M.D. ( HA75 ) 3/10/03 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1016
| Target |
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CHF |
Dp |
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GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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800843851 | PUO | 29407184 | | 128041 | 4/20/1998 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 4/20/1998 Report Status: Signed
Discharge Date: 7/19/1999
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
SECONDARY DIAGNOSES:
1. CORONARY ARTERY VASOSPASM.
2. HYPERTRIGLYCERIDEMIA.
3. PROTEINURIA.
4. GASTROESOPHAGEAL REFLUX DISEASE.
5. HYPERTENSION.
6. GOUT.
OPERATIONS/PROCEDURES: On 4/25/98 , cardiac catheterization and
echocardiogram.
HISTORY OF PRESENT ILLNESS: Mr. Candice Izola Otha Signs is a 52 year old Asian
male with known coronary artery
disease and extensive cardiac history , including: ( 1 ) In 1988 , the
patient had a CABG x2 vessels ( LIMA to LAD and RIMA to PDA ); ( 2 )
PTCA to PDA in 1994; ( 3 ) PTCA of LAD ( proximal to LIMA and left
circumflex ) including stent in 10/6 The patient discharged
himself AMA at that time. ( 4 ) The patient was admitted on 10/17/98
for symptoms consistent with CHF. He had a dobutamine MIBI at that
time , which was markedly positive with significant ST changes in
the inferior leads. He underwent a cardiac catheterization , where
a 90% long instant restenosis was found in the left circumflex.
The area was rotablated , and then angioplastied. During the
procedure , the patient experienced episodes of asystole. A V-pacer
was placed. The pacer was D/C'd the next morning , and the patient
was discharged home on 11/17/98.
Since that time , the patient states he has been pain free , except
when he exercises on the treadmill. He , therefore , takes one
sublingual nitroglycerin before and one after the treadmill.
However , the patient now reports that he has developed rest angina
over the past two weeks. The patient states that he has every day
rest pain , with approximately 1-3 episodes per day relieved by one
sublingual nitroglycerin and lasting for minutes of each episode.
On the day of admission , the patient presented to his primary care
doctor at VH for upper respiratory infection symptoms , which
started approximately on 7/15/98. The patient felt chest pain
again while walking up the stairs to his doctor's office. He
reported this to the doctor , and was sent to I Warho Hospital for further evaluation.
On presentation , he denies nausea , vomiting , or arm tingling. He
does report occasional shortness of breath and intermittent
paroxysmal nocturnal dyspnea , ? no orthopnea. He sleeps with one
pillow. His other review of systems was positive for productive
cough over the past week , yellow phlegm , no fevers or chills ,
diarrhea , or other. He was pain free in the Emergency Room. The
patient was therefore admitted with a diagnosis of unstable angina
for further evaluation. He was heparinized in the Emergency Room.
PAST MEDICAL HISTORY: ( 1 ) Coronary artery disease status post a
CABG in 1988; ( 2 ) PTCA in 1994; ( 3 ) Status
post rotablation in 11/25 ( 4 ) Hyperlipidemia; ( 5 ) Focal/segmental
glomerulosclerosis. His peak creatinine was 3.4 after his last
dye; ( 6 ) Chronic renal insufficiency; ( 7 ) Gout; ( 8 ) Status post lap
cholecystectomy in 1997; ( 9 ) No history of diabetes mellitus.
MEDICATIONS: Lisinopril 20 mg orally every day; Lopressor 100 mg orally
twice a day; Ecotrin 325 mg orally every day; nitroglycerin sublingual
as needed; simvastatin 20 mg orally every day; Vitamin E 400 U orally every day;
Prilosec 20 mg orally every day; allopurinol 200 mg orally every day
ALLERGIES: He is allergic to Naprosyn , which causes renal
dysfunction.
SOCIAL HISTORY: He has a history of four packs per day for 20
years and quit years ago. No alcohol or other
drugs.
FAMILY HISTORY: Notable for a sister status post CABG.
PHYSICAL EXAMINATION: VITAL SIGNS: Temp 97.8 , heart rate 67 , BP
146/98 , satting 95% on two liters. GENERAL:
This is an Asian male in no apparent distress. HEENT: His eyes
were anicteric , PERRL , EOMI. Oropharynx showed moist mucous
membranes. NECK: JVP approximately 10-11 cm of water , with no
bruit. HEART: He had a II/VI systolic ejection murmur in the
right and left upper sternal border , and positive S4 , no S3.
LUNGS: Rales 1/2 to 3/4 of the way up on the left side. The right
was clear to auscultation. ABDOMEN: Obese. He had bowel sounds
and no masses. EXTREMITIES: No clubbing , cyanosis , or edema. He
had 2+ dorsalis pedis pulses.
LABORATORY DATA: Chest x-ray was a poor film. It was an AP done
only. It showed no obvious infiltrates. EKG
showed sinus brady- , with first degree AV block and no acute ST or
T-wave changes. Laboratories on admission showed a BUN and
creatinine of 9 and 1.4. White count 6.37 , hematocrit 43 ,
platelet count 146. CK 90 , troponin-I 0.06. His protein was 12.3 ,
INR 1.1 , PTT 32.7.
HOSPITAL COURSE: Mr. Signs was subsequently admitted for R/O MI , and
unstable angina. The patient was did R/O for MI
by EKG and enzymes. He was heparinized and continued on all of his
medications that he presented on , and he was also continued on
nitropaste sliding scale to keep him pain free.
On hospital day #1 , the nitropaste was taken off , given that the
patient had a headache. In the evening , however , the cross-cover
intern was called as the patient developed 4 out of 10 chest pain
with deep breathing , which the patient stated felt like his typical
angina. Therefore , the nitropaste was restarted and the patient
was pain free within approximately two minutes.
The patient underwent an echocardiogram on hospital day #2 , which
showed an EF of 60-65% , 1+ MR , and borderline inferior hypokinesis.
He had an ETT MIBI done on 9/17/98. He exercise approximately 9
minutes and 45 seconds and stopped secondary to his chest pain and
fatigue. His peak heart rate was 89 , and BP 170/98. He had
horizontal downsloping of 1 mm , ST depression in the inferior leads
and V5-V6 , which was persistent in recovery. He got one sublingual
nitroglycerin given. On the images , it showed: ( 1 ) Moderate to
severe ischemia of the inferior wall and the posterior septum ( RCA )
7 out of 20 segments; ( 2 ) Mild ischemia of the anterior wall and
septum ( LAD ) 4 out of 20 segments; ( 3 ) An EF of 59%. The patient
was continued on heparin , nitropaste , and aspirin , and was sent for
cardiac catheterization on hospital day #3. Cardiac
catheterization showed: ( 1 ) A left main which was okay;
( 2 ) Totally occluded RCA; ( 3 ) Totally occluded LAD after the D1;
( 4 ) His left circ was 30-40% with a mid instant occlusion; ( 5 ) LIMA
to LAD was patent; ( 6 ) A treated LIMA , gaze TNG arrow patent;
( 7 ) Status post RIMA PTCA/stenting with significant spasm of the
entire RIMA. The patient , therefore , had a LIMA to PTCA stenting
performed and underwent some vasospasm on cardiac catheterization.
However , he was given Isordil and nifedipine for the spasm , which
resolved. The patient was in stable condition and pain free after
the catheterization and did not develop any complications such as a
hematoma or otherwise.
The patient was discharged to his home on 9/19/99 in stable
condition.
DISCHARGE MEDICATIONS: Allopurinol 200 mg orally every day; ECASA 325 mg
orally every day; Isordil 10 mg orally three times a day;
lisinopril 20 mg orally every day; Lopressor 75 mg orally twice a day; nifedipine
30 mg orally every day; nitroglycerin 1 tab sublingual as needed chest pain; Prilosec
20 mg orally every day; Vitamin E 400 U orally every day; simvastatin 20 mg orally
every bedtime; Plavix 75 mg orally every day x30 days.
DISCHARGE FOLLOW-UP: The patient will follow-up with Dr. Bernas
in 1-2 weeks , and with his primary care
doctor in 1-2 weeks as well.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: ISADORA LUPTON , M.D. DF54
Attending: RUFUS C. BERNAS , M.D. XS9
YB546/1754
Batch: 45092 Index No. OUEPUF65Z D: 1/22/99
T: 1/17/99
CC: 1. RUFUS C. BERNAS , M.D.
Document id: 1017
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
427401895 | PUO | 15815753 | | 585219 | 4/22/2002 12:00:00 a.m. | CHRONIC HEART FAILURE , HIP FRACTURE | Signed | DIS | Admission Date: 8/16/2002 Report Status: Signed
Discharge Date: 9/6/2002
ADMISSION DIAGNOSIS: LEFT HIP FRACTURE.
SECONDARY DIAGNOSES: 1. FAT EMBOLI SYNDROME.
2. CONGESTIVE HEART FAILURE.
3. DECUBITUS ULCERS.
HISTORY OF PRESENT ILLNESS: Mr. Julias is a 68-year-old man who
came in with a chief complaint of hip
pain after a mechanical fall. The patient had been hospitalized in
4/17 for ischemic right toes requiring debridement and amputation.
At that time , his hospital course was complicated by a non-Q wave
MI. Cardiology have recommended medical management with Lopressor
at that time and an echocardiogram revealed an ejection fraction of
45%. Dobutamine MIBI revealed a severe fixed perfusion defect in
the inferoposterior and inferoseptal left ventricle without any
peri-infarct ischemia. Ejection fraction by MIBI imaging was 26%
in contrast to the echo results. The patient was ultimately
discharged on Lopressor , however , she stopped taking the Lopressor
for unclear reasons. For the few months prior to admission , he
developed increasing dyspnea on exertion with paroxysmal nocturnal
dyspnea and increasing pedal edema , as well as nocturia , however ,
denied any orthopnea , any chest pain , fevers , melena , bright red
blood per rectum or palpitations. A few days prior to admission ,
the patient developed a dry cough and some rhinorrhea.
On the morning of admission , the patient sustained a mechanical
fall while trying to retrieve a newspaper. He had no
light-headedness , palpitations , pain in his chest , nausea or
vomiting , sweating or change in vision or sensory symptoms prior to
or after the fall. The patient fell onto his left side and
immediately developed left-sided leg and hip pain for which she
presented to the emergency room at I Warho Hospital .
PAST MEDICAL HISTORY: Coronary artery disease , cardiomyopathy
( ischemic ) , peripheral vascular disease ,
status post amputation of right-sided toes , status post right
femoral to physical therapy avascularization , diabetes type II , status post CVA ,
hypertension.
MEDICATIONS: HCTZ 50 mg orally every day , enteric-coated aspirin 325 mg
orally every day , Zestril 20 mg orally every day , glyburide 5 mg
orally every day , multivitamins , cough medicine as needed
ALLERGIES: Aminoglycosides , unknown reaction.
SOCIAL HISTORY: The patient has a history of smoking one pack per
day x40 years , quit five years prior to admission.
He has one drink of liquor per day , lives at home alone in Mon Chand Long Boise , and is in the insurance business.
FAMILY HISTORY: Notable for mother died of cancer at 74. Father
died at 55 of heart disease. Mother died at 50 of
a heart attack.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile , temperature 97.3 ,
heart rate 106 , blood pressure 162/77 ,
oxygenation 94% on room air. GENERAL: He was alert and oriented.
LUNGS: Clear. HEART: Regular rate and rhythm. PELVIS: Stable.
His left lower extremity had well-healed scars from donor site for
bypass grafting , strong dopplerable physical therapy and DP pulses. His left leg
was externally rotated. Sensation was intact to light touch.
LABORATORY DATA: Sodium 135 , potassium 4.4 , chloride 102 , bicarb
19 , BUN 56 , creatinine 2.5. White count 12 ,
hematocrit 33 , platelets 388. PTT 40.5 , INR 1.2. EKG showed sinus
tach at 102 , with occasional PVCs , normal axis , normal intervals ,
no evidence of ischemia. Chest x-ray showed bilateral pulmonary
edema. X-rays of his left pelvis and femur revealed fracture of
the left intertrochanter and subtrochanteric fracture with lesser
trochanteric fracture intact by 3 cm , less than five degrees
angulation. His femoral head was reduced.
IMPRESSION: A 68-year-old man with significant cardiac history
and vascular disease , status post left hip fracture
with mechanical fall , with pulmonary edema noted on chest x-ray.
HOSPITAL COURSE: 1. Cardiovascular - Initially , the patient was
to be admitted to the orthopedic service with
medicine consult for wrist stratification. However , the patient
was transferred to the medicine service for further evaluation and
management. The patient was noted to have a troponin leak although
CK enzymes remained negative for ischemia. He had a MIBI performed
which revealed an unchanged fixed defect. He remained in sinus
tach with occasional PVCs and runs of nonsustained ventricular
tachycardia lasting 3-4 beats at a time throughout his admission.
Sinus tach was attributed pain and discomfort , possibly with
element of hypoxia contributing as well. A troponin leak was
attributed to strain particularly in the setting of his
tachycardia. He was started on beta blocker , Ace inhibitor and
continued on an aspirin. He was aggressively diuresed with
afterload reduction. He was titrated upward as noted.
2. Pulmonary - The patient's crackles persisted on lung exam after
aggressive diuresis , prompting performance of a chest CT which
revealed an interstitial pattern with peripheral nodularity
consistent with fat emboli syndrome , positive component of
congestive heart failure and aspiration pneumonia as well. The
patient was continued on a regimen of Lasix for diuresis and was
treated for aspiration pneumonia as noted below. His oxygen
requirement diminished over a few days and he was maintained on two
liters of nasal cannula oxygen at the time of transfer to rehab.
3. Renal - The patient developed some renal failure in the setting
of diuresis , which improved with hydration. The patient
subsequently tolerated further diuresis with improvement in his
creatinine and it is possible that renal failure is due to fat
emboli syndrome as well and should improve slowly.
4. ID - The patient was treated with vancomycin , Flagyl and
levofloxacin for presumed aspiration pneumonia , course completed
6/18/02. The patient remained afebrile. His white blood count on
admission and discharge was 12.
5. Neurologically - The patient apparently had baseline mild
perfusion. The possibly worsened due to the fat embolic syndrome
and was at baseline prior to discharge per the patient's daughter.
6. Heme - The patient was continued on Lovenox 60 mg subcutaneously twice a day
for prophylaxis against DVT post-hip surgery to continue for six
months minimal followed by orthopedic surgery.
7. GI - The patient developed some diarrhea. C. diff. cultures
were negative to date at the time of discharge. The patient was
maintained on Nexium prophylaxis in the setting of his
anticoagulation.
8. Endocrine - The patient was restarted on orally hypoglycemics
prior to discharge in addition to sliding scale insulin. The
patient had a Foley and a triple lumen catheter , both of which were
removed on 6/18/02. The patient was evaluated by plastic surgery
for his peripheral vascular disease with ulcers. Recommended dry
sterile dressings to the right and left foot wound changed every day
with DuoDerm to the left lower leg wound to be changed every 3 days ,
with pressure sore prevention.
9. FEN - The patient was discharged on standing 20 mEq of K-Dur
every day It is likely to be checked every other day to monitor for any further
requirements particularly in the setting of his runs of
nonsustained V-tach as noted above.
10. Ortho - The patient is followed daily by orthopedic surgery
and was discharged with staples on his left lower extremities to be
discontinued per orthopedic surgery recommendations in the future.
11. Disposition - The patient was stable for discharge to rehab on
7/28/02. He was to follow up with his primary care physician ,
orthopedic surgery , cardiology , and pulmonary medicine within the
next two weeks. His labs are to be drawn for a metabolic panel ,
magnesium and calcium every other day for as long as the primary care
physician feels it is necessary with repletion of his electrolytes
as needed. He is to have physical therapy performed as needed.
His weightbearing status is non-weightbearing on the left lower
extremity and weightbearing as tolerated on his right lower
extremity per orthopedic surgery at the time of discharge.
DISCHARGE DIET: ADA diet , low fat , low cholesterol , low salt.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 325 mg orally every day ,
Lopressor 12.5 mg orally three times a day , hold for
systolic blood pressure less than 100 or heart rate less than 55 ,
lisinopril 5 mg orally every day , hold for systolic blood pressure less
than 100 , Lasix 100 mg orally every day , Lovenox 60 mg subcutaneously twice a day x6
months , glipizide 2.5 mg orally every day , sliding scale insulin , Nexium
20 mg orally every day , Silvadene wet-to-dry dressing , please appy dry
sterile dressing to right and left foot wound to change every day Apply
DuoDerm to left lower leg wound and change every 3 days , continue
pressure care precautions.
Dictated By: MARIETTE MOLANDS , M.D. GX428
Attending: AVRIL TAPLIN , M.D. FW48
EC172/261077
Batch: 4854 Index No. MTADYD23J8 D: 4/28/02
T: 4/28/02
Document id: 1018
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
N |
N |
N |
N |
- |
N |
N |
N |
N |
N |
N |
N |
271212527 | PUO | 83130630 | | 128466 | 8/30/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/12/1995 Report Status: Signed
Discharge Date: 3/2/1995
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE WITH UNSTABLE ANGINA.
ASSOCIATED DIAGNOSES: 1 ) HISTORY OF CORONARY ARTERY BYPASS
SURGERY IN 1988.
2 ) ISCHEMIC HEART DISEASE SINCE 1983.
3 ) INFERIOR WALL MYOCARDIAL INFARCTION IN
1988.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old man with
a history of ischemic heart disease
since 1983. He had a non-Q wave myocardial infarction at this time
and in 1988 , he had an inferior wall myocardial infarction and a
subsequent coronary artery bypass graft times three. In 1991 , he
sustained an inferoposterior myocardial infarction and persantine
thallium study demonstrated a fixed inferolateral defect. He was
well maintained on beta blockers and aspirin until September 1992.
At this time , he developed symptoms consistent with unstable
angina. He was ruled out for myocardial infarction at this time.
An echo was significant for hypokinesis of the inferior and
posterior walls and ejection fraction was noted to be 50%.
Persantine thallium in September 1995 demonstrated posterobasilar
defect with 60% redistribution. After this episode , he had again
been symptom free. On 9/13/95 , the patient began experiencing
substernal chest pressure , 10/10 , with radiation to the left arm
with good response to sublingual nitroglycerin with total episode
time of five minutes. On 11/23/95 , he had a similar episode for
approximately two minutes which he rated as a 7/10. On the day of
admission , the patient had a fifty minute 10/10 episode of
substernal chest pressure associated with diaphoresis and dyspnea.
EKG was significant only for non-specific low T waves. Patient was
heparinized , provided with beta blockers , and given aspirin and
nitrates. The patient ruled out for myocardial infarction and the
plan was to do a persantine thallium. The patient continued to
have pain of the chest at rest and was transferred to the Pagham University Of for further evaluation and cardiac
catheterization.
PAST MEDICAL HISTORY: As above as well as significant for polio
with subsequent muscle weakness of the left
hip and leg.
CURRENT MEDICATIONS: On admission were notable for Lopressor 50 mg
every 6 hours , aspirin 325 mg orally every day ,
nitroglycerin intravenous infusion 20 micrograms per minute , and
Heparin 1300 units per hour.
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAMINATION: Vital signs on admission were notable for a
blood pressure of 112-116/64-84 with a heart
rate of 53-75 , extraocular movements were intact , there was no
jugular venous distention , carotids were 2+ bilaterally , lungs were
clear to auscultation , and cardiac examination showed the point of
maximal intensity was non-displaced , regular rate and rhythm ,
normal S1 and S2 , no murmurs , no gallops , and no rubs. Abdomen was
soft , non-tender , and non-distended with no hepatosplenomegaly ,
extremities showed no cyanosis and no edema , femoral pulses were 2+
bilaterally without bruit , and pedal pulses were 2+ bilaterally.
LABORATORY EXAMINATION: On admission was notable for a hematocrit
of 40.3 , a white count of 10.8 , potassium
of 3.7 , physical therapy and PTT of 12.7 and 55 with an INR of 1.1 , and
cholesterol was noted to be 287.
HOSPITAL COURSE: While here , Mr. Patcher had one episode of 10/10
substernal chest pressure not associated with
diaphoresis , nausea , or vomiting and relieved with sublingual
nitroglycerin. EKG with pain as compared to old EKG demonstrated
inversion of T waves in V1 through V3 and questionable inversions
in III and F. These inversions were present on a 11/28/95 EKG but
not on a 6/25/95 EKG. The EKG changes with the past medical
history was most likely significant of ongoing instability of the
patient's anginal symptoms and ischemic heart disease. At this
time , the plan was for cardiac catheterization. This is a 57 year
old male with a history of multiple myocardial infarctions in the
past status post three vessel coronary artery bypass graft in 1988
admitted with unstable angina and recurrent chest pain at rest.
Aspirin , Heparin , nitrates , and beta blockers were continued.
Cardiac catheterization results were notable for three vessel
disease but the bypass grafts , the LIMA to the left anterior
descending , was patent , the saphenous vein graft to the proximal
descending artery was patent , the saphenous vein graft to the ramus
was occluded , and the left circumflex to the saphenous vein graft
to the ramus may be the culprit lesion contributing to the
patient's pain and EKG changes. The patient was continued on
Heparin overnight post-catheterization and it was deemed
appropriate to PTCA the ramus lesion. The patient was taken to the
Catheterization Laboratory on 1/11/95 for successful PTCA of the
ramus occlusion. Post-procedure , the patient was stable and chest
pain free. Post-catheterization , the patient was afebrile with a
blood pressure of 106/68 and a pulse of 64. The right femoral
catheter site was without hematoma , no bruits , and femoral pulses
were 2+. Dorsalis pedis pulses were intact bilaterally and there
was no cyanosis. The patient was enrolled on the IFH protocol as
per Dr. Varoz and as such , received 36 hours of intravenous
protocol therapy post-catheterization. The right groin sheaths
were removed without difficulty , hematocrit at this time was 35.7 ,
and the patient remained in stable condition with complaint of
chest pain. The patient was discharged home on the fourth hospital
day. Physical examination was notable for a blood pressure of
130/80 , a pulse of 65 , respiratory rate of 20 , temperature of 99.4 ,
O2 saturations of 93 and 94% , and examination was within normal
limits. Cardiac examination showed the point of maximal intensity
non-displaced , regular rate and rhythm , and no murmurs , gallops , or
rubs.
DISPOSITION: The patient is stable upon discharge and symptom
free.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day and
Lopressor 50 mg orally four times a day.
FOLLOW-UP: The patient is to follow-up with Dr. Donn Humberto Breana Kissam at
Ly Healthcare
Dictated By: VERLIE J. EVIE SWANDA , M.D. UV35
Attending: JACKSON E. PART , M.D. RM7
OH912/5227
Batch: 29805 Index No. I5HRYI81AC D: 7/11/95
T: 8/18/96
Document id: 1019
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
005865944 | PUO | 26026900 | | 5486171 | 6/18/2006 12:00:00 a.m. | Congestive heart failure | | DIS | Admission Date: 11/4/2006 Report Status:
Discharge Date: 10/19/2006
****** FINAL DISCHARGE ORDERS ******
LAWVER , DANIEL 914-97-37-4
Vallpo Ford
Service: CAR
DISCHARGE PATIENT ON: 8/12/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LYN , JR , FLOYD T. , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ALLOPURINOL 200 MG orally DAILY
Override Notice: Override added on 9/25/06 by
WALTERS , ELIZABET C. , M.D.
on order for COUMADIN orally ( ref # 499611388 )
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
Reason for override: daily coags checked
ECOTRIN ( ASPIRIN ENTERIC COATED ) 325 MG orally DAILY
Override Notice: Override added on 9/25/06 by
WALTERS , ELIZABET C. , M.D.
on order for COUMADIN orally ( ref # 499611388 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: daily coags checked
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 9/25/06 by
WALTERS , ELIZABET C. , M.D.
on order for COUMADIN orally ( ref # 499611388 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: daily coags checked
COLCHICINE 0.6 MG orally DAILY
DIGOXIN 0.125 MG orally DAILY Starting IN a.m. ( 7/7 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
LANTUS ( INSULIN GLARGINE ) 10 UNITS subcutaneously DAILY
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , units subcutaneously
If BS is 125-150 , then give 3 units subcutaneously
If BS is 151-200 , then give 4 units subcutaneously
If BS is 201-250 , then give 5 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally DAILY
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 6/1/06 by
WALTERS , ELIZABET C. , M.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: daily electrolytes checked
LISINOPRIL 5 MG orally DAILY
Override Notice: Override added on 6/1/06 by
WALTERS , ELIZABET C. , M.D.
on order for K-DUR orally ( ref # 500959157 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: daily electrolytes checked
Previous override information:
Override added on 3/17/06 by PULWER , VERNELL AMALIA , M.D.
on order for KCL SLOW RELEASE orally ( ref # 727221244 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: ok
Previous override information:
Override added on 1/6/06 by DESJARDIN , RENDA S. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
556831518 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: mda
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NAFCILLIN 2 GM intravenous every 4 hours
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
TRAZODONE 50 MG orally BEDTIME as needed Insomnia
COUMADIN ( WARFARIN SODIUM ) 10 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 9/25/06 by
WALTERS , ELIZABET C. , M.D.
SERIOUS INTERACTION: ALLOPURINOL & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: daily coags checked
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Innarelli , PUO Infectious Disease 11/5/06 at 9:30am ,
Dr. Loerwald , Vascular Surgery 10/19/06 at 9:30am ,
Dr. Cathie Reisman , PUO Cardiology 10/19/06 2:20pm ,
Dr. Threlfall , your Primary care doctor in 2-3 weeks. ,
Arrange INR to be drawn on 3/1/06 with f/u INR's to be drawn every
tobedeterminedbyINR. days. INR's will be followed by Skilled nursing facility/rehab MD
ALLERGY: LINEZOLID
ADMIT DIAGNOSIS:
Congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN CAD history of CABG 3v obesity DM ( ) history of ICD reduced LVEF ~30%
( ) history of MRSA bacteremia ( )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
CC: CHF exacerbation
HPI: 63M with history of CAD history of CABG , ischemic CMP , EF 25-30 , DM , CKD ( baseline
1.7-1.9 ) and mutiple toe amputations admitted from rehab with volume
overload. Most recently he was admitted for treatment of osteomyelitis
invovling the R. 1st metatarsal. He was treated with intravenous abx and
debridement and initiated a 8-week course of Nafcillin. He has been at
rehab and notes increasing weight gain , LE edema , PND , orthopnea and
DOE.
+early satiety x 2 days. NO cp/palpitations. No recent F/C/NS. No
n/v/d. No dysuria. In consultation with his outpatient
cardiologists ( Dr. Reisman ) he has uptitrated his Lasix from 20 orally to
80 orally twice a day. Yet notes no significant improvement in sx. Admitted for
diuresis.
ROS: notes occasional BRBPR when wiping - last colonoscopy 1 yr ago -
no polyps.
----------------------------------------------------------
PMH/PSH
1. osteomyelitis -- recurrent non-healing ulcer under the 1st
metatarsal at the site of Right transmetatarsal amputation. MSSA
started on 8 weeks of treatment. ( STARTED 5/20 END
4/30 )
2. DMII
3. CAD history of NSTEMI
4. PVD history of amputation of 1st and 5th toes of L.foot.
5. ischemic CMP ( ef-25-30% )
6. CKD - baseline 1.7-1.9
7. ICD - implant 5/30/04
8. gout
9. Type II diabetes , insulin dependent
10. CABG - 1988 ( LIMA to LAD , SVG to PDA and OM1 occluded )
11. R shoulder surgery
--------------------------------------------------------
Allergies:
Linezolid - thrombocytopenia or anemia Cardiac
---------------------------------------------------------
Imaging: ECHO
8/30/06 LV mod dilated , LVF mod to severely decreased , EF
25-30% , LV is akinetic/hypokinetic , mod LAE/RAE , mild MR and
TR STRESS
6/7/05 No evidence for ischemia , but with decreased
sensitivity because maximal HR below diagnostic target ( <85% max HR ).
Peak O2 uptake was above anaerobic threshold
-----------------------------------------------
Outpatient Medications: Medications
Text nafcillin 2g q4 ( 5/7 Last day is 11/5/06 )
lasix 40mg
daily colchicine 0.6 every day
iron 325 daily
ASA 325 daily
lipitor 80 daily
digoxin 0.125 daily
colace 100 twice a day
coumadin 12.5 daily
lisinopril 5 daily
lopressor 25 q6
oxycodone 5-10 as needed
ibuprofen 600 q6 as needed
NPH , RISS
ferrous sulfate 325 every day.
------------------------------------
Family History: DM: positive for DM2
CAD: both parents sides of the family
HBP: father
Renal disease: none
Hyperlipidemia: unknown
------------------------------------------------
Social History: Currently an inpatient at Chipark Ness Memorial Hospital And Health to receive Nafcillin intravenous every 4 hours Previously , patient lives with his
wife in Blomoaleralty Hampm Inbirm Walks his son's dog daily. He has been unable to
work for 10yrs due to
CHF. Formerly worked in sheet metal. No smoking. Rare EtOH. No IDVU.
---------------------------------------------
ADMIT Physical Examination: T 96.8 BP 120/78 HR 95 RR 20 O2sat 96% RA.
116.6 KG ( dry weight 106.4 Kg )
Gen: fatigued appearing , pleasant. Speaking in full
sentences. HEENT: anicteric , conjunctivae pink , EOM
full. MMM , no thrush ,
Neck: JVP to angle jaw at 90 degrees. No Lymphadenopathy.
Heart: PA tap , RV heave , RRR , III/VI holosystolic musical murmur
throughout precordium. No S3/S4 or rubs.
Lungs: Fine crackles right base. o/with clear. Abd: soft , NT/ND , +BS. no
shifting dullness. Ext: 2+ pitting edema to above knee. Right foot
bandaged. No open wounds L. foot. L foot: no hair , taught skin , no
skin breakdown R foot: deep clean surgical wound at midpoint of
TMA , wound down to bone , no surrounding erythema , no discharge.
Healthy appearing tissue.
---------------------------------------------
DATA on admission: Na 143. K 4.3. BUN 40 , Cr 2.1. WBC 7.6 HCT 32.8 , PLTS
254. Digoxin 0.2. BNP 711 ( increased from 186 on 2/23/06 ).
--------------------------------------------------------
DISCHARGE Status/Events ( 5/25 ): Feeling better and back to baseline
respiratory status. Tmax 98.4 , Tc 96.1 , P70-92. BP 110-120/60-80 , 02 sat
99% on RA.
Diuresing well JVP flat. Lungs fine bibasilar crackles on inspiration.
RRR. 3/6 MR murmur. 1+LE edema to below knees.
-----------------------------------------------------
DISCHARGE LABS: 2/1 nasal 139 , K 4.3 , Cl 103 , bicarb 26 , BUN 40 , Cr 1.9. Mg
2.4 WBC 6.4 HCT 32.3 , PLTS 217. INR 2.2 PTT 41.5
---------------------------------------------------
A/P: 63M with history of CAD history of CABG , iCMP ( EF 25-30% ) , ICD , placed who
presents with volume overload , worsening SOB , LE edema , PND ( NYHA
III. )
CV:
i: No active issues. Continued beta-blocker , Ace-i. ( Cr on admit
elevated 2.2 compared to baseline 1.7-1.9. ). Patient will be discharged
on Toprol XL 100 mg every day instead of Metoprolol 25 four times a day.
p: Patient presented with volume overload , 22 lbs over dry weight. -He
diuresed well with Lasix 80 intravenous twice a day with stable creatinine of 1.9-2.0 and
average of 2-2.2L net negative per day. Symptoms improved dramatically
with resolution of paroxysmal nocturnal dyspnea and shotness of breath at
rest. O2 sats were 98-99% on RA. Electrolytes stable without additional
repletion on standing KDur.
-He will be discharged on Lasix 80 mg orally twice a day.
r: Sinus rhythm. Nonspecific IVCD. Monitored on tele without events.
ENDO: DM - Regular ISS. Added basal coverage of Lantus 10 units subcutaneously every day on
day of discharge as blood glucose was running 180-220 prior to meals and
requiring average of 4-5 units of sliding scale.
ID: Continued Nafcillin 2g intravenous every 4 hours for r. foot osteomyelitis.
Seen by vascular surgery consult while in house for advice on
wound care. He had twice a day dressing changes and the wound had
granulation tissue with no surrounding erythema.
-Continue wound care as per vascular surgery recs:
-No need for debridgement. Wet to dry dressings twice a day. Has followup
appointment with dr. Legerski , of Vascular surgery in 2 weeks.
HEME:
-Continued on coumadin ( low EF. history of LV thrombus. ) INR was in therapeutic
range of 2.0-2.2 on coumadin dose of 10 mg every day.
PROPH:
-Anticoagulation. No indication for PPI.
FEN: CHF diet. 2L fluid restrict.
ACCESS: -Right upper arm PICC.
Full Code
ADDITIONAL COMMENTS: -You will continue all medications you were on previously.
-There were 2 changes made:
1. Allopurinol was started ( a medication to help prevent gout. )
2. Lasix does is 80mg by mouth , two times a day.
-Followup appointments are listed.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WALTERS , ELIZABET C. , M.D. ( FX647 ) 8/12/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1020
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
Y |
U |
Y |
Y |
Y |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
Y |
- |
Y |
Y |
Y |
N |
Y |
Y |
N |
Y |
N |
N |
N |
- |
057006129 | PUO | 06591496 | | 6289722 | 11/20/2005 12:00:00 a.m. | ANGINA , MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 11/20/2005 Report Status: Signed
Discharge Date: 7/30/2005
ATTENDING: BARNABA , CARA CHANCE MD
PRINCIPAL DIAGNOSIS ON ADMISSION: Non-ST elevation , acute
myocardial infarction , and acute renal failure. She was
transferred from the Siscate Nor Hospital to the Pagham University Of
HISTORY OF PRESENT ILLNESS: This is a 78-year-old lady with
diabetes and known coronary artery disease status post CABG and
status post multiple PCIs. She was in her usual state of health
until three weeks ago when she began with classical paroxysmal
nocturnal dyspnea. She was taken to Siscate Nor Hospital on
three different occasions in the past three weeks prior to
admission , where she was treated for pulmonary edema. Prior to
her admission to the Pagham University Of , she had had a
troponin leak of up to 3.6. This was on the 5 of July . She also was admitted with acute renal failure. Her
creatinine on the 15 of June per note was 1.1. When we
admitted her creatinine was 2.6. This was likely secondary to
the fact that she had received amikacin for urinary tract
infection at the Siscate Nor Hospital and she had also had a
chest , abdominal , and pelvis contrast CT leading to contrast
nephropathy. When she was admitted , her main problems were the
following: She had a non-ST elevation myocardial infarction.
She was a high-risk patient with a TIMI score of 5. She had
acute renal failure probably secondary to a number of factors
including contrast dye what she had received at the outside
hospital and amikacin which she had received for urinary tract
infection. Her other problem was she had a urinary tract
infection per report secondary to E. Coli resistant to Levaquin
and gentamicin.
Her past medical history was relevant for the following:
She had diabetes type 2 with chronic renal insufficiency
secondary to the diabetes. She has anxiety disorder. She had
coronary artery disease status post CABG in 1992. She is status
post PCI with a stent placed in 2002 , and 2004 apparently. She
also had congestive heart failure with an EF per an echo
performed at Siscate Nor Hospital was 35%. She had GERD and
Barrett's esophagus. She had hypertension and
hypercholesterolemia. She had had a pacemaker placed. She had
hemorrhoids. She had osteoarthritis with both knees. She had
spinal stenosis and chronic back pain status post cholecystectomy
and a history of asthma.
Her allergies included the following: Bactrim , penicillin ,
erythromycin , Keflex , Metformin , clindamycin , and ciprofloxacin.
Her social history , she was in a nursing facility. She is
divorced. She has four kinds. Lives in Wa Noo Lietrance and is often
visited by her children.
PHYSICAL EXAMINATION: On admission , her temperature was 96 , her
pulse 77 , her blood pressure was 170/95 , although admittedly it
was difficult taking her blood pressure by auscultation. This
was measured by palpation and confirmed by Doppler. She was
satting 96% on 3.5 L via nasal cannula. She is alert and
oriented x3 in no acute distress. She had arcus senilis. Her
extraocular movements are intact. She had pupils equal , round ,
and reactive to light. Her chest showed bibasilar crackles/rales
two-thirds way up. Her JVP is 10 cm water. Her heart had a
regular rate and rhythm with no gallop. No rubs or murmurs
heard. Her abdomen is benign. Her extremities are warm with no
edema and she is grossly neurologically intact.
Her first set of labs at the Pagham University Of
revealed the following: Sodium 140 , potassium 4.2 , chloride 105 ,
CO2 24 , BUN 40 , creatinine 2.5 , glucose 95 , white blood cell
count of 10.16 , a hemoglobin of 10.0 , platelets 232 , INR 1.5.
Her BNP was 2138. Her lipase was 7. Her troponin level was
0.75.
HOSPITAL COURSE BY PROBLEM:
Non-ST elevation acute myocardial infarction. On presentation ,
the patient had several EKG changes consistent with an acute
coronary syndrome. She was in normal sinus rhythm with T wave
flattening or inversion in leads V4 to V6 and in the inferior
leads also 2 , 3 , aVF. She had Q-S complexes in V1 through V3.
She was deemed to be a high-risk patient for the TIMI score of
5and they documented troponin leak. She was managed medically ,
not interventionally given her acute renal failure. She was
treated with unfractionated heparin with a PTT level of 50 to 70
seconds. She was given aspirin , Plavix. She was also given
eptifibatide intravenously for five days and is also treated with
beta blockers and ACE inhibitor. After five days , she had no
recurrent chest pain. Her EKG changes were persistent but her
troponin levels have trended downwards and she has really been
asymptomatic in this regard. Regarding her pulmonary edema , we
treated with Lasix initially 40 mg intravenous Lasix x1 and then on
standing orally Lasix 40 mg daily , and diuresed her and also gave her
morphine and oxygen. Within four or five days , her physical
examination was much better and her crackles and rales had
markedly decreased. On admission , she was saturating 96% on 3.5
L. She progressed. Her oxygen requirements decreased. She was
diuresed and was finally weaned off oxygen and is currently
saturating 97% on room air. The plan is for her to continue on
aspirin , Plavix , high-dose Lipitor , and beta-blocker , and
nitrates as needed.
2. In terms of her acute renal failure , based on the records
from the Siscate Nor Hospital , her creatinine had jumped from
1.1 to 2.5 in three days. This was felt to be most likely due to
intrinsic renal failure. She did not have a low urine output and
she had received amikacin in the past few days prior to admission
as well as contrast dye and she did have a history of contrast
dye induced nephropathy leading to a predialysis state , although
she did not get dialysis on that occasion. Here , we simply
avoided nephrotoxic agents , were judicious in the use of Lasix
with strict ??____?? controls , and her creatinine gradually began
to decrease and today it is down to 1.6. Infectious Disease
wise , she came with the documented urinary tract infection
reported to be due to E. coli resistant to levofloxacin and
gentamicin. Here , we cultured her again and found E. coli more
than a 100 , 000 colonies , which was resistant to ampicillin ,
gentamicin , ciprofloxacin , and levofloxacin. It was sensitive to
ceftazidime and she therefore received renally dosed ceftazidime
for her UTI to complete a 7 to 10-day course. Blood cultures
drawn on the 24 of April showed no growth to date. The
patient has also been afebrile in with a white blood cell count
between 7 and 11 , 000. In terms of her hypertension , of note , it
has been difficult to measure her blood pressure , probably
measuring her blood pressure in her left arm by palpation is a
most reliable way to do this. She was treated here with
hydralazine , Lopressor , and diuretics. On discharge , she feels
well. Today , she told me that she has not filled this for a long
time. She had no recurrent chest pain or shortness of breath.
She is afebrile with a temperature of 98. Her pulse ranges
between 60 and 70. Her blood pressure is between 102 and 150
systolic and she is satting 95% on room air. Her current weight
is 73 kg and she is deemed to be euvolemic so this should be her
target weight and she is ambulating with assistance. She is
alert and oriented x3 in no acute distress. She has got pupils
equal , round , and reactive to light. She has only a few
bibasilar crackles on bases. Otherwise , her lungs are clear.
Her heart has a regular rate and rhythm with no gallops , rubs , or
murmurs. Her abdomen is benign. Her extremities are warm. Her
right calf is quite tender to palpation. She has a documented
old DVT in her gastrocnemius vein. This is old and she has
probably got some postphlebitic syndrome and should be followed.
She is neurologically grossly intact.
Her laboratories at discharge include the following:
Sodium 139 , potassium 4.7 , her creatinine is 1.6 , BUN is 50 , her
white blood cell count is 11.01 , hematocrit 28.5 , hemoglobin 9.2 ,
and platelets 258 with an INR of 1.2.
Her medications at discharge include the following:
1. Enteric-coated aspirin 325 mg orally daily.
2. Ceftazidime 1 g intravenous every 24 hours until August to complete a
7-day course.
3. Colace 100 mg orally twice a day in case of constipation.
4. Lasix 40 mg orally every 12 hours
5. Heparin 5000 units subcutaneously three times a day , while
the patient is bedridden.
6. Isosorbide dinitrate 10 mg orally three times a day.
7. Lopressor 37.5 mg orally three times a day with hold
parameters , hold if systolic blood pressure is less than 110 , or
a heart rate is less than 55.
8. Sublingual nitroglycerin as needed.
9. Vicodin one tablet every six hours in case of pain.
10. Risperidone 0.5 mg orally once a day.
11. Lipitor 80 mg orally once a day.
12. Plavix 75 mg orally once a day.
13. Celexa 20 mg orally once a day.
14. Esomeprazole 20 mg orally once a day.
15. Lantus 17 units subcutaneously every morning.
16. Novolog sliding scale.
DISPOSITION AND PLAN: The patient is to go to rehabilitation.
Things to do specifically include the following:
She should be diuresed with Lasix as needed to achieve a dry
weight goal of 72 kg. She should continue on ceftazidime for her
urinary tract infection until August and her calf pain -
DVT should be followed , one possibly to raise the Siscate Nor Hospital as this may represent in a cold malignancy , for which she
may need to be worked up once the acute setting is over.
Studies performed at this hospital include the following:
A renal ultrasound as part of her workup for acute renal failure
reveal a right kidney with a size of 11.8 cm and apical cortical
cyst , left kidney 10.6 cm , and no hydronephrosis. The patient
also had a MIBI , SPECT of her heart , which revealed the
following:
The combined ??____?? ischemia plus scar during the stress were
moderately abnormal with a summed stress score of 9. Her rest LV
ejection fraction was 50%. The patient's PET CT test results
were normal and consistent with a small region of myocardial
ischemia in the septal area and also a focus of ischemia in the
OM territory. She had abnormal global LV systolic function and
these results demonstrated in interval progressing per her prior
study performed on November , 2004.
eScription document: 0-5615808 ISSten Tel
CC: Cara Chance Barnaba MD
Nebraska
Jo Reve
CC: Leone Bonnie
Setlake Caardlin County Medical Center
Quisbed Street , Lis Chi , Pennsylvania
De
Dictated By: BEOUGHER , GEORGINE JENIFER TRACIE
Attending: BARNABA , CARA CHANCE
Dictation ID 5556110
D: 9/19/05
T: 9/19/05
Document id: 1021
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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010700797 | PUO | 27527229 | | 179371 | 10/4/1998 12:00:00 a.m. | ? CEREBROVASCULAR ACCIDENT | Signed | DIS | Admission Date: 3/8/1998 Report Status: Signed
Discharge Date: 5/24/1998
HISTORY OF PRESENT ILLNESS: This is a 62 year old Latin American
female with a past medical history
notable for type II diabetes , chronic atrial fibrillation on
Coumadin , congestive heart failure , hypercholesterolemia ,
hypertension , and obesity , who presents complaining of awakening on
22 of August with vertical diplopia , imbalance , falling to the left ,
and weakness in both legs , ? left greater than right , but not in
her arms. Patient reports feeling that her speech was weak , but
not hoarse. Patient denied having difficulty with swallowing , no
headaches , no change in visual acuity , no hearing changes , no
facial weakness or sensory changes. Patient denied any recent
illness , though had been recently hospitalized in mid April ,
1997 for a CHF bronchitis exacerbation and was treated with Biaxin.
Diltiazem had also been started during that hospitalization.
PAST MEDICAL HISTORY: As above. 1. Type II diabetes. 2.
Chronic atrial fibrillation on Coumadin. 3.
Congestive heart failure. 4. Hypercholesterolemia. 5.
Degenerative joint disease. 6. Chronic renal insufficiency. 7.
Status post bilateral cataract surgery. 8. Obesity. 9.
Hypertension. 10. Gastroesophageal reflux disease. 11. ? sleep
apnea.
ALLERGIES: No known drug allergies.
MEDICATIONS: Coumadin 17 mg orally every day , simvastatin 20 mg orally
every day , Zaroxolyn 2.5 mg orally every week , Prilosec 20 mg
orally every day , insulin 70/30 134 subcutaneously every day before noon , 84 subcutaneously every afternoon ,
diltiazem CD 180 mg orally every day , KCl 10 mEq orally every day , lisinopril
20 mg orally twice a day , Relafen 1000 mg orally twice a day , amitriptyline 50 mg
orally every day , Lasix 120 mg orally twice a day
SOCIAL HISTORY: No tobacco or alcohol use reported.
PHYSICAL EXAMINATION: Temperature 98 , blood pressure 128/70 ,
pulse 75. Obese middle aged female in no
acute distress. HEENT was atraumatic , normocephalic. Neck was
supple with no bruits. Lungs were clear to auscultation
bilaterally. Cardiovascular exam showed distant heart sounds ,
irregularly irregular. Abdomen was soft , nontender , nondistended ,
morbid obesity. Normal active bowel sounds. Extremities showed a
healing right shin superficial wound , 1+ edema bilaterally.
Neurologic exam showed mental status , orientation , attention and
language intact. Speech was low , but not clearly hoarse. Cranial
nerves right pupil irregular but reacts 2.5 to 2. Left pupil
irregular status post iridectomy. Visual fields intact. Right eye
slightly adducted at rest without diplopia. Mild decreased
abduction and adduction on the right without diplopia , even on
extreme gaze. No nystagmus. Unable to converge fully with the
right eye. No facial droop. Cranial nerves otherwise intact. Gag
present. Able to swallow without difficulty. Motor showed normal
tone and power to confrontation , symmetric bulk , ? slight slowing.
No clear pronator drift. Tendon reflexes trace brachialis , 2+
biceps , no triceps , trace knee reflexes , no ankle jerks. Equivocal
toes bilaterally. Sensation is notable for decreased vibration
sense , left greater than right at the toes , intact position sense
symmetric. Symmetric exam to temperature and light touch. ?
cerebellar exam with mild dysmetria on finger to nose on the left ,
Romberg stable with slight swaying to the left. Gait slow with
small steps , but fairly steady.
LABORATORY EXAMINATION: Labs showed sodium 143 , potassium 4.6 ,
chloride 100 , bicarb 29 , BUN 19 ,
creatinine 1.1 , glucose 67 , white blood cell count 8 , hematocrit
36 , platelets 222 , physical therapy 17 , INR 2.3 , PTT 32. EKG showed atrial
fibrillation with no acute changes noted. Chest x-ray showed mild
cardiomegaly , no congestive heart failure or infiltrate. Head CT
showed movement artifact with no obvious CVA , ? hypodensity in the
right upper pons but likely artifact.
HOSPITAL COURSE: The patient was admitted with symptoms of
vertical diplopia and unsteadiness/imbalance ,
falling to the left , with improvement overnight. Patient still had
an abduction defect with her right eye on the morning after
admission and mild leftward gait unsteadiness , but her vertical
diplopia had resolved. The patient was continued to be monitored.
Her blood pressure was followed. Patient was kept on Coumadin.
Patient was scheduled for an open air MRI , given her significant
size. Patient was scheduled for an open MRI at the MRI in
Ron Ston Sa , Georgia On 3 of August , patient underwent MRI with particular
interest in visualization of the posterior fossa. No acute infarct
or hemorrhage was noted on MRI MRA. The patient was continued on
her Coumadin. Coumadin had been increased from admission dose of
17 mg to 18 mg orally every afternoon Initially , her INR went down slightly
on 3 of August to 1.7 , likely secondary to a missed dose earlier in the
week. On 17 of July , patient reported feeling back to her baseline of
one week ago. Patient denied any new symptoms. Patient denied
further imbalance or vertical diplopia. Patient was thought to
have had a likely small vessel cerebral infarct and , although no
stroke was demonstrated on MRI , involvement of patient's left side
suggested a cerebral lesion in the brain stem in order to explain
the diplopia. Patient probably had a very small vessel stroke/TIA.
Patient has known major risk factors for both small vessel and
large vessel and cardioembolic disease. Patient was discharged to
continue further risk factor modification in the outpatient clinic.
Patient is to continue her cardiac medical regimen. Patient will
continue with Coumadin for a goal INR of 2-3 for her chronic atrial
fibrillation. Patient was discharged on 5 of March She was
instructed to call KTDUOO on Monday morning to schedule an
appointment with her primary care physician within the next 10
days. Patient is discharged in stable condition.
DISCHARGE MEDICATIONS: Amitriptyline 50 mg orally every day , Colace
100 mg orally every day , Lasix 120 mg orally
twice a day , Prilosec 20 mg orally every day , diltiazem CD 180 mg orally every day ,
simvastatin 20 mg orally every bedtime , Relafen 1000 mg orally twice a day , insulin
70/30 134 units subcutaneously every day before noon , insulin 70/30 84 units subcutaneously every afternoon ,
Zaroxolyn 2.5 mg orally every week , Coumadin 18 mg orally every afternoon ,
instructions to be further adjuster as per INR in outpatient
clinic. KCl slow release 10 mEq x 1 orally every day.
DISCHARGE INSTRUCTIONS: 1. Patient will need her Coumadin dose
readjusted as per her primary physician
and Coumadin clinic , with instructions to keep her goal INR of 2-3
for chronic atrial fibrillation. 2. Patient instructed to call
KTDUOO at 459-7195 on Monday , 2 of May and scheduled to follow up with
primary physician within 10 days of discharge. Patient will need
to have a physical therapy/INR check for readjustment of her Coumadin.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Patient was discharged with VNA services.
Dictated By: CORRINE U. MCCULLEN , M.D. PA68
Attending: DERICK YAN , M.D. AZ67
AP861/7602
Batch: 43514 Index No. W2PFZU09JF D: 5/10/98
T: 3/10/98
Document id: 1022
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
N |
N |
Y |
Y |
Y |
N |
N |
Y |
N |
N |
N |
208940543 | PUO | 24103682 | | 4895592 | 1/15/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/15/2003 Report Status: Signed
Discharge Date:
ADMISSION DIAGNOSES: PNEUMONIA , RULE OUT MYOCARDIAL INFARCTION
( MI ).
CHIEF COMPLAINT: CHEST PAIN AND SHORTNESS OF BREATH.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male
with a history of hypertension , LVH ,
and heroin use , who presented with shortness of breath times
several weeks which was sometimes associated with chest pain. The
patient noted that the shortness of breath was often brought on by
heroin use ( He has not used cocaine for several years. His last
heroin use was the day prior to admission. ). His shortness of
breath was "off and on , " worse with exertion. It was not
necessarily worse when lying flat. He has had this shortness of
breath for several months , although as mentioned , was worse in the
weeks prior to admission. His chest pain was hard for him to
describe , although , he did mention that it was not heavy in
character. He admitted to some chest discomfort when he became
excited or agitated. He also described his chest pain as sharp.
There was no nausea. He did complain of some dizziness. His pain
did not radiate to the neck or arms and was different from
heartburn pain. Of note , the patient has not taken his outpatient
medications for the last six months and admits to diet
noncompliance with salty foods. The patient's last heroin use , as
mentioned , was the day prior to admission. In the past , he has
noticed that he cannot go more than two days without symptoms of
withdrawal.
REVIEW OF SYSTEMS: Positive for constipation for which he takes
laxatives. There is no abdominal pain.
Occasional headache. No change in vision. No dysuria.
PAST MEDICAL HISTORY: 1. Remarkable for intravenous drug abuse - heroin
currently , cocaine in the past.
2. Hypertension times many years. 3. Gout. 4. Left ventricular
hypertrophy.
MEDICATIONS: The patient has taken no medications for six months.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in A Os A No Laverlont with his
brother and his sister. He is on disability since
1992. He smokes one pack every 3 days. He rarely uses alcohol.
He does use intravenous drugs as mentioned.
PHYSICAL EXAMINATION: Temperature 97.3 , heart rate 95. Upon
presentation to the emergency room , his
blood pressure was 190/110 , respiratory rate 24 , O2 sat 100% on two
liters. GENERAL: The patient was seated and in no acute distress.
HEENT: Conjunctiva was slightly pink but nonicteric. Extraocular
muscles are intact. Pupils are equal , round , and reactive to
light. He had poor dentition. His JVP was 7 cm. LUNGS: Clear to
auscultation on the left. On the right there were some crackles
midway up the lung field. HEART: Regular rate and rhythm with a
normal S1 , S2. There were no murmurs , rubs , or gallops.
ABDOMEN: Markedly hypoactive bowel sounds. His belly was soft and
obese , nontender. There were no obvious masses. EXTREMITIES: The
patient had 2+ pulses. There was no clubbing , cyanosis , or edema.
NEUROLOGIC: The patient was alert and oriented x 3. Neural exam
was otherwise nonfocal.
ADMISSION LABORATORY DATA: Sodium 141 , potassium 3.4 , chloride
106 , bicarbonate 23 , BUN 21 , creatinine
2.1 , glucose 107 , calcium 8.4. CK was 158 with an MB of 2.2 ,
troponin was 0.12. Toxicology screen was negative. Urine
toxicology was positive for opiates. Urinalysis was remarkable for
1+ blood and 3+ protein. CBC white count was 6.9 , hematocrit 45.7 ,
platelets 301 , 000. physical therapy was 13.2 , PTT 32.6 , INR 1.0.
Chest x-ray showed cardiomegaly with a right pleural effusion and a
right middle lobe pneumonia. EKG on arrival to the emergency room
showed an irregular ventricular rate at 156 which was likely atrial
fibrillation vs flutter. There was a normal axis. There were
T wave inversions in the inferior leads as well as V5 and V6. The
EKG was then repeated after the patient had received diltiazem
which showed sinus rhythm at 86. There were still T wave
inversions in AVL and V6. There was borderline first-degree AV
block. There was LVH and T waves were flat inferiorly.
HOSPITAL COURSE BY SYSTEMS: 1. Cardiovascular - ischemia. The
patient ruled out for MI by CKs but
had a troponin which peaked at 0.12. This was thought to be rate
related. Blood pressure control was established with verapamil
( The patient had severe bronchospasms to Lopressor and it was
unclear whether it was cardiac asthma or real bronchospastic
reaction. ) , clonidine , and losartan. ( The patient had cough and
desaturation to captopril. ) Aspirin was given. A lipid panel was
checked and showed a total cholesterol of 188 , LDL 130 , HDL 56 and
triglycerides of 63. The patient was initially continued on
simvastatin. Because of the worry of CHF , ( History of low EF ,
possible orthopnea ) an echocardiogram was performed which showed
LVEF only 25% with global hypokinesis and inferior/posterior
akinesis. The etiology of his heart failure was unclear as he had
never had a known myocardial infarction in the past. A chemical
stress test was performed on June , 2003 , and showed no
reversible defect but a large inferior scar. The patient was
subsequently taken to cardiac catheterization to determine whether
he had coronary artery disease. There was no coronary artery
disease on left heart cath. Right heart cath showed an elevated
pulmonary capillary wedge pressure close to 30 and a central venous
pressure of 18. His cardiomyopathy was not shown to be ischemic in
origin. There was no indication seen for AICD placement. However ,
for the elevated central pressures , the patient was aggressively
diuresed with intravenous Lasix which was then changed to orally torsemide.
Aspirin and simvastatin were discontinued given lack of coronary
artery disease for the sake of simplifying his medical regimen in
order to optimize the chance of medical compliance.
2. Pulmonary. The patient was given levofloxacin for
community-acquired pneumonia and improved. On the evening of
admission , he had a severe bronchospastic reaction to Lopressor so
this was discontinued. He received nebulizers around the clock for
recurrent wheeze and cough. It was noted that the onset of his
cough was after his captopril dosing. For this reason , captopril
was discontinued and changed to losartan which he tolerated well
and with resolution of his cough.
3. Renal. The patient's creatinine was noted to be up to the
mid-2s from a baseline in the mid-1s. Potential etiologies on
admission where thought to be hypertension , gout , heroin use or a
low flow during his cardiac arrhythmia on presentation. A phenol
was calculated and was shown to be less than 1%. A 24-hour protein
was performed and showed over 3 gm of protein. The most likely
cause of this proteinuria was thought to be CHF , although , the
patient should have renal follow up. The patient refused Mucomyst
in anticipation of his cardiac catheterization. He underwent a
renal ultrasound which showed increased echogenicity of both
kidneys which was consistent with medical renal disease. There was
no hydronephrosis seen. There were bilateral renal cysts and a
right renal calculus. The patient will be seen in follow up with
Dr. Weissman of renal.
4. Heroin addiction. The GRH team was consulted for heroin
addiction. Methadone was given and was tapered to off during his
admission.
5. Other. Allopurinol was given for his history of gout.
6. Prophylaxis. The patient was kept on subcutaneously heparin.
The patient will follow up with Dr. Squiers , his primary care
doctor , on Tuesday , August , 2003 , at 8:00 a.m. and with
Dr. Weissman of renal on August , 2003 , at 1:30 PM.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Allopurinol 200 mg orally every day , losartan
100 mg orally every day , albuterol inhaler two
puffs four times a day as needed wheeze , amlodipine 10 mg orally every day and
torsemide 40 mg orally twice a day
Dictated By: MATILDE BREZNAY , M.D. NQ73
Attending: RASHEEDA BRAGAS , M.D. QM42
VN717/021100
Batch: 99315 Index No. ADES9F2CPF D: 9/8/03
T: 9/8/03
CC: 1. DR. BASLEY , AT SA PEHALL
Document id: 1023
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
897713346 | PUO | 28491128 | | 233251 | 3/8/1996 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/5/1996 Report Status: Unsigned
Discharge Date: 2/3/1996
PRINCIPAL DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE AND
MIXED MITRAL VALVE DISEASE
HISTORY OF THE PRESENT ILLNESS: Ms. Hebdon is an 87 year-old
woman with a history of coronary
artery disease , mitral regurgitation and multiple sclerosis. She
has been complaining of chest pain and pressure on exertion as well
as dyspnea on exertion associated with limitation of activity and
increasing sublingual nitroglycerin use for the six to seven months
prior to admission. Of note , the patient developed atrial
fibrillation , atrial flutter back in October , 1995. An
echocardiogram at that time demonstrated an ejection fraction of
40% , inferior hypokinesis , moderate mitral regurgitation , and a
left atrial size of 6.1 centimeters. The patient required
hospitalization in October , 1996 , for congestive heart failure. She
returned to the hospital in February , 1996 , with complaints of chest
pain at rest and shortness of breath. She was ruled out for
myocardial infarction at Put Wathern Hospital and transferred to
Pagham University Of , where she refused cardiac
catheterization. Echocardiogram at that time demonstrated an
ejection fraction of 45% , inferior , posterior and anterior septal
hypokinesis , mild to moderate mitral stenosis and moderate mitral
regurgitation. Again , there was left atrial enlargement measured
at 6.1 centimeters. The patient returned home and was doing well
until February , 1996 , when she developed headache , chest pain and
shortness of breath. She again presented to Put Wathern Hospital where
she was found to be in acute pulmonary edema. She was stabilized
and transferred to Pagham University Of for further
management.
PAST MEDICAL HISTORY: Significant for coronary artery disease ,
status post anterior myocardial infarction.
Mitral regurgitation. Mitral stenosis. Atrial fibrillation.
Hypertension. Hypothyroidism. Gastroesophageal reflux disease.
Peptic ulcer disease. Normocytic anemia. Polymyalgia rheumatica.
History of left humeral fracture. She is status post appendectomy ,
cholecystectomy , and laser therapy for retinal disease of the right
eye.
ALLERGIES: Erythromycin , which causes vomiting and hypertension ,
as well as to sulfa drugs which cause vomiting. She
has a possible allergy to penicillin as well.
MEDICATIONS ON ADMISSION: Synthroid 100 micrograms orally every day;
Lasix 40 milligrams orally every day; Axid 150
milligrams orally twice a day; aspirin 325 milligrams orally every day;
prednisone 5 milligrams orally every day; digoxin 0.125 milligrams orally
every day; Vasotec 5 milligrams orally twice a day; Zocor 10 milligrams orally
every day; Lopressor 25 milligrams orally four times a day; Isordil 10 milligrams
orally three times a day; Coumadin alternating 1 and 2 milligrams every day On
transfer , the patient was also on intravenous heparin and
Nitropaste.
SOCIAL HISTORY: She is widowed and retired. She has no smoking
or alcohol history.
PHYSICAL EXAMINATION: She is in atrial fibrillation at a rate of
83. Her blood pressure is 100/60 and is 95%
on room air. HEENT: Significant for upper and lower dentures
without any oropharyngeal lesions. NECK: Supple with 2+ carotid
pulses and no bruits. LUNGS: Bibasilar crackles. CARDIOVASCULAR:
Irregularly irregular rate and rhythm. Normal S1/S2. III/VI
holosystolic murmur radiating from the apex to the axilla. ABDOMEN:
Soft , nontender , obese. EXTREMITIES: Without cyanosis , clubbing
or edema. There are varicosities in bilateral lower extremities
with minimal varicosities over the thigh areas. There is bilateral
knee swelling. Pedal pulses are 1+ bilaterally. NEUROLOGICAL:
Nonfocal.
LABORATORY DATA: BUN is 35 , creatinine 1.5. White blood cell count
8.3. Hematocrit 32. physical therapy 11.9 , PTT 28.4.
HOSPITAL COURSE: The patient was admitted to the Pagham University Of Cardiology Service , where she
was maximized medically. The patient underwent cardiac
catheterization on January , 1996 , where she was noted to have
right coronary artery stenosis in the mid portion which was 50% and
distally had 80%. Finally , 90% with subtotal occlusion after the
posterior descending artery. The left anterior descending artery
had 40% stenosis after diagonal 1. Diagonal 1 itself had 90%
stenosis in the mid portion. The left circumflex had a 70%
stenosis at the mid portion and another 70% stenotic area at the
distal portion. Left ventricular ejection fraction was estimated
at 45%. Inferior hypokinesis was noted as was 3-4+ mitral
regurgitation. Right atrial pressures were 6 , right ventricle was
52/10 , pulmonary artery 52/22 , with mean of 33 , pulmonary capillary
wedge pressure was 27 and left ventricle was 160/16. The patient
was evaluated by the Cardiac Surgical Service for coronary artery
bypass grafting and replacement of her mitral valve. On March , 1996 , the patient was taken to the Operating Room where she
underwent coronary artery bypass grafting times four with saphenous
vein graft to posterior descending artery , saphenous vein graft to
obtuse marginal one , saphenous vein graft to left anterior
descending artery , diagonal one and to left anterior descending
artery. She also had mitral valve replacement with 31 millimeter
Hancock. The patient tolerated the procedure well and was
transferred postoperatively to the Cardiac Intensive Care Unit on
nitroglycerin , Dopamine drip. She was weaned to extubate without
difficulty. She was restarted on Captopril and digoxin as well as
Coumadin. The patient had minimal response to diuretics ,
associated with a rise in her creatinine to 1.9. The Captopril was
discontinued and the creatinine returned again to 1.3. Although
the chest x-ray demonstrated small bilateral pleural effusions , the
patient did not require aggressive diuresis initially as she had
excellent oxygenation on room air. Of note the patient was not
restarted on Lopressor as her blood pressures remained in the
90-100 range. The patient was , however , started on her prednisone
at 5 milligrams orally every day as well as on her Synthroid. Chest tubes
and invasive monitoring were discontinued early in the patient's
hospital course and she was transferred to the floor on
postoperative day number four. The patient was followed by
physical therapy and occupational therapy for progression of her
mobility. She was determined to benefit from intensive
rehabilitation at a facility.
CONDITION ON DISCHARGE: The patient was ambulating with
assistance. She was tolerating a regular
diet. She was seen to be in atrial fibrillation but ventricular
response was well controlled in the 60s to 70s. Of note , her
electrocardiogram demonstrated persistent right bundle branch block
as well as a left anterior fascicular block. Although the patient
had been receiving more than her normal doses of Coumadin , her INR
had not reached the therapeutic range. She was , however ,
therapeutic on heparin.
DISPOSITION: The patient will be transferred to a facility for
intensive conditioning and rehabilitation. There she
will continue to receive her heparin until she is therapeutic on
her Coumadin. Coumadin dosing will be handled by primary care
doctor , Dr. Gaylene Faniel , or a physician at the rehabilitation
center. Dr. Swayzer 's number is 326-615-2066. The goal INR is 2
to 2.5. The patient will also require follow-up chest x-rays as
prior to discharge , her chest x-ray demonstrated bilateral pleural
effusions which were small and were not compromising her
respiration at all.
DISCHARGE MEDICATIONS: Tylenol #3 one to two tablets orally every 3-4h.
as needed pain; digoxin 0.125 milligrams orally
every day; Colace 100 milligrams orally three times a day while taking Tylenol #3;
Lasix 80 milligrams orally every day to be continued initially but may be
discontinued at the discretion of the primary care or cardiology
physicians , pending the resolution of the pleural effusions and her
respiratory status; Synthroid 150 micrograms orally every day The patient
will require thyroid function tests in four weeks. Multivitamin
one tablet orally every day; Coumadin , dose to be determined by the
patient's INR , again the goal is 2 to 2.5. The patient received 4
milligrams on September , and 3 milligrams on September , and her
INR on September is 1.3. Axid 150 milligrams orally twice a day; K-Dur
10 mEq orally every day , potassium will also need to be monitored while
she is on the Lasix; intravenous heparin 800 units per hour with a
PTT goal of 50-60. The patient's PTT today on this dosing is 54.
FOLLOW-UP: The patient should follow-up with Dr. Colasamte in four to
six weeks , with Dr. Hamblet in two weeks , and with Dr.
Swayzer in one to two weeks.
Dictated By: SHERISE WANKUM , M.D. YC13
Attending: ISABELLE E. COLASAMTE , M.D. CL7
GX992/6464
Batch: 1853 Index No. T6LRIZ5WJ5 D: 6/13/96
T: 6/13/96
Document id: 1024
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
715012642 | PUO | 07021160 | | 0556590 | 9/24/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 7/12/2006 Report Status: Signed
Discharge Date: 11/4/2006
ATTENDING: MALADY , CASSONDRA MD , MS
PRINCIPAL DIAGNOSIS:
CHF exacerbation.
PAST MEDICAL HISTORY:
Hypertension , hypertrophic cardiomyopathy , cigarette smoking ,
obstructive sleep apnea on CPAP , morbid obesity , status post
gastric banding in 1998 , chronic lower back pain , sciatica ,
history of DVT off Coumadin since 2000 and aortic insufficiency.
HISTORY OF PRESENT ILLNESS:
This is a 57-year-old female with history of CHF who presents
with worsening shortness of breath over the week prior to
admission secondary to increased salt intake over the weekend at
her sister's house as well as not taking her Lasix. The patient
reports lower extremity edema , increasing dyspnea on exertion
with walking to the bathroom and increased orthopnea as well as
intermittent chest pain both on the left and right side of her
chest. In the Emergency Department , the patient received Lasix
80 mg intravenous x1 , Nitro paste , aspirin , Tylenol and oxycodone.
HOME MEDICATIONS:
Norvasc 10 mg daily , Toprol-XL 50 mg orally daily , Lasix 80 mg orally
twice a day , clonidine 0.2 mg orally twice a day , lisinopril 40 mg orally
daily , Lipitor 20 mg orally nightly , ASA 81 mg orally daily , Claritin
10 mg orally daily , albuterol inhaler three times a day as needed and oxycodone 5
mg every 6 hours as needed
ALLERGIES:
Penicillin ( rash ) and Motrin ( GI upset ).
PHYSICAL EXAMINATION ON ADMISSION:
Vital signs: Afebrile , heart rate 68 , blood pressure 160/70 ,
respiratory rate 24 , O2 saturation 96% on 3 liters.
General: Obese , sitting up in bed , nasal cannula in place.
HEENT: Anicteric , EOMI , OP clear. JVP 10 cm.
CV: III/VI SM/DM upper sternal border.
Pulmonary: Crackles left base , no wheezes.
Abdomen: Positive bowel sounds , soft , nontender , nondistended , obese.
Extremities: 1+ pitting edema bilaterally to midcalf.
DATA:
Sodium 146 , hematocrit 43.3 , white blood cells 6.84. Cardiac
enzymes negative x3. BNP 312.
Chest x-ray stable , moderate-to-severe cardiomegaly , mild
pulmonary edema , small bilateral pleural effusions.
MIBI in 4/3 , ejection fraction of 46% and normal perfusion.
Echo in 4/3 , LV normal , moderate concentric LVH , EF of 60% , mild LAE ,
moderate to severe AR , thickened MV with mild MR , moderate TR ,
PAP 34.
HOSPITAL COURSE:
This is a 57-year-old female with CHF exacerbation.
Cardiovascular: The patient was found to be fluid
overloaded. She received Lasix 80 mg intravenous in the Emergency
Department. She was started on Lasix 100 intravenous twice a day and then
three times a day with good response. On 1/7/06 , Zaroxolyn 5 mg was added
with excellent response. On the day of discharge , her weight is
284 pounds , her recorded dry weight is 276 pounds. Her
creatinine slightly increased when Zaroxolyn was started to 1.3.
The patient is to have her creatinine rechecked on 6/19/06. The
patient's repeat echo showed an ejection fraction of 60-65% , mild
atrial fibrillation at least moderate AR , trace to mild MR. The
patient ruled out for MI with cardiac enzymes x3 and serial EKGs.
She was continued on ASA , beta-blocker , ACE inhibitors , and
statin. Her telemetry was discontinued. Her fasting lipids
profile was cholesterol 141 , triglycerides 121 , HDL 46 , LDL 71 ,
VLDL 24. The patient was referred to the Rluke Norph Health
Plan is for VNA with tele-monitoring upon discharge. Of note is
that the patient's clonidine was increased to 0.3 mg twice a day for
better blood pressure control. The blood pressure range on the
day of discharge was 102-140/54-84.
Pulmonary: The patient has a history of restrictive lung
disease , obstructive sleep apnea ( on CPAP at home ) and asthma.
The patient was continued on her as needed albuterol. With this CHF
exacerbation , the patient needed 3 liters on O2 to keep her O2
saturation greater than 91%. Her chest x-ray on 5/15/06 showed
mild edema , no effusions. The patient is not on home O2 at
baseline. On the day of discharge , her O2 saturation was 95% on
room air with ambulation.
The patient was instructed to stop smoking.
Heme: The patient has a macrocytic anemia. Her B12 was 622.
Folate was 8. The patient was started on folate.
Musculoskeletal: The patient was continued on oxycodone as needed
for chronic back pain. Her right shoulder pain improved with
rotator cuff pendulum exercises.
PROPHYLAXIS: The patient was on Lovenox and Nexium while inhouse.
DISCHARGE MEDICATIONS:
Tylenol 650 mg orally every 4 hours as needed headache , ASA 81 mg orally daily ,
albuterol inhaler 2 puffs four times a day as needed shortness of breath and
wheezing , Norvasc 10 mg orally daily , Artificial Tears 2 drops each
eye three times a day , Lipitor 20 mg orally daily , clonidine 0.3 mg orally
twice a day , Colace 100 mg orally twice a day , Pepcid 20 mg orally twice a day ,
folate 1 mg orally daily , Lasix 100 mg orally twice a day , lisinopril 40
mg orally daily , Claritin 10 mg orally daily , Maalox liquid maximum
strength 10 mL orally every 6 hours as needed dyspepsia , Zaroxolyn 5 mg orally
every day before noon to be taken half an hour before a.m. Lasix dose , Toprol-XL
50 mg orally daily , Percocet one tab orally three times a day as needed pain. The
patient received a prescription for 30 tablets and Ocean nasal
spray two sprays nasal four times a day
FOLLOW-UP INSTRUCTIONS:
Return to the hospital if you experience worsening shortness of
breath , stop smoking , eat a low-salt diet , take medications as
prescribed. Follow up with Annabel Verfaille in the Rluke Norph Health on 10/3/06 had 3:00 p.m. and with Dr. Alexis , your new
primary care physician in KTDUOO on 5/23/06 at 2:10. Have your
blood drawn on 6/1/06 to monitor your kidney function ( creatinine ).
ADVANCED DIRECTIVES:
The patient is full code.
eScription document: 3-7828633 EMSSten Tel
Dictated By: NICKLIN , MOIRA
Attending: MALADY , CASSONDRA
Dictation ID 3800471
D: 9/25/06
T: 9/25/06
Document id: 1025
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
N |
Y |
N |
N |
N |
- |
N |
N |
Y |
N |
Y |
N |
975102819 | PUO | 37701119 | | 591729 | 2/21/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/18/1996 Report Status: Signed
Discharge Date: 10/27/1996
DISCHARGE DIAGNOSIS: INAPPROPRIATE SINUS PAUSE , ADMITTED FOR
PACEMAKER PLACEMENT.
SECONDARY DIAGNOSES: 1 ) CORONARY ARTERY DISEASE.
2 ) STATUS POST PTCA OF RIGHT CORONARY ARTERY
( TIMES TWO ) IN 1992.
3 ) STATUS POST MYOCARDIAL INFARCTION IN
1992.
4 ) STATUS POST CORONARY ARTERY BYPASS GRAFT
TIMES TWO VESSELS IN 1992.
5 ) PERIPHERAL VASCULAR DISEASE , LEFT GREATER
THAN RIGHT CLAUDICATION.
6 ) DEPRESSION.
7 ) STATUS POST CHOLECYSTECTOMY.
8 ) STATUS POST PELVIC FLOOR SUSPENSION TIMES
TWO ( RECTOCELE AND CYSTOCELE ).
9 ) STATUS POST APPENDECTOMY.
10 ) HISTORY OF BOWEL OBSTRUCTION ( STATUS POST
PELVIC SURGERY WITH ADHESIONS ) TREATED
WITH LYSIS OF ADHESIONS.
HISTORY OF PRESENT ILLNESS: Patient is a 61 year old female with
coronary artery disease ( status post
PTCA , myocardial infarction , and coronary artery bypass graft ) who
presented with a few week history of near syncope and evidence of
inappropriate sinus arrest on Holter monitor for pacemaker
placement. Ms. Bartholomeu 's pertinent medical history was significant
for longstanding peripheral vascular disease and coronary artery
disease. In early 1992 , she first noted the onset of exertional
chest discomfort. Symptoms progressed and an exercise tolerance
test was performed in 1/4 which was standard Bruce protocol at
six minutes and thirty seconds with a maximal heart rate of 160 and
maximal blood pressure of 144 stopping secondary to 2 to 2.5 mm ST
depression inferolaterally. Cardiac catheterization in 6/9
revealed left anterior descending of 80 to 90% and mid right
coronary artery 99% ( with left-to-right and right-to-right
collaterals ). The right coronary artery lesion was PTCA to a 20%
residual which re-occluded and was re-PTCA to a 20% then
re-occluded again ( no PTCA a third time ). Echo in 6/9 revealed
an ejection fraction of 50% , inferior hypokinesis consistent with
prior myocardial infarction , and mild MVP/MR was also seen.
Coronary artery bypass graft times two vessels ( LIMA to left
anterior descending and saphenous vein graft to the proximal
descending artery ) was performed in 6/9 ( Dr. Colasamte ). Since
then , she had done well with no further chest pain. Starting
approximately one month prior to admission , the patient began to
experience episodes of near syncope. Episodes consisted of the
sensation of light headedness , tunnel vision , tinnitus , and
diaphoresis ( although she felt near-syncopal , she had never
actually experienced true syncope ). During episodes , she
frequently felt the sensation of facial flushing with diaphoresis.
She could not recall precipitating events prior to the episodes but
did note that the events never occurred when she was active , only
when she was at rest ( but not asleep ). Holter monitor on September , 1996 revealed multiple three to four second pauses. The
patient's anti-hypertensive , metoprolol ( 25 mg twice a day ) was
discontinued , however , repeat Holter on 10/9/96 revealed multiple
pauses ( 114 pauses in a 24-hour period ) with the longest lasting
4.2 seconds. The patient was then sent to the Pagham University Of for further evaluation and management.
PAST MEDICAL HISTORY: As described in Secondary Diagnoses above.
SOCIAL HISTORY: Divorced , retired x-ray technician , former smoker
of one pack per day times thirty years quitting
eleven years ago , and history of ethanol consumption at the time of
divorce. Her primary medical doctor was Dr. Verda Triarsi
( Jeoffroy ).
FAMILY HISTORY: Father died of a myocardial infarction at age 76
and history of hypercholesterolemia , mother died
at age 86 of gastrointestinal ulceration and had a history of
insulin dependent diabetes mellitus , and sister with non-insulin
dependent diabetes mellitus and gastrointestinal ulcers.
CURRENT MEDICATIONS: ASA 325 mg orally every day , Lopressor 25 mg orally
twice a day ( discontinued three weeks ago ) ,
vitamin supplements ( vitamin E , lysine , Co-Q10 , vitamin C , calcium ,
Centrum Silver , and primrose oil ) , and no over-the-counter
medications.
ALLERGIES: Penicillin , Zantac , and Comtrex , all of which produce
angioedema and tetracycline ( sun sensitivity ).
PHYSICAL EXAMINATION: Vital signs showed a blood pressure of
160/110 , pulse 92 , temperature 97.0 ,
respirations 16 , and 97% on room air. GENERAL: Energetic white
female in no apparent distress. HEENT: Extraocular movements
intact , pupils equally round and reactive to light , oropharynx
without erythema or exudate , and no cervical lymphadenopathy or
thyromegaly. NECK: Supple and carotids 2+ bilaterally without
bruits. CARDIOVASCULAR: Regular rate and rhythm at 72 with no
rubs , gallops , or murmurs. LUNGS: Clear to auscultation and
percussion. ABDOMEN: Obese with cholecystectomy scar , chest tube
scars , and bowel surgery scar ( right just lateral of the midline ) ,
normal bowel sounds times four , non-tender , non-distended , no
hepatosplenomegaly , and no bruits. EXTREMITIES: No cyanosis ,
clubbing , or edema , femoral pulses were barely palpable , and distal
pulses were 1+ bilaterally on the right and left lower extremity.
NEUROLOGICAL: Alert and oriented times three , cranial nerves
II-XII intact , strength 5/5 , sensory intact , deep tendon reflexes
3+ bilaterally throughout , and toes downgoing.
LABORATORY EXAMINATION: SMA 7 was remarkable for a potassium of
3.9 , BUN 14 , creatinine 0.7 , liver
function tests within normal limits , white blood count equalled
7.8 , hematocrit equalled 41 , and platelets were 233. physical therapy was 12.3
( 1.1 ) and PTT equalled 30.4. Chest x-ray showed status post
coronary artery bypass graft and bibasilar atelectasis but no acute
air space disease and EKG showed a normal sinus rhythm at 79 with
an axis of 60 degrees , T wave inversion in V2 to V3 with upright in
V4 and V6 , and Q waves in II , III , and F.
HOSPITAL COURSE: Patient is a 61 year old female with peripheral
vascular disease and coronary artery disease
status post coronary artery bypass graft now admitted for
evaluation and management of near syncope. Holter monitor had
demonstrated persistence of sinus pauses despite discontinuation of
beta blocker ( metoprolol ). The patient was admitted for
observation over the weekend. She experienced multiple sinus
pauses , particularly at nighttime. The longest pause recorded was
4.7 seconds. Though she was aware of the irregular heart rhythm ,
she never became truly syncopal or had evidence of hemodynamic
instability. She was enrolled in the SWH trial and underwent
placement of a dual chamber pacemaker randomized to the VVIR mode on
9/10/96. She tolerated the procedure without complication. Post-operative
chest x-ray revealed appropriate location of atrial and ventricular leads and
no evidence of pneumothorax. Interrogation of the pacemaker
revealed appropriate response. The patient did well overnight and
was discharged on May , 1996 with instructions to follow-up
with Dr. Dominguez in ten days.
DISPOSITION: The patient is discharged on May , 1996 in good
condition.
DISCHARGE MEDICATIONS: ASA 325 mg orally every day and Percocet one to
two tablets orally every 4 hours as needed pain.
FOLLOW-UP: She was instructed to follow-up with Dr. Dominguez on
August , 1996 at 1 p.m.
Dictated By: MOSHE J. SHUGRUE , M.D. CR87
Attending: ROSSIE K. MANKOSKI , M.D. AO19
RB525/8289
Batch: 92669 Index No. YUNLC1531X D: 9/23/96
T: 10/11/96
Document id: 1026
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OSA |
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275489010 | PUO | 14088690 | | 9660833 | 2/9/2004 12:00:00 a.m. | CHEST PAIN | Signed | DIS | Admission Date: 5/4/2004 Report Status: Signed
Discharge Date: 3/14/2004
ATTENDING: QUINN JAKE KUSH MD
HISTORY OF PRESENT ILLNESS: Briefly , the patient is a
76-year-old woman with coronary artery disease status post
coronary artery bypass graft in 1992 who was recently admitted
with non ST elevation MI/congestive heart failure at which time
catheterization revealed an increased wedge with decreased
patency in both venous grafts and a patent LIMA graft with
collaterals. The patient has an extensive past medical history
of hypercholesterolemia , chronic renal insufficiency , insulin
dependent diabetes , coronary artery disease status post multiple
MI , CABG , hypertension , degenerative joint disease , CVA , gout ,
schizoaffective disorder , tardive dyskinesia and hypothyroidism.
At her baseline she has been staying at the Sa Pehall and on
admission was complaining of chest pressure since waking , similar
to the pressure she felt during a prior admission. She had a
certain amount of shortness of breath , some nausea , two episodes
of vomiting and her symptoms were not responsive to nitroglycerin
tablets at the Sa Pehall The patient came to the I Warho Hospital Emergency Department where she reported that her
chest pressure had resolved. She was treated with intravenous TNG. In
the Emergency Department she was also treated with Lopressor ,
aspirin , intravenous trinitroglycerin and was heparinized. The patient
then pulled out the lines. Her admission vitals were significant
for a blood pressure of 180/90. The patient had a heart rate of
86 , was afebrile and was breathing at 100% at 2 liters. She had
an elevated JVP , had clear sounding lungs , trace edema and at the
left upper sternal border and left lower sternal border a
systolic ejection murmur II-III/VI was heard with S1 and S2.
Admission labs were significant for an elevated creatinine of
2.0. Cardiac enzymes were negative. The patient had elevated
platelets from a baseline of 30 to 80 to 673 on admission , a
white count of 9.3 , hematocrit of 35. EKG was notable for a Q3
which had been seen on a prior EKG. T-wave inversions also seen
on a prior EKG. The patient had an echo on 7/4 which showed
concentric LVH with an EF of 30-35% , posterolateral and inferior
akinesis was also seen. A calcified aortic valve with trace AI
and mild MR was seen. On 10/19 , the patient had catheterization
which showed that her circulation was right dominant with an LAD
90% and 100% lesions , left circumflex with 100% lesion , RCA with
100% lesions. She had an SVG to PDA graft with 100% lesion , SVG
to circumflex graft with 85% lesion stented to 10% at that time.
She had a LIMA to LAD graft which was patent , and she had lots of
collaterals. The right heart cath was significant for a wedge of
39 and a PA of 75/34 and right atrial pressure of 14 and a
cardiac index of 1.7.
HOSPITAL COURSE: By system ,
1. Ischemia: The patient was initially treated with aspirin ,
beta blockers , statin , Plavix , Heparinized and was ruled out with
enzymes. On the first day of hospitalizations , the patient's
heparin was stopped , the patient's intravenous trinitroglycerin was
stopped as well. The patient was started on nadolol and that
dose was increased to 80 every day which the patient tolerated well
and seemed to control the patient's blood pressure and heart rate
reasonably well. The patient's attending felt that the patient
was a poor candidate for catheterization and other interventions
and would not benefit significantly from it. The symptoms the
patient was having was similar she was having during a prior
hospitalization which had ended just two days before this
admission. It was felt that her nausea , vomiting and chest
pressure were probably noncardiac in nature. The only change in
the patient's cardiac medications at the time of discharge is an
increase in nadolol to 80 mg every day.
Rhythm: The patient's rhythm was monitored on telemetry for most
of her stay during this hospitalization. Significant events were
not observed.
Pump: The patient was continued at her regular dose of
outpatient medications which seemed to be effective. The patient
had multiple complaints of chest pain/pressure during her
hospitalization which resulted in periodic examinations and EKGs.
All of these workups were negative.
2. GI: On 10/26 it was noted that the patient had an increased
white count of 16 , 000. Also on exam on that day it was noted
that the patient had marked right upper quadrant abdominal
tenderness and fullness. She was not tender anywhere else in her
abdomen. Abdominal exam was also significant for a central mass
representing an umbilical hernia. At that time , General Surgery
consult was called. Lipase and amylase were sent off. They were
negative. Liver function tests were also in the normal range at
that time. Surgery felt that the patient was a poor surgical
candidate given her comorbidities at that time but did recommend
a cholecystectomy in the future. They recommended initial
antibiotic course of amp , Levo and Flagyl which she was started
on. They also recommended making the patient NPO treated her
with Pepcid and giving her adequate intravenous hydration. The major
intervention they suggested was a cholecystectomy tube by
Interventional Radiology which was placed on the night of
3/16/04. On 9/24 , the patient's white count was down to 10 with
a Tmax of 100 , and at the time of discharge the patient had a
white count in the normal range around 7 and was also afebrile.
Surgery followed the patient during her stay in the hospital as
did Interventional Radiology. Bile was sent out for culture
which showed yeast as well as a gram stain which showed gram
positive cocci. The patient's antibiotics were switched to
Vancomycin , Levo and Flagyl. Initially the Vancomycin and Flagyl
were given intravenous and the Levo was given orally One day prior to
discharge , the patient's Flagyl was switched to orally and on the
day of discharge the Vancomycin was stopped after the patient had
received seven days of Vancomycin. The patient will be
discharged on Flagyl orally and Levo orally The patient was also
started no Fluconazole 100 to treat the yeast that was noted in
her bile cultures. The IR drain will need to be in the patient's
gallbladder for a minimum of six weeks or until the patient has
her elective cholecystectomy which will be scheduled at a later
date.
3. ID: The patient is colonized with MRSA and appropriate
precautions were taken and the patient was also noted to have an
infection in her gallbladder and was treated for it as such.
4. Pain: The patient was treated for abdominal pain during her
stay in the hospital with Demerol and also with Morphine.
5. Psychiatry: The patient was seen by Psychiatry on admission
to help manage her agitation and delirium. They did a
preliminary assessment of the patient. The patient did show
certain signs of agitation and multiple code grays had to be
called on the patient for difficult behavior , though the patient
was never in danger of truly hurting herself or others.
ADMISSION DIAGNOSIS: Cardiac chest pain.
DISCHARGE DIAGNOSIS: Cholecystitis now resolved.
MEDICATIONS ON DISCHARGE: ASA 325 , Colace 100 twice a day , Lasix 80
twice a day , insulin sliding scale , Levoxyl 175 , nadolol 80 , Lipitor
80 every bedtime , Lantis 18 units , Diovan 80 , levofloxacin 500 every 24
hours to complete a 14 day course , Fluconazole 100 to complete a
14 day course , Flagyl 500 three times a day to complete a 14 day course ,
Plavix 75 , famotidine 20 twice a day , iron 325 every day.
eScription document: 2-8292194 DBSSten Tel
CC: Belinda Esannason M.D.
Sno
Mont , Michigan
Dictated By: ESANNASON , BELINDA
Attending: KUSH , QUINN JAKE
Dictation ID 2479778
D: 10/18/04
T: 10/18/04
Document id: 1027
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GER |
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OSA |
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567692877 | PUO | 54622825 | | 730625 | 10/19/1998 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 8/13/1998 Report Status: Signed
Discharge Date: 10/7/1998
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: Mr. Sare is a 70 year old man who
recently had been experiencing an
increase in frequency of chest pain with exertion. As a result of
his recent increase in symptoms , he was administered an exercise
tolerance test which was predictive of ischemia and revealed an
ejection fraction of approximately 50%. As a result of his
positive exercise tolerance test , he was referred for cardiac
catheterization on May , 1998 which revealed three vessel
coronary artery disease. At this time , he was referred to the
cardiac surgery service for revascularization.
PAST MEDICAL/SURGICAL HISTORY: Significant for transitional cell
carcinoma of the bladder , the
patient was status post radical cystectomy in 1992 with an ileal
loop bypass , no chemotherapy or radiation therapy was used in the
treatment of this cancer , also significant history of asthma
treated at home with the use of inhalers , and patient also reported
a history of gallstones which were asymptomatic.
CURRENT MEDICATIONS: Cardizem 180 mg once a day , 81 mg of aspirin
a day , and Lipitor 10 mg orally once a day.
The patient used Beclovent metered dose inhaler at three puffs once
a day at home to control his asthma symptoms.
SOCIAL HISTORY: Patient reported a remote history of tobacco use
with no tobacco use for the last thirty years.
Likewise , he reported no current use of alcohol.
ALLERGIES: Patient reported no known drug allergies.
PHYSICAL EXAMINATION: At the time of admission , temperature was
98.4 degrees Fahrenheit , heart rate of 80
beats per minute and regular , blood pressure of 120/80 , and an
oxygen saturation of 94% on room air. HEENT: Essentially within
normal limits revealing no audible bruits over his carotid
arteries , no jugular venous distention , no lymphadenopathy , and his
oropharynx was benign with reasonably good dentition. CARDIAC:
Examination revealed the heart to be in a regular rate and rhythm
at 80 beats per minute with no audible murmur , gallop , or rub.
CHEST: Examination revealed the lungs to be clear to auscultation
in bilateral lung fields. ABDOMEN: Examination was benign with
the exception of the ileal loop mentioned above. The abdomen was
otherwise nontender and nondistended without any focal findings.
EXTREMITIES: Examination revealed no cyanosis , clubbing , or edema ,
2+ dorsalis pedis pulses bilaterally , and no evidence of varicose
veins. RECTAL: Examination revealed normal tone and guaiac
negative stool.
LABORATORY EXAMINATION: Values at the time of admission included a
BUN of 17 , a creatinine of 1.1 , sodium of
140 , potassium of 4.3 , white blood cell count of 9 , platelet count
of 245 , 000 , and a hematocrit of 49.1.
HOSPITAL COURSE: Patient was taken to the Operating Room on January , 1998 where he underwent coronary artery bypass
grafting times four including left internal mammary artery to the
left anterior descending coronary artery and saphenous vein grafts
to the posterior descending coronary artery , the obtuse marginal ,
and the PLV. For further details of this operation , please refer
to the dictated Operative Note. Patient progressed well in his
postoperative course. He was extubated on postoperative day number
one and transferred from the Intensive Care Unit to the Stepdown
Unit on postoperative day number two. On postoperative day number
three , the patient had a his chest tubes and temporary cardiac
pacing wires discontinued and began working on increasing his
ambulation and mobility. Patient continued to progress well on the
Stepdown Unit and was now in good condition for discharge to home
with visiting nurse services on postoperative day number six. The
only complication of note during his postoperative course was
positive urine culture for which the patient was started on
levofloxacin to be continued for a total course of seven days.
DISPOSITION: The patient is in good condition for discharge to
home on postoperative day number six.
DISCHARGE MEDICATIONS: Beclovent three puffs inhaled once a day ,
aspirin 325 mg orally every day , Niferex 150 mg
orally twice a day , diltiazem 30 mg orally three times a day , and levofloxacin 500 mg
orally every day times four days.
FOLLOW-UP: He has been instructed to make follow-up appointments
with his cardiologist for one week following discharge
and to return to see his cardiac surgeon , Dr. Genny Barrette , six
weeks following discharge from the hospital.
Dictated By: SVETLANA SALLINGS , P.A.
Attending: GENNY S. BARRETTE , M.D. ZD6
OK339/6140
Batch: 83626 Index No. KUNCBB4H6A D: 10/23/98
T: 5/15/98
Document id: 1028
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CHF |
Dp |
DM |
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GER |
Gou |
HC |
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OSA |
PVD |
VI |
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616230831 | PUO | 56022710 | | 951036 | 5/22/2001 12:00:00 a.m. | BILATERAL PLEURAL EFFUSION | Signed | DIS | Admission Date: 9/23/2001 Report Status: Signed
Discharge Date: 10/22/2001
PRINCIPAL DIAGNOSIS: RECURRENT PLEURAL EFFUSIONS AND SHORTNESS OF
BREATH FROM YELLOW NAIL SYNDROME.
SECONDARY DIAGNOSES: 1. HYPERTENSION.
2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
3. ANXIETY.
4. DIABETES MELLITUS.
5. CHRONIC RENAL INSUFFICIENCY.
CHIEF COMPLAINT: DYSPNEA ON EXERTION.
HISTORY OF PRESENT ILLNESS: Ms. Fritze is a 70-year-old woman with
a history of yellow nail syndrome ,
hypertension , chronic obstructive pulmonary disease and diabetes ,
who has had multiple admissions since October 2001. The first was
an admission to an outside hospital from 5/25/01 - 11/20/01.
At that time , she had increased shortness of breath , and was
diagnosed with bilateral pleural effusions and a pericardial
effusion. She had a pericardial window and 600 cc were drained
from her pericardium , as well as pleural effusions drained. She
was discharged at that time with a diagnosis of congestive heart
failure , secondary to cor pulmonale. The second admission was
from 8/28/01 - 8/10/01 at the Kernan To Dautedi University Of Of . At that time , she had
increased lower extremity edema. She was diuresed during that
admission , and again her pleural effusions were tapped. An
echocardiogram at that time revealed mild LVH , an ejection fraction
of 55-60% , no wall motion abnormalities and a moderate-large
pericardial effusion with fibrinous strands.
A catheterization of her left and right heart revealed a right
atrial pressure of 5 , an RV pressure of 45/11 , PA pressures of
38/18 and a pulmonary capillary wedge pressure of 22 , LV pressure
was 127/14. There was no constrictive pericardial disease or
restrictive cardiomyopathy. She also had no malignant cells in her
pleural effusion , which was exudated. ANCA , ANA , SPEP were
negative. She also had a renal ultrasound that was without mass or
hydronephrosis , 24 hour urine collection with decreased protein.
The third admission was at Kernan To Dautedi University Of Of from 11/15/01 - 1/16/01 , for
increasing shortness of breath and increasing lower extremity
edema. At that time she was diuresed , found to be iron deficient.
She had bilateral thoracentesis , which revealed exudative
effusions. PFTs revealed a FEV1 of .9 , 40% of predicted , an FVC of
1.26 , 43% of predicted , an FEV1/FVC ratio of 93% , a TLC of 2.07 ,
40% of predicted , and a DLCO of 8.42 , also 40% of predicted. She
was ruled out for TB with serial ASBs during this admission.
She was also diagnosed with yellow nail syndrome at that time ,
consisting of the clinical syndrome of recurrent pleural effusions ,
lymphedema and yellow fingernails. She was started on high dose
Vitamin E , and evaluated by CT surgery for a possible pleurodesis.
However , she was sent home at that time with an increased dose of
diuretics.
Since her discharge in July , she has been aggressively diuresed ,
but the diuretics were stopped secondary to hyperkalemia. In September
2001 , she was found to have a 10 pound weight gain and was
restarted on Lasix. Over the week prior to admission , she has had
increasing dyspnea on exertion. She has baseline shortness of
breath and orthopnea , but her orthopnea has also worsened. Her
weight at discharge in July was 208 , and on admission she
currently weighs 238 , and was 231 pounds a month prior to
admission. She denies wheezing , but does have a chronic cough with
white sputum. She has had some substernal chest pain that is sharp
with dyspnea on exertion , which lasts for awhile without radiation.
She also has increasing lower extremity edema. In the emergency
department , she was found to be afebrile , heart rate 103 ,
respiratory rate 24 , blood pressure 95/41 and satting 91% on 2
liters. She was given Albuterol and Atrovent nebs without
improvement and Lasix 160 mg intravenous with a 600 cc diuresis.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Chronic anemia.
3. Lymphedema , chronic. 4. Right tibial
plateau fracture in October 2000 , status post open reduction and
internal fixation right knee reconstruction. 5. Anxiety. 6.
Chronic obstructive pulmonary disease on home oxygen. 7. Yellow
nail syndrome. 8. Obesity. 9. Diabetes. 10. Acute
interstitial nephritis secondary to Levaquin. 11. Peptic ulcer
disease. 12. Left oophorectomy.
REVIEW OF SYSTEMS: Denies headache , fevers , chills , URI symptoms ,
wheezing , reflux , nausea , vomiting , diarrhea ,
bright red blood per rectum , dysuria or hematuria. She does have
chronic constipation and dark stools from iron supplementation.
Also , lower back and shoulder pain from gout.
MEDICATIONS: 1. Colchicine 0.6 mg every other day 2. Zestril 2.5 mg q.
d. 3. K-Dur 20 milliequivalents twice a day 4. Procrit
10 , 000 units biweekly 5. Glyburide 5 mg every day. 6. Aspirin 325 mg
every day. 7. Colace 100 mg orally twice a day 8. Iron 300 mg three times a day 9.
Lasix 160 mg orally twice a day 10. Atrovent inhalers two puffs four times a day
11. Magnesium gluconate 500 mg four times a day 12. Zantac 150 mg as needed
13. Vitamin E 1200 units every day 14. Allopurinol 300 mg every day.
15. Xanax .125-2.5 three times a day as needed 16. Percocet 1-2 tabs every 4-6h.
as needed pain. 17. Albuterol nebulizers every 4 hours as needed.
ALLERGIES: Levofloxacin , which has caused acute interstitial
nephritis.
SOCIAL HISTORY: Lives with her daughter , ETOH socially , just
occasionally , Tobacco , quit 10 years ago - has a
30 pack year history. No intravenous drug use.
FAMILY HISTORY: Her mother died at age 88. Father died at age 87
of natural causes.
PHYSICAL EXAMINATION: Temperature 98.4 , heart rate 112 , blood
pressure 132/84 , respiratory rate of 30 ,
oxygen saturation 95% on 2 liters. General , older woman in
moderate respiratory distress.
HEENT: Pupils equal , round and reactive to light , extraocular
movements are intact , OP clear , mouth moist.
Neck: No jugular venous distention , no lymphadenopathy , 2+
carotids without bruits bilaterally.
Cardiovascular: Tachycardic , normal S1 , S2 , no murmurs , rubs or
gallops.
Pulses: Intact
Chest: Decreased breath sounds bilaterally half way up lung
fields , no E-A changes , crackles on top of effusions , clear to
auscultation at the apices.
Abdomen: Obese , soft , non-tender , non-distended , active bowel
sounds , no hepatosplenomegaly , no masses.
Extremities: Warm , 3+ edema to the hips , no clubbing or cyanosis.
Nails: Thickened , yellow fingers and toenails.
Neurological: Cranial nerves II-XII grossly intact , sensation
grossly intact , motor strength 5/5 upper extremities and lower
extremities , DTS could not be obtained , toes were equivocal
bilaterally.
Rectal: Hemoccult negative per emergency department.
LABORATORY STUDIES: Sodium 126 , potassium 3.2 , chloride 85 , bicarb
31 , BUN 31 , creatinine 1.7 , glucose 96 , ALT 7 , AST 13 , alkaline
phosphatase 82 , total bilirubin 0.2 , albumin 3.4 , calcium 9.7 ,
total protein 7.2 , CK 25 , troponin 0.00. White count 11.3 ,
hematocrit 36.1 , platelets 361 , MCV 89.4. Differential of the
white count is 12 , 82 neutrophils , 6 monocytes. ESR 99. physical therapy 12.2 ,
PTT 24.4 , INR 1.0. D-Dimer >1000.
EKG: Normal sinus rhythm , rate 114 , low voltage. Normal axis ,
normal intervals , Q-wave in three , Q-wave flattening in 3 and F , no
acute ST or T-wave changes.
Chest x-ray: Bilateral pleural effusions , right = left , left
effusion is bigger than in July 2001.
LENIS: Negative for evidence for deep venous thrombosis , but limited study.
SUMMARY: This is a 70-year-old woman with history of hypertension ,
diabetes , chronic obstructive pulmonary disease , home 02
requirement and yellow nail syndrome. She was admitted with
increasing dyspnea on exertion and orthopnea and a weight gain over
the past week prior to admission. She has most likely had a
failure of home diuretics , and needed to have her effusions tapped
along with some definitive therapy for her yellow nail syndrome in
terms of recurrent pleural effusions.
HOSPITAL COURSE: 1. Pulmonary. We initially diuresed Ms. Fritze
with intravenous Lasix , along with Diuril. She had brisk
diuresis overnight , but was still short of breath the next day. On
hospital day #2 , we did a thoracentesis on her right side and were
able to remove 1.5 liters of clear , yellowish fluid. The fluid was
sent for cytology , as well as chemistries and returned as an
exudative effusion with predominant lymphocytes. The cytology was
negative for any malignant cells. The pulmonary team was
consulted , who decided that she would benefit from a pleurodesis to
prevent effusions from recurring. We consulted thoracic surgery ,
who requested a CT scan after a thoracentesis to assess her lungs
for evidence of malignancy.
CT scan was done on 9/19/01 , but due to atelectasis and having to
do the study without intravenous contrast , there were areas in her right and
left lungs that appeared nodular or opacified and could have been
malignancies. CT surgery also requested cardiac clearance before
any definitive surgical therapy was done due to new onset SVT. We obtained a
stress MIBI. On 9/4/01 , she was taken to the operating room for surgery
of the right chest. At that time , Dr. Finseth , the cardiothoracic
surgeon took biopsies of her pleura , which were reportedly
thickened and yellow. She also took a wedge biopsy of the right
lower lobe. Those biopsies have returned , and revealed mild
nonspecific interstitial pneumonitis with chronic bronchiolitis.
The diaphragm was also biopsied , and was determined to be lymphoid
tissue in a fibrous tissue fragment. She had a chest tube placed
at the time of operation and tolerated that well. However , after that
procedure , she was deemed unstable by the PACU team and was
admitted to MICU overnight. She extubated without problems and
remained on a few liters of oxygen overnight , with oxygen
saturations in the 90%. She was readmitted to the medicine team
on the following day , 8/28/01. Overall , she tolerated that
procedure well. Her chest tube that was placed on the right side
did not drain much fluid over the next few days. However , the
pleural effusion on the left side , did increase in size and we did
a thoracentesis on 8/28/01. We removed 1 liter of turbid ,
yellowish brown fluid. The chemistries revealed a lymphocyte and
macrophage predominance and the cytology is still pending at this
time. As her chest tube was not draining much fluid , the thoracic
surgery team decided to pleurodese her with doxycycline , which has
shown to be effective in yellow nail syndrome in patient's 70% of
the time. The pleurodesis was on 3/29/01. She tolerated this
procedure well , and had little chest tube drainage over the next 48
hours. The chest tube was pulled on 6/2/01.
Mrs. Fritze 's shortness of breath was much improved after the
initial thoracentesis on the right , and she is currently on her
home oxygen requirement of 2 liters , satting in the mid-90%. The
plan is for her to see Dr. Finseth in 2 weeks and also have a
follow-up chest x-ray. At that time , Dr. Finseth will determine if
there is fluid reaccumulating on the right after the pleurodesis.
She can then have a repeat pleurodesis on the right , or an initial
pleurodesis on the left.
2. Cardiovascular. Mrs. Fritze was tachycardic on admission , and
continued to be tachycardic throughout the admission. She was
initially diuresed with intravenous Lasix and Diuril , and was probably over
diuresed , a total of 2-3 liters over a number of hours overnight.
On hospital day #2 , she was found to be tachycardic with rates in
the 140s-150s and atrial fibrillation. She converted back to
normal sinus rhythm with 3 doses of intravenous calcium channel blockers and
a Diltiazem drip. She was then maintained on Diltiazem SR 60 mg orally
twice a day throughout the admission and remained in normal sinus
rhythm. However , her tachycardia was noted to be multifocal HL
tachycardia during her MICU admission. At the time of admission ,
we did a pulsus which was only 8 mmhg. She had a bedside
echocardiogram to rule out a pericardial effusion , which revealed a
trace pericardial effusion. She also had a dobutamine MIBI for
cardiac clearance for the cardiothoracic surgical procedure. Her
heart rate increased from 107-129 , and the blood pressure decreased
from 115/70 - 110/70 at peak stress. The clinical response to
dobutamine was non-ischemic , the blood pressure response was
normal , and the EKG response to dobutamine was non-ischemic. There
were no definite regional perfusion defects seen on the stress or
rest images. However , only planer images could be obtained , due to
difficulty with positioning of the patient's left arm. Her results
were determined to be normal , and suggestive of no evidence of
hemodynamically secondary CAD , although the study was technically
limited.
In terms of her diuresis , Ms. Fritze was kept on intravenous Lasix for only
the first few days of her admission , and then was switched to orally
diuretics. Initially at a dose of 200 mg orally twice a day , and then
decreased to 120 mg orally twice a day Her lower extremity edema decreased
significantly , along with her pleural effusions.
3. Renal. Ms. Fritze 's baseline creatinine is 1.7 , her creatinine
throughout her admission varied between 1.6-1.9. We caused a mild
contraction alkalosis with diuretics , but were able to replete her
electrolytes as needed. She will follow with Dr. Spillett for her
renal insufficiency as an outpatient.
4. Endocrine. Ms. Fritze has type II diabetes and was on glyburide
5 mg every day as an outpatient. She continued that therapy as an
inpatient , and her finger sticks were in good control during this
admission.
5. Rheumatology. Ms. Fritze has a history of gout , and we were
concerned about precipitating a gout attack with the aggressive
diuresis. We continued her colchicine and decreased her
allopurinol to 200 mg orally every day We also continued her Vitamin E
therapy for the yellow nail syndrome.
6. Hematology. She has chronic anemia , and we continued her iron
and Procrit treatment during the admission.
DISPOSITION: Ms. Fritze will be discharged to home with VNA
services to administer her twice weekly Procrit doses , and physical
therapy to aid her in regain her strength and range of motion in
her joints infected with gout. She has been instructed to make
follow-up appointments with Dr. Finseth in a few weeks , and to have
a chest x-ray on the day that she sees Dr. Felts She should also
follow-up with Dr. Spillett in the renal clinic.
DISCHARGE MEDICATIONS: 1. Allopurinol 200 mg orally every day 2.
Aspirin 325 mg orally every day 3. Colchicine .6
mg orally every other day 4. Diltiazem SR 60 mg orally twice a day 5. Colace 100 mg
orally twice a day 6. Procrit 10 , 000 units S.C. biweekly 7. Iron 300 mg orally
three times a day 8. Lasix 120 mg orally twice a day 9. Glyburide 5 mg orally every day
10. Atrovent inhaler two puffs four times a day 11. Lisinopril 2.5 mg orally
every day 12. Magnesium gluconate 500 mg orally every day 13. Percocet 1-2
tabs orally every 6 hours as needed 14. Ranitidine 150 mg orally twice a day 14. Senna
two tablets orally twice a day 15. Vitamin E 1200 units orally every day 16.
Atrovent nebulizer .5 mg four times a day 17. K-Dur 10 milliequivalents orally
twice a day
Dictated By: DULCIE SCOVEL , M.D. YB96
Attending: FERNANDA FINSETH , M.D. YA46
MP483/848161
Batch: 20513 Index No. FTAJEX8254 D: 4/16/01
T: 1/26/01
CC: FERNANDA FINSETH , M.D. YA46
SILVA SPILLETT , M.D. ZN585
Document id: 1029
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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996633297 | PUO | 93707946 | | 954819 | 4/3/2002 12:00:00 a.m. | SYNCOPE | Signed | DIS | Admission Date: 1/21/2002 Report Status: Signed
Discharge Date: 10/11/2002
PRINCIPAL DIAGNOSIS: ORTHOSTATIC HYPERTENSION.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old woman
with end stage renal disease on
hemodialysis. She has history of hypertension treated with
Labetalol 400 mg orally three times a day and candesartan 32 mg orally every day. She
came in on 11/23/02 with an episode of syncope while getting up
from the bathroom. There was no prodrome , no shortness of breath ,
no palpitations and no headache. She said they lasted for a few
seconds. She did not have any incontinence. No numbness , no
tingling , no dysarthria , no opposition , no motor events were
observed. She had a similar event in early July and one in September ,
similar in nature following going to the bathroom and micturating.
She discontinued her own Labetalol for a week and was free of these
events during that time. However , restarted them. She did not
have any chest pain or shortness of breath. Of note , she has had
diabetes mellitus type II and has been poorly controlled. She is
on insulin for that.
PAST MEDICAL HISTORY: Significant for end stage renal disease ,
hypertension , obesity , diabetes mellitus
with peripheral neuropathy , as well as retinopathy and nephropathy ,
cellulitis in the past , anemia , history of uremic pericarditis and
nonerosive esophagitis and gastritis.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAMINATION: Physical examination was significant for
vital signs upon presentation , temperature
97.6 , blood pressure 148/88 , heart rate 78 , respirations were 20.
She was satting 99% on room air. In general , she was an obese
woman lying in comfortably in bed in no acute distress , appearing
slightly lethargic. ENT was unremarkable. Pharynx was benign.
Moist , mucous membranes , anicteric conjunctiva. Her heart was
regular rate and rhythm , S1 , S2. She had 2/6 holosystolic ejection
murmur that was heard at the left sternal border. Her neck , she
had no carotid bruits , no jugular venous pressure. Pulses were
bilaterally symmetric in the carotid arteries. Her lungs were
clear to auscultation bilaterally. Extremities were warm and well
perfused , no clubbing , cyanosis or edema. Neurologically , she was
intact. Cranial nerves II-XII were intact grossly. She was alert
and oriented x3. Gait was intact. Finger-to-nose intact.
Strength 5/5 bilaterally and symmetrically. Reflexes 2+
symmetrically. Her abdomen was soft and non-tender and there was
no hepatosplenomegaly.
LABORATORY VALUES: On admission , her sodium was 140 , potassium
4.3 , chloride 94 , bicarb 28 , BUN 52 , creatinine
2.9 , glucose 255 , CK initially was 449 , troponin .02 , calcium 9.8 ,
magnesium 1.9 , phosphorous 6.9. Her white blood cell count was
9.9 , hematocrit 34.4 , platelets 283. There was no left shift.
Her EKG showed a heart rate of 70 , normal sinus rhythm with Q-waves
in III and AVF. No new ST segment changes.
Head CT was negative in the emergency department as well. Chest
x-ray was unremarkable.
HOSPITAL COURSE: The patient underwent a rule out for a myocardial
infarction and ruled out with enzymes and 0 EKGs
by hospital day #2. She underwent cardiac echocardiogram which was
negative. It showed only some LVH with mild aortic insufficiency
trace , and trace mitral insufficiency. She had cardiac ultrasounds
bilaterally , which were negative for any disease.
She demonstrated to be orthostatic with change in systolic blood
pressure of 40 mmHG from lying down to standing position multiple
times during this admission. This seemed to be exacerbated by
dialysis. In dialysis , her dry weight was increased and her blood
pressure medications were discontinued completely. She was seen by
cardiology as well. They recommended starting on DVAVP for most
likely an autonomic neuropathy causing orthostatic symptoms and
hypotension. There were no complications to her medical stay.
DISCHARGE MEDICATIONS: She is being discharged on Tylenol 650 mg
orally every 4 hours as needed headache , calcium acetate
1334 mg orally three times a day , Folate 1 mg orally every day , Insulin NPH 30 units S.C.
in the a.m. , Insulin NPH 25 units S.C. in p.m. , Reglan 5 mg orally
four times a day , Lopressor was discontinued , Nephrocaps 1 tab orally every day ,
Celexa 20 mg orally every day , Nexium 20 mg orally every day.
FOLLOW-UP: The patient is scheduled to follow-up in the Xis Health tomorrow for dialysis with her
primary nephrologist , Pattie Flinspach She is also scheduled for
follow-up with ophthalmology , as well as podiatry in clinic.
Appointment here on January , 2002.
CONDITION ON DISCHARGE: Good.
Dictated By: ANNABEL VERFAILLE , M.D. MA33
Attending: SILVA SPILLETT , M.D. US76
IT146/591583
Batch: 42148 Index No. YIRIH3370L D: 1/14/02
T: 1/14/02
Document id: 1030
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
N |
Y |
U |
Y |
U |
Y |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
N |
Y |
N |
Y |
N |
Y |
N |
N |
N |
Y |
N |
N |
N |
214866727 | PUO | 60483792 | | 5750040 | 7/24/2005 12:00:00 a.m. | heart failure , mitral regurgitation | | DIS | Admission Date: 11/12/2005 Report Status:
Discharge Date: 7/16/2005
****** DISCHARGE ORDERS ******
SLITER , ELKE HUNTER 112-91-28-5
Ette
Service: CAR
DISCHARGE PATIENT ON: 11/4/05 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ROBBLEE , NERISSA H. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VITAMIN C ( ASCORBIC ACID ) 500 MG orally every day
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 10/22/05 by
BENCH , MACIE G. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: tolerates
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
BISOPROLOL FUMARATE 10 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 10/22/05 by
BENCH , MACIE G. , M.D.
on order for TIAZAC orally ( ref # 74555903 )
POTENTIALLY SERIOUS INTERACTION: BISOPROLOL FUMARATE &
DILTIAZEM HCL Reason for override: tolerates
Number of Doses Required ( approximate ): 4
DOFETILIDE 500 MCG orally twice a day Starting IN a.m. ( 9/20 )
Override Notice: Override added on 10/22/05 by
BENCH , MACIE G. , M.D.
on order for METFORMIN orally ( ref # 81144492 )
POTENTIALLY SERIOUS INTERACTION: DOFETILIDE & METFORMIN HCL
Reason for override: tolerates
Previous override information:
Override added on 10/22/05 by BENCH , MACIE G. , M.D.
POTENTIALLY SERIOUS INTERACTION: METFORMIN HCL & DOFETILIDE
POTENTIALLY SERIOUS INTERACTION: METFORMIN HCL & DOFETILIDE
Reason for override: tolerates , monitoring
COUMADIN ( WARFARIN SODIUM ) 10 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 9/20 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/22/05 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
COUMADIN ( WARFARIN SODIUM ) 12 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 9/20 )
Instructions: on Friday , Monday
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/22/05 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
Alert overridden: Override added on 10/22/05 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: tolerates , monitored
GLUCOVANCE ( GLYBURIDE/METFORMIN ) 2.5/500 MG orally twice a day
Instructions: Take 1.5 pills in morning and 2 pills in
evening as you have been doing
Alert overridden: Override added on 10/22/05 by :
POTENTIALLY SERIOUS INTERACTION: DOFETILIDE & METFORMIN HCL
POTENTIALLY SERIOUS INTERACTION: DOFETILIDE & METFORMIN HCL
Reason for override: tolerates , monitored
DILTIAZEM CD 120 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 10/22/05 by :
POTENTIALLY SERIOUS INTERACTION: BISOPROLOL FUMARATE &
DILTIAZEM HCL Reason for override: tolerates , monitored
LASIX ( FUROSEMIDE ) 40 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Prewer , call for appointment within 1 week ,
Arrange INR to be drawn on 5/5/05 with f/u INR's to be drawn every
30 days. INR's will be followed by anticogulation clinic 254-1706
ALLERGY: LISINOPRIL , Codeine , PROCAINAMIDE
ADMIT DIAGNOSIS:
mitral regurgitation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
heart failure , mitral regurgitation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HYPERCHOLESTEROLEMIA PAF RF REFLUX ESOPHAGITIS
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Diuresis
BRIEF RESUME OF HOSPITAL COURSE:
CC: 56 year-old woman with MR , PAF , admitted with SOB ,
orthopnea , PND. HPI: patient was in USOH until 5 d PTA when she went
into atrial fibrillation. She has a long history of PAF and during
her episodes tends to feel very poorly with fatigue , palpitations ,
DOE. She was cardioverted back to NSR the day prior to
admission , and went home feeling well. Overnight , however , she awoke
with PND , orthopnea , cough , and audible wheeze. She reports never
having had a similar episode in the past , though she does note
that she has been having some increasing exertional dyspnea over the
last few months. No chest pain , N/V , diaphoresis. She has never had
peripheral edema.
She presented to PUO ED after discussion with her cardiologist
Dr. Denisha Mcrorie In the ED , vitals stable with HR 70s-80s and
BP 133/64. SaO2 96-98% on RA. patient was admitted.
PMH: MR ( mod on echo 2002 ) secondary to rheumatic heart dz as child.
Nl LV fxn echo 2002. PAF , history of multiple cardioversions. On coumadin.
DM , hypercholesterolemia , endocarditis 1967 , TAH/BSO ,
hx procainamide-induced SLE.
MEDS:Glucovance 1.5 every am , 2 every afternoon
Bisoprolol10 twice a day Coumadin 6/24 M and F. Dofetilide .5 twice a day lipitor
40. Dilt CR 120qd. ASA 81. Garlic , Vit C , Vit D.
SH: tob quit age 20 , no etoh. She is a minister in non-denominational
church.
PE: obese , pleasant woman in NAD.
Notable for MR murmur apex-->axilla. Lungs clear. JVP at angle of
jaw. DP pulses palpable.
LABS: Notable for INR 3.8 , BNP 311.
EKG: NSR , LAE.
CXR: enlarged heart , sm L effusion. ?increased vascular
prominence.
ECHO: Day PTA , final report pending , by verbal report
shows severe MR ( moderate on past studies ).
ASSESSMENT: 56 year-old woman with MR and PAF admitted with symptoms of heart
failue most likely related to chronic worsening MR.
HOSPITAL COURSE:
**CV:
I: No evidence ichemia , no known CAD. Continued on ASA , statin.
P: MR secondary to RHD. Current sx heart failure likely related to
worsening MR. Ms. Sliter responded very well to diuresis with improvement
in her dyspnea , orthopnea , cough and wheeze. She was discharged on a
standing dose 40 orally lasix every day and was instructed to follow up with
Dr. Prewer for discussion of future management options including MVR
R: PAF , NSR at present. Her weight 4/25 is 114kg. She was continued on her
home anti-arrhythmic regimen as well as on coumadin. coumadin held for
elevated INR 1/1
**ENDOCRINE: DM Type II. Home regimen held in favor of lantus
basal insulin and novolog ss for tighter glycemic control in-house. patient
was restarted on home regimen at discharge.
**FEN: 2 gm Na , carbohydrate controlled.
**PPX: on coumadin
**CODE:FULL
ADDITIONAL COMMENTS: 1. Resume all your normal home medications at the doses you were taking.
2. Your new medication is lasix , which helps remove excess fluid from the
body. Have your blood chemistries checked ( potassium , magnesium )
3. Make an appointment to see Dr. Prewer within one week.
4. Ask Dr. Remley to check your EKG on dofetilide to make sure that your
"QTc" ( heart function ) is not long due to metformin + dofetilide
5. Your sugars have been mildly elevated ( 190s ). Have your sugars
checked as meds adjusted as an outpt
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. follow up ECHO - Dr. Prewer will compare in-patient ECHO and priors
to determine interval change in valve function , ?when to undergo repair
vs. replacement
2. optimize medical regimen for management of mitral regurgitation ,
lasix + consider hydral + nitrates for afterload reduction ( patient was
told she had ?'lupus like' symptoms on lisinopril ). ACE-I would be
best if she can tolerate this
No dictated summary
ENTERED BY: CLARDY , CHRISTY ALVINA , M.D. ( BL29 ) 11/4/05 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1031
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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- |
- |
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- |
- |
- |
342305124 | PUO | 63975551 | | 2307141 | 1/9/2006 12:00:00 a.m. | history of ICD implant | | DIS | Admission Date: 2/29/2006 Report Status:
Discharge Date: 3/17/2006
****** FINAL DISCHARGE ORDERS ******
LITTEER , KAMALA 809-34-84-4
Mi Eette E
Service: CAR
DISCHARGE PATIENT ON: 2/12/06 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SCHOEPPNER , AVA SANFORD , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day before noon
Starting IN a.m. ( 11/10 )
HOLD IF: resume immediately upon d/c home
Override Notice: Override added on 2/12/06 by OSDOBA , JEANA
on order for TORADOL intravenous ( ref # 731685144 )
SERIOUS INTERACTION: ASPIRIN & KETOROLAC TROMETHAMINE , INJ
Reason for override: patient currently off plavix
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 8/19/06 by JESTER , LI
on order for NIASPAN orally ( ref # 219473376 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override:
Home regimen - closely monitored.
COREG ( CARVEDILOL ) 12.5 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
KEFLEX ( CEPHALEXIN ) 250 MG orally four times a day X 28 doses
Number of Doses Required ( approximate ): 20
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Saturday ( 9/12 )
Override Notice: Override added on 2/12/06 by OSDOBA , JEANA
on order for TORADOL intravenous ( ref # 731685144 )
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
KETOROLAC TROMETHAMINE , INJ Reason for override:
patient currently off plavix
GLIPIZIDE 10 MG orally every day before noon Starting IN a.m. ( 3/28 )
LISINOPRIL 40 MG orally every day before noon Starting IN a.m. ( 11/10 )
Override Notice: Override added on 8/19/06 by JESTER , LI
on order for ALDACTONE orally ( ref # 589354742 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override:
Home medication regimen - closely monitored.
NIASPAN ( NICOTINIC ACID SUSTAINED RELEASE ) 0.5 GM orally twice a day
Starting IN a.m. ( 3/28 )
Alert overridden: Override added on 8/19/06 by
JESTER , LI
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override:
Home regimen - closely monitored.
OXYCODONE 5-10 MG orally every 6 hours as needed Pain
PAXIL ( PAROXETINE ) 20 MG orally every day before noon Starting IN a.m. ( 3/28 )
ALDACTONE ( SPIRONOLACTONE ) 25 MG orally every day before noon
Starting IN a.m. ( 3/28 ) Food/Drug Interaction Instruction
Give with meals
Alert overridden: Override added on 8/19/06 by
JESTER , LI
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override:
Home medication regimen - closely monitored.
COUMADIN ( WARFARIN SODIUM ) 4 MG orally x1
Starting Tomorrow ( 11/10 )
Instructions: follow previous coumadin regimen
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/12/06 by :
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: per previous home regimen
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: No heavy lifting/lifting right arm above head x 1 month
Lift restrictions: Do not lift greater then 5-10 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Ava Schoeppner 7/22/06 9 a.m. scheduled ,
Arrange INR to be drawn on 2/4/06 with f/u INR's to be drawn every
3-4 days. INR's will be followed by cardilogist
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of ICD implant
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) history of PPM/AICD ( history of implanted cardiac
defibrillator ) CHF ( congestive heart failure ) AVR ( cardiac valve
replacement ) CABG ( cardiac bypass graft surgery ) stent ( coronary
stent ) LBBB ( bundle branch block )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CRT-D placement in EP lab
BRIEF RESUME OF HOSPITAL COURSE:
64 year old man with a history of valvular heart
disease history of mechanical AVR and CAD/MI history of CABG and multiple PCIs. EF
15-20% with LBBB morphology on ECG. CRT-D device placed in 10/4
Subsequent pocket infection ( E coli ) prompting removal of the
system. Now admitted for reimplantation of CRT-D device.
history of procedure today: Guidant Contak Renewal. Leads in RV apex , RAA ,
and CS. DDD 40 - 120. Access via R cephalic and R axillary. No
complications. pCXR
ok. Per attending will defer anticoagulation and plavix.
5/25/06 : patient did well overnight. c/o mild-moderate pain at wound site.
mild swelling , no gross hematoma appreciated. VS , tele , and CXR reviewed.
Plavix will be restarted on saturday. coumadin resumed tomorrow. ASA 325
mg resumed today. f/u with dr schoeppner on 2/26/06. have INR checked in 3-4
days.
ADDITIONAL COMMENTS: Please have your INR level checked with Dr. Meduna 3-4 days after
resuming your coumadin. You may resume your plavix on saturday. Please
resume taking a full aspirin ( 325 mg ) tonight when you get home from the
hospital. You may resume your coumadin , at 4 mg per day , tomorrow
( Thursday ).
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: OSDOBA , JEANA ( QE84 ) 2/12/06 @ 11:12 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 1032
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
Y |
U |
U |
Y |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
Y |
N |
N |
Y |
Y |
Y |
N |
Y |
- |
N |
N |
N |
N |
N |
N |
348919353 | PUO | 94918484 | | 827714 | 11/16/1997 12:00:00 a.m. | NEW ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 10/23/1997 Report Status: Signed
Discharge Date: 8/21/1997
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old woman who
had a two vessel coronary artery
bypass graft on 3/10/97. She was discharged to home on 5/4/97 to
F. Memorial Hospital where she developed
epigastric discomfort and recurrent atrial fibrillation and was
transferred back to I Warho Hospital .
Her cardiac history dates back to October of 1995 when she was
admitted to I Warho Hospital for an asthma flare. At that
time she ruled out for a myocardial infarction. Her CKs were
negative. An exercise test at that time showed she was able to go
eight minutes on a Bruce protocol with 2 mm ST depressions in leads
2 , 3 , and F. A MIBI showed a small reversible defect inferiorly
and she was managed medically at that time.
In February of 1996 she was again admitted to I Warho Hospital with chest pain. She ruled out for a myocardial
infarction. She was started on Prilosec for presumed
gastroesophageal reflux disease. In September of 1996 an exercise
Thallium test showed she went eight minutes on a Bruce protocol
with a heart rate of 125 , blood pressure 170/80 , and no ECG
changes. She stopped secondary to chest pain.
From 3/30/97 through 3/5/97 she presented with chest pressure at
rest which radiated to her shoulders and jaw. On presentation she
was noted to be in rapid atrial fibrillation. An ECG at that time
showed elevated T-waves in V1 and V2. She was treated with
Lopressor with slowing of the rate and relief of her chest pain.
She ruled in for a myocardial infarction with a peak CK of 473 with
an MB fraction of 32. Her Lopressor was changed to Verapamil
secondary to increased wheezing requiring nebulizers. The patient
underwent a cardiac catheterization. The catheterization revealed
an left anterior descending artery that had 70% proximal lesion
with collaterals , left circumflex artery with long 80 to 90%
stenosis , right coronary artery 30 to 40% stenosis , left ventricle
with ejection fraction of 58% , and apical akinesis. She
spontaneously converted to normal sinus rhythm. Following
catheterization the patient agreed to a coronary artery bypass
graft but the procedure was postponed until she received Epogen
therapy since she is a Jehovah's Witness. She was discharged in
sinus rhythm.
She returned on 10/17/97 and underwent a coronary artery bypass
graft times two which was complicated by a perioperative myocardial
infarction with inferior ST elevations and peak CK of 386 and MB
fraction of 8.1. Atrial fibrillation was not controlled with
Verapamil. The patient was loaded on Digoxin and had multiple
episodes of atrial fibrillation. She converted to normal sinus
rhythm and was discharged to rehabilitation on 5/4/97 in normal
sinus rhythm.
Her postoperative course was notable for gastrointestinal distress
with epigastric burning , reflux , nausea , vomiting , and
constipation. On 5/4/97 at rehabilitation the patient noted
worsening epigastric burning with a sour taste in her mouth. This
was relieved with Maalox. She was awakened from sleep with
epigastric burning radiating to the right back and palpitations.
ECG showed rapid atrial fibrillation at a rate of 125 to 150 and
she was treated with Verapamil 2.5 mg intravenous times two and converted to
normal sinus rhythm. The patient was noted to have ST elevations
of 1 mm in 1 , 3 , and F and she was transferred to I Warho Hospital for further evaluation. She had no complaint of shortness
of breath , orthopnea , paroxysmal nocturnal dyspnea , syncope , or
presyncope. At I Warho Hospital she was noted to have
epigastric burning similar to a prior episode and was treated with
Maalox with relief.
PHYSICAL EXAMINATION: She was lying in bed in no apparent
distress. HEENT: Normocephalic ,
atraumatic. Pupils equal , round , and reactive to light and
accommodation. Extraocular movements intact. Oropharynx benign.
Neck: Supple. Full range of motion. No lymphadenopathy.
Carotids 2+ without bruits. JVP 8 cm. Heart: No heave and no
thrill. Regular rate. S1 , split S2. 2/6 systolic murmur at apex.
Positive for frictional rub. Lungs clear to auscultation. No
wheeze or rhonchi. Chest had midline sternotomy without any
exudate or erythema. Sternum was stable. Back: No costovertebral
angle tenderness. Abdomen: Keloid in right upper quadrant. Soft ,
nontender , nondistended. No hepatosplenomegaly. Extremities: No
clubbing , cyanosis , or edema. Neurologic: Alert and oriented
times three. Cranial nerves II - XII intact. Intact sensation and
strength throughout. Reflexes symmetric and toes downgoing.
LABORATORY DATA: Sodium 129 , potassium 5.4 , creatinine 1.0 , BUN
20 , glucose 227. Digoxin level 2.6. Hematocrit
45.1 , WBC 9.2. Her triponin-1 level was 0.7. ECG at I Warho Hospital was in normal sinus rhythm. Normal left axis ,
normal intervals. 0.16 , 0.88 , 0.36. Rate of 85. Left atrial
enlargement. 1 mm ST depressions in 1 and 2 which is consistent
with Digoxin effect. 1 mm upsloping ST elevations in 2 , 3 , and F
unchanged from prior ECG on 8/28/97. Chest x-ray showed mediastinal
shadow. Stable with question of atelectasis at left base.
HOSPITAL COURSE: The patient ruled out for a myocardial infarction
and her chest burning was primarily due to
gastrointestinal reflux which was relieved with Maalox , as well as
chest discomfort in her left shoulder which was due to
musculoskeletal pain and was relieved with Tylenol and Percocet or
Darvocet. On monitor she showed no evidence of atrial fibrillation
although she did have supraventricular tachycardia and one incident
of a ten-beat run. In light of the fact that the patient is a
Jehovah's Witness and is not a candidate for being Coumadinized for
episodes of rapid atrial fibrillation , it was felt that we would
use the anti-arrhythmic agent , Propafenone , to prevent episodes in
the perioperative period of atrial fibrillation. Her Digoxin was
discontinued and she tolerated Propafenone load of 150 mg three times a day
well along with her Verapamil dose.
Other issues during this admission were that her blood sugar was
high requiring sliding scale of insulin. Also the patient had
hyponatremia with sodium in the high 120s and low 130s throughout
her stay , as well as a potassium which was mildly elevated , ranging
from 5.0 to 5.8. Cortisol levels were drawn and results are
pending for possibility of adrenal insufficiency. The question of
a renal tubular acidosis type intravenous was raised.
Throughout the admission her chest burning was well controlled with
Maalox. Her Pepcid dose was increased to 20 mg twice a day
Helicobacter pylori and IgG antibodies were sent and results are
pending. Her musculoskeletal pain which is primarily in her left
shoulder radiating to her arm has been well controlled with
Tylenol.
PAST MEDICAL HISTORY: Significant for coronary history as above ,
asthma which has required hospitalization in
the past but no intubations , adult-onset diabetes mellitus for
which she takes Micronase , hypertension , gastroesophageal reflux
disease , hypercholesterolemia , status post cholecystectomy , left
lower lobe granuloma followed by chest CT scan , and cataracts.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours , Albuterol inhaler
2 puffs four times a day , Ecasa 81 mg orally every day ,
Beclovent 2 sprays three times a day , Colace 100 mg orally twice a day , Epogen 10 , 000
units subcutaneously three times a week , Gliburide 5 mg orally every day , Mevacor
20 mg orally every afternoon , Prilosec 20 mg orally twice a day , Propafenone 150 mg
orally three times a day , Verapamil SR 120 mg orally every day
ALLERGIES: Beta blockers and Lisinopril. It is questionable
whether she has allergy to Naprosyn as well.
SOCIAL HISTORY: She lives at home with her daughter. No alcohol.
No tobacco.
DISPOSITION: The patient is being discharged to F. Memorial Hospital She will likely require a
short course of physical therapy and rehabilitation and will be
returning to home following her course of rehabilitation.
FOLLOWUP: She will follow-up in the future with her primary care
physician , Dr. Crooked , as well as with her cardiologist , Dr.
Paetzold CONDITION ON DISCHARGE: The patient is stable on the day
of discharge.
Dictated By: KAYLEEN ROAOO , M.D.
Attending: FLOYD T. LYN , M.D. OX2
CM201/2689
Batch: 5910 Index No. MZBX5H793U D: 4/21/97
T: 4/21/97
CC: 1. CORRINA CROOKED , M.D. SJ80
Document id: 1033
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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186460411 | PUO | 64944861 | | 0756627 | 7/2/2004 12:00:00 a.m. | ACUTE MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/28/2004 Report Status: Signed
Discharge Date: 8/4/2004
ATTENDING: ALEXANDRA POPOVIC MD , PHD
ADMISSION DIAGNOSIS: Coronary artery disease status post
inferior myocardial infarction.
PRINCIPAL DISCHARGE DIAGNOSIS: Inferior myocardial infarction.
OTHER DIAGNOSES: Rheumatoid arthritis , myocardial infarction ,
chronic obstructive pulmonary disease , coronary artery disease
status post carotid endarterectomy , status post cerebrovascular
accident , gastroesophageal reflux disease , diabetes mellitus ,
cerebral artery aneurysm , and depression.
The patient is a 77-year-old female with coronary artery disease
who presented to an outside hospital with chest pain that she
thought was GERD but became concerned when it started radiating
down her left arm. At the outside hospital , she was noted to be
febrile with temperature 39.8 and noted on EKG to have ST
elevations in the inferior leads. The patient was med-flighted
to Totin Hospital And Clinic for an emergent cath. The patient had 70%
LAD lesion , 50% proximal RCA , and 90% mid RCA lesion that was
stented to 0% , and a 60% PDA lesion , and LVEDP of 33 on initial
cath. Started on Integrilin post cath and transferred to CCU.
The patient did well in the CCU and was transferred out on the
next day. Previous to admission , the patient resided in a
assisted living facility and was fairly active but has had
increasing dyspnea on exertion , decreasing exercise tolerance
over the past six months.
PHYSICAL EXAMINATION ON ADMISSION: Temperature was 98.8 , heart
rate was in the 70s , BP was 120s/60s , respirations was 22 ,
saturation was 90% on 2 liters nasal cannula. Generally , she is
an obese female in mild distress. Some cough. Her HEENT exam
showed a clear oropharynx. No erythema or injection. Skin had
no rashes or other lesions. Neck was supple with full range of
motion. JVP was approximately 2 with 2+ carotid pulses without
bruits. No thyromegaly or nodules. Chest was noted to have
diffuse wheezing with bilateral bibasilar crackles. Questionable
right-sided consolidation , PMI nondisplaced with a regular rate
and rhythm with S4 , S1 with physiologically split S2. No
significant murmurs or rubs. Abdomen was nondistended and
nontender. Positive bowel sounds. No hepatosplenomegaly. Her
extremities showed no cyanosis , clubbing , or edema. 2+ femoral ,
DP , and physical therapy pulses. Neurologically , she was alert and oriented
with normal mental status and nonfocal exam. Her chest x-ray
showed evidence of pulmonary edema with focal consolidation of
right upper lobe with chest consistent with pneumonia. Her EKG
on admission , was normal sinus rhythm in the 60s with normal axis
and inferior Q waves with T-wave inversions inferiorly and
laterally.
IMPRESSION: This is a 77-year-old female status post IMI with
concurrent COPD exacerbation secondary to probable right upper
lobe pneumonia.
HOSPIATL COURSE BY SYSTEMS:
1. Cardiovascular: The patient did very well status post
revascularization. She did have some persistent pain while in
the intensive care unit and this went away on transfer to the
floor. She was medically optimized and continued on aspirin and
Plavix , added a beta blocker and ACE inhibitor to the patient's
1B pump. The patient had compensated heart function on
discharge , euvolemic , but she did require intermittent Lasix.
She was discharged on Lasix to treat heart failure. Rhythm-wise ,
the patient remained in normal sinus rhythm throughout the course
of hospitalization.
2. Pulmonary: The patient was treated for COPD exacerbation
with a rapid prednisone taper , and her home nebulizers , and a
10-day course of levofloxacin. Incidentally , the patient also
admitted to having a TB exposure. We placed a TB and that was
nonreactive and had induced sputums that were negative x 3.
3. Renal: The patient had well preserved renal function
normalized at discharge.
4. FEN: The patient was tolerating orally diet well and was
indicated on her instructions that she should have low-calorie ,
low-fat , low-cholesterol diet particularly given her diabetes and
she should watch her sugar and was maintained on her own.
5. Psychiatry: The patient has a history of depression and
noted to be depressed throughout the course of hospitalization
with some suicidal ideations toward the end of her
hospitalization. For that reason , we requested that psychiatry
come and evaluate her. They did so deeming her safe to return to
her facility and adjusting her antidepressants. The patient was
discharged in stable condition.
Procedures included percutaneous coronary intervention with
stenting to her right coronary artery x 2. Please see full
report for details.
Her discharge medications include aspirin 325 mg , atenolol 25 mg
orally every day , Prozac 20 mg orally every day , Lasix 40 mg orally every day ,
Atrovent inhaler two to four puffs four times a day as needed , lisinopril 2.5
mg orally every day , Ativan 0.5 mg orally twice a day as needed insomnia or
anxiety , prednisone she was completing a taper with 40 mg x 2
days , 20 mg x 2 days , 10 mg x 2 days , and then off , trazodone 50
mg orally every bedtime as needed sleep , Zocor 40 mg orally every bedtime , Flovent 110
mcg twice a day , Plavix 75 mg orally every day , Serevent one puff inhaled
twice a day , Nexium 20 mg orally every day , and Elmiron 100 mg orally three times a day
The patient had followup set up with her primary care doctor ,
cardiology as well as her psychiatrist.
eScription document: 9-4353857 ISSten Tel
Dictated By: FLEISHER , LUETTA
Attending: POPOVIC , ALEXANDRA
Dictation ID 2762045
D: 10/23/04
T: 5/28/04
Document id: 1034
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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852336607 | PUO | 23627230 | | 5484750 | 5/30/2005 12:00:00 a.m. | ascites | | DIS | Admission Date: 4/26/2005 Report Status:
Discharge Date: 5/16/2005
****** DISCHARGE ORDERS ******
DENSLEY , ABRAHAM 986-04-69-9
Ton Usly War
Service: MED
DISCHARGE PATIENT ON: 12/10/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BRAGAS , RASHEEDA K. , M.D. , M.PH.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours as needed Pain
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 5/2/05 by
FREED , KIETH LENARD , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: following
DIGOXIN 0.125 MG orally every day
Override Notice: Override added on 5/2/05 by
FREED , KIETH LENARD , M.D. , M.P.H.
on order for VERAPAMIL HCL orally ( ref # 86844085 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & VERAPAMIL HCL
Reason for override: following
Previous override information:
Override added on 5/2/05 by FREED , KIETH LENARD , M.D. , M.P.H.
on order for SYNTHROID orally ( ref # 34064623 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: following
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
GLIPIZIDE 5 MG orally every day Starting Today ( 2/29 )
SYNTHROID ( LEVOTHYROXINE SODIUM ) 88 MCG orally every day
Alert overridden: Override added on 5/2/05 by
FREED , KIETH LENARD , M.D. , M.P.H.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: following
ZESTRIL ( LISINOPRIL ) 10 MG orally every day Starting Today ( 2/29 )
Alert overridden: Override added on 12/10/05 by
GILSTRAP , KIRSTIN GARNETT , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: SPIRONOLACTONE &
LISINOPRIL Reason for override: aware
THIAMINE HCL 100 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 5/2/05 by
FREED , KIETH LENARD , M.D. , M.P.H.
on order for SYNTHROID orally ( ref # 34064623 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: following
Previous override information:
Override added on 5/2/05 by FREED , KIETH LENARD , M.D. , M.P.H.
on order for ZOCOR orally ( ref # 01659584 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: following
Previous override information:
Override added on 5/2/05 by FREED , KIETH LENARD , M.D. , M.P.H.
on order for TRICOR orally ( ref # 63585851 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & FENOFIBRATE ,
MICRONIZED Reason for override: following
Previous override information:
Override added on 5/2/05 by FREED , KIETH LENARD , M.D. , M.P.H.
on order for ECASA orally ( ref # 86562242 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: following
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 5/2/05 by
FREED , KIETH LENARD , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: following
RISPERIDONE 2 MG orally every bedtime
TRICOR ( FENOFIBRATE ) 145 MG orally every day
Alert overridden: Override added on 5/2/05 by
FREED , KIETH LENARD , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & FENOFIBRATE ,
MICRONIZED Reason for override: following
Number of Doses Required ( approximate ): 4
CALTRATE + D ( CALCIUM CARB + D ( 600MG ELEM CA... )
1 TAB orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
LANTUS ( INSULIN GLARGINE ) 15 UNITS subcutaneously every day
Starting Today ( 2/29 )
LASIX ( FUROSEMIDE ) 20 MG orally every day
DIET: Patient should measure weight daily
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Coffen 10/14/05 scheduled ,
Arrange INR to be drawn on 7/24/05 with f/u INR's to be drawn every
7 days. INR's will be followed by primary care physician
ALLERGY: STREPTOMYCIN , FENTANYL , MIDAZOLAM
ADMIT DIAGNOSIS:
lightheaded , chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
ascites
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) chf , diastolic dysfunction ( congestive
heart failure ) pulmonary hypertension ( pulmonary hypertension ) atrial
fibrillation ( atrial fibrillation ) DM ( diabetes
mellitus ) OSA ( sleep apnea ) hypothyroidism
( hypothyroidism ) anemia ( anemia ) HTN
( hypertension ) thrombocytopenia ( low platelets ) anxiety
( anxiety ) depression ( depression ) peripheral neuropathy ( peripheral
neuropathy ) DJD ( degenerative joint disease ) history of fall ( history of falls )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: hypotension
67 year-old F history of PAF recently admitted with ascites believed 2/2 pulmonary
htn ( SAG at NVH 1 mo ago 2.4 ) , aggressively diuresed , d/ced to home and
became lightheaded , SBP checked by VNA 87.
Status: A and O x 3
Procedures: none
Consults: none ( Lingwest Tal/ Hospital involved during previous admit )
Problems:
1. GI--ascites: diuresis. On lasix 40 orally at home + aldactone.
Became LH and dizzy , resolved with 700 cc IVF in ED. will cont to hold
aldactone and cut lasix to 20 orally every day Held all antihtn
( except verapamil ) BP 130/70 Hr 105 at d/c so restarted ACEI. patient weight
170 lbs on admission. patient and family instructed to weigh her daily and call
primary care physician for weight >172 lbs 2. Afib--patient intermittently tachy to 130 , verapamil
SR 240 every day patient started on coumadin 5 bedtime 7/21 INR 1.3 11/19 primary care physician to f/u in
a.m.. Digoxin , dig level Pend. Of note had bradycardic arrest at NVH a
several weeks ago in setting of EGD. 3. CP--Had completely reproducible CP
in ED , EKG unchanged , MSO4 for pain , enzymes neg x 1. CP free on d/c. 4.
ARF-Cr 1.7 up from 1.0 , likely prerenal , got IVF in ED , Cr 1.3 on d/c. F/u
c primary care physician 2/18 5. Pulmonary HTN: Possibly 2/2 OSA , has refused CPAP at bedside
in past. ECHO ( 2/13/05 ): EF 60-65% , RV dil/ RVH , RAE , pApress 36 , triv
pericardial effusion , mild MR , mod TR 6. Endo: novolog ss , c/with lantus 15
every day 7. Heme on coumadin for AF goal INR 2-2.5 , but
subtherapeutic. Will recheck level in 2-3 days and redose
accordingly. Discharged in stable condition , ambulating well around Maine
without dizziness or unsteadiness. BP and HR wnl.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Your dry weight is 170 lbs. Weigh yourself every morning. Call your primary care physician
if your weight rises above 172 lbs.
No dictated summary
ENTERED BY: WESTBERG , KAMALA M. , M.D. , PH.D. ( QE231 ) 12/10/05 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1035
| Target |
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GER |
Gou |
HC |
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| output/system_textual_annotation.xml | textual |
U |
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U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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N |
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- |
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N |
015243975 | PUO | 83968701 | | 851014 | 11/14/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/12/1994 Report Status: Signed
Discharge Date: 10/17/1994
DISCHARGE DIAGNOSIS: RULE OUT MYOCARDIAL INFARCT.
CONTRIBUTING DIAGNOSIS: HYPERTENSION , CORONARY ARTERY DISEASE ,
DIABETES , SCHIZOPHRENIA.
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old black
female with a history of diabetes ,
hypertension , coronary artery disease , SVT and schizophrenia
presented with 45 minutes of substernal burning , shortness of
breath and diaphoresis. The patient has a long history of chest
pain which began in 1988 with her first rule out for MI. She has
had extensive cardiac workup including a recent ETT MIBI during
which she went 5 minutes 40 seconds with a maximum heart rate of
71 , blood pressure of 138/68 with no ST segment changes and no
evidence for ischemia. MIBI images: anteroapical defect on stress
images with reperfusion at rest consistent with ischemia. These
studies were done in October of 1992. The patient was thought to have
rate related ischemia which is induced by SVTs or other
precipitants that increase her heart rate. The patient has had no
substernal chest pressures since October of 1992. She experiences no
chest discomfort on exertion. She has had a good rate control on
Lopressor 75mg orally twice a day The patient presented in the Emergency
Room today complaining of epigastric burning in her chest 1 time a
week which awakened her from sleep at night. It is usually relieved
by Mylanta. On the day of admission , however , the patient
experienced a sudden onset of substernal chest burning without
radiation while lying in bed. She had eaten 1 hour before going to
bed. The pain was accompanied by palpitations , shortness of breath
and diaphoresis. She denied nausea and vomiting. It was not
relieved by Mylanta. The patient received a sublingual
nitroglycerin in the ambulance resulting in relief. The patient's
cardiac risk factors include hypertension , diabetes , history of
tobacco use and hypercholesterolemia. PAST MEDICAL HISTORY: As
above: Adult onset diabetes mellitus , hypertension , a left great
toe ingrown toe nail , diverticulosis , history of frequent nose
bleed , multiple right pinna ear infection , schizophrenia , history
of colonic polyps with guaiac positive stools in 1987 and a barium
enema the same year demonstrating colonic diverticula , degenerative
joint disease of the knees. MEDICATIONS: Medications on admission:
Verapamil SR 240mg orally every day , Naprosyn 375mg orally twice a day as needed ,
fluphenazine 35cc intramuscular every 2 weeks , Ibuprofen 400mg orally three times a day ,
Nitropatch , Lopressor 75mg orally twice a day , NPH insulin 45 units
every day before noon , Pepcid 20mg twice a day , enteric coated aspirin 1 tablet orally every
d , Librium 10mg orally twice a day ALLERGIES: The patient has no known
drug allergies. Family history includes a brother who died at 60 of
an MI , a sister who died at 71 of an MI. Social History: The
patient is a widow with 4 children , lives with grandson , a retired
factory seamstress who stopped smoking 25 years ago. She had smoked
a 1/2 pack a day for 5 years and has no history of ethanol usage.
PHYSICAL EXAMINATION: She was a pleasant black female in no
apparent distress with a temperature of 98.2 ,
pulse of 100 , blood pressure 140/80 , respirations at 16. HEENT:
Pupils were equal , round , reactive to light. Oropharynx was clear.
Neck was supple with no lymphadenopathy. No carotid bruits. Lungs
were clear to auscultation. Heart: Heart had a regular rate and
rhythm with distant heart sounds and normal S1 , S2. Abdomen:
Abdomen was with normal bowel sounds , was soft , obese and
non-tender with a hyperpigmented patch centrally. EXTREMITIES:
Extremities are without edema or joint effusions. The left great
toe had hypertrophic toe nails , tender to palpation with an ingrown
toenail. Rectal was with guaiac positive stool. NEURO: Neuro exam
was grossly non-focal. Skin had no new rashes.
LABORATORY EXAMINATION: Admission data included a sodium of 144 ,
a potassium of 4 , chloride of 107 , bicarb
of 27 , BUN of 24 , creatinine of 1.1 , glucose of 155. CK was 430
with an MB fraction of 1.5 and as an aside , the patient is known to
have chronically elevated CKs. White count was 8.7 , hematocrit of
36 with an MCV of 90 and 93 , 000 platelets. physical therapy 13 , PTT 30. LFTs
were within normal limits. EKG demonstrated normal sinus rhythm at
95 beats per minute with intervals of .18 , .81 , .35 and axis of 21
with Q waves in V1 , V2 , T wave flattening in V2. Chest x-ray was
without infiltrates or effusions.
HOSPITAL COURSE: Hospital course by system: The patient was ruled
out for MI , had CKs of 430 with an MB fraction of
1.544 with an MB fraction of 1.9 and 404 with an MB fraction of .8.
There were no further EKG changes. The patient had no chest pain
while in the hospital. The patient's Lopressor was increased to
75mg four times a day while in house and the patient also underwent a
diagnostic cardiac catheterization with the following results: An
LAD without critical stenosis , an OMB1 with a 90% proximal stenosis
and OMB2 with diffuse disease and serial lesions , an RCA with a
proximal 90% stenosis and a distal 70% stenosis , and normal
ventricular function. The patient was offered PTCA of her critical
lesions and the patient declined. As the patient had not been
compliant with her medical regimen , it was felt that we would send
her out on her increased dosage of Lopressor and monitor her level
of chest discomfort and perhaps re-offer her PTCA at a later date.
The patient's toe was evaluated by podiatry who felt that she had ,
in fact , an ingrown toenail which was treated via avulsion of the
margin of the nail and a 4 day course of Cephradine 500mg orally
four times a day The patient had all Ansaid held secondary to her guaiac
positive stool and her hematocrit monitored and it suggested that
the patient have a GI workup as an outpatient. The patient had
anemia which was thought secondary to chronic GI bleed. Iron
studies performed while in house detected an iron level of 31 ,
total iron binding capacity of 246 , a B12 of 904 , folate of 10.4 ,
and a ferritin of 235; all not consistent with iron deficiency
anemia. The patient also presented with thrombocytopenia which was
thought perhaps secondary to Pepcid or Ansaid. These medications
were held while she was in house and her platelet level remained
approximately 100 and was so upon discharge.
DISPOSITION: The patient continued her normal medical regimen for
schizophrenia and was discharged in stable condition
on the following medicines: MEDICATIONS: Enteric coated aspirin
325mg a day , Librium 10mg twice a day , NPH insulin 42 units sub every
every day before noon , Lopressor 100mg orally three times a day , verapamil SR 240mg orally every day ,
Prolixin Decanoate 12.5mg intramuscular every o weekly and nitroglycerin 1/150 1
tablet sublingual every 5 minutes x 3 as needed chest pain. The patient
will have home health aid and VNA services to ensure more
compliance with medication regimen and diet , also to check finger
stick glucose every day , blood pressure every week and to
administer her Prolixin every week. The patient is recommended to
be on a 800 ADA diet and will have follow-up with Dr.
in the KTDUOO Clinic.
Dictated By: CHRISTOPHER LEOPOLD , M.D. FQ63
Attending: DAMON KRINSKY , M.D. HP0
HQ696/8901
Batch: 4532 Index No. W1RFWJ9QFX D: 11/25/94
T: 6/5/94
Document id: 1036
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
N |
Y |
N |
N |
- |
Y |
N |
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N |
386459848 | PUO | 31341276 | | 419777 | 4/23/1997 12:00:00 a.m. | ?MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/23/1997 Report Status: Signed
Discharge Date: 11/2/1997
PRINCIPAL DIAGNOSIS: 1. ACUTE MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: Mrs. Rathgeb is a 69 year old woman
with a history of coronary artery
disease , status post an inferoposterior myocardial infarction in
January 1996. She had a cardiac catheterization at the time , which
showed an 80% mid left anterior descending artery lesion , and 80%
left circumflex lesion before OM1 , 50% proximal right coronary
artery lesion , and an 80% posterior left ventricular branch lesion.
She was also noted to have inferior and anterolateral HK with an
ejection fraction of 52%. The patient expressed her desire to be
managed conservatively , and was medically managed for the following
year. She had a sub-max exercise tolerance test prior to discharge
and one month later had a full BRUCE protocol going six minutes
with less than 1 mm ST segment depressions in several leads. The
patient did well for the past year without symptoms until 1:00 a.m.
on the morning of admission when she woke from sleep with
substernal chest pain. She took sublingual nitroglycerin with
relief after half and hour but at 3:00 a.m. the pain recurred with
nausea. The patient took two sublingual nitroglycerin with
resolution of the pain by 4:00 a.m. She presented to the emergency
department free of pain and electrocardiogram at the time showed
changes consistent with anterior ischemia. The patient was
admitted with unstable angina for evaluation.
PAST MEDICAL HISTORY: Remarkable for coronary artery disease ,
hypertension , status post cholecystectomy.
MEDICATIONS ON ADMISSION: Include simvastatin 10 mg every bedtime ,
sublingual nitroglycerin , enalapril
5 mg twice a day , aspirin 325 mg every day , Atenolol 50 mg twice a day
ALLERGIES: She had no known drug allergies.
PHYSICAL EXAMINATION: Revealed a pulse of 62 , regular and blood
pressure 160/80 , respiratory rate 12 , oxygen
saturation of 99% on three liters nasal cannula. There was no
evidence of jugular venous distention , carotids 2+ bilaterally , no
bruits. Chest is clear to auscultation bilaterally. Heart
examination revealed a regular rate and rhythm and an S4 was
present. Abdomen was obese , soft , nontender and nondistended with
normal bowel sounds present. Extremities were without edema.
LABORATORY DATA: On admission the patient's initial CK was 111.
Her second CK was 452 , with an MB fraction of
45.1 , third CK was 550 with an MB fraction of 47.9 , and a fourth CK
of 439 with MB fraction of 33.5 , fifth CK of 261 , with MB fraction
of 14.9 , and a sixth CK of 156. SMA seven was normal.
Troponin I was 0.0 on admission. White blood count of 11 ,
hematocrit 39.7. Chest x-ray was unremarkable for any infiltrate
or any congestive heart failure evidence. Electrocardiogram
revealed normal sinus rhythm at 75 , axis 0 , 2 to 3 ST segment
elevation in V1 through V3 , 1 mm elevation in V4 , less than 1 mm ST
segment depressions in 1 , AVL , and V5 , V6. These changes were new
compared to a previous electrocardiogram from January 1996.
HOSPITAL COURSE: The patient was admitted to CCU , at which time
she was pain free and her electrocardiogram
abnormalities had resolved. Her heart rate and blood pressure were
controlled with intravenous medications and she was managed
medically until hospital day three when she was taken of the
cardiac catheterization laboratory. Cardiac catheterization
revealed a 90% plus left anterior descending artery lesion distal
to D1 with evidence of thrombus , 60% proximal left circumflex
lesion with diffuse disease in the OM1 , a 40% right coronary artery
lesion , left ventriculogram revealed anterior lateral apical and
septal HK and AK. The patient returned to the cardiac
catheterization laboratory the following day for PTCA and stenting
of her left anterior descending artery lesion followed by ReoPro
infusion. From the time of her admission to the Cardiac Care Unit
throughout her hospital stay the patient did not have recurrence of
her chest pain. Cardiac enzymes returned to baseline.
Electrocardiogram revealed ST segments also returned to baseline.
MEDICATIONS ON DISCHARGE: Include aspirin 325 mg orally every day ,
simvastatin 10 mg orally every bedtime , Ticlid 250
mg orally twice a day for 11 days , Atenolol 25 mg orally twice a day , enalapril
20 mg orally every day The patient is instructed to resume a low fat , low
cholesterol diet. Activity as tolerated.
FOLLOW-UP: With Dr. Salvia on 9/21/97 at 3:50 p.m. and will
also follow-up with Dr. Forand in the end of August or
beginning of April , to be arranged.
Dictated By: REFUGIA BAUCHSPIES , M.D. YX00
Attending: SHAVONNE D. MAINER , M.D. QP3
FV487/5683
Batch: 70481 Index No. PGNML18472 D: 6/2/97
T: 2/19/97
Document id: 1037
| Target |
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CHF |
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DM |
Gs |
GER |
Gou |
HC |
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441894442 | PUO | 99917513 | | 088577 | 9/17/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/28/1996 Report Status: Signed
Discharge Date: 3/23/1996
SERVICE: General Medical Service , Nacolnna , Arizona 27817
ADMITTING DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
ADDITIONAL DIAGNOSIS: HEMORRHAGIC CYSTITIS.
IDENTIFICATION: Mr. Croson is a 69 year old gentleman with a
history of adult onset diabetes mellitus ,
peripheral vascular disease , chronic hemorrhagic cystitis who is
currently transfusion dependent , who was admitted with congestive
heart failure and elevated CK , MB in the setting of profound anemia
and presents for a blood transfusion.
HISTORY OF PRESENT ILLNESS: The patient has a long , complex
urologic history which includes
prostate cancer which was treated with radiation approximately
twenty years ago. More recently , superficial bladder cancer which
was treated with partial resection. He developed hematuria
approximately April 1995. A workup revealed hemorrhagic cystitis
which was felt to be secondary to prior radiation treatments. He
has required approximately 1 unit of red cells per week for the
past three months to keep up with ongoing urologic blood loss.
The patient has no known cardiac history. His risk factors include
diabetes , hypertension , tobacco use , and male sex. No history of
hypercholesterolemia or family history. He describes 4-5 episodes
of chest tightness occurring over the past five years , the last
episode occurring approximately three months ago. He does note
progressive pedal edema over the past six weeks and over the past
two to three days has had increasing fatigue and dyspnea on
exertion. On the day prior to admission , routine VNA blood draw
revealed a hematocrit of 17. His primary care physician was
notified and the patient was instructed to report to I Warho Hospital on the day of admission for transfusion. Repeat
hematocrit on the day of admission was 18. He received two units
of packed red cells and chemotherapy infusion and shortly after
transfusion developed shortness of breath without chest pain.
Chest x-ray was consistent with congestive heart failure. His
initial CK was 770 with 70 MB fraction. The patient was
transferred to the Emergency Room for further evaluation where he
was treated with topical Nitro paste , 40 mg of intravenous Lasix , resulting
in 1500 cc of urine output. Aspirin and heparin were held
secondary to hemorrhagic cystitis. Beta blocker was also held
secondary to question of bronchospasm.
The patient was then transferred to the Cardiac Care Unit for
further treatment.
PAST MEDICAL HISTORY: 1. AODM. 2. Peripheral vascular disease.
3. Neuropathy. 4. Prostate cancer. 5.
Bladder cancer in 1995 and 1990. 6. Status post appendectomy. 7.
History of TIAs three to four years ago. Workup revealed 50%
bilateral carotid stenosis. 8. Chronic obstructive pulmonary
disease. 9. Hypertension.
ALLERGIES: Penicillin causes edema. Steroids cause cytosis.
ADMISSION MEDICATIONS: Glyburide 10 mg orally twice a day , Cardizem CD
180 mg orally every day , folate 1 mg orally every day ,
iron sulfate 300 mg orally every day , Colace 100 mg orally twice a day
FAMILY HISTORY: Mother died of leukemia. Father had a CVA and
kidney problems. No known coronary artery
disease.
SOCIAL HISTORY: Two pack per day smoking , 1-2 drinks per day. The
patient is a retired teacher at a Bern Lis He currently lives alone and is single.
PHYSICAL EXAMINATION: This is a pleasant older gentleman in no
apparent distress. Temperature 98.6 , blood
pressure 110/62 , heart rate 98. Oxygen saturation of 97% on 2
liters. HEENT: Examination is benign , no JVD , JVP was at 7 cm ,
neck was supple. CHEST: Bibasilar crackles. CARDIAC: 2+
carotids , no bruits , regular rate and rhythm , no murmurs , rubs , or
gallops. ABDOMEN: Two frontal scars , liver was palpable 2 cm
below the right costal margin. The abdomen was soft , non-tender ,
nondistended , normal bowel sounds , no masses. BACK: No CVA or
spinal tenderness. RECTAL: Guaiac negative in the Emergency Room.
EXTREMITIES: 1+ left greater than right pedal edema. Superficial
ulcers on bilateral soles. NEURO: Alert and oriented times three.
Nonfocal.
LABORATORY DATA ON ADMISSION: Sodium 132 , potassium 4.7 , chloride
96 , bicarb 25 , BUN 7 , creatinine
0.9 , glucose 186 , CK of 776 , MB 70.5. LFTs were within normal
limits. Hematocrit was 28.3 , white count 10.4 , platelet count 283 ,
physical therapy 13.5 , PTT 26.2 , normal differential.
Urinalysis grossly bloody , 10-20 white cells.
Chest x-ray showed congestive heart failure with small bilateral
effusions , right greater than left , plus Kerley B-lines.
EKG was normal sinus rhythm at 90 , intervals 212/72/368 , and axis 7
degrees. No ischemic changes.
ASSESSMENT & PLAN: This is a 69 year old gentleman with multiple
cardiac risk factors , chronic anemia secondary
to severe hemorrhagic cystitis , no transfusion dependent , who was
admitted with congestive heart failure after blood transfusion and
positive CK , MB. No definitive EKG changes and no clear history of
angina but recent history of increased pedal edema. The patient
likely had recent myocardial infarction and congestive heart
failure in the setting of transfusion.
HOSPITAL COURSE: The patient was admitted to the Cardiac Care Unit
for further care. As mentioned above , heparin
and aspirin were held secondary to the risk of worsening
hemorrhagic cystitis. The patient received further blood
transfusions to maintain a hematocrit greater than 30. He remained
in the Cardiac Care Unit overnight. Serial CKs revealed an A set
of 776 ( MB 70.5 ) , B set 747 ( MB 54.7 ) , C set 564 ( MB 33.2 ). CTNI
was 25.1. EKG's were without evolution. The patient was therefore
ruled in for a non Q-wave myocardial infarction. An echocardiogram
was performed on 4/17/96 which showed normal LV function , mild LVH ,
no regional wall motion abnormalities but of a somewhat suboptimal
quality. The patient received a total of four units of red blood
cells with a subsequent rise in hematocrit from 17 to 30.1 by the
first hospital day and received initially 40 mg of intravenous Lasix in the
Emergency Room , followed by two doses of 20 mg with excellent urine
output.
The patient was transferred from the CCU to General Medical
Service , Na Ence Buff Sa on his second hospital day , 9/23/96. His post MI
course was uncomplicated , notable only for two runs of
non-sustained ventricular tachycardia overnight on the first
hospital day. The patient had no recurrent angina and no recurrent
evidence of congestive heart failure.
He underwent a routine post MI submax ETT on 9/3/96. The patient
went 4 minutes and 4 seconds with a peak work load of 31 , peak
heart rate of 80 , and peak blood pressure of 160/80. He stopped
secondary to fatigue. He occasional PVC's but no chest pain and no
ST changes. The test was thought to show no evidence of ischemia
but had a low work load. It was thought appropriate to discharge
the patient to home for further medical management and further
urologic workup as an outpatient. The most important medical
intervention would be to keep his hematocrit greater than 30 with
vigilant monitoring. During this admission , the patient received a
total of six units of packed red cells. and had a hematocrit of
30.9 on discharge.
From a urologic standpoint , the patient was followed by Urology
during his hospitalization , who felt that his condition was
secondary to radiation cystitis. Given that he was now having
hematuria to the extent of requiring frequent transfusions , surgery
i.e. a urinary diversion with ileal conduit , will most likely be
necessary in the near future. He will continue to follow-up with
Urology as an outpatient.
DISCHARGE MEDICATIONS: Ferrous sulfate 300 mg orally every day , folic
acid 1 mg orally every day , Glyburide 10 mg orally
twice a day , Lopressor 25 mg orally twice a day , sublingual nitroglycerin
as needed chest pain.
CONDITION ON DISCHARGE: The patient was discharged in good
condition and will follow-up with Dr. Mackenzie Tyacke and also with Dr. Lemmings as well as Urology.
Dictated By: CARRI G. KATCSMORAK , M.D. VA03
Attending: MACKENZIE TYACKE , M.D. KC8
KX139/6041
Batch: 83252 Index No. T4JMYN23P2 D: 1/13/96
T: 10/19/96
Document id: 1038
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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453802027 | PUO | 16219070 | | 9974311 | 10/16/2003 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 10/16/2003 Report Status: Signed
Discharge Date: 8/17/2003
ATTENDING: GWYNETH ALMEDA DEPSKY MD
ATTENDING PHYSICIAN ON ADMISSION:
Gwyneth Almeda Depsky , M.D.
ATTENDING PHYSICIAN ON DISCHARGE:
Colin Naji , M.D.
CHIEF COMPLAINT:
Mr. Vonsoosten is a 43-year-old man with morbid obesity , type II
diabetes , hypertension , hyperlipidemia , chronic renal
insufficiency , and severe peripheral arterial disease status post
femoral popliteal bypass in September which was complicated by repeated
return of cellulitis x 2 who was admitted with cellulitis and
volume overload.
HISTORY OF PRESENT ILLNESS:
The patient has had two wound complications after his femoral
popliteal bypass requiring two separate incisions and drainages
including courses of intravenous nafcillin x 4 weeks and with
vancomycin x 4 weeks. He had been seen by Vascular Surgery five
days prior to admission and had been started on dicloxacillin for
a third episode of cellulitis. He had also presented with fluid
overload and spironolactone was added to his diuretic regimen.
His primary care provider saw him the day prior to admission , and
the patient reported a recent fall and the primary care physician
recommended admission to the hospital. The patient does report
some fever and shaking chills and decreased appetite. Also ,
reported weakness in bilateral lower extremities and right foot
pain. He has chronic loss of sensation in both feet.
PAST MEDICAL HISTORY:
Morbid obesity , type II diabetes , chronic renal insufficiency
with a baseline creatinine of 2-2.5 , dyslipidemia , hypertension ,
coronary artery disease , peripheral vascular disease , anemia ,
history of deep vein thrombosis , obstructive sleep apnea , anger
disorder , peptic ulcer disease , and tinea pedis.
MEDICATIONS ON ADMISSION:
Atenolol 100 mg every day , spironolactone , torsemide 160 mg twice a day ,
Hyzaar 50/12.5 every day , lisinopril 60 mg every day , Neurontin 1200 mg
three times a day , Norvasc 10 mg every day before noon and 5 mg every afternoon , Coumadin 8 mg ,
aspirin , Humalog sliding scale , Percocet , Pletal 100 mg twice a day ,
Procrit , Zantac , nitroglycerin as needed , and NPH 80 every day before noon and
every afternoon
PHYSICAL EXAMINATION:
On physical exam , the patient was afebrile and had a temperature
of 99 , a heart rate of 70 , blood pressure 200/79 possibly taken
with an undersized cuff , 18 and 99% on room air. He is obese and
comfortable man in bed and in no acute distress. His JVP could
not be assessed from the size of his neck. Heart sounds were
distant. Chest was clear. His abdomen is obese with bowel
sounds , nontender , and nondistended. Extremities: Notable for 3+
edema , and including 1+ extending to the groin. His pulses were
Dopplerable bilaterally with a triphasic wave on the right and
biphasic on the left. The medial aspect of his right leg had a
surgical scar. A healed annular burn wound in the medial knee
and an area of erythema along the scar with warmth , moderate
tenderness , no fluctuance and minimal induration , no discharge.
The diameter of his right leg was greater than his left. His
right heel had an intact ??blough?? and his left heel had a dry
pressure sore. His right big toe was tender to palpation.
LABORATORY STUDIES:
Labs were notable for a creatinine of 3.4 and an INR of 7.1. His
EKG showed normal sinus rhythm at 75.
HOSPITAL COURSE BY PROBLEMS:
Problem #1. Infectious Disease: The patient was started on
vancomycin intravenous on admission for his right medial thigh cellulitis
at the site of the femoropopliteal bypass with rapid
defervescence and improvement. No drainage , no fluctuance.
Additional antibiotic coverage was added specifically of
fluoroquinolone for anti-psuedomonal coverage for his diabetic
foot ulcers. The right heel also looked increasingly purulent
during his hospitalization and bilateral foot plain films were
done. These were negative for osteomyelitis but showed a metal
sliver in the right foot and an acute fracture of the first
metatarsal. Surgical debridement was done in the operating room
with drainage of pus , but the metal showed could not be located
even with fluoroscopy. The patient will complete a 14-day course
of levofloxacin and clindamycin for these foot ulcers , and will
be discharged home with visiting nursing care for twice a day
wet-to-dry dressing changes. He will follow up with Jerica Tanya Youngberg , M.D. in one to two weeks.
Problem #2. Renal: The patient was volume overloaded on
admission. His torsemide was changed to intravenous and metolazone was
added and was given 30 minutes prior to his first torsemide dose
of the day. A diuresis of 1.5-2 liters a day was achieved with
this regimen with the exception of a 4 liter diuresis overnight
on the first day of admission. His electrolytes were replaced as
needed. I have expected his creatinine increase to 4.5 by
discharge. He will need close renal follow ups as he may be
approaching need for dialysis. The Renal Service followed him
during this hospitalization and at their recommendation ,
spironolactone will be discontinued upon discharge since his
diuresis will be slowed.
Problem #3. Vascular: Diuresis was essential for resolution of
his cellulitis. Pletal was continued and because of his severe
peripheral arterial disease , he will require excellent wound care
to optimize healing.
Problem #4. Heme: Initially , his Coumadin was held for a
supratherapeutic INR. This was restarted when his INR was 2.2
and he his now in the therapeutic range and will need to be
followed.
Problem #5. Cardiovascular: He was hypertensive on arrival
which was treated with Hydralazine initially and transitioned to
his orally home medicines. Even with a large cuff , his blood
pressure continued to run high in the 150s-180s. On hospital day
#9 , Hydralazine orally was added with good effect which lowered his
systolic blood pressure to the range of the 120s-130s. Goal is
below 130/80.
Problem #6. Endocrine: The patient was admitted with NPH and
Humalog. The Diabetes Service saw the patient and at their
recommendation NPH doses were increased , and he is now on 90
units in the morning and 85 units at night. The goal for this
patient is below 150 particularly given the need for wound
healing.
Problem #7: GI: The patient was seen by Nutrition and will be
evaluated as an outpatient by Bariatric Surgery pending next
week. This is of utmost importance for this patient with
life-threatening morbid obesity who already has severe
complications of obesity-related conditions. The patient has
obesity , hyperventilation syndrome.
Problem #8. Pulmonary: The patient has obstructive sleep apnea.
A CPAP machine was brought to the patient bedside , but the
patient was unable to tolerate the nose mask. He will use his
own device when he returns home.
DISCHARGE INSTRUCTIONS:
He will go home with visiting nurse care and will need to see his
nephrologist , vascular surgeons , primary care provider , and
Bariatric Surgery following discharge.
eScription document: 1-9575418 EMSSten Tel
Dictated By: BUCCHERI , FELICE
Attending: DEPSKY , GWYNETH ALMEDA
Dictation ID 7864433
D: 8/7/03
T: 8/7/03
Document id: 1039
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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933271567 | PUO | 75751674 | | 6694972 | 10/27/2005 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/18/2005 Report Status: Unsigned
Discharge Date: 3/4/2006
ATTENDING: STUKOWSKI , JANAY MD
DISPOSITION: To rehabilitation.
PRINCIPAL DISCHARGE DIAGNOSIS: Status post CABG x3/LIMA.
OTHER DIAGNOSES: Excessive bleeding , history of GI bleeding from
diverticulosis which resulted in colectomy , history of
myelofibrosis followed by a hematologist.
HISTORY OF PRESENT ILLNESS: Mr. Mira Sickafoose is a 78-year-old male
with a history of CAD and previous MI , angioplasty in 1995 and
stent placement in 2001 , complained about episodes of shortness
of breath and increasing intolerance of physical activity. He
was using nitroglycerin and rest during such an episode with
obvious success. His cardiac catheterization was done at PUO
which revealed three-vessel coronary artery disease with EF of
55%. He has a permanent pacemaker installed 10/29 due to sick
sinus syndrome and an intermittent AV block , second-degree.
Latest echo reported presence of mild-to-moderate mitral
regurgitation.
PREOPERATIVE CARDIAC STATUS: Urgent. The patient presented with
critical coronary anatomy/myocardial infarction in 1987 requiring
hospitalization. The patient has a history of class III angina.
There has been recent stable angina. There is a history of class
II heart failure. Recent signs and symptoms of congestive heart
failure include dyspnea on exertion. The patient is in normal
sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTIONS: 10/29 off pump
biventricular permanent pacemaker. PTCAS/atherectomy in 1995 and
stent in 2001.
PAST SURGICAL HISTORY: Colectomy due to bleeding from
diverticulosis , THR , right inguinal hernia.
FAMILY HISTORY: Coronary artery disease. Father with MI , died
at age 46 from MI.
SOCIAL HISTORY: No history of tobacco use. The patient is a
retired judge.
ALLERGIES: To penicillin , which results in rash and heparin.
ADMISSION MEDICATIONS: Atenolol 25 mg daily , allopurinol 300 mg
daily , and Flomax 0.8 mg daily.
PHYSICAL EXAMINATION: Height and weight 6 feet and 76 kilos.
Vital signs: Temperature 98 , heart rate 65 , BP right arm 118/60 ,
left arm 120/58 , oxygen saturation 97% room air. HEENT:
PERRLA/dentition without evidence of infection/no carotid bruits.
Chest: No incisions. Cardiovascular: Regular rate and rhythm.
All distal pulses intact. Allen's test: Left upper extremity
normal , right upper extremity normal. Respiratory: Breath
sounds clear bilaterally. Abdomen: Laparotomy scar , soft , no
masses. Extremities: Without scarring , varicosities , or edema.
Neuro: Alert and oriented , no focal deficits.
LABORATORY DATA: Chemistry: Sodium of 138 , potassium 3.9 ,
chloride 108 , CO2 24 , BUN 19 , creatinine 1 , glucose 98 , and
magnesium 2.1. Hematology: WBC 19.78 , hematocrit 30.4 ,
hemoglobin 10.2 , platelets 525 , physical therapy 17.3 , INR 1.4 , PTT 51. UA was
normal. Cardiac catheterization data from 9/23/05 performed at
PUO showed coronary anatomy 60% distal left main , 60% ostial LAD ,
70% proximal circumflex , 80% proximal RCA , 60% distal RCA , right
dominant circulation. EKG from 9/23/05 showed paced rhythm ,
rate of 64. Chest x-ray from 9/23/05 consistent with COPD , left
pacemaker permanent , cardiomegaly , thoracic vertebral
degeneration. Patient was admitted to PUO CSS and stabilized for
surgery. Date of surgery 8/24/05.
PREOPERATIVE DIAGNOSIS: CAD.
PROCEDURE: CABG x3 with LIMA to LAD , sequential graft , SVG1
connects aorta to NW6 then PDA. Bypass time 97 minutes. Circa
arrest for 5 minutes. There were no complications. The patient
was transferred to the unit in stable fashion with lines and
tubes intact.
ICU PROGRESS EVENT SUMMARY: 7/13/05 , postop day #1 , hypotensive
low SVR , vasopressin started , rising creatinine. 10/29/05 ,
postoperative day #2 , started on dopamine for oliguria and rising
creatinine. 7/12/05 , postop day #3 , creatinine down to 1.4 ,
episode of bradycardia. Postop day #4 , continued on dopamine at
2 mcg , continued high chest tube output. Official echo report
essentially unchanged. Postop day #5 , weaned off dopamine , left
chest tube discontinued , persistent SVG harvesting site bleed.
Postop day #6 , 9/3/05 , no significant events , medial chest
tubes were discontinued without complications. The patient was
transferred to the Step-Down Unit on 9/3/05 , postop day #6.
SUMMARY BY SYSTEM:
Neurologically: Intact.
Cardiovascular: On aspirin , has pacemaker for sick sinus.
Battery is low , cannot pace above 65 beats per minute with plans
to exchange generator. Pressure is better , paced externally at
90 BPM.
Respiratory: Saturating well on 2 liters of oxygen delivered by
nasal cannula so was moderate chest tube output.
Diet: Advanced as tolerated.
Renal: Postop increase in creatinine requiring dopamine ,
creatinine now down to 1.5. P.o. Lasix started.
Endocrine: No issues.
Hematology: Anticoagulation with aspirin.
ID: Antibiotics are off. Afebrile.
Elevated white count secondary to myelofibrosis. Transferred to
Step-Down Unit on postoperative day #6. Postop day #7 , 9/19/05 ,
last remaining chest tube removed. Patient still complains of
shortness of breath , saturating well on room air. Chest x-ray
looked slightly wet but nothing significant noted. Echo showed
moderate TR. No changes from prior echos. Send troponin , BNP to
help rule out PE per cards , very slow to ambulate , needs physical therapy ,
probably rehab , is being paced to 70 BPM with external V wire ,
has internal pacer working at 60 beats per minute but needs
battery change by EPS.
FOLLOW-UP APPOINTMENTS: Dr. Stukowski wants him on low flow O2 for
time being. 8/10/05 , postop day #8 , sinus rhythm 2 liters ,
patient with bilateral lower extremity DVT's , right IJ clot , and
left upper extremity DVT as well , started on argatroban , PTT to
titrate the goal of 50/70. HIT screen came back positive.
Hematology , following recommended vascular consult for blue
fingers and toes. If color on extremities does not improve on
argatroban , will get vascular to see. So far color in right hand
looks better. Left fingers and toes bilaterally , no worse , no
better. Respiratory status worsens , consider CT angiogram with
contrast to rule out PE with Mucomyst given creatinine of 2.1.
Blood cultures sent for white count. The patient with left chest
effusion , will get chest ultrasound once stable , still has wires
in and being externally paced at 70 until internal PPM can have
battery change. 6/17/05 , postop day #9 , HIT positive with
worsening clinical syndrome. Positive DVT's in all extremities ,
started on argatroban , transferred to ICU for further monitoring ,
intubated in early a.m. for respiratory distress. 9/6/05 ,
postop day #10 , echo obtained. RV strain , moderate-to-severe TR.
Renal ultrasound with Doppler obtained , no evidence of portal
venous vascular thrombosis. Argatroban continued , persistently
high minute ventilatory requirement. Postop day #11 , transfused
2 units packed red blood cells with improvement in hematocrit ,
creatinine , and BP after second unit , required left femoral CVL
placement for poor peripheral access and concern for worsening of
right arm swelling after blood administration in the ipsilateral
arm. Postop day #12 , right hand cyanosis worsening.
Ortho/plastic/vascular service following , thrombolytic therapy at
this time given current anticoagulation on argatroban on
propofol , went weaned to PSV. Total bilirubin elevated at 4.1 ,
direct bilirubin at 1.5. 2/7/05 , postop day #13 , left hand
ischemia continues to progress , too agitated to be extubated ,
continues to be therapeutic on argatroban. Microthrombi ,
conservative management planned. Tube feeds started , bronched
moderate amount of seropurulent secretions. Postop day #14 ,
9/23/05 , left hand ischemia showed signs of demarcation , PTT
therapeutic on argatroban , plastic C valve patient , suggested
conservative therapy , low urine output which resolved with
albumin bolus , CK is trending down , GI consult was obtained for
melena. 7/5/05 , postop day #15 , increase sodium , free water
added , left hand continues to demarcate , argatroban dose
increased to get PTT therapeutic. 5/25/05 , postop day #16 ,
thick secretions plugged to desaturated , cup leak and poor TVs ,
prompted increasing FIO2 , temperature spike , blood glucose high ,
pancultured for question of sepsis. 2/27/05 , postop day #17 ,
Serratia marcescens in sputum culture , started on ceftazidime ,
awaiting sensitivities , GI bleed , hematocrit dropped from 28-23 ,
2 units packed red blood cells given , NG-tube aspiration with
bilious fluid , presumed lower GI bleed , argatroban reduced to
lower end of therapeutic window. 7/13/05 , postop day #18 , GI
bleed continues , hematocrit dropped having 1 unit transfusion ,
bilirubin increased from 1.7-3.3 , echo was essentially unchanged
showing RV strain. Postop day #19 , persistent respiratory
alkalosis with improvement of blood gas with adequate sedation ,
decreased minute ventilation. 4/17/05 , postop day #20 , became
hypotensive , oliguric , profound metabolic acidosis septic , source
likely chest , lines rewired , pressors started , resedated and put
on a rate , also further per bleeding requiring 1 unit
transfusion. 5/28/05 , postop day #21 , general surgery consult ,
no surgical etiology at the current point , ultrasound showed no
pericholecystic fluid , positively distended gallbladder , add
fluconazole and Flagyl prophylactically , argatroban held given
profuse GI bleeding requiring 3 units of packed red blood cells ,
hematocrit currently stable. Postop day #22 , no further GI
bleed , argatroban remains off , continues on vasopressin and
dopamine. Postop day #23 , no GI bleed , off vasopressin , dopamine
weaned too , left hand looks a little better , trial of extubation ,
now tachypneic. 11/18/05 , postop day #24 , extubated , tolerating
BiPAP. 10/14/05 , postop day #25 , tachypneic on BiPAP ,
hypotensive , bolus with albumin. 10/19/05 , postop day #26 ,
tolerating facemask , overnight started tube feeds , sugars
controlled on no insulin and possibly improving , we will allow to
further demarcate for further two weeks. 1/8/05 , postop day
#27 , GI bleed , hematocrit stable , tachypneic , intolerant of BiPAP
requiring suctioning. Postop day #28 , GI bleed , hematocrit
dropped from 30-27 , back to 29 appears stable , remains on
argatroban , bronched yesterday with serous secretions. 3/23/05 ,
postop day #29 , no GI bleeds bleed , transfused 1 unit for
hematocrit of 26 , intermittent problems with external pacer
capture and internal pacer not firing , neurologically continues
to improve. 1/9/05 , postop day #30 , EPS interrogated pacer and
backup , pacing appears to be intact , internal pacer set backup
rate at 65 , currently patient overdrive paced at rate of 100 ,
external wires working. 2/16/05 , postop day #31 , venous blood
gas overnight revealed pH 7.28 , BiPAP initiated resulting in
decreased BP , held Lasix drip with decreased BP , patient much
more alert and oriented after 2 hours on BiPAP. Postop day #32 ,
right upper extremity swelling continues to worsen , positive
pressure mask ventilation. Postop day #33 , more communicative
overnight. Postop day #34 , more communicative overnight. Postop
day #35 , increased pacemaker threshold overnight from 2-7.
Postop day #36 , 9/16/05 , increased pacemaker threshold overnight
from 2-7. 10/21/05 , postop day #36 , continues to improve for
speech and swallow and EP assessment. 11/28/05 , postop day #37 ,
plans for pacemaker battery changed , external wire threshold at 7
milliamps , argatroban , off diuresis , intravenous Lasix restarted , Dobbhoff
tube pulled out by patient. Postop day #38 , had pacing generator
changed , off argatroban at present. Postop day #39 , failed video
swallow , tube feed to continue , argatroban restarted , Lopressor
started , pacemaker working well , wires discontinued. 2/9/05 ,
postop day #40 , argatroban dose reduced to maintain PTT of 50.
Postop day #41 , INR 2.3 , will check INR off argatroban , large
number of loose stools. Postop day #42 , C. diff pending ,
argatroban restarted. Postop day #43 , nausea , no vomiting
yesterday , tube feeds turned off temporarily , more tachypneic.
Postop day #44 , GNR from A line , sputum Gram stain , gram-positive
cocci , and gram-positive rods , febrile to 101.8. Postop day #45 ,
A line removed , argatroban off , sputum culture grew Staph aureus
and pseudomonas , afebrile. Foley removed , patient voiding ,
transferred back to Step-Down Unit on 4/13/05 , postop day #46 ,
PTT therapeutic on argatroban , INR tending up , fingers and toes
still discolored , continue to follow. Foley in place secondary
to retention , continues on tube feeds , continues on triple
antibiotic therapy for sputum/blood culture , rehabilitation when
ready. 11/14/05 , postop day #47 , V paced/room air , family
meeting , patient to have video swallow on Tuesday , plastics came
up today , planned to take to OR next week for amputation of left
fingers and some toes , patient doing much better with physical therapy , goal
PTT is 50 , argatroban to come off once INR is over 2 , starting
Flomax since he had urinary retention and Foley had to be
reinserted , we will do another voiding trial 48 hours. Postop
day #48 , on Flomax , to do voiding trial at midnight tonight , on
Coumadin and argatroban for HIT , goal PTT is 50-70 , plans to
discontinue argatroban when INR greater than 2. Plastics most
likely to take to OR next week for removal of left fingers/hand.
Patient under impression that it is just fingertips , family are
aware and may be more once Dr. Authur makes final decision as to
what he will do , will need to make patient aware , toes are also
to be amputated , most likely will not do all at once , physical
therapy has been working with him , very happy with the progress
he has been making , speech and swallow to video swallow on
Tuesday. 10/24/05 , postop day #49 , V paced room air , argatroban
and Coumadin for HIT , status unchanged , awaiting plastics input.
Postop day #50 , paced room air , plastics talked at length to the
patient to take him to OR later this week , continue argatroban ,
Coumadin held , physical therapy working closely with patient , hemodynamically
stable and afebrile , high white blood cell count unchanged.
Postop day #51 , V paced room air , failed video swallow , keep
npo , patient and family will decide by the a.m. if they will
proceed with surgery on Thursday , wound looking better per RN ,
otherwise status quo. Postop day #52 , V paced room air , patient
going to OR with plastics for toe finger amputations/left hand
debridement , holding tube feeds and argatroban after midnight ,
patient on day #9 of #14 of levofloxacin for EC bacteremia and
day #9 of #21 off linezolid for pseudomonas pneumonia. Postop
day #53 , V paced room air , went to OR today , had complete
amputation of left hand and most of toes bilateral , toes were
left open , left arm was closed with a large skin flap , JP drain
left in place at left wrist , about 2 unit units of packed red
blood cells postop. Psych consulted to help patient coping , they
will see him tomorrow , restarted argatroban at 05:00 p.m. ,
restarting Coumadin. Postop day #54 , 4/4/05 , plastics
following , patient has JP drain in wrist , status post left hand
amputation , bilateral toe amputation , psych consulted for further
eval , patient not depressed , coping well , remains on tube feeds ,
followed by speech and swallow with no records for orally feeds at
this point , physical therapy following , will continue to advance mobilization
as wounds heal , stable hemodynamically. 1/21/05 , postop day
#55 , plastics following , patient remains on tube feeds , pending
speech and swallow advancement , stable hemodynamically , repeat
blood cultures drawn , white count still elevated , currently
remaining on argatroban or INR subtherapeutic. 10/27/06 , postop
day #56 , plastic following , removed left wrist JP drain , white
count remains elevated , remains on tube feeds , speech and swallow
following , PTT therapeutic , INR not yet therapeutic , started
low-dose Neurontin per plastics , stable. 5/17/06 , postop day
#57 , white count up a bit , cultures remain negative at baseline ,
white blood cell elevation upon admit , patient very concerned
about being tube fed , planned speech and swallow reevaluation
scheduled for tomorrow , ambulate out of bed to chair with lift
team and may weight bear with physical therapy , plastics following , PTT
therapeutic on argatroban. 1/2/06 , postop day #58 , V paced via
internal PPM , BP stable , satting well on room air , out of bed
with physical therapy , ambulated a little , plastics/vascular following , left
upper extremity and bilateral toe amputation site healing well ,
argatroban dose increased from 0.1 to 0.2 , bridging to Coumadin ,
speech and swallow reevaluate at bedside , may repeat video
swallow study later this week as patient continues to work with
physical therapy and increase strength , remains on Dobbhoff tube feeds , patient
has baseline neutrophilia but mildly above baseline , afebrile ,
following pancultures including C. diff for loose stools , dosing
Lasix for reduced urine output. Foley in place , discontinued
PCA , rehabilitation screen initiated. 8/6/06 , postop day #59 ,
V paced via internal pacemaker , BP stable , remains afebrile ,
remains on linezolid for EC bacteremia , chest x-ray continues to
demonstrate persistent opacifications and left mid , left lower ,
and right base , had been on levofloxacin 1/13/05 through
10/14/05 and 3/5/05 through 1/2/06 , satting well on room air ,
strictly npo , all nutrition via Dobbhoff , patient has been
working diligently with physical therapy , speech and swallow to reassess again
Thursday and Friday , remains on argatroban with subtherapeutic
INR , titrating Coumadin dose , plastics following left hand and
bilateral toe amputation sites which are clean and healing well.
9/6/06 , postop day #60 , remains ventricularly paced via
internal PPM , BP stable , ambulated out of room today with physical therapy ,
Speech and Swallow Service encouraged by recent physical therapy gains , felt
bedside exam today indicated potential for advancement , scheduled
for repeat video swallow , remains strictly npo , fed via
Dobbhoff , white count at preop baseline , afebrile completing 21
day course of linezolid for EC bacteremia , chest x-ray continues
to demonstrate persistent although mildly improved opacifications
in the left mid , left lower , and right base , has been on
levofloxacin , saturating well on room air , urine output , JVD , and
chest x-ray improved after adding low-dose Lasix , remains on
argatroban with subtherapeutic INR. Plastics following. Postop
day #61 , 4/15/06 , long postop course complicated by HIT
positive , Speech and Swallow Service were encouraged enough by
recent physical therapy gains to reassess video swallow but again was seen to
aspirate with all consistencies , keeping strictly npo , all
nutrition and meds via Dobbhoff NGT , no PEG planned at this
point , the patient is afebrile , completing 21 day course
linezolid for EC bacteremia. Chest x-ray continues to
demonstrate persistent although improved calcifications in the
left mid , left lower , and right base. 9/13/06 , postop day #62 ,
remains on argatroban drip for HIT , INR trending up , npo tube
feeds via Dobbhoff , three more days of Linezolid for EC
bacteremia. 1/26/06 , postop day 63# , VP room air , remains on
argatroban for HIT , INR 2.5 , rising slowly. Order for portable
chest x-ray , 20 mg intravenous Lasix for increased labored breathing
today , weight has been stable past few days , positive on I's/O's ,
white count high but at baseline secondary to his history of
myeloproliferative disorder , patient remained afebrile.
10/14/06 , postop day #64 , V paced room air , decreased argatroban.
4/16/06 , postop day #65 , V paced , argatroban discontinued as
INR now therapeutic , working with physical therapy doing well , patient was
evaluated by Cardiac Surgery Service to be stable to discharge to
rehabilitation on 10/19/06 with the following discharge
instructions.
DIET: Osmolite 1.2 tube feeds at 80 cc an hour with plans to
advance orally as swallow function improved.
FOLLOW UP APPOINTMENTS: Dr. Stukowski , 117-219-4079 in 5-6 weeks ,
Dr. Moriarity , 1551-911-3307 in 1-2 weeks , Dr. Lichota 165-072-5287 in
1-2 weeks , Dr. Authur PUO Plastics at 679-827-8734 in 7-10 days.
ADDITIONAL COMMENTS: The patient should have speech and swallow
follow up while at rehab for ongoing evaluation of swallow
function. He is going to rehabilitation with Dobbhoff tube in
place for feeding with plans to advance diet to orally intake once
swallow function improves. Mr. Mira Sickafoose should not receive any
heparin products , he has HIT and has required anticoagulation
therapy/surgical amputation as a result.
TO DO PLAN: Make all follow-up appointments , local wound care ,
wash wounds daily with soap and water , shower patient daily.
Please follow PUO Plastic Surgery Service records for dressing
changes , bilateral lower extremities and left wrist. Watch
wounds for signs of infection , redness , swelling , fever , pain ,
discharge. Call primary care physician/cardiologist or PUO Cardiac Surgery Service
at 117-219-4079 with any questions or Dr. Authur at 679-827-8734
with any questions regarding amputation sites.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Tylenol 325-650 mg PNGT every 4 hours as needed
pain , atenolol 12.5 mg daily , Dulcolax 10 mg PR daily as needed
constipation , Chloraseptic spray one spray every 2 hours as needed pain
instructions for throat pain due to NG tube , Colace 100 mg three times a day
as needed constipation , ferrous sulfate 300 mg PNGT three times a day , Lasix 40
mg PNGT twice a day , gentamicin sulfate two drops each eye every 8 hours , regular
insulin sliding scale , regular insulin 8 units subcutaneously every 6 hours with
instructions to hold if tube feeds off or npo , milk of
magnesia 30 mL daily as needed constipation , nystatin suspension 1
million units four times a day swish and spit , multivitamin therapeutic
with minerals 15 mL PNGT daily , simvastatin 20 mg PNGT. every bedtime ,
Atrovent nebulizers 0.5 mg four times a day , Neurontin 100 mg three times a day ,
Ambien 10 mg every bedtime as needed insomnia , K-Dur 20 mEq PNGT twice a day ,
Flomax 0.8 mg daily , miconazole nitrate 2% powder topical twice a day ,
Nexium 40 mg daily , Coumadin with variable dosage to be
determined based on INR , and Prochlorperazine 20 mg PR every 12 hours
as needed emesis.
eScription document: 2-9319965 EMSSten Tel
CC: Janay Stukowski MD
DIVISION OF CARDIAC SURGERY
Pem Et Fran
Dictated By: CRIDGE , LORRETTA PA
Attending: STUKOWSKI , JANAY
Dictation ID 8714081
D: 10/19/06
T: 10/19/06
Document id: 1040
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
Y |
Y |
Y |
N |
N |
N |
N |
Y |
N |
- |
N |
N |
N |
N |
919305632 | PUO | 04213756 | | 585026 | 11/21/1997 12:00:00 a.m. | BRONCHITIS | Signed | DIS | Admission Date: 6/26/1997 Report Status: Signed
Discharge Date: 5/23/1997
PRINCIPAL DIAGNOSIS: Bronchitis.
PAST MEDICAL HISTORY: 1 ) Hypertension . 2 ) History of
cerebrovascular accident in 1983 with left
sided involvement. 3 ) History of congestive heart failure. 4 )
Insulin dependent diabetes mellitus. 5 ) Arthritis. 6 )
Cataracts. 7 ) Total abdominal hysterectomy. 8 ) History of sinus
problems. 9 ) Stable angina.
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old woman with
past hospitalizations for congestive
heart failure ( last October , 1996 ) and hypertension , who 3-4 weeks
prior to admission had been having increasing cough. Initially she
thought it was because of allergies , but it progressed and over the
3-4 days prior to admission she had increasing cough productive of
yellow sputum. Over the three days prior to admission the patient
felt feverish , chills , shortness of breath and wheezing. She had a
fever to 101 on the day prior to admission. She denied ill
contacts or recent travel. Her last pneumonia vaccine was in September
of 1997. She has stable three pillow orthopnea. She has no PND ,
recent leg swelling. She has no recent increase in frequency in
angina and no recent weight gain or increase in abdominal girth.
She describes increasing shortness of breath when lying on her left
side which is relieved by sleeping on her right side. Her most
recent echocardiogram in October of 1996 showed an ejection
fraction of 40% with 1 plus mitral regurgitation. She had a
Persantine MIBI in October of 1996 , on which she had no fixed or
reversible ischemia. The patient presented to the I Warho Hospital in the emergency room on the day of admission and she was
afebrile.
PAST MEDICAL HISTORY: 1 ) Hypertension. 2 ) Status post
cerebrovascular accident in 1983 with left
sided involvement but no residual symptoms. 3 ) History of
congestive heart failure: Echocardiogram - October of 1996
revealing 1+ mitral regurge , 1+ tricuspid regurge , normal left
ventricular size with mild decrease in systolic function , mild left
ventricular hypertrophy with ejection fraction of 40% , inferior
wall with slight hypokinesis and apex mildly abnormal , with
bi-atrial enlargement. 4 ) Persantine MIBI in October of 1996 with
maximum heart rate of 89 , maximum blood pressure 180/120 with no
fixed or reversible perfusion abnormalities. Catheterization in
April of 1992 showed normal coronaries. 5 ) Insulin dependent
diabetes mellitus - hemoglobin A1C of 7.6 in October of 1997. 6 )
Arthritis. 7 ) Cataracts - status post right sided cataract
surgery in 1993. 8 ) Total abdominal hysterectomy. 9 ) History of
sinus problems. 10 ) Stable angina - "chest heaviness" after
climbing one flight of stairs , relieved by rest and one sublingual
nitroglycerin.
MEDICATIONS ON ADMISSION: 1 ) Lasix 40 mg. per day. 2 ) Insulin
70/30 28 units every day before noon and 5 units every afternoon
3 ) Verapamil SR 120 mg orally twice a day 4 ) Enteric coated aspirin 325 mg
every day. 5 ) KCL 10 mEq orally every day. 6 ) Premarin 0.625 mg orally every day.
7 ) Zestril 20 mg twice a day 8 ) Atenolol , recently discontinued. 9 )
Tofranil 75 mg orally every HS.
No known drug allergies.
FAMILY HISTORY: Mother died at age 82 from kidney failure. No
history of diabetes , coronary artery disease or
hypertension in the family.
SOCIAL HISTORY: The patient lives with her two grandchildren and
her daughter. She does not use tobacco and does
not drink alcohol. She is originally from Bo Alan La where the rest
of her family currently lives. She left there several months ago.
PHYSICAL EXAM: The patient was a pleasant woman lying comfortably
in bed in no apparent distress. Her temperature was 98.4 , pulse
106 , blood pressure 150/70 , respiratory rate 20 , saturation 95% on
room air. HEENT: Surgical right pupil , anicteric sclera , no nasal
discharge , moist oropharynx. Neck: Supple. No jugular venous
distention and no lymphadenopathy , full range of motion. Lungs:
Diffusely rigorous , no crackles or wheezes bilaterally.
Cardiovascular: Distant heart sounds. S1 and S2 , no S3 and no S4 ,
no murmurs. Abdomen: Normal active bowel sounds. Soft ,
non-tender , non-distended and no hepatosplenomegaly. Extremities:
No edema. Dorsalis pedis pulses 2+ bilaterally. Neurological:
Mild decreased sensation left side of face , otherwise cranial
nerves III-XII are grossly intact. Reflexes in upper extremities
were 1 plus , no reflexes elicited in lower extremities.
LABORATORY DATA: White blood cell count 9.3 , hematocrit 43 ,
platelet count 312. BUN 20 , creatinine 1.4 ,
glucose 377 , LDH 220. Sputum revealed 4+ polys , 4+ epithelial
cells , gram negative and gram positive cocci. Chest x-ray revealed
no evidence of congestive heart failure and no infiltrates.
HOSPITAL COURSE: This is a 69 year-old woman with a history of
congestive heart failure and hypertension who
presented with a productive cough which was worsening over the past
3-4 days and fever to 101 with chills and shakes and increasing
shortness of breath. She was afebrile however at the time of
admission. Her exam was remarkable for diffuse rhonchi and
moderate jugular venous distention. She had a white blood cell
count of 9.3 with 54% polys and 9.6 % eosinophils. Blood glucose
of 377 and a chest x-ray without evidence of congestive heart
failure or infiltrate. She was treated in the emergency room with
Albuterol nebulizer and plans were to discharge her to home ,
however , her saturations dropped to 89% on room air with exercise
in the emergency room and was admitted for further observation.
She was started on intravenous Cefuroxime , and initially improved
with decrease in cough and shortness of breath however , the patient
continued to desat with exercise. A repeat chest x-ray was
performed which showed no change when compared to the admission
film. Her sputum culture grew out Pen-sensitive E-coli and she was
continued on her intravenous and then orally antibiotics. She
continued to desat with exercise , however , and her cough persisted
although she remained afebrile with a slightly elevated white count
and moderate peripheral eosinophilia. Her chest exam remained
rancorous and the reason for this remained unclear. Given the
finding of E-coli in the sputum sample , in addition to the elevated
eosinophilia and lack of finding on chest x-ray despite significant
findings on chest exam , the possibility of a worm or parasitic
disease was raised. The patient is from Utjack Drive but had not been
there in 8 years. She did have a history of diarrhea for several
weeks a few months prior to this admission. Stool specimen was
sent but was rejected by the laboratory and the patient was unable
to produce another stool specimen before discharge. The patient
was discharged to home with Albuterol inhaler and instructions to
follow up with her primary physician. In addition , plans were made
for her to have PFTs done as an outpatient and plan for chest CT if
her symptoms continued without other etiology being discovered.
MEDICATIONS ON DISCHARGE: 1 ) Enteric coated aspirin 325 mg orally
every day. 2 ) Cefuroxime 500 mg orally twice a day
3 ) Premarin 0.625 mg orally every day. 4 ) Lasix 40 mg orally every day. 5 )
Tofranil 75 mg orally every HS. 6 ) Zestril 20 mg orally twice a day 7 ) Verapamil
SR 120 mg orally twice a day 8 ) Insulin 70/30 28 units every day before noon and 5 units
every afternoon subcue. 9 ) Potassium slow release 10 mEq orally every day. 10 )
Albuterol inhaler two puffs inhaled four times a day
DISPOSITION: At the time of discharge the patient's saturation was
92 to 93% on room air and dropping slightly to 90 to
91% with exercise , however she was tolerating this well and was
getting relief from her Albuterol inhaler. She was to finish a
full ten day course of antibiotics for presumed bronchitis and to
follow up with her primary physician in clinic for further
evaluation including PFTs and possible chest CT if symptoms did not
abate.
Dictated By: KATIA POPPELL , M.D. MA60
Attending: HERMINA T. TUOMALA , M.D. WZ0
MD273/8763
Batch: 18159 Index No. DNVN635C64 D: 10/30/97
T: 11/18/97
CC: 1. KATIA POPPELL , M.D. MA60
2. HERMINA T. TUOMALA , M.D. WZ0
Document id: 1041
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196171816 | PUO | 61679016 | | 694940 | 4/5/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/19/1991 Report Status: Signed
Discharge Date: 5/17/1991
DISCHARGE DIAGNOSIS: UNSTABLE ANGINA.
STATUS POST MOTOR VEHICLE ACCIDENT.
HISTORY OF PRESENT ILLNESS: The patient was a 45 year old
gentleman with a history of a
non-Q-wave myocardial infarction in 23 of September He was also recently
involved in a motor vehicle accident , and has had left pressure
since the accident. His cardiac history began in 26 of September , when he
suffered a non-Q-wave myocardial infarction. A cardiac
catheterization at that time revealed a 90% proximal left anterior
descending lesion with anterolateral akinesis , which was treated
with angioplasty. He had a limited stress test on 18 of July , which
was limited by symptoms of chest pressure. The electrocardiogram
and thallium done at that time were both unrevealing. The patient
was involved in a motor vehicle accident in July , and then again
in January , 1991. He suffered multiple contusions , but no fractures.
Subsequent to the accidents , however , he described having left
flank and left side pain , which was exacerbated by movement and was
associated with the development of his left substernal chest
pressure. Nitroglycerin did seem to provide him some relief. The
patient was seen recently at Ley Rotal University Medical Center in Tonbalt for chest
discomfort , and electrocardiogram and cardiac enzymes did not show
any evidence of myocardial infarction. The patient has continued
to complain of chest discomfort over the past month , but all
electrocardiograms have been negative. An exercise tolerance test
was performed at Roose County Memorial Hospital , which was positive for
chest discomfort and for ST depressions in the inferolateral leads.
Thallium examination was not performed because of infiltration of
the intravenous access. He was transferred from Roose County Memorial Hospital on 22 of November , for further work-up and possible cardiac
catheterization.
PHYSICAL EXAMINATION: On admission , the patient was a well
nourished , well appearing young black male.
His blood pressure was 130/80 , pulse 55 , respiratory rate 12. Lungs
were clear. Cardiac examination revealed S1 , S2 , with an S4
present , the jugular venous pressure was 5. The patient had 2+
carotid upstrokes without bruits. The abdomen was soft , good bowel
sounds , with left-sided tenderness and left flank tenderness to
palpation. Extremities showed no edema and good distal pulses.
Neurologic examination showed cranial nerves intact , motor
examination showed some decreased power on the left , but this was
thought secondary to pain. Sensory examination was normal , and his
plantar reflexes were downgoing.
LABORATORY EXAMINATION: On admission , potassium was 4.6 ,
creatinine 1.3 , ALT 155 , AST 80 , LDH 228 ,
creatinine kinase 79 , cholesterol 212 , triglyceride 316 , white
blood count 6.1 , hematocrit 39 , prothrombin time 13.5 , partial
thromboplastin time 89.4. Admission chest x-ray showed no
abnormalities. Admission electrocardiogram revealed normal sinus
rhythm at 56 beats per minute with some inverted T-waves in leads
II , III , F , and V2 through V4. The inverted T-wave in lead II
appeared to be new from a transfer electrocardiogram.
HOSPITAL COURSE: The patient was admitted on 22 of November , and was seen
by the Dental Service for his atypical pain
radiating to the neck. His cardiac risk factors included a
positive family history and a smoking history of less than 1 pack
per day. He had no history of diabetes or previous hypertension.
The patient continued to have chest pain , which responded only to
morphine. He underwent cardiac catheterization on 30 of April , which
revealed a right dominant circulation , kinking of the proximal left
anterior descending artery with a 70% stenosis. The patient
tolerated the cardiac catheterization well without hematoma or
bruit in the right groin. The patient continued to have episodes
of chest pain with 5/10 left-sided sternal chest pain without clear
electrocardiogram changes from the admission electrocardiogram. He
underwent an exercise tolerance test which showed he had 4/10 chest
pain prior to beginning the exercise tolerance test , but then got
worsening chest pain during the test after 8 minutes and 15
seconds , peak heart rate 160 , blood pressure 166/40. He did
develop 1 millimeter of downsloping ST depressions in the lateral
leads , and a pseudonormalization of the T-waves. The results were
discussed with the patient and the options were discussed , that is
medical management versus a repeat angioplasty or possible surgery.
The patient preferred medical management and wanted to be at home
to see if increased medical management would stabilize his chest
pain. The patient was discharged on 9 of September
DISPOSITION: The patient was discharged to home. He was to have
close FOLLOW-UP and management of his cardiac disease
with the Cardiology Group. MEDICATIONS ON DISCHARGE included
Motrin 600 milligrams by mouth 3 times a day , diltiazem 90
milligrams by mouth 3 times a day , Lopressor 50 milligrams by mouth
twice a day , Ecotrin 1 tablet by mouth per day , Pepcid 20
milligrams by mouth twice a day , Isordil 40 milligrams by mouth 3
times a day , Percocet 1 to 2 tablets by mouth every 6 hours as
needed for pain , and Halcion 0.25 milligrams by mouth at hour of
sleep. The patient had a FOLLOW-UP appointment with Dr. Murelli in
Bile Lum
TO856/9147
MOSHE J. SHUGRUE , M.D. PJ4 D: 10/26/91
Batch: 5686 Report: A0957C71 T: 7/24/91
Dictated By: ELA M. LODEN , M.D.
Document id: 1042
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010648020 | PUO | 23877852 | | 6560808 | 2/19/2004 12:00:00 a.m. | ATRIAL TACHYCARDIA | Signed | DIS | Admission Date: 10/7/2004 Report Status: Signed
Discharge Date: 11/29/2004
ATTENDING: ROSSIE MANKOSKI M.D.
ATTENDING PHYSICIANS:
1. Rossie K. Mankoski , M.D.
2. Santa V. Cathrine Chowanec , MD
PRINCIPAL DIAGNOSES: Clotted AV fistula , atrial fibrillation ,
and change in mental status.
HISTORY OF PRESENT ILLNESS: Ms. Tylor is a 61-year-old female
with a history of idiopathic dilated cardiomyopathy status post
cardiac transplant in 1991 complicated by allograft coronary
artery disease , rejection x2 , post transplant MVR and TVR , also
with end-stage renal disease on hemodialysis , diabetes mellitus ,
hypertension and a subacute change in her mental status over the
last few months that presented with a clot in her right upper
extremity AV fistula. Her last hemodialysis session was two days
prior to admission , and she is usually dialyzed on Mondays ,
Wednesdays and Fridays. Interventional radiology did not perform
a thrombectomy of the right upper extremity fistula clot , as the
patient's systolic blood pressures were in the 90s , and they were
concerned about the patient's change in mental status as she
would need conscious sedation for the procedure. She was also
noted upon admission to have an EKG that displayed an atrial
tachyarrhythmia with 2:1 block that was presumed to be atrial
flutter. Her heart rate was noted to be in the 110s to 120s , and
the rest of her vital signs were stable. The patient denied any
chest pain , shortness of breath , lightheadedness , or
palpitations. It should be noted however that the patient was
not entirely conversant. After speaking with the patient's son ,
more information was obtained about this patient's subacute
change in her mental status. The patient was admitted in July
of 2004 for a fall and femur fracture. During that admission ,
the son stated that the patient had an acute change in her mental
status such that she did not know who she was or where she was.
She was not answering questions appropriately. This was
persistent during that hospital stay and was of unclear etiology.
Prior to that admission , the patient is at baseline oriented to
person , place and time , and she is also very conversant. The son
does admit that the patient occasionally becomes confused about
the day of the week. Upon discharge from that admission , the
patient was sent to the Sa Pehall for rehabilitation. The
son says that over the last few months , she has become slightly
better but definitely not at her baseline. He states that she is
often disoriented to person and place , although she does answer
some questions appropriately. The day prior to her admission ,
the patient's other son visit with her at the Sa Pehall and
did not notice any change in her mental status since her
discharge. He has noted decreased orally intake over the last
month with the patient often refusing to eat. Upon questioning
the patient , she denies chest pain , abdominal pain , shortness of
breath , lightheadedness , and palpitations. Although , she does
answer yes and no to some questions , she is not very conversant
and does not volunteer any additional information.
PAST MEDICAL HISTORY:
1. Idiopathic cardiomyopathy status post heart transplant in
1991 complicated by allograft coronary artery disease ,
post-transplant MVR and TVR , and transplant rejection x2.
2. End-stage renal disease on hemodialysis ( Monday , Wednesday ,
Friday hemodialysis ).
3. Diabetes mellitus.
4. Hypertension.
5. Peptic ulcer disease.
6. History of right frontal CVA.
7. Recurrent falls of unclear etiology with a Reveal monitor
implanted.
8. Asthma.
HOME MEDICATIONS: Labetalol 400 mg orally twice a day , Imdur 30 mg orally
every day , lisinopril 5 mg orally every day , insulin NPH 20 units subcutaneously
every day before noon , Nephrocaps one tablet orally every day , Nexium 40 mg orally
every day , prednisone 5 mg orally every day , Imuran 50 mg orally every day ,
rapamycin 8 mg orally every day , sevelamer 800 mg orally three times a day , Lipitor
20 mg orally every day , aspirin 81 mg orally every day.
ALLERGIES: Percocet.
PHYSICAL EXAMINATION: Temperature 96.3 , pulse 110 , blood
pressure 90/60 , respiratory rate 18 , oxygen saturation 96% on
room air. In general , the patient appears slightly cachetic and
is in no acute distress. She is awake and is occasionally
responding to questions but is otherwise not very conversant.
She is oriented to place. Her head and neck exam is
unremarkable. Her cardiovascular exam is notable for regular
rate and rhythm , normal S1 and S2 , no gallops , 2/6 systolic
murmur at the apex. Her JVP was noted to be 8 cm. Her lungs
were clear to auscultation bilaterally on a limited physical exam
( the patient is not inspiring deeply on request ). Her abdomen is
benign. Her extremities are warm with 1+ DP pulses. Her right
upper extremity graft is without thrill and without bruit.
LABORATORY DATA: Her laboratory values were notable for a BUN of
44 , creatinine 6.8 , calcium 11.2 , PTH 263 , white blood cells 6.7 ,
hematocrit 47.3 , and platelets 261.
EKG: Her EKG displayed a flutter with a 2:1 block. Her heart
rate was estimated to be at 110.
Studies: Ms. Tylor had a noncontrast head CT that was notable
for widened ventricles and subarachnoid spaces. She was noted to
have extensive periventricular and subcortical white matter
changes. There was a focal lesion in the frontal lobe on the
right consistent with old infarct and unchanged from her CT scan
two months prior. There was no evidence for hemorrhage. In
general , there was no change in the CT scan when compared to her
CT scan from 5/17/04. The patient underwent a transthoracic
echocardiogram on 8/20/04. This TTE showed LV with a normal
size and moderate concentric LVH. Her LVEF was noted to be 55%.
There were no wall motion abnormalities. Her RV size and
function was grossly normal. Her mitral valve was noted to be
status post repair with a transmitral gradient of 4.0 mmHg.
There was trace MR. There was no change in this echocardiogram
when compared to her echocardiogram from 4/7/04. The patient
also underwent a lumbar puncture. Her CSF was notable for an
elevated protein. Her CSF had a normal glucose , two white blood
cells with lymphocyte predominance , gram stain that did not show
any organisms , and cultures that are no growth to date. On
cytology , there were no malignant cells seen in the CSF. Her
cryptococcal antigen was negative. CSF studies that are pending
include the following: CMV culture , HSV culture , VZV culture ,
Listeria culture , HSV PCR , CMV PCR , HHV6 PCR , VZV PCR , and VDRL.
The cultures thus far have had no growth to date.
ASSESSMENT AND PLAN: Ms. Tylor is a 61-year-old female with a
history of idiopathic dilated cardiomyopathy status post cardiac
transplant in 1991 complicated by allograft coronary artery
disease , post transplant MVR and TVR , and rejection , also with
end-stage renal disease on hemodialysis , hypertension and
diabetes mellitus who presented with a right upper extremity
fistula clot , new atrial flutter with 2:1 block and a change in
her mental status that has been of many months.
1. Cardiovascular:
A. Pump: The patient is status post cardiac transplant and has
been maintained on her outpatient immunosuppressive regimen.
This includes prednisone , rapamycin , and Imuran. She has
remained euvolemic during her hospital admission.
B. Ischemia: There were no active issues , and the patient was
maintained on her outpatient regimen of aspirin , statin and
Imdur.
C. Rhythm: Electrophysiology has been seeing the patient and
has recommended medical management for her atrial flutter/atrial
fibrillation with 2:1 block. The patient's heart rate ranged
from the 80s to 120s , and she was started on diltiazem 60 mg orally
four times a day She seemed to respond well to the diltiazem , although it
was hard to measure a response since the patient often refused
her medications. The patient was also maintained on metoprolol
75 mg orally four times a day It was hoped that the addition of the
diltiazem to the metoprolol would allow for the rate control of
this patient's atrial arrhythmia.
2. Renal: The patient has a history of end-stage renal disease
on hemodialysis. A tunneled hemodialysis catheter was placed on
3/9/04 for temporary access for hemodialysis. She was dialyzed
while in the hospital and maintained on Nephrocaps. She is
scheduled on 11/28/04 for a right upper extremity venogram in
order to access her anatomy for the vascular surgeons to create
hemodialysis access.
3. Neurology/psychiatry: The patient's change in mental status
over the last few months is still of an unclear etiology. She
underwent an EEG that showed diffuse slowing that was consistent
with a toxic metabolic etiology. There was no seizure activity.
She underwent two CT scans of her head without contrast that were
negative for bleed. There were no changes in her CT scans when
compared to prior CT scan. She also underwent an LP with CSF as
mentioned above. An MRI was not completed as the patient has an
event monitor in her heart. The differential diagnosis for this
patient is changed and her mental status still includes
depression and pseudodementia , and we are still ruling out
infectious etiologies with the CSF studies that are pending at
the moment ( although this is unlikely ). It is hoped that she
will be able to follow up with neuropsychiatric testing in order
to further evaluate her change in mental status. It should be
noted that during her hospital stay , the patient's level of
interaction with the staff varied. There were days where she was
more conversant and would answer many questions appropriately.
There were also times when the patient refused to speak with
staff , appeared withdrawn and refused medications and treatments.
The son has noted that she was actually better in the hospital ,
appearing more conversant and interactive. It does not appear
that these periods of increased interaction with staff and family
were in any correlation with this patient's hemodialysis.
4. Endocrinology: The patient has type 2 diabetes on insulin at
home. She was maintained on a sliding scale of lispro with
fingersticks blood glucose before every meal and before sleeping.
Her blood sugars were in control and ranged between 110 to 240.
5. Infectious diseases: The patient has had a few low-grade
temperatures to the 100.0. An infectious workup did not yield
any etiology. She has not had an elevation in her white blood
cell count , although this may be a result of her
immunosuppression. Blood cultures from 7/10/04 yielded no
growth. Urine was not cultured , as the patient is anuric.
6. Feeding and electrolytes: The patient was hypercalcemic on
admission. This was attributed to vitamin D per the renal
fellow. Her calcium levels were followed and trended into the
normal range. She was fed a pureed and honey thick diet after
her speech and swallow evaluation indicated that the patient had
intact swallowing function.
7. GI: The patient has a history of peptic ulcer disease , and
she was given Nexium 40 mg orally every day.
DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day , Imuran 50 mg
orally every day , Colace 100 mg orally twice a day , heparin 5000 units
subcutaneously three times a day , prednisone 5 mg orally every day , simvastatin 40
mg orally every day , Imdur sustained release 30 mg orally every day ,
Nephrocaps one tablet every day , sliding scale of lispro insulin ,
rapamycin 8 mg orally every day , Cartia XT 240 mg orally every day , and
Toprol XL 300 mg orally every day.
The patient was discharged to a Rehabilitation Center in stable
condition. She is to follow up with vascular surgery for a new
access for hemodialysis. It is hoped that she will follow up
with neuropsychiatric testing in order to further evaluate her
subacute change in mental status. The patient has three sons
that are very involved in her care. One of her sons is named
Adelaida Tylor , and his phone number is 628-128-5920.
eScription document: 0-9073313 ISSten Tel
Dictated By: YEAGLEY , MA
Attending: MANKOSKI , ROSSIE
Dictation ID 3161486
D: 10/11/04
T: 11/28/04
Document id: 1043
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987200965 | PUO | 16588109 | | 803591 | 3/11/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/11/1991 Report Status: Signed
Discharge Date: 7/30/1992
DIAGNOSES: STATUS POST CARDIAC TRANSPLANT ON 26 of August
AORTIC DISSECTION.
NON-INSULIN-DEPENDENT DIABETES MELLITUS.
HISTORY OF TOBACCO ABUSE IN THE PAST.
HEPATITIS-C ANTIBODY POSITIVE.
HISTORY OF PRESENT ILLNESS: The patient was a 51 year old
gentleman with a history of coronary
artery disease with myocardial infarction in 1977 , status post
coronary artery bypass grafting in 1977 , and myocardial infarction
in 1985 , with redo coronary artery bypass grafting at C Enwiram Memorial Hospital , complicated by cardiogenic shock , treated with an
intra-aortic balloon pump in 1985. Since 24 of November , the patient
reported recurrent congestive heart failure with chest pain and a
variable bundle branch block requiring pacer placement with a DDD
pacer in 1990. He had an electrophysiologic study at the time ,
which was negative for ventricular tachycardia. In 1 of January , the
patient reported to Put Wathern Hospital with severe congestive heart
failure and was transferred to Pagham University Of after
treatment for transplant evaluation. At Pagham University Of on 3 of March , the patient's work-up included an exercise
tolerance test with oxygen uptake of 11.1 milliliters per kilogram
per minute , and a cardiac catheterization showing an essentially
open left internal mammary artery with saphenous vein grafts and
occluded native vessels. The right atrial pressure was 10 ,
pulmonary artery pressure 54/28/30 , pulmonary capillary wedge
pressure 36 , cardiac output 3.6 , cardiac index 2 , PVR 44 , SVR 1440.
The echocardiogram revealed severely decreased ejection of around
15% with 2+ mitral regurgitation. Other issues included a positive
tobacco history in the past with a moderately decreased FEV-1 of
2.2 , and also hepatitis-C antibody positivity. The patient went
home after evaluation for 2 weeks and did well without fever or
chills. He did have some constipation. For 2 days , he had some
increased cough when lying down similar to his previous congestive
heart failure. The patient was readmitted on the night prior to
transplantation on 9 of September , for increasing congestive heart
failure and Dobutamine treatment. PAST MEDICAL HISTORY was as
stated above. ALLERGIES were no known drug allergies. SOCIAL
HISTORY revealed a 25-pack-year history of tobacco , none since
1977. He has 4 children , married. MEDICATIONS ON ADMISSION on
transfer included digoxin .25 milligrams by mouth each day , Pepcid
20 milligrams by mouth twice a day , captopril 25 milligrams by
mouth 3 times a day , Lasix 80 milligrams by mouth twice a day ,
Ecotrin 1 by mouth each day , Coumadin , Dobutamine drip.
PHYSICAL EXAMINATION: The patient was a somewhat cachectic male ,
comfortable with oxygen. Head , eyes , ears ,
nose and throat examination was benign. Neck was supple without
adenopathy. Lungs were clear at the tops with bibasilar crackles.
Cardiovascular examination was notable for S1 , S2 and S3 , no S4 ,
murmur or rub. Abdominal examination was benign. Extremities
showed no edema. Rectal examination revealed guaiac negative
stool , no mass.
LABORATORY EXAMINATION: At the time of admission , laboratory
values were essentially normal , except for
hyperglycemia , mildly increased liver function tests and creatinine
1.1. On admission , blood urea nitrogen was 18 , creatinine .9 ,
glucose 176 , sodium 137 , potassium 4.1 , prothrombin time 13.1 ,
partial thromboplastin time 29 , calcium 8.5 , albumin 3.7 , magnesium
2 , ALT 17 , alkaline phosphatase 155 , total bilirubin 1.1.
Urinalysis was negative. Hematocrit was 38.8 , platelets 199 , 000 ,
white blood cell count 8.3. The electrocardiogram revealed AV
pacing at 90. Chest x-ray showed cardiomegaly with a pacer with
the wires in the right ventricle. An echocardiogram obtained prior
to transplantation revealed right atrial pressure 10 , pulmonary
artery 54/28/38 , pulmonary capillary wedge pressure 36 , cardiac
output 3.6 , cardiac index 2 , PVR 44 , SVR 1440 , ejection fraction
15% , 2+ mitral regurgitation.
HOSPITAL COURSE: The patient was taken to the operating room on
15 of November , and received an orthotopic heart
transplant. This was complicated by a descending aortic dissection
from the iliac to the left subclavian vein secondary to femoral
catheterization , because the patient had had 2 previous bypasses
and would not have tolerated aortic bypass. The patient did well
postoperatively and was placed on Cyclosporine-A and prednisone.
The patient was weaned off the ventilator and Dobutamine and
diuresed without difficulty. Of note , one of the two preoperative
blood cultures grew out Clostridium perfringens. Three subsequent
blood cultures were negative , however. An Infectious Disease
Service consultation was obtained , and it was felt that intravenous
penicillin for 10 to 14 days , 30 million units every 4 hours , would
be warranted given the patient's underlying immunosuppression. The
patient underwent right ventricular biopsies according to the
protocol , and there was no evidence of rejection on any biopsies.
The patient underwent magnetic resonance imaging evaluation of the
aortic dissection on 11 of February , and then follow-up on 10 of March These
revealed a type-B dissection from the left iliac to the subclavian.
The ascending aorta was not involved. There was flow in both the
true and false lumen on both tests. The renal , SMA and ciliac
arteries were all intact. An echocardiogram on 11 of February , revealed
good left ventricular function , a small amount of mitral
regurgitation , some increased pulmonary pressures and the
dissection of the aorta. The patient underwent abdominal
computerized tomography scan to rule out any occult source of
abscess which would be responsible for the Clostridium bacteremia ,
as recommended by the gastroenterology consultant. No such source
was found. The patient's blood pressure was initially controlled
with Nifedipine 3 times a day 30 milligrams , until the patient
reached the expected postoperative denervated tachycardia. After
this point , a beta blocker in the form of atenolol 25 milligrams by
mouth each day was added to decrease force on the wall of the
dissection. The patient was transferred to the Cardiology Service
from the Cardiothoracic Surgery Service on 11 of February , and did well.
Adjustments were made in his Cyclosporine dose. He was initially
tried on some NPH insulin for hyperglycemia , but eventually with
the prednisone taper had good blood sugars on Glyburide 2.5
milligrams by mouth each day. The goal was set for the patient's
blood pressure to be kept at all times below 140 , and this was for
the most part achieved. The patient was anemic during admission ,
but postoperatively gradually his red blood cell count increased.
He was started on iron sulfate to assist in his hematologic
recovery. B12 and folate levels were normal despite polys on
stain. The patient's chest tube wounds were cultured during the
postoperative course and grew normal skin flora. They were packed
with wicks as necessary. The left groin lymph area drained clear
fluid and persisted , but had decreased substantially prior to
discharge. The patient was evaluated by the Psychiatry Service for
some features of hypomania on 17 of May They recommended Valium 5
milligrams by mouth 3 times a day to counter the steroid-induced
hypomania. Physical Therapy Service was active in the patient's
ambulation and felt comfortable that the patient would be able to
go home and manage on his own.
DISPOSITION: The patient was discharged to home. COMPLICATIONS
included aortic dissection type B from left iliac to
left subclavian. MEDICATIONS ON DISCHARGE were Cyclosporine-A 250
milligrams by mouth twice a day , Imuran 50 milligrams by mouth each
day , prednisone 25 milligrams by mouth each day , atenolol 75
milligrams by mouth each day , Glyburide 2.5 milligrams by mouth
each day , Nifedipine 30 milligrams by mouth 4 times a day ,
Septra-Double-Strength 1 by mouth every other day , Nystatin 15 cc
by mouth 4 times a day , iron sulfate 325 milligrams by mouth 3
times a day , Valium 2.5 milligrams by mouth 3 times a day.
CONDITION ON DISCHARGE was stable. The patient was to follow a
low-saturated fat , low-cholesterol , no-added-salt diet. He will
advance his activity as tolerated. The patient was to have a
visiting nurse daily until he feels comfortable with his own care.
The visiting nurse will assist in wound dressing changes , taking
his finger sticks twice a day , taking his blood pressure and
notifying physicians for blood pressure greater than 140. They
were to check differential blood pressures between right and left
arms. The patient will also receive physical therapy assistance to
continue his progress in ambulation. The patient was to FOLLOW-UP
with the Cardiac Transplant Clinic on 28 of November , for routine
FOLLOW-UP.
WM442/7718
SANTA V. CHOWANEC , M.D. OX2 D: 5/22/92
Batch: 4984 Report: S4135Z6 T: 8/28/92
Dictated By: ERVIN P. DERINGER , M.D.
cc: 1. SACHIKO S. BORRIELLO , M.D.
2. ISABELLE COLASAMTE , M.D.
Document id: 1044
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CHF |
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DM |
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968582732 | PUO | 04239054 | | 8340812 | 10/30/2007 12:00:00 a.m. | renal failure , supraventricular tachycardia , hypocalcemia | | DIS | Admission Date: 3/13/2007 Report Status:
Discharge Date: 8/17/2007
****** FINAL DISCHARGE ORDERS ******
HUGUELEY , TRENT 180-76-24-2
Stock Monttempeford Son
Service: MED
DISCHARGE PATIENT ON: 10/10/07 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TROJAN , LUISE R. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally every day
2. ALBUTEROL INHALER HFA 2 PUFF inhaled every 6 hours
3. CALCITRIOL 1.5 MCG orally every day
4. CALCIUM ACETATE ( 1 GELCAP=667 MG ) 1334 MG orally three times a day
5. ERGOCALCIFEROL 50000 UNITS orally QWEEK
6. FERROUS SULFATE 325 MG orally three times a day
7. FUROSEMIDE 40 MG orally every day
8. METOPROLOL SUCCINATE EXTENDED RELEASE 100 MG orally every day
9. SODIUM BICARBONATE 1300 MG orally twice a day
10. EPOETIN ALFA 10 , 000 UNITS subcutaneously QWEEK
11. LISINOPRIL 40 MG orally every day
12. AMLODIPINE 5 MG orally every day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting IN a.m. ( 4/11 )
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
NORVASC ( AMLODIPINE ) 5 MG orally DAILY
Starting IN a.m. ( 4/11 ) Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CALCITRIOL 2 MCG orally twice a day Starting IN a.m. ( 7/1 )
PHOSLO ( CALCIUM ACETATE ( 1 GELCAP=667 MG ) )
1 , 334 MG orally before meals Instructions: give with meals
Number of Doses Required ( approximate ): 6
CALCIUM CITRATE 1 , 900 MG orally DAILY
Instructions: give BETWEEN meals
PROCRIT ( NON-ONCOLOGY ) ( EPOETIN ALFA ( NON-ONC... )
10 , 000 UNITS subcutaneously QWEEK
ERGOCALCIFEROL 50 , 000 UNITS orally QWEEK
Instructions: on Wednesday
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
LISINOPRIL 40 MG orally DAILY Starting IN a.m. ( 4/11 )
METOPROLOL SUCCINATE EXTENDED RELEASE 150 MG orally DAILY
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SODIUM BICARBONATE 1 , 300 MG orally twice a day
DIET: Fluid restriction
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Tibolla Wednesday , August 10am ,
ALLERGY: Penicillins , AMPICILLIN , PROCARDIA
ADMIT DIAGNOSIS:
renal failure , tachycardia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
renal failure , supraventricular tachycardia , hypocalcemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Supraventricular tachycardia , Stage 4 chronic kidney disease , gout
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
V/Q scan
ECHO
LENI
CXR
Adenosine for treatment of SVT
BRIEF RESUME OF HOSPITAL COURSE:
RFA: Supraventricular tachycardia , hypocalcemia , renal failure
.
CC: bilateral foot pain , sob , palpitations
HPI: 35 F with CKD intravenous/V ( renal: Kisielewski ) 2/2 minimal change dz
was in USOH until 6 days PTA when developed bilateral foot pain
typical of gout flare. 5 days PTA developed SOB and heart racing
which was constant. Attributed sx to prednisone and stopped
prednisone 3 days PTA. Yet SOB and sensation of rapid heart rhythm
continued. She had never had the sensation before and has no history of
tachyarrhythmia. On DOA , she came to ED for evalulation of her bilateral
gouty foot pain and was found to be tachycardic to 150 bpm. EKG notable
for narrow complex tachycardia ( SVT/likely AVNRT. )
. IN ED: given adenosine 6 mg intravenous x 1 with conversion to NSR for less
than a minutes , and then reversion back to SVT. She responded to
additional adenosine 12 mg intravenous x 1 and reverted to SR for the remainder of
her hospital stay.
PMH: CKD intravenous/V 2/2 minimal change dz with left UE AVF in prep for
likely future HD , gout , sickle cell trait , anemia , HTN , history of PE history of
coumadin , morbid obesity
ALLERGIES: PCN , ampicillin->hives. Procardia->h/a .
ADMIT EXAM: Afeb , heart rate 80 ( post conversion with adenosine ) BP 118/80. 100% 2l
NC. JVP +8cm. lungs clear. +transmitted bruit from LUE AVF heard
throughout precordium. LUE AVF with strong bruit and thrill. abd benign.
Tr le edema at ankles.
.
NOTABLE ADMIT LABS: BUN 80 , Cr 11.0 ( up from 8 ) INR 1.2 WBC 12.7 ( N77 ,
L17 ) , HCT 26.6 ( bl 25-28 ) , plt 244 cardiac: troponin<assay , CK-MB 2.3 ,
CK335. Calcium 6.0 , iCa 0.79 , Mg 1.6. phos 5.4. PTH 914 ( up from 861 in
10/24 )
.
STUDIES: echo: no rv strain. EF 40%. +diastolic dysfxn. LV
d.6.30cm ( mild-mod enlarge ) , mild RAE , LAE , RV enlargement.no pericardial
effusion. Echo is significantly changed from prior 11/21 when
EF was 55-60% and no LVH.
cxr: cardiomegaly
ekg 10/22 QTC=.504
V/Q scan: No perfusion defect. low probability
.
35F with history of CKD intravenous/V 2/2 minimal change dz who presents with 6 days of
DOE , heart racing shortly after starting prednisone for bilateral foot
pain 2/2 gout. Found to be in SVT with rate to 150 bpm. Initially ,
high suspicion of PE , given history of PE , evolution of pleuritic chest pain ,
and SVT. LENI's were negative. She was empirically started on heparin
intravenous. Yet on HD2 , she had a V/Q scan with NO perfusion defect and heparin
was discontinued. The precipitating event leading to SVT was not
determined. No PE or evidence of ischemic event. However , she had
multiple metabolic derangements , especially hyocalcemia ( Ca 6.0 , iCa
0.79 , Mg. 1.6 ) as well as evidence worsening structural heart disease and
evolving cardiomyopathy. Her SVT resolved after adenosine 12 mg intravenous x 1
and she remained in SR during the rest of hospital stay. ECHO showed EF
40% , diastolic dysfunction and LVH likely 2/2 longstanding HTN. This
was a change from ECHO in 2002 when she had nl EF 60% , no e/o diastolic
dysfunction and no ventricular enlargement. The cause of her new
cardiomyopathy is possibly HTN and concern raised for high-output state
due increase flow thru AV fistula. We discussed the case briefly with
the vascular surg service. There is no definitive test to determine if
flow throught the aVF is too great. This may need to be discussed between
her primary renal doctors and vascular.
.
HYPOCALCEMIA: VitD level pending , PTH dramatically elevated at 914. Noted
to have elevated QTc of QTC 504 msec in setting hypocalcemia. Calcitriol
was increased and calcium citrate was initiated. Calcium was also
repleted with calcium gluconate boluses and magnesium supplementation.
Ionized calcium was followed. She is being discharged home on Calcium
citrate twice a day , calcitriol 2mcg every day , and prior dose of ergocalciferol.
.
CODE: FULL
ADDITIONAL COMMENTS: You were admitted after experiencing a rapid heart rhythm that normalized
after treatment with medicine. There is no clear explanation for why you
went into this abnormal rhythm , there are a few possibilities. These
include disturbances in your electrolytes , such as very low calcium , as
low as changes in your heart from high blood pressure and fluid
retention. You did not have a clot to your lungs or in your legs. You
were started on calcium supplements ( calcium citrate ) , calcitriol dose
was increased. Metoprolol dose was increased to treat your high blood
pressure.
.
KEY MEDICINE CHANGES:
1. Increase metoprolol dose
2. Increase calcitriol dose
3. Start calcium citrate: takes this medicine BETWEEN meals , as it will
be less effective if taken with meals.
4. It is important that you take all prescribed medicines to keep your
heart healthy and to make sure your electrolytes and calcium stay in
acceptable limits. If you have problems filling your medicines , please
notifiy your primary or renal doctors.
.
Contact a physician or return to the emergency room if you develop
recurrent shortness of breath , chest pain , sensation of rapid heart
rhythm that does not go away after a few minutes or comes on with
breathing problems or chest pain.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check metabolic panel , including calcium.
2. F/u on vitamin D level ( pending at d/c )
3. Check BP on elevated dose metoprolol ER
No dictated summary
ENTERED BY: YEAGLEY , MA , M.D. ( VE850 ) 10/10/07 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1045
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Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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OSA |
PVD |
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294342874 | PUO | 13596362 | | 493717 | 7/20/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/24/1996 Report Status: Signed
Discharge Date: 4/30/1996
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE STATUS POST CORONARY
ARTERY BYPASS GRAFT , RIGHT SIDED CAROTID
ENDARTERECTOMY , AND POST-OPERATIVE ATRIAL
FIBRILLATION.
HISTORY OF PRESENT ILLNESS: Patient was admitted March , 1996
with a history of one to two months of
stable exertional angina which became crescendo angina and an
exercise stress test , thallium , revealed multivessel disease.
PAST MEDICAL/SURGICAL HISTORY: Significant for coronary artery
bypass grafting on March ,
1996 , right carotid endarterectomy on March , 1996 , he had some
post-operative atrial fibrillation/flutter as above , he was status
post a myocardial infarction , he had a history of hypertension ,
insulin dependent diabetes times three years , and gout.
ALLERGIES: He had no known drug allergies.
SOCIAL HISTORY: Included an eight pack year tobacco history which
he quit approximately thirty years ago and he
drank alcohol socially.
FAMILY HISTORY: Negative for coronary artery disease and
questionable for diabetes mellitus.
PHYSICAL EXAMINATION: He was a well-developed , well-nourished
white man in no apparent distress. On
transfer to Medicine , his vital signs were a temperature of 98.8 ,
heart rate of 140 in atrial flutter , blood pressure 150/70 , and
breathing at 18 with a room air saturation of 94%. HEENT:
Examination showed his extraocular muscles intact , pupils equal ,
round , and reactive to light , his right carotid endarterectomy had
Steri-Strips , his left carotid pulse was 2+ without bruit , he had
no lymphadenopathy , and his oropharynx was benign. LUNGS: Clear
bilaterally. CARDIAC: Examination revealed a regular rate and
rhythm and he was tachycardic without a murmur. ABDOMEN:
Examination showed that bowel sounds were present and it was
benign. EXTREMITIES: Examination showed no clubbing , cyanosis , or
edema , posterior tibial pulses were 2+/2+ , and his dorsalis pedis
pulses were trace bilaterally. NEUROLOGICAL: Examination showed
that he was alert and oriented times three and grossly non-focal.
LABORATORY EXAMINATION: Significant for a normal SMA 7 , CBC which
had a white count of 3.7 , a hematocrit of
33.8 with 407 platelets , a sedimentation rate was 48 , his digoxin
level on transfer was 1.3 , his procainamide level was 2.6 , and his
NAPA was 1.1 on transfer. An EKG showed atrial flutter at 140.
HOSPITAL COURSE: He underwent cardiac catheterization on July , 1996 which revealed a left dominant system
with left anterior descending with serial 60% complex lesions , mid
left anterior descending 70% lesion , and a ramus 40% lesion. The
left circumflex was totally occluded proximally and the right
coronary artery was small with an 80% mid vessel stenosis. Left
ventriculogram revealed normal systolic function. On November ,
1996 , he underwent a coronary artery bypass graft surgery with a
LIMA to his left anterior descending , saphenous vein graft to his
OM1 , and a saphenous vein graft to his OM2. On May , 1996 ,
he developed atrial fibrillation with a rate in the 180 range ,
blood pressure 160/90 , he complained of palpitations , and was
diaphoretic. He received Lopressor 5 mg intravenously times two ,
his blood pressure responded with decrease to 120/72 , and his heart
rate remained in the 140 range with atrial fibrillation. He
converted to normal sinus rhythm in the eighties. He was loaded
with Digoxin and maintained on Lopressor 50 mg orally twice a day That
evening , he had a second episode of atrial fibrillation. On
March , 1996 , he underwent right carotid endarterectomy for an
asymptomatic 90% stenosis. In the PACU , he had atrial fibrillation
in the 150 range with decreased blood pressure to the seventies.
On March , 1996 , he had another episode of atrial fibrillation
lasting approximately thirty minutes which converted to normal
sinus rhythm with 5 mg of Lopressor. On January , 1996 , he
converted into atrial fibrillation at approximately 4 a.m. and his
blood pressure was 160/100 , his heart rate was approximately in the
130 range , and carotid sinus pressure produced no change in his
rate. An ECG revealed a supraventricular tachycardia at 130 beats
per minute , likely atrial flutter , with 2:1 conduction. Verapamil
5 mg every 5 minutes times two intravenously resulted in a heart rate
drop from 120 to 70 which revealed atrial flutter. At this point ,
he was transferred to Medicine for further management. His
medications on transfer included magnesium and potassium sliding
scale , Axid 150 orally twice a day , enteric coated aspirin 325 mg orally
every day , Digoxin 0.25 mg orally every day , Percocet one to two tablets
as needed , Zocor 20 mg orally every bedtime , Colace 100 mg orally three times a day ,
Lopressor 50 mg orally twice a day , insulin sliding scale , Benadryl
as needed , Lasix 20 mg orally every day , Lisinopril 10 mg orally every day , Procan
SR 500 mg orally four times a day started on March , 1996 , and Metamucil
as needed Post-transfer , he was maintained on his cardiac regimen
overnight. He remained in atrial flutter throughout the night , was
slight diaphoretic but had no other associated symptoms. He was
cardioverted electrically on November , 1996 into normal sinus
rhythm with a heart rate in the seventies to nineties.
DISPOSITION: He is discharged on September , 1996 after
cardioversion in stable condition.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Lisinopril 20 mg orally every day , Lopressor 50 mg
orally twice a day , Percocet one to two tablets every 3-4h. as needed , Procan SR
750 mg orally four times a day , and Zocor 20 mg orally every bedtime
FOLLOW-UP: He has follow-up appointments with Dr. Myerscough
Dictated By: FLO VERSIE TITTERNESS , M.D. JT55
Attending: CHRISTINE DARIO , M.D. AW87
WS783/3101
Batch: 98826 Index No. DEAJVF1DVX D: 1/12/96
T: 3/7/96
Document id: 1046
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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441741320 | PUO | 35049600 | | 889750 | 8/14/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/17/1996 Report Status: Signed
Discharge Date: 11/12/1996
PRINCIPAL DIAGNOSIS: RULE OUT CORONARY ARTERY DISEASE.
IDENTIFICATION: This is a 63 year old gentleman with diabetes
mellitus and peripheral vascular disease who was
transferred Osri Medical Center after he had a positive
Persantine-Thallium test preoperatively for vascular surgery
procedure. The patient was transferred for cardiac
catheterization.
HISTORY OF PRESENT ILLNESS: Cardiac risk factors: Diabetes ,
history of smoking , hypertension ,
hypercholesterolemia , positive family history.
This 63 year old gentleman is disabled as a consequence of cardiac
and peripheral vascular disease. The patient was transferred to
Osri Medical Center from a Cock Dia Medical Center on 29 of January for management of
cellulitis and ulceration on the anterior tibial area on the left.
The patient was placed on antibiotics and noninvasive lower
extremity demonstrated significant aorto-iliac and occlusive
disease. The patient was started on intravenous heparin and antibiotics
with moderate improvement in the cellulitis. The patient's
metformin was discontinued and plans were made for aorto-bi-fem
angiography. However , the patient had a cardiology work-up
including echo and Persantine-Thallium which demonstrated
significant coronary ischemia. As a result , the patient was
transferred to Pagham University Of for further evaluation
of his cardiac disease and for cardiac catheterization.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes mellitus for
12 to 15 years with consequence of diabetic
neuropathy and diabetic retinopathy. History of incontinence ,
status post bilateral carotid endarterectomy left in 1991 , right in
1995 after TIAs revealed amaurosis fugax. Status post ulnar nerve
transplant. Status post cholecystectomy in 1981 , Status post
laser for diabetic retinopathy. Hypothyroidism. Status post
removal of ganglion cyst of the left ankle.
MEDICATIONS: Metoprolol 50 mg twice a day , Synthroid 0.125 mg every day
Glyburide 5 mg twice a day , Isosorbide 10 mg three times a day ,
Percocet 1-2 tabs orally as needed , Ativan , Zoosyn , Pravastatin 20 mg
orally every day , Diltiazem 150 mg orally twice a day
SOCIAL HISTORY: The patient is a disabled man , used to work in
pulling business , lives alone , divorced and has
five children , ages 27 to 40. Tobacco use - 2 and 1/2 to 3 packs
per day times 25 to 30 years. No significant alcohol use.
FAMILY HISTORY: Mother died at age 55 from schizophrenia and
catatonia. Father age 57 from myocardial
infarction.
REVIEW OF SYSTEMS: The patient has had impotence times 10 years.
Post prandial fullness times several years.
Rest pain and unable to walk more than 10 feet because of the
severe lower extremity pain.
PHYSICAL EXAMINATION: The patient was an anxious man lying in his
bed. Vitals - T 99.2 , heart rate 82 , blood
pressure 128/70 , respiratory rate 20. Oxygen saturation was 94% on
room air. HEENT: Significant for bilateral carotid bruits. Lungs
were clear to auscultation. Cardiovascular - Regular rate and
rhythm. Abdomen - Positive bowel sounds , nondistended , nontender.
Extremities - The patient had bilateral femoral bruits. No
palpable pedal pulses. Nonhealing intertibial ulcer. However , the
patient had no cyanosis.
LABORATORY DATA: Sodium 141 , potassium 4.5 , chloride 102 , CO2 28 ,
creatinine of 1.1 , BUN 13 , glucose 139 , WBC 9.1.
Hematocrit 39.3 , platelets of 219 , physical therapy 12.1 , PTT 28.4 , INR 1.0 , ABI
from Osri Medical Center - right DP was 0.44 , physical therapy 0.21 , left DP
0.51 , physical therapy 0.44.
HOSPITAL COURSE: The patient was admitted for cardiac work-up.
Since the patient had received a week of intravenous
antibiotics , the cellulitis seemed to have resolved. The Zoosyn
was stopped. The patient's cardiac medications were continued.
The patient had a cardiac catheterization on 15 of July which revealed
60% RCA , 50% lad , 60 to 70% D-1 and 100% distal left circumflex
lesion with an ejection fraction of 55%. Thus coronary artery
disease would not need revascularization prior to peripheral
vascular surgery.
As a result , the patient will be transferred to Osri Medical Center for vascular surgical procedure. The patient was strongly
advised against smoking , however , he continued to smoke frequently
throughout the hospitalization course.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Dulcolax 10 mg orally every day , Diltiazem SR 150
mg orally twice a day , Colace 100 mg orally twice a day , glyburide 5 mg orally
twice a day , insulin sliding scale , Synthroid 125 mcg orally every day ,
metoprolol 50 mg orally twice a day , nitroglycerin sublingual 1/150 as needed , Serax
15 to 30 mg orally every bedtime , Percocet 1-2 tabs orally every 4 hours as needed leg
pain , pravastatin 20 mg orally every day
CONDITION ON DISCHARGE: Good.
Dictated By: NORMAND SIGLIN , M.D. BQ9
Attending: SHAVONNE D. MAINER , M.D. QP3
AZ935/4611
Batch: 8132 Index No. NKFLDG1LF2 D: 7/24/96
T: 7/24/96
CC: 1. OSRI MEDICAL CENTER
Document id: 1047
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499285760 | PUO | 69475676 | | 5849355 | 1/26/2007 12:00:00 a.m. | UNSTABLE ANGINA | Signed | DIS | Admission Date: 6/11/2007 Report Status: Signed
Discharge Date: 5/28/2007
ATTENDING: KERTESZ , ALETA M.D.
DISCHARGE DIAGNOSIS: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
gentleman with a past medical history significant for
NIDDM and hypertension. He was transferred from an outside hospital after
presenting there with sudden onset of substernal
chest pain radiating to his neck and jaw and associated with
shortness of breath. The patient denied having nausea , vomiting
or diaphoresis. In the ambulance he was given three sprays of
nitroglycerin and his pain improved. In the Emergency
Department , he was noted to have a blood pressure of 200/100 ,
however had no ischemic ST changes on his EKG. His initial
troponin was less than 0.04. He was admitted to that hospital
CCU where he was started on an intravenous nitroglycerin drip and heparin
drip. The following day , his troponin had risen to 0.3 and he
had small ST elevations in his aVF. He was loaded with Plavix
and started on intravenous Integrilin and was transferred to Pagham University Of for catheterization and further treatment.
PAST MEDICAL HISTORY: Hypertension , peripheral vascular disease
with 3.5 cm abdominal aortic aneurysm , diabetes mellitus treated
with orally agents at home , hypercholesterolemia and COPD with
bronchodilator therapy.
PAST SURGICAL HISTORY: None.
FAMILY HISTORY: Significant for coronary artery disease. The
patient's father had a myocardial infarction at age 72. The
patient's son died of spontaneous DVT/PE at age 32.
SOCIAL HISTORY: A 24-pack-year history of cigarette smoking.
The patient quit smoking 30 years ago.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS: Toprol-XL 100 mg daily , Diovan 320 mg
daily , hydrochlorothiazide 12.5 mg daily , metformin , aspirin 325
mg daily and Pulmicort twp puffs twice a day
PHYSICAL EXAMINATION: Height 5 feet 10 inches , weight 107 kg.
Vital signs , temperature 97.3 degrees , heart rate 78 , blood
pressure 130/80 , O2 saturation 97% on room air. HEENT: PERRLA ,
dentition without evidence of infection , no carotid bruits.
Chest: No incisions. Cardiovascular: Regular rate and rhythm ,
no murmurs. Respiratory: Breath sounds clear bilaterally.
Abdomen: Soft , no masses. Extremities , without scarring ,
varicosities or edema. Neuro: Alert and oriented , no focal
deficits. Pulses 2+ bilaterally at carotids , radials , femorals
and PTs. 1+ bilaterally at DPs. Allen's test of the right and
left upper extremities were both normal.
PREOPERATIVE LABS: Sodium 137 , potassium 4.3 , chloride 102 ,
bicarbonate 25 , BUN 14 , creatinine 1 , glucose 173 , magnesium 1.8 ,
white blood cell count 10 , hematocrit 41.2 , hemoglobin 14.3 ,
platelets 236. physical therapy 14.5 , INR 1.1 , PTT 32.3. Preoperative
urinalysis was normal. Cardiac catheterization performed on
10/27/07 at Pagham University Of showed stenoses in the
following coronary arteries: 70% proximal circumflex , 90% ostial
ramus , 90% proximal D1 , 90% proximal LAD and 100% ostial RCA.
There was right dominant circulation and the ventriculogram
showed 56% ejection fraction with inferior hypokinesis. EKG on
10/27/07 showed normal sinus rhythm with a heart rate of 71.
There are Q waves in leads III and aVF and inverted T waves in
leads I , III , aVR , aVL and V1 through V4. Chest x-ray on
10/27/07 shows clear lungs with mild cardiomegaly and a stable
elevation of the right hemidiaphragm.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization on 10/2/07. He was found to have critical
coronary artery disease and was referred to the Cardiac Surgery
Service. The patient underwent a completion of a preoperative
workup and on 9/5/07 went to the operating room where Dr.
Kertesz performed a CABG x5. The LIMA was used to bypass the LAD ,
the left radial artery was used to bypass the ramus , and
saphenous vein was used to bypass the OM1 , PDA and LVB1. The
cardiopulmonary bypass time was 145 minutes and the aortic
cross-clamp time was 116 minutes. The patient tolerated the
procedure well and was transferred to the Cardiac Surgery
Intensive Care Unit in hemodynamically stable condition. On
postoperative day #1 , the patient was extubated. He complained of
right hand weakness and numbness but was otherwise recovering
very well. The Neurology Service was consulted and they suggested
that the right hand symptoms were from surgical manipulation of
the chest or positioning of the arm intraoperatively.
Occupational therapy and physical therapy were consulted to treat
the patient's right hand weakness and numbness. Otherwise , the
patient was progressing very well. He was started on Lopressor
to prevent atrial fibrillation and diltiazem for his radial
artery bypass graft. He was off all hemodynamic drips and was in
a stable rhythm with a stable blood pressure. The patient's diet
was advanced as tolerated and he was producing good urine output.
The patient was followed very closely throughout the
postoperative period by the Diabetes Management Service for high
glucose levels. On postoperative day #2 , the patient's pacer
wires and chest tubes were removed without complication. He was
ambulating and showed good postoperative progress. On
postoperative days 3 and 4 , the patient continued diuresis for
postoperative fluid retention. The patient's white blood cell
count was noted to be 13.7 and a urinalysis and urine culture
were sent. The urine culture grew greater than 100 , 000 colony
forming units of gram-negative rods and he was started on
ciprofloxacin for five-day course for postoperative urinary tract
infection. Otherwise , by postoperative #5 the patient had
progressed extremely well. He was ambulating in the halls. He
had moved his bowels and had no difficulties with urination.
He had no complaints of pain. He had remained in a sinus rhythm
with a stable blood pressure and was oxygenating well on room
air. The patient was ready for discharge home. The Diabetes
Management Service met with the patient to discuss taking insulin
at home for his poor glucose control. He agreed to take Lantus
at night and follow up with his primary care physician for future
management of his diabetes mellitus. On the morning of discharge
home , the patient's vital signs were temperature 97.7 degrees ,
heart rate 86 in the sinus rhythm , blood pressure 110/70 ,
respiratory rate 20 and O2 saturation 95% on room air. The
patient was still 5 kg above his preoperative weight and should
continue Lasix for five more days , once he is discharged home.
LABORATORY DATA: Labs on the day of discharge home. Sodium 136 ,
potassium 4.6 , chloride 102 , bicarbonate 25 , creatinine 1 , BUN
23 , glucose 165 , calcium 8.2 , magnesium 2 , white blood cell count
10.6 , hemoglobin 10.5 , hematocrit 30.3 , platelets 279 , physical therapy 15.2 ,
INR 1.2.
DISCHARGE CONDITION: Stable.
DISPOSITION: Discharged home with VNA Services.
DISCHARGE DIET: A low-cholesterol , low-saturated fat , 2100
calorie per day ADA diet.
ACTIVITY: The patient should be walking as tolerated and elevate
his feet with prolonged periods of sitting. The patient should
arrange followup appointments with his cardiologist Dr. Suriano ,
at 068-531-3966 in one to two weeks , with his primary care
physician , Dr. Bending at 241-103-7858 in two to four weeks and
with his cardiac surgeon , Dr. Aleta Kertesz at 117-219-4079 in four
to six weeks.
DISCHARGE MEDICATIONS: Acetaminophen 325 mg take one to two
tablets every four hours as needed for pain , enteric-coated
aspirin 325 mg daily , Pulmicort inhaler two puffs inhaled twice a day ,
ciprofloxacin 500 mg orally every 12 hours , take 9 more doses to complete
a five-day course for postoperative urinary tract infection ,
diltiazem 15 mg orally three times a day for six weeks for the radial artery
bypass graft , Lasix 60 mg daily x5 more doses for postoperative
fluid retention , glipizide 5 mg orally every day before noon , Motrin 600 mg orally
every 6 hours as needed pain , Lantus 44 units subcutaneously every 10 hours p.m. ,
potassium chloride slow release 30 mEq orally daily x5 doses to be
taken with Lasix , Toprol-XL 100 mg orally daily , oxycodone 5 mg
orally every 4 hours as needed pain , Zocor 40 mg orally daily , Diovan 320 mg
orally daily.
ADDITIONAL COMMENTS: As indicated , the patient should take Lasix
for five more days for postoperative fluid retention. The
patient should be weighed daily and the physician should be
contacted if the patient's weight , peripheral edema or work of
breathing is measurably increasing. The patient should complete
his course of ciprofloxacin for postoperative UTI. The patient's
vital signs should be monitored by the visiting nurses. In
addition his wound should be monitored for signs or symptoms of
infection. The patient was started on insulin and should follow
up with his primary care physician for future management of his
diabetes mellitus. He should be checking and documenting his
blood glucose levels with his home glucometer.
eScription document: 0-6890767 CSSten Tel
CC: Aleta Kertesz M.D.
Division of Cardiac Surgery
Pagham University Of , I
Roche Ineetteingette
CC: Kori Suriano M.D.
Rah Dibarl General Health
Ton- H
Angelesre
CC: Elfrieda Winzer M.D.
Che S Virg
Cin Bi
Ostonsing Cam Ly , NM
Dictated By: MUMMA , MARYLOU
Attending: KERTESZ , ALETA
Dictation ID 2397964
D: 2/2/07
T: 2/2/07
Document id: 1048
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HTG |
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| output/system_textual_annotation.xml | textual |
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838440387 | PUO | 59556390 | | 4823857 | 1/22/2006 12:00:00 a.m. | chest pain | Unsigned | DIS | Admission Date: 1/22/2006 Report Status: Unsigned
Discharge Date: 2/9/2007
ATTENDING: CADOFF , LINDY MD
CHIEF COMPLAINT: Dizziness , weakness and chest pressure.
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female with a
prior history of hypertension , diabetes , coronary disease status
post CABG and angio interventions. She was in her usual state of
health until returning from the bathroom at 1 a.m. on the day of
admission when she felt weak. She describes the sensation as if
she was going to die. She had a burning sensation in her mid
sternum and upper abdominal pain and also felt lightheaded. The
patient describes the pain is worse when lying flat and
associated with mild shortness of breath and intermittent nausea
without vomiting. She denies radiation of the pain.
Of note , the patient has had many recent HTN episodes in the
with associated lightheadedness
prompting many visits to the Norap Valley Hospital Emergency Room. She was admitted about one to two weeks ago to
the Norap Valley Hospital for similar complaints with hypertensive
urgency. Her blood pressure medications were adjusted. She had
a negative cardiac workup.
REVIEW OF SYSTEMS: The patient denies cough , cold symptoms ,
fevers , chills , weight changes , changes in vision , numbness ,
diarrhea , melena or urinary symptoms. She reports her dry weight
of 152 pounds. Fingerstick blood sugars per the patient on
report had been in the low 100s recently and she had been
complaint with all her medications.
PAST MEDICAL HISTORY: Hypertension , diabetes , coronary disease ,
CABG x2 with redo sternotomy both in the 1970s and 1990s ,
peripheral artery disease , renal artery stenosis , status post
left renal stent , paroxysmal atrial fibrillation , right carotid
endarterectomy.
HOME MEDICATIONS: Aspirin 325 mg daily , Plavix 75 mg daily ,
glyburide 1.25 mg daily , Lasix 20 mg daily , Toprol XL 50 mg
daily , Lisinopril 15 mg twice a day ( recently increased to this dose
while at during her last admission to the P Therford Hospital ) and Lipitor
80 mg daily.
ALLERGIES: Penicillin which causes rash.
FAMILY HISTORY: Identified as noncontributory.
SOCIAL HISTORY: The patient is a retired nurse who had worked in
Put Wathern Hospital . She lives with her son. She has four children
who are alive and well and living in the area. She has a remote
smoking history. She denies alcohol or illicit drug use.
ADMISSION PHYSICAL EXAMINATION: She is afebrile. Heart rate 59 ,
blood pressure 136/58 , respiratory rate 18 , oxygen saturation
100% on 2 liters. In general , the patient describes as elderly
lying supine in bed , resting comfortably. She is awake , speaking
in full sentences without difficulty. She is in no acute
respiratory distress. HEENT , normocephalic and atraumatic ,
anicteric sclerae , mucous membranes are moist. Neck is supple
without lymphadenopathy. JVP was approximately 7-8 cm. Chest ,
she had bibasilar fine rales with fair aeration throughout. No
rhonchi or wheezes. Cardiovascular , regular rate and rhythm , S1
and S2 with bradycardic rate at 48 beats per minute. Abdomen has
many old healed scars , no rashes , bowel sounds are positive. She
is soft , nondistended , nontender without hepatosplenomegaly.
Extremities are warm and well perfused. No clubbing , cyanosis or
edema. A 2+ dorsalis pedal pulses. Skin is intact without rash.
Neuro , cranial nerves II to XII intact with no focal deficits.
She is alert and oriented x3. Vascular , she has bilateral
femoral bruits which were audible with stethoscope.
ADMISSION LABS: Sodium 140 , potassium 4.5 , chloride 108 , CO2 23 ,
anion gap of 9 , calcium 9 , magnesium 1.8 , total bilirubin 0.7 ,
BNP 165 , cardiac enzymes were not elevated , white count 6.91 ,
hematocrit 35.9 , platelets 227. Urinalysis was within normal
limits. physical therapy 12.1 , PTT 43.2 , INR 1.0. A portable chest x-ray was
without any evidence of acute pulmonary process. EKG with sinus
bradycardia with rate of 55 with T-wave inversions in leads V5
and V6 , leads 1 , 2 and AVF. All present on prior EKG. There
were no acute ST changes.
EMERGENCY ROOM COURSE: Systolic blood pressure was in 190s. She
received aspirin x1 , Lopressor 25 mg orally x1 , Lopressor 5 mg intravenous
x1 , and blood pressure went down to 170s prior to her transfer to
the floor.
HOSPITAL COURSE:
1. Cardiovascular:
Ischemia: The patient ruled out for myocardial infarction by serial enzymes.
Her EKG was abnormal , but unchanged from 1/28 She continued on aspirin ,
Plavix and
Lipitor. Fasting lipids did not indicate need for change in
statin treatment. On 3/1 , the patient had a recurrence of
her chest pain symptoms in the setting of her only hypertensive
event during this admission. Her EKG was notable for new flipped
Ts in leads V3 and V4 ( which happened to be seen previously
during this admission when she had atrial fibrillation with rapid
ventricular response on 6/3 ). The medical team suspects
hypertensive-induced microvascular angina. A repeat rule out MI
has been re-initiated and is currently in progress at the time of
this dictation. A&B set enzymes were negative.
Pump: Echocardiogram at the Norap Valley Hospital on 10/6
revealed normal left ventricle with an EF of 60% , left atrial
enlargement , 1-2+ mitral valve regurgitation , 1+ tricuspid
regurgitation , and mild pulmonary hypertension ( with pulmonary
artery pressure of 43 ). The patient had fine rales on her admit
exam with BNP of 160. Of note , on 10/6 at Norap Valley Hospital the
patient had her Lisinopril increased to 15 mg twice a day to facilitate
better blood pressure control. ACE inhibitor and Lasix were held
during this admission due to arise in her creatinine. Lisinopril was
restarted at a dose reduction of 5 mg twice a day and Lasix was restarted
on 3/1 in the setting of symptomatic chest pain which began while the
patient was receiving a second unit of blood ( see heme below of more
details ). Her BNP following the transfusion was 265. The current plan
is to titrate ACE inhibitor to affect as long as her creatinine
does not climb.
Rhythm: The patient had asymptomatic sinus bradycardia with rates ranging
45-58 until 5/3 when she had an episode of atrial fibrillation with rapid
ventricular response
to 130s to 140s. She was effectively treated with
Lopressor 25mg x1 , 5 mg intravenous x2 , then diltiazem 10 mg x1. The patient later
then converted to sinus rhythm , sinus bradycardia. On 6/8 , the
patient had a 12-22 symptomatic ventricular pause. The consulting
cardiologist ( Dr. Tyacke ) was notified of the atrial
fibrillation and ventricular pause event. Dr. Tyacke
recommended starting an amiodarone load which has been
implemented and is currently in progress. He recommended no
inpatient EP eval this admission because the patient had no
further symptomatic pauses. Dr. Tyacke deferring decision and
arrangements for Holter versus loop monitors to the patient's
outpatient cardiologist Dr. Schweitzerren.
According to the prior cardiac cath reports , the patient should
be on lifelong Plavix. It is Dr. Tyacke 's preference for
the patient to be started on thromboembolic prophylatic Coumadin
( in the setting of paroxysmals of atrial fibrillation ) and to
discontinue the aspirin because of possible bleeding risk on
combination aspirin , Plavix and Coumadin. However , he is
deferring this decision to be made by the patient's outpatient
cardiologist.
Blood Pressure: The cardiologist consultation Dr.
Tyacke felt that the chest pain and hypertension symptoms could
be consistent with recurrence of renal artery stenosis. On
10/27/07 , a Doppler renal ultrasound was notable for significant
re-stenosis of the left renal artery. The patient an
angioplasty and stent was placed without peri-procedure
complication aside from the possibility of small blood loss ( as
will be described in heme section below ).
2. Hematology: The patient has baseline hypoproliferative
normocytic normochromic anemia of chronic disease identified by
iron studies. Her B12 and folate levels were within normal
limits. On 11/8 , the patient had a hematocrit drop from
30-26 , but this was considered to be either a lab variant or due
to blood loss in her subcutaneous tissue from previous Lovenox
injections. Lovenox was discontinued and the team decided to use
TEDs alone for DVT prophylaxis as the patient was ambulatory. On
10/28 , one day post-angio intervention , the patient was complaining of
lethargy. She had a post-procedure crit drop from 30-25 which the
repeat study was stable at 25. Her hemodynamics
was also stable as was her leg exam. The Angiography Team
advised that the hematocrit drop could be as result of blood loss
from recent angio intervention. The Angio Team advised that
there will be no need to pursue imaging to search for source
of blood loss unless the patient has further hematocrit drop or unless she
develops leg , abdominal and back pain symptoms. Because of the
patient's history of coronary disease , she was ordered for a 2units
a blood. She only received one unit of blood because
she was symptomatic with hypertension and chest pain when the
second bag was hung ( see cardiovascular pump section above ).
Post-transfusion hematocrit was 30.1 and was felt no further
blood would be needed.
3. Endocrine: The patient has a history of diabetes. During
this admission , her orally agents were held and the team implemented the
Totin Hospital And Clinic Insulin Diabetic Protocol using NPH basal
insulin and pre-prandial aspart scales. The hemoglobin A1c was
6.8.
4. Fluids , electrolytes , nutrition/renal: The patient had
essentially stable renal function during this admission. A
change in the patient's creatinine from 7/28/28 was
attributed to medication-induced ( likely from recent lisinopril
dose increased from last NVH admit , and/or dehydration ). Lasix was
and ACE inhibitor were both held. Lasix and ACE were both
restarted on 3/1 ( see cardiovascular section above ).
5. Gastrointestinal: During this admission the patient had
reported crampy abdominal pain and diarrhea. The medical team
suspects possible cause could be ischemia in the setting of
hypertension , as the patient has significant celiac disease that
was identified on an MRA obtained at P Therford Hospital in 10/13 All
stool studies were negative and as on 9/6 her diarrhea
resolved.
6. MISC: After a lengthy discussion with the patient , she opted to be a
DNI otherwise wanted all other resuscitative measures.
IMPRESSION: This is an 82-year-old female who presents with
complaints of intermittent lightheadedness and sudden onset of
severe chest and abdominal pressure in the setting of
hypertensive urgency with documented blood pressure of 194/74.
Her symptoms resolved with blood pressure control. The medical
team suspects that:
1. The cause of the patient's episodic lightheadedness prompting
multiple visits to the Norap Valley Hospital may be from atrial
fibrillation with RVR and/or ventricular pauses. Additional
workup for this can be pursued by Dr. Krinsky as an outpatient.
2. Given the significant history of vascular disease and the
findings on recent MRA , the team suspects that the patient may
have hypertension-induced gut ischemia and microvascular cardiac
angina.
This is preliminary discharge summary and the discharge addendum
including discharge medications , final diagnoses and medical
followup will need to be dictated at the time of discharge.
eScription document: 1-9935216 CSSten Tel
Dictated By: HOLLWAY , TABATHA
Attending: CADOFF , LINDY
Dictation ID 7767829
D: 9/5/07
T: 4/29/07
Document id: 1049
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
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HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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624487742 | PUO | 42100083 | | 543269 | 3/10/2000 12:00:00 a.m. | UNSTABLE ANGINA , R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/9/2000 Report Status: Signed
Discharge Date: 4/26/2000
ADMISSION DIAGNOSIS: CHEST PAIN OF UNCLEAR ETIOLOGY.
HISTORY OF THE PRESENT ILLNESS: Ms. Baffa is a 72 year old woman
with a past medical history
significant for coronary artery disease , diabetes , and hypertension
who presented with worsening chest pain and shortness of breath.
She had a long history of coronary artery disease with an exercise
stress test in 1997 that was positive for ischemic ST-T wave
changes. She had a catheterization at that time which revealed
diffuse three vessel disease , none of which was significant. In
1998 , she developed a left bundle branch on her EKG but it was not
clear when exactly this happened. She stated that for the past
year , she got these stabbing pains in the center of her chest that
then progressed to a squeezing pain with palpitations. Sometimes ,
there was relation to exertion but no relation to meals or position
and this chest pain had been increasing in frequency over the past
two to three weeks so now it occurred approximately two to three
times a week and was associated with shortness of breath. Two days
prior to admission , she developed constant chest pain that went to
her left arm and made four of her left fingers numb. She was quite
short of breath though she denied paroxysmal nocturnal dyspnea ,
orthopnea , lower extremity edema , increased nocturia , and diet or
medication noncompliance.
PAST MEDICAL HISTORY: Significant also for diabetes for which she
took insulin and checked her sugars at home
which ran 170 range to 200 range , hypertension , and she had
idiopathic drop attacks. She got these episodes where her legs
fell out from under her without warning but she did not lose
consciousness. She had had an MRI/MRA that showed some diffuse
small vessel disease but the MRA was normal.
CURRENT MEDICATIONS: Atenolol 50 twice a day , hydrochlorothiazide 25
every day , Lisinopril 40 every day , simvastatin 10
every day , metformin 500 every day , and NPH 43 every day before noon and 24 every afternoon
ALLERGIES: Penicillin caused a rash and intravenous contrast dye
caused hives.
SOCIAL HISTORY: She was a retired nurses' aide who retired in
1992 , she was a widow , and she had two living
children who were grown. She lived alone and took care of her
eight year old great-grandson but had a daughter and son-in-law who
lived next door.
PHYSICAL EXAMINATION: On admission , significant for an elderly
obese African-American woman lying in bed in
some mild respiratory distress. Her oropharynx was moist , her
jugular venous pressure was 12 cm , her lungs had scattered crackles
at the bases , her heart was regular with an S4 , her belly was soft
and nontender , her extremities had trace edema , and her rectal
examination showed guaiac negative brown stool.
LABORATORY EXAMINATION: Her EKG showed a left bundle branch block
and chest x-ray showed mild pulmonary
edema and Kerley B lines. Her laboratories on admission were all
within normal limits. Her initial CK was 97 with troponin of 0.01.
ASSESSMENT: In summary , this is a 72 year old woman with multiple
cardiac risk factors who presented with chest pain of
unclear etiology. She was admitted for evaluation.
HOSPITAL COURSE: 1. Cardiovascular - She was admitted for
catheterization which showed three vessel
disease , again nonsignificant and not changed from the
catheterization in 1997. She ruled out for a myocardial
infarction. She had an echo which showed some element of diastolic
dysfunction and pulmonary artery systolic pressure of 36 plus RA
but no wall motion abnormalities. It was felt that she had some
element of diastolic dysfunction that caused her to go into a bit
of pulmonary edema , maybe subendocardial ischemia. Therefore ,
while she was maintained on her aspirin and simvastatin , her blood
pressure regimen was advanced. Her heart rate was in the fifties
to sixties and Atenolol 50 twice a day was added. She was on a maximum
of Lisinopril at 40 milligrams so nifedipine extended release was
added and titrated up to 120 milligrams every day where she maintained
systolic blood pressures in the 160 range nevertheless. This could
be further titrated as an outpatient.
2. For her congestive heart failure , she diuresed approximately
four liters through admission with Lasix at 40 intravenously and
would be discharged on a seven day course of Lasix at 20 orally every day
for further diuresis.
3. Pulmonary - She did have hypoxia on admission to 85% on room
air while lying in bed. This was felt to be out of proportion to
her mild congestive heart failure and further causes were sought.
Her D-dymer was greater than 1000 and she then went for a V/Q scan
which was low probability. Her lower extremity noninvasives were
negative. She also had a chest CT which showed no interstitial
lung disease. She had pulmonary function tests which were
consistent with restrictive picture and were not much changed from
her pulmonary function tests in 1998. A pulmonary consultation was
obtained who believed that the congestive heart failure along with
obesity underlying restrictive lung disease could be the cause of
her hypoxia and , in fact , after further diuresis , her shortness of
breath much improved and she had O2 saturations that were 93% on
room air.
4. Endocrine - She was maintained on metformin during admission
and also on half of her dose of her normal dose of NPH given her
decreased orally intake , however , given the fact that she stated that
her sugars at home on her regimen of 43 every day before noon and 24 every afternoon were
170 to 200 , she was discharged on this regimen with instructions to
check her sugar and call her doctor if they were low.
DISPOSITION: She is discharged in stable condition on January ,
2000. She will follow up with Dr. Nhek , her primary
care doctor , and in addition , with Dr. Tyacke , her cardiologist.
DISCHARGE MEDICATIONS: Atenolol 50 twice a day , hydrochlorothiazide 25
every day , Lisinopril 40 every day , nifedipine
extended release 120 every day , metformin 500 every day , NPH 43 every day before noon and 24
every afternoon , simvastatin 10 every day , aspirin 325 every day , and Lasix 20
milligrams orally every day times seven days.
Dictated By: COLETTA VERRY , M.D. JA00
Attending: RUFUS C. BERNAS , M.D. XS9
QI263/8113
Batch: 43184 Index No. GKWO9Q3388 D: 7/19
T: 7/19
Document id: 1050
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563635080 | PUO | 32361549 | | 660194 | 4/23/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/5/1991 Report Status: Signed
Discharge Date: 4/8/1991
DISCHARGE DIAGNOSIS: STATUS POST CARDIAC TRANSPLANT.
OTHER DIAGNOSIS: ORAL HERPES.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old man with
a longstanding history of non-ischemic
cardiomyopathy with congestive heart failure who was originally
admitted on 30 of March with worsening fatigue and dyspnea on exertion
for augmentation of cardiac function. He was well until l96l when
he initially presented with left bundle-branch block , left
ventricular hypertrophy , and transient chest pain. He then had
high grade ventricular ectopic activity in l972 treated with
Quinaglute. Subsequently from l972 to l988 , examination was
notable for worsening left ventricular function. In l988 , he had
recurrent frequent congestive heart failure and underwent cardiac
catheterization which showed an enlarged hypokinetic ventricle with
an ejection fraction of around 32%. His coronary arteries showed
acute marginal of 70% stenosis and 40% of the mid circumflex. In
1/5 , his ejection fraction by right ventriculogram was 20%. In
2/8 , he had atypical pneumonia followed by recurrent congestive
heart failure. Subsequent course was notable for dyspnea on
exertion , paroxysmal nocturnal dyspnea , and orthopnea. He was
treated with Lasix , Zaroxolyn , Captopril , and Quinaglute. In
March , he was admitted to the Pagham University Of for
worsening symptoms , weight gain , and creatinine of 2.9. He was
managed with decreased Lasix , increased Captopril , and ultimately
decided to treate with Lasix and Zaroxolyn. He was then placed on
the Cardiac Transplant List and underwent transplant evaluation.
Exercise tolerance test showed 8 minutes and 43 seconds bicycle
with O2 uptake of l2. Right heart catheterization showed wedge
pressure of 25. PPD was negative and abdominal ultrasound was
negative. Echo showed global left ventricular dysfunction , apical
thrombus , mild tricuspid regurgitation , and mild mitral
regurgitation. Cholesterol was l53 , l-2 immunoglobulins within
normal limits , and toxo was plus IgG and minus IgM. He had
negative hepatitis , histo , blasto , or coccidiomycosis. CMV showed
borderline IgG and negative IgM and EBV showed positive IgG and
negative IgM. Since his discharge in August , he has noted
worsening of symptoms with decreased exercise tolerance and
increased orthopnea.
HOSPITAL COURSE: The patient was admitted and ended up being
started on Dobutamine and had gradually declining
course during his admission culminating in having a cardiac
transplant when a heart became available. This occurred on
10/9/9l. His post-operative course was uncomplicated and his
subsequent course was complicated only by acute worsening of his
renal function associated with high Cyclosporin levels with the
Cyclosporin held and the level allowed to come down. His renal
function returned to baseline. He also developed an orally herpes
lesion. He subsequently did very well post-operatively. Multiple
right ventricular biopsies were negative for rejection. On biopsy
on 11/21 , his wedge pressure was l8 , right atrial pressure l3 ,
right ventricular 48/l4 , and PA pressure of 48/24. He tolerated
slow taper of his steroids without event and it was noted that he
had some tremor also post-operatively which was attributed to
Cyclosporin toxicity. Other than that , his post-operative course
was uncomplicated.
DISPOSITION: The patient is discharged to home on 1/13/9l. He is
to have follow-up with Dr. Lyn as well as Dr. Paparello
DISCHARGE MEDICATIONS: Persantine 75 mg orally three times a day , Clotrimazole
Troche one orally four times a day , Bactrim DS one orally every other day , Procardia XL 60
mg orally every day , Cyclosporin l50 mg orally twice a day , Carafate one gram
orally four times a day , Prednisone taper per the Transplant Team , Imuran 50 mg
orally every day , Restoril l5 to 30 mg orally every bedtime , and Acyclovir Ointment
5% to lip six times per day. CONDITION ON DISCHARGE: Good.
YB454/2207
CHARLYN HOAGE , M.D. RJ4 D: 3/24/91
Batch: 7940 Report: D6248I6 T: 11/19/91
Dictated By: JACKSON E. PART , M.D. JX68
Document id: 1051
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684604007 | PUO | 38714545 | | 1260837 | 5/30/2005 12:00:00 a.m. | Pericardial effusion | | DIS | Admission Date: 10/30/2005 Report Status:
Discharge Date: 1/21/2005
****** DISCHARGE ORDERS ******
PREUETT , LATRICIA 285-03-79-5
Kansas
Service: CAR
DISCHARGE PATIENT ON: 3/25/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NOLAN , BYRON S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
LASIX ( FUROSEMIDE ) 20 MG orally every day
ATENOLOL 50 MG orally every day
OMEPRAZOLE 40 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Your primary care physician , Dr. Leola Musich within 1-2 weeks from discharge. Pls call to schedule your appointment. ,
Dr. Rufus Bernas , Cardiology. Please call 311-181-1609 to arrange appointment within 1-2 weeks of discharge. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Pericardial effusion
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pericardial effusion
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
pericardial effusion , pleural effusion , empiric treatment for PE
OPERATIONS AND PROCEDURES:
Pericardiocentesis
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHO
BRIEF RESUME OF HOSPITAL COURSE:
47 year-old m with morbid obesity admitted for elective
pericardiocentesis and R heart cath after dx pericardial effusion
week pta. HPI:
physical therapy had recent PUO admission for pleural effusion ( transudative , no ev
infx or malig ) , dx with PE and started on Coumadin. Then readmitted last
week with increasing sx
exertional dyspnea/lighheadedness. Found on echo to have 2-cm
pericardial effusion. Could not be tapped due to elevated INR ( on
coumadin empirically for ? PE as cause of effusion ) , so patient d/c'd and
returns today for procedure. R heart cath today shows equalization
of pressures-->tamponade physiology. However , subxyphoid
pericardiocentesis felt not safe given habitus , CT surgery consulted
re window placement , feel not safe given habitus unless drain already
in place. PMH: Morbid obesity , recent pleural effusion thought
possibly secondary to PE , rx with lasix and coumadin. Gastric bypass
sched February Diverticulitis , history of sigmoid colectomy. L tibial ORIF.
Former smoker. ON EXAM T 98 , P 86 , BP 102/58 , RR 18 , O2 sat 94% RA.
Gen morbidly obese male. JVP , Kussmaul's difficult to assess.
Diminished breath sounds at bases. Distant HS. Abd obese , with
hernia , no tenderness. Ext 1-2+ edema , LLE>RLE ( chronic per
patient ). Hospital
Course: 1.
CV Ischemia: no
issues Pump: 8/15/05 drained 400 cc bloody fluid by
transcutaneuous approach , sent for studies , c/with hemopericardium
and exudative process ,
cytology is pending at time of discharge. patient feeling better. ESR , CRP , RA ,
PPD negative
last admission. May have some pericardial irritation from drain , rx
with morphine , not nsaids. Cards fellow pulled drain
in PM 6/16 , repeat ECHO 1/12 showed no accum of fluid ( prelim report
says nl EF , with fat pad over anterior R ventricle ). Restarted
lasix at home dose 8/9 Atenolol had been held at time of
admission , instructed to restart at time of d/c home. Rhythm: No acute
rhythm issues at this time; monitored on tele.
2. Pulm: patient has been diagnosed with PE ( SOB with positive D dimer ) and
started on Coumadin 5/20 , though no V/Q scan or CT scan able to
confirm since he is too big to fit in scanner. Coumadin was held for
several days prior to this admission so that patient could undergo
pericardiocentesis. Attempt made to try to confirm PE on this
admission. AS mentioned , patient unable to do CT PE ( weight ) is
499 pounds ) or VQ scan. Tried to arrange for open MRI 1/12 to r/o
PE and malignancy given pleural and pericardial effusion. 1/12 patient went
for open MRI at Var Arltoburg Wayne Hospital in Saint , but patient too big
to fit in the scanner , study will need to be deferred to outpt. Since
patient's pericardial effusion c/with hemopericardium , do not recommend restarting
Coumadin at this time given risk of rebleeding and cardiac tamponade.
3. FEN: Cardiac diet 4. CODE:
FULL
4. Dispo: D/C'd home 3/25/05 with VNA services. physical therapy instructed to make
follow up appointment with primary care physician Dr. Olivia within 1-2 weeks of discharge.
Unfortunately , malignancy/PE workup unable to be completed due to body
habitus. patient planning to undergo gastric bypass in near future , would
recommend reevaluation for malignancy when he has lost sufficient weight.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1 ) No new medications have been prescribed. Please continue on all home
medications , except for Coumadin.
2 ) Schedule f/up appointment with your cardiologist Dr. Nolan and your
primary care physician Dr. Olivia within 1-2 weeks of
discharge home. We are unable to schedule an appointment for you at this
time because the offices are closed.
No dictated summary
ENTERED BY: PELLISH , BRENDAN KARY C M.D. ( AJ600 ) 3/25/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1052
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010700797 | PUO | 27527229 | | 330698 | 1/9/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/22/1995 Report Status: Signed
Discharge Date: 11/26/1995
PRINCIPAL DIAGNOSIS: 1. CHEST PAIN , FOR RULE OUT MYOCARDIAL
INFARCTION
SECONDARY DIAGNOSES: 2. INSULIN DEPENDENT DIABETES
3. CHRONIC ATRIAL FIBRILLATION
4. HYPERTENSION
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old , vietnamese
speaking woman with multiple cardiac
risk factors who presented complaining of unstable chest pain. The
patient's cardiac risk factors include adult onset diabetes ,
hypertension , hypercholesterolemia , a positive family history ,
previous history of smoking as well as postmenopausal state
secondary to hysterectomy 21 years ago and not on estrogen
replacement therapy. The patient has a two to three year history
of exertional angina. Of note , approximately one year ago she
began to have substernal chest pain at rest. The patient states
that currently she is having approximately three episodes a day on
average. She describes these as substernal chest pressure which
radiates to her bilateral arms as well as her jaw. She denies any
associated shortness of breath but does occasionally note
diaphoresis. She denies any nausea or vomiting or palpitations.
In September of 1994 the patient underwent an echocardiogram which
showed a left atrial size of 4.0 cm and ejection fraction of
approximately 60% with mild left ventricular hypertrophy and mild
tricuspid regurgitation. Since this time she has been followed by
Dr. Chas Petrov in KTDUOO Clinic who initiated an antianginal regimen
which resulted in decreased frequency of her symptoms. Of note the
patient recently stopped taking Aspirin. Her symptoms then
recurred. On the 5 of February , 1995 the patient underwent a
Dobutamine MIBBE on which she went 6 minutes and 48 seconds
reaching a maximal heart rate of 154 , a blood pressure of 172/82.
The test showed 2 mm ST depressions diffusely. The MIBBE showed
moderate to severe reversible anterior and anteroseptal wall
ischemia. Of note , on the morning of admission the patient was
seen by her VNA. During her VNA's visit the patient began to have
her typical anginal symptoms with radiation to her arms and jaw as
well as shortness of breath. She denied any diaphoresis or nausea.
The patient was given three sublingual Nitroglycerins after her
primary M.D. was called and her pain resolved after approximately
15 minutes. PAST MEDICAL HISTORY: Remarkable for a 10 year
history of Insulin dependent diabetes with complications including
neuropathy and retinopathy. Chronic atrial fibrillation included a
normal TSH. Hypertension. Degenerative joint disease.
Gastroesophageal reflux. Status post hysterectomy approximately 21
years ago. MEDICATIONS ON ADMISSION: Atenolol 50 mg orally every day ,
Axid 150 mg orally twice a day , Enteric Coated Aspirin 325 mg orally every day
which the patient recently stopped , Coumadin 10 mg orally every bedtime ,
Diltiazem 240 mg orally every day , Lisinopril 10 mg orally every day , Lopipd 600
mg orally every day , Lasix 40 mg orally every day , Insulin , NPH , 75 units subcutaneously
every day before noon , 50 units every afternoon , Insulin Regular 25 units subcutaneously every day before noon
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Her heart rate was 58 , blood pressure
141/73 , O-2 saturation 97% on 2 liters ,
respiratory rate 16 and unlabored. HEENT exam showed pupils equal
round and reactive to light. Extraocular movements were intact.
Oropharynx was clear. Mucous membranes were moist. Neck was
supple with full range of motion. Jugular venous pressure was
difficult to assess secondary to increased soft tissue around the
neck. Carotids were 2+ and without bruits. Cardiac exam showed an
irregularly irregular rate and rhythm , a normal S-1 and S-2 , a I/VI
systolic ejection murmur noted at the left upper sternal border.
Lungs were clear to auscultation and percussion. Abdomen was soft ,
nontender , obese with active bowel sounds. Extremities showed a
right shin scar which was healing well. There was no clubbing or
cyanosis , no evidence of any femoral bruits. Rectal examination
was guaiac negative. On neurologic examination the patient was
alert and oriented x 2. Cranial nerves II-XII were intact.
Strength was 5/5 bilaterally. There was decreased sensation to
light touch bilaterally in the lower extremities.
LABORATORY DATA: On admission Sodium 134 , Potassium 4.7 , Chloride
96 , Bicarb 22 , BUN 28 , Creatinine 1.3 , Blood
Glucose 472 , Digoxin level 1.0. physical therapy 14.5 , PTT 26. Urinalysis was
negative. EKG showed atrial fibrillation at a rate of 60 with a
normal axis. T wave inversions were noted in both leads 3 and F
and Q waves were noted in V-1 through V-3. Chest x-ray showed no
evidence of infiltrates or effusions. There was borderline
cardiomegaly.
HOSPITAL COURSE: The patient was admitted to Medicine Team Hi Co
She was ruled out for myocardial infarction with
serial CK , MB and EKG's. Heparin was initially started given the
possibility that this was unstable angina. The Cardiology Team was
consulted for recommendations on possible cardiac catheterization.
On further review of her history the Cardiology Team decided to
schedule a cardiac catheterization. This was performed on the 7 of October and showed mildly elevated right sided pressure including a
right atrial pressure of 15 , an RV pressure of 50/16 with a mean PA
pressure of 32 , pulmonary capillary wedge of 22. The coronary
arteries were noted to be normal and left ventricular function was
also assessed as normal. The patient tolerated this procedure well
and without complications. Given the confluence of her data , two
possible explanations were postulated including either syndrome X
or small vessel disease , not noted on cardiac catheterization. The
patient remained stable , status post cardiac catheterization and
was prepared for discharge. Also during her hospital course the
patient's Insulin dosages were adjusted in the manner to keep her
blood sugars in the approximately 200 range.
DISPOSITION: MEDICATIONS ON DISCHARGE: Enteric Coated Aspirin 325
mg orally every day; Lasix 40 mg orally every day; Lopid 600 mg
orally every day; Insulin NPH 100 units subcutaneously every day before noon , 70 units subcutaneously
every bedtime , Insulin Regular 25 units subcutaneously every day before noon; Lisinopril 10 mg
orally every day; Nitroglycerin 1/150th one tablet sublingual every 5 minutes
x 3 as needed chest pain; Omeprazole 20 mg orally every day; Coumadin 10 mg
orally every bedtime; Diltiazem CD 240 mg orally every day FOLLOW-UP CARE: The
patient will follow-up with her primary M.D. , Dr. Charleen Ivel in
the KTDUOO Clinic.
Dictated By: IRVING ESCALANTE , M.D. GB42
Attending: RHEBA R. NAKAI , M.D. NN08
WX198/1282
Batch: 8329 Index No. O1PPWJ52C3 D: 10/8/95
T: 6/17/95
CC: 1. CHAS C. PETROV , M.D. WS33
Document id: 1053
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805053407 | PUO | 90043314 | | 2510510 | 9/17/2005 12:00:00 a.m. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE | Signed | DIS | Admission Date: 9/17/2005 Report Status: Signed
Discharge Date: 3/26/2005
ATTENDING: CRIDGE , LORRETTA M.D.
PRIMARY CARE PHYSICIAN: Nadia Wankum , MD
PRINCIPAL DIAGNOSIS: Tracheostomy tube change.
DIAGNOSES: Redundant oropharyngeal tissue , aspiration.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old woman
with severe COPD , insulin dependent diabetes , and morbid obesity
who presents from acute inpatient rehab with recurrent trach tube
dislocations and need for a trach tube change. The
patient has had numerous intubations and an ICU stay from October
to July 2005 due to her severe COPD and poor respiratory status.
On admission , she did report tight breathing and shortness of
breath. She denies any chest pain , abdominal pain , diarrhea ,
constipation , dysuria , fevers , or chills.
PAST MEDICAL HISTORY: Severe COPD with numerous admissions
including an ICU admission from October to July 2005. The patient
also has schizoaffective disorder , adult-onset type 2 diabetes ,
requiring insulin therapy , morbid obesity , coronary artery
disease , and left ventricular ejection fraction of 30%.
MEDICATIONS ON ADMISSION: Combivent four puffs four times a day ,
prednisone 20 mg per GT daily , Novolin insulin subcutaneously 40 units every day before noon
and 18 units every afternoon , transdermal nitro one patch topical daily ,
lactulose 45 mL GT twice a day , Lasix 80 mg GT every day before noon , Mepron
suspension 750 mg GT daily , Colace liquid 200 mg GT twice a day ,
Ultram 50 mg GT four times a day as needed , Cardizem 30 mg four times a day GT , vitamin
C 500 mg GT twice a day , Depakene syrup 250 mg GT every bedtime , Genasyme 80
mg GT twice a day , Celexa 20 mg GT every day before noon , Lopressor 6.25 mg GT
twice a day , aspirin 81 mg GT daily , Novolin insulin sliding scale subcutaneously
before every meal , Captopril 25 mg GT three times a day , Clozaril 100 mg GT every bedtime and
50 mg GT every day before noon , Reglan 15 mg GT four times a day , Feosol 300 mg GT three times a day ,
Protonix 40 mg GT daily , vitamin B1 100 mg GT daily , Singulair 10
mg GT daily , fleets enema , one enema PR daily , as needed
constipation , Tylenol elixir 1000 mg orally four times a day as needed pain or
fever , and Flovent 220 mcg two puffs twice a day
ALLERGIES: Penicillin and sulfa.
SOCIAL HISTORY: The patient denies tobacco , alcohol , or intravenous drug
use. She has two children and lives alone since hospitalization.
FAMILY HISTORY: Noncontributory.
ADMISSION PHYSICAL EXAMINATION: Temperature 99.2 , pulse 89 ,
blood pressure 130/86 , respiratory rate 20 , and oxygen saturation
100% on room air. General , the patient is in no acute distress ,
but is unable to talk with the trach tube currently in place.
HEENT , mucous membranes are moist and there are no OP lesions.
Neck , JVP is not appreciated due to the patient's body habitus.
Cardiovascular , heart rate is regular , regular rhythm , no
murmurs , gallops , or rubs. Chest , decreased breath sounds in all
fields with a prolonged expiratory phase. Abdomen , bowel sounds
are present , abdomen is obese , nontender , and there is a G tube
in place. Extremities , no cyanosis , clubbing , or edema.
Extremities are obese. Skin , no rashes or bruises. Neurologic ,
no cranial nerve , sensory , or motor deficits noted. Gait is
deferred.
LABORATORY FINDINGS ON ADMISSION: The patient's CBC reveals a
hematocrit of 29.2 , which is consistent with her baseline of 28
to 30. Her CBC , chem-7 , and LFTs are all unremarkable.
PROCEDURES:
1. Trach tube change - the patient's tracheostomy tube was
changed to a Custom #6 Bivona on 10/21/05 by Dr. Peteet ( Surgery ).
2. Bronchoscopy - A bronchoscopy was performed on 5/28/05 and
revealed erythematous soft tissue in the posterior pharynx ,
compromising the airway above the trach tube. Granulation tissue
was noted above the site of the trach tube that also appeared to
potentially compromise the airway.
3. Modified barium swallow - modified barium swallow was
performed on 10/21/05 , which revealed a moderate aspiration risk.
The patient was recommended for a mechanical soft diet.
HOSPITAL COURSE:
1. Trach change: On admission , the patient was admitted to the
General Medical Service for problems with her trach tube. Over
the course of this admission , her trach tube did become dislodged
on numerous occasions. During these times , either surgery or
respiratory therapy were required to reinsert the trach tube.
However , the patient remained stable throughout these events with
a pulse oximetry reading greater than 92% , even when the
tube became dislodged. The patient required a Custom fit #6
Bivona cuffless trach tube. Dr. Peteet ( General Surgery ) inserted this tube
without incident. Initially , the patient did feel some irritation once the
tube was inserted , however , this resolved with deep suctioning and nebulizer
therapy. Once inserted , the new trach tube fit well and the
patient was comfortable , with oxygen saturations greater than 92%
on trach mask oxygen.
2. Redundant oropharyngeal tissue: During this admission , the
patient underwent a bronchoscopy to evaluate for possibile
decannulation. However , this procedure revealed
excessive tissue in her upper oropharynx and
what appeared to be edematous tissue in the airway. The significance of this
finding was uncertain , although it was felt that this tissue could
compromise the airway if her trach tube was removed. Therefore ,
the patient should not be decannulated without repeat evaluation of her
upper airway. Throughout this hospital
course , the patient had her trach tube in place. She was able to
use a Passey-Muir valve for speaking and she may continue to use
one with her trach tube in place.
3. Aspiration pneumonia: Given the patient's history of
recurrent pneumonia and poor pulmonary function , the patient
underwent a modified barium swallow evaluation for possible
aspiration pneumonia. She was found to have some difficulty
during this evaluation , and Speech and Swallow recommended the
patient continue a mechanical soft diet without fluid
restrictions indefinitely. During this hospital course , the
patient had been on tube feeds through her G tube , although these
may be tapered once the patient is tolerating orally food well.
COMPLICATIONS: None.
CONSULTANTS: Dr. Glinda Bancourt , General Surgery.
PHYSICAL EXAMINATION AT DISCHARGE: On discharge , the patient's
temperature was 97.8 , pulse 81 , blood pressure 122/84 ,
respiratory rate 22 , and oxygen saturation 100% on supplemental
oxygen of 30% by trach mask. General , no acute distress ,
pleasant , obese woman. HEENT , mucous membranes are moist.
Pupils are round. Extraocular movements are intact. Neck , JVP
could not be assessed. Chest , distant breath sounds with
occasional wheezes , but no appreciable crackles or rhonchi.
Cardiovascular , S1 and S2 intact , regular , but distant heart
sounds. Abdomen is obese , soft , and nontender , positive bowel
sounds , without appreciable masses. Extremities are obese , but
without edema.
DISCHARGE MEDICATIONS: Tylenol elixir 1000 mg orally four times a day as needed
pain , aspirin 81 mg orally p. G daily , albuterol nebulizer 2.5 mg
every 2 hours as needed shortness of breath or wheezing , artificial tears
one drop both eyes every 8 hours as needed dry eyes , vitamin C 500 mg orally
twice a day , Captopril 25 mg orally or p. G three times a day , Cardizem 30 mg orally
or p. G four times a day , Colace liquid 200 mg p. G twice a day , Lasix 60 mg p.
G or orally every day before noon , NPH insulin 40 units subcutaneously every day before noon , NPH insulin 18
units subcutaneously every afternoon , lactulose 45 mL orally or p. G twice a day , milk of
magnesia 30 mL orally or p. G daily , Reglan 15 mg orally or p. G
four times a day , Lopressor 12.5 mg orally or p. G twice a day , nitroglycerin
patch 0.4 mg/h topical daily , oxazepam 15 to 30 mg orally or p. G
every bedtime as needed insomnia , prednisone 15 mg orally or p. G daily ,
fleets enema one bottle PR daily as needed constipation , thiamine
100 mg orally daily , Depakene 250 mg orally every bedtime , Clozaril 50 mg
per G tube every day before noon and every bedtime , Ultram 50 mg p. G or orally four times a day ,
Mepron 750 mg p. G daily with meals , Flovent 220 mcg inhaled
twice a day , Celexa 20 mg p. G daily , Singulair 10 mg orally or p. G
daily , Nexium 20 mg orally or p. G daily , DuoNeb 3/0.5 mg nebulized
every 6 hours , Novolog sliding scale before every meal , Maalox one to two tablets
orally or p. G every 6 hours as needed upset stomach , and Feosol elixir 300 mg
orally or p. G three times a day
DISPOSITION: The patient is discharged to inpatient rehab in
fair condition.
FOLLOW-UP: The patient should follow up with her primary care
physician as needed. If her trach tube requires further
revision , she should return to the hospital.
ADVANCED DIRECTIVE: Full code.
eScription document: 4-1075609 CSSten Tel
CC: Lorretta Cridge M.D.
Pulmonary Division , Pagham University Of
Tonboiselos Ba
Delpsterldi
CC: Nadia Wankum M.D.
Kernan To Dautedi University Of Of
Valleston
Iatl 1
Dictated By: MCCORD , ADAH
Attending: CRIDGE , LORRETTA
Dictation ID 7188596
D: 11/28/05
T: 11/28/05
Document id: 1054
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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680159882 | PUO | 61129049 | | 560821 | 2/9/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/28/1996 Report Status: Signed
Discharge Date: 10/12/1996
DISCHARGE DIAGNOSIS: ATYPICAL ANGINA AND CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: This is a 76 year old male with
increased anginal symptoms for
approximately one month post-PTCA. This patient had known
multivessel coronary artery disease status post angioplasty
admitted with six hours of rest chest pain with non-diagnostic EKG
changes and initial troponin and CK negative. Patient's risk
factors include a history of hypertension , prior history of
tobacco , non-insulin dependent diabetes , his age , and sex. In
April 1995 , the patient developed his first symptoms of cardiac
angina. He was admitted on 7/10/95 with chest pain at rest and
minimal EKG changes. CK initially was 210 and MB was not done.
Patient did not rule in. On 10/23/95 , the patient underwent
cardiac catheterization with elevated right atrial pressure of 39
and 14 , mildly elevated , and three vessel disease with 70% proximal
stenosis of his left anterior descending artery , 90% apical
stenosis with 30% stenosis of the left circumflex , and two serial
95% stenoses distally of the left circumflex noted. His first
diffuse marginal branch had 30% to 40% diffuse luminal irregularity
in his right coronary artery. Posterior descending artery was
noted to have a 90% mid stenosis. Systolic function was normal
with ejection fraction of 71%. On 10/23/95 , the patient had a
balloon angioplasty of the proximal and 95% stenosis of his left
circumflex artery. On 11/1/95 , the patient continued to complain
of chest pressure. He underwent exercise tolerance test. He went
five minutes and one second stopping secondary to leg fatigue with
a 2 mm ST segment depression. He underwent cardiac catheterization
with angioplasty of his mid posterior descending artery with 30%
residual stenosis and a small dissection of the inferior margin of
the vessel. He was discharged home aspirin , Lisinopril , Atenolol ,
Micronase , and enoxaparin. Patient was well at home until the day
of his admission when he had retrosternal chest pressure of 10/10
at approximately 6 p.m. He took three sublinguals without relief
and presented to the Emergency Room with 5/10 chest pressure. In
the Emergency Room , he had some relief of his chest pressure with
sublingual nitroglycerin and intravenous nitroglycerin brought
significant relief. He had non-diagnostic EKG changes but was
admitted to the CCU for concern for unstable anginal pattern.
PAST MEDICAL HISTORY: Significant for C4-C5 radiculopathy with
steroid injection for pain control , inguinal
hernia , and benign prostatic hypertrophy status post transurethral
resection of the prostate.
CURRENT MEDICATIONS: Enteric coated aspirin 325 every day , Lisinopril
7.5 every day , Atenolol 75 every day , Micronase 5 every day ,
and enoxaparin 60 mg every 12 hours
ALLERGIES: Patient was allergic to penicillin with a rash.
PHYSICAL EXAMINATION: On admission , patient was in no acute
distress with a heart rate of 54 , blood
pressure 114/78 , respiratory rate 18 , and saturation 97% on four
liters. On 100 micrograms of nitroglycerin and Heparin , there was
no chest discomfort. HEENT: Benign. LUNGS: Few basilar
crackles. CARDIOVASCULAR: Examination showed bradycardia with
II/VI systolic murmur at the left lower sternal border and apex.
ABDOMEN: Benign. EXTREMITIES: No clubbing , cyanosis , or edema.
LABORATORY EXAMINATION: On admission was notable for a potassium
of 3.9 , hematocrit of 37.1 , troponin of 0 ,
and CK initially of 121. EKG revealed a sinus bradycardia with
normal intervals , normal axis , and no new change as compared to old
EKG.
HOSPITAL COURSE: Assessment was that this was basically a 76 year
old with known coronary artery disease presenting
with unstable angina with no significant troponin or CK values.
Given his history of recent intervention and coronary artery
disease , this appeared consistent with unstable angina. The
patient was ruled out for a myocardial infarction with his CK flat
and repeat troponin of 0. He was continued on intravenous Heparin
and nitroglycerin in the interval amount of time until he ruled out
and his aspirin therapy was decreased down to 81 with simvastatin
started. Patient received repeat catheterization on 1/9/96 which
revealed 50% stenosis at the mid left circumflex at the PTA site ,
30% to 40% stenosis of the distal posterior descending artery at
the PTA site , 40% proximal left anterior descending , 95% distal
left anterior descending at the apex , and 70% distal left
circumflex giving rise to two PLV branches. The plan was that the
patient would get a distal left circumflex PTCA tomorrow when there
would be surgical back-up available. The patient was continued on
intravenous Heparin and nitroglycerin overnight without any
recurrent chest discomfort. On 10/16/96 , the patient had PTCA
times three at the mid left circumflex 50% to 60% stenosis
ballooned to 30% , distal left circumflex 80% stenosis was ballooned
to 30% residual , and distal left anterior descending with 90%
stenosis ballooned to 20% residual. Post-PTCA , the patient was
continued on Heparin overnight without any recurrent chest
discomfort. There was a issue with this patient of whether his
chest discomfort given its atypical nature was cardiac in etiology
although he definitely had disease on angiography but he had
significant possibility for other etiologies as a source for his
discomfort such as cervical radiculopathy with left arm numbness
and occasional anterior chest discomfort which he had difficulty
distinguishing from any anginal-like discomfort. He also had a
history of gastrointestinal distress with frequent gaseousness.
The patient was basically observed 24 hours after his Heparin was
stopped , he was restarted on enoxaparin , and continued on aspirin ,
Captopril , Lopressor , and simvastatin. Patient did not have any
recurrent chest discomfort in the interim observation and he was
discharged home on a stable out-patient regimen. Additional
in-house issues included that gastrointestinally , patient was
continued on Prilosec and Maalox therapy for his gaseousness and
gastrointestinal distress. Given the crackles on examination , he
had a chest x-ray which was negative for any infiltrate and he
required some O2 supplementation initially when he presented but he
was weaned off O2 prior to discharge. As far as his diabetes , he
continued on his out-patient Micronase with twice a day fingerstick
monitoring which was normal. Fluids , electrolyte , and nutrition
wise , his potassium and magnesium were kept optimally repleted
given his cardiac history.
DISPOSITION: Patient is discharged in stable condition.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Atenolol 25 mg every day , Micronase 5 mg every day ,
Lisinopril 2.5 mg every day , and sublingual nitroglycerin.
FOLLOW-UP: Patient is to schedule a follow-up appointment with Dr.
Meduna for cardiac follow-up. The plan was that
he would call Dr. Meduna for follow-up.
Dictated By: CORRINA I. CROOKED , M.D. SJ80
Attending: JACKSON E. PART , M.D. RM7
KU610/9003
Batch: 37758 Index No. OJTVI03H9S D: 10/25/96
T: 7/6/96
Document id: 1055
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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589836784 | PUO | 68474572 | | 6497480 | 3/9/2006 12:00:00 a.m. | CAD | | DIS | Admission Date: 4/14/2006 Report Status:
Discharge Date: 6/18/2006
****** FINAL DISCHARGE ORDERS ******
BREISCH , LATRINA 982-53-63-8
Ra
Service: CAR
DISCHARGE PATIENT ON: 6/17/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BACHMANN , LASHANDA L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ATENOLOL 125 MG orally DAILY Starting Today ( 6/16 )
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Instructions: p/with angina , history of PCI
Alert overridden: Override added on 9/23/06 by
AGGERS , RASHAD DENIS , M.D.
SERIOUS INTERACTION: MICONAZOLE NITRATE & ATORVASTATIN
CALCIUM
SERIOUS INTERACTION: MICONAZOLE NITRATE & ATORVASTATIN
CALCIUM
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
KEFLEX ( CEPHALEXIN ) 500 MG orally four times a day
Starting Today ( 6/16 )
Instructions: started 1/10 , stop 8/22
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 10/7 )
ENTERIC COATED ASA 325 MG orally DAILY
LASIX ( FUROSEMIDE ) 80 MG orally twice a day Starting IN a.m. ( 7/3 )
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
10 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 6/17/06 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
LISINOPRIL 5 MG orally DAILY
Override Notice: Override added on 1/29/06 by
BENCH , MACIE G. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
127547863 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 3/9/06 by WESTBERG , KAMALA M. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: monitering
MICONAZOLE NITRATE 2% CREAM TP twice a day
Instructions: apply in between toes B/L
Override Notice: Override added on 9/23/06 by
AGGERS , RASHAD DENIS , M.D.
on order for LIPITOR orally ( ref # 308576761 )
SERIOUS INTERACTION: MICONAZOLE NITRATE & ATORVASTATIN
CALCIUM Reason for override: aware
Previous override information:
Override added on 3/9/06 by WESTBERG , KAMALA M. , M.D. , PH.D.
SERIOUS INTERACTION: SIMVASTATIN & MICONAZOLE NITRATE
SERIOUS INTERACTION: SIMVASTATIN & MICONAZOLE NITRATE
Reason for override: aware
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: apply to groin
Override Notice: Override added on 9/23/06 by
AGGERS , RASHAD DENIS , M.D.
on order for LIPITOR orally ( ref # 308576761 )
SERIOUS INTERACTION: MICONAZOLE NITRATE & ATORVASTATIN
CALCIUM Reason for override: aware
NIASPAN ( NICOTINIC ACID SUSTAINED RELEASE ) 0.5 GM orally every afternoon
Instructions: Take aspirin 30 minutes before- hand to
prevent facial flushing
Override Notice: Override added on 9/23/06 by
AGGERS , RASHAD DENIS , M.D.
on order for LIPITOR orally ( ref # 308576761 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
Previous override information:
Override added on 3/9/06 by WESTBERG , KAMALA M. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Tiede , Primary Care 1-2 weeks. Please call the office if you do not hear from them in the next 2 days. ,
Dr. Tyacke , Cardiology 790-135-8393 Please call in 1-2 days if you do not hear from the office. You must be seen in 2-4 weeks. ,
ALLERGY: Shellfish
ADMIT DIAGNOSIS:
angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
2 VESSEL CAD HTN +ETT 4/22 W/ ST DEPRESSION ANGINA , ? UNSTABLE
CURRENTLY STABLE NO CHEST PAIN SINCE 10/9 history of CATH 6/9
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
cardiac cath
BRIEF RESUME OF HOSPITAL COURSE:
cc: SOB/DOE x 9 months
HPI: 60M HTN , obese , CAD history of stent in '96 to LCx , with DOE and
substernal chest tightness with walking approx 200 yards. Sx resolve
with rest. Associated with SOB and periodic radiation to the R chest.
Have been slowly progressing over the past months. Since
last cath in '96 , has had few episodes of chest pain releived with sublingual
nitro. On ROS positive orthopnea ( 3 pillows ) , no PND. No
lightheadedness , dizziness , nausea , emesis , cough , abd pain. No fever
or chills. Recent gain of 100 lb in setting of family illnesses.
In the last week , got PECT ( neg ) , Stress Echo negative for ischimia
with submax HR , + MIBI. Admitted for further evaluation.
In ED: T98.6 P70 BP141/69 Sat 94%RA. Given ASA and Keflex ( for LE
cellulitis ).
********
*PMHx: CAD ( history of 2 stents to LCx '96 ) , HTN , hyperlipidemia , hepatitis
( resolved ) , colonic polyps , osteoarthritis , history of appy , history of R
THR *ALL: Shellfish -->
Rash *Home Meds: norvasc 10mg , lasix 40mg every day , lipitor
80mg every day , atenolol 100mg every day , isordil 20mg three times a day , ASA 325mg
every day *Social Hx: married , wife in VLH with Alzheimer's.
Lives alone. Mother died a year ago from malignancy , used to take
care of her. Past tobacco ( 40pk yrs ) , no ETOH or
drugs *Fam Hx: no
CAD
*********
**Stress Echo 2/3 EF 45% , borderline LVE , concentric LVH , post
basilar HK and mid-inf HK. LAE. No ischimia , but submax stress test
( peak HR 85bmp ) **MIVI ( 2/22/06 ): non-ischimic. Patchy uptake
diffusely with small reversible apical defect -> ? mild ischimia in LAD
territory. Small defect of medium intensity in the basal
inferolateral wall that is fixed c/with LCx/OM
scar. **PECT 2/3 no evidence of
PE **CXR ( admission ): R hilar
opacity. **EKG: SR 75bmp , RBBB , LEA , PVC , strain
pattern
Cath 10/23/06 : Right Dominant , LAD ( Proximal ) , Discrete 55% lesion , LCX
( Mid ) , Discrete 80% lesion , RCA ( Proximal ) , Discrete 99% lesion , RT LV-BR
( Ostial ) , Discrete 55% lesion , RT PDA ( Proximal ) , Discrete 50% lesion ,
Collateral flow from LAD to RT PDA , Collateral flow from CX to RT LV-BR
Right heart Cath 10/23/06 : RA 13/13 RV 41/-1 , PA 47/16 , PW 27/25 PA:74%
Fick CO:6.95 Thermal CO: SVR:1163
Fick CI:2.76 Thermal CI: PVR:69
Cath 4/3/06 : PCI and stent to LCx.
**********
*Daily Status: T98.3 P94 BP130/80 Sat 96%RA GEN: NAD ,
A&Ox3 HEENT: mmm , PERRLA , JVP 8cm , CEA scars
b/l CV: RRR , 1/6 RUSB ejection murmur; non-displaced PMI
, B/L CEA scars , no bruits. ABD: obese , NABS , nt , nd , no HSM , B/L
femoral bruits PULM: CTA
b/l EXTR: 3+ b/l edema to knees , b/l ankle erythema and
warmth with exudation on L , + onchomycosis B/L. NEURO: full strength &
sensation. Limited R eye abduction ( Lateral Rectus ).
PERRLA.
***********
A/P: 60 year-old M with CAD , HTN and Hyperlipidemia admitted with
increasing DOE and intermidiate MIBI as out-patient in setting of
significant deconditioning and multiple cardiac risk
factors. 1. CV: i- no evidence of active ischemia. Admission
cardiac markers negative. Continued statin/high dose ASA ( post
stent )/started Plavix ( post stent )/increased atenolol from 100mg to 125
mg. Started Niaspan for low HDL ( Trig 138 , HDL 38 , LDL 85 ). Subtotal RCA
occlusion , 80% OM , 50% mid LAD. Cypher Stents in mid RCA to os. Returned
to cath lab for
Lcx PCI 6/26 and cypher stent placed. Wedge elevated. EF 45% on stress
echo. Difficult to determine volume status by clinical exam alone.
Increased lasix from 40 mg orally daily to 80 mg orally twice a day , increased b-blocker ,
continued norvasc and stopped isordil. Will stop norvasc to allow room
for ACE-I titration. r-telemetry
monitoring revealed 2 episodes of NSVT post-PCI. Continue ASA/Plavix at
current doses x 1 year. 2. PULM: likely symptoms
related to cardiac etiology.
No evidence of PE per out-patient scan within the last week. 3. ID: lower
extremity cellulitis in setting of
venous stasis and likely peripheral vascular disease. Treat with
keflex x 2 weeks and continue longer if legs still erythematous. ABX
started 1/10 , stop 6/17 4. FEN: cardiac diet. Started low dose potassium
10 mEq daily as increased lasix. Will have patient check lytes in 2 days.
FULL CODE
ADDITIONAL COMMENTS: You have been diagnosed with coronary artery disease. You have new stents
to keep blood flowing to your heart. You MUST continue your aspirin and
plavix. Do NOT discontinue these medications without speaking to your
doctor. We have increased your lasix and your atenolol. You are on
antibiotics for cellulitis ( a skin infection ). Continue your toe
cream. Come to the ER if you have any trouble breathing , chest pain , leg
swelling , or any other concerning symptoms.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Follow lytes , LFTs on meds
2. Follow LE cellulitis to resolution
3. ECHO as outpt
4. Encourage weight reduction
No dictated summary
ENTERED BY: WESTBERG , KAMALA M. , M.D. , PH.D. ( QE231 ) 6/17/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1056
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
Y |
Y |
Y |
Y |
N |
N |
N |
N |
Y |
N |
581312753 | PUO | 77634248 | | 1146138 | 3/12/2006 12:00:00 a.m. | hyperkalemia | Unsigned | DIS | Admission Date: 4/8/2006 Report Status: Unsigned
Discharge Date: 7/16/2006
ATTENDING: HAUB , PERRY M.D.
PRINCIPAL DIAGNOSES: Congestive heart failure exacerbation ,
pneumonia.
LIST OF OTHER PROBLEMS AND DIAGNOSES CONSIDERED DURING THIS
ADMISSION: Bronchoalveolar cancer , atrial fibrillation ,
hypertension , hypothyroidism , mitral valve repair , and chronic
renal failure.
HISTORY OF PRESENT ILLNESS: Ms. Boning is a 75-year-old female
with past medical history significant for coronary artery
disease , congestive heart failure with an EF of 30% , mitral valve
repair in 11/26 , lung cancer likely stage IIIB , and atrial
fibrillation , who was recently discharged on 7/22/2006 after
being admitted for acute renal failure and chronic renal failure
and hyperkalemia. Since being discharged on 7/22/2006 , the
patient reported that she had been doing well until the date of
admission when she noticed a 2.5-pound weight gain , increased
shortness of breath with activity and increased oxygen
requirement during the day. She reports that she normally uses 2
liters of oxygen at night , however , she was needing the oxygen
during the day. She also reports 2 episodes of substernal chest
pain which occurred at rest. There was no radiation , no nausea ,
vomiting , or diaphoresis. These episodes of chest pain lasted 3
or 4 minutes and resolved with nitroglycerin sublingual. The
patient also noted that she had been urinating very much , does
report she had been taking all of her medications as directed at
discharge. She thus called her primary cardiologist , Dr.
Gihring , who instructed her to get labs drawn. She was found to
have potassium of 5.4 and a creatinine of 2.3 and thus was told
to report to the ED.
REVIEW OF SYSTEMS: The patient denied any fever , chills , nausea
or vomiting , abdominal pain , diarrhea , or rashes.
PAST MEDICAL HISTORY: Coronary artery disease , she is status
post PCI to OM1 in 1991 , LAD was stented in 1997 , left circumflex
was stented in 2001 , and the right coronary artery was stented in
2002; history of dyslipidemia; history of CHF with an EF of
30%-35% , she has a dry weight of 158 pounds; hypertension , mitral
valve repair in 10/18 atrial fibrillation for which she is
rate controlled and is on Coumadin; history of renal artery
stenosis , she is status post a left renal artery stent; chronic
renal insufficiency , she has a baseline creatinine of 1.9 to 2.2;
GERD; peripheral vascular disease; iron deficiency anemia;
bronchoalveolar lung cancer , she is status post a right upper
lobe and right lower lobe wedge resections. Also , history of
uterine cancer , she is status post a TAH-BSO , hypothyroidism , and
non-insulin-dependent diabetes mellitus.
ALLERGIES: The patient has no known drug allergies.
HOME MEDICATIONS: Torsemide 40 mg orally twice a day , aspirin 325 mg
once a day , allopurinol 100 mg daily , Ativan 0.5 mg twice a day
as needed , Colace 100 mg twice a day , Coumadin 1 mg by mouth in
the evening , ferrous sulfate 325 by mouth twice a day , glipizide
5 mg by mouth twice a day , isosorbide dinitrate 5 mg orally three times a day ,
Levoxyl 100 mcg orally daily , multivitamin 1 tablet daily , Nexium
20 daily , pravastatin 40 mg each evening , and Toprol 100 mg by
mouth daily.
PHYSICAL EXAMINATION ON ADMISSION: She had a temperature of
97.3 , pulse of 80 , blood pressure 146/76 , and respiratory rate of
16. O2 saturation of 96% on room air. HEENT: She had moist
mucous membranes. Her oropharynx was clear. She had a left
pupil which was enlarged and nonreactive secondary to that being
a surgical eye. Right eye was reactive. She had no
lymphadenopathy. Lungs: left side was clear to
auscultation. The right side had decreased breath sounds at the
base , few crackles at the right base. Cardiovascular
Examination: She had irregularly irregular rhythm. She had a
normal S1 , S2 , did not have any murmurs , rubs , or gallops and was
found to have a flat JVP on admission. Abdominal Examination:
She had positive bowel sounds , she was soft , nontender ,
nondistended. She did not have any hepatomegaly. Extremities:
She was warm and well perfused. Distal pulses were not palpable.
She did have trace edema , left greater than right which was
chronic. She was alert and oriented x3.
HOSPITAL COURSE BY PROBLEM:
Pulmonary/Oncology: The patient was admitted in stable condition
and was requiring 2 liters of oxygen to keep her saturations in
the mid 90s. She had a chest x-ray which showed a right pleural
effusion. Review of previous imaging done on 8/18/2006
demonstrated an area of consolidation in the right lower lobe ,
which was surrounded by a right pleural effusion of moderate
size. The patient also had a PET scan in early August , which
showed that the consolidation lit up extensively. Review of
these studies prompted consideration of possible pneumonia versus
a bronchioalveolar carcinoma spread. Pulmonary was consulted and
they suggested starting the patient on antibiotics for possible
postobstructive pneumonia. She was started on levofloxacin ,
vancomycin , and Flagyl on 10/2/2006. She received 7 days of
these antibiotics while in hospital. On day 4 of her
hospitalization , a thoracentesis was performed for both
diagnostic and therapeutic reasons. The pleural fluid
demonstrated a transudative picture. Gram stain was negative.
Cultures did not grow anything. Cytology , preliminary read was
negative. She had 50 white blood cells and 2000 red blood cells
approximately 800 mL were removed and the patient felt much less
short of breath following the thoracentesis requiring much less
oxygen. A followup CT scan was obtained , which showed continued
infiltrate in the right lower lobe with decreased right pleural
effusion , no pneumothorax was observed. Radiology felt that her
consolidation was most likely consistent with pneumonia and that
it was not postobstructive given that the bronchioles were in fact
quite patent and thus it was decided that the patient would
continue a 14-day course of levofloxacin with followup with
pulmonary to consider whether or not a bronchoscopy would be
indicated for further workup of this patient's infiltrate with
followup imaging to occur as well.
Cardiovascularly , for this patient , ischemia wise , the patient
did have 2 episodes of chest pain prior to admission. She did
not have any EKG changes. Two sets of cardiac markers were
obtained which were both negative , thus assumed that she did not
have ischemic event that occurred. She was continued on her
aspirin and pravastatin while inhouse. Pump wise , the patient
has a diagnosis of CHF with an EF of 30%. She presented
approximately 2 kg above her dry weight. She was continued on
her home dose of torsemide 40 twice a day and also on the isosorbide
dinitrate although this was increased to 10 mg three times a day , she was
also started on hydralazine 10 mg three times a day and did diurese
approximately 500 mL to 1 liter each day. She returned to her
dry weight and on the day of discharge , has a weight of 72.6 kg ,
had been admitted with a dry weight of 74.9 kg. Rhythm wise , the
patient has a history of atrial fibrillation. She was rate
controlled with her metoprolol 37.5 mg daily. Her Coumadin was
continued except for brief period during which it was held prior
to the tap of this. Coumadin was restarted prior to discharge.
Endocrine wise , this patient's fingersticks were well controlled.
She was put on a course of Lantus and NovoLog before every meal sliding
scale as needed. Fingersticks were maintained within a normal
range. Her Levoxyl was 100 mcg daily , was continued and her
allopurinol 100 mg daily was continued for her history of gout.
On discharge , she is being put back on her glipizide for the
diabetes.
Fluid , electrolytes , and nutrition. The patient came in
hyperkalemic. She was given Kayexalate 30 mg x1 in the emergency
room to which she responded and had a normal potassium throughout
her hospital stay.
Renal. For this , the patient with her diuresis she did and with
the addition of the hydralazine , she did have her creatinine drop
from 2.2 down to 1.7 during her hospital admission on the day of
discharge , it was 1.9 , which is within her baseline for her
chronic renal insufficiency.
Hematology wise , the patient had a stable hematocrit in the low
30s. She was continued on her iron 325 twice a day for her iron
deficiency anemia. LENI's also performed and showed no evidence of DVT.
On the day of discharge , notable findings on physical exam , she
was afebrile. Heart rate was 71 to 85. Blood pressure 100-114
over 40-66. She was saturating 93% to 97% on room air.
Cardiovascular Examination: She was irregularly irregular. S1 ,
S2 were present. There were no murmurs , rubs , or gallops. Her
JVP was noted to be 9 cm. Examination of her lungs revealed that
they were clear to auscultation on the left. On the right , she
had crackles approximately halfway up , but did not have decreased
breath sounds as noted on admission. She did not have any
pitting edema.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily , allopurinol 100 mg
daily , Colace 100 mg twice a day , ferrous sulfate 325 mg twice a
day , glipizide 5 mg twice a day , isosorbide dinitrate 10 mg 3
times a day , Levoxyl 100 mcg daily , Toprol XL 100 mg daily ,
Coumadin 1 mg every afternoon , multivitamin 1 tablet daily , pravastatin 40
mg daily , torsemide 40 mg twice a day , Nexium 20 mg daily ,
levofloxacin 500 mg by mouth , every 48 hours for a total course of 4 more
doses , hydralazine 10 mg 3 times a day , Ativan 0.5 mg as needed.
DISPOSITION: The patient was in stable condition.
PENDING TESTS: Final pathology report on the cytology studies
from her thoracentesis is still pending.
FOLLOWUP PLANS: The patient has an appointment scheduled with
her primary care physician , Dr. Kum Pidro on 5/27/2006.
The patient has a followup with pulmonary medicine on 10/1/2006
with Dr. Giard
CODE STATUS DURING THIS ADMISSION: Do not resuscitate , do not
intubate.
PRIMARY CARE PHYSICIAN: Dr. Broderick Pretty
eScription document: 3-1713226 HFFocus
Dictated By: MANKOSKI , ROSSIE
Attending: HAUB , PERRY
Dictation ID 6138284
D: 10/21/06
T: 11/29/06
Document id: 1057
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684054136 | PUO | 08505725 | | 5486085 | 11/25/2005 12:00:00 a.m. | RENAL FAILURE | Signed | DIS | Admission Date: 10/6/2005 Report Status: Signed
Discharge Date: 10/29/2005
ATTENDING: NORSETH , ARDELLA M.D.
ADMISSION DIAGNOSES:
1. Acute renal failure.
2. Edema.
DISCHARGE DIAGNOSES:
1. Acute renal failure.
2. End-stage renal disease with initiation of hemodialysis.
3. Volume overload.
4. Urinary tract infection with enterobacter cloacae.
HISTORY OF PRESENT ILLNESS:
Mr. Toma is a 70-year-old man with chronic renal
insufficiency , hypertension , diabetes , history of stroke , deep
venous thrombosis , and history of congestive heart failure with
diastolic dysfunction who was transferred from Sa Pehall with
increasing edema , fatigue , and weight gain. He was found to have
worsening renal function at Thoeaston Healthcare At rehab ,
attempts at diuresis had been unsuccessful with increasing
diuretic doses. As he became increasingly volume overloaded , he
began to complain of left neck pain and swelling as well as left
lower extremity edema. In addition , his mental status became
increasingly more somnolent and he began to have twitching
movements of his upper extremities. At admission to Pagham University Of , Mr. Toma denied chest pain , shortness of
breath. He did note approximately four days of left neck pain.
He also denied abdominal pain , nausea , vomiting , diarrhea. He
did note some constipation. He denied any fevers or chills.
PAST MEDICAL HISTORY:
1. Congestive heart failure with ejection fraction to 55% as of
2/22
2. Diabetes mellitus.
3. Hypertension.
4. Hyperlipidemia.
5. Chronic renal insufficiency.
6. Right lower extremity deep venous thrombosis in 2/22
7. Coronary artery disease status post non-ST elevation MI in
4/14 with CAT showing nonobstructive coronary artery disease.
8. History of CVA.
9. BPH.
10. Status post pacemaker placement in 10/19
11. Anemia of chronic renal insufficiency.
12. History of syphilis although no further details are
available.
MEDICATIONS ON TRANSFER FROM REHAB:
1. Enteric coated aspirin 81 mg orally daily.
2. Prilosec 20 mg orally daily.
3. Lasix 80 mg twice a day
4. Coumadin 4 mg orally daily.
5. Epogen 10 , 000 units every week.
6. Zaroxylyn 2.5 mg orally x1.
7. Norvasc 10 mg orally daily.
8. Nephrocaps.
9. Flomax 0.4 mg orally daily.
10. Celexa 20 mg orally daily.
11. Calcium carbonate plus vitamin D one tab twice a day
12. Neurontin 100 mg twice a day
13. Lipitor 10 mg orally at bedtime.
14. Colace.
15. Senna.
16. Niferex 150 mg orally twice a day
17. Novolog sliding scale insulin.
18. Calcitriol 0.25 mg twice a day
19. Clonodine 0.6 mg topical.
20. Hydralazine 100 mg orally three times a day
21. Labetolol 1200 mg orally twice a day
ALLERGIES:
Mr. Toma has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION:
His temperature was 96.2 degrees Fahrenheit. His heart rate was
62 beats per minute and his blood pressure was 170/72. His
oxygen saturation was 99% on 2 liters. He was awake and alert
and in no acute distress. His jugular venous pressure was
approximately 12 cm of water. His heart had a regular rate and
rhythm with normal S1 and S2 and a systolic murmur at the left
upper sternal border. He did not have any signs of pulses
paradoxes. His lungs had decreased breath sounds at the right
base with rales at the left base. His abdomen was soft and
distended but nontender. There were normoactive bowel sounds.
The extremities had 1+ pitting edema bilaterally at the shins.
His neurologic exam was nonfocal.
LABORATORY STUDIES ON ADMISSION:
His sodium was 134 and his potassium was 3.4. His chloride was
100 and his bicarb was 21. His BUN was 140 and his creatinine
was 7.0. His white blood cell count was 8.4 and his hematocrit
was 26.1. His INR was 2.5. His calcium was 9.0. His EKG showed
normal sinus rhythm at the rate of 61 beats per minute. This was
a paced rhythm. His chest x-ray showed volume overload and
cardiomegaly.
HOSPITAL COURSE:
1. Renal: On admission , Mr. Toma had significant volume
overload with weight gain , edema , and chest x-ray evidence of
pulmonary edema. He also had significant azotemia with a BUN of
140. His creatinine had also increased from his baseline
creatinine of 5.0 to 7.0 at admission. His physical examination
the morning after admission showed worsening somnolence and slow
asterixis with jerky myoclonic movements. On 8/26/05 , the
tunneled hemodialysis catheter was placed in his right internal
jugular vein by interventional radiology. This procedure was
tolerated without complication. Mr. Toma had his first run of
hemodialysis on 9/27/05 , which he tolerated well with subsequent
improvement in his mental status and resolution of his asterixis.
He again underwent hemodialysis on 5/30/05 , 9/15/05 and
9/14/05. In addition , he underwent a two-hour run of
ultrafiltration on 5/24/05 with removal of nearly four liters of
fluid. Mr. Toma will continue with intermittent hemodialysis
on a Tuesday , Thursday , Saturday schedule after discharge from
Pagham University Of . Plans are underway for Mr. Toma
to have an AV fistula placed. He has a follow-up appointment on
4/3/05 with vascular surgery at Pagham University Of .
2. Fluids , electrolytes , nutrition: Mr. Toma was maintained
on a renal diet. He was started on Nephrocaps multivitamin. On
9/27/05 , he was started on Phoslo 667 mg three times a day for a phosphorus
level of 5.8. However , on 5/24/05 , his phosphorus level was 1.8
and therefore his Phoslo was held.
3. Cardiovascular: Mr. Toma has a long history of
hypertension and he is treated with multiple medications. His
systolic blood pressures have ranged in the 160-180s during this
admission. He was continued on his Norvasc and labetolol. He
was also continued on hydralazine at 100 mg three times a day In addition ,
lisinopril was added and titrated to 10 mg orally daily. In
addition , he was continued on his clonidine at 0.6 mg twice a day Mr.
Wentzlaff blood pressure did not return to a normal level after he
was dialyzed repeatedly. His blood pressure will need to be
continued to be monitored at rehab with potentially additional
medicines added. In addition , Mr. Toma has a history of
coronary artery disease with recent non-ST elevation MI. He was
initially due to be discharged on 9/15/05 , but shortly after
hemodialysis , he had one 15-minute episode of sharp left-sided
chest pain. He was therefore ruled out for myocardial infarction
with serial enzymes and EKGs. He showed no evidence of
myocardial infarction.
4. Hematology: Mr. Toma is maintained on Coumadin for history
of deep venous thrombosis. When he was first admitted , his
Coumadin was held in preparation for placement of a tunneled
hemodialysis catheter. He received one orally dose of vitamin K as
well as fresh frozen plasma prior to placement of the line. He
was subsequently restarted on his Coumadin and it was titrated
while being treated with antibiotics. His previous dose was 4 mg
and he will be discharged on that dose.
5. Endocrine: Mr. Toma has a history of diabetes mellitus and
was maintained on a regular insulin sliding scale.
6. Infectious Disease: Mr. Toma became febrile to 101 degrees
Fahrenheit on 1/13/05. He was again febrile on 9/14/05. His
urine culture grew out enterobacter cloacae , which was
subsequently found to be pan resistant. Prior to his
sensitivities being obtained , he was treated with levofloxacin.
When it was determined that the enterobacter was resistant to
levofloxacin , he was switched to gentamicin 60 mg intravenous x1 on
1/18/05. He should receive several additional days of
gentamicin approximately five or six days. He should be dosed
after hemodialysis for a gentamicin level less than 5. Mr.
Toma did have one positive blood culture from 7/18/05 that
grew out gram-positive cocci in clusters at the time of this
dictation. There was only one out of four bottles that grew out
these gram-positive cocci. He did receive one dose of vancomycin
in the early morning of 1/18/05. It was felt that this blood
culture most likely represented a contaminant. All of his other
blood cultures remained negative at the time of this dictation.
DISPOSITION:
Mr. Toma will be discharged to the Thoeaston Healthcare His
blood pressure and INR will need to be monitored. He will
continue on hemodialysis three times per week. He has an
appointment at vascular surgery on 4/3/05 to plan for AV
fistula formation.
PHYSICAL EXAMINATION AT DISCHARGE:
He was afebrile. He was alert and conversational. He had
occasional rales at his bases. His heart had a regular rate and
rhythm with a 1/6 systolic murmur at his left sternal border.
His abdomen had normoactive bowel sounds , it was soft , nontender ,
and nondistended. His extremities were warm and there was no
edema. He showed no signs of uremia with no asterixis.
MEDICATIONS ON DISCHARGE:
1. Tylenol 650 mg orally every 4 hours as needed
2. Phoslo 667 mg orally three times a day with meals , holding for a
phosphorus level of less than 3.0.
3. Clonidine 0.6 mg orally twice a day , holding for systolic blood
pressure less than 90.
4. Colace 100 mg orally twice a day
5. Hydralazine 100 mg orally three times a day , holding for a systolic blood
pressure of less than 90.
6. Regular insulin sliding scale at meals.
7. Labetolol 1200 mg orally twice a day , holding for systolic blood
pressure of less than 90 or heart rate less than 60.
8. Lactulose 30 ml orally four times a day as needed constipation.
9. Senna tablets two tablets orally twice a day
10. Simvastatin 20 mg orally at bedtime.
11. Norvasc 10 mg orally daily , holding for systolic blood
pressure of less than 90 or a heart rate of less than 60.
12. Neurontin 200 mg orally daily.
13. Nephrocaps one tab orally daily.
14. Flomax 0.4 mg orally daily.
15. Celexa 20 mg orally daily.
16. Prilosec 20 mg orally daily.
17. Coumadin 4 mg orally every afternoon
18. Aspirin 81 mg orally daily.
19. Lisinopril 10 mg orally daily.
20. Gentamicin 60 mg intravenous post hemodialysis for the next five to
six days.
eScription document: 4-3051302 EMSFocus transcriptionists
Dictated By: MOOSE , BUCK
Attending: NORSETH , ARDELLA
Dictation ID 4742198
D: 5/24/05
T: 5/24/05
Document id: 1058
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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510946735 | PUO | 03371550 | | 899504 | 11/26/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/11/1995 Report Status: Signed
Discharge Date: 11/19/1995
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION
OTHER PROBLEMS: 1. STATUS POST CHOLECYSTECTOMY
2. ASTHMA
HISTORY OF PRESENT ILLNESS: The patient is a 41 year old
Afro-American woman who has the
diagnosis of inferior wall myocardial infarction on 4/26/95
transferred from Clagib Toner Community Hospital for postmyocardial infarction
angina.
CARDIAC RISK FACTORS: Hypertension , smoking , family history of
coronary artery disease , and CVA. No
diabetes. She is not postmenopausal , no history of elevated
cholesterol. No previous myocardial infarction history.
Two and a half weeks prior to admission while sorting mail , she had
20 minutes of Cushing substernal chest pressure , increased
shortness of breath with diaphoresis and radiation down the left
arm and across to the right chest. Initially , she thought she had
gastrointestinal distress. Pain often appeared 1 to 2 hours after
eating , was not associated with exertion , and is questionable if
affected by position. There were no EKG changes. In the intervening
period she had several additional episodes of this pain and
presented to CHH where she was treated with Disalcid and Tagamet.
The pain persisted in a crescendo pattern until 4/26/95 when she
presented to CHH with a complaint of two days of unrelenting chest
pressure. She was sent to Clagib Toner Community Hospital where she ruled in for
myocardial infarction with a CK equal to 1508 MB fractions. MB of
126 with a peak of 1900 on 8/6 EKG demonstrated Q waves in 3 and
ADF. T waves aversions of 2 ST segment depressions in V2 through
V5. She was treated with intravenous nitroglycerin , heparin , oxygen ,
diltiazem , Metoprolol and aspirin. She apparently had additional
pain while on this regimen and was transferred to the Pagham University Of for catheterization and management.
MEDICATIONS: Her medications as an outpatient were only
hydrochlorothiazide 25 mg every day. Upon transfer her
medications included Colace 100 mg twice a day , aspirin 325 mg once a
day , Diltiazem CD 240 mg once a day , Metoprolol 25 mg twice a day , intravenous
nitroglycerin , intravenous heparin , and Percocet for pain.
ALLERGIES: No known drug allergies , but has an allergy to seafood
- she gets hives.
FAMILY HISTORY: As above. Coronary artery disease and
cerebrovascular accident in the early 40's in both
her father and mother.
SOCIAL HISTORY: She smokes one pack a day of cigarettes for the
past 20 years with occasional alcohol.
PHYSICAL EXAMINATION: Upon admission to the Coronary Care Unit at
the Pagham University Of is notable
for a blood pressure of 130/85 , the pulse is 79 , respiratory rate
of 16 to 20 on three liters of 100% face mask. HEENT exam -
sclerae are anicteric , pupils equal and reactive to light ,
extraocular movements are intact , oropharynx were clear. There were
no carotid bruits , jugular venous pressure at 6 cm flat. Chest -
there was a poorly healed scar on the anterior chest. Lungs were
clear to auscultation and percussion bilaterally. No CVA
tenderness. Cardiac exam - PMI nondisplaced , regular rate and
rhythm , normal S1 , split S2. There is a 2 out of 6 whooshing
crescendo/decrescendo systolic murmur at the left upper sternal
border that radiates to the apex. There was an S4. Abdomen - obese
with a surgical scar in the right upper quadrant. No
hepatosplenomegaly. Femoral pulses are intact with a right bruit.
Extremities were without edema , symmetrical distal pulses.
Neurologic exam was nonfocal. Reflexes were intact. Toes were
downgoing bilaterally.
LABORATORY ON ADMISSION: Notable for potassium of 3.8 , a white
blood cell count of 13.6 , hematocrit of
37.8 , platelets of 179 , magnesium 2.3 and CK of 201 , physical therapy-PTT 13.2 ,
59 with an INR of 1.2. Urinalysis was notable for 25 to 30 white
blood cells , 5 to 10 red blood cells , 2+ squamous cells , 1+
leukocyte esterase. There were no effusions or evidence of failure
on chest x-ray.
HOSPITAL SUMMARY: On admission this is a 41 year old woman with
multiple cardiac risk factors who ruled in for
an inferior wall myocardial infarction and is now experiencing
postmyocardial infarction pain either secondary to current angina
versus pericarditis , although there was no EKG evidence to support
this. In the FTTCH she was treated with heparin , beta blocker ,
aspirin. Calcium channel blocker was discontinued. intravenous
nitroglycerin was continued , oxygen. The patient was scheduled for
a catheterization of the heart the morning after transfer with
pretreatment of 60 mg of Prednisone x two for history of shellfish
allergy. The patient underwent cardiac catheterization on 10/12/95
with the results being right atrial filling pressure of 8 ,
pulmonary capillary weight pressure of 12. There was a third OM
( first large OM was noted to have a thrombus nonobstructive with
good distal flow. ) The remainder of the coronary arteries were
deemed normal. On the 7 of October , the patient was transferred
out of the Coronary Care Unit to the stepdown unit. Of note ,
postcatheterization femoral pulses were 1+ bilaterally with a bruit
on the right which was there prior to catheterization. An
echocardiogram done demonstrated an ejection fraction of 45 to 50%
with posterior hypokinesis and mild mitral regurgitation. On the
7 of October , the patient was noted to have a white blood cell
count of 20.7 at this time , PTT of 74.3. EKG was notable for T wave
inversions in 2-3-S , V2 through V6 which were seen on EKG's from
1/7 The patient's MI was felt to be consistent with a lesion
from the thrombus seen on catheterization. It was thought at this
time that the increased white blood cell count was most likely
secondary to the Prednisone given as pretreatment prior to
catheterization. The patient's does of Lopressor was increased to
75 mg four times a day to achieve a heart rate in the 60's. She was
continued on the stepdown unit on Heparin , intravenous nitroglycerin and
continued on cardiac monitor. On the 29 of July , the patient
had an episode of recurrent pain 3 out of 10 , radiating to the left
arm with no associated symptoms of nausea and vomiting , but slight
diaphoresis. At note , at this time , the intravenous nitroglycerin was being
weaned down. Her vital signs at this event were 130/90 with a pulse
of 80. Cardiac exam was notable for a normal S1 , S2 and S4 , no new
murmurs noted on exam. Lung was clear. EKG was notable to be a
sinus rhythm at a rate of 78 with T wave inversion and 3 and R
which were old , as well as ST segment elevations of 1 mm in V2
which were old and suitable normalization in V6. She was given one
sublingual nitroglycerin and the intravenous nitroglycerin was dialed up.
She was likewise given 5 mg intravenous push of Lopressor for recontrol and
Serax 15 mg x one. Her chest pain was reduced to 2 out of 10 with
these interventions with no radiation in the arm. She described it
as a heaviness. Blood pressure was 144/87 , pulse was 74. EKG at
this point was notable for sinus rhythm at 75 , normal intervals. T
wave inversions in 3R ST segment elevations of 1 mm in V2 , V3 , V5
with T wave sinusoidality and V6 T wave slightly inverted. intravenous
nitroglycerin was dialed up further , morphine 2 mg x 1 was divided
and oxygen two liters , nasal cannula was in place. Patient was
pain-free with these interventions and a second 5 mg intravenous Lopressor
was given for better late recontrol. Duration of total episode was
approximately 20 minutes. The pain-free EKG was notable for a rate
of 78 wit V5 T wave more upright than sinusoidal and V6 T wave
upright , else no change. The intravenous TNG was dialed up further for a
blood pressure of 129/76 and rate was now 70. A second bolus of intravenous
morphine was obtained at this time. CK and Isoenzymes were sent
and Cardiology attending was made aware. The patient was made NPO
in case of any need for catheterization the following morning if
symptoms were to recur. The CK following this event was magnified
with a triponin I of 14.1. On the 29 of July it was deemed
appropriate to continue with the intravenous heparin one more day and
control symptoms with intravenous nitroglycerin. if the symptoms were to
increase , it was still deemed appropriate to considering this
patient for recurrent cath. On the 20 of February , the patient
returned to catheterization which demonstrated a discrete 90%
distal left circumflex stenosis. There was a PTCA performed of this
distal stenosis which left a residual 60% stenosis. A stent was
placed in the distal stenosis to provide a 0% residual stenosis.
The lesion in the proximal circumflex developed a greater than 50%
stenosis during the procedure , and two stents were placed in the
proximal left circumflex to provide a 0% residual stenosis for a
total of three stents in place in the left circumflex. EKG's were
stable postcatheterization. There was no remarkable hematoma in the
right groin. CK postcatheterization was 64. On the 18 of November
the patient's Lopressor was changed to Atenolol and the patient was
started on Coumadin for the stents. The patient at this time on
6 of October had a heart rate in the 68 to 75 range with a
blood pressure of 120/75% , O2 sats were 99%. As the patient was
being coumadinized on the 18 of February , she had a
supertherapeutic response coumadinization with an INR of 5.7. The
plan was to recheck the INR to secure a downward trend as well as
to start planning for discharge. On the 24 of April , the INR
was 4.6 , demonstrating a downward trend with a subsequent maximum
INR , while supertherapeutic , of 6.5.
DISCHARGE: The patient was discharged home on June with
followup with Dr. Barnaba and Dr. Dewitz at the Masta Medical Center
MEDICATIONS ON DISCHARGE: Aspirin 325 mg orally twice a day , Anusol
Suppositories one suppository pr every day ,
Atenolol 125 mg orally every day , Colace 100 mg orally twice a day , Lisinopril 5 mg
orally every day , nitroglycerin 1/150 one tablet sublingual every 5 minutes x
three as needed chest pain , Coumadin 4 mg orally bedtime , Axid 150 mg orally twice a day
Diet - low fat , low saturated and low cholesterol.
On discharge , patient was stable with followup as above.
Dictated By: VERLIE SWANDA , M.D. UV35
Attending: CARA C. BARNABA , M.D. HL86
GX146/3221
Batch: 19305 Index No. D8DFZJ0FJT D: 9/30/96
T: 9/30/96
Document id: 1059
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262260684 | PUO | 44536773 | | 0687806 | 3/10/2005 12:00:00 a.m. | R/O HEART BLOCK | Unsigned | DIS | Admission Date: 8/29/2005 Report Status: Unsigned
Discharge Date: 5/29/2005
ATTENDING: KATHERYN GRUNTZ MD
PROCEDURES DURING ADMISSION:
1. Insertion of a pacemaker , 8/16/05.
2. Electrophysiology study , 8/16/05.
3. Cardiac catheterization , 2/5/05.
ADMITTING DIAGNOSES:
1. Third-degree heart block.
2. Syncope.
3. Status post motor vehicle collision.
4. Rule out stroke.
PRINCIPAL DISCHARGE DIAGNOSES:
1. Third-degree heart block; resolved.
2. Status post motor vehicle collision.
3. Lateral and medial menisci tears , left knee.
4. Old CVA.
SECONDARY DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Diabetes.
3. Hypertension.
HISTORY OF PRESENT ILLNESS:
Mr. Vlasak is a 73-year-old gentleman who is a restrained driver
in a single car motor vehicle collision , in which the car went
off the road at a moderate rate of speed ( approximately 45 miles
an hour ) , and struck a telephone pole. There are no skin marks
noted at the scene. There was airbag deployment , and the patient
was wearing a seatbelt. The patient reports feeling "fine" prior
to the motor vehicle collision. However , he has no recollection
of the motor vehicle collision itself , and the next thing he
remembers is waking up and finding the airbag is deployed , and
being in severe pain. He does remember EMS arriving.
Upon arrival of the EMS , he was found to have a heart rate of 30
in a third-degree AV block. The patient denies any chest pain ,
shortness of breath , nausea or vomiting before the motor vehicle
collision. He also denies any fevers , chills , night sweats ,
shortness of breath , headaches or visual changes either before or
after. He had no recent changes in any doses of his medications.
He was also complaining of knee pain.
ED COURSE: In the Emergency Department , he was seen by the
Trauma Team. A full dictation of the Emergency Department
courses has been completed. Please see the computer for further
details of this dictation. However , in brief , he had numerous
CAT scans performed while in the Emergency Department. These
included a CAT scan of the abdomen and pelvis , head , and chest.
There was also a CT of the cervicothoracic and lumbar spine , with
reconstructions performed. As well as plain x-rays films of the
lower extremity as well a pelvis , C-spine , and chest. Of
significance , the plain films of the knee were negative. The CAT
scan of the chest demonstrated a right frontal periventricular
hypodensity , which was thought to represent a subacute infarct.
He was subsequently admitted to the Cardiac Step-Down Floor. He
was seen by the Neurology Service ( Dr. Richmann , who is the
Neurology resident ) , who initially saw him.
PAST MEDICAL HISTORY:
1. Significant for myocardial infarction , eight years ago. He
received cardiac stents at that time.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes.
5. Renal cyst.
6. Cataract.
PAST SURGICAL HISTORY:
1. Significant for coronary stenting; two were placed eight
years ago during his MI , and he had an additional two stents
placed in September of 2004.
2. Cataract removal.
MEDICATIONS AT HOME:
1. Glyburide 100 mg orally twice a day
2. Metformin 500 mg orally twice a day
3. Aspirin 81 mg orally every day.
4. Zocor 80 mg orally every day.
5. Plavix 75 mg orally every day.
6. Prilosec 20 mg orally every day.
7. Isosorbide dinitrate 40 mg orally three times a day
8. Atenolol 100 mg orally every day.
ALLERGIES:
He has no known allergies.
PHYSICAL EXAMINATION UPON ADMISSION:
Blood pressure of 123/51 , heart rate of 48 , respiratory rate of
16. General appearance: He is a well-developed , well-nourished ,
and well-hydrated male , in mildly acute distress. HEENT:
Normocephalic and atraumatic. Extraocular motions are intact.
Pupils are equal , round , and reactive to light and accommodation
at 4 mm. The conjunctivae are pink and the sclera is anicteric.
The oropharynx is significant for a slight bite mark on the
tongue , without any active bleeding. There are moist mucosal
membranes. The neck is supple , and there is no midline
tenderness. There is no JVD. The chest is clear to
auscultation. There is tenderness over the right ribs , as well
as mild sternal tenderness. The heart is regular rhythm ,
although markedly bradycardiac. The abdomen is soft , nontender ,
and nondistended. There are good bowel sounds in all four
quadrants. There is no CVA tenderness. The pelvis is stable to
rock. Extremities: There is tenderness in the abrasions over
the left knee. The left knee is in an immobilizer , at the time
of admission to the floor. He has full range of motion in
ankles , shoulders , and elbows bilaterally. There is decreased
range of motion in the left knee. There is no bony tenderness
along any of the long bones of the upper or lower extremities ,
with exception of the knee. Peripheral vascular , dorsalis pedis ,
posterior , tibial , and radial pulses are all equal bilaterally.
Neuro exam: He is awake , alert , and oriented x3. Cranial nerves
II-XII are intact. Motor is 5/5 in the upper and lower
extremities bilaterally. Sensation is equal bilaterally , in the
upper extremities , lower extremities , and face. There is no
dysmetria or dysarthria. Finger-to-nose is fast and accurate
bilaterally. There is no drift. Skin is warm , dry , and
well-perfused.
LABORATORY DATA UPON ADMISSION:
CT C-spine negative. CT head shows a right frontal subacute
infarct. CT chest shows anterior fifth rib fractures
bilaterally. There was also some supraclavicular stranding along
the left side , without any evidence of vessel injury. CT of the
abdomen and pelvis is negative , except for a ruptured renal cyst.
He was also incidentally noted to show diverticulosis , without
any diverticulitis. The CT of the thoracic and lumbar spines
also demonstrated no fractures , although there were incidentally
noted to be anterior osteophytes in numerous levels. CT of the
chest demonstrated the rib fractures , but was otherwise negative.
Laboratory , sodium 138 , potassium 4.4 , chloride 103 , bicarbonate
25 , BUN 28 , creatinine 1.3 , glucose 185 , and anion gap is 10 , AST
and ALT are 20 and 25 respectively. Alkaline phosphatase is 80.
Lipase is 51. Calcium is 8.8 , the albumin is 4.6 , the CK is 89 ,
CKMB is 3.6 , and troponin was less than assay. His serum
toxicology screen was negative for aspirin , Tylenol ,
benzodiazepine , barbiturates , and tricyclics. Urine drug screen
is also negative. physical therapy , PTT , and INR were 13 , 25.8 , and 0.9
respectively. CBC was significant for white count of 12.0 ,
hemoglobin and hematocrit were 14.6 and 42.2 , and platelets are
250. Urinalysis was negative.
Review of the prehospital EKG demonstrated a complete
( third-degree ) heart block. However , EKG done immediately upon
admission to the Petersram Medical Center demonstrated a bifascicular block ,
with a rate in the 40s.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: He was admitted to the Cardiac Step-Down
Unit. He had Zoll pacer pads were placed upon his chest , and
atropine remained at his bedside. He also had an additional Zoll
pacer pads , as well as the pacemaker standby at the bedside ,
however , these were not needed , as he has completed asymptomatic
with his bifascicular block. He had serial enzymes , which were
performed , he was ruled out for myocardial infarction. He went
to the Cardiac Cath Lab , which demonstrated some coronary artery
disease. Please see the dictated cardiology reports for the
findings of the Cath Lab. It was felt , however , this was
unchanged from prior studies. He also went to the
Electrophysiology Lab. They were unable to induce any
ventricular tachycardia or other dysrhythmias during the
prolonged EP studies. He had a pacemaker inserted. The
pacemaker was followed by the Electrophysiology Service , and was
found to be working adequately. The attending was Dr. Ava Schoeppner , with the Electrophysiology Service. Dr. Gruntz with the
Cardiology Service saw him and was attending on record.
2. Neurology: He was seen by the Neurology Service. So , this
was under Dr. Fiona Authur , the attending neurologisT on the
case. He had an MRI/MRA performed of his head and neck. The
diffusion-weighted images demonstrated no evidence of any
abnormality. There was a region of increase signal intensity on
the T2 and FLAIR images , involving the vasoganglion , extending
the corona radiata. Therefore , given the fact that signal was
seen on the T2 and FLAIR , not on the diffusion-weighted , it was
felt that this was at least 10 days old. Therefore , this was not
felt to be either the cause nor an affect of the motor vehicle
collision. It was most likely represented an old CVA , which was
not previously detected. Given the fact that the patient
remained asymptomatic , and had a normal neurological exam , and
radiographic data demonstrated that this infarct was more than 10
days old , and this was not further addressed. An MRA of his head
and neck demonstrated tortuous vertebrobasilar system. The
MRI/MRA of the neck was essentially normal , however , the left
bifurcation was thought to be without any significant stenosis.
The right bifurcation is probably without significant stenosis ,
however , could not be completed excluded. Given artifact , this
could be further followed up with an outpatient venous duplex of
the carotid arteries.
3. Musculoskeletal: He was seen by the Orthopedic Service in
the Emergency Department at the time of the trauma , he ultimately
had an MRI that was performed of his knee. This showed tears of
the medial and lateral menisci. There was no evidence of
fracture. He remained in a knee immobilizer. He saw Physical
Therapy , which felt that further therapy would be indicated.
With the impression of the Orthopedic Service that no acute
intervention was needed , and that he should follow-up with Sports
Medicine or Orthopedics in approximately 3-4 weeks. In addition ,
he was noted to have several rib fractures. The rib fractures
were felt to be the source of his pain , he continue to complain
of some inspiratory pain throughout his chest. However , he
adamantly denied any pain throughout his chest wall upon
inspiring. It was therefore felt that given the negative enzymes
and the negative Cath , and the known rib fractures that the chest
pain was strictly a result of a musculoskeletal pain. This pain
was well controlled with the combination of Dilaudid and
oxycodone. He was encouraged to take several deep breaths per
hour to reduce the risk of atelectasis or pneumonia.
4. Infectious Disease: There was no evidence of any acute
infection. Of note , his white count was trending upwards , on the
last two days of admission. It was felt that this probably
represented stress , given all the recent procedures that were
done , including the catheterization and the electrophysiology
studies , rather than A2 infection. The chest x-ray was performed
on the 17 of August , which demonstrated no infiltrate. This was reviewed
with an attending radiologist who reported low lung volumes.
Otherwise , it was essentially negative. In addition , a repeat
urinalysis was performed. The results are pending at the time of
dictation , however , will be followed up prior to the patient's
discharge from the hospital. The patient appears well , and
states that he is feeling at his best since the accident.
However , further workup for his white count is not performed at
the present time , however , the patient is informed , as the Rehab
Hospital and the discharge summary , which show that the patient
seem to develop any evidence of infection that he should be
reevaluated by a physician.
5. Nutrition: The patient is able to eat without any
difficulty. He was eating regular house diabetic/cardiac diet.
6. Hypercholesterolemia: He was continued on his Zocor
throughout the hospitalization.
7. Prophylaxis: He was initially treated with Lovenox 40 mg
sub-Q. every day for a prophylaxis against DVTs. He is also on
aspirin and Plavix for secondary cardiac and neurological
prophylaxis. The Lovenox is discontinued , at the request of the
Electrophysiology Service on the 4 of April
8. Endocrine: Given the numerous contrast studies , initially
his metformin was held. However , he was later restarted on this.
In addition , he was continued on his glyburide and covered with
sliding scale insulin. His blood sugar was never any significant
problem during his hospitalization.
9. Disposition: The patient will be going to Rehab Facility , in
stable condition. At the Rehab , he will continue to get physical
therapy , which he has received in the hospital. It was felt that
a short course of rehab would benefit the patient to allow him to
go back living independently again. He will be discharged to the
Rehab in stable condition.
MEDICATIONS AT DISCHARGE:
1. Tylenol 650 mg orally every 4 hours as needed pain.
2. Aspirin 81 mg orally every day.
3. Atenolol 100 mg orally every day.
4. Colace 100 mg orally twice a day
5. Glyburide 5 mg orally twice a day
6. Dilaudid 1-2 mg intravenous every 4 hours as needed pain.
7. Isosorbide dinitrate 40 mg orally three times a day
8. Ativan 1-2 mg intravenous as needed anxiety.
9. Oxycodone 5-10 mg orally every 6 hours as needed pain.
10. Senna tablets 2 orally twice a day
11. Keflex 250 mg orally four times a day x12 doses. Keflex should be
completed on Monday night.
12. Zocor 80 mg orally every bedtime
13. Ambien 5 mg orally every bedtime
14. Tessalon 100 mg orally three times a day as needed cough.
15. Plavix 75 mg orally every day.
16. Novalog slides.
17. Prilosec 20 mg orally twice a day
18. Maalox 1-2 tabs orally every 6 hours as needed pain.
The patient has following discharge appointments. He has
appointments with Dr. Rosalyn Mcalmond , with Sports Medicine , Dr.
Ava Schoeppner in 10-14 days , and Dr. Victor Money in one
week. Appointment with Dr. Mcalmond is in 3 weeks.
ADDENDUM:
Mr. Vlasak had this pacemaker placed and was recovering
uneventfully. However , it was noted that he started having
increasing white count. It was felt this was perhaps due to a
mild urine infection and was started on Levaquin. However , he
started the next day complaining increasing pain in his knee. At
this time , his white count had risen to 23 , 000. The knee was
obviously a concern for possible infection. His knee was warm ,
was tender and was erythematous , compared to the contralateral
side. As a result , the Orthopedic Service was again consulted.
An arthrocentesis was performed on his left knee , this was a dry
tap; no fluid was able to be obtained. The subsequent day , he
was complaining of increasing pain , and the sed rate returned in
the 99 with a CRP of 190. The EP Service again evaluated the
patient , and felt that there was no evidence of any clear
infection from the pacer site. He continued to have no erythema
or tenderness around the pacer site. His chest x-ray was
essentially unremarkable. The next day ( 10/9/05 ) , he was seen
by the Rheumatology Service , under Dr. Strite who also felt this
was most likely to be prepatellar bursitis , probably septic in
nature , with a hematoma. He was asked to seen by the Infectious
Disease Service , under Dr. Lamorte and Abe Girardi
He was started on Ancef 1 gm every 8 hours A PICC line will be placed
later today on the 5/15/05 and he will be discharged to rehab.
Of note , he has been afebrile for more than 48 hours while on the
Ancef , and his white count has improved dramatically , into the
approximately 10000 range. He will continue to get intravenous Ancef
every 8 hours for an additional 12 days. New consultants on the case ,
again Dr. Lamorte and Dr. Abe Girardi with Infectious
Disease , Dr Brannigan and Dr. Claretha Hendy with Orthopedics and Dr.
Strite with Rheumatology.
eScription document: 6-7522492 IS
CC: Rosalyn Mcalmond M.D.
PUO /Sports Medicine
CC: Victor Money MD
Peake Xing Arl Arill Con Con
La Niiclatonla Spo
CC: Rossie Mankoski M.D.
Put Wathern Hospital
CC: Jeannette Lackner MD
Edsmen's Zelmcarlpe Pkwy.
A
CC: Ava Schoeppner MD
Cardiac Arrhythmia Service Pagham University Of
Ok Pacean Ttl
Valle Yonkers Leigh
CC: Katheryn Gruntz MD
Wa
Clairbcand St. , Jomore , Virginia 36426
Dictated By: MANKOSKI , ROSSIE
Attending: GRUNTZ , KATHERYN
Dictation ID 2448399
D: 5/2/05
T: 10/1/05
Document id: 1060
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431408937 | PUO | 16880402 | | 5581928 | 6/20/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 1/30/2006 Report Status: Signed
Discharge Date: 2/2/2006
ATTENDING: KERTESZ , ALETA M.D.
SERVICE: Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS: Mr. Chauvette is a 78-year-old
gentleman with history of ischemic cardiomyopathy and
myocardial infarction in 1998 with known ejection fraction of
20%. PET scan in October of 2006 revealed decreasing ejection
fraction and severe left anterior descending territory perfusion
defect. The patient was planned to be electively cathed , but has
deferred until now because of seasonal allergies. The patient
admits to baseline dyspnea on exertion. Cardiac catheterization
from 10/10/06 revealed the following: Left anterior descending
coronary artery with a proximal 85% stenosis and a mid 70%
stenosis , first diagonal coronary artery with an ostial 95%
stenosis , left circumflex coronary artery with a 90% ostial
stenosis and a 75% proximal stenosis , right coronary artery with
a 30% proximal stenosis , right dominant circulation.
Echocardiogram revealed an ejection fraction of 25% with mild
mitral insufficiency , trivial tricuspid insufficiency , moderate
pulmonic insufficiency , the mid and distal anterior septum ,
entire apex , posterior wall , basal inferior segment and basal
septum segments are akinetic. The anterolateral wall , basal
anterior septum segment , mid septum segment and mid inferior
segments are hypokinetic. Global right ventricular systolic
function is moderately reduced. The patient also has a history
of class III heart failure with marked limitation of physical
activity and recent signs and symptoms of congestive heart
failure including pulmonary edema on chest x-ray.
PAST MEDICAL AND SURGICAL HISTORY: Significant for hypertension ,
peripheral vascular disease , dyslipidemia , renal failure , peptic
ulcer disease with history of upper GI bleed and anxiety
disorder.
ALLERGIES: The patient has allergies to heparin , he is HIT
positive , and to sulfa where he develops a rash.
MEDICATIONS ON ADMISSION: Toprol 37.5 mg daily , quinapril 5 mg
daily , aspirin 81 mg daily , Claritin and Nasacort.
PHYSICAL EXAMINATION: 5 feet 8 inches , 63.2 kg , temperature
96.4 , heart rate is 79 and regular , blood pressure right arm
88/60 , left arm is 90/64 and O2 saturation is 94% on room air.
Cardiovascular regular rate and rhythm with no murmurs , rubs or
heaves. Peripheral vascular 2+ pulses bilaterally throughout.
Respiratory , breath sounds clear bilaterally with distant breath
sounds. Is otherwise noncontributory.
Admission labs; sodium 138 , potassium 3.9 , chloride of 104 , CO2
of 28 , BUN of 23 , creatinine 1.1 , glucose of 119 and magnesium
1.8. WBC 8.02 , hematocrit 40.7 , hemoglobin 13.6 , platelets of
134 , 000. physical therapy 14 , physical therapy-INR of 1.1 and PTT of 29.1. Carotid
noninvasives were also performed , which revealed a left internal
carotid artery with 25-49% occlusion and a right internal carotid
artery with a 1 to 25% occlusion.
HOSPITAL COURSE: Mr. Chauvette was brought to the operating room on
8/19/06 where he underwent an elective coronary artery bypass
graft x3 with left internal mammary artery to left anterior
descending coronary artery , saphenous vein graft to the first
obtuse marginal coronary artery and a saphenous vein graft to the
posterior descending coronary artery. Total bypass time was 85
minutes. Total crossclamp time was 65 minutes.
Intraoperatively , the transesophageal echocardiogram revealed an
ejection fraction of 25% with no tricuspid regurgitation. The
patient did well intraoperatively , came off bypass without
incident , was brought to the Intensive Care Unit in normal sinus
rhythm and in stable condition on epinephrine and Levophed.
Postoperatively , the patient did well. He required transfusion
of 1 unit of packed red blood cells for some postoperative anemia
and was transferred to the Step-Down Unit on postoperative day
#2. The patient was seen by the Physical Therapy Service and
recommended rehabilitation after discharge and he was cleared for
transfer to rehab on postoperative day #4. He otherwise has had
an unremarkable postoperative course.
DISCHARGE LABS: Sodium 140 , potassium 4.7 , chloride of 105 , CO2
29 , BUN of 18 and creatinine 1.0. Glucose 107 , magnesium 1.7 ,
WBC 10.11 , hematocrit 28.6 , hemoglobin 9.5 , platelets of 146 , 000 ,
physical therapy 13.8 , physical therapy/INR 1.1 and PTT of 29.9.
DISCHARGE MEDICATIONS: Vitamin C 500 mg twice a day , Lipitor 40 mg
daily , enteric-coated aspirin 325 mg daily , Lasix 40 mg daily for
three days along with potassium chloride slow release 20 mEq a
day for three days , Dilaudid 1 to 2 mg every 4 hours as needed pain , Motrin
600 mg every 8 hours as needed pain , NovoLog sliding scale before every meal and at
bedtime , NovoLog 4 units subcutaneously before every meal , Lopressor 25 mg four times a day ,
Niferex 150 mg twice a day and multivitamin therapeutic 1 tab orally
daily.
Mr. Chauvette will be transferred to rehab in stable condition. He
will follow up with Dr. Aleta Kertesz in six weeks and his
cardiologist Dr. Cole Aini in one week. He is
discharged in stable condition.
eScription document: 7-7127472 CSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: KERTESZ , ALETA
Dictation ID 0036523
D: 1/18/06
T: 1/18/06
Document id: 1061
| Target |
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415352296 | PUO | 32764707 | | 831780 | 10/2/2001 12:00:00 a.m. | ? MYOCAEDIAL INFARCTION | Signed | DIS | Admission Date: 7/29/2001 Report Status: Signed
Discharge Date: 2/29/2001
HISTORY OF PRESENT ILLNESS: Mr. Plassman is a 51 year old gentleman
with history of insulin dependent
diabetes mellitus and unstable angina. The patient was doing yard
work in the afternoon when he experienced an episode of nausea and
vomiting along with chest discomfort. The patient presented to his
primary care physician who noted EKG changes with ST depressions in
V3 to V6 and was sent to the emergency room which was noted to have
an old T wave inversion in lead 3 which was now upright and ST
depressions that were normalizing. CKs at that time were 974 , MB
24.3 , Troponin level was 1.77. The patient received aspirin 5 mg
of intravenous Lopressor , Heparin drip and Adenosine MIBI which was
performed back in April of 1999 revealed inferior ischemia. The
patient underwent cardiac catheterization on June , 2001 which
revealed the following: Right dominant system , no significant left
main lesions identified , left anterior descending coronary artery
with a discreet mid 65% lesion , distal 99% lesion and first
diagonal coronary artery with a proximal discrete 70% lesion , left
circumflex coronary artery with a distal after the second obtuse
marginal discrete 60% lesion , supplying the second obtuse marginal.
First marginal coronary artery had an ostial discrete 90% lesion
and a second obtuse marginal had an ostial discrete 100% lesion.
Right coronary artery had a mid discrete 95% lesion supplying the
right posterior descending coronary artery. He was also noted to
have collateral flow from left anterior descending artery to the
right posterior descending artery. The patient underwent
echocardiogram on June , 2001 which revealed the following: 1.
There was mild concentric left ventricular hypertrophy with normal
cavity size. Left ventricular systolic function is mildly reduced
with an estimated ejection fraction of 45%. There is severe
hypokinesis of the basal and mid segments of the inferior wall and
inferior septum. In addition , there is severe hypokinesis of the
posterior wall , apex and distal anterior wall. THis is suggestive
of multiple coronary artery disease. 2. The right ventricle
appears normal in size and systolic function. 3. The mitral valve
appears mildly thickened. The anterior mitral leaflet is mildly
elongated and there might be mild systolic prolapse of the anterior
leaflet. Mild mitral regurgitation is seen. 4. The aortic valve
is trileaflet and appears mildly thickened. There is no aortic
stenosis or regurgitation. 5. The tricuspid valve appears
structurally normal. No significant tricuspid regurgitation is
seen. 6. There is no pericardial effusion.
PAST MEDICAL HISTORY/ PAST SURGICAL HISTORY: Significant for
insulin dependent
diabetes mellitus , hypertension , hypercholesterolemia , peripheral
vascular disease.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: On admission are Lisinopril 10 mg once a day , Zocor
40 mg once a day , vitamin E , enteric coated aspirin
325 mg every other day , NPH Humulin insulin 40 units in the morning
and 10 in the evening , regular insulin 6 units twice a day and
multivitamin.
PHYSICAL EXAMINATION: Noncontributory.
HOSPITAL COURSE: Mr. Plassman was rushed to the operating room on
January , 2001 where he underwent a coronary
artery bypass graft x 3 with a left internal mammary artery to left
anterior descending artery , saphenous vein graft to the obtuse
marginal coronary artery and saphenous vein graft to the
intermediate coronary artery. The patient did well
intraoperatively , came off bypass without incident , was brought up
to the intensive care unit in normal sinus rhythm and in stable
condition. Postoperatively , Mr. Plassman did very well. He was
extubated on postoperative day number one and transferred to the
step down unit. He had an unremarkable postoperative course until
the night prior to discharge when he was noted to have serous
drainage from the inferior aspect of his sternal incision. On
physical examination , he was noted to have no sternal click and his
white count did go from 9.2 on April to 11.26 on February . The
patient had a T.max of 99. We did start him on Keflex 500 mg four
times a day for 10 days and he will have a follow-up white blood
cell count on August , 2001 which shall be called into his primary
care physician. Mr. Bevilaqua other labs for February , 2001 are as
follows: Glucose 291 , BUN 20 , creatinine of 0.9 , sodium 136 ,
potassium 5 , chloride of 97 , CO2 of 31 , magnesium of 1.5. WBC was
11.26 , hemoglobin 9.2 , hematocrit 28.2 , platelets 438. physical therapy was
12.7 , physical therapy/INR of 1.1.
DISCHARGE MEDICATIONS: For Mr. Plassman are as follows: Enteric
coated aspirin 325 mg once a day , ibuprofen
200 to 800 mg every 4 to 6 h as needed pain , NPH Humulin insulin 44
units in the morning , 14 units in the evening , regular insulin 6
units twice a day , Niferex 150 mg twice a day , potassium chloride
20 mEq once a day , Zocor 40 mg once in the evening , Atenolol 50 mg
once a day , Lisinopril 10 mg once a day , Keflex 500 mg four times a
day for 10 days for his superficial sternal wound infection and
torsemide 60 mg twice a day.
DISPOSITION: Mr. Plassman will be discharged to home in stable
condition. He will follow-up with Dr. Gaylene Faniel in
six weeks , Dr. Cara Barnaba in two weeks and his primary care
doctor , Dr. Ogden in one week. He is discharged in stable condition.
Dictated By: PRISCILLA BARBELLA , P.A.
Attending: GAYLENE G. FANIEL , M.D. HK34
MH087/0365
Batch: 01302 Index No. U8SBY75L3Y D: 8/4/01
T: 6/2/01
Document id: 1062
| Target |
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547888517 | PUO | 64606051 | | 523396 | 2/6/2001 12:00:00 a.m. | ARRYTHMIA | Signed | DIS | Admission Date: 11/9/2001 Report Status: Signed
Discharge Date: 3/16/2001
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female
with a history of lupus , hypertension ,
asthma , breast cancer status post mastectomy and chemotherapy ,
rheumatic heart disease and atrial fibrillation who was found
pauses of up to 6.6 seconds on a Holter monitor and was admitted
for consideration of pacer placement. The patient states that over
the last several months since October , 2001 , she has noted
increasing dyspnea on exertion and decreased exercise tolerance.
She also has noticed episodes of palpitation. She presented to her
primary care physician in October , 2001 with these complaints. He
put a Holter monitor on her 10/1/01 which showed her to have
paroxysmal atrial fibrillation with rates between 67 and 214 with a
mean rate of 117 beats per minute. Her primary care physician , Dr.
Douse , initially put the patient on digoxin and Coumadin. Her
rate remained elevated , however , so he changed the Coumadin to
Cardizem. About one month ago he also added propafenone 150 mg
orally three times a day On 10/5 she presented to her cardiologist , Dr.
Bernas , complaining of continued palpitations and ankle edema.
He stopped her Cardizem at that time as he felt that was what was
contributing to her lower extremity edema and placed her on
atenolol 25 mg orally.every day instead. She had a leepy Holter monitor
placed from 8/29/23. Wednesday morning , her second day of
atenolol , she noted having episodes where "I felt my heart pause
and then surge when it started to beat again". This was associated
with lightheadedness x several seconds. She did not have any
associated chest pain , shortness of breath , nausea and vomiting ,
diaphoresis or syncope. She called Dr. Bernas on 6/16 and he
told her to stop her atenolol and continue her propafenone. Over
the last two days she has had flutter episodes of irregular heart
beat but has had no lightheadedness since stopping the atenolol on
Wednesday. She has noted increased shortness of breath over the
last couple of days , as well , on climbing one flight of stairs.
She also has orthopnea using two pillows at night , does not have
PND , does have lower extremity edema. On the day of admission
which was 10/25/01 Dr. Barnaba received a transmitted Holter recording
from Potwood Kinlis Wellscajohns Health Center that showed the patient had normal sinus rhythm with
episodes of atrial fibrillation with high rates but also that she
had episodes of 6.6 second pauses. Thus , she called the patient
and had her sent via ambulance to the I Warho Hospital
emergency department for consideration of admission for pacemaker
placement. In the emergency department the patient's vitals were
she was afebrile with a pulse of 112 , blood pressure 150/81 ,
breathing 18 , satting 95% on room air. Her review of systems was
negative for fever , chills , or sweats , chest pain , syncope ,
abdominal pain , nausea and vomiting , diarrhea , dysuria or rash. In
the emergency department she revealed 40 of intravenous Lasix and was sent
to the floor.
PHYSICAL EXAMINATION: GENERAL: She is a 52-year-old female
resting comfortably at 45 degrees , in no
acute distress. HEENT: Pupils equal , round and reactive to light
and accommodation. Oropharynx revealed moist mucous membranes , no
erythema. Neck veins appeared to be around 10 cm. CHEST:
Wheezing bilaterally and crackles at both bases. CARDIOVASCULAR:
Regular rate and rhythm , normal S1S2 , did have an S4 and did have a
3/6 holosystolic murmur loudest at the apex to the axilla. She
also had a 1/6 diastolic decrescendo murmur at the left upper
sternal border. ABDOMEN: Soft , nontender , nondistended , with good
bowel sounds. EXTREMITIES: Warm , well perfused. She did have 2+
lower extremity edema.
LABORATORY DATA: On admission. Sodium 146 , potassium 3.6 ,
chloride 117 , bicarb 19 , BUN 15 , creatinine 0.9 ,
glucose 120 , CK 76 , troponin 0 , CBC showed a white count of 8.73 ,
hematocrit 29.1 which was around her baseline. Her baseline had
been 30-38 on the last admission. Her platelets were 289. ESR was
75 which is what it had been in July . INR was 3.1
Chest x-ray showed cardiomegaly and pulmonary vascular
redistribution. Electrocardiogram showed a normal sinus rhythm at
94 with a normal axis , normal intervals. She did have left atrial
enlargement as well as right atrial enlargement. Her last echo
done at LMC on 10/13/01 showed an ejection fraction of 63% ,
concentric left ventricular hypertrophy , LV systolic function
preserved , a thickened mitral valve , moderate to severe mitral
regurgitation plus left atrial enlargement , aortic valve thickened ,
mild AI , no AS. Moderate tricuspid regurgitation , moderately
increased pulmonary artery pressures , normal RV plus her atrial
enlargement and they made notes that the mitral regurgitation was
increased on this echo when compared with an echo done one year
prior at LMC .
PAST MEDICAL HISTORY: 1. Breast cancer status post left
mastectomy with lymph node dissection
in 5/1 Pathology revealed invasive
ductal carcinoma , grade 3/3 , node
negative. She is status post four
cycles of Adriamycin and cytoxan.
2. History of lupus x 21 years.
3. History of rheumatic heart disease.
4. History of hypertension.
5. History of asthma diagnosed three years
ago.
6. History of recent atrial fibrillation.
MEDICATIONS ON ADMISSION: Lisinopril 40 every day; prednisone 10 every day;
Coumadin 5 every day; Prevacid 30 every day;
chloroquine 100 every day; Plaquenil 200 twice a day; Lasix 20 every day;
albuterol inhaler as needed; Flovent 220 2-3 puffs twice a day; Flonase
twice a day; propafenone 150 three times a day
ALLERGIES: Tetracycline which give her nausea and vomiting
and sometimes she got that with aspirin.
SOCIAL HISTORY: She is a nurse currently on a medical leave of
absence. She lives alone. Tobacco history she
does smoke 1 pack per day since she was 23. No ethanol.
FAMILY HISTORY: Brother with sarcoid plus a history of
hypertension. Father with prostate cancer.
HOSPITAL COURSE: 1 ) Cardiovascular: From an ischemia standpoint
she ruled out for a myocardial infarction. We
did continue her antihypertensive regimen of lisinopril 40 every day
From a pump standpoint we felt that perhaps her mitral
regurgitation was the main cause of her 2-3 month history of
increasing dyspnea on exertion , exercise intolerance , and
increasing orthopnea. Thus , we got a repeat echo which showed
borderline left ventricular hypertrophy with an estimated ejection
fraction of 55% , normal RV. The mitral valve was moderately
thickened and rheumatic in appearance. The mitral valve area was
estimated at 1.3 cm squared although this may have an under
estimate. There is severe mitral regurgitation and moderate left
atrial enlargement. The aortic valve was calcified. There was
mild aortic insufficiency. There was mild tricuspid regurgitation
with a regurgitant velocity of 3.5 consistent with mild elevation
in pulmonary systolic pressures of approximately 48 mmHg plus right
atrial pressure. Given her severe and symptomatic mitral
regurgitation we then decided that she would likely benefit from a
mitral valve replacement. Then we proceeded to cardiac
catheterization. Her left heart catheterization showed a left
dominant system with clean coronary arteries. Her right heart
catheterization revealed elevated right ventricular and pulmonary
artery pressures and elevated pulmonary capillary wedge pressure of
31. She was diuresed several kg from her admission weight with intravenous
Lasix and she was continued on her ace inhibitor for afterload
reduction. Consultation with Dr. Suyama of cardiothoracic surgery
was obtained and he felt that patient would indeed benefit greatly
from an MVR. Thus , plan was made for patient to be discharged home
and then to be readmitted electively when Dr. Suyama returned from
vacation for an MVR. From a rate and rhythm standpoint , the
patient was in normal sinus rhythm for the majority of her hospital
stay. We continued her propafenone and Coumadin for her history of
atrial fibrillation and she did have excellent rate control on
this. She had no further pauses on telemetry during hospital stay
and thus it was felt that given she was asymptomatic and did not
have any pauses off of beta blockade , that she did not need
pacemaker placement on this admission.
2 ) Pulmonary: From a pulmonary standpoint we felt that likely she
had cardiac asthma as with diuresis her wheezing and shortness of
breath was nearly 100% improved.
3 ) Rheumatology: From a rheumatologic standpoint her lupus was in
good control. She did not have of her typical lupus flare symptoms
such as arthralgias or rash , fever and , thus , we continued her on
her Plaquenil , her chloroquine and her prednisone.
4 ) Renal: She did not appear to have any renal involvement of her
lupus and her renal function was within normal limits throughout
her stay.
5 ) Heme: She had a normal cytic anemia at 29 which was within her
baseline range of 29-38. Full iron studies were sent and it was
felt that it was most likely consistent with anemia of chronic
disease.
6 ) Prophylaxis: From a prophylaxis standpoint she was on Coumadin
for atrial fibrillation so was not considered for heparin and she
was continued on Prilosec throughout her stay.
DISCHARGE MEDICATIONS: Plaquenil 200 mg orally twice a day; lisinopril 40
mg orally.every day; magnesium gluconate 2 grams
orally twice a day; prednisone 10 mg orally every day before noon; propafenone 225 mg orally
three times a day; Coumadin 5 mg orally.every day; K-Dur 60 mEq orally.every day; Flovent 220
mg inhaled twice a day; Flonase 2 sprays nasally every day for her allergies
and postnasal drip; Prevacid 30 mg orally.every day; chloroquine 100 mg
orally.every day; Lasix 80 mg orally twice a day
FOLLOWUP: She had an appointment to follow up with Dr. Bernas
in one week's time and to follow up with Dr. Suyama in
two weeks' time when he returned from vacation. At that time would
then follow up with an elective admission for MVR.
Dictated By: CLEORA GEKAS , M.D. OI99
Attending: CARA NEVA KENEKHAM , M.D. WA5
IL259/942290
Batch: 17370 Index No. LQDEDB1DQK D: 1/1/01
T: 6/26/01
Document id: 1063
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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842385275 | PUO | 27156611 | | 133894 | 2/25/2002 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 3/19/2002 Report Status: Signed
Discharge Date: 1/23/2002
Mr. Bridenbaker is a 73-year-old gentleman who returned to I Warho Hospital to the emergency room on 8/20/02 with crescendo
spontaneous angina and shortness of breath. He is three and one
half months after a presentation with subacute left circumflex
thrombosis , ischemic mitral regurgitation , pulmonary edema and a
small nontransmural myocardial infarction. His angiography at that
time revealed diffuse coronary atherosclerosis with attenuation and
diffuse narrowing of the left anterior descending coronary artery
and a small codominant right coronary system with extensive diffuse
disease. Large circumflex system with focally severe and
additional diffuse but noncritical stenosis with superimposed
thrombus. Dilatation of the left circumflex resulted in extensive
dissection but with eventual achievement of a very good
angiographic and clinical result after placement of multiple stents
and that his course was that of gradual recovery and uneventful
return home.
He remained frail and limited prior to this admission and
approximately six weeks prior to admission , began to have
occasional pain and shortness of breath. He went to the cardiac
catheterization laboratory for intervention. He underwent a
rotablator procedure on 8/20/02 in the cath. laboratory which
resulted in perforation of circumflex coronary artery into the
pericardial space with extravasation of blood. He went into
cardiogenic shock which was alleviated by intra-aortic balloon pump
placement and was seen in consultation by the cardiac surgery
service for emergent coronary artery bypass grafting. He went to
the operating room on 8/20/02 where he underwent emergent coronary
artery revascularization. He sustained a retained rotablator burr
in the left circumflex system and a left circumflex perforation.
He underwent coronary artery bypass grafting x 5 with left internal
mammary artery to the left anterior descending coronary artery ,
saphenous vein graft to the posterior descending artery , saphenous
vein graft to the obtuse marginal #2 , #3 and #1 and removal of a
rotablator burr , repair of the left ventricular apex vent. site.
He came off bypass on 2 mcg of epinephrine and his intra-aortic
balloon pump. During his code in the cath. lab , the patient had
become hypotensive requiring intubation and intra-aortic balloon
pump placement as noted above. A Foley catheter was placed by the
urology service attending with much difficulty. His chest was left
open at the time of operation as the patient was coagulopathic and
Esmarch closure was placed.
His postoperative course: His coagulopathy was reversed with blood
products and his chest was closed without event on August , 02. He
was also seen in consultation by the diabetic management service to
help with his diabetic management. He continued to have
postoperative cardiac failure , remained on Dopamine , intra-aortic
balloon pump , was slowly weaned and diuresis ensued. His
intra-aortic balloon pump was removed on postoperative day three
uneventfully. He continued to make good improvement and was
extubated on postoperative day four and transferred to the
step-down unit. He had mild confusion but has had a history of
cerebrovascular accident in the past. He still requires diuresis.
Chest tubes remained in place for very high chest tube output. He
was seen in consultation by the vascular surgery service for his
severe peripheral vascular disease and painful right foot. He was
also continued to be followed by urologic service and his Foley was
left in place. He did have a bump in his BUN and creatinine and
renal consult was obtained and helps with management of his fluid
balance. He was also seen in consultation by the thoracic surgery
service for increased chest tube output , mainly from the right
pleural chest tube. His other chest tubes were discontinued
without any complications and his acute renal failure began to
resolve. He received Albumin and packed cells to correct
hypoalbuminemia and also his postoperative anemia along with Lasix
for diuresis. He continued to make slow improvement and advanced
nutritionally. He had a vascular MRI which was done as requested
by vascular surgery service in preparation for potential
revascularization to his right leg. He continued to improve. His
BUN and creatinine were 90/3.5 at their highest level and have been
slowly declining over the past several weeks to today's level of 47
for BUN and 1.3 for creatinine. He continues to have low blood
cell counts; his white blood cell count is 3 today and his
hematocrit is 32.8. Platelet count is 98. He will require
follow-up for these on a two times weekly basis. His MRI shows
mild irregularity of the distal abdominal aorta as well as the left
common iliac artery , mild narrowing over long segment about three
cm. over the right external iliac artery. There is moderate focal
narrowing in the right common femoral artery at the bifurcation
between the superficial femoral and deep femoral and there is
complete occlusion in the distal right superficial femoral artery
with reconstitution three cm further. Multiple areas of focal
narrowing are seen in the proximal and distal left superficial
femoral artery , high grade stenosis in the proximal left popliteal
artery. The posterior tibial artery on the right side is
completely occluded proximally. On the left side , there is high
grade stenosis in the anterior tibial proximally as well as
occlusion of the anterior tibial in the mid calf with
reconstitution distally and complete occlusion of the posterior
tibial artery at it's origin. Peroneal shows moderate posterior
stenosis. He has moderate to severe atherosclerotic disease in the
lower extremities with multiple areas of narrowing inclusion. He
is to follow-up with Dr. Rossie Mankoski , Division of Vascular
Surgery for revascularization of his lower extremities.
Mr. Bridenbaker is to be discharged on the following medications:
Meclizine 20 mg once a day , simvastatin 10 mg once a day , Lopressor
25 mg three times a day , enteric coated aspirin 325 mg once a day ,
Nystatin suspension 5 ml four times a day , swish and swallow ,
Miracle cream topical three times a day , Lupron 25.2 mg every 3 months
as Depot injection , NPH insulin Humulin 16 units subcutaneously every
morning , regular insulin 6 units subcutaneously every morning , Lasix 40 mg
once a day , NPH insulin 10 units subcutaneously at 4:30 p.m. pre-dinner ,
please and also Humulin , Ditropan 2.5 mg three times a day. CZI
sliding scale , Percocet one tablet every 6 to 8 h as needed for
foot pain , Albuterol nebulizer 2.5 mg every 6 hours by neb for
wheezing , Atrovent nebulizer 0.5 mg four times a day for wheezing ,
Imodium 2 mg by mouth every six hours as needed for diarrhea.
He is to be discharged to the care of Dr. Loida Golebiowski , Division
of Cardiology , I Warho Hospital and also to Dr. Tommye Andracki I Warho Hospital , Wa Land as above.
Dictated By: CHRISTY CLARDY , P.A.
Attending: ISABELLE E. COLASAMTE , M.D. CL7
EZ888/070674
Batch: 8124 Index No. H8QTCP18EL D: 4/5/02
T: 4/5/02
CC: ROSSIE MANKOSKI , M.D. EX35
QUINN J. KUSH , M.D. PQ5
TOMMYE ANDRACKI , M.D. LP8
Document id: 1064
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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833886231 | PUO | 11020818 | | 9141097 | 3/18/2005 12:00:00 a.m. | HYPOTENSION | Signed | DIS | Admission Date: 8/18/2005 Report Status: Signed
Discharge Date: 10/2/2005
ATTENDING: FIERMONTE , EARNESTINE M. M.D.
PRINCIPAL DIAGNOSES:
1. Acute renal failure.
2. Hypertension.
SECONDARY DIAGNOSES:
1 Hypertension.
2. Diabetes mellitus.
3. Hyperlipidemia.
4. Status post coronary artery bypass graft in 1995 with left
internal mammary artery to left anterior descending graft ,
saphenous vein graft to posterior descending graft , and saphenous
vein graft to obtuse marginal 1 graft.
5. Recent Kernan To Dautedi University Of Of admission in September 2005 , for congestive heart
failure exacerbation , treated with furosemide drip and
subsequently discharged to home on orally torsemide.
6. A non-ST elevation myocardial infarction in 2000 , status post
percutaneous coronary intervention with right coronary artery
stenting with 5 drug-eluting stents.
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female
with a history of coronary artery disease , status post a CABG in
1995 and a non-ST elevation MI in 2000 , also with a history of
idiopathic cardiomyopathy , status post a biventricular pacer and
ICD placed in 2003 , who presents with hypertension to the Kernan To Dautedi University Of Of
ED with a systolic blood pressure in the 80s on home monitor and
also lightheadedness , fatigue , malaise for 2 days prior to the
date of admission on February , 2005. She reports taking poor
orally over the last 2 days prior to admission and stopping her
home dose of Imdur and labetalol , but continued to take the
torsemide and spironolactone.
In the ER , she presented and was found to have a creatinine of
2.8 from a baseline of 1.8 to 2.0. She was , therefore , for
hypertension and acute and chronic renal failure.
REVIEW OF SYSTEMS: She reports being fatigued , but denies chest
pain or shortness of breath. She also reports lightheadedness ,
but no rotational dizziness. No palpitations. Furthermore , she
describes having a mild headache and increased urinary frequency ,
but denies dysuria or hematuria.
ALLERGIES: Erythromycin , penicillin , and cephalosporin , which
give her a rash.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg daily.
2. Lipitor 80 mg daily.
3. Imdur 90 mg daily.
4. Labetalol 50 mg orally twice a day
5. Nexium 20 mg orally daily.
6. Aldactone 25 mg orally daily.
7. Colchicine 0.6 mg every other day
8. Potassium chloride 40 mEq every day before noon and 20 mEq every afternoon
9. Insulin NPH 47 units every day before noon and 12 units every afternoon
10. Colace 100 mg orally twice a day
11. Senna 2 tablets as needed constipation.
12. Torsemide 60 mg orally twice a day
13. Tylenol 325 mg daily.
14. Amiodarone 200 mg orally daily.
15. Synthroid 125 mcg orally daily.
SOCIAL HISTORY: The patient denies consumption of alcohol and
has no history of tobacco or injection drug use.
FAMILY HISTORY: Noncontributory.
ADMISSION PHYSICAL EXAMINATION: General: The patient was in no
acute distress. HEENT: Revealed a JVP at 8 to 9 cm of water.
Benign oropharynx. Moist mucous membranes. Pulmonary: Showed
no wheezes , rhonchi , or crackles , and a clear exam to
auscultation in both lung fields. Cardiovascular: Regular rate
and rhythm with a normal S1 and S2. No murmur , rub , or gallop
was appreciated. Abdomen: She had positive bowel sounds. She
was nontender and nondistended , obese , but no suprapubic
tenderness. No hepatosplenomegaly. Extremities: There is no
cyanosis , clubbing , or edema appreciated. She had 1+ dorsalis
pedis pulses bilaterally.
LABORATORY DATA: Pertinent laboratory findings at the time of
admission include hematocrit of 36.3 , white count of 7.7 , and
platelets 317 , 000. Sodium 138 , potassium 3.4 , chloride 96 ,
bicarbonate 28 , BUN 102 , and creatinine 2.8. Glucose was 88.
Otherwise , she was not coagulopathic and normal liver function
tests , and a negative set of cardiac enzymes. Her EKG on
admission showed she was ventricularly paced at 54 beats per
minute and that her EKG was unchanged from her prior EKG from
September , 2005.
HOSPITAL COURSE BY PROBLEMS:
1. Cardiovascular pump: Initially , the patient's Imdur and
labetalol were held out of concern for hypertension and poor
renal perfusion. However , on the hospital day #1 without intravenous
hydration and holding of her orally blood pressure medications.
Her creatinine returned towards baseline , value is 2.3. As such ,
the patient was restarted on her home Imdur on February ,
2005. However , her spironolactone continued to be held. In
addition , her torsemide was held. Her urine output was
monitored , revealed that she put out over 2 L on her second
hospital day. As such , the patient was started on home dose of
beta-blocker Toprol-XL 50 mg orally daily on hospital day #2 as
well as once daily dosing of her torsemide 60 mg. The patient's
creatinine continued to improve. It was felt that the patient
was achieving good forward systolic flow and then her
hypertension was resolved with blood pressures ranging from the
130s to 150s on hospital day #2. However , over the course of
hospital admission , the patient was felt to be retaining fluid
with a weight of 99 kg , up from an admission weight of 97 kg. As
the patient had previous admissions for pulmonary edema and CHF
exacerbation , it was felt that the patient should be more
aggressively diuresed to prevent pulmonary edema. As such , the
patient restarted on her home torsemide 60 mg , however , continued
to gain weight and retained fluid. As such , the patient was
changed to 80 mg orally twice a day of Lasix 2 days prior to discharge
and was maintained on that dose achieving over 1 L of net
diureses on the 2 days prior to her discharge. She was
discharged on 80 mg orally twice a day of Lasix and achieves good effect
and maintaining adequate blood pressure.
2. Ischemia: The patient continued her home Lipitor and aspirin
doses for known coronary artery disease. However , overnight , the
evening of August , 2005 , and the morning of February ,
2005 , she developed irritant anginal pain radiating to her jaw.
Imdur had been held at admission for concern of hypertension , but
was restarted for her anginal pain and she responded well. There
were no EKG changes for this event , and her cardiac enzymes ,
which were excessive , currently negative. She was maintained on
aspirin , Lipitor , Imdur and as needed sublingual nitroglycerin for
the remainder of her admission. She had no further chest pain
events.
3. Rhythm and rate: The patient was ventricularly paced and
maintained on telemetry. She was continued on her amiodarone 200
mg orally daily over her hospital course and tolerated this with
good effect. She also continued her Coumadin at 1.5 mg orally
daily for known atrial fibrillation and achieved a therapeutic physical therapy
at 2.8. The patient had no complications or events from her
rhythm or rate standpoint.
4. Renal: The patient's creatinine returned to baseline by
hospital day #3. It was felt that her acute and chronic renal
failure may have been related to poor orally intake prior to
admission and subsequent hypovolemia. The patient had no further
issues from a renal standpoint and did not require aggressive
hydration , taking good orally On November , 2005 , the patient
developed an episode of 10/10 left flank pain with associated
nausea , but no vomiting , lasting 30 minutes , which she reported
was due to known gallstone in the neck of her gallbladder ,
identified by a CT of the abdomen without contrast within the
past year and by ultrasound in 2004. However , given the
dislocation of the pain , it was felt that this also may be
related to renal colic and as such , a CT of the abdomen stone
protocol was obtained on November , 2005 , which showed no
evidence of a kidney stone , however , did demonstrate once again
gallstone in the neck of the gallbladder. The patient responded
well to 30 mg orally codeine for pain control and had resolution of
her symptoms by August , 2005 , hospital day #3.
5. Gastrointestinal: The known biliary colic had resolved by
August , 2005. The patient was continued on as needed codeine
orally 30 mg every 6 hours and Tylenol 325 mg to 650 mg every 6 hours as needed The
patient did not require intravenous morphine , requesting not to use
narcotics , and had no further events of pain on her hospital
course.
6. Endocrine: The patient was initially started on her home
dose of NPH insulin 47 units every day before noon and 20 units every afternoon and
regular insulin sliding scale. The a.m. fingersticks were low ,
ranging from the 60s to the 70s as were her p.m. fingersticks.
This was felt to be due to decreased orally in the hospital
setting. As such , the diabetes service after consultation
recommended decreasing her NPH insulin dose to 35 units every day before noon
and her p.m. insulin to 10 units every afternoon The patient requested
minimal injections during her hospital course and at home. As
such , there was still preprandial insulin administered , as the
patient continued to express preference for twice daily
injections. The patient achieved goal fingersticks over her
hospital course and was discharged on regimen of NPH insulin. In
addition , a TSH was obtained during the hospital course which
showed a level of 19 , being elevated , as such her Synthroid was
increased to 150 mcg daily. She will follow up with her
endocrinologist to repeat her TSH and hemoglobin A1c.
7. Fluids , Electrolytes , Nutrition: The patient was restarted
on her K-Dur 40 mEq every day before noon and 20 mEq every afternoon for potassium loss
secondary to diureses. Her electrolytes remained stable over
course of her hospital stay. She was continued on a
low-cholesterol low-fat diet and ADA diet.
8. Infectious Disease: The patient had a UA with 8 to 10 white
blood cells , concerning for possible low-grade UTI , especially
given her initial presenting symptoms. As such , she was started
on a 3-day course of Bactrim , and completed this course. She
remained afebrile over the course of her hospitalization and her
urine culture , which showed only 50 , 000 colony-forming units of
mixed flora , her white blood cell count remained within normal
limits over her hospital admission. As such , no further therapy
was required.
9. The patient was discharged home on January , 2005 , with
VNA services.
PLAN FOLLOWING DISCHARGE:
1. To have her endocrinologist follow up her hemoglobin A1c and
to repeat her TSH level to maximize her insulin regimen as well
as her Synthroid regimen.
2. To have followup with Dr. Fiermonte in the Coumadin Clinic to
maximize her Coumadin therapy and ensure that she is therapeutic.
MEDICATIONS AT THE TIME OF DISCHARGE:
1. Amiodarone 200 mg orally daily.
2. Coumadin 1.5 mg orally daily.
3. Aspirin 81 orally daily.
4. Colchicine 0.6 mg orally every other day
5. Insulin NPH 35 units every day before noon and 10 units every afternoon
6. Synthroid 150 mcg orally daily.
7. Sublingual nitroglycerin 0.4-mg tablet 1 tablet every 5
minutes x3 days for as needed chest pain.
8. Toprol-XL 25 mg orally daily.
9. Imdur 90 mg orally daily.
10. Potassium chloride slow release 40 mEq orally every day before noon
11. Potassium chloride slow release 20 mEq orally every afternoon
12. Lipitor 80 mg orally daily.
13. Nexium 20 mg orally daily.
14. Lasix 80 mg orally twice a day
The patient has followup appointments with Dr. Buck Moose on
January , 2005 , at 10 a.m. and with Dr. Earnestine Fiermonte on
July , 2005 , at 11 a.m.; both of which are scheduled.
eScription document: 5-8630184 SSSten Tel
CC: Buck Diego Moose MD
A Na H Ny Boiseor Stam
I M Oaksster Derddownfayla
CC: Earnestine M. Fiermonte M.D.
PUO Cardiovascular Division
Bock Pit Paul
Manhishayard Y Ontlouis
Dictated By: MANKOSKI , ROSSIE
Attending: FIERMONTE , EARNESTINE M.
Dictation ID 0263092
D: 8/15/05
T: 8/15/05
Document id: 1065
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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253378606 | PUO | 24553429 | | 0078511 | 9/10/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 5/5/2006 Report Status: Signed
Discharge Date: 8/5/2006
ATTENDING: KERTESZ , ALETA M.D.
DISCHARGE DIAGNOSIS: Three-vessel coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old woman
from Tor Sa O Co , Rhode Island 96425 with type II diabetes mellitus , renal
insufficiency , hypertension and congestive heart failure. She
presented to Pagham University Of with an exacerbation of
her CHF , and despite negative enzymes , she was referred for
cardiac catheterization which revealed three-vessel coronary
artery disease. At that point , she was referred to the Cardiac
Surgery Service for surgical revascularization for her coronary
artery disease. The patient does have a history of stroke in
January 2005 with mild residual right-sided weakness. At the time
of admission , the patient had no complaints of chest pain , no TIA
or stroke symptoms. Her primary presenting complaint was
shortness of breath , which was worsening.
PAST MEDICAL HISTORY: Hypertension , peripheral vascular disease ,
status post stroke with extremity weakness of the right upper and
lower extremities , insulin-dependent diabetes mellitus ,
hypercholesterolemia , excessive bleeding while on Plavix in the
past , and uterine fibroids.
PAST SURGICAL HISTORY: Cholecystectomy.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is from Ence E Seatnix and has a large , supportive
family.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Toprol-XL 50 mg daily.
2. Amlodipine 5 mg daily.
3. Isordil 20 mg three times a day
4. Aspirin 81 mg daily.
5. Furosemide 40 mg twice a day
6. Spironolactone 25 mg daily.
7. Lovastatin 20 mg daily.
8. Nexium 20 mg daily.
9. Insulin NPH 36 units every day before noon and 32 units every afternoon
10. Insulin sliding scale with meals.
PHYSICAL EXAMINATION: Height 4 feet 11 inches , weight 95 kg.
Vital signs: Temperature 97 degrees , heart rate 65 , right arm
blood pressure 130/80 , left arm blood pressure 140/84 , and O2
saturation 98%. HEENT: PERRLA , sclerae are discolored , no
carotid bruits. Chest: No incisions , large body habitus.
Cardiovascular: Regular rate and rhythm , no murmurs.
Respiratory: Breath sounds clear bilaterally. Abdomen:
Horizontal right upper quadrant incision well healed , soft , no
masses. Extremities: Mild peripheral edema right greater than
left. Neuro: Alert and oriented , extremity weakness , right
upper extremities 4+/5 compared the left upper extremity , which
is 5/5. Pulses 2+ bilaterally at carotids , radials and femorals ,
2+ at the right DP; left DP and bilateral physical therapy's are present by
Doppler.
PREOPERATIVE LABS: Sodium 143 , potassium 4.5 , chloride 104 ,
bicarbonate 30 , BUN 45 , creatinine 1.6 , glucose 87 , magnesium
2.2 , BNP 18 , white blood cell count 8 , hematocrit 35.2 ,
hemoglobin 11.9 , platelets 313 , physical therapy 13.7 , INR 1 , and PTT 31.5.
Carotid imaging: Left and right internal carotid arteries , both
with 0% occlusion. Cardiac catheterization performed at Pagham University Of on 10/18/06 showed stenosis in the following
coronary arteries: 70% proximal PDA , 90% proximal LAD , 70% mid
circumflex with right dominant circulation. Ventriculogram
showed an ejection fraction of 35%. EKG on 4/5/06 showed
normal sinus rhythm with a heart rate of 63. There was poor
R-wave progression in the precordial leads and inverted T waves
in leads III , V5 and V6. Chest x-ray on 4/5/06 was consistent
with congestive heart failure and an enlarged cardiac silhouette.
There is mild CHF , bilateral atelectasis.
HOSPITAL COURSE: The patient was admitted on the day prior to
her scheduled surgery for completion of her preoperative workup.
On 5/26/06 , she was brought to the operating room where Dr.
Kertesz performed a CABG x3 using the LIMA to bypass the LAD and
saphenous vein graft to bypass the OM1 and saphenous vein graft
to bypass the PDA. The cardiopulmonary bypass time was 107
minutes and the aortic cross-clamp time was 83 minutes. The vein
was harvested from both legs. The patient was transferred to the
Cardiac Surgery Intensive Care Unit after her surgery where she remained
intubated for two days due to poor lung
compliance. She was also hypotensive in the postoperative period
and treated with vasoactive medications. By postoperative day
#2 , the patient was extubated and hemodynamically stable ,
however , she experienced atrial fibrillation overnight and her
Lopressor was increased. By post-operative day #3 , her atrial fibrillation
was rate controlled and she was started on Coumadin. By
postoperative day #4 , she was ready for transfer from the ICU to
the Step-Down Unit. At that point , she was neurologically intact
and her pain was well controlled. She was being treated with
beta-blockers and Coumadin for AFib. From a respiratory
perspective , the patient was being treated with aggressive
pulmonary toilet and chest physical therapy. Her chest x-ray showed a small
right pleural effusion and she was oxygenating well with
supplemental oxygen via nasal cannula. The patient's diet was
advanced as tolerated and she exhibited adequate urine output.
The patient was treated with Lasix for postoperative fluid
retention. She also was seen by the Diabetes Management Service
throughout her postoperative stay for optimal glycemic control.
On the step-down Unit on postoperative day #5 , the patient
experienced a bradycardic incident with a heart rate of 38 and
she became hypotensive with a blood pressure of 80/50 after her
diltiazem was increased. She was transferred back to the
Intensive Care Unit where she was observed for three more days.
During that time , the patient's hemodynamics stabilized although
she remained in rate controlled atrial fibrillation. On
postoperative day #8 , she was ready again to transfer back to the
Step-Down Unit where she spent the remaining six days of her
hospital stay. The patient's chest x-ray suggested that she was
volume overloaded and the patient was aggressively treated with
Lasix and Zaroxolyn as her creatinine began to increase slowly
from 1.3 to 1.5 to 1.7. The diuretics were decreased. A chest
ultrasound to evaluate pleural effusion for thoracentesis
revealed that the patient had considerable atelectasis and
minimal effusion. The focus then became on chest physical therapy , pulmonary
toilet and deep breathing and coughing. The patient continued to
ambulate with physical therapy and by postoperative day #13 , the
patient's chest x-ray showed improvement of the atelectasis in
the right lung and the patient had decreased oxygen requirements.
From a cardiac perspective in the Step-Down Unit , the patient
was in atrial fibrillation from postoperative days #9 through #11
and then converted to a sinus rhythm where she remained for the
final three days of her hospital stay. The patient had been
started on Coumadin for her postoperative atrial fibrillation and
this medication should continue at least until she follow up with
a cardiologist in an outpatient setting to reevaluated her heart
rhythm. By postoperative day #14 , the patient was in a sinus
rhythm with a stable blood pressure. She was oxygenating well on
room air and was ambulating effectively on her own. She had no
complaints and was ready for discharge to home. On that day , her
temperature was 96.4 degrees , heart rate 76 and sinus rhythm ,
blood pressure 110/60 , respiratory rate 18 , O2 saturation 94% on
room air. The patient was seven kilograms below her preoperative
weight.
DISCHARGE CONDITION: Stable.
DISPOSITION: Discharged to home with VNA Services.
DISCHARGE DIET: A low-cholesterol , low-saturated fat 2100
calorie per day , 4 gm sodium per day diet.
ACTIVITY: The patient should be walking as tolerated and elevate
her feet with prolonged periods of sitting.
FOLLOWUP APPOINTMENTS: The patient should arrange followup
appointments with her cardiologist Dr. Nina Surace at
575-803-4363 in one to two weeks. She should also see Ross Allegrini , NP in the diabetes Clinic in one to two weeks. Her
phone number is 919-088-7001 tyhgphlkk 1. Finally , the patient
should see her cardiac surgeon , Dr. Aleta Kertesz at 117-219-4079
in four to six weeks. The patient should arrange her followup
appointments as indicated , and upon return home to Ent Lau Cho ,
she should followup with either her primary care physician or
cardiologist who will follow her in the future.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg take one to two tablets every four hours
as needed for pain.
2. Enteric-coated aspirin 81 mg daily.
3. Diltiazem 30 mg three times a day
4. Nexium 40 mg daily.
5. Lasix 40 mg twice a day
6. Insulin NPH human 30 units every day before noon and 22 units every afternoon
subcutaneously.
7. Lovastatin 20 mg orally daily.
8. Toprol-XL 200 mg orally twice a day
9. Oxycodone 5 mg orally every 4 hours as needed pain.
10. Aldactone 25 mg daily.
11. Coumadin , the patient should take 3.5 mg on the evening of
10/28/06. The VNA should draw an INR on 10/4/06 and future
Coumadin dosing will vary for an INR goal of 2 to 3 and will
managed by the Diabetes Management Service at Pagham University Of Their phone number is 132-202-5576.
DISCHARGE INSTRUCTIONS: The patient's vital signs should be
monitored as well as her wound for signs or symptoms of
infection. The patient should shower daily and keep her
incisions clean and dry. The patient should breath deeply and
cough to open her lungs. She should continue to ambulate
frequently. The patient should be weighed daily and a physician
should be contacted if her weight , peripheral edema or work of
breathing noted to be increasing. The patient should continue to
take Coumadin as directed at least until follow-up with a
cardiologist.
eScription document: 8-8441995 CSSten Tel
CC: Aleta Kertesz M.D.
Prings Son
Surgery
A
CC: Nina Surace M.D.
Cardiology , Pagham University Of
O
Oak
Dictated By: MUMMA , MARYLOU
Attending: KERTESZ , ALETA
Dictation ID 8305277
D: 8/3/06
T: 8/3/06
Document id: 1066
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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185613886 | PUO | 62956387 | | 1367137 | 6/8/2006 12:00:00 a.m. | atypical CP | | DIS | Admission Date: 4/30/2006 Report Status:
Discharge Date: 1/18/2006
****** FINAL DISCHARGE ORDERS ******
FLAUDING , SANJUANITA 311-09-20-8
Ter U Wark
Service: CAR
DISCHARGE PATIENT ON: 7/25/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LYN , JR , FLOYD T. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled every 4 hours
as needed Shortness of Breath , Wheezing
Instructions: may change to q4-6h frequency at discharge
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally every day Starting IN a.m. ( 8/11 )
Override Notice: Override added on 5/14/06 by SZWEDA , ALFREDA A. , M.D. on order for COUMADIN orally ( ref # 120626584 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
COUMADIN ( WARFARIN SODIUM ) 7.5 MG orally every afternoon
Starting NOW ( 2/16 )
Instructions: WITHIN HOUR OF PHARMACY APPROVAL
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 5/14/06 by SZWEDA , ALFREDA A. , M.D. on order for ZOCOR orally ( ref # 993527399 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware Previous override information:
Override added on 5/14/06 by SZWEDA , ALFREDA A. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 5/14/06 by
SZWEDA , ALFREDA A. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
RAMIPRIL 5 MG orally every day HOLD IF: sbp < 100
Alert overridden: Override added on 5/14/06 by
SZWEDA , ALFREDA A. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
RAMIPRIL Reason for override: aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
AMIODARONE 200 MG orally every day
Alert overridden: Override added on 3/1/06 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: patient outpt regimen
DIET: House / NAS / Low saturated fat
low cholesterol (FDI)
ACTIVITY: Resume regular exercise
Full weight-bearing: as tolerated
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr Tompson ( 295 ) 614-2416 1/21/06 @ 1;30 pm ,
PUO Psych ( 982 ) 431-9166 Clinic will contact patient to schedule appointment ,
PUO Anticoag clinic ( 405 ) 082-3371 Clinic will contact patient with date and time ,
PUO Cardiology Dr Dorough ( 048 ) 968-4013 10/26/06 @ 2:30 pm ,
Arrange INR to be drawn on 4/13/06 with f/u INR's to be drawn every
7 days. INR's will be followed by coumadin clinic
ALLERGY: Morphine , Penicillins , Heparin , Beef , turkey
ADMIT DIAGNOSIS:
atypical CP , ? unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical CP
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) hyperchol ( elevated cholesterol ) obesity
( obesity ) cad ( coronary artery disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
exercise MIBI: 7'30" reached 85% max predicted HR , no perfusion defects
seen , EF 59% , no chest pain
BRIEF RESUME OF HOSPITAL COURSE:
Attending: Lyn
-----------
CC: chest pain
HPI: ( history from a patient who is inconsistent in giving details , with
contradictory stories to multiple providers ) 50 year-old man with history of HTN ,
hyperchol , hx MI 4/17 ( in Holl with no details ) , with obesity , +FHx of
CAD presents with story of unstable angina. CP began night prior to DOA
when he was sitting still watching TV , had palpitations , diaphoresis ,
dizziness/LH/nausea , and pain disappeared with 1 nitro sublingual. on DOA , 2
more episodes of CP , both resolved with nitro. last episode of CP
accompanied by syncope around noon , lost consciousness for 2-3 minutes ,
no incontinence , no head injury , but was alert and oriented after he
came to. no CP on exertion ( but +SOB ) , no PND/orthopnea or LE swelling.
no F/C/nt sweats/wt changes. no changes in bowel movements. +dry cough x
2days. patient also has sig psych history: mother and father both died within
the last yr ( although 2001 on ZH records ) , only brother died in 8/3
( 6/22/01 on ZH ) , no other family. in the past , has been worked up
multiple times for chest pain/ r/o MI , has history of of leaving AMA , refusing
medical intervention.
-------------------------
In the ED:
CBC , lytes , troponin
ASA 325mg given; lovenox 100mg x1
CXR: b/l pleural thickening ( asbestosis )
head CT: neg for bleeds
------------
ADMIT EXAM:
Vitals: 97.1 63 144/55 20 97%RA
GEN: obese , WDWN man in NAD
HEENT: PERRL , EOMI , sclerae anicteric , MMM , OP clear no masses no lesions
Neck: supple , no cervical LAD , JVP flat
Chest: CTAB no with r/r
CV: distant RRR nl s1 s2 , no m/r/g
Abd: obese s ND NT +BS no HSM no masses , +ventral hernia; well-healed
scar
Ext: 2+ DP/physical therapy pulses b/l , no c/c/e
Neuro: A&Ox3 , MAE , grossly nonfocal
------------
DAILY STATUS
5/18 threatened to leave AMA , still no records
10/28 records at RH in storage; resting dobutamine MIBI; still CP free
although patient states he has "30 sec episodes"
10/28 increased coumadin to 7.5mg; ECHO done ,
1/14 exercise MIBI showed XXX
----------
ASSESSMENT/PLAN:
50 year-old man with multiple past admissions ( last PUO admit 4/12 , last KAAH
admit 4/12/06 ) for ROMI , sig psych history , admitted for chest pain ,
story c/with unstable angina.
1 ) Cardiac: ( i ) patient with risk factors by history , but had nl cardiac exam ,
flat enzymes , nl EKG. Ruled out , low suspicion for ACS. stress test
( exercise MIBI ) 1/14 showed no perfusion defects after 7'30" exercise ,
reached 85% max predicted heart rate ( p ) euvolemic on exam.
given syncope story , obtained ECHO 10/28 which showed EF 60% , nl LV and RV
function , no WMAs , and LAE. ( r ) on telemetry , NSR.
---> cont asa , low BB , plavix , ACEi , zocor; Lovenox twice a day
---> fasting lipids high , HgA1C high ( 7.2 )
---> hold amio until records available , amio level pending; patient told to
resume home amiodarone dose
2 ) Heme: on coumadin at home , continue to titrate to INR goal 2 to 3;
follow-up scheduled with PUO coumadin clinic
3 ) asthma: cont albuterol as needed , no active issues
4 ) Psych: carries dx of mood disorder NOS from previous PUO admit in
2002. reported PMH completely contradicts records at PUO ( TH records
from SMCO pending ). ? munchausen syndrome. psych appt scheduled for
outpt f/u. psych consult called 10/28 to evaluate for ? thoughts of
hurting himself ( per conversations with cards care coordinator september petretti , although patient never admitted to thoughts of SI or HI to
housestaff )
5 ) FEN: cardiac diet as tolerated , replete lytes as needed
6 ) PPX: heparin allergy , lovenox , coumadin , PPI , bowel regimen
7 ) dispo: home when cardiac care plans finalized , PM 5/11/06. has f/u with
new primary care physician , cardiology , and psych
----------
FULL CODE
ADDITIONAL COMMENTS: 1 ) follow-up with you primary care physician after discharge from the
hospital ( already scheduled )
2 ) continue to take your heart medications regularly ( including coumadin
and amiodarone )
3 ) follow-up with the coumadin clinic regarding blood draws and
adjustments to your coumadin dose; continue lovenox shots twice daily
until coumadin clinic tells you to stop
DISCHARGE CONDITION: Fair
TO DO/PLAN:
1 ) f/u anticoagulation , adjust coumadin for INR goal 2-3
2 ) review cardiac medications , ? need for amiodarone ( patient to cont home
dose upon discharge )
3 ) outpt psych f/u
4 ) surgery referral for ventral hernia
No dictated summary
ENTERED BY: SZWEDA , ALFREDA A. , M.D. ( UV99 ) 7/25/06 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1067
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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961263184 | PUO | 29665945 | | 4174488 | 6/21/2006 12:00:00 a.m. | b | | DIS | Admission Date: 4/12/2006 Report Status:
Discharge Date: 1/10/2006
****** FINAL DISCHARGE ORDERS ******
KITA , LUDIVINA 567-67-41-4
Ni Ale Glend
Service: CAR
DISCHARGE PATIENT ON: 8/23/06 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAMBLET , BRITTANEY NICKI , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Starting Today ( 8/24 )
ATENOLOL 100 MG orally twice a day Starting Today ( 8/24 )
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Starting Today ( 8/24 )
Instructions: Please cut your lipitor 80mg tablet in half
using your pill cutter.
ZETIA ( EZETIMIBE ) 10 MG orally DAILY
HYDROCHLOROTHIAZIDE 50 MG orally DAILY
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 120 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 40 MG orally DAILY Starting Today ( 8/24 )
Instructions: Please take one 40mg tablet daily.
Alert overridden: Override added on 8/23/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override:
NIFEDIPINE ( SUSTAINED RELEASE ) ( NIFEDIPINE ( S... )
90 MG orally DAILY Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr. Rossie Mankoski St,ral Eni Medical Center 7/18 at 3pm scheduled ,
Cardiologist Dr. Hermina Tuomala 812-914-0910 Rougecentseastli Nither Hospital Medical Center 11/19 at 8: scheduled ,
Cardiac catheterization at PUO , please go to Admitting in the lobby to register at 7:30am , do not eat breakfast 11/25 at 7:30am scheduled ,
ALLERGY: GEMFIBROZIL
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
b
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN HYPERLIPIDEMIA
ATYPICAL C.PAIN STEMI 3/16 Echo 3/16 EF 60% , mild LVH , RV with
HK mi 8/17 history of RCA stent
8/17 DM ( diet-controlled ) chronic renal insufficiency ( chronic renal
dysfunction )
OPERATIONS AND PROCEDURES:
None.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
stress test
BRIEF RESUME OF HOSPITAL COURSE:
***CC: Chest pain
***HPI: 52M pastor history of NIDDM , HTN , hypercholesterolemia , and known
3-vessel CAD history of NSTEMI ( 2002 ) with failed angioplasty to Marg1 occlusion ,
CYPHER stent to RCA ( 2003 ) , recurrent unstable angina with last cath ( 8/27 )
with diffuse CAD precluding CABG/PTCA but with patent RCA stent , last
perfusion stress ( 8/27 ) with moderate rev ischemia in Diag/PDA territories ,
ETT ( 9/21 ) with CP and ST depression in inferolateral leads , last Echo
( 8/27 ) with EF 55-60% no WMA , physically active at baseline p/with CP. At
8:45am patient first noticed left-sided substernal pain/pressure after
breakfast and coffee while walking to living room , well-circumscribed ,
4/10 intensity , constant , without radiation to jaw/arm/back , worse on deep
inspiration , with associated nausea and dizziness. patient sat down with pain
2/10 , administered nitro spray x2 without relief , wife measured BP 158/90s
( usu 140/85 ). No other sx , but patient describes pain as similar but less
intense than that experienced in 2002 MI. Denies history of CP since then
despite recently active baseline ( yesterday washing windows/ climbing
ladders , over last months doing cement work in church ) , but notes DOE
with walking 2 blocks uphill. patient reports frequent prophylactic use of
nifedipine sprays immediately prior to exertion/activity. On 2/29/06 , patient
was evaluated for CABG by surgeon Dr. Janay Stukowski , who noted possible
candidacy for combined CABG/TMLR since diagonal likely too small to
bypass. Since patient was asymptomatic with nlm LVEF , he has remained on medical
therapy. Last visit to primary care physician Dr. Rossie Mankoski at Barbto Be Medical Center
on 5/17/06 was routine , and he is followed by cardiologist Dr. Hermina Tuomala
****ED Course: CP spontaneously resolved ( total duration 1hr ) prior to
arrival by car at PUO ED where VS Afebrile HR118 BP 150/68 RR18
98%RA. Received lopressor 5mg intravenous x1` HR 80s , ASA. ECG showed NSR@95bpm with
ST depression and T wave flattening in 2 , 3 , V5 , V6 different from prior ECG
7/3/06 , high voltage and LVH also present. Received heparin 5000U bolus
x1 and 1500U/heart rate infusion. Labs: CK 647 ( history of chronically elev CKs
400-1300s ) , CK-MB 3.8 , TnI <0.10 , WBC 6.41 , Hct 44.2 , Plt 228 , Cre 1.3 ,
PTT 33.6.
****ROS: patient notes ( intentional ) 20lb weight loss ( 215`195lb ) over last
month since starting metformin. Pertinent negatives include no systemic
complaints/ LOC/ change in vision/ diaphoresis/ cough/ orthopnea/ edema/
leg pain or claudication/ change in GU/GI habits.
****PMH/PSH:
*CAD ( 3-vessel as below )
-history of NSTEMI ( 2002 ) with recurrent UA
-L Cath 3/16 "Diffuse CAD precludes CABG/PTCA;" RCA stents patent;
Diag1 ostial 80% , Diag2 prox 80% , LCx prox 40% , LCx mid 50% , Marg1 ostial
100% ( collat LCx ) , Marg2 ostial 50% , RCA dist 100% ( collat to PDA from
RCA intracoronary ) , no sig LM/LAD lesions
L cath 9/13 Failed angioplasty Marg1 ostial 100% ( inability to
cross occlusion ) , no sig LM/LCx/LAD/RCA lesions
L cath 8/26 Cypher stent to RCA; RCA distal 100% , RCA prox 60% ,
RCA mid 85% , RCA mid 95% , LCx mid 35% , Marg1 ostial 100% 3/6
Failed angioplasty to Marg1 100%; RCA 90% , PDA 100%
- Stress: 11/13 ETT , std Bruce , 6.0 METS: 4/10 CP 3min , 1mm ST dep
in 2 , 3 , F , V5-6 , Duke -7 ( mod ) , HRR 13 3/16 Exercise MIBI SPECT , 7.0
METS: CP , 1mm ST dep in 2 , 3 , F , V5-6 , 65% APHR , rev ischemia in
Diag , PDA territories ( sum stress/diff 7/7 mild/mod )
6/20 Ex MIBI SPECT , 7.6 METS , CP , no perf defect
1/25 Ex MIBI SPECT , 6.4 METS , CP , rev isch LCx territory , sum
stress/diff 7/5 )
7/14 Ex MIBI SPECT , 7.6 METS , CP , rev isch LCx , PDA territory
scar , sum stress/diff 15/11 ) 1/26 Adeno MIBI SPECT , no perf defect ,
sum stress 2
5/9 ETT , std Bruce 56%APHR , CP 4min , 1mm ST dep 2 , 3 , F
-Echo: 3/16 LV nlm size , EF 55-60% , no WMA , thick MV , mild
RVE/RAE , trace MR/PR 7/25 ( Stress ): EF 55-60% , nlm ventricular
contractility 3/6 EF 55-60% , mild concentric LV hypertrophy , no
WMA , thick MV , trace MR/PR
-CT/A Ch/Abd/Pel ( 9/21 ): nlm Ao without dissection/aneurysm
*NIDDM ( 2005 ) , HgbA1c 7.1 ` Metformin 1mo ago
*Hypercholesterolemia ( <2000 ) -history of elev CKs ( 400-1300s on gemfibrozil ,
statins )
*HTN ( 1996 )
*chronic renal insufficiency , bl Cre 1.2
refused renal MRA 5/1
*Carotid stenoses ( 2006 ) , R ICA 55-60% , L ICA >50% asx
*Erectile dysfunction history of penile prosthesis placement
****MEDS ( pre- admission ): ASA 81mg orally qdayAtenolol 100mg orally
BIDLisinopril 80mg orally qdayImdur ER ( isosorbide ) 120mg orally qdayLipitor 80mg
orally qdayZetia ( ezetimibe ) 10mg orally qdayHCTZ 50mg orally qdayMetformin 500mg orally
qdayNifedipine ER 90mg orally qdayNitroglycerin 0.4MG/SPRAY orally x1 as needed chest
pain
****ALLERGIES: Gemfibrozil ` elev CK ( 400-1300s )
****SH: Denies history of tob/EtOH/drugs. patient lives in North Dakota with wife of 30yrs ,
3 grown children , 5 grandchildren all healthy. Pastor at Ph x30yrs.
****FH: Significant history of DM , HTN. Father 91yo history of MI ( 62yo ) , CVA ( 76yo ) ,
HTN , DM. Mother 80yo history of HTN , DM , identical twin history of HTN , DM. Denies history of
cancer.
****PHYSICAL EXAM:VS: T 98 HR 63 reg BP 126/67 RR 18 O2Sat 98%
RAGen: black male in NAD , lying in bed , pleasantHEENT: PEERLA , MMM ,
oropharynx clearCV: nlm S1 , S2 , no murmur JVP ~8cm , No obvious
carotid bruits bilat , symmetric No bruit at fem groove bilat , DP 2+
bilatResp: mild bibasilar crackles , no wheeze , no accessory muscle
useAbd: Soft , NT , obeseSkin & Ext: WWP , no edema , nails unremarkable
( remnant red paint )Neuro: A&Ox3 , CN II-XII grossly intact
****ADMISSION LABS: WBC 6.4 , hct 44 , Cr 1.3 , enz neg , ddimer 530s
****ADMISSION EKG ( 4/30 ): NSR@95bpm with ST depression and T wave
flattening in 2 , 3 , V5 , V6 different from prior ECG 7/3/06 , high voltage
and LVH also present. Radiology:
****ADMISSION CXR ( 4/30 ): nlm heart , clear lungs , no
PTX/edemaMicrobiology:UA , USed ( 4/30 ): WNL
****STUDIES:
-ETT MIBI: abnormal imaging - preliminary results showed that he stopped
after 5 minutes due to chest pain , 1mm ST depressions in inferior and
lateral leads , and mild ischemia in Diag1 territory which raises concern
for balanced ischemia.
****ASSESSMENT and PLAN:
52M pastor with unstable angina in setting of known 3-vessel CAD history of stent
to RCA '03 last cath 6 of July with diffuse CAD precluding CABG/PTCA , medically
managed and asymptomatic until present. Vitals stable , enzymes negative ,
stress test with abnormal perfusion.
CV *ischemia* Known 3vd history of stent. Rest chest pain. NSSTT
inferolaterally , Negative enzymes. Stress test prelim read shows
abnormal perfusion: stopped after 5 minutes due to chest pain , 1mm ST
depressions in inferior and lateral leads , mild ischemic in Diag1
territory which is concerning for "balanced ischemia" rather than an
improvement compared to previous nuclear imaging in 8/21 Inpatient cardiac
cathterization advised by medical
team but refused by patient patient opts to be discharged and follow up for
elective cardiac catheterization on Tue 9/3 The risks of this plan were
discussed with him by his outpatient cardiologist , Dr. Hermina Tuomala
While an inpatient , patient was medically managed with ASA , hep drops , statin ,
bb , acei. Lipid panel checked with TC 101 , tri 89 , HDL 41 , LDL 31. Statin
dose lowered for persistently high CK. Acei dose lowered as marginal BP
effect above ULN dose. Heparin drops was discontinued prior to discharge.
On discharge , patient instructed to take ASA , bb , acei , imdur , lipitor , zetia.
He was advised to discontinue metformin for 2 days before and 2 days
after cardiac catheterization. He was advised to be minimally active
and to call his physician or 911 if he experienced any further chest pain ,
shortness of breath , palpitations , lightheadedness or any other symptoms c
concerning to him.
*pump* Appears euvolemic. Nl EF. HTN controlled as above with bb , acei.
*rhythm* Sinus rhythm. patient continued on home atenolol.
RENAL: *CRI* Possibly related to HTN/DM. patient with Cr 1.3 , within baseline.
ENDO: *DM* Metformin held. patient rx'ed with SSI. HgA1c checked and pending.
TSH also checked and pending.
PROPH: nexium/heparin drops
CODE: FULL
DISPOSITION: patient discharged to home with plans for elective outpatient
cardiac cathterization , cardiology , primary care physician f/u
DISCHARGE STATUS: afebrile P 50s-90s SBP 120s/70s sat RA
Exam without significant change from admission. Labs with Hct 40.2 , Cr 1.2
ADDITIONAL COMMENTS: You were admitted with chest pain. Your blood tests show that you did not
have a heart attack. You had a stress test which is concerning for regions
of your heart not receiving enough blood flow. The medical team
advised cardiac catheterization during this admission , but your plan is to
go home today and return for an elective outpatient cardiac catherization
on Tuesday 11/25 at 7:30am. Please go to the Admitting Office on the Jo Win I to register. Do not eat anything after midnight Monday
night. Do not eat breakfast or drink liquids after midnight. Your
medications have been changed as follows: a ) stop
taking metformin for 2 days before and 2 days after your cardiac
catheterization b ) take lisinopril 40 mg daily instead of 80 mg daily
c ) take lipitor 40 mg daily instead of 80 mg daily. Do not do any
significant exertion until your cardiac catheterization. Call your doctor
or go to the ED if you experience any further chest pain , dizziness ,
palpitations , shortness of breath , or other symptoms concerning to you.
DISCHARGE CONDITION: Fair
TO DO/PLAN:
primary care physician/cards:
-f/u official results of stress test
-f/u results of outpatient cardiac catheterization
( prehydration/mucomyst peri-cath )
-f/u results of HgA1c and TSH
No dictated summary
ENTERED BY: NOAKES , MARLEEN D , M.D. ( NK97 ) 8/23/06 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1068
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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067302414 | PUO | 57138785 | | 190728 | 5/24/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/20/1996 Report Status: Signed
Discharge Date: 9/3/1996
PROCEDURES: 1. Cardiac catheterization on 4/9/96. 2.
Angioplasty of an RCA and PDA lesion on 7/24/96. 3.
Carotid ultrasound on 7/18/96. 4. Cardiac echo on 7/18/96.
PRIMARY DIAGNOSIS: CORONARY ARTERY DISEASE , STATUS POST
ANGIOPLASTY OF A RCA AND PDA LESION.
OTHER DIAGNOSIS:
1 ) SYNCOPE
2 ) DIABETES MELLITUS.
3 ) HYPERTENSION.
4 ) HYPERCHOLESTEROLEMIA.
5 ) HYPOTHYROIDISM.
6 ) HISTORY OF GUAIAC POSITIVE STOOL.
7 ) VITAMIN B-12 DEFICIENCY.
8 ) GALLSTONE DISEASE.
9 ) URINARY INCONTINENCE.
10 ) HISTORY OF A CYSTOCELE.
11 ) HISTORY OF A FROZEN LEFT SHOULDER.
CHIEF COMPLAINT: 63 year old female with hypertension , diabetes
mellitus , coronary artery disease , who presents
two days status post a syncopal episode in the setting of chest
pain. Her cardiac risk factors are hypertension , diabetes
mellitus , hypercholesterolemia , postmenopausal , and she has no
family history of coronary artery disease , and denies the use of
tobacco. Her cardiac history is as follows: She has a history of
chronic stable angina. She underwent a cardiac catheterization in
January of 1992 notable for 75% OM2 lesion , 50% ostial right RCA
lesion , and ejection fraction at the time was 75%. She had an ETT
performed in September of 1994 which she exercised for 3 minutes 42
seconds with a peak heart rate of 127 , systolic blood pressure of
156 , rate pressure product of 20k. She was stopped secondary to
chest pain , she had some T wave inversions in the inferolateral
leads felt to be consistent with but not diagnostic of ischemia.
She also had an echocardiogram performed in August of 1994 with
an ejection fraction of 60-65% , no regional wall motion
abnormalities. She has been followed in the KTDUOO Clinic by Dr.
Rigler , maintained on the regimen of Isordil 40 mg three times a day ,
Lopressor 50 mg orally twice a day , Captopril 25 mg three times a day , enteric coated
aspirin , and Procardia XL 60 mg every day. She reports her angina has
been stable for years. She takes 1-2 sublingual nitroglycerin per
week. Her pain is typically precipitated by brisk walking or other
forms of exercises. She reports that her daily workout consists of
some situps three times a day , and also usually a walk. She states
that two days prior to admission while walking her normal speed
towards the bus station , she developed some right chest wall
tightness and shortness of breath consistent with her typical
angina. She was in the middle of the street , decided to walk
across the street with the plan to take a sublingual nitroglycerin ,
however she felt light headed on continued ambulation and had a
syncopal episode. She reports that on awakening she had no
confusion. She did report the loss of urine incontinence but has
urinary incontinence at baseline. She denies any stool
incontinence , no seizure activity per observers. No complications
prior to the episode. She denies any orthopnea or PND at baseline.
PAST MEDICAL HISTORY: 1. Notable for coronary artery disease , as
above. 2. Hypertension. 3. Diabetes
mellitus , she is on insulin. 4. Hypercholesterolemia. 5.
Hypothyroidism. 6. History of guaiac positive stools. 7.
History of a frozen shoulder. 8. Vitamin B 12 deficiency. 9.
Gallstone disease. 10. Urinary incontinence. 11. History of a
cystocele.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS: Isordil 40 mg three times a day , NPH insulin 66 units
every day before noon and 15 units every PM , Procardia XL 60 mg
every day , metoprolol 50 mg twice a day , vitamin B 12 1 mg intramuscular every month ,
Captopril 25 mg three times a day , Synthroid .125 mg every day , aspirin 325 mg
every day , as needed sublingual nitroglycerin.
FAMILY HISTORY: Negative for coronary artery disease. Positive
for diabetes mellitus in her mother and her
daughter. Also positive for lung cancer.
SOCIAL HISTORY: She lives in Clavea alone , no pets. She has
ten children , 32 grandchildren , and 4 great
grandchildren. She denies any use of tobacco or denies any use of
alcohol.
PHYSICAL EXAMINATION: Vital signs showed a temperature of 98.9 ,
heart rate of 78 , blood pressure 160/90 ,
respiratory rate of 20 , with a room air saturation of 93%. In
general , obese black female in no apparent distress. HEENT
examination was PERRL , EOMI , neck supple , full range of motion , she
had a soft carotid bruit on the left , no bruits on the right , and
2+ pulses bilaterally. Lungs were clear. Cardiovascular
examination revealed a regular rate and rhythm with a soft grade
1/6 systolic ejection murmur , best heard at the left lower sternal
border. Abdomen had positive bowel sounds , non-tender ,
nondistended. She was guaiac negative. Extremities showed no
clubbing , cyanosis , or edema. 2+ femoral pulses , no bruits. 2+
dorsalis pedis and posterior tibial pulses. Neurologic examination
was grossly nonfocal.
DIAGNOSTIC STUDIES: EKG on admission showed a heart rate of 73 ,
intervals of .164 , .076 , .049 seconds for PR ,
QRS , and QTC. Axis was 71. No Q waves and no acute ST or T wave
changes.
LABORATORY EXAMINATION: Sodium 140 , potassium 4.4 , chloride 103 ,
bicarb 25 , BUN and creatinine of 16 and
1.3 , glucose of 282. LFTs were within normal limits. CK of 213 ,
cholesterol 179. Other labs showed a TSH of 1.5 , ferritin 181 ,
TIBC of 226 , troponin I was 0.0 , hematocrit was 39.4 , white count
7.15 , platelet count of 348 , 000. Coagulation studies were within
normal limits. Urinalysis showed 2-4 WBCs , 3+ bacteria. Her urine
culture revealed 50 , 000 suspected enteric gram negative rods. This
is a urine culture from 7/24/96. A chest x-ray revealed no
infiltrates.
HOSPITAL COURSE:
1. CARDIAC: Cardiac wise , she ruled out for an MI by enzymes and
EKG. She underwent a standard Bruce protocol ETT on 7/10/96. She
exercised for 8 minutes , stopped secondary to fatigue. Maximum
heart rate was 95 , maximum blood pressure 170/75. She developed
typical angina in her recovery which spontaneously resolved. She
had 1 mm down sloping ST segment depressions in II , III , F , V4
through V6 , which resolved into recovery. These changes were
suggestive of ischemia , but less specific because of her baseline
LVH. She subsequently underwent a cardiac catheterization on
7/28/96 , revealing a 40% left main with 90% mid RCA , 90% stenosis at
the origin of the PDA , 30% mid LAD , and 50% OM2. She subsequently
underwent angioplasty of the RCA and the PDA lesion on 4/1/96 with
some mild haze at the PDA. Therefore , recommendations were for
heparinization for a 24 hour period. She remained pain free
throughout this hospitalization. The EPS Service saw her regarding
the issue of syncope. Further workup was performed including
carotid ultrasounds which revealed no significant stenosis in
either of the carotid arteries. She underwent a cardiac
echocardiogram on 2/4/96 to rule out evidence of regional wall
motion abnormality that might suggest the possibility of a prior MI
as a source of potential ectopy. She was noted to have 2+ mitral
regurgitation , noted to have an ejection fraction of 74% , and had
no reported regional wall motion abnormality. She also had no
arrhythmias while on monitors throughout the hospitalization. The
EPS Service agreed with the thought that the ischemia in the RCA
probably was the most likely etiology of her syncopal episodes with
possible bradycardia during ischemic episodes. They favored
holding off on the EPS study. They felt that the revascularization
and follow-up stress testing were the recommended workup for this
patient and recommendations are for follow-up ETT in four to six
weeks. Her medical regimen was adjusted in the form of increasing
her Lopressor from 50 mg orally twice a day to 100 mg orally twice a day as her
rate and blood pressure tolerated this regimen. She remained pain
free throughout the hospitalization. She will have follow-up with
her primary M.D.
2. DIABETES MELLITUS: Her glucose remained under fairly good
control during this hospitalization with her regimen of NPH.
Hemoglobin A1C was checked and is pending at the time of discharge.
3. URINARY: She was noted to have 3+ bacteria on her urinalysis
and 50 , 000 colony forming units on a urine culture of 7/24/96. We
will empirically treat her for a UTI with Bactrim 1 DS twice a day times
three days.
FOLLOW-UP: Follow-up will be with Dr. Leaf She is to have an
appointment in one to two weeks. She is also to have a
follow-up ETT in four to six weeks. She should also have a repeat
urine culture in the KTDUOO Clinic during her follow-up.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg orally every day ,
Captopril 25 mg orally three times a day , Isordil 40 mg
three times a day , Synthroid .125 micrograms every day , metoprolol 100 mg twice a day ,
Procardia XL 60 mg every day , nitroglycerin .4 mg as needed , NPH insulin
66 units every day before noon and 15 units subcutaneously every PM , and Bactrim 1 DS orally twice a day
times three days.
DISPOSITION: Discharge to home.
CONDITION ON DISCHARGE: Good. Her diet should be low fat , low
cholesterol ADA diet. Activity as
tolerated.
COMPLICATIONS DURING HOSPITALIZATION: None.
Dictated By: CHIQUITA M. TARA , M.D. HR86
Attending: REYES D. MCPECK , M.D. TW21
VG254/9176
Batch: 67519 Index No. C2SETL4BKG D: 9/25/96
T: 7/17/96
CC: 1. ANIBAL V. RIGLER , M.D. YN47
2. REYES D. MCPECK , M.D. TW21
Document id: 1069
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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302833316 | PUO | 14368263 | | 5978688 | 5/10/2006 12:00:00 a.m. | non-cardiac syncope | | DIS | Admission Date: 11/3/2006 Report Status:
Discharge Date: 8/9/2006
****** FINAL DISCHARGE ORDERS ******
SOBE , TASHIA 713-62-70-9
Tland Ster
Service: CAR
DISCHARGE PATIENT ON: 8/6/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HAMBLET , BRITTANEY NICKI
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
ACETYLSALICYLIC ACID 325 MG orally DAILY
AMITRIPTYLINE HCL 25 MG orally BEDTIME
Override Notice: Override added on 8/6/06 by DASE , ANNABEL D. , M.D. on order for LEVOFLOXACIN orally ( ref # 668779656 )
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: aware
LAC-HYDRIN 12% ( AMMONIUM LACTATE 12% ) TOPICAL TP twice a day
Instructions: please apply to lower extremities
bilaterally.
KEFLEX ( CEPHALEXIN ) 250 MG orally twice a day X 5 doses
Starting IN a.m. ( 1/24 )
HOLD IF: in a.m. of dialysis , hold until after dialysis
Instructions: on days of hemodialysis , give dose after
dialysis
VASOTEC ( ENALAPRIL MALEATE ) 20 MG orally twice a day
Alert overridden: Override added on 11/16/06 by DASE , ANNABEL D. , M.D. on order for VASOTEC orally ( ref # 706437012 )
patient has a PROBABLE allergy to LISINOPRIL; reaction is
COUGH. Reason for override: aware , patient tolerates
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Alert overridden: Override added on 8/6/06 by :
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & SALMETEROL
XINAFOATE Reason for override: aware
LISPRO ( INSULIN LISPRO ) 18 UNITS subcutaneously before meals
INSULIN NPH HUMAN 50 UNITS subcutaneously every day before noon Starting Today ( 10/27 )
HOLD IF: please give 1/2 prescribed dose if patient NPO
Instructions: please give 1/2 prescribed dose if patient NPO.
INSULIN NPH HUMAN 25 UNITS subcutaneously every afternoon
LEVOFLOXACIN 500 MG orally every 48 hours X 5 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 8/6/06 by DASE , ANNABEL D. , M.D.
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: aware
COZAAR ( LOSARTAN ) 25 MG orally DAILY
Number of Doses Required ( approximate ): 7
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day X 14 doses
Starting Today ( 10/27 )
Instructions: please apply to groin and all other affected
areas
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
TRAMADOL 50 MG orally every 6 hours as needed Pain
DIET: House / Adv. as tol. / 2 gm Na / Renal diet (FDI)
ACTIVITY: Resume regular exercise
Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician DR BOCKEMEHL ( 854 ) 804-3988 6/28/06 @ 10:20 a.m. scheduled ,
VASC SURG DR LOERWALD ( 170 ) 780-1970 8/18/06 @ 1:30 PM scheduled ,
EP- Cards DR AVA SCHOEPPNER ( 460 ) 131-7924 2/12/06 @ 0930am scheduled ,
Ton Ra Community Hospital -- they will call yuo to set up an appointment in the next 2 weeks , but you can also call 2- 418-576-1298 to set up an appointment earlier. ,
ALLERGY: FLUORESCEIN DYE , TETRACYCLINE ANALOGUES , LISINOPRIL ,
intravenous Contrast
ADMIT DIAGNOSIS:
syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
non-cardiac syncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN Dx`89 DM insulin dependent Dx `89 obesity
( obesity ) L knee DJD nephrotic syndrome 4/8 ( nephrotic
syndrome ) hypercholesterolemia ( elevated cholesterol ) history of medullary
CVA 7/4 right PICA 7/4 Echo-mod LVH , EF 65% , no WMA Anemia ( anemia )
OPERATIONS AND PROCEDURES:
EP study
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: syncope
DDx: arrythmia vs obstructive sleep apnea vs vasovagal episode
HPI: This is a 55yo F with history of ESRD , DM , HTN , morbid obesity , presents
with recurrent episodes of unresponsiveness at dialysis ( x2 ). On am of
admission , patient was unresponsive , CPR initiated , and patient had spontaneous
return of vital signs. Of note , an AED placed on her and determined patient
did not have shockable rhythm. AED unfortunately did not print any
strips , so we have no record of the incident. MD at Bea Duna Medical Center reports
patient was cyanotic , apenic , with no carotid or raidal pulses , and had no
heart sounds by cardiac auscultation. MD reports patient's skin color
improved significantly with initiation of adequate bag mask ventilation.
Whiel patient being moved from chair to ground , patient's HD access was lost. patient
asymptomatic on transfer , and in ER.
----
PMH: Coronary artery disease , CHF , echo in July of 1999 shows
moderate left ventricular hypertrophy of about 65% , diabetes type 2
20 years including with retinopathy , nephropathy and neuropathic pain ,
ypertension for the past 20 years , hypercholesterolemia , history of
medullary CVA July 1999 , right PICA resulting Wallenberg's syndrome ,
morbid obesity , left knee degenerative joint
disease , iron-deficiency anemia.
---
MEDS AT HOME:
Toprol 200 twice a day
Enalapril 20 twice a day
Lispro 18 subcutaneously before meals
Insulin NPH 50U qAM
Insulin NPH 25U qPM
Losartan 25 mg every day
Advair Discus
Tramodol 25 mg orally q6 as needed
Protonix 40 mg orally every day
Oxycodone 2.5 mg orally twice a day as needed
Amitryptilline 25 mg qPM
Nephrocaps 1 tab every day
---
STUDIES:
ECHO 7/23 showed LVEF 60-65% with mild concentric LVH
and no RWMA
ECHO 9/30/06 : nl LV size , nl LV functino , EF 55-60%
with no RWMA. enlarged RV , mild LAE , nl RA , trave MR< mild TR , no
change from prior study in 8/18
EKG: rhythm 100 beats per minute with no acute ST changes and old T-wave
inversion in V2.
----------
PET perfusion stress test 1/17/06 :Image quality was excellent. The images
demonstrated normal LV size and normal tracer uptake in the lungs. They
also demonstrated a mildly dilated RV with normal RV tracer uptake at
rest. There were no regional perfusion defects seen on the stress or
rest images. normal perfusion , LVEF 72% , moderate RVH
CXR 3/22/06 : PA and lateral films of the chest demonstrate right central
line at SVC. There are degenerative changes of the dorsal spine. The
heart is not enlarged. There are no acute infiltrates or effusions.
--------------
PROCEDURE: 10/7/06 : EP study revealed normal SA node functino , normal
conduction , and no tachyarrythmias were stimulated. An implanted loop
recorder device , the Medtronic Reveal Plus , was plced in patient's chest.
patient tolerated procedure with no complications , bleeding or signs/sx of
infection.
-------
Exam on Admission: T99.3 , BP 110-120/50-60 P88-90R O2
98RA Morbidly obese , CV: RRR , distant , II/VI systolic
murmur at RUSB. Pulm: bibasilar crakles R>L , distant breath
sounds Abdomen: large pannus , RUQ scar from prior appy ,
soft , NT , ND , BS+. Ext: No edema , +brawny venous stasis feet b/l ,
palpable thrill on patient's right distal forearm at site of patient's a-v fistula.
WWP , DP palpable b/l. Neuro: alert ,
EOMI.
--------
SIG LABS on ADMISSION:
Na 130 K 4.2 Cl 96 CO2 33 BUN 17 Cr 5.5 Ca 8.6 Mg 1.5 CK104 CKMB 0.6
TnI<assay , WBC 6.8 Hct 31.8 Plat 166
---------
ASSESSMENT AND HOSPITAL COURSE BY PROBLEM
55F with ESRD on HD ( 2/2 DM ) who had apparent syncopal episode while
at HD on 7/12 , which was similar in presentation to 4/11 episode from
recent admission.
1 ) CV: Whether or not patient actually ever a V-fib arrest seems to be in some
doubt , as she has never had an arrhythmia on tele. However , given this
is the second presentation , a proper arrhythmia evaluation was
warranted. The patient's differential included arrythmia vs obesity
hypoventilation ( patient reports OSA sx ) , hypoglycemia , and HD-related
hypotension. Ischemia ) serial cardiac enzymes negative. patient was
continued on asa , bb , and placed on statin and NTG as needed while ruling out
ischemic heart disease in anticipation of possible EP study. PET
perfusion scan for reversible ischemia was negative , showing normal
perfusion. Pump: JVP not appreciated , decreased LE edema relative to
prior admission. patient was continued home dose diuretic , and kept on a BB ,
CCB , and her ACEi to goal SBP<120. Rhythm: patient was placed on telemetry to
monitor for arrythmia while on floor. No events were noted , but given
history , patient was taken to cath lab for EP study on 4/19/06. EPS showed
normal conduction , normal SA node , and so a loop recorder device was
implanted , which will monitor patient's HR and record if HR> or < parameters ,
or if patient triggers device to record. No signs/sx of bleeding , infectino ,
hematoma. patient discharged on 3 day course of Keflex , to be given after HD.
RENAL: ESRD on HD. patient HD on Wed and Sat am of admission , which she
tolerated with no difficulty. patient was continued on EPO 10 , 000U qHD. patient
has tunneled line in Right IJ for access.
HEME: Anemia: in setting of ESRD , baseline Hct around 30. patient on
epogen. Anemia studies WNL.
ENDO: Diabetes type 2: Long and short-acting subcutaneously insulin. twice a day NPH
started at lower than home dose while orally diet is held , with lower
sliding scales , due to significant parts os stay where patient was NPO for
procedures. Wil lbe discharged on home insulin regimen.
ID: patient reports 4 day history of productive cough prior to admission. patient
afebrile , but on HD6 , patient has eleavtion in WBC ( 6.9-->12 ) , however
patient afebrile , asymptomatic , CXR shows no infiltrative process , and in
setting of recent procedure. patient was placed on levofloxacin renally dosed.
DERM: Brawny skin changes: Lac Hydrin started. Candidiasis noted in folds
between patient's pannus and groin. 2% Miconazole topical poder started
PPX: physical therapy received heparin subcutaneously , and Nexium , wil be discharged on protonix.
Code: patient is Full Code. Health care proxy is Tashia Sobe
092-489-2806
ADDITIONAL COMMENTS: You have been evaluated for your unresponsive episodes. We looked at
your heart and put a recorder in your chest to monitor for any irregular
heartbeats. Please follow up with your appointments , and return to the
hospital if you notice any chest pain , lightheadedness , or if you pass out
again. YOu have also been referred for an outpatient sleep study to
evaluate your obstructive sleep apnea. Please make an appointment with
them if they do not contact you.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) We recommend patient get outpt polysomnography evaluation for OSA , and
potential fitting for CPAP. Referral placed , patient will receive call from
Abois Che Memorial Hospital 2- 418-576-1298 to make appointment for sleep study.
2 ) patient's home BP and insulin regimen unchanged.
3 ) ANtibiotics: continue patient's 3 day regimen of Keflex , in additino to 5
day regimen of Levofloxacin dosed renally for broader coverage.
4 ) started mild keratolytic Lac-Hydrin top twice a day for patient's brawny skin
changes.
5 ) short course miconazole 2% powder for patient's candidal nifectino in groin
skin folds
No dictated summary
ENTERED BY: DASE , ANNABEL D. , M.D. ( JG897 ) 8/6/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1070
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125960861 | PUO | 68313462 | | 0676974 | 6/25/2003 12:00:00 a.m. | VOLUME OVERLOAD | Signed | DIS | Admission Date: 6/25/2003 Report Status: Signed
Discharge Date: 11/22/2003
ATTENDING: DOUGLASS BOVA M.D.
Discharge date to be determined.
DISCHARGE DIAGNOSIS: Congestive heart failure.
OTHER ASSOCIATED PROBLEMS:
1. Congestive heart failure , EF of 33% , etiology unknown.
2. Hypertension.
3. Dyslipidemia.
4. Acute renal failure.
5. History of paroxysmal atrial fibrillation with rapid
ventricular response.
6. Anemia.
7. Gastritis.
HISTORY OF PRESENT ILLNESS: This is a 63-year-old female with
history of congestive heart failure in the past with an ejection
fraction of 55% to 60% in October of 2003 , who presented with
bilateral lower extremity edema as well as increasing shortness
of breath. The patient reports that she has not been taking her
Lasix as she was prescribed due to the inconvenience of going to
the bathroom frequently. She was feeling overwhelmed by so many
medicines. Currently , she is feeling better with improved
breathing. No fever , chills , or chest pain.
PAST MEDICAL HISTORY:
1. Congestive heart failure with ejection fraction of 55% to 60%
in October of 2003.
2. Deep venous thrombosis bilaterally with PE in October 2003.
3. Acute renal failure , nephrotic syndrome.
4. Pneumonia.
5. Iron and folate deficiency anemia.
6. Paroxysmal atrial fibrillation with rapid ventricular
response.
7. Nonsustained ventricular tachycardia.
8. Insulin-dependent diabetes mellitus.
9. Hypertension.
10. Cholesterol.
11. Chronic knee and back pain.
12. Arthroscopic knee surgery bilaterally.
13. Gastritis.
14. Benign colon polyps greater than 10.
15. Cataracts.
16. Glaucoma.
MEDICATIONS AT HOME:
1. Lasix 120 mg orally twice a day
2. Atenolol 50 mg orally every day
3. Iron sulfate 300 twice a day
4. Folate 1 mg every day
5. NPH insulin 20 units every day
6. Oxycodone 5 mg to 10 mg every 4-6h. as needed pain.
7. Senna.
8. Multivitamins.
9. Zocor 40 mg orally every day
10. Norvasc 10 mg orally every day
11. Accupril 80 mg orally every day
12. Miconazole 2% topical twice a day
13. Celexa 20 mg orally every day
14. Avandia 8 mg orally every day
15. Nexium 20 mg orally every day
16. Albuterol as needed
SOCIAL HISTORY: The patient has a history of 3-packs-per-day
smoking for 30 years and no alcohol.
FAMILY HISTORY: No family history of heart disease.
PHYSICAL EXAM: On presentation , T 97.3 , BP 143/70 , pulse 57 , 98%
on 2 liters. This is an obese female in no apparent distress ,
sitting up in bed. HEENT: Extraocular movements intact. Sclerae
anicteric. Neck: Supple , JVP at 14 cm. Chest: Crackles
bilaterally , left greater than right , half way up both lung
fields with mild decreased breath sounds at the bases.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No
murmur , rubs , or gallops. Abdomen: Soft , nontender , and
nondistended with positive bowel sound and no hepatosplenomegaly.
Extremities with 3+ edema as well as areas of erythematous and
shiny shallow ulcerations. Neurologically , euthymic without
focal deficits.
LABORATORY DATA: On admission , significant for sodium 147 ,
potassium 3.4 , chloride 110 , CO2 26 , BUN 23 , creatinine 1.6 , and
glucose 69. CBC was significant for white count of 6.7 ,
hematocrit 39.4 , and platelets of 258. Her CK was 432. Her
troponin was less than assay. Her BNP was greater than assay and
D-dimer was 50 and 69.
Chest x-ray showed decreased lung volumes with moderate cardiac
enlargement. EKG showed sinus bradycardia with a rate of 59 ,
axis of -36 and no acute changes.
ASSESSMENT: This is a 63-year-old woman with history of
congestive heart failure who presented with likely congestive
heart failure exacerbation.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: Ischemia: There was concern regarding acute
and subacute silent ischemia given new ST-T wave changes in
lateral leads on the EKG. The patient was continued on her
aspirin as well as statin. She was ruled out for an MI with
negative troponins x 3. She was continued on a low-dose
short-acting beta-blocker ( Lopressor ). She was also continued on
an ACE inhibitor with this switched to captopril as a
short-acting ACE inhibitor , which was titrated up as tolerated
for a goal blood pressure of systolic of 120. An adenosine MIBI
was performed which was negative for perfusion defects. However ,
echo showed global hypokinesis with depressed ejection fraction.
Cardiology consult was called and they recommended further workup
with cardiac catheterization. However , the patient refused the
catheterization.
Rhythm: The patient has a history of atrial fibrillation.
However , she remained in normal sinus rhythm throughout her
admission. She was monitored by cardiac telemetry with several
episodes of 6 to 10 beats of nonsustained ventricular
tachycardia. Her electrolytes were carefully monitored and
repleted as necessary. She remained asymptomatic with the runs
of NSVT and was continued on her beta-blocker. Given her history
of atrial fibrillation as well as depressed ejection fraction ,
she was restarted on Coumadin.
Pump: The patient presented with a frank fluid overload with
elevated JVP , lower extremity edema , and a BNP greater than
assay. She was aggressively diuresed with a goal of greater than
-2 liters a day. She responded to 80 mg of intravenous Lasix three times a day Her
creatinine was carefully followed and did increase on 11/26/03 ,
at which point diuresis was put on hold. The patient diuresed
about 3 to 4 liters each day during her hospital stay until
7/7/03. At this point , she was thought to be very close to
euvolemic.
Given the patient's echo findings with depressed ejection
fraction and global hypokinesis , a workup for dilated
cardiomyopathy was begun. The patient did not wish for further
investigation with cardiac catheterization or a cardiac MRI. Her
other labs were unremarkable including a TSH , which was normal ,
an ANA which was negative , iron studies which did not show iron
overload , and thiamine which is pending at the time of this
dictation. The patient will require close followup with careful
fluid balance monitoring as well as followup with congestive
heart failure service.
Pulmonary: She initially presented with shortness of breath.
However , this resolved with diuresis. She has a history of PE as
well as DVT and an elevated dimer was found on admission. There
was initial concern for pulmonary embolism , but the resolution of
symptoms with diuresis and a history that was not suggestive of
pulmonary emboli , did not require further followup with spiral
chest CT.
Heme: The patient's hematocrit was followed. The patient has
chronic folate and iron-deficiency anemia and she was continued
on folate and iron replacement.
Endocrine: The patient was continued on NPH 20 units for her
known diabetes. Her blood sugars were in excellent control on
this regimen. Avandia was held given it contraindication in
heart failure.
Renal: The patient's creatinine was 1.6 on admission , which is up
from about 0.8 in October of 2003. Her urine eosinophils and
sediment were unremarkable , but frank proteinuria was noted which
is consistent with her known nephrotic syndrome. Her creatinine
remained stable in the 1.5 to 1.6 range until 11/26/03 , when her
creatinine bumped to 2 and kept rising until 1/28/03 , when it
reached 2.7. Repeat urine electrolytes , urine eosinophils and
sediment were sent at this point and they are pending at the time
of this dictation. The most likely explanation for increasing
creatinine was aggressive diuresis and intravascular volume
depletion. Diuresis was put on hold on 11/2/03 and 10/10/03.
Given her increased creatinine , her ACE inhibitor dose was halfed
on 10/10/03. The plan is to continue to monitor her creatinine
function , follow up on her urine chemistries and if her
creatinine resolves , to resume gentle diuresis as necessary.
Infectious Disease: The patient was found to have a UTI with E.
Coli that was sensitive to Bactrim and she was treated with
Bactrim with resolution.
Rheumatological: The patient with known chronic pain as well as
arthritis. Her Celebrex was held given her increased creatinine
and its propensity to cause fluid retention. Her joint exam
revealed swollen PIP joints of both hands as well as marked
swelling over both wrists. A rheumatoid factor was sent and that
came back negative. For her pain , she was given oxycodone as needed
Once her acute renal failure resolves , she may be transitioned
to Celebrex or other antiinflammatory medications which may be
more effected for her arthritis. ANA came back negative.
Psyche: She was continued on Celexa for depression.
Code status: Full code.
FOLLOWUP: The patient needs to follow up with the congestive
heart failure service as well as her primary care physician.
DISCHARGE MEDICATIONS ( at the time of this dictation on
1/28/03 ):
1. Aspirin 81 mg orally every day
2. Colace 100 mg orally twice a day
3. Iron sulfate 325 mg orally every day
4. Prozac 20 mg orally every day
5. Folate 1 mg orally every day
6. Lasix 160 mg orally every day ( this dose was held on 11/2/03 and
1/28/03 and should be held until creatinine increases and
restarted once symptoms and sign of fluid overload occur ).
7. NPH human insulin 20 units subcutaneously every afternoon
8. Zestril 30 mg orally every day
9. Oxycodone 5 mg to 10 mg orally every 4-6h. as needed pain.
10. Senna tablets 2 mg orally twice a day
11. Aldactone 25 mg orally every day ( this medication was held on
11/2/03 and 1/28/03 given increasing creatinine and should be
held until creatinine decreases ).
12. Multivitamins with minerals one tablet orally every day
13. Coumadin 5 mg orally every bedtime
14. Zocor 40 mg orally every bedtime
15. Toprol XL orally every day
16. Imdur 30 mg orally every day
17. Bactrim one tablet orally twice a day for 7 days ( started on
5/5/03 ).
18. Prednisolone acetate 0.125% one drop each eye four times a day
19. Nexium 40 mg orally every day
20. Albuterol inhaler 2 puffs inhaler four times a day as needed wheezing.
21. Miconazole nitrate powder topical twice a day as needed
ADDENDUM: The patient was restarted on Coumadin on 5/5/03 for
known paroxysmal atrial fibrillation. Her INR needs monitoring
with a goal INR of 2 to 3.
The patient's discharge is pending resolution of acute renal
failure. At the time of this dictation , creatinine is still
elevated and this dictation will be updated with medications as
well as a course of resolution of her acute renal failure.
eScription document: 4-0143862 ISSten Tel
Dictated By: PANCHAL , PENNI
Attending: BOVA , DOUGLASS
Dictation ID 5351745
D: 1/28/03
T: 1/28/03
Document id: 1071
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761661806 | PUO | 21953661 | | 0434535 | 10/21/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 10/21/2006 Report Status: Signed
Discharge Date: 7/22/2006
ATTENDING: EHLER III , DANIAL JADWIGA MD
ADDENDUM
SERVICE: Cardiac Surgery Service.
PRINCIPAL DIAGNOSIS: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: Mr. Boreen is a 56-year-old male
with a past medical history significant for inferior myocardial
infarction in 1995 , which was treated with angioplasty at that
time. Since then , he has been stable on medical management until
approximately two months prior to this admission , when he began
noting anterior chest pain with exertion. He underwent a stress
test , which was found to be abnormal , and was referred for cardiac
catheterization. Cardiac catheterization was performed on
9/10/06 at Pagham University Of . This study revealed a
70% proximal stenosis of his left anterior descending coronary
artery , a 90% mid segment stenosis of his first diagonal coronary
artery , a 50% mid segment stenosis of his circumflex coronary
artery , a 90% ostial stenosis of his first obtuse marginal , a
100% proximal stenosis of his right coronary artery as well as a
30% ostial stenosis of the left main coronary artery. Collateral
flow was noted from the left anterior descending to the posterior
descending coronary artery. Given the results of this cardiac
catheterization , he was referred for elective revascularization.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for hypertension , hypercholesterolemia , lower back
pain , nephrolithiasis as well as a 3.4 cm infrarenal abdominal
aortic aneurysm at the bifurcation of the aorta.
PAST SURGICAL HISTORY: Significant for open cholecystectomy in
the 1990s as well as removal of a cyst from his left wrist in
2005. In addition , the patient underwent lithotripsy in July of
2006.
FAMILY HISTORY: The patient reports a family history of coronary
artery disease. His brother has undergone coronary artery bypass
grafting in the past and his mother , father and brother all have
suffered myocardial infarction. He also has a significant family
history of hypertension in both of his parents.
SOCIAL HISTORY: The patient reports a 20-pack-year cigarette
smoking history as well as a history of social alcohol use ,
approximately five to six beers on the weekend.
ALLERGIES: The patient reports no known drug allergies , however
tetanus immunization in the past has led to arm swelling.
MEDICATIONS ON ADMISSION: Atenolol 100 mg orally daily , lisinopril
40 mg orally daily , aspirin 325 mg orally daily , atorvastatin 40 mg
orally daily , fenofibrate 145 mg orally daily , Vicodin 5 mg orally as
needed for low back pain as well as vitamins C , D , A , and E.
The patient was seen in the Motor Fielda Gic County Hospital on 10/27/06
and underwent physical examination.
PHYSICAL EXAMINATION: Physical examination at that time revealed
the patient to be afebrile with resting heart rate of 52 beats
per minute and regular. The patient had a resting blood pressure
of 142/76 in the right arm and 148/76 in the left arm. He had a
room air oxygen saturation of 95%. Examination of the head ,
eyes , ears , nose and throat revealed the pupils to be equal ,
round , reactive to light and accommodation. The dentition was
without evidence of infection and carotid bruits were not
appreciable bilaterally over the carotid arteries. Examination
of the heart revealed it to be in regular rate and rhythm with a
grade 2/6 systolic murmur heard best at the right upper sternal
border. Examination of the lungs revealed breath sounds to be
clear bilaterally throughout all lung fields. Examination of the
abdomen revealed a well-healed right upper quadrant incision
consistent with prior open cholecystectomy. Examination of the
extremities revealed them to be without scarring , varicosities or
edema and pulses were 2+ and equal to full extent of all
extremities. Neurologically , the patient was alert and oriented
x3 with no focal neurological deficits.
LABORATORY DATA: Laboratory values obtained in the Motor Fielda Gic County Hospital on 10/27/06 included a sodium of 139 , potassium of
3.7 , BUN of 24 , creatinine of 1.2 , glucose of 82 , magnesium of
1.6 , white blood cell count of 10.9 , hematocrit 49.2 , and
platelet count of 386 , 000. Coagulation studies were within
normal limits with an INR of 1 and the urinalysis was within
normal limits. Cardiac catheterization data from 9/10/06 are as
stated above in the history of present illness. Echocardiogram
performed on 05/20/06 revealed a 65% ejection fraction with
trivial mitral valve insufficiency and no noted regional wall
motion abnormalities. EKG obtained on 9/10/06 showed a normal
sinus rhythm at 55 beats per minute with no acute ST or T-wave
changes. Chest x-ray performed on 9/27/2006 was without
evidence of active cardiopulmonary disease.
HOSPITAL COURSE: The patient was admitted on 10/26/06 as a
same-day admission and was taken directly to the operating room
where he underwent coronary artery bypass grafting x4 including
the left internal mammary artery to left anterior descending
coronary artery , saphenous vein graft to the ramus and second
obtuse marginal coronary arteries and the left radial artery to
the right coronary artery. Significant times of this operation
included a cardiopulmonary bypass time of 173 minutes with an
aortic cross-clamp time of 156 minutes. For further details of
this operation , please refer to the dictated operative note. The
patient's immediate postoperative period was uncomplicated. He
was extubated on the day of surgery and considered a good
candidate for transfer from the Intensive Care Unit to the
Step-Down Unit on postoperative day #1. His temporary cardiac
pacing wires and chest drainage tubes and a Jackson-Pratt drain
were all discontinued on postoperative day #2. On the Step-Down
Unit , he was noted to have a high white blood cell count of
approximately 17 in the immediate perioperative period , however
the white blood cell count had improved markedly to 11.9 by
postoperative day #3. He had a PA and lateral chest x-ray on
postoperative day #3 , which revealed satisfactory postoperative
appearance of the chest. The patient was ambulating and
tolerating a full diet without difficulty and is now considered
in good candidate for discharge to home with visiting nurse
services on 1/8/06 , postoperative day #4.
DISCHARGE MEDICATIONS: Medications at the time of discharge
include aspirin 325 mg orally daily , atorvastatin 40 mg orally daily ,
diltiazem 30 mg orally three times a day , Colace 100 mg orally three times a day as needed
for constipation , Zetia 10 mg orally daily , fenofibrate 145 mg orally
daily , Lasix 40 mg orally daily x5 days , K-Dur 20 mEq orally daily x5
days , metformin 500 mg orally daily , Toprol-XL 25 mg orally daily ,
and oxycodone 5-10 mg orally every 4 hours as needed for pain.
DISCHARGE INSTRUCTIONS: The patient is instructed to make and
keep all of his follow-up appointments and shower and wash his
wounds with soap and water each day. He is to continue diuresis
with Lasix 40 mg orally daily for five days and then discontinue
until his re-evaluation at a follow-up appointment with his primary care physician
or cardiologist and 1-2 weeks. Of note , this patient was
diagnosed for the first time as a type II diabetic during this
admission with a hemoglobin A1c of 7.2 prior to admission. He
was followed by the Diabetes Management Service postoperatively ,
and was started on metformin 500 mg a day and should follow up
with his primary care physician in 1-2 weeks for follow-up check
of his blood sugar and any necessary adjustment in his diabetic
medications. He is instructed to make follow-up appointments
with his cardiac surgeon Dr. Ehler for two weeks following
discharge from the hospital and to return to see his primary care
physician , Dr. Willeford one to two weeks following discharge from
the hospital.
eScription document: 4-3190025 CSSten Tel
Dictated By: SALLINGS , SVETLANA
Attending: EHLER III , DANIAL JADWIGA
Dictation ID 8898986
Addendum Created by EHLER , III , DANIAL JADWIGA , M.D.
A: 7/5/06
Dictation ID : 4064811BNL
Document id: 1072
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PVD |
VI |
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226150645 | PUO | 05155308 | | 046240 | 3/11/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/30/1993 Report Status: Signed
Discharge Date: 2/24/1993
S Monte Ora SERVICE
PRINCIPAL DIAGNOSIS: PRESYNCOPE.
HISTORY OF THE PRESENT ILLNESS: This is a 56 year old black female
with coronary artery disease ,
status post three myocardial infarctions and a coronary artery
bypass graft between the years of 1973 and 1984 , who now came into
the hospital with back pain and one episode of dizziness with a
racing heart. Her cardiac history begins in 1973 when she had her
first myocardial infarction. She has had two more in 1983 and in
1984. She had a coronary artery bypass graft in 1984 in which her
LIMA was placed to her LAD , and the saphenous vein graft placed to
her obtuse marginal and the diagonal branch. The coronary artery
bypass graft in 1984 was very successful , and she has been stable
since that time without angina or congestive heart failure
symptoms. She reports that she had a negative exercise tolerance
test one year ago , Holter two to three years ago was reportedly
normal also. The only time the patient recalls having a racing
heart prior to the day of admission was when her brother died two
years ago.
On the day of admission , the patient awoke with a dull ,
nonradiating pain between her shoulder blades that remained until
the patient was given 02 in the Emergency Ward which was
approximately 12 hours after awakening. The patient was never with
this pain before the day of admission. In additional , as the
patient was walking down the street near her home on the morning of
the day of admission , she felt herself stagger , and the world
seemed to rotate around her. She sat down for about 10 minutes
until the spell passed. During this episode , her back pain did not
change in quality or intensity. She had no chest pain , shortness
of breath , nausea , vomiting , diaphoresis , loss of consciousness ,
trauma , headache , neck stiffness , blurry vision , paroxysmal
nocturnal dyspnea , or orthopnea. She does report an accompanying
racing heart that seemed regular. After this episode , the patient
drove herself to the Pagham University Of Emergency Ward
for evaluation.
REVIEW OF SYSTEMS: The patient had menopause at 42 years of age.
She has never had a mammogram or regular breast exams. The rest of
her review of systems was noncontributory. PAST MEDICAL HISTORY:
Coronary artery disease , status post coronary artery bypass graft
in 1984 as reported in the history of the present illness. She has
had hypertension for ten years. An echocardiogram in 3/27 showed
left ventricular enlargement , inferior apicokinesis , lateral
hypokinesis , and 1+ mitral regurgitation. ALLERGIES: To
Penicillin which leads to anaphylaxis. MEDICATIONS ON ADMISSION:
Were only Isordil and Cardizem. The patient has a 15 pack-year
history of smoking. She quit two months ago. She does not drink
alcohol or abuse intravenous drugs. She lives alone and is unemployed as an
unemployed LPN , and has one child.
PHYSICAL EXAMINATION: She was a well developed well nourished
black female very anxious and teary eyed.
Blood pressure on admission was 180/90 in the right arm and 180/95
in the left arm , pulses were equal at 72. She was afebrile at
98.7 , and respirations of 20. She was not orthostatic. The skin
was warm and dry. There were no rashes or bleeding. HEENT exam
was benign. The neck was supple , positive jugular venous
distention at about 10 cm , but no coronary artery bruits. The
lungs were clear. The back was without costovertebral angle
tenderness or spinal tenderness. Cardiovascular exam: Regular
rate and rhythm with an S3 and a palpable S4 , with a holosystolic
murmur at the apex and a systolic ejection murmur at the left lower
sternal border. No radiation of either murmur. Her PMI was
diffuse with a sternal heave. Abdominal exam was benign.
Extremities were benign. Pulses: Femoral on the left with a
bruit , and 2+ femoral on the right without a bruit , and 1+. The
rest of the pulses were 1-2+ bilaterally. No renal artery bruits
were heard. Neurologically , the patient was alert and oriented ,
and her exam was nonfocal.
LABORATORY DATA: On admission showed a normal SMA-7. Her
hematocrit was 41.5 with a low MCV at 78.7 , low
MCH at 31.3 , and a RDW of 16.1. The patient ruled out for a
myocardial infarction with normal CK's. Her chest x-ray showed a
globular heart , question of some cardiomegaly , clearly post
coronary artery bypass graft with lots of clips. She had right
atrial enlargement with loss of the retrosternal air space , but no
evidence of aortic widening of the mediastinum. No pulmonary
edema , no pulmonary vascular redistribution was detected. EKG
showed normal sinus rhythm at 80 with a PR interval of .14 , QRS
.11 , and a QT of .45. She had left atrial enlargement , old lateral
T-wave inversions as well as inferior T-wave inversions. The
patient had no acute changes.
HOSPITAL COURSE: Involved placing the patient on a cardiac
monitor , rule her out for an myocardial
infarction , obtaining exercise stress test , echocardiogram , drawing
blood for thyroid function tests , VMA's , metanephrines in the
urine. In addition , a beta blocker was added to her hypertensive
regimen , and she was started on an aspirin a day. Her cardiac
monitor demonstrated no dysrhythmias except for a few PVC's. The
results of the 24 hour Holter on discharge were still pending. She
ruled out for a myocardial infarction. An exercise stress test
showed that the patient went 5 minutes and 45 seconds on a standard
Bruce protocol , no ischemic symptoms , stopped due to leg pains.
EKG was with 1 mm upsloping ST depressions in V4 and V5. It was
reportedly consistent with but not diagnostic of ischemia. Because
of this , the patient should probably have an exercise MIBI on the
outside as an outpatient. An echocardiogram demonstrated an
ejection fraction of 45-50% , severe hypokinesis of the
anterolateral and posterior wall , akinesis of the inferior wall ,
2-3+ mitral regurgitation , and an intra-atrial septal aneurysm , no
tumor or thrombus was detected.
Laboratory studies on admission did demonstrate an elevated protein
of 8.5 and a globulin fraction of 4.2. Therefore , an S-PEP , IgG
and IgM's were sent and were pending on discharge.
DISPOSITION: MEDICATIONS ON DISCHARGE: Isordil 10 mg three times a day ,
Cardizem 60 mg four times a day , Lopressor 25 mg twice a day , and an
Aspirin a day. The patient was discharged to home in very stable
condition and will followup in KTDUOO on 8/28/93 at 1:30. A copy of
this discharge should be sent to Dr. Gossard , telephone number
666-4434 , who is her primary medical doctor. During her stay here ,
we were not able to get hold of him and notify him of the patient's
status.
Dictated By: GAYLENE FANIEL , M.D. KM4
Attending: COLE T. AINI , M.D. TY82
IA979/4242
Batch: 0983 Index No. ZGMWS32DJ5 D: 6/23/93
T: 6/23/93
CC: 1. DR. WHACK ,
Document id: 1073
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
Y |
N |
- |
N |
N |
Y |
N |
N |
Y |
N |
- |
- |
544049601 | PUO | 71033623 | | 3389291 | 7/8/2003 12:00:00 a.m. | musculoskeletal pain | | DIS | Admission Date: 3/11/2003 Report Status:
Discharge Date: 10/13/2003
****** DISCHARGE ORDERS ******
SMOLINSKY , LARAE 642-35-01-2
Mont In Glend
Service: MED
DISCHARGE PATIENT ON: 5/15/03 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Other:sob
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Alert overridden: Override added on 4/27/03 by
DASE , ANNABEL D. , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NSAID'S
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: will monitor
LASIX ( FUROSEMIDE ) 10 MG orally every day
Alert overridden: Override added on 4/27/03 by
DASE , ANNABEL D. , M.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: ok
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally three times a day
HOLD IF: sbp<90 , HR<50 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
COUMADIN ( WARFARIN SODIUM ) 10 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 4/27/03 by DASE , ANNABEL D. , M.D. on order for ECASA orally ( ref # 37473339 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: will monitor
CITRUCEL ( METHYLCELLULOSE ) 1 TBSP orally twice a day
Number of Doses Required ( approximate ): 3
IRBESARTAN 150 MG orally every day HOLD IF: sbp<90
Number of Doses Required ( approximate ): 5
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician one week ,
Radiology for Carotid ultrasound 8/24/03 ,
Arrange INR to be drawn on 11/26/03 with f/u INR's to be drawn every
30 days. INR's will be followed by Dr. Gruntz
ALLERGY: Sulfa , Nsaid's
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
musculoskeletal pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma ( asthma ) pneumonia ( community acquired pneumonia ) diabetes
( diabetes mellitus ) htn
( hypertension ) history of PE ( history of pulmonary embolism ) history of cva ( history of
cerebrovascular accident )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
72y/o female with multiple crf's and history of PE was in
USOH until tuesday pm when she experienced left chest pain under her
breast and SOB. no n/v/diaphoresis , +jaw discomfort c/o stuttering
CP lasting 5-10 min. Denies PND and
orthopnea PMH: NIDDM , HTN , asthma , PE , CVA ,
PUD , diverticulosis
Meds: Irbesartan 150mg every day , furosemide 10mg every day , Coumadin 10mg every day ,
Albuterol as needed , Lanzoperazole 30mg twice a day ,
citrucel. All: Theophylline , sulfa , ?asa ,
Lisinopril SH; no
tob/drugs/etoh FH:
non-contributory PE: Afebril 79 164/90 20 100%
RA NAD , JVP
flat RRR
CTA b soft obese
nt no LE
edemea. Labs: enzymes neg , EKG 1st AVB ,
NSR CV: r/o April MIBI EF 55% , no st
changes , frequent pac's , isolated PVC's; nl
MIBI with no areas of ischemia or fixed defects.
Endo: insulin SS Rheum/Muscul: left neck pain to palpation and
left blurry vision: concern for temporal arteritis , but esr 23.
carotid u/s to be performed as outpt on 1/17/03 at 9:30 am
ADDITIONAL COMMENTS: If you experience any further chest pain , shortness of breath , or any
other concerning symptoms , call your doctor.
Follow up with your doctor in one week.
VNA: please assist patient with at home medication management.
Also would like to have a home physical therapy evaluation conducted.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with Carotid u/s on Tuesday 1/17/03 at 9:30am
No dictated summary
ENTERED BY: BAUCHSPIES , REFUGIA , M.D. ( AG45 ) 5/15/03 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1074
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Q |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
N |
- |
N |
N |
N |
N |
Y |
- |
N |
N |
Y |
N |
N |
- |
854363147 | PUO | 71281680 | | 2827335 | 8/13/2003 12:00:00 a.m. | Angina | | DIS | Admission Date: 10/10/2003 Report Status:
Discharge Date: 2/18/2003
****** DISCHARGE ORDERS ******
SMOLINSKY , LARAE 439-51-66-3
O Hunt
Service: MED
DISCHARGE PATIENT ON: 11/19/03 AT 07:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BEDATSKY , DENA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Override Notice: Override added on 8/18/03 by
PRAINO , ISIDRA , M.D.
on order for COUMADIN orally ( ref # 67123122 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
WELLBUTRIN ( BUPROPION HCL ) 200 MG orally twice a day
KLONOPIN ( CLONAZEPAM ) 2 MG orally three times a day
LASIX ( FUROSEMIDE ) 20 MG orally twice a week
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 as needed Pain
PERCOCET 1-2 TAB orally every 6 hours as needed Pain
COUMADIN ( WARFARIN SODIUM ) 12.5 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 8/18/03 by
PRAINO , ISIDRA , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
NEURONTIN ( GABAPENTIN ) 600 MG orally three times a day
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
30 MG orally every day HOLD IF: SBP <100 , HR <60
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Alert overridden: Override added on 11/19/03 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: home med
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Franza 1-2 weeks ,
Arrange INR to be drawn on 11/13/03 with f/u INR's to be drawn every
14 days. INR's will be followed by coumadin clinic
No Known Allergies
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Angina
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of TVH for menorhag hyperlipidemia
obesity panic attacks ( panic attacks ) pe ( pulmonary
embolism ) ivc filter ? CAD ( ? coronary artery disease )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
43 year-old f , previous hx of pe , neg hypercoag with u , therapeutic on coumadin ,
long hx of chest pain , mult r/o , cath 1999 with 30% LAD ostial lesion ,
repeat cath 2000 negative. Presumptive diagnosis of vasospasm , though
unclear if evocative testing was done during these caths. Most recent
ETT 7/23/03 negative. Represents with CP for 1hr X 1d , apparently
relieved by 3 NTGs. EKG unchanged , TnI nl.
patient was ruled out for myocardial infarction by enzymes and serial EKGs.
She was started on isordil in addition to her nifedipine for
vasodilation and blood pressure control in an effort to address her
coronary vasospasm.
On exam , patient was in NAD with stable vital signs. She showed no evidence
of volume overload. Exam was notable for R forearm swelling and
ecchymosis after patient "broke up a fight" between her brother and his girl
friend. patient denied domestic violence , and states that she feels safe at
home. patient had no areas of focal tenderness. X-rays of the wrist ,
radius/ulna , and elbow were negative for fracture. Pain control was
addressed with percoset.
ADDITIONAL COMMENTS: Please call your doctor if you have signs or symptoms of difficulty
breathing , shortness of breath
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BUBOLZ , LOREN A. , M.D. ( PN92 ) 11/19/03 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1075
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
539482074 | PUO | 02103007 | | 4144937 | 5/28/2003 12:00:00 a.m. | pneumonia | | DIS | Admission Date: 10/28/2003 Report Status:
Discharge Date: 2/3/2003
****** DISCHARGE ORDERS ******
SIDOROWICZ , YADIRA 414-08-66-3
Ry Ville Ton
Service: PUL
DISCHARGE PATIENT ON: 3/17/03 AT 10:15 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WILDT , DEVORA DALTON , M.D.
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
ACETYLSALICYLIC ACID ( CHILDREN'S ) 81 MG orally every day
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
as needed Shortness of Breath , Wheezing
MIACALCIN ( CALCITONIN-SALMON ) 1 SPRAY nasal every day
Number of Doses Required ( approximate ): 4
CEFTAZIDIME 2 , 000 MG intravenous every 8 hours
Alert overridden: Override added on 4/19/03 by EBERLIN , AMAL M. , M.D. POSSIBLE ALLERGY ( OR SENSITIVITY ) to CEPHALOSPORINS
Reason for override: will observe carefully
FLEXERIL ( CYCLOBENZAPRINE HCL ) 10 MG orally three times a day
Number of Doses Required ( approximate ): 5
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
HEPARIN 5 , 000 U subcutaneously twice a day
INSULIN REGULAR HUMAN
Sliding Scale subcutaneously ( subcutaneously ) twice a day
Instructions: may use am lab draw results for am sliding
scale , please fingerstick in pm. thank you
If BS is less than 200 , then give 0 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ATIVAN ( LORAZEPAM ) 0.5 MG orally Q6-8H as needed Anxiety
MAALOX PLUS EXTRA STRENGTH 15 milliliters orally every 6 hours
as needed Indigestion
MOM ( MAGNESIUM HYDROXIDE ) 30 milliliters orally every day
as needed Constipation
TOBRAMYCIN SULFATE 140 MG intravenous every 8 hours
MS CONTIN ( MORPHINE SUSTAINED RELEASE ) 15 MG orally every 12 hours
as needed Pain
PRAVACHOL ( PRAVASTATIN ) 80 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
HUMIBID L.A. ( GUAIFENESIN CR TABLET ) 2 TAB orally twice a day
Number of Doses Required ( approximate ): 4
LISINOPRIL/HYDROCLOROTHIAZIDE 20/25 MG orally every day
HOLD IF: sbp <100 Number of Doses Required ( approximate ): 4
BACTRIM DS ( TRIMETHOPRIM /SULFAMETHOXAZOLE DO... )
1 TAB orally M , W , F
TIAZAC ( DILTIAZEM EXTENDED RELEASE ) 300 MG orally every day
HOLD IF: sbp <100 , heart rate < 55 Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ALLEGRA ( FEXOFENADINE HCL ) 180 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PULMICORT ( BUDESONIDE ORAL INHALER ) 1 PUFF NEB twice a day
PROVENTIL HFA ( ALBUTEROL INHALER HFA ) 2 PUFF inhaled four times a day
Number of Doses Required ( approximate ): 10
SINGULAIR ( MONTELUKAST ) 10 MG orally every afternoon
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
CALTRATE + D ( CALCIUM CARB + D ( 600MG ELEM CA... )
2 TAB orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG inhaled every 4 hours
PREDNISONE Taper orally
Give 30 mg every day X 2 day( s ) ( 8/11/03 -08 ) , then ---done
Give 25 mg every day X 3 day( s ) ( 11/15/03 -08 ) , then ---done
Give 20 mg every day X 10 day( s ) ( 3/9/03 -08 ) , then ---done
After taper , continue PREDNISONE at 20 mg every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Wildt - 9 a.m. 11/19/03 ,
ALLERGY: Penicillins , Shellfish
ADMIT DIAGNOSIS:
pneumonia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) gerd ( gastroesophageal reflux disease )
copd ( chronic obstructive pulmonary disease ) pneumonia ( pneumonia )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
66 year-old woman with severe asthma/COPD on home O2 ,
steroids , never intubated , now with recurrent pseudomonas pneumonia.
Sensitive to ceftazidime and tobramycin.
PE general: obese ,
NAD HEENT:
Cushingoid Chest: faint BS , scattered
wheezes CVS: faint S1 ,
S2 Abdomen: soft protuberant ,
+bs
Plan:
1. pulmonary: O2 by NC sats >92%. Tapered Pred to 30 mg 7/21/03. Will
txfr with prednisone taper.
2. ID: ceftz/tobramycin - intravenous Picc placed
10/21/03
3. CV: cardizem , pravachol , ASA , ECHO showed EF 55%
4. GI: prevacid
5. Endo: fs every afternoon
6. Musculoskel: Persistent back pain , most likely attributed to
coughing. rec'd
lidocaine injxn to shoulder Sat 7/6 for musculoskel pain. also
MSo4 and flexeril. Would like to wean patient off morphine.
7. Anxiety: ativan 0.5mg q8
ADDITIONAL COMMENTS: Please continue intravenous tobramycin for 1 week and switch to Toby nebulizer.
If patient worsens , please return to intravenous tobramycin.
Please continue intravenous ceftaz x 14d.
Prednisone taper: 30mg every day x 3d; 25mg every day x 3d; 20mg every day indefinitely
Can page Dr. Wildt at PUO pager #03278
Pain management: offer tylenol first
DISCHARGE CONDITION: Stable
TO DO/PLAN:
F/u with Dr. Wildt
No dictated summary
ENTERED BY: EBERLIN , AMAL M. , M.D. ( TS77 ) 3/17/03 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 1076
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
171486426 | PUO | 43712082 | | 4498636 | 10/22/2004 12:00:00 a.m. | Community-Acquired Pneumonia | | DIS | Admission Date: 6/3/2004 Report Status:
Discharge Date: 9/22/2004
****** DISCHARGE ORDERS ******
SIPHO , GRETTA 607-02-83-0
Land Ci
Service: MED
DISCHARGE PATIENT ON: 10/22/04 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Shortness of Breath
DEXEDRINE ( DEXTROAMPHETAMINE SULFATE ) 10 MG orally every day
ROBITUSSIN ( GUAIFENESIN ) 10 MILLILITERS orally every 4 hours
as needed Other:cough
LEVOTHYROXINE SODIUM 125 MCG orally every day
LISINOPRIL 30 MG orally every day Starting on 4/4
Alert overridden: Override added on 9/12/04 by
CHMURA , AL , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: monitoring
METOPROLOL TARTRATE 12.5 MG orally every day Starting Today ( 4/4 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
REMERON ( MIRTAZAPINE ) 7.5 MG orally every bedtime
Number of Doses Required ( approximate ): 2
LAMICTAL ( LAMOTRIGINE ) 200 MG orally twice a day
Number of Doses Required ( approximate ): 8
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
*LIPITOR 10 MG orally every day
PREMPRO 0.45 mg/mg orally every day
Instructions: 0.45/1.5 mg formulation
LEVOFLOXACIN 500 MG orally every day X 9 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
DIET: 4 gram Sodium
RETURN TO WORK: IN 7 DAYS
FOLLOW UP APPOINTMENT( S ):
Dr. Defore 9/10/04 scheduled ,
ALLERGY: Demerol , Penicillins , Codeine , Morphine , Sulfa ,
intravenous Contrast
ADMIT DIAGNOSIS:
Community-Acquired Pneumonia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Community-Acquired Pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
sz ( seizure disorder ) graves ( Graves' disease ) hypothyroidism
( hypothyroidism ) HTN ( hypertension ) hyperchol
( hyperlipidemia ) ADD ( attention deficit disorder ) RLL PNA ( community
acquired pneumonia ) tachycardia ( tachycardia )
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
62 F admitted with R-sided suspected pneumococcal pneumonia. PMH
notable for 1 ) Seizure D/O: temporal partial sz ( manifests as
confusion , not Tonic-Clonic ) , last Sz 1 month PTA , recently increased
Lamictal 200mg twice a day; 2 ) Subclavian Steal Syndrome stented @ Ouf County General Hospital 3 ) Vertebral Art Stenosis; 4 ) Posterior Ciruclation TIA
( admitted to Poguary Medical Center 1998 ) , on clopidogrel now; 5 ) Graves' Disease ,
now hypothyroid on replacement; 6 ) HTN with last stress-ETT 4/23 @ Poguary Medical Center wnl; 7 ) hypercholestrolemia; 8 ) ADD; 9 ) 100 pk-yr current tob.
CURRENTLY: in USOH until 2wks PTA developped productive cough with
yellow sputum , rhinnorreah , facial pain -> sxs resolved spontaneously
over 1 wk -> howver , night PTA , developped ++chills , with
right-sided mid-scapular back pain ( non-radiating , non-pleuritic ,
exacerbated by coughing ) , poor balance/difficulty standing , malaise
& cough. In ED: diagnostics notable for WBC 23.8. CXR revealed a
consolidation in the superior segment of the RLL.
HOSPITAL COURSE:
1 ) PULM: Suspected R-sided CAP with initial concerns including
ill-feeling/appearing , ST=100-120s , BP=90s/60s , 2-4L O2 requirement , &
lekocytosis , mild ARF & underlying tobacco.
- received cefotax + azithro/flagyl empirically ( no FQ intravenous given concern
of sz d/o & felt OK to challenge with cephalosporin given unclear remote
history of PCN allergy.
- sputum cx subsequently with widely sensitive strep pneumo thought
pathogenic. patient switched to intravenous cefotax alone c/with sensitivititis for 5d
in house ( of note , PPD negative here )
- patient to switch to orally levo as outpt ( discussed with neurologist who like
primary team believed that orally levo with lower & acceptable risk ); no amox
icillin given possible PCN allergy & allergy team unable to skin-test
for PCN as inpt.
- after receiving additional IVFs on HODs #1-2 & bronchodlators for
suspected secondary bronchspasm , patient with definite improvement including
a ) symptomatic improvement including less cough/CP; b ) stable BPs without
IVFs and re-institution of antihypertensives; c ) no hypoxia including
with ambulation; d ) decreased HR with max=105 with ambulation; e ) no fevers
& dec WBC; e ) resolved ARF.
- of note , received flu & pneumococcal vaccines prior to DC; was on
LMWH prophylaxis throughout hospitalization
2 ) NEW LBBB: 2 separate episodes of transient LBBB ( on 5/29 ,
and 6/15 ) with likely sinus rhythm and tachy to 110s on 12 lead ECG.
Asymptomatic with negative serial cardiac enzymes -> thought likely 2/2
rate-related LBBB conduction dz as not appear with HR <105. Of note ,
tachycardia thought 2/2 infection +/- initial B-blocker withdrawal
ADDITIONAL COMMENTS: Please note that we have made no changes to your medications which you
were taking prior to your hospitalization , and you should continue them
as per your primary care physician's instructions. You are being
discharged with a 9 day course of Levofloxacin ( 500mg orally every day ) to treat
your pneumonia. There is a slight risk that this medication lowers the
seizure threshhold. If you develop any concerns , please seek medical
attention immediately. Please follow-up with your primary care physician
as outlined.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: CHMURA , AL , M.D. ( NW72 ) 10/22/04 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1077
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DM |
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GER |
Gou |
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935606280 | PUO | 15163458 | | 7825326 | 9/29/2005 12:00:00 a.m. | same | | DIS | Admission Date: 9/10/2005 Report Status:
Discharge Date: 1/6/2005
****** FINAL DISCHARGE ORDERS ******
MUNSINGER , SANTO 728-68-85-6
Roll Field Gilbti
Service: GGI
DISCHARGE PATIENT ON: 8/10/05 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ELIXIR ( ACETAMINOPHEN ORAL LIQUID ) 650 MG orally every 4 hours
as needed Pain , Headache
OXYCODONE 1 MG/1 ML SOLUTION 5 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 8/4/05 by :
on order for OXYCODONE 1 MG/1 ML SOLUTION orally ( ref #
62569385 )
patient has a PROBABLE allergy to Morphine; reaction is Rash.
Reason for override: patient tolerating dilaudid
without problems
RANITIDINE HCL SYRUP 150 MG orally twice a day
COLACE ELIXIR ( DOCUSATE SODIUM ) 100 MG orally twice a day
ACTIGALL ( URSODIOL ) 300 MG orally three times a day
DIET: Gastric bypass protocol
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 20 pounds
FOLLOW UP APPOINTMENT( S ):
call immediately to schedule follow up with Dr. Hornbeak 1154626537 within next 7-10 days ,
call immediately to schedule follow up with your primary care physician. ,
ALLERGY: PROCHLORPERAZINE , Morphine , TRIAMCINOLONE ,
TRIMETHOPRIM/SULFAMETHOXAZOLE , LATEX
ADMIT DIAGNOSIS:
morbid obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN
OPERATIONS AND PROCEDURES:
10/2/05 HORNBEAK , LAUREL I. , M.D.
LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
UGI - negative for leak or obstruction
BRIEF RESUME OF HOSPITAL COURSE:
The patient tolerated the procedure and had an uncomplicated
post-operative course. Her pain was controlled initially PCEA and PCA ,
and then orally medications when tolerating regular diet. Diet was
advanced per protocol after her UGI revealed no leakage or
obstruction. She remained cardiovascularly stable , she did not develop
an O2 requirement Patient tolerated a regular diet , and was passing
flatus prior to discharge. She developed migraine in teh post operative
course taht was managed with multiple pain medications. She received
heparin for DVT prophylaxis , and intravenous ancef and flagyl for perioperative
antibiotic coverage. She was able to ambulate without assistance and
deemed ready for discharge
ADDITIONAL COMMENTS: 1-Please resume all home meds , but crush pills. 2-Do not drive while
taking narcotic medications 3-Patient may shower , but do not immerse
incision - no tub baths/swimming. 4-Small white steri-strips bandages
will fall off in 5-7 days , you may remove at that time if irritating. 5
-Call if incision becomes markedly more red , swollen , or begins to drain
purulent fluid , or for fever more than 101.5 6. Call if any change in
bowel habits , vomiting , red or black stools. 7. Diet: follow gastric
bypass protocol.8. F/U appointment with primary care physician for treatment of migraine
DISCHARGE CONDITION: Stable
TO DO/PLAN:
follow up with Dr. Hornbeak
No dictated summary
ENTERED BY: BORGESON , DIANA ELNORA , M.D. ( JE126 ) 8/10/05 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 1078
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Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
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OSA |
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552459857 | PUO | 45048123 | | 569965 | 9/22/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/8/1999 Report Status: Signed
Discharge Date: 6/11/1999
PRINCIPAL DIAGNOSIS: 1. Stroke.
SECONDARY DIAGNOSIS: 2. Coronary artery disease.
3. Hypertension. 4. Hypercholesterolemia.
5. Type II diabetes mellitus. 6. Gastroesophageal reflux
disease.
PRINCIPAL PROCEDURES AND OPERATIONS: The patient had a head MRI ,
an echocardiogram , and head
CT scan.
HISTORY OF PRESENT ILLNESS: This 61-year-old male was in his usual
state of health until the morning of
admission when he woke up with speech difficulty noticed by his
wife. The patient was noted to make paraphasic errors. In
addition , there was a question of a right facial droop. The
patient presented to the emergency room. There were no other
neurologic symptoms.
PHYSICAL EXAMINATION: Physical examination on admission revealed
pulse 78 , temperature 98.8 , and blood
pressure 160/78. The patient was in no apparent distress. The
head and neck examination was unremarkable. The neck was supple.
The thyroid gland was not enlarged. The lungs were clear. There
was a normal S1 and S2 , with no murmurs , gallops or rubs. The
abdomen was soft and non-tender. There was no peripheral edema.
The patient was alert and oriented to his name and to place. The
patient had difficulty giving the exact date and month. The
patient was unable to register three objects properly. The
patient's speech was non-fluent with impaired naming. Repetition
was also affected. There was right left confusion , severe
acalculia , as well as poor reading and writing. The patient had no
neglect or apraxia. The patient was able to copy a complicated
figure without problems. The cranial nerves were intact , except
for a mild right upper motor neuron facial palsy. There was no
pronator drift and the strength was 5/5 in all four extremities.
Sensation was intact to primal modalities. The reflexes were 2+
and symmetric with downgoing toes. The patient had normal gait.
LABORATORY DATA: Laboratory data on admission revealed serum
electrolytes to be normal , except for a potassium
of 5.3. The glucose was 168. The white count was 7.8 , hematocrit
38.8 , and platelets 223. A physical therapy and PTT were normal. A head CT scan
showed a subtle hyperdensity in the left frontal region. This was
later confirmed by MRI. The patient had carotid ultrasounds , which
showed a 60% stenosis of the left internal carotid artery. The
right internal carotid was stenosed to 25%.
HOSPITAL COURSE: The patient was admitted to the hospital with a
diagnosis of probable embolic stroke. An MRI
showed a wedge shaped frontal lobe infarct. Clinically , the
patient's speech improved and he regained fluency within the next
24 hours. The patient's naming was relatively preserved.
Comprehension was intact for simple commands. However , the patient
continued to have right left indiscrimination , acalculia , as well
as a defect in reading and writing. The patient was initially
unable to add two plus two , but by the end of the hospitalization ,
he was able to add nine plus six. However , the patient's
calculation never returned to his baseline function. The patient
had an echocardiogram , which revealed an ejection fraction of 60% ,
with no significant valvular disease. There was no thrombus noted
in the left atrium. The patient was started on intravenous Heparin
on admission , and was then converted to orally Coumadin. The patient
ruled out for myocardial infarction on admission. The patient was
kept on a cardiac monitor with no cardiac events noted. The
patient was seen by the Neurobehavioral Service because of his
aphasia.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on Allopurinol , Atenolol ,
Colchicine , Prilosec , Lipitor , and Coumadin. FOLLOW-UP: The
patient was instructed to follow-up with Dr. Stephco of the
Neurology Service at Pagham University Of .
Dictated By: FLORETTA THRONEBURG , M.D. EL76
Attending: MIRNA C. BABULA , M.D. PM56
RX162/9603
Batch: 31413 Index No. NNMSZJ9E90 D: 8/14/99
T: 11/1/99
CC: 1. MYONG B. STEPHCO , M.D. KV4
QF9
Document id: 1079
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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060907716 | PUO | 56225750 | | 4800740 | 2/23/2003 12:00:00 a.m. | COPD exacerbation , | | DIS | Admission Date: 2/12/2003 Report Status:
Discharge Date: 5/15/2003
****** DISCHARGE ORDERS ******
FAUSTINO , MERISSA 842-99-66-8
Full
Service: MED
DISCHARGE PATIENT ON: 9/4/03 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ABSHEAR , CARLTON J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally twice a day Starting Today ( 8/3 )
REG INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously ( subcutaneously ) before every meal & HS
If BS is less than 200 , then give 0 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
OPTICAL LUBRICANT OINTMENT ( LACRI-LUBE ) TOPICAL each eye every day
PREDNISONE Taper orally
Give 40 mg am X 2 day( s ) ( 3/1/03 -04 ) , then ---done
Give 30 mg am X 2 day( s ) ( 6/26/03 -04 ) , then
Give 20 mg am X 2 day( s ) ( 5/25/03 -04 ) , then
Give 10 mg am X 2 day( s ) ( 4/18/03 -04 ) , then
DARVOCET N 100 ( PROPOXYPHENE NAP./ACETAMINOPHEN )
2 TAB orally every afternoon
OCEAN SPRAY ( SODIUM CHLORIDE 0.65% ) 2 SPRAY nasal four times a day
as needed dry nose
PAXIL ( PAROXETINE ) 20 MG orally every day
Override Notice: Override added on 4/29/03 by VACEK , WALTON JANELLA , MD , MPH
on order for LEVOFLOXACIN orally 250 MG every day ( ref # 98985962 )
POTENTIALLY SERIOUS INTERACTION: PAROXETINE HCL &
LEVOFLOXACIN Reason for override: md aware
Previous override information:
Override added on 6/24/03 by VACEK , WALTON JANELLA , MD , MPH
on order for LEVOFLOXACIN intravenous 250 MG every 24 hours ( ref #
18967064 )
POTENTIALLY SERIOUS INTERACTION: PAROXETINE HCL &
LEVOFLOXACIN Reason for override: md aware
Previous override information:
Override added on 9/22/03 by VACEK , WALTON JANELLA , MD , MPH
on order for LEVOFLOXACIN intravenous ( ref # 66674025 )
POTENTIALLY SERIOUS INTERACTION: PAROXETINE HCL &
LEVOFLOXACIN Reason for override: md will monitor
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLOVENT ( FLUTICASONE PROPIONATE ) 44 MCG inhaled twice a day
LIVOSTIN ( LEVOCARBASTINE HCL 0.05% ) 2 DROP each eye twice a day
Number of Doses Required ( approximate ): 5
XALATAN ( LATANOPROST ) 2 DROP each eye every afternoon
Number of Doses Required ( approximate ): 5
ALPHAGAN ( BRIMONIDINE TARTRATE ) 2 DROP OS twice a day
Instructions: to R eye only
Number of Doses Required ( approximate ): 5
LEVOFLOXACIN 250 MG orally every day X 14 Days
Starting Today ( 6/9 )
Alert overridden: Override added on 4/29/03 by
VACEK , WALTON JANELLA , MD , MPH
SERIOUS INTERACTION: THEOPHYLLINE & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: PAROXETINE HCL &
LEVOFLOXACIN Reason for override: md aware
Previous override reason:
Override added on 6/24/03 by VACEK , WALTON JANELLA , MD , MPH
SERIOUS INTERACTION: THEOPHYLLINE & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: PAROXETINE HCL &
LEVOFLOXACIN Reason for override: md aware
Previous Alert overridden
Override added on 9/22/03 by VACEK , WALTON JANELLA , MD , MPH
SERIOUS INTERACTION: THEOPHYLLINE & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: PAROXETINE HCL &
LEVOFLOXACIN Reason for override: md will monitor
SINGULAIR ( MONTELUKAST ) 10 MG orally every afternoon
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LANTUS ( INSULIN GLARGINE ) 10 UNITS subcutaneously every day before noon
HOLD IF: fsbg is <90
CLARINEX ( DESLORATADINE ) 5 MG orally every day
Number of Doses Required ( approximate ): 5
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed shortness of breath
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
CAPTOPRIL 37.5 MG orally three times a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Alert overridden: Override added on 9/4/03 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
CAPTOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
CAPTOPRIL Reason for override: will follow
ATENOLOL 25 MG orally every day Starting Today ( 8/3 )
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Genny Barrette ,
ALLERGY: Cephalosporins
ADMIT DIAGNOSIS:
sob
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
COPD exacerbation ,
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma ( asthma ) hep c ( hepatitis C ) hep b ( hepatitis
B ) htn ( hypertension ) dm ( diabetes
mellitus ) depression ( depression ) osa ( sleep
apnea ) pulmonary htn ( pulmonary hypertension ) chf ( congestive heart
failure ) glaucoma ( glaucoma )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
59yo F with history of asthma , recent diagnosis of CHF ,
HTN and elevated PA pressures ( 50s ) now presents after a recent KAAH
admission ( 10/13/12 ) where she was diuresed aggressively ( 20 pounds ) ,
diagnosed with OSA ( given CPAP ) and received 3days of
levo for a UTI. She now presents with increased
SOB ( had been able to climb 1 flight of stairs
on discharge ) now can not talk in full sentences.
Of note patient had PFTs in 3/16 that showed
little reversibility.
ECHO ( 5/13 ): EF59% , no WMA , moderate MR , LAE , RV pressure is
50. EKG ( 3/18 ): ST at 114. Nl axis , poor R wave
progre ssion , LAE. TwF in
Avl. CXR: No obvious infiltrate , mildly plump
vessels , cardiomegaly.
Allergies: Cefs - SOB and hives Labs: WBC 25. Bands of 23. BNP
862. PE on admit: 100.5 , p111. BP 137/91. 89%
5L. Could not speak in full sentences secondary
to resp distress. Buffalo hump , round face. No
LAD. JVP at angle of the jaw. Tachy. Decreased BS
at bases R>L. mild expiratory wheezes , moderate
air movement. Tachy , no m/r/g. Ext warm with 1+
edema to knees and trace to the sacrum
B. HOSPITAL COURSE BY
SYSTEM: 1. ID. Elevated WBC ( 25 ) with left shift ,
fever , productive cough. No infiltrate on CXR. CT
scan shows Bilateral lower lobe pneumonia. On
Levo ( ceph allergic ). Urine culture and blood
cx negative. By 4/30 much improved WBC and
breathing. 2. Pulm: Likely not an astham flare. Patient
also likely with COPD. Cont nebulizers ,
home meds , Prednisone ( on taper ) Initiated Flovent
on 10/8 3. Endo: DM on NPH 24 twice a day at home.
With prednisone elevated BS. Started Lantus
for more consistent coverage. Increase if
still high on 4/10 RISS. Hemoglobina a1c 6.7. 4.
CV. Pump. Mildly fluid overloaded goal even
to -500cc. Creat bumped with
aggressive diuresisi. Lasix 40 twice a day. 5. CV. HTN. Cont
Norvasc - now at 10 , Captopril decreased on 5/15 due
to creat bump. Now added Lopressor 12.5 - titrate
up if called for elevated BP. Watch for
wheezing though given lung disease. 6. Rheum:
COnt Darvocet , celebrex. 7. Renal: patient with
ARI ( baseline creat 1.2 at KAAH 5/13 ). Likely
secondary to diuresesis , ACE , CT dye. Now
declining.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: COCOMAZZI , REA , MD
****** END OF DISCHARGE ORDERS ******
Document id: 1080
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Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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| output/system_intuitive_annotation.xml | intuitive |
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759646448 | PUO | 39691196 | | 4134467 | 2/12/2002 12:00:00 a.m. | noncardiac chest pain , possible GERD | | DIS | Admission Date: 1/18/2002 Report Status:
Discharge Date: 10/10/2002
****** DISCHARGE ORDERS ******
KROCHMAL , STACI 757-96-96-7
Yonkers
Service: CAR
DISCHARGE PATIENT ON: 9/19/02 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS CARLIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VENTOLIN ( ALBUTEROL INHALER ) 2 PUFF inhaled four times a day
ALLOPURINOL 300 MG orally every day
Override Notice: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for THEOPHYLLINE ( SLOW RELEASE ) orally 200 MG three times a day
( ref # 89538329 )
POTENTIALLY SERIOUS INTERACTION: ALLOPURINOL & THEOPHYLLINE
Reason for override: aware Previous override information:
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for THEOPHYLLINE ( SLOW RELEASE ) orally ( ref #
73129998 )
POTENTIALLY SERIOUS INTERACTION: ALLOPURINOL & THEOPHYLLINE
Reason for override: home med
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for COUMADIN orally 5 MG every bedtime ( ref # 39548554 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware Previous override information:
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware
CYCLOBENZAPRINE HCL 10 MG orally three times a day
DILTIAZEM SUSTAINED RELEASE 120 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for LASIX orally 40 MG every day ( ref # 90065416 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: aware Previous override information:
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for LASIX orally ( ref # 15973148 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: aware
Number of Doses Required ( approximate ): 8
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: aware Previous Alert overridden
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: aware
LISINOPRIL 30 MG orally every day Starting Today ( 7/8 )
Override Notice: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for KCL SLOW RELEASE orally ( ref # 30962062 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3
as needed chest pain
THEOPHYLLINE ( SLOW RELEASE ) 200 MG orally three times a day
Food/Drug Interaction Instruction
Follow manufacturer's info re: take with food.
Give with meals
Override Notice: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for COUMADIN orally 5 MG every bedtime ( ref # 39548554 )
POTENTIALLY SERIOUS INTERACTION: THEOPHYLLINE & WARFARIN
Reason for override: aware Previous override information:
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & THEOPHYLLINE
POTENTIALLY SERIOUS INTERACTION: ALLOPURINOL & THEOPHYLLINE
Reason for override: aware Previous Alert overridden
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & THEOPHYLLINE
POTENTIALLY SERIOUS INTERACTION: ALLOPURINOL & THEOPHYLLINE
Reason for override: home med
MVI THERAPEUTIC W/MINERALS ( THERAP VITS/MINERALS )
1 TAB orally every day
COUMADIN ( WARFARIN SODIUM ) 6.5 MG orally every bedtime
Starting Today ( 7/8 ) Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: THEOPHYLLINE & WARFARIN
Reason for override: aware Previous Override Notice
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for THEOPHYLLINE ( SLOW RELEASE ) orally 200 MG three times a day
( ref # 89538329 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & THEOPHYLLINE
Reason for override: aware Previous override information:
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for ECASA orally ( ref # 08796705 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware Previous override information:
Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
on order for THEOPHYLLINE ( SLOW RELEASE ) orally ( ref #
73129998 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & THEOPHYLLINE
Reason for override: home med
SEREVENT ( SALMETEROL ) 2 PUFF inhaled twice a day
KCL SLOW RELEASE 20 MEQ X 1 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 6/1/02 by FERRIERA , EVAN KRISTIE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
FLOVENT ( FLUTICASONE PROPIONATE ) 880 MCG inhaled twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
RETURN TO WORK: Immediately
FOLLOW UP APPOINTMENT( S ):
Primary care physician 1-2 weeks ,
ALLERGY: Inderal ( beta-blockers ) , Quintrim
ADMIT DIAGNOSIS:
r/o MI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
noncardiac chest pain , possible GERD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ASTHMA HTN OSTEONECROSIS HIPS W/ REPL. GOUT DIVERTICULITIS LEUKOPLAKIA
cardiomyopathy ( ? etiology ) ? angina nevi excised from
legs EF 30-40% history of EtOH abuse ( history of alcohol
abuse ) history of LV thrombus on coumadin AVN R elbow ( avascular necrosis
femoral head ) PVD ( peripheral vascular
disease ) history of diverticulosis ( history of diverticulosis ) history of Trigeminy
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
53M with history of CAD history of MI 1995 , CMP EF 30% , history of heavy EtOH use admitted
with 1 week of waxing and waning "crushing substernal CP" 2/10-8/10
lasting minutes to hours , radiating to back , without associated sx
other than some diaphoresis. Pain is NOT like previous angina. Not
associated with exertion. ROS otherwise negative. sleeps on 4 pillows
for chronic hip pain; no PND/LE edema. Admits to drinking 6
beers/day. PMH also sig for COPD/asthma , bilateral hip replacements , LV
thrombus on coumadin.
In ED 88 157/97 97% 2L NC exam sig for JVP 5 cm ,
RRR S1/S2 +S4 no murmurs. CTAB. Abd obese , no HSM. No LE edema , 2+
pulses EKG NSR 78 bpm LAD ?LAFB labs sig for CK 167 TnI 0.05 BNP 21.
WBC 5 HCt 43 Plt 88 ( has been low in past ). INR 1.8.
##CV
- completed r/o by enzymes/EKG x3
- cont home meds; apparently intolerant of beta-blockers in past. BP
control. No evidence of volume overload by hx or exam.
- dobutamine MIBI 4/6 max HR 127 , double product 23K. No chest pain
or EKG changes. Moderately dilated LV , severely dilated RV , LVEF 51%.
Fixed severe inferobasal defect with moderate inferior wall HK c/with
prior PDA infarct. No evidence of ischemia.
##Heme - thrombocytopenia but stable on repeat CBC , possibly secondary
to alcohol. Continued coumadin for LV thrombus
##GI
- antacids , PPI. Patient reports significant relief of GERD sx with
PPI. Will discharge with trial of PPI; possible that chest pain result
of GERD/dyspepsia.
##EtOH
- prophylactic lorazepam given , no evidence of withdrawal during
admission. patient counseled on EtOH abstinence/reduction.
##pulm
- cont COPD meds
ADDITIONAL COMMENTS: 1 ) Call your doctor , return to ED or call 911 for crushing chest pain
that does not respond to 3 sublingual nitroglycerin tablets and lasts
more than 20 minutes.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
recheck your coumadin level as instructed
No dictated summary
ENTERED BY: FRANKENBERRY , ANDREAS , M.D. ( TP16 ) 9/19/02 @ 06
****** END OF DISCHARGE ORDERS ******
Document id: 1081
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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378576931 | PUO | 59506466 | | 0596976 | 5/29/2006 12:00:00 a.m. | bronchitis , COPD excaerbation , DVT | | DIS | Admission Date: 5/7/2006 Report Status:
Discharge Date: 11/19/2006
****** FINAL DISCHARGE ORDERS ******
FALASCO , FELICA SHELIA 855-84-73-6
S En Sun
Service: MED
DISCHARGE PATIENT ON: 1/29/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CHAIX , TRISH LOREAN , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL NEBULIZER 2.5 MG NEB every 2 hours
as needed Shortness of Breath , Wheezing
FOSAMAX ( ALENDRONATE ) 35 MG orally QWEEK
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
81 MG orally DAILY
Override Notice: Override added on 10/18/06 by
OSMERS , TESSA M.
on order for COUMADIN orally ( ref # 004429055 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ATENOLOL 100 MG orally DAILY HOLD IF: sbp < 100 , HR < 55
Override Notice: Override added on 10/18/06 by
ARUIZU , JULIANNE MARIE , M.D.
on order for TIAZAC orally ( ref # 387950786 )
POTENTIALLY SERIOUS INTERACTION: ATENOLOL & DILTIAZEM HCL
Reason for override: patient tolerates
LIPITOR ( ATORVASTATIN ) 10 MG orally DAILY
WELLBUTRIN SR ( BUPROPION HCL SUSTAINED RELEAS... )
100 MG orally DAILY
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
1 TAB orally twice a day
CARDIZEM CD ( DILTIAZEM CD ) 120 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 1/29/06 by :
POTENTIALLY SERIOUS INTERACTION: ATENOLOL & DILTIAZEM HCL
Reason for override: will follow
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
HUMULIN N ( INSULIN NPH HUMAN ) 10 UNITS subcutaneously every day before noon
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
LEVOFLOXACIN 750 MG orally every 48 hours X 2 Days
Starting Today ( 10/5 )
Instructions: To be completed by 11/23
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 10/18/06 by
OSMERS , TESSA M.
on order for COUMADIN orally ( ref # 004429055 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: aware
LISINOPRIL 20 MG orally twice a day
Override Notice: Override added on 10/18/06 by
OSMERS , TESSA M.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
664221461 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
PREDNISONE Taper orally Give 50 mg every 24 hours X 1 dose( s ) , then
Give 40 mg every 24 hours X 2 dose( s ) , then
Give 30 mg every 24 hours X 2 dose( s ) , then
Give 20 mg every 24 hours X 2 dose( s ) , then
Give 10 mg every 24 hours X 2 dose( s ) , then Starting Today ( 10/5 )
AVANDIA ( ROSIGLITAZONE ) 4 MG orally twice a day
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 3/9/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: aware
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Squiers within the next 2 weeks- please call to make an appointment ,
Arrange INR to be drawn on 4/3/06 with f/u INR's to be drawn every
5 days. INR's will be followed by KTDUOO - Dr. Zula Squiers
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
brochitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bronchitis , COPD excaerbation , DVT
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NIDDM OBESIY HTN vietnamese-SPEAKING ONLY PSORIASIS
( SEVERE ) atrial fibrillation ( atrial fibrillation ) history of appendectomy
( history of appendectomy ) high cholesterol ( elevated
cholesterol ) history of pelvic abcess requiring ileostomy ( history of abscess ) CRI
( chronic renal dysfunction ) hypothyroidism ( hypothyroidism ) diverticultis
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHO
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB x 2 days
****
HPI: 67F with asthma , history of DVT , DM , AF , HTN admitted with SOB at rest
x 2 days. patient also c/o fever , dry cough , and fleeting pleuritic chest
pain. patient had been off of her coumadin in July for surgery
( re-anastamosis of ileum/colon ) and restarted a couple of weeks ago.
patient's INR has been subtherapeutic at 1.8-1.9. patient c/o left leg
swelling. Denies N/V/D , dysuria , abd pain. In ED , patient was given
levoflox , nebulizers , and prednisone
60mg.
****
HOME MEDS: atenolol 100 every day , tiazac 120 every day , flovent 110 twice a day , coumadin
4mg M/F , 2mg T/WED/TH/SAT/SUN , ASA 81 , avandia 4 twice a day , wellbutrin 100
every day , caltrate D , albuterol as needed , folate every day , fosamax 35 QWk , NPH 13U
every day , Lasix 20 every day , lisinopril 10 every day , oxycodone as needed , protonix 40 every day ,
Kdur 20 every day
****
ALL: NKDA
****
EXAM: T 100.1 P103 BP 172/84 RR26 96%3L GEN: physical therapy in NAD ,
AAOx3 HEENT: NC/AT , JVP difficult to
assess PULM: diffuse wheezing and
rhonchi CVS: nl s1s2 , irregularly
irregular ABD: obese , staples at ostomy
site EXT: LLE>RLE , +edema ,
nontender SKIN: multiple psoriatic plagues all over
body
****
LABS: Cr 1.7 , WBC 15.5 , BNP 312 , INR 2.7 EKG: AF , no significant
changes CXR: vascular engorgement , no
infiltrate VQ scan: low
probablilty LENI: +LLE
DVT
****
HOSPITAL COURSE: 67F with cough , bronchospam x 2 days-> likely
bronchitis. patient also with LLE DVT. * PULM: Duoneb ATC and as needed
Prednsione 60 every day and taper as tolerated. Levoflox x 5days. Cont
flovent * VASC: LLE DVT found. Cont coumadin for goal INR
2-3. Low prob PE per VQ scan * CV: Cont atenolol , tiazac , ASA ,
lisinopril , zocor , lasix. Cardiac enzymes were negative x3. ECHO
revealed EF 55% , moderate MR , and elevated PAP and R atrial pressure.
patient had an episode of MAT and was given intravenous magnesium with good result.
May need intravenous dilt if has further episodes of
tachycardia. * DM: NPH 25u twice a day and novolg 10u before every meal per insulin
protocol. Check AIC * ENDO: TSH 0.1. patient has history of multinodular goiter.
Free T4 1.5. * PROPH: coumadin/PPI. INR 3.8 , so coumadin
held
***************
The patient was admitted and treated with steroids , antiobiotics , and
inhaled bronchodilators. Her respiratory status improved quickly and on
the day prior to discharge her SaO2 on room air was 99% at rest and 97%
with ambulation. During her admission she was noted to have left leg
swelling and had been subtherapeutic on her coumadin. LENNI showed DVT.
Her coumadin dose was adjusted and was slightly elevated in the setting
of levofloxacin. She is therapeutic at discharge and will be followed by
the PUO Coumadin Clinic.
**On 11/14 the patient was stable and feeling well. She is discharged to
home with VNA services for INR check on Monday and cardiorespiratory
status. She has been instructed to call Dr. Squiers Monday for a follow
up appointment within the next two weeks.
ADDITIONAL COMMENTS: 1. ) Follow up with Dr. Squiers within the next two weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HEIDELBERGER , LATICIA THADDEUS , M.D. ( VE083 ) 1/29/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 1082
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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378576931 | PUO | 59506466 | | 4127927 | 8/29/2004 12:00:00 a.m. | INTRAABDOMINAL PHLEGMON | Signed | DIS | Admission Date: 8/29/2004 Report Status: Signed
Discharge Date: 3/2/2004
ATTENDING: SHERISE WANKUM MD
ADDENDUM
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg every six hours , hold for heart rate less
than 55 and blood pressure less than 100.
2. Dulcolax 10 mg PR every day , hold for greater than two bowel
movements per day.
eScription document: 9-7189235 EMSSten Tel
Dictated By: VUKOVICH , MORRIS
Attending: MARILYN V. FREHSE , M.D. RL29
Dictation ID 1677410
D: 5/3/04
T: 5/3/04
Document id: 1083
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
090880408 | PUO | 16120712 | | 394168 | 3/19/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/10/1991 Report Status: Signed
Discharge Date: 3/30/1991
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old Hispanic
female with insulin-dependent diabetes
mellitus and hypertension , who fell at home approximately 1 week
before admission. She suffered a right-sided Colles fracture that
was treated with closed reduction and half cast. Furthermore , she
suffered a nondisplaced left-sided patella fracture , which was
primarily treated with a knee immobilizer. Since the follow-up
x-ray of the distal radius 1 week after trauma showed shortening
and dorsal angulation , the patient was admitted for closed
reduction and external fixation. PAST MEDICAL HISTORY reveals
insulin-dependent diabetes mellitus , hypertension , anxiety. PAST
SURGICAL HISTORY reveals she is status post open reduction and
internal fixation of a left-sided tibial plateau fracture 9 months
ago. MEDICATIONS ON ADMISSION were Verapamil 80 milligrams by
mouth 3 times a day , Chlorthalidone 50 milligrams by mouth per day ,
humulin-N 40 units subcutaneously each morning , multivitamin 1
tablet by mouth per day.
PHYSICAL EXAMINATION: On admission , the patient was a 62 year old
female in no acute distress. Lungs were
clear. Cardiovascular examination showed regular rate and rhythm ,
III/VI holosystolic murmur , regular S1 and S2 , no S3 or S4. Abdomen
was soft , nontender , no palpable masses or hepatosplenomegaly.
Extremities showed the right forearm and wrist immobilized in a
splint , there was regular VMF of all 5 digits , good capillary
refill , radial and ulnar pulses were 2+/2+. Left knee had positive
effusion , no signs of ligamentous instability , straight leg raising
possible , but with 15 to 20 degree extension deficit.
LABORATORY EXAMINATION: On admission , x-ray of the left knee , PA
and lateral , shows nondislocated patella
fracture ( fracture line almost not visible ). Distal radius PA and
lateral showed shortening and dorsal angulation of the articulate
surface. On admission , electrolytes were within normal limits ,
blood urea nitrogen 23 , creatinine 1.3 , hemoglobin 13.0 , hematocrit
38.2 , white count 8 , 100 , platelet count 411 , 000 , prothrombin time
12.3 , partial thromboplastin time 23.4. Urinalysis was without
pathological findings.
HOSPITAL COURSE: On 9 of February , the patient underwent closed reduction
and external fixation of her distal radial
fracture. The patient tolerated the procedure very well and the
postoperative course was without complications. Postoperative
x-ray control showed an optimal result with anatomical reduction of
the radial articulate surface. During the early postoperative
course , the radial ramus of the radial nerve seemed to be
irritated , but recovered without any further intervention and the
patient was without any neurological deficit from the 4th
postoperative day on. While the left leg was immobilized with a
brace , the patient started to ambulate with a platform walker and
with full weight-bearing on the left leg. Prior to discharge , the
patient was afebrile with stable vital signs. Serial electrolytes ,
blood urea nitrogen and creatinine were within normal limits.
Leukocytes were 8 , 000 , hemoglobin 12.9 , hematocrit 38.0 , platelet
count 489 , 000 , last blood glucose level prior to discharge from
7:00 am was 169 , 4:00 pm 73 , 10:00 pm 230. The pin sites on the
right forearm were without signs of infection. X-ray control done
on 13 of August , showed unchanged positioning of the right radius , as
well as the left patella.
DISPOSITION: MEDICATIONS ON DISCHARGE are the same as on
admission. CONDITION ON DISCHARGE was stable. The
patient is going home. The plan is for postoperative FOLLOW-UP in
1 week at the Orthopaedic Clinic of Pagham University Of .
Until then , the patient is advised to keep the right arm elevated
and to seek medical attention in case of fever , reddening of the
pin sites , and/or secretion from any pin site. Hence , the patient
is not able to do her finger sticks for blood sugar measurement by
herself , and Visiting Nurse Association was ordered.
HE758/4195
CAITLIN RADEMAN , M.D. MW29 D: 10/8/91
Batch: 0309 Report: S4392P40 T: 10/15/91
Dictated By: BREANNA CARIDINE , M.D.
Document id: 1084
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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759422354 | PUO | 29460046 | | 9999319 | 11/5/2005 12:00:00 a.m. | chest pain | | DIS | Admission Date: 11/5/2005 Report Status:
Discharge Date: 4/20/2005
****** FINAL DISCHARGE ORDERS ******
JACINTO , ROSAURA 877-11-43-2
Do Moines
Service: MED
DISCHARGE PATIENT ON: 4/4/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA 325 MG orally every day
CAPTOPRIL 50 MG orally three times a day HOLD IF: SBP < 100
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
FOLATE ( FOLIC ACID ) 1 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally every day
Starting Today ( 8/27 ) HOLD IF: HR<50 , SBP<100
PAXIL ( PAROXETINE ) 20 MG orally every day
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Primary care physician next week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Unstable angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
r/o mi ( R/O myocardial infarction ) disk herniation ( herniated
disc ) hypercholesterolemia ( elevated cholesterol )
OPERATIONS AND PROCEDURES:
adenosine mibi
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest tightness
HPI: 63 M with history of CAD history of LAD/ diag stents '98 , R MCA CVA 4/9 with
residual L weakness , dysarthria , dysphagia. 1 D PTA had transient
upper body flushing , T = 100 , chest tightness while sitting ,
resolved without intervention. On 5/29 , before dinner , became nauseous ,
vomitted and had chest tightness , resolved without intervention. Came to
ED. ROS: + for intermittent choking with eating x 2
months VSS , c/o transient CP self-resolved. EKG: pseudo-normalization TW
in 1 , V5 , V6 Tn , MB negative x2 separated by 12 hours. Received ASA ,
BB PMH: R MCA CVA , CAD history of LAD/ diag CVA , HTN , past heavy tob , hyperchol
Imp: Given significant CAD risk factors , and history , story concerning
for UA ( patient is a minimizer per his wife ). However , cardiac enzymes
are negative and an adenosine stress MIBI done on 8/27 was negative for
ischemia and showed normal LV function.
Plan:
1 ) isch: ASA , continue Zocor 20 mg , lopressor.. Hold
Plavix for now. Pharm MIBI in a.m. was normal
2 ) pump: EF~65% continue home captopril
3 ) rhythm: tele
4 ) GI: history of dysphagia. Possible etiol of symptoms
would be esophageal spasm. -S & S eval - recomended video swallow and
possible EDG for stricture evaluation. Mr. Sakai 's covering primary care physician was
spoken to by Dr. Taplin and recomended that he see his primary care physician next
week for video swallow and EDG referal.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: DELAGLIO , CHRISTIANA S. , M.D. , PH.D. ( LP34 ) 4/4/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1085
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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696126968 | PUO | 04840770 | | 5368015 | 9/13/2005 12:00:00 a.m. | post-concussive syndrome | | DIS | Admission Date: 4/9/2005 Report Status:
Discharge Date: 11/19/2005
****** FINAL DISCHARGE ORDERS ******
IOZZO , JEANNA 650-02-09-0
Sterjack
Service: MED
DISCHARGE PATIENT ON: 10/17/05 AT 01:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TAPLIN , AVRIL , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day Starting Today ( 6/6 )
ALPRAZOLAM 0.5 MG orally four times a day Starting Today ( 8/14 )
HOLD IF: oversedation , RR<12
Instructions: take as you were taking at home
BETOPTIC-S 0.25% ( BETAXOLOL HCL 0.25% ) 1 DROP OD twice a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 225 MCG orally every day
METOPROLOL TARTRATE 25 MG orally twice a day Starting Today ( 6/6 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOLOFT ( SERTRALINE ) 100 MG orally twice a day
Starting Today ( 8/14 )
NEURONTIN ( GABAPENTIN ) 800 MG orally four times a day
EFFEXOR XR ( VENLAFAXINE EXTENDED RELEASE ) 187.5 MG orally every day
Starting Today ( 6/6 )
Number of Doses Required ( approximate ): 10
LUMIGAN ( BIMATOPROST 0.03% ) 1 DROP OD every bedtime
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
LISINOPRIL 5 MG orally every day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
NITROFURANTOIN SUSTAINED RELEASE 100 MG orally twice a day
Food/Drug Interaction Instruction Give with meals
Take with food or milk.
IBUPROFEN 600 MG orally three times a day Starting Today ( 6/6 ) as needed Pain
Instructions: with meals Food/Drug Interaction Instruction
Take with food
OXYCODONE 10 MG orally twice a day Starting Today ( 8/14 ) as needed Pain
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Santangelo 2:15pm 2/25/05 scheduled ,
Dr. Roselli 1:30pm 3/2/05 scheduled ,
Dr. Tonsil 4:15pm 1/5/05 scheduled ,
Cardiologist in 2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Headaches and falling
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
post-concussive syndrome
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) diet-controlled DM ( 6 ) history of assault to head with gun
( 13 ) CAD ( coronary artery disease ) psychiatric
history? GERD ( gastroesophageal reflux disease ) hypothyroid
( hypothyroidism ) glaucoma ( glaucoma ) hyperlipidemia
( hyperlipidemia ) AS? ( 30 ) Reflex sympathetic dystrophy ( reflex
sympathetic dystrophy ) depression ( depression ) anxiety ( anxiety )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
telemetry monitoring
echocardiogram
BRIEF RESUME OF HOSPITAL COURSE:
**CC:falling episodes
**HPI: 64 year-old M history of head assault-blunt trauma ( L crown ) 1/9 with possible
LOC. Reports frequent falling , n/v , with one ED visit in 4/20 , neg eval
by neuro. No prodrome , assoc with weakness , no CP , no palpitations , no
jerking movements , no incontinence. C/o h/a almost daily for last 3
wks , mostly on L side to post.+ blurry vision.
**PE on discharge: afeb , 80 , 120/70 , not orthostatic. RR 14 , 94-97% RA.
Surgical R pupil. No JVD. RRR S1S2 , III/VI cres/decres ejection murmur at
RUSB. CTAB. +BS , soft NTND. No edema. +gait imbalance.
**Studies: CXR-negative , Head CT-negative. Echo-EF 65-70% , + mild to
moder AS , valve area 1.4 , mean aortic vavle gradient 47. EKG NSR @ 70bpm ,
nml axis/intervals , on ST changes.
**Consults: Neuro ( Dr. Picariello ) , Psych ( Dr. Kriticos ) ,
**Hosp Course by System:
1 ) Cards: Ischemia: Low suspicion for ACS given sxs , however ruled out
for ACS. Pump: patient with low SBPs on admission in 80s-90s , increased to
120s-130s with hydration. B-blockers , nitrates , ACE-I held on admission
given low BPs. Low dose B-blocker restarted HD 3. ACE-I restarted at
half dose on HD4 given patient's renal dysfunction/hypotension on admission.
Can be uptitrated as outpt. Will continue to hold nitrate for now , may be
restarted by primary care physician if needed; as currently with SBPs in 120s-130s do not
think patient will tolerate right now. TTE results as described above. Mild to
moderate AS , no indication for surgical correction , very unlikely to be
cause of patient's falling episodes. patient to follow up with outpt cardiologist.
Rythym: Monitored on telemetry throughout hospitalization. On HD 4 , patient had
short run of NSVT ( 9 beats ) with associated chest tightness lasting for a
few seconds. His vital signs remained stable at this time and an EKG taken
immediately after showed NSR at 67 beats per minute with no changes
from previous ekg's. Given that he was largely asymptomatic with stable
vital signs , has normal EF , his Magnesium was repleted and he will follow
up with his outpt. cardiologist.
2 ) Pulm: On admission patient had roncherous lung exam with normal chest
X-ray. Improvd after neb treatment. O2sats mid to high 90s on RA , with
no O2 requirement during hospitalization.
3 ) Renal: Admitted with Cr of 2.4 , decreased to 1.1 on HD 2 after
hydration. FeNa on admission <1% suggesting pre-renal etiology. Held patient's
NSAIDs given renal failure on admission.
4 ) Neuro: patient has clear gait instability. Had work-up in January 2005
including MRI/MRA head , neck which were negative. patient was re-evaluated by
Neurology who felt sxs not indicative of cerebellar disease , felt
possibly post-concussive syndrome. To follow up with outpt Neurologist.
RPR negative. Utox/serum tox negative.
5 ) Heme: Hct 33 ( around baseline ) , anemia work up negative , manual smear
normal. Guiaic negative. Should be followed as outpatient.
6 ) GU: patient with hx of bladder neck stenosis. Evaluated by GU. No post void
residual , so only recs were follow up with outpt Urologist ( Dr. Tonsil )
in 1 month. With UTI , resistant to flouroquinolones. Being treated with
Nitrofurantion 100mg op twice a day x 2 weeks. To have repeat urine studies with
Dr. Tonsil 9/10 after tx.
7 ) Endo: Cortisol nml , TSH normal , covered with RISS.
8 ) GI: No emesis since admission. Tolerated regular diet well. LFTs nml ,
amylase sublingual incr , lipase nml.
9 ) Psych: Evaluated by psych who recommmended tapering benzos , however patient
refused until discussed with outpt psychiatrist. Attempted to contact
outpt MD without success. patient unclear about exact benzo regimen , received
0.5mg alprazolam four times a day which may be slightly less than home regimen. No
signs of withdrawal.
10 ) Pain: Has chronic pain from reflex sympathetic dystrophy. Good pain
control with oxycodone 10mg q6 as needed
11 ) Prophy-received subcutaneously lovenox for dvt prophy
Contact: wife - 092-778-9599
ADDITIONAL COMMENTS: Please continue to take your antibiotics ( Nitrofurantoin ) until 10/5/05.
We made the following changes to your medications:
1 ) Decreased Lisinopril in 1/2 ( decreased to 5mg )
2 ) Stopped Toprol and started Metoprolol - this is at a lower dose so your
blood pressure won't get so low.
3 ) Stopped your Isosorbide. You can discuss restarting these medications
with your primary care doctor. You should follow up with your cardiologist
in the next 2 weeks. We also started you on a baby aspirin.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Continue antibiotics until June
No dictated summary
ENTERED BY: VEAZIE , OK E. , M.D. ( JY28 ) 10/17/05 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1086
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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373092506 | PUO | 66257495 | | 9054481 | 3/27/2007 12:00:00 a.m. | bilateral breast reduction , panniculectomy | | DIS | Admission Date: 10/16/2007 Report Status:
Discharge Date: 6/17/2007
****** FINAL DISCHARGE ORDERS ******
HAWF , KATE 684-96-57-9
Alb Ster Athens
Service: PLA
DISCHARGE PATIENT ON: 8/8/07 AT 09:00 a.m.
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CARTIER , EARLENE CARLO , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
MEDICATIONS ON ADMISSION:
1. ACETAMINOPHEN 1000 MG orally every 6 hours
2. LEVOTHYROXINE SODIUM 75 MCG orally every day
3. QUINAPRIL 20 MG orally every day before noon
4. RANITIDINE HCL 150 MG orally every day
5. MULTIVITAMINS 1 CAPSULE orally every day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
VITAMIN C ( ASCORBIC ACID ) 500 MG orally twice a day
DULCOLAX ( BISACODYL ) 5-10 MG orally DAILY as needed Constipation
KEFLEX ( CEPHALEXIN ) 500 MG orally four times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally twice a day
DILAUDID ( HYDROMORPHONE HCL ) 2-4 MG orally every 3 hours as needed Pain
Alert overridden: Override added on 7/17/07 by :
on order for DILAUDID orally 2-4 MG every 3 hours ( ref # 411579203 )
patient has a PROBABLE allergy to Morphine; reaction is GI
Intolerance. Reason for override: fine
Previous Alert overridden
Override added on 7/17/07 by DRYLIE , ASHA NOE , M.D. , PH.D.
on order for DILAUDID orally ( ref # 356450987 )
patient has a PROBABLE allergy to Morphine; reaction is GI
Intolerance. Reason for override: aware
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS Medium Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 3 units subcutaneously
If BS is 251-300 , then give 5 units subcutaneously
If BS is 301-350 , then give 7 units subcutaneously
If BS is 351-400 , then give 8 units subcutaneously
Call HO if BS is greater than 350
If receiving standing regular insulin , please give at same
time and in addition to standing regular insulin
SYNTHROID ( LEVOTHYROXINE SODIUM ) 75 MCG orally DAILY
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG intravenous every 6 hours as needed Nausea
ZOFRAN ( POST-OP N/V ) ( ONDANSETRON HCL ( POST-... )
1 MG intravenous every 6 hours X 2 doses as needed Nausea
QUINAPRIL 20 MG orally DAILY
Override Notice: Override added on 7/17/07 by
AMIRAULT , ERVIN A. , M.D.
on order for KCL intravenous ( ref # 722417257 )
POTENTIALLY SERIOUS INTERACTION: QUINAPRIL HCL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: QUINAPRIL HCL & POTASSIUM
CHLORIDE Reason for override: needs
Number of Doses Required ( approximate ): 2
SIMETHICONE 80 MG orally four times a day as needed Upset Stomach
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
TIGAN ( TRIMETHOBENZAMIDE HCL ) 200 MG PR every 6 hours as needed Nausea
TIGAN ( TRIMETHOBENZAMIDE HCL ) 300 MG orally every 6 hours as needed Nausea
Number of Doses Required ( approximate ): 10
DIET: No Restrictions
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 10 pounds
FOLLOW UP APPOINTMENT( S ):
dr. g , - please call 414 853-2997 to schedule 7 days ,
ALLERGY: Morphine
ADMIT DIAGNOSIS:
macromastia , panniculectomy
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bilateral breast reduction , panniculectomy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of massive weight loss 2/2 gastric bypass , breast reduction ,
panniculectomy
OPERATIONS AND PROCEDURES:
7/17/07 CARTIER , EARLENE CARLO , M.D.
BILATERAL REDUCTION MAMMOPLASTY , EXCISION PUBIC PANNICUECTOMY
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
57 year-old female with macromastia and abdominal skin laxity history of massive
weight loss 2/2 gastric bypass , admitted to plastic surgery on 7/17/07
for bilateral breast reduction and panniculectomy. patient tolerated all
procedures without difficulty. post-op period has been uneventful. at
discharge patient is afebrile with stable vitals , taking orally's/voiding every
shift , ambulating independently and pain has been well managed.
Incisions are clean , dry and intact. Jp's with moderate serosanguinous
output remain in place. patient is discharged to home rehab stable condition
. instructions given.
ADDITIONAL COMMENTS: 1. Medications: resume previously prescribed medications. Do not take
medications that cause bleeding - no aspirin , motrin , aleve , advil or
ibuprfen. Do not drink/drive/operate machinery with pain medications.
Take a stool softener to prevent constipation.
2. Monitor/return for increased pain , swelling , redness , fever or other
concerns. Call dr. xx , or Santina Slagel NP for questions 974 904-1742
pager 32875.
3. Activity - sponge baths only while drains are in place. Walking as
tolerated. No lifting more than 10 pounds. No jogging , swimming , or
aerobics x 4-6 weeks.
4. Continue your antibiotics as long as you have a drain in place.
Drain care - monitor/record drain output , when less than 30 cc in 24
hours , call for appointment for removal. change drain sponges daily.
strip drains twice daily
5. daily wound check , dsd as needed.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
wound check , drain care
No dictated summary
ENTERED BY: SLAGEL , SANTINA M , NP ( ) 8/8/07 @ 09:51 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 1087
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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357793799 | PUO | 20732472 | | 277826 | 8/18/1998 12:00:00 a.m. | LEG INJURY | Signed | DIS | Admission Date: 9/26/1998 Report Status: Signed
Discharge Date: 1/28/1998
PRINCIPAL DIAGNOSIS: Trimalleolar left ankle fracture.
PROCEDURE: Open reduction and internal fixation of left ankle.
DATE OF PROCEDURE: July , 1998.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old white
female who slipped on the ice on
July , 1998 , resulting in a trimalleolar left ankle fracture.
She had no other injuries.
MEDICATIONS ON ADMISSION: Her medications on admission were
Imitrex on a as needed basis.
ALLERGIES: The patient has no known drug allergies.
PAST MEDICAL HISTORY: Migraine headaches.
PAST SURGICAL HISTORY: Negative.
PHYSICAL EXAMINATION: Her vital signs were normal. In general ,
she is a thin white female , in no apparent
distress. HEENT , cardiovascular , pulmonary , and abdominal
examinations were all normal. Her left lower extremity was
neurovascularly intact with obvious deformity. The patient's
radiographic workup demonstrated an isolated left trimalleolar
fracture dislocation. The dislocation was reduced and she was
splinted in the Emergency Room.
HOSPITAL COURSE: The patient underwent the above noted procedure
on July , 1998. She tolerated this well and
was taken to the Recovery Room in stable condition.
Postoperatively , her main problem was nausea. She had minimal pain
in the left foot , and maintained strict elevation. However , she
developed significant nausea and vomiting in the first twenty-four
hours after surgery. This limited her ability to participate in
physical therapy , and she was maintained on intravenous fluids for
twenty-four hours. The nausea resolved over a twenty-four to
thirty-six hour period. Her diet was advanced and she was
tolerating a regular diet at the time of discharge. She was
cleared by Physical Therapy on April , 1998 , and was discharged
in stable condition to home.
DISCHARGE MEDICATIONS: 1. Darvocet-N 100 one to two tablets every 4 hours
as needed for pain. 2. Enteric coated
aspirin one tablet orally every day x six weeks. 3. She was given
perioperative antibiotics for infection prophylaxis , and aspirin
for deep venous thrombosis prophylaxis.
FOLLOW-UP: She will follow-up with Dr. Gaylene Faniel in two weeks.
CONDITION ON DISCHARGE: Her condition at the time of discharge is
stable. Her weightbearing status will be
nonweightbearing on the left lower extremity. She was given all
standard cast care instructions and discharged in stable condition
on April , 1998.
Dictated By: IRVING ESCALANTE , M.D. QY7
Attending: GAYLENE FANIEL , M.D. LX02
ZY526/9808
Batch: 15424 Index No. O4COH680U4 D: 2/12/98
T: 1/9/98
Document id: 1088
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
590980069 | PUO | 76289876 | | 053298 | 2/14/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 2/14/1991 Report Status: Unsigned
Discharge Date: 4/19/1991
DISCHARGE DIAGNOSIS: UROSEPSIS.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male
with diabetes , rheumatoid arthritis
and hypertension who had a fever of 102 and shaking chills without
symptoms of upper respiratory infection. He did complain of
intermittent dysuria and he is known to have prostatism. He was
therefore admitted to the Medicine Service. Past medical history
is coronary artery disease , myocardial infarction , diabetes
mellitus , rheumatoid arthritis and hypertension. Past surgical
history is negative. He has no known drug allergies. Medications
on admission are Tenormin , Dolobid , Diabinase , Mevacor , Ecotrin ,
Nifedipine.
PHYSICAL EXAMINATION: This is a mildly ill-appearing white male
in no acute distress , afebrile with
stable vital signs. Head and neck are unremarkable. Lungs are
clear. Heart has a regular rate and rhythm with a I/VI
holosystolic murmur. Abdomen is nontender. GU examination on
admission by the Emergency Room internist was not recorded.
LABORATORY DATA: On admission are remarkable for a white
blood cell count of 12.2 thousand ,
creatinine 1.2. Urinalysis had a pH of 5.5 , 1+ leukocyte esterase
and too numerous to count white blood cells.
HOSPITAL COURSE: The patient was admitted with the
diagnosis of urosepsis and placed on
intravenous antibiotics. He was transferred to the urology service
after consideration of his prostatism was made and he would be an
eventual candidate for transurethral resection of the prostate.
During his hospitalization , he promptly defervesced and remained
afebrile for three days. He was therefore changed to orally
antibiotics and observed for 24-hours and because he was stable , he
was felt to be ready for discharge.
DISPOSITION: The patient is discharged to home.
CONDITION ON DISCHARGE is stable. Follow
up is with Dr. Lorretta P. Cridge MEDICATIONS on discharge are
Isordil 20 mg orally three times a day , Atenolol 50 mg orally every day , Procardia XL
60 mg orally every day , Mevacor 20 mg orally every day , Diabinase 100 mg orally
every day , Ecotrin 1 tablet orally every day , Hytrin 1 mg orally every bedtime and
Ciprofloxacin 500 mg orally twice a day x ten days.
VV857/8287
LORRETTA P. CRIDGE , M.D. QI7 D: 11/6/91
Batch: 6561 Report: V8470N98 T: 10/9/91
Dictated By: VIVIANA NEWBERT , M.D. YX40
cc: 1. SHERRILL BRAUCKS , M.D.
Document id: 1089
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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386996915 | PUO | 22149326 | | 0482464 | 5/19/2006 12:00:00 a.m. | history of Rt TKR | | DIS | Admission Date: 10/2/2006 Report Status:
Discharge Date: 7/5/2006
****** FINAL DISCHARGE ORDERS ******
CORLETT , DAPHNE NIA 689-20-53-1
Ing Ee Stalin
Service: ORT
DISCHARGE PATIENT ON: 3/6/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RADEMAN , CAITLIN , M.D.
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
Starting Today ( 3/10 )
as needed Pain , Headache , Other:fever greater than
Instructions: Do not exceed 4000mg in 24 hours.
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ )
500 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FAMOTIDINE 20 MG orally twice a day
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously every 6 hours
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LEVOTHYROXINE SODIUM 50 MCG orally DAILY
Alert overridden: Override added on 8/23/06 by
STIDMAN , GENOVEVA , M.D.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: will monitor
MVI ( MULTIVITAMINS ) 1 TAB orally DAILY
Override Notice: Override added on 8/23/06 by
STIDMAN , GENOVEVA , M.D.
on order for ZOCOR orally ( ref # 752361755 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: will monitor
OXYCODONE 5 MG orally every 6 hours Starting Today ( 3/10 ) as needed Pain
HOLD IF: somnolent , mental status changes
COUMADIN ( WARFARIN SODIUM ) 6 MG orally x1
Instructions: Dose for 1/7/06. Monitor a daily physical therapy/INR in
rehab and adjust the dose for a goal INR of
1.5-2.5;DVT prophylaxis is planned X 3 weeks
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 8/23/06 by
STIDMAN , GENOVEVA , M.D.
on order for ZOCOR orally ( ref # 752361755 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will monitor
Previous override information:
Override added on 8/23/06 by STIDMAN , GENOVEVA , M.D.
on order for LEVOTHYROXINE SODIUM orally ( ref # 767853250 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: will monitor
NORVASC ( AMLODIPINE ) 10 MG orally DAILY
Starting IN a.m. ( 3/9 ) HOLD IF: SBP < 110
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
METFORMIN 500 MG orally twice a day
Starting when TOLERATING ADA DIET
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 10 MG orally every 12 hours
HYZAAR ( 25 MG/100 MG ) ( HYDROCHLORTHIAZIDE 25M... )
1 TAB orally DAILY Starting IN a.m. ( 3/9 ) HOLD IF: SBP < 110
Number of Doses Required ( approximate ): 6
ACTOS ( PIOGLITAZONE ) 15 MG orally DAILY
Starting when TOLERATING ADA DIET
Food/Drug Interaction Instruction
May be taken without regard to meals
INSULIN NPH HUMAN 42 UNITS subcutaneously every day before noon HOLD IF: NPO
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
DIET: House / Low chol/low sat. fat
ACTIVITY: weight bear as tolerated with UE support
FOLLOW UP APPOINTMENT( S ):
Dr Rademan 4/27/06 Xray at 2:00pm Appt at 3:00pm 3/25/06 ,
Arrange INR to be drawn on 9/20/06 with f/u INR's to be drawn every
MONDAY/THURSDAY days. INR's will be followed by PUO Anticoagulation service , 592.004.9708
ALLERGY: LISINOPRIL
ADMIT DIAGNOSIS:
OA Rt Knee
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of Rt TKR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Osteoarthritis , Hypertension , Diabuetes Mellitus , Hypothyroidism
OPERATIONS AND PROCEDURES:
8/23/06 RADEMAN , CAITLIN , M.D.
RT TKR
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
N/A
BRIEF RESUME OF HOSPITAL COURSE:
patient underwent a Rt TKR on 6/20/06 for endstage OA. The patient tolerated
the procedure well , and had an uncomplicated post-operative course on the
TKR pathway with exception of post-op delerium which required a sitter
for safety on POD 2. Patients MS gradually improved , and returned to
baseline by POD 3 , at which time the sitter was discontinued. patient was HD
stable with no transfusion requirements during her hospitalization. Hct
was trending up on POD 4 at 28.7. Standard care with PCEA for acute pain
management/CPM , prophylactic intravenous abx , and Coumadin/TEDS/P-boots for DVT
prophylaxis. patient mobilized OOB with physical therapy WBAT. Refer to the page 3 for
ROM/functional details. Wound clean and healing at time of discharge. patient
stable for transfer to rehab on POD 4.
ADDITIONAL COMMENTS: DSD every day The wound may be left OTA when dry. Staples may be removed in
rehab or by the VNA as of 2/30/06 , please sterristrip the wound. Continue
TEDS for DVT prophylaxis. When the patient is discharged home , please
arrange blood draws for physical therapy/INR every Mon/Thurs with results called to the CKMH
Anticoagulation Service he439-008-7022 hki 3 for outpatient
anticoagulation management. Goal INR is 1.5-2.5;DVT prophyalxis is planned
X 3 weeks. Any outpatient anticoagulation issues or action values should
be called to the Anticoagulation Service.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Arrange blood draws for physical therapy/INR every Mon/Thurs with results called to
765-060-3001 jys 9 for outpatient anticoagulation management
NOTIFY the Anticoagulation Service when the patient is discharged home
Staple removal 7/27/06
Follow up with Dr Rademan as scheduled
No dictated summary
ENTERED BY: SCOVEL , DULCIE , PA-C ( XP60 ) 3/6/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1090
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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727288776 | PUO | 81812239 | | 764716 | 10/19/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/30/1991 Report Status: Signed
Discharge Date: 7/18/1991
CHIEF COMPLAINT: The patient is a 42-year-old woman
admitted for treatment of two pulmonary
embolisms and a urinary tract infection.
PRINCIPAL DIAGNOSIS: 1. Pulmonary embolisms times two.
2. Urinary tract infection.
3. Status post total abdominal
hysterectomy.
PRESENT ILLNESS: Twenty years ago the patient suffered a
pulmonary embolism which was poorly
documented after a tubal ligation. She was treated with heparin
and Coumadin. Since that time she has been well. On 21 of April
the patient underwent elective total abdominal hysterectomy
secondary to fibroids and menorrhagia. On 22 of May , the night
before discharge , the patient noted the onset of sharp pleuritic
chest pain upon movement in bed. It was felt this was musculo-
skeletal and she was discharged. While at home before admission ,
the patient noted some shortness of breath and a temperature to
101. She continued to have a pleuritic chest pain and came to
the emergency room. She was admitted on 17 of November
Past medical history: ( 1 ) Pulmonary embolism. ( 2 ) Cholecys-
tectomy. ( 3 ) Costochondritis. ( 4 ) Status post TAH for
fibroids. ( 5 ) Asthma.
The patient's family history is notable for a cousin with lupus.
The patient doesn't smoke. The patient drinks occasionally.
PHYSICAL EXAMINATION: The patient was an obese women who
appeared tired and was having some
discomfort breathing. Her temperature in the emergency room was
102.5. Her blood pressure was 110/80. Heart rate was 120.
Respirations were 32 which went down to 24 as she calmed down.
Her O2 saturation on room air was 99%. An ABG was not done. Head
was unremarkable. Neck was supple. Lungs were clear without a
rub. Cardiac exam shows regular rate and rhythm without murmurs
appreciated. Abdomen was soft and has bowel sounds. The wound
had its dressing in place and there was a small amount of
serosanguinous drainage appreciated. It was nontender.
Neurologic exam was nonfocal.
LABORATORY DATA: Electrolytes were within normal limits.
BUN 6 , creatinine 0.8 , glucose 114 ,
white count 12.2 , hematocrit 26 , platelets 508 , 000. physical therapy 13.4 , PTT
25.6. Chest x-ray showed bilateral basilar atelectasis. EKG
showed sinus tachycardia at 104 with normal interval and axis.
There was T-wave inversion in 3 and V1 without other ST-T wave
changes. VQ scan obtained prior to admission was read as low
probability.
HOSPITAL COURSE: The patient was admitted and started on
heparin. The PTT was quickly thera-
peutic. The patient had informal noninvasive studies , mainly
ultrasound of the thighs which failed to show deep venous
thrombosis. She , therefore , underwent on the second hospital day
pulmonary angiography which showed two small pulmonary embolisms
on the left side. In the meantime , her VQ scan had been reinter-
preted as showing intermediate probability with notch defect on
left and right. The patient had been started on Coumadin.
In the meantime , after her procedure she developed a procedure.
She had some dysuria. Her urine had white cells and bacteria and
eventually grew out Enterobacter aerogenes. In the meantime she
was treated with ceftizoxime and defervesced and was converted to
orally Bactrim and remained afebrile. The Enterobacter was sensi-
tive to this antibiotic. The patient was discharged on 1 mg
orally every bedtime of Coumadin with a physical therapy the preceding day of 19.
CONDITION ON DISCHARGE: The patient's condition is good.
DISPOSITION: The patient will be transferred to the
Habra Raco Hospital under the care of
Dr. Lolita Shotkoski who is the patient's primary care physician.
A physical therapy will need to be checked on arrival. Most likely the
patient's physical therapy will be in the range of 18 to 20 and she will need
approximately 1 mg orally of Coumadin.
Discharge medications: Bactrim one double strength tablet orally
twice a day; iron sulfate 325 mg orally every day; Motrin 800 mg orally three times a day;
Colace 100 mg orally three times a day; Coumadin 1 mg orally every bedtime
Dictated By: EVERETT L. IRIAS , M.D. WJ00
VE533/4252
BRYCE E. TRONNES , M.D. UL5 D: 5/1/91
T: 3/28/91
Batch: M529 Report: NM013G33 T:
Document id: 1091
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
N |
N |
- |
N |
N |
N |
N |
N |
Y |
N |
603229379 | PUO | 20240916 | | 4412581 | 6/2/2003 12:00:00 a.m. | LEFT GROIN INFECTION | Signed | DIS | Admission Date: 6/2/2003 Report Status: Signed
Discharge Date: 4/9/2003
ATTENDING: ROSSIE MANKOSKI MD
ATTENDING PHYSICIAN: Rossie Mankoski , M.D.
HISTORY OF PRESENT ILLNESS: Mr. Mucerino is a 51-year-old man who
was recently admitted for repair of left pseudoaneurysm in his
groin. He was in home and doing fine after discharge from
Pagham University Of on 6/14/2003. One week later , he
noticed pus draining from his wound site. He was doing daily
dressing changes at home. He was seen in Dr. Derham 's office on
6/2/2003 with only mild improvement. He was admitted from
clinic for more aggressive management. He has no history of
fever , chills , nausea , vomiting , constipation , or diarrhea. No
chest pain and no shortness of breath.
PHYSICAL EXAMINATION: On exam , he was afebrile. Vital sings are
stable. He is 100% on room air. He had on the left , 2+ femoral ,
no DP , monophasic physical therapy pulse with cold foot. On the right , TMA ,
warm foot , femoral 2+ , DP monophasic , physical therapy monophasic. Wound site
with some erythema and drainage , nontender , no odor.
PAST MEDICAL HISTORY: Includes coronary artery disease status
post CABG , peripheral vascular disease status post aortobifemoral
bypass and status post femoropopliteal bypass , COPD , chronic
renal failure , and diabetes mellitus.
PAST SURGICAL HISTORY: Repair of pseudoaneurysm.
MEDICATIONS: Aspirin 325 mg once a day; digoxin 0.125 mg once a
day; Zestril 2.5 mg once a day; Ultralente 14 mg every day before noon , 4 mg
every afternoon; Zocor 10 mg once a day; Toprol 25 mg once a day; Imdur 30
mg once a day; torsemide 100 mg once a day; and Dilaudid as needed
ALLERGY: He has an allergy to penicillin.
SOCIAL HISTORY: One pack a day smoker. Occasional alcohol.
EMERGENCY DEPARTMENT COURSE: The patient was admitted for intravenous
antibiotics and further surgical therapy with the diagnosis of
dehiscence of left thigh bypass graft wound. He received
wet-to-dry dressing changes three times a day initially. On 3/2/2003 , he
was taken to the operating room for left groin closure with flap
by Plastic Surgery and Vascular Surgery. The flap initially was
pink and viable , however , on 5/14/2003 , there were noted some
pale areas and mottling of the flap. He was injected with
heparin solution. Following this , flap received serial needle
pricks and the appearance gradually improved as such there was no
further pallor or mottling. The patient developed diarrhea. He
was on vancomycin , levofloxacin , with orally Flagyl for empiric
treatment for C. diff. C. diff cultures were negative on
10/16/2003 , in addition his drain cultures on 10/20/2003 , showed
rare Staphylococcus aureus. On 3/2/2003 , repeat culture of
the groin were negative. He had an episode of nausea , which
improved after Flagyl was discontinued. The patient was seen by
Cardiology during his stay here. On postoperative #2 , he was
noted to be volume overloaded. His torsemide was increased to
100 mg twice a day with goal diuresis of 1-2 liters per day. intravenous Lasix
was added as needed to achieve this goal. After his episode of
nausea , his EKG was checked to rule out any sort of cardio
ischemic cause for this nausea , EKG was normal. His morphine was
discontinued as a possible cause. He did well with orally pain
medications. Renal: His Zestril was held secondary to an
elevation in creatinine to 3.3 from his baseline of 1.8. This
gradually resolved. Creatinine was 2.5 at the time of discharge.
The patient was also seen by the Nutrition and recommended
supplements , vitamin C , and Zinc for wound healing. By
10/16/2003 , the patient's flap was stable , pink , and viable. He
had lower extremity pulses that were Dopplerable. He was
discharged home in stable condition with services.
Discharge medications include enteric-coated aspirin 325 mg once
a day; digoxin 0.125 once a day; Ultralente 16 units every day before noon , 4
units every afternoon; Zocor 10 mg once a day; Toprol 25 mg once a day;
Imdur 30 mg once a day; torsemide 100 mg once a day; lisinopril
2.5 mg once a day; colace; and Percocet.
eScription document: 5-1668887 BF
Dictated By: VANDENBURGH , STEPHANIE CASSANDRA
Attending: MANKOSKI , ROSSIE
Dictation ID 5777085
D: 10/7/03
T: 4/8/03
Document id: 1092
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
540167155 | PUO | 66456892 | | 016688 | 11/12/2002 12:00:00 a.m. | aplastic anemia | | DIS | Admission Date: 6/1/2002 Report Status:
Discharge Date: 4/30/2002
****** DISCHARGE ORDERS ******
ATHMANN , ETHELYN 386-98-58-9
Ca H Rich
Service: HEM
DISCHARGE PATIENT ON: 6/12/02 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BRADEY , JR , ANISA I. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
20 UNITS every day before noon; 15 UNITS every afternoon subcutaneously 20 UNITS every day before noon 15 UNITS every afternoon
REG INSULIN HUMAN ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously ( subcutaneously ) before every meal & HS
If BS is less than 200 , then give 0 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ZESTRIL ( LISINOPRIL ) 40 MG orally every day
Override Notice: Override added on 1/15/02 by
RETZLER , ELLIS , M.D. , PH.D.
on order for KCL intravenous ( ref # 73812993 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 1/15/02 by RETZLER , ELLIS , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref # 72835445 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
METHADONE HCL 30 MG orally three times a day
OXYCODONE 5-10 MG orally every 3 hours as needed pain
SENNA TABLETS 2 TAB orally twice a day
ZOLOFT ( SERTRALINE ) 100 MG orally every day
VISCOUS LIDOCAINE ( LIDOCAINE VISCOUS 2% )
15 MILLILITERS orally every 3 hours as needed mouth pain
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Myrtis Vantull at 11:30 a.m. 10/24/02 scheduled ,
Daron Sloane at 11:30 a.m. 9/21/02 scheduled ,
ALLERGY: Aspirin
ADMIT DIAGNOSIS:
aplastic anemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
aplastic anemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
aplastic anemia ( anemia ) hemochromatosis ( hemochromatosis ) DM
( diabetes mellitus ) hcv ( hepatitis
C ) hep B ( hepatitis B ) AVN => bilateral THR ( avascular necrosis
femoral head ) multiple episodes of line sepsis ( sepsis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
patient will need VNA for the following services:
1. PICC care
2. Safety Evaluation
3. Medication Compliance
4. Check weight and diet
5. Check hydration
BRIEF RESUME OF HOSPITAL COURSE:
38 year old woman with a hx of aplastic anemia history of
fall with hypersomnoloence and facial trauma. patient dx with aplastic
anemia at age 12 and has been chronically transfusion dependent since
then. Baseline hct 23-25 and platelets 9-teens.
Has developed hemochromatosis 2/2 transfusions.
patient apparently fell asleep while standing up the
night prior to admission. She landed on her face
and developed a hematoma. Head CT and
mandibular X-rays negative. Pain med managment a major
issue as she is on methadone 90 three times a day at
baseline as well as taking numerous others as needed
Course by problem:
1. Aplastic Anemia: patient initial platelets less than 10 with a hct of 18.
She was transfused 2 units platelets and 2 units PRBCs. Platelets did
not bump much and she was transfused an additional 2 units platelets.
PLatlets the night prior to admission were 35. Hemostasis achieved of
wounds and hct bumped to 23.
2. Fall: Fall has been attributed to hypersomnolence , likely due to
over use of narcotics and possible a sleep disorder. patient did become
more alert during admission once pain meds changed and patient got some
sleep.
3. Pain: Pain consultant recommended changing her to the regimen of
methadone 30 three times a day with oxycodone 5-10 every 3 hours as needed She did well on this
regimen with minimal breakthrough pain.
4. DMII: Patient with blood sugars ranging from 50-330 during this
admit while she was maintained on her outpatient nph regimen. Noted
significant dietary indiscretion.
5. Follow-Up: patient to be discharged with one week supply of pain meds and
will have follow-up with Dr. Robblee in one week.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow-up with Dr. Robblee 10/11 and Daron Sloane 7/27
2. Take pain meds as prescribed.
3. VNA for : PICC care , safety evaluation , medication compliance , check
weight , diet , and hydration.
No dictated summary
ENTERED BY: RETZLER , ELLIS , M.D. , PH.D. ( EU77 ) 6/12/02 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 1093
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
- |
N |
265806893 | PUO | 09555241 | | 9062636 | 9/6/2003 12:00:00 a.m. | Coronary Artery Disease. | | DIS | Admission Date: 9/27/2003 Report Status:
Discharge Date: 4/26/2003
****** DISCHARGE ORDERS ******
TROWERY , DEDE C. 964-60-43-5
Delp Cla Nasribi
Service: CAR
DISCHARGE PATIENT ON: 6/5/03 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARNABA , CARA CHANCE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACYCLOVIR 400 MG orally twice a day
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 11/25/03 by
PART , JACKSON , M.D.
on order for COUMADIN orally ( ref # 88403336 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
DIGOXIN 0.375 MG orally every day
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
Alert overridden: Override added on 11/25/03 by
PART , JACKSON , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: aware
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
75 UNITS every day before noon; 55 UNITS every afternoon subcutaneously 75 UNITS every day before noon 55 UNITS every afternoon
MVI THERAPEUTIC W/MINERALS ( THERAP VITS/MINERALS )
1 TAB orally every day
Alert overridden: Override added on 11/25/03 by
PART , JACKSON , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 11/25/03 by
PART , JACKSON , M.D.
on order for ZOCOR orally ( ref # 68883735 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware Previous override information:
Override added on 11/25/03 by PART , JACKSON , M.D.
on order for BACTRIM DS orally ( ref # 65130242 )
SERIOUS INTERACTION: WARFARIN & SULFAMETHOXAZOLE
Reason for override: aware Previous override information:
Override added on 11/25/03 by PART , JACKSON , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 11/25/03 by
PART , JACKSON , M.D.
on order for MVI THERAPEUTIC W/MINERALS orally ( ref #
40667338 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
Previous override information:
Override added on 11/25/03 by PART , JACKSON , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
TESSALON PEARLS ( BENZONATATE ) 100 MG orally three times a day
Number of Doses Required ( approximate ): 3
BACTRIM DS ( TRIMETHOPRIM /SULFAMETHOXAZOLE DO... )
1 TAB orally qMWF
Alert overridden: Override added on 11/25/03 by
PART , JACKSON , M.D.
SERIOUS INTERACTION: WARFARIN & SULFAMETHOXAZOLE
Reason for override: aware
DILTIAZEM EXTENDED RELEASE 180 MG orally every day HOLD IF: SBP<80
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 11/25/03 by
PART , JACKSON , M.D.
on order for LASIX orally ( ref # 36733043 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: aware
LOSARTAN 50 MG orally every day
Number of Doses Required ( approximate ): 1
ESOMEPRAZOLE 20 MG orally every day
MAGNESIUM OXIDE ( 241 MG ELEMENTAL MG ) 400 MG orally twice a day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Barnaba , LMC ,
Dr. Bartkus , SSR scheduled ,
Arrange INR to be drawn on 5/17/02 with f/u INR's to be drawn every
7 days. INR's will be followed by primary care physician
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Cardiomyopathy
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Coronary Artery Disease.
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Hodgkins Dx AAA repair 1994 Exertional
CP-epigastric 1997: mediast recur of HD CVPP x1
velban , araC , cisplt x3 VP16 , vinblast , dex , cisplat 3/19
Afib/flutter history of CHF from adria
OPERATIONS AND PROCEDURES:
Cardiac Cath with Angiography.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none.
BRIEF RESUME OF HOSPITAL COURSE:
54y M with history of recurrent Hodgkin's Dz , history of
multiple chemo/xrt and history of auto-BMT 11/25 , Cardiomyopathy ( EF 50% , mod
MR ) uncertain etiology admitted for elective R/L heart cath
with angiography. Stress echo ( 8/24 ) negative
for ischemia , ECG sugg. possible old
inferoseptal infarct.
PMH--Hodgkin's disease; CMP; AAA history of repair; claudication; IDT2DM;
Atrial Fib. Meds--Losartan , Coumadin , Diltiazem ER;
Nexium; NPH; Humalog CZI; Folate; Digoxin; Bactrim
MWF; Acyclovir twice a day; Lasix 40;
MagOxide. PE--JVP flat , no carotid bruit. IRIR , 1/6 SM ,
no gallop; few crackles R base;
WWP. Cath--Elevated filling pressures ( RA 15-18;
PCW 15-20; RVP 60/20; PA mean 35;
CI=1.6 Coronary--LMain Nl; LAD-90% prox , 80-90% mid ,
60% distal; D1-80%; LCx diffuse 50%;
RCA-subtotal occlusion ( R dom
anatomy ). HOSPITAL
COURSE: 1. CV--Routine post cath care. Increase Dilt
to 180 every day to maximize rate control. Given 3VD
in setting of DM , consulted surgery re
elective revascularization.
2 ) A/C: Heparin , bridge to Coumadin ( reduce standing dose to
5qd ). 3 ) Onc/ID: Cont Bactrim/Acyclovir
prophylaxis.
ADDITIONAL COMMENTS: Take all medicines as directed--note the new doses of Diltiazem
( 180mg ) and Coumadin ( now just one 5mg tab every night ).
In the event of chest pain , sweatiness , worsening shortness of breath ,
nausea , or any other concerns , call your doctor or return to the
emergency room immediately.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
PFT's , Echocardiogram as outpatient.
No dictated summary
ENTERED BY: PART , JACKSON , M.D. ( QG55 ) 6/5/03 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1094
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
208740236 | PUO | 00779629 | | 789244 | 9/25/2000 12:00:00 a.m. | MORBID OBESITY | | DIS | Admission Date: 7/23/2000 Report Status:
Discharge Date: 6/12/2000
****** DISCHARGE ORDERS ******
WUERZ , JAME 371-66-78-1
Co
Service: GGI
DISCHARGE PATIENT ON: 10/2 AT 11:30 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
LISINOPRIL 5 MG orally twice a day Starting IN a.m. ( 4/6 )
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 5 ML orally every day
Starting IN a.m. ( 4/6 )
ROXICET ELIXIR ( OXYCODONE+APAP LIQUID ) 5-10 ML orally Q3-4H
as needed pain
DIET: ROMOS DIET / tahsey walkma stown medical center cohens diet
Activity - Ambulate with assist
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
COHENS 10 DAYS ,
No Known Allergies
ADMIT DIAGNOSIS:
Morbid Obesity
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
MORBID OBESITY
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
NIDDM , HTN , DEPRESSION
OPERATIONS AND PROCEDURES:
5/14 COHENS , ANGELINE VICKI , M.D.
VERTICAL BANDED GASTRIC BYPASS
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
32 Y.O MALE C/ MOBID OBESITY. BMI>60. ON 11/19 HE WAS TAKEN TO THE OR AND
UNDERWENT VERTICAL BANDED GASTRIC BYPASS. HE TOLERATED THIS PROCEDURE
WELL. THE POST-OPERATIVE COURSE WAS UNCOMPLICATED. DIET WAS STARTED
FROM HCCH AND ADVENCED. HE TOLERATED AND DISCHARGE HOME C/ STABLE
CONDITION.
ADDITIONAL COMMENTS: NEED HOME SAFTY EVAL.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
ENTERED BY: BUSHROD , LARHONDA , M.D. ( IX4 ) 10/2 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 1095
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688357585 | PUO | 23105624 | | 7609560 | 3/26/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/26/2005 Report Status: Signed
Discharge Date:
ATTENDING: GILFOY , DEANDRA LAZARO MD
ATTENDING PHYSICIAN: Kathlyn Kammerdiener , M.D.
PRINCIPAL DIAGNOSIS: Pseudogout.
ADMISSION DIAGNOSIS: Fever.
OTHER DIAGNOSES: Hypertension , urinary tract infection , and
diabetes.
BRIEF HISTORY OF PRESENT ILLNESS: Ms. Stefan Toline is a
77-year-old female with past medical history notable for
diabetes , urinary incontinence , hypertension and chronic low back
pain who was recently discharged to rehab from Pagham University Of on 7/20/05 after a hospitalization which
included medical ICU stay for urosepsis and left lower lobe
pneumonia. During that hospitalization , she developed the issues
with infection but eventually got better and was discharged on
the 10/8/05. At rehab , she initially did well but then
developed on the 4/4/05 fever to 101 and a white count up to
27. She also had some diaphoresis on the 7/16/05. The patient
and the daughter report that she had been improving steadily
until this point. Given the development of these symptoms , while
on levofloxacin and Flagyl since her last discharge , she was
transferred back to the Totin Hospital And Clinic Emergency Department
for further workup. In the emergency department , her temperature
was 101. The labs were remarkable for white count 27 without
bands , hematocrit of 32.1 , creatinine 1.3 up from her baseline of
1. A urinalysis showed white blood cells too numerous to count
and 2+ bacteria with 3+ yeast. Chest x-ray in the emergency
department showed no definite consolidation and no definite acute
process. At that time , she was alert and oriented. She received
Tylenol , levofloxacin , Flagyl and cefuroxime in the Emergency
Department. Of note , the patient and the daughter report that
the Foley catheter than was present upon discharge from Pagham University Of had not been changed at the rehab.
PAST MEDICAL HISTORY: In terms of her past medical history ,
diabetes secondary to pancreatectomy in the setting of alcohol
abuse in 1959 , multiple mechanical falls in the past 6 to 7
months , spinal stenosis , C3-C4 compression along with cervical
spondylosis , L2-L3 cord compression , gait instability ,
osteoarthritis of the right acromioclavicular joint , shoulders ,
elbows and hands , urinary incontinence , senile dementia , chronic
diarrhea , hypertension , peptic ulcer disease , history of GI
bleed , depression , PPD positive , history of shingles ,
nephrolithiasis , pyelonephritis in 2003 , iron deficiency anemia ,
status post cholecystectomy 2003 and status post splenectomy.
ALLERGIES: Her allergies are to Naprosyn where she develops GI
bleed from that.
MEDICATIONS: Her meds on transfer from rehab were Lopressor ,
metronidazole , levofloxacin , nifedipine , glucagon , Lantus ,
heparin , Pancreas , protein supplement , calcium , Senna , PhosLo ,
iron , Effexor , Nexium , and Paxil.
FAMILY HISTORY: Her family history is noncontributory.
SOCIAL HISTORY: She is retired , used to work at a saloon. She
is status post discharge from Men'ser Cfirst for
management of pain due to cervical spondylosis. She is widowed ,
two children , does not live alone. Quit smoking 20 years ago.
No alcohol since early 80s. No illicit drug use.
PHYSICAL EXAMINATION: Upon admission , her temperature was 101
down to 97.9 on the floor. Heart rate in the 70s , respiratory
rate 12 , BP 157/75. In general , she was alert , oriented ,
uncomfortable , and easily conversant. HEENT exam: No
lymphadenopathy. Pupils equally round and reactive to light.
Pulmonary exam shows soft bibasilar crackles bilaterally worse on
the left. Cardiovascular: Regular rate and rhythm , normal S1
and S2 , 2/6 systolic ejection murmur at the right sternal border
without radiation. JVP was less than 10. Peripheral pulses full
and symmetric. Abdomen was soft , nondistended , positive bowel
sounds. No tenderness. She had diffuse edema of her lower
extremities bilaterally and lower extremities were also tender to
palpation. Her perineum showed tender erythematous area of
induration surrounding her labia and anus with adherent white
plaques. Neuro: Cranial nerves II through XII intact. Range of
motion on lower extremities is limited by pain.
LABS ON ADMISSION: 27.6 white count and 32.1 hematocrit.
Glucose of 57. Blood smear showed 1+ target cells , ____ , and
tear drops.
HOSPITAL COURSE: She was admitted to the floor.
1. ID. She was initiated on cefuroxime every 12 hours , levofloxacin ,
and Flagyl. Urine culture showed greater than 100 , 000 yeast ,
likely explained by persistent Foley catheter and perineal yeast
infection. Her Foley was changed upon admission to the floor.
Blood culture was negative as was the stool culture. The patient
continued to be febrile and had elevated white count despite
antibiotic therapy without fevers , so the antimicrobial therapy
was discontinued on hospital day #3. Evaluation by the
Infectious Disease team with further studies did not yield a
clear source of infection. Therefore , Rheumatology consult was
called.
2. Rheumatology: Evaluation by the Rheumatology Service lead to
joint aspirations performed in the right MCP and right knee
joints , which revealed fluid with around 2000 white blood cells
and both negatively by refringent and positively by refringent
crystals consistent with gout and pseudogout. DVT was ruled out
as a cause of this extremity swelling. The patient was started
on Colchicine with improvement of pain and decrease of joint
swelling. An intraarticular ankle injection of Depo-Medrol was
performed on 7/9/05 with good affect. By the 6/13/05 , the
patient reported marked improvement in her range of motion and
pain control.
3. Endocrine: The patient was initially maintained on her rehab
dose of insulin which was Lantus 18 units at night , aspart 4
units at meals plus a sliding scale of Novolog. However , due to
intermittent decreased orally intake , she suffered several episodes
of hypoglycemia with blood sugars in the 30s to 50s. Her insulin
dosing was titrated initially downward and then after she
increased her orally intake it was titrated upwards. Pancreatic
enzymes were given with meals.
4. Cardiovascular: Ms. Mira Sickafoose blood pressure was persistently
elevated on her rehab regimen of antihypotensive medication.
Control was achieved in house by titrating her metoprolol up to
75 mg four times a day and adding Captopril at 50 mg three times a day No hypotension
while in house.
5. Neurologic: Her mental status initially declined at the
beginning of hospitalization. But by hospital day #3 , she began
to improve and became more coherent and alert. Her pain was
controlled on admission as well by both oxycodone and colchicine.
CT myelography was performed on 6/13/05 to evaluate the
patient's spinal stenosis disease. Results are still pending at
the time of this dictation.
6. Renal: Her electrolytes and renal functions were followed
closely in the setting of a recent urosepsis during the last
admission , her creatinine remained less than 1.2 throughout her
hospitalization and her electrolytes were repleted as necessary.
Urine output remained sufficient.
PLAN: Plan was for discharge in stable condition to Gapemont Medical Center with instructions to follow up her primary care physician , Peggy Romig , in one
to two weeks after discharge.
CODE STATUS: Full.
Daughter is her health care proxy.
DISCHARGE MEDICATIONS: Will be dictated at the time of
discharge.
eScription document: 1-3400538 ISSten Tel
Dictated By: PHILLEY , DORINDA
Attending: GILFOY , DEANDRA LAZARO
Dictation ID 0531551
D: 6/13/05
T: 6/13/05
Document id: 1096
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618283162 | PUO | 09342280 | | 593200 | 11/3/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/11/1990 Report Status: Unsigned
Discharge Date: 5/16/1990
HISTORY OF PRESENT ILLNESS: The patient is a vigorous , healthy
79-year-old retired garment industry
worker followed by Dr. Douglass Pettinger at I Warho Hospital
for the question of transient ischemic attacks but is otherwise
well. On the night of admission , the patient and his wife noted
fatigue , lightheadedness and diaphoresis three different times
during the day. The patient took one to two ounces of ethanol to
relieve this discomfort. Several hours later , attempting to climb
stairs , the patient fell and was unable to get up. Soon after , he
had an episode of melenic soft stool in large volume without frank
blood and then a moderate amount of coffee ground emesis. The
emergency medical technicians were called. In the ambulance , Mr.
Mursch heart rate was 110 with a blood pressure of 110/68. At the
Gle Ra Csylv Valley Medical Center Emergency Ward , his blood pressure had dropped to
95/60 and he was symptomatically orthostatic.
Esophagogastroduodenoscopy ( EGD ) was performed in the Emergency
Room which showed an actively bleeding 1 cm antral lesion in the
greater curvature of the stomach which was cauterized. This was
felt to be consistent with a pancreatic rest versus leiomyoma
versus rarely metastatic lesion as well as some mild esophagitis.
Mr. Litteer had no previous history of peptic ulcer disease. He has
been taking aspirin , one to two per day for several months because
of a question of TIA and for hip pain. He does have a history of
daily ethanol use , approximately two to three ounces per day times
many years. There was no history of nausea , vomiting , diarrhea ,
weight loss , abdominal pain , anorexia , or other constitutional
symptoms. There was a remote history of abdominal pain and spastic
colon with a negative barium enema , upper GI series and abdominal
ultrasound in 1976. He was admitted to the I Warho Hospital Medical Intensive Care Unit where he was transfused with 5
units of packed red blood cells and his hematocrit and vital signs
stabilized. He was then transferred to the General Medical Service
with a stable hematocrit at 37. It had been as low as 21 in the
MICU. MEDICATIONS: On admission included aspirin , two orally every day
and steroid cream to the psoriatic area. PAST MEDICAL HISTORY:
Noteable for chronic psoriasis. Vertigo with question of TIA.
Status post multiple excisions of basal cell skin carcinoma.
History of hiatal hernia with a question of reflux esophagitis.
Status post suprapubic prostatectomy many years ago because of BPH.
Status post herniorrhaphy. Status post appendectomy. History of
glucose intolerance , diet controlled. Status post right cataract
removal with lens implantation. ALLERGIES: NO KNOWN MEDICAL
ALLERGIES. FAMILY HISTORY: Multiple siblings healthy in their
late 80's. Positive family history of pancreatic CA in brother.
History of hypertension in mother and sister. No history of
coronary artery disease , diabetes , tuberculosis , hepatic or renal
disease. SOCIAL HISTORY: The patient is a retired womens clothing
manufacturer. He lives with his wife in Reve Ra Cla He has a moderate
ethanol use and has not used tobacco for 30 years. REVIEW OF
SYSTEMS: Negative except for vertigo.
PHYSICAL EXAMINATION: After stabilization revealed a 79-year-old
looking remarkably well and fit. Vital
signs revealed a heart rate of 60 , blood pressure 132/70.
Temperature 98. Skin revealed multiple patches of psoriasis. Head
and neck revealed normal pupils. Extraocular movements were intact
except for slight decrease in upward gaze mobility. The oropharynx
was benign. Neck was normal. Chest was clear. Cardiac
examination revealed S4 , S1 , S2 , no S3. A slow murmur heard on
admission was absent after transfusion. Abdomen was soft , flat
without hepatosplenomegaly. Extremities revealed pulses to be
intact without clubbing , cyanosis or edema. Stool was positive.
Neurological exam was grossly intact.
LABORATORY DATA: Significant data included as mentioned , the
hematocrit down to 21 which became stable at 37.
There was also evidence of mild pyuria and hematuria. Otherwise ,
some mild elevations of liver enzymes were noted toward the end of
his hospitalization.
HOSPITAL COURSE: The patient underwent the following studies
including a repeat EGD which showed in the antrum
a 1 cm area along the greater curvature which was ulcerated with
raised borders. Biopsies were not taken of that lesions , however ,
biopsies of large folds distal to the antrum in the duodenum were
biopsied. The patient underwent an abdominal CT scan which showed
question of small cystic lesion in the pancreas , either ductal
dilatation or a cyst but almost certainly an incidental finding
without any evidence of intraabdominal malignancy. Upper GI series
performed on the following day again showed thickened gastric folds
but was unremarkable. The patient was discharged on 4/25/90 on the
following medications: Pepcid , 20 mg orally twice a day; steroid cream for
psoriasis. Follow-up will be arranged with Dr. Mcausland and Dr.
Brister The patient was in stable condition upon discharge.
________________________________ YR453/4515
SACHIKO S. BORRIELLO , M.D. WP8 D: 11/7/90
Batch: 6898 Report: H2658P54 T: 9/17/90
Dictated By: SVETLANA S. SALLINGS , M.D. MX95
cc: DOUGLASS N. PETTINGER , M.D.
LACY L. MCAUSLAND , M.D.
DERICK D. YAN , M.D.
Document id: 1097
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753578182 | PUO | 47094392 | | 1345387 | 10/30/2005 12:00:00 a.m. | RESPIRATORY INSUFFICIENCY | Signed | DIS | Admission Date: 4/25/2005 Report Status: Signed
Discharge Date: 11/8/2005
ATTENDING: TAPLIN , AVRIL MD
CONSULTS: Consults for this patient included Urology and
Cardiology.
PROCEDURES: Procedures for this patient included a urological
procedure with placement of a ureteral stent and subsequent
removal of the ureteral stent.
MEDICATIONS: Her medications on admission included Lasix 20 mg
twice a day , OxyContin 90 twice a day and 40 every 2 p.m. , lisinopril 40
daily , Norvasc 5 twice a day , digoxin 0.125 twice a day , Levoxyl 88 mcg ,
Ativan 0.5 at bedtime , Niferex 150 twice a day , Colace twice a day ,
lactulose 50 daily , Faslodex 250 intramuscular every month , Coumadin 5 daily ,
Zometa every month , Fosamax 70 every week , and exemestane 25 mg orally
daily.
ALLERGIES: Her allergies included penicillin , which resulted in
pruritus and a rash.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old woman with a
history of rheumatic heart disease , status post St. Jude's mitral
valve repair as well as AV and TV repair who has CHF at baseline
with an EF of 40% to 45% as well as metastatic breast cancer and
a recent history of hydronephrosis who initially presented with
chest discomfort with exertion that resolved with rest. The
chest pain started five days prior to admission , which is
described as a 7 or 8 out of 10 associated with nausea and
shortness of breath , but the patient denied any radiation of the
pain , any vomiting , or any diaphoresis. She also said that she
had PND and orthopnea at baseline and she had recently increased
her number of pillows that she sleeps on , from two to three. Her
weight had been stable with no change in diet. She ruled out for
an MI; however , given her hydronephrosis , thought to be secondary
to her metastatic cancer and her rise in creatinine , it was
decided to place a ureteral stent , which was done by the Urology
Service. However , after the stent was placed , she developed
severe pain , fever , and increased white blood cell count.
Although the fever and white blood cell count resolved , she
continued to feel pain , and it was decided to remove the ureteral
stent since it was not decreasing her creatinine.
PHYSICAL EXAMINATION: Her admission physical exam was notable
for a blood pressure of 168/94. Other vitals included a
temperature 97.2 , pulse 69 , respiratory rate 16 , and saturating
98% on room air. Her JVP was 9. She had left lower lung
crackles , otherwise clear. She has a very loud ejection murmur ,
loud S1 and S2. She was in atrial fibrillation with a
irregularly irregular heart rate with no rub and she had a 1 to
2+ edema bilaterally and she was trace guaiac positive.
PROBLEM LIST BY SYSTEM:
Heart: Ischemia: She had a negative MIBI and her A and B sets
of troponins were negative , however her C set was 0.14 , which was
thought to be an error. Her aspirin and statin were continued.
Pump: Her EF was 35% to 40%. She was kept on hydralazine ,
Lasix , and beta-blocker , and her digoxin was stopped due to
bradycardia during this admission. In terms of her valves , she
has a St. Jude valve as well as other valve abnormalities and her
INR goal was 2 to 3. She was taken off her Coumadin for her
stent procedure and then bridged with heparin for a PTT goal of
60 to85. Her Coumadin was restarted and we waited until she was
therapeutic at an INR above 2 before she was discharged. Rate:
She is normally in atrial fibrillation. She developed
bradycardia for several days , which was though to be a
combination of some Lopressor given to her in ED when she was
having her rule out as well as slightly elevated levels of
digoxin. Her dioxin was stopped. Her beta-blocker was stopped
and then restarted at a lower dose. By discharge , she was
tolerating low-dose Lopressor. During the hospital stay , on
2/29/05 she had 10 beats of VT during which she was
asymptomatic. Her blood pressure was stable.
Renal: She had acute renal failure on admission and as I had
dictated previously she had a ureteral stent placed on 2/29/05
and that was then removed on 2/24/05 because of her severe pain.
Endocrine: She was kept on her Levoxyl.
Heme: She was guaiac positive , and her stools were guaiaced and
her hematocrit was monitored. Although it dropped initially , it
did not drop further during the hospital stay. She was kept on
her home pain control medications and she required additional
pain medications when she had her stent placed.
Psych: She continued her home medications.
GI: She stayed on her lactulose and Colace and bowel regimen was
titrated to bout BM's.
DISPOSITION: She was stable on the day of discharge. She was
discharged to home , I believe , with VNA.
DISCHARGE MEDICATIONS: Her medications on the day of discharge
were Coumadin 6 every afternoon , hydralazine 25 mg orally three times a day , Lasix 20
in the morning and 40 at night , Lopressor 12.5 three times a day , Aranesp
100 subcutaneous every week , OxyContin 90 every 12 hours and 40 every 2.p.m. ,
Nexium 40 daily , Zocor 20 mg at bedtime , aspirin 81 , Colace 100 ,
Niferex 150 , Levoxyl 88 , Senna daily , and exemestane 25 mg orally
daily.
FOLLOWUP: She was instructed to follow up with her primary care physician.
eScription document: 9-4907296 IS
Dictated By: TARBERT , BEATA
Attending: TAPLIN , AVRIL
Dictation ID 9032883
D: 5/24/05
T: 5/24/05
Document id: 1098
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742375610 | PUO | 53267321 | | 8234101 | 10/27/2007 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/12/2007 Report Status: Unsigned
Discharge Date:
ATTENDING: SPILLETT , SILVA M.D.
HOSPITAL COURSE: For the events of the earlier part of the
hospitalization , please see the dictation by the Vascular Surgery
team. The patient was transferred to the Medical Service for
further management on 3/7/07. Briefly , this is a 59-year-old
female with diabetes , end-stage renal disease on hemodialysis ,
history of recurrent MRSA infections including vertebral osteo
status post compression fracture and fusion admitted to Pagham University Of on 10/6/07 from rehab after rupture of her
right forearm AV fistula. The patient underwent surgical
ligation of her brachial artery. The patient had a significant
drop in her hematocrit to 14 , and she received several units of
packed red blood cells and underwent surgical ligation of the
brachial artery. She subsequently remained intubated on Levophed
in the Surgical ICU. She was then weaned off Levophed and
transferred to the Surgery Service. The patient completed a
course of linezolid for treatment of her recent bacteremia , which
ended on 9/11/07. She was started on fluconazole 400 mg once
daily for treatment of recent candidemia , course ending 10/2/07 ,
and she was also started on vancomycin 125 mg orally twice a day for
ongoing suppressive treatment of recurrent C. diff. The
patient's hospital course was subsequently complicated by severe
deconditioning , refeeding syndrome , poor nutritional status and
decubitus ulcers.
PAST MEDICAL HISTORY:
1. End-stage renal disease due to diabetes on hemodialysis since
6/25
2. Type I diabetes with neuropathy , nephropathy , retinopathy and
gastroparesis.
3. Hypertension.
4. Hyperlipidemia.
5. History of atrial fibrillation.
6. Depression.
7. Status post MRSA osteomyelitis bacteremia and infected AV
graft in 1/24 status post left BKA for osteomyelitis in 10/29
8. History of gram-negative rod sepsis status post removal of
new AV graft in 10/13
9. T5-T6 diskitis osteomyelitis complicated by spinal cord
compression status post fusion in 10/13
10. History of C. diff colitis recurrent and unresponsive to
metronidazole.
11. Candidemia and VRE bacteremia as noted above.
Before this hospitalization , she was hospitalized with the
presumed line associated fungemia for which she has been
receiving fluconazole. She had a TTE and eye exam , which were
negative. Hemodialysis line was pulled and a new one placed on
2/12/07.
MEDICATIONS ON TRANSFER:
1. Amiodarone.
2. Fluconazole.
3. Heparin prophylaxis.
4. NPH and regular insulin sliding scale.
5. Nephrocaps.
6. Reglan.
7. Lopressor.
8. Vancomycin orally 125 mg twice a day
9. Neutra-Phos 750 mg orally three times a day
ALLERGIES: To lisinopril and celecoxib.
MICRODATA: Significant for two sets of C. diff that were
negative , last one on 4/11/07. Blood culture , no growth to date
during this admission.
PHYSICAL EXAMINATION: Temperature 97.8 , heart rate 80 , blood
pressure 96/48 , respiratory rate 16 and 100% on room air. Alert ,
mumbling , well-appearing , no apparent distress. No scleral
icterus. Oropharynx , dry mucous membranes. Neck was supple.
Crackles at the bases on lung exam. Regular rate and rhythm.
2/6 systolic ejection murmur at left sternal border , no heaves.
Abdomen , soft and obese. Bowel sounds were present , nontender.
No rebound or guarding. Extremities significant for the left BKA
wound well healing. Right lower extremity trace edema. Right
upper extremity with absent radial pulses and atrophy and
contracture. Ulnar pulse was positive. Right upper extremity
was cooler than left. Left upper extremity with radial and ulnar
pulses present. Skin significant for sacral decubitus ulcers
stage II and III with pink granulation tissue , no evidence of
purulent discharge. Neuro exam , alert and oriented x1.
LABORATORY DATA: Significant for a potassium of 3.4 , BUN and
creatinine 23 and 2.5 , calcium 7.7 , phos 2.8 , mag 1.6. White
blood cell count 13.3 , hematocrit 27.5 , platelets 137 , 000.
Albumin 2.1.
HOSPITAL COURSE: A 59-year-old female with diabetes , end-stage
renal disease on hemodialysis , history of recurrent infections
including MRSA vertebral osteo , bacteremia in 1/24 and
gram-negative rod sepsis in 10/6 with T5-6 osteo and cord
compression status post fusion in 10/6 admitted on 10/6/07 for
AV fistula rupture and bleed now status post brachial artery
ligation.
Hospital course complicated by severe deconditioning , poor
nutritional status and decubitus ulcers.
1. Infectious disease: The patient started to become afebrile
48 hours after transfer to the Medical Service with temperatures
as high as 102.5. Vital signs were stable. Blood cultures are
still no growth to date. Chest x-ray without any evidence of
infiltrate. The patient is anuric , likely source decubitus
ulcers versus recurrent osteo. Blood cultures were obtained on a
daily basis , which were no growth today at the time of this
dictation. Fluconazole and vancomycin orally were continued ,
course ending on 2/10/07. The ID. Service was asked to consult
for further help with management of the patient's fevers.
Plastics consult was obtained to evaluate decubitus ulcers.
.
2. Renal: The patient was followed by Renal Service and had
dialysis on Tuesdays , Thursdays and Saturdays.
3. GI: The patient was maintained on Reglan for gastroparesis
and continued on Nexium.
4. Heme: The patient had guaiac-positive stools. Her
hematocrit was 28 and dropped to 25.8 upon transfer. She
received two units of packed red blood cells transfusion on
3/26/07 during dialysis.
5. Endocrine: The patient had uncontrolled hyperglycemia likely
secondary to the stress of her hospitalization. She was
initially on 40 units of NPH twice a day and this was titrated up to
maintain normal glycemia.
6. Derm: She had decubitus ulcers followed by the wound care
nurse , Dominique Fendley She was continued on Panafil and XenoDerm.
A Plastics consult was obtained regarding need for further
debridement.
7. FEN: The patient's course was complicated by refeeding
syndrome with severe electrolyte imbalances requiring aggressive
repletion of her electrolytes including phos , K and mag. She was
maintained on tube feeds. A Speech and Swallow evaluation was
obtained , which determined that she can be started on pureed
diet. However , it was unlikely that she would be able to
maintain adequate orally intake.
8. Prophylaxis The patient was maintained on heparin prophylaxis
for DVT and Nexium given her guaiac-positive stools.
At time of this dictation , the plan is for a family meeting to
discuss the patient's prognosis , nutritional status and goals of
care.
eScription document: 2-9252335 CSSten Tel
Dictated By: GETTINGS , OTELIA
Attending: SPILLETT , SILVA
Dictation ID 4132860
D: 3/26/07
T: 3/26/07
Document id: 1099
| Target |
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OA |
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OSA |
PVD |
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| output/system_textual_annotation.xml | textual |
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U |
U |
| output/system_intuitive_annotation.xml | intuitive |
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N |
093439918 | PUO | 98075597 | | 591108 | 1/10/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/10/1992 Report Status: Signed
Discharge Date: 3/28/1993
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old right
handed man who was admitted to the
neurology service on 1/10/92. He has a two week history of right
sided slowly improving. The neurology service felt that the
findings on exam was most consistent with cervical disc disease and
they asked neurosurgery to consult. In brief , the patient's chief
complaint is right sided weakness. The patient was in his usual
state of health until approximately three and a half weeks prior to
admission. He noted pain in his right shoulder over four to five
hours , the pain increased. He also noted numbness in his right
toes. His right hand was weak as well and he had difficulty
holding a cup. Conservative management failed , i.e. , bedrest. He
came to the emergency room at the request of his local doctor and
was admitted to the neurology service. While here , on Decadron ,
Motrin and Flexeril , he noted some improvement. Of note , he fell
flat on his face first on 10/21/92 and sustained a sprained ankle.
At that time , he had no back or neck pain. While in house , he felt
that he could walk three times around the Frehouscoll More Ottepesa At that point , he
experienced weakness and numbness on the fourth trip around. He
has also noted some urgency since the onset of his neck pain. He
has normal peroneal sensation except for the transient occurrences
of some saddle distribution of abnormal sensation. He has
constipation which has now improved. PAST MEDICAL HISTORY: L4-5
laminectomy in 1970 and 1982. In 1980 , he had a perforated ulcer.
In 1982 , he had surgery for a hiatal hernia. In 1983 , he had a
cholecystectomy. In 1984 , he had a partial gastrectomy and
colectomy for swallowing a toothpick. He has a history of anxiety
attacks related to highway driving. He is a past smoker , stopped
seven years ago after three packs per day times 40 years. History
of alcohol abuse but does not drink now. He has no cardiac ,
respiratory or GI disturbances.
PHYSICAL EXAMINATION: On admission revealed the patient to be
afebrile. Vital signs were stable. General
exam was within normal limits. He had full range of motion with
increased pain with extension of his neck. He was alert and
oriented with a normal mental status. Speech was fluent with no
dysarthria. Cranial nerves were entirely within normal limits. He
had no pronator drift. On the left he was 5/5 throughout. On the
right he had 5- strength in his biceps , triceps , wrist extensors
and intrinsics. Hip flexors were 4/5. Knee flexors and knee
extensors were 4/5. He was essentially 5/5 throughout the rest of
his lower extremities. His reflexes were 1-2+ in his upper
extremities and approximately 3+ at the knees with downgoing toes.
He had 3-4 beat clonus on the right. Coordination was okay
bilaterally. Gait tested revealed a tendency to fall with
decreased ability to weight bear on the right. Sensory exam
revealed decreased sensation in the right hand and the last three
digits of the left hand. He had no subjective numbness in his
right leg , on the dorsum of his left foot , he had decreased
sensation with a cut off before the toes.
MRI was a poor quality study which showed C5-6 and C6-7 disc bulge.
CAT scan showed severe stenosis of C6-7 with osteophyte , moderate
stenosis at C5-6.
HOSPITAL COURSE: The patient was seen by Dr. Mccleery who agreed
with the plan for C5-6 and C6-7 laminectomies.
He was taken to the operating room on 10/8/93. Preoperative
diagnosis with cervical stenosis with myelopathy. Postoperative
diagnosis was the same. The procedure was C4-5 , C5-6 , C6-7
laminectomy. He had a Hemovac placed postoperatively. The
estimated blood loss was less than 100 cc. Postoperatively , he did
very well. He had good upper extremity strength which seemed to
improve. He was seen by physical therapy. He had a slightly
swollen calf and had noninvasive vascular studies of his lower
extremities which were negative. He did , however , note some
shooting pain in his left lower extremity. His wound was clean and
healing well. He was out of bed with a walker. The plan was for
discharge home. He may need further evaluation of his lumbar spine
at some point but he seems to be doing well with Percocet only.
PRINCIPAL DIAGNOSIS: CERVICAL SPONDYLOSIS STATUS POST MULTIPLE
LEVEL CERVICAL LAMINECTOMIES.
HISTORY OF LUMBAR DISC DISEASE.
HISTORY OF ALCOHOL AND TOBACCO ABUSE ,
NONE CURRENTLY.
PERFORATED ULCER.
HIATAL HERNIA.
STATUS POST CHOLECYSTECTOMY , GASTRECTOMY
AND COLECTOMY.
ANXIETY ATTACKS.
DISPOSITION: MEDICATIONS: On discharge included Colace ,
klonopin , Flexeril and Percocet. He will follow-up
with Dr. Mccleery in one to two weeks.
Dictated By: LOWELL BANOS , M.D. EI77
Attending: KATHERYN GRUNTZ , M.D. RD25
VE270/5545
Batch: 7407 Index No. KFJRGEWGW D: 1/17/93
T: 8/14/93
Document id: 1100
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742375610 | PUO | 53267321 | | 8955354 | 1/24/2006 12:00:00 a.m. | ABDOMINAL PAIN | Unsigned | DIS | Admission Date: 8/19/2006 Report Status: Unsigned
Discharge Date: 6/1/2006
ATTENDING: BRAGAS , RASHEEDA MD
SERVICE:
GMS Gle
PRIMARY CARE PHYSICIAN:
Romona Ranno , M.D.
PRINCIPAL DIAGNOSES:
End-stage renal disease and osteomyelitis.
LIST OF OTHER PROBLEMS AND DIAGNOSES:
Insulin-dependent diabetes mellitus , peripheral neuropathy , left
Charcot foot complicated by ulceration requiring partial
thickness debridement on 3/26/06 in the setting of new Aircast
started on 8/21/06 now with a cast applied to the left foot ,
hypertension , chronic renal insufficiency , hyperlipidemia , spinal
stenosis , anemia of chronic disease , thrombocytopenia , and ascus
6/10 and 11/6
BRIEF HISTORY OF PRESENT ILLNESS:
The patient is a 58-year-old female with chronic renal
insufficiency , baseline creatinine 3.8 , diabetes mellitus ,
hypertension , and anemia , who present with two weeks of diffuse
abdominal pain that acutely worsened one day prior to admission
with associated nausea , nonbloody emesis , and chills. The
patient was found to be febrile with leukocytosis in the ED. The
patient had been seen previously in the ED on 10/11/06 at which
time she was treated with a UTI. She was sent home with a
seven-day course of ciprofloxacin and oxycodone for pain. The
ciprofloxacin was renally dosed. The patient reports that she
stopped taking oxycodone and ciprofloxacin. After developing
constipation , it is unclear if she completed her full course of
antibiotics. She currently present with complaints of diarrhea
in the setting of having taken laxative at home. No melena or
hematochezia. The pain is not related to food , urination , or
defecation. She has poor orally intake , denies any sick contacts
at home. No recent travel.
REVIEW OF SYSTEMS:
Positive for blood sugars ranging from 180-190 , although she had
a blood sugar of 499 on the morning of admission. She has
fatigue but no myalgias , no cough , chest pain , shortness of
breath , no dysuria. In the ED , she was given ampicillin 2 g intravenous ,
gentamicin 80 mg intravenous , Flagyl 500 mg intravenous and 8 units of insulin.
ALLERGIES:
Medication reaction , she has an allergy to lisinopril with
reaction of elevated creatinine at a low dose. To levofloxacin ,
she has reflux and celecoxib gives her dizziness and elevated
creatinine.
BRIEF ADMISSION PHYSICAL EXAMINATION:
She had a temperature of 101 , pulse of 106 , blood pressure
172/71 , oxygen saturation of 100% on room air. She was alert and
oriented x3 , in mild distress. Her lungs were clear to
auscultation bilaterally. Her heart had a regular rate and
rhythm with a 2/6 early systolic murmur at the left lower sternal
border. She was obese , but had a nontender , nondistended abdomen
with normal abdominal bowel sounds. She was guaiac negative , and
her left foot was in a cast.
PERTINENT LABORATORY TESTS AND RESULTS:
She had a sodium of 127 , corrected to 131 with her glucose ,
potassium of 4.9 , bicarbonate of 27 , BUN 95 , creatinine 4.5 ,
glucose 329. LFTs were normal , amylase 19 , lipase 8 , negative
keto acids in the serum and urine. Her white blood count was
26.8 , INR was 1.4 , PTT was 36.6. She had a dirty urinalysis.
She had an abdominal CT that showed a non-incarcerated hernia , no
evidence of colitis.
OPERATIONS AND PROCEDURES:
The patient had a debridement of her left foot on 9/25/06. She
also had hemodialysis initiated on 10/9/06.
HOSPITAL COURSE BY SYSTEMS:
1. Infectious disease: The patient's left foot was encasted by
orthopedics surgery on 2/29/06 with evidence of underlying
infection. Her wound cultures grew MRSA with probes to the bone.
X-rays were unrevealing and MRI showed severe osteomyelitis. In
addition , the patient had an ESR of 109. The patient was thus
put on levofloxacin , vancomycin , and Flagyl. Blood cultures from
6/16/06 additionally grew gram-positive cocci in clusters which
eventually yielded MRSA. However , surveillance cultures with
treatment on levofloxacin , vancomycin , and Flagyl were negative.
The patient received debridement of her left foot on 9/25/06.
In the OR , the bone looked necrotic and infected. The bone was
sent to pathology and microbiology , the results of which are
pending. Given the appearance of her bone during debridement , it
is presumed that the patient will need eight weeks of vancomycin.
Because she did have a clear source of fevers after it was found
that she had osteomyelitis , the patient was discontinued off
Flagyl and levofloxacin on 5/6/06.
2. GI: The patient has abdominal pain with gastric emptying
study on 6/16/06 showing 0% clearance at 90 minutes consistent
with severe gastroparesis versus obstruction. Radiology did not
feel that an upper GI series would give further information
regarding obstruction and it was judged to be unlikely given that
the patient has bowel movements and rare emesis. Later on in the
hospital course , the patient was put on erythromycin with a
decrease in her symptoms of abdominal pain , nausea , and vomiting.
The patient did have any evidence of bowel ischemia on MRA.
Later , erythromycin was changed to Reglan on 4/8/06 per renal
request during hemodialysis. There is no evidence of pancreatis
or liver disease and the patient was also kept on Compazine for
nausea.
3. Renal: The patient had , on admission , acute on chronic renal
failure. There was a concern for prerenal azotemia in the
setting of nausea and vomiting and diarrhea. She had a
fractional excretion of sodium which was 0.3% , but it was
difficult to interpret in the setting of end-stage renal disease.
Lasix and Cozaar were held. However , the creatinine continued
to worsen reaching 6.1 on 9/14/06. Renal was consulted
regarding the need for dialysis. On admission , the patient did
have matured AV fistula graft and she was thus started on
hemodialysis on 10/9/06.
4. Hematology: The patient had an INR which was elevated.
Hematocrit was also decreased to 25.5 from 34. She was guaiac
negative and did have any schistocyte. Her LDH was also normal
with her haptoglobin high. It was judged from her iron studies
that the patient was iron deficient. She was put on iron
supplementation. She also was felt to have renal component to
her anemia and she was started on darbepoetin initially and
changed to erythropoietin later during dialysis by renal.
5. Cardiovascular: The patient was maintained on aspirin , a
statin , and calcium channel blocker. She started prophylactic
beta-blocker during her hospital course as well.
6. Endocrine: The patient had hemoglobin A1c of 7.8. She was
transitioned to NPH and Aspart during her hospital stay. She had
intermittent problems with hypoglycemia in the setting of being
NPO pending operations and procedures; however , her insulin
regimen was titrated to good glycemic response.
7. Prophylaxis: The patient was kept on heparin and Nexium.
8. Fluids , electrolytes , and nutrition: Her intravenous fluids were
stopped as the patient was oliguric and anuric initially before
hemodialysis. Later on , she was also put on 1500 mL fluid
restriction. Later on during dialysis , her volume status
resolved euvolemia. She was kept on a low fat and low
cholesterol diabetic diet. The patient is full code.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4. as needed headache.
2. Aspirin 81 mg orally daily.
3. Colace 100 mg orally twice a day
4. Heparin 5000 units subcutaneously three times a day
5. Dilaudid 0.4-0.8 mg orally every 4. as needed pain.
6. Insulin NPH human 20 units subcutaneously twice a day
7. Lactulose 30 mL orally four times a day as needed constipation.
8. Reglan 5 mg orally before every meal
9. Reglan 5 mg orally every bedtime
10. Lopressor 50 mg orally four times a day
11. Senna tablets two tabs orally twice a day
12. Norvasc 10 mg orally daily.
13. Compazine 5-10 mg orally every 6 hours as needed nausea.
14. Nephrocaps one tab orally daily.
15. Insulin Aspart sliding scale subcutaneously before meals
16. Insulin Aspart 4 units subcutaneously before every meal
17. Lipitor 80 mg orally daily.
18. Protonix 40 mg orally daily.
19. Vancomycin 1 g intravenous three times a week. These doses are all
to be given during hemodialysis.
20. Ergocalciferol 50 , 000 units orally every week for six weeks.
eScription document: 8-0241860 EMSSten Tel
Dictated By: POLO , MALINDA
Attending: BRAGAS , RASHEEDA
Dictation ID 2793697
D: 5/5/06
T: 5/5/06
Document id: 1101
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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902260517 | PUO | 05373993 | | 8022238 | 7/12/2004 12:00:00 a.m. | Dehydration | | DIS | Admission Date: 6/10/2004 Report Status:
Discharge Date: 1/26/2004
****** DISCHARGE ORDERS ******
MASELLA , DOVIE 565-56-05-5
Rageu Spo Bilearb
Service: MED
DISCHARGE PATIENT ON: 4/22/04 AT 04:30 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
No CPR / No defib / No intubation /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 9/4/04 by DASE , ANNABEL D. , M.D. on order for COUMADIN orally ( ref # 12356473 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: will monitor
FOLATE ( FOLIC ACID ) 1 MG orally every day Starting Today ( 9/30 )
LISINOPRIL 30 MG orally every day
Override Notice: Override added on 9/4/04 by DASE , ANNABEL D. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
66324887 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
THIAMINE HCL 100 MG orally every day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 9/4/04 by DASE , ANNABEL D. , M.D. on order for SIMVASTATIN orally ( ref # 08203904 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: will monitor
CREON 20 ( PANCRELIPASE 20000U ) 4 CAPSULE orally three times a day
Instructions: with meals
LEVOFLOXACIN 500 MG orally every day Starting Today ( 9/30 )
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 8/29/04 by
SHOUPE , ZOFIA C. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
Reason for override: monitoring
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously every day
Starting Today ( 9/30 )
LASIX ( FUROSEMIDE ) 40 MG orally every day
LIPITOR ( ATORVASTATIN ) 20 MG orally every day
Alert overridden: Override added on 4/22/04 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override:
will not prescribe niacin
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/22/04 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: will follow closely
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Everett Irias - You will be contacted with an appointment for this week ,
Arrange INR to be drawn on 7/14/04 with f/u INR's to be drawn every
3 days. INR's will be followed by Dr. Zebley
No Known Allergies
ADMIT DIAGNOSIS:
Hyperglycemia , dehydration
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Dehydration
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , complete heart block ETOH , HTN , substance abuse
history of PACER PLCT 1980 history of SILENT IMI history of l
nephrectomy history of appy history of spinal stenosis DM 2/2 pancreatitis
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHOCARDIOGRAM 2/20/04 - EF 20-25% , moderate to severe global
hypokinesis , trace AI , mild MR , TV pacer wire still has clot/veg.
OFFICIAL READ STILL PENDING AT TIME OF DISCHARGE
ABDMONINAL CT 10/26/04 - No acute disease , gall stones , RLL inflammation
? PNA , ectatic aorta , non-obstructing ventral hernia
V/Q SCAN 10/26/04 - Low probability
BRIEF RESUME OF HOSPITAL COURSE:
66 YO male with complicated PMH including CHF with EF 25% , COPD , PVD ,
DM2 , CHB with pacer and evidence of clot on pacer wire , non-compliant
with medications and diet and who developed sx of abd pain and SOB with
FS of 500-600. primary care physician asked patient to come to ED where he was found to
have FS of 700 with hypotension 70s-80s SBP but mentating. No gap and
no ketones. No signs or sx of infection with admission for medical
management.
VS: 99.5 101/62 70s SaO2 96% on room air
EXAM:
GEN: elderly ill appearing male in NAD
HEENT: Anicteric sclera , PERRL , dry mucous membranes , poor dentition
NECK: Supple , no adenopathy , JVP flat
CHEST: CTA bilaterally
CV: RRR with diffuse PMI , Nl S1 , S2 S3 present
ABD: Reducible ventral hernia , NT , ND , bowel sounds present
EXT: No edema or wounds
SKIN: No rashes
EKG: paced
CXR: clear with NAD
ABD CT: small ventral hernia , gallstones , ectasia of the infrarenal
aorta , RLL inflammatory changes suggestive of PNA
VQ: Low probability
LABS: Creatinine of 2.2 that dropped to 1.5 with hydration ( BL
1.2-1.3 ). HCT 41.6 with drop after aggresive hydration. Lipase of 132
but has chronic pancreatitis and is now normalizing. UA and ACE
negative.
ASSESSMENT & PLAN: 66 YO male with complicated PMH admitted with
hyperglycemia likely due to non-compliance and hypotension likely due
to hypovolemia. In ED the patient received 5 liters of IVF and 36U of
insulin. His blood pressure stabilized with volume and he was
transfered to the medical floor.
ENDOCRINE - DMII but with history of pancreatitis so behaves more like
type 1 - needs insulin all the time. Per patient he had been taking 20
units of Lantus every day before noon but patient admitted to poor compliance with both
diet and insulin. His A1C was checked and returned at 19. The patient
was started on Lantus and Lispro and maintained on an ADA diet. He was
titrated to 20 units of Lantus every bedtime and was requring Lispro for FS
ranging from 120-600. By 8/22 his FS remained better controlled but
were still high ranging from 200 to 400 on Lantus 16. On 3/22 the
patient expressed that he would like to leave. He is discharged o
n Lantus 20 and Lispro SS with VNA to follow finger sticks. He
was maintained on an ADA diet , however , there was some concern he
may have been eating sweets on his own. Nutrition was consulted
and provided teaching regaring diet and diabetes. The patient is
discharged to home on Lantus and lispro with VNA following
HEME - on coumadin for hx of pacer clot. Echo shows pacer clot but
not clear whether patient will be compliant enough to go home on
coumadin as he has not been in the past. After discussion with
patient agreement is that we will d/c on coumadin 5 every day ( INR on
day of d/c 1.2 ) with enough supply for one week. He will have
blood drawn by VNA with results sent to Dr. Conkin If he his not
compliant with his lab work the coumadin will be stopped.
CV -
ISCHEMIA: Nonobstuctive CAD on cath in September with no evidence
of acute episode. Maintained on ASA , ACEi , and Statin. No BB as
current cocaine user and considered to dangerous
PUMP: EF: 20-25% Hypovolemic at admission with good response to
hydration. No episodes of volume overload. On ACEi for AL reduction.
RHYTHM: CHB with PPM in place
GI: elevated lipase with chronic pancreatitis with no symptoms and
resolution after hydration.
DISPO: The patient is discharged to home in fair condition. He has been
given teaching regarding nutrition , diabetes , and coumadin. His
medications has been discussed with him. He agrees to be compliant with
all medications , to work with VNA , and to attend all of his
appointments and blood draws. He is discharged home on coumadin and
Lantus to be followed by VNA. He is to follow up with Dr. Zebley within
the next week and will be contacted with an appointment
CODE: DNR/DNI
ADDITIONAL COMMENTS: 1. ) Please take your insulin shot ( 20 units of Lantus ) every night at
10 PM. You will get your dose for Sunday 3/22 in the hospital. You
first dose at home will be Monday 7/2 at 10 PM.
2. ) Visiting nursing will come to your home tomorrow to help you with
your medications.
3. ) Please take all your medications as directed. It is very important
to have your blood checked regularly to make sure your medications are
at the right level.
DISCHARGE CONDITION: Fair
TO DO/PLAN:
1. ) Take your Lantus every night at 10 PM starting on Monday 9/6/04.
Take a shot with 20 units of insulin in it.
2. ) Check your fingersticks daily and record the level. Please call Dr.
Zebley if your blood sugar is higher then 350 or lower then 50.
3. ) Take all you other medications as directed. Do not take any
medications that are not on this list.
4. ) Please attend all of your appointments and blood draws
No dictated summary
ENTERED BY: HEIDELBERGER , LATICIA THADDEUS , M.D. ( VE083 ) 4/22/04 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1102
| Target |
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CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
- |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
057538315 | PUO | 08990455 | | 2289024 | 9/23/2006 12:00:00 a.m. | morbid obesity | | DIS | Admission Date: 4/1/2006 Report Status:
Discharge Date: 9/13/2006
****** FINAL DISCHARGE ORDERS ******
FREEDLAND , NAM 361-10-90-7
Ter
Service: GGI
DISCHARGE PATIENT ON: 2/26/06 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HORNBEAK , LAUREL I. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ROXICET ELIXIR ( OXYCODONE+APAP LIQUID )
5 MILLILITERS orally every 4 hours as needed Pain
PHENERGAN ( PROMETHAZINE HCL ) 25 MG PR every 6 hours as needed Nausea
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY Instructions: chewable
DIET: stage 2 gastric band
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Hornbeak 2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
history of Lap Band
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
morbid obesity
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of lap band
OPERATIONS AND PROCEDURES:
2/6/06 HORNBEAK , LAUREL I. , M.D.
LAPARO PLACEMENT ADJUSTABLE GASTRIC BAND LAPAROSCOPIC HIATAL HERNIA
REP
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to the Nessinee Ker Hospital Medical Center surgery service on 9/23/2006 after
undergoing laparoscopic gastric banding. No concerning intraoperative
events occurred; please see dictated operative note for details. The
patient was transferred to the floor from the PACU in stable condition.
Patient had adequate pain control and no issues overnight into POD1 and
that time the patient was started on a Stage I diet which was tolerated.
The patient was then advanced to clears and discharged to home a Stage II
diet. The incision was C/D/I , with no evidence of hematoma collection or
infection. The remainder of the hospital course was relatively
unremarkable , and the patient was discharged in stable condition ,
ambulating and voiding independently , and with adequate pain control.
The patient was given explicit instructions to follow-up in clinic with
Dr. Hornbeak in two weeks.
ADDITIONAL COMMENTS: May shower 2 days after surgery , but do not tub bathe , swim , soak , or
scrub incision for 2 weeks. Bandage strips will fall off over time.
Seek medical attention for fevers ( temp>101.5 ) , worsening pain , drainage
or excessive bleeding from incision , chest pain , shortness of breath , or
any other symptoms of concern. Follow up with your surgeon in 1-2 weeks.
Please do not drive or consume alcohol while taking pain medications.
Crush pills , open capsules , or take elixirs.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MULNEIX , AYANNA R. , M.D. ( OC30 ) 2/6/06 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 1103
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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654786184 | PUO | 34102882 | | 2137598 | 4/20/2005 12:00:00 a.m. | chest discomfort unclear etiology | | DIS | Admission Date: 10/6/2005 Report Status:
Discharge Date: 10/6/2005
****** FINAL DISCHARGE ORDERS ******
CUKAJ , CATHI M 210-40-13-7
Purak Ave. , Endo Bo A Mancuseporco
Service: MED
DISCHARGE PATIENT ON: 8/4/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SHOPBELL , MYRIAM P. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally 3x/Week M-W-F
Alert overridden: Override added on 8/4/05 by
RICCIARDONE , NELLY , M.D. , PH.D.
on order for ECASA orally ( ref # 02944418 )
patient has a DEFINITE allergy to Aspirin; reaction is GI
upset. Reason for override: Takes as outpatient
LISINOPRIL 1.25 MG orally every day
Alert overridden: Override added on 8/4/05 by
RICCIARDONE , NELLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: Aware
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ATENOLOL 50 MG orally every day
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
GLYBURIDE 1.25 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
pcp - Dr. Stepanie Loban ( 489-7760 1-2 weeks ,
cardiology - Reyes Mcpeck 4/30 3.20p ,
vascular surgery - Reedy ( 118-846-4599 ) 10/6 ( call for time ) ,
ALLERGY: Penicillins , intravenous Contrast , AZITHROMYCIN , Shellfish ,
Aspirin
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest discomfort unclear etiology
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
unstable angina hypercholesterol history of TAH , RSO history of splenectomy - stab woun
asthma history of hepatitis history of L hemicolectomy - polyp r/o for mi 4/22
10/25 GIB from diverticuli , 6/8 MIBI old scar inf/lat
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
prelim STRESS MIBI - negative for acute or reversible defects.
non-reversible scar inf/lat. final read P
BRIEF RESUME OF HOSPITAL COURSE:
patient is a 64F with hx of CAD ( NSTEMIs x 2 in 1997/2001 , cath 2000 RCA , LCx
in 2000 , which were
complicated by in-stent thrombosis ?3 years ago ) , HTN , DM ( hba1c 6.2 ) ,
PVD , recent admit ( 8/26 ) for ROMI ( negative and declined inpatient
stress ) , presents with atypical chest pain. Constant x 6 days SSCP , no
associated sx. No pulm/infectious component.
In the ED , BP 159/69 , P 60. No EKG changes new. first set of enzymes
negative. d dimer negative.
**********
Hospital Course
patient was admitted for observation and ROMI with stress test. There was low
suspicion for ACS given her history. However , patient with multiple CRF and
felt that inpatient stress was warranted ( last MIBI 2002 ).
patient underwent chemical-MIBI on 9/19 ( hx of PVD can only walk 2 block
equivalent ) that was negative for any acute , reversible changes ( final
P ).
Unclear etiology for her pain. The diagnosis of potential pericarditis
was entertained , but again , the history was not consistent , no viral
prodome , no EKG changes , no pulsus/rub appreciated. No reproducible/MSK
pain.
Her pain was only controlled with oxycodone. She was pain-free at
discharge. patient was continued on all her outpatient medications. no changes.
patient will be discharged to home with follow-up already scheduled with Dr.
Mcpeck , her cardiologist at the end of the month.
Of note patient had an elevated WBC ( 15.2 ) which seems to be chronic in nature.
No fevers , localizing signs/symptoms of infection.
ADDITIONAL COMMENTS: please continue to take the same medications as you were before this
admission. call your primary care physician to make an appointment in 1-2 weeks ( number
above ). Your cardiology appts with dr mcpeck and surgery appointment
with dr. starrett , also listed above.
your stress test was negative for any new heart disease - your chest pain
was unlikely due to heart disease.
return to the ED or call your primary care physician with new chest pain , shortness of
breath , palpitations.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. patient has follow up with cardiology and vascular surgery scheduled.
no new medications this admission.
No dictated summary
ENTERED BY: DYDELL , ALISON ISABELLE , M.D. ( EF69 ) 8/4/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1104
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
832108590 | PUO | 62422817 | | 986700 | 1/11/1997 12:00:00 a.m. | VAGINAL BLEED | Signed | DIS | Admission Date: 10/17/1997 Report Status: Signed
Discharge Date: 8/10/1997
ADMITTING DIAGNOSIS: Menorrhagia , vaginal hemorrhage.
PRINCIPAL PROCEDURE: Total abdominal hysterectomy , left
salpingo-oophorectomy. There were no
complications.
ADDITIONAL ADMITTING DIAGNOSIS: NONE.
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old gravida
5 , para 5 with known uterine fibroids
who presented to the Emergency Room with prolonged and progressively
heavy bleeding. The patient also noted dizziness and
light-headedness. On presentation to the Emergency Room , she was
noted to have a blood pressure of 90/palp with diaphoresis. She
states that she has been bleeding heavily for three weeks , however ,
on the day of admission , the bleeding was particularly excessive.
PAST MEDICAL HISTORY: She has no past significant medical history.
PAST OBSTETRIC HISTORY: Five full term normal spontaneous vaginal
delivery and a tubal ligation.
PAST SURGICAL HISTORY: Tubal ligation.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a non-smoker.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: In the Emergency Room , she was an overweight
black female in Trendelenburg. Her vital
signs were blood pressure of 70/palp , heart rate in the 70s and 02
saturation of 97% on room air and a temperature of 98.2. Her skin
was pale. Her HEENT examination was pale conjunctiva , anicteric
sclerae. Her cardiac examination was regular rate and rhythm. Her
lungs were clear to auscultation. Her abdomen was soft and
non-distended with a palpable mass at the level of the umbilicus ,
non-tender. Her pelvic speculum examination revealed a large
running of clot in the vault. The cervix was not able to be
visualized. Bimanual examination revealed a 2-3 centimeter dilated
cervix with a palpable fibroid prolapsing through the os of the
uterus with additional 20 week size and irregular. Her hematocrit
on presentation was 31.
Given her symptoms and heavy bleeding with an aborting prolapsing
fibroid and hemodynamic instability , the patient was taken to the Operating
Room for a total abdominal hysterectomy on June , 1997 at 12:30 a.m.
HOSPITAL COURSE: On June , 1997 at 12:30 a.m. she underwent
a total abdominal hysterectomy , left
salpingo-oophorectomy with an estimated blood loss of 500 cc. She had received
one unit intraoperatively. Please see the operative report for details of that
surgery. However , notably , she had an 18 week size fibroid uterus with
multiple large fibroids including an eight centimeter submucosal
fibroid prolapsing through the cervix. Her tubes and ovaries were
normal. Her appendix was normal. Her liver edge and kidneys were
normal. Both ureters were identified peristalsing at the beginning
and at the end of the case.
Her postoperative course was relatively unremarkable. A
postoperative hematocrit in the PACU was 32.1 after one unit of
intraoperative packed cells. On postoperative day #1 , her
hematocrit stabilized at 27.7. She was discharged home in good
condition on postoperative day #3. Follow-up will be in 2 weeks with
Dr. Aber
Dictated By: ROBBYN E. WEINGARTNER , M.D. EZ00
Attending: BUENA CHALMERS , M.D. QT74
WL523/4386
Batch: 92003 Index No. CMUFI2N6N D: 2/12/98
T: 2/3/98
Document id: 1105
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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141445265 | PUO | 18125885 | | 7369715 | 2/20/2005 12:00:00 a.m. | Chostochondritis | | DIS | Admission Date: 11/14/2005 Report Status:
Discharge Date: 10/2/2005
****** FINAL DISCHARGE ORDERS ******
LAZARINI , ALEJANDRINA E. 579-93-49-2
Asparks Ln.
Service: MED
DISCHARGE PATIENT ON: 7/7/05 AT 07:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ENALAPRIL MALEATE 5 MG orally twice a day
Override Notice: Override added on 7/18/05 by
WOLFLEY , LUCRETIA S. , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 37841690 )
POTENTIALLY SERIOUS INTERACTION: ENALAPRIL MALEATE &
POTASSIUM CHLORIDE Reason for override: md aware
LASIX ( FUROSEMIDE ) 40 MG orally every day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 25 MCG orally every day
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 21
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
CELEXA ( CITALOPRAM ) 20 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
AVANDIA ( ROSIGLITAZONE ) 4 MG orally every day
NOVOLIN INNOLET 70/30 ( INSULIN 70/30 HUMAN )
0 UNITS subcutaneously every day
Instructions: pleas take as instructed by regular doctor
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician next week ,
ALLERGY: Codeine
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chostochondritis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) CAD ( coronary artery disease ) history of cabg ( history of
cardiac bypass graft surgery ) IDDM
( ) hypercholesterolemia ( elevated cholesterol ) peripheral neuropathy ( )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NOne
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest Pain
ID/Dx: 64M with known CAD history of 4vsl CABG in 2002 ( cath in 2/17 shows
patency of 3/4 grafts ) , CHF with EF 45% , IDDM , Hyperlipidemia , PVDz ,
presents with 1 d hx of CP at rest and worsening nature than
baseline chest pain.
PMH:
-S/p MI and CABG in 3/16 with 4 vsl bypass cath in 2/17 shows patency of
3/4 and good flow thru coronary
tree -CHF with EF 45% in
8/13 -Hyperlipidemia ,
-IDDM -BPH
-PVDz history of L fempop 04 -Hypothyroidism
Hospital Course:
-Ischemia- concern for UA , started on heparin drip ( guaiac neg , 5k
unit bolus , 1k/heart rate drip ) , ruled out by serial enzymes and EKG's , On BB ,
ASA , plavix , statin , acei;Cards eval felt CP atypical and no cath
or Stress-testing required. Pump-ef 45% , euvolemic , restarted on home
lasix.
ENDO:
SSI HYPOTHYROID-restarted levoxyl
PSYCH- cont'd anti-depressants
CODE-FULL
ADDITIONAL COMMENTS: Please return for worsening chest pain or shortness of breath
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please contact your regular doctor for an appointment in 1-2 weeks
No dictated summary
ENTERED BY: BOWARD , SHAINA MURIEL , M.D. ( PB82 ) 7/7/05 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 1106
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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125030691 | PUO | 78741820 | | 8728598 | 8/3/2005 12:00:00 a.m. | VENTRICULAR TACHYCARDIA | Unsigned | DIS | Admission Date: 6/12/2005 Report Status: Unsigned
Discharge Date: 4/4/2005
ATTENDING: BARNABA , CARA CHANCE MD
PRINCIPAL DIAGNOSIS: Ventricular fibrillation.
HISTORY OF PRESENT ILLNESS: Mr. Brash is a 75-year-old man
with ischemic cardiomyopathy with an EF of 15% status post ICD
and biventricular pacer , moderate aortic stenosis who was
admitted on July , 2005 after his ICD fired at home for
ventricular fibrillation. He notes a productive cough , a
subjective fever and nausea and vomiting at home. He was
subsequently seen in Electrophysiology Clinic. He had a low
grade fever of 100.0 at that time. He was electively admitted
but on the way to the floor , his ICD fired again. He was given
lidocaine and after a third firing of his ICD , he was begun on
amiodarone. The patient then became short of breath and was in
pulmonary edema , requiring intubation. Chest x-ray showed a
right upper lobe white out. The patient was taken to Cath for
possible ischemia contributing to his ventricular fibrillation.
He had a proximal 80% LAD lesion and a mid 70% LAD lesion which
were both stented with Seifer stents. He also had a 60% D1
lesion which was angioplastied to a residual 40% lesion. He also
had a 70% left circumflex lesion. After catheterization , the
patient was admitted to the Cardiac Intensive Care Unit. He was
continued on his amiodarone load. He had no further arrhythmias
during his ICU stay. He was extubated the following day and was
diuresed for congestive heart failure. He also began treatment
for both community acquired pneumonia and aspiration pneumonia.
He was transferred out of the Intensive Care Unit on May ,
2005.
PAST MEDICAL HISTORY: Coronary artery disease , EF of 15% , status
post ICD and biventricular pacer , moderate aortic stenosis ,
paroxysmal atrial fibrillation , diabetes , chronic renal
insufficiency with a baseline creatinine of 1.5 , and
hypothyroidism.
HOME MEDICATIONS:
1. Synthroid.
2. Lasix.
3. Coumadin.
4. Lopressor.
5. Lorazepam.
6. Colace.
7. Prilosec.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Upon transfer out of the Intensive Care
Unit , the patient was afebrile with a pulse of 81 , blood pressure
108/74 , oxygen saturation of 84% on room air , and 97% on four
liters. JVP of 14 cm. Lungs with bibasilar rales. Cardiac exam
revealed a regular rate and rhythm. His abdomen was soft with a
pulsatile liver and mild right lower quadrant tenderness with no
rebound or guarding. His extremities had trace pitting edema.
Examination of his skin revealed vesicles at the sternum above
the nipple line with a papular rash extending in a dermatomal
pattern around to the right side of the back to the midline as
well as extension down the inner portion of his upper arm.
LABS: Labs were significant for a creatinine of 2.1 , and a
negative troponin on the day of admission.
IMPRESSION: 75-year-old man with ischemic cardiomyopathy
admitted with ventricular fibrillation of unclear etiology ,
though possibilities include underlying infection or cardiac
ischemia.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: The patient was taken to the Cath Lab and
had stents placed in the LAD with other residual disease
remaining. The patient was continued on a regimen of aspirin ,
Plavix and a statin. The patient often refused to take the
statin , though this was recommended. He was also started on a
low dose of ace inhibitor which the patient frequently refused as
well. We would recommend starting a beta-blocker when the
patient is more stable. The patient continued to be diuresed
with Lasix until he was uvolemic and then resumed his home dose
of Lasix 80 mg daily. An echo during admission showed an EF of
15% with moderate aortic stenosis. For his episodes of
ventricular fibrillation , the patient was begun on an amiodarone
load with a goal of a total of 10 grams at which point he should
be tapered to 40 mg per day. He has one day remaining of his
amiodarone load and should begin the 400 mg per day dose on September , 2005. He was monitored on telemetry without significant
event. The patient should follow up with Dr. Grap in
Electrophysiology Clinic.
2. Infectious Disease: The patient was treated for both
community acquired pneumonia and aspiration pneumonia with
cefotaxime , azithromycin and Flagyl. The patient completed a
5-day course of azithromycin. He is still in the process of
completing a total 10 day course of cephalosporin and Flagyl. He
has one more day of therapy remaining. The patient was also
noted to have shingles. The patient reports experiencing pain
that started on his back before the rash appeared. The rash was
present prior to admission. He was started on acyclovir on May , 2005 and this was stopped on November , 2005 given that there
was likely little utility of treatment begun greater than 48
hours into the course and because the patient preferred not to
take the medication.
3. Renal: The patient has chronic renal insufficiency with a
baseline creatinine of 1.5. Creatinine was initially elevated to
2.1 , but improved back to baseline prior to discharge.
4. Endocrine: The patient has a history of diabetes , but was on
no medications as an outpatient. He received a diabetic diet and
was treated with a regular insulin sliding scale during
admission. Hemoglobin A1c was 6.6 , indicating poor glycemic
control. He was started on a low dose of glipizide and the
regular insulin sliding scale was discontinued. The patient also
has a history of hypothyroidism. TSH was checked and was 1.6 ,
which is within normal limits. The patient was also noted to
have a low calcium level and was found to be vitamin D deficient.
We have started supplementation of vitamin D.
5. Heme: The patient is anticoagulated for atrial fibrillation
and low ejection fraction. The patient's Coumadin was initially
held but then restarted on October , 2005. He is now
therapeutic. Goal INR is 2-3. He will need to be monitored and
Coumadin adjusted as needed. The patient also has iron
deficiency anemia. He will need GI evaluation in the future. He
was begun on iron supplementation , however , the patient
frequently refuses to take this medication.
6. Prophylaxis: The patient is therapeutic on Coumadin.
7. Code status: The patient is full code.
FOLLOW UP INSTRUCTIONS:
1. Blood draw in 2-3 days to monitor INR and creatinine. Please
adjust Coumadin dose for a goal INR of 2-3.
2. Taper amiodarone to 40 mg daily on September , 2005 from the
loading dose of 400 mg three times a day
3. Please encourage the patient to take simvastatin , captopril
and iron supplements. The patient frequently refuses to take
these recommended medications.
4. Last day of antibiotics is March , 2005.
5. The patient will need GI evaluation for his iron deficiency
anemia.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours as needed headache.
2. Amiodarone 400 mg orally three times a day x4 doses.
3. Aspirin 325 mg orally daily.
4. Dulcolax 10 mg orally every day as needed constipation.
5. Vitamin D or calcitriol 0.25 mcg orally daily.
6. Captopril 3 mg orally three times a day
7. Colace 100 mg orally twice a day
8. Iron 325 mg orally daily.
9. Lasix 80 mg orally daily.
10. Glipizide 2.5 mg orally daily.
11. Atrovent inhaler 2 puffs inhaler four times a day as needed wheezing.
12. Synthroid 175 mcg orally daily.
13. Ativan 0.5 mg orally twice a day as needed nausea or anxiety.
14. Flagyl 500 mg orally three times a day x4 doses.
15. Senna tablets 2 tablets orally twice a day as needed constipation.
16. Trazodone 50 mg orally every bedtime as needed insomnia.
17. Coumadin 5 mg orally every afternoon
18. MSIR 7.5 mg orally every 6 hours as needed pain.
19. Simvastatin 20 mg orally every bedtime
20. Ambien 10 mg orally every bedtime as needed insomnia.
21. Plavix 75 mg orally daily.
22. Nexium 20 mg orally daily.
23. Amiodarone 400 mg orally daily , starting on September , 2005.
24. Cefpodoxime 200 mg orally twice a day x2 doses.
25. Reglan 10 mg orally four times a day as needed nausea.
FOLLOW UP APPOINTMENTS:
1. Dr. Grap in Cardiology at Pagham University Of ,
phone number 527-424-0072. Please schedule next available
appointment.
2. Dr. Bernas , primary care physician at LMC . Please
schedule next available appointment.
DIET: House diet , low cholesterol , low saturated fat. Diabetic
2100 calories per day , 2 grams sodium.
eScription document: 7-4530521 MCS
Dictated By: HOPKINSON , BRANDEN
Attending: BARNABA , CARA CHANCE
Dictation ID 5713181
D: 9/13/05
T: 9/13/05
Document id: 1107
| Target |
Ast |
CAD |
CHF |
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PVD |
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| output/system_textual_annotation.xml | textual |
U |
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U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
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281801955 | PUO | 38766817 | | 588038 | 6/5/1996 12:00:00 a.m. | PANCREATITIS | Signed | DIS | Admission Date: 6/5/1996 Report Status: Signed
Discharge Date: 11/6/1996
ADMISSION DIAGNOSES: ABDOMINAL PAIN AND CONSTIPATION.
OTHER DIAGNOSES: 1 ) HYPONATREMIA.
2 ) DIABETES.
3 ) HYPERTENSION.
4 ) RIGHT FOOT CALCANEAL FLAP.
5 ) HEMATURIA.
6 ) NEUROGENIC BLADDER.
HISTORY OF PRESENT ILLNESS: This 52 year old female presented with
a four day history of nausea ,
vomiting , and abdominal discomfort and a one week history of right
scapular pain radiating down bilateral arms , worse on the right.
This was a 52 year old female with severe and poorly controlled
diabetes mellitus and hypertension recently hospitalized for repair
of a diabetic foot ulcer. She was discharged to rehabilitation
postoperatively on Clindamycin and apparently did well at
rehabilitation. She was recently , this past week , discharged home
and four days prior to admission , however , the patient noted the
onset of nausea and vomiting two to three times a day and severe
constipation. There was no blood in her vomit , no sick contacts ,
no bowel movements for the past four or five days , no hematemesis ,
and no fever or chills. She was unable to keep down any orally She
also noted over the past week an increase in her chronic bilateral
arm pain and onset of new right scapular pain. Arm pain and hand
pain had been attributed to carpal tunnel syndrome in the past.
She reported chest pressure but denied shortness of breath ,
diaphoresis , paroxysmal nocturnal dyspnea , orthopnea , and any other
chest pain syndrome. Patient also complained of right upper
quadrant epigastric abdominal tenderness. She had a history of an
open cholecystectomy in 1980. She did not drink alcohol and she
had had no other abdominal surgery. The pain was associated with
nausea and vomiting. She presented to the Emergency Ward and was
found to have a lipase of 529. She was evaluated for acute
pancreatitis. She received hydration in the Emergency Room and was
admitted to the general medical service for work-up.
REVIEW OF SYSTEMS: No sick contacts , anxiety brought out burning
in the chest , no history of diabetic
ketoacidosis , negative for vaginal discharge and diarrhea but
history of chronic constipation , and no history of hepatitis , lung
disease , or peptic ulcer disease.
CURRENT MEDICATIONS: Vasotec 10 mg orally every day , NPH 60 every day before noon and 20
every afternoon , Tegretol as needed for pain , Clindamycin
300 mg orally three times a day , and some opiate the patient had been taking
without a bowel regimen.
ALLERGIES: Augmentin , Keflex , and Percocet.
SOCIAL HISTORY: Married , no smoking , no ethanol , no sexually
transmitted diseases , no recent travel history ,
and no sick contacts.
PAST MEDICAL HISTORY: 1 ) Diabetes. 2 ) Hypertension. 3 ) Carpal
tunnel syndrome. 4 ) Angina. 5 )
Peripheral vascular disease. 6 ) Left lower extremity ulcers. 7 )
Persantine MIBI done in 11/23 showed moderate ischemic anterior
wall.
PHYSICAL EXAMINATION: Temperature was 97.8 , heart rate 84 , blood
pressure 124/66 , respiratory rate 22 on two
liters saturating 98%. HEENT: Benign. NECK: Without thyroid
masses , supple , and no adenopathy. BACK: No costovertebral angle
tenderness and reproducible tenderness over right scapula. PULSES:
2+ throughout. NODES: No cervical , occipital , axillary , or
supraclavicular adenopathy. HEART: S1 , S2 , and no rubs , murmurs ,
or gallops. LUNGS: Bilateral basilar crackles , left greater than
right , otherwise clear to auscultation. ABDOMEN: Slightly
distended , mildly tympanitic , decreased bowel sounds but present ,
mild to moderate abdominal tenderness that was diffuse but
increased on palpation in the epigastric region , no fluid wave , and
no rebound. EXTREMITIES: Right ankle ulcer , dry. RECTAL: Guaiac
negative. NEUROLOGICAL: Nonfocal.
LABORATORY EXAMINATION: Chest x-ray showed mild increase in heart
size and no effusions or infiltrates. KUB
showed no evidence of obstruction and full of stool. EKG showed
normal sinus rhythm at 84 and downsloping ST segments inferiorly
and laterally that were not new. Laboratories showed a sodium of
115 , potassium 4.4 , bicarbonate of 14 , and arterial blood gas
showed pH of 7.48 , pCO2 of 36 , pO2 of 112 , lipase of 529 that on
repeat was 351. Urinalysis showed 3+ budding yeast , 3+ bacteria ,
and white blood cells 5-10.
HOSPITAL COURSE: Patient was admitted to the general medical
service with abdominal pain and hyponatremia.
Abdominal pain was felt to be secondary to longstanding
immobilization and morphine precipitating constipation. Abdominal
CT was negative. Pain improved with aggressive bowel regimen. She
was found to have a neurogenic bladder and developed hematuria due
to Foley trauma. This cleared with irrigation and ofloxacin
treatment times five days was recommended by urology. She had a
follow-up plastic surgery appointment scheduled for the following
day after discharge. Her hyponatremia of 115 resolved with
hydration with normal saline. Patient was discharged with normal
liver function tests and normal amylase and lipase. Serum sodium
had returned to baseline.
DISPOSITION: She is discharged in stable condition.
DISCHARGE MEDICATIONS: Vasotec 10 mg orally every day , NPH insulin 30
units subcutaneously every day before noon , NPH insulin 10
units subcutaneously every afternoon , Cisapride 10 mg orally four times a day , ofloxacin
200 mg orally twice a day times four days , and Colace 100 mg orally twice a day
Dictated By: MOSHE J. SHUGRUE , M.D. UB39
Attending: CHANTELL F. BADALAMENTI , M.D. CH89
QL007/1193
Batch: 48280 Index No. WZOX8E8XC9 D: 6/7/97
T: 8/12/97
Document id: 1108
| Target |
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073178719 | PUO | 99310817 | | 445601 | 2/8/2000 12:00:00 a.m. | ABD PAIN | Signed | DIS | Admission Date: 6/15/2000 Report Status: Signed
Discharge Date: 7/29/2000
HISTORY OF PRESENT ILLNESS: The patient is a 33 year-old woman
with diet controlled diabetes
mellitus , morbid obesity , who presents to the emergency department
with periumbilical pain , radiating to the right lower quadrant. In
her first trip to the emergency department her pain was diffuse and
was thought to be gastroenteritis. After being sent home , she had
an increase in pain and vomiting and was unable to tolerate orally On
her second trip one day later she was vomiting with no fever but
chills and no flatus. The decision was made to take her to the
operating room to explore for appendicitis.
PAST MEDICAL HISTORY: Non Insulin dependent diabetes mellitus ,
diet controlled.
PAST SURGICAL HISTORY: None.
MEDICATION: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient was a morbidly obese woman in
no acute distress. She was tachycardic.
Chest was clear. Abdomen was soft with positive bowel sounds ,
tenderness in the right and left lower quadrant with positive psoas
and Rovsing's sign. Rectal examination showed normal tone and no
stool. Pelvic examination showed no cervical motion tenderness.
LABORATORY: Abdominal CT was obtained which showed 5x5 cm cecal
thickening with extraluminal air. This was thought to be consistent with a
perforated appendicitis or phlegmon. CBC showed a white blood
count 19 , 000. Her urine HCG was negative.
HOSPITAL COURSE: The patient was taken to the operating room on
May , by Dr. Civale , who initially opened the
right lower quadrant to explore for appendicitis. In exploring the
abdomen , purulent material was found in the right lower quadrant ,
and the appendix was not able to be visualized. The decision was
made to open the midline incision which was done. Details of the
operation may be found in Dr. Civale 's operative report. By
report , she had gangrenous portions of the right colon ,
necessitating a right colectomy. This was performed , and she
tolerated the procedure well and was transferred extubated in
stable condition to the floor. Her immediate postoperative course
was complicated by supraventricular tachycardia to a rate of 200
with hypotension , requiring beta blockade and adenosine. She was
transferred to the Surgical ICU for further management. After the
use of beta blockade and adenosine , her arrhythmia resolved. This
was found to occur with magnesium of 1.5 which was repleted. Per
recommendations of the Cardiology Service , an echocardiogram was
obtained which was normal , and she ruled out for myocardial
infarction by serial CKs and electrocardiograms. An NG tube was in
place which was continued on the first postoperative day , and she
was kept on Zantac. She was kept on ampicillin , levofloxacin and
Flagyl. A central line was in place. Over the next few
postoperative days , as her NG tube was removed and her diet slowly
advanced with sips , she was converted to orally medication. At one
point she developed a second episode of supraventricular
tachycardia and was thought to be either atrial fibrillation versus
sinus tachycardia. This did not respond immediately to Lopressor
and per Cardiology's recommendations , she was changed to diltiazem
followed by Diltiazem drip. When stabilized , her dose of Lopressor
was increased , Diltiazem stopped and she was converted to orally
Lopressor 50 three times a day which kept her in sinus rhythm and a stable
rate. By the third and fourth postoperative day , she was
tolerating a regular diet , passing flatus and bowel movements and
ambulating independently. She was weaned off her oxygen and her
central line was discontinued. She was stable for discharge.
The patient was discharged to home on August , 2000. At that time
she will have completed a 5-day course of ampicillin , levofloxacin
and Flagyl. She is tolerating a regular diet , ambulating
dependently and requiring minimal amounts of orally analgesics. She
received wet to dry dressing changes twice a day to her wounds , which
will need to be continued as an outpatient by a visiting nurse.
DISCHARGE MEDICATION: Lopressor 50 mg orally three times a day , Percocet 1-2
tabs orally every 3-4 hours as needed pain , Colace 100
mg twice a day while on Percocet.
FOLLOWUP: The patient is instructed to followup with Dr. Civale
in 1-2 weeks and should call his office for an
appointment.
Dictated By: FRANCISCA A. URBANIAK , M.D. EZ60
Attending: LOVELLA CIVALE , M.D. HF71
SZ503/1605
Batch: 9126 Index No. CKPO8X5DZE D: 5/28
T: 5/28
Document id: 1109
| Target |
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Gou |
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OSA |
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439979649 | PUO | 95273219 | | 9990288 | 8/19/2005 12:00:00 a.m. | Colonic Dysplasia | Signed | DIS | Admission Date: 4/18/2005 Report Status: Signed
Discharge Date: 7/27/2005
ATTENDING: CIVALE , LOVELLA MD
PRIMARY CARE PHYSICIAN: Trang Hien Coda , M.D.
PRINCIPAL DIAGNOSIS: Colonic dysplasia.
LIST OF PROBLEMS/DIAGNOSES:
1. Colonic dysphasia.
2. Hypertension.
3. Hypercholesterolemia.
4. Obesity.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female
who was doing well until approximately 1 year ago when she began
having intermittent bleeding per rectum. She underwent
colonoscopy in July 2005 , which showed a 5 cm superficial
spreading villous polyp involving the cecum and the ileocecal
valve. There were also aphthous erosions seen in the ileum and
the ascending colon , consistent with inflammatory bowel disease.
The patient recently had 20% of the polyp removed.
biopsy. The polyp pathology was low-grade dysplasia consistent
with a villoglandular polyp. The erosions were shown to be
chronic inflammation without evidence of dysplasia. The patient
presents on April , 2005 , to Pagham University Of for
laparoscopic-assisted right colectomy.
PREADMISSION MEDICATIONS: Atenolol , hydrochlorothiazide ,
lisinopril , and Celexa.
SOCIAL HISTORY: The patient denies alcohol or tobacco use.
ALLERGIES: No known drug allergies.
ADMISSION PHYSICAL EXAMINATION: Vital Signs: Temperature 98 ,
blood pressure 118/78 , pulse 54 , and respirations 16. General:
The patient is a pleasant and obese female in no apparent
distress. HEENT: No orally lesions noted. Moist mucous
membranes. Neck: No cervical lymphadenopathy. Supple. Heart:
Regular rate and rhythm. No murmurs , rubs or gallops. Lungs:
Clear to auscultation bilaterally. Abdomen: Obese , nontender ,
positive bowel sounds. Extremities: Warm , 2+ distal pulses , 5/5
strength in all 4 extremities.
OPERATIONS: On April , 2005 , laparoscopic-assisted right
colectomy by Dr. Lovella Civale
HOSPITAL COURSE: The patient underwent laparoscopic-assisted
right colectomy as noted above without complications. By
postoperative day #1 , the patient was tolerating clears , but was
limited in ambulation for the first couple of hospital days. The
patient was continued on clear liquids until hospital day #4 when
she had a bowel movement and she was advanced to house diet. On
hospital day #6 , the patient began to experience some abdominal
pain and nausea and was given some methacholine and Reglan. On
hospital day #8 , the patient had one episode of bilious vomiting and
then passed flatus. These
symptoms were consistent with postoperative ileus; the
patient was placed back on clears and by hospital day #8 , was
passing flatus and ambulating and tolerating orally pain
medication. On hospital day #9 , postoperative day #8 , the
patient and medical staff agreed that discharge was appropriate.
At that time , the patient had no complaints. She was having
regular bowel movements and her abdominal incision was clean , dry
and intact. There were no complications.
Key features of physical examination at discharge as noted above.
The patient's abdomen was soft , nontender , and nondistended.
Incisions were clean , dry and intact with no signs of infection.
Her heart rate was regular rate and rhythm. Her lungs were clear
to auscultation bilaterally.
DISCHARGE MEDICATIONS: Atenolol 50 mg orally every day ,
hydrochlorothiazide 50 mg orally every day , lisinopril 40 mg orally every day ,
oxycodone 5 mg orally every 3 hours as needed pain.
DISPOSITION: Home.
eScription document: 1-3965337 SS
Dictated By: POLIVICK , HERTHA
Attending: CIVALE , LOVELLA
Dictation ID 2105864
D: 10/4/05
T: 10/4/05
Document id: 1110
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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601453381 | PUO | 58735436 | | 5211855 | 9/4/2006 12:00:00 a.m. | LOWER GASTROINTESTINAL BLEED | Unsigned | DIS | Admission Date: 1/6/2006 Report Status: Unsigned
Discharge Date: 5/21/2006
ATTENDING: MCMILLAN , TWILA M.D.
PERSONAL PHYSICIAN: Mariah Semetara , M.D.
PRINCIPAL DIAGNOSIS: Lower gastrointestinal bleed.
SECONDARY DIAGNOSES: Endstage renal disease , hemodialysis.
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with endstage renal
disease , on hemodialysis and prior peptic
ulcer disease , who underwent EGD and colonoscopy four days prior to
arrival for evaluation of guaiac-positive stool. He underwent
polypectomy at that time without complication , but on the day of
admission noted bright red blood per rectum. Additionally he felt weak and
lightheaded and presented to the ED where his initial vital signs showed a
blood pressure 105/48 and heart rate of 60. He subsequently
became hypotensive with a systolic blood pressure in the 70s.
Labs showed a hematocrit of 28 , down from a prior hematocrit of
43 in April . He was given a liter of intravenous fluids with moderate
improvement and was evaluated by the GI Service. GI at that time
felt the source was most likely secondary to the polypectomy
site. He was admitted to the ICU for further monitoring with a
planned colonoscopy the following day.
PAST MEDICAL HISTORY:
1. End-stage renal disease , on hemodialysis with a history of
several failed grafts and shunts , currently using a left lower
extremity shunt.
2. Pelvic ulcer disease , status post partial gastrectomy with a
Billroth I in 1960 and upper GI bleed in 1996.
3. History of a bezoar.
4. Mild mental retardation.
5. Sick sinus syndrome , status post pacemaker.
6. Hepatitis C.
7. Hypertension.
8. Paranoid schizophrenia.
9. Hyperparathyroid status post partial thyroidectomy.
10. Seizure.
11. SVT.
12. Hemodialysis-related hypotension.
13. Anemia with elevated MCV.
OUTPATIENT MEDICATIONS: Aspirin 81 mg daily , Toprol-XL 100 mg
daily , Cardura 4 mg daily , Nephrocaps one orally daily , calcium
carbonate 500 mg three times a day , Renagel 800 mg three times a
day , Procrit 15 , 000 units subcutaneous three times a week with
dialysis , iron sulfate 325 mg a day , Fosamax 70 weekly ,
calcitriol 0.5 mcg at hemodialysis , B12 50 mcg orally daily , folate
1 mg orally daily , Risperdal 1 mg at bedtime , Zyprexa 5 mg at
bedtime , Zoloft 15 mg daily , Colace 100 mg twice a day , Protonix
40 mg daily.
ALLERGIES: No known allergies.
SOCIAL HISTORY: He lives with his cousin Kathyrn Rude who is his
healthcare proxy.
FAMILY HISTORY: Noncontributory.
ADMISSION PHYSICAL EXAM: Afebrile , heart rate 80 , blood pressure
127/64 , O2 saturation 100% on 2 liters , breathing 12 times a
minute , alert and oriented x2 in no acute distress. Neck:
Supple neck with a thyroidectomy scar. Lungs are clear to
auscultation bilaterally. Heart: Regular rate and rhythm
without murmur , rubs or gallops. JVP 9. AV fistula in the
bilateral upper and lower extremities with no thrill or bruit.
Abdomen: Obese , soft , nontender , nondistended , positive bowel
sounds. Neurologic: Slow , responsive , but appropriate , moving
all extremities , ambulatory. Digital rectal examination positive
for blood.
ADMISSION LABORATORY STUDIES: Notable for a potassium of 5.3 ,
BUN of 79 , creatinine of 10.3 , lactic acid 1.5 , WBCs of 5 ,
hematocrit of 28.7 , platelets of 162.
PROCEDURES: Colonoscopy with embolization of the ileocecal
artery on 1/6/2006 , repeat colonoscopy on 10/6/2006.
HOSPITAL COURSE BY PROBLEM:
GI: The patient was admitted to the MICU following presentation
to the emergency room with bright red blood per rectum and a
hematocrit of 28. Over the first couple of days in intensive
care , he received 8 to 9 units of packed red blood cells and On hospital day
#2 , he underwent an embolization of the ileocecal artery with subsequent
improvement in clinical picture. Over the next couple of days , he continued to
have
guaiac-positive and melena stools but with stabilization in his
hematocrit. A repeat colonoscopy was completed on 11/22/2006 ,
which showed a single white ulcer in the colon thought to be the
old polypectomy site but no signs of new or old blood.
Throughout the rest of his hospitalization , his hematocrit
remained stable and he was maintained on PPIs twice a day.
Renal: The patient has end-stage renal disease on
hemodialysis three times a week. This was continued during his
hospitalization. He has had recurrent issues with AV fistula
failure. On admission , he was relying on the left lower
extremity shunt. There was a hardened area proximal to the shunt
found on physical exam and an absence of a thrill at
the site. Per Renal recommendation , this was evaluated
with an AV fistulogram and a subsequent ultrasound. The
ultrasound revealed that there was complex fluid collection
proximal to his AV graft. He was evaluated by Surgery who did
not feel further workup was indicated at this time. The patient
will be discharged to resume his routine renal regimen.
Psych: The patient has a history of schizophrenia and mild
mental retardation. We continued his outpatient psychiatric
medications. There were no acute issues.
Heme: The patient has a chronic anemia with a high MCV. Iron
studies suggest an anemia of chronic disease. He will be
discharged on his preadmission medications of B12 , folate and
iron once a day. His hematocrit has remained in the mid 30s.
Cardiovascular: There were no acute issues during his initial
hospitalization when he was hypotensive secondary to GI bleed.
His home beta-blocker was held. This was restarted prior to
discharge without incident. His Cardura was not restarted and
the patient did not become hypertensive. He will be discharged
without it. Additionally , we are holding his aspirin at
discharge until his followup primary care appointment.
Prophylaxis: pneumoboots; ambulation and
twice-a-day proton pump inhibitor.
FEN: Renal diet.
DISPOSITION: The patient was being discharged home. He was seen
and evaluated by Physical Therapy who felt that this would be a
safe disposition plan.
CODE: He was a full code.
eScription document: 2-5701157 RFFocus
Dictated By: SEMETARA , MARIAH
Attending: MCMILLAN , TWILA
Dictation ID 0265535
D: 4/16/06
T: 4/16/06
Document id: 1111
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
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719243531 | PUO | 24802754 | | 4545606 | 5/4/2004 12:00:00 a.m. | Hypoglycemia | | DIS | Admission Date: 4/25/2004 Report Status:
Discharge Date: 4/13/2004
****** DISCHARGE ORDERS ******
REINE , MAGDALENE 706-24-80-0
Ca
Service: CAR
DISCHARGE PATIENT ON: 10/18/04 AT 03:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LONGAKER , NATISHA AURELIA , M.D. , PH.D.
CODE STATUS:
No defib / No intubation /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 8/14 )
LASIX ( FUROSEMIDE ) 20 MG orally every day
INSULIN NPH HUMAN 4 UNITS subcutaneously every afternoon
INSULIN NPH HUMAN 15 UNITS subcutaneously every day before noon Starting Today ( 8/14 )
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
LISINOPRIL 30 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 4/8/04 by
GOLDFEDER , MAXINE , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: patient takes chronically
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
Alert overridden: Override added on 10/18/04 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override:
patient takes at home
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
HYTRIN ( TERAZOSIN HCL ) 5 MG orally every day
PEPCID ( FAMOTIDINE ) 20 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lolita Shotkoski 8/28/04 11:15 a.m. 8/11/04 scheduled ,
Annalisa Tricoche 6/15/04 10:20 a.m. 6/21/04 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
ROMI , hypoglycemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hypoglycemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) PVD ( peripheral vascular disease ) DM
( diabetes mellitus ) legally blind ( visual
impairment ) htn ( hypertension ) hyperlipidemia ( hyperlipidemia )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
67F with mult CV risk factors presents following hypoglycemic episode
and poss seizure. Found this afternoon by family unresponsive , frothing
at the mouth. FS=30 by EMS and D50 ampule given with increased
responsiveness. Was oriented by PUO ED but suddenly experienced 7-8/10
SSCP with SOB/N/diaphoresis. ST elevations in II , III , aVF , V4-V6 with TWI
I , aVL observed in this context. NTG and morphine led to resolution
of symptoms 1-2/10. EKG normalized with correction of blood sugar and
anti-anginals ( i.e. by time patient reached floor ). Additinally , patient HTN to
sbp 170 and tachy 100-110s: given lopressor 5mg intravenous x2 and 25mg orally. She
also received ASA and 5000U heparin dose with 1000U/heart rate drip. She was
repeatedly hypoglhcemic on the floor , at least once to the 30s.
ROS: endorses chills , diaphoresis , occ non prod cough , chest tightness ,
subjective SOB , increased fatigue , has not had recent sickness ,
dysuria/vomit/diarrhea; chronic 2 pillow orthopnea and c/p on exertion;
RUE tremor at rest intermitttently
PMH: CAD history of stents x 4 , LVEF 35-40% , AICD ( inducible vt ) , PVD history of
fem-tib bypass , DM , CRI , HTN , hyperlipid , glaucoma
MEDS: NKDA ECASA 325 , Terazosin , NPH Insulin 25U qAM 5U qPM , Isordil
20tid , lasix 20 orally , lipitor 20 , lisinopril 30 , lopressor 50 twice a day ,
nephroaps , pepcid
SHx: lives with daughter , estranged from husband , evasive about home
situation , no tob/etoh/illicit drugs
FHx: replete with DM , HD
Admit exam
96.3 148/80@64 100% 2L
NAD
R ptosis , L cataract , R dilated opacified cornea , no reaction to
light; tongue hematoma
no JVD
RRR LLSB systolic murmur 2/6 CTAB with coarse BS at bases
Benign abd
dp2+ , no cce , wwp
CN III-XII intact , 5+ strength , 2+ reflexes ,
LABS: Cr 2.2 LFT/pancrease wnl , CK 415 MB 10.9 TnI LTA; UA slightly
dirty , CXR clear aside from cardiomegaly , EKG--LVH , LAD , ST depressions
which resolved with normoglycemia/anti-anginals
Impression: demand related ischemia 2/2 hypoglycemia
HOSPITAL COURSE:
The patient had no recurrence of chest pain once she arrived on the
floor , or for that matter , SOB/N/V. She initally had difficulty
maintaining her blood sugars and was given another amp of d50 and
orange juice on the floor. After the first 12 hours , her blood sugars
have been consistently over 120. Although she was very enzyme posive
for NSTEMI ( MB 31.2-->32.4-->15.4 today ) , chest pain did not recur. IN
fact , her EKG has been normal since arriving on the floor. Therefore ,
her episode of ischemia was thought to be demand related ischemia in
the context of hypoglycemia. Causes of the hypoglycemia included hypoth
yroidism , adrenal insufficiency , and iatrogenesis. Given the finite
duration of the hypoglycemia , the latter possibility was deemed most
likely ( TSH , a.m. cortisol wnl ). The patient's cardiac enzymes have
peaked ( MB: 31.2-->31.4--> 15.4 ). The patient's home situation has been
previouisly known to be suboptimal--she had a son who may have been
dealing drugs in her home 2 years ago. This time , there was concern
over potential tension betwee her and her estranged husband or
medication errors. Social work was called and spoke with the daughter.
She appears to be appropriately concerned about her mother's health
and open to the idea of placement in an assisted living facility at
some later date. It is clear that an elaborate and effective system has
been worked out to monitor and treat the patient's blood sugars. The
patients visiting nurse service ( Stalbri Rehabilitation Hospital ) was contacted to reemphasize
the importance of evaluating the patient's medication regimen. The
nurse involved in the patient's care also will initiate a request
for a home health aide to visit the patient more frequently. Elder
services was informed to initiate a consult. The social worker at
Whidd Ton Medical Center was also informed of this admission. The
patient's home situation is deemed safe for discharge. She will
follow up with Dr. Grap on November VNA will visit her
tommorrow. The patient's hematocrit dropped slightly the day of dischar
ge. However , the patient was guaiac negative. Parenthetically , the
patient had a slightly dirty UA on admission. She was initially treated
but given her lack of symptoms , this was discontinued.
ADDITIONAL COMMENTS: Your insulin dosage has been decreased because your blood sugar was too
low. Your visiting nurse should check your blood sugars and call your
physician if they are consistently above 150. Your dose of lipitor has
been increased because your LDL on this admission was 92.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: GOLDFEDER , MAXINE , M.D. , PH.D. ( OA25 ) 10/18/04 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1112
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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344200926 | PUO | 90744314 | | 0407863 | 3/7/2006 12:00:00 a.m. | CAD | | DIS | Admission Date: 9/18/2006 Report Status:
Discharge Date: 10/27/2006
****** FINAL DISCHARGE ORDERS ******
SCHUERMAN , ANNETTA K 262-15-64-2
Po Raa Cou , New Jersey 16222
Service: CAR
DISCHARGE PATIENT ON: 1/24/06 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRAP , RONA J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
COREG ( CARVEDILOL ) 25 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 124
CLINDAMYCIN HCL 300 MG orally four times a day X 28 doses
Starting after intravenous ANTIBIOTICS END
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
INSULIN NPH HUMAN 36 UNITS subcutaneously every day before noon and every afternoon
Starting IN a.m. ( 7/5 )
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 40 MG orally DAILY
LORAZEPAM 0.5 MG orally three times a day as needed Anxiety
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Activity as allowed by instruction from EP
FOLLOW UP APPOINTMENT( S ):
EP Clinic in P Therford Hospital 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Ischemic Cardiomyopathy , RV lead damage.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD Ischemic Cardiomyopathy history of BIVentricular pacemaker/AICD.
Chronic renal insufficiency Diabetes Mellitus - txed with Insulin
Peripheral neuropathy. CVA 2/10
OPERATIONS AND PROCEDURES:
Lead extraction and pacemaker exchange.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: ICD lead extraction
******************************
HPI: 75M with history of ischemic cardiomyopathy ( EF25% ) , CAD history of
multiple PCI , VF arrest history of AICD placement , hypertension ,
hypercholesterolemia who presented with ICD lead malfunction found on
rountine device interrogation on 8/10 Patient is completely
asymptomatic. Baseline ADLs and ambulates without assist. No
symptoms associated with lead malfunction. Some baseline DOE. No
orthopnea , no PND.
**********************************
PMH: As above , CVA 4/6 c residual verbal defects ( word finding ) , IDDM ,
Colon ca history of resection ( remote ). Initial pacer implanted 11/3 after MI ,
upgraded to Bi-V AICD for sxs of CHF in 5/9 , Atrial lead
malfunction in 9/21 was replaced.
**********************************
Home Medications:
1. Coreg 25 twice a day
2. Plavix 75 every day
3. Lipitor 40 every day
4. Lisinopril 40qd
5. Lasix 40 twice a day
6. Imdur 30qd
7.NPH 36 twice a day
8.ASA 325qd
9. Lorazepam 0.5 three times a day as needed
**********************************
ALL:PCN
**********************************
SHx: lives c wife in Tole More , daughter assists with transportation etc.
Remote history ETOH abuse - quit 18 years ago. No tobbacco.
********************
Discharge Physical Exam
VS: T: 98 HR: 60-70 ( paced ) BP: 110-140s/60-70 RR: 18 SaO2: 95% RA
Neck: JVP ~8cm
Cardiac: RRR , no murmurs
Lungs: CTAB - some DOE.
Extremities: WWP , no edema. Pressure dressing @ L shoulder.
********************
DATA:
EKG - narrow complex c pacing spike rate 60s
********************
STATUS:
2/4 - admitted
7/5 - in EP lab for lead extraction.
4/21 - Small hematoma @ PPM pocket site. Held for one additional day for
observation
********************
HOSPITAL COURSE: Assessment - 75M c multiple cardiac risk factors
inc ischemic CMP who p/with right ventricular ICD lead dysfunction.
1. Cardiac:
Ischemia: no acute issues at this time , no symptoms , EKG wnl , cont
current regimen of ASA , plavix , coreg , imdur. One dose of plavix held
secondary to hematoma.
Pump: BP stable , cont lisinopril , lasix , imdur , coreg
Rhythm - paced in 60s , not pacer dependent , went for extraction and
replacement of old atrial lead and malfunctioning RV lead - complicated
by small hematoma at pacemaker pocket. Pacemaker generator exchanged.
Maintained on telemetry throughout with no issues.
2. HEME: HCT fairly stable throughout hospital course - 43 at time of
admission , 38 at time of discharge. WBC remained normal throughout
3. RENAL: Baseline renal dysfunction with Cr @ admission = 1.3 - down as
low as 1.2 - 1.4 @ time of discharge. Received Mucomyst peri-procedure
for prophylaxis of contrast induced nephropathy.
4. PULM: O2 sat stable. Patient reports some baseline DOE. No evidence
of pneumothorax on CXR.
5. ENDO: Maintained on NPH 36 units twice a day. Some issues with hypoglycemia
while NPO ( lowest sugar 53 - resolved with 1 amp D50 ). While eating -
range in the low 100s.
6. GI/FEN: Maintained on cardiac , diabetic diet with 2 gm sodium
restriction and 2L fluid restriction with repletion of K ( orally ) and Mg ( intravenous )
to >4 and >2 respectively.
ADDITIONAL COMMENTS: 1. If you begin to develop pain , redness , discharge at the site of your
pacemaker pocket , or fever >101 you should contact your physician.
2. Wound Care: Follow all instructions provided to you by EP. You may take
that gauze off of your left shoulder wound the day after discharge but
leave the steristrips in place.
3. Continue taking your usual medications. We have not changed any of
your original medications during this admission. You will need to take an
additional 7 days of clindamycin 300 mg four times a day x 7days.
4. If you develop chest pain/pressure , lightheadedness , SOB , nausea or
vomiting , you should contact your physician.
5. Follow up with your doctor in Tl Ertsa Hi in 1-2 weeks to check your
wound and your creatinine ( a test of kidney function ).
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Cardiologist in Po
No dictated summary
ENTERED BY: POK , LIZETTE W. , M.D. ( LV48 ) 1/24/06 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1113
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
U |
N |
U |
U |
U |
N |
U |
Y |
U |
U |
N |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
- |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
N |
- |
750395034 | PUO | 51756156 | | 5614830 | 1/21/2006 12:00:00 a.m. | Change in mental status | | DIS | Admission Date: 3/26/2006 Report Status:
Discharge Date: 5/26/2006
****** FINAL DISCHARGE ORDERS ******
GARSIA , JOSLYN 333-28-47-7
Scond
Service: MED
DISCHARGE PATIENT ON: 10/28/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PIDRO , KUM ANDREW , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
VITAMIN C ( ASCORBIC ACID ) 500 MG orally twice a day
CIPROFLOXACIN 400 MG orally every 12 hours Starting Today ( 11/17 )
Instructions: Please take until 7/21/06.
Number of Doses Required ( approximate ): 2
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
LACTULOSE 30 MILLILITERS orally four times a day Starting Today ( 11/17 )
Instructions: please do not skip doses even if many loose
stools.
FLAGYL ( METRONIDAZOLE ) 500 MG orally every 8 hours
Starting Today ( 11/17 )
Instructions: Stop taking on 7/21/06.
ALDACTONE ( SPIRONOLACTONE ) 75 MG orally twice a day
Food/Drug Interaction Instruction Give with meals
Override Notice: Override added on 3/12/06 by
GIRARDI , ABE E. , M.D.
on order for KCL intravenous ( ref # 144875285 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: monitoring
THIAMINE HCL 100 MG orally DAILY
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
MSIR ( MORPHINE IMMEDIATE RELEASE ) 7.5 MG orally every 4 hours as needed Pain
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
CELEXA ( CITALOPRAM ) 20 MG orally DAILY
CELECOXIB 100 MG orally DAILY Starting Today ( 11/17 )
as needed Pain
Instructions: Please do not increasing dosing to twice a day ,
given risk of cardiac side effects.
Food/Drug Interaction Instruction Take with food
KEPPRA ( LEVETIRACETAM ) 1 , 000 MG orally twice a day
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
1 TAB orally twice a day
LIDODERM 5% PATCH ( LIDOCAINE 5% PATCH ) TOPICAL TP DAILY
Starting Today ( 11/17 )
Instructions: one to lumbar area. apply for 12 heart rate and
remove for 12 heart rate
NOVOLOG ( INSULIN ASPART )
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
VITAMIN K ( PHYTONADIONE ) 5 MG orally DAILY
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
50 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
MAGNESIUM OXIDE 420 MG orally twice a day
DIET: House / 2 gm Na / low protein (I) (FDI)
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Pidro rheumatology - arthritis center 123-112-2058 10/25 @ 12:30 pm scheduled ,
Dr Sodachanh SSR 3/17 @ 2:30 scheduled ,
Dr. Ivaska - please call for appointment Next available ,
ALLERGY: HALOPERIDOL , LORAZEPAM
ADMIT DIAGNOSIS:
Change in mental status
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Change in mental status
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of gi bleed ( history of upper GI bleeding ) EtOH abuse ( alcohol abuse )
coagulopathy
cirrhosis , hepatic encephalopathy COPD ( chronic obstructive pulmonary
disease ) fracture of left hand - 2nd/3rd metacarpals , 4th/5th proximal
phalanges
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Chest x-ray , head CT , right upper quadrant ultrasound , right lower
extremity ultrasound.
BRIEF RESUME OF HOSPITAL COURSE:
CC: Change in mental status
-----
HPI: 57 year-old F with complex PMH including squamous
cell lung cancer history of RML lobectomy 9/22 Has history of cirrhosis and
hepatic encephalopathy. Came to ED obtunded ( no spontaneous conversation )
with decreased BP. Reportedly received all of her medications as
prescribed in morning at her nursing home. In ED , received thiamine and
narcan. Became more responsive and uncomfortable after narcan. Ammonia
level elevated at 233.
-----
PMH:
++Lung cancer - squamous cell , history of RML lobectomy and RUL wedge resection
++Cirrhosis - alcoholic and hep C virus , history of esophageal varices and GI
bleed.
++COPD - not on home oxygen
++HTN
++PVD
++Seizure disorder - on Keppra
++history of SDH - had craniotomy
++large abdominal ventral hernia
++chronic back pain - known spinal compression fractures at T8 and
bilateral sacral insufficiency fractures
-----
SHx: Nursing home resident for past 2 years. 30 pack-year smoking
history. Significant EtOH history. Has 2 daughters involved in her care.
-----
FHx: Mother COPD , Father prostate cancer / CAD.
-----
Admit PE: T 96.5 P 64 BP 98/53 RR 14 SaO2 93%RA 97%3L
Gen - Awakens briefly when spoken to. Able to respond only with single
words to simple questions. Appears sedated.
HEENT - PERRL , scleral icterus
NECK - No LAN , no bruits , JVP flat.
CHEST - Bilateral expiratory wheezes.
HEART - RRR , nl S1/S2 , no m/r/g.
ABD - Full-appearing , large ventral hernia , multiple scars , soft ,
non-tender , +BS , no masses , no HSM.
EXT - 1+ edema bilaterally ( R>L ).
SKIN - jaundiced , palmar erythema , bruises spread diffusely.
RECTAL - Guaiac pos , light brown soft stool.
NEURO - Oriented to place and person. Year is "1993". Drifting in and out
of ability to communicate. Perseverates on answers to questions: this is
a "hospital , hospital , hospital" , CN II through XII intact , DTR's 2+
symmetric in LE + UE , toes downgoing bilaterally
-----
Studies:
+CXR 8/19 - no acute cardiopulmonary process
+Head CT 8/19 - negative
+RUQ US 8/19 - gallstones , biliary sludge
+RLE LENI 8/19 - neg for DVT
-----
Hospital Course:
57 year-old F with complex medical history here with mental status
change likely secondary to hepatic encephalopathy with some component of
medication-induced delirium ( from opiates ).
++Mental Status - Avoided increasing narcotics. Given lactulose four times a day.
Mental status improved significantly in first 24 hours of
hospitalization. Patient then remained at her baseline mental status for
rest of hospital stay.
++MSK - Patient has history of chronic low back pain that is
likely related to bilateral sacral insufficiency fractures seen on MRI on
6/5/06. We avoided increasing her narcotic dose for concern of her
altered mental status. Pain was controlled effectively with MSIR as needed ,
celecoxib daily as needed ( should not increase to twice a day given ? increase risk of
cardiac side effects ) , and a lidoderm patch over her lower back. Other
NSAIDS were avoided given history of GI bleed. Patient is scheduled to f/u with
Dr. Pidro ( Rheumatology ) for management of her back pain and
consideration of sacroplasty. Patient should be seen by physical therapy at her nursing
home to help her with her walking.
++GI/ID - Had low-grade fevers overnight on HD 1 and 2. Patient had mild
RUQ tenderness which raised a question of possible GI / biliary source of
infection. Blood cultures were positive for coag negative staph in 2/4
bottles. She was treated with Ciprofloxacin and
Metronidazol starting on HD 1 , and vancomycin until speciation of blood
cultures. Blood cultures repeated on 11/18 and 7/27
were negative to date. Coag neg staph blood cultures were thought to be
due to contamination. Patient has remained afebrile and abdominal
tenderness has resolved over hospital stay. Vancomycin was discontinued
on HD 3 and Cipro and Flagyl were continued. She was discharged with
instructions to complete a 14-day course of Cipro and Flagyl. Her WBC
count and platelets decreased gradually throughout her hospital stay and
were 3.88 and 122 respectively. A CBC should be checked on Monday 6/25 to
make sure that she is not becoming neutropenic or thrombocytopenic.
++Pulm - The possibility of PE was considered given lower extremity
swelling and her change in mental status. Given that she was at her
baseline oxygen requirement and had negative LENIs , PE was thought to be
low probability. She remained at her baseline oxygen saturation ( 93-98%
on room air ) for the duration of her hospitalization. Given flovent for
known COPD.
++CV - EKG at admission was unchanged from previous EKGs. Patient's dose
of Lopressor was decreased , given her low BP at time of admission. Her
heart rate and blood pressure remained in the normal range throughout her
admission.
++Endo: MRI read from 3/8/06 showed evidence of osteoporosis. Started
caltrate , vit D. Unable to give fosamax because of history of esophageal
varices. Giving zometa x 1. Corrected calcium was normal. Will need to
re-check calcium in 1 week.
++FEN - Given thiamine , folate , fluids , Is/Os , weights.
++PPX - Lovenox , nexium , aspiration precautions.
ADDITIONAL COMMENTS: You are being discharged from the hospital to your nursing home in
Tamp Wispolan Beth with a few changes in your medications. We have changed your pain
medication to MSIR every 4 hours as needed , celebrex , and lidoderm patch.
Please call your doctor if you are feeling that your thinking is not
clear or if you start to have fevers. And please return to the emergency
department if you are having increased abdominal pain , chest pain ,
difficulty breathing , or other concerning symptoms. You should have your
blood counts checked on Monday and your calcium checked next week.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr. Ivaska at next available appointment. Please call Dr.
Olazabal office to schedule. Follow up with Dr. Sodachanh and Dr. Pidro
as scheduled. Patient should be seen by physical therapy at her nursing
home. Patient should have a CBC drawn on Monday 6/25 to check her white
count and platements , which were trending down slowly throughout her
admission and recheck calcium ( corrected for albumin ) in one week.
No dictated summary
ENTERED BY: GIRARDI , ABE E. , M.D. ( ZL18 ) 10/28/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 1114
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
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- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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744712106 | PUO | 93437527 | | 082856 | 1/29/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/9/1992 Report Status: Signed
Discharge Date: 3/28/1992
DIAGNOSIS: LEFT URETERAL STRICTURE.
OPERATIONS/PROCEDURES: FLEXIBLE CYSTOSCOPY , LEFT EXTERNAL
URETERAL STENT PLACEMENT , REPAIR OF
LEFT DISTAL URETERAL STRICTURE
( BOARI FLAP ) BY DR. RUNYONS , ERMA SHERILL
ON 9 of September INTERNALIZATION OF LEFT
STENT BY DR. RUNYONS , ERMA SHERILL ON
12 of November
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old female
who underwent a left ureteral
lithotomy in 1985. She subsequently developed a left ureteral
stricture at the pelvic brim , which was balloon dilated in 18 of November
The patient received 2-1/2 years of relief , but the presented with
left flank pain and left hydronephrosis in 23 of September She had relief
with a left percutaneous nephrostomy , and later another balloon
dilatation. She had a third balloon dilatation in 7 of March , and this
was of a 4-centimeter segment. A stent was left in place. The
stent presently is within the ureter. The patient now presents for
the above-mentioned procedure. PAST MEDICAL HISTORY was as above.
PAST SURGICAL HISTORY was as above , plus thyroid cyst excision ,
liposuction of bilateral lower extremities , cholecystectomy ,
appendectomy , vein stripping , carpal tunnel release bilaterally ,
and tubal ligation. MEDICATIONS ON ADMISSION were Levothyroxine
0.025 milligrams 2 tablets per day , Motrin as needed , Tylenol as
needed , Percocet as needed. ALLERGIES included penicillin which
caused a rash.
PHYSICAL EXAMINATION: The patient was an obese female in no acute
distress. Head , eyes , ears , nose and throat
examination was clear. Neck was supple without lymphadenopathy.
Back has no costovertebral angle tenderness. Lungs were clear.
Heart had regular rate and rhythm. Abdomen was obese , soft ,
nondistended , nontender , good bowel sounds , multiple surgical scars
along the abdomen which were well-healed. Rectal examination
showed increased tone , tender secondary to hemorrhoid. Neurologic
examination was grossly nonfocal.
LABORATORY EXAMINATION: On admission , hematocrit was 29.7 ,
prothrombin time 11.8 , partial
thromboplastin time 21.2.
HOSPITAL COURSE: The patient was admitted on 25 of June , for a
procedure on 9 of September She underwent the
above-mentioned procedure without difficulty. The patient did lose
1 liter of blood , however , and received 2 units of autologous
packed red blood cells as well as 4 , 000 cc of lactated Ringer's and
2 , 000 cc of Hespan and 500 cc of albumin. In the operating room ,
they found the left distal ureteral stricture , approximately 8
centimeters with a small stone cluster. The patient left the
operating room in stable condition with a Foley to gravity , a
7-French single pigtail external ureteral stent , as well as a
Jackson-Pratt drain to suction. Postoperatively , the patient did
well. She did have a low hematocrit in the immediate postoperative
period requiring 2 units of blood. Her level was 21.9. Otherwise ,
electrolytes were stable and the patient was doing well. The
patient was taken to the ward for the remainder of her
postoperative care. We kept her on intravenous antibiotics and
nothing-per-orally until she passed flatus , at which point she was
able to tolerate a diet. Because of the duration of surgery , as
well as her large size , pulmonary toilet was encouraged with the
patient. On postoperative day #3 , the patient persisted with a
fever of unknown origin , again thought to be respiratory as
mentioned above. Cultures were taken and she remained on
antibiotics. Stentogram was done on postoperative day #10. This
showed extravasation of fluid distally in the ureter. Cystogram
showed no bladder extravasation. With that in mind , the Foley was
taken out and the stent was left in place. It was anticipated that
she would be taken back another time for stent removal. The
patient was discharged on 15 of May The external stent had actually
been switched over to an internal stent at the time of discharge.
DISPOSITION: The patient was discharged to home. CONDITION ON
DISCHARGE was stable. The patient was to FOLLOW-UP
with Dr. Yahaira M. Mcmillian , and will call the genitourinary staff
or come to the emergency room for fevers , chills , nausea , vomiting
or other questions or concerns. MEDICATIONS ON DISCHARGE were
Percocet and Keflex.
YZ063/4386
YAHAIRA M. MCMILLIAN , M.D. EX72 D: 5/11/92
Batch: 8996 Report: S6660I1 T: 5/25/92
Dictated By: KATHLINE WEAGRAFF , M.D.
Document id: 1115
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
U |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
- |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
946845360 | PUO | 39737797 | | 4814338 | 10/29/2007 12:00:00 a.m. | history of cath , GI Bleed | | DIS | Admission Date: 10/28/2007 Report Status:
Discharge Date: 2/9/2007
****** FINAL DISCHARGE ORDERS ******
KAHRER , LORNA T 276-31-99-6
Le Arvville
Service: CAR
DISCHARGE PATIENT ON: 4/29/07 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MEDUNA , DORIS LENNA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
GOLYTELY 4 , 000 MILLILITERS orally x1
Ingredients contain 76 MEQ KCL x1
Starting IN a.m. ON 1/10/06 ( 10/18 )
Alert overridden: Override added on 4/29/07 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
ECASA 325 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
Starting Today ( 10/18 )
CLOPIDOGREL 75 MG orally DAILY Starting IN a.m. ( 8/4 )
ARICEPT ( DONEPEZIL HCL ) 10 MG orally DAILY
Number of Doses Required ( approximate ): 10
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
GLYBURIDE/METFORMIN 5/500 MG orally twice a day
Alert overridden: Override added on 4/29/07 by :
on order for GLYBURIDE/METFORMIN orally ( ref # 979667066 )
patient has a DEFINITE allergy to GLYBURIDE; reaction is GI
UPSET. Reason for override: takes at home
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 2
LISINOPRIL 40 MG orally DAILY
Override Notice: Override added on 9/5/07 by
BILDER , DORIA J. , P.A.
on order for GOLYTELY orally ( ref # 716872541 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: MD request
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
150 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 3 doses
as needed Chest Pain
Alert overridden: Override added on 4/29/07 by :
on order for NITROGLYCERIN 1/150 ( 0.4 MG ) sublingual ( ref #
600053061 )
patient has a PROBABLE allergy to ISOSORBIDE; reaction is HA.
Reason for override: as needed for angina
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
ACTOS ( PIOGLITAZONE ) 30 MG orally DAILY
Starting Today ( 10/18 ) Food/Drug Interaction Instruction
May be taken without regard to meals
QUININE SULFATE 260 MG orally BEDTIME
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 7/9/07 by
MELVIN , RAINA T , MD
on order for QUININE SULFATE orally ( ref # 254441073 )
patient has a DEFINITE allergy to QUININE; reaction is NAUSEA.
Reason for override: on medication at home
FLOMAX ( TAMSULOSIN ) 0.4 MG orally DAILY
Alert overridden: Override added on 7/9/07 by
MELVIN , RAINA T , MD
on order for FLOMAX orally ( ref # 987915897 )
patient has a POSSIBLE allergy to GLYBURIDE; reaction is GI
UPSET. Reason for override: already on this
SPIRIVA ( TIOTROPIUM ) 18 MCG inhaled DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: light activity , no heavy lifting or driving x 2 days. ok to shower , no swimming or bathing x 5 days
Lift restrictions: Do not lift greater then 10-15 pounds
FOLLOW UP APPOINTMENT( S ):
Dr Treva Lipsett next week ,
Dr Timmy Harajly 1-2 weeks ,
Gastrenterology monday 4/7 , 7:30a ,
ALLERGY: ISOSORBIDE , NIFEDIPINE , Penicillins , NITROPATCH ,
QUININE , AMITRIPTYLINE , VERAPAMIL , BUPROPION , GLYBURIDE ,
FLUOXETINE HCL
ADMIT DIAGNOSIS:
CAD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of cath , GI Bleed
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn , history of cva , dyslipidemia , smoking , cad , anemia , occult GIB
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of LAD angioplasty and stenting
history of EGD
history of Echo
BRIEF RESUME OF HOSPITAL COURSE:
72 year-old M with tob history , htn , hyperlipidemia ,
severe PAD who presented to TH with unstable angina in the setting
of HCT 25 ( presumably from GIB ). Tx to PUO for cath which revealed
severe PAD and L dom coronary system with distal Cx dz and
prox LAD stenosis ( 80% ). This was PCI/stented with BMS with good
angiographic results. ASA/Plavix ( at least 30 days ). patient to also get
GI consult while in house for
?colonoscopy/EGD. 1/24/07
patient denies CP , SOB or diaphoresis. He is ambulating and voiding
without difficulty. patient underwent EGD today that showed no sign of
disease or bleeding. He will undergo colonoscopy tomorrow for further
evaluation. NPO after midnight.
4/2
Patient was not adequately prepped for colonoscopy so not able to be
performed. echo done. patient has had no further chest pain. hct is stable
at 32 since transfusion on 5/3 at osri medical center . plan d/c this
am given unable to have colonoscopy now- will be scheduled for outpt
colonoscopy prior to discharge.
ADDITIONAL COMMENTS: -you must take aspirin indefinitely
-you must take plavix for the stent in your heart for 1 month
-stop verapamil and take lisinopril and toprol xl for you blood pressure
-continue your other medications at their usual doses
-you have an appointment for a colonoscopy at Pagham University Of at
8am on monday 10/3 you must arrive at the GI suite at San , West Virginia 03591 by
7:30a
-you will need to be on a clear liquid diet all weekend and start
go-lytely on sunday morning- you need to drink all of the go lytley- 4
liters in total. you can drink clear liquids as well until midnight then
no food after midnight.
-see Dr Durepo early next week and bring all your medications with you so
you can review the changes with her
- you had an endoscopy while at Kernan To Dautedi University Of Of which did not show anything.
-if you develop weakness , dizziness , lighheadedness , or see blood when
you move you bowels please go to the emergency room immediately
-you need to stop smoking
-call with questions or concerns
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STAHLHUT , DALIA K. , PA-C ( RV67 ) 4/29/07 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 1116
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
N |
N |
N |
N |
Y |
- |
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N |
972470178 | PUO | 65505285 | | 425290 | 11/20/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/9/1993 Report Status: Signed
Discharge Date: 2/19/1993
DISCHARGE DIAGNOSIS: 1 ) PAROXYSMAL ATRIAL FIBRILLATION.
2 ) DIABETES MELLITUS.
3 ) HYPERTENSION.
HISTORY OF PRESENT ILLNESS: This is a 72 year old female with a
history of paroxysmal atrial
fibrillation who has been intolerant of Quinidine and Procainamide
and is admitted for initiation of Disopyramide and Digoxin
treatment. Patient has a history of Insulin dependent diabetes
mellitus , hypertension , and many years of paroxysmal atrial
fibrillation/flutter. In September 1992 , the patient began having
prolonged , that is up to thirty to sixty minute , sensations of
chest pounding without chest pain , shortness of breath , or light
headedness. A Holter showed atrial premature beats , ventricular
premature beats , and supraventricular tachycardia. She began
having daily sensations and saw her primary physician , Dr.
Gignac , who performed an EKG which showed atrial flutter with an
atrial rate of 300 and ventricular rate of approximately 85. She
had been treated on Diltiazem which was changed to Verapamil with
discontinuation of her palpitations. On 11/12/92 , she had an echo
which showed an ejection fraction of 67% , left atrium of 4 cm , and
normal left ventricular size and thickness. The sensation of
palpitations resumed , however , and she was admitted to Pagham University Of on April , 1993 to begin Quinidine treatment.
She started Quinidine without complications , however ,
post-discharge , developed headache , diarrhea , nausea , and fever to
102 on February , 1993. Therefore , she was readmitted on August , 1993 for Procainamide load and was discharged on a dose of 500
mg orally every 6 hours However , ten days after that , she developed
arthralgias in her left and right shoulders and right elbow and
wrist. Procainamide was discontinued one week prior to this
admission. She denies any rash , pleuritic chest pain , nausea ,
vomiting , diarrhea , constipation , fever , dysuria , orthopnea ,
peripheral edema , claudication , or shortness of breath. She is now
admitted for Disopyramide and Digoxin initiation and therapy. PAST
MEDICAL HISTORY: 1 ) History of deep venous thromboses treated
with Heparin and Coumadin. The last episode was twelve years ago.
2 ) History of motor vehicle accident in 1975. 3 ) History of
exploratory laparotomy at age fourteen secondary to "incarcerated
colon" secondary to trauma. 4 ) Status post appendectomy. 5 )
Diabetes times twenty years , Insulin dependent times three years.
6 ) Hypertension. ALLERGIES: No known drug allergies. CURRENT
MEDICATIONS: Insulin Humulin 70/30 48 units subcutaneously every day before noon
and 22 units subcutaneously every afternoon , Verapamil SR 240 mg orally every day ,
and Procainamide discontinued one week ago. SOCIAL HISTORY: She
is a home tutor , she is a retired teacher , lives at home with her
husband , she has seven children and thirteen grandchildren , no
tobacco , and no ethanol use. FAMILY HISTORY: Father deceased at
age 46 with Streptococcus viridans infection and mother deceased at
an early age of pneumonia. She has a brother deceased from
alcoholism and a sister deceased from unknown causes.
PHYSICAL EXAMINATION: Temperature was 98.8 , heart rate was 87 ,
blood pressure 150/80 , respirations 18 , and
she was 81.8 kg. This was a well-developed , well-nourished
pleasant female in no acute distress. HEENT: Examination showed
pupils equal , round , and reactive to light , oropharynx clear , no
lymphadenopathy , and 2+ carotids bilaterally with no bruits.
CARDIAC: Examination showed a regular rate and rhythm , distant S1
and S2 , no murmurs , gallops , or rubs , and no jugular venous
distention. LUNGS: Clear to auscultation bilaterally. ABDOMEN:
Well healed scar , positive bowel sounds , soft , non-tender , and no
masses. EXTREMITIES: No cyanosis , clubbing , or edema , 2+
bilateral dorsalis pedis , 2+ femorals bilaterally , and no femoral
bruits. NEUROLOGICAL: Examination showed her to be alert and
oriented times three , cranial nerves II-XII intact , and light
touch , joint position sense , and vibratory sense intact.
Coordination showed finger-to-nose and fine finger movements
intact , deep tendon reflexes were 1+ throughout , no patellar or
ankle reflexes , and equivocal plantar reflexes. Muscle strength
was 5/5.
LABORATORY EXAMINATION: Sodium was 138 , potassium 4.2 , BUN 16 ,
creatinine 0.9 , and glucose 222. White
blood count was 6.8 , hematocrit was 39 with an MCV of 84.1 , RDW of
12.3 , and platelets 224 , 000. Liver function tests were normal ,
cholesterol was 119 , triglycerides 167 , physical therapy was 11.4 , phosphate was
3.5 , and calcium was 9.2. Urinalysis showed trace glucose and 0-1
white blood cells. EKG showed a normal sinus rhythm at 75 ,
intervals 0.21/0.13/0.428 , QTC was 0.477 with left bundle-branch
block , and left axis deviation.
HOSPITAL COURSE: The patient was admitted to the Cardiology T Pidspit Me Team
and begun on Disopyramide at a dose of 300 mg SR
orally twice a day , the Verapamil was discontinued , and she was loaded
with Digoxin orally and then continued on a maintenance dose of
0.125 mg every day The patient experienced frequent episodes of
paroxysmal atrial flutter/atrial fibrillation and the Disopyramide
dose was increased to 200 mg of immediate release every 6 hours orally
However , she continued to have five to ten minute runs of atrial
fibrillation which were symptomatic with sensation of palpitations
and anxiety. She was begun on intravenous Heparin. Because of urinary
retention on disopyramide , the disopyramide was discontinued , and
she was begun on Propafenone at 150 mg orally every 8 hours After discontinuation of the
Disopyramide , her QTC came down to 0.5 and after Propafenone initiation , she
was also started back on Verapamil 80 mg orally every 8 hours and the Digoxin was
discontinued. She experienced no further episodes of atrial
fibrillation/flutter prior to discharge. Therefore , her Heparin was
discontinued. Her QT was 0.4 and QRS 0.12 on discharge.
DISPOSITION: She is to call Dr. Hamblet for a follow-up appointment.
She is discharged on Humulin 70/30 40 units every day before noon
and 22 units every afternoon , Propafenone 150 mg every 8 hours , and Verapamil SR 250
mg orally every day
Dictated By: AHMED M. TOLLEFSON , M.D. BV18
Attending: BRITTANEY N. HAMBLET , M.D. XJ2
SD321/9795
Batch: 1152 Index No. RYTTMB14QC D: 1/13/93
T: 3/1/93
Document id: 1117
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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449325050 | PUO | 44544705 | | 2409101 | 1/12/2005 12:00:00 a.m. | Heart Failure; Pneumonia | | DIS | Admission Date: 6/12/2005 Report Status:
Discharge Date: 10/22/2005
****** FINAL DISCHARGE ORDERS ******
LABRE , MANUELA 542-30-17-1
Derminkvieve Hwy , Cou , Arkansas 66899
Service: CAR
DISCHARGE PATIENT ON: 5/24/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MECKLEY , STAN J. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
DIGOXIN 0.125 MG orally every day
ENALAPRIL MALEATE 20 MG orally every day HOLD IF: sbp<90; heart rate<50
LASIX ( FUROSEMIDE ) 80 MG orally every day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
GABAPENTIN 100 MG orally three times a day
LEVOFLOXACIN 500 MG orally every 24 hours X 5 doses
Starting Today ( 11/24 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
LANTUS ( INSULIN GLARGINE ) 22 UNITS subcutaneously every bedtime
Starting Today ( 7/28 )
NOVOLOG ( INSULIN ASPART ) 5 UNITS subcutaneously before meals
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: *******NEEDS FOLLOW UP AT COUMADIN
CLINIC******* ( Ny Billnor Hospital )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 5/21/05 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: ok
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
REIDER DA OF MEDICAL CENTER , please call to schedule ,
LMC primary care physician , Dr. Julieann Geeding , please call to schedule ,
Talc Hospital Coumadin Clinic , please have first INR check 7/30/05 ,
Arrange INR to be drawn on 7/30/05 with f/u INR's to be drawn every
2-3 days. INR's will be followed by Clagib Toner Community Hospital Coumadin clinic
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Heart Failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Heart Failure; Pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CMP ( cardiomyopathy ) HTN ( hypertension ) DM ( diabetes
mellitus ) breast cancer ( breast cancer )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Diuresis and orally heart failure medication optimization
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old F with history of new-onset CM ( EF15% ) , recurrent
metastatic BCA history of 3 cycles taxol , one year herceptin , history of DM , HTN
who p/with acute onset SOB following chemo this a.m.. patient was recently
admitted for new-onset CM 1/19/05. One month prior , after
beginning taxol therapy , patient began to have increased SOB and fatigue
with no CP , orthopnea , LE swelling ( some cough lying down ). A chest CT
performed on 10/10 showed interval progression of CHF. At time ,
she was started on LAsix but did not fill the presciption till 4/29
An echo at P Therford Hospital showed an EF of 15% with LV thrombus , and physical therapy
admitted to PUO . She was treated with anticoagulation ( bridged to
coumadin ) , Had negative Adenosine-MIBI for ischemia ( though non
diagnostic ) and negative labs for CM. She was d/c following diuresis
in good condtion , stating she could walk 1/2 mile with out SOB , PND ,
orthopnea , cough , F/C. In this state , patient had chemotherapty this a.m..
After recieving Taxol with requisite NaCl load , patient become acutely short
of breath , was noted to have rales to apex. patient was
given lasix , NTG , MSo4 and transferred to PUO . In ED , patient sating 86% ,
RR32 , HR140 , BP137/82 , T97. Given Lasix 50 intravenous. patient noted to have trop
0.27 and was started on ASA 325 , heparin drip. Also noted to have
?RLL PNA and given 1 dose Levo 500mg and 10U insulin for BS684. patient
transferred to floor with P110 , BP130/80 , RR26 , Sating 98
3L. PMH:Metastatic Breast CA , CM , LV THrombus , HTn ,
DM FH: Mother with DM; SH: -smoking , occl
drinks Exam: 102 130/70; 24; 99 3l; JVP 10-11cm , Tachy ,
warm , -edema. CXR: RLL Infiltrate--> Interval
change EKG:
Unchanged Labs: Na 129 , Gluc 684 , Trop .27-->.61 , BNP 734 ,
AlkPh170 , WBC 10.35 , 1Band UA 3+BAct , 2nd neg. PLAN:
1. )Pump: Continued Lasix 80qd; I/O; Weights; Replete Lytes , Continued
Ace ( watch renal function stable ) initially , then increased , Continued
BB , Dig decreased to 0.125mg every day Echo performed with no interval change
since 4/20 , except no LV thrombus noted.
Check TFT's ( Last TSH. Likely will need Cath to assess CAD this
admission esp with
+trop. 2. )Ischemia:Starting ASA , STATIN. Continue BB. Heparin
on for PTT( 50-70 ). Continue ACE ( watch renal ). Trending trop/ekg ( May
be + from flash edema ). Consider cath this admission pending attd.
NPO after mid.
3. )Rhythm: Tele; Sinus tach- continued BB; Considered increasing , but not
simulatneous with ACE to avoid drops in blood pressure 4. )Pulm: Continued Diuresis
for Flash Edema. ?PNA on admission CXR-->LEvo 500qd X 7days. O2
therapy provided as needed. 5. )Renal: BUN/Cre>20. Hyaline casts present.
Watch urine output/cre for pre-renal; Not likely UTI given 2nd neg UA.
7. ) Endo: TFT's persistently low TSH with otherwise nl values X 2--Watch
for development of clinical hypothyroidism; DIABETES:: Initially
continued Home insulin regimin but given sugars inthe 300-400's ,
increased Lantis to *** with SS coverage at all meals , Her pre-chemo
decadrone may make glucose control difficult , and patient may benefit from a
formal endocrinologist is this is the case.
8. ) FEN: Checked lytes; Low nasal , ADA diet , Low fat/Low chol; Fluid
restrict < 2L
* HOSP COURSE *
patient diuresed well and sx improved. D/C'd home stable with HF , ONC and
COumadin F/U. To Complete levo course outpt ( 3 remaining doses )
ADDITIONAL COMMENTS: patient should follow closely with LMC Heart Failure Clinic for successful
optimization of outpatient control of symptoms.
patient should eat low nasal diet , Watch fluid intake ( <2L/day ) , take prescribed
medications regularly.
patient should work with primary care physician to gain better control of Diabetes. We have
increased your lantus dose so please monitor glucose frequently.
patient should continue to have INR monitored for Theraputic coumadin levels.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: FANIEL , GAYLENE G. , M.D. , PH.D. ( LG397 ) 5/24/05 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1118
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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878696591 | PUO | 75926089 | | 1692192 | 7/26/2007 12:00:00 a.m. | right femur fracture | Unsigned | DIS | Admission Date: 10/27/2007 Report Status: Unsigned
Discharge Date: 5/27/2007
ATTENDING: PILLING , WEI M.D.
ADMISSION DIAGNOSIS: Hip fracture.
DISCHARGE DIAGNOSES: Status post hip surgery and end-stage renal
disease.
Please see original dictation for the history of present illness ,
past medical history , medications on admission , allergies , social
history , the family history , physical exam on admission , EKG on
admission and all data. Please also see that for the initial
hospital course this dictation only goes from August
through 3/24/07.
1. Orthopedics. There is no update on his orthopedics course.
He needs to continue his heparin 5000 units subcutaneously twice
daily for one month following his surgery , which was 7/11/07 , so
he just about to complete this one month course. He should be on
Ultram 50 mg every twelve hours as needed for pain. All
narcotics should be avoided as these results in severe delirium
for Mr. Funnell
No update to cardiovascular ischemia.
Cardiovascular rhythm. His Lopressor continued to be held for
the remainder of his hospitalization. His blood pressure was
within normal limits between 100-110/60-70 and his heart rate
remained in the 60s-70s , no higher than the 80s. If his blood
pressure increases , starting Lopressor again at 25 mg twice daily
would be wise , however , currently his blood pressure is not high
nor does his rate require this.
There is no uptake to his renal course. He continued on his
dialysis on Tuesday , Thursday , and Saturdays. However , he also
got dialysis on Friday the 6 of July since he is being discharged
today , so that he can be changed to a Monday , Wednesday , and
Friday dialysis course at the Ni Medical Center
From an endocrine perspective , he remained on sliding scale
insulin only. He did not need to be restarted on his Lantus.
There is no further update to his GI oncologic history. He
should continue to follow up with Dr. Lacava on in 4/15/07 at
3:00 p.m.
From a delirium perspective , his Zyprexa 2.5 mg at bedtime was
discontinued after his sense of delirium has been cleared for
multiple days. However , if he were to start to have any sorts of
hallucinations or issues with confusion , we would restart the
Zyprexa immediately 2.5 mg at bedtime +2.5 mg as needed. The
patient is currently stable again off Zyprexa , but it has only
been discontinued for two days , so he may well need this to be
added on. As soon as the Zyprexa is added on , he has cleared his
delirium pretty quickly , so this has been quite effective for
him.
From an ID perspective. He was continued on his rifampin 300 mg
twice daily as well as his penicillin 2 million units every four
hours and these antibiotics should be continued through 12/10/07.
He has an appointment with Dr. Wohlford in the ID Clinic on
8/20/07 at 8:00 a.m. to follow up on these issues. Please make
sure that the patient attends this appointment as it is very
important in terms of deceptive time running any changes in his
antibiotic course. He completed his course of Valtrex and does
not need any further treatment with Valtrex.
Gout. The patient developed gout in his right MCP and PIP joints
several days prior to discharge. He was restarted on his
colchicine every other day. He was also started on a higher dose
of prednisone of 20 mg daily. This should be continued for five
additional days and then he can be decreased back down to 10 mg
for several days and then down to his baseline dose of 5 mg
daily. He should continue on 5 mg of prednisone daily for the
foreseeable future.
From an FEN perspective , Nutrition was following the patient and
they recommended that he has his phosphorous checked regularly
and that he have assistance with his meals as much as possible so
that he can eat as much as possible.
From a hyponatremia perspective , his sodium was improved at the
time of this dictation and in fact on discharge , his sodium was
132. He should continue on free water restriction at the
Ni Medical Center as his hyponatremia is likely from
hypervolemic hyponatremia given his low albumin and poor oncotic
pressure.
Code status , the patient will continue to be full code at the
time of this discharge addendum.
TO DO: Please make sure the patient continues with his
antibiotics through 7/4/07 also make sure that he sees Cecily Wohlford in the ID Clinic on 8/20/07 at 8 a.m. Please also make
sure that he sees Dr. Eden Lacava at the Setlake Caardlin County Medical Center on 4/15/07 at 3 p.m. as well as Dr. Daria Scoby on
2/5/07 11:30 a.m. He should also follow up with his primary
care physician , Dr. Hunnell following discharge from Ni Medical Center
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg every other day.
2. Colace 100 mg by mouth twice daily.
3. Heparin 5000 units subcutaneously twice a day , which should be
continued through the time of his discharge from rehabilitation.
4. NovoLog insulin as per sliding scale premeals.
5. Synthroid 75 mcg by mouth daily.
6. Nephrocaps 1 tab by mouth daily.
7. Zyprexa 2.5 mg by mouth every twelve hours as needed for
agitation or delirium.
8. Omeprazole 20 mg by mouth three times daily.
9. Penicillin G 2 million units intravenous every 4 hours
10. Prednisone 20 mg every 24 hours for five doses , and then 10
mg every 24 hours for five doses , and then 5 mg every 24 hours
permanently.
11. Rifampin 300 mg by mouth twice daily.
12. Senna 2 tabs by mouth twice daily.
13. Flomax 0.8 mg by mouth daily.
14. Ultram 50 mg by mouth every twelve hours as needed for pain.
15. Effexor extended release 150 mg by mouth after dialysis.
16. ConvaTec Aquacel silver one topical daily.
Please remember to avoid narcotics and benzodiazepines in this
patient as he is very sensitive to medicines and may well
developed repeat delirium as has given them.
eScription document: 9-0895202 CSSten Tel
Dictated By: GIRARDI , ABE
Attending: PILLING , WEI
Dictation ID 1078318
D: 7/28/07
T: 7/28/07
Document id: 1119
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164007289 | PUO | 65202772 | | 110799 | 1/27/2002 12:00:00 a.m. | cellulitis , osteomyelitis | | DIS | Admission Date: 2/8/2002 Report Status:
Discharge Date: 11/13/2002
****** DISCHARGE ORDERS ******
OBERMEYER , SUZANNE 062-19-87-1
Au Tons Villepalm
Service: MED
DISCHARGE PATIENT ON: 10/24/02 AT 09:00 a.m.
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DEPSKY , GWYNETH ALMEDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
ASPIRIN BUFFERED 325 MG orally every day
LASIX ( FUROSEMIDE ) 20 MG orally every day
GLYBURIDE 2.5 MG orally every day
HEPARIN 5 , 000 U subcutaneously twice a day
IMIPENEM-CILASTATIN 500 MG intravenous every 6 hours Starting Today ( 5/29 )
Instructions: Please continue for an additional 3 weeks
until September
This order has received infectious disease approval from
HOLDA , ALYSE , M.D.
Alert overridden: Override added on 7/5/02 by BURVINE , ALVERTA A. , M.D. POSSIBLE ALLERGY ( OR SENSITIVITY ) to IMIPENEM
POSSIBLE ALLERGY ( OR SENSITIVITY ) to IMIPENEM
Reason for override: aware
Number of Doses Required ( approximate ): 12
LISINOPRIL 20 MG orally every day
PREMPRO 0.625MG/2.5 MG 1 TAB orally every day
Number of Doses Required ( approximate ): 5
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
Alert overridden: Override added on 4/3/02 by :
POTENTIALLY SERIOUS INTERACTION: GLYBURIDE & OMEPRAZOLE
POTENTIALLY SERIOUS INTERACTION: GLYBURIDE & OMEPRAZOLE
Reason for override: Patient requires both
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: After D/C from SNF
FOLLOW UP APPOINTMENT( S ):
Dr. Rolanda Eckler , ortho 2/25/02 scheduled ,
Dr. Arnulfo Berkovitch , ID 10/20/02 scheduled ,
Dr. Hoerter 7/30/02 scheduled ,
ALLERGY: Penicillins , Cephalosporins ,
Fluoroquinolones ( quinolones )
ADMIT DIAGNOSIS:
cellulitis , osteomyelitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cellulitis , osteomyelitis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) htn ( hypertension )
edema ( peripheral edema ) obesity ( obesity )
recurrent cellulitis ( cellulitis ) mitral prolapse ( mitral valve
prolapse ) uti ( urinary tract infection ) atopic dermatitis ( dermatitis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
LENIs
ABI
PVRs
BRIEF RESUME OF HOSPITAL COURSE:
57 year-old female history of NIDDM , recurrent cellulitis , morbid obesity presents
with 2-3 days worsening cellulitis of LE b/l. starting 11/14 patient
has been getting various antibiotics for left LE cellulitis , starting
on Keflex , switched to intravenous Clinda for osteo diagnosed 8/22 , switched to
intravenous Ancef with PICC after osteo diagnosed 10/18/02 with orally ciproflox. 3
days PTA patient getting intravenous vanc through PICC with no success.
Erythema , tenderness , warmth worse on LLE and now spreading to RLE.
Patient otherwise completely asymptomatic with no F/C/N/N/V. No
CP/SOB/dysuria/diarrhea/dizzy. VSS in ED and on floor. ID consulted
and intravenous imepenem/cilistatin started 500 every 6 hours Patient got LENI's
HSD2 which were normal b/l , also got ABI/PVR , antibiotics continued
with improvement , less erythema/tenderness , but ulcer to tendon on left
lateral foot still present. Patient to go to SNF on intravenous
imepenem/cilistatin with f/u with Ortho clinic , ID clinic and primary
Dr. Fickes
ADDITIONAL COMMENTS: Please continue intravenous antibiotics for an additional 3 weeks until
October .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Going to SNF with PICC and intravenous imepenem/cilistatin
To follow up with primary Dr. Hoerter , 7/21/02 1:30PM
To follow up with Ortho Dr. Francom , 4/24/02 9AM
To follow up with ID Dr. Arnulfo Berkovitch , 4/2/02 10AM
No dictated summary
ENTERED BY: BURVINE , ALVERTA A. , M.D. ( DT26 ) 10/24/02 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1120
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380075158 | PUO | 43908087 | | 5038760 | 3/23/2003 12:00:00 a.m. | Renal failure | | DIS | Admission Date: 10/13/2003 Report Status:
Discharge Date: 1/18/2003
****** DISCHARGE ORDERS ******
TOMA , AYAKO 113-98-54-8
Montana
Service: RNM
DISCHARGE PATIENT ON: 1/1/03 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ARGANBRIGHT , DENAE DENEEN , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
PHOSLO ( CALCIUM ACETATE ) 1 , 334 MG orally three times a day
Instructions: with meals
CATAPRES ( CLONIDINE HCL ) 0.3 MG/DAY TP Q168H
HOLD IF: sbp<100
ERYTHROPOIETIN ( EPOETIN ALFA ) 4 , 000 UNITS subcutaneously 3x/week
LABETALOL HCL 600 MG orally four times a day HOLD IF: sbp<100 , heart rate<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 40 MG orally every day HOLD IF: sbp<100
Override Notice: Override added on 1/17/03 by
TIBOLLA , MADISON , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 62064556 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 1/17/03 by TIBOLLA , MADISON , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
24585359 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
PREDNISONE 10 MG orally every other day
ZOCOR ( SIMVASTATIN ) 10 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 7/4/03 by
TIBOLLA , MADISON , M.D.
on order for NEPHROCAPS orally ( ref # 61290473 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
FK506 ( TACROLIMUS ) 1 MG orally every 12 hours X 60 Days
Food/Drug Interaction Instruction
Separate antacids by at least two hours and avoid
grapefruit juice
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 7/4/03 by
TIBOLLA , MADISON , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
NIFEDIPINE ( SUSTAINED RELEASE ) ( NIFEDIPINE ( S... )
30 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DOXERCALCIFEROL 2.5 MCG orally every day
RENAGEL 800 MG orally three times a day
Instructions: please give only with meals. thanks.
KEFLEX ( CEPHALEXIN ) 500 MG orally every day X 7 Days
FLEXERIL ( CYCLOBENZAPRINE HCL ) 10 MG orally three times a day
as needed back pain
COLCHICINE 0.6 MG orally every other day
DIET: House / ADA 1800 cals/day / Renal diet (FDI)
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Kidney Doctor - Dr. Pilling , February at 8:40 am 4/4/03 scheduled ,
Dialysis at Kernan To Dautedi University Of Of Thurs 10/28 at 11:30 am ,
No Known Allergies
ADMIT DIAGNOSIS:
end stage renal disease
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Renal failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
dm ( diabetes mellitus ) htn ( hypertension ) sleep apnea ( sleep
apnea ) gout ( gout ) depression
( depression ) obesity ( obesity ) left total hip replacement
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
PATIENT IDENTIFICATION: 50 year-old male history of renal transplant presents will
acute on chronic renal failure.
HISTORY OF PRESENT ILLNESS: 50 year-old male with ESRD secondary to HTN , on
hemodialysis from 94-99 , history of cadaveric renal transplant in 5/22 Over
the past few yrs , patient with increasing Cr: 4 in 2001 , 7 in 2002 , 8 in
early February of this year. He was in his USOH until 1 wk ago when he
developed R axilla infection ( hidradenitis suppurativa ) + DOE. Seen in
urgent care 10/18 , given keflex. Seen in renal clinic 1/27 and labs
revealed: Cr of 10 , bicarb 6 , k 6.8. patient then sent to ED.
HOSPITAL COURSE:
RENAL: patient admitted with acute on chronic failure. The etiology was
unclear. His FK level was 4.8 , his UA was normal , urine eos were
negative. His low bicarb was due to his underlying renal failure , and
his non-complaince with taking his bicarb replacement at home.
He was started on D5W + 3 amps HCO3 and was ultimately taken to
dialysis 6/11 due to his bicarb. As per renal his immunosupressive
regimen was changed. His cellcept was discontinued , his prednisone was
decreased to 10 every other day , and his FK dose was decreased from 2 to 1mg twice a day ,
and was then to end after a period of 60 days. The patients K was
initially at 6.8. It subsequently decreased with kayexalate and
dialysis. The patient iPTH was checked and elevated at 399. He was to
continue dialysis upopn discharge.
ID - The patient was on renally dosed ancef for a right axilla
skin infection which improved during his hospitalization. His blood
cultures were negative to date at the time of discharge. His is to
finish a 7 day course of keflex as an outpatient. The patient
complained of right ankle pain on 8/2 , a plain film revealed no
fracture.
PULM: The patient had an incidental finding of a pulmonary nodule on
his CXR. A CT revealed that this was just his first right
costo-chondrojunction with osteophytes.
ADDITIONAL COMMENTS: Return to the emergency room or call your doctor for any concern.
Follow up with your kidney doctor Dr. Pilling
Follow up with your primary care doctor for the infection in your arm.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TIBOLLA , MADISON , M.D. ( RF05 ) 1/1/03 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1121
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933271567 | PUO | 75751674 | | 8976523 | 10/20/2002 12:00:00 a.m. | LOWER GASTROINTESTINAL BLEED | Signed | DIS | Admission Date: 1/15/2002 Report Status: Signed
Discharge Date: 10/30/2002
PRINCIPLE DIAGNOSIS: LOWER GASTROINTESTINAL BLEED.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male with
a history of coronary artery disease
status post five catheterization with a pacemaker in place ,
arthritis , gout , benign prostatic hypertrophy , hypertension and
myelodysplasia who presents with a history of lower
gastrointestinal bleeds. He has had three episodes in the past.
He presented to an outside hospital four days prior to admission
with symptoms of bright red blood per rectum. His vital signs at
that time were normal and stable with a hematocrit of 33. A tagged
red blood cell scan was negative during that hospitalization as was
an upper endoscopy. Colonoscopy revealed diverticula throughout
the large colon with more on the right than on the left. During
that hospitalization at the outside hospital , he was transfused
with four units of packed red blood cells and then transferred to
the Pagham University Of for further evaluation and
treatment.
HOSPITAL COURSE: On admission , his hematocrit was 32.9.
Subsequent serial hematocrits over the following
two days were stable. During the first hospital day , he had two
grossly heme-positive bowel movements and , by the second hospital
day , he had bowel movements that were brown and formed but guaiac
positive still. His hematocrit remained stable between 30 and 35
throughout his earlier hospitalization.
Given the patient's history of multiple gastrointestinal bleeds ,
the decision was made to perform a right hemicolectomy to prevent
further episodes. This was performed on hospital day number three.
See Operative Note for details.
The procedure and recovery were unremarkable. He was started on
sips on postoperative day number one and clear liquids on
postoperative day number two. He tolerated all of this well. His
Foley catheter was removed on postoperative day number two. His
diet was advanced. On postoperative day number three , he had
passed flatus. He began to have loose bowel movements. His diet
was advanced and , by postoperative day number four , he was
tolerating a regular house diet.
On the day of discharge , the patient was stable and tolerating
orally's quite well. His pain was well controlled with orally pain
medication of Percocet and he was voiding freely without
difficulty. He was ambulating successfully. Therefore , it was
deemed that he was suitable for discharge.
The patient was seen by his cardiologist , Dr. Lyn throughout his
hospitalization. Prior to surgery , he was deemed suitable for
surgery without any serious cardiac risks. On postoperative day
#2 , the patient was noted to have a run of V-tach 10 beats ,
asymptomatic , no chest pain or discomfort , no shortness of breath.
He said that he was coughing at the time that that tracing came up.
A CK and troponin were sent which were both flat. The patient had
previously been ruled out for MI. Postoperatively , as a
prophylactic course , given that he has a ventricular pacemaker and
we could not follow EKGs based on that. The patient did well
thereafter , and had no further cardiac symptoms or issues. The
patient was seen by physical therapy throughout his postoperative
course and prior to discharge was deemed suitable for discharge to
home , was able to do all necessary activities to go home.
DISCHARGE MEDICATIONS: Allopurinol 300 mg orally every day , atenolol
25 mg orally every day , Colace 100 mg orally twice a day
as needed constipation , Percocet 1-2 tablets orally every 4 hours as needed pain ,
Zantac 150 mg orally twice a day , Flomax 0.8 mg orally every day
He will follow up with Dr. Daniel , his hematologist , in 2-4 weeks.
He will follow up with Dr. Zufelt on 2/5/02. He was stable at
the time of discharge and is discharged to home with services.
Dictated By: KATELYNN DARRUP , M.D. JQ59
Attending: CHANELLE ZUFELT , M.D. KE40
JQ492/556368
Batch: 57249 Index No. PLJL9G84Z1 D: 1/9/02
T: 1/9/02
Document id: 1122
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490615097 | PUO | 67095171 | | 8475281 | 2/7/2007 12:00:00 a.m. | Partial small bowel obstruction , pneumonia , CHF | | DIS | Admission Date: 10/7/2007 Report Status:
Discharge Date: 9/23/2007
****** FINAL DISCHARGE ORDERS ******
LEVETO , ALMEDA E 438-54-75-5
Oge
Service: MED
DISCHARGE PATIENT ON: 8/19/07 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: NO ( see an addendum )
Attending: DELMENDO , CRISTINE V , M.D.
WILL D/C ORDER BE USED AS THE D/C SUMMARY: ADDENDUM 1:
YES
Addended Cal , Mammie L. , M.D. ( WC235 ) on 1/15/07 @ 02:54 PM
CODE STATUS:
Full code
DISPOSITION: Home with services
MEDICATIONS ON ADMISSION:
1. AMLODIPINE 5 MG orally every day before noon
2. AMLODIPINE 2.5 MG orally every afternoon
3. CALCIUM CARBONATE 1500 MG ( 600 MG ELEM CA )/ VIT D 200 IU 1 TAB orally twice a day
4. DOCUSATE SODIUM 100 MG orally twice a day
5. EPOETIN ALFA 5000 UNITS subcutaneously QWEEK
6. ESOMEPRAZOLE 40 MG orally every day
7. FERROUS SULFATE 325 MG orally twice a day
8. FUROSEMIDE 80 MG orally twice a day
9. INSULIN ASPART SLIDING SCALE subcutaneously before meals
10. INSULIN ASPART 4 UNITS subcutaneously WITH BREAKFAST AND WITH LUNCH
11. INSULIN GLARGINE 8 UNITS subcutaneously every day
12. ISOSORBIDE MONONITRATE 30 MG orally twice a day
13. SEVELAMER 400 MG orally every afternoon
14. VALSARTAN 120 MG orally every day
15. WARFARIN SODIUM 1 MG orally every afternoon
MEDICATIONS ON DISCHARGE:
NORVASC ( AMLODIPINE ) 5 MG every day before noon; 2.5 MG every afternoon orally 5 MG every day before noon
2.5 MG every afternoon Instructions: CRUSHED MEDS
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CALCIUM CARBONATE 1 , 500 MG ( 600 MG ELEM CA )/ VIT D 200 IU
1 TAB orally twice a day
PROCRIT ( NON-ONCOLOGY ) ( EPOETIN ALFA ( NON-ONC... )
5 , 000 UNITS subcutaneously QWEEK Instructions: on tuesday
FERROUS SULFATE 325 MG orally twice a day
Food/Drug Interaction Instruction Avoid milk and antacid
LASIX ( FUROSEMIDE ) 160 MG orally twice a day HOLD IF: SBP<100
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
Low Scale Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
If ordered before every meal administer at same time as , and in addition
to ,
standing insulin aspart order. If ordered HS administer
alone
INSULIN ASPART 7 UNITS subcutaneously before meals HOLD IF: NPO
LANTUS ( INSULIN GLARGINE ) 12 UNITS subcutaneously every afternoon
Instructions: give 1/2 dose if NPO
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally twice a day
HOLD IF: SBP < 100 Instructions: do not crush Imdur. thanks.
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LEVAQUIN ( LEVOFLOXACIN ) 500 MG orally every 48 hours
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 8/19/07 by
CAL , MAMMIE L. , M.D.
on order for COUMADIN orally 3 MG every afternoon ( ref # 095917954 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: will monitor
Previous override information:
Override added on 4/5/07 by CAL , MAMMIE L. , M.D.
on order for COUMADIN orally ( ref # 009090101 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: aware , will monitor
Previous override information:
Override added on 8/10/07 by NOAKES , MARLEEN D. , M.D.
POTENTIALLY SERIOUS INTERACTION: PROCHLORPERAZINE &
LEVOFLOXACIN Reason for override: md aware
Previous Override Notice
Override added on 11/19/07 by NOAKES , MARLEEN D. , M.D.
on order for COMPAZINE intravenous ( ref # 513943899 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
PROCHLORPERAZINE Reason for override: md aware
FLAGYL ( METRONIDAZOLE ) 500 MG orally every 8 hours
Food/Drug Interaction Instruction Take with food
Override Notice: Override added on 8/19/07 by
CAL , MAMMIE L. , M.D.
on order for COUMADIN orally 3 MG every afternoon ( ref # 095917954 )
SERIOUS INTERACTION: METRONIDAZOLE , ORAL/VAG & WARFARIN
Reason for override: will monitor
Previous override information:
Override added on 4/5/07 by CAL , MAMMIE L. , M.D.
on order for COUMADIN orally ( ref # 009090101 )
SERIOUS INTERACTION: METRONIDAZOLE , ORAL/VAG & WARFARIN
Reason for override: aware , will monitor
SEVELAMER 400 MG orally every afternoon Instructions: before dinner.
DIOVAN ( VALSARTAN ) 120 MG orally DAILY
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 8/19/07 by
CAL , MAMMIE L. , M.D.
SERIOUS INTERACTION: METRONIDAZOLE , ORAL/VAG & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: will monitor Previous Alert overridden
Override added on 4/5/07 by CAL , MAMMIE L. , M.D.
SERIOUS INTERACTION: METRONIDAZOLE , ORAL/VAG & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: aware , will monitor
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Jagla , Norap Valley Hospital , 068-847-6488 7/10/07 at 2pm ,
Arrange INR to be drawn on 10/3/07 with f/u INR's to be drawn every
3 days. INR's will be followed by PUO Coumadin Clinic
ALLERGY: Codeine , DIPHENHYDRAMINE
ADMIT DIAGNOSIS:
Abdominal pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Partial small bowel obstruction , pneumonia , CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Diabetes mellitus , S/p mitral valve replacement , Atrial fibrillation , CHF
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
See dictation
BRIEF RESUME OF HOSPITAL COURSE ADDENDUM 1:
CC: Abdominal pain
HPI: This is an 86 year-old woman with a history of CHF , chronic kidney
disease , diabetes , Afib on cuomadin , rheumatic heart disease history of MVR/TVR ,
and history of partial SBO , and a recent admission in 11/29 for abdominal
pain and bilateral aspiration pneumonia who presented with abdominal pain
for 36 hours. The pain was 10/10 , difficult to localize , and constant.
She did have nausea and 3 episodes of emesis ( non-bilious , non-bloody ).
Her last bowel movement was on 6/9 , no recent melena or BRBPR , no
diarrhea. She does report flatus. She also reports increasing SOB over
the past 48 hrs , unclear if orthopnea , PND , or increased leg swelling.
She denies chest pain , palpitations. No fevers or chills.
In ED , temp 96.5 , HR 76 , BP 135/51 , O2sat 97% RA. CXR showed RLL PNA and
pulmonary edema. KUB did not show free air. Abd CT showed partial or
early SBO without transition point. Given 1500cc IVF , 2mg Morphine intravenous ,
phenergan 25mg intravenous , zofran 1mg , cefuroxime 750m
*****
PMHx: Hypertension , diabetes , atrial fibrillation on coumadin , rheumatic
heart disease history of bioprosthetic MVR/TVR in 2000 , diastolic heart failure ,
TTE 8/27 ( EF 45-50% , mod LVH , no RWMA , history of MVR , severe TR ) , chronic
kindey disease , history of small-bowel obstruction with hernia repair in
2005 , history of GI bleed ( angiectasis/lymphangiectasis ) , unclear history
of mesenteric ischemia , history of right total hip replacement , history of CVA at age
55 , Cdiff colitis , history of appendectomy
*****
Medications on Admission: Calcium 500mg twice a day , Renagel 400mg before
dinner only , Coumadin 3mg daily , Norvasc 5mg every day before noon & 2.5mg every afternoon , Imdur
30mg twice a day , Diovan 120mg daily , Lasix 80mg orally twice a day , Novolog 5u qAC +
sliding scale , Lantus 10u every bedtime , Iron 325mg twice a day , Procrit 5000u qTUES , MVI.
*****
Alergies: codeine , benadryl
*****
Social Hx: lives with daughter in Vo Leahme , Georgia 06813 No tobacco. Rare EtOH.
****
Physical Exam on Admission: T 100.6 , HR 82 , BP 120/60 , RR16 , O2sat 93%2L
FS 222. Somnolent ( after 2mg morphine intravenous ) , NAD. OP clear , dry MMM. JVP
difficult to assess with severe TR and pulsations to jaw. Heart rhythm
irregular , 3/6 SEM loudest at the apex. Lungs with crackles 1/2 up bilat ,
no wheezes. Abdomen soft , nontender even to deep palpation , no
rebound , normal bowel sounds , passing gas. Guiaic negative. Extremities
warm , trace edema , venous stasis changes with purpura/petechiae on legs.
Somnolent , Ox2 , grossly nonfocal neurological exam.
*****
Studies on Admission:
- Labs: Na 135 , K 4.1 , CL 97 , CO2 23 , BUN 96 , Cr 2.6 , glucose 186. ALT 8 ,
AST 13 , Alk 67 , Tbili 0.9 , amylase 53 , lipase 30. WBC 14.7 ( 91% polys ) ,
hct 31 , plts 377. INR 2.3. BNP 705. UA WBC 5 , RBC 2 , 1+ luek , 1+ bact , 1+
sq epi.
- EKG: Afib , HR 79 , poor RWP , isolated Q in AvL , QTc 488 , no changes from
prior
- CXR: Pulmonary edema with possibly underlying right lower lobe
pneumonia. Unchanged cardiomegaly.
- KUB: No pneumoperitoneum and no evidence of small bowel obstruction.
- Abd/pelvis CT abd ( I- ): Partial or early small bowel obstruction ,
without definite transition point. No change in bilateral lower lobe
pneumonias. Cholelithiasis. Coronary artery disease and atherosclerosis
with cardiomegaly.
*****
Procedures: none
Consultants: none
*****
HOSPITAL COURSE: This is a 86F with hx CHF , Afib , CKD , and diabetes who
was admitted with partial SBO , bilateral aspiration pneumonia , and CHF
exacerbation.
-
GI: Admitted with partial SBO. She was treated wtih conservative
management. No NGT was required. The SBO resolved and she was passing
stool and tolerating a normal diet.
-
CV: She has a history of diastolic dysfunction. Echo 8/27 with EF 45-50% ,
no RWMA , mod LAE and RAE , bioprosthetic MV with tr MR , tr AR , severe TR ,
mild-mod PR. She reported SOB prior to admission which ws thought to be
due to a CHF exacerbation. She was not agressively diuresed in the
setting of the partial SBO. She is on variable doses of lasix
( 80-200mg orally twice a day ) at home. She was initially given lasix 80mg twice a day which
required additional doses of lasix intravenous as needed to diurese , so the dose was
increased to 160mg orally twice a day Repeat CXR on 3/17 looks a little better than
admission. Overall her SOB and hypoxia improved. She no longer required
supplemental oxygen. She has a history of hypertension and was continued
on norvasc and imdur. She also has a history of Afib , now on coumadin.
Her rate was adequately controlled. The coumadin was initially held due
to possible procedures related to the SBO. The INR remained in 2-3 range ,
likely due to the antibiotics. The Coumadin was restarted on 10/20 as the
INR was trending down , and was started at lower dose ( 2mg instead of 3mg )
given the antibiotics. Her INR will be followed and coumadin adjusted as
an outpatient.
-
Pulmonary: She has a history of aspiration PNA. The Abd CT showed
bilateral lower lobe PNA , likely aspiration. She was treated with levo
and flagyl. Her WBC was elevated on admission and decreased during
hospitalization. She was afebrile. With treatment of the pneumonia and
CHF she was no longer hypoxic or SOB. She will continue levofloxacin and
flagyl for an 8-day course.
-
Renal: She has a history of CKD with Cr baseline of 2.6-2.8. Her Cr was
2.6 on admission and 2.3 on discharge. She continued home sevelamer.
-
Diabetes: Her insulin was initially held on admission due to NPO for the
SBO. When her SBO resolved and she was eating again , her home regimen of
lantus 100 units daily , Novolog 5 units before every meal , and Novolog sliding scale
was restarted. Her fingersticks continued to be high , perhaps due to
pneumonia. The insulin was titrated up for better glucose control to
Lantus 12 units daily , Novolog 7 units before every meal , and Novolog sliding scale.
The daughter is a nurse and will monitor and adjust her insulin at home.
HbA1c 8.2.
-
ID: Treatment for aspiration pneumonia as above with levofloxacin and
flagyl. Ucx with mixed flora.
-
Heme: Hct at baseline. As above , her INR remained high off coumadin ,
likely due to the antibiotics. Coumadin restarted on 10/20 at a lower
dose. INR will be followed and coumadin adjusted as an outpatient
-
Nutrition: She had a radiologic swallowing evaluation which showed deep
laryngeal penetration with thin and nectar-thick liquid with no
aspiration and a tiny Zenker diverticulum. Diet recommendations were
ground diet ( for lack of teech ) and thin liquids.
-
Disposition: physical therapy recommended rehab. Patient and daughter prefer patient to
go home with services. The daughter is a nurse. New primary care physician is Dr. Jagla
( geriatrics ) at 12/10 at 2pm at
P Therford Hospital .
-
Code: Full
-
Addended Cal , Mammie L. , M.D. ( WC235 ) on 1/15/07 @ 02:54 PM
ADDITIONAL COMMENTS: 1. Pneumonia: She will be discharged on levofloxacin and flagyl to treat
her pneumonia to complete an 8-day course , which will end on 6/20
2. CHF: She will continue to take the lasix.
3. Hypertension: She should continue to take her previous medications.
4. Diabetes: Her insulin has been increased during hospitalization.
Continue to monitor the glucose levels and adjusting her insulin.
5. Coumadin: Her coumadin was restarted on 10/20 at 2pm ( lower dose than
prior due to the effect of antibiotics increasing the INR ). However , her
INR has been low at 1.5 and 1.4 , so the coumadin has been increased to
3mg at discharge. Continue to monitor her INR and adjust her coumadin as
needed.
6. Continue home physical therapy as recommended.
7. Seek medical attention if she develops fever , chills , shortness of
breath , chest pain , worsening cough , or any other concerning symptoms.
8. The patient has an appointment with a new primary care physician , Dr. Jagla of the Dept
of Geriatrics , on 7/10/07 at Norap Valley Hospital .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Pneumonia: Patient will complete an 8-day course of levo and flagyl.
Monitor for resolution of pneumonia.
2. CHF: Patient will continue lasix. Continue to monitor volume status.
3. Afib: Patient will continue coumadin , will be monitored and adjusted
by Coumadin Clinic.
4. Diabetes: Patient will continue insulin regimen at home.
5. primary care physician: Patient will have a new primary care physician , Dr. Jagla , who she will see on 10/8
No dictated summary
ENTERED BY: CAL , MAMMIE L. , M.D. ( WC235 ) 8/19/07 @ 01
Addended Cal , Mammie L. , M.D. ( WC235 ) on 1/15/07 @ 02:54 PM
****** END OF DISCHARGE ORDERS ******
Document id: 1123
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
599469755 | PUO | 67755170 | | 2022175 | 6/26/2006 12:00:00 a.m. | Vertiginous fall | | DIS | Admission Date: 6/26/2006 Report Status:
Discharge Date: 10/24/2006
****** FINAL DISCHARGE ORDERS ******
KARNOPP , CHER B 512-95-24-9
Ragecam Mil Moe
Service: MED
DISCHARGE PATIENT ON: 10/26/06 AT 01:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: EDNIE , MARICELA C. , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
ATENOLOL 50 MG orally DAILY HOLD IF: SBP <100 , l HR<60
CIPROFLOXACIN 500 MG orally every 12 hours X 12 doses
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
DEPAKOTE ( DIVALPROEX SODIUM ) 750 MG orally twice a day
Starting Today ( 10/12 )
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
PROZAC ( FLUOXETINE HCL ) 30 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY HOLD IF: SBP <100
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
Starting Today ( 7/18 )
MOTRIN ( IBUPROFEN ) 600 MG orally every 6 hours as needed Pain
Food/Drug Interaction Instruction Take with food
INSULIN 70/30 HUMAN 20 UNITS subcutaneously every day before noon
INSULIN 70/30 HUMAN 15 UNITS subcutaneously every afternoon
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally DAILY
HOLD IF: SBP <100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LACTULOSE 15-30 MILLILITERS orally four times a day as needed Constipation
LIDODERM 5% PATCH ( LIDOCAINE 5% PATCH ) TOPICAL TP DAILY
Instructions: apply to painful area as directed by patient
ZYPREXA ( OLANZAPINE ) 15 MG orally BEDTIME
Number of Doses Required ( approximate ): 6
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
HOLD IF: RR<10 or hypersomnolence
OXYCONTIN ( OXYCODONE CONTROLLED RELEASE ) 10 MG orally every 12 hours
Starting Today ( 10/12 ) HOLD IF: RR<10 or hypersomnolence
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
ZOCOR ( SIMVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Ortho Dr Nwankwo ( 359 ) 461-8829 7/25/06 @ 12:45 pm ,
Pain clinic Dr Imparato ( 478 ) 225-8185 10/22/06 @ 10:45 am ,
Rosanne Vernet ( 616 ) 312-9247 10/15/06 @ 1:00 pm ,
ALLERGY: benadryl , haldol
ADMIT DIAGNOSIS:
Syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Vertiginous fall
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
DM , HTN , HL , Bipolar , Epilepsy , L knee arthroplasty for septic knee
( 9/21 ) , Bilat TKR , CAD history of MI 2003
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Yall , with u for syncope
**
HPI: 46F with DM , HTN , CAD , epilepsy and bilateral knee operations who
felt vertiginous and fell while transferring from wheechair to toilet ,
hurting her left knee , which according to ortho has an old fracture. She
had not felt well for a few days , hot and cold flashes. She took her
insulin and other meds 30 minutes prior to the episode. No CP/SOB , no
LOC.
**
PMH: DM , HTN , HL , Bipolar , Epilepsy , L knee arthroplasty for septic
knee ( 9/21 ) , bilat TKR , CAD history of MI ( 2003 )
**
ALL: Haldol
**
Admit Data: VS: 96.8 89 130/80 16 97%
RA PE: NAD , obese , NCAT , CTAB , RRR c 2/6 SM , abd
benign , L knee tender c large effusion , 1+ bl edema Lab: BMP wnl , WBC
6.8 , Hct 35.1 , biomarkers neg , INR 7.3 , U/A neg
Studies: CT head neg , CXR R base atelectasis , EKG old LBBB , Knee XR L
knee fracture through cement spacer and tibial stem
**
1 ) CV - [I] Ruled out with enzymes negative x3 , LBBB ( old ) on EKG. Cont
ASA , statin , BB , nitrate. No complaints of chest discomfort. [P] HTN ,
euvolemic , continued BB , nitrate. Echo showed normal EF 55-60% and no
structural or valvular abnormalities. [R] NSR on telemetry.
2 ) Neuro - doubt seizure with no loss of consciousness , depakote
level low ( 32 , therapeutic range 50-100 ). Will increase dose to 750mg
twice a day , may need recheck as outpatient.
3 ) Ortho - ortho consulted , will need f/u as outpatient for surgery
4 ) Heme - on coumadin after surgery in 9/21 , should have stopped taking
it. INR 7.3 on admission so holding all anticoagulation
5 ) Prophy: hold DVT prophy for now given INR , ppi
6 ) Pain: nightly has 10 second episodes of apnea , snoring , bradypnea to
6-8/min with O2 desats to mid 80's on RA. Could be oversedation with
narcotics though she exhibited these episodes even when holding narcs ,
so more likely Pickwickian syndrome , will need a sleep study as
outpatient. She continues to complain of 8/10 pain even on her home
regimen of oxycontin/oxycodone , so we tried adding dilaudid and
morphin IR for breakthrough pain. Due to her apneic episodes and the
fact that she has not moved her bowels since admission we stopped these
and decreased her oxycontin by half to 10mg twice a day Per pain service recs ,
we discontinued trazadone and added neurontin , as trazodone could be
contributing to her daily drowsiness , and neurontin may help with her
chronic pain. On discharge , we will not add any new narcotics. F/u pain
service as outpt.
7 ) Dispo: physical therapy consulted for possible rehab placement
8 ) ID: spiked to 101.2 on 7/18 , UA shows likely UTI , awaiting cx's ,
treating empirically with cipro 500 orally twice a day x 7 days
9 ) Full Code
ADDITIONAL COMMENTS: You will be discharged to a rehabilitation facility. Please seek medical
attention if you have any episodes of fainting.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
-continue ciprofloxacin for 7 days for UTI
-increased dose of valproic acid from 500mg twice a day to 750mg twice a day for a
subtherapeutic level of 32 ( goal 50-100 ). will need this rechecked as
outpatient
-f/u with orthopedics re: L knee fracture
-f/u with pain clinic re: chronic pain
-f/u with primary care physician Rosanne Vernet , may need outpt sleep study for obesity
hypoventilation syndrome
No dictated summary
ENTERED BY: GOLDFEDER , MAXINE H. , M.D. ( VK81 ) 11/24/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 1124
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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874062468 | PUO | 55475693 | | 595972 | 1/20/2002 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 10/14/2002 Report Status:
Discharge Date: 2/16/2002
****** DISCHARGE ORDERS ******
TRIOLA , CORLISS 449-83-94-0
Da More U
Service: CAR
DISCHARGE PATIENT ON: 10/21/02 AT 02:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRUNTZ , KATHERYN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 100 MG orally every day HOLD IF: sbp<100 , heart rate<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LASIX ( FUROSEMIDE ) 40 MG orally every day HOLD IF: sbp<100
TRAZODONE 50 MG orally HS as needed insomnia
HOLD IF: oversedation , rr<10
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
COZAAR ( LOSARTAN ) 50 MG orally every day HOLD IF: sbp<90 CCB.
Number of Doses Required ( approximate ): 6
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
NITROPATCH ( NITROGLYCERIN PATCH ) 0.4 MG/HR TP every day
DIET: House / Low chol/low sat. fat
Activity - As tolerated
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Bernas , cardiology 1-2 weeks ,
ALLERGY: Ace inhibitor , Amlodipine , Niacin ( nicotinic acid )
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn ( hypertension ) chest pain ( angina ) arthritis ( unspecified or
generalized OA ) gerd ( esophageal
reflux ) cad ( coronary artery disease ) osteoarthritis ( OA of cervical
spine ) anxiety ( anxiety ) diverticulosis
( diverticulosis ) l arm fx ( arm pain ) hypercholesterolemia ( elevated
cholesterol )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
76 year-old female with CAD history of CABG 2/1 and PTCA/stent 3/14 , HTN ,
hyperlipidemia who p/with chest pain. Patient had 4v CABG 4/22/02
( LIMA->LAD , SVG->diag , SVG->OM1 , SVG->PDA ). Patient returned
6/9 with recurrent angina. Adenosine MIBI positive for moderate
reversible defects in the inferolateral and mid to basal inferior
walls. Patient developed severe SOB with adenosine and test was
terminated early. Patient had ST depresssions in V4-V6 ,
II , III. Cath 1/14/02 revealed patent LIMA->LAD , SVG->diag , SVG->PDA.
Cath showed occluded SVG->OM; this was PTCA/stented and 80% stenosed
LCx , which was also PTCA/stented. Patient was chest pain free until
8/10/02 , when she developed chest pain at rest. Four hours later , VNA
arrived. Patient was still having chest pain , SBP 190. She was taken
to Tona Medical Center She ruled out for MI. ECHO EF 75% , mild MR , mild
conc LVH. Atenolol increased and Imdur added to regimen of ASA and
statin. Patient had chest pain at 3 pm on day of transfer , relieved
with sublingual NTG and MSO4. Patient transferred to PUO for further
evaluation. On admission , HR 60 BP 140/90 Lungs clear No JVD , RRR ,
II/VI systolic murmur at LUSB. Abdomen benign. No pedal edema , warm
extremities. Labs sig for Cre 1.3 , hct 32.5 Hospital course was as
follows: 1 ) CV- patient ruled out by enzymes. On ASA , atenolol , zocor. Short
course intravenous heparin , intravenous TNG for questionable unstable angina , but both
d/c'd 3/1 after r/o. ETT MIBI ( modified bruce ) was suboptimal and
non diagnostic. patient lasted only 2 minute 30 seconds , limited by dypnea.
patient reached 61% maximal predicted heartheart and had fixed inferior and
anterior-apical defects. patient ruled out for dissection by chest CT; she
was evalauted because quality of her chest pain was different than her
typical angina and radiated to her back. Of note , chest CT shopwed a
right thyroid nodule which will nedd further evaluation. patient was also
started on cozaar for SBP in 160s. 2 )GI- started on nexium. Abdominal
U/S normal. patient complained of bitterness in her mouth and abdominal
discomfort , which were consistent with GERD. Instructed to take maalox
if symptoms recur.
ADDITIONAL COMMENTS: you should continue to take your heart medications as you have been. we
have started you on a new blood pressure medication called cozaar and
nitropatch to be changed once a day. You will have visiting nurses
for cardiopulmonary checks and help with medications. Call Dr. Bernas
to set up an appointment in the next 7-10 days. Return to hospital or
call MD if you experience chest pain , shortness of breath , light
headedness , or palpiations.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: CREAN , RAY T. , M.D. ( GM454 ) 10/21/02 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 1125
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
- |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
635696667 | PUO | 87751095 | | 758397 | 8/15/1994 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/9/1994 Report Status: Unsigned
Discharge Date: 10/10/1994
DISCHARGE DIAGNOSIS: COLON CANCER STATUS POST SIGMOID COLECTOMY
WITH A PRIMARY ANASTOMOSIS.
HISTORY OF PRESENT ILLNESS: Patient is a 73 year old male who
immigrated from Cu Tasti Fre approximately
fifteen years ago. He has had a several year history of
constipation but no melena , hematochezia , weight loss , night
sweats , chills , abdominal pain , or change in size/caliber of stool.
His daughters were concerned about the long history of constipation
and therefore scheduled a colonoscopy. On 10/5/94 , the patient
underwent a colonoscopy at Ouf County General Hospital and a mass was
noted in the transverse colon. A biopsy was taken and the results
are not known but were reported to Dr. Bowcutt as colon cancer.
CT of the abdomen on 6/3/94 revealed no adenopathy or evidence of
metastasis but an infrarenal IVC dilatation of approximately 3 cm.
PAST MEDICAL HISTORY: Non-Insulin dependent diabetes times ten
years , coronary artery disease with a history of coronary artery
bypass graft in 1990 , hypercholesterolemia , and low back pain.
PAST SURGICAL HISTORY: Significant for an appendectomy as a young
man and a coronary artery bypass graft times three vessels in 1990.
CURRENT MEDICATIONS: Glyburide 2.5 mg every day and Lovastatin 20 mg
every day ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure was 104/64 , temperature 97.6 ,
and pulse 54. GENERAL: Cooperative
gentleman , well-nourished , well-developed , and in no acute
distress. HEENT: Within normal limits. LUNGS: Clear to
auscultation bilaterally. HEART: Regular rhythm and rate with no
murmurs , gallops , or rubs with a midline scar from sternotomy.
ABDOMEN: Soft , non-tender , non-distended , positive bowel sounds ,
liver , spleen , and kidney non-palpable , and no masses palpable.
RECTAL: Guaiac negative with normal tone and prostate was smooth
and not enlarged. EXTREMITIES: No cyanosis , clubbing , or edema.
PULSES: Slightly decreased in the left posterior tibial and
dorsalis pedis as compared to the right but present.
LABORATORY EXAMINATION: EKG showed normal sinus rhythm with no
ischemia or infarct.
HOSPITAL COURSE: The patient was admitted and pre-operatively , was
seen by a Cardiology consultant who cleared the
patient for surgery and recommended following serial CK , MB , and
EKG but not a formal rule out protocol. The patient was taken to
the Operating Room on 10/24/94 where he underwent a mid transverse
to mid descending colectomy and primary anastomosis. The patient
tolerated the procedure well and was stable post-operatively.
Patient continued to progress well without any difficulty and had
no evidence of ischemia or changes on the EKG. On post-operative
day number three , the patient developed a productive cough and
chest X-Ray was obtained which showed only atelectasis and small
bilateral effusions but no consolidation or infiltrate. Patient
was encouraged to cough and deep breath and the productive cough
resolved without any antibiotic treatment. The nasogastric tube
was discontinued on post-operative day number five and the patient
began tolerating clear sips without any difficulty. By
post-operative day number six , the patient was on a regular diet
and had a bowel movement times six. Patient was discharged on
post-operative day number seven without any complications.
DISPOSITION: DISCHARGE MEDICATIONS: Glyburide 2.5 mg every day ,
Lovastatin 20 mg every day , Aspirin one every day , Colace 100
mg twice a day , Axid 150 mg twice a day , Percocet one to two every 4-6h. as needed
pain. The disposition on discharge is no heavy lifting times six
weeks and the patient is to follow-up with Dr. Bowcutt in seven to
eight days for staple removal from his wound. Pathology was
adenocarcinoma of the colon 4 cm in size , clear margins , and ten
out of ten nodes were negative. It was Duke's class B2. Patient
is discharged home in stable condition.
Dictated By: MA G. YEAGLEY , M.D. ZX90
Attending: SIU F. BOWCUTT , M.D. KY4
EF281/9798
Batch: 4200 Index No. FMND5310G1 D: 8/2/94
T: 9/8/94
Document id: 1126
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281676199 | PUO | 45516411 | | 3090491 | 9/21/2004 12:00:00 a.m. | cad | | DIS | Admission Date: 3/14/2004 Report Status:
Discharge Date: 8/5/2004
****** DISCHARGE ORDERS ******
ROLLAG , BENNY E. 274-01-24-2
Ri Kan Brida
Service: CAR
DISCHARGE PATIENT ON: 10/22/04 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REEDY , LILIA DOMINGA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
LASIX ( FUROSEMIDE ) 20 MG orally twice a day
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain
Instructions: Do not administer if receiving intravenous
nitroglycerin.
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 9/23/04 by BURDSALL , ANDREE D. , M.D. on order for NORVASC orally ( ref # 90145738 )
patient has a PROBABLE allergy to DILTIAZEM; reaction is EDEMA.
patient has a PROBABLE allergy to NIFEDIPINE; reaction is
EDEMA. Reason for override: Home meds
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Instructions: Begin Plavix tomorrow if a loading dose was
administered on the day of the procedure.
NOVOLOG ( INSULIN ASPART ) 50 UNITS subcutaneously every afternoon
NOVOLOG MIX 70/30 ( INSULIN ASPART 70/30 ) 48 UNITS subcutaneously every day before noon
LABETOLOL 200 MG orally twice a day
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: no heavy lifting for 3-4 days
FOLLOW UP APPOINTMENT( S ):
Dr. Toni 1-2wks ,
ALLERGY: intravenous Contrast , LIDOCAINE , DILTIAZEM , LISINOPRIL ,
LOSARTAN , NIFEDIPINE
ADMIT DIAGNOSIS:
CAD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cad
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid obesity HTN UTI Possible meningitis ( viral )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
history of cardia cath
BRIEF RESUME OF HOSPITAL COURSE:
55 year-old F. Positive SPECT study for non-anginal CP ,
SOB and palpitations. Known for IDDM , HTN and obesity. Via Rt Radial
access , angiogram was done and confirmed that there was a mid-LAD
lesion as well as 2 sequential RCA lesions ( mid
and distal ). The former lesion was treated with
2.5x28 Cypher while RCA lesion were treated with a
Cypher 3.5x18 ( mid ) and 3.0x23 ( distal ). PCI done
under Angiomax. Radial access was pulled postPCI.
No complication.
2/25/04
patient stable and ready for d/c
ADDITIONAL COMMENTS: Please take Plavix 75mg everyday for at least 90 days and Aspirin for
life. DO NOT STOP either of these medications without speaking to your
cardiologist first.
Call with any questions or concerns
Follow-up with Dr. Toni in 1-2 wks
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STRAUHAL , MARCELINA ( ) 10/22/04 @ 10:39 a.m.
****** END OF DISCHARGE ORDERS ******
Document id: 1127
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583501406 | PUO | 16045109 | | 428916 | 2/2/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: Report Status: Signed
Discharge Date: 6/20/1999
PRINCIPAL DIAGNOSIS: RIGHT HIP OSTEOARTHRITIS
SURGERY: RIGHT TOTAL HIP REPLACEMENT ON 6/27/99
HISTORY OF PRESENT ILLNESS: Mr. Lohn is a 68 year old man who
presents for total hip replacement on
the right for end-stage osteoarthritis. The patient has a long
history of progressive right hip pain , and he has become
increasingly impaired with ambulation for which he requires the
support of a cane.
PAST MEDICAL HISTORY: Notable for osteoarthritis , coronary artery
disease status post myocardial infarction in
1982 , chronic atrial fibrillation , history of pulmonary
thromboembolism in 1972 , non-insulin dependent diabetes mellitus ,
sleep apnea.
PAST SURGICAL HISTORY: Notable for abdominal aortic aneurysm
repair , right inguinal hernia repair , left
inguinal hernia repair , status post pacemaker in 1997.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Imdur 30 mg in the morning , Verapamil
40 mg four times a day , digoxin 0.25 mg
per day , allopurinol 300 mg once a day , Coumadin 2 mg , 2 mg , 1 mg
three day cycle , Nitrostat as needed , Neurontin 200 mg 4-6 a day ,
aspirin 81 mg once a day , glyburide 125 mg once a day , triamterene
37.5/25 once a day that is 2 tablets , 2 tablets and 0 tablet three
day cycle.
PHYSICAL EXAM: This is an elderly male ambulating with a cane.
Blood pressure 90/70 , pulse 60 , no adenopathy.
HEENT: Pupils equal , round and reactive to light and
accommodation. Oropharynx is clear. LUNGS: Clear to auscultation.
HEART: Pacemaker in the chest wall. Regular rate and rhythm.
EXTREMITIES: Right hip range of motion is 10-95 degrees , 0-15
degrees of external rotation , 0-5 degrees of internal rotation.
Neurovascularly intact except for some decreased sensation in the
right foot which is baseline. He has a trace pulse dorsally.
HOSPITAL COURSE: The patient was taken to the operating room on
6/27/99 for osteoarthritis of the right hip. He
had a right total hip replacement performed without complication
and the patient was transferred to the floor. He required a
cardiology consultation postoperatively. They felt he was stable
and there was no need for cardiac monitor. They reminded us that
his INR should be 2.0-3.0. He received all of his autologous units
of blood and was transferred to rehabilitation on the fourth
postoperative day.
DISPOSITION ON DISCHARGE: The patient will be sent to the
rehabilitation facility in stable
condition.
MEDICATIONS ON DISCHARGE: Imdur 30 mg in the morning , Verapamil
40 mg four times a day , digoxin 0.25 mg
once a day , Allopurinol 30 mg once a day , Coumadin 2 mg , 2 mg , 1 mg
alternating a three day cycle , Nitrostat as needed for chest pain ,
Neurontin 300 mg 4-6 a day as needed , aspirin 81 mg once a day ,
Glyburide 1.25 mg once a day , Triamterene 37.5/25 2 tablets , 2
tablets and 0 tablets in a three days cycle. For pain he is on
Darvocet N/100 1-2 by mouth every 3-4h as needed pain.
DISCHARGE INSTRUCTIONS: The patient will need to be on Coumadin
long term. Please contact his
cardiologist for dosing. His INR goal should be 2.0-3.0. He needs
to go back on his aspirin. He needs to undergo the standard total
hip protocol. Please schedule follow up appointment for Dr.
Irving Escalante in approximately 6 weeks time.
CONDITION ON DISCHARGE: Stable.
Dictated By: KIA MIERZWIAK , M.D. YE07
Attending: IRVING ESCALANTE , M.D. YR8
NE308/6674
Batch: 7265 Index No. G7GDQ969YJ D: 4/30/99
T: 4/30/99
Document id: 1128
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CHF |
Dp |
DM |
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GER |
Gou |
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228929386 | PUO | 26756252 | | 5484190 | 1/13/2004 12:00:00 a.m. | GERD | | DIS | Admission Date: 9/17/2004 Report Status:
Discharge Date: 10/10/2004
****** DISCHARGE ORDERS ******
NARET , KATHELEEN E. 826-89-69-5
U Land Sand
Service: MED
DISCHARGE PATIENT ON: 9/19/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
ISORDIL ( ISOSORBIDE DINITRATE ) 40 MG orally three times a day
LISINOPRIL 20 MG orally every day
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally three times a day
Instructions: with meals
VERAPAMIL SUSTAINED RELEAS 120 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
INSULIN 70/30 ( HUMAN ) 32 UNITS subcutaneously every day before noon
Number of Doses Required ( approximate ): 4
INSULIN 70/30 ( HUMAN ) 8 UNITS subcutaneously every afternoon
Number of Doses Required ( approximate ): 4
NEURONTIN ( GABAPENTIN ) 300 MG orally every bedtime
COZAAR ( LOSARTAN ) 25 MG orally every day
Number of Doses Required ( approximate ): 4
VIOXX ( ROFECOXIB ) 25 MG orally every day
Food/Drug Interaction Instruction Take with food
ESOMEPRAZOLE 40 MG orally twice a day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Romig - please schedule for 2-3 weeks ,
ALLERGY: Nortriptyline ( nortriptyline hcl ) ,
Glucophage ( metformin ) , Labetalol ( labetalol hcl ) ,
Albuterol ( inhaler ) ( albuterol inhaler ) , Penicillins
ADMIT DIAGNOSIS:
angina , GERD
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
GERD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma CP - nl echo'96/nl cath'89 DJD- motrin HTN
NIDDM tobacco abuse ? ocular chol emboli COPD
steroid-induced confusion neg ett mibi 6/19 GERD ( esophageal reflux )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
71 year-old woman with hx of GERD , ?anginal pain , DM , HTN , asthma , DJD ,
gastroparesis admitted with two episodes of chest pain on the night PTA
relieved by nitroglycerin. Chest pain was burning , substernal and
resolved 5 minutes after taking NTG. No EKG changes in the ED. Has
had past admissions for chest pain but unable to decipher GI vs.
cardiac origin. Negative dobutamine echo in '98; no CAD as of '89
catheterization. Has an atrophic left kidney.
Meds: asa , cozaar , lisinopril , lovastatin , isordil , lasix , nexium ,
neurontin , prozac , verapamil , atrovent , vioxx , insulin
Soc Hx: lives with grandson; quit tobacco in 2003; no alcohol
EKG: NSR , TWF V4-V6; LAE
***************************************
The patient was ruled out for myocardial infarction by cardiac enzymes.
Her nexium dose was increased and she was initiated on reglan. Although
she initially agreed to an ETT-MIBI ( refused dobutamine , avoiding
adenosine/persantine due to COPD/asthma ) , on the day of the procedure
she refused saying "there is nothing wrong with my heart". A similar
refusal occurred on a past admission. She is to be discharged with f/u
with Dr. Kaupp
ADDITIONAL COMMENTS: If you have any more chest pain please take a nitroglycerin. If the
pain does not go away call an ambulance. You may have heart disease
causing chest pain and so you will benefit from a stress test. Please
discuss with your doctor about scheduling this. Continue to take your
home medications. We have changed the dosing on the nexium and we have
added Reglan to help move food along.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: EBERLIN , AMAL M. , M.D. ( TS77 ) 9/19/04 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1129
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044665570 | PUO | 11803300 | | 957660 | 8/27/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/15/1990 Report Status: Unsigned
Discharge Date: 4/25/1990
DISCHARGE DIAGNOSES: 1 )ATHEROSCLEROTIC OCCLUSIVE CORONARY ARTERY
DISEASE.
2 )PERIPHERAL VASCULAR DISEASE.
3 )GLUCOSE INTOLERANCE.
PROCEDURES: 1 )Cardiac catheterization on 30 of January 2 )Reop coronary
artery bypass grafting times three by Dr. Golebiowski on
9 of June 3 )Intra-aortic balloon placement on 9 of June
HISTORY OF PRESENT ILLNESS: This patient is a 69-year-old
gentleman who has hypertension , known
diabetes mellitus , and coronary artery disease. He underwent
coronary artery bypass grafting in 1970 and a follow-up
catheterization in 1971 revealed all but one occluded saphenous
vein graft. He presents now because of accelerating angina.
HOSPITAL COURSE: He underwent cardiac catheterization on 30 of January
The cath revealed all grafts were occluded and he
had a 99% left main with severe three vessel disease. Because of
the patient's persistent chest pain with minimal exertion while in
the hospital he was taken urgently to surgery on 7 of August where he
had an intra-aortic balloon pump placed prior to his surgery. At
the time of the procedure he underwent reop coronary artery bypass
grafting times three utilizing the saphenous vein graft from the
aorta to the LAD and aorta to D1 and aorta to OM 2. His postop
course was relatively uneventful. He remained hemodynamically
stable and his intra-aortic balloon pump was discontinued on the
first postop day. There were no problems discontinuing the IABP
and despite his peripheral vascular disease there was no problem
with the balloon pump. He continued to progress satisfactorily ,
was transferred to the Stepdown Unit , and was transferred to the
floor. He was placed back on his medication and he did have some
trouble swallowing postop but he had undergone an upper GI series
two weeks prior to his procedure which was read as normal. The
rest of his postop course was uneventful. His incisions healed
quite nicely and he was discharged on postop day six. His blood
sugar was controlled with CZI sliding scale while hospitalized. He
did have mild elevation in his BUN and creatinine to 32 and 1.6.
DISPOSITION: He was discharged with close follow-up to see Dr.
Brucz in the office in four days. DISCHARGE
MEDICATIONS: Included Cardizem 60 mg three times a day , Percocet as needed pain ,
Digoxin .25 mg every daily , Trental 400 mg twice a day , and Ecotrin one every
daily. His discharge instructions include a regular diet , no heavy
lifting or driving for at least six weeks. FOLLOW-UP: With Dr.
Golebiowski in approximately six weeks time. He will see Dr. Brucz for
diabetic care as well as routine postoperative visit.
________________________________ II804/5553
LOIDA F. GOLEBIOWSKI , M.D. MC6 D: 10/25/90
Batch: 7052 Report: U3823P23 T: 11/20/90
Dictated By: CELESTINE T. JANNING , M.D. LU40
Document id: 1130
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717671856 | PUO | 59553955 | | 736977 | 8/28/1998 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 6/1/1998 Report Status: Signed
Discharge Date: 4/12/1998
PRINCIPAL DIAGNOSIS: TRACHEOBRONCHITIS.
SECONDARY DIAGNOSES: ( 1 ) STATUS POST ST. JUDE'S MITRAL VALVE
REPLACEMENT 1996.
( 2 ) STATUS POST TWO VESSEL CORONARY ARTERY
BYPASS GRAFT ( CABG ) 1996.
( 3 ) HISTORY OF ASTHMA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE.
( 4 ) HYPERTENSION.
( 5 ) GALLSTONES.
( 6 ) PULMONARY DISEASE ( PUD ).
( 7 ) HIATAL HERNIA.
( 8 ) MIGRAINES.
( 9 ) FIBROMYALGIA.
( 10 ) OSTEOARTHRITIS.
( 11 ) STATUS POST TOTAL ABDOMINAL HYSTERECTOMY
BILATERAL SALPINGO-OOPHORECTOMY.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old woman ,
who is status post MVR and CABG , who
presented with orthopnea and dyspnea on exertion for three days.
She recently presented with CHF/bronchospasm syndrome in 1996 that
was ultimately ascribed to mitral regurgitation and thought
secondary to rheumatic heart disease. Her symptoms resolved after
St. Jude's mitral valve replacement in 2/10 She has been in her
usual state of health until approximately one week before
admission , when she contracted a flu-like illness with fever , cough
productive of yellow sputum , headache , and diffuse myalgias ,
postnasal discharge. She was prescribed amoxicillin by her primary
care provider with minimal relief. Approximately three days before
admission she noted increasing shortness of breath when lying flat
accompanied by cough and wheezing. She has also had dyspnea on
exertion such as while doing laundry. She denies chest pain ,
except some soreness at her CABG scar whenever she coughs. She
denies light-headedness or palpitations. She does describe
increasing lower extremity edema compared to her baseline. She has
no calf tenderness. She denies significant dietary indiscretion or
medical noncompliance.
ALLERGIES: Codeine causes nausea or vomiting. Iodine causes
hives. Morphine causes respiratory distress.
MEDICATIONS: Coumadin , Lopressor , Lasix , Zantac , Elavil , K-Dur ,
and Premarin.
PHYSICAL EXAMINATION: VITAL SIGNS - Temp 98.2 , heart rate 94 , BP
in the ED 220/118 , later on the floor
140/78 , respiratory rate 28 , O2 sat 94% on room air , peak flow 370.
GENERAL - She is comfortable sitting upright , but has paroxysmal
coughing when lying flat. LUNGS - Crackles halfway up bilaterally ,
diffuse loud wheezing and rhonchi , especially anteriorly , JVP 6 cm.
HEART - Crisp S1 , S2 , no murmur , rubs , or gallops. ABDOMEN -
Obese , mildly distended , positive bowel sounds. No tenderness.
EXTREMITIES - 1+ peripheral edema , positive calf tenderness on
left , negative cord , negative Homan. NEURO - Non-focal. In the
Emergency Department she was treated with nebulizers with marked
clearing of her lung sounds.
LABORATORY DATA: Normal Chem-7. White count 10 , hematocrit 42.
Normal LFTs. Albumin 4.2 , physical therapy 20 , INR 3. EKG -
Normal sinus rhythm at 90 , normal axis , normal intervals , no
Q-waves , no acute ST-T wave changes. Chest x-ray - Mild
cardiomegaly , mild increase in interstitial markings , no effusions ,
no infiltrates.
HOSPITAL COURSE: She was admitted to the Cardiology Service. She
was diuresed about one liter per day. During her
admission , and echocardiogram was done on 11/7/98 that showed
normal EF , normal systolic function , and normal valve motion. She
was hemodynamically stable throughout the course of her admission ,
showing only mild symptoms of heart failure that improved with
diuresis. She was continued on Coumadin , but given half her
regular dose because of antibiotic therapy. She was afebrile with
negative cultures during her admission , but complained of severe
paroxysmal coughing especially at night. For this , she was treated
with Atrovent and normal saline nebs , Robitussin , Entex , and
Tessalon-Perles. Her dose of Lopressor was half to relieve her
bronchospasm. By the day of discharge , her cough was much improved
and she was discharged home in stable condition.
DISCHARGE MEDICATIONS: Premarin 1.25 mg orally every day; Robitussin before meals
5-10 ml orally every 4-6h. as needed cough;
Lopressor 25 mg orally twice a day; nortriptyline 125 mg orally bedtime;
Coumadin 10 mg orally every day; Axid 150 mg orally twice a day; Tessalon-Perles
100 mg orally three times a day as needed cough; Entex LA 1 tab orally twice a day as needed
cough; Lasix 40 mg orally every day By the day of discharge , she had
completed a five day course of azithromycin.
DISCHARGE FOLLOW-UP: She will follow-up with her primary care
doctor , Dr. Prall within one week. She
will follow-up with her cardiologist , Dr. Abshear in 2-3 weeks , and
with the Coumadin nurse in one day. She will also check her blood
pressure at home daily.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: CHERY ASTILLERO , M.D. CS54
Attending: SHAVONNE D. MAINER , M.D. QP3
QP430/8441
Batch: 13590 Index No. FGHCX519DT D: 2/13/98
T: 2/13/98
Document id: 1131
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CHF |
Dp |
DM |
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GER |
Gou |
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228929386 | PUO | 26756252 | | 926003 | 4/23/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/1/1993 Report Status: Signed
Discharge Date: 11/18/1993
PRINCIPAL DIAGNOSIS: 1. ASTHMA EXACERBATION
SECONDARY DIAGNOSES: 2. UPPER RESPIRATORY INFECTION
3. ATYPICAL CHEST PAIN
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old female
with the history of asthma , admitted
with increasing shortness of breath and chest congestion. She has
a history of asthma and has never been intubated. She has been
treated with steroid tapers in the past and hospitalized two times
before , most recently in 5 of September Her usual asthma exacerbant is an
upper respiratory infection. She smoked until 5 days ago. She
complained of 3-4 days of chest congestion and runny nose. She
denies any productive cough , fever , sinus tenderness or GI
symptoms. She called her KTDUOO physician and was put on Prednisone
for the past two days. She felt that her wheezing was increasing
and she came to the Emergency Ward. Her peak flow was 100. She
was treated with three nebulizers and her peak flow increased to
130. Her oxygen saturations is 95% on room air and no blood test
was done. PAST MEDICAL HISTORY: She has the history of chest
burning when she doesn't take her medications or walks too much;
has had labile T-waves in the past with catheterization in 1989 ,
revealed clean coronary arteries. There is no change with food and
there is no acid taste associated with this burning pain. She has
the history of hypertension; degenerative joint disease; anxiety;
right lower quadrant pain , ultrasound in 4 of February , revealed fatty
liver , HIDA was negative; status post hysterectomy. MEDICATIONS ON
ADMISSION: At the time of admission , the patient was on Atrovent
inhaler , Azmacort inhaler , aspirin one orally every day , Verapamil SR 240 mg
orally every am with 180 mg orally every pm , Colace 100 mg orally twice a day , Isordil 40 mg
orally three times a day , Clinoril as needed , Valium 5 mg orally four times a day as needed , Prednisone x 2
days. ALLERGIES: NKDA. SOCIAL HISTORY: She lives alone in a
second floor apartment. She has three children and
several grandchildren. She is a retired nurse aid. She denies any
history of alcohol use. She smoked 1/2 pack per day until 5 days
ago.
PHYSICAL EXAMINATION: On admission showed an obese black female in
no acute distress , able to speak without
difficulty. The blood pressure was 184/100 , pulse 80 , respiratory
rate 22 and temperature 97.8 with 96% saturations on 2 liters. The
oropharynx was clear with no erythema or exudate. The pupils
equal , round and reactive to light and accommodation; extraocular
movements were intact. The neck was supple with no
lymphadenopathy , jugular venous distention or carotid bruits. The
cardiac was regular rate and rhythm with no murmurs , gallops or
rubs. The lungs showed prolonged expiratory phase with diminished
air movement and diffuse wheezing. The abdomen was soft , non
tender , normal bowel sounds. She did have mild right upper
quadrant tenderness but no liver edge was palpable; Murphy's
significant was negative. The extremities showed trace edema
bilaterally. The neurological examination was non focal.
LABORATORY DATA: On admission was remarkable for normal SMA ,
normal CBC. The chest x-ray revealed no
infiltrate. The EKG was normal sinus rhythm with some mild T-wave
flattening.
HOSPITAL COURSE: The patient was admitted with asthma
exacerbation. She was treated with
bronchodilator nebulizers around the clock and initially intravenous
steroids. On the following day , she had mildly decreased wheezing.
Her peak flow had increased to 200. She was changed to orally
steroids. She continued to improve slowly with slow improvement in
her peak flow. Her steroid taper was begun early given the past
history of paranoia with steroids. She felt that the Bactrim gave
her cramping and therefore this was discontinued as it was felt
highly unlikely that she had a bacterial infection and much more
likely that she had a viral upper respiratory infection disposing
her to her asthma exacerbation. She slowly continued to improve
and was discharged to home to complete a steroid taper. She had no
episodes of chest pain or other difficulties while in the hospital.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on Atrovent two puffs four times a day , enteric
coated aspirin one orally every day , Verapamil SR 240 mg orally every am with 180 mg
orally every pm , Azmacort inhaler two puffs twice a day , Isordil 40 mg three times a day ,
Clinoril 150 mg orally twice a day , Alupent inhaler two puffs orally every 4 hours ,
Prednisone 40 mg orally every day x 3 days then 20 mg every day x 3 days then 10 mg
orally every day x 3 days then 5 mg orally every day x 3 days then discontinue ,
Lactulose 30 cc orally three times a day as needed FOLLOW UP CARE: The patient is to
follow up with Dr. Romig in KTDUOO in 2-3 weeks.
Dictated By: MARYJO D. LURA , M.D. JL78
Attending: PEGGY K. ROMIG , M.D. AB14
EQ861/4349
Batch: 9161 Index No. PHHJWM67XQ D: 4/8/93
T: 11/9/93
Document id: 1132
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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074457628 | PUO | 27492448 | | 2879750 | 6/28/2005 12:00:00 a.m. | Left globus pallidus hemorrhage | | DIS | Admission Date: 6/28/2005 Report Status:
Discharge Date: 10/21/2005
****** INCOMPLETE DISCHARGE ORDERS ******
SHEARER , OSWALDO 643-37-54-6
S
Service: NEU
DISCHARGE PATIENT ON: 2/7/05 AT 03:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VERNET , ROSANNE SOON , M.D.
CODE STATUS:
Full code
Incomplete Discharge
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 20 MG orally every day
HYDRALAZINE HCL 10 MG intravenous every 6 hours as needed Other:SBP>160mmHg
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously qAC , every bedtime
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
LISINOPRIL 20 MG orally every day
MAGNESIUM GLUCONATE 500 MG orally twice a day
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally every day as needed Constipation
METOPROLOL TARTRATE 25 MG orally three times a day Starting IN PM on 5/3
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 10
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Gala Racer ( primary care physician ) Next Available ,
Coletta Verry ( Neurology ) 359-688-0204 Next Available ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Left globus pallidus hemorrhage
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Left globus pallidus hemorrhage
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
aortic stenosis heart block with ppm atrial fibrillation diabetes gout CAD
BPH gout
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CT scan of brain
CXR
EKG
BRIEF RESUME OF HOSPITAL COURSE:
HPI:
82 year-old RHM with history of HTN , DM-2 , CAD and AVR ( on coumadin until 9/22 )
was last seen normal when went to nap this afternoon at 12:45pm. At
2:30pm he woke up somewhat confused with slurred speech , mild RUE
weakness. Initial vitals 148/80 , p-62. sent to FH where coags and
platelets WNL , head CT showed right thalamic bleed with 3rd ventricle
extension.
Received Mannitol -> referred to PUO ER for further with u.
PMH:
Aortic valve stenosis -history of AVR + CABG , with #25 CE-MAGNA PERICARDIAL
BIOPROSTHESIS
AVB history of Pacemaker placement ( and a-fib focus ablation )
DM-2 complicated by neuropathy and nephropathy
Gout
Glaucoma
CHF: last EF: 55%
history of right 3rd toe amp and history of left 2nd tow amp.
MEDS:
BRIMONIDINE 0.2% twice a day
LASIX 20 orally every day
XALATAN 0.005 each eye every bedtime
GLIPIZIDE 10MG orally every day
NEXIUM 20MG orally every day
FLOMAX 0.4 every day
ZOCOR 20MG every day
METOPROLOL 50MG every day
METFORMIN 1000MG twice a day
LISINOPRIL 10MG every day
NIFEREX 150 twice a day
ASA 81 orally every day
Coumadin: by report held since 9/22 , for unclear reason
ALL:
Sulfa , amoxicillin , azithro: unclear reactions
SH:
Lives with his wife , retired from a phone company. Remote ( 45y ago )
history of smoking , raer etoh
ROS: denied diplopia , numbness of face , vertigo/tinnitus , dysphagia or
dysarthria ( prior to this event ) , HA F/C/N/V , CP/pressure , heartburn ,
constipation , diarrhea , dysuria , rashes , joint aches. Reports occasional
SOB even in mild effort.
EXAM
VS: T: afebrile BP: 145/64 P: 60 RR: 18 O2 sat: 97%r.a
General: WNWD , NAD
HEENT: Anicteric , MMM without lesions , OP clear
Neck: Supple , No LAD
CV: s1s2 paced , pronounce S2 , 3/6 systolic murmur , 2/6
diastolic
Resp: CTAB
Abd: +BS Soft/NT/ND
Ext: No C/C/E , history of above amputation
MS: Awake and alert , oriented to date , place and self
Attention: DOW backwards
Memory: registration 3/3 , recall 2/3 at 5 min 3/3 with
prompting.
Language: fluent , +comprehension , +repetition , +naming intact ,
Nondominant: no neglect to DSS , able to salute/brush teeth ,
CN: II , III - pupils 3 ` 2 bilaterally , VFF by confrontation;
III , intravenous , VI - EOMI , no ptosis , no nystagmus;
V- sensation intact to LT/PP , corneal reflex intact;
VII - mild right facial weakness
VIII - hears finger rub
IX , X - voice dysarthric , palate elevates symmetrically , gag intact;
XI - SCM/Trapezii 5/5 B
XII - tongue protrudes midline
Motor: Right pronator drift. No asterixis. nl bulk and tone , no
tremor , rigidity or bradykinesia.
Strength:
| ShFl | ElFl | ElEx | WrFl | WrEx | FgSp | HpFl | KnEx | KnFl | Dors | Plan |
R | 4 | 4+ | 4+ | 5 | 4+ | 5 | 5 | 5 | 5 | 5 | 5 |
L | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
DTRs: Bi ( C56 ) BR ( C6 ) Tri ( C7 ) Pa ( L34 )Ac ( S12 )Plantar
L 2 2 2 1 0 amputated
R 1 1 1 1 0 up
Sensory: significant for decreased LT , temperature , vibration
distally up to knees
Coord: finger tap rapid & symm , FNF & finger follow intact ( for
weakness ). foot tap rapid & symm.
Gait: deferred
LABS:
SODIUM 141 ( 136-142 )
mmol/L
POTASSIUM 4.7 ( 3.5-5.0 )
mmol/L
CHLORIDE 103 ( 98-108 )
mmol/L
TOTAL CO2 29 ( 23-32 )
mmol/L
ANION GAP 9 ( 3-15 )
mmol/L
CK 33 * ( 41-266 )
U/L
CKMB QUANT 1.7 # ( 0.0-5.0 )
ng/mL
CALCIUM 9.0 ( 8.8-10.5 )
mg/dL
MAGNESIUM 1.6 * ( 1.8-2.5 )
mg/dL
cTn-I See Result Below ( 0.00-0.10 )
ng/mL
GLUCOSE 130 * ( 54-118 )
mg/dL
UREA N 20 ( 9-25 )
mg/dL
CREATININE 0.9 ( 0.7-1.3 )
mg/dL
eGFR 86
WBC 7.83 ( 4-10 )
K/uL
RBC 4.15 * ( 4.5-6.4 )
M/uL
HGB 11.9 * ( 13.5-18.0 )
g/dL
HCT 35.5 *# ( 40-54 )
%
MCV 85.6 # ( 80-95 )
um3
MCH 28.7 ( 27-32 )
uug
MCHC 33.6 ( 32-36 )
g/dL
RDW 13.9 ( 10-14.5 )
PLT 215 # ( 150-450 )
K/uL
LYMP % 24.2 ( 18-41 )
MONO % 6.7 ( 2.5-8.5 )
NEUT % 65.9 ( 48-76 )
EOS % 2.6 ( 0-5 )
BASO % 0.6 ( 0-1.5 )
LYMP # 1.89 ( 0.8-4.1 )
K/uL
MONO # 0.52 ( .10-0.8 )
K/uL
NEUT # 5.16 ( 1.9-7.6 )
K/uL
EOS # 0.21 ( 0-0.5 )
K/uL
BASO # 0.04 ( 0.00-0.15 )
K/uL
physical therapy 14.3 # ( 11.8-14.6 )
sec
PTT 29.2 # ( 23.8-36.6 )
sec
physical therapy( INR ) 1.1 ( 0.9-1.1 )
CT I-:
Small left putamminal bleed extending above l-thalamus. Small amount of
blood in left occipital horn. Stable compared to CT at NVH
A/P:
82 year-old RHM with history of HTN , DM-2 , CAD and AVR ( on coumadin until 9/22 )
was last seen normal when went to nap this afternoon at 12:45pm. At
2:30pm woke up dysarthric , mild RUE weakness. His wife noticed slowing
and confusion. Head CT at NVH ( repeated here ) showed small left BG bleed ,
extending to left lateral ( occipital horn ). Given location , most likely
hypertensive bleed. Cannot rule out underlying small stroke. Given history of
AVR will r/o endocarditis as well. Plan
1. admit to NICU. When transfer to the floor LMC
2. BP control with home regimen. keep SBP<140
3. Hold ASA. Continue holding coumadin , clarify indication in
the future
4. Hold metformin for now ( in case needs CT/A ) , add insulin
sliding scale
Brief Hospital Course:
The hemorrhage was stable on follow-up imaging. INR was 1.1.
Neurologic exam was stable , with persistent dysarthria , right pronator
drift , and mild right leg weakness. Patient evaluated by physical therapy/OT and
deemed appropriate candidate for acute rehab.
Cardiovascular: Continued to be in atrial fibrillation. Pacemaker was
firing , but on 5/25 pm had an episode of heart rate 30's x few seconds , and for
rest of night heart rate 40's - 50's. EKG unchanged from admission - atrial
fibrillation , left anterior fascicular block , some pvc's. Consulted
LMC Cardiology , who analyzed the telemetry and found that bradycardic
readings were artifactual. There was no EKG obtained during bradycardia
and no documented physical exam findings to suggest bradycardia.
Cardiology felt there was no other evidence of pacer malfunction.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Fair
TO DO/PLAN:
Follow up with outpatient cardiologist , neurologist , and primary care physician.
No dictated summary
ENTERED BY: RACZ , MIREILLE N. , M.D. ( TW73 ) 2/7/05 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1133
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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446035935 | PUO | 58141286 | | 5024079 | 4/20/2006 12:00:00 a.m. | same | | DIS | Admission Date: 1/26/2006 Report Status:
Discharge Date: 7/27/2006
****** FINAL DISCHARGE ORDERS ******
HOUDE , FAE 934-41-82-3
Lu Co
Service: GGI
DISCHARGE PATIENT ON: 4/3/06 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MIRIELLO , MILAGROS , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ROCALTROL ( CALCITRIOL ) 0.5 MCG orally twice a day
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ )
1 , 000 MG orally every 6 hours
Instructions: 500mg elemental calcium is the equivalent of
1250mg of calcium carbonate
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
Starting Tomorrow ( 7/21 )
SYNTHROID ( LEVOTHYROXINE SODIUM ) 200 MCG orally twice a day
Instructions: ( typical dose is 1 mcg per lb. )
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
ATENOLOL 100 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Miriello please call to schedule ,
Primary Care please call to schedule ,
ALLERGY: Erythromycins
ADMIT DIAGNOSIS:
metastatic thyroid cancer
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OBESITY SLEEP APNEA PNEUMONIA
OPERATIONS AND PROCEDURES:
LT. PARATRACHEAL & MODIFIED RADICAL NECK DISSECTION DR MIRIELLO 3/10/06
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
43 year-old F with metastatic tall cell papillary ca to bilateral IJ nodes.
history of RAI
history of Left paratracheal and modified radial neck dissection.
Left recurrent laryngeal nerve was identified.
Left parathyroids were not identified , and were not seen in the specimen.
She is already moderately hypoparathyroid from her total thyroidectomy in
8/18 ( pre op ca 7.6 )
The left IJ was noted to be clotted at the end of the case and was
ligated.
mild oozing in the upper portion of the surgical bed was treated with
fibrillar ( cotton surgicel ).
The inferior aspect of the wound was quite deep ( thymus taken with the
specimen ).
7 JP drain placed along the dissection bed.
PMH: asthma , PSVT in 2001 , obesity , obstructive sleep apnea , thalessemia
trait
PSH: gastric bypass 15 of May , history of cholecystectomy , bowel obstruction 2/1
total thyroidectomy 5/9
Meds: atenolol 100 every day , hctz 25 every day , levoxyl 200 twice a day , rocaltrol 0.5 twice a day ,
calcium 500 mg elemental 6 times per day.
All: erythromycin leads to GI upset.
patient underwent the above procedure , brief desciption as above , please see
operative note for full details. patient tolerated the procedure well. patient's
diet was advanced , pain was well controlled on orally medications. ON
pod#0 patient was hypertensive requiring multiple doses of intravenous medication
( labetalol and hydralazine ) in order to control. pod#1 she was
restarted on all her orally medications and her pressure lowered
appropriately. pod#1 , she ate a fatty meal as instructed for lunch
and there was no evidence of a chyle leak and her JP drain was
d/c'd. Her serum calcium levels were 7.5 and a recheck was 8.1. the patient was
neurologically intact , af , hd stable and wound was c/d/i. patient was deemed
ready for d/c to f/u c dr weisinger patient to call to schedule.
ADDITIONAL COMMENTS: 1. Please call if fever greater than 101.5 , if increased redness around
wound , if discharge from wound , if increased pain uncontrolled by pain
medications.
2. Please do not immerse wound in bath , swimming , or sauna for 2 weeks.
3. Please do not drive while taking narcotics.
4. Please follow up with primary care provider concerning
hospitalization.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE , M.D. ( UK91 ) 4/3/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1134
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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333208802 | PUO | 98278947 | | 2040740 | 11/6/2006 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 6/7/2006 Report Status:
Discharge Date: 5/2/2006
****** FINAL DISCHARGE ORDERS ******
MCCOOEY , CHRISTAL 842-76-53-8
Ville , Colorado 48970
Service: MED
DISCHARGE PATIENT ON: 2/29/06 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CASSEM , JERAMY S. , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASPIRIN ENTERIC COATED 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally BEDTIME
Alert overridden: Override added on 2/29/06 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override:
patient's home med regimen
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LASIX ( FUROSEMIDE ) 20 MG orally twice a day Starting Today ( 8/21 )
HOLD IF: sbp<100
LANTUS ( INSULIN GLARGINE ) 34 UNITS subcutaneously BEDTIME
Starting Today ( 8/21 )
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
LOSARTAN 50 MG orally DAILY HOLD IF: sbp<100
Alert overridden: Override added on 7/11/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LOSARTAN POTASSIUM Reason for override: aware
Previous Override Notice
Override added on 7/11/06 by KINDERKNECHT , OLIMPIA K. , M.D. , M.P.H.
on order for KCL IMMEDIATE RELEASE orally ( ref #
852241397 )
POTENTIALLY SERIOUS INTERACTION: LOSARTAN POTASSIUM &
POTASSIUM CHLORIDE Reason for override: aware
Number of Doses Required ( approximate ): 4
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Override Notice: Override added on 7/11/06 by
DUSSAULT , LARAINE , M.D. on order for ZOCOR orally ( ref # 118208519 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: monitor
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Tetrick 486-705-2610 4/17/06 @ 10:50 am ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
TYPE intravenous HYPERCHOLESTEROLEMIA SMOKER FHX HTN history of CABG CAD
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
chest x-ray
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB and LEE
****
HPI: 49M with history of CAD , history of CABG , HTN , DM who presents with
progressive SOB , DOE for the last couple of weeks , orthopnea ,
and swelling of his legs ( dry weight 90Kg on last admission ).
Denies CP , or palpitations. Stopped all his medication recently ( states
too many medications , copays expensive ) and doesn't adhere to low salt
diet. primary care physician mentioned that he has begun to consume more alcohol recently ,
and that may be the reason for medical non-compliance.
****
PMH: HTN , CAD , history of CABG 1999 ( SVG->PDA , OM1 , D1 LIMA->LAD ) , history of Cath
2004 ( DES to LAD ) , Hypothyroidism and ETOH abuse.
****
Meds last D/C: Aspirin 81mg , Plavix 75 , Lasix 40 twice a day , Levoxyl 100mcg ,
SLNTG , MVI , Thiamine , Folic Acid , Zocor 20 , Metformin 1gr twice a day ,
Losartan 50mg , Coreg 12.5mg twice a day , Lantus 20 every bedtime , Zetia 10mg , Advair ,
Prilosec.
****
Exam: VS: 97.5 , 100R , 144/103 , 22 , 99% PA.
NAD , JVP 12cm , lungs B basilar crackles R>L , PMI displaced lateral ,
RRR S1 S2 , +S3 , 2/6 systolic murmur , 2+LE edema
****
Labs/Studies: Normal CBC and Chem-7 , Cr-1.0 BNP 923 CXR- Cardiomegaly ,
mild edema EKG:NSR , nl axis , and intervals , LAE , TWI V3-6
( unchanged ). Echo 6/4 LVEF-25% , mod MR , TR
***
HOSPITAL COURSE BY PROBLEM:
#CHF: EF 25% , systolic and diastolic dysfunction , decompensation in the
setting of medical and dietary noncompliance. patient's last dry weight 6/4
90kg ( 198lbs ). patient diuresed with lasix to 197lbs this admission ,
beta-blocker held while admitted. patient will continue ASA , ARB , statin ,
beta-blocker as outpatient. patient currently NYHA class 2 , can consider
addition of spironolactone to patient's regimen--deferred for now in the
interest of simplifying patient's regimen given patient's history of non-compliance with
too many medications. patient to continue lasix as outpatient 20mg orally twice a day
-please recheck K in 1-2 weeks to see if patient needs orally K replacement
on lasix
-started toprol xl 25mg every day
-can consider ICD placement in patient with low EF
-restarted plavix per primary care physician's rec
-restarting lipitor for patient's hyperchol , holding zetia for now wanting to
simplify regimen , but can restart as outpt if needed
#COPD: patient with CXR c/with COPD , with long smoking hx. Patient's initial SOB
likely 2/2 CHF , reports breathing much improved with diuresis.
-consider PFTs as outpatient
-advair inhaler
#IDDM:-restarted patient on lantus insulin with insulin-aspart before
meals and held metformin while in hospital.
-last HgA1c 10.9 in 10/5
-HgA1C drawn , pending
-patient to continue lantus , metformin. consider adding short-acting insulin
prior to meals as outpt , currently starting on only lantus to simplify
regimen.
#history of hypothyroid , TSH>50 this admission. patient reports not taking levoxyl
-continue levoxyl at prior dose
-F/U TSH level in 1 month
-drew fT4 level as inpatient , pending
#history of EtOH abuse: patient has no history of withdrawal szs/DTs
-continue MVI , can restart folate/thiamine as outpt if needed
#CODE STATUS: patient reports wants to be DNR/DNI
primary care physician: Dr. Tetrick
ADDITIONAL COMMENTS: Please bring a copy of D/C sum to Pcp appt
DISCHARGE CONDITION: Stable
TO DO/PLAN:
check K as outpatient while on lasix
No dictated summary
ENTERED BY: KINDERKNECHT , OLIMPIA K. , M.D. , M.P.H. ( UT26 ) 2/29/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1135
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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259895307 | PUO | 80528967 | | 9249801 | 9/6/2005 12:00:00 a.m. | Asthma exacerbation | | DIS | Admission Date: 11/10/2005 Report Status:
Discharge Date: 4/14/2005
****** DISCHARGE ORDERS ******
SWARTZBAUGH , MALCOLM 191-06-56-4
Sey Histercharl Xand
Service: MED
DISCHARGE PATIENT ON: 9/26/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WARRAN , MARCOS , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
CARDIZEM SR ( DILTIAZEM SUSTAINED RELEASE ) 120 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/5/05 by GORRELL , JULIETTE D. , M.D. on order for LOPRESSOR orally ( ref # 06639813 )
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: aware
Previous override information:
Override added on 4/9/05 by MAGBITANG , BENITA , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: ok
Number of Doses Required ( approximate ): 99
HYDROCHLOROTHIAZIDE 25 MG orally every day
LISINOPRIL 30 MG orally every day
Override Notice: Override added on 4/9/05 by
KANOZA , CHER L. , M.D. , PH.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
96552435 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
LORAZEPAM 0.5 MG orally twice a day as needed Anxiety
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally twice a day
Starting Today ( 9/5 ) HOLD IF: HR<50 , SBP<100
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Reason: Override added on 4/9/05 by
MAGBITANG , BENITA , M.D.
on order for CARDIZEM SR orally ( ref # 21228040 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: ok
Previous override information:
Override added on 4/9/05 by MAGBITANG , BENITA , M.D.
on order for CARDIZEM orally ( ref # 71692349 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: ok
PREDNISONE 40 MG orally every day before noon X 10 doses
Starting Today ( 9/5 )
Instructions: Taper: 40mg for 2 days , then 35mg for 2days ,
then 30mg for 2days , then 25mg for 2days , then 20mg
indefinitely.
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
CLOPIDOGREL 75 MG orally every day
CALCIUM CARB + D ( 600MG ELEM CA + VIT D/200 IU )
1 TAB orally every day
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
ATOVAQUONE 750 MG orally twice a day
Food/Drug Interaction Instruction Give with meals
NAPROSYN ( NAPROXEN ) 250-500 MG orally twice a day as needed Pain
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 9/26/05 by :
POTENTIALLY SERIOUS INTERACTION: CLOPIDOGREL BISULFATE &
NAPROXEN Reason for override: musculoskeletal pain
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. TETRICK , primary care physician 2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
asthma exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Asthma exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of NSTEMI , stent to LAD OBESITY OSA HTN
diabetes mellitus 2/2 chronic steroid use
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ECHO
BRIEF RESUME OF HOSPITAL COURSE:
45 Yo obese F ho IDDM , sleep apnea , asthma on
chronic prednisone , HTN , CAD history of NSTEMI in 9/21 with stent to LAD
presents with SOB x 3 days. patient was in USH until 2 days PTA , when she
noticed sudden onset of shortness of breath and chest pressure. She
states that her chest feels heavy at times , sometimes worse when taking
a deep breath. She states that since onset of chest pressure , her chest
tightness has become more severe and worse with exertion. She also states
that she occasionally gets palpitations since her MI , but no
N/V/diaphoresis. patient states that she has also developed a dry cough over
past few days , no fevers , no sick contacts. No lower ext edema , but has
had stable 3-pillow orthopnea and PND.
PE: BP 170/105 HR 80 100%RA
NAD , AOx3 , JVP 8cm , sternum tender to palpation , bilat exp wheezes
throughout , prolonged expiratory phase , s1 s2 , abd soft , no
c/c/e
labs: trop neg x3 , D-dimer<200 , BNP 19
EKG: NSR , nl Axis , no ST changes
CXR: lungs clear bilaterally , costophrenic sulci sharp bilat , no acute
pulm process
45 year-old F IDDM , known CAD history of recent MI with stent to LAD , asthma on chronic
prednisone , presents with 3 days worsening dyspnea and chest pressure. patient
treated for asthma exacerbation with prednisone and no relief of symptoms.
Given known CAD , recent MI , ho PND and orthopnea , considered both cardiac
and pulmonary etiologies of symptoms.
CV: ROMI with neg cardiac enzymes x3 , no ischemic changes on ECG. ECHO
shows concentric LVH but EF 65% , no evidence of wall motion abnormalities
or systolic/diastolic dysfunction. BNP , TnI normal. JVP 8cm. One episode
of subjective palpitations during
admission , with no evidence of arrhythmia on telemetry. She did have one
brief episode of apparent broad-complex tachycardia on telemetry which , on
closer inspection and review by the EP fellow , was clearly shown to be
artefactual ( normal sinus rhythm observed throughout in lead I ).
Ischemia: continue zocor , clopidogrel , ECASA. nitrates as needed.
Pump: continue lisinopril , HCTZ , cardizem. Lopressor 12.5mg orally twice a day.
Rhythm: NSR. stable.
Pulm: Dyspnea and wheezing with ho multiple asthma exacerbations on
presentation. Never hospitalized , chronic prednisone therapy. history of gentle
diuresis , pred , nebs with improvement of symptoms. D-dimer<200.
Admission peak flow 150 ( baseline nl 300-350 ) , at discharge 275-300.
Ambulatory O2 sat WNL
-Combivent , Advair , steroid taper ( 40mg to 20mg over 8 days ) , primary care physician ppx
with twice a day Atovaquone in setting of chronic prednisone.
ENDO: Chronic steroid use , Insulin SS in-house. -calcium/vit D
supplement.
MUSC: Reproducible sternal pain on palpation consistent with
costochondritis. Naprosyn as needed pain.
Psych: Continue Zoloft for depression and Lorazepam for anxiety.
PPx: PPI
FULL CODE
ADDITIONAL COMMENTS: Please call your primary care physician or come to the emergency room if you experience any
of the following: loss of consciousness , chest pain , difficulty
breathing , swelling in legs.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Assess:
-efficacy of prednisone 20mg upon completion of taper.
-status of dyspnea/asthma symptoms on low dose beta-blocker.
-chest pain/costochondritis with as needed NSAIDs.
-compliance with atovaquone ppx.
No dictated summary
ENTERED BY: MAGBITANG , BENITA , M.D. ( LV88 ) 9/26/05 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1136
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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761622641 | PUO | 80826409 | | 9069769 | 2/6/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/20/2006 Report Status: Signed
Discharge Date:
ATTENDING: BRAUCKS , SHERRILL M.D.
INTERIM DICTATION THROUGH September , 2006
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This patient is a 69-year-old woman
with diabetes , hypertension , congestive heart failure ,
rheumatologic overlap syndrome with rheumatoid
arthritis/dermatomyositis , who was admitted for chest wall pain.
Of note , two weeks prior to admission , the patient reports a fall
during which she hit her chest on the floor. Upon admission , the
reasons for the patient's chest pain were unclear. Her cardiac
enzymes were negative and her EKG was unchanged. Chest x-ray was
negative for infiltrate. However , soon after the patient was
admitted to the floor she had high fevers and grew out
methicillin-resistant Staphylococcus aureus from her blood.
PAST MEDICAL HISTORY:
1. Dermatomyositis diagnosed in 2006.
2. Insulin-dependent diabetes complicated by neuropathy.
3. Hypertension.
4. History of Graves' disease status post radiotherapy.
5. Rheumatoid arthritis/rheumatologic overlap syndrome.
6. Status post SBO.
7. B12 deficiency.
8. Idiopathic cardiomyopathy ( ejection fraction 45% ).
ALLERGIES: Penicillin , aspirin , codeine , Zocor.
SOCIAL HISTORY: The patient lives alone in Hi Burb Sbrid , NV She
has a home VNA two times per week. She is a former smoker , but
denies intravenous drug use and ethanol use.
STUDIES:
1. Transthoracic echocardiogram performed on March , 2006
revealed a left ventricle normal in size. Estimated ejection
fraction was 55% ( previous echocardiograms had showed an ejection
fraction of 45% ). There were no regional wall motion
abnormalities. There was no significant pericardial effusion.
No vegetations were seen.
2. Transesophageal echocardiogram performed on May , 2006
revealed a normal left ventricular wall thickness with no
regional wall motion abnormalities , trace mitral regurgitation
was seen. There was no evidence of valvular vegetations or
abscesses.
3. A CT scan of the chest without contrast on August , 2006 showed
a slight soft tissue prominence at the costosternal joint , but no
abscess and no bone destruction was seen. There was no drainable
fluid collection or bone destruction seen on the scan. MRI on
May , 2006 revealed a linear low signal within the sternum
suspicious for a fracture with adjacent rim-enhancing collection
extending both anterior and posterior to the sternum , suspicious
for an abscess. Hematoma is also possible.
HOSPITAL COURSE:
1. Cardiovascular: The patient had a negative rule out
myocardial infarction protocol. She was maintained on her
antihypertensive medications during her hospitalization and she
was hemodynamically well controlled. Because the patient had
MRSA bacteremia upon admission and because the patient had
elevated ESR and CRP , endocarditis was entertained as a possible
diagnosis. TTE and TEE , however , showed no vegetations on the
patient's valves. The patient's CRP on May , 2006 was 135 , the
patient's ESR on November , 2006 was 90.
2. Infectious disease: The patient had fevers upon admission to
greater than 101. Initial blood cultures revealed four of four
bottles to be MRSA bacteremia. Despite treatment with
vancomycin , the patient also had positive blood cultures on August , 2006. At the time of this dictation , the patient had negative
blood cultures from September , 2006 through March , 2006. She had a
bandemia to 6 on admission. It was not obvious initially what
the source was of the patient's MRSA bacteremia. Given her
elevated ESR and CRP , endocarditis was entertained as a
diagnosis. However , both TTE and TEE showed no evidence of
vegetations on the valves. The patient had a soft tissue
prominence on examination over her sternal manubrial joint on the
right side of her sternum. The original CT scan showed a soft
tissue prominence but no fluid collection. However , MRI on May , 2006 showed evidence of an abscess or hematoma in the right
subpectoral region. The patient had a CT-guided aspiration
performed on February , 2006 and 15 mL of pus was removed. The
drain was left in place. Studies from this fluid were pending at
the time of this dictation. However , the Thoracic Surgery
Service was consulted for possible debridement of the wound.
Infectious disease service was also consulted concerning the
timing for the placement of the PICC line , as well as the
duration of the patient's vancomycin.
3. Musculoskeletal: Chest x-ray showed evidence of an old left
shoulder fracture.
4. Rheumatology: The patient was maintained on prednisone for
dermatomyositis.
5. Endocrine: The patient was maintained on her home dose of
NPH. On this dose , the patient's blood sugars were well
controlled. The patient's TSH was measured A6 at 5.129 with a T4
of 7.2 and a THBR of 1.27. The patient's dose of Synthroid was
not altered.
6. Hematology: The patient was anemic on admission with
hematocrits ranging from 24-29. B12 level on November , 2006 was
199. She was given supplementation , both orally and intramuscular , and on
November , 2006 her B12 level was 842. She was also found to have
both iron deficiency anemia and anemia of chronic disease. Iron
studies from September , 2006 revealed an iron less than assay , a TIBC
of 202 , and ferritin 182. The patient was started on orally iron
supplementation during her hospitalization.
7. Skin: The patient was noted to have excoriations and open
lesions on her legs , which were likely due to itching. The
patient was given Bactroban. All of these excoriations were
clean , dry and intact. There was no evidence of infection.
9. Neurologic: The patient was maintained on amitriptyline and
Neurontin during her hospital stay.
10. Renal: On November , 2006 , the patient had a creatinine to
1.7. It is the feeling of the team that this is due to
gentamicin toxicity. At one point during the patient's
hospitalization , gentamicin had been added for synergistic effect
with vancomycin. Gentamicin had been added as the patient was
continuing to spike fevers despite vancomycin treatment. When
the patient's creatinine began to rise , gentamicin was
discontinued. Creatinine will likely resolve with time without
gentamicin administration in the future.
A component of the arf was due to repeated gadolidium exposure from repeat
mri of sternum and a hemodynamic with worsening when acei reinitiated.
PHYSICAL EXAMINATION: March , 2006: In general , the patient is
fatigued and somnolent. At multiple times during the patient's
hospitalization , she became difficult to arouse. Upon touching
her sternum , however , the patient opened her eyes and was alert
and oriented. This seems to be her baseline behavior. There was
no lymphadenopathy. Cardiovascular exam revealed regular rate
and rhythm , normal S1 , S2. No murmurs , rubs or gallops. The
patient had bilateral anterior chest wall pain to mild palpation
at the T3 level. Overlying the skin there was no erythema or
warmth. However , there was a fluctuant mass underneath the skin
surface. The patient's lungs were clear to auscultation
bilaterally , but she had shallow respirations due to pain on deep
breaths. Her abdominal exam was soft and nontender. Examination
of her extremities revealed multiple excoriations that were
clean , dry , and intact. Although the patient was somnolent at
times and difficult to arouse , she was alert and oriented x3 and
her neurologic exam was nonfocal. It appears that the patient's
excessive tiredness and excessive sleeping is her baseline
behavior. When the patient needed to be awake and oriented to
perform certain tasks , such as getting an MRI , she was able to do
so. Moreover , when she was witnessed interacting with her son ,
she was more alert.
CODE STATUS: Full code.
CONSULTS:
1. Infectious disease ( Gaylene Faniel , Infectious Disease fellow ).
2. Thoracic surgery.
Dr. Stepanie Tijuana Loban will dictate the remainder of the patient's
hospital course , including his disposition and discharge
medications.
eScription document: 5-3776900 PSSten Tel
Dictated By: WARRELL , KRYSTIN
Attending: WERNER REGINIA CASEBIER , M.D. YQ0
Dictation ID 4963536
D: 11/8/06
T: 11/8/06
Document id: 1137
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
N |
- |
N |
N |
N |
N |
N |
- |
921778812 | PUO | 49448215 | | 099790 | 3/6/1998 12:00:00 a.m. | DIVERTICULAR ABSCESS | Signed | DIS | Admission Date: 3/6/1998 Report Status: Signed
Discharge Date: 4/14/1998
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old female
with history of an inferior myocardial
infarction , coronary artery disease , and diverticulosis initially
admitted on 11/6/98 for conservative treatment of acute
diverticulitis. She was discharged on 10/30/98. The patient now
presents for elective sigmoid colectomy. The patient had had no
recent angina since her prior admission in January of 1998. According
to the patient she has rare , about one time every two weeks ,
episode of stable angina which presents as left arm pain relieved
by sublingual nitroglycerin. The patient did not present with any
pattern of unstable angina. The patient denies recent fevers ,
chills , nausea , vomiting , diarrhea , bright red blood per rectum ,
melena , cough , or pneumonia. The patient does report dyspnea on
exertion after climbing approximately one flight of stairs. The
patient has orthopnea as she sleeps with two pillows.
PAST MEDICAL HISTORY: Status post myocardial infarction times two.
History of atrial fibrillation. History of
atrial flutter. Status post cardioversion times three in 1994.
History of hypertension. History of rheumatic heart disease.
History of congestive heart failure. Non-insulin dependent
diabetes mellitus. History of two deep venous thromboses in 1970s.
PAST SURGICAL HISTORY: Mitral valve commissurotomy. Mitral valve
repair with St. Jude's valve in 1981.
Appendectomy. Left hip fracture.
ALLERGIES: Penicillin , sulfa , aspirin , Sotalol , as well as
Procainamide and Quinaglute.
MEDICATIONS: Lasix 80 mg , Lopressor 180 mg three times a day , Glyburide 10 mg
twice a day , Lisinopril 10 mg every day , Plaquenil 200 mg
twice a day , Isordil tempids 40 mg three times a day , and Coumadin 5 mg every day
PHYSICAL EXAMINATION: Well developed , well nourished female in no
acute distress. Lungs clear to auscultation
without crackles. Heart: Mechanical S1 and normal S2. Abdomen:
Soft , nontender , nondistended. Bowel sounds positive. 2+ edema to
calves bilaterally. Feet were warm and dry with normal capillary
refill.
LABORATORY DATA: ECG was significant for normal rate , atrial
fibrillation rhythm. No acute ST-T wave changes.
The patient had Q-waves in leads 3 and aVF. The patient's x-ray
was consistent with pulmonary edema.
HOSPITAL COURSE: The cardiology service was consulted with the
recommendations that the patient be diuresed
aggressively , daily weights and ins-and-outs be followed , and fluid
and sodium restriction to patient. The patient was placed on
heparin preoperatively.
On hospital day #2 preoperatively , the patient was admitted to the
Surgical Intensive Care Unit after she experienced a hypotensive
event with systolic blood pressure in the 50s with associated
drowsiness while maintaining her own airway. The feeling was that
the patient's event was likely secondary to the initiation of
Verapamil for rate control of her atrial fibrillation. The rate
control was then continued with Lopressor and Verapamil was held.
Goal potassium greater than 3.5 and magnesium greater than 2 were
maintained. The patient's diuresis was continued. The patient was
felt to be stable for surgery.
On hospital day #3 , 3/29/98 , the patient was brought to the
operating room for sigmoid colectomy with primary anastomosis , as
well as drainage of abscess. Postoperatively , the patient was
transferred back to the Surgical Intensive Care Unit for further
monitoring of her cardiopulmonary issues. Postoperatively , the
patient progressed well. She was maintained on perioperative
Vancomycin , Levofloxacin , and Flagyl. Cardiovascularly , she was
maintained on Lopressor , Nitropaste , Hydralazine , and Digoxin for
her atrial flutter. The patient did well on the floor , tolerating
intravenous to orally pain control , reinstitution of Coumadin for
anticoagulation , tolerating regular activity. Of note ,
the patient completed a rule out for myocardial infarction by
serial enzymes and ECGs. The patient was seen by the physical
therapy service and noted to have progressively improving activity.
The patient was discharged in stable condition.
DISPOSITION: The patient will be discharged to the Sa Pehall ,
a rehabilitation hospital. DISCHARGE MEDICATIONS:
Digoxin 0.125 mg orally every day , Lasix 40 mg orally every day , Plaquenil 200 mg
orally twice a day , Isordil tempids 40 mg orally three times a day , Lisinopril 10 mg
orally every day , Lopressor 150 mg orally three times a day , Percocet 1 to 2 tablets
orally q4 - 6h as needed pain , Levofloxacin 500 mg orally every day times six
days- starting on 6/11/98 , Coumadin 10 mg orally every bedtime for evenings of
8/21/98 and 3/27/98 ; 5 mg orally every day starting on 5/6/98. The
patient should have physical therapy and PTT with INR checked three times a week
on Monday , Wednesday , and Friday. She has a goal INR of 3.0. The
patient is not being discharged on Glyburide 10 mg twice a day because
she has had consistently low blood sugars. Fingerstick blood
glucose should be checked twice a day with resumption of Glyburide when
necessary. FOLLOWUP: The patient will follow-up with Dr. Marilyn Frehse in the Nessinee Ker Hospital Medical Center surgical clinic in one to two weeks. She
should call to schedule an appointment. The patient should also
call to schedule an appointment to follow-up with her primary care
physician , Dr. Annette Schoultz , in one week.
Dictated By: PAOLA NOFTSIER , M.D. OC69
Attending: MARILYN V. FREHSE , M.D. RL29
KO543/2892
Batch: 9757 Index No. CQCATJ6SOR D: 8/21/98
T: 8/21/98
CC: 1. ANNETTE SCHOULTZ , M.D. JW7
Document id: 1138
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
U |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
Y |
Y |
N |
N |
Y |
Y |
N |
N |
N |
Y |
N |
- |
838088254 | PUO | 21416641 | | 0191497 | 6/12/2005 12:00:00 a.m. | confusion | | DIS | Admission Date: 4/20/2005 Report Status:
Discharge Date:
****** DISCHARGE ORDERS ******
SHAFTIC , LUDIE 171-73-70-0
As
Service: NEU
DISCHARGE PATIENT ON: 2/29/05 AT 10:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RENFROW , CHARLEY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
as needed Headache , Temperature greater than:100.3
ACETYLSALICYLIC ACID 325 MG orally every day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day Starting Today ( 10/21 )
HEPARIN 5 , 000 UNITS subcutaneously twice a day
LISINOPRIL 40 MG orally every day
METOPROLOL TARTRATE 100 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NAHCO3 ( SODIUM BICARBONATE ) 180 MG orally twice a day
SIMVASTATIN 10 MG orally every bedtime Starting Today ( 10/21 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 2/29/05 by
TORRESON , CHRISTINE , M.D.
on order for NEPHROCAPS orally ( ref # 78823055 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally every day
Alert overridden: Override added on 2/29/05 by
TORRESON , CHRISTINE , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: will monitor
ISOSORBIDE MONONIT.( SR ) 60 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
CYCLOBENZAPRINE HCL 10 MG orally every afternoon
EPOGEN ( EPOETIN ALFA ) 4 , 000 UNITS subcutaneously QWEEK
DIET: House / ADA 2000 cals/day / Low saturated fat
low cholesterol (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Sco Medical Center for EEG , Ventman Tonbockverco Mond , Nevada 02120 June at 10 a.m. scheduled ,
Dr Charley Renfrow , LMC Neurology , Norap Valley Hospital June at 2pm , Wa Rih S scheduled ,
Dr Kaloustian , primary care physician March scheduled ,
Dr Pilling , Nephrology , Hoya Ascience Hospital Medical Center 2 months scheduled ,
ALLERGY: Morphine
ADMIT DIAGNOSIS:
confusion
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
confusion
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
UTI RENAL STONES HTN NIDDM SLLEP APNEA
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
MRI and MRA brain ( preliminary read ): no acute stroke , normal appearing
vessels
BRIEF RESUME OF HOSPITAL COURSE:
Chief Complaint: Left arm numbness and confusion
HPI: This is a 72 year old female with a history of DM and HTN who
was brought in by her family after transient sensation and confusion.
According to patient , while on her way back from her sleep apnea clinic
appointment , she felt a sudden pressure from her 'head down.' She had
been holding onto a strap on the bus with her left hand and suddenly
felt unable to hold on any longer and she felt tingling on her left arm.
While this was happening , she also became acutely confused and didn't
recognize her own neighborhood or even the house across from hers. She
was able to stand up and walk off of the bus as well as up five steps on
her front porch with assistance from the bus driver. By the time she
reached the front porch , 5 minutes after her symptoms started , she was
back to her normal self. At no time during this did she experience
headache , dizziness , vision/hearing changes , abnormal smell or nausea.
Her other extremities were not involved. She also never lost
consciousness.
ROS: positive for transient left arm tingling/numbness five times over
last three weeks but not associated with confusion.
General: Denies f/c/n/v , rash , diarrhea , BRBPR , abd pain , CP ,
palpitations , cough , SOB , DOE , change in bowel or bladder habits , joint
pain/swelling , weight gain/loss , sleep difficulties , headache.
Neurologic: Also denies abnormal gait , incontinence , or difficulty with
swallowing.
Past Medical History:
NIDDM
CRI ( left AV fistula in place but never used )
Sleep Apnea
Spinal Stenosis
HTN and hypercholesterolemia
history of Appendectomy , cholecystectomy , hysterectomy
Medications:
Lasix 80mg twice a day
Norvasc 10mg every day
Lisinopril 40mg every day
Metoprolol 100mg twice a day
Epogen 4000U subcutaneously qweek
NaHCO3 180mg twice a day
Zocor 10mg every day
Isosorbide Mononitrate every day Nephrocaps 1mg every day
Ferrex 150mg four times a day Avandia 4mg every day
Glyburide 5mg every day Flonase
Allergies: Morphine
Social and Family History:
Tobacco - No
EtOH - No
Illicit drugs:No
Home living situation: Lives with daughter
Examination:
VS: Temp: Afebrile HR: 67reg BP: 142/68
RR: 20 O2 Sat: 98% RA
General: Appearance: WDWN , NAD
HEENT: NCAT , MMM , OP clear
Neck: supple , no thyromegaly , no LAN , no bruits
Chest: CTAB
CVS: RRR , no m/r/g
Abd: soft , NT , +BS
Ext: no c/c/e , bilateral distal pulses strong , no rash
MS: General: alert , appropriately interactive , normal
affect
Orientation: In tact to person , place , date and situation
Attention: Normal
Speech/Lang: fluent without paraphasic errors; follows simple and
complex commands without L/R confusion; repetition , naming
Memory: Normal fund of knowledge
Neglect: no visual or sensory neglect
CN:
I: not tested
II , III: PERRLA 3 -> 2
III , intravenous , V: EOM full without nystagmus , no ptosis. Normal
saccades/pursuits
V: sensation intact to LT/PP
VII: face symmetric without weakness
VIII: hears finger rub bilaterally
IX , X: voice normal
XI: SCM/trapezii 5/5
XII: tongue protrudes midline , no atrophy or
fasciculation
Motor: Normal bulkd tone; no tremor , rigidity , or
bradykinesia. No pronator drift. Strength 5/5 proximally and distally
throughout.
Coord: Rapid alternating and finger-nose-finger movements
intact.
Reflex: No abnormal reflexes.
Bi Tri Bra Pat An Plantar
C6 C7 C6 L4 S1
R 1 1 0 0 1 Flexor
L 1 1 0 0 1 Flexor
Sens: LT , joint position intact. decreased sensation to PP in stocking
and glove distribution. No extinction.
Gait: Posture , stance , stride , and arm-swing normal. Tandem gait intact.
Romberg negative.
Laboratory Studies:
nasal 137 , K 4.5 , CL 106 , CO2 20 , BUN 69 , CRE 6.9 ( near baseline ) , GLU 99
CA 9.3 , TP 7.7 , ALB 4.2
ALT/SGPT 17 , AST/SGOT 22 , ALKP 74 , TBILI 0.3
CK 648 , CK-MB 6.6 , TROP-I
WBC 4.73 , HCT 34.8 , MCV 94.0 , PLT 187
%POLY-A 73.0 , %LYMPH-A 12.2 , %MONO-A 8.4 , %EOS-A 5.7 , %BASO-A 0.8
physical therapy 14.2 , physical therapy-INR 1.1 , PTT 28.1
EKG: NSR
MRI/MRA: ( Preliminary ) Negative for acute stroke or hemorrhage. Normal
vessels.
Impression: 72 year old female with repetitive left
arm symptoms over last three weeks consistent with compression
neuropathy and an episode of confusion yesterday. The confusion spell
could have been secondary to her metabolic derangements but other
possibilities include transient global amnesia and partial seizure.
Hospital course:
1. Neuro: she had no further episodes of confusion. She was continued on
ASA every day An outpatient EEG and neurology follow up appointment were
arranged
2. CVR: She was continued on her home BP meds.
3. FEN: She was started on a diabetes diet. Continued home diabetes meds
4. Renal: creatinine was near baseline
ADDITIONAL COMMENTS: if you develop more episodes of confusion please seek medical attention
DISCHARGE CONDITION: Stable
TO DO/PLAN:
EEG as outpatient ( see follow up appointments )
Follow up final MRI/MRA read
Peripheral neuropathy workup
No dictated summary
ENTERED BY: BENADOM , ROMA C. , M.D. ( GE2 ) 2/29/05 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1139
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
Y |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
- |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
- |
507703890 | PUO | 57505335 | | 5987010 | 2/14/2006 12:00:00 a.m. | CAD , history of PCI to LAD | | DIS | Admission Date: 3/27/2006 Report Status:
Discharge Date: 10/27/2006
****** FINAL DISCHARGE ORDERS ******
MOMAN , MARCELLA 261-65-46-0
Ing Tonsta Go
Service: MED
DISCHARGE PATIENT ON: 7/26/06 AT 02:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BRAGAS , RASHEEDA K. , M.D. , M.PH.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ECASA 81 MG orally DAILY Starting Today ( 2/30 )
LISINOPRIL 30 MG orally DAILY Starting Today ( 2/30 )
Override Notice: Override added on 1/1/06 by
VERBLE , KESHA O. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
393991072 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 1/1/06 by VERBLE , KESHA O. , M.D.
on order for POTASSIUM CHLORIDE intravenous ( ref # 194127107 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
LIPITOR ( ATORVASTATIN ) 40 MG orally BEDTIME
Starting Today ( 2/30 )
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 2/13 )
Instructions: Take until you are instructed to stop taking
it
LANTUS ( INSULIN GLARGINE ) 60 UNITS subcutaneously BEDTIME
Starting Today ( 2/30 ) Instructions: give 1/2 dose when npo
HUMALOG INSULIN ( INSULIN LISPRO ) 15 UNITS subcutaneously before meals
HOLD IF: not taking anything by mouth
ATENOLOL 100 MG orally DAILY
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician ( 811 ) 818-5928 1/4/06 @ 9:40 a.m. ,
Cardiology at Pagham University Of . Call 168-474-4491 ivc. 80201 to make an appointment. 2 week ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Shortness or breath.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CAD , history of PCI to LAD
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD
OPERATIONS AND PROCEDURES:
R + L heart catheterization on 9/29/02. PCI + Cypher x 1 to mid LAD.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
CC: chest pain and SOB
************************
HPI: 49 year-old woman with history of hyperlipidemia , HTN , DM , and spotty med
compliance presents with 2 months of exertional dyspnea and "burning"
chest discomfort which became acutely worse on day of admission while
walking four blocks. Symptoms improved with rest , worsened with activity.
Denied associated nausea/diaphoresis. When patient reclined in bed for the
night , sxs became acutely worse ( both SOB and burning ); these
improved immediately when she sat up. Typically uses 2 pillows at
night , denies PND. Has not taken lisinopril or lipitor in past week
b/c ran out of meds. ROS + two days of cough , occ LE
edema , but not currently. No fevers , chills , N/V/diarrhea.
In ED HR 91 , BP 186/99 , SpO2 87% RA ( 98%4L ) , with rales 3/4 way up ,
therefore 40mg intravenous lasix given -->900 cc UOP , RA sat 98%.
************************
PMH: DIABETES , INS DEP
HX FATTY LIVER/PANCREATITIS OF PREGNANCY '82 DEPRESSION
OBESITY HYPERLIPIDEMIA
Last echo 3/14 EF is 65%. Mild concentric LVH o/with nl. Reports
having had stress test 3 yrs ago at ?BMD - "normal" per her
memory.
************************
MEDS: Lantus 60 UNITS subcutaneously every bedtime
Lipitor 40MG orally every day Lisinopril 20 MG orally every day
Humalog 12-15 subcutaneously before meals Asa 81 MG orally every day
************************
ALL: NKDA
************************
SH/FH: Works at motor veh registry. Divorced in 1995. In past
difficult social interactions with children have been source of
depression. Has helpful stepdaughter. Nonsmoker. Rare EtOH. No
drugs.
************************
PHYSICAL EXAM AT DISCHARE T98.6 , 130/68 , 70s , 94%RA GEN: NAD , AAOx3 ,
obese HEENT: PERRL , EOMI ,
MMM CHEST: CTA BL
base CV: S1 S2 RRR No
MRG ABD: S , NT/ND
+BS EXT: No edema b/l , +2 DP pulses b/l , warm and well
perfused NEURO: CNII-XII intact , grossly
nonfocal.
************************
STUDIES/DATA: PE-CT No PE or DVT; low atten thyroid nodules;
asymmetric b/l ground glass opacity , L>R &dependent , fatty
liver. EKG: NSR at 84 bpm; no acute ST-T changes except
perhaps ? minor TWI in AVL; LAE. MIBI with moderate ischemia in midLAD
territory. R Cath: normal right-heart filling pressures: RA 6 , PCW 9 , PA
31/12. Left heart-cath: R dominant system. No significant LM lesions.
DIffuse 70% prox-mid LAD lesion with focal 90% stenosis after S2. No
significant LCx lesions , tubular 50% lesion in MARG1 , Mid RCA diffuse 50%
lesion.
************************
HOSPITAL COURSE BY PROBLEM AND PLAN
1 ) CV.
( isch ): patient admitted with SOB and pulm congestion. Formally ruled-out
Ruled out by enzymes x 3; pharm MIBI with moderate ischemia in midLAD
territory. Had cardiac cath on 7/10 showing R dominant system. No
significant LM lesions. DIffuse 70% prox-mid LAD lesion with focal 90%
stenosis after S2. No significant LCx lesions , tubular 50% lesion in
MARG1 , Mid RCA diffuse 50% lesion. PCI to LAD with cypher stenting. No
procedural complications. Cont ASA , plavix , statin. Titrated lopressor
( ultimately switched to atenolol ) and increased lisinopril from 20 to 30
mg orally every day
( p ): currently euvolemic; cont lisinopril , betablocker. Echo from 9/19
shows mild LVH EF 65%.
( r ): telemetry , beta blocker
2 ) Endo: DM. A1c=7.2. Shes discharged on home regimen , which should be
optimized in the outpatient setting.
3 ) FEN: nutrition c/s re obesity management
4 ) PPX: lovenox while in hosp.
5 ) Code: FULL
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Optimize DM regimen.
Secondary prevention on CAD.
No dictated summary
ENTERED BY: BEOUGHER , GEORGINE JENIFER TRACIE , M.D. ( MF3 ) 7/26/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1140
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
U |
Y |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
- |
Y |
N |
Y |
N |
Y |
N |
Y |
Y |
N |
N |
N |
N |
N |
- |
182796277 | PUO | 05941893 | | 611024 | 8/25/2002 12:00:00 a.m. | chf | | DIS | Admission Date: 11/19/2002 Report Status:
Discharge Date: 5/21/2002
****** DISCHARGE ORDERS ******
CURTSINGER , BEE 070-83-52-9
Ley Leah
Service: MED
DISCHARGE PATIENT ON: 8/7/02 AT 03:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: UNTERKOFLER , AL MARYJO , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
Override Notice: Override added on 2/26/02 by
BENADOM , EMERITA E. , M.D.
on order for COUMADIN orally 7.5 MG every day ( ref # 11805398 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: noted Previous override information:
Override added on 4/14/02 by BENADOM , EMERITA E. , M.D.
on order for COUMADIN orally ( ref # 81929464 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: noted Previous override information:
Override added on 4/14/02 by BENADOM , EMERITA E. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: noted
ATENOLOL 25 MG orally every day HOLD IF: sbp<90 , heart rate<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
GLYBURIDE 10 MG orally twice a day
LISINOPRIL 5 MG orally every day HOLD IF: sbp <90
COUMADIN ( WARFARIN SODIUM )
EVEN days: 7.5 MG every day; ODD days: 5 MG every day orally every day
Starting Today ( 10/18 ) Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/26/02 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: noted Previous Override Notice
Override added on 4/14/02 by BENADOM , EMERITA E. , M.D.
on order for ZOCOR orally ( ref # 57731300 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: noted Previous override information:
Override added on 4/14/02 by BENADOM , EMERITA E. , M.D.
on order for ASA orally 325 MG every day ( ref # 07291853 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: noted
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 2/26/02 by
BENADOM , EMERITA E. , M.D.
on order for COUMADIN orally 7.5 MG every day ( ref # 11805398 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: noted Previous override information:
Override added on 4/14/02 by BENADOM , EMERITA E. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: noted
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
LASIX ( FUROSEMIDE ) 60 MG orally twice a day
METFORMIN 1 , 000 MG orally twice a day
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Unterkofler 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
chf
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chronic Afib G-E Reflux HTN
NIDDM , DIET CTRL CHF ( EF 65% ) ( congestive heart failure ) history of
colectomy for diverticulitis ( history of colectomy ) history of ventral hernia
repair ( history of hernia repair ) history of carpal tunnel release ( history of carpal
tunnel repair )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ruq u/s
BRIEF RESUME OF HOSPITAL COURSE:
76yoF with history of afib ( rate controlled with
atenolol; unable to tolerate higher doses secondary to bradycardia and
syncope ) , chf ( ef 50-55% in 8/01 ) , DM , HTN p/with sob x 3
days. patient had dietary indiscretion over the
holidays ( increased salt load ) but has been taking
her lasix. Reports sob , inc abd girth , le
edema , orthopnea , pnd; no cough/fever.
PE: rales 1/3 way up bilaterally. very distended abd. 3+ pitting edema
bilat. CXR: slightly wet. 1. CV: Received 80IV lasix in ED with 2L
diuresis and improvement. Started on orally lasix then
switched to intravenous. Continued on home meds
( atenolol , asa , lisnopril , zocor ). r/o for MI as cause
of exacerbation.
2. GI: abd distension appears out of proportion to right hear failure.
LFTs normal but checking u/s with doppler to r/o hepativ/portal
venous thrombus. On
nexium.
3. Heme: on coumadin for afib but with history of gib.
4. endo: dm. on metformin , glyburide , czi.
Patient discharged on 4/4/01 after an adequate period of diuresis , to
follow up with Dr. Viray within the next one to two weeks.
ADDITIONAL COMMENTS: Patient needs to adhere to 2 gm sodium diet , and fluid restrict to no
more than 8 glasses of liquid/water daily. She should check her weight
daily , and call primary care physician if weight increases by more than three pounds. She
should call primary care physician office to schedule a follow-up appointment within the
next one to two weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA to follow patient to measure weights , fill pill box , check heart rate and
blood pressure and check that she is taking lasix every day patient will need INR check in 3
days ( with results sent to Dr. Viray ) and qweek.
No dictated summary
ENTERED BY: KETTERING , LOUELLA ROBT , M.D. ( HJ90 ) 8/7/02 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1141
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
N |
N |
N |
N |
Y |
N |
N |
Y |
Y |
N |
N |
775300068 | PUO | 72320696 | | 915988 | 2/1/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 2/1/1996 Report Status: Signed
Discharge Date: 11/21/1996
PRINCIPAL DIAGNOSIS: OPTIC NEURITIS.
OTHER SIGNIFICANT PROBLEMS: 1. Atrial fibrillation with DDD pacer
2. Hypertension
3. Sleep apnea
4. Asthma
5. Anemia
HISTORY OF PRESENT ILLNESS: 54 year old lady with a history of
obesity , paroxysmal atrial
fibrillation , who is on Coumadin and a DDD pacer , who was in her
usual state of health until approximately one week ago when she had
the gradual onset of diffuse bilateral headache and slowly
progressive visual loss. She had a flu vaccination approximately
one week prior to this presentation. She was seen in KTDUOO with the
above complaints and a head CT was ordered which was subsequently
negative. Over the course of the weekend , her visual acuity
continued to decline to frank blindness. She had an ophthalmology
appointment on April and was noted to have bilateral
papilledema with a few hemorrhages , and referred to the Emergency
Room for lumbar puncture. In the Emergency Room , she had a head CT
with contrast that was unchanged and negative. A lumbar puncture
demonstrated an opening pressure of 290 and elevated white count of
160 , primarily lymphocytosis of 83%. She had an elevated protein
of 93. She was admitted and treated for possible pseudotumor
cerebri with steroids and Diamox. She was also evaluated by
Ophthalmology at that time , whose leading diagnosis was pseudotumor
cerebri versus optic neuritis.
PAST MEDICAL HISTORY: Notable for history of paroxysmal atrial
fibrillation , status post DDD pacemaker ,
history of hypertension , history of asthma , history of sleep apnea ,
currently on CPAP , history of anemia with a negative colonoscopy.
MEDICATIONS ON ADMISSION: Nifedipine 60 mg orally every day , Coumadin
alternating at 7.5 and 5 mg orally every day ,
iron sulfate , atenolol 100 mg every day , and as needed Motrin.
ALLERGIES: None known.
SOCIAL HISTORY: She is an EKG technician who works at Pande Memorial Hospital She has no history of cigarette
smoking since 1978 , no alcohol abuse. She is separated and has
five daughters and one son. She lives at home with her daughter.
FAMILY HISTORY: Notable for lung , thyroid , and questionable head
and neck cancer. She has no history of CVA or
brain tumors.
PHYSICAL EXAMINATION: Heart rate was 68 , blood pressure 150/88 ,
afebrile. She was obese. She has mildly
proptotic eyes , no evidence of ocular pulsations , no sinus or scalp
tenderness. Neck was supple , nontender , no evidence of
lymphadenopathy. The rest of the exam was essentially
unremarkable. Neurologic exam is notable for being alert and
oriented x 4. Her cranial nerves showed bilateral papilledema.
LABORATORY EVALUATION: Notable for BUN/creatinine of 11/0.9.
White count 9.6 , hematocrit 36. Current
serologies are still pending at this time. RPR was negative.
Serologic tests for ANA are still pending at this time. Glucose of
the CSF was 65. Gram stain on the CSF was negative. Cultures on
the CSF were subsequently negative. Lyme test is still pending
however.
HOSPITAL COURSE: She was admitted to the Neurology service ,
started on Solu-Medrol 1 gm intravenous every day x a total of
five days. She was also started on Diamox 500 four times a day Over the
course of her stay here at the hospital , she had an uneventful
course , had partial resolution of her vision to where she could see
shadows. Her headache had resolved and she had no other systemic
complaints. She will be discharged to home on May , 1996.
DISCHARGE MEDICATIONS: Her admitting medications as well as
Solu-Medrol 1 gm every day intravenous for two more days
as well as a prednisone taper beginning at 100 every day , increasing by
20 every three days. She will go home on atenolol 100 every day ,
nifedipine 60 mg orally every day , Coumadin alternating doses of 5 mg on
Saturday , Thursday and Tuesday and 7.5 on Sunday , Monday ,
Wednesday , Friday. Axid 150 twice a day
CONDITION ON DISCHARGE: Good , apart from partial blindness.
FOLLOWUP: She will receive followup in Ophthalmology clinic with
Dr. Schlappi on March , 1996 and have neurology
followup with Dr. Mondelli on March , 1996. At home , she will
receive VNA care as well as home health aide.
Dictated By: ULYSSES GELDRICH , M.D. HD87
Attending: MATHEW S. STAUTZ , M.D. YO1
TN106/8589
Batch: 84473 Index No. K6GKQS2Z25 D: 4/1/96
T: 5/19/96
Document id: 1142
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
Y |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
- |
N |
Y |
Y |
N |
Y |
N |
N |
- |
- |
047587056 | PUO | 84856165 | | 6451531 | 5/13/2005 12:00:00 a.m. | LLL pneumonia , CHF | | DIS | Admission Date: 7/25/2005 Report Status:
Discharge Date: 10/19/2005
****** FINAL DISCHARGE ORDERS ******
KUHTZ , NAOMA 785-01-56-8
Obetnor Parkway , Po Mont H , Washington 94683
Service: MED
DISCHARGE PATIENT ON: 11/6/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BARSKI , GENOVEVA L. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
DESIPRAMINE HCL 25 MG orally HS
Override Notice: Override added on 8/30/05 by
CRAGER , MARYANNE , M.D.
on order for LEVAQUIN orally ( ref # 58762362 )
POTENTIALLY SERIOUS INTERACTION: DESIPRAMINE HCL &
LEVOFLOXACIN Reason for override: monitored.
Previous override information:
Override added on 8/30/05 by CRAGER , MARYANNE , M.D.
on order for LEVAQUIN intravenous ( ref # 46740558 )
POTENTIALLY SERIOUS INTERACTION: DESIPRAMINE HCL &
LEVOFLOXACIN Reason for override: MD is aware , will follow
Previous override information:
Override added on 8/30/05 by TOBOLSKI , IN L. , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN &
DESIPRAMINE HCL Reason for override: will monitor
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ROBITUSSIN before meals ( GUAIFENESIN before meals ) 5 MILLILITERS orally every 4 hours
HOLD IF: If sedated
Alert overridden: Override added on 9/9/05 by
CRAGER , MARYANNE , M.D.
on order for ROBITUSSIN before meals orally ( ref # 88307666 )
patient has a DEFINITE allergy to Codeine; reaction is
Nausea/Vomiting.
patient has a PROBABLE allergy to TRAMADOL; reaction is GI
upset. Reason for override: Will keep patient upright and
prescribe as needed anti-emetic.
SYNTHROID ( LEVOTHYROXINE SODIUM ) 175 MCG orally every day
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally every 6 hours as needed Nausea
HOLD IF: If sedated or develops EPS/dystonic symptoms
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
HOLD IF: for oversedation , rr<12
Alert overridden: Override added on 8/30/05 by
TOBOLSKI , IN L. , M.D. , M.P.H.
on order for OXYCODONE orally ( ref # 61642051 )
patient has a PROBABLE allergy to Codeine; reaction is
Nausea/Vomiting.
patient has a PROBABLE allergy to TRAMADOL; reaction is GI
upset. Reason for override: pharm side-effect , not true
allergy
SENNA TABLETS 2 TAB orally twice a day HOLD IF: for diarrhea
PRAVACHOL ( PRAVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 60 MG orally every day
HOLD IF: for sbp<110 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day COPD
Number of Doses Required ( approximate ): 9
MICONAZOLE NITRATE 2% POWDER TOPICAL TP twice a day
Instructions: please apply to undersides of B.breasts/
groin folds , thank you
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 8/30/05 by
CRAGER , MARYANNE , M.D.
on order for LEVAQUIN orally ( ref # 58762362 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: monitored.
Previous override information:
Override added on 8/30/05 by CRAGER , MARYANNE , M.D.
on order for LEVAQUIN intravenous ( ref # 46740558 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: MD is aware , will follow
Previous override information:
Override added on 8/30/05 by TOBOLSKI , IN L. , M.D. , M.P.H.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & SALMETEROL
XINAFOATE Reason for override: will monitor
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
DICLOXACILLIN 500 MG orally every 6 hours
Instructions: take for 10 more days
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Heidelberger , call to reschedule if cannot make appt Thurs 9/2 at 3:30pm scheduled ,
ALLERGY: Sulfa , Codeine , TRAMADOL
ADMIT DIAGNOSIS:
LLL pneumonia , CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
LLL pneumonia , CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
djd lumbar , history of fusion high chol history of urinary incontinence hypothyroidism
CAD history of CABG '96 essential thrombocytosis history of
TIA history of laminectomy ( history of laminectomy ) L knee meniscal tear history of
surgery 30 of May ( meniscal tear ) COPD , on 2L home O2 ( chronic obstructive
pulmonary disease ) chf , EF 45-50% ( congestive heart
failure ) history of MRSA pna ( 3 ) history of baker's cyst L.leg ( history of Bakers
cyst ) DM2 , diet controlled CRI , baseline cr 1.4 ( chronic renal
dysfunction ) history of anal fissure ( history of anal fissure ) history of urinary
incontinence ( history of urinary incontinence )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
82F with "COPD"/smoke inhalation injury ( FEV1 1.56 68% , FVC 1.79 , ratio 116 ,
on cont 2L home O2 ) , CAD , 3V CABG '96 ( SVG-> LAD , PDA , Diag1; cath '97:
all occluded , PTCA to PLV ) , CHF ( EF 45-50% ) , pulm HTN , DM2 ( diet
controlled ) , hyperchol , hypothyroidism who was last adm in 2/17 for MRSA
pna/CHF. She was in USOH until 9/9 , when she slipped and fell , hurting
her lower back and R.wrist ( no fx ) , sent home with pain meds. Represented
to ED on 7/23 with 1d of wheeze/cough -> no intervention. Worsened over the 2d
pta , with increasing dry cough , wheezing , SOB/DOE , chest tightness. P/to
TH where satting 98%4L ->89%8L , received ceftriax/azithro , 20iv lasix ,
nebs , 125iv solumedrol , 2mg intravenous morphine , phenergan. Labs there notable
for Cr 1.7 ( baseline 1.4 ) , hct 29 , wbc 8 , dirty UA , BNP 852 , ddimer neg.
CXR suggestive of LLL infiltrate. Transferred here , received another
20 intravenous lasix in ED , albuterol neb , 500 orally azithro.
*
ALL: tramadol , codeine , sulfa MEDS at home: asa 81 , alb neb ,
desipramine 25 , combivent , advair 250/50 , pravachol 40 , lopressor
50 twice a day , synthroid 175 , lasix 20 , nexium 20 , temazepam 15 three times a day , hydrea
100 , darvocet
*
FH/SH: Lives below son/daughter. Remote tob hx.
*
STUDIES:
-- CXR 8/12/05 : cardiomegaly , LLL opacification , cephalization
-- EKG 8/12/05 : NSR at 71 bpm , QW v1 , nl axis/ intervals , TWI in v1-2
( old ) , biphasic TW in v4 , II ( new ) and aVF.
-- ECHO ( 2/17 ): EF 45-50% , nl LV size , global HK with wma , mild RVE/decreased
function , BAE , mild TR/ tr MR , PAP 61 + RAp , triv pericardial effusion
-- PFTs ( 2/3 ): FEV1 685 FVS 61% , ratio 116 , TLC 55% , RV 48% , DLCOc 60%
*
PHYSICAL EXAM: T99.2 P72 BP 145/59 R22 O2sat 98%4L
Obese F , able to speak in full sentences , hoarse voice , frequent dry
cough , PERRL , o/p MMM , JVP 8cm , RRR , no m/r/g appreciated , bilateral
coarse rhonchi with L.basilar crackles. Abd soft , obese , NT , +BS. LE with trace
edema , mild purplish-erythema without warmth over ankles , decreased DP
bilaterally. Mild tenderness with erythema ( old ) , no calf pain/ tenderness/
cords. erm: Erythema and some maceration in intertriginous areas under
breast bilaterally. No warmth or tenderness.
*
IMPRESSION: 82F with COPD , CHF , CAD , DM , hypothyroidism who p/with 2-3 d of
cough , wheezing , SOB/ DOE , CXR c/with LLL pna and mild-mod CHF likely
precipiated by pna. Admitted for abx , gentle diuresis.
*
HOSPITAL COURSE:
1 ) CVS ( I ): Ruled out for MI. On baby ASA , statin , nitrate , low-dose BB.
Chol panel wnl in 4/3 ( chol 150 , TG 127 , HDL 51 , LDL 74 ). Had recurrent
nausea on 7/28 and 10/20 with chest tightness with dry heaves. Repeat EKG showed
min. changes ( TWI in v3-4 ) , but negative enzymes. Chest discomfort
appeared more related to cough/ retching than ischemia.
CVS ( P ): Mild-mod CHF on admission. On 20 orally lasix at home. Attempted
diuresis with Lasix 20 mg intravenous ( received 3 doses total in EDs/ floor ) with
unclear response. Good response to 40 intravenous lasix x 1 , with neg neg 1.6L.
Wt down from 97 on admit to 93.6 ( though bed vs. standing ). JVP remained
somewhat elevated to 8-10cm , though may be confounded by patient's mild TR.
O2sats quickly returned to baseline , 96% 2L. Followed 'lytes , strict I/O ,
every day weights , and low-salt diet. Of note , Cr was elevated to 1.7 on admit
( from baseline of 1.2-1.4 ) and remained stable with diuresis.
CVS ( R ): NSR. Maintained on telemetry for r/o MI. Tele notable for 5b run
NSVT and several pauses ( <2sec each ). patient asymptomatic.
2 ) PULM/ID: CXR d/o lobar pneumonia. Covered with vanc/levoflox initially ,
then switched to linezolid/levo , given patient's hx of MRSA in sputum. Sputum
cx on this admission showed Staph aureus , not MRSA , and was changed to
diclox. continued advair , duonebs q4 , antitussive , supplemental O2.
6 ) RENAL: Acute elev of Cr ?2/2 chf exacerbation vs intravascular vol
depletion in setting of infection. . Since could be redistribution of
volume , diuresed v. gently/cautiously. Cr stable following diuresis at
1.7. UA at TH notable for +LE/ nitr/ 20 wbc. Urine cx here neg with 100 GNR.
Foley was placed at th , was d/c'd here post-diuresis on 1/24
7 ) GI: Nexium for epigastric pain ( more likely related to
coughing ). Recurrent nausea likely related to coughing/nebs/ abx vs.
constipation vs ischemia ( ruled out ). Treated with reglan intravenous , bowel
regimen. KUB pending.
8 ) HEME: hct 33.5 , MCV 70 , +iron def ( Fe 31 in 4/9 , TIBC 445 , ferr 32 ) ,
No scopes on record. Guaiced all stool. Hct remained stable at 30-34.
Discuss outpatient colonoscopy , though patient at age 82 , may not wish to
pursue this option. Started iron suppl.
9 ) ENDO: DM , diet controlled. Covered here with RISS. ADA diet. FS ranged
100-200s. Last HbA1c in 4/3 was 5.3. TSH 0.556
10 ) FEN: low salt/ fat/chol , ADA diet , 2L FR
11 ) PPX: heparin , nexium
12 ) DERM: Nystatin cream/miconazole powder to intertriginous areas. H/o
cellulitis under L.breast , and though this area looked macerated , it was
not warm/tender , likely still candidiasis rather than bacterial
infection.
13 ) OTHER: physical therapy eval. patient refused rehab , so plan to d/c home with services.
FULL CODE
ADDITIONAL COMMENTS: if develop worsening shortness of breath , chest pain , fever. chills ,
worsening cough please call your doctor. Complete course of antibiotics
( dicloxacillin as directed ).
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Follow up with your primary care physician as arranged
2 ) Take all your medications as prescribed.
3 ) Call your doctor if you have any worsening shortness of breath , chest
discomfort , leg swelling , or any other worrisome symptoms
4 ) Consider outpt Colonoscopy to work up iron deficiency anemia
5 ) complete 10d course of diclox
No dictated summary
ENTERED BY: JANSING , VIDA , M.D. ( TR83 ) 11/6/05 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 1143
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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081902465 | PUO | 13645026 | | 2183877 | 9/11/2006 12:00:00 a.m. | Right Shoulder Pain | | DIS | Admission Date: 9/11/2006 Report Status:
Discharge Date: 8/27/2006
****** FINAL DISCHARGE ORDERS ******
SHEARER , OSWALDO 792-80-35-8
Kee Vo Wi
Service: ORT
DISCHARGE PATIENT ON: 8/7/06 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BERNAS , RUFUS , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally twice a day
DILAUDID ( HYDROMORPHONE HCL ) 2-6 MG orally every 4 hours as needed Pain
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
2 PUFF inhaled four times a day as needed Shortness of Breath
Food/Drug Interaction Instruction
Contraindicated in Patients with Peanut , Soya or Soyabean
Allergy
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally twice a day
HOLD IF: SBP<110 , HR<60 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 45 MG orally every day before noon
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 30 MG orally every afternoon
SIMVASTATIN 80 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TERAZOSIN HCL 10 MG orally DAILY
Number of Doses Required ( approximate ): 3
DIET: No Restrictions
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Moczygemba 1/2/06 scheduled ,
ALLERGY: intravenous Contrast , Tape
ADMIT DIAGNOSIS:
Right Shoulder Pain ?Infection
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Right Shoulder Pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
asthma
OPERATIONS AND PROCEDURES:
8/27/2006 : CT guided aspiration of R shoulder joint fluid
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Pain Control
BRIEF RESUME OF HOSPITAL COURSE:
Mr. Grabonski was admitted to the Orthopaedic Hand Service on 9/11/2006
with a history of increased R shoulder pain following a cellulitis of
the right hand. An ESR was checked on admission and was slightly
elevated at 18. He was afebrile and non-toxic , therefore was not started
on antibiotics. Dilaudid was added to his pain regimen for his increased
discomfort.
On 5/30/2006 a CT guided R shoulder joint fluid aspiration was performed
by Radiology. Analysis of this fluid was not consistant with joint
infection.
He received Lovenox for DVT prophylaxis during his admission. On HD#4 he
was awake , alert , appropriate and afebrile with stable vitals signs. His
pain was well controlled on orally medications. He was discharged to home
and instructed to follow up with Dr. Moczygemba at his previously scheduled
appointment on 4/27/2006. His final joint fluid cultures were pending at
the time of discharge , he will be contacted at home if these turn
positivie.
ADDITIONAL COMMENTS: 1. Do pendulum range of motion exercises regularly. This is very
important in maintaining full range of motion. You should not add any
additional exercises until cleared to do so by Dr. Rinck
2. You have been given a prescription for a narcotic for pain control. Do
not drive a motor vehicle , drink any alcohol or operate machinery while
taking this medication. As your pain allows , you should reduce the amount
of this medication accordingly. Narcotic pain medications can cause
constipation , so you should drink plenty of water and take a stool
softener ( Colace ) to help prevent this side effect.
3. Call Dr. Moczygemba at the number above , or your Primary Care Physician , or
go to a local emergency room if you develop fevers/chills , redness around
your incision that is warm to the touch , pus-like drainage from the
wound , loss of function ( either strength or sensation ) in your hand ,
return to your original symptoms , chest pain , shortness of breath or any
other concerning symptoms.
4. You may not drive a car until cleared to do so by Dr. Rinck
5. Resume home medications unless specifically instructed otherwise.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ARMENDARIZ , ENDA M. , M.D. ( PY70 ) 8/7/06 @ 09
****** END OF DISCHARGE ORDERS ******
Document id: 1144
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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- |
- |
- |
- |
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- |
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- |
695831179 | PUO | 85228280 | | 0130166 | 10/27/2005 12:00:00 a.m. | ANAPHYLAXIS | Signed | DIS | Admission Date: 10/2/2005 Report Status: Signed
Discharge Date: 6/10/2005
ATTENDING: TIBOLLA , MADISON M.D.
ADMISSION DIAGNOSES: Anaphylaxis.
ASSOCIATED DIAGNOSES:
1. Congestive heart failure.
2. Hypertension.
3. Hypothyroidism.
4. Insulin-dependent diabetes mellitus.
5. Polymyalgia rheumatica.
6. Diabetic retinopathy.
7. Urinary tract infection.
8. Adrenal insufficiency.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female
with a history of polymyalgia rheumatica for which she takes
steroids and has developed adrenal insufficiency. She presented
to the emergency room with shortness of breath , wheezing , and a
maculopapular rash after receiving the pneumovax shot. She
received this shot upon discharge from admission to the Ouf County General Hospital for syncope and dehydration. The treatment there
was intravenous fluids in short course and increase in her steroids. In
the emergency room , she was treated with steroids , Benadryl , and
Pepcid.
PAST MEDICAL HISTORY: As above.
HOSPITAL COURSE BY SYSTEM:
1. Immunology: The patient was found to have anaphylactic
reaction to the Pneumovax shot that she received. Her
symptoms resolved by hospital day #1 after receiving intravenous Benadryl
around the clock , Pepcid , and an increased dose in her Hydrocort
to 100 mg intravenous every 6 hours The steroids were started on a taper and on
the night of the first admission , the patient was noted to have increased
shortness of breath and
oxygen requirements. She was treated with oxygen and increased
steroids again for presumed reexacerbation of anaphylaxis.
2. Pulmonary: The episode of wheezing that she had on the first
day of admission could also be partly explained by fluid
overload. By hospital day #2 , she had developed crackles and
jugular venous distention. She has a history of diastolic heart
dysfunction , and diuresis was initiated. Despite receiving 3
doses of intravenous Lasix , she had an episode of flash pulmonary edema on the
second night of hospitalization. A chest x-ray was obtained at
that time which was consistent with pulmonary edema. She was
stabilized with additional Lasix and 100% nonrebreather mask , and
nitroglycerin. Her blood pressure was 200 systolic at that time.
The plan for continued diuresis was interrupted on hospital day
#3 when she became hypotensive and febrile with a UA consistent with infection.
She was started on Levo for presumed urosepsis.
On hospital day #4 , diuresis was resumed as her blood pressure
stabilized around 110 , and she still had a 5-6L oxygen requirement. The
patient reports her dry weight is 140 to 143 lbs. Her
primary care doctor suspects it more like 149 lbs. She is
currently receiving diuresis to wean oxygen requirement and is
down to 1 L per nasal cannula. Her goal fluid status is to
negative 1 L per day , and she continues to receive Lasix intravenous to
meet that goal.
She was also restarted on orally Lasix 30 mg orally daily. There
was some concern about aspiration by the nursing staff. She
immediately had trouble with swallowing liquids and Speech and
Swallow was consulted. The patient failed the bedside swallow
exam and so a video swallow was obtained , which actually showed
no evidence of aspiration , and so she was continued on a regular
diet. By the time of discharge she did not require any oxygen. She would
intermittently desat to the high 80s , which would quickly resolve with deep
breathing or chest physical therapy.
3. Endocrinology. The patient has a history of PMR and adrenal
insufficiency , on 30 mg of Hydrocort daily at home. On the
May , 2005 , in the setting of urosepsis she was placed back on stress
dose steroids which was then tapered back to her home dose throughout the
rest of her hospitalization. She has a history of
diabetes type 2 requiring insulin inhouse or orally agents. Oral
agents were held and insulin was given for glucose control , NPH
30 units in the morning and 10 units in the evening seemed to
control the a.m. and p.m. sugars pretty well. Regular insulin
was added 6 units in the morning with breakfast with the morning
NPH for 1 p.m. blood sugar control , as this was the highest blood
sugar daily. Obviously , this needs to be monitored and adjusted
as needed as well the medicine staff is going to be following her
as to whether she should resume the orally agents. She does on
occasion drop her blood sugar to 50 or 60 , which is usually
asymptomatic.
4. Renal: Her baseline creatinine was 1.0. Both her BUN and
creatinine were elevated with diuresis. Her creatinine needs to
be monitored closely and medications need to renally dosed.
5. Infectious Disease: Her urine was positive for greater than
100 , 000 group B hemolytic Streptococci and she was initially
started with Levaquin. It was switched to penicillin on January , 2005 , after the gram-positive organism was discovered and she
was switched back to Levaquin after the sensitivities came back ,
and it was sensitive to Levaquin. The Levaquin is ideal because
her coughing could also represent bronchitis. She has complained
of a cough since weeks before admission , which is now resolving.
6. Disposition: The patient does not feel that she can care for
herself at home and screening was placed to Porangecatheox Medical Center Of , and that was accepted for the acute care center
for Saturday , March , 2005.
DISCHARGE INSTRUCTIONS: The patient is just to follow up with
primary care physician. She should also follow up with Dr.
Lucus from Pulmonary at the Pagham University Of An
appointment will be made for her. She should return to the
emergency room if she experiences chest pain , further shortness
of breath , severe sweating , nausea , vomiting , abdominal pain , or
other concerns.
LABORATORY DATA: On discharge , glucose 116 , BUN 30 , creatinine
1.3 , sodium 139 , potassium 3.4; please make a note that her
potassium requires repletion and should be monitored; chloride
93 , CO2 33 , CK 34 , calcium 8.7 , magnesium 1.8 , troponin less than
assay. White blood cell count is 7.04 , hemoglobin 10.6 ,
hematocrit 32.8 , and platelet 274 , 000. Urinalysis , greater than
100 , 000 with 4+ beta-hemolytic Streptococcus group B , sensitive
to penicillin and Cipro; with Cipro being a better choice , i.e. ,
levofloxacin because of her bronchitis.
CONDITION UPON DISCHARGE: Stable.
See radiologic data. Swallowing study on July , 2005 ,
showed normal video swallow. Portable chest x-ray on October ,
2005 , showed new bilateral perihilar opacification consistent
with pulmonary edema. Minimal left-sided effusion is present and
there are no pneumothoraces. The heart is normal in size.
MEDICATIONS UPON DISCHARGE: Tylenol 650 mg orally every 4 hours as needed
headache; aspirin 81 mg orally daily; albuterol nebulizer 2.5 mg
every 4 hours as needed shortness of breath or wheezing , of note , this is
not the patient's usual medication , she does not have a history
of asthma or COPD; Dulcolax 5 mg orally daily; citrate of magnesia
150 mL orally every 6 hours as needed constipation; Benadryl 25 mg every 8 hours
as needed wheezing or itching; Colace 100 mg orally twice a day; Lasix 20
mg orally daily; Robitussin 10 mL orally every 4 hours as needed cough;
hydrocortisone 30 mg orally daily; insulin NPH 30 units
subcutaneously every day before noon; insulin NPH Humulin 10 units
subcutaneously every afternoon , Insulin Regular Humulin 6 units
subcutaneously daily with breakfast; acidophilus 4 tablets orally
three times a day; lactulose 30 mL orally four times a day as needed constipation;
Synthroid 88 mcg orally daily; Senna tablet 2 tablets orally twice a day;
multivitamin 1 orally daily; Norvasc 5 mg orally daily , hold if
systolic blood pressure less than 120; Compazine 5 mg to 10 mg
orally every 6 hours as needed nausea; Lovenox 40 mg subcutaneously daily;
potassium 20 mEq daily , please note the potassium should be
monitored and potassium repleted as necessary; levofloxacin 250
mg orally every 24 hours 12 more total doses; Nexium 40 mg orally daily;
DuoNeb 3/0.5 mg nebulizers every 6 hours as needed , please note that this is
not a home medication; Lumigan each eye every day; NovoLog sliding scale
subcutaneously before meals and bedtime; Maalox as needed
ALLERGIES: The patient is allergic to sulfa , which causes a
rash; azathioprine , which causes fever; sertraline , which causes
nausea; Reglan , which causes angioedema; also the pneumococcal
vaccine , which causes anaphylaxis.
eScription document: 5-2932489 SSSten Tel
Dictated By: RUKA , BERNA
Attending: TIBOLLA , MADISON
Dictation ID 2229509
D: 4/13/05
T: 4/13/05
Document id: 1145
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868974943 | PUO | 59358428 | | 534458 | 4/9/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/26/1992 Report Status: Signed
Discharge Date: 10/8/1992
PRINCIPAL DIAGNOSIS: 1. MYOCARDIAL INFARCTION.
2. STATUS POST CARDIAC CATHETERIZATION WITH
PTCA.
3. UPPER GASTROINTESTINAL BLEED.
4. HYPOTENSION.
5. HISTORY OF ESOPHAGITIS.
6. HISTORY OF URINARY RETENTION SECONDARY TO
BENIGN PROSTATIC HYPERTROPHY.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man with
a history of hypertension and pipe
smoking , who was admitted with a one month history of exertional
dizziness and diaphoresis. The patient had an ETT in September 1992
where he went 6 minutes and 34 seconds on a standard Bruce to a
maximum heart rate of 145 and a maximum blood pressure of 170/90.
The patient stopped secondary to fatigue and did not have any chest
pain. The EKG showed 1 mm upsloping ST depressions in II , III and F and
V4-V6 , and was read as suggestive of coronary artery disease. The
patient was put on Atenolol 500 mg every day two weeks prior to
admission. The patient was also diagnosed with hypertension at
this time. One day prior to admission , the patient had three
episodes of exertional substernal chest tightness associated with
lightheadedness , diaphoresis , and shortness of breath. Each
episode lasted 20-40 minutes and resolved with rest. The final
episode being on the day of admission at 9 A.M. There was no
nausea and vomiting. The patient denies paroxysmal nocturnal
dyspnea and leg edema. The patient was treated in the Emergency
Room with Aspirin , Nitro Paste and oxygen , and sent to the floor
for further evaluation and treatment of his unstable angina. PAST
MEDICAL HISTORY: Includes a history of a hiatal hernia , history of
recurrent esophagitis , with endoscopy in January 1991 which was
negative for Barrett's esophagus. The patient also had a history
of lower GI bleeding in July of 1991 , and a colonoscopy showed
diverticulosis. The patient had a history of urinary retention
secondary to benign prostatic hypertrophy. He also has a history
of urethral calculi and is status post an appendectomy. The
patient has no known drug allergies. MEDICATIONS ON ADMISSION:
Include Atenolol 50 orally every day and Zantac 150 twice a day The patient is
a long time pipe smoker , and he denies alcohol use. FAMILY
HISTORY: Is notable for a father who died of a myocardial
infarction in 1962.
PHYSICAL EXAMINATION: On exam , he was a 63 year old male in no
acute distress with a temperature of 98.2 ,
blood pressure 110/60 , pulse 64 , and respiratory rate of 18. His
pupils were equal , round , and reactive to light. The extraocular
movements were intact. His oropharynx was clear. He had no
jugular venous distention. He had 2+ carotid pulses without
bruits. His lungs were clear. His heart was a regular rate and
rhythm , S1 and S2 , without murmurs , rubs , or gallops. His abdomen
was soft , nontender , with positive bowel sounds , and no
hepatosplenomegaly. Extremities showed no cyanosis , clubbing , or
edema. His neurological exam was nonfocal. The rectal exam was
guaiac negative in the Emergency Room.
LABORATORY EXAMINATION: Sodium 141 , potassium 4.3 , chloride 107 ,
CO2 26 , BUN 18 , creatinine 1.2 , glucose
148. The admission CK was 70. He had normal liver function tests.
His LDH was 144 , cholesterol 171 , triglycerides 257 , hematocrit
45.5 , platelets 198 , white blood count 7.42 with a normal
differential. physical therapy 12.4 , PTT 27.4. His chest x-ray showed clear
lungs , and the EKG showed sinus bradycardia at 57 with an axis of
-4 degrees. There were T-waves in aVF , T-wave inversion in lead
III. There was no change from an EKG in October 1992.
HOSPITAL COURSE: The patient was admitted to the floor for rule
out myocardial infarction and treatment of his
unstable angina. On the floor , the patient experienced chest pain
and an EKG showed ST elevation in the inferior leads. As this
indicated that the patient was having an acute inferior myocardial
infarction , the patient was taken to an emergent catheterization as
PTCA was contraindicated because of his history of diverticulosis
with lower GI bleeding. At catheterization , the patient was noted
to have a 90% RCA lesion and a 90% LAD lesion. The RCA lesion was
successfully dilated , and the patient was admitted to the CCU for post
myocardial infarction care. His post MI course was complicated on 5/10/92 by
400 cc of coffeeground emesis. The patient's hematocrit fell from
40 to 35 , but was then stable. His Heparin and Aspirin were held ,
and the patient was given Omeprazole and antacids. The patient
also had an episode of left arm pain without any significant EKG
changes. As well , the patient experienced an episode of
hypotension with the blood pressure falling to the 70's following a
dose of Metoprolol 5 mg intravenous. The patient was treated with intravenous fluids
and was then stable. On 2/15/92 , an echocardiogram was notable for
left atrial size of 4.0 , inferior and posterior left ventricular moderate
hypokinesis but good overall LV systolic function. There
was 1+ TR , 1+ AI , and 1+ MR as well. On 2/15/92 , the patient was
transferred to the floor where he was noted to have a low grade
fever of 100.2. A subclavian catheter was removed and cultured ,
and several blood cultures were sent. The catheter tip culture
grew coagulase negative Staph but his blood cultures were negative.
This was felt to represent a contaminant and not requiring intravenous
treatment. The patient thereafter showed no signs of infection and
was afebrile. On the evening of 10/16/92 , the patient experienced
two episodes of sharp left sternal chest pain , one lasting five
minutes and the other three minutes , though unfortunately no EKG
was done at the time. The following day , the patient was
ambulating without chest pain. There were no further episodes of
chest pain. The patient was begun on low dose Inderal 5 mg three times a day
On the second , the patient had an ETT with a modified Bruce
protocol which was stopped at 8 minutes secondary to fatigue and
shortness of breath , and a maximum heart rate of 120 , and blood
pressure of 140/70. There were 1 mm ST depressions in leads I , L ,
anda V2-V6 which persisted during recovery. The patient was
presented with the option of remaining in the house with a repeat
catheterization with probable angioplasty of his LAD lesion the
following Monday ( 3/15/92 ) or recovering at home with readmissions
in one to two weeks for a repeat catheterization with
PTCA. The patient and his wife decided to opt for recovery at
home , and the patient was discharged on 6/8/92.
DISPOSITION: DISCHARGE MEDICATIONS: Enteric coated Aspirin one
every day , Omeprazole 20 twice a day , Inderal 5 three times a day ,
sublingual Nitroglycerin as needed , and Ativan 0.5 to 1 mg q6-8 hours
as needed CONDITION ON DISCHARGE: Stable. He was to followup with
Dr. Geraldine Kittell
NJ753/4150
CARA BARNABA , M.D. HL86 D: 3/16/92
Batch: 1169 Report: M8920C63 T: 11/26/92
Dictated By: RUFUS C. BERNAS , M.D.
cc: 1. CARA BARNABA , M.D.
c/o CHH - Tadoil Blvd.
Document id: 1146
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| output/system_intuitive_annotation.xml | intuitive |
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110132746 | PUO | 12605164 | | 4796244 | 1/9/2005 12:00:00 a.m. | HEMOPTYSIS | Signed | DIS | Admission Date: 1/9/2005 Report Status: Signed
Discharge Date: 6/4/2005
ATTENDING: TIBOLLA , MADISON M.D.
DATE OF BIRTH: 9/4/45.
ADMISSION DIAGNOSIS: Hemoptysis.
DISCHARGE DIAGNOSES: Pulmonary hypertension , question
cellulitis.
MEDICATIONS ON DISCHARGE: Tylenol 650 mg orally every 4 hours as needed ,
allopurinol 200 mg orally daily , atenolol 50 mg orally daily ,
colchicine 0.6 mg orally daily , Colace 100 mg orally twice a day , Motrin
80 mg orally every 6 hours as needed , miconazole cream 2% topical twice a day ,
Kenalog 0.1% cream topical daily to legs bilaterally , Diovan 320
mg orally daily , miconazole powder 2% twice a day to legs , Procardia XL
300 mg orally daily , Nexium 20 mg orally daily , Keflex 1 g orally
four times a day x5 more days and Lasix 80 mg orally twice a day
OTHER DIAGNOSES: Hypertension , history of DVT , history of
multiple PEs , TPA for PE in 1987 and status post IVC filter
placement , venostasis dermatitis , pulmonary hypertension , and
gout.
OPERATIONS AND PROCEDURES: None.
OTHER TREATMENTS AND PROCEDURES: None.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with
morbid obesity and history of multiple DVTs and pulmonary emboli ,
status post IVC filter placement who presented to the emergency
room with hemoptysis episode x1. He reported two tablespoons of
bright red blood when coughed up , but he did not have a
persistent cough. No shortness of breath. No fevers , chills ,
night sweats or other symptoms.
PAST MEDICAL HISTORY: Morbid obesity , DVTs , PEs , hypertension ,
total hip replacement and status post hernia repair.
ALLERGIES: Versed.
EXAM ON ADMISSION: Temperature 97 , respirations 22 , blood
pressure 114/78 , oxygen 97 on room air. General: He is obese ,
talkative , walking around. Had moist mucous membranes. Unable
to assess JVP due to size. Lungs: Clear. Heart: Regular
without murmurs. S1 and S2 were normal. Abdomen: Obese ,
nontender , and nondistended and soft. Extremities: Show chronic
venostasis changes without evidence of cyanosis , open wound and
some edema was present. EKG on admission showed normal sinus
rhythm at 74 beats per minute with no significant ST-T changes.
Chest x-ray that he brought from an outside hospital showed right
hilar prominence with question of a mass. Chest x-ray in the
emergency room at the Pagham University Of showed no
acute process and severe pulmonary congestion.
LABORATORY DATA ON ADMISSION: Sodium 144 , potassium 4.1 ,
chloride 102 , carbon dioxide 30 , BUN 28 , creatinine 1.1 , glucose
104 , white blood cell 3.7 , hematocrit 54 , platelets 188 , INR 2.1 ,
PTT 33. An echo in September 2005 showed mild LVH and ejection
fraction of 55%-60% , increased RV , right systolic function mildly
reduced and mild RAE and LAE.
HOSPITAL COURSE: In the emergency room , the patient received
vitamin K 6 mg x1 to reverse his Coumadin in the setting of
hemoptysis.
1. Pulmonary: The source of his hemoptysis was initially
unclear. His sputum looked only blood tinged on the admission
exam , but the patient reported bright red blood prior to
admission. His chest x-ray from the outside hospital looked like
a right hilar prominence , which was read as a possible mass , but
a repeat study done in the emergency room at the Kernan To Dautedi University Of Of showed
only pulmonary congestion and no mass or acute process. He has
very minimal history of smoking cigarettes in the past. He was
too large to fit into a CAT scan machine , so he underwent a V/Q
scan , which demonstrated low probability for pulmonary embolus.
The pulmonary service was consulted and their impression was that
his hemoptysis was likely secondary to severe pulmonary
hypertension but not a mass or infection. They opted not to
perform a bronchoscopy and recommended starting sildenafil for
pulmonary hypertension. The Masan Oak Hospital , the Pulmonary
Hypertension Service was then consulted. They did not recommend
the sildenafil so that was actually not started. They did
recommend starting torsemide 80 twice a day for better diuresis and
this was initiated and resulted in good urine output. His home
dose of diuretic was 80 mg of Lasix daily. Upon discharge , he
was sent home on 80 mg of Lasix twice a day with recommendations
to have his blood drawn , to measure electrolytes within a week ,
and follow up with his primary care physician as soon as possible. The Lingwest Tal/ Hospital
recommended an outpatient cath and he was instructed to follow up
with them. He also reports a history of sleep apnea and BiPAP
use at home , although he admits that he does not use the BiPAP
machine. He was set up with BiPAP and nighttime oxygen inhouse
and he was continued on Coumadin for his history of pulmonary
emboli. His Coumadin was held initially on admission in the
setting of hemoptysis , but it was restarted after the V/Q scan
was low probability. He was also placed on a heparin drip while
the Coumadin was not therapeutic. He was discharged on 12 mg of
Coumadin daily.
2. Cardiovascular and hypertension: He was continued on his
home meds.
3. Infectious disease: He did develop bilateral lower extremity
erythema and tenderness on 1/14/05 and he was started on intravenous
Ancef 2 g every 8 hours for presumed cellulitis. This was changed to
Keflex upon discharge.
4. Gout: He continued on his home meds without incident.
DISCHARGE CONDITION: Stable.
DISCHARGE INSTRUCTIONS: The patient was instructed to have his
lytes drawn within a week by the primary care physician , VNA , or lab center. He was
instructed to have his INR measured on Monday or Tuesday and for
the results to be sent to his primary care physician and/or the Coumadin Clinic. He
was instructed to use oxygen 2 liters via nasal cannula for 15
hours overnight and to use the BiPAP machine and elevate his legs
while not walking or standing and to wear compression stockings.
ALLERGIES: Midazolam.
FOLLOWUP APPOINTMENT: He has an appointment with Dr. Lamia ,
468-305-3814 on 7/11/05 at 9:30 a.m.
eScription document: 4-3071524 ISSten Tel
Dictated By: RUKA , BERNA
Attending: TIBOLLA , MADISON
Dictation ID 9829851
D: 11/14/05
T: 7/6/05
Document id: 1147
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Dp |
DM |
Gs |
GER |
Gou |
HC |
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VI |
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244081005 | PUO | 47574158 | | 2365534 | 6/4/2005 12:00:00 a.m. | CHEST PAIN , RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 7/27/2005 Report Status: Signed
Discharge Date: 6/23/2005
ATTENDING: GRUNTZ , KATHERYN MD
PRINCIPAL DIAGNOSIS: Coronary artery disease with myocardial
infarction.
OTHER DIAGNOSES:
1. CAD.
2. Hypertension.
3. Congestive heart failure.
4. Diabetes.
5. Hypercholesterolemia.
6. Peripheral vascular disease.
7. Smoking history.
8. History of alcohol abuse.
9. History of seizure disorder.
10. Atrial fibrillation with rapid ventricular response.
HISTORY OF PRESENT ILLNESS: Mr. Naslund is a 72-year-old man with
history of CAD status post CABG , PCI with history of stable
angina , type 2 diabetes , peripheral vascular disease , former
smoking history and also history of seizure disorder with
cataracts and recently discharged after an admission for atrial
fibrillation with rapid ventricular response. He had occasional
anginal symptoms prior to discharge. He took about two
nitroglycerins per week. Over the past week , he had escalating
chest pain requiring one nitroglycerin per day. The pain was
relieved by rest and nitroglycerin. One week prior to admission ,
his digoxin was stopped and his amiodarone was decreased. His
Plavix was stopped and his Coumadin was held. On the morning of
admission , he had chest pain. He had two nitroglycerins and
rested but the pain persisted. He was taken to the ED. In the
ED , he received Lopressor , Enalapril , Lovenox treatment dose and
a Plavix load.
PAST MEDICAL HISTORY: Includes CAD , hypertension , CHF , diabetes ,
hypercholesterolemia , peripheral vascular disease and past
smoking history.
ALLERGIES: To penicillin.
SOCIAL HISTORY: Significant for past alcohol and smoking
history. He quit alcohol 25 years ago.
PHYSICAL EXAMINATION: Significant for afebrile , heart rate 45
and blood pressure 95/50. He had a left surgical pupil , left eye
ptosis at baseline. His heart had no murmurs , rubs or gallops.
His lungs were clear. His abdomen was soft , nontender and
nondistended. He had bilateral femoral bruits , 2+ distal pulses.
No pronator drift.
LABS: Significant for hematocrit baseline at 30 to 32 , white
count of 13. His troponin peaked at 6.4.
EKG showed ST depressions in V3 through V6 that were new.
Echocardiogram on 3/23/05 showed an EF of 25 to 30% with septal
akinesis lateral and posterior hypokinesis and mild tricuspid
regurgitation.
Chest x-ray showed mild pulmonary edema.
HOSPITAL COURSE: Hospital course for this 72-year-old man with
non-ST-elevation MI.
1. Cardiovascular: A catheterization on hospital day 1 showed
four-vessel disease. No intervention was taken at that point , as
it was unclear which region was the culprit. Afterwards , he was
in hypotensive respiratory distress , likely secondary to flash
pulmonary edema. He received Lasix and morphine and he was
started on a nitro drip with improvement in symptoms. He was
found to have flash pulmonary edema and in atrial fibrillation
with rapid ventricular response. He was taken back to the
catheterization lab and given four stents to his saphenous vein
graft , OM1 with good resolution of his symptoms and he went to
the CCU afterwards. On hospital day 3 , he was transferred to the
floor and was given an amiodarone load given his ejection
fraction and increased ectopy on telemetry. His troponin had
been trended down to the 0.2s by discharge. His beta-blocker and
ACE inhibitor were titrated to heart rate and blood pressure.
Prior to anticipated discharge , he re-developed flash pulmonary
edema secondary to atrial fibrillation with rapid ventricular
response. Electrophysiology consult evaluated him and based on
his prior ejection fraction symptoms , it was decided to place a
dual-chamber pacemaker with AICD. He has had no respiratory
events since that placement. He has remained in atrial
fibrillation and was re-loaded with digoxin. He was started on
his Coumadin two days prior to discharge and was not yet
therapeutic. His repeat echo did show an EF of 55%. This was
after the pacemaker was placed.
2. Renal: He has chronic renal insufficiency. He was given
Mucomyst precath with good effect. His creatinine on discharge
was 1.1 and he was making urine.
3. GU: He has had some symptoms of urinary retention with
difficult-to-place Foley. He was started on Flomax with good
effect. His prostate was not overtly large on exam. His PSA was
within normal limits.
4. Endocrine: He is a type 2 diabetic. His home dose of
metformin was held. He was continued on Lantus with sliding
scale insulin.
5. Hematology: His hematocrit was transiently down to 24. When
transferred out of the CCU , he was given three units of packed
red blood cells given his history of CAD. Since this , his
hematocrit has been stable in the 30-to-32 range. An abdominal
CT did not show any evidence of retroperitoneal bleed. His groin
had only a very small hematoma. His stool guaiac was only trace
positive.
DISPOSITION: He was discharged home in stable condition with VNA
services. He will follow up with his primary care physician on 10/19/05 , with Dr.
Gruntz on 1/14/05 , and he should have his INR checked on
3/5/05 or 1/14/05 and Coumadin adjusted accordingly.
PHYSICAL EXAMINATION ON DISCHARGE: His physical exam on
discharge was largely unchanged , afebrile and hemodynamically
stable. He had now a pacemaker placed over the left chest.
Incision looked clean , slightly tender to palpation. He had no
murmurs or rubs , no pedal edema. His chest was clear.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg orally daily.
2. Enteric-coated aspirin 325 mg orally daily.
3. Librium 10 mg orally twice a day
4. Colace 200 mg orally twice a day
5. Ferrous gluconate 324 mg orally three times a day
6. Lasix 40 mg orally twice a day
7. Nitroglycerin one tab orally every 5 minutes as needed chest pain.
8. Dilantin 100 mg orally twice a day
9. Senna two tabs orally twice a day
10. Coumadin 3 mg orally every afternoon
11. Lipitor 80 mg orally daily.
12. Flomax 0.4 mg orally daily.
13. Plavix 75 mg orally daily.
14. Lantus 14 units subcutaneous at nighttime.
15. Metformin 500 mg orally twice a day
16. Ranitidine 150 mg twice a day
17. Digoxin 0.125 mg orally daily.
18. Enalapril 10 mg orally daily.
19. Atenolol 50 mg orally twice a day
He was discharged home with VNA services.
FOLLOW-UP: He has follow-up appointments with his primary care physician , Dr. Wendi Newand at A Triaded Health on 10/24/05 , with Dr. Hermina Tuomala of
Electrophysiology 11/14/05 at 3 p.m. and Dr. Gruntz 6/12/05
scheduled.
He will have his INR drawn on 3/5/05 with follow-up INRs to be
drawn every seven days and Coumadin adjusted accordingly.
eScription document: 2-4513014 CSSten Tel
CC: Wendi Bradford Newand MD
Chand , New York 26990
Peckhar Ln.
Hishi
Dictated By: HARKLEY , JACQULYN
Attending: GRUNTZ , KATHERYN
Dictation ID 5992058
D: 1/14/05
T: 1/14/05
Document id: 1148
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| output/system_intuitive_annotation.xml | intuitive |
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864945124 | PUO | 81278338 | | 637749 | 7/6/2000 12:00:00 a.m. | PNEUMONIA , CARDIOMYOPATHY | Signed | DIS | Admission Date: 7/6/2000 Report Status: Signed
Discharge Date: 6/12/2000
CARDIOLOGY SERVICE
PRINCIPAL DIAGNOSIS: CARDIOMYOPATHY.
SECONDARY DIAGNOSES: 1. CONGESTIVE HEART FAILURE.
2. CARDIOMYOPATHY.
3. ARRHYTHMIA.
HISTORY OF PRESENT ILLNESS: Thirty-two year old man with known
familial cardiomyopathy who was
admitted with a three month history of intermittent cough ,
increasing orthopnea , decreased appetite , and a 20 pound weight
loss. He is taking antibiotics intermittently for cough without
relief. Denies pedal edema. Has had chills. Has not taken his
temperature. Has no documented fever. Does have nasal congestion.
No known exposure to significant illness. Has increasing dyspnea
on exertions. Several episodes of sudden onset light-headedness
with visual changes including darkening and light flashes lasting 5
to 10 minutes , sudden onset. No frank syncope or palpitations.
The patient reports noncompliance with salt and fluid restriction
at home.
PAST MEDICAL HISTORY: Status post appendectomy , thyroidectomy ,
adenoidectomy.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Cardiomyopathy. One sibling died of sudden
cardiac death. Another sibling is status post
cardiac transplant.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile , pulse in the 90s ,
blood pressure 88/74 mmHg , saturating 94% on
room air. HEENT: Jugular venous pressure 14 centimeters. No
sclerae icterus. Mucous membranes moist , and no skin lesions.
LUNGS: Crackles at the bases. Diffuse rhonchi. Very laterally
displaced point of maximal impulse. Audible S3. Loud holosystolic
murmur. No S1. No RV impulse. ABDOMEN: Liver slightly enlarged
at 16 centimeters , nontender , pulsatile. EXTREMITIES: Leg
lukewarm without edema. NEUROLOGIC: Alert and oriented x3.
LABORATORY DATA: EKG showed sinus rhythm at 100 , left atrial
enlargement , left ventricular enlargement. Chest
x-ray shows interstitial edema , cardiomegaly. No focal
consolidating process.
PROCEDURES: Placement of an ICD by the electrophysiology service
on January , 2000 without complication.
HOSPITAL COURSE: The patient was put on intravenous fluids , high
doses of Lasix for diuresis of a goal of 1.5 to 2
liters per day. The patient's jugular venous pressure decreased
over his hospital course. His cough improved and his lung
examination improved , as well. Due to increasing heart failure , we
have decreased work capacity shown on laboratory tests prior to
admission. The patient was evaluated by the cardiology service for
a possible heart transplant. Given the patient's history of
presyncopal episodes , the electrophysiology service evaluated him ,
as well , for placement of ICD.
COMPLICATIONS: None.
DISCHARGE MEDICATIONS: Captopril 75 milligrams orally three times a day ,
digoxin 0.125 milligrams orally every day , Colace
100 milligrams orally twice a day as needed for constipation , Isordil 20
milligrams orally three times a day , Keflex 250 milligrams orally four times a day x3 days ,
Claritin 10 milligrams orally every day , Nasacort internasally 2 puffs
once a day , torsemide 50 milligrams orally every day , potassium chloride
SR by mouth 40 milliequivalents once a day , Tylenol 650 to 1 , 000
milligrams orally every 4 hours as needed for headache or pain , Percocet 1-2
tablets orally q4-6h as needed for severe pain.
DISPOSITION: Home.
FOLLOW-UP: Follow-up appointments include Dr. Dominguez scheduled
for October , Dr. Lyn please call for
appointment , 3MDFT testing scheduled for October , 2001.
CONDITION UPON DISCHARGE: Stable.
Dictated By: JERALD ALPER , M.D. MN5
Attending: SANTA V. CHOWANEC , M.D. OX2
HZ878/4074
Batch: 24829 Index No. FBAUBA7Q5H D: 5/25
T: 5/25
Document id: 1149
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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853516001 | PUO | 35755325 | | 6048350 | 4/29/2006 12:00:00 a.m. | lower extremity ulcer , cellulitis , bradycardia | | DIS | Admission Date: 3/12/2006 Report Status:
Discharge Date: 5/25/2006
****** FINAL DISCHARGE ORDERS ******
KAZUNAS , JULIET MOZELL 063-93-17-8
Valle And Ro
Service: MED
DISCHARGE PATIENT ON: 5/18/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SVENNINGSEN , CHRISTIAN VIVAN , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
ASCORBIC ACID 500 MG orally twice a day
BACITRACIN TOPICAL TP twice a day
Instructions: apply to ulceration on toes.
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
1 TAB orally DAILY
CIPROFLOXACIN 250 MG orally every 12 hours
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally twice a day HOLD IF: SBP<100
ULTRAVATE 0.05% ( HALOBETASOL PROPIONATE 0.05% )
OINTMENT TP DAILY
VICODIN ( HYDROCODONE 5 MG + APAP 500MG ) 1 TAB orally every 8 hours
Starting Today ( 7/28 ) as needed Pain
LISINOPRIL 40 MG orally DAILY HOLD IF: SBP<100
Alert overridden: Override added on 3/19/06 by
GETTINGS , OTELIA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: MDA
Previous Alert overridden
Override added on 2/21/06 by GETTINGS , OTELIA H. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
Previous Override Notice
Override added on 8/18/06 by GETTINGS , OTELIA H. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
339216342 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: for hypokalemia
LOSARTAN 100 MG orally DAILY
Alert overridden: Override added on 5/18/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LOSARTAN POTASSIUM Reason for override: MDA
NEPHRO-VIT RX 1 TAB orally DAILY
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
TRAZODONE 50 MG orally BEDTIME as needed Insomnia
URSODIOL 300 MG orally three times a day
ZINC SULFATE 220 MG orally DAILY
Food/Drug Interaction Instruction
Take 1 hour before or 2 hours after meals.
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Ellzey pcp 5/14 @ 8:15 scheduled ,
Dr Halechko ( vascular surgery ) 10/24/06 scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
lower ext ulcer
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
lower extremity ulcer , cellulitis , bradycardia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
R LE ulcer due to chronic venous stasis , bradycardia
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: lower ext ulcer
HPI: 68y/o obese F with HTN , PBC , CRI p/with 2 months of painful R
anterior shin ulcer and swollen R calf. Both the ulceration and
swelling got progressively worse over the past 2 months. The patient
has limited mobility due to b/l knee pain which is chronic. Denies
F/C/CP/SOB. No trauma to the area. No insect bites. She has no pets.
No recent travel.
ED VS:97 50 130/77 98% RA , received ancef in ED
***
PMH: HTN , primary biliary cirrhosis , obesity , psoriasis ,
osteoarthritis , hyperparathyridism 2/2 CRI , colovesicular fistula
repair 1/22
***
Meds on admit: ASA , trazodone , atenolol , ursodiol , losartan ,
lisinopril , caltrate +D , vicodin
***
NKDA
***
Exam: T= 97 HR=34-51 NSR BP=138/71 R 16 98%RA Obese ,
NAD Distant heart sounds. RRR. Nl s1 and S2. No
m/r/g. CTAB. Abd obese , NT/ND. Extremities with chronic
brwany venous stasis changes bilaterally. 2 by 2 cm stage 3 ulder on
R shin. bilaterll hammer toe at second toe. RLE>LLE. Area surrounding
ulcer of warmth/tenderness.
R foot films - no osteo LENIS - no
DVT Labs: Cr 1.8 ( BL 1.4 to 1.7 )
HCT 37.5 ( 35-37 ) plt 253 , WBC
6.05
***
HOSPITAL COURSE: 68F with a hx of HTN , CRI , obesity , psoriasis presenting
with RLE ulcer and cellulitis. Hospital course complicated by episodes of
sinus brady to 30's with 4-6 sec pauses , asx , evaluated by EP , no need for
PPM at present.
**
1 ) R lower ext Ulcer and cellulitis - cellulitis initially treated with
nafcillin intravenous for 5 days with improvement in both swelling , erythema , and
pain. Discharge from the wound was cultured and grew out Ecoli and
Enterobacter , sensitive to cipro. Abx were switched to cipro which would
provide coverage for the gram negatives growing from her wound and also
cover her cellulitis. She will complete a total abx course of 12 days
( additional 5 days of cipro ). There was an initial concern for DVT but
LENIS were negative. Zinc and Vit C were added to her regimen. She will
also need Wound changes with NS wet to dry twice a day. The ulcer is most likely
due to poor wound healing in the setting of chronic venous stasis. It was
also noted that she had very weak LE pulse so vascualar surgery was
consulted. She was found to have + peripheral pulses by doppler , and
follow up with vascular surgery was set up for her. She will also get
umaboots and ABI at her followup.
***
2 ) bradycardia: to 30's during sleep. patient came in on atenolol which we
discontinued , esecially in the setting of CRI. No tachyarrythmia on Tele.
Good HR response with actviity up to 70s. Evaluated by EP and felt that
she was not a candidate for a PPM at this point , especially since her
bradycardia is assymptomatic. It was felt that her bradycardia is most
likely due to her OSA , and that she would benefit from a sleep study. If
her bradycardia does not improve after treatment of her OSA , then she
will need to follow up with EP for further evaluation.
***
3 ) ENdo - fasting glucose normal , HGA1C -5.4.
***
4 ) Renal - CRI at baseline. No issues during hospitalization
ADDITIONAL COMMENTS: 1. take antibiotics for full course , if ulcer or cellulitis worsens or
does not improve after antibiotics please call your doctor
2. stop taking atenolol
3. New medications: cipro , ascorbic acid ( vit C ) , zinc
4. Follow up with primary care physician
5. Appt for sleep study ( sleep clinic will call with your scheduled
appt. )
6. Wound care: twice a day wet to dry dressing changes with NS
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. d/c atenolol , avouid nodal blocking agents
2. sleep study - clinic will call patient with appt date
3. if there is no improvement of bradycardia after tx for OSA , follow up
with EP.
4. Complete abx course ( 5 more days of cipro )
5. vascular surgery appt with Dr. Burghard
No dictated summary
ENTERED BY: GETTINGS , OTELIA H. , M.D. ( QG33 ) 5/18/06 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1150
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
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626207833 | PUO | 91500274 | | 714963 | 4/12/1998 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 5/20/1998 Report Status: Signed
Discharge Date: 11/26/1998
CHIEF COMPLAINT: Chest and epigastric pain.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old woman who
is having a significant amount of GI
distress with belching and gas over several months to years who
presents with three hours of upper abdominal and chest discomfort
which she described after a fall day of volunteering and doing her
exercise. Actually she was sitting down to eat and then developed
this symptom that lasted for about three hours. The patient did
not that she has run out of her Atenolol for more than three days
prior to admission and came to the Emergency Room when her pain did
not resolve after taking some Tums and some water. The patient
denies any previous history of angina. She came into the Emergency
Room and had a blood pressure of 190/97 with a normal EKG. The
patient was given 5 mg of Lopressor and started back on her
Atenolol with decrease of her heart rate and blood pressure and
resolution of her symptoms.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Hypercholesteremia.
ALLERGIES: Streptomycin.
MEDICATIONS:
1. Lisinopril 20 mg twice a day
2. Atenolol 50 mg twice a day
3. Aspirin 325 mg every day
4. Niacin 250 mg twice a day
5. Colace.
6. Multivitamin.
7. NPH insulin 20 units every day before noon
SOCIAL HISTORY: The patient lives in a senior's home. She does
not smoke or drink alcohol.
PHYSICAL EXAMINATION: VITAL SIGNS: She was afebrile. Blood
pressure 150/90 , heart rate 84. O2
saturation was 94-97% on room air. GENERAL: The patient was a
pleasant obese woman in no acute distress , belching during her
history. NECK: Supple. LUNGS: Clear to auscultation except for
some initial left basilar crackles , which have cleared. HEART:
Regular rate and rhythm without any murmurs , gallops or rubs.
ABDOMEN: Soft , non-tender. RECTAL: Heme negative , per
examination in the Emergency Room. EXTREMITIES: She did have some
bilateral trace edema. NEUROLOGIC: Non-focal.
DIAGNOSTIC STUDIES: SMA-7 was significant for a glucose 236. CPK
was 74 , troponin 0.04. CBC and coags were
normal. Chest x-ray did show a top normal cardiac silhouette with
mild evidence of CHF. EKG showed normal sinus rhythm with no acute
ST or T wave changes.
HOSPITAL COURSE: The patient was admitted to the Short Stay Unit.
She was put on cardiac telemetry and was ruled
out for myocardial infarction with serial CPKs and EKGs. She had
no further episodes of her discomfort but did have continued
belching. On further discussion with the patient , she was actually
a relatively active woman who did not have any anginal symptoms in
the past and never described any shortness of breath , PND or
orthopnea. The plan was made to get an echocardiogram and do an
adenosine stress test. Her adenosine stress test was negative for
chest pain or EKG changes and her MIBI was negative for fixed
reversible defects. She therefore was felt to be negative for
ischemia. However , on her MIBI and her echocardiogram she did have
a mildly decreased LV function of 40-45% , of unknown significance
and unknown etiology. It was felt that this could be further
worked up for other causes , including sending out for TSH , SPEP ,
UPEP , and iron studies as an outpatient , as the patient was anxious
to leave the hospital. This could be done in clinic by her primary
care physician.
DISPOSITION: The patient was discharged on her admission
medications with the addition of Axid 150 mg orally
twice a day and simethicone 80 four times a day as needed for her gas. The patient
will discuss her GI symptoms with her primary care physician and
would benefit from further workup as an outpatient. The patient
was discharged in stable condition with no adverse drug reactions.
The patient will follow up with Dr. Ola Fraschilla in approximately
one to two weeks.
Dictated By: MYRON VANIER , M.D. CW89
Attending: MYRON VANIER , M.D. CW89
ZB386/2772
Batch: 14336 Index No. KBNZMX3RPZ D: 4/26/98
T: 8/27/98
Document id: 1151
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
U |
N |
U |
U |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
N |
N |
N |
- |
N |
N |
Y |
N |
N |
Y |
N |
N |
N |
713378456 | PUO | 63374638 | | 795361 | 9/9/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/9/1992 Report Status: Signed
Discharge Date: 10/26/1992
ADMISSION DIAGNOSIS: CHEST PAIN. SECONDARY DIAGNOSIS IS CEREBRAL
PALSY WITH MENTAL RETARDATION.
HISTORY OF PRESENT ILLNESS: The patient is a 27 year old black man
with a history of cerebral palsy and
mental retardation who now presents with chest pain of three days
duration. His cardiac risk factors include positive family history
and a history of hypertension. He does not smoke tobacco and has
no history of diabetes. Note that the patient is a very poor
historian , however , through his mother , he complains of
approximately three weeks of increasing fatigue and malaise. The
week prior to admission , he had a single episode of chest pain at
"work" ( actually his day activity center ) which resolved
spontaneously. Three days prior to admission , the patient had
poorly defined chest pain with marked diaphoresis. This pain was
worse with deep inspiration and , in addition , he had generalized
nausea and malaise with shortness of breath. This pain waxed and
waned over the day and was not exertional in nature. He was seen
at Bussadd Southrys Community Hospital where no laboratories were drawn and he was
referred to follow-up on Friday. One day before admission , the
patient had chest pain radiating to the left upper arm with
numbness in that extremity. He had nausea and occasional
diaphoresis. He had an echocardiogram on that day at Bussadd Southrys Community Hospital which revealed mild left ventricular hypertrophy but no
regional wall motion abnormality and was otherwise normal. On the
day of admission , the patient complained of increased severity of
chest pain with shortness of breath. He "felt sick" but denied
vomiting or diaphoresis. He came to the Pagham University Of Emergency Room where he continued to complain of chest
pain radiating to the left shoulder as well as into the abdomen.
This symptom was worsened with inspiration as well as with central
sternal palpation. At baseline , the patient does little exercise
secondary to his cerebral palsy , he has three-pillow orthopnea but
no paroxysmal nocturnal dyspnea , and he has no prior episodes of
chest pain except as described above. PAST MEDICAL HISTORY:
Significant for cerebral palsy as above and also for pneumonia in
1986. CURRENT MEDICATIONS: He takes no medications. ALLERGIES:
He has no allergies. SOCIAL HISTORY: He does not smoke tobacco ,
he does not drink alcohol , and he does not use intravenous drugs.
He is a regular church goer , he lives with his mother , and attends
a day rehabilitation care center. FAMILY HISTORY: Significant for
angina in his mother and a grandfather with coronary artery
disease.
PHYSICAL EXAMINATION: He was afebrile , his blood pressure was
160/130 , heart rate was 65 , respiratory rate
was 20 , and he was 98% saturated on room air. He was an obese
black man in no acute distress. SKIN: Clear. HEENT: The
oropharynx was clear , there was no jugular venous distention ,
carotids were 2+ and equal , pupils were equal , round , and reactive
to light and accommodation , and the neck was supple without
lymphadenopathy. The fundi were not well seen secondary to poor
cooperation. LUNGS: Clear to auscultation. CARDIAC: There was a
regular rate and rhythm , S1 and S2 were heard , and there was a
II/VI systolic ejection murmur at the left upper sternal border.
ABDOMEN: Obese with positive bowel sounds , it was non-tender ,
slightly tympanitic , there was no hepatosplenomegaly , and the
patient was guaiac negative. EXTREMITIES: Examination revealed no
clubbing , cyanosis , or edema. There was no focal tenderness and
pulses were intact bilaterally. NEUROLOGICAL: He was alert and
oriented times three and he was unable to do simple calculations ,
however , cranial nerves II-XII were intact. Sensory and motor in
the upper and lower extremities were within normal limits , reflexes
were brisk and symmetric , and toes went down.
LABORATORY EXAMINATION: EKG revealed normal sinus rhythm with an
axis of 0 degrees and normal intravals.
There was left ventricular hypertrophy by voltage in aVL and there
were no acute ST or T wave changes , however , there was no old EKG
for comparison. An SMA 7 was benign , a CK on admission was 283
with 10 MB , white count was 9.4 , and urinalysis was negative.
Chest X-Ray initially revealed evidence of pulmonary vascular
redistribution , however , a repeat chest X-Ray an hour later was
clear.
HOSPITAL COURSE: The patient was admitted to the floor and given
his rather indistinct complaints , a broad-based
work-up was initiated including a rule out for myocardial
infarction. Although the patient continued to have elevated CK
with elevated MB , these were electrophoresed and found not to be
MB. There was concern given the pleuritic nature of his chest pain
that the patient may have suffered a pulmonary embolism. Lower
extremity non-invasives were negative as was a VQ scan. The
patient was kept on cardiac monitor until his rule out for
myocardial infarction was complete. Throughout his
hospitalization , the patient continued to complain of diffuse body
pain as well as "feeling sick" , however , he continued to be
afebrile with normal laboratories. On the second hospital day , the
patient became aware of the fact that his mother had been admitted
to an outside hospital for a rule out myocardial infarction. He
became quite agitated and at that time complained of increasing
abdominal pain. He was treated with laxatives and reassurance and
seemed improved. On the fourth hospital day , it was felt that the
patient was not suffering from any serious illness and that the
most dangerous entities had been ruled out. It was felt that he
was most likely suffering from a viral flu syndrome. His blood
pressure was controlled with a beta blocker and he was discharged
in stable condition to home.
DISPOSITION: DISCHARGE MEDICATIONS: Atenolol 2.5 mg orally every day ,
Nifedipine XL 30 mg orally every day , and Pepcid 20 mg orally
twice a day He will follow-up with Dr. Chaskey in KTDUOO Clinic in one
month's time.
CR151/5558
MARCELA M. JONE , M.D. CF4 D: 4/28/92
Batch: 6353 Report: N6807G1 T: 2/22/92
Dictated By: GLORY CHASKEY , M.D.
Document id: 1152
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
098812026 | PUO | 57870793 | | 658088 | 8/5/2001 12:00:00 a.m. | pulmonary edema | | DIS | Admission Date: 8/5/2001 Report Status:
Discharge Date: 6/3/2001
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Alabama
Service: MED
DISCHARGE PATIENT ON: 9/17/01 AT 07:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CODA , TRANG HIEN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ATENOLOL 50 MG orally twice a day Instructions: begin at 9am.
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 1 , 250 MG orally three times a day
PREMARIN ( CONJUGATED ESTROGENS ) 0.625 MG orally every day
Override Notice: Override added on 8/9/01 by
TALFORD , EDMUNDO JOHNNIE , M.D.
on order for BUTALBITAL orally OTHER every 4 hours ( ref # 37959599 )
POTENTIALLY SERIOUS INTERACTION: CONJUGATED ESTROGENS &
BUTALBITAL Reason for override: patient has had TAH
Previous override information:
Override added on 8/9/01 by TALFORD , EDMUNDO JOHNNIE , M.D.
on order for BUTALBITAL orally ( ref # 41645587 )
POTENTIALLY SERIOUS INTERACTION: CONJUGATED ESTROGENS &
BUTALBITAL Reason for override: patient will be warned
GUAIFENESIN 10 MILLILITERS orally every 4 hours as needed cough
HCTZ ( HYDROCHLOROTHIAZIDE ) 12.5 MG orally every day
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
BUTALBITAL 90 MG orally every 4 hours as needed headache
Alert overridden: Override added on 8/9/01 by
TALFORD , EDMUNDO JOHNNIE , M.D.
POTENTIALLY SERIOUS INTERACTION: CONJUGATED ESTROGENS &
BUTALBITAL Reason for override: patient has had TAH
Previous Alert overridden
Override added on 8/9/01 by TALFORD , EDMUNDO JOHNNIE , M.D.
POTENTIALLY SERIOUS INTERACTION: CONJUGATED ESTROGENS &
BUTALBITAL Reason for override: patient will be warned
hypertensive so imitrex not appropriate.
Number of Doses Required ( approximate ): 4
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 4
FUROSEMIDE 40 MG orally every day
DIET: No Restrictions
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Reffitt 10/30/01 scheduled ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
upper respiratory infection
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pulmonary edema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension morbid obesity
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
43 year-old woman with COPD , sleep apnea , chronic
hypoxia , obesity , & von Willebrand's disease presents with fatigue and
increased dyspnea slowly progressing over the last
few weeks. She is hypoxemic with PO2 47 correctable
with nasal cannula ( 2.5 L ). She has not been using
her CPAP and has not been taking her atenolol.
BP in ED was 180/70-100. Chest CT neg for PE
but showed ground-glass in bases ( ?edema ,
?atypical PNA ). patient also has few social supports and
likely requires more VNA , home help , physical therapy. Lasix 40mg
intravenous 7/18 produced moderate increase in U/O. Patient no longer dyspneic
on 8/24 Her room air O2 Sat is 89-90%. She will be discharged on
new antihypertensives as well as furosemide 40mg orally every day with VNA to
check BP , O2 Sats , weight.
ADDITIONAL COMMENTS: 1. For VNA: please check BP , please help with C-PAP , please check O2
Sat , please check weight daily. Call Dr. Jackson Part with results.
Thanks.
2. For Ms Shost Follow up appointment with Dr. Jackson Part on
November , 2001 at 3:10pm. Please call him with questions or
concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: TALFORD , EDMUNDO JOHNNIE , M.D. ( BX33 ) 8/9/01 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1153
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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175125252 | PUO | 53630458 | | 0479558 | 9/8/2006 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 10/4/2006 Report Status: Signed
Discharge Date: 10/20/2006
ATTENDING: GOLEBIOWSKI , LOIDA MD
SERVICE:
Cardiac Surgery Service.
DISPOSITION:
To rehabilitation.
PRINCIPAL DISCHARGE DIAGNOSIS:
Status post AVR with a 25 CE Magna valve and CABG x2/LIMA.
OTHER DIAGNOSES:
Diabetes mellitus type II , hypercholesterolemia , arthritis , and
increasing forgetfulness.
HISTORY OF PRESENT ILLNESS:
Mr. Tortorella is a 70-year-old Caucasian male with CAD , stented five
years ago , known as calcific aortic stenosis with progression of
exertional dyspnea. He has chronic atrial fibrillation. He is
planned for catheter in the morning , AVR and possible CABG.
PREOPERATIVE CARDIAC STATUS:
Elective. The patient presented with critical coronary
anatomy/valve dysfunction. The patient has a history of class II
angina. There has been no recent angina. There is history of
class III heart failure. The patient is in atrial fibrillation.
The patient has history of Afib/flutter treated with
drugs/beta-blocker.
PREVIOUS CARDIOVASCULAR INTERVENTIONS:
PTCA/atherectomy in 1996 and 1997. Stent in 1996 and 1997.
PAST SURGICAL HISTORY:
Right ACL repair , appendectomy , benign breast mass excision in
the right side.
FAMILY HISTORY:
No family history of CAD.
SOCIAL HISTORY:
History of tobacco 150-pack-year cigarette smoking history.
ALLERGIES:
No known drug allergies.
PREOP MEDICATIONS:
Toprol 50 mg every day before noon and 25 mg every afternoon , Coumadin , Lasix 20 mg
daily , atorvastatin 20 mg daily , Neurontin 100 mg three times a day ,
metformin 1000 mg twice a day , and glipizide 2.5 mg twice a day
PHYSICAL EXAMINATION:
Height and weight 5 feet 10 inches , 108 kilos. Vital Signs:
Temperature 96.4 , heart rate 75 , BP right arm 127/62 , left arm
110/75 , oxygen saturation 97% on room air. HEENT:
PERRLA/dentition without evidence of infection/no carotid
bruits/edentulous. Chest: No incisions. Cardiovascular:
Regular rhythm and systolic murmur. All distal pulses intact
with the exception of the right dorsalis pedis , which was present
by Doppler only and posterior tibial pulses were present by
Doppler bilaterally. Allen's test left upper extremity normal ,
right upper extremity normal. Respiratory: Breath sounds clear
bilaterally. Abdomen: No incisions , soft , no masses.
Extremities: Thread veins. Minor varicosities. Larger
varicosities right thigh. Neuro: Alert and oriented , no focal
deficits.
PREOPERATIVE LABORATORY DATA:
Chemistries: Sodium 138 , potassium 4.5 , chloride 102 , CO2 of 26 ,
BUN 20 , creatinine 1 , glucose 170. Hematology: WBC 8.25 ,
hematocrit 42.6 , hemoglobin 14.7 , platelets 300 , physical therapy 18.2 , INR
1.5 , PTT 45.9. UA was normal. Cardiac catheterization data from
10/25/06 performed at PUO showed coronary anatomy 80% proximal
RCA stenosis , 80% mid RCA , 80% distal RCA , 50% proximal LAD.
Echo from 3/2/05 showed 45% ejection fraction , aortic stenosis ,
mean gradient 33 mmHg , peak gradient 51 , and calculated valve
area 1 cm2 , mild aortic insufficiency , moderate mitral
insufficiency , trivial tricuspid insufficiency , aortic root 4.4
cm. EKG from 8/22/06 showed atrial fibrillation rate of 97 ,
inverted T waves in leads AVR. Chest x-ray from 8/22/06 was
normal. The patient was admitted to CSS and stabilized for
surgery.
DATE OF SURGERY:
1/13/06.
PREOPERATIVE DIAGNOSIS:
CAD , AS , and Afib.
PROCEDURE:
AVR with a 25 CE magna valve , CABG x2 with LIMA to LAD and SVG1
to PDA , pulmonary vein isolation , and left atrial appendage
resection.
BYPASS TIME:
171 minutes.
CROSSCLAMP TIME:
107 minutes.
??__04:13___?? antegrade/retrograde cardioplegia. Patient is in
normal sinus rhythm , rate of 80 at end of case. There were no
complications. The patient was transferred to the unit in stable
fashion with lines and tubes intact. 9/6/06 , postop day 1 , the
patient was slow to ambulate. Postop day 2 , responded to gentle
diuresis. Meds changed to orally Postop day 3 , chest tubes and
wires were discontinued. Somnolence resolved. Fluid overloaded.
Loss of secretions. Able to clear up. Postop day 4 , failed
speech and swallow. Wires discontinued. Hemodynamically stable
in Afib since evening. Rate controlled. Diuresing well.
Transferred to Step-Down Unit on postoperative day 4.
SUMMARY BY SYSTEM:
Neurologic: Mildly confused immediately postoperative , now
resolved , neurologically intact.
Cardiovascular: Cardiac meds: Aspirin , Lopressor , and Coumadin.
Hemodynamically stable on Lopressor , now back in Afib , stable
rate of 90s , respiratory ventilated greater than 24 hours
postoperatively. Extubated on postoperative day 1 without
complication. Currently on 5 liters of O2 and some pulmonary
edema , improving with Lasix 20 mg intravenous three times a day and diuresis.
GI: Failed speech and swallow. Bedside Dobhoff placed. Started
on Osmolite tube feeds at 20 mL an hour. Awaiting nutrition
input for goals. Needs video swallow to assess swallow function.
Renal: Appropriately diuresing , maintaining 1.5 liters negative
until preop weight.
Endocrine: Stable on CVI. Hematology: Anticoagulation.
Coumadin and aspirin for atrial fibrillation.
ID: No issues. Prophylactic antibiotics for chest tubes. In
step-down unit proceeded to progress well. Postop day 4 strict
npo per speech and swallow for aspiration with all
consistencies , currently on sitter. Postop day #5 , the patient
self discontinued the Dobbhoff feeding tube twice last night
requiring meds intravenous today until tube replaced and KUB confirmed tip
this afternoon. Dobbhoff currently okay to use. We will resume
tube feeds. Heart rate elevated to 90s-130s and also run of VT ,
which was asymptomatic. Rechecking electrolytes , BP stable.
Preop EF of 45%. Ordered echo to assess postop EF given run of
VT , which was 9 beats. Normal a.m. electrolytes. Remains on 3
liters of O2 , diuresing well. Speech and swallow will reassess
next week. Strict npo for history of aspiration. Afebrile.
White count improved to 10.9 , remains on sitter for mild
confusion. Plan rehabilitation when ready. Postop day 6 ,
chronic Afib , rate has been difficult to control , patient was on
Lopressor 75 mg orally four times a day postop via Dobbhoff tube. Patient
has self discontinued Dobbhoff several times and is quite
sensitive to missed dose of orally Lopressor so dosing intravenous Lopressor
currently. Heart rate is still a bit elevated at 100-120s , BP
stable. Mental status improved off sitter. Remains on 1.5
liters of O2 junky cough , unable to produce sputum. Afebrile.
White count stable at 10.4.
Chest x-ray looks okay. No echo ordered for her fellow. Repeat
electrolytes. Titrate beta-blocker. We will reorder echo if VT
recurs. physical therapy consult placed. Postop day 7 , past video swallow
exempted. Dobbhoff out on sitter because he is having suicidal
ideations. He has been quite hyperglycemic with blood sugar in
350 range. EMS following. Screening for rehabilitation. Postop
day #8 , running a bit fast in Afib. Increase Lopressor. Mood
has improved. Will most likely be able to discontinue sitter
soon. Screen for rehabilitation. Postop day #9 in Afib running
between 90-100 , had been on a sitter up until this a.m. for
suicidal ideation a couple of days ago eating well. Screening
for rehab. Postop day 10 , rate controlled Afib/room air.
Patient followed by psych for postoperative confusion/possible
suicidal ideation. Patient stable on Celexa. Patient's UA from
7/12/06 with probable enterogram-negative rods. Started Cipro
x3 days. Continue rehabilitation screen. Postop day 11 , Afib ,
rate controlled/room air. Patient's chest x-ray with no edema ,
slight left middle lobe atelectasis. Neurologically stable and
Celexa ordered per psych. Awaiting rehabilitation bed. Postop
day 12 Afib/room air doing well with blood pressure. Seen by
psych and recommend follow up with them post DC for memory
studies. No new ??__??. Ready for rehabilitation. Just waiting
for acceptance and bed. Postop day 13 , rate controlled Afib/room
air. Patient waiting for rehab bed. On Coumadin for Afib ,
followed by psych for confusion/delirium and note by them that
they would like to follow up with him when he is discontinued.
Postop day 14 , the patient was evaluated by Cardiac Surgery
Service to be stable to discharge to rehabilitation with the
following discharge instructions:
DIET:
House , low-cholesterol , low-saturated fat , ADA 2100 calories per
day.
FOLLOW-UP APPOINTMENTS:
Dr. Golebiowski , 117-219-4079 in 5-6 weeks , Dr. Meduna 416-714-2085
in 1-2 weeks , and Dr. Kamb 303-385-0448 in one to two weeks.
ADDITIONAL COMMENTS:
Per PUO psychiatry department they would recommend follow up as
outpatient for continued evaluation of forgetfullness/mental
status.
TO DO PLAN:
Make all follow-up appointments , local wound care , wash wounds
daily with soap and water , shower patient daily , keep legs
elevated while sitting/in bed. Watch all wounds for signs of
infection , redness , swelling , fever , pain , discharge , call
primary care physician/cardiologist or Pagham University Of Cardiac Surgery
Service at 117-219-4079 with any questions.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Acetaminophen 325-650 mg every 4 hours as needed pain or temperature
greater than 101 , DuoNeb every 6 hours as needed wheezing , enteric-coated
aspirin 81 mg daily , Dulcolax 10 mg PR daily as needed constipation ,
Celexa 10 mg daily , Colace 100 mg three times a day , Nexium 20 mg daily ,
Lasix 20 mg daily for 5 days , Neurontin 100 mg three times a day , Robitussin
10 mL every 6 hours as needed cough , NovoLog insulin on sliding scale
before every meal and at bedtime , NovoLog insulin 14 units subcutaneously with lunch
and supper , NovoLog insulin 22 units subcutaneously with breakfast , Lantus
insulin 42 units subcutaneously at 10 p.m. , Atrovent nebulizers four times a day ,
K-Dur 10 mEq daily for five days , Toprol-XL 200 mg twice a day ,
miconazole nitrate powder topical twice a day , Niferex 150 mg twice a day ,
simvastatin 40 mg at bedtime , multivitamin therapeutic one tab
daily , Coumadin with variable dosage to be determined based on
INR , and Boudreaux's Butt Paste topical apply to effected areas.
eScription document: 4-6890129 EMSSten Tel
Dictated By: CRIDGE , LORRETTA PA
Attending: GOLEBIOWSKI , LOIDA
Dictation ID 7087524
D: 10/28/06
T: 10/28/06
Document id: 1154
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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940930034 | PUO | 82415767 | | 8310279 | 7/16/2006 12:00:00 a.m. | gerd | | DIS | Admission Date: 10/29/2006 Report Status:
Discharge Date: 3/6/2006
****** FINAL DISCHARGE ORDERS ******
MARCHIONESE , VIVIAN 008-62-31-3
Brown West Ve Do
Service: MED
DISCHARGE PATIENT ON: 2/8/06 AT 07:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SVENNINGSEN , CHRISTIAN VIVAN , M.D. , M.P.H.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
DIAZEPAM 5 MG orally every 6 hours as needed Anxiety
HYDROCHLOROTHIAZIDE 12.5 MG orally DAILY
HOLD IF: SBP<100 HR<55
LISINOPRIL 5 MG orally DAILY HOLD IF: SBP<100 HR<55
Override Notice: Override added on 2/8/06 by
HIPKINS , ERMA M. , M.D. , PH.D.
on order for KCL IMMEDIATE RELEASE orally ( ref #
971942959 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: needs
PROTONIX ( PANTOPRAZOLE ) 40 MG orally twice a day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
see your primary care doctor within 2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
gerd
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN OA
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: SSCP/epigastric pain
HPI: 51M with obesity , HTN negative MIBI 4/3 p/with 1 wk intermittent
SSCP/epigastric discomfort , nonradiating. no lh , n/v/diaph. no sob ,
doe. ?related to orally intake. a/with b/l UE pain/soreness history of
fall with fx rt humerus 4 mo ago. PMH: as above , panic
attacks meds: ASA 81 , valium as needed , HCTZ 12.5 , lisinopril 5 ,
diclofenac 50 as needed , protonix 40 all:
nkda SH: no tob , etoh , drugs.
FH: mother with MI age 40 PE 96.7 63 108/69 98%
RA Gen:
NAD HEENT: no
jvd Cor: RRR no
M Pulm:
CTA ABd: obese
nt ext: no
c/c/e neuro:
nonfocal labs: CK 142/126 , MB 0.7 , 0.7. tni<ass x2 , Cr 0.9 ,
HCT 43 CXR: no acute
process EKG: NSR 79 no st/t
changes a/p: 51 year-old M with obesity , HTN p/with chest/epigastric
discomfort. admitted from obs since MIBI rescheduled until a.m.. likely
non cardiac. GERD. 1. CV ( I ) ruled out. cont asa , acei
statin. ( P ) euvolemic. cont
aceI ( R )
tele 2. MSk- unclear etiology. tylenol
as needed 3. FEN/GI: npo @ md. k/mg scales.
increased ppi to twice a day 4. ppx:
lovenox/ppi 5. Dispo: FC. ambulates.
DISPOSITION: patient discharged several hours after arrival on the floor. No
need for stress testing as history not consistent with cardiac chest
pain. patient has hx of negative stress test in 2005. Will trial twice a day protonix
( increased from every day ) as sxs suggestive of mild GERD and occurred after two
fatty meals followed by supine position. F/u with primary care physician.
ADDITIONAL COMMENTS: please take your medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. take your protonix twice daily and followup with your primary care
doctor within 2 weeks.
No dictated summary
ENTERED BY: HIPKINS , ERMA M. , M.D. , PH.D. ( SE52 ) 2/8/06 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 1155
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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950440305 | PUO | 45326415 | | 6268572 | 8/6/2006 12:00:00 a.m. | Labile Blood Pressure , Viral illness | | DIS | Admission Date: 8/6/2006 Report Status:
Discharge Date: 10/23/2006
****** FINAL DISCHARGE ORDERS ******
HAWVER , OTHA A 423-35-25-2
La
Service: MED
DISCHARGE PATIENT ON: 9/12/06 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MALADY , CASSONDRA F. , M.D. , M.S.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally twice a day
Instructions: 4pm and 9pm
ACETYLSALICYLIC ACID 81 MG orally DAILY
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
1 TAB orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
NOVOLOG ( INSULIN ASPART ) 18 UNITS subcutaneously every day before noon
NOVOLOG ( INSULIN ASPART ) 20 UNITS subcutaneously every afternoon
Starting Today ( 10/24 )
Instructions: Please give before dinner
LANTUS ( INSULIN GLARGINE ) 72 UNITS subcutaneously every afternoon
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 60 MG orally DAILY
HOLD IF: sbp<90 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LABETALOL HCL 400 MG orally twice a day HOLD IF: sbp<130 , heart rate<55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LEVOXYL ( LEVOTHYROXINE SODIUM ) 112 MCG orally every day before noon
Instructions: 8am
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
OXYCODONE 5 MG orally Q10am
Alert overridden: Override added on 7/25/06 by
OSMERS , TESSA M
on order for OXYCODONE orally ( ref # 412219439 )
patient has a PROBABLE allergy to Codeine; reaction is NAUSEA.
Reason for override: aware
SPIRONOLACTONE 12.5 MG orally EVERY OTHER DAY
Food/Drug Interaction Instruction Give with meals
Override Notice: Override added on 9/12/06 by
RUKA , BERNA , PA-C
on order for KCL IMMEDIATE RELEASE orally ( ref #
874073338 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: monitor Previous override information:
Override added on 7/25/06 by RUKA , BERNA , PA-C
on order for KCL IMMEDIATE RELEASE orally ( ref #
412242868 )
SERIOUS INTERACTION: SPIRONOLACTONE & POTASSIUM CHLORIDE
Reason for override: monitor
VALSARTAN 160 MG orally DAILY
Override Notice: Override added on 9/12/06 by
RUKA , BERNA , PA-C
on order for KCL IMMEDIATE RELEASE orally ( ref #
874073338 )
POTENTIALLY SERIOUS INTERACTION: VALSARTAN & POTASSIUM
CHLORIDE Reason for override: monitor
Previous override information:
Override added on 7/25/06 by RUKA , BERNA , PA-C
on order for KCL IMMEDIATE RELEASE orally ( ref #
412242868 )
POTENTIALLY SERIOUS INTERACTION: VALSARTAN & POTASSIUM
CHLORIDE Reason for override: monitor
DIET: House / NAS / Carbohydrate Controlled / Low saturated fat
low cholesterol (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician , call for apt within 2 weeks ,
ALLERGY: AMOXICILLIN , Codeine , LISINOPRIL ,
NUTS AND STRAWBERRIES , intravenous Contrast
ADMIT DIAGNOSIS:
Hypertensive urgency
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Labile Blood Pressure , Viral illness
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of R CEA ON 10/2 DM SINCE 1980 S.P L THR history of L TIBIAL FRACTURE HTN
history of PTCA 3/3 RCA diastolic heart failure ( congestive heart failure )
CRI ( chronic renal dysfunction ) hypercholesterolemia ( elevated
cholesterol ) osteoporosis ( osteoporosis ) Hypothyroidism
( hypothyroidism ) PVD ( peripheral vascular disease ) history of L fifth toe
amputation CAD history of MI ( coronary artery disease ) history of coronary stents
X3 ( history of coronary stent )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Head CT. Portable CXR. Renal Ultrasound.
BRIEF RESUME OF HOSPITAL COURSE:
CC: Lightheadness , nausea
---
DDX: Hypertensive Urgency
---
HPI: 77 year old female with CAD history of three stents , DM , HTN and CKD
was sent to ED by primary care physician after she presented to office with malaise ,
nausea and lightheadedness. Her symptoms first developed on
Thursday. She had checked her BS and BP at that time and they were
300 and 150 systolic. Her symptoms resolved but returned on Sunday
PTA and persisted throughout the day so Monday she went to
see her primary care physician. At the PCPs office her BP was noted to be 212 systolic
and she was sent to the ED for evaluation. Of note , on route to the
primary care physician office she had a fleeting episode of chest "cramping" which
was unlike her previous angina or MI pain. ---
In the ED: The patient received labetolol 10mg intravenous X2 , labetolol 400mg
orally X1 , nitropaste 3". Her BP remained above 200 despite these
medications and then she received hydralazine 10mg intravenous X1 which
resulted in dropping her BP to 150 systolic.
---
PMH: see list.
---
Meds at Home: Asa 81 , Lasix 40 , Plavix 75 , Nexium 20 , Valsartan
160 , labetolol 400 twice a day , Imdur 60 , Spironolactone 12.5 every other day , Lipitor
80 , Levoxyl 112 , Oxycodone as needed , lantus 70 every bedtime , Humalog 18q breakfast ,
20q supper , colace 100 three times a day as needed , NTG sublingual
as needed
---
ALL: amox-diarrhea , codeine-nausea , Lisinopril-cough , Nuts &
strawberries--anaphylaxis.
---
PE on Admit: VS: T 96.3 , HR 84 , BP 128/64 , RR 20 , O2 97% on 2L
GEN: NAD , pale HEENT: PERRLA , anicteric
NECK: no JVD or LAD
PULM: CTA CV: RRR , +SEM at RUSB Abd: Soft , NT ,
ND Ext: no c/c/e Neuro: no focal deficits
---
CXR: stable cardiomegaly ECHO 1/28 EF 60-65% , no
RWMA Cath 2/25 pLAD discrete 45% lesion , mid LCx
discrete 65% lesion , pRCA discrete 35% lesion Head CT: no acute
intracranial process
---
HOSPITAL COURSE: The patient was admitted for management of
hypertensive urgency.
---
CV: The cause of her high BP is not clear. There is no indication of
med non-compliance. Her primary care physician reports labile BPs are a problem for her.
Her BP was controlled after she arrived to the floor. She
was resumed on her home dose of Labetolol. There was discussion of
increasing her labetolol dose but this ended up not being necessary.
In fact she was symptomatic with a BP of 120 in terms of
feeling lightheaded. Therefore her hold parameters were increased to
130 systolic. In addition she had occasional ectopic apical heart
beats which resulted in early QRS complex and occasional
slight pauses <2sec. No major events on telemetry. Her heart rate was
relatively slow around 50-55 much of the time. Her EKG did show
slight ( 1mm ) ST segment depressions in antero-lateral leads and her
CKMB was elevated on admission. She ruled out for MI with three sets
of neg troponins. She may have had slight demand ischemia in setting
of hypertension. Her CKMB was normal on day of discharge. Her troponins
were always negative. She had no s/s of CHF. She was monitored on
telemetry with no major events.
---
RENAL: The patient is a diabetic and in addition reports a recent
history of contrast induced nephropathy. She had proteinuria on
admission which is slighly higher than usual ( 3+ compared to 2+ ) but
her creatinine was improved from baseline to 1.6 ( 1.8-2.2 ). A renal
ultrasound showed normal kidneys with no hydronephrosis. UPEP , SPEP
and spot urine/protein were ordered. Her spot urine protein was 222. Her
proteinuria in a chronic problem. UPEP/SPEP need to be followed up as
outpt but suspicion for malignancy is very low.
---
ENDO: The patient has history of DM and takes Lantus and Humolog at home.
She missed her lantus dose the night of admission and subsequent am
BS was high. She received NPH to cover her for the HD#1 and then
she resumed Lantus that evening. She also received her home humulog
and a sliding scale. She received a carb controlled diet. Her TSH was
1.2 on home Levoxyl.
---
FEN: Her lytes were repleted as needed.
---
GI: Her renal ultrasound showed sludge in the gallbladder and a
slightly distended CBD. Bili T and D were added and are normal. She had
no abd pain or tenderness so her gallbladder sludge is not likely to
represent a pathology.
---
ADDITIONAL COMMENTS: 1. Monitor your BP at home and call your primary care physician if >180.
2. Monitor Fingersticks at home three times a day ( before each meal ) and
record in a note book to bring to primary care physician appointment
3. Return to ED if you experience chest pain , shortness of breath ,
worsening nausea , extreme sweating , fainting , falling or other concerns
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up UPEP/SPEP. Follow Blood Pressures. Follow Fingersticks.
No dictated summary
ENTERED BY: RUKA , BERNA , PA-C ( YP61 ) 9/12/06 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1156
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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737023301 | PUO | 82038223 | | 334026 | 1/22/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/22/1991 Report Status: Signed
Discharge Date: 5/18/1991
ADMISSION DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION.
HISTORY OF PRESENT ILLNESS: Patient is a 59 year old white female
with a history of coronary artery
disease status post bypass in l988 who presented with atypical
chest pain consistent with unstable angina for rule out myocardial
infarction. Patient has multiple risk factors including a history
of inferior myocardial infarction , smoking history , family history ,
and age. She does not have diabetes mellitus or increased
cholesterol. In 1/24 , she had an inferior myocardial infarction
and had a catheterization in April of l988 showing 70% left anterior
descending , 50% right circumflex , and l00% right coronary artery
lesion with an ejection fraction of 80%. In l988 , she had three
vessel coronary artery bypass graft with a LIMA to her left
anterior descending and saphenous vein graft to her OMB2 and right
coronary artery. The patient also has a history of peptic ulcer
disease diagnosed with melena in 3/10 and had an
esophagogastroduodenoscopy showing antral gastritis. In 11/23 , she
had a colonoscopy that showed diverticula and she has a history of
chronic anemia with a hematocrit in the mid to high twenties and an
MCV of 68. Patient was treated with H2 blockers and iron but
stopped secondary to constipation. In 7/18 , the patient again
presented with orthostatic changes and shortness of breath with
pain to her arm similar to her previous myocardial infarction pain.
Her hematocrit at that time was 20.8. She was transfused three
units of packed red blood cells and given Lasix and H2 blockers.
She ruled out for myocardial infarction and had a catheterization
in 7/18 that showed patent LIMA to her left anterior descending ,
her left anterior descending native vessel was free of disease , and
a 50% long proximal circumflex lesion as well as a proximal OM2
lesion that was narrowed to 70% at its origin. An
esophagogastroduodenoscopy at that time was negative and the
patient was discharged home for colonoscopy with Small Bowel
Follow-Through that was never done. In the interval period prior
to admission , the patient was in her usual state of fair health
when she had an hour of chest pain in the morning and thirty
minutes in the evening per week. She also noted several episodes
at rest principally with increased anxiety and with confusion. The
patient presented to CHH with a thirty minute history of
substernal chest pressure that was not responsive to sublingual
Nitroglycerin and was associated with diaphoresis and mild
shortness of breath. PAST MEDICAL HISTORY: Significant for
coronary artery disease as described above , peptic ulcer disease as
above , left neck basal carcinoma in l986 , chronic iron deficiency
anemia , history of biliary colic and hiatal hernia , history of
chronic vertigo , and history of a thyroid nodule in the past.
PHYSICAL EXAMINATION: On admission , her blood pressure was l22/90 ,
pulse of 90 , respiratory rate of l6 , and
temperature 98.2. HEENT: Unremarkable. LUNGS: Clear to
auscultation. NECK: Supple without adenopathy or thyromegaly.
CARDIOVASCULAR: Showed non-displaced point of maximal intensity ,
regular rate and rhythm with a positive S4. There were no murmurs ,
rubs , or gallops. She had 2+ carotid pulses without bruits.
ABDOMEN: Showed active bowel sounds and was obese , soft , and
non-tender without hepatosplenomegaly or masses. EXTREMITIES:
Showed 2+ femoral , radial , and dorsalis pedis pulses without
bruits. She had no cyanosis , clubbing , or edema. RECTAL: Showed
normal tone without masses and was guaiac negative. NEUROLOGICAL:
Grossly non-focal and within normal limits.
LABORATORY EXAMINATION: Of note , she had a hematocrit of 27.0 with
a white count of 6.9 and an MCV of 63.
Her EKG showed normal sinus rhythm with axis of 20 degrees ,
intervals of 0.l6 , 0.08 , and 0.40 with a Q wave in III , and T wave
inversions in III , V3 , and Vl-V4. These were all unchanged from
her previous EKG from 5/6
HOSPITAL COURSE: Remarkable only for a rule out myocardial
infarction in which she had serial CK and EKG
that were completely within normal limits. Her CK were l54 , 482 ,
and 592 with normal MB fractions most consistent with either a very
small myocardial infarction or , more likely , CK leak from some
other source. Patient had several episodes of atypical chest pain
after being moved down to the floor and EKG were completely within
normal limits without any evidence of acute changes. Patient was
transferred to the floor on September and her significant laboratory
data included a white blood cell count of 5.89 , hematocrit 34 ,
platelets 458 , and MCV of 68. Calcium was 9.4 , magnesium 2.6 ,
sodium l37 , potassium 4.6 , chloride l03 , bicarbonate 22 , BUN l8 ,
creatinine l.l , and glucose 9l. Serial CK were l54 , 482 , 592 , 553 ,
464 , and 3l2 , with MB fractions all less than l0. Her iron was l4
and her TIBC was 479 with a ferritin pending. Urinalysis showed
20-30 white blood cells with 3+ bacteria and a urine culture showed
greater than l00 , 000 E. coli. This was treated with Bactrim. On
July , the patient had no more episodes of chest pain and had an
exercise stress test on which he went nine minutes on a modified
Bruce protocol stopping secondary to fatigue. Her peak heart rate
was 95 , blood pressure l75/75 without chest pain , and only unifocal
premature ventricular contractions with her exercise. She had
non-specific ST and T wave changes only without evidence for
ischemia. This was thought to be inconsistent with ongoing
ischemia and the patient was discharged to home. Of note , the
patient is not an CHH patient and has no primary doctor.
Therefore , I am going to assume her care as an out-patient in KTDUOO .
Pending laboratory data includes ferritin level.
OPERATIONS AND PROCEDURES: Exercise tolerance test as above and
blood products received were none.
DISPOSITION: DISCHARGE MEDICATIONS: 1 ) Aspirin , ECASA , 80 mg
orally every day 2 ) Bactrim one tablet double-strength
orally twice a day times seven days. 3 ) Sublingual Nitroglycerin one every 5
minutes with chest pain as directed. 4 ) Metoprolol 75 mg orally
three times a day 5 ) Iron Sulfate 325 mg orally four times a day 6 ) Pepcid 20 mg orally
twice a day The patient will be followed in my clinic in the next
available and I have scheduled her for an Upper Series With Small
Bowel Follow-Through to follow-up on her gastrointestinal bleeding.
I started her on Iron Sulfate and have encouraged her to make sure
that she takes this in order to increase her hematocrit.
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE STATUS POST CORONARY
ARTERY BYPASS GRAFT , URINARY TRACT INFECTION ,
GASTROINTESTINAL BLEED , AND IRON DEFICIENCY
ANEMIA.
QZ694/6444
RUFUS C. BERNAS , M.D. XS9 D: 11/6/91
Batch: 6844 Report: M1603Q12 T: 7/10/91
Dictated By: HERMINA T. TUOMALA , M.D.
Document id: 1157
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DM |
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HTG |
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OSA |
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| output/system_intuitive_annotation.xml | intuitive |
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707826215 | PUO | 17768471 | | 7778606 | 11/7/2005 12:00:00 a.m. | Chest pressure | | DIS | Admission Date: 11/7/2005 Report Status:
Discharge Date: 2/14/2006
****** FINAL DISCHARGE ORDERS ******
TORRELL , JAMAL 728-74-26-8
Me Ho
Service: MED
DISCHARGE PATIENT ON: 8/6/06 AT 11:00 a.m.
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
PERSANTINE ( DIPYRIDAMOLE ) 50 MG orally twice a day
LASIX ( FUROSEMIDE ) 10 MG orally every day
ATIVAN ( LORAZEPAM ) 3.5 MG orally every bedtime
HOLD IF: RR<12 or oversedation
ATIVAN ( LORAZEPAM ) 2 MG orally four times a day as needed Anxiety
HOLD IF: RR<12 or oversedation
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 doses as needed Chest Pain
NITROGLYCERIN PASTE 2% 1 INCHES TP twice a day
HOLD IF: SBP<100 and call HO
INDERAL ( PROPRANOLOL HCL ) 10 MG orally four times a day
HOLD IF: sbp<100 or HR<55 and call HO
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SUCRALFATE 1 GM orally four times a day Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
PAXIL ( PAROXETINE ) 10 MG orally every day
NORVASC ( AMLODIPINE ) 2.5 MG orally every day
HOLD IF: SBP<100 and call HO
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 1/21/05 by
FOLLANSBEE , DENNIS A. , M.D. , PH.D.
on order for NORVASC orally 5 MG every day ( ref # 336281060 )
patient has a PROBABLE allergy to DILTIAZEM ; reaction is
Mental Status Change. Reason for override: patient tolerates
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 30 MG orally twice a day
HOLD IF: SBP<100 and call HO
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
COZAAR ( LOSARTAN ) 50 MG orally every day
HOLD IF: SBP<100 and call HO
Number of Doses Required ( approximate ): 3
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
GLYBURIDE 2.5 MG orally every day
ZETIA ( EZETIMIBE ) 10 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Gruntz May at 3:30 PM ,
Dr. Schoeppner 2/6/06 ,
ALLERGY: Penicillins , Aspirin , DILTIAZEM , ATORVASTATIN
ADMIT DIAGNOSIS:
Chest pressure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chest pressure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn elev chol bph , history of turp x4 history of partial gastrectomy IMI '73 CAD
history of CABG x3 ( history of cardiac bypass graft surgery )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: "Feeling sick"
HPI: History was obtained from patient , who is a poor historian. He is
an 83 year-old man with a history of CAD history of MI in 1973 , history of CABG x3 , T2DM ,
hypertension who presents "feeling sick" since last night. He states
that he took a Percocet for back pain and that after that he began to
feel numb in his arms and legs and around his head. He also had some
chest pressure. He took some sublingual nitro and doesn't remember if it helped.
Says it also wasn't relieved by positional change or rest. He denies
shortness of breath. He was having some nausea but no vomiting. He does
have some blurry vision at baseline , unchanged. He awoke this morning
and took his blood pressure. When he found his systolic was 190 , he
called EMS. He said he felt dizzy , "like I have pressure in my head , "
and could not describe it beyond that. He states that when his BP is
elevated his head feels like this and he gets flushed in the face.-----
PMH: CAD ( Katheryn Gruntz is outpt cards ) , history of 3V CABG , history of UGIB and
partial gastrectomy for PUD , chronic back pain , history of TURP , DM
-------
MEDS:Protonix 40 mg orally every day before noon , Sucralfate 1g orally four times a day , Lasix 10 mg orally every day ,
Lescol 20 mg orally every day , Cozaar 50 mg orally every day , Glyburide 2.5 orally every day , Paxil 10
mg orally every day , Ativan 2 mg orally four times a day , Norvasc 5 mg orally every day , Inderal
10 mg orally four times a day , Persantine 50 mg twice a day , Imdur SR 30 mg orally
twice a day
--------
Exam on admit:T 96.5 P: 64 BP: 140/60 RR: 20 O2 Sat: 100% on
2L. No significant findings. CN 2-12 intact. AAOx3 but a bit
circular in speech
Labs: cardiac enzymes neg , UA clean
EKG: A-paced , unchanged from January
CXR: no acute process
Stress test January 2005:A small to medium sized
region of myocardialscar/hibernation in the distribution of
the PDA coronary artery. No evidence of stress induced
ischemia at a low cardiac workload.
Dobutamine MIBI 10/16 EF 48% , no reversible ischemia , fixed inferior
defect ( old ). Basoinferolateral wall not interpretale due to bowel
activity. When given dobutamine he went in to a V-paced rhythm-->?
paroxysmal Afib. Test was submaximal with max HR 98 ( 77% predicted ).
HOSPITAL COURSE:
1. CV: Ischemia: History of CAD but no signs of ischemia at present.
Ruled out for MI with 3 sets of cardiac enzymes and serial EKGs.
Continued B-blocker , statin , and persantine. No ASA
since history of GIB with it. Monitored on telemetry without any
events. Had an adenosine MIBI on 4/5/05 with results as above. Because
he went into brief VT , his PM was evaluated by EP to r/o pAF. EP
interoogation revealed no mode shifts. patient continued to do well post MIBI.
Pump: HTN: Continued cozaar , ideral , imdur , lasix.
Rhythm: Has pacemaker , no change on EKG. Monitored on telemetry
2. PULM: No active issues. Weaned O2 to sat>93%.
3. RENAL: Creatinine at baseline and UA clean. Monitored Cr every day and it
remained at baseline.
4. GI: History of GIB and partial gastrectomy for ulcer. Avoided
aspirin , continued PPI.
5. ENDO: T2DM. Held orally hypoglycemic while in house. Covered with
SSI regular before every meal
6. NEURO: "Dizziness" unclear , does not give history of room spinning or
lightheadedness. It is probably a symptom of his hypertension since he
has had this in the past.
7. FEN: Low-fat , low salt diet. No further fluids after what he got
in ED. Taking good POs
8. PPX: Sc lovenox , PPI
9. DISPO: physical therapy consult placed. Discharged home with VNA.
10. Full code
ADDITIONAL COMMENTS: Please call physician if you develop fevers , chills , shortness of breath ,
or any other symptoms you find concerning. Please continue taking your
home medications as before; there have been no changes.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
Pacemaker interrogation.
No dictated summary
ENTERED BY: MANGANELLI , ADELINA , M.D. ( PG98 ) 8/6/06 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1158
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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032003429 | PUO | 50415670 | | 3369356 | 4/6/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Unsigned | DIS | Admission Date: 5/15/2006 Report Status: Unsigned
Discharge Date: 5/4/2006
ATTENDING: COLASAMTE , ISABELLE EVON MD
DISPOSITION: Home with VNA service.
PRINCIPAL DISCHARGE DIAGNOSIS: Status post rehab CABG x3.
OTHER DIAGNOSES: Hypertension , PVD status post repair of AAA in
1996 , diabetes mellitus type 1 , hypercholesterolemia , COPD ,
diabetic retinopathy , hard of hearing right ear , deaf in left
ear.
HISTORY OF PRESENT ILLNESS: Ms. Beebee is a 58-year-old woman
with extensive history of vascular disease including CABG ,
aorto-bifem bypass graft who presents for rehab CABG , recurrent
anginal equivalent jaw pain for several months.
PREOPERATIVE CARDIAC STATUS: Elective. The patient has a
history of class II angina. There has been no recent angina.
There is a history of class II heart failure. The patient is in
normal sinus rhythm.
PREVIOUS CARDIOVASCULAR INTERVENTION: 1987 CABG x3 with LIMA to
LAD , SVG to PDA and SVG to OM1.
PAST SURGICAL HISTORY: Aortoiliac occlusive disease
reconstruction , aorto-bifem bypass graft in 1996 , AAA repair ,
aortic aneurysm repair at the same time of aorto-bifem in 1996
status post epinephrine , status post resection of ovaries 1970
status post TAH-BSO in 1985 status post CABG x3 in 1987 , status
post full mouth dental extractions in 1994.
FAMILY HISTORY: Father deceased from MI at age 52. Mother 87
years old , alive and well. Vascular disease prevalent in
paternal aunts , one sister.
SOCIAL HISTORY: History of tobacco use , 80-pack-year cigarette
smoking history. The patient is a retired MSW since 1986.
ALLERGIES: No known drug allergies.
PREOP MEDICATIONS: Pindolol 0.5 , diltiazem 180 mg daily ,
isosorbide 30 mg twice a day , aspirin 325 mg daily , Plavix daily ,
hydrochlorothiazide 25 mg daily , simvastatin 80 daily , estradiol
patch 0.05 every week , Lantus 40 units nightly , Klonopin 0.5 mg
twice a day and Spectravite Senior Multivitamin.
PHYSICAL EXAMINATION: Height and weight: 5 feet and 6 inches ,
65 kilos. Vital signs: Temperature 98 , heart rate 55. BP ,
right arm 108/50 , left arm 108/50. Oxygen saturation 97% room
air. HEENT: PERRLA/upper and lower dentures/no carotid bruits.
Chest: Midline sternotomy/left leg SVG harvest site.
Cardiovascular: Regular rate and rhythm. S4 murmur. All distal
pulses intact. Respiratory: Brisk rales present bilaterally.
Abdomen: Mid abdominal incision through bilateral groins , soft ,
no masses. Extremities: Left leg SVG harvest site incision.
Neuro: Alert and oriented , no focal deficits.
PREOP LABS: Chemistries: Sodium 131 , potassium 3.6 , chloride
98 , CO2 24 , BUN 9 , creatinine 0.7 , glucose 152 and magnesium 1.5.
Hematology: WBC 7.93 , hematocrit 42.1 , hemoglobin 15.1 ,
platelets 189 , 000 , physical therapy 13.1 , INR 1.0 and PTT 28.8. UA normal.
Carotid imaging CNIS , left internal carotid artery less than 25%
occlusion , right internal carotid artery less than 25% occlusion.
Cardiac catheterization data of 11/10/2006 performed at PUO of
coronary anatomy , 70% mid left main stenosis , 90% proximal LAD ,
90% proximal ramus , 90% proximal circumflex , 100% proximal RCA ,
90% proximal ramus , right dominant circulation. EKG from
5/1/2006 showed normal sinus rhythm rate of 50 , non-specific
T-wave abnormalities. Chest x-ray from 1/7/2006 is normal.
The patient was admitted to CSS and stabilized surgery.
DATE OF SURGERY: 3/7/2006.
PREOPERATIVE DIAGNOSIS: Status post 1987 CABG x3 with LIMA to
LAD , SVG1 to RPLVD , SVG2 to OM2.
PROCEDURE: Rehab CABG x3 with wide graft. SVG1 connects aorta
to D1 , SVG2 connects SVG1 to OM2 , SVG3 to LVB1.
BYPASS TIME: 235 minutes.
CROSS CLAMP TIME: 138 minutes.
LIMA remained open during case , cold to 18 degree Celsius ,
started on dextran 40 at 20 mL an hour and Plavix to start once
the patient is extubated. She was transferred to the ICU in a
stable fashion , appliance and tubes intact.
Postop day 1 , extubated on epinephrine , balloon weaned off.
Postop day 2 , weaning epinephrine , responding to fluids.
Postop day 3 , tolerating Lopressor ambulating/stable.
Transferred to the Step-Down Unit on postop day 3.
SUMMARY BY SYSTEM:
1. Neurologic: A and O x3. MAE FC out of bed to chair , takes
Klonopin every 12 hours for long-standing anxiety and smoking. He was
using nicotine patch while hospitalized but does not otherwise as
she is an active smoker.
2. Cardiovascular: Cardiac meds , Lopressor , initially on
epinephrine slow wean of epinephrine , received 2 units of blood
for hematocrit of 22.4 and was unable to wean of epinephrine , now
in normal sinus rhythm , heart rate 70s , BP 101/40.
3. Respiratory: Continues to have activity related shortness of
breath and increased wheezing on 2 liters of O2 by nasal cannula.
4. GI: Tolerating orally , bowel sounds present.
5. Renal: On Lasix 40 mg twice a day , responding.
6. Endocrine: On insulin x3 years , poor monitoring of her preop
sugars. Her longstanding endocrine MD aware of style care.
Hemoglobin A1C in decent range , only use Lantus at home. Also ,
has rare partial lipodystrophy syndrome which strongly influenced
her sugars. Currently , on insulin drip , NovoLog with meals on
sliding scale and Lantus as per DMS.
7. Hematology: Received 2 units PRBC for hematocrit of 22.4 ,
was on dextran and now on Plavix for poor targets.
8. ID: Febrile , T max 101.5 , pan cultured. The patient was
transferred to the Step-Down Unit where she proceeded to progress
well.
Starting postop day 4 , sinus rhythm/3 liters transfusing 2 units
packed red blood cells for hematocrit of 23.1. Increase
Lopressor 25 mg every 6 hours as AFib prophylaxis per Dr. Napenas , her
cardiologist. Do not hold Lopressor even if very low BP
diuresing well , 7 kg above preop wait and is still on
supplemental O2.
Postop day 5 , sinus rhythm/room air doing much better today after
receiving blood transfusion yesterday , continuing to diurese 8 kg
above preop. Two episodes of AFib , one this morning and one the
night before I started low dose of Coumadin for these episodes
otherwise in sinus rhythm all day , getting nebs for wheeziness.
Postop day 6 , doing well. ??____?? is following , no note , no
more AFib. So far today , he remains on Coumadin. Plan DC to
home 1-2 days.
Postop day 7 , doing well. Plan was to DC today but the patient
want to stay an extra day to diurese/walk , plan to DC home
tomorrow.
Postop day 8 , the patient was evaluated by cardiac surgery
service to be stable to discharge to home with VNA service. Of
note , her outpatient cardiologist felt that there was no need to
continue Coumadin therapy at this time. She was discharged with
the following discharge instructions:
1. Diet , low-cholesterol with saturated fat.
2. ADA , 2100 calories per day.
FOLLOWUP APPOINTMENT: Dr. Colasamte ( 985-1344-930 ) 5-6 weeks , Dr.
Napenas ( 865-556-8789 ) 1-2 weeks , Dr. Frame ( 808-843-9641 ) 1-2
weeks.
ADDITIONAL COMMENTS: Take Keflex x7 days for SVG site erythema.
TO DO PLAN: Make all followup appointments of wound care , local
wound care , wash the wounds daily with soap and water , watch all
wounds for signs of infection ( redness , swelling , fever , pain ,
discharge ). Keep legs elevated while sitting/in bed. Call
primary care physician/cardiologist or PUO Cardiac Surgery Service at 117-219-4079
with any questions.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Enteric-coated aspirin 81 mg daily ,
Keflex 500 four times a day for 28 doses , Klonopin 0.5 mg twice a day , Plavix 75
mg daily , Colace 100 mg twice a day , estradiol patch 0.05 mg every
week on Thursday , Zetia 10 mg daily and Lasix 60 mg twice a day
INSTRUCTIONS: Take medications twice a day for 5 days , then daily
until followup appointment with primary care physician/cardiologist , Motrin 600 mg
orally every 6 hours as needed pain , NovoLog insulin on sliding scale ,
Lantus insulin 20 units subcutaneously at bedtime , K-Dur 30 mEq at twice a day
with instructions to take medications b.i..d. x5 days then
continue daily until followup appointments with primary care physician/cardiologist ,
nicotine patch 21 mg per day , Niferex 150 mg twice a day , oxycodone 5
mg every 4 hours as needed breakthrough pain , pindolol 5 mg twice a day ,
Simvastatin 80 mg nightly and multivitamin 1 tablet daily.
eScription document: 3-1674384 BFFocus
Dictated By: CRIDGE , LORRETTA PA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 1359547
D: 11/16/06
T: 10/24/06
Document id: 1159
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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777803061 | PUO | 83517641 | | 084494 | 5/23/1999 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 9/2/1999 Report Status: Signed
Discharge Date: 6/1/1999
PRINCIPAL DIAGNOSIS: Non Q-wave myocardial infarction.
CHIEF COMPLAINT: The patient is a 60-year-old woman who was
admitted for chest pain.
HISTORY OF PRESENT ILLNESS: The patient has a history of diabetes
mellitus , cerebrovascular accident in
1994 , gastroesophageal reflux disease , recurrent transient ischemic
attack , who was in her usual state of health until the day prior to
admission when she developed chest burning 3 days ago. The
symptoms were associated with nausea. She tried Maalox and H2
blocker without relief. The patient had stuttering symptoms off
and on throughout the day and night without relief. She was
brought in to LMC today , given aspirin , sublingual Nitroglycerin
and transferred to the Pagham University Of for further
evaluation. In the Emergency Room , her systolic blood pressure is
130. She was tachycardic , and she was given intravenous Nitroglycerin. The
patient then became hypotensive due to overaggressive
Nitroglycerin. The patient received Inderal for tachycardia. No
tirofiban was given given her history of cerebrovascular accident.
Her chest burning was not resolved with intravenous Nitroglycerin. She was
given Morphine sulfate x 2 mg , Inderal and an esmolol drip.
PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Diabetes mellitus.
3. Hypertension. 4. Borderline personality
disorder. 5. Gastroesophageal reflux disease. 6. Parathyroid
adenoma. 6. Status post total abdominal hysterectomy. 7. History
of migraine headache. 8. Chronic re-elevated liver function tests.
MEDICATIONS: 1. Atenolol 50 mg orally twice a day 2. Insulin 70/30.
3. Regular insulin. 4. NPH. 5. Metformin. 6.
Valium. 7. Aspirin. 8. Synthroid.
ALLERGIES: PENICILLIN , NOVOCAINE , ALDACTONE which all give hives.
FAMILY HISTORY: Mother with CVA at age 21.
SOCIAL HISTORY: She is a schoolteacher. No alcohol or tobacco
use.
PHYSICAL EXAMINATION: Blood pressure 132/84. Heart rate 94.
O2 saturation 93% on 2 liters. Sclerae were
anicteric. The lungs were clear. Heart was tachycardic , regular
with no murmurs , rubs or gallops. Abdomen was with slight
hepatomegaly. Normal bowel sounds with slight right upper quadrant
pain. Lower extremities were without edema.
LABORATORY DATA: CK 336 with an MB of 9.7. Troponin was 8.4.
Chem-7 was normal with a BUN of 8 and a
creatinine of 0.9. Hematocrit was 42. White count was 7.
Platelets 196. EKG showed a normal sinus rhythm with left axis
deviation , normal intervals. There were Q-waves inferiorly and
anteriorly with poor R-wave progression and persistent S in V6.
There were slight ST segment increased elevations in V2 of 1 mm and
T-wave inversions in V2 through V6.
HOSPITAL COURSE: Due to her history of cerebrovascular accident ,
no thrombolysis was attempted. She was admitted
to the Coronary Care Unit and treated overnight with increased
dosages of beta blocker and had intermittent symptoms. She went to
catheterization and was found to have 100% left anterior descending
with right to left collaterals and poor distal flow as well as a
90% mid and 90% distal right coronary artery with significant
vessel tortuosity. The left anterior descending was percutaneous
transluminal coronary angioplastied with question of distal
dissection which required stent placement. It led to initial good
result. A wire was passed through the stent , but no balloon could
be passed. There was no proximal stent placed due to poor outflow.
The plan was to return to Catheterization Laboratory to attempt
right coronary artery stenting. However , she subsequently spiked a
temperature to 103 degrees Fahrenheit. She was pan cultured and
her sheaths were removed. No antibiotics were started at that
time. Her urine subsequently grew greater than 100 , 000 E. coli ,
and she was started on levofloxacin with plan for a repeat
catheterization once afebrile x 24 hours. She underwent repeat
catheterization and had percutaneous transluminal coronary
angioplasty of the right coronary artery lesion. She was
transferred to the floor on 3/3 On the night at the procedure ,
she had an episode of desaturation to the mid 80 percent range on
room air. A chest x-ray revealed a question of congestive heart
failure vs. a right upper lobe infiltrate. She had another fever
to 102.2 , and she was pan cultured. Her diuresis was increased at
that time.
On 11/27 , the patient began to show signs of paranoia and
inappropriate behavior , and a psychiatry consultation was obtained.
The patient described visual perception about her room being
smaller and was complaining about changes in her medications
without her being informed. Psychiatry felt that she was delirious
and they recommended getting her family more involved to help
reorient the patient. On 3/15 , the patient was oriented and in her
usual state of mental status according to her cardiologist , Dr.
Fisch The patient was demanding to go home at that time. Dr.
Gruntz preferred to have a dobutamine MIBI test performed prior to
her discharge , but it was decided that this could be done at a
later time as an outpatient.
MEDICATIONS ON DISCHARGE: 1. Acyclovir 800 mg orally five times a day
for 5 days. 2. Aspirin 325 mg orally every day
3. Atenolol 50 mg orally twice a day 4. Synthroid 175 mcg orally every day 5.
Nitroglycerin sublingual as needed for chest pain. 6. Nitropatch 0.4
mg per hour topical every day 7. Ranitidine 150 mg orally twice a day 8.
Simvastatin 40 mg orally every bedtime 9. Insulin 70/30 30 units subcutaneously every day before noon
and 18 units subcutaneously every afternoon 10. Plavix 75 mg orally every day x 30 days.
FOLLOW-UP CARE: The patient was to follow-up with her primary care
physician the week of discharge and to follow-up
with Dr. Gruntz the following week. She was to have her thyroid
function tested in 6 weeks. She was advised to check her
fingerstick sugars four times a day , keep a diary of those numbers
in order for her insulin dosage to be adjusted.
Dictated By: GENOVEVA STIDMAN , M.D. GI79
Attending: CARA NEVA KENEKHAM , M.D. WA5
QB880/9441
Batch: 12552 Index No. F7SLC12HI7 D: 9/14/99
T: 8/13/99
Document id: 1160
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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945883288 | PUO | 42270791 | | 904624 | 11/23/2000 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 2/10/2000 Report Status: Signed
Discharge Date: 6/10/2000
ADMISSION DIAGNOSIS: PERICARDIAL TAMPONADE.
SECONDARY DIAGNOSES: 1 ) SUBACUTE LUNG TRANSPLANT REJECTION.
2 ) BACK PAIN.
3 ) ACUTE TUBULAR NECROSIS.
HISTORY OF PRESENT ILLNESS: The patient is a 53 year-old male with
a history of idiopathic pulmonary
fibrosis status post left lung transplant in 1996 , hypertension ,
steroid induced type 2 diabetes mellitus , deep venous thrombosis
and pulmonary embolus in 1998 , who was previously admitted to
Pagham University Of on January , 2000 for pericarditis. The
patient was discharged home on non-steroidal anti-inflammatory
drugs , however returned to the hospital on November , 2000
complaining of crushing chest pain , nausea , sweating and shortness
of breath , worse on exertion. On the previous admission , the
patient had an echocardiogram suggestive of a small pericardial
effusion and also perhaps pericarditis. The patient was admitted
to the hospital for further evaluation of his chest pain and to
rule out pericardial tamponade.
PAST MEDICAL HISTORY: 1 ) Single left lung transplant in October of
1996 for idiopathic pulmonary fibrosis. 2 )
Idiopathic pulmonary fibrosis diagnosed in 1994. 3 ) Steroid
induced type 2 diabetes mellitus , myopathy , osteoporosis , gouty
arthropathy. 4 ) Hypertension. 5 ) Thromboembolic disease status
post deep venous thrombosis. 6 ) Esophageal dysmotility. 7 )
Diverticulosis , status post diverticulitis and sigmoid colectomy in
1999. 8 ) Nephrolithiasis , status post temporary ureteral stent.
9 ) Status post appendectomy. 10 ) Chronic obstructive sleep apnea
on C-PAP.
ALLERGIES: The patient is allergic to Compazine which causes a
rash and dystonia.
MEDICATIONS ON ADMISSION: 1 ) Cyclosporine. 2 ) Prednisone. 3 )
Azathioprine. 4 ) Diltiazem sustained
release. 5 ) Lopressor. 6 ) Glyburide. 7 ) Vomox. 8 ) Oxycontin
as needed pain. 9 ) Calcitriol.
SOCIAL HISTORY: The patient is married with three children. He
works as an engineer. He has a 40 year history of
smoking tobacco , approximately 2-3 packs per day. He stopped
smoking in 1994. He occasionally drinks alcohol.
FAMILY HISTORY: His mother and brother have diabetes. His father
has kidney disease.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.4 degrees ,
heart rate 130-150 , blood pressure
100-120/70-80 , respiratory rate 20 , oxygen saturation 96% on two
liters at rest. Neck was supple , non-tender , no lymphadenopathy ,
no jugular venous distension appreciated. Oropharynx was clear.
Lungs revealed dense rales , decreased breath sounds , bibasilar
egophony with increased fremitus on the right , left lung clear.
Cardiovascular examination was tachycardic with regular rhythm , no
murmurs , gallops or rubs appreciated. Abdomen was obese , positive
bowel sounds , soft , non-tender , non-distended , no
hepatosplenomegaly appreciated. Skin revealed numerous auricular
papules. He also had a circumscribed plaque on his left leg noted
to be old. Neurological examination was grossly intact with a mild
hand tremor.
LABORATORY: Laboratory studies on admission revealed a white blood
cell count of 11.4 , hematocrit 30.5 , platelet count
267. SMA-7 revealed a sodium of 139 , potassium 4.3 , chloride 102 ,
bicarbonate 25 , BUN 34 , creatinine 2.1 , glucose 238. Creatinine
kinase was 12. Troponin I was 0.17. Electrocardiogram on
admission was significant for a supraventricular tachycardia at 140
beats per minute. There were no ST segment elevations and no acute
changes. Chest x-ray was significant for low volume in the right
lung. The left lung was essentially clear. There was no
compression. Echocardiogram on admission was suggestive of
pericardial tamponade.
HOSPITAL COURSE: The patient was admitted to General Medical
Service on November , 2000 and taken to the cardiac
catheterization laboratory where he was found to have pericardial
tamponade. Pericardiocentesis was attempted in the catheterization
laboratory on November , 2000 , however it was complicated by right
ventricular puncture. The patient was transferred to the operating
room emergently on November , 2000 for right ventricular puncture
repair and for pericardial window. The patient was followed by the
Surgical Service postoperatively until his cardiac and pulmonary
function were stable. He was transferred back to the Medical
Service on August , 2000 for further evaluation and treatment of
pain and further evaluation of his renal function. Hospital course
by treatment issues as follows: 1 ) Chronic pain: The patient's
pain was felt to be likely due to chronic back conditions and also
pericardial pain. The patient was given narcotics , however became
somnolent requiring Narcan reversal. Pain Service consultation
suggested a regimen of Ultram , Vioxx and Prednisone. The patient
showed improvement on this regimen. In addition , the patient
received steroid trigger point injections with some symptomatic
relief.
2 ) Acute tubular necrosis: On August , 2000 through April ,
2000 , the patient had increase in his creatinine to 2.5 thought to
be of pre-renal etiology secondary to Lasix he had received on the
Surgical Service. He received fluid boluses improving his
creatinine. However , he developed hypernatremic diuresis on September , 2000 through January , 2000 which was thought to be a post
acute trivial necrosis diuresis. He was treated with continuous
intravenous fluids of D5 1/2 normal saline with improvement. By
September , 2000 , his creatinine continued to improve to a level of
1.1 , and the patient's diuresis subsided.
MEDICATIONS ON DISCHARGE: 1 ) Albuterol nebulizer 2.5 mg nebulized
every 4 hours as needed for wheezing. 2 ) Imuran
100 mg orally every day. 3 ) Calcitriol 0.25 mg orally every day. 4 )
Glipizide 5 mg orally every day. 5 ) Heparin 5 , 000 units subcutaneously
twice a day 6 ) Insulin Regular sliding scale before every meal and every bedtime 7 )
Lopressor 25 mg orally twice a day 8 ) Niferex-150 150 mg orally twice a day 9 )
Prilosec 20 mg orally every day. 10 ) Prednisone taper orally every day as
follows: Give 30 mg orally every day times two days , then 20 mg orally q.
day times two days , then 10 mg orally every day times two days starting
on September , 2000. 11 ) Hytrin 1 mg orally every bedtime 12 ) Multivitamin
one tablet orally every day. 13 ) Zoloft 100 mg orally every day. 14 )
Atrovent nebulizer 0.5 mg nebulized four times a day as needed for wheeze. 15 )
Atrovent nebulizer 0.5 mg nebulized four times a day 16 ) Neoral 150 mg orally
twice a day 17 ) Ultram 100 mg orally twice a day as needed pain.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISPOSITION: The patient is scheduled for transfer to
rehabilitation on August , 2000.
FOLLOW-UP: The patient will call Dr. Leuga 's office for a
follow-up appointment.
Dictated By: ABE GIRARDI , M.D. ZZ82
Attending: JANAY D. STUKOWSKI , M.D. JX47
EN895/7338
Batch: 3820 Index No. DDFI2Q93ZY D: 8/25
T: 8/25
Document id: 1161
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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995906475 | PUO | 07554150 | | 681337 | 7/30/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/25/1995 Report Status: Signed
Discharge Date: 11/25/1995
PRINCIPAL DIAGNOSIS: SUPERFICIAL THROMBOPHLEBITIS.
SECONDARY DIAGNOSES: SLEEP APNEA , HISTORY OF RECURRENT
DVT'S , GERD.
HISTORY OF PRESENT ILLNESS: Ms. Sturghill is a 50 year old woman
followed by Dr. Devin Brady in KTDUOO Clinic
with a history of recurrent DVTs who presented with pleuritic chest
pain and left lower extremity calf pain. She had a DVT about 10
years ago in the left lower extremity. She was coumadinized at that
time for 3 months. In September of 1994 she had an abdominal hernia
repair and had recurrent DVT by LENIs but was not treated. On 8/5
she presented again with a left lower extremity pain and was found
to have an acute and chronic deep venous thrombosis and was
anticoagulated with Heparin and changed to Coumadin at home. The
patient was poorly compliant with her Coumadin. In October of 1995
she was too depressed to take her Coumadin. Her INR dropped. She
had sharp chest pain like gas over her precordium. The pain cleared
spontaneously. Eventually she called her KTDUOO primary doctor , Dr.
Brady complaining of this pain and was admitted to the I Warho Hospital for rule out MI and rule out PE. VQ scan at that
time was low probability. She was discharged on Coumadin 5mg a day
and Lasix 20mg a day for lower extremity edema. A dobutamine MIBI
was also performed and was negative. On 1/10 she came to the EW
complaining of chest pressure and left lower extremity swelling.
She reported that since 7/25 she started having right anterior
chest pain with chest wall pain which was increased with deep
ventilation , no cough. She did have some increased shortness of
breath and she reported increased swelling and pain of the left
lower extremity and overall was feeling poorly.
PAST MEDICAL HISTORY: Is as above and also includes obesity and
osteoarthritis of the knees.
MEDICATIONS: Coumadin , Lasix , Zoloft.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: She was obese black female. Temperature 98.1 ,
heart rate 72 , blood pressure 138/80.
Respiration is 20. 02 saturation on 4 liters was 96%. HEENT:
Unremarkable other than obesity and a sick sounding voice. Chest:
Clear to auscultation. Cardiac Exam: Regular rate and rhythm with a
II/VI systolic murmur over the left sternal border , no S3 , no S4.
Abdomen: Obese , soft , non-tender. EXTREMITIES: Left lower extremity
was tender in the calf but not warm , no erythematous. She did have
trace edema. Her pulses distally were 2+ on both sides.
LABORATORY EXAMINATION: Notable for a hematocrit of 47 , a white
count of 5.2 , platelets of 236 , normal
SMA7 , a physical therapy of 13.9 and INR of 1.3 , a PTT of 31.5. Chest x-ray
showed no acute infiltrate. Her EKG showed normal sinus rhythm at
78 with an axis of 58 , normal intervals , Q in III , and F in I ,
upright Ts in III , no RVH , no strain compared with prior EKGs. ABG
on room air was pH of 7.39 , PC02 of 47 and P02 of 57 , 88%
saturation. LENIs showed no right DVT , a left greater saphenous
vein superficial venous thrombosis , no change compared with 10/16/95.
A VQ scan was low probability and when compared to the study of
October 1995 was entirely unchanged.
HOSPITAL COURSE: The patient was admitted , heparinized and begun on
Coumadin with a goal PTT of 60-80 and INR of 2-3.
Her calf pain was felt secondary to superficial thrombophlebitis
and post phlebitic syndrome. Interventional Radiology was consulted
to obtain a PA gram , however they felt that the risk of the
procedure outweighed the benefits given that her VQ scan was
entirely unchanged from prior. Her hypoxia seemed related more to
her sleep apnea. She was started on CPAP , which she tolerated
rather poorly , however was encouraged to continue to use it given
her potential long-term benefits. She had an 02 saturation on room
air in the high 80s to low 90s , which improved when she used the
CPAP. There was an initial thought that there may be cellulitis in
the left lower extremity , however this was born out clinically and
she was initially started on I.V. oxacillin in the Emergency Room
but this was stopped after one day. Of note , her chest pain seemed
to be quite esophageal or reflux related and she was started on
Axid with remarkable decrease in her symptoms. Sputum culture was
obtained and showed orally flora. She had no infiltrate on chest
x-ray and was not treated for bronchitis either.
DISPOSITION: She was therefore discharged in stable condition to
follow up with Dr. Brady in Clinic as well as the Sleep
Study Lab recommended that she follow up with ENT to see if any
surgical options were available to her in correcting her sleep
apnea. MEDICATIONS: Lasix 20mg orally every day , Coumadin 5mg orally
every bedtime , Zoloft 50mg orally every day , Axid 150mg orally twice a day She will
follow up with Dr. Devin Brady in Clinic and in the ENT Clinic 1-2
weeks after discharge. She will also follow up in Coumadin Clinic
two days after discharge to have her INR checked in KTDUOO .
Dictated By: DEANDRA L. GILFOY , M.D. HC88
Attending: CORDELIA D. BLACKNALL , M.D. DB91
GL212/1560
Batch: 8677 Index No. P9MKMS92TO D: 5/10/95
T: 5/10/95
CC: 1. DEANDRA L. GILFOY , M.D. HC88
2. DEVIN MARISHA CARLA BRADY , M.D. TO7
3. CORDELIA D. BLACKNALL , M.D. DB91
Document id: 1162
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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128580680 | PUO | 13086344 | | 2679252 | 10/11/2003 12:00:00 a.m. | asymptomatic pyuria | | DIS | Admission Date: 10/11/2003 Report Status:
Discharge Date: 10/19/2003
****** DISCHARGE ORDERS ******
KAZUNAS , JULIET M. 598-09-70-0
Man
Service: MED
DISCHARGE PATIENT ON: 7/20/03 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOYNES , TALITHA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Alert overridden: Override added on 3/2/03 by HUESO , JOYCE ROSS , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
25 UNITS every day before noon; 10 UNITS every afternoon subcutaneously 25 UNITS every day before noon 10 UNITS every afternoon
LISINOPRIL 10 MG orally every day
LOPRESSOR ( METOPROLOL TARTRATE ) 6.25 MG orally three times a day
Starting Today ( 5/25 ) Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COUMADIN ( WARFARIN SODIUM ) 7.5 MG every other day; 5 MG every other day orally
7.5 MG every other day 5 MG every other day Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 3/2/03 by HUESO , JOYCE ROSS , M.D. on order for ECASA orally ( ref # 10361425 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: aware Previous override information:
Override added on 3/2/03 by HUESO , JOYCE ROSS , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 3/2/03 by HUESO , JOYCE ROSS , M.D. on order for COUMADIN orally ( ref # 74672772 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
FLOMAX ( TAMSULOSIN ) 0.8 MG orally every day
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: House / ADA 2100 cals/dy
ACTIVITY: Elevate feet with prolonged periods of sitting
FOLLOW UP APPOINTMENT( S ):
Dr. Jeffery Huff -please call to make appointment ,
Arrange INR to be drawn on 2/24/03 with f/u INR's to be drawn every
4 days. INR's will be followed by Dr. Huff
No Known Allergies
ADMIT DIAGNOSIS:
UTI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
asymptomatic pyuria
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
UTI BPH HTN IDDM ( diabetes mellitus ) PVD ( peripheral vascular
disease ) OSA ( sleep apnea ) morbid obesity
( obesity ) OA ( osteoarthritis ) DVT ( deep venous
thrombosis ) GERD ( gastroesophageal reflux disease )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
58 year-old morbidly obese M history of IDDM , PVD , BPH and
recurrent UTIs admitted after episode of acute onset bilateral upper
extremity weakness and feeling faint x 90 minutes , resolved
spontaneously after some "fresh air" and supplemental O2 in
the ambulance. patient is history of R fem-fem bypass
graft revision and R great toe amputation in 10/17
His hosp course was c/b an Enterococcus UTI and
a polymicrobial toe infxn and he was d/c'ed
to rehab on 14 days of Levo/Amp/Flagyl. during
rehab , developed another UTI for which he was given 20
da ys of Levo. On arrival to ED , felt fine and
wanted to leave but noted to have pyuria on U/A , so
given Amp and Ceftaz for possible Levo-resistant UTI
and admitted for intravenous
ABx. PE: 96.7 , 92/57 , 66 , 16 , 100%RA. NAD ,
morbidly obese. Lungs CTA. RRR. Abd benign. Dressing over
R foot. No CVA
tenderness. Data: WBC 12.5 , lytes/LFTs unremarkable , INR
1.6. U/A 1+LE , 80-85 WBC , Tr bacteria. CXR
without infiltrate.
Hosp course: 1.ID-Levo-resistant UTI vs. sterile
pyuria. Patient has had two urine analysis both dirty catch.
His urine cx was contaminated with mixed bacterial flora. Patient has
refused straight catheterization in setting of being treated for UTI
and possible asymptomatic pyuria with no indwelling or mechanical
object. Given absence of fever , sx of UTI , and contaminated
urine , patient was not started on antibiotics. On 5/25 , patient was
asymptomatic , afebrile , feeling well with no urinary complaints and
therefore is to be discharged home today.
2. Pulm-history of OSA , on BiPAP 3.CV-history of HTN , high chol. COnt statin , EcASA ,
BB , ACEI. Had neg MIBI in
1/10 4. Endo-history of IDDM , Patient was continued on NPH +
RISS 5. Vasc-history of DVT , cont Coumadin ( target INR
2-3 ). history of PVD , cont drsng changes
twice a day 6.GU-history of BPH , cont
flomax 7.GI-history of GERD , cont
PPI 8. Psych-smoker , received nicotine
patch while in hospital.
Dispo: Discharge home with van and wheelchair.
ADDITIONAL COMMENTS: Please continue dressing changes to your R foot.
Please call Dr. Huff to make an appointment with him.
Please call your doctor or come to ER if you experience weakness ,
urinary symptoms or fevers.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HUESO , JOYCE ROSS , M.D. ( KR24 ) 7/20/03 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1163
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
Y |
N |
N |
- |
N |
N |
- |
N |
N |
- |
N |
N |
N |
618812326 | PUO | 26921747 | | 2358986 | 4/3/2005 12:00:00 a.m. | non-cardiac chest pain | | DIS | Admission Date: 4/29/2005 Report Status:
Discharge Date: 1/4/2005
****** DISCHARGE ORDERS ******
BISSETT , LYLE A. 810-49-64-8
Ver
Service: MED
DISCHARGE PATIENT ON: 4/23/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SHOPBELL , MYRIAM P. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
Starting Today ( 10/24 )
ATENOLOL 50 MG orally every day HOLD IF: sbp<110 or heart rate<60
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
TOPAMAX ( TOPIRAMATE ) 600 MG orally every bedtime
Number of Doses Required ( approximate ): 3
LAMICTAL ( LAMOTRIGINE ) 200 MG orally every bedtime
Number of Doses Required ( approximate ): 3
SEROQUEL ( QUETIAPINE ) 450 MG orally every bedtime
Number of Doses Required ( approximate ): 4
EFFEXOR XR ( VENLAFAXINE EXTENDED RELEASE ) 187.5 MG orally every day
Number of Doses Required ( approximate ): 3
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
DEXEDRINE ( DEXTROAMPHETAMINE SULFATE ) 10 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Romig , please call for appt in the next 1-2 weeks ,
ALLERGY: Penicillins , Erythromycins ,
FERROUS SULFATE , PROZAC , VALIUM , AMPICILLIN , FLUOXETINE HCL ,
DIAZEPAM , LORAZEPAM , FLUOXETINE , FERROUS SULFATE , SERTRALINE
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
non-cardiac chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
depression history of R THAL BLEED'93 R ORBITAL
HEADACHES history of 24 wk IUFD 2 PTL deliveries ? PET -
GBS - morbid obesity - 350 lbs SUICIDE ATTEMPTS
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: chest pain r/o MI
HPI: 42 year-old F smoker , obesity , +FH for CAD comes in with 2 hour history of
chest pain on day of admission. She complains that she had
intermittend SSCP earlier in the day that she felt was
"heartburn" , but then had a much more severe 10/10
SSCP radiating to left neck that took breath
away initially but then had no
SOB/diaphoresis/N/V. Started while sitting and drinking coffee
and smoking tobacco- relieved in ER after 2 hours
with 2 sublingual NTG. patient has history of chest pain in past and
had 9/7 admit with dobutamine echo that was
negative except for hyperdynamic LV , cath 10 years ago
at CEMH negative. New med this month is
dexadrine ( amphetamine ) for her depression. In ED: 96.1 94
16 105/66 pain free , NAD , RRR , CTAB , ext no edema PMH: history of chest pain
no documented CAD , s/o ICH after suicide attempt 1993 , sz d/c ,
migraines , bipolar , history of renal cell CA history of nephrectomy
2002 , history of gastric bypass 1980.
ALL" Zoloft , erythro , PCN , prozac MEDS: Neurontin , Seroquel , Atenolol ,
Topamax , Naproxen ( held on admit ) , Protonix ,
Lamictal , Effexor XR , Dexadrine
( held ) A/P: 42 year-old F with some cardiac RF:obesity ,
FH , smoking and concerning story admitted for R/O
MI. CV: Pain free; ASA/lipitor 80/atenolol/ AB
sets negative. C set pending today 4pm. Lipid
panel. Plan pharm MIBI in a.m. Monday
1/21 patient ruled out for MI with 3 negative sets of cardiac enzymes.
myocardial PET scan was negative for ischemia. LDL level was excellent
at 76. patient's chest pain seems to have been noncardiac. She will be
discharged on baby ASA and atenolol.
Pulm: encouraged smoking cessation.
GI: Nexium. HEME: anemia , ferritin was 5 , suggestive of Fe deficiency.
patient no longer has menstrual periods , so seems most likely GI blood
loss. patient will need workup as outpatient. patient is allergic to FeSO4 and
Fe gluconate , so will not write prescription for this. She has had Fe
infusions in the past with no problem. This will need to be addressed as
an outpatient. Psych:
Continued home meds except dexadrine- stimulant in setting of r/o MI.
ADDITIONAL COMMENTS: Your stress test was negative for any signs of coronary artery disease.
Please call your primary care physician if you have any further chest pain.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HAUSRATH , CLEMENTINE H. , M.D. ( LR09 ) 4/23/05 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1164
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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472205463 | PUO | 29439805 | | 1699004 | 7/18/2004 12:00:00 a.m. | vasovagal presyncope | | DIS | Admission Date: 11/3/2004 Report Status:
Discharge Date: 5/4/2004
****** DISCHARGE ORDERS ******
ADSIDE , EMELINA 906-63-99-8
Memp Stera Ey
Service: CAR
DISCHARGE PATIENT ON: 4/19/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LONGAKER , NATISHA AURELIA , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
Alert overridden: Override added on 1/10/04 by
PRINCE , DARLA VELLA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: aware
LASIX ( FUROSEMIDE ) 20 MG orally every day Starting Today ( 3/28 )
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
Instructions: please give 100 mcg/d 5 days a week and 125
mcg/d 2 days a week
Alert overridden: Override added on 1/10/04 by
PRINCE , DARLA VELLA , M.D.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally twice a day
HOLD IF: sbp<100 or heart rate<60 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual every 5 minutes X 3
as needed Chest Pain HOLD IF: SBP < 100
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 4/3 )
Instructions: give 2 mg in PM on MMon Wed Fri Sun and 3 mg
on Tue Thu Sat Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 1/10/04 by
PRINCE , DARLA VELLA , M.D.
on order for SYNTHROID orally ( ref # 85765566 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware Previous override information:
Override added on 1/10/04 by PRINCE , DARLA VELLA , M.D.
on order for ZOCOR orally ( ref # 08012421 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware Previous override information:
Override added on 1/10/04 by PRINCE , DARLA VELLA , M.D.
on order for AMIODARONE orally ( ref # 88682418 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 4/3 )
Instructions: give 2 mg in PM on Mon Wed Fri Sun and 3 mg
in PM on Tue Thu Sat Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 1/10/04 by
PRINCE , DARLA VELLA , M.D.
on order for SYNTHROID orally ( ref # 85765566 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware Previous override information:
Override added on 1/10/04 by PRINCE , DARLA VELLA , M.D.
on order for ZOCOR orally ( ref # 08012421 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware Previous override information:
Override added on 1/10/04 by PRINCE , DARLA VELLA , M.D.
on order for AMIODARONE orally ( ref # 88682418 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & AMIODARONE HCL
Reason for override: aware
ZOCOR ( SIMVASTATIN ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 1/10/04 by
PRINCE , DARLA VELLA , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
HOLD IF: sbp<100 Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
DIOVAN ( VALSARTAN ) 80 MG orally every day HOLD IF: sbp<100
Number of Doses Required ( approximate ): 8
SERAX ( OXAZEPAM ) 10 MG orally every bedtime X 3 doses
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Badalamenti 6/7/04 scheduled ,
Dr. Hamblet ( cardiology ) 3/16/04 scheduled ,
Dr. Dominguez 9/16/04 scheduled ,
Arrange INR to be drawn on 8/22/04 with f/u INR's to be drawn every
7 days. INR's will be followed by Dr. Badalamenti
ALLERGY: Codeine , Morphine , Demerol , AMOX./CLAV.ACID 250/125 ,
AZELASTINE
ADMIT DIAGNOSIS:
presyncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
vasovagal presyncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) htn ( hypertension ) hyperchol ( elevated
cholesterol ) hiatal hernia ( hiatal hernia ) cad ( coronary artery
disease ) hypothyroid ( hypothyroidism ) diabetes ( diabetes
mellitus ) paf ( paroxysmal atrial fibrillation ) femoral pseudoaneurysm
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
DC cardioversion
BRIEF RESUME OF HOSPITAL COURSE:
CC. Pre-syncope
HPI. 76 year-old F with CAD CABGx4 in 1992 , CHF ( EF 20% ) , PAF on BiV pacer since
10/24 , in USOH until 7/7 when noted lightheadedness on toilet having
BM , + tunnel vision. A/with diaphoresis , flushing , nausea , no vomitting ,
mild heart racing. Denies CP , SOB , orthopnea , wt gain. Has noted poor
appetite for 1 wk , unclear etiology , and very dry mouth for 1 week.
Also describes decerased water intake , feeling "cold" , but no fever ,
cough , dysuria. Describes Lasix recently increased to 40 every day from 20
every day in 10/10
PMH - CAD , CABG x4 , CHF EF 20% , PAF , DM diet controlled , HTN , increased
lipids , BiV pacer
MEDS - coumadin , diovan , amiodarone , lasix imdur , zocor , lopressor ,
synthroid
PE - VS 97.6 , HR 108 , 115/79 ( not orthostatic ) , RR 20 , 96% on RA. NAD ,
PERRL , OP dry , lungs CTAB. COR Irreg , no M/R/G , JVP 5-6 cm , Abd +
BS/NT/ND , Ext no C/C/E. Neuro nonfocal.
LABS: Cardiac Enz negative X3. Lytes unremarkable , with BUN 19/Cr 1.0.
CBC WBC 9.06 , HCT 40.4 , PLT 181
EKG: LBBB , AF at 88 , paced , no changes from 9/15
IMPRESSION: 76 year-old F with multiple cardiac risk factors presented with
pre-syncope with BM , likely vasovagal vs. dehydration secondary to poor
orally intake and Lasix dose increased in April .
HOSPITAL COURSE BY SYSTEM:
CV - ISCHEMIA: Ruled out for MI with 3 sets of enz and EKG neg.
Continued her Lasix , Imdur , Zocor , Lopressor , Diovan. PUMP: Dry to
euvolemic , not orthostatic. Lasix was continued at home doses ,
electrolytes remained steady , but she was D/C'd on 20 every day , ( half of her
regular home dose ). We continued Lopressor and Diovan. Encouraged orally
intake. RHYTHM: Atrial fib with bi-V pacer , on
amiodarone. EP service did not feel that symptoms were due to bi-V
failure , and that interrogation of pacer was not indicated. However ,
she was DC cardioverted on day 2 of admission without complications.
Heme: Therapeutic on coumadin
Endo: Complained of feeling cold , no weight gain. Continued
synthroid. TSH was WNL ( 3.47 ).
ID: U/A was unremarkable , not c/with UTI.
FEN: NAS diet , encouraged orally intake. Echo from 10/22 showed EF of 20
% , IVF was not indicated at she took POs.
PROPHY: Therapeutic on Coumadin and taking POs.
DISPO: Will follow-up with Dr. Badalamenti ( primary care physician ) on 9/17/04 at 10am , Dr.
Hamblet ( cardiology ) on 10/8/04 at 11am , Dr. Dominguez on 11/25/04 at 11:3
0am. Patient will continue to take coumadin and amiodarone until her
appt with the cardiologist , and has been instructed to continue her
regular INR follow-up.
PE ON DISCHARGE: VSS , NAD , PERRL , OP BENIGN ,
Lungs CTAB , CV RRR , no M/R/G , Abd +BS , NT/ND , Ext without edema , Neuro
nonfocal.
MEDICATIONS ON DISCHARGE: HOME REGIMEN -- Coumadin 2 mg 4x wk , 3mg 3x
wk , Amiodarone 200 mg every day , Lasix 20 mg every day , Imdur 30 mg every day , Zocor 5 mg
every day , Diovan 80 mg every day , Synthroid 100 mcg 5x/wk , 125 mcg 2x/wk , Serax 10
mg every bedtime as needed insomnia ( 3 pills ).
ADDITIONAL COMMENTS: Please continue to take your coumadin and follow up with your regular
INR checks. Please continue to take all your regular home medications.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Continue to take all your regular home medications , but decrease Lasix
to 20 daily ( half of your previous dose ). Continue to keep your regular
appointments
at coumadin clinic. Follow up with Dr. Badalamenti 9/17/04 at 10am.
Follow up with Dr. Hamblet 10/8/04 at 11am.
Follow up with Dr. Dominguez 11/25/04 at 11:30am.
No dictated summary
ENTERED BY: HENDY , CLARETHA , M.D. , PH.D. ( TD18 ) 4/19/04 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1165
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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- |
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- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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127873200 | PUO | 51793321 | | 554914 | 3/24/2002 12:00:00 a.m. | chest pain resolved , r/o MI | | DIS | Admission Date: 3/20/2002 Report Status:
Discharge Date: 2/12/2002
****** DISCHARGE ORDERS ******
LUEDEMAN , GENEVIVE M 045-15-93-2
Tall
Service: MED
DISCHARGE PATIENT ON: 2/30/02 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SVENNINGSEN , CHRISTIAN VIVAN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 50 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PRINIVIL ( LISINOPRIL ) 10 MG orally twice a day
Alert overridden: Override added on 4/3/02 by
IGARTUA , DENAE KAM , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
OCEAN SPRAY ( SODIUM CHLORIDE 0.65% ) 2 SPRAY nasal four times a day
as needed congestion
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 4/3/02 by
IGARTUA , DENAE KAM , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: noted
DOVONEX ( CALCIPOTRIENE 0.005% ) CREAM TP twice a day
Instructions: apply to affected areas
Number of Doses Required ( approximate ): 10
FLOMAX ( TAMSULOSIN ) 0.4 MG orally every day
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 10
LIPITOR ( ATORVASTATIN ) 40 MG orally every bedtime
Alert overridden: Override added on 2/30/02 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware , no problems
PALMITATE A 15 , 000 unit unknown orally every day
AMARYL ( GLIMEPIRIDE ) 2 MG qAM; 4 MG qPM orally 2 MG qAM
4 MG qPM
DIET: House / ADA 2100 cals/dy
RETURN TO WORK: After Appt with local physician
FOLLOW UP APPOINTMENT( S ):
Dr. Chan Monday ,
nuclear medicine , rest-MIBI 7 am Monday ,
No Known Allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chest pain resolved , r/o MI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn elev chol NIDDM , Hgb A1C7.5
1/29 retinitis pigmentosis , poor peripheral vision
history of renal calculi , 4/17 cystoscopy and R ureteral stent mild CRI psoriasis
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
ETT-Mibi , ECHO
BRIEF RESUME OF HOSPITAL COURSE:
The patient is a 58 year-old man with NIDDM , HTN , elevated
cholesterol , and CRI , who presented to his primary care physician 11/23 c/o 2D of SS chest
pressure. The patient has had prior admissions for chest pressure
but negative ETT 1998-1999 ( ETT-mibi 1999 with no fixed
or reversible defects , EF 50% ). He reports that
2D ago he developed SS chest pressure with L
arm tingling/pain; episode occured at rest and
lasted 10-15'. He has had a few episodes per day
since , almost all at rest ( the patient went up a
few flights of stairs last night without difficulty ).
Not associated with N/diaphoresis/SOB. Did not change with position.
The patient's wife feels that his sx are similar to his complaints in 1999.
The patient reported a history of "heavy/labored breathing" over past
few weeks , concurrent with some weight gain ( the patient had been
trying to lose weight but "lost his motivation" and
went from 275->305 10/18 ).
No PND/orthopnea/DOE , + some mild swelling
around ankles. patient also reports URI sx over past
week with dry cough/stuffiness , no f/c , +
mild nausea. URI sx resolved before chest
pressure episodes began. The patient presented to his
primary care physician with this complaint and was brought to ED , given
1 SLNTG and pressure resolved. He also
received lopressor 2.5 intravenous/25 orally and ASA 325.
Home meds included
cardizem/amaryl/prinivil/lipitor/asa/flomax/detrol/
palmitate A. No tob since age 18. +FH early MI. PE in ED: T 96.7 , HR
80 , BP 139/80 , 100% 2L. R eye deviated laterally. Periph field
cut. Chest clear. JVP 7 cm. RRR , I/VI SEM RUSB , obese , nl abd
exam , trace pretibial edema. EKG no change from
prior. 1st set enz flat. Labs Cr 1.4 ( baseline
1.3-1.6 ).
Hospital course:
CV: CAD/ischemia: multiple CRF ,
past negative ETTs , sx unrelated to exertion but
c/with angina otherwise ( pressure/L arm paresthesia ) ,
with no assoc sx. patient was r/o for MI by serial enz/ekgs. Cardizem was
dc'd and he was started on lopressor and transitioned to atenolol fo
r d/c ( though it was not possible to get an accurate assessment of
BP on lopressor given short stay/nitro paste in house. ) He was
continued on ACE/lipitor. Stress portion of ETT-mibi ( separate from
rest given patient's weight/need for higher doses of marker ): patient walked
for 5'20s , reached DP of 24 , 480. He had no CP or EKG changes and
only small amt SOB at max exertion. Mibi showed a small defect in
the mid-basal portion of the inf-lateral wall , which if reversible
would suggest a small area of ischemia in the OM distribution. It was
decided that the lesion , even if reversible , was of low enough risk
that the patient could go home and return for the rest portion on
Monday. He was dc'd on his adjusted meds as above and will f/u with
Dr. Chan Monday to arrange BP check. Pump: the patient did not s
how evidence of fluid overload on exam , and it was thought that his
inc SOB x 1 mth or more was due to his weight gain , but ECHO was o
btained for baseline study and results were pending at dc.
DM: amaryl held while in house , ISS. microalbumin/Cr ratio was nl at
6.1 , compared to 51 in
11/14 amaryl restarted for d/c.
Renal: Cr at baseline
ID: history of URI , resolving: ocean spray
GU:
detrol/flomax.
ADDITIONAL COMMENTS: return to ED if you experience significant chest pain unrelieved by
nitroglycerin.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: YOUNKER , NILDA , M.D. , PH.D. ( VV8 ) 2/30/02 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1166
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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456825623 | PUO | 18013347 | | 1528687 | 7/20/2006 12:00:00 a.m. | CHEST PAIN | Unsigned | DIS | Admission Date: 10/27/2006 Report Status: Unsigned
Discharge Date: 10/4/2006
ATTENDING: TONI , CARMELITA M.D.
SERVICE: Cardiac Surgical Service under the care of Dr.
Shelley Starnauld
HISTORY OF PRESENT ILLNESS: Mr. Carnine is a 62-year-old man who
recently had a cardiac catheterization that revealed three-vessel
coronary artery disease. He reported several weeks of substernal
pressure occurring at both rest and with activity. He reported
the consent to his primary care physician in seven months for an
exercise tolerance test , which was positive. As stated above ,
cardiac catheterization revealed coronary artery disease. He was
referred to Dr. Carmelita Toni for coronary revascularization.
PAST MEDICAL HISTORY: Hypertension , diabetes mellitus ,
hyperlipidemia , renal cell carcinoma status post nephrectomy.
PAST SURGICAL HISTORY: Right nephrectomy.
FAMILY HISTORY: Coronary artery disease.
SOCIAL HISTORY: Five pack year cigarette smoking history;
however , he quit smoking 20 years ago.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS: Lisinopril 20 mg orally daily , aspirin
81 mg orally daily , hydrochlorothiazide 12.5 mg orally daily , Zocor
20 mg orally daily , metformin 500 mg orally every day before noon
PHYSICAL EXAMINATION: Vital signs: Temperature 97.5 , heart rate
62 , blood pressure in the right arm 140/76 , blood pressure in the
left arm 130/66. HEENT: Dentition without evidence of
infection , no carotid bruit. Cardiovascular: Regular rate and
rhythm without murmur. Peripheral pulses are all 2+ and include
the carotid , radial , femoral , dorsalis pedis , and posterior
tibial. Respiratory: Breath sounds clear bilaterally.
Extremities: Without scarring , varicosities or edema. Neuro:
Alert and oriented with no focal deficits.
PREOPERATIVE LABS: Sodium 141 , potassium 4.2 , chloride 106 ,
carbon dioxide 26 , BUN 22 , creatinine 1.3 , glucose 102 , and
magnesium 2. White blood cells 6.97 , hematocrit 35.2 , hemoglobin
11.9 , platelets 235 , 000 , physical therapy 13.4 , INR 1 , and PTT 90. Cardiac
catheterization data on 4/22/06 , coronary anatomy , 80% ostial
LAD , 90% proximal D1 , 80% proximal circumflex , 100% proximal PDA
with right dominant circulation. ECG on 4/22/06 shows normal
sinus rhythm at 48 with inverted T waves in aVL. Chest x-ray on
4/22/06 was read as normal.
HOSPITAL COURSE:
Brief operative note.
DATE OF SURGERY:
4/25/06.
PREOPERATIVE DIAGNOSIS:
Coronary artery disease.
POSTOPERATIVE DIAGNOSIS:
Coronary artery disease.
PROCEDURE:
CABG x4 , sequential graft , SVG1 connects aorta to D1 and OM2 ,
LIMA to the LAD and SVG2 to PDA.
BYPASS TIME:
124 minutes.
CROSSCLAMP TIME:
112 minutes. One ventricular wire was placed. The patient came
off cardiopulmonary bypass on one of Levophed.
COMPLICATIONS:
None.
After the operation , the patient was transferred in stable
condition to the Cardiac Intensive Care Unit. Upon arrival to
the Cardiac Intensive Care Unit , he was noted to have low
hematocrit and was given 1 unit of packed red blood cells. After
obtaining another hematocrit level once this transfusion to
place , his hematocrit was found to be increasing appropriately.
He was transferred to the Cardiac Step-Down Unit on postoperative
day #1. While on the Cardiac Step-Down Unit , his course was
complicated by the following:
1. On postoperative day #4 , it was noted that the Ms. Carnine
had some erythema on the superior portion of his mediastinal
incision that was also tender to palpation. As a precautionary
step , the patient was started on vancomycin , levofloxacin , and
Flagyl. Cardiac Surgical Team elected to keep Mr. Carnine in the
hospital while his mediastinal incision was observed. Over the
next several days , Mr. Carnine 's erythema had decreased and there
was no noted discharge from the incision. It was felt that there
was no evidence of mediastinal as Mr. Carnine remained afebrile
and did not have leukocytosis. His triple antibiotic therapy was
stopped and Mr. Carnine will be sent home on orally antibiotics.
Otherwise , Mr. Carnine did well on his hospital course and will
be discharged home on the following medications: Augmentin one
tablet orally three times a day x7 days , aspirin 325 mg orally daily , Colace 100
mg orally three times a day as needed constipation , metformin 500 mg orally every day before noon ,
Toprol-XL 100 mg orally daily , oxycodone 5 mg orally every 4 hours as needed
pain , Zocor 20 mg orally nightly. Mr. Carnine will follow up with
Dr. Toni , cardiac surgeon , in six weeks and Dr. Sasnett , the
patient's primary care physician in one to two weeks , Dr. Barnaba ,
the patient's cardiologist in three to four weeks.
eScription document: 3-0369190 CSSten Tel
Dictated By: TRIARSI , VERDA
Attending: TONI , CARMELITA
Dictation ID 0349911
D: 1/6/06
T: 6/1/06
Document id: 1167
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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957920206 | PUO | 19483662 | | 9324690 | 10/21/2005 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 5/19/2005 Report Status: Signed
Discharge Date: 7/3/2005
ATTENDING: STAUTZ , MATHEW MD
INTERIM PHYSICIAN: Malinda Polo , MD
ATTENDING PHYSICIAN: Fernande Prewer , MD
SERVICE: Cardiology Adue Y
The condition responsible for causing this admission is
congestive heart failure exacerbation. Other diagnoses include
left bundle branch block , paresthesias in the fingers , benign
prostatic hypertrophy , prostatic adenocarcinoma , Gleason's score
2/4 , C5-C6 and C6-C7 disk disease , status post left nephrectomy
for renal cell carcinoma , hyperplastic polyps in 1993 and also
status post AICD and dual chamber pacer.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male
well known to the CHF Service with long-standing New York Heart
Association class 3B idiopathic dilated cardiomyopathy presenting
with shortness of breath and increasing orthopnea over the last
night prior to admission from 8 to 9 p.m. The patient first went
to Forestblan Conwake Hospital ER then left AMA without further treatment after
waiting four hours. He reports increasing cough with white
sputum since 5/8 , dyspnea on exertion and orthopnea especially
over the last three days. Also there is a questionable increase
in abdominal distention. The patient had been admitted five
times in the last six months with the last admission also for
worsening dyspnea on exertion , orthopnea and cough in which he
notably had a TEE-guided cardioversion and diuresis. He was
discharged on creatinine of 1.7. The patient freely admits that
he has had dietary indiscretion over the last two months ,
claiming that he has been "eating like a horse" with meat and
heavy sauces on pasta. The patient denies chest pain , fevers ,
sick contacts , chills , weight gain or nausea.
ALLERGIES: The patient has allergies to erythromycin and
penicillin , which causes a rash. He also describes an allergy to
contrast.
PHYSICAL EXAMINATION: The patient was alert and oriented and in
no acute distress with blood pressure of 82/62 , heart rate of 80
beats per minute. His HEENT exam was unremarkable. Carotid
upstrokes were brisk without bruits. There were no thyromegaly
and his chest exam was clear to auscultation and percussion.
Cardiac exam did demonstrate JVP of about 18 cm and also regular
rate and rhythm with an S1 , S2 as well as an S3 and 1/6
holosystolic murmur at the apex. The abdominal exam was notable
for an enlarged abdomen , but nondistended and without pulsatile
palpable liver edge. There was no tenderness to palpation. The
extremities were warm and with 1+ distal pulses and only trace
edema.
LABORATORY DATA: On admission were notable for BUN of 45 ,
creatinine of 1.6 , K of 4.3 and sodium of 136. The INR was 1.3.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular. The patient was in volume overload and his
ARB and Aldactone were held. Aggressive diuresis was undertaken
for most of this stay including an intravenous Lasix drip , which was later
weaned to a torsemide intravenous twice a day which was later changed to orally
twice a day for a questionable reaction to the intravenous formation in the
form of itchiness. He was also put on Zaroxolyn throughout the
stay and he was started on dopamine drip , which was later
discontinued on 7/20/05 for long runs of NSVT that he had
possibly secondary to sensitivity to the dopamine. However ,
dobutamine was started on 2/11/05 and this dosage was increased
gradually over 8/1/05 to 1/19/05 to rate about 3 mcg/kg and
the patient tolerated this dosage fairly well. In addition ,
electrolytes were repleted throughout the stay and the patient
underwent a workup for an LVAD placement including PFTs ,
peripheral and carotid Dopplers and an abdominal ultrasound. He was shown to
have significant aortic vascular disease which was felt to represent a
contra-indication for LVAD. Discussion ongoing with the patient during his
stay revealed that he would prefer not to have the LVAD
even if he were eligible. He understood that he was not likely to live long
with the severity of his heart failure. The decision was later made to send
the patient home with a Hickman catheter placed on 11/6/05 , so that he could
receive home dobutamine. In terms of ischemia , the first set of
enzymes were flat and ischemia was judged not to be an active
issue. There were no changes on EKG. In terms of rhythm , the
patient does have history of prior AFib , however , he has remained
in normal sinus rhythm , status post cardioversion. He has had
asymptomatic runs of NSVT on the dopamine and less so on the
dobutamine as mentioned above. Currently he was paced with an
AICD. We kept the patient on amiodarone and digoxin as well as
on tele.
2. Renal: The patient has a history of chronic renal
insufficiency and is status post left nephrectomy. We monitored
the patient's BUN and creatinine while diuresing and although ,
the patient did have an increased BUN to about 70 , diuretic
treatment was continued as a primary goal.
3. Endo. The patient has diabetes and we held orally glycemics ,
putting him on regular insulin sliding scale and NPH doses. Also
the patient had low TSH. This is probably due to subclinical
hypothyroidism or sick euthyroid.
4. Heme. The patient is on Coumadin as an outpatient and we
titrated his INR to a goal of 2-3. The patient did have some
nosebleeds on 10/21 and his Coumadin was temporarily held , but
restarted again for this goal of 2-3 later. The INR goal was
decreased less than 1.5 where the placement of Hickman catheter
with the plan to restart the Coumadin after placement.
5. Prostate. The patient does have a history of prostate
adenocarcinoma , Gleason 2/5 on biopsy in 2004. This has been
discussed with the patient by his urologist and the patient has
refused surgery now with an increased PSA , however , we did
consult a Urology while the patient was here and it was deemed
that his prostate should not be a major prognostic consideration
given the degree of his heart failure.
Physical exam at discharge , in general the patient was
comfortable and in no apparent distress , sitting up and eating
his food comfortably as far as the HEENT and neck exam his JVP
was about 10 cm. Cardiovascular exam showed occasional PVCs and
a loud P2 and S3. In general unchanged from admission.
Respiratorywise his lungs were clear to auscultation and breath
sounds were equal bilaterally. His abdomen was somewhat
decreased in size from admission , soft and non-tensed.
Extremities were warm without edema. Pulses were 1+ radial and
dorsalis pedis pulses bilaterally as with admission he did have
some wasted lower extremities.
DISPOSITION: The patient will be discharged to home with VNA
Services. The plan is to follow his INR on Coumadin and to
continue to monitor his heart for NSVT while on dobutamine. Also
consider an ARB or Aldactone. The patient has stable kidney
function with decreasing creatinine.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg orally daily.
2. Digoxin 0.125 mg orally four times a day
3. intravenous dobutamine 3 mcg/kg/minute and D5 water continue with intravenous.
4. Folate 1 mg orally daily.
5. Zaroxolyn 2.5 mg orally every day before noon
6. Multivitamin one tablet orally daily.
7. KCl slow release 40 mEq orally three times a day
8. Torsemide 200 mg orally twice a day
9. Glipizide 10 mg orally daily.
10. Coumadin 3 mg orally every afternoon
eScription document: 8-1646113 CS
Dictated By: POLO , MALINDA
Attending: FERNANDE RANDY PREWER , M.D. ND75
Dictation ID 0247306
D: 11/6/05
T: 10/10/05
Document id: 1168
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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045613251 | PUO | 02392257 | | 615734 | 7/9/1994 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/4/1994 Report Status: Signed
Discharge Date: 3/5/1994
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE
SECONDARY DIAGNOSES: 1. PULMONARY EMBOLUS
2. DILATED CARDIOMYOPATHY
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old woman
with dilated cardiomyopathy secondary
to Adriamycin , status post recent admission for increased shortness
of breath and left pleural effusion. He returns now with increased
cough productive of white phlegm and progressive dyspnea on
exertion. The patient has a history of breast carcinoma in 1989 ,
treated with left lumpectomy x 2 and XRT , accompanied by
chemotherapy completed in early 1990. The patient then presented in
July of 1992 with progressive dyspnea on exertion , found to have
an ejection fraction of 17%. She was diagnosed with cardiomyopathy
felt secondary to Adriamycin toxicity. She was then treated with
Digoxin , Lasix , Captopril and Coumadin with good result. She had
subsequent development of SVT with a rapid ventricular rate of
approximately 180. The patient eventually underwent EPEP studies
with therapeutic ablation. Subsequently she had done quite well
until February of 1994 when she presented with mild cough
productive of white phlegm and increasing symptoms of right and
left-sided heart failure. She was treated with increased Lasix and
Digoxin and an empiric course of amoxicillin with little change in
her symptoms. She was then admitted on 8/7 after she was found to
have a large left-sided pleural effusion. The patient underwent
ultrasound guided thoracentesis complicated by a pneumothorax
requiring chest tube placement. Evaluation of the pleural fluid
revealed a transudative effusion with all cultures and cytology
remaining negative. The patient was treated with Ancef for
approximately 7 days while the chest tube was in place and then
discharged on 6/20/94. Since that time the patient has had no
improvement in her symptoms but rather notes increasing cough which
remains productive of white sputum with occasional "specks of red"
and progression of her dyspnea on exertion. She is now unable to
go greater than six steps of stair without significant dyspnea.
This is a significant change from approximately one month ago where
she was able to go two flights without extreme difficulty. She has
stable 3 + pillow orthopnea and pedal edema. Her weight has
increased only slightly recently. She denies any fever , chills ,
sweats , chest discomfort or pleuritic chest pain. She does not
anorexia and malaise without myalgias or arthralgias. PAST MEDICAL
HISTORY: 1. Dilated cardiomyopathy as above. 2. Breast carcinoma
as above. 3. Hypothyroid 4. Depression ALLERGIES: No known drug
allergies. Habits , distant tobacco use , none since 1967 , no ETOH.
MEDICATIONS: Digoxin 0.25 mg every day , Lasix 80 mg every day , Capoten 50
mg three times a day , aspirin one per day , Synthroid 2 gr. per day , Tamoxifen
10 mg twice a day , Elavil 75 mg every day , K-Dur 1 every day. SOCIAL HISTORY:
The patient lives with her boyfriend , she is widowed without
children. She is a semi-retired Accounts Manager. FAMILY HISTORY:
There is no family history of cardiac disease.
PHYSICAL EXAMINATION: Temperature 100.6 , blood pressure 116/65 ,
heart rate is 100 , respiratory rate 18. 02
saturation 90% on room air. The patient is alert , responsive ,
febrile and in no acute distress. Her conjunctiva are clear ,
extraocular movements intact , her oropharynx is clear. She has no
lymphadenopathy. Jugular venous pressure is approximately 8 cm at
30 degrees. Lung examination is remarkable for a few rales at the
left base , decreased breath sounds at the right base with dullness
to percussion. Cardiac examination , regular rate and rhythm with
normal SI , SII , positive SIII. Abdomen is soft and non-tender ,
slightly distended. She has pitting edema almost to the knees
bilaterally. Neurological examination is non focal.
LABORATORY DATA: SMA-7 is notable for a potassium of 5.4 and
creatinine of 1.2 with a BUN of 20. CBC
demonstrated a white count of 14 , hematocrit of 42.9 , platelets
289 , Digoxin level was 1.2. Chest x-ray showed a left pleural
effusion which is unchanged , a new right pleural effusion +-
consolidation. EKG showed sinus rhythm at 98 , left axis deviation ,
normal intervals , low voltage with poor R wave progression , no
significant change compared with 7/24/94.
HOSPITAL COURSE: The patient was admitted with a picture of chronic
productive cough , progressive dyspnea with low
grade fevers and increased white blood cell count , in addition to
new opacity on chest x-ray. This clinical picture was felt to be
mostly from a progressive infectious process superimposed on
underlying congestive heart failure versus post-obstructive
infection versus atelectasis with an endobronchial lesion. The
patient was started on empiric course of antibiotics including
cefotaxime and clarithromycin. She was seen in consultation by the
Pulmonary Service which felt that a therapeutic trial of aggressive
diuresis was warranted prior to any more aggressive intervention
such as bronchoscopy or repeat thoracentesis. The patient was thus
treated with aggressive intravenous diuresis with excellent symptomatic
result. As her symptoms and chest x-ray cleared , it was felt that
a chest CT would be valuable in evaluating her left lower lobe for
possible endobronchial lesion leading to volume loss. She thus
underwent a chest CT on 2/6/94 with demonstration of a large
peripheral , red , right lower lobe opacity , highly suggestive of a
right lower lobe pulmonary infarction. No endobronchial lesions or
lymphadenopathy were noted. Given the patient's history of dilated
cardiomyopathy , off anticoagulation , an extensive discussion of the
chest CT findings with the Chest Radiologist and Pulmonary Consult
Team , it was felt that the patient should be treated empirically
for a pulmonary embolus. She was thus started on intravenous Heparin with
achievement of therapeutic PTT prior to switching to orally Coumadin
without complications. In addition the patient underwent lower
extremity non-invasives which were negative for deep venous
thrombosis as well as a cardiac echocardiogram which showed no
evidence of RV strain or right ventricular thrombus. Of note , this
echocardiogram again demonstrated moderately large left ventricle
with severely depressed systolic function and an estimated ejection
fraction of 15-20%. Though the possibility that the wedge shaped
opacification seen on CT was due to pneumonia rather than
infarction , it was felt that given the patient's low ejection
fraction she would need to be anticoagulated on this basis alone ,
and thus pulmonary angiogram or VQ scan would not be likely to
alter management. The patient was discharged to home.
DISPOSITION: The patient was discharged to home. MEDICATIONS:
Elavil 75 mg orally every bedtime; Captopril 50 mg orally three times a day;
Biaxin 500 mg orally twice a day; Digoxin 0.125 mg alternating with 0.25
mg every day; Lasix 80 mg orally twice a day; Tamoxifen 10 mg orally twice a day;
Thyroid 2 grains orally every day; Coumadin 5 mg orally every day; K-Dur 20 mg
orally twice a day; Ambien 10 mg orally every bedtime Followup with Dr. Schwerd at
the Na Memorial Hospital
Dictated By: ALVERTA A. BURVINE , M.D. KJ83
Attending: FRANCISCA A. URBANIAK , M.D. MS1
ER907/4997
Batch: 8853 Index No. DFWY4DD66 D: 3/10/94
T: 8/10/94
Document id: 1169
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
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954774163 | PUO | 83438326 | | 3765182 | 8/14/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/27/2006 Report Status: Signed
Discharge Date:
ATTENDING: REISMAN , CATHIE MINDI MD
INTERIM DISCHARGE SUMMARY
SERVICE: Cardiology Ta
PRINCIPAL DIAGNOSES:
1. CHF exacerbation.
2. Atrial fibrillation and flutter.
LIST OF PROBLEMS AND DIAGNOSES:
1. Insulin-dependent diabetes mellitus.
2. Hypertension.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with a
history of CAD , CHF with an ejection fraction of 30% , atrial
fibrillation ( diagnosed in 2000 , status post 4 cardioversions , on
amiodarone until January 2005 , when it was discontinued due to skin
discoloration; since then , the patient has been on Toprol ) ,
insulin-dependent diabetes mellitus , who has done well since a
stent was placed in 2002 , not requiring any hospitalizations for
cardiac-related issues. In July 2006 , he notes that he began to
feel weak with increased dyspnea on exertion and occasional
palpitations , although he denied any chest pain. He was found to
be in atrial fibrillation and was started on Coumadin , with
continuation of the Toprol for rate control. He was cardioverted
in September 2006 , resulting in symptomatic improvement until January 2006
when he again reportedly felt weak , had increased dyspnea with
exertion. An echocardiogram was done in January 2006 , showing an
ejection fraction of 28%. Given his increased risk for sudden
death , a single-chamber ICD was placed.
He continued to feel even more unwell towards the later end of
January , with episodes of nausea , diaphoresis , shortness of breath ,
and abdominal pain with exertion ( these were his typical angina
symptoms in the past ). Consequently , ETT was done on 9/18/2006 ,
which was terminated after 1 minute when the patient's heart rate
went up to 130. Electrophysiology adjusted his ICD , still he
reports continued symptoms as previously described as well as
decreased appetite and weight gain of 15 pounds over 6 weeks. He
endorses worsening orthopnea and PND over the several weeks prior
to admission. He was started on amiodarone on 11/4/2006 for
atrial fibrillation. Given his worsening symptoms , he presented
to Dr. Lyn 's clinic on the day of admission for evaluation. He
was admitted for diuresis in the setting of a CHF exacerbation
and for consideration of options in the treatment of his atrial
fibrillation.
PREADMISSION MEDICATIONS:
1. Toprol XL 50 mg twice a day
2. Diovan 160 mg daily.
3. Coumadin 5 mg on Monday , Wednesday , Friday , Saturday , and
Sunday; 7.5 mg on Tuesday and Thursday.
4. Amiodarone 200 mg daily.
5. Lasix 20 mg every other day.
6. K-Dur 10 mEq every Monday and Friday.
7. Aspirin 81 mg daily.
8. Zetia 10 mg daily.
9. Pravachol 40 mg daily.
10. Glyburide/metformin 2-5/500 mg twice a day
11. Lantus 24 units subcutaneously daily.
12. Elavil 10 mg daily.
13. Nexium 40 mg daily.
14. Multivitamin.
15. Vitamin C.
16. Vitamin B12.
17. Magnesium.
18. Zinc.
19. Folic acid.
20. Coenzyme Q10.
SOCIAL HISTORY: Mr. Persall is a retired lobbyist. He currently
lives in Corpo with his wife. He does not smoke. He does not
drink excessively. He does have an occasional glass of wine or
two at dinnertime.
FAMILY HISTORY: Significant for brother who died of an MI at age
58 , father who died of an MI at age 78 , and mother with
atherosclerosis.
ALLERGIES: Flagyl to which he gets edema and Demerol.
ADMISSION PHYSICAL EXAMINATION: Vitals were temperature of 95.7 ,
heart rate 80 , blood pressure 144/78 , respiratory rate 20 , O2
saturation 97% on room air. Generally , this is a
comfortable-at-rest-appearing gentleman in no respiratory
distress. Neck shows JVP is approximately 7 cm. His heart exam
is irregularly irregular with abnormal S1 and S2 , soft S3. Soft
systolic murmur at the right lower sternal border. No S4 or rub.
No heave or palpable thrill. His lungs are clear to
auscultation bilaterally. His abdomen is obese , mildly tender
without hepatosplenomegaly. Extremities are warm and well
perfused with 2+ pulses and 1+ pitting edema from ankles to
thighs bilaterally. His neuro exam is grossly intact , and he is
alert and oriented x3.
ADMISSION LABORATORY DATA: Sodium 137 , potassium 5.2 , BUN 33 ,
creatinine 1.6 , glucose 218. ALT 26 , AST 29 , total bilirubin
0.3 , alkaline phosphatase 66. BNP 659. White blood cells 599 ,
hematocrit 39.3 , platelets 196 , 000. Lipids: Total cholesterol
121 , triglycerides 166 , HDL 37 , LDL 51. EKG showed atrial
fibrillation with ventricular rate in the 70s. Normal intervals.
No ST changes. Echocardiogram , 10/27/2006 : Ejection fraction
30%. Left ventricular diameter , end-diastole , 6.2%; end-systole
4.8%. Septum is thin and akinetic at the apex. There is a
hypokinetic mid to distal wall , posterior and inferior wall.
Mild mitral regurgitation and tricuspid regurgitation. There is
a dilated aortic root. Chest x-ray , 10/27/2006 , shows
cardiomegaly with an interstitial process and without effusions.
PROCEDURES: On 2/25/2006 , the patient was started on
dofetilide.
HOSPITAL COURSE BY PROBLEM:
1. Congestive Heart Failure: The patient was started with a
diuretic regimen of Lasix 40 mg intravenous twice a day given that he
appeared to be volume overloaded by clinical exam. On
presentation , he was compensated for his congestive heart
failure , with a creatinine of 1.6. The daily goal for his was -2
to 2.5 L , and he did very well on this dose of Lasix for the in
and out goal. He was switched over to Lasix 80 mg orally daily on
10/20/2006. His Toprol was continued in-house , but his ACE
inhibitor was held in the setting of increases in his serum
creatinine. The plan was to restart his ACE inhibitor following
complete diuresis to dry weight. There were no symptoms or signs
consistent with ischemia in-house. The patient was continued on
aspirin and Zetia for hyperlipidemia.
2. Atrial Fibrillation: Given the patient's history of atrial
fibrillation and flutter since 2000 and his continued symptoms on
Toprol ( amiodarone was not an option that the patient wished to
pursue given the side effects of skin discoloration that he had
previously experienced ). It was decided to proceed with
dofetilide therapy on 10/20/2006. His QTc was monitored
throughout this process , and the plan was for a transesophageal
echocardiogram and DC cardioversion on 8/7/2006 for further
treatment of the atrial fibrillation. The patient's Coumadin was
continued in-house for a goal INR of between 2 to 3. To achieve
this goal , he was continued on his home regimen of Coumadin.
3. Insulin-Dependent Diabetes Mellitus: The patient was taken
off orally hypoglycemics in-house but continued on his home dose of
Lantus 24 units before bedtime as well as an insulin sliding
scale.
An addendum will be added to this summary by Dr. Shemeka Bogin
eScription document: 6-1857996 HFFocus
Dictated By: UNG , HORTENCIA
Attending: REISMAN , CATHIE MINDI
Dictation ID 2486333
D: 6/28/06
T: 7/7/06
Document id: 1170
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
Y |
U |
Y |
U |
U |
Y |
U |
- |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
- |
N |
- |
Y |
N |
Y |
N |
N |
N |
N |
460646645 | PUO | 16111280 | | 2487900 | 11/28/2007 12:00:00 a.m. | atypical chest pain , shoulder arthritis | | DIS | Admission Date: 2/24/2007 Report Status:
Discharge Date: 1/29/2007
****** FINAL DISCHARGE ORDERS ******
RAMSEYER , SHIRLEY C 154-60-54-3
Ey Hunt O
Service: MED
DISCHARGE PATIENT ON: 1/16/07 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HEIDELBERG , AMIE SALLY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours
Starting Today ( 6/14 )
as needed Pain , Headache , Other:shoulder pain
NORVASC ( AMLODIPINE ) 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/9/07 by EARLES , SHONNA A , MD on order for NORVASC orally ( ref # 134640268 )
patient has a PROBABLE allergy to DILTIAZEM ; reaction is gerd.
Reason for override: takes at home
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
GLYBURIDE 10 MG orally DAILY Starting Today ( 6/14 )
HYDROCHLOROTHIAZIDE 25 MG orally DAILY
IBUPROFEN 200 MG orally every 12 hours as needed Other:shoulder pain
Food/Drug Interaction Instruction Take with food
LABETALOL HCL 200 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
LISINOPRIL 40 MG orally DAILY
Alert overridden: Override added on 1/16/07 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
METFORMIN 1 , 000 MG orally DAILY Starting Today ( 6/14 )
SIMETHICONE 80 MG orally four times a day as needed Upset Stomach
ZOCOR ( SIMVASTATIN ) 20 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 2/9/07 by EARLES , SHONNA A , MD POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: on Monday , Wed , Friday , Sat , Sun
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 2/9/07 by EARLES , SHONNA A , MD on order for ZOCOR orally ( ref # 256633254 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
PREVACID ( LANSOPRAZOLE ) 30 MG orally twice a day
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: on Tues and Thurs
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 2/9/07 by EARLES , SHONNA A , MD on order for ZOCOR orally ( ref # 256633254 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Loudin ( 655-882-1064 ) 6/11 3:20pm scheduled ,
Arrange INR to be drawn on 5/21/07 with f/u INR's to be drawn every
7 days. INR's will be followed by Dr. Loudin
ALLERGY: MAXZIDE , TRIAMTERENE , CODEINE , DILTIAZEM
ADMIT DIAGNOSIS:
atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain , shoulder arthritis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
PE HTN IDDM history of TAH cystocoele
chronic abd pain , workup - atypical chest pain
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
5/28/07 Cardiac PET without perfusion abnormality , improved from prior
studies.
BRIEF RESUME OF HOSPITAL COURSE:
CC: R sided CP/shoulder pain
---
HPI: 70W c history of non-obs CAD on cath 10/5 , atypical CP , HTN p/with R-sided
CP/ shoulder pain x 3d. No SOb. Distant hx PE. Neg CTA in ED , biomarkers
neg and ECG unchged from prior. Admitted for risk stratification given
repeated admits for atypical CP.
---
STATUS on discharge: T99.7 HR72 BP 130/70 100%
RA R shoulder pain incr c mvmt/palp
---
STUDIES/PROC: 8/27 CTA neg for PE
8/26 Cardiac PET without perfusion abnormality , improved from prior
studies.
---
CONSULTS:
---
A/P: 1 ) CV I: Neg biomarkers and ECGs x 3 , given repeat
admits for atypical CP and history of known nonobs CAD 1 year obtained cardiac
PET on 5/28/07 , negative for reversible ischemia. P: HTN at BL , on home
regimen of BB , ACEI , norvasc R: On tele - no events.
-
2 ) Shoulder pain: Has known arthritic changes of before meals joint on CXRs. Did
not like oxycodone and has many medication intolerances. Will send out on
Tylenol , very low dose ibuprofen ( 200 twice a day ).
-
3 ) DM: Hypoglycemic in ED but improved quickly , may need titration of
orally hypoglycemics as outpt. Had decreased pos on admit 2/2 pain.
-
4 ) history of PE with IVC filter: On coumadin
ADDITIONAL COMMENTS: During this admission we evaluated your heart to make sure that it
was not the cause of your pain. In fact , your studies were improved from
your previous studies of yoru heart. It seems that your pain is likely
more due to your shoulder arthritis since the heart study we
performed was negative for blood flow problems to the heart. When you
have shoulder pain , you should try heat to the painful area ( or ice if
that helps more ) as well as Tylenol. You may also try ibuprofen in small
doses. Ibuprofen ( also known as Advil or Motrin ) is available in generic
form in your drugstore. It is not good for your stomach or your kidneys
so you should take only a very small amount as detailed in your discharge
summary. Because you had low blood sugar on admission to the hospital
we would like for you to take your diabetes pills only once a day
instead of twice a day until Dr. Loudin tells you differently. Your
medications are otherwise unchanged from your medications prior to your
admission. If you have weakness , shortness of breath , or
any other concerning symptoms you should seek medical attention
immediately.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Adjust pain medications for shoulder pain
2. Referral for physical therapy
3. Adjustment of orally hypoglycemics if FSBGs are high - orally agents have
been reduced to once daily as patient was hypoglycemic on admission
No dictated summary
ENTERED BY: MENIETTO , WYATT M. , M.D. ( SA88 ) 1/16/07 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1171
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094033690 | PUO | 03092837 | | 1959508 | 7/11/2005 12:00:00 a.m. | liver hematoma history of liver biopsy | | DIS | Admission Date: 8/8/2005 Report Status:
Discharge Date: 1/11/2005
****** FINAL DISCHARGE ORDERS ******
ZITA , ELENORA S 988-08-24-1
Ey Vu Irv
Service: MED
DISCHARGE PATIENT ON: 11/7/05 AT 06:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CRANFORD , JULIAN H. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
PROZAC ( FLUOXETINE HCL ) 80 MG orally every day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 75 MCG orally every day
OXYCODONE 5 MG orally every 4 hours as needed Pain
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
METFORMIN 500 MG orally every day
CELEBREX ( CELECOXIB ) 200 MG orally every day
Food/Drug Interaction Instruction Take with food
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 11/7/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware
DIET: No Restrictions
ACTIVITY: as tolerated
FOLLOW UP APPOINTMENT( S ):
Julian Cranford ( primary care physician ) please call to schedule ,
Germaine Blackgoat ( GI ) please call to schedule ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
liver hematoma history of liver biopsy
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
liver hematoma history of liver biopsy
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
adrenal adenoma , morbid obesity , OA , HTN , DM , AS , lung sarcoidosis , OCD
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
HPI:
66F with obesity , HTN , DM , aortic stenosis and history of abnormal LFTs
evaluated Dr. Germaine Blackgoat , for which differential has included NASH ,
hypothyroidism , drug ( avandia? , less likely ACE or lipitor ). She
underwent an U/S guided liver bx 6/26 performed by IR. After the
procedure , she had documented hypotension with a presyncopal episode.
Immediate CT showed hematoma around her R and L liver lobes and some
peritoneal blood superior to spleen but noretroperitoneal blood. She was
sent to the ED for evaluation. Her BP normalized with NS , and she was
never tachycardic. Serial hematocrtis were 35.1 , 32.8 and 29.8. She
was not transfused. A repeat CT showed stable hematoma with
peripancreatitc stranding , and she was admitted for further observation.
After the procedure she complained of RUQ and periumbilical pain. She
currently denies pain and expresses interest in eating. Denies N/V.
=====
PMH: adrenal adenoma , morbid obesity c/b OSA , OA c/b bilat THRs , R TKR ,
HTN , DM , AS ( valve are 1.4 cm in 10/7 ) , Lung sarcodosis , OCD , Melanoma
=====
PE: Vitals afeb , HR 93 , BP 102/60 , 20 , 98% RA , obese , Lungs CTA bilat , abd
NT ND soft , drsg from liver bx mid epig CDI , trace edema bilat
=====
HOSP COURSE:
The patient has had elevated LFTs of unknown etiology and had a liver
biopsy on 6/26 after which she developed a liver hematoma by CT with Hct
drop from 35 to 29.8 ( in the context of hydration for a pre-syncope
episode ). Repeat CT showed the hematoma was stable but also showed some
peri-pancreatic fat stranding somewhat concerning for pancreatitis by
needle aggravation ( since not significant amounts of blood were observed in
the retroperitoneal area ). Lipase and amylase were slightly elevated at 85
and 74 respectively , but she had no symtpoms of abd pain , nausea , vomiting.
Recheck of lipase and amylase within 12 hours showed stable or improved
values of 69 and 74 respectively. Her Hct was stable at 31.5 upon recheck.
She had peristent absence of abdominal pain and tolerated a full diet
without complications. Her anti-hypertensive meds ( HCTZ and ACE ) were
held due to SBPs in the 100s and should be continued as outpatient as
necessary per followup with primary care physician Prince Raugust Her ASA was also held and
should be restarted per Dr. Cranford as outpt.
ADDITIONAL COMMENTS: 1. Follow up apt with Germaine Blackgoat to get results of liver biopsy
2. Follow up apt with primary care physician Julian Cranford for restarting BP meds and ASA
3. Return to ED if you have any abdominal pain or rpt sx of
light-headedness , racing heart , SOB , sweating
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow up apt with Germaine Blackgoat to get results of liver biopsy
2. Follow up apt with primary care physician Julian Cranford for restarting BP meds and ASA
3. Return to ED if you have any abdominal pain or rpt sx of
light-headedness , racing heart , SOB , sweating
No dictated summary
ENTERED BY: SIMITIAN , FIDELIA M. , M.D. , PH.D. ( PR75 ) 11/7/05 @ 07
****** END OF DISCHARGE ORDERS ******
Document id: 1172
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CHF |
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DM |
Gs |
GER |
Gou |
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| output/system_intuitive_annotation.xml | intuitive |
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808692123 | PUO | 35816926 | | 8583932 | 10/21/2006 12:00:00 a.m. | r/o aCUTE CORORNARY SYNDROME | Signed | DIS | Admission Date: 10/21/2006 Report Status: Signed
Discharge Date: 4/10/2006
ATTENDING: NORSETH , ARDELLA M.D.
CODE STATUS: Full code.
The patient was admitted to the Renal Transplant PA Service.
ADMITTING DIAGNOSES:
1. Acute renal failure.
2. Congestive heart failure.
3. End-stage renal disease , status post renal transplant.
PRINCIPAL DISCHARGE DIAGNOSES:
1. Acute renal failure requiring dialysis initiation.
2. CHF -improved.
3. End-stage renal disease , status post failed renal transplant.
OTHER DIAGNOSES AND CONDITIONS AFFECTING TREATMENT OR STAY:
Hypertension , congestive heart failure , chronic renal
dysfunction , renal transplant , CVA and pulmonary hypertension.
OPERATIONS AND PROCEDURE: Not applicable.
OTHER TREATMENTS AND PROCEDURES: Initiation of dialysis , intravenous
diuretics.
BRIEF SUMMARY OF HOSPITAL COURSE:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Mr. Hollow is a 60-year-old male
with history of end-stage renal disease secondary to diabetes
mellitus , status post living related transplant September 2005
complicated by delayed graft function , severe ATN and CVA with
resultant hemiplegia , multiple reexplorations of transplant site
for wound infection , transplant artery stenosis , multiple renal
biopsies for delayed graft function , most recent on October of 2006
consistent with ATN. Mr. Hollow presented to the ER from Rehab
with worsening shortness of breath. Upon arrival , he was found
to have moderate bibasilar crackles , elevated BNP and bilateral
pedal edema. He was given Lasix 20 mg intravenous x2 , aspirin and nitro
paste. He denied any chest pain at that time and his troponin
was 0.17. His BP upon arrival to the ED was 195/86 , oxygen
saturation 96% on 5 liters. EKG showed no acute changes.
Creatinine upon admission was 3.6 and potassium 4.8. Mr. Hollow
has had several admissions over the past few months for several
complaints and congestive heart failure. He has been at a Rehab
Facility where he had been doing okay , although without much
improvement in functional status. He persistently complains of
pain over the coccyx area. He denied any fevers , cough , chest
pain or abdominal pain. He reports voiding regularly. The
patient denies any pruritus or metallic taste in his mouth.
Reports good appetite.
REVIEW OF SYSTEMS: As above , otherwise negative in detail.
PAST MEDICAL HISTORY: The patient has ESRD secondary to diabetes
type 2 , status post living related transplant 10/27/05 , CKD
baseline creatinine about 2.5 , history of CVA x3 including one
posttransplant resulting in dense left hemiplegia , congestive
heart failure. The patient had transthoracic echocardiogram in
February 2006 , ejection fraction 55% , LVH , mild tricuspid
regurgitation , has a history of hypertension , has a history of
lumbar fracture , status post fusion with a history of C. diff ,
history of lower GI bleed , which has been stable off Plavix ,
history of depression , anxiety , history of BPH with urinary
retention during the last hospitalization.
MEDICATIONS: On admission include CellCept 500 mg orally twice a day ,
Decadron 1 mg orally daily , Bactrim one tab orally every other day ,
aspirin 81 mg orally daily , torsemide 50 mg orally twice a day ,
hydralazine 25 mg orally three times a day , labetolol 400 mg orally twice a day ,
Aranesp 40 mcg subcutaneously every week , iron 324 mg orally twice a day , NPH 10
units subcutaneously every day before noon , Aspart sliding scale before every meal and at bedtime ,
Neurontin 300 mg orally three times a day , Remeron 30 mg orally at bedtime ,
trazodone 50 mg orally at bedtime , Flomax 0.4 mg orally daily , Xanax
0.25 mg orally at bedtime , Percocet 5/325 mg every 6 hours as needed pain ,
heparin 5000 units subcutaneously twice a day , Nexium 40 mg orally daily , Colace
100 mg orally twice a day , lactulose 30 mg orally every day before noon
PHYSICAL EXAM ON ADMISSION: Temperature 97.2 , pulse 61 , BP
172/80 , respirations 20 , O2 sat 98% on 5 liters. Generally , the
patient is a well-developed , obese white male in moderate
distress. HEENT , normocephalic , EOMI. PERRLA. No
lymphadenopathy. No jugular venous distention. Oropharynx
clear. Lungs with bibasilar rales. Heart , regular rate and
rhythm. S1 , split S2. Abdomen , soft , nontender and mildly
distended , normoactive bowel sounds , allograft nontender.
Musculoskeletal , 1+ edema in the lower extremities bilaterally ,
stage 2 coccyx decubitus ulcer. Neuro , alert and oriented x3.
No tremor. Mood okay.
HOSPITAL COURSE:
Renal: Creatinine elevated to 4.0. The patient exhibiting
uremic symptoms. The patient was started on dialysis on 9/12/06
to improve his uremic symptoms as well as his volume overload
status and CHF. He has a left upper extremity AV fistula for
access , which is functioning well.
Immunosuppression: The patient's CellCept was decreased to 250
mg twice a day secondary to graft failure and initiation of dialysis.
Cardiovascular: The patient was admiited with congestive heart failure ,
hypovolemia. BP has been fairly well controlled. Volume
status- the patient is euvolemic , status post dialysis. The
patient will continue on torsemide 100 mg orally twice a day and
metolazone 10 mg daily.
Musculoskeletal: The patient should be using an air mattress to
alleviate pressure sores. His fentanyl patch 0.25 mcg every 72
hours and oxycodone 5 mg orally every 6 hours as needed for breakthrough
pain. His pain is well controlled on this regimen. Please hold
both for sedation.
Fluid and Electrolytes: The patient is on a 1 liter fluid
restriction , strict Is and Os , daily weight , renal diet.
Psych: The patient is on trazodone , Remeron , Xanax and Zyprexa
as needed 2.5 mg as needed agitation. Hold if sedated. Mr. Hollow was
discharged home in stable condition with VNA Services today.
ADDITIONAL COMMENTS: The patient was instructed to call the
Renal Transplant Nursing Line at 511-204-6794 if he had any
questions or concerns. He was also instructed if it was an
emergency during the night or in the weekend to have the renal
fellow on-call paged. He was also instructed to return to the
hospital if he developed any worsening shortness of breath , chest
pain , fever or abdominal pain.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg orally daily.
2. Xanax 0.25 mg orally at bedtime.
3. Calcium acetate 667 mg orally before every meal Instructions to be given
with meals.
4. Decadron 1 mg orally daily.
5. Colace 100 mg orally twice a day
6. Nexium 40 mg orally daily.
7. Fentanyl 25 mcg transdermal , every 72 hours
8. Neurontin 100 mg orally daily.
9. NovoLog sliding scale before every meal and at bedtime.
10. Insulin NPH Human 10 units subcutaneously every day before noon
11. Labetalol 50 mg orally twice a day
12. Metolazone 10 mg orally daily.
13. Miconazole nitrate 2% powder topical twice a day
14. Remeron 30 mg orally at bedtime.
15. CellCept 250 mg orally twice a day
16. Nephrocaps one tab orally daily.
17. Zyprexa 2.5 mg orally every 12 hours as needed agitation.
18. Oxycodone 5 mg orally at bedtime. as needed pain , hold if the
patient sedated.
19. Flomax 0.4 mg orally daily.
20. Torsemide 100 mg orally twice a day
21. Trazodone 50 mg orally at bedtime.
22. Bactrim single strength one tab orally every other day.
eScription document: 6-4573036 CSSten Tel
Dictated By: REIDHERD , CAROYLN
Attending: NORSETH , ARDELLA
Dictation ID 7863126
D: 8/4/06
T: 8/4/06
Document id: 1173
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
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472510821 | PUO | 58706198 | | 100237 | 10/29/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/20/1995 Report Status: Signed
Discharge Date: 6/10/1995
HISTORY OF PRESENT ILLNESS: Ms. Huertes is a 62 year old woman with
cardiac risk factors including
hypertension , diabetes mellitus , postmenopausal , who presents with
exertional angina x four months. On the day prior to admission ,
she had a nondiagnostic exercise tolerance test , and was admitted
for cardiac catheterization on March , 1995. Upon further
questioning when the patient presented for catheterization , it was
found that she had a previous allergic reaction to intravenous
contrast dye that caused laryngeal edema. For that reason , the
patient was admitted for premedication overnight prior to
catheterization.
The patient , again , is a 62 year old , and is a patient of Dr.
Castillanos , with multiple cardiac risk factors including hypertension ,
diabetes , elevated cholesterol , a positive family history , and
being a postmenopausal woman. She first noted exertional
substernal chest pain about four months prior to admission. The
pain radiates to her left arm , and is associated with shortness of
breath , but no diaphoresis or nausea or vomiting. The pain is
relieved by rest within two minutes , or by a sublingual
Nitroglycerin , which she has used in the past week x two. Her
exercise tolerance is limited by this pain , and is diminished to
+/- 50 yards on the flat surface at present. The patient had one
episode of pain at rest three nights prior to admission. She
denies shortness of breath , orthopnea , paroxysmal nocturnal
dyspnea.
She was admitted for rule out myocardial infarction on August ,
1995 , and ruled out by enzymes and electrocardiogram. She had an
echocardiogram done which revealed an ejection fraction of 60
percent , with no regional wall motion abnormalities. She had 2+
mitral regurgitation , 1+ aortic regurgitation , and 1+ tricuspid
regurgitation. The day prior to admission , she underwent an
exercise tolerance test. She went two minutes on standard Bruce
protocol , stopped secondary to diaphoresis and shortness of breath
without chest pain , and she had nondiagnostic electrocardiogram
changes. The patient was admitted for premedication for her dye
allergy and subsequently catheterization.
PAST MEDICAL HISTORY: Her past medical history is significant for:
1. Hypertension.
2. Diabetes.
3. Hypercholesterolemia.
4. She has a history of a deep venous thrombosis in 1994.
5. She has chronic renal insufficiency , with a GFR of 48 , and the
twenty-four hour urine shows 3.8 grams of protein.
6. She is status post cholecystectomy.
7. She has vitiligo.
MEDICATIONS ON ADMISSION: 1. Aspirin every day
2. Enalapril 20 mg twice a day
3. Cardizem 300 mg every day
4. Insulin mixed 70/30 with 60 units in the morning and 30 in the
evening.
5. Atenolol 50 mg every day
ALLERGIES: Her allergies include contrast dye which gives her a
rash and laryngeal edema , Penicillin which gives her
edema.
SOCIAL HISTORY: The patient lives alone , but has two very
supportive daughters. She has no smoking or
alcohol history.
FAMILY HISTORY: Her family history is significant for brothers who
had myocardial infarctions in their 50's and 60's ,
and a mother who had a myocardial infarction when she was 69.
PHYSICAL EXAMINATION: On examination , this is a very pleasant
Pitster woman , who speaks predominantly
irish , who is in no acute distress. Her vital signs were a
temperature of 98.6 , heart rate 71 , blood pressure 168/70 ,
respiratory rate 18. The remainder of her examination was
significant for flat jugular venous pressure , but questionable
bruit in the left carotid. Cardiac examination was significant for
a normal S1 and S2 , with an S3 noted , no murmur. Her extremities
showed trace edema bilaterally , 2+ pulse in the left femoral , no
pulses palpated on the right , and 1+ dorsalis pedis pulses.
LABORATORY DATA: Her labs are significant for a creatinine of 1.7 ,
an elevated cholesterol at 294. Her urine showed
3+ protein , 1+ glucose. Her electrocardiogram was normal sinus
rhythm at 78 , with normal axis and interval , and lateral V4 through
V6 T wave flattening.
HOSPITAL COURSE: The patient was catheterized on March ,
1995 , with results showing proximal left anterior
descending stenosis of 50 percent , mid left anterior descending
stenosis of 70 percent. The distal left anterior descending was
diffusely diseased , and her first diagonal showed a discrete
stenosis of 80 percent. On the right , she had in the proximal
right coronary artery a discrete lesion of 50 percent , and in the
mid right coronary artery diffusely diseased at 50 percent. The
patient underwent successful balloon angioplasty of the mid left
anterior descending artery stenosis from 70 percent to 10 percent.
The patient's post catheterization course was complicated by a loss
of 150 cc of blood after her right groin sheath was removed , but
the bleeding was stopped after 90 minutes of compression. Her
hematocrit on admission was 35.9 , which dropped to 30.1 after the
sheath removal , but remained stable and she was discharged with a
hematocrit of 30.8. The patient also had one mild occurrence of
chest pain post catheterization which was relieved with two
sublinguals , and showed no electrocardiogram changes.
Upon discharge , the patient was noted to have elevated liver
function tests , with an ALT going from 16 to 156 , an AST going from
16 to 65 , an alkaline phosphatase going from 87 to 171. The
patient's primary medical doctor , Dr. Castillanos , was notified and
agreed to workup the elevated liver function tests. The patient
was discharged on her admitting medications.
DISCHARGE MEDICATIONS: 1. Aspirin 325 mg every day
2. Enalapril 20 mg twice a day
3. Cardizem 300 mg every day
4. Atenolol 50 mg twice a day
5. Additionally , she was started on Simvastatin 10 mg every bedtime
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
FOLLOW-UP: The patient was discharged with a scheduled appointment
the day after discharge with Dr. Comparoni
Dictated By: FLORETTA THRONEBURG , TFD
Attending: SHAVONNE MAINER , M.D. QP3
EQ969/8783
Batch: 45292 Index No. Y7XRR4724C D: 1/17/95
T: 1/17/95
Document id: 1174
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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354507117 | PUO | 63517168 | | 0884792 | 8/1/2006 12:00:00 a.m. | HAND CELLULITIS | Signed | DIS | Admission Date: 5/22/2006 Report Status: Signed
Discharge Date: 3/6/2006
ATTENDING: PRAZAK , ELINORE HYMAN MD
PRINCIPAL DIAGNOSIS: Cellulitis.
LIST OF PROBLEMS/DIAGNOSES:
1. Inflammatory breast cancer.
2. Type II diabetes.
3. Hypertension.
4. Hypercholesterolemia.
5. CHF with preserved systolic function.
6. Obstructive sleep apnea.
7. Asthma.
8. Spinal stenosis with herniated discs.
BRIEF HISTORY OF PRESENT ILLNESS: Ms. Holecek is a 72-year-old
female with newly diagnosed ductal carcinoma and inflammatory
breast cancer of the left breast with a mass in the lung that is
suggestive of likely stage intravenous disease who has also multiple other
medical problem including diabetes , who presents with a two-day
history of right and left finger warmth , tenderness and swelling.
The patient is undergoing chemotherapy with Adriamycin and
cytoxan and is status post cycle 2 on 9/6/06 and began to
feel like she was recovering from her chemotherapy approximately
three days prior to admission. A spinal MRI obtained on Tuesday
to evaluate her spinal stenosis was uneventful but later on that
day the patient developed redness on the dorsum of her right hand
in the area in which her intravenous was placed per the MRI. The
following morning the patient had a pustular lesion on the fourth
digit of her right hand distal to the dorsal redness and went to
LMC Urgent Care where she received one dose of ceftriaxone and
was given a orally script for Augmentin. She was sent home but at
home she developed expulsive diarrhea and vomiting on that
evening , was not able to tolerate her orally antibiotics. The next
day she noticed a similar lesion on the fourth digit of her left
hand looking much like that on the right hand. She returned to
the LMC urgent care for one more dose of ceftriaxone and was
then admitted to the hospital for intravenous antibiotics. The patient
denies any cat bites , travel , soil or water contract. She has no
bruises , scrapes or previous lesions.
PAST MEDICAL HISTORY: As detailed above.
MEDICINES:
1. Lantus 40 units nightly.
2. Aspirin 81 mg daily.
3. Lipitor 40 mg daily.
4. Zestril 2.5 mg daily.
5. Cardizem ER 240 mg daily.
6. Lasix 20 mg daily.
7. Procrit 40000 units weekly.
8. Pamidronate.
9. Dexamethasone with chemotherapy.
10. before meals chemo.
11. Neulasta.
12. Ativan as needed
13. Multivitamin.
14. Iron sulfate.
15. Isosorbide dinitrate 10 mg three times a day
11. Allegra 60 , 000 mg twice a day
ALLERGIES:
1. Percodan.
2. Halothane causing fevers.
3. Atenolol causing sweating.
4. Sulfa causes a rash.
SOCIAL HISTORY: The patient lives alone in Tolestarocheron Wa She has a
very sad social history in which her husband is a Li Rich Ni war
veteran and came back to the Trawa St. , North Ra Sta and was service
connected with the inalp preswo hospital psychiatric
disturbances following his tour of duty. She has had three sons ,
two twins who died earlier in life of some unspecified heart
illness and a third son who died at the age of 21 after a long
hospital stay with clear cell sarcoma of bone. She lives alone
in a second floor walkup in Alabama near Te Et Hou She
has a distant history of tobacco 50 years ago. She rarely drinks
alcohol. Her friend and healthcare proxy is Robena Chuppa , and
the phone # 342-749-8201.
FAMILY HISTORY: There is no history of breast cancer. Mother
had colon cancer. Three aunts and maternal grandmother also had
colon cancer. Her son had a clear cell sarcoma of bone.
REVIEW OF SYSTEMS: Positive for nausea , vomiting , diarrhea ,
lightheadedness and dizziness associated with her chemo but she
denies fevers , chills , sweats in the past 72 to 96 hours prior to
admission. She did have chest pain on 3/28/06 two days after
her chemo but none since and in the time leading up to her
hospitalization.
ADMISISON PHYSICAL EXAM: Temperature was 98.9 , pulse 98 , blood
pressure 132/55 , respiratory rate 16 , 95% on room air. The
patient's physical exam was significant for alopecia and obesity.
She was in no acute distress , alert and oriented. Her pupils
were equal , round and reactive. Conjunctivae were pink. She was
anicteric and her oropharynx was clear. JVP was hard to assess
due to neck fullness and she wears hearing aids. The lungs were
clear to auscultation except for decreased breath sounds with
crackles at the left base. Cardiovascular exam was regular rate
and rhythm with a normal S1 , S2 and no murmur , rubs or gallops.
Abdomen was soft and benign. Extremities had trace to 1+ edema.
The patient had an approximately 4 x 2 cm area of redness but no
swelling , positive warmth and positive tenderness on the dorsal
surface of her right hand. She had a pustular lesion on her left
fourth digit and right third digit that had been I&D in LMC
Urgent Care.
LABORATORY DATA: Labs are significant for creatinine of 1 , white
blood cell count of 4.33 , hematocrit of 25.5 and platelets of
108. EKG showed a normal sinus rhythm with a leftward axis and
first degree AV block. Chest x-ray was unremarkable.
HOSPITAL COURSE BY PROBLEM: This is a 72-year-old woman with
stage III or stage intravenous breast cancer who now presents with
paronychia and possible cellulitis of her right and left hands.
Infectious Disease: The patient was initially started on intravenous
vancomycin given the proximity of her recent chemotherapy. Her
finger lesions and dorsal right hand lesions began to heal within
two days of her admission. She underwent incision and drainage
of her left hand's pustular lesion with improved speed of healing
and decreased pain. After 48 hours in the hospital the patient's
vancomycin was switched to Keflex at which time the patient
developed a area of redness on her left forearm that measured
approximately 6 cm x 4 cm in area. The lesion was notable for an
erythematous base with punctuate red lesions that did not appear
to be blanching. At the same time , she developed a very similar
lesion on her right index finger between her MCP and PIP. The
patient was switched back to intravenous vancomycin and the Infectious
Disease consultants were called to assist with the management of
the patient's evolving lesions. A TTE was obtained that showed no
vegetations and serial blood cultures showed no bacteremia. The
Infectious Disease consultants suggested that the patient had
paronychia in her digits with transfer of bacterial infestation
due to skin breakdown in the area around her nails on her hands.
The concern for septic emboli for which the patient was initially
treated became less likely in the setting of the new lesions that
were not in distribution that has been consistent with septic
emboli. 48 hours later the patient was again switched from
vancomycin to Keflex and within 12 hours developed new
maculopapular rash on her right neck and furuncles on her left
and right outer labia that were exquisitely painful. The patient
was given one more dose of intravenous vancomycin and then resumed on
Keflex. Dermatologists were consulted to help determine whether
the patient was suffering from shingles and they deemed that she
was not and that her new rash was likely eczematous in nature and
topical steroid creams were prescribed. The new rash on the
right neck quickly resolved and the furuncles on her labia were
symptomatically managed with sitz bath three times daily in
addition to her orally cephalosporin antibiotic.
Throughout the course of evolving dermatologic findings that the
patient experienced and the pain associated with them the patient
had continued to have absolutely no systemic complications
associated with these lesions. In particular , she did not have
fever at all during the course of her hospitalization , she did
not have chills or sweats , she developed no new heart murmurs ,
and her blood cultures remained negative throughout the course.
The patient was started on intravenous acyclovir when her new rash
developed and on the day of discharge was switched over to
Valtrex 1000 mg three times a day for management of presumed HSV infection
though cultures remained pending at the time of discharge. The
patient will be discharged on Keflex and Valtrex to complete a
course of ten days on each.
Endocrine: The patient has a history of type II diabetes , was
placed on a weight based insulin regimen with good effect during
the course of her hospitalization. On discharge , she will resume
her Lantus 40 units nightly.
Cardiovascular: The patient has a history of diastolic
dysfunction with a clean cath in 2005. Her aspirin , statin ,
Zestril , Cardizem , Lasix and nitrates were continued during the
course of her hospitalization in the same way that she takes them
at home with very well controlled blood pressures and no issues
with her rhythm.
The patient has a history of obstructive sleep apnea but does not
use CPAP and do not have any difficulties with her oxygenation
even while sleeping.
Heme: The patient was initially anemic and thrombocytopenic on
admission. She received one unit of packed red blood cells and
her hematocrit remained stable through the duration of her
hospitalization.
Oncology: The patient has ductal carcinoma and inflammatory
breast cancer that is likely stage intravenous and she is status post
cycle 2 of 16 of neoadjuvant chemotherapy with Adriamycin and
cytoxan with a plan for surgical removal after her
chemotherapy.
DISPOSITION: The patient will be discharged to home with VNA
services and physical therapy at home.
DISCHARGE MEDICATIONS: Tylenol 650 mg orally every 4 hours as needed
headache , aspirin 81 mg daily , Lipitor 40 mg daily , bacitracin
topical to rash twice daily , Keflex 500 mg orally four times a day x5 days
starting on 2/8/06 to be completed on 9/23/06 , chlorhexidine
three packets daily washing area of rash , darbepoetin 100 mcg
subcutaneously weekly , diltiazem ER 240 mg daily , Colace 100 mg
twice daily , ferrous sulfate 300 mg daily , Allegra 60 mg twice
daily , Lasix 20 mg daily , hydrocortisone 2.5% cream topically
twice daily to rash , Dilaudid 2 to 4 mg orally every 4 hours as needed pain ,
Lantus 40 units subcutaneously every evening , isosorbide
dinitrate 10 mg three times daily , Zestril 2.5 mg daily , Ativan
0.5 mg twice daily as needed nausea , insomnia and anxiety , ocean
nasal spray two sprays nasally four times a day , multivitamin one
tab daily , Valtrex 1000 mg every 8 hours x21 doses , triamcinolone cream
topically once daily.
PHYSICIAN FOLLOWUP PLANS: The patient will call Dr. Prazak 's
clinic to make an appointment to follow up with her.
The patient is full code.
eScription document: 5-5146041 CSSten Tel
Dictated By: LANE , DELOIS
Attending: PRAZAK , ELINORE HYMAN
Dictation ID 1367657
D: 2/8/06
T: 2/8/06
Document id: 1175
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368722051 | PUO | 96863669 | | 9520165 | 10/11/2004 12:00:00 a.m. | MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/4/2004 Report Status: Signed
Discharge Date: 6/1/2004
ATTENDING: LEOLA MUSICH M.D.
HISTORY OF PRESENT ILLNESS:
This is a 46-year-old man with type 2 diabetes and a family
history significant for coronary artery disease including the
father who had an MI at the of 51 , was admitted to PUO on 9/17
with acute chest pain. The patient was seen at an outside
hospital at 4:30 p.m. on 1/15/04. He developed acute onset of
substernal chest pain while riding on a train home from Ank Ank
The pain radiated to both arms , left greater than right , jaw and
was associated with shortness of breath , nausea , and sweats. He
presented to the emergency room at the outside hospital and had
an EKG two hours later showing marked ST elevations in V2 and V3 ,
1 aVL and was reciprocal ST depressions inferiorly. The patient
was treated with aspirin , heparin , Plavix , and sublingual
nitroglycerin , Lopressor , Integrilin and was transferred to the
Pagham University Of for an emergent PCI.
PAST MEDICAL HISTORY:
Significant for type 2 diabetes controlled only with orally
hypoglycemics ( glyburide ) , anxiety.
MEDICATIONS ON ADMISSION:
Glyburide 10 mg orally every day
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
Of note , the patient recently with stress relating to his place
of work. The patient is expected a job interview on day of
admission to the hospital. The patient lives with his wife who
had an MI one year ago. The patient has no history of tobacco
with occasional alcohol one to two times a month , denies use of
street drugs.
PHYSICAL EXAM ON ADMISSION:
The patient was alert and oriented and in moderate amount of
distress secondary to anxiety following his cath. Vital Signs:
He had a temp of 100.2 , his blood pressure was 120/79 , and his
heart rate was 96 beats per minute. He was satting at 96% on 2 L
of nasal cannula. HEENT: His JVP was at 9 cm , he had 2+ carotids
without bruits. His extraocular motions were intact. His pupils
were equal , round , and reactive to light. His cardiac exam was
significant for regular rate and rhythm , S1 and S2 , and an S4.
There were no murmurs. His lungs had decreased breath sounds on
the lower right base with crackles about one-third of the way up
on that side. His left lung was clear. His abdomen was soft ,
nontender , and nondistended. Bowel sounds were present.
Extremities: He had 2+ pedal pulses. There was no pitting edema.
Skin: Noted to be hypopigmented , the patient has a history of
albinism. Of note , one additional comment about his HEENT exam ,
the patient is legally blind. He is able to see most objects at
about 6 or 7 feet away from him.
His chest x-ray showed a right middle opacification concerning
for an infiltrative pneumonia. His EKG on admission post cath
showed a rate of 98 , sinus rhythm , and ST elevations 2 mm in V2
through V3 and ST depressions in leads II , III , and aVF. Labs on
admission were significant for creatinine of 1.4 up from a
baseline of 1.2. His cardiac enzymes showed a CK of 178 and MB
of 3.7 and troponin of less than assay. His CBC was normal.
There was no left shift. His UA was significant for a specific
gravity of 1.086 , 1+ protein , 3+ glucose , 2+ ketones , 2+ blood ,
1-3 white blood cells , 2-4 red blood cells , and trace bacteria.
HOSPITAL COURSE BY SYSTEM:
1. CV: Ischemia. An emergent cath on admission on 2/18/04
showed two-vessel disease and 100% LAD , osteal lesion , and a 90%
marginal 1 lesion. The LAD was stented with a 3.5 x 8 mm and a
3.0 x 13 mm and a 3.0 x 18 mm Cipher stents all to 0%. The
marginal 1 was not stented during this cath. The patient's CK
peaked at 10 , 438 , and a CK-MB at 452 and his troponin at 721.
The patient was transferred to the CCU after his cath. He was
treated with aspirin , Plavix , Lopressor , captopril , Integrilin
x12 hours. The patient recovered well except for his heart rate
remained in tachycardiac at 90 to 110 range despite Lopressor
which was increased to 100 mg orally four times a day With the setting of
tachycardia , he developed ST elevation in 1 aVL with ST
depressions and 3 aVF in the evening of 3/7/04 , although his
cardiac enzymes continued to turn down. The patient underwent a
second cath on 8/12/04 , which showed that all his stents placed
in his LAD previously remained patent. The marginal 1 was
stented at this time with Cipher stent 0. The patient was doing
very well after his second procedure. His heart rate remained
slightly tachycardiac , the patient experienced no further EKG
changes.
2. Pump: The patient was on Lopressor and captopril , and his
blood pressure remained stable after his procedures. Echo on
2/10/04 showed an LVEF of 30% as well as akinesis of the mid
distal anterior wall felt in the entire apex. There was
hypokinesis of the basal anterior septum and the basal to mid
lateral wall with preserved function of the basal to mid inferior
and posterior wall. The apex is near aneurysmal. The patient
was put on heparin GTT given the risk of intraventricular
thrombus. The patient was started on Coumadin prior to
discharge.
3. Rhythm and rate: The patient remained mildly tachycardiac.
His Lopressor was titrated up to 100 mg four times a day for rate control
but no concerning arrhythmias were noted on telemetry. His sinus
tachycardia was thought to be secondary to a bacterial pneumonia.
4. Endocrine: The patient has type 2 diabetes. The hemoglobin
A1c was 10.57 demonstrating the patient's conservative treatment
was insufficient. He was started on NPH and insulin sliding
scale in the hospital. Metformin was started on 1/12/04 , and he
was restarted on Glucotrol before discharge. Diabetic teaching
was instituted.
5. Renal: Mucomyst was given before and after both of his
caths. His creatinine turned into his baseline of 1.2.
6. Heme: The patient was sent home on Coumadin given his
echocardiogram significant for near aneurysmal LV and a
hypokinetic apex. The patient will need to be followed in
Coumadin Clinic. Code status for this patient remained full
throughout his hospitalization.
7. Pulmonary: The patient was noted to be febrile and to have a
right middle lobe infiltrate on admission. The patient was
treated with five days of levofloxacin but remained febrile and
tachycardiac. The patient was started on azithromycin for a
total of five-day course. The patient defervesced after 24 hours
of being on azithromycin. Also of note , on a follow-up chest
x-ray prior to discharge , was read as the patient having a
question of a cavitating lesion in his right lobe. It was
recommended that this be followed up as an outpatient.
DISCHARGE MEDICATIONS:
The patient was discharged on following medications.
Enteric-coated aspirin 325 mg orally every day , Colace 100 mg orally
twice a day , nitroglycerin 1/150 one tab sublingual every 5 minutes x2
doses as needed for chest pain , azithromycin 500 mg orally every day x4
doses , simvastatin 40 mg orally every bedtime , metformin 500 mg orally
twice a day , Plavix 75 mg orally every day , Nexium 40 mg orally every day ,
lisinopril 50 mg orally every day , Toprol XL 200 mg orally every day , and
Coumadin 5 mg orally every afternoon
FOLLOW-UP APPOINTMENTS:
1. The patient was instructed to call his cardiologist and
primary care doctor , Dr. Peaks , within one to two days of
discharge. Dr. Peaks is expecting the patient's call.
2. The patient is scheduled to go to the Coumadin Clinic at the
Norap Valley Hospital within five days of discharge. Dr.
Luoma number of ( 310 ) 642-0134 was provided to the
patient and as well as the phone number for the Coumadin Clinic
at Norap Valley Hospital .
THINGS TO DO AT DISCHARGE:
1. Follow up with Dr. Peaks regarding a cardiac regimen.
2. Follow up with Dr. Peaks regarding your blood sugar
control and possibly being started on insulin.
3. Follow up with Dr. Peaks regarding the question of a
cavitating lesion on your chest x-ray prior to discharge.
4. The doctor to phone with questions is Dr. Loser
eScription document: 0-3422376 EMSSten Tel
Dictated By: MAGLIONE , KRISTIAN
Attending: MUSICH , LEOLA
Dictation ID 6199034
D: 3/6/04
T: 3/6/04
Document id: 1176
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508192805 | PUO | 59229315 | | 9021088 | 11/25/2003 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 6/2/2003 Report Status: Signed
Discharge Date: 7/30/2003
ATTENDING: GAYLENE GRACE FANIEL MD
The patient is in Cardiac Surgery Service.
INDICATIONS FOR SURGERY: The patient with three-vessel coronary
artery disease and question mitral regurgitation.
HISTORY OF PRESENT ILLNESS: A 54-year-old man with IDDM who had
been in his usual state of health , but on October , 2003 ,
noted to have difficulty breathing as well as nausea and
vomiting. The patient was taken to KAAH at that time. He started
to have peritoneal signs as well as ST elevations. The patient
underwent a diagnostic laparoscopy. The laparoscopy was
negative , although there was a question of mesenteric ischemia.
He underwent a cardiac catheterization , which had demonstrated
three-vessel disease. Of note , he was also noted to have right
iliac stenosis at that time. The patient's troponin peaked to
20.12 and an echo demonstrated EF of 54% with WMA , but a
significant LVH. ___ CABG at some time , but the patient unhappy
with the kit he was receiving and this was discontinued , and the
patient was discharged from the hospital , was doing well at home
this week until during an episode of eating he became short of
breath and felt like "I was drowning because of fluids in my
lungs." This episode was repeated on 10/26 and he reported to
Norap Valley Hospital . The patient was diuresed , placed on heparin ,
and transferred to PUO for further care.
Preoperative cardiac status: Myocardial infarction on 9/6/03 ,
hospitalized. Troponin 0.12. The patient does not have
symptomatic heart failure.
Previous cardiovascular interventions: None.
PAST MEDICAL HISTORY: Hypertension; peripheral vascular disease;
___; iliac stenosis , believed to be at the time of recent cath;
diabetes mellitus , on insulin therapy; hypercholesterolemia;
coronary artery disease; osteoarthritis; status post TKR and left
exploratory laparoscopy , negative , but question of mesenteric
ischemia.
PAST SURGICAL HISTORY: Status post TKR , status post exploratory
laparoscopy , negative.
FAMILY HISTORY: No family history of CAD.
SOCIAL HISTORY: A 20-pack-per-year cigarette smoking history at
present.
SOCIAL HISTORY: History of alcohol use.
ALLERGIES: NKDA.
MEDICATIONS: Lopressor 50 mg orally four times a day , captopril 25 mg orally
three times a day , nitroglycerin sublingual 0.04 , aspirin 325 mg orally every day ,
furosemide 40 mg intravenous every 2 hours , atorvastatin 20 mg orally every day , Colace
100 mg orally twice a day , Protonix 40 mg every day , folate , thiamine , and
multivitamins.
Of note , the patient was not on any home medications prior to
visit to OR.
PHYSICAL EXAMINATION: Height 5 feet 9 inches , weight 73.63 kg.
Vital Signs: Temperature 100.5 , heart rate 63 , blood pressure
155/85. HEENT: PERRLA. Dentition without evidence of infection ,
no carotid bruits , upper and lower dentures. Chest: No
incisions. Cardiovascular: Regular rate and rhythm and no
murmurs. Pulses: Carotid , radial , and femoral are bilaterally
2+ , dorsalis pedis and posterior tibial are bilaterally 1+.
Allen's test normal. Respiratory: Breath sounds are clear
bilaterally with mild crackles at the right base. Abdomen:
Laparoscopic incisions. Umbilical , midline , and right upper
quadrant: No evidence of infection. Soft and no masses. Rectal:
Deferred. Extremities: Mild scarring in bilateral lower LE ,
well-healed surgical site from previous left KR. Neurologic:
Alert and oriented , no focal deficits.
ADMISSION LABORATORY: Sodium 133 , potassium 4.1 , chloride 93 ,
bicarbonate 33 , BUN 1.3 , creatinine 1.4 , glucose 364 , magnesium
1.7 , WBC 12.68 , hematocrit 34.5 , hemoglobin 11.7 , platelets 410 ,
physical therapy 14 , INR 1 , PTT 39.9. Cardiac catheterization done on 1/22
showed 80% proximal RCA , 75% mid LAD , 95% ostial PDA. EF 54% on
outside echo. ECG on 9/6/03 , normal sinus rhythm , chest
benign , ST elevation in V2. Chest x-ray on 9/6/03 , bilateral
patchy fluffy infiltrates at TH .
DATE OF SURGERY: 3/29/03.
PROCEDURE: CABG x 2 ( SVG1 to OM1 , LIMA to LAD ).
BYPASS TIME: 89 minutes.
CROSS CLAMP TIME: 37 minutes.
Ventricular wire and chest tubes were inserted.
FINDINGS: Severe coronary artery disease. The left radial was
calcified and not usable.
COMPLICATIONS: None.
The patient was transferred to intensive care unit in stable
condition. The patient extubated and blood gases are
appropriate. The patient was transferred to the stepdown floor
on postoperative day #1. On postop day #2 , epicardial
ventricular pacing wires were removed without complications ,
chest tubes are too red to pull out. Chest tubes were removed on
4/8/03. Postpull chest x-ray showed small bilateral effusion ,
but no pneumothorax. Urinalysis and sputum were sent for the
trending up WBC and also started on Ancef for inferior aspect of
the sternal incisional drainage , which is minimal and
nonpurulent. On 11/21 , urinalysis and blood cultures came
negative and WBC also trending down. The patient ambulated well
and decided to sent home on 10/27/03 in stable condition.
DISCHARGE MEDICATIONS: Lasix 40 mg orally every day x 5 days , ECASA 325
mg orally every day , Colace 100 mg orally three times a day as needed constipation ,
Dilaudid 2 mg orally every 3-4h. as needed pain , NPH Humulin insulin 4
units in the morning and 4 units in the bedtime subcutaneously , Lopressor 50
mg orally four times a day , Niferex 150 mg orally twice a day , Theo-Dur 20 mEq x one
orally every day x 5 days , Keflex 500 mg orally four times a day x 7 days ,
atorvastatin 20 mg orally every bedtime
DISCHARGE FOLLOWUP APPOINTMENTS: Dr. Huitron , Phone number:
117-219-4079 , in 5 to 6 weeks , cardiologist in 1 to 2 weeks , and
Dr. Rickey Olivia , Phone number: 161-856-3442 , in 1 week.
eScription document: 5-1256166 ISSten Tel
CC: Gaylene Grace Faniel MD
DIVISION OF CARDIAC SURGERY
Gene
CC: , Primary Care Physician
Dictated By: ESPAILLAT , BOBBIE
Attending: HUITRON , SHERRY CATRICE
Dictation ID 7835913
D: 10/22/03
T: 10/22/03
Document id: 1177
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472709336 | PUO | 85841461 | | 9781705 | 1/2/2004 12:00:00 a.m. | Hypotension , NSTEMI | | DIS | Admission Date: 10/14/2004 Report Status:
Discharge Date: 10/5/2004
****** DISCHARGE ORDERS ******
MCCOO , JENNINE 122-63-50-9
Erworth Des Ro
Service: RNM
DISCHARGE PATIENT ON: 1/5/04 AT 11:15 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BUSSLER , FRAN , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ENALAPRIL MALEATE 10 MG orally twice a day
Instructions: hold on mornings of dialysis
Alert overridden: Override added on 2/9/04 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: following K , HD MWF
Previous Alert overridden Override added on 8/21/04 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: following k Previous Alert overridden
Override added on 10/21/04 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: home regimen , following k
Previous Alert overridden
Override added on 10/21/04 by BENADOM , ROMA C. , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to ACE INHIBITORS
Reason for override: home regimen , following k
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN )
2 UNITS every day before noon; 3 UNITS every afternoon subcutaneously 2 UNITS every day before noon 3 UNITS every afternoon
NTG 1/150 ( NITROGLYCERIN 1/150 ( 0.4 MG ) )
1 TAB sublingual Q5MIN X 3 as needed Chest Pain
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/21/04 by
BENADOM , ROMA C. , M.D.
on order for NEPHROCAPS orally ( ref # 95457240 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: home regimen
Previous override information:
Override added on 10/21/04 by BENADOM , ROMA C. , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to HMG CoA REDUCTASE
INHIBITORS Reason for override: md aware , home regimen
IMDUR ( ISOSORBIDE MONONIT.( SR ) ) 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
NEPHROCAPS ( NEPHRO-VIT RX ) 2 TAB orally every day
Alert overridden: Override added on 10/21/04 by
BENADOM , ROMA C. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: home regimen
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 200 MG orally every bedtime
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DIET: House / 2 gm Na / ADA 2100 cals/day / Low saturated fat
low cholesterol / Renal diet (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Mathew Stautz ( cardiology at Totin Hospital And Clinic ) 4:00pm 4/18/04 scheduled ,
Primary care physician 2 weeks ,
ALLERGY: Lisinopril , Zocor ( hmg coa reductase inhibitors )
ADMIT DIAGNOSIS:
hypotension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Hypotension , NSTEMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
1. NIDDM 2. AI/AS , bicuspid aortic valve , LVH 3. HTN 4. history of
thyroglossal duct cyst excision 5. history of
noncompliance with meds 6. 3 vessel cad ( coronary artery
disease ) 7. ESRD ON HD ( end stage renal disease ) 8. CHF , unclear
etiology ( congestive heart failure ) 9. hyperlipidemia
( hyperlipidemia ) 10. history of syphilis ( history of syphilis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Persantine and viability cardiac PET scan 4/18/04
BRIEF RESUME OF HOSPITAL COURSE:
erate global LV systolic dysfunction.
3. The results are essentially unchanged from his prior study
of February , 2003.
CC: Hypotension after dialysis
HPI: 56 year-old male with history of ESRD , CAD , CHF ( EF 20-25% ) admitted for
hypotension after HD. He was in his USOH until 2 days PTA when he
developed stomach upset , diarrhea , dry heaves , and a dry cough. He
denied recent travels , and had remote Abx use. At Ton Hospital ,
he had 5.5 liters removed and afterwards his BP was 66/30. 1 liter of
NS was given and his BP rose to 73/40.
ROS: Chronic PND , uses 1 pillow , gained 8kg in 2 weeks but compliant
with meds , no melena , no BRBPR
Physical Exam T 97 p85 BP 114/67->160/97 rr 16-24 89% RA
Chronically ill appearing , NAD
Neck: Supple
Chest: Bibasilar rales
CVS: palpable S3 , Lat displaced PMI , II/VI SEM at RUSB , JVP < 7cm
Abd: Soft NT ND , + BS , no HSM
Ext: Trace pedal edema , hyperpigmentation in sock distribution
Labs: WBC 5 , TnI 0.37 , CK 153 , CKMB8.2 ( chronically elevated cardiac
enzymes )
EKG: NSR , 1st deg AVB , LAE , LVH , old TWI in 1 , L , V5 , V6 , more pronounced
ST dep in V5 than 9/24
CXR: R pl effusion , CMG
Assessment: Hypotension after dialysis in setting of GI
upset/diarrhea/vomiting , likely was dehydrated. The BP rose after
fluids and his current hypoxia is likely from mild pulm edema.
Although chronically elevated cardiac enzymes , there is concern about
new ishemia , and concern for PE given hypoxia in ED.
Hospital course
1. CVS: Ischemia: NSTEMI: contined medical management with asa , beta
blocker , imdur , zocor , ntg as needed The CkMB peaked at 12 and Tni to 4. His
cardiologist ( Dr Stautz ) recommended PET scan to assess for viable
myocardium and ischemia. His last stress test 1 year ago showed only
scarring with no ischemia. In the past , patient's wife refused for him to go
for CABG. They are reconsidering this option currently.
The results of the PET scan are as follows:
- A small region of myocardial scar/hibernation along with mild
residual stress induced peri-infarct ischemia in the distal LAD
distribution.
- Moderate global LV systolic dysfunction.
- The results are essentially unchanged from his prior study of February ,
2003.
The family was called to stress the importance of follow up with
cardiology ( They have missed appointments in the past )
Pump: ( EF 20-25% ) , increased enalapril to 10mg twice a day , BNP was sent and
pending and echo revealed EF 30% , Mod AI.
Rhythm: no events occurred on telemetry
2. Pulm: monitored sats with fluid restriction. RA sats improved to
97%
3. Renal: HD MWF , home renal meds. He was dialyzed to a weight below
his previous baseline per cardiology recommendations. In the past he
has had elevated RH filling pressures after HD. The Lesum On- Community Hospital was
called by the attendting renal physician ( Dr. Bussler ) about his goal
weight.
4. ID: Blood cx were no growth
5. GI: He was continued on his home nexium
6. Proph: SQ heparin was used for DVT prophylaxis
ADDITIONAL COMMENTS: It is very important that you attend your follow up appointment with
the cardiologist , Dr Stautz
Please take the medications listed above and do not take enalapril on
mornings of dialysis
Please adhere to your dietary restrictions. If you gain more than 3 kg
between dialysis sessions please restrict your fluid intake. The diet
guidelines will be coordinated by the staff at Ton Hospital
DISCHARGE CONDITION: Stable
TO DO/PLAN:
see above
No dictated summary
ENTERED BY: BENADOM , ROMA C. , M.D. ( GE2 ) 1/5/04 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 1178
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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921778812 | PUO | 49448215 | | 7704181 | 11/22/2004 12:00:00 a.m. | pneumonia | | DIS | Admission Date: 5/21/2004 Report Status:
Discharge Date: 6/23/2004
****** DISCHARGE ORDERS ******
LIPPMAN , CRISTAL 772-64-47-0
Liet Ma
Service: MED
DISCHARGE PATIENT ON: 5/29/04 AT 05:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LACKNER , JEANNETTE M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
AMIODARONE 200 MG orally every day
Override Notice: Override added on 4/4/04 by
SHOUPE , ZOFIA C. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 75554464 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitioring
Previous override information:
Override added on 4/4/04 by SHOUPE , ZOFIA C. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 79098129 )
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitoring
Previous override information:
Override added on 4/4/04 by SHOUPE , ZOFIA C. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & AMIODARONE
HCL Reason for override: monitoring
GLIPIZIDE 2.5 MG orally every day
Alert overridden: Override added on 4/4/04 by
SHOUPE , ZOFIA C. , M.D. , PH.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates glyburide at home
Previous Alert overridden
Override added on 4/4/04 by SHOUPE , ZOFIA C. , M.D. , PH.D.
POSSIBLE ALLERGY ( OR SENSITIVITY ) to SULFA
Reason for override: tolerates at home
GUAIFENESIN 10 MILLILITERS orally every 6 hours Starting Today ( 3/28 )
as needed Other:cough
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: sbp<110 , call ho if holding
SARNA TOPICAL TP every day Instructions: to lower extremities
COUMADIN ( WARFARIN SODIUM ) 2.5 MG orally every other day
Starting Today ( 3/28 )
Instructions: alternating with 5mg every other day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/4/04 by
SHOUPE , ZOFIA C. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL & WARFARIN
Reason for override: monitoring
HYDROCORTISONE 1% -TOPICAL CREAM TP twice a day
Instructions: to R elbow eczema
LEVOFLOXACIN 250 MG orally every day Starting IN a.m. ( 5/7 )
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Override Notice: Override added on 4/4/04 by
SHOUPE , ZOFIA C. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 75554464 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: monitioring
Previous override information:
Override added on 4/4/04 by SHOUPE , ZOFIA C. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 79098129 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & WARFARIN
Reason for override: monitoring
Previous override information:
Override added on 4/4/04 by SHOUPE , ZOFIA C. , M.D. , PH.D.
on order for AMIODARONE orally ( ref # 50410952 )
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & AMIODARONE
HCL Reason for override: monitoring
NIZORAL 2% SHAMPOO ( KETOCONAZOLE 2% SHAMPOO )
TOPICAL TP tiweek
SYNALAR 0.025% CREAM ( FLUOCINOLONE 0.025% CREAM )
TOPICAL TP twice a day Instructions: `
apply below knees on both legs.
PLAQUENIL ( HYDROXYCHLOROQUINE ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Aspacio , Friday July 10:30AM scheduled ,
Arrange INR to be drawn on 9/2 with f/u INR's to be drawn every
3 days. INR's will be followed by Darin Jeffirs , 537-738-6908
ALLERGY: Sotalol , Procainamide , Aspirin , Penicillins , Sulfa ,
Quinaglute , Asa
ADMIT DIAGNOSIS:
pneumonia , transient ischemic attack vs exacerbation of underlying
neurologic deficits
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
pneumonia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN; CHF;history of St. Jude MVR for MS ( history of cardiac valve replacement ) Hx
AFib/flutter ( history of atrial fibrillation ) history of IMI ( history of myocardial
infarction ) NIDDM ( diabetes mellitus ) gout ( gout ) Hx DVT '70 ( history of
deep venous thrombosis ) history of appy ( history of appendectomy ) history of umbilical
hernia repair ( history of hernia repair ) history of sigmoidectomy for
diverticulitis history of L hip # '95 ( history of hip
fracture ) PE ( pulmonary embolism )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
Mrs. Lippman is an 81 year-old woman who presents with one day of
chest pain , difficulty speaking , nausea , and lightheadedness. She had
URI symptoms about two weeks ago and then 5d pta developed minimal
ly productive cough and then SOB for the past 2-3 days. She denies any
noctural dyspnea or increase in number of pillows. She lives alone ,
and a reverend checks up on her daily; the day prior to admission he
suggested she go to the hospital. She does not feel that she had any
speech difficulties at that time , but when she awoke she noted
heaviness of her tongue and workd finding difficulties. In addition , she
had sweating and chest pain that radiated to her shoulder ( L>R ) , and
back. This was different than her usual anginal symptoms ( which do not
involve back radiation ). The pain was pleuritic in nature , and she
denied palpitations. She also noticed nausea and had several episodes
of dry heaving. While leaving the bathroom she had a single episode of
"lightheadness." This did not involve any sensation of vertigo , or any
vision changes. She sat down immediately , and felt better within a few
seconds. There was no fall and no LOC. Around 8am , her housekeeper
came , and immediately noticed a change in Mrs. Lippman 's voice. Mrs.
Lippman describes the change as a "thickening of my tongue" and some
problems finding words. She has been taking all of her medications as
prescribed over the last week.
ROS: On arrival to the floor , Mrs. Lippman noted a raised , painful
area on her L forearm. She does not recall any trauma to the area. She
denies any fever.
PMedHx:
1. H/o agina ( a ) Echo ( 4/3 ) , EF 55% , abnormal septal motion , mild AR ,
no MR ( through mech valve ) , mod TR. ( b ) Holter 11/21 - multiform VE
( bigem , cooup ) , SVE's 1st degree A-V block.
2. D.M. AGA1c 6.1 ( 8/24 )
3. subacute thalamic stroke noted on CT 4/3
4. Afib - on coumadin
5. Mitral stenosis - MVR St Jude ( 11/6 )
6. CHF , admitted many times , latest 5/8
7. Restrictive lung disease- 3/16 PFTs FVC 1.33 , FEV1 0.98
8. Sigmoid colostomy
9. Ventral hernia repair.
10 Bladder calcifications on CT urogram ( 4/3 ) - needs cystoscopy.
11. HTN
12. RA
13. Recent eye hemorrhage.
Physical:
VS: T 98.9 P 103 , BP 160/74 , RR 20 , OxySat 97% 2L NC , FSG 172
Gen: soft voice , audible clicking sound , NAD
HEENT: PERRL , EOMI
Card: irregularly irregular , no S1 , mechanical S2 , II/VI early systolic
murmur , loudest at base of heart.
Pulm: reduced breath sounds at
dependant 1/3 b/l. No wheezes heard.
Abd: well healed midline scars. No bruits ascultated , +BS. Soft , NT ,
ND , no masses.
Integ: diffuse macular ( 5-10mm ) hyperpigmented rash distal to knees
b/l.
Ext: 2x3 cm raised tender area on L forearm , no skin changes. <3 s cap
refill L hand. Full ROM of left fingers ( with pain ). 2+ physical therapy pulses
b/l , 1+ DP pulses b/l. 2+ radial/ulnar pulses b/l
Neuro: A&O x 3 , attentive , cooperative. Naming intact , follows commands ,
repetition intact , fluent English CN 2-12: reactive pupils , Eomi ,
sensation intact throughout , hearing intact to finger rub , palate
elevates , tongue midline , full strength trap and SCM. Face symmetric
Motor: Strength: R arm: 5/5 Del/Bi/Tri , L arm 4/5 with giveway
character Del/Bi/Tri L leg 4-/5 HF 5/5 KE/PF/DF R leg 5/5
HF/KE/PF/DFTone: normalCoordination: FNF normal b/l , heel-shin R leg
normal , effort limited L leg.
Gait: not assessed.
Hospital course by system:
Neuro: Speech difficulties: resolved by the time patient was in ER , making
diagnosis difficult. Possible etiologies include TIA or illness
exacerbating deficits from old stroke. Head CT in ER showed old
infarcts , but no acute process. Patient did not have any speech
difficulties throughout admission or other neurologic findings.
CV: ischemia: No ST changes on EKG , one set of cardiac enzymes were
negative. Given low probability of ischemia , no further enzymes were
drawn. Pump: EF 55% , patient was normotensive even after d/c of
some of her home HTN meds ( see renal ). Rhythm: patient was on telemetry for
first day of admission , and alternated between sinus rhythm and afib.
Pulm: PNA: patient had left lower lobe opacity on CXR. Decision was made to
start antibiotics. patient had a positive d-dimer , but PE was very unlikely
in the setting of therapeutic anticoagulation. The patient has a
history of CHF , but had no signs of CHF on exam during this
hospitalizaiton although her cxr was read as mild pulmonary edema.
Renal: ARF: Creatine on admission was 1.8 , up from a baseline of
1.2-1.3. Given her history of poor orally intake and euvolemic to dry exam ,
this was thought likely due to prerenal hypovolemia. Her
lasix , lisinopril and colchicine were held , as they might contribute to
further ARF , and she got gentle ivf ( approximately 1L ) and her
creatinine improved. However , after restarting her medications her Cr
again bumped to 1.8. Her UA was unremarkable. She was d/c home off
lasix , lisinopril and colchicine with a Cr of 1.8 presuming that sh
e was still prerenal. The plan is for VNA to check her chem7 in 3days
days , results to go to Dr. Aspacio for monitoring and deciding when to
restart her medications.
MSK: patient developed the left forearm swelling and pain while in the hosp
for the first night. A radiograph was negative for fracture and it was
felt to be a small hematoma. The pain remitted with Tylenol. At
discharge the pain was a dull ache , and the swelling was reduced.
Heme: Anticoagulation. She was maintained on her home dose of INR was
maintained in a theraputic range. This will have to be closely
monitored as an outpatient while on levofloxacin. Her INR was 3 after 2
days of levofloxacin and will be checked again by VNA 3 days
after discharge , results to be followed by Darin Jeffirs
Endo: D.M. patient was switched from micronase to glipizide 2.5mg every day given
her worsening renal insufficiency. Fingersticks remained in acceptable
range ( 100-148 ) during admission.
Dispo: to home with close VNA followup ( daily ). patient will have weight
and BP checked every day She will have Chem-7 and INR drawn on Thursday and
Monday , and the results will be called to Dr. Aspacio ( KTDUOO ). She will
finish 6 more days of Levo ( total 10 ).
ADDITIONAL COMMENTS: If you develop a fever , become short of breath , have increasing left arm
pain , or any other symptoms that concern you , call your doctor.
The visiting nurse is an important followup to your
hospitalization. Your diabetes medication was changed to glipizide -stop
taking the micronase. Your lasix , lisinopril and colchicine have been
stopped , don't restart them until Dr. Aspacio tells you to restart. Your othe
medications are the same. Weigh yourself daily and if your weight increa
ses more than 2lbs in 2 days call Dr. Schoultz
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. VNA will check BP and weight every day Any BP > 140/90 or wt gain of 2
lbs in 2 days will be called to Dr. Aspacio ( KTDUOO 994-926-6262 )
2. Thursday ( 20 of September ) and Mon ( 1 of April ) VNA will draw a Chem-7 and INR
and call results to Dr. Aspacio ( KTDUOO ); INR should be communicated to Darin Jeffirs at 268-445-9819.
3. patient has followup appointment on 8 of September at 10:30am with
Dr. Schoultz 4. There are 6 more days of Levofloxacin course.
No dictated summary
ENTERED BY: SHOUPE , ZOFIA C. , M.D. , PH.D. ( YT478 ) 5/29/04 @ 05
****** END OF DISCHARGE ORDERS ******
Document id: 1179
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
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- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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402105256 | PUO | 89357151 | | 230818 | 3/18/1993 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 6/3/1993 Report Status: Unsigned
Discharge Date: 8/9/1993
DIAGNOSIS: CORONARY ARTERY DISEASE.
OPERATIONS/PROCEDURES: CORONARY ARTERY BYPASS GRAFTING ON
17 of October , BY DR. GOLDSBERRY ,
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old male with
crescendo angina. The patient has a
long history of coronary artery disease and suffered an anterior
septal myocardial infarction in 1989. The patient did well on
medical management , until recently when he has developed increasing
fatigue and angina with decreased exertion. The patient had an
exercise stress thallium test on 16 of June , which showed ST depression
in V5 after 6 minutes and 38 seconds. The thallium aspect of the
test showed apical inferior reperfusion defect. A cardiac
catheterization in 18 of June , showed a 60 to 80% lesion at the left
anterior descending , 60% lesion of the first diagonal and 50%
lesion of the circumflex , 100% lesion of the right coronary artery.
Inferiorly , the heart was noted to be akinetic with areas of
dyskinesis. The ejection fraction was 45%. PA pressures were
32/20 with a mean pulmonary capillary wedge pressure of 13 mm/HG.
The patient now presents with increasing angina , failing medical
therapy. The patient denied a history of paroxysmal nocturnal
dyspnea , orthopnea , pedal edema. PAST MEDICAL HISTORY included
insulin-dependent diabetes mellitus times 14 years , status post
cerebrovascular accident left parieto-occipital hemorrhagic infarct
without any cognitive residual defects. The patient has a seizure
disorder since then , controlled on phenobarbital. History also
included hypertension , bursitis. PAST SURGICAL HISTORY included
status post right knee surgery times 3 , status post patellar
fracture in 1958. ALLERGIES included Demerol , which produces
nausea and vomiting. MEDICATIONS ON ADMISSION were Cardizem-CD 240
milligrams by mouth each day , Isordil 40 milligrams by mouth 3
times a day , Lopressor 200 milligrams by mouth twice a day ,
enteric-coated aspirin 1 each day discontinued 10 days prior to
admission , phenobarbital 30 milligrams by mouth 3 times a day ,
humulin 70/30 - 36 units each morning. FAMILY HISTORY was
significant for myocardial infarction. HABITS included a
90-pack-year smoking history , discontinued in 1989. Alcohol use
was discontinued in 1991.
PHYSICAL EXAMINATION: The patient was a nervous , but pleasant
white male in no apparent distress. The
temperature was 97.7 , pulse 76 , respiratory rate 24 , blood pressure
136/84 , 98% room air saturation. Cardiac examination showed
regular rate and rhythm , normal S1 , S2 , without murmurs , gallops or
rubs. Neck was supple. Chest was clear to auscultation. Abdomen
was obese , soft , positive bowel sounds. Extremities showed pulses
intact bilaterally , no varicosities , no bruits.
HOSPITAL COURSE: The patient was admitted and underwent the usual
preoperative evaluation , and was taken to the
operating room on 17 of October , for 3-vessel coronary artery bypass
grafting by Dr. Warm The patient tolerated the procedure well ,
and initially recovered in the Cardiac Surgery Intensive Care Unit.
The patient was followed by the Cardiology Service as is routine.
The patient's lines and tubes were pulled in the usual fashion at
the appropriate times. The patient was stable and was transferred
to the Step-Down Cardiac Surgery Floor. Postoperatively , the
patient developed atrial fibrillation , which resolved
spontaneously. postoperatively , the lower sternal wound had a
small amount of serosanguineous drainage and a small amount of
erythema. The patient was given a course of intravenous Ancef.
The patient received a total of 5 days of intravenous Ancef. The
patient was discharged home on 6 of February , tolerating a regular diet
and ambulating without difficulty. The patient's wound had cleared
up and was free of erythema or drainage. The sternum was stable at
discharge.
DISPOSITION: The patient will be discharged to home. MEDICATIONS
ON DISCHARGE were Tylenol #3 as needed ,
enteric-coated aspirin 1 each day , Lopressor 25 milligrams by mouth
twice a day , phenobarbital 45 milligrams by mouth 3 times a day ,
humulin 70/30 usual preoperative dose. The patient will FOLLOW-UP
with his cardiologist in 1 to 2 weeks , and with Dr. Pittinger in 6
weeks.
Dictated By: GLYNIS M. VERBRIDGE , M.D. ND84
Attending: GAYLENE G. FANIEL , M.D. II8
KP935/3496
Batch: 8825 Index No. DQECPXBK8 D: 7/19/93
T: 9/4/93
Document id: 1180
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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744135337 | PUO | 95637816 | | 4633599 | 10/6/2003 12:00:00 a.m. | chf exacerbation | | DIS | Admission Date: 10/6/2003 Report Status:
Discharge Date: 2/2/2003
****** DISCHARGE ORDERS ******
STEWARDSON , TYRON D. 569-60-85-8
Ho
Service: CAR
DISCHARGE PATIENT ON: 8/24/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: SERVICE , QUINN STEPANIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
VITAMIN C ( ASCORBIC ACID ) 1 , 000 MG orally every day
PROPINE ( DIPIVEFRIN 0.1% ) 1 DROP each eye twice a day
FOLIC ACID 1 MG orally every day
LENTE INSULIN ( HUMAN ) ( INSULIN LENTE HUMAN )
100 UNITS subcutaneously every bedtime
SYNTHROID ( LEVOTHYROXINE SODIUM ) 200 MCG orally every day
ZAROXOLYN ( METOLAZONE ) 5 MG orally every day before noon
OXYCODONE 5 MG orally every 6 hours as needed Pain
Alert overridden: Override added on 3/16/03 by
VISVARDIS , JAYME TARSHA , M.D.
DEFINITE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
PHENANTHRENES
POSSIBLE ALLERGY ( OR SENSITIVITY ) to NARCOTICS ,
PHENANTHRENES Reason for override: md aware
VITAMIN B 6 ( PYRIDOXINE HCL ) 50 MG orally every day
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
Override Notice: Override added on 9/15/03 by MANGANELLI , ADELINA
on order for ZOCOR orally ( ref # 61203847 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware
HUMULIN 70/30 ( INSULIN 70/30 ( HUMAN ) ) 70 UNITS subcutaneously every day before noon
NEURONTIN ( GABAPENTIN ) 300 MG orally three times a day
TORSEMIDE 100 MG orally twice a day
TRUSOPT ( DORZOLAMIDE 2% ) 1 DROP each eye twice a day
Number of Doses Required ( approximate ): 30
FLONASE ( FLUTICASONE NASAL SPRAY ) 1-2 SPRAY inhaled twice a day
Number of Doses Required ( approximate ): 10
XALATAN ( LATANOPROST ) 1 DROP each eye every afternoon
Number of Doses Required ( approximate ): 10
ADVAIR DISKUS 100/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
Override Notice: Override added on 3/16/03 by VISVARDIS , JAYME TARSHA , M.D. on order for LEVAQUIN orally ( ref # 52440616 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: md aware
Previous override information:
Override added on 3/16/03 by MANGANELLI , ADELINA
on order for LEVOFLOXACIN orally ( ref # 42324056 )
POTENTIALLY SERIOUS INTERACTION: SALMETEROL XINAFOATE &
LEVOFLOXACIN Reason for override: will follow EKG
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
ALBUTEROL INHALER HFA 2 PUFF inhaled Q4-6H as needed Wheezing
REGULAR INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
54 UNITS subcutaneously every afternoon
TAMOXIFEN 20 MG orally bedtime
B12 ( CYANOCOBALAMIN ) 1 , 000 MCG orally every day before noon
REGULAR INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
2-50 UNITS subcutaneously every day before noon Instructions: per ladetend community hospital diabetes scale
KCL SLOW RELEASE 20 MEQ X 2 orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Desirae Marcott 3/3/03 at 11:00am scheduled ,
Dr. Service 2/1/03 at 15:40 scheduled ,
ALLERGY: Penicillins , Demerol , Macrodantin ( nitrofurantoin )
ADMIT DIAGNOSIS:
chf exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) dm ( diabetes mellitus ) atrial
fibrillation ( atrial fibrillation ) urinary tract infection ( urinary
tract infection )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
71F with extensive PMHs including CHF , diastolic
dysfxn ( EF 60% ) , AS , AFib , DM , CRI , OSA p/with progressive dyspnea , fatigue ,
periph edema , weight gain. Admitted 3wks ago with similar complaints -
was diuresed heavily with~8lb weight loss
and symptomatic relief. Post D/C , did well for a
few days , then started developing progressive DOE ,
fatigue , orthopnea , as well as weight gain
of ~8-10lbs. On admission , she could not walk more than few feet without
SOB. patient claimed that she was compliant with her medications and
practiced dietary
discretion. On day of present admission , patient presented with CHF flare ,
acute
on chronic RF. In ED , BP 87/45 , P 75 , 96%RA , afeb. EKG showed AF with
no ST-T changes , enz neg. HCT 30.7 , BUN 105 , Cr
2.4 ( baseline Cr
~2.0 ) PE: AOx3 , resp distress , JVP? , S1S2 ,
3/6 AS murmur , trace rales , abd? , 3+ pitting LE
edema. Impression: 71yo woman with CHF , AFib , AS , DM ,
CRI , with hx of recent CHF exacerbation now p/with with
vol overload , dyspnea , and renal failure. Etiology of CHF exacerbation
unclear:she r/o for MI , no worsening of her afib , no si/sx's of
infection ,
no hx to suggest dietary indiscretion , medical non-compliance , lack of
medications CV:Isch- no evidence of ischemia: patient r/o for MI with
negative enzymes. PUMP: patient was gently diuresed ~2L/day on Torsemide
100 intravenous three times a day x 4 days with excellent response and then switched to her
home diuretic regiment of 100 mg twice a day of orally torsemide and 5 mg orally
Zaroxolyn on the day prior to discharge still with good diuretic
effect. Her admission wt was 132.9KG and on day of discharge she
weighed 125.8kg: net total loss of 7.1 kg or 15.6 lbs per this admit.
During this admission , strict I/O's , daily weight. fluid
and salt restriction were maintained. She was not re-started on
Cozaar given BP's in low range with SBP:90;s. RHYTHM: chronic afib
with good rate
control without agent and no rate issues during this admission. patient is not
on coumadin given hx
of GI bleed. Pulm: patient was continued on her Advair disk , flonase , as needed
nebs. She was placed on CPAP @ night and did well with cpap;
arrangements were made for patient to have her CPAP at home changed to
hospital setting and equipment. HEME:1 )ANEMIA
patient was admitted with HCT of 30.7 , lower then her normal. She had 3
positive stool guiaic's , low normal Fe
studies , and stable HCT during this admission. Her ASA was stopped 2/2
concern for GIB. patient is scheduled to follow-up with her GI doctor , Dr. Sid Tavolieri 2 days after discharge.2 )THROMBOCYTOPENIA:patient had a drop in
platlets that was initially concerning , but ultimately appeared
to be lab variation with its resolution on the next blood
draw. RENAL:patient was admitted with acute
on chronic renal failure felt to be secondary to decreased CO. Her CRT
elevation gradually resolved from 2.4 on admission to 1.8 at time of
discharge. Her celebrex was stopped 2/2 ARF.
Proph: patient was placed on
Heparin 5000u subcutaneously twice a day for DVT prophylaxis and Nexium
40 GI:patient was noted to have elevated LFT's on admission labs. Her peak
LFT's were ALT:368 , AST: 274 , AP:158 with nl BILIT 0.5 and biliD
0.3. DDX included congestion vs infection vs medications. hepatitis
deemed unlikely but hep panel still pending at time of discharge.
Since patient's LFT's did not resolve with excellent diuresis , it was felt
that it was not likely due to congestion. Most likely etiology was felt
to be reaction to drug. patient was taken off the following hepatotoxic
meds: tylenol , statin , percocet , allopurinol. She was continued on her
tamoxifen , although case reports of hepatotoxicity noted; other
consideration included the neurontin , but lft's began to normalize on
medication. patient is scheduled to follow-up with GI , Dr. Himelfarb 2
days following discharge. FEN: patient's lytes were aggressively repleted;
she required significant K repletion each day and will be d/c'd on K.
She was maintained on a nasal and fluid restriction and placed on a
cardiac and diabetic diet. ( ENDO ): DM: patient was initially placed on RISS
given concern for hypogylcemia and her home regiment was gradually
added to her inpatient regiment with elevated FS.
patient was stable at time of discharge , sx's much improved , and scheduled f
or follow-up with cardiologist and CHF nurse on 8/28/03.
ADDITIONAL COMMENTS: 1 )please stop the following medications: tylenol , percocet , Zocor ,
cozaar , celebrex , allopurinol , aspirin
2 )follow-up on your liver enzyme elevations and guiaic positive stools
with Dr. Himelfarb
3 )if you have any worsening shortness of breath , fatigue , lower
extremity swelling , or any concerning symptoms , please call your doctor
immediately.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 )follow-up for LFT elevations: hepatitis panel still pending at d/c
2 )follow-up for guiaic( + )stool and Hct drop
3 )The following medications were stopped during this admission given
concern re: elevated LFT's , ARF , and guiaic + stools: tylenol ,
percocet , zocor , cozaar , celebrex , allopurinol , ASA.
No dictated summary
ENTERED BY: VISVARDIS , JAYME TARSHA , M.D. ( WL61 ) 8/24/03 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1181
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
698812086 | PUO | 12566492 | | 382885 | 4/7/2002 12:00:00 a.m. | chf | | DIS | Admission Date: 6/27/2002 Report Status:
Discharge Date: 1/9/2002
****** DISCHARGE ORDERS ******
PARDA , CRAIG N 175-19-82-4
T Dale , Maryland 25744
Service: MED
DISCHARGE PATIENT ON: 1/23/02 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: LEGORE , TERRY ROSETTE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
Override Notice: Override added on 10/9/02 by
LUNDEMO , LADY CELINDA , M.D.
on order for COUMADIN orally 3 MG every day ( ref # 55315357 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: noted Previous override information:
Override added on 5/27/02 by BOISER , ESTELL J. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: will watch
WELLBUTRIN ( BUPROPION HCL ) 75 MG orally twice a day
B12 ( CYANOCOBALAMIN ) 400 MCG orally every day
Number of Doses Required ( approximate ): 6
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day Starting IN a.m. on 9/29
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PYRIDOXINE HCL 25 MG orally every day
COUMADIN ( WARFARIN SODIUM ) 2 MG tonight; 4 MG every bedtime orally every day
2 MG tonight 4 MG every bedtime Starting Today ( 8/30 )
Instructions: take 2 mg tonight and then 4 mg every night
starting tomorrow night Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/9/02 by
LUNDEMO , LADY CELINDA , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: noted Previous override reason:
Override added on 5/27/02 by BOISER , ESTELL J. , M.D.
on order for ASA orally ( ref # 62189705 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ASPIRIN
Reason for override: will watch
Previous override information:
Override added on 5/27/02 by BOISER , ESTELL J. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: will watch
NORVASC ( AMLODIPINE ) 2.5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
RAMIPRIL 20 MG orally every day
Number of Doses Required ( approximate ): 6
COZAAR ( LOSARTAN ) 50 MG orally twice a day
Number of Doses Required ( approximate ): 2
PREMPRO 0.625MG/2.5 MG 1 TAB orally every day
Number of Doses Required ( approximate ): 6
HUMALOG ( INSULIN LISPRO ) 2 UNITS subcutaneously before meals
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously every afternoon
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
Alert overridden: Override added on 1/23/02 by :
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: following
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
Alert overridden: Override added on 1/23/02 by :
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & OMEPRAZOLE
Reason for override: following
RETURN TO WORK: IN 3 DAYS
FOLLOW UP APPOINTMENT( S ):
Dr. Lickiss in 1-2 wks ,
No Known Allergies
ADMIT DIAGNOSIS:
CHF
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chf
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
IDDM HTN CAD.history of IMI 1986 PERIPHERAL NEUROPATHY RETINOPATHY
NEPHROPATHY Mild CHF with ? pneumonia mitral insuff ( mitral
insufficiency ) history of cva 10/12 ( )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
55 year-old F with CAD , history of MI , DM , history of CVA 10/12 , CRF , admitted with 5 lb weight
gain and orthopnea/PND. patient has chronic CHF , with flares approximately
every 6 months. Her baseline weight is 130-135 lbs , and she follows
daily weights at home. Baseline exercise tolerance is 5 flights of
stairs. Over the past 5 days , she noticed increased weight ( 1 lb/d x
5d ) , slight incr. SOB , and some presacral edema. On night before
admission , she awoke from sleep SOB , and had to sleep sitting upright
for remainder of night. No clear dietary indiscretion; no immediately
recent med change , but has not been on ARB since stroke in order to
keep BP higher. On exam , afebrile , JVP 12 cm , lungs wet 1/2 way up
with dullness at both bases. CK , TnI negative x 3; TSH normal; Labs
notable for HCt of 30% ( baseline = 40% ). Diuresed 1L over first
night , goal diuresis an additional 1-2L on HD#2. Added back ARB 7/24
and plan to discharge home with slightly higher Lasix dose until
weight down to ~130lbs. Check INR Wed 3/3 with goal 2-3 and follow up
with Dr. Dansie
ADDITIONAL COMMENTS: Blood draw for INR check Wednesday and call results in to Dr. Lickiss
for Coumadin adjustment. Follow daily weights.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
INR check 3/3
Follow weights
No dictated summary
ENTERED BY: HAUB , PERRY , M.D. ( YY19 ) 1/23/02 @ 10
****** END OF DISCHARGE ORDERS ******
Document id: 1182
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
N |
N |
Y |
N |
N |
N |
Y |
- |
N |
N |
N |
N |
N |
N |
434124582 | PUO | 57838278 | | 440395 | 1/27/2002 12:00:00 a.m. | Stent stenoses , episodes of asymptomatic afib , aflutter , and atrial tachycardia with RVR | | DIS | Admission Date: 2/8/2002 Report Status:
Discharge Date: 10/12/2002
****** DISCHARGE ORDERS ******
TRAPPER , VANIA 514-98-22-2
Sas
Service: CAR
DISCHARGE PATIENT ON: 9/14/02 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: RAABE , SUNSHINE DANA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 4/3/02 by
EVERLETH , ROSEMARY F.
on order for COUMADIN orally ( ref # 14284431 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: Will monitor physical therapy.
MIACALCIN ( CALCITONIN-SALMON ) 1 SPRAY nasal every other day
Number of Doses Required ( approximate ): 10
CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) 1 , 250 MG orally three times a day
GUAIFENESIN 10 MILLILITERS orally every 4 hours as needed cough
LOPRESSOR ( METOPROLOL TARTRATE ) 75 MG orally three times a day
HOLD IF: HR<50 , SBP<95 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 9/14/02 by
RUMAN , RUBIE O. , M.D.
on order for VERAPAMIL HCL orally 60 MG three times a day ( ref # 88365117 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: aware
Previous override information:
Override added on 10/24/02 by GREIGO , VIOLET STEFANI , M.D.
on order for VERAPAMIL HCL orally 80 MG three times a day ( ref # 09007340 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: aware
Previous override information:
Override added on 10/24/02 by :
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL &
METOPROLOL TARTRATE Reason for override: aware
Previous Override Notice
Override added on 10/24/02 by RUMAN , RUBIE O. , M.D.
on order for VERAPAMIL HCL orally ( ref # 39536445 )
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: aware
THEOPHYLLINE ( SLOW RELEASE ) 300 MG orally twice a day
Food/Drug Interaction Instruction
Follow manufacturer's info re: take with food.
Give with meals
Override Notice: Override added on 4/3/02 by
EVERLETH , ROSEMARY F.
on order for COUMADIN orally ( ref # 14284431 )
POTENTIALLY SERIOUS INTERACTION: THEOPHYLLINE & WARFARIN
Reason for override: Will monitor physical therapy.
VERAPAMIL HCL 60 MG orally three times a day HOLD IF: sbp<95 , heart rate<55
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 9/14/02 by
RUMAN , RUBIE O. , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: aware
Previous Alert overridden
Override added on 10/24/02 by RUMAN , RUBIE O. , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: aware
Previous Alert overridden
Override added on 10/24/02 by RUMAN , RUBIE O. , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: Aware
Previous Override Notice
Override added on 10/24/02 by RUMAN , RUBIE O. , M.D.
on order for LOPRESSOR orally 75 MG three times a day ( ref # 93362873 )
POTENTIALLY SERIOUS INTERACTION: VERAPAMIL HCL &
METOPROLOL TARTRATE Reason for override: aware
Previous override information:
Override added on 10/24/02 by RUMAN , RUBIE O. , M.D.
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
VERAPAMIL HCL Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every day
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/3/02 by
EVERLETH , ROSEMARY F.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: THEOPHYLLINE & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: Will monitor physical therapy.
SIMVASTATIN 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 4/3/02 by
EVERLETH , ROSEMARY F.
on order for COUMADIN orally ( ref # 14284431 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: Will monitor physical therapy.
SEREVENT ( SALMETEROL ) 2 PUFF inhaled twice a day
FLOVENT ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
Instructions: two puffs
CLOPIDOGREL 75 MG orally every day Starting IN a.m. ( 1/11 )
ALBUTEROL INHALER 2 PUFF inhaled as needed shortness of breath
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Lewis Kuba , Kernan To Dautedi University Of Of , 1pm 5/17/02 scheduled ,
Denisha Mcrorie 8/12/02 ,
ALLERGY: Penicillins , Sulfa
ADMIT DIAGNOSIS:
Coronary artery disease
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Stent stenoses , episodes of asymptomatic afib , aflutter , and atrial tachycardia with RVR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) copd ( chronic obstructive pulmonary
disease ) niddm ( diabetes mellitus ) episodes of afib , aflutter , and
atrial tachycardia ( )
OPERATIONS AND PROCEDURES:
Cardiac catheterization with angioplasty of OM and Diagonal arteries ,
and brachytherapy.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
75yo male with COPD , NIDDM , and CAD history of cath in
3/10 with stents of LCX and diag , presented to TH on 11/9/02 with CP ,
similar to that in 9/11 patient described CP as pain
and pressure , extending from the middle of his chest up into his jaw.
Pain began when patient arose from his couch , and escalated quickly. CP only
ceased after nitro was administered in the ER 30 minutes later. At TH ,
patient ruled out for MI by enzymes , with
no EKG ischemic changes , and was treated with Lovenox. At TH , patient had
an episode of asymptomatic atrial
tachycardia , resolving spontaneously. On 8/11/02 ,
patient was transferred to PUO for cardiac cath and potential
stent/brachytherapy if necessary.
Hospital
course:
CV - patient underwent cath 3/24/02. Both stents
from 3/10 were found to be stenosed ( LACX 85% and diagonal 95% ).
LAD had 50% stenosis. Stents were tx with angioplasty and brachytherapy.
patient placed on integrilin intravenous for 14 hours. patient ruled out per routine for
MI by CK after procedure. He had no episodes of chest pain after his
admission to TH .
- patient has had multiple episodes of
asymptomatic
afib , aflutter , and atrial tachycardia , with RVR into the 150's , with
rate responding
well to 5mg intravenous lopressor. On 4/29/02 , lopressor increased to
75mg orally three times a day in hopes of achieving rhythm/rate
control , unsucessfully. EP was consulted as to a possible ablation
procedure , but felt that medical management , if possible , would be a
better solution , given that multifocal atrial tachycardias and afib
would not necessary be resolved with an ablation procedure. The
patient also preferred medical management. On 1/27/02 , verapamil
40mg orally three times a day was added to the regimen , with patient still having
episodes of rapid heart rate. Verapamil was increased to 80mg orally
three times a day with resulting rate control. However , patient had two episodes
of asymptomatic low BP ( 90/50 ). On 4/6/02 , verapamil was decreased
to 60mg orally three times a day , with both HR and BP control. Abnormal rhythms
continued , without RVR.
- Given afib/aflutter rhythms , patient was placed on coumadin 5mg orally every day
on 1/27/02 ( prior to his procedure , he was maintained on heparin drip ,
and immediately post-procedure , he was maintained on integrilin drip ).
- patient placed on statin at TH ; maintained on statin at PUO . Patient
maintained on asa.
- New d/c medications: Given difficulty of maintaining patient's heart
rate and blood pressure , patient was d/c'ed on verapamil and lopressor ,
both three times a day drugs. At f/u appt with cardiologist or primary care physician , this regimen
can be altered as appropriate. patient also d/c'd on coumadin , plavix
( for 6months ) , and simvastatin.
Pulm - Severe COPD , treated with home O2.
Baseline O2 92% on 2L , and SOB with minor exertion. patient
was tx with steroids until 6 months ago.
Continued on theophylline , flovent , serevent ,
guifenisin , atrovent inhaler as needed Stable while in hospital.
Endo - patient was given one dose of solumedrol in TH . FS high ( low 200's )
on admission; he was begun on an insulin SS , but did not require
insulin while in hospital.
ADDITIONAL COMMENTS: Please return to hospital ER if you have any chest pain , increased
shortness of breath or oxygen requirement , dizziness , lightheadedness ,
fainting , or any other concerns. If you have palpitations or a
sensation of a racing heart , please call your primary care doctor.
Please go to Dr. Gari ' office on Monday for coumadin levels.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check INR levels and adjust coumadin dose as appropriate.
2. Adjust CCB and BBlocker dosing regimen to maintain heart rate and
blood pressure control as appropriate.
No dictated summary
ENTERED BY: RUMAN , RUBIE O. , M.D. ( UW92 ) 9/14/02 @ 04
****** END OF DISCHARGE ORDERS ******
Document id: 1183
| Target |
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128497124 | PUO | 84843297 | | 6991632 | 1/1/2004 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 1/1/2004 Report Status:
Discharge Date: 3/1/2004
****** DISCHARGE ORDERS ******
AMEJORADO , PETE 744-55-43-9
La Oburg Knox
Service: MED
DISCHARGE PATIENT ON: 5/14/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KEITEL , LYNWOOD D. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
LASIX ( FUROSEMIDE ) 40 MG orally every day
LABETALOL HCL 500 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Override Notice: Override added on 5/28/04 by
MIN , MARCELINE M. , M.D..PH.D.
on order for VERAPAMIL SUSTAINED RELEAS orally ( ref #
09592889 )
POTENTIALLY SERIOUS INTERACTION: LABETALOL HCL & VERAPAMIL
HCL , SUSTAINED-REL Reason for override:
patient takes at home
VERAPAMIL SUSTAINED RELEAS 180 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 5/28/04 by
MIN , MARCELINE M. , M.D..PH.D.
POTENTIALLY SERIOUS INTERACTION: LABETALOL HCL & VERAPAMIL
HCL , SUSTAINED-REL Reason for override:
patient takes at home
HYZAAR ( 25 MG/100 MG ) ( HYDROCHLORTHIAZIDE 25M... )
1 TAB orally every day
DIET: House / 2 gm Na / ADA 2000 cals/day / Low saturated fat
low cholesterol (I) (FDI)
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Delgardo - keep appointment as previously scheduled ,
Dr. Viray as scheduled ,
DR. Pritt , contact for an appointment in the next month ,
ALLERGY: "BROMURA" , ACE Inhibitor
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
mitral regurg HTN Type II heart block mild diabetes history of pacer DDD
1997 CHF
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
75F with iCMP( EF:30-30% 11/1 ) , HTN , diet-controlled DM ( HgbA1c: 5.7 ) , history of
PM , MR , subclavian thrombus p/with SOB; admitted with CHF flare. Multiple
admits for CHF in past; most recently 4/25 felt to be 2/2 med
non-compl & dietary indiscretion. Presented with chest pain ( left sided
squeezing ) and DOE. In the ED , 163/90 P:70. Given 1 SLTNG for BP.
Admit labs notable for BNP: 1493 ( 1800 last CHF admit ). To have
biventricular PPM placed by Dr. Richard Delgardo
1. CV-- Ishcemia: cont home medications of asa labetalol , verapamil.
The patient had negative cardiac enzymes , no hx of CP and previous
non-obstructive CAD Pump: The patient diuresed about 4 literes total
for the duration of her admission , weight dropped from 67kg
to 63kg with diuresis. Cont hyzaar. ( continuing home meds since not in
decompensated failure ). For better fluid control the patient was
discharged on lasix 40mg every day and her labetalol was increased to
500mg twice a day for better BP control. Rhythm: AVpacer to be replaced to
biventricular by Dr. delgardo ( at later time ); the patient will follow up
with cardiology , her primary care physician , and Dr. Brumet
ADDITIONAL COMMENTS: necessicita pesarse todos los dias. Si su peso aumenta mas de dos
libras , llame su doctor. No beba mas de 2 litros en el dia.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: ARUIZU , JULIANNE MARIE , M.D. ( QS40 ) 5/14/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1184
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000597448 | PUO | 96398256 | | 4811635 | 9/10/2006 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/23/2006 Report Status: Signed
Discharge Date: 1/1/2006
ATTENDING: REISMAN , CATHIE MINDI MD
PRIMARY CARE PHYSICIAN:
September Petretti , M.D.
PRINCIPAL DIAGNOSES:
GI bleed , V-fib arrest , status post stent placement and status
post ICD placement , CVA , DM , CAD , GERD , hypertension status post
CABG , status post St. Jude's MVR , hyperlipidemia , memory deficit ,
left-sided weakness and status post evacuation of left subdural
hematoma.
BRIEF HISTORY OF PRESENT ILLNESS ( to CCU admission ):
The patient was admitted to PUO on 5/25/06. He had been behaving unlike
himself and was having black tarry stools for two days. The patient was found
to
be guaiac positive. A head CT showed no new lesions but did show
multiple infarcts that were known to be old. On 10/18/06 , the
patient had an EGD showing clot in the distal esophagus. This
clot was removed , and the possible culprit vessel was clipped.
Around midnight on 8/19/06 , the patient became borderline
hypertension for an unclear reason. His hematocrit was
stable. The patient's ACE inhibitor and beta-blocker
were held. Also , the patient's Lasix was
held. On 8/19/06 at around 4:00 a.m. , the patient was
reportedly having fitful sleeping and went to the bathroom. Soon
afterwards , the nurse noticed that the patient was having more
ectopy on telemetry. Soon after 4:30 a.m. , the patient was
either found unresponsive or ventricular fibrillation was seen on
telemetry and a code was called. The rhythm was shown to be
V-fib. Chest compressions were initiated , and the patient was
shocked. Soon thereafter , he had two more shock episodes for
V-fib and was loaded on amiodarone 300 mg intravenous x1. Soon
thereafter , his V-fib terminated and subsequently , the patient
had an episode of slow PEA treated with atropine , epinephrine ,
calcium and magnesium. Code labs showed a potassium of 3.3. The
patient was intubated. A left femoral line was placed. The
patient was transported to the CCU with stable blood pressure on
neosynephrine. He was easily weaned off neosynephrine. The
patient does not have any history of an arrhythmia.
PAST MEDICAL HISTORY:
The patient's past medical history is significant for:;
1. coronary artery disease status post CABG ( SVG to RCA ) with mitral valve
replacement in 1999. In 2003 , the
patient underwent catheterization for unstable angina. The LAD
and D1 were stented. In 2004 , the patient underwent
catheterization for unstable angina showing restenosis of D1
which was re-stented.
2. Ischemic cardiomyopathy.
3. CVA.
4. Seizure disorder.
5. Subdural hematoma while on Coumadin , status post burr hole
evacuation.
MEDICATIONS PRIOR TO ADMISSION:
The patient's medications prior to admission included:
1. Lasix 20 mg daily.
2. Toprol-XL 200 mg daily.
3. Lipitor 80 mg daily.
4. Keppra 1 g twice a day
5. Aspirin 81 mg daily.
6. TriCor 145 mg daily.
7. Zestril 20 mg daily.
8. Colace 100 mg twice a day
9. Prilosec.
10. Lovenox 70 mg subcutaneous twice a day
11. Lantus 44 units every day before noon
12. NovoLog 12 units before every meal
SOCIAL HISTORY:
The patient was not known to be a smoker or to use alcohol.
ALLERGIES:
desquamating rash to phenytoin and also a possible
allergy to Ancef which occurred during this hospitalization.
PHYSICAL EXAMINATION ON ADMISSION:
On admission on 10/20/06 , the patient's vital signs were
temperature 98.3 , pulse 86 , blood pressure 122/73 , respiratory
rate 16 , O2 sat 97% on room air. He was not in any acute
distress. He was alert and oriented x3. He was interactive and
appropriate. Skin was normal. HEENT showed an old left-sided
facial droop which was unchanged per patient and the family. The
JVP was 6 cm. There was no lymphadenopathy. The chest was
clear. Cardiac exam showed a mechanical S1 and normal S2 , no
extra sounds or murmurs. Abdominal exam was benign. Extremities
had 2+ pulses without clubbing , cyanosis or edema. Neurological
exam showed a left-sided facial hemiparesis. Otherwise , cranial
nerves II through XII were intact. The patient had 4/5 strength
on the left side , 5/5 strength on the right side. Toes were
downgoing.
ADMISSION LABS:
Labs on admission were notable for a creatinine of 1.7 , glucose
of 237 , hematocrit of 37.
OPERATIONS AND PROCEDURES:
10/18/06 , elective inpatient EGD for heme-positive black stool
performed by Dr. Natisha Longaker in the presence of Dr. Lorretta Cridge
On 11/16/06 , urgent cardiac cathet1erization for cardiac arrest
performed by Dr. Jeannette Mendonsa with stent placement in the
circumflex.
On 4/22/06 , dual chamber ICD placed by Dr. Brumet
HOSPITAL COURSE BY PROBLEM:
This is a 66-year-old man with coronary artery disease and
mitral valve replacement. He was initially admitted for an upper
GI bleed and was then admitted to the CCU status post V-fib arrest
and found to have NSTEMI. His course in the CCU was as follows:
1. Cardiovascular:
A. Ischemia: NSTEMI. The patient had a troponin elevation
beginning 15 minutes after a code was started , suggesting that the NSTEMI
occurred
and then caused V-fib arrest. The peak troponin was 111.
Cardiac catheterization showed severe 3-4 vessel disease ,
and occlusion of the SVG graft. Two drug-eluting stents were placed
in the left circumflex. The patient was treated with aspirin ,
Plavix , beta-blocker , and ACE. The patient's beta-blocker and
ACE doses were titrated during his hospital stay. The patient
was also taken off of Lipitor briefly due to concern about his
liver function. At discharge , he is being restarted on his
outpatient doses of Lipitor as well as a Fibrate.
B. Pump: The patient had congestive heart failure causing
pulmonary edema. By echo , he had an ejection fraction of 25-30%
with a moderately dilated left ventricle , severe global
hypokinesis with posterior and inferior akinesis. The patient
diuresed well during his CCU stay and on the floor. His I's and
O's were followed. He was net negative , and he was discharged
at a weight of 87 kilos. The patient had an echo to evaluate
for dyssynchrony. This echo did not find significant evidence of
dyssynchrony.
C. Rhythm: The patient had a V-fib arrest and returned to
normal sinus rhythm. He received an amiodarone load as well as
amiodarone 400 mg three times a day After he stabilized , the amiodarone was
discontinued after AICD implantation on on 7/1/06. The implantation itself
was uncomplicated though the patient developed hives thought to be due to
administration of prophylactic Ancef. The patient was switched
to vancomycin for prophylaxis , followed by orally clindamycin. His allergic
symptoms
resolved with one dose of intravenous Benadryl.
2. GI: The patient came in with an upper GI bleed. A bleeding
vessel at the GE junction was clipped. The patient had a
transient LFT elevation consistent with shock liver. LFTs were
followed and declined appropriately during his hospitalization
and normalized before discharge. The patient was also maintained
on a proton pump inhibitor during his stay.
3. Hematocrit: The patient was transfused two units of red blood
cells on 4/12/06 and 9/28/06. His hematocrit remained stable therafter. The
patient was taking Lovenox as an
outpatient for protection of his mechanical mitral valve. During
the peri-procedure period for his ICD implantation , the patient
was switched to heparin drip and was maintained on the heparin
drip for four days after device implantation. At that time , he
was restarted on his outpatient regimen of Lovenox 70 mg twice a day
4. Neuro: The patient has a history of CVA with a residual left
hemiparesis. These symptoms were stable. The patient was also
seen by the Psychiatry Service to evaluate his memory deficits
and abilities to make decisions. The Psychiatry team recommended
that the patient be followed by Neurology after discharge and
that the patient be considered for a formal neuropsychiatric
testing for evaluation of his neurologic and cognitive deficits.
5. Pulmonary: The patient's pulmonary edema resolved with
diuresis.
6. ID: The patient presented with fever and an elevated white
blood cell count initially and a question of an infiltrate on chest
x-ray. This patient was covered with levofloxacin and Flagyl for
three days empirically for aspiration pneumonia. During
hospitalization , he did have very transient low-grade
temperatures on two other occasions. Cultures including chest
x-ray , urine and blood cultures were negative. The patient was afebrile prior
to discharge. As of the day of
this dictation , C. difficile tests were also negative.
7. Renal: The patient's creatinine was elevated reaching a peak
of 1.9 on 4/12/06 in the setting of his cardiac arrest. The
patient's creatinine normalized and on the day prior to discharge
was 1.2.
8. Nutrition: The patient was evaluated by Speech and Swallow.
Initially , he was put on a puree-thin diet that was advanced to
mechanical soft and thin liquids prior to discharge.
9. Endocrine: The patient is diabetic and was maintained on NPH
22 units twice a day and a sliding scale. At the time of discharge ,
the patient's blood sugars were well controlled. He is being
discharged on Lantus 48 units at bedtime ( a light increase over his outpatinet
dose ) as well as a NovoLog sliding scale for coverage during meals.
PHYSICAL EXAMINATION AT DISCHARGE:
On the day of discharge , the patient was afebrile. Heart rate
70-80s , blood pressure 90-120/66-70. Oxygen saturation 96-98% on
room air. Weight 87 kilograms. Pertinent labs include a
creatinine of 1.2 , hematocrit of 36. The patient's exam showed
continuing left facial hemiparesis. Lungs were clear. Cardiac
exam was notable for a mechanical S1 , no extra sounds or murmurs.
His abdomen was soft , and the ICD placement site was well healed
without swelling , tenderness or erythema.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally daily.
2. Lipitor 40 mg orally daily.
3. Plavix 75 mg orally daily.
4. Benadryl 25-50 mg orally every 6 hours as needed itch.
5. Colace 100 mg orally twice a day
6. Lovenox 70 mg subcutaneous twice a day
7. TriCor 145 mg orally daily.
8. NovoLog sliding scale before every meal If blood sugar less than 125 ,
give zero units. If blood sugar 125-150 , give 2 units. If blood
sugar 151-200 , give 3 units. If blood sugar 200-250 , give 4
units. If blood sugar 251-300 , give 6 units. If blood sugar
301-350 , give 8 units. If blood sugar 351-400 or greater , give
10 units.
9. Lantus 48 units at bedtime.
10. Keppra 1000 mg orally twice a day
11. Lisinopril 5 mg orally daily.
12. Toprol-XL 150 mg orally daily.
13. Prilosec 20 mg orally daily.
14. Sarna topical lotion every 2 hours as needed itching.
15. Senna tablets two tabs orally twice a day as needed constipation.
16. Multivitamin daily.
DISPOSITION:
The patient is being discharged to a rehab facility.
eScription document: 7-9176215 EMSSten Tel
CC: September Petretti M.D.
Za , Utah 20379
Callventbethcharl Wark Louis Lit Ti
cc: Dr. Fiermonte
Dictated By: BALLER , MAX
Attending: REISMAN , CATHIE MINDI
Dictation ID 1225629
D: 3/19/06
T: 3/19/06
Document id: 1185
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593491386 | PUO | 67745627 | | 912292 | 4/28/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 4/28/1990 Report Status: Unsigned
Discharge Date: 11/4/1991
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: Mr. Phanco is a 72 year old man who
is status post a coronary artery
bypass graft and mitral valve replacement who presents with
recurrent unstable angina. He was admitted to the Cardiology
Service for cardiac catheterization. His history began in l976
when he presented with substernal chest pain and shortness of
breath. In l98l , he experienced an anterior myocardial infarction
and in October of l98l , underwent a three-vessel coronary artery
bypass graft with mitral valve replacement. He did fairly well
with no recurrent symptoms until September of l989 when he presented
with congestive heart failure and ruled out for myocardial
infarction. A thallium exercise treadmill test revealed
inferoapical ischemia and the patient was continued with medical
therapy. He did well until one to two weeks prior to admission
when he developed chest pain which radiated to the left arm and was
persistent for three hours after which time it was treated with
Nitroglycerin at Osri Medical Center and resolved. An exercise
treadmill test was stopped secondary to shortness of breath and
thallium scan revealed inferoapical scarring and septal apical
reperfusion abnormality. The patient subsequently underwent
cardiac catheterization at Pagham University Of which
revealed l00% occlusion of his left anterior descending graft and
patent posterior descending artry graft and OM2 graft. His native
vessels were remarkable for significant disease throughout his left
anterior descending , an l00% circumflex lesion at the obtuse
marginal l , l00% proximal obtuse marginal lesion , and l00% right
coronary artery occlusion. Left ventriculogram revealed an
ejection fraction of 0.6 with apical hypokinesis. The patient was
referred to Cardiac Surgery Service for evaluation and coronary
artery bypass grafting was elected. PAST MEDICAL HISTORY:
Remarkable for diet controlled diabetes mellitus , history of an
asymptomatic abdominal aortic aneurysm , and a hiatal hernia.
CURRENT MEDICATIONS: Inderal , Procardia , Aspirin , Lasix , Pepcid ,
Maalox , Nitrol Paste , and intravenous Heparin. ALLERGIES: No
known drug allergies. SOCIAL HISTORY: The patient has a
longstanding cigarette smoking history which was stopped in l98l.
PAST SURGICAL HISTORY: As above.
PHYSICAL EXAMINATION: He was a pleasant moderately obese male in
no acute distress. HEAD/NECK: Within
normal limits. CHEST: Clear bilaterally. CARDIAC: Regular rate
and rhythm. ABDOMEN: Benign. EXTREMITIES: Without cyanosis ,
clubbing , or edema with good peripheral pulses.
LABORATORY EXAMINATION: Electrocardiogram revealed sinus
bradycardia with first degree AV block and
right bundle-branch block.
HOSPITAL COURSE: On July , patient underwent coronary artery
bypass grafting and a left internal mammary
artery was anastomosed to the left anterior descending artery.
The patient tolerated the procedure well. Post-operatively , the
patient developed intermittent rhythm disturbances with several
episodes of ventricular ectopy and bradycardia which were not felt
to be significant enough to warrant further investigation by the
Cardiology Service. The patient developed a blood culture that was
positive for enterobacter and the patient subsequently underwent
placement of a Hickman catheter to receive a four week dose of
Gentamicin and Ceftriaxone. This was well tolerated without
complication.
DISPOSITION: CONDITION ON DISCHARGE: Good. The patient is
discharged home and will receive a full course of
four weeks of intravenous antibiotic therapy. DISCHARGE
MEDICATIONS: Coumadin , Lopressor , and Pepcid.
________________________________ DT510/1677
LOIDA F. GOLEBIOWSKI , M.D. MC6 D: 7/6/91
Batch: 9578 Report: P9451J21 T: 8/4/91
Dictated By: MAXIMO G. BULLS , M.D. UL11
Document id: 1186
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144089827 | PUO | 43364462 | | 772460 | 3/25/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/24/1993 Report Status: Signed
Discharge Date: 7/10/1993
CARDIOLOGY Brid
DISCHARGE DIAGNOSES: 1. CORONARY ARTERY DISEASE.
2. STATUS POST PTCA TIMES TWO.
3. SICK SINUS SYNDROME , STATUS POST PACER
PLACEMENT.
HISTORY OF THE PRESENT ILLNESS: The patient is a 72 year old woman
with coronary artery disease who
is status post PTCA times two with a sick sinus syndrome , status
post DDD pacemaker , and Hodgkin's disease who presented with
unstable angina. Her cardiac risk factors include hypertension ,
diabetes mellitus , family history , and past smoking history. She
had angina in April 1992 and underwent coronary angiography in
October 1993 which revealed an 80% RCA lesion , 70% OM , 70% mid-LAD ,
and 50% D1. The LV-gram was normal. She had a PTCA to the RCA
lesion with a 30% residual. She had recurrent exertional angina
one month later and a repeat catheterization at that time showed no
change. In February 1993 , she had several episodes of lightheadedness
and syncope which was felt to be secondary to sick sinus
syndrome. A DDD pacemaker was placed. She later had recurrent
chest pain at rest and again went to cardiac catheterization which
showed a 70% mid LAD lesion , 30% RCA , and a normal LV-gram with 75%
ejection fraction. She underwent PTCA to the mid-LAD lesion with a
20% residual. She was then discharged on Lopressor , Procardia , and
Aspirin. In February 1993 , she underwent an ETT , and exercised
4 minutes and 35 seconds on a standard Bruce stopping due to
shortness of breath and fatigue. No ischemic changes were noted.
She has done well until two days prior to admission when she
experienced recurrent angina at rest , and was admitted to
Kendsonre Ale Ater Hospital where she ruled out for a
myocardial infarction. She was discharged one day prior to
admission and on the day of admission had recurrent angina while
doing housework. She took three Nitroglycerins , and the pain was
relieved. Her primary physician recommended that she be seen in
he Emergency Room.
PAST MEDICAL HISTORY: ( 1 ) Hodgkin's disease in remission , status
post 13 cycles of ABVD chemotherapy. ( 2 )
Sick sinus syndrome , status post DDD pacemaker. ( 3 ) Hypertension.
( 4 ) Peripherovascular disease. ( 5 ) BOOP possibly Bleomycin
toxicity. Pulmonary function tests have shown a restrictive
picture. ( 6 ) Noninsulin dependent diabetes mellitus. ( 7 ) Status
post hysterectomy. MEDICATIONS ON ADMISSION: Nifedipine XL 60 mg
every day , Lopressor 25 mg twice a day , Mevacor 20 mg every day , Aspirin one
tablet every day , Micronase 1.25 mg every day , Nitroglycerin sublingually
as needed , Relafen and Trental. ALLERGIES: Compazine causes a
possible dystonia. FAMILY HISTORY: Mother died in her 40's from
diabetes. Father died in his 60's with a myocardial infarction.
SOCIAL HISTORY: The patient lives alone in Ertrock Chi Sa and is former
smoker.
PHYSICAL EXAMINATION: Temperature 98.8 , heart rate 68 , blood
pressure 120/70. HEENT: There was no
thyromegaly , no jugular venous distention. Carotids were 2+
bilaterally without bruits. Lungs: Rales were heard at the right
base. Heart: Regular rate and rhythm , S1 and S2 , and a II/VI
systolic murmur radiating to the axilla. Abdomen: A midline scar
was noted , otherwise soft , nontender , without hepatosplenomegaly.
Extremities: 2+ bilateral femoral pulses , dorsalis pedis pulses ,
no edema. Neurological exam: Alert and oriented times three.
LABORATORY DATA: Sodium 139 , potassium 4.2 , BUN 18 , creatinine
0.8. The first CK was 120. The white blood
count was 6.9 , hematocrit 38.6 , platelets 177. The physical therapy was 13.1 ,
and the PTT was 57.3 ( possibly drawn off a line which had been
hep-flushed ). EKG: Sinus bradycardia at a rate of 59 , left axis
deviation , left ventricular hypertrophy , nonspecific T-wave
abnormalities.
HOSPITAL COURSE: The patient was continued on her Lopressor ,
Aspirin , and Nifedipine. Nitro Paste was added
on admission. On 3/30/93 , she underwent cardiac catheterization
which showed a 30% RCA lesion and a 30% proximal LAD. No other
lesions were seen. Her medications were continued except for
changing her Lopressor to Atenolol 50 mg every day She was monitored
over a weekend until she could have an exercise test. She had some
belching during this time , and Propulcid was added to her medical
regimen. On 5/23/93 , the patient underwent a standard Bruce
protocol ETT and went 4 minutes and 30 seconds , stopping due to
shortness of breath and fatigue. There were no EKG changes or
arrhythmias noted during exercise , and there was no evidence of
ischemia. She was therefore discharged in good condition to her
home with followup with her physician , Dr. Queen Rothery and
her cardiologist , Dr. Jackson Part
DISPOSITION: MEDICATIONS ON DISCHARGE: Procardia XL 90 mg every day ,
Atenolol 50 mg every day , Mevacor 20 mg every day , Aspirin one
tablet every day , Micronase 1.25 mg every day , Relafen 500 mg every day before noon as needed
back pain , and Trental. She will followup with her primary
internist , Dr. Queen Rothery , and her cardiologist , Dr. Jackson Part
Dictated By: FIONA AUTHUR , M.D. NK94
Attending: LAQUITA OVERSTROM , M.D. NF54
CN827/7043
Batch: 8959 Index No. WKPKX78F8U D: 10/29/94
T: 7/6/94
Document id: 1187
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HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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756484975 | PUO | 14374811 | | 093127 | 4/12/2001 12:00:00 a.m. | DIVERTICULAR ABSCESS | Signed | DIS | Admission Date: 4/12/2001 Report Status: Signed
Discharge Date: 1/24/2002
HISTORY OF PRESENT ILLNESS: This is a 72-year-old woman with
history of diverticulitis who
presented with a diverticular abscess with nausea , vomiting and
crampy abdominal pain.
PAST MEDICAL HISTORY: CAD , status post MI x2 , status post V. fib
arrest , status post CABG , asthma , COPD ,
sleep apnea , obesity , hypercholesterolemia , status post chole ,
status post DVT , status post Greenfield placement , status post AAA
repair , GERD , gout , DM neuropathy , carpal tunnel syndrome , CHF ,
iron deficiency anemia , chronic renal insufficiency , baseline
creatinine 1.4-2.0.
MEDICATIONS: ASA 325 mg every day , Lasix 20 mg every day , allopurinol 100 mg
every day , Prevacid 20 mg every day , Isordil 40 mg three times a day ,
Atrovent nebulizers four times a day , K-Dur 20 mEq every day , eprosartan 150 mg
every day , Afrin and Imodium as needed
ALLERGIES: Sulfa , erythromycin , levofloxacin , intravenous dye , iron.
HOSPITAL COURSE: This is a 72-year-old female with a history of
diverticulitis who presented with crampy
abdominal pain , nausea and vomiting times several days. CT on
admission noted a diverticular abscess. CT was unable to drain it
due to its limited size. However , the patient continued to have
crampy abdominal pain , nausea and vomiting. The patient was taken
to the OR on 10/19/01 for an exploratory laparotomy , sigmoid
colectomy and colostomy. The patient tolerated the procedure well
and was maintained NPO , with an epidural for pain control , until
return of bowel function as witnessed by the gas and feces in the
colostomy bag.
By the time of discharge , the patient was ambulating with a wheeled
walker. She was tolerating a regular diet , had good pain control
on 2-4 mg every 4 hours of Dilaudid. Of note , the patient has a
significant history of coronary artery disease , had a rule out MI
postoperatively with initial evidence of cardiac injury. However ,
the patient did complain of some atypical chest pain on
postoperative day #3. A repeat rule out MI illustrated a troponin
leak likely secondary to increased cardiac demands postoperatively.
The patient was started on diltiazem 60 mg orally four times a day in order to
control rates with a good effect. The patient was also continued
on a course of intravenous antibiotics , ampicillin , ceftazidime , Flagyl and
Diflucan. Drainage from that particular abscess eventually
revealed enterococci , yeast and Pseudomonas responsive to these
antibiotics.
DISCHARGE INSTRUCTIONS: ( 1 ) Routine colostomy care and teaching.
( 2 ) Wet-to-dry dressings three times a day to open
abdominal wound. Staples to be D/C'd in about 7-10 days.
( 3 ) Please see physical therapy recommendations per rehab
recommendations.
DISCHARGE MEDICATIONS: Tylenol 650 mg PR/orally every 4 hours as needed fever ,
diltiazem 60 mg orally four times a day , hold for
systolic blood pressure less than 90 , heart rate less than 50 ,
fluconazole 300 mg orally every day x5 days , starting 3/2/02 , Lasix 20 mg
orally every day , Dilaudid 2-4 mg orally every 6 hours as needed pain , insulin sliding
scale , Isordil 40 mg orally three times a day , hold for SBP less than 110 ,
Zantac 150 mg orally twice a day , Atrovent nebulizer 0.5 mg nebulizers
every 4 hours , Lovenox 40 mg subcutaneously every day while at rehab only , nitroglycerin
1 tab sublingual every 5 minutes x3 as needed chest pain , eprosartan 150
mg orally every day , Augmentin 500/125 mg 1 tab orally three times a day x5 days ,
starting 8/29/02.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharge to acute rehab.
Dictated By: MA YEAGLEY , M.D. GK80
Attending: VERDA A. TRIARSI , M.D. JJ76
WA411/384197
Batch: 4666 Index No. BVGMN05F76 D: 4/14/02
T: 4/14/02
Document id: 1188
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
- |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
Y |
N |
N |
Y |
Y |
- |
N |
261285847 | PUO | 73166318 | | 758550 | 7/23/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/22/1995 Report Status: Signed
Discharge Date: 5/18/1995
PRINCIPAL DIAGNOSIS: RIGHT BREAST ABSCESS.
SIGNIFICANT PROBLEMS: 1 ) OBESITY.
2 ) DEPRESSION.
3 ) HYPERTENSION.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old woman
followed by Dr. Elleby in the KTDUOO
Clinic for problems related to obesity , depression and poorly
controlled hypertension. In February of 1994 , she complained of
right breast tenderness with a palpable nodule. A mammogram at
that time revealed mildly dense parenchyma and no calcium and an
ultrasound revealed 4 mm hypoechoic nodule compatible duct
obstruction with debris. Her symptoms of right breast tenderness
waxed and waned and follow-up ultrasound in April of 1994
revealed a 1 X 0.5 cm mass unchanged from the previous ultrasound.
She was advise to return in three months for repeat ultrasound and
aspiration. In October of 1995 , she had a palpable indurated area at
12:00 on the right breast. She was seen by Dr. Foerschler in the
Surgery Clinic and scheduled for a right breast biopsy , but because
of persistent hypertension as an outpatient , she is now admitted
for blood pressure control prior to the breast biopsy on August ,
1995.
PAST MEDICAL HISTORY: Significant for 1 ) Hypertension , 2 ) Obesity ,
3 ) Tobacco use , 4 ) Depression , 5 ) Uterine
leiomyoma , 6 ) Polymyalgia rheumatica.
MEDICATIONS ON ADMISSION: 1 ) Lisinopril 20 mg orally every day. 2 )
Diltiazem 240 mg orally every day.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: Significant for six children. She is divorced.
She has a 40 pack year history of smoking and
denies alcohol abuse.
FAMILY HISTORY: Positive for hypertension and cerebral vascular
disease.
PHYSICAL EXAMINATION: The patient is an obese woman in no apparent
distress. Vital signs: Blood pressure
170/110 , heart rate 80. Her pupils equal , round and reactive to
light. Discs are sharp and there are narrowed vessels on
fundoscopic examination. She has no lymphadenopathy and no bruits.
Her lungs are clear to auscultation. Her right breast shows
indurated 2 X 3 cm mass just above the right nipple , with an
overlying erythema which is moderately tender. Her cardiac
examination reveals a normal S1 and S2 and regular rate and rhythm
with a two out of six systolic ejection murmur heard best at the
left upper sternal border. Her abdomen is obese with a midline
scar , positive bowel sounds and no hepatosplenomegaly. Her
extremities revealed no clubbing , cyanosis or edema and she has
diminished peripheral pulses. Her neurological examination is
grossly intact.
LABORATORY: On admission , her EKG shows normal sinus rhythm
without any ischemic changes , unchanged from EKG in
September of 1992.
HOSPITAL COURSE: The patient was admitted to the General Medical
Service and given more aggressive hypertensive
medications including increasing her ACE inhibitor to Lisinopril 40
mg orally every day and discontinuing her Diltiazem and started on
Hydrochlorothiazide 25 mg orally every daily and starting Beta blocker
Lopressor 25 mg orally four times a day and increasing as tolerated according
to her blood pressure. She was taken to surgery on August , 1995.
The right breast abscess was drained without incident. Post
surgery , she was started on intravenous antibiotics which included Ancef 1
gram intravenous every 8 hours Other notable events in the hospital included a
Psychiatry consult who suggested that the patient had a history of
major depression and recommended ruling organic brain disease. A
polysonography was done for monitoring of sleep apnea and an MMTI
for further diagnostic evaluation. The patient had an uneventful
postoperative course with her blood pressure remaining moderately
elevated and resolution of her symptoms of right breast tenderness
which was followed by the Nessinee Ker Hospital Medical Center Surgical Service. The patient
was discharged home on Keflex and Cephradine with follow-up in the
KTDUOO Clinic with Dr. Elleby and in a Nessinee Ker Hospital Medical Center Medical Service.
MEDICATIONS ON DISCHARGE: 1 ) Enteric coated aspirin 325 mg orally
every day. 2 ) Colace 100 mg orally twice a day
3 ) Hydrochlorothiazide 25 mg orally every daily. 4 ) Lisinopril 40 mg
orally every daily. 5 ) Tylox 1-2 capsules orally every 4-6h. as needed pain.
6 ) Atenolol 100 mg orally every daily. 7 ) Cephradine 100 mg orally
four times a day times five days.
Dictated By: LAVELLE A. JULIUSSON , M.D. /D.PHIL MV7
Attending: GENNY S. BARRETTE , M.D. DU91
JU659/9746
Batch: 71553 Index No. DYQQVS7SA D: 8/10/96
T: 8/17/96
CC: CAROYLN E. REIDHERD , M.D. IS34
HORACIO C. FOERSCHLER , M.D. QO25
Document id: 1189
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
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- |
- |
- |
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- |
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- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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- |
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054171831 | PUO | 17914981 | | 560701 | 8/18/2001 12:00:00 a.m. | RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/19/2001 Report Status: Signed
Discharge Date: 10/17/2001
ADMISSION DIAGNOSIS: UNSTABLE ANGINA.
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE , STATUS POST STENT OF
THE RCA.
OTHER SIGNIFICANT PROBLEMS: EXTENSIVE CARDIAC HISTORY , DVT WITH
PE X TWO , CHRONIC RENAL INSUFFICIENCY ,
HEPATITIS B POSITIVE.
HISTORY OF PRESENT ILLNESS: This is a 63-year-old male presenting
with unstable angina. His first presentation with coronary disease
was in 1986 , when he ruled in for MI and a cath revealed 100%
occlusion of the circumflex , 99% D1 , and a subsequent angioplasty
of the circ to a 70% residual. He had an exercise treadmill two
months later and a repeat cath at that time showed 95% restenosis
of the circ and a 60% LAD lesion , and a 90% D1. In October of
1992 the patient again presented with exertional angina. Cath
revealed 70% occlusion of the RCA , 70-80% LAD , and diffuse disease
in the circumflex with a 50% mid-circumflex lesion. He had diffuse
global hypokinesis and an EF of 40-50%. His angina progressed and
in 1994 he underwent a four vessel CABG , SVG to the PDA and OM-1 ,
and a LIMA to the LAD and D2. He did well until 1997 , when he
presented with presyncope and was found to have a massive saddle
pulmonary embolism. He had a negative hypercoagulative workup
after this. In the recent years he has had a number of episodes of
epigastric pain with exertion and positive stress tests , but no
additional myocardial infarctions. His most recent cath in July
of 1997 showed an occluded circumflex , 80% LAD , and subtotal
occlusion distally , a 60% mid-RCA lesion , and patent SVG to the PDA
and the OM , as well as the LIMA to the LAD. In recent months the
patient describes increasing frequency of anginal episodes provoked
by walking more than five minutes or climbing stairs. Most often
the pain is epigastric , but occasionally substernal. He denies
associated symptoms of nausea , diaphoresis , or radiation of the
pain , but says it is hard to catch his breath. The patient denies
orthopnea , PND , or lower extremity edema. He has never had pain at
rest. On February the patient underwent an exercise treadmill
test walking five minutes on the standard Bruce protocol , reaching
a heart rate of 96 and a blood pressure of 130/70. He had chest
pain as well as 1 mm ST depressions. Since then his angina has
occurred with less and less exertion until the morning of
admission , when he walked outside and experienced substernal chest
tightness. He again denies nausea , diaphoresis , palpitations , or
radiation of the pain , but does have some shortness of breath. The
pain lasts approximately 10-15 minutes and the patient was advised
by his cardiologist , Dr. Jackson Part , to come to the Emergent
Department. In the Emergent Department he was pain free and
received aspirin and was started on heparin. EKG showed no acute
changes. CK was 47 and a troponin of 0.24.
PAST MEDICAL HISTORY: Diabetes , hypertension ,
hypercholesterolemia , chronic DVTs with
pulmonary embolism x two , CVA , left temporal in the setting of an
INR of 4 , with some residual memory and expressive deficits. He is
now on Lovenox subcutaneously for DVT prophylaxis. Chronic renal
insufficiency with a baseline creatinine of 1.5 , hepatitis B
positive , and recent eye surgery in January of 2001.
ALLERGIES: Benadryl , which causes shortness of breath.
MEDICATIONS ON ADMISSION: Glucophage 1000 mg orally twice a day ,
glyburide 10 mg orally twice a day , Avandia 4
mg orally twice a day , atenolol 50 mg orally every day , aspirin 325 mg every day ,
gemfibrozil 600 mg orally twice a day , and Lipitor 10 mg orally every day.
INITIAL PHYSICAL EXAM: Temperature 98.6 , heart rate 60 , blood
pressure 110/90 , upper 70 , oxygen
saturation 98% on 2 L. In general , he is a 63-year-old Asian male ,
well appearing and in no acute distress. HEENT: Pupils equal ,
round , and reactive. Extraocular muscles intact. Oral mucosa are
moist. There is no jugular venous distention , no lymphadenopathy.
Neck is supple. LUNGS: Clear to auscultation bilaterally , without
wheezes or rales. CARDIOVASCULAR: Regular rate and rhythm ,
without murmurs , rubs , or gallops. ABDOMEN: Soft , nondistended ,
and mildly tender to palpation in the epigastrium. There is no
rebound or guarding. Extremities are warm and well perfused , with
no edema.
INITIAL LABORATORIES: Sodium 140 , potassium 4.7 , chloride 106 ,
bicarb 24 , BUN 15 , creatinine 1.5 , glucose
253 , white count 5.3 , hematocrit 36.8 , platelets 144 , calcium 9.5 ,
mag 1.7 , CK 47 , troponin slightly elevated at 0.23 , INR 1.1. EKG
reveals normal sinus rhythm at 60 , with normal axis and inferiorly
flattened T waves , with T in 1 , L in 6.
HOSPITAL COURSE: 1. Cardiovascularly , the patient was continued
on heparin and ruled out for MI by CKs. On 10/21
he underwent cardiac catheterization , which showed an 80% proximal
LAD , 100% proximal circ , 80% proximal RCA , and 80% proximal right
PDA. His LIMA to the D2 and the LAD were patent , as was the SVG to
OM-1. The SVG to the RCA was 100% occluded. A stent was placed in
the native mid-RCA and angioplasty was undertaken of the right PDA.
After the procedure , the heparin was discontinued and he was
transitioned to Lovenox 40 mg subcutaneously every day for DVT prophylaxis. An
echo was obtained , which showed mildly enlarged left ventricle with
moderate reduction in function and EF of 35%. There is thinning
and hypokinesis to akinesis of the posterior and inferior segments ,
as well as hypokinesis to akinesis of the distal septum. The RV
was normal. Pulmonary artery pressures are 25+ right atrial
pressure. The patient continues to have episodes of epigastric
discomfort and belching , and his EKG revealed only nonspecific T
wave changes. He was scheduled to undergo a submax exercise
treadmill test , but this was held due to an increase in his
troponin initially from .23 to .73 , suggesting that he was having
some mild ischemia with the likely culprit being the small PDA that
had been angioplastied during cath. Recath was thought to be low
yield without anything to intervene upon after discussion with the
interventional Cardiology Service. His medical regimen was
maximized and included a beta blocker , ACE inhibitor , and nitrates.
His cardiac enzymes trended down to a CK of 32 and a troponin of
0.33 upon discharge. He underwent submaximum ETT on 3/10 and
walked for nine minutes without EKG changes , but did experience
6/10 chest pain and some belching. The test was considered
consistent with but not diagnostic of ischemia. Of note , he
reached a max heart rate of 68 and a blood pressure of 142/80
during this submaximum stress test. The patient will be discharged
to home to have close follow-up with his cardiologist , Dr. Jackson Part He will also have a follow-up stress test. He will see his
primary care physician , Dr. Mccants , for monitoring of his other
medical issues , including his diabetes. Discharge condition is
stable , discharge diet is low fat diabetic diet , and discharge
medications are enteric coated aspirin 325 mg orally every day , atenolol
50 mg orally twice a day , gemfibrozil 600 mg orally twice a day , glyburide 10 mg
orally twice a day , Isordil 20 mg orally three times a day , nitroglycerin 0.4 mg one
tab sublingual a.every 5 minutes x three as needed chest pain , ramipril 5
mg orally every day , Lovenox 40 mg subcutaneously every day x 70 days , Plavix 75 mg
orally every day x 25 days ( a total of 30 days since the stent ) , Lipitor
10 mg orally every bedtime , and Avandia 4 mg orally twice a day
Dictated By: MELLIE WIEBERG , M.D. WS76
Attending: JACKSON E. PART , M.D. RM7
HV457/315994
Batch: 08875 Index No. GQKRGJ5RZD D: 6/10/01
T: 6/10/01
Document id: 1190
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
312168433 | PUO | 35188668 | | 4418749 | 1/1/2004 12:00:00 a.m. | ISCHEMIC COLITIS | Signed | DIS | Admission Date: 6/19/2004 Report Status: Signed
Discharge Date: 10/18/2004
ATTENDING: VERNON RANDKLEV M.D.
CHIEF COMPLAINT:
Nausea , vomiting , and diarrhea.
HISTORY OF PRESENT ILLNESS:
This 81-year-old female with diabetes mellitus , hypertension , and
atrial fibrillation presents with nausea , vomiting , left lower
quadrant pain for one day and chronic nonbloody diarrhea on
6/23/04. The patient has had diarrhea for years , but this
episode was more severe and it was accompanied by nausea and
vomiting. Upon evaluation , she was found to have heme negative
stool. An abdominal CT showed a focal segment of colitis at the
splenic flexure with significant atheromatous disease of the SMA.
Findings were worrisome for mesenteric ischemia. As part of her
preoperative evaluation , she underwent a stress MIBI which showed
anterolateral , apical , and inferoposterior ischemia consistent with
three-vessel disease or left main disease. She does report
intermittent chest pressure and shortness of breath at rest and
with mild exertion over the past few years , increasing in the last three
months. She also reports two-pillow orthopnea and PMD. Given
these findings , the patient underwent cardiac catheterization on
6/11/04 as well as evaluation for celiac , SMA and IMA.
Catheterization showed 40% left main lesion. Otherwise , patent
coronary artery.
PAST MEDICAL HISTORY:
Includes diabetes with a hemoglobin A1c of 5.7 in 9/15 ,
hypertension , question of COPD , depression , coronary artery
disease with an echo showing an EF of 45% on baseline inferior
hypokinesis.
MEDICATIONS:
Lasix , atenolol , bupropion , Fosamax , metformin , and lisinopril.
She has no known drug allergies.
On physical exam , the patient was afebrile with a heart rate of
72 , blood pressure of 132/61 , respiratory rate 20 , with an O2
saturation of 93% on room air. Cardiovascular exam was
remarkable for a regular heart rate with a normal S1 and S2.
Lungs were clear to auscultation bilaterally. Abdominal exam was
remarkable for quiet by all sounds. No tenderness and no
distention. Extremities had no edema , 2+ dorsalis pedis pulses
bilaterally.
Abdominal angiography showed patent celiac SMA and IMA.
There was enhanced vascularity in the definitive or sliding
flexure but no embolic or angiographic cut off. The patient was
treated with NG tube to suction which improved his symptoms
although she cotinued to have.
LAB DATA: Remarkable for negative cardiac enzymes x3. Calcium
and magnesium , and potassium were repleted as needed. EKG was
unchanged with normal sinus rhythm with occasional PVCs.
Remainder of hospital course:
1. Cardiovascular: The patient was started on mild Lasix diuresis for
shortness of breath with slight improvement in symptoms.
Echocardiogram showed an ejection fracture of 50% with thick
aortic valve , thick mitral valve with trace MR , trace TR and
hypokinesis. There is severe baseline anteroseptal
distal-lateral apical hypokinesis and base posterior wall is
mildly hyperkinetic. Compared to report from 7/17 , LV
function appeared slightly worse. She was continued on aspirin ,
ACE inhibitor , beta-blocker , statin. She was mainly in normal
sinus rhythm but due to recent paroxysmal atrial fibrillation
with rapid ventricular rate , she remained under rate control with
beta-blockers.
2. GI: The patient was npo with an NG tube to suction for the
first several days of her admission with resolution of nausea and
vomiting with continued diarrhea. Her diet was advanced to
clears and then a low-residue diet , which she tolerated
well. Her workup for chronic diarrhea included C. diff. , stool
cultures , fecal leukocytes , fecal fat , TSH , ESR , ANA , which were
all negative. Celiac sprue serologies were also sent and were
pending upon discharge. At this point , GI was consulted and the
patient underwent a colonoscopy and EGD. Colonoscopy showed
diverticula in the rectus sigmoid. There is overlying erythema
over the splenic flexure with shallow erosions suggestive of
ischemic colitis. Random biopsies were taken to rule out
microscopic colitis. EGD was unremarkable. Biopsies were
obtained and are pending to rule out H. pylori. Colonoscopy and
EGD biopsies should be followed up as an outpatient. Likely
etiology secondary to microscopic ischemia secondary to
malabsorption of celiac sprue.
:3. Infectious diseases: She completed a six-day course of
ampicillin , levofloxacin , and Flagyl. On 6/11/04 , the patient
remained C. diff negative during the hospitalization.
4. Pulmonary: Shortness of breath likely secondary to pulmonary
process or underlying pulmonary disease in light of normal heart
function which should be followed up as an outpatient.
5. Endocrine: Metformin was held during the hospitalization
secondary to contrast administration. She remained on a regular
insulin sliding scale with adequate blood sugar control.
6. Renal: The patient was hydrated , pre and post di-loads with
unremarkable course of renal function.
7. Prophylaxis: The patient was maintained on subcutaneously heparin and
Pepcid.
The patient was stable , tolerating orally intake and orally meds.
She was discharged to rehab and will follow up with her primary
care physician and with cardiology and GI.
eScription document: 1-7659916 EMSSten Tel
Dictated By: MIN , MARCELINE
Attending: RANDKLEV , VERNON
Dictation ID 9764328
D: 8/23/04
T: 8/23/04
Document id: 1191
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
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423651763 | PUO | 65078385 | | 0369966 | 2/22/2007 12:00:00 a.m. | CHF; hemoptysis | | DIS | Admission Date: 11/16/2007 Report Status:
Discharge Date: 9/3/2007
****** FINAL DISCHARGE ORDERS ******
BICKNESE , JR , LAYNE 147-82-32-2
Alb
Service: CAR
DISCHARGE PATIENT ON: 8/29/07 AT 01:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: STAUTZ , MATHEW SAMMY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 325 MG orally every day
2. ALENDRONATE 70 MG orally QWEEK
3. ATORVASTATIN 40 MG orally every day
4. CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 1250 MG orally three times a day
5. CLOPIDOGREL 75 MG orally every day
6. CYCLOSPORINE MICRO ( NEORAL ) 50 MG orally twice a day
7. DILTIAZEM CD ( 24 HR CAPS ) 300 MG orally every day
8. DOXAZOSIN 4 MG orally every day
9. HYDROCHLOROTHIAZIDE 12.5 MG orally every day
10. MAGNESIUM OXIDE ( 241 MG ELEMENTAL MG ) 400 MG orally every day
11. NIFEREX 150 150 MG orally twice a day
12. PREDNISONE 5 MG orally every day before noon
13. SIROLIMUS 2 MG orally every day
14. ESOMEPRAZOLE 20 MG orally every day
15. METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally every day
MEDICATIONS ON DISCHARGE:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Alert overridden: Override added on 1/12/07 by
BAILLEU , ARA L. , M.D.
on order for ACETYLSALICYLIC ACID orally ( ref # 577816551 )
patient has a DEFINITE allergy to Aspirin; reaction is orbital
edema. Reason for override:
patient has had desensitization ,
and needs aspirin given stent. home med.
FOSAMAX ( ALENDRONATE ) 70 MG orally QWEEK
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Take with 8 oz of plain water
Alert overridden: Override added on 8/29/07 by :
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
ALENDRONATE SODIUM Reason for override: aware
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 8/29/07 by :
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE &
ATORVASTATIN CALCIUM Reason for override: aware
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
NEORAL CYCLOSPORINE ( CYCLOSPORINE MICRO ( NEORAL ) )
100 MG orally twice a day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 5/16/07 by WERGIN , TOMAS HAILEY , M.D.
on order for SIMVASTATIN orally 40 MG every bedtime ( ref # 963750844 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & SIMVASTATIN
Reason for override: mda Previous override information:
Override added on 8/8/07 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & CYCLOSPORINE
Reason for override: mda Previous Override Notice
Override added on 8/8/07 by BAILLEU , ARA L. , M.D.
on order for SIMVASTATIN orally ( ref # 939499233 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & SIMVASTATIN
Reason for override: aware Previous override information:
Override added on 1/12/07 by BAILLEU , ARA L. , M.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
CYCLOSPORINE Reason for override: aware. home med.
DILTIAZEM CD ( 24 HR CAPS ) 300 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 8/29/07 by :
POTENTIALLY SERIOUS INTERACTION: METOPROLOL TARTRATE &
DILTIAZEM HCL Reason for override: aware. home meds.
CARDURA ( DOXAZOSIN ) 4 MG orally DAILY HOLD IF: \
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
Starting IN a.m. ( 1/9 )
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
10 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LEVOFLOXACIN 500 MG orally EVERY OTHER DAY X 8 Days
Starting Today ( 5/3 ) Instructions: last day 6/2/07
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 8/8/07 by
GUSTOVICH , MARLO , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POLYSACCHARIDE IRON
COMPLEX & LEVOFLOXACIN Reason for override: mda
MAGNESIUM OXIDE ( 241 MG ELEMENTAL MG ) 400 MG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Alert overridden: Override added on 8/29/07 by :
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL &
METOPROLOL TARTRATE Reason for override: aware. home med.
NIFEREX 150 150 MG orally twice a day
Override Notice: Override added on 8/8/07 by
GUSTOVICH , MARLO , M.D. , PH.D.
on order for LEVOFLOXACIN orally ( ref # 543604478 )
POTENTIALLY SERIOUS INTERACTION: POLYSACCHARIDE IRON
COMPLEX & LEVOFLOXACIN Reason for override: mda
PREDNISONE 5 MG orally every day before noon
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: please use oxygen
FOLLOW UP APPOINTMENT( S ):
your primary care physician Dr. Petramale - please call for an appointment in one week ,
Cardiac Transplant , PUO O E Vallleigh ph 575-803-4363 1/12/07 at 11:15am scheduled ,
Dr. Robotham , Pulmonary , PUO Ci Cra ph 947-164-2074 9/9/07 at 1pm scheduled ,
PET CT scan - BEFORE YOUR PULMONARY APPT - PLEASE GO TO Pervo Ph Sta at Leah Ant H , NUCLEAR MEDICINE 9/9/07 at 10:40am scheduled ,
ALLERGY: Aspirin , PROCAINAMIDE HCL , ACE Inhibitor
ADMIT DIAGNOSIS:
shortness of breath
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF; hemoptysis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
heart transplant 1997 ( CAD , ischemic cardiomyopathy ); allograft
vasculopathy - MI sp PCI to LAD in 10/24 ); history of pulmonary hemorrhage and
hemoptysis 11/12 lung mass v atelectatic lung on CT; claudication;
NIDDM; HTN; nasal polyps
OPERATIONS AND PROCEDURES:
Bronchoscopy 11/8/07 : active bleeding from RML bronchus , which prevented
visualization of the subsegments or assessment of the bronchus. BAL of
the RML orifice could not be achieved.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Adjustment of immune suppressants , addition of diuretics , empiric
levofloxacin.
LENIs negative.
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB
***
HPI: 58yo M with history of ischemic cardiomyopathy history of heart transplant 1997
c/b allograft vasculopathy , CAD history of LAD stent 10/24 , ASA desensitization ,
recent admission for pulmonary hemorrhage/PNA presents with
hemoptysis. Over past week , developed ST , cough , increasing
orthopnea , PND , wheezing and worsening DOE. No chest pain , leg pain.
No F/C , no epistaxis. Seen in clinic today , found to have O2 sat 89%
and RLE swelling , sent to ED. In ED , afeb , P95 , 165/82 , 90%
on RA ( baseline 92-93% ). PE-CT negative for PE. Given IVFs but then
diuresed.
***
PMH: CABG 1990 , iCMP history of transplant 1997 c/b allograph vasculopathy
( biopsy 11/29 neg for rejection ) , history of LAD stent 10/24 , claudication ,
diet controlled DM , HTN , nasal polyps.
***
ALL: procainamide , ASA ( desensitized )
***
Admission EXAM: Afeb , P90 , 142/70 , 28 , 92-93% on
2L Tachypneic , decreased BS at bases , JVP 10 , RRR no
M/G/R , prominent PMI , abd bengin , LLE 2+ edema , RLE no edema , 2+ DP
bilat , warm ext
***
STUDIES Creat 1.7 ( baseline ) , Hct 31
( stable ) ABG on RA 7.45/34/63
*EKG 7/10 NSR , 1st degree AVB , nonspecific ST-T , no change from prior
*PE-CT 10/26 No PE. ? Filling defect in distal SVC vs IVC. New bilateral
pleural eff , stable cardiomeg , new fibrotic changes upper lobe , diffuse
ground glass opacities ( pulm edema vs PNA )
*TTE October 2007- EF 40% , rWMAs
*R heart cath October 2007- Wedge 12
***
daily events:
11/5 neg LENIs , pulm consult ( fellow Fowler ) , had echo , getting sputum
9/17 some neck swelling , maybe from Mucomyst , dced Mucomyst , now stable ,
checking sputum for primary care physician
2/12 improved neck swelling , nl ambulatory sats 95% on RA , and nl HRs in
80s
1/24 Bronch showed active RML bleeding , bronchial washings performed ,
fluid sent for micro
***
Discharge physical exam: afebrile , HR 80s-100s , blood pressure 120s-130s/60s-80s ,
94-95% RA. Ambulatory O2 sat 87% RA.
comfortable NAD. Lungs decreased breath sounds at bases. Heart RRR , no
murmurs/rubs/gallops. JVP flat. Abd soft. Ext LLE trace edema , RLE edema.
Warm and well perfused.
*******
IMPRESSION: 58yo M history of cardiac transplant c/b allograft vasculopathy ,
recent admission in 10/6 for pulmonary hemorrhage/PNA admitted with
increased SOB and hemoptysis. Likely CHF exacerbation +/- ILD +/- PNA
( CAP , atypicals , TB , primary care physician , fungal ). Patient's shortness of breath responded
to diuresis , and his symptoms improved. However bronchoscopy revealed
RML fresh blood , and CT chest is concerning for RML mass. Will need
follow up with pulmonary which is already arranged.
1. ) CV: No evidence of ischemia. Patient continued outpatient ASA ,
bblocker , statin , plavix. H/o cardiac transplant. Cyclosporine level on
10/27 was 152. His cyclosporine was increased during admission to 100mg orally
twice a day. His sirolimus was discontinued.
PUMP- He was intially volume overloaded on exam. BNP on admission was 674.
He was diuresed with lasix 40mg orally twice a day , and will be discharged on lasix
40mg orally daily. Also given potassium 10meq a day , will need lytes
followed. His HCTZ was discontinued. Weight on day of discharge was
62.2kg. BP control with home regimen of dilt , lopressor , cadura.
2. ) PULM: Pulmonary was consulted. CT was negative for PE. He had a
bronchoscopy which was described above ( fresh blood oozing from RML ). BAL
was sent for multiple studies. primary care physician was negative , influenza negative , adeno
negative , viral studies , cultures , and cytology are pending at this time.
Galact Ag was negative. GBM antibody was negative. ANCA is pending.
Bronchoscopy and chest CT were concerning for RML mass. He will follow up
with a PET CT and Pulmonary appointment on 9/2/07. Allergy was consulted
re whether his symptoms could be an allergic pneumonitis ( given history of
ASA allergy , an previous desensitization , and they felt it was unlikely.
Rheumatology was consulted re possible vasculitis given new proteinuria -
thought unlikely although final consult recommendations were pending at
time of discharge. He will be discharged on oxygen given desat to 87% on
RA with ambulation. He will be treated empirically with levofloxacin x 14
day course to finish on 6/2/07 in case mass seen in RML is infectious.1
3. ) HEME: LENIs negative. has iron defiency anemia which will need to be
continued to follow.
4. ) ENDO: NIDDM , diet controlled.
6. ) renal: proteinuria , no explanation , will need further follow up.
baseline renal dysfunction.
FULL CODE
ADDITIONAL COMMENTS: You were admitted to Pagham University Of with shortness of
breath. You were diuresed with furosemide ( lasix ) and your shortness of
breath has improved. You have continued to need oxygen when you walk or
exert yourself , and you will be discharged with oxygen which you should
use whenever you walk or exert yourself.
You had a bronchoscopy during this hospital admission which revealed some
blood in your right middle lung. You will need follow up with a
pulmologist regarding this finding. It is very important that you keep
your appointment for a follow up PET CT scan on 10/27 , and the appointment
the same day with the pulmonologist. You also have an appointment with
the heart transplant service here at PUO on 3/15 , and it is important
that you keep that appointment as well. Please call your primary care
doctor and arrange to see him in the next week to follow up this
hospitalization.
There were several changes to your medication. These include:
1 ) STOP YOUR SIROLIMUS ( rapamune )
2 ) INCREASE CYCLOSPORINE to 100mg twice a day ( you had been taking 50mg
twice a day )
3 ) STOP YOUR HYDROCHLOROTHIAZIDE
4 ) START FUROSEMIDE ( LASIX ) , a diuretic , 40mg once a day
5 ) START LEVOFLOXACIN , an antibiotic , and take one pill every other day to
complete a fourteen day course , last day 6/2/07
6 ) START POTASSIUM CHLORIDE 10mEq a day
7 ) CONTINUE YOUR OTHER MEDICATIONS
YOU WILL HAVE VISITING NURSES COME to the house to assist you with your
oxygen , medication checks and teaching , and a home safety evaluation.
They should also check your electrolytes twice a week , and specifically
monitor your creatinine , potassium , and magnesium with reports to your
primary care physician who can adjust your medications.
Please seek medical attention if you again develop any shortness of
breath , coughing up blood , chest pain , lightheadedness or fainting , or
any other concerning symptoms.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) follow cyclosporine levels , Sirolimus was discontinued during this
hospital admission.
2 ) follow up rheumatoid factor levels , hepatitis serologies , ANCA , CH50 ,
iron deficiency anemia , proteinuria , BAL viral studies , BAL cultures
3 ) follow up BAL cytology
4 ) follow up the lung mass seen on CT scan and blood oozing on
bronchoscopy from RML. Patient has a PET CT scheduled for 10/27 , and
follow up in Pulmonary clinic 10/27
5 ) complete empiric levofloxacin course 14 days , last day 6/2/07
LABS onday of discharge K 3.5 ( given potassium ) , Cr 1.9 , Mg 1.9. Hct
27.5.
No dictated summary
ENTERED BY: BAILLEU , ARA L. , M.D. ( UL372 ) 8/29/07 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1192
| Target |
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HC |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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585843377 | PUO | 62142260 | | 0869471 | 8/6/2006 12:00:00 a.m. | MYOCARDIAL INFARCTION , RENAL INSUFFICIENCY | Unsigned | DIS | Admission Date: 8/6/2006 Report Status: Unsigned
Discharge Date: 4/21/2006
ATTENDING: TONI , CARMELITA M.D.
SERVICE: Cardiac Surgical Service.
HISTORY OF PRESENT ILLNESS: Mr. Pilger is a 74-year-old male who
two weeks prior to admission had some shortness of breath and
fatigue. Family brought him to Forestblan Conwake Hospital Emergency Department for
questionable mental status changes and the patient was found to
have an elevated troponin level. He had a cardiac
catheterization at Abois Che Memorial Hospital , which showed coronary artery
disease. He was referred to Dr. Toni for coronary
revascularization.
PAST MEDICAL HISTORY: Includes hypertension , diabetes mellitus ,
Rolaids treatment , hyperlipidemia , renal failure , COPD , and
atrial fibrillation.
PAST SURGICAL HISTORY: Three-vessel CABG in 1995 , PTCA in 1985.
FAMILY HISTORY: Positive for coronary artery disease.
SOCIAL HISTORY: No history of tobacco use.
ALLERGIES: Shellfish and clams cause GI intolerance.
DRUG ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS: Pretransfer medications , Lopressor
37.5 mg orally three times a day , amlodipine 10 mg orally daily , aspirin 325 mg
orally daily , heparin 150 units an hour , and atorvastatin 80 mg
orally daily.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.8 , heart rate
85 , and blood pressure in the right arm 110/80. HEENT:
Dentition without evidence of infection , no carotid bruits.
Chest: Midline sternotomy. Cardiovascular: Regular rhythm
without murmur. Following peripheral pulses are each 2+ , the
carotid , radial , and femoral. The dorsalis pedis , posterior
tibial are each 1+ bilaterally. Respiratory: Breath sounds
clear bilaterally. Extremities: Left leg saphenous vein harvest
scar. Neurologic: Alert and oriented with no focal deficits.
PREOPERATIVE LABS: Sodium 132 , potassium 4.3 , chloride 99 ,
carbon dioxide 25 , BUN 28 , creatinine 1.8 , glucose 232 , magnesium
1.7 , white blood cell 8.96 , hematocrit 30.1 , hemoglobin 9.8 ,
platelets 281 , 000 , physical therapy 15.6 , INR 1.2 , and PTT 45.6. Cardiac
catheterization data on 9/12/06 , coronary anatomy 100% proximal
LAD , 100% proximal D1 , 80% ostial LAD , 100% mid circumflex , 90%
mid RCA , 100% mid RCA , 70% proximal PDA with right-dominant
circulation , 70% proximal SVG1 to PDA , 90% distal SVG1 to PDA ,
100% proximal SVG3 to LAD. Echocardiogram on 9/12/06 showed 35%
ejection fraction. ECG on 9/12/06 showed atrial fibrillation at
66 with inverted T waves in leads III and aVL. Chest x-ray on
7/25/06 consistent with pneumonia.
HOSPITAL COURSE/BRIEF OPERATIVE NOTE
DATE OF SURGERY:
10/18/06.
PREOPERATIVE DIAGNOSIS:
Coronary artery disease.
POSTOPERATIVE DIAGNOSIS:
Coronary artery disease.
PROCEDURE:
Reoperative CABG x2 with LIMA to LAD , SVG1 to PDA.
BYPASS TIME:
120 minutes.
CROSSCLAMP TIME:
64 minutes.
Two atrial wires , one ventricular wire , one pericardial tube , one
retrosternal tube , one left pleural tube , and one right pleural
tube were placed. The patient came off cardiopulmonary bypass on
5 of epinephrine and 6 of Levophed.
COMPLICATIONS:
None.
After the operation , the patient was transferred in stable
condition to the Cardiac Intensive Care Unit. While on the
Cardiac Intensive Care Unit , his course was complicated by the
following;
1. The patient remained intubated until the morning of
postoperative day #2 , at which time he was extubated without
difficulty. He also remained on both epinephrine and Levophed
until postoperative day #2 , at which time , these were both weaned
off and he was transferred to the Cardiac Step-Down Unit on
postoperative day #2. While on the Cardiac Step-Down Unit , his
course was complicated by the following;
1. Mr. Pilger has had episodes of hyperglycemia during the
postoperative period. Diabetes Management Service had been
following him throughout his hospital course and their
recommendations had been followed. Although he was on
subcutaneous insulin while in the hospital , Diabetes Management
Service recommended that he be discharged on his home
medications. Their recommendation was followed , Mr. Pilger will
go home on his preoperative diabetic regimen.
Otherwise , Mr. Pilger had done quite well and was weaned from his
oxygen requirement and diuresed close to his preoperative weight.
He will be discharged to home on postoperative day #6.
He also , has had a leukocytosis during the postoperative period
that was as high as 20 , 500. His white blood cell count on the
day of discharge is 15 , 000. He has no evidence of any ongoing
infection at this time.
DISCHARGE MEDICATIONS/DISCHARGED INSTRUCTIONS: He will be
discharged to home on the following medications: Aspirin 81 mg
orally daily , Colace 100 mg orally three times a day as needed constipation , Prozac
20 mg orally daily , glipizide 5 mg orally daily , Motrin 600 mg orally
every 8 hours as needed pain , metformin 1 gm orally twice a day , Toprol-XL 150 mg
orally twice a day , Niferex 150 mg orally twice a day , Actos 50 mg orally daily ,
Zocor 20 mg orally nightly , Coumadin for which he will take 2 mg
today. The patient is on Coumadin for atrial fibrillation. Goal
INR is 2-3. Dr. Darci Thepbanthao will be following his INR. Her
number is 245-499-5355. Please draw INR on 3/4/06 and then
twice a week thereafter. Mr. Pilger will follow up with Dr. Toni ,
cardiac surgeon , in six weeks and Dr. Arendz , the patient's
primary care physician in one week , and Dr. Barnaba , the patient's
cardiologist , in two to three weeks.
eScription document: 9-5670626 CSSten Tel
Dictated By: TRIARSI , VERDA
Attending: TONI , CARMELITA
Dictation ID 7332518
D: 11/29/06
T: 11/29/06
Document id: 1193
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
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PVD |
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| output/system_textual_annotation.xml | textual |
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662599763 | PUO | 22537055 | | 4134720 | 4/2/2005 12:00:00 a.m. | ST elevation MI from in stent thrombosis | | DIS | Admission Date: 4/10/2005 Report Status:
Discharge Date: 10/11/2005
****** FINAL DISCHARGE ORDERS ******
KINSTLER , ALBINA 114-14-65-2
Tuc Cam
Service: CAR
DISCHARGE PATIENT ON: 1/1/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ROBBLEE , NERISSA H. , M.D. , PH.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
HYDROCHLOROTHIAZIDE 25 MG orally every day
LISINOPRIL 10 MG orally every day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally every day Starting Today ( 1/4 )
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
LIPITOR ( ATORVASTATIN ) 80 MG orally every day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Starting Tomorrow ( 1/4 )
PROTONIX ( PANTOPRAZOLE ) 40 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Abe Girardi , St,ral Eni Medical Center Wednesday 9/4/05 at 2:00 PM scheduled ,
Dr. Jeana Osdoba , PUO /Cardiology Tuesday , 2/16/05 at 3:00 PM scheduled ,
St,ral Eni Medical Center clinc on 2/3 , please goto clinic and ask that your medications be checked by nurse , that you have appt soon. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Myocardial Infarction
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
ST elevation MI from in stent thrombosis
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , hypertension , hypercholesterolemia ,
obesity , lumbosacral disc degeneration
OPERATIONS AND PROCEDURES:
Cardiac catheterization and emergent balloon angioplasty
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: Chest Pain
------
HPI:57 year-old F with HTN , CAD history of 2 cypher stent in
distal RCA 2/2 NSTEMI representing on 10/30/05 c/o 10/10 Lt ant CP
with EKG changes inc ST elevation in II , III , AVF ->urgent Cath found
total in-stent thrombosis ->reperfused after balloon angioplasty of
stents. ?Noncompliant Plavix Use? Recurrent CP post-cath after
eating 3 dinner trays while supine , less severe -> gone after
SLNTGx1 , suspect GERD.
------
PMH: HTN , CAD history of PCI x 2 stent in RCA history of lysis of acute in-stent
thrombosis , EF 45-50% , Sciatica/Chronic LBP.
------
MEDS: ( noncompliant ) ECASA 325 mg every day , Lisinopril 10 mg every day , sublingual NTG 0.4
mg q5x3 , Toprol XL 200 mg every day , Lipitor 80 mg every day , Plavix 75 mg every day ,
Percocet 1 tab orally every day , HCTZ 25 mg every day
------
ALL:NKDA
------
A+O , obese , CV: Distant heart sounds , RRR , nl S1 , S2 ,
JVP~10. RESP: CTAB. EXT: no edema , 2+ pedal pulses.
------
Studies: EKG 10/27/05 : NSR , LAE , PRWP , TWI in I , aVL ,
V6. MIBI 5/1 EF 43% , severe hypokinesis mid and
basal inferior wall. Cath 4/6/05 : Mid-distant RCA
stenosis , stentx2. EKG 10/22/05 in ED: NSR @75 with ST elevation in II ,
III , AVF with reciprocal depression in V2 , AVL EKG post-Cath 10/22/05 : ST
normalization in II , III , AVF , ST elevation in
V3 TTE 10/22/05 : EF 45-50% , mild global hypokinesis
with post+postlat hypokinesis , mild-mod MR , mild TR
------
Impression: 57 year-old F with HTN and CAD with poor medical adherance history of
in-stent thrombosis requiring emergent balloon angioplasty.
Hospital course:
1. CV-Ischemia- history of NSTEMI with PCI RCAx2 on 10/21/05
requiring angioplasty for in-stent thrombosis on 10/30/05 after
failing to take Plavix as directed.
- Serial cardiac biomarkers trended down -> CKMB 65.1 ( Peak 129 ) , TnI
20.5 ( Peak 33 )
- On ASA , Plavix , BB , Statin , ACE-I , SLNTG as needed , morphine as needed.
- Encouraged smoking cessation , wt loss , therapeutic lifestyle changes
with social work , smoking cessation , and nutritional education
administered. patient was repeatedly advised danger of not taking prescribed
post MI medication and risk of rethrombosis if meds including aspirin and
plavix were not taken. Patient acknowledged this.
- Pump - JVP~10 , HCTZ , BB , no active diuresis
- Rhythm - NSR , on metoprolol then toprol. Incidentally had 2 episodes of
3 second pauses asymptomatic prior to d/c and beta blocker titrated down.
2.PULM-Considered sleep apnea , but no acute issues.
3.GU-Had some minor vaginal bleeding. HCT stable , f/u as outpatient.
4.F/E/N-cardiac diet , K+ , Mg++ scales
5. ENDO - RISS , HgbA1C 6 though most glucose WNL.
6. PPx-Nexium 20mg every day , on heparin subcutaneously
7. SW - Evaluate for help in medical compliance
8. Code - Full
ADDITIONAL COMMENTS: Please take your medicines. Follow up with appointments. Please try to
reduce your smoking. Seek medical attention if you have any more chest
pain , shortness of breath , or concerning symptoms.
DISCHARGE CONDITION: Satisfactory
TO DO/PLAN:
1. Continue Plavix at least 6 months , ASA indefinitely , titrate beta
blocker and ACE-I , continue high dose statin.
2. Close f/u with primary care physician with interim check with KTDUOO NP for med adherance ,
c/u with cardiology. Continue smoking cessation , wt loss guidance.
3. Consider outpatient stress for prognosis. Consider cardiac rehab given
low exercise tolerance.
4. Consider sleep study given possiblity of sleep apnea.
No dictated summary
ENTERED BY: SCHUNEMAN , ELLENA M. , M.D. ( ZO77 ) 1/1/05 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1194
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CHF |
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DM |
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GER |
Gou |
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OSA |
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664437979 | PUO | 89529032 | | 8614787 | 8/17/2006 12:00:00 a.m. | CELLULITIS | Signed | DIS | Admission Date: 10/11/2006 Report Status: Signed
Discharge Date: 1/9/2006
ATTENDING: FANIEL , GAYLENE M.D.
MEDICAL SERVICE: General Medicine Team Snascond Si De , Indiana 55545
HISTORY OF PRESENT ILLNESS: Mr. Abo is a 42-year-old man with
history of diabetes , end-stage renal disease on hemodialysis ,
left Charcot foot complicated by recurrent cellulitis , who
presented with left lower leg swelling , erythema , and pain. The
patient does not recall having fevers at home , however , notes
that he "get fevers all the time" so he feels that he may not
have noticed. He did report that he had a temperature to about
101 and hemodialysis prior to admission for which he received one
dose of vancomycin. He denied having any symptoms of headache ,
chest pain , shortness of breath , abdominal pain , joint aches or
rash. He did endorse feeling fatigued with little energy. The
patient was referred to the Emergency Department given his
temperature of 101 at hemodialysis.
The patient has a long history of pain in his left foot secondary
to Charcot joint and chronic recurrent cellulitis including a
history of MRSA cellulitis. He has had numerous admissions to
PMH in the past year for treatment of the foot for which he
received several courses of antibiotics. He was treated from
10/5 through 10/24 with antibiotics posthemodialysis. At
the end of 10/24 , after returning from weekend away he had
severe exacerbation of the pain in his left foot with progressive
development of swelling on the bottom of his foot. At this time ,
he had extensive evaluation including an MRI of the foot and it
was felt that there was no evidence of osteomyelitis. His
antibiotics were discontinued at this time and he was discharged
to a nursing home for rehabilitation. He remained in the nursing
home from 1/18 through 5/22 and was discharged home two
weeks prior to admission.
PAST MEDICAL HISTORY:
1. Diabetes since the age of 23 , unclear if it is type 1 or type
2. The patient reports that he has a history of type 1 diabetes ,
but also reports that he had been without insulin for three years
after diagnosis. He does have consequent neuropathy ,
retinopathy , and nephropathy.
2. End-stage renal disease on hemodialysis since 7/17
3. Diabetic neuropathy in his legs bilaterally and Charcot feet
bilaterally.
4. History of a left foot , fourth metatarsal osteomyelitis with
surgical resection of the left fourth digit.
5. Retinopathy with history of retinal hemorrhage and
vitrectomy.
6. Hypertension x19 years with a history of malignant
hypertension with documented ophthalmologic and renal
involvement.
7. Gastroesophageal reflux disease.
8. Hyperlipidemia.
9. Recurrent lower extremity cellulitis.
10. History of chronic right foot ulcer.
HOME MEDICATIONS: Colace 100 mg twice a day , folate 1 mg orally daily ,
gemfibrozil 600 mg twice a day , Lantus 30 mg subcutaneously every afternoon , Lipitor 80
mg nightly , Nephrocaps , Neurontin 300 mg daily , PhosLo 2001 mg
three times a day , Protonix 40 mg daily , Renagel 3200 mg three times a day , Requip 2 mg
orally twice a day , Coumadin
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Significant for diabetes.
SOCIAL HISTORY: The patient lives with his parents and his
12-year-old daughter.
PHYSICAL EXAMINATION ON ADMISSION: The patient had a temperature
100.8 , heart rate of 111 , a blood pressure of 140/70 , he was
satting 95% on room air. Physical exam on admission notable for
a 2/6 systolic ejection murmur heard best at the left lower
sternal border. His left lower extremity was notable for 1+
pitting edema with erythema on the anterior shin and as well as
the foot. It was also associated with increased warmth.
PERTINENT STUDIES:
Radiology:
CXR ( 9/10/06 ): no acute cardiopulmonary disease
MRI LE ( 10/23/06 ): 4 cm fluid pocket in the subcutaneous tissue of
the plantar aspect of the left foot demonstrating communication
with the
medial tendon sheaths and the ankle joint with findings worrisome
for abscess and osteomyelitis of at least the medial malleolus ,
calcaneus , cuboid and talus.
Labs:
LFTs: WNL
Alb 2.8
ESR 75 , CRP 276
Hep B surf Ag negative , HCV Ab negative ( 2/22/06 )
Micro:
Blood cx 1/12/7 , 6 growth
Foot aspirate ( 2/22/06 ): gram stain-2+ polys , no org; Cx without
growth
Ankle aspirate ( 2/22/06 ): gm stain-4+ polys , no org; Cx without
growth
Pathology from L BKA ( 1/3/06 )-clean margins
CONSULTS:
Orthopedics ( Dr. Goodnow ) , ID ( Dr. Lapin ) , Psychiatry ( Dr.
Kriticos ) , Acute Pain Service.
HOSPITAL COURSE BY SYSTEM:
1 ) ID-Given his presentation of L lower leg swelling and
erythema , Mr. Abo was started on Vancomycin and Unasyn in the
emergency department. An X-ray of his L foot revealed significant
fragmentation and erosion of the tarsal/metatarsal bases and
focal soft tissue abnormality in the plantar region concerning
for abscess formation and possible osteomyelitis in the setting
of known Charcot arthropathy as well as diffuse soft tissue
swelling extending along the calf. Given these findings , he was
ordered for an MRI. With his MRI pending and his L leg looking
somewhat improved , his Unasyn was discontinued on HD 3 and he was
started on Augmentin and his Vancomycin was continued given his
history of MRSA cellulitis in the past. He spiked a fever on HD 3
and again on HD 4. On HD 5 , he had an MRI under conscious
sedation ( was attempted prior to this , but patient unable to
tolerate ). MRI revealed 4 cm fluid pocket in the subcutaneous
tissue of the plantar aspect of the left foot demonstrating
communication with the medial tendon sheaths and the ankle joint
with findings worrisome for abscess and osteomyelitis of at least
the medial malleolus , calcaneus , cuboid and talus. Infectious
disease was consulted and he was started on intravenous Levofloxacin and
intravenous Flagyl to cover gram negatives and anaerobes respectively and
his vancomycin continued to be dosed for level less than 20.
Orthopedics was consulted who performed an arthrocentesis of his
ankle as well as an arthrocentesis of the fluid collection at the
bottom of his foot. Ankle aspirate gram stain was negative , but
with 4+ polys. Fluid differential revealed >160 , 000 WBCs. In
consultation with infectious disease , orthopedics , and the
patient , it was decided that the best course of action would be a
L below knee amputation given the extent of the infection. This
was performed on HD 8 by Dr. Drenning He did have fever spikes
again on HD 8-9 and had repeat blood cultures which were
negative. An echocardiogram was performed on HD 12. While he did
have a tiny focal thickening of the aortic cusp , this was
reviewed with Cardiology and infectious disease and was not
though to represent a vegetation. He was afebrile x >48 hours
prior to discharge. His surgical pathology returned with clean
margins on day of discharge , and as per ID consult service , he
does not need further antibiotics. He should have dry sterile
dressing changes to his residual limb daily. He may need an extra
dose of pain medication prior to this. If there is any evidence
of erythema or drainage , Dr. Goodnow 's office should be
contacted at 537-773-4828.
2 ) Renal-Mr. Abo was on the renal service and had hemodialysis
3 times a week ( M/W/F ) without complication. Of note , he is
awaiting kidney transplant from his sister and is followed by Dr.
Gaylene Faniel at KAAH .
3 ) Heme-Mr Abo was on coumadin as an outpatient. We obtained
his hospital records from PMH and a vascular study from 9/19
showed evidence of a DVT in the L internal jugular vein from
5/5 The details surrounding this DVT are not documented ,
however Mr. Abo reports that his vascular surgeon told him
that he should remain on Coumadin. His coumadin was held prior to
going to the OR and he was placed on a heparin drip. His coumadin
was restarted after his BKA and he was bridged with heparin with
a goal PTT of 60-80. Prior to discharge , he PTT was 103 and his
heparin drip was decreased from 2100 to 1950units per hours. He
should have a repeat PTT checked on transfer to his acute
rehabilitation center with goal PTT 60-80. INR on day of
discharge was 1.8 , 1.6 day prior to discharge. His heparin drip
can be discontinued once his INR is therapeutic with goal of 2-3.
His INR will need to be followed every 2-3 days until stable off
of levofloxacin.
4 ) CV
Ischemia-Mr Abo was on gemfibrozil 600mg twice a day and lipitor 80mg
as an outpatient. His lipid panel was checked: TC 140 , TG 151 ,
LDL 82 , HDL 28. Given that his LDL was 82 and the risk of
rhabdomylosis on high dose gemfibrozil and lipitor , his lipitor
was decreased to 20mg. He should have a repeat lipid panel in 4-6
weeks. He was also started on low dose b-blocker to reduce
perioperative MI risk prior to his surgery. He reported that he
is not on aspirin given that he has had b/l vitrectomies and his
doctor felt that the risk of bleeding was too high. This can be
readdressed as an outpatient.
Pump-patient had elevated systolic blood pressures to the 160s in the
beginning of his stay. He was started on lisinopril which was
uptitrated to 5mg and also lopressor.
Rhtyhm-He had no evidence of arrythmias.
5 ) Endocrine-Mr. Abo has DM which was diagnosed at age 23. It
is unclear if he has type I or II as he reported that he was told
he has Type I , but had a three year stint after diagnosis where
he was not on insulin. His FS on admission were elevated , likely
secondary to his infection and his lantus was uptitrated. He was
also started on prandial coverage. Prior to discharge , he was his
home dose of Lantus as well as Aspart with meals. He reported
that he already has an outpatient endocrinologist with whom he
will follow up. An HgA1c was 8.4.
6 ) Pain-Mr. Abo had significant post operative pain which
seemed to be mostly phantom limb pain. The acute pain service was
consulted and he was initially placed on a ketamine drip and
Fentanyl PCA. His fentanyl PCA and ketamine drip were
discontinued and he was started on oxycontin 80mg three times a day with
oxycodone for breakthrough pain. He was also started on Lyrica
for neuropathic pain. He was comfortable prior to discharge on
this current regimen. As his pain improves , he pain regimen
should be decreased.
7 ) Psychiatry-After learning that he would likely receive a
transplant from his sister , Mr. Abo reports that he has had
significant anxiety prior to going for dialysis. Psychiatry
service was consulted who recommended low dose Ativan prior to
him going to dialysis.
DISCHARGE EXAM:
Gen: pleasant , well appearing gentleman , in NAD
VS: Tmax: 98.5 Tc: 97.6 BP 122-144 /70-80 P 74-84 R 18 95%
on RA
Pulm: CTA bilaterally , no rales/wheezes
CV: RRR , II/VI SEM at LSB , normal S1/S2
Abd: obese , soft , NT , NABS , no HSM
Ext: L residual limb with dressing that is clean/dry/intact
LABS ON DAY OF DISCHARGE:
( prior to dialysis ) Na 136 , K 4.5 , Cr 6.0 , WBC 7.6 , Hct 28.6 , INR
1.8 , PTT 103
TO DO:
-dry sterile dressing changes to L residual limb daily; if
evidence of erythema , drainage , please contact Dr. Goodnow ???s
office at 007-586-0134
-check PTT on admission to rehabilitation with goal PTT 60-80;
can d/c heparin once INR therapeutic at
2-3
-daily INR until stable at goal 2-3 off of levofloxacin; will
likely need to titrate coumadin
-monitor FS and adjust DM regimen as needed
-monitor pain scale and decrease pain medications as pain
improves
-hemodialysis M/W/F
FOLLOW UP:
-Dr. Tsuji voice message was left on his medical assistant???s
voice mail at 007-586-0134 to contact patient???s parents to arrange
follow up appt in 7-10 days for wound check
-Dr. Hershelman 2/23/06 at 9:30am
eScription document: 7-9999256 CSSten Tel
Dictated By: VEAZIE , OK
Attending: FANIEL , GAYLENE
Dictation ID 0175132
D: 1/18/06
T: 1/18/06
Document id: 1195
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
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U |
U |
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U |
U |
U |
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Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Q |
N |
N |
N |
N |
N |
N |
N |
- |
N |
N |
Y |
N |
N |
N |
736473937 | PUO | 87757880 | | 818940 | 10/22/1999 12:00:00 a.m. | VENTRICULAR TACHYCARDIA | Signed | DIS | Admission Date: 10/22/1999 Report Status: Signed
Discharge Date: 1/14/1999
IDENTIFICATION: This is a 58-year-old gentleman admitted for an
EPS study.
HISTORY OF PRESENT ILLNESS: This is a 58-year-old white male
status post aortic root homograft in
1995 for aortic insufficiency secondary to a bicuspid aorta. The
patient was doing very well. He was followed biannually by Dr.
Fournier Recent echocardiogram showed an ejection fraction of
65% with the graft intact. The patient noted several episodes of
light-headedness over the last several weeks. Most recently while
playing tennis he collapsed; however , denied loss of consciousness.
He denied palpitations. The patient was seen today in Dr.
Berezny clinic where he had a ETT test which was stopped
secondary to runs of monomorphic ventricular tachycardia.
PAST MEDICAL HISTORY: Polio in 1955 , aortic valve root homograft
in 1999.
MEDICATIONS: Cardizem CD 240 milligrams every day , Vasotec 5 milligrams
twice a day , enteric coated aspirin 325 milligrams every day
SOCIAL HISTORY: He denies tobacco and alcohol. He is married with
two children.
FAMILY HISTORY: Negative for arrhythmias.
ALLERGIES: None.
PHYSICAL EXAMINATION: Temperature 98.9 , heart rate 87 , blood
pressure 146/96 , saturating at 96% on room
air. In general , obese male in no acute distress. HEENT: Moist
mucous membranes. There is a left facial droop with decreased
muscle tone. Pulmonary: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. No murmur. Abdomen:
Soft , nontender , obese. Normal bowel sounds. Extremities: No
edema. Neurologic: Alert and oriented times three. Cranial
nerves II-XII grossly intact.
EKG: Normal sinus rhythm. QT intervals normal.
LABORATORY: Sodium 141 , creatinine 1.0 , white count 8.6 , platelet
count 186 , 000. His echocardiogram in October 1999
showed an ejection fraction of 65% , normal homograft function. His
Holter monitor showed sinus rhythm with occasional PVCs and some
couplets. His ETT done in clinic showed he did eight minutes and
33 seconds on a standard Bruce protocol. He had three beats of
polymorphic ventricular tachycardia , asymptomatic. Peak heart rate
was 150 , peak blood pressure 182 systolic.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service. His hypertensive medications were
continued. The patient had a repeat echocardiogram confirming that
he had normal valve function. The patient's echocardiogram showed
an ejection fraction around 50% which revealed AI , no valve
dysfunction. His QT interval remained normal on his EKG. The
patient underwent both a left heart catheterization to rule out
significant coronary artery disease as well as an EP study on
10/21/99. The patient's catheterization showed normal vessels ,
ejection fraction of 55%. His EP study showed normal AV function ,
no inducible SVT. Repeated , new runs of nonsustained monomorphic
as well as polymorphic ventricular tachycardia , some observed on
the ETT test. The recommendations were to start a betablocker and
place an ICD. On June , 1999 , the patient had an ICD placed
without any complications. The patient remained asymptomatic
during his hospital stay. He had no episodes of syncope.
The patient was discharged on May , 1999 in stable condition
with instructions to return to the Emergency Room if he felt his
heart racing as well as to avoid strong magnetic fields and to
maintain a low level of activity until after he sees his physician
for follow up. He has a follow up appointment with Dr. Fiermonte
as well as to follow up with the EP service with Dr. Aroyo within
one month.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 milligrams every day ,
Atenolol 50 milligrams every day , Vasotec 5
milligrams twice a day and Keflex 250 milligrams four times a day for three days.
Dictated By: NINA SURACE , M.D. FS2
Attending: DENISHA H. MCRORIE , M.D. VM86
YG054/4436
Batch: 22055 Index No. BRYQ7S92BT D: 11/28/99
T: 11/28/99
Document id: 1196
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
N |
U |
Y |
U |
- |
U |
Y |
Y |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
N |
N |
Y |
N |
- |
N |
Y |
Y |
N |
- |
- |
N |
N |
N |
235953373 | PUO | 23235646 | | 5509425 | 11/21/2006 12:00:00 a.m. | chronic cough , LBBB | | DIS | Admission Date: 6/24/2006 Report Status:
Discharge Date: 9/22/2006
****** FINAL DISCHARGE ORDERS ******
RIECKE , MAJORIE C 518-70-21-4
Li
Service: MED
DISCHARGE PATIENT ON: 9/24/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
LIPITOR ( ATORVASTATIN ) 40 MG orally DAILY
Alert overridden: Override added on 9/24/06 by :
POTENTIALLY SERIOUS INTERACTION: AZITHROMYCIN &
ATORVASTATIN CALCIUM Reason for override:
will be monitored by primary care physician
AZITHROMYCIN 250 MG orally DAILY X 3 doses
Starting IN a.m. ( 11/10 ) Food/Drug Interaction Instruction
Avoid antacids Take with food
Alert overridden: Override added on 9/27/06 by
WOLFLEY , LUCRETIA S. , M.D.
SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & AZITHROMYCIN
Reason for override: will monitor
ECASA 325 MG orally DAILY
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY nasal DAILY
Number of Doses Required ( approximate ): 6
LANTUS ( INSULIN GLARGINE ) 100 UNITS subcutaneously DAILY
HUMALOG INSULIN ( INSULIN LISPRO ) 12 UNITS subcutaneously before meals
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day Starting Today ( 10/8 ) as needed Wheezing
Instructions: use with a spacer
LORATADINE 10 MG orally DAILY Starting Today ( 10/8 )
Instructions: you can buy the over the counter version of
this medication Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
METFORMIN 1 , 000 MG orally twice a day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally DAILY
Starting Today ( 10/8 )
Instructions: You can by the over the counter version of
prilosec
DIOVAN ( VALSARTAN ) 160 MG orally DAILY
Override Notice: Override added on 9/27/06 by
WOLFLEY , LUCRETIA S. , M.D.
on order for POTASSIUM CHLORIDE IMMED. REL. orally ( ref #
044152177 )
POTENTIALLY SERIOUS INTERACTION: VALSARTAN & POTASSIUM
CHLORIDE Reason for override: will monitor
Number of Doses Required ( approximate ): 6
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Cleverley 348-779-0994 call to make appt at your convenience 1-2 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chronic cough , atypical chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
chronic cough , LBBB
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
htn iddm CRI Colon CA Prostate CA hyperchol otitis externa bullous
myringitis
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: upper respiratory sx
**************************
HPI: 63 year-old M with hx of IDDM , HTN , hyperchol , obesity p/with URI sx. 4 wks
chronic productive cough , rhinorrhea , sensation of nasal discharge
down back of throat. Also with assoc episode of mild CP 2 days.
2 episodes of CP assoc with cough , lasting min , did not occur
with exertion , no SOB , no N/V/diaphoresis , resolved spontaneously.
Presented to ED 2/2 cough which was keeping him up at night. No
F/C/SOB/DOE/PND/orthopnea. No LE edema. Able to walk 3-4 miles 2-3
times per wk with exertional symptoms. Noted to have LBBB that was new
from last ekg done 12 yrs ago , admitted for ROMI.
***************************
PMH: as above , colon CA history of partial colectomy 1992 , prostate CA history of
XRT ( dx 6 yrs ago ) , CRI ( Cr 1.0-1.9 ) 2/2 htn , dm;
LBP
***************************
MEDS: diovan , asa , lisinopril , lipitor , metformin , lantus ,
humalog
***************************
STUDIES: LABS: nl chem7 , nl CBC , neg cardiac
enzymes x3 CXR: no acute
process
****************************
HOSPITAL COURSE: 63M with hx of DM , HTN , obesity , hyperlipidemia a/with
chest pain 2 d ago atypical of cardiac etiology with LBBB from last
ekg in 1994 C/V:
I: hx very atypical of cardiac chest pain , more likely related to
cough. Given LBBB , cardiac enzymes were checked and were negative x 3
( would have
expected + enzymes on initial set if ischemia was present given pain was
>24 hrs prior to presentation ). Lipid panel shows LDL at goal for
diabetic; HDL slightly low but can be followed up by primary care physician. Cont ASA and
statin. Consider outpt ETT-mibi ( LBBB
precludes simple ETT ) , but will defer to primary care physician at this point. P: Cont home
anti-htnsive regimen. No sx of CHF
to warrant echo at this
time. R: new LBBB since last ekg 12 yrs ago , no events on tele
Pulm/Chronic Cough: Most likely gerd v PND v
bronchitis. Given sx worse at night , may have GERD component given
body habitus- trial of PPI. Given sx for 1 mo , started on z-pak.
Added flonase and loratidine for PND. Inhalers for
wheezing as needed ( improved prior to d/c ). ENDO: cont home
regimen ONC: no active inpatient
issues RENAL: at baseline
creatinine FEN: cardiac , diabetic ,
diet PROPHY: lovenox ,
nexium CODE:
full DISPO: f/u with primary care physician for poss outpt
stress imaging
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1 ) Follow up with Dr Slocumb he can decide to have you undergo a stress
test as an outpatient 2 ) Take your medications as directed
No dictated summary
ENTERED BY: WOLFLEY , LUCRETIA S. , M.D. ( WS59 ) 9/24/06 @ 11
****** END OF DISCHARGE ORDERS ******
Document id: 1197
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
- |
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304033148 | PUO | 51423386 | | 742522 | 8/5/1995 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/3/1995 Report Status: Unsigned
Discharge Date: 6/6/1995
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE
ADDITIONAL DIAGNOSES: 1 ) HYPERTENSION; 2 ) HYPER-
CHOLESTEROLEMIA; 3 ) OBESITY
HISTORY OF PRESENT ILLNESS: Mr. Gueretta is a 45 year old gentle-
man with a long history of coronary
artery disease , the first admission to I Warho Hospital
due to myocardial infarction was October , 1988. Coronary
angiography in 1988 revealed three vessel coronary artery disease
with ejection fraction of 45%. The next hospitalization at I Warho Hospital in 1993 due to syncopal episode. Since the last
admission , Mr. Gueretta was doing well , essentially the same level
of symptoms. Objectively , however , there was evidence of
significant progression of coronary disease with Thallium images
suggestive of severe multivessel coronary artery disease and
developed LV dysfunction. Recent admission to I Warho Hospital for coronary artery catheterization and eventual
myocardial revascularization.
PHYSICAL EXAMINATION: 55 year old man , overweight. Blood
pressure 122/80 , heart rate 56 , regular.
Weight 204. Lungs clear. Jugular venous pressure not elevated at
30 degrees. Hepatojugular reflex is negative. Carotid upstroke
normal without bruits. Normal S1 and S2. No murmurs. Abdomen
obese , but otherwise benign. Peripheral pulses are intact
throughout. No pitting edema.
LABORATORY VALUES: White count 7 , 000 , hematocrit 42% ,
184 platelets. BUN 24 , creatinine
1.1 , 1.0 , glucose 101 and sodium 139 , potassium 4.4. physical therapy 12.9 , PTT
25.4 , INR 1.2. EKG - sinus bradycardia and inferior myocardial
infarction. Cardiac catheterization report from the 25 of October ,
1995 revealed coronary artery disease with total occlusion of the
left anterior descending artery in its proximal portion , left
circumflex artery is small , non dominant and large obtuse marginal
branch and the right coronary artery totally occluded in its mid
portion. The left ventriculogram revealed markedly enlarged
ventricle with inferior hypokinesis and apical akinesis.
Calculated left ventricular ejection fraction of 46%.
OPERATION: Coronary bypass to anterior
descending and posterior descending
arteries on the 22 of February , 1995 , surgeon was Dr. Warm
POSTOPERATIVE COURSE: The patient was extubated on the
first postoperative day and
transferred to the ward. Further postoperative course was
uneventful so the patient could be discharged in good postoperative
condition on the fifth ( 5th ) postoperative day.
DISCHARGE MEDICATIONS: 1 ) Aspirin , 325 mg orally every day and
2 ) Tenormin , 50 mg orally every day
CC: Dr. Kenyatta Feazel
Dr. Mackenzie Tyacke
Dictated By: ARLETTA RAUP
Attending: GAYLENE G. FANIEL , M.D. II8
UN003/4502
Batch: 3962 Index No. RNSHRW74Z5 D: 10/11/95
T: 10/11/95
Document id: 1198
| Target |
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CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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562068549 | PUO | 57714321 | | 272887 | 6/14/1996 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 8/30/1996 Report Status: Unsigned
Discharge Date: 4/30/1996
PRINCIPAL DIAGNOSIS: CALCIFIED AORTIC STENOSIS.
ADDITIONAL DIAGNOSES: CORONARY ARTERY DISEASE , STATUS POST
CORONARY ARTERY BYPASS SURGERY IN 1989.
NON-INSULIN-DEPENDENT DIABETES MELLITUS.
HYPERTENSION.
PSORIASIS.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old lady with
known history of coronary artery
disease , who underwent coronary artery bypass grafting x three in
1989 , with left internal mammary artery to the left anterior
descending , saphenous vein graft to the obtuse marginal , and
saphenous vein graft to the right coronary artery. In the last
four months , she experienced chest tightness and dyspnea on
exertion , and during the last month , her fatigue was extreme. The
patient was admitted on 7/22/96 to Docdrew University Hospital where an
echocardiogram revealed low-normal ejection fraction with severe
aortic stenosis and mild aortic insufficiency. Aortic valve area
was calculated on 0.8 square centimeters. Cardiac catheterization ,
performed in the same hospital , revealed an ejection fraction of
66% with normal pulmonary artery pressures , aortic valve area of
0.6 square centimeters , and gradient across the valve of 44 mm
of Hg. Native coronary artery disease showed 70% stenosis of the
left main , occluded left anterior descending , 50% stenosis of the
obtuse marginal , and 70% stenosis of the right coronary arteries.
The graft to the left anterior descending and to to the OM1 were
patent. The saphenous vein graft to the right coronary artery was
occluded.
ADMISSION MEDICATIONS: Aspirin 325 mg orally every day Micronase. Lasix
40 mg every day Captopril 12.5 mg orally three times a day
Procardia. Colace.
PHYSICAL EXAMINATION: GENERAL: Pleasant 61-year-old lady.
Afebrile. VITAL SIGNS: Pulse 72 and
regular. Blood pressure 106/80. NECK: Supple. No bruits.
LUNGS: Clear. HEART: S1 and S2 clear. A 3/6 systolic murmur
over right upper sternal border. ABDOMEN: Soft. Benign.
Nontender. EXTREMITIES: Saphenous vein graft harvesting scar on
the medial aspect of the left thigh. Pressure pulse palpable.
NEUROLOGIC: Intact.
LABORATORY DATA: Sodium was 140 , potassium 3.7 , BUN 24 , creatinine
0.7 , glucose 204 , white count ___ , hematocrit 40.
HOSPITAL COURSE: Due to the significant aortic stenosis and
severity of the symptoms , the patient was
referred to Cardiac Surgery for an aortic valve replacement and
possible coronary artery bypass grafting. The patient underwent
aortic valve replacement with a St. Jude valve on August , 1996;
the surgeon was Dr. Warm The immediate postoperative course
was uneventful. The patient was extubated on the first
postoperative day and transferred to the floor. Further recovery
on the floor was not associated with significant complications.
Antibiotic therapy with Ofloxacin was started for the urinary tract
infection. The patient regained a significant level of her
preoperative physical ability. Anticoagulation with Coumadin was
started on the first postoperative day. The patient was discharged
from the hospital in stable postoperative condition on September ,
1996 , with:
DISCHARGE MEDICATIONS: Tylenol one to two tablets every three to four
hours. Lasix 40 mg orally every day Micronase 5
mg orally twice a day Lopressor 50 mg orally twice a day Procardia XL 30 mg
orally twice a day Coumadin , according to the INR values with goal values
of 2 to 2.5. Ofloxacin 200 mg orally twice a day for four days.
Dictated By: DESTINY FABBRI , M.D. UK97
Attending: GAYLENE G. FANIEL , M.D. II8
HY791/4653
Batch: 03439 Index No. L7CRZH6EZT D: 3/24/96
T: 1/13/96
Document id: 1199
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
Y |
N |
N |
N |
680123950 | PUO | 23765166 | | 3114728 | 7/12/2005 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 3/9/2005 Report Status:
Discharge Date: 3/6/2005
****** DISCHARGE ORDERS ******
BOISE , ALEISHA 606-72-17-2
Ville Daleusintemperich
Service: CAR
DISCHARGE PATIENT ON: 11/18/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: PEDERZANI , SHIZUKO E. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 81 MG orally every day
LASIX ( FUROSEMIDE ) 120 MG orally twice a day
ZESTRIL ( LISINOPRIL ) 30 MG orally every day
HOLD IF: sbp<100 and please notify h.o.
Override Notice: Override added on 8/17/05 by MAROLA , TIA GWEN , M.D. on order for ALDACTONE orally ( ref # 44769965 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override: will follow
Previous override information:
Override added on 8/17/05 by MAROLA , TIA GWEN , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will follow
ALDACTONE ( SPIRONOLACTONE ) 25 MG orally every day HOLD IF: sbp<100
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 8/17/05 by MAROLA , TIA GWEN , M.D.
SERIOUS INTERACTION: POTASSIUM CHLORIDE & SPIRONOLACTONE
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override: will follow
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
TOPROL XL ( METOPROLOL ( SUST. REL. ) ) 75 MG orally every day
HOLD IF: sbp<100 , heart rate<55 and call h.o
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 10
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: 2 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr Verbridge , LMC 1-2 wks ,
LMC Clinic 1-2 wks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN , borderline DM2 , obesity
OPERATIONS AND PROCEDURES:
LHC 1/27 -> no epicardial disease
RHC 1/27 -> mildly elevated filling pressures
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: DOE x 6 months
HPI:67M with HTN , hyperlipidemia , DM2 , ?NSTEMI in 1999 ( cath 4/8
with non-occlusive CAD ) presenting with 6 months of worsening DOE and
PND , increased abdomnal girth , 8lb wt gain in last 2 wks and increased
LEE in last 1 week. 2-3 pillow orthopnea. Ran out of BP meds 2 days
ago. Lives in Me Gene T , comes to Go Sand Ga intermittently for medical care.
In ED 165/115 ->130s/100 after lasix 40 , 80 intravenous and lopressor ,
started heparin drops
PMH:HTN / DM2 ( not on treatment of any kind ) / obesity
Meds:not taking any ( prescribed atenolol 100 twice a day , norvasc 10 )
NKDA
EXAM:96.7 67 128/80 22 98%2L
tachypneic , sitting up JVP 11-12 RRR distant heart sounds , no
m/r/g bibasilar crackles ( had been lower 1/2 in ED ) extr 1+pitting edema
to mid shin , cool 1+dp bilaterally
LABS:HCO3 18 / HCT 49.6 / BNP 1161 TnI 0.43 / CK 196 / MB 5
CXR:enlarged cardiac silhouette and pulm edema
EKG:LBBB ( new )
HOSPITAL COURSE
OVERVIEW: 67M with non occlusive CAD on cath 4/8 who presented with s/s
L and R heart failure and troponin leak attrubuted to CHF. ECHO this
admission showed EF 15-20%. Diuresed 3 kg , started on CHF medical
regimen.
CV:
ISCH:Ruled out for MI , troponin leak attributed to CHF , however given
low EF <15% ( 30% in 1999 ) and new LBBB went for LHC 1/27 to evaluate for
ischemic CMP which showed no epicardial disease.
PUMP:fluid OL on admission. Felt much better after 3 kg diuresis , RHC on
1/27 showed mildly elevated filling pressures. DRY WEIGHT ON DISCHARGE
WAS: SBPs on current regimen were 110-120.
Started on ACE , BB , aldactone and transitioned to orally lasix.
RR: admission EKG showed LBBB which was new. Remained stable in NSR with
LBBB. Had 4-6 beat runs of WCT on tele.
HEME: HCT stable post cath
ENDO: per patient had diagnosis of DM2 x2 years , not clear if on treatment ,
though patient thinks he is on something at home. FSG here on ADA diet
were 100-120 in a.m. and pre-lunch , pre-dinner 170-190. Suggested diet ,
exercise and metformin 500 every day However , he will see his primary care physician who will
likely address this issue as his fingersticks have him elevated while in
the hospital.
RENAL:mild CRI ( at baseline 1.3 )
FC
ADDITIONAL COMMENTS: Weigh yourself each day , if your weight goes up by 2 lbs in 2 days , call
your doctor about adjusting your lasix dose. You need to stick to your
low salt and 2 liter fluid diet.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: VARONE , THURMAN B. , M.D. ( UU934 ) 11/18/05 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 1200
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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202194964 | PUO | 71735494 | | 919756 | 7/20/1999 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/13/1999 Report Status: Signed
Discharge Date: 11/2/1999
PRINCIPAL DIAGNOSIS: 1. Atrial flutter. 2. Congestive heart
failure.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old male with
a history of congestive heart failure
and history of atrial flutter in September of 1998. The patient was
admitted to Cardiology for treatment of atrial flutter and
worsening congestive heart failure. The patient initially
presented to Pagham University Of in September of 1998 with
acute shortness of breath and atrial flutter. Chest x-ray at that
time showed congestive heart failure. The patient was initially
rate controlled with Verapamil and Digoxin and converted to normal
sinus rhythm. However , on Digoxin , the patient developed
junctional tachycardia , which reverted back to normal sinus rhythm
after Digoxin was discontinued. Echocardiogram at that time showed
an ejection fraction of 35%. The patient was discharged on 11 of May
in normal sinus rhythm. The patient was discharged on Lopressor ,
Verapamil , Aspirin , and Coumadin , which was stopped five months
ago. The patient did extremely well after discharge until about
five days ago when he ran out of his Atenolol , which he had not
taken since then. Over the past week , the patient had extreme
fatigue and dyspnea on exertion , which steadily worsened. Today ,
the patient was taking out the trash and experienced a few seconds
of chest heaviness on the left side , without any radiation. The
patient reported being short of breath , but had no other symptoms.
Upon trying to the mailbox , the patient was extremely short of
breath and fell to the ground , but had no loss of consciousness.
There was no warning or dizziness. The patient was brought to
Gle Ra Csylv Valley Medical Center Emergency Department. There , the patient was
noted to be in atrial flutter at a rate of 150. The patient was
given intravenous Lopressor , 5 mg , and his heart rate came down to 106.
REVIEW OF SYSTEMS: A review of systems was positive for three
pillow orthopnea , paroxysmal nocturnal dyspnea , and increasing
lower extremity swelling over the past week. The patient denied
any fever , chills , night sweats , or change in bowel movements.
PAST MEDICAL HISTORY: Past medical history was significant for
high blood pressure , left ankle and left knee arthritis ,
questionable history of gout , gonococcal urethritis ,
diverticulosis , elevated cholesterol , and cardiomyopathy with
ejection fraction of 35% by echocardiogram in September of 1998.
ALLERGIES: The patient has no known drug allergies. MEDICATIONS
ON ADMISSION: At the time of admission , the patient was on
Simvastatin 10 mg orally every day , Amlodipine 5 mg orally every day ,
Atenolol 25 mg orally every day , which the patient self discontinued
five days prior to admission , Lisinopril 20 mg every day , Aspirin ,
B12 , Folate , and Multivitamins. SOCIAL HISTORY: The patient's
social history was significant for tobacco , one pack per day for
forty years. The patient quit in February of 1998. Alcohol was
significant for two to three drinks per day , with none since
September of 1998. There was no history of drug use. The patient
lives in Colorado alone. The patient is a retired social worker.
FAMILY HISTORY: The patient's family history was significant for a
mother with a myocardial infarction at 60 , brother with myocardial
infarction at 54 , and father who is deceased from cerebrovascular
accident.
PHYSICAL EXAMINATION: On physical examination , the patient was
afebrile. The heart rate was 115 , blood
pressure 150/100 , and saturation 95% on 2 liters. In general , the
patient was alert and oriented and in no acute distress. HEENT
revealed the patient to be normocephalic , atraumatic. The pupils
were equal , round and reactive to light. The extraocular movements
were intact. The oropharynx was moist. The neck was supple
without bruits. The chest was clear to auscultation.
Cardiovascular examination revealed a 1/6 holosystolic murmur. The
patient was in atrial flutter. The abdominal examination was
benign. The extremities showed 1+ edema bilaterally. There was no
clubbing or cyanosis. Electrocardiogram on admission showed atrial
flutter at rate of 50 , as well as left axis deviation , right bundle
branch block , left ventricular hypertrophy with QRS widening , old
inferior myocardial infarction , and right bundle branch block.
Chest x-ray showed cardiomegaly with pulmonary vascular congestion ,
consistent with congestive heart failure , and bilateral pleural
effusions.
LABORATORY DATA: Laboratory data on admission showed sodium 146 ,
potassium 4.4 , creatinine 1.2 , white blood cell
count 6.7 , hematocrit 42.5 , CK 95 , and troponin 0.05.
HOSPITAL COURSE: The patient was admitted to the Cardiology floor
for treatment of atrial flutter and congestive
heart failure. The patient was ruled out for myocardial
infarction. It was felt that the patient's worsening congestive
heart failure was likely secondary to his flutter. The patient was
started on Lasix in addition to being started on a beta blocker.
However , the patient remained in atrial flutter with poor rate
control. Echocardiogram on 7 of September showed an ejection fraction of
30-35% with global hypokinesis. Of note , also , the patient's
ventricular myocardium showed an echo bright appearance consistent
with possible infiltrative disease. On 14 of October , the patient
underwent cardioversion without complications , as he was still in
atrial flutter and was not having good rate control. The patient
was successfully cardioverted and remained in sinus rhythm
afterwards. However , on 23 of May , the patient was still significantly
short of breath and hypoxic. This was felt probably likely
secondary to fluid overload , and the patient was started on Lasix.
However , the patient underwent a VQ scan and was ruled out for
pulmonary embolism. The patient did well and , on 6 of April , the patient
experienced bilateral lip swelling , consistent with angioedema.
The patient's Lasix and Captopril were discontinued , as it was
unclear which agent had caused this , however , it was most likely
the Captopril. This responded well to Benadryl. The patient was
started on ethacrynic acid and Hydralazine for diuresis and
afterload reduction. The patient did well on this regimen. On
26 of February , the patient was discharged home in stable condition. The
patient was in sinus rhythm and was satting well on room air.
MEDICATIONS ON DISCHARGE: At the time of discharge , the patient
was on Albuterol nebulizer 2.5 mg
inhaled every 4-6 hours as needed for wheezing , Enteric coated aspirin
325 mg orally every day , Atenolol 25 mg orally every day , Edecrin 25 mg orally
twice a day , Folate 1 mg orally every day , Hydralazine 10 mg orally four times a day ,
Simvastatin 10 mg orally every bedtime , Amlodipine 5 mg orally every day , and
Benadryl 50 mg orally every 6 hours as needed for lip swelling.
FOLLOW-UP: The patient was instructed to follow-up with Dr. Mcneely
in one week. DISPOSITION: The patient was discharged to home with
services , to be followed by Airv Paulfullna Well , Connecticut 07292 VNA for blood pressure and
weight checks every other day
Dictated By: MA YEAGLEY , M.D. AE12
Attending: DENISHA H. MCRORIE , M.D. XT0
OH081/9907
Batch: 76565 Index No. ZJYPFY4YEE D: 3/17/99
T: 8/20/99
QF9
Document id: 1201
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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987234569 | PUO | 94878180 | | 9419085 | 11/19/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/2/2004 Report Status: Signed
Discharge Date:
ATTENDING: ISABELLE EVON COLASAMTE MD
SERVICE: Cardiac Surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male
who was being worked up for other surgery and during preoperative
testing he was noted to have an abnormal EKG. This prompted a
cardiac stress test , which was abnormal. He therefore received
additional cardiac workup and was found to have coronary artery
disease. He does have a history of atrial fibrillation in the
past , but reports that he has not had any symptoms prior to his
initially planned shoulder surgery. He therefore presented for
CABG rather than having shoulder surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Hyperlipidemia.
4. COPD.
5. BPH.
6. Paroxysmal atrial fibrillation.
7. Nephrolithiasis.
8. Impotence.
9. Bursitis.
10. Non-allergic rhinitis.
11. History of hepatitis in 1960.
12. Constipation.
13. Right-sided renal artery stenosis.
14. Renal insufficiency.
PAST SURGICAL HISTORY:
1. Left rotator cuff repair in 1991.
2. Tonsillectomy.
3. Thumb surgery in childhood.
FAMILY HISTORY: No history of coronary artery disease.
SOCIAL HISTORY: The patient has a history of smoking. He also
drinks approximately 2 beers per month.
ALLERGIES: Procainamide , which causes diarrhea and arthralgia ,
also verapamil , which can cause constipation.
MEDICATIONS UPON ADMISSION:
1. Toprol 25 mg orally every day
2. Lisinopril 10 mg orally every day
3. Propafenone 150 mg orally every day
4. Aspirin 325 mg orally every day
5. Rhinocort Aqua 32 mcg every day
6. Simvastatin 20 mg orally every day
7. Metformin 500 mg orally every day
8. Glyburide 5 mg orally twice a day
PHYSICAL EXAMINATION: Upon admission , height 5 feet 10 inches ,
weight 102 kg , heart rate of 54 , blood pressure 130/88 in the
right arm and 142/88 in the left arm. HEENT: Pupils equal ,
round , and reactive to light. Extraocular movements are intact.
Mucous membranes are moist. Oropharynx is clear. There are no
carotid bruits. Dentition is without evidence of infection.
Chest is free of incisions. Cardiovascular: Regular rate and
rhythm. There are no murmurs. Pulses: Carotid , radial ,
femoral , dorsalis pedis , and posterior tibialis pulses are all 2+
bilaterally. Allen's test in the left upper extremity was normal
with using a pulse oximeter. Respiratory: The patient has clear
breath sounds bilaterally. Abdomen: There are no incisions.
Abdomen is soft , nontender , and nondistended with normoactive
bowel sounds. Extremities: Are free of scarring , varicosities
or edema. Neurologic: The patient is alert and oriented. He
has no focal deficits.
LABS UPON ADMISSION: Sodium 140 , potassium 4.0 , chloride 105 ,
bicarbonate 28 , BUN 18 , creatinine 1.3 , glucose 178 , magnesium 2 ,
white count 8 , hematocrit 38.5 , hemoglobin 13.6 , platelets 163 ,
physical therapy 16 , INR 1.3 , PTT 34.9. Urinalysis is normal. Cardiac
catheterization done on 8/28/04 revealed a 90% ostial LAD
lesion , 70% ostial ramus , 90% mid D1 , 80% ostial D3 , 75% proximal
circumflex , 50% ostial RCA , 90% proximal PDA. There was right
dominant circulation and 75%-80% right renal artery stenosis. He
had an ejection fraction of approximately 60%.
HOSPITAL COURSE: The patient was admitted to hospital on
4/25/04 and was taken to the operating room on 10/19/04 where he
received a five-vessel CABG in which the left internal mammary
artery was sewn to the LAD. Saphenous vein graft 1 to first
diagonal artery. Right internal mammary artery was sewn to the
ramus. The left radial artery was harvested and sewn to LVB2 and
LVB1. Bypass time was 159 minutes. Cross clamp time 111
minutes. Postoperatively , he was taken to the cardiac intensive
care unit where he was hemodynamically stable. He was rapidly
weaned of the ventilator without problems. He did develop a bout
of rapid atrial fibrillation in the first two days
postoperatively. This was treated by restarting the patient's
propafenone , which he was taken preoperatively for atrial
fibrillation. The patient's other primary issue postoperatively
while in the intensive care unit was an episode of oliguria , near
anuria. A renal consult was obtained at this time. He did
receive a bilateral renal ultrasound , which showed kidneys to be
essentially equal in size with no hydronephrosis. He was started
on low-dose dopamine and once his systolic pressure went back to
his baseline preoperative systolic pressure of approximately 160 ,
he began to make adequate amounts of urine. It was therefore
determined that his renal perfusion is largely pressure dependent
with him requiring a mean pressure of close to 100. He remained
hemodynamically stable. He did have some constipation , which was
treated with an aggressive bowel regimen and subsequently
resolved. He will be transferred out to the cardiac step-down
unit on 9/7/04.
The remainder of this discharge summary will be dictated at the
time of discharge.
eScription document: 0-8065399 ISSten Tel
Dictated By: MARCOTT , DESIRAE
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 5586214
D: 6/14/04
T: 6/14/04
Document id: 1202
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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492693143 | PUO | 37085341 | | 891835 | 10/23/1991 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 6/12/1991 Report Status: Unsigned
Discharge Date: 8/16/1991
HISTORY OF PRESENT ILLNESS: This is a 58-year-old Oriental male
with three vessel coronary artery
disease awaiting surgical evaluation. The initial onset of angina
was in 1972. He had a positive ETT with ST depressions in V5 and
V6. He had only rare angina since then treated with sublingual
nitroglycerin or rest. On 5/16/91 , he had a positive ETT which was
stopped secondary to chest pain. The EKG showed 2 mm ST
depressions in two , three , F and V4 through V6. He was encouraged
to have a cardiac catheterization , but he was reluctant to do this.
He has good exercise tolerance; takes long walks with his wife
without chest pain and swims for an hour a day. He had a cardiac
catheterization on the day of admission which showed 70% left main ,
100% left circumflex , 100% RCA and 90% LAD. PAST HISTORY:
Significant for GI bleed in the past. MEDICATIONS ON ADMISSION:
Atenolol; Persantine.
PHYSICAL EXAMINATION: Revealed a pleasant man in no acute
distress. The HEENT exam was benign. The
neck was supple and nontender. The lungs were clear. The heart
exam revealed a regular rate and rhythm. Pulses were 2+
bilaterally without bruits. The neuro exam was nonfocal.
ASSESSMENT: 58-year-old Oriental male with unimpressive symptoms
but strongly positive ETT and severe three vessel coronary artery
disease including left main at catheterization.
HOSPITAL COURSE: The patient was seen by cardiac surgery and
evaluated. He was taken to the operating room on
8/12/91. He had a coronary artery bypass graft times four with a
LIMA to the LAD and saphenous vein grafts to the diagonal , marginal
and PDA. Postoperatively he did very well with the exception of
24-48 hours of severe confusion and agitation after extubation
requiring four point restraints and Haldol. He gradually resolved
this by postop day #3 and began gently diuresing. His wound had
continuous oozing from the left thigh with no erythema or sign of
infection. This was continued on dressing changes.
DISPOSITION: He was discharged uneventfully on postop day #7 with
VNA follow up for his wound. FOLLOW UP will be with
Dr. Pittinger in three weeks.
PI427/2102
GAYLENE G. FANIEL , JR , M.D. II8 D: 4/11/91
Batch: 2215 Report: S3074J1 T: 10/18/91
Dictated By: ELENA S. BIALY , M.D. FO02
Document id: 1203
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
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- |
161893834 | PUO | 47837344 | | 055003 | 1/15/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/16/1991 Report Status: Signed
Discharge Date: 2/5/1991
CHIEF COMPLAINT: Rule out myocardial infarction.
HISTORY OF PRESENT ILLNESS: This is a 39-year-old white male with
multiple risk factors for coronary
artery disease , including sex , weight , hypertension , smoking ,
positive family history and cholesterol. He had a four month
history of exercise induced crescendo angina with palpitations and
had an exercise thallium study done on the day of admission. The
results of this showed questionable evidence of ischemia. He was
able to exercise for nine minutes and 16 seconds with a heart rate
of 160 and a blood pressure of 166/84. His test was stopped for
mild chest pain of 3/10 and fatigue. There was no EKG changes
except for some APCs , PVCs and upsloping ST changes. A thallium
scan showed a fixed inferior defect and anterior redistribution on
a later scan; this was on a preliminary reading. The final reading
is pending at this time. After the study , he continued to have
waxing and waning episodes of chest pressure that were not
completely relieved with nitroglycerin. In the emergency room , he
was treated with metoprolol , sublingual nitroglycerin , heparin
drip and aspirin. ALLERGIES: None known.
PHYSICAL EXAMINATION: Revealed a well appearing anxious man in no
apparent distress. The HEENT exam was
unremarkable. The neck was supple with a 0.5 cm nodule in the left
upper pole of the thyroid that is moveable and nontender. The
cardiovascular exam revealed no extra heart sounds or murmurs. The
lungs were clear. The abdomen was soft and nontender. The
extremities were without cyanosis , clubbing or edema. He had good
distal pulses and no bruits in the femoral arteries post
catheterization. The wound was clean.
LABORATORY EXAMINATION: Cholesterol 285; serial CKs 112 , 81 and
66; T-3 149; T-4 6.6; TSH 1.5.
HOSPITAL COURSE: He continued to have chest pain during the
evening with normal EKGs unchanged from
admission. Because of the continued nature of the pain , he was
placed on a nitroglycerin drip and given morphine sulfate which
controlled the pain. On the second hospital day he had a cardiac
catheterization of both sides of the heart which showed normal LV
function and normal coronaries per the cardiology note. He has
been free of chest pain since the procedure and has been taken off
of all of his medications.
DISPOSITION: He was discharged in good condition. MEDICATIONS ON
DISCHARGE: Tylenol 650 mg orally as needed pain. FOLLOW
UP will be with Dr. Theiling , his cardiologist. Dr. Pigler has
been informed of the findings on cardiac catheterization , and the
patient has been instructed to call her after his meeting with the
cardiologist. He has also been advised to lose some weight and to
modify his diet in order to correct his hypercholesterolemia. Dr.
Pigler will follow up on the thyroid nodule and the high
cholesterol.
DISCHARGE DIAGNOSES: 1. RISK FACTORS FOR CORONARY ARTERY DISEASE.
2. HYPERTENSION.
3. TEN PACK YEAR SMOKING HISTORY ( INACTIVE ).
4. TONSILS AND ADENOIDS , ORAL SURGERY.
5. HYPERCHOLESTEROLEMIA.
OPERATIONS/PROCEDURES: CARDIAC CATHETERIZATION , 10/3/91.
ZV321/4916
RUFUS CARLIE BERNAS D: 4/13/91
Batch: 7408 Report: M7600A8 T: 1/11/91
Dictated By: HERMINA T. TUOMALA , M.D.
Document id: 1204
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
- |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
U |
U |
Y |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
Y |
- |
N |
Y |
Y |
N |
N |
N |
N |
Y |
N |
411225632 | PUO | 76422484 | | 4604948 | 10/16/2007 12:00:00 a.m. | sepsis | Unsigned | DIS | Admission Date: 8/9/2007 Report Status: Unsigned
Discharge Date: 9/23/2007
ATTENDING: YEAGLEY , MA GLADIS MD
PRINCIPAL DIAGNOSIS: Cholecystitis.
SECONDARY DIAGNOSES: Bacteremia , hypotension , coronary artery
disease , diabetes , hypertension , hyperlipidemia.
CHIEF COMPLAINT: Chills/hypotension.
HISTORY OF PRESENT ILLNESS: Mr. Broitzman is a pleasant
69-year-old gentleman with a history of CAD , PVD , diabetes who
presents with 3 days of feeling poorly. He initially had lower
abdominal pain 4/10/2007. He went to see his primary care
doctor on 7/26/2007 where labs were drawn. He had one episode
of emesis ( watery and nonbilious ). On the day of admission , he
woke up with chills and called his primary care physician who recommended he go to
the ED for further evaluations.
REVIEW OF SYSTEMS: Remarkable for a poor appetite. He denied
any shortness of breath , cough , current abdominal pain , diarrhea ,
or dysuria. In the ED his temperature was 104.8 , his blood
pressure was 70/45 , with heart rate in the 120s. His exam was
also remarkable for altered mental status with confusion
regarding dates and requiring frequent reorientation. A central
line was placed and he was given vancomycin , levofloxacin , and
Flagyl prior to transfer to the MICU for further care.
PAST MEDICAL HISTORY: Hypertension , diabetes type 2 which has
been diet controlled , hypercholesterolemia , coronary artery
disease status post 4 vessel CABG in 2004 , EF of 35% ( per echo in
2004 ) , history of A-Fib on chronic Coumadin , a history of
peripheral vascular disease status post left popliteal bypass ,
bilateral ankle grafts , gallstones on right upper quadrant
ultrasound in 2/27
MEDICATIONS ON ADMISSION: Aspirin , atenolol , lisinopril , Lasix ,
Zocor , digoxin , Cilostazol , multivitamins , Protonix , K-Dur ,
Ambien , lorazepam , and Coumadin.
ALLERGIES: Penicillin causes hives , Norvasc , Plavix ( GI upset ).
PHYSICAL EXAMINATION: On admission on transfer to floor after
MICU stabilization , temperature 97.9 , heart rate 99 , blood
pressure 98/60 , respiratory rate 20 , sating 100% on 2 liters. In
general , he was awake and alert , and appropriately answering
questions. His HEENT exam was notable for upper dentures.
Otherwise , his oropharynx was clear. His neck was supple , a
right IJ was in place. He had no bruits. His lungs were clear
to auscultation bilaterally. His heart rate was tachycardic ,
irregularly irregular , without any murmurs. His abdomen was
soft , nontender , nondistended , with good bowel sounds with no
hepatosplenomegaly and a negative Murphy's sign. His extremities
had no edema. There were trace DP pulses. His bilateral
extremities were cool. His neuro exam , he was alert and oriented
x3. He was moving all extremities and his cranial nerves were
intact.
STUDIES/PROCEDURES:
Surgery: A laparoscopic cholecystectomy was attempted and
failed. "White bile" drained from his gallbladder , his liver was
very friable. The surgeons aborted the procedure and recommended
medical therapy.
CT of Abdomen/Pelvis: Demonstrated ascending/transverse colitis.
HOSPITAL COURSE BY PROBLEMS:
1. Cholecystitis/Bacteremia: The patient presented with septic
physiology with the source thought to be acute cholecystitis. He
was brought to the OR for laparoscopic cholecystectomy which was
aborted due to his liver disease causing his friable liver and
his high operative risk. The surgical team recommended medical
therapy. He improved markedly on Cipro/Flagyl and is planned for
a 2-week course at discharge. Due to his liver disease ,
hepatitis serologies were checked which did not reveal ongoing
infection. It is recommended that he follow up with a
gastroenterologist for further workup.
2. Cardiovascular ( Ischemia ): Mr. Broitzman has a history of
CAD status post CABG with an episode of hypotension/sepsis. In
this setting , he had an NSTEMI with troponin peaking at 0.95. He
is continued on his aspirin and his statin.
3. Cardiovascular ( Pump ): Given his septic presentation , his
antihypertensives were initially held. They were restarted 3
days prior to discharge , and Mr. Broitzman had pressures in the
90s but was asymptomatic with these pressures. It was thought
that he was clinically dry. So , Lasix was held at discharge with
the plan to restart them with any weight gain ( the patient weighs
himself daily ) , shortness of breath as advised by his cardiac
nurse ( who will see early on the week of discharge ).
4. Cardiovascular ( Rhythm ): Mr. Broitzman has a history of
A-Fib on Coumadin , digoxin , and atenolol at home. He will be
discharged on Coumadin/digoxin/Lopressor given his marginal blood
pressures with low-dose beta blockade.
5. Heme: The patient's INR increased to 3.9 at the time of
discharge ( likely secondary to Cipro and Coumadin interaction ).
This was discussed with the patient's Megoo Sweven Hospital anticoagulation
nurse and plans were made to hold Coumadin for 3 days' time and
recheck it on 11/23/2007.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily , ciprofloxacin 250 mg
every 12 hours , digoxin 0.25 mg daily , Colace 100 mg orally twice
daily , lisinopril 2.5 mg at bedtime , Maalox as needed upset stomach ,
Lopressor 12.5 twice a day , Flagyl 500 mg three times a day , omeprazole 40 mg
twice a day , oxycodone 5-10 mg every 6 hours as needed pain , Zocor 40 mg nightly ,
multivitamin one tablet daily.
eScription document: 7-3414754 HFFocus
Dictated By: ARORA , ROMANA
Attending: YEAGLEY , MA GLADIS
Dictation ID 8188450
D: 3/24/07
T: 3/24/07
Document id: 1205
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
500428092 | PUO | 11359155 | | 2836420 | 2/15/2006 12:00:00 a.m. | POST OP LOWER EXTREMITY EDEMA | Unsigned | DIS | Admission Date: 2/15/2006 Report Status: Unsigned
Discharge Date: 5/28/2007
ATTENDING: TONI , CARMELITA M.D.
PRINCIPAL DIAGNOSIS: Congestive heart failure , question
incisional cellulitis.
HISTORY OF PRESENT ILLNESS: 68-year-old woman who underwent
mitral valvuloplasty and CABG on 10/2/06 , postoperative issues
included atrial fibrillation. She was
discharged on 1/3/06 and now returns to the emergency room with
lower extremity swelling as well as erythema noted at the lower
pole of her sternal wound. The patient denies purulent drainage
from wound , chills or nausea and vomiting. She reports recent
low-grade temperatures of 100.
PAST MEDICAL HISTORY: Hypertension , insulin-dependent diabetes
mellitus , hypothyroidism , hypercholesterolemia , COPD , GERD ,
depression , history of GI bleed on Coumadin therapy and pulmonary
hypertension.
PAST SURGICAL HISTORY: Status post appendectomy , status post
cholecystectomy , status post tonsils and adenoids , status post
tubal ligation and removal of left upper extremity lipoma.
FAMILY HISTORY: Mother died of cervical cancer.
SOCIAL HISTORY: The patient has a remote history of smoking ,
quit 9 years ago , no alcohol use. The patient lives with her
husband on the Ine 1 , Corp Ster S She is a retired
clothing company worker.
ALLERGIES: Bactrim causing hives and erythromycin causing
abdominal cramps.
MEDICATIONS ON ADMISSION:
1. Toprol 25 orally daily.
2. Valsartan 40 mg orally daily.
3. Aspirin 81 mg orally daily.
4. Plavix 75 mg orally daily.
5. Coumadin variable dose daily.
6. Lasix 40 mg orally twice a day
7. Spironolactone 25 mg orally daily.
8. Simvastatin 20 mg orally daily.
9. Nortriptyline 50 mg orally daily.
10. Fluoxetine 20 mg orally daily.
11. Synthroid 88 mcg orally daily.
PHYSICAL EXAMINATION: Height 5 feet 2 inches tall and weight 97
kg. Vital signs , temperature 98.8 , heart rate 90 , blood pressure
120/72 and oxygen saturation 98% on room air. HEENT , PERRL ,
oropharynx benign. Chest with midline incision. Cardiovascular ,
regular rate and rhythm , no murmurs , stable sternum. No clicks.
Respiratory , breath sounds are clear bilaterally. Abdomen
without incisions , soft , no masses. Extremities with 2+
bilateral lower extremity edema , erythema on the left. Pedal pulses are 1+
bilaterally. Radial pulses 2+
bilaterally. Neuro , alert and oriented , grossly nonfocal exam.
LABORATORY DATA: Chemistries include the following , sodium of
132 , BUN of 15 , creatinine of 0.8 and BNP of 2520. Hematology
includes white blood cell count of 6.8 and hematocrit of 24.6.
HOSPITAL COURSE: The patient was admitted on 4/12/06. Her exam
was notable for significant lower extremity edema with probable
lower extremity cellulitis on the left as well as pulmonary
wheezing. The patient was admitted to the Intensive Care Unit
for dyspnea and underwent transthoracic echocardiogram , which
revealed ejection fraction of 40% to 45% and a stable mitral
valve. The patient was started on a Lasix drip and Diuril with
improvement of symptoms. She was also started on antibiotics for
coverage of possible lower extremity cellulitis. The Pulmonary
team was consulted , as the patient has history of COPD and they
recommended regimen of Advair and steroid
taper for her COPD. She was empirically covered for pneumonia
with levofloxacin and Flagyl and continued to diurese well on a
Lasix drip. She was transferred to the Step-Down Unit the
following day. Her preadmission cardiac meds as well as her
Coumadin for atrial fibrillation were restarted. The patient required ongoing
aggressive diuresis to eventually achieve a fluid balance of is
negative 1 liter daily. With diuresis , the patient complained of
postural dizziness , lightheadedness and nausea. Liver function
tests as well as amylase and lipase were checked and noted to be
normal. KUB was without evidence of
small-bowel obstruction or perforation , and with stool throughout the colon.
The patient's nausea and vomiting resolved when her bowels began to move.
The patient continues her course of antibiotics both to cover
lower extremity cellulitis and pneumonia.
DISPOSITION: She is discharged to home in good condition on
hospital day #8 on the following medications:
1. Enteric-coated aspirin 81 mg orally daily.
2. Zetia 10 mg orally daily.
3. Fluoxetine 20 mg orally daily.
4. Advair Diskus one puff nebulized twice a day
5. Lasix 60 mg orally twice a day
6. NPH insulin 30 units subcutaneously every afternoon
7. NPH insulin 20 units subcutaneously every day before noon
8. Potassium slow release 30 mEq orally daily.
9. Levofloxacin 500 mg orally every 24 hours x4 doses.
10. Levothyroxine 88 mcg orally daily.
11. Toprol-XL 100 mg orally daily.
12. Nortriptyline 50 mg orally nightly.
13. Prednisone taper 30 mg every 24 hours x3 doses , 20 mg every 24 hours x3
doses followed by a 10 mg every 24 hours x3 doses , then 5 mg every 24 hours x3
doses.
14. Simvastatin 40 mg orally nightly.
15. Diovan 20 mg orally daily.
16. Coumadin to be taken as directed to maintain INR 2 to 2.5
for atrial fibrillation.
The patient is to have followup appointments with her
cardiologist , Dr. Pianalto in one to two weeks with her cardiac
surgeon , Dr. Toni in four to six weeks. VNA will monitor her
vital signs , weight and wounds and the patient's INR and Coumadin
dosing will be followed by Pagham University Of
Anticoagulation Service at 132-202-5576.
eScription document: 4-2443769 CSSten Tel
Dictated By: JACOBSON , CHRISTEEN
Attending: TONI , CARMELITA
Dictation ID 3622235
D: 1/16/07
T: 1/16/07
Document id: 1206
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
- |
Y |
N |
N |
N |
158426861 | PUO | 72358743 | | 109715 | 11/13/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/30/1995 Report Status: Signed
Discharge Date: 3/30/1995
DIAGNOSIS: MORBID OBESITY
PROCEDURE: Panniculectomy
HISTORY OF PRESENT ILLNESS: This is a 42 year old female nurse
chronically obese , whose last weight
two weeks ago was 430 pounds , after a loss of 90 pounds since
February The patient's mobility is limited to short walks around
the house and she has had some shortness of breath with exertion.
PAST MEDICAL HISTORY: Significant for a congenital heart murmur
with major depression , diagnosed in 1990;
duodenal ulcer in 1972; diabetes mellitus , type II , diagnosed in
1995; status post laparotomy in 1974.
MEDICATIONS: Paxil , 60 mg orally every day before noon; Diabeta , 5 mg orally every day before noon;
Trazadone , 100 mg every bedtime; Ultram , 100 mg every 4-6 hours
as needed; Reglan , 10 mg every 6 hours as needed nausea; Bactroban ointment twice a day;
Lotrisone cream twice a day topically; Afrin nasal spray every 12 hours as needed;
Proventil inhalers , two puffs as needed.
ALLERGIES: To Penicillin , which produces a rash; Corticosteroids
Phenothiazine and aspirin.
PHYSICAL EXAM: Vital signs on admission , temperature 99 , pulse 80 ,
respirations 20 , blood pressure 102/70; height 4
feet , 11 inches; weight 430 pounds. Physical exam in general - this
is a massively obese woman lying down in no apparent distress. Her
skin is warm and dry. Her HEENT is benign. Lungs were clear to
auscultation bilaterally. Heart - normal S1 , normal S2 and a
regular rate and rhythm and without any appreciable murmur at this
time. Abdomen - morbidly obese , with a pannus hanging down to
below the knee level , it is soft , non tender and with difficulty
auscultating bowel sounds. Neurologically , she is alert and
oriented x 3 with no focal deficits. Extremities - she is able to
stand on her feet with no motor or sensory deficits.
HOSPITAL COURSE: The patient was admitted on 10/1/95 with concern
for her being at high risk of skin breakdown and
infection. Plans were made for panniculectomy , however , prior to
this procedure , she was admitted for intravenous Ancef three times a day; Hibiclenz
showers and subcutaneously Heparin. Preoperatively , her pulmonary function
was assessed and found to have an FEV-1 of 53% of predicted; FVC of
57% of predicted and an FEV-1/FVC of 93% of predicted. Chest x-ray
showed no active cardiopulmonary disease and an EKG showed a normal
sinus rhythm with a non specific T wave abnormality without change
since 1994. Her hematocrit preoperatively was 39.8 and her white
count was 9. A pulmonary consultation was also obtained because of
concern about her pulmonary status for the operation. On their
recommendation , the patient was treated with Azmacort inhalers ,
Albuterol nebulizer , and aggressive chest physical therapy. On 8/10/95 , the
patient was taken to the operating room where a panniculectomy was
performed by Dr. Authur , without any complications.
Postoperatively , the patient was transferred to the Lo Ale Na ICU , where
she continued to be intubated and on ventilatory support. On
postoperative day one , the patient was successfully extubated in
the morning , had 100% saturation on 40% face mask and she was
mobilized early with aggressive chest physical therapy and deep breathing
encouragement stopped. The patient received two ( 2 ) units of
autologous red blood cells; after which her hematocrit was 32%.
Postoperative day two , the patient was found to have a hematocrit
down to 25.2 , likely due to re-equilibration and over the next two
days received two ( 2 ) units of blood with a hematocrit reaching
29%. Though she complained of light headiness prior to the
transfusion , afterwards she was up and walking without difficulty.
From postoperative day two , the patient was saturating at greater
than 93% on room air; had a wound that was clean and dry and intact
with serosanguineous drainage in the Jackson-Pratt drains and
showed no evidence of cellulitis , purulent drainage or fever , on intravenous
Ancef. On postoperative day five , two of the four Jackson-Pratt
drains were removed after their output fell below 30 ccs per day
and the patient was discharged in good condition on postoperative
day six with plans for home visiting nurse for dressing changes
daily and orally Keflex while two Jackson-Pratt drains were in. The
patient will be following up in outpatient clinic with Dr. Authur
in one ( 1 ) week.
DISCHARGE MEDICATIONS: 1 ) Keflex , 500 mg orally four times a day; 2 ) Percocet
one to two orally every 4 hours as needed pain; 3 )
Lotrisone topically , TP twice a day; 4 ) Paxil , 60 mg orally every day before noon; 5 )
Azmacort , four puffs inhaled four times a day; 6 ) Bactroban topically TP
twice a day; 7 ) Diabeta , 5 mg orally every day before noon; 8 ) Ferrous Sulfate , 300 mg orally
three times a day; 9 ) Proventil inhaler , two puffs inhaled four times a day
Dictated By: MILAGROS MIRIELLO , M.D. OI85
Attending: FIONA J. AUTHUR , M.D. WM4
XG974/0868
Batch: 10032 Index No. MDCLDL8Z2P D: 2/25/95
T: 2/25/95
Document id: 1207
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
- |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
- |
N |
Y |
N |
- |
N |
- |
Y |
N |
N |
N |
N |
N |
N |
009189075 | PUO | 55313086 | | 2437222 | 10/21/2004 12:00:00 a.m. | NON ST EVEVATION MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 10/21/2004 Report Status: Signed
Discharge Date: 10/6/2004
ATTENDING: STEFFANIE T. DOCIMO MD , PHD
ATTENDING: Rossie Mankoski , M.D.
ADMIT DIAGNOSIS: Non-ST elevation MI.
OTHER DIAGNOSIS: Thromboembolic coronary artery occlusion ,
rheumatic heart disease , mitral valve replacement , aortic valve
replacement with St. Jude's valve , status post tricuspid repair ,
CHF , type II diabetes , atrial fibrillation , esophageal ulcer ,
osteoporosis.
In brief , Ms. Wolsey is a 63-year-old Hindi speaking woman with
CAD , rheumatic heart disease , status post mitral valve
replacement , aortic valve replacement , A. fib , diabetes type II ,
history of subacute bacterial endocarditis transferred from
Norap Valley Hospital with a troponin of 64. She had presented with
several days of neck and back pain and some vague mild left sided
chest pain. No shortness of breath and diaphoresis. No cough.
At Norap Valley Hospital , EKG demonstrated atrial fibrillation with
some 1-2 mm depressions in V2 through V5. There was a question
of dig effect. Her chest x-ray demonstrated a right lower lobe
infiltrate and patient was given aspirin , Lovenox and transferred
to PUO for catheterization.
PAST MEDICAL HISTORY: CAD , rheumatic heart disease , mitral valve
replacement , aortic valve replacement , A. fib , SBE , diabetes.
HOSPITAL COURSE:
1. Ischemia: The patient presented again with a non-ST
elevation MI with elevated troponin. The patient had had a
negative catheterization just two years ago and it was unclear
whether or not her troponin leak was from epicardial coronary
artery disease or from another source such as pericarditis or
erosion from endocarditis into her myocardium. Also , given the
back pain , there was a concern for aortic dissection and a chest
CT was done on 8/4/04 which showed no aortic dissection. She
was continued on heparin , Plavix , aspirin , and beta-blocker and
will be restarted on her ACE inhibitor , was not restarted in
hospital , by her primary care physician. Given her continued neck pain with endemic
ST changes which included depressions in V2 through V5 , and her
substantial elevation in her troponin I to a peak of 64 , a
catheterization was done that demonstrated thrombosis on OM2 at
the ostia which was thought to be embolic. All her other
coronary arteries appeared normal , so this 100% lesion was
angioplastied to 50% residual. Post procedure course was
complicated by pulmonary edema with rising O2 requirement. She
diuresed well with improvement to room air , satting 100%. She
again had neck pain in V2 through V5 depressions on 6/17 , just
three days after the catheterization on 3/25 This was
medically managed because the dynamic changes did not return and
thought to be left over plaque from the last lesion. The patient
had been stable for about one week before discharge without any
complaints of neck pain whatsoever and her troponins had trended
down significantly during this event. The patient had not
complained of any symptoms while walking.
Pump-wise , her echo showed an EF of 60% with preserved LV and RV
function. Her old RVSP increased roughly to 65 , possible
increase in mitral gradient. The patient had had RVSP before and
it had been increased at roughly to 55 mmHg. Possible increase
in mitral gradient and no veg on her echo though it was tough to
evaluate given her artificial valve. The patient then had a TEE
which was negative for vegetation or thrombus. It was thought
that the thrombus she had already thrown to her OM2 would most
likely be the thrombus that she had had and there was none left
on the valves. For that reason , patient was volume overloaded
and was diuresed on torsemide 100 orally twice a day which seems to be a
good regimen for her as far as her dry weights seem to be around
50 kilos , maybe even 48 kilos , and she should have daily weights
checked.
Rhythm-wise , the patient had A. fib. She was on tele and no
events and she is being anticoagulated both for her valve and for
her A. fib.
ID-wise , she had increased white blood cell count and a left
shift with one band , the right lower lobe infiltrate and
completed a 7-day course of levo. Was afebrile throughout the
hospitalization and had negative blood cultures , and again the
negative TEE.
Heme-wise , her INR goal is now 3 to 4 , ideally 3 to 3.5 , and this
is essential. Patient will follow up with the Coumadin Clinic.
Her INR was 5.3 on 1/4/04. She was treated on 3/25/04. She
had an INR of ??__?? She is to be drawn by the VNA the next day ,
11/4/04 , and they should call Coumadin Clinic with the result.
Given high INR , we held the Coumadin on 10/20 and restarted dose
on 6/26 at a dose of 3 every afternoon
Respiratory-wise , the patient finished levo for presumed
pneumonia and had no other respiratory problems. She did
complain sometimes of subjective shortness of breath , but her
oxygen saturation remained at 100% throughout the rest of the
hospitalization besides after the cath.
GI-wise , she is stable. She got some simethicone for gas and a
bowel regimen. She was doing well , but given her continued pain ,
GI and surgery consulted on her for a question of mesenteric
ischemia. A CT angiogram of the abdomen was performed with
negative workup for mesenteric ischemia. They thought that most
of her discomfort was due to constipation.
FEN-wise , we replaced her lytes. Also we put her on carnitine
for diet supplementation.
Renal-wise , the patient had increase in creatinine secondary to
the dye load from the cath and both her CT scans. The creatinine
was .9 on day of discharge. We held off on starting the ACE
because of this , but she should consider getting an ACE to add to
her regimen given her diabetes and recent MI. That should be
started as an outpatient.
Endocrine-wise , her diabetes is in really poor control. She had
sugars ranging from 40 to 400. We changed her regimen to Lantus
26 units every afternoon along with novalog pre-meal with 16 before
breakfast and 8 of novalog before lunch and 8 of novalog before
dinner. Her sugars improved greatly , all in the 100s. She had
severe osteoporosis as well and vitamin C deficiency. Consider
starting Zometa as an outpatient per primary care doctor , Dr.
Bredeson Prophylaxis with heparin and Nexium.
DISPO: She refused rehab and wanted to go home with services and
she should get home physical therapy and a home VNA. She is full code.
PLAN: Follow up with the Coumadin Clinic and get her blood drawn
every 2-3 days. The VNA should call 988-605-5355 with the
results of her INR. In addition , her goal again is to have an
INR of 3-4. She should follow up with Dr. Rochat , her
cardiologist , in 1-2 weeks and Dr. Dia Riemenschneid will come to
see her on 3/2 , 11:30 a.m. at her house. I also recommended
that patient not add salt to her diet and not drink fluids
greater than one liter per day and also check her daily weights.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg orally every day.
2. Digoxin 0.125 mg orally every day.
3. Folate 100 mg orally twice a day
4. Ativan 0.25 mg orally every 6 hours as needed anxiety.
5. Nitroglycerin 0.4 1/150 one tab sublingual every 5 minutes x3
as needed chest or neck pain.
6. Oxycodone 5-10 mg orally every 6 hours as needed pain.
7. Ocean spray sodium chloride 0.65% two sprays four times a day as needed
congestion.
8. Coumadin 3 mg orally every afternoon again starting on 4/18
9. Caltrate Plus Vitamin D 1 tab orally twice a day
10. Nexium 20 mg orally every day.
11. Maalox 1-2 tabs orally every 6 hours as needed upset stomach.
12. Toprol XL 200 mg orally every day.
13. Lipitor 10 mg orally every day.
14. Combivent two puffs inhaled four times a day as needed shortness of
breath.
15. Torsemide 100 mg orally twice a day
16. Lactulose 30 ml orally four times a day as needed constipation.
17. Lantus 26 units subcutaneously every afternoon
18. Novalog 16 units subcutaneously before meals before breakfast , novalog 8 units
subcutaneously before meals before lunch , and novalog 8 units subcutaneously before meals before
dinner.
eScription document: 7-7664632 MCSSten Tel
CC: Dia Riemenschneid M.D.
Ton
Ra Gle Cuse
Dictated By: GUSMAR , GAYE
Attending: ELFRIEDA KUM WINZER , MD
Dictation ID 0103946
D: 1/12/04
T: 1/12/04
Document id: 1208
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791029131 | PUO | 65844760 | | 163877 | 6/6/1996 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/5/1996 Report Status: Signed
Discharge Date: 2/12/1996
DISCHARGE DIAGNOSIS: MORBID OBESITY.
HISTORY OF PRESENT ILLNESS: Taunya Paloma is a 21 year old
morbidly obese female with a long
history of obesity. She had been involved in multiple weight loss
programs. Last attempt was with the use of PHEN/FEN but she had
been unable to tolerate medications. She was successful in a sixty
pound weight loss two years ago but regained all this weight back.
She was five feet and five inches tall and was currently at her
maximum weight which was 264 pounds. Her body mass index was 44.
Patient now presented to Pagham University Of for Roux-en-Y
gastric bypass.
PAST MEDICAL/SURGICAL HISTORY: No history of any prior
hospitalizations or significant
illnesses and no past surgical history.
CURRENT MEDICATIONS: Oral contraceptives.
ALLERGIES: Patient had no known drug allergies.
PHYSICAL EXAMINATION: Findings on admission generally were that
Taunya Paloma was a very obese 21 year
old white female in no apparent distress. SKIN: Warm and dry with
no rashes and good skin turgor. There was no lymphadenopathy
appreciated. HEAD/NECK: Examinations were all within normal
limits. LUNGS: Clear bilaterally. CARDIAC: Regular rate and
rhythm with no murmur appreciated and her pulses were all intact.
ABDOMEN: Soft , non-tender , non-distended , and no masses were
appreciated. NEUROLOGICAL: The patient had a normal neurologic
examination as well as normal extremities with no clubbing ,
cyanosis , or edema appreciated.
HOSPITAL COURSE: On January , 1996 , the patient underwent a
Roux-en-Y gastric bypass procedure. The patient
tolerated the procedure well. There were no intraoperative
complications. Her post-operative course was uncomplicated per the
gastrojejunostomy protocol. She was begun on clear liquids on
post-operative day number two which she tolerated well. She was
advanced per the protocol to Carnation Instant Breakfast four times a day
supplemented with clear liquids which she also tolerated well and
she was discharged to home on post-operative day number four in
good condition tolerating the diet per the gastrojejunostomy
protocol.
DISPOSITION: Patient is discharged to home.
DISCHARGE MEDICATIONS: Roxicet elixir 5-10 ml orally every 3-4h. as needed
pain and one multivitamin tablet crushed
orally every day
FOLLOW-UP: Patient will follow-up with Dr. Dierker in his office.
Dictated By: GENNY BARRETTE , M.D. NU79
Attending: ZORA DIERKER , M.D. TF78
TQ239/6924
Batch: 17103 Index No. NDRPES85JM D: 1/10/96
T: 4/10/96
Document id: 1209
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805574265 | PUO | 97875387 | | 0751748 | 4/6/2006 12:00:00 a.m. | C-DIFF.COLITIS | Unsigned | DIS | Admission Date: 5/15/2006 Report Status: Unsigned
Discharge Date: 7/30/2006
ATTENDING: GUMINA , MARJORY SHELA MD
HISTORY OF PRESENT ILLNESS: Mr. Loque is an 81-year-old gentleman
whose chief complaint was abdominal pain and diarrhea. He had a
past medical history of ischemic cardiomyopathy and recent
complex medical history including a septic right knee arthritis
with MRSA complicated by a PICC line-induced right upper extremity
DVT followed by bacteremia with multi-resistant Klebsiella
pneumoniae , treated with meropenem for 14 days with the course
ending on 11/11/2006. The patient presented with left lower quadrant abdominal
pain during his last admission 2 weeks ago associated with low-volume mucus
diarrhea , C. diff toxin assay was at that time negative on 1/24
Abdominal CT showed diverticulosis with stranding of the sigmoid colon.
Blood cultures grew klebsiella , treated with 14 days of meropenem
as previously noted. However , since this discharge , the mild
abdominal pain persisted. He continues to have low-grade mucus
diarrhea about 5 times a day , not associated with fever , chills
or anorexia. Over the last 2 days prior to this admission , the
diarrhea became high volume , still nonbloody and not associated
again with fever or chills. He was brought into the emergency
department at which time , he was afebrile with a blood pressure
of 85/49 , heart rate in the 80s , respiratory rate of 20 , O2
saturation 93% on room air. At that time , he received volume
resuscitation with 2 liters of intravenous fluids , stool samples for C.
diff assay were sent. He received empiric therapy with orally
vancomycin. An abdominal CT in the emergency department showed
thickening of the sigmoid colon and rectum.
PAST MEDICAL HISTORY: Includes coronary artery disease as noted
with an anterior MI in 2003 , that had complicated to VT arrest ,
status post CABG in 2003 that was a left internal mammary artery
to LAD with saphenous vein graft to the PTA and obtuse marginal.
He has had a catheterization in 3/12 that showed patent grafts
and drug-eluting stent to the left circumflex. He has chronic
kidney disease , baseline creatinine between 1.3 and 1.5 ,
hypertension , hypercholesterolemia , C. diff colitis in 2003 , BPH ,
asthma , GERD , status post right upper extremity PICC-related DVT
and right knee septic arthritis.
MEDICATIONS: aspirin 81 mg , Plavix 75 mg , Coumadin 5 mg , digoxin 0.125 mg ,
Lasix 49 mg daily , lisinopril 10 mg daily , Lopressor 25 mg twice a day , Zocor 80 mg
daily , Flomax 0.4 mg daily and Flovent 110 mcg twice a day
ALLERGIES: penicillin which caused hives and swelling.
SOCIAL HISTORY: He previously a smoker. He does not drink. He
is a nursing home resident.
FAMILY HISTORY: Significant for coronary artery disease , two
brothers who had coronary artery disease in their 60s. No family
history of cancer.
PHYSICAL EXAMINATION: Vitals as previous noted , blood pressure
in the 80s/49 , heart rate 80 , regular , respiratory rate 20 , O2
saturation 93% on room air. Patient was afebrile. Pertinent
physical findings included: Pulmonary: He had a prolonged
expiratory phase , but no crackles. Cardiovascular: Distant heart
sounds , regular rate and rhythm. Normal S1 and S2. No rubs or
gallops. Systolic ejection or murmur 3/6 at the left lower
sternal border. Abdomen: Obese , distended abdomen , left lower
quadrant tenderness to palpation. No rebound at this time.
Extremities are warm , 2+ pulses with 1+ bilateral lower extremity
edema to the shins. Neurologic: Alert and oriented x3 , cranial
nerves grossly intact , no abnormalities.
admission abdominal CT showed bowel wall thickening in
the descending sigmoid colon and rectum. Chest x-ray showed
left-sided pleural effusion , atelectasis in the left lower lobe.
LABORATORY DATA: Labs were significant for a white count of
15.7 , hematocrit of 35.5 and INR of 3.2. Electrolytes were
normal.
Patient was initially admitted to the MICU for hypertension and
infectious etiology. He was stabilized there and transferred to
the floor within a few days.
HOSPITAL COURSE:
1. Colitis , presumed infectious etiology , descending and sigmoid
colon. Colitis was worse over the last month , associated with
diarrhea. Abdominal CT is consistent with an infectious
inflammatory bowel process. Given history of C. diff colitis , C.
diff was the most likely infectious etiology , but others were
possible. Ischemic colitis was considered secondary to low
forward flow , given patient's cardiomyopathy and low ejection
fraction of 20% to 35% and he also got a pattern of inflammatory
colitis or nonspecific colitis. Stool samples were sent for a C.
diff toxin and assay and all were negative x at least 3 samples.
Stool cultures were sent and did not grow anything out during
admission. Empiric treatment was started with orally vancomycin.
Patient's abdominal pain continued to improve and completely
resolved. By discharge , patient remained afebrile and white
blood cell count decreased. Advance patient's diet as tolerated
and by discharge the patient was up to soft solids. We added
lactobacillus orally for probiotics and patient also had flex sig
two days before discharge , showing resolving inflammation
consistent with colitis of inflammatory etiology. The flex sig
did not change his management. We did discharge the patient on a
2-week course orally vancomycin alone.
2. Coronary artery disease. Patient had no evidence for acute
coronary syndrome on admission. We continued his aspirin ,
Plavix , statin and beta-blocker. Patient had no ischemic issues
or coronary artery disease issues during his admission.
3. CHF. Patient has previous EF noted at 20% to 35% , so a
gentle hydration therapy at first in the MICU for hypertension
and then as patient's blood pressure increased , was able to
restart patient's Lasix dose in order to diurese all of the extra
fluid gained during the rehydration therapy , was restarted on the
Lasix 40 mg orally daily , his daily dose at home. Also considered
restarting lisinopril , but deferred discharge to outpatient
follow up with primary care physician for restart of lisinopril ,
once patient is fully recovered.
4. Chronic kidney disease. Patient had a baseline of creatinine
1.2 to 1.5 and he came into the hospital with a creatinine of 1.0.
The patient was below baseline and remained below baseline during
admission. He did not have any renal issues.
5. Hematology. Patient has a history a line-induced DVT , has
been treated with Coumadin , with no definitive evidence as to how
along patient should be treated , given that the DVT was line
induced. Coumadin was therapeutic on admission , became
supertherapeutic in the MICU. Held Coumadin until INR fell below
3 , restarted Coumadin afterwards at 6 mg orally daily , patient's
normal dose. Patient was therapeutic on discharge. Will follow
up with primary care physician for Coumadin monitoring.
6. Nutrition. Patient was in the MICU and was npo given
abdominal pain and colitis. When transferred to floor , was
started on liquid diet and advanced to soft solid diet. By
discharge , the patient did not have abdominal pain and most of
the diarrhea had resolved.
PROCEDURES PERFORMED: The patient had a flexible sigmoidoscopy
during the admission that showed colitis consistent with
inflammatory etiology.
DIAGNOSIS: Patient had repeated negative C. diff toxin assays ,
but colitis was presumed to be C. diff and given history , could
have been other infectious or inflammatory etiologies. Patient
continued to improve on vancomycin and thus was discharged with
presumed C. diff colitis diagnosis.
DISCHARGE MEDICATIONS: Included aspirin 81 mg orally daily , Plavix
75 mg orally daily , digoxin 0.125 mg orally daily , Nexium 20 mg orally
daily , Flovent 110 mcg inhale twice a day , Lasix 40 mg orally daily ,
lactobacillus 2 tabs orally three times a day , metoprolol 25 mg orally twice a day ,
simvastatin 80 mg orally at bed time , Flomax 0.4 mg orally every
evening , vancomycin 250 mg orally every 6 hours x8 days at
discharge and Coumadin 5 mg orally every evening.
Patient had to follow up with primary care physician , setup for 2
to 3 weeks after discharge.
eScription document: 2-7190495 HFFocus
Dictated By: BALDAUF , WILLOW
Attending: GUMINA , MARJORY SHELA
Dictation ID 6257188
D: 10/27/06
T: 4/24/06
Document id: 1210
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702744113 | PUO | 14759295 | | 012263 | 1/1/1997 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/3/1997 Report Status: Signed
Discharge Date: 1/24/1997
SERVICE: Dallno U Heim
DIAGNOSIS: LEFT LOWER LOBE PNEUMONIA.
STATUS POST CORONARY ARTERY BYPASS GRAFTING ON 19 of October
STATUS POST STERNAL WOUND DEBRIDEMENT ON 15 of May
ADULT-ONSET DIABETES.
DEPRESSION.
RIGHT KNEE ARTHROSCOPY.
STATUS POST MYOCARDIAL INFARCTION IN 1994 AND 1996.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old male
status post coronary artery bypass
grafting and sternal wound infection , admitted with 3 days of
increasing shortness of breath. The patient has had severe
ischemic cardiomyopathy with an ejection fraction of approximately
20% , and multiple regional wall motion abnormalities. He underwent
a 4-vessel coronary artery bypass grafting with a left internal
mammary artery to the left anterior descending and saphenous vein
grafts to the LVB , D1 and first obtuse marginal on 19 of October His
postoperative course was complicated by a sternal wound infection ,
with debridement performed on 15 of May He was put on vancomycin
and sent home 3 days prior to admission on intravenous vancomycin.
He felt okay , until 1 or 2 days prior to admission when he had
increased dyspnea on exertion and shortness of breath. He also
complained of increasing orthopnea and a mild cough accompanied by
shaking chills the night prior to admission. He also complained of
mild upper and lower back pain. The patient denied dysuria. PAST
MEDICAL HISTORY is as noted above. The patient has no known drug
ALLERGIES. MEDICATIONS ON ADMISSION were aspirin , 325 milligrams
each day , Captopril , 25 milligrams 3 times a day , digoxin , 0.125
milligrams each day , Lasix , 40 milligrams each day , Colace , 100
milligrams twice a day , NPH insulin , 35 units each morning , regular
insulin , 5 units each evening , metoprolol , 25 milligrams 3 times a
day , Niferex , 150 milligrams twice a day , Percocet as needed ,
vancomycin , 1.25 milligrams twice a day , Axid , 150 milligrams twice
a day , and KCL , 40 milligrams each day. SOCIAL HISTORY revealed
the patient lives with his wife , he is an exposed smoker and
occasional ethanol drinker. He is retired secondary to his
cardiomyopathy. He was able to ambulate and play golf prior to the
coronary artery bypass grafting in October .
PHYSICAL EXAMINATION: The patient was uncomfortable , tachypneic.
Vital signs were temperature 100.7 , heart
rate 97 , blood pressure 108/67 , 96% oxygen saturation on 4 liters
by nasal cannula. Head , eyes , ears , nose and throat examination
showed extraocular movements were intact , pupils equal , round ,
reactive to light , oropharynx benign. Neck was supple with no
lymphadenopathy. Chest showed left base bronchial breath sounds
with egophony , with a few scattered wheezes throughout.
Cardiovascular examination showed JVP approximately 8 centimeters ,
carotids were I+ bilaterally , no bruits , regular rate and rhythm ,
S1 , S2 , very distant heart sounds. The liver edge was palpable.
Abdomen was nontender , positive bowel sounds. Skin showed the
upper chest wound where debridement had taken place , approximately
6 centimeters long at the incisional site , which was slightly
tender and erythematous. Back showed no costovertebral angle
tenderness. Extremities showed the patient had TEDS stockings on ,
there was trace edema , II+ pulses bilaterally. Neurologic
examination showed the patient was alert and oriented , fluent , and
the examination was nonfocal.
LABORATORY EXAMINATION: On admission , SMA-7 showed sodium 135 ,
potassium 5.1 , chloride 101 , bicarbonate
22 , BUN 12 , creatinine 1.2 , glucose 128. CK was 13 , triponin 0.0.
Prothrombin time was 14.1 , partial thromboplastin time 27.5.
Digoxin level was 0.6. Complete blood count showed white blood
count 7.8 , differential 69 neutrophils , 16 lymphs , 7 monos , 8
eosinophils , hematocrit 28.7 , platelets 735 , 000. Sputum from
27 of January showed 4+ Hemophilus influenza , which was pan sensitive.
Chest x-ray on the date of admission showed a left lower lobe
infiltrate with possible effusion. Electrocardiogram showed left
bundle branch block. VQ scan was low probability.
HOSPITAL COURSE: 1. Infectious disease. The patient had a
maximum temperature of 102.3 on 27 of February He was
on vancomycin , gentamicin and ceftazidime. On 13 of June , gentamicin
and ceftazidime were discontinued , and ofloxacin was started
secondary to decreasing creatinine. After his temperature spike on
21 of August , the patient's maximum temperature declined each of the
following days , and he has remained afebrile the last 2 days. The
sternal wound appeared less erythematous , and he was continued on
vancomycin for the coagulase negative Staphylococcus that grew from
the wound site on 15 of May The patient had a computerized
tomography scan of his chest to rule out an abscess at the sternal
wound site and no abscess was seen. Thoracentesis was done on the
left pleural effusion , and the tap was an exudate with pH 7.51 ,
glucose 114 , total protein 4.9 , amylase 16 , LDH 38. There were 756
white blood cells on differential , of which 93% macrophages and 7%
mesothelioma cells , 127 , 000 red blood cells , and the fluid was
grossly blood. Cultures from the fluid were negative for bacteria
and fungal growth. Gram stain showed no organisms , no
polymorphonuclear cells. Vancomycin was redosed to 1 gram every 48
hours secondary to increased creatinine and elevated levels. Given
his recent requirement for debridement , vancomycin will be
continued for 2 weeks after discharge. Ofloxacin will also be
continued for the same. All cultures from this hospitalization are
negative to date.
2. Cardiovascular. The patient ruled out for myocardial
infarction. VQ scan was low probability on admission. This was
performed secondary to his baseline tachycardia. Lower extremity
noninvasive studies and ultrasound were done and were negative for
deep vein thrombosis. The patient's triponin on admission was 0.0.
The patient was aggressively diuresed as a component of his initial
dyspnea on exertion was likely secondary to a degree of congestive
heart failure. His admission weight was 100.6 kilograms , and
weight on discharge was 95.8 kilograms. With aggressive diuresis
during hospitalization , Lasix was discontinued on the day prior to
discharge. Digoxin level on admission was 0.6 , on discharge was
1.0. The patient had several episodes of hypotension with systolic
blood pressure in the mid 70's to low 80's. Captopril and
Lopressor were decreased and held at certain stages during his
hospitalization. On discharge , he was on a stable dose of
Captopril , 6.25 milligrams 3 times a day , and Lopressor , 12.5
milligrams twice a day. He was not orthostatic on the day prior to
discharge.
3. Renal. The patient was aggressively diuresed. His BUN and
creatinine rose from 12 and 1.2 on admission , to a peak of 36 and
2.6 on 20 of November Subsequently , the creatinine has declined , and on
9 of July , BUN was 37 , creatinine 2.2. The patient had an
eosinophilia , which peaked at 18% on 16 of March , and subsequently
decreased to 11% on discharge. Urine eosinophils were not present.
It appeared that his eosinophilia was related to ceftazidime , which
was discontinued on 24 of January It is unlikely that his increasing
renal insufficiency is secondary to acute tubular necrosis. More
likely , it is secondary to the aggressive diuresis undertaken to
decrease his congestive heart failure. Follow-up laboratory values
will likely reveal improvement in BUN and creatinine status , as
well as a decrease in his peripheral eosinophilia.
4. Psychiatry. The patient has had anxiety , especially at night ,
and has been treated successfully with Ativan , but Serax resulted
in nightmares. The patient has a history of depression and may
benefit from counseling. The patient's decreased orally intake ,
nightmares , and anxiety may all be related to an underlying
depressive component over his prolonged illness.
5. Endocrine. The patient's blood sugar levels have been well
controlled on a regimen of NPH , 20 each morning. He has not
required any additional coverage , and regular insulin coverage has
been discontinued for 2 days.
DISPOSITION: CONDITION ON DISCHARGE is fair. MEDICATIONS ON
DISCHARGE are Tylenol , 650 milligrams by mouth every
4 hours as needed for headache , enteric-coated aspirin , 325
milligrams by mouth each day , Captopril , 6.25 milligrams by mouth
every 8 hours , held if systolic blood pressure is less than 85 ,
digoxin , 0.125 milligrams by mouth each day , Benadryl , 25 to 50
milligrams by mouth every 4 hours as needed for itching , Colace ,
100 milligrams by mouth twice a day , NPH insulin , 20 units
subcutaneously each morning , Atrovent inhaler , 2 puffs 4 times a
day , Ativan , 0.5 to 1 milligram by mouth every 6 hours as needed
for anxiety and insomnia , Lopressor , 12.5 milligrams by mouth twice
a day , held for systolic blood pressure less than 80 or heart rate
less than 60 , Niferex , 150 milligrams by mouth twice a day ,
Percocet , 1 or 2 tablets by mouth every 4 hours as needed for pain ,
Sarna lotion topically to back as needed , vancomycin , 1 gram
intravenously every 48 hours times 10 days , Axid , 150 milligrams by
mouth twice a day , ofloxacin , 200 milligrams by mouth twice a day
times 7 days.
The patient will be transferred to Tipalms Hospital
on 5 of September He will have a FOLLOW-UP appointment with Dr. Schwerd
in approximately 2 weeks.
Dictated By: DAN BURKLEO , M.D. JT7
Attending: FRANCISCA A. URBANIAK , M.D. MS1
ZD395/7577
Batch: 8583 Index No. GXMB96X82 D: 11/10/97
T: 4/18/97
CC: 1. FRANCISCA A. URBANIAK , M.D. MS1
2. DAN BURKLEO , M.D. JT7
3. NEAGEE TAMHILLS FREQUEST HEALTH CARE
Document id: 1211
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786065903 | PUO | 92899557 | | 683535 | 3/26/2000 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 3/28/2000 Report Status: Signed
Discharge Date: 3/25/2000
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
HISTORY OF PRESENT ILLNESS: Mr. Millwee is a 58-year-old man with a
history of ischemic cardiomyopathy
dating back several years. He developed angina in 1983 and
underwent a coronary artery bypass grafting x 3 with a LIMA to LAD ,
SVG to the diag 1 , OM1 and PDA. He did relatively well after that
and then developed dyspnea on exertion. He underwent cardiac
catheterization in 3/5 but only the SVG to the PDA was diffusely
diseased. He then had a myocardial infarction in October of 1999
and apparently underwent another coronary artery bypass graft at
the Ouf County General Hospital The anatomy of this is unknown. He felt
well postoperatively , but began to develop shortness of breath and
orthopnea in the last few months. He denies any chest pain ,
palpitations or syncope and is sometimes dizzy when he walks. He
is not admitted for optimization , his medications , tailored
therapy , and a transplant evaluation.
PAST MEDICAL HISTORY: Notable for coronary artery disease and
ischemic cardiomyopathy. An echo in 10/28
shows an EF of 25% and a thinning and akinesis of the inferior
wall. GERD status post esophageal dilation x 2. Status post
polypectomy 4 years ago for status post appendectomy. Status post
hernia repair.
ADMISSION MEDICATIONS: Lisinopril 5 mg orally every day , digoxin 0.125
mg orally every day , Lasix 240 mg orally every day ,
aspirin 325 mg orally every day.
ALLERGIES: None known.
SOCIAL HISTORY: Smoker with 1 1/2 packs per day times many years ,
quit 2 years ago. Social drinker and a widower.
His wife died 6 years ago of cancer. He lives with his two sons in
Sa
PHYSICAL EXAMINATION: Temperature 97.4 , heart rate 98 , blood
pressure 78/66 , O2 sat of 97%. In general
he is awake and alert , in no acute distress. HEENT: Pupils are
equal , round and reactive to light. Extraocular movements intact.
JVP is around 12. CHEST: Shows bibasilar crackles.
CARDIOVASCULAR: Regular rate and rhythm with an S3 , no murmurs.
ABDOMEN: Soft , nontender , nondistended. Positive bowel sounds.
EXTREMITIES: Show 2+ dorsalis pedis pulses.
ADMISSION LABORATORY: Sodium 139 , potassium 4.0 , chloride 99 ,
bicarb 34 , BUN 35 , creatinine 1.3 , glucose
138. White count 14.9 , hematocrit 43.8 , 282 platelets , sed rate
12 , patient 11.7 , PTT 27.0 , INR 1.0. Liver function tests were within
normal limits. Notably his albumin is 4.3 , calcium 4.9.
Cholesterol 166 , triglycerides were 358 , LDL 63 , and HDL was 31.
HOSPITAL COURSE: The patient was admitted to the hospital and by
organ system his course was notable for:
1. Cardiovascular. The patient was briefly admitted to the CCU
for placement of a pulmonary artery catheter and was diuresed with
200 mg intravenous twice a day of Lasix and Captopril and Isordil was started and
his medications were titrated. His last set of numbers showing
central venous pressure of 6 , cardiac index of 2.0 , PA pressures of
46/21 , SVR of 1 , 200 and 18 and pulmonary vascular resistance of
152. The patient continued to do well with diuresis , Captopril ,
and Isordil. He initially was shortness of breath and dyspneic in
any position and eventually was able to lie flat and sleep.
2. Transplant Evaluation. The patient underwent a number of
diagnostic studies including abdominal ultrasound , A chest CT and
pulmonary function tests , and had teaching from the transplant
nurse.
3. Psychiatric. The patient is very anxious and was evaluated by
the transplant psychiatrist who recommended low dose
benzodiazepines which were given.
DISPOSITION: The patient was discharged to home in good condition.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 orally every day ,
Captopril 50 mg orally three times a day , digoxin 0.125
mg orally every day , Colace 100 mg orally twice a day , Lasix 240 mg orally twice a day ,
Robitussin 10 mg every 4 hours as needed , Isordil 20 mg orally three times a day ,
Ativan 0.5 mg orally every bedtime as needed for insomnia , multivitamin ,
vitamin E 800 units orally every day , Ambien 5 mg orally every bedtime as needed for
insomnia , Diuril 500 mg orally every day to be taken for a 3 pound weight
gain.
Dictated By: DESIRAE MARCOTT , M.D. AU32
Attending: SACHIKO BORRIELLO , M.D. EO3
LP514/3855
Batch: 34474 Index No. SYJA7X07T0 D: 4/30
T: 3/10
Document id: 1212
| Target |
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| output/system_intuitive_annotation.xml | intuitive |
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103961817 | PUO | 90919012 | | 9398348 | 5/21/2006 12:00:00 a.m. | THREE VESSELL DISEASE | Signed | DIS | Admission Date: 5/21/2006 Report Status: Signed
Discharge Date: 10/21/2006
ATTENDING: TALAMANTE , LOGAN B. MD
SERVICE:
Interventional Cardiovascular Medicine PA Service.
PRINCIPAL DIAGNOSIS ON THIS PATIENT:CAD
The patient is an 82-year-old female
with a history of myocardial infarction , diabetes , hypertension , high
cholesterol , coronary artery disease and colon cancer in 1980 status
post a right hemicolectomy who presented to Osri Medical Center
on 9/15/06 with progressively worsening shortness of breath and
some mild chest pain. She ruled out for myocardial infarction and then
underwent a cardiac catheterization at Osri Medical Center that revealed
three-vessel coronary artery disease. The patient was then
transferred to the Pagham University Of for cardiac
surgery. However , the patient and family refused cardiac surgery
and decided to undergo multivessel percutaneous coronary
intervention. The patient underwent stenting of the LAD and
diagonal lesions on 10/24/06 with Cypher stents with good
results. She was then admitted for an overnight observation
where she remained stable. Her creatinine remained stable at 1
and the plan was to undergo RCA angioplasty on Monday , 10/11/06.
The patient remained in the hospital over the weekend without
complaints or any problems and on Monday , 7/5/06 , she underwent
stenting of this RCA lesion with Cypher stent with good result.
The patient was seen on 7/25/06 and the patient did not have any
complaints of chest pain or shortness of breath and had no
difficulty with urination and was ambulating without any
difficulty. Her vital signs remained stable with a heart rate in
the 50s and blood pressure of 124/50.
PHYSICAL EXAMINATION:
On physical exam , at discharge , her lungs were clear to
auscultation bilaterally. On cardiac exam , regular rate and
rhythm without any murmurs. Her right groin was soft and
nontender with no bruit , hematoma and no ecchymosis with 2+
femoral pulses. Extremities are warm with no edema and with 1+
DP and physical therapy pulses bilaterally.
LABORATORY DATA:
Her lab data are within normal limits. She had discharge
potassium of 3.7 , sodium of 140 , BUN of 25 , creatinine of 1.2 ,
hematocrit of 31.3 , hemoglobin 10.7 , white count of 7.3 ,
platelets of 215 , 000 , CK of 135 and MB of 5.4 , cholesterol of
131 , triglycerides of 137 , HDL 20 and LDL of 76.
Her EKG showed sinus bradycardia with no ST-T wave changes and
she had no events on telemetry throughout her admission.
DISCHARGE MEDICATIONS:
She was discharged home on the following medications , amlodipine
2.5 daily , captopril 50 orally twice a day , aspirin 325 mg daily ,
pravastatin 20 mg daily , Prozac 20 mg daily , Lantus 12 units
every afternoon , Humalog 7 units every day before noon and 10 units at lunch and 7 units
at night , she was also discharged home on Plavix 75 mg daily for
at least
one year.
FOLLOW-UP APPOINTMENT:
She will be following up with Dr. Timmy Harajly in approximately
1-2 weeks and we have instructed her if she develops any chest
pain that she go to her nearest emergency room.
eScription document: 7-3799113 EMSSten Tel
Dictated By: STRAUHAL , MARCELINA
Attending: TALAMANTE , LOGAN B.
Dictation ID 9758099
D: 2/4/07
T: 10/12/07
Document id: 1213
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695801012 | PUO | 31258907 | | 766416 | 10/23/1996 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 8/12/1996 Report Status: Unsigned
Discharge Date: 5/25/1996
HISTORY OF PRESENT ILLNESS: Mr. Kelli Stoff is a 78 year old
gentleman with known coronary artery
disease who underwent coronary artery catheterization one month
prior to the most recent admission , and was found to have two
vessel coronary artery disease. The medical treatment was
attempted following cardiac catheterization which has not
eliminated his angina. He was admitted to the hospital with
unstable angina after conservative therapy. On echocardiogram from
July , 1996 , he had a moderately depressed left ventricular
function and ejection fraction of 45 percent. Coronary
catheterization showed 90 percent stenosis of the left anterior
descending coronary artery , occluded circumflex artery , and mild
disease of his right coronary artery.
PHYSICAL EXAMINATION ON ADMISSION: The patient is a well-appearing
78 year old gentleman. Head
and neck supple. No bruits over the carotid arteries. Heart , S1
and S2 are clear , no murmurs. The lungs with discrete wheezes over
both sides. The abdomen is soft , non-tender , benign , no
organomegaly. Extremities , no edema , no varicosities.
HOSPITAL COURSE: The patient underwent a coronary artery bypass
grafting x two with reverse vein graft to the
second obtuse marginal graft and the left anterior descending
coronary artery on July , 1996 , the surgeon was Dr. Forejt The
patient's postoperative recovery in the Intensive Care Unit was
uncomplicated. The patient was extubated on the first
postoperative day and transferred to the Floor. Further recovery
on the Floor was not associated with any significant complications.
The patient regained a significant level of his preoperative
physical activity , and was able to be discharged out of the
hospital on May , 1996 in stable postoperative condition on the
following medications.
DISCHARGE MEDICATIONS: Aspirin 325 mg every day; Lasix 40 mg every day;
insulin 60 units every day before noon; metoprolol 50 mg
three times a day; Percocet one to two tablets orally every 3-4h as needed for pain;
and potassium chloride slow release , 20 meq once a day for three
days.
Dictated By: DESTINY FABBRI , M.D. UK97
Attending: JANAY D. STUKOWSKI , M.D. JX47
WN666/6030
Batch: 61036 Index No. P5GZG053D2 D: 9/27/96
T: 10/24/96
Document id: 1214
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288431774 | PUO | 41739484 | | 8790519 | 3/28/2005 12:00:00 a.m. | PULMONARY EMBOLISM | Signed | DIS | Admission Date: 8/8/2005 Report Status: Signed
Discharge Date: 8/8/2005
ATTENDING: ISABELLE EVON COLASAMTE MD
SERVICE:
The patient was admitted on the cardiac surgical service under
the care of Dr. Lottie Gudiel
HISTORY OF PRESENT ILLNESS:
Mr. Harajly is a 69-year-old male with end-stage renal disease on
hemodialysis. He is status post CABG x1 and aortic valve
replacement in February 2004. He presented to the emergency
department prior to admission with shortness of breath. Chest
x-ray was taken that revealed pulmonary edema. Stated he had
been complaining of shortness of breath over the month prior to
admission with no dyspnea on exertion or chest pain. While in
the emergency department , he had respiratory distress with O2
oxygen saturations 69%. An echocardiogram was done at that time.
It was significant for showing evidence of a dehiscence of the
bioprosthetic aortic valve with prolapse into the left
ventricular outflow tract. It was noted that there is at least
moderate perivalvular aortic regurgitation. It also noted mitral
valve had moderate to severe mitral regurgitation. As stated
previously , he was admitted to the cardiac surgical service for
repair/replacement of his aortic and mitral valves.
PAST MEDICAL HISTORY:
Includes hypertension , diabetes mellitus , renal failure ,
hyperlipidemia , gout , GERD , closed angle glaucoma , history of
colonic lymphoma.
PAST SURGICAL HISTORY:
Right arm AV fistula that was originally placed in the year 2000
and revised in 2001 , 2002 , and 2003. A right brachiocephalic
stent was also placed.
SOCIAL HISTORY:
No history of tobacco use.
ALLERGIES:
No known drug allergies.
PREOPERATIVE MEDICATIONS:
Labetalol , 100 mg orally three times a day , amlodipine 10 mg orally daily ,
lisinopril , 20 mg orally day , Zocor 40 mg orally daily , PhosLo 1334
mg orally before meals
PHYSICAL EXAMINATION:
Vital signs , temperature 95.8 , heart rate 74 , blood pressure in
the right arm 134/62. HEENT , dentition without evidence of
infection , no carotid bruit. Cardiovascular , regular rate and
rhythm. Peripheral pulses are the following , peripheral pulses
are 2+the carotid , radial , and femoral. The dorsalis pedis and
posterior tibial are each present by Doppler bilaterally.
Respiratory rales present bilaterally. Neuro , cool extremities
with monophasic pulse.
PREOPERATIVE LABS:
Sodium 141 , potassium 4.4 , chloride 102. Carbon dioxide 29 , BUN
26 , creatinine 5.8 , glucose 195 , magnesium 1.9 , white blood cells
6.11 , hematocrit 28 , hemoglobin 9.5 , and platelets 98 , 000. physical therapy
14.8 , INR 1.1 , PTT 42.2. Arterial blood gas showed pO2 of 64 , pH
7.38 , PCO2 of 52 and the base excess of 4. Cardiac
catheterization data on 6/29/04 , coronary anatomy , 10% proximal
LAD , 5% proximal circumflex , 85% mid RCA with a codominant
circulation. ECG on 11/29/05 shows first-degree AV block with
left anterior hemiblock with inverted Ts. Chest x-ray on
1/28/05 consistent with congestive heart failure.
Brachiocephalic and right subclavian stents were in place.
HOSPITAL COURSE
BRIEF OPERATIVE NOTE:
Date of surgery , 2/18/05.
PREOPERATIVE DIAGNOSIS:
See magna valve three months prior. EPL on echo showed grossly
mobile on the stable aortic valve prosthesis moderate , MR. No
vegetations.
PROCEDURE:
Reoperation of ascending aortic dissection , aortic valve
replacement , #24 homograph , MVP with Alfieri suture.
BYPASS TIME:
355 minutes ,
CROSSCLAMP TIME:
265 minutes.
One ventricular wire , one pericardial tube , one retrosternal
tube , two left pleural tubes and two right pleural tubes were
placed.
FINDINGS:
Dense inflammatory edematous scar tissue throughout pericardium ,
especially periaortic. Right axillary cannulation with 6 mm
Hemashield side. Percutaneous right CF decannulation.
Uneventful re-sternotomy.
Previous SVG PDA injured during dissection , repaired with
interrupted 7-0 Prolene. Aortic valve prosthesis dehisced 3/4 of
circumference with question of an abscess cavity near LCC/RCC
junction. Debridement , the annulus is of extensive inflammatory
tissue. Previous Dacron aortic root patch removed due to pocket
of pus on the anterior aspect. No. 24 allograft placed with
double layer proximal suture line. SVG and both coronary
arteries implanted as buttons. Distal suture line continuous 4-0
Prolene. Transaortic and mitral valves replaced.
After the operation , the patient was transferred to the cardiac
intensive care unit in stable condition. His postoperative
course was complicated by the following:
1. Infectious disease: Although , Mr. Harajly had multiple blood
cultures , sent , they all proved to be negative as of the date of
discharge. Although Mr. Harajly was never felt to be bacteremic ,
the cultures that were sent from the operating room were of the
aortic valve prosthesis. This never showed the organisms
identified on Gram stain and MSSA stain. However , the infectious
disease physicians were consulted and felt that Mr. Harajly should
be on vancomycin , rifampin , and gentamicin. As at the time of
discharge , Mr. Harajly has finished his regimen of gentamicin and
will continue to be on both vancomycin and rifampin until
11/12/04. The rifampin he will take orally and the vancomycin he
will get after dialysis three times a week. While an inpatient ,
Mr. Harajly never had any evidence of leukocytosis or bacteremia.
2. Cardiovascular: Ms. Harajly was noted to have a first-degree
AV block on postoperative day #7 with a PR interval of 0.35. Up
into this point he had been receiving labetalol. This was held
and the electrophysiology consult was obtained. The
electrophysiology service saw the patient agreed to be an
excellent candidate for permanent pacemaker. Initially they
attempted to gain access to the right brachiocephalic/subclavian.
However , this proved to be difficult and ultimately obtain
access through the left iliac. His permanent pacemaker was
placed on 10/3/05 and was interrogated the following day and
felt to be functioning appropriately. He was restarted on his
labetalol and as of the time of discharge , has had no symptoms.
Other than the above , Ms. Harajly was weaned from his oxygen
requirement , mobilized rapidly following surgery. All epicardial
pacing wires and chest tubes were removed without complication.
He will be discharged home on the following medications aspirin
325 mg orally daily , hydralazine 100 mg orally four times a day , labetalol100
mg orally three times a day , lisinopril 40 mg orally twice a day , oxycodone 5 mg orally
6 hours as needed pain , rifampin 300 mg orally every 8 hours , vancomycin for
which he will receive following dialysis until 2/28/05 , Zocor 40
mg orally every bedtime , losartan 100 mg orally daily. Mr. Harajly will
follow up with Dr. Colasamte , cardiac surgeon , in six weeks , and Dr.
Journeay , cardiologist , in three to four weeks , Dr. Macisaac , the
patient's primary care physician , in one to two weeks and Dr.
Grinstead , cardiologist , in two weeks.
eScription document: 5-4925515 EMSSten Tel
Dictated By: TRIARSI , VERDA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 5070774
D: 11/8/05
T: 11/8/05
Document id: 1215
| Target |
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GER |
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| output/system_textual_annotation.xml | textual |
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U |
U |
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| output/system_intuitive_annotation.xml | intuitive |
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800843851 | PUO | 29407184 | | 3389250 | 7/14/2007 12:00:00 a.m. | Stable Angina , Atrial Flutter | | DIS | Admission Date: 3/17/2007 Report Status:
Discharge Date: 6/11/2007
****** FINAL DISCHARGE ORDERS ******
SIGNS , CANDICE 174-51-86-5
Hend Goton
Service: CAR
DISCHARGE PATIENT ON: 10/27/07 AT 12:30 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: TYACKE , MACKENZIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALLOPURINOL 100 MG orally EVERY OTHER DAY
NORVASC ( AMLODIPINE ) 10 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ECASA 325 MG orally DAILY
Alert overridden: Override added on 9/14/07 by GREENFELDER , SILVIA VINCE , M.D. , PH.D.
on order for ECASA orally 325 MG every day ( ref # 787393363 )
patient has a POSSIBLE allergy to NSAIDs; reaction is Unknown.
Reason for override: aware
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 9/14/07 by GREENFELDER , SILVIA VINCE , M.D. , PH.D.
on order for GEMFIBROZIL orally ( ref # 153407157 )
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
GEMFIBROZIL Reason for override: war
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Alert overridden: Override added on 9/14/07 by GREENFELDER , SILVIA VINCE , M.D. , PH.D.
on order for PLAVIX orally ( ref # 807935916 )
patient has a POSSIBLE allergy to TICLOPIDINE HCL; reaction is
Unknown. Reason for override: aware
DOXAZOSIN 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 10 MG orally twice a day
GEMFIBROZIL 300 MG orally DAILY
Alert overridden: Override added on 9/14/07 by GREENFELDER , SILVIA VINCE , M.D. , PH.D.
SERIOUS INTERACTION: ATORVASTATIN CALCIUM & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
GEMFIBROZIL Reason for override: war
HYDRALAZINE HCL 50 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 150 MG orally DAILY
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
METHADONE 20 MG orally every 12 hours
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally twice a day
HOLD IF: sbp<90 , heart rate<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB orally Q5MIN
as needed Chest Pain HOLD IF: SBP<100
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: As tolerated
FOLLOW UP APPOINTMENT( S ):
You will be called for appointment for ECHO and for Heart Monitoring ,
Please call your primary care physician Dr. Konstantinidi at 035-525-0894 to schedule follow-up appointment in 2 weeks. ,
ALLERGY: NSAIDs , TICLOPIDINE HCL
ADMIT DIAGNOSIS:
Stable Angina , Atrial Flutter
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Stable Angina , Atrial Flutter
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( history of CABG , history of PTCA ) , GOUT , PROTEINURIA , CRI , hypertriglyceridemia ,
htn , Hep B , GERD , COPD
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
cc: chest pain
***
hpi: 60M with known CAD history of CABG in 88' with stenting since ( last in
9/21 ) who presents with 3 episodes of chest pressure , palpitations , and
neck pain on 4/30/06 during the day. Responded to NTG , but
recurred. Thus came in - no EKG changes , cardiac markers negative.
Got Heparin bolus only , NTG drip , morphine , maalox/nexium/zofran.
Also found to have new aflutter on the floor. On 10/6/06 , felt much
better and back in NSR
***
PMHx: CAD ( CABG in 1988 ) , hyperlipidemia , HTN , CRI , COPD , DMII ,
Pancytopenia , hep B , GERD
***
Home meds: ASA , Plavix , Norvasc , hydralazine , lopressor , lipitor ,
lasix , gemfibrizol , imdur , methadone , allopurinol , doxazosin , sublingual
NTG
***
ALL: Ticlid , NSAIDS
***
Admit exam: 96.5 P40's BP 138/80 99% on 2L , NAD , JVP 8 , bibasilar
crackles , nl S1 S2 1/6 SEW at USB , no pitting edema , 2+ DP
bilaterally
***
Data:
CXR: cardiomegaly , no acute process
EKG: atrial flutter with slow v response , no ischemia
***
A/P: 60M with known CAD , GERD , CRI , and new aflutter who presents
with chest pain that has resolved.
C: [I]: hx of CAD , likely has chronic angina , was started on heparin
drops , but this stopped after negative markers X 2 , stayed on home meds
and did well with no further CP. Likely long-term uncorrectable
chronic stable angina. Continued ASA , Plavix , Statin , Gemfibrizol ,
Imdur , Lopressor
[P]: hx of HTN , last EF of 65%. Will get ECHO as outpatient. Cont
Hydral , Norvasc , Doxazosin - euvolemic during admission. Continued
lasix
[R]: Had new aflutter on floor and promptly went back into afib. At this
point , will not start antiarhythmic and no long-term anticoag given
that he is on ASA and plavix. He will get cardiac monitoring as an
outpatient.
*ENDO: DMII with neuropathy , Gout , HBA1c pending , Will continue methadone
and allopurinol
*Renal: CRI , Cr with in baseline range.
*GI: GERD - Gave PPI
*Code: Full
ADDITIONAL COMMENTS: You have been admitted to the hospital with chest pain. Your chest pain
is likely due to a combination of your coronary artery disease and
anxiety. You did not have a heart attack. Rather this appears to be
stable angina and your current medication regimen is maximized for this
treatment. You also developed a fast heart rhythm called atrial flutter
when you were admitted , but your heart returned to normal rhythm on its
own. Thus , no medications are being started for this. As an
outpatient you will get an ECHO and also some heart monitoring that
will be arranged by Dr. Laware You will be called with the times for
this. You should continue the same medications that you were previously
taking. If you develop light-headedness , chest pain , or shortness of
breath , you should call your doctor.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*primary care physician - patient will need ECHO and Cardiac Monitoring as an outpatient.
No dictated summary
ENTERED BY: BOISER , ESTELL J. , M.D. ( JI174 ) 10/27/07 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1216
| Target |
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GER |
Gou |
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HTG |
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923502857 | PUO | 39602883 | | 4749133 | 8/29/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 1/23/2005 Report Status: Signed
Discharge Date:
ATTENDING: CHANELLE XOCHITL COLLICA M.D.
DISCHARGE DATE: To be determined.
SERVICE: GMS Y Eu
PRIMARY DIAGNOSIS: Failure to thrive.
SECONDARY DIAGNOSES: Congestive heart failure ,
hypercholesterolemia , gastroesophageal reflux disease , venous
stasis , postherpetic neuralgia , atrial fibrillation , and urinary
tract infection.
HISTORY OF PRESENT ILLNESS: This is an 87-year-old female with a
history of congestive heart failure , atrial fibrillation status
post pacemaker placement , and chronic venous stasis who presents
with nausea , vomiting , and failure to thrive. The patient was
recently admitted to Pagham University Of in early
October with a congestive heart failure exacerbation and lower
extremity cellulitis. She was treated with diuresis ( ultimately
with ethacrynic acid as she developed a rash on torsemide and
itching with Lasix ) and a seven-day course of levofloxacin. At
the end of this admission , she was sent to a rehabilitation
facility. The patient had returned on the day of admission to
see her primary care physician. She had been vomiting and
appears severely dehydrated. She reported nausea and vomiting
for eight to nine days , intermittent nonbloody , nonbilious. She
also reported dysphagia for the last two months. She describes
recent dysuria. She also states that she has had no bowel
movement for a week prior to admission. She has had flatus. She
also complains of a baseline right ear pain due to her
postherpetic neuralgia. She has significantly decreased orally
intake with increasing generalized weakness. She denies chest
pain or shortness of breath.
PAST MEDICAL HISTORY: Congestive heart failure ,
hypercholesterolemia , gastroesophageal reflux disease , venous
stasis , T6 fracture and lower back pain , history of herpes zoster
with postherpetic neuralgia affecting the right face and ear ,
atrial fibrillation status post pace replacement , and history of
guaiac-positive stools.
MEDICATIONS: Colace , senna , lisinopril 5 mg every day , Lopressor 25
mg twice a day , oxycodone 5 mg every 6 hours as needed pain , OxyContin 10 mg
every 12 hours , calcium 500 mg three times a day , Neurontin 100 mg twice a day , Fosamax
70 mg every week , Protonix 40 mg every day , and ethacrynic acid 25 mg
twice a day
ALLERGIES: Lasix , torsemide , penicillin , erythromycin , capsicum ,
and quinidine.
SOCIAL HISTORY: Recently at the Neyrance F/kane Hospital in
Tinema Mo Wa , otherwise , lives alone in Clear Verl At baseline is
ambulatory with a walker. Remote history of tobacco , quit 50
years ago. No history of alcohol use.
FAMILY HISTORY: Asthma and heart disease in three brothers.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 96 , heart rate
81 , blood pressure 119/56 , respiratory rate of 20 , O2 sat 99% on
room air. The patient is alert , but uncomfortable and ill
appearing. HEENT: Pupils equal and reactive to light.
Extraocular movements intact. Mucous membranes are dry.
Oropharynx is otherwise clear. There is ptosis of the right lid
( baseline ) and exquisite tenderness over the right base and right
ear. Neck: JVP is 7 cm. Neck is otherwise supple with no
tenderness to palpation. Cardiovascular: Regular rate and
rhythm with a 2/6 systolic murmur at the apex. Lungs are clear
to auscultation bilaterally. Abdomen: Soft , nontender ,
nondistended with normal active bowel sounds. Foley in place
draining a dark , cloudy urine. Extremities: Violaceous skin
changes of the legs bilaterally. 2+ edema. There is an area of
erythema in the left medial great toe , but no evidence of
infected ulceration. Neuro: Alert and oriented x3. Cranial
nerves intact ( except right lid ptosis ). The patient did not
feel well enough to cooperate with a full neurologic exam , but
her strength was symmetric throughout.
LABS ON ADMISSION: Remarkable for a chemistry panel within
normal limits. BUN was 22 , creatinine 1.1 , white count was
13.27 , hematocrit 41.4 , platelets 448 , 000 , ALT 25 , AST 35 ,
alkaline phosphatase 339 , total bilirubin 1.0 , albumin 4.0 ,
amylase 39 , and lipase 14.
IMPRESSION: An 87-year-old female presenting with nausea ,
vomiting , and dehydration as well as dysuria , most likely mainly
due to urinary tract infection secondary to chronic Foley
placement.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular:
a. Ischemia: No acute issues. The patient was continued on her
beta-blocker. No aspirin was given , as the patient is on
Coumadin and has a history of guaiac-positive stool.
b. Pump: The patient was dry on admission in the setting of
nausea , vomiting , and decreased orally intake. Her last echo
showed an EF of 55% presumed diastolic dysfunction ,
mild-to-moderate MR as well as pulmonary hypertension of unclear
etiology ( pulmonary artery pressure was 64 mmHg plus right atrial
pressure ). Initially , the patient's ethacrynic acid was held
given dehydration , but was restarted towards the end of her
admission and titrated out to twice a day dosing to maintain a
slightly negative fluid balance. The patient was also continued
on her beta-blocker and ACE inhibitor after she was adequately
hydrated for blood pressure control.
c. Rhythm: The patient has a history of paroxysmal atrial
fibrillation. She has a pacer placed and is V-paced. She is on
Coumadin with her INR at goal.
2. Pulmonary: The admission chest x-ray was read as a streaky
opacity of the right lung base possibly representing an
infiltrate , but curve has been artifact due to low lung volume.
The patient had no clinical evidence of pneumonia ( no cough , lung
exam clear ).
3. GI: The patient had nausea , vomiting for several days prior
to admission with decreased orally intake. She also reported no
bowel movement in the last weeks prior to admission. A KUB was
obtained on admission , which showed no evidence of obstruction or
free air. The patient was given stool softeners and laxatives
as needed and began to have her regular bowel movements. She was
continued on Nexium for her history of gastroesophageal reflux
disease. The patient's nausea and vomiting improved overall
throughout her admission , however , intermittently returned.
There is no clear cause for this nausea and vomiting , but it was
thought likely to be a contribution of her opioid medications ,
which were increased early on in her hospitalization to address
her postherpetic neuralgia. The patient's nausea improved with
Reglan. Nausea , vomiting was improved on the day of discharge.
The patient had significantly better orally intake. The patient
also complained of dysphagia for two months prior to admission ,
this occurred mainly with solid foods. Per Speech and Swallow ,
the patient was initially on a soft mechanical/thin liquid diet
and is concerned for an obstructive lesion. A video swallow was
obtained on 3/4/05. This study showed no aspiration and normal
passage of fluid of varying consistencies ( although a note was
made of cricopharyngeal prominence ). Speech and Swallow
recommended a minced solid/thin liquid diet , which the patient
has tolerated well. The patient has a history of an elevated
alkaline phosphatase ( with elevated GGT ) of unclear etiology.
Abdominal ultrasound on her last admission in October 2005
showed gallstones , but no other process to explain the
abnormalities in alkaline phosphatase. The patient had no right
upper quadrant pain on this admission.
4. Renal/FEN: The patient was initially given intravenous
fluids for dehydration. She was also found to have a urinary
tract infection and was initially started on levofloxacin
empirically. The urine culture returned was Staph aureus ( the
patient has had indwelling Foley ) and the patient was switched to
doxycycline ( the patient is allergic to sulfa drugs , penicillin ,
and erythromycin ). Blood cultures were negative. The patient
has been afebrile through this admission. She was also noted to
have a urinary retention on a few occasions where an attempt was
made to remove her Foley catheter. This was thought most likely
due to urinary tract infection and to use opioid medications.
The patient will be discharged to rehab with her Foley in place
and is scheduled for a follow-up appointment with Urology on
October , 2005.
5. Neuro: The patient has postherpetic neuralgia affecting her
right face/ear. She was admitted on OxyContin and oxycodone ,
which was titrated out in an attempt to make her more comfortable
and Neurontin was also titrated out with good effect on her pain.
Given her nausea and urinary retention , the patient's opioid
medications were decreased. A trial of a lidoderm patch on the
affected area was attempted prior to discharge.
6. Heme: The patient's INR was at goal ( 2 to 3 ) on Coumadin for
her history of paroxysmal atrial fibrillation.
7. Prophylaxis: The patient was on Nexium and Coumadin.
8. Code status: DNR/DNI.
9. Disposition: The patient will be discharged to a
rehabilitation facility. She will follow up with her primary
care doctor Dr. Avril Taplin In addition , an appointment has
been made for her to see Dr. Dominguez on January , 2005 at 9:30
a.m. In addition , an appointment has been made with Dr. Tonsil
in Neurology on October , 2005 at 11:15 a.m. and it is requested
that the patient's basic metabolic panel be monitored while she
is on ethacrynic acid. In addition , her weight should be
followed daily to check for fluid accumulation. She will also
benefit from physical therapy as she is deconditioned. The
patient is stable at the time of this dictation.
The discharge medications will be dictated in an addendum to this
discharge summary.
eScription document: 1-0615859 ISSten Tel
CC: Avril Taplin M.D.
KTDUOO
Lu Broke Green
Neaeans
CC: Chanelle Xochitl Collica M.D.
Dictated By: CONEDY , ARMINDA
Attending: COLLICA , CHANELLE XOCHITL
Dictation ID 1677703
D: 10/9/05
T: 1/27/05
Document id: 1217
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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979471841 | PUO | 51095484 | | 8857335 | 11/7/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 10/1/2006 Report Status: Signed
Discharge Date: 11/28/2006
ATTENDING: KERTESZ , ALETA M.D.
This is a discharge summary dictation addendum to the previously
dictated note dictated by Coletta Verry , PA-C , describing
Mr. Krizan ' preoperative history , physical , operative procedure
( CABG x3 ) on 8/9/06 and postoperative course from 8/9/06
through 1/13/06.
While on the cardiac surgery step-down unit , Mr. Krizan continued
to demonstrate swollen ecchymotic area at the left lower extremity
along the SVG harvest site incision with white blood cell count
rising to 15.6 on 10/25/06 , although remaining afebrile. A left
lower extremity ultrasound obtained at that time revealed a fluid
collection along the prior SVG tract , corresponding to the area with
the most significant erythema. Mr. Krizan was continued on
vancomycin and levofloxacin and was taken back to the operating
room on 9/6/06 for drainage and irrigation of left lower extremity
endoscopic saphenous vein harvest site. No obvious purulence was noted
in the operating room. Cultures were sent from the OR which
subsequently revealed no growth. Postoperatively , the wound was
packed with wet-to-dry dressing , changed daily , and the patient
was continued on vancomycin intravenous antibiotics with white blood cell
count improving. Following operative reintervention , SVG harvest
site incision appeared less inflamed , less tender and less erythematous ,
with corresponding improvement in cellulitis. A plan had been made to
subsequently discharge the patient on postoperative day #13 , 5/2/06.
A long line was placed at this time in anticipation of discharge for
continuation of seven days of intravenous vancomycin. However , white blood
count rose to 19.4 on planned day of discharge , 3/28/06 , and ,
althought the patient remained afebrile and the wound continued to
remain clean with minimal cellulitis , Mr. Krizan was kept inpatient
overnight for continued observation and re-assessment of WBC. On
3/25/06 , white blood cell count improved to 14.3 , the patient
remained afebrile , and the wound continued to remain clean with
packing changed wet-to-dry daily. Additional sources of leukocytosis
were sought including sputum culture , which subsequently demonstrated
no significant growth. Urinalysis was noted to be mildly dirty , for
which the patient began a short course of orally levofloxacin.
Sternal wound continued to remain intact with no sternal click ,
erythema , or drainage noted. Mr. Krizan is discharged to
rehabilitation today , postoperative day #14 , for continued
cardiopulmonary rehabilitation following coronary artery bypass
graft x3 and drainage and irrigation of left extremity saphenous vein
harvest site.
PROCEDURES:
1. 8/9/06 , CABG x3 with LIMA to LAD , SVG1 to PDA , SVG2-OM1.
Bypass time 97 minutes , crossclamp time 73 minutes. Please refer
to operative note for details.
2. 9/6/06 , drainage and irrigation of left lower extremity
saphenous vein endoscopic harvest site incision. Please refer to
operative note for details.
PHYSICAL EXAMINATION:
On day of discharge , 3/25/06 , Mr. Krizan is a pleasant elderly
male , alert and oriented x3 in no acute distress. Vital signs
were as follows: Temperature 99.0 degrees Fahrenheit , heart rate
80 sinus rhythm , blood pressure 110/58 , and oxygen saturation 96%
on room air. Today's weight listed as 3.3 kilograms below his
preoperative weight of 84.4 kilograms. HEENT: PERRL , no carotid
bruits or JVD appreciated. Pulmonary: Lungs are clear
auscultation bilaterally with slightly diminished breath sounds
at left base. Coronary: Regular rate and rhythm , no murmurs ,
rub , or gallops appreciated. Abdomen: Soft , nontender ,
nondistended , positive bowel sounds. Extremities: No peripheral
edema present , 2+ pulses at all extremities bilaterally. Skin:
Midline sternotomy incision well approximated and healing well
with no erythema or drainage present , no sternal click elicited on
examination. Left lower extremity endoscopic SVG harvest site
incision , clean , granulating well. Mild erythema and warmth
remaining , however , improved from prior examination , no purulent
discharge present. Clean sterile packing with wet-to-dry
dressing in place. Neuro: Intact , nonfocal examination.
LABORATORY VALUES:
On day of discharge , 3/25/06 : Sodium 137 , potassium 4.0 , BUN
17 , creatinine 1.0. Glucose 91 , calcium 8.4 , magnesium 1.8 ,
white blood cell count 14.3 , hematocrit 28.1 , platelet count 561.
Microbiology negative for VRE and MRSA and routine surveillance
screening sent 1/5/06. Urine culture negative for growth
11/24/06. Blood culture 1/6/06 with question pseudomonas
aeruginosa contaminant. Second blood culture from 1/6/06 with
no growth by final read. Repeat blood cultures from 10/29/06 and
3/28/06 with no growth. Urine culture on 3/28/06 with no
growth. Operative culture from left lower extremity wound
9/6/06 with no growth thus far on day of discharge. Pathology ,
no specimens received.
DIAGNOSTIC IMAGING:
Chest x-ray PA and lateral view obtained on today prior to
discharge , 3/28/06 , demonstrates small left pleural effusion , no
pulmonary edema , mild cardiomegaly , subsegmental atelectasis
present left lower lobe , unchanged from prior chest x-rays. No
areas of infiltrate or pneumothorax present. Old rib fractures
noted at right side. Left lower extremity ultrasound 10/25/06
remarks on 9 x 1.2 x 1.1 cm area of fluid collection with an
inflamed soft tissues extending from just above the medial knee
and the area of incision at the SVG harvest site along the left
lower extremity to the medial calf with marked inflammation , soft
tissues overlying this region.
DISPOSITION:
Mr. Krizan has recovered well following his elective coronary
artery bypass graft procedure and has continued to recover well
following evacuation of left lower extremity endoscopic SVG
harvest site incision hematoma. He is discharged to
rehabilitation today , postoperative day #14 , to continue
cardiopulmonary recovery. Mr. Krizan will return to Pagham University Of for followup with his cardiac surgeon , Dr.
Kertesz , in approximately four weeks. Additionally , Mr. Krizan
will follow up with his primary care physician in one week and
with his cardiologist , Dr. Krinsky , in two to four weeks. Mr. Krizan
has been instructed to monitor all incisions for signs of
worsening infection and to take all medications as directed.
Additionally , he is to continue daily ambulation and physical
therapy as tolerated. Mr. Krizan will require follow up with his
primary care physician for continued evaluation and management of
hypertension , dyslipidemia , BPH , mild postoperative hyperglycemia
and additionally he will follow up with his cardiologist for
continued evaluation and management of blood pressure , heart
rate , heart rhythm , lipid levels and for possible future
adjustment of medications. Dressing changes to continue to left
lower extremity wound daily , packing loosely with sterile tape
subsequently covering with wet-to-dry sterile gauze. Notify
Department of Cardiac Surgery immediately if the patient develops
fever , purulent drainage , increasing erythema , left lower
extremity worsening pain or further signs of worsening infection.
DISCHARGE CONDITION:
Stable.
DISCHARGE MEDICATIONS:
Discharge medications include the following: Tylenol 325-650 mg
orally every 4 hours as needed pain or temperature greater than 101 degrees
Fahrenheit , Norvasc 5 mg orally daily , enteric-coated aspirin 325
mg orally daily , Colace 100 mg orally twice a day , Nexium 20 mg orally
daily , ibuprofen 400-600 mg orally every 8 hours as needed pain , levofloxacin
500 mg orally daily x4 days for UTI postoperatively , Toprol-XL 300
mg orally daily , oxycodone 5-10 mg orally every 4 hours as needed pain ,
simvastatin 40 mg orally nightly , vancomycin HCL 1 g intravenous every 12 hours ,
last dose on Monday , 5/28/06 , to be administered by long line
placed 3/28/06 , Ambien 5 mg orally nightly.
Thank you for referring this patient to our service. Please do
not hesitate to call with further questions or concerns.
eScription document: 2-1940269 EMSSten Tel
CC: Aleta Kertesz M.D.
CC: Buck Moose MD
Ing
Mont
Woodworce Ro
Dictated By: SURGEON , PRICILLA
Attending: KERTESZ , ALETA
Dictation ID 9183656
D: 3/25/06
T: 3/25/06
Document id: 1218
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
U |
Y |
- |
U |
U |
U |
U |
U |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
N |
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N |
N |
N |
N |
N |
Y |
N |
N |
Y |
Y |
N |
N |
210455437 | PUO | 80492459 | | 0086133 | 3/22/2006 12:00:00 a.m. | SEPSIS | Signed | DIS | Admission Date: 10/28/2006 Report Status: Signed
Discharge Date: 6/18/2006
ATTENDING: BOHANAN , SHEA M.D.
CHIEF COMPLAINT:
Weakness , shortness of breath , and dizziness.
HISTORY OF PRESENT ILLNESS:
This is a 48-year-old female who was discharged to home on
1/25/06 from Whid Downdoc Rehabilitation Of after an ICU admission for
pneumonia and Klonopin overdose. Two days prior to admission
here , she experienced shortness of breath at rest and some
lightheadedness. At baseline , she becomes dyspneic after walking
20 feet secondary to obesity and many years of smoking. She also
notes several days of headache and some questionable darkening in
her visual fields bilaterally. She admits that her orally intake
has been rather poor since coming home secondary to anorexia and
that she has felt dehydrated. On review of systems , she also
notes chronic waxing and waning erythema of the right lower
extremity which in recent days has worsened with accompanying
swelling and mild tenderness , although her son says that it has
been worse in the past. Also , she has noted loose stools since
8/4/06. She denies chest pain , pleurisy , abdominal pain , blood
in her stool or urine , dysuria , change in frequency , character or
urination , or focal weakness. No new medications other than a
recent antibiotic course at Whid Downdoc Rehabilitation Of completed there for
pneumonia. She has not taken her lisinopril or methadone in the
last two days. She has no sick contact. She saw her primary care physician on
2/8/06 who found her to be hypotensive and hypoxic and then
sent her to Whid Downdoc Rehabilitation Of ED. Her family is not clear on her
discharge diagnosis , but they report that her kidney function was
abnormal and she was dehydrated. She was not admitted. She then
came to the ED at Totin Hospital And Clinic for persistent shortness of
breath and dizziness. In the ED , her vital signs were that she
was afebrile , her systolic blood pressure was in the high 60's ,
her heart rate was 110 , respiratory rate in the 30's , and O2
saturations were in the high 80's. She was given vancomycin ,
Levaquin and gentamicin and 3 liters of normal saline. She was
aggressively given fluids and was started on Levophed for blood
pressure support. Her EKG was notable for low voltage on
precordial leads and borderline right axis deviation. Chest
x-ray showed cardiomegaly , but otherwise clear. In the MICU , her
blood pressure was stabilized on Levophed , but she was also noted
to drop her blood pressure to the 70's when initiated on her home
BiPAP settings.
PAST MEDICAL HISTORY:
She had endocarditis 20 years ago. She has obstructive sleep
apnea , on her home BiPAP , morbid obesity , and hypertension. She
had a right ankle injury more than 20 years ago during the motor
vehicle accident , which was complicated by an ankle infection.
She has chronic right lower extremity pain and she is on
methadone. She had a Klonopin overdose. She had Enterobacter
pneumonia. She was treated with cefepime at that time ,
questionable the vancomycin. She has a questionable diagnosis of
COPD with her extensive smoking history. In a well state , her
PCO2 was 49 , her O2 saturation is 89% , and she has also history
of depression.
MEDICATIONS AT HOME:
Lisinopril and methadone. She is not taking her lisinopril. She
has in the past taken lisinopril with hydrochlorothiazide.
ALLERGIES:
She is allergic to penicillin and sulfa drugs.
SOCIAL HISTORY:
She smoked half a pack a day for 30 years. No alcohol for three
years. No illicit drugs. She lives at home , but does not work.
She is on disability.
PHYSICAL EXAMINATION:
She was afebrile , heart rate in the 100's , blood pressure 130/80 ,
respiratory of 18 , and O2 saturation 95% on 8 liters of oxygen.
She was awake and alert and in no acute distress. She is
anicteric , without pallor. She had a thick neck. Pulmonary:
She had decreased breath sounds and crackles at the bases
bilaterally. Cardiovascular: She was tachy , regular , but
distant S4. JVP was difficulty to ascertain secondary to neck
habitus. Her abdomen was obese , + bowel sounds , nontender and
nondistended. Extremities were without erythema of her legs , but
with mild swelling of the right lower ankle. The ankles were
without swelling and with full range of motion. Neurologically ,
she was alert and oriented , but unfocused in conversation , moving
all her extremities. Her strength was intact.
LABORATORY STUDIES ON ADMISSION:
Please see LMR.
ASSESSMENT AND PLAN:
This is a 49-year-old woman with a recent ICU stay at an outside
hospital who presented with hypotension , tachycardia , and acute
renal failure. Presentation was most consistent with right
pulmonary embolus and right ventricular failure.
HOSPITAL COURSE BY SYSTEM:
1. Pulmonary/Vascular: There was initial concern for a PE given
the presentation of severe hypotension , tachycardia , and Aa
gradient without evidence of infection or primary cardiac
disease. An echo showed a dilated RV with depressed RV function
suggestive of PE. Her initial PE scan was nondiagnostic
secondary to poorly timed contrast and motion of the patient. A
VQ scan showed intermediate probability. She was started on
heparin drip with a goal of 60 to 80. Her second PECT showed a
small PE to the right upper lobe , but it was not large enough to
explain her dramatic presentation. The working hypothesis is
that there was a significant recanalization prior to this repeat
CT which took place two days after the first CT. She was
initially on oxygen in the ICU. She was never intubated. She
was on face mask , and upon transfer to the floor , she was on
nasal cannula 4 liters. Her O2 saturations were acceptable
in-house , although she did desaturate to 90% when she took her
oxygen off a night. She multiple times refused BiPAP while in
the hospital , but she will go back on it when she returns home.
2. Cardiovascular: She had a mild troponin elevation on
admission , likely secondary to RV strain. She had severe
hypotension and was on two pressors. She was weaned off of these
on 3/9/06 , but did have an episode of hypotension when her
BiPAP was started. She was given a little bit of low dose
dobutamine and then she was weaned off of that on 10/4/06.
Rhythm: She has no active issues. We continued to hold her
lisinopril while in-house. Her blood pressures were stable , but
not high enough to withstand on additional blood pressure
lowering medication. It was discussed with her primary care physician that she
perhaps will need this medication restarted as an outpatient.
She does have a history of severe hypertension.
3. Renal: As she was in acute failure on admission with a
creatinine of 6.9 , it dropped to 0.5 , most likely this was due to
prerenal azotemia and decreased renal perfusion in the setting of
hypotension. Hypoperfusion of the kidneys in setting of
hypovolemia and right heart failure resulting in decreased left
ventricular preload. Mucomyst and bicarb were given prior to the
PECTs of her renal protection. She did not develop any
additional contrast nephropathy after her CT scans. Her
creatinine on discharge was 0.6.
4. Endocrine: She had a normal increase in her cortisol level
with ACTH stimulation. Her fingersticks were monitored while she
was in-house and she never had any need for supplemental insulin.
5. FEN: She was on a house diet.
6. ID: She was empirically covered on admission with
vancomycin , levofloxacin and gentamicin. Her antibiotics were
given again on 10/8/06 and on 2/8/06. There was no evidence
of an infection found , no fever , normal white count , with a
normal differential , normal UA , chest x-ray is without
infiltrate , and antibiotics were discontinued on 2/5/06. She
continued to remain afebrile in-house without any evidence of
infection.
7. Urology: She did complain of bladder spasms while having the
Foley in place. She was started on Ditropan. She had multiple
negative urinalysis and urine cultures. Once the Foley was
discontinued , she was able to void and she stopped having bladder
spasms. She was started on Monistat for a yeast infection.
8. Allergy: She did have an elevated eosinophilia on
presentation and it was 4% on admission and increased to 8% on
2/5/06. On the day of discharge , it was 7.5. There is no
clinical evidence of allergy , rheumatic disease or parasitic
infection. Her obstructive lung disease may be of an asthma
variant , and there is the possibility she may need inhaled
corticosteroids as an outpatient.
9. Heme: She was on unfractionated heparin for her presumed PE
until 2/5/06 and then she was changed to Lovenox in the morning
of that day on 120 mg subcutaneously Her weight at that time was 157 kg.
Her Coumadin , her initially given 10 , then a dose of 5 and then 2
dose of 7.5. Her INR was therapeutic on the day of discharge at
2.5. She will continue on the Lovenox for two additional days.
Her INR will be monitored by Dr. Enny , her primary care physician.
10. Psych/Addiction: We are continuing her methadone. It has
been switched from 20 mg orally daily to 10 mg orally twice a day She was
also given a little bit of Ativan while in-house to help with her
agitation and anxiety. She was initially given a little bit of
Haldol , but that was discontinued on 1/29/06 and there was no
additional need for that. She did have a central line placed on
10/18/06 , which was discontinued on 2/5/06 without any evidence
of any line infection and without any problems. She was seen by
Social Work and physical therapy. The patient refused to go to any sort of
rehab or nursing home. It was decided that the patient would
return home with skilled nursing and with physical therapy as needed.
eScription document: 9-4018582 EMSSten Tel
Dictated By: YEAGLEY , MA
Attending: BOHANAN , SHEA
Dictation ID 2778415
D: 11/12/06
T: 11/12/06
Document id: 1219
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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615038343 | PUO | 94076394 | | 6538683 | 4/13/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 4/13/2003 Report Status: Signed
Discharge Date:
ATTENDING: GERARD MUHLSTEIN MD
CHIEF COMPLAINT: Shortness of breath , hematuria.
HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman with
a history of chronic renal insufficiency , elevated ammonia levels
chronically , CAD , ischemic cardiomyopathy with an EF of 40% in
LVH , recently discharged from I Warho Hospital on 7/10
and subsequently transferred to Bussadd Southrys Community Hospital The patient
presents with increased shortness of breath. The prior admission
was related to renal failure and increased encepholopathy ( no
dictated summary available ). The patient reported doing well in
rehab for several days. However , over the past 2-3 days the
patient developed increased shortness of breath , and dyspnea on
exertion with very minimal movement. The patient reports stable
two pillow orthopnea. No upper respiratory symptoms. No fevers ,
chills , nausea or vomiting. The patient without palpitation.
The patient does report that shortness of breath was increased
over past baseline. The patient also notes noted increased
hematuria , although the patient has had a chronic hematuria for
over 1-2 years per patient. The patient does report that he had
a Foley in during the prior admission , and has had increased
hematuria since that discharge. The patient denies chest pain.
The patient was felt to have "crackles" at the rehab , and was
sent to the I Warho Hospital for further care. In ED
the patient was afebrile , heart rate of 74 , blood pressure
127/75 , and satting 95% on room air. He was given 80 intravenous Lasix ,
Percocet and Lactulose for elevated ammonia. Labs were notable
for elevated BNP of 655 , elevated ammonia of 83.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Diabetes.
3. Chronic hyper ammonium levels NH3 ranging from 70 to 90
( prior workup largely negative however never able to image the
abdomen secondary to severe obesity ).
4. History of normal LFTs in the past.
5. Hypertension.
6. CAD and past troponin leak early 10/10
7. Chronic leg pain.
8. History of VT on sotalol.
9. Migraines.
10. Hypercholesterolemia.
11. Chronic renal insufficiency with a baseline creatinine of
approximately 3.7 - 3.9.
12. BPH status post Targis procedure.
13. Anemia.
14. Anxiety.
15. History of multiple myeloma , monoclonal gammopathy status
post Cytoxan.
MEDICATIONS:
1. Sotalol 40 mg orally twice a day
2. Klonopin.
3. Lasix 80 mg orally twice a day
4. Calcitriol.
5. Aspirin 325 mg orally every day.
6. Sodium bicarb.
7. Atorvastatin 40 every day.
8. Phoslo 667 three times a day
9. Toprol 100 orally every day.
10. Lactulose 30 mg four times a day
11. Epogen.
12. CPAP at night.
13. Doxepin.
14. NPH 8 units every day before noon
15. Proscar.
ALLERGIES: Ciprofloxacin , Codeine causing rash and dizziness.
SOCIAL HISTORY: The patient lives with wife. No tobacco or
alcohol history.
PHYSICAL EXAMINATION: The patient was afebrile with a heart rate
of 82 , blood pressure 132/72 , respiratory rate 94% on room air ,
weight 420 lbs. General: Morbidly obese , speaking in full
sentences. HEENT: Oropharynx clear , anicteric sclerae. Neck:
JVP less than 6 cm though difficult to assess secondary to
habitus. No lymphadenopathy. Cardiovascular: RRR , no MRG , no
S3 or S4 appreciated. Lungs: Increased crackles at the bases.
Abdomen: Obese , no obvious liver edge , no fluid wave.
Extremities: Lower extremity edema approximately 2-3+. Skin:
The patient with chronic excoriations on abdomen ( the patient
reports they have been improving over the past year ) , and the
patient also with chronic ulcer/lesions throughout lower legs
bilaterally. Neuro: The patient was alert and oriented x3.
Motor strength someone decreased proximal leg and arms.
LABORATORY DATA: Sodium 139 , potassium 4.1 , chloride 103 , CO2
26 , BUN 64 , creatinine 4.0 ( baseline creatinine of 3.7 - 3.9 ) ,
albumin 3.4 , white count of 7.1 , hematocrit of 33.5 , platelets of
137 , ( baseline hematocrit usually 32-35 ) , LFTs within normal
limits ( ALT , AST , alk phos , T bili ). First set of ED enzymes
were negative. BNP elevated at 655. Ammonia elevated at 83.
INR 1.2 , PTT 36.
Chest x-ray revealed enlarged central pulmonary arteries which
were suggestive of pulmonary hypertension in this patient with
obstructive sleep apnea , left base subsegmental atelectasis. EKG
first degree AV block , left axis deviation , a left ??anticular??
vesicular block , no ST or T-wave changes. UA with 3+ blood ,
15-20 white blood cells , trace bacterial. Of note , renal
ultrasound on 9/29/03 ( prior admission )I revealed no
hydronephrosis , distended gallbladder with multiple small stones.
ETT MIBI on 9/14/03 stress images only performed revealed small
area of myocardial scar in mid LAD/diagonal territory with
moderate stress induced peri-infarct ischemia. Echo performed
2/25/03 revealed an EF of 45-50% , positive LVH. Inferior and
lateral hypokinesis.
HOSPITAL COURSE:
1. Ischemia: The patient with a history of CAD and positive
MIBI in 10/10 The patient with no EKG changes , and also no
chest pain. The patient initially continued on aspirin , beta
blocker and a statin. On 8/25/03 the patient with a troponin
leak ( peak of .84 ) which subsequently trended down. The patient
also had had a prior troponin leak prior to the previously
described MIBI. At that time cardiology was following and
recommended medical management secondary to difficulty with
aggressive intervention in this patient. For this admission ,
cardiology was again consulted and cardiology recommended doing a
repeat MIBI to assess. The MIBI was completed on 3/28/03 and
results are pending at the time of this dictation. Again , very
difficult to perform intervention secondary to habitus.
Continued aspirin , beta blocker and statin. To follow up with
Cardiology for further read of the MIBI test. Pump: The patient
with elevated BNP and some fluid overload. Chest x-ray as
described above ( also a question of small pleural effusion slowly
improved from before ). It was felt that the patient's shortness
of breath could be secondary to increased pulmonary edema. So ,
the patient's Lasix was increased to 80 mg orally three times a day ( from
twice a day dosing ). Prior echo is as described above , revealing an
EF of 45%. The patient did have successful diuresis on the
increased Lasix dosing. On 1/24 the Lasix was lowered back to
twice a day dosing since the patient's creatinine began to rise.
Creatinine normalized to patient's baseline on 10/14 At time of
discharge the patient is on a home regimen of Lasix 80 mg orally
twice a day Rhythm: The patient with a history of VT and the patient
was continued on sotalol , and monitored on telemetry without
alarms.
2. Pulmonary: The patient with shortness of breath increased
over baseline and chest x-ray as described above. Secondary to
the elevated BNP and increased lower extremity edema , the patient
was diuresed as described above. The patient does use BiPAP at
night for obstructive sleep apnea.
3. Endocrine: The patient with diabetes on insulin sliding
scale and a.m. NPH. No ace inhibitor was added secondary to the
significantly elevated creatinine. The patient's NPH was
increased to 10 units every day before noon secondary to elevated sugars
( resulting in more improved glycemic control ).
4. Renal: The patient with chronic renal insufficiency with a
baseline creatinine of approximately 4. This is likely secondary
to several factors , including diabetes , effects of paraprotein
associated with monoclonal gammopathy ( obesity ). The patient was
continued on Phoslo , Calcitriol and Epogen. The patient also
with increased hematuria , and this was discussed with urology.
Previously extensive urological workup ( including cystoscopy ) was
largely negative but were poor studies secondary to large
habitus. Urology attending was not comfortable with aggressive
intervention at this time , and thought hematuria was likely
secondary to significant BPH ( and associated engorged veins ).
The patient is status post Targis procedure as described above ,
and hematuria secondary to recent Foley trauma from past
admission. The patient to follow up with urology in the future.
A urine cytology was obtained and is pending at this time.
5. GI: The patient with elevated ammonia levels , with normal
LFTs. This has also been worked up in the past according to the
patient which resulted in no clear diagnosis. The patient is too
obese for any abdominal imaging per CT. The patient does have a
history of multiple myeloma which could be the source of elevated
ammonia , versus a hepatic source. Ammonium level was 83. The
patient had no asterixis and had normal mentation while inhouse.
The patient's medication of Lactulose was continued.
6. Heme: The patient with chronic anemia as described in the
lab section. The patient did have an episode of epistaxis that
subsequently resolved , and hematuria as described above , though
also somewhat improved at time of discharge. Hematocrit was
stable throughout this , and there was no need for transfusion.
7. Oncology: The patient with a history of IgA monoclonal
gammopathy status post Cytoxan therapy. The oncologist
attending , Dr. Malachi , who knows the patient felt there was
no need for additional chemo at this time. Previous Cytoxan
therapy has not been significantly effective.
8. Neuro: The patient also complaining of muscle weakness ,
proximal muscles greater than distal muscles. A neurology
consult was called , who felt that this was largely secondary to
deconditioning and secondary to patient's multiple comorbidities ,
this is not likely secondary to a myositis. No further workup
was performed.
PLAN TO DO: The patient to be discharged to rehabilitation for
further care , physical therapy and medical management. The
patient to follow up with Cardiology , primary care physician and Urology. Continue
wound care dressing changes twice a day
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Tylenol 325 orally every 6 hours as needed pain.
2. Aspirin 325 mg orally every day.
3. Calcitriol .75 mcg orally every day.
4. Colace 100 mg orally twice a day
5. Doxepin 10 mg orally four times a day
6. Lasix 80 mg orally twice a day
7. NPH 10 units subcutaneously every day before noon
8. Insulin sliding scale before every meal and bedtime
9. Atrovent two puffs inhaled twice a day
10. Lactulose 30 ml orally every 4 hours , instructions goal 4-5 soft bowel
movements per day.
11. Maalox 50 ml orally every 6 hours as needed indigestion.
12. Serax 10 mg orally every bedtime as needed insomnia.
13. Oxycodone 5-10 mg orally every 6 hours as needed pain.
14. Afrin 2 sprays nasal twice a day as needed
15. Senna tablets 2 tablets orally twice a day
16. Sodium bicarbonate 650 mg orally three times a day
17. Zoloft 50 mg orally every day.
18. Proscar 5 mg orally every day.
19. Simvastatin 20 mg orally every bedtime
20. Sotalol 40 mg orally twice a day
21. Toprol XL 100 mg orally every day.
22. Ambien 5 mg orally every bedtime as needed insomnia.
23. Mirapex .5 mg orally three times a day
24. Fluticasone nasal spray 1-2 sprays nasally every day.
eScription document: 4-7121425 DBSSten Tel
Dictated By: INNARELLI , DONNETTE
Attending: MUHLSTEIN , GERARD
Dictation ID 8746163
D: 3/28/03
T: 3/28/03
Document id: 1220
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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577107798 | PUO | 85269295 | | 3891893 | 6/20/2006 12:00:00 a.m. | bone cancer | Unsigned | DIS | Admission Date: 6/20/2006 Report Status: Unsigned
Discharge Date: 6/8/2006
ATTENDING: HEIDELBERG , AMIE SALLY MD
PRIMARY ADMITTING DIAGNOSIS: Pulmonary embolism.
SECONDARY DIAGNOSES: Diabetes , hypertension , hypothyroid and
GERD.
ADMISSION MEDICATIONS: Atenolol 50 daily , lisinopril 5 daily ,
Protonix 40 daily , metformin 1500 daily , Lantus 60 daily , Humalog
20 before meals , Byetta 5 mcg twice daily , levothyroxine ( dose
unknown ) , OxyContin 40 every eight hours , Percocet two tabs every
3 hours as needed for pain and gabapentin ( dose unknown ).
CHIEF COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: This is a 66-year-old man with
diabetes , hypertension , obesity and non-Hodgkin's lymphoma of the
right hip on chemotherapy ( R-CHOP ) , which began on 11/29/06 and
will continue for 18 weeks. He reported no complications from
ischemic chemotherapy. At baseline he cannot bear weight on his
right leg and he devised this complicated system where he shifts
himself down the stairs to the bottom of the steps using his
upper body strength and a family member to assist him. All
during this maneuver he felt unusually short of breath the day of
admission and in the context of breathing heavily began to sweat
and feel lightheaded and then lost consciousness temporarily.
Sister was present and called EMS. On arrival to the emergency
room , he was hypotensive and received intravenous normal saline as volume
resuscitations. His pressures initially were noted to be in the
70s to 80s systolic and improved to 90 systolic after 4 L of
fluid from the emergency room. The patient was admitted for
syncope. On admission as part of the workup for syncope an
initial set of cardiac enzymes was negative.
PHYSICAL EXAMINATION: On physical exam , the patient was
afebrile , heart rate in the 90s , blood pressure systolic 100 ,
respirations 20 and O2 sat 94% on room air. Pupils were equal ,
round and reactive to light. There was no cervical
lymphadenopathy. JVP was not visualized due to large neck.
Lungs were clear. The heart was regular. There was an S1 , S2
with a loud and widened split P2 component of the second heart
sound. Abdomen was soft and nontender. The right hip was tender
to palpation. The extremities had 1+ edema bilaterally.
The patient was admitted with a preliminary diagnosis of syncope.
HOSPITAL COURSE: The second set of cardiac enzymes was positive
with a troponin of 2. Echocardiogram the morning following
admission showed a dilated right ventricle consistent with right
ventricular strain. This was followed by a PE protocol CT scan ,
which showed a large saddle embolus. The patient was treated
initially with intravenous heparin , transitioned to Coumadin and then the
decision was made to try Lovenox therapy for long-term
anticoagulation. Cardiac enzymes normalized. Repeat
echocardiogram showed mild improvement in right heart function.
eScription document: 2-9299876 CSSten Tel
Dictated By: BONNIE , LEONE
Attending: HEIDELBERG , AMIE SALLY
Dictation ID 1419764
D: 1/26/06
T: 1/26/06
Document id: 1221
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
Y |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
N |
N |
N |
N |
340018453 | PUO | 20849307 | | 2658799 | 2/22/2006 12:00:00 a.m. | congestive heart failure , acute on chronic renal failure | | DIS | Admission Date: 1/13/2006 Report Status:
Discharge Date: 2/17/2006
****** FINAL DISCHARGE ORDERS ******
RODIBAUGH , ISADORA 638-24-84-0
Kentucky
Service: MED
DISCHARGE PATIENT ON: 10/14/06 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KENDRICKS , ADDIE M. , M.D.
CODE STATUS:
No CPR , Other - withhold CPR for sudden death
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
Override Notice: Override added on 4/15/06 by
HARKLEY , JACQULYN D. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 552199391 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware , reg home meds
Previous override information:
Override added on 1/2/06 by BURVINE , ALVERTA A. , M.D.
on order for COUMADIN orally ( ref # 031228803 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally three times a day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
HYDRALAZINE HCL 25 MG orally three times a day HOLD IF: SBP<90
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ISORDIL ( ISOSORBIDE DINITRATE ) 20 MG orally three times a day
HOLD IF: SBP<85
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally three times a day
HOLD IF: sbp < 100 , heart rate < 55
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DILANTIN ( PHENYTOIN ) 100 MG orally four times a day
Food/Drug Interaction Instruction
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after )
Override Notice: Override added on 4/15/06 by
HARKLEY , JACQULYN D. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 552199391 )
POTENTIALLY SERIOUS INTERACTION: PHENYTOIN & WARFARIN
Reason for override: aware , reg home meds
Previous override information:
Override added on 1/2/06 by BURVINE , ALVERTA A. , M.D.
on order for COUMADIN orally ( ref # 031228803 )
POTENTIALLY SERIOUS INTERACTION: PHENYTOIN & WARFARIN
Reason for override: aware
PREDNISONE 10 MG orally every day before noon
SODIUM BICARBONATE 325 MG orally three times a day
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 4/15/06 by
HARKLEY , JACQULYN D. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: PHENYTOIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: SULFAMETHOXAZOLE & WARFARIN
Reason for override: aware , reg home meds
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Alert overridden: Override added on 1/2/06 by
BURVINE , ALVERTA A. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: aware
LOVENOX ( ENOXAPARIN ) 50 MG subcutaneously every day Starting Today ( 11/26 )
Instructions: STOP ONCE INR>2.0
GLIPIZIDE XL 2.5 MG orally every day
BACTRIM DS ( TRIMETHOPRIM/SULFAMETHOXAZOLE DOU... )
1 TAB orally 3x/Week M-W-F
Override Notice: Override added on 4/15/06 by
HARKLEY , JACQULYN D. , M.D. , PH.D.
on order for COUMADIN orally ( ref # 552199391 )
SERIOUS INTERACTION: SULFAMETHOXAZOLE & WARFARIN
Reason for override: aware , reg home meds
Previous override information:
Override added on 1/2/06 by BURVINE , ALVERTA A. , M.D.
SERIOUS INTERACTION: WARFARIN & SULFAMETHOXAZOLE
Reason for override: aware
FLOVENT ( FLUTICASONE PROPIONATE ) 220 MCG inhaled twice a day
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
ESOMEPRAZOLE 40 MG orally every day
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours
DARBEPOETIN ALFA 25 MCG subcutaneously QWEEK
Reason for ordering: Renal Disease
Last known Hgb level at time of order: 9.2 g/dL on
8/6/06 at PUO
Diagnosis: Chronic Renal Failure 585
Treatment Cycle: Initiation
LIPITOR ( ATORVASTATIN ) 40 MG orally every day
Alert overridden: Override added on 10/14/06 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: reg home meds
DIET: House / NAS / ADA ADA 1600 cals/daycals/dy / Low saturated fat
low cholesterol / Renal diet / LOW POTASSIUM (I) (FDI)
ACTIVITY: walking with walker and 2L O2 with assist
FOLLOW UP APPOINTMENT( S ):
Dr. Leola Musich 9/9 @ 3:30 scheduled ,
Dr. Otilia Ienco ( renal ) 5/21 @ 1:30 scheduled ,
Dr. Hora ( cardiology ) 11/18/06 at 1pm scheduled ,
Arrange INR to be drawn on 4/1/05 with f/u INR's to be drawn every
1 days. INR's will be followed by Rehab facility , then Dr. Leola Musich
ALLERGY: Penicillins , ACE Inhibitor , DICLOXACILLIN
ADMIT DIAGNOSIS:
acute on chronic renal failure , congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure , acute on chronic renal failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ANEMIA CRI ( Cr 1.7 ) seizures ( partial
seizures ) dvt , left calf ( deep venous thrombosis ) appendectomy
( appendectomy ) colon adenoma ( colonic polyps ) TAH
( hysterectomy ) anemia ( anemia ) PPM 3/15 for
SSS history of MI 1997 , 4/12 with stents to LAD , D1 , LCx severe pulmonary
sarcoidosis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB , Increased Cr.
***
HPI: Ms Tollett is a 74 year-old female with history of CAD history of LAD stent 4/12 , CHF with EF
50% , and CRI with Cr ( 1.9-2.4 ) who presents with elevated K and Cr and
increasing SOB. patient reports 1 yr of weight loss and decreased orally more
notable within past 1-2 wks. On ROS +sweating @ night o/with negative. patient
has been off her usual dose of lasix per renal input because on recent
admit ( 10/5 ) she had elevated Cr thought to be prerenal , which is when
lasix was stopped. No chest pain , pressure or palp. No LE edema , no PND.
***
PMH: CHF with EF 50% in 10/25 by TTE showing LAE , mild MR/TR , HK inf
septum & posterior basal , MI 1997 , history of LAD , D1 , LCx stents in 2002 ,
Anemia , CRI ( baseline Cr 1.9-2.4 ) , H/o partial seizures on
dilantin , HTN , history of DVT L calf , history of TAH/ appy , H/o cervical CA , history of
2-3 mm polyp in 1993 , SSS history of DDD pacemaker in 1997 , Sarcoid with
severe restrictive pulmonary dz , NIDDM type II , dyslipidemia
***
Admit PE: T 97.2 BP 147/66 P 52 R 18 100%
RA Gen: Frail appearing elderly
female. HEENT: EOMI , + ?exopthalmos , anicteric ,
mmm Neck: thyromegaly vs. submandibular fullness , no
nodules , non-painful , no cervical LAD. Pulm: bilateral crackles to
apeces CV: RRR , II/VI HSM @ LLSB , JVP @ ear Abd: nt , nd , +hyperactive BS ,
no hsm Ext: no c/c/e ,
** EKG: atrial paced , not capturing SB @ 56 , nl axis ,
nl intervals. no st-t wave changes
***
Consults: Renal , Cards , EP , Nutrition , physical therapy
****
Imp: 74 year-old woman with pulmonary sarcoid and CHF and CRI here with SOB
after stopping lasix several weeks ago. Given clinical exam and CXR it
appears that she is in decompensated CHF , and in worse renal failure.
HOSPITAL COURSE:
1 ) Cardiovascular: She was in mildly decompensated CHF , and was started
on more aggressive diuresis , starting with lasix 40 intravenous twice a day increased to 80
twice a day on HD2 as she was not meeting her diuresis goal. With cardiology
service consulting , she was increase to lasix drip at 15/heart rate on HD3 , with
i/o goal 1-2 l neg. She did well on this and by HD5 was near her dry
weight of 49kg and her drip was transitioned back to orally lasix. She is no
on lasix 80 orally twice a day , which is felt to be adequate to maintain her dry
weight. She was continued on Hydralazine , lopressol and was restarted on
Isordil on HD3 , titrated up to 20 three times a day She has history of MI with
stents and was continued on Asa , Plavix , Zocor. He cardiac enzymes were
negative. Her BNP fell from 3500 on admit to 1500 at her dry wt on HD6.
She was paced intermittent ( pacer placed in past for sick sinus ,
functioning properly at a backup rate of 50 ).
2 ) Renal: She presented with acute on chronic RF possibly due to poor for
forward flow in the setting of CHF decompensation. Cr up to 3.6 on
HD3 , but as she diuresed , her Cr stabilized. Renal consult was following
and recommended diureses , low K diet , good glucose control , and
withholding ace inhibitor. She is discharge at her dry weight with a Cr
stable at 3.5. She should probably not go on Ace Inhibitor again.
3 ) FEN- Hyperkalemia without EKG change. Improved with lasix. Rec'd Kayexylate
in ED. Now improved. Follow K/Mg. She should not be on an Ace inhibitor
or a K-sparing diuretic.
4 ) ENDO- glipizide at home which was restarted on HD5. Add insulin SS for
tight control. TSH high. T4 low. This should be rechecked as an outpt
before initiating therapy.
5 ) Heme- ON coumadin for history DVT. Held on HD3 for an INR
3.1 and was restarted shortly after , but her INR is 1.4. She
received 1.5 U of PRBC for goal HCT >30 and is currently 30.8. Her
anemia is 2/2 chronic renal disease and she was started on
darbopoetin 25 qwk. She developed a clot in her Right external
jugular ( site of prior intravenous ) and was place on renal dose of lovenox
until her INR>2. Lovenox should be stopped once her INR is >2.
6 ) Neuro- On dilantin for history of partial seizures.
7 ) Code- no CPR if sudden death , but intubation/defibrillation ok in the
setting of instability.
Dispo: She was discharged to Oswe Mastook Hospital at a euvolemic state with a dry
weight of 49kg. She should continue on 80 orally lasix twice a day unless her Cr rises
above new baseline of 3.5 or if she gains weight or shows signs of new
overload. Lovenox should be stopped once her INR is > 2. Coumadin dose
should be adjusted according to INR goal 2-3. She should be on a renal
diet with low potassium and low glucose but with diabetic caloric
supplements like GLUCERNA. She should receive a HOT PACK to her neck 2-3x
per day and to her vein before blood draw for comfort.
She should receive physical therapy daily with the goal of gait stability ,
home safety , and good O2 sats on 2L O2. She should go home with home O2 at
2L and with VNA services for meds. She lives at home alone and it would be
ideal if she had a relative stay with her for a few days to a week after
going home.
resume VNA services upon dc.
contact: son Shearer in Akrieau Walk 413-145-5910
ADDITIONAL COMMENTS: Please return to the hospital or call your doctor if you experience
worsening shortness of breath , fever over 100.5 , chest pain , decreased
urine output , weight gain over 5 pounds , or any other concerning
symptoms.
Please keep your follow-up appts.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
follow up with Dr. Alberro ( primary care physician ) , Dr. Robards ( renal ) , and cardiology. as noted.
1 ) d/c Lovenox once INR > 2
2 ) renal , diabetic , low potassium , low salt diet with glucerna
supplements
3 ) continue physical therapy for goal of safe ambulation , home safety , and good O2 sat
on 2L
No dictated summary
ENTERED BY: HARKLEY , JACQULYN D. , M.D. , PH.D. ( JU16 ) 10/14/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1222
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| output/system_intuitive_annotation.xml | intuitive |
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210293346 | PUO | 96573734 | | 584187 | 5/8/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/8/1990 Report Status: Unsigned
Discharge Date: 7/22/1990
HISTORY OF PRESENT ILLNESS: The patient is a morbidly obese , 53
year old , white male who presented
with new onset chest pain and melena. He had been in his usual
state of good health and was without known cardiac risk factors.
The night prior to the night of admission , while walking from the
bathroom to his bed in the heat , he developed new chest tightness
which he described as somebody sitting on his chest. He had
shortness of breath and diaphoresis but no nausea , vomiting ,
palpitations or radiation. He returned to this bed , and the pain
resolved after several minutes of rest. He was without further
episodes until the night of admission , when walking to work he had
2-3 episodes of chest tightness similar to the night before. Each
of them lasted at most 10-15 minutes. He went to the Pagham University Of emergency ward for evaluation. He denied any pain
like this previously. He denied paroxysmal nocturnal dyspnea or
orthopnea but did have daily ankle swelling for the past five
minutes and some new shortness of breath after walking 200 yards
over the past 5-6 months. He also reported two episodes of black
loose stools , one 2-3 weeks prior to admission and one on the night
of admission. He had some transient abdominal discomfort 2-3 weeks
prior to admission which he treated with ibuprofen 800 mg three times a day to
four times a day for 3-4 days. He had no recent abdominal pain , nausea ,
vomiting , hematemesis , hematochezia or coffee ground emesis. He
was without history or family history of peptic ulcer disease. He
was without recent weight loss or gain. He has had long time
ingestion of 6-8 beers a day but no recent binges. He took four
Excedrin the day prior to admission for a headache. An NG tube in
the emergency ward showed bilious material which was guaiac
negative. He denied fevers , chills , cough , sputum , dysuria ,
obstructive urinary symptoms , headache , visual changes ,
paresthesias , early satiety or bleeding diatheses. PAST HISTORY:
Chronic nasal congestion; right sciatica. MEDICATIONS ON
ADMISSION: Sudafed as needed ALLERGIES: None known. FAMILY
HISTORY: Mother died of cancer; father died of "heart failure" in
his late 60s. No family history of diabetes mellitus or
hypertension. SOCIAL HISTORY: He smoked four and a half packs of
cigarettes per day times 15 years; quit 15 years ago. He drinks
6-8 beers a day. He lives in Ux with his wife and three
of his seven adult children. He has three small grandchildren. He
works the night shift as a fork lift operator for the post office.
PHYSICAL EXAMINATION: Revealed a morbidly obese man in no
apparent distress. Pulse 84 and blood
pressure 142/80 lying; pulse 86 and blood pressure 150/100 sitting;
respirations 26; afebrile. The head was normocephalic and
atraumatic. The extraocular muscles were intact; pupils equal ,
round and reactive to light; conjunctivae clear. The oropharynx
was clear. The neck revealed full range of motion; no thyromegaly;
no masses; unable to evaluate JVD secondary to a thick neck. There
was no CVA or spinal tenderness. The chest was clear to
auscultation and percussion; decreased breath sounds throughout;
barrel chest. The cardiovascular exam revealed a nearly inaudible
S1 and S2; no murmurs audible. The abdomen was soft and
protuberant; nontender; normal bowel sounds. The extremities were
without clubbing , cyanosis , clear edema or calf tenderness or
swelling. The neuro exam was nonfocal. The rectal exam revealed
black and maroon guaiac positive stool.
LABORATORY EXAMINATION: Hematocrit 37.0; white blood cell count
17.2 with 75 polys , 1 band , 18 lymphs , 4
monos , 2 eos; platelets 439 , 000; sodium 136; potassium 4.4;
chloride 104; CO2 23; BUN 60; creatinine 2.0; glucose 168; calcium
10.2; phosphate 3.8; protein 7.3; albumin 4.6; AST 37; ALT 23; LDH
271; alkaline phosphatase 87; cholesterol 210; triglyceride 226;
CPK 72 on admission. The chest x-ray showed fat in the
mediastinum , normal heart , no infiltrate or effusion. A KUB showed
no obstruction or free air. A tagged red blood cell scan in the EW
was negative for bleeding source. The EKG showed a normal sinus
rhythm with a rate of 90; frequent PVCs; intervals 0.15 , 0.07 and
0.39; axis 40 degrees; flipped T wave in L; flat Ts in V6.
HOSPITAL COURSE: #1 ) Angina. The patient was admitted with a
story classic for angina. He was admitted for a
rule out MI protocol. His EKG remained essentially unchanged. He
was noted to be in bigeminy and had some frequent PVCs on several
EKGs and on monitor , however , his EKG remained unchanged except for
some labile T waves in the lateral lead which changed with lead
placement. He was ruled out for an MI with CPKs which actually
went up from a CK of 72 to a peak of 331 , but on electrophoresis
there was no MB fraction found. The bump in the CK level was felt
to be secondary to multiple attempts at a central line placement in
the EW and skeletal muscle trauma. He was treated with sliding
scale Nitropaste and nifedipine for blood pressure control in the
hospital. An echocardiogram was done to assess left ventricular
function which revealed no regional wall motion abnormality , some
slight decrease in compliance but good LV function. An exercise
tolerance test could not be completed secondary to his sciatica.
On ETT he went for one minute and 44 seconds with a heart rate of
81-122 , blood pressure 136/80 to 144/80. There were no ST changes
noted. There were some asymptomatic VPBs and no chest pain. He
was discharged on Procardia XL 30 daily and given a prescription
for nitroglycerin and instructed on how to use this. #2 ) GI
bleed. He was admitted with melena and a falling hematocrit. A
hematocrit drawn at CHH in January was 48 and on admission here was
37 and dropped to a low of 28. He received three units of packed
red blood cells in the hospital. An endoscopy on 2/6/90 showed
two small ulcers in the prepyloric antrum , one measuring 3 mm and
the other 5-6 mm. Both were superficial and benign appearing at
the time , and neither had stigmata of a recent bleed. Biopsies
were taken with good hemostasis. No varices or esophagitis were
noted. The GI bleed was presumed to be secondary to his ulcer
disease. He was treated during the hospitalization with an H2
blocker which was to continued for 8-12 weeks after discharge. He
was instructed to not take aspirin or nonsteroidal
anti-inflammatory drugs or to drink alcohol after discharge. The
discharge hematocrit was approximately 35 and remained stable. #3 )
Leukocytosis. He was noted to have a leukocytosis without bands on
admission. This resolved with hydration and was felt to be most
likely secondary to stress reaction. #4 ) Sleep apnea. He was
noted to be apneic at night by the nurses with sinus bradycardia
and sinus pauses during the apneic episodes. He had one sinus
pause at seven seconds. On the third night of admission , he was
monitored on a sat monitor overnight which noted him to desaturate
to the 60% and 70% range during his apneic episodes. He was
presumed to have sleep apnea and will be worked up as an outpatient
with a sleep study per Dr. Chuong #5 ) Renal. He had an
increased BUN and creatinine on admission. This decreased with
hydration. The discharge BUN was 23 and creatinine 1.1.
DISPOSITION: The patient was discharged home in stable condition.
COMPLICATIONS: None. MEDICATIONS ON DISCHARGE:
Pepcid 40 mg orally daily; Procardia XL 30 mg orally daily;
nitroglycerin 0.4 mg sublingual as needed chest pain. FOLLOW UP will
be with his internist , Dr. Prall , and with Dr. Jerabek in eight
weeks for a repeat endoscopy and with Dr. Schlesener for a sleep study.
DISCHARGE DIAGNOSES: 1. NEW ONSET ANGINA.
2. GASTROINTESTINAL BLEED.
3. SLEEP APNEA.
________________________________ EE933/1707
TARSHA Y. PRALL , M.D. FT68 D: 10/24/90
Batch: 0318 Report: X9584J9 T: 5/5/90
Dictated By: MARCELINE NEWYEAR , M.D.
cc: IRINA R. JERABEK , M.D.
TRESSA I. SCHLESENER , M.D.
Document id: 1223
| Target |
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CHF |
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| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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285338157 | PUO | 46939548 | | 8219939 | 1/14/2005 12:00:00 a.m. | AORTIC STENOSIS | Signed | DIS | Admission Date: 5/29/2005 Report Status: Signed
Discharge Date: 6/25/2005
ATTENDING: STUKOWSKI , JANAY MD
HISTORY OF PRESENT ILLNESS:
Ms. Borror is an 81-year-old female with 5-year history of
known aortic stenosis. She has been followed by serial
echocardiograms. Most recent showed an aortic valve area of 0.7
cm2. She states that she does have some mild shortness of
breath. She was referred to Dr. Janay Stukowski for aortic valve
replacement.
PAST MEDICAL HISTORY:
Hypertension , CVA , diabetes mellitus , hyperlipidemia , COPD ,
status post colon cancer , osteoarthritis , GERD.
SOCIAL HISTORY:
A 10-pack-year cigarette smoking history. She drinks one drink
nightly.
ALLERGIES:
Morphine causes itching.
MEDICATIONS:
Lisinopril 20 mg orally daily , Lasix 20 mg orally every day , Advair Diskus
1 puff inhaler twice a day , atorvastatin 10 mg orally daily , Celebrex
200 mg orally twice a day
PHYSICAL EXAMINATION:
Vital signs , heart rate 64 , blood pressure in the right arm
144/64 , blood pressure in the left arm 144/62. HEENT , right
carotid bruit. Cardiovascular: Irregular rhythm with a harsh 4/6
holosystolic murmur. Peripheral pulses are all 2+ and include
the carotid , radial , femoral , dorsalis pedis , posterior tibial.
Respiratory: Breath sounds clear bilaterally. Extremities are
without scarring , varicosities or edema. Neuro: Alert and
oriented with no focal deficits.
PREOPERATIVE LABS:
Sodium 137 , potassium 4 , chloride 100 , carbon dioxide 30 , BUN 29 ,
creatinine 0.7 , glucose 86 , magnesium 2 , white blood cells 5.50 ,
hematocrit 36.3 , hemoglobin 12.6 , platelets 196 , 000 , physical therapy 12.8 , INR
0.9 , PTT 29.7 , hemoglobin A1c 5.8. Carotid imaging , left
internal carotid artery 25-40% occlusion , right internal carotid
artery , no occlusion. Cardiac catheterization dated 9/26/05 ,
coronary anatomy right dominant circulation with normal coronary
arteries. Echocardiogram on 2/13/04 shows aortic stenosis with
peak gradient 77 mmHg , calculated valve area 0.7 cm2. Mitral
stenosis with peak gradient of 7 mmHg. ECG not recorded. Chest
x-ray on 10/10/05 was read as normal.
HOSPITAL COURSE:
Brief operative note , date of surgery 3/25/05. preoperative
diagnosis , aortic stenosis. Postoperative diagnosis aortic
stenosis. Procedure aortic valve replacement with a #21
Carpentier-Edwards magna valve. Bypass time was 59 minutes ,
cross clamp time was 48 minutes. Two atrial wires , one
ventricular wire , one pericardial tube , one retrosternal tube
replaced. Findings , heavily calcified trileaflet aortic valve.
Weaned from cardiopulmonary bypass , she was in complete heart
block. A wires and V wires were placed. After the operation ,
the patient was transferred to the cardiac intensive care unit in
stable condition. While in the cardiac intensive care unit , her
course was complicated by complete heart block immediately
following surgery. At that time , she had to be paced and
developed a junctional rhythm in the 30s. On postoperative day
#2 , she was in sinus rhythm in the 70's with occasionally paced
beats. At that time patient was started on no nodal agents of
any kind. Also , while in the cardiac intensive care unit , it was
found that she had a low hematocrit and was given 1 unit of
packed red blood cells and her hematocrit has been stable since.
On postoperative day 2 , the patient was transferred to the
cardiac step-down unit. While on the cardiac step-down unit ,
course was complicated by the following: As stated previously ,
the patient was on no nodal blockers upon transfer. She
developed rapid atrial fibrillation on postoperative day 3 with
heart rates between 100 and 120. Because her epicardial pacing
wires were functioning appropriately , it was felt that patient
would benefit from a beta-blocker. Lopressor was started and the
patient tolerated this dose of beta-blocker without any
bradycardiac episodes. However , patient continued in and out of
atrial fibrillation for the next two days. On postoperative day
5 , she was started on diltiazem drip. Once the drip was
implemented , she was she converted to normal sinus rhythm. When
the diltiazem drip was discontinued and her beta-blocker was
continued , the patient as of today discharge has been in normal
sinus rhythm for greater than 48 hours. Of note , patient was
subtherapeutic on her INR prior to discharge. Her INR will be
closely followed by Pagham University Of anticoagulation
clinic.
DISCHARGE MEDICATIONS:
She was discharged home in stable condition on the following
medications: Tylenol 650 mg orally every 6 hours as needed pain , aspirin 81 mg
orally daily , Colace 100 mg orally three times a day as needed constipation ,
glipizide 2.5 mg orally every day before noon , Niferex 150 mg orally twice a day , Toprol
XL 150 mg orally daily , Advair Diskus 250/50 1 puff inhaler twice a day ,
atorvastatin 10 mg orally every day , Coumadin of which she will
receive 3 mg today.
PLAN:
As stated previously , patient is on Coumadin for her rapid atrial
fibrillation. Goal INR is 2-3. Please draw her INR on 11/28/05
and then daily until therapeutic. Pagham University Of
anticoagulation clinic will be following her INR. The phone
number is 132-202-5576. The patient is to follow up with Dr.
Stukowski , cardiac surgeon in six weeks and Dr. Adee cardiologist
in two weeks.
eScription document: 6-0018010 EMS
Dictated By: TRIARSI , VERDA
Attending: STUKOWSKI , JANAY
Dictation ID 7391748
D: 6/18/05
T: 6/18/05
Document id: 1224
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
- |
Y |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
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Y |
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Y |
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N |
845969624 | PUO | 27087407 | | 6793202 | 11/20/2005 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 11/20/2005 Report Status: Signed
Discharge Date: 10/8/2005
ATTENDING: BARNABA , CARA CHANCE MD
CARDIOLOGY SERVICE
PRINCIPAL DIAGNOSIS:
Congestive heart failure exacerbation.
PROBLEMS/DIAGNOSES:
1. Coronary artery disease status post CABG.
2. Diabetes.
3. Hypertension.
4. CVA.
5. Hyperlipidemia.
6. Legally blind.
7. Stress incontinence.
8. Diastolic heart failure.
HISTORY OF PRESENT ILLNESS:
This is an 84-year-old female with history of diastolic CHF ,
IDDM , hypertension , hyperlipidemia , and coronary artery disease
status post CABG in 1992 with multiple catheterizations here
( last catheterization 10/24 ) without interventions , status post
four stents ( 6/8 ) , presents with acute shortness of breath
while at dinner at night prior to admission with associated left
arm tingling. No overt chest pain. No nausea or vomiting.
Positive diuresis. The patient came to the Pagham University Of ED where she was noted to be hypoxic to 73% and required
non-rebreather initially , and was also noted to have a blood
pressure of 183/83 in the emergency department. She was given intravenous
Lasix in the emergency department and was on 2 liters nasal
cannula by the time she arrived on the floor.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Status post CABG in 1992.
3. Diabetes.
4. Hypertension.
5. CVA.
6. Hyperlipidemia.
7. Legally blind.
8. Stress incontinence.
9. Diastolic CHF.
PRE-ADMISSION MEDICATIONS:
1. Ecasa 325 mg orally daily.
2. Colace 100 mg twice a day.
3. Lasix 40 mg once a day.
4. Insulin NPH 40 units every day before noon and 20 units every afternoon
5. Pravachol 40 mg once a day.
6. Imdur 60 mg twice a day.
7. Plavix 75 mg once a day.
8. Lisinopril 20 mg once a day.
9. Nitroglycerin as needed
10. Zetia 10 mg once a day.
11. Toprol XL 25 mg once a day.
12. Zantac 150 mg twice a day.
13. Ativan 0.5 mg once a day.
SOCIAL HISTORY:
Lives in living facility in Cy Agesden Masto St , Mer Et Eno No alcohol or tobacco.
FAMILY HISTORY:
Noncontributory.
ALLERGIES:
1. Gemfibrozil.
2. Atorvastatin.
3. Bactrim.
4. Oxycodone.
ADMISSION PHYSICAL EXAMINATION:
Afebrile. Blood pressure 106/60. Pulse 61. Respirations 20.
Oxygen saturation 97% on 2 liters nasal cannula. General exam
shows elderly female in no acute distress , on 2 liters nasal
cannula. HEENT exam shows moist mucus membranes , no
lymphadenopathy. Cardiovascular exam shows 2/6 systolic ejection
murmur at the left lower sternal border. Regular rate. No
murmurs or gallops. JVP at 9 cm. Pulmonary exam shows crackles
bilateral lower one-half. Abdominal exam shows obese abdomen ,
nontender , nondistended. No hepatosplenomegaly. Extremities
show 2+ pulses distally and 1+ edema to the knees.
ADMISSION LABS:
Pertinent for sodium of 131 , glucose of 232 , a CK of 327 , CK-MB
of 10.5 , and a troponin less than assay. Urinalysis was
pertinent for 3+ protein , 2+ blood , 2+ leucocytes , and negative
nitrites. EKG on admission showed normal sinus rhythm at 93 with
left atrial enlargement but unchanged otherwise. Chest x-ray on
admission showed pulmonary edema.
PROCEDURES:
Cardiac catheterization 11/9/05 ; no interval change since last
catheterization. 100% LAD , 100% left circumflex , 20% RCA
stenosis , LIMA graft to the LAD , patent SVG to D1. Disease was
not amenable to intervention. Please see catheter report for
further details.
HOSPITAL COURSE:
Cardiovascular:
Ischemia: Initial troponin was negative. No EKG changes but on
the second set of cardiac enzymes , the troponin was elevated to
0.82. The patient was sent to Cath Lab for NSTEMI on 11/9/05 ,
with no interval change on cath noted and no intervention
performed. Troponins trended down thereafter less than assay.
The patient did have an episode of chest pain on 8/18/05 in the
setting of systolic blood pressure of 200 without EKG changes
currently. After assessing source of troponin leak on admission ,
but positively secondary to demand in the setting of hypertension
and acute/pulmonary edema. We will continue beta-blocker , ACE
inhibitor , statin , Imdur , Plavix and aspirin as an outpatient.
Pump: EF preserved on cath. Volume overloaded on admission
likely secondary to flash pulmonary edema secondary to
hypertension , diastolic dysfunction. The patient was diuresed
well on 40 mg of Lasix orally during her stay with the team on an
outpatient maintenance dose of Lasix 60 mg daily. The patient
was euvolemic on discharge. The blood pressures were labile
initially but better controlled with amlodipine and an increased
dose of captopril. Will continue as an outpatient on
beta-blocker , ACE inhibitor , calcium channel blocker.
Rhythm: Intermittent brachycardia to the high 30s , but always
asymptomatic. Lopressor dose was decreased from three times a day to twice a day
during her stay. She will continue on home dose of Toprol XL 25
mg orally daily.
Pulmonary: Status post acute shortness of breath episode prior to
admission requiring initially nonrebreather and nasal cannula
thereafter , which markedly improved with diuresis. The patient
was stable on room air at the time of discharge.
Endocrine: The patient was continued on her home insulin regimen
along with sliding scale , and she will be discharged on home
insulin regimen.
ID: The patient was noted to have a urinalysis consistent with
urinary tract infections and completed a 7-day course of
ciprofloxacin for complicating TI.
DISPOSITION:
The patient was discharged in stable condition to rehab as an
outpatient.
PHYSICAL EXAMINATION AT DISCHARGE:
Temperature 98 degrees , blood pressure 122/55 , heart rate 55 , O2
saturation 93-95% on room air. General exam shows an elderly
female , resting , no acute distress , alert and oriented.
Cardiovascular: Shows regular rate and rhythm with a 2/6 systolic
ejection murmur at the right upper sternal border. JVP at 8 cm.
Upon re-exam , shows bibasilar crackles. Abdominal exam shows
soft , abdomen that is nontender , nondistended with normoactive
bowel sounds and extremity exam shows +1 edema to the calves.
The patient was to follow up with Dr. Geraldine Kittell She will be
contacted in regard to the appointment date. She was instructed
to call Dr. Barnaba if she notes a weight gain of 2 pounds at any
given day or a 5-pound weight gain in a week.
eScription document: 7-0943240 EMSSten Tel
Dictated By: WOLFLEY , LUCRETIA
Attending: BARNABA , CARA CHANCE
Dictation ID 9103816
D: 9/19/05
T: 9/19/05
Document id: 1225
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
U |
U |
U |
U |
U |
Y |
U |
Y |
Y |
U |
Y |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
N |
N |
N |
N |
N |
Y |
N |
Y |
Y |
N |
Y |
Y |
N |
N |
N |
369440064 | PUO | 14496663 | | 7123150 | 10/13/2006 12:00:00 a.m. | Pulmonary Emoblism | | DIS | Admission Date: 10/13/2006 Report Status:
Discharge Date: 4/8/2006
****** FINAL DISCHARGE ORDERS ******
SCHWOYER , HERMINIA 231-68-13-0
Nebraska
Service: MED
DISCHARGE PATIENT ON: 11/14/06 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ASKVIG , LASHELL JAKE , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
DULCOLAX ( BISACODYL ) 5-10 MG orally DAILY as needed Constipation
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FLUTICASONE NASAL SPRAY 2 SPRAY inhaled twice a day
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
FONDAPARINUX 7.5 MG subcutaneously DAILY
Alert overridden: Override added on 8/3/06 by
JAYNE , KAROLE J. , M.D.
SERIOUS INTERACTION: HEPARIN & FONDAPARINUX SODIUM
Reason for override: aware
SINGULAIR ( MONTELUKAST ) 10 MG orally BEDTIME
NORTRIPTYLINE HCL 10 MG orally BEDTIME
SIMVASTATIN 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/4/06 by JAYNE , KAROLE J. , M.D. on order for COUMADIN orally ( ref # 484920588 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
COUMADIN ( WARFARIN SODIUM ) 7 MG orally every afternoon
Starting NOW ( 3/2 )
Instructions: WITHIN HOUR OF PHARMACY APPROVAL
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/4/06 by
JAYNE , KAROLE J. , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
ACTIVITY: weight bearing as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Sugimoto ,
Arrange INR to be drawn on 10/28/06 with f/u INR's to be drawn every
1 days. INR's will be followed by Rehab Center
ALLERGY: LISINOPRIL , Aspirin , NSAIDs
ADMIT DIAGNOSIS:
Pulmonary Embolism
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Pulmonary Emoblism
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HTN ( hypertension ) Asthma ( asthma ) Arthritis
( arthritis ) hypercholesterol ( elevated cholesterol ) GERD
( gastroesophageal reflux disease ) obese
( obesity ) knee repair ( knee surgery )
OPERATIONS AND PROCEDURES:
Chest CT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: SOB/Large Rt main PE
****
HPI: 62yo F with HTN , asthma , recent history of L total knee replacement
presents with SOB. Today she c/o pain in the chest with deep
inspiration and coughing. She also reports pain in the right leg. patient
underwent surgery on 4/5 and had routine post-op course. Of
note , patient only received routine peri-operative prophylactic Abx. patient
was D/C home on 2/3 and did well for a few days. She was readmitted
for gastroenteritis 6/5 and sent home without Abx. She
has been followed by VNA and home physical therapy. Her Coumadin was stopped
5/19 after 3 weeks post-op however her INRs had not been
therapeutic.
-------------------
ROS: denies fevers. Continues to have nausea , vomiting and diarrahea.
But difficult to fully assess b/c entire ROS positive per patient.
Mostly c/o pleuritic left CP , and bilateral LE
pain.
-------------------
ED course: PECT positive for PE and DVT. Started on Heparin.
-----
PMH: HTN , Asthma-no intub , past hosp x2 , OA-history of L
knee surg , Hypercholestrolemia , GERD , Cervical and thoracic disc dz ,
Fibromyalgia , obesity
-----
Meds: Cozaar 100mg
every day Nortriptyline 10mg
every bedtime HCTZ 25mg
every day Atenolol 75
every day Lipitor 40mg
every day Singular 10mg
every bedtime Albuterol inhaled
as needed Advair 250/50
twice a day Fluticasone nasal spray
twice a day Prilosec 20mg
every day Coumadin 3mg
every day Morphine 30mg every 12 hours
as needed Hydromorphone 2-6mg q4-6hr as needed
-----
All: Lisinopril ( cough ) , ASA ( SOB ) , NSAIDS ( GI ) FH: ? history of clot in her
mother SH: Tob: none. EtOH: none. IVDU: none
-----
Exam: 98 83 172/92 18 93%RA , 100%
FM NAD , AAOx3. Non-icteric , MMM. Supple. CTA( B ) with
decreased BS on the RLL no wheezes , RRR , nl S1 S2. Soft , obese BS ,
EXT: Nontender , no palpable cords , no edema , 2+ ( B ) pedal pulses.
Left leg - ted stocking and TKR bandages.
-----
PECT 8/3 Rt main pulm artery PE extending into
lovar and subsegmental arteries. Small PE LLL subsegmental
vessels. Rt DVt LE. EKG 8/3 NSR , no RVH , normal axis , normal
intervals , no S1Q3T3
-----
Hospital Course:
62yo F with HTN , asthma and recent L total knee replacement
presented with extensive PE. She was extremely SOB and c/o pleuritic
chest pain. Her ekg and exam were not suggestive of cardiac
dysfunction. Cardiac enzymes were negative. The patient was initially
anticoagulated with Heparin. However , her platelets were noted to drop
from 237 to 93. HIT was suspected and Heparin was discontinued. The
patient was started on Fondaparinux. A PF4 Antibody was sent and pending
at the time of discharge. Coumadin was started after one day of
Fondaparinux with an intent to bridge over at least 5 days with a goal
INR of 2-3. The patient's blood pressure was decreased over the course of
her admission. All antihypertensives were held. She may be preload
dependent in the setting of an acute PE. During her admission an
echocardiogram was performed. It did not show evidence of right heart
strain or LV dysfunction. Her EF was 65-70%. Over the course of the
hospitalzation , the patient's symptoms improved dramatically. Her oxygen
requirement decreased. Her vital signs remained stable.
The patients respiratory status remained stable on home regiment
of inhalers and nebulizers as needed.
Ortho evaluated the patient while hospitalized and recommended weight
bearing as tolerated. The patient did not require narcotics for pain
associated with TKR.
Heparin products should be avoided. The PF4 antibody will need to be
followed by the primary care physician.
FULL CODE
ADDITIONAL COMMENTS: Please notify your doctor of any shortness of breath or chest pain.
Please continue your Fonduparinox and Coumadin as directed.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please bridge Fondaparinux to coumadin with at least a 5 day
overlap. Please continue for at least 2 days once the patient is
therpeutic on Coumadin with INR 2-3. 11/14/06 is the fourth day
of Fondaparinux and third day of coumadin.
- Monitor INR closely and platelet count.
No dictated summary
ENTERED BY: VERNET , ROSANNE S. , M.D. ( UG81 ) 11/14/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1226
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
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- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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420837134 | PUO | 07550114 | | 7346567 | 7/9/2004 12:00:00 a.m. | congestive heart failure | | DIS | Admission Date: 7/15/2004 Report Status:
Discharge Date: 7/23/2004
****** DISCHARGE ORDERS ******
LEUENBERGER , BRIAN 755-86-09-0
Rie
Service: CAR
DISCHARGE PATIENT ON: 10/20/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MCPECK , REYES DALE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ASA ( ACETYLSALICYLIC ACID ) 325 MG orally every day
ALBUTEROL NEBULIZER 2.5 MG NEB every 3 hours as needed Wheezing
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
Alert overridden: Override added on 10/20/04 by LAPATRA , DARWIN MADELEINE , M.D. on order for OXYCODONE orally ( ref # 26847656 )
patient has a PROBABLE allergy to Codeine; reaction is Rash.
Reason for override: aware
TRAZODONE 50 MG orally HS as needed Insomnia
PAXIL ( PAROXETINE ) 20 MG orally every day
LISPRO ( INSULIN LISPRO )
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
ADVAIR DISKUS 500/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
LANTUS ( INSULIN GLARGINE ) 70 UNITS subcutaneously every day
Starting Today ( 2/5 )
ALBUTEROL AND IPRATROPIUM NEBULIZER 3/0.5 MG NEB every 6 hours
LASIX ( FUROSEMIDE ) 120 MG orally every day
Alert overridden: Override added on 10/20/04 by :
on order for LASIX orally ( ref # 36777254 )
patient has a POSSIBLE allergy to Sulfa; reaction is Rash.
Reason for override: tolerates
LISINOPRIL 5 MG orally every day Starting Today ( 2/5 )
Alert overridden: Override added on 10/20/04 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
LIPITOR ( ATORVASTATIN ) 40 MG orally every bedtime
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
DIET: House / 2 gm Na / ADA 2000 cals/day / Low saturated fat
low cholesterol (I) (FDI)
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Millard Kaui at Spi Ian University Hospital 8:45AM on 11/15/04 ,
Dr. Abshear , cardiology at Totin Hospital And Clinic 9:40AM on 3/5/04 ,
ALLERGY: Penicillins , Sulfa , Codeine
ADMIT DIAGNOSIS:
congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of MI 1989 AFTER GIVEN EPI FOR ASTHMA IDDM
HYPERCHOLESTEROLEMIA history of AFIB ASTHMA EXACERBATION LACURNAR CVA 2/8/95
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
55 year-old female with history of obesity , OSA , asthma , CVA with LLE weakness , DM2
( periph neuropathy and charcot foot ) , MI in 1987 but no CAD by cath ,
normal MIBI in 8/17 , EF55% , smoking and anemia of unknown etiology ,
presents with 2 weeks of progressive SOB. Unable to walk 10 feet
without resting. Normaly uses O2 only at night , now using during the
day. Increased nebs and MDI without good response. Also noticed LE
swelling , increased abdomial girth , orthopnea , PND. Incrased dose of
lasix to 80BID. Denies chest pain or palpitations , dietary
indiscretions or med noncompliance. PMH: history of lacunar CVA with LLE
weakness , DM2( periph neuropathy , charcot foot , AIC 12.1 in 2/19 ) CRI
1.5-2.1 , asthma ( no intubations ) , MI 1987 in setting of epi in asthma
flare- cath with clean coronaries , but inf/apical dyskinesis. , obesity
OSA , anemia. SocHx: +smoking PE: Mild respiratory distress. Obese.
Lungs-diffuse wheezes , bibasilar crackles. 2+ LE edema to knees.
CV:distant , rrr. Labs: BNP 685 , HCT 27 ( basline 30 ) , Cr. 1.5 , Gluc
207. Cardiac enzymes neg x2 EKG: LBBB , unchanged from 10/4 , not
present on 8/28
Hospital Course:
CV: Based on exam and labs , the patient was felt to be in mild CHF
on admission. She was Rule out for MI with negative cardiac enzymes
x3. Trans-thoracic Echo was done which showed EF of 50-55% with
hypokinesis of anterior and antero-septal wall. Tissue dopplers
suggested diastolic dysfunction , no valvular abnormalities except
trace TR. The patient was started on an ACEI for better BP control ,
no betablocker given history of asthma. On statin , increased dose to
simvastatin 80. TSH negative. The patient responded well to Lasix intravenous
diuresis and felt that her breathing was back to baseline after two
days of diuresis.
Pulm: The patient has a history of asthma and OSA; she was continued
on nebs , MDI , O2. Recieved 1 dose of steroids in ED , but these were
not continued since her presentation was more consistent with CHF.
The patient needs CPAP at night , but does not take this at home
since she lost her CPAP machine.
Renal: The patient has a hx of CRI ( 1.5-2.1 ) due to diabetes , her
creatinine was stable between 1.7-1.9 during her admission with
diuresis and the addition of the ACE inhibitor.
HEME: The patient was anemic with a Hct of about 28 on admission. Iron
studies sent which showed Fe of 23 and TIBC of 367 ( transferrin sat
approx 6% ) This is consistent with Fe deficient anemia. The patient's
Hct subsequently dropped to 24.5 with slightly guaiac pos stool and she
was transfused 2u PRBC with resulting Hct 29.9. The patient has a
family hx of colon cancer and she recently missed colonoscopy in July .
Should reschedule as an outpatient to start with u for Fe def
anemia and guaiac pos stools.
Endo: The patietn has a hx of poorly controlled DM2 in the past with
HgbA1c as high as 12 , HbA1c was repeated and found to be 7.2%.
Diabetes management service was consulted and recommended continuation
of Lantus at 70u every day before noon with adjustment in Humalog sliding scale. The
patietn should be scheduled for follow up with diabetes clinic as
an outpatient. The patient has significant neuropathic pain in her
feet due to diabetic neuropathy , has been unable to obtain neurontin
from akcare hospital , pain currently managed on a as needed basis with occ
oxycodone at night.
ADDITIONAL COMMENTS: You should take all of your medications as directed by your doctors.
It is very important to visit your doctors for follow up to make sure
that your diabetes , blood pressure , and heart failure are under
control. If you have additional trouble breathing or chest pain or any
other emergency , do not hesitate to return to the emergency room.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Follow up with diabetes management service
2. Follow up for colonoscopy to with u Fe deficient anemia
3. Patient needs sleep study or referral to obtain another CPAP machine
4. Follow up with cardiology ( Dr. Jackson Part ) to manage heart failure
No dictated summary
ENTERED BY: ARUIZU , JULIANNE MARIE , M.D. ( QS40 ) 10/20/04 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1227
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
- |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
- |
Y |
Y |
N |
N |
208836970 | PUO | 01799636 | | 6394687 | 2/23/2004 12:00:00 a.m. | ATYPICAL ENDOMETRIAL HYPERPLASIA | Signed | DIS | Admission Date: 5/17/2004 Report Status: Signed
Discharge Date: 2/17/2004
ATTENDING: CARLE , CHADWICK KATHE LANI
ADMITTING DIAGNOSIS: Endometrial cancer.
ADDITIONAL DIAGNOSIS: Morbid obesity , coronary artery disease ,
hypercholesterolemia , and diabetes.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old obese female
with coronary disease and a focus of adenocarcinoma in
endometrial intraepithelial neoplasia. She presents for
operative management.
PAST MEDICAL HISTORY: Significant for coronary disease with a
cardiac catheterization performed in October 2004 showing 100%
occlusion of the LAD. A concurrent echocardiogram showed an
ejection fraction of 70%. Other past medical history is
significant diet-controlled type 2 diabetes , hypertension , and
sleep apnea.
PAST SURGICAL HISTORY: D&C and cardiac catheterization.
MEDICATIONS ON ADMISSION: Atenolol , lisinopril , Lipitor , Zyrtec ,
Singulair , and aspirin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted and underwent an
uncomplicated TAHBSO with minimal blood loss. At 8 p.m. on
postoperative day 0 , she developed a temperature of 102 and
repeat 101.3. Exam was nonfocal. A CBC showed white count of
12.9 with 7% bands , UA suggestive of UTI. She was started on
levofloxacin. On postoperative day #1 , she was again febrile to
102 and cultures were sent. On postoperative day #2 , there was
no growth on her cultures. Her T-max was 100.7 and she was
observed for an additional 24 hours for fever. On postoperative
day #3 , she was afebrile. She had been afebrile all day and she
was discharged to rehab on postoperative day #4 in stable
condition , tolerating orally's , voiding spontaneously , passing gas ,
with pain control with orally pain medications. Rehabilitation
placement was obtained because she had significant difficulty
ambulating in the setting of her morbid obesity and needed
physical therapy services prior to returning home where she lives
alone.
DISCHARGE MEDICATIONS: Percocet 1-2 tablets orally every 3 hours as needed
pain , Motrin 800 mg orally every 6 hours as needed pain , Colace 100 mg orally
twice a day as needed constipation , atenolol 50 mg orally every day ,
lisinopril 30 mg orally every day , Lipitor 20 mg orally every day , aspirin
81 mg orally every day , Zyrtec 10 mg orally every day , Singular 10 mg orally
every day , multivitamin one tab orally every day , levofloxacin 500 mg
orally every day , x4 doses for treatment of postoperative fever ,
Lovenox 40 mg subcutaneously every day , x10 doses for DVT prophylaxis.
FOLLOWUP: She will follow up with Dr. Anette Leuga 6 weeks
postoperatively.
ADDITIONAL INSTRUCTIONS: The patient's staples should be removed
on postoperative day #7 , which will be Friday 3/18/04. A staple
remover and Steri-Strips will be sent with her to rehab to
facilitate this. The Steri-Strip should be placed perpendicular
to her incision after the staples are removed. Additionally , she
should continue on Lovenox for DVT prophylaxis until January
Should she be discharged from rehab facility , VNA will need to be
arranged to facilitate her subcutaneously injections at home.
eScription document: 6-9786038 ISSten Tel
CC: Clint Defore M.D.
Au Or Ri
Liet Ette Nix
Dictated By: LEBEOUF , DEBERA
Attending: LEUGA , ANETTE
Dictation ID 1251645
D: 3/20/04
T: 3/20/04
Document id: 1228
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
Y |
Y |
Y |
Y |
U |
U |
U |
U |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
Y |
Y |
Y |
Y |
N |
N |
Y |
N |
N |
N |
- |
N |
N |
N |
682582454 | PUO | 74601423 | | 632911 | 10/28/2002 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/10/2002 Report Status: Signed
Discharge Date: 9/27/2002
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old man with
ischemic cardiomyopathy , estimated EF
15-20% who presents with an 8-10 pound weight gain over the past
3-5 days , increased fatigue. Also reports increased shortness of
breath which has progressed over the past few months and notes that
he now gets shortness of breath after walking as few as 10-20
steps. He also complains of lightheadedness but denies chest pain ,
palpitations. He also complains of occasional sweats and chills
without nausea , diarrhea , constipation , melena , or bright red blood
per rectum. He reports that lately his blood sugars have been
lower than usual , in the 40s-80s. Denies orthopnea , PND , or lower
extremity edema. Denies dietary indiscretions or medical
noncompliance. However , there is a recent history of discontinuing
certain medications and the patient is unclear to which medications
he should actually be taking at this point.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction in 1979 and 1985 ,
status post three-vessel CABG in 1987 , ischemic cardiomyopathy ,
estimated ejection fraction 15-20% , cardiac cirrhosis ,
hypothyroidism , nephrolithiasis , gallstones , irritable bowel
syndrome , psoriasis.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION: Torsemide , Synthroid 100 mcg orally.every day;
Lantus 98 units subcutaneously every day before noon; potassium
60 mEq orally twice a day; Humalog insulin 12 units subcutaneously every day before noon and q.
p.m.; Restoril 30 mg orally every bedtime; Xanax as needed; Prozac 40 mg orally
every day before noon; Lipitor 40 mg orally every bedtime; digoxin 0.125 mg orally.every day;
Captopril 25 mg orally three times a day; Aldactone 25 mg orally.every day Per patient
his digoxin , Captopril and Aldactone have been on hold. Apparently
these were held after a clinic visit on 1/23/02 via Dr. Board
when the patient was complaining of orthostatic symptoms and his
torsemide was held over the past five days prior to admission.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.8 , heart rate
72 , blood pressure 91/63 , breathing 95% on
room air. GENERAL: This is a comfortable , pleasant gentleman in
no acute distress. Alert and oriented x 3. HEENT: Normocephalic ,
atraumatic. Pupils equal , round and reactive to light and
accommodation. Extraocular movements intact. Moist mucous
membranes. NECK: JVP estimated at 12 cm/water. LUNGS: Decreased
breath sounds at bases , otherwise clear to auscultation.
CARDIOVASCULAR: Normal S1S2. Regular rate and rhythm. No heart
sounds. No murmurs , rubs or gallops appreciated. ABDOMEN: Soft ,
nontender , obese. EXTREMITIES: Warm , no clubbing , cyanosis or
edema. 2+ dorsalis pedis pulses.
LABORATORY DATA: Creatinine 1.2 , troponin-I 0.06.
Electrocardiogram showing sinus rhythm at 67 beats/minute , first
degree AV block , left axis deviation , right bundle branch block. Q
waves in II , III and AVF consistent with old inferior infarct. All
these findings unchanged from the prior EKG in 2/14
ADMISSION DIAGNOSES:
1. ISCHEMIC CARDIOMYOPATHY.
2. CONGESTIVE HEART FAILURE.
3. VOLUME OVERLOAD.
4. DIABETES MELLITUS.
5. HYPOTHYROIDISM.
HOSPITAL COURSE: 1 ) Cardiovascular: The patient on admission was
clinically volume overloaded. He was diuresed
with torsemide intravenous boluses with good response. He was diuresing two
liters negative per day on torsemide intravenous or orally as well as
spironolactone 25 mg orally.every day However , his clinical volume status
were difficult to assess and accordingly on 8/12/02 he underwent
right heart catheterization and tailored therapy. By report his
right atrial pressure on right heart catheterization was 17 , his
wedge pressure was 43 and pulmonary artery pressure was 65/37
indicating that he still has substantial volume overload. On
therapy his vasodilators were cautiously added to decrease his
systemic vascular resistance and total vascular resistance with
success with low doses of Captopril. His PA catheter was
discontinued on 6/24/02. He has continued to be diuresed with
torsemide 10 orally twice a day , spironolactone 25 mg orally.every day He should
be at or near euvolemia on 11/10/02 and he was discharged on a
diuretic regimen of torsemide 50 mg orally twice a day and spironolactone
25 mg orally.every day in addition to Captopril 6.25 mg orally three times a day
Ischemia: There were no ischemic issues during this hospital
admission.
Rhythm: Electrocardiogram with first degree AV block. The patient
was monitored on telemetry throughout his hospital course. No
evidence of significant arrhythmias were noted. No further workup
was pursued from a rhythm standpoint.
2 ) Endocrine: The patient had a history of hypothyroidism. It is
unclear how this came to be but at some point in the past his
Synthroid had been stopped and only relatively recently restarted.
He had been maintained at a dose of 225 mcg every day in the past. When
he was restarted on Synthroid by the outpatient endocrinologist ,
Dr. Thode , his Synthroid was started at a relatively low dose and
titrated slowly upwards because of his severe cardiomyopathy and
there was concern that increasing his dose too quickly would
precipitate angina. On admission his TSH was 50 and after some
discussion with Dr. Thode his Synthroid was increased to 125 mcg
orally.every day On 9/22/02 an endocrine consult was requested because on
7/30/02 his repeat TSH of 75.8 , T4 of 6.5 and a THBR of 1.10.
Endocrine consult recommended increasing Synthroid to 150 mcg
orally.every day and slowly titrating Synthroid upwards by no more than 25
mcg every 3-4 weeks to a goal of 200 mcg per day , again slowly
titrating upwards to reduce the risk of precipitating angina.
Further management of his hypothyroidism could be done on an
outpatient basis.
The patient also on admission had a history of Type II diabetes
maintained on insulin. His insulin doses had been titrated
downwards during his hospital diabetes mellitus because of low
fingersticks , likely secondary to a relatively healthy diet while
in the hospital. He required only 60 units of Lantus insulin q.
a.m. He was discharged on that dose with Humalog 10 units subcutaneously q.
a.m. and every afternoon to be followed and possibly titrated back upwards
by his outpatient endocrinologist , Dr. Colella
3 ) Psychiatric: The patient had a history of depression and
during this admission he was maintained on his outpatient
medications of Prozac and Restoril. His Prozac dose was titrated
upwards to 60 mg orally every day before noon without any notable side effects. He
was discharged on this dose , 60 mg orally every day before noon No further
psychiatric evaluation or interventions were required during his
inpatient stay. His mood remained stable during this admission.
4 ) Renal: The patient's creatinine was monitored throughout his
hospital course remaining relatively stable despite diuresis. No
further renal evaluation or intervention was required during this
hospital stay.
DISCHARGE MEDICATIONS: The patient was discharged on 11/10/02 on e
following medications: spironolactone 25
mg orally.every day; Captopril 6.25 mg orally three times a day; torsemide 50 mg orally
twice a day; simvastatin 80 mg orally every bedtime; Lantus insulin 60 units
subcutaneously every day before noon; Humalog insulin 10 units subcutaneously every day before noon and every afternoon;
K-Dur 40 mEq orally.every day; Synthroid 150 mcg orally.every day; Prozac 60 mg
orally every day before noon; Restoril 30 mg orally.every day
ADMISSION DIAGNOSES: CONGESTIVE HEART FAILURE , ISCHEMIC
CARDIOMYOPATHY , DIABETES MELLITUS ,
HYPOTHYROIDISM , DEPRESSION.
DISCHARGE DIAGNOSES: CONGESTIVE HEART FAILURE , ISCHEMIC
CARDIOMYOPATHY , VOLUME OVERLOAD ,
HYPOTHYROIDISM , DIABETES MELLITUS , DEPRESSION.
CONDITION UPON DISCHARGE: The patient was discharged in stable
condition afebrile on 11/10/02 without
shortness of breath , without chest pain , without any complaints.
DISPOSITION: He was discharged home with VNA arranged to visit him
on 8/13/02 for the first time to monitor his weight ,
to monitor his electrolytes and to monitor his blood sugars and to
adjust his insulin and diuretic dose as needed.
FOLLOWUP: He was instructed to follow up with Dr. Board in
1-3 weeks and to follow up with his outpatient
endocrinologist , Dr. Thode , in 1-2 weeks. Physical therapy was also
arranged for home physical therapy to begin after discharge.
Dictated By: EVAN KRISTIE FERRIERA , M.D. HC74
Attending: SANTA V. CHOWANEC , M.D. OX2
LV690/650538
Batch: 78295 Index No. NMIB0E03PE D: 8/13/02
T: 8/13/02
CC: 1. GAYLENE G. FANIEL , M.D. LU3
Document id: 1229
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
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- |
- |
- |
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- |
001136519 | PUO | 94521329 | | 424684 | 10/24/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/3/1992 Report Status: Signed
Discharge Date: 10/24/1992
DISCHARGE DIAGNOSIS: 1 ) DEGENERATIVE JOINT DISEASE , RIGHT ANKLE
( RIGHT TIBIOTALAR JOINT ) SECONDARY TO
TRAUMATIC ARTHRITIS.
2 ) INSULIN DEPENDENT DIABETES.
3 ) HYPERTENSION.
OPERATIONS AND PROCEDURES: Tibiotalar fusion with cross-cannulated
AO screws times three and local bone
graft performed 1/10/92 by Dr. Brooke Lemmen
HISTORY OF PRESENT ILLNESS: This 44 year old Phys. Ed. teacher had
a long history of ankle pain on the
right side. He had a fracture as a child which was fixed with an
open reduction and internal fixation. He sustained a second ankle
fracture a number of years later when he fell off a ladder and
refractured his ankle. Currently , he has pain on all movements of
the ankle while walking and performing any activity. The pain is
primarily in the ankle joint but also in his mid foot. He has been
controlling his pain with Darvocet as well as intramuscular Tordal
15 to 30 mg four times a day. He denies any other joint
involvement and he denies any motor or sensory changes. PAST
MEDICAL HISTORY: Significant for Insulin dependent diabetes
currently managed with 32 units of NPH Humulin. He also has a
history significant for hypertension. He denies bowel or bladder
dysfunction , he denies coronary artery disease , dysrrhythmia , or
murmur , he denies peptic ulcer disease , and he denies thyroid gland
abnormality. PAST SURGICAL HISTORY: Significant for fracture
times two of his right ankle status post open reduction and
internal fixation first time in 1965 and second time in 1988 , he
had herniorrhaphy in 1978 , he had drainage of a right thumb abscess
in 1988 , and he has had septicemia treated at Whid Downdoc Rehabilitation Of in
February and September of 1991. CURRENT MEDICATIONS: NPH Insulin
32 units every morning , Procardia XL 90 mg every day before noon , Lotensin 40 mg
orally every day , Lasix 40 mg orally every day , potassium supplement , and then
Ketorolac 15-30 mg intramuscularly four times a day , and Darvocet N-100 one
to four tablets every day ALLERGIES: He has no known drug allergies.
He denies smoking history and he denies ethanol abuse. REVIEW OF
SYSTEMS: Negative for dyspnea on exertion , shortness of breath ,
palpitations , or anginal like symptoms. He does get bilateral leg
edema. He has not had any evidence of neuropathy , retinopathy , or
nephropathies associated with his diabetes.
PHYSICAL EXAMINATION: Well-developed 44 year old male who appears
stated age. HEENT: Demonstrated pupils to
be equal and reactive , extraocular muscles intact , and oropharynx
was clear. NECK: Supple with full painless range of motion and
there was no goiter , adenopathy , or jugular venous distention.
LUNGS: Clear to auscultation. CARDIAC: Demonstrated a regular
rate and rhythm without significant murmur , rub , or thrill.
ABDOMEN: Soft , non-obese , and non-tender without evidence of
hepatosplenomegaly. ORTHOPEDIC: Demonstrated that he had
approximately 10 degrees of dorsiflexion , 10 degrees of plantar
flexion with very limited subtalar motion , good mid foot motion but
with some pain on motion of the mid foot. There was pain during
movement of his tibiotalar joint. Specifically , there was little
pain with motion of the subtalar joint or the mid foot. He had
good dorsalis pedis and posterior tibialis pulses , he had normal
sensation at the first dorsal web space , dorsum , and plantar
aspects of the foot , and the hindfoot appeared to be in neutral
position. There did not appear to be any supination or pronation
deformities. He had full painless range of motion at the hip and
at the knee on the ipsilateral side.
LABORATORY EXAMINATION: X-Rays demonstrated marked degenerative
joint disease with a complete obliteration
of the articular joint space in the lateral half of the joint.
There were also some degenerative changes in the mid foot. His
pre-operative laboratory evaluation demonstrated EKG with normal
sinus rhythm and no evidence of ischemic changes , glucose was 133 ,
BUN was 35 , creatinine 1.2 , potassium of 4.2 , liver function tests
were entirely within normal limits , hematocrit was 42.8 , white
blood cell count was 9 , and the physical therapy and PTT were 11.6 and 28.2
respectively. The patient's urinalysis was entirely clear for
bacteria and negative for glucose and ketones.
HOSPITAL COURSE: The patient was admitted as a same day surgery
candidate with traumatic arthritis at the right
tibiotalar joint and he underwent tibiotalar fusion with
cross-cannulated AO screws and local bone graft. The procedure
involved partial fibulectomy as well as a partial osteotomy of the
medial malleolus. The position of the ankle at the end of the
procedure was neutral dorsiflexion , plantar flexion , and neutral
varus/valgus. He had a general endotracheal anesthetic for failed
sciatic nerve block , estimated blood loss was 200 cc , and total
tourniquet time was 1 hour and 57 minutes. He received 2500 cc of
crystalloid intraoperatively and he tolerated the procedure well.
Post-operatively , his motor and sensory examinations were intact
with regard to deep and superficial peroneal and posterior tibialis
nerves. His Hemovac put out a total of 150 cc and was removed on
post-operative day number one. He initially was kept in a
posterior splint with anterior wings. This was changed on
post-operative day two. The wound appeared to be clean and dry and
he was placed in a short-leg fiberglass cast since there was little
swelling apparent. He had an X-Ray after placement of the cast and
the position of the ankle looked to be in neutral position and
neutral varus/valgus. He was cleared by Physical Therapy
ambulatory , non-weight bearing , with use of crutches. He did not
have any difficulties with the cast , no significant swelling , and
was discharged on post-operative day three. The patient did have
some elevated temperatures which were attributed to atelectasis and
was encouraged to cough and deep breath.
DISPOSITION: Patient will follow-up with Dr. Brooke Lemmen in
approximately three weeks at which time the cast will
be changed and stitches removed. DISCHARGE MEDICATIONS: The
medications that he was admitted on with the addition of Vicodan
one to two orally every 3-4h. as needed , Naprosyn 500 mg orally twice a day as a
substitute for the Tordal , and Halcion 0.125 to 0.25 mg orally every bedtime
as needed
YU239/5860
BROOKE D. LEMMEN , M.D. SG66 D: 1/24/92
Batch: 2550 Report: F9439C5 T: 2/1/92
Dictated By:
Document id: 1230
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
U |
U |
U |
U |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
N |
N |
N |
N |
N |
N |
N |
993268545 | PUO | 20926109 | | 762689 | 2/29/1997 12:00:00 a.m. | R/O MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 2/29/1997 Report Status: Signed
Discharge Date: 4/14/1997
FINAL DIAGNOSIS: ( 1 ) UNSTABLE ANGINA
( 2 ) CORONARY ARTERY DISEASE
( 3 ) DIABETES MELLITUS
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old female
with history of coronary artery
disease who presented with unstable angina. The patient's cardiac
risk factors include diabetes mellitus , hypercholesterolemia , and
post-menopausal. She presented to an outside hospital in 1992 with
substernal chest pain. A cardiac catheterization at that time
revealed an right coronary artery with diffuse disease , moderate to
severe proximal left anterior descending artery lesion at diagonal
1 , moderate mid- left anterior descending artery lesion , and a
tight left circumflex. She underwent a PTCA of the left circumflex
artery with improvement. She was well until approximately one year
ago when she began having exertional chest pain. Her chest pain
has been worsening over the past several months and has been
occurring with less and less exertion. She was admitted in July
of 1996 for chest pain and ruled out for a myocardial infarction.
An exercise Thallium test was negative. She was well until February
of 1997 when she again developed exertional chest pain. She said
that the chest pain was substernal. It had no radiation and no
nausea or vomiting and no diaphoresis. She had an exercise test on
10/15/97 where she was only able to exercise for three minutes and
stopped secondary to shortness of breath. She was scheduled for an
elective catheterization on 9/20/97 but her chest pain has been
slowly worsening over the past couple of months. She reports a
history of exertional chest pain at only one-half block. Normally
her chest pain was relieved with one sublingual nitroglycerin. On
the evening prior to admission she woke up at 3 a.m. with severe
substernal chest pain. She had no relief with three sublingual
nitroglycerin and , therefore , presented to the emergency room.
In the emergency room she was made pain-free with intravenous nitroglycerin.
PAST MEDICAL HISTORY: Coronary artery disease as above. Diabetes
mellitus.
MEDICATIONS: Lopressor 100 mg orally twice a day , aspirin 325 mg orally
every day , Zocor 20 mg orally every bedtime , and Metformin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to the emergency room
department with chest pain but became pain-free
with sublingual nitroglycerin. The heparin was started in the
emergency room and the patient was given aspirin. The patient's
admission ECG demonstrated sinus bradycardia with no changes from
her previous ECG.
During the first several days of admission the patient began
complaining of some left chest pain but , on further questioning ,
the pain was under her left breast and radiating to her right back
and she was tender to palpation. Examination under the left breast
revealed three to four vesicles on an erythematous base felt to be
consistent with zoster. The patient was therefore started on
Famvir with some improvement of the pain and the lesion. In
addition to the superficial chest pain the patient did have some
chest pain which was felt to be cardiac in origin although she did
not have any ECG changes. She was continued on nitroglycerin and
heparin and her Lopressor was increased as tolerated.
The patient underwent a cardiac catheterization on 5/26/97.
Although the final catheterization report is not available yet , the
catheterization showed three vessel disease with normal left
ventricular function. It was felt that the patient needed to go
for coronary artery bypass graft but , due to the fact that she had
the herpes zoster under her left breast , it was decided to wait to
do the coronary artery bypass graft until her zoster had improved.
Therefore the patient was discharged to home and will undergo
coronary artery bypass graft in several weeks. Prior to discharge
the patient was seen by surgery and anesthesia for her preoperative
workup. There were no complications.
DISPOSITION: DISCHARGE MEDICATIONS: Aspirin 325 mg orally every day , NPH
26 units every day before noon and 20 units every afternoon , Lopressor 100
mg orally twice a day , nitroglycerin 0.4 mg sublingual q5m times three ,
Prilosec 20 mg orally every day , Percocet 1 to 2 tablets orally every 4 hours as needed
pain , Zocor 20 mg orally every bedtime , Famciclovir 500 mg orally three times a day times 7
days. FOLLOWUP: The patient will follow-up with Dr. Bree Theiling
on 2/20/97 and will follow-up with cardiac surgery.
Dictated By: MA YEAGLEY , M.D. AM16
Attending: LASHANDA L. BACHMANN , M.D. XR66
JF789/1407
Batch: 1081 Index No. UWJJKT65ME D: 3/30/97
T: 3/30/97
Document id: 1231
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
Y |
- |
Y |
U |
U |
U |
U |
U |
Y |
Y |
U |
Y |
Y |
Y |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
Y |
- |
Y |
N |
N |
N |
- |
N |
Y |
Y |
N |
Y |
Y |
Y |
N |
- |
350457905 | PUO | 34112342 | | 993330 | 7/6/2002 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Signed | DIS | Admission Date: 11/6/2002 Report Status: Signed
Discharge Date: 10/26/2002
FINAL DIAGNOSES: 1. OBSTRUCTIVE SLEEP APNEA.
2. HYPERTENSION.
3. OSTEOARTHRITIS.
4. SECOND DEGREE AV BLOCK.
5. OBESITY.
PROCEDURE:
1. Chest x-ray.
2. Dobutamine MIBI.
3. Echocardiogram.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old woman
with a history of hypertension ,
asthma , congestive heart failure , and coronary artery disease who
has left ventricular hypertrophy with left ventricular dysfunction.
She presented to the I Warho Hospital emergency room
department with two weeks of cough and two days of multiple
episodes of emesis and diarrhea. The review of systems was
otherwise negative.
PAST MEDICAL HISTORY: Congestive heart failure. Echocardiogram in
October of 2000 showed mild to moderate
left ventricular dysfunction , septal apical hypokinesis , and
abnormal septal motion. Coronary artery disease. Dobutamine MIBI
in October of 2000 showed small fixed apical inferior defect , mild
ischemia in the lateral wall. Hypertension. Asthma. Morbid
obesity. Hyperlipidemia.
MEDICATIONS: Atrovent , Flovent , Serevent , Vioxx , Zocor , Lopressor ,
Lasix , Losartan , aspirin , nitroglycerin.
ALLERGIES: Lisinopril.
SOCIAL HISTORY: She lives with two daughters and granddaughter.
Never smoked. No alcohol.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8 , heart rate
120 , blood pressure 215/91 , respiratory rate
22 , oxygen saturation 93% on room air. The physical examination is
notable for morbid obesity. LUNGS: Clear to auscultation
bilaterally. EXTREMITIES: 2+ pitting edema.
LABORATORY DATA: WBC 7 , hematocrit 45.5 , platelet count 211 , 000.
Chem-7 within normal limits. ECG: No acute
changes. Chest x-ray: Mild pulmonary vascular congestion.
SUMMARY: This is a 62 year-old woman admitted with two weeks of
dry cough , malaise , and resolving gastrointestinal
symptoms suspicious for a slowly resolving viral infection coupled
with mild congestive heart failure.
HOSPITAL COURSE: Cardiovascular: The patient was ruled out for a
myocardial infarction while in the hospital. The
patient had multiple nocturnal episodes of bradycardia and second
degree heart block with occasional irregular PR intervals. These
episodes were mostly asymptomatic although she did suffer one
episode of flash pulmonary edema on 1/21/02. Echocardiogram was
done in the hospital which showed an ejection fraction of 61% with
no wall motion abnormalities and mild concentric left ventricular
hypertrophy. Dobutamine MIBI was also performed and this showed no
ischemia. The electrophysiology service was consulted and they
determined that the patient was not a candidate for pacing. While
she was in the hospital , the patient enjoyed excellent diuresis on
intravenous Torsemide and was discharged on orally Lasix.
Pulmonary: The patient had a persistent cough which improved with
diuresis and with a five day course of levofloxacin to treat
possible bacterial bronchitis. Nocturnal oxygen saturation monitor
revealed likely obstructive sleep apnea with episodic desaturations
to as low as 57%. These episodes of desaturation were coupled with
second degree AV block as mentioned above. The patient was started
on C-PAP , however , she did not tolerate and refused to use as outpatient.
Gastrointestinal: The patient's nausea and vomiting resolved
following admission.
DISPOSITION: DISCHARGE MEDICATIONS: Ventolin 2 puffs inhaler
four times a day , aspirin 325 mg orally every day , Lasix 120 mg every day before noon
and 80 mg every afternoon , Robitussin 10 ml orally every 4 hours as needed cough , Atrovent
inhaler 2 puffs four times a day , Zantac 150 mg orally twice a day , Verapamil 40 mg
orally three times a day , Zocor 20 mg orally every bedtime , Norvasc 10 mg orally every day , Imdur
30 mg orally every day , Serevent 2 puffs inhaler twice a day , Flovent 220 mcg
inhaler twice a day , Cozaar 100 mg orally every day , Levaquin 500 mg orally every day ,
Vioxx 25 mg orally every day DIET: Low saturated fat. CONDITION ON
DISCHARGE: Stable. FOLLOWUP: Followup with Dr. Elois Polcovich ,
Braan Health Also , pulmonary outpatient workup to
evaluate obstructive sleep apnea.
Dictated By: LYNWOOD KEITEL , M.D. RM8
Attending: CORAZON MERTIE DANIEL , M.D. TT11
JQ130/736451
Batch: 7047 Index No. FYLPNI5Z1E D: 10/3/02
T: 10/3/02
Document id: 1232
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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671469451 | PUO | 73720075 | | 772724 | 2/23/1997 12:00:00 a.m. | ? MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 5/14/1997 Report Status: Signed
Discharge Date: 10/19/1997
PRINCIPAL DIAGNOSIS: RULE OUT MYOCARDIAL INFARCTION
HISTORY OF THE PRESENT ILLNESS: This is a 36 year-old male who
presented with chest pain for one
and one-half hours. In September , 1989 , he developed chest pain and
suffered an inferior myocardial infarction. He had an angioplasty
of his right coronary artery performed at that time. In April ,
1989 , he had more chest pain. Cardiac catheterization indicated
left anterior descending artery lesion. An angioplasty was
attempted and he had abrupt left anterior descending artery
closure , requiring emergent single vessel coronary artery bypass
grafting. He did well until August , 1996 , when he had more
angina. Cardiac catheterization showed a high grade left
circumflex lesion. Percutaneous transluminal coronary angioplasty
of the left circumflex was successful. At that time , his cardiac
catheterization also showed that his saphenous vein to left
anterior descending artery graft was patent. His ejection fraction
was 68% by left ventriculogram at that time. In April , 1996 , he
had more chest pain and his cardiac catheterization showed no
significant change compared to his August , 1996 , cardiac
catheterization. One week prior to admission , the patient had
chest pain , which was quickly relieved by one sublingual
nitroglycerin. On the day of admission , while resting , he
developed anterior chest pressure with radiation to his neck ,
associated with some lightheadedness and nausea. There was no
diaphoresis or dyspnea. He took three sublingual nitroglycerin
with minimal relief. He came to the Emergency Room and his pain
resolved after one inch of nitroglycerin paste , 2 milligrams of
intravenous morphine , 325 milligrams of aspirin and supplemental
oxygen. The total duration of his pain was one and one-half hours.
He was then admitted to the Medical Short Stay Unit.
MEDICATIONS: Medications on admission were Atenolol 100
milligrams twice a day; Cardizem 60 milligrams orally
twice a day; pravastatin 20 milligrams orally every day; aspirin 325 milligrams
every day; sublingual nitroglycerin as needed
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Hepatitis C; hypercholesterolemia;
hypertension; coronary artery disease with
coronary artery bypass grafting in 1989.
SOCIAL HISTORY: He does not smoke.
REVIEW OF SYSTEMS: He denied recent orthopnea or PND.
PHYSICAL EXAMINATION: He was comfortable and pleasant.
Temperature was 97.8. Blood pressure
124/68. Heart rate 64. Respiratory rate 18. Oxygen saturation
96% on room air. Neck without jugular venous distention.
Cardiovascular regular rate and rhythm. Normal S1/S2. No murmurs.
Abdomen soft , nontender , nondistended. Extremities no cyanosis ,
clubbing or edema. Rectal occult blood negative.
Chest x-ray was negative by report. Electrocardiogram with pain
showed normal sinus rhythm at 61. Axis was 0. There was no
significant change compared to a September , 1997 , electrocardiogram. His
laboratory studies were notable for a CPK of 103. Liver function
tests were within normal limits. Troponin was 0.0. Hematocrit was
40.7.
HOSPITAL COURSE: He was admitted to the Medical Short Stay Unit
with chest pain. He underwent a rule out
myocardial infarction protocol with negative serial CPKs. He had
no events on cardiac monitor. He had no further episodes of chest
pain while in the hospital. On hospital day number two , he
underwent an exercise test. It was a standard Bruce protocol and
he exercised for 9 minutes 1 second , stopping secondary to leg
fatigue. He had no chest pain. His peak heart rate was 131. Peak
blood pressure was 200/100 with no electrocardiographic changes.
His test was read as showing no evidence of ischemia. The patient
was then discharged to home. There were no medication changes.
DISCHARGE MEDICATIONS: Same as on admission.
Dictated By: IRVING M. ESCALANTE , M.D. FB73
Attending: IRVING M. ESCALANTE , M.D. FB73
XA276/5627
Batch: 5560 Index No. PGEQ6E9I3B D: 2/30/97
T: 2/30/97
CC: 1. BRITTANEY N. HAMBLET , M.D. XJ2
Document id: 1233
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
550343443 | PUO | 55691308 | | 142217 | 11/27/1998 12:00:00 a.m. | PNEUMONIA | Signed | DIS | Admission Date: 10/23/1998 Report Status: Signed
Discharge Date: 2/15/1998
PRINCIPAL DIAGNOSIS: COMMUNITY ACQUIRED PNEUMONIA.
PROBLEM LIST: 1 ) COMMUNITY ACQUIRED PNEUMONIA.
2 ) HISTORY OF MYOCARDIAL INFARCTION.
3 ) NON-INSULIN DEPENDENT DIABETES MELLITUS.
4 ) RECENT DIAGNOSIS OF SLEEP APNEA.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old male
whose past medical history is
significant for myocardial infarction in 1996 without residual
angina , non-insulin dependent diabetes mellitus , and a recent
diagnosis of sleep apnea. He was in his usual state of health
until three days prior to admission when he began to develop a
cough productive occasionally of yellow sputum , dyspnea on exertion
and temperatures to 102 degrees. One day prior to admission , he
went to his primary healthcare provider where he was diagnosed with
pneumonia and given Erythromycin and Ciprofloxacin without
improvement. The following day , he went back to his primary care
provider and was given cough syrup with Codeine , but without relief
and through the course of that day , he developed increasing
shortness of breath , chills and diaphoresis and so he presented to
the emergency room. In the emergency room , he had a temperature of
100 degrees with room air oxygen saturations between 90% and 95%.
He was cultured and a chest x-ray was taken which showed a right
middle lobe infiltrate and therefore , he was admitted with a
community acquired pneumonia resistant to outpatient management.
PAST MEDICAL HISTORY: As above.
PHYSICAL EXAMINATION: Vital signs: Temperature 100.1 degrees ,
blood pressure 130/80 , heart rate 60 , oxygen
saturation 99% on three liters nasal cannula. His HEENT
examination was unremarkable. His lung examination revealed
rhonchorous breath sounds throughout with decreased breath sounds
at his bases , right greater than left. He also had diffuse
inspiratory and expiratory wheezes. His cardiac examination
revealed a regular rate and rhythm , S1 and S2 , no murmurs , gallops
or rubs. The abdominal examination was benign. His extremities
revealed no edema. His neurological examination was non-focal.
LABORATORY: His laboratory studies were notable for a chem-7 that
was within normal limits. His CBC revealed a white
blood cell count of 7.3 with a hematocrit of 33.5 and a platelet
count of 130. His EKG showed normal sinus rhythm at 60 with left
atrial enlargement. There were no ischemic changes. His chest
x-ray revealed diffuse infiltrates bilaterally with a more focal
area of consolidation in the right middle lobe.
HOSPITAL COURSE: The patient is a 65 year-old male with diabetes
mellitus , coronary artery disease and sleep apnea
who was admitted with a community acquired pneumonia who had failed
outpatient management. He was initially started on intravenous
Cefuroxime and Azithromycin for likely community acquired bacterial
pathogens and atypical organisms. He was cultured and sputums were
obtained , however no organisms were ever isolated throughout his
hospital course. On hospital day number two , he developed
increasing shortness of breath with oxygen saturations of roughly
86% on six liters. At this time , his lung examination was notable
for marked increase in the inspiratory and expiratory wheezes with
decreased air movements. The rest of his examination at this time
including the cardiac examination was unremarkable. This event was
felt to be bronchospasm due to airway inflammation and he was
treated with numerous Albuterol nebulizers and intravenous Lasix on
which his oxygenation gradually improved to 96% on six liters.
Because of the concern of reactive airway disease and perhaps
worsening pneumonia , he was at this time switched to Legionella
doses of Azithromycin and was started on aggressive nebulizer
treatments. However , at this time , the possibility of flash
pulmonary edema causing cardiac problems was also raised. However ,
it was noted at this time that there was no clear precipitant for
an episode of flash pulmonary edema and that his blood pressure was
at baseline. His heart rate was at 70 and he had not become
obviously fluid overloaded. Nonetheless , he received a cardiac
work-up which concluded that he was being ruled out for a
myocardial infarction and the following day , he received an
echocardiogram which revealed an ejection fraction of 58% with
apical inferior and inferoseptal akinesis. There was no marked
left ventricular hypertrophy. Therefore , it was thought unlikely
that flash pulmonary edema had significantly contributed to his
hypoxia and he was subsequently treated solely for severe community
acquired pneumonia with a large bronchospastic component. He was
therefore continued on Cefuroxime and Azithromycin with gradual
resolution of his fevers and a significant improvement in his air
movement and his pulmonary examination. Two weeks prior to this
admission , he was started on a Prednisone taper and subsequent
underwent marked improvement in his air movement and in the degree
of bronchospasm. Therefore , he was discharged home on the
following medications.
MEDICATIONS ON DISCHARGE: 1 ) Biaxin 500 mg orally twice a day times two
day to complete a long course for
atypical coverage. 2 ) Albuterol inhaler 2 puffs four times a day as needed
shortness of breath. 3 ) Enteric coated aspirin. 4 ) Glyburide 5
mg orally every day. 5 ) Lopressor 50 mg orally twice a day 6 ) Prednisone
taper. 7 ) Timoptic one drop each eye every PM. 8 ) Cardura one orally q.
day.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
FOLLOW-UP: The patient is to follow-up with his primary care
provider. We have also asked him to follow-up on two
laboratory abnormalities which came back through his
hospitalization and he was noted to have a microcytic anemia and he
had iron studies sent which revealed an iron of 16 and a TIBC of
241. His primary care provider is aware of this and will follow-up
on this as an outpatient.
DISPOSITION: The patient was discharged to home.
Dictated By: ARNULFO MACKLER , M.D. QL70
Attending: MELDA X. IVASKA , M.D. WK97
LE311/7148
Batch: 28003 Index No. YXCAQPEV1 D: 9/3/98
T: 5/25/98
Document id: 1234
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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342305124 | PUO | 63975551 | | 3396596 | 1/17/2006 12:00:00 a.m. | ATRIAL FIBRILLATION | Signed | DIS | Admission Date: 2/24/2006 Report Status: Signed
Discharge Date: 1/15/2006
ATTENDING: REISMAN , CATHIE MINDI MD
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male
with a history of coronary artery disease , CHF , EF of 15% status
post AVR , history of NSTEMI initially presenting to outside
hospital on 8/19/06 with chief complaint of shortness of breath ,
found to be volume overloaded with a clinical exam and laboratory
findings consistent with heart failure. The patient was found to
have a BNP of 747 as well as a troponin I of 0.43. A repeat echo
at that time revealed an EF of 15% , down from a previous EF of 25
to 35% with a functional aortic valve , moderate-to-severe mitral
insufficiency. A persantine MIBI demonstrated left ventricular
enlargement and three-vessel disease with ischemia in the mid
distal LAD and left circ territory as well as a fixed inferior
wall defect consistent with a right coronary artery infarct. The
patient was diuresed , started on Carvedilol and improved.
Troponins trended down. The patient continued to have frequent
runs of ectopy and SVT. The patient was placed on a heparin drip
and transferred to the Pagham University Of for
catheterization and possible percutaneous intervention. On
admission , the patient reported to be feeling much better , denied
shortness of breath or chest pain. The patient reports
progressive dyspnea on exertion over the past several months ,
inability to lay flat , positive orthopnea and PND , reports
ability to climb two flights of stairs , also reports occasional
palpitations. No fevers , chills , nausea , vomiting , constipation ,
diarrhea , bright red blood per rectum or pedal edema. The
patient reports poor compliance with diabetes management , denies
dietary indiscretion , reports medical compliance.
PAST MEDICAL HISTORY: Includes coronary artery disease status
post CABG in 1994 , coronary artery disease , CHF , cardiomyopathy ,
non-ST-wave MI , status post aortic valve replacement with St.
Jude's valve , hyperlipidemia , diabetes , anxiety.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Include aspirin 81 , lisinopril 20 ,
Plavix 75 , verapamil 240 sustained release , gemfibrozil 600
twice a day , nystatin 500 twice a day , Paxil 20 daily , glipizide 10 daily ,
Coumadin 4 prior to admission to outside hospital , Carvedilol
6.25 daily , heparin drip and spironolactone.
SOCIAL HISTORY: The patient currently uses tobacco. No alcohol
use. The patient is retired , lives with wife in Jackciotte , teaches
graduate courses.
FAMILY HISTORY: The patient denies a family history of coronary
artery disease , however , there is hypertension and
cerebrovascular disease in his family.
PHYSICAL EXAMINATION: On admission , the patient was afebrile ,
heart rate 58 , BP 124/60 , respiratory rate of 20 , saturating 98%
on 2 L. The patient was in no acute distress , lying flat ,
speaking in full sentences. Mucous membranes moist , oropharynx
clear. JVP 12 with bibasilar crackles , left greater than right
and expiratory wheeze with long , pronounced expiratory phase.
Heart , S1 , S2 , prosthetic S2. No murmurs , gallops or rubs
appreciated. Abdomen soft , nontender and nondistended with
positive bowel sounds. Extremities are without edema. DP
intact. Feet are cool but well perfused. Skin warm , dry and
intact , no rashes. The patient is alert and oriented x3.
LABORATORY DATA: Labs notable for creatinine of 1 , hematocrit of
39.5 , platelets of 113 , cholesterol 157 , triglycerides 76 , HDL
32 , LDL 110 , hemoglobin A1c 6.3 , TSH 1.9. EKG , sinus rhythm ,
left bundle branch block with multiple PVCs , a widened QRS of
duration of 190 milliseconds. Chest x-ray , cardiomegaly
consistent with mild interstitial edema.
HOSPITAL COURSE: In summary , this is a 64-year-old male with a
history of coronary artery disease status post CABG and NSTEMI ,
CHF with a known EF of 15% , status post aortic valve replacement ,
presenting through an outside hospital with CHF exacerbation
likely secondary to ischemia.
1. Cardiovascular:
Ischemia: No evidence of ongoing ischemia on admission.
Elevated troponin at outside hospital trended down possibly
secondary to NSTEMI prior to admission versus demand. The
patient was continued on aspirin , Plavix , beta-blocker and ACE
inhibitor , which were titrated to effect. The patient was
started on a statin and continued on Niaspan , left heart cath
revealed occluded graft and 2+ aortic insufficiency with 100% LAD
stenosis , 70% diagonal 1 , 90% circumflex , 45% RCA and 100%
effused LIMA graft to circumflex and a 100% effused SVG graft to
LAD. The patient is now status post stenting the OM V1 and LAD.
The patient has remained asymptomatic and shortness of breath has
improved.
Pump: EF 15% on repeat echo with severe MR. The patient was
continued on spironolactone. The patient continued to be
diuresed initially and is now euvolemic. He will need a repeat
echo in three months to evaluate his ejection fraction and
determine the utility of an AICD placement.
Rhythm: We held verapamil secondary to double AV nodal blockade.
However , with the patient's history of widened QRS and multiple
PVCs and SVT , the patient will follow up with EP to assess the
utility of AICD.
2. Respiratory: The patient has no acute issues. Shortness of
breath has improved. Continues to complain of residual shortness
of breath while lying flat on his left side.
3. Renal: Creatinine has been stable at baseline. We will
closely follow status post chat. The patient was pretreated with
bicarbonate and Mucomyst. Creatinine remained stable.
4. GI: LFTs are mildly increased likely secondary to right
heart failure.
5. Heme: The patient's hematocrit was 39 on admission. It
trended down status post cath likely secondary to blood loss
given the long case and hemodilution; however , hematocrit fell to
38 concerning for retroperitoneal bleed. Despite patient
remaining hemodynamically stable and groin without evidence of
hematoma , the patient underwent a CT scan , which was negative.
His hematocrit was stabilized. He was not transfused , as he was
asymptomatic and recently revascularized. The patient was noted
to be guaiac positive without evidence of gross bleeding , thus
will need outpatient follow-up and colonoscopy. The patient
continues his heparin-bridged Coumadin with a goal of INR 2 to 3.
In addition , the patient suffers from long-term
thrombocytopenia. His platelet count was 113 on admission.
Review of records revealed thrombocytopenia on previous admission
to Kernan To Dautedi University Of Of as well as on presentation to outside hospital prior
to heparinization , thus low suspicion for HIT. The patient's
platelet level remained stable. He should consider outpatient
evaluation by Hematology.
6. Endocrine: The patient has a history of diabetes on orally
hypoglycemics , which were discontinued on admission. The patient
was controlled with regular insulin and placed back on his orally
hypoglycemics prior to discontinuing. A1c was within normal
limits.
7. ID: No acute issues.
8. Psych: History of anxiety , on Paxil and Ativan.
9. FEN: The patient was maintained on a cardiac diet.
10. Prophylaxis: The patient was encouraged to stop smoking.
He was maintained on a nicotine patch during his hospital stay ,
which he tolerated well. He will be discharged with a
prescription for the nicotine patch as well.
DISCHARGE CONDITION: Stable.
DISCHARGE INSTRUCTIONS: The patient is to follow up with primary care physician and
Cardiology as well as EP. Patient encouraged to check his daily
weights and report a weight increase of more than 2 pounds daily
or 3 pounds a week to his primary care physician. The patient will also follow up
with INR checks as an outpatient.
DISCHARGE APPOINTMENTS: With his primary care physician , Dr. Reidherd , telephone
033-718-0172 , on 10/26/06 at 1:45 , Cardiology with Dr.
Feazel at 397-060-6586 on 6/2/06 at 3:15 and with
Electrophysiology , Dr. Schoeppner on 2/6/06 at 10:20. The patient
should arrange to have his INR drawn on 5/29/06 and follow-up
INRs to be drawn every seven days. INRs will be followed by his
primary care physician.
DISCHARGE MEDICATIONS:
1. Aspirin 325 orally daily.
2. Lisinopril 4 mg orally daily.
3. Nicotine patch 14 mg per day topical.
4. Spironolactone 25 mg orally daily.
5. Paxil 25 mg orally daily.
6. Atorvastatin 80 mg daily.
7. Niaspan 0.5 gm orally twice daily.
8. Carvedilol 12.5 mg orally twice daily.
9. Plavix 75 mg daily.
10. Gemfibrozil 900 mg orally twice daily.
11. Coumadin 5 mg orally at night.
eScription document: 1-3757238 CSSten Tel
Dictated By: YEAGLEY , MA
Attending: REISMAN , CATHIE MINDI
Dictation ID 6478295
D: 6/13/06
T: 6/13/06
Document id: 1235
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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164978504 | PUO | 47078784 | | 5934655 | 3/15/2006 12:00:00 a.m. | NSTEMI , CHF | | DIS | Admission Date: 2/27/2006 Report Status:
Discharge Date: 4/8/2006
****** FINAL DISCHARGE ORDERS ******
BREZEE , TAINA 048-74-46-1
Ridport Boulevard
Service: CAR
DISCHARGE PATIENT ON: 1/16/06 AT 05:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MAINER , SHAVONNE D. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASPIRIN ( ASPIRIN ENTERIC COATED )
325 MG orally DAILY
Override Notice: Override added on 1/5/06 by HIGHTREE , SHONDRA D. , M.D. on order for COUMADIN orally ( ref # 166812497 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MDA
ATENOLOL 50 MG orally twice a day Starting Today ( 9/1 )
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting Tomorrow ( 6/27 )
LOVENOX ( ENOXAPARIN ) 100 MG subcutaneously twice a day X 14 doses
Starting Today ( 6/27 ) HOLD IF: INR 2-3
Instructions: Only use until INR is therapeutic 2-3
ZETIA ( EZETIMIBE ) 10 MG orally DAILY
FELODIPINE 5 MG orally DAILY
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FENOFIBRATE ( TRICOR ) 145 MG orally DAILY
Override Notice: Override added on 1/5/06 by HIGHTREE , SHONDRA D. , M.D. on order for COUMADIN orally ( ref # 166812497 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: MDA
Previous override information:
Override added on 10/8/06 by HIGHTREE , SHONDRA D. , M.D.
on order for SIMVASTATIN orally ( ref # 047032930 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
SIMVASTATIN Reason for override: MDA
Number of Doses Required ( approximate ): 20
GLYBURIDE 2.5 MG orally DAILY
HYZAAR ( 12.5 MG/50 MG ) ( HYDROCHLOROTHIAZIDE 1... )
1 TAB orally twice a day
Alert overridden: Override added on 1/16/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LOSARTAN POTASSIUM
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LOSARTAN POTASSIUM Reason for override: mda
SIMVASTATIN 80 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 1/5/06 by HIGHTREE , SHONDRA D. , M.D. on order for COUMADIN orally ( ref # 166812497 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: MDA Previous override information:
Override added on 10/8/06 by HIGHTREE , SHONDRA D. , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
456782069 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: MDA
Previous override information:
Override added on 10/8/06 by HIGHTREE , SHONDRA D. , M.D.
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
SIMVASTATIN Reason for override: MDA
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting NOW , Within Hour of Pharmacy Approval
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 1/5/06 by HIGHTREE , SHONDRA D. , M.D.
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: MDA
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 4 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
CARD DR OROZ ( 048 ) 968-4013 CLINIC WILL CONTACT ,
Dr. SWANSBROUGH , SONDRA 053-351-9001 CLINIC WILL CONTACT ,
Coumadin clinic 2-3 days ,
Arrange INR to be drawn on 8/10/06 with f/u INR's to be drawn every
7 days. INR's will be followed by Coumadin Clinic affiliated with primary care physician
ALLERGY: PERCOCET
ADMIT DIAGNOSIS:
NSTEMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTEMI , CHF
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
chf ( congestive heart failure ) icmp
cad ( coronary artery disease ) cabg ( cardiac bypass graft surgery ) avr
( cardiac valve replacement ) afib ( atrial
fibrillation ) oa ( osteoarthritis ) djd ( degenerative joint
disease ) dm ( diabetes mellitus ) hyperlipidemia
( hyperlipidemia ) osa ( sleep apnea ) gerd ( gastroesophageal reflux
disease ) colon polyps ( colonic polyps ) tobacco history ( past smoking )
OPERATIONS AND PROCEDURES:
Catheterization 5/8/06 -- restented distal OM2 thrombosed stent with a
CYPHER DES
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
TTE 4/18/06 : Pending
CXR 3/2/06 : CLINICAL INDICATION: Non-ST elevation MI , pulmonary
edema.
IMPRESSION: PA and lateral examination is interpreted without
comparison. The lungs are well expanded and are free of
consolidations. The lungs are well expanded and free of
consolidations or effusions.
The patient is status post CABG and cardiac valve surgery. There
is moderate cardiomegaly. Calcification is seen in the arch of
the aorta but the mediastinum appears otherwise unremarkable.
BRIEF RESUME OF HOSPITAL COURSE:
HPI:
73 year-old M with history of CAD history of 4 vessel CABG and AVR for AS in
1991 ( LIMA to LAD , SVGs to RCA , D1 , OM2 ) , Afib , IMI , hyperlipids ,
+tob , DM2 , +Fam hx , recent PCI in 6/19 with 3 stents ( 2 CYPHERs to
SVG/OM2 , 1 BMS to OM2 distal to insertion point ) , now p/with 2 weeks
increasing DOE , and acute SOB with minimal exertion on 3/1 No CP , no
orthopnea , no PND , no edema or abd pain , no palpitations ,
dizziness. patient has never experienced classical angina. Presented to
TH , +EKG changes , +BNP , + TNI , started on Integrilin/Heparin drops
************
Exam on admission:
T 97.1 , 94 , 130/80 , 20 , 97%
2L NAD , EOMI , PERL , injected sclera
bilat JVP ~ 12
cm CTAB , no wheezes , no
crackles Irregular rhythm , nl s1/s2 , +1-2/6 LUSB metallic murmur with no
radiation , +LV thrill , no RV heave. S/NT/ND
Ext WWP , no C/C/E Neuro A and O X 3 , CN 2-12 intact.
*************
LABS: TNI peak 15 --> 12 --> 5
5 CKMB peak 28 --> 3
5 BNP 669 --> 250
274 Cr 0.9 , Hct 47 , WBC 13 , UA with 3+ RBC , no
WBC EKG: new TWI , ST depressions anterolat leads.
************
PROCEDURES/TESTS:
TH 10/1/06 CXR: ? PNA , ? Effusion
CXR 3/2/06 : no infiltrate , no effusions. +cardiomegaly.
MIBI 8/29/06 : TH : akinetic septum , HK inf/apex , lat/inf wall
reversible defect. 31% EF
Cath: CYPHER DES to native OM2 2.5X13mm.
************
CONSULTS: None
************
PROBLEMS BY SYSTEM: 73 year-old M with NSTEMI , history of 3VD history of CABG , transferred
here for re-cath. patient with recent PCI 6/19 and had instent thrombosis of
OM2. Also had CHF exacerbation , Afib with RVR at TH . patient with no history of CP with
cardiac events , only SOB. So any new SOB should be considered angina
equivalent. --CV:
1. ) [I] -- NSTEMI with enzymes trending downward. Cont'd ASA 325 , Zetia ,
Fenofibrate. Changed ARB to Captopril and titrated up to 25 mg three times a day
Will DC on orally lisinopril. Titrated BB up to metoprolol 50 four times a day , then
switched to Toprol 200 every day Cath on 4/29 showing instent thrombosis
likely 2/2 discontinuing of Plavix. Stent was restented with CYPHER DES ,
and patient was started on Integrilin drops as 18 hours , Heparin stopped. On
Plavix now. patient should remain on Plavix for likely > 3 months given history of
instent thrombosis. At the same time should also be careful for bleeding
given on ASA/Coumadin/Plavix.
2. ) [P] -- Last EF 31%. Diuresed > 2L at TH . Cont'd Lasix ( no drops ) 40
mg intravenous then orally twice a day and patient diuresed well at PUO . Repeat Echo 4/18/06
pending results. patient's exam , CXR , and sxs all resolved throughout hospital
course. May need aldosterone antagonist given failure.
3. ) [R] -- Afib with no RVR. Cont Tele. Has had some pauses up to 4
seconds ( these have not been new -- were noted years ago on holter
monitor ). May need AICD +/- biventricular PPM. This will be done as
outpt by Dr. Lorean Kadow Will also get re-eval of LV fxn in 6-8 weeks.
--PULM: patient with severe OSA. Hasn't started CPAP as outpt. Started CPAP as
inpt. patient tolerated this well. Needs to f/u with primary care physician to get CPAP at home.
--GI:ADA/low Na/low Chol diet. Replete lytes. Mg/Kcl SS. LFTs were
resolving. Likely elevated 2/2 hepatic congestion.
--RENAL: baseline Cr 1.3. given Mucomyst/Bicarb pericath. No history of CRI.
--ENDO: Held home DM meds , A1C--> 6.4 , started on basal/prandial/SS
insulin to keep BS < 110.
--NEURO/PAIN:No issues.
--PROPHY: Lovenox bridge to Coumadin.
--CODE: FULL
ADDITIONAL COMMENTS: Dear Mr. Brezee , it was a pleasure taking care of you while you were in
the hospital. As you know , you had a heart attack because your
previous stent was occluded. The interventional cardiologist restented
this vessel in the catheterization lab. Please , it is crucial that you
continue taking your medications as instructed , especially ASPIRIN and
PLAVIX. Please take these medications every day until instructed
otherwise by your doctors. Please weigh yourself daily and keep
records of your weight. If you experience worsening shortness of breath
with exertion or at rest , have chest pain , dizziness , fainting , or
swelling , please call your doctor right away or go to the emergency room.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. ) Titrate Coumadin to goal INR 2-3.
2. ) patient likely needs CPAP machine at home ( failed sleep study )
3. ) Titrate ACEi ( was previously on ARB ) as tolerated , BB ( now on Toprol
XL 200 , instead of atenolol 25 )
4. ) Likely needs re-eval of LV fxn in 6-8 meeks , AICD/PPM , consider
aldosterone antagonist.
No dictated summary
ENTERED BY: TIMPSON , JACK T. , M.D. , PH.D. ( JQ078 ) 1/16/06 @ 02
****** END OF DISCHARGE ORDERS ******
Document id: 1236
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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351667992 | PUO | 22298869 | | 6002225 | 8/27/2004 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/27/2004 Report Status: Signed
Discharge Date: 7/20/2004
ATTENDING: PERRY HAUB M.D.
DATE OF DISCHARGE: To be determined.
SERVICE: Heart Failure.
CHIEF COMPLAINT: Referred by primary care physician for
increased dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: A 63-year-old male with COPD , CABG ,
ischemic cardiomyopathy , hypertension , CRI , CAD , atrial
fibrillation , distant history of DVT , morbid obesity , presents
with three weeks of increased dyspnea on exertion despite an
increase in his Lasix dose from 80 mg twice a day to 200 mg orally
twice a day He has also had progressive fatigue and somnolence. He
denies PND , orthopnea , chest pain , recently ( one week ago ). He
had productive cough and was started on amoxicillin with some
initial improvement in his energy , but has had a continuous
decline since then. He can do his activities of daily living ,
but he gets shortness of breath when he is wheeling around in his
wheelchair. He went to his primary care physician , Dr. Tien Rester who felt that he was volume overloaded and noticed a
desaturation to 81% on room air and admitted him to the Heart
Failure Service for diuresis and optimization.
PAST MEDICAL HISTORY:
1. Ischemic cardiomyopathy.
2. Morbid obesity.
3. Chronic renal insufficiency ( baseline 1.6 to 1.9 ).
4. Gynecomastia.
5. Peripheral vascular disease.
6. Coronary artery disease.
7. Diabetes 2.
8. Venous stasis ulcer.
9. COPD.
10. Two-vessel CABG in 1995.
11. Echo in 2003 showing EF of 25% to 30%.
12. Atrial fibrillation.
13. Left leg amputation status post a diabetic ulcer.
14. Peptic ulcer disease.
15. Distant history of DVT.
16. Status post bilateral FEM-POP surgeries.
17. Chronic venous stasis ulcers.
18. History of bilateral diaphragm paralysis.
19. Echocardiogram 4/23/04 showed EF 25% to 30% , akinesis of
the inferior wall , right ventricular function was moderately
reduced , trace aortic insufficiency , mild mitral regurgitation ,
mild tricuspid regurgitation , PASP of 36 plus right atrial
pressure.
20. Hemoglobin A1c on 11/29/04 was 5.6.
ALLERGIES: Linezolid.
MEDICATIONS ON ADMISSION:
1. Lasix 180 mg orally twice a day ( increased from 120 mg twice a day on
4/13/04 ).
2. Imdur 30 mg orally every day started on 11/9/04.
3. Toprol-XL 12.5 mg orally every day.
4. Coumadin as needed for INR of 2 to 3.
5. Glipizide 10 mg orally twice a day
6. Niferex 150 mg orally every day.
7. Allopurinol 300 mg orally every day.
The following medications have been stopped recently:
1. ACE inhibitor ( for hyperkalemia ).
2. Zocor.
PHYSICAL EXAMINATION: Temperature 96.7 , pulse 95 , blood pressure
140/66 , respirations 20 , saturation 83% on room air up to 90% on
2 liters. The patient was in no apparent distress at rest , but
had mild shortness of breath with repositioning. His JVP was 13
to 14 cm. He had crackles bilaterally , one-third of the way up
his lungs. Heart was regular rate and rhythm , 2/7 left upper
sternal border murmur. Abdomen: Obese , nontender , nondistended ,
normoactive bowel sounds. He had a left below the knee
amputation , which was warm and clean. Right leg was fully
intact , but there is severe crusting of the skin of the leg from
the knee down , very swollen right foot with skin intact and no
palpable pulses.
LABORATORIES: Sodium 139 , potassium 5.7 , chloride 101 ,
bicarbonate 30 , BUN 71 , creatinine 1.7 , glucose 125. BNP was
473 , digoxin 0.8 , albumin 3.7. White blood cell count 6.2 ,
hematocrit 39.8 , platelets 122 , 000 , INR 3.0 , PTT 68.9. Chest
x-ray showed small bilateral effusions and enlarged cardiac
silhouette. EKG left bundle-branch block with no peaked T waves ,
normal sinus rhythm , T-wave inversion in I , L , V5 , V6 ( which
represent repolarization abnormality because they are asymmetric ,
consistent with LVH although it does not meet formal LVH
criteria ).
HOSPITAL COURSE:
1. Cardiovascular:
a. Ischemia: The patient had no clear evidence of ischemia , but
given his symptoms , the troponin was checked and that was
negative.
b. Pump: The patient was felt to be volume overloaded. His
admission weight was 130 kg. He was started on intravenous Lasix for
diuresis and began to diurese well putting out approximately 2 to
3 liters negative per day. He had a right heart catheterization
which showed right atrial pressure 16 , pulmonary artery pressure
of 66/26 with a mean of 42 , mean wedge pressure of 25 suggesting
high left-sided and right-sided filling pressures. Cardiac
output was 7.83 , cardiac index was 3.09 , SVR was 695 , PVR was
174. Therefore , the patient was felt to still be volume
overloaded and was diuresed further. At the time of this
dictation , his weight has dropped to 118 kg from 130 on
admission.
From the perspective of blood pressure , he was started on
hydralazine and Isordil to reduce his afterload and these were
titrated up with the goal systolic blood pressure of less than
120.
c. Rhythm: The patient had atrial fibrillation and he was kept
on Coumadin with a goal INR of 2 to 3 except when he was being
prepped for his right heart cath. He is now being restarted on
Coumadin following the cath with the goal INR of 2 to 3.
2. Pulmonary: The patient seemed to have several possible
causes for his shortness of breath including volume overload and
his underlying COPD and body habitus. An arterial blood gas was
done with 2 liters nasal cannula on 10/11/04 and this showed pH
of 7.28 , CO2 of 76 , oxygen of 67 , and bicarbonate of 37. This is
on 2 liters nasal cannula giving an A-a gradient of 16. Compared
to his prior ABG in January 2003 , which showed pH 7.43 , carbon
dioxide of 52 , and oxygen of 60 with a bicarbonate of 37. This
suggested that the patient was hypoventilating. Therefore , he
was started on BiPAP overnight and he said that his sense of
comfort of breathing improved following BiPAP. At this point , he
will be sent home on home BiPAP.
3. Chest x-ray showed small- to moderate-sized bilateral
effusions , which were confirmed on a chest CT. However , because
the patient was still volume overloaded and seemed to be
improving with diuresis , a pleural tap was not attempted.
4. Dermatological: The patient had severe skin thickening from
his lymphedema. Dermatology was consulted for proper care of his
legs. They were initially concerned that there could have been a
superimposed cellulitis and the patient was initially started on
levofloxacin; however , there do not appear to be significant
clinical evidence of cellulitis and therefore , the levofloxacin
was discontinued after two days. Dermatology made specific
recommendations for care specifically , one-quarter strength
Dakin's soaks twice a day moist-to-dry on the legs followed by
betamethasone cream and Lac-Hydrin cream mixture twice a day.
There is also an indurated plaque on the right bridge of the
patient's nose for which Dermatology performed a shave biopsy for
concern of a basal cell carcinoma versus a squamous cell
carcinoma. This showed endophytic squamous proliferation with
atypia although the basal layer was not fully represented. This
was potentially the most superficially portion of a squamous cell
carcinoma and deeper sampling was required for more definitive
diagnosis. Deeper sampling has not yet occurred at this point.
5. Urology: The patient was noted to have a blood-tinged urine
output into his Foley. Initially , this was dark red; however ,
this lightened significantly. There are also some clots evident.
The Foley was removed and the patient was able to urinate on his
own; however , his urine is still tinged with blood although it
appears to have lightened up. Further followup will be required
likely with Urology as an outpatient.
6. Endocrine: The patient has diabetes mellitus , type 2 , which
is well controlled after his recent weight loss. He was
maintained on glipizide and lispro sliding scale.
7. Renal: The patient has chronic renal insufficiency secondary
to his diabetes mellitus. We avoided contrast dye. The
patient's creatinine has not increased during the diuresis
process going from 1.7 on admission to 1.7 on 1/23/04.
The discharge medications and instructions will be dictated as an
addendum at the time of discharge.
eScription document: 5-7204665 ISSten Tel
CC: Perry Haub M.D.
Ha Ca Josemon
Ka
CC: Tien Rester M.D.
State'stro Dun Hospital
Green
Ette Ster Tul
Dictated By: TUOMALA , HERMINA
Attending: HAUB , PERRY
Dictation ID 1947305
D: 10/27/04
T: 10/27/04
Document id: 1237
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490354722 | PUO | 62050394 | | 116388 | 10/16/2000 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 10/16/2000 Report Status: Signed
Discharge Date: 6/9/2000
PRINCIPAL DIAGNOSIS: CORONARY ARTERY DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old male with
mitral regurgitation and a history of
congestive heart failure , who presents for cardiac catheterization
and a coronary artery bypass graft. He has a history of severe
coronary artery disease and insulin-dependent diabetes mellitus.
He is status post multiple previous myocardial infarctions and
presents with dyspnea on exertion over the last several months.
However , he denies any frank chest pain. The patient's cardiac
workup revealed four vessel coronary artery disease and severe
mitral regurgitation. He is preoperatively admitted to the
cardiology service for surgical planning for coronary artery bypass
grafting.
PAST MEDICAL HISTORY: Insulin-dependent diabetes mellitus;
osteomyelitis; anemia; right 5th and left
third toe amputation; peripheral vascular disease; anemia; chronic
renal insufficiency; status post laminectomy; tobacco and alcohol
use.
MEDICATIONS: Insulin , Lasix , Accupril , Digoxin , Isordil , and
aspirin.
ALLERGIES: To fish , which causes swelling.
PHYSICAL EXAMINATION: GENERAL: irish-speaking male in no acute
distress. NECK: No carotid bruits. LUNGS:
Crackles at the bases bilaterally. HEART: II/VI systolic ejection
murmur at the axilla , with a displaced of PMI. ABDOMEN: Soft ,
non-tender. EXTREMITIES: The femoral pulses are palpable
bilaterally , however , there were no palpable distal pulses. There
was no evidence of any significant varicosities. The left shin is
significant for two small eschars with a minimal rim of erythema.
His lower extremity is consistent with chronic vascular disease.
HOSPITAL COURSE: The patient was admitted for surgical planning.
Previous echocardiogram showed an ejection
fraction of 25-30% , a dilated left atrial size , 4+ MR , and moderate
TR. There was also severe hypokinesis of the inferior posterior
wall of left ventricle. Cardiac catheterization performed on
2/8 showed four vessel disease. Follow-up ABI studies were
stable with the right at 0.68 and the left at 1.61. Carotid
noninvasive studies showed no significant carotid disease to
warrant surgical evaluation.
On 7/23 , the patient was taken to the operating room , where
quadruple coronary artery bypass graft was performed , as well as a
mitral valve repair with a #26 posterior Cosgrove annuloplasty
band. The patient tolerated the procedure well and was transported
to the cardiac surgery ICU.
Postoperatively , the patient's course was significant for acute and
chronic renal insufficiency in the setting of a low ejection
fraction , congestive heart failure , and volume overload. The
patient was weaned off of epinephrine and diuresed accordingly. He
was subsequently transferred to the stepdown unit after several
days in the ICU. He continued to progress well with the additional
diuresis. His chest tubes and wires were removed without
difficulty. Radiographs showed improvement in bilateral pulmonary
edema.
On the day of discharge , the patient was stable with stable vital
signs. He was afebrile , with no significant leukocytosis. His
renal function had returned to his baseline of around 2.0.
DISCHARGE MEDICATIONS: ( 1 ) Aspirin 81 mg orally every day; ( 2 ) captopril
25 mg orally three times a day; ( 3 ) Digoxin 0.25 mg orally
every day; ( 4 ) Lasix 60 mg orally twice a day; ( 5 ) Niferex 150 mg orally twice a day;
( 6 ) Coumadin for goal INR of 2-3; ( 7 ) Lipitor 10 mg orally every day; ( 8 )
NPH 20 U subcutaneously every day before noon; ( 9 ) ibuprofen 600 mg orally every 6 hours as needed
pain.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: SYLVIA ONIELL , M.D. MB61
Attending: GENNY S. BARRETTE , M.D. ZD6
BQ422/7487
Batch: 97924 Index No. WGACVRBC97 D: 10/6
T: 10/6
CC: 1. GENNY S. BARRETTE , M.D.
Document id: 1238
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837738844 | PUO | 92204102 | | 701285 | 8/5/2001 12:00:00 a.m. | ACUTE MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 2/14/2001 Report Status: Signed
Discharge Date: 3/5/2001
PRINCIPAL DIAGNOSIS: INFERIOR MYOCARDIAL INFARCTION.
SECONDARY DIAGNOSES: 1. HYPERTENSION.
2. LEFT FRONTAL LOBE MENINGIOMA.
3. DIASTOLIC DYSFUNCTION.
HISTORY OF PRESENT ILLNESS: Ms. Olivio is a 90+ year-old woman with
a history of hypertension , prior
atrial fibrillation , who presented to the Norap Valley Hospital on
2/14/01 with shortness of breath and some chest pain lasting
several hours at home. She was brought in by her great
granddaughter and found to have ST segment elevations inferiorly on
an electrocardiogram concerning for inferior myocardial infarction.
At that point she was transferred to Pagham University Of
for emergent catheterization. In the emergency room she was
treated with Lasix , Lopressor , morphine , nitropaste , aspirin and
heparin and then sent for cardiac catheterization. Cardiac
catheterization showed a right dominant system with no left main
disease , mid left anterior descending coronary artery 80 percent
lesion , a proximal left circumflex left anterior descending
coronary artery lesion and a proximal 100 percent posterior
descending coronary artery stenosis. The posterior descending
coronary artery was intervened upon and stented to a residual
stenosis of 0 percent. The patient tolerated the procedure well
without any complications and was then transferred to the intensive
care unit for further monitoring. On admission to the coronary
care unit the patient had no complaints , including no shortness of
breath , and no chest pain. She was noted to have a right groin
hematoma for which pressure was held.
PAST MEDICAL HISTORY: Hypertension , atrial fibrillation , history
of pulmonary edema , left frontal lobe
meningioma as documented by MRI of the brain in February of 2000.
MEDICATIONS ON ADMISSION: Lasix dose unknown , atenolol 50 mg orally
every day , Zestril 10 mg per day , Isordil 10
mg three times a day and meclizine as needed
ALLERGIES: No known drug allergies.
PHYSICAL EXAM: Temperature 98 , heart rate 75 , blood pressure
140/70 , respiratory rate 16 , 94 percent on 2 liters
of oxygen. GENERAL: Awake , alert and oriented in no acute
distress. Oropharynx is clear. Crackles present bilaterally
throughout both lung fields. CARDIAC: Regular , rate and rhythm.
Normal S1 and S2. II/VI systolic murmur at the left lower sternal
border. No radiation to the neck. ABDOMEN: Soft , nontender and
nondistended. Positive bowel sounds. EXTREMITIES: No edema. 2
plus dorsalis pedis pulses bilaterally. NEUROLOGICAL: Neurologic
status intact. Nonfocal exam.
LABORATORY DATA ON ADMISSION: White blood cell count 13.6 ,
hematocrit 39 , platelets 222 , 000.
Sodium 141 , potassium 3.6 , BUN 100 , bicarbonate 26 , BUN 37 ,
creatinine 2.0 , glucose 192. physical therapy was 11 , PTT 23 , INR 0.88. CK
number one is 216 with no MB fraction done prior to transfer. CK
number two post cardiac catheterization 2577 , MB 310 , troponin
3.49.
Electrocardiogram prior to transfer showed normal sinus rhythm at
the time pre-catheterization. Rate of 75. Two millimeter ST
segment elevation in leads II , III and F.
HOSPITAL COURSE: 1. Cardiovascular: The patient was transferred
to the coronary care unit after cardiac
catheterization and right coronary artery stent for further
management. She ruled in for a myocardial infarction. Her peak CK
was 2577 with a MB fraction of 310. Troponin on admission was
3.49. She was placed on aspirin , Plavix , Lopressor , Zestril and
simvastatin. Two days after this initial catheterization on
10/10/01 , the patient was transferred to the floor and subsequently
had an episode of flash pulmonary edema and was thought to be to
diastolic dysfunction. This occurred in the context of her having
a systolic blood pressure of 200. She was then transferred back to
the coronary care unit where she had intermittent complaints of
chest pain. Electrocardiogram showed pseudo normalization of the T
waves laterally. Her CKs continued to trend down however due to
the concern of further ischemia she was placed on heparin and
brought back to the catheterization laboratory on 6/27/01 for
stenting of the left circumflex lesion. Since the second stent she
continued to do well from a cardiovascular standpoint. Her CKs
continued to trend down. An echocardiogram was done which showed
an ejection fraction of 45 percent , inferior posterior akinesis ,
moderate mitral regurgitation and moderate tricuspid regurgitation.
She was managed with aspirin , Plavix with plans to keep her on this
for one month , Zocor and Lopressor. Due to a rising creatinine
after the second catheterization her Zestril has been stopped and
she has been started on hydralazine until her creatinine
normalizes.
2. Renal: The patient has a baseline creatinine of 1.6 which
increased to 4.0 after her second catheterization. The etiology is
deemed to be contrast induced nephropathy. Her creatinine is now
improving down to 3.2 at the time of discharge. This should be
followed and her Zestril restarted at 10 mg per day and the
hydralazine stopped when the creatinine normalizes to below 2.0.
Electrolytes were stable throughout the admission.
3. Pulmonary: No active issues currently. She did have an
episode of flash pulmonary edema in the setting of high blood
pressure found to be due to diastolic dysfunction. The goal is to
control the patient's blood pressure to avoid these episodes.
There is no need for diuresis.
4. Gastrointestinal: The patient was admitted with a hematocrit
of 39 but did drop to 27 slowly during the course of the admission.
She did have guaiac positive stools while on heparin. She was
transfused a total of two units to keep her hematocrit above 30 and
for the five days prior to discharge , her hematocrit was stable at
34. The patient consumes a low fat low cholesterol diet and is on
Prilosec 20 mg every day.
5. Psychiatry/neurologic: The patient was noted to sun down at
night with episodes of confusion and agitation. A psychiatry
consult was obtained and felt that the patient's behavior was
consistent with dementia and recommended starting Zyprexa. The
patient was placed on standing Zyprexa 5 mg at night and continued
to improve on this medication. She had no episodes of agitation
after being transferred to the floor. In addition she has a
history of left frontal lobe mass which is consistent with a
meningioma. This has been noted on CT and MRI scans done in February
of 2000. Neurosurgery consult was obtained and felt that surgery
would not be a good option for this patient , in addition they did
not feel that the mass was responsible for any mental status
changes.
6. Infectious disease: The patient has a history of a positive
RPR which has not been treated previously. She is now being
treated for syphilis with benzathine penicillin 2.4 million units
times three injections. She has one injection pending which is due
on 3/5/01. In addition she has had a negative lumbar puncture
for neurologic syphilis.
DISPOSITION ON DISCHARGE: The patient is to be discharged to the
Xi Sley Ralpi Medical Center with
eventual plans to return to home.
She will also follow up with a new primary care provider , Dr. Yelena Northey at the Barbto Be Medical Center on 2/2/01.
MEDICATIONS ON DISCHARGE: Tylenol 650 mg orally every 4 hours as needed
pain , aspirin 325 mg orally every day , Colace
100 mg orally twice a day , Robitussin 15 cc orally every 4 hours as needed cough ,
hydralazine 20 mg orally four times a day Plan to stop hydralazine when
creatinine returns below 2.0 and at that time Zestril 10 mg per day
should be started. Lopressor 50 mg orally three times a day , nitroglycerin
as needed , Prilosec 20 mg orally every day , penicillin benzathine 2.4
million units intramuscular every weeks , last dose on 3/5/01. Percocet 1-2
tablets orally every 8 hours as needed osteoarthritic pain , Zocor 20 mg orally
every HS , Imdur 30 mg orally every day , Zyprexa 5 mg orally every bedtime , Plavix 75
mg orally every day times 24 days.
Dictated By: CLARETHA PLATANIA , M.D. PZ00
Attending: EARNESTINE MAE FIERMONTE , M.D. ND6
AG714/5885
Batch: 8954 Index No. T9OECI9QB1 D: 11/8/01
T: 11/8/01
cc: Yelena Northey , MD
Document id: 1239
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320197530 | PUO | 19832836 | | 052305 | 4/5/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 11/1/1992 Report Status: Signed
Discharge Date: 10/24/1992
PRINCIPAL DIAGNOSIS: 1. CORONARY ARTERY DISEASE
SECONDARY DIAGNOSES: 2. HYPETENSION
3. DYSPEPSIA
4. ADJUSTMENT DISORDER WITH ANXIETY
ID/CHIEF COMPLAINT: The patient is a 70 year old white female
status post non Q wave MI in 18 of October , with
thrombolytic therapy and cardiac risk factors of long standing
hypertension , hypercholesterolemia , and history of tobacco use , who
presents upon transfer from Abois Che Memorial Hospital with chief
complaint of post MI unstable angina.
HISTORY OF PRESENT ILLNESS: The patient has the history of
long standing hypertension and has had
chest pain in the past including at least one previous episode of
rule out MI. She was admitted on 26 of March , to Tionmark Hospital with
signs and symptoms consistent with acute MI , and apparently
received salvage therapy with intravenous Streptokinase and TPA. Limited
records are available from this hospitalization. The patient
apparently had a submax exercise tolerance test before discharge
which is reportedly unremarkable. Upon discharge from Tionmark Hospital the patient additionally did well and then had three
episodes of typical substernal chest pain with minimal exertion
that were relieved with sublingual Nitroglycerin.
On 10 of August , the patient presented to Abois Che Memorial Hospital with an
episode of heavy substernal chest pressure that was similar in
quality to her previous MI. This pain was not relieved with sublingual
Nitroglycerin. There was no associated shortness of breath ,
nausea , vomiting or diaphoresis. In the Mi Lakeield Sonme ER , she was
treated with sublingual and topical nitrates with subsequent relief of her
chest pain. Her presentation was also significant for a chest
x-ray consistent with interstitial edema. Otherwise , her
examination was unremarkable and her EKG showed no worrisome
ischemic changes. She ruled out for MI and on 21 of August , was
transferred to PUO on intravenous Heparin , intravenous Nitroglycerin , beta blockade
and aspirin. At the time of her admission , the patient was without
chest pain and denied other associated symptoms.
PAST MEDICAL HISTORY: Coronary artery disease status post MI in
18 of October , as above; long standing hypertension ,
75 pack year history of cigarette smoking , hypercholesterolemia ,
chronic dyspepsia , history of positive PPD with normal chest x-ray ,
remote history of breast cancer. PAST SURGICAL HISTORY: Status
post cholecystectomy , status post appendectomy , status post renal
stone removal , status post C. section x 3 , status post breast
lumpectomy. MEDICATIONS ON TRANSFER: intravenous Nitroglycerin at 140
micrograms per minute , intravenous Heparin drip , Lopressor , aspirin one a
day. ALLERGIES: Penicillin which causes anaphylaxis. FAMILY
HISTORY: Negative for premature cardiac disease , negative for
diabetes mellitus. SOCIAL HISTORY: Most significant for her
husband's recent diagnosis of GI malignancy which will require
inpatient admission at PUO and the recent death of a brother-in-law
at PUO .
PHYSICAL EXAMINATION: The patient is an obese white female in no
apparent distress , pleasant and cooperative.
The vital signs were temp 97.8 , pulse 48 , BP 140/60 , respirations
16 with O2 sat of 95% on O2 2 liters per minute. HEENT exam was
unremarkable. There were normal carotid upstrokes without bruit.
The chest exam showed bibasilar rales right greater than left but
otherwise the lungs were clear to auscultation , no wheezing. CV
exam showed a regular rate and rhythm with distant heart sounds ,
normal S1 and S2 , question of S4 , no appreciable murmurs. The
abdomen was obese , soft with normoactive bowel sounds. There were
previous surgical scars. No masses or hepatosplenomegaly was
noted. There were normal femoral and distal pulses , no peripheral
edema , no peripheral bruits. Neuro exam was unremarkable.
LABORATORY DATA: The admission labs showed hematocrit 34.2 , WBC
6.7 , platelets 159 , 000 , PTT 50.0 on intravenous Heparin.
Urinalysis was essentially within normal limits. Glucose was 110 ,
BUN 12 , creatinine 1.0 , sodium 142 , potassium 4.0 , chloride 106 and
bicarb 29. LFT's were all within normal limits. Admission CK was
32 , albumin 3.9 , magnesium 2.0 , uric acid 6.2 , cholesterol 186. The
chest x-ray was unavailable. EKG showed sinus bradycardia at a
rate of 50 , first degree AV block axis +60 , ST elevation in leads
V2-V4 , poor R wave progression leads V1-V3.
HOSPITAL COURSE: The patient did well over the first 24 hours of
admission. On 29 of November , the patient went to cardiac
cath. Angiogram showed 50% mid circumflex , 60% mid left anterior
descending and only luminal irregularities in the right RCA ,
anterior wall hypokinesis but overall good LV systolic function
with an EF of approximately 72%. Average pulmonary capillary wedge
pressure was 20 and right atrial pressure 9. Cardiac output was
4.5 with cardiac index of 2.5. Careful review of the cath films
showed no hemodynamically significant lesions felt to be
responsible for the patient's chest pain. Echo performed on
12 of August , showed left ventricular hypertrophy with low normal LV
systolic function , estimated EF of 50-55% , inferior posterior
hypokinesis , and trace of tricuspid and mitral regurgitation. There
was mild right ventricular hypertrophy and normal estimated
pulmonary artery pressure.
Postcatheterization , the patient showed mild hypertension which was
treated by the addition of a calcium channel blocker , and she was
also diuresed for fluid overload. Prior to discharge , she had two
additional episodes of chest pain that were low in intensity but
prolonged. Each of these required several Nitroglycerins and
antacids to be relieved. It was felt that the chest pain was
unlikely to be cardiac in origin and more likely represented either
GI symptomatology or an anxiety reaction. The patient repeatedly
expressed great concern over her husband's illness and understood
the possible connection between this and her chest pain. On 7 of August ,
the patient underwent exercise treadmill test on the modified Bruce
protocol. She went 10 minutes and 30 seconds stopping secondary to
fatigue. Maximum heart rate was 108 , maximum BP 164 systolic , no
symptoms and no EKG changes , and the test was interpreted as
showing no evidence for ischemia. The patient was discharged to
home and is to follow up at CHH .
COMPLICATIONS: None. MEDICATIONS ON DISCHARGE: Nifedipine XL 90
mg orally every am , Lopressor 50 mg orally twice a day , Zantac 150 mg orally every bedtime ,
aspirin 81 mg orally every day , Serax 15 mg orally every 6 hours or every bedtime as needed ,
Nitroglycerin 1/150 grain every 5 minutes x 3 sublingual as needed chest pain.
CONDITION ON DISCHARGE: Good. FOLLOW UP CARE: With her primary
care physician , Dr. Serena Dench , and her cardiologist , Dr. Bree Theiling , at CHH .
ES310/9785
DENISHA H. MCRORIE , M.D. XT0 D: 10/9/92
Batch: 3611 Report: Y0504V32 T: 9/17/92
Dictated By: TIEN RESTER , M.D.
cc: 1. SERENA W. DENCH , M.D.
2. BREE M. THEILING , M.D.
Document id: 1240
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707826215 | PUO | 17768471 | | 077835 | 10/14/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/14/1993 Report Status: Signed
Discharge Date: 8/27/1993
HISTORY OF PRESENT ILLNESS: Patient is a 71 year old male with
coronary artery disease status post a
coronary artery bypass graft times two now presenting with chest
pain. He has had anginal type chest pain for years , never
associated with numbness , nausea , or sweating. Usually , they were
about four times a week but three months ago , he began getting pain
four to five times a day not with any exertion. He has had
decreased exercise tolerance. He takes one to four Nitroglycerin
tablets a day. The day of admission , he felt light headed and had
subsequent substernal chest pain. He took two Nitroglycerin with
no relief and called an ambulance where he had Morphine and
Nitroglycerin with relief. This pain was non-radiating but was
associated with nausea and urge to defecate. He was not quite sure
it was same as his inferior myocardial infarction which he had in
1973. In 1980 , he had a coronary artery bypass graft and again in
1982. Catheterization in 1987 revealed that the grafts were patent
with the native vessels occluded. In 7/25 , he had an echo with
overall contraction normal , there was inferior and posterior
hypokinesis , mild anteroseptal , and diastolic dimension was judged
to be possibly global. In 1993 , he had an exercise tolerance test
consistent with but not diagnostic of ischemia. He went six
minutes and seven seconds with a pulse of 70 and a blood pressure
of 150/70 with typical chest pain. He had a thallium at the same
time and that showed mild non-transmural defect inferiorly with no
ischemia. Also on 9/2/93 , he presented with a cough and had an
abnormal chest X-Ray. He was treated with antibiotics. He denies
any recent cough , fever , chills , or sources for infection. PAST
MEDICAL HISTORY: Significant for coronary artery disease , status
post a myocardial infarction in 1973 , a coronary artery bypass
graft in 1982 , he is status post a partial gastrectomy thirty years
ago , he had a recent upper respiratory infection in 10/18 , benign
prostatic hypertrophy with four transurethral resection of the
prostate , the last being in 1990 , hypertension , pneumonia in 1976 ,
sigmoid diverticulosis , and benign polyps removed at the Clare'sry Hwall Medical Center CURRENT MEDICATIONS: Isordil Tembids four
times a day , Diltiazem 60 mg four times a day , Ativan 1 mg three
times a day , Persantine 50 three times a day , Carafate one every day before noon ,
Aspirin , and Ativan 3 mg orally every bedtime as needed ALLERGIES: He has no
known drug allergies. SOCIAL HISTORY: He is a former smoker , he
denies any use of tobacco or alcohol , he lives with his wife , and
patient is from Tole Louis Prona FAMILY HISTORY: Congestive heart disease
in his father , his mother had died at the age of 42 of cancer of
the stomach , and he has a sister and a maternal aunt who have heart
disease.
PHYSICAL EXAMINATION: He was well-developed and well-nourished in
no acute distress with a temperature of 98 ,
pulse of 60 , respirations 16 , and blood pressure 130/70. HEENT:
Pupils were equal , round , and reactive to light , extraocular
movements were intact , and pharynx was benign. NECK: Supple.
CHEST: Without wheezes or rales of the right greater than the
left. LUNGS: Clear to auscultation. CARDIAC: Examination showed
that he had a regular rate and rhythm with no murmurs , gallops , or
rubs , the apex was normal , there was no jugular venous distention ,
and carotids were 2+ with no bruits. ABDOMEN: Had normal active
bowel sounds and was soft and non-tender with no hepatomegaly.
RECTAL: Examination was deferred. NEUROLOGICAL: Examination was
completely intact.
LABORATORY EXAMINATION: Chest X-Ray revealed that he was status
post a coronary artery bypass graft with
lower lobe infiltrates bilaterally and EKG showed a rate of 50 ,
axis of 0 , intervals were normal , he had early R waves , and he had
questionable ST elevation in V2 , II , III , and F. His creatinine
was 1.4 with a BUN of 24 , glucose of 106 , sodium 138 , potassium
4.3 , chloride 99 , and bicarbonate 31. He had 190 platelets ,
hematocrit of 41 , and a white count of 5.4.
HOSPITAL COURSE: Patient was assessed as having possible chest
pain and was put on a rule out myocardial
infarction protocol. The pain was said to be atypical but it was
considered best to rule him out. He was also started on
Ceftriaxone for a possible pneumonia. He had blood cultures times
two taken which subsequently came back normal and a PA and lateral
chest X-Ray , he did not have infiltrates so that was discontinued.
He went on to rule out for a myocardial infarction and he underwent
exercise thallium on which , on a modified Bruce protocol , he went
eight minutes with a heart rate of 93 , blood pressure 150/70 with
no ischemia but chest pain without episode of mild or reversible
defect , and an anterior transmural reversible defect. Patient was
told of his condition and was started on a beta blocker per
Cardiology. In the hospital , patient developed some episodes of
chest pain with EKG normal each time. His stomach had also felt
ascitic lately. Cardiology saw him and did not feel that the pain
was cardiac with a myocardial infarction. He was placed on orally
Pepcid for ascitic stomach. Patient tolerated his Inderal he was
started on well and went to 20 mg.
DISPOSITION: Patient is discharged to home in stable condition to
follow-up with Dr. Fisch DISCHARGE MEDICATIONS:
Ativan as needed , Diltiazem 60 mg four times a day , Inderal 20 mg four
times a day , Hydrochlorothiazide 25 once a day , Aspirin , Persantine
15 three times a day , and Isordil 40 mg four times a day.
Dictated By: LOIDA GOLEBIOWSKI , M.D.
Attending: CARA NEVA KENEKHAM , M.D. WA5
GQ536/8137
Batch: 3579 Index No. ZPZG5W4O0J D: 2/7/94
T: 6/19/94
Document id: 1241
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
Y |
U |
U |
Y |
U |
U |
U |
Y |
Y |
U |
U |
- |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
Y |
N |
N |
Y |
N |
N |
N |
Y |
Y |
N |
N |
- |
N |
N |
- |
719243531 | PUO | 24802754 | | 697904 | 2/5/1999 12:00:00 a.m. | RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 2/5/1999 Report Status: Signed
Discharge Date: 4/15/1999
PRINCIPAL DIAGNOSIS: UNSTABLE ANGINA.
SECONDARY DIAGNOSES:
1. INSULIN-DEPENDENT DIABETES MELLITUS FOR 30 YEARS.
2. HYPERLIPIDEMIA.
3. HYPERTENSION.
4. CORONARY ARTERY DISEASE.
5. STATUS POST RIGHT CORONARY ARTERY STENT PLACEMENT IN THE LEFT
CIRCUMFLEX AND THE OBTUSE MARGINAL ARTERIES IN 1997.
6. TOTAL BLINDNESS X2 YEARS.
HISTORY OF PRESENT ILLNESS: Mrs. Magdalene Reine is a 63 year
old woman with cardiac risk factors
including hypertension , insulin-dependent diabetes mellitus x30
years , elevated cholesterol , known coronary artery disease status
post MI , who presented with 1 1/2 hours of chest pain. This chest
pain began at approximately 9:30 a.m. while the patient was
awaiting her ride to the center for the blind , where she spends
most of her mornings and afternoon. The patient began as a dull
ache substernal in location , described as a squeezing sensation
similar to her past angina , but less strong than the angina she had
had last week before coming to the I Warho Hospital . The
patient described this as 4/10 chest pain. She also had shortness
of breath , diaphoresis , and wrist tingling on the left. The
patient took one sublingual nitro at home with some relief , but the
pain came back as she walking around her home looking for her
hospital identification care. She had worsening of the pain with
exercise. She sat down and her visiting nurse gave her two more
sublingual nitroglycerin with some relief of pain and called the
ambulance. In the ambulance , the patient continued to have the
pain and she received one more sublingual nitroglycerin and nasal
cannula oxygen. The pain was gone upon arrival to I Warho Hospital In the Emergency Department , the patient was found to be
afebrile with heart rate in the high 90s , BP 200s/100s. EKG with
questionable changes compared to old , showing normal sinus rhythm
to leftward axis and LVH. For her elevated heart rate and blood
pressure , the patient received 5 mg of intravenous Lopressor and 20 mg of
labetalol in the Emergency Department and was started on heparin.
ALLERGIES: No known drug allergies.
MEDICATIONS: Zocor 40 mg orally every day; NPH 25 U subcutaneously every day before noon;
Regular insulin 15 U subcutaneously every day before noon; captopril 37.5 mg
orally three times a day; Lopressor 50 mg orally three times a day; Imdur 60 mg orally every day;
ECASA 325 mg orally every day; Adalat CC 30 mg orally every day before noon
SOCIAL HISTORY: The patient was born in Mongbock A Ven and immigrated to
the Sonan Palm Etteaeans in 1968. The patient formerly
worked as a nurses aide at Bussadd Southrys Community Hospital . The patient lives
with her son and his wife , and their four children. The patient
has never smoked and does not drink.
PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 73 , BP 93/51 ,
oxygen saturation 98% on room air , and was
afebrile when she arrived on the floor. GENERAL: The patient was
alert and in no acute distress , and as previously noted , the
patient is blind. HEENT: An atrophic right eye with two palpable
recoiled muscles in the upper and lower palpebral margin. Her left
eye is mobile , but has a clouded pupil area. She does not blink to
threat. CHEST: Clear to auscultation bilaterally. NECK: Her
jugular venous pressure was not elevated. HEART: Regular rate and
rhythm , with audible S1 , S2 , no murmur , rubs , or gallops were
appreciated. ABDOMEN: Soft , mildly obese , non-tender ,
non-distended. The patient had audible bowel sounds. EXTREMITIES:
No clubbing or cyanosis. She has trace edema in the lower
extremities , good pulses bilaterally in her lower extremities and
in her upper extremities. NEURO: Grossly intact , except for her
visual exam. SKIN: No rashes , warm , and dry.
LABORATORY DATA: Initial labs when the patient arrived included a
normal Chem-7. CBC that was normal , including a
white blood cell count 8 , hematocrit 41.3 , platelets 254 , with 52
polys , 33 lymphs , and 0 bands on her differential. Coags - physical therapy
19.9 , INR 0.8. Initial CK 251 , initial troponin 1.26.
HOSPITAL COURSE: Initial questioning of the patient revealed that
she had actually been admitted less than two
weeks earlier with similar syndrome of chest pain , though as the
patient describes , worse two weeks previously. At that point , the
patient had had a modified Bruce protocol with duration of the test
5 minutes 12 seconds , with 63% of heart rate achieved. The patient
had stopped secondary to chest pain and had had ST-T wave segment
abnormalities , with 1 mm ST segment depressions in inferior leads
and angina. The test was interpreted as being highly predictive of
significant coronary disease. However , at that time , the patient
refused catheterization and decided on medical management for this
anginal pain. However , with the return of this pain and her return
admission to the hospital , the patient made the decision that she
would be catheterized and she was placed on this schedule. Other
initial interventions , other than what was done in the Emergency
Room , which included maximizing blood pressure and heart rate
management with Lopressor. The patient was continued on her daily
aspirin and Zocor. The patient was ruled out for a MI. The
patient's cholesterol and lipids were checked , and an initial
echocardiogram was also obtained on the patient. That echo done on
4/23/99 in the morning revealed overall normal left ventricular
size with preserved systolic function , an estimated ejection
fraction of 60% , and hypokinesis of inferior posterior wall and
septum. The mitral valve was minimally thickened with minimal
mitral regurgitation. There was no significant aortic or tricuspid
valve regurgitation or dysfunction. There was normal right
ventricular size and function. There was no evidence of
pericardial effusion. The left ventricle was thought to be
moderate to severely hypertrophied. However , the inferior
posterior walls were less hypertrophied than other areas. The
patient had one episode of chest pain over the weekend as her cath
was planned for Monday morning. This chest pain occurred on
4/23/99 , again of elevated blood pressure 200/107. It was
relieved by increasing her intravenous TNG drip to 7.5 mg , intravenous Lopressor , and
three sublingual nitroglycerins. The patient had no EKG changes ,
and had no other chest pain over the weekend. The patient was
continued on heparin , intravenous TNG , aspirin , and captopril. Over the
week , her Lopressor was increased to 37.5 mg three times a day for better beta
blockade. The patient also had her dose of NPH adjusted to half
her regular dose , as she was having low blood sugars.
The patient's catheterization ultimately was 2/11/99. Findings
included a clean left main coronary artery , a LAD with luminal
irregularities , small vessel in general , and a T1 with about 60%
stenosis , also small vessel , and circumflex with about 70% mid
stenosis. The RCA , where her past stents had been placed , was
completely occluded , which was ballooned and a brief examination of
the abdominal aorta for renal artery stenosis revealed no evidence
of renal artery stenosis. Thus , no stents were placed , but the
patient's old stents were ballooned open with good achieved flow
and 40% residual after ballooning. The patient continued to do
well the day post-cath and ultimately was sent home the following
morning with follow-up with her cardiologist , Dr. Gilcreast
DISCHARGE MEDICATIONS: ECASA 325 mg orally every day; captopril 37.5 mg
orally three times a day; NPH 25 U subcutaneously every day before noon;
Regular 15 U subcutaneously every day before noon; nitroglycerin 1/150 sublingual 1 tab orally every 5
minutes x3 as needed for chest pain; Zocor 40 mg orally every day; Imdur
60 mg orally every day; Adalat CC 30 mg orally every day before noon; Lopressor 50 mg orally
three times a day
DISCHARGE FOLLOW-UP: The patient will follow-up with her
cardiologist , Dr. Laskey in 1-2 weeks.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE DISPOSITION: The patient was discharged to home.
Dictated By: ROSSIE MANKOSKI , M.D. IS35
Attending: LEOLA C. MUSICH , M.D. VG64
KZ433/6673
Batch: 02884 Index No. SSMW6PHBZ D: 10/15/99
T: 11/5/99
CC: 1. LEOLA C. MUSICH , M.D.
2. SOMER R. LASKEY , M.D.
Document id: 1242
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
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- |
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540474571 | PUO | 37597077 | | 8231346 | 2/8/2006 12:00:00 a.m. | Left leg pain , hypocalcemia | | DIS | Admission Date: 2/8/2006 Report Status:
Discharge Date: 2/25/2006
****** FINAL DISCHARGE ORDERS ******
ARNE , LIBERTY 519-33-20-1
Juan T Eversa
Service: MED
DISCHARGE PATIENT ON: 6/10/06 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: ABSHEAR , CARLTON J. , M.D.
CODE STATUS:
No CPR , No defib , No intubation , No pressors
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
CALCIUM CARBONATE 1 , 500 MG ( 600 MG ELEM CA )/ VIT D 200 IU
1 TAB orally twice a day
ACETYLSALICYLIC ACID 81 MG orally DAILY
CALCITRIOL 0.5 MCG orally DAILY
PHOSLO ( CALCIUM ACETATE ( 1 GELCAP=667 MG ) )
1 , 334 MG orally three times a day
Number of Doses Required ( approximate ): 4
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
LASIX ( FUROSEMIDE ) 40 MG orally DAILY
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
25 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 2
NEPHROCAPS ( NEPHRO-VIT RX ) 1 TAB orally DAILY
Override Notice: Override added on 1/3/06 by CISTRUNK , EDGARDO JUAN , M.D. , PH.D.
on order for SIMVASTATIN orally ( ref # 003900168 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: md aware
SIMVASTATIN 10 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 1/3/06 by CISTRUNK , EDGARDO JUAN , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: md aware
DIET: No Restrictions
ACTIVITY: Partial weight-bearing
FOLLOW UP APPOINTMENT( S ):
Orthopedic clinic. Call 891-726-4063 on 11/9/06 ,
Dr. Shavonne Mainer Please followup with your Primary Provider in 1-2 weeks after discharge. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Left fibula/tibia fracture.
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Left leg pain , hypocalcemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) CHF ( congestive heart failure ) CRF
( chronic renal dysfunction ) HTN
( hypertension ) DM ( diabetes mellitus type 2 ) hypocalcemia
chronic anemia ( anemia ) vitamin D deficiency ( vitamin D deficiency )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
CC: The patient was brought to the PUO ED by her daughter with the chief
complaint of left leg pain. They were concerned about the healing of her
left fibula/tibia fracture.
---
HPI: The patient is a 72-year-old woman with CAD history of CABG , chronic kidney
disease ( declined HD ) , congestive heart failure ( EF 30% ) , HTN , and
hypocalcemia. She has also been hospitalized numerous times in the past
two years for CHF exacerbations in the setting of NSTEMI. She has
preferred not to take any of her prescribed medications despite repeated
discussions about benefits of decreased mortality , prevention of
re-hospitalization , and symptom management. In April 2006 she sustained a
displaced LLE tib/fib fx after banging her leg into her bed while driving
her motorized scooter in her apartment. She has been treated by Dr.
Verna Eckloff at PUO . She initally refused surgical repair and was
casted , but subsequent films have shown valgus angulation and poor
healing. She declined surgery ( and was a high-risk surgical candidate
given her multiple comorbidities. On 11/27/06 the cast was removed by
Dr. Ibey and has been in a walking boot since then. She states that
she has pain of the left midleg that she has treated with Tylenol and
that has limited her ability to try and bear weight.
Her daughter brings her in today because of concern for her mother's left
leg. The air cast was taken off yesterday and since then , she has had
worsening pain of the leg. She has been unable to move it or bear any
wait. There is a valgus deformity. They are requesting orthopedic
evaluation. She denies new numbness/tingling or weakness in the
extremities. She also notes multiple chronic problems including
decreased appetite with 40lb weight loss over the past 4-6 months ,
lethargy , apathy. "I just want to be able to walk again and do the
things I used to like doing." ( Going to the horse track , walking
outside. ) She states that she is NOT depressed but sleeps most of the
day.
The family has discussed these symptoms with her primary care physician. In the past ,
symptoms have been attributed to her worsening renal failure , cardiac
status in this patient who refuses to take any medications. She has
wanted to remain home yet has had documented discussions with primary care physician about
the benefits of placement to a nursing home for longterm care. Family is
currently looking into assisted living facilities. She also has
requested DNR/DNI status in the past.
PAST MEDICAL HISTORY:
1. Coronary artery disease: history of IMI and 2-V-CABG , July of 2001
( LIMA>LAD , SVG>PDA. ) Her anginal equivalents are N/V but not CP. She is
followed by a cardiologist , Dr. Branden Hopkinson at KAAH . She is uninterested
in pursuing any additional cardiac evaluation.
2. CHF with EF 26% ( 5/25 ). Mod-Severe MR. Several exacerbations over
past yr. in setting of NSTEMI ( 3/22 )
3. Hypertension.
4. Diabetes mellitus type 2 , non-insulin requiring. Her most recent
hemoglobin A1c was less than 6% without medications. Her diabetic
complications include peripheral neuropathy and chronic kidney disease.
5. Chronic kidney disease 2/2 DM with a baseline creatinine of 3.5 to 4.
She has no interest in hemodialysis.
6. Hypocalcemia secondary to chronic kidney disease and profound vitamin
D deficiency with an associated myopathy and bone pain. She also has
severe secondary hyperparathyroidism.
7. History of colon cancer status post a partial colectomy. The patient
has requested no follow-up for this problem.
8. Osteoarthritis status post a left total hip replacement for aseptic
necrosis. Since that time she has a leg length discrepancy and uses
crutches to ambulate until a recent tib/fib fx which has left her
WC-dependent.
9. Chronic anemia secondary to chronic kidney disease. She does have a
history of prior upper GI bleeding secondary to peptic ulcer disease.
ROS: No recent fevers/chills or night sweats. No shortness of breath ,
cough or chest pain. No abdominal pain. No constipation/diarrhea. No
dysuria. Denies numbness or tingling in extremities.
ALLERGIES: NKDA
MEDS: SHE STATES THAT SHE CURRENTLY IS NOT TAKING ANY MEDICINES. THE
FOLLOWING ARE MEDICATIONS THAT ARE PRESCRIBED TO HER:
aspirin 81 mg orally qdcalcitriol 0.5mcg orally qdcalcium carbonate 500mg orally
tidLasix 40 mg orally qdLifeline personal help Nephrocaps 1 tab orally
qdnitroglycerin transdermal patch 0.2mg/heart rate transdermal every 24 hours Toprol XL
25 mg orally qdZocor 10mg orally every bedtime
Social Hx: Lives alone. Gets VNA and PCA. Has been using wheelchair to
ambulate. Has 3 kids ( 2 daughters and son. )
Tobacco: Remote
Etoh :None
Physical Exam:
VS T 96.8 BP 130/80 HR 75 RR 16 Pulsox 100% RA
General: NAD. Poor eye contact , looking down often. Pale.
HEENT: EOM full. Sclerae anicteric. OP without erythema/thrush. No
thyromegaly. No cervical , supraclav lymphadenopathy.
CV: RRR , S1 , S2 , 2/6 HSM at apex. no carotid bruits. JVP + 14cm.
Chest: Crackles halfway up bilaterally. No wheezes.
Abd: Soft. Nontender , nondistended. Liver edge smooth. Palpated on
inspiration to descend 2cm below CM
Extrem: RLE with multiple hyperpigmented nodules with superficial
excoriations. LLE dry with cracked/flaking skin. Foot is edematous.
Leg appears to have varus deformity. Left foot is edematous. There is a
band of constriction where bandage was wrapped. Sensation intact to
light touch bilaterally. Pain elicited on movement of left leg. Cannot
logroll left leg due to pain in tibia that is elicited.
Neuro: Aox3. CN II-XII nl. 5/5 strength in UE. LLE 5/5. RLE 4/5
ankle dorsi/plantarflex. No asterixis.
Labs:
Na 140/K 4.6/ Cl108/ Co2 22/ BUN 59/Cr 4.0/GLU 164
Mg 2.0/ Ca 5.6/ IoCa Unsat/
WBC 4.01/HCT 36.6/PLT 167. MCV 83.4 RDW 16.6
PTT 27.1/ INR 1.2
LFT's: P
EKG: SR with first degree AVB. Q's in II , III , avF. No change from prior.
CXR: Cardiomegaly. No evidence edema or infiltrate.
Pain film of left leg: Transverse fractures through the mid tibia and
fibula diaphysis with mild medial displacement , and valgus and
anterior angulation , unchanged.
_________________________________________
IMPRESSION:
72F with multiple chronic medical problems history of recent tib/fib fx
( non-surg mgmt ) admitted for evaluation of her fracture. She was admitted
to medicine for "longterm placement." Yet upon interview of the family
they intend for Ms. Arne to go home after this hospital stay. From
there , she will transition to assisted living. Over the last few months ,
she has declined to take any medications or treatment for her chronic
kidney disease or cardiac disease. This has led to progressive renal
disease , electrolyte abnormalities and myopathy. The family brings her
in with concerns regarding her left leg. While they do want to
transition to assisted living , they do not intend to place her directly
from PUO to VLH or Rehab. They hope she will go home after this hospital
stay and continue with VNA/services.
ORTHO: Tib/fib fracture. Non-surgically managed. Followed by Dr.
Cariaga Seen by Orthopedic service who discussed the 2 options:
casting with patellar tendon bearing cast or surgery. As before ,
patient declined surgery ( this decision has been supported by her primary care physician and
cardiologist as she is a high risk surgical candidate. ) There were no
casting technicians in-house this weekend. Therefore she will followup in
the Orthopedics clinic on Wednesday , as instructed by the ortho resident
on call.
.
CKD. Monitor renal function and lytes. Patient agreed to take vitamin
supplements such as nephrocaps. Phosphate was wnl despite not taking
phoslo at home.
.
CHRONIC HYPOCALCEMIA: Elevated PTH. Patient agreed to take calcitriol
.
ENDOCRINE: recent elevated TSH. T3/T4 pending at discharge.
-H/o Diabetes yet with progressive renal failure , does not require
insulin and with nl A1C
.
CV: EF 30% , multiple prior admits for CHF. Was in NOT in CHF on admission
and had stable O2 saturation at 98-100% on RA with no recent increase in
DOE.
.
FEN: House diet. Needs nutritional supplements/boost. Nephrocaps.
DISPO: screen for assisted living.
-physical therapy consult
-SW consult
.
PROPH: Heparin three times a day. Nexium ( has history of esophagitis. )
.
CODE: Has been DNR/DNI in past. Daughter wants to discuss further with
mother. Will discuss tomorrow.
HC proxy: Faustina Krishnan 497-508-1669 ( cell )
ADDITIONAL COMMENTS: No changes were made to your medications. We strongly advise you to take
the medications that your cardiologist and primary care doctor have
prescribed.
.
You were seen by the Orthopedic Surgery service while you were in
hospital and the recommendation is that you are fitted for a special cast
called a "patellar tendon bearing cast."
.
Please contact the Orthopedics Clinic first thing on Tuesday a.m.
572-383-6109. They will arrange for you to see Dr. Rorrer on
Wednesday for casting.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: WALTERS , ELIZABET C , MD ( FX647 ) 6/10/06 @ 03
****** END OF DISCHARGE ORDERS ******
Document id: 1243
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
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| output/system_intuitive_annotation.xml | intuitive |
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488848876 | PUO | 10837947 | | 478802 | 9/18/2002 12:00:00 a.m. | dyspnea | | DIS | Admission Date: 10/12/2002 Report Status:
Discharge Date: 10/12/2002
****** DISCHARGE ORDERS ******
STRAWN , DILLON 905-64-61-7
Ette
Service: MED
DISCHARGE PATIENT ON: 9/14/02 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DEPSKY , GWYNETH ALMEDA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
BABY ASPIRIN ( ACETYLSALICYLIC ACID ( CHILDREN'S ) )
81 MG orally every day
ALBUTEROL NEBULIZER 2.5 MG NEB every 4 hours as needed dyspnea
LASIX ( FUROSEMIDE ) 60 MG orally every day Starting Today ( 6/22 )
Alert overridden: Override added on 9/14/02 by
VERASTEQUI , BERNIE KAI , M.D.
POTENTIALLY SERIOUS INTERACTION: DILTIAZEM HCL & FUROSEMIDE
Reason for override: patient will be monitored
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 60 UNITS subcutaneously twice a day
INSULIN REGULAR HUMAN 30 UNITS subcutaneously twice a day
RANITIDINE HCL 150 MG orally twice a day
K-DUR ( KCL SLOW RELEASE ) 10 MEQ X 1 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LOSARTAN 100 MG orally every day
Number of Doses Required ( approximate ): 10
LIPITOR ( ATORVASTATIN ) 30 MG orally every day
Alert overridden: Override added on 9/14/02 by :
DEFINITE ALLERGY ( OR SENSITIVITY ) to HMG CoA REDUCTASE
INHIBITORS Reason for override:
patient is on this drug as an outpt.
CARDIZEM CD ( DILTIAZEM CD ) 300 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Alert overridden: Override added on 9/14/02 by :
POTENTIALLY SERIOUS INTERACTION: FUROSEMIDE & DILTIAZEM HCL
Reason for override: patient is on med as an outpt
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: IN 3 DAYS
FOLLOW UP APPOINTMENT( S ):
Primary care doctor- Please call for appt. ,
ALLERGY: Latex , Lovastatin , Enalapril maleate , Codeine ,
Penicillins , Pravachol ( pravastatin ) ,
Levamisole ( levamisole hcl )
ADMIT DIAGNOSIS:
dyspnea
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
dyspnea
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes ( diabetes mellitus ) CHF ( congestive heart failure ) HTN
( hypertension )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
50 year-old female with multiple medical problems
including obesity , IDDM , hypercholesterolemia , hypertension , sleep
apnea presents with worsening SOB x 1 month. She reports that
following a pneumonia about 1 year ago , she has
felt progressively short of breath. Over the
past month , her symptoms have become
incerasingly bothersome , interfering with her ability to
talk , walk , and exert herself. She denies
fever/chills/ chest pain/palpitations/PND , but does report
4 pillow orthopnea ( increased from 2 ) , nocturia
( at baseline ). She presented to her pulmonologist
5/6 who felt that her lung disease was
most consistent with restrictive lung disease due
to her obesity. She presented to her allergist
3 days PTA , who felt that she had a CXR
consistent with CHF and increased her lasix to 100 qdx 3 days
with some effect. She presented to her primary care physician on the
day of admission and was noted to have a decreased
O2 sat; she was sent to PUO for further evaluation.
Of note , she has many allergies , including latex , was a 1.5 ppd smoker
x 30 years , quit one and a half years ago , and has recently started a
weight loss program , losing 22 pounds in 3
months. In the ED , she was given aspirin ,
solumedrol , nebs , and ativan with some relief. Pertinent exam
findings: markedly obese , labored breathing at times , but speaking
in full sentences. No JVD. Lungs: rare wheezes , few crackles at
bases , no signs of consolidation. CV: distant , RRR , S1 S2
Abd: soft , obese Ext: trace edema , WWP , no calf tenderness. A/P: Pulm:
Likely restrictive component due to obesity as well as deconditioning ,
likely anxiety component as well as possible pulmonary hypertension due
to sleep apnea , smoking hx. Subjectively , acute exacerbation of sx may
also be related to heat/humidity. Nebs for comfort , but primary goal
is for increased cardiopulmonary fitness , weight loss. CPAP for sleep
apnea as well. Outpatient pulmonary rehab. O2 sat 97% on RA with
ambulation prior to d/c. Symptoms improved. CV: continue cardiac
meds , lipid lowering agents. ID: no infectious etiology/sx Endo: Type 2
DM- continue current regimen. Sent HgbA1C.
patient was discharged home in stable condition she will follow up with her
primary care doctor.
ADDITIONAL COMMENTS: If you have chest pain , increasing shortness of breath , headache ,
fever , or other worrisome symptoms , please call your doctor or return
to the hospital.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
If you do not get your CPAP machine prior to d/c , please obtain one as
an outpatient.
No dictated summary
ENTERED BY: VERASTEQUI , BERNIE KAI , M.D. ( MU36 ) 9/14/02 @ 12
****** END OF DISCHARGE ORDERS ******
Document id: 1244
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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856450649 | PUO | 99098383 | | 9804773 | 10/9/2004 12:00:00 a.m. | Congestive heart failure | | DIS | Admission Date: 1/17/2004 Report Status:
Discharge Date: 9/3/2004
****** DISCHARGE ORDERS ******
CUBETA , LEOLA T 685-91-92-4
Oven Nassrockpeakebi Fay
Service: MED
DISCHARGE PATIENT ON: 1/21/04 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: CADOFF , LINDY S. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 150 MG orally every day
Alert overridden: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
METROGEL 0.75% ( METRONIDAZOLE ) TOPICAL TP twice a day
Instructions: apply to affected area per wife/patient
Alert overridden: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
SERIOUS INTERACTION: WARFARIN & METRONIDAZOLE , TOPICAL
Reason for override: aware
Number of Doses Required ( approximate ): 3
PREDNISONE Taper orally Give 60 mg every 24 hours X 1 dose( s ) , then
Give 40 mg every 24 hours X 1 dose( s ) , then
Give 30 mg every 24 hours X 1 dose( s ) , then
Give 20 mg every 24 hours X 1 dose( s ) , then
Give 10 mg every 24 hours X 1 dose( s ) , then
Starting ON 3/5/04 ( 2/15 )
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
2 PACKET orally twice a day
TERAZOSIN HCL 2 MG orally every bedtime
Number of Doses Required ( approximate ): 2
TRAZODONE 50 MG orally every bedtime
COUMADIN ( WARFARIN SODIUM ) 5 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time ) ( 8/25 )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
on order for METROGEL 0.75% TP ( ref # 71684717 )
SERIOUS INTERACTION: WARFARIN & METRONIDAZOLE , TOPICAL
Reason for override: aware Previous override information:
Override added on 2/22/04 by BIRDETTE , KATHARYN Z. , M.D. , PH.D.
on order for ALLOPURINOL orally ( ref # 40800988 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware
TRAMADOL 75 GM orally every day before noon
Override Notice: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
on order for CELEXA orally ( ref # 49722674 )
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & CITALOPRAM
HYDROBROMIDE Reason for override: aware
Number of Doses Required ( approximate ): 4
TRAMADOL 150 MG orally 2pm
Override Notice: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
on order for CELEXA orally ( ref # 49722674 )
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & CITALOPRAM
HYDROBROMIDE Reason for override: aware
Number of Doses Required ( approximate ): 3
TRAMADOL 75 MG orally every afternoon
Override Notice: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
on order for CELEXA orally ( ref # 49722674 )
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & CITALOPRAM
HYDROBROMIDE Reason for override: aware
Number of Doses Required ( approximate ): 3
TORSEMIDE 80 MG orally every day Starting Today ( 8/25 )
CELEXA ( CITALOPRAM ) 40 MG orally every day
Alert overridden: Override added on 2/22/04 by
BIRDETTE , KATHARYN Z. , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & CITALOPRAM
HYDROBROMIDE
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & CITALOPRAM
HYDROBROMIDE
POTENTIALLY SERIOUS INTERACTION: TRAMADOL HCL & CITALOPRAM
HYDROBROMIDE Reason for override: aware
COMBIVENT ( IPRATROPIUM AND ALBUTEROL SULFATE )
2 PUFF inhaled four times a day
SEREVENT DISKUS ( SALMETEROL DISKUS ) 2 PUFF inhaled twice a day
POLLYSACCHARIDE IRON 150 % orally every day
PRILOSEC ( OMEPRAZOLE ) 40 MG orally every day
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Hallman 1wk ,
Arrange INR to be drawn on 2/12/04 with f/u INR's to be drawn every
4 days. INR's will be followed by primary care physician Dr. Hallman
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Congestive heart failure
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Congestive heart failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Morbid Obesitiy atrial fibrilation ( atrial fibrillation ) anxiety
( anxiety ) depression ( depression ) sleep apnea ( sleep
apnea ) copd ( chronic obstructive pulmonary disease ) chf ( congestive
heart failure ) gout ( gout ) anemia ( anemia ) osteoarthritis
( osteoarthritis ) pancreatitis ( pancreatitis )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Electrocardiogram
Chest X-ray
BRIEF RESUME OF HOSPITAL COURSE:
64M c CHF , morbid obesity and sequelae p/with gradual increasing SOB and
malaise times 10d. patient has hx of asthma dx this year , has sleep apnea ,
hx of empyema , A-fib , and CHF. At baseline he uses 2L of O2 at home
and CPAP at night. With humid days , he normally has SOB , and ~10d ago
the humidity precipitated SOB which has not resolved. He reports
increased wheezing and an occasional cough and brown sputum production
during this time. He was given azithromycin by primary care physician that helped. He
denies LEE ( usu sx of CHF exas ) , f/c , n/v. Also reports increasing
incontinence. Denies CP
Admission Data:
VS 96.6 60 120/67 94% on 3LNC
NAD , A&O
Irreg rhythm , 2/6 holosystolic M rad to axilla
LUNGS:distant occas dep crackles
ABD Obese , NTND , some dependent Edema
Ext: chronic stasis changes. Warmth R>L ( slightly ) , ruptured blister of
R great toe , healing wound of L 2nd toe , healing lesions at L upper
thigh.
LABS: BNP 204 , TNI <assay , Ddimer 568 , INR 2.3 , WBC 6.8
Assessment: 64M c morbid obesity and SOB from mild CHF exacerbation vs
COPD exacerbation.
---HOSPITAL COURSE---
1 )CV: Pump: CXR/PE difficult to interpret given habitus. CHF may be
exacerbated 2/2 concurrent URI/COPD. patient with mild dependent edema ,
therefore patient was diuresed with his outpatient torsemide and intravenous lasix.
He diuresed approximately 2L while in house and noted improved ease of
breathing. On discharge , his torsemide was increased to 80mg twice a day. patient
should f/u for repeat echocardiogram as an outpt.
Rhythm: NSR on admission , hx of A-Fib , cont coumadin
Ischemia: no acute issues , enzymes negative.
2 )Pulm: possible COPD exas , though no clear hx of COPD and only
recently dx c asthma. Will cont treatment in ED with short course
steroids. q6nebs while in house. Doxycycline for 7 day course given
recent use of azithromycin and interaction of levofloxacin and
coumadin. patient felt at his baseline on d/c.
3 )ID: Pneumonia unlikely possible PNA , though no focal infiltrates on
portable CXR.
4 )PPX: on coumadin
5 )GI: patient states that he has appt for bariatric surgery evaluation in
Che Hamp Ter on 2/17
FULL CODE
ADDITIONAL COMMENTS: Please followup with Dr. Hallman in 1 week for rechecking of electrolytes
with new torsemide dose.
PLease taper steroids as instructed
Please take doxycycline for 5 more days
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Followup c primary care physician in one week for electrolytes
Echocardiogram as an outpt to eval change in cardiac function
Steroid taper
Doxycycline for 7days
Increase torsemide to 80BID
No dictated summary
ENTERED BY: BIRDETTE , KATHARYN Z. , M.D. , PH.D. ( BG51 ) 1/21/04 @ 01
****** END OF DISCHARGE ORDERS ******
Document id: 1245
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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040283740 | PUO | 93385970 | | 265793 | 6/9/1998 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 7/20/1998 Report Status: Signed
Discharge Date: 9/12/1998
ADMISSION DIAGNOSIS: CORONARY ARTERY DISEASE.
OPERATIVE PROCEDURE: Reop coronary artery bypass graft x two
via left thoracotomy and left radial artery
harvest - 20 of May
HISTORY OF PRESENT ILLNESS: Mr. Sterle is a 55 year old man with
premature coronary artery disease and
an angioplasty in 1981 and coronary artery bypass graft x two in
1988 who presented in October of 1998 with unstable angina.
Cardiac catheterization on August , 1998 revealed an occluded
proximal left anterior descending , 80% diagonal 1 stenosis , left
circumflex with luminal irregularities and a proximal right
coronary artery occlusion. The left internal mammary artery to the
left anterior descending artery was patent , but the saphenous vein
graft to the right coronary artery had slow flow with narrowed
distal vessels. Medical management was attempted without success.
Repeat catheterization on 21 of September for attempted angioplasty was
unsuccessful.
PAST MEDICAL HISTORY: Coronary artery bypass graft in 1988 ,
pyloric stenosis surgery as an infant , and
T&A.
ALLERGIES: No known drug allergies.
MEDICATIONS: Atenolol 25 mg once daily , Isosorbide 30 mg twice
daily , simvastatin 10 mg once daily , aspirin 1 tablet
once daily.
SOCIAL HISTORY: Smoking history of 1/2 pack per day for 10-12
years 20 years ago. Drinks 2-3 beers
occasionally. He is on a low fat diet. He is divorced with four
children and three grandchildren. He lives with his daughter
currently.
PHYSICAL EXAMINATION: He is afebrile , pulse 76 and regular ,
blood pressure 140/90. No jaundice , no
anemia , no cyanosis , no clubbing , no pedal edema. Neck is supple
with no carotid bruits. Lungs are clear to auscultation. Heart
with normal heart sounds , no murmur. Abdomen is obese , nontender ,
with normal bowel sounds. Well healed median sternotomy scar. All
peripheral pulses palpable. Allen's test negative on right via
pulse oximetry.
LABORATORY EVALUATION: Sodium 141 , potassium 4.5 , chloride 102 ,
CO2 30 , BUN 17 , creatinine 0.9 , glucose 76.
White count 7.2 , hematocrit 37 , platelets 221. INR 0.9 , physical therapy 11 , PTT
23. Chest x-ray normal. EKG revealed sinus rhythm at 58.
HOSPITAL COURSE: He was taken to the operating room and underwent
coronary artery bypass graft x two via left
thoracotomy using saphenous vein graft to the obtuse marginal and
left radial artery to 1st diagonal. The cardiopulmonary bypass
time was 111 minutes and this was done under hyperthermia and
fibrillation. No crossclamp was used. Postoperatively , he
was transferred to the Intensive Care Unit where he was extubated
on postoperative day one and transferred to the floor on the same
evening. He required a PCA for pain control. The remainder of his
postoperative period was uneventful and he made slow but steady
progress and is being discharged home in stable condition on
postoperative day five. His discharge temperature was 99.2 and 78
in sinus rhythm , 114/83 , room air saturation of 95%. His weight
was below preop weight by 2.3 kg. Chest x-ray on discharge showed
an elevated left hemidiaphragm with a small left effusion.
Discharge laboratory data included a sodium of 133 , potassium 3.8 ,
chloride 97 , CO2 30 , BUN 16 , creatinine 0.8 , glucose 92. White
count 6.8 , hematocrit 29.3 and platelets 236.
DISCHARGE DISPOSITION: Home with services. Low cholesterol , low
saturated fat diet , activity as tolerated.
Followup appointment with Dr. Huitron in six weeks , cardiologist in
two weeks. These appointments need to be scheduled.
DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg once daily ,
diltiazem 30 mg three times a day , Colace
100 mg three times a day , Motrin 600 mg every 6 hours , Lopressor 12.5 mg
three times a day , Percocet 1-2 tablets every 3-4h. for pain , Axid 150
mg orally twice daily , simvastatin 10 mg at bedtime.
Dictated By: CORETTA TAHIR , M.D. UN19
Attending: GAYLENE G. FANIEL , M.D. HK34
KM462/8664
Batch: 44188 Index No. R2AHMYOTZ D: 4/19/98
T: 4/18/98
Document id: 1246
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
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| output/system_intuitive_annotation.xml | intuitive |
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756484975 | PUO | 14374811 | | 398734 | 5/5/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/8/1991 Report Status: Signed
Discharge Date: 5/5/1991
ADMISSION DIAGNOSIS: CORONARY ARTERY DISEASE , QUESTION ASTHMA.
DISCHARGE DIAGNOSIS: CORONARY ARTERY DISEASE.
IDENTIFICATION DATA: This patient is a 59-year-old white female
with known coronary artery disease , past
history of myocardial infarction admitted 4/9/91 with three weeks
of worsening dyspnea on exertion and chest discomfort.
HISTORY OF PRESENT ILLNESS: The patient's coronary risk factors
include hypertension , elevated
cholesterol , 25-pack-year smoking history and a positive family
history. In 1983 , the patient was admitted to Norap Valley Hospital
where she ruled in for a non Q wave myocardial infarction with peak
CK of 182 , 7% MB. EKG showed global T wave inversions. The
patient was transferred to Pagham University Of where a
cardiac catheterization was performed which showed an 80% proximal
LAD lesion and a 30% mid RCA lesion. The patient was then
transferred to Ouf County General Hospital for PTCA. The angioplasty
procedure was not done. The patient was managed medically and did
well for the next seven years from a cardiac standpoint. She had
only minimal anginal symptoms and shortness of breath during that
period. In April of 1988 , the patient had an echocardiogram
which showed significant LVH , decreased LV compliance , borderline
left atrial enlargement and no regional wall motion abnormalities.
In October of 1991 , the patient had an ETT in which she exercised for
four minutes , 28 seconds achieving a peak heart rate of 103 and a
peak blood pressure of 150/60 , stopping secondary to fatigue and
shortness of breath without chest pain or EKG changes. Also in
October of 1991 , the patient had pulmonary function tests which
showed normal spirometry and lung volumes. On 7/28/91 , the patient
was having progressive shortness of breath and dyspnea on exertion
that morning. She presented to Dick Stookheights Community Hospital with worsening
dyspnea , wheezing. Her respiratory rate was 30 , and O2 saturation
was 85%. The patient was treated for presumed asthma with
Bronkosol nebulizers and Solu-Medrol. During the second Bronkosol
treatment , the patient developed 2/10 substernal chest pressure
radiating to the left arm which was relieved completely with one
sublingual nitroglycerin. There were no EKG changes. The patient
was transferred to Pagham University Of where she underwent
a V-Q scan , the results of which showed low probability of
pulmonary embolus. O2 saturation was 95%. The patient was sent
home on Ventolin inhaler. The patient stayed at home for the next
three weeks , symptom-free. On 7/14 , the patient while walking at
the Scot Re became acutely short of breath with 2/10
substernal chest pressure radiating to the right arm without
nausea , vomiting or diaphoresis or lightheadedness. The chest
pressure and shortness of breath decreased with rest. The patient
then presented to the Sco Medical Center and was then transferred to
Pagham University Of . PAST MEDICAL HISTORY: Coronary
artery disease , status post myocardial infarction as above.
Hypertension. Type II hyperlipidemia. Sjorgren's syndrome.
History of deep venous thromboses in 1981. Status post IVC
umbrella placement in 1981. Fibrocystic breast disease.
MEDICATIONS: On admission included diltiazem SR , 90 mg twice a day;
Ventolin inhaler; aspirin. ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Mother died of heart attack at age 78. SOCIAL
HISTORY: The patient works as a Bookkeeper at a law firm. She is
divorced with three grown children. She is a 40-pack-year smoker
and stopped one year ago.
PHYSICAL EXAMINATION: On admission revealed an obese white
female in no apparent distress. Vital signs
revealed a heart rate of 92 , blood pressure 120/70 , respirations
20 , afebrile. Skin and HEENT exams were normal. Chest revealed no
CVA tenderness. Lungs revealed trace inspiratory crackles at both
bases. There were no wheezes heard. Cardiac exam revealed PMI
nonpalpable , regular rate and rhythm. There was a I/VI midsystolic
murmur heard at the left sternal border , no gallops. JVP was not
appreciated. Carotids were 2+ bilaterally without bruits. Abdomen
was obese , well healed old surgical scars , soft , nontender , no
hepatosplenomegaly. Extremities showed trace pedal edema and
symmetrical pedal pulses. Neurological exam was nonfocal. Rectal
exam was normal.
LABORATORY DATA: On admission included a sodium of 137 , potassium
4.5. Chloride was 103. CO2 19. BUN 18.
Creatinine 1.2. Glucose 205 which normalized to 93 the next day.
Hematocrit was 36. White blood cell count was 14.2. Platelet
count 328 , 000. Urinalysis showed trace red blood cells and some
bacteria. EKG while pain free , showed normal sinus rhythm at 93 ,
axis of 40 degrees , intervals 0.21/0.10/0.36 and flat T waves in I
and L. Chest x-ray showed a question infiltrate in the left base
consistent with atelectasis.
HOSPITAL COURSE: The patient was admitted to the Kernan To Dautedi University Of Of Emergency
Room where she was tachypneic and wheezing with a
pO2 of 86%. EKG showed only T wave flattening in I and L. The
patient was admitted for presumed asthma and bronchitis and treated
with Bronkosol nebulizers. In the setting of the Bronkosol , the
patient had substernal chest pressure radiating to the left arm.
EKG showed 1 mm of ST depression in I and L and 1 mm ST elevation
in lead III. The pain resolved with three sublingual
nitroglycerin. The pain recurred a few minutes later and was again
resolved with Nitropaste and intravenous Lopressor. The patient ruled out
for myocardial infarction with CPK's of 43 , 36 , 37. The patient
was then transferred to the Medical Service and was managed with
diltiazem , Lopressor , Isordil and aspirin. On hospital day number
two , the patient went for echocardiogram which was not obtained
because the patient had developed 5/10 substernal chest pressure
which resolved with one sublingual nitroglycerin. There were no
EKG changes , the patient was started on heparin with question of
unstable angina at that time. On hospital day number three , the
patient went for cardiac catheterization which showed serial 40 and
50% lesions in the LAD and also an 80% lesion in the distal RCA.
There were no complications post catheterization. It was
questionable whether these lesions were serious enough to account
for the patient's symptoms. The patient's medical regimen was
advanced and she has tolerated that well and has been symptom free
for the past 48 hours. She was discharged home in stable
condition. She will follow-up with Dr. Gruntz in one week. The
patient also had asymptomatic pyuria and bacteruria and was treated
for a presumed urinary tract infection with three days of orally
Bactrim.
DISPOSITION: MEDICATIONS: On discharge included diltiazem SR ,
120 mg orally twice a day; Lopressor , 100 mg twice a day; Isordil ,
20 mg three times a day; aspirin , one every day.
EJ666/1399
CARA NEVA KENEKHAM , M.D. FJ1 LL6 D: 9/28/91
Batch: 3485 Report: E1785I6 T: 9/9/91
Dictated By: LOIDA GOLEBIOWSKI , VVX5
Document id: 1247
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
U |
U |
Y |
Y |
Y |
U |
Y |
U |
U |
Y |
U |
U |
Y |
U |
U |
U |
| output/system_intuitive_annotation.xml | intuitive |
N |
N |
Y |
Y |
Y |
N |
Y |
N |
N |
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N |
245876836 | PUO | 99067599 | | 869494 | 10/10/1997 12:00:00 a.m. | CONGESTIVE HEART FAILURE , RULE OUT MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 8/2/1997 Report Status: Signed
Discharge Date: 9/6/1997
PRINCIPAL DIAGNOSIS: CONGESTIVE HEART FAILURE.
ADDITIONAL DIAGNOSES: 1 ) CHEST PAIN.
2 ) HYPERTENSION.
3 ) DIABETES MELLITUS.
4 ) GASTROESOPHAGEAL REFLUX DISEASE.
5 ) DEPRESSION.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old woman
with a history of congestive heart
failure who presented with shortness of breath over the past two
months to the point of having difficulty with walking to her car.
She also has noted one to two days of chest tightness , worse with
exertion and improving with Mylanta. She was recently on May , 1997 by her primary doctor with similar symptoms. She was found
to have on chest x-ray , chronic congestive heart failure and at
that time and was continued on Lasix and Prinivil. Finally , the
patient notes increased lower extremity swelling and weight gain
over one months time.
PAST MEDICAL HISTORY: As above.
ALLERGIES: The patient is allergic to Penicillin which causes
tongue swelling.
MEDICATIONS ON ADMISSION: 1 ) Prinivil 20 mg orally every day. 2 )
Aspirin 325 mg orally every day. 3 ) Lasix
80 mg orally every day. 4 ) Prozac 20 mg orally every day. 5 ) Insulin
70/30 80 units subcutaneously every day before noon , 40 units subcutaneously every PM.
SOCIAL HISTORY: The patient lives in I Perrietman Kale Blvd. She has a
distant history of tobacco abuse. She does not
use alcohol.
FAMILY HISTORY: Non-contributory.
REVIEW OF SYSTEMS: Positive for a 14 lb. weight gain over the past
month. She denies orthopnea or paroxysmal
nocturnal dyspnea.
PHYSICAL EXAMINATION: Vital signs: Afebrile , heart rate 92 , blood
pressure 126/73 , oxygen saturation 98% on
two liters , 94% on room air. General: She is an obese , elderly
black female in no apparent distress. HEENT examination was
unremarkable. Chest showed bibasilar crackles. Cardiovascular
examination revealed regular rate and rhythm with a soft systolic
murmur at the left lower sternal border. Jugular venous pressure
was elevated at 10 cm. Her abdomen was obese , soft , non-tender.
Extremities showed 2+ edema , pitting to the knees.
LABORATORY: Laboratory studies on admission revealed a BUN of 19
and a creatinine of 1.4. CBC was normal. EKG was
normal sinus rhythm at 97 with first degree atrioventricular block
and left ventricular hypertrophy and no change compared with October
of 1997. Chest x-ray showed congestive heart failure.
HOSPITAL COURSE: The patient was admitted with congestive heart
failure , diuresed with increasing doses of Lasix ,
Prinivil was increased to 30 mg a day. An echocardiogram was
obtained which showed normal left ventricular function and left
ventricular hypertrophy with an ejection fraction of 60% and 3+
mitral regurgitation. With this result , Lopressor was added 25 mg
orally twice a day for presumptive diastolic dysfunction. Her Lasix dose
was increased on discharge to 80 mg orally twice a day She also underwent
Dobutamine stress test. She tolerated 9 minutes , 36 seconds with
Dobutamine infusion with a peak blood pressure of 150/60 and a peak
heart rate of 135. She had no significant EKG changes however did
have 9 minutes of atypical epigastric discomfort which was relieved
with burping. The test was interpreted as no evidence for ischemia
and the nuclear images were also negative for any fixed or
reversible defects.
FOLLOW-UP: The patient is to follow-up in the KTDUOO Clinic with Dr.
Avril Taplin on May , 1997.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
MEDICATIONS ON DISCHARGE: 1 ) Prinivil 30 mg orally every day. 2 )
Lasix 80 mg orally twice a day 3 ) Prozac 20
mg orally every day. 4 ) Insulin 70/30 80 units subcutaneously every day before noon ,
40 units subcutaneously every PM. 5 ) Lopressor 25 mg orally twice a day
Dictated By: DEANDRA L. GILFOY , M.D. HC88
Attending: DEANDRA L. GILFOY , M.D. HC88
ZY587/6898
Batch: 15722 Index No. PWOC1R82UZ D: 9/14/97
T: 10/8/97
CC: 1. AVRIL F. TAPLIN , M.D. QI3
Document id: 1248
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
| output/system_intuitive_annotation.xml | intuitive |
- |
- |
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- |
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155787624 | PUO | 82390417 | | 4620412 | 5/21/2006 12:00:00 a.m. | FEVER | Unsigned | DIS | Admission Date: 5/21/2006 Report Status: Unsigned
Discharge Date: 10/21/2006
ATTENDING: BRAGAS , RASHEEDA MD
HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman who was
previously admitted to Pagham University Of in mid
September for a mitral valve and tricuspid valve repair by Dr.
Delson Postoperative course was complicated by atrial
fibrillation , which has since resolved and C. diff colitis at
rehab. She was discharged from the Kernan To Dautedi University Of Of to rehabilitation
facility on 10/4/06 where she developed C. diff colitis and
diarrhea. She was started on orally Flagyl , which she continued
until the first week of August . Prior to that , she had been
treated with Cipro for UTI while at the Kernan To Dautedi University Of Of . She was
improving clinically until about three days prior to admission
when she noted persistent diarrhea. She began to feel lethargic
with subjective fevers and chills. She also noticed chest pain
that was substernal and intermittent with left arm pain. Pain
was described as diffuse , constant and 3/10 in intensity. Pain
was nonexertional. She also noted persistently loose stools
without blood. On arrival to the emergency room , she had a fever
to 102 Fahrenheit. No tenderness in her chest to suggest
mediastinitis. She was seen by Thoracic Surgery in the emergency
room and cleared.
ED COURSE: Echo was obtained. Chest x-ray , chest CT and blood
and urine cultures were obtained. She was given vancomycin 1 gm
plus Flagyl 500 x1 , given intravenous fluids 500 mL normal saline and
potassium.
PAST SURGICAL HISTORY: Partial hysterectomy in the 1970s ,
cholecystectomy and appendectomy in 1970s and inguinal hernia
repair in 1992.
PAST MEDICAL HISTORY: CHF with EF of 45-50% in 10/22 , cardiac
cath in 3/22 , no significant coronary artery disease. Mitral
valve insufficiency and status post repair on 10/26/06.
Hypertension , asthma , fatty liver disease , status post
pancreatitis , osteoarthritis of hips , pulmonary nodule on
10/11/04 by CAT scan , obesity , history of AFib , history of
rheumatoid arthritis , history of H. pylori treated with
amoxicillin , Flagyl and omeprazole , history of thyroiditis ,
history of kidney stone , history of abnormal mammogram.
PAST CARDIAC HISTORY: Ischemic cardiopathy myopathy with mitral
regurg , diastolic dysfunction. No coronary artery disease on
cath but defects on SPECT and MRI , subendocardial MI on 10/24/06
per cardiac MI , history of AFib. Coronary risk factors include
hypertension , history of smoking , no hypercholesterolemia , no
diabetes , no family history of heart disease. Positive obesity
and sedentary lifestyle.
HOME MEDICATIONS: Advair 250/50 one puff twice a day , amoxicillin for
procedures , Colace , Coumadin 2.5 daily , diltiazem 30 mg three times a day ,
aspirin 81 daily , Lasix 40 twice a day orally , Gemfibrozil 600 mg daily ,
ibuprofen 600 three times a day as needed pain , K-Dur 20 mEq orally twice a day ,
metoprolol 75 mg orally three times a day , Niferex 150 mg orally twice a day ,
omeprazole 20 mg orally daily , simvastatin 20 mg daily , Synthroid
175 mcg daily.
ALLERGIES: Lisinopril causes angioedema. intravenous contrast causes
hives.
SOCIAL HISTORY: Former bus driver. Divorced with 10 children ,
many of them visit.
LIVING SITUATION: She lives in an apartment alone. Denies
alcohol or smoking. Her daughter is very involved in her care.
PHYSICAL EXAMINATION ON ADMISSION: Vital Signs: Temperature
101 , heart rate in the 110s , O2 saturation 96% on 2 L ,
respiratory rate is 15. General: She is alert and oriented x3
and sleepy , using accessory muscles of respiration. Neck: JVP
is flat , no neck lymphadenopathy. HEENT: Mucous membranes dry.
CV: Irregular. Lungs: Clear to auscultation bilaterally.
abdomen: Mild epigastric tenderness , nontender , nondistended.
Neuro: Grossly nonfocal. Extremities: Warm with pulse. No
clubbing , cyanosis or edema.
LABORATORY DATA ON ADMISSION: Sodium 137 , potassium 3.4 , CO2 26 ,
BUN over creatinine 12/0.9 , glucose 126 , anion gap of 9 , calcium
8.8 , albumin 3.7 , AST over ALT 15/7 , alkaline phosphatase 0.8 ,
troponin negative , CK 39. White count 11.5 , hematocrit 33.6 , INR
1.6.
EKG showed a sinus tachycardia at a rate of 131 , left atrial
enlargement , left ventricular hypertrophy by aVL criteria , normal
axis , no ST-T changes.
ASSESSMENT: This is a 71-year-old woman with a history of
hypertension , CHF , status post a mitral valve/tricuspid valve
repair in mid September , complicated by postoperative C. diff
colitis and UTI who presented with persistent diarrhea and three
days of fever , chills and chest pain. The patient's fatigue was
most likely related to dehydration secondary to persistent C.
diff related diarrhea. Over the course of her hospitalization ,
it became clear that she experienced chest pain during her
intermittent episodes of ventricular ectopy. Now that her NSVT
is under better control , she is chest pain-free.
HOSPITAL COURSE:
1. Cardiovascular:
Ischemia: The patient was continued on aspirin , beta-blocker ,
statin and gemfibrozil. She had negative cardiac enzymes x3 and
ruled out by biomarkers.
Pump: The patient was initially dry on exam. She was rehydrated
with normal saline. The patient developed shortness of breath on
hospital day #4 , most likely secondary to overhydration. She was
gently diuresed with intravenous Lasix. Electrolytes were repleted twice
daily. She was then transitioned to 40 of Lasix orally daily and
finally per cardiology recommendation 20. She will be discharged
to home on 20 twice a day orally
Rhythm: The patient has a history of atrial fibrillation. On
hospital day #2 , she developed atrial fibrillation with
hypotension most likely secondary to Diltiazem , which was
subsequently held. The patient's blood pressure improved
dramatically with gentle intravenous hydration on hospital day #2. Her
Diltiazem will be discontinued. The patient is on Coumadin now
with therapeutic INR on discharge at 2.6. Per cardiology , her
beta-blocker was increased to 75 four times a day and then she was
transitioned to Toprol 300 daily; however , she had persistent
nocturnal NSVT , which caused her some chest pain and was quite
frightening to her. Per cardiology , she was loaded on amiodarone
400 three times a day , which will be continued for 5 days post-discharge and
then the patient will be transitioned to 400 amiodarone daily.
At the same time , her Toprol will be decreased to 100 mg daily ,
her discharge dose. Echocardiogram was ordered on the day of
discharge per cardiology. See LMR for formal report.
2. Infectious Disease: The patient with recent UTI and C. diff
colitis in the setting of recent hospitalization antibiotic use
presented with diarrhea and elevated white count and fever.
Continued on Flagyl orally and vancomycin orally for Flagyl failure.
She had one C. diff positive stool. Stool became C. diff
negative as of 9/2/06. Her diarrhea rapidly slowed on dual
therapy. She will be discharged with seven more days of
antibiotics to complete.
3. Endocrine: The patient on home dose Synthroid. TSH
initially low , however , rechecked and found to be within normal
limits. Continue home dose of Synthroid.
4. Heme: The patient's hematocrit was stable throughout her
hospitalization. Continue Niferex at home dose , continue
Coumadin at 2.5 mg nightly.
5. Pulmonary: The patient had a low pretest probability for PE.
Given her allergy to intravenous contrast , she was not a candidate for
PECT; however , a V/Q scan was obtained on 1/19/06. The result
was low probability for pulmonary embolism. Her respiratory exam
improved greatly on twice a day Lasix.
6. Renal. The patient's creatinine was stable throughout her
hospitalization.
7. Prophylaxis: Coumadin with therapeutic INR plus proton pump
inhibitor.
8. FEN: The patient was initially started on a clear liquid
diet. On hospital day #3 , she began to eat solid foods and
tolerated well.
9. Code status: The patient was a full code throughout her
hospitalization.
DISCHARGE INSTRUCTIONS:
1. Continue home medications as indicated.
2. Continue vancomycin and Flagyl for 7 more days.
3. VNA instructed to draw INR on Thursday , 2 days post-discharge
and follow up with Pagham University Of Coumadin Clinic.
4. Stop Diltiazem and metoprolol.
5. Start Toprol-XL 100 mg daily.
6. Continue amiodarone 400 mg three times a day until Sunday , 5/29/06 and
then switch to 400 mg daily.
7. Check LFTs and TSH on Friday and weekly thereafter.
8. Check electrolytes on Friday and twice weekly thereafter.
CONTINUING CARE PLANS FOR MD:
1. Continue vancomycin and Flagyl orally until 12/10/06 , stop on
8/11/06.
2. Continue home medications as indicated.
3. Check electrolytes on Friday. Consider adding orally magnesium
and potassium repletion after diarrhea resolves.
4. Check INR and adjust accordingly for goal INR 2-3.
5. Check TSH and LFTs on Friday and thereafter weekly.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg daily.
2. Amiodarone 400 mg orally three times a day
3. Advair 250/50 one puff twice a day
4. Lasix 20 mg twice a day
5. Gemfibrozil 600 mg daily.
6. K-Dur 20 mEq twice a day
7. Synthroid 175 mcg orally daily.
8. Toprol 100 mg orally daily.
9. Flagyl 500 mg three times a day
10. Niferex 150 mg orally twice a day
11. Omeprazole 20 mg orally daily.
12. Zocor 20 mg orally before bedtime.
13. Vancomycin 125 mg orally every 6 hours
14. Coumadin 2.5 mg orally every afternoon
FOLLOWUP APPOINTMENTS:
1. The patient is to see her primary care physician , Dr. Wendi Newand , on 7/9/07 at
1:20.
2. The patient is to see Dr. Verry of Cardiology at
575-803-4363 , patient will be called with appointment; however ,
the patient received should see cardiologist next week.
3. The patient is to follow up with Pagham University Of
Coumadin Clinic. Coumadin Clinic will contact the patient.
eScription document: 7-1446342 CSSten Tel
Dictated By: ECKLER , ROLANDA
Attending: BRAGAS , RASHEEDA
Dictation ID 9431139
D: 7/25/06
T: 7/25/06
Document id: 1249
| Target |
Ast |
CAD |
CHF |
Dp |
DM |
Gs |
GER |
Gou |
HC |
HTN |
HTG |
OA |
Obe |
OSA |
PVD |
VI |
| output/system_textual_annotation.xml | textual |
- |
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- |
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| output/system_intuitive_annotation.xml | intuitive |
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816645569 | PUO | 32646255 | | 1674683 | 10/4/2006 12:00:00 a.m. | asthma | Signed | DIS | Admission Date: 10/4/2006 Report Status: Signed
Discharge Date: 3/16/2006
ATTENDING: TROJAN , LUISE M.D.
SERVICE:
MH team.
PRIMARY CARE PHYSICIAN:
Dr. Sana Azua
PRINCIPAL DIAGNOSIS FOR ADMISSION:
Asthma exacerbation.
LIST OF PROBLEMS DURING HOSPITALIZATION:
1. Asthma exacerbation.
2. Diabetes mellitus.
3. Iron deficiency anemia.
HISTORY OF PRESENT ILLNESS:
This is a 38-year-old female with a history of asthma , type II
diabetes mellitus , obesity , depression , and iron deficiency
anemia who presented to Pagham University Of on 3/9/06
complaining of worsening shortness of breath and chest tightness
over the past three days after running out of her asthma
medications approximately two weeks ago. The patient had ran out
of her Advair , albuterol , and Singulair as well as her Lasix.
She denied any fevers or chills , no nausea , vomiting , diarrhea ,
chest pain , or cough. She did report some increased lower
extremity edema over the past several days and admits to not
taking her Lasix. She went to KTDUOO urgernt care on the day of admission and was
found to have an oxygen saturation of 84% on room air and she was
sent to the Emergency Room for admission. In the ED , she
received nebulizer treatments and prednisone 60 mg x1 and her O2
saturation improved to 95% on 2 liters.
HOME MEDICATIONS:
The patient takes Advair 500/50 twice a day , albuterol nebulizers
every 4 hours as needed , iron 325 mg three times a day , glyburide 2.5 mg daily , Lasix
40 mg orally daily , lisinopril 2.5 mg orally daily , metformin 850 mg
twice a day , Prozac 40 mg daily , Singulair 10 mg daily , and a
multivitamin daily.
ALLERGIES:
The patient has no known drug allergies.
REVIEW OF SYSTEMS:
Pertinent for shortness of breath and chest tightness.
PHYSICAL EXAMINATION ON ADMISSION:
Exam on admission , patient was afebrile. Her pulse was 100 ,
blood pressure 116/70 , respiratory rate 22 , and O2 saturation of
95% on 2 liters. The patient was awake , alert and oriented x3
and in no apparent distress. Her lungs had scattered wheezing
bilaterally with good air movement. Heart with normal S1 , S2 and
tachycardic. Abdomen is obese , soft , nondistended , nontender.
Extremities had 1+ bilateral pitting edema and mild erythema of
her bilateral shins.
PERTINENT LABORATORY DATA ON ADMISSION:
White blood cell count was 10.6 and hematocrit 30. Chest x-ray
showed a large cardiac silhouette with no evidence of effusion or
infiltrate. The patient had a PE protocol CT which was a
suboptimal study due to poor body habitus but it was negative for
PE , it did show bilateral ground glass opacities and evidence of
air trapping. It also showed moderate hepatomegaly.
PROCEDURES DURING HOSPITALIZATION:
The patient had a PECT and she also had pulmonary function tests
performed.
HOSPITAL COURSE BY PROBLEM:
This is a 38-year-old female with asthma , diabetes , anemia , and
morbid obesity who was admitted with his asthma exacerbation in
the setting of running out of her medications at home.
1. Pulmonary: The patient was started on prednisone 60 mg orally
daily and remained on it for approximately seven days. It was
difficult to taper her prednisone due to oxygen desaturations
with ambulation. The patient's oxygen desaturated to 74-84% with
ambulation. The patient , however , was tapered and is currently
on 50 mg daily , of prednisone and will be sent out on a seven-day
taper. She was also continued on her Advair and Singulair. As
mentioned above , she had a PE protocol CT that showed no PE.
However , it was a suboptimal study due to patient's body habitus.
It did show ground glass opacities. Because the patient had
desaturations with ambulation , it was concerned that the patient
possibly had an atypical pneumonia given these ground glass
opacities. She was started on levofloxacin and should complete a
five-day course. The patient was also tested for HIV which was
negative. She had a BNP to rule out any evidence of volume
overload that was contributing to her oxygen desaturations. BNP
was 5. The patient also had hepatitis serologies due to
hepatomegaly seen on PECT and these were negative as well.
Influenza swabs were negative. The patient was seen in consult
by the pulmonary team and they felt that the patient requireed
home oxygen especially at night and with ambulation. The
patient's O2 saturation while sleeping was 84%. It is highly
suspected that the patient has a component of sleep apnea and she
is to be set up for an outpatient sleep study. Pulmonary also
recommended obtaining a pulmonary function test. These were done
and it showed an FVC of 51% and an FEV1 of 49% and an FEV-FVC
ratio of 97% as well as a total lung capacity of 53% and a DLCO
of 82%. Pulmonary function tests were consistent with
restrictive disease and this is likely due to patient's obesity.
The patient most likely has obesity hypoventilation. We spoke
with her in depth about the importance of losing weight to help
improve her respiratory status as well as her overall health.
The patient is scheduled to have an outpatient sleep study and
she is also to follow up with her outpatient pulmonologist , Dr.
Chuong Home oxygen was set up for the patient as well.
2. Cardiovascular: The patient was continued on her lisinopril
and her Lasix was resumed for her lower extremity edema. This
did improve throughout her hospitalization. A lipid panel was
checked and this was in the normal range. The patient should be
started on aspirin given her diabetes and her hypertension.
However , she has been experienced menorrhagia and is anemic so
the aspirin should be started as an outpatient after her
menorrhagia is addressed.
3. Hematology: The patient was found to be iron deficient by
labs and she was continued on iron supplements three times a day.
The patient also complains of heavy menstruation and she has a
history of uterine fibroids , she was supposed to follow up with
GYN as an outpatient but missed her appointment. She was
instructed to follow up with GYN.
4. Endocrine: The patient's home medications of glyburide and
metformin were held and she was placed on NPH 25 units twice a day
with a NovoLog sliding scale and 12 units before every meal Her hemoglobin
A1c was 7. She was resumed on her home regimen at discharge.
5. Prophylaxis: The patient received Lovenox and Nexium for
prophylaxis.
PHYSICAL EXAMINATION AT DISCHARGE:
The patient was awake , alert , oriented x3. She is 95% on room
air at rest but did continue to desaturate into the 80s with
ambulation. She is awake , alert , oriented x3. Her lungs were
clear bilaterally. There were no other pertinent findings on
exam at discharge.
CONSULTANTS DURING HOSPITALIZATION:
Pulmonary was Dr. Sulentic
DISCHARGE MEDICATIONS:
The patient was sent home on albuterol inhaler two puffs four times a day ,
ferrous sulfate 325 mg orally twice a day , Prozac 40 mg orally daily ,
Advair Diskus 500/50 one puff twice a day , Lasix 40 mg orally daily ,
glyburide 2.5 mg orally daily , Levaquin 750 mg orally daily , x1 more
dose , lisinopril 2.5 mg orally daily , metformin 850 mg orally twice a day ,
Singulair 10 mg orally daily , Nexium 40 mg orally daily , and a
prednisone taper 40 mg daily x2 days , then 30 mg daily x2 days ,
then 20 mg daily x2 days , then 10 mg daily x2 days , then stopping
it and multivitamin one tablet daily.
INSTRUCTIONS ON DISCHARGE:
The patient was encouraged to follow up with GYN as an outpatient
regarding her uterine fibroids and menorrhagia. A follow-up
appointment was scheduled with both her primary care physician
and Dr. Schlesener in February She met with Nutrition during the
hospitalization and had a long conversation with the medical team
regarding weight loss strategies.
ADVANCE DIRECTIVES:
The patient is a full code.
eScription document: 5-9396153 EMSSten Tel
Dictated By: OSMERS , TESSA
Attending: TROJAN , LUISE
Dictation ID 3557453
D: 2/27/06
T: 2/27/06